Exercise training (ET) based cardiac rehabilitation (ExCR) is considered as a ‘pillar’ of heart failure (HF) management, alongside drug and medical device treatment improving health related quality of life and reducing hospitalizations. However, it is reported that the large beneficial effects of optimal medical therapy (OMT) and device therapy may have reduced the potency of ExCR in patients with HF and reduced ejection fraction (HFrEF), associated with a non-clear benefit in mortality, as well as, with modest changes in aerobic capacity, at least compared to the pre-OMT era. The present review explores a ‘hypothesis of an OMT associated attenuation of ET effectiveness’. It investigates the evolvement and potency of ExCR during the last 70 years with respect to medical innovations in patients with HFrEF and focuses on the three largest multicenter ET randomized controlled trials, HF-ACTION, SMARTEX-HF, ARISTOS-HF, investigating ‘breakthrough’ interventions such as moderate continuous aerobic training, high intensity interval training and aerobic/resistance/inspiratory training outcomes, respectively. It is suggested that ET delivery using ‘poly-muscle training’ and a ‘high ET dosage’ may improve the effectiveness of ET programs in the era of OMT, although further confirmation is required.

Background: Premature ventricular contractions (PVCs) are common arrhythmias associated with symptoms such as fatigue and, in severe cases, PVC-induced cardiomyopathy. Catheter ablation (CA) is a primary treatment for symptomatic PVCs, particularly when pharmacological therapies fail or are undesired. While improvements in: quality-of-life following ablation are documented, its impact on functional capacity remains underexplored. Objectives: This study evaluated the impact of CA on functional capacity and cardiac stress markers in patients with symptomatic PVCs using cardiopulmonary exercise testing (CPET) and NT-proBNP levels. Methods: A total of 30 patients underwent successful PVC ablation and completed baseline and follow-up CPET evaluations under the Bruce protocol. PVC burden, left ventricular ejection fraction (LVEF), NT-proBNP levels, and CPET parameters, including VO2 max, METS, ventilatory efficiency, and anaerobic threshold (AT), were analyzed pre- and post-ablation. Results: PVC burden significantly decreased post-ablation (23,509.3 ± 10,700.47 to 1759 ± 1659.15, p < 0.001). CPET revealed improved functional capacity, with VO2 max increasing from 24.97 ± 4.16 mL/kg/min to 26.02 ± 4.34 mL/kg/min (p = 0.0096) and METS from 7.16 ± 1.17 to 7.48 ± 1.24 (p = 0.0103). NT-proBNP significantly decreased (240.93 ± 156.54 pg/mL to 138.47 ± 152.91 pg/mL, p = 0.0065). LVEF and ventilatory efficiency metrics (VE/VO2 and VE/VCO2) remained stable. Conclusions: Catheter ablation improves functional capacity, reduces cardiac stress, and minimizes medication dependency in patients with symptomatic PVCs. These findings support the utility of ablation in enhancing aerobic capacity and overall exercise performance.

Modification of psychosocial risk factors is an integral part of preventive cardiology. Through psychosocial interventions lifestyle changes can be facilitated with emphasis on the acquisition of purpose in life which may be associated with improved prognosis in cardiovascular disease. Τo examine the effect of interdisciplinary psychotherapeutic intervention in patients (pts) with increased cardiovascular risk. Patients and Methods: 20 pts were studied (18M/2F), age 55±10, 35-70 years, 50% with a history of myocardial infarction, 50% with a diagnosis of hypertension and/or dyslipidemia. Patients participated in a psychotherapeutic-educational group (Heart-Mind) coordinated by a cardiologist trained in systemic therapy approach and a psychotherapist. Group members participated in 10 (two-hour) meetings twice per month. The topic of each meeting was chosen by the group coordinators and dealt with risk factors (stress, smoking, diet, relationships, anger, expression of emotions). For the initial stimulus individual drawing, music and listening to life scenes were used. Group Therapy (SCIT), Self-Help Group and Mindfulness-Type Relaxation techniques were used. At baseline and at the end of the cycle, group members completed the validated Purpose in Life Questionnaire (PILQ) and Resilience Questionnaire (RESQ). The TAT (Thematic Apperception Test) evaluation method was also used which is a valid projective test to reveal an individual's perception of interpersonal relationships. There was a significant improvement in PILQ score comparing final vs baseline assessment (112±11 vs 104±14, p=0.014). There was also a non-statistically significant trend towards an improvement in final vs baseline RESQ score (166±24 vs 156±25, p=0.113). According to TAT qualitative analysis there was an impressive change in the participants stories. Instead of feeling incompetent, they revealed their anger and discomfort as they realized the pressing conditions of the context. Heart-Mind interdisciplinary approach in the form of group psychotherapy may be a valuable intervention to facilitate clinically important lifestyle changes in cardiovascular disease mainly via an enhanced sense of purpose in life. A Heart-Mind interdisciplinary approach may by introduced as a new method of psychosocial intervention to be part of cardiac rehabilitation programs.

Music has been shown to potently reduce the perception of fatigue and exertion through dissociation and distraction during exercise. Listening to music prior to and during exercise has been shown to increase motivation and effort, leading to improved performance outcomes. To study the effects of music listening on clinical, ECG and hemodynamic indices measured during exercise in patients (pts) with documented coronary artery disease (CAD) and a history of percutaneous coronary intervention (PCI). Thirty two asymptomatic pts (29M/3F) with CAD and a history of previous PCI (12-36 months) were studied during follow-up treadmill exercise test (Bruce Protocol). All pts maintained good LV function assessed by standard echocardiography. Sixteen pts consisting music group (MG) (mean age 60±9) were openly exposed to instrumental classical music delivered during exercise via high quality audio system connected to speakers. Another group of 16 pts (NMG) (mean age 59±8) was not exposed to music during exercise and acted as a control group. All pts were assessed according to standard hemodynamic and ECG measurements obtained during exercise testing in CAD pts. All pts were asked post-exercise to indicate levels of anxiety-stress felt during the procedure on a Visual Analogue Scale (VAS) (range 0-10 cm). All pts achieved >85% of their max predicted heart rate and no pt developed angina symptoms during the test. ST-T segment exercise ECG abnormalities were detected in 4(25%) pts in MG compared to 5(31%) pts in NMG group (p=ns). Twelve (81%) pts in MG and 13 (87%) in NMG group were on a b-blocker during the test. Exercise duration was longer in MG (9.4±1.6 min) compared to NMG (8.0±1.2 min) (p=0.009). In addition, VAS score was lower in M (4.8±1.8 cm) vs NM group (6.2±1.3 cm) (p=0.017) indicating a reduced level of perceived anxiety-stress in MG . Music listening improves exercise tolerance during treadmill exercise in pts with CAD and history of PCI. This improvement may be related to a reduction in the perception of anxiety induced by music listening on exercise. Music may be a useful tool to achieve maximal performance and optimize exercise testing diagnosis in cardiovascular pts.

Abstract Background Up to 5-10% of patients (pts) report long-term cardiac symptoms associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Aim To evaluate by cardiopulmonary exercise testing (CPET) pts with laboratory confirmed SARS-CoV-2 infection who reported fatigue or dyspnea symptoms 3 months after infection. Methods Pts hospitalization data, demographics, severity of COVID-19 disease and comorbidities were collected. Evidence of cardiac involvement during hospitalization was documented. All pts underwent an extensive clinical protocol with biomarkers, electrocardiography, 2D echocardiography, 24 hour Holter monitoring and a treadmill CPET. Results The cohort consisted of 85 pts (mean age 44 ± 8 yrs): 55 hospitalized pts (mean hospitalization 11.8 ± 4.3 days) and 30 non-hospitalized pts. Five percent of the cohort had evidence of troponin rise upon infection. A relevant cardiac diagnosis was identified in 48% of the cohort. The dominant diagnoses were cardiomyopathy (18%) and healed myocarditis (13%) followed by diastolic heart failure (5%), pulmonary hypertension (4%) and cardiac arrhythmias (3%). Fifty eight (68%) pts of the cohort (mean age 43±8) underwent a treadmill CPET, 25 (43%) of them complaining of fatigue and (28) 57% of effort dyspnea at presentation. However, they showed an overall satisfactory exercise capacity on CPET by achieving (mean 88±15 %) of the max predicted pVO2 with achieved VE/VCO2 also within normal range (mean 31±4). Conclusions Cardiac involvement is identified in almost half of young patients with long-Covid symptoms of fatigue or dyspnea who were referred to a tertiary cardiac center. However, despite symptoms their aerobic capacity objectively measured by CPET was not impaired.

Thus, COVID-19 crisis should be looked not only as a disaster, but also as an opportunity to transform CR (and other rehabilitation) services, promoting change in order to increase the efficiency and effectiveness but also to fully integrate this intervention into healthcare services.In this way, healthcare systems will also become better prepared to face a future pandemic, if needed.

AIMS:An 'optimum' universally agreed exercise programme for heart failure (HF) patients has not been found. ARISTOS-HF randomized clinical trial evaluates whether combined aerobic training (AT)/resistance training (RT)/inspiratory muscle training (IMT) (ARIS) is superior to AT/RT, AT/IMT or AT in improving aerobic capacity, left ventricular dimensions, and secondary functional outcomes.METHODS AND RESULTS:Eighty-eight patients of New York Heart Association II-III, left ventricular ejection fraction  ≤ 35% were randomized to an ARIS, AT/RT, AT/IMT, or AT group, exercising 3 times/week, 180 min/week for 12 weeks. Pre- and post-training, peakVO2 was evaluated with cardiopulmonary exercise testing, left ventricular dimensions using echocardiography, walking distance with the 6-min walk test (6MWT), quality of life by the Minnesota Living with HF Questionnaire (MLwHFQ), while a programme preference survey (PPS) was used. Seventy-four patients of [mean 95% (confidence interval, CI)] age 66.1 (64.3-67.9) years and peakVO2 17.3 (16.4-18.2) mL/kg/min were finally analysed. Between-group analysis showed a trend for increased peakVO2 (mL/kg/min) [mean contrasts (95% CI)] in the ARIS group [ARIS vs. AT/RT 1.71 (0.163-3.25)(.), vs. AT/IMT 1.50 (0.0152-2.99)(.), vs. AT 1.38 (-0.142 to 2.9)(.)], additional benefits in circulatory power (mL/kg/min⋅mmHg) [ARIS vs. AT/RT 376 (60.7-690)*, vs. AT/IMT 423 (121-725)*, vs. AT 345 (35.4-656)*], left ventricular end-systolic diameter (mm) [ARIS vs. AT/RT -2.11 (-3.65 to (-0.561))*, vs. AT -2.47 (-4.01 to (-0.929))**], 6MWT (m) [ARIS vs. AT/IMT 45.6 (18.3-72.9)**, vs. AT 55.2 (27.6-82.7)****], MLwHFQ [ARIS vs. AT/RT -7.79 (-11 to (-4.62))****, vs. AT -8.96 (-12.1 to (-5.84))****], and in PPS score [mean (95% CI)] [ARIS, 4.8 (4.7-5) vs. AT, 4.4 (4.2-4.7)*] [(.) P ≤ 0.1; *P ≤ 0.05; **P ≤ 0.01; ***P ≤ 0.001; ****P ≤ 0.0001].CONCLUSION:ARISTOS-HF trial recommends exercise training for 180 min/week and supports the prescription of the ARIS training regime for HF patients (Clinical Trial Registration: http://www.clinicaltrials.gov. ARISTOS-HF Clinical Trial number, NCT03013270).

Background: Myocardial viability (VIA) prevalence in post myocardial infarction (MI) patients (pts) in association with angina (ANG) or not has not been prospectively evaluated.Methods and Findings: Fifty-five post-MI pts with reduced ejection fraction (EF≤40%) underwent stress thallium-201 scintigraphy (Tl-201) viability (VIA) evaluation.ANG at exercise-treadmill-test (ETT) (Borg scale) and at everyday-life (Canadian Cardiovascular Society -CCS) classification was recorded.Groups VIA (29 pts -53%) vs non-VIA respectively had similar EF (31 ± 7)% vs (33 ± 8)% (NS), higher diseased vessels number 2.8 ± 1.6 vs 1.9 ± 1.3 (p=0.02),CCS 1.7 ± 0.8 vs 1.3 ± 0.6 (p<0.05),CCS≥2 71% vs 41% (p<0.03).Five pts from each group reported ETT ANG (17% vs 21% -NS), with Borg scale 7.7 ± 3.0 vs 7.2 ± 2.4 (NS).CCS≥2 was associated with greater 201 Tl reversibility indices within stress defect (p<0.04) or total myocardial mass reversibility (p<0.02).Binary logistics analysis associated VIA positively with number of diseased vessels and negatively with smoking, while CCS≥2 ANG positively with number of diseased vessels.The main limitation is the relatively small number of pts.Conclusions: Viability, while not significantly correlated to ETT angina, was positively associated only with more frequent everyday-life (CCS) angina.Clinically, in ischemic cardiomyopathy VIA evaluation is indicated, regardless of ANG.

Background: We hypothesized that the ability to sustain maximal inspiratory pressure (SPImax) over time as a measure of work capacity may be more severely affected than inspiratory muscle strength (PImax) in patients with heart failure (HF).Methods: We retrospectively investigated eighty patients with HF, NYHA II/III/ambulatoryIV and a (mean +/- SD) LVEF 27 +/- 8%, and compared them to 25 healthy subjects (HS). During a maximal inspiratory manoeuvre from residual volume (RV) to total lung capacity, PImax was measured as the maximum mouth pressure at RV, inspiratory contraction time (ICT) as the time from RV to end of inspiration and SPImax as the area under a pressure-time curve using an electronic pressure manometer with designed-purpose software (Trainair (R), Project Electronics Ltd., London, UK). Exercise capacity was assessed with cardiopulmonary exercise testing and the 6-minute walk test (6MWT).Results: Patients achieved a (mean +/- SD) peak VO2 = 15.7 +/- 3.4 ml/kg/min and 6MWT = 338 +/- 88 m. PImax, ICT and SPImax were reduced in HF pts at 75%***, 61%*** and 52%*** of HS, and correlated with NYHA (r = -0.485***), (r = -0.507**), (r = -0.500***), peakVO(2) (r = 0.501***), (r = 0.655***), (r = 0.508***) and 6MWT (r = 0.477***), (r = 0.345**), (r = 0.530***), respectively (*p < 0.05, **p < 0.01, ***p < 0.001).Conclusion: PImax, ICT and SPImax were impaired in HF patients compared to HS and may be important determinants of exercise capacity. SPImax was severely depressed even in patients with relatively preserved PImax and should be considered as an additional target index for inspiratory muscle training. Equations are provided to predict SPImax in relation to age and exercise capacity in HF. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

AimsVent‐HeFT is a multicentre randomized trial designed to investigate the potential additive benefits of inspiratory muscle training (IMT) on aerobic training (AT) in patients with chronic heart failure (CHF).Methods and resultsForty‐three CHF patients with a mean age of 58 ± 12 years, peak oxygen consumption (peak VO2) 17.9 ± 5 mL/kg/min, and LVEF 29.5 ± 5% were randomized to an AT/IMT group (n = 21) or to an AT/SHAM group (n = 22) in a 12‐week exercise programme. AT involved 45 min of ergometer training at 70–80% of maximum heart rate, three times a week for both groups. In the AT/IMT group, IMT was performed at 60% of sustained maximal inspiratory pressure (SPImax) while in the AT/SHAM group it was performed at 10% of SPImax, using a computer biofeedback trainer for 30 min, three times a week. At baseline and at 3 months, patients were evaluated for exercise capacity, lung function, inspiratory muscle strength (PImax) and work capacity (SPImax), quality of life (QoL), LVEF and LV diameter, dyspnoea, C‐reactive protein (CRP), and NT‐proBNP. IMT resulted in a significantly higher benefit in SPImax (P = 0.02), QoL (P = 0.002), dyspnoea (P = 0.004), CRP (P = 0.03), and NT‐proBNP (P = 0.004). In both AT/IMT and AT/SHAM groups PImax (P < 0.001, P = 0.02), peak VO2 (P = 0.008, P = 0.04), and LVEF (P = 0.005, P = 0.002) improved significantly; however, without an additional benefit for either of the groups.ConclusionThis randomized multicentre study demonstrates that IMT combined with aerobic training provides additional benefits in functional and serum biomarkers in patients with moderate CHF. These findings advocate for application of IMT in cardiac rehabilitation programmes.

OBJECTIVES:The present study investigated the potential of the failing myocardium of patients with ventricular assist devices (VAD) to respond to physiological growth stimuli, such as exercise, by activating growth signalling pathways. This may be of therapeutic relevance in identifying novel pharmacological targets for therapies that could facilitate recovery after VAD implantation.METHODS:Twenty-two patients bridged to heart transplantation (HTx) with VAD were included in the study. A group of patients underwent moderate intensity aerobic exercise (GT), while another group of patients did not receive exercise training (CG). Thyroid hormone receptor alpha1 (TRα1) protein and total (t) and phosphorylated (p) protein kinase B (Akt) and c-Jun N-terminal kinase (JNK) kinase signalling were measured in myocardial tissue by western blotting at pre-VAD and pre-HTx period. In addition, Thyroid hormone (TH) levels were measured in plasma.RESULTS:Peak oxygen consumption (VO2) at pre-HTx period was higher in patients subjected to training protocol [18.0 (0.8) for GT when compared with 13.7 (0.7) for CG group, P = 0.002]. N-terminal-prohormone of brain natriuretic peptide (NT-proBNP) levels were 1068 (148) for CG vs 626 (115) for GT group, P = 0.035. A switch towards up-regulation of physiological growth signalling was observed: the ratio of p-Akt/t-Akt was 2-fold higher in GT vs CG, P < 0.05 while p-JNK/t-JNK was 2.5-fold lower (P < 0.05) in GT vs CG, in pre-HTx samples. This response was accompanied by a 2.0-fold increase in TRα1 expression in pre-HTx samples with concomitant increase in circulating T3 in GT vs CG, P < 0.05. No differences in peak VO2, NT-proBNP, T3, TRα1, p/t-AKT and p/t-JNK were found between groups in the pre-VAD period.CONCLUSIONS:The unloaded failing myocardium responded to physical training by enhancing thyroid hormone signalling. This response was associated with an up-regulation of Akt and suppression of JNK activation.

Music can influence a wide range of physiological and psychological effects and is effective in decreasing stress and facilitating relaxation responses. Music therapy has been widely used in a variety of cultures for centuries to decrease patients’ perception of pain, anxiety and depression, and boost their feelings of relaxation. Music can be used as a safe and inexpensive non-pharmacologic antianxiety intervention to enhance relaxation and decrease stress in ICU patients.

BackgroundWe hypothesised that combined aerobic training (AT) with resistance training (RT) and inspiratory muscle training (IMT) could result in additional benefits over AT alone in patients with chronic heart failure (CHF).MethodsTwenty-seven patients, age 58±9years, NYHA II/III and LVEF 29±7% were randomly assigned to a 12-week AT (n=14) or a combined AT/RT/IMT (ARIS) (n=13) exercise program. AT consisted of bike exercise at 70–80% of max heart rate. ARIS training consisted of AT with RT of the quadriceps at 50% of 1 repetition maximum (1RM) and upper limb exercises using dumbbells of 1–2kg as well as IMT at 60% of sustained maximal inspiratory pressure (SPImax). At baseline and after intervention patients underwent cardiopulmonary exercise testing, echocardiography, evaluation of dyspnea, muscle function and quality of life (QoL) scores.ResultsThe ARIS program as compared to AT alone, resulted in additional improvement in quadriceps muscle strength (1RM, p=0.005) and endurance (50%1RM×number of max repetitions, p=0.01), SPImax (p<0.001), exercise time (p=0.01), circulatory power (peak oxygen consumption×peak systolic blood pressure, p=0.05), dyspnea (p=0.03) and QoL (p=0.03).ConclusionsARIS training was safe and resulted in incremental benefits in both peripheral and respiratory muscle weakness, cardiopulmonary function and QoL compared to that of AT. The present findings may add a new prospective to cardiac rehabilitation programs of heart failure patients whilst the clinical significance of these outcomes need to be addressed in larger randomised studies.

High systolic blood pressure (SBP) has been linked to worse cardiovascular outcomes. However, emerging data suggest that in patients with heart failure (HF), low SBP correlates with increased mortality. The purpose was to examine the impact of baseline and post-exercise systolic and diastolic blood pressure (DBP), as well as pulse pressure (PP), on cardiac mortality in patients with systolic HF. One hundred sixty patients with systolic HF (left ventricular ejection fraction 33 ± 8) were studied. Blood pressure (BP) levels were determined at rest and at peak exercise during a cardiopulmonary exercise test. Patients were followed up for a period of 2.5 ± 0.8 years. During this period 22 patients died and 5 subjects underwent heart transplantation. Patients with higher SBP and DBP at rest, and patients with SBP ≥160 mmHg and PP ≥75 mmHg at peak exercise had the most favorable prognosis. There was a fourfold increase in cardiac mortality risk for patients with SBP <160 mmHg at peak exercise (hazard ratio: 3.97, 95% confidence interval: 1.60–9.84) and a threefold increase for patients with PP <75 mmHg at peak exercise (hazard ratio: 2.96, 95% confidence interval: 1.29–6.82). There is an inverse relationship between SBP and cardiac mortality in patients with systolic HF. BP response to exercise could serve as a simple risk stratification model in HF patients.

High systolic blood pressure (SBP) has been linked to worse cardiovascular outcomes. However, emerging data suggest that in patients with heart failure (HF), low SBP correlates with increased mortality. The purpose was to examine the impact of baseline and post- exercise systolic and diastolic blood pressure (DBP), as well as pulse pressure (PP), on cardiac mortality in patients with systolic HF. One hundred sixty patients with systolic HF (left ventricular ejection fraction 33 ± 8) were studied. Blood pressure (BP) levels were determined at rest and at peak exercise during a cardiopulmonary exercise test. Patients were followed up for a period of 2.5 ± 0.8 years. During this period 22 patients died and 5 subjects under- went heart transplantation. Patients with higher SBP and DBP at rest, and patients with SBP C160 mmHg and PP C75 mmHg at peak exercise had the most favorable prognosis. There was a fourfold increase in cardiac mor- tality risk for patients with SBP \160 mmHg at peak exercise (hazard ratio: 3.97, 95% confidence interval: 1.60-9.84) and a threefold increase for patients with PP \75 mmHg at peak exercise (hazard ratio: 2.96, 95% confidence interval: 1.29-6.82). There is an inverse rela- tionship between SBP and cardiac mortality in patients with systolic HF. BP response to exercise could serve as a simple risk stratification model in HF patients.