Abstract Background Optimising exercise intensity is central to cardiovascular rehabilitation (CR), and emerging discussions emphasise that guideline-recommended intensities must truly reflect individual physiological responses to ensure a metabolic stimulus equivalent across individuals. The first and second ventilatory thresholds (VT1 and VT2) mark the transitions from low to moderate and moderate to vigorous exercise, respectively, providing a framework for personalised, metabolism-guided CR prescriptions. Purpose To assess the validity of the updated American Heart Association/ American Association of Cardiovascular and Pulmonary Rehabilitation (AHA/AACVPR) Scientific Statement (2024/2025) for recommended percentages of heart rate reserve (%HRR) for moderate-intensity cardiorespiratory exercise by comparing them with actual heart rate (HR) responses at ventilatory thresholds (VTs) in a large multicentre cohort of patients with cardiometabolic disease (CMD). Methods This retrospective study involved 12 centres across 9 countries. In 2,554 individuals with CMD who underwent cardiopulmonary exercise testing (CPET), HR at VT1 and VT2 were compared with values estimated by the AHA/AACVPR moderate-intensity range (40–59% HRR). Analyses comprised Wilcoxon tests, intraclass correlation coefficients (ICC), median absolute percentage error (MdAPE), and Bland–Altman plots. Results The cohort was predominantly male (79.2%), median age 63, with 71.7% having coronary artery disease, 22.5% HFrEF, and 75.3% on beta-blockers. HR at VT1 closely matched 40% HRR (P = .826), whereas HR at VT2 significantly exceeded 59% HRR (P < .001). ICCs were 0.844 (95% CI: 0.833–0.855) at the lower and 0.768 (95% CI: 0.053–0.915) at the upper limit, both classified as ‘good’. The wide CI at the upper limit indicated substantial inter-individual variability, and MdAPE and Bland–Altman analyses confirmed reduced accuracy and agreement at VT2. Conclusions The AHA/AACVPR recommended %HRR range for moderate-intensity exercise closely matched VT1, representing the lower limit of moderate intensity, but substantially underestimated VT2, the upper limit, in patients with CMD. Revising %HRR targets to better reflect CPET-derived ventilatory thresholds could improve exercise prescription, enhance clinical outcomes, and strengthen research validity.For image description, please refer to the figure legend and surrounding text. For image description, please refer to the figure legend and surrounding text.

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Abstract Background Physical activity is a key intervention for improving health outcomes across the continuum of heart failure with preserved ejection fraction (HFpEF). Despite its benefits, uptake and compliance remain limited. The PRIORITY trial was designed to evaluate the effectiveness of a partially supervised and remotely guided personalized exercise and physical activity intervention in patients with different stages of HFpEF. Purpose This sub-analysis of PRIORITY evaluates if differences in compliance to a hybrid exercise and physical activity intervention affects improvements in physical fitness in patients with HFpEF after the first phase (i.e. 4 months). Methods total of 156 HFpEF patients were randomized to the intervention group. All received a hybrid intervention combining 10 supervised sessions with a home-based remotely monitored (Garmin Forerunner S45) physical activity programme. Compliance in the first 4 months was assessed in 107 patients using weekly TRIMP (training volume × intensity across HR zones based on HR@VAT), and spectral clustering was applied. Physical fitness variables were measured at baseline (M0) and four months (M4) by means of cardiopulmonary exercise test. The Kruskal–Wallis test assessed differences between clusters at M0, M4 and for Δ (M4-M0), while paired t-tests evaluated within-group changes. Fisher’s exact test assessed associations between gender and HF stage. To examine differential responses over time, a two-way ANOVA was performed with Δ as the dependent variable and the cluster, HF stage and their interaction as factors. Finally, a linear mixed-effects models with time, cluster, and their interaction as fixed effects and patient ID as a random intercept was applied. Results Spectral clustering identified two clusters (Figure 1): 49 highly compliant and 58 low compliant, with mean TRIMP of 403 and 73, respectively. No differences in HFpEF stage, sex, age and VO2 peak were found between clusters. At baseline, compliant patients had lower HR at ventilatory anaerobic threshold (HR@VAT) (92.6±14.2 vs. 108.5±18.9 bpm, p < 0.0001). Regarding Δ, high compliant patients improved HR@VAT whereas low compliant patients showed a reduction (3.7±9.9, -5.35±16.7 bpm, p = 0.0005) (Table 1). ANOVA on Δ showed cluster-dependent changes in VO2VAT (absolute and relative), workload at VAT, and HR@VAT, with HF stage additionally affecting Δ VO2VAT and workload. A Cluster × HF-stage interaction was observed for predicted %VO2 measures. Mixed-effects models confirmed significant Time×Cluster interactions for VO2VAT, workload at VAT, and HR@VAT, indicating differing submaximal responses over time. Conclusion Higher compliance with the hybrid intervention was associated with greater short-term improvements in physical fitness. These findings highlight the importance of personalized exercise programs to enhance engagement. Longer follow-up is needed to determine the long-term impact of compliance on HFpEF outcomes.Figure 1For image description, please refer to the figure legend and surrounding text. Table 1For image description, please refer to the figure legend and surrounding text.

Abstract Background Cardiopulmonary exercise testing (CPET) provides the most accurate method for determining ventilatory thresholds (VT1 and VT2) and for guiding individualized aerobic exercise prescriptions. However, the limited availability of CPET restricts its routine use in clinical settings. When gas exchange analysis is unavailable, alternative approaches are needed to estimate heart rate (HR) at ventilatory thresholds. Purpose This study investigated whether incorporating resting echocardiographic indices with conventional exercise-derived predictors improves the accuracy of HR estimation at VT1 and VT2 in patients with cardiometabolic disease (CMD). Methods A cohort of 126 adults with CMD underwent CPET combined with resting echocardiography. Multivariate models were developed to predict HR at VT1 and VT2 using conventional parameters (resting HR and peak HR) and echocardiographic variables including left atrial volume index (LAVi), left ventricular end-diastolic volume index (LVEDVi), and E/e′ ratio. Results Previously developed predictive equations for estimating heart rate (HR) at ventilatory thresholds demonstrated strong performance: HR at VT1 = 4.866 + (0.405 × HR_peak) + (0.542 × HR_rest) (R² = 0.77) HR at VT2 = –2.606 + (0.773 × HR_peak) + (0.254 × HR_rest) (R² = 0.88) The integration of resting echocardiographic indices did not enhance HR prediction at VT1, while at VT2, inclusion of LVEDVi yielded only a minimal incremental improvement (R² = 0.839 vs. 0.832). Conclusion Although echocardiography remains essential for cardiac assessment in CMD, its contribution to predicting HR at ventilatory thresholds beyond resting and peak HR parameters are negligible. Predictive equations based solely on exercise-derived variables provide a practical alternative when CPET is unavailable.For image description, please refer to the figure legend and surrounding text.

Abstract Background/Introduction Chronotropic incompetence (CI) is common in individuals with heart failure with preserved ejection fraction (HFpEF). However, current CI definitions rely on only one or two time-point measurements during cardiopulmonary exercise testing (CPET). As a result, they do not capture the full complexity of the heart rate (HR) response throughout exercise. Moreover, many definitions depend on peak HR metrics, which are highly sensitive to patient effort and may therefore misclassify chronotropic dysfunction. Purpose To identify distinct HR phenotypes in HFpEF using clustering of the HR and oxygen consumption (ml/kg/min) trajectories during CPET, and to determine how these phenotypes relate to conventional CI parameters, HFpEF likelihood scores, and major adverse cardiovascular events (MACE). Methods We retrospectively analysed data from 341 individuals with HFpEF (stage A–C) undergoing CPET in two Belgian centres. For both HR and VO2/kg increase, regression models (y = a + b·time + c·age) generated age-adjusted residual time series. These residuals were clustered using dynamic time warping with k-medoids, stratified by β-blocker use. Clusters were compared on conventional CI measures, clinical characteristics, HFpEF likelihood scores (H2FPEF and the morphological and functional HFA-PEFF domains) analysed as continuous variables, and prediction of MACE (heart failure hospitalisation, acute coronary event, or cardiovascular death) after a median follow-up of 3 years. Results Among patients not taking β-blockers (n = 162), three distinct clusters were identified. Clusters did not differ in age, overall fitness or HFA-PEFF score. Patients in cluster 3 showed the poorest chronotropic response, presented with a markedly flatter HR–VO2 slope, worse conventional CI measures, higher BMI, and higher H2FPEF scores, as confirmed by a positive regression coefficient after adjustment for age and obesity (p = 0.002). This low-chronotropy cluster was predictive of MACE (HR 2.91, p = 0.038). In patients using β-blockers (n = 179), three clusters were also observed. Cluster 3, characterized by the weakest chronotropic response showed a similarly distinct pattern. The association with higher H2FPEF scores remained significant after adjustment (p = 0.023), and this cluster predicted MACE (HR 3.95, p = 0.032). Conclusion Distinct HR phenotypes can be identified in patients with HFpEF using time-series clustering of CPET data. This approach offers an age-independent and more comprehensive evaluation of chronotropic function. In both β-blocker users and non-users, the phenotype with the poorest chronotropic response consistently showed worse conventional CI parameters, higher H2FPEF scores, and an increased risk of MACE, underscoring the value of the full chronotropic response in assessing the HFpEF likelihood and risk stratification.The heart rate phenotypesFor image description, please refer to the figure legend and surrounding text. Characteristics of the HR phenotypesFor image description, please refer to the figure legend and surrounding text.

While interpreting the mechanisms underlying exercise limitation in cardiopulmonary exercise testing (CPET), oxygen pulse (O2pulse) is often assumed to be a surrogate for stroke volume (SV). However, in the rearranged Fick’s equation, O2pulse represents the product of SV and arteriovenous oxygen difference (a-vO2diff). Consequently, interpreting O2pulse exclusively as a reflection of SV can be misleading, as it disregards one of its key determinants. To assess the effort response of the determinants of O2pulse (SV and a-vO2Diff) by simultaneous CPET and echocardiography (CPETecho) or invasive CPET (iCPET). This observational study analysed the O2pulse in CPETecho and iCPET examinations conducted between July/15 and May/24. SV in CPETecho was measured using the ultrasound velocity time integral of the left ventricular outflow tract, and with VO2, a-vO2diff was calculated. For iCPET, a-vO2diff was directly measured using arterial and mixed-venous blood gas analyses, while SV was calculated. During CPETecho, measurements were taken at rest, intermediate, and peak exercise, whereas during iCPET, at rest, at 3, 6, 9 minutes, and at peak exercise. Variables were compared using one-way ANOVA with post hoc Tukey tests, with statistical significance set at p < 0.05. CPETecho: A total of 1,866 exams were analyzed (54.1% male; age: 65.4±13.9 y). The main indication was heart failure with preserved ejection fraction (HFpEF, 39.7%), valvular heart disease (35.5%), myocardial ischemia (6.3%), and others (18.5%). O2pulse increased significantly from rest to intermediate and peak (4.0±1.9, 9.0±3.3, and 10.9±3.9 mL/beat, respectively; p<.0001; Figure 1). SV increased from rest to intermediate load (70.2±18.1 vs. 84.5±20.9 mL/beat; p<.0001), with no further significant increase from intermediate to peak exercise (84.5±20.9 vs. 85.1±21.3 mL/beat; p=.07). In contrast, a-vO2 diff increased progressively from rest to intermediate and peak (p<.001). iCPET: A total of 68 exams were analyzed, primarily conducted in suspected HFpEF (age: 64.1±10.6 y). O2pulse increased progressively from rest to peak (p<.0001; Figure 2). SV significantly increased from rest to the 6-minute measurement, with no further significant changes thereafter. In contrast, a-vO2diff showed a continuous progressive increase from rest to peak exercise. Analysis of the determinants of O2pulse (SV and a-vO2diff) using both CPETecho and iCPET demonstrated that the increase in O2pulse from intermediate to peak exercise is primarily driven by a rise in a-vO2diff, while SV remains relatively constant. Therefore, in cardiac patients, changes in O2pulse should not be assumed to reliably reflect changes in SV alone but rather represent the combined effects of SV and peripheral oxygen extraction. For a definitive interpretation of the O2pulse response during exercise, performing measurement of either SV or a-vO2diff is essential.Figure 1.Variables measured by CPETechoFigure 2.Variables measuredf by iCPET

Cardiovascular and physical deconditioning are common in breast cancer patients undergoing chemotherapy, which can impact functional ability and quality of life (QoL). Physical activity interventions have shown promise in improving these outcomes. However, the impact of telerehabilitation during and after chemotherapy is not known. This pilot study investigated the feasibility and efficacy of remotely guided physical activity during and after chemotherapy on peak oxygen uptake (VO2peak) and QoL in breast cancer patients. Twenty breast cancer patients were randomized (non-stratified, non-matched) into intervention (n=10) and control (n=10) groups. The intervention group participated in remotely guided physical activity during and after chemotherapy, focusing on step count and minutes of moderate-to-vigourous physical activity (MVPA). Assessments were conducted at baseline (T0), post-chemotherapy (T1) and three months post-chemotherapy (T2), measuring VO2peak during exercise echocardiography (CPETecho) and health-related QoL (HRQoL) using FACT-B and FACIT-F. Analysis used linear mixed models (LMMs) and generalized pairwise comparison (GPC) to assess net treatment benefit (NTB). The intervention group completed questionnaires on satisfaction, implementability (acceptability, appropriateness, feasibility) and provided open responses. The intervention group showed a greater improvement in VO2peak from T0 to T2 (+0.7 ±2.7 mL/kg/min) compared to the control group ((+0.7 ±2.7 vs +0.2 ±3.5 mL/kg/min; p=0.55). For HRQoL, both the FACT-B and FACIT-F scores improved in the intervention group (+4.4 ±18.8 and +11.9 ±28.1 respectively), while the control group demonstrated a decrease in HRQoL scores (-3.6 ±18.1 and -6.3 ±19.67, respectively; p=0.19 and 0.12). The NTB for exercise capacity and QoL favored the intervention group. However, as this pilot study was not powered on clinical outcomes, these differences were not statistically significant. Patient-reported outcomes reflected high satisfaction (8.1/10 ±1.7) and implementability ratings (81.5% ±11). Qualitative feedback underscored the intervention's role in fostering trust, motivation, and psychological support, with participants valuing the personalized guidance, regular contact, and encouragement provided during challenging periods. This pilot study demonstrates that remotely guided physical activity during and after chemotherapy is both feasible and well-received by patients. Trends toward improved VO2peak and HRQoL in the 10 patients receiving the intervention were not statistically significant. The findings highlight the promise of telerehabilitation as a supportive intervention in cancer care, warranting further investigation in larger trials to determine its effectiveness and clinical benefits.Baseline characteristicsStudy outcome plots

The global rise in obesity—a chronic condition characterized by a body mass index (BMI) ≥30 kg/m²—significantly impacts health outcomes and healthcare expenditures. Regular physical activity offers significant health benefits, and tailoring exercise intensity using ventilatory thresholds (VTs) is the preferred strategy to enhance physical fitness, quality of life, and support weight management. To analyze heart rate (HR) responses at VTs in patients with obesity, comparing guideline-directed percentages of peak HR (%HRpeak) and HR reserve (%HRR), the recently adjusted-%HRR, and predictive equations for HR at first and second VTs (VT1 and VT2, respectively) developed for cardiometabolic diseases (CMD). An observational analysis of 860 cardiopulmonary exercise tests (CPETs) from patients with obesity at a center in Brazil was performed. Inclusion criteria: sinus rhythm, identification of both VTs, and respiratory exchange ratio ≥1.00. Measured HR at VTs were compared to estimates using guideline-ranges for moderate aerobic exercise (%HRpeak: 55–74%; %HRR: 40–69%)(1), adjusted-%HRR (42–77%)(2), and predictive equations [HR at VT1 = 4.866 + (0.405 x HRpeak) + (0.542 x HRrest); HR at VT2 = -2.606 + (0.773 x HRpeak) + (0.254 x HRrest)](2). Accuracy and agreement were assessed with mean absolute percentage error (MAPE) and Bland-Altman plots. Participants [median BMI 32.3 kg/m² (IQR 30.9–34.4), age 45 years (IQR 36–54), 65% males] presented with hypertension (33%), dyslipidemia (33%), and diabetes (7%). Median HR at VT1 was 117 bpm (IQR: 109, 126), and at VT2, 154 bpm (IQR: 141, 166). Estimated HR varied according to the method and MAPEs for VT1 were 21.1% (%HRpeak), 6.1% (%HRR), 6.0% (adjusted-%HRR), and 5.9% (equation). For VT2, MAPEs were 9.0% (%HRpeak), 8.7% (%HRR), 5.2% (adjusted-%HRR), and 5.3% (equation). Bland-Altman plots showed high dispersion at both VTs, with %HRpeak having the highest bias (Figures 1 and 2). At VT1, adjusted-%HRR and the predictive equation showed the lowest biases (-1.7 and -2.4 bpm, respectively), while guideline-directed %HRR had a comparable bias (-3.5 bpm). At VT2, biases were significantly higher for guideline-directed %HRR (-13.2 bpm) compared to adjusted-%HRR and the equation (-6.0 and -6.2 bpm, respectively). The measured %HRR at VT2 in this population (84%) exceeded the adjusted-%HRR from a prior study of patients with CMD (77%)(2). The adjusted-%HRR and individualized predictive equations provided the most accurate HR estimates at VTs in patients with obesity, outperforming guideline-directed %HRpeak and %HRR, especially at VT2, enhancing the precision of exercise intensity prescriptions. The %HRpeak method proved to be the least accurate by a significant margin. These findings offer insights into optimizing exercise intensity prescriptions, potentially enhancing the effectiveness of interventions in this population.

Abstract Background The respiratory system is not the limiting step to humans’ tolerance to dynamic exercise in most physiological circumstances. For instance, minute ventilation at peak exercise (VEpeak) is appreciably lower than the maximal sustained ventilatory capacity (MSVC). Using the estimated (from forced expiratory volume in one second (FEV1)) maximal voluntary ventilation (MVVest) as a surrogate of the MSVC, a peak breathing reserve (BRpeak= [1-(VEpeak /MVVest)] x 100) > 15% has been widely recommended as the decision node to rule out ventilatory limitation. Supportive evidence for this contention, however, stems from small samples tested on a cycle ergometer, an exercise modality associated with lower ventilatory demands than those elicited by treadmill - the commonest ergometer in cardiology. Purpose To determine the prevalence of ventilatory limitation to treadmill incremental cardiopulmonary exercise testing (CPET) based on BRpeak≤15% in a large sample of apparently healthy men and women showing a large age span. Methods We retrospectively analyzed treadmill CPET data from 3,544 apparently healthy individuals aged 20 to 80 years living in Midwest Brazil. As recommended by current guidelines(1-2), we multiplied FEV1 by 35 or 40. We established the prevalence of BRpeak≤15% in subjects stratified by sex and age (20-39, 40-59, and 60-80 years). Anticipating a high prevalence of low BRpeak using 35 or 40, we aimed to establish which coefficient should be used to multiplying FEV1 to decrease the prevalence of ventilatory limitation to ≤5% and ≤1% in each sex. Results BRpeak≤15% was found in 21.7% of women and 48.0% of men when FEV1 was multiplied by 35: corresponding values were 5.8% and 17.4% when the multiplying coefficient was 40, respectively (Figure 1). Regardless of sex, particularly high prevalence of BRpeak≤15% was found in the middle-aged group (Figure 2). Using 40.5 to multiply FEV1 in women and 45 in men resulted in ≤5% prevalence of ventilatory limitation. Further discriminative power (≤1% of BRpeak≤15%) required coefficients as high as 45 and 49 for women and men, respectively (Figure 2). Conclusion To avoid unacceptable high false positive rates for ventilatory limitation to incremental CPET on a treadmill (BRpeak≤15%), pre-exercise FEV1 should be multiplied by higher coefficients than those commonly recommended for cycle ergometer-based tests. This is particularly critical for men who reach high exercise intensities. Ever if appropriate coefficients are employed, BRpeak should be used with caution as the sole criterion to rule in or out a contribution of "the lungs" to exercise limitation in individual subjects(3).

Abstract Background/Introduction Physical activity in daily life (PADL) is a crucial factor influencing mortality and quality of life in individuals with cardiovascular diseases (CVDs). While previous research demonstrates notable differences in exercise habits and PADL levels between men and women in the general population, little is known about the patterns of PADL among men and women with CVDs. Purpose To compare PADL between men and women with coronary heart disease (CHD), heart failure with preserved ejection fraction (HFpEF), and peripheral artery disease (PAD). Methods This retrospective and cross-sectional analysis used baseline data from three exercise intervention studies. Participants were recruited between 2017 and 2023 at a University Hospital, were on optimal medical treatment and stable for at least four weeks. PADL was evaluated using validated activity monitors (ActiGraph GT9X Link or SenseWear Armband) with measurements deemed valid when participants recorded at least 3 weekdays and 1 weekend-day with a minimum of 10 hours of wear-time. Primary outcomes included the number of steps per day and the total amount of activity performed at least moderately (≥3METs) denoted as moderate-to-vigorous physical activity (MVPA). A two-way ANCOVA with Bonferroni post hoc test correction was conducted to examine the independent effects of sex and CVD diagnosis on PADL, after controlling for age, BMI and period of PADL assessment. The results are presented as mean differences, 95% confidence intervals (CI), and p-values. Results The analysis included 258 patients (age: 64±11 years, BMI: 28.7±4.5 kg/m²). Among them, 111 patients were diagnosed with CHD (80% men), 96 with HFpEF (51% men, 46% stage A, 30% stage B, 24% stage C) and 51 with PAD (75% men). Adjusted means and standard errors of steps and minutes of MVPA per day are presented in Figure 1. There was no statistically significant interaction between sex and CVD on steps per day (p = .181, partial η2 = .014). The main effect of CVD showed a statistically significant difference in adjusted mean steps per day which was lower for those with PAD (4,549 steps/day) versus those with CHD (12,239 steps/day), (-7,690 [95%CI, -9,785 to -5,594] steps/day, p = <0.001) and those with HFpEF (12,325 steps/day), (-7,776 [95%CI, -11,228 to -4,323] steps/day, p = <0.001). In contrast, there was a statistically significant interaction between sex and CVD on MVPA (p = .032, partial η2 = .027). The effect of sex in patients with PAD was not statistically significant (p = .517). The difference in adjusted mean MVPA was statistically significantly lower in men versus women with HFpEF (-22 [95%CI, -43 to -2] min/day, p = .035) and CHD (-44 [95%CI, -69 to -19] min/day, p < .001). Conclusion Our study reveals sex-related differences in PADL among patients with CVDs. Men with CHD or HFpEF exhibit lower MVPA in their daily life compared to women, emphasizing the need for tailored interventions to improve PADL. PADL Variation: Men vs. Women in CVDs.

Abstract Background Peak oxygen uptake (VO2peak), measured by cardiopulmonary exercise test (CPET), is an established variable for prognostic assessment. Other VO2peak-derived variables, such as the peak oxygen pulse (peakO2pulse), also provide valuable information for risk stratification in patients with cardiac diseases. For individualized assessment, the measured peakO2pulse can be compared to reference standards using predictive equations, such as the FRIEND Registry [peakO2pulse = 23.2 – (0.09 × Age) – (6.6 × Sex (female:1; male: 0)]. However, the applicabilty of this equation in a Brazilian population sample has never been evaluated. Purpose To conduct an external validation of the FRIEND registry prediction equation for treadmill peakO2pulse in a sample of healthy Brazilian individuals. Methods Cross-sectional study involving subjects assessed by treadmill CPET in the Brazilian Midwest region from January 2011 to March 2020. Inclusion criteria: healthy individuals aged ≥ 20 years with a peak respiratory exchange ratio ≥ 1.00. Exclusion criteria: history of cardiovascular or pulmonary disease, presence of cardiovascular risk factors (hypertension, diabetes mellitus, current smoking, and obesity), and abnormalities on CPET. Variables were described as median and interquartile range (IQR). Statistical comparisons between measured and predicted values were conducted using the Wilcoxon signed rank test, including the calculation of the median differences and the 95% confidence interval (CI). Furthermore, Bland-Altman agreement analysis was utilized to assess the concordance between measured and estimated values. Results A total of 7,843 CPETs were performed. After applying inclusion and exclusion criteria, 3,544 assessments were included (1,574 females and 1,970 males) aged between 20 to 80 years. In the females, the median and IQR of measured peakO2pulse and predicted values were 10.4 (9.0; 12.1) and 13.1 (12.3; 13.7) ml/beat, respectively. This difference was statistically significant (p < 0.001), with a median difference of 2.54 mL/beat (95% CI: 2.40; 2.69). For males, the measured and predicted values were 17.3 (15.1; 19.7) and 19.7 (19.0; 20.2) ml/beat, respectively. The median difference was statistically significant at 2.26 mL/beat (95% CI: 2.11; 2.46) (p < 0.001) (Figure 1). Bland-Altman agreement analysis indicated a bias of 2.33 mL/beat (95% limits of agreement: -2.17 to 6.83) in females and 2.15 mL/beat (95% limits of agreement: -4.34 to 8.65) in males (Figure 2). Conclusions The study reveals that measured median peakO2pulse values are consistently lower than predicted across both sexes, highlighting a significant bias, which limits the applicability of the FRIEND registry prediction equation in the Brazilian population and underscores the international heterogeneity of the variable. The findings advocate for the development of region-specific reference standards to enhance accuracy in predicting peakO2pulse values.

Abstract Introduction Adults with type 2 diabetes mellitus (T2DM) commonly present with a worse exercise capacity compared to their healthy peers. The underlying mechanisms of this exercise intolerance, such as impaired microcirculation and altered tissue oxygenation, remain to be elucidated. Purpose To evaluate the role of muscle oxygenation during exercise using near-infrared spectroscopy (NIRS) in adults with T2DM. Methods and analyses Data were collected from 60 adults with T2DM (36 men, 59 ± 10.21 years old) participating in the PROTECTION trial. A graded maximal cardiopulmonary exercise test was performed on a cycle ergometer (Vyntus CPX, Duomed) to assess exercise capacity, by means of V02peak. Concurrently, muscle oxygenation was measured in the vastus lateralis muscle, using NIRS (Portamon, Artinis). Changes in deoxyhemoglobin (HHb), reflecting oxygen utilization, and the tissue saturation index (TSI), reflecting the balance between oxygen delivery and utilization, were analysed, during both exercise and recovery. During exercise, changes in HHb were calculated from start to termination, whereas changes in TSI were computed from maximum to minimum value. During recovery, changes in HHb and TSI were calculated between the cessation of the exercise to the following 30 seconds. Adults with T2DM were then divided into four subgroups based on quartiles of exercise capacity. One-way ANOVA and chi-squared tests were used to evaluate differences between groups. Two-tailed p-values ≤0.05 were considered statistically significant. Results 34 adults with T2DM (57%) had poor-quality NIRS measurements. Poor quality measurements were more frequent among females (21 poor quality vs 3 good quality, p=0.002) and those with higher fat mass (poor quality 39.58 ± 8.04 % vs high quality 30.63 ± 6.23, p<0.001), despite similar body mass index (poor quality 30.86 ± 5.61 kg/m² vs high quality 30.08 ± 6.27 kg/m², p=0.612). 26 adults with T2DM (43%) had high-quality NIRS measurements which could be used in the final analysis. During exercise, no significant differences in changes in HHb and TSI could be observed among the four quartiles (p>0.05 for all) (Fig 1A and 1C). During recovery, adults with T2DM with the worst exercise capacity (Q1) showed significant smaller changes in HHb, compared to those with best exercise capacity (Q4) (p<0.05) (Fig 1B). Additionally, a trend towards a smaller increase of TSI in adults with T2DM with a poorer exercise capacity was found (Fig 1D). Conclusion These findings suggest a relationship between worsened reoxygenation after exercise and low V02peak, indicating that muscle oxygenation may affect exercise capacity. This highlights the need for further exploration into the use of NIRS in adults with T2DM. However, the high proportion of low quality measurements warrants further exploration on how the use of NIRS can be optimized in more obese clinical populations.

Abstract Background Physical activity plays a crucial role in cardiac rehabilitation for secondary prevention. Despite its importance, participation rates in cardiac rehabilitation programs remain low. Telemedicine, particularly telerehabilitation, presents a viable solution by offering remote access to cardiac rehabilitation services. This innovative approach has the potential to significantly enhance patient outcomes. Purpose This study aimed to assess the effectiveness of digital health intervention in improving physical activity in cardiac rehabilitation center. Methods A prospective randomised controlled trial was conducted, enrolling 80 eligible cardiac rehabilitation patients. Participants were 1:1 randomised into two groups: a 12-week center-based cardiac rehabilitation program (control group), and a 12-week center-based cardiac rehabilitation program combined with a digital health intervention (intervention group). This digital health intervention consists of smartphone, web, and tablet applications to monitor physical activity outside of rehabilitation sessions and motivate patients to engage in more physical activities. Results Of the initial 80 patients, 70 completed the study, and the results are presented in Table 1. In the intervention group, there was a statistically significant improvement in peak rate of oxygen consumption (VO2 peak) (p < 0.01) and peak power output (W peak) (p < 0.01), as measured by cardiopulmonary exercise testing between the end and the beginning of the study at the significance level of 0.05. Similar improvements were also observed in the control group (p = 0.0002 for VO2 peak and p < 0.01 for W peak). After 12 weeks of intervention, significant between-group differences were found: We observe a greater improvement in VO2 peak, on average 1.39 (95% CI: 0.23-2.54) ml/kg, and in W peak, on average, 12.29 (95% CI: 4.12-20.45), higher in the intervention group compared to the control group. Regarding physical activity, the intervention group showed a significant improvement in step count (P = 0.002), measured by an accelerometer, whereas no significant improvement was observed in the control group (P = 0.9714). There is a statistically significant difference in the change of step count between the intervention and control group at the significance level of 0.05. We observe a greater improvement, on average 14 788 steps (95% CI: 4 246 – 25 331), in the intervention group compared to the control group. Conclusion This study shows that a combination of a digital health intervention based telerehabilitation with a center-based cardiac rehabilitation is more effective in increasing patient’s exercise capacity and physical activity compared with a center-based cardiac rehabilitation.Table 1:results

Objective Tinnitus, the perception of sound without an external source, affects many adults, impacting quality of life. While factors like hearing loss and psychological distress are linked to tinnitus, the relationship with physical activity remains unclear. This study aimed to explore the association between physical activity, sedentary behaviour, and the presence of tinnitus. Design This study is a cross-sectional study. The participants completed the long form of the International Physical Activity Questionnaire. Adjusted logistic regression models were used to investigate associations between (components of) physical activity and the presence of tinnitus, and odds ratios (ORs) were calculated. Study SampleThis study involved 3004 participants (2751 tinnitus patients, 253 healthy controls). Results Engaging in moderate or vigorous-intensity physical activity during leisure time for more than 2.5 hours per week was associated with a reduced risk of having tinnitus (OR = 0.515, p < 0.001). Conversely, individuals who reported sitting for more than 7 hours per day had a significantly higher risk of having tinnitus (OR = 2.366, p < 0.001). Conclusions The study suggests a potential protective effect of leisure-time physical activity against tinnitus and highlights the importance of reducing sedentary behaviour. Further research is needed to confirm these findings and to understand underlying mechanisms.

Abstract Background An impressive amount of evidence exists on the effectiveness of guideline-based exercise for cardiac rehabilitation and secondary prevention. Also, studies show that exercise prescriptions are sub-optimal and not compliant with ESC/EAPC exercise guidelines. Decision support systems (DSS) for guideline-based exercise prescription, such as the EAPC endorsed EXPERT tool, have the potential to implement the guidelines in daily practice in an accessible way. This follows the assumption that a DSS for exercise prescription is readily adopted in clinical practice. Purpose While the general usability of the EXPERT tool has iteratively been studied and improved, no former study investigated its associated technology acceptance. The current study hypothesized that the technology acceptance of a DSS is influenced by internal and external factors, and by perceived barriers. Methods The technology acceptance (TA) study was embedded in a study on exercise prescription compliance, and on the training effect of the EXPERT tool. The intervention in this prospective, non-randomized intervention study was a one-month training with the EXPERT tool. At baseline and post-intervention, prescription compliance for three fictive patient cases with different complexity, with the ESC/EAPC guidelines was assessed. At the same points in time, questionnaires on TA (a modified TAM questionnaire) including possible barriers for adoption of clinical DSS, were presented to the participants. Results The current data analysis focused on findings in 24 participants that completed the study with the EXPERT training tool, out of 122 initial participants. All of them were Belgian physiotherapists, with varying experience. 15 participants (62.5%) were female, and the majority (66.7%) was younger than 31. 15 participants (62.5%) worked in a hospital, 5 of them were also involved in a private practice. No significant differences were found in responses to the TA questionnaire before and after the intervention. Significant negative correlations were found between the employment in a hospital and the "Perceived usefulness" (p=0.001), "Perceived ease of use" (p=0.019), "Attitude" (p=0.002) and "Subjective norm" (p=0.007). "Technological infrastructure in the workplace" was ranked as the main external barrier to usage of a DSS for guideline-based exercise prescription. Next on the list were "Time", "Evidence on the effectiveness of the system", "Organizational structure" and "Compatibility with standards of practice". The highest ranked internal barrier was "Experience" followed by "Familiarity" and "Knowledge". 16 out of 24 participants (66.7%) indicated that they are not aware of existing clinical DSS. Conclusion The results reveal that organizational factors and barriers are more decisive to technology acceptance than individual beliefs or technological attributes of the DSS. Aligning organizational practices with ESC/EAPC guidelines is essential and should be ambitioned.

Abstract Background Cardiopulmonary exercise testing (CPET) is the gold-standard for determining ventilatory thresholds (VTs) and prescribing exercise intensity for patients with cardiometabolic diseases (CMD). Multivariable equations to predict heart rate (HR) at the first and second VTs (VT1, VT2) offer a new alternative for indirect prescription when CPET is unavailable. However, there is still a need for external validation, and it is unknown if the equations are ergometer-specific. Purpose To externally validate and test the ergometer interchangeability of treadmill HR prediction equations for VTs in a large multicentric cycle-ergometer European database; to compare the agreement, accuracy, and reliability of the equations with the guideline-based recommendations. Methods Observational study of cycle-ergometer CPETs performed on CMD patients from eight European countries (Belgium, Denmark, France, Germany, Italy, Spain, the Netherlands, Switzerland). Inclusion criteria: sinus rhythm, identification of both VTs, and a respiratory exchange ratio ≥ 1.00. Measured HR at VT was compared to estimated values using the equations [HR at VT1 = 3.453 + (0.887 × HRpeak) – (0.555 × (HRpeak - HRrest)) + (1.044 × METpeak); HR at VT2 = - 8.256 + (0.979 × HRpeak) – (0.232 × (HRpeak - HRrest)) + (1.418 × METpeak)]. Accuracy, agreement, and reliability were assessed with Bland-Altman plots, mean absolute percentage error (MAPE), and intraclass correlation coefficient (ICC). Results were compared to European and Brazilian recommendations for moderate intensity according to the percentage of HRpeak and HR reserve (%HRpeak, %HRR). Results The analysis included 1,117 CPETs (81% males, median age: 69 years). Most had coronary artery disease (69%). The measured and estimated median HR differed between methods. Accuracy analysis showed a MAPE of 7.1% for VT1 and 5.6% for VT2. The results for %HRpeak recommendations revealed lower accuracy, with MAPE ranging from 10.8 to 26.3% for VT1 and 7.1 to 17.2% for VT2, while the results for %HRR were similar to the equation for VT1 (6.4 to 7.4%) and VT2 (5.1 to 5.7%). The %HRpeak method also showed the lowest values for ICC and the highest bias in Bland-Altman plots. The equations exhibited agreement and reliability similar to the %HRR methods (Figures 1 and 2). Thus, despite being developed for the treadmill, the prediction equations showed clinically acceptable accuracy, agreement, and reliability in a cycle ergometer sample. Conclusion The prediction equations for HR at VTs were externally validated and revealed ergometer interchangeability in a large multicentric European database. The %HRpeak method showed higher inaccuracy and lower reliability, raising concerns about its clinical applicability. The %HRR method had similar accuracy and reliability to the equations. Thus, prescribing exercise intensity using two variables (HRpeak and HRrest), by both %HRR or the equations, is an appropriate method when CPET is unavailable.

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): FWO - Research Foundation – Flanders. Background Exercise is a key therapy for patients across all the stages of heart failure with preserved ejection fraction (HFpEF). Despite being a class I recommendation, the EUROASPIRE registry showed that only a third of patients is sufficiently active, with numbers being even lower among patients with symptomatic HFpEF (stage C). Knowledge of barriers and confidence to exercise is needed to increase the uptake of exercise and a physically active lifestyle. Objective To assess barriers to exercise and self-efficacy in patients along the continuum of HFpEF and to detect possible differences between patients in different HFpEF stages. Methods The first 60 patients (n = 20 HFpEF stage A, 20 HFpEF stage B, 20 HFpEF stage C) from the PRIORITY randomized controlled trial (PeRsonalIzed remOtely guided preventive exeRcIse therapy for a healThY heart) were included. Barriers to exercise and self-efficacy were evaluated using the Exercise Barrier Questionnaire and the Exercise Self-Efficacy Scale. Results Patients with HFpEF stage C were older (72 ± 9.41 years), more likely to be female (70%) and were less physically fit (peak VO2 14.09 ± 2.58 ml/min/kg) compared to patients with HFpEF stage A (63.5 ± 9.10 years, 40% women and peak VO2 21.43 ± 4.94 ml/min/kg) and stage B (70.5 ± 5.25 years, 40% women and peak VO2 17.84 ± 5.15 ml/min/kg). As shown in Figure 1, patients with HFpEF stage C reported more barriers to exercise compared to patients with HFpEF stage A or HFpEF stage B. In particular, 50% of HFpEF stage C reported that they would not exercise when they perceived the exercise as boring (vs A:21%, B:22%), not fun (vs A: 21%, B:21%), if supervised by a bad instructor (vs A:32%, B:33%) or during holidays (vs A:26%, B:17%). Almost 40% of patients with HFpEF stage C reported that having to exercise alone would be a barrier for them (vs A:11%, B:22%). As shown in Figure 2, patients with HFpEF stage C were less confident that they 1) could overcome barriers to exercise by finding appropriate exercise resources (A:0%, B:6%, C:11%), 2) would exercise when feeling tired (A:5%, B:24%, C:28%), 3) would exercise without family support (A:5%, B:6%, C: 17%) or 4) without professional support (A:11%, B:18%, C:17%). Conclusion Barriers to exercise and self-efficacy were rated differently by the 3 stages of HFpEF. Patients with more advanced stages of HFpEF experienced more challenges to be physically active.

ABSTRACT Background Exercise prescriptions by clinicians to patients with cardiovascular disease (CVD) often disagree with recommendations, thus requiring improvement. Aim To assess whether exercise prescriptions by physiotherapists to patients with CVD are better in agreement with European (ESC/EAPC) recommendations when the EXPERT (EXercise Prescription in Everyday practice & Rehabilitative Training) Training tool is used for digital educational training. Design In a prospective non-randomized intervention study. Methods Twenty-three belgian physiotherapists first prescribed exercise intensity, frequency, session duration, program duration and exercise type (endurance or strength training) for the same three patient cases, from which the agreement with ESC/EAPC recommendations (based on a maximal score of 60/per case: agreement score) was assessed. Next, they completed a one-month digital training by using the EXPERT Training tool and completed 31 ± 13 training cases. The EXPERT tool is a training and decision support system that automatically generates a (personalised) exercise prescription according to the patient’s characteristics, thus integrating the exercise prescriptions for different CVDs and risk factors, all based on ESC/EAPC recommendations. Thereafter, the same three patient cases as at entry of study were filled out again, with re-assessment of level of agreement with ESC/EAPC recommendations. Results After using the EXPERT Training tool, the physiotherapists prescribed significantly greater exercise frequencies, program durations and total exercise volumes in all three patient cases (p < 0.05). In cases 1, 2 and 3, the agreement score increased from 29 ± 9 (out of 60), 28 ± 9, and 34 ± 7 to 41 ± 9, 41 ± 10, and 45 ± 8, respectively (p < 0.001). Hence, the total agreement score increased from 91 ± 17 (out of 180) to 127 ± 19 (p < 0.001, +44 ± 32%). A lower starting agreement score and younger age correlated with a greater improvement in total agreement score (p < 0.05). Conclusions Exercise prescriptions to patients with CVD, generated by physiotherapists, are significantly better in agreement with European recommendations when the EXPERT Training tool is used, indicating its educational potential.

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the Flemish Research Fund (FWO, FWO-ICA: G0F4220N). Background Exercise prescriptions by clinicians to patients with cardiovascular disease (CVD) often disagree with recommendations, thus requiring improvement. Aim To assess whether exercise prescriptions by clinicians to patients with CVD are better in agreement with ESC/EAPC recommendations when the EXPERT Training tool is used for digital training. Design: Prospective non-randomized intervention study. Methods Twenty-three Belgian physiotherapists first prescribed exercise intensity, frequency, session duration, program duration and exercise type (endurance or strength training) for the same three patient cases, from which the agreement with ESC/EAPC recommendations (based on a maximal score of 60/per case: agreement score) was assessed. Next, they completed a one-month digital training by using the EXPERT Training tool and completed 31±13 (out of 45 available) training cases. Thereafter, the same three patient cases as at entry of study were filled out again, with re-assessment of level of agreement with ESC/EAPC recommendations. Results After using the EXPERT Training tool the clinicians’ prescribed significantly greater exercise frequencies, program durations and total exercise volumes in all three patient cases (p<0.05). In case 1, 2 and 3, the agreement score increased from 29±9 (out of 60) to 41±9, from 28±9 to 41±10, and from 34±7 to 45±8, respectively (p<0.001). Hence, the total agreement score increased from 91±17 (out of 180) to 127±19 (p<0.001, +44±32%). A lower starting agreement score and younger age correlated significantly with a greater improvement in total agreement score (p<0.05). Conclusions Exercise prescriptions to patients with CVD, generated by clinicians, are significantly better in agreement with ESC/EAPC recommendations when the EXPERT Training tool is used.

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Hasselt University Background Adding resistance training on top of endurance training is recommended in the rehabilitation of patients with heart failure. However, it is unknown which intensity of resistance training should be preferred. Purpose To compare the effects of the addition of high- vs. low-intensity resistance training on top of endurance training in patients with heart failure. Methods Nineteen patients with heart failure were block randomized (by gender and sex) in a combined high-intensity resistance and endurance group (HIG; n=8, age=61±12y, 7 males, LVEF=38±10%) vs. combined low-intensity resistance and endurance group (LIG; n=9, age=68±21y, 8 males, LVEF=38±13%). Patients trained 3x/week for 45 sessions. The resistance exercises were volume-matched between groups and consisted of three sets of leg press, pull down and dip exercises, separated by 30s of rest, done at 55-70% 1RM in HIG vs. 35-40% 1RM in LIG. Both groups did moderate-intense endurance training on a bicycle, cross-trainer, treadmill and arm ergometer for 30 min per training. Maximal oxygen consumption was evaluated with an incremental cardiopulmonary cycling test and muscle strength by 1-RM testing, while quality of life was assessed with the Minnesota questionnaire, and walking distance by a 6-minute walking test. Mann-Whitney U test was used for analyzing differences between groups in all variables and Wilcoxon signed-rank test for evaluating pre-post difference of the entire sample. P values <0,05 (2-tailed) were considered statistically significant. Results Training adherence was similar in both groups (LIG vs HIG: 41±6 vs 37±9 sessions, p=0,370; Table 1). Overall, the intervention improved maximal oxygen consumption, walking capacity and muscle strength (p<0,05), but the between-group changes in maximal oxygen consumption (LIG vs HIG: 3±2 vs 3±4 ml/kg/min, p=0,963), quality of life (LIG vs HIG: -8±23 vs -1±5 points, p=0,931) and muscle strength (LIG vs HIG: Dip 34±34 vs 18±20kg, p=0,481; Leg press, 66±87 vs 47±53kg, p=0,486; Pull down, 9±6 vs 9±7kg, p=0,574) were similar. Conclusion Adding either high- or low-intensity resistance training on top of endurance training seems equally effective for improving aerobic capacity and walking performance in patients with heart failure. The study is ongoing.