BACKGROUND:Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients' groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well.METHODS:Generation of evidence and search of literature have been described in part 1.RESULTS:Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for "distress management" and "lifestyle changes". PE is able to increase patients' knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients' groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR.CONCLUSIONS:ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Belastungsinduzierte Dyspnoe und reduzierte körperliche Leistungsfähigkeit sind Schlüsselsymptome der Herzinsuffizienz. Deshalb sollten Sie Ihre Patienten zu regelmäßiger körperlicher Aktivität und Training motivieren. Und auch die richtige Kost zeigt positive Effekte.

Via a postal survey of patients, three months after their hospital stay at a cardiologic and orthopaedic rehabilitation clinic, the importance that they place on pastoral care in the rehabilitation process was investigated. The answers of the respondents show that the experiences of empathy, security, comfort, and of being understood and noticed are particularly helpful in pastoral care. The effect of pastoral care is described by most as a help for the integration of sickness in life. Clinical pastoral care is once again proven through this investigation as a useful addition in the course of treatment, because it introduces a dimension to the healing process that has elements of finding meaning, overcoming fear and stabilising self-esteem, which are important for coping positively with the illness.

Background: Chronic kidney disease (CKD) is a frequent comorbidity among elderly patients and those with cardiovascular disease. CKD carries prognostic relevance. We aimed to describe patient characteristics, risk factor management and control status of patients in cardiac rehabilitation (CR), differentiated by presence or absence of CKD.Design and methods: Data from 92,071 inpatients with adequate information to calculate glomerular filtration rate (GFR) based on the Cockcroft-Gault formula were analyzed at the beginning and the end of a 3-week CR stay. CKD was defined as estimated GFR <60 ml/min/1.73 m(2).Results: Compared with non-CKD patients, CKD patients were significantly older (72.0 versus 58.0 years) and more often had diabetes mellitus, arterial hypertension, and atherothrombotic manifestations (previous stroke, peripheral arterial disease), but fewer were current or previous smokers had a CHD family history. Exercise capacity was much lower in CKD (59 vs. 92Watts). Fewer patients with CKD were treated with percutaneous coronary intervention (PCI), but more had coronary artery bypass graft (CABG) surgery. Patients with CKD compared with non-CKD less frequently received statins, acetylsalicylic acid (ASA), clopidogrel, beta blockers, and angiotensin converting enzyme (ACE) inhibitors, and more frequently received angiotensin receptor blockers, insulin and oral anticoagulants. In CKD, mean low density lipoprotein cholesterol (LDL-C), total cholesterol, and high density lipoprotein cholesterol (HDL-C) were slightly higher at baseline, while triglycerides were substantially lower. This lipid pattern did not change at the discharge visit, but overall control rates for all described parameters (with the exception of HDL-C) were improved substantially. At discharge, systolic blood pressure (BP) was higher in CKD (124 versus 121 mmHg) and diastolic BP was lower (72 versus 74 mmHg). At discharge, 68.7% of CKD versus 71.9% of non-CKD patients had LDL-C <100 mg/dl. Physical fitness on exercise testing improved substantially in both groups. When the Modification of Diet in Renal Disease (MDRD) formula was used for CKD classification, there was no clinically relevant change in these results.Conclusion: Within a short period of 3-4 weeks, CR led to substantial improvements in key risk factors such as lipid profile, blood pressure, and physical fitness for all patients, even if CKD was present.

AIM:Metabolic syndrome (MetS) is a clustering of factors that are associated with increased cardiovascular risk. We aimed to investigate the proportion of patients with MetS in patients undergoing cardiac rehabilitation (CR), and to describe differences between patients with MetS compared to those without MetS with regard to (1) patient characteristics including demographics, risk factors, and comorbidities, (2) risk factor management including drug treatment, and (3) control status of risk factors at entry to CR and discharge from CR.METHODS:Post-hoc analysis of data from 27,904 inpatients (Transparency Registry to Objectify Guideline-Oriented Risk Factor Management registry) that underwent a CR period of about 3 weeks were analyzed descriptively in total and compared by their MetS status.RESULTS:In the total cohort, mean age was 64.3 years, (71.7% male), with no major differences between groups. Patients had been referred after a ST elevation of myocardial infarction event in 41.1% of cases, non-ST elevation of myocardial infarction in 21.8%, or angina pectoris in 16.7%. They had received a percutaneous coronary intervention in 55.1% and bypass surgery (coronary artery bypass graft) in 39.5%. Patients with MetS (n = 15,819) compared to those without MetS (n = 12,085) were less frequently males, and in terms of cardiac interventions, more often received coronary artery bypass surgery. Overall, statin use increased from 79.9% at entry to 95.0% at discharge (MetS: 79.7% to 95.2%). Patients with MetS compared to those without MetS received angiotensin converting enzyme inhibitors, angiotensin receptor blockers, oral antidiabetics, and insulin at entry and discharge more frequently, and less frequently clopidogrel and aspirin/clopidogrel combinations. Mean blood pressure was within the normal range at discharge, and did not differ substantially between groups (124/73 versus 120/72 mmHg). Overall, between entry and discharge, levels of total cholesterol, low density lipoprotein cholesterol, and triglycerides were substantially lowered, in particular in MetS patients. Thus, control rates of lipid parameters improved substantially, with the exception of high density lipoprotein cholesterol. Low density lipoprotein cholesterol rates <100 mg/dL increased from 38.7% at entry to 73.8% at discharge (MetS: from 39.4% to 74.6%) and triglycerides control rates (<150 mg/dL) from 58.1% to 70.4% (MetS: 43.7% to 62.2%). Physical fitness on exercise testing improved substantially in both groups.CONCLUSION:Patients with and without MetS benefited substantially from the participation in CR, as their lipid profile, blood pressure, and physical fitness improved. Treatment effects were similar in the two groups.

BACKGROUND:Anxiety and depression are often found in cardiac patients, but also in the general population. Therefore, evaluation of these symptoms in patients requires a comparison with norm values. The purpose of this study was to explore differences between cardiac patients and the general population in age dependency of anxiety and depression, and to discuss possible reasons for these differences.METHODS:A sample of German cardiac patients (n = 2,696) and a sample of the German general population (n = 2,037) were tested using the Hospital Anxiety and Depression Scale (HADS).RESULTS:While we confirmed a linear age trend of anxiety and depression in the general population, we observed an inverted U-shaped age dependency in the patient sample. Young patients are especially affected by anxiety and depression. Five items of the HADS that mainly contributed to the age differences were identified. Formal characteristics of these 5 items could not explain the age differences. Concerning the meaning of the items, however, most of the items refer to worrying about the future.CONCLUSIONS:The relatively low rates of anxiety and depression in older patients (compared with the general population) indicate that adaptation processes took place, which should be taken into account in studies concerning the psychological status of patients. Young patients need special attention when dealing with mental distress.

Zusammenfassung. Die vorliegende Studie wählt erstmalig einen gesundheitsverhaltenstheoretischen Ansatz zur Untersuchung der Herzgruppenteilnahme und untersucht mit der Wahl des sozial-kognitiven Prozessmodells gesundheitlichen Handelns die Annahmen dieses Stadienmodells erstmalig für die Teilnahme an einem Aktivitätsprogramm. Geprüft werden die Annahmen, dass sich die drei Stadien Motivation, Intention und Handlung für eine regelmäßige Herzgruppenteilnahme sechs Monate nach Entlassung aus einer stationären kardiologischen Phase II Rehabilitation finden lassen und dass Risikowahrnehmung, Konsequenz- und Selbstwirksamkeitserwartungen stadienspezifisch bedeutsam sind (Diskontinuitätshypothese). Die Stichprobe stammt aus dem 6-Monats Follow-up der CARO II Studie (N = 640). Die Ergebnisse bestätigen die Diskontinuitätshypothese für Risikowahrnehmung, negative Konsequenzerwartungen sowie für Selbstwirksamkeitserwartungen. Positive Konsequenzerwartungen hingegen steigen linear über die drei Stadien an. Zusammenfassend liefert die Studie einen ersten Hinweis darauf, dass dieses (Inanspruchnahme-)Verhalten als dynamischer Verhaltensänderungsprozess auf Grundlage des sozial-kognitiven Prozessmodells gesundheitlichen Handelns beschrieben werden kann und eine stadienspezifisch zugeschnittene Intervention zur Förderung der Herzgruppenteilnahme Erfolg versprechend ist.

The purpose of this review is to give an overview of the rehabilitation measures provided for cardiac patients in Germany and to outline its legal basis and outcomes. In Germany the cardiac rehabilitation system is different from rehabilitation measures in other European countries. Cardiac rehabilitation in Germany since 1885 is based on specific laws and the regulations of insurance providers. Cardiac rehabilitation has predominantly been offered as an inpatient service, but has recently been complemented by outpatient services. A general agreement on the different indications for offering these two services has yet to be reached. Cardiac rehabilitation is mainly offered after an acute cardiac event and bypass surgery. It is also indicated in severe heart failure and special cases of percutaneous coronary intervention. Most patients are men (>65%) and the age at which events occur is increasing. The benefits obtained during the 3-4 weeks after an acute event, and confirmed in numerous studies, are often later lost under 'usual care' conditions. Many attempts have been made by rehabilitation institutions to improve this deficit by providing intensive aftercare. One instrument set up to achieve this is the nationwide institution currently comprising more than 6000 heart groups with approximately 120 000 outpatients. After coronary artery bypass grafting or acute coronary syndrome cardiac rehabilitation can usually be started within 10 days. The multidisciplinary rehabilitation team consists of cardiologists, psychologists, exercise therapists, social workers, nutritionists and nurses. The positive effects of cardiac rehabilitation are also important economically, for example, for the improvement of secondary prevention and vocational integration.

Aims Risk stratification is important for decisions about the intensity of treatment in primary prevention. Risk factors and lifestyle factors are responsible for over 80% of cardiovascular morbidity and mortality. However, body mass index (BMI), physical activity and smoking (cigarettes/day) are not or not quantitatively represented in the risk stratification system. Methods and results CARdiovascular RISk MAnagement (CARRISMA) is a software program considering the prognostic impact of BMI, physical activity and cigarettes per day adjusted for age and sex based on multivariate regression analyses from the literature on top of one of the three major scores to improve risk stratification. The 10-year European Society of Cardiology Systematic COronary Risk Evaluation (SCORE) cardiovascular mortality risk for an intermediate risk region, e.g. increases from 3 to 6% by considering smoking of 30 cigarettes per day instead of just ‘smoking’ and by taking into account a BMI of 34. Whereas the 10-year ESC cardiovascular mortality risk of a 55-year-old active individual decreases from 5 to 3%, by considering a physical activity equivalent of 2100 kcal/week, the Framingham or PROspective CArdiovascular Munster (PROCAM) risks change accordingly. Conclusion CARRISMA facilitates the application of knowledge of the current literature in the individual patient in a user-friendly manner allowing a more detailed and yet time-efficient risk stratification and risk management in primary prevention, particularly in the intermediate risk range. Eur J Cardiovasc Prev Rehabil 14: 141-148 © 2007 The European Society of Cardiology

The purpose of this review is to give an overview of the rehabilitation measures provided for cardiac patients in Germany and to outline its legal basis and outcomes. In Germany the cardiac rehabilitation system is different from rehabilitation measures in other European countries. Cardiac rehabilitation in Germany since 1885 is based on specific laws and the regulations of insurance providers. Cardiac rehabilitation has predominantly been offered as an inpatient service, but has recently been complemented by outpatient services. A general agreement on the different indications for offering these two services has yet to be reached. Cardiac rehabilitation is mainly offered after an acute cardiac event and bypass surgery. It is also indicated in severe heart failure and special cases of percutaneous coronary intervention. Most patients are men (>65%) and the age at which events occur is increasing. The benefits obtained during the 3-4 weeks after an acute event, and confirmed in numerous studies, are often later lost under ‘usual care’ conditions. Many attempts have been made by rehabilitation institutions to improve this deficit by providing intensive aftercare. One instrument set up to achieve this is the nationwide institution currently comprising more than 6000 heart groups with approximately 120 000 outpatients. After coronary artery bypass grafting or acute coronary syndrome cardiac rehabilitation can usually be started within 10 days. The multidisciplinary rehabilitation team consists of cardiologists, psychologists, exercise therapists, social workers, nutritionists and nurses. The positive effects of cardiac rehabilitation are also important economically, for example, for the improvement of secondary prevention and vocational integration.

Patienten ärztlich überwacht körperlich aktiv sind. Durch die neue Gesetzgebung besteht ein Rechtsanspruch auf die AHG-Teilnahme. Die Kostenträger übernehmen die Finanzierung (6,00 Euro pro Übungseinheit) für 90 Übungseinheiten. Danach wird dem Patienten die Teilnahme auf eigene Kosten empfohlen. Derzeit nehmen nur 13–40% aller berechtigten Patienten das Angebot der AHG-Teilnahme wahr. In einem neuen Positionspapier zur AHG wurde das etablierte Konzept AHG unter Berücksichtigung veränderter gesetzlicher und vertraglicher Vorgaben weiterentwickelt und zukunftweisend konkretisiert. Die AHG-Träger müssen ihr Angebot der neuen Gesetzgebung und den damit verbundenen Veränderungen anpassen. Neben notwendigen Änderungen der Struktur- und Prozessqualität ist die „Eröffnung“ der AHG für neue und/oder bis jetzt vernachlässigte Patientengruppen (z. B. Frauen, alte Patienten, Herzinsuffizienzpatienten, junge Erwachsene mit angeborenen Herzfehlern) vorrangig. Ergebnisse einer Fall-Kontroll-Studie, die die Langzeitwirkung der AHG-Teilnahme untersuchte, wiesen neben einer Verbesserung der körperlichen Leistungsfähigkeit eine Reduktion der kardialen Morbidität um 54% sowie der Behandlungskosten um ca. 47% nach. Eine weitere Überprüfung der Ergebnisqualität durch qualitativ anspruchsvolle Untersuchungen ist dringend erforderlich.

Currently, more than 6,600 heart groups (AHGs) have been established in Germany, in which more than 110,000 patients are physically active. Following cardiac rehabilitation (CR) after an acute event, in the AHG patients aim to meet the set rehabilitation goals in groups of about 15-20 patients, instructed by a competent exercise therapist and attended by a physician. While physical activity has been the dominant aspect thus far, psychosocial and educative elements are now more strongly integrated to stabilize secondary prevention. According to the German rehabilitation law, the patient is legally entitled to participate in AHGs. The insurance companies pay 6.00 Euros for go therapeutic units at 60-90 min each. Thereafter, the patient should be encouraged to continue participation at his/her own cost. The opportunity to participate in AHG is not yet sufficiently responded to by the patients. According to different studies, only 13-40% of all patients attend an AHG after phase 11 CR. In future, special emphasis has to be placed on the recruitment of more patients into AHGs, especially those groups which are known to be underrepresented (e.g., women, old patients, patients with low socioeconomic status). Furthermore, AHGs have to be established for patients with special needs, e.g., heart failure patients or young grown-ups with congenital heart diseases. until now, the efficiency of AHG participation has not been sufficiently investigated. In a case-control study analyzing the long-term results of AHG participation, an improvement in physical performance as well as a reduction of cardiovascular morbidity (54%) and medical costs (approximately 47%) were observed. In future, more high-class investigations on this field are needed.