INTRODUCTION:Despite the strong recommendations and obvious benefits, cardiac rehabilitation remains underutilised or is often discontinued in real-world practice. To improve patient care, a hybrid (mix of home and centre) program (Read'Hy) has been developed, combining exercise training sessions and therapeutic education, with weekly face-to-face follow-up. METHODS:After a check-up and minimum five days initiation in the centre, patients returned home, equipped with a heart rate monitor and a mobile application. A personalised 10-week program was drawn up. Asynchronous home exercise was recorded and analysed daily by the rehabilitation technician. Each week, the patient came back to the centre for a supervised training session and interviews allowing to adjust the program. RESULTS:Out of 353 patients (mean age 55±11 years), 89% completed the program with 91% attendance and 35 physical activity sessions performed. Peak VO2 increased by 20% (21.8 to 26.1 ml/min/kg, p<0.0001), as did VO2 at point of intersection (16.6 to 19.9 ml/min/kg, p<0.0001) and maximum workload (140 to 168 Watts, p<0.0001). Only one rhythmic event was reported. Quality of life improved (VAS +14%, p<0.0001), and weekly physical activity quantified by IPAQ-SF increased by 53% (p<0.0001). After one year, IPAQ-SF remained 43.6% higher than the initial level (p<0.0001). CONCLUSION:This hybrid program, both safe and effective, promotes the sustainable integration of physical activity into daily life.

Introduction Despite the strong recommendations and obvious benefits, cardiac rehabilitation remains underutilised or is often discontinued in real‐world practice. To improve patient care, a hybrid (mix of home and centre) program (Read'Hy) has been developed, combining exercise training sessions and therapeutic education, with weekly face-to-face follow-up. Methods After a check-up and minimum five days initiation in the centre, patients returned home, equipped with a heart rate monitor and a mobile application. A personalised 10-week program was drawn up. Asynchronous home exercise was recorded and analysed daily by the rehabilitation technician. Each week, the patient came back to the centre for a supervised training session and interviews allowing to adjust the program. Results Out of 353 patients (mean age 55±11 years), 89% completed the program with 91% attendance and 35 physical activity sessions performed. Peak VO2 increased by 20% (21.8 to 26.1 ml/min/kg, p<0.0001), as did VO2 at point of intersection (16.6 to 19.9 ml/min/kg, p<0.0001) and maximum workload (140 to 168 Watts, p<0.0001). Only one rhythmic event was reported. Quality of life improved (VAS +14%, p<0.0001), and weekly physical activity quantified by IPAQ-SF increased by 53% (p<0.0001). After one year, IPAQ-SF remained 43.6% higher than the initial level (p<0.0001). Conclusion This hybrid program, both safe and effective, promotes the sustainable integration of physical activity into daily life.

Introduction La maladie coronarienne reste une des premières causes de morbi-mortalité, et est responsable d'un coût social important. La reprise du travail est un objectif essentiel quand cette pathologie concerne les patients en activité professionnelle. Les données françaises restent parcellaires et relativement anciennes. Le GERSP (Groupe Exercice Réadaptation Sport et Prévention) de la Société Française de Cardiologie a proposé une étude multicentrique afin d'actualiser ces données. Méthodes Au décours d'un syndrome coronarien aigu, l’équipe cardiologique proposait au patient qui était en activité professionnelle de répondre à un questionnaire portant sur la pathologie, la profession et le projet de reprise. Un entretien au-delà de 6 mois permettait d'analyser la situation clinique et professionnelle du patient, afin d’étudier les facteurs associés à la reprise du travail. Résultats Entre 2018 et 2019, 364 patients ont été inclus dans 6 centres interventionnels et 17 centres de réadaptation cardiaque. Le taux de reprise était de 81 % (n = 295), dont 93 % dans le même poste, dans un délai moyen de 106 ± 56 jours. Les facteurs indépendants de non-reprise étaient sur le plan cardiologique la fraction d’éjection ventriculaire gauche, la présence d'un anticoagulant, un angor ou une insuffisance cardiaque, et sur le plan professionnel un travail posté, l'exposition au froid et les cadences imposées. Les facteurs d'allongement du délai de reprise étaient le retard d'accès à la réadaptation, le port de charges lourdes, les positions difficiles, les cadences imposées, mais également l'absence de projet du patient, l'absence d'avis du cardiologue et la demande d'aménagement du poste de travail. Conclusion Le taux de reprise du travail reste assez stable malgré l’évolution de la prise en charge de la maladie, et le délai de reprise relativement élevé. Une piste pour améliorer la situation consiste à améliorer l'accès aux programmes de réadaptation cardiaque, en proposant par exemple des alternatives comme la télé-réadaptation pour une partie des patients. Cela permettra de consacrer plus de temps aux patients plus sévères afin de mieux les préparer physiquement et psychologiquement à la reprise du travail, ce qui aura également un effet bénéfique économique.

INTRODUCTION:Coronary heart disease remains one of the leading causes of morbidity and mortality, and is responsible for significant social costs. Resumption of work is an essential objective when this pathology concerns working patients. French data remain patchy and relatively old. The French Society of Cardiology's Exercise, Rehabilitation, Sport and Prevention Group has proposed a multicentre study to update these data. METHODS:Following an acute coronary syndrome (ACS), the cardiology team asked the patient, who was currently working, to complete a questionnaire on his or her pathology, occupation and plans to return to work. An interview after 6 months enabled the clinical and professional situation of the patient to be analyzed, in order to study the factors predictive of a return to work. RESULTS:364 patients were included in 6 interventional and 17 cardiac rehabilitation centres between 2018 and 2019. The resumption rate was 81% (n = 295), 93% of them in the same position, with a mean delay of 106 ± 56 days. The cardiologic independent factors for non-return were left ventricular ejection fraction, the presence of an anticoagulant, angina or heart failure, and occupational factors, shift work, exposure to cold, and imposed work rates. Factors that lengthened the time taken to return to work included delayed access to rehabilitation, the carrying of heavy loads, difficult postures and imposed work rates, as well as the patient's lack of a project, the absence of a cardiologist's opinion and the request for a modified workstation. CONCLUSION:The rate of return to work remains fairly stable despite the evolution of disease management, and the time to return to work relatively high. One way of improving the situation is to enhance access to cardiac rehabilitation programs, for example by offering alternatives such as tele-rehabilitation for a proportion of patients. This will free up more time for more severe patients, to better prepare them physically and psychologically for a return to work, which will also have a beneficial economic effect.

The exercise test is performed routinely in cardiology; its main indication is the diagnosis of myocardial ischemia, evaluated along with the subject's pretest probability and cardiovascular risk level. Other criteria, such as analysis of repolarization, must be taken into consideration during the interpretation of an exercise test, to improve its predictive value. An exercise test is also indicated for many other cardiac diseases (e.g. rhythm and conduction disorders, severe asymptomatic aortic stenosis, hypertrophic cardiomyopathy, peripheral artery disease, hypertension). Moreover, an exercise test may be indicated for specific populations (women, the elderly, patients with diabetes mellitus, patients in a preoperative context, asymptomatic patients and patients with congenital heart defects). Some cardiac diseases (such as chronic heart failure or arterial pulmonary hypertension) require a cardiopulmonary exercise test. Finally, an exercise test or a cardiopulmonary exercise test is indicated to prescribe a cardiac rehabilitation programme, adapted to the patient.

The exercise test is still a key examination in cardiology, used for the diagnosis of myocardial ischemia, as well as for the clinical evaluation of other heart diseases. The cardiopulmonary exercise test can further define functional capacity and prognosis for any given cardiac pathology. These new guidelines focus on methods, interpretation and indications for an exercise test or cardiopulmonary exercise test, as summarized below. The safety rules associated with the exercise test must be strictly observed. Interpretation of exercise tests and cardiopulmonary exercise tests must be multivariable. Functional capacity is a strong predictor of all-cause mortality and cardiovascular events. Chest pain, ST-segment changes and an abnormal ST/heart rate index constitute the first findings in favor of myocardial ischemia, mostly related to significant coronary artery disease. Chronotropic incompetence, abnormal heart rate recovery, QRS changes (such as enlargement or axial deviations) and the use of scores (based on the presence of various risk factors) must also be considered in exercise test interpretation for a coronary artery disease diagnosis. Arrhythmias or conduction disorders arising during the exercise test must be considered in the assessment of prognosis, in addition to a decrease or low increase in blood pressure during the exercise phase. When performing a cardiopulmonary exercise test, peak oxygen uptake and the volume of expired gas/carbon dioxide output slope are the two main variables used to evaluate prognosis.

BACKGROUND:Advances in congenital heart disease (CHD) have transferred the mortality from childhood to adulthood. Exercise capacity in young patients with CHD remains lower than in the general population, resulting in deconditioning and impaired quality of life. Evidence based-medicine in cardiac rehabilitation in this age group with CHD remains limited. We present the QUALI-REHAB study rationale, design and methods.METHODS:The QUALI-REHAB trial is a nationwide, multicentre, randomised, controlled study, aiming to assess the impact of a combined centre and home-based cardiac rehabilitation program on the quality of life of adolescents and young adults (13 to 25 years old) with CHD. Patients with a maximum oxygen uptake (VO2max) < 80% and/or a ventilatory anaerobic threshold (VAT) < 55% of predicted VO2max, will be eligible. Patients will be randomised into 2 groups (12-week cardiac rehabilitation program vs. controls). The primary outcome is the change in the PedsQL quality of life score between baseline and 12-month follow-up. A total of 130 patients are required to observe a significant increase of 7 ± 13.5 points in the PedsQL, with a power of 80% and an alpha risk of 5%. The secondary outcomes are: VO2max, VAT, stroke volume, clinical outcomes, physical and psychological status, safety and acceptability.CONCLUSION:After focusing on the survival in CHD, current research is opening on secondary prevention and patient-related outcomes. The QUALI-REHAB trial intends to assess if a combined centre and home-based rehabilitation program, could improve the quality of life and the exercise capacity in youth with CHD.TRIAL REGISTRATION:Clinicaltrials.gov (NCT03690518).

Background. - Sleep-related disordered breathing is common in patients with chronic heart failure. Aim. - To assess the efficacy of short-term nocturnal ventilatory therapy combined with exercise training (V + ET) compared with exercise training alone (ET) in patients with chronic heart failure with sleep-disordered breathing. Methods. - Patients in New York Heart Association functional class II-IIIb, with an apnoea-hypopnoea index (AHI) > 15/h, and enrolled in a cardiac rehabilitation programme, were centrally randomized to V + ET or ET. Subjects were classified as having obstructive sleep apnoea (OSA) (n=49) or central sleep apnoea (CSA)/mixed (n=69). The primary outcome was the change in the 10-second average oxygen consumption at maximum exercise (VO2peak) at the end of the cardiac rehabilitation programme. Results. - Fifty-eight patients were randomized to V + ET and 60 patients to ET. The median increase in VO2peak was 15% [interquartile range 6-36%] in the V + ET group and 16% [0-31%] in the ET group (P=0.34). AHI decreased in both groups, but significantly more in the V + ET group (P=0.006). The decrease in the ventilatory efficiency (VE/VCO2) slope was not statistically different between the two-randomization groups (P=0.10). In subjects with CSA, the VE/VCO2 slope decreased significantly more in the V + ET group (P=0.03), while there was no difference between the two-randomization groups in subjects with OSA (P=0.75). Six cardiovascular events occurred in patients with OSA (all randomized to the ET group); in subjects with CSA, two events occurred in the V + ET group and three in the ET group. Conclusions. - Short-term nocturnal ventilation combined with exercise training does not increase the exercise capacity of patients with chronic heart failure. (C) 2018 Elsevier Masson SAS. All rights reserved.

Les grands progrès de la prise en charge médicale et chirurgicale des cardiopathies congénitales ont permis à de nombreux enfants de parvenir à l’âge adulte avec souvent un bon résultat hémodynamique. Mais la plupart de ces adultes ont néanmoins une limitation de leur capacité fonctionnelle. Cette limitation, plus ou moins importante, les pénalise dans leur vie quotidienne et altère leur qualité de vie. L’origine de cette limitation est en générale multifactorielle. Elle est liée, bien sûr, à la sévérité de la cardiopathie et à la qualité du résultat opératoire. Mais il existe très fréquemment un déconditionnement physique. Lui-même peut être secondaire à la cardiopathie mais il est aussi bien souvent secondaire à un manque d’activité physique. Ce sont les parents, parfois surprotecteurs, mais surtout les médecins qui ont imposé, souvent à tort, cette restriction. La réadaptation cardiaque constitue un outil privilégié pour délivrer des conseils, dans un environnement adapté et apporte des bénéfices importants sur la santé et la qualité de vie. Ceci nécessite une collaboration étroite entre les réadaptateurs cardiaques et les cardiologues congénitalistes pour proposer des prises en charge adaptées. Nous apportons ici quelques réflexions et les éléments de base pour guider le réentraînement des ces patients.

The great advances in the medical and surgical management of congenital heart diseases have allowed many children to reach adulthood with often a good hemodynamic result. Nevertheless most of these adults have a limitation of their functional capacity. This limitation is more or less important, penalizes them in their daily life and alters their quality of life. The origin of this limitation is generally multifactorial. It is linked, of course, to the severity of the heart disease and the quality of the operative result. But there is very often a physical deconditioning. It can be secondary to the heart disease but is often secondary to a lack of physical activity. It is the parents, sometimes overprotective, but frequently the doctors who imposed, often wrongly, this restriction. It is essential to take this dimension into account in view of the important benefits expected for health and quality of life. Cardiac rehabilitation is a privileged tool for providing advice in a suitable environment. This requires close collaboration between cardiac rehabilitators and congenital cardiologists to offer appropriate care. We bring here some reflections and the basic elements to guide the re-training of these patients.

En complément des paramètres chiffrés de condition physique que nous obtenons de façon systématique par l’évaluation à l’effort, nous avons mis en place une quantification de l’état émotionnel du patient par un questionnaire de qualité de vie. Les résultats ont été comparés entre le début et la fin du programme de réadaptation cardiaque pour chaque patient. Le questionnaire est remis au patient en salle d’attente du test d’effort avec pour instruction « remplissez sans trop réfléchir… » Le patient évalue ses sentiments à l’aide d’une échelle de 0 à 4, sur laquelle 65 sentiments sont regroupés en 7 émotions présentées sous forme d’une courbe. Résultats Quatre cent questionnaires ont étés remplis, saisis et comparés. 164 hommes et 36 femmes, 59,7 ± 11,9 ans, 106 coronariens et 94 non coronariens, 83 patients opérés et 117 non opérés. Durée de séjour 24,4 ± 10,8 jours Ont été diminuées et de façon significative : l’anxiété de 9,3 ± 5,1 à 6,6 ± 4,2 (p < 0,05), la colère de 8,0 ± 6,4 à 6,4 ± 4,9 (p < 0,001), la dépression de 6,5 ± 7,7 à 3,8 ± 6,3 (p < 0,001), la fatigue de 6,3 ± 5,3 à 4,2 ± 4,3 (p < 0,001) et la confusion de 5,9 ± 3,3 à 5,2 ± 2,9 (p < 0,001). En parallèle, ont été augmentés : la vigueur de 16,5 ± 6,1 à 19,7 ± 5,2 (p < 0,001) et le relationnel 19,2 ± 4,9 à 21,0 ± 4,3 (p < 0,001). L’indice de forme globale qui est la combinaison de la vigueur et de la fatigue, augmente de façon significative en passant de 10,2 ± 9,9 à 15,5 ± 8,0 (p < 0,001). En l’absence de groupe témoin, il n’est pas possible de conclure que c’est notre programme de réadaptation cardiaque qui est l’élément déterminant de l’amélioration des patients par rapport à un autre traitement ou par rapport aux 24 jours de temps écoulé. Toutefois, après le séjour, on constate une amélioration significative des 7 « émotions » en comparant les questionnaires d’entrée et de sortie quel que soit l’âge du patient, la durée d’hospitalisation et le mode de séjour. Tous les types de population : homme/femme, opérés/non opérés, coronariens ou non, sont répondeurs. Le POMS est un outil validé, simple d’utilisation, rapide et pratique. Il permet d’avoir des éléments chiffrés et de constater l’amélioration franche et significative des états émotionnels et de la qualité de vie des patients après le séjour en réadaptation cardiaque (Fig. 1).

Les troubles respiratoires du sommeil (TRS) sont fréquents chez les patients insuffisants cardiaques (IC). L’entraînement physique améliore la capacité d’effort et le pronostic de ces patients. Toutefois, l’effet du traitement des TRS pendant la réadaptation cardiaque n’est pas connue. Le but de l’étude est d’évaluer l’apport éventuel de la ventilation chez des patients IC apnéique sur les capacités d’effort. Nous avons inclus 118 patients IC avec IAH > 15/h (polygraphie), randomisés en deux groupes : G1 (entraînement seul, n = 58) et G2 : (combiné entraînement + ventilation adaptée au type d’apnée, n = 60). Ces patients ont bénéficié de 20 séances d’entraînement avec évaluation des capacités d’effort par épreuve cardiopulmonaire avant et en fin de programme. Les événements indésirables ont été recueillis durant le programme de réadaptation (8 semaines). Population : âge : 62 ± 10 ans, 89 % sexe masculin, FEVG : 30 % ; IAH moyen 34 ± 14/h. Tous les patients améliorent significativement leur pic de VO2 (G1 : 13,8 ± 4,6 à 16,3 ± 5,7 et G2 : 14,0 ± 4,1 à 17,2 ± 5,7 mL/kg/min, sans différence significative entre les deux groupes). En revanche, l’amélioration de la pente VE/VCO2 est significative (p = 0,02) dans le groupe combiné. Enfin, le nombre de décompensations cardiaques pendant l’étude est significativement moindre dans le G2 (G1 = 7,6 % vs G2 = 3,3 %, p < 0,05). Chez les IC avec IAH > 15/h, la ventilation n’apporte pas d’augmentation supplémentaire sur le pic de VO2, mais permet de réduire la pente VE/VCO2 et semble, à court terme, réduire les décompensations cardiaques.

Les troubles respiratoires du sommeil (TRS) sont fréquents dans l’insuffisance cardiaque. L’entraînement physique (EP) améliore la capacité d’effort et le pronostic chez ces patients. L’EP améliore les TRS chez les patients avec apnées obstructives. Mais le rôle de l’EP sur les apnées centrales et mixtes est mal connu. L’objectif est d’évaluer les effets de l’EP sur l’index d’apnée hypopnée (IAH) chez ses patients insuffisants cardiaques adressés en réadaptation cardiaque. Au total, 58 patients en insuffisance cardiaque (fraction d’éjection < 40 %) et avec un IAH > 15/h, adressés en réadaptation ont été inclus dans cette étude prospective, multicentrique. Avant et après le programme de réadaptation cardiaque les patients ont bénéficié d’une évaluation de la VO2 et d’une polygraphie du sommeil. L’âge moyen est de 65 ± 10 ans, 89 % d’hommes, 52 % en classe II de NYHA et 46 % en classe III. Au début du programme 45 % avaient des apnées obstructives, 55 % des apnées centrales ou mixtes. Après 8 semaines d’EP, la FEVG et le pic de VO2 ont augmenté respectivement de 30 ± 7 à 37 ± 10 % et de 13,8 ± 4,6 à 16,3 ± 5,5, p < 0,001. On observe une réduction de l’IAH de 36 ± 15 à 22 ± 16, p = 0,003. Chez les patients avec apnées centrales ou mixtes, la réduction de IAH est significative : 40 ± 20 à 24 ± 19, p = 0,03, avec une tendance similaire chez les obstructifs (31 ± 14 à 20 ± 13, p = 0,06). L’entraînement physique permet une réduction significative des apnées centrales ou mixtes chez les patients en insuffisance cardiaque. La réadaptation doit faire partie de la prise en charge des patients IC avec TRS.

Sleep-disordered breathing (SDB) is commonly in chronic heart failure (CHF) patients. Exercise training (ET) improves exercise tolerance and reduces cardiac decompensations in CHF population. Otherwise, ventilation therapy (VT) improves prognosis and exercise capacity in CHF patients with SDB. However, the effect of the combination therapy: ET and VT is still unexplored. The aim of our study is to evaluate the effects on hemodynamic status (cardiac decompensations) of ET and VT in stable CHF patients referred to cardiac rehabilitation (CR). We included 118 stable CHF patients with an apnea-hypopnea index (AHI) >15/h diagnosed by polygraphy. They were randomized into exercise training (ET group n=58) or combined exercise and ventilation (ET+VT group n=60). The follow up period was the 8 weeks during which 20 exercise training sessions were scheduled. Severe episodes of cardiac decompensations were recorded. The mean age was 62.6±10.3 years, 89% were males, 50% NYHA class II and 50% in class III, mean LVEF was 30%. 40% and 60% of patients had respectively obstructive and central and/or mixed apneas, with a mean AHI 34.4±14.3/h. Patients of ET+VT group had significantly fewer acute cardiovascular events than those of ET group (2/60 vs. 7/58; 3.3% vs. 15.5%, p<0.05). Ventilation therapy combined with ET in severe CHF patients seems to reinforce benefits of ET alone. Screening of SDB in CR could be proposed in order to optimize the global management of the heart disease.

Background. - Assessment of health-related quality of life is widely recommended by European health agencies in relevant research studies as well as in clinical care.Aims. - To validate the French version of the MacNew heart disease health-related quality of life questionnaire.Methods. - As part of the International HeartQoL Project, 323 French-speaking patients with ischaemic heart disease (angina, n = 76; myocardial infarction [MI], n= 155; heart failure, n = 91; mean age 58.6 +/- 11.3 years) were recruited at seven cardiac rehabilitation centres. All patients completed the French versions of the MacNew questionnaire, the Short Form-36 Health Survey (SF-36) and the Hospital Anxiety and Depression Scale, to evaluate the psychometric properties of the French version of the MacNew instrument.Results. - The mean MacNew global scale scores were 4.6 +/- 0.8, 5.0 +/- 1.0 and 4.8 +/- 0.9. in patients with angina, MI and heart failure, respectively (P < 0.05, MI versus angina). We observed minimal missing items and ceiling effects and no floor effects. Factor analysis confirmed a three factorial structure explaining 55.9% of the observed variance. Internal consistency reliability (Cronbach's alpha) ranged from 0.86 to 0.94 and test-retest reliability ranged from 0.68 to 0.73 Convergent validity was confirmed in the total group and each diagnosis, although the correlations between the MacNew physical subscale and the SF-36 mental component summary were higher than expected. Discriminative validity was partially confirmed with the SF-36 health transition item and fully confirmed with anxiety and depression as predictor variables.Conclusion. - The French version of MacNew questionnaire is recommended for assessing health-related quality of life in French-speaking patients with ischaemic heart disease. (C) 2014 Elsevier Masson SAS. All rights reserved.

Sleep-disordered breathing (SDB) is commonly in chronic heart failure (CHF) patients. Exercise training (ET) improves exercise tolerance and reduces cardiac decompensations in CHF population. Otherwise, ventilation therapy (VT) improves prognosis and exercise capacity in CHF patients with SDB. However, the effect of the combination therapy: ET and VT is still unexplored. The aim of our study is to evaluate the effects on hemodynamic status (cardiac decompensations) of ET and VT in stable CHF patients referred to cardiac rehabilitation (CR). We included 118 stable CHF patients with an apnea-hypopnea index (AHI) > 15/h diagnosed by polygraphy. They were randomized into exercise training (ET group n = 58) or combined exercise and ventilation (ET + VT group n = 60). The follow up period was the 8 weeks during which 20 exercise training sessions were scheduled. Severe episodes of cardiac decompensations were recorded. The mean age was 62.6 ± 10.3 years, 89% were males, 50% NYHA class II and 50% in class III, mean LVEF was 30%. 40% and 60% of patients had respectively obstructive and central and/or mixed apneas, with a mean AHI 34.4 ± 14.3/h. Patients of ET + VT group had significantly fewer acute cardiovascular events than those of ET group (2/60 vs. 9/58; 3.3% vs. 15.5%, P < 0.05) and fewer cardiac decompensations (2/60 vs. 7/58; 3.3 vs 12%, P < 0.05). This difference is particularly significant in obstructive sleep apneas patients. Ventilation therapy combined with ET in severe CHF patients seems to reinforce benefits of ET alone. Screening of SDB in CR could be proposed in order to optimize the global management of the heart disease.