2023 共识声明：慢性冠脉综合征和／或心力衰竭患者的标准化运动处方

共识心血管内科· 冠心病与冠脉疾病 · 2023

Standardised Exercise Prescription for Patients with Chronic Coronary Syndrome and/or Heart Failure: A Consensus Statement from the EXPERT Working Group

Authors

Abstract

Whereas exercise training, as part of multidisciplinary rehabilitation, is a key component in the management of patients with chronic coronary syndrome (CCS) and/or congestive heart failure (CHF), physicians and exercise professionals disagree among themselves on the type and characteristics of the exercise to be prescribed to these patients, and the exercise prescriptions are not consistent with the international guidelines. This impacts the efficacy and quality of the intervention of rehabilitation. To overcome these barriers, a digital training and decision support system [i.e. EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool], i.e. a stepwise aid to exercise prescription in patients with CCS and/or CHF, affected by concomitant risk factors and comorbidities, in the setting of multidisciplinary rehabilitation, was developed. The EXPERT working group members reviewed the literature and formulated exercise recommendations (exercise training intensity, frequency, volume, type, session and programme duration) and safety precautions for CCS and/ or CHF (including heart transplantation). Also, highly prevalent comorbidities (e. If an assessment of (an)aerobic metabolism by cardiopulmonary exercise testing is not available, relative effort intensities in the 'moderate' domain have been used: these are expressed as percentage of peak heart rate (%HR peak ) or percentage of heart rate reserve (%HRR), or according to Borg RPE scales. However, the equivalence of %HRR versus %VO 2 reserve has been questioned in patients with CHF both on and off beta-blockers, since the exercise intensity domains derived from these parameters often disagree with the first and second ventilatory threshold (which is, in essence, the patient's personal exercise intensity). High-intensity interval exercise might also be considered in some patients (level of evidence: 1, grade of recommendation: B). Generally, 15-40 min/day exercise sessions are advised, but shorter sessions are preferred at the beginning of the training programme in patients with poor exercise capacity, fatigue and/or recent haemodynamic instability (level of evidence: 1, grade of recommendation: A). The session duration should be progressed according to patients' tolerance, trying to reach at least a 30-min session duration (level of evidence: 1, grade of recommendation: A). In most studies, a minimum of three sessions per week have been used, and stable patients in New York Heart Association (NYHA) class I-III had three to five sessions per week without adverse effects (level of evidence: 1, grade of recommendation: A). Even in patients with recent haemodynamic instability, starting an individually tailored training programme of three sessions per week has been shown to be safe (level of evidence: 1, grade of recommendation: A). When such an exercise programme is initiated, an attempt should be made to continuously increase the physical activity level (level of evidence: 1, grade of recommendation: A), although it remains difficult to define the minimal programme duration. A lifestyle approach by including common activities into the daily routine (e.g. walking instead of driving, climbing stairs rather than taking the elevator, engaging in active recreational pursuits) also is effective and to be recommended (level of evidence: 1, grade of recommendation: B). Alignment of activity modes with individual preferences and interests is most likely to increase patient's adherence to sustained activity. Particular types of exercise training (e.g. dancing, yoga) have been shown to be well accepted and beneficial in terms of functional capacity. Exercise modes like running or jogging traditionally are considered to be contraindicated, since they are considered to be potentially very strenuous and often performed without supervision. However, further investigations are needed to clarify this point. In all patients with clinically stable CHF, dynamic resistance training should be included into the training programme as a supplement to endurance exercise training. Training intensity for resistance training is very similar to those for patients with CCS (see Sect. 5.3.1 for more details) and should include 8-10 exercises involving the large muscle groups and should consist of at least one set of 8-12 repetitions per exercise (type of evidence: 1, level of recommendation: A). Furthermore, resistance training should be performed as interval training, and single muscles should be trained step by step. On the basis of expert opinion, in patients with CHF, dynamic resistance training should preferably be guided by experienced exercise therapists or physiotherapists. In the rehabilitation of patients with CHF, and particularly in those with inspiratory muscle weakness [maximal inspiratory muscle strength (PImax) < 70%], inspiratory muscle training (IMT) may be clinically relevant, since the combination of aerobic/resistance/inspiratory training might be the optimal for patients with CHF (level of evidence: 2, grade of recommendation: B) [88] . IMT involves use of respiratory muscle-specific training devices to improve respiratory muscle function, thereby improving respiratory functional status and reducing dyspnoea. Respiratory muscle dysfunction predominantly has been observed in patients with advanced CHF. Modes of IMT usually involve inspiratory muscles, and training is performed at a percentage of PImax. Strength devices are pressure threshold load trainers. Devices targeting endurance include isocapnic hyperpnoea endurance trainers, or incremental inspiratory endurance trainers with computer biofeedback. In patients with CHF with poor exercise capacity, respiratory endurance training has been shown to improve respiratory muscle function, reduce dyspnoea and increase VO 2peak as well as quality of life. IMT may thus be used in patients with CHF with low functional capacit When using inspiratory endurance trainers, an intensity of 60% of sustained PImax with a build-up towards a duration of 20-30 min and a frequency of 3 days per week for a minimum of 8-10 weeks has been proposed. If a pressure threshold trainer is used, respiratory training is usually started at 30% of PImax and readjusted every 7-10 days up to 60% of PImax. Training duration again should be 20-30 min/day, three to five times a week and for a minimum of 8 weeks.

Safety precautions: patients with CHF should be informed about the nature of cardiac prodromal symptoms and exercise-related warning symptoms including chest pain or discomfort, abnormal dyspnoea, dizziness or malaise and should seek prompt medical care if such symptoms develop. Regular follow-up depending on severity of CHF and the category of risk is recommended. Intensive isometric exercise such as heavy weight lifting can have a marked pressor effect and should be avoided [91] . Stopping exercise suddenly should be avoided as it may result in a precipitous drop in blood pressure. Patients with exertional dyspnoea, chest discomfort or palpitations need further examination, which includes exercise testing, echocardiography, Holter monitoring or combinations thereof.

5.3.3 Pacemaker, Implantable Cardioverter Defibrillator and Resynchronisation Therapy

Intervention aim: to increase physical fitness, and increase confidence during exercise, to improve mental health, quality of life and prognosis.

Exercise training recommendations [26, : As proposed by clinical guidelines, sports with a low cardiovascular demand and no competitive context are allowed for all ICD and pacemaker patients (level of evidence: 3, grade of recommendation: D). Leisure-time recreational physical activities with low-to-moderate dynamic or static demand are also allowed. Recommendations restricting participation in these activities are primarily based on the fear of exerciseinduced device or lead complications, lack of data regarding the effectiveness of device therapy in metabolic, autonomic or ischaemic conditions, and potential inappropriate antitachycardic pacing or shock delivery due to misclassification of sinus tachycardia as malignant arrhythmia. However, recent data suggest that these recommendations, particularly in younger, physically active patients (with congenital structural heart disease or channelopathies) and middle-aged patients with arrhythmogenic substrate due to ischaemic or dilated cardiomyopathy might be too restrictive. As yet, in athletes with ICD, competitive sports or strenuous exercise are still contraindicated. However, disqualifying young ICD patients from participating in sports without solid risk evidence might be unnecessary and advice should be based on an individualised risk-benefit decision [26] . The Heart Rhythm Society (HRS), European Heart Rhythm Association (EHRA) and Asia Pacific Heart Rhythm Society (APHRS) guidelines give several disease-specific recommendations to allow participation in competitive activities. Under exercise conditions, appropriate and inappropriate ICD shock delivery and antitachycardic stimulation occur frequently, but clinically relevant complications are rare even in patients with CHF (HF-ACTION trial) [104] . Nevertheless, regular intensive exercise can promote worsening of the course of underlying cardiac diseases [arrhythmogenic right ventricular cardiomyopathy (ARVC), dilated cardiomyopathy (DCM)]. During CR, supervised exercise training in ICD carriers can be safely performed (continuous moderate intensity, with a gradual build-up towards 45-60 min/day, at a frequency of 3-5 days per week) as well as home-based moderate-intensity endurance exercise during the subsequent outpatient period. To achieve an optimal adherence to the prescribed exercise intensity (i.e. within a certain range), monitoring equipment measuring HR behaviour can be considered. Aerobic interval training (i.e. interval training of a significantly lower intensity when compared with HIIT) in ICD patients leads to a significant increase in VO 2peak and cycle ergometer workload as well as improvement in endothelial function. Furthermore, regular exercise training has been shown to have an important impact on the psychological stability of ICD patients.

There are no separate evidence-based training recommendations for ICD and pacemaker patients per se. Recommendations for exercise participation should be individualised based on the following modifiers:

1. Underlying heart disease (coronary artery disease, congenital or acquired structural heart disease, channelopathies), 2. Recent supraventricular and ventricular rhythm stability, 3. Indication for device implantation (primary or secondary prevention), 4. LV systolic and diastolic function, 5. Revascularisation status, 6. Settings of the device.

Also, highly prevalent comorbidities (e.g. peripheral arterial disease) or cardiac devices (e.g. pacemaker, implanted cardioverter defibrillator, left-ventricular assist device) were considered, as well as indications for the in-hospital phase (e.g. after coronary revascularisation or hospitalisation for CHF). The contributions of physical fitness, medications and adverse events during exercise testing were also considered. The EXPERT tool was developed on the basis of this evidence. In this paper, the exercise prescriptions for patients with CCS and/or CHF formulated for the EXPERT tool are presented. Finally, to demonstrate how the EXPERT tool proposes exercise prescriptions in patients with CCS and/or CHF with different combinations of CVD risk factors, three patient cases with solutions are presented. EXPERT stands for 'EXercise Prescription in Everyday practice & Rehabilitative Training'. This working group is endorsed by the European Association of Preventive Cardiology (EAPC).

1 Introduction

Exercise training, as part of multidisciplinary rehabilitation, leads to significant improvements in functional capacity, muscle strength and endurance capacity, as well as quality of life in patients with chronic coronary syndrome (CCS) and/or congestive heart failure (CHF), thereby reducing cardiovascular event rates, hospitalisations and/or mortality [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] .

Alongside dietary intervention, psychosocial support/ counselling, smoking cessation and the prescription of cardioprotective medication, exercise training is classified as a type 1A intervention in the treatment of CCS and/or CHF, and its importance is endorsed by several international position statements and guidelines [11] [12] [13] [14] . In general, it is recommended that patients with CCS and/or CHF perform at least 150 min of continuous low-to-moderateintensity endurance exercise training per week, ideally spread over 3-5 days per week. An energy expenditure of 1000-2000 kcal per week should be achieved in this way,

3 General Approach to Exercise Prescription in Chronic CCS and CHF

Next to anticipated improvements in endurance exercise capacity and muscle strength, exercise interventions should also be tailored to positively affect all modifiable cardiovascular risk factors, as well as to motivate patients to integrate physical activity and training into their lifestyles and to remain physically active throughout their lives. Even though detailed exercise recommendations for different CVD risk factors have been reported [20] , tailoring the exercise training programme to each single patient according to their overall CVD risk profile remains difficult as the CVD risk factors and diseases are often considered separately. For example, to optimally reduce adipose tissue mass or arterial blood pressure, or to improve blood lipid profile or glycaemic control, more tailored exercise prescriptions are required [20] . Moreover, the co-existence of comorbidities, the intake of certain medications, physical deconditioning or the presence of abnormalities or adverse events during exercise testing warrant further individualised adjustments of these exercise prescriptions [21] . We therefore speculated that patients with CCS and/or CHF can benefit from a more standardised way of tailoring exercise prescription [21] , aiming for greater clinical benefits, maintaining optimal medical safety and improving exercise adherence. As a result, clinicians and healthcare professionals involved in CR can now use a decision support system (EXPERT tool) that, on the basis of the variables provided in this system, suggests how exercise should be individually prescribed [22, 23] . Such an interactive digital decision support system can provide an exercise prescription but still leave the user the opportunity to fine-tune the programme, on the basis of specific patient characteristics or preferences, and the available infrastructure. and endurance exercise training should be complemented by dynamic resistance exercise training two times per week at a moderate intensity [11] [12] [13] [14] [15] [16] .

Despite the availability of international exercise guidelines for the secondary prevention in CCS and CHF [11] [12] [13] [14] [15] [16] , a study from the European Association of Preventive Cardiology (EAPC) EXPERT (Exercise Prescription in Everyday practice & Rehabilitative Training) working group reported a significant inter-clinician variance in exercise prescription for these patients [17] . As an example, for the same patient recovering from coronary artery bypass graft (CABG) surgery with different comorbidities (including obesity, hypertension, type 2 diabetes, CHF) the prescribed exercise volume per programme ranged from 300 up to 9000 peakeffort training minutes, which is an unacceptable variance [17] . In subsequent studies, similar heterogeneous exercise prescriptions were shown for primary care physicians and physiotherapists [18, 19] . This indicates that state-of-the-art exercise prescription for patients with CCS and/or CHF is far from being well established and that clinicians and healthcare professionals need guidance that goes beyond existing guidelines and position statements (i.e. specifically how to tailor exercise interventions based on the patient's cardiovascular disease (CVD) type, risk profile, physical fitness and medication intake).

The aim of this manuscript was to provide a consensus statement for state-of-the-art exercise prescription and exercise training safety precautions for patients with CCS and/or CHF, as integrated into the EXPERT tool. Different CVD risk factors, comorbidities or devices, the intake of cardioprotective medications, adverse events during exercise testing and physical deconditioning are also taken into account. Finally, simulations of exercise prescriptions for these patients, as provided by the EXPERT tool, will be presented.

4 Methods

4.1 Formulation of Exercise Prescriptions and Construction of EXPERT Tool

Previously, details of the composition and activities of the EXPERT network working group ( > 30 members out of > 10 European countries), and how exercise guidelines were collected from the literature, were provided [22] . Also, the development and functioning of the EXPERT tool, definitions for CVD risk factors and goals of CR have already been described in detail [22] . This project is endorsed by the European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology.

In brief, working group members (see author list) were allocated to different topics according to their expertise [CCS, CHF, pacemaker, implantable cardioverter defibrillator (ICD), left-ventricular assist device (LVAD), peripheral arterial disease (PAD), heart transplantation], and were then requested to consult PubMed and/or Web of Science (up to February 2023) to: (1) define the criteria or definitions for the specific conditions, (2) identify the primary goal of exercise training interventions for each disease/condition, (3) provide exercise training recommendations and (4) highlight exercise safety precautions. These recommendations and definitions had to be based on (with decreasing level of evidence) current clinical guidelines and position statements from the European Society of Cardiology (ESC) and/ or EAPC, meta-analyses, systematic reviews or randomised controlled trials. If not available, cohort studies, observational studies or expert opinions were also considered. The allocation of these experts to specific steering groups was based on their specific scientific/clinical expertise as indicated by their PubMed track records. All this information was handed over to the project coordinator, who, in collaboration with computer scientists from Hasselt University, developed the EXPERT tool (Fig. 1 ). This paper is an extension of a previous manuscript paper in which exercise prescriptions in (different combinations of) CVD risk factors were explained in detail [24] .

4.2 Classification of Level of Evidence and Grades of Recommendation

To classify the level of evidence and the grade of recommendation for exercise prescription guidelines, the validated SIGN system was used throughout this paper, as shown in Supplementary Table 1 [25] .

4.3 Classification of Exercise Training Intensity

Supplementary Table 2 presents the classification of exercise training intensity which is also used in the EXPERT tool [26] .

4.4 Limitations of the EXPERT Tool

The EXPERT tool, version of July 2023, is prone to some limitations. The tool applies a classification of exercise training intensity as mentioned in Supplementary Table 2 [based mainly on heart rate (HR)], even though it is well established that the use of the ventilatory threshold (VT) leads to a far more precise determination of exercise intensity (more in line with personal exercise response) and a greater improvement in exercise tolerance [27] . However, the user of this tool can still adjust the target HR if desired (e.g. when the HR at VT2 has been assessed). In addition, the EXPERT tool generates an exercise prescription that ideally matches the CVD risk profile and medical treatment goals. However, it does not take into account the patient's feasibility and adherence issues (e.g. attractiveness, capabilities, personal goals, fears, etc.) relating to this prescription: these remain to be finally decided or implemented by the user of the tool. , service planning and management, as well as service evaluation [29] . Moreover, to optimise exercise prescription, cardiopulmonary exercise testing (CPET) is strongly recommended [27] . This will allow personalisation/ fine-tuning of the endurance exercise intensity and energy expenditure targets, as well as the assessment of the medical safety of (high-intensity) endurance exercise.

5 Consensus Statements from the EXPERT Network Working Group

Devices

Personalised exercise prescripƟon for CCS and CHF

The focus of this paper is on CCS and CHF, since CCS may progress to CHF (and subsequently to heart transplantation). Moreover, as PAD is often co-existent in patients with CCS, this clinical condition is also discussed in this paper. Finally, patients with CHF are often also candidates for implantation of ICD, pacemaker and/or LVAD, so how to prescribe exercise in these cases is described in detail. The proposed exercise prescriptions are summarised in Table 2 . Since CR is most often started after hospitalisation due to angina pectoris, acute coronary syndrome or decompensation in CHF, it is important to offer active mobilisation as early as possible (phase 1 CR), given sufficient medical safety [16] .

5.2 Phase 1 Cardiovascular Rehabilitation

For definitions of diseases, see Table 3 .

Intervention aim: To achieve early mobilisation, given sufficient medical safety. With prolonged bed rest, the associated maladaptation will lead to an excessive rise in HR during orthostatic stress, cardiac atrophy, reduced exercise capacity, decreased blood volume and muscle atrophy. A downward spiral of inactivity and deconditioning might occur.

Exercise training recommendations: Because some patients are so greatly deconditioned, graded programmes should be proposed. Early mobilisation as well as supervised and differentiated exercise training interventions should be provided in a supportive environment. Early mobilisation can be initiated when patients are haemodynamically stable and may include progressive therapeutic activities such as bed mobility exercises, sitting on the edge of the bed, standing, transferring to a chair and ambulation.

Because of a lack of data from randomised controlled trials, the below-mentioned recommendations are expert opinions (level of evidence: 4, grade of recommendations: D). In early mobilisation it is proposed to follow a stepped care plan, including pre-participation screening, what to assess during mobilisation and how to select exercise modalities.

Preparticipation Screening and Parameter Registration During Mobilisation in Phase 1 Cardiovascular Rehabilitation In the early mobilisation of patients with CCS and/or CHF, it is important to assess the patient's clinical status to verify the medical safety of such intervention, as well as to register significant parameters during mobilisation. These data are presented in Table 4 .

How to Select and Progress Exercise Modalities in Phase 1 Cardiovascular Rehabilitation

Step 1

• Note obstacles, barriers or challenges related to the patient and environment and plan appropriately (e.g. set up equipment -chairs, transfer belt, mobility aids, length of leads/lines). • Determine whether the benefits outweigh the risk (see pre-participation screening). • Obtain baseline vital signs (see 'what to assess during mobilisation').

Step 2

• Use proper body mechanics during transfer and allow gradual change from lying to upright position. Encourage circulation exercises, i.e. foot and ankle, knee flexion/ extension, before commencing more demanding mobilisation procedures. • Monitor closely. Watch for signs of fatigue, pain, dizziness, diaphoresis and intolerance during activity.

Frequently ask the patient how he/she feels. Evaluate the patient's status at each progression to determine whether to continue or stop. Determine the limiting factor of the mobilisation and any undesirable response(s). Use objective outcome measures to monitor progress, e.g. ease of transfer, sitting duration, walking distance, HR, RR, BP, oxygen saturation, Borg ratings of perceived exertion (RPE), and pain. • After mobilisation, monitor patients until vital signs have returned to pre-activity level.

Step 3 Intensity and duration of mobility/exercise sessions, and their progression, are further individualised according to response and tolerance: Training duration again should be 20-30 min/day, 3-5 times a week and for a minimum of 8 weeks Pacemaker, ICD or resynchronisation device

A distinction is made between athletes vs. sedentary individuals For athletes (or people with ambition towards competitive sports): in athletes with ICDs, competitive sports or strenuous exercise are contraindicated. However, disqualifying young ICD patients from participating in sports without solid risk evidence might be unnecessary and advice should be based on an individualised risk-benefit decision (based on the patient's phenotype and characteristics of the desired sports) For sedentary individuals (entering CR): a continuous moderate intensity is advised, with a gradual build-up towards 45-60 min/day, at a frequency of 3-5 days per week, for at least 8-10 weeks (with preferentially a further prolongation in exercise participation to maintain achieved benefits). Aerobic interval training can also be proposed in some individuals LVAD A combination of endurance and resistance exercise should be offered For endurance exercise: endurance exercise training at a continuous moderate intensity is advised, with a gradual build-up towards 45-60 min/day, at a frequency of 3-5 days per week, for at least 8-10 weeks (with preferentially a further prolongation in exercise participation to maintain achieved benefits For resistance exercise: patients with LVAD are patients with CHF and would thus benefit from resistance exercise training, as well as IMT (see Sect. 5.

3.2) Heart transplantation

A combination of endurance and resistance exercise should be offered For endurance exercise: these patients should engage in continuous moderate-intensity exercise (at 60-70% VO 2peak or 12-14 Borg RPE), for up to 30-60 min per session, at a frequency of minimally 3 days per week, for at least 20 weeks (with preferentially a further prolongation in exercise participation), if possible, and with a gradual buildup towards this intensity and volume of exercise For resistance exercise: resistance training up to 50-60% of 1-RM, for 10-20 repetitions per series and 3-6 series per large muscle group should be prescribed arm ergometry, weight bearing/weight shifting exercises (calf muscle strengthening, heel lift), walking in the room/corridor (begin walking practice with appropriate aids, increasing distance and frequency as patient tolerates) and individualised mobilisation prescription.

5.3 Phase 2 Cardiovascular Rehabilitation

5.3.1 Chronic Coronary Syndrome

Intervention aim: To increase the physical fitness and/or reduce/prevent angina pectoris (in case of stable angina pectoris) and thereby to improve prognosis (hospitalisation, cardiovascular re-event rate, mortality) and quality of life. Peripheral arterial disease A combination of endurance and resistance exercise should be offered For endurance exercise: supervised exercise training should be performed over 30-45 min, in sessions performed at least three times per week for a minimum of 12 weeks. Regimen of walking to near-maximal pain provides the best improvement. Exercise training programmes that use intermittent walking to near-maximal claudication pain performed at a relatively low treadmill grade (i.e. 40% of maximal grade) or a relatively high grade (i.e. 80% of maximal grade) may both be used. The initial workload of the treadmill or speed during outdoor track walking should be set to a speed (and grade) that elicits claudication symptoms within 3-5 min. Patients walk at this workload until they achieve claudication of moderate severity, which is then followed by a brief period of standing or sitting to permit symptoms to resolve. The exercise-rest-exercise pattern should then be repeated throughout the exercise session. Adding upper body exercise to walking, as is the case with pole striding training (e.g. Nordic walking) or arm cycling exercise, significantly improves the clinical indicators of cardiovascular fitness and quality of life, and decreases symptoms of claudication pain during exertion. Prolonged programmes (up to 6 months) provide the greatest benefits For resistance exercise: moderate-to-high intensity resistance exercise, i.e. 60-80% of 1-RM, is advised. Each exercise session, three sets (8-12 repetitions with 1-2 min rest intervals per set) of resistance exercise should be completed. Whole-body progressive resistance training incorporating 6-8 exercises including the primary muscle groups involved in walking should then be targeted Being hospitalised for at least 3 days due to CCS or acute coronary syndrome (ACS) (with or without revascularisation), decompensation in CHF, heart transplantation CCS To detect CCS non-invasive stress imaging (e.g. cardiac magnetic resonance, stress echocardiography, positron emission tomography or single-photon emission computed tomography) may be considered for the assessment of myocardial ischaemia and viability in patients with CHF and/or CCS (considered suitable for coronary revascularisation) [185]

ACS

The clinical definition of ACS denotes the presence of acute myocardial injury detected by abnormal cardiac biomarkers in the setting of evidence of acute myocardial ischaemia [186] . Detection of an elevated cardiac troponin value above the 99th percentile upper reference limit is defined as myocardial injury [186] . The injury is considered acute if there is a rise and/or fall of cardiac troponin values CHF CHF is a clinical syndrome characterised by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress [187] . Patients with CHF with a left-ventricular ejection fraction < 40% are considered as having CHF with reduced EF (HfrEF), while CHF with preserved EF (HfpEF) is present when the left-ventricular ejection fraction is ≥ 50% [187]

PAD

In the diagnosis of PAD the ankle-brachial index (ABI) is a useful, first-line, non-invasive outcome parameter. An ABI < 0.91 represents insufficient perfusion of the extremities, while an ABI > 1.40 represents arterial stiffening (medial arterial calcification) [188] . In the case of a deviating ABI, the following additional diagnostic tools/investigations can be considered for further optimisation of diagnosis and treatment: Doppler ultrasound, computed tomography angiography and/or magnetic resonance angiography [188] Investigations, blood chemistry (e.g. haemoglobin, red blood cell count, glycaemia, fluid/electrolytes) 6. Risk factors (blood pressure, waist circumference, blood lipid profile, blood C-reactive protein content) and lifestyle conditions 7. Physician's recommendations and specific restrictions on mobilisation according to acute and post-acute clinical conditions The patient, family and team member should also be requested to provide more details on: 1. Multisystem review (e.g. cognition, respiratory, cardiac, musculoskeletal and neurologic system) 2. Level of cooperation 3. Ask the patient what he/she currently feels about mobilisation concerns and readiness 4. Consider the impact of the illness or medical procedures (e.g. patient waiting for cardiac valvular surgery or myocardial revascularisation) and medications on the patient's mobility [e.g. g. weakness from disuse, pain, equipment needs (e.g. walker)] 5. Coordinate with team members regarding the timing of treatment with medication, availability of equipment and of personnel to optimise effectiveness The following contra-indications for early mobilisation should be respected and known by healthcare professionals (the cited values are not absolute criteria for withholding mobilisation but are within the range of concern) [14] Exercise training recommendations [14, 16, 27, : patients with CCS are generally advised to start with a session duration of 10 min in the initial stage (for up to maximally 2 weeks or ahead of cardiopulmonary exercise testing) at a low to moderate intensity, but gradually increase up to 20 min, if possible to 30-45 min in the improvement stage (from 2 up to 12 weeks) (level of evidence: 1, grade of recommendation: C). In the maintenance stage (after 8-10 weeks of CR) it is advised to complete exercise sessions of 20-45 min or even up to 60 min or more if tolerated (level of evidence: 1, grade of recommendation: C). For some outcomes (e.g. VO 2peak , glycaemic control) a slight reduction in minimal exercise session duration (from 30 to 20 min) can be allowed to maintain the achieved benefits, particularly when a higher exercise intensity is applied. This does not, however, apply to every CVD risk factor and should thus be carefully considered and implemented. In the initial and improvement stage patients with CCS are advised to exercise 3-5 days per week (level of evidence: 1, grade of recommendation: B). This exercise frequency can be maintained or could be increased ≥ 5 days per week in the improvement stage (level of evidence: 1, grade of recommendation: B), while in the maintenance stage daily exercise should be promoted (level of evidence: 1, grade of recommendation: C). Patients with CCS are advised to perform endurance exercises at a moderate intensity. In some patients (e.g. patients with preserved physical fitness and absence of exerciseinduced hypertension, myocardial ischaemia, or cardiac arrhythmias during exercise testing) high-intensity interval training (HIIT) can be offered as an alternative: HIIT has a similar adherence as moderate-intensity exercise training in patients with CCS [67] . In addition, cumulating evidence is showing that an up-titration of the exercise intensity during CR (as a progression) can elicit significantly greater clinical benefits [68, 69] . Hence, in some patients this can be considered. A minimal programme duration of 12 weeks should be achieved (level of evidence: 1, grade of recommendation: B), although a permanent increment in physical activity is recommended (level of evidence: 1, grade of recommendation: C). Resistance training should routinely be added to endurance exercise provided that patients are clinically stable, and only dynamic resistance training (in contrast to isometric strength training) is applied (see Sect. 5.3.7) (level of evidence: 1, grade of recommendation: C). Dynamic resistance training may be implemented by using specialised training devices in supervised institutions (e.g. prevention and rehabilitation centres) or simple devices like dumbbells, expanders and Therabands. In the initial stage resistance exercise intensity should be set at < 30% of one repetition maximum (1-RM) [RPE Borg ≤ 11] , for five to ten repetitions per muscle group (one to three sets per unit), at a frequency of two to three training units per week (level of evidence: 1, grade of recommendation: B). In the first improvement stage, resistance exercise intensity should be set at 30-50% 1-RM, for 10-15 repetitions per muscle group (one to three sets per unit), at a frequency of two to three training units per week (level of evidence: 1, grade of recommendation: B). In the second improvement stage, resistance exercise intensity should be set at 40-60% 1-RM, for 10-15 repetitions per muscle group (one to three sets per unit), at a frequency of two to three training units per week (level of evidence: 1, grade of recommendation: B). In the third improvement stage (in selected patients in good clinical condition, with heavy physical employment, and/or those returning to sports) resistance exercise intensity should be set at 60-80% 1-RM, for eight to ten repetitions per muscle group (one to three sets per unit), at a frequency of two to three training units per week (level of evidence: 1, grade of recommendation: B).

Safety precautions: Safety precautions during exercise training depend on the clinical status of the patients [13, 14, 16] . Therefore, a distinction is made between all patients with CCS, patients after ACS, percutaneous coronary intervention (PCI) or CABG.

All patients with CCS: Endurance training intensity has to be set below the ischaemic threshold (if present) as defined by an exercise stress test before starting the training. The training modalities have to be individually adjusted for each patient with respect to clinical cardiovascular conditions (e.g. ischaemia, CHF, atrial fibrillation, PAD; for patients after ACS or after CABG see below), individual non-cardiac limitations [e.g. frailty, concomitant diseases such as chronic obstructive pulmonary disease (COPD), individual fitness] and individual preferences to increase motivation and adherence. Patients after ACS: Participating in a centre-based, structured and multimodal CR programme is strongly advised for all patients after ACS to implement an individually adjusted training programme, to optimise all other aspects of secondary prevention (information and motivation for lifestyle changes, medication and self-control), and to early recognise and prevent potential complications (e.g. g. recurrent ischaemia, life-threatening cardiac arrhythmia, CHF) (level of evidence: 1, grade of recommendation: B). Patients after CABG: Participating in a centre-based, structured and multimodal CR programme is strongly advised for all patients after CABG to implement an individually adjusted training programme, to optimise all other aspects of secondary prevention, and to prevent and to early recognise and treat potential complications (e.g. recurrent ischaemia due to early bypass dysfunction, arrhythmia, CHF, post-operative infections, wound healing problems, Dressler syndrome) (level of evidence: 1, grade of recommendation: B). In addition, exercise training has to be adjusted according to the time course of wound healing and all other potential complications (level of evidence: 1, grade of recommendation: C), and thoracic shear and pressure stress [e.g. unilateral weight lifting with one arm, excessive bilateral horizontal shoulder flexion/extension (with fixation cushion on chest if performed on a machine)] has to be strictly avoided during the first 6-8 weeks after thoracotomy/sternotomy (level of evidence: 1, grade of recommendation: C). Patients after elective PCI: exercise training may be started immediately after healing of the punctured vessel. This may be as early as 1 day after the intervention (radial artery, level of evidence: 1, grade of recommendation: C), or 1 week after puncture of the femoral artery. However, all patients must be under regular supervision by their local physician (level of evidence: 1, grade of recommendation: C), participation in local cardiovascular prevention centres and/or professionally supervised "heart groups" is strongly advised (level of evidence: 1, grade of recommendation: C), and all public training centres must provide safety equipment including automated external defibrillators.

5.3.2 Congestive Heart Failure

Intervention aim: To improve exercise capacity, or to halt or slow the rate of any further decline in exercise capacity that, at least in part, will optimise long-term outcome and quality of life.

Exercise training recommendations [8, 13, 14, 16, 27, 30, 70-90]: Continuous endurance exercise at a moderate intensity is recommended as the core component of the rehabilitation intervention (level of evidence: 1, grade of recommendation: A). The lower and upper limits of the endurance training intensity in patients with CHF have, however, not been established yet. Aerobic training intensities as low as 40% of peak oxygen uptake (VO 2peak ) (≈ 25% VO 2reserve ) have been effective in improving exercise capacity in patients with CHF with a significantly reduced VO 2peak (see below for definition). An endurance training intensity approaching the first ventilatory threshold (i.e. around 50-60% VO 2peak ) has been proposed as a safe lower limit. There is emerging evidence from clinical trials showing that patients with CHF also may be trained at intensities close to the second ventilatory threshold (critical power) without additional risk. Further investigations are needed to determine the optimal training intensity in representative patient populations. If an assessment of (an)aerobic metabolism by cardiopulmonary exercise testing is not available, relative effort intensities in the 'moderate' domain have been used: these are expressed as percentage of peak heart rate (%HR peak ) or percentage of heart rate reserve (%HRR), or according to Borg RPE scales. In addition, several limitations regarding the device system have to be considered, such as chronotropic incompetence, inappropriate sensor function for rate-adaptive pacing (under-or overresponsive), sinus tachycardia above the upper tracking limit [dual-chamber and cardiac resynchronisation therapy (CRT) devices], under-and oversensing (pacemaker and ICD), arrhythmias (ventricular or supraventricular extra beats, junctional rhythm, supraventricular and ventricular tachyarrhythmias) and/or changes in atrioventricular (AV) conduction.

Safety precautions: the main target here is to prevent inappropriate therapy delivery under exercise conditions, and maintain system integrity.

For all patients with ICD/pacemakers:

- For patients with antibradycardia pacemakers:

-Stress testing of chronotropic competence prior to exercising and, if necessary, reprogramming (rate response mode) is recommended. -Stress testing for the exclusion of under-/oversensing and programming of the upper synchronisation frequency is recommended.

For patients with a cardiac resynchronisation device (CRT-D, CRT-P):

-Control of left ventricular pacing threshold, AV delay (effectiveness of biventricular pacing) and effectiveness of rate response under metabolic conditions are recommended. -Patients should be informed about signs of progressive CHF due to exercising.

For patients with ICD:

-Define the maximum exercise HR at least 10-20 beats below ICD intervention frequency (exercise testing and Holter ECG prior to exercise prescription needed). -Exercise modalities during which a short loss of consciousness is dangerous (e.g. swimming, diving, climbing) should be avoided in symptomatic patients with secondary preventive implantation indication or in patients with current ICD discharge within the last 3 months. -Prophylactic prescription of antiarrhythmic or bradycardic therapy should be contemplated. -After appropriate or inappropriate ICD discharge, advanced risk stratification should be performed before restarting exercising.

For athletes with ICD:

-The desire of the athlete with ICD to continue athletic competition should be secondary to evaluating the suitability for strenuous exercise. -All recommendations should be based on an individual risk stratification including underlying genetic or structural heart disease, arrhythmogenic disposition and haemodynamic parameters. -Individual programming corresponding to the maximum exercise HR (ICD intervention frequency at least 10-20 beats above exercise HR measured by exercise testing and 24 h Holter monitoring).

-Start at least 3 months after the ICD implantation or 3 months after the last ICD-treated arrhythmia with class IA sports (level of evidence: 2, grade of recommendation: C) or with higher peak static and dynamic components than class IA depending on the likelihood of appropriate and inappropriate shocks and the potential for device-related trauma in high-impact sports (level of evidence: 2, grade of recommendation: C).

5.3.4 Left-Ventricular Assist Device

Intervention aim: to achieve early mobilisation and improve functional/exercise capacity, and thereby to lead to an improvement in quality of life.

Exercise training recommendations [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138] [139] : patients with an LVAD should engage in cycle and/or treadmill exercise training at a continuous moderate intensity, with a gradual build-up towards 45-60 min/day, at a frequency of 3-5 days per week, for at least 8-10 weeks (with preferentially a further prolongation in exercise participation to maintain achieved benefits [level of evidence: 4, grade of recommendation: D]). In theory, patients with LVAD are patients with CHF and would thus benefit from resistance exercise training, as well as IMT (see Sect. 5.3.2).

Safety precautions: patients with LVAD are a heterogeneous patient population whose clinical condition can vary widely. Peak exercise capacity often remains limited (e.g. at 50% of prediction), while functional performance is better (e.g. at 80% of prediction). The most common complications are bleeding, thromboembolic events, driveline infections or right-sided CHF. In patients with a newly implanted LVAD system, the initiation of functional or exercise-oriented interventions should primarily be based on individual clinical conditions and disease progression. Before initiating functional and/or exercise therapy, patients must be in a clinically and haemodynamically stable condition. Exclusion criteria for exercise training include: low volume status with orthostatic response, bleeding, signs of systemic infection, ventricular arrhythmias and/or technical LVAD problems. Guidance should be provided by experienced, well-trained therapists who are familiar with the management of the LVAD systems used, general safety aspects and the specific emergency management. Before carrying out functional and exercise measures, the following safety aspects must be strictly observed: checking the batteries, checking the drive length and position, selecting and checking the attachment of the controller and batteries. When performing function and/or exercisebased measures, the following termination criteria must be observed: reduction in pump flow < 3 l/min, inappropriate increase in pump energy demand in watts (watch for thrombus formation), oxygen saturation < 90% (pulse oximeter), and bleeding (e.g. nose bleed). Special care is required in the selection of exercises and the choice of training equipment.

When performing functional and sporting activities, rapid changes in body position (e.g. from sitting to standing with rapid blood volume shifts) should always be avoided due to blood volume shifts and the risk of suction events. All activities that carry an increased risk of bleeding should be strictly avoided (e.g. water sports, contact sports, competitive forms of play, etc.). Treadmill walking can also be dangerous to some patients (e.g. those with frailty in whom an increased fall risk may be present, and patients with (short) episodes of dizziness). Visualisation of the output/resistance curve of the device could be necessary in case of symptomatic syncope during exercise, particularly in hot conditions, and/or when the patient sweats profusely. HR monitoring is not valid for exercise prescription: the exercise intensity should be based on workload or Borg RPE.

5.3.5 Heart Transplantation

Intervention aim: to achieve early mobilisation and thereby to lead to an improvement in exercise capacity and life expectancy, and to improve physical performance in daily life activities.

Exercise training recommendations [140] [141] [142] [143] [144] [145] [146] [147] [148] [149] [150] [151] [152] [153] [154] : It is agreed that these patients should engage in continuous moderate-intensity exercise (at 40-59% VO 2peak or 12-13 Borg RPE), for up to 30-60 min per session, at a frequency of minimally 3 days per week, for at least 20 weeks (with preferentially a further prolongation in exercise participation) (level of evidence: 3, grade of recommendation: C), if possible, and with a gradual build-up towards this intensity and volume of exercise. A good evaluation of exercise tolerance is strongly recommended at entry to CR, since a significant proportion of these patients can suffer from severe exercise intolerance (due to skeletal muscle dysfunction (as a result of, at least in part, anti-rejection therapy, corticoid myopathy and from deconditioning as a result of pre-operative physical inactivity). Cardiac reinnervation occurs in a subgroup of heart transplantation recipients, which is associated with higher peak HR and HRR as well as a greater exercise tolerance. Therefore, a regular assessment of the workload-HR relationship is important to re-establish the target HR during exercise training. In addition, resistance exercises should be considered as well due to the high likelihood of muscle weakness and/or wasting (level of evidence: 4, grade of recommendation: D). In this regard, resistance training up to 50-60% of 1-RM, for 10-20 repetitions per series and 3-6 series per large muscle group should be prescribed.

Safety precautions: the heart transplantation patient very often presents at CR with a delayed exercise-onset and exercise-offset HR response due to denervation. As a result, a warm-up period before each session and steady-state aerobic exercise is recommended at the beginning, and a slowed HR recovery after exercise may also occur. This denervation also gradually leads to an emptying of the catecholamine storage in the myocardium, meaning that the transplanted heart is then reliant on the stimulation of circulating catecholamines. Hence, these catecholamine receptors display an increased sensitivity. In an unfavourable case, this can lead to an increased incidence of cardiac arrhythmia. Therefore, particularly in the first weeks of CR, continuous ECG monitoring during exercise could be considered.

5.3.6 Peripheral Artery Disease

For definition, see Table 3 .

Intervention aim: to improve pain-free walking distance and thereby lead to improvements in daily life activities and quality of life.

Exercise training recommendations [155] [156] [157] [158] [159] [160] [161] [162] [163] [164] [165] [166] [167] [168] [169] [170] : exercise programmes in patients with PAD are of significant benefit compared with placebo or usual care in improving walking time and distance. Supervised exercise training should be performed over 30-45 min, in sessions performed at least three times per week for a minimum of 12 weeks (level of evidence: I, grade of recommendation: A). A regimen of walking to near-maximal pain provides the best improvement (level of evidence: IIa, grade of recommendation: A). Exercise training programmes that use intermittent walking to near-maximal claudication pain performed at a relatively low treadmill grade (i.e. 40% of maximal grade) or a relatively high grade (i.e. 80% of maximal grade) may both be used. However, the volume of exercise provided in terms of energy expenditure should be the same. The higher the intensity of exercise, the greater the cardiovascular responses, the higher the number of motor units recruited in the active muscles, and the greater the metabolic responses (level of evidence: IIa, grade of recommendation: C). The initial workload of the treadmill or speed during outdoor track walking should be set to a speed (and grade) that elicits claudication symptoms within 3-5 min. Patients walk at this workload until they achieve claudication of moderate severity, which is then followed by a brief period of standing or sitting to permit symptoms to resolve. The exercise-rest-exercise pattern should then be repeated throughout the exercise session (level of evidence: IIa, grade of recommendation: A). An improvement in exercise tolerance can be observed within 3 months after initiating the exercise prescription. However, exercise programmes longer than 6 months induced greater improvements in exercise tolerance (level of evidence: IIb, grade of recommendation: C). Training by walking results in greater increases in walking performance, when compared with mixed or alternative activity programmes, including cycling or resistance-type exercise. However, muscle atrophy related to chronically reduced perfusion to skeletal muscles and inactivity in patients with PAD markedly influences exercise performance and patient mobility. Patients with PAD benefit from resistance training as do patients with other forms of CVD, and its use, as tolerated, for general fitness is complementary to walking but not a substitute for it (see below for further details) (level of evidence: IIa, grade of recommendation: C). Adding upper body exercise to walking as is the case with pole striding training (e.g., Nordic walking) significantly improves the clinical indicators of cardiovascular fitness and quality of life, and decreases symptoms of claudication pain during exertion. Dynamic arm exercise training can be followed by similar improvement (pain-free and maximal walking distance) to that seen with treadmill walking exercise training (level of evidence: IIb, grade of recommendation: C). It is recommended to start arm exercise training at one work level (10 W) below the maximal level achieved during baseline arm ergometry test at a rate of 50 cycles per min. Intermittent exercise periods of 2 min can be applied, followed by two minutes of rest, for a total of up to 60 min. After 3 weeks of exercise training, the intensity can be increased to the work level in watts achieved during the baseline arm ergometry test. Thereafter a progressive increase in each cycle by 1 min every 2-3 weeks can be implemented during the training period with decreases in rest periods by 1 min, to a maximal volume of 5 min of exercise and 1 min of rest for 60 min (50 min of exercise). In this regard, moderate-to-high intensity resistance exercise, i.e. 60-80% of 1-RM, is advised. Monthly reassessments of muscle strength, and routine monitoring of HR and blood pressure (BP), are advised. Each exercise session, three sets (8-12 repetitions with 1-2 min rest intervals per set) of resistance exercise should be completed. Whole-body progressive resistance training incorporating six to eight exercises including the primary muscle groups involved in walking (e.g. gastrocnemius, tibialis anterior, quadriceps, hamstrings and gluteals) should then be targeted.

Safety precautions: although the majority of exercise trials have focussed on the efficacy of walking to pain as treatment, there is some evidence that inflammation accompanying the onset of claudication may theoretically contribute to further vascular endothelium damage, and thus not be optimal. Therefore, there is a compelling rationale for further definitive, robust trials of alternative/complementary exercise prescriptions and guidelines for PAD. It is important to pay attention to any poorly healing or non-healing wounds of the legs or feet, since they constitute a contraindication to exercise training due to the potential aggravation of the wounds during walking by reason of mechanical irritation. Because of the frequently concomitant clinical or occult coronary artery disease, it is advised to perform treadmill or bicycle exercise testing with 12-lead ECG monitoring before starting an exercise training program. The test should be repeated after improvement of symptoms and consideration given to alternative stress tests if exercise capacity is limited by claudication symptoms.

5.3.7 Resistance Training for Cardiovascular Disease: Safety Aspects

Although endurance exercise training is often the primary element of rehabilitation programmes to many patients with CCS or CHF, resistance training is considered as an important addition. This paragraph elaborates in greater detail how resistance training can be applied safely in these clinical conditions [169, [171] [172] [173] [174] [175] [176] [177] [178] [179] [180] [181] [182] .

Performing resistance exercise can lead to inappropriate BP increase. However, by taking into account the factors that cause a rise in BP under exercise conditions, this can be avoided. While static (isometric) loads are associated with a significant increase in BP, low to moderately dosed dynamic resistance exercises only result in a modest increase in BP, comparable to that seen in moderate-intensity endurance training. In addition to the exercise mode (isometric/isotonic component), the BP response depends on exercise intensity, (in relation to the individual maximum strength), the amount of the muscle mass used, the number and speed/rhythm of repetitions, the duration of loading as well as the number of sets and the resting period between sets. The Valsalva manoeuvre (a forced expiration invoked against the closed glottis) during resistance exercise causes a more pronounced rise in BP. Moreover, carrying out the Valsalva manoeuvre leads to an increase in intrathoracic pressure, and in turn to a decreased venous return and a potential reduction in cardiac output. The physiological response includes an increase in HR to maintain cardiac output and peripheral vasoconstriction to maintain BP, which otherwise may decrease with decreasing cardiac output. Furthermore, the termination of the compressed breathing causes a dramatic increase in venous return and subsequently an increase in cardiac output being forced through a constricted arterial vascular system. The resulting dramatic rise and drop in BP can limit myocardial oxygen delivery resulting in potentially dangerous arrhythmias and/or reduced perfusion of the coronary arteries leading to ischaemia. Therefore, the Valsalva manoeuvre should be avoided by exhaling during the contraction or exertion phase of the lift and inhaling during the relaxation phase. The resistance exercises should be performed in a rhythmical manner at a moderate controlled speed through a full range of motion, avoid a continuous, tensed-up grip, and if symptoms occur (vertigo, arrhythmias, dyspnoea, angina pectoris), training should be discontinued immediately. Additional special directions for the execution of resistance training should be given: use standardised exercises for mobilisation and stretching for warming up, preparation, and cooling down, and emphasise familiarisation with learning how the movement is performed correctly. Moreover, the assessment of muscle strength should be performed as soon as possible after a sufficiently thorough familiarisation. If exercise is being performed more than 3 days a week, 1-day breaks between training sessions of the same muscle groups should be planned.

5.3.8 Medications

Beta-blockers, alpha-blockers, vasodilators, simvastatin, sulfonylurea, meglitinide and exogenous insulin administration may all affect the acute response to exercise, for which modifications in exercise prescription could be proposed, as explained in a previous paper by this working group [24] . In patients with CCS or CHF taking anticoagulants, sports or exercise with direct bodily contact or prone to trauma should be avoided.

5.3.9 Adverse Events During Exercise Testing

The safety of exercise for patients with CVD is strongly related to having an exercise prescription based on an exercise test. In patients after ACS the incidence of life-threatening adverse events was zero in 277,721 patient-hours of CR exercise when based on an exercise test prescription, whereas two such adverse events occurred during 105,375 patient-hours when exercise training was not based on an exercise test [183] . Patients with CCS and those with CHF are more prone to the development of myocardial ischaemia. As myocardial ischaemia may increase the likelihood of cardiac arrhythmias in CCS and CHF (e.g. atrial fibrillation or ventricular tachyarrhythmia) and/or lead to a reduced cardiac contractility (e.g. reduced stroke volume), such possibilities should be ruled out by cardiopulmonary exercise testing. If such myocardial ischaemia with cardiac arrhythmias is noticed, it is advised to terminate the exercise test and postpone exercise training until clinically effective medical treatment is initiated. In addition, the BP response during exercise should be monitored closely to rule out exercise hypertension [e.g. if systolic blood pressure (SBP) rises > 200 mmHg at a workload of 100 W] [26] or a decrease in SBP during exercise.

5.3.10 Physical Fitness

It is generally recommended to start exercise training at a rather low exercise intensity, and to build it up to the originally recommended exercise intensity, in patients with a VO 2peak < 75% of the predicted normal value, as explained in a previous paper by this working group [24] . To demonstrate how the EXPERT tool [22, 23] proposes exercise prescriptions in patients with CCS and/or CHF with different combinations of CVD risk factors, three patient cases with solutions are presented in Table 5 (exercise safety precautions are not shown). The EXPERT tool always starts with the general recommendation for endurance exercise prescription in (secondary) prevention of CVD (150 min low-to-moderate-intensity endurance exercise training per week, spread over 3-5 days, expending 1000-2000 kcal, for a duration of at least 12 weeks) [16] . However, the tool further adjusts exercise prescription based on the input of further variables. Case 1: A 75-year-old, slightly underweight [body mass index (BMI) 19.04 kg/m 2 ], male is referred to multidisciplinary rehabilitation for CABG. In this patient, the primary aim is to improve physical fitness. It is therefore important to offer a sufficient exercise volume ( > 150 min per week), to select a sufficient exercise intensity (moderate intensity, HR 95-105 bpm) and whole-body exercises (walking, stepping, rowing, cross-training), and to offer additional resistance exercise training (i.e. because of the low BMI and having undergone CABG, a lowered skeletal muscle mass may be present) [184] . However, the patient displays a significantly lowered physical fitness (e.g. VO 2peak at 67% of predicted value). Therefore, it is advised to start at a lower endurance exercise intensity and build up towards moderate-intensity endurance training within a few weeks. The preparticipation screening also reveals arterial hypertension. As a result, reducing BP becomes an important additional rehabilitation goal. For these reasons, a build-up towards at least moderate-intensity endurance training, and with a sufficient exercise session duration (30-45 min) (at least 21 sets) (leading to greater reductions in glycated haemoglobin (HbA1c)) is advised. However, the patient must be monitored carefully, taking into account potential issues that could lead to increased exercise risk (e.g. postoperative anaemia, sarcopenia or cachexia, BP medication). Case 2: a 68-year-old obese male with preserved physical fitness is referred for multidisciplinary rehabilitation after PCI. As a result, the general recommendation for endurance exercise prescription after PCI (150 min low-to-moderate intensity endurance exercise training per week, spread over 3-5 days, expending 1000-2000 kcal, for a duration of at least 12 weeks, with the addition of resistance exercise training) is applicable. Because of the obese state (BMI 30.77 kg/m 2 ), a significant energy expenditure by exercise training is warranted ( > 1500 kcal per week) by offering whole-body exercises (e.g. walking, rowing, stepping, etc.) and by increasing the frequency and duration of the exercise sessions. A prolongation of the rehabilitation programme is then also indicated, as well as an appropriate dietary intervention.

Case 3: a 72-year-old female with preserved physical fitness is referred to multidisciplinary rehabilitation for heart failure with reduced ejection fraction (HFrEF) and CRT-P. As a result, the general recommendation for endurance exercise prescription in CHF (150 min low-to-moderateintensity endurance exercise training per week, spread over 3-5 days, achieving 1000-2000 kcal, for a duration of at least 12 weeks, with the addition of resistance exercise training) is applicable. However, if the patient takes statins, and should thus be considered to experience dyslipidaemia, a total weekly energy expenditure > 900 kcal is desired. Finally, IMT should also be added in the exercise prescription. All precautions regarding patients with CRT-P should be considered.

7 Conclusion

In this manuscript, state-of-the-art exercise prescription, based on a robust review of evidence, has been proposed for patients with CCS and/or CHF, and associated co-morbidities. With the EXPERT tool, clinicians and healthcare professionals are assisted in the selection of proper exercise training modalities in these populations.

|physiologists or physiotherapists do not administer or use|assessment/testing skills [e.g. HR and blood pressure (BP)| |---|---|

|them themselves). Although CR programmes within hos-|Patients with CCS and/or CHF are more prone to develop measurement, exercise, functional capacity and muscle|

|pitals should be coordinated by a cardiologist, the direct|cardiovascular, metabolic or pulmonary complications dur-strength testing], physical activity planning and exercise pre-|

|assistance and guidance during exercise training to patients|ing physical exercise. Therefore, it is advised that rehabilita-scription, abilities to lead and deliver the supervised exercise|

|(especially in peripheral centres or private practices) is|tion or exercise training facilities are specifically designed session, forward planning, management of emergency pro-|

|nearly always offered by allied healthcare professionals|and equipped (Table 1), and healthcare professionals are cedures (e.g. symptom recognition, care in case of syncope,|

|(such as physiotherapists, cardiac nurses, clinical exercise|properly educated [28]. Even though intravenous tubing resuscitation)|

|physiologists). To ensure sufficient patient safety, it is rec-|and emergency drugs/solutions may not be administered or|

|ommended that these allied healthcare professionals have|used by clinical exercise physiologists or physiotherapists,|

|acquired specific clinical competencies, composed of: core|it is recommended that these materials should be availa-|

|knowledge (e.g. clinical exercise physiology, pathology,||

|pharmacology), professional behaviour, communication||

|skills, abilities in supervised exercise training application,||

||Obesity| |---|---|

||Type 1 or 2 diabetes|

|Adjustments in exercise prescripƟon|Hypertension Dyslipidemia VO2peak CardioprotecƟve medicaƟons|

||Cardiovascular comorbidiƟes|

|1. During patient care, e.g. during washing, turns and trans-| |---|

|fers (i.e. blood pressure, O 2 saturation and ECG should stay normal or within normal ranges during such care,|

|and should thus be followed/observed by the healthcare|

|professional accordingly).|

|2. Consider the inclusion of breathing exercises with or|

|without a respiratory trainer set, stretching exercises,|

|balance/coordination exercises for head, neck and trunk,|

|sitting balance exercises (with sit to stand exercises),|

|:| |---|

|Absolute contra-indications:|

|-Acute coronary syndrome < 48 h|

|-Known untreated and clinically relevant main stem stenosis|

|-Uncontrolled cardiac arrhythmias at rest or during exercise|

|-Severe aortic valve stenosis or other severe valvular heart disease|

|-Decompensated heart failure|

|-Acute pulmonary embolism or pulmonary infarction|

|-Acute aortic dissection|

|-Acute non-cardiac conditions that limit exercise capacity or are worsened by physical exertion (e.g. infection, sepsis, hyperthyroidism/hypothyroidism)|

|-Acute deep vein thrombosis|

|-Acute myocarditis or pericarditis|

|-Active endocarditis|

|-Recent stroke or TIA|

|-Physical disability that prevents safe and appropriately dosed exercise training|

|-Other clinical situations that worsen under physical exertion|

|Relative contra-indications:|

|-Significant anaemia|

|-Severe, disease-relevant electrolytic derailments|

|-Therapeutically uncontrolled tachy-or bradycardia/arrhythmias, e.g|

|• Untreated sick sinus syndrome|

|• Untreated and/or higher-grade (e.g. II) AV blockages|

|• Atrial fibrillation with uncontrolled ventricular rate|

|-HOCM with maximum resting LVOT gradient > 25 mmHg|

|-Known aortic dissection (Stanford B type, stable)|

|-Orthostatic hypotension (particularly in the elderly)|

|-Severe arterial hypertension at rest (systolic blood pressure ≥ 180 mm Hg and diastolic blood|

|Pressure ≥ 110 mmHg)|

|-Blood pressure drop of systolic ≥ 20 mmHg during mobilisation|

|-Uncontrolled diabetes mellitus|

|-Cognitive impairment that prevents/significantly limits cooperation during exercise testing and training|

|-Relevant pericardial effusion|

||Patient characteristics||EXPERT exercise prescription|EXPERT exercise prescription| |---|---|---|---|---|

|||||95-105 bpm|

||Body height:|176 cm|Frequency (days/week)|Start with 3, building up to daily exercise|

|||||(for optimal glycaemic control)|

||Body weight:|59 kg|Session duration|Start at 20 min, building to 45 min (for|

|||||blood pressure control)|

||BMI:|19.04 kg/m 2|Programme duration|> 24 weeks|

||Sex:|Male|Strength training|Yes|

||VO 2max :|1302 ml/min (67% of normal value) Additional training Advice Start at lower exercise intensity and build towards original proposal. Strength train-|1302 ml/min (67% of normal value) Additional training Advice Start at lower exercise intensity and build towards original proposal. Strength train-|1302 ml/min (67% of normal value) Additional training Advice Start at lower exercise intensity and build towards original proposal. Strength train-|

|||||ing for the arm muscles is allowed only|

|||||when the sternum is stabilised|

|||||For resistance training: 2 days/week, build|

|||||towards 40-80% of 1-RM, 12-15 reps/|

|||||set to 60-70% of 1-RM, 8-12 reps/set.|

|||||Also, ≥ 21 sets is advised for optimal|

|||||glycaemic control|

||Resting HR:|74 bpm|||

||Peak exercise HR:|126 bpm|||

||Total cholesterol:|102 mg/dl|||

||LDL cholesterol:|35 mg/dl|||

||Fasting glycaemia:|135 mg/dl|||

||Blood pressure:|164/106 mmHg|||

||Medication intake:|Statin, beta-blocker, metformin|||

||Comorbidities:|Type 2 diabetes|||

||Indication for rehabilitation: CABG|Indication for rehabilitation: CABG|||

||Body height:|173 cm|Frequency|Start at 3 days/week, but increase up to > 5|

|||||times|

||Body weight:|92 kg|Session duration|20 min, building towards 60 min|

||BMI:|30.77 kg/m 2|Programme duration|> 24 weeks|

||VO 2max :|1823 (95% of normal value)|Additional training advice Elevated energy expenditure by exercise training ( > 1500 kcal/week) is advised|Additional training advice Elevated energy expenditure by exercise training ( > 1500 kcal/week) is advised|

|||||(prefer whole-body exercises), as well|

|||||as dietary intervention, for optimal body|

|||||weight control|

|||||For strength training: 2 days/week, build|

|||||set|

||Resting HR:|65 bpm|||

||Peak exercise HR:|122 bpm|||

||Total cholesterol:|161|||

||LDL cholesterol:|80|||

||Fasting glycaemia:|95|||

||Blood pressure:|114/77 mmHg|||

||Medication intake:|Beta blocker|||

||Comorbidities:|None|||

||Indication for rehabilitation: PCI|Indication for rehabilitation: PCI|||

||Body height:|159 cm|Frequency|3 days/week|

||Body weight:|61.6 kg|Session duration|20 min, building towards 45 min|

||BMI:|24.4 kg/m 2|Programme duration|> 24 weeks|

||Sex:|Female|Strength training|Yes|

||VO 2max :|1176 ml/min (95% of normal value) Additional training advice > 900 kcal/week of energy expenditure should be achieved for optimal effect on|||

|||||HDL-c,|

|||||For IMT: advice to use a pressure|

|||||threshold: start at 30% of PImax and|

|||||readjusted every 7-10 days up to 60% of|

|||||PImax. Training duration again should|

|||||be 20-30 min/day, 3-5 times a week|

||Resting HR:|66 bpm|||

||Peak exercise HR:|117 bpm|||

||Total cholesterol:|129 mg/dl|||

||LDL cholesterol:|48 mg/dl|||

||Fasting glycaemia:|115 mg/dl|||

||Blood pressure:|170/55 mmHg|||

||Medication intake:|Beta-blocker, statin|||

||Co-morbidities:|Resynchronisation therapy|||

||Indication for rehabilitation: Heart failure (HFrEF)||||

Supplementary Information

Exercise prescription approach to patients with CCS and/or CHF using the EXPERT tool. CCS chronic coronary syndrome, CHF congestive heart failure, VO 2peak peak oxygen uptake

minutes of low-to-moderate-intensity endurance exercise training per week, ideally spread over 3-5 days per week, complemented by resistance exercise training two Ɵmes per week at a moderate intensity

Summarised exercise prescription recommendations for each disease separately

Definitions

Preparticipation screening and parameter monitoring in phase 1 cardiovascular rehabilitation CR cardiovascular rehabilitation, TIA transient ischaemic attack, HOCM hypertrophic obstructive cardiomyopathy, LVOT left ventricular outflow tract, HR heart rate, BP blood pressure Preparticipation screening in Phase 1 CR 1. Medical history: changes in body weight and weight goal, diet, previous (pre-hospitalisation) clinical status, symptom(s) description and recognition, physical activity level and weekly exercise training hours. Barriers to care (language, literacy, culture, transportation, insurance, ability to pay, caregiver, self-care, knowing when to contact a provider) 2. Pre-hospitalisation level of function (e.g. mobility aids), activity and exercise response 3. Primary diagnosis 4. Medications 5.

this intake/screening phase, it is important to know what to monitor during exercise/activities: 1. Subjective: dizziness, vertigo, shortness of breath, fatigue, nausea, pain [consider use of scales, e.g. Borg rating of perceived exertion (RPE)] 2. Objective: cognition, balance, perspiration, cyanosis, HR, oxygen saturation, respiratory rate and BP and all other factors relevant to patient and mobility tasks, e.g., cardiac rhythm in those patients when ECG is essential during mobilisation. For the neurological status, assess the ability to follow commands, for spontaneous movements, pupil size, cranial nerve function and ability to recognise parents. Assess oriented times, and follow nursing standards of care These objective parameters should include: BP and mean arterial pressure, HR, cardiac rhythm (symptoms, assess radial pulse or monitor cardiac rhythm using devices (monitors or pulse oximetry)), respiratory rate and effort (use pulse oximetry, perform arterial blood gases (if needed), assess breath sounds), clinical status as well as haemodynamic and respiratory adaptations to mobilisation (central venous pressure (if available) and peripheral perfusion), body temperature, invasive catheters and tube drainage conditions

Exercise prescriptions for simulated CVD risk patients by the EXPERT tool

is warranted. Moreover, as the patient takes metformin, he should be considered to have type 2 diabetes. With these CVD risk factors, in theory, resistance exercise training BMI body mass index, VO 2max maximal oxygen uptake, HR heart rate, LDL low-density lipoprotein, CABG coronary artery bypass graft, RM repetition maximum, PCI percutaneous coronary intervention, HDL high-density lipoprotein, IMT inspiratory muscle training, PImax maximal inspiratory pressure continued)

The online version contains supplementary material available at https:// doi. org/ 10. 1007/ s40279-023-01909-x.

Author contributions All authors contributed to the conception or design of the work, contributed to the acquisition, analysis or interpretation of data for the work drafted the manuscript, and critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.

Declarations

Funding The realisation of the proof of concept of the EXPERT tool was supported by an UHasselt Industrial Research Fund (IOF) Proof of Concept (PoC) project. This work was supported by the Flemish Research Fund (FWO, FWO-ICA: G0F4220N).

Conflict of interest

The authors disclose that there are no financial or non-financial interests that are directly or indirectly related to the work submitted for publication.

References

引用 / 出处

2023 共识声明：慢性冠脉综合征和／或心力衰竭患者的标准化运动处方. 2023.