Publications by authors named "Josef Niebauer"

177 Publications

Exercise and sports after COVID-19-Guidance from a clinical perspective.

Transl Sports Med 2021 May 4;4(3):310-318. Epub 2021 May 4.

Institute of Sports Medicine, Prevention and Rehabilitation Paracelsus Medical University Salzburg Salzburg Austria.

SARS-CoV-2 infection has emerged as not only a pulmonary but also potentially multi-organ disease, which may cause long-term structural damage of different organ systems including the lung, heart, vasculature, brain, liver, kidney, or intestine. As a result, the current SARS-CoV-2/COVID-19 pandemic will eventually yield substantially increased numbers of chronically diseased patients worldwide, particularly suffering from pulmonary fibrosis, post-myocarditis, chronic heart failure, or chronic kidney disease. Exercise recommendations for rehabilitation are complex in these patients and should follow current guidelines including standards for pre-exercise medical examinations and individually tailored exercise prescription. It is of utmost importance to start exercise training at an early stage after COVID-19 infection, but at the same time paying attention to the physical barriers to ensure safe return to exercise. For exercise recommendations beyond rehabilitation programs particularly for leisure time and elite athletes, more precise advice is required including assessment of sports eligibility and specific return-to-sports exercise programs. Because of the current uncertainty of long-term course of SARS-CoV-2 infection or COVID disease, long-term follow-up seems to be necessary.
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http://dx.doi.org/10.1002/tsm2.247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8250714PMC
May 2021

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1.

J Clin Med 2021 May 19;10(10). Epub 2021 May 19.

Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice (ifam), Medical Faculty of the Heinrich-Heine University, Werdener Straße. 4, D-40227 Düsseldorf, Germany.

Background: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases.

Methods: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the " (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation.

Results: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs.

Conclusions: These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.
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http://dx.doi.org/10.3390/jcm10102192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8161282PMC
May 2021

Patient-Generated Health Data (PGHD) Interoperability: An Integrative Perspective.

Stud Health Technol Inform 2021 May;281:228-232

Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria.

With advances in Digital Health (DH) tools, it has become much easier to collect, use, and share patient-generated health data (PGHD). This wealth of data could be efficiently used in monitoring and controlling chronic illnesses as well as predicting health outcome. Although integrating PGHD into clinical practice is currently in a promising stage, there are several technical challenges and usage barriers that hinder the full utilization of the PGHD potential in clinical care and research. This paper aims to address PGHD opportunities and challenges while developing the DH-Convener project to integrate PGHD into the Electronic Health Record in Austria (ELGA). Accordingly, it provides an integrative technical-clinical-user approach for developing a fully functional health ecosystem for exchanging integrated data among patients, healthcare providers, and researchers.
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http://dx.doi.org/10.3233/SHTI210154DOI Listing
May 2021

Exercise-induced changes in miRNA expression in coronary artery disease.

Clin Chem Lab Med 2021 May 11. Epub 2021 May 11.

University Institute of Sports Medicine, Prevention and Rehabilitation and Research Institute of Molecular Sports Medicine and Rehabilitation, Paracelsus Medical University, Salzburg, Austria.

Objectives: Micro ribonucleic acids (miRNAs) are small non-coding RNA molecules that control gene expression by translational inhibition. Exercise has been shown to affect several miRNAs' expression in healthy subjects, but this has not yet been studied in patients with coronary artery disease (CAD). Since exercise training confers beneficial long-term effects and may also trigger acute coronary events, it is of utmost interest to be able to identify those who are risk for untoward effects. Therefore, we set out to assess miRNA expression in response to maximal ergospirometry in patients with CAD.

Methods: Total RNA was extracted from blood drawn immediately before and 5 min after maximal cycle-ergospirometry (10 male and 10 female CAD patients). A qRT-PCR was performed for 187 target miRNAs associated with endothelial function/dysfunction, cardiovascular disease, myocardial infarction, and sudden cardiac death.

Results: In response to a maximal ergospirometry, 33 miRNAs significantly changed their expression levels. Of these miRNAs 16 were significantly differently expressed between gender. Using multi-variance analysis, nine miRNAs (let-7e-5p; miR-1; miR-19b-1-5p; miR-103a-3p; miR-148b-3p; miR-181b-5p; miR-188-5p; miR-423-5p; miR-874-3p) showed significantly different responses to maximal ergospirometry between genders.

Conclusions: We report for the first time that in patients with CAD, miRNA expression is amenable to maximal ergospirometry and that the extent of changes differs between genders. Affected by exercise and gender were miRNAs that are associated, among others, with pathways for glucose metabolism, oxidative stress, and angiogenesis. Future studies should assess whether disease-specific miRNA expression in response to maximal exercise might serve as a marker for patient outcome.
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http://dx.doi.org/10.1515/cclm-2021-0164DOI Listing
May 2021

Athletes with valvular heart disease and competitive sports: a position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology.

Eur J Prev Cardiol 2021 Apr 13. Epub 2021 Apr 13.

Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany.

This article provides an overview of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology on sports participation in individuals with valvular heart disease (VHD). The aim of these recommendations is to encourage regular physical activity including sports participation, with reasonable precaution to ensure a high level of safety for all affected individuals. Valvular heart disease is usually an age-related degenerative process, predominantly affecting individuals in their fifth decade and onwards. However, there is an increasing group of younger individuals with valvular defects. The diagnosis of cardiac disorders during routine cardiac examination often raises questions about on-going participation in competitive sport with a high dynamic or static component and the level of permissible physical effort during recreational exercise. Although the natural history of several valvular diseases has been reported in the general population, little is known about the potential influence of chronic intensive physical activity on valve function, left ventricular remodelling pulmonary artery pressure, and risk of arrhythmia. Due to the sparsity of data on the effects of exercise on VHD, the present document is largely based on clinical experience and expert opinion.
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http://dx.doi.org/10.1093/eurjpc/zwab058DOI Listing
April 2021

Current Activities Centered on Healthy Living and Recommendations for the Future: A Position Statement from the HL-PIVOT Network.

Curr Probl Cardiol 2021 Jun 27;46(6):100823. Epub 2021 Feb 27.

Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-University of Queensland School of Medicine, New Orleans, LA.

We continue to increase our cognizance and recognition of the importance of healthy living (HL) behaviors and HL medicine (HLM) to prevent and treat chronic disease. The continually unfolding events precipitated by the coronavirus disease 2019 (COVID-19) pandemic have further highlighted the importance of HL behaviors, as indicated by the characteristics of those who have been hospitalized and died from this viral infection. There has already been recognition that leading a healthy lifestyle, prior to the COVID-19 pandemic, may have a substantial protective effect in those who become infected with the virus. Now more than ever, HL behaviors and HLM are essential and must be promoted with a renewed vigor across the globe. In response to the rapidly evolving world since the beginning of the COVID-19 pandemic, and the clear need to change lifestyle behaviors to promote human resilience and quality of life, the HL for Pandemic Event Protection (HL-PIVOT) network was established. The 4 major areas of focus for the network are: (1) knowledge discovery and dissemination; (2) education; (3) policy; (4) implementation. This HL-PIVOT network position statement provides a current synopsis of the major focus areas of the network, including leading research in the field of HL behaviors and HLM, examples of best practices in education, policy, and implementation, and recommendations for the future.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100823DOI Listing
June 2021

Personalized exercise prescription in the prevention and treatment of arterial hypertension: a Consensus Document from the European Association of Preventive Cardiology (EAPC) and the ESC Council on Hypertension.

Eur J Prev Cardiol 2021 Mar 24. Epub 2021 Mar 24.

Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK.

Treatment of hypertension and its complications remains a major ongoing health care challenge. Around 25% of heart attacks in Europe are already attributed to hypertension and by 2025 up to 60% of the population will have hypertension. Physical inactivity has contributed to the rising prevalence of hypertension, but patients who exercise or engage in physical activity reduce their risk of stroke, myocardial infarction, and cardiovascular mortality. Hence, current international guidelines on cardiovascular disease prevention provide generic advice to increase aerobic activity, but physiological responses differ with blood pressure (BP) level, and greater reductions in BP across a population may be achievable with more personalized advice. We performed a systematic review of meta-analyses to determine whether there was sufficient evidence for a scientific Consensus Document reporting how exercise prescription could be personalized for BP control. The document discusses the findings of 34 meta-analyses on BP-lowering effects of aerobic endurance training, dynamic resistance training as well as isometric resistance training in patients with hypertension, high-normal, and individuals with normal BP. As a main finding, there was sufficient evidence from the meta-review, based on the estimated range of exercise-induced BP reduction, the number of randomized controlled trials, and the quality score, to propose that type of exercise can be prescribed according to initial BP level, although considerable research gaps remain. Therefore, this evidence-based Consensus Document proposes further work to encourage and develop more frequent use of personalized exercise prescription to optimize lifestyle interventions for the prevention and treatment of hypertension.
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http://dx.doi.org/10.1093/eurjpc/zwaa141DOI Listing
March 2021

Viral myocarditis: a forbidden indication for cardiac rehabilitation?

Eur J Prev Cardiol 2021 Feb 26. Epub 2021 Feb 26.

Department of Rehabilitation Medicine, Faculty of Health Science, University of Potsdam, Potsdam, Germany.

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http://dx.doi.org/10.1093/eurjpc/zwaa159DOI Listing
February 2021

Delphi consensus recommendations on how to provide cardiovascular rehabilitation in the COVID-19 era.

Eur J Prev Cardiol 2021 05;28(5):541-557

IHF - Institut für Herzinfarktforschung, Ludwigshafen, Germany.

This Delphi consensus by 28 experts from the European Association of Preventive Cardiology (EAPC) provides initial recommendations on how cardiovascular rehabilitation (CR) facilities should modulate their activities in view of the ongoing coronavirus disease 2019 (COVID-19) pandemic. A total number of 150 statements were selected and graded by Likert scale [from -5 (strongly disagree) to +5 (strongly agree)], starting from six open-ended questions on (i) referral criteria, (ii) optimal timing and setting, (iii) core components, (iv) structure-based metrics, (v) process-based metrics, and (vi) quality indicators. Consensus was reached on 58 (39%) statements, 48 'for' and 10 'against' respectively, mainly in the field of referral, core components, and structure of CR activities, in a comprehensive way suitable for managing cardiac COVID-19 patients. Panelists oriented consensus towards maintaining usual activities on traditional patient groups referred to CR, without significant downgrading of intervention in case of COVID-19 as a comorbidity. Moreover, it has been suggested to consider COVID-19 patients as a referral group to CR per se when the viral disease is complicated by acute cardiovascular (CV) events; in these patients, the potential development of COVID-related CV sequelae, as well as of pulmonary arterial hypertension, needs to be focused. This framework might be used to orient organization and operational of CR programmes during the COVID-19 crisis.
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http://dx.doi.org/10.1093/eurjpc/zwaa080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717287PMC
May 2021

Secondary prevention through comprehensive cardiovascular rehabilitation: From knowledge to implementation. 2020 update. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology.

Eur J Prev Cardiol 2020 Apr 7. Epub 2020 Apr 7.

REHPA-Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark, Odense University Hospital, Denmark.

Secondary prevention through comprehensive cardiac rehabilitation has been recognized as the most cost-effective intervention to ensure favourable outcomes across a wide spectrum of cardiovascular disease, reducing cardiovascular mortality, morbidity and disability, and to increase quality of life. The delivery of a comprehensive and 'modern' cardiac rehabilitation programme is mandatory both in the residential and the out-patient setting to ensure expected outcomes. The present position paper aims to update the practical recommendations on the core components and goals of cardiac rehabilitation intervention in different cardiovascular conditions, in order to assist the whole cardiac rehabilitation staff in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and patients in the recognition of the positive nature of cardiac rehabilitation. Starting from the previous position paper published in 2010, this updated document maintains a disease-oriented approach, presenting both well-established and more controversial aspects. Particularly for implementation of the exercise programme, advances in different training modalities were added and new challenging populations were considered. A general table applicable to all cardiovascular conditions and specific tables for each clinical condition have been created for routine practice.
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http://dx.doi.org/10.1177/2047487320913379DOI Listing
April 2020

Sudden Cardiac Death Risk in Downhill Skiers and Mountain Hikers and Specific Prevention Strategies.

Int J Environ Res Public Health 2021 02 8;18(4). Epub 2021 Feb 8.

Department of Sport Science, University of Innsbruck, A-6020 Innsbruck, Austria.

Sudden cardiac death (SCD) still represents an unanticipated and catastrophic event eliciting from cardiac causes. SCD is the leading cause of non-traumatic deaths during downhill skiing and mountain hiking, related to the fact that these sports are very popular among elderly people. Annually, more than 40 million downhill skiers and mountain hikers/climbers visit mountainous regions of the Alps, including an increasing number of individuals with pre-existing chronic diseases. Data sets from two previously published case-control studies have been used to draw comparisons between the SCD risk of skiers and hikers. Data of interest included demographic variables, cardiovascular risk factors, medical history, physical activity, and additional symptoms and circumstances of sudden death for cases. To establish a potential connection between the SCD risk and sport-specific physical strain, data on cardiorespiratory responses to downhill skiing and mountain hiking, assessed in middle-aged men and women, have been included. It was demonstrated that previous myocardial infarction (MI) (odds ratio; 95% CI: 92.8; 22.8-379.1; < 0.001) and systemic hypertension (9.0; 4.0-20.6; < 0.001) were predominant risk factors for SCD in skiers, but previous MI (10.9; 3.8-30.9; < 0.001) and metabolic disorders like hypercholesterolemia (3.4; 2.2-5.2; < 0.001) and diabetes (7.4; 1.6-34.3; < 0.001) in hikers. More weekly high-intensity exercise was protective in skiers (0.17; 0.04-0.74; = 0.02), while larger amounts of mountain sports activities per year were protective in hikers (0.23; 0.1-0.4; <0.001). In conclusion, previous MI history represents the most important risk factor for SCD in recreational skiers and hikers as well, and adaptation to high-intensity exercise is especially important to prevent SCD in skiers. Moreover, the presented differences in risk factor patterns for SCDs and discussed requirements for physical fitness in skiers and hikers will help physicians to provide specifically targeted advice.
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http://dx.doi.org/10.3390/ijerph18041621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915124PMC
February 2021

The need for exercise sciences and an integrated response to COVID-19: A position statement from the international HL-PIVOT network.

Prog Cardiovasc Dis 2021 Feb 4. Epub 2021 Feb 4.

Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA.

COVID-19 is one of the biggest health crises that the world has seen. Whilst measures to abate transmission and infection are ongoing, there continues to be growing numbers of patients requiring chronic support, which is already putting a strain on health care systems around the world and which may do so for years to come. A legacy of COVID-19 will be a long-term requirement to support patients with dedicated rehabilitation and support services. With many clinical settings characterized by a lack of funding and resources, the need to provide these additional services could overwhelm clinical capacity. This position statement from the Healthy Living for Pandemic Event Protection (HL-PIVOT) Network provides a collaborative blueprint focused on leading research and developing clinical guidelines, bringing together professionals with expertise in clinical services and the exercise sciences to develop the evidence base needed to improve outcomes for patients infected by COVID-19.
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http://dx.doi.org/10.1016/j.pcad.2021.01.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859729PMC
February 2021

Prehabilitation Coming of Age: IMPLICATIONS FOR CARDIAC AND PULMONARY REHABILITATION.

J Cardiopulm Rehabil Prev 2021 05;41(3):141-146

Cardiology Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, and Cardiology Division, Stanford University, Stanford, California (Dr Myers); University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University, Salzburg, Austria (Dr Niebauer); and College of Health Professions & Biomedical Sciences, University of Montana, Missoula (Dr Humphrey).

While cardiac and pulmonary rehabilitation programs traditionally involve exercise therapy and risk management following an event (eg, myocardial infarction and stroke), or an intervention (eg, coronary artery bypass surgery and percutaneous coronary intervention), prehabilitation involves enhancing functional capacity and optimizing risk profile prior to a scheduled intervention. The concept of prehabilitation is based on the principle that patients with higher functional capabilities will better tolerate an intervention, and will have better pre- and post-surgical outcomes. In addition to improving fitness, prehabilitation has been extended to include multifactorial risk intervention prior to surgery, including psychosocial counseling, smoking cessation, diabetes control, nutrition counseling, and alcohol abstinence. A growing number of studies have shown that patients enrolled in prehabilitation programs have reduced post-operative complications and demonstrate better functional, psychosocial, and surgery-related outcomes. These studies have included interventions such as hepatic transplantation, lung cancer resection, and abdominal aortic aneurysm (repair, upper gastrointestinal surgery, bariatric surgery, and coronary artery bypass grafting). Studies have also suggested that incorporation of prehabilitation before an intervention in addition to traditional rehabilitation following an intervention further enhances physical function, lowers risk for adverse events, and better prepares a patient to resume normal activities, including return to work. In this overview, we discuss prehabilitation coming of age, including key elements related to optimizing pre-surgical fitness, factors to consider in developing a prehabilitation program, and exercise training strategies to improve pre-surgical fitness.
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http://dx.doi.org/10.1097/HCR.0000000000000574DOI Listing
May 2021

Mobile Technologies to Promote Physical Activity during Cardiac Rehabilitation: A Scoping Review.

Sensors (Basel) 2020 Dec 24;21(1). Epub 2020 Dec 24.

Ludwig Boltzmann Institute for Digital Health and Prevention, 5020 Salzburg, Austria.

Promoting regular physical activity (PA) and improving exercise capacity are the primary goals of cardiac rehabilitation (CR). Mobile technologies (mTechs) like smartphones, smartwatches, and fitness trackers might help patients in reaching these goals. This review aimed to scope current scientific literature on mTechs in CR to assess the impact on patients' exercise capacity and to identify gaps and future directions for research. PubMed, CENTRAL, and CDSR were systematically searched for randomized controlled trials (RCTs). These RCTs had to utilize mTechs to objectively monitor and promote PA of patients during or following CR, aim at improvements in exercise capacity, and be published between December 2014 and December 2019. A total of 964 publications were identified, and 13 studies met all inclusion criteria. Home-based CR with mTechs vs. outpatient CR without mTechs and outpatient CR with mTechs vs. outpatient CR without mTechs did not lead to statistically significant differences in exercise capacity. In contrast, outpatient CR followed by home-based CR with mTechs led to significant improvement in exercise capacity as compared to outpatient CR without further formal CR. Supplying patients with mTechs may improve exercise capacity. To ensure that usage of and compliance with mTechs is optimal, a concentrated effort of CR staff has to be achieved. The COVID-19 pandemic has led to an unprecedented lack of patient support while away from institutional CR. Even though mTechs lend themselves as suitable assistants, evidence is lacking that they can fill this gap.
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http://dx.doi.org/10.3390/s21010065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7795145PMC
December 2020

Effect of Different Endurance Training Protocols During Cardiac Rehabilitation on Quality of Life.

Am J Med 2021 06 6;134(6):805-811. Epub 2021 Feb 6.

University Institute of Sports Medicine, Prevention and Rehabilitation and Research Institute of Molecular Sports Medicine and Rehabilitation, Paracelsus Medical University Salzburg, Austria; Exercise Biology Group, Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany; Ludwig Boltzmann Institute for Digital Health and Prevention. Electronic address:

Background: This study aimed to assess the effect of different types of endurance training during outpatient cardiac rehabilitation on patients' health-related quality of life (HRQL).

Methods: The MacNew Heart Disease HRQL questionnaire and the Hospital Anxiety and Depression Scale were used to assess changes in HRQL in 66 patients before and after 6 weeks of cardiac rehabilitation. Patients were randomized to 1 of 3 types of supervised endurance training: continuous endurance training, high-intensity interval training, and pyramid training. Two-way analysis of variance for repeated measure and chi-square test were used to analyze changes before and after rehabilitation.

Results: Attendance rate during the 6 weeks of exercise training was 99.2%. Physical work capacity increased from 136.1 to 165.5 watts (+22.9%; P < .001), and there were no statistical differences between training protocols. Fully completed questionnaires at both time points were available in 46 patients (73.9%; 61.3±11.6 years, 34 males, 12 females). Regardless of the type of supervised endurance training, there was significant improvement during rehabilitation in each of the categories of the MacNew questionnaire (ie, emotion, physical, social, global; all P < .05) and the Hospital Anxiety and Depression Scale (anxiety: P = .05; depression: P = .032), without significant differences between protocols.

Conclusions: All 3 types of endurance training led to significant and well comparable increases in physical work capacity, which was associated with an increase in HRQL independent of the type of training. Our findings support further individualization of training regimes, which could possibly lead to better compliance during life-long home-based exercise training.
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http://dx.doi.org/10.1016/j.amjmed.2020.10.048DOI Listing
June 2021

[ESC guidelines on sports cardiology 2020 : Which sports can be performed with heart diseases?]

Herz 2021 Feb 17;46(1):38-45. Epub 2020 Dec 17.

Universitätsinstitut für präventive und rehabilitative Sportmedizin, Uniklinikum Salzburg, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.

The guidelines for sports cardiology have recently been published for the first time by the European Society of Cardiology (ESC). They address recommendations for leisure time exercise and competitive sports in athletes with cardiovascular diseases. The spectrum ranges from women during pregnancy, athletes with increased cardiovascular risk and risk factors or with a genetic predisposition, such as ion channelopathies, cardiomyopathies, congenital heart diseases as well as patients with valvular heart diseases, coronary heart disease, after myocardial infarction, with arrhythmia and with heart failure. A detailed cardiological evaluation of the athlete with heart disease is the basis for detailed and individually tailored recommendations with respect to the type of sport, mode, duration and intensity of physical exercise, physical training and the capability for competitive sports. Evidence from the current literature and the experience of the sports cardiologist are the basis for shared decision making between the sports cardiologist and the athlete/patient, which is becoming increasingly more important. Together, they will decide which sport can be practiced defining intensity and duration.
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http://dx.doi.org/10.1007/s00059-020-05008-9DOI Listing
February 2021

Physical Activity in Cardiac Rehabilitation: Towards Citizen-Centered Digital Evidence-Based Interventions.

Stud Health Technol Inform 2020 Nov;275:228-229

CAPHRI Department of Health Promotion, Maastricht University, Maastricht, The Netherlands.

Physical activity is a vital part of cardiac rehabilitation (CR). However, heart-healthy physical activity levels in people with cardiovascular disease drop significantly after CR. This exploratory study employs qualitative and survey methods within a co-creation approach. The aim is to understand the mechanisms of healthy behavior and habit formation in order to create a novel evidence-based (post-)rehabilitation approach that employs digital means to sustain long-term physical activity levels in people with cardiovascular disease.
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http://dx.doi.org/10.3233/SHTI200730DOI Listing
November 2020

Impact of exercise training and supplemental oxygen on submaximal exercise performance in patients with COPD.

Scand J Med Sci Sports 2021 Mar 20;31(3):710-719. Epub 2020 Nov 20.

Institute of Sports Medicine, Prevention and Rehabilitation and Research Institute for Molecular Sports Medicine and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria.

Functional impairment caused by chronic obstructive pulmonary disease (COPD) impacts on activities of daily living and quality of life. Indeed, patients' submaximal exercise capacity is of crucial importance. It was the aim of this study to investigate the effects of an exercise training intervention with and without supplemental oxygen on submaximal exercise performance. This is a secondary analysis of a randomized, controlled, double-blind, crossover trial. 29 COPD patients (63.5 ± 5.9 years; FEV 46.4 ± 8.6%) completed two consecutive 6-week periods of high-intensity interval cycling and strength training, which was performed three times/week with either supplemental oxygen or medical air (10 L/min). Submaximal exercise capacity as well as the cardiocirculatory, ventilatory, and metabolic response were evaluated at isotime (point of termination in the shortest cardiopulmonary exercise test), at physical work capacity at 110 bpm of heart rate (PWC 110), at the anaerobic threshold (AT), and at the lactate-2 mmol/L threshold. After 12 weeks of exercise training, patients improved in exercise tolerance, shown by decreased cardiocirculatory (heart rate, blood pressure) and metabolic (respiratory exchange ratio, lactate) effort at isotime; ventilatory response was not affected. Submaximal exercise capacity was improved at PWC 110, AT and the lactate-2 mmol/L threshold, respectively. Although supplemental oxygen seems to affect patients' work rate at AT and the lactate-2 mmol/L threshold, no other significant effects were found. The improved submaximal exercise capacity and tolerance might counteract patients' functional impairment. Although cardiovascular and metabolic training adaptations were shown, ventilatory efficiency remained essentially unchanged. The impact of supplemental oxygen seems less important on submaximal training effects.
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http://dx.doi.org/10.1111/sms.13870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984048PMC
March 2021

Serum neurofilament level increases after ascent to 4559 m but is not related to acute mountain sickness.

Eur J Neurol 2021 Mar 26;28(3):1004-1008. Epub 2020 Nov 26.

Department of Neurology, Medical University of Graz, Graz, Austria.

Background And Purpose: At high altitude the brain is exposed to hypoxic stress, which may result in neurological conditions, with acute mountain sickness (AMS) being the most common. We aimed to test the hypothesis that rapid ascent to high altitude alters neuro-axonal integrity, which can be detected by increased concentration of serum neurofilament light (sNfL) in the blood and may even be exaggerated in people with AMS.

Methods: Serum neurofilament light was measured using a single-molecule array (Simoa, Quanterix, Lexington, MA, USA) assay at low altitude (423 m) in 47 healthy study participants and 44 h after rapid and active ascent to high altitude (4559 m). Peripheral oxygen saturation (SpO ) and partial pressures of oxygen (pO ) were obtained at low and high altitude. The Acute Mountain Sickness-Cerebral (AMS-C) scoring system was used to assess AMS incidence and AMS severity.

Results: There was an increase in sNfL from its baseline value compared with its value at high altitude (6.34 ± 1.96 vs. 7.19 ± 3.14 pg/ml; p = 0.014), but sNfL level did not correlate with SpO (r = -0.19; p = 0.066) or pO (r = -0.19; p = 0.068). The incidence of AMS at high altitude was 62%. Neither at low altitude (p = 0.706) nor at high altitude (p = 0.985) was there a difference in sNfL between participants with and without AMS as measured 3 days after rapid ascent and 44 h of high-altitude exposure. Altitude sNfL did not correlate with AMS-C, either overall or with single-item scores such as headache severity.

Conclusions: Rapid ascent of healthy people to high altitude provokes an increase in sNfL 44 h after arrival at 4559 m, which is not related to the magnitude of hypoxemia or AMS incidence and severity, suggesting that neuro-axonal injury does not directly contribute to AMS.
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http://dx.doi.org/10.1111/ene.14606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898504PMC
March 2021

Timed physical exercise does not influence circadian rhythms and glucose tolerance in rotating night shift workers: The EuRhythDia study.

Diab Vasc Dis Res 2020 May-Jun;17(5):1479164120950616

Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Objectives: Night shift workers are at cardiometabolic risk due to circadian misalignment. We investigated whether infrequent exercise before each night shift that intentionally would not improve physical performance improves glucose tolerance and 24-h blood pressure profiles and synchronizes circadian rhythms of melatonin and cortisol in rotating night shift workers.

Methods: A total of 24 rotating night shift workers (mean age, 35.7 ± 11.8 years) were randomized to exercise or no intervention. Workers in the exercise group performed 15.2 ± 4.5 exercise sessions within 2 h before each night shift. Before and after 12 weeks of exercise intervention and 12 weeks after the intervention, spiroergometry, oral glucose tolerance testing and 24-h blood pressure profiles were performed. Plasma melatonin and cortisol levels were measured in 3-hourly intervals during one 24-h period on each study day.

Results: Exercise did not significantly change serum glucose nor insulin levels during oral glucose tolerance testing. Timed physical exercise had no effect on physical performance, nor did it change the circadian rhythms of melatonin and cortisol or influence 24-h blood pressure profiles.

Conclusion: Physical exercise before each night shift at a low intensity level that does not improve physical performance does not affect circadian timing, glucose tolerance or 24-h blood pressure profiles in rotating night shift workers.
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http://dx.doi.org/10.1177/1479164120950616DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919228PMC
January 2021

Acute Effects of Winter Sports and Indoor Cycling on Arterial Stiffness.

J Sports Sci Med 2020 09 13;19(3):460-468. Epub 2020 Aug 13.

Department of Sport and Exercise Science, University of Salzburg, Austria.

Sedentary lifestyle predisposes to endothelial dysfunction, increased arterial stiffness and cardiovascular diseases, all of which can be positively modified by regular physical exercise training. A decrease in physical activity during winter months coincides with higher rates of cardiovascular events. In order to identify winter sports suitable to overcome this seasonal exercise deficit and thus contribute to cardiovascular health, it was the aim of this study to compare immediate effects of cross-country skiing (XCS) and alpine skiing (AS) on arterial stiffness as an alternative to indoor cycling (IC). After baseline assessment, eighteen healthy subjects performed one session of XCS, AS, and IC in randomized order. Pulse wave analysis was conducted (Mobil-o-Graph) before and 10-min after exercise. Parameters of arterial stiffness and wave reflection were reduced after XCS and IC, but not after AS: central systolic blood pressure (IC: -8.0 ± 5.4 mmHg; p < 0.001), amplitude of the backward pressure wave (IC: -1.4 ± 2.7 mmHg; p < 0.05), reflection coefficient (XCS: -6.0 ± 7.8%; IC: -5.7 ± 8.1%; both p < 0.1), and pulse wave velocity (IC by -0.19 ± 0.27 m/s; p < 0.01). Higher exercise intensities correlated with greater reductions of arterial stiffness (all p < 0.05). Single sessions of XCS, IC but not AS led to comparable improvement in arterial stiffness, which was even more pronounced during higher exercise intensities. With regard to arterial stiffness, IC and XCS emerge as more effective to counteract the winter exercise deficit and thus the deleterious cardiovascular effects of a sedentary lifestyle.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429433PMC
September 2020

Recommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease (CHD): position statement of the Sports Cardiology & Exercise Section of the European Association of Preventive Cardiology (EAPC), the European Society of Cardiology (ESC) Working Group on Adult Congenital Heart Disease and the Sports Cardiology, Physical Activity and Prevention Working Group of the Association for European Paediatric and Congenital Cardiology (AEPC).

Eur Heart J 2020 11;41(43):4191-4199

Cardiology Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK.

Improved clinical care has led to an increase in the number of adults with congenital heart disease (CHD) engaging in leisure time and competitive sports activities. Although the benefits of exercise in patients with CHD are well established, there is a low but appreciable risk of exercise-related complications. Published exercise recommendations for individuals with CHD are predominantly centred on anatomic lesions, hampering an individualized approach to exercise advice in this heterogeneous population. This document presents an update of the recommendations for competitive sports participation in athletes with cardiovascular disease published by the Sports Cardiology & Exercise section of the European Association of Preventive Cardiology (EAPC) in 2005. It introduces an approach which is based on the assessment of haemodynamic, electrophysiological and functional parameters, rather than anatomic lesions. The recommendations provide a comprehensive assessment algorithm which allows for patient-specific assessment and risk stratification of athletes with CHD who wish to participate in competitive sports.
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http://dx.doi.org/10.1093/eurheartj/ehaa501DOI Listing
November 2020

Effects of Exercise Training on Vascular Markers of Disease Progression in Patients with Small Abdominal Aortic Aneurysms.

Am J Med 2021 04 22;134(4):535-541. Epub 2020 Aug 22.

Veterans Affairs Palo Alto Health Care System, Division of Cardiology, Department of Medicine, Stanford University, Stanford, Calif. Electronic address:

Background: Currently, no medical therapy is effective in limiting progression of small abdominal aortic aneurysms (AAA; ≤5.5 cm). Previously, we have demonstrated safety and efficacy of exercise training in patients with AAA. However, the impact of exercise training on vascular markers of AAA progression, such as lipid accumulation product and matrix metalloproteinase 9 (MMP-9, linked to destruction of aortic matrix), is unknown. The aim of this study was to assess the impact of exercise training on AAA diameter, lipid accumulation product, MMP-9, and other risk markers of vascular disease.

Methods: In this randomized trial, complete data of 96 patients (male: n = 87, female: n = 9; exercise training (exercise) n = 42, usual care n = 54) were studied. Changes in AAA diameter, exercise capacity, lipid accumulation product (men = [waist circumference 65] × fasting triglycerides; women = [waist circumference -58] × triglycerides) and MMP-9 were performed.

Results: The exercise group demonstrated a significant increase in maximal exercise time and estimated metabolic equivalent of tasks. Lipid accumulation product decreased in exercise and increased in usual care (P < .001 between groups); MMP-9 remained statistically unchanged in exercise, but increased significantly in usual care (P = .005; between groups P = .094). In both groups, there was a significant increase in transverse diameter, but no difference between groups; neither group assignment nor level of fitness correlated with AAA enlargement. No adverse clinical events occurred.

Conclusions: This is the first study to demonstrate that in AAA, exercise beneficially modifies lipid accumulation product and MMP-9, both markers of vascular disease, without inducing aneurysmal growth beyond what is otherwise observed during usual care.
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http://dx.doi.org/10.1016/j.amjmed.2020.07.029DOI Listing
April 2021

Effect of Exercise on Cardiovascular Function Following Spinal Cord Injury: A REVIEW.

J Cardiopulm Rehabil Prev 2021 01;41(1):13-18

Departments of Spine and Spinal Cord Surgery (Dr Liu) and Clinical Laboratory (Dr Wang), Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China; Faculty of Rehabilitation Medicine, Capital Medical University, Beijing, China (Drs Liu and Wang); Research Institute of Molecular Sports Medicine and Rehabilitation, Paracelsus Medical University, and Institute of Sports Medicine, Prevention and Rehabilitation, University Hospital Salzburg, Salzburg, Austria (Dr Niebauer).

Spinal cord injury (SCI) is associated with a reduced level of physical activity, deterioration of patient body composition, metabolic profile, quality of life, and psychological functioning. As a result, risk of cardiovascular disease (CVD) increases and CVD-related death occurs at an earlier age than in individuals without SCI. Regular participation in exercise has been shown to exert beneficial effects also in patients with SCI. In this review, we analyze and discuss the effects of regular exercise training in SCI on cardiovascular function, autonomic function of the cardiovascular system, arterial stiffness, metabolism, inflammation, and gene expression.
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http://dx.doi.org/10.1097/HCR.0000000000000534DOI Listing
January 2021

Systemic Inflammation, Vascular Function, and Endothelial Progenitor Cells after an Exercise Training Intervention in COPD.

Am J Med 2021 03 8;134(3):e171-e180. Epub 2020 Aug 8.

University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University of Salzburg, Austria; Research Institute for Molecular Sports Medicine and Rehabilitation, Paracelsus Medical University of Salzburg, Austria. Electronic address:

Background: Exercise training is a cornerstone of the treatment of chronic obstructive pulmonary disease (COPD) in all disease stages. Data about the training effects with supplemental oxygen in nonhypoxemic patients remains inconclusive. In this study we set out to investigate the training and oxygen effects on inflammatory markers, vascular function, and endothelial progenitor cells in this population of increased cardiovascular risk.

Methods: In this prospective, randomized, double-blind, crossover study, 29 patients with nonhypoxemic COPD performed combined endurance and strength training 3 times a week while breathing medical air or supplemental oxygen for the first 6-week period, and were then reallocated to the opposite gas for the following 6 weeks. Exercise capacity, inflammatory biomarkers, endothelial function (peripheral arterial tone analysis), and endothelial progenitor cells were assessed. Data were also analyzed for a subgroup with endothelial dysfunction (reactive hyperemia index <1.67).

Results: Following 12 weeks of exercise training, patients demonstrated a significant improvement of peak work rate and an associated decrease of blood fibrinogen and leptin. Eosinophils were found significantly reduced after exercise training in patients with endothelial dysfunction. In this subgroup, peripheral arterial tone analysis revealed a significant improvement of reactive hyperemia index. Generally, late endothelial progenitor cells were found significantly reduced after the exercise training intervention. Supplemental oxygen during training positively influenced the effect on exercise capacity without impact on inflammation and endothelial function.

Conclusions: This is the first randomized controlled trial in patients with COPD to show beneficial effects of exercise training not only on exercise capacity, but also on systemic/eosinophilic inflammation and endothelial dysfunction.
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http://dx.doi.org/10.1016/j.amjmed.2020.07.004DOI Listing
March 2021

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators.

Europace 2021 01;23(1):147-148

Department of Cardiology, University of Padova, Padova, Italy.

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.
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http://dx.doi.org/10.1093/europace/euaa106DOI Listing
January 2021