Publications by authors named "Paul Dendale"

162 Publications

Future of preventive cardiology: EAPC vision 2020-22.

Eur J Prev Cardiol 2021 May;28(4):356-358

Depatment of Cardiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.

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http://dx.doi.org/10.1093/eurjpc/zwaa116DOI Listing
May 2021

Pacemaker guided screening for severe sleep apnea, a possible option for patients with atrial fibrillation: A systematic review and meta-analysis.

Pacing Clin Electrophysiol 2021 May 7. Epub 2021 May 7.

Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, Hasselt, 3500, Belgium.

Introduction: Obstructive sleep apnea is often underdiagnosed in atrial fibrillation (AF) patients although it is an important risk factor. A systematic review and meta-analysis was performed to assess which techniques cardiac implantable electronic devices (CIED) and Holter monitors use to screen for sleep apnea (SA), and to evaluate if these are suitable for AF patients from a diagnostic accuracy perspective.

Methods: The search was conducted in accordance with the PRISMA-guidelines. PICO was defined as (P) patients with AF, (I) Holter monitors or CIED suitable for screening for SA, (C) overnight polysomnography (PSG), (O) positive screening with subsequent positive polysomnographic diagnosis of SA. Optimal index test cut-off points corresponding to reference test cut-off for severe SA (PSG-AHI30) were compared. Meta-analysis was conducted for the diagnostic odds ratio (DOR), with forest plot and ROC-curve for summary DOR.

Results: A total of 5 prospective cohort studies (n = 192) were included in the systematic review of which 4 studies (n = 132) were included in the meta-analysis. All included studies use transthoracic impedance measurement as a screening parameter. No studies evaluating Holter monitors were included. The population consisted of patients indicated for pacemaker implantation. The summary DOR was 27,14 (8,83; 83,37), AUC was 0,8689 (0,6872; 0,9456) and Q* was 0,8390 (0,7482; 0,9013).

Conclusion: At optimal pacemaker-cut-off, pacemaker-guided screening for severe SA in patients with AF can be an effective triage tool for clinical practice. Further studies with larger sample sizes are needed to strengthen the evidence for this conclusion. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/pace.14256DOI Listing
May 2021

The Jessa Hospital experience for cardiac rehabilitation.

Eur Heart J 2021 Apr;42(15):1451-1453

EAPC president, Hasselt University, Heartcentre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium.Tel: +32 11 33 70 73, email:

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http://dx.doi.org/10.1093/eurheartj/ehaa439DOI Listing
April 2021

Iron Deficiency Is Associated With Impaired Biventricular Reserve and Reduced Exercise Capacity in Patients With Unexplained Dyspnea.

J Card Fail 2021 Apr 7. Epub 2021 Apr 7.

Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.

Background: Iron deficiency (ID) is frequent and associated with diminished exercise capacity in heart failure (HF), but its contribution to unexplained dyspnea without a HF diagnosis at rest remains unclear.

Methods And Results: Consecutive patients with unexplained dyspnea and normal echocardiography and pulmonary function tests at rest underwent prospective standardized cardiopulmonary exercise testing with echocardiography in a tertiary care dyspnea clinic. ID was defined as ferritin of <300 µg/L and a transferrin saturation of <20% and its impact on peak oxygen uptake (peakVO), biventricular response to exercise, and peripheral oxygen extraction was assessed. Of 272 patients who underwent cardiopulmonary exercise testing with echocardiography, 63 (23%) had ID. For a similar respiratory exchange ratio, patients with ID had lower peakVO (14.6 ± 7.6 mL/kg/minvs 17.8 ± 8.8 mL/kg/min; P = .009) and maximal workload (89 ± 50 watt vs 108 ± 56 watt P = .047), even after adjustment for the presence of anemia. At rest, patients with ID had a similar left ventricular and right ventricular (RV) contractile function. During exercise, patients with ID had lower cardiac output reserve (P < .05) and depressed RV function by tricuspid s' (P = .004), tricuspid annular plane systolic excursion (P = .034), and RV end-systolic pressure-area ratio (P = .038), with more RV-pulmonary artery uncoupling measured by tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure ratio (P = .023). RV end-systolic pressure-area ratio change from rest to peak exercise, as a load-insensitive metric of RV contractility, was lower in patients with ID (2.09 ± 0.72 mm Hg/cm vs 2.58 ± 1.14 mm Hg/cm; P < .001). ID was associated with impaired peripheral oxygen extraction (peakVO/peak cardiac output; P = .036). Cardiopulmonary exercise testing with echocardiography resulted in a diagnosis of HF with preserved ejection fraction in 71 patients (26%) based on an exercise E/e' ratio of >14, with equal distribution in patients with (28.6%) or without ID (25.4%, P = .611). None of these findings were influenced in a sensitivity analysis adjusted for a final diagnosis of HFpEF as etiology for the unexplained dyspnea.

Conclusions: In patients with unexplained dyspnea without clear HF at rest, ID is common and associated with decreased exercise capacity, diminished biventricular contractile reserve, and decreased peripheral oxygen extraction.
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http://dx.doi.org/10.1016/j.cardfail.2021.03.010DOI Listing
April 2021

EAPC Core Curriculum for Preventive Cardiology.

Eur J Prev Cardiol 2021 04 1. Epub 2021 Apr 1.

Department of Prevention and Sports Medicine, University Hospital rechts der Isar, Technical University Munich, German Centre for Cardiovascular Research, Georg-Brauchle-Ring 56, 80992 Munich, Germany.

Preventive cardiology encompasses the whole spectrum of cardiovascular disease (CVD) prevention, at individual and population level, through all stages of life. This includes promotion of cardiovascular (CV) health, management of individuals at risk of developing CVD, and management of patients with established CVD, through interdisciplinary care in different settings. Preventive cardiology addresses all aspects of CV health in the context of the social determinants of health, including physical activity, exercise, sports, nutrition, weight management, smoking cessation, psychosocial factors and behavioural change, environmental, genetic and biological risk factors, and CV protective medications. This is the first European Core Curriculum for Preventive Cardiology, which will help to standardize, structure, deliver, and evaluate training in preventive cardiology across Europe. It will be the basis for dedicated fellowship programmes and a European Society of Preventive Cardiology (EAPC) subspecialty certification for cardiologists, with the intention to improve quality and outcome in CVD prevention.
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http://dx.doi.org/10.1093/eurjpc/zwab017DOI Listing
April 2021

Cardiac Function is Preserved in Adolescents With Well-Controlled Type 1 Diabetes and a Normal Physical Fitness: A Cross-sectional Study.

Can J Diabetes 2021 Jan 23. Epub 2021 Jan 23.

Faculty of Rehabilitation Sciences, Rehabilitation Research Centre, Hasselt University, Diepenbeek, Belgium; Faculty of Medicine and Life Sciences, Biomedical Research Centre, Hasselt University, Diepenbeek, Belgium; Jessa Hospital, Heart Centre Hasselt, Hasselt, Belgium.

Objectives: Cardiovascular diseases and exercise intolerance elevate mortality in type 1 diabetes (T1D). Left ventricular systolic and diastolic function are already affected in T1DM adolescents, displaying poor glycemic control (glycated hemoglobin [A1C]>7.5%) and exercise intolerance. We investigated to the extent to which left ventricular function is affected by disease severity/duration and whether this is related to exercise capacity.

Methods: Transthoracic echocardiography was performed in 19 T1DM adolescents (14.8±1.9 years old, A1C 7.4±0.9%) and 19 controls (14.4±1.3 years old, A1C 5.3±0.2%), matched for age and Tanner stage. Diastolic and systolic (ejection fraction [EF]) function were assessed. Cardiopulmonary exercise testing was used to evaluate exercise capacity, as measured by peak oxygen uptake (VO).

Results: VO and left ventricular systolic and diastolic function were similar in both groups. Within the T1D group, EF was negatively associated with disease duration (r=-0.79 corrected for age, standardized body mass index, glucose variability and VO; p=0.011). Regression analyses revealed that 37.6% of the variance in EF could be attributed to disease duration.

Conclusions: Although left ventricular systolic and diastolic function are preserved in T1D with adequate exercise capacity, disease duration negatively affects EF. The detrimental effects of T1D seem to be driven by disease duration, rather than by disease severity, at least during adolescence. Young T1D patients may, therefore, benefit from cardiovascular evaluation in order to detect cardiovascular abnormalities early in the disease course, and therefore, improve long-term cardiovascular health.
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http://dx.doi.org/10.1016/j.jcjd.2021.01.010DOI Listing
January 2021

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

Eur J Prev Cardiol 2020 Nov 5. Epub 2020 Nov 5.

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
November 2020

Providing comprehensive cardiac rehabilitation during and after the COVID-19 pandemic.

Eur J Prev Cardiol 2020 Nov 25. Epub 2020 Nov 25.

Heart Centre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium.

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http://dx.doi.org/10.1093/eurjpc/zwaa107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717272PMC
November 2020

Exercise capacity is related to attenuated responses in oxygen extraction and left ventricular longitudinal strain in asymptomatic type 2 diabetes patients.

Eur J Prev Cardiol 2020 Nov 20. Epub 2020 Nov 20.

Department of REVAL - Rehabilitation Research Centre, Faculty of Rehabilitation Sciences, Hasselt University, Belgium.

Aims: Type 2 diabetes mellitus (T2DM) is associated with reduced exercise capacity and cardiovascular diseases, both increasing morbidity and risk for premature death. As exercise intolerance often relates to cardiac dysfunction, it remains to be elucidated to what extent such an interplay occurs in T2DM patients without overt cardiovascular diseases. Design: Cross-sectional study, NCT03299790.

Methods And Results: Fifty-three T2DM patients underwent exercise echocardiography (semi-supine bicycle) with combined ergospirometry. Cardiac output (CO), left ventricular longitudinal strain (LS), oxygen uptake (O2), and oxygen (O2) extraction were assessed simultaneously at rest, low-intensity exercise, and high-intensity exercise. Glycaemic control and lipid profile were assessed in the fasted state. Participants were assigned according to their exercise capacity being adequate or impaired (EXadequate: O2peak <80% and EXimpaired: O2peak ≥80% of predicted O2peak) to compare O2 extraction, CO, and LS at all stages. Thirty-eight participants (EXimpaired: n = 20 and EXadequate: n = 18) were included in the analyses. Groups were similar regarding HbA1c, age, and sex (P > 0.05). At rest, CO was similar in the EXimpaired group vs. EXadequate group (5.1 ± 1 L/min vs. 4.6 ± 1.4 L/min, P > 0.05) and increased equally during exercise. EXimpaired patients displayed a 30.7% smaller increase in O2 extraction during exercise compared to the EXadequate group (P = 0.016) which resulted in a lower O2 extraction at high-intensity exercise (12.5 ± 2.8 mL/dL vs. 15.3 ± 3.9 mL/dL, P = 0.012). Left ventricular longitudinal strain was similar at rest but increased significantly less in the EXimpaired vs. EXadequate patients (1.9 ± 2.5% vs. 5.9 ± 4.1%, P = 0.004).

Conclusions: In asymptomatic T2DM patients, an impaired exercise capacity is associated with an impaired response in oxygen extraction and myocardial deformation (LS).

Trial Registry: Effect of High-intensity Interval Training on Cardiac Function and Regulation of Glycemic Control in Diabetic Cardiomyopathy (https://clinicaltrials.gov/ct2/show/NCT03299790).
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http://dx.doi.org/10.1093/eurjpc/zwaa007DOI Listing
November 2020

The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology.

Eur J Prev Cardiol 2020 Jul 3. Epub 2020 Jul 3.

Faculty of Medicine and Life Sciences, UHasselt - Hasselt University, Belgium.

The role of comprehensive cardiac rehabilitation is well established in the secondary prevention of cardiovascular diseases such as coronary artery disease and heart failure. Numerous trials have demonstrated both the effectiveness as well as the cost-effectiveness of comprehensive cardiac rehabilitation in improving exercise capacity and quality of life, and in reducing cardiovascular mortality and morbidity. However, the current COVID-19 pandemic has led to closure of many cardiac rehabilitation centres in Europe resulting in many eligible patients unable to participate in the optimisation of secondary prevention and physical performance. This elicits an even louder call for alternatives such as cardiac telerehabilitation to maintain the delivery of the core components of cardiac rehabilitation to cardiovascular disease patients. The present call for action paper gives an update of recent cardiac telerehabilitation studies and provides a practical guide for the setup of a comprehensive cardiac telerehabilitation intervention during the COVID-19 pandemic. This set up could also be relevant to any cardiovascular disease patient not able to visit cardiac rehabilitation centres regularly after the COVID-19 pandemic ceases.
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http://dx.doi.org/10.1177/2047487320939671DOI Listing
July 2020

EAPC's 'Country of the Month' prevention web section going global.

Eur J Prev Cardiol 2020 Apr 17. Epub 2020 Apr 17.

Hasselt University, Heartcentre Hasselt, Belgium.

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http://dx.doi.org/10.1177/2047487320915808DOI Listing
April 2020

Standardization and quality improvement of secondary prevention through cardiovascular rehabilitation programmes in Europe: The avenue towards EAPC accreditation programme: A position statement of the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology (EAPC).

Eur J Prev Cardiol 2020 Jun 1. Epub 2020 Jun 1.

Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Italy.

Despite the proven efficacy and cost-effectiveness of contemporary cardiovascular rehabilitation programmes, the referral to/uptake of and adherence to cardiovascular rehabilitation remains inadequate. In addition, heterogeneity persists amongst different cardiovascular rehabilitation centres in Europe, despite the available scientific documents describing the evidence-based rehabilitation format/content. This position statement was elaborated by the Secondary Prevention and Rehabilitation (SP/CR) section of EAPC. It defines the minimal and optimal cardiovascular rehabilitation standards. In addition, it describes the relevant quality indicators of cardiovascular rehabilitation programmes to date. Compliance of European cardiovascular rehabilitation centres with these standards will improve cardiovascular rehabilitation process standardization in Europe and hence increase the quality of cadiovascular rehabilitation programmes.
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http://dx.doi.org/10.1177/2047487320924912DOI Listing
June 2020

Optimising implementation of European guidelines on cardiovascular disease prevention in clinical practice: what is needed?

Eur J Prev Cardiol 2020 Jun 3. Epub 2020 Jun 3.

Trinity College Dublin, Ireland.

Cardiovascular disease is a model example of a preventable condition for which practice guidelines are particularly important. In 2016, the joint task force created by the European Society of Cardiology (ESC) together with 10 other societies released the new version of the European guidelines on cardiovascular disease prevention. To facilitate the implementation of the ESC guidelines, a dedicated prevention implementation committee has been established within the European Association of Preventive Cardiology. The paper will first explore potential barriers to the guidelines' implementation. It then develops a discussion that seeks to inform the future development of the committee's work, including a new definition of the guidelines' stakeholders (health policy-makers, healthcare professionals and health educators, patient organisations, entrepreneurs and the general public), future activities within four specific areas: strengthening awareness of the guidelines among stakeholders; supporting organisational changes to facilitate the guidelines' implementation; motivating stakeholders to utilise the guidelines; and present ideas on new implementation strategies. Providing multifaceted cooperation between healthcare professionals, healthcare management executives and health policy-makers, the novel approach proposed in this paper should contribute to a wider use of the 2016 ESC guidelines and produce desired effects of less cardiovascular disease morbidity and mortality. Furthermore, the solutions presented within the paper may constitute a benchmark for the implementation of practice guidelines in other medical disciplines.
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http://dx.doi.org/10.1177/2047487320926776DOI Listing
June 2020

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

Is there an optimal dose of cardiac rehabilitation in coronary artery disease patients?

Int J Cardiol 2021 May 2;330:7-11. Epub 2021 Feb 2.

UHasselt - Hasselt University, Faculty of Medicine and Life Sciences, Agoralaan, 3590 Diepenbeek, Belgium; Jessa Hospital, Department of Cardiology, Stadsomvaart 11, Hasselt, 3500, Belgium.

Background: Many studies have shown that participation in cardiac rehabilitation reduces long-term morbidity and mortality after myocardial infarction. Therefore, both American and European evidence-based guidelines recommend cardiac rehabilitation. However, it is still unclear what the optimal dose of cardiac rehabilitation is.

Methodology: The study is a monocenter, retrospective cohort study. We identified patients with stable ischemic heart disease, who participated in at least one phase II center-based cardiac rehabilitation session between 2010 and 2015. A total of 609 patients were included in this study.

Results: We retrospectively reviewed the medical records of 609 patients. Statistically significant baseline differences between the four groups were observed for index coronary artery revascularization technique, age, dual antiplatelet therapy and smoking status. A total of number of 84 patients (13.8%) had a MACE in the four-year follow-up period. After adjustment for all significant predictors in the univariate analysis, patients who attended 36 or more sessions had a 47% lower risk of MACE (hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.31 to 0.92), patients who attended 24 to 35 sessions had a 68% lower risk of MACE (hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.15 to 0.67), patients who attended 12 to 23 sessions had a 56% lower risk of MACE (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.21 to 0.92) than those who attended 1 to 11 sessions.

Conclusion: There is a clear clinical benefit from participating in more than 11 CR sessions. The best outcomes are achieved in patient who participated between 24 and 35 CR sessions. These results underline again the importance of improving participation and adherence to CR programmes in Europe.
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http://dx.doi.org/10.1016/j.ijcard.2021.01.065DOI Listing
May 2021

Chronotropic incompetence is more frequent in obese adolescents and relates to systemic inflammation and exercise intolerance.

J Sport Health Sci 2021 Jan 30. Epub 2021 Jan 30.

Rehabilitation Research Centre (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, Hasselt 3500, Belgium; Biomedical Research Institute (BIOMED), Faculty of Medicine and Life Sciences, Hasselt University, Hasselt 3500, Belgium; Heart Centre Hasselt, Jessa Hospital, Hasselt 3500, Belgium.

Background: Adults with obesity may display disturbed cardiac chronotropic responses during cardiopulmonary exercise testing, which relates to poor cardiometabolic health and an increased risk for adverse cardiovascular events. It is unknown whether cardiac chronotropic incompetence (CI) during maximal exercise is already present in obese adolescents and, if so, how that relates to cardiometabolic health.

Methods: Sixty-nine obese adolescents (body mass index standard deviation score = 2.23 ± 0.32, age = 14.1 ± 1.2 years; mean ± SD) and 29 lean adolescents (body mass index standard deviation score = -0.16 ± 0.84, age = 14.0 ± 1.5 years) performed a maximal cardiopulmonary exercise testing from which indicators for peak performance were determined. The resting heart rate and peak heart rate were used to calculate the maximal chronotropic response index. Biochemistry (lipid profile, glycemic control, inflammation, and leptin) was studied in fasted blood samples and during an oral glucose tolerance test within obese adolescents. Regression analyses were applied to examine associations between the presence of CI and blood or exercise capacity parameters, respectively, within obese adolescents.

Results: CI was prevalent in 32 out of 69 obese adolescents (46%) and 3 out of 29 lean adolescents (10%). C-reactive protein was significantly higher in obese adolescents with CI compared to obese adolescents without CI (p = 0.012). Furthermore, peak oxygen uptake and peak cycling power output were significantly reduced (p < 0.05) in obese adolescents with CI vs. obese adolescents without CI. The chronotropic index was independently related to blood total cholesterol (standardized coefficient β = -0.332; p = 0.012) and C-reactive protein concentration (standardized coefficient β = -0.269; p = 0.039).

Conclusion: CI is more common in the current cohort of obese adolescents, and is related to systemic inflammation and exercise intolerance.
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http://dx.doi.org/10.1016/j.jshs.2021.01.010DOI Listing
January 2021

Asymptomatic type 2 diabetes mellitus display a reduced myocardial deformation but adequate response during exercise.

Eur J Appl Physiol 2021 Mar 8;121(3):929-940. Epub 2021 Jan 8.

REVAL-Rehabilitation Research Centre, Faculty of Rehabilitation Sciences, Hasselt University, Agoralaan, Building A, 3590, Diepenbeek, Belgium.

Background And Purpose: The development of myocardial fibrosis is a major complication of Type 2 diabetes mellitus (T2DM), impairing myocardial deformation and, therefore, cardiac performance. It remains to be established whether abnormalities in longitudinal strain (LS) exaggerate or only occur in well-controlled T2DM, when exposed to exercise and, therefore, cardiac stress. We therefore studied left ventricular LS at rest and during exercise in T2DM patients vs. healthy controls.

Methods And Results: Exercise echocardiography was applied with combined breath-by-breath gas exchange analyses in asymptomatic, well-controlled (HbA1c: 6.9 ± 0.7%) T2DM patients (n = 36) and healthy controls (HC, n = 23). Left ventricular LS was assessed at rest and at peak exercise. Peak oxygen uptake (V̇O) and workload (W) were similar between groups (p > 0.05). Diastolic (E, e', E/e') and systolic function (left ventricular ejection fraction) were similar at rest and during exercise between groups (p > 0.05). LS (absolute values) was significantly lower at rest and during exercise in T2DM vs. HC (17.0 ± 2.9% vs. 19.8 ± 2% and 20.8 ± 4.0% vs. 23.3 ± 3.3%, respectively, p < 0.05). The response in myocardial deformation (the change in LS from rest up to peak exercise) was similar between groups (+ 3.8 ± 0.6% vs. + 3.6 ± 0.6%, in T2DM vs. HC, respectively, p > 0.05). Multiple regression revealed that HDL-cholesterol, fasted insulin levels and exercise tolerance accounted for 30.5% of the variance in response of myocardial deformation in the T2DM group (p = 0.002).

Conclusion: Myocardial deformation is reduced in well-controlled T2DM and despite adequate responses, such differences persist during exercise.

Trial Registration: NCT03299790, initially released 09/12/2017.
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http://dx.doi.org/10.1007/s00421-020-04557-5DOI Listing
March 2021

Digital Health in Cardiac Rehabilitation and Secondary Prevention: A Search for the Ideal Tool.

Sensors (Basel) 2020 Dec 22;21(1). Epub 2020 Dec 22.

Heart Centre Hasselt, Jessa Hospital, 3500 Hasselt, Belgium.

Digital health is becoming more integrated in daily medical practice. In cardiology, patient care is already moving from the hospital to the patients' homes, with large trials showing positive results in the field of telemonitoring via cardiac implantable electronic devices (CIEDs), monitoring of pulmonary artery pressure via implantable devices, telemonitoring via home-based non-invasive sensors, and screening for atrial fibrillation via smartphone and smartwatch technology. Cardiac rehabilitation and secondary prevention are modalities that could greatly benefit from digital health integration, as current compliance and cardiac rehabilitation participation rates are low and optimisation is urgently required. This viewpoint offers a perspective on current use of digital health technologies in cardiac rehabilitation, heart failure and secondary prevention. Important barriers which need to be addressed for implementation in medical practice are discussed. To conclude, a future ideal digital tool and integrated healthcare system are envisioned. To overcome personal, technological, and legal barriers, technological development should happen in dialog with patients and caregivers. Aided by digital technology, a future could be realised in which we are able to offer high-quality, affordable, personalised healthcare in a patient-centred way.
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http://dx.doi.org/10.3390/s21010012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792579PMC
December 2020

Neurological outcome after minimally invasive coronary artery bypass surgery (NOMICS): An observational prospective cohort study.

PLoS One 2020 23;15(12):e0242519. Epub 2020 Dec 23.

Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium.

Background/objectives: Endoscopic coronary artery bypass grafting (Endo-CABG) is a minimally invasive CABG procedure with retrograde arterial perfusion. The main objective of this study is to assess neurocognitive outcome after Endo-CABG.

Methods/design: In this prospective observational cohort study, patients were categorised into: Endo-CABG (n = 60), a comparative Percutaneous Coronary Intervention (PCI) group (n = 60) and a healthy volunteer group (n = 60). A clinical neurological examination was performed both pre- and postoperatively, delirium was assessed postoperatively. A battery of 6 neurocognitive tests, Quality of life (QoL) and the level of depressive feelings were measured at baseline and after 3 months. Patient Satisfaction after Endo-CABG was assessed at 3-month follow-up. Primary endpoints were incidence of postoperative cognitive dysfunction (POCD), stroke and delirium after Endo-CABG. Secondary endpoints were QOL, patient satisfaction and the incidence of depressive feelings after Endo-CABG.

Results: In total, 1 patient after Endo-CABG (1.72%) and 1 patient after PCI (1.67%) suffered from stroke during the 3-month follow-up. POCD in a patient is defined as a Reliable Change Index ≤-1.645 or Z-score ≤-1.645 in at least two tests, and was found in respectively 5 and 6 patients 3 months after Endo-CABG and PCI. Total incidence of POCD/stroke was not different (PCI: n= 7 [15.9%]; Endo-CABG: n= 6 [13.0%], p = 0.732). ICU delirium after Endo-CABG was found in 5 (8.6%) patients. QoL increased significantly three months after Endo-CABG and was comparable with QoL level after PCI and in the control group. Patient satisfaction after Endo-CABG and PCI was comparable. At follow-up, the level of depressive feelings was decreased in all groups.

Conclusions: The incidence of poor neurocognitive outcome, including stroke, POCD and postoperative ICU delirium until three months after Endo-CABG is low and comparable with PCI.

Trial Registration: Registered on ClinicalTrials.gov (NCT02979782).
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242519PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757846PMC
January 2021

Frailty is highly prevalent in specific cardiovascular diseases and females, but significantly worsens prognosis in all affected patients: A systematic review.

Ageing Res Rev 2021 03 14;66:101233. Epub 2020 Dec 14.

REVAL, Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium; Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium; BIOMED, Biomedical Research Center, Hasselt University, Diepenbeek, Belgium.

Cardiologists are more often confronted with older (>60 years) cardiovascular disease (CVD) patients. These patients have particular needs in clinical care because, for example, of frailty. However, it remains to be established what is the prevalence of frailty in different CVD's and how it relates to mortality. In this systematic review studies were included if they: (i) examined subjects (men and women) aged ≥60 years who suffered from any CVD with or without cardiac surgery, (ii.) examined the presence of frailty with a well-defined frailty tool and (iii.) reported prevalence rates of frailty. From thirty studies comprising 96.841 participants, it is found that 1. Frailty is highly common in older patients with CVD (in particular in females (approximately 1.6 times more than in males), in heart failure (up to 80 % of patients) and aortic valve disease (up to 74 % of patients)), and 2. Frailty is related to a 2.5-3.5-fold elevated mortality risk, even in patients with less severe CVD (e.g. percutaneous coronary intervention). Moreover, there is a lack of consistency on how to assess frailty as up to 20 different tools/assessment batteries are currently used. It is concluded that frailty should be assessed in all older CVD patients in a uniform manner to enhance clinical care and outcomes.
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http://dx.doi.org/10.1016/j.arr.2020.101233DOI Listing
March 2021

Motivation of overweight patients with atrial fibrillation to lose weight or to follow a weight loss management program: a cross-sectional study.

Acta Cardiol 2020 Nov 24:1-10. Epub 2020 Nov 24.

Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium.

Aims: Overweight increases the risk of recurrence and progression of atrial fibrillation (AF). This study assesses the knowledge of overweight AF patients about the relation between their weight and AF, to gauge their motivation losing weight and/or following weight reduction programs.

Methods: A multicenter cross-sectional descriptive study was performed at three Belgian hospitals. A validated self-developed questionnaire was presented to AF patients with a body mass index (BMI) >27 kg/m and it addressed: motivation to reduce weight and its related factors; knowledge about the relation between weight and AF; and interest in weight reduction programs.

Results: One hundred and forty-three patients completed the questionnaire. 75.5% was currently motivated to reduce weight. Multivariate regression analysis showed that a higher BMI, a college/university degree, male gender, without hypertension, previous weight loss attempt(s) and living with a partner, were significantly associated with greater motivation for weight reduction. Only 69.9% of the patients was aware of the positive effect of weight reduction on the progression of AF. A completely home-based/telerehabilitation program was the preferred approach for 57.9% of the patients.

Conclusions: AF patients with overweight need to be better informed about overweight as a risk factor for AF. Female AF patients with a lower degree of education, hypertension, living alone, who have never attempted to reduce weight and with a lower but still elevated BMI need more external motivation to lose weight. A tailored weight reduction program (home-based) is the preferred option for patients. This will require further development and validation of telecoaching programs for this patient group.
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http://dx.doi.org/10.1080/00015385.2020.1848274DOI Listing
November 2020

Patient experiences and willingness-to-pay for cardiac telerehabilitation during the first surge of the COVID-19 pandemic: single-centre experience.

Acta Cardiol 2021 Apr 13;76(2):151-157. Epub 2020 Nov 13.

Faculty of Medicine and Life Sciences, UHasselt - Hasselt University, Agoralaan, Diepenbeek, Belgium.

Background: The first surge of the ongoing COVID-19 pandemic led to a shutdown of all non-urgent medical services such as cardiac rehabilitation. Therefore, centres had to develop remote and innovative ways to deliver the core components of CR during this shutdown. This increase in usage of remote rehabilitation services provides a chance to assess patients' experiences and willingness-to-pay of remote CR sessions.

Methods: This was a prospective single-centre study. From 17 July 2020, to 19 August 2020, we conducted an anonymous survey about the patient experiences of the cardiac telerehabilitation services provided at Jessa Hospital Hasselt during the COVID-19 pandemic. A link to an electronic questionnaire was sent email to 155 patients who were invited to participate in the cardiac telerehabilitation sessions during the closure of the rehabilitation centre due to COVID-19.

Results: Fifty-five patients (35% of all invited patients) did participate in remote CR and completed the questionnaire. The mean age of the respondents was 65.4 ± 10.5 years, 63% were male and 70% of the participants were retired. A total of 91% possessed a smartphone and all those patients used their smartphone regularly to send text messages. Ninety-four per cent of the participants were satisfied with the provided telerehabilitation sessions and 70% of the participants would be prepared to pay for these sessions like for centre-based CR sessions. Twenty per cent of patients would even prefer the telerehabilitation sessions above centre-based CR sessions.

Conclusion: Most patients believed that remote CR could be an option after the COVID-19 pandemic when it is combined with centre-based CR sessions. Patients are willing to pay the same amount for a telerehabilitation session as a centre-based CR session. This demonstrates that highly motivated patients are open to shift certain parts of CR from face-to-face interactions to digital interactions.
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http://dx.doi.org/10.1080/00015385.2020.1846920DOI Listing
April 2021

Effect of targeted education for atrial fibrillation patients: Design of the EduCare-AF Study.

Eur J Clin Invest 2021 Jan 17;51(1):e13442. Epub 2020 Nov 17.

Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium.

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http://dx.doi.org/10.1111/eci.13442DOI Listing
January 2021

The European Association of Preventive Cardiology.

Eur Heart J 2020 07;41(28):2610-2611

EAPC Scientific Advisor, Clinical Research Department Cardiology, Heartcentre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium.

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http://dx.doi.org/10.1093/eurheartj/ehaa203DOI Listing
July 2020

The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology.

Eur J Prev Cardiol 2020 Jul 2:2047487320939671. Epub 2020 Jul 2.

Faculty of Medicine and Life Sciences, UHasselt - Hasselt University, Belgium.

The role of comprehensive cardiac rehabilitation is well established in the secondary prevention of cardiovascular diseases such as coronary artery disease and heart failure. Numerous trials have demonstrated both the effectiveness as well as the cost-effectiveness of comprehensive cardiac rehabilitation in improving exercise capacity and quality of life, and in reducing cardiovascular mortality and morbidity. However, the current COVID-19 pandemic has led to closure of many cardiac rehabilitation centres in Europe resulting in many eligible patients unable to participate in the optimisation of secondary prevention and physical performance. This elicits an even louder call for alternatives such as cardiac telerehabilitation to maintain the delivery of the core components of cardiac rehabilitation to cardiovascular disease patients. The present call for action paper gives an update of recent cardiac telerehabilitation studies and provides a practical guide for the setup of a comprehensive cardiac telerehabilitation intervention during the COVID-19 pandemic. This set up could also be relevant to any cardiovascular disease patient not able to visit cardiac rehabilitation centres regularly after the COVID-19 pandemic ceases.
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http://dx.doi.org/10.1177/2047487320939671DOI Listing
July 2020

Use of cardiac telerehabilitation during COVID-19 pandemic in Belgium.

Acta Cardiol 2020 Jun 30:1-4. Epub 2020 Jun 30.

Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Limburg, Belgium.

The COVID-19 pandemic has forced many cardiac rehabilitation centres to focus more on the remote delivery of cardiac rehabilitation (CR) components. This increased focus and the lessons learned from this period could enhance the implementation of telerehabilitation and increase the participation in CR in Belgium. We conducted a survey between April and May 2020 about the implementation of telerehabilitation services during the COVID-19 pandemic. The electronic questionnaire was sent email to the heads of 42 Belgian CR centres. Three reminders email were sent during the study period. 27 CR centres (64%) returned completed questionnaires after three mailings. 52% of the CR centres provided remote CR services during the lockdown due to the COVID-19 pandemic. All CR centres that provided remote CR services delivered exercise training. The most used medium to deliver the CR components were online videos (71%) followed by online information on the website (64%) and emails (64%). It is interesting that the COVID-19 pandemic has encouraged many CR centres to implement remote delivery of CR components. This can help to speed up the research and implementation of telerehabilitation in daily clinical practice. The COVID-19 pandemic could be the push for a large multicentre implementation study that could prove that telerehabilitation is feasible and effective in the Belgian setting.
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http://dx.doi.org/10.1080/00015385.2020.1786625DOI Listing
June 2020

The use of cardiac imaging in the evaluation of athletes in the clinical practice: A survey by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and University of Siena, in collaboration with the European Association of Cardiovascular Imaging, the European Heart Rhythm Association and the ESC Working Group on Myocardial and Pericardial Diseases.

Eur J Prev Cardiol 2020 Jun 12:2047487320932018. Epub 2020 Jun 12.

Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.

Aims: Pre-participation evaluation (PPE) is recommended to prevent sudden cardiac death in athletes. Although imaging is not advocated as a first-line screening tool, there is a growing interest in the use of echocardiography in PPE of athletes. This survey aimed to map the use of imaging in the setting of PPE and explore physician beliefs and potential barriers that may influence individual practices.

Methods: An international survey of healthcare professionals was performed across ESC Member Countries. Percentages were reported based on the number of respondents per question.

Results: In total, 603 individuals from 97 countries participated in the survey. Two-thirds (65%) of respondents use echocardiography always or often as part of PPE of competitive athletes and this practice is not influenced by the professional or amateur status of the athlete. The majority (81%) of respondents who use echocardiography as a first-line screening tool perform the first echocardiogram during adolescence or at the first clinical evaluation, and 72% repeat it at least once in the athletes' career, at 1-5 yearly intervals. In contrast, cardiac magnetic resonance is reserved as a second-line investigation of symptomatic athletes. The majority of the respondents did not report any barriers to echocardiography, while several barriers were identified for cardiac magnetic resonance.

Conclusions: Echocardiography is frequently used as a first-line screening tool of athletes. In the absence of scientific evidence, before such practice is recommended, large studies using echocardiography in the PPE setting are necessary.
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http://dx.doi.org/10.1177/2047487320932018DOI Listing
June 2020