1
|
Milani JGPO, Milani M, Verboven K, Cipriano G, Hansen D. Exercise intensity prescription in cardiovascular rehabilitation: bridging the gap between best evidence and clinical practice. Front Cardiovasc Med 2024; 11:1380639. [PMID: 39257844 PMCID: PMC11383788 DOI: 10.3389/fcvm.2024.1380639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 08/01/2024] [Indexed: 09/12/2024] Open
Abstract
Optimizing endurance exercise intensity prescription is crucial to maximize the clinical benefits and minimize complications for individuals at risk for or with cardiovascular disease (CVD). However, standardization remains incomplete due to variations in clinical guidelines. This review provides a practical and updated guide for health professionals on how to prescribe endurance exercise intensity for cardiovascular rehabilitation (CR) populations, addressing international guidelines, practical applicability across diverse clinical settings and resource availabilities. In the context of CR, cardiopulmonary exercise test (CPET) is considered the gold standard assessment, and prescription based on ventilatory thresholds (VTs) is the preferable methodology. In settings where this approach isn't accessible, which is frequently the case in low-resource environments, approximating VTs involves combining objective assessments-ideally, exercise tests without gas exchange analyses, but at least alternative functional tests like the 6-minute walk test-with subjective methods for adjusting prescriptions, such as Borg's ratings of perceived exertion and the Talk Test. Therefore, enhancing exercise intensity prescription and offering personalized physical activity guidance to patients at risk for or with CVD rely on aligning workouts with individual physiological changes. A tailored prescription promotes a consistent and impactful exercise routine for enhancing health outcomes, considering patient preferences and motivations. Consequently, the selection and implementation of the best possible approach should consider available resources, with an ongoing emphasis on strategies to improve the delivery quality of exercise training in the context of FITT-VP prescription model (frequency, intensity, time, type, volume, and progression).
Collapse
Affiliation(s)
- Juliana Goulart Prata Oliveira Milani
- Rehabilitation Research Center (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
- Graduate Programme in Health Sciences and Technologies, University of Brasilia (UnB), Brasilia, Brazil
| | - Mauricio Milani
- Rehabilitation Research Center (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
- Graduate Programme in Health Sciences and Technologies, University of Brasilia (UnB), Brasilia, Brazil
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Kenneth Verboven
- Rehabilitation Research Center (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute (BIOMED), Hasselt, Belgium
| | - Gerson Cipriano
- Graduate Programme in Health Sciences and Technologies, University of Brasilia (UnB), Brasilia, Brazil
- Graduate Program in Human Movement and Rehabilitation of Evangelical (PPGMHR), UniEVANGÉLICA, Anápolis, Brazil
| | - Dominique Hansen
- Rehabilitation Research Center (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute (BIOMED), Hasselt, Belgium
| |
Collapse
|
2
|
Festa RR, Jofré-Saldía E, Candia AA, Monsalves-Álvarez M, Flores-Opazo M, Peñailillo L, Marzuca-Nassr GN, Aguilar-Farias N, Fritz-Silva N, Cancino-Lopez J, Soto-Sánchez J, Sepulveda C, Huerta Ojeda Á, Núñez-Espinosa C, Valladares-Ide D, Jannas-Vela S. Next steps to advance general physical activity recommendations towards physical exercise prescription: a narrative review. BMJ Open Sport Exerc Med 2023; 9:e001749. [PMID: 37920278 PMCID: PMC10619125 DOI: 10.1136/bmjsem-2023-001749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/04/2023] Open
Abstract
Physical inactivity is a major health concern, associated with the development of several non-communicable diseases and with an increased mortality rate. Therefore, promoting active lifestyles has become a crucial public health necessity for enhancing overall health and quality of life. The WHO guidelines for physical activity (PA) present valuable contributions in this respect; however, we believe that greater specificity should be added or complemented towards physical exercise (PE) testing, prescription and programming in future recommendations. In this review article, we suggest simple and practical tools accessible to the entire population to improve the specificity of this approach, highlighting aspects of PE programming used by trained subjects. By adopting these suggestions, exercise professionals, clinicians and physical trainers can optimise the current general PA recommendations towards PE prescription to improve fitness status and encourage PE adherence in the general population.
Collapse
Affiliation(s)
| | - Emilio Jofré-Saldía
- Instituto de Ciencias de la Salud, Universidad de O'Higgins, Rancagua, Chile
- Interuniversity Center for Healthy Aging RED21993, Santiago, Chile
| | - Alejandro A Candia
- Instituto de Ciencias de la Salud, Universidad de O'Higgins, Rancagua, Chile
| | - Matías Monsalves-Álvarez
- Instituto de Ciencias de la Salud, Universidad de O'Higgins, Rancagua, Chile
- Geroscience Center for Brain Health and Metabolism (GERO), Santiago, Chile
| | | | - Luis Peñailillo
- Exercise and Rehabilitation Sciences Institute, Faculty of Rehabilitation Sciences, Universidad Andrés Bello, Santiago, Chile
| | - Gabriel Nasri Marzuca-Nassr
- Interuniversity Center for Healthy Aging RED21993, Santiago, Chile
- Departamento de Ciencias de la Rehabilitación, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
| | - Nicolas Aguilar-Farias
- Department of Physical Education, Sports and Recreation, Universidad de La Frontera, Temuco, Chile
| | - Nicole Fritz-Silva
- Interuniversity Center for Healthy Aging RED21993, Santiago, Chile
- Health Department, Universidad de Los Lagos, Puerto Montt, Chile
- Research Group in Prevention and Health in Exercise and Sport, University of Valencia, Valencia, Spain
| | - Jorge Cancino-Lopez
- Exercise Physiology and Metabolism Laboratory, Escuela de Kinesiología, Universidad Finis Terrae, Santiago, Chile
| | - Johana Soto-Sánchez
- Laboratorio de Actividad Física, Ejercicio y Salud, Centro de Biomedicina Aplicada, Universidad Mayor, Santiago, Chile
| | - Carlos Sepulveda
- Laboratory of Exercise Science, Innovation Center, Clinica MEDS, Las Condes, Chile
- Laboratory of Research in Nutrition and Physical Activity, Institute of Nutrition and Technology of Food, University of Chile, Santiago de Chile, Chile
| | - Álvaro Huerta Ojeda
- Núcleo de Investigación en Salud, Actividad Física y Deporte ISAFYD, Universidad de Las Americas, Viña del Mar, Chile
| | - Cristian Núñez-Espinosa
- Interuniversity Center for Healthy Aging RED21993, Santiago, Chile
- Escuela de Medicina, Universidad de Magallanes, Punta Arenas, Chile
- Centro Asistencial Docente y de Investigación, Universidad de Magallanes, Punta Arenas, Chile
| | - Denisse Valladares-Ide
- Instituto de Ciencias de la Salud, Universidad de O'Higgins, Rancagua, Chile
- Interuniversity Center for Healthy Aging RED21993, Santiago, Chile
| | - Sebastian Jannas-Vela
- Instituto de Ciencias de la Salud, Universidad de O'Higgins, Rancagua, Chile
- Interuniversity Center for Healthy Aging RED21993, Santiago, Chile
| |
Collapse
|
3
|
Verdicchio C, Freene N, Hollings M, Maiorana A, Briffa T, Gallagher R, Hendriks JM, Abell B, Brown A, Colquhoun D, Howden E, Hansen D, Reading S, Redfern J. A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement. Heart Lung Circ 2023; 32:1035-1048. [PMID: 37516652 DOI: 10.1016/j.hlc.2023.06.854] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/31/2023]
Abstract
Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.
Collapse
Affiliation(s)
- Christian Verdicchio
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Centre for Heart Rhythm Disorders, University of Adelaide, SAHMRI and Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Nicole Freene
- Physiotherapy, Faculty of Health, University of Canberra, Canberra, ACT, Australia; Health Research Institute, University of Canberra, Canberra, ACT, Australia
| | - Matthew Hollings
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Andrew Maiorana
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia; Curtin School of Allied Health, Curtin University, Perth, WA, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Robyn Gallagher
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jeroen M Hendriks
- Centre for Heart Rhythm Disorders, University of Adelaide, SAHMRI and Royal Adelaide Hospital, Adelaide, SA, Australia; Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Qld, Australia
| | - Alex Brown
- Telethon Kids Institute, Australian National University, Canberra, ACT, Australia
| | - David Colquhoun
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia; Faculty of Medicine, Wesley Medical Centre, Brisbane, Qld, Australia
| | - Erin Howden
- Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Vic, Australia
| | - Dominique Hansen
- UHasselt, REVAL/BIOMED (Rehabilitation Research Centre), Hasselt University, Hasselt, Belgium
| | - Stacey Reading
- Department of Exercise Sciences, University of Auckland, Auckland, New Zealand
| | - Julie Redfern
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
4
|
Wattanapisit A, Ng CJ, Angkurawaranon C, Wattanapisit S, Chaovalit S, Stoutenberg M. Summary and application of the WHO 2020 physical activity guidelines for patients with essential hypertension in primary care. Heliyon 2022; 8:e11259. [PMID: 36325139 PMCID: PMC9618974 DOI: 10.1016/j.heliyon.2022.e11259] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/15/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
The new World Health Organization (WHO) 2020 guidelines on physical activity (PA) and sedentary behavior include recommendations for adults with chronic conditions. The guidelines provide adaptable and general recommendations for people living with chronic medical conditions. This article summarizes the content and provides suggestions for the application of the guidelines for patients with essential hypertension in primary care. The WHO 2020 PA guidelines recommend broad advice for adults and older adults with chronic conditions. The key recommendations are consistent with other hypertension guidelines. A systemic approach to promote PA in primary care (i.e., PA assessment, safety considerations, PA prescription, behavioral counseling, and referral) along with applying the WHO guidelines is required. Health risk assessment and safety issues related to hypertension (e.g., current PA levels, level of blood pressure, treatment plans, comorbidities) should be concerned. The FITT Pro (frequency, intensity, time, type, and progression) can be adopted as a framework to break down the guidelines into specific PA prescription. The WHO 2020 PA guidelines address the importance of PA in clinical populations. The guidelines can be adapted for patients with hypertension in primary care settings.
Collapse
Affiliation(s)
- Apichai Wattanapisit
- Department of Clinical Medicine, School of Medicine, Walailak University, Nakhon Si Thammarat, Thailand,Family Medicine Clinic, Walailak University Hospital, Nakhon Si Thammarat, Thailand
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia,SingHealth Polyclinics, Singapore, Singapore,Duke-NUS Medical School, Singapore, Singapore
| | - Chaisiri Angkurawaranon
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand,Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand,Corresponding author.
| | | | - Sirawee Chaovalit
- Department of Physical Therapy, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Mark Stoutenberg
- Department of Kinesiology, College of Public Health, Temple University, Philadelphia, USA
| |
Collapse
|
5
|
Lehtonen E, Gagnon D, Eklund D, Kaseva K, Peltonen JE. Hierarchical framework to improve individualised exercise prescription in adults: a critical review. BMJ Open Sport Exerc Med 2022; 8:e001339. [PMID: 35722045 PMCID: PMC9185660 DOI: 10.1136/bmjsem-2022-001339] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/04/2022] Open
Abstract
Physical activity (PA) guidelines for the general population are designed to mitigate the rise of chronic and debilitating diseases brought by inactivity and sedentariness. Although essential, they are insufficient as rates of cardiovascular, pulmonary, renal, metabolic and other devastating and life-long diseases remain on the rise. This systemic failure supports the need for an improved exercise prescription approach that targets the individual. Significant interindividual variability of cardiorespiratory fitness (CRF) responses to exercise are partly explained by biological and methodological factors, and the modulation of exercise volume and intensity seem to be key in improving prescription guidelines. The use of physiological thresholds, such as lactate, ventilation, as well as critical power, have demonstrated excellent results to improve CRF in those struggling to respond to the current homogenous prescription of exercise. However, assessing physiological thresholds requires laboratory resources and expertise and is incompatible for a general population approach. A case must be made that balances the effectiveness of an exercise programme to improve CRF and accessibility of resources. A population-wide approach of exercise prescription guidelines should include free and accessible self-assessed threshold tools, such as rate of perceived exertion, where the homeostatic perturbation induced by exercise reflects physiological thresholds. The present critical review outlines factors for individuals exercise prescription and proposes a new theoretical hierarchal framework to help shape PA guidelines based on accessibility and effectiveness as part of a personalised exercise prescription that targets the individual.
Collapse
Affiliation(s)
- Elias Lehtonen
- Department of Sports and Exercise Medicine, Clinicum, University of Helsinki, Helsinki, Finland.,Helsinki Clinic for Sports and Exercise Medicine, Foundation for Sports and Exercise Medicine, Helsinki, Finland
| | - Dominique Gagnon
- Department of Sports and Exercise Medicine, Clinicum, University of Helsinki, Helsinki, Finland.,Helsinki Clinic for Sports and Exercise Medicine, Foundation for Sports and Exercise Medicine, Helsinki, Finland.,School of Kinesiology, Laurentian University, Sudbury, Ontario, Canada.,Center for Research in Occupational Health and Safety, Laurentian University, Sudbury, Ontario, Canada
| | - Daniela Eklund
- Department of Sports and Exercise Medicine, Clinicum, University of Helsinki, Helsinki, Finland.,Helsinki Clinic for Sports and Exercise Medicine, Foundation for Sports and Exercise Medicine, Helsinki, Finland
| | - Kaisa Kaseva
- Department of Sports and Exercise Medicine, Clinicum, University of Helsinki, Helsinki, Finland.,Helsinki Clinic for Sports and Exercise Medicine, Foundation for Sports and Exercise Medicine, Helsinki, Finland
| | - Juha Evert Peltonen
- Department of Sports and Exercise Medicine, Clinicum, University of Helsinki, Helsinki, Finland.,Helsinki Clinic for Sports and Exercise Medicine, Foundation for Sports and Exercise Medicine, Helsinki, Finland
| |
Collapse
|
6
|
Bok D, Rakovac M, Foster C. An Examination and Critique of Subjective Methods to Determine Exercise Intensity: The Talk Test, Feeling Scale, and Rating of Perceived Exertion. Sports Med 2022; 52:2085-2109. [PMID: 35507232 DOI: 10.1007/s40279-022-01690-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
Abstract
Prescribing exercise intensity is crucial in achieving an adequate training stimulus. While numerous objective methods exist and are used in practical settings for exercise intensity prescription, they all require anchor measurements that are derived from a maximal or submaximal graded exercise test or a series of submaximal or supramaximal exercise bouts. Conversely, self-reported subjective methods such as the Talk Test (TT), Feeling Scale (FS) affect rating, and rating of perceived exertion (RPE) do not require exercise testing prior to commencement of the exercise training and therefore appear as more practical tools for exercise intensity prescription. This review is intended to provide basic information on reliability and construct validity of the TT, FS, and RPE measurements to delineate intensity domains. The TT and RPE appear to be valid measures of both the ventilatory threshold and the respiratory compensation threshold. Although not specifically examined, the FS showed tendency to demarcate ventilatory threshold, but its validity to demarcate the respiratory compensation threshold is limited. Equivocal stage of the TT, RPE of 10-11, and FS ratings between fairly good (+ 1) and good (+ 3) are reflective of the ventilatory threshold, while negative stage of the TT, RPE of 13-15, and FS ratings around neutral (0) are reflective of the respiratory compensation threshold. The TT and RPE can effectively be used to elicit homeostatic disturbances consistent with the moderate, heavy, and severe intensity domains, while physiological responses to constant FS ratings show extensive variability around ventilatory threshold to be considered effective in demarcating transition between moderate and heavy intensity domains.
Collapse
Affiliation(s)
- Daniel Bok
- Faculty of Kinesiology, University of Zagreb, Zagreb, Croatia.
| | - Marija Rakovac
- Faculty of Kinesiology, University of Zagreb, Zagreb, Croatia
| | - Carl Foster
- Department of Exercise and Sport Science, University of Wisconsin-La Crosse, La Crosse, WI, USA
| |
Collapse
|
7
|
Hansen D, Abreu A, Ambrosetti M, Cornelissen V, Gevaert A, Kemps H, Laukkanen JA, Pedretti R, Simonenko M, Wilhelm M, Davos CH, Doehner W, Iliou MC, Kränkel N, Völler H, Piepoli M. Exercise intensity assessment and prescription in cardiovascular rehabilitation and beyond: why and how: a position statement from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology. Eur J Prev Cardiol 2022; 29:230-245. [PMID: 34077542 DOI: 10.1093/eurjpc/zwab007] [Citation(s) in RCA: 119] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/02/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
A proper determination of the exercise intensity is important for the rehabilitation of patients with cardiovascular disease (CVD) since it affects the effectiveness and medical safety of exercise training. In 2013, the European Association of Preventive Cardiology (EAPC), together with the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation, published a position statement on aerobic exercise intensity assessment and prescription in cardiovascular rehabilitation (CR). Since this publication, many subsequent papers were published concerning the determination of the exercise intensity in CR, in which some controversies were revealed and some of the commonly applied concepts were further refined. Moreover, how to determine the exercise intensity during resistance training was not covered in this position paper. In light of these new findings, an update on how to determine the exercise intensity for patients with CVD is mandatory, both for aerobic and resistance exercises. In this EAPC position paper, it will be explained in detail which objective and subjective methods for CR exercise intensity determination exist for aerobic and resistance training, together with their (dis)advantages and practical applications.
Collapse
Affiliation(s)
- Dominique Hansen
- Department of Cardiology, Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- UHasselt, Faculty of Rehabilitation Sciences, BIOMED-REVAL-Rehabilitation Research Centre, Hasselt University, Agoralaan, Building A, 3590 Hasselt, Belgium
| | - Ana Abreu
- Cardiology Department, Hospital Universitário de Santa Maria/Centro Académico de Medicina de Lisboa (CAML), Exercise and Cardiovascular Rehabilitation Laboratory, Centro Cardiovascular da Universidade de Lisboa (CCUL), Lisbon, Portugal
| | - Marco Ambrosetti
- Cardiac Rehabilitation Unit, ASST Ospedale Maggiore Crema, Crema, Italy
| | - Veronique Cornelissen
- Research Unit of Cardiovascular Exercise Physiology, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Belgium
| | - Andreas Gevaert
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Belgium
| | - Hareld Kemps
- Department of Cardiology, Maxima Medical Centre, Veldhoven, The Netherlands
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, The Netherlands
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jari A Laukkanen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
- Cardiovascular Department, IRCCS MultiMedica, Care and Research Institute, Sesto San Giovanni, Milano, Italy
| | - Roberto Pedretti
- Heart Transplantation Outpatient Department, Cardiopulmonary Exercise Test Research Department, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Maria Simonenko
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Wilhelm
- Cardiovascular Research Laboratory, Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Constantinos H Davos
- BCRT-Berlin Institute of Health Center for Regenerative Therapies, Department of Cardiology (Virchow Klinikum), Charité - Universitätsmedizin Berlin, Partner Site Berlin, Germany
| | - Wolfram Doehner
- Cardiac Rehabilitation and Secondary Prevention Department, Corentin Celton Hospital, Assistance Publique Hopitaux de Paris Centre Université de Paris, Paris, France
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin D-1220, Germany
| | - Marie-Christine Iliou
- Charité - University Medicine Berlin, Campus Benjamin Franklin, Department of Cardiology, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Nicolle Kränkel
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin D-1220, Germany
- Klinik am See, Rehabilitation Centers for Internal Medicine, Berlin, Germany
| | - Heinz Völler
- Department of Rehabilitation Medicine, University of Potsdam, Potsdam, Germany
- Heart Failure Unit, G. da Saliceto Hospital, AUSL Piacenza and University of Parma, Parma, Italy
| | - Massimo Piepoli
- Heart Failure Unit, G. da Saliceto Hospital, AUSL Piacenza and University of Parma, Parma, Italy
| |
Collapse
|