• „ EXPERT OPINION

Comprehensive cardiac rehabilitation as the keystone in the secondary prevention of cardiovascular disease

Expert Opinion of the Cardiac Rehabilitation and Exercise Physiology Section of the Polish Cardiac Society

Anna Jegier1*, Dominika Szalewska2*, Agnieszka Mawlichanów3, Tadeusz Bednarczyk4, Zbigniew Eysymontt5, Michał Gałaszek5, Artur Mamcarz6, Anna Mierzyńska7, 12, Ewa Piotrowicz8, Ryszard Piotrowicz7, 9, Krzysztof Smarż10, Edyta Smolis-Bąk7, Ewa Straburzyńska-Migaj11, Jadwiga Wolszakiewicz7

Reviewers: Małgorzata Kurpesa13, Piotr Dylewicz14

1Department of Sports Medicine, Medical University of Lodz, Outpatient Rehabilitation Unit, Central Teaching Hospital of the Medical University of Lodz, Łódź, Poland

2Department of Rehabilitation Medicine, Faculty of Health Sciences, Medical University of Gdansk, Gdańsk, Poland

3Cardiac Rehabilitation Unit, The John Paul II Hospital, Kraków, Poland

4Cardiac Rehabilitation Unit, Voivodship Clinical Hospital No. 2, Rzeszów, Poland

5Silesian Rehabilitation and Prevention Centre, Ustroń, Poland

63rd Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland

7Department of Coronary Artery Disease and Cardiac Rehabilitation, Cardinal Stefan Wyszynski National Institute of Cardiology, Warszawa, Poland

8Telecardiology Center, Cardinal Wyszynski National Institute of Cardiology, Warszawa, Poland

9The University of Rehabilitation in Warsaw, Warszawa, Poland

10Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warszawa, Poland

111st Department of Cardiology, University of Medical Sciences in Poznan, University Hospital of Lord’s Transfiguration, Poznań, Poland

12Department of Rehabilitation, Centre of Postgraduate Medical Education, Professor Adam Gruca Independent Public Teaching Hospital in Otwock, Otwock, Poland

13Department of Cardiology, Medical University of Lodz, Łódź, Poland

14Institute for Health and Physical Education, State Higher Vocational School in Leszno, Leszno, Poland

*Both authors equally contributed to the work.

COMPREHENSIVE CARDIAC REHABILITATION: DEFINITION, GOALS, TARGET POPULATION, AND ORGANIZATION OF REHABILITATION SERVICES

In developed countries, cardiovascular disease (CVD) is the most common cause of premature death, which, in many cases, could be prevented. Primary and secondary prevention of CVD, defined as lifestyle modification with regular exercise training and optimal pharmacotherapy, is a well-established strategy to reduce morbidity, hospital readmission, and mortality due to cardiovascular causes. Cardiac rehabilitation (CR) is a mainstay of the secondary prevention of CVD. In the European Society of Cardiology guidelines, comprehensive CR has the highest class of recommendation and level of evidence as an effective method for the treatment of patients with ST-segment elevation myocardial infarction [1], after myocardial revascularization [2], with chronic coronary syndrome (CCS) [3], for CVD prevention in clinical practice [4], and in patients with heart failure (HF) [5–7]. Patients with acute coronary syndrome (ACS), decompensation of HF, and previous cardiac surgery or percutaneous coronary intervention (PCI) should be referred for an early CR program immediately after hospitalization. Each week’s delay in CR requires an additional month of exercise to obtain the same level of health benefit [8, 9]. Priority patient groups that should be offered a CR program are presented in Table 1 [10, 11]

.

Comprehensive CR is defined as a tailored multidisciplinary intervention that includes clinical evaluation (medical history, physical examination, functional examination, questionnaires, laboratory tests, resting and exercise electrocardiography [ECG], echocardiography and other diagnostic tests if indicated), management and modification of cardiovascular risk factors, physical activity counseling, prescription of an appropriate exercise training program, dietary counseling, as well as psychological, social, and vocational support [11]. The aim of CR is also to optimize pharmacotherapy and cardiac implantable electronic devices function (pacemaker, implantable cardioverter-defibrillator [ICD], cardiac resynchronization pacemaker, ventricular assist devices, etc.), diagnose frailty syndrome, educate patients and their families about healthy behavior and first-aid principles, as well as monitor rehabilitation outcomes. Currently, the duration of CR in European countries ranges from 8 to 24 weeks, and from 3 to 4 weeks for inpatient programs [11, 12].

In facilities offering CR services, the medical team should include a physical therapist, a nurse, and an electroradiology technician in addition to medical doctors. Cooperation with a psychologist and a dietitian is important, which also applies, in larger facilities, to a rehabilitation services manager.

Comprehensive CR is a process that should be implemented as soon as possible, continued without interruption, and should consist of multiple stages. Moreover, it should be tailored to the individual clinical situation and should be accepted by the patient and their family, friends, and caregivers.

The CR intervention can be divided into early CR (phases I and II) and late CR (phase III).

Early comprehensive cardiac rehabilitation: phase I

Phase I CR begins during hospitalization for a cardiovascular event and is provided in an intensive care room or a postoperative, cardiology, internal medicine, or CR wards. This phase should start on admission to the hospital and should last until the patient is stable and can be discharged from the acute ward. The main goal of phase I is for the patient to achieve independence and self-care in performing daily activities, to prevent complications of immobility, and to evaluate the patient’s response to exercise associated with daily activities.

Early comprehensive cardiac rehabilitation: phase II

Phase II CR may be provided in the inpatient setting (residential); in the ambulatory setting at an outpatient clinic or day rehabilitation unit; as hybrid cardiac telerehabilitation with phase I rehabilitation program in the in-hospital or ambulatory setting, followed by phase II delivered remotely at the patient’s home using data transmission technology.

Inpatient phase II CR should be provided primarily to individuals at high cardiovascular risk. This may include patients:

• • with complications of ACS, cardiac surgery, or PCI;
• • with other cardiovascular complications or comorbidities and high cardiovascular risk with stable advanced HF (New York Heart Association [NYHA] functional class III–IV) and/or requiring short- or long-term intravenous therapy and/or with ventricular assist devices and/or other cardiac implantable electronic devices;
• • immediately after heart transplantation;
• • who cannot undergo a CR program at an outpatient clinic or a day rehabilitation unit [10].

Late comprehensive cardiac rehabilitation: phase III

Phase III of the CR program is most often delivered in the ambulatory setting at an outpatient clinic or a day rehabilitation unit. This phase centers on physical exercise and on educating patients and their families about a healthy lifestyle, and it should be planned, provided, and regularly monitored with consideration of the individual patient’s needs, cardiovascular risk profile, and personality traits. Phase III should be lifelong as part of the healthy lifestyle intervention [13].

At each phase, different models of physical exercises (A, B, C, or D) may be prescribed depending on the individual patient’s exercise tolerance and cardiovascular risk [13]. Model A is applied in patients with the best exercise tolerance and the lowest cardiovascular risk, while model D, in patients with poor exercise tolerance and high cardiovascular risk. Models B and C are used in patients with intermediate levels of exercise tolerance and cardiovascular risk.

Effects of comprehensive cardiac rehabilitation

All forms of CR provide beneficial health effects. In particular, CR

• • modifies CVD risk factors by increasing physical activity, lowering blood pressure (BP), reducing or maintaining body weight, improving the lipid profile to achieve obtain guideline-recommended targets, controlling glucose levels, lowering insulin resistance;
• • improves endothelial function;
• • inhibits the development of atherosclerosis and its clinical sequelae, and even causes regression of atherosclerotic lesions;
• • improves cardiopulmonary efficiency and exercise tolerance;
• • reduces the risk of frailty syndrome;
• • improves musculoskeletal function;
• • improves psychophysical fitness;
• • improves the quality of life;
• • motivates patients to engage with treatment;
• • reduces the risk of disability;
• • improves family and social activity of patients;
• • facilitates a return to work.

These benefits are due to the pleiotropic effects of exercise training, among other factors. When combined with patient education and optimal medical therapy, exercise training reduces the risk of acute cardiovascular events, delays disease progression, and shortens the duration of treatment after acute events and exacerbations. This results in a lower number of hospital readmissions, improved quality of life, and prolonged longevity [14, 15].

EXERCISE TRAINING IN COMPREHENSIVE CARDIAC REHABILITATION: ELIGIBILITY CRITERIA, CONTRAINDICATIONS, AND METHODS

Determining patient eligibility for comprehensive cardiac rehabilitation: general principles

Exercise training can be prescribed only to clinically stable patients. Patients are referred for CR by a physician based on medical history, physical examination, and additional tests. Medical history should include disease course, comorbidities that may affect exercise tolerance and training (e.g., diabetes, kidney failure, chronic obstructive pulmonary disease, thyroid disease, cancer, chronic inflammatory diseases, anemia, as well as musculoskeletal and neurologic disorders). Before starting the exercise training program, the patient should be assessed for current symptoms (NYHA functional classification, Canadian Cardiovascular Society classification of angina pectoris, Fontaine and Rutherford classification of peripheral artery disease) as well as cardiovascular risk (Table 2).

Patients after cardiac surgery should be assessed for the presence of postoperative complications: sternal instability, improper wound healing, postoperative infections, postpericardiotomy syndrome, and postoperative anemia. Current medical therapy is also evaluated, and modification is considered depending on the clinical status and according to general guidelines. When referring the patient for physical training, the function of cardiac implantable electronic devices should be assessed and potential indications for implantation should be considered (pacemaker, ICD, cardiac resynchronization therapy, and ventricular assist devices).

The patient is examined by a physician before and after the CR program. Eligibility is determined on the basis of the patient’s general condition, symptoms of HF, heart rate (HR) and BP measurement, presence of arrhythmia, peripheral vascular disease, as well as musculoskeletal and neurologic disorders that limit physical exercise. Medical examination should be also performed before each training session in patients at high risk of complications, after the training program has been modified, or in case of complications.

Patients are assessed for eligibility and cardiovascular risk using the following diagnostic tools:

• • the ECG — standard ECG should be performed in all patients before and after each phase of CR and in the presence of symptoms that constitute an indication for ECG;
• • the exercise test — recommended before the patient is referred for phase II and III CR. The exercise test is used to determine exercise intensity, exercise-related risk, as well as changes in exercise capacity after completing each phase of CR. It is also applied to determine workload for subsequent physical activity associated with work and leisure [16];
• • the cardiopulmonary exercise test (CPET) — is recommended for functional assessment and rehabilitation of patients with CVD (particularly HF) as well as heart and lung transplant recipients. The CPET allows a precise assessment of exercise capacity by measuring minute ventilation as well as oxygen and carbon dioxide concentrations in exhaled air during the test [17];
• • the 6-minute walk test [18] — is used in patients who cannot do the exercise test either on a treadmill or bicycle ergometer [11]. However, the treadmill stress or bicycle ergometry test should be always performedas soon as possible if there are no contraindications;
• • long-term ambulatory Holter ECG monitoring — should be performed in patients who develop symptoms that constitute an indication for this type of ECG moni­toring [19];
• • transthoracic echocardiography — if current results after a recent cardiovascular event are not available, transthoracic echocardiography should be performed at a center providing a phase II CR program. Standard anatomical and functional parameters should be assessed. Before referral for exercise-based CR, it is important to assess the pericardium and to exclude mobile thrombi in heart cavities. Mobile thrombi constitute an absolute contraindication to exercise training. Transthoracic echocardiography is used in risk stratification of patients undergoing exercise training (Table 2). Moreover, echocardiography should be performed in patients with disease exacerbation or other indications as defined by the guidelines of European Society of Cardiology and the Polish Society of Cardiology [20, 21];
• • laboratory tests — the following laboratory tests should be performed before the patient is referred for CR: complete blood count, lipid profile (total cholesterol, high- and low-density lipoprotein cholesterol, and triglycerides), fasting glucose, glycated hemoglobin HbA1c in patients with diabetes, creatinine, electrolytes, uric acid, and international normalized ratio (in patients receiving vitamin K antagonists). The frequency of laboratory testing should follow the established guidelines.

Exercise training in comprehensive cardiac rehabilitation: basic concepts, contraindications, and methods

Exercise training in CR is a key treatment of patients with CVD and is prescribed at each phase of CR.

• • Phase I: exercise training is started as soon as the patient with an emergency medical condition is stabilized or after an elective procedure. Depending on the disease course (complicated vs uncomplicated) and in the absence of contraindications, active rehabilitation starts after 12 to 48 hours of immobilization in patients with a stable clinical condition. Subsequent components of the training program are implemented depending on the disease course and complications during the acute phase.
• • Phase II: exercise training depends on exercise capacity and the risk of complications as the most important criteria to be considered when referring the patient for one of the 4 models of physical exercise (A, B, C, or D). The training can be performed in the in-hospital setting, ambulatory setting (outpatient clinic/day rehabilitation unit), or as part of hybrid cardiac telerehabilitation.
• • Phase III: exercise training is delivered as part of late CR in the ambulatory setting. The goal of exercise training is to further improve exercise tolerance, maintain treatment outcomes, and reduce the risk of disease recurrence. Exercise training at this stage should be lifelong.

To increase patient safety during training, a number of measures should be undertaken. Before training, the patient’s clinical condition should be assessed, while during training, the patient should be monitored for sudden paleness, excessive sweating, blue lips, and other symptoms. Patients should be educated about any exercise-related symptoms such as chest pain, dyspnea, and dizziness as well as the need to report them to the rehabilitation team. Before and after an exercise training session as well as on each change of the body position, BP and HR should be measured. Knowledge of first-aid principles also increases patient safety.

Any emergency medical condition and unstable CVD constitute absolute contraindications to exercise training. An exercise training program should be tailored to the individual patient’s needs or temporarily discontinued (especially phases I and II) in the following conditions:

• • poorly controlled hypertension;
• • orthostatic BP reduction of more than 20 mm Hg with clinical symptoms;
• • sinus tachycardia resistant to treatment (HR >100 bpm);
• • malignant ventricular tachycardia;
• • exercise-induced bradycardia;
• • significant stenosis of the atrioventricular or arterial ostium;
• • cardiomyopathy with left ventricular outflow tract stenosis;
• • ischemic ST-segment depression of 2 mm or higher on resting ECG;
• • a positive exercise test result suggesting myocardial ischemia at peak exercise;
• • decompensated HF;
• • acute inflammation and uncontrolled comorbidities;
• • electrolyte imbalance [13, 22].

Secondary prevention should be one of the most important tasks in CR. It is achieved by health education, motivation to lifestyle changes, and modification of medical therapy [4, 11, 70].

The treatment of patients with diabetes is multifactorial and includes monitoring of glucose levels, lipid disorders, BP, and body mass. Although intensive treatment of high blood glucose levels reduces the risk of vascular complications, it is important to avoid episodes of hypoglycemia, especially in elderly patients. In all patients with diabetes and high blood glucose levels, secondary prevention should involve statin treatment with a reduction of low-density lipoprotein levels to reach the same targets as in very high-risk patients. Patients with type 2 diabetes and cardiovascular comorbidities were shown to benefit from treatment with canagliflozin [83, 84] and incretin drugs (glucagon-like peptide-1 receptor agonists) [85–87]. Intensive treatment of hyperglycemia reduces the risk of microvascular complications. The target glycated hemoglobin HbA1c is less than 7%, with more stringent targets in young patients (≤6.5%) and less stringent targets in elderly patients due to the risk of hypoglycemia (<8% or even ≤9% in elderly individuals with multiple comorbidities, frailty, and a higher risk of hypoglycemia) [88].

1. 1. Ibanez B, James S, Agewall S, et al. ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39(2): 119–177, doi: 10.1093/eurheartj/ehx393, indexed in Pubmed: 28886621.
2. 2. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019; 40(2): 87–165, doi: 10.1093/eurheartj/ehy394, indexed in Pubmed: 30165437.
3. 3. Knuuti J, Wijns W, Saraste A, et al. ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020; 41(3): 407–477, doi: 10.1093/eurheartj/ehz425, indexed in Pubmed: 31504439.
4. 4. Piepoli MF, Hoes AW, Agewall S, et al. ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: the sixth joint task force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016; 37(29): 2315–2381, doi: 10.1093/eurheartj/ehw106, indexed in Pubmed: 27222591.
5. 5. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC Committee for Practice Guidelines (CPG). ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the task force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail. 2008; 10(10): 933–989, doi: 10.1016/j.ejheart.2008.08.005, indexed in Pubmed: 18826876.
6. 6. Ponikowski P, Voors AA, Anker SD, et al. ESC Scientific Document Group. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016; 37(27): 2129–2200, doi: 10.1093/eurheartj/ehw128, indexed in Pubmed: 27206819.
7. 7. Seferovic PM, Ponikowski P, Anker SD, et al. Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019; 21(10): 1169–1186, doi: 10.1002/ejhf.1531, indexed in Pubmed: 31129923.
8. 8. Pelliccia A, Sharma S, Gati S, et al. ESC Scientific Document Group. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J. 2021; 42(1): 17–96, doi: 10.1093/eurheartj/ehaa605, indexed in Pubmed: 32860412.
9. 9. Haykowsky M, Scott J, Esch B, et al. A meta-analysis of the effects of exercise training on left ventricular remodeling following myocardial infarction: start early and go longer for greatest exercise benefits on remodeling. Trials. 2011; 12: 92, doi: 10.1186/1745-6215-12-92, indexed in Pubmed: 21463531.
10. 10. Cowie A, Buckley J, Doherty P, et al. British Association for Cardiovascular Prevention and Rehabilitation (BACPR). Standards and core components for cardiovascular disease prevention and rehabilitation. Heart. 2019; 105(7): 510–515, doi: 10.1136/heartjnl-2018-314206, indexed in Pubmed: 30700518.
11. 11. Ambrosetti M, Abreu A, Corrà U, et al. 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 [Epub ahead of print]: 2047487320913379, doi: 10.1177/2047487320913379, indexed in Pubmed: 32223332.
12. 12. Abreu A, Schmidt JP, Piepoli ME. ESC Handbook of cardiovascular rehabilitation: a practical clinical guide. Oxford University Press 2020: doi: 10.1093/med/9780198849308.001.0001.
13. 13. Piotrowicz R, Jegier A, Szalewska D. Recommendations for the implementation of comprehensive cardiac rehabilitation. Expert Opinion of the Cardiac Rehabilitation and Exercise Physiology Section of the Polish Cardiac Society [article in Polish]. AsteriaMed, Gdańsk 2017.
14. 14. Alter DA, Oh PI, Chong A. Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system. Eur J Cardiovasc Prev Rehabil. 2009; 16(1): 102–113, doi: 10.1097/HJR.0b013e328325d662, indexed in Pubmed: 19165089.
15. 15. Rauch B, Davos CH, Doherty P, et al. ‘Cardiac Rehabilitation Section’, European Association of Preventive Cardiology (EAPC), in cooperation with the Institute of Medical Biometry and Informatics (IMBI), Department of Medical Biometry, University of Heidelberg, and the Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Heinrich-Heine University, Düsseldorf, Germany. The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies - The Cardiac Rehabilitation Outcome Study (CROS). Eur J Prev Cardiol. 2016; 23(18): 1914–1939, doi: 10.1177/2047487316671181, indexed in Pubmed: 27777324.
16. 16. Smarż K, Jaxa-Chamiec T, Bednarczyk T, et al. Electrocardiographic exercise testing in adults: performance and interpretation. An expert opinion of the Polish Cardiac Society Working Group on Cardiac Rehabilitation and Exercise Physiology. Kardiol Pol. 2019; 77(3): 399–408, doi: 10.5603/KP.a2018.0241, indexed in Pubmed: 30566222.
17. 17. Smarż K, Jaxa-Chamiec T, Chwyczko T, et al. Cardiopulmonary exercise testing in adult cardiology: expert opinion of the Working Group of Cardiac Rehabilitation and Exercise Physiology of the Polish Cardiac Society. Kardiol Pol. 2019; 77(7–8): 730–756, doi: 10.33963/KP.14889, indexed in Pubmed: 31290480.
18. 18. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002; 166(1): 111–117, doi: 10.1164/ajrccm.166.1.at1102, indexed in Pubmed: 12091180.
19. 19. Steinberg JS, Varma N, Cygankiewicz I, et al. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. Ann Noninvasive Electrocardiol. 2017; 22(3): e12447, doi: 10.1111/anec.12447, indexed in Pubmed: 28480632.
20. 20. Lipiec P, Bąk J, Braksator W, et al. Transthoracic echocardiography in adults — guidelines of the Working Group on Echocardiography of the Polish Cardiac Society [Polish]. Kardiol Pol. 2018; 76(2): 488–493, doi: 10.5603/KP.2018.0051, indexed in Pubmed: 29457625.
21. 21. Steeds RP, Garbi M, Cardim N, et al. 2014–2016 EACVI Scientific Documents Committee. EACVI appropriateness criteria for the use of transthoracic echocardiography in adults: a report of literature and current practice review. Eur Heart J Cardiovasc Imaging. 2017; 18(11): 1191–1204, doi: 10.1093/ehjci/jew333, indexed in Pubmed: 28329307.
22. 22. Gielen S, Laughlin MH, O’Conner C, et al. Exercise training in patients with heart disease: review of beneficial effects and clinical recommendations. Prog Cardiovasc Dis. 2015; 57(4): 347–355, doi: 10.1016/j.pcad.2014.10.001, indexed in Pubmed: 25459973.
23. 23. Smolis-Bak E, Kazimierska B. Cardiac physiotherapy [article in Polish]. Lapisart, Warszawa 2013.
24. 24. Piotrowicz R, Piotrowicz E. Telerehabilitation [article in Polish]. Tekst sp. z o.o., Warszawa 2011.
25. 25. Piotrowicz E. How to do: telerehabilitation in heart failure patients. Cardiol J. 2012; 19(3): 243–248, doi: 10.5603/cj.2012.0045, indexed in Pubmed: 22641542.
26. 26. Piotrowicz E, Piepoli MF, Jaarsma T, et al. Telerehabilitation in heart failure patients: the evidence and the pitfalls. Int J Cardiol. 2016; 220: 408–413, doi: 10.1016/j.ijcard.2016.06.277, indexed in Pubmed: 27390963.
27. 27. Piotrowicz E, Pencina MJ, Opolski G, et al. Effects of a 9-week hybrid comprehensive telerehabilitation program on long-term outcomes in patients with heart failure: the telerehabilitation in heart failure patients (TELEREH-HF) randomized clinical trial. JAMA Cardiol. 2020; 5(3): 300–308, doi: 10.1001/jamacardio.2019.5006, indexed in Pubmed: 31734701.
28. 28. Piotrowicz E, Baranowski R, Bilinska M, et al. A new model of home-based telemonitored cardiac rehabilitation in patients with heart failure: effectiveness, quality of life, and adherence. Eur J Heart Fail. 2010; 12(2): 164–171, doi: 10.1093/eurjhf/hfp181, indexed in Pubmed: 20042423.
29. 29. Piotrowicz E, Zieliński T, Bodalski R, et al. Home-based telemonitored nordic walking training is well accepted, safe, effective and has high adherence among heart failure patients, including those with cardiovascular implantable electronic devices: a randomised controlled study. Eur J Prev Cardiol. 2015; 22(11): 1368–1377, doi: 10.1177/2047487314551537, indexed in Pubmed: 25261268.
30. 30. Piotrowicz E, Korzeniowska-Kubacka I, Chrapowicka A, et al. Feasibility of home-based cardiac telerehabilitation: results of TeleInterMed study. Cardiol J. 2014; 21(5): 539–546, doi: 10.5603/CJ.a2014.0005, indexed in Pubmed: 24526507.
31. 31. Piotrowicz R, Krzesiński P, Balsam P, et al. Cardiology telemedicine solutions opinion of the experts of the Committee of Informatics and Telemedicine of Polish Society of Cardiology, Section of Non-invasive Electrocardiology and Telemedicine of Polish Society of Cardiology and Clinical Sciences C [article in Polish]. Kardiol Pol. 2018; 76(3): 698–707, doi: 10.5603/KP.a2018.0058, indexed in Pubmed: 29441511.
32. 32. Jankowski P, Niewada M, Bochenek A, et al. Optimal model of comprehensive rehabilitation and secondary prevention [Polish]. Kardiol Pol. 2013; 71(9): 995–1003, doi: 10.5603/KP.2013.0246, indexed in Pubmed: 24065281.
33. 33. Regulation of the Minister of Health of 16 December 2016 amending the Regulation regarding guaranteed benefits in the field of therapeutic rehabilitation [text in Polish]. Dz. U. 2016, item 2162.
34. 34. Jankowski P, Gąsior M, Gierlotka M, et al. Coordinated care after myocardial infarction. The statement of the Polish Cardiac Society and the Agency for Health Technology Assessment and Tariff System [Polish]. Kardiol Pol. 2016; 74(8): 800–811, doi: 10.5603/KP.2016.0118, indexed in Pubmed: 27553352.
35. 35. Anderson L, Thompson DR, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016; 67(1): CD001800, doi: 10.1002/14651858.CD001800.pub3, indexed in Pubmed: 26730878.
36. 36. de Vries H, Kemps HMC, van Engen-Verheul MM, et al. Cardiac rehabilitation and survival in a large representative community cohort of Dutch patients. Eur Heart J. 2015; 36(24): 1519–1528, doi: 10.1093/eurheartj/ehv111, indexed in Pubmed: 25888007.
37. 37. Ponikowski P, Voors AA, Anker SD, et al. Authors/Task Force Members, Document Reviewers. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016; 18(8): 891–975, doi: 10.1002/ejhf.592, indexed in Pubmed: 27207191.
38. 38. Fletcher GF, Ades PA, Kligfield P, et al. American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013; 128(8): 873–934, doi: 10.1161/CIR.0b013e31829b5b44, indexed in Pubmed: 23877260.
39. 39. Piepoli MF, Conraads V, Corrà U, et al. Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Heart Fail. 2011; 13(4): 347–357, doi: 10.1093/eurjhf/hfr017, indexed in Pubmed: 21436360.
40. 40. Mezzani A, Hamm LF, Jones AM, et al. Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation. Eur J Prev Cardiol. 2013; 20(3): 442–467, doi: 10.1177/2047487312460484, indexed in Pubmed: 23104970.
41. 41. Adamopoulos S, Corrà U, Laoutaris ID, et al. Exercise training in patients with ventricular assist devices: a review of the evidence and practical advice. A position paper from the Committee on Exercise Physiology and Training and the Committee of Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019; 21(1): 3–13, doi: 10.1002/ejhf.1352, indexed in Pubmed: 30474896.
42. 42. Potapov EV, Antonides C, Crespo-Leiro MG, et al. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg. 2019; 56(2): 230–270, doi: 10.1093/ejcts/ezz098, indexed in Pubmed: 31100109.
43. 43. Kindermann M, Schwaab B, Finkler N, et al. Defining the optimum upper heart rate limit during exercise: a study in pacemaker patients with heart failure. Eur Heart J. 2002; 23(16): 1301–1308, doi: 10.1053/euhj.2001.3078, indexed in Pubmed: 12175667.
44. 44. Abreu A, Frederix I, Dendale P, et al. Secondary Prevention and Rehabilitation Section of EAPC, Secondary Prevention and Rehabilitation Section of EAPC Reviewers: Marco Ambrosetti. 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 [Epub ahead of print]: 2047487320924912, doi: 10.1177/2047487320924912, indexed in Pubmed: 32475160.
45. 45. Caimmi PP, Sabbatini M, Kapetanakis EI, et al. A randomized trial to assess the contribution of a novel thorax support vest (corset) in preventing mechanical complications of median sternotomy. Cardiol Ther. 2017; 6(1): 41–51, doi: 10.1007/s40119-016-0078-y, indexed in Pubmed: 27995554.
46. 46. Sibilitz KL, Berg SK, Tang LH, et al. Exercise-based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database Syst Rev. 2016; 3: CD010876, doi: 10.1002/14651858.cd010876.pub2, indexed in Pubmed: 26998683.
47. 47. Ribeiro GS, Melo RD, Deresz LF, et al. Cardiac rehabilitation programme after transcatheter aortic valve implantation versus surgical aortic valve replacement: systematic review and meta-analysis. Eur J Prev Cardiol. 2017; 24(7): 688–697, doi: 10.1177/2047487316686442, indexed in Pubmed: 28071146.
48. 48. Piepoli MF, Corrà U, Benzer W, et al. Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010; 17(1): 1–17, doi: 10.1097/HJR.0b013e3283313592, indexed in Pubmed: 19952757.
49. 49. Kuch M, Janiszewski M, Mamcarz A. Cardiac rehabilitation [article in Polish]. Medical Education, Warszawa 2014.
50. 50. Anderson L, Nguyen TT, Dall CH, et al. Exercise-based cardiac rehabilitation in heart transplant recipients. Cochrane Database Syst Rev. 2017; 4(4): CD012264, doi: 10.1002/14651858.CD012264.pub2, indexed in Pubmed: 28375548.
51. 51. DuBois CM, Lopez OV, Beale EE, et al. Relationships between positive psychological constructs and health outcomes in patients with cardiovascular disease: a systematic review. Int J Cardiol. 2015; 195: 265–280, doi: 10.1016/j.ijcard.2015.05.121, indexed in Pubmed: 26048390.
52. 52. Ladwig KH, Lederbogen F, Albus C, et al. Position paper on the importance of psychosocial factors in cardiology: update 2013. Ger Med Sci. 2014; 12: Doc09, doi: 10.3205/000194, indexed in Pubmed: 24808816.
53. 53. Pogosova N, Saner H, Pedersen SS, et al. Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology. Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology. Eur J Prev Cardiol. 2015; 22(10): 1290–1306, doi: 10.1177/2047487314543075, indexed in Pubmed: 25059929.
54. 54. Mierzyńska A, Kowalska M, Stepnowska M, et al. Psychological support for patients following myocardial infarction. Cardiol J. 2010; 17(3): 319–324, indexed in Pubmed: 20535728.
55. 55. Beniamini Y, Johnston M, Karademas EC. Assessment in health psychology. Hogrefe Publishing GmbH, Göttingen 2016.
56. 56. Diener E, Emmons RA, Larson RJ, Griffin S. Satisfaction with life scale SWLS. In: Juczyński Z. ed. Measurement Tools in the Promotion and Psychology of Health [text in Polish]. Pracownia Testow Psychologicznych PTP, Warszawa 2001: 134–138.
57. 57. Golicki D, Niewada M. EQ-5D-5L Polish population norms. Arch Med Sci. 2017; 13(1): 191–200, doi: 10.5114/aoms.2015.52126, indexed in Pubmed: 28144271.
58. 58. Höfer S, Lim L, Guyatt G, et al. The MacNew heart disease health-related quality of life instrument: a summary. Health Qual Life Outcomes. 2004; 2: 3, doi: 10.1186/1477-7525-2-3, indexed in Pubmed: 14713315.
59. 59. Kokoszka A, Jastrzębski A, Obrębski M. Psychometric properties of the polish version of Patient Health Questionnaire-9 [article in Polish]. Psychiatria. 2016; 13(4): 187–193.
60. 60. Łojek E, Wójcik E, Stańczak J. Depression Scale Questionnaire. Textbook [text in Polish]. Pracownia Testów Psychologicznych PTP, Warszawa 2015.
61. 61. Makowska Z, Merecz D. Mental health assessment on a research basis by David Goldberg Questionnaires [text in Polish]. Wydawnictwo Instytutu Medycyny Pracy, Łódź 2001.
62. 62. Locke AB, Kirst N, Shultz CG. Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician. 2015; 91(9): 617–624, indexed in Pubmed: 25955736.
63. 63. Juczyński Z, Ogińska-Bulik N. Tools for measuring stress and for coping with stress [text in Polish]. Pracownia Testów Psychologicznych PTP, Warszawa 2010.
64. 64. Strelau J, Jaworowska A, Wrześniewski K, Szczepaniak P. The Coping Inventory for Stressful Situations (CISS). Textbook [text in Polish]. Pracownia Testów Psychologicznych PTP, Warszawa 2005.
65. 65. Uchmanowicz I, Wleklik M. Polish adaptation and reliability testing of the nine-item European Heart Failure Self-care Behaviour Scale (9-EHFScBS). Kardiol Pol. 2016; 74(7): 691–696, doi: 10.5603/KP.a2015.0239, indexed in Pubmed: 26620684.
66. 66. Moon SJ, Lee WY, Hwang JS, et al. Accuracy of a screening tool for medication adherence: A systematic review and meta-analysis of the Morisky Medication Adherence Scale-8. PLoS One. 2017; 12(11): e0187139, doi: 10.1371/journal.pone.0187139, indexed in Pubmed: 29095870.
67. 67. Pogosova N, Kotseva K, De Bacquer D, et al. EUROASPIRE Investigators. Psychosocial risk factors in relation to other cardiovascular risk factors in coronary heart disease: results from the EUROASPIRE IV survey. A registry from the European Society of Cardiology. Eur J Prev Cardiol. 2017; 24(13): 1371–1380, doi: 10.1177/2047487317711334, indexed in Pubmed: 28534422.
68. 68. Mierzyńska A, Jurczak K, Piotrowicz R. Psychological interventions in cardiology — short-term motivational strategies. Archives of Psychiatry and Psychotherapy. 2017; 19(2): 15–24, doi: 10.12740/app/73266.
69. 69. Lichtman JH, Bigger JT, Blumenthal JA, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation. 2008; 118(17): 1768–1775, doi: 10.1161/CIRCULATIONAHA.108.190769, indexed in Pubmed: 18824640.
70. 70. Piepoli MF, Abreu A, Albus C, et al. Update on cardiovascular prevention in clinical practice: A position paper of the European Association of Preventive Cardiology of the European Society of Cardiology. Eur J Prev Cardiol. 2020; 27(2): 181–205, doi: 10.1177/2047487319893035, indexed in Pubmed: 31826679.
71. 71. Knuuti J, Wijns W, Saraste A, et al. ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020; 41(3): 407–477, doi: 10.1093/eurheartj/ehz425, indexed in Pubmed: 31504439.
72. 72. Mach F, Baigent C, Catapano AL, et al. ESC Scientific Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020; 41(1): 111–188, doi: 10.1093/eurheartj/ehz455, indexed in Pubmed: 31504418.
73. 73. Nissen SE, Nicholls SJ, Sipahi I, et al. ASTEROID Investigators. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial. JAMA. 2006; 295(13): 1556–1565, doi: 10.1001/jama.295.13.jpc60002, indexed in Pubmed: 16533939.
74. 74. Cannon CP, Blazing MA, Giugliano RP, et al. IMPROVE-IT Investigators. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015; 372(25): 2387–2397, doi: 10.1056/NEJMoa1410489, indexed in Pubmed: 26039521.
75. 75. Sabatine MS, Giugliano RP, Keech AC, et al. FOURIER Steering Committee and Investigators. Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med. 2017; 376(18): 1713–1722, doi: 10.1056/NEJMoa1615664, indexed in Pubmed: 28304224.
76. 76. Schwartz GG, Steg PG, Szarek M, et al. ODYSSEY OUTCOMES Committees and Investigators. Alirocumab and cardiovascular outcomes after acute coronary syndrome. N Engl J Med. 2018; 379(22): 2097–2107, doi: 10.1056/NEJMoa1801174, indexed in Pubmed: 30403574.
77. 77. Berrington de Gonzalez A, Hartge P, Cerhan JR, et al. Body-mass index and mortality among 1.46 million white adults. N Engl J Med. 2010; 363(23): 2211–2219, doi: 10.1056/NEJMoa1000367, indexed in Pubmed: 21121834.
78. 78. Wormser D, Kaptoge S, Di Angelantonio E, et al. Emerging Risk Factors Collaboration. Separate and combined associations of body-mass index and abdominal adiposity with cardiovascular disease: collaborative analysis of 58 prospective studies. Lancet. 2011; 377(9771): 1085–1095, doi: 10.1016/S0140-6736(11)60105-0, indexed in Pubmed: 21397319.
79. 79. Wolfe BM, Kvach E, Eckel RH. Treatment of obesity: weight loss and bariatric surgery. Circ Res. 2016; 118(11): 1844–1855, doi: 10.1161/CIRCRESAHA.116.307591, indexed in Pubmed: 27230645.
80. 80. O’Neil PM, Birkenfeld AL, McGowan B, et al. Efficacy and safety of semaglutide compared with liraglutide and placebo for weight loss in patients with obesity: a randomised, double-blind, placebo and active controlled, dose-ranging, phase 2 trial. Lancet. 2018; 392(10148): 637–649, doi: 10.1016/S0140-6736(18)31773-2, indexed in Pubmed: 30122305.
81. 81. Mirabelli M, Chiefari E, Caroleo P, et al. Long-term effectiveness of liraglutide for weight management and glycemic control in type 2 diabetes. Int J Environ Res Public Health. 2019; 17(1): 207, doi: 10.3390/ijerph17010207, indexed in Pubmed: 31892206.
82. 82. Williams B, Mancia G, Spiering W, et al. ESC Scientific Document Group. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018; 39(33): 3021–3104, doi: 10.1093/eurheartj/ehy339, indexed in Pubmed: 30165516.
83. 83. Wanner C, Lachin JM, Inzucchi SE, et al. EMPA-REG OUTCOME Investigators. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015; 373(22): 2117–2128, doi: 10.1056/NEJMoa1504720, indexed in Pubmed: 26378978.
84. 84. Wiviott SD, Raz I, Bonaca MP, et al. DECLARE–TIMI 58 Investigators. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2019; 380(4): 347–357, doi: 10.1056/NEJMoa1812389, indexed in Pubmed: 30415602.
85. 85. Marso SP, Daniels GH, Brown-Frandsen K, et al. LEADER Steering Committee, LEADER Trial Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016; 375(4): 311–322, doi: 10.1056/NEJMoa1603827, indexed in Pubmed: 27295427.
86. 86. Husain M, Birkenfeld AL, Donsmark M, et al. PIONEER 6 Investigators. Oral semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2019; 381(9): 841–851, doi: 10.1056/NEJMoa1901118, indexed in Pubmed: 31185157.
87. 87. Zelniker TA, Wiviott SD, Raz I, et al. Comparison of the effects of glucagon-like peptide receptor agonists and sodium-glucose cotransporter 2 inhibitors for prevention of major adverse cardiovascular and renal outcomes in type 2 diabetes mellitus. Circulation. 2019; 139(17): 2022–2031, doi: 10.1161/CIRCULATIONAHA.118.038868, indexed in Pubmed: 30786725.
88. 88. Cosentino F, Grant PJ, Aboyans V, et al. ESC Scientific Document Group. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2020; 41(2): 255–323, doi: 10.1093/eurheartj/ehz486, indexed in Pubmed: 31497854.
89. 89. Chow CK, Jolly S, Rao-Melacini P, et al. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation. 2010; 121(6): 750–758, doi: 10.1161/CIRCULATIONAHA.109.891523, indexed in Pubmed: 20124123.
90. 90. Cahill K, Stevens S, Perera R, et al. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013(5): CD009329, doi: 10.1002/14651858.CD009329.pub2, indexed in Pubmed: 23728690.
91. 91. Malas M, van der Tempel J, Schwartz R, et al. Electronic cigarettes for smoking cessation: a systematic review. Nicotine Tob Res. 2016; 18(10): 1926–1936, doi: 10.1093/ntr/ntw119, indexed in Pubmed: 27113014.
92. 92. Ghosh S, Drummond MB. Electronic cigarettes as smoking cessation tool: are we there? Curr Opin Pulm Med. 2017; 23(2): 111–116, doi: 10.1097/MCP.0000000000000348, indexed in Pubmed: 27906858.
93. 93. Law MR, Morris JK, Wald NJ. Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. BMJ. 1997; 315(7114): 973–980, doi: 10.1136/bmj.315.7114.973, indexed in Pubmed: 9365294.
94. 94. DiGiacomo SI, Jazayeri MA, Barua RS, et al. Environmental tobacco smoke and cardiovascular disease. Int J Environ Res Public Health. 2018; 16(1): 96, doi: 10.3390/ijerph16010096, indexed in Pubmed: 30602668.
95. 95. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med. 2008; 35(2): 158–176, doi: 10.1016/j.amepre.2008.04.009, indexed in Pubmed: 18617085.
96. 96. Barua RS, Rigotti NA, Benowitz NL, et al. 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2018; 72(25): 3332–3365, doi: 10.1016/j.jacc.2018.10.027, indexed in Pubmed: 30527452.
97. 97. Samitz G, Egger M, Zwahlen M. Domains of physical activity and all-cause mortality: systematic review and dose-response meta-analysis of cohort studies. Int J Epidemiol. 2011; 40(5): 1382–1400, doi: 10.1093/ije/dyr112, indexed in Pubmed: 22039197.
98. 98. Talbot LA, Morrell CH, Fleg JL, et al. Changes in leisure time physical activity and risk of all-cause mortality in men and women: the Baltimore Longitudinal Study of Aging. Prev Med. 2007; 45(2–3): 169–176, doi: 10.1016/j.ypmed.2007.05.014, indexed in Pubmed: 17631385.
99. 99. Piepoli MF, Davos C, Francis DP, et al. ExTraMATCH Collaborative. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). BMJ. 2004; 328(7433): 189, doi: 10.1136/bmj.37938.645220.EE, indexed in Pubmed: 14729656.
100. 100. Young DR, Hivert MF, Alhassan S, et al. Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Functional Genomics and Translational Biology; and Stroke Council. Sedentary behavior and cardiovascular morbidity and mortality: a science advisory from the American Heart Association. Circulation. 2016; 134(13): e262–e279, doi: 10.1161/CIR.0000000000000440, indexed in Pubmed: 27528691.
101. 101. Fletcher GF, Ades PA, Kligfield P, et al. American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013; 128(8): 873–934, doi: 10.1161/CIR.0b013e31829b5b44, indexed in Pubmed: 23877260.
102. 102. Bruning RS, Sturek M. Benefits of exercise training on coronary blood flow in coronary artery disease patients. Prog Cardiovasc Dis. 2015; 57(5): 443–453, doi: 10.1016/j.pcad.2014.10.006, indexed in Pubmed: 25446554.
103. 103. Huffman JC, Niazi SK, Rundell JR, et al. Essential articles on collaborative care models for the treatment of psychiatric disorders in medical settings: a publication by the academy of psychosomatic medicine research and evidence-based practice committee. Psychosomatics. 2014; 55(2): 109–122, doi: 10.1016/j.psym.2013.09.002, indexed in Pubmed: 24370112.
104. 104. Bishop GD, Kaur D, Tan VLM, et al. Effects of a psychosocial skills training workshop on psychophysiological and psychosocial risk in patients undergoing coronary artery bypass grafting. Am Heart J. 2005; 150(3): 602–609, doi: 10.1016/j.ahj.2004.10.015, indexed in Pubmed: 16169348.