Do clinicians prescribe exercise similarly in patients with different cardiovascular diseases? Findings from the EAPC EXPERT working group survey

Abstract

Background Although disease-specific exercise guidelines for cardiovascular disease (CVD) are widely available, it remains uncertain whether these different exercise guidelines are integrated properly for patients with different CVDs. The aim of this study was to assess the inter-clinician variance in exercise prescription for patients with various CVDs and to compare these prescriptions with recommendations from the EXercise Prescription in Everyday practice and Rehabilitative Training (EXPERT) tool, a digital decision support system for integrated state-of-the-art exercise prescription in CVD. Design The study was a prospective observational survey. Methods Fifty-three CV rehabilitation clinicians from nine European countries were asked to prescribe exercise intensity (based on percentage of peak heart rate (HR)), frequency, session duration, programme duration and exercise type (endurance or strength training) for the same five patients. Exercise prescriptions were compared between clinicians, and relationships with clinician characteristics were studied. In addition, these exercise prescriptions were compared with recommendations from the EXPERT tool. Results A large inter-clinician variance was found for prescribed exercise intensity (median (interquartile range (IQR)): 83 (13) % of HR), frequency (median (IQR): 4 (2) days/week), session duration (median (IQR): 45 (18) min/session), programme duration (median (IQR): 12 (18) weeks), total exercise volume (median (IQR): 1215 (1961) peak-effort training hours) and prescription of strength training exercises (prescribed in 78% of all cases). Moreover, clinicians' exercise prescriptions were significantly different from those of the EXPERT tool ( p < 0.001). Conclusions This study reveals significant inter-clinician variance in exercise prescription for patients with different CVDs and disagreement with an integrated state-of-the-art system for exercise prescription, justifying the need for standardization efforts regarding integrated exercise prescription in CV rehabilitation.

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

“…Patients with CKD are considered to be at high (stage 3 CKD) or very-high risk (stage 4-5 CKD or on dialysis) of CVD, and should be managed accordingly Blood pressure monitoring Arterial hypertension as the leading risk factor should properly be detected and treated, according to CKD-specific targets present between clinicians when defining exercise intensity, duration, volume and type, meaning that in clinical practice the same cardiovascular (risk) patient can receive very different exercise prescriptions when consulting different clinicians. 165 This is actually of no surprise, because tailoring the exercise prescription can be very difficult, in which the following factors/aspects should be taken into account: patient phenotype, prevalent disease and risk factors, medication intake and exercise response/capacity. In order to assist clinicians in the tailoring of exercise prescription, a digital decision support system ('EXPERT tool') has therefore been developed and made available, 166 thus being a potential facilitator of the application of recommendations.…”

Recommendations for resistance exercise in cardiac rehabilitation: Do they need reconsideration?

“…Since the introduction of resistance exercise in cardiac rehabilitation, there have been a number of debates about the best intensity of exercise, searching for a balance between optimum efficacy and medical safety. This controversy is evident in clinical practice 8 as well as in the available study results, where the training intensity has been set between 30 and 80% of one repetition maximum (1RM), which makes it difficult to evaluate the overall results. [8][9][10] The former reluctance to implement resistance training in cardiac rehabilitation was mainly based on the caution that its performance may lead to an inadequate blood pressure response and/or other inadequate cardiovascular responses.…”

“…This controversy is evident in clinical practice 8 as well as in the available study results, where the training intensity has been set between 30 and 80% of one repetition maximum (1RM), which makes it difficult to evaluate the overall results. [8][9][10] The former reluctance to implement resistance training in cardiac rehabilitation was mainly based on the caution that its performance may lead to an inadequate blood pressure response and/or other inadequate cardiovascular responses. However, an inadequate response can be avoided by taking into account influencing factors, such as the mode of exercise (the isometric/isotonic components), the amount of the muscle mass used, the exercise intensity, the number and speed/rhythm of repetitions, the duration of loading, the number of sets and the resting period between sets.…”

The EXPERT vision of exercise training in cardiovascular disease patients: A routine, practical and reasonable technique

“…First, the variance in exercise prescription between clinicians was calculated for every case separately, then ET prescriptions that were generated by the clinicians were compared with prescriptions generated by the EXPERT tool. A large inter-clinician variance for all ET components was evident, 17 and ET prescriptions were significantly different between clinicians and the EXPERT tool. Although the EXPERT tool is not proven to be a 'gold standard', these findings confirm the need for a mixed and integrated attitude of ET prescription in order to favour a daily life approach together with the importance of standardisation in CVD rehabilitation.…”

“…To verify the EXPERT tool's application and functioning versus traditional ways of acting, Hansen et al 17 analysed ET prescriptions in five patient cases, from the easiest (case 1) to the most difficult (case 5). Participants were incompletely involved in the EXPERT working group, but were all actively involved in CVD rehabilitation.…”