Ärztliche Betreuung von ambulanten Herzgruppen

Positionspapier der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung (DGK) in Kooperation mit der Deutschen Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen (DGPR)

Physician support for outpatient cardiac rehabilitation groups

Position paper of the German Cardiac Society (DGK) in cooperation with the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR)

Zusammenfassung

Ambulante Herzgruppen sind ein wichtiger Teil der kardiovaskulären Langzeitprävention. Der eigentlich notwendigen Ausweitung des Angebotes ambulanter Herzgruppen steht der zunehmende ärztliche Fachkräftemangel entgegen, da bisher alle Herzgruppen von Ärzten begleitet werden müssen. Studiendaten zeigen, dass während der letzten Jahrzehnte das Risiko von schwerwiegenden kardiovaskulären Ereignissen während Bewegungstherapie gesunken ist. Dies ist v. a. auf die Fortschritte der kardiovaskulären Medizin im Hinblick auf Revaskularisationsstrategien und medikamentöse Therapie zurückzuführen. Es erscheint somit nicht mehr notwendig, jede Herzgruppe von einem Arzt begleiten zu lassen, sondern es sollte eine Risikostratifikation erfolgen. In der „Standardherzgruppe“ ist keine ärztliche Anwesenheit erforderlich. Die Gruppe wird von einem nichtärztlichen Herzgruppenleiter angeleitet, der über eine entsprechende Qualifikation verfügt. Zudem muss ein automatischer externer Defibrillator (AED) vor Ort sein und die Möglichkeit eines sofortigen Notrufes an den Rettungsdienst gegeben sein. In der „Herzgruppe mit erhöhtem Betreuungsbedarf“ wird hingegen eine ärztliche Anwesenheit benötigt. In diese Gruppe werden Patienten eingeteilt, bei denen Risikokriterien, wie z. B. Angina pectoris oder Dyspnoe bei Belastung, erfüllt sind. Ausgenommen von dieser Risikostratifikation sind Patienten, die die Aufnahmekriterien einer „Herzinsuffizienzherzgruppe“ erfüllen. Diese neu seit Anfang 2020 eingeführte Hochrisikoherzgruppe wird durch speziell ausgebildete Herzgruppenleiter und Ärzte angeleitet. Es wird kalkuliert, dass nach der vorgeschlagenen Regelung bei etwa 50 % aller Herzgruppenpatienten keine ärztliche Gruppenbegleitung mehr benötigt wird. Durch dieses Modell könnten zukünftig noch mehr Patienten von ambulanten Herzgruppen profitieren, ohne dass ein Verlust an Sicherheit oder Effektivität zu befürchten wäre.

Abstract

Phase III outpatient cardiac rehabilitation groups (cardiac rehab groups) are crucial for effective cardiovascular prevention and rehabilitation. The need to increase the number of these groups is limited by the decreasing availability of physicians as it has been mandated that all cardiac rehab groups have to be supervised by physicians. Study data have shown that during the last decades the risk of serious events during exercise training of cardiovascular patients has decreased due to the improvements in cardiovascular medicine. Therefore, physician support for cardiac rehab groups should now depend on risk stratification. In the “standard cardiac rehab group” physician attendance is not necessary. The group is supervised by a qualified non-physician exercise therapist. It is mandatory that during training in these groups an automated external defibrillator (AED) is available and an immediate emergency call to the emergency medical services is possible. In the “cardiac rehab group with increased need for support” attendance of a physician is required. This group is reserved for patients with risk criteria, such as angina pectoris or dyspnea during exercise. Patients that fulfill the criteria for the novel “heart failure rehab groups” are excluded from this risk stratification. These new high-risk cardiac rehab groups have recently been introduced into clinical practice in 2020 and are attended by specially trained cardiac group leaders and physicians. It has been calculated that following the proposed risk stratification approximately 50% of the cardiac rehab group patients will no longer need supervision by a physician. It is expected that implementation of this model into practice will increase the number of cardiac patients who will participate in cardiac rehab groups without a loss of safety or effectiveness.

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Literatur

  1. 1.

    Piepoli MF, Hoes AW, Agewall S et al (2016) 2016 European guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 37:2315–2323

    PubMed  PubMed Central  Article  Google Scholar 

  2. 2.

    Hambrecht R, Albus C, Halle M et al (2017) Kommentar zu den neuen Leitlinien (2016) der Europäischen Gesellschaft für Kardiologie (ESC) zur kardiovaskulären Prävention. Kardiologe 11:21–26

    Article  Google Scholar 

  3. 3.

    Ärztekammer Berlin (2018) Dramatischer Ärztemangel in Herzsportgruppen. Pressemeldung der Ärztekammer Berlin. Zugegriffen am: 10.10.2020 https://www.aerztekammer-berlin.de/40presse/15_meldungen/000054_Aerztemangel_Herzsportgruppen.html

  4. 4.

    Brüggemann I, Guha M (2018) Herzgruppen in Deutschland: Hintergründe, Rahmenbedingungen und aktuelle Situation. Diabetes Stoffwechsel Herz 27:336–340

    Google Scholar 

  5. 5.

    Chow CK, Jolly S, Rao-Melacini P, Fox KA, Anand SS, Yusuf S (2010) Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation 121:750–758

    PubMed  Article  PubMed Central  Google Scholar 

  6. 6.

    Maron DJ, Mancini GBJ, Hartigan PM et al (2018) Healthy behavior, risk factor control, and survival in the COURAGE trial. J Am Coll Cardiol 72:2297–2305

    PubMed  Article  PubMed Central  Google Scholar 

  7. 7.

    Hambrecht R, Walther C, Moebius-Winkler S et al (2004) Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation 109:1371–1378

    PubMed  Article  PubMed Central  Google Scholar 

  8. 8.

    Hambrecht R, Gielen S, Linke A et al (2000) Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: a randomized trial. JAMA 283:3095–3101

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  9. 9.

    Wienbergen H, Hambrecht R (2012) Physical exercise training for cardiovascular diseases. Herz 37:486–492

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  10. 10.

    Kotseva K, De Backer G, De Bacquer D et al (2019) Lifestyle and impact on cardiovascular risk factor control in coronary patients across 27 countries: results from the European society of cardiology ESC-EORP EUROASPIRE V registry. Eur J Prev Cardiol 26:824–835

    PubMed  Article  PubMed Central  Google Scholar 

  11. 11.

    Fach A, Osteresch R, Erdmann J et al (2019) Long-term prevention after myocardial infarction in young patients ≤ 45 years: the intensive prevention program in the young (IPP-Y) study. Eur J Prev Cardiol. https://doi.org/10.1177/2047487319883960

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Kuepper-Nybelen J, Rothenbacher D, Hahmann H, Wusten B, Brenner H (2003) Changes of risk factors in patients with coronary heart disease after in-patient rehabilitation. Dtsch Med Wochenschr 128:1525–1530

    Article  Google Scholar 

  13. 13.

    Graf C, Bjarnason-Wehrens B, Löllgen H (2004) Ambulante Herzgruppen in Deutschland – Rückblick und Ausblick. Dtsch Z Sportmed 55:339–346

    Google Scholar 

  14. 14.

    Haberecht O, Bärsch-Michelmann A (2013) Herzgruppen in Deutschland: Stand und Perspektiven. Herzmedizin 4:33–38

    Google Scholar 

  15. 15.

    Bjarnason-Wehrens B, Boethig S, Brusis OA et al (2004) Herzgruppe der DGPR – Positionspapier. Deutschen Gesellschaft für Prävention und Rehabilitation e. V. (DGPR), Koblenz

    Google Scholar 

  16. 16.

    Ponikowski P, Voors AA, Anker SD et al (2016) 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 37:2129–2200

    PubMed  Article  PubMed Central  Google Scholar 

  17. 17.

    von Haehling S, Arzt M, Doehner D (2020) Improving exercise capacity and quality of life using non-invasive heart failure treatments: evidence from clinical trials. Eur J Heart Fail. https://doi.org/10.1002/ejhf.1838

    Article  Google Scholar 

  18. 18.

    Brüggemann I, Guha M (2019) Herzgruppen für Patienten mit hohem kardio-vaskulärem Ereignisrisiko – Herzinsuffizienzgruppen. Diabetes Stoffwech Herz 28:336–340

    Google Scholar 

  19. 19.

    Deutsche Gesellschaft für Prävention und Rehabilitation e. V. (DGPR) (2019) Die Herzinsuffizienzgruppe. Positionspapier der DGPR

    Google Scholar 

  20. 20.

    Anderson L, Oldridge N, Thompson DR et al (2016) Exercise-based cardiac reha-bilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 67:1–12

    PubMed  Article  PubMed Central  Google Scholar 

  21. 21.

    Doimo S, Fabris E, Piepoli M et al (2019) Impact of ambulatory cardiac rehabilitation on cardiovascular outcomes: a long-term follow-up study. Eur Heart J 40:678–685

    PubMed  Article  PubMed Central  Google Scholar 

  22. 22.

    Rauch B, Davos CH, Doherty P et al (2016) The prognostic effect of cardiac rehabi-litation 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 23:1914–1939

    PubMed  PubMed Central  Article  Google Scholar 

  23. 23.

    Deutsche Gesellschaft für Prävention und Rehabilitation e. V. (DGPR) (2020) S3-Leitlinie zur kardiologischen Rehabilitation (LL-KardReha) im deutschsprachigen Raum Europas Deutschland, Österreich, Schweiz (D-A-CH).Zugegriffen am: 10.10.2020 https://www.awmf.org

  24. 24.

    Taylor RS, Walker S, Smart NA et al (2019) Impact of exercise rehabilitation on exercise capacity and quality-of-life in heart failure: individual participant meta-analysis. J Am Coll Cardiol 73:1430–1443

    PubMed  Article  PubMed Central  Google Scholar 

  25. 25.

    Salzwedel A, Jensen K, Rauch B et al (2020) Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine: update of the cardiac rehabilitation outcome study (CROS-II). Eur J Prev Cardiol. https://doi.org/10.1177/2047487320905719

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Bjarnason-Wehrens B, Nebel R, Jensen K et al (2020) Exercise-based cardiac rehabilitation in patients with reduced left ventricular ejection fraction: the cardiac rehabilitation outcome study in heart failure (CROS-HF): a systematic review and meta-analysis. Eur J Prev Cardiol 27:929–952

    PubMed  Article  PubMed Central  Google Scholar 

  27. 27.

    Buchwalsky G, Buchwalsky R, Held K (2002) Langzeitwirkungen der Nachsorge in einer ambulanten Herzgruppe. Eine Fall‑/Kontrollstudie. Z Kardiol 91:139–146

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  28. 28.

    Gayda M, Ribeiro PA, Juneau M, Nigam A (2016) Comparison of different forms of exercise training in patients with cardiac disease: where does high-intensity interval training fit? Can J Cardiol 32:485–494

    PubMed  Article  PubMed Central  Google Scholar 

  29. 29.

    Cornelis J, Beckers P, Taeymans J, Vrints C, Vissers D (2016) Comparing exercise training modalities in heart failure: a systematic review and meta-analysis. Int J Cardiol 221:867–876

    PubMed  Article  PubMed Central  Google Scholar 

  30. 30.

    Santos FV, Chiappa GR, Ramalho SHR et al (2018) Resistance exercise enhances oxygen uptake without worsening cardiac function in patients with systolic heart failure: a systematic review and meta-analysis. Heart Fail Rev 23:73–89

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  31. 31.

    Wang Z, Peng X, Li K, Wu CJ (2019) Effects of combined aerobic and resistance training in patients with heart failure: a meta-analysis of randomized, controlled trials. Nurs Health Sci 21:148–156

    PubMed  Article  PubMed Central  Google Scholar 

  32. 32.

    Ambrosetti M, Abreu A, Corra U et al (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. https://doi.org/10.1177/2047487320913379

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Thompson PD, Franklin BA, Balady GJ et al (2007) Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American heart association council on nutrition, physical activity, and metabolism and the council on clinical cardiology. Circulation 115:2358–2368

    PubMed  Article  PubMed Central  Google Scholar 

  34. 34.

    Borjesson M, Urhausen A, Kouidi E et al (2011) Cardiovascular evaluation of middle-aged/senior individuals engaged in leisure-time sport activities: position stand from the sections of exercise physiology and sports cardiology of the European association of cardiovascular prevention and rehabilitation. Eur J Cardiovasc Prev Rehabil 18:446–458

    PubMed  Article  PubMed Central  Google Scholar 

  35. 35.

    Lippi G, Maffulli N (2009) Biological influence of physical exercise on hemostasis. Semin Thromb Hemost 35:269–276

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  36. 36.

    Haskell WL (1978) Cardiovascular complications during exercise training of cardiac patients. Circulation 57:920–924

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Van Camp SP, Peterson RA (1986) Cardiovascular complications of outpatient cardiac rehabilitation programs. JAMA 256:1160–1163

    CAS  PubMed  Article  Google Scholar 

  38. 38.

    Vongvanich P, Paul-Labrador MJ, Merz CN (1996) Safety of medically supervised exercise in a cardiac rehabilitation center. Am J Cardiol 77:1383–1385

    CAS  PubMed  Article  Google Scholar 

  39. 39.

    Franklin BA, Bonzheim K, Gordon S, Timmis GC (1998) Safety of medically supervised outpatient cardiac rehabilitation exercise therapy: a 16-year follow-up. Chest 114:902–906

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  40. 40.

    Pavy B, Iliou MC, Meurin P, Tabet JY, Corone S (2006) Safety of exercise training for cardiac patients: results of the French registry of complications during cardiac rehabilitation. Arch Intern Med 166:2329–2334

    PubMed  Article  PubMed Central  Google Scholar 

  41. 41.

    Rognmo O, Moholdt T, Bakken H et al (2012) Cardiovascular risk of high- versus moderate-intensity aerobic exercise in coronary heart disease patients. Circulation 126:1436–1440

    PubMed  Article  PubMed Central  Google Scholar 

  42. 42.

    Ismail H, McFarlane JR, Nojoumian AH, Dieberg G, Smart NA (2013) Clinical outcomes and cardiovascular responses to different exercise training intensities in patients with heart failure: a systematic review and meta-analysis. JACC Heart Fail 1:514–522

    PubMed  Article  PubMed Central  Google Scholar 

  43. 43.

    O’Connor CM, Wheelan DJ, Lee KL et al (2009) Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 301:1439–1450

    PubMed  PubMed Central  Article  Google Scholar 

  44. 44.

    Pina IL, Apstein CS, Balady GJ et al (2003) Exercise and heart failure: a statement from the American heart association committee on exercise, rehabilitation, and prevention. Circulation 107:1210–1225

    PubMed  Article  PubMed Central  Google Scholar 

  45. 45.

    Long L, Mordi IR, Bridges C et al (2019) Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev 1:CD3331

    PubMed  PubMed Central  Google Scholar 

  46. 46.

    Borjesson M, Dellborg M, Niebauer J et al (2019) Recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: a position statement from the sports cardiology section of the European association of preventive cardiology (EAPC). Eur Heart J 40:13–18

    PubMed  Article  PubMed Central  Google Scholar 

  47. 47.

    Knuuti J, Wijns W, Saraste A et al (2020) 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 41:407–477

    PubMed  Article  PubMed Central  Google Scholar 

  48. 48.

    Bundesarbeitsgemeinschaft für Rehabilitation e. V. (BAR) (2020) Qualifikationsanforderungen Übungsleiter/-in Rehabilitationsport

    Google Scholar 

  49. 49.

    Minneboo M, Lachman S, Snaterse M et al (2017) Community-based lifestyle intervention in patients with coronary artery disease: the RESPONSE‑2 trial. J Am Coll Cardiol 70:318–327

    PubMed  Article  PubMed Central  Google Scholar 

  50. 50.

    Wienbergen H, Fach A, Meyer S et al (2019) Effects of an intensive long-term prevention programme after myocardial infarction - a randomized trial. Eur J Prev Cardiol 26:522–530

    PubMed  Article  PubMed Central  Google Scholar 

  51. 51.

    Lenzen MJ, Boersma E, Bertrand ME et al (2005) Management and outcome of patients with established coronary artery disease: the Euro heart survey on coronary revascularization. Eur Heart J 26:1169–1179

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  52. 52.

    Morbach C, Wagner M, Guntner S et al (2017) Heart failure in patients with coronary heart disease: prevalence, characteristics and guideline implementation—results from the German Euroaspire IV cohort. BMC Cardiovasc Disord 17:108

    PubMed  PubMed Central  Article  Google Scholar 

  53. 53.

    Iung B, Delgado V, Rosenhek R et al (2019) Contemporary presentation and manage-ment of valvular heart disease: the EURObservational research programme valvular heart disease II survey. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.119.041080

    Article  PubMed  PubMed Central  Google Scholar 

  54. 54.

    Graf C, Halle M (2015) Aktuelle Aspekte im Herzsport. Kardiologe 9:67–80

    Article  Google Scholar 

  55. 55.

    Klingenheben T, Loellgen H, Bosch R, Trappe HJ (2018) Manual zum Stellenwert der Ergometrie. Kardiologe 12:342–355

    CAS  Article  Google Scholar 

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Correspondence to Prof. Dr. H. Wienbergen.

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Wienbergen, H., Schwaab, B., Bjarnason-Wehrens, B. et al. Ärztliche Betreuung von ambulanten Herzgruppen. Kardiologe (2020). https://doi.org/10.1007/s12181-020-00433-w

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Schlüsselwörter

  • Ambulante Herzgruppen
  • Kardiovaskuläre Prävention und Nachsorge
  • Körperliches Training
  • Ärztlicher Fachkräftemangel
  • Risikostratifikation

Keywords

  • Phase III outpatient cardiac rehabilitation groups
  • Cardiovascular prevention and rehabilitation
  • Exercise training
  • Availability of physicians
  • Risk stratification