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Objective: Although physical training has been associated with an increase in survival, its role in reducing Exercise-induced arrhythmias (EIA) in patients with heart disease has not yet been dilucidated. We aim to compare the effect of physical training on the occurrence of EIA in patients with heart disease. Methodology: We evaluated a retroprospective and self-controlled cohort of patients older than 18 years with heart disease who entered the cardiac rehabilitation program of the National Institute of Cardiology Ignacio Chávez in México, during January 2015 to December 2016. In all patients, cardiovascular risk was stratified, including a cardiopulmonary exercise test, which was also performed at the end of the program. The occurrence of arrhythmias was evaluated before and after the training program. Results: 160 patients were analyzed, of which 126 (79%) were male. The proportion of patients who developed EIA in the first exercise testing was 56% and in the second one was 48%. In the first group 35% of patients did not developed EIA in the second test. Of the 71 patients who did not present EIA at the beginning of the program, twenty (28%) presented arrhythmias at second test. In relation to the effect of the training program on the occurrence of arrhythmias, we could observe that it had a protective effect, with a RR = 0.49 (95% CI: 0.35-0.67, p <0.001). Conclusion: In this study, physical training was associated with a decreased risk of developing EIA.

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OBJECTIVE: Exercise-induced premature ventricular complexes (EiPVCs) are often considered as benign arrhythmias, although they are associated with a high risk of all-cause death in the general healthy population. However, an intermediate pathophysiological process remains unclear, particularly in patients with known cardiovascular disease. The aim of this study was to find an association between EiPVCs, the occurrence of life-threatening ventricular arrhythmias (LACO), and all-cause mortality in patients with cardiovascular disease. METHODS: This was an observational study of a cohort of patients with coronary artery disease (CAD) or idiopathic cardiomyopathy (ICM). Stress testing was performed as a part of the routine cardiovascular evaluation. The occurrence of EiPVCs was evaluated during exercise testing (ET). At follow-up, long-term occurrence of LACO was evaluated. A bivariate and multivariate analysis was performed. RESULTS: Out of the total of 1442 patients analysed, 700 (49%) had EiPVCs. During 14 years of following-up after ET, 106 LACO outcomes were observed. Long-term all-cause mortality was 4% (n=61). A bivariate analysis showed that patients with EiPVCs had an increased risk for LACO (RR=2.81, 95% CI; 1.9-4.3, P<.001), and for mortality (RR=2.1, CI95% 1.2-3.4, P<.01). Occurrence of LACO was also associated with a higher mortality risk (RR=5.7, 95% CI; 3.4-9.4, P<.001). After a post hoc analysis, LACO remained as a highly predictive variable for mortality. CONCLUSION: Patients with EiPVCs have a high risk of LACO and all-cause mortality. The presence of LACO could be an intermediate stage between EiPVCs and mortality in subjects with cardiovascular disease.

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Abstract Objective: Exercise-induced premature ventricular complexes (EiPVCs) are often considered as benign arrhythmias, although they are associated with a high risk of all-cause death in the general healthy population. However, an intermediate pathophysiological process remains unclear, particularly in patients with known cardiovascular disease. The aim of this study was to find an association between EiPVCs, the occurrence of life-threatening ventricular arrhythmias (LACO), and all-cause mortality in patients with cardiovascular disease. Methods: This was an observational study of a cohort of patients with coronary artery disease (CAD) or idiopathic cardiomyopathy (ICM). Stress testing was performed as a part of the routine cardiovascular evaluation. The occurrence of EiPVCs was evaluated during exercise testing (ET). At follow-up, long-term occurrence of LACO was evaluated. A bivariate and multivariate analysis was performed. Results: Out of the total of 1442 patients analysed, 700 (49%) had EiPVCs. During 14 years of following-up after ET, 106 LACO outcomes were observed. Long-term all-cause mortality was 4% (n = 61). A bivariate analysis showed that patients with EiPVCs had an increased risk for LACO (RR = 2.81, 95% CI; 1.9---4.3, P < .001), and for mortality (RR = 2.1, CI95% 1.2---3.4, P < .01). Occurrence of LACO was also associated with a higher mortality risk (RR = 5.7, 95% CI; 3.4---9.4, P < .001). After a post hoc analysis, LACO remained as a highly predictive variable for mortality. Conclusion: Patients with EiPVCs have a high risk of LACO and all-cause mortality. The presence of LACO could be an intermediate stage between EiPVCs and mortality in subjects with cardiovascular disease.

Resumen Objetivo: La extrasistolia ventricular inducida por ejercicio (EVIE) suele considerarse una arritmia benigna, sin embargo, ha sido asociada a mayor mortalidad en población general. Hasta hoy no se ha encontrado el proceso fisiopatológico involucrado, particularmente en pacientes con enfermedad cardiovascular. El objetivo del estudio fue establecer una asociación entre EVIE con la ocurrencia de arritmias ventriculares potencialmente malignas (APM) y letalidad a largo plazo, en sujetos con enfermedad cardiovascular. Método: Estudiamos una cohorte de pacientes con enfermedad coronaria o miocardiopatía dilatada, que realizaron una prueba de ejercicio al inicio del estudio. Inicialmente evaluamos la ocurrencia de EVIE, APM y letalidad a largo plazo y posteriormente se realizó un estudio bivariable y multivariable. Resultados: Se incluyeron 1,442 pacientes de los cuales 700 presentaron EVIE (49%). Durante 14 an˜os de seguimiento, 106 sujetos presentaron APM y la mortalidad total fue de 61 casos (4%). El estudio bivariable mostró que aquellos pacientes con EVIE tuvieron un riesgo de presentar APM de 2.81 (IC95% de 1.9 a 4.3, p < 0.001) y de mortalidad de 2.1 (IC95% de 1.2 a 3.4, p < 0.01). Los individuos con APM tuvieron mayor riesgo de mortalidad (RR= 5.7, IC95% de 3.4 a 9.4, p < 0.001). Después de un análisis multivariable, la APM continuó siendo una variable altamente predictiva de mortalidad. Conclusión: Los pacientes con EVIE tienen un riesgo elevado de presentar APM y de mortalidad a largo plazo. Los resultados sugieren que las APM podrían representar un estado intermedio entre la presencia de EVIE y la mortalidad en pacientes con enfermedad cardiovascular.

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Abstract: Objective: The aim of this paper is to compare the state of Cardiac Rehabilitation Programs (CRP) in 2009 with 2015. Focus is directed on health care, training of health-providers, research, and the barriers to their implementation. Methods: All authors of RENAPREC-2009, and other cardiac rehabilitation leaders in Mexico were requested to participate. These centres were distributed into two groups: RENAPREC-2009 centres that participated in 2015, and the new CRP units. Results: In 2009 there were 14 centres, two of which disappeared and another two did not respond. CRP-units increased by 71% (n = 24), and their geographic distribution shows a centripetal pattern. The coverage of CRP-units was 0.02 centres per 100,000 inhabitants. Only 4.4% of eligible patients were referred to CRP, with a rate of 10.4 patients/100,000 inhabitants in 2015. The ratio of Clinical Cardiologists to Cardiac Rehabilitation Specialists was 94:1, and the ratio of Intervention Specialists to cardiac rehabilitation experts was 16:1. Cardiac rehabilitation activities and costs varied widely. Patient dropout rate in phase II was 12%. Several barriers were identified: financial crisis (83%), lack of skilled personnel (67%), deficient equipment (46%), inadequate areas (42%), and a reduced number of operating centres (38%). Conclusions: CRPs in Mexico are still in the process of maturing. Mexican CRP-centres have several strengths, like the quality of the education of the professionals and the multidisciplinary programs. However, the lack of referral of patients and the heterogeneity of procedures are still their main weaknesses.

Resumen: Objetivo: El propósito de este trabajo es comparar el estado actual de los programas de rehabilitación cardiaca (PRC) en México con el RENAPREC-2009, dirigido a la asistencia, docencia, investigación y barreras. Métodos: Se convocó a participar a todos los autores de RENAPREC-2009 y a otros líderes en rehabilitación cardiaca de México. Los centros fueron distribuidos en 2 grupos: los que participaron en el 2015 y las nuevas unidades de PRC. Resultados: En 2009 había 14 centros operativos, de los cuales 2 cerraron y 2 no respondieron. En 2015 se registraron 24 centros en total, representando un aumento neto del 71%. La distribución geográfica fue centrípeta. La cobertura fue de 0.02 centros/100,000 habitantes y de solamente un 4.4% de los pacientes elegibles (10.4 pacientes/100,000 habitantes). La relación cardiólogo clínico-rehabilitador cardiaco es de 94:1 y la de intervencionista-rehabilitador cardiaco es de 16:1. Las actividades realizadas y los costos de los PRC varían de forma importante de centro a centro. En promedio, el 12% de los pacientes en fase ii abandonaron el programa. Las principales barreras para el desarrollo de PRC fueron: económicas (83%), falta de personal capacitado (67%), falta de equipo (46%), áreas inadecuadas (42%) y un insuficiente número de centros operativos (38%). Conclusiones: Los PRC en nuestro país continúan en crecimiento. Se observan fortalezas como el nivel de docencia y el enfoque multidisciplinario, así como deficiencias en la homogeneidad de las actividades y la falta de referencia de la población elegible.

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OBJECTIVE: The aim of this paper is to compare the state of Cardiac Rehabilitation Programs (CRP) in 2009 with 2015. Focus is directed on health care, training of health-providers, research, and the barriers to their implementation. METHODS: All authors of RENAPREC-2009, and other cardiac rehabilitation leaders in Mexico were requested to participate. These centres were distributed into two groups: RENAPREC-2009 centres that participated in 2015, and the new CRP units. RESULTS: In 2009 there were 14 centres, two of which disappeared and another two did not respond. CRP-units increased by 71% (n=24), and their geographic distribution shows a centripetal pattern. The coverage of CRP-units was 0.02 centres per 100,000 inhabitants. Only 4.4% of eligible patients were referred to CRP, with a rate of 10.4 patients/100,000 inhabitants in 2015. The ratio of Clinical Cardiologists to Cardiac Rehabilitation Specialists was 94:1, and the ratio of Intervention Specialists to cardiac rehabilitation experts was 16:1. Cardiac rehabilitation activities and costs varied widely. Patient dropout rate in phase II was 12%. Several barriers were identified: financial crisis (83%), lack of skilled personnel (67%), deficient equipment (46%), inadequate areas (42%), and a reduced number of operating centres (38%). CONCLUSIONS: CRPs in Mexico are still in the process of maturing. Mexican CRP-centres have several strengths, like the quality of the education of the professionals and the multidisciplinary programs. However, the lack of referral of patients and the heterogeneity of procedures are still their main weaknesses.

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Heart failure is a health problem associated with disability and mortality. Physicians may stratify the risk of adult patients with heart failure using a cardiopulmonary exercise testing. Until now, in childhood this evaluation has been poorly used. The purpose of this study is to compare the peak oxygen uptake and minute ventilation/carbon dioxide production slope among children with heart failure versus children without heart disease (control). METHODS: Thirty-eight children with heart failure were compared with 194 children without heart disease. All of them performed cardiopulmonary exercise testing using a symptom-limited ramp protocol. Differences between groups were compared using Chi-squared test, Student's t test, or ANOVA. Any value of p < 0.05 was considered significant. RESULTS: Children with heart failure were older, taller, and with a higher prevalence of male gender. This group had also a lower peak oxygen uptake (27 ± 10 ml O2/kg/min) compared to the control group (37 ± 10 ml O2/kg/min); p < 0.001. The minute ventilation/carbon dioxide production was higher in the heart failure group (31 ± 4) than in controls (28 ± 6); p < 0.001. CONCLUSION: Children with heart failure showed lower peak oxygen uptake and higher minute ventilation/carbon dioxide production slope than the control group.

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