Hello everybody. My name is Christian Schmied. I'm Chief of Service and lecturer at the University Heart Center in Zurich, Switzerland. And I'd like to talk to you about cardiovascular rehabilitation. With the coronary reperfusion, with the successful treatment of myocardial infarction, the disease has not at all been cured. The disease has just yet begun. Cardiac rehabilitation is important, and it works, And I just want to show you some exemplary data on how it works. You see that it is major outcome data and major benefits for re-infarction, for all-cause mortality and also cardiac mortality. So, rehab works, and it should be provided to every patient. But who qualifies for a cardiac rehabilitation? At first, patients with an acute or chronic cardiovascular disease. Coronary heart disease, of course, patients after a myocardial infarction, but also, patients with valvular heart disease, patients with heart failure and myocardial disease, post percutaneous and surgical interventions, very important, patients with peripheral artery disease, and patients, in general, with an increased cardiovascular risk, but however, insufficiently controlled cardiovascular risk factors, particularly sedentary patients. So, the evidence again for the effectiveness of cardiac rehabilitation is really striking. It's, as I mentioned before, a reduction of rehospitalizations, it's an early resumption and better sustainability for the ability to work. It's most important for the reduction of cardiovascular and all-cause mortality. It's a reduction of the re-infarction rate and also other cardiovascular events. Furthermore, an improvement of the quality of life, the decrease of psychological consequences, it's an improved physical capacity in daily life and during training of course, it's a sustention and a slight regression with the addition of medication for atherosclerosis. And it also has a positive effect on diastolic and systolic heart failure and various other cardiovascular diseases, particularly also hypertension. Cardiac rehabilitation is separated and differentiated in four different phases. I want to focus on these phases within the next slide now. Phase one starts at the very first day of the intervention, of the disease, and of the event. From the event to day one, maybe two, maybe three, it has the major aim to preserve the physical baseline activity. The preservation of cardiovascular circulation and the vegetative status. And the prevention of collateral damage due to immobilization. Furthermore, the aim is an optimal preparation for phase two rehabilitation, which I will come to in the next slides. So, phase two cardiac rehabilitation begins from day two to three and lasts up to week three or week 12 respectively. I will come to that in a minute. This is depending on the concept of cardiac rehab, which we provide. The major aim after a physical and medical evaluation is a controlled and supervised physical exercise and training. It addresses the cardiovascular risk factors, all of them, and the initiation of a lifestyle intervention, particularly regarding nutrition, smoking cessation, stress management, and physical and medical evaluation. We also support, or try to give support, regarding reintegration into patient's daily lives. So, as I mentioned before, there are mainly two major concepts we follow in cardiac rehabilitation phase two: One is home-based, so the patient sleeps and stays at home and he comes in three times a week, mainly Monday, Wednesday, and Friday for 12 weeks for training sessions that lasts 60 to 90 minutes. The advantages of this concept are that patients can stay in their normal environments, the integration of relatives and families is possible, we have a longer and persistent observation phase, and there is a possibility to restart work earlier. The other concept is the hospital-based rehabilitation. The daily training sessions are an advantage in this case, it lasts only for 2-3 weeks. So, it's still a hospital environment. Patients can get out of the hospital earlier, they can stay at intermediate care there. Maybe this is more for complex patients with comorbidities. The change of the environment maybe even desired for the patients and Their families. It's important to mention in the end that both of these concepts show the similarly positive effects on cardiovascular risk factors and Outcomes. So, we can really decide on an individual base here. Phase three and four are crucial for the patients because they add on phase two. And the major aim is the maintenance of a healthy and cardiovascular healthy lifestyle. So, this is crucial, it lasts for a lifetime. But it's a challenging phase or challenging phases because it's important to keep patients adherent to a positive lifestyle. What kind of sports, what kind of exercise and lifestyle do we recommend? I want to come to this in the next final minutes. So, there's a lot of possibilities to classify training. I think in the end, the right mixture is the key to success. I Just want to focus on some possibilities to quantification: One is, of course, the exercise intensity. We know that moderate to intensive exercise brings us health and cardiovascular benefits and you see some examples on this slide. There are three cornerstones, training modalities in heart disease and cardiovascular rehab: One, of course, is endurance training, which is separated in continuous endurance training and interval endurance training. Strength training and some parts of resistance training are very important for our patients. And, last but not least, there are lately some very nice data regarding specific respiratory muscle training. This is a typical concept, which we provide in our rehab program phase two. You see parts of continuous and interval endurance training, you see some points regarding strength training and respiratory training, and you see that we have the possibility to increase the intensity and the repetitions in all these modalities. As mentioned before, strength training is an important part of our rehab phase two training. And it's important that we mainly prescribe so-called dynamic strength training. Once you follow maximum strength training, hypertrophy training with few repetitions, with a maximum of burden, you really gain the risk of increased blood pressures. So, once you follow repetitions of 12, maybe 20 repetitions, follow a dynamic strength training, you're on the safe side, and this is what we recommend to patients. To focus a little bit more in detail on strength training, let me differentiate the strength training in three steps: We start with step one, the so-called pre-training. The aim is to correctly implement and perceive the movements first. The form is dynamic, as I said. Step two really follows the resistance training, So, we improve the local aerobic endurance and inter-muscular coordination. It's still dynamic and we increase the repetitions a little bit. And finally, step three, really has the aim to build up muscle training, we increase the muscle mass. Again, dynamic training, and we increase a little bit more intensity. Let me finalize my talk with the so-called concept of super compensation. It's an old concept, you maybe have heard of it, but it's very important, particularly for our patients. So, let me guide you through this graph here. Once you start your training, first, at the end of the training, your physical capacity is decreased, you're tired, you're exhausted, then you recover in phase two. And after some sessions, after some weeks of training, you even get in phase three. So, you super compensate, you get a training effect, and this is the aim for us, for all of us, for the patients and for athletes. And then if you provide the next session, the next training repetition of sessions, then you can really build up a training effect, you can really improve your physical capacity. But there's an adverse effect, there's also another side: Once you start your next training sessions too early, maybe in phase two, once you didn't recover totally, you can get on a downward slope, you can really decrease your physical capacity to so-called overtraining. So, it's really important for our patients to be aware of the effects that recreation, recovery is very important. I tend to say, training lasts 24 hours and it consists of the exercise, but the most important part, in my mind, particularly for our patients, is recreation. So, let me conclude. Cardiac rehabilitation works. I hope I could show you that, there's a strong evidence for various health benefits and outcome data for cardiovascular diseases, particularly coronary heart disease. Cardiac rehabilitation starts at the very first day of a cardiovascular event and should last for a lifetime. Adherence to a healthy lifestyle after supervised phase two rehabilitation, is the crucial key. And finally, the rehabilitation program should be diversified and integrate lifestyle modifications and various training modalities. Regeneration, recreation is an important part of the training. I hope you have enjoyed this lecture and I wish you a nice day.