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Cardiovascular diseases are still the number one killer in developed countries. The term “death from cardiovascular disease,” however, includes not only acute myocardial infarction, but also death from chronic ischemic heart disease, stroke, peripheral artery disease, and pulmonary embolism. A more detailed analysis shows that only approximately 18% of the cardiovascular deaths arise from myocardial infarction, while a continuously increasing percentage result from ischemic heart disease. Although modern medicine significantly improved the short-term outcome of acute myocardial infarction, it shifted the problem from a decrease in mortality to an increase in morbidity. Therefore, the challenge of modern medicine is not only to further reduce the already declining cardiovascular mortality,, but also to reduce cardiovascular morbidity.

Exercise intolerance is a key feature of most cardiovascular diseases. Its value for describing the stage of the disease is so important that standardized classification systems of exercise limitation (i.e. the New York Heart Association Classification) were developed more than half a century ago. While the symptoms of reduced maximal exercise capacity may be similar, the underlying mechanisms causing exercise limitations are fundamentally different between major disease entities.

Since the late 1950s, numerous scientific reports have examined the relationships between physical activity, physical fitness, and cardiovascular health. Expert panels convened by organizations such as the Centers for Disease Control and Prevention (CDC), American College of Sports Medicine (ACSM), the European Working Group on Exercise Physiology and Rehabilitation, and the American Heart Association (AHA),– along with the US Surgeon General’s Report on Physical Activity and Health, have reinforced scientific evidence linking regular physical activity to various measures of cardiovascular health. The prevailing view in these reports is that more active or fit individuals tend to experience less coronary heart disease (CHD) than their sedentary counterparts, and when they do acquire CHD, it occurs at a later age and tends to be less severe.

Coronary artery disease (CAD) is a chronic disorder with a natural history that spans multiple decades. In each affected individual, the disease can go over to a number of well-defined clinical phases: asymptomatic, stable angina, progressive angina, unstable angina, and acute myocardial infarction. Therefore, the approach to diagnosis and risk stratification of the coronary disease patient varies according to the phase of the disease in which the patient presents.

Cardiopulmonary exercise testing (CPX) is being increasingly used in patients with chronic heart failure (CHF) for diagnostic and prognostic purposes. It provides major insights regarding the degree of functional impairment, the prognosis, and the effect of treatment. Despite the availability of simple and rapid gas analyzers, the general belief is that the procedure is complex, which is not the case. Peak oxygen uptake (peak VO) is generally the only variable used to evaluate exercise capacity and prognosis. However, CPX provides a lot of information besides peak VO.

Exercise testing (ET) has been the cornerstone in the diagnosis and prognostic evaluation of coronary artery disease (see Chapter 14)., Even in apparently healthy men exercise testing provides important prognostic informations. Although ET was recently recommended in the management of asymptomatic patients with valvular heart disease (VHD),, this recommendation is based on a small database. In the Euro Heart Survey on Valvular Heart Disease of the European Society of Cardiology, exercise testing was used in less than 8% of 5001 patients, evaluated in hospital or as an outpatient in 27 European countries. 6 The reasons for performing exercise testing in these patients are listed in Table 16-1.

Regular physical exercise and a high exercise capacity have been hallmarks of health and vitality for millennia and were associated with a distinct survival advantage in a hostile environment. In the modern civilized environment it is usually not the external enemy who is to be defeated. One of the enemies of survival is lack of physical activity and the resulting decreased physical fitness: both emerge once again as enemies of survival, this time in an all too friendly and comfortable environment.

Diabetes mellitus type 2 is one of the most common diseases in industrialized countries and is one of the main risk factors for the development of micro- and macrovascular diseases. Vascular complications are causes of death in up to 80% of these patients and 75% of deaths are due to coronary artery disease.,

We are all on a trajectory to heart disease. It’s called age. (J. N. Cohn, University of Minneapolis, at the Annual Scientific Meeting of the Heart Failure Society of America, Toronto, Canada, 2004)

Exercise training is the core component of cardiac rehabilitation in patients with coronary artery disease (CAD) and the positive effects have been studied extensively (see Chapter 17).– Markedly less information is available concerning the results of exercise training in patients with valvular heart disease (VHD). This is mainly due to the fact that patients with native VHD have rarely been considered candidates for exercise training. In the guidelines on the management of patients with VHD no comments are made on this topic in patients with native VHD or after valve surgery. In the new recommendation by the working group on valvular heart disease of the European Society of Cardiology suggestions for exercise training after valve surgery are outlined.