Interval training can be defined as repeated bouts of short-duration, high to severe- or severe to extreme-intensity exercise (i.e. 10 seconds to five minutes), separated by brief periods of lower-intensity CWR exercise allowing for active recovery. The term aerobic interval training (AIT) is often used to describe interval training in the high to severe-intensity domain. Although a significant contribution from anaerobic energetic sources to the total energy yield is unavoidable in this domain, most of the energy needed is still produced aerobically (see Domains of exercise intensity: the appropriate basis for exercise prescription above). Currently, the most used AIT model consists of 10min warm-up followed by 4×4-min intervals at 85–95%peak HR, with active recovery phases of 3 min at ∼70%peak HR (Figure 5). This AIT model has now been used in several studies, both in healthy subjects and in various cardiac patient populations,95,96,99,100 with absolute increases in peak VO2 per exercise session actually remarkably similar among patient groups (Figure 6).
AIT has shown significantly greater cardiovascular effects when compared with isocaloric moderate to high- intensity continuous training, both in coronary artery disease (CAD) and CHF patients95,96 (Figure 6). AIT has also been shown to exert favourable effects on left ventricular systolic function. In healthy men, stroke volume has been shown to increase significantly more after high-intensity AIT compared with lower-intensity training of the same energy expenditure.99 In CHF patients, Wisløff et al.96 found reverse left ventricular remodelling after AIT, while continuous training produced no significant changes in left ventricular volumes and resting haemodynamics; furthermore, left ventricular contractile function was shown to markedly improve only in AIT patients. Also left ventricular diastolic properties have been found to improve significantly more after AIT than after continuous training in both CHF96 and stable CAD subjects.101 Improved endothelial function, reductions in atherosclerosis and better calcium regulation in cardiomyocytes are among the possible explanations for these findings and data in humans seem to confirm basic experimental data.102 Both AIT and moderate to high-intensity continuous training have been found to improve endothelial function in cardiac patients, with significantly larger improvement in brachial artery flow-mediated dilatation after AIT in CHF patients96 and both improvement in endothelial function and reduction in in-stent restenosis in patients with previous percutaneous coronary intervention (PCI) and stent implantation.103 It is reasonable to suggest that higher shear stress during AIT may trigger larger responses than moderate to high-intensity continuous training at the cellular and molecular level and be responsible for the observed effects on endothelial function.104
In contrast to the described 4×4-min AIT model, shorter, sprint-type intervals of all-out severe to extreme- intensity exercise have been shown to induce rapid changes in exercise capacity, improving work performance due to enhanced skeletal muscle energy metabolism with modest effects on peak VO2.105,106 This type of interval training is poorly documented in CAD patients, although some acute effects of severe to extreme-intensity interval training have been reported in stable CAD patients.97,107 However, a study applying two-minute-long severe to extreme-intensity intervals found a similar improvement in peak VO2 to that after more traditional continuous training in CAD patients, but with increased time to exhaustion at 90%VO2R.108
In a clinical setting, AIT can be performed as uphill walking or running on a treadmill according to the 4×4- min protocol. Patients are supposed to exercise with an intensity corresponding to 85–95%peak HR during the high to severe-intensity intervals, which makes patients breathe heavily without experiencing chest or leg pain. To ensure that the relative intensity is maintained throughout the whole training period, the WR should be adjusted continuously based on the individual HR response. In the recovery periods, patients are supposed to exercise at intensities of ∼70%peak HR. In clinical practice, however, it is sometimes necessary to adjust the HR zones, especially the moderate to high-intensity recovery ones, based on the patient's subjective feelings. In the RPE Borg scale, patients should exercise at an intensity of 15–18 in the high to severe-intensity intervals. Exercise modes other than treadmill walking are possible and AIT using an aerobic exercise group setting has been shown to be feasible in CHF patients.109 Although AIT has proven efficient in increasing cardiovascular health in CAD patients, there is still a need to further investigate feasibility, long-term effects and safety aspects of this training modality. In CHF patients, a preserved walking distance on the six-minute walking test was found one year after ending a formal AIT program.110 Moreover, in patients with previous coronary artery by-pass graft a further increase in peak VO2 was seen six months after the end of an AIT rehabilitation period.100 A large ongoing multicentre randomized trial, the Study of MyocArdial Recovery AfTer EXercise Training in Heart Failure (SMARTEX-HF), will address the feasibility, safety and efficacy of AIT in a large group of CHF patients.111
In addition to the differences in physiological responses to acute arm versus leg exercise, the principle of exercise training specificity suggests that cardiovascular and metabolic adaptation to acute exercise is specific to the type of exercise performed and the muscles involved.118 Specifically, training upper limbs or lower limbs results in only minor improvement in submaximal and maximal exercise parameters when testing the untrained limbs. Lastly, the role of arm exercise in a patient whose primary goal is weight loss should be balanced against the patient's need to significantly improve upon the acute exercise response to arm exercise (training adaptation). If the patient has the expectation to resume participation in occupational or recreational activities which require substantial upper limb aerobic capacity, a significant component of the cardiac rehabilitation exercise training program may need to include arm exercise.118–120 However, primarily assigning increased utilization of lower extremity exercise, with their increased exercise efficiency and enhanced ability to exercise at higher absolute WR, may substantially increase the calorie expenditure of the exercise program.
Obesity or being overweight affects more than half of the adult populations in the developed world and both are associated with an increased risk of many chronic diseases. A large body of evidence demonstrates that even modest weight loss, as low as 3–5% of body weight, by regular physical activity is associated with decreased chronic disease risk.121 Higher intensity and longer duration physical activity, conducted on a regular basis, are both associated with greater weight loss and less long-term weight gain compared with lower intensity or shorter duration exercise. Weight loss induced by increased daily physical activity without caloric restriction can significantly reduce obesity (particularly abdominal obesity) and insulin resistance. Exercise without overall weight loss reduced abdominal fat and prevented further weight gain.122 Evidence supports that low to moderate-intensity physical activity of 150–250 minutes per week will result in modest weight loss and is effective in preventing weight gain. Higher intensities and longer duration of physical activity (>250 min/week) are associated with significant weight loss.123 Maintenance of weight loss is optimal with low to moderate- or moderate to high-intensity physical exercise of more than 250 min/week duration. A recent systematic review noted a dose–response relationship between the intensity of activity and the loss of visceral fat, with at least 10 METs·h/week of aerobic exercise (brisk walking, light jogging or stationary ergometer usage) required for visceral fat reduction.123 Both men and women benefit from maintaining higher levels of physical activity over a long period of time, but the benefits may be even greater for women.124–126
The results of the research cited above suggest that incorporating physical activity into daily life improves health outcomes, body weight and visceral adiposity. There appears to be a dose–response related to weight loss from light to high-intensity activity, but both light to moderate- and moderate to high-intensity activity may result in significant weight loss when maintained over time, and especially when combined with appropriate caloric intake for body size and daily energy expenditure. Research suggests that a minimum of 30 minutes of light to moderate activity on a daily basis is the threshold to result in weight loss, but that increasing the duration to 45–60 minutes, or increasing the intensity to moderate to high levels, may further enhance weight loss and cardiorespiratory fitness.
Once a patient's exercise risk has been determined without the aid of a standard exercise test or a CPX, an exercise prescription can be developed using Borg scales and/or subjective tools such as the ‘talk test’.68,137 RPE correlates sufficiently well with exercise HR and VO2 to allow for an exercise prescription to be determined;138,139 an RPE Borg scale rating of 9–12 should be sufficient to elicit light to moderate exertion while remaining below the 1stVT in both patients and normal subjects69–73,140 (see The RPE versus VO2or HR relationship above). In addition, the use of RPE as an acceptable measure of the physiologic response to exercise appears to be valid for patients receiving beta-blockers.76 In the ‘talk test’ or the ‘walk and talk test’, patients should be able to maintain a certain level of exercise and still be able to talk in full sentences. As with RPE, its use in CAD populations to determine levels of physical exertion that approximate those objectively assessed by CPX has not been robustly evaluated. However, considering that its use in healthy populations does appear to correlate with 1stVT141 and VO2R,142 it is thus not unreasonable to consider its use also in patients with CAD.
Indications for aerobic exercise intensity prescription in specific cardiac patient groups are summarized in Table 5; only intensity domain data for which scientific evidence is available in a given cardiac patient group have been included, with grey-shaded areas indicating that there are no available data to warrant a recommendation. Physiological, performance and perceived exertion limits of the different exercise intensity domains are provided in Table 3, and both directly (i.e. by incremental CPX) and indirectly (i.e. by incremental standard exercise test) assessed physiological and performance limits are shown. As already emphasized in Prescribed exercise intensity: general concepts above, the choice between different exercise intensities in a specific patient will depend on the individual's clinical and pathophysiological status, the evidence-based benefits of exercise in the different intensity domains for that specific patient group and the goals of the rehabilitation program. The information provided in this section are to be considered complementary to those furnished by the recently published EACPR paper ‘Importance of characteristics and modalities of physical activity and exercise in the management of cardiovascular health in individuals with cardiovascular disease (Part III)’.143
For patients with stable angina pectoris (SAP) secondary to coronary atherosclerosis, the benefits of cardiac rehabilitation are unequivocal and it should be considered standard care for all patients with CAD.144,145 The overwhelming consideration within this population remains exercise safety. The surest way to maximize both patient safety and exercise enjoyment and attain improved cardiorespiratory fitness is to first assess the patient using an incremental standard exercise test or CPX, develop an exercise intensity prescription based on the results of that test and then ensure an adequate warm-up and cooling down period prior to and after, respectively, training sessions.
The purpose of the warm-up is to increase blood flow to the skeletal muscles, in preparation for exercise, and to facilitate coronary vasodilatation. The anti-ischemic benefits of an adequate warm-up, prior to the initiation of light to moderate/moderate to high exercise have been demonstrated.146–148 As far as training intensity is concerned, the current recommendation for persons without SAP is to perform moderate to high-intensity exercise sessions in order to improve cardiorespiratory fitness.149 This same recommendation has been extended to patients with SAP.37 In a number of small studies, moderate to high-intensity exercise training in patients with SAP has been shown to reduce myocardial ischemic burden assessed by either myocardial perfusion scintigraphy150,151 or 24-hour ambulatory electrocardiographic monitoring.152 The mechanisms by which exercise training improves mortality in the SAP population include enhanced metabolic performance of working muscles, reduced endothelial dysfunction, improvements in insulin resistance and favourable adjustments in neurohormonal abnormalities.153
In recent years, research into the most appropriate intensity of exercise training for patients with CAD has focused on the use of AIT (see Interval training prescription above). Although the cardiorespiratory benefits of AIT are well documented in athletes, a recent systematic review of interval training in patients with CAD found only two controlled and five randomized controlled trials, with a total of 213 patients.104 The review found that interval training improved cardiorespiratory fitness, endothelial function and ventricular function and morphology to a greater degree than conventional light to moderate- and moderate to high-intensity continuous aerobic training. In a study on SAP patients, Guiraud and co-workers found that shorter bouts of severe to extreme-intensity exercise (15 seconds compared with 60 seconds) combined with a passive, rather than active, recovery phase, resulted in improved patient comfort and longer time spent at >80% of peak VO2.154 In patients with SAP, it is important that exercise intensity be prescribed at a HR that is below the ischemic threshold;44 for patients with documented silent ischemia, it is critical that patients be instructed to never exceed the upper HR limit for exercise intensity. The purpose of the cool-down period post-exercise is to invoke a return to a resting state. Studies in healthy populations have indicated that a cool-down period following exercise returns both the HR and ventilation toward pre-exercise levels faster than without a cool-down.155,156
In summary, it is suggested that patients with SAP exercise three to five times per week, following an adequate warm-up of five to 15 minutes, at moderate to high intensity (in any case below the ischemic threshold) for a period of 20 to 40 minutes (not including warm-up and cool-down), followed by a cool-down period of five to 10 minutes. Most importantly, patients with SAP should engage in the type of exercise activity they find most enjoyable and, therefore, sustainable.
The same evidence and clinical practice recommendations developed for patients with SAP regarding exercise (seeStable angina pectoris above) are likely applicable to most patients post-PCI. Presently, there is no evidence to suggest that early exercise training and exercise testing post-PCI is either unsafe or adversely affects patient outcomes,157–159 even if high-intensity exercise may actually increase thrombin generation.160 With respect to the best timing to begin an exercise training program of moderate to high intensity, Parker et al. found that exercise testing and training were safe in a low risk post-PCI population less than two weeks after acute PCI for ST-elevation myocardial infarction.161 As post-PCI patients may be at particular risk for failing to increase their physical activity levels and exercise,162 a more rapid access to exercise training may be particularly useful in this population.163 Exercise training programs post-PCI have been consistently associated with improvements in functional capacity;103,157,164–166 conversely, failure to improve functional capacity post-PCI, despite exercise training, may be a marker for coronary artery restenosis.167
Data on the specific effects of exercise intensity on patient outcomes post-PCI are sparse. Munk et al. found that high to severe-intensity interval training helped to reduce six month restenosis in the stented coronary artery segment as assessed by quantitative coronary angiography; this effect was associated with improvements in aerobic capacity and attributed to improved endothelial function and reduced systemic inflammation.103 Other investigators have found similar findings with respect to improved functional capacity and reduced inflammation for post-PCI patients.164,166 Aerobic training may result in increased endothelial NO production and/or reduced NO destruction and this may lead to reduced vascular inflammation and reduced restenosis.168–170 In addition to these benefits, moderate to high-/high to severe-intensity exercise training post-PCI may also improve left ventricular remodeling171 and HR variability.172,173 However, whether such a training modality is safe for all patients post-PCI, particularly those with a history of anterior/apical myocardial infarction, or with poor left ventricular systolic function, and those with a history of CHF, remains to be determined.
Patients implanted with permanent pacemakers (PMs) usually follow the same principles for aerobic training intensity prescription as non-PM-implanted patients, provided an adequate chronotropic response to exercise is warranted by the patient's sinus node and/or the device.174 In rate-responsive PM, this is usually the case when the upper-rate limit is matched to the expected training intensity. On the other hand, if an exercising patient's chronotropic response exceeds the PM upper-rate limit, the device should usually produce a Wenckebach pattern to maintain a relatively high HR without risking rapid ventricular responses. If a Wenckebach pattern is produced at exercise intensity levels lower than those prescribed, the upper-rate limit may need to be increased. Of note, patients with VVI PM devoid of rate-adaptive function lack the ability to increase HR. In the absence of rate modulation, the exercise capacity of VVI paced patients may be greatly reduced when compared with those with rate modulation and AV synchrony. However, it has been shown that exercise training may produce significant increases in peak VO2 also in this population.175
Patients with implantable cardioverter defibrillators (ICDs) can undergo aerobic exercise training, but care must be taken to avoid receiving inappropriate shocks during exercise. These could occur in the event that the exercise HR increases so that it is within the programmed ventricular tachycardia zone or if exercise-induced supraventricular tachycardia develops. Exercise intensities in the light to moderate and moderate to high domains have been found effective in improving peak VO2 in patients with an ICD. It is important to note that exercise training intensities used in all of these studies resulted in HRs that were 15–20 beats lower than the ICD threshold for detection and termination of ventricular tachycardia.176–179 Thus, as recently stated, exercise heart rates should not exceed ICD therapy thresholds and ideally be set between 10 and 20 beats below first line therapy thresholds.3
Chronic atrial fibrillation (AF) is a very common arrhythmia, characterized by irregularly irregular atrial and ventricular depolarizations. The prevalence of chronic AF is quite high in patients older than 60 years and the arrhythmia may present as ‘lone’ AF or associated with comorbid conditions, such as CHF or valvular heart disease. Patients with chronic AF frequently have incomplete ventricular filling, which leads to an impaired cardiac output response to exercise, very rapid ventricular rates during effort (possibly exceeding predicted maximum) and, ultimately, reduced peak VO2 and VO2 at 1stVT in comparison with patients in sinus rhythm.180 Patients with CHF and chronic AF show peak VO2 values lower than those of CHF patients in sinus rhythm, but with 1stVT occurring at a higher percentage of peak VO2.181 Training intensities in the light to moderate- and moderate to high-intensity domains have been used in patients with chronic AF, improving both exercise capacity (i.e. peak VO2) and chronotropic response to exercise.182–184 Of note, the highly variable ventricular chronotropic response at submaximal levels of exercise typical of chronic AF patients may render HR of little utility for aerobic training prescription in some patients, making subjective RPE the most reliable means for exercise intensity assessment and prescription. In this regard, given the high prevalence of chronic AF in elderly patients, randomized controlled studies addressing the most effective type of exercise intensity assessment and prescription in this population are strongly needed.
Patients who have undergone traditional open-chest coronary artery by-pass graft (CABG) surgery as well as minimally invasive procedures are a substantial proportion of cardiac rehabilitation exercise programming participants, and this group includes many patients who are age 65 years or older.185 Outpatient rehabilitation can be started, as appropriate, within one week of hospital discharge (2–3 weeks post-surgery).186 Exercise prescription methodology is generally the same as that used with CAD patients. Initially, some patients may need lower- intensity or modified exercise because of musculoskeletal discomfort or healing issues at their incision sites, including not only the chest, but possibly also legs and arms. Specifically, patients should completely refrain from upper-extremity aerobic exercise training, for example arm ergometry and resistance training, for 4–6 weeks post-surgery to ensure the stability of the sternum and sternal wound healing. The exception is appropriate upper and lower body stretching and flexibility exercises to promote mobility. In patients with previous CABG, several aerobic training intensities have proven effective,100,187–192 the choice of which will depend on both the level of exercise-related risk and the patient's clinical condition. In this regard, it must be borne in mind that, among patients entering a rehabilitation program after a recent acute cardiac event, those with recent CABG have been found to have the lowest peak VO2.193
Because of the possibility of graft closure, program staff should be alert for new patient complaints of angina pectoris or angina-equivalent symptoms or signs, such as exercise intolerance or new ECG signs of myocardial ischemia. Patients should also be educated regarding these possibilities. Recognizing whether the revascularization was complete or incomplete is valuable in this regard as the latter may increase the likelihood of postsurgical signs and symptoms of residual myocardial ischemia during exercise, which may significantly affect the results of the rehabilitation process.194
The exercise prescription and training of patients with recent valve replacement or repair is very similar to that used with CABG surgery patients.186,195,196 However, the physical activity of some valvular heart disease patients may have been very restricted for an extended period of time prior to the surgical intervention. Consequently, the resulting low functional capacity may require these patients to initiate, and proceed with, exercise in a conservative fashion, especially during the early stages of the exercise training program.193 Rehabilitation professionals should take care to avoid upper-extremity exercise, as described in Coronary surgical revascularization above. Exercise intensities in the light to moderate- and moderate to high-intensity domains have been used in patients with recent heart valve replacement or repair and balloon valvuloplasty, demonstrating significant effects on exercise capacity and quality of life.197–201 Preliminary data also indicate a possible reverse left ventricular remodelling effect of prolonged aerobic training in patients with previous aortic valve replacement.202 Anticoagulation therapy is very common in patients who have undergone valve surgery; consequently, this necessitates caution for exercise-related injuries and subsequent bleeding. Staff should frequently remind patients undergoing exercise training of the increased risk of such events.
Patients with valvular heart disease but without valve repair or replacement may also be referred for cardiac rehabilitation. In these patients, critical aortic stenosis is a formal contraindication for exercise training. Patients with less-severe aortic stenosis can exercise but may develop symptoms, for example dyspnoea and significant fatigue, at a given WR. Exercise training intensity should be kept under the threshold that precipitates the onset of symptoms, because these symptoms indicate that their cardiac output is not capable of meeting the demands of that level of exercise.
A reduced ability to perform aerobic exercise is the hallmark of the CHF pathophysiological picture.203 It is related to changes in both peripheral and central links of the O2 transport chain from ambient air to the skeletal muscle, the major consequence of which is a reduced cardiac output and peripheral microcirculatory response relative to exercise-related metabolic needs.204,205 Moreover, ventilation is increased at comparable absolute submaximal levels of effort in CHF patients with respect to age-matched normal subjects.206 Among the proposed causes of the increased ventilatory response to exercise are a reduced oxygen-diffusing capacity due to an impairment of alveolar–arterial oxygen transfer,207 an increase in dead space ventilation because of a mismatching of ventilation relative to pulmonary perfusion,206 and an exaggerated ergoreflex response originating in the exercising skeletal muscles during effort.208 Finally, skeletal muscle metabolic potential is also reduced, due to altered redistribution of flow to exercising muscles, endothelial dysfunction and impaired mitochondrial enzymes activity.209 These changes promote a vicious cycle of deterioration involving catabolic drive and reflex neurohormonal over-activation,210 which may lead to disease progression and functional deterioration. As a consequence, in CHF, peak VO2 and VO2 at 1stVT are typically reduced with respect to age-matched normal subjects, and their reduction is proportional to the severity of the syndrome.211 A wide range of aerobic exercise intensities, that is, from light to moderate to high to severe, has been tested in CHF patients. All intensities have been shown to be effective in improving patients' exercise capacity, whereas the ability to induce reverse left ventricular remodelling and improvements in left ventricular ejection fraction has been demonstrated only for moderate to high- and high to severe-intensity aerobic training.85,86,96,212 This offers a wide range of possibilities for the choice of aerobic exercise intensity in CHF, even if more work is needed to investigate safety aspects of high to severe-intensity training in this population (see Interval Training Prescription above).
Among patients with advanced CHF, that is, by definition with severely reduced exercise capacity and presumed high exercise-related risk, left ventricular assist device implantation is increasingly used as a bridge to transplantation or even as permanent therapy. Patients with left ventricular assist devices can often be managed at outpatient clinics, and an early initiation of exercise training after implantation has been reported to be associated with improvements in exercise capacity.213 Walking in the hospital ward as well as aerobic exercise on a cycle ergometer or a treadmill can be performed with the aim of improving exercise capacity. Light to moderate training intensities adjusted at the 1stVT level or possibly even slightly higher (12–14 score in the RPE Borg scale) have succeeded in improving peak VO2 in this population.214–216
Exercise training is recommended for all patients before and after heart transplantation.186,217 Patients with severe heart failure, awaiting heart transplantation, are usually significantly deconditioned due to metabolic changes that occur with heart failure, resulting in significant limitations in the ability to do physical work.218 Functional capacity following transplantation may be affected by the patient's baseline capacity prior to surgery, or by underlying cause(s) of heart failure, the clinical course in the hospital, surgical complications, skeletal muscle weakness, use of corticosteroids and other post-transplant medications and surgical denervation of the heart.219
Given the complexity of hemodynamic and cardiorespiratory responses during incremental exercise in this population, exercise intensity may best be determined by RPE. At the start of training programs, an RPE of 10–12, that is, light to moderate-intensity in the RPE Borg scale, will generally account for the surgical and disease deconditioning as well as any potential exercise issues associated with steroid myopathy.220 If the patient's clinical condition allows, the exercise intensity can gradually increase to moderate to high to enhance patient outcomes. High to severe-intensity aerobic interval training programs have also been evaluated in selected heart transplanted patients and have proven to be safe and effective.221,222 Following heart transplantation, an improvement in functional capacity of approximately 20–50% is associated with participation in a cardiac rehabilitation program.220–223 Exercise should be initially performed in a supervised setting to fully evaluate and monitor the patient's response to aerobic training.
This statement was approved by the European Association for Cardiovascular Prevention and Rehabilitation on 28 November 2011, the American Association of Cardiovascular and Pulmonary Rehabilitation Board of Directors on 6 March 2012 and the Canadian Association of Cardiac Rehabilitation on 5 June 2012.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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