Resistance Training in Patients With Coronary Artery Disease, Heart Failure, and Valvular Heart Disease: A REVIEW WITH SPECIAL EMPHASIS ON OLD AGE, FRAILTY, AND PHYSICAL LIMITATIONS : Journal of Cardiopulmonary Rehabilitation and Prevention

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Invited Reviews

Resistance Training in Patients With Coronary Artery Disease, Heart Failure, and Valvular Heart Disease

A REVIEW WITH SPECIAL EMPHASIS ON OLD AGE, FRAILTY, AND PHYSICAL LIMITATIONS

Bjarnason-Wehrens, Birna PhD; Schwaab, Bernhard PhD, MD; Reiss, Nils PhD, MD; Schmidt, Thomas PhD

Author Information
Journal of Cardiopulmonary Rehabilitation and Prevention: September 2022 - Volume 42 - Issue 5 - p 304-315
doi: 10.1097/HCR.0000000000000730
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KEY PERSPECTIVE:

What is novel?

  • A summary of the results of current meta-analyses demonstrates the safety and effectiveness of resistance training (RT) in patients with coronary artery disease and/or heart failure with reduced left ventricular ejection fraction.
  • In patients with heart failure with preserved left ventricular ejection fraction (HFpEF) or valvular heart disease (VHD), there is limited evidence on the feasibility, efficacy, and safety of RT, but the available data show promising results.
  • In old patients entering cardiac rehabilitation (CR), the prevalence of skeletal muscle deconditioning, physical limitations, and frailty is high and the need for specifically tailored RT is significant but understudied.

What are the clinical and/or research implications?

  • Further high-quality studies investigating the impact of RT in patients with HFpEF and VHD are needed to fill the gaps of knowledge in these cohorts.
  • Additional high-quality studies are needed to evaluate the impact of RT on the growing population of older patients attending CR, and the efficacy and safety of RT in frail elderly also need further attention.
  • Muscular deconditioning, physical limitations, and frailty must be assessed using standardized assessment tools prior to initiation and at the time of CR determination in order to provide individually tailored RT in vulnerable patients with coronary artery disease and to ensure reliable CR outcomes.

Because of the growing evidence and the broader application of preventive and therapeutic approaches, the group of patients who benefit and are able to carry out cardiac rehabilitation (CR) measures and exercise training is constantly growing and is becoming more and more diverse and heterogenous.1,2 Thereby, the number of elderly individuals undergoing cardiac surgery or intervention is steadily growing and an increasing number of older patients with substantial therapeutic needs is entering CR.1,2 This is a challenge for CR providers, requiring program adaptation, particularly in view of the high prevalence of multimorbidity, reduction in muscle mass, and strength (sarcopenia) and frailty.3–6

The prevalence of frailty increases with age and is higher in patients with cardiovascular diseases (CVD).4,7,8 In older patients with CVD, it is associated with higher rates of adverse cardiovascular events, increased risk of hospitalization,9 and poor long-term survival.8,10,11

The diagnoses of sarcopenia or the presence of components of sarcopenia is associated with higher risk of developing CVD5 and higher CVD and all-cause mortality.12 The prevalence of reduced muscle mass and muscle strength at beginning of CR is high13 and musculoskeletal comorbidities are common.14 Comorbidities such as arthritis, osteoporosis and age-related sarcopenia, low exercise and functional capacity, and overall reduced physical performance are more frequently diagnosed in elderly individuals.3,14,15 These conditions are the main causes of limitations and disability in daily living. Deconditioning of the skeletal muscle is more prevalent in patients with diabetes mellitus,16 heart failure (HF),17,18 and/or valvular heart diseases (VHDs).19 Muscular strength is a strong modifiable risk factor that influences several CVD, and the positive impact of dynamic resistance training (RT) on many CVD risk factors,20,21 autonomic function,22 endothelial function,23 and aortic systolic and diastolic pressure24 is well known. In addition, a recent meta-analysis revealed a significant association with a 21% reduction in all-cause mortality in the RT group compared with the nontraining control group.25

In CR, the goal of dynamic RT, defined as contraction in which the muscle develops force in motion against a moving mass, is generally to increase muscle strength and endurance. In contrast, in static contraction the muscle develops force against resting masses or resistance, whereby the length of the muscle does not change (isometric muscle work).2 Within this review, the focus is exclusively on the dynamic mode of RT and the abbreviation RT is for dynamic RT.

The efficacy and safety of RT in numerous CVD diagnoses have received increasing attention in recent years. Current guidelines2,26,27 recommend individually adapted RT as a part of the exercise regime in patients with CVD. In addition, RT, which have been contraindicated in various medical conditions (eg, arterial hypertension), has become a guideline-recommended treatment option in hypertensive patients as well.28

The aim of this review was to provide insight into the current knowledge and understanding of the usefulness, feasibility, safety, and effectiveness of RT in patients with coronary artery disease (CAD), HF, and VHD. Special emphasis was placed on the role of RT in elderly and/or frail patients. In addition, on the basis of the results obtained, the suitability and applicability of the current recommendations for this patient population were critically reviewed to determine whether a revision is warranted.

REVIEW METHODS

This review was based on an intensive literature search using the following search strategies: (1) systematic reviews and meta-analyses published in 2010 or later; (2) search for more recent published studies that are not integrated into meta-analyses or systematic reviews; and (3) search by manual searches using reference lists of other reviews and key literature as well as from relevant international guidelines.

Search items were meta-analysis, systematic reviews, RT, strength training, CR, CAD, HF, VHD, old age, frailty, muscular strength, and sarcopenia. The following databases were used: PubMed (via National Center for Biotechnology Information [NCBI]-Platform); Cochrane Database of Systematic Reviews (CDSR); and the Physiotherapy Evidence Database (PEDro).

RESULTS

CORONARY ARTERY DISEASE

Patient Characteristics

In patients with CAD (left ventricular ejection fraction [LVEF] 49 ± 11%), after elective percutaneous coronary intervention and coronary artery bypass grafting surgery and after adjustment for other prognostic factors, high levels of quadriceps isometric strength are associated with a significant reduction in overall mortality (−23%) and CVD mortality (−34%).29 Furthermore, quadriceps isometric strength is a predictor of the peak oxygen uptake (V˙o2peak) level.30 Lower lean body mass index is predictive of a higher incidence (55%) of adverse outcomes from major cardiac events.31 Lower body muscle weakness is prominent in patients with CAD compared with healthy controls with markedly reduced quadriceps isometric endurance resulting in enhanced skeletal muscle fatigue.32 Upon entry to CR, elderly patients14,15 and those with diabetes16 are likely to have significant reductions in muscle strength and functional capacity, especially when these patients undergo CR after coronary artery bypass grafting surgery. The use of the Short Physical Performance Battery Score (SPPB) in older patients (>75 yr) at entry to CR early after cardiac surgery classified 44% of patients with severe or moderate physical limitations. Patients with severe limitations, according to the SPPB, were older and predominantly female.33 The prevalence of frailty, diagnosed using Fried phenotype model, in elderly patients with CAD (>80 yr) is high (28%)8 and is associated with poorer prognosis and survival rate.8,10 In addition, the presence of frailty negatively affects the health-related quality of life (QoL) of patients, regardless of the severity of the disease.8

Effects of RT

Results of five meta-analyses (Table 1) demonstrate the beneficial effects and safety of moderate RT in patients with CAD.15,34–37 None of the integrated studies reported severe CVD events related to the RT.

Table 1 - Effects of Resistance Training in Patients With Coronary Artery Diseasea
Meta-analysis and Patients Group Comparisons Parameters
Marzolini34 (2012)
12 studies, n = 504
Combined AT/RT vs AT Peak V˙o 2, VAT, peak work capacity, body composition (fat-free mass, percent body fat, trunk fat mass, percent trunk fat), knee extension, biceps curl
Yang et al35 (2015) RT vs control Peak V˙o 2, peak work capacity, lower limb strength, upper limb strength
27 studies, n = 1151 RT vs AT
Combined AT/RT vs AT
Yamamoto et al15 (2016)
22 studies, n = 1095
RT vs control
and
Middle aged (<65 yr) vs elderly (≥65 yr)
Peak V˙o 2, peak work capacity, mobility, knee extension (1RM or isometric or isokinetic), chest press or biceps curl (1RM)
Hollings et al36 (2017)
34 studies, n = 1940
RT vs control
RT vs. AT
Peak V˙o 2, peak work capacity, muscular strength (1RM or isometric or isokinetic), knee extension, bench press
Combined AT/RT vs AT
Lee et al37 (2020) Combined AT/RT vs control Peak V˙o 2, muscle strength, muscle hypertrophy
21 studies, n = 1092
Parameter Meta-analysis RT vs Control RT vs AT Combined AT/RT vs Control Combined AT/RT vs AT
Exercise capacity (peak V˙o 2— mL/kg/min) Marzolini et al34 (2012) x x x 9 studies, n = 399
MD: 0.41 (−0.05 to 0.88)
Yang et al35 (2015) 3 studies, n = 146 5 studies, n = 223 x 9 studies, n = 362
SMD: 2.42 (1.27-3.56) SMD: 0.01 (−0.39 to 0.41) SMD: 0.37 (−0.11 to 0.86)
Yamamoto et al15 (2016) 10 studies, n = 384 x x x
(middle aged: <65 yr) MD: 0.92 (0.12-1.72)
Yamamoto et al15 (2016) 5 studies, n = 244 x x x
(elderly: ≥65 yr) MD: 0.70 (0.03-1.37)
Yamamoto et al15 (2016) 15 studies, n = 628 x x x
(all patients) MD: 0.82 (0.03-1.37)
Hollings et al36 (2017) x 4 studies, n = 172 x 13 studies, n = 591
SMD: −0.15 (−0.63 to 0.33) SMD: 0.14 (−0.02 to 0.31)
Lee et al37 (2020) x x 18 studies, n = 1022 x
SMD: 0.94 (0.67-1.22)
Peak work capacity (watts or exercise duration) Marzolini et al34 (2012) x x x 3 studies, n = 92
SMD: 0.88 (0.45-1.31)
Yang et al35 (2015) 3 studies, n = 184 2 studies, n = 159 x 8 studies, n = 339
SMD: 0.42 (−0.16 to 1.01) SMD: −0.13 (−0.40 to 0.14) SMD: 0.19 (−0.03 to 0.41)
Yamamoto et al15 (2016) 12 studies, n = 462 x x x
(middle aged: <65 yr) SMD: 0.49 (0.22-0.77)
Yamamoto et al15 (2016) 1 study, n = 133 x x x
(elderly: ≥65 yr) SMD: 0.38 (0.04-0.73)
Yamamoto et al15 (2016) 13 studies, n = 595 x x x
(all patients) SMD: 0.48 (0.24-0.73)
Hollings et al36 (2017) x 5 studies, n = 243 x 12 studies, n = 560
SMD: −0.13 (−0.38 to 0.12) SMD: 0.30 (0.12-0.48)
Mobility Yamamoto et al15 (2016) 3 studies, n = 105 x x x
(middle aged: <65 yr) SMD: 0.13 (−0.25 to 0.52)
Yamamoto et al15 (2016) 4 studies, n = 118 x x x
(elderly: ≥65 yr) SMD: 0.61 (0.21-1.01)
Yamamoto et al15 (2016) 7 studies, n = 223 x x x
(all patients) SMD: 0.38 (0.09-0.67)
Lower body muscular strength Marzolini et al34 (2012) x x x 7 studies, n = 225
Knee extension
SMD:0.77 (0.49-1.04)
Yang et al35 (2015) 2 studies, n = 42 4 studies, n = 123 x 7 studies, n = 289
SMD: 1.08 (0.54-1.62) SMD: 0.60 (0.07-1.14) SMD:0.14 (0.01-0.28)
Yamamoto et al15 (2016) 12 studies, n = 375 x x x
(middle aged: <65 yr) Knee extension
SMD:0.65 (0.35-0.95)
Yamamoto et al15 (2016) 4 studies, n = 224 x x x
(elderly: ≥65 yr) Knee extension
SMD: 0.63 (0.05-1.21)
Yamamoto et al15 (2016) 16 studies, n = 599 x x x
(all patients) Knee extension
SMD: 0.63 (0.37-0.90)
Hollings et al36 (2017) 3 studies, n = 123 x x 14 studies, n = 675
Knee extension Knee extension
SMD: 0.57 (0.17-0.96) SMD: 0.60 (0.32-0.89)
Lee et al37 (2020) x x 18 studies, n = 874
SMD: 1.24 (0.90-1.59)
Upper body muscular strength Marzolini et al34 (2012) x x x 9 studies, n = 262
Biceps curl
SMD: 1.07 (0.76-1.38)
Yang et al35 (2015) 2 studies, n = 42 3 studies, n = 91 x 8 studies, n = 322
SMD:0.60 (0.24-0.95) SMD: 0.90 (0.31-1.48) SMD: 0.39 (0.28-0.51)
Yamamoto et al15 (2016) 9 studies, n = 263 x x x
(middle aged: <65 yr) Chest press or biceps curl
SMD: 0.73 (0.48-0.99)
Yamamoto et al15 (2016) 3 studies, n = 85 x X x
(elderly: ≥ 65 yr) Chest press or biceps curl
SMD: 1.18 (0.56-1.80)
Yamamoto et al15 (2016) 12 studies, n = 348 x x x
(all patients) Chest press or biceps curl
SMD: 0.82 (0.60-1.04)
Hollings et al36 (2017) 3 studies, n = 93 x x 9 studies, n = 320
Bench press Bench press
SMD: 1.43 (0.73-2.13) SMD: 0.52 (0.30-0.75)
Abbreviations: AT, aerobic training; MD, mean difference; RT, resistance training; SMD, standardized mean difference; V˙o2peak, peak oxygen uptake.
aValues in boldface are significant differences.

The use of RT alone led to significant improvement in exercise capacity,15,35 peak work capacity,15 mobility,15 and lower body15,35,36 and upper body muscular strength15,36 when compared with control. Combined aerobic training (AT) and RT lead to greater benefits in peak work capacity34,36 and lower34–36 and upper body muscular strength,34–36 as well on body composition,34 when compared with AT alone, and on exercise capacity and lower body muscular strength when compared with controls.37 One limitation is the considerable variation in interventions and exercise characteristics for the RT across the included studies. One meta-analysis37 performed subgroup analysis to identify potential factors influencing the intervention effect. They found that there were no significant influences of exercise characteristics (program duration, exercise frequency, and intensity). However, they did observe a tendency that a higher exercise volume (≥40 sets and ≥500 repetitions/wk) was associated with larger effect on muscle strength.37

Few of the included studies focused on the effects of RT in older patients and only one meta-analysis presented age-differentiated results15: In older patients, the effects on upper body muscle strength were more pronounced than in younger patients. Exercise capacity increased significantly in both groups; however, mobility improved significantly only in the older patients.15 In contrast, Lee et al37 found significantly greater improvement of muscle strength in a subgroup of <60 yr compared with subgroups of ≥60 yr but no difference in effects on exercise capacity between subgroups.

Only a few studies have evaluated the effect of RT on psychosocial variables and QoL. They reported benefits of combined AT/RT compared with AT alone on self-efficacy of lower and upper body physical activity tasks, depression scores,38 and for physical health–related QoL score.38,39 Caruso et al40 report a positive influence of RT on resting heart rate variability.

HEART FAILURE

HF With Reduced Ejection Fraction

Patient characteristics

Patients with heart failure with reduced ejection fraction (HFrEF), especially those of advanced age and after decompensation, can be expected to have significantly reduced physical performance.41 This is caused by cardiac dysfunction (reduced LVEF, chronotropic incompetence) with consecutive reduction in pulmonary capacity42 and impaired peripheral adaptive mechanisms43,44 and peripheral vasoconstriction due to elevated neurohumoral activation leading to progressive skeletal muscle deconditioning with reduction in muscle mass and muscle strength.43 Sarcopenia is prevalent in 30-50% of HFrEF patients.17 In its most severe form, sarcopenia is associated with increased frailty, morbidity, and mortality.45 Approximately 5-15% of patients, particularly those with advanced HFrEF, develop cachexia with marked reduction in skeletal muscle mass, adipose tissue, and bone density.46 This results in significantly reduced functional capacity, which is associated with more frequent hospitalizations and a worsened prognosis.47 In patients with HFrEF (average LVEF 27.5%), knee extensor strength is an independent predictor of rehospitalization.48 Reduced functional capacity assessed by either the SPPB or the 6-min walk test distance was independently associated with increased 1-yr postdischarge adverse event rates in hospitalized elderly patients with acute HF.49

Alterations in skeletal muscle have been well documented in HFrEF for more than 20 yr.43,44,50,51 These changes range from alterations in fiber type and capillarization to atrophy and modulation of mitochondrial energy supply and may contribute to exercise intolerance in HFrEF and HF with preserved ejection fraction (HFpEF).43,44,50

The prevalence of prefrailty (46%) and frailty (40%) in patients with HF is high7,11 and was associated with poorer prognosis and survival rate.11 In the recently published REHAB-HF study52 of elderly patients participating in CR after acute decompensated HF, 42% of the cohort was diagnosed as frail and 55% as prefrail at baseline. Furthermore, the mean SPPB score was low, indicating moderate to severe physical limitations in the cohort. Thus, for older patients with HF, RT can be an important strategy for preventing sarcopenia, maintaining and increasing muscle mass and strength, and improving exercise capacity and physical performance.6,50

Effects of RT

Numerous meta-analyses (Table 2) have analyzed the beneficial effects and safety of moderate RT in patients with HFrEF.53–58 Central hemodynamic response is comparable during RT and AT59 and RT does not negatively affect left ventricular (LV) systolic function or remodeling.53,55,57 When compared directly, there were no significant differences between RT and AT in terms of exercise capacity, cardiac structure, and function.57 None of the available studies reported serious adverse effects related to the RT, thus further confirming the safety of this exercise mode with moderate intensity in the HFrEF population.

Table 2 - Effects of Resistance Training in Patients With Heart Failure With Reduced Left Ventricular Ejection Fractiona
Meta-analysis and Patients Group Comparisons Parameters
Jewiss et al53 (2016) RT vs control Peak V˙o 2, 6MWD, QoL, LVEF, HR (rest + peak), SBP (rest), mortality, hospitalizations
27 studies, n = 2321 Combined RT/AT vs AT
Combined RT/AT vs control
Giuliano et al54 (2017) RT vs control Peak V˙o 2, 6MWD, QoL, leg press (1RM), lower body muscle strength (isokinetic 60°/s + 180°/s)
10 studies, n = 240
Santos et al55 (2018) RT vs control Peak V˙o 2, LVEF, LVEDV
59 studies, n = 5046 RT vs AT
Combined RT/AT vs AT
Combined RT/AT vs control
AT vs control
Gomes-Neto et al56 (2019) Combined RT/AT vs AT Peak V˙o 2, VE/VCOs slope, QoL, knee extensors (isometric)
39 studies, n = 2008 Combined RT/AT vs control
Fischer et al57 (2021)
15 studies, n = 458
RT vs control
RT vs AT
Peak V˙o 2, 6MWD, QoL, LVEF, LVEDV, LVESV, LVEDD, LVESD, HR (rest + peak), SBP (rest), DBP (rest), leg press (1RM), leg extension (1RM), leg curl (1RM), knee extensor (isokinetic 60°/s + 180°/s and isometric), pectoralis (1RM), latissimus dorsi (1RM)
Righi et al58 (2021) Combined RT/AT vs AT Peak V˙o 2, quadriceps muscle strength (1RM and dynamometer)
28 studies, n = 1308 Combined RT/AT vs control
Parameter Meta-analysis RT vs. Control RT vs. AT Combined AT/RT vs. Control Combined AT/RT vs. AT
Exercise capacity (peak o 2—mL/kg/min) Jewiss et al53 (2016) 4 studies, n = 142 x 10 studies, n = 413 6 studies, n = 413
MD: 3.99 (1.47-6.51) MD: 1.43 (0.63-2.23) MD: 0.61 (−0.14 to 1.36)
SMD: 1.72 (0.52-2,93) SMD: 0.73 (0.22-1.23) SMD: 0.24 (−0.03 to 0.51)
Giuliano et al54 (2017) 9 studies, n = 224 x X X
MD: 2.71 (1.96-3.45)
Santos et al55 (2018) 5 studies, n = 124 3 studies, n = 75 13 studies, n = 588 8 studies, n = 283
MD: 3.57 (2.45-4.68) MD: 0.12 (−1.22 to 1.45) MD: 2.48 (0.88-4.09) MD: 0.69 (−0.87 to 2.25)
Gomes-Neto et al56 (2019) x x 17 studies, n = 638 11 studies, n = 319
MD: 2.94 (1.6-4.4) MD: 0.54 (−0.22 to 1.3)
Fischer et al57 (2021) 8 studies, n = 193 4 studies, n = 101 X X
MD: 2.64 (1.67-3.60) MD: 0.26 (−0.90 to 1.42)
Righi et al58 (2021) x x 17 studies, n = 718 11 studies, n = 401
SMD: 0.77 (0.39-1.14) SMD: −0.01 (−0.36 to 0.34)
Mobility Jewiss et al53 (2016) 2 studies, n = 40 x 7 studies, n = 665 x
6MWD 6MWD
MD: 41.77 (21.90-61.64) MD: 13.49 (1.13-25.84)
SMD: 1.25 (0.53-1.98) SD: 0.22 (−0.17 to 0.60)
Giuliano et al54 (2017) 4 studies, n = 57 x x x
6MWD
MD: 59.26 (36.75-81.78)
Fischer et al57 (2021) 6 studies, n = 140 x x x
6MWD
MD: 49.94 (34.59-65.29)
Lower body muscular strength Giuliano et al54 (2017) 4 studies, n = 71
Leg press, 1RM
x x x
SMD: 0.60 (0.43-0.77)
Gomes-Neto et al56 (2019) x x 7 studies, n = 315 6 studies, n = 167
Knee extensors, isometric Knee extensors, isometric
SMD: 0.64 (0.41-0.87) SMD: 0.66 (0.34-0.98)
Fischer et al57 (2021) 4 studies, n = 71 x x x
Leg press, 1RM
SMD: 0.76 (0.26-1.25)
Righi et al58 (2021) x x 5 studies, n = 194 7 studies, n = 190
Quadriceps, dynamometer Quadriceps, 1RM
SMD: 0.32 (0.03-0.61) SMD: 0.44 (0.15-0.74)
Upper body muscular strength Fischer et al57 (2021) 4 studies, n = 71 x x x
Pectoralis, 1RM
SMD: 0.85 (0.35-1.35)
Quality of life (MLWHFQ) Jewiss et al53 (2016) x x 8 studies, n = 748 x
MD: −8.31 (−14.3 to −2.33)
SMD: −0.32 (−0.58 to −0.06)
Giuliano et al54 (2017) 3 studies, n = 70 x x x
MD: −5.71 (9.85 to −1.56)
Gomes–Neto et al56 (2019) x x 8 studies, n = 524 5 studies, n = 138
MD: −9.8 (−15.2 to −4.5) MD: −2.55 (−5.04 to −0.06)
Fischer et al57 (2021) 5 studies, n = 108 2 studies, n = 56 x x
MD: −8.25 (−11.51 to −4.99) MD: 0.36 (4.72 to 5.45)
LVEF (%) Jewiss et al53 (2016) 4 studies, n = 40 x 5 studies, n = 280 x
MD: 0.23 (−3.37 to 3.82) MD: −0.68 (−2.48 to 1.12)
SMD: −0.06 (−0.84 to 0.72) SMD: −0.32 (−0.91 to 0.28)
Santos et al55 (2018) 4 studies, n = 86 x 11 studies, n = 468 3 studies, n = 78
MD: 1.91 (3.71 to 7.53) MD: 0.02 (1.47 to 1.52) MD: 0.06 (4.14 to 4.27)
Fischer et al57 (2021) 6 studies, n = 117 3 studies, n = 80 x x
MD: 2.75 (0.90-4.59) MD: 2.10 (4.91 to 0.72)
Abbreviations: AT, aerobic training; LVEF, left ventricular ejection fraction; MD, mean difference; MLHFQ, Minnesota Living With Heart Failure Questionnaire; 1RM, one-repetition maximum; RT, resistance training; 6MWT, 6-min walk test; SMD, standardized mean difference; V˙o2peak, peak oxygen uptake.
aValues in boldface are significant differences.

Compared with a control group, RT is effective for improving exercise capacity,53–55,57 mobility,53,54,57 and lower body54,57 and upper body muscular strength57 in patients with HFrEF. Furthermore, significant improvements in QoL54,57 and LVEF57 were reported. A negative effect of RT on LV systolic function or remodeling was not observed.53,55,57 Thus, in patients with HFrEF, who are unable or unwilling to participate in aerobic activities, RT alone is appropriate to achieve relevant benefits.

Compared with control, combined AT/RT leads to significant improvements in exercise capacity,53,55,56,58 mobility,53 lower body muscular strength,56,58 and QoL.53,56 The results showed no adverse effects on LV function or remodeling.53,55 No significant positive or negative effect on hospitalization or mortality was observed.53 Righi et al58 made subgroup analysis to identify potential factors influencing the intervention effect. The analysis revealed only the time of session and the duration of the rehabilitation program to be moderators of the effects of combined AT/RT. Using longer combined AT/RT sessions has a greater impact on exercise capacity.58

Compared with AT alone, combined AT/RT is more effective in improving lower body muscle strength56,58 and QoL56 (Table 2).

Older adults and patients with advanced HF are underrepresented in RT studies. None of the aforementioned meta-analyses conducted age- or disease-specific subgroup analyses. Future studies are needed to address the relevant questions of efficacy and safety of RT in these cohorts. In this context, the recently published REHAB-HF trial is of great interest.52 Despite high levels of frailty and moderate to severe physical limitations in the cohort, CR participation resulted in significant improvements in physical performance (SPPB score) compared with controls52 and thus proved to be safe and effective in improving physical performance and frailty.

HF With Preserved Ejection Fraction

Patient characteristics

Aging and obesity are hallmarks of HFpEF and the prevalence of type 2 diabetes and hypertension and other comorbidities in these patients is very high. Heart failure with preserved ejection fraction is associated with comparable alterations in skeletal muscle as in patients with HFrEF with a significant deconditioning of the skeletal muscles and reduced peripheral muscle mass.60 A significantly lower percent total and leg lean mass have been diagnosed in older HFpEF patients when compared with healthy controls.51

Patients with HFpEF are more often highly symptomatic and the physical resilience in everyday life is severely limited.47 The prevalence of frailty in these patients is reported to be up to 75%61,62 and to be associated with higher risk of hospitalization and mortality.62,63 In HFpEF patients, both sarcopenia and obesity are well documented as separate entities20,64 and the incidence of sarcopenic obesity is high.18 All these factors initiate a harmful vicious cycle of physical inactivity, exercise intolerance, frailty and physical limitations, and poor QoL, and contribute to increased comorbidity and high burden of hospitalization and mortality.18,65

Effects of RT

Only a few randomized controlled trials (RCTs) have evaluated the impact of exercise training in HFpEF, mainly with focus on AT. The results consistently show significant effect on exercise capacity, mobility, QoL, and echocardiographically determined diastolic function.63,66 Studies integrating RT into the exercise regime are rare. In a small RCT, a 3-mo combined AT/RT resulted in significant increase in exercise capacity and significant improvement in diastolic function as assessed by echocardiography, when compared with control.67 The QoL improved significantly within the training group in the pre-/postcomparison but not between groups.68 The positive results of exercise training on exercise capacity, diastolic function, and QoL were confirmed over a 6-mo follow-up period.68 In a small RCT, combined AT and RT led to a significant improvement of the diastolic function, measured as E/e' ratio and an increase in LVEF when compared with AT alone.39 However, the value of the results published to date63,66 is limited by the fact that most of these trials integrated relatively young patients without complex disorders and/or frailty comprising a minority of patients with HFpEF. These interesting results need to be further investigated and confirmed by studies with a larger population.

In this context, the results of the recently published REHAB-HF trial52,69 are of great interest (n = 349, >60 yr, 53% with LVEF ≥ 45%). The prevalence of diabetes was high (53%) in this study population, and patients with diabetes scored significantly lower in physical performance and mobility at baseline than those with no diabetes.69 Despite high levels of frailty and moderate to severe physical limitations in the both cohorts, participation in CR that among others included RT resulted in significant improvements in physical performance (SPPB) compared with controls,52,69 with no significant differences between patients with or with no diabetes.69

VALVULAR HEART DISEASE

Patient Characteristics

The reported prevalence of frailty in older patients with VHD varies widely (6-90%) mainly due to different scoring systems used.19 Irrespective of how frailty is assessed, however, it is associated with a poor prognosis in this population. Frailty is an independent predictor of mortality in patients undergoing transcatheter aortic valve implantation70,71 and also predicts functional deterioration after transcatheter aortic valve implantation.72 Mobility is a significant contributor to frailty and its assessment is often used to approximate its presence. Patients with aortic stenosis and low physical capacity, determined by either a 6-min walk test or a timed-up-and-go test, have a poorer prognosis than those with higher capacity.73 In elderly patients after transcatheter aortic valve implantation, mobility (via timed-up-and-go test) is a significant predictor of all-cause mortality in the first year after implantation.73 A recently published RCT assessed the degree of physical frailty in 86 elderly patients admitted to CR after a surgical or interventional heart valve procedure. The SPPB and the 5-m walk test were used for assessment. Both methods identified more than one-third of patients as frail (SPPB: 36.8%; 5-m walk test: 39.1%) and a substantial number of patients as prefrail (SPPB 29.5%; 5-m walk test: 41.3%).74

Effects of RT

High-quality RCT, evaluating the impact of any mode of exercise intervention after surgical or interventional heart valve correction, is missing. The few available data, mostly from small RCT and cohort studies, report results from heterogenic measures, with regard to patient profile75 as well as type and duration of intervention.76,77 Qualitatively sufficient evidence-based data on exercise-related adverse events, mortality, QoL, symptoms, and reversible LV remodeling are not yet available.75 However, the results of a large registry study (>40 000 patients post–open valve surgery) show that participation in exercise-based CR (32 sessions) is associated with a lower 1-yr cumulative hospital stay and a lower risk of death after valve surgery.78 The feasibility, efficacy, and safety of adapted RT in VHD patients are insufficiently studied. Considering the high prevalence of frailty and the reduced physical performance in older patients after valve procedure, RT would be a conceivable exercise modality to counteract the loss of muscle strength, muscle mass, and physical frailty.79 In a small RCT including patients with transcatheter aortic valve implantation, 8-wk combined AT and RT led to an increase in exercise capacity and muscle strength compared with the control group.80 In a second RCT,74,81 the effects of additional RT and balance training during CR in elderly patients after valve surgery or intervention compared with usual care CR were evaluated. The results revealed improvements in exercise capacity, mobility, SPPB, 5-m walk test, leg strength, QoL, and frailty levels in both groups with no difference between groups. The improvements achieved were sustained over 3-mo follow-up. Interestingly, a significant difference in frailty levels in favor of the intervention was reported at 3-mo follow-up. This could be a result of higher levels of physical activity after CR since members of the intervention group spent significantly more time in daily physical activity during follow-up than control.74,81

The results of the few available studies are promising and show that RT is feasible and can help achieve the intended effects on mobility and frailty. High-quality studies, however, are urgently needed to close the gaps in evidence about RT in VHD patients.

DISCUSSION

This review highlights that in recent years, numerous meta-analyses have been published that evaluated the effects and safety of RT in patients with CAD and HFrEF. Overall, the results show that individualized RT at moderate intensity is safe and effective in improving exercise capacity,15,35,37,53–55 mobility,15,53,54 muscle strength,15,34–37,54,57 and QoL.38,39,54 Also, RT does not negatively affect LV systolic function or remodeling.53,55,57 In contrast, there are only a few studies available on patients with HFpEF or VHD. In addition, these studies are mostly small and with a great heterogeneity in terms of patient characteristics and interventions offered. Nevertheless, the results are promising and show that RT is feasible, safe, and effective.52,67,69,74,80,81 More high-quality studies are warranted in these patient cohorts.

Few studies have addressed the feasibility and impact of RT in elderly patients with CAD, and data on the efficacy and safety of RT in frail elderly patients are currently limited.15,37,74 Physical dysfunction and frailty often go unrecognized in elderly patients with CAD, and most of the available CR and RT studies have excluded or included only a few elderly frail patients and/or those with physical limitations.82 The results of this review underscore the high prevalence of age-related sarcopenia, disease-related skeletal muscle deconditioning and reduced peripheral muscle mass, musculoskeletal comorbidities, physical limitations and frailty, and overall reduced physical performance in older patients with heart disease. They thus demonstrate the need for a different approach and an individually tailored exercise concept aimed at improving functional status, mobility, physical performance, and muscle strength.6,21 They, furthermore, highlight the importance of the use of assessment tools to diagnose frailty, mobility/functional capacity, and physical performance in the elderly admitted to CR. An effective individualized RT approach requires knowledge about the physical strengths and limitations of the patient.6 Outcome measures should also focus on determinants of the ability of the patient to live an independent, self-determined life. Assessment of functional capacity (ie, 6-min walk test, timed-up-and-go, gait speed) is helpful in discriminating limitations as well as overall CR outcomes in elderly patients.49,52,74 However, less experience is available for the assessment of frailty in CR. A diversity of diagnostic options has been suggested, although the suitability for elderly patients with CAD is usually not sufficiently evaluated.6,83,84 The SPPB is a proven tool for assessing physical performance and identifying physical limitations and frailty in older people.6 It has been shown to be a suitable tool for distinguishing patients on admission to CR as well as an outcome parameter.33,49,52,74,85

The importance of adequate RT to counteract the loss of muscle strength, muscle mass, and physical performance is significant.79 Muscular strength and endurance are key components of physical fitness13 and minimal levels are necessary to maintain the ability to perform activities of daily living and to obtain functional independence in old age and/or disease-related impairment. The best method to increase muscle mass and strength,86 even in the very old, is RT.87 Use of RT can mitigate age-related changes in muscle function and improve activities of daily living such as walking endurance, walking speed, and stair climbing.88 Combined RT and balance training improve stability and gait ability, enhance security of movement, and thus play an important role in preventing falls.89

Current research provides evidence that RT is an effective tool to counteract the loss of muscle strength, muscle mass, and physiological vulnerability, and to combat the associated debilitating effects on physical functioning, mobility, independence, psychological well-being, and QoL.79 An RT can be implemented using weight machines and/or free weights, weight cuffs, or resistance bands.

The use of weight machines allows for a more precise individually adjusted exercise load and the predetermination of the movement execution, thus reducing the risk of overload and/or injury. Intensive and time-consuming individual supervision is required, including familiarization and strength testing optimally on the machines used later on for training. Weight machines are expensive, and suitable equipment is often not available for elderly patients with CAD. Performing RT with free weights, weight cuffs, or resistance bands is a good alternative and/or addition to RT with weight machines. These portable, low-cost options are easy to use and, when used correctly, allow for safe and individually differentiated RT in a group setting. The exercises are closer to the activities of daily living and the adaptations to the coordinative skills are higher. Performing RT with free weights or resistance bands requires careful supervision of the patient. This is imperative to avoid overloads and incorrect loads due to incorrect execution. The combination of the two training options is optimal.2

Since the introduction of RT in CR, there have been debates about the best mode of its implementation in respect to balance between optimal effectiveness and medical safety. This controversy is evident in clinical practice as well as in the available study results. A review of the literature reveals substantial heterogeneity and considerable variation in interventions and exercise characteristics across studies, which makes it difficult to evaluate the overall result and develop specific recommendations for RT based on the data obtained. The only meta-analysis drawing attention to this question found no significant influence of exercise characteristics (program duration: ≤12 vs >12 wk; exercise frequency: ≤2 vs ≥3 d/wk; exercise intensity: low: 30-49% vs moderate: 50-69% vs high: 70-84% of one repetition maximum [1RM]; exercise volume: <40 vs ≥40 sets/wk and <500 vs ≥500 repetitions/wk). Higher exercise volume (≥40 sets and ≥500 repetitions/wk) tended to be associated with larger effect on muscle strength.37 On the other hand, it is known that high-intensity RT (≥70% 1RM) increases muscular strength and neural adaptations more effectively than low-intensity training86,90; this is also true for older individuals.91 An evaluation of RT at different intensities on blood pressure response, heart rate, and cardiac output in patients with CAD suggests that the number of repetitions and the duration of the exercise are more important than the intensity.92 If the CV demand is lower in high-intensity than low-intensity RT, then is it time to reconsider clinical practice and guidelines for CR?

Current guidelines2,26,27 recommend individually adapted RT as a part of the exercise regime in CR. Table 3 summarizes the current recommendations for RT in CR. These recommendations include dosage parameters such as intensity, number of repetitions and sets, frequency, and rate of progression providing corridors within which RT is safe and effective. It is up to the CR professional to decide the optimal RT intensity and volume for the individual patient. Most patients admitted to CR have little or no experience with RT and/or use of the RT equipment. A familiarization process at low intensity (<30% 1RM) is therefore essential to avoid injury and to ensure correct lifting technique without compensatory movements and breath holding. In general, a cautious approach, starting with low intensity (<30% 1RM) and gradually increasing up to 60-80% 1RM on an individual basis, is recommended. The load should never exceed the extent that the patient can cope without compensatory movements and/or breath holding. Thus, in our opinion, these recommendations are sufficient and do not need to be reconsidered. They offer the CR professional the possibility to adapt the RT program individually to the conditions and needs of the patient within a sufficiently broad corridor. Before high-intensity RT can be recommended for all patients with CVD, further high-quality RT studies comparing the outcomes of different exercise intensities and volumes are needed.

Table 3 - Current Recommendations for the Implementation of Individually Adapted Dynamic Resistance Training in Cardiac Rehabilitation (According to Schwaab et al2)
Training Stage Training Objective Training Method Training Intensity Number of Repetitions/Muscle Group Training Volume
Initial stage (pre-training, familiarization) Implementation of exercise: Learning and practicing the correct execution improvement of self-perception and coordination Dynamic <30% 1RM; RPE ≤11 5-10 2-3 units/wk, 1-3 sets/unit, 1- to 2-min rest between sets
Testing of muscular strength Determination of 1RM
Improvement stage I Improvement of aerobic endurance, improvement of coordination Dynamic 30-50 % 1RM, RPE 12-13 10-15 2-3 units/wk, 1-3 sets/unit, 1- to 2-min rest between sets
Improvement stage II Increase in muscle cross-sectional area (hypertrophy), improvement of coordination Dynamic 40-60 % 1RM, RPE: 14-15 8-15 2-3 units/wk, 1-3 sets/unit, 1- to 2-min rest between sets
Improvement stage III Increase in muscle cross-sectional area (hypertrophy), improvement of coordination Dynamic 60-80 % 1RM, selected patients in good clinical condition 8-10 2-3 units/wk, 1-3 sets/unit, 1- to 2-min rest between sets
Abbreviations: 1RM, one-repetition maximum; RPE, rating of perceived exertion.

SUMMARY

The effects and safety of RT in patients with CAD and HFrEF have been demonstrated by numerous meta-analyses. In contrast, few studies have been conducted on the integration of RT in patients with HFpEF or VHD. In addition, few studies have addressed the feasibility and effects of RT in elderly and/or frail patients with CAD. Further high-quality studies are needed in this special cohort of patients. The findings of this review underscore the high prevalence of age-related sarcopenia, disease-related skeletal muscle deconditioning, physical limitations, and frailty in older patients with different kinds of heart disease. They emphasize the need for a specific approach and an individually tailored training concept, including RT, with the aim of improving functional status, mobility, physical performance, and muscle strength in elderly patients. In addition, the results demonstrate the importance of using assessment tools for diagnosing, as well as outcome control, of frailty, of mobility/functional capacity, and of physical performance in elderly patients admitted to CR.

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Keywords:

cardiac rehabilitation; coronary artery disease; heart failure; resistance training

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