A standardized approach to evaluate effectiveness of aerobic exercise training interventions in cardiovascular disease at the individual level

BACKGROUND

Reliable change indices can determine pre-post intervention changes at an individual level that are greater than chance or practice effect. We applied previously developed minimal meaningful change (MMCRCI) scores for oxygen uptake (V̇O2) values associated with estimated lactate threshold (θLT), respiratory compensation point (RCP), and peak oxygen uptake (V̇O2peak) to evaluate the effectiveness of exercise training in cardiovascular disease patients.

METHODS

303 patients (65 ± 11 yrs.; 27% female) that completed a symptom-limited cardiopulmonary exercise test (CPET) before and after 6-months of guideline-recommended exercise training were assessed to determine absolute and relative V̇O2 at θLT, RCP, and V̇O2peak. Using MMCRCI ∆V̇O2 scores of ±3.9 mL·kg-1·min-1, ±4.0 mL·kg-1·min-1, and ± 3.6 mL·kg-1·min-1 for θLT, RCP, and V̇O2peak, respectively, patients were classified as "positive" (ΔθLT, ΔRCP, and/or ΔV̇O2peak ≥ +MMCRCI), "non-" (between ±MMCRCI), or "negative" responders (≤ -MMCRCI).

RESULTS

Mean RCP (n = 86) and V̇O2peak (n = 303) increased (p < 0.05) from 19.4 ± 3.6 mL·kg-1·min-1 and 18.0 ± 6.3 mL·kg-1·min-1 to 20.1 ± 3.8 mL·kg-1·min-1 and 19.2 ± 7.0 mL·kg-1·min-1 at exit, respectively, whereas θLT (n = 140) did not change (15.5 ± 3.4 mL·kg-1·min-1 versus 15.7 ± 3.8 mL·kg-1·min-1, p = 0.324). For changes in θLT, 6% were classified as "positive" responders, 90% as "non-responders", and 4% as "negative" responders. For RCP, 10% exhibited "positive" changes, 87% were "non-responders", and 2% were "negative" responders. For ΔV̇O2peak, 57 patients (19%) were classified as "positive" responders, 229 (76%) as "non-responders", and 17 (6%) as "negative" responders.

CONCLUSION

Most patients that completed the exercise training program did not achieve reliable improvements greater than that of chance or practice at an individual level in θLT, RCP and V̇O2peak.

Cardiac hemodynamics phenotypes and individual responses to training in coronary heart disease patients

BACKGROUND

In patients with coronary heart disease (CHD), individualized exercise training (ET) programs are strongly recommended to optimize peak oxygen uptake (V ̇ $$ \dot{\mathrm{V}} $$ O2peak) improvement and prognosis. However, the cardiac hemodynamic factors responsible for a positive response to training remain unclear. The aim of this study was to compare cardiac hemodynamic changes after an ET program in responder (R) versus non-responder (NR) CHD patients.

METHODS

A total of 72 CHD patients completed a 3-month ET program and were assessed by cycle ergometer cardiopulmonary exercise test (CPET:V ̇ $$ \dot{\mathrm{V}} $$ O2peak assessment) with impedance cardiography (ICG) for hemodynamic measurements before and after training. Cardiac hemodynamics (e.g., CO, CI, SV, ESV, EDV, and SVR) were measured by ICG during CPET. The R and NR groups were classified using the median change inV ̇ $$ \dot{\mathrm{V}} $$ O2peak (>the median for R and ≤the median for NR).

RESULTS

In the R group,V ̇ $$ \dot{\mathrm{V}} $$ O2peak (+17%, p < 0.001), CO, CI, SV, and HR increased by 17%, 17%, 13%, and 5%, respectively (p < 0.05) after the training program. In the NR group,V ̇ $$ \dot{\mathrm{V}} $$ O2peak, CO, CI, and SV increased by 0.5%, 5%, 8%, and 6%, respectively (p < 0.01). The SVR decreased in both groups (-19% in R and -11% in NR, p < 0.001).

CONCLUSION

Among CHD patients, the R group showed a better improvement in peak cardiac output via an increase in peak stroke volume and heart rate and a reduced systemic vascular resistance than the NR group. Different cardiac phenotype adaptations and clinical individual responses were identified in CHD patients according to the aerobic fitness responder's status.

Adaptive Posture-Balance Cardiac Rehabilitation Exercise Significantly Improved Physical Tolerance in Patients with Cardiovascular Diseases

Cardiac rehabilitation (CR) requires more professional exercise modalities to improve the efficiency of treatment. Adaptive posture-balance cardiac rehabilitation exercise (APBCRE) is an emerging, balance-based therapy from clinical experience, but lacks evidence of validity. Our study aimed to observe and assess the rehabilitation effect of APBCRE on patients with cardiovascular diseases (CVDs). All participants received one-month APBCRE therapy evenly three times per week and two assessments before and after APBCRE. Each assessment included cardiopulmonary exercise testing (CPET), resting metabolic rate (RMR) detection, and three questionnaires about general health. The differences between two assessments were analyzed to evaluate the therapeutic effects of APBCRE. A total of 93 participants (80.65% male, 53.03 ± 12.02 years) were included in the analysis. After one-month APBCRE, oxygen uptake (VO2, 11.16 ± 2.91 to 12.85 ± 3.17 mL/min/kg, p < 0.01) at anaerobic threshold (AT), ventilation (VE, 28.87 ± 7.26 to 32.42 ± 8.50 mL/min/kg, p < 0.01) at AT, respiratory exchange ratio (RER, 0.93 ± 0.06 to 0.95 ± 0.05, p < 0.01) at AT and oxygen uptake efficiency slope (OUES, 1426.75 ± 346.30 to 1547.19 ± 403.49, p < 0.01) significantly improved in CVD patients. The ≤55-year group had more positive improvements (VO2 at AT, 23% vs. 16%; OUES, 13% vs. 6%) compared with the >55-year group. Quality of life was also increased after APBCRE (47.78 ± 16.74 to 59.27 ± 17.77, p < 0.001). This study proved that APBCRE was a potentially available exercise rehabilitation modality for patients with CVDs, which performed significant increases in physical tolerance and quality of life, especially for ≤55-year patients.

Differences in cognitive function, cardiorespiratory fitness and BDNF concentration in physically active CHD patients vs healthy controls

BACKGROUND

Coronary heart disease (CHD) is frequently associated with cognitive impairment (CI), whereas physical exercise may improve cognition. To date, the cognitive profile of physically active CHD patients remains poorly understood. Physical activity and cognition has been associated with neurotrophic biomarkers that are positively modulated by a higher cardiorespiratory fitness (V̇ O₂peak) and/or active lifestyle. This study aimed to compare the cognitive functions, V̇ O₂peak and trophic biomarkers in physically active CHD patients vs healthy controls.

METHODS

Thirty-nine CHD patients and 20 controls performed a cardiopulmonary exercise test, a neuropsychological assessment (short-term and working memory, processing speed, executive functions, and long-term verbal memory), and a blood draw to measure brain-derived neurotrophic factor (BDNF), insulin-like growth factor-1 (IGF1), and cathepsin B (CTSB) plasma concentrations. Physical activity was also measured with an accelerometer for 1 week.

RESULTS

Compared to controls, CHD patients had lower V̇ O₂peak (22.2 vs 29.3 mL/min/kg, p<0.001), but similar moderate to vigorous physical activity levels (27.5 vs 34.4 min/day, p=0.114). CHD patients had poorer performances for executive functions (0.198 vs -0.370, p=0.004) and processing speed (0.150 vs -0.293, p=0.025), as well as lower BDNF concentrations (166.4 vs 300.2 ng/ml, p=0.027), but similar IGF-1 and CTSB concentrations (p>0.05) when compared to controls. BDNF was an independent predictor of processing speed in CHD, and IGF-1 and BDNF were independent predictors of verbal memory in healthy controls.

CONCLUSION

Despite similar physical activity levels, fit CHD patients had lower V̇ O₂peak values, cognitive performances (executive functions and processing speed) and BDNF concentrations when compared to controls.

Acute effects of exercise on cerebrovascular response and cognitive performance in individuals with stable coronary heart disease

BACKGROUND

Individuals with coronary heart disease (CHD) exhibit cognitive deficits and cerebrovascular dysfunctions, and are at higher risk of developing dementia. Cognitive function in individuals with CHD has never been studied during acute aerobic exercise. Given the increasing popularity of training at high peak power output (PPO), its impact on cerebrovascular and cognitive functions in individuals with CHD should be further studied.

METHOD

Thirty-eight individuals with CHD and 16 healthy controls completed two exercise bouts at 30% and 70% of their individualized PPO on an ergocycle while performing a cognitive task including non-executive and executive conditions. Variations of oxy- deoxy-hemoglobin, and total hemoglobin concentrations were measured on left prefrontal cortex at both PPO using near-infrared spectroscopy.

RESULTS

Cognitive task performances were equivalent between groups at all intensity levels. Individuals with CHD exhibited larger variation of deoxyhemoglobin in the executive condition and larger variation in total hemoglobin concentration in all task conditions compared to healthy controls at 70% of PPO.

CONCLUSION

Exercising at high intensity seems to have a larger impact on cerebral blood volume in CHD patients compared to healthy age-matched controls. Higher exercise intensity has negative impacts on cerebral blood volume variations during a cognitive task in CHD patients and could potentially lead to other neurocognitive dysfunctions. Other studies are needed to determine if a cognitive task administered during an exercise test could help identify individuals with CHD at higher risk of developing cognitive decline.

Impact of aerobic training periodisation on global and regional right ventricular strain in coronary heart disease

Linear aerobic training periodisation (LP) is recommended for patients with coronary heart disease (CHD). However, the effects of training periodisation on the right heart mechanics in patients with CHD have never been examined. This study aimed to explore the effects of LP and non-linear periodisation (NLP) on right heart mechanics. We prospectively randomised CHD patients to 12 weeks of aerobic training with LP or NLP. While there was a weekly increase in energy expenditure with LP, there was a steeper increase during the first 3 weeks, followed by a decrease in the fourth week with NLP. Echocardiography was performed at baseline and after the training period to assess the right ventricular free wall (RVFW) and right atrial strain. Thirty patients with CHD were included (NLP, n = 16; LP, n = 14). The traditional right and left heart parameters showed no significant time effects. There was a decrease of RVFW strain with time in both groups (+1.3 ± 0.9% with NLP, and +1.5 ± 0.8% with LP; p = 0.033). Mid-ventricular RVFW strain changed significantly with time (+2.0 ± 1.3% with NLP, and from +2.3 ± 1.2% with LP; p = 0.025). There was no time effect on the right atrial strain. In stable CHD patients, LP and NLP resulted in right ventricular strain decrements with a segment-specific pattern. This study was registered at ClinicalTrials.gov (identifier number: NCT03414996). Novelty: In stable coronary heart disease patients, both linear and non-linear aerobic training periodisation programs result in right ventricular strain decrements with time, particularly in the mid-ventricular segment. Traditional right and left heart parameters and right atrial strain showed no significant time effect in both 12 weeks aerobic training periodisation programs.

The effects of 12-months supervised periodized training on health-related physical fitness in coronary artery disease: a randomized controlled trial

We compared the impact of a one-year periodized exercise training versus a non-periodized exercise training on health-related physical fitness (HRPF) including body composition, cardiorespiratory and muscular fitness in patients with coronary artery disease (CAD). Fifty CAD patients (60.4 ± 9.9 years) were randomized to either a periodized training group (PG) (n = 25) or a non-periodized training group (NPG) (n = 25). Both consisted of a combined training programme, performed 3 days/week for 12 months. Thirty-six CAD patients (PG: n = 18, NPG: n = 18) successfully completed the exercise regimes. In both groups, a favourable main effect for time was evident for peak VO₂, peak workload, anaerobic threshold and respiratory compensation point workloads and VO₂, whole body skeletal muscle mass and quality index at 12 months.In conclusion, a periodized model is as effective as a non-periodized model in promoting increases in HRPF outcomes following a one-year intervention. These findings indicate that health-professionals can add variation to cardiac rehabilitation workouts without compromising effectiveness.

Periodization: Variation in the Definition and Discrepancies in Study Design

Over the past several decades, periodization has been widely accepted as the gold standard of training theory. Within the literature, there are numerous definitions for periodization, which makes it difficult to study. When examining the proposed definitions and related studies on periodization, problems arise in the following domains: (1) periodization has been proposed to serve as the macro-management of the training process concerning the annual plan, yet research on long-term effects is scarce; (2) periodization and programming are being used interchangeably in research; and (3) training is not periodized alongside other stressors such as sport (i.e., only resistance training is being performed without the inclusion of sport). Overall, the state of the literature suggests that the inability to define periodization makes the statement of its superiority difficult to experimentally test. This paper discusses the proposed definitions of periodization and the study designs which have been employed to examine the concept.

Impact of 2 different aerobic periodization training protocols on left ventricular function in patients with stable coronary artery disease: an exploratory study

We compared the impacts of linear (LP) and nonlinear (NLP) aerobic training periodizations on left ventricular (LV) function and geometry in coronary artery disease (CAD) patients. Thirty-nine CAD patients were randomized to either a 3-month isoenergetic supervised LP or NLP. All underwent standard echocardiography with assessment of 3D LV ejection fraction (LVEF), diastolic function, strain (global longitudinal, radial, and circumferential), and strain rate at baseline and study end. Training was performed 3 times/week and included high-intensity interval and moderate-intensity continuous training sessions. Training load was progressively increased in the LP group, while it was deeply increased and intercepted with a recovery week each fourth week in the NLP group. For the 34 analyzed patients, we found similar improvements for 3D LVEF (effect size (ES): LP, 0.29; NLP, 0.77), radial strain (ES: LP, 0.58; NLP, 0.48), and radial strain rate (ES: LP, 0.87; NLP, 0.17) in both groups (time for all: p ≤ 0.01). All other parameters of cardiac function remained similar. In conclusion, NLP and LP led to similar improvements in 3D LVEF and radial strain, suggesting a favourable positive cardiac remodelling through myofibers reorganization. These findings must be investigated in patients with more severe cardiac dysfunction. The study was registered on ClinicalTrials.gov (NCT03443193). Novelty: Linear and nonlinear periodization programs improved radial strain, accompanied by improvement of ejection fraction. Both aerobic periodization programs did not negatively impact cardiac function in coronary artery disease patients.

Women and men with coronary heart disease respond similarly to different aerobic exercise training modalities: a pooled analysis of prospective randomized trials

We aimed to compare cardiopulmonary exercise test (CPET) parameters, cardiac adaptations, and proportion of responders after different aerobic training programs amongst women and men with coronary heart disease (CHD). Patients with CHD were evaluated with a CPET and echocardiography before and after 3 months of aerobic exercise training. Peak oxygen uptake exercise training response was assessed according to the median peak oxygen uptake change for post- versus pretraining in the whole cohort (stratification non/low responders (NLR) vs. high-responders) and normalized for lean body mass (LBM). Eighty-three CHD patients were included (19 women, 64 men; 27 patients with interval, 19 with continuous, and 37 with combination exercises). Peak oxygen uptake, peak workload normalized for LBM, pulmonary variables (i.e., ventilation and oxygen uptake efficiency slope), and O₂ pulse were significantly lower in women versus men. These parameters improved similarly with training in both sexes (p < 0.05). There were no differences in the proportion of NLR among women and men with CHD (7/19 (37%) vs. 35/64 (55%), p = 0.1719). Left ventricular ejection fraction and mean peak early diastolic mitral annulus velocity improved similarly with training in both sexes (p < 0.05). Women and men with CHD have a similar exercise training response regarding key CPET and echocardiographic parameters. The proportion of responders is similar. ClinicalTrials.gov: NCT03414996, NCT02048696, NCT03443193. Novelty: Cardiopulmonary adaptations to exercise training are similar among CHD men and women. Proportion of peak oxygen uptake for non/low/high responders is similar in CHD men and women. Left ventricular systolic and diastolic function improved similarly after exercise training in CHD men and women.