Optimizing Outcomes in Cardiac Rehabilitation: The Importance of Exercise Intensity

Exploring timing and delivery of lifestyle advice following an acute cardiac event hospitalization: The cardiac patient's perspective

OBJECTIVE

To explore the perspective of cardiac patients regarding the timing and manner of delivering lifestyle advice following an acute cardiac event hospitalization.

METHODS

Dutch cardiac patients who experienced a cardiac event hospitalization participated in a semi-structured interview (n = 14) or a cross-sectional survey study (n = 119).

RESULTS

Our findings indicate that cardiac patients are receptive to lifestyle advice throughout the care trajectory. Advice delivered by a cardiologist had the highest self-reported impact. Furthermore, receiving advice at multiple phases during the care trajectory was associated with a greater intention to change lifestyle (B = 0.37, CI = 0.17 - 0.57). Patients favored clear-cut, feasible, and friendly but confronting advice. Moreover, they stressed the importance of advice being aligned with their identity and beliefs about the causes of their disease.

CONCLUSION

The period following an acute cardiac event provides a unique opportunity to offer tailored and patient-centered lifestyle advice. This "teachable window" for lifestyle change, when used wisely, may improve health outcomes for cardiac patients.

PRACTICE IMPLICATIONS

Healthcare professionals should initiate lifestyle advice already during hospitalization and continue during follow-up appointments and cardiac rehabilitation. Advice should be feasible and empathy-based, as well as tailored to the patient's needs, values, and perceptions of the causes of their cardiovascular disease.

Different High-Intensity Interval Training Programs versus Moderate Intensity Continuous Training for Heart Failure Patients: a systematic review and meta-analysis

OBJECTIVE

To explore the effect sizes of different HIIT protocols on cardiorespiratory parameters when compared with the MICT in different HF subtypes.

DATA SOURCES

Electronic databases were searched from their inception date until January 23rd, 2023.

STUDY SELECTION

Randomized controlled trials (RCTs) were included if they compared HIIT to MICT in HF patients. The primary outcomes was peak oxygen consumption (VO2peak). Two reviewers independently evaluated 99 initially identified studies, resulting in the selection of 15 RCTs that met the eligibility criteria.

DATA EXTRACTION

Data was extracted independently by two observers using data extraction form drafted based on the CONSORT statement and the TIDieR; and the The methodological quality of the studies was analyzed individually based on the TESTEX scale.

DATA SYNTHESIS

Fifteen RCTs with 553 HF patients were included in the systematic review. The studies included had moderate to good overall methodological quality. The results showed that HIIT was generally more effective than MICT at improving VO2peak in HF patients (n=541, 15 RCT; MD: 1.49 mL/kg/min, I2=66%, p<0.001). However, the effect size varied depending on the HF subtype and HIIT protocol used. For HFrEF patients, the long-interval (high-intensity interval lasting≥ 4 min) and high-volume HIIT (high-intensity efforts in total ≥ 15 min) showed the largest benefits over the MICT (n=261, 6 RCT; MD: 2.11 mL/kg/min, p<0.001); followed by the short-interval (≤ 1 min) and high-volume HIIT (≥ 15 min; n=71, 3 RCT; MD: 0.91 mL/kg/min, p=0.12); and the short-interval and low-volume HIIT showed the least superiority over MICT (n=68, 3 RCT; MD: 0.54 mL/kg/min; p=0.05). For HFpEF patients, there was a modest beneficial effect from HIIT over MICT (n=141, 3 RCT; MD: 0.55 mL/kg/min; p=0.32).

CONCLUSIONS

The long-interval and high-volume HIIT protocol may produce greater benefits than MICT for improving cardiopulmonary fitness in HFrEF patients. Further research is needed to determine the optimal HIIT protocol for different HF subtypes and to provide definitive recommendations for clinical practice.

Accurate Prediction Equations for Ventilatory Thresholds in Cardiometabolic Disease When Gas Exchange Analysis is Unavailable: Development and Validation

AIMS

To develop and validate equations predicting heart rate (HR) at the first and second ventilatory thresholds (VTs) and an optimized range-adjusted prescription for patients with cardiometabolic disease (CMD). To compare their performance against guideline-based exercise intensity domains.

METHODS

Cross-sectional study involving 2,868 CMD patients from nine countries. HR predictive equations for first and second VTs (VT1, VT2) were developed using multivariate linear regression with 975 cycle-ergometer cardiopulmonary exercise tests (CPET). 'Adjusted' percentages of peak HR (%HRpeak) and HR reserve (%HRR) were derived from this group. External validation with 1,893 CPET (cycle-ergometer or treadmill) assessed accuracy, agreement, and reliability against guideline-based %HRpeak and %HRR prescriptions using mean absolute percentage error (MAPE), Bland-Altman analyses, intraclass correlation coefficients (ICC).

RESULTS

HR predictive equations (R²: 0.77 VT1, 0.88 VT2) and adjusted %HRR (VT1: 42%, VT2: 77%) were developed. External validation demonstrated superiority over widely used guideline-directed intensity domains for %HRpeak and %HRR. The new methods showed consistent performance across both VTs with lower MAPE (VT1: 7.1%, VT2: 5.0%), 'good' ICC for VT1 (0.81, 0.82) and 'excellent' for VT2 (0.93). Guideline-based exercise intensity domains had higher MAPE (VT1: 6.8%-21.3%, VT2: 5.1%-16.7%), 'poor' to 'good' ICC for VT1, and 'poor' to 'excellent' for VT2, indicating inconsistencies related to specific VTs across guidelines.

CONCLUSION

Developed and validated HR predictive equations and the optimized %HRR for CMD patients for determining VT1 and VT2 outperformed the guideline-based exercise intensity domains and showed ergometer interchangeability. They offer a superior alternative for prescribing moderate intensity exercise when CPET is unavailable.

Short-duration aerobic high-intensity intervals versus moderate exercise training intensity in patients with peripheral artery disease: study protocol for a randomised controlled trial (the Angiof-HIIT Study)

INTRODUCTION

Supervised exercise training is among the first-line therapies for patients with peripheral artery disease (PAD). Current recommendations for exercise include guidance focusing on claudication pain, programme and session duration, and frequency. However, no guidance is offered regarding exercise training intensity. This study aims to compare the effects of 12-week-long supervised walking exercise training (high-intensity interval training (HIIT) vs moderate-intensity exercise (MOD)) in patients with chronic symptomatic PAD.

METHODS AND ANALYSIS

This study is a monocentric, interventional, non-blinded randomised controlled trial. 60 patients (30 in each group) will be randomly allocated (by using the random permuted blocks) to 12 weeks (three times a week) of HIIT or MOD. For HIIT, exercise sessions will consist of alternating brief high-intensity (≥85% of the peak heart rate (HRpeak)) periods (≤60 s) of work with periods of passive rest. Patients will be asked to complete 1 and then 2 sets of 5-7 (progressing to 10-15×60 s) walking intervals. For the MOD group, exercise training sessions will consist of an alternation of periods of work performed at moderate intensity (≤76% HRpeak) and periods of passive rest. Interventions will be matched by training load. The primary outcome will be the maximal walking distance. Secondary outcomes will include functional performance, functional capacity, heath-related quality of life, self-perceived walking abilities, physical activity and haemodynamic parameters.

ETHICS AND DISSEMINATION

The Angiof-HIIT Study was approved by the Human Research Ethics Committee of the Canton de Vaud (study number: 2022-01752). Written consent is mandatory prior to enrolment and randomisation. The results will be disseminated via national and international scientific meetings, scientific peer-reviewed journals and social media.

TRIAL REGISTRATION NUMBER

NCT05612945.

Assessing cardiorespiratory fitness in clinical and community settings: Lessons and advancements in the 100th year anniversary of VO2max

Cardiorespiratory fitness (CRF) is a well-established biomarker that has applications to all adults across the health and disease spectrum. Despite overwhelming evidence supporting the prognostic utility of CRF, it remains vastly underutilized. CRF is optimally measured via cardiopulmonary exercise testing which may not be feasible to implement on a large scale. Therefore, it is prudent to develop ways to accurately estimate CRF that can be applied in clinical and community settings. As such, several prediction equations incorporating non-exercise information that is readily available from routine clinical encounters have been developed that provide an adequate reflection of CRF that could be implemented to raise awareness of the importance of CRF. Further, technological advances in smartphone apps and consumer-grade wearables have demonstrated promise to provide reasonable estimates of CRF that are widely available, which could enhance the utilization of CRF in both clinical and community settings.

Evaluating the Effects of an Enhanced Strength Training Program in Remote Cardiological Rehabilitation: A Shift from Aerobic Dominance-A Pilot Randomized Controlled Trial

(1) Background: Cardiac rehabilitation often emphasizes aerobic capacity while overlooking the importance of muscle strength. This study evaluated the impact of an enhanced remote strength training program (RCR-ST) on cardiac rehabilitation. (2) Methods: In this randomized prospective study (RCT registration number SMC-9080-22), 50 patients starting cardiac rehabilitation were assessed for muscle strength, aerobic capacity, and self-reported outcomes at baseline and after 16 weeks. Participants were divided into two groups: the RCR-ST group received a targeted resistance training program via a mobile app and smartwatch, while the control group received standard care with general resistance training advice. (3) Results: The RCR-ST group demonstrated significant improvements in muscle endurance, notably in leg extension and chest press exercises, with increases of 92% compared to 25% and 92% compared to 13% in the control group, respectively. Functional assessments (5-STS and TUG tests) also showed marked improvements in agility, coordination, and balance. Both groups improved in cardiorespiratory fitness, similarly. The RCR-ST group reported enhanced physical health and showed increased engagement, as evidenced by more frequent use of the mobile app and longer participation in the rehabilitation program (p < 0.05). (4) Conclusions: Incorporating a focused strength training regimen in remote cardiac rehabilitation significantly improves muscle endurance and patient engagement. The RCR-ST program presents a promising approach for optimizing patient outcomes by addressing a crucial gap in traditional rehabilitation protocols that primarily focus on aerobic training.

Effect of exercise on functional capacity and body weight for people with hypertension, type 2 diabetes, or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Hypertension, type 2 diabetes, and cardiovascular disease affect the activities of daily living at varying degree. While the effects of aerobic exercise on functional capacity are well-documented, the extent of change for different types of exercise in these chronic conditions remains unexplored. Additionally, there is conflicting evidence regarding the role of exercise in reducing body weight.

METHODS

We conducted systematic review with meta-analysis and trial sequential analysis and searched various databases from inception to July 2020. We included randomised clinical trials adding any form of trialist defined exercise to usual care versus usual care in people with either hypertension, type 2 diabetes, and/or cardiovascular disease irrespective of setting, publication status, year, and language. The outcomes assessed were i) functional capacity assessed through different scales separately i.e., Maximal Oxygen Uptake (VO2max), 6-min walk test (6MWT), 10-m walk test (10MWT), and ii) body weight.

RESULTS

We included 950 studies out of which 444 trials randomising 20,098 participants reported on various functional outcomes (355 trials) and body weight (169 trials). The median follow-up was 3 months (Interquartile ranges (IQR): 2.25 to 6). Exercise added to the usual care, improved VO2max (Mean Difference (MD):2.72 ml/kg/min; 95% Confidence Interval (CI) 2.38 to 3.06; p < 0.01; I2 = 96%), 6MWT (MD: 42.5 m; 95%CI 34.95 to 50.06; p < 0.01; I2 = 96%), and 10MWT (MD: 0.06 m/s; 95%CI 0.03 to 0.10; p < 0.01; I2 = 93%). Dynamic aerobic and resistance exercise showed a consistent improvement across various functional outcomes, whereas body-mind therapies (MD: 3.23 ml/kg/min; 95%CI 1.97 to 4.49, p < 0.01) seemed especially beneficial for VO2max and inspiratory muscle training (MD: 59.32 m; 95%CI 33.84 to 84.80; p < 0.01) for 6MWT. Exercise yielded significant reduction in body weight for people with hypertension (MD: -1.45 kg; 95%CI -2.47 to -0.43; p < 0.01), and type 2 diabetes (MD: -1.53 kg; 95%CI -2.19 to -0.87; p < 0.01) but not for cardiovascular disease with most pronounced for combined exercise (MD: -1.73 kg; 95%CI -3.08 to -0.39; p < 0.05). The very low certainty of evidence warrants cautious interpretations of the results.

CONCLUSION

Exercise seemed to improve functional capacity for people with hypertension, type 2 diabetes, and/or cardiovascular disease but the effectiveness seems to vary with different forms of exercise. The potentially superior improvement in VO2max and 6MWT by body-mind therapies and inspiratory muscle training calls for further exploration. Additionally, prescribing exercise for the sole purpose of losing weight may be a potential strategy for people with hypertension and type 2 diabetes. The extent of improvement in functional capacity and body weight reduction differed with different exercise regimens hence personalised exercise prescriptions tailored to individual needs may be of importance. PROSPERO REGISTRATION: PROSPERO registration number: CRD42019142313.

Evaluation of Wrist-Worn Photoplethysmography Trackers with an Electrocardiogram in Patients with Ischemic Heart Disease: A Validation Study

PURPOSE

Photoplethysmography measurement of heart rate with wrist-worn trackers has been introduced in healthy individuals. However, additional consideration is necessary for patients with ischemic heart disease, and the available evidence is limited. The study aims to evaluate the validity and reliability of heart rate measures by a wrist-worn photoplethysmography (PPG) tracker compared to an electrocardiogram (ECG) during incremental treadmill exercise among patients with ischemic heart disease.

METHODS

Fifty-one participants performed the standard incremental treadmill exercise in a controlled laboratory setting with 12-lead ECG attached to the patient's body and wearing wrist-worn PPG trackers.

RESULTS

At each stage, the absolute percentage error of the PPG was within 10% of the standard acceptable range. Further analysis using a linear mixed model, which accounts for individual variations, revealed that PPG yielded the best performance at the baseline low-intensity exercise. As the stages progressed, heart rate validity decreased but was regained during recovery. The reliability was moderate to excellent.

CONCLUSIONS

Low-cost trackers AMAZFIT Cor and Bip validity and reliability were within acceptable ranges, especially during low-intensity exercise among patients with ischemic heart disease recovering from cardiac procedures. Though using the tracker as part of the diagnosis tool still requires more supporting studies, it can potentially be used as a self-monitoring tool with precautions.

Acute effects of high intensity interval training versus moderate intensity continuous training on haemostasis in patients with coronary artery disease

Exercise training is associated with an acute net increase in coagulation, which may increase the risk of atherothrombosis in coronary artery disease (CAD) patients. We sought to compare the acute haemostatic effects of a bout of moderate-intensity continuous (MICT) and high-intensity interval training (HIIT) in patients with CAD. Patients after a recent myocardial infarction were randomized into a HIIT or MICT session of exercise training on a stationary bike. Blood was sampled at baseline, after the exercise bout and after a one-hour resting period. We measured overall haemostatic potential (OHP), overall coagulation potential (OCP), fibrinogen, D-dimer and von Willebrand factor (vWF) and calculated overall fibrinolytic potential (OFP). Linear mixed models for repeated measures were constructed to assess the treatment effect. A total of 117 patients were included. OCP, OHP, fibrinogen, D-dimer and vWF significantly increased after exercise and returned to baseline after a one-hour rest, OFP decreased after exercise and returned to baseline levels after a one-hour rest. Linear mixed models showed a significant difference between HIIT and MICT in fibrinogen (p 0.043) and D-dimer (p 0.042). Our study has shown that an exercise bout is associated with a transient procoagulant state in patients with CAD, with similar exercise-induced haemostatic changes for HIIT and MICT.

A New Player in the Game: Can Exergame Be of Support in the Management of Atrial Fibrillation?

Atrial fibrillation (AF) is the most common form of cardiac arrhythmia, currently affecting 2-3% of the world's population. Traditional exercise and physical activity interventions have been successfully implemented in the management of AF, with the aim of improving patients' quality of life and their exercise capacity, as well as reducing their mortality rate. Currently, new technology-mediated approaches to exercise, defined as exergame, have been shown to be successful in the delivery of exercise home-based interventions in patients with cardiovascular diseases. However, data on the effects of exergame on AF are not yet available. In this paper, we summarise the current literature on the role of traditional exercise in AF and how it affects the pathophysiology of this condition. We also review the current literature on exergame and its employment in cardiac rehabilitation and suggest its potential role in the management of AF patients. A review of the evidence suggests that traditional exercise (of light-to-moderate intensity) is beneficial in patients with AF. Additionally, exergame seems to be a promising approach for delivering exercise interventions in patients with cardiovascular diseases. Exergame may be a promising tool to improve the quality of life and exercise capacity in patients with AF, with the additional advantage of being remotely delivered, and the potential to increase patients' engagement. Proper guidelines are required to prescribe exergame interventions, considering the principles of traditional exercise prescription and applying them to this new e-health approach. Further studies are needed to validate the use of exergame in patients with AF.

Lifestyle Walking Intervention for Patients With Heart Failure With Reduced Ejection Fraction: The WATCHFUL Trial

BACKGROUND

Physical activity is pivotal in managing heart failure with reduced ejection fraction, and walking integrated into daily life is an especially suitable form of physical activity. This study aimed to determine whether a 6-month lifestyle walking intervention combining self-monitoring and regular telephone counseling improves functional capacity assessed by the 6-minute walk test (6MWT) in patients with stable heart failure with reduced ejection fraction compared with usual care.

METHODS

The WATCHFUL trial (Pedometer-Based Walking Intervention in Patients With Chronic Heart Failure With Reduced Ejection Fraction) was a 6-month multicenter, parallel-group randomized controlled trial recruiting patients with heart failure with reduced ejection fraction from 6 cardiovascular centers in the Czech Republic. Eligible participants were ≥18 years of age, had left ventricular ejection fraction <40%, and had New York Heart Association class II or III symptoms on guidelines-recommended medication. Individuals exceeding 450 meters on the baseline 6MWT were excluded. Patients in the intervention group were equipped with a Garmin vívofit activity tracker and received monthly telephone counseling from research nurses who encouraged them to use behavior change techniques such as self-monitoring, goal-setting, and action planning to increase their daily step count. The patients in the control group continued usual care. The primary outcome was the between-group difference in the distance walked during the 6MWT at 6 months. Secondary outcomes included daily step count and minutes of moderate to vigorous physical activity as measured by the hip-worn Actigraph wGT3X-BT accelerometer, NT-proBNP (N-terminal pro-B-type natriuretic peptide) and high-sensitivity C-reactive protein biomarkers, ejection fraction, anthropometric measures, depression score, self-efficacy, quality of life, and survival risk score. The primary analysis was conducted by intention to treat.

RESULTS

Of 218 screened patients, 202 were randomized (mean age, 65 years; 22.8% female; 90.6% New York Heart Association class II; median left ventricular ejection fraction, 32.5%; median 6MWT, 385 meters; average 5071 steps/day; average 10.9 minutes of moderate to vigorous physical activity per day). At 6 months, no between-group differences were detected in the 6MWT (mean 7.4 meters [95% CI, -8.0 to 22.7]; P=0.345, n=186). The intervention group increased their average daily step count by 1420 (95% CI, 749 to 2091) and daily minutes of moderate to vigorous physical activity by 8.2 (95% CI, 3.0 to 13.3) over the control group. No between-group differences were detected for any other secondary outcomes.

CONCLUSIONS

Whereas the lifestyle intervention in patients with heart failure with reduced ejection fraction improved daily steps by about 25%, it failed to demonstrate a corresponding improvement in functional capacity. Further research is needed to understand the lack of association between increased physical activity and functional outcomes.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03041610.

Exercise may not just be good for sleep; It can also help lower cardiovascular event risk

Cardiovascular diseases (CVD) stand at the forefront of global mortality, presenting an immense and urgent public health challenge on a global scale. Effectively addressing the associated risk factors is pivotal in not only preventing but also stabilizing and potentially reversing the progression of these conditions. Emerging research illuminates a compelling correlation between sleep disorders and CVD. Clinically, individuals afflicted with existing CVD or those possessing risk factors frequently grapple with sleep disturbances, exacerbating their conditions, particularly in severe cases where disease progression is accelerated. Even among ostensibly healthy individuals, chronic sleep deprivation exacts a toll on cardiovascular function. The strategic implementation of exercise interventions emerges as a potent tool in enhancing sleep quality, surpassing the efficacy of pharmaceutical treatments. Furthermore, the maintenance of optimal sleep patterns significantly contributes to lowering the risk of cardiovascular diseases. This comprehensive review delves deeply into the intricate relationship between exercise and the amelioration of cardiovascular disease risk associated with sleep. Moreover, it meticulously elucidates the complex mechanisms through which exercise operates, effectively reducing cardiovascular disease risk from the unique perspective of sleep science.

Standardised Exercise Prescription for Patients with Chronic Coronary Syndrome and/or Heart Failure: A Consensus Statement from the EXPERT Working Group

Whereas exercise training, as part of multidisciplinary rehabilitation, is a key component in the management of patients with chronic coronary syndrome (CCS) and/or congestive heart failure (CHF), physicians and exercise professionals disagree among themselves on the type and characteristics of the exercise to be prescribed to these patients, and the exercise prescriptions are not consistent with the international guidelines. This impacts the efficacy and quality of the intervention of rehabilitation. To overcome these barriers, a digital training and decision support system [i.e. EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool], i.e. a stepwise aid to exercise prescription in patients with CCS and/or CHF, affected by concomitant risk factors and comorbidities, in the setting of multidisciplinary rehabilitation, was developed. The EXPERT working group members reviewed the literature and formulated exercise recommendations (exercise training intensity, frequency, volume, type, session and programme duration) and safety precautions for CCS and/or CHF (including heart transplantation). Also, highly prevalent comorbidities (e.g. peripheral arterial disease) or cardiac devices (e.g. pacemaker, implanted cardioverter defibrillator, left-ventricular assist device) were considered, as well as indications for the in-hospital phase (e.g. after coronary revascularisation or hospitalisation for CHF). The contributions of physical fitness, medications and adverse events during exercise testing were also considered. The EXPERT tool was developed on the basis of this evidence. In this paper, the exercise prescriptions for patients with CCS and/or CHF formulated for the EXPERT tool are presented. Finally, to demonstrate how the EXPERT tool proposes exercise prescriptions in patients with CCS and/or CHF with different combinations of CVD risk factors, three patient cases with solutions are presented.

Time-course evolution of functional performance during a 3-month supervised exercise training program in patients with symptomatic peripheral artery disease

INTRODUCTION

Functional performance is impaired in patients with peripheral artery disease (PAD). The effects of a supervised exercise training (SET) program on functional performance have yet to be clearly determined. The aim was to investigate the time-course evolution of functional performance during a 3-month SET program.

METHODS

Patients with chronic symptomatic PAD participating in a 3-month SET program were investigated. Six-minute walking distance (6MWD), the stair climbing test (SCT), and the Short Physical Performance Battery (SPPB) were assessed before SET, after the first and second months of SET, and following the SET program. The ankle- and toe-brachial indices were measured before and after the SET program.

RESULTS

Ninety patients with PAD (age 65.4 ± 10.2 years) were analyzed. The 6MWD significantly improved after the first (+7%, p ⩽ 0.001) and second months (+13%, p ⩽ 0.001) and following SET (+14%, p ⩽ 0.001) compared to before the SET program. The 6MWD significantly improved after the 2nd month (+6%, p ⩽ 0.001) and following SET (+7%, p ⩽ 0.001) compared to after the first month of the SET program. The SPPB score and SCT performance significantly improved after the first (SPPB score: +9%, p ⩽ 0.001; SCT: +17%, p ⩽ 0.001) and second months (SPPB score: +11%, p ⩽ 0.001; SCT: +24%, p ⩽ 0.001) and following SET (SPPB score: +12%, p ⩽ 0.001; SCT: +25%, p ⩽ 0.001) compared to before the SET program. No significant differences were observed following SET compared to the second month of the SET program. Vascular parameters did not change significantly.

CONCLUSIONS

A 3-month SET program improves several components of functional performance, and adaptations mainly occur during the 1st and 2nd months of the SET program.

Cluster Sets to Prescribe Interval Resistance Training: A Potential Method to Optimise Resistance Training Safety, Feasibility and Efficacy in Cardiac Patients

The integration of resistance training for cardiac patients leads to important health outcomes that are not optimally obtained with aerobic exercise; these include an increase in muscle mass, maintenance of bone mineral density, and improvements in muscular fitness parameters. Despite the proliferation of evidence supporting resistance exercise in recent decades, the implementation of resistance training is underutilised, and prescription is often sub-optimal in cardiac patients. This is frequently associated with safety concerns and inadequate methods of practical exercise prescription. This review discusses the potential application of cluster sets to prescribe interval resistance training in cardiac populations. The addition of planned, regular passive intra-set rest periods (cluster sets) in resistance training (i.e., interval resistance training) may be a practical solution for reducing the magnitude of haemodynamic responses observed with traditional resistance training. This interval resistance training approach may be a more suitable option for cardiac patients. Additionally, many cardiac patients present with impaired exercise tolerance; this model of interval resistance training may be a more suitable option to reduce fatigue, increase patient tolerance and enhance performance to these workloads. Practical strategies to implement interval resistance training for cardiac patients are also discussed. Preliminary evidence suggests that interval resistance training may lead to safer acute haemodynamic responses in cardiac patients. Future research is needed to determine the efficacy and feasibility of interval resistance training for health outcomes in this population.

A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

Exercise Training in Non-Hospitalized Patients with Post-COVID-19 Syndrome-A Narrative Review

Post COVID-19 Syndrome (PCS) is the persistence of symptoms after an infection with SARS-CoV-2 in both hospitalized and non-hospitalized COVID-19 survivors. Exercise was proposed as a rehabilitation measure for PCS and early studies focused on patients post-hospital discharge. The objective of this review is to summarize the results of trials investigating exercise interventions in non-hospitalized subjects with PCS and propose practical recommendations concerning safe exercise programming. A literature search in the databases MEDLINE and Scopus was conducted until 26 July 2023 and resulted in seven studies that met the criteria. In total, 935 subjects with PCS were investigated. Exercise enhanced aerobic fitness and physical function and relieved symptoms of dyspnea, fatigue and depression. Participants reported lower Post COVID-19 Functional Status scores post-intervention. The exercise programs were well tolerated with no adverse events. To ensure safety, medical examinations should take place in advance and there should be a regular evaluation of the individual responses to the training. Caution is advised when working with patients suffering from post-exertional malaise or diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome. There is a growing need for additional randomized controlled trials to investigate the effectiveness and safety of exercise in individuals with PCS.

Elucidating the primary mechanisms of high-intensity interval training for improved cardiac fitness in obesity

Obesity is a global and rising multifactorial pandemic associated with the emergence of several comorbidities that are risk factors for malignant cardiac remodeling and disease. High-intensity interval training (HIIT) has gained considerable attention due to its favorable outcomes of cardiometabolic health in individuals with overweight or obese. The primary aim of this review is to discuss the fundamental processes through which HIIT improves cardiac impairment in individuals with obesity to develop viable treatments for obesity management. In this review, a multiple database search and collection were conducted from the earliest record to January 2013 for studies included the qualitative component of HIIT intervention in humans and animals with overweight/obesity related to cardiac remodeling and fitness. We attempt to integrate the main mechanisms of HIIT in cardiac remolding improvement in obesity into an overall sequential hypothesis. This work focus on the ameliorative effects of HIIT on obesity-induced cardiac remodeling with respect to potential and pleiotropic mechanisms, including adipose distribution, energy metabolism, inflammatory response, insulin resistance, and related risk profiles in obesity. In conclusion, HIIT has been shown to reduce obesity-induced risks of cardiac remodeling, but the long-term effects of HIIT on obesity-induced cardiac injury and disease are presently unknown. Collective understanding highlights numerous specific research that are needed before the safety and effectiveness of HIIT can be confirmed and widely adopted in patient with obesity.

Comparison of telehealth and supervised phase III cardiac rehabilitation in regional Australia: protocol for a non-inferiority trial

INTRODUCTION

Exercise-based cardiac rehabilitation programmes (ExCRP) promote recovery and secondary prevention for individuals with cardiovascular disease (CVD). Despite this, enrolment and adherence to ExCRP in rural locations is low. Telehealth programmes provide a convenient, home-based intervention, but concerns remain about compliance to exercise prescription. This paper presents the rationale and protocol design to determine if telehealth delivered ExCRP is not inferior to supervised ExCRP for improving cardiovascular function and exercise fidelity.

METHOD AND ANALYSIS

A non-inferiority, parallel (1:1), single-blinded randomised clinical trial will be conducted. Fifty patients with CVD will be recruited from a rural phase II ExCRP. Participants will be randomly assigned to telehealth or supervised ExCRP and prescribed three weekly exercise sessions for 6 weeks. Exercise sessions will include a 10 min warm up, up to 30 min of continuous aerobic exercise at a workload equivalent to the ventilatory anaerobic threshold and a 10 min cool down. The primary outcome will be change in cardiorespiratory fitness as measured by cardiopulmonary exercise test. Secondary outcome measures will include change in blood lipid profile, heart rate variability, pulse wave velocity, actigraphy measured sleep quality and training fidelity. Non-inferiority will be confirmed if intention-to-treat and per-protocol analyses conclude the same outcome following independent samples t-test with p<0.025.

ETHICS AND DISSEMINATION

Research ethics committees at La Trobe University, St John of God Health Care and Bendigo Health approved the study protocol and informed consent. Findings will be published in peer-reviewed journals and disseminated among stakeholders.

TRIAL REGISTRATION NUMBER

ACTRN12622000872730p; pre-results.

Effect of Constant vs. Variable Moderate-Intensity Load on Peak Oxygen Uptake in Outpatient Cardiac Rehabilitation

Background: In outpatient center-based cardiac rehabilitation (O-CBCR), moderate-intensity continuous training (MICT) based on the anaerobic threshold (AT) determined by cardiopulmonary exercise stress testing is recommended. However, it is unclear whether differences in exercise intensity within the MICT domain affect peak oxygen uptake (%peakV̇O2). Methods and Results: We retrospectively evaluated patients who underwent O-CBCR at Japan Community Healthcare Organization Osaka Hospital. Those treated with the constant-load method were designated as Group A (n=38), whereas those treated with the variable-load method were designated as Group B (n=48). Although the change in exercise intensity was significantly greater in Group B by approximately 4.5 W, the change in %peakV̇O2 was not significantly different between groups. Group A had a significantly longer exercise time than Group B (by approximately 4-5 min). No deaths or hospitalizations occurred in either group. The percentage of episodes with exercise cessation was similar between the 2 groups, but the percentage of episodes with load reduction was significantly higher in Group B, mostly because of the increased heart rate. Conclusions: In supervised MICT based on AT, the variable-load method increased exercise intensity more than the constant-load method without severe complications, but did not improve %peakV̇O2.

Effectiveness of high intensity interval training on cardiorespiratory fitness and endothelial function in type 2 diabetes: A systematic review

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a chronic metabolic syndrome characterized by insulin resistance and hyperglycemia that may lead to endothelial dysfunction, reduced functional capacity and exercise intolerance. Regular aerobic exercise has been promoted as the most beneficial non-pharmacological treatment of cardiovascular diseases. High intensity interval training (HIIT) seems to be superior than moderate-intensity continuous training (MICT) in cardiovascular diseases by improving brachial artery flow-mediated dilation (FMD) and cardiorespiratory fitness to a greater extent. However, the beneficial effects of HIIT in patients with T2DM still remain under investigation and number of studies is limited.

AIM

To evaluate the effectiveness of high intensity interval training on cardiorespiratory fitness and endothelial function in patients with T2DM.

METHODS

We performed a search on PubMed, PEDro and CINAHL databases, selecting papers published between December 2012 and December 2022 and identified published randomized controlled trials (RCTs) in the English language that included community or outpatient exercise training programs in patients with T2DM. RCTs were assessed for methodological rigor and risk of bias via the Physiotherapy Evidence Database (PEDro). The primary outcome was peak VO₂ and the secondary outcome was endothelial function assessed either by FMD or other indices of microcirculation.

RESULTS

Twelve studies were included in our systematic review. The 12 RCTs resulted in 661 participants in total. HIIT was performed in 310 patients (46.8%), MICT to 271 and the rest 80 belonged to the control group. Peak VO₂ increased in 10 out of 12 studies after HIIT. Ten studies compared HIIT with other exercise regimens (MICT or strength endurance) and 4 of them demonstrated additional beneficial effects of HIIT over MICT or other exercise regimens. Moreover, 4 studies explored the effects of HIIT on endothelial function and FMD in T2DM patients. In 2 of them, HIIT further improved endothelial function compared to MICT and/or the control group while in the rest 2 studies no differences between HIIT and MICT were observed.

CONCLUSION

Regular aerobic exercise training has beneficial effects on cardiorespiratory fitness and endothelial function in T2DM patients. HIIT may be superior by improving these parameters to a greater extent than MICT.

An evaluation of the role of the exercise training dose for changes in exercise capacity following a standard cardiac rehabilitation program

BACKGROUND

To retrospectively characterize and compare the dose of exercise training (ET) within a large cohort of patients demonstrating different levels of improvement in exercise capacity following a cardiac rehabilitation (CR) program.

METHODS

A total of 2310 patients who completed a 12-week, center-based, guidelines-informed CR program between January 2018 and December 2019 were included in the analysis. Peak metabolic equivalents (MET_peak) were determined pre- and post-CR during which total duration (ET time) and intensity [percent of heart rate peak (%HR_peak)] of supervised ET were also obtained. Training responsiveness was quantified on the basis of changes in MET_peak from pre- to post-CR. A cluster analysis was performed to identity clusters demonstrating discrete levels of responsiveness (i.e., negative, low, moderate, high, and very-high). These were compared for several baseline and ET-derived variables which were also included in a multivariable linear regression model.

RESULTS

At pre-CR, baseline MET_peak was progressively lower with greater training responsiveness (F_(4,2305) = 44.2, P < 0.01, η²_p = 0.71). Likewise, average training duration (F_(4,2305) = 10.7 P < 0.01, η²_p = 0.02) and %HR_peak (F_(4,2305) = 25.1 P < 0.01, η²_p = 0.042) quantified during onsite ET sessions were progressively greater with greater training responsiveness. The multivariable linear regression model confirmed that baseline MET_peak, training duration and intensity during ET, BMI, and age (P < 0.001) were significant predictors of MET_peak post-CR.

CONCLUSIONS

Along with baseline MET_peak, delta BMI, and age, the dose of ET (i.e., training duration and intensity) predicts MET_peak at the conclusion of CR. A re-evaluation of current approaches for exercise intensity prescription is recommended to extend the benefits of completing CR to all patients.

The effect of low volume high-intensity interval training on metabolic and cardiorespiratory outcomes in patients with type 2 diabetes mellitus: A systematic review and meta-analysis

Aims

The present systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to investigate the effect of low volume high-intensity interval training (LVHIIT) on the metabolic and cardiorespiratory outcomes in patients with type 2 diabetes mellitus (T2DM).

Methods

Relevant articles were sourced from PubMed, EBSCO, Web of Science, Embase, and the Cochrane Library from inception to October 2022. The study search strategy and all other processes were implemented in accordance with the PRISMA statement.

Results

Five randomized controlled trials that satisfied the inclusion criteria were included in this meta-analysis. The LVHIIT group had significantly lower fasting blood glucose levels (RR= -1.21; 95% CI= -2.02- -0.40, p = 0.0032) and HbA1c levels (RR= -0.65; 95% CI= -1.06- -0.23, p = 0.002) and higher levels of insulin resistance indicator HOMA-IR (RR= -1.34; 95% CI = -2.59- -0.10, p = 0.03) than the control group. Moreover, our results show that LVHIIT can reduce body mass (RR = -0.94, 95% CI = -1.37- -0.51, p<0.0001) and body mass index (RR = -0.31, 95% CI = -0.47- -0.16, p<0.0001). LVHIIT had a better therapeutic effect on blood lipid metabolism, such as total cholesterol, high-density lipoprotein, low-density lipoprotein and triglycerides. However, the change in fasting insulin levels was not statistically significant (RR= -1.43; 95% CI = -3.46- 0.60, p =0.17). Furthermore, LVHIIT reduced the systolic blood pressure (RR =-4.01, 95% CI = -4.82 - -3.21, p<0.0001) and improved peak oxygen uptake (VO2peak) compared to the control group (RR= 5.45; 95% CI = 1.38 - 9.52, p =0.009).

Conclusion

After a certain period of LVHIIT, glycaemic control, insulin resistance, body weight, lipid profile and cardiorespiratory outcomes were significantly improved in T2DM patients.

Patient Preferences for Cardiac Rehabilitation - A Systematic Review

BACKGROUND

Although a large number of studies have demonstrated the effectiveness of cardiac rehabilitation(CR), patient preferences for CR remain unclear. Knowing patient preferences may contribute to increasing patient participation and adherence, thus improving patient prognosis.

METHODS

A systematic search was carried out using electronic databases and manual reference checks from inception until 15th June 2022. Quantitative studies, qualitative studies and mixed methods studies assessing patient preferences for CR were included. Two researchers independently conducted study selectionand data extraction. CR preferences were divided into three categories: CR settings, CR components, and CR contents. A narrative synthesis was applied to integrate the results of the included studies. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of included studies.

RESULTS

Ultimately, 17 publications were included in this study. Regarding CR settings, most patients preferred the hospital to home, some considered both, and a few were willing to accept the local CR club as an alternative setting to the hospital. For CR components, regardless of age and gender, patients considered exercise training and nutrition counseling to be the most important and smoking cessation to be the least important. In exercise intervention of CR contents, progress discussion and encouragement were rated as most critical, and non-conflicting with other activities was rated as least critical. In psychological intervention of CR contents, most patients were willing to accept psychological intervention, and a few patients wanted to heal the trauma with the passage of time.

CONCLUSION

This systematic review provides important insights into patient preferences for CR, clarifying patient preferences for CR settings, components, and contents, along with possible influencing factors. Patient preferences may change due to the COVID-19 epidemic, and there is still a need to focus on patient preferences for CR and conduct more relevant primary research to validate the findings of this paper in the future.

The Utility of High Intensity Interval Training to Improve Cognitive Aging in Heart Disease Patients

Adults with cardiovascular disease and heart failure are at higher risk of cognitive decline. Cerebral hypoperfusion appears to be a significant contributor, which can result from vascular dysfunction and impairment of cerebral blood flow regulation. In contrast, higher cardiorespiratory fitness shows protection against brain atrophy, reductions in cerebral blood flow, and cognitive decline. Given that high intensity interval training (HIIT) has been shown to be a potent stimulus for improving cardiorespiratory fitness and peripheral vascular function, its utility for improving cognitive aging is an important area of research. This article will review the physiology related to cerebral blood flow regulation and cognitive decline in adults with cardiovascular disease and heart failure, and how HIIT may provide a more optimal stimulus for improving cognitive aging in this population.

The Comparison of High-Intensity Interval Training Versus Moderate-Intensity Continuous Training after Coronary Artery Bypass Graft: A Systematic Review of Recent Studies

Currently, no international consensus on cardiac rehabilitation exists, leading to great variability in the intensity recommendations for training programs for cardiac patients, including those undergoing coronary artery bypass graft surgery (CABG). While some countries prefer the high-intensity interval training (HIIT) method to improve cardiorespiratory fitness, other countries opt for moderate-intensity continuous training (MICT). The aim of this systematic review was to compare the effects of HIIT and MICT on aerobic fitness and quality of life (QoL) in patients undergoing CABG with the intention of providing support for a consensus on exercise therapy.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted using the online publication databases PubMed, the Cochrane Library and the Bibliothèque nationale du Luxembourg (BnL) covering the last ten years to July 2022. Relevant identified studies respecting the inclusion/exclusion criteria were selected, screened and extracted by four reviewers. Furthermore, the methodological quality of the clinical trials was assessed using the PEDro scale, which was reinforced using the Cochrane Risk of Bias Tool for Randomized Trials (RoB2) for the evaluation of the risk of bias to provide more detail in the evaluation. The certainty of the evidence analysis was established using different levels of evidence in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework.

RESULTS

A total of 379 patients from five RCTs diagnosed with coronary artery disease, including patients undergoing CABG, performed aerobic exercise over different time periods and were assessed based on peakVO2, VO2max and QoL. Overall, both training methods provided improvements in cardiorespiratory fitness and quality of life, with greater changes in HIIT groups.

CONCLUSION

Both trainings methods provide improvements in cardiorespiratory fitness and QoL, with greater increases from HIIT. The moderate quality of evidence supports the use of HIIT and MICT to improve cardiorespiratory fitness and QoL.

COVID-19, cardiac involvement and cardiac rehabilitation: Insights from a rehabilitation perspective - State of the Art

Since the beginning of the pandemic, many novel coronavirus disease 2019 (COVID-19) patients have experienced multisystem involvement or become critically ill and treated in intensive care units, and even died. Among these systemic effects, cardiac involvement may have very important consequences for the patient’s prognosis and later life. Patients with COVID-19 may develop cardiac complications such as heart failure, myocarditis, pericarditis, vasculitis, acute coronary syndrome, and cardiac arrhythmias or trigger an accompanying cardiac disease. The ratio of COVID-19 cardiac involvement ranges between 7 and 28% in hospitalized patients with worse outcomes, longer stay in the intensive care unit, and a higher risk of death. Furthermore, deconditioning due to immobility and muscle involvement can be seen in post-COVID-19 patients and significant physical, cognitive and psychosocial impairments may be observed in some cases. Considering that the definition of health is “a state of complete physical, mental and social well-being”, individuals with heart involvement due to COVID-19 should be rehabilitated by evaluating all these aspects of the disease effect. In the light of the rehabilitation perspective and given the increasing number of patients with cardiac manifestations of COVID-19, in this review, we discuss the rehabilitation principles in this group of patients.

The Predictive Value of Barthel Score, Sequential Organ Failure Assessment Score, and D-Dimer in the 28-Day Prognosis of Patients with Non-ST Elevation Myocardial Infarction: A Retrospective Study of 358 Patients

Purpose

To investigate the nursing prediction value of Barthel score, sequential organ failure assessment (SOFA) score and D-dimer on non-ST-elevation myocardial infarction (NSTEMI) inpatients.

Methods

The clinical data of 358 NSTEMI patients admitted to the emergency department were analyzed using logistic regression equation and a ROC curve was drawn. The area under ROC curve (AUC) of different indicators was compared. A COX regression model was created, and a survival curve was drawn.

Results

There were significant differences in age, D-dimer, WBC, NT-proBNP, EF (%), BI score, MEWS score, and SOFA score between the 28-day death group and the survival group (P < 0.05). The results showed that D-dimer (P = 0.002), SOFA score (P = 0.017), BI score (P < 0.001), and chest pain symptoms (P < 0.001) were independent predictors of 28-day death. When chest pain symptoms (AUC = 0.585), D-dimer (AUC = 0.945, Z = 8.00, P < 0.01), BI score (AUC = 0.145, Z = 5.36, P < 0.01), and SOFA score (AUC = 0.847, Z = 4.93, P < 0.01) were compared, the results showed that BI score (HR = 0.961, P < 0.01) and SOFA score (HR = 1.316, P < 0.001) had statistical significance on the 28-day survival time of the dead patients.

Conclusion

The Barthel score, SOFA score, and D-dimer are all essential in predicting the severity of NSTEMI patients, with a high nursing evaluation value. The Barthel and SOFA scores are associated with the risk of death within 28 days.

Effectiveness and Safety of Four Aerobic Exercise Intensity Prescription Techniques in Rehabilitation Training for Patients with Coronary Heart Disease

Background and Objectives. Exercise intensity is a key indicator for the safety and effectiveness of aerobic exercise program in cardiac rehabilitation (CR) in patients with coronary heart disease (CHD). The majority of CR guidelines recommend aerobic exercise prescription based on moderate intensity and suggest many techniques for setting the heart rate target of exercise to match the intensity. But even high-risk CHD patients rarely adhere to exercise training under medical monitoring. The effectiveness and safety of exercise under these high-intensity techniques is still a paucity of evidence. The purpose of this study was to determine if these techniques can safely and effectively inform exercise prescription for individuals with CHD. Methods. A retrospective study was conducted on all patients with CHD who were admitted to CR and completed cardiopulmonary exercise tests (CPET) in Guangdong Hospital of traditional Chinese medicine. According to the risk stratification method of CHD, all participants were divided into three groups: low, moderate, and high risk. The training target heart rates (HRt) of each participant were calculated according to the formula of heart-rate-reserve (HRR), maximum-heart-rate (MHR), target-heart-rate (THR), and anaerobic threshold (AT) method provided in the guideline. Among them, the HRR method using the maximum-heart-rate obtained by the age formula was named “HRR method A,” and that using the actual measured peak heart rate was named “HRR method B.” For the three groups, the effectiveness and safety indexes at the target-heart-rate zone set by the different formulas above are counted and compared using CPET data. Results. A total of 324 patients were included in the analysis. There was no significant difference between the target-heart-rate set by the HRR method A and AT method among the three groups ( $P>0.05$ ). The mean value of HRt set by other methods was lower than the AT heart rate ( $P<0.05$ ). The HRt set by the THR method was close to the AT, while that set by the MHR method was the lowest. The frequency of patients whose HRt was set by the MHR method was lower than the AT one, which was the highest. None of the participants had serious adverse events. There were no risks of ECG abnormalities in the low- and moderate-risk groups. The HRR method A had the highest incidence of various risks of ECG abnormalities, while the MHR method had the lowest one, and the safety of the THR method is close to that of the AT method ( $P<0.05$ ). Conclusion. The heart rate calculated by HRR method A is more consistent with the actual AT. All four techniques are safe in low- and moderate-risk patients. In high-risk patients, using HRR method A has certain risks. It is recommended to use the MHR method for safety reasons, but its effectiveness is low. If considering both effectiveness and safety, the THR method can be conservatively selected at the beginning of the CR program.

Exercise Prescription and Progression Practices among US Cardiac Rehabilitation Clinics

Background: Little is known about exercise prescription practices in cardiac rehabilitation (CR). Therefore, the purpose of this study was to understand how initial exercise is prescribed and how exercise intensity is progressed among cardiac patients enrolled in United States CR programs. Methods: A 22-question survey was sent out to US CR clinics. Results: Ninety-three clinics responded to the survey. RPE was the most commonly reported exercise intensity indicator used for prescribing exercise, followed by resting HR + 20–30 bpm. Exercise progression practices were also based on patient sustained RPE values. Conclusions. Exercise prescription practice has become reliant on subjective indicators of exercise intensity. This may limit patient outcomes, such as improvement in functional measures.

Exercise training in cardiac rehabilitation: Setting the right intensity for optimal benefit

Cardiac rehabilitation (CR) programs are recommended standard-of-care by all major cardiovascular medicine professional organizations. Exercise training is the cornerstone for CR, with aerobic training being the primary form of training. The benefits of exercise training are multiple; however, improved cardiorespiratory fitness is of utmost importance. Moderate-intensity continuous training, supplemented with resistance training, has traditionally been the most common form of exercise training in CR. This review discusses the role of aerobic exercise training in CR and the importance of effective and personalized exercise prescription for optimized results. We also focus on the benefits and utility of high-intensity interval training across different clinical populations commonly seen in the CR setting.

The need for physical medicine and rehabilitation as an integral component in the medical education curriculum in India

Enhanced quality of health care and increased life expectancy come with issues about the quality of life. This challenge is especially relevant to physical medicine and rehabilitation (PM and R)—a specialty focused on enhancing the quality of life. With the increasing burden of chronic diseases and disabling conditions, requirement for PM and R specialists will increase. This narrative review discusses the changing demographics, the disability trends, and the unmet needs both at present and anticipated in future. We also discussed problems faced by the present training system in PM and R, identified the lacunae, and attempted to provide suggestions to fill those.