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

The effects of exercise training on cardiovascular responses to muscle metaboreflex activation in patients after coronary artery bypass grafting

PURPOSE

To investigate cardiovascular responses to muscle metaboreflex activation in patients with coronary artery disease (CAD) after coronary artery bypass grafting (CABG) and assess the effects of exercise training on these responses.

METHODS

Cardiovascular responses of 11 post-CABG patients (60 ± 8 years) and 9 controls (CTL, 54 ± 6 years) were compared at rest, during a cold pressor test (CPT), and muscle metaboreflex activation using a post-exercise circulatory arrest (PECA) protocol. After baseline comparisons, the post-CABG group underwent 12 weeks of exercise training and was reevaluated.

RESULTS

During CPT, the post-CABG group exhibited greater increases in mean arterial pressure [MAP] (38.0 ± 9.0 vs. 18.7 ± 16.8 mmHg; P < 0.01) and systemic vascular resistance [SVR] (1053.0 ± 600.5 vs. 499.8 ± 481.0 mmHg.s/mL; P = 0.04) than CTL group. Muscle metaboreflex activation induced greater increases from rest in post-CABG than CTL for systolic blood pressure [SBP] (27.5 ± 17.3 vs. 14.2 ± 4.5 mmHg; P = 0.04), diastolic blood pressure [DBP] (10.1 ± 6.5 vs. 4.2 ± 1.8 mmHg; P = 0.02), MAP (27.5 ± 17.3 vs. 14.2 ± 4.5 mmHg; P = 0.04), SVR (149.7 ± 86.9 vs. 61.0 ± 47.4 mmHg.s/mL; P = 0.02), and blood lactate (0.48 ± 0.42 vs. - 0.18 ± 0.40 mmol/L; P < 0.01). After training, the post-CABG group reduced DBP response to CPT by 30% (P = 0.05). In addition, changes from rest induced by muscle metaboreflex in DBP, MAP, and blood lactate decreased by 28% (P = 0.05), 28% (P = 0.04), and 85% (P = 0.01), respectively.

CONCLUSION

Patients who underwent CABG exhibit exacerbated pressor responses to muscle metaboreflex activation, driven by increased SVR and blood lactate levels. This response potentially involves dysregulation in the brain stem or the efferent pathway of the muscle metaboreflex. Exercise training effectively attenuated these responses, highlighting its beneficial impact in CAD management.

TRIAL REGISTRATION

The study was registered on 01/12/2023 at EnsaiosClinicos.gov.br (RBR- 497 mxmm).

Exercise Training and Cardiac Rehabilitation in Patients After Percutaneous Coronary Intervention: Comprehensive Assessment and Prescription

Current guidelines on acute and chronic coronary syndromes recommend comprehensive and multidisciplinary exercise-based cardiac rehabilitation in Class I. Indeed, in patients after a percutaneous coronary intervention, this supervised and structured rehabilitation program improves cardiovascular risk and reduces adverse events and mortality. After an initial assessment, including a peak exercise capacity evaluation, patients follow a tailored multidisciplinary program consisting of aerobic and resistance exercise training, risk factor management, dietary counselling, physical activity counselling, weight control management, psychosocial support, and education. However, tailored management and exercise prescription require careful assessment and risk consideration of several variables such as left ventricular dysfunction, comorbidities, aging, coronary artery disease severity, physical activity capacity, and type of coronary syndrome. The functional and prognostic benefits of cardiac rehabilitation have been widely demonstrated in patients after a percutaneous coronary intervention; however, referral is still limited, although exercise should be strongly recommended to these patients in the context of cardiovascular prevention. Therefore, the aim of our article is to provide an updated, critical, and state-of-the-art review of exercise training and cardiac rehabilitation programs in patients after a percutaneous coronary intervention. Furthermore, practical approaches to the management of these patients with a multidisciplinary and personalized intervention will be provided.

Exploring the impact of exercise on women with ovarian cancer: A call for more methodologically standardized RCTs to enable a realistic systematic review

INTRODUCTION

Ovarian cancer remains a leading cause of mortality among gynecological malignancies, often diagnosed at advanced stages due to nonspecific symptoms and limited screening tools. Standard treatment, including cytoreductive surgery and chemotherapy, can cause fatigue, physical dysfunction, and psychological distress, impacting quality of life. Exercise interventions have shown potential to mitigate these effects, but inconsistent methodologies in randomized controlled trials (RCTs) limit reliable conclusions and clinical integration.

METHODS

A systematic review was conducted following PRISMA guidelines. RCTs assessing physical exercise effects on women with ovarian cancer were included, excluding pilot trials, reviews, and combined therapies. Data extraction and GRADE assessments were performed by two independent reviewers, and a narrative synthesis was conducted due to study heterogeneity.

RESULTS

Eleven RCTs were analyzed, covering aerobic, resistance, and yoga interventions. Findings indicated improvements in physical function, fatigue, and psychological outcomes, such as reduced depressive symptoms and cognitive enhancements. Patients adhering to ≥150 min of moderate-intensity exercise per week experienced the most consistent benefits. Preoperative walking expedited recovery, though significant heterogeneity in study protocols precluded meta-analysis.

DISCUSSION

Evidence supports the feasibility and benefits of exercise across ovarian cancer stages. However, inconsistency in exercise intensity, duration, and reporting hinders the development of standardized protocols. Compared to cardiological rehabilitation, ovarian cancer exercise guidelines remain underdeveloped, emphasizing the need for tailored, evidence-based interventions.

CONCLUSION

Exercise interventions can improve physical and mental health in ovarian cancer patients. Standardized RCTs are urgently needed to establish robust exercise protocols and enable clinical implementation, enhancing survivorship outcomes and quality of life.

Effect of a new resistance training method on the metaboreflex in cardiac rehabilitation patients: a randomized controlled trial

Patients with cardiac disease exhibit exaggerated sympathoexcitation, pressor, and ventilatory responses to muscle metaboreflex activation (MMA). However, the effects of cardiac rehabilitation (CR) and especially resistance training (RT) modalities on MMA are not well known. This study investigated how CR impacts MMA in such patients, specifically examining the effects of two different resistance training (RT) protocols following 12 weeks of CR. In addition to endurance exercises, 32 patients were randomized into either a 3/7 RT modality (comprising 5 sets of 3-7 repetitions) or a control (CTRL) modality (involving 3 sets of 9 repetitions), with distinct inter-set rest intervals (15 s for 3/7 and 60 s for CTRL). MMA, gauged by blood pressure (BP) and ventilatory (Ve) responses during a handgrip exercise at 40% effort and subsequent post-exercise circulatory occlusion, demonstrated CR's significant impact. Systolic BP, initially at + 28 ± 23% pre-CR, improved to + 11 ± 15% post-CR (P = .011 time effect; P = .131 group effect). Diastolic BP showed a similar trend, from + 27 ± 23% to + 13 ± 15% (P = .099 time effect; P = .087 group effect). Ve, initially at + 60 ± 39%, reduced to + 14 ± 19% post-CR (P < .001 time effect; P = .142 group effect). Critical parameters-maximal oxygen consumption, lean mass, hand grip, and quadriceps strength-exhibited parallel increases in both 3/7 and CTRL groups (P < .05 time effect; P > .3 group effect). Ultimately, CR demonstrated comparable improvements in MMA across both RT modalities, indicating its positive influence on cardiovascular responses and physical performance in individuals with cardiac conditions.

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 AND RESULTS

Cross-sectional study involving 2868 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 1893 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). 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.

The effect of cardiac rehabilitation prescription on medication complications and ET-1, WMSI in elderly patients with coronary heart disease

OBJECTIVE

To explore the effects of cardiac rehabilitation prescriptions on medication complications, Endothelin 1 (ET-1), and Wall Motion Score Index (WMSI) in elderly patients with coronary heart disease.

METHODS

98 elderly patients with coronary heart disease admitted to the Department of Cardiology of a hospital from January 2020 to June 2022 are selected. According to the red and blue ball method, 98 research subjects are divided into a control group and an observation group. The control group receives routine treatment and exercise intervention, while the observation group receives cardiac rehabilitation prescriptions. After a follow-up of 6 months, the incidence of medication complications between the two groups is compared. The changes in ET-1 and WMSI levels are compared before treatment, 1 month, 3 months, and 6 months after treatment.

RESULTS

The two groups had no significant difference in ET-1 and WMSI levels before intervention. After intervention, both groups showed significant reductions in ET-1 and WMSI compared with baseline. The ET-1 of the observation group decreased significantly faster than the control group after 1 month, 3 months, and 6 months of intervention. The WMSI decreased more significantly at 6 months. The repeated measurement variance showed that there was a significant difference in the trend of ET-1 changes between the two groups, while the difference between the WMSI groups was not significant. The incidence of medication complications in the observation group was 10.20%, significantly lower than the 26.53% in the control group.

CONCLUSION

Cardiac rehabilitation prescriptions can reduce the incidence of medication complications in elderly patients with coronary heart disease. It can reduce ET-1 levels faster, improve myocardial motor function, which has better myocardial function and medication safety than conventional treatment.

From the armchair to contemporary cardiac rehabilitation: the remarkable ongoing journey of exercise training in ischemic heart disease

Exercise is an important physiological activity with several health benefits. In the setting of ischemic heart disease (IHD), the view toward exercise has greatly evolved throughout the years, concurrently to several major advances in the management of this complex entity. Currently, exercise training has broad applications across the IHD continuum as a powerful tool in its overall management, being a core component of comprehensive cardiac rehabilitation programs. Beyond this, exercise has also been incorporated as an integral part of contemporary methodologies aiming to provide diagnostic and prognostic data, such as cardiopulmonary exercise stress testing or stress echocardiography. In this article, we provide a pragmatic overview concerning the role of exercise in IHD, with a focus on its incorporation in cardiac rehabilitation frameworks, while also discussing some of the challenges and unmet needs concerning these interventions.

Exercise intensity prescription in cardiovascular rehabilitation: bridging the gap between best evidence and clinical practice

Optimizing endurance exercise intensity prescription is crucial to maximize the clinical benefits and minimize complications for individuals at risk for or with cardiovascular disease (CVD). However, standardization remains incomplete due to variations in clinical guidelines. This review provides a practical and updated guide for health professionals on how to prescribe endurance exercise intensity for cardiovascular rehabilitation (CR) populations, addressing international guidelines, practical applicability across diverse clinical settings and resource availabilities. In the context of CR, cardiopulmonary exercise test (CPET) is considered the gold standard assessment, and prescription based on ventilatory thresholds (VTs) is the preferable methodology. In settings where this approach isn't accessible, which is frequently the case in low-resource environments, approximating VTs involves combining objective assessments-ideally, exercise tests without gas exchange analyses, but at least alternative functional tests like the 6-minute walk test-with subjective methods for adjusting prescriptions, such as Borg's ratings of perceived exertion and the Talk Test. Therefore, enhancing exercise intensity prescription and offering personalized physical activity guidance to patients at risk for or with CVD rely on aligning workouts with individual physiological changes. A tailored prescription promotes a consistent and impactful exercise routine for enhancing health outcomes, considering patient preferences and motivations. Consequently, the selection and implementation of the best possible approach should consider available resources, with an ongoing emphasis on strategies to improve the delivery quality of exercise training in the context of FITT-VP prescription model (frequency, intensity, time, type, volume, and progression).

Effects of a brief intervention based on Acceptance and Commitment Therapy versus usual care for cardiac rehabilitation patients with coronary heart disease (ACTonHEART): a randomised controlled trial

OBJECTIVES

The main objective of the study is to investigate the short-term efficacy of Acceptance and Commitment Therapy (ACT) on the simultaneous modification of biological indicators of risk and psychological well-being in patients with coronary heart disease attending cardiac rehabilitation (CR).

DESIGN

This was a two-arm randomised controlled trial comparing a brief, manualised, ACT-based intervention with usual care (UC).

SETTING

The study was conducted in an outpatient CR unit in Italy. Data collection took place from January 2016 to July 2017.

PARTICIPANTS

Ninety-two patients were enrolled and randomised, following an unbalanced randomisation ratio of 2:1 to the ACT group (n=59) and the control group (n=33). Eighty-five patients completed the ACT (n=54) and the UC (n=31) interventions and were analysed.

INTERVENTIONS

The control group received UC, a 6 weeks multidisciplinary outpatient CR programme, encompassing exercise training, educational counselling and medical examinations. The experimental group, in addition to UC, participated in the Acceptance and Commitment Therapy on HEART disease (ACTonHEART) intervention encompassing three group sessions based on ACT.

OUTCOMES

The primary outcomes were Low Density Lipoproteins (LDL)cholesterol, resting systolic blood pressure, body mass index (BMI) and psychological well-being measured by the Psychological General Well-Being Index (PGWBI). Outcome measures were assessed at baseline and at the end of CR.

RESULTS

Based on linear mixed models, no significant group × time interaction was observed for either the primary outcomes (β, 95% CI: PGWBI =-1.13, -6.40 to -4.14; LDL cholesterol =-2.13, -11.02 to -6.76; systolic blood pressure =-0.50, -10.76 to -9.76; diastolic blood pressure =-2.73, -10.12 to -4.65; BMI =-0.16, -1.83 to -1.51, all p values >0.05) or the secondary outcomes (all p values >0.05). A significant time effect was found for the PGWBI total (beta=4.72; p=0.03).

CONCLUSIONS

Although analyses revealed null findings, the results can inform the design of future ACT-based CR interventions and can help researchers to strike a balance between the idealised implementation of an ACT intervention and the structural limitations of existing CR programmes.

TRIAL REGISTRATION NUMBER

NCT01909102.

Managing chronic coronary syndrome: how do we achieve optimal patient outcomes?

INTRODUCTION

Chronic coronary syndrome (CCS) remains the leading cause of death worldwide with high admission/re-admission rates. Medical databases were searched on CCS & its management.

AREAS COVERED

This review discusses phenotypes per stress-echocardiography, noninvasive/invasive testing (coronary computed-tomography angiography-CCTA; coronary artery calcium - CAC score; echocardiography assessing wall-motion, LV function, valvular disease; biomarkers), multidisciplinary management (risk factors/anti-inflammatory/anti-ischemic/antithrombotic therapies and revascularization), newer treatments (colchicine/ivabradine/ranolazine/melatonin), cardiac rehabilitation/exercise improving physical activity and quality-of-life, use of the implantable-defibrillator, and treatment with extracorporeal shockwave-revascularization for refractory symptoms.

EXPERT OPINION

CCS is age-dependent, leading cause of death worldwide with high hospitalization rates. Stress-echocardiography defines phenotypes and guides prophylaxis and management. CAC is a surrogate for atherosclerosis burden, best for patients of intermediate/borderline risk. Higher CAC-scores indicate more severe coronary abnormalities. CCTA is preferred for noninvasive detection of CAC and atherosclerosis burden, determining stenosis' functional significance, and guiding management. Combining CAC score with CCTA improves diagnostic yield and assists prognosis. Echocardiography assesses LV wall-motion and function and valvular disease. Biomarkers guide diagnosis/prognosis. CCS management is multidisciplinary: risk-factor management, anti-inflammatory/anti-ischemic/antithrombotic therapies, and revascularization. Newer therapies comprise colchicine, ivabradine, ranolazine, melatonin, glucagon-like peptide-1-receptor antagonists. Cardiac rehabilitation/exercise improves physical activity and quality-of-life. An ICD protects from sudden death. Extracorporeal shockwave-revascularization treats refractory symptoms.

The Attitudes of Patients with Cardiovascular Diseases towards Online Exercise with the Mobile Monitoring of Their Health-Related Vital Signs

The health care cost of cardiovascular diseases (CVD) in the EU is estimated to be today over 282 billion euros. It is well documented today that exercise training is one of the main strategies for secondary disease prevention and the follow-up integration of these patients. This study aimed to examine patients' attitudes towards online exercise with mobile monitoring of their vital signs. More specifically, the research objectives were as follows: (a) to examine patients' attitudes and expectations of online exercise, (b) cluster patients in high- and low-attitude groups and examine their intention to participate in online exercise, and (c) to examine age and gender differences in terms of their intention to exercise online. The final goal of this project was to develop a real application that could be of use to patients and professionals. Data were collected from fifty patients in the city of Thessaloniki, Greece. The results revealed that most patients were positive about exercising online if the programs were perceived as fun and, especially, safe. The use of an online monitoring application with the distant supervision of health professionals could both motivate them and strengthen their feeling of safety.

Quo vadis cardiac rehabilitation; the role of comprehensive cardiac rehabilitation in modern cardiology

In accordance with the guidelines established by prominent European and global cardiology associations, comprehensive cardiac rehabilitation (CR) stands as an officially endorsed and highly recommended therapeutic approach (class I recommendations; level of evidence A) for a diverse spectrum of cardiac patients. Nevertheless, it is a cause for concern to observe that fewer than 50% of eligible patients are being effectively referred for CR, whether in an outpatient or inpatient setting. Concurrently, studies reveal that a substantial proportion of individuals with atherosclerotic cardiovascular disease maintain unhealthy lifestyles and exhibit suboptimal management of modifiable cardiovascular risk factors, including hypertension, lipid levels, and diabetes. Beyond the conventional patient profile encompassing those recovering from acute coronary syndrome with or without percutaneous coronary intervention, as well as patients who have undergone coronary or valvular surgery, contemporary CR now emphasizes specialized subgroups of patients. These include frail elderly patients, the female population with its unique considerations, individuals burdened by multiple cardiovascular comorbidities, those who have developed psychological consequences due to a cardiac illness and particularly those grappling with chronic heart failure. This editorial seeks to offer a state-of-the-art assessment of the significance and role of comprehensive CR within modern cardiology.

Effects of High-Intensity Interval Training Using the 3/7 Resistance Training Method on Metabolic Stress in People with Heart Failure and Coronary Artery Disease: A Randomized Cross-Over Study

The 3/7 resistance training (RT) method involves performing sets with increasing numbers of repetitions, and shorter rest periods than the 3x9 method. Therefore, it could induce more metabolic stress in people with heart failure with reduced ejection fraction (HFrEF) or coronary artery disease (CAD). This randomized cross-over study tested this hypothesis. Eleven individuals with HFrEF and thirteen with CAD performed high-intensity interval training (HIIT) for 30 min, followed by 3x9 or 3/7 RT according to group allocation. pH, HCO3-, lactate, and growth hormone were measured at baseline, after HIIT, and after RT. pH and HCO3- decreased, and lactate increased after both RT methods. In the CAD group, lactate increased more (6.99 ± 2.37 vs. 9.20 ± 3.57 mmol/L, p = 0.025), pH tended to decrease more (7.29 ± 0.06 vs. 7.33 ± 0.04, p = 0.060), and HCO3- decreased more (18.6 ± 3.1 vs. 21.1 ± 2.5 mmol/L, p = 0.004) after 3/7 than 3x9 RT. In the HFrEF group, lactate, pH, and HCO3- concentrations did not differ between RT methods (all p > 0.248). RT did not increase growth hormone in either patient group. In conclusion, the 3/7 RT method induced more metabolic stress than the 3x9 method in people with CAD but not HFrEF.