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Exercise Training in Patients with Heart Disease:Review of Beneficial Effects and ClinicalRecommendations

Stephan Gielena,⁎, M. Harold Laughlinb, Christopher O’Connerc, Dirk J. Dunckerd

aMartin-Luther-University Halle/Wittenberg, University Hospital, Dept. of Int. Medicine III, Halle/Saale, GermanybDalton Cardiovascular Research Center, Departments of Biomedical Sciences and Medical Pharmacology and Physiology, University ofMissouri, Columbia, MO, USAcDuke University Medical Center, Durham, NC, USAdDivision of Experimental Cardiology, Department of Cardiology, Thoraxcenter Erasmus MC University Medical Center Rotterdam, PO Box2040, 3000, Rotterdam, CA, The Netherlands

A R T I C L E I N F O

⁎ Address reprint requests to Stephan GieleDept. of Internal Medicine III (Cardiology), UHalle, Germany. Tel.: +49 345 557 2847; fax: +

E-mail address: stephan.gielen@uk-halle.

http://dx.doi.org/10.1016/j.pcad.2014.10.0010033-0620/© 2014 Elsevier Inc. All rights rese

Please cite this article as: Gielen S, et al. ExRecommendations. Prog Cardiovasc Dis (20

A B S T R A C T

Keywords:

Over the last decades exercise training has evolved into an established evidence-basedtherapeutic strategy with prognostic benefits in many cardiovascular diseases (CVDs): Instable coronary artery disease (CAD) exercise training attenuates disease progression bybeneficially influencing CVD risk factors (i.e., hyperlipidemia, hypertension) and coronaryendothelial function. In heart failure (HF) with reduced ejection fraction (HFrEF) trainingprevents the progressive loss of exercise capacity by antagonizing peripheral skeletalmuscle wasting and by promoting left ventricular reverse remodeling with reduction incardiomegaly and improvement of ejection fraction. Novel areas for exercise traininginterventions include HF with preserved ejection fraction (HFpEF), pulmonary hyperten-sion, and valvular heart disease. In HFpEF, randomized studies indicate a lusitropic effect oftraining on left ventricular diastolic function associated with symptomatic improvement ofexercise capacity. In pulmonary hypertension, reductions in pulmonary artery pressurewere observed following endurance exercise training.Recently, innovative training methods such as high-intensity interval training, resistancetraining and others have been introduced. Although their prognostic value still needs to bedetermined, these approaches may achieve superior improvements in aerobic exercisecapacity and gain in muscle mass, respectively.In this review, we give an overview of the prognostic and symptomatic benefits of exercisetraining in the most common cardiac disease entities. Additionally, key guidelinerecommendations for the initiation of training programs are summarized.

© 2014 Elsevier Inc. All rights reserved.

Exercise trainingHeart diseaseCoronary artery diseaseHeart failurePulmonary hypertensionValvular heart disease

n, MD, Professor of Medicine, Director, Cardiac Catheterization Laboratory, Deputy Director,niversity Hospital, Martin-Luther-University of Halle/Wittenberg, Ernst-Grube-Str. 40, 0612049 345 557 2072.de (S. Gielen).

rved.

ercise Training in Patients with Heart Disease: Review of Beneficial Effects and Clinical14), http://dx.doi.org/10.1016/j.pcad.2014.10.001

Abbreviations and Acronyms

CAD = coronary artery disease

CR = cardiac rehabilitation

CV = cardiovascular

CVD = cardiovascular disease

EF = ejection fraction

EDV = end diastolic volume

ESV = end systolic volume

HIIT = high intensity intervaltraining

HF = heart failure

HFpEF = heart failure—preservedejection fraction

HFrEF = heart failure—reducedejection fraction

LV = left ventricular

MI = myocardial infarction

OMT = optimal physical therapy

PA = physical activity

PCI = percutaneous coronaryintervention

PAH = pulmonary arterialhypertension

VO2 = oxygen consumption

PH = pulmonary hypertension

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Please cite this article as: Gielen S, et aRecommendations. Prog Cardiovasc Dis

“Lack of activity de-stroys the good condi-tion of every humanbeing, while move-ment and methodicalphysical exercise saveit and preserve it.”

[(Plato, Greekphilosopher)]

Theantiquewisdomon the benefits of regu-lar exercise for healthwas based on the ob-servation thatwell-trained individ-uals were less likelyto become sick. Today,large-scalepopulation-based tri-als have confirmedthat there is indeed acorrelation betweenleisure-time PA andall-cause/cardiovascular (CV)mortality: 15 min ofexercise per day con-fers a 14% mortalityreduction.1 A 4% reduc-tion can be added foreach additional 15 minof daily exercise time.1

During the last50 years the concept

that exercise reduces CV mortality was also extended topatients with manifest heart disease: 1) In coronary arterydisease (CAD) patients a consistent 18%–20% reduction inall-cause mortality was confirmed in meta-analyses.2,3 Afteran acute coronary syndrome the effects seem to be evenmorepronounced leading to a 40% decline in 6-month mortality.4;2) In heart failure (HF) with reduced ejection fraction (HFrEF), aEuropean meta-analysis of pooled patient data from random-ized studies found a significant reduction of total mortality by35% and of hospitalization by 28%.5 This was, however, notconfirmed in a prospective large-scale multicenter study,probably as a result of lower-than-expected adherence to theprescribed training programme.6 It is clear, however, thattraining programs result in a 15%–25% increase in exercisecapacity, a concomitant improvement of New York HeartAssociation (NYHA) functional class, and a reversal of leftventricular remodeling with reduction of cardiomegaly; 3)Recently, the beneficial training effects on symptoms, exercisecapacity and left ventricular diastolic function were alsoconfirmed in HF with preserved ejection fraction (HFpEF) inthe ExDHF study7; And 4) Training as a therapeutic conceptis also being extended to patient groups which wereformerly advised not to engage in recreational PA orstructured exercise programs (e.g., patients with pulmonary

l. Exercise Training in Patien(2014), http://dx.doi.org/10.

hypertension,8 valvular and congenital heart disease). Clinicalresearch in these areas is just beginning and although firstproof-of-concept studies confirmed safety and efficacy it is tooearly to extrapolate the findings to prognostic improvements.

Exercise training has multiple physiologic effects on the CVsystem, most notably a reduction of resting heart rate as aresult of increasedparasympathetic tone, an improved vascularendothelial function with augmented flow-mediated vasodila-tion during exercise, an increased vasculogenesis throughendothelial progenitor cells, and multiple metabolic changesin the myocardium resulting in improved tolerance for ische-mia and reperfusion injury.9,10,11

Beneficial clinical and prognostic effects of exercisetraining in heart disease

Contrary to former textbook recommendations, there are infact only a few cardiac pathologies in which patients do notderive a symptomatic or prognostic benefit from regulartraining programs. The list of clear contraindications includesunstable angina, and recent myocardial infarction, uncon-trolled cardiac arrhythmia, symptomatic severe aortic steno-sis or other valvular disease, decompensated symptomaticHF, and acute myocarditis or pericarditis.

Relative contraindications usually lead to temporarysuspension of training programs and should be correctedbefore the exercise training is reinitiated. Most relevant areuncontrolled tachy- and bradyarrhythmias, severe arterialhypertension (systolic blood pressure >200 mm Hg, diastolicblood pressure >110 mm Hg), electrolyte disorders or uncor-rected severe anemia.

In this review, only key indications for exercise-basedcardiac rehabilitation (CR) can be briefly discussed. We willtherefore focus on (1) stable CAD, (2) post-infarction rehabil-itation, and (3) HF (both HFrEF and HFpEF). As novel andupcoming indications for exercise training, we assess trainingin valvular heart disease, congenital heart disease, andpulmonary hypertension.

Stable coronary artery disease

The oldest account that physical exercise can improve thesymptoms of ischemic heart disease comes from thephysician, who first described the clinical syndrome ofangina pectoris, William Heberden. He reported that apatient with angina pectoris was nearly cured of hissymptoms after sawing wood every day for half a year. Asthis observation would at best qualify for a class C recom-mendation in modern guidelines we need to look intoprospective clinical studies.

Prognostic benefits of exercise training in coronary artery diseaseIn a large, high-quality meta-analysis, Taylor and colleaguescollected clinical follow-up data in 8940 patients with CADincluded in 48 prospective randomized clinical exercisetraining studies.2 Exercise-based CR, was associated with asignificant decrease in all-cause mortality by 20% (odds ratio0.80; 95% confidence interval 0.68 to 0.93) and in cardiac

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mortality by 26% (odds ratio 0.74; 95% confidence interval 0.61to 0.96).2 These figures were recently confirmed in the 2011Cochrane database systematic meta-analysis, which included47 studies randomizing 10,794 patients.3 In medium to longerterm (i.e., 12 or more months of follow-up), exercise-based CRsignificantly reduced overall and CVmortality [RR 0.87 (95% CI0.75, 0.99) and 0.74 (95% CI 0.63, 0.87), respectively], andhospital admissions [RR 0.69 (95% CI 0.51, 0.93)].3 Recently,combined resistance–endurance training has been shown tobe more effective than aerobic endurance training in improv-ing body composition, strength, and some indicators of CVfitness.12 Interval training leads to equal if not greaterincreases in exercise capacity compared to aerobic endurancetraining without higher adverse event rates, however, prog-nostic data are still lacking.13

Apart from the profound beneficial effects of exercisetraining in patients with manifest CAD, regular physicalactivity (PA) has been shown to reduce CV and all-causemortality in a primary prevention setting. In large-scaleprospective cohort studies examining the relation betweenleisure time PA and mortality, participants with the highestproportion of leisure PA had the lowest all-cause and CVmortality.14–16 Likewise, higher physical fitness was predic-tive of reduced CV and all-cause mortality.17,18 According tothe meta-analysis of Kodama and colleagues, each 1 meta-bolic equivalent (MET) increase in aerobic capacity wasassociated with a 13% risk reduction of all-cause mortalityand a 15% reduction in CAD events.19

Role of regular exercise and optimal medical therapy in stablecoronary artery diseaseProspective randomized studies have documented that inpatients with small ischemic areas (<10% of the myocardium), atreatment strategy with optimal medical therapy (OMT) plusexercise is not inferior to an interventional strategy.20,21 In asmall pilot study, 101 patients with significant coronary arterystenosis and exercise-induced myocardial ischemia were ran-domized, with the training arm including 12 months of ergom-eter training 20 min per day. The training group had improvedevent-free survival and symptom-free exercise capacity ascompared to those randomized to interventional therapy.22

Endurance exercise training also attenuates the progression ofcoronary atherosclerosis23–26 and improves endothelialfunction.27 Niebauer et al. showed that 5–6 h/week of moderateintensity exercise training (>2200 kcal/week leisure-time physi-cal activity per week) can induce regression of coronaryplaques.28 However, since the changes in angiographic luminaldiameter are minute most of the clinical effect of training oncoronary perfusion seems to be mediated by enhancedendothelium-derived vasodilation.11 Taken together, exercisetraining is not just a means to improve the patients exercisecapacity and symptoms but bears the potential to modify theprogressive course of the underlying disease — coronaryatherosclerosis.

Post myocardial infarction

Long before the prognostic benefits of endurance exercise onthe progression of CAD were appreciated, exercise-based CR

Please cite this article as: Gielen S, et al. Exercise Training in PatienRecommendations. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.

programs were developed for patients after acute myocardialinfarction (MI) to help them regain their previous exercisecapacity and facilitate reintegration into working life. Inpatients with uncomplicated course post MI PA such aswalking may resume as soon as the patient has left thecoronary care unit (usually after 48 h of ECG monitoring). Inmore complicated cases with large myocardial damage, CRshould start after clinical stabilization and PA can be increasedslowly according to symptoms.

Meta-analyses and reviews have primarily addressed twoimportant aspects of exercise-based CR post MI: 1) The effectson mortality and cardiac event rate (i.e., non-fatal myocardialinfarctions); and 2) the effects on cardiac remodeling and leftventricular function.

Specific Cochrane Library analyses for exercise-based CRpost myocardial infarction are lacking. Although there isgeneral consensus that exercise-based rehabilitation reducesall-cause and CR mortality, the meta-analyses on which thisconsensus is based date back to the late 1980s29,30 — prior toprimary percutaneous coronary intervention (PCI), modernantiplatelet therapy, and widespread statin use. It is there-fore likely that the reported 24% reduction of all-causemortality and 25% reduction of CV mortality following CRcould be lower today.29 Home-based and center-based CRyield comparable beneficial results after MI.31 The keymessage, however, was that only a minority of patients postMI – in the UK for example less than 40% – actually benefitfrom any form of exercise-based CR. The real challenge istherefore universal access to CR for all post-MI patients.32

In regard to the beneficial effects of training on left ventricular(LV) remodeling, Haykowski et al. analyzed trials which reportedejection fraction (EF) (12 trials, n =647), end systolic volume (ESV)(9 trials, n =475) and end diastolic volume (EDV) (10 trials, n =512).33 He was able to confirm that improvements in LVEFdecreased as the time between the MI and initiation of theexercise program increased. The increase in LVEF was greaterwith longer duration of the training program. Greater reductionsin ESV and EDV were observed with earlier initiation of exercisetrainingandwith longer trainingdurations. Eachweekof traininginitiation delay required one additional month of training toachieve the same level of benefit on LV remodeling.33

In heart failure

It was not before the early 1990s that exercise training wasintroduced as a therapeutic concept in heart failure patients byCoats and colleagues.34 For decades the opposite concept –reducing PA to reduce exercise-induced symptoms in HF andavoid hemodynamic overload for the diseased ventricle – haddominated the textbooks. Coatswas able to show that there is nocorrelation between LVEF and exercise capacity in HFpatients but a clear relation between skeletal muscle massand exercise capacity.34 Thus, peripheral factors potentiallyamenable to exercise therapy became therapeutic targets fortraining interventions; peripheral hypoperfusion resultingfrom impaired endothelium-dependent vasodilation, re-duced strength of respiratory muscles, and profound mor-phologic, metabolic, and functional alterations in theskeletal muscles.34–39

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0

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CAD - all causemortality

CAD -cardiovascular

mortality

HF - all causemortality - 1 y

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HF - all causemortality - >1 y

FU

HF - HF-specifichospitalisation

Fig 1 – Effects of exercise-based rehabilitation in coronaryartery disease (CAD) and heart failure (HF) patients. Thefigure shows the point estimates and upper and lowerconfidence intervals. Point estimates marked with “*” aresignificant. The odds ratios are based on Cochrane Libraryintervention reviews.3,46,47 For other indications (i.e.post-myocardial infarction, pulmonary hypertension,valvular heart disease) no Cochrane Library reviews arecurrently available.

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From multiple prospective randomized exercise trainingstudies in patients with HFrEF, we know that aerobic endurancetraining interventions are both safe and effective.5,40–42 Endur-ance training induces reverse cardiac remodeling with reducedEDV, and improved systolic and diastolic function in HFrEFpatients.42–44 Meta-analyses confirmed significant improve-ments of clinically relevant outcomeparameters such as exercisecapacity,43,45 quality of life, and HF related hospitalization.46

However, it is still a matter of continuing debate as towhether endurance training effects also reduces all-cause andCVmortality: In the EXTRA-MATCHmeta-analysis data basedon 9 mostly European prospective randomized single-centerstudies including a total of 801 HFrEF patients,5 a significant35% reduction of all-cause mortality and a 28% reduction forthe combined end-point of death or hospital admission werereported.5 In the United States, the HF-ACTION study wastherefore initiated as a large multi-center prospective out-come trial for endurance training in HF.6 Surprisingly, nosignificant reduction of all-cause mortality or hospitalizationwas observed in the protocol-specified analysis. After adjust-ment for highly prognostic predictors of the primary endpoint, exercise training was, however, associated withmodestsignificant reductions for both all-cause mortality or hospi-talization and CVmortality or HF hospitalization.6 However, itwas argued that the lack of significant mortality reductionsresulted from the low rates of compliance with the prescribedtraining protocol (≈60%) Due to the large number of partici-pants (2331 patients), this study was also carried over into the2010 Cochrane systematic meta-analysis, which described nosignificant training effect on all-cause mortality and all-causehospitalizations.46 To reconcile the question of prognostictraining effects, a sub-analysis confirmed a dose–responserelationship between training intensity (asmeasured by MET-hper week) and outcome improvement, indicating significantreductions in adjusted hazard ratios for all cause/cardiacmortality or all-cause/cardiac hospitalization for those exercis-ing between 3 and 7 MET-h per week (Fig 1).48 Taken together,available data are consistent with a dose-related improvementof clinical outcomes that reaches significant levels above 3MET-h per week of aerobic continuous exercise training.

Among new training methods introduced in HFrEF patientsare high intensity interval training (HIIT) and strength training.High intensity interval training achieves greater improvementsin exercise capacity and quality of life with no apparentdeleterious effects to LV remodeling.49,50 Combined strength–endurance training seems to induce more pronounced in-creases in muscle strength and muscle mass as compared tosteady-state endurance training.12,51,52 Recently, training as atherapeutic intervention also proved to be effective in HFpEFwith improved exercise capacity and diastolic function afteraerobic training.7 Outcome studies are ongoing.

In other disease entities

Based on the positive clinical effects in CAD, after MI, and inHF, training interventions are being tested in a number ofother CVDs, in which pharmacologic options are limited andimpairment of exercise capacity is pronounced. Among thesedisease entities are: 1) Pulmonary arterial hypertension (PAH)/

Please cite this article as: Gielen S, et al. Exercise Training in Patients with Heart Disease: Review of Beneficial Effects and ClinicalRecommendations. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.10.001

Pulmonary Hypertension (PH); 2) Valvular heart disease; and3) Congenital heart disease. In all these disease conditionsthere are a few clinical studies – mostly small scale withfunctional end-points – which indicate safety and efficacy.However, the evidence-base is too narrow to make anyguideline-based recommendations for clinical application atthis time.

Pulmonary arterial hypertension (PAH)/pulmonaryhypertension (PH)In the first prospective randomized study on aerobic exercisetraining in patients with PH Mereles et al. found an improved6-min walking distance (+111 m versus control, P < 0.001) aswell as improved quality of life, functional class, and peakoxygen consumption (VO2).8 However, systolic pulmonaryartery pressure values at rest did not change significantlyafter 15 weeks in the training group.8 After this firstproof-of-concept trial other studies confirmed the safety andefficacy of training to improve exercise capacity. Weinstein etal. reported a significantly improved fatigue severity scale andhuman activity profile scores in response to 10 weeks ofaerobic exercise training plus education in comparison toeducation alone.53 Training improves exercise capacity notonly through cardiopulmonary effects but also throughincreased quadriceps muscle strength and endurance.54 In asmall pilot study, respiratory muscle training in combinationwith aerobic exercise training significantly increased twitchmouth pressure during nonvolitional supramaximal magneticphrenic nerve stimulation and 6 min walking distance over the15 week study period.55

The following positive results were reported in other PAHcohorts: 1) In PAH associated with congenital heart disease,

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Becker-Grünig and colleagues described improved quality oflife-score and peak VO2 after 15 weeks of exercise training inan observational intervention study.56; 2) Thirty-five patientswith invasively confirmed inoperable or residual chronicthromboembolic pulmonary hypertension received exercise train-ing in-hospital for 3 weeks and continued at home for15 weeks. In this observational study, significant improve-ments of peak VO2 and NT-proBNP were noted, associatedwith a better-than-expected three year survival rate of 86%.57;and 3) In 21 patients with connective tissue disease-associatedpulmonary arterial hypertension heart rate at rest, peak VO2,oxygen saturation and maximal workload improved signifi-cantly after in-hospital exercise training for 3 weeks followedby home-based training for 15 weeks.58 Despite these trialswe still lack outcome studies which address the prognosticbenefit of training in an adequately powered multicenterstudy model.

Valvular heart disease

Exercise training after surgical correction. Traditionally, ex-ercise training in valvular heart disease was recommendedonly after surgical correction of the dysfunctional valve. Eventhis recommendation, however, is based on a surprisinglysmall number of randomized59 and non-randomizedstudies.60–62 Timing of exercise training seems to be criticalsince patients post aortic/mitral valve replacement startinglate into exercise-based rehabilitation (i.e., 9 weeks postsurgery) did not show greater improvements in maximalexercise capacity versus a non-randomized control group.61

In a large French registry involving 251 patients after mitralvalve repair, exercise training significantly improved peakVO2 by +22%.63 Isolated cases of patients engaging instrenuous PA after aortic valve surgery indicate thathigh-intensity exercise training is safe and can improveLV-function.64 Taken together, patients with valvular heartdisease post surgical correction seem to respond in the samemanner as other established cohorts (i.e., post-AMI,post-CABG, etc.) following participation in CR.65

Exercise training in native valvular heart disease. Few studieshave specifically evaluated training interventions in pa-tients with valvular heart disease. Therefore, recommenda-tions are necessarily less reliable and are based onpathophysiological considerations rather than on hardclinical evidence. In patients with stable asymptomaticmoderate degree valvular heart disease (up to grade II),moderate-intensity exercise is possible. There is, however,no evidence suggesting that regular exercise interventionsinfluence the progression of established valvular heartdisease. For example, once aortic valve sclerosis hasdeveloped, exercise training does not change the course ofthe valvular heart disease in mice.66 However, rat studies inaortic regurgitation document a reduction of cardiomegalyand a better myocardial performance index in trained versussedentary animals.67 Clear contraindications to exercisetraining include critical and highly symptomatic valvularlesions on the edge to cardiac decompensation, stable aorticstenosis with a valvular orifice area <0.75 cm2 and a peak

Please cite this article as: Gielen S, et al. Exercise Training in PatienRecommendations. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.

pressure gradient >50 mm Hg. In general, patients withvalvular heart disease and a clear (class I and IIa) indicationfor cardiac surgery should abstain from exercise traininguntil after valve surgery.

Specific risks for special valvular lesions:

Mitral valve prolapse: Although considered a benign abnor-mality occurring in up to 5% in the general population,sudden death has been reported as a rare complication.Exercise is considered safe in patients without significantarrhythmias at rest and during exercise, without a familyhistory of sudden cardiac death, and without any previousthromboembolic event or syncope.Mitral regurgitation: In patients with HF, relative mitralregurgitation is frequent and does not preclude theinitiation of training therapy provided the patient is instable condition (i.e., NYHA II-III).Mitral stenosis: Patients with a mitral valve orifice >1.5 cm2

may safely participate in normal exercise training ses-sions. Those with moderate to severe mitral stenosis(<1.5 cm2) are usually limited by exercise-induced dyspneaand can only tolerate low levels of physical exertion. Inthese symptomatic patients, treatment of mitral stenosisby balloon valvuloplasty or valve replacement should beperformed prior to starting a training program.Aortic regurgitation: Patients with mild to moderate aorticregurgitation may engage in training without problems.However, LV diameters need to be reassessed every 3–6months to watch for worsening of the valve disease.

Congenital heart disease

In most cases adult patients with congenital heart diseaseseek medical advice regarding exercise not because theywant to enter a structured cardiac rehabilitation program,but because they want to engage in sports activities. Ashighlighted in a recent recommendations paper68 only aminority of patients with congenital heart disease receiveformal advice on physical activity. Instead they are often-times encouraged to avoid physical exertion as a result ofoverprotection and uncertainty as to which activities aresafe and can be recommended. In contrast to the abovementioned adult heart diseases no general recommenda-tions can be made. An individualized evaluation of eachpatient is recommended.

Conclusion

Exercise training has become an established part ofevidence-based clinical therapy in stable CAD, post MI, andin HFrEF. Its role is expanding in HFpEF, where it is currentlythe only intervention shown to be effective in randomizedstudies, in PAH/PH, and in stable valvular heart disease.

The greatest challenge, however, is to implement theexisting knowledge regarding training benefits in CVDs as astandard in clinical practice and to increase the participationrates of patients with a clear indication for exercise-based CRin existing programs.

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Table 1 – Recommendations for exercise training therapy in key indications. The recommendations are based on the position paper from the Cardiac RehabilitationSection of the European Association of Cardiovascular Prevention and Rehabilitation.69

Diagnosis Indication Contraindiation

Recommended TrainingProgram EACPRPosition Paper

EACPR PositionPaperRecommendationGrade

SymptomaticImpact

PrognosticImpact

StableCoronaryArteryDisease

Percutaneouscoronary intervention(PCI)

✓ Unstable angina pectoris✓ Acute endomyocarditis or other

acute infections✓ Recent pulmonary artery

embolism or phlebothrombosis✓ Hemodynamically relevant

arrhythmia✓ Critical obstructions of the left

ventricular outflow tract

✓ Medically supervised exercise trainingprograms are recommended for patientswith multiple risk factors, and withmoderate-to-high risk (i.e. recent heartfailure episode) for training initiationand motivation to long-term adherence

✓ Expanding physical activity to includeresistance trainingAlso refer to ‘Post-ACS and post primaryPCI’ issues

I (B) +++ +++IIb (C)

S/PMyocardialInfarction

✓ Acute coronarysyndrome (STEMIand NSTEMI)

✓ Post infarctionanginapectoris (dueto incomplete revascularization)

✓ Heart failure (refer torecommendations for heartfailure patients)Also refer to contraindicationslisted under stable CAD

✓ Exercise training should be recommended toall patients (supervised or monitored inmoderate to high-risk ones). The programshould include: at least 30 min, 5 days/week,aerobic exercise

✓ At 70%–85%of the peakheart rate, or at 70%–85%of the heart rate at the onset of ischemia(defined as ≥1 mmof ST depression, in case ofasymptomatic exercise-induced ischemia).Prophylactic nitroglycerine can be taken atthe start of the training session)

✓ At 50%of the peakheart rate inhigh-risk patientsbecause of left ventricular dysfunction, coro-nary disease severity, co-morbidities, ageing

✓ Resistance training

I (B) +++ +++IIb (C)

S/P CardiacSurgery

✓ S/P CABG✓ S/P Valve surgery✓ S/P Aortic surgery

✓ wound infection aftersternotomy, harvesting ofsaphenous veins and/orradial arteries

✓ Exercise training can be started early in-hospital✓ Programs should last 2–4 weeks for

in-patient or up to 12 weeks forout-patient settings

I (B) +++ + for CABG

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✓ respiratory infectione.g. secondary to sternotomyAlso refer to contraindicationslisted under stable CAD

✓ Upper-body training can begin when thesternal wound is stable

✓ Exercise training should be individuallytailored according to the clinical condition,baseline exercise capacity, ventricularfunction, and different valve surgery(after mitral valve replacement exercisetolerance is much lower than that afteraortic valve replacement, particularlyif there is residual pulmonary hypertension)Also refer to ‘Post-ACS and post primary PCI’issues (including resistance training)

ChronicHeartFailure(HFREF)

✓ Patients with stablecompensatedHFREF in NewYork HeartAssociation(NYHA) functionalclass I–III.

✓ Progressive worsening ofexercise tolerance or dyspneaat rest over previous 3–5 days

✓ Significant ischemia duringlow-intensity exercise(<2 METs, 50 W)

✓ Uncontrolled diabetes✓ Recent embolism✓ Thrombophlebitis✓ New-onset atrial fibrillation/

atrial flutter

Progression of aerobic exercise training forstable patients

✓ Initial stage (first 1–2 weeks): intensityshould be kept at a low level in patientswith NYHA functional class III (50% ofpeak VO2), increasing duration from20 to 30 min according to perceivedsymptoms and clinical status

✓ Improvement stage: a gradual increase ofintensity (60%, 70%–80% of peak VO2,if tolerated) is the primary aim. Prolongationof exercise session is a secondary goal

✓ Supervised, hospital-based (in- or out-patient)program may be recommended, especiallyinitially, to verify individual responses andtolerability, clinical stability, and promptlyidentify signs and symptoms indicating tomodify or terminate the program

✓ Resistance training

I (A) +++ +/− for allstudies + above3 MET-h perweek of aerobiccontinuousexercisetraining

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