Eur J Appl Physiol (2000) 83: 457±462
Ó Springer-Verlag 2000
ORIGINAL ARTICLE
J. Perk á G. Veress
Cardiac rehabilitation: applying exercise physiology in clinical practice
Accepted: 12 June 2000
Abstract In this paper new insights into the bene®cial
e€ects of physical training for patients with coronary
artery disease are reviewed. Endurance training as part
of a comprehensive cardiac rehabilitation programme in
combination with strength training, smoking cessation
and lipid management may slow down and in some cases
reverse the progress of coronary atherosclerosis. Thus,
exercise training remains an invaluable tool in the hands
of the clinical cardiologist dealing with chronic coronary
care.
Key words Cardiac rehabilitation á Exercise
physiology á Ischaemic heart disease á Physical training
Introduction
Cardiac rehabilitation has been de®ned as, ``The sum of
interventions required to ensure the best possible physical, psychological and social conditions so that patients
with chronic or post-acute cardiac disease may, by their
own e€orts, preserve or resume their proper place in
society.''(Tavazzi et al. 1992). There are several detailed
guidelines on the provision of comprehensive cardiac
rehabilitation (Tavazzi et al. 1992; Wenger et al. 1999).
Exercise training remains the cornerstone of these programmes, in which physical training, smoking cessation,
dietary intervention, psychosocial support and stress
management are combined, aiming at a lasting cardioPresented at the Annual Spring Meeting of the Working Group on
Cardiac Rehabilitation and Exercise Physiology of the European
Society of Cardiology, BalatonfuÈred, May 1999
J. Perk (&)
Department of Internal Medicine and Rehabilitation,
Oskarshamn Hospital, 572 28 Oskarshamn, Sweden
e-mail: joep@ltkalmar.se
Tel.: +46-491-782000; Fax: +46-491-782643
G. Veress
State Hospital for Cardiology,
BalatonfuÈred, Hungary
protective change in lifestyle as stated in a recent review
(Gohlke and Gohlke-BaÈrwolf 1998).
Meta-analysis has shown that cardiac rehabilitation
reduces cardiac mortality by up to 25% (O'Connor et al.
1989; Oldridge et al. 1988) and long-term follow-up has
con®rmed the protective e€ect of the comprehensive
care against recurrent cardiac events (HedbaÈck et al.
1993; HaÈmaÈlainen et al. 1989). Yet, the access to cardiac
rehabilitation varies widely; in several countries only a
minority of the population in need of this service is enrolled in multidimensional programmes. Women, elderly
and socially deprived patients are often excluded
(Evenson et al. 1998; Melville et al. 1999). Even the organization of programmes shows wide variations, indicating a demand for a clearer logistic direction including
a consensus on quality assurance (Thompson et al.
1997).
Over the past decade early intervention with
thrombolysis and dilatation techniques in patients with
acute coronary syndromes has attracted much attention,
whereas secondary prevention against coronary artery
disease (CAD) and behavioural changes have not always
been a priority for the clinical cardiologist. Recently the
guidelines of the Second Joint Task Force of European
and other Societies on Coronary Prevention contributed
to renewed interest in this ®eld (Second Joint Task Force
of European and other Societies on Coronary Prevention 1998). These guidelines include recommendations
for physical activity.
There are several reports in the recent literature on
the novel bene®cial e€ects of exercise training for
patients with CAD.
Therefore, the aim of this review is to highlight the role
of exercise training in comprehensive cardiac rehabilitation with the main emphasis on recent publications. This
review is restricted to exercise training, its role in comprehensive programmes and health-economic aspects.
For the remaining components of cardiac rehabilitation,
i.e. dietary counselling, smoking cessation, and other
lifestyle changes, we refer to previous reviews (Gohlke
and Gohlke-BaÈrwolf C 1998; Wenger et al. 1999).
458
Exercise training programmes
Physical training is usually practised as part of an outpatient-based multidimensional rehabilitation programme. Patients who have had myocardial infarction
(MI), coronary artery bypass grafting (CABG) and
coronary angioplasty (PTCA) start, 2±6 weeks after
discharge from hospital, endurance training sessions at a
sub maximal level. Group training is available for 45±
60 min twice/thrice weekly for three months. Patients
are encouraged to increase their leisure time physical
activity by walking, cycling, swimming, etc. In Central
and Eastern Europe a considerable proportion of the
cardiac population with cardiac disease is o€ered exercise training in specialized residential centres. After
completing the programme long-term physical training
is supported by heart-patient foundations, coronary
clubs or other voluntary organizations. Encouragement
from the cardiologist or the patient's general practitioner is helpful in maintaining a physically active lifestyle,
as regular exercise may attenuate the progress of coronary atherosclerosis; endurance exercise at the level of
more than 2000 kcal per week is needed (Hamprecht
et al. 1993; Niebauer et al. 1997; Schuler and Hamprecht 1996).
Earlier studies have shown that exercise training
contributes to an improvement in cardiorespiratory ®tness, with a lower heart rate and blood pressure at
comparable workloads. It improves peripheral adaptation, high-density and low-density lipoprotein (HDL/
LDL) cholesterol balance and a€ects the threshold for
angina. Bene®cial e€ects on ®brinolysis, carbohydrate
metabolism, blood viscosity, weight reduction and
mental health have been reported.
New insights into the effects of physical training
Exercise training a€ects the production of free radicals:
Leaf et al. (1999) compared lipid peroxidation (i.e. expired ethane, pentane and plasma malondealdehyde)
between a group of ten cardiac patients participating in
exercise training and ten non-exercising patients. Physical training increased the work capacity in the training
group without a concomitant increase of markers of
free-radical production, indicating that more intense
physical work could be performed with less oxidative
stress (Leaf et al. 1999). Deskur et al. (1998) compared
hydrogen peroxide levels during bicycle ergometry before and after a 3-week endurance training programme.
At the initial test hydrogen peroxide levels increased by
27% whereas no increase was observed at the posttraining test, indicating a bene®cial e€ect of the programme on the generation of free radicals (Deskur et al.
1998). From the same programme Dylewicz and coworkers (1999) reported a reduction of insulin resistance
in post-MI patients with hyperinsulinemia. Insulin blood
levels fell from 23.9 (4.4) lIU/ml to 15.0 (1.9) lIU/ml
after training; insulin binding increased by 26% (Dylewicz et al. 1999).
Hyperhomocystinemia is a signi®cant risk factor in
patients with normal lipid levels. Exercise training reduces homocysteine levels by 12%, which may lead to
20±30% reductions in overall CAD risk (Ali et al. 1998).
Paramo et al. (1998) studied the e€ect on ®brinolysis
of a 9-month training programme for patients after a
®rst MI. There was a marked decrease in functional
PAI-1, indicating improved ®brinolysis both at
3 months and at the end of the programme.
Nitric oxide (NO) may be a major adaptive mechanism by which chronic aerobic training a€ects the cardiovascular system. This was shown by Rodriguez-Plaza
et al. (1997), who investigated the urinary excretion of
NO metabolites in four groups: 14 highly trained marathon runners before and after a marathon race, 11 well
trained runners before and after a 15-km run, 12 sedentary individuals and 13 CAD patients before and after
a 6-km walk. The urinary excretion of NO metabolites
was 10.10 mmol/g creatinine, 5.60 mmol/g, 1.59 mmol/g
and 0.35 mmol/g in the four groups. After a 12-week
cardiac rehabilitation programme the urinary excretion
increased by 157% in the CAD group. This increase was
correlated with the increase in exercise capacity
(Rodriguez-Plaza et al. 1997).
Patients with CAD and signs of myocardial ischaemia at ergometer testing and radionuclide imaging
did not show physiological adaptations at a submaximal work level after 6 months of exercise training, in
spite of an improvement in their maximal work capacity.
The threshold for ischaemia did not increase either
(Digenio et al. 1999). However Linxue et al. (1999) reported that myocardial perfusion increased signi®cantly
after a long-term (>1 year) training programme. In 20
of the 35 training patients showed improvement in perfusion during stress 201 TI scintigraphy as compared to
3 of the 23 patients in the control group (Linxue et al.
1999).
Severe coronary disease seems to limit improvement,
as shown by Klainman et al. (1997). After a programme
lasting 6±9 months, CAD patients with one- or twovessel disease and patients with impaired left ventricular
function had a signi®cantly increased ventilatory
anaerobic threshold, whereas patients with three-vessel
disease did not.
The mode of physical training does play a role in the
outcome assessment of the programme: when comparing
a 6-week programme dominated by cycling with a programme containing both cycling and walking/jogging,
Nieuwland et al. (1998) reported signi®cant di€erences
in the increase of peak oxygen consumption (V_ O2 ) at
cycle ergometer and treadmill testing (Nieuwland et al.
1998).
Comprehensive cardiac rehabilitation may protect
against sudden death (Beniamini et al. 1997) possibly
through the bene®cial e€ect of physical training (Hull
et al. 1995). The mechanism for this protective e€ect
remains uncertain, but changes in sympathetic balance
459
may o€er an explanation. Malfatto et al. (1998) divided
53 patients after acute MI in three groups: group 1
participated in physical training without concomitant
use of beta blockers, group 2 combined physical training
and beta blocker therapy whereas group 3 used a beta
blocker but did not participate in the training programme. The indices of heart rate variability (HRV)
showed no change in group 3 over time, but groups 1
and 2 had comparable and signi®cant increased parasympathetic tone. The authors concluded that the e€ects
of training and beta blocker therapy are not redundant;
their combination accelerates the recovery of a normal
autonomic pro®le after MI. Identical results relating to
HRV, independent of the presence of systemic hypertension, were reported by Bryniarski et al. (1997): all
HRV parameters improved after 4 weeks of early postdischarge exercise training. Hypertensive and normotensive MI patients showed similar results. Among
patients with chronic heart failure, a comparable outcome of physical training was demonstrated as physical
training a€ected the circadian pattern of HRV (Adamopoulos et al. 1995). The e€ect of training on the longterm prognosis of patients with congestive heart failure
remains unclear, in spite of the well documented bene®cial e€ects on exercise tolerance, anaerobic threshold,
oxidative capacity, autonomic balance and on changes
in skeletal muscle ultrastructure.
The role of resistance training
In cardiac rehabilitation programmes, physical training
has been undertaken as aerobic endurance exercise,
mainly cycling, walking, running and swimming. Many
patients will have to return to a work environment
where static labour is required. Therefore, strength
training is being included in an increasing number of
programmes as an addition to endurance training.
The major aim is to increase dynamic muscle
strength, which may lead to an improvement in peak
exercise performance, submaximal endurance and to
reduced ratings of perceived leg e€ort (McCartney
1998). This is highly relevant for patients returning to
physically demanding labour, but also for elderly patients and patients with congestive heart failure or after
transplantation, whose activities of daily living must be
enhanced.
Stewart et al. (1998) showed that weight training can
be started safely 4 weeks after MI provided the patients
are free from coronary ischaemia, complex arrhythmia
or major anterior Q-wave MI. The combination of
weight and cycle training results in greater arm and leg
strength, and also an increase in V_ O2max and cycle time.
There is no consensus on the optimal workload for
circuit weight training: protocols of varied intensity [40±
60% of one-repetition maximum load (1-RM)] are safe
for cardiac patients (DeGroot et al. 1998).
Adams et al. (1999) o€ered 8 weeks of weight training twice weekly to patients with three di€erent levels of
ejection fraction [23.6 (7.8), 40 (4.6), 58 (7.7)%], starting
at 60% of 1-RM and progressing to 80% of 1-RM. All
patients made signi®cant gains in muscular strength and
no adverse events were observed (Adams et al. 1999).
Beniamini et al. (1998) compared adding strength
training to conventional cardiac rehabilitation with the
addition of ¯exibility training. Strength training resulted
in an increase in muscular strength, local muscle endurance and in treadmill time, as well as a loss of body
fat when compared to ¯exibility training (Beniamini
et al. 1998). Increases in strength correlate with improvements in quality-of-life parameters, i.e. self-ecacy, mood and well-being scores (Beniamini et al. 1997).
Thus, there is strong support in the literature for the
value of adding high-intensity strength training to the
exercise training protocols of cardiac rehabilitation.
Effect on dyslipidaemia and being overweight
The anorectic e€ect of physical training and increased
caloric expenditure may reduce excessive body mass. Is
physical training without dietary restriction sucient to
reduce excess body mass? Mertens et al. (1998) studied
this question in moderately overweight patients. A 12month programme of daily walking for 40 min resulted
in an average weight loss of 4.5 kg and a 7% decrease of
body fat content. Cardioprotective changes in the lipid
pro®le were observed. The combination of a low-fat diet
and physical training is commonly used in comprehensive programmes. This combination may attenuate the
course of coronary atherosclerosis, as recently shown by
Niebauer et al. (1997).
Combined programmes are more e€ective in the
management of hyperlipidemia than standard lipid
counselling. Verges et al. (1998) compared the outcome
of hypolipidemic treatment (referral to a dietician and
a lipidologist) as part of cardiac rehabilitation with a
control group of patients only seen by a dietician and a
lipidologist. In the study group a signi®cantly greater
reduction of total cholesterol (23 versus 13%), LDL
cholesterol (28 versus 12%), the LDL/HDL ratio (34
versus 13%) and triglycerides (33 versus 21%) was seen,
whereas there was no di€erence in the use of hypolipidemic treatment (Verges et al. 1998). Similar ®ndings
were reported by Ades et al. (1999), who showed that
the systematic lipid review and physical training in a
comprehensive rehabilitation programme resulted in a
threefold increase of pharmacological modi®cations and
lower LDL cholesterol values among the participants
compared to patients receiving standard care.
Exercise training and female and elderly CAD patients
There is convincing scienti®c evidence of the bene®cial
e€ect of physical training for women, i.e. improvement
of risk factors and functional capacity (Limacher 1999).
However, women tend to be enrolled in rehabilitation
460
programmes less often. Psychosocial variables play important but di€erent roles in the reconvalescence of
women and men. Thus, gender-speci®c tailoring of cardiac rehabilitation may render them more amenable to
female CAD patients (Con et al. 1998).
Moore et al. (1998) studied exercise patterns in a
group of 40 post-MI or post-CABG women for
3 months after completion of a phase II exercise programme. Although 83% had started exercising almost
one-third had stopped within a month and at the end of
the study only half of the women were still as physically
active as recommended. The authors assume that, after
acute cardiac events, women are exercising well below
the recommended guidelines.
Yet the physiological bene®ts of a 12-month exercise
programme are evident among female cardiac patients
and do not di€er between the fourth, ®fth and sixth
decades of life. In all three decades lower resting heart
rates and higher peak V_ O2 could be demonstrated in a
population of 330 women (Hamm et al. 1999).
The majority of CAD patients are senior citizens;
several surveys have shown that the elderly often are
excluded from exercise training in spite of the potential
value of reconditioning. StaÊhle et al. (1999) reported the
outcome of a 1-year controlled follow-up of elderly
patients participating in a 3-month group training programme. Signi®cant e€ects on physical ®tness and selfreported health-related quality of life were found at
3 months but there was a tendency to lose part of the
initial results at the 1-year follow-up.
The maintenance of the ability to perform activities
of daily life should be an important goal of exercise
training. A combination of resistive and aerobic training
may be a relevant modality: Fragnoli-Munn et al. (1998)
o€ered 12 weeks of combined training to a group of 45
patients shortly after MI. Nineteen patients were elderly.
The strength of both the younger and the older population improved similarly. Within the older patient
group men were signi®cantly stronger at baseline, but
elderly women tended to improve their strength to a
greater degree (leg strength 66 versus 29%, bench press
29 versus 10%).
New types of physical training are gaining popularity
among the elderly. Among these methods, Tai Chi has
reached large groups even outside the Chinese sphere.
Lan et al. (1999) included 20 post-CABG men after
phase-II rehabilitation in a 1-year Tai Chi programme,
during which the patients exercised at 48±57% of their
maximum heart rate. The control group was recommended to continue home-based exercise with similar
intensity as in phase-II rehabilitation. The Tai Chi group
showed higher peak V_ O2 and peak workload after
1 year, whereas the control group showed a slight
decrease (Lan et al. 1999). This type of group training
with little risk of orthopedic injuries could be an
attractive option for elderly.
Recently the role of physical exercise for cardiac
transplant patients was investigated in a group of 27
patients. After a 6-month cardiac rehabilitation pro-
gramme the training group had increased their workload
(49 versus 18%) and peak V_ O2 (59 versus 18%) to a
signi®cantly greater extent than the control group
(Kobashigawa et al. 1999).
Cost-effectiveness
The cost-e€ectiveness of comprehensive cardiac rehabilitation has been convincingly demonstrated in
several studies (Ades et al. 1997; Levin et al. 1991;
Oldridge 1998; Oldridge et al. 1993). Fewer cardiac
events, fewer hospital admissions and a better rate of
return to work outweigh the cost of these programmes.
Cost-e€ectiveness can be estimated in total costs per
year of life saved (YLS). Ades et al. (1997) calculated
this cost to 4950 $/YLS at 1995 values. In comparison
with other post-MI methods of treatment, cardiac rehabilitation is considered to be more cost-e€ective than
thrombolytic therapy, CABG and cholesterol-lowering
drugs. Only smoking cessation programmes are more
cost-e€ective.
Discussion
At the hospital of Epidauros in Ancient Greece, sports
were an essential part of the medical treatment. Patients
were encouraged both to participate in physical exercise
and to enjoy watching sports games. This classical example has, in many hospitals, been reduced to access to
a television set with a sports channel in spite of the
abundant documentation of the bene®cial metabolic,
circulatory and mental e€ects of physical training. Few
modern cardiologists have included exercise programmes in their arsenal of coronary intervention programmes and drug treatment. There may be di€erent
explanations for this lack of interest. During medical
university studies and post-graduate training, there is
little room for education in the clinical application of
exercise physiology. This lack of knowledge may contribute to the limited clinical use of physical training.
Patients are referred to physiotherapists or rehabilitation centres, but the professional communication between the clinician and the referral centre can
be improved. Family doctors have little time for the
follow-up of lifestyle changes, and the patient's physical
activity is not a high priority.
If exercise training is to be upgraded as a cornerstone
in the treatment of CAD patients, clinicians will wish to
know more about di€erent types of training, speci®c
indications, programme length and content, outcome
measurements and long-term maintenance of physical
activity. A consensus among exercise physiologists and
cardiologists is needed on the clinical application of
training programmes. Before consensus can be reached
further research is needed both in the exercise laboratory
and in the clinical setting. What is the minimal level of
physical training for cardioprotection and for regression
461
of coronary atherosclerosis? What are the e€ective interactions of the di€erent components of cardiac rehabilitation? Can patients with mild to moderate ischaemia
bene®t from training programmes or is revascularization
needed before entering the programme? What is the role
of early high-intensity training in residential specialized
centres? Is there a need for special training protocols for
female CAD patients and what is the most cost-e€ective
model for the large group of elderly patients? Is there an
optimal training model for patients with heart failure
and should patients with severe heart failure (NYHA gr.
IV) be o€ered physical training at all?
Many important questions remain to be answered in
order to clarify the role of applied exercise physiology.
Therefore, exercise physiologists and clinicians face a
rewarding challenge. In light of this, the Working Group
on Cardiac Rehabilitation and Exercise Physiology of
the European Society of Cardiology may o€er a forum
for scienti®c co-operation and lead the way to a
contemporary Epidauros.
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