aerobic exercise intensity & rx in cardiac rehab.pdf

www.jcrpjournal.com Position Statement / 327

Copyright © 2012 American Association of Cardiovascular and Pulmonary Rehabilitation and European Society of Cardiology

Alessandro Mezzani, MD,1* Larry F. Hamm, PhD,2* Andrew M. Jones, PhD,3 Patrick E. McBride, MD, MPH,4 Trine Moholdt, PhD,5 James A. Stone, MD, PhD,6 Axel Urhausen, JP, MD, MPH, PhD,7 and Mark A. Williams, PhD8

Aerobic Exercise Intensity Assessment and Prescription in Cardiac Rehabilitation

A JOINT POSITION STATEMENT OF THE EUROPEAN ASSOCIATION FOR CARDIOVASCULAR PREVENTION AND REHABILITATION, THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION, AND THE CANADIAN ASSOCIATION OF CARDIAC REHABILITATION

■ ABSTRACT: Aerobic exercise intensity prescription is a key issue in cardiac rehabilitation, being directly linked to both the amount of improvement in exercise capacity and the risk of adverse events during exercise. This joint position statement aims to provide professionals with up-to-date information regarding the identification of different exercise intensity domains, the methods of direct and indirect determination of exercise intensity for both continuous and interval aerobic training, the effects of the use of different exercise protocols on exercise intensity prescription and the indications for recommended exercise training prescription in specific cardiac patients’ groups. The importance of functional evaluation through exercise testing prior to starting an aerobic training program is strongly emphasized, and ramp incremental cardiopulmonary exercise test, when available, is proposed as the gold standard for a physiologically comprehensive exercise intensity assessment and prescription. This may allow a shift from a ‘range-based’ to a ‘threshold-based’ aerobic exercise intensity prescription, which, combined with thorough clinical evaluation and exercise-related risk assessment, could maximize the benefits obtain-able by the use of aerobic exercise training in cardiac rehabilitation.

K E Y W O R D S

Aerobic training

energy expenditure

peak VO2

ventilatory thresholds

cardiac rehabilitation

Received 14 March 2012; accepted 16 August 20121Salvatore Maugeri Foundation IRCCS, Scientific Institute of Veruno, Exercise Pathophysiology Laboratory, Cardiac Rehabilitation Division, Italy: 2George Washington University Medical Center, School of Public Health and Health Services, Department of Exercise Science, Washington, DC, USA; 3University of Exeter, School of Sport and Health Sciences, UK; 4University of Wisconsin, School of Medicine and Public Health, Department of Medicine, and Medicine and Family Medicine, USA; 5Norwegian University of Science and Technology, KG Jebsen Center of Exercise in Medicine, Department of Circulation and Medical Imaging, Trondheim, Norway; 6Cardiac Wellness Institute of Calgary, University of Calgary, Libin Cardiovascular Institute of Alberta, Canada; 7Hospital Centre of Luxembourg, Centre of Locomotor System, Sports Medicine and Prevention, CRP-Santé, Luxembourg; 8Creighton University School of Medicine, Division of Cardiology, Department of Medicine, Omaha, USA.*Co-Chair.

Conflict of interest: None declared.

Correspondence: Alessandro Mezzani, Salvatore Maugeri Foundation IRCCS, Scientific Institute of Veruno, Exercise Pathophysiology Laboratory, Cardiac Rehabilitation Division, Via per Revislate 13, 28010 Veruno (NO), Italy. Email: [email protected] article is copublished in the European Journal of Preventive Cardiology.DOI: 10.1097/HCR.0b013e3182757050

HCR200267.indd 327HCR200267.indd 327 10/28/12 1:43 PM10/28/12 1:43 PM

328 / Journal of Cardiopulmonary Rehabilitation and Prevention 2012;32:327-350 www.jcrpjournal.com


INTRODUCTION

The intensity of aerobic exercise training is a key issue in cardiac rehabilitation. Exercise intensity is directly linked to both the amount of improvement in exercise capacity and the risk of adverse events during exer-cise, and intensity ranges for aerobic training prescrip-tion are included in several guidelines and publica-tions regarding secondary prevention and cardiac rehabilitation.1–4 The purpose of this joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR), American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) and Canadian Association of Cardiac Rehabilitation (CACR) is to provide profession-als with a reappraisal of all aspects related to aerobic exercise intensity assessment and prescription, with specific reference to patients with heart disease. Key issues discussed in this statement include: 1) identifica-tion of different exercise intensity domains based on the physiological response to constant-work-rate (CWR) exercise; 2) a review of the methods of direct and indirect determination of exercise intensity for both continuous and interval aerobic training; 3) dis-cussion of the potential effects that different exercise protocols may have on exercise intensity prescription; and 4) indications for recommended exercise training prescription in specific cardiac patient groups.

Of note, in addition to intensity, two other major components of the weekly volume of aerobic training are duration and frequency of the exercise sessions.5 As indicated in Domains of exercise intensity: the appropriate basis for exercise prescription below, ses-sion duration is intuitively and causally dependent on the chosen exercise intensity, that is, the higher the exercise intensity, the shorter the exercise duration, whereas, regarding training frequency, for the pur-pose of this paper a frequency of three to four ses-sions per week will be assumed; it is acknowledged that a higher or lower frequency may require modifi-cations of the exercise intensity prescription. As far as the training modality is concerned, the term ‘continu-ous’ training used in this position statement is intended as a training modality in which an exercise session can be performed for at least 20 minutes with a mild or moderate sense of fatigue; on the other hand, the term ‘interval’ training refers to shorter exer-cise sessions that cannot be sustained longer on account of an excessive sense of fatigue. Finally, the terms ‘incremental’ and ‘graded’, as referred to for an exercise test, are used interchangeably throughout the text, and the term ‘exercise test’, whenever quoted, stands for incremental/graded exercise test, unless otherwise specified.

DIRECT EXERCISE INTENSITY ASSESSMENT: PHYSIOLOGICAL BASES

Descriptors of the O2 Transport and Utilization System ResponseAerobic exercise intensity is strictly and causally linked to energy expenditure during effort. In an oxygen-dependent biological system, the latter is mostly described by oxygen uptake (VO2) through the O2 energy equivalent, equal on average to 20 kJ or 5 kcal per litre of O2 consumed. As a consequence, peak VO2 and the first and second ventilatory thresh-olds (i.e. the physiological descriptors of the O2 trans-port and utilization system response to exercise) are the gold standard references for the evaluation of aerobic metabolism function and, consequently, for aerobic exercise intensity assessment and prescrip-tion. For the purposes of this statement, the terms ‘ventilatory’ and ‘lactate’ threshold are considered interchangeable; those interested in the relationship between blood lactate and ventilatory gases modifica-tions are referred to previously published reviews.6,7

First Ventilatory ThresholdDuring light to moderate-intensity incremental exer-cise, aerobic metabolism satisfies almost all of the body’s energy needs and blood lactate is not (or is only marginally) elevated above the resting value. However, with increasing effort intensity, a threshold is reached, termed first ventilatory threshold (1stVT), above which blood lactate and pH start to increase and decrease, respectively.6–9 To counteract the ongo-ing metabolic acidosis, intracellular bicarbonates buf-fer hydrogen ions generated by lactic acid dissociation and produce CO2 in excess of that produced by aero-bic metabolism, which makes the VCO2 versus VO2 relationship become steeper.6–9 The 1stVT can thus be determined by analysing the slope of the VCO2 versus VO2 relationship, and can be identified as the point of transition in the VCO2 versus VO2 slope from less than 1 to greater than 1 (Figure 1(a)).6–9 At the same time, the VE/VO2 ratio inverts its trend in the presence of a still decreasing or constant VE/VCO2, which makes the 1stVT also identifiable as the nadir of the VE/VO2 versus work rate (WR) relationship (Figure 1(b)).6–9 The 1stVT marks the limit between the light to moder-ate- and the moderate to high- intensity effort domains;10,11 this is reached at around 50–60% of peak VO2 or 60–70% of peak heart rate (HR).6–11

Second Ventilatory ThresholdWith increasing exercise intensity and lactic acid pro-duction above the 1stVT, a point is reached when intracellular bicarbonates are no longer able to




vary among subjects/patients, thereby making the 2ndVT identification potentially difficult. When identi-fiable, the 2ndVT is usually attained at around 70–80%peak VO2 and 80–90%peak HR reached during incremental exercise, and it has been proposed to be related to the so-called ‘critical power’ (CP),12 that is, the upper intensity limit for prolonged aerobic exer-cise13–15 (see Moderate to high-intensity exercise and High to severe-intensity exercise below). However, it is important to recognize that a mechanistic link between 2ndVT and CP has not as yet been proven.

adequately counteract exercise-induced metabolic acidosis.6–9 At this point, respiratory alkalosis develops through a VE increase in excess of VCO2, and this is termed the second ventilatory threshold (2ndVT) or respiratory compensation point’. Simultaneously, the VE/VCO2 ratio inverts its trend (increase versus initial decrease), and the 2ndVT is identifiable as the nadir of the VE/VCO2 versus WR relationship (Figure 1(b)).6–9 The possibility of identifying the 2ndVT depends to a large extent on the gain of the chemo-ceptive response to metabolic acidosis, which can

Figure 1. (a) VCO2 as a function of VO2 during ramp incremental cardiopulmonary exercise test. The point where the VCO2 versus VO2

slope increases its steepness is the first venti-latory threshold. The initial and final phases of exercise (vertical dotted rectangles) are usually excluded from the analysis due to possible hyperventilation during these periods. (b) Ventilatory equivalents for O2 and CO2 as a function of work rate during ramp incremental exercise. The nadir of VE/VO2 identifies the first ventilatory threshold, whereas the nadir of VE/VCO2 identifies the second ventilatory threshold. Open circles are blood lactate concentration. 1stVT: first ventilatory threshold; VE/VO2: ventilatory equivalent for O2; VE/VCO2: ventilatory equivalent for CO2; 2ndVT: second ventilatory threshold; WR: work rate.




Peak VO2

Peak VO2 is defined as the VO2 value, averaged over a 20- to 30-s period, achieved at presumed maximal effort during an exercise test, while performing dynamic work involving large muscle groups.8,9 Peak VO2 may or may not be equal to VO2max (intended as the ‘true’ insuperable upper limit for aerobic power), even if the available evidence suggests that these two concepts are substantially equivalent.16 Achievement of maximal or near-maximal effort (and thus of reli-able peak VO2 values) is crucial for correct aerobic training prescription,17 and is often assumed in the presence of one or more of the following criteria:18

• Failure of VO2 and/or HR to increase with further increases in WR;

• Peak respiratory exchange ratio (VCO2/VO2) �1.10;• Post-exercise blood lactate concentration

�8mmol/L;• Rating of perceived exertion (RPE) �18 in the Borg

‘Category Scale’ or �8 in the Borg ‘Category-Ratio Scale’;19

• Patient appearing exhausted.

Of these, a plateau in the VO2 versus WR relationship during incremental exercise is considered the gold standard for the determination of maximal effort, whereas the cut-offs for peak respiratory exchange ratio and post-exercise blood lactate concentration values proposed above are somewhat limited by high inter-individual variability.20

Domains of Exercise Intensity: The Appropriate Basis for Exercise PrescriptionAerobic exercise training of cardiac patients has tradi-tionally been performed using the CWR modality. In this regard, it is noteworthy that the metabolic and gas exchange responses to CWR exercise differ depending on exercise intensity. This allows for the identification of four exercise intensity domains: light to moderate, moderate to high, high to severe, and severe to extreme. The physiological characteristics of the four exercise intensity domains are summarized in Table 1.

Light to Moderate-Intensity ExerciseThe light to moderate exercise domain encompasses all WRs engendering steady-state VO2 values below that corresponding to the 1stVT.10,11 During light to moderate CWR exercise, blood acid- base status is not perturbed and blood lactate is not (or is only barely) elevated above the resting value (i.e. 1–2 mmol/L). In this domain, VO2 and ventilation steady-states are attained relatively rapidly following the onset of exer-cise. The steady-state is attained more rapidly in trained subjects and is typically delayed by aging, prolonged inactivity and chronic diseases. The attain-ment of an early physiological steady-state has the effect of limiting the contribution of non-oxidative metabolism to energy turnover and reducing the depletion (e.g. phosphocreatine, glycogen) or accu-mulation (e.g. inorganic phosphate, Hp) of fatigue-related metabolites in the working muscles.10,11 For this reason, exercise is generally well tolerated in this domain and is expected to be sustainable for a long period of time (�30–40 min) with only a modest sense of fatigue.

Moderate to High-Intensity ExerciseThis intensity domain comprises those WRs lying between the 1stVT and the CP (Figure 2). CP repre-sents the highest WR still sustainable in conditions of both VO2 and lactate steady-state12–14,21–26 and is a crucial (though seldom used) marker of the upper limit of sustainable prolonged aerobic exercise.27 The CP corresponds to around 60–70%peak WR and peak VO2 and 70–80%peak HR as assessed by incremental exercise testing, but with higher steady-state %peak VO2 and %peak HR values during CWR exercise. This is due to the appearance of a ‘slow component’ of the VO2 kinetics after approximately two to three minutes of the start of CWR exercise in this intensity domain, which is not detectable during incremental exercise.28 The VO2 slow component elevates the VO2 above the VO2 that would be expected for a given WR, resulting in a delayed attainment of the VO2 steady-state (by as much as 10–15 minutes or more). In other words, the

T a b l e 1 • Physiological Characteristics of the Different Intensity Domains for Constant-Work-Rate Exercise

VO2 Steady-state

LactateSteady-state

ExerciseDuration

VO2 vs. WR LinearRelationship

TrainingModality

Light to moderate Yes NA �30 min Yes Continuous

Moderate to high Yes Yes ~20–30 min No Continuous

High to severe No No ~3–20 min NA Interval

Severe to extreme No No �3 min NA Interval

WR: work rate; NA: not applicable.




VO2 and HR steady-state is reached at a level higher than expected according to the below-1stVT VO2 ver-sus WR relationship10,11,28 (Figures 3 and 4). The VO2

slow component represents a loss of muscle efficien-cy,29 which elevates the O2 cost of exercise and, for this reason, exercise in the moderate to high domain cannot be sustained for as long as that in the light to moderate domain. However, continuous exercise ses-sions of 30-minute duration are obtainable in the moderate to high-intensity domain even in patients with a significantly reduced exercise capacity, such as those with chronic heart failure (CHF).30

High to Severe-Intensity ExerciseThis intensity domain comprises all the WRs above CP that cause VO2 to reach its peak value with no steady-state attainment.10,11 For the very highest WRs in this intensity domain no VO2 slow component is evident and VO2 may rise with a close to mono-exponential profile that is truncated at peak VO2. Consequently, the high to severe-intensity domain presents a broad range of exercise WRs at which peak VO2 will be reached. In this domain, blood acid-base balance is severely per-turbed,25 as reflected by a continuous rise in blood lactate until the exercise is terminated. Of note, the failure to attain a physiological steady-state in the high to severe-intensity domain is also evident regarding skeletal muscle (phosphocreatine) and pH.31 The dura-tion of exercise in this domain is highly predictable21–23 (Figure 2) and is typically in the range of 3–20 min. Given both such a short exercise session duration and the impossibility of a steady-state attainment, this intensity domain can only be used for interval, rather than continuous, aerobic training prescription.

The slow component rise in VO2 during moderate to high- and high to severe-intensity CWR exercise means that VO2 changes not only as a function of WR, but also as a function of time in these domains. Consequently, irrespective of the subject’s/patient’s peak exercise capacity, without precise stipulation of the exercise conditions and timing of measurements, it is difficult to define a given intensity as a percentage of peak VO2 in these intensity domains.

Severe to Extreme-Intensity Exercise Given the finite kinetics of VO2, it is inevitable that some WRs are so high that fatigue intervenes before peak VO2 can be achieved. In this domain the tolera-ble duration of exercise is limited to less than about 3 min.32 Interestingly, due in part to the short duration of exercise before exhaustion occurs, blood lactate at the end of exercise in this domain may not reach such high values as those recorded at the end of high to severe-intensity exercise until exhaustion.

Need for Direct Evaluation of Functional Capacity: The Role of Exercise TestingThe administration of an incremental, that is, graded, exercise test to patients entering outpatient cardiac rehabilitation programs has been recommended since the 1970s.33,34 Current EACPR, AACVPR, CACR, European Society of Cardiology and American Heart Association guidelines for cardiac rehabilitation pro-grams strongly recommend exercise testing as a key component of the initial patient assessment, and address the concept of exercise testing as a tool for exercise training evaluation, risk stratification to deter-mine the required level of supervision and monitoring,

Figure 2. Time to exhaustion as a function of power in patients with chronic heart failure and in untrained normal subjects. Critical power is the power asymptote of the hyperbolic relation-ship linking time to exhaustion and power (work rate) during constant-work-rate exercise in the high to severe- and severe to extreme-intensity domains. Five constant-work-rate exercise tests at 50%, 65% and 80% of the difference between peak work rate and that corresponding to the first ventilatory threshold, and to 100% and 120% of peak work rate were used to fit the relationship. Open circles and filled squares represent patients with chronic heart failure and untrained normals, respectively. Dashed vertical lines are mean criti-cal power values for the two groups. Redrawn from Mezzani et al.30




and individualized exercise prescription.1–4,35–39 Despite these recommendations, there has been an increasing trend in both Europe and the United States for patients being referred to and entering cardiac rehabilitation without an exercise test. Reasons stated for the lack of testing include shorter hospital stays, more aggressive revascularization interventions, increased sophistica-tion of diagnostic procedures, extreme deconditioning, orthopaedic limitations, left ventricular dysfunction, knowledge of the coronary anatomy, recent and suc-cessful coronary revascularization and uncomplicated myocardial infarction.39

For cardiac rehabilitation patients for whom there are no exercise test results, it is recommended that the exercise prescription could be based on the level of exercise performed during the inpatient phase of rehabilitation and recommended home exercise activities, while monitoring for signs and symptoms of exercise incompetence. In this context, it is impor-tant to understand the difference between a diagnos-tic exercise test and one performed to assess the functional capacity for cardiac rehabilitation pur-poses. A diagnostic exercise test is often carried out in pharmacologic wash-out as one of the initial steps in determining whether signs or symptoms that are present (e.g. chest pain or dyspnoea) are cardiac in origin. At entry into cardiac rehabilitation, patients already have documented cardiac disease; thus, a test administered at this time on current therapy serves primarily as a functional evaluation to quantify exer-cise capacity, chronotropic and inotropic responses to exercise, and presence and severity of dysrhyth-mias, as well as identify signs, symptoms, or other clinical evidence of any residual myocardial isch-emia. Using an alternative standardized approach to prescribing exercise intensity (e.g. 20 bpm �resting HR) that is not based on current exercise capacity because exercise test data are not available (see Unavailability of exercise testing below), potentially minimizes the beneficial effects of exercise training and is likely to retard patient progress during cardiac

T a b l e 2 • ACSM Classification of Exercise Relative Intensity

%HRR or VO2R %peak VO2 %peak HR RPE Borg Scale

Very light �20 �25 �35 �10

Light 20–39 25–44 35–54 10–11

Moderate 40–59 45–59 55–69 12–13

Heavy 60–84 60–84 70–89 14–16

Very heavy �85 �85 �90 17–19

Maximal 100 100 100 20

Modified from Tipton et al.43; ACSM: American College of Sports Medicine; HRR: heart rate reserve; VO2R: VO2 reserve; HR: heart rate; RPE: rating of perceived exertion.

rehabilitation. Thus, it is important to administer a functional sign/symptom-limited exercise test prior to patients beginning cardiac rehabilitation. In this regard, an incremental standard exercise test or car-diopulmonary exercise test with respiratory gas analysis (CPX), which is the gold standard for a direct assessment of the exercise intensity descriptors outlined in Descriptors of the O2 transport and utili-zation system response and Domains of exercise intensity: the appropriate basis for exercise prescrip-tion above, should be used whenever possible to obtain an exercise prescription tailored on the indi-vidual patient’s functional capacity and pathophysi-ological picture.

INDIRECT EXERCISE INTENSITY ASSESSMENT

The Heart Rate Versus VO2 RelationshipHR is widely used for exercise intensity assessment and prescription on the grounds that a linear relationship between HR and both VO2 and WR increase during incremental exercise is known to exist.40,41 Thus, after having measured peak HR, the intensity of effort cho-sen as the training stimulus is indirectly determined by means of published regression equations42 or tables (Table 2)43 as the percentage of the peak HR value cor-responding to a given percentage of peak VO2. On this basis, a ‘target HR range’ is usually proposed in normal subjects ranging between 70 and 85%peak HR.44 In cardiac patients, available guidelines suggest training intensities equal to 40–80%peak VO2,

3,44,45 that is, roughly ranging from 50 to 85%peak HR (Table 2). However, it must be considered that intensity classifica-tions such as those shown in Table 2 do not reveal to which precise intensity the 1stVT and 2ndVT corre-spond in an individual patient. Indeed, %peak HR values commonly used for training prescription both in normal subjects and cardiac patients have been found




to be associated with levels of metabolic stress higher than those of both the 1stVT and 2ndVT.46–49 This seems to hold true also for subjects treated with beta-blockers50 and patients with left ventricular dysfunction both on- and off-beta-blocking therapy.51

The Heart Rate Reserve Versus VO2 Reserve RelationshipThe concept of HR reserve (HRR) and VO2 reserve (VO2R), defined as the difference between the basal and peak HR and VO2 values, respectively,52–55 are cur-rently used for training prescription purposes. A per-centage of HRR (%HRR) equal to 60% has been indi-cated to correspond to the 1stVT,52,53 and %HRR has been found to equal percentages of VO2R (%VO2R) in both normal individuals undergoing both cycle and treadmill exercise54–56 (Table 2) and in cardiac patients.57 Of note, the ‘VO2 reserve’ concept fits closely the need for a precise exercise intensity definition since it describes the true amount of energy one can utilize for maximal effort attainment, taking into account the baseline level. As a consequence, %HRR has been adopted by the American College of Sports Medicine as the gold standard for exercise intensity indirect assess-ment, and ‘training HRR ranges’ of 60–80 %HRR for persons without overt disease44 and 40–70 %HRR for cardiac patients45 have been proposed. Moreover, a recent systematic review has confirmed the validity of %HRR for both indirect assessment and prescription of aerobic training intensity.58 Of note, it has been dem-onstrated that %HRR values commonly used for train-ing prescriptions in normal subjects and cardiac patients both on- and off-beta-blockers can correspond to energy expenditures ranging from light to moderate to moderate to high.47,50,59–61 These same values hold true for patients with left ventricular dysfunction.51,62

However, a loss of linearity of both the VO2 versus WR and HR versus WR relationships as peak VO2 is approached has been described in cardiac patients63 in whom chronotropic incompetence may be present due to age-, pathology- and/or drug (beta-blockers)-related sinus node dysfunction.64,65 On this basis, a very high uncertainty in predicting %VO2R values on the basis of %HRR has been demonstrated in CHF patients both on- and off-beta-blockers.66 However, recent data suggest that the %HRR–%VO2R equiva-lence may be preserved in CHF patients on optimized beta-blocking therapy.67

The RPE Versus VO2 or HR RelationshipRPE is commonly employed in cardiac rehabilitation, either as a primary indicator of exercise intensity or as an adjunct to HR monitoring.19,44,68 Its use is particu-larly valuable in patients who have difficulty obtaining a reliable or meaningful exercise-related HR, e.g.

patients with atrial fibrillation; patients whose HRs may not adequately reflect their level of exertion because of beta-blockade, absence of autonomic cardiac inner-vation occurring after heart transplantation, chrono-tropic incompetence or certain types of pacemakers; and patients in whom the ability to physically obtain an accurate pulse is limited due to a variety of reasons. Obtaining a rating of perception of exertion is also of assistance to cardiac rehabilitation staff members when comparing the perceived demands of various exercise devices, for example arm versus leg exercise.

The commonly utilized scales for the RPE include the original ‘Category Scale’ (RPE Borg scale), which rates exercise intensity from 6 to 20, and the ‘Category-Ratio Scale’ (CR10 Borg scale), which utilizes a numer-ical range from 0 to 10.19 The average RPE range associated with exercise adaptation is 13–16 (‘some-what hard’ to ‘hard’) on the RPE Borg scale, which is loosely associated with a 70–90% range of peak HR and a 50–85% range of peak VO2 (Table 2). This approximately corresponds to 2.5–6 on the CR10 Borg scale, which is also loosely associated with a 60–90% range of peak HR and approximately 50–85% of peak VO2. Several papers have supported the reliability of RPE for effort intensity assessment and prescription in normal individuals and cardiac patients both off- and on-beta-blockers, with a good correspondence between a value of around 13 and the 1stVT.69–76 However, the response can vary greatly both between and within individuals, dependent as it is upon indi-vidual physiologic responses to exercise and percep-tion of effort.77 Moreover, the RPE reported by a patient can be affected by factors other than the phys-ical effort of the exercise, including both psychological factors and environmental conditions. In patients who have a change in the dose of beta-blocker medication, the original calculation of exercise intensity using HR is likely no longer valid.78 In this case, the best approach is to repeat an exercise test, but if this is not possible, a reasonable alternative is to prescribe an exercise intensity based on the reported RPE during exercise prior to the medication change.

Intensity and Volume of Exercise TrainingVolume of exercise training is associated with overall energy expenditure expressed in kilocalories, for example kilocalories per week.79 For cardiac patients, the volume goal of exercise training should ultimately reach 1500 kcal/week,44,80–82 although this level may be difficult to attain for some patients, particularly early in the post-hospitalization phase of exercise training. During this period, exercise training intensity is low, frequently in the range 4–6 kcal/min. Hence the importance of both the frequency and duration of exercise sessions. Early post-hospitalization exercise




energy expenditure higher than expected (moder-ate to high-intensity domain) or equal to peak VO2 irrespective of the prescribed relative intensity (high to severe-intensity domain) when performing CWR exercise; as a consequence, %peak VO2 must be used with caution as a reference for training intensity prescription in these domains, since the individual patient’s actual energy expenditure dur-ing CWR exercise is not easily predictable.

2. In the CWR moderate to high-intensity domain some relative intensities may not be easily attain-able (‘chequered area’ in Figure 3).

3. As shown in Figure 4, for a given VO2 value, the WRs included in the light to moderate domain are not the same when performing incremental versus CWR exercise. The VO2 versus WR relationship is shifted to the right in the former due to an initial lag in the VO2 increase,83 on the grounds that in CWR exercise the VO2 versus WR values are mea-sured after a VO2 steady-state has been reached, thus excluding the initial VO2 on-response delay. As a consequence, when prescribing CWR training in the light to moderate domain on the basis of incremental exercise data, it is necessary to reduce the WR prescription to a lower iso-VO2 value (Figure 4). The more prolonged the initial lag of the VO2 response to incremental exercise is, the greater the reduction should be and, as a rule of thumb, should amount to around 10 W for a 10 W/min incremental protocol in the general population of cardiac patients. Experimental confirmations are needed as to this point for moderate to high-inten-sity CWR exercise.

Bearing this in mind, the available evidence sup-porting the prescription of aerobic training in car-diac patients in the different intensity domains is as follows:

1. Light to moderate-intensity domain. The lowest aero-bic training intensity still able to provide a training effect likely depends mostly, in both normal subjects and cardiac patients, on pre-training exercise capac-ity. In agreement with the lower fitness–lower train-ing stimulus intensity principle,84 intensities even much lower than those corresponding to the 1stVT should be effective in cardiac patients with a mark-edly reduced exercise capacity. In keeping with this concept, aerobic training intensities as low as 40%peak VO2 (corresponding to about 25%VO2R) have proven to be effective in CHF patients with significantly reduced pre-training peak VO2.

85,86 The light to moderate-intensity training is possibly the most indicated for patients with recent hemody-namic decompensation, for those with a high exer-cise-related risk, and for those in whom a light to

training typically involves a minimum of 20–30 min-utes per session, three to four days per week. Using an average of 5 kcal/min and exercising for 30 min, one would expend 150 kcal/session; thus, with 3 ses-sions/week one would expend approximately 450 kcal (four sessions expending 600 kcal). In order to increase the volume of exercise kcal expenditure to achieve the desired level (1500 kcal/week), one must consider the adjustments of intensity, frequency and duration of activity, modifying a single parameter or a combination of these three parameters. Thus, at a given exercise intensity, for example 5 kcal/min, one would need to ultimately utilize a combination of increases in frequency and duration, as follows:

(5 kcal/min) · (40 min/session) · (6 sessions/week) � 1200 kcal/week

Unfortunately, although the intensity of effort may be appropriate, the stamina required to exercise for 40 minutes and six days per week may be overwhelm-ing. However, as patients improve their fitness level, and become able to expend, say, 7kcal/min, duration and/or frequency can be adjusted.

(7 kcal/min) · (30 min/session) · (6 sessions/week) � 1260 kcal/week

As the volume of exercise will impact kilocalorie expenditure, it is important to consider the contribu-tion of all three components of the exercise prescrip-tion, namely exercise intensity, duration of activity and frequency of exercise sessions.

EXERCISE INTENSITY PRESCRIPTION

Prescribed Exercise Intensity: General ConceptsThe idea proposed in this statement is that aerobic exer-cise prescription in cardiac patients should be based on the choice of a specific exercise intensity domain deter-mined by: i) the patient’s clinical and pathophysiologi-cal picture, ii) the peculiar physiological response to and the evidence-based benefits of exercise in the dif-ferent intensity domains and iii) the goals of the reha-bilitation program. This involves a shift from a ‘range-based’ to a ‘threshold-based’ aerobic training prescrip-tion, based on data obtained by incremental standard exercise test or CPX in the individual patient.

Of note, some caveats must be taken into account when transferring information obtained from incre-mental exercise testing to CWR exercise, as underlined in Domains of exercise intensity: the appropriate basis for exercise prescription above and in Figures 3 and 4:

1. Beyond the 1stVT, a given relative exercise inten-sity expressed as %peak VO2 will result in an




Figure 3. Relationship between relative exer-cise intensity as evaluated by ramp incremen-tal cardiopulmonary exercise test and during constant-work-rate exercise sessions at corre-sponding work rates. The linear relationship between VO2 and work rate is lost for con-stant-work-rate exercise above the first venti-latory threshold, as determined during the incremental cardiopulmonary exercise test. This means that the VO2 steady-state is reached at a level higher than expected according to the below-first ventilatory threshold VO2 versus work rate relationship (moderate to high-intensity domain) or not attained at all (high to severe-intensity domain). Given the above, for constant-work-rate exercise in the moderate to high-intensity domain some relative intensities may not be easily attainable nor prescribable (chequered area). The relationships shown in the moder-ate to high-intensity domain are illustrative, and may not be quantitatively confirmed in individual patients. See text for further details. 1stVT: first ventilatory threshold; 2ndVT: second ventilatory threshold; CWR: constant-work-rate; SS: steady-state.

Figure 4. VO2 as a function of work rate in a single ramp incremental versus several con-stant-work-rate cardiopulmonary exercise tests. The initial lag of the VO2 response (grey area) during incremental exercise (full line) shifts the VO2 versus work rate relationship rightwards with respect to that obtained from several constant-work-rate tests (open dia-monds–dotted line). For a given VO2 value, the first and second ventilatory thresholds will thus be reached at a lower work rate when exercising at constant-work-rate than during incremental exercise. A VO2 slow component adds to the on-response during constant-work-rate exercise above the first ventilatory thresh-old, projecting the steady-state VO2 to a level higher than expected according to the below-first ventilatory threshold VO2 versus work rate relationship (dotted line). Critical power, assessed as shown in Figure 2, is the highest work rate sustainable in VO2 steady-state con-ditions (filled diamond). In the high to severe-intensity domain, VO2 is, by definition, sys-tematically projected to peak VO2 irrespective of the applied work rate. See text for further details. 1stVT: first ventilatory threshold; 2ndVT: second ventilatory threshold; CP: criti-cal power; sc: VO2 slow component; WR: work rate.




moderate training intensity is indicated for clinical/therapeutic reasons (i.e. need for weight loss).

2. Moderate to high-intensity domain. Strong evidence has accumulated with regards to adverse event-free moderate to high-intensity exercise in cardiac patients with both preserved and reduced left ven-tricular ejection fraction.87–91 Aerobic training in this domain can still be performed in a continuous modality, with reported training sessions of 15–30 min duration.87–91 The possibility to train patients in the moderate to high-intensity domain is notewor-thy, especially when considering that cardiac patients with reduced exercise capacity perform daily activi-ties at a higher percentage of their peak VO2 com-pared with normal subjects. For example, it has been reported that during a six-minute walking test (considered to closely mimic habitual walking activ-ities), CHF patients exercise at a percentage of peak VO2 often above that corresponding to their 1stVT.92–94 In such a pathophysiological context, the capacity to train in steady-state VO2 conditions above the 1stVT could be crucial to avoid fatigue and termination during activities of daily living. In this regard, recent data show that CHF patients may exercise at the CP (i.e. the upper limit of the moderate to high-intensi-ty domain) for 30 minutes without incurring adverse events;30 however, further research is needed to confirm this point.

3. High to severe and severe- to extreme-intensity domains. In recent years, training in the high to severe- and even severe to extreme-intensity domain using interval training has proven effective in improving exercise capacity in different cardiac patient populations,95–97 including stable CHF patients with a pre-training peak VO2 as low as 13 ml/kg per min96 (see Interval training prescription below). As indicated in Domains of exercise inten-

sity: the appropriate basis for exercise prescription above, the upper limit of the high to severe-inten-sity domain is the highest WR that will allow for the attainment of peak VO2. Of note, times to exhaustion during CWR exercise at 100% peak WR and 135% peak WR have been reported to last on average three minutes and 90 seconds, respective-ly, not only in both untrained and trained normal subjects but also in CHF patients.30,98

Based on the physiological definition of CWR exer-cise intensity domains (Table 1), the upper limits of such domains can be defined by using physiological and/or performance parameters as shown in Table 3, where correspondence with exercise intensity classes according to the ACSM exercise intensity classification is also reported. In the absence of a direct assessment of aerobic metabolism descriptors by CPX, effort rela-tive intensities can be expressed as %peak HR, %HRR, %peak WR, or using Borg scales. Generally speaking, and with the limitations reported in The heart rate versus VO2 relationship, The heart rate reserve versus VO2 reserve relationship and The RPE versus VO2 or HR relationship above, intensities close to the 1stVT (50%peak VO2) should lie around 60%peak HR, 50%peak HRR, 50%peak WR, or 12–13 in the RPE Borg scale, whereas intensities close to the 2ndVT (70-80%peak VO2) should lie around 70%peak WR or 15–16 in the RPE Borg scale (Table 3).

Interval Training PrescriptionInterval training can be defined as repeated bouts of short-duration, high to severe- or severe to extreme-intensity exercise (i.e. 10 seconds to five minutes), separated by brief periods of lower-intensity CWR exercise allowing for active recovery. The term aero-bic interval training (AIT) is often used to describe

T a b l e 3 • Upper Limits of the Different Intensity Domains

Physiological Upper Limit Performance Upper Limit Perceived Exertion

Upper LimitACSM ClassDirectly Assessed

Indirectly Assessed Directly Assessed

Indirectly Assessed

Light to moderate VO2 or VO2R at 1stVT HR or HRR at 1stVT

~60% peak HR ~50% HRR

WR at 1stVT ~50% peak WR 12–13 RPE Borg scale

VL to Mod

Moderate to high NA NA CP WR at 2nd VT(?)

~70% peak WR(?) 15–16 RPE Borg scale

Mod to H

High to severe Peak VO2 ? Highest WR still allow-ing peak VO2 attainment

�100% peak WR

19-20 RPE Borg scale

H to Max

Severe to extreme NA NA ��100% peak WR ��100% peak WR

19–20 RPE Borg scale

NA

ACSM Class: American College of Sports Medicine exercise intensity classification; VO2R: VO2 reserve; 1stVT: first ventilatory threshold; WR: work rate; HR: heart rate; HRR: heart rate reserve; RPE: rating of perceived exertion; NA: not applicable; CP: critical power; 2ndVT: second ventilatory threshold; VL to Mod: very light to moderate; Mod to H: moderate to high; H to Max: high to maximal; >>: much higher than.




interval training in the high to severe-intensity domain. Although a significant contribution from anaerobic energetic sources to the total energy yield is unavoidable in this domain, most of the energy needed is still produced aerobically (see Domains of exercise intensity: the appropriate basis for exercise prescription above). Currently, the most used AIT model consists of 10min warm-up followed by 4�4-min intervals at 85–95%peak HR, with active recovery phases of 3 min at ~70%peak HR (Figure 5). This AIT model has now been used in several studies, both in healthy subjects and in various cardiac patient popu-lations,95,96,99,100 with absolute increases in peak VO2 per exercise session actually remarkably similar among patient groups (Figure 6).

AIT has shown significantly greater cardiovascular effects when compared with isocaloric moderate to high- intensity continuous training, both in coronary artery disease (CAD) and CHF patients95,96 (Figure 6). AIT has also been shown to exert favourable effects on left ventricular systolic function. In healthy men, stroke volume has been shown to increase signifi-cantly more after high-intensity AIT compared with lower-intensity training of the same energy expendi-ture.99 In CHF patients, Wisløff et al.96 found reverse left ventricular remodelling after AIT, while continu-ous training produced no significant changes in left ventricular volumes and resting haemodynamics; fur-thermore, left ventricular contractile function was shown to markedly improve only in AIT patients. Also left ventricular diastolic properties have been found to improve significantly more after AIT than after con-tinuous training in both CHF96 and stable CAD sub-jects.101 Improved endothelial function, reductions in atherosclerosis and better calcium regulation in car-diomyocytes are among the possible explanations for these findings and data in humans seem to confirm basic experimental data.102 Both AIT and moderate to high-intensity continuous training have been found to improve endothelial function in cardiac patients, with

significantly larger improvement in brachial artery flow-mediated dilatation after AIT in CHF patients96 and both improvement in endothelial function and reduction in in-stent restenosis in patients with previ-ous percutaneous coronary intervention (PCI) and

Figure 5. The 4 � 4 min aerobic interval training model. Intensity is given as percentage of peak heart rate.

Figure 6. Peak VO2 before and after aerobic interval training and moderate to high-intensity continuous training in patients with coro-nary artery disease and chronic heart failure. Modified from Rognmo et al.95 and Wisløff et al.96 CAD: coronary artery disease; CHF: chronic heart failure; AIT: aerobic interval training; MCT: moderate to high-intensity continuous training; *p � 0.05 vs. MCT.




stent implantation.103 It is reasonable to suggest that higher shear stress during AIT may trigger larger responses than moderate to high-intensity continuous training at the cellular and molecular level and be responsible for the observed effects on endothelial function.104

In contrast to the described 4�4-min AIT model, shorter, sprint-type intervals of all-out severe to extreme- intensity exercise have been shown to induce rapid changes in exercise capacity, improving work performance due to enhanced skeletal muscle energy metabolism with modest effects on peak VO2.

105,106 This type of interval training is poorly documented in CAD patients, although some acute effects of severe to extreme-intensity interval training have been reported in stable CAD patients.97,107 However, a study applying two-minute-long severe to extreme-intensity intervals found a similar improve-ment in peak VO2 to that after more traditional con-tinuous training in CAD patients, but with increased time to exhaustion at 90%VO2R.108

In a clinical setting, AIT can be performed as uphill walking or running on a treadmill according to the 4�4- min protocol. Patients are supposed to exercise with an intensity corresponding to 85–95%peak HR during the high to severe-intensity intervals, which makes patients breathe heavily without experiencing chest or leg pain. To ensure that the relative intensity is maintained throughout the whole training period, the WR should be adjusted continuously based on the individual HR response. In the recovery periods, patients are supposed to exercise at intensities of ~70%peak HR. In clinical practice, however, it is sometimes necessary to adjust the HR zones, espe-cially the moderate to high-intensity recovery ones, based on the patient’s subjective feelings. In the RPE Borg scale, patients should exercise at an intensity of 15–18 in the high to severe-intensity intervals. Exercise modes other than treadmill walking are possible and AIT using an aerobic exercise group setting has been shown to be feasible in CHF patients.109 Although AIT has proven efficient in increasing cardiovascular health in CAD patients, there is still a need to further investigate feasibility, long-term effects and safety aspects of this training modality. In CHF patients, a preserved walking distance on the six-minute walking test was found one year after ending a formal AIT program.110 Moreover, in patients with previous coro-nary artery by-pass graft a further increase in peak VO2 was seen six months after the end of an AIT rehabilitation period.100 A large ongoing multicentre randomized trial, the Study of MyocArdial Recovery AfTer EXercise Training in Heart Failure (SMARTEX-HF), will address the feasibility, safety and efficacy of AIT in a large group of CHF patients.111

Arm Exercise Intensity PrescriptionPeak HR and VO2 values are significantly lower for arm than for leg exercise, likely due to the reduced muscle mass of the arms. Additionally, at the same absolute WRs, the VO2 for arm work is greater than that of leg work, owing to the reduced mechanical efficiency of arm exercise. Consequently, the cardiovascular responses to standardized WRs during arm ergometry are greater, particularly HR and blood pressure, com-pared with leg exercise.112–116 Exercise prescriptions based upon %peak VO2 derived from treadmill CPX, by way of example, may result in absolute WRs which are substantially greater than what a patient may be able to comfortably achieve during arm ergometry. The exercise prescription generated from %HRR or %peak HR methods attained from standard treadmill or cycle ergometry exercise testing will often provide a safe guideline for the patient, whereby WR can be adjusted to achieve an appropriate HR response. In this regard, it has been suggested that, at a given submaximal WR, for obtaining a HR similar to that obtained during leg ergometry, a WR equal to about two- thirds of the latter should be used during arm ergometry.117

In addition to the differences in physiological responses to acute arm versus leg exercise, the prin-ciple of exercise training specificity suggests that car-diovascular and metabolic adaptation to acute exer-cise is specific to the type of exercise performed and the muscles involved.118 Specifically, training upper limbs or lower limbs results in only minor improve-ment in submaximal and maximal exercise parameters when testing the untrained limbs. Lastly, the role of arm exercise in a patient whose primary goal is weight loss should be balanced against the patient’s need to significantly improve upon the acute exercise response to arm exercise (training adaptation). If the patient has the expectation to resume participation in occupational or recreational activities which require substantial upper limb aerobic capacity, a significant component of the cardiac rehabilitation exercise train-ing program may need to include arm exercise.118–120 However, primarily assigning increased utilization of lower extremity exercise, with their increased exercise efficiency and enhanced ability to exercise at higher absolute WR, may substantially increase the calorie expenditure of the exercise program.

Weight Loss-Targeted Exercise Intensity and Daily Physical Activities Intensity PrescriptionObesity or being overweight affects more than half of the adult populations in the developed world and both are associated with an increased risk of many chronic diseases. A large body of evidence demon-strates that even modest weight loss, as low as 3–5%




of body weight, by regular physical activity is associ-ated with decreased chronic disease risk.121 Higher intensity and longer duration physical activity, con-ducted on a regular basis, are both associated with greater weight loss and less long-term weight gain compared with lower intensity or shorter duration exercise. Weight loss induced by increased daily physical activity without caloric restriction can signifi-cantly reduce obesity (particularly abdominal obesity) and insulin resistance. Exercise without overall weight loss reduced abdominal fat and prevented further weight gain.122 Evidence supports that low to moder-ate-intensity physical activity of 150–250 minutes per week will result in modest weight loss and is effective in preventing weight gain. Higher intensities and lon-ger duration of physical activity (�250 min/week) are associated with significant weight loss.123 Maintenance of weight loss is optimal with low to moderate- or moderate to high-intensity physical exercise of more than 250 min/week duration. A recent systematic review noted a dose–response relationship between the intensity of activity and the loss of visceral fat, with at least 10 METs·h/week of aerobic exercise (brisk walking, light jogging or stationary ergometer usage) required for visceral fat reduction.123 Both men and women benefit from maintaining higher levels of physical activity over a long period of time, but the benefits may be even greater for women.124–126

These results support findings that 30 minutes of activity daily may be sufficient to lose weight and prevent weight gain.127,128 In the STRRIDE study, over-weight individuals were randomized to high-, moder-ate-, or low- activity groups. Although all groups lost weight and body fat, the high-activity group lost more weight and body fat. These findings support the rec-ommendation that higher intensities and longer dura-tions of physical activity are optimal for weight main-tenance, but that even moderate activity is beneficial. This study also noted that the positive caloric imbal-ance observed in the overweight controls was modest and could be reversed by a modest amount of exer-cise, equivalent to walking 30 minutes every day. However, other observational studies suggest that higher durations of activity may be necessary for middle-aged and older adults. This age-associated effect may be related to the inability of many older adults to exercise at higher intensities, especially ini-tially, and thus longer durations of physical activity and lower intensities are required in order to achieve the negative caloric balance that is sufficient for weight loss.129,130 Moreover, this may be due to the well-documented age-related declines in resting meta-bolic rate and lean body mass in older adults and suggests that, in addition to activity, reduced energy intake is vital to prevent weight gain with age.131

The results of the research cited above suggest that incorporating physical activity into daily life improves health outcomes, body weight and visceral adiposity. There appears to be a dose–response related to weight loss from light to high-intensity activity, but both light to moderate- and moderate to high-intensity activity may result in significant weight loss when maintained over time, and especially when combined with appropriate caloric intake for body size and daily energy expenditure. Research suggests that a mini-mum of 30 minutes of light to moderate activity on a daily basis is the threshold to result in weight loss, but that increasing the duration to 45–60 minutes, or increasing the intensity to moderate to high levels, may further enhance weight loss and cardiorespira-tory fitness.

Unavailability of Exercise TestingThere is no contemporary, scientifically validated rea-son for cardiac rehabilitation programs to substitute the current standard of formal incremental exercise test or CPX, including diagnostic 12-lead ECG apprais-al, for other assessments of functional capacity (see Need for direct evaluation of functional capacity: the role of exercise testing above). Therefore, cardiac rehabilitation professionals are strongly encouraged to use every option and opportunity to ensure their patients benefit from standard exercise tests or CPX. However, in cardiac rehabilitation programs where these kinds of exercise tests are not available, there are alternative strategies that may assist programs in both stratifying patients with regard to their risk of exercise-associated adverse events and in developing an exercise prescription. In an effort to try to determine subsequent event risk in cardiac rehabilita-tion populations without exercise testing results, the six-minute walking test has been proposed as a rea-sonable alternative to a more formal exercise capacity evaluation.132–134 However, the assertion or presump-tion that the six-minute walking test and CPX are interchangeable is not supported by the current litera-ture.36 Other well-validated and widely utilized clas-sification schemes such as the Canadian Cardiovascular Society (CCS) classification of stable angina pectoris135 and the New York Heart Association (NYHA) func-tional classification136 have not been adequately stud-ied to fully and completely assess their validity as accurate determinants of myocardial ischemic burden, ventricular function and functional capacity. The above observations not withstanding, in cardiac reha-bilitation programs where formal exercise testing can-not be performed or is simply not a readily available service, a risk stratification protocol utilizing the patient’s CCS Class, NYHA Class and six-minute walk-ing test has been developed (Table 4).37 Importantly,




however, this risk stratification scheme has not been externally validated.

Once a patient’s exercise risk has been determined without the aid of a standard exercise test or a CPX, an exercise prescription can be developed using Borg scales and/or subjective tools such as the ‘talk test’.68,137 RPE correlates sufficiently well with exercise HR and VO2 to allow for an exercise prescription to be determined;138,139 an RPE Borg scale rating of 9–12 should be sufficient to elicit light to moderate exertion while remaining below the 1stVT in both patients and normal subjects69–73,140 (see The RPE versus VO2 or HR relationship above). In addition, the use of RPE as an acceptable measure of the physiologic response to exercise appears to be valid for patients receiving beta-blockers.76 In the ‘talk test’ or the ‘walk and talk test’, patients should be able to maintain a certain level of exercise and still be able to talk in full sen-tences. As with RPE, its use in CAD populations to determine levels of physical exertion that approxi-mate those objectively assessed by CPX has not been robustly evaluated. However, considering that its use in healthy populations does appear to correlate with 1stVT141 and VO2R,142 it is thus not unreasonable to consider its use also in patients with CAD.

PATIENT GROUPS

Indications for aerobic exercise intensity prescription in specific cardiac patient groups are summarized in Table 5; only intensity domain data for which scien-tific evidence is available in a given cardiac patient group have been included, with grey-shaded areas indicating that there are no available data to warrant a recommendation. Physiological, performance and perceived exertion limits of the different exercise intensity domains are provided in Table 3, and both directly (i.e. by incremental CPX) and indirectly (i.e. by incremental standard exercise test) assessed physi-ological and performance limits are shown. As already

emphasized in Prescribed exercise intensity: general concepts above, the choice between different exercise intensities in a specific patient will depend on the individual’s clinical and pathophysiological status, the evidence-based benefits of exercise in the different intensity domains for that specific patient group and the goals of the rehabilitation program. The informa-tion provided in this section are to be considered complementary to those furnished by the recently published EACPR paper ‘Importance of characteristics and modalities of physical activity and exercise in the management of cardiovascular health in individuals with cardiovascular disease (Part III)’.143

Stable Angina PectorisFor patients with stable angina pectoris (SAP) second-ary to coronary atherosclerosis, the benefits of cardiac rehabilitation are unequivocal and it should be consid-ered standard care for all patients with CAD.144,145 The overwhelming consideration within this population remains exercise safety. The surest way to maximize both patient safety and exercise enjoyment and attain improved cardiorespiratory fitness is to first assess the patient using an incremental standard exercise test or CPX, develop an exercise intensity prescription based on the results of that test and then ensure an adequate warm-up and cooling down period prior to and after, respectively, training sessions.

The purpose of the warm-up is to increase blood flow to the skeletal muscles, in preparation for exer-cise, and to facilitate coronary vasodilatation. The anti-ischemic benefits of an adequate warm-up, prior to the initiation of light to moderate/moderate to high exercise have been demonstrated.146–148 As far as train-ing intensity is concerned, the current recommenda-tion for persons without SAP is to perform moderate to high-intensity exercise sessions in order to improve cardiorespiratory fitness.149 This same recommenda-tion has been extended to patients with SAP.37 In a number of small studies, moderate to high-intensity exercise training in patients with SAP has been shown to reduce myocardial ischemic burden assessed by either myocardial perfusion scintigraphy150,151 or 24-hour ambulatory electrocardiographic monitor-ing.152 The mechanisms by which exercise training improves mortality in the SAP population include enhanced metabolic performance of working mus-cles, reduced endothelial dysfunction, improvements in insulin resistance and favourable adjustments in neurohormonal abnormalities.153

In recent years, research into the most appropriate intensity of exercise training for patients with CAD has focused on the use of AIT (see Interval training prescription above). Although the cardiorespiratory benefits of AIT are well documented in athletes, a

T a b l e 4 • Exercise-related Risk Stratification

Risk Category CCS Class NYHA Class 6-min WT

Low 0–1 I �400

Intermediate 2 II 301–400

High 3 III 201–300

Very high 4 IV �200

CCS: Canadian Cardiovascular Society classification of angina pectoris; NYHA: New York Heart Association; 6-min WT: distance walked at six- minute walking test.




recent systematic review of interval training in patients with CAD found only two controlled and five randomized controlled trials, with a total of 213 patients.104 The review found that interval training improved cardiorespiratory fitness, endothelial func-tion and ventricular function and morphology to a greater degree than conventional light to moderate- and moderate to high-intensity continuous aerobic training. In a study on SAP patients, Guiraud and co-workers found that shorter bouts of severe to extreme-intensity exercise (15 seconds compared with 60 seconds) combined with a passive, rather than active, recovery phase, resulted in improved patient comfort and longer time spent at �80% of peak VO2.

154 In patients with SAP, it is important that exercise intensity be prescribed at a HR that is below the ischemic threshold;44 for patients with docu-mented silent ischemia, it is critical that patients be instructed to never exceed the upper HR limit for exercise intensity. The purpose of the cool-down period post-exercise is to invoke a return to a resting state. Studies in healthy populations have indicated that a cool-down period following exercise returns both the HR and ventilation toward pre-exercise levels faster than without a cool-down.155,156

In summary, it is suggested that patients with SAP exercise three to five times per week, following an adequate warm-up of five to 15 minutes, at moderate to high intensity (in any case below the ischemic threshold) for a period of 20 to 40 minutes (not

including warm-up and cool-down), followed by a cool-down period of five to 10 minutes. Most impor-tantly, patients with SAP should engage in the type of exercise activity they find most enjoyable and, there-fore, sustainable.

PCIThe same evidence and clinical practice recommen-dations developed for patients with SAP regarding exercise (see Stable angina pectoris above) are likely applicable to most patients post-PCI. Presently, there is no evidence to suggest that early exercise training and exercise testing post-PCI is either unsafe or adversely affects patient outcomes,157–159 even if high-intensity exercise may actually increase thrombin generation.160 With respect to the best timing to begin an exercise training program of moderate to high intensity, Parker et al. found that exercise testing and training were safe in a low risk post-PCI population less than two weeks after acute PCI for ST-elevation myocardial infarction.161 As post-PCI patients may be at particular risk for failing to increase their physical activity levels and exercise,162 a more rapid access to exercise training may be particularly useful in this population.163 Exercise training programs post-PCI have been consistently associated with improvements in functional capacity;103,157,164–166 conversely, failure to improve functional capacity post-PCI, despite exer-cise training, may be a marker for coronary artery restenosis.167

T a b l e 5 • Evidence-based Prescribable Aerobic Exercise Intensity in Cardiac Patient Groups

Exercise Intensity Domains

Light to moderate Moderate to high High to severe Severe to extreme

Stable angina pectoris √a √a √a

Chronic CAD (no residual ischaemia) √ √ √ √

PCI √ √ √

Pacemaker √ √

ICD √ √

Chronic AF √b √b

CABG √ √ √

Valve repair/replacement √ √

CHF √ √ √

LVAD √

Heart transplantation √c √c √c

The boxed areas identify intensity domains for which no scientific evidence is available in a specific population; CAD: coronary artery disease; PCI: percutaneous coronary intervention; ICD: implantable cardioverter defibrillator; AF: atrial fibrillation; CABG: coronary artery by-pass grafting; CHF: chronic heart failure; LVAD: left ventricular assist device; aHeart rate and/or work rate must in any case be lower than those corresponding to the isch-aemic threshold; bHeart rate may not be usable due to highly variable chronotropic response; cHeart rate may not be usable due to denervation-related blunted chronotropic response.




Data on the specific effects of exercise intensity on patient outcomes post-PCI are sparse. Munk et al. found that high to severe-intensity interval training helped to reduce six month restenosis in the stented coronary artery segment as assessed by quantitative coronary angiography; this effect was associated with improvements in aerobic capacity and attributed to improved endothelial function and reduced systemic inflammation.103 Other investigators have found simi-lar findings with respect to improved functional capacity and reduced inflammation for post-PCI patients.164,166 Aerobic training may result in increased endothelial NO production and/or reduced NO destruction and this may lead to reduced vascular inflammation and reduced restenosis.168–170 In addition to these benefits, moderate to high-/high to severe-intensity exercise training post-PCI may also improve left ventricular remodeling171 and HR variability.172,173 However, whether such a training modality is safe for all patients post-PCI, particularly those with a history of anterior/apical myocardial infarction, or with poor left ventricular systolic function, and those with a his-tory of CHF, remains to be determined.

Pacemakers and Implantable CardioverterDefibrillatorsPatients implanted with permanent pacemakers (PMs) usually follow the same principles for aerobic training intensity prescription as non-PM-implanted patients, provided an adequate chronotropic response to exer-cise is warranted by the patient’s sinus node and/or the device.174 In rate-responsive PM, this is usually the case when the upper-rate limit is matched to the expected training intensity. On the other hand, if an exercising patient’s chronotropic response exceeds the PM upper-rate limit, the device should usually produce a Wenckebach pattern to maintain a rela-tively high HR without risking rapid ventricular responses. If a Wenckebach pattern is produced at exercise intensity levels lower than those prescribed, the upper-rate limit may need to be increased. Of note, patients with VVI PM devoid of rate-adaptive function lack the ability to increase HR. In the absence of rate modulation, the exercise capacity of VVI paced patients may be greatly reduced when compared with those with rate modulation and AV synchrony. However, it has been shown that exercise training may produce significant increases in peak VO2 also in this population.175

Patients with implantable cardioverter defibrillators (ICDs) can undergo aerobic exercise training, but care must be taken to avoid receiving inappropriate shocks during exercise. These could occur in the event that the exercise HR increases so that it is within the pro-grammed ventricular tachycardia zone or if exercise-

induced supraventricular tachycardia develops. Exercise intensities in the light to moderate and mod-erate to high domains have been found effective in improving peak VO2 in patients with an ICD. It is important to note that exercise training intensities used in all of these studies resulted in HRs that were 15–20 beats lower than the ICD threshold for detection and termination of ventricular tachycardia.176–179 Thus, as recently stated, exercise heart rates should not exceed ICD therapy thresholds and ideally be set between 10 and 20 beats below first line therapy thresholds.3

Chronic Atrial FibrillationChronic atrial fibrillation (AF) is a very common arrhythmia, characterized by irregularly irregular atrial and ventricular depolarizations. The prevalence of chronic AF is quite high in patients older than 60 years and the arrhythmia may present as ‘lone’ AF or associated with comorbid conditions, such as CHF or valvular heart disease. Patients with chronic AF fre-quently have incomplete ventricular filling, which leads to an impaired cardiac output response to exercise, very rapid ventricular rates during effort (possibly exceeding predicted maximum) and, ulti-mately, reduced peak VO2 and VO2 at 1stVT in com-parison with patients in sinus rhythm.180 Patients with CHF and chronic AF show peak VO2 values lower than those of CHF patients in sinus rhythm, but with 1stVT occurring at a higher percentage of peak VO2.

181 Training intensities in the light to moderate- and moderate to high-intensity domains have been used in patients with chronic AF, improving both exercise capacity (i.e. peak VO2) and chronotropic response to exercise.182–184 Of note, the highly variable ventricular chronotropic response at submaximal levels of exercise typical of chronic AF patients may render HR of little utility for aerobic training prescrip-tion in some patients, making subjective RPE the most reliable means for exercise intensity assessment and prescription. In this regard, given the high prevalence of chronic AF in elderly patients, randomized con-trolled studies addressing the most effective type of exercise intensity assessment and prescription in this population are strongly needed.

Coronary Surgical RevascularizationPatients who have undergone traditional open-chest coronary artery by-pass graft (CABG) surgery as well as minimally invasive procedures are a substantial pro-portion of cardiac rehabilitation exercise programming participants, and this group includes many patients who are age 65 years or older.185 Outpatient rehabilita-tion can be started, as appropriate, within one week of hospital discharge (2–3 weeks post-surgery).186 Exercise prescription methodology is generally the same as that




used with CAD patients. Initially, some patients may need lower- intensity or modified exercise because of musculoskeletal discomfort or healing issues at their incision sites, including not only the chest, but possi-bly also legs and arms. Specifically, patients should completely refrain from upper-extremity aerobic exer-cise training, for example arm ergometry and resis-tance training, for 4–6 weeks post-surgery to ensure the stability of the sternum and sternal wound healing. The exception is appropriate upper and lower body stretching and flexibility exercises to promote mobility. In patients with previous CABG, several aerobic train-ing intensities have proven effective,100,187–192 the choice of which will depend on both the level of exercise-related risk and the patient’s clinical condi-tion. In this regard, it must be borne in mind that, among patients entering a rehabilitation program after a recent acute cardiac event, those with recent CABG have been found to have the lowest peak VO2.

193

Because of the possibility of graft closure, program staff should be alert for new patient complaints of angina pectoris or angina-equivalent symptoms or signs, such as exercise intolerance or new ECG signs of myocardial ischemia. Patients should also be edu-cated regarding these possibilities. Recognizing whether the revascularization was complete or incom-plete is valuable in this regard as the latter may increase the likelihood of postsurgical signs and symptoms of residual myocardial ischemia during exercise, which may significantly affect the results of the rehabilitation process.194

Valve repair or replacementThe exercise prescription and training of patients with recent valve replacement or repair is very similar to that used with CABG surgery patients.186,195,196 However, the physical activity of some valvular heart disease patients may have been very restricted for an extended period of time prior to the surgical interven-tion. Consequently, the resulting low functional capacity may require these patients to initiate, and proceed with, exercise in a conservative fashion, especially during the early stages of the exercise train-ing program.193 Rehabilitation professionals should take care to avoid upper-extremity exercise, as described in Coronary surgical revascularization above. Exercise intensities in the light to moderate- and moderate to high-intensity domains have been used in patients with recent heart valve replacement or repair and balloon valvuloplasty, demonstrating significant effects on exercise capacity and quality of life.197–201 Preliminary data also indicate a possible reverse left ventricular remodelling effect of pro-longed aerobic training in patients with previous aor-tic valve replacement.202 Anticoagulation therapy is

very common in patients who have undergone valve surgery; consequently, this necessitates caution for exercise-related injuries and subsequent bleeding. Staff should frequently remind patients undergoing exercise training of the increased risk of such events.

Patients with valvular heart disease but without valve repair or replacement may also be referred for cardiac rehabilitation. In these patients, critical aortic stenosis is a formal contraindication for exercise train-ing. Patients with less-severe aortic stenosis can exer-cise but may develop symptoms, for example dyspnoea and significant fatigue, at a given WR. Exercise training intensity should be kept under the threshold that pre-cipitates the onset of symptoms, because these symp-toms indicate that their cardiac output is not capable of meeting the demands of that level of exercise.

CHF and Left Ventricular Assist DevicesA reduced ability to perform aerobic exercise is the hallmark of the CHF pathophysiological picture.203 It is related to changes in both peripheral and central links of the O2 transport chain from ambient air to the skeletal muscle, the major consequence of which is a reduced cardiac output and peripheral microcircula-tory response relative to exercise-related metabolic needs.204,205 Moreover, ventilation is increased at com-parable absolute submaximal levels of effort in CHF patients with respect to age-matched normal sub-jects.206 Among the proposed causes of the increased ventilatory response to exercise are a reduced oxygen-diffusing capacity due to an impairment of alveolar–arterial oxygen transfer,207 an increase in dead space ventilation because of a mismatching of ventilation relative to pulmonary perfusion,206 and an exaggerated ergoreflex response originating in the exercising skeletal muscles during effort.208 Finally, skeletal muscle metabolic potential is also reduced, due to altered redistribution of flow to exercising muscles, endothelial dysfunction and impaired mito-chondrial enzymes activity.209 These changes pro-mote a vicious cycle of deterioration involving cata-bolic drive and reflex neurohormonal over-activa-tion,210 which may lead to disease progression and functional deterioration. As a consequence, in CHF, peak VO2 and VO2 at 1stVT are typically reduced with respect to age-matched normal subjects, and their reduction is proportional to the severity of the syndrome.211 A wide range of aerobic exercise inten-sities, that is, from light to moderate to high to severe, has been tested in CHF patients. All intensities have been shown to be effective in improving patients’ exercise capacity, whereas the ability to induce reverse left ventricular remodelling and improve-ments in left ventricular ejection fraction has been demonstrated only for moderate to high- and high to




severe-intensity aerobic training.85,86,96,212 This offers a wide range of possibilities for the choice of aerobic exercise intensity in CHF, even if more work is need-ed to investigate safety aspects of high to severe-intensity training in this population (see Interval Training Prescription above).

Among patients with advanced CHF, that is, by definition with severely reduced exercise capacity and presumed high exercise-related risk, left ventricular assist device implantation is increasingly used as a bridge to transplantation or even as permanent ther-apy. Patients with left ventricular assist devices can often be managed at outpatient clinics, and an early initiation of exercise training after implantation has been reported to be associated with improvements in exercise capacity.213 Walking in the hospital ward as well as aerobic exercise on a cycle ergometer or a treadmill can be performed with the aim of improving exercise capacity. Light to moderate training intensities adjusted at the 1stVT level or possibly even slightly higher (12–14 score in the RPE Borg scale) have suc-ceeded in improving peak VO2 in this population.214–216

Heart TransplantationExercise training is recommended for all patients before and after heart transplantation.186,217 Patients with severe heart failure, awaiting heart transplanta-tion, are usually significantly deconditioned due to metabolic changes that occur with heart failure, result-ing in significant limitations in the ability to do physi-cal work.218 Functional capacity following transplanta-tion may be affected by the patient’s baseline capacity prior to surgery, or by underlying cause(s) of heart failure, the clinical course in the hospital, surgical complications, skeletal muscle weakness, use of corti-costeroids and other post-transplant medications and surgical denervation of the heart.219

Given the complexity of hemodynamic and cardio-respiratory responses during incremental exercise in this population, exercise intensity may best be deter-mined by RPE. At the start of training programs, an RPE of 10–12, that is, light to moderate-intensity in the RPE Borg scale, will generally account for the surgical and disease deconditioning as well as any potential exercise issues associated with steroid myopathy.220 If the patient’s clinical condition allows, the exercise intensity can gradually increase to mod-erate to high to enhance patient outcomes. High to severe-intensity aerobic interval training programs have also been evaluated in selected heart trans-planted patients and have proven to be safe and effective.221,222 Following heart transplantation, an improvement in functional capacity of approximately 20–50% is associated with participation in a cardiac rehabilitation program.220–223 Exercise should be

initially performed in a supervised setting to fully evaluate and monitor the patient’s response to aero-bic training.

CONCLUSIONS

In current cardiac rehabilitation practice, the choice of the aerobic training stimulus intensity in individual patients remains largely a matter of clinical judge-ment. This European, US and Canadian joint position statement provides evidence-based indications for a shift from a ‘range-based’ to a ‘threshold-based’ aero-bic exercise intensity prescription, to be combined with thorough clinical evaluation and exercise-related risk assessment. The importance of functional evalua-tion through exercise testing prior to starting an aero-bic training program is strongly emphasized, and an incremental cardiopulmonary exercise test, when available, is proposed as the gold standard for a physiologically comprehensive exercise intensity assessment and prescription. This would allow profes-sionals to match the unique physiological responses of different exercise intensity domains to the individ-ual patient pathophysiological and clinical status, maximizing the benefits obtainable from aerobic exer-cise training in cardiac rehabilitation.

—Acknowledgments—This statement was approved by the European Association for Cardiovascular Prevention and Rehabilitation on 28 November 2011, the American Association of Cardiovascular and Pulmonary Rehabilitation Board of Directors on 6 March 2012 and the Canadian Association of Cardiac Rehabilitation on 5 June 2012.

FundingThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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