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IHD – Chest Pain – Positive/Negative cycle

There is strong evidence that physical activity improves the blood supply to the heart (11-12) from better arterial blood flow (1-8) and increased collateral blood flow (9-10).  This will also reduce the atherosclerosis process (13-15) and has anti-inflammatory effects on platelets (1,7). This will improve the function of the left ventricle (16) to contract more effectively. This combined effect is to reduce the perception and frequency of chest pain (17).

Cycles developed after expert consultation and both quantitative and qualitative reviews of available literature.


1. Chen YW, Apostolakis S, Lip GY. Exercise-induced changes in inflammatory processes: implications for thrombogenesis in cardiovascular disease. Ann Med. 2014;46:439–455.
2. Adams V, Besler C, Fischer T, Riwanto M, Noack F, Hollriegel R, Oberbach A, Jehmlich N, Volker U, Winzer EB, Lenk K, Hambrecht R, Schuler G, Linke A, Landmesser U, Erbs S. Exercise training in patients with chronic heart failure promotes restoration of high-density lipoprotein functional properties. Circ Res. 2013;113:1345–1355.
3. Sixt S, Beer S, Bluher M, Korff N, Peschel T, Sonnabend M, Teupser D, Thiery J, Adams V, Schuler G, Niebauer J. Long- but not short-term multifactorial intervention with focus on exercise training improves coronary endothelial dysfunction in diabetes mellitus type 2 and coronary artery disease. Eur Heart J. 2010;31:112–119.
4. Erbs S, Hollriegel R, Linke A, Beck EB, Adams V, Gielen S, Mobius-Winkler S, Sandri M, Krankel N, Hambrecht R, Schuler G. Exercise training in patients with advanced chronic heart failure (NYHA IIIb) promotes restoration of peripheral vasomotor function, induction of endogenous regeneration, and improvement of left ventricular function. Circ Heart Fail. 2010;3:486–494.
5. Ting-Hin Luk, Yuk-Ling Dai, Chung-Wah Siu, Kai-Hang Yiu, Hiu-Ting Chan, Stephen WL Lee, Sheung-Wai Li,
Bonnie Fong, Wai-Keung Wong3, Sidney Tam3, Chu-Pak Lau1 and Hung-Fat Tse. Effects of exercise training upon endothelial function in patients with cardiovascular disease. Eur J of Prev Card. 20012;19(4) 830–839.
6. Adams V, Linke A, Krankel N, Erbs S, Gielen S, Mobius-Winkler S, Gummert JF, Mohr FW, Schuler G, Hambrecht R. Impact of regular physical activity on the NAD(P)H oxidase and angiotensin receptor system in patients with coronary artery disease. Circulation. 2005;111:555–562.
7. Henderson KK, Turk JR, Rush JW, Laughlin MH. Endothelial function in coronary arterioles from pigs with early-stage coronary disease induced by high-fat, high-cholesterol diet: effect of exercise. J Appl Physiol. 2004;97:1159–1168.
8. Hambrecht R, Wolf A, Gielen S, Linke A, Hofer J, Erbs S, Schoene N, Schuler G. Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med. 2000;342:454–460.
9. Mobius-Winkler S, Uhlemann M, Adams V, Sandri M, Erbs S, Lenk K, Mangner N, Mueller U, Adam J, Grunze M, Brunner S, Hilberg T, Mende M, Linke AP, Schuler G. Coronary collateral growth induced by physical exercise: results of the impact of intensive exercise training on coronary collateral circulation in patients with stable coronary artery disease (EXCITE) trial. Circulation. 2016;133:1438–1448.
10. Zbinden R, Zbinden S, Meier P, Hutter D, Billinger M, Wahl A, Schmid JP, Windecker S, Meier B, Seiler C. Coronary collateral flow in response to endurance exercise training. Eur J Cardiovasc Prev Rehabil. 2007;14:250– 257.
11. Scalone G, Coviello I, Barone L, Pisanello C, Sestito A, Lanza GA, Crea F. Brief low-workload myocardial ischaemia induces protection against exercise- related increase of platelet reactivity in patients with coronary artery disease. Heart. 2010;96:263–268.
12. Estorch M, Flotats A, Serra-Grima R, Mari C, Prat T, Martin JC, Berna L, Catafau AM, Tembl A, Carrio I. Influence of exercise rehabilitation on myocardial perfusion and sympathetic heart innervation in ischaemic heart disease. Eur J Nucl Med. 2000;27:333–339.
13. M, Washio T, Kumabe N, Hirayama A. Coronary plaque regression and lifestyle modification in patients treated with pravastatin: assessment mainly by daily aerobic exercise and an increase in the serum level of high- density lipoprotein cholesterol. Circ J. 2010;74:954–961.
14. Niebauer J, Hambrecht R, Marburger C, Hauer K, Velich T, von Hodenberg E, Schlierf G, Kubler W, Schuler G. Impact of intensive physical exercise and low-fat diet on collateral vessel formation in stable angina pectoris and angiographically confirmed coronary artery disease. Am J Cardiol. 1995;76:771–775.
15. Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, McLanahan SM, Kirkeeide RL, Brand RJ, Gould KL. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial Lancet. 1990;336:129–133.
16. Amundsen BH, Rognmo O, Hatlen-Rebhan G, Slordahl SA. High-intensity aerobic exercise improves diastolic function in coronary artery disease. Scand Cardiovasc J. 2008;42:110
17. Røysland I. Ø., Friberg F., Brinchmann B. S., Svello S. N., Valborgland T., Larsen A. I., 2016. Confronting one’s vulnerability–patients with chest pain participating in a high-intensity exercise programme. Journal of Clinical Nursing, 26, 2006–2015
18. Madssen E, Moholdt T, Videm V, Wisloff U, Hegbom K, Wiseth R. Coronary atheroma regression and plaque characteristics assessed by grayscale and radiofrequency intravascular ultrasound after aerobic exercise. Am J Cardiol. 2014;114:1504–1511.
19. Marchionni N, Fattirolli F, Fumagalli S, et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized con- trolled trial. Circulation. 2003;107:2201–2206.
20. Belardinelli R, Paolini I, Cianci G, Piva R, Georgiou D, Purcaro A. Exercise training intervention after coronary angioplasty: the ETICA trial. J Am Coll Cardiol. 2001;37:1891–1900.
21. Nina Mann, Anthony Rosenzweig. Can Exercise Teach Us How to Treat Heart Disease? Circulation. 2012 Nov 27; 126(22): 2625–2635.
22. Mitchell R., Muggli M., Sato A., 1999. CR: participating in an exercise program in a quest to survive. Rehab nursing : Official J. of the Assoc of Rehab Nurses; vol. 24 (no. 6); pp.236-239
23. Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease: cochrane systematic review and meta-analysis. J Am Coll Cardiol. 2016;67:1–12.
24. Taylor et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No: CD001800. DOI: 10.1002/14651858.CD001800.pub2.
25. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682–692.
26. Belardinelli R, Paolini I, Cianci G, Piva R, Georgiou D, Purcaro A. Exercise training intervention after coronary angioplasty: the ETICA trial. J Am Coll Cardiol. 2001;37:1891–1900.