Evidence summary (Updated 2022)
A large body of good quality randomised controlled data shows consistent improvements in cardiovascular fitness(1–10 ) and quality of life(4,11–14). These two factors combined will undoubtedly improve a patient’s self-reported energy(15). Cardiorespiratory fitness is also a strong predictor for mortality and heart failure in individuals with IHD.
Overall QoL improvements are seen in several studies across a number of interventions including HIIT(16), resistance and aerobic training(17), yoga(18) and Tai Chi(19). Long et al were unable to draw conclusions about the impact of exercise-based cardiac rehabilitation on HR-QoL (Health related quality of life score) but did find low quality evidence in 5 studies supporting improvements in exercise capacity (standardised mean difference (SMD) 0.45, 95% CI 0.20 to 0.70).(20) The recent Cochrane review showed the exercise-based CR improved HRQoL though the improvement was small and not always clinically meaningful.(21)
When assessing individual intervention types yoga compared to controls was found to significantly improve QoL (SMD, 0.07; 95%CI, 0.01-0.14).(18) Tai Chi was found to be superior to other low-intensity exercise interventions but not as effective as HIIT in improving VO2 max.(19) This was further confirmed in a SR and MA in which Tai Chi groups showed a large and significant improvement in aerobic endurance compared with both active and non-active control interventions (standard mean difference (SMD) 1.12; 95% confidence interval (CI): 0.58-1.66; p <0.001) and a significant improvement in QoL (SMD=0.73; 95%CI: 0.39 to 1.08, p<0.001).(22)
Combined resistance and aerobic training is effective at significantly improving cardiopulmonary exercise function(p<0.0001) however there was high heterogeneity across the 38 studies of 2465 participants (i2=81%).(17) Resistance training is more effective than aerobic training at increasing muscle strength and aerobic capacity.(17) And HIIT was found to be superior to moderate intensity continuous training in improving fitness in a systematic review of 953 participants(23) and in a number of other studies.(24,25) A further review looking at HIIT versus moderate continuous intensity exercise of 1272 participants showed fitness (VO2max, peak power and anaerobic threshold).(16) The improvements seen in HIIT training were found to be significant regardless of the frequency, duration, and type of HIIT training.(26)
A SR and MA of over 13000 participants considered the intensity of the aerobic exercise intervention and the affect on peak VO2 in patients with IHD, post myocardial infarction and revascularisation. While moderate, moderate to vigorous and vigorous intensity exercise all produced improvements in peak VO2 there was no clinically meaningful difference between intensities.(27)
Quality of evidence
B – Moderate quality
Strength of recommendation
1 – Strong
There is evidence to support improvements in this group of patients with cardiovascular disease in QoL, fitness and energy outcomes. However, a recent Cochrane review did not find all outcomes to be of a good quality of evidence.
When considering intervention type and intensity there is evidence supporting a wide range of activities at varying intensities
- Adams V, Besler C, Fischer T, Riwanto M, Noack F, Hollriegel R, et al. Exercise training in patients with chronic heart failure promotes restoration of high-density lipoprotein functional properties. Circ Res. 113:1345–1355.
- Erbs S, Hollriegel R, Linke A, Beck EB, Adams V, Gielen S, et al. 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 Hear Fail. 3:486–494.
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- Amundsen BH, Rognmo O, Hatlen-Rebhan G, Slordahl SA. High-intensity aerobic exercise improves diastolic function in coronary artery disease. Scand Cardiovasc J. 42(110).
- Hambrecht R, Walther C, Mobius-Winkler S, Gielen S, Linke A, Conradi K, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation. 109(1371):1378.
- Marchionni N, Fattirolli F, Fumagalli S. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized con- trolled trial. Circulation. 107:2201–2206.
- Adachi H, Koike A, Obayashi T, Umezawa S, Aonuma K, M I. Does appropriate endurance exercise training improve cardiac function in patients with prior myocardial infarction? Eur Hear Journal Engl. 17(10):1511–1521.
- Saeidifard F, Wang Y, Medina-Inojosa JR, Squires RW, Huang H-H, Thomas RJ. Multicomponent Cardiac Rehabilitation and Cardiovascular Outcomes in Patients With Stable Angina: A Systematic Review and Meta-analysis. Mayo Clin proceedings Innov Qual outcomes [Internet]. 2021 Aug [cited 2022 Oct 8];5(4):727–41. Available from: https://pubmed.ncbi.nlm.nih.gov/34355130/
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- Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, et al. Exercise-based cardiac rehabilitation for coronary heart disease: cochrane systematic review and meta-analysis. J Am Coll Cardiol. 67:1–12.
- Taylor. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. (ue 7. Art. No: CD001800).
- Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 116:682–692.
- R. M, M. M, A S. CR: participating in an exercise program in a quest to survive. Rehab Nurs Off J Assoc Rehab Nurses. 24(6):236–239.
- Du L, Zhang X, Chen K, Ren X, Chen S, He Q. Effect of high-intensity interval training on physical health in coronary artery disease patients: A meta-analysis of randomized controlled trials. J Cardiovasc Dev Dis [Internet]. 2021 Nov 1 [cited 2022 Oct 7];8(11). Available from: /pmc/articles/PMC8622669/
- Fan Y, Yu M, Li J, Zhang H, Liu Q, Zhao L, et al. Efficacy and Safety of Resistance Training for Coronary Heart Disease Rehabilitation: A Systematic Review of Randomized Controlled Trials. Front Cardiovasc Med [Internet]. 2021 Nov 5 [cited 2022 Oct 7];8. Available from: https://pubmed.ncbi.nlm.nih.gov/34805309/
- Li J, Gao X, Hao X, Kantas D, Mohamed EA, Zheng X, et al. Yoga for secondary prevention of coronary heart disease: A systematic review and meta-analysis. Complement Ther Med [Internet]. 2021 Mar 1 [cited 2022 Oct 6];57. Available from: https://pubmed.ncbi.nlm.nih.gov/33338581/
- Yang YL, Wang YH, Wang SR, Shi PS, Wang C. The Effect of Tai Chi on Cardiorespiratory Fitness for Coronary Disease Rehabilitation: A Systematic Review and Meta-Analysis. Front Physiol [Internet]. 2018 Jan 4 [cited 2022 Oct 7];8(JAN). Available from: https://pubmed.ncbi.nlm.nih.gov/29354065/
- Long L, Anderson L, Dewhirst AM, He J, Bridges C, Gandhi M, et al. Exercise-based cardiac rehabilitation for adults with stable angina. Cochrane database Syst Rev [Internet]. 2018 Feb 2 [cited 2022 Oct 7];2(2). Available from: https://pubmed.ncbi.nlm.nih.gov/29394453/
- Dibben G, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane database Syst Rev [Internet]. 2021 Nov 6 [cited 2022 Oct 8];11(11). Available from: https://pubmed.ncbi.nlm.nih.gov/34741536/
- Liu T, Chan AWK, Liu YH, Taylor-Piliae RE. Effects of Tai Chi-based cardiac rehabilitation on aerobic endurance, psychosocial well-being, and cardiovascular risk reduction among patients with coronary heart disease: A systematic review and meta-analysis. Eur J Cardiovasc Nurs [Internet]. 2018 Apr 1 [cited 2022 Oct 7];17(4):368–83. Available from: https://pubmed.ncbi.nlm.nih.gov/29256626/
- Hannan A, Hing W, Simas V, Climstein M, Coombes J, Jayasinghe R, et al. High-intensity interval training versus moderate-intensity continuous training within cardiac rehabilitation: a systematic review and meta-analysis. Open access J Sport Med [Internet]. 2018 Jan [cited 2022 Oct 7];9:1–17. Available from: https://pubmed.ncbi.nlm.nih.gov/29416382/
- Zhang X, Xu D, Sun G, Jiang Z, Tian J, Shan Q. Effects of high-intensity interval training in patients with coronary artery disease after percutaneous coronary intervention: A systematic review and meta-analysis. Nurs open [Internet]. 2021 May 1 [cited 2022 Oct 7];8(3):1424–35. Available from: https://pubmed.ncbi.nlm.nih.gov/33528117/
- Chen L, Tang L. Effects of interval training versus continuous training on coronary artery disease: an updated meta-analysis of randomized controlled trials. Physiother Theory Pract [Internet]. 2021 [cited 2022 Oct 8];37(12):1273–82. Available from: https://pubmed.ncbi.nlm.nih.gov/32073332/
- Ballesta García I, Rubio Arias JÁ, Ramos Campo DJ, Martínez González-Moro I, Carrasco Poyatos M. High-intensity Interval Training Dosage for Heart Failure and Coronary Artery Disease Cardiac Rehabilitation. A Systematic Review and Meta-analysis. Rev Esp Cardiol (Engl Ed) [Internet]. 2019 Mar [cited 2022 Oct 7];72(3):233–43. Available from: https://pubmed.ncbi.nlm.nih.gov/29650445/
- Mitchell BL, Lock MJ, Davison K, Parfitt G, Buckley JP, Eston RG. What is the effect of aerobic exercise intensity on cardiorespiratory fitness in those undergoing cardiac rehabilitation? A systematic review with meta-analysis. Br J Sports Med [Internet]. 2019 Nov 1 [cited 2022 Oct 8];53(21):1341–52. Available from: https://pubmed.ncbi.nlm.nih.gov/30121584/