Documente Academic
Documente Profesional
Documente Cultură
K E Y
W O R D S
Aerobic training
energy expenditure
peak VO2
ventilatory thresholds
cardiac rehabilitation
Salvatore Maugeri Foundation IRCCS, Scientific Institute of Veruno, Exercise Pathophysiology Laboratory, Cardiac Rehabilitation Division, Italy:
George 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-Sant, Luxembourg; 8Creighton University School of Medicine, Division of Cardiology, Department of Medicine, Omaha, USA.
*Co-Chair.
2
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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 exercise, and intensity ranges for aerobic training prescription are included in several guidelines and publications regarding secondary prevention and cardiac
rehabilitation.14 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 professionals 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) identification 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) discussion 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, session 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 purpose of this paper a frequency of three to four sessions per week will be assumed; it is acknowledged
that a higher or lower frequency may require modifications of the exercise intensity prescription. As far as
the training modality is concerned, the term continuous 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 exercise 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.
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Peak VO2
Lactate
Steady-state
Exercise
Duration
Training
Modality
Light to moderate
Yes
NA
30 min
Yes
Continuous
Moderate to high
Yes
Yes
~2030 min
No
Continuous
High to severe
No
No
~320 min
NA
Interval
Severe to extreme
No
No
3 min
NA
Interval
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%peak VO2
%peak HR
20
25
35
10
Light
2039
2544
3554
1011
Moderate
4059
4559
5569
1213
Heavy
6084
6084
7089
1416
85
85
90
1719
100
100
100
20
Very light
Very heavy
Maximal
43
Modified from Tipton et al. ; ACSM: American College of Sports Medicine; HRR: heart rate reserve; VO2R: VO2 reserve; HR: heart rate; RPE: rating of perceived
exertion.
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training typically involves a minimum of 2030 minutes 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 sessions/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 overwhelming. 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 contribution of all three components of the exercise prescription, namely exercise intensity, duration of activity
and frequency of exercise sessions.
energy expenditure higher than expected (moderate 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 patients actual energy expenditure during CWR exercise is not easily predictable.
2. In the CWR moderate to high-intensity domain
some relative intensities may not be easily attainable (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 measured 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-intensity CWR exercise.
Bearing this in mind, the available evidence supporting the prescription of aerobic training in cardiac patients in the different intensity domains is as
follows:
1. Light to moderate-intensity domain. The lowest aerobic training intensity still able to provide a training
effect likely depends mostly, in both normal subjects
and cardiac patients, on pre-training exercise capacity. In agreement with the lower fitnesslower training stimulus intensity principle,84 intensities even
much lower than those corresponding to the 1stVT
should be effective in cardiac patients with a markedly 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 hemodynamic decompensation, for those with a high exercise-related risk, and for those in whom a light to
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Figure 3. Relationship between relative exercise intensity as evaluated by ramp incremental cardiopulmonary exercise test and during
constant-work-rate exercise sessions at corresponding work rates. The linear relationship
between VO2 and work rate is lost for constant-work-rate exercise above the first ventilatory 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-workrate 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 moderate 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.
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Indirectly
Assessed
NA
Peak VO2
NA
NA
Directly Assessed
Perceived
Exertion
Upper Limit
ACSM
Class
WR at 1stVT
~50% peak WR
1213 RPE
Borg scale
VL to
Mod
CP
WR at 2nd VT(?)
1516 RPE
Borg scale
Mod to H
100% peak
WR
19-20 RPE
Borg scale
H to Max
100% peak WR
100% peak
WR
1920 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.
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Figure 6. Peak VO2 before and after aerobic interval training and
moderate to high-intensity continuous training in patients with coronary artery disease and chronic heart failure. Modified from Rognmo
et al.95 and Wislff 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.
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of body weight, by regular physical activity is associated with decreased chronic disease risk.121 Higher
intensity and longer duration physical activity, conducted 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 significantly 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 moderate-intensity physical activity of 150250 minutes per
week will result in modest weight loss and is effective
in preventing weight gain. Higher intensities and longer 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 doseresponse relationship between
the intensity of activity and the loss of visceral fat,
with at least 10 METsh/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.124126
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, overweight individuals were randomized to high-, moderate-, 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 recommendation that higher intensities and longer durations of physical activity are optimal for weight maintenance, but that even moderate activity is beneficial.
This study also noted that the positive caloric imbalance observed in the overweight controls was modest
and could be reversed by a modest amount of exercise, 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 initially, 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 metabolic 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
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PATIENT GROUPS
Indications for aerobic exercise intensity prescription
in specific cardiac patient groups are summarized in
Table 5; only intensity domain data for which scientific 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 physiological and performance limits are shown. As already
T a b l e 4 Exercise-related Risk
Stratification
Risk Category
CCS Class
NYHA Class
6-min WT
01
400
Intermediate
II
301400
High
III
201300
Very high
IV
200
Low
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Moderate to high
High to severe
PCI
Pacemaker
ICD
Chronic AF
CABG
Valve repair/replacement
CHF
LVAD
Heart transplantation
Severe to extreme
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 ischaemic 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.
PCI
The same evidence and clinical practice recommendations 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,157159 even if highintensity 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;103,157,164166 conversely, failure
to improve functional capacity post-PCI, despite exercise training, may be a marker for coronary artery
restenosis.167
Position Statement / 341
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Heart Transplantation
Exercise training is recommended for all patients
before and after heart transplantation.186,217 Patients
with severe heart failure, awaiting heart transplantation, are usually significantly deconditioned due to
metabolic changes that occur with heart failure, resulting in significant limitations in the ability to do physical work.218 Functional capacity following transplantation may be affected by the patients 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 corticosteroids and other post-transplant medications and
surgical denervation of the heart.219
Given the complexity of hemodynamic and cardiorespiratory responses during incremental exercise in
this population, exercise intensity may best be determined by RPE. At the start of training programs, an
RPE of 1012, 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 patients clinical condition allows,
the exercise intensity can gradually increase to moderate to high to enhance patient outcomes. High to
severe-intensity aerobic interval training programs
have also been evaluated in selected heart transplanted patients and have proven to be safe and
effective.221,222 Following heart transplantation, an
improvement in functional capacity of approximately
2050% is associated with participation in a cardiac
rehabilitation program.220223 Exercise should be
CONCLUSIONS
In current cardiac rehabilitation practice, the choice of
the aerobic training stimulus intensity in individual
patients remains largely a matter of clinical judgement. This European, US and Canadian joint position
statement provides evidence-based indications for a
shift from a range-based to a threshold-based aerobic exercise intensity prescription, to be combined
with thorough clinical evaluation and exercise-related
risk assessment. The importance of functional evaluation through exercise testing prior to starting an aerobic 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 professionals to match the unique physiological responses
of different exercise intensity domains to the individual patient pathophysiological and clinical status,
maximizing the benefits obtainable from aerobic exercise 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.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-forprofit sectors.
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