Abstract
BackgroundWe hypothesized that a 2-week twice daily aquatic endurance plus calisthenics exercise training program: (i) increases aerobic exercise capacity (peak oxygen uptake/O2peak), (ii) improves endothelium-dependent flow-mediated vasodilation (FMD), and (iii) reduces circulating markers of low-grade inflammation and hemostasis, as compared to land-based endurance plus calisthenics exercise training or no exercise in patients undergoing short-term residential cardiac rehabilitation after a recent coronary artery disease (CAD) event.MethodsPatients with a recent myocardial infarction or revascularization procedure were randomized into two interventional groups and a control group. The interventional groups underwent supervised aerobic endurance plus calisthenics exercise training either in thermo-neutral water or on land at moderate intensity (60–80% of the peak heart rate achieved during symptom-limited graded exercise testing) for 30 min twice daily for 2 weeks (i.e., 24 sessions). The control group was deferred from supervised exercise training for the 2-week duration of the intervention, but was advised low-to-moderate intensity physical activity at home while waiting. At baseline and after the intervention period, all participants underwent estimation of aerobic exercise capacity, brachial artery flow-mediated dilatation (FMD, measured ultrasonographically at rest and during reactive hyperemia after 4.5 min of forearm cuff inflation), markers of cardiac dysfunction (NT-proBNP), inflammation (hsCRP, IL-6, IL-8, IL-10), cell adhesion (ICAM, P-selectin), and hemostasis (fibrinogen, D-dimer).ResultsA total of 89 patients (mean age 59.9 ± 8.2 years, 77.5% males, O2peak at baseline 14.8 ± 3.5 ml kg-1 min-1) completed the study. Both exercise modalities were safe (no significant adverse events recorded) and associated with a significant improvement in O2peak as compared to controls: age and baseline O2peak-adjusted end-of-study O2peak increased to 16.7 (95% CI 16.0–17.4) ml kg-1 min-1 with land-based training (p < 0.001 for change from baseline) and to 18.6 (95% CI 17.9–19.3) ml kg-1 min-1 with water-based training (p < 0.001 for change from baseline), but not in controls (14.9 ml kg-1 min-1; 95% CI 14.2–15.6; p = 0.775 for change from baseline). FMD also increased in both intervention groups (from 5.5 to 8.8%, p < 0.001 with land-based, and from 7.2 to 9.2%, p < 0.001 with water-based training, respectively), as compared to controls (p for change 0.629). No significant changes were detected in biomarkers of inflammation, cell adhesion or hemostasis, whereas levels of NT-proBNP (marker of cardiac dysfunction) decreased in the water-based training group (p = 0.07 vs. controls).ConclusionEndurance plus calisthenics exercise training in thermo-neutral water is safe, and improves aerobic exercise capacity and vascular function in patients undergoing short-term residential cardiac rehabilitation after a recent CAD event.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier NCT02831829.
Highlights
Exercise-based cardiac rehabilitation remains a cornerstone of management and secondary prevention in patients with coronary artery disease (CAD) (Piepoli et al, 2010; Anderson et al, 2016)
Acute coronary events – such as a recent myocardial infarction and/or coronary artery bypass grafting (CABG) procedure – may impair the ability of individuals to engage in exercise because of cardiac dysfunction, risks associated with the acute effects of exercise, post-procedure recovery, or immediate post-event psychological concerns (Anderson et al, 2016)
Aerobic exercise training on land – either alone, or supplemented by nonweight bearing exercises or low-weight resistance training – has been the most studied and the most widely implemented (Bjarnason-Wehrens et al, 2010) exercise modality in cardiac rehabilitation programs. This exercise modality is safe in CAD patients, purportedly because it provides a regulated cardiac output increase to meet the perfusion demand of large exercising muscle groups, minimizing safety concerns over raised pre- and afterload in high-risk cardiac patients with low aerobic exercise capacity – such as those after a recent myocardial infarction or revascularization procedure (Balady et al, 2007). This exercise modality has been shown to mitigate risk factors and metabolic abnormalities (Casillas et al, 2007; Ismail et al, 2013), which contribute to CAD and its progression, as well as to improve endothelial dysfunction, which plays a central role in all stages of atherosclerosis
Summary
Exercise-based cardiac rehabilitation remains a cornerstone of management and secondary prevention in patients with coronary artery disease (CAD) (Piepoli et al, 2010; Anderson et al, 2016). Acute coronary events – such as a recent myocardial infarction and/or coronary artery bypass grafting (CABG) procedure – may impair the ability of individuals to engage in exercise because of cardiac dysfunction, risks associated with the acute effects of exercise, post-procedure recovery, or immediate post-event psychological concerns (Anderson et al, 2016) In this respect, cardiac rehabilitation – either in outpatient settings or as an intensive short-term residential program – provides sufficient monitoring and reassurance to patients in the immediate aftermath of a recent CAD event, empowering them to confidently adopt long-term regular exercise and a healthy lifestyle (Mampuya, 2012; Menezes et al, 2014). We hypothesized that a 2-week twice daily aquatic endurance plus calisthenics exercise training program: (i) increases aerobic exercise capacity (peak oxygen uptake/V O2peak), (ii) improves endothelium-dependent flow-mediated vasodilation (FMD), and (iii) reduces circulating markers of low-grade inflammation and hemostasis, as compared to land-based endurance plus calisthenics exercise training or no exercise in patients undergoing short-term residential cardiac rehabilitation after a recent coronary artery disease (CAD) event
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