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Int J Sports Med 2021; 42(01): 19-26
DOI: 10.1055/a-1198-5573
Review

Current Insights into Exercise-based Cardiac Rehabilitation in Patients with Coronary Heart Disease and Chronic Heart Failure

Simon Nichols
1   Sheffield Hallam University Centre for Sports and Exercise Science, Sheffield, United Kingdom of Great Britain and Northern Ireland
,
Gordon McGregor 
2   University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, Coventry University, United Kingdom of Great Britain and Northern Ireland
,
Jeff Breckon
3   Academy of Sport and Physical Activity, Sheffield Hallam University, Sheffield, United Kingdom of Great Britain and Northern Ireland
,
Lee Ingle
4   Department of Sport, Health & Exercise Science, University of Hull, Hull, United Kingdom of Great Britain and Northern Ireland
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Abstract

Cardiac rehabilitation is a package of lifestyle secondary prevention strategies designed for patients with coronary heart disease and chronic heart failure. A community-based cardiac rehabilitation programme provides patients with a structured exercise training intervention alongside educational support and psychological counselling. This review provides an update regarding the clinical benefits of community-based cardiac rehabilitation from a psycho-physiological perspective, and also focuses on the latest epidemiological evidence regarding potential survival benefits. Behaviour change is key to long-term adoption of a healthy and active lifestyle following a cardiac event. In order for lifestyle interventions such as structured exercise interventions to be adopted by patients, practitioners need to ensure that behaviour change programmes are mapped against patient’s priorities and values, and adapted to their level of readiness and intention to engage with the target behaviour. We review the evidence regarding behaviour change strategies for cardiac patients and provide practitioners with the latest guidance. The ‘dose’ of exercise training delivered to patients attending exercise-based cardiac rehabilitation is an important consideration because an improvement in peak oxygen uptake requires an adequate physiological stimulus to invoke positive physiological adaptation. We conclude by critically reviewing the latest evidence regarding exercise dose for cardiac patients including the role of traditional and more contemporary training interventions including high intensity interval training.

Key words

exercise dose - behaviour change - risk factors - clinical outcomes - high intensity interval training


Publication History

Received: 17 March 2020

Accepted: 03 June 2020

Article published online:
10 July 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Tipton CM. The history of “Exercise Is Medicine” in ancient civilizations. Adv Physiol Educ 2014; 38: 109-117
    CrossrefPubMedGoogle Scholar
  • 2 Heberden W. Commentaries on the History and Cure of Diseases. T. Payne, London; 1802
    PubMed
  • 3 Mampuya WM. Cardiac rehabilitation past, present and future: An overview. Cardiovasc Diagn Ther 2012; 2: 38-49
    PubMedGoogle Scholar
  • 4 World Health Organisation. Expert Committee on The Rehabilitation of Patients With Cardiovascular Disease. Geneva; 1964
    PubMed
  • 5 World Health Organisation. Rehabilitation after cardiovascular diseases, with special emphasis on developing countries: A report of a WHO Committee. World Health Organ Tech Rep Ser 1993; 831: 1–122
    PubMed
  • 6 BACPR. Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2017. Available from: http://www.bacpr.com. Accessed March 2020
    PubMed
  • 7 Anderson L, Oldridge N, Thompson DR. et al. Exercise-based cardiac rehabilitation for coronary heart disease cochrane systematic review and meta-analysis. J Am Coll Cardiol 2016; 67: 1-12
    CrossrefPubMedGoogle Scholar
  • 8 Long L, Mordi IR, Bridges C. et al. Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev 2019; 1: Cd003331
    PubMedGoogle Scholar
  • 9 AACVPR. AACVPR Cardiac Rehabilitation Resource Manual. Leeds, UK: Human Kinetics;; 2006
    Google Scholar
  • 10 Savarese G, Lund LH. Global public health burden of heart failure. Card Fail Rev 2017; 3: 7-11
    CrossrefPubMedGoogle Scholar
  • 11 Ponikowski P, Voors AA, Anker SD. et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology [ESC]. Developed with the special contribution of the Heart Failure Association [HFA] of the ESC. Eur J Heart Fail 2016; 18: 891-975
    CrossrefPubMedGoogle Scholar
  • 12 Harriss DJ, Macsween A, Atkinson G. Ethical standards in sport and exercise science research: 2020 update. Int J Sports Med 2019; 40: 813-817
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Long L, Anderson L, He J. et al. Exercise-based cardiac rehabilitation for stable angina: Systematic review and meta-analysis. Open Heart 2019; 6: e000989
    CrossrefPubMedGoogle Scholar
  • 14 Heran BS, Chen J, Ebrahim S. et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011; 7: CD001800
    PubMedGoogle Scholar
  • 15 Powell R, McGregor G, Ennis S. et al. Is exercise-based cardiac rehabilitation effective? A systematic review and meta-analysis to re-examine the evidence. BMJ Open 2018; 8: e019656
    CrossrefPubMedGoogle Scholar
  • 16 Jolliffe J, Rees K, Taylor RR et al. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2000; 4: CD001800
    PubMed
  • 17 D’Souza SP, Mamas MA, Fraser DG. et al. Routine early coronary angioplasty versus ischaemia-guided angioplasty after thrombolysis in acute ST-elevation myocardial infarction: A meta-analysis. Eur Heart J 2011; 32: 972-982
    CrossrefPubMedGoogle Scholar
  • 18 Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: A quantitative review of 23 randomised trials. Lancet 2003; 361: 13-20
    CrossrefPubMedGoogle Scholar
  • 19 Taylor RS, Sagar VA, Davies EJ. et al. Exercise-based rehabilitation for heart failure. Cochrane Syst Rev 2014; 4: CD003331
    PubMedGoogle Scholar
  • 20 Lavie CJ, Menezes AR. De Schutter et al. Impact of cardiac rehabilitation and exercise training on psychological risk factors and subsequent prognosis in patients with cardiovascular disease. Can J Cardiol 2016; 32: S365eS373
    CrossrefPubMedGoogle Scholar
  • 21 Dalal HM, Taylor RS, Jolly K. et al. The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: The REACH-HF multicentre randomized controlled trial. Eur J Prev Cardiol 2019; 26: 262-272
    CrossrefPubMedGoogle Scholar
  • 22 Carroll S, Tsakirides C, Hobkirk J. et al. Differential improvements in lipid profiles and framingham recurrent risk score in patients with and without diabetes mellitus undergoing long-term cardiac rehabilitation. Arch Phys Med Rehab 2011; 92: 1382-1387
    CrossrefPubMedGoogle Scholar
  • 23 Gayda M, Brun C, Juneau M. et al. Long-term cardiac rehabilitation and exercise training programs improve metabolic parameters in metabolic syndrome patients with and without coronary heart disease. Nutr Metab Cardiovasc Dis 2008; 18: 142-151
    CrossrefPubMedGoogle Scholar
  • 24 Reibis R, Treszl A, Bestehorn K. et al. Comparable short-term prognosis in diabetic and non-diabetic patients with acute coronary syndrome after cardiac rehabilitation. Eur J Prev Cardiol 2012; 19: 15-22
    CrossrefPubMedGoogle Scholar
  • 25 Lavie CJ, Morshedi-Meibodi A. et al. Impact of cardiac rehabilitation on coronary risk factors, inflammation, and the metabolic syndrome in obese coronary patients. J Cardiometab Syndr 2008; 3: 136-140
    CrossrefPubMedGoogle Scholar
  • 26 van Tol BAF, Huijsmans RJ, Kroon DW. et al. Effects of exercise training on cardiac performance, exercise capacity and quality of life in patients with heart failure: A meta-analysis. Eur J Heart Fail 2006; 8: 841-850
    CrossrefPubMedGoogle Scholar
  • 27 Hambrecht R, Adams V, Erbs S. et al. Regular physical activity improves endothelial function in patients with coronary artery disease by increasing phosphorylation of endothelial nitric oxide synthase. Circulation 2003; 107: 3152-3158
    CrossrefPubMedGoogle Scholar
  • 28 Zheng H, Luo M, Shen Y. et al. Effects of 6 months exercise training on ventricular remodelling and autonomic tone in patients with acute myocardial infarction and percutaneous coronary intervention. J Rehabil Med 2008; 40: 776-779
    CrossrefPubMedGoogle Scholar
  • 29 Hambrecht R, Walther C, Möbius-Winkler S. et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: A randomized trial. Circulation 2004; 109: 1371-1378
    CrossrefPubMedGoogle Scholar
  • 30 Lewinter C, Doherty P, Gale CP. et al. Exercise-based cardiac rehabilitation in patients with heart failure: A meta-analysis of randomised controlled trials between 1999 and 2013. Eur J Prev Cardiol 2014; 6: 322-335
    PubMedGoogle Scholar
  • 31 Sandercock G, Cardoso F, Almodhy M. et al. Cardiorespiratory fitness changes in patients receiving comprehensive outpatient cardiac rehabilitation in the UK: A multicentre study. Heart 2013; 99: 785-790
    CrossrefPubMedGoogle Scholar
  • 32 Sandercock G, Hurtado V, Cardoso F. Changes in cardiorespiratory fitness in cardiac rehabilitation patients: A meta-analysis. Int J Cardiol 2013; 167: 894-902
    CrossrefPubMedGoogle Scholar
  • 33 Sandercock G, Cardoso F, Almodhy M. Cardiorespiratory fitness changes in patients receiving comprehensive outpatient cardiac rehabilitation in the UK: A multicentre study. Heart 2013; 99: 1298-1299
    CrossrefPubMedGoogle Scholar
  • 34 Ingle L, Carroll S. Cardiac rehabilitation and exercise training. Heart 2013; 56
    PubMedGoogle Scholar
  • 35 Khushhal A, Nichols S, Carroll S. et al. Insufficient exercise intensity for clinical benefit? Monitoring and quantification of a community-based Phase III cardiac rehabilitation programme: A United Kingdom perspective. PLoS One 2019; 14: e0217654
    CrossrefPubMedGoogle Scholar
  • 36 Kotseva K, De Backer G, De Bacquer D. et al. Lifestyle and impact on cardiovascular risk factor control in coronary patients across 27 countries: Results from the European Society of Cardiology ESC-EORP EUROASPIRE V registry. Eur J Prev Cardiol 2019; 26: 824-835
    CrossrefPubMedGoogle Scholar
  • 37 NACR. National Audit of Cardiac Rehabilitation [NACR] Quality and Outcomes Report 2018. Available from: https://www.bhf.org.uk/informationsupport/publications/statistics/national-audit-of-cardiac-rehabilitation-quality-and-outcomes-report-2018. Accessed Jan 2020
    PubMed
  • 38 West RR, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial [RAMIT]: Multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction. Heart 2012; 98: 637-644
    CrossrefPubMedGoogle Scholar
  • 39 Naar-King S, Earnshaw P, Breckon J. Towards a universal maintenance intervention: integrating motivational interviewing with cognitive-behavioural strategies for maintenance of behaviour change. J Cogn Psychother 2013; 27: 26-37
    CrossrefPubMedGoogle Scholar
  • 40 Foster C, Hillsdon M, Thorogood M. et al Interventions for promoting physical activity. Cochrane Database Syst Rev 2005; 1: CD003180
    PubMedGoogle Scholar
  • 41 Marcus B, Forsyth L, Stone E. et al. Physical activity behavior change: Issues in adoption and maintenance. Health Psychol 2000; 19: 32-41
    CrossrefPubMedGoogle Scholar
  • 42 Scott S, Breckon JD, Copeland R. An integrated motivational interviewing and cognitive behavioural intervention promoting physical activity maintenance for adults with chronic health conditions: A feasibility study. Chronic Illn 2019; 15: 276-292
    CrossrefPubMedGoogle Scholar
  • 43 Hutchison A, Johnston L, Breckon J. Grounded theory based research within exercise psychology: A critical review. Qual Res Psychol 2011; 8: 247-272
    CrossrefPubMedGoogle Scholar
  • 44 Breckon JD. Motivational interviewing to promote physical activity and nutrition behavior change. In: Anderson M, Hanrahan S, Eds. Doing Exercise Psychology. Human Kinetics, Champaign, Ill; 2015: 75–100
    PubMed
  • 45 Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process 1991; 50: 179-211
    CrossrefPubMedGoogle Scholar
  • 46 Fishbein M, Ajzen I. Predicting and Changing Behavior: The Reasoned Action Approach. New York, NY. Taylor & Francis; 2011
  • 47 Schwarzer R, Lippke S, Luszczynska A. Mechanisms of health behavior change in persons with chronic illness or disability: The health action process approach [HAPA]. Rehabil Psychol 2011; 56: 161-170
    CrossrefPubMedGoogle Scholar
  • 48 Knittle K, Nurmi J, Crutzen R. et al. How can interventions increase motivation for physical activity? A systematic review and meta-analysis. Health Psychol Rev 2018; 12: 211-230
    CrossrefPubMedGoogle Scholar
  • 49 Hilton C, Johnston L. Health psychology: It’s not what you do, it’s the way that you do it. Health Psychol Open 2017; 4: 2055102917714910
    CrossrefPubMedGoogle Scholar
  • 50 Lundby C, Montero D, Joyner M. Biology of VO2 max: Looking under the physiology lamp. Acta Physiol (Oxf) 2017; 220: 218-228
    CrossrefPubMedGoogle Scholar
  • 51 Kavanagh T, Mertens DJ, Hamm LF. et al. Prediction of long-term prognosis in 12 169 men referred for cardiac rehabilitation. Circulation 2002; 106: 666-671
    CrossrefPubMedGoogle Scholar
  • 52 Kavanagh T, Mertens DJ, Hamm LF. et al. Peak oxygen intake and cardiac mortality in women referred for cardiac rehabilitation. J Am Coll Cardiol 2003; 42: 2139-2143
    CrossrefPubMedGoogle Scholar
  • 53 Mancini DM, Eisen H, Kussmaul W. et al. Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure. Circulation 1991; 83: 778-786
    CrossrefPubMedGoogle Scholar
  • 54 Brubaker PH, Kitzman DW. Chronotropic incompetence: Causes, consequences, and management. Circulation 2011; 123: 1010-1020
    CrossrefPubMedGoogle Scholar
  • 55 Belardinelli R, Lacalaprice F, Carle F. et al. Exercise-induced myocardial ischaemia detected by cardiopulmonary exercise testing. Eur Heart J 2003; 24: 1304-1313
    CrossrefPubMedGoogle Scholar
  • 56 Poole DC, Hirai DM, Copp SW. et al. Muscle oxygen transport and utilization in heart failure: Implications for exercise [in] tolerance. Am J Physiol Heart Circ Physiol 2012; 302: H1050-H1063
    CrossrefPubMedGoogle Scholar
  • 57 Clark AL, Poole-Wilson PA, Coats AJS. Exercise limitation in chronic heart failure: Central role of the periphery. J Am Coll Cardiol 1996; 28: 1092-1102
    CrossrefPubMedGoogle Scholar
  • 58 Nichols S, O’Doherty AF, Taylor C. et al. Low skeletal muscle mass is associated with low aerobic capacity and increased mortality risk in patients with coronary heart disease – a CARE CR study. Clin Physiol Funct Imaging 2019; 39: 93-102
    CrossrefPubMedGoogle Scholar
  • 59 Fülster S, Tacke M, Sandek A. et al. Muscle wasting in patients with chronic heart failure: Results from the studies investigating co-morbidities aggravating heart failure [SICA-HF]. Eur Heart J 2013; 34: 512-519
    CrossrefPubMedGoogle Scholar
  • 60 Aspenes ST, Nilsen TI, Skaug EA. et al. Peak oxygen uptake and cardiovascular risk factors in 4631 healthy women and men. Med Sci Sports Exerc 2011; 43: 1465-1473
    CrossrefPubMedGoogle Scholar
  • 61 Keteyian SJ, Brawner CA, Savage PD. et al. Peak aerobic capacity predicts prognosis in patients with coronary heart disease. Am Heart J 2008; 156: 292-300
    CrossrefPubMedGoogle Scholar
  • 62 Shephard RJ. Maximal oxygen intake and independence in old age. Br J Sports Med 2009; 43: 342-346
    CrossrefPubMedGoogle Scholar
  • 63 Nichols S, Taylor C, Page R. et al. Is cardiorespiratory fitness related to cardiometabolic health and all-cause mortality risk in patients with coronary heart disease? A CARE CR Study. Sports Med Open 2018; 4: 22
    CrossrefPubMedGoogle Scholar
  • 64 Vanhees L, Fagard R, Thijs L. et al. Prognostic value of training-induced change in peak exercise capacity in patients with myocardial infarcts and patients with coronary bypass surgery. Am J Cardiol 1995; 76: 1014-1019
    CrossrefPubMedGoogle Scholar
  • 65 Martin BJ, Arena R, Haykowsky M. et al. Cardiovascular fitness and mortality after contemporary cardiac rehabilitation. Mayo Clin Proc 2013; 88: 455-463
    CrossrefPubMedGoogle Scholar
  • 66 Nichols S, Taylor C, Goodman T et al. Routine exercise-based cardiac rehabilitation does not increase aerobic fitness: A CARE CR Study. Int J Cardiol 2020; 305: 25–34
    PubMed
  • 67 Price KJ, Gordon BA, Bird SR. et al. A review of guidelines for cardiac rehabilitation exercise programmes: Is there an international consensus?. Eur J Prev Cardiol 2016; 23: 1715-1733
    CrossrefPubMedGoogle Scholar
  • 68 Turk-Adawi K, Supervia M, Pesah E. et al. Availability and delivery of cardiac rehabilitation in the Eastern Mediterranean Region: How does it compare globally?. Int J Cardiol 2019; 285: 147-153
    CrossrefPubMedGoogle Scholar
  • 69 British Heart Foundation. National Audit of Cardiac Rehabilitation [NACR] Quality and Outcomes Report 2019. Available at: https://www.bhf.org.uk. Accessed Jan 2020
    PubMed
  • 70 Smith KM, Arthur HM, McKelvie RS. et al Differences in sustainability of exercise and health-related quality of life outcomes following home or hospital-based cardiac rehabilitation. Eur J Prev Cardiol 2004; 11: 313-319
    CrossrefPubMedGoogle Scholar
  • 71 Kodama S, Saito K, Tanaka S. et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: A meta-analysis. JAMA 2009; 301: 2024-2035
    CrossrefPubMedGoogle Scholar
  • 72 Martin B-J, Arena R, Haykowsky M. et al. Cardiovascular fitness and mortality after contemporary cardiac rehabilitation. Mayo Clin Proc 2013; 88: 455-463
    CrossrefPubMedGoogle Scholar
  • 73 ACPICR. Standards for physical activity and exercise in the cardiac population 2015. Available at: http://acpicr.com accessed Nov 2019
    PubMed
  • 74 Mezzani A, Hamm LF, Jones AM. et al. 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. Eur J Prev Cardiol 2013; 20: 442-467
    CrossrefPubMedGoogle Scholar
  • 75 Garber CE, Blissmer B, Deschenes MR. et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 2011; 43: 1334-1359
    CrossrefPubMedGoogle Scholar
  • 76 Franklin BA, Thompson PD, Al-Zaiti SS et al. Exercise-related acute cardiovascular events and potential deleterious adaptations following long-term exercise training: Placing the risks into perspective-an update: A scientific statement from the American Heart Association. Circulation 2020; 141: e705–e736
    PubMed
  • 77 Liou K, Ho S, Fildes J. et al. High intensity interval versus moderate intensity continuous training in patients with coronary artery disease: A meta-analysis of physiological and clinical parameters. Heart Lung Circ 2016; 25: 166-174
    CrossrefPubMedGoogle Scholar
  • 78 Gomes Neto M, Duraes AR, Conceicao LSR. et al. High intensity interval training versus moderate intensity continuous training on exercise capacity and quality of life in patients with heart failure with reduced ejection fraction: A systematic review and meta-analysis. Int J Cardiol 2018; 261: 134-141
    CrossrefPubMedGoogle Scholar
  • 79 Gomes-Neto M, Duraes AR, Reis H. et al. High-intensity interval training versus moderate-intensity continuous training on exercise capacity and quality of life in patients with coronary artery disease: A systematic review and meta-analysis. Eur J Prev Cardiol 2017; 24: 1696-1707
    CrossrefPubMedGoogle Scholar
  • 80 Elliott AD, Rajopadhyaya K, Bentley DJ. et al. Interval training versus continuous exercise in patients with coronary artery disease: A meta-analysis. Heart Lung Circ 2015; 24: 149-157
    CrossrefPubMedGoogle Scholar
  • 81 Quindry JC, Franklin BA, Chapman M. et al. Benefits and risks of high-intensity interval training in patients with coronary artery disease. Am J Cardiol 2019; 123: 1370-1377
    CrossrefPubMedGoogle Scholar
  • 82 Wewege MA, Ahn D, Yu J. et al. High-intensity interval training for patients with cardiovascular disease-is it safe? a systematic review. J Am Heart Assoc 2018; 7: e009305
    CrossrefPubMedGoogle Scholar
  • 83 Rognmo O, Moholdt T, Fau-Bakken H. et al. Cardiovascular risk of high- versus moderate-intensity aerobic exercise in coronary heart disease patients. Circulation 2012; 136-140
    PubMedGoogle Scholar
  • 84 Conraads VM, Pattyn N, De Maeyer C. et al. Aerobic interval training and continuous training equally improve aerobic exercise capacity in patients with coronary artery disease: The SAINTEX-CAD study. Int J Cardiol 2015; 179: 203-210
    CrossrefPubMedGoogle Scholar
  • 85 Ellingsen O, Halle M, Conraads V. et al. High-intensity interval training in patients with heart failure with reduced ejection fraction. Circulation 2017; 135: 839-849
    CrossrefPubMedGoogle Scholar
  • 86 Taylor JL, Holland DJ, Spathis JG. et al. Guidelines for the delivery and monitoring of high intensity interval training in clinical populations. Prog Cardiovasc Dis 2019; 62: 140-146
    CrossrefPubMedGoogle Scholar
  • 87 Ribeiro PAB, Boidin M, Juneau M. et al. High-intensity interval training in patients with coronary heart disease: Prescription models and perspectives. Ann Phys Rehabil Med 2017; 60: 50-57
    CrossrefPubMedGoogle Scholar
  • 88 Pymer S, Nichols S, Prosser J. et al. Does exercise prescription based on estimated heart rate training zones exceed the ventilatory anaerobic threshold in patients with coronary heart disease undergoing usual-care cardiovascular rehabilitation? A United Kingdom perspective. Eur J Prev Cardiol 2019; 2047487319852711
    PubMedGoogle Scholar
  • 89 Hansen D, Bonne K, Alders T. et al. Exercise training intensity determination in cardiovascular rehabilitation: Should the guidelines be reconsidered?. Eur J Prev Cardiol 2019; 26: 1921-1928
    CrossrefPubMedGoogle Scholar
  • 90 Nichols S, Gleadall-Siddall DO, Antony R. et al. Estimated peak functional capacity: An accurate method for assessing change in peak oxygen consumption after cardiac rehabilitation?. Clin Physiol Funct Imaging 2018; 38: 681-688
    CrossrefPubMedGoogle Scholar
  • 91 De Schutter A, Kachur S, Lavie CJ. et al. Cardiac rehabilitation fitness changes and subsequent survival. Eur Heart J Qual Care Clin Outcomes 2018; 4: 173-179
    CrossrefPubMedGoogle Scholar
  • 92 Gevaert AB, Adams V, Bahls M. et al. Towards a personalised approach in exercise-based cardiovascular rehabilitation: How can translational research help? A ‘call to action’ from the Section on Secondary Prevention and Cardiac Rehabilitation of the European Association of Preventive Cardiology. Eur J Prev Cardiol 2019; 2047487319877716
    PubMedGoogle Scholar
  • 93 Sharman JE, La Gerche A, Coombes JS. Exercise and cardiovascular risk in patients with hypertension. Am J Hypertension 2015; 28: 147-158
    CrossrefPubMedGoogle Scholar