Susan Marzolini

Effect of combined aerobic and resistance training versus aerobic training alone in individuals with coronary artery disease: a meta-analysis:

Background: Resistance training (RT) has only a permissive role as an adjunct to aerobic training (AT) in cardiac rehabilitation. Design and methods: To compare the effect of AT with combined RT and AT (CT) we searched MEDLINE, Cochrane Controlled Trials Register, EMBASE, PreMedline, SPORT DISCUS, CINAHL (from the earliest date available to October 2009) for randomized controlled trials (RCTs), examining effects of CT versus AT on body composition, cardiovascular fitness (VO2peak), strength, and quality-of-life (QOL) in coronary artery disease (CAD) (excluding heart failure). Two reviewers selected studies independently. Results: Twelve studies met the study criteria (229 AT patients, 275 CT patients). Compared with AT, CT decreased percent body fat by −2.3% (WMD (weighted mean difference); 95% CI: −3.59 to −1.02), decreased trunk fat (SMD (standardized mean difference): −0.56; 95% CI: −0.96 to −0.15) and increased fat-free mass by 0.9 kg (WMD; 95% CI: 0.39 to 1.36) in three studies (n = 106). Similarly CT was associated with larger increases in lower body strength (seven studies, n = 225, SMD: 0.77; 95% CI: 0.49 to 1.04) and upper body strength (eight studies, n = 262, SMD: 1.07; 95% CI: 0.76 to 1.38). Compared to AT, CT improved peak work capacity (three studies, n = 92, SMD: 0.88; 95% CI: 0.45 to 1.31) and there was a trend for CT to increase V . O 2peak by 0.41 ml/kg/min (nine studies, n = 399, WMD; 95% CI: −0.05 to 0.88). Qualitative analysis of QOL data favors CT. Study withdrawals were similar for AT (14.2% ± 13.2) and CT (11.5% ± 15.5). No serious adverse events were reported. Conclusions: CT is more effective than AT in improving body composition, strength, and some indicators of cardiovascular fitness, and does not compromise study completion or safety when compared to AT.

Sex differences in completion of a 12-month cardiac rehabilitation programme: an analysis of 5922 women and men.

Background The reasons for greater premature withdrawal from cardiac rehabilitation programmes (CRP) in women compared with men and differences in baseline predictors of withdrawal have not been extensively studied. Methods Reasons for withdrawal from a 12-month CRP in 1089 women and 4833 men were ascertained by interview. Regression analysis was used to determine demographic and baseline medical conditions that predicted noncompletion. Results Noncompletion was higher in women than men (35 vs. 29%, P < 0.001), however, multivariate regression revealed that sex was not the main driver of withdrawal but rather, other factors common to women at entry to CR could predict noncompletion (i.e. not being married, being obese, lower peak oxygen uptake, not having earlier coronary artery bypass graft surgery, being on antidepressant medication and not on lipid lowering or β-blockade medication). By interview, a greater proportion of women than men withdrew for medical issues (P < 0.001), specifically musculoskeletal conditions (P = 0.002) and multiple medical problems (P = 0.02). A greater proportion of women withdrew for transportation (P < 0.001) and family issues (P = 0.009), whereas work issues affected men more than women (P = 0.009), as did lack of interest (P = 0.009). Women were more likely to withdraw than men regardless of age (P < 0.05). Conclusion Women were significantly more likely to withdraw from CRP than men because of greater medical problems, specifically musculoskeletal and multiple medical reasons. Lack of interest and work obligations were greater barriers for men while transportation and family obligations more often affected women. Difference in withdrawal can be explained by the profile of women rather than by sex independently. Eur J Cardiovasc Prev Rehabil 15:698703

Adherence to a home-based exercise program for individuals after stroke.

Abstract Background: Although aerobic training (AT) and resistance training (RT) have been shown to improve functional abilities in patients post stroke, few patients participate, with many doing so for only a short duration. Purpose: To retrospectively identify factors that affect adherence to a home-based exercise program adapted for stroke patients in a cardiac rehabilitation program during and after program completion. Methods: Fourteen participants (age 63 ± 3 years, 37 ± 34 months post stroke) attended the rehabilitation center on a weekly (24 weeks) and then monthly (2 months) basis. Patients were required to complete 4 AT and 1 to 2 RT sessions away from the center each week. A 16-item survey exploring adherence to home-based workouts was administered. Results: Seven patients were currently participating (mean time in program, 19.4 ± 8 weeks) and 7 had graduated (mean of 32.8 ± 28 weeks post graduation) from the program. Current participants had higher adherence than graduated participants to AT (100% vs 76%; P < .01) and RT (100% vs 55%; P < .01). The most common factors motivating participants were to improve overall health, improve functional abilities, and enhance confidence and to reduce musculoskeletal issues. The most common factors preventing workouts were lack of motivation, musculoskeletal issues, and fatigue. There was a negative correlation between age and adherence to AT in the graduated group. Conclusion: Adherence to home-based exercise is superior during participation in an organized group program, with decline after graduation.

The Effects of an Aerobic and Resistance Exercise Training Program on Cognition Following Stroke

Background. Cognitive benefits obtained from exercise in healthy populations support the idea that aerobic and resistance training (AT+RT) would confer benefit for poststroke recovery. However, there is little evidence regarding the effectiveness of such programs. Objective. To evaluate the effects of a 6-month exercise program of AT+RT on cognition in consecutively enrolled patients with motor impairments ≥10 weeks poststroke. Methods. Outcomes were measured before and after 6 months of AT+RT on 41 patients. Cognition was measured by the Montreal Cognitive Assessment (MoCA). Secondary measures included evaluation of gas exchange anaerobic threshold (ATge), body composition by dual energy X-ray absorptiometry, and depressive symptoms by questionnaire. Results. There were significant improvements in overall MoCA scores (22.5 ± 4.5 to 24.0 ± 3.9, P < .001) as well as in the subdomains of attention/concentration (4.7 ± 1.7 to 5.2 ± 1.3, P = .03) and visuospatial/executive function (3.4 ± 1.1 to 3.9 ± 1.1, P = .002). There was a significant reduction in the proportion of patients meeting the threshold criteria for mild cognitive impairment (MCI) at baseline compared with posttraining (65.9% vs 36.6%, P < .001). In a linear regression model, there was a positive association between change in cognitive function and change in fat-free mass of the nonaffected limbs (β = .002; P = .005) and change in attention/concentration and change in ATge (β = .383; P ≤ .001), independent of age, sex, time from stroke, and change in fat mass and depression score. Conclusion. A combined training model (AT+RT) resulted in improvements in cognitive function and a reduction in the proportion of patients meeting the threshold criteria for MCI. Change in cognition was positively associated with change in fat-free mass and ATge.

Major Depressive Disorder Predicts Completion, Adherence, and Outcomes in Cardiac Rehabilitation: A Prospective Cohort Study of 195 Patients With Coronary Artery Disease

OBJECTIVE To compare completion, adherence, and cardiac rehabilitation (CR) outcomes between participants with and without major depressive disorder (MDD) undertaking CR. METHOD In a prospective cohort study of consecutive patients with coronary artery disease (n = 195) entering 1-year outpatient CR between January 2006 and August 2008, rates of noncompletion (comprehensive CR criteria), nonadherence (< 70% attendance at scheduled CR visits), and CR outcomes were compared between patients with and without MDD based on the Structured Clinical Interview for DSM-IV criteria. RESULTS Major depressive disorder was diagnosed in 22.1% of participants. Rates of noncompletion were 44.2% and 28.9%, and rates of nonadherence were 53.0% and 34.9% for those with and without MDD, respectively. Major depressive disorder was associated with increased risks of noncompletion (multivariate hazard ratio [HR], 2.5; 95% confidence interval [CI], 1.3-4.7) and nonadherence (multivariate HR, 2.4; 95% CI, 1.3-4.2). More participants with MDD failed to complete CR for medical reasons than those without MDD (25.6% vs 12.3%, respectively; P = .031) in post hoc comparisons. Participants with MDD achieved poorer cardiopulmonary fitness increases (change in mean ± SD peak oxygen uptake of 3.3 ± 3.2 vs 6.6 ± 5.7 mL/kg/min; P = .021) and poorer body fat outcomes (a mean ± SD increase of 2.1% ± 4.5% vs a decrease of 0.4% ± 3.4%, P = .009) than those without MDD. CONCLUSIONS Major depressive disorder was associated with poorer rates of completion and adherence in CR, and it mitigated improvements in clinical outcomes. Despite depression screening and psychosocial support as structured components of care, MDD remained a significant barrier to effective CR.

Feasibility and effects of adapted cardiac rehabilitation after stroke: a prospective trial

BackgroundDespite the cardiovascular etiology of stroke, exercise and risk factor modification programs akin to cardiac rehabilitation (CR) are not available. This study aimed to establish the feasibility of adapting a CR model for individuals with mild to moderate stroke disability. A secondary objective was to determine the programs effects on aerobic and walking capacity, and stroke risk factors.MethodsA repeated measures design was used with a 3-month baseline period and 6-month adapted CR intervention (n = 43, mean ± SD age 65 ± 12 years, 30 ± 28 months post stroke). Feasibility was determined by the number of participants who completed the study, occurrence of adverse events and frequency, duration and intensity of exercise performed. To determine effectiveness of the program, outcomes measured included aerobic capacity (VO2peak, ventilatory threshold), 6-Minute Walk Test (6MWT) distance, and risk factors. Descriptive statistics characterized the classes attended and number and intensity of exercise sessions. Paired t-tests, one-factor repeated measures analyses of variance contrasts and chi-square analyses were used to compare changes over time.ResultsTwo participants withdrew during the baseline period. Of the remaining 41 participants who commenced the program, 38 (93%) completed all aspects. No serious adverse effects occurred. Post-intervention, VO2peak improved relative to the stable baseline period (P = 0.046) and the increase in ventilatory threshold approached significance (P = 0.062).ConclusionsCR is feasible after stroke and may be adapted to accommodate for those with a range of post-stroke disability. It is effective in increasing aerobic capacity. CR may be an untapped opportunity for stroke survivors to access programs of exercise and risk factor modification to lower future event risk.Trial registrationClinicalTrials.gov registration number: NCT01067495

Aerobic and Resistance Training in Coronary Disease: Single versus Multiple Sets

PURPOSE The purpose of this study was to compare resistance training (RT) (one set vs three sets) combined with aerobic training (AT) versus AT alone in persons with coronary artery disease. METHODS Subjects (n = 72) were randomized to AT (5 d x wk(-1)) or combined AT (3 d x wk(-1)) with either one set (AT/RT1) or three sets (AT/RT3) of RT performed 2 d x wk(-1). VO2peak, ventilatory anaerobic threshold (VAT), strength and endurance, body composition, and adherence were measured before and after 29 wk of training. RESULTS Fifty-three subjects (mean +/- SEM age 61 +/- 2) completed the training. The increase from baseline in VO2peak (L x min(-1)) averaged 11% for AT (P < 0.05), 14% for AT/RT1 (P < 0.01), and 18% for AT/RT3 (P < 0.001), however, the difference between groups was not significant. VAT improved significantly in the AT/RT3 group only (P < 0.05). The AT/RT3 group gained more lean mass than the AT group (1.5 versus 0.4 kg, P < 0.01), yet gains between AT/RT1 and AT were similar (P = 0.2). Only AT + RT groups demonstrated a reduction in body fat (P < 0.05). Strength and endurance increased more in the AT + RT groups than AT alone (P < 0.05). Adherence to number of sets performed was lower in AT/RT3 than AT/RT1 (P < 0.02). CONCLUSIONS Combined AT + RT yields more pronounced physiological adaptations than AT alone and appears to be superior in producing improvements in VO2peak, muscular strength and endurance, and body composition. The data support the use of multiple set RT for patients desiring an increased RT stimulus which may further augment parameters that affect VO2peak, VAT, lower body endurance, and muscle mass in a cardiac population.

Exercise intervention and inflammatory markers in coronary artery disease: A meta-analysis

BACKGROUND Inflammatory activity plays a role in the development and progression of coronary artery disease (CAD), and exercise confers survival benefit. We performed a meta-analysis of changes in inflammatory biomarkers over the course of exercise interventions in patients with CAD. METHODS We searched MEDLINE, Embase, the Cochrane Collaboration, AMED, and CINAHL for studies reporting peripheral inflammatory biomarker concentrations before and after exercise interventions of ≥ 2 weeks in patients with CAD. Data were summarized using standard mean differences (SMD) and 95% CIs. RESULTS Twenty-three studies were included. Concentrations of C-reactive protein (CRP; SMD -0.345, 95% CI -0.444 to -0.246, n = 1,466, P < .001), interleukin 6 (SMD -0.546, 95% CI -0.739 to -0.353, n = 280, P < .001), fibrinogen (SMD -0.638, 95% CI -0.953 to -0.323, n = 247, P < .001), and vascular cell adhesion molecule 1 (SMD -0.413, 95% CI -0.778 to -0.048, n = 187, P = .027) were lower postintervention. Higher total cholesterol (B = -0.328, 95% CI -0.612 to -0.043, P = .026) and higher total/high-density lipoprotein cholesterol ratios (B = -0.250, 95% CI -0.425 to -0.076, P = .008) at baseline were associated with greater reductions in CRP. In controlled studies, follow-up concentrations of CRP (SMD -0.500, 95% CI -0.844 to -0.157, n(exercise/control) = 485/284, P = .004), and fibrinogen (SMD -0.544, 95% CI -1.058 to -0.030, n(exercise/control) = 148/100, P = .038) were lower in subjects who exercised compared with controls. CONCLUSION Exercise training is associated with reduced inflammatory activity in patients with CAD. C-reactive protein and fibrinogen have provided the strongest evidence. Higher baseline CRP and adverse baseline lipid profiles predicted greater reductions in CRP.

Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis

Background Cardiovascular disease continues to be among the leading causes of morbidity and mortality among men and women globally. However, research suggests that women are significantly underrepresented in cardiac rehabilitation (CR), programmes which are shown to reduce recurrent cardiac events and related premature death. However, sex differences in referral rates have not been systematically and quantitatively reviewed. Hence, the objective of the study was to assess whether a significant sex difference exists. Methods We searched Scopus, MEDLINE, CINAHL, PsycINFO, PubMed, and The Cochrane Library databases for studies reporting CR referral rates in women and men published between July 2000 and July 2011. Titles and abstracts were screened, and the selected full-text articles were independently screened based on predefined inclusion/exclusion criteria. Included articles were assessed for quality using STROBE. Results Of 623 screened articles, 19 observational studies reporting data for 241,613 participants (80,505 women) met the inclusion criteria. In the pooled analysis, women (39.6%) were significantly less likely to be referred to CR compared to men (49.4%; odds ratio 0.68, 95% confidence interval 0.62–0.74). Heterogeneity was considered significant (I2 = 90%). There was no change in significant findings when subgroup analyses were conducted, examining fee for service vs. no fee, high-quality studies vs. others, or studies pooled by different study methodologies. Conclusions CR referral remains low for all patients, but is significantly lower for women than men. Evidence-based interventions to increase referral for all patients, including women, need to be instituted. It is time to ensure broader implementation of these strategies.

The Feasibility of Cardiopulmonary Exercise Testing for Prescribing Exercise to People After Stroke

Background and Purpose— Despite the importance of exercise training in mitigating cardiovascular risk, the development of exercise programs for people poststroke has been limited by lack of feasibility data concerning cardiopulmonary exercise testing (CPET) to inform the exercise prescription. Therefore, we examined the feasibility of CPETs for developing an exercise prescription in people ≥3 months poststroke. Methods— CPET results from 98 consecutively enrolled patients poststroke with motor impairments and 98 age- and sex-matched patients with coronary artery disease were examined at baseline and after 6 months of exercise training. Results— The proportion of patients with stroke and coronary artery disease attaining an intensity sufficient for prescribing exercise at baseline was 68.4% versus 82.7%, respectively (P=0.02) and 84.7% versus 83.8% (P=0.9) at 6 months. Women were less likely than men poststroke to achieve a sufficient intensity at baseline (40% versus 80.9%, P<0.001) but not at 6 months (78.3% versus 87.1, P=0.3). A clinically relevant abnormality occurred in 11.2% of stroke and 12.2% of patients with coronary artery disease on baseline CPETs (P=0.8) and 10.6% of stroke and 5.9% of patients with coronary artery disease on the 6-month CPET (P=0.4). No serious cardiovascular events occurred during 349 CPETs. Conclusions— Most patients after stroke achieved a level of exertion during the CPET sufficient to inform an exercise prescription. At least 1 of 10 patients poststroke developed a clinically relevant abnormality on baseline and postprogram CPETs with no serious cardiovascular events. These data support the feasibility and safety of CPETs for prescribing exercise poststroke. Strategies to improve use of baseline CPETs for women poststroke require further investigation.