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Moderate training intensity sufficient to improve coronary collateral circulation

Comment by Hareld Kemps, EAPC Exercise, Basic and Translational Research Section


Despite great advances in interventional cardiology in the last decades, angina pectoris is still a debilitating symptom in a substantial number of patients with coronary artery disease. Currently, stable angina pectoris is considered an indication for cardiac rehabilitation in many national and international guidelines. Yet, recent studies showed that cardiac rehabilitation adoption rates in these patients are very low.

Recently, Möbius-Winkler and colleagues performed a controlled randomised trial, the EXCITE trial, evaluating the effect of moderate- and high-intensity exercise training on coronary collateral flow in patients with symptomatic Fractional Flow Reserve (FFR)-confirmed single or multivessel coronary artery disease. The exercise training program consisted of four 30-min interval training sessions, 5 days per week, at 70% and 95% of the angina threshold in the high intensity group (n=20); in the moderate intensity group training consisted of six to eight 20-min training sessions per day at 60% of the angina threshold in combination with lifestyle modification training (n=20).

After 4 weeks, both groups showed a significant increase in the coronary flow index of 39% and 41% as compared to 0.7% in the control group. Moreover, this increase was associated with improvements in peak VO2 and symptoms in both intervention groups. There were no adverse events related to the training program.

The authors concluded that a significant improvement in Collateral Flow Index (CFI) was demonstrated in response to moderate- and high-intensity exercise performed for 10 hours per week.

Although it can be argued whether the statistical power was sufficient to detect a statistical difference between both training regimes, this study shows that moderate training intensity is already sufficient to improve coronary collateral circulation.

From a clinical point of view, this study adds important new evidence for the application of cardiac rehabilitation in patients with stable angina pectoris and documented single or even multivessel coronary artery disease. Future studies should explore what the optimal training regime should be in terms of improving coronary collateral circulation. Another challenge is to increase awareness among cardiologists and health care insurers to include exercise training routinely in the treatment of patients with stable angina pectoris.


Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology