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Non-linear and linear progressive periodized aerobic training in cardiac rehabilitation are equally effective

Comment by Professor Maja-Lisa Løchen, Population Science and Public Health Section

Rehabilitation and Sports Cardiology
Risk Factors and Prevention

Participation in a cardiac rehabilitation program for patients hospitalised for an acute coronary event or revascularisation is recommended. Exercise training is an integrated and well-documented part of this program as it reduces cardiovascular mortality and hospital admissions and improves quality of life (1,2).

In a current randomised controlled trial in 39 Canadian coronary heart disease patients by Boidin and co-authors (3), the authors compared two different progressive periodised aerobic training protocols. The patients had mean age 65 years, were on optimal medical treatment and were supervised and closely followed over three months (36 sessions) in linear versus non-linear aerobic training on the cardiopulmonary exercise response. The exercise program included isoenergetic aerobic training and a resistance training program. Weekly energy expenditure was constantly increased in the linear group for the aerobic training, while it was deeply increased and intercepted with a recovery week every fourth week in the non-linear group. Various gas exchange measurements including peak VO2 were performed.

Peak VO2 and the other cardiopulmonary exercise testing variables increased significantly and similarly in both groups. The VO2 increase was 8% in the linear group and 5% in the non-linear group, and even this modest increase could have a clinical impact. It has been shown that a 1% increase in peak VO2 is associated with a 2% decrease in cardiovascular disease mortality and better prognosis (4,5). Adherence to training was 100% in both groups and the proportion of non-, low and high responders was similar. More variation in the training load did not make any difference regarding cardiopulmonary response. The training programs were equally effective with no adverse events.

In an accompanying editorial (6) the author highlighted the interesting and novel study design and results, but noted that the study is too small to draw firm conclusions regarding the results for the regular coronary heart disease patient.

Despite the documented benefits of exercise-based cardiac rehabilitation, it is underused in Europe where only half of coronary patients were referred and a minority attended (7). Increasing knowledge and referral to cardiovascular rehabilitation is warranted. One should inspire and guide health professionals to use evidence-based guidelines in their decision-making. Referral to an exercise based rehabilitation program for coronary heart disease patients is a role that should be taken on by general practice as well as specialists. EAPC President, Martin Halle, has emphasized improved treatment of cardiovascular risk factors as a priority for his EAPC Presidency, and it is obvious that there is still a great potential to improve the situation for these patients by providing a modern secondary preventive cardiac program.

Patients with coronary heart disease are at high risk of severe complications from COVID-19 infection, and they have been advised to self-isolate to lower the risk of contracting the virus. For these patients, the ability to exercise and follow a self-care rehabilitation intervention without leaving the home is very important. Health personnel should develop and deliver home-based cardiac rehabilitation programs including exercise advice digitally and remotely, which includes patient interaction and professional supervision (8). We have learnt that both linear and non-linear aerobic exercise training in these patients are effective and safe, so the important issue is to start acting for the best of the patients, although more robust evaluation of new modes will have to be provided in the future.

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


Maja-Lisa Løchen commented on this article:

3. Boidin M, Trachsel LD, Nigam A, Juneau M, Tremblay J, Gayda M. Non-linear is not superior to linear aerobic training periodization in coronary heart disease patients. Eur J Prev Cardiol 2020;27:1691-8.

Additional references:

1. Piepoli MF, Abreu A, Albus C, et al. Update on cardiovascular prevention in clinical practice: A position paper of the European Association of Preventive Cardiology of the European Society of Cardiology. Eur J Prev Cardiol 2020;27:181-205.
2. 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.
4. Vanhees L, Fagard R, Thijs L, Amery A. 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;76:1014-9.
5. De Schutter A, Kachur S, Lavie CJ, Menezes A, Shum KK, Bangalore S, Arena R, Milani RV. Cardiac rehabilitation fitness changes and subsequent survival. Eur Heart J Qual Care Clin Outcomes 2018;4:173-179.
6. Corrà U. Alternative aerobic training session in coronary artery disease patients in cardiac rehabilitation. A new stone thrown in the pond. Eur J Prev Cardiol 2020;27:1688-90.
7. Kotseva K, Wood D, De Bacquer D et al. Determinants of participation and risk factor control according to attendance in cardiac rehabilitation programmes in coronary patients in Europe: EUROASPIRE IV survey. Eur J Prev Cardiol 2018;25:1242-51.
8. Dalal H, Taylor RS, Greaves C, et al. Correspondence to the EJPC in response to position paper by Ambrosetti M et al. 2020: Cardiovascular rehabilitation and COVID-19: The need to maintain access to evidence-based services from the safety of home. Eur J Prev Cardiol. 2020 Apr 28:2047487320923053.