Cardiorespiratory fitness and quality of life at different exercise intensities after myocardial infarction

Abstracts

FUNDAMENTO: Estudos que relacionam exercícios físicos e saúde têm contribuído para a compreensão da influência de hábitos sedentários com a incidência de doenças cardiovasculares. OBJETIVO: Comparar o efeito de diferentes intensidades de exercício aeróbio sobre a capacidade funcional (VO2 pico) e a qualidade de vida de pacientes pós-infarto agudo do miocárdio. MÉTODOS: 87 homens (57,7 anos, ± 6,1) participaram deste estudo prospectivo, com 12 semanas de treinamento físico de alta intensidade (n=29), a 85% da frequência cardíaca máxima, de intensidade moderada (n=29), a 75% da frequência cardíaca máxima, ou no grupo controle (n=29), que recebeu acompanhamento clínico. O exercício aeróbio foi realizado cinco vezes por semana, 45 minutos por sessão, além de exercícios de resistência muscular e alongamentos. O VO2 pico foi mensurado com teste cardiopulmonar, e a qualidade de vida foi avaliada pelo questionário MacNew. RESULTADOS: A ANOVA two-way revelou aumento do VO2 pico significativo (p<0,05) no grupo de alta intensidade (29,9 ± 2,2 ml/kg.min para 41,6 ± 3,9 ml/kg.min) em relação ao grupo de moderada intensidade (32,0 ± 5,3 ml/kg.min para 37,1 ± 3,9 ml/kg.min). Além disso, ambos os grupos de exercício aumentaram significativamente em relação ao grupo controle (31,6 ± 3,9 para 29,2 ± 4,1). A qualidade de vida teve melhora significativa (p<0,05) no grupo de alta intensidade (5,66 para 6,80) e de moderada intensidade (5,38 para 6,72), mas não no grupo controle (5,30 para 5,15) CONCLUSÃO: Os exercícios de maior intensidade resultaram em maior aumento na capacidade funcional e na qualidade de vida em pacientes no pós-infarto do miocárdio.

Exercício; aptidão física; qualidade de vida; infarto do miocárdio

FUNDAMENTO: Estudios que relacionan ejercicios físicos y salud han estado contribuyendo a la comprensión de la influencia de hábitos sedentarios con la incidencia de enfermedades cardiovasculares. OBJETIVO: Comparar el efecto de diferentes intensidades de ejercicio aerobio sobre la capacidad funcional (VO2 pico) y la cualidad de vida de pacientes postinfarto agudo del miocardio. MÉTODOS: 87 varones (57,7 años, ± 6,1) participaron de este estudio prospectivo, con 12 semanas de entrenamiento físico de alta intensidad (n=29), al 85% de la frecuencia cardíaca máxima, de intensidad moderada (n=29), al 75% de la frecuencia cardíaca máxima, o en el grupo control (n=29), que recibió seguimiento clínico. El ejercicio aerobio se llevó a cabo cinco veces por semana, 45 minutos por sesión, además de ejercicios de resistencia muscular y alargamientos. El VO2 pico se cuantificó con prueba cardiopulmonar, y la cualidad de vida se evaluó por el cuestionario MacNew. RESULTADOS: La ANOVA two-way reveló incremento del VO2 pico significativo (p<0,05) en el grupo de alta intensidad (29,9 ± 2,2 ml/kg.min para 41,6 ± 3,9 ml/kg.min) en relación con el grupo de moderada intensidad (32,0 ± 5,3 ml/kg.min para 37,1 ± 3,9 ml/kg.min). Además de ello, ambos grupos de ejercicio aumentaron significativamente con relación al grupo control (31,6 ± 3,9 para 29,2 ±4,1). La calidad de vida tuvo mejora significativa (p<0,05) en el grupo de alta intensidad (5,66 para 6,80) y de moderada intensidad (5,38 para 6,72), sin embargo no en el grupo control (5,30 para 5,15). CONCLUSIÓN: Los ejercicios de mayor intensidad resultaron en mayor aumento en la capacidad funcional y en la calidad de vida en pacientes en el postinfarto del miocardio.

Ejercicio; aptitud física; calidad de vida; infarto del miocardio

ORIGINAL ARTICLES

Cardiorespiratory fitness and quality of life at different exercise intensities after myocardial infarction

Magnus Benetti^I,II; Cintia Laura Pereira de Araujo^I; Rafaella Zuianello dos Santos^II

^IUniversidade do Estado de Santa Catarina

^IIClínica Cardiosport, Florianópolis, SC - Brasil

Mailing address

ABSTRACT

BACKGROUND: Studies relating physical exercises and health have contributed to elucidate the influence of sedentary habits on the incidence of cardiovascular diseases.

OBJECTIVE: To compare the effect of different intensities of aerobic exercises on patients' functional capacity (VO_2peak) and quality of life after acute myocardial infarction.

METHODS: Eighty-seven men (57.7 ± 6.1 years old) were enrolled in this prospective study and assigned to one of three groups: a) high-intensity physical training (n=29) at 85% maximum heart rate for 12 weeks; b) moderate-intensity training (n=29) at 75% maximum heart rate for 12 weeks; and c) control group (n=29), who were followed. The training groups did aerobic exercises five times a week in 45-minute sessions, besides muscular strengthening and stretching exercises. Maximum VO₂ was measured through a cardiopulmonary test, and quality of life was assessed through the MacNew Questionnaire.

RESULTS: Two-way ANOVA revealed a significant increase in VO_2peak (p<0.05) in the high-intensity training group (from 29.9 ± 2.2 ml/kg.min to 41.6± 3.9 ml/kg.min) compared with the moderate-intensity training group (from 32.0 ± 5.3 ml/kg.min to 37.1 ± 3.9 ml/kg.min). Additionally, both training groups showed a significant increase in this parameter compared with the control group (from 31.6 ± 3.9 ml/kg.min to 29.2 ±4.1 ml/kg.min). Quality of life improved significantly (p<0.05) in the high-intensity training group (from 5.66 to 6.80) and in the moderate-intensity training group (from 5.38 to 6.72), but not in the control group (from 5.30 to 5.15).

CONCLUSION: Exercises of greater intensity resulted in an increase in functional capacity and quality of life in patients after myocardial infarction.

Key words: Exercise; physical fitness; quality of life; myocardial infarction.

Introduction

Individuals who suffered acute myocardial infarction (AMI) usually have impaired physiological, social, and labor conditions, with poor quality of life (QOL)^1,2. QOL assessment has been emphasized as an important variable in clinical practice, since it brings medical knowledge that can result in healthcare changes and in the consolidation of new paradigms for the health-disease process³.

Cardiac rehabilitation (CR) is a series of prophylactic and therapeutic measures aimed at reducing the physical and psychosocial impacts caused by the individual's limiting conditions. Its goal is to improve the functional capacity, QOL, and prognosis⁴ and, if possible, to reverse the progression of coronary artery disease (CAD) as well^5,6. CR can reduce general mortality by 20% and heart-related mortality by 26% in 2-5 years after the cardiac event⁷.

Apparently, there is an inverse correlation between the level of physical fitness and the occurrence of CAD manifestations⁸. In this context, the individual's lifestyle, including physical activity, has an impact on the treatment of AMI, even as a potential factor for disease regression^5,9,10.

Aerobic exercises are an important tool in CR because they are cost-effective, reduce risk factors for CAD, and consequently improve the individual's QOL and cardiorespiratory fitness^6,11-13, which is one of the most important cardiovascular parameters in the prognosis of coronary pathologies^11,13. Both the functional capacity (VO_2peak) and QOL assessment proved to be important for the strategic treatment and prognosis of CAD¹⁴.

However, there are few studies involving infarcted patients undergoing a CR program. We do not yet know whether exercise intensity should be considered a critical factor and what this intensity should be^15,16. We also lack well-defined guidance on the intensity required to reach the benefits of aerobic exercises on VO_2peak and QOL.

Therefore, the objective of this study was to compare the effect of different aerobic exercise intensities on VO_2peak and QOL of post-AMI patients.

Methods

Sample

In this prospective study, patients from the Greater Florianópolis region who had suffered an AMI in the previous 12 months were assessed. Exclusion criteria were: female gender; age under 18 years; heart failure; poorly controlled diabetes; chronic obstructive pulmonary disease; systolic and diastolic arterial pressure higher than 160 mmHg and 95 mmHg, respectively; smokers; and those who had not been sedentary for at least 12 months. Of the 153 patients initially assessed, 55 did not meet these criteria and therefore were excluded. All subjects underwent the tests at least 60 days after the infarction date.

Ninety-eight patients met the following inclusion criteria: adult (18 years old or older), male gender, sedentary life for 12 months or more, and AMI in the previous 12 months, and were randomly assigned to one of three groups. Of the 98 patients who started the training program, 11 did not conclude the trial: one patient moved to another city; two patients had unstable angina episodes and were referred to medical reassessment; one patient had joint problems; one patient was advised to leave the program by a second medical opinion; one patient underwent another percutaneous transluminal angioplasty; and one patient did not like the program.

The 87 patients who concluded the trial joined a 12-week intervention program; their mean age was 57 ± 6.1 years. All subjects agreed to participate in this clinical trial by signing an Informed Consent Form according to the Brazilian Health Council Resolution No.196/96. This study was approved by the Research Ethics Committee of the State University of Santa Catarina, under Protocol No. 62/2007.

Measurement instruments

All subjects underwent a cardiopulmonary test on an ATL 15000 Embramed treadmill equipped with a Micromed Elite ErgoPC 13 computerized system (Brasília, Brazil) and a Cortex ergospirometry system (Germany, 2005) with breath-by-breath gas analyzer. A multistage, multiple-workload Ellestad protocol, indicated for diagnostic tests and functional assessments, was used. It consists of six stages, starting at 1.7 mph and a 10% slope for 3 minutes, increasing the workload by two metabolic equivalents (METs) per stage until reaching 6.0 mph at a 15% slope.

The anthropometric measurements used were: height (cm), measured by a SANNY stadiometer (accuracy 0.1cm), and weight (kg), measured by a Filizola^TM scale (resolution 100g), for Body Mass Index (BMC) calculation (kg/cm²); waist and hip circumference (cm); and waist-to-hip ratio (WHR)¹⁷.

The heart rate was measured at all exercise sessions using a Polar^TM SF1 heart rate monitor. QOL was assessed using the MacNew Quality of Life after Myocardial Infarction Questionnaire (MacNew QLMI), developed by Oldridge et al¹⁸ and validated in Portuguese by Benetti et al¹⁹. This questionnaire quantitatively assesses QOL perception, and the recommended score involves emotional, physical, and social domains. It contains questions on humor, self-esteem, stress, disposition, independence, sexuality, confidence regarding the heart problem, chest pains, physical capacity, etc.

Exercise training program

The individuals were assigned to a high-intensity (HI) aerobic exercise program (n=29), a moderate-intensity (MI) aerobic exercise program (n=29), or a control group (C) (n=29). For the HI aerobic exercise program, patients exercised at around 85% of their maximum heart rate (HR) achieved in the stress test, whereas for the MI program, patients exercised at a approximately 75% of their HR_max. Both groups did aerobic exercises five times a week during 45 minutes, followed by stretching and muscular strengthening exercises for 15 minutes. Patients in the control group did not do any exercises. The three groups were instructed to maintain their usual diet.

Statistical analysis

Descriptive statistics (mean and standard deviation) were used to describe the sample. All data were evaluated through Analysis of Variance (Two-way ANOVA) and the Tukey's post-hock test when necessary. The level of significance used was 0.05.

Results

Subject characteristics

Table 1 shows the characteristics of the study subjects. There were no significant differences among the groups for the parameters analyzed (p < 0.05). Concerning the anthropometric characteristics, subjects in groups MI and C were overweight (BMI > 24.9 kg/cm²) and subjects in the HI group were obese (BMI > 30 kg/cm²), according to the WHO classification¹⁷. The waist-to-hip ratio (WHR) was higher than the reference values (0.95 for men), indicating that the sample was within the risk range¹⁷. Table 1 also shows that high-density lipoprotein cholesterol (HDL-c) levels were lower than those recommended (40 mg/dl) in the three groups¹⁹.

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Cardiorespiratory fitness

Figure 1 shows VO_2oeak results for the three groups. It can be observed that VO_2peak improved significantly in both aerobic training groups (HI and MI) after a 12-week intervention. Also, there was a significant statistical difference between the training groups and the control group after the intervention period. Finally, the HI group achieved a significant improvement compared with the MI group (p < 0.05).

Quality of life

Table 2 shows the results related to QOL scores. The group analysis before and after intervention demonstrated that the practice of physical exercises, regardless of their intensity, improved QOL perception compared with the control group. However, the comparison between HI and MI training groups revealed that exercise intensity had a significant impact on QOL improvement (p < 0.05).

Discussion

Studies relating physical exercises and health have contributed to elucidate the influence of sedentary habits on the incidence of cardiovascular diseases^4,20-22. A clinical trial conducted with heart disease patients demonstrated that the capacity to exercise is a strong predictor of death risk¹³. Therefore, non-pharmacological interventions, such as physical exercise programs, are recommended as primary and secondary measures for preventing these diseases²³. However, the anti-atherogenic mechanisms associated with exercise have not yet been fully explained.

This study demonstrated that patients who do HI aerobic exercises attain better cardiorespiratory fitness and QOL than those who do MI exercises and those who are sedentary. Apparently, for healthy subjects and patients with CAD, the greater the capacity to exercise, the greater the protection against death even in the presence of other risk factors¹³. Hagberg et al²⁴ demonstrated that patients with CAD improved their myocardial oxygenation and left ventricular ejection fraction by undergoing high-intensity training (70-90% VO_2max) for 12 months, in 1-hour sessions, five times a week. Those findings corroborate ours. Additionally, patients improved their glucose intolerance, insulin sensitivity, and lipid profile.

A study with 62 patients with stable angina randomized to regular physical exercise (n=29) or clinical follow-up for 12 months revealed that the practice of physical exercises increases VO_2max significantly in patients with symptomatic CAD. To get this benefit, patients should burn around 1,400 kcal/week through some form of physical activity, which corresponds to three or four hours of aerobic resistance training⁶.

High-intensity aerobic exercises apparently improve coronary endothelial function and circulation associated with non-stenotic coronary atherosclerosis, probably due to the recruitment of collateral vessels and blood flow increase in the ischemic areas of the myocardium. In that study, ten patients underwent a physical exercise program and nine made up the control group. The four-week exercise program consisted of 10-minute supervised sessions at 80% HR_max, six days a week. The findings revealed a 54% reduction in paradoxical coronary vasoconstriction in response to the acetylcholine infusion in the exercise group compared with the control group. Physical exercises also improved coronary reserve and flow-dependent coronary vasodilatation (p < 0.01), against no changes in the control group. Thus, aerobic physical exercises proved to improve the endothelial function of coronary arteries in patients with known CAD and endothelial dysfunction²⁵.

The effect of high intensity (90-95% HR_max) and moderate intensity (70-85% HR_max) exercises on VO_2max was studied in 40 healthy, physically active and non-smoking subjects. The subjects exercised three times a week for eight weeks. At the end of the intervention period, a significant increase in VO_2max was observed in the individuals who did high-intensity physical exercises compared with those of moderate and low intensities²⁶. This increase in functional capacity may be considered a modifiable protection factor, since each 1-MET increment in cardiorespiratory fitness was associated with a 12% reduction in cardiovascular mortality¹³.

Another study demonstrated that the practice of physical exercises, even if moderate, at 60% VO_2max, can increase by 30% the myocardial perfusion observed with thallium in patients with CAD. The coronary angiography revealed also a significant increase in collateral circulation, which, at least in part, accounts for the improvement in myocardial perfusion²⁷. Another study of patients with progressive stenotic injuries reported a reduction in myocardial ischemia, suggesting, through conventional angiography, that collateral circulation is in part responsible for the increase in myocardial perfusion²⁸.

A recently published study assessed 4,940 men after AMI and/or coronary artery bypass graft that underwent a CR program and were followed for nine years. In this CR program, patients walked three miles in 45 minutes, five times a week. It was concluded that the improvement in walking distance is a strong predictor of CAD prognosis compared with the increase in VO_2max. The practice of moderate-intensity exercises proved efficient in heart disease patients, even without significant increase in VO_2max.²⁹.

Although several articles have shown that the practice of exercises improves primary cardiac risk factors, the effect of a regular exercise program on health-related QOL remains unknown. Quality of life is currently defined as "the individuals' perceptions of their position in life in the context of the culture and value systems where they live and in relation to their goals, expectations, standards and concerns"³⁰.

It is understandable that daily problems and other intervening events resulting from the chronic disease need to be addressed in the context of the individual's interaction and adaptation to the disease and the environment, aiming for a better QOL. Besides the physiological benefits on CAD, physical exercise interventions provided good social integration and easy access to information and education on the disease, which might have improved QOL perception in patients undergoing CR³¹.

After an eight-week program of aerobic exercises two times a week at 65% HR_max, patients returned to productive life, improved their emotional status, reduced their anxiety, and increased their tolerance to exercise compared with the control group³². The 201 individuals enrolled in the study suffered from moderate depression or anxiety. Another trial demonstrated that an eight-week program of physical exercises at 70%-85% HR_max, performed either at home or in the hospital, improved the subjective QOL perception and tolerance to exercise among post-AMI patients of all age groups, but particularly in patients up to 75 years of age³³.

As for the VO_2peak results, a significant difference in physical perception was observed between groups HI and MI, suggesting that such physiological improvement was reflected in QOL. However, exercise intensity apparently does not affect the emotional and social aspects of QOL perception. These results could possibly be explained by the fact that both training groups stayed in closer contact with the multidisciplinary team, receiving information and education, which tend to result in better compliance with healthy life habits and a better understanding of the disease³⁴.

Conclusions

The improvement in functional capacity and quality of life is more significant when higher intensity exercises are prescribed. The practice of exercises, regardless of their intensity, improves the perceived quality of life.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Sources of Funding

There were no external funding sources for this study.

Study Association

This study is not associated with any post-graduation program.

References

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Publication Dates

• Publication in this collection
  16 July 2010
• Date of issue
  Sept 2010

History

• Reviewed
  06 Jan 2010
• Received
  01 Mar 2009
• Accepted
  12 Feb 2010