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Open Access Systematic Review
Exercise-based cardiac rehabilitation after myocardial revascularization: a systematic review and meta-analysis
Helton Oliveira Campos1,2,†, Quézia Teixeira Rodrigues2,†, Lucas Rios Drummond2,3, Paulo Marcelo Andrade Lima2,4, Mateus da Costa Monteiro2, Samuel Penna Wanner5, Cândido Celso Coimbra2,*
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1 Department of Biological Sciences, University of the State of Minas Gerais – Carangola Unit, 36800-000 Carangola, Brazil
2 Department of Physiology and Biophysics, Institute of Biological Sciences, Federal University of Minas Gerais, 31270-901 Belo Horizonte, Brazil
3 Department of Physical Education, State University of Minas Gerais – Divinópolis Unit, 35501-170 Divinópolis, Brazil
4 Faculty of Medicine, University of Rio Verde, 74923-250 Aparecida de Goiânia, Brazil
5 Department of Physical Education, Federal University of Minas Gerais, 31270‑901 Belo Horizonte, Brazil
*Correspondence: coimbrac@icb.ufmg.br (Cândido Celso Coimbra)
†These authors contributed equally.
Academic Editor: Peter A. McCullough
Rev. Cardiovasc. Med. 2022, 23(2), 74; https://doi.org/10.31083/j.rcm2302074
Submitted: 14 December 2021 | Revised: 20 January 2022 | Accepted: 24 January 2022 | Published: 22 February 2022
(This article belongs to the Special Issue Cardiac rehabilitation)
Copyright: © 2022 The Author(s). Published by IMR Press.
This is an open access article under the CC BY 4.0 license.
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Abstract

Background: The present study aimed to analyze the effects of exercise-based cardiac rehabilitation (CR) on physical performance after myocardial revascularization. In addition, we compared the type and duration of exercise-based CR protocols to determine which ones produced the best performance improvements. Methods: This systematic review and meta-analysis was conducted and reported in accordance with PRISMA statement. A systematic search of PubMed, Web of Science, SPORTDiscus and ProQuest, was performed in July 2020. Studies that met the following criteria were included: (i) participants submitted to myocardial revascularization (i.e., coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI)), (ii) participants submitted to exercise-based CR, and (iii) participants submitted to protocols for assessing physical performance before and after the exercise-based CR. Results: Thirteen and eleven studies evaluating the effects of exercise-based CR after myocardial revascularization were included in the systematic review and meta-analysis, respectively. Exercise-based CR increased physical performance after myocardial revascularization (mean effect size (ES) 0.75; 95% confidence interval (CI) 0.62, 0.88), particularly when aerobic (ES 0.85; 95% CI 0.68, 1.01) and combined training (ES 1.04; 95% CI 0.70, 1.38) lasting 8–12 weeks (ES 1.20; 95% CI 0.87, 1.53) was prescribed. Conclusions: The present systematic review and meta-analysis indicates that exercise-based CR increases physical performance after myocardial revascularization. The prescription of physical training for these patients should emphasize aerobic and combined training lasting at least 8–12 weeks, which is more effective in improving physical performance. Impact: Our findings demonstrate the effectiveness of physical training in improving physical performance after myocardial revascularization.

Keywords
myocardial revascularization
exercise-based cardiac rehabilitation
physical training
1. Introduction

Ischemic heart disease is a major cause of morbidity and mortality worldwide. Manifested by unstable angina pectoris and acute myocardial infarction, this syndrome is caused by a decreased blood supply to the heart muscle due to either narrowing of the vessels that supply the heart or blood clot. Chest pain during rest is the primary symptom that initiates diagnosis and treatment of this syndrome [1, 2, 3].

The initial approach should address pain relief and early risk stratification and include a haemodynamic assessment, antithrombotic and anticoagulant therapy, monitoring and early treatment of arrhythmias, and a decision on whether to use invasive or conservative strategies [4]. The main invasive methods for treating ischemic heart disease include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) [5, 6, 7, 8]. These procedures can be performed in the context of acute or chronic ischemic heart disease, and the choice of the appropriate procedure depends on predicted surgical mortality, complexity of the coronary anatomy, and comorbidities [8].

CABG is a technique based on revascularization that involves diverting blood flow to other arteries to increase the blood supply to the heart muscle [9], while PCI, commonly known as coronary angioplasty, is performed by inflating a balloon to allow blood to flow through the vessel again, followed by the insertion of coronary stents into the vessel to ensure it remains open [10].

Cardiac rehabilitation (CR) programs are helpful for patients undergoing cardiac surgeries, including CABG and PCI. These programs may include a variety of therapies, with exercise training being a central and strongly indicated element [11, 12, 13, 14]. CR promotes several benefits, such as increased cardiovascular function and physical performance, decreased cardiovascular symptoms and cardiovascular morbidity and mortality, and improved quality of life [14, 15, 16].

Among the different physical training protocols available, it is worth mentioning, at this point, aerobic training, resistance training, combined training and high intensity interval training (HIIT). Aerobic training is designed to increase endurance, the term aerobic training generally refers to training in oxidative metabolism as opposed to glycolytic metabolism [17]. Resistance training consists of exercise designed to improve muscular fitness (strength, power, hypertrophy, and/or endurance) through exercise against external resistance [18]. Finally, combined training corresponds to protocols involving a combination of aerobic and resistance exercises, whereas HIIT involves repeated bouts of high-intensity effort followed by various recovery times [19].

Recent systematic reviews assessed the effect of CR in different cardiovascular conditions, such as coronary heart disease, heart valve surgery, and cardiac surgery [14, 20, 21]. However, the benefits of exercise-based CR, including the best exercise training protocol, specifically after myocardial revascularization, are still not well established. Therefore, this systematic review and meta-analysis aimed to analyze the effects of exercise-based CR on physical performance after myocardial revascularization (i.e., CABG and PCI). In addition, we compared the type and duration of exercise-based CR protocols to determine which ones produce the best performance improvements.

2. Materials and methods
2.1 Search strategy

This systematic review and meta-analysis were conducted and reported according to the guidelines outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement [22, 23]. A systematic search of electronic databases, including PubMed, Web of Science, SPORTDiscus and ProQuest, was performed in July 2020 without any date restrictions. The search strategy used combinations of the following keywords: myocardial revascularization, exercise-based cardiac rehabilitation, exercise, exercise-based rehabilitation, cardiac rehabilitation, physical training, physical exercise, exercise rehabilitation, physical activity and cardiorespiratory fitness.

2.2 Study selection

Studies that met the following criteria were included in this systematic review and meta-analysis: (i) participants submitted to myocardial revascularization (i.e., CABG and PCI), (ii) participants submitted to exercise-based CR and (iii) participants submitted to protocols for assessing physical performance before and after the exercise-based CR. Reviews, abstracts, case studies, and letters were not included, although this bibliography was consulted. Studies involving experimental research models were excluded. Based on the search and inclusion/exclusion criteria, 13 and 11 studies were selected for inclusion in the systematic review and meta-analysis, respectively (Fig. 1). Two studies were not included in the meta-analysis. The first did not present data as mean and standard deviation [24], whereas the second did not assess physical performance before and after the exercise-based CR [25]. Notably, several studies measured more than one physical performance variable or performed more than one physical training protocol. Thus, each performance variable or physical training analyzed in a given study will be presented as a trial, and therefore the number of trials reported will be greater than the number of studies.

Fig. 1.

Summary of the study selection process. The stages of the study selection process are highlighted with the number of studies selected and the number of studies excluded at each stage.

2.3 Data grouping

The characteristics of the exercise-based CR protocols included in the systematic review and meta-analysis are shown in Table 1 (13 studies, 16 trials), while the studies selected for the systematic review are shown in Table 2 (13 studies, 42 trials). The studies selected for inclusion in the meta-analysis (11 studies, 39 trials) were initially divided to analyze the effect of exercise-based CR on patients undergoing CABG (6 studies, 15 trials) or PCI (5 studies, 10 trials). Then they were grouped according to the characteristic of the exercise-based CR performed: combined training (aerobic and resistance exercises) (6 studies, 17 trials), aerobic training (3 studies, 15 trials), and HIIT (2 studies, 6 trials). The studies were then divided according to the duration of the exercise-based CR as follows: less than 8 weeks (3 studies, 8 trials) or 8–12 weeks (5 studies, 22 trials). Once the physical performance was assessed using different protocols (i.e., 6-minute walk test, cardiopulmonary exercise testing on a cycle ergometer, Bruce protocol on a treadmill), we divided the reported variables into four categories: maximum oxygen consumption (6 studies, 11 trials), distance travelled (3 studies, 5 trials), exercise duration (3 studies, 6 trials) or workload (3 studies, 5 trials). This categorisation allowed us to analyze and compare performance measured in different studies. Thus, increased distance travelled, maximal oxygen consumption, exercise duration, and workload indicate improved physical performance.

Table 1.Exercise-based cardiac rehabilitation protocol of the studies included in systematic review and meta-analysis.
References Exercise-based cardiac rehabilitation
Exercise Training duration (weeks) Frequency Session duration (min) Intensity
(x/week)
Aikawa et al. [29] Aerobic and resistance training 24 3 90 Aerobic exercise: 30–60% HRr⁢e⁢s⁢t
- 5 min warm up Resistance exercise: 30–60% 1RM
- 30 min treadmill and cycloergometer
- 20 min free weights
- 5 min relaxation
Arak-Lukman et al. [30] Aerobic training (bicycle) 12 3 50 80% of anaerobic threshold
- 10 min warm-up
- 30 min aerobic exercise
- 10 min cool-down
Aron et al. [31] Aerobic and resistance training 12 3 45–60 11–14 on the Borg (6 to 20 scale)
- 10 min warm-up calisthenics and stretching
- 30–45 min aerobic exercise
- 5–10 min resistance exercise
- 5–10 min cool-down
Hermes et al. (1) [32] Aerobic and resistance training 12 2 60 Aerobic exercise: 55–65% HRr⁢e⁢s⁢e⁢r⁢v⁢e and 4–6 on the Borg scale
- 30 min aerobic exercise on a treadmill and bike Resistance exercise: 50% 1RM
- 20 min resistance ex­ercise
- 10 min stretching and relaxation
Hermes et al. (2) [32] Aerobic and resistance training with inspiratory muscle training 12 2 60 Aerobic exercise: 55–65% of HRr⁢e⁢s⁢e⁢r⁢v⁢e and 4–6 on the Borg scale
- Inspiratory muscle training Resistance exercise: 50% 1RM
- 30 min aerobic exercise on a treadmill and bike
- 20 min resistance ex­ercise
- 10 min stretching and relaxation
Iliou et al. [33] Aerobic training 4–7 3–5 60 70–80% HRr⁢e⁢s⁢e⁢r⁢v⁢e
- Callisthenics and bike or treadmill
Jelinek et al. [34] Aerobic training (cycle ergometer, treadmill and rowing) 6 3 45–70 55–70% VO2⁢p⁢e⁢a⁢k and 11–13 on the Borg scale
- 5–10 min warm-up
- 15–20 min endurance training
- 10–15 min strength/resistance training
- 5–10 min cool-down/relaxation
Munk et al. [35] High-intensity interval training 24 3 60 60–70% HRm⁢a⁢x or 80–90% HRm⁢a⁢x
- 10 min warm-up
- High-intensity interval training (4 min: cycle ergometer or running and 3 min: active recovery)
- 5 min cool-down
- 10 min abdominal and spine resistance exercises
- 5 min stretching and relaxation
Nilsson et al. [36] High-intensity interval training 12 2 50 50–90% HRm⁢a⁢x
- Warm-up
- Aerobic exercise: low, moderate and high intensity
- Flexibility
- Strength exercise
- Cold down and stretching
Rechciński et al. [37] Cardiac rehabilitation program 3 6 - Cycling: Workload 10W–100W
- Warm-up
- 10–30 min cycling
- 30–45 min walking
- Resistance exercise
Santos et al. (1) [38] Moderate-to-high intensity inspiratory muscle training 12 2 60 Aerobic exercise: 4–6 on the Borg scale.
Aerobic and resistance exercises Resistance exercise: 50% 1RM
Santos et al. (2) [38] Low intensity inspiratory muscle training 12 2 60 Aerobic exercise: 4–6 on the Borg scale.
Aerobic and resistance exercises Resistance exercise: 50% 1RM
Szmigielska et al. [24] Cycle ergometer interval training 8 3 45 60–80% HRr⁢e⁢s⁢e⁢r⁢v⁢e and 11–16 on the Borg scale
Chuang et al. [25] Submaximal endurance training exercise (Virtual Reality) 12 2 30 85% HRm⁢a⁢x or 75% VO2⁢p⁢e⁢a⁢k
Wosornu et al. (1) [39] Aerobic training 24 3 12–60 Not reported
Wosornu et al. (2) [39] Resistance training 24 3 12–60 Not reported
1RM, one-repetition maximum; HRr⁢e⁢s⁢t, resting heart rate; HRm⁢a⁢x, maximal heart rate; HRr⁢e⁢s⁢e⁢r⁢v⁢e, heart rate reserve; VO2⁢p⁢e⁢a⁢k, peak oxygen consumption.
Table 2.Characteristics of the studies included in the systematic review.
References Groups N Age Surgery Outcomes
(♂/♀) Test protocol Variables Results
Aikawa et al. (1) [29] - 9 66 CABG 6-min walk test Distance (m) Pre: 459 ± 94
(5/4) Post: 547 ± 83*
Aikawa et al. (2) [29] - 9 66 CABG 1RM - Biceps Muscle strength (kg) Pre: 9.7 ± 4.1
(5/4) Post: 12.5 ± 4.9
Aikawa et al. (3) [29] - 9 66 CABG 1RM - Quadriceps Muscle strength (kg) Pre: 19.3 ± 9.3
(5/4) Post: 24.4 ± 9.1*
Arak-Lukman et al. (1) [30] GI: VO2⁢p⁢e⁢a⁢k >19 7 55.1 ± 10.1 CABG Bicycle cardiopulmonary testing Exercise duration (min) Pre :11.8 ± 3.3
PCI Post: 15.1 ± 3.0*
Arak-Lukman et al. (2) [30] GI: VO2⁢p⁢e⁢a⁢k >19 7 55.1 ± 10.1 CABG Bicycle cardiopulmonary testing Maximal load (W) Pre: 151.4 ± 32.9
PCI Post: 184.3 ± 21.1*
Arak-Lukman et al. (3) [30] GI: VO2⁢p⁢e⁢a⁢k >19 7 55.1 ± 10.1 CABG Bicycle cardiopulmonary testing VO2 at maximal load Pre: 20.5 ± 1.1
PCI (mL∙kg−⁢1∙min−⁢1) Post: 23.9 ± 3.3*
Arak-Lukman et al. (4) [30] GI: VO2⁢p⁢e⁢a⁢k >19 7 55.1 ± 10.1 CABG Bicycle cardiopulmonary testing Heart rate at maximal load (beats.min-1) Pre: 134.8 ± 14.3
PCI Post: 147.7 ± 12.2*
Arak-Lukman et al. (5) [30] GII: VO2⁢p⁢e⁢a⁢k 11–19 24 61.1 ± 7.8 CABG Bicycle cardiopulmonary testing Exercise duration (min) Pre: 7.5 ± 2.4
PCI Post: 11.4 ± 1.9*
Arak-Lukman et al. (6) [30] GII: VO2⁢p⁢e⁢a⁢k 11–19 24 61.1 ± 7.8 CABG Bicycle cardiopulmonary testing Maximal load (W) Pre: 106.5 ± 26.7
PCI Post: 145.4 ± 21. 2*
Arak-Lukman et al. (7) [30] GII: VO2⁢p⁢e⁢a⁢k 11–19 24 61.1 ± 7.8 CABG Bicycle cardiopulmonary testing VO2 at maximal load Pre: 15.5 ± 2.4
PCI (mL∙kg−⁢1∙min−⁢1) Post: 18.9 ± 3.2*
Arak-Lukman et al. (8) [30] GII: VO2⁢p⁢e⁢a⁢k 11–19 24 61.1 ± 7.8 CABG Bicycle cardiopulmonary testing Heart rate at maximal load (beats.min-1) Pre: 126.2 ± 10.1
PCI Post: 138.5 ± 16.0*
Arak-Lukman et al. (9) [30] GIII: VO2⁢p⁢e⁢a⁢k <11 5 64.6 ± 8.9 CABG Bicycle cardiopulmonary testing Exercise duration (min) Pre: 3.5 ± 2.7
PCI Post: 7.8 ± 5.0*
Arak-Lukman et al. (10) [30] GIII: VO2⁢p⁢e⁢a⁢k <11 5 64.6 ± 8.9 CABG Bicycle cardiopulmonary testing Maximal load (W) Pre: 70.0 ± 25.5
PCI Post: 114.0 ± 51.8*
Arak-Lukman et al. (11) [30] GIII: VO2⁢p⁢e⁢a⁢k <11 5 64.6 ± 8.9 CABG Bicycle cardiopulmonary testing VO2 at maximal load Pre: 8.7 ± 2.1
PCI (mL∙kg−⁢1∙min−⁢1) Post: 12.8 ± 4.9*
Arak-Lukman et al. (12) [30] GIII: VO2⁢p⁢e⁢a⁢k <11 5 64.6 ± 8.9 CABG Bicycle cardiopulmonary testing Heart rate at maximal load (beats.min-1) Pre: 107.4 ± 20.1
PCI Post: 121.6 ± 11.8*
Aron et al. (1) [31] Off pump 150 65.3 ± 10.3 CABG - Grip strength Pre: 37.0 ± 11.0
(110/40) Post: 38.9 ± 11.6*
Aron et al. (2) [31] On pump 145 64.9 ± 9.5 CABG - Grip strength Pre: 36.0 ± 11.1
(113/32) Post: 38.2 ± 12.0*
Hermes et al. (1) [32] CR 12 59.5 ± 8.7 CABG Treadmill exercise test - Bruce protocol VO2⁢p⁢e⁢a⁢k (mL∙kg−⁢1∙min−⁢1) Pre: 26.0 ± 5.6
(10/2) Post: 35.7 ± 4.9*
Hermes et al. (2) [32] CR + inspiratory muscle training 12 55.2 ± 7.9 CABG Treadmill exercise test - Bruce protocol VO2⁢p⁢e⁢a⁢k (mL∙kg−⁢1∙min−⁢1) Pre: 25.5 ± 3.7
(7/5) Post: 27.2 ± 4.1
Iliou et al. (1) [33] Early rehabilitation 1821 56.1 ± 11.5 PCI Exercise stress test Workload (W) Pre: 105 ± 35.5
(1578/243) Post: 133 ± 44
Iliou et al. (2) [33] Late rehabilitation 1311 57.3 ± 11.2 PCI Exercise stress test Workload (W) Pre: 105 ± 38
(1076/235) Post: 130 ± 46
Jelinek et al. (1) [34] CABG 22 62.5 ± 9.9 CABG 6-min walk test Distance (m) Pre: 504.3 ± 93.5
(18/4) Post: 565.8 ± 98.8*
Jelinek et al. (2) [34] CABG 22 62.5 ± 9.9 CABG 6-min walk test VO2⁢p⁢e⁢a⁢k (mL∙kg−⁢1∙min−⁢1) Pre: 11.9 ± 1.6
(18/4) Post: 12.9 ± 1.6*
Jelinek et al. (3) [34] PCI 16 64.9 ± 8.8 PCI 6-min walk test Distance (m) Pre: 548.1 ± 62.0
(13/3) Post: 589.0 ± 78.1*
Jelinek et al. (4) [34] PCI 16 64.9 ± 8.8 PCI 6-min walk test VO2⁢p⁢e⁢a⁢k (mL∙kg−⁢1∙min−⁢1) Pre: 12.6 ± 1.0
(13/3) Post: 13.3 ± 1,3*
Munk et al. (1) [35] - 20 57 ± 14 PCI Ergospirometry - 20 W/min ramp protocol VO2⁢p⁢e⁢a⁢k (mL∙kg−⁢1∙min−⁢1) Pre: 23.2 ± 5.7
(17/3) Post: 27.1 ± 8.0*
Munk et al. (2) [35] - 20 57 ± 14 PCI Ergospirometry - 20 W/min ramp protocol Ventilatory threshold (mL∙kg−⁢1∙min−⁢1) Pre: 15.6 ± 5.0
(17/3) Post: 20.4 ± 7.1*
Munk et al. (3) [35] - 20 57 ± 14 PCI Ergospirometry - 20 W/min ramp protocol Workload (W) Pre: 180 ± 49
(17/3) Post: 202 ± 46
Munk et al. (4) [35] - 20 57 ± 14 PCI Ergospirometry - 20 W/min ramp protocol HRp⁢e⁢a⁢k (beats.min-1) Pre: 153 ± 26
(17/3) Post: 154 ± 34
Nilsson et al. (1) [36] - 86 57 ± 9 PCI Running protocol VO2⁢p⁢e⁢a⁢k (mL∙Kg-1∙min–⁢1) Pre: 31.9 ± 7.6
CABG Post: 35.9 ± 8.6*
Nilsson et al. (2) [36] - 86 57 ± 9 PCI Running protocol Exercise duration (s) Pre: 569 ± 104
CABG Post: 645 ± 107*
Rechciński et al. (1) [37] Imcomplete revascularization 49 58 ± 10 PCI Treadmill exercise test - Bruce protocol Workload (MET) Pre: 7.3 ± 3.0
(36/13) Post: 8.8 ± 2.9*
Rechciński et al. (2) [37] Complete revascularization 141 58 ± 9 PCI Treadmill exercise test - Bruce protocol Workload (MET) Pre: 7.6 ± 2.8
(89/52) Post: 9.2 ± 2.9*
Santos et al. (1) [38] IMT + CT 12 55.0 ± 7.0 CABG Treadmill cardiopulmonary exercise test VO2⁢p⁢e⁢a⁢k (mL∙kg−⁢1∙min−⁢1) Pre:19.3 ± 0.9
(8/4) Post: 23.6 ± 1.1*
Santos et al. (2) [38] IMT + CT 12 55.0 ± 7.0 CABG 6-min walk test Distance (m) Pre: 412.9 ± 53.1
(8/4) Post: 537.9 ± 56.8*
Santos et al. (3) [38] Sham-IMT + CT 12 56.6 ± 5.5 CABG Treadmill cardiopulmonary exercise test VO2⁢p⁢e⁢a⁢k (mL∙kg−⁢1∙min−⁢1) Pre:19.1 ± 0.8
(9/3) Post: 22.3 ± 0.4*
Santos et al. (4) [38] Sham 12 56.6 ± 5.5 CABG 6-min walk test Distance (m) Pre: 403.1 ± 50.9
IMT + CT (9/3) Post: 459.1 ± 53.0*
Szmigielska et al. (1) [24] PCI 72 55.7 ± 8.5 PCI Exercise test (cycle ergometer) Workload (W) Pre: 90
(72/0) Post: 120*
Szmigielska et al. (2) [24] CABG 59 56.4 ± 8.9 CABG Exercise test (cycle ergometer) Workload (W) Pre: 90
(59/0) Post: 120*
Chuang et al. [25] Trained 20 65.7 ± 14.4 CABG Endurance training sessions Speed (mph) Non-VR: 3.7 ± 0.8
VR: 4.6 ± 1.4*
Wosornu et al. (1) [39] Aerobic 15 57 ± 9 CABG Treadmill exercise test - Balke II protocol Exercise duration (min) Pre: 791.2 ± 306.5
(15/0) Post: 891.4 ± 287.9*
Wosornu et al. (2) [39] Power 20 60 ± 6 CABG Treadmill exercise test - Balke II protocol Exercise duration (min) Pre: 800.4 ± 290.5
(20/0) Post: 900.3 ± 300.8*
1RM, one-repetition maximum; VO2, oxygen consumption; VO2⁢p⁢e⁢a⁢k, peak oxygen consumption; HRp⁢e⁢a⁢k, heart rate peak; IMT + CT, inspiratory muscle training + combined; Non-VR, no virtual reality; VR, virtual reality. * indicates statistical difference between groups.
2.4 Risk of bias assessment

The risk of bias was assessed by two independent reviewers using an adapted Assessment, Development and Assessment Rating of Recommendations (GRADE) instrument [26, 27]. When there was disagreement between the two evaluators, a third evaluator was consulted for resolution. This approach allowed us to evaluate the risk of bias in each study included in the present systematic review. Domains reflecting allocation concealment, blinding of participants and personnel, incomplete outcome data, selective outcome reporting, and other sources of bias were evaluated. Inadequacy in one of these domains reduced the methodological quality of each study according to the following sequence: high, moderate, low and very low.

2.5 Statistical analysis

The mean and standard deviation values of the physical performance indexes in both the exercise rehabilitation and control trials were obtained from data provided in the consulted research papers. Heterogeneity was evaluated using the χ2 test for homogeneity and the I2 statistic. The effect size (Cohen’s d or Hedges’ g) was calculated for the physical performance indexes in each study. A weighted-mean estimate of the effect size (ES) was calculated to account for differences in the sample sizes, along with the mean unweighted ES and associated 95% confidence interval (CI). When CI included zero, ES was considered not significant. Threshold values for ES were defined as negligible (<0.2); small (0.20–0.49); moderate (0.50–0.79); and large (>0.8) [28].

3. Results
3.1 Systematic review

In total, 9073 studies were identified through the database and reference searches. After the selection process based on eligibility criteria, 13 and 11 studies were included in the systematic review and meta-analysis, respectively (Fig. 1).

Exercise-based CR protocols of all 13 studies included in the systematic review and meta-analysis are summarized in Table 1, including the type of exercise, duration of the training protocol, weekly frequency, intensity and duration of the exercise sessions. The studies mainly investigated aerobic and combined training, with a duration varying from 3 to 24 weeks and a frequency of 2 to 6 times per week (Table 1, Ref. [24, 25, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39]). It is noteworthy to mention that the intensity of aerobic training was controlled in several different ways, including peak oxygen consumption, anaerobic threshold, percentage of maximum heart rate, percentage of reserve heart rate, and perceived exertion scale. Meanwhile, when reported, resistance training was controlled by the percentage of one-repetition maximum (1RM), ranging from 30 to 60%. Most studies started exercise-based cardiac rehabilitation within one month after myocardial revascularization. However, two studies included patients up to 1 year after coronary artery bypass graft surgery.

Table 2 (Ref. [24, 25, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39]) characterizes the studies included in the systematic review, including groups, sample size, age, type of surgery, training protocol, training duration, protocol, analyzed variables and results. The main variables used to assess physical performance were maximum oxygen consumption, exercise duration, distance travelled and workload obtained through cardiopulmonary exercise test (on a cycle ergometer or treadmill) and the 6-minute walk test. Overall, the results demonstrate that patients undergoing myocardial revascularization (either CABG or PCI) have increased physical performance after exercise-based CR.

3.2 Meta-analysis
3.2.1 Exercise-based cardiac rehabilitation

In total, 11 studies (39 trials and 3865 individuals) were included in the meta-analysis. The mean effect size was 0.75 (95% CI 0.62, 0.88), which indicates that exercise-based CR had a moderate and significant effect on physical performance after CABG and PCI (p < 0.05; Fig. 2). According to a fixed-effects analysis, heterogeneity was observed among these studies (I2 = 72.5%; Q = 138.1, df = 38, p = 0.000).

Fig. 2.

Forest plot of physical performance following physical training in patients undergoing myocardial revascularization (CABG and PCI). SMD, standardized mean difference.

3.2.2 PCI

After pooling the data from ten trials (5 studies, 3358 individuals), the mean effect size 0.64 (95% CI 0.59, 0.69), which indicates that exercise-based CR had a moderate and significant effect on physical performance after PCI (p < 0.05; Fig. 3). According to a fixed-effects analysis, no heterogeneity was observed among these studies (I2 = 7.7%; Q = 9.7, df = 9, p = 0.371).

Fig. 3.

Forest plot of physical performance following physical training in patients undergoing CABG or PCI. SMD, standardized mean difference.

3.2.3 CABG

After pooling the data from 15 trials (6 studies, 428 individuals), the mean effect size was 1.01 (95% CI 0.61, 1.41), which indicates that exercise-based CR had a large and significant effect on physical performance after CABG (p < 0.05; Fig. 3). According to a random-effects analysis, heterogeneity was observed among these studies (I2 = 84.1%; Q = 88.1, df = 14, p = 0.000).

3.2.4 Combined training

After pooling the data from 17 trials (6 studies, 556 individuals), the mean effect size was 1.04 (95% CI 0.70, 1.38), which indicates that combined training had a large and significant effect on physical performance after CABG and PCI (p < 0.05; Fig. 4). According to a random-effects analysis, heterogeneity was observed among these studies (I2 = 85.9%; Q = 113.5, df = 16, p = 0.000).

Fig. 4.

Forest plot of physical performance following combined, aerobic and HIIT training in patients undergoing myocardial revascularization (CABG and PCI). SMD, standardized mean difference.

3.2.5 Aerobic training

After pooling the data from 15 trials (3 studies, 3183 individuals), the mean effect size was 0.85 (95% CI 0.68, 1.01), which indicates that aerobic training had also a large and significant effect on physical performance after CABG and PCI (p < 0.05; Fig. 4). According to a random-effects analysis, heterogeneity was observed among these studies (I2 = 56.0%; Q = 31.85, df = 14, p = 0.004).

3.2.6 High intensity interval training

After pooling the data from six trials (2 studies, 106 individuals), the mean effect size was 0.55 (95% CI 0.37, 0.73), which indicates that HIIT had a moderate and significant effect on physical performance after CABG and PCI (p < 0.05; Fig. 4). According to a fixed-effects analysis, no heterogeneity was observed among these studies (I2 = 0.0%; Q = 4.47, df = 5, p = 0.483).

3.2.7 Exercise-based CR duration: ≤8 weeks

After pooling the data from eight trials (3 studies, 3360 individuals), the mean effect size was 0.65 (95% CI 0.60, 0.69), which indicates that exercise-based CR lasting ≤8 weeks had a moderate and significant effect on physical performance after CABG and PCI (p < 0.05; Fig. 5). According to a random-effects analysis, heterogeneity was observed among these studies (I2 = 58.7%; Q = 5.53, df = 7, p = 0.033).

Fig. 5.

Forest plot of physical performance following physical training with duration <8 weeks and between 8–12 weeks in patients undergoing myocardial revascularization (CABG and PCI). SMD, standardized mean difference; CR, cardiac rehabilitation.

3.2.8 Exercise-based CR duration: >8 and ≤12 weeks

After pooling the data from 22 trials (5 studies, 441 individuals), the mean effect size was 1.20 (95% CI 0.87, 1.53), which indicates that exercise-based CR lasting >8 and ≤12 weeks had a large and significant effect on physical performance after CABG and PCI (p < 0.05, Fig. 5). According to a random-effects analysis, heterogeneity was observed among these studies (I2 = 83.3%; Q = 125.9, df = 21, p = 0.000).

3.2.9 Physical performance variables: maximum oxygen consumption

After pooling the data from 11 trials (6 studies, 204 individuals), the mean effect size was 1.33 (95% CI 0.78, 1.88), which indicates that exercise-based CR had a large and significant effect on oxygen consumption after CABG and PCI (p < 0.05; Supplementary Fig. 1). According to a random-effects analysis, heterogeneity was observed among these studies (I2 = 82.8%; Q = 58.0, df = 10, p = 0.000).

3.2.10 Physical performance variables: distance travelled

After pooling the data from five trials (3 studies, 59 individuals), the mean effect size was 0.98 (95% CI 0.47, 1.48), which indicates that exercise-based CR had a large and significant effect on distance travelled after CABG and PCI (p < 0.05; Supplementary Fig. 1). According to a fixed-effects analysis, no heterogeneity was observed among these studies (I2 = 47.3%; Q = 7.59, df = 4, p = 0.108).

3.2.11 Physical performance variables: exercise duration

After pooling the data from six trials (3 studies, 157 individuals), the mean effect size was 0.81 (95% CI 0.37, 1.25), which indicates that exercise-based CR had a large and significant effect on exercise duration after CABG and PCI (p < 0.05; Supplementary Fig. 1). According to a random-effects analysis, heterogeneity was observed among these studies (I2 = 58.7%; Q = 12.11, df = 5, p = 0.033).

3.2.12 Physical performance variables: workload

After pooling the data from five trials (3 studies, 3342 individuals), the mean effect size was 0.63 (95% CI 0.56, 0.71), which indicates that exercise-based CR had a moderate and significant effect on workload after CABG and PCI (p < 0.05; Supplementary Fig. 1). According to a fixed-effects analysis, no heterogeneity was observed among these studies (I2 = 31.0%; Q = 5.80, df = 4, p = 0.215).

3.3 Risk of bias

The risk of bias was assessed in the 13 included studies. Twelve studies did not present any major risk of bias. Only one study showed the absence of allocation. Thus, 92.3% of the studies showed consistent control of the risk of bias and were classified as good quality studies (Supplementary Table 1).

4. Discussion

The present study confirms that exercise-based CR significantly affected physical performance after myocardial revascularization. More specifically, aerobic and combined training were the most efficient exercise-based CR protocols for improving performance in patients who underwent myocardial revascularization (i.e., CABG or PCI). In addition, the duration of the exercise-based CR was also an issue in these patients, as the results show that more effective improvements require at least 8 to 12 weeks.

Although international guidelines emphasize exercise prescription for CR [16], it is unclear which training program is the safest or whether there is any training protocol that could negatively affect CR patients. Thus, this study evaluated, for the first time, the differences between three programs of exercise (i.e., combined training, aerobic training, and HIIT) on physical performance in patients submitted to myocardial revascularization.

The American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation have recommended that aerobic training (e.g., walking, treadmill, cycling, stair climbing, rowing) should be performed for 20–60 minutes per session, 3–5 sessions per week, and at an intensity of 40–80% VO2⁢p⁢e⁢a⁢k (peak oxygen uptake) or HRm⁢a⁢x (maximum heart rate), based on a maximal exercise test. For resistance training (calisthenics, hand weights, pulleys, dumb-bells, free weights, machine weights), the recommendation is 1–3 sets or 10–15 repetitions for 8–10 different exercises, 3 sessions per week (on non-consecutive days) at 50% of the one-repetition maximum (1RM) progressing to 60–70% 1RM [40, 41]. Our findings support these recommendations and indicate that aerobic or combined training may be more effective for CR patients.

After a careful selection and quality assessment, three guidelines on CR were included in a recent systematic review: the International Council of Cardiovascular Prevention and Rehabilitation (2016), National Institute for Health and Care Excellence (2013) and Scottish Intercollegiate Guideline Network (2017). By consensus, the three guidelines indicated that the CR should focus on exercise training, nutritional counseling, risk factor modification, psychological management, and patient education. Specifically for regular physical activity, the counseling is to perform physical exercise 20–30 minutes a day, choosing the exercise modality of your preference and gradually progressing the duration and intensity of sessions to increase physical performance [42].

The meta-analysis demonstrated that two exercise training protocols (aerobic and combined) effectively promoted improvements in the physical performance of patients undergoing myocardial revascularization. In a comparative analysis of effect sizes, the combined training showed the greatest effect size (1.06), followed by aerobic training (0.79). Moreover, as expected, it was found that physical performance increases proportionally to the training duration, since a period of 8–12 weeks had a greater effect than training lasting up to 8 weeks (ES = 1.33 and 0.64, respectively).

Scientific evidence indicates that physical training results in improvements in physical performance, being a key component of CR. Countless reasons explain the improvements in physical performance induced by exercise training, such as the positive effect of training on muscle strength and mobility in elderly patients [43], the restoration of sensitivity to autonomic modulation in recently heart-transplanted subjects [44], and the improvements in cardiopulmonary fitness [45], and utilization of energetic substrates [46].

Aerobic training is an intervention recommended in all international guidelines; however, differences are evident in the intensity and duration of exercise and frequency of training sessions that are recommended. The most contentious issue in cardiac patients is related to exercise intensity, as the lower and upper safe and effective limits are still debated in several guidelines worldwide [16]. Studies indicate that higher intensity exercise generally results in more evident increases in cardiorespiratory fitness [47], but it may be associated with an increased risk of cardiac events [48] or not be personally acceptable and/or sustainable for some patients. Thus, the individualized prescription of physical exercise must take into account the optimal intensity, acceptability, and safety [49].

It is important to note that the population evaluated in this review consists of patients who have already undergone an invasive cardiac remodeling procedure; they are in a group with higher cardiac risk and are less susceptible to adaptation to HIIT than other individuals. One of the reasons that corroborate this statement is the small number of studies that used HIIT (2 studies, 6 trials), probably due to the individual assessments of the patients’ ability to adhere to the training or to caution being used in prescribing this type of training to these patients.

The meta-analysis showed that combined training effectively improved physical performance in patients after myocardial revascularization, even though resistance training is not routinely included in exercise-based CR guidelines to the same level as aerobic exercise prescription [16]. In this sense, dynamic resistance training is also beneficial for patients participating in CR, leading to an increase in physical strength and improved independence in activities of daily living and positively influencing quality of life [50]. Evidence indicates that combined training results in a greater increase in muscle mass and a reduction in body fat compared to aerobic training alone [51]. Thus, the prescription of resistance training to an exercise-based CR programme may also optimize responses to aerobic training as a result of increased muscle strength, leading to more favorable effects on exercise performance [51].

In general, exercise-based CR can be part of the multidisciplinary approach during the late postoperative period since exercise is part of the prevention and treatment of chronic diseases that are risk factors for coronary syndromes. The exercise prescription must respect patient wellness and limitations and authorities’ recommendations and be evidence-based to optimize adherence and, consequently, the training results.

The present systematic review and meta-analysis indicates that exercise-based cardiac rehabilitation increases physical performance after myocardial revascularization. The prescription of physical training for these patients should emphasize aerobic and combined training lasting 8–12 weeks, which are more effective in improving physical performance.

Author contributions

All authors have contributed to the development of the research question and study design. HOC, QTR, LRD and MdCM developed the literature search. HOC, LRD, QTR, PMAL and MdCM performed the study selection. HOC, QTR and LRD analysed the data. HOC, QTR, LRD, PMAL, MdCM, SPW and CCC interpret the results and wrote the manuscript. All authors reviewed and approved the manuscript.

Ethics approval and consent to participate

Not applicable.

Acknowledgment

Not applicable.

Funding

This study was funded by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq 421460/2018-0), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES – PROEX 23038.014268/2020-59) and Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG). The funding institutions had no role in the study design, data analysis, decision to publish or preparation of the article.

Conflict of interest

The authors declare no conflict of interest.

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