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Aerobic Interval Vs. Continuous Training In Sports Med https://doi.org/10.1007/s40279-018-0885-5 SYSTEMATIC REVIEW Aerobic Interval vs. Continuous Training in Patients with Coronary Artery Disease or Heart Failure: An Updated Systematic Review and Meta-Analysis with a Focus on Secondary Outcomes 1,2 1 1 Nele Pattyn • Randy Beulque • Ve´ronique Cornelissen Ó Springer International Publishing AG, part of Springer Nature 2018 Abstract Results Twenty-four papers were identified (n = 1080; Background In a previous meta-analysis including nine mean age 60.7 ± 10.7 years). Aerobic interval training trials comparing aerobic interval training with aerobic resulted in a higher increase in peak oxygen uptake com- continuous training in patients with coronary artery dis- pared with aerobic continuous training in all patients ease, we found a significant difference in peak oxygen (1.40 mL/kg/min; p \ 0.001), and in the subgroups of uptake favoring aerobic interval training. patients with coronary artery disease (1.25 mL/kg/min; p = Objective The objective of this study was to (1) update the 0.001) and patients with chronic heart failure with reduced original meta-analysis focussing on peak oxygen uptake ejection fraction (1.46 mL/kg/min; p = 0.03). Moreover, a and (2) evaluate the effect on secondary outcomes. larger increase of the first ventilatory threshold and peak Methods We conducted a systematic review with a meta- heart rate was observed after aerobic interval training in all analysis by searching PubMed and SPORTDiscus data- patients. Other cardiorespiratory parameters, cardiovascu- bases up to March 2017. We included randomized trials lar risk factors, and quality of life were equally affected. comparing aerobic interval training and aerobic continuous Conclusion This meta-analysis adds further evidence to training in patients with coronary artery disease or chronic the clinically significant larger increase in peak oxygen heart failure. The primary outcome was change in peak uptake following aerobic interval training vs. aerobic oxygen uptake. Secondary outcomes included cardiores- continuous training in patients with coronary artery disease piratory parameters, cardiovascular risk factors, cardiac and chronic heart failure. More well-designed randomized and vascular function, and quality of life. controlled trials are needed to establish the safety of aer- obic interval training and the sustainability of the training response over longer periods. Nele Pattyn and Randy Beulque contributed equally to the article. Key Points Electronic supplementary material The online version of this article (https://doi.org/10.1007/s40279-018-0885-5) contains supple- Aerobic interval training is more beneficial mentary material, which is available to authorized users. compared with aerobic continuous training in & Nele Pattyn increasing peak oxygen uptake in patients with [email protected] coronary artery disease and chronic heart failure. Randy Beulque A larger increase of the first ventilatory threshold [email protected] and peak heart rate was observed after aerobic ´ Veronique Cornelissen interval training compared with aerobic continuous [email protected] training in all cardiac patients, while other 1 Department of Rehabilitation Sciences, KU Leuven, Leuven, cardiorespiratory parameters, cardiovascular risk Belgium factors, and quality of life were equally influenced. 2 Department of Cardiology, KU Leuven, Leuven, Belgium 123 N. Pattyn et al. 1 Background systolic blood pressure and diastolic blood pressure (SBP and DBP), resting HR, blood lipids, and blood glucose], (3) Cardiovascular diseases are the main cause of death cardiac function [left ventricular ejection fraction (LVEF)], worldwide [1] and in Europe [2], accounting for 31.5% [1] (4) vascular function [flow-mediated dilation (FMD)] and and 45% [2] of all deaths, respectively. Exercise-based (5) quality of life (QoL). cardiac rehabilitation is a cornerstone in the secondary prevention of cardiovascular diseases, reducing cardio- vascular mortality by 26% in patients with coronary artery 2 Methods disease (CAD) [3]. These improved survival rates are mediated amongst others through training-induced increa- The systematic review and meta-analysis were conducted ses in peak oxygen uptake (peak VO2), which is an in accordance with the guidelines from Preferred Reporting important prognostic parameter for all-cause and cardio- for Systematic Review and Meta-Analysis [17]. vascular morbidity and mortality [4]. That is, an increase of 1mLO2/kg/min has been shown to result in an almost 2.1 Literature Search 15% increase in survival [4]. Traditional training methods include continuous training We conducted a literature search in the electronic PubMed (30–60 min) at moderate intensity (40–80% of peak VO2) and SPORTDiscus databases from the earliest available [aerobic continuous training; ACT], leading to gains in date up to March 2017 with the following search terms peak VO2 of approximately 20% after 12 weeks of three- (‘All field’ terms): [(Aerobic interval training OR high times-weekly exercise sessions [5]. Training at a higher intensity interval training OR interval training OR inter- intensity leads to higher increases in peak VO2 [6]. How- mittent training OR high intensity exercise) AND (coro- ever, it is impossible to sustain higher intensities for longer nary artery disease OR coronary heart disease OR heart periods. Therefore, to prolong the time that training could failure OR myocardial infarction OR coronary artery be sustained at higher intensities, interval training was bypass surgery OR ischemic heart disease OR angina suggested [7]. About 15 years ago, aerobic interval training pectoris OR percutaneous coronary intervention)], without (AIT) was introduced in cardiac rehabilitation in Norway. any further limitations. Screening of all titles and abstracts These first small studies reported that the increments in was performed by two independent investigators (NP and peak VO2 were significantly higher after AIT in both RB). Results from both investigators were compared and patients with CAD [8] and chronic heart failure (CHF) [9]. papers were selected after consensus. The reference lists of Since then, research investigating the potential superiority retrieved papers were manually searched to identify other of AIT for improving peak VO2 in different cardiac patient appropriate studies. groups has grown rapidly. Results of the individual studies were contradictory and inconclusive, while meta-analyses 2.2 Eligibility Criteria collating the results showed significantly higher increases after AIT ranging from 1.04 [10] to 2.14 mL/kg/min [11]in We included (1) randomized clinical trials comparing the both patients with CAD [12–15] and CHF [10–12, 16]. effects of supervised AIT with ACT in patients with CAD Since the publication of our first meta-analysis in 2014 and/or CHF, (2) with a duration of at least 4 weeks, (3) [15] involving only nine study groups and 206 patients, an reporting on peak VO2 (mean changes or pre- and post- increasing number of larger randomized clinical trials have intervention means and variability measures), and (4) been published comparing the efficacy of AIT and ACT in published in a peer-reviewed journal up to March 2017. cardiac patients. This larger number of trials allows now Exclusion criteria included any study not meeting any of for a more precise estimate of the effect on peak VO2 but the criteria listed above. also on other relevant secondary outcomes. Therefore, our aim was to update the original meta- 2.3 Measured Outcomes analysis [15] comparing the efficacy of AIT and ACT on peak VO2 in patients with CAD and CHF. Moreover, we The primary outcome for this meta-analysis was the change focused on secondary outcomes including (1) cardiorespi- in peak VO2 in mL/min/kg. Secondary outcomes included ratory parameters [peak heart rate (HR), oxygen pulse (O2 (1) cardiorespiratory parameters (peak HR, O2 pulse, VT1, pulse), first ventilatory threshold (VT1), oxygen uptake OUES, VE/VCO2 slope, HRR 1 min), (2) cardiovascular efficiency slope (OUES), ventilatory efficiency slope (VE/ risk factors (body weight, SBP and DBP, resting HR, blood VCO2 slope), heart rate recovery after 1 min of exercise lipids, and blood glucose), (3) cardiac function (LVEF), (4) (HRR 1 min)], (2) cardiovascular risk factors [body weight, vascular function (FMD), and (5) QoL. 123 AIT vs. ACT in Patients with CAD and CHF: A Meta-Analysis 2.4 Data Extraction coefficient (corr) of 0.5 for each outcome. We used ran- dom-effects models to pool the data, given the small The two main authors (NP and RB) independently sample sizes of study groups and the differences in study extracted characteristics of patients and intervention, and populations. Each effect size was weighted by the inverse point and variability data on primary and secondary out- of its variance. The results are reported as weighted means comes, in a standardized form. Results were compared and and 95% CI. Two-sided tests for overall effects were discrepancies were resolved after mutual agreement or by considered significant at p B 0.05. consulting the senior author (VC). Cohen’s kappa was Statistical heterogeneity among the trials was assessed 0.83, showing a very good interrater agreement. using Cochrane’s Q statistic and an alpha value for statis- tical significance of 0.10 indicated significant heterogene- 2.5 Study Quality ity. In addition, the I2 parameter was used to quantify inconsistency of treatment effects across trials (I2 =[Q - Papers were
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