Aerobic Exercise Intensity & RX in Cardiac Rehab PDF

Aerobic Exercise Intensity
Assessment and Prescription

in Cardiac Rehabilitation
A JOINT POSITION STATEMENT OF THE EUROPEAN ASSOCIATION
FOR CARDIOVASCULAR PREVENTION AND REHABILITATION,
THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND
PULMONARY REHABILITATION, AND THE CANADIAN
ASSOCIATION OF CARDIAC REHABILITATION
Alessandro Mezzani, MD,1* Larry F. Hamm, PhD,2* Andrew M. Jones, PhD,3 Patrick E. McBride, MD, MPH,4
Trine Moholdt, PhD,5 James A. Stone, MD, PhD,6 Axel Urhausen, JP, MD, MPH, PhD,7 and Mark A. Williams, PhD8
ABSTRACT: Aerobic exercise intensity prescription is a key issue in cardiac
rehabilitation, being directly linked to both the amount of improvement
in exercise capacity and the risk of adverse events during exercise. This
joint position statement aims to provide professionals with up-to-date
information regarding the identification of different exercise intensity
domains, the methods of direct and indirect determination of exercise
intensity for both continuous and interval aerobic training, the effects of
the use of different exercise protocols on exercise intensity prescription
and the indications for recommended exercise training prescription in
specific cardiac patients groups. The importance of functional evaluation
through exercise testing prior to starting an aerobic training program is
strongly emphasized, and ramp incremental cardiopulmonary exercise
test, when available, is proposed as the gold standard for a physiologically
comprehensive exercise intensity assessment and prescription. This may
allow a shift from a range-based to a threshold-based aerobic exercise
intensity prescription, which, combined with thorough clinical evaluation
and exercise-related risk assessment, could maximize the benefits obtainable by the use of aerobic exercise training in cardiac rehabilitation.
K E Y
W O R D S
Aerobic training
energy expenditure
peak VO2
ventilatory thresholds
cardiac rehabilitation
Received 14 March 2012; accepted 16 August 2012

1
Salvatore Maugeri Foundation IRCCS, Scientific Institute of Veruno, Exercise Pathophysiology Laboratory, Cardiac Rehabilitation Division, Italy:
George Washington University Medical Center, School of Public Health and Health Services, Department of Exercise Science, Washington, DC,
USA; 3University of Exeter, School of Sport and Health Sciences, UK; 4University of Wisconsin, School of Medicine and Public Health, Department
of Medicine, and Medicine and Family Medicine, USA; 5Norwegian University of Science and Technology, KG Jebsen Center of Exercise in
Medicine, Department of Circulation and Medical Imaging, Trondheim, Norway; 6Cardiac Wellness Institute of Calgary, University of Calgary,
Libin Cardiovascular Institute of Alberta, Canada; 7Hospital Centre of Luxembourg, Centre of Locomotor System, Sports Medicine and Prevention,
CRP-Sant, Luxembourg; 8Creighton University School of Medicine, Division of Cardiology, Department of Medicine, Omaha, USA.
*Co-Chair.
2
Conflict of interest: None declared.

Correspondence: Alessandro Mezzani, Salvatore Maugeri Foundation IRCCS, Scientific Institute of Veruno, Exercise Pathophysiology
Laboratory, Cardiac Rehabilitation Division, Via per Revislate 13, 28010 Veruno (NO), Italy. Email: alessandro.mezzani@fsm.it
This article is copublished in the European Journal of Preventive Cardiology.
DOI: 10.1097/HCR.0b013e3182757050
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Position Statement / 327
Copyright 2012 American Association of Cardiovascular and Pulmonary Rehabilitation and European Society of Cardiology
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INTRODUCTION
The intensity of aerobic exercise training is a key issue
in cardiac rehabilitation. Exercise intensity is directly
linked to both the amount of improvement in exercise
capacity and the risk of adverse events during exercise, and intensity ranges for aerobic training prescription are included in several guidelines and publications regarding secondary prevention and cardiac
rehabilitation.14 The purpose of this joint position
statement of the European Association for
Cardiovascular Prevention and Rehabilitation (EACPR),
American Association of Cardiovascular and Pulmonary
Rehabilitation (AACVPR) and Canadian Association of
Cardiac Rehabilitation (CACR) is to provide professionals with a reappraisal of all aspects related to aerobic
exercise intensity assessment and prescription, with
specific reference to patients with heart disease. Key
issues discussed in this statement include: 1) identification of different exercise intensity domains based on
the physiological response to constant-work-rate
(CWR) exercise; 2) a review of the methods of direct
and indirect determination of exercise intensity for
both continuous and interval aerobic training; 3) discussion of the potential effects that different exercise
protocols may have on exercise intensity prescription;
and 4) indications for recommended exercise training
prescription in specific cardiac patient groups.
Of note, in addition to intensity, two other major
components of the weekly volume of aerobic training
are duration and frequency of the exercise sessions.5
As indicated in Domains of exercise intensity: the
appropriate basis for exercise prescription below, session duration is intuitively and causally dependent on
the chosen exercise intensity, that is, the higher the
exercise intensity, the shorter the exercise duration,
whereas, regarding training frequency, for the purpose of this paper a frequency of three to four sessions per week will be assumed; it is acknowledged
that a higher or lower frequency may require modifications of the exercise intensity prescription. As far as
the training modality is concerned, the term continuous training used in this position statement is
intended as a training modality in which an exercise
session can be performed for at least 20 minutes with
a mild or moderate sense of fatigue; on the other
hand, the term interval training refers to shorter exercise sessions that cannot be sustained longer on
account of an excessive sense of fatigue. Finally, the
terms incremental and graded, as referred to for an
exercise test, are used interchangeably throughout the
text, and the term exercise test, whenever quoted,
stands for incremental/graded exercise test, unless
otherwise specified.
DIRECT EXERCISE INTENSITY

ASSESSMENT: PHYSIOLOGICAL BASES
Descriptors of the O2 Transport and Utilization
System Response
Aerobic exercise intensity is strictly and causally
linked to energy expenditure during effort. In an
oxygen-dependent biological system, the latter is
mostly described by oxygen uptake (VO2) through the
O2 energy equivalent, equal on average to 20 kJ or
5 kcal per litre of O2 consumed. As a consequence,
peak VO2 and the first and second ventilatory thresholds (i.e. the physiological descriptors of the O2 transport and utilization system response to exercise) are
the gold standard references for the evaluation of
aerobic metabolism function and, consequently, for
aerobic exercise intensity assessment and prescription. For the purposes of this statement, the terms
ventilatory and lactate threshold are considered
interchangeable; those interested in the relationship
between blood lactate and ventilatory gases modifications are referred to previously published reviews.6,7
First Ventilatory Threshold

During light to moderate-intensity incremental exercise, aerobic metabolism satisfies almost all of the
bodys energy needs and blood lactate is not (or is
only marginally) elevated above the resting value.
However, with increasing effort intensity, a threshold
is reached, termed first ventilatory threshold (1stVT),
above which blood lactate and pH start to increase
and decrease, respectively.69 To counteract the ongoing metabolic acidosis, intracellular bicarbonates buffer hydrogen ions generated by lactic acid dissociation
and produce CO2 in excess of that produced by aerobic metabolism, which makes the VCO2 versus VO2
relationship become steeper.69 The 1stVT can thus be
determined by analysing the slope of the VCO2 versus
VO2 relationship, and can be identified as the point of
transition in the VCO2 versus VO2 slope from less than
1 to greater than 1 (Figure 1(a)).69 At the same time,
the VE/VO2 ratio inverts its trend in the presence of a
still decreasing or constant VE/VCO2, which makes
the 1stVT also identifiable as the nadir of the VE/VO2
versus work rate (WR) relationship (Figure 1(b)).69
The 1stVT marks the limit between the light to moderate- and the moderate to high- intensity effort
domains;10,11 this is reached at around 5060% of peak
VO2 or 6070% of peak heart rate (HR).611
Second Ventilatory Threshold

With increasing exercise intensity and lactic acid production above the 1stVT, a point is reached when
intracellular bicarbonates are no longer able to
328 / Journal of Cardiopulmonary Rehabilitation and Prevention 2012;32:327-350
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adequately counteract exercise-induced metabolic

acidosis.69 At this point, respiratory alkalosis develops
through a VE increase in excess of VCO2, and this is
termed the second ventilatory threshold (2ndVT) or
respiratory compensation point. Simultaneously, the
VE/VCO2 ratio inverts its trend (increase versus initial
decrease), and the 2ndVT is identifiable as the nadir
of the VE/VCO2 versus WR relationship (Figure
1(b)).69 The possibility of identifying the 2ndVT
depends to a large extent on the gain of the chemoceptive response to metabolic acidosis, which can
vary among subjects/patients, thereby making the

2ndVT identification potentially difficult. When identifiable, the 2ndVT is usually attained at around
7080%peak VO2 and 8090%peak HR reached during
incremental exercise, and it has been proposed to be
related to the so-called critical power (CP),12 that is,
the upper intensity limit for prolonged aerobic exercise1315 (see Moderate to high-intensity exercise and
High to severe-intensity exercise below). However, it is
important to recognize that a mechanistic link between
2ndVT and CP has not as yet been proven.
Figure 1. (a) VCO2 as a function of VO2 during

ramp incremental cardiopulmonary exercise
test. The point where the VCO2 versus VO2
slope increases its steepness is the first ventilatory threshold. The initial and final phases of
exercise (vertical dotted rectangles) are usually
excluded from the analysis due to possible
hyperventilation during these periods. (b)
Ventilatory equivalents for O2 and CO2 as a
function of work rate during ramp incremental
exercise. The nadir of VE/VO2 identifies the
first ventilatory threshold, whereas the nadir
of VE/VCO2 identifies the second ventilatory
threshold. Open circles are blood lactate
concentration. 1stVT: first ventilatory threshold;
VE/VO2: ventilatory equivalent for O2; VE/VCO2:
ventilatory equivalent for CO2; 2ndVT: second
ventilatory threshold; WR: work rate.
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Peak VO2
Light to Moderate-Intensity Exercise
Peak VO2 is defined as the VO2 value, averaged over

a 20- to 30-s period, achieved at presumed maximal
effort during an exercise test, while performing
dynamic work involving large muscle groups.8,9 Peak
VO2 may or may not be equal to VO2max (intended as
the true insuperable upper limit for aerobic power),
even if the available evidence suggests that these two
concepts are substantially equivalent.16 Achievement
of maximal or near-maximal effort (and thus of reliable peak VO2 values) is crucial for correct aerobic
training prescription,17 and is often assumed in the
presence of one or more of the following criteria:18
The light to moderate exercise domain encompasses

all WRs engendering steady-state VO2 values below
that corresponding to the 1stVT.10,11 During light to
moderate CWR exercise, blood acid- base status is not
perturbed and blood lactate is not (or is only barely)
elevated above the resting value (i.e. 12 mmol/L). In
this domain, VO2 and ventilation steady-states are
attained relatively rapidly following the onset of exercise. The steady-state is attained more rapidly in
trained subjects and is typically delayed by aging,
prolonged inactivity and chronic diseases. The attainment of an early physiological steady-state has the
effect of limiting the contribution of non-oxidative
metabolism to energy turnover and reducing the
depletion (e.g. phosphocreatine, glycogen) or accumulation (e.g. inorganic phosphate, Hp) of fatiguerelated metabolites in the working muscles.10,11 For
this reason, exercise is generally well tolerated in this
domain and is expected to be sustainable for a long
period of time (3040 min) with only a modest
sense of fatigue.
Failure of VO2 and/or HR to increase with further

increases in WR;
Peak respiratory exchange ratio (VCO2/VO2) 1.10;
Post-exercise blood lactate concentration
8mmol/L;
Rating of perceived exertion (RPE) 18 in the Borg
Category Scale or 8 in the Borg Category-Ratio
Scale;19
Patient appearing exhausted.
Of these, a plateau in the VO2 versus WR relationship
during incremental exercise is considered the gold
standard for the determination of maximal effort,
whereas the cut-offs for peak respiratory exchange
ratio and post-exercise blood lactate concentration
values proposed above are somewhat limited by high
inter-individual variability.20
Domains of Exercise Intensity: The Appropriate

Basis for Exercise Prescription
Aerobic exercise training of cardiac patients has traditionally been performed using the CWR modality. In
this regard, it is noteworthy that the metabolic and gas
exchange responses to CWR exercise differ depending
on exercise intensity. This allows for the identification
of four exercise intensity domains: light to moderate,
moderate to high, high to severe, and severe to
extreme. The physiological characteristics of the four
exercise intensity domains are summarized in Table 1.
Moderate to High-Intensity Exercise

This intensity domain comprises those WRs lying
between the 1stVT and the CP (Figure 2). CP represents the highest WR still sustainable in conditions of
both VO2 and lactate steady-state1214,2126 and is a
crucial (though seldom used) marker of the upper
limit of sustainable prolonged aerobic exercise.27 The
CP corresponds to around 6070%peak WR and peak
VO2 and 7080%peak HR as assessed by incremental
exercise testing, but with higher steady-state %peak
VO2 and %peak HR values during CWR exercise. This
is due to the appearance of a slow component of the
VO2 kinetics after approximately two to three minutes
of the start of CWR exercise in this intensity domain,
which is not detectable during incremental exercise.28
The VO2 slow component elevates the VO2 above the
VO2 that would be expected for a given WR, resulting
in a delayed attainment of the VO2 steady-state (by as
much as 1015 minutes or more). In other words, the
T a b l e 1 Physiological Characteristics of the Different Intensity Domains for Constant-Work-Rate

Exercise
VO2
Steady-state
Lactate
Steady-state
Exercise
Duration
VO2 vs. WR Linear

Relationship
Training
Modality
Light to moderate
Yes
NA
30 min
Yes
Continuous
Moderate to high
Yes
Yes
~2030 min
No
Continuous
High to severe
No
No
~320 min
NA
Interval
Severe to extreme
No
No
3 min
NA
Interval
WR: work rate; NA: not applicable.
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Figure 2. Time to exhaustion as a function of

power in patients with chronic heart failure and
in untrained normal subjects. Critical power is
the power asymptote of the hyperbolic relationship linking time to exhaustion and power (work
rate) during constant-work-rate exercise in the
high to severe- and severe to extreme-intensity
domains. Five constant-work-rate exercise tests at
50%, 65% and 80% of the difference between
peak work rate and that corresponding to the first
ventilatory threshold, and to 100% and 120% of
peak work rate were used to fit the relationship.
Open circles and filled squares represent patients
with chronic heart failure and untrained normals,
respectively. Dashed vertical lines are mean critical power values for the two groups. Redrawn
from Mezzani et al.30
VO2 and HR steady-state is reached at a level higher

than expected according to the below-1stVT VO2 versus WR relationship10,11,28 (Figures 3 and 4). The VO2
slow component represents a loss of muscle efficiency,29 which elevates the O2 cost of exercise and, for
this reason, exercise in the moderate to high domain
cannot be sustained for as long as that in the light to
moderate domain. However, continuous exercise sessions of 30-minute duration are obtainable in the
moderate to high-intensity domain even in patients
with a significantly reduced exercise capacity, such as
those with chronic heart failure (CHF).30
High to Severe-Intensity Exercise

This intensity domain comprises all the WRs above CP
that cause VO2 to reach its peak value with no steadystate attainment.10,11 For the very highest WRs in this
intensity domain no VO2 slow component is evident
and VO2 may rise with a close to mono-exponential
profile that is truncated at peak VO2. Consequently, the
high to severe-intensity domain presents a broad range
of exercise WRs at which peak VO2 will be reached. In
this domain, blood acid-base balance is severely perturbed,25 as reflected by a continuous rise in blood
lactate until the exercise is terminated. Of note, the
failure to attain a physiological steady-state in the high
to severe-intensity domain is also evident regarding
skeletal muscle (phosphocreatine) and pH.31 The duration of exercise in this domain is highly predictable2123
(Figure 2) and is typically in the range of 320 min.
Given both such a short exercise session duration and
the impossibility of a steady-state attainment, this
intensity domain can only be used for interval, rather
than continuous, aerobic training prescription.
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The slow component rise in VO2 during moderate

to high- and high to severe-intensity CWR exercise
means that VO2 changes not only as a function of WR,
but also as a function of time in these domains.
Consequently, irrespective of the subjects/patients
peak exercise capacity, without precise stipulation of
the exercise conditions and timing of measurements,
it is difficult to define a given intensity as a percentage
of peak VO2 in these intensity domains.
Severe to Extreme-Intensity Exercise

Given the finite kinetics of VO2, it is inevitable that
some WRs are so high that fatigue intervenes before
peak VO2 can be achieved. In this domain the tolerable duration of exercise is limited to less than about
3 min.32 Interestingly, due in part to the short duration
of exercise before exhaustion occurs, blood lactate at
the end of exercise in this domain may not reach such
high values as those recorded at the end of high to
severe-intensity exercise until exhaustion.
Need for Direct Evaluation of Functional

Capacity: The Role of Exercise Testing
The administration of an incremental, that is, graded,
exercise test to patients entering outpatient cardiac
rehabilitation programs has been recommended since
the 1970s.33,34 Current EACPR, AACVPR, CACR,
European Society of Cardiology and American Heart
Association guidelines for cardiac rehabilitation programs strongly recommend exercise testing as a key
component of the initial patient assessment, and
address the concept of exercise testing as a tool for
exercise training evaluation, risk stratification to determine the required level of supervision and monitoring,
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and individualized exercise prescription.14,3539 Despite

these recommendations, there has been an increasing
trend in both Europe and the United States for patients
being referred to and entering cardiac rehabilitation
without an exercise test. Reasons stated for the lack of
testing include shorter hospital stays, more aggressive
revascularization interventions, increased sophistication of diagnostic procedures, extreme deconditioning,
orthopaedic limitations, left ventricular dysfunction,
knowledge of the coronary anatomy, recent and successful coronary revascularization and uncomplicated
myocardial infarction.39
For cardiac rehabilitation patients for whom there
are no exercise test results, it is recommended that
the exercise prescription could be based on the level
of exercise performed during the inpatient phase of
rehabilitation and recommended home exercise
activities, while monitoring for signs and symptoms
of exercise incompetence. In this context, it is important to understand the difference between a diagnostic exercise test and one performed to assess the
functional capacity for cardiac rehabilitation purposes. A diagnostic exercise test is often carried out
in pharmacologic wash-out as one of the initial steps
in determining whether signs or symptoms that are
present (e.g. chest pain or dyspnoea) are cardiac in
origin. At entry into cardiac rehabilitation, patients
already have documented cardiac disease; thus, a test
administered at this time on current therapy serves
primarily as a functional evaluation to quantify exercise capacity, chronotropic and inotropic responses
to exercise, and presence and severity of dysrhythmias, as well as identify signs, symptoms, or other
clinical evidence of any residual myocardial ischemia. Using an alternative standardized approach to
prescribing exercise intensity (e.g. 20 bpm resting
HR) that is not based on current exercise capacity
because exercise test data are not available (see
Unavailability of exercise testing below), potentially
minimizes the beneficial effects of exercise training
and is likely to retard patient progress during cardiac
rehabilitation. Thus, it is important to administer a

functional sign/symptom-limited exercise test prior
to patients beginning cardiac rehabilitation. In this
regard, an incremental standard exercise test or cardiopulmonary exercise test with respiratory gas
analysis (CPX), which is the gold standard for a
direct assessment of the exercise intensity descriptors
outlined in Descriptors of the O2 transport and utilization system response and Domains of exercise
intensity: the appropriate basis for exercise prescription above, should be used whenever possible to
obtain an exercise prescription tailored on the individual patients functional capacity and pathophysiological picture.
INDIRECT EXERCISE INTENSITY

ASSESSMENT
The Heart Rate Versus VO2 Relationship
HR is widely used for exercise intensity assessment and
prescription on the grounds that a linear relationship
between HR and both VO2 and WR increase during
incremental exercise is known to exist.40,41 Thus, after
having measured peak HR, the intensity of effort chosen as the training stimulus is indirectly determined by
means of published regression equations42 or tables
(Table 2)43 as the percentage of the peak HR value corresponding to a given percentage of peak VO2. On this
basis, a target HR range is usually proposed in normal
subjects ranging between 70 and 85%peak HR.44 In
cardiac patients, available guidelines suggest training
intensities equal to 4080%peak VO2,3,44,45 that is,
roughly ranging from 50 to 85%peak HR (Table 2).
However, it must be considered that intensity classifications such as those shown in Table 2 do not reveal to
which precise intensity the 1stVT and 2ndVT correspond in an individual patient. Indeed, %peak HR
values commonly used for training prescription both in
normal subjects and cardiac patients have been found
T a b l e 2 ACSM Classification of Exercise Relative Intensity

%HRR or VO2R
%peak VO2
%peak HR
RPE Borg Scale
20
25
35
10
Light
2039
2544
3554
1011
Moderate
4059
4559
5569
1213
Heavy
6084
6084
7089
1416
85
85
90
1719
100
100
100
20
Very light
Very heavy
Maximal
43
Modified from Tipton et al. ; ACSM: American College of Sports Medicine; HRR: heart rate reserve; VO2R: VO2 reserve; HR: heart rate; RPE: rating of perceived
exertion.
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to be associated with levels of metabolic stress higher

than those of both the 1stVT and 2ndVT.4649 This
seems to hold true also for subjects treated with betablockers50 and patients with left ventricular dysfunction
both on- and off-beta-blocking therapy.51
The Heart Rate Reserve Versus VO2 Reserve

Relationship
The concept of HR reserve (HRR) and VO2 reserve
(VO2R), defined as the difference between the basal
and peak HR and VO2 values, respectively,5255 are currently used for training prescription purposes. A percentage of HRR (%HRR) equal to 60% has been indicated to correspond to the 1stVT,52,53 and %HRR has
been found to equal percentages of VO2R (%VO2R) in
both normal individuals undergoing both cycle and
treadmill exercise5456 (Table 2) and in cardiac patients.57
Of note, the VO2 reserve concept fits closely the need
for a precise exercise intensity definition since it
describes the true amount of energy one can utilize for
maximal effort attainment, taking into account the
baseline level. As a consequence, %HRR has been
adopted by the American College of Sports Medicine as
the gold standard for exercise intensity indirect assessment, and training HRR ranges of 6080 %HRR for
persons without overt disease44 and 4070 %HRR for
cardiac patients45 have been proposed. Moreover, a
recent systematic review has confirmed the validity of
%HRR for both indirect assessment and prescription of
aerobic training intensity.58 Of note, it has been demonstrated that %HRR values commonly used for training prescriptions in normal subjects and cardiac
patients both on- and off-beta-blockers can correspond
to energy expenditures ranging from light to moderate
to moderate to high.47,50,5961 These same values hold
true for patients with left ventricular dysfunction.51,62
However, a loss of linearity of both the VO2 versus
WR and HR versus WR relationships as peak VO2 is
approached has been described in cardiac patients63
in whom chronotropic incompetence may be present
due to age-, pathology- and/or drug (beta-blockers)related sinus node dysfunction.64,65 On this basis, a
very high uncertainty in predicting %VO2R values on
the basis of %HRR has been demonstrated in CHF
patients both on- and off-beta-blockers.66 However,
recent data suggest that the %HRR%VO2R equivalence may be preserved in CHF patients on optimized
beta-blocking therapy.67
The RPE Versus VO2 or HR Relationship

RPE is commonly employed in cardiac rehabilitation,
either as a primary indicator of exercise intensity or as
an adjunct to HR monitoring.19,44,68 Its use is particularly valuable in patients who have difficulty obtaining
a reliable or meaningful exercise-related HR, e.g.
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patients with atrial fibrillation; patients whose HRs may

not adequately reflect their level of exertion because
of beta-blockade, absence of autonomic cardiac innervation occurring after heart transplantation, chronotropic incompetence or certain types of pacemakers;
and patients in whom the ability to physically obtain
an accurate pulse is limited due to a variety of reasons.
Obtaining a rating of perception of exertion is also of
assistance to cardiac rehabilitation staff members when
comparing the perceived demands of various exercise
devices, for example arm versus leg exercise.
The commonly utilized scales for the RPE include
the original Category Scale (RPE Borg scale), which
rates exercise intensity from 6 to 20, and the CategoryRatio Scale (CR10 Borg scale), which utilizes a numerical range from 0 to 10.19 The average RPE range
associated with exercise adaptation is 1316 (somewhat hard to hard) on the RPE Borg scale, which is
loosely associated with a 7090% range of peak HR
and a 5085% range of peak VO2 (Table 2). This
approximately corresponds to 2.56 on the CR10 Borg
scale, which is also loosely associated with a 6090%
range of peak HR and approximately 5085% of peak
VO2. Several papers have supported the reliability of
RPE for effort intensity assessment and prescription in
normal individuals and cardiac patients both off- and
on-beta-blockers, with a good correspondence
between a value of around 13 and the 1stVT.6976
However, the response can vary greatly both between
and within individuals, dependent as it is upon individual physiologic responses to exercise and perception of effort.77 Moreover, the RPE reported by a
patient can be affected by factors other than the physical effort of the exercise, including both psychological
factors and environmental conditions. In patients who
have a change in the dose of beta-blocker medication,
the original calculation of exercise intensity using HR
is likely no longer valid.78 In this case, the best
approach is to repeat an exercise test, but if this is not
possible, a reasonable alternative is to prescribe an
exercise intensity based on the reported RPE during
exercise prior to the medication change.
Intensity and Volume of Exercise Training

Volume of exercise training is associated with overall
energy expenditure expressed in kilocalories, for
example kilocalories per week.79 For cardiac patients,
the volume goal of exercise training should ultimately
reach 1500 kcal/week,44,8082 although this level may
be difficult to attain for some patients, particularly
early in the post-hospitalization phase of exercise
training. During this period, exercise training intensity
is low, frequently in the range 46 kcal/min. Hence
the importance of both the frequency and duration of
exercise sessions. Early post-hospitalization exercise
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training typically involves a minimum of 2030 minutes per session, three to four days per week. Using
an average of 5 kcal/min and exercising for 30 min,
one would expend 150 kcal/session; thus, with 3 sessions/week one would expend approximately 450
kcal (four sessions expending 600 kcal). In order to
increase the volume of exercise kcal expenditure to
achieve the desired level (1500 kcal/week), one must
consider the adjustments of intensity, frequency and
duration of activity, modifying a single parameter or a
combination of these three parameters. Thus, at a
given exercise intensity, for example 5 kcal/min, one
would need to ultimately utilize a combination of
increases in frequency and duration, as follows:
(5 kcal/min) (40 min/session) (6 sessions/week)
1200 kcal/week
Unfortunately, although the intensity of effort may be
appropriate, the stamina required to exercise for 40
minutes and six days per week may be overwhelming. However, as patients improve their fitness level,
and become able to expend, say, 7kcal/min, duration
and/or frequency can be adjusted.
(7 kcal/min) (30 min/session) (6 sessions/week)
1260 kcal/week
As the volume of exercise will impact kilocalorie
expenditure, it is important to consider the contribution of all three components of the exercise prescription, namely exercise intensity, duration of activity
and frequency of exercise sessions.
EXERCISE INTENSITY PRESCRIPTION

Prescribed Exercise Intensity: General Concepts
The idea proposed in this statement is that aerobic exercise prescription in cardiac patients should be based on
the choice of a specific exercise intensity domain determined by: i) the patients clinical and pathophysiological picture, ii) the peculiar physiological response to
and the evidence-based benefits of exercise in the different intensity domains and iii) the goals of the rehabilitation program. This involves a shift from a rangebased to a threshold-based aerobic training prescription, based on data obtained by incremental standard
exercise test or CPX in the individual patient.
Of note, some caveats must be taken into account
when transferring information obtained from incremental exercise testing to CWR exercise, as underlined
in Domains of exercise intensity: the appropriate basis
for exercise prescription above and in Figures 3 and 4:
1. Beyond the 1stVT, a given relative exercise intensity expressed as %peak VO2 will result in an
energy expenditure higher than expected (moderate to high-intensity domain) or equal to peak VO2
irrespective of the prescribed relative intensity
(high to severe-intensity domain) when performing
CWR exercise; as a consequence, %peak VO2 must
be used with caution as a reference for training
intensity prescription in these domains, since the
individual patients actual energy expenditure during CWR exercise is not easily predictable.
2. In the CWR moderate to high-intensity domain
some relative intensities may not be easily attainable (chequered area in Figure 3).
3. As shown in Figure 4, for a given VO2 value, the
WRs included in the light to moderate domain are
not the same when performing incremental versus
CWR exercise. The VO2 versus WR relationship is
shifted to the right in the former due to an initial
lag in the VO2 increase,83 on the grounds that in
CWR exercise the VO2 versus WR values are measured after a VO2 steady-state has been reached,
thus excluding the initial VO2 on-response delay.
As a consequence, when prescribing CWR training
in the light to moderate domain on the basis of
incremental exercise data, it is necessary to reduce
the WR prescription to a lower iso-VO2 value
(Figure 4). The more prolonged the initial lag of
the VO2 response to incremental exercise is, the
greater the reduction should be and, as a rule of
thumb, should amount to around 10 W for a 10 W/
min incremental protocol in the general population
of cardiac patients. Experimental confirmations are
needed as to this point for moderate to high-intensity CWR exercise.
Bearing this in mind, the available evidence supporting the prescription of aerobic training in cardiac patients in the different intensity domains is as
follows:
1. Light to moderate-intensity domain. The lowest aerobic training intensity still able to provide a training
effect likely depends mostly, in both normal subjects
and cardiac patients, on pre-training exercise capacity. In agreement with the lower fitnesslower training stimulus intensity principle,84 intensities even
much lower than those corresponding to the 1stVT
should be effective in cardiac patients with a markedly reduced exercise capacity. In keeping with this
concept, aerobic training intensities as low as
40%peak VO2 (corresponding to about 25%VO2R)
have proven to be effective in CHF patients with
significantly reduced pre-training peak VO2.85,86 The
light to moderate-intensity training is possibly the
most indicated for patients with recent hemodynamic decompensation, for those with a high exercise-related risk, and for those in whom a light to
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Figure 3. Relationship between relative exercise intensity as evaluated by ramp incremental cardiopulmonary exercise test and during
constant-work-rate exercise sessions at corresponding work rates. The linear relationship
between VO2 and work rate is lost for constant-work-rate exercise above the first ventilatory threshold, as determined during the
incremental cardiopulmonary exercise test.
This means that the VO2 steady-state is
reached at a level higher than expected
according to the below-first ventilatory
threshold VO2 versus work rate relationship
(moderate to high-intensity domain) or not
attained at all (high to severe-intensity
domain). Given the above, for constant-workrate exercise in the moderate to high-intensity
domain some relative intensities may not be
easily attainable nor prescribable (chequered
area). The relationships shown in the moderate to high-intensity domain are illustrative,
and may not be quantitatively confirmed in
individual patients. See text for further
details. 1stVT: first ventilatory threshold;
2ndVT: second ventilatory threshold; CWR:
constant-work-rate; SS: steady-state.
Figure 4. VO2 as a function of work rate in a

single ramp incremental versus several constant-work-rate cardiopulmonary exercise
tests. The initial lag of the VO2 response (grey
area) during incremental exercise (full line)
shifts the VO2 versus work rate relationship
rightwards with respect to that obtained from
several constant-work-rate tests (open diamondsdotted line). For a given VO2 value, the
first and second ventilatory thresholds will
thus be reached at a lower work rate when
exercising at constant-work-rate than during
incremental exercise. A VO2 slow component
adds to the on-response during constant-workrate exercise above the first ventilatory threshold, projecting the steady-state VO2 to a level
higher than expected according to the belowfirst ventilatory threshold VO2 versus work rate
relationship (dotted line). Critical power,
assessed as shown in Figure 2, is the highest
work rate sustainable in VO2 steady-state conditions (filled diamond). In the high to severeintensity domain, VO2 is, by definition, systematically projected to peak VO2 irrespective
of the applied work rate. See text for further
details. 1stVT: first ventilatory threshold;
2ndVT: second ventilatory threshold; CP: critical power; sc: VO2 slow component; WR:
work rate.
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moderate training intensity is indicated for clinical/

therapeutic reasons (i.e. need for weight loss).
2. Moderate to high-intensity domain. Strong evidence
has accumulated with regards to adverse event-free
moderate to high-intensity exercise in cardiac
patients with both preserved and reduced left ventricular ejection fraction.8791 Aerobic training in this
domain can still be performed in a continuous
modality, with reported training sessions of 1530
min duration.8791 The possibility to train patients in
the moderate to high-intensity domain is noteworthy, especially when considering that cardiac patients
with reduced exercise capacity perform daily activities at a higher percentage of their peak VO2 compared with normal subjects. For example, it has
been reported that during a six-minute walking test
(considered to closely mimic habitual walking activities), CHF patients exercise at a percentage of peak
VO2 often above that corresponding to their 1stVT.9294
In such a pathophysiological context, the capacity to
train in steady-state VO2 conditions above the 1stVT
could be crucial to avoid fatigue and termination
during activities of daily living. In this regard, recent
data show that CHF patients may exercise at the CP
(i.e. the upper limit of the moderate to high-intensity domain) for 30 minutes without incurring adverse
events;30 however, further research is needed to
confirm this point.
3. High to severe and severe- to extreme-intensity
domains. In recent years, training in the high to
severe- and even severe to extreme-intensity
domain using interval training has proven effective
in improving exercise capacity in different cardiac
patient populations,9597 including stable CHF
patients with a pre-training peak VO2 as low as 13
ml/kg per min96 (see Interval training prescription
below). As indicated in Domains of exercise inten-
sity: the appropriate basis for exercise prescription

above, the upper limit of the high to severe-intensity domain is the highest WR that will allow for
the attainment of peak VO2. Of note, times to
exhaustion during CWR exercise at 100% peak WR
and 135% peak WR have been reported to last on
average three minutes and 90 seconds, respectively, not only in both untrained and trained normal
subjects but also in CHF patients.30,98
Based on the physiological definition of CWR exercise intensity domains (Table 1), the upper limits of
such domains can be defined by using physiological
and/or performance parameters as shown in Table 3,
where correspondence with exercise intensity classes
according to the ACSM exercise intensity classification
is also reported. In the absence of a direct assessment
of aerobic metabolism descriptors by CPX, effort relative intensities can be expressed as %peak HR, %HRR,
%peak WR, or using Borg scales. Generally speaking,
and with the limitations reported in The heart rate
versus VO2 relationship, The heart rate reserve versus
VO2 reserve relationship and The RPE versus VO2 or HR
relationship above, intensities close to the 1stVT
(50%peak VO2) should lie around 60%peak HR,
50%peak HRR, 50%peak WR, or 1213 in the RPE
Borg scale, whereas intensities close to the 2ndVT
(70-80%peak VO2) should lie around 70%peak WR or
1516 in the RPE Borg scale (Table 3).
Interval Training Prescription

Interval training can be defined as repeated bouts of
short-duration, high to severe- or severe to extremeintensity exercise (i.e. 10 seconds to five minutes),
separated by brief periods of lower-intensity CWR
exercise allowing for active recovery. The term aerobic interval training (AIT) is often used to describe
T a b l e 3 Upper Limits of the Different Intensity Domains

Physiological Upper Limit
Directly Assessed
Light to moderate
Moderate to high
High to severe
Severe to extreme
Indirectly
Assessed
VO2 or VO2R at 1stVT ~60% peak HR

HR or HRR at 1stVT
~50% HRR
NA
NA
Peak VO2
NA
NA
Performance Upper Limit

Indirectly
Assessed
Directly Assessed
Perceived
Exertion
Upper Limit
ACSM
Class
WR at 1stVT
~50% peak WR
1213 RPE
Borg scale
VL to
Mod
CP
WR at 2nd VT(?)
~70% peak WR(?)
1516 RPE
Borg scale
Mod to H
Highest WR still allowing peak VO2 attainment
100% peak
WR
19-20 RPE
Borg scale
H to Max
100% peak WR
100% peak
WR
1920 RPE
Borg scale
NA
ACSM Class: American College of Sports Medicine exercise intensity classification; VO2R: VO2 reserve; 1stVT: first ventilatory threshold; WR: work rate; HR:
heart rate; HRR: heart rate reserve; RPE: rating of perceived exertion; NA: not applicable; CP: critical power; 2ndVT: second ventilatory threshold; VL to Mod:
very light to moderate; Mod to H: moderate to high; H to Max: high to maximal; >>: much higher than.
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Figure 5. The 4 4 min aerobic interval

training model. Intensity is given as
percentage of peak heart rate.
interval training in the high to severe-intensity

domain. Although a significant contribution from
anaerobic energetic sources to the total energy yield
is unavoidable in this domain, most of the energy
needed is still produced aerobically (see Domains of
exercise intensity: the appropriate basis for exercise
prescription above). Currently, the most used AIT
model consists of 10min warm-up followed by 44min intervals at 8595%peak HR, with active recovery
phases of 3 min at ~70%peak HR (Figure 5). This AIT
model has now been used in several studies, both in
healthy subjects and in various cardiac patient populations,95,96,99,100 with absolute increases in peak VO2
per exercise session actually remarkably similar
among patient groups (Figure 6).
AIT has shown significantly greater cardiovascular
effects when compared with isocaloric moderate to
high- intensity continuous training, both in coronary
artery disease (CAD) and CHF patients95,96 (Figure 6).
AIT has also been shown to exert favourable effects
on left ventricular systolic function. In healthy men,
stroke volume has been shown to increase significantly more after high-intensity AIT compared with
lower-intensity training of the same energy expenditure.99 In CHF patients, Wislff et al.96 found reverse
left ventricular remodelling after AIT, while continuous training produced no significant changes in left
ventricular volumes and resting haemodynamics; furthermore, left ventricular contractile function was
shown to markedly improve only in AIT patients. Also
left ventricular diastolic properties have been found to
improve significantly more after AIT than after continuous training in both CHF96 and stable CAD subjects.101 Improved endothelial function, reductions in
atherosclerosis and better calcium regulation in cardiomyocytes are among the possible explanations for
these findings and data in humans seem to confirm
basic experimental data.102 Both AIT and moderate to
high-intensity continuous training have been found to
improve endothelial function in cardiac patients, with
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significantly larger improvement in brachial artery

flow-mediated dilatation after AIT in CHF patients96
and both improvement in endothelial function and
reduction in in-stent restenosis in patients with previous percutaneous coronary intervention (PCI) and
Figure 6. Peak VO2 before and after aerobic interval training and
moderate to high-intensity continuous training in patients with coronary artery disease and chronic heart failure. Modified from Rognmo
et al.95 and Wislff et al.96 CAD: coronary artery disease; CHF:
chronic heart failure; AIT: aerobic interval training; MCT: moderate
to high-intensity continuous training; *p 0.05 vs. MCT.
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stent implantation.103 It is reasonable to suggest that

higher shear stress during AIT may trigger larger
responses than moderate to high-intensity continuous
training at the cellular and molecular level and be
responsible for the observed effects on endothelial
function.104
In contrast to the described 44-min AIT model,
shorter, sprint-type intervals of all-out severe to
extreme- intensity exercise have been shown to
induce rapid changes in exercise capacity, improving
work performance due to enhanced skeletal muscle
energy metabolism with modest effects on peak
VO2.105,106 This type of interval training is poorly
documented in CAD patients, although some acute
effects of severe to extreme-intensity interval training
have been reported in stable CAD patients.97,107
However, a study applying two-minute-long severe to
extreme-intensity intervals found a similar improvement in peak VO2 to that after more traditional continuous training in CAD patients, but with increased
time to exhaustion at 90%VO2R.108
In a clinical setting, AIT can be performed as uphill
walking or running on a treadmill according to the
44- min protocol. Patients are supposed to exercise
with an intensity corresponding to 8595%peak HR
during the high to severe-intensity intervals, which
makes patients breathe heavily without experiencing
chest or leg pain. To ensure that the relative intensity
is maintained throughout the whole training period,
the WR should be adjusted continuously based on the
individual HR response. In the recovery periods,
patients are supposed to exercise at intensities of
~70%peak HR. In clinical practice, however, it is
sometimes necessary to adjust the HR zones, especially the moderate to high-intensity recovery ones,
based on the patients subjective feelings. In the RPE
Borg scale, patients should exercise at an intensity of
1518 in the high to severe-intensity intervals. Exercise
modes other than treadmill walking are possible and
AIT using an aerobic exercise group setting has been
shown to be feasible in CHF patients.109 Although AIT
has proven efficient in increasing cardiovascular
health in CAD patients, there is still a need to further
investigate feasibility, long-term effects and safety
aspects of this training modality. In CHF patients, a
preserved walking distance on the six-minute walking
test was found one year after ending a formal AIT
program.110 Moreover, in patients with previous coronary artery by-pass graft a further increase in peak
VO2 was seen six months after the end of an AIT
rehabilitation period.100 A large ongoing multicentre
randomized trial, the Study of MyocArdial Recovery
AfTer EXercise Training in Heart Failure (SMARTEX-HF),
will address the feasibility, safety and efficacy of AIT
in a large group of CHF patients.111
Arm Exercise Intensity Prescription

Peak HR and VO2 values are significantly lower for arm
than for leg exercise, likely due to the reduced muscle
mass of the arms. Additionally, at the same absolute
WRs, the VO2 for arm work is greater than that of leg
work, owing to the reduced mechanical efficiency of
arm exercise. Consequently, the cardiovascular
responses to standardized WRs during arm ergometry
are greater, particularly HR and blood pressure, compared with leg exercise.112116 Exercise prescriptions
based upon %peak VO2 derived from treadmill CPX,
by way of example, may result in absolute WRs which
are substantially greater than what a patient may be
able to comfortably achieve during arm ergometry. The
exercise prescription generated from %HRR or %peak
HR methods attained from standard treadmill or cycle
ergometry exercise testing will often provide a safe
guideline for the patient, whereby WR can be adjusted
to achieve an appropriate HR response. In this regard,
it has been suggested that, at a given submaximal WR,
for obtaining a HR similar to that obtained during leg
ergometry, a WR equal to about two- thirds of the latter
should be used during arm ergometry.117
In addition to the differences in physiological
responses to acute arm versus leg exercise, the principle of exercise training specificity suggests that cardiovascular and metabolic adaptation to acute exercise is specific to the type of exercise performed and
the muscles involved.118 Specifically, training upper
limbs or lower limbs results in only minor improvement in submaximal and maximal exercise parameters
when testing the untrained limbs. Lastly, the role of
arm exercise in a patient whose primary goal is
weight loss should be balanced against the patients
need to significantly improve upon the acute exercise
response to arm exercise (training adaptation). If the
patient has the expectation to resume participation in
occupational or recreational activities which require
substantial upper limb aerobic capacity, a significant
component of the cardiac rehabilitation exercise training program may need to include arm exercise.118120
However, primarily assigning increased utilization of
lower extremity exercise, with their increased exercise
efficiency and enhanced ability to exercise at higher
absolute WR, may substantially increase the calorie
expenditure of the exercise program.
Weight Loss-Targeted Exercise Intensity and

Daily Physical Activities Intensity Prescription
Obesity or being overweight affects more than half of
the adult populations in the developed world and
both are associated with an increased risk of many
chronic diseases. A large body of evidence demonstrates that even modest weight loss, as low as 35%
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of body weight, by regular physical activity is associated with decreased chronic disease risk.121 Higher
intensity and longer duration physical activity, conducted on a regular basis, are both associated with
greater weight loss and less long-term weight gain
compared with lower intensity or shorter duration
exercise. Weight loss induced by increased daily
physical activity without caloric restriction can significantly reduce obesity (particularly abdominal obesity)
and insulin resistance. Exercise without overall weight
loss reduced abdominal fat and prevented further
weight gain.122 Evidence supports that low to moderate-intensity physical activity of 150250 minutes per
week will result in modest weight loss and is effective
in preventing weight gain. Higher intensities and longer duration of physical activity (250 min/week) are
associated with significant weight loss.123 Maintenance
of weight loss is optimal with low to moderate- or
moderate to high-intensity physical exercise of more
than 250 min/week duration. A recent systematic
review noted a doseresponse relationship between
the intensity of activity and the loss of visceral fat,
with at least 10 METsh/week of aerobic exercise
(brisk walking, light jogging or stationary ergometer
usage) required for visceral fat reduction.123 Both men
and women benefit from maintaining higher levels of
physical activity over a long period of time, but the
benefits may be even greater for women.124126
These results support findings that 30 minutes of
activity daily may be sufficient to lose weight and
prevent weight gain.127,128 In the STRRIDE study, overweight individuals were randomized to high-, moderate-, or low- activity groups. Although all groups lost
weight and body fat, the high-activity group lost more
weight and body fat. These findings support the recommendation that higher intensities and longer durations of physical activity are optimal for weight maintenance, but that even moderate activity is beneficial.
This study also noted that the positive caloric imbalance observed in the overweight controls was modest
and could be reversed by a modest amount of exercise, equivalent to walking 30 minutes every day.
However, other observational studies suggest that
higher durations of activity may be necessary for
middle-aged and older adults. This age-associated
effect may be related to the inability of many older
adults to exercise at higher intensities, especially initially, and thus longer durations of physical activity
and lower intensities are required in order to achieve
the negative caloric balance that is sufficient for
weight loss.129,130 Moreover, this may be due to the
well-documented age-related declines in resting metabolic rate and lean body mass in older adults and
suggests that, in addition to activity, reduced energy
intake is vital to prevent weight gain with age.131
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The results of the research cited above suggest that

incorporating physical activity into daily life improves
health outcomes, body weight and visceral adiposity.
There appears to be a doseresponse related to
weight loss from light to high-intensity activity, but
both light to moderate- and moderate to high-intensity
activity may result in significant weight loss when
maintained over time, and especially when combined
with appropriate caloric intake for body size and daily
energy expenditure. Research suggests that a minimum of 30 minutes of light to moderate activity on a
daily basis is the threshold to result in weight loss, but
that increasing the duration to 4560 minutes, or
increasing the intensity to moderate to high levels,
may further enhance weight loss and cardiorespiratory fitness.
Unavailability of Exercise Testing

There is no contemporary, scientifically validated reason for cardiac rehabilitation programs to substitute
the current standard of formal incremental exercise
test or CPX, including diagnostic 12-lead ECG appraisal, for other assessments of functional capacity (see
Need for direct evaluation of functional capacity: the
role of exercise testing above). Therefore, cardiac
rehabilitation professionals are strongly encouraged to
use every option and opportunity to ensure their
patients benefit from standard exercise tests or CPX.
However, in cardiac rehabilitation programs where
these kinds of exercise tests are not available, there
are alternative strategies that may assist programs in
both stratifying patients with regard to their risk of
exercise-associated adverse events and in developing
an exercise prescription. In an effort to try to
determine subsequent event risk in cardiac rehabilitation populations without exercise testing results, the
six-minute walking test has been proposed as a reasonable alternative to a more formal exercise capacity
evaluation.132134 However, the assertion or presumption that the six-minute walking test and CPX are
interchangeable is not supported by the current literature.36 Other well-validated and widely utilized classification schemes such as the Canadian Cardiovascular
Society (CCS) classification of stable angina pectoris135
and the New York Heart Association (NYHA) functional classification136 have not been adequately studied to fully and completely assess their validity as
accurate determinants of myocardial ischemic burden,
ventricular function and functional capacity. The
above observations not withstanding, in cardiac rehabilitation programs where formal exercise testing cannot be performed or is simply not a readily available
service, a risk stratification protocol utilizing the
patients CCS Class, NYHA Class and six-minute walking test has been developed (Table 4).37 Importantly,
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however, this risk stratification scheme has not been

externally validated.
Once a patients exercise risk has been determined
without the aid of a standard exercise test or a CPX,
an exercise prescription can be developed using Borg
scales and/or subjective tools such as the talk
test.68,137 RPE correlates sufficiently well with exercise
HR and VO2 to allow for an exercise prescription to
be determined;138,139 an RPE Borg scale rating of 912
should be sufficient to elicit light to moderate exertion
while remaining below the 1stVT in both patients and
normal subjects6973,140 (see The RPE versus VO2 or HR
relationship above). In addition, the use of RPE as an
acceptable measure of the physiologic response to
exercise appears to be valid for patients receiving
beta-blockers.76 In the talk test or the walk and talk
test, patients should be able to maintain a certain
level of exercise and still be able to talk in full sentences. As with RPE, its use in CAD populations to
determine levels of physical exertion that approximate those objectively assessed by CPX has not been
robustly evaluated. However, considering that its use
in healthy populations does appear to correlate with
1stVT141 and VO2R,142 it is thus not unreasonable to
consider its use also in patients with CAD.
PATIENT GROUPS
Indications for aerobic exercise intensity prescription
in specific cardiac patient groups are summarized in
Table 5; only intensity domain data for which scientific evidence is available in a given cardiac patient
group have been included, with grey-shaded areas
indicating that there are no available data to warrant
a recommendation. Physiological, performance and
perceived exertion limits of the different exercise
intensity domains are provided in Table 3, and both
directly (i.e. by incremental CPX) and indirectly (i.e.
by incremental standard exercise test) assessed physiological and performance limits are shown. As already
T a b l e 4 Exercise-related Risk
Stratification
Risk Category
CCS Class
NYHA Class
6-min WT
01
400
Intermediate
II
301400
High
III
201300
Very high
IV
200
Low
CCS: Canadian Cardiovascular Society classification of angina pectoris;

NYHA: New York Heart Association; 6-min WT: distance walked at sixminute walking test.
emphasized in Prescribed exercise intensity: general

concepts above, the choice between different exercise
intensities in a specific patient will depend on the
individuals clinical and pathophysiological status, the
evidence-based benefits of exercise in the different
intensity domains for that specific patient group and
the goals of the rehabilitation program. The information provided in this section are to be considered
complementary to those furnished by the recently
published EACPR paper Importance of characteristics
and modalities of physical activity and exercise in the
management of cardiovascular health in individuals
with cardiovascular disease (Part III).143
Stable Angina Pectoris

For patients with stable angina pectoris (SAP) secondary to coronary atherosclerosis, the benefits of cardiac
rehabilitation are unequivocal and it should be considered standard care for all patients with CAD.144,145 The
overwhelming consideration within this population
remains exercise safety. The surest way to maximize
both patient safety and exercise enjoyment and attain
improved cardiorespiratory fitness is to first assess the
patient using an incremental standard exercise test or
CPX, develop an exercise intensity prescription based
on the results of that test and then ensure an adequate
warm-up and cooling down period prior to and after,
respectively, training sessions.
The purpose of the warm-up is to increase blood
flow to the skeletal muscles, in preparation for exercise, and to facilitate coronary vasodilatation. The
anti-ischemic benefits of an adequate warm-up, prior
to the initiation of light to moderate/moderate to high
exercise have been demonstrated.146148 As far as training intensity is concerned, the current recommendation for persons without SAP is to perform moderate
to high-intensity exercise sessions in order to improve
cardiorespiratory fitness.149 This same recommendation has been extended to patients with SAP.37 In a
number of small studies, moderate to high-intensity
exercise training in patients with SAP has been shown
to reduce myocardial ischemic burden assessed by
either myocardial perfusion scintigraphy150,151 or
24-hour ambulatory electrocardiographic monitoring.152 The mechanisms by which exercise training
improves mortality in the SAP population include
enhanced metabolic performance of working muscles, reduced endothelial dysfunction, improvements
in insulin resistance and favourable adjustments in
neurohormonal abnormalities.153
In recent years, research into the most appropriate
intensity of exercise training for patients with CAD
has focused on the use of AIT (see Interval training
prescription above). Although the cardiorespiratory
benefits of AIT are well documented in athletes, a
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T a b l e 5 Evidence-based Prescribable Aerobic Exercise Intensity in Cardiac Patient Groups

Exercise Intensity Domains
Light to moderate
Moderate to high
High to severe
Stable angina pectoris
Chronic CAD (no residual ischaemia)
PCI
Pacemaker
ICD
Chronic AF
CABG
Valve repair/replacement
CHF
LVAD
Heart transplantation
Severe to extreme
The boxed areas identify intensity domains for which no scientific evidence is available in a specific population; CAD: coronary artery disease;
PCI: percutaneous coronary intervention; ICD: implantable cardioverter defibrillator; AF: atrial fibrillation; CABG: coronary artery by-pass grafting;
CHF: chronic heart failure; LVAD: left ventricular assist device; aHeart rate and/or work rate must in any case be lower than those corresponding to the ischaemic threshold; bHeart rate may not be usable due to highly variable chronotropic response; cHeart rate may not be usable due to denervation-related blunted
chronotropic response.
recent systematic review of interval training in

patients with CAD found only two controlled and five
randomized controlled trials, with a total of 213
patients.104 The review found that interval training
improved cardiorespiratory fitness, endothelial function and ventricular function and morphology to a
greater degree than conventional light to moderateand moderate to high-intensity continuous aerobic
training. In a study on SAP patients, Guiraud and coworkers found that shorter bouts of severe to
extreme-intensity exercise (15 seconds compared
with 60 seconds) combined with a passive, rather
than active, recovery phase, resulted in improved
patient comfort and longer time spent at 80% of
peak VO2.154 In patients with SAP, it is important that
exercise intensity be prescribed at a HR that is below
the ischemic threshold;44 for patients with documented silent ischemia, it is critical that patients be
instructed to never exceed the upper HR limit for
exercise intensity. The purpose of the cool-down
period post-exercise is to invoke a return to a resting
state. Studies in healthy populations have indicated
that a cool-down period following exercise returns
both the HR and ventilation toward pre-exercise
levels faster than without a cool-down.155,156
In summary, it is suggested that patients with SAP
exercise three to five times per week, following an
adequate warm-up of five to 15 minutes, at moderate
to high intensity (in any case below the ischemic
threshold) for a period of 20 to 40 minutes (not
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including warm-up and cool-down), followed by a

cool-down period of five to 10 minutes. Most importantly, patients with SAP should engage in the type of
exercise activity they find most enjoyable and, therefore, sustainable.
PCI
The same evidence and clinical practice recommendations developed for patients with SAP regarding
exercise (see Stable angina pectoris above) are likely
applicable to most patients post-PCI. Presently, there
is no evidence to suggest that early exercise training
and exercise testing post-PCI is either unsafe or
adversely affects patient outcomes,157159 even if highintensity exercise may actually increase thrombin
generation.160 With respect to the best timing to begin
an exercise training program of moderate to high
intensity, Parker et al. found that exercise testing and
training were safe in a low risk post-PCI population
less than two weeks after acute PCI for ST-elevation
myocardial infarction.161 As post-PCI patients may be
at particular risk for failing to increase their physical
activity levels and exercise,162 a more rapid access to
exercise training may be particularly useful in this
population.163 Exercise training programs post-PCI
have been consistently associated with improvements
in functional capacity;103,157,164166 conversely, failure
to improve functional capacity post-PCI, despite exercise training, may be a marker for coronary artery
restenosis.167
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Data on the specific effects of exercise intensity on

patient outcomes post-PCI are sparse. Munk et al.
found that high to severe-intensity interval training
helped to reduce six month restenosis in the stented
coronary artery segment as assessed by quantitative
coronary angiography; this effect was associated with
improvements in aerobic capacity and attributed to
improved endothelial function and reduced systemic
inflammation.103 Other investigators have found similar findings with respect to improved functional
capacity and reduced inflammation for post-PCI
patients.164,166 Aerobic training may result in increased
endothelial NO production and/or reduced NO
destruction and this may lead to reduced vascular
inflammation and reduced restenosis.168170 In addition
to these benefits, moderate to high-/high to severeintensity exercise training post-PCI may also improve
left ventricular remodeling171 and HR variability.172,173
However, whether such a training modality is safe for
all patients post-PCI, particularly those with a history
of anterior/apical myocardial infarction, or with poor
left ventricular systolic function, and those with a history of CHF, remains to be determined.
Pacemakers and Implantable Cardioverter

Defibrillators
Patients implanted with permanent pacemakers (PMs)
usually follow the same principles for aerobic training
intensity prescription as non-PM-implanted patients,
provided an adequate chronotropic response to exercise is warranted by the patients sinus node and/or
the device.174 In rate-responsive PM, this is usually the
case when the upper-rate limit is matched to the
expected training intensity. On the other hand, if an
exercising patients chronotropic response exceeds
the PM upper-rate limit, the device should usually
produce a Wenckebach pattern to maintain a relatively high HR without risking rapid ventricular
responses. If a Wenckebach pattern is produced at
exercise intensity levels lower than those prescribed,
the upper-rate limit may need to be increased. Of
note, patients with VVI PM devoid of rate-adaptive
function lack the ability to increase HR. In the absence
of rate modulation, the exercise capacity of VVI paced
patients may be greatly reduced when compared with
those with rate modulation and AV synchrony.
However, it has been shown that exercise training
may produce significant increases in peak VO2 also in
this population.175
Patients with implantable cardioverter defibrillators
(ICDs) can undergo aerobic exercise training, but care
must be taken to avoid receiving inappropriate shocks
during exercise. These could occur in the event that
the exercise HR increases so that it is within the programmed ventricular tachycardia zone or if exercise-
induced supraventricular tachycardia develops.

Exercise intensities in the light to moderate and moderate to high domains have been found effective in
improving peak VO2 in patients with an ICD. It is
important to note that exercise training intensities used
in all of these studies resulted in HRs that were 1520
beats lower than the ICD threshold for detection and
termination of ventricular tachycardia.176179 Thus, as
recently stated, exercise heart rates should not exceed
ICD therapy thresholds and ideally be set between 10
and 20 beats below first line therapy thresholds.3
Chronic Atrial Fibrillation

Chronic atrial fibrillation (AF) is a very common
arrhythmia, characterized by irregularly irregular atrial
and ventricular depolarizations. The prevalence of
chronic AF is quite high in patients older than 60
years and the arrhythmia may present as lone AF or
associated with comorbid conditions, such as CHF or
valvular heart disease. Patients with chronic AF frequently have incomplete ventricular filling, which
leads to an impaired cardiac output response to
exercise, very rapid ventricular rates during effort
(possibly exceeding predicted maximum) and, ultimately, reduced peak VO2 and VO2 at 1stVT in comparison with patients in sinus rhythm.180 Patients with
CHF and chronic AF show peak VO2 values lower
than those of CHF patients in sinus rhythm, but with
1stVT occurring at a higher percentage of peak
VO2.181 Training intensities in the light to moderateand moderate to high-intensity domains have been
used in patients with chronic AF, improving both
exercise capacity (i.e. peak VO2) and chronotropic
response to exercise.182184 Of note, the highly variable
ventricular chronotropic response at submaximal
levels of exercise typical of chronic AF patients may
render HR of little utility for aerobic training prescription in some patients, making subjective RPE the most
reliable means for exercise intensity assessment and
prescription. In this regard, given the high prevalence
of chronic AF in elderly patients, randomized controlled studies addressing the most effective type of
exercise intensity assessment and prescription in this
population are strongly needed.
Coronary Surgical Revascularization

Patients who have undergone traditional open-chest
coronary artery by-pass graft (CABG) surgery as well
as minimally invasive procedures are a substantial proportion of cardiac rehabilitation exercise programming
participants, and this group includes many patients
who are age 65 years or older.185 Outpatient rehabilitation can be started, as appropriate, within one week of
hospital discharge (23 weeks post-surgery).186 Exercise
prescription methodology is generally the same as that
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used with CAD patients. Initially, some patients may

need lower- intensity or modified exercise because of
musculoskeletal discomfort or healing issues at their
incision sites, including not only the chest, but possibly also legs and arms. Specifically, patients should
completely refrain from upper-extremity aerobic exercise training, for example arm ergometry and resistance training, for 46 weeks post-surgery to ensure
the stability of the sternum and sternal wound healing.
The exception is appropriate upper and lower body
stretching and flexibility exercises to promote mobility.
In patients with previous CABG, several aerobic training intensities have proven effective,100,187192 the
choice of which will depend on both the level of
exercise-related risk and the patients clinical condition. In this regard, it must be borne in mind that,
among patients entering a rehabilitation program after
a recent acute cardiac event, those with recent CABG
have been found to have the lowest peak VO2.193
Because of the possibility of graft closure, program
staff should be alert for new patient complaints of
angina pectoris or angina-equivalent symptoms or
signs, such as exercise intolerance or new ECG signs
of myocardial ischemia. Patients should also be educated regarding these possibilities. Recognizing
whether the revascularization was complete or incomplete is valuable in this regard as the latter may
increase the likelihood of postsurgical signs and
symptoms of residual myocardial ischemia during
exercise, which may significantly affect the results of
the rehabilitation process.194
Valve repair or replacement

The exercise prescription and training of patients with
recent valve replacement or repair is very similar to
that used with CABG surgery patients.186,195,196
However, the physical activity of some valvular heart
disease patients may have been very restricted for an
extended period of time prior to the surgical intervention. Consequently, the resulting low functional
capacity may require these patients to initiate, and
proceed with, exercise in a conservative fashion,
especially during the early stages of the exercise training program.193 Rehabilitation professionals should
take care to avoid upper-extremity exercise, as
described in Coronary surgical revascularization
above. Exercise intensities in the light to moderateand moderate to high-intensity domains have been
used in patients with recent heart valve replacement
or repair and balloon valvuloplasty, demonstrating
significant effects on exercise capacity and quality of
life.197201 Preliminary data also indicate a possible
reverse left ventricular remodelling effect of prolonged aerobic training in patients with previous aortic valve replacement.202 Anticoagulation therapy is
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very common in patients who have undergone valve

surgery; consequently, this necessitates caution for
exercise-related injuries and subsequent bleeding.
Staff should frequently remind patients undergoing
exercise training of the increased risk of such events.
Patients with valvular heart disease but without
valve repair or replacement may also be referred for
cardiac rehabilitation. In these patients, critical aortic
stenosis is a formal contraindication for exercise training. Patients with less-severe aortic stenosis can exercise but may develop symptoms, for example dyspnoea
and significant fatigue, at a given WR. Exercise training
intensity should be kept under the threshold that precipitates the onset of symptoms, because these symptoms indicate that their cardiac output is not capable of
meeting the demands of that level of exercise.
CHF and Left Ventricular Assist Devices

A reduced ability to perform aerobic exercise is the
hallmark of the CHF pathophysiological picture.203 It
is related to changes in both peripheral and central
links of the O2 transport chain from ambient air to the
skeletal muscle, the major consequence of which is a
reduced cardiac output and peripheral microcirculatory response relative to exercise-related metabolic
needs.204,205 Moreover, ventilation is increased at comparable absolute submaximal levels of effort in CHF
patients with respect to age-matched normal subjects.206 Among the proposed causes of the increased
ventilatory response to exercise are a reduced
oxygen-diffusing capacity due to an impairment of
alveolararterial oxygen transfer,207 an increase in
dead space ventilation because of a mismatching of
ventilation relative to pulmonary perfusion,206 and an
exaggerated ergoreflex response originating in the
exercising skeletal muscles during effort.208 Finally,
skeletal muscle metabolic potential is also reduced,
due to altered redistribution of flow to exercising
muscles, endothelial dysfunction and impaired mitochondrial enzymes activity.209 These changes promote a vicious cycle of deterioration involving catabolic drive and reflex neurohormonal over-activation,210 which may lead to disease progression and
functional deterioration. As a consequence, in CHF,
peak VO2 and VO2 at 1stVT are typically reduced
with respect to age-matched normal subjects, and
their reduction is proportional to the severity of the
syndrome.211 A wide range of aerobic exercise intensities, that is, from light to moderate to high to severe,
has been tested in CHF patients. All intensities have
been shown to be effective in improving patients
exercise capacity, whereas the ability to induce
reverse left ventricular remodelling and improvements in left ventricular ejection fraction has been
demonstrated only for moderate to high- and high to
HCR200267.indd 343
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severe-intensity aerobic training.85,86,96,212 This offers a

wide range of possibilities for the choice of aerobic
exercise intensity in CHF, even if more work is needed to investigate safety aspects of high to severeintensity training in this population (see Interval
Training Prescription above).
Among patients with advanced CHF, that is, by
definition with severely reduced exercise capacity and
presumed high exercise-related risk, left ventricular
assist device implantation is increasingly used as a
bridge to transplantation or even as permanent therapy. Patients with left ventricular assist devices can
often be managed at outpatient clinics, and an early
initiation of exercise training after implantation has
been reported to be associated with improvements in
exercise capacity.213 Walking in the hospital ward as
well as aerobic exercise on a cycle ergometer or a
treadmill can be performed with the aim of improving
exercise capacity. Light to moderate training intensities
adjusted at the 1stVT level or possibly even slightly
higher (1214 score in the RPE Borg scale) have succeeded in improving peak VO2 in this population.214216
Heart Transplantation
Exercise training is recommended for all patients
before and after heart transplantation.186,217 Patients
with severe heart failure, awaiting heart transplantation, are usually significantly deconditioned due to
metabolic changes that occur with heart failure, resulting in significant limitations in the ability to do physical work.218 Functional capacity following transplantation may be affected by the patients baseline capacity
prior to surgery, or by underlying cause(s) of heart
failure, the clinical course in the hospital, surgical
complications, skeletal muscle weakness, use of corticosteroids and other post-transplant medications and
surgical denervation of the heart.219
Given the complexity of hemodynamic and cardiorespiratory responses during incremental exercise in
this population, exercise intensity may best be determined by RPE. At the start of training programs, an
RPE of 1012, that is, light to moderate-intensity in
the RPE Borg scale, will generally account for the
surgical and disease deconditioning as well as any
potential exercise issues associated with steroid
myopathy.220 If the patients clinical condition allows,
the exercise intensity can gradually increase to moderate to high to enhance patient outcomes. High to
severe-intensity aerobic interval training programs
have also been evaluated in selected heart transplanted patients and have proven to be safe and
effective.221,222 Following heart transplantation, an
improvement in functional capacity of approximately
2050% is associated with participation in a cardiac
rehabilitation program.220223 Exercise should be
initially performed in a supervised setting to fully

evaluate and monitor the patients response to aerobic training.
CONCLUSIONS
In current cardiac rehabilitation practice, the choice of
the aerobic training stimulus intensity in individual
patients remains largely a matter of clinical judgement. This European, US and Canadian joint position
statement provides evidence-based indications for a
shift from a range-based to a threshold-based aerobic exercise intensity prescription, to be combined
with thorough clinical evaluation and exercise-related
risk assessment. The importance of functional evaluation through exercise testing prior to starting an aerobic training program is strongly emphasized, and an
incremental cardiopulmonary exercise test, when
available, is proposed as the gold standard for a
physiologically comprehensive exercise intensity
assessment and prescription. This would allow professionals to match the unique physiological responses
of different exercise intensity domains to the individual patient pathophysiological and clinical status,
maximizing the benefits obtainable from aerobic exercise training in cardiac rehabilitation.
Acknowledgments
This statement was approved by the European
Association for Cardiovascular Prevention and
Rehabilitation on 28 November 2011, the American
Association of Cardiovascular and Pulmonary
Rehabilitation Board of Directors on 6 March 2012
and the Canadian Association of Cardiac Rehabilitation
on 5 June 2012.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-forprofit sectors.
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Aerobic Exercise Intensity

Assessment and Prescription

Received 14 March 2012; accepted 16 August 2012

Conflict of interest: None declared.

Position Statement / 327

DIRECT EXERCISE INTENSITY

First Ventilatory Threshold

Second Ventilatory Threshold

328 / Journal of Cardiopulmonary Rehabilitation and Prevention 2012;32:327-350

adequately counteract exercise-induced metabolic

vary among subjects/patients, thereby making the

Figure 1. (a) VCO2 as a function of VO2 during

Position Statement / 329

Light to Moderate-Intensity Exercise

Peak VO2 is defined as the VO2 value, averaged over

The light to moderate exercise domain encompasses

Failure of VO2 and/or HR to increase with further

Domains of Exercise Intensity: The Appropriate

Moderate to High-Intensity Exercise

T a b l e 1 Physiological Characteristics of the Different Intensity Domains for Constant-Work-Rate

VO2 vs. WR Linear

WR: work rate; NA: not applicable.

330 / Journal of Cardiopulmonary Rehabilitation and Prevention 2012;32:327-350

Figure 2. Time to exhaustion as a function of

VO2 and HR steady-state is reached at a level higher

High to Severe-Intensity Exercise

The slow component rise in VO2 during moderate

Severe to Extreme-Intensity Exercise

Need for Direct Evaluation of Functional

and individualized exercise prescription.14,3539 Despite

rehabilitation. Thus, it is important to administer a

INDIRECT EXERCISE INTENSITY

T a b l e 2 ACSM Classification of Exercise Relative Intensity

RPE Borg Scale

332 / Journal of Cardiopulmonary Rehabilitation and Prevention 2012;32:327-350

to be associated with levels of metabolic stress higher

The Heart Rate Reserve Versus VO2 Reserve

The RPE Versus VO2 or HR Relationship

patients with atrial fibrillation; patients whose HRs may

Intensity and Volume of Exercise Training

EXERCISE INTENSITY PRESCRIPTION

334 / Journal of Cardiopulmonary Rehabilitation and Prevention 2012;32:327-350

Figure 4. VO2 as a function of work rate in a

Position Statement / 335

moderate training intensity is indicated for clinical/

sity: the appropriate basis for exercise prescription

Interval Training Prescription

T a b l e 3 Upper Limits of the Different Intensity Domains

VO2 or VO2R at 1stVT ~60% peak HR

Performance Upper Limit

~70% peak WR(?)

Highest WR still allowing peak VO2 attainment

336 / Journal of Cardiopulmonary Rehabilitation and Prevention 2012;32:327-350

Figure 5. The 4 4 min aerobic interval

interval training in the high to severe-intensity

significantly larger improvement in brachial artery

Position Statement / 337

stent implantation.103 It is reasonable to suggest that

Arm Exercise Intensity Prescription

Weight Loss-Targeted Exercise Intensity and

338 / Journal of Cardiopulmonary Rehabilitation and Prevention 2012;32:327-350

The results of the research cited above suggest that