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027 The effects of high-intensity interval training, Nordic walking and moderate-to-vigorous intensity continuous training on functional capacity, depression and quality of life in patients with coronary artery disease enrolled in cardiac rehabilitation: A randomized controlled trial (CRX study)
HIIT, Nordic walking, and moderate to vigorous continuous were tried for people with coronary artery disease. All 3 groups improved functionally, but HIIT and Nordic walking appeared superior for improving mental health.
Authors
1. Jennifer L. Reed
2. Tasuku Terada
3. Lisa M. Cotie
4. Heather E. Tulloch
5. Frans H. Leenen
6. Matheus Mistura
7. Harleen Hans
8. Hong-Wei Wang
9. Sol Vidal-Almela
10. Robert D. Reid
11. Andrew L. Pipe
Affiliations
1. Physiology and Cardiovascular Health Lab, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
2. School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
3. School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
4. Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
5. School of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
6. Brain and Heart Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
7. Institut du savoir Montfort, Hôpital Montfort, Ottawa, Canada
Summary
Participants were randomly assigned to HIIT, NW, or MICT groups and participated in twice-weekly exercise sessions for 12 weeks.
The results showed that all exercise programs were well-attended, safe, and beneficial in improving physical and mental health. However, NW was statistically and clinically superior in increasing functional capacity compared to HIIT and MICT. Depression scores significantly improved in all groups, while BDNF concentrations remained unchanged. Significant improvements were also observed in general and disease-specific quality of life measures.
The study concludes that while all three exercise programs were effective in improving physical and mental health in CAD patients, Nordic walking was the most beneficial in increasing functional capacity, which is a predictor of future cardiovascular events.
Results
The study concludes that while all three programs were effective in improving physical and mental health in CAD patients, Nordic walking was the most beneficial in increasing functional capacity, which is a predictor of future cardiovascular events.
Processes
exercises
1. High-Intensity Interval Training (HIIT):
- Structure: Involves 4 sets of 4-minute high-intensity work periods.
2. Nordic Walking (NW):
- Structure: Participants engaged in walking at a pace that elevated their heart rate to Resting Heart Rate (RHR)
3. Moderate-Intensity Continuous Training (MICT):
- Structure: Similar to NW, participants performed continuous moderate-intensity exercise.
exercise duration
4-minute high-intensity work periods.
number of intervals
4 sets
exercise intensity
85% to 95% of their peak heart rate (HR)
method of evaluation
Functional capacity (six-min walk test [6MWT]), depression (Beck Depression Inventory-II [BDI-II]), BDNF (from a blood sample), and general (Short-Form 36 [SF-36]) and disease-specific (HeartQoL) QoL were measured at baseline and follow-up. Linear mixed-effects models for repeated measures were used to test the effects of time, group and time × group interactions
quantification of measurements
The interaction between time and group (p = 0.042) revealed that the Nordic Walking (NW) group experienced a greater increase in the 6-Minute Walk Test (6MWT) distance, averaging 77.2 meters, compared to the High-Intensity Interval Training (HIIT) group at 51.4 meters and the Moderate-Intensity Continuous Training (MICT) group at 48.3 meters. All groups showed significant improvements in Beck Depression Inventory-II (BDI-II) scores (HIIT: -1.4, NW: -1.6, MICT: -2.3, p < 0.001), but there were no significant changes in Brain-Derived Neurotrophic Factor (BDNF) levels (HIIT: -2.5, NW: -0.4, MICT: -1.2 ng/mL, p > 0.05). Significant improvements were also observed in SF-36 and HeartQoL scores over time (p < 0.05).
Variables
- Exercise Interventions:
- High-Intensity Interval Training (HIIT)
- Nordic Walking (NW)
- Moderate-Intensity Continuous Training (MICT)
2. Dependent Variables (Outcomes)
- Functional Capacity:
- Measured by the Six-Minute Walk Test (6MWT)
- Mental Health:
- Assessed using the Beck Depression Inventory-II (BDI-II)
- Biomarker:
- Brain-Derived Neurotrophic Factor (BDNF) concentrations from blood samples
- Quality of Life (QoL):
- General QoL measured by the Short-Form 36 (SF-36)
- Disease-specific QoL measured by HeartQoL
3. Demographic Variables
- Age: Mean age of participants (61 ± 7 years)
- Gender: Proportion of male participants (85%)
Full Study
Abstract
Background
Coronary artery disease (CAD) patients undergoing revascularization procedures often experience ongoing, diminished functional capacity, high rates of depression and markedly low quality of life (QoL). In CAD patients, studies have demonstrated that high-intensity training (HIIT) is superior to traditional moderate-to-vigorous intensity continuous training (MICT) for improving functional capacity, whereas no differences between Nordic walking (NW) and MICT have been observed. Mental health is equally as important as physical health, yet few studies have examined the impact of HIIT and NW on depression and QoL. The purpose of this randomized controlled trial (RCT) was to compare the effects of 12 weeks of HIIT, NW and MICT on functional capacity in CAD patients. The effects on depression severity, brain-derived neurotrophic factor (BDNF) and QoL were also examined.
Methods
CAD patients who underwent coronary revascularization procedures were randomly assigned to: (1) HIIT (4 × 4-min of high-intensity work periods at 85%–95% peak heart rate [HR]), (2) NW (resting HR [RHR] + 20–40 bpm), or (3) MICT (RHR + 20–40 bpm) twice weekly for 12 weeks. Functional capacity (six-min walk test [6MWT]), depression (Beck Depression Inventory-II [BDI-II]), BDNF (from a blood sample), and general (Short-Form 36 [SF-36]) and disease-specific (HeartQoL) QoL were measured at baseline and follow-up. Linear mixed-effects models for repeated measures were used to test the effects of time, group and time × group interactions.
Results
N = 135 CAD patients (aged 61 ± 7 years; male: 85%) participated. A significant time × group interaction (p = 0.042) showed greater increases in 6MWT distance (m) for NW (77.2 ± 60.9) than HIIT (51.4 ± 47.8) and MICT (48.3 ± 47.3). BDI-II significantly improved (HIIT: −1.4 ± 3.7, NW: −1.6 ± 4.0, MICT: −2.3 ± 6.0 points, main effect of time: p < 0.001) whereas BDNF concentrations did not change (HIIT: -2.5 ± 9.6, NW: -0.4 ± 7.7, MICT: −1.2 ± 6.4 ng/mL, main effect of time: p > 0.05). Significant improvements in SF-36 and HeartQoL values were observed (main effects of time: p < 0.05). HIIT, NW and MICT participants attended 17.7 ± 7.5, 18.3 ± 8.0 and 16.1 ± 7.3 of the 24 exercise sessions, respectively (p = 0.387).
Conclusions
All exercise programmes (HIIT, NW, MICT) were well attended, safe and beneficial in improving physical and mental health for CAD patients. NW was, however, statistically and clinically superior in increasing functional capacity, a predictor of future cardiovascular events.
Study design
This single-centre, parallel-group, RCT was conducted at the University of Ottawa Heart Institute (UOHI), a tertiary care cardiovascular institute. This study was registered with ClinicalTrials.gov (NCT02765568) and carried out in accordance with the consolidated standards of reporting trials (CONSORT) and template for intervention description and replication (TIDieR) checklist.19 The protocol was approved by the Ottawa Health Science Network Research Ethics Board (protocol #: 20160127-01H).
Recruitment
Functional capacity
Functional capacity was assessed using a 6MWT on a measured indoor track at baseline and follow-up.24 Patients were instructed to walk as far as possible for 6 min but not to run or jog. At 2, 3, and 4 min of the 6MWT, patients were provided with standardized encouragement and informed of the time remaining. Total walking distance was measured in meters. The measures were performed in duplicate; the average was used for statistical analyses. A suggested minimal clinically important difference
Results
Of the 1222 patients who were screened, 135 were eligible and consented to participate; a total of 43, 43 and 44 patients were randomized to HIIT, NW and MICT, respectively (see Fig. 1). Patients' demographics, anthropometrics, medical conditions and medications are presented in Table 1. Most patients were male and identified, on average, as being overweight or obese, and normotensive (many due to medical management). Most were taking statins, acetylsalicylic acid, β-blockers, anti-platelets,
Discussion
The physical and mental health benefits of traditional CR involving MICT are well established for patients with CAD.35 This RCT examined the efficacy of alternative exercise interventions (i.e. HIIT and NW) for improving functional capacity, depression severity, BDNF concentrations and QoL in patients with CAD who recently underwent coronary revascularization procedures. Contrary to our hypothesis, a significantly greater in functional capacity was achieved following NW when compared
Conclusion
The findings from this RCT reveal that NW facilitated greater improvements in functional capacity, an important predictor of future cardiovascular events,8 when compared to HIIT and MICT in patients with CAD. All exercise modalities produced significant, beneficial changes in functional capacity and improved depression severity and QoL. These offerings were well attended and safe. Depending on space, equipment, personnel (e.g. expertise, experience in NW instruction) and patient preference, CR
Sources of funding
This investigator initiated research was supported by the Innovations Fund of the Alternate Funding Plan for the Academic Health Sciences Centres of the Ministry of Ontario (PIs: Pipe, Reed) and Heart and Stroke Foundation of Canada (PI: Reid).
Declaration of Competing Interest
The authors declare they have no conflicts of interests.
Acknowledgments
We would like to thank the patients, CR staff and Anna Clarke, Christie Cole, Dr. Daniele Chirico, Kyle Scott, Brenna Czajkowski, Rachelle Beanlands, Janet Wilson, Aaron Brautigam and Yannick MacMillan for their contributions to this research
Intellectual Property Information
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