Research Article| Volume 167, ISSUE 3, P894-902, August 10, 2013

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Changes in cardiorespiratory fitness in cardiac rehabilitation patients: A meta-analysis

Published:December 30, 2011DOI:



      Improving patients' cardiorespiratory fitness is an important therapeutic outcome in cardiac rehabilitation. The ability of cardiac rehabilitation to reduce mortality and morbidity has been evidenced through several meta-analyses. Whether cardiac rehabilitation can increase cardiorespiratory fitness and which factors may influence such gains are less well quantified.


      We performed detailed literature searches of electronic databases and manually searched papers concerning changes in cardiorespiratory fitness in cardiac rehabilitation patients. We performed random-effects meta-analysis of mean improvements in cardiorespiratory fitness and subgroup analyses to determine potential sources of heterogeneity.


      Data from 31 studies produced 48 groups (n=3827) with a mean improvement of 1.55 (95% CI 1.21–1.89) METs, (p<0.001); equivalent to standardised effect size of ES=0.97 (95% CI 0.80–1.13). As this value was highly heterogeneous (Q=852, p<0.001) we performed subgroup analyses on the effect size data. Gains in fitness were highest in patients receiving >36 exercise sessions in studies where fitness was assessed using the Naughton Protocol. Patient characteristics associated with the highest fitness gains were age (being young) and sex (being male training in a male-only exercise group). Changes in fitness were unrelated to programme type (comprehensive or exercise-only), duration or study design. There was no association with patient's baseline fitness levels.


      This is the first meta-analysis of changes in cardiovascular fitness in cardiac rehabilitation patients and shows clinically significant improvements in a large sample of patients from a variety of rehabilitation programmes. This analysis helps describe the characteristics of cardiac rehabilitation programmes which can increase patients' cardiorespiratory fitness.


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        • O'Connor G.T.
        • Buring J.E.
        • Yusuf S.
        • et al.
        An overview of randomized trials of rehabilitation with exercise after myocardial infarction.
        Circulation. 1989; 80: 234-244
        • Oldridge N.B.
        • Guyatt G.H.
        • Fischer M.E.
        • Rimm A.A.
        Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials.
        JAMA. 1988; 260: 945-950
        • Jolliffe J.A.
        • Rees K.
        • Taylor R.S.
        • Thompson D.
        • Oldridge N.
        • Ebrahim S.
        Exercise-based rehabilitation for coronary heart disease.
        Cochrane Database Syst Rev. 2001; : CD001800
        • Taylor R.S.
        • Brown A.
        • Ebrahim S.
        • et al.
        Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.
        Am J Med. 2004; 116: 682-692
        • Conn V.S.
        • Hafdahl A.R.
        • Moore S.M.
        • Nielsen P.J.
        • Brown L.M.
        Meta-analysis of interventions to increase physical activity among cardiac subjects.
        Int J Cardiol. 2009; 133: 307-320
        • Lee C.D.
        • Blair S.N.
        • Jackson A.S.
        Cardiorespiratory fitness, body composition, and all-cause and cardiovascular disease mortality in men.
        Am J Clin Nutr. 1999; 69: 373-380
        • Taylor R.S.
        • Unal B.
        • Critchley J.A.
        • Capewell S.
        Mortality reductions in patients receiving exercise-based cardiac rehabilitation: how much can be attributed to cardiovascular risk factor improvements?.
        Eur J Cardiovasc Prev Rehabil. 2006; 13: 369-374
        • Thompson D.
        Cardiac rehabilitation: adding years to life and life to years.
        Journal of Research in Nursing. 2009; 14: 207-219
        • Lavie C.J.
        • Milani R.V.
        Benefits of cardiac rehabilitation and exercise training in elderly women.
        Am J Cardiol. 1997; 79: 664-666
        • McAuley P.
        • Pittsley J.
        • Myers J.
        • Abella J.
        • Froelicher V.F.
        Fitness and fatness as mortality predictors in healthy older men: the veterans exercise testing study.
        J Gerontol A Biol Sci Med Sci. 2009; 64: 695-699
        • Lyerly G.W.
        • Sui X.
        • Church T.S.
        • Lavie C.J.
        • Hand G.A.
        • Blair S.N.
        Maximal exercise electrocardiography responses and coronary heart disease mortality among men with diabetes mellitus.
        Circulation. 2008; 117: 2734-2742
        • Sui X.
        • Laditka J.N.
        • Hardin J.W.
        • Blair S.N.
        Estimated functional capacity predicts mortality in older adults.
        J Am Geriatr Soc. 2007; 55: 1940-1947
        • Williams M.A.
        • Ades P.A.
        • Hamm L.F.
        • et al.
        Clinical evidence for a health benefit from cardiac rehabilitation: an update.
        Am Heart J. 2006; 152: 835-841
        • Blair S.N.
        • Kohl III, H.W.
        • Barlow C.E.
        • Paffenbarger Jr., R.S.
        • Gibbons L.W.
        • Macera C.A.
        Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men.
        Jama. 1995; 273: 1093-1098
        • Gulati M.
        • Pandey D.K.
        • Arnsdorf M.F.
        • et al.
        Exercise capacity and the risk of death in women.
        Circulation. 2003; 108: 1554-1559
        • Balady G.J.
        • Jette D.
        • Scheer J.
        • Downing J.
        Changes in exercise capacity following cardiac rehabilitation in patients stratified according to age and gender. Results of the Massachusetts Association of Cardiovascular and Pulmonary Rehabilitation Multicenter Database.
        J Cardiopulm Rehabil. 1996; 16: 38-46
        • Myers J.
        • Prakash M.
        • Froelicher V.
        • Do D.
        • Partington S.
        • Atwood J.E.
        Exercise capacity and mortality among men referred for exercise testing.
        N Engl J Med. 2002; 346: 793-801
        • Dorn J.
        • Naughton J.
        • Imamura D.
        • Trevisan M.
        Results of a multicenter randomized clinical trial of exercise and long-term survival in myocardial infarction patients: the National Exercise and Heart Disease Project (NEHDP).
        Circulation. 1999; 100: 1764-1769
        • Kavanagh T.
        • Mertens D.J.
        • Hamm L.F.
        • et al.
        Peak oxygen intake and cardiac mortality in women referred for cardiac rehabilitation.
        J Am Coll Cardiol. 2003; 42: 2139-2143
        • Swain D.P.
        • Franklin B.A.
        Comparison of cardioprotective benefits of vigorous versus moderate intensity aerobic exercise.
        Am J Cardiol. 2006; 97: 141-147
        • Dusseldorp E.
        • van Elderen T.
        • Maes S.
        • Meulman J.
        • Kraaij V.
        A meta-analysis of psychoeduational programs for coronary heart disease patients.
        Health Psychol. 1999; 18: 506-519
        • Swain D.P.
        Moderate or vigorous intensity exercise: which is better for improving aerobic fitness?.
        Prev Cardiol. 2005; 8: 55-58
        • Taylor R.S.
        • Watt A.
        • Dalal H.M.
        • et al.
        Home-based cardiac rehabilitation versus hospital-based rehabilitation: a cost effectiveness analysis.
        Int J Cardiol. 2007; 119: 196-201
        • Morales F.J.
        • Montemayor T.
        • Martinez A.
        Shuttle versus six-minute walk test in the prediction of outcome in chronic heart failure.
        Int J Cardiol. 2000; 76: 101-105
        • Higgins J.
        • Thompson S.
        • Deeks J.
        • Altman D.
        Statistical heterogeneity in systematic reviews of clinical trials: a critical appraisal of guidelines and practice.
        J Health Serv Res Policy. 2002; 7: 51-61
        • Davey Smith G.
        • Egger M.
        • Phillips A.N.
        Meta-analysis. Beyond the grand mean?.
        BMJ. 1997; 315: 1610-1614
        • Miller N.H.
        • Haskell W.L.
        • Berra K.
        • DeBusk R.F.
        Home versus group exercise training for increasing functional capacity after myocardial infarction.
        Circulation. 1984; 70: 645-649
        • Dressendorfer R.H.
        • Franklin B.A.
        • Cameron J.L.
        • Trahan K.J.
        • Gordon S.
        • Timmis G.C.
        Exercise training frequency in early post-infarction cardiac rehabilitation. Influence on aerobic conditioning.
        J Cardiopulm Rehabil. 1995; 15: 269-276
        • Brubaker P.H.
        • Warner Jr., J.G.
        • Rejeski W.J.
        • et al.
        Comparison of standard- and extended-length participation in cardiac rehabilitation on body composition, functional capacity, and blood lipids.
        Am J Cardiol. 1996; 78: 769-773
        • Arya A.
        • Maleki M.
        • Noohi F.
        • Kassaian E.
        • Roshanali F.
        Myocardial oxygen consumption index in patients with coronary artery disease.
        Asian Cardiovasc Thorac Ann. 2005; 13: 34-37
        • Williams M.A.
        • Maresh C.M.
        • Esterbrooks D.J.
        • Harbrecht J.J.
        • Sketch M.H.
        Early exercise training in patients older than age 65 years compared with that in younger patients after acute myocardial infarction or coronary artery bypass grafting.
        Am J Cardiol. 1985; 55: 263-266
        • Adams B.J.
        • Carr J.G.
        • Ozonoff A.
        • Lauer M.S.
        • Balady G.J.
        Effect of exercise training in supervised cardiac rehabilitation programs on prognostic variables from the exercise tolerance test.
        Am J Cardiol. 2008; 101: 1403-1407
        • Ades P.A.
        • Waldmann M.L.
        • Gillespie C.
        A controlled trial of exercise training in older coronary patients.
        J Gerontol A Biol Sci Med Sci. 1995; 50A: M7-M11
        • Ades P.A.
        • Grunvald M.H.
        Cardiopulmonary exercise testing before and after conditioning in older coronary patients.
        Am Heart J. 1990; 120: 585-589
        • Blumenthal J.A.
        • Rejeski W.J.
        • Walsh-Riddle M.
        • et al.
        Comparison of high- and low-intensity exercise training early after acute myocardial infarction.
        Am J Cardiol. 1988; 61: 26-30
        • Blumenthal J.A.
        • Fredrikson M.
        • Kuhn C.M.
        • Ulmer R.L.
        • Walsh-Riddle M.
        • Appelbaum M.
        Aerobic exercise reduces levels of cardiovascular and sympathoadrenal responses to mental stress in subjects without prior evidence of myocardial ischemia.
        Am J Cardiol. 1990; 65: 93-98
        • Carlson J.J.
        • Johnson J.A.
        • Franklin B.A.
        • VanderLaan R.L.
        Program participation, exercise adherence, cardiovascular outcomes, and program cost of traditional versus modified cardiac rehabilitation.
        Am J Cardiol. 2000; 86: 17-23
        • Dressendorfer R.H.
        • Franklin B.A.
        • Gordon S.
        • Timmis G.C.
        Resting oxygen uptake in coronary artery disease. Influence of chronic beta-blockade.
        Chest. 1993; 104: 1269-1272
        • Gordon N.F.
        • English C.D.
        • Contractor A.S.
        • et al.
        Effectiveness of three models for comprehensive cardiovascular disease risk reduction.
        Am J Cardiol. 2002; 89: 1263-1268
        • Hao S.
        • Chaitman B.
        • Klingfield P.
        Heart rate recovery response to symptom-limited treadmill exercise after cardiac rehabilitation in patients with coronary artery disease with and without recent events.
        Am J Cardiol. 2002; 90: 763-765
        • Hevey D.
        • Brown A.
        • Cahill A.
        • Newton H.
        • Kierns M.
        • Horgan J.H.
        Four-week multidisciplinary cardiac rehabilitation produces similar improvements in exercise capacity and quality of life to a 10-week program.
        Journal of Cardiopulmonary Rehabilitation and Prevention. 2003; 23: 17-21
        • Kosydar-Piechna M.
        • Bilinska M.
        • Janas J.
        • Piotrowicz R.
        Influence of exercise training on leptin levels in patients with stable coronary artery disease: a pilot study.
        Cardiol J. 2010; 17: 477-481
        • Lavie C.J.
        • Milani R.V.
        • Littman A.B.
        Benefits of cardiac rehabilitation and exercise training in secondary coronary prevention in the elderly.
        J Am Coll Cardiol. 1993; 22: 678-683
        • Lavie C.J.
        • Milani R.V.
        Effects of cardiac rehabilitation and exercise training on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in women.
        Am J Cardiol. 1995; 75: 340-343
        • Milani R.V.
        • Lavie C.J.
        • Mehra M.R.
        Reduction in C-reactive protein through cardiac rehabilitation and exercise training.
        J Am Coll Cardiol. 2004; 43: 1056-1061
        • Milani R.V.
        • Lavie C.J.
        Reducing psychosocial stress: a novel mechanism of improving survival from exercise training.
        Am J Med. 2009; 122: 931-938
        • Lear S.A.
        • Ignaszewski A.
        • Linden W.
        • et al.
        The Extensive Lifestyle Management Intervention (ELMI) following cardiac rehabilitation trial.
        Eur Heart J. 2003; 24: 1920-1927
        • Wosornu D.
        • Bedford D.
        • Ballantyne D.
        A comparison of the effects of strength and aerobic exercise training on exercise capacity and lipids after coronary artery bypass surgery.
        Eur Heart J. 1996; 17: 854-863
        • Shiran A.
        • Kornfeld S.
        • Zur S.
        Determinants of improvement in exercise capacity in patients undergoing cardiac rehabilitation.
        Cardiology. 1997; 88: 207-213
        • Nieuwland W.
        • Berkhuysen M.A.
        • Landsman M.L.
        • Lie K.I.
        • Rispens P.
        Training effects on peak VO2, specific of the mode of movement, in rehabilitation of patients with coronary artery disease.
        Int J Sports Med. 1998 Jul; 1998: 358-363
        • Seki E.
        • Watanabe Y.
        • Sunayama S.
        • et al.
        Effects of phase III cardiac rehabilitation programs on health-related quality of life in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP).
        Circ J. 2003; 67: 73-77
        • Seki E.
        • Watanabe Y.
        • Shimada K.
        • et al.
        Effects of a phase III cardiac rehabilitation program on physical status and lipid profiles in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP).
        Circ J. 2008; 72: 1230-1234
        • Shabani R.
        • Gaeini A.A.
        • Nikoo M.R.
        • Nikbackt H.
        • Sadegifar M.
        Effect of cardiac rehabilitation program on exercise capacity in women undergoing coronary artery bypass graft in Hamadan-Iran.
        Int J Prev Med. 2010; 1: 247-251
        • Onishi T.
        • Shimada K.
        • Sato H.
        • et al.
        Effects of phase III cardiac rehabilitation on mortality and cardiovascular events in elderly patients with stable coronary artery disease.
        Circ J. 2010; 74: 709-714
        • NZGG
        Best practice evidence-based guideline: cardiac rehabilitation.
        New Zealand Guidelines Group, Auckland2002
        • BACR
        Standards and core components for cardiac rehabilitation (2007).
        ([Available from])
        • Thomas R.J.
        • King M.
        • Lui K.
        • et al.
        AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2007; 50: 1400-1433
        • SIGN
        SIGN 57 cardiac rehabilitation. A national clinical guideline.
        Royal College of Physicians, Edinburgh2002
        • Balady G.J.
        • Williams M.A.
        • Ades P.A.
        • et al.
        Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.
        Circulation. 2007; 115: 2675-2682
        • Corra U.
        • Piepoli M.F.
        • Carre F.
        • et al.
        Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation.
        Eur Heart J. 2010; 31: 1967-1974
        • Corra U.
        • Mendes M.
        • Piepoli M.
        • Saner H.
        Future perspectives in cardiac rehabilitation: a new European Association for Cardiovascular Prevention and Rehabilitation Position Paper on ‘secondary prevention through cardiac rehabilitation’.
        Eur J Cardiovasc Prev Rehabil. 2007; 14: 723-725
        • Ades P.A.
        • Savage P.D.
        • Brawner C.A.
        • et al.
        Aerobic capacity in patients entering cardiac rehabilitation.
        Circulation. 2006; 113: 2706-2712
        • Berlin J.A.
        Invited commentary: benefits of heterogeneity in meta-analysis of data from epidemiologic studies.
        Am J Epidemiol. 1995; 142: 383-387
        • Vanhees L.
        • Fagard R.
        • Thijs L.
        • Amery A.
        Prognostic value of training-induced change in peak exercise capacity in patients with myocardial infarcts and patients with coronary bypass surgery.
        Am J Cardiol. 1995; 76: 1014-1019
        • Thompson P.D.
        • Buchner D.
        • Pina I.L.
        • et al.
        Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (subcommittee on exercise, rehabilitation, and prevention) and the Council on Nutrition, Physical Activity, and Metabolism (subcommittee on physical activity).
        Circulation. 2003; 107: 3109-3116
        • Conn V.S.
        • Hafdahl A.R.
        • Brown L.M.
        Meta-analysis of quality-of-life outcomes from physical activity interventions.
        Nurs Res. 2009; 58: 175-183
        • Piepoli M.F.
        • Corra U.
        • Benzer W.
        • et al.
        Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation.
        Eur J Cardiovasc Prev Rehabil. 2010; 17: 1-17
        • Bouchard C.
        • Rankinen T.
        Individual differences in response to regular physical activity.
        Medicine and Science in Sports and Exercise. 2001; 33 ([discussion S452-443]): S446-S451
        • Swain D.P.
        • Franklin B.A.
        Is there a threshold intensity for aerobic training in cardiac patients?.
        Med Sci Sports Exerc. 2002; 34: 1071-1075
        • Bateman L.A.
        • Slentz C.A.
        • Willis L.H.
        • et al.
        Comparison of aerobic versus resistance exercise training effects on metabolic syndrome (from the Studies of a Targeted Risk Reduction Intervention Through Defined Exercise — STRRIDE-AT/RT).
        Am J Cardiol. 2011; 108: 838-844
        • Meyer K.
        Resistance exercise in chronic heart failure—landmark studies and implications for practice.
        Clin Invest Med. 2006; 29: 166-169
        • Rees K.
        • Bennett P.
        • West R.
        • Davey S.G.
        • Ebrahim S.
        Psychological interventions for coronary heart disease.
        Cochrane Database Syst Rev. 2004; : CD002902
        • De Feo S.
        • Tramarin R.
        • Ambrosetti M.
        • et al.
        Gender differences in cardiac rehabilitation programs from the Italian survey on cardiac rehabilitation (ISYDE-2008).
        Int J Cardiol. 2012 Oct 4; 160: 133-139
        • Caulin-Glaser T.
        • Blum M.
        • Schmeizl R.
        • Prigerson H.G.
        • Zaret B.
        • Mazure C.M.
        Gender differences in referral to cardiac rehabilitation programs after revascularization.
        J Cardiopulm Rehabil. 2001; 21: 24-30
        • Schuster P.M.
        • Waldron J.
        Gender differences in cardiac rehabilitation patients.
        Rehabil Nurs. 1991; 16: 248-253
        • Tardivel J.
        Gender differences in relation to motivation and compliance in cardiac rehabilitation.
        Nurs Crit Care. 1998; 3: 214-219
        • Ginzel A.R.
        Women's compliance with cardiac rehabilitation programs.
        Prog Cardiovasc Nurs. 1996; 11: 30-35
        • Mikhail G.W.
        Coronary heart disease in women.
        BMJ. 2005; 331: 467-468
        • Conn V.S.
        Anxiety outcomes after physical activity interventions: meta-analysis findings.
        Nurs Res. 2010; 59: 224-231
        • Sakuragi S.
        • Takagi S.
        • Suzuki S.
        • et al.
        Patients with large myocardial infarction gain a greater improvement in exercise capacity after exercise training than those with small to medium infarction.
        Clin Cardiol. 2003; 26: 280-286

      Linked Article

      • Improved fitness as a measure of success of cardiac rehabilitation: Do those who get fitter live longer?
        International Journal of CardiologyVol. 167Issue 3
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          Cardiac rehabilitation programs are multifaceted interventions that focus primarily on exercise training and are designed to optimize physical, psychological, and social functioning in a broad spectrum of patients with cardiovascular disease [1]. In large studies and meta-analyses of patients with coronary artery disease, cardiac rehabilitation has been demonstrated to reduce the rates of all-cause and cardiovascular mortality [2–7]. As a result, it is widely promoted by various health care organizations and is strongly advocated by position statements all over the world [8–15].
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