Resistance training is an effective exercise therapy in cardiac rehabilitation program for patients with coronary artery disease: a systematic review
Beni-Suef University Journal of Basic and Applied Sciences volume 11, Article number: 22 (2022)
Exercise-based cardiac rehabilitation program is a comprehensive intervention for the rehabilitation of coronary artery disease patients. Exercise therapy is a valuable, effective, and integral intervention of cardiac rehabilitation. Aerobic training is the gold standard exercise therapy in cardiac rehabilitation programs. In addition, combined training with added resistant training is also used. This systematic review aimed to provide the physical therapy clinicians with a consensus regarding the effect of resistant training by answering the question of what is the cardiovascular and non-cardiovascular effect (s) of resistant training in the cardiac rehabilitation program for patients with coronary artery disease?
The Physiotherapy evidence database (PEDro) was used as a search engine to select articles through study eligibility criteria. Adult or adult and old stable coronary artery disease patients engaged in a site-based (Phase II) exercise-based cardiac rehabilitation program that includes aerobic and resistant training. Selected articles applied cardiovascular and non-cardiovascular outcome measures to measure the effectiveness of resistant training. The author reviewed the selected articles and applied quantitative non-statistical analysis and appraisal for these articles. The systematic selection process resulted in 10 studies with a total participants number of 3877. Analyzing the articles revealed that adding resistant training to aerobic training resulted in a favorable improvement in outcome measures for coronary artery disease patients. Resistant training produced improvement in the exercise capacity (VO2 peak), blood pressure, skeletal muscle strength, endurance, body composition, sleep quality, depression, and health-related quality of life.
The addition of resistant training to aerobic training in cardiac rehabilitation induces more positive cardiovascular and non-cardiovascular effects for stable coronary artery disease patients.
Cardiac rehabilitation program (CRP) is a comprehensive useful and effective program for prevention and rehabilitation which is recommended by the American Heart Association and the American College of Cardiology for treatment and management of patients with coronary artery disease (CAD) [1,2,3,4,5,6,7]. Exercise therapy is an integral component of CRP proved to be a valuable and effective non-pharmacological intervention for patients with CAD and is designed to improve exercise capacity, cardiovascular health, and overall health status [1, 2, 8,9,10,11]. The American Heart Association guideline recommends aerobic training (AT) and resistance training (RT) as the core elements of exercise-based CRP . Traditionally in CRP, the AT has been considered as the basic exercise modality which is proved to be effective in improving and maintaining exercise capacity and cardiovascular fitness [12,13,14,15]. In addition to AT and RT, the exercise-based CRP consists of combined training (CT) in which the RT is added to the AT and showed to be an effective intervention to restore physical function and exercise capacity and to improve coronary risk factors including hypertension, hyperglycemia, and dyslipidemia in CAD patients . The addition of RT to AT in CRP enhances strength and endurance of skeletal muscles (SM), functional capacity and level of independence, health-related quality of life (HRQOL), as well as reduces disability [16,17,18,19]. The effects of RT also include a positive impact on metabolic risk factors, functional capacity, and psychosocial well-being on CAD patients [16, 20]. However, there is a lack of clear consensus regarding the exact effects of RT as a part of CRP for CAD patients . And although the safety and efficacy of RT for patients with CAD [21,22,23,24], both post-myocardial infarction (MI) [25, 26] and post coronary artery bypass graft (CABG) surgery , has been recently investigated and demonstrated beneficial effects, there is insufficient information available and there is still a need to draw a conclusion [17, 18, 28,29,30,31,32]. It is also believed that because RT is important in CRP, additional research is required to determine the effectiveness of RT as added to AT . Complications of CRP in general and exercise therapy specific for CAD patients include major adverse cardiovascular events and even death . These serious complications raise the importance of depending on evidence-based practice for the implementation of exercise-based CRP for CAD patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses. The PRISMA focuses on the reporting of reviews evaluating randomized trials but can also be used as a basis for reporting systematic reviews of other types of research, particularly evaluations of interventions . Therefore, the purpose of the current systematic review is to provide the physical therapy clinicians with a consensus regarding the effects of RT by answering the question of what is the cardiovascular and non-cardiovascular effect (s) of resistant training in the cardiac rehabilitation programs for stable CAD patients?
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The study protocol and information source used the PRISMA items, including the PRISMA 2009 checklist, were the reference of the current systematic review reporting  and the physiotherapy evidence database (PEDro) was the search engine for it. The PEDro is a free database of over 43,000 randomized trials, systematic reviews, and clinical practice guidelines in physiotherapy, and all trials on PEDro are independently assessed for quality . Eligibility Criteria: The following inclusion criteria were considered for records (articles/studies) selection: 1- Type of records: randomized controlled trials (RCTs), systemic review (SR), and meta-analysis (MA) 2- Time frame: records published within the last 10 years (2010 to 2019), 3- Age of participants: Adult (18–60 years) or adult and old (above 60 years). 4- Diagnosis: patients with stable CAD (e.g., MI, CABG surgery), 5- Type of CRP: Site-based supervised CRP (Phase II cardiac rehabilitation, 5–9 days post-cardiac event or cardiac revascularization), 6- Objective of the records: to measure the effects of RT, 7- Language of the records: English language, 8- Type of intervention: RT or CT, 9- Type of outcome measures: cardiovascular and non-cardiovascular, 10- Publication status: Free access to the full record. The exclusion criteria included: 1- home-based CRP, 2- Participants with heart failure, heart transplants or implantable defibrillators, 3- records with pediatric or only old age participants. Search and Study Selection: The used electronic search strategy and selection process is based on the PRISMA flow diagram  as shown in (Fig. 1). Data Collection Process and Data Items: The data were extracted from the records’ texts and/or in their tables and figures. Extracted data were presented in a table-based. The table included items of patients, intervention, comparison, outcome measure (PICO). Then, qualitative data analysis was done, and no quantitative statistical data analysis was applied. The COMs and NCOMs effects of exercise therapy interventions (AT, RT, and CT) were presented in another table. The review also included other resources in terms of the relevant articles within the reference list of the records included in the current SR. Data of these other resources are used to enrich the background, provide explanations, and emphasize the results of the analysis of the 10 included records. Assessment of Characteristics of Records: The Risk of bias assessment and assessment of study quality was conducted by quality scores determined by the PEDro Rating Scale (maximum score is 10 with the higher score reflecting greater methodological quality). This PEDro Rating Scale is designed to determine the adequacy of random allocation, concealed allocation, the similarity of groups at baseline, blinding of the subject, therapist, and/or assessor, measures of at least one key outcome from more than 85% of the subjects initially allocated to groups, intention-to-treat analysis, between-group analysis, and point estimates and variability.
The study selection and flow of records through the review resulted initially in 49 records. These 49 records were screened and assessed for eligibility at 3 stages as shown in the PRISMA flow diagram in Fig. 1. Out of these 49 records, 39 records were excluded based on the SR eligibility criteria. Reasons for exclusion are presented in Table 1. The studies that met the eligibility criteria and were included in the review were 10 (3 MA of RCTs and 7 RCTs). Other resources included 40 relevant articles which were in the reference list of the 10 studies.
The studies’ characteristics and results of the included articles indicated that the most common inclusion criteria in the 10 studies included in the current SR were stable patients with ejection fraction < 45 and with ≥ 50% or with ≥ 70% arterial diameter narrowing of at least one major coronary artery. Meanwhile, severe, or uncontrolled cardiac arrhythmia or unstable angina pectoris or uncontrolled hypertension, and musculoskeletal conditions limiting participation in exercise training were the most mentioned exclusion criteria within the 10 studies. Patients’ age was of wide range in 4 studies (from 40th to late 60th or early 70th) and in one study it was of limited range (55–60 years) and in 3 studies the mean of patients’ age was around 60 years. In all studies patients were of both gender except in 2 studies, only men were included. To study the effect of RT, different exercise-based protocols were used in the 10 studies. Four studies compared CT and AT. Two studies compared two CT protocols with different RT (RT of 2 sets X 12 repetitions Vs. RT of 3 sets X 15 repetitions in one study and concentric RT Vs. eccentric RT in the other study). In one study, a comparison of two CT protocols with different AT was found. Comparison between three protocols was also found in 2 studies: AT, RT, and CT in the first one and CT (RT of one set), CT (RT of 3 sets), and AT in the second study. The effect of isometric RT Vs. dynamic RT was found in one study. Duration of training protocol was varied; it lasts for about one month (4 or 5 weeks) (3 studies), for 2 months (one study) for 3 months (one study), for 6 months (one study), more than 7 months (one study), from 1 to 6 month (one study), from 1 to 7 months (one study) and from one to more than 7 months (one study). The range of frequency of RT protocol was from 2 times to 2–5 times/week. The intensity of the RT was determined through one of the following measures; a percentage from the one-repetition maximum (1 RM) (6 studies) (range from 30% to over 80% of the 1RM), a percentage from the maximum voluntary contraction (2 studies) in one study 70% of isometric maximum voluntary contraction and in another study 60% of dynamic maximum voluntary contraction, heart rate reserve (HRR) (one study) (75–85% of HRR), ratings of perceived exertion of Borg scale (2 studies) with the weight to elicit a score of 11–15 in one study and weight to elicit a score of 4–6 on a modified Borg scale of 1 through 7 in the other study. Regarding the volume of RT, the range of the number of sets was from one to 8, the range of exercise repetitions was from 10 to 20 and the number of exercises ranged from 2 to 10 exercises. The AT protocol was also of variant duration (ranged from 8 to 60 min) and variant intensity (ranged from 60 to 80% of peak oxygen consumption (VO2 peak) in one study, 40–85% of peak heart rate in one study and 60%-70% of HRR in another study). The 10 studies included cardiovascular outcome measures (COMs) and non-cardiovascular outcome measures (NCOMs). Within the COMs were the exercise capacity in terms of VO2 peak or VO2 max (4 studies), maximum metabolic equivalent (MET) (one study), exercise time during symptom-limited cardiopulmonary exercise testing (one study), the left ventricle ejection fraction (LVEF) (2 studies) and cardiac output (one study). Among the NCOMs were SM strength (6 studies) and SM endurance (one study). The SM strength included lower extremity, upper extremity, and trunk muscles. The HRQOL was also a common NCOM as it was used in 5 studies. Other NCOMs included the body composition (2 studies) and body weight and body mass index (BMI) (one study). Adverse effects or side effects were measured in 4 studies. Summary of the basic characteristics of the 10 included studies is presented in Table 2 in terms of PICO in addition to the grade quality of evidence in a score out of 10. The summary data for all effects of exercise therapy including the AT, RT, and CT are shown in Table 3. The presented effects of exercise therapy included COMs and NCOMs.
The results of the effects of resistant training of this SR revealed that adding RT to the AT in CT exercise-based protocol resulted in favorable improvement in COMs and NCOMs for adult CAD patients. In 4 studies (2 MA of RCTs and 2 RCTs), out of the 10 studies included in this SR, there was a significant improvement for CT more than the AT alone in different COMs and NCOMs as exercise capacity (VO2 peak, exercise time), HRV, upper and lower extremities SM strength and leg press muscle endurance, body composition and HRQOL [2, 10, 37,38,39]. In the RCT  in which 2 CT (eccentric RT Vs. concentric RT) were compared, results showed that there was a tendency for a better improvement symptom-limited VO2 and ankle plantar flexor isometric maximum voluntary contraction in the eccentric group. Meanwhile, the RCT that compared between 2 different RT protocols (isometric Vs. dynamic), indicated that there was a pre-post significant increase in peak power output with favorable to isometric protocol . The pre-post training significant increase in maximal HR and systolic blood pressure (SBP) was with no significant difference between the isometric and dynamic protocols. The isometric RT protocol significantly decreased the maximal diastolic blood pressure (DBP) while the dynamic protocol significantly increased it. The upper and lower extremities SM strength was significantly increased with both protocols with no significant difference. Both protocols had no effect on the body composition nor in the anthropometric variables (BMI), waist circumference). In the second RCT  that compared between 2 CT (RT of 2 sets X 12 repetitions Vs. 3 sets X 15 repetitions), both RT volumes produced pre-post improvement in CVOMs (VO2 peak) and NCOMs (SM strength) with no significant difference between both volumes. It was remarkable that although AT alone did not change lipid profiles (high-density lipoprotein) or HRQOL (Self-evaluated health), the addition of RT did . Results proved that RT is safe for stable CAD patients as no side effects or adverse effects were observed [34, 39, 40].
To discuss the results of this SR, it can be claimed that the AT is the gold standard protocol in CRP for CAD patients and in the past 3 decades, RT started to be added to the AT. The decrease of exercise capacity of patients with CAD causes limitation in their physical activity, musculoskeletal fitness, and functional capacity which markedly affect their HRQOL, especially the physical component. This reason raised the need for another protocol, in addition to the AT, to improve their functional capacity. The RT was the perfect candidate for this purpose as it is well known to improve musculoskeletal fitness in terms of SM strength as well as endurance. Results of this SR can provide the physical therapy clinicians with the clear consensus that RT is an effective and safe exercise therapy as added to AT in exercise-based CRP for patients with CAD. The positive effects of RT were reported for both the COMs and NCOMs.
The addition of RT to AT resulted in increased improvement of exercise capacity, VO2 peak [2, 37], and this increase may be related to the improvement in the SM strength associated with RT which enabled patients to participate more effectively in the CRP and benefit more from the cardiovascular health improvement associated with AT. It was proved that SM strength of CAD patients is lower than that of age-matched subjects  and impaired SM strength is strongly associated with poor exercise capacity , so it could be hypothesized that improvement in SM strength would improve the exercise capacity. This hypothesis is supported by the fact that AT may be discontinued because of muscular pain because of muscle fatigue due to SM weakness.
The RT was claimed to elevate the BP, particularly SBP, which could be risky for CAD patients, and this claim delayed RT joining to CRP up to the early 1990th. The current SR acts as proof to discontinue this claim for 3 reasons. 1- there was no observed side effects or adverse events in CT with added RT which indicates that the RT is as safe as AT. 2- the isometric RT reduced the DBP in one study  of the review and it produced no change in both SBP and DBP in another study . It was suggested that the undesirable elevations in SBP and HR occur when the duration of RT exceeds around 10 repetitions per set,  so it is applicable that physical therapy clinicians can design the RT in sets of 10 repetitions with an interval resting of 30 s between sets. 3- low-intensity RT with 15 to 20 repetitions resulted in only a modest elevation in BP, like the hemodynamic changes observed with AT [16, 44], and this intensity and repetitions could be considered in describing RT. The current SR even indicates the possible anti-hypertensive effect of the RT as in one study of the review the systolic and diastolic aortic pressure were measured as indicators for the central BP and RT had a similar result in decreasing the systolic pressure as the AT and even RT decreased the diastolic pressure while the AT produced no change post-training . Different mechanisms could be responsible for the reduction of central BP with RT including improved microvascular perfusion, peripheral muscular artery dilation, and peripheral vascular resistance. And in another study of the review, the RT as part of CT produced no change in both SBP and DBP .
The current SR identified that CT with added RT had an advantage to improving upper and lower extremities SM strength and endurance compared to AT alone. This improvement was confirmed in other studies [21, 22, 45, 46] and it is important from the HRQOL point-of-view as it allows individuals to perform activities of daily living and work-related tasks. It also positively affects proprioceptive abilities, thereby leading to a gradual improvement in coordination and gait control which reduces the risk of falls thereby maintaining functional independence for a greater period especially in elderly CAD patients [47, 48]. In addition, it reduces cardiac demands (HR and SBP) when lifting a given load .
Adding RT to AT produced more improvement in body composition than AT alone. The proposed reasons for this improvement are that RT promotes greater muscle mass than AT, and thus may contribute to fat mass loss via the increase in the resting metabolic rate [37, 50] and that RT increased SM endurance allowing subjects to perform activities with long duration and result in more burn of fat as a source of fuel. This improvement has clinical implications because there is a growing prevalence of obesity among CAD patients and as the amount of fat mass increases especially abdominal fat, it elevates blood lipid levels, BP, and risk of CAD . That is why weight loss, particularly trunk fat loss, became CRP basic goal and RT is the key protocol to address this issue [37, 51].
The current SR adopts the hypothesis that improvement in the exercise capacity and SM strength and endurance are logically to be reflected functionally and improve the CAD patients’ HRQOL. The adopted hypothesis is in line with the opinion that improvement in SM strength benefits to reduce risk of injury from falls, improved ability to perform activities of daily living and help to promote independent living, which are key components of HRQOL . Also, when the CAD patients get rid of the limitation of exercise capacity which restricts their functional abilities, and become physically free and able to perform the daily activities independently, the mental status would improve in the forms of decreased depression level and the improved quality of sleep. It was interesting to find out that the AT alone could not improve the HRQOL, and the recorded improvement was related to CT with RT addition .
The RT should be considered as an integral exercise therapy of exercise-based CRP for stable CAD patients. It is safe as well as the AT. The CT with added RT to AT has beneficial effects on COMs and NCOMs even more than the AT alone. The effectiveness of RT includes improvement in exercise capacity (VO2 peak and exercise time), BP, SM strength and endurance, body composition, sleep quality, depression, and HRQOL.
This SR had implications for physical therapy clinical practice as it highlighted the following clinical issues for exercise-based CR program for CAD adult patients; 1- stopping contra-indicating the RT for the false claim that RT produces undesirable elevated BP and even start thinking about its anti-hypertensive effect, 2- inclusion of losing bodyweight and improving body composition within the goals, 3- eccentric and isometric RT would be the preferred RT protocol.
Limitations of the study include that only one author reviewed the records. Although the PEDro is the best and the most trustable evidence-based electronic database and search engine, it was the only electronic search engine used.
Availability of data and materials
The datasets analyzed during the current systematic review study are available on the PEDro web page at https://pedro.org.au/.
Cardiac rehabilitation program
Coronary artery disease
Randomized controlled trials
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Coronary artery bypass graft
Health-related quality of life
Cardiovascular outcome measures
Non-cardiovascular outcome measures
- VO2 :
Heart rate reserve
Heart rate variability
Systolic blood pressure
Diastolic blood pressure
Body mass index
Left ventricle ejection fraction
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El-Sobkey, S.B. Resistance training is an effective exercise therapy in cardiac rehabilitation program for patients with coronary artery disease: a systematic review. Beni-Suef Univ J Basic Appl Sci 11, 22 (2022). https://doi.org/10.1186/s43088-022-00206-2