Effect of exercise-based cardiac rehabilitation on arterial stiffness and inflammatory and endothelial dysfunction biomarkers: A randomized controlled trial of myocardial infarction patients
Introduction
Atherosclerosis, defined as a process of endothelial dysfunction and chronic inflammation [1], has been associated with increased arterial stiffness (AS) [2], which has been observed in coronary artery disease (CAD) and post-myocardial infarction (MI) patients [3]. The harmful effects of AS derive from hemodynamic changes, as increases in systolic and pulse pressures [4], which are related to cardiac overload and a reduction in coronary perfusion that can lead to myocardial ischemia [5]. Carotid-femoral pulse wave velocity (cf-PWV), an indicator of aortic wall stiffness, have shown an independent predictive value for cardiovascular and all-cause mortality [6], [7]. Additionally, inflammatory and endothelial dysfunction biomarkers, cardiovascular risk predictors in CAD patients [8], [9], have been associated with AS [10].
Therefore, interventions to reduce AS and related factors could be of great significance. However, the effects of aerobic exercise training on AS have been understudied in CAD patients [11]. Likewise, only a small-uncontrolled study was conducted investigating whether an exercise training effect on AS is related to possible changes in inflammatory biomarkers [12]. Nevertheless, this study did not assess the main measure of AS, cf-PWV.
In addition, it has been reported that daily physical activity is independently and inversely associated with several AS indexes [13], and that cardiac rehabilitation programs could increase physical activity levels of patients [14]. Otherwise, a recent systematic review has stated that nutritional intervention could alleviate AS [15]. Despite the associations of daily physical activity and diet with AS [13], [15] these two important lifestyle components were not assessed in any study, hindering the evaluation of an independent effect of exercise. Thus, the purpose of the present randomized controlled trial was to examine the effects of an 8-week exercise-based cardiac rehabilitation program (ECR) on AS, endothelial dysfunction, and chronic low-grade inflammation biomarkers in post-MI patients, assessing the potential contributory influences of daily physical activity and dietary intake.
Section snippets
Study design, randomization and implementation
This randomized controlled trial was performed from May 2011 to November 2012 at the Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal. Patients, 4 weeks after acute MI, were randomly assigned to an ECR program (i.e., the EG) or to the control group (CG), both receiving usual medical care (i.e., regular appointments with a cardiologist and optimized medication). Randomization and allocation sequence was based on a block size fixed to 8 and generated through a computerized random number
Intention-to-treat analysis
A total of 96 patients were enrolled and randomly assigned to the EG or CG (Fig. 1). Following baseline assessments, 2 patients of each group dropped out and were excluded from data analysis. Nevertheless, there were no significant differences between baseline values of the patients who dropped out and those who completed the study (p > 0.05). Additionally, 3 patients of each group were excluded since their hs-CRP levels were >10 mg/L. For the remaining patients (n = 86), baseline
Discussion
The main findings of the present study indicate that 8 weeks of an ECR program in general (i.e., intention-to-treat analysis) did not promote changes in AS, endothelial dysfunction and inflammatory biomarkers, despite increasing cardiorespiratory fitness of post-MI patients. On the other hand, when we considered only those EG patients who attended at least 80% of the exercise sessions, it was observed a significant reduction in AS. However, due to the large number of comparisons performed, this
Conflict of interest
None declared.
Acknowledgments
This work was supported by European Regional Development Fund through the Operational Competitiveness Programme, and by Foundation for Science and Technology (FCT) of Portugal – within the projects FCOMP-01-0124-FEDER-014706 (Reference. FCT: PTDC/DES/113753/2009) and PEst-OE/SAU/UI0617/2011. The FCT supported the authors Norton Luis Oliveira (grant number SFRH/BD/48875/2008) and Fernando Ribeiro (grant number SFRH/BPD/69965/2010).
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