Arab Journal of Nutrition and Exercise (AJNE) | AJNE: Vol 2, No 2 (2017) | pages: 74-90

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1. Introduction

According to World Health Organisation [1] chronic diseases are among the primary causes of global mortality. The most common causes of mortality in 2012 were: cardiovascular diseases (46.2% of all deaths), cancer (21.7%), respiratory diseases (10.7%) and diabetes (4%) [1].

Several studies show that frequent physical exercise helps in the prevention of several chronic diseases and reduces the mortality rate from all causes, including cardiovascular diseases [3,4,7,5,2,6]. Aerobic exercise is extremely important for patients with CHD with or without MI [8]. Taylor and colleagues [9] report that rehabilitation programs based on aerobic exercise have reduced the total mortality rate by 20% and the cardiovascular disease mortality rate by 26% and they have helped in reducing risk factors such as hypertension, hypercholesterolemia, diabetes, and obesity in patients with MI, angina and CHD [9].

In addition exercise improves well-being and QoL [11]. Exercise is important especially for patients with coronary heart disease (CHD) [10] because it improves functional capacity, reduces coronary ischemia and angina and improves endothelial function [13]. However benefits from exercise rehabilitation programs depend heavily on the parameter of the program most notably the intensity and volume of exercise [12]. Studies show that perhaps interval exercise especially with high intensity might be superior in comparison with other forms of exercise in improving cardiac function, functional capacity and ultimately QoL in patients with CHD especially after myocardial infarction [16,14], (Nillson Westheim & Risberg, 2008b; Moholdt Madssen Rognmo & Aamot 2014).

2. Methods

2.1. Search Strategy

The following electronic databases were searched from March until June 2014: Science Direct, MEDLINE and Cumulative Index to Nursing and Allied Health Literature [CINAHL]. The medical subject headings (MeSH) “myocardial infarction”, “coronary heart disease”, “high intensity interval training” AND “moderate intensity continuous exercise” were used alone or in combination. Each specific phrase was combined with the Boolean operator to limit the search and make it more specific. Additional searches were carried out by scanning the reference lists of related articles in order to maximize the amount of investigations involved in the current review.

3. Study Criteria and Selection

In order to define and frame the research questions the Population(s), Intervention(s), Comparator(s), Outcome(s) and Study Design (PICOS) were used [17]. The titles and abstracts of all records were screened initially against the basic initial eligibility criteria. A single failed eligibility criterion was sufficient for a study to be excluded from a review [17]. Moreover, the records that remained after initial eligibility screening, were therefore screened against the full eligibility criteria outlined in Table 1.

Table 1

Full eligibility screening criteria.


Inclusion Criteria Exclusion Criteria PICOS
Was the study a RCT? Study designs other than RCT Quasi experimental studies, pilot studies Study
Was the study published in English? Duplicates Abstract and pilot-studies publications
Did the study include males and females with CHD and MI? Included subjects with disease risk factors Population
Was the intervention HIIT or MICE and was it combined with another type of exercise? Not HIIT or MICE Not specified Intervention
Were the outcomes measures relevant? Not relevant outcomes measures Outcomes
Were the interventions compared with another type of exercise, or placebo or non therapy? Comparison

3.1. Outcome Measures

All relevant outcome measures were considered. Specifically measures such as QoL, VO2peak, functional capacity, fatigue or perceived rate of exertion, left ventricular function, and exercise time were considered relevant.

3.2. Data Extraction and Assessment of Risk of Bias

For each RCT included, data were extracted regarding: first author, year of publication, study outcomes, groups and exercise parameters, and assessed for bias using the Cochrane risk of bias tool. The quality assessment was performed to identify the quality of papers. Trials should provide full details of the randomisation process, allocation concealment or blinding of outcome assessment to be considered high quality. The quality of included studies was assessed using the Jadad scale [20], a three-point questionnaire form. Each question was to be answered with a yes and score a single point, or a no and scored zero points.

4. Results

4.1. Identification of Records and Study Selection

The search strategy from the three databases identified a total of 1095 records. An initial screen of the article title resulted in exclusion of 830 papers. Three hundred and sixty five studies were assessed for eligibility using the inclusion and exclusion criteria of Table 1. Following this process of the eligibility criteria, 352 records were excluded, due to reason described in detail in Figure 1. The remaining 13 records met the eligibility criteria and were included in the final review.

Figure 1

PRISMA diagram for included studies [19].

fig-1.jpg

4.2. Description of Included Studies

Thirteen studies were included in this review. A summary of the studies' characteristics is presented in Table 2. Eight of the studies [24,22,23,25,26,31,30,29] compared HIIT with MICE alone or in combination with a control group, whereas the remaining studies [14,15,27,28,21] examined only HIIT or MICE in relation to another type of exercise.

Six of the studies [30,29,31,25,22,23] had a small sample (below 30) and the rest had sample that varied from 59 to 200 participants. Most of the studies used an exercise program of 10-16 weeks with a frequency of 2-3 times per week, however one study used a program of four week with a higher frequency (5times/week) and one study used a 1-year program of 2 sessions per week.

Generally both forms of exercise seemed to improve QoL, maximum aerobic capacity, functional capacity and left ventricular function. HIIT and MICE were superior to control intervention in two of the studies that had a control group [24,31] in terms of aerobic capacity, functional capacity and QoL. In addition HIIT was superior to a control group in another two studies [14,15] in terms of functional capacity, QoL and exercise time. HIIT was also superior in improving VO2peak compared to aerobic exercise (no further information regarding parameters) in two additional studies [27,28]. No study compared MICE with a control group only. From the eight studies that examined both HIIT and MICE, five favoured HIIT [30,29,31,26,25] in at least one outcome measure or one time point, while 3 studies [22,23,24] showed no differences between the two forms of exercise.

Table 2

Summary of the studies included in the review. Abbreviations: OUES:oxygen uptake efficiency slope; HRpeak: heart rate peak; IT: interval training; MICE: moderate intensity continuous training; LV Funtion: left ventricle function; QOL: quality of life; HR: heart rate; VO2: oxygen consumption; AT: anaerobic threshold; O2P slope: oxygen pulse; ↔: Similar improvement; : Greater improvement; : Reduction. FMD: Flow mediated dilation.


Authors Sample size/Groups Duration / Frequency Equipment Exercise protocol Outcome measures
29 21 participants IT/MICE 10 weeks 3days/week Treadmill I T group 4×4min at 80-90%VO2peak [33min] IT group had greater ↑ of VO2peak compared to MICE group
MICE group 50-60%VO2peak [41min]
30 14 participants IT/MICE 16 weeks 2days/week Additional 3days/week Treadmill, Stair-climber, Combined arm and leg cycle ergometer I T group 40%VO2reserve (2 min) with intervals at 90%VO2reserve (2 min) [30min] 65% VO2reserve [Resistance exercise, 30min] IT and Mice groups had similar ↑of VO2 Peak IT group had greater of AT
MICE group 65% VO2reserve [30min] 65% VO2reserve [Resistance exercise, 30min]
31 27 participants IT/MICE/CONTROL 12 weeks 3days/week Treadmill I T group 50–60% HRpeak (3 min) with intervals at 90–95% HRpeak (4 min) [38min] IT group had greater of LV remodeling, VO2peak and endothelium function compared to MICE and CONTROL groups. QOL improved both after IT and MICE exercise. No changes occurred in the CONTROL group regarding the QOL.
MICE group 70% HRpeak [47min]
CONTROL group (Walking and counseling) 70% HRpeak [47min]
14 80 participants IT/CONTROL 16 weeks 2days/week Aerobic dance movements (with music) and involved the use of both upper and lower extremities, including endurance, strength, and stretching exercises I T group 3×5–10 min at RPE = 15–18 [50min] Greater of functional capacity, workload (watts), exercise time (seconds) and QOL significantly improved for the exercise group.
CONTROL group Without exercise
15 80 participants IT/CONTROL 1year 2days/week Aerobic dance movements (with music) and involved the use of both upper and lower extremities, including endurance, strength, and stretching exercises I T group 3×5–10 min at RPE = 15–18 [50min] Greater of functional capacity, workload (watts), exercise time (seconds) and QOL significantly improved for the exercise group.
CONTROL group Without exercise
26 59 participants IT/MICE 4weeks 5days/week Treadmill I T group 4×4min intervals at 90% HRmax with active pauses of 3min of walking at 70%HRmax OfVO2peak in both groups after 4 weeks. After 6 months IT group significantly improved VO2peak compared to MICE group. QOL significantly at 4weeks and 6months, with no significant difference between the groups. No changes occurred at 4 weeks regarding the blood markers and LV function. However,there was a change at 6 months on both groups.
MICE group 70%HRmax [46min]
25 20 participants IT/MICE 2 sessions 2 weeks difference Cycle ergometer I T group 2sets of 10min composed of repeated phases of 15s at 100% PPO, interspersed by 15s of passive recovery IT protocol resulted in lower mean ventilation for a small difference in metabolic demand. Participants preferred the IT mainly because the perceived exertion measured by the Borg scale was lower.
MICE group 70% PPO
AEROBIC group N/A
27 107 participants IT/AEROBIC 12 weeks 2daysς/week Treadmill Aerobic exercises I T group 4×4min intervals at 85–95% HRmax with active pauses of 3min of walking at 70% HRmax [38min] IT group had greater of VO2peak. ↔ Improvement of endothelial function, QOL and blood markers between the groups.
AEROBIC group N/A
28 107 participants IT/AEROBIC 12 weeks 2days/week Measurement at 6 and 30 months Treadmill Aerobic exercises I T group 4×4min intervals at 85–95% HRmax with active pauses of 3min of walking at 70% HRmax [38min] After 6 and 30 months, VO2peak in both groups declined. At 30 months the improvement of VO2peak in IT group, was still significant.
AEROBIC group N/A
[14] 22participants IT/MICE 12 weeks 3days/week Cycle ergometer IT group 10minX 1-min cycling intervals at 89% PPO separated by 1-min intervals at 10% PPO ↔ Improvement of endothelial function, between the groups. No change in HR recovery or variability following 12 weeks of exercise
MICE group 58% of PPO [50min]
[15] 14 participants IT/MICE 12 weeks 2days/week Cycle ergometer IT group 10minX 1-min cycling intervals at 88% PPO separated by 1-min intervals at 10%PPO . FMD was increased post-training with no differences between groups. There was a significant improvement in cardiorespiratory fitness following both training programs, with no group differences.
MICE group 60% of PPO [50min]
24 71 participants IT/MICE/CONTROL 16 weeks 3days/week Treadmill IT group Alternation of 90% HRpeak and 60% HRpeak every 2min [30min] IT group had greater of O2P slope. No changes of VE/VCO2 slope and OUES occurred between groups.
MICE group 70–75% HRmax [30min]
CONTROL group Without exercise
24 200 participants I T/CONTINUOUS 12 weeks 3days/week Cycle ergometer I T group 4×4min at 90–95% HRpeak with active pauses of 3min of 50–70% HRpeak ↔ Improvement of endothelial function, cardiovascular risk factors and QOL.
CONTINUOUS group 70-75% HRpeak

4.3. Risk of Bias Assessment

The Jadad score ranged between 0 and 3 out of 5 (Table 3). One study scored 0 [25]; two studies scored 1 [30,24], four studies scored 2 [31,22,23,21] and six studies scored 3 [29][14,15][26][27,28]. These scores indicated that approximately half of the studies were low quality. This is due to the fact that the double-blinding criterion is not feasible in these kind of RCT within exercise intervention. On the Jadad scale 40% of the score accounts for the double-blinding criterion (Hempel et al., 2011).

Table 3

Assessment of the methodological quality of the studies using the Jadad score.


Potential Score
JADAD SCORING CRITERIA [29] [30] [31] [14]
The study described as randomized? 1 0 1 1
Was the method of randomization described and appropriate to conceal allocation? 1 1 1 1
Was there a description of withdrawals and drop outs? 1 0 0 1
Was the study described Double-blinded? 0 0 0 0
Was the method of blinding inappropriate? 0 0 0 0
FINAL SCORE (0 – 5) 3/5 1/5 2/5 3/5
The study described as randomized? 1 1 1 1
Was the method of randomization described and appropriate to conceal allocation? 1 1 1 1
Was there a description of withdrawals and drop outs? 1 1 1 1
Was the study described Double-blinded? 0 0 0 0
Was the method of blinding inappropriate? 0 0 0 0
FINAL SCORE (0 – 5) 3/5 3/5 3/5 3/5
JADAD SCORING CRITERIA [25] [22] [23] [24] [21]
The study described as randomized? 0 0 0 1 0
Was the method of randomization described and appropriate to conceal allocation? 0 1 1 0 1
Was there a description of withdrawals and drop outs? 0 1 1 0 1
Was the study described Double-blinded? 0 0 0 0 0
Was the method of blinding inappropriate? 0 0 0 0 0
FINAL SCORE (0 – 5) 0/5 2/5 2/5 1/5 2/5

All the included studies were evaluated in terms of its risk of bias (Table 4). Major sources of the risk of bias were related to allocation concealment, blinding study subjects or research personnel and blinding of outcome assessment. Risk of reporting bias was low in general. Therefore, a high risk of bias might be introduced in most of the RCTs included.

Table 4

Risk of bias assessment. 1, Random sequence generation (selection bias); 2, Allocation concealment (selection bias); 3 Blinding of participants and personnel (performance bias); 4, Blinding of outcome assessment (detection bias); 5, Incomplete outcome data (attrition bias); 6, Selective reporting (reporting bias); 7, Other bias. + low risk of bias - high risk of bias ? unclear risk of bias.


1 2 3 4 5 6 7
29 - - + + - + +
30 + ? - - + + +
31 + + + - + + +
14 + + + - + + +
15 + + + - + + +
26 - ? + - + + +
27 + - + - + + +
28 + - - - + + +
25 - - - - + + +
22 - - - - - + +
23 + - - - + + +
24 - - - - + + +
21 - + + + + + +

5. Limitations

Jadad et al. [20] reported that RCTs of high quality, must score between 3 and 5 points on the above scale. The quality assessment of the papers demonstrated that only six studies reached the minimum score to be considered of adequate quality. However, none of the records were excluded based on the score. Therefore, a high risk of bias exists in most studies.

The comprehensive search strategy was performed in order to minimise publication bias. Nevertheless, it may not have been sufficient to prevent bias, as identifying and improving potential biases is not easy [32]. The exclusion of non-English language records may have introduced language bias, and this is another limitation of this review. The search of the records was updated during the process of the review, to prevent any time-lag biases; however it is impossible to exclude such biases. In addition, the review included only thirteen studies and most of them had a small sample. This makes the interpretation and generalisation of the results difficult.

6. Conclusion

Despite the limitations in the studies, HIIT and MICE both improve QoL and functional capacity of patients with MI and therefore are recommended. However there seems to be a slight advantage of HIIT over MICE but this is not a universal finding. Obviously there is significant heterogeneity in methodologies among the different trials. Despite this, the findings of this review suggest that HIIT is safe and may improve QoL in patients with MI. However, additional studies with higher sample sizes and improved methodological quality are required to confirm these findings. In light of the limitations that have been reported, the results must be interpreted with caution.

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