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Gonçalves PEO et al. Rev Cienc Saude. 2023;13(4):4-10
ORIGINAL ARTICLE
Adherence to Heart Rate Training Zones in an Exercise Training Program in
Adults with Coronary Artery Disease
Patric Emerson Oliveira Gonçalves1,* , Tiago da Silva Nogueira2, Bruno Rezende Passos2,
Danielle Aparecida Gomes Pereira2 , Scott Thomas3, Raquel Rodrigues Britto2
1School of Kinesiology, The University of British Columbia, Vancouver, British Columbia, Canada.
2Cardiovascular and Metabolic Rehabilitation Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo
Horizonte, Minas Gerais, Brazil.
3Faculty of Kinesiology and Physical Education, Toronto, Ontario, Canada.
Received 2023 Aug 15, accepted 2023 Nov 12, published 2023 Dec 26
ABSTRACT
Objectives: To investigate the effect of exercise intensity on functional capacity in individuals with
coronary artery disease, assess adherence to the heart rate training zone (HRTZ), and relationship
between trained intensity and functional capacity.
Methods: Retrospective study led with medical records of 54 outpatients with coronary artery
disease in a public hospital. The prescribed intensity started at 50 – 60% of heart rate reserve,
increasing monthly to 70 – 80% by the third month. Spearman’s test was used to assess the
correlation between improvement in distance in the incremental shuttle walk test (ISWT), exercise
intensity, and rating of perceived exertion (Borg–RPE). Adherence was classified as ‘below’ when
HRTZ was not achieved in any phase of the program, ‘intermediate’ when HR was within the HRTZ
for one or two months, and ‘above’ when HR was at or higher than HRTZ two months.
Improvement was tested with t-test and one-way ANOVA.
Results: 51.9% of participants had an increase in ISWT of ≥70 m (p < 0.0001). In at least one month,
50.9% trained below HRTZ. Trained intensity did not go below 8.6% of the prescribed minimal
threshold of HRTZ. Changes in ISWT were not significantly correlated with exercise intensity (p =
0.87) or Borg–RPE (p = 0.16).
Conclusion: While a significant increase in functional capacity was found, considerable
heterogeneity in changes were observed. This may, in part, be related to adherence to HRTZ with
progressive exercise intensity and to the variability in exercise volume in cardiovascular
rehabilitation programs.
*Corresponding author:
Addr.: Medical Sciences Block C, 2176 Health Sciences Mall, Vancouver, British Columbia, Canada V6T 1Z3.
Phone: (604) 618-5404.
E-mail: patricog@alumni.ubc.ca (Gonçalves PEO)
The study was conducted at Hospital das Clínicas, Universidade Federal de Minas Gerais.
https://doi.org/10.21876/rcshci.v13i4.1464
How to cite this article: Gonçalves PEO, Nogueira TS, Passos BR, Pereira DAG, Thomas S, Britto RR. Adherence to Heart Rate
Training Zones in an Exercise Training Program in Adults with Coronary Artery Disease. Rev Cienc Saude. 2023;13(4):4-10.
https://doi.org/10.21876/rcshci.v13i4.1464
2236-3785/© 2023 Revista Ciências em Saúde. This is an open-access article distributed under a CC BY-NC-SA license
(https://creativecommons.org/licenses/by-nc-sa/4.0/deed.en)
KEYWORDS
Cardiac Rehabilitation
Coronary Disease
Exercise
Walk test
Gonçalves PEO et al. Rev Cienc Saude. 2023;13(4):4-10 5
INTRODUCTION
Exercise training is essential for restoring
previous functionality and activity levels and preventing
new cardiac events and is recommended as part of
cardiovascular rehabilitation programs (CVR)1,2. Large
cohort studies have found that exercise capacity
strongly predicts mortality, myocardial infarction
events, and downstream revascularization. In fact, even
a 0.5-MET (metabolic equivalent) increase in exercise
intensity capacity is associated with a lower mortality
rate3,4.
Studies have also shown substantial variability in
exercise prescriptions among CVR centers5,6.
Investigations of different prescribed parameters among
professionals revealed significant variation in the
duration, frequency, and prescribed intensity for the
same patient with coronary artery disease7.
Intensity plays a critical role in enhancing the
conditioning response. However, there remains a gap in
understanding why some individuals do not adhere to the
prescribed heart rate training zone (HRTZ) during CVR
sessions. Researchers have observed that in their
outpatient CVR programs, 67% trained below the lower
intensity threshold8.
Not all patients referred to CVR programs are
functionally capable of being subjected to a graded
exercise test (GXT). Moreover, not all CVR programs in
middle- or low-income countries can afford a GXT, which
is why functional capacity tests such as the incremental
shuttle walk test (ISWT) are fundamental9.
If CVR participants do not achieve or sustain
HRTZ, the exercise stimulus may be suboptimal, and
consequently, improvements in functional capacity may
be hindered10,11.
Therefore, this study aimed to assess the actual
training intensity relative to the prescribed HRTZ,
changes in functional capacity following exercise
training, and the relationship between training intensity
and functional capacity.
METHODS
Study design
A retrospective study with data collected from
the medical records of patients with coronary artery
disease (CAD) at an outpatient CVR program. This study
was approved by the Ethics and Research Committee of
the Federal University of Minas Gerais (CAAE:
11020919.9.0000.5149, opinion number 3331.948, of
2019 May 17). Informed consent was waived given this
study was a retrospective study.
Sample
The medical records of outpatients admitted to
the CVR program at the Cardiovascular and Metabolic
Rehabilitation Center of a public university institution,
at Jenny de Andrade Faria Institute at the Hospital das
Clínicas, Belo Horizonte, Minas Gerais, Brazil, were
analyzed.
We included adults older than 18 years with CAD,
post-myocardial infarction, or acute coronary syndrome
with left ventricular ejection fraction ≥ 40% as assessed
through a recent echocardiogram (< 6 months) by a
trained cardiologist. To be eligible, participants had to
be first-time participants in a CVR program, perform a
GXT and a functional capacity test (i.e., incremental
shuttle walking test) before and after the CVR program,
and have attended at least ≥ 50% of the program.
Individuals were excluded if they did not attend for two
or more consecutive weeks or had another diagnosed
cardiovascular disease.
Rehabilitation design
Participants initially underwent a history and
physical examination by a cardiologist, followed by a
GXT to guide exercise prescription12. Due to protocols
for financial contingency, the GXT and not a
cardiopulmonary test was performed at admission only,
with a treadmill using a ramp or the Bruce protocol13. If
the GXT had been reported as ischemic in participants
with stable angina, heart rate peak (HRpeak) was
defined as 10 bpm below the ischemic heart rate (HR)14.
The three-month program was supervised by physical
therapists, with exercise intensity prescribed as a
percentage of the heart rate reserve (%HRR) using the
Karvonen formula. In the first month of the program,
participants performed supervised training 3x/week at
50-60% HRR, 2x/week at 60-70% HRR in the second
month, and 1x/week at 70-80% HRR in the third month15.
Each session lasted 50 min and comprised a 5-min
warm-up, 30 min of aerobic training (treadmill, lower
limb cycle ergometer, or a circuit training), 5-min cool
down, and 10 min of resistance training. All participants
were also instructed to perform unsupervised exercises
to meet the exercise recommendation guidelines (150
min/week, and 2x/week of resistance training).
Measurements
Exercise intensity
Data were collected from the last session of each
month in the CVR program to mitigate the early training
adaptation bias from the initial sessions.
Heart rate was monitored using a chest heart rate
monitor or with self-pulse oximeters and was recorded
at rest while seated before exercise and 10 and 30 min
during exercise to objectively assess exercise intensity.
The modified Borg scale was used to assess exercise
intensity subjectively16,17.
Functional capacity
The ISWT assesses functional capacity, is
validated for use in CVR programs, and is well correlated
with maximal oxygen uptake and the Veterans Specific
Activity Questionnaire (VSAQ), and both were completed
at admission and discharge18–20.
Gonçalves PEO et al. Rev Cienc Saude. 2023;13(4):4-10 6
Statistical analysis
Sample characteristics are presented as mean ±
standard deviation (SD) or median (IQR: 25th, 75th
percentiles), according to data normality or percentage.
The normality of the data was tested using the Shapiro–
Wilk test. The independent variables were training
intensity (i.e., mean HR achieved in sessions, expressed
as a percentage of HRR) and mean perceived exertion
(Borg–RPE). The dependent variable, functional
capacity, was recorded through the walking distance, in
meters, in the ISWT. Paired t-tests compared the
distance walked after vs. before the CVR program.
Spearman’s correlation tests assessed the relationships
between changes in ISWT and 1) the average exercise
intensity expressed as a %HRR and 2) perceived exertion,
as measured by RPE.
One-way ANOVA was used to test differences in
ISWT between groups: below, intermediate, or above
prescribed HRTZ. Adherence was classified as ‘below’
when the participant did not achieve, on average,
prescribed HR in any phase of the program,
‘intermediate’ when it was within HRTZ for one or two
months, and ‘above’ when HR was maintained at or
higher than HRTZ for at least two months. The
Bonferroni test was used for post hoc analyses. Alpha =
5% was used for significance. The analysis was performed
using IBM SPSS Statistics for MacBook (Version 23.0, IBM
Corp).
RESULTS
We screened 197 medical records, 54 of which
completed the program, met the eligibility criteria, and
were subsequently included in the study (Figure 1, Table
1).
Figure 1 — Study participants flowchart. ISWT= incremental shuttle walking test. LVEF=
left ventricle ejection fraction.
Overall, 50.9% of participants exercised below
HRTZ for at least a month. Adherence to HRTZ decreased
with increasing exercise intensity (Figure 2). No
statistically significant difference in the between-groups
analysis for distance walked in the ISWT was found
(Table 2).
The average training intensity below the lower
HRTZ threshold was 4.2%, 6.6%, and 8.6% in the first,
second, and third months, respectively.
The average walked distance during the ISWT
before the 3-month CVR program was 378.3 m (128.7)
and 442.8 m (136.4) after (Figure 3). There was a median
improvement in functional capacity of 70 m (10, 110), p
< 0.0001 [39.4, 89.6], with 51.9% of patients showing a
≥ 70 m improvement in ISWT.
The results suggested low correlations between
exercise intensity and changes in ISWT (rho = 0.02, p =
0.87), as well as between RPE and changes in ISWT (rho
= 0.19, p = 0.16). The correlations when intensity was
calculated as a percentage of the maximal HR reached
during the GXT or for each phase of the program
individually were also low. Outliers, defined as
participants who did not fall within ± 2 SD of the mean,
did not affect the correlations or t-tests.
Gonçalves PEO et al. Rev Cienc Saude. 2023;13(4):4-10 7
Table 1 — Sample characteristics. Values shown as mean
(SD) or n (%).
Variables
Values
Age, yr, mean (SD)
61 (8.2)
Sex, n (%) male
45 (83.3)
BMI, kg/m2 mean (SD)
27.4 (3.6)
LVEF, mean (SD)
58 (9.7)
Ex-smokers, n (%)
32 (68.1)
Myocardial infarction, STEMI, n (%)
36 (75)
Physically active, n (%)
15 (29.4)
AACVPR risk classification, n (%)
Low
28 (57.1)
Moderate
18 (36.7)
High
3 (5.6)
VSAQ, mean (SD)
6.2 (2)
Beta-blocker use, n (%)
50 (92.6)
Systemic Arterial Hypertension, n (%)
37 (69.8)
Dyslipidemia, n (%)
28 (56)
Diabetes mellitus, n (%)
16 (29.6)
Graded exercise test
Peak MET, mean (SD)
7.7 (2.7)
HR peak, bpm, mean (SD)
122.3 (19.2)
Maximal double product, mm Hg x bpm,
mean (SD)
19,885.5
(4,592.7)
AACVPR= American Association of Cardiovascular and Pulmonary
Rehabilitation; BMI= body-mass index; HR peak= peak heart rate
reached during graded exercise test expressed as a percentage of
age predicted heart rate; LVEF= left ventricle ejection fraction;
MET= metabolic equivalent; SD= standard deviation; STEMI= ST
segment elevation myocardial infarction; VSAQ= Veterans Specific
Activity Questionnaire.
DISCUSSION
This study reveals that fewer participants
maintained their exercise intensities within the
prescribed HRTZ with the progressive protocol.
Nevertheless, improvements in functional capacity were
still observed, likely owing to participants not training
too far below the lower HRTZ threshold.
In our study, 48.1% of the participants did not
have their functional capacity improved above the 70 m
minimal clinically relevant difference21. We found a
weak correlation between mean exercise HR, Borg–RPE,
and changes in functional capacity. This may be related
to how often participants trained below the minimum
HRTZ threshold, which did not exceed 8.6%. Khushhal et
al. found that participants trained on average 3% below
the lower HR threshold of their prescribed intensity8.
Although they exercised on average 6.5% below the HRTZ
in our study, we believe that this was not sufficient to
impair improvements in functional capacity. Other
factors could have influenced it, such as focusing on
maintaining above the minimum HR threshold rather
than the midpoint or upper HR limit within the HRTZ.
Another reason could be the participants not meeting
their weekly exercise unsupervised goals. In addition,
92.6% of our participants were prescribed β-blockers,
which attenuate the HR response to exercise,
consequently narrowing the HRR and potentially
impairing the ability to remain within higher HRTZ.
Thus, tracking exercise intensity using subjective
measures such as Borg–RPE can help track exercise
intensity in such participants. However, this study did
not find a correlation between functional capacity and
Borg-RPE.
Retrospective studies have known limitations
related to their design, such as not having a control
group and restrictions on their generalizability and
external validity. However, our study contributes to the
literature and clinical practice because it focuses on an
important functional capacity measure (i.e., distance
walked).
Additionally, the ISWT is a valid instrument that
correlates with increases in maximal oxygen uptake. Our
study shows that although many participants do not
exercise within the HRTZ, particularly as the intensity
progresses, there are still improvements in functional
performance measured by the ISWT. This, nevertheless,
may reflect our limited ability to quantify the training
stimulus.
This study was performed in a public university
hospital setting, in which cardiac rehabilitation
therapists are often responsible for assisting 2-4 patients
simultaneously, and participants cannot always afford
heart rate monitors. Moreover, our participants were
mainly older adults who reportedly had not previously
exercised using a treadmill before enrolling in this CVR
Table 2 — Outcomes by adherence to heart rate training zones: below, intermediate, or above HRTZ.
HRTZ
Below (n = 13) Intermediate (n = 15) Above (n = 26) p-value
Pre ISWT, meters 355.4 (145.8) 384 (124.3) 386.1 (123.4) 0.77
Post ISWT, meters 423.8 (167.3) 405.3 (122.5) 465.4 (131.5) 0.38
Delta ISWT, meters 68.5 (89.4) 21.3 (86.6) 79.2 (98.9) 0.16
HR rest, bpm 68 (6) 71 (8) 65 (7) 0.05
HR at peak exercise, bpm 96 (12) 99 (13) 101 (16) 0.48
HRTZ= heart rate training zone, Delta ISWT= post-pre distance walked in the incremental shuttle walk test (ISWT); HR= heart
rate in beats per minute. Significance level was set at p < 0.05.
Gonçalves PEO et al. Rev Cienc Saude. 2023;13(4):4-10 8
Figure 2 — Heart rate training zone adherence. HRTZ: heart rate training zone.
Figure 3 — Boxplot with mean distance walked in the Incremental Shuttle Walk
Test (functional capacity) pre, post and in response to the cardiovascular
rehabilitation program. CVR= cardiovascular rehabilitation. *Statistically
significant change (p < 0.05). Open circles () represent outliers.
program. Inexperience may have induced fear of going
further, especially after a cardiac event, and the general
challenge of having one-on-one guidance from a
therapist throughout the entire session.
One participant showed a decrease of 180 m in
the distance walked in the ISWT, had a depressed
chronotropic response (chronotropic index: 0.56;
reference > 0.62) in their admission GXT, a drop in
systolic blood pressure in 16.6% of their CVR sessions,
and trained below HRTZ during 75% of the program.
Another outlier decreased the distance walked in the
ISWT by 150 m after the CVR program. In their screening
test, this patient had an EFLV of 42% and hypokinesia of
the left ventricle. During this participant’s program,
they were suspended from treadmill training because of
dyspnea and dizziness and trained under their HRTZ in
35% of their sessions.
The other two outliers were individuals who had
improved by 300 and 320 m. The first trained above their
HRTZ in 41.6% of the sessions and stated they
consistently performed unsupervised exercise training,
and the second trained above their HRTZ in 62.5% and
within HRTZ in 37.5% of the sessions and never exercised
below HRTZ. The current literature agrees that higher
meters
*
Gonçalves PEO et al. Rev Cienc Saude. 2023;13(4):4-10 9
intensities achieved during CVR can optimize the
benefits of exercise. Although the limited data from two
participants precludes the ability to draw definitive
conclusions, it nevertheless suggests the importance of
adhering to the overload principle: greater intensities
generally yield greater outcomes.
There are discrepancies in exercise prescription
approaches and the volume of training across
cardiovascular rehabilitation programs, making it
complex to analyze overall improvements. Other studies
have found a correlation between exercise intensity and
cardiorespiratory improvements such as VO2peak and
functional capacity22-23. Our study agrees with the
recommendations reviewed by Mitchell et al.22 in that
we investigated adherence to exercise prescription as
one of the major factors influencing functional
improvements.
Thus, our recommendation for future studies is to
include an exercise diary to monitor training volume and
define training profiles to measure its impacts on
functional capacity. We believe this is an accurate and
realistic clinical study in a public hospital in a low- to
middle-income country and can be generalized to other
similar settings. Our study shows that even in scenarios
with few resources and financial support, exercise in
CVR programs is essential to improve functional capacity
in patients with post-myocardial infarction. Future
studies should aim for a larger sample size and
randomized trials.
Our main take-home messages are that any
exercise is better than none in outpatients referred to
CVR programs. Also, exercise intensity is not the sole
factor responsible for increases in functional capacity.
Encouraging participants of CVR programs to engage in
unsupervised physical activity is also crucial. Further
investigations should be conducted to identify the
relationships between training volume in rehabilitation
programs that also use progressive intensities.
CONCLUSION
Despite improvements in functional capacity in
most participants, 48.1% did not show significant
achievements in this progressive exercise program,
which can partly, but surely not solely, be attributed to
participants not exercising within their prescribed HRTZ.
This points to the importance of keeping within HRTZ
and reinforcing the participant of CVR programs their
role in monitoring HR during exercise, especially where
a one-on-one approach is not possible, and their role in
engaging in unsupervised exercise to optimize the
benefits of cardiac rehabilitation.
ACKNOWLEDGMENTS
Special thanks to Andy Hung for his invaluable
assistance in improving clarity and coherence of this
manuscript and to the patients and volunteers at the
Cardiovascular and Metabolic Rehabilitation Center
(Jenny Faria).
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Conflicts of interest: No conflicts of interest were declared concerning the publication of this article.
Indications about the contributions of each author:
Conception and design: PEOG, DAGP, RRB, ST
Data analysis and interpretation: PEOG, TSN, DAGP, RRB, ST
Data collection: PEOG, TSN
Writing of the manuscript: PEOG, TSN, BRP, DAGP, RRB, ST
Critical revision of the text: PEOG, TSN, BRP, DAGP, RRB, ST
Final approval of the manuscript*: PEOG, TSN, BRP, DAGP, RRB, ST
Overall responsibility for the study: PEOG, RRB, ST
*All authors have read and approved the final version of the article submitted to Rev Cienc Saude.
Funding information: Not applicable.
