Effects of Acute Aerobic Exercise Performed in a Single Supervised Cardiovascular Rehabilitation Session on Cardiovascular Disease Patients

doi:10.21203/rs.3.rs-8187705/v1

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Research Article

Effects of Acute Aerobic Exercise Performed in a Single Supervised Cardiovascular Rehabilitation Session on Cardiovascular Disease Patients

https://doi.org/10.21203/rs.3.rs-8187705/v1

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Purpose

To evaluate the effects of acute aerobic exercise in a supervised Cardiac Rehabilitation (CR) session on cardiovascular parameters. To verify the association between health-related factors (anthropometry, quality of life, functional capacity and physical activity level) and cardiovascular parameters.

Methods

This experimental study evaluates cardiovascular parameters before and after a single CR session using the Mobil-O-Graph®. Quality of life was assessed by SF-36. Functional capacity and physical activity level (PAL) were evaluated by Duke Activity Status Index (DASI) and Human Activity Profile (HAP), respectively. It was a convenience sample, composed of patients who participated in a CR program.

Results

71 patients (75.14 ± 10.28 years) were included. Heart rate significantly increased and systolic volume decreased (p = 0.0005) after exercise. The reflection coefficient and aortic pulsatility decreased significantly after exercise. Pulse wave velocity (PWV) negatively correlated with DASI scores (r= -0.5387, p = 0.0001) and HAP [adjusted activity score (r= -0.4964, p = 0.0001) and maximum activity score (r= -0.2904, p = 0.0140)], physical functioning and physical limitation of SF-36 applied before the CR session. Mean arterial pressure, central systolic and diastolic blood pressure positively associated with the SF-36 General Health Status component. cDBP associated with DASI and adjusted activity score.

Conclusion

PWV negatively correlated with DASI and HAP scores, indicating that individuals with lower PALs present higher PWV. The reduction in aortic pulsatility after exercise suggests a protective effect on high-flow organs.

CONDENSED ABSTRACT

This study evaluated cardiovascular parameters before and after a single CR session; and verified the association of these parameters with quality-of-life (SF-36), functional capacity (DASI) and physical activity level (HAP) of individuals with cardiovascular diseases. Pulse wave velocity negatively correlated with DASI and HAP scores and aortic pulsatility reduced after exercising.

Vascular stiffness

functional capacity

pulse wave velocity

acute exercise

aerobic exercise

What does this paper add to the current literature?

This study demonstrates that the reflection coefficient and aortic pulsatility decrease after acute aerobic exercise, suggesting a reduction in left ventricular overload and a protective effect on high-flow organs such as the kidneys and brain.
It provides new insights into the relationship between pulse wave velocity (PWV) and functional capacity, showing that lower physical activity levels and reduced functional capacity are associated with higher arterial stiffness.

What new knowledge is added by this study?

To our knowledge, this is the first study to evaluate the acute effects of aerobic exercise on cardiovascular parameters in patients with cardiovascular disease.
Findings suggest that studies incorporating different exercise intensities and longer follow-up times may better detect vascular abnormalities and cardiovascular risk.
The results reinforce the importance of regular physical activity in modulating PWV, which is the gold standard for assessing arterial stiffness in clinical practice.

What is novel?

The reflection coefficient and aortic pulsatility decreased after exercise, suggesting reductions in the overload of the left ventricle and a protective effect on high-flow organs such as kidney and brain.
Pulse wave velocity (PWV) was negatively correlated with functional capacity evaluated using Duke Activity Status Index (DASI) and physical activity level assessed by Human Activity Profile (HAP), suggesting that individuals with lower functional capacity and physical activity level present higher PWV.

What are the clinical and/or research implications?

To our knowledge, the present study was the first to evaluate the effects of acute aerobic exercise on cardiovascular parameters in patients with cardiovascular disease and studies with different exercise intensities and longer segment time after exercise may be more sensitive for revealing vascular abnormalities and cardiovascular risk.
Regular physical activity and the consequent improvement in functional capacity may have positively modulated the PWV, considered the gold standard for arterial stiffness, assessment in clinical practice.

Cardiac rehabilitation (CR) is a multidisciplinary treatment program designed to guide people who have or have had cardiovascular disease to regain their cardiovascular health and improve their quality of life ^1–3. This treatment modality includes exercise training, physical activity promotion, health education, cardiovascular risk management and psychological support, personalized to the individual needs of patients with diagnosed heart disease⁴. In a Cochrane systematic review of randomized controlled trials, Anderson & Taylor (2014) found a survival benefit for patients receiving CR compared with no CR. In addition, they observed that the benefit of CR appears to be through direct physiological effects of exercise training and through effects of CR on risk factors, behavior and mood⁵.

Assessment of functional capacity, physical activity level and quality of life in CR is essential to monitor progress, adapt treatments, motivate patients and reduce complications, contributing to more effective clinical results and a healthier life after cardiac events^6,7. Cardiopulmonary exercise testing is considered the gold standard for objectively quantifying functional capacity, but presents a high financial cost, which makes it inaccessible for most patients⁸. However, the use of validated scales and questionnaires to assess functional capacity is highly clinically relevant⁸.

Arterial stiffness is widely used as a method for assessing the severity and progression of cardiovascular diseases⁹. Increased arterial stiffness indices, such as a higher pulse wave velocity (PWV) and augmentation index (AIx@75), are directly and independently associated with an increased risk of for CV complications and events^10,11. Targeting multiple modifiable risk factors, such as sedentarism, has become the main therapeutic strategy to improve arterial stiffness in patients at high cardiovascular risk¹².

Arterial stiffness is determined by changes in function and vascular structure and can be modulated according to the type of exercise training^13,14. In a systematic review and meta-analysis, Pierce et al. (2018) quantified the effect of aerobic acute exercise on arterial stiffness and wave reflection in apparently healthy young human adults (18–45 years). Aerobic exercise was either performed on a cycle ergometer or a treadmill with varying intensities and durations. The authors observed that acute aerobic exercise did not change cf-PWV, but resulted in increased AIx@75¹³. To our knowledge, no study has compared the effects of central and peripheral blood pressure, hemodynamic parameters and arterial stiffness indices after a single session of CR in older adult patients with cardiovascular disease. Therefore, the primary objective of this study was to evaluate the effects of acute aerobic exercise performed in a single supervised CR session on cardiovascular parameters. The secondary objective was to verify which health-related factors (anthropometry, quality of life score, functional capacity and level of physical activity) are associated with arterial stiffness indices and central and peripheral blood pressure parameters.

Study design and participants

This is an experimental study which evaluated cardiovascular parameters before and after a single supervised CR session. Furthermore, the association between the scores assessed in the quality-of-life questionnaire, Duke Activity Status Index (DASI) and Human Activity Profile (HAP) was verified.

The sample was taken by convenience, composed of patients of both sexes, aged 50 to 90 years, undergoing follow-up in a CR program for at least 6 months. The inclusion of patients was voluntary upon signing an Informed Consent Form. Patients with a diagnosis of arrhythmia, those using a cardiac pacemaker, and those who engaged in physical activity in the last 24 hours were excluded.

PROCEDURES

Experimental protocol

Weight and height were assessed, and the body mass index was calculated. Cardiovascular parameters were collected before and after the CR session. The questionnaires were applied before the cardiovascular measurements, always by the same researcher and with standardized speech. Information on medication use and comorbidities was collected from medical records.

Cardiovascular rehabilitation session

Each session lasted 60 minutes¹⁵. Participants warmed up for 15 minutes with dynamic exercises. Then, they performed another 15 minutes of dynamic exercises on a mat involving the large muscle groups of the lower limbs. The aerobic exercises lasted 30 minutes and were performed on a treadmill (LX160 Treadmill, Movement, Brazil) and horizontal bicycle (RT 230 Professional Training, Movement, Brazil). We standardized the bicycle as the last activity to be performed. Exercise intensity was low to moderate for patients who had performed the exercise test. The prescription for patients who started the program without a functional test was based on the modified subjective perception of exertion scale (Borg 0–10), ranging between 2 and 4^15,16.

Each session lasted 60 minutes. Participants began with a 15-minute warm-up consisting of dynamic exercises, such as circular movements of arms and shoulders, walking high kicks, and butt kicks. Following the warm-up, they performed 15 minutes of dynamic exercises on a mat that included at least four types of exercises targeting the large muscle groups of the lower extremities, such as bridges, mountain climbers, and knee-bent leg lifts. The aerobic exercises lasted 30 minutes and were performed on a treadmill (LX160 Treadmill, Movement, Brazil) and a horizontal bicycle (RT 230 Professional Training, Movement, Brazil), with the bicycle standardized as the final activity.

For participants who performed an exercise test, the intensity of the aerobic exercises was prescribed as low to moderate, based on heart rate ranges corresponding to 50–70% of heart rate reserve or Borg scale ratings of perceived exertion (RPE) between 2 and 4. For those who initiated the program without a functional test, the exercise intensity was determined using the modified Borg 0–10 scale, also ranging between 2 and 4. These parameters aimed to standardize the internal load and ensure a safe and effective intervention.

INSTRUMENTS

Cardiovascular parameters assessment

Cardiovascular parameters were evaluated using a Pulse Wave Analysis Monitor (Mobil-O-Graph®, IEM, Germany) in accordance with previous studies by our group^17–19. This device uses the oscillometric method of evaluating brachial artery blood pressure for a non-invasive estimation of the central or aortic pulse wave. The central pulse wave provides the augmentation index corrected to 75 bpm (AIx@75) and the central vascular pressures [systolic blood pressure (cSBP), diastolic blood pressure (cDBP), pulse pressure (cPP) and mean arterial pressure (cMAP)]. The Alx@75 was evaluated from the aortic pulse wave through the difference in pressure between the peak of the reflection wave (P2) and the peak of the incident wave (P1), expressed as a percentage of the central pulse pressure (cPP) [AIx@75 = (P2-P1)/cPP x 100]. The ARCSolver method enables estimating PWV using a mathematical model, taking into account several parameters obtained by aortic pulse wave analysis and wave separation analysis²⁰. Hemodynamic parameters [cardiac output (CO), total vascular resistance (RVT), cardiac index (CI)] and heart rate (HR) were also evaluated. Aortic pulsatility (cPP/cMAP) was analyzed from the hemodynamic parameters²¹.

The device carried out an evaluation of the quality of the records, where quality 1 means signal acquisition greater than 80%, 2 means signal acquisition greater than 50% and quality 3 and 4 records mean low quality and were not considered²². Three measurements were taken, and the average was considered for final analysis.

The Mobil-O-Graphy® cuff was selected based on the circumference of the participant’s left arm, positioned 2 cm from the cubital fossa of the left arm. Assessments were done by a single trained evaluator. The baseline measurement, meaning before exercise, was carried out with the patient in a sitting position, after 10 minutes of rest. The baseline measurement, meaning before exercise, was carried out with the patient in a sitting position, on a chair with the soles of both feet apart and resting on the floor, after 10 minutes of rest. The post-exercise measurement was performed in the same position immediately after exercise.

Quality of life assessment: Short-form Health Survey (SF-36)

The quality of life assessed using the Short-Form Health Survey (SF-36), a generic instrument which assesses the patient’s perception of health-related quality of life. This tool contains 36 items that encompass 8 domains involving physical and mental aspects: functional capacity (10 items); physical performance (4 items); pain (2 items); general health status (5 items); vitality (4 items); social aspects (2 items); emotional aspects (3 items) and mental health (5 items). The physical component assesses functional capacity, general clinical status, pain and physical appearance. The mental component encompasses aspects that refer to vitality, social issues, emotional issues and mental health assessment. The counts of the 36 questions are transformed into a scale of 0-100, where higher values indicate a better perception of health status^23,24.

Assessment of physical activity level: HAP questionnaire

The physical activity level was assessed using the HAP questionnaire. This questionnaire consists of 94 items which assess the individual’s self-care, work, social activities and physical activity level classified according to the energy expenditure necessary to perform each task. The items are arranged in increasing order of energy expenditure, meaning that higher numbers correspond to greater energy expenditure. Respondents were asked to indicate whether they were “still doing this activity”, whether they had “stopped doing this activity” or had “never done this activity”. The HAP can be applied to individuals with different functional levels, from very low (getting up and sitting down from a chair or bed without assistance) to very high (running 4.8 kilometers), thus providing two scores: Maximum Activity Score (MAS) and Adjusted Activity Score (AAS)^25,26. MAS is the number of the activity that presents the highest oxygen demand that the participant is still performing. The AAS is calculated from the MAS, which is the number of items that the individual “stopped doing” prior to the last one that he/she “still does” and is subtracted from the MAS. This latter score is considered a more stable estimate of the individual’s daily activity compared to the MAS. The AAS can be used to classify an individual’s general level of physical fitness and activity into three categories: inactive (score below 53), moderately active (score between 53 and 74), and active (score above 74)^27,28.

Assessment of functional capacity: DASI questionnaire

Functional capacity was assessed using the DASI questionnaire, which was developed to evaluate patients with cardiovascular diseases²⁹. It is a self-report questionnaire containing 12 questions that are based on activities of daily living^29,30. Each questionnaire´s item presents a corresponding MET value of the task performed. Its score varies from 0 to 58.2 ml.kg^− 1.min^− 1, directly proportional to the individual’s functional capacity. The higher the score, the greater the functional capacity²⁹.

Sample size calculation

The sample size was calculated with a computational software (G Power version 3.1.9.6)³¹ considering the AIx@75 values before and after physical exercise from a pilot study, with the effect being d = 0.34, significance level of 5% and power (beta) of 80%. The sample size calculation resulted in a final sample of 70 patients.

Statistical analysis

Numerical variables were described as central tendency (mean) and variability measures (SD), and categorical variables were described as absolute and relative frequencies. Data normality was assessed using the Kolmogorov-Smirnov test. For comparisons of variables before and after the intervention, the paired Student’s t-test or Wilcoxon test was used, when appropriate. For correlation analysis, Pearson’s correlation coefficient was used for parametric data or Spearman’s correlation coefficient for non-parametric data. The level of significance adopted in all tests was 5%. Data analysis was performed using the Prism 8 software program (GraphPad Software, Inc., San Diego, CA, USA).

Patients were recruited from 10/2022 to 07/2023 from a CV clinic. A total of 110 patients were eligible for the study, and 75 agreed to participate. Of these, four patients were excluded for the following reasons: one patient experienced technical issues with the signal from the Mobil-O-Graph device, likely due to improper cuff positioning or movement during measurement, which compromised the reliability of the data; two patients had a diagnosis of arrhythmia, making it impossible to capture data, and one patient reported having performed weight training during the last 24 hours prior to data collection. Thus, 71 patients completed all stages of the study (Fig. 1).

Tables 1 and 2 respectively show the sociodemographic data and cardiovascular parameters of the participants. Stroke volume was significantly lower and heart rate significantly higher after exercise. AIx@75 was significantly higher after exercise. A higher prevalence of participants with a diagnosis of coronary heart disease and use of drugs for hypertension and dyslipidemia (controlled with drugs) is related to greater vascular involvement, common pathophysiological aspects of patients with cardiovascular disease

Table 1: Sample characterization
Variables	Mean ± SD	n	%
Sex
Male		42	59.15%
Female		29	40.85%
Age (years)	75.14 ± 10.28
Weight (kg)	73.00 ± 13.64
Height (cm)	165.29 ± 0.11
BMI (kg/m²)	26.65 ± 3.97
Medication use
Antihypertensives		61	85.91%
Statins		56	78.87%
Beta blockers		32	45.07%
Anticoagulants		27	38.02%
Anti-glycemic agents		14	19.71%
Cardiovascular diseases
Coronary artery disease		31	43.66%
Acute myocardial infarction		9	12.67%
Congestive heart failure		3	4.22%
Valvulopathy		3	4.22
Comorbidities
Dyslipidemia		55	77.46%
Systemic arterial hypertension		54	76.05%
Obesity		13	18.30%
Diabetes Mellitus		12	16.90%
Acidente Vascular Cerebral		3	4.22%
Chronic Renal Disease		2	2.81%
Procedures/surgeries
Stent placement		15	21.12%
Coronary artery bypass surgery		5	7.04%
Valve replacement surgery		3	4.22%
BMI: Body Mass Index

Table 2

Comparison of peripheral and central blood pressure values, hemodynamic variables, and arterial stiffness before and after exercise
Variables	Before (n = 71)	After (n = 71)	P-value
Peripheral blood pressure (mmHg)
Systolic blood pressure (pSBP)	122.60 ± 15.84	122.10 ± 14.37	0.6773
Diastolic blood pressure (pDBP)	75.40 ± 12.86	75.90 ± 12.41	0.3981
Mean blood pressure (pMAP)	97.10 ± 13.37	97.00 ± 12.47	0.9555
Pulse pressure (pPP)	47.38 ± 10.66	46.10 ± 9.57	0.1901
Central blood pressure (mmHg)
Systolic blood pressure (cSBP)	111.60 ± 14.79	110.00 ± 13.74	0.5918
Diastolic blood pressure (cDBP)	76.60 ± 12.84	77.40 ± 12.37	0.2149
Pulse pressure (cPP)	34.70 ± 8.15	33.60 ± 7.43	0.0672
Mean blood pressure (cMAP)	88.29 ± 12.97	88.64 ± 12.34	0.6095
Hemodynamics Parameters
Systolic volume (ml)	69.92 ± 11.87	65.15 ± 15.17	0.0005
Cardiac output (L/min)	4.84 ± 0.65	4.95 ± 0.64	0. 588
Total vascular resistance (s*mmHg/ml)	1.23 ± 0.19	1.20 ± 0.19	0.1478
Cardiac index (L/min/m²)	2.69 ± 0.42	2.75 ± 0.45	0.2311
Heart rate (bpm)	70.37 ± 11.41	78.59 ± 16.31	0.0001
Arterial stiffness
Augmentation pressure (mmHg)	23.48 ± 9.37	21.59 ± 9.20	0.0643
Coefficient of reflection	65.82 ± 8.42	64.04 ± 7.96	0.0237
AIx@75 (%)	22.35 ± 8.36	24.41 ± 9.78	0.0973
Pulse wave velocity (m/s)	10.59 ± 1.99	10.59 ± 1.88	0.9718
Aortic pulsatility cPP / cMAP	0.40 ± 0.10	0.39 ± 0.10	0.0465

Data presented as mean ± SD. AIx@75: AIx normalized to a 75 beats/minute heart rate.

The associations between cSBP, cDBP and pMAP with SF-36 are shown in Figs. 2A, 2B, and 2C, respectively. Association between cDBP with DASI and Adjusted Activity Score from HAP are shown in Figures D and E, respectively. Figure 3 shows the PWV associations between MAS (3A), AAS (3B), Physical functioning (3C), Physical limitation (3D) from SF-36 and DASI (3E).

In the present study we evaluated the effect of a CR session on cardiovascular parameters. Arterial stiffness indices, blood pressure and hemodynamic changes occurring in the recovery phase after a single exercise bout have not been extensively studied in patients with cardiovascular disease. The hemodynamic changes with exercise may be more sensitive for revealing vascular abnormalities and cardiovascular risk.

Different than expected, central and peripheral vascular pressures assessed before and after the CR session did not differ from each other. According to the known physiological responses to exercise, it was expected that blood pressure would reduce after aerobic exercise. Aerobic exercise results in sustained widespread vasodilation. With pronounced peripheral vasodilation, total peripheral resistance is reduced, leading to prolonged post-exercise hypotension³². Patik et al. (2021) performed a study with healthy young adults and observed that both brachial and aortic SBP were significantly decreased relative to baseline from 40 min post-exercise through 120 min, with the peak reduction occurring at 60 min. In this study, the arterial pressure in healthy young men that exercise decreased peripheral and central SBP, as well as peripheral and central DBP³².

In the present study we observed that stroke volume, heart rate and aortic pulsatility changed in relation to the baseline assessment. Despite the reduction in stroke volume and the increase in heart rate after exercise, the cardiac index remained unchanged in relation to the baseline assessment.

We also observed that the reflection coefficient reduced after the cardiovascular rehabilitation session. This index represents the magnitude of the reflection wave and is defined by the relationship between the amplitude of the reflection wave and the ejection wave³³. Patik et al. (2021) tested the hypothesis that reflection wave amplitude is reduced beyond one hour after cycling at 60% of V̇O₂peak for 60 min in young adults³². The authors observed that reflected pressure waves decreased and delayed after exercise, suggesting that these changes contribute to peak reductions in overload of the left ventricle. The exercise intensity imposed by Patik et al. (2021) was moderate, while in the present study it was mild to moderate³².

In the present study, PWV after exercise did not differ from the baseline assessment. Milatz (2015) studied healthy young people in a single 60-minute session of aerobic exercise on an aerobic bike (45% VO₂max), observing that PWV remained significantly reduced even after 60 minutes of recovery³⁴. Zang et al. (2022) investigated the effects of acute aerobic exercise on arterial stiffness in young male adults with different blood pressure levels. PWV was measured in brachial-ankle pulse wave velocity (baPWV) at both the baseline and immediately after exercise³⁵. The baPWV decreased after acute aerobic exercise mainly in the non-hypertension compared to the hypertension group. A possible explanation for the divergence of results may be related to several factors: 1 - The exercise intensity, which was considered light in some patients, which may not have been sufficient to produce significant changes in arterial stiffness; 2 - The location of the PWV measurement. The PWV assessed between the femoral-aorta artery is considered a central measurement and the brachial-ankle artery is considered peripheral; and 3 - Population involved in the study. Milatz's study³⁴ involved people considered healthy and the participants in the present study were mainly older adults, with many comorbidities and use of several medications. In this sense, lower age and better health status have previously been associated with greater significant reductions in post-exercise PWV. ³⁶

In the current study we observed that aortic pulsatility decreased after exercise. Due to its viscoelastic properties, the aorta helps in dampening the pulsatility of blood pressure. The pulsatile flow at the resistance level in arteries will be transformed into a continuous flow to allow optimal perfusion of end organs such as the kidneys and brain³⁷. Increased hemodynamic pulsatility is associated with microvascular lesions in high-flow organs such as the brain and kidney. These organs have low impedances and are damaged by excessive pulsatility³⁸. Pulsatility is not directly considered an index of arterial stiffness. However, when arterial stiffness is present, cPP increases and pulsatility typically occurs. Although cPP (34.7 ± 8.15 mmHg vs. 33.6 ± 7.43 mmHg; p = 0.0672) did not decrease significantly, the little decrease contributed to reducing aortic pulsatility. To our knowledge, this is the first study which has evaluated aortic pulsatility after an acute aerobic exercise session.

Physical activity promotes cardiovascular health and health related quality of life³⁹. In the present study, we observed a positive association between the “General Health Status” domain of the SF-36 questionnaire and the hemodynamic MAP, cSBP, and cDBP parameters. In a systematic review and meta-analysis, Trevisol et al. (2011) identified lower scores on the SF-36 in hypertensive patients for physical and mental components. Quality of life was lower in the eight domains of the SF-36: physical and functional functioning, physical and emotional role, bodily pain, general health, vitality and mental health⁴⁰. The difference in results may be related to the different blood pressure levels of patients between the studies. In the present study, only 5 patients had SBP greater than 140 mmHg, considered normal for this population. Recent studies suggest values of 140 mmHg for older adults, depending on the patient’s general health status and other risk factors⁴¹.

Regular physical activity is the most widely adopted strategy for reducing cardiovascular disease risk with aging, more likely due to its vascular health-enhancing influence^42,43. In a recent meta-analysis, Liu et al. (2023) demonstrated that aerobic exercise improved PWV in adults with cardiovascular disease or high cardiovascular disease risk⁴⁴. In the present study, PWV was negatively correlated with functional capacity assessed by the DASI. The study population had been participating in a cardiovascular rehabilitation program for at least six months. Our results suggest that regular physical activity and the consequent improvement in functional capacity may have positively modulated PWV in these patients. PWV also negatively correlated with AAS and MAS scores. To our knowledge, this is the first study to verify the association between PWV and DASI and PWV and HAP.

STUDY LIMITATIONS

This study has some limitations. First, the proposed assessment of cardiovascular parameters was to be carried out immediately after the end of the exercise. However, in some situations there was a delay in this collection due to technical complications in data acquisition, which may have compromised the identification of changes in cardiovascular changes during this period. Secondly, our study sample was composed of patients with cardiovascular diseases undergoing CR treatment for a minimum period of 6 months, limiting the generalizability of our results to the entire population with cardiovascular diseases. Third, due to our sample size, we cannot categorize patients by sex or cardiovascular disease category. Fourth, it was a single-center study, with CR standardized by the service. CR programs vary greatly between centers exercise-based cardiac rehabilitation can be offered in different modalities, such as continuous or interval aerobic training, resistance, and inspiratory muscle training.

PWV negatively correlated with DASI and HAP scores, indicating that individuals with lower functional capacity and lower physical activity levels present higher PWV. Aortic pulsatility reduced after exercise, suggesting a protective effect on high-flow organs such as the brain and kidneys.

Ethics approval and consent to participate

This study was approved by the Research Ethics Committee of the Faculty of Medical Sciences of Belo Horizonte/MG (FCM-MG), Brazil, CAAE 58283422.0.0000.5134 (number: 5.646.387).

All participants provided written informed consent prior to inclusion in the study, in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare no conflict of interest.

Funding

This study was funded by Fundação Lucas Machado (FELUMA), the Postgraduate Program in Health Sciences at Faculdade Ciências Médicas de Minas Gerais (FCM-MG), and Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG). Bernardes JI received a FAPEMIG undergraduate research fellowship, and Velloso TA received a FELUMA undergraduate research fellowship. No other external funding was received.

Author contributions

TCSA: Conceived and designed the study, selected patients, coordinated and supervised the data collection; analyzed and interpreted the data, drafted, reviewed and edited the manuscript.

JIB: Applied all questionnaires and contributed to the collection of cardiovascular parameters, analyzed and interpreted the data, drafted, reviewed and edited the manuscript.

TAV: Analyzed and interpreted the data, drafted, reviewed and edited the manuscript.

JCP: Reviewed and edited the manuscript, and critically reviewed the manuscript for important intellectual content.

MTR: Analyzed and interpreted the data, drafted, reviewed and edited the manuscript.

MGRM: Conceived and designed the study, analyzed and interpreted the data, drafted, reviewed and edited the manuscript, and critically reviewed the manuscript for important intellectual content.

All authors have read and approved the manuscript and meet the 4 ICMJE criteria for authorship.

Acknowledgements

This work was supported by a local educational and research foundation and a graduate program in health sciences. One of the authors, an undergraduate student from the Physiotherapy course, received support from a regional research funding agency. We are grateful to a PhD-level statistician for assistance with statistical analysis.

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Effects of Acute Aerobic Exercise Performed in a Single Supervised Cardiovascular Rehabilitation Session on Cardiovascular Disease Patients

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Abstract

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Contribution of paper

KEY PERSPECTIVE

INTRODUCTION

METHODS

Study design and participants

PROCEDURES

Experimental protocol

Cardiovascular rehabilitation session

INSTRUMENTS

Cardiovascular parameters assessment

Quality of life assessment: Short-form Health Survey (SF-36)

Assessment of physical activity level: HAP questionnaire

Assessment of functional capacity: DASI questionnaire

Sample size calculation

Statistical analysis

RESULTS

DISCUSSION

STUDY LIMITATIONS

CONCLUSION

Declarations

References

Additional Declarations

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