Resistance Training in Cardiovascular Diseases: A Review on Its Effectiveness in Controlling Risk Factors

Figures & data

Figure 1 PRISMA Flow Chart. Schematic representation of the identification process for studies through databases and registers.

Table 1 Absolute and Relative Contraindications Aerobic and Resistance Exercises in Cardiovascular Diseases

Absolute Contraindications	Relative Contraindications
Unstable CAD Uncontrolled arrhythmias Decompensated heart failure Severe and symptomatic stenosis Severe pulmonary hypertension (with mean pulmonary arterial pressure >55mmHg) Uncontrolled hypertension with blood pressure >180/110 mmHg Acute endocarditis, myocarditis, or pericarditis Syndrome of Marfan Aortic dissection	Major risk factors for CAD Uncontrolled hypertension with blood pressure >160/>100 mmHg Diabetes at all ages Presence of musculoskeletal limitations Low functional capacity (<4 METs) Patients on pacemakers or defibrillators

Abbreviations: CAD, Coronary artery disease, METs: Metabolic equivalents.

Table 2 Recommendation of Resistance Training Prescription in Cardiovascular Diseases Patients

Components of Exercise Prescription
Frequency	2–3x/week on non-consecutive days
Intensity	40–60% of 1-RM or RPE 11–13 on the Borg scale 6–20
Sets and Repetitions	1–3 sets of 8–10 repetitions
Type	Using safe and comfortable equipment
Special Considerations	In heart failure patients, exercise given with: Frequency 1–2x a week on non-consecutive days Intensity 50% for the lower body and 40% of 1-RM for the upper body. Load is increased gradually to 70% from 1-RM Given 1–3 sets of 8–10 repetitions Exercise using machines.
	In patients with sternotomy, upper body movements should be avoided until 8–12 weeks after surgery.
	In patients with Peripheral Arterial Disease, the given intensity is relatively higher 60–80% than 1-RM, and exercise is focused on large muscle groups with emphasis on lower limb muscles.

Abbreviations: RPE, the rating of perceived exertion; 1-RM, one-repetition maximum.

Table 3 Exercise Protocols Used in Previous Studies

No	Study (year)/Study Design	Exercise Protocols
		Frequency	Intensity and Duration	Type	Progression	Program Duration
1	Díaz-Vegas et al (2018)/ A randomized controlled trial.^Citation37	3 times a week	4 sets of 8 reps CRT: 1-second flexion and 5-second extension ERT: 5-second flexion and 1-second extension	Concentric and eccentric squat with a Russian belt assist	Not applicable	4 weeks
2	Campa et al (2020)/ A randomized controlled trial.^Citation38	The high group: 3 times a week on alternating days The low group: once a week	45 minutes, 4 sets of 8–12 reps, a 30-second contraction at 60–80% of 1-RM followed by 1-minute rest	7 exercises for lower limb, trunk, thorax, and shoulder muscles on the isotonic machines with 2-min rest between exercises	Increased intensity by 5% every 2 weeks	24 weeks including 2 weeks of familiarization initially
3	Hussein et al (2015)/ A randomized clinical trial.^Citation39	No data	60% of 1-RM, 2 sets of 8–12 reps for each machine	Knee extension, knee flexion, and chest press with RT machines	Intensity was adjusted to a new 1-RM achieved every 2 weeks	AE during the first 18 sessions and continued with RT for the next 18 sessions
4	Ghalavand et al (2014)/Quasi-experimental study.^Citation40	No data	In the first weeks, exercise at 30–40% of 1-RM, 3 sets of 15–20 reps. A 40–60-second and 3-5-minute rest between sets	Exercise for deltoid, thorax, trunk, biceps, triceps, and lower limb muscles with RT machines	Increased intensity gradually to achieve 60–70% of 1-RM in the last week. Decreased reps gradually to 8–10 as the intensity increased	8 weeks
5	Schroeder et al (2019)/A randomized controlled trial.^Citation17	3 times a week	Exercise to the point of exhaustion in each set, started with 2 sets of 18–20 maximal reps, 1–2 minutes rest between sets	12 exercises for upper and lower limb, thorax, and trunk muscles with RT machines	Progressed to 3 sets of 10–14 maximal reps, 1–2 minutes rest between sets	8 weeks
6	Salehi et al (2017)/ A randomized clinical trial.^Citation41	No data	20–25 minutes, started with 10 reps	Weight lifting for shoulder, elbow, and knee joints	Intensity (3–5%), reps, and sets were increased alternatingly in every session to achieve 3 sets	16 sessions
7	Tibana et al (2013)/ pre-post experimental.^Citation42	3 sessions a week on Monday, Tuesday, and Friday	3 sets of 8–12 maximum reps, 1-minute rest between exercises and sets	Exercise with an RT machine for the thorax, upper-lower limbs, and trunk muscles with different exercise sequences and types for each session (Monday, Tuesday, and Friday regiments)	Intensity was adjusted to a new 1-RM achieved in every session	10 weeks including 2 weeks of familiarization initially

Abbreviations: Reps, repetitions; CRT, concentric resistance training; ERT, eccentric resistance training; 1-RM, one-repetition maximum; RT, resistance training.

Table 4 Studies Related to the Effect of Resistance Training on Cardiovascular Risk Factors

No	Study (Year)/ Study Design	Objectives	Participants	Outcome Measures	Result
1	Díaz-Vegas et al (2018)/ A randomized controlled trial.^Citation37	To evaluate the effect of CRT and ERT on BP, BMI, central obesity, peak VO2, and the prevalence of R and NR in exercise	Male with overweight or obesity (n: s22)	MBP, SBP, and DBP RPP which is a product of HR × SBP divided by one hundred BMI WC Peak VO2 Prevalence of R and NR to exercise	CRT WC significantly decreased by −5.5% (from 111.1 ± 4.30 to 109.4 ± 4.69 cm) No significant effect of CRT on BMI SBP significantly decrease by 2.1% (from 119.7 ± 6.41 to 117 ± 5.32 mm Hg) DBP or MBP were not change RPP diminished from 95.9 ± 12.76 to 91.6 ± 10.03 Peak VO2 increased by 3.5% (from 29.5 ± 2.01 to 30.5 ± 1.43 mL/kg/min) NR prevalence was 20% ERT WC decreased significantly from 110.5 ± 4.69 to 104.4 ± 4.05 cm which corresponds to −2.5% (greater than CRT) SBP decreased significantly by 3.5% (from 121.2 ± 4.74 to 116.9 ± 5.18 mm Hg) DBP decreased but was not statistically significant MBP decreased by −3.7% (from 97.1 ± 5.35 to 93.4 ± 4.25 mm Hg) RPP diminished (from 100.1 ± 11.82 to 90.6 ± 10.41) Peak VO2 increased by 11.7% (from 28.6 ± 2.34 to 31.92 ± 2.31 mL/kg/min). Increased in peak VO2 was greater than CRT NR prevalence was 16.6% (lower than CRT)
2	Campa et al (2020)/ A randomized controlled trial.^Citation38	To evaluate the effect of RE three times (high frequency) and once a week (low frequency) on BC, HS, and cardiometabolic RF	Obese and overweight women (n: 45)	BC: weight, BMI, WC, FM HS: DHS, AHS, RHS BP: SBP, DBP Lipid profile: TC, LDL, HDL, and TG Insulin resistance: HbA1c, FBS, insulin, HOMAIR	Low frequency TG, HDL, and HbA1c were similarly changed (p<0.05) FBS reduced significantly by 2.6% Insulin was reduced significantly by 6.5% HOMAIR reduced significantly by 8.9% Weight, BMI, WC, and FM decreased by 4.9%, 4.9%, 4.7% and 5.3%, respectively (all values decreased significantly) Increased in strength values by 4.6%, 4.7%, and 10.2% for DHS, AHS, and RHS, respectively (only RHS changed significantly) High frequency TC, TG, LDL, and HbA1c were significantly decreased HDL was increased significantly FBS reduced significantly by 8.7% Insulin was reduced significantly by 16% HOMAIR reduced significantly by 23% Weight, BMI, WC, and FM decreased by 8.7%, 8.7%, 9.0% and 9.8%, respectively (all values decreased significantly) Strength values increased by 18.7%, 30.1%, and 19.8% for AHS, RHS, and DHS, respectively (all strength values changed significantly) SBP and DBP were not significantly changed in low-frequency and high frequency
3	Hussein et al (2015)/ A randomized clinical trial.^Citation39	To compare the coronary risk factors, body composition, MET, and muscle strength between CE group and AE in obese CAD patients	CAD patients (n: 50)	Lipid profiles include TC, TG, HDL, and LDL BP (SBP, DBP), HR, and RPP Body composition (body density, BMI, LBM, percent body fat MET 1-RM	Lipid profile TC, TG, and LDL decreased in the CE group only HDL significantly increased in both groups Greater reduction in TC in the CE group compared to the AE group Blood pressure Resting SBP, DBP, and RPP significantly decreased in both CE and AE groups Body composition Percent body fat reduced significantly by −18.8% in the CE group The lean mass increase by 5.7 kg in the CE group The decrease in percent of body fat and the increase in lean mass were greater in the CE group compared to the AE group MET increased significantly and was similar in both groups. Muscle strength Muscle strength increased in both CE and AE groups, but was not significant in the AE group Greater improvement in muscle strength in the CE group compared to the AE group (42–54% compared to 9–12%)
4	Ghalavand et al (2014)/Quasi-experimental study.^Citation40	To explore the effect of RE on glycaemic control, BP, and RHR compared to a non-exercising CG	Type 2 diabetes adult male (n: 20)	FBS HbA1c BP (SBP, DBP) RHR	After 8 weeks of RE: FBS decrease significantly (from 146.3 ± 35.3 to 124.2 ± 28.2; p=0.002) HbA1c decrease significantly (from 6.4 ± 0.7 to 5.8 ± 1.0; p=0.025) SBP decrease significantly (from 133.5 ± 8.8 to 126.9 ± 4.5; p=0.022) DBP and RHR not significantly decrease (from 86.5 ± 7.6 to 84.7 ± 4.5; p=0.239 and from 88.5 ± 4.2 to 86.2 ± 2.6; p=0.055, respectively) RE vs CG: FBS significantly different (from −22.1 ± 16.7 to +1.3 ± 13.1; p=0.003) HbA1c significantly different (from −0.6 ± 0.7 to −0.2 ± 0.2; p=0.031) SBP, DBP, and RHR are not significantly different
5	Schroeder et al (2019)/A randomized controlled trial.^Citation17	To compare the effect of AE, RE, and CE on CVD RF including BP, BC, CRF, MS, FBS, and lipid profile	Adults with elevated BP or hypertension without anti-hypertensive medications, overweight/obesity, and sedentary lifestyle (n: 69)	BP: peripheral blood pressure (SBP and DBP), central blood pressure (SBP and DBP), and RHR BC: weight, BMI, WC, FM, and LBM CRF: VO2max MS: lower body MS and upper body MS FBS Lipid profile: TC, TG, LDL, and HDL	AE only reduced body weight by −1 kg and FM by −0.9 kg and increased CRF by 7.7 mL/kg/min RE only reduced WC by −1.7 cm and increased lower body MS by 13 kg CE significantly reduced peripheral DBP by −4 mmHg and central DBP by −4 mmHg, LBM increased by 0.8 kg, CRF increased by 4.9 mL/kg/min, lower body MS and upper body MS increased by 11 kg and 4 kg respectively Neither AE nor RE alone showed significant reductions in BP The composite score of CVD RF shows a greater reduction with CE compared to CG
6	Salehi et al (2017)/ A randomized clinical trial.^Citation41	To investigate the effect of RE on lipid profile in patients with CAD compared to a non-exercising CG	CAD patients (n: 40)	TC, LDL, HDL, and TG	RE for 8 weeks decreased TC by −6,26±23,86, TG by −7,55±50,80, and LDL by −3,35±33,78 No significant differences in TC, LDL, HDL, and TG values after the intervention RE vs CG: No significant differences in TC, LDL, HDL, and TG values
7	Tibana et al (2013)/ pre-post experimental.^Citation42	To investigate the effects of 8 weeks of RT on biochemical and cardiovascular risk factors of metabolic syndrome, neuromuscular variables, and anthropometric in obese/overweight women.	Middle-aged obese/overweight women (n:14)	Muscle strength: frontal lat pull-down, chest press Isometric hand-grip strength Muscle thickness: biceps brachii and rectus femoris Anthropometric indexes: body adiposity index, BMI, visceral fat volume, and neck, waist, and hip circumferences Insulin HbA1c Blood glucose TG HDL-C	After 8 weeks RT: No significant differences in anthropometric indexes, insulin, HbA1c, blood glucose, TG, HDL-C, and biceps brachii muscle thickness Significant increase in muscle strength (chest press by 6.8 kg and front lateral pull-down by 6.1 kg), isometric left and right hand grip by 2.2 kg and 1.7 kg respectively, and rectus femoris muscle thickness by 2.8 mm. No significant differences in biceps brachii muscle thickness and total muscle mass

Abbreviations: 1-RM, one-repetition maximum; AE, aerobic exercise; AHS, absolute hand grip strength; BC, body composition; BMI, body mass index; BP, blood pressure; CAD, coronary artery disease; CE, combined resistance and aerobic exercise; CG, control group; CRF, cardiorespiratory fitness; CRT, concentric resistance training; CVD, cardiovascular disease; DBP, diastolic blood pressure; DHS, dominant hand grip strength; ERT, eccentric resistance training; FBS, fasting blood glucose; FM, fat mass; HbA1C, glycated haemoglobin; HDL, high-density lipoprotein; HOMA_IR, homeostasis model assessment for insulin resistance; HR, heart rate; HS, hand grip strength; LBM, lean body mass; LDL, low-density lipoprotein; MBP, mean blood pressure; MET, metabolic equivalent; MS, muscular strength; NR, non-responding; peak VO2, peak oxygen consumption; R, responding; RE, resistance exercise; RF, risk factor; RHR, resting heart rate; RHS, relative hand grip strength; RPP, rate-pressure product; SBP, systolic blood pressure; TC, total cholesterol; TG, triglyceride; WC, waist circumference.

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