Response to exercise training during cardiac rehabilitation differences by sex.

1. CENTRE FOR PHYSIOTHERAPY AND REHABILITATION SCIENCES
JAMIA MILLIA ISLAMIA
TOPIC –Response to exercise training during Cardiac Rehabilitation
differences by sex.
Presented by-
Purnima Kushwaha
MPT- 3rd semester (cardiopulmonary)
Roll no. 18MPC003

2. Introduction
• Cardiac rehabilitation (CR) has been shown to reduce mortality and
morbidity and improve quality of life, exercise capacity, and physical
function.( Ades PA, 2001; Leon et al., 2005; Piepoli et al., 2014)
• Based on the complex determinants for exercise response, exercise
prescription should ideally evolve towards a more individualised and
specifically tailored approach, taking sex, clinical condition and
characteristics into account.
• The growing awareness of sex differences in cardiovascular diseases also
led to the observation that despite the higher mortality and complication
risk after an acute coronary syndrome, women are less frequently enrolled
in exercise-based CR, and if enrolled show a lower adherence.(Samayoa et
al., 2014; Chernomordik et al., 2017; Minges et al., 2017)

3. Overview of physiological differences in women and men that
determine their various responses to exercise training

5. Exercise based CR in Heart failure
• Unfortunately, women are underrepresented in exercise-based CR trials in
HF. Women included in the HF-ACTION trial (28%) had a lower baseline
VO2peak (13.4 ml/kg/min, Q1 10.8, Q3 16.3) compared to men (14.9
ml/kg/min, Q1 11.9, Q3 18.2), but both sexes significantly increased their
VO2peak after 3 months of endurance training (mean change0.77+2.7
ml/kg/min in men, 0.88+2.2 ml/kg/min in women). Interestingly, all-cause
mortality and hospitalisation significantly decreased in women (hazards
ratio (HR) 0.74, 95% confidence interval (CI) 0.59–0.92), but not in men
(HR 0.99, 95% CI 0.86–1.13),(Pina et al., 2014) and this even despite the
lower training adherence in women.
• This is in contrast to Keteyian and colleagues 111 who examined 10 men
and five women with HFrEF who completed a 14–24-week aerobic ET
programme (at least 40 minutes, three sessions per week). Here, baseline
VO2peak was not significantly different between the sexes
(16.9ml/kg/min+1.1 in men vs. 15.2+1.1 in women), but they found a 20%
increase in VO2peak in men versus only 2% in women, with similar
adherence to the prescribed training regime.

6. Exercise based CR in CAD
• Little research has been undertaken on the effect of sex on responses to
ET in individuals with CAD, and again women are understudied in ET trials
in CAD. Moreover, women are mostly older and present with more severe
CAD and more cardiovascular risk factors than men,(Anjo et al., 2014)
therefore making the direct comparison of responses difficult.
• In a recent retrospective cohort study in 772 CAD patients, no significant
differences in VO2peak between women and men of the aerobic interval
training group at baseline were shown (24.8+9.2 ml/kg/min vs.
24.8+7.7ml/kg/min, respectively). However, after 6 months aerobic
interval training,a significantly higher VO2peak in men was observed
(33.3+7.9 ml/kg/min vs. 31.0+4.8 ml/kg/min in women), which might be
attributed to sex differences in adherence.
• Following CR in CAD patients, a higher decrease in fasting blood glucose in
women was shown, whereas equal improvements in haemoglobin A1c
and BMI were observed.

7. • Differences in the effect of CR on lipid metabolism have been shown. One
study showed similar improvements in all lipid parameters, in contrast to
another study in which women experienced greater high-density
lipoprotein cholesterol improvements than men, despite similar changes
in BMI, waist and other lipid parameters.
• Furthermore, an equal improvement in New York Heart Association
(NYHA) class,functional capacity (expressed as metabolic equivalents),
resting heart rate, heart rate recovery and mean brain natriuretic peptide
(BNP) in both sexes, and a higher change in functional parameters of daily
living (Barthel index) and 6-minute walking test in women were
observed.(Feola et al., 2015) However, a greater NT-proBNP improvement
in women has also been observed.(Anjo et al., 2014)

8. Sex dependent barriers to ET
• The most common barriers for exercise in patients with HF, which can be
categorised in socioeconomic factors, factors related to the healthcare
team/system, patient-related factors, condition related factors and
therapy-related factors. These are reasons for both lower participation
rates, lower adherence and higher drop-out.
• Important socioeconomic factors for exercise adherence and drop-out
among women include family responsibilities or less time to spend on
exercise compared to men, probably because of women’s combined
commitments to family, work and community activities. Financial factors
constituting barriers included lower socioeconomic state and no
reimbursement for participation and transportation.

9. • Factors that are related to the healthcare team/ system include less
determined treatment of women and consequently lack of referral of
women to CR,(Barth et al., 2009) delays in diagnosis and treatment or
undertreatment limited availability of rehabilitation programmes or
exercise facilities, contradictory information provided by healthcare co-
workers and low awareness of the disease.
• Patient-related factors for lower adherence are diverse and include older
age, lower level of education, minority status, anxiety, depression and
lower selfesteem, experiencing CR as tiring or painful and other (non-
cardiac) comorbidities such as osteoporosis, urinary incontinence,
diabetes, obesity or lower skeletal muscle strength.
• Furthermore, among the factors that account for non-attendance or non-
referral exclusively in women are pregnancy and the belief that the
menstrual cycle has a negative impact on ET and performance.

11. References
1. Ades PA. (2001) Cardiac rehabilitation and secondary prevention of
coronary heart disease. N Engl J Med. ;345:892-902.
2. Anjo D, Santos M, Rodrigues P, et al. (2014) The benefits of cardiac rehabilitation
in coronary heart disease: a gender issue? Rev Port Cardiol (English Ed) ; 33: 79–
87.
3. Barth J, Volz A, Schmid J-P, et al. (2009) Gender differences in cardiac
rehabilitation outcomes: do women benefit equally in psychological health? J
Women’s Health ; 18: 1–9.
4. Chernomordik F, Sabbag A, Tzur B, et al. (2017) Cardiac rehabilitation
following an acute coronary syndrome: trends in referral, predictors and
mortality outcome in a multicenter national registry between years
2006–2013: report from the Working Group on Cardiac Rehabilitation,
the Israeli Heart Societ. Eur J Prev Cardiol ; 24: 123–132.
5. Feola M, Garnero S, Daniele B, et al. (2015) Gender differences in the efficacy of
cardiovascular rehabilitation in patients after cardiac surgery procedures. J
Geriatr Cardiol ; 12: 575–579.
6. Leon AS, Franklin BA, Costa F, et al. (2005) Cardiac rehabilitation and secondary
prevention of coronary heart disease. Circulation. ;111:369-376.

12. 7. Minges KE, Strait KM, Owen N, et al. (2017) Gender differences in
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Preventive Cardiology 0(00) infarction in adults: a prospective,
observational study. Eur J Prev Cardiol ; 24: 192–203.
8. Pina IL, Bittner V, Clare RM, et al. (2014) Effects of exercise training on
outcomes in women with heart failure: analysis of HF-ACTION (Heart
Failure – A controlled Trial Investigating Outcomes of Exercise TraiNing)
by sex. JACC Heart Fail ; 2: 180–186.
9. Piepoli MF, Corra U, Adamopoulos S, et al. (2014) Secondary prevention
in the clinical management of patients with cardiovascular diseases.
Core components, standards and outcome measures for referral and
delivery: a policy statement from the cardiac rehabilitation section of the
European Association for Cardiovascular Prevention & Rehabilitation.
Endorsed by the Committee for Practice Guidelines of the European
Society of Cardiology. Eur J Prev Cardiol. ;21(6):664‐681.
10. Samayoa L, Grace SL, Gravely S, et al. (2014) Sex differences in cardiac
rehabilitation enrollment: a meta-analysis. Can J Cardiol ; 30: 793–800.

14. THANK YOU