Background-More than 80% of patients entering cardiac rehabilitation (CR) are overweight, and Ͼ50% have metabolic syndrome. Current CR exercise protocols result in little weight loss and minimal changes in cardiac risk factors. We sought to design an exercise protocol that would lead to greater weight loss and risk factor change. Methods and Results-We performed a randomized controlled clinical trial to evaluate the effect of high-calorieexpenditure exercise (3000-to 3500-kcal/wk exercise-related energy expenditure) compared with standard CR exercise (7 to 800 kcal/wk) on weight loss and risk factors in 74 overweight patients with coronary heart disease. Both groups were counseled for weight loss and taking evidence-based preventive medications.

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CR participants are now older, more frequently present with features of the metabolic syndrome, and are relatively less fit. However, a 3-fold increase in statin use over 10 years has contributed to a marked improvement of lipid parameters.