Background Exercise training is a key component of cardiac rehabilitation but there is a discrepancy between the high volume of exercise prescribed in trials comprising the evidence base and the lower volume prescribed to UK patients. Objective To quantify prescribed exercise volume and changes in cardiorespiratory fitness in UK cardiac rehabilitation patients. Methods We accessed n=950 patients who completed cardiac rehabilitation at four UK centres and extracted clinical data and details of cardiorespiratory fitness testing pre-and post-rehabilitation. We calculated mean and effect size (d) for change in fitness at each centre and converted values to metabolic equivalent (METs). We calculated a fixed-effects estimate of change in fitness expressed as METs and d. Results Patients completed 6 to 16 (median 8) supervised exercise sessions. Effect sizes for changes in fitness were d=0.34-0.99 in test-specific raw units and d=0.34-0.96 expressed as METs. The pooled fixed effect estimate for change in fitness was 0.52 METs (95% CI 0.51 to 0.53); or an effect size of d=0.59 (95% CI 0.58 to 0.60). Conclusion Gains in fitness varied by centre and fitness assessment protocol but the overall increase in fitness (0.52 METs) was only a third the mean estimate reported in a recent systematic review (1.55 METs). The starkest difference in clinical practice in the UK centres we sampled and the trials which comprise the evidencebase for cardiac rehabilitation was the small volume of exercise completed by UK patients. The exercise training volume prescribed was also only a third that reported in most international studies. If representative of UK services, these low training volumes and small increases in cardiorespiratory fitness may partially explain the reported inefficacy of UK cardiac rehabilitation to reduce patient mortality and morbidity.

The incremental shuttle walk test (ISWT) is used to assess functional capacity of patients entering cardiac rehabilitation. Factors such as age and sex account for a proportion of the variance in test performance in healthy individuals but there are no reference values for patients with cardiovascular disease. The aim of this study was to produce reference values for the ISWT. Participants were n = 548 patients referred to outpatient cardiac rehabilitation who underwent a clinical examination and performed the ISWT. We used regression to identify predictors of performance and produced centile values using the generalised additive model for location, scale and shape model. Men walked significantly further than women (395 ± 165 vs. 269 ± 118 m; t = 9.5, P < 0.001) so data were analysed separately by sex. Age (years) was the strongest predictor of performance in men (β = -5.9; 95% CI: -7.1 to -4.6 m) and women (β = -4.8; 95% CI: -6.3 to 3.3). Centile curves demonstrated a broadly linear decrease in expected ISWT values in males (25-85 years) and a more curvilinear trend in females. Patients entering cardiac rehabilitation present with highly heterogeneous ISWT values. Much of the variance in performance can be explained by patients' age and sex. Comparing absolute values with age-and sex-specific reference values may aid interpretation of ISWT performance during initial patient assessment at entry to cardiac rehabilitation.

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ObjectiveTo determine if the metabolic cost of the incremental shuttle-walking test protocol is the same as treadmill walking or predicted values of walking-speed equations.SettingPrimary care (community-based cardiac rehabilitation).ParticipantsEight Caucasian cardiac rehabilitation patients (7 males) with a mean age of 67±5.2 years.Primary and secondary outcome measuresOxygen consumption, metabolic power and energy cost of walking during treadmill and shuttle walking performed in a balanced order with 1 week between trials.ResultsAverage overall energy cost per metre was higher during treadmill walking (3.22±0.55 J kg/m) than during shuttle walking (3.00±0.41 J kg/m). There were significant post hoc effects at 0.67 m/s (p<0.004) and 0.84 m/s (p<0.001), where the energy cost of treadmill walking was significantly higher than that of shuttle walking. This pattern was reversed at walking speeds 1.52 m/s (p<0.042) and 1.69 m/s (p<0.007) where shuttle walking had a greater energy cost per metre than treadmill walking. At all walking speeds, the energy cost of shuttle walking was higher than that predicted using the American College of Sports Medicine walking equations.ConclusionsThe energetic demands of shuttle walking were fundamentally different from those of treadmill walking and should not be directly compared. We warn against estimating the metabolic cost of the incremental shuttle-walking test using the current walking-speed equations.

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