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Mayo Clin Proc. Author manuscript; available in PMC 2020 September 01.
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Published in final edited form as:

Mayo Clin Proc. 2019 September ; 94(9): 1718–1730. doi:10.1016/j.mayocp.2019.04.033.

High-Intensity Interval Training in Cardiac Rehabilitation: Impact

on Fat Mass in Myocardial Infarction Patients
Yaoshan Dun, MD, PhD1,2, Randal J. Thomas, MD, MS2, Jose R. Medina-Inojosa, MD, M.Sc2,
Ray W. Squires, PhD2, Hsuhang Huang, MD, MS2, Joshua R. Smith, PhD2, Suixin Liu, MD,
PhD1, Thomas P. Olson, PhD., MS2
1Divisionof Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya
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Hospital Central South University, Changsha, Hunan, CHN

2Division
of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic,
Rochester, MN, USA

Abstract
Objective: To examine the effect of High-intensity interval training (HIIT) on body fat mass and
distribution in cardiac rehabilitation (CR) patients with myocardial infarction (MI).

Patients and Methods: We retrospectively screened 391 consecutive MI patients enrolled in

CR between September 1st, 2015 and February 28th, 2018. We included 120 patients who
completed 36 CR sessions and pre-post dual-energy X-ray absorptiometry (DXA); ninety engaged
in HIIT and 30 engaged in moderate-intensity continuous training (MICT). HIIT included 4–8
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alternating intervals of high- (30–60 seconds at RPE 15–17 [Borg 6–20]) and low-intensity (1–5
min at RPE <14), and MICT performed 20–45 min of exercise at RPE 12–14. Body weight, fat
mass, and lean mass were measured via DXA with lipid profile measured via clinical procedures.

Results: HIIT and MICT groups were similar age (67 vs. 67 yrs), sex (27% vs. 27%) and BMI
(30.3 vs.29.5 kg/m2) at baseline. HIIT group demonstrated greater reductions in body fat
percentage (−2.3±1.8 vs. −0.4±2.0 %, P<.001), fat mass (−2.5±2.2 vs. −0.5±2.0 kg, P<.001),
abdominal fat percentage (−3.3±3.2 vs. −0.1±3.2 %, P<.001), and waist circumference (−3±5 vs.
−0±5 cm, P=.01). HIIT group demonstrated greater reductions in total cholesterol (P=.002), low-
density lipoproteins (P<.001), and triglycerides (P=.006). Improvements in total body mass and
BMI were not different across groups. After matching exercise duration, intensity, and energy
expenditure; HIIT induced improvements in total fat mass (P=.02), body fat percentage (P=.01)
and abdominal fat percentage persisted (P=.02).
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Corresponding Authors: Thomas P. Olson, Mayo Clinic, Department of Cardiovascular Medicine, 200 First Street SW, Rochester,
MN 55905, USA; Telephone number, 507-990-9501; Fax number, 507-255-4861; [email protected], Suixin Liu, Xiangya
Hospital Central South University, Division of Cardiac Rehabilitation, 87 Xiangya Road, Changsha, Hunan, P.R. China; Telephone
number, +86 (731) 84327179; [email protected].
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 Dun et al. Page 2

Conclusion: Our data suggest supervised HIIT results in significant reductions in total fat mass
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and abdominal fat percentage, and improved lipid profile in CR patients with MI.

INTRODUCTION
Each year more than 7 million people experience acute myocardial infarction (MI)
worldwide1, and with more effective treatment, substantial reductions in mortality have been
reported in recent decades.1,2 Despite consistent improvements in mortality following first
MI, among patients who do survive a MI, 20% suffer a second cardiovascular event in the
first year and ~50% present with major coronary events when having previously been
discharged from the hospital following diagnosis with MI.3

Increasing evidence suggest that body fat and abdominal fat percentage are independent risk
factors for long-term cardiovascular events and mortality in patients with4 and those without
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coronary heart disease (CHD),5 and may be better predictors than body weight and BMI.6,7
For example, in patients with established CHD who are in the highest quartile of body fat
percentage, the risk of cardiovascular events is double when compared with those in the
lowest quartile.4 Exercise training is considered an adjunctive therapy in patients with MI
based on current guidelines.8 However, there remains no universal agreement on the most
effective exercise prescription to improve body composition and fat distribution for patients
with CHD. Traditional moderate-intensity continuous training (MICT) is generally used to
halt weight gain for individuals who are overweight or obese,9 and has demonstrated sex-
based differences in substrate metabolism during MICT, women have a larger depot of
intramyocellular lipid available to support MICT fuel needs, suggestive of a greater capacity
to use intramyocellular lipid.10 Recent studies have demonstrated that high-intensity interval
training (HIIT) may be more effective at reducing subcutaneous and abdominal body fat,
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11–14 increasing cardiopulmonary fitness, and improving insulin resistance15 than MICT in

apparently healthy overweight or obese individuals.11–15 There is a paucity of research

which examines the sex-based difference in effects of HIIT on body composition. Townsend
et al. reported that the total post-exercise oxygen consumption, a key mechanism of exercise
reducing body fat, was not significantly different between men and women,16 which suggest
that HIIT may be able to elicit same health benefit to both men and women.

The purpose of this study was to quantify the efficacy of HIIT on body composition and
adipose distribution in patients undergoing CR after MI. We hypothesized that HIIT will be
associated with greater improvements in total body fat and abdominal adipose tissue for
patients with MI compared to MICT.

METHODS
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Study Design and Participants

This study was a retrospective cohort review of consecutive patients enrolled in cardiac
rehabilitation after MI at Mayo Clinic, Rochester, MN, between September 1st, 2015 and
February 28th, 2018. A total of 391 consecutive MI patients enrolled in early outpatient
(phase II) cardiac rehabilitation (CR) were retrospectively screened. We included all 120
patients who completed all 36 prescribed CR sessions and underwent both pre and post dual-

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energy X-ray absorptiometry (DXA). Of the 120 patients, 90 engaged in HIIT with 30
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MICT. All aspects of this study conformed to the principles outlined in the Declaration of
Helsinki and were approved by the Mayo Clinic Institutional Review Board. All participants
agreed to the use of their medical records for research purposes.

HIIT and MICT Protocols

Supervised exercise training was performed on a treadmill, cycle ergometer or recumbent
stepper on average three times per week at the Mayo Clinic CR center. Three days of self-
guided home based exercise when not at the CR center was also recommended. All patients
performed MICT during the first week of CR, after which, if patients were able to exercise
for ≥ 20 minutes at a rating of perceived exertion (RPE: Borg 6–20) of 12–14, they chose to
continue MICT or transition to HIIT. Patients were excluded if they presented with impaired
cognition, language barriers, angina at low workload and musculoskeletal limitations
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including injuries, frailty, and weakness. The HIIT sessions included brief, intermittent bouts
of high intensity exercise, interspersed with periods of low intensity exercise (active
recovery). Since the majority of patients are prescribed rate modulating pharmacotherapy
after MI, the intensity of HIIT in the present study was prescribed using RPE in an effort to
maximize generalizability and ensure real-world applicability. These patients began with 4
high intensity intervals of 30–60 seconds at a RPE of 15–17 interspersed with 1–5 minutes
of low intensity intervals at a RPE<14, and progressed to 5–8 high intensity intervals of 2–4
minutes at RPE 15–17 during 20–45 minutes of training. The exercise training modality was
intentionally patient selected to maximize adherence to the protocol. HIIT was performed
only during supervised sessions with the frequency not to exceed 3 days per week (non-
consecutive days). MICT was performed for 20–45 min at a RPE of 12–14. Exercise
intensity and duration of every session of HIIT and MCIT were documented. For all
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patients, sessions included a 5–10 minute warm-up and cool-down at an RPE<12. Heart rate
(HR) and rhythm was continuously monitored via a Q-Tel tele-monitoring system (Welch
Allyn, USA) during the training sessions with blood pressure (systolic [SBP] and diastolic
[DBP]) measured by manual sphygmomanometry at rest, after the second or third interval
(in the HIIT group) or after 15 minutes (in the MICT group), and at the end of each exercise
training session. Metabolic equivalent (MET) was calculated according to American College
of Sports Medicine (ACSM)’ metabolic calculation equations.17 Energy expenditure (EE)
was calculated according to the physical activity calculation equation from the ACSM
guidelines, Kcal· min−1 = [(METs × 3.5 mL· kg−1· min−1 × body weight in kg) ÷1,000] ×
518.

Anthropometric Measurement
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Body composition was measured using DXA scans (Lunar iDXA Series X, Madison, WI,
USA). Scans were performed by trained radiology technicians using standardized
procedures recommended by GE-Healthcare as described previously.19 The DXA scans
were performed within one week prior to the start and within one week after the completion
of 36 CR sessions. These scans were used to measure total body mass, body fat percentage,
body fat mass, total body lean mass, and abdominal region fat percentage (defined as the
area between the ribs and the pelvis by GE-Healthcare systems). Percentages of total were
calculated accordingly. The scanner was calibrated daily against a standard calibration block

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supplied by the manufacturer to control for possible baseline drift. Height was measured
using a stadiometer. Body mass index (kg/m2) was calculated using the formula: body
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weight (kg)/height (m)2. Waist and hip circumference were manually measured according to
standard procedures of ACSM guidelines.18

Lipid Profile
Total cholesterol, high-density lipoprotein cholesterol (HDL-c) and triglycerides were
measured within one week prior to the start and within one week after the completion of 36
sessions of CR. Low-density lipoprotein cholesterol (LDL-c) was estimated using the
Friedewald equation as described previously.20 Non-HDL cholesterol (Non-HDL-c) was
calculated as total cholesterol minus HDL cholesterol. Blood samples were analyzed and
reported to the medical record using standard clinical procedures of Mayo Clinic.
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Dietary Assessment
Diet was assessed using the Rate-Your-Plate (RYP) questionnaire developed by Gans et al.21
in the late 1980s (periodically updated thereafter) and is recommended as a tool to assess
patient’s dietary quality by the American Association of Cardiovascular and Pulmonary
Rehabilitation. The RYP tool consists of 24 questions, each response corresponding with a
point value for the total RYP score. Total scores range from 24 to 72, with higher scores
indicating better diet quality.21 The RYP tool has been validated and shown to have a strong
relationship with body adiposity with higher RYP diet quality scores being associated with
lower measures of body adiposity.22 All patients performed an interviewer‐administered
RYP survey during the first and last CR session.

Statin Therapy Intensity Assessment

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Statin therapy intensity was assessed within one week prior to the start and within one week
after the completion of 36 sessions of CR. Statin therapy intensities were stratified in high-,
moderate-, and low-intensity using ACC/AHA guidelines on the treatment of blood
cholesterol as described previously.23 Statin intensity therapy is defined as a pseudo
continuous variables, 3 = high intensity, 2 = moderate intensity, 1 = low intensity, and 0 =
none.

Exercise Capacity
Exercise capacity was routinely assessed at the start of CR via using exercise stress test,
cardiopulmonary exercise test (CPET) or 6 minute walk test (6 MWT) appropriately. The
present study collected the patients’ maximal oxygen consumed (VO2peak) data that was
determined by CPET to assess patients’ exercise capacity.
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Depressive Symptoms Assessment

Depressive symptoms were evaluated using the Patient Health Questionnaire (PHQ-9) over
the course of 36 sessions of CR as prescribed previously.24

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Statistical Analysis
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Baseline data are presented as frequency and percentage for categorical variables and
compared across groups using Pearson chi-square test or Fisher exact test. Continuous data
are presented as mean and standard deviation and compared across groups using two-sample
t-test or non-parametric Wilcoxon rank-sum test, as appropriate depending on distribution.
Changes from baseline to 36 sessions of CR are summarized using mean and standard
deviation and compared within group using paired t-test. Normality was evaluated and
changes looked approximately normally distributed. In order to compare change in each
parameter of interest across groups, analysis of covariance (ANCOVA) was used. In this
analysis, change was modelled as the outcome in a linear regression model and group effects
were tested with adjustment for the baseline value of the parameter being tested. These
analyses were repeated in a matched subset of each group to control for potential differences
in exercise duration, exercise intensity, and exercise energy expenditure. In order to assess
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differences over time across groups, a repeated measures analysis of variance (ANOVA) was
used. In this analysis, measurements at each week were used the interaction of time and
group was tested to examine differences in effects over time across group. Energy
expenditure and METs was log transformed in these analyses to approximate normality prior
to analysis. Means and confidence intervals were back-transformed to the original scale for
presentation. Comparisons at each week used the method of Scheffe to adjust p-values for
multiple comparisons. SAS version 9.4 (Cary, NC) was used for analyses and Two-sided p-
values ≤ .05 were considered to be statistically significant.

RESULTS
Study Participants
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Baseline characteristic were not different for MICT and HIIT groups, although three
medications were not well balanced across groups: antiplatelet drugs, diuretics, and Digoxin
(Table 1). Mean age (67±16 vs. 67±12 y, P=.84), body weight (86.6±3.0 vs. 87.5±1.7, kg,
P=.80), and BMI (30.3±4.5 vs. 29.5±4.8, kg/m2, P=.42) were not different across groups at
baseline. Only 27% of the patients were women in both groups. Percentage of participants
who underwent PCI (47% vs. 43%, P=.75) and CABG (30% vs. 19%, P=.20) was not
significantly different across MICT and HIIT groups. The number of days between patients’
MI event and beginning of CR was also not significantly different across MICT and HIIT
groups (14±6 vs. 14±10, days, P =.15).

Resting Heart Rate and Blood Pressures

Prior to exercise training, there were no differences across groups at rest for HR (P=.05),
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SBP (P=.65), or DBP (P=.88). After 36 sessions of CR, the HIIT group demonstrated a
significant lower resting HR (P=.003) whereas the MICT group had no change in resting
HR. Patients both in MICT and HIIT groups demonstrated significantly lower DBP (P=.02,
P<.001), but not in SBP after CR (Table 2).

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Training Intensity and Energy Expenditure during 36 sessions of Cardiac Rehabilitation

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The HIIT group demonstrated significantly higher average HR, average exercise intensity,
longer duration of exercise, and higher energy expenditure at each time point compared to
MICT group (P<.05) with the exception of the average exercise intensity at the 12-weeks
(P=.10). There were no differences in average HR (P=.98), duration of exercise (P=.99) and
energy expenditure per session (P=.43) across groups over time. Evidence of a difference
across groups in average exercise intensity was noted (P=.04) (Figure 1).

Dietary Quality
The RYP scores were not different across MICT and HIIT groups at baseline (P=.06).
Changes were different across groups after the completion of 36 CR sessions (P=.02).

Exercise Capacity and Depressive Symptoms

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There were 26 (87%) patients in MICT group and 74 (82%) patients in HIIT performed
CPET at the start of CR. There were no differences for VO2peak across groups (P = .90).
The PHQ-9 scores were significant different from baseline to the completion of 36 CR
sessions in HIIT group (P < .001), not different in MICT group (P=.07). Change were not
different across groups after the completion of 36 CR sessions (P=.24).

Statin Therapy Intensity Assessment

The average statin therapy intensities were not different from baseline to the completion of
36 CR sessions within each MICT (P=.65) and HIIT (P=.40). Changes were different across
groups after the completion of 36 CR sessions (P=.75)

Anthropometric Outcomes
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Body weight (P<.001), BMI (P<.001), body fat percentage (P<.001), fat mass (P<.001),
abdominal fat percentage (P<.001), waist circumference (P<.001), hip circumference (P=.
007) and waist/hip circumference ratio (P=.03) showed a significant decrease, with an
increase in lean mass from baseline to completion of CR in the HIIT group (P<.001) (Table
2). Patients in MICT demonstrated no significant difference from baseline to completion of
CR in body weight, BMI, body fat percentage, fat mass, lean mass, abdominal fat
percentage, waist circumference, hip circumference and waist/hip ratio. The changes in body
weight, BMI, lean mass, hip circumference, and W/H ratio were no significant across MICT
and HIIT groups (P>.05). However, patients in the HIIT group demonstrated greater
reductions in body fat percentage (P<.001), total fat mass (P<.001) and abdominal fat
percentage (P<.001), waist circumference (P=.01). (Table 2 and Figure 2)
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Lipid Profile
The HIIT group demonstrated a significant decrease in total cholesterol (P<.001), low-
density cholesterol (P<.001), triglycerides (P<.001), and Non-HDL-c (P<.001), with
increased high-density cholesterol from baseline to completion of the CR program (P=.02).
Patients in MICT had no significant changes in the lipid values. Compared to the MICT
group, the HIIT group showed significantly greater decreases in total cholesterol (P=.002),

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low-density cholesterol (P<.001), triglycerides (P=.006), and Non-HDL-c (P<.001). (Table

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2)

Sub-Group Analysis
Due to differences in total exercise duration, exercise intensity, and energy expenditure per
session over the course of the CR intervention we selectively matched a group of HIIT and
MICT participants based specifically on these metrics. After matching, the HIIT group
continued to demonstrate a significantly greater reduction in total body fat mass (P=.02),
body fat percentage (P=.01) and abdominal fat percentage (P=.02), as well as in total
cholesterol (P=.04), low-density cholesterol (P=.04) and Non-HDL-c (P=.03) compared to
MICT, with a significant difference in Rate-Your-Plate scores across groups (P=.02) as well
as no difference in statin therapy intensity within each group from baseline to the completion
of 36 CR sessions (P=.46) (Table 3).
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DISCUSSION
This study evaluated the impact of HIIT on body composition and adiposity in MI patients
enrolled in early outpatient CR. The present study has, for the first time, demonstrated that
HIIT can reduce total body, abdominal fat and waist circumference in patients with MI, to a
greater extent than MICT.

Overweight and obesity have become increasingly common worldwide, with overweight and
obesity defined conventionally as having a BMI of >25 kg/m2 and >30 kg/m2, respectively.
Overweight and obesity are associated with increased likelihood of developing
cardiovascular disease and all-cause mortality.25,26 In contrast to the general population,
patients with CHD demonstrate an inverse relationship between BMI and mortality, which
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has been termed the obesity paradox.27 However, it is now apparent that the obesity paradox
is more specifically related to the preservation of lean muscle mass as there is no apparent
paradox either in the general population28 or patients with CHD4 when measuring body fat
percentage in place of BMI. Body fat mass and percentage are associated with a higher risk
of cardiovascular events and all-cause mortality,4,28 whereas higher amounts of fat-free mass
is related to a lower risk of cardiovascular events.4 Body fat percentage is considered to be a
more powerful predictor of cardiovascular disease risk than body weight and BMI.6,7
Several other studies have examined the efficacy of HIIT on reducing subcutaneous and
abdominal fat in overweight adolescents,29 young women30 and type 2 diabetic men.31 For
example, Trapp et al. compared HIIT and MICT and found that individuals in the HIIT
group showed greater decreases in subcutaneous fat.30 In contrast, Haifeng Zhang et al.14
demonstrated both MICT and HIIT significantly reduced total and abdominal fat mass in
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young female university students (age, 18–22), but with no differences across groups. The
difference of outcomes between Haifeng’s study and the present study were likely due to
differences in participant characteristics, including age (22 vs. 67 yrs), medical history
(health university student vs. patients with MI), and sex (all women vs. combination of
women and men). Combined, these data suggest that HIIT has a greater impact on reducing
fat mass in patients with MI compared to MICT.

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The effect of exercise on reducing body fat is influenced by both energy intake and
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expenditure. The present study initially found that both MICT and HIIT significantly
improved RYP scores (dietary quality), and HIIT induced more energy expenditure (EE)
during exercise compared with MICT in patients with MI. However, after matching groups
for exercise EE, exercise duration, and exercise intensity the HIIT group continued to
demonstrate a significantly greater reduction in body fat and abdominal fat percentage, and
in total cholesterol, low-density cholesterol compared to MICT, with no difference in RYP
scores across groups as well as no difference in statin therapy intensity within each group
from baseline to the completion of 36 CR sessions (Table 3).

Mechanisms underlying the HIIT-induced effect on fat loss remain unclear. These findings
may be related to exercise induced alterations in mitochondrial function, allowing for greater
utilization of adipose tissue as a fuel source. For example, we have previously demonstrated
that 4-week aerobic exercise can enhance skeletal muscle and myocardium mitochondrial
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biogenesis and function in male mice.32 Motta et al. also showed that HIIT ameliorated the
fructose-induced metabolic dysfunction in male mice through affecting markers of
mitochondrial biogenesis and β-oxidation, irisin and peroxisome proliferator-activated
receptor gamma coactivator 1-alpha (PGC1 α), in liver, white adipose tissue and skeletal
muscle.33 Moreover, several more recent trials have demonstrated that 3–12 weeks HIIT can
significantly increase resting metabolic rate,34 post-exercise oxygen consumption in healthy
adults,35 and fat oxidation in obese adolescents.36 On the basis of our findings and previous
studies, future work is needed to examine the effects of HIIT on mitochondrial function and
its relationship with resting metabolic rate and post-exercise oxygen consumption in patients
with MI.

Improvements in lipid profile have been shown after exercise training in overweight or obese
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individuals.37–39 The present study demonstrated a significant improvement in the lipid

profile for patients in the HIIT group, but not in the MICT group while the statin therapy
intensities were not different from baseline to the completion of 36 CR sessions within each
MICT and HIIT group. It has recently been reported that HIIT has also shown a lower
plasma triglyceride concentrations to a greater extent than MICT in young males.40 These
finding are clinically significant because the majority of patients with MI have dyslipidemia
and are administered lipid lowering pharmacotherapy as is consistent in the present study. It
is important to note that several studies have demonstrated favorable effects on the lipid
profile only in individuals who are overweight or obese,37,38 but not in normal weight
individuals. The underlying mechanism(s) responsible for the impact of HIIT on the lipid
profile remain unclear; however, our results indicate that HIIT should be considered as an
important adjunct treatment strategy to improve dyslipidemia in patients with MI, especially
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for those who are overweight or obese.

A variety of HIIT protocols have been developed and used for CHD patients,41–43 which
vary in intensity, high intensity interval duration, low intensity interval (recovery) duration,
and number of intervals. Further, the exercise intensity is generally prescribed using a
percent of maximal oxygen consumption, percent of maximal heart rate, percent of maximal
power, or RPE (Borg scale).41,42 Buchheit et al.44 and Levinger et al.45 demonstrated that
the RPE has shown a great correlation with HR, ventilation, and VO2 in individuals with and

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without CAD, and the correlation is not impacted by beta blocker medication, a commonly
used HR modulating medication by patients with MI.45 Therefore, the present study used
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patient perception of effort via the RPE scale to prescribe the intensity of the stimulus and
recovery periods with accompanying HR monitoring in attempting to solve the limit that HR
of patients with MI who are prescribed HR modulating pharmacotherapy is not greatly
associated with exercise intensity. Utilizing combination of RPE and HR as a guide for
prescribing exercise intensity may be more appropriate than HR or maximal oxygen
consumption alone. Further, this strategy may be more generalizable and ensure real-world
applicability since many patients may not be able to reliably monitor HR when undergoing
exercise outside the conventional CR setting.

Compared to MICT, increasing research suggests that HIIT has the capacity to induce
changes in numerous physiological and health related markers,46 including greater
improvement in cardiopulmonary fitness,47,48 quality of life48,49 and skeletal muscle
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myopathy50 in CHD patients. However, there are controversial concerns regarding the
potential for increased adverse events in clinical populations when undergoing HIIT where
the likelihood of an untoward episode is already increased. It must be noted that HIIT
protocols employed by studies for clinical populations have generally been modified to be
less strenuous for greater tolerance and applicability.43,46 Current HIIT protocols used in
clinical practice are usually characterized by a lower absolute intensity but with a longer
duration of work and shorter rest periods compared with the more traditional sprint interval
training protocols used in athletes.51,52 These adapted HIIT protocols have been found to be
well tolerated and safe to practice in clinical populations with CVD. Although the present
study is not powered to determine the safety of HIIT, 90 participants in this study completed
at least two hundred and sixteen sessions of HIIT (each patient completing at least 24
sessions) without a single major adverse event.
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Study Limitations
The patients in this study were overweight and therefore future studies focused on MI
patients with normal body weight are encouraged. Although no major adverse events were
registered, the currently study was not designed to establish the safety of HIIT in patients
with MI. However, the safety of supervised HIIT in CR is generally well documented in
patients with established coronary artery disease.53,54 The ideal dose of exercise training in
patient with MI with regards to the intensity and duration is still not known. Furthermore,
future studies focused on recruitment of women should be conducted as only 27% of the
patients in this study were women. Although not unusual in similar studies, this sex bias was
an unintended consequence of our clinical population but constitutes a limitation of the
generalizability of the results.
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CONCLUSION
The present study showed that 36 sessions of supervised HIIT was superior to MICT for
reducing total body fat mass and abdominal fat percentage, and improving the lipid profile in
patients after MI. These findings support the hypothesis that supervised HIIT should be
considered an important treatment strategy for outpatient CR patients with MI.

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ACKNOWLEDGEMENTS
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We thank the patients and staff of Mayo Clinic Cardiac Rehabilitation Program, in Rochester, MN, for their
valuable contributions to the study.

Grant Support: The present study was supported in part by grants from the National Institutes of Health
(HL-126638 to TPO) and Hunan Development and Reform Commission Foundation of China (Grant no. [2012]
1521).

Abbreviations and Acronyms:

CHD coronary heart disease

CR cardiac rehabilitation

DXA dual-energy X-ray absorptiometry

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HIIT high-intensity aerobic interval training

MICT moderate-intensity continuous training

MI myocardial infarction

BMI body mass index

RPE rating of perceived exertion

RYP Rate-Your-Plate

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Figure 1:
Exercise parameters over the course of cardiac rehabilitation. HIIT = high-intensity interval
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training; MICT = moderate-intensity continuous training

A. Average heart rate during training. HIIT vs. MICT, 2-weeks: 117 vs. 100 bpm, P=.01; 4-
weeks: 118 vs. 99 bpm, P=.006; 8-weeks: 121 vs. 102 bpm, P=.01; 12-weeks: 121 vs. 102
bpm, P=.004, respectively. There was no evidence of a difference across groups over time
(P=.98).
B. Average intensity. 2-weeks: 3.6 vs. 2.5 METs, P=.003; 4-weeks: 3.8 vs. 2.6 METs, P=.
003; 8-weeks: 3.8 vs. 2.8 METs, P=.02; 12-weeks: 3.8 vs. 3.1 METs, P=.10, respectively.
Evidence of a difference across groups over time was noted (P=.04).
C. Duration of exercise. 2-weeks: 32 vs. 24 mins, P<.001; 4-weeks: 33 vs. 25 mins, P<.001;
8-weeks: 35 vs. 27 mins, P<.001; 12-weeks: 35 vs. 27 mins, P=.006, respectively. There was
no evidence of a difference across groups over time (P=.99).
D. Energy expenditure per session. 2-weeks: 166 vs. 80 kcal, P<.001; 4-weeks: 183 vs. 93
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kcal, P<.001; 8-weeks: 192 vs. 107 kcal, P<.001; 12-weeks: 188 vs. 112 kcal, P=.008,
respectively. There was no evidence of a difference across groups over time (P=.43). Results
presented are mean and 95% confidence limits based on repeated measures ANOVA.
Comparisons at each time point are adjusted for multiple comparisons using the method of
Scheffe.

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 Dun et al. Page 15
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Figure 2:
Changes in body composition and abdominal fat distribution within and across MICT and
HIIT groups. BMI = body mass index; HIIT = high-intensity interval training; MICT=
moderate-intensity continuous training.
A. Changes in body weight and BMI from baseline to the completion of 36 sessions of
cardiac rehabilitation (CR) across groups.
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B. Changes in total body fat mass and lean mass from baseline to the completion of 36 CR
sessions across groups. C. Changes in abdominal fat percentage and waist circumference
from baseline to the completion of 36 CR sessions across groups.
Values are reported as Mean ± Standard deviation, the change from baseline to the
completion of 36 CR sessions across groups was analyzed by ANCOVA:

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 Dun et al. Page 16

TABLE 1.
a,b
Baseline Characteristics of Study Patients
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MICT (n=30) HIIT (n=90) p-value

Age, mean ± SD, y 67±16 67±12 P=.84
Female sex, n (%) 8 (27) 24 (27) P>.99
BMI, mean ± SD, kg/m2 30.3±4.5 29.5±4.8 P=.42
Height, mean ± SD, cm 169±2 172±1 P=.08
Body weight, mean ± SD, kg 86.6±3.0 87.5±1.7 P=.80
Days between CR and MI, mean ± SD, days 14±6 14±10 P=.15
Co-morbidities, n (%)
PCI 14 (47) 39 (43) P=.75
CABG 9 (30) 17 (19) P=.20
Hyperglycemia 3 (10) 10 (11) P>.99
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Hypertension 24 (80) 78 (87) P=.38

Dyslipidemia 12 (40) 41 (46) P=.60
Metabolic syndrome 10 (33) 33 (36.7) P=.74
Ever Smoker 12 (40) 38 (42) P=.83
Medications, n (%)
ACEIs/ARBs 15 (50) 49 (54) P=.67
Antiplatelet drugs 24 (80) 88 (98) P=.003
Anticoagulants 1 (3) 3 (3) P>.99
Beta receptor blockers 23 (77) 74 (82) P=.50
CCBs 4 (13) 18 (20) P=.59
Diuretics 7 (23) 6 (7) P=.02
Digoxin 3 (10) 0 P=.01
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Nitrates 5 (17) 12 (13) P=.65

Statins 27 (90) 85 (94) P=.41
VO2peak, ml·kg−1·min−1 23.03±7.33 22.82±5.85 P=.90

a
ACEIs = indicates angiotensin-converting enzyme inhibitors; ARBs = angiotensin II receptor blockers; BMI = body mass index; CABG =
coronary artery bypass grafting; CCBs = Calcium channel blockers; HIIT = high-intensity interval training; MICT = moderate-intensity continuous
training, PCI = percutaneous coronary intervention; VO2peak = maximal oxygen consumed.

b
Data are reported as Mean ± Standard deviation or number and percent population (%). Values were analyzed with two-sample t-test or Wilcoxon
rank-sum test for continuous variables and Chi-square or Fisher exact test for categorical variables.
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 Dun et al. Page 17

TABLE 2.
a,b
Main Outcomes
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MICT (n=30) HIIT (n=90) ANCOVA

Baseline Change p-value Baseline Change p-value p-value

Resting HR, bpm 70±12 −2±10 P=.36 66±13 −4±12 P=.003 P=.03
SBP, mmHg 118±22 2±21 P=.64 120±17 −2±18 P=.34 P=.41
DBP, mmHg 70±10 −6±13 P=.02 70±11 −6±13 P<.001 P=.93
Rate-Your-Plate scores 53±8 4±9 P=.01 56±7 5±5 P<.001 P=.02
Statin therapy intensity 2.3±1.0 0.1±0.8 P=.65 2.6±0.8 −0.0±0.5 P=.40 P=.75
Anthropometric measurements
Body weight, kg 86.4±14.6 −0.3±3.5 P=.89 87.6±16.7 −1.4±3.9 P<.001 P=.16
BMI, kg/m2 30.3±4.5 −0.2±1.8 P=.60 29.5±4.8 −0.5±1.2 P<.001 P=.15
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Body fat, % 38.1±7.3 −0.4±2.0 P=.24 36.3±7.7 −2.3±1.8 P<.001 P<.001

Fat mass, kg 32.2±8.7 −0.5±2.0 P=.14 31.2±10.1 −2.5±2.2 P<.001 P<.001
Lean mass, kg 51.4±9.2 0.2±2.8 P=.70 53.5±9.8 0.9±1.4 P<.001 P=.07
Abdominal fat, % 45.9±9.0 −0.1±3.2 P=.91 44.5±10.1 −3.3±3.2 P<.001 P<.001
Waist circum., cm 106±12 0±5 P=.70 104±14 −3±5 P<.001 P=.01
Hip circum., cm 107±8 −1±4 P=.07 107±10 −2±5 P=.007 P=.86
W/H ratio 1.0±0.1 0.00±0.1 P>.99 1.0±0.1 −0.00±0.1 P=.03 P=.15
Lipid profile
TC, mg/dl 165.3±49.6 −6.8±48.2 P=.54 167.8±46.1 −35.1±41.4 P<.001 P=.002
HDL-c, mg/dl 43.4±9.1 2.7±8.2 P=.16 47.5±13.4 2.0±7.3 P=.02 P=.88
LDL-c, mg/dl 90.7±44.7 −9.9±39.7 P=.28 93.5±38.9 −33.5±36.5 P<.001 P<.001
Triglycerides, mg/dl 164.3±89.1 −6.4±55.2 P=.61 137.9±84.9 −24.8±50.0 P<.001 P=.006
Non-HDL-c, mg/dl 121.9±44.8 −9.5±46.2 P=.37 120.3±44.8 −37.1±40.2 P<.001 P<.001
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PHQ-9 scores 4.1±2.3 −1.2±3.8 P=..07 3.9±3.3 −1.7±3.8 P<.001 P=.24

a
DBP= diastolic blood pressure; HDL-c = high-density lipoprotein cholesterol; HR = heart rate; LDL-c = low-density lipoprotein cholesterol; SBP
= systolic blood pressure; PHQ = patient health questionnaire-9; W/H = waist/hip circumference; TC = total cholesterol.
b
Values are reported as Mean ± Standard deviation or number and percent population (%). The changes within group from baseline to the
completion of 36 sessions of cardiac rehabilitation (CR) are assessed with paired t-test; the difference of changes across groups from baseline to the
completion of 36 CR sessions, and Rate-Your-Plate scores comparisons at baseline and the completion of 36 CR sessions are analyzed by
ANCOVA.
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TABLE 3.

Outcomes after sub-group matching for differences in exercise duration, exercise intensity and exercise energy
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a,b
expenditure per session over the course of the 36 sessions CR

MICT (n=15) HIIT (n=15) ANCOVA

Baseline Change p-value Baseline Change p-value p-value

Rate-Your-Plate scores 56±6 2±5 P=.19 52±6 8±5 P<.001 P=.02
Statin therapy intensity 2.1±1.3 0.3±0.7 P=.16 2.8±0.6 −0.1±0.3 P=.33 P=.46
Anthropometric measurements
Body weight, kg 86.4±12.3 −0.3±3.7 P=.55 86.4±18.2 −0.6±1.9 P=.43 P=.74
BMI, kg/m2 30.5±4.2 −0.6±1.8 P=.25 30.2±4.8 0.0±1.4 P=.99 P=.33
Body fat, % 39.0±6.0 0.1±1.9 P=.89 38.9±6.1 −1.9±2.0 P=.003 P=.01
Fat mass, kg 32.6±7.3 −0.1±1.6 P=.83 32.7±9.2 −1.7±1.9 P=.003 P=.02
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Lean mass, kg 50.6±7.9 −0.2±3.0 P=.82 51.0±10.7 1.1±1.6 P=.02 P=.15

Abdominal fat, % 45.5±6.9 0.4±3.1 P=.62 47.5±8.1 −2.6±3.3 P=.008 P=.02
Waist circum., cm 106±10 −0±5 P=.80 108±17 −2±5 P=.13 P=.36
Hip circum., cm 107±7.4 −1±4 P=.63 106±9 −0±10 P=.87 P=.97
W/H ratio 1.0±0.1 0.0±0.1 P=.71 1.0±0.1 −0.0±0.1 P=.61 P=.66
Lipid profile
TC, mg/dl 166.4±37.7 0.9±47.6 P=.96 174.7±40.1 −38.9±39.5 P=.006 P=.04
HDL-c, mg/dl 44.1±5.5 3.0±8.5 P=.39 51.3±16.6 0.2±10.2 P=.96 P=.81
LDL-c, mg/dl 89.4±27.8 −5.3±35.3 P=.71 97.2±34.7 −38.1±35.3 P=.005 P=.04
Triglycerides, mg/dl 187.7±97.5 −7.6±53.2 P=.72 158.3±104.4 −28.8±60.0 P=.13 P=.08
Non-HDL-c, mg/dl 122.3±35.9 −2.1±48.0 P=.91 123.3±38.6 −39.1±42.2 P=.008 P=.03

a
HDL-c = high-density lipoprotein cholesterol; LDL-c = low-density lipoprotein cholesterol; W/H = waist/hip circumference; TC = total
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cholesterol.
b
Values are reported as Mean ± Standard deviation or number and percent population (%). The changes within group from baseline to the
completion of 36 sessions of cardiac rehabilitation are assessed with paired t-test, and the difference of changes across groups was analyzed by
ANCOVA.
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Mayo Clin Proc. Author manuscript; available in PMC 2020 September 01.