ObjectiveSupervised exercise training is recommended for people with peripheral artery disease (PAD), yet it remains underutilised. Home-based exercise programmes are a potential alternative. The aim of this study was to assess the feasibility of conducting a full scale trial of a 12-week home-based exercise programme (HBEP) for people living with symptomatic PAD.MethodsIn a randomised feasibility trial, patients with intermittent claudication (IC) were allocated to either a HBEP or a non-exercise control. The HBEP group were given a Fitbit to use during a 12-week exercise programme comprising of personalised step goals and a resistance-based circuit to be undertaken at home twice weekly. The primary outcome was feasibility, assessed via eligibility, recruitment, attrition, tolerability, and adherence. Acceptability was assessed via semi-structured interviews. Secondary analysis was undertaken to determine the feasibility of collecting clinical outcome data.Results188 people were screened, 133 were eligible (70.7%), 30 were recruited (22.6%) and one withdrew (3.33%). Mean adherence to the daily step goal was 53.5% (range=29.8–90.5%), and 58.6% of prescribed circuits were completed of which 56.4% were at the desired intensity. Six adverse events were recorded, three of which were related to study involvement. No significant differences were observed in exploratory outcomes. Small clinically important differences were seen in walking speed and pain-free treadmill walking distance which should be confirmed or refuted in a larger trial.ConclusionThe HBEP was feasible and well tolerated, with successful recruitment and minimal attrition. The intervention was acceptable, with walking seen as more enjoyable than circuit exercise. The WALKSTRONG programme may be suitable for those who will not, or cannot, take part in supervised exercise outside of the home.

Objective: To perform a cost-effectiveness analysis of high-intensity interval training (HIIT) compared with moderate intensity steady-state (MISS) training in people with coronary artery disease (CAD) attending cardiac rehabilitation (CR). Design: Secondary cost-effectiveness analysis of a prospective, assessor-blind, parallel group, multi-center RCT. Setting: Six outpatient National Health Service cardiac rehabilitation centers in England and Wales, UK. Participants: 382 participants with CAD (N=382). Interventions: Participants were randomized to twice-weekly usual care (n=195) or HIIT (n=187) for 8 weeks. Usual care was moderate intensity continuous exercise (60%-80% maximum capacity, MISS), while HIIT consisted of 10 pound 1-minute intervals of vigorous exercise (>85% maximum capacity) interspersed with 1-minute periods of recovery. Main Outcome Measures: We conducted a cost-effectiveness analysis of the HIIT or MISS UK trial. Health related quality of life was measured with the EQ-5D-5L to estimate quality-adjusted life years (QALYs). Costs were estimated with health service resource use and intervention delivery costs. Cost-utility analysis measured the incremental cost-effectiveness ratio (ICER). Bootstrapping assessed the probability of HIIT being cost-effective according to the UK National Institute for Health and Care Excellence (NICE) threshold value (20,000 pound per QALY). Missing data were imputed. Uncertainty was estimated using probabilistic sensitivity analysis. Assumptions were tested using univariate/1-way sensitivity analysis. Results: 124 (HIIT, n=59; MISS, n=65) participants completed questionnaires at baseline, 8 weeks, and 12 months. Mean combined health care use and delivery cost was 676 pound per participant for HIIT, and 653 pound for MISS. QALY changes were 0.003 and-0.013, respectively. For complete cases, the ICER was 1448 pound per QALY for HIIT compared with MISS. At a willingness-to-pay threshold of 20,000 pound per QALY, the probability of HIIT being cost-effective was 96% (95% CI, 0.90 to 0.95). Conclusion: For people with CAD attending CR, HIIT was cost-effective compared with MISS. These findings are important to policy makers, commissioners, and service providers across the health care sector.

ObjectiveTo compare the characteristics of “responders” and “non-responders” to 8-weeks of exercise training to determine differences in key cardiovascular disease outcomes in people with coronary artery disease (CAD).DesignSecondary analysis of data from the HIIT or MISS UK trial.SettingSix outpatient National Health Service cardiac rehabilitation centers in the UK. In people with CAD attending cardiac rehabilitation, the HIIT or MISS UK trial reported that short-term, low-volume, high intensity interval training (HIIT) was more effective than moderate intensity steady state (MISS) exercise training for improving peak oxygen uptake (VO2peak).Participants382 participants with CAD (mean age: 58.8 ± 9.6 years; mean BMI: 29.0 ± 4.3 kg∙m−2).Main Outcome MeasuresWe identified “responders” and “non-responders” based on a meaningful change in peak oxygen uptake, using two established methods. Key clinical, quality of life, and cardiopulmonary exercise test (CPET)-derived outcomes were compared between groups.ResultsResponders were more likely to be younger (P<0.05), and demonstrate greater improvement in CPET-related outcomes e.g. oxygen uptake efficiency slope (OUES), ventilatory efficiency (VE/VCO2 slope), and peak power output (all comparisons, P<0.001). Responders were more likely to observe improvements in quality of life (EQ-5D-5L; mean Δ 13.6 v mean Δ 9.4; P=0.045), and HDL-cholesterol (mean Δ 0.09 mmol.L−1 v mean Δ 0.04 mmol.L−1; P=0.004), compared to non-responders.ConclusionsIn people with CAD attending cardiac rehabilitation, “responders” to exercise training were more likely to be younger, and demonstrate greater improvements in health-related QoL and HDL-cholesterol.

Introduction The WALKSTRONG trial includes a programme of community walking and home-based circuit training which has been developed for people with intermittent claudication (IC). The aim of the present study was to determine the acceptability of the programme for those who took part, by gleaning their opinions and experiences. Methods All participants eligible for the WALKSTRONG trial were approached regarding completing a semi-structured interview, selected from three groups: A) programme completers, B) programme withdrawers and C) programme decliners. Interviewers were interested in participants’ views on the programme structure, willingness to participate, and the experiences of those who did take part. Interviews were audio recorded, transcribed verbatim and thematic analysis was undertaken. Results Five of the 14 participants in the intervention group and four of the 20 programme decliners agreed to an interview. The one who withdrew from the exercise programme did not consent to be interviewed. The three themes that emerged from the interviews were: 1) ‘overall positive experiences with the programme, 2) ‘importance of guidance and pain management’, and 3) ‘barriers are both similar to supervised exercise and unique to home-based programmes’. The programme was well received by programme completers, with some aspects preferred over others. Some participants reported improvements in both physical activity behaviour and IC symptoms, and would recommend the programme to others. Conclusion The home-based circuit programme received several recommendations for further improvement. Along with the feasibility findings, a fully powered, randomised controlled trial of this intervention is warranted. Trial registration NCT05059899.

Peripheral artery disease (PAD) is an atherosclerotic cardiovascular condition affecting the lower limbs. A classic symptom of PAD is intermittent claudication (IC), which precipitates on exertion and is relieved with rest. Supervised exercise programmes (SEPs) are first line treatments for patients with IC. Despite the benefits of exercise, there are inconsistencies between guidelines regarding the recommended level of prescribed claudication pain. The aim of this commentary is to highlight the limitations of current guidance which will lead to variability in care. The National Institute of Health and Care Excellence (NICE), American Heart Association and British Association of Sport and Exercise Sciences recommend exercising to maximal claudication pain. Supporting this, an early meta-analysis showed walking to near maximal pain to be most beneficial at improving maximal walking and pain-free walking distances. Indicating that greater amounts of ischaemia induced may produce greater haemodynamic and metabolic adaptations. Furthermore, high-intensity walking, eliciting moderate–severe ischaemic leg symptoms, was superior to low-intensity without ischaemic leg symptoms. Conversely, the American College of Sports Medicine and Exercise and Sports Science Australia suggest moderate pain is most beneficial. A systematic review suggested mild to moderate claudication pain yields optimal results in walking distance and cardiorespiratory fitness when compared to maximal pain. The conclusions were in line with the Vascular Disease Foundation and the American Association of Cardiovascular and Pulmonary Rehabilitation guidelines in that lower limb exercise should be performed to a threshold of mild–moderate pain. Despite the inconsistencies aforementioned, alarmingly several guidelines do not report a level of claudication pain to work towards, whilst others suggest working at a speed and gradient that induces claudication pain within 3–5 min, without specifying the intensity of the pain. As such, clinicians are not provided with clear guidance. A major issue is that guidelines are not fully inclusive of the evidence, as they do not consider pain-free exercise. A metaanalysis showed significant improvements in absolute and initial walking distance without inducing claudication pain. A recent systematic review also suggests pain-free SEPs elicit similar improvements in walking performance and functional outcomes compared to moderate pain. The missed consideration of pain-free SEPs and high claudication pain prescription may lead to poor uptake, as high claudication pain has been commonly cited as a barrier to exercise adherence and uptake of SEPs. Indeed patients taking part in a low pain SEP where 1.52 times more likely to complete the SEP than those in the high pain SEP. As SEPs are the first line of treatment for patients with PAD, guidelines must ensure greater participation occurs; consequently, patient ability and preference should be considered, so it is tolerable and beneficial for all patients. In conclusion, there are inconsistencies regarding the recommended level of claudication pain for clinicians to prescribe. Furthermore, there is no consideration for the evidence base regarding pain-free exercise. It is clear there is a need for a universal set of guidelines that consider optimising patient outcomes as well as uptake and adherence in relation to claudication pain. No research has directly compared maximal, pain-free and moderate claudication pain; however, trials are underway.

OBJECTIVES:Commercially available wearable activity monitors can promote physical activity behaviour. Clinical trials typically quantify physical activity with research grade activity monitors prior to testing interventions utilising commercially available wearable activity monitors aimed at increasing step count. Therefore, it is important to test the agreement of these two types of activity monitors. OBJECTIVES:Observational. METHODS:Thirty adults (20-65 years, n = 19 females) were provided a Fitbit Charge 4©. To determine reliability using an intraclass correlation coefficient, two, one-minute bouts of treadmill walking were performed at a self-selected pace. Subsequently, participants wore both an ActiGraph wGT3X-BT and the Fitbit for seven days. To determine agreement, statistical equivalence and the mean absolute percentage error were calculated and represented graphically with a Bland-Altman plot. Ordinary least products regression was performed to identify fixed or proportional bias. RESULTS:The Fitbit showed 'good' step count reliability on the treadmill (intraclass correlation coefficient = 0.75, 95 % CI = 0.53-0.87, p < 0.001). In free-living however, it overestimated step count when compared to the ActiGraph wGT3X-BT (mean absolute percentage error = 26.02 % ± 14.63). Measurements did not fall within the ± 10 % equivalence region and proportional bias was apparent (slope 95 % CI = 1.09-1.35). CONCLUSIONS:The Fitbit Charge 4© is reliable when measuring step count on a treadmill. However, there is an overestimation of daily steps in free-living environments which may falsely indicate compliance with physical activity recommendations.

Cardiopulmonary exercise testing (CPET) is the 'gold standard' method for evaluating functional capacity, with oxygen pulse (O2Pulse) inflections serving as a potential indicator of myocardial ischaemia. However, the reliability and agreement of identifying these inflections have not been thoroughly investigated. This study aimed to assess the inter- and intra-observer reliability and agreement of a subjective quantification method for identifying O2Pulse inflections during CPET, and to propose a more robust and objective novel algorithm as an alternative methodology. A retrospective analysis was conducted using baseline data from the HIIT or MISS UK trial. The O2Pulse curves were visually inspected by two independent examiners, and compared against an objective algorithm. Fleiss' Kappa was used to determine the reliability of agreement between the three groups of observations. The results showed almost perfect agreement between the algorithm and both examiners, with a Fleiss' Kappa statistic of 0.89. The algorithm also demonstrated excellent inter-rater reliability (ICC) when compared to both examiners (0.92-0.98). However, a significant level (P ≤0.05) of systematic bias was observed in Bland-Altman analysis for comparisons involving the novice examiner. In conclusion, this study provides evidence for the reliability of both subjective and novel objective methods for identifying inflections in O2Pulse during CPET. These findings suggest that further research into the clinical significance of O2Pulse inflections is warranted, and that the adoption of a novel objective means of quantification may be preferable to ensure equality of outcome for patients.

BACKGROUND:Exercise therapy is an important treatment option for people with intermittent claudication (IC). Appropriate reporting of exercise interventions in populations with IC within randomised controlled trials (RCTs) is important to ensure that research can be translated into clinical practice. Therefore, the purpose of our review is to evaluate the reporting of exercise interventions in RCTs of exercise therapy in patients with IC.METHODS:A systematic search was performed to identify relevant trials in patients with IC published until May 2020. Studies including only participants with critical limb ischaemia or asymptomatic peripheral artery disease were excluded. Each trial was scored using the recently developed 'Consensus on Exercise Reporting Template' (CERT) which has a maximum obtainable score of 19.RESULTS:Of 1489 unique records identified from the search, 73 trials were included, reporting 107 exercise interventions. Overall, the average CERT score was 10/19. The exercise equipment used, the use of supervision and a description of whether the exercise prescription was tailored or generic were the most frequently reported intervention components. The motivational strategies used, intervention adherence and intervention fidelity were the most underreported CERT components. There was no trend indicating that CERT scores were higher in more recent publications.CONCLUSIONS:We have identified that important details about exercise interventions are frequently missing from the published literature. These missing data hinder replication of research findings and limit the translation of evidence into clinical practice.

BackgroundThere is a lack of international consensus regarding the prescription of high-intensity interval training (HIIT) for people with coronary artery disease (CAD) attending cardiac rehabilitation (CR).AimsTo assess the clinical effectiveness and safety of low-volume HIIT compared with moderate-intensity steady-state (MISS) exercise training for people with CAD.Methods and resultsWe conducted a multi-centre RCT, recruiting 382 patients from 6 outpatient CR centres. Participants were randomized to twice-weekly HIIT (n = 187) or MISS (n = 195) for 8 weeks. HIIT consisted of 10 x 1 min intervals of vigorous exercise (> 85% maximum capacity) interspersed with 1 min periods of recovery. MISS was 20-40 min of moderate-intensity continuous exercise (60-80% maximum capacity). The primary outcome was the change in cardiorespiratory fitness [peak oxygen uptake (VO2 peak)] at 8 week follow-up. Secondary outcomes included cardiovascular disease risk markers, cardiac structure and function, adverse events, and health-related quality of life. At 8 weeks, VO2 peak improved more with HIIT (2.37 mL.kg(-1).min(-1); SD, 3.11) compared with MISS (1.32 mL.kg(-1).min(-1); SD, 2.66). After adjusting for age, sex, and study site, the difference between arms was 1.04 mL.kg(-1).min(-1) (95% CI, 0.38 to 1.69; P = 0.002). Only one serious adverse event was possibly related to HIIT.ConclusionsIn stable CAD, low-volume HIIT improved cardiorespiratory fitness more than MISS by a clinically meaningful margin. Low volume HIIT is a safe, well-tolerated, and clinically effective intervention that produces short-term improvement in cardiorespiratory fitness. It should be considered by all CR programmes as an adjunct or alternative to MISS.

Background: Peripheral artery disease affects over 236 million people globally and the classic symptom is intermittent claudication (IC) which is associated with reduction in physical activity. The evidence that supervised exercise programmes (SEPs) improve pain-free and maximal walking distance is irrefutable. However, adherence rates are low with exercise-related pain cited as a contributing factor. National and international guidelines recommend exercising at a moderate to maximal level of claudication pain to improve walking ability; however, exercising pain-free or at mild claudication pain has been shown to achieve this outcome. There is limited evidence that compares the relative effects of exercise prescribed at different levels of claudication pain. Objective: The objective of this study is to directly compare the effects of exercise prescribed at three different levels of claudication pain on walking performance. Design: This study will be a single-centre randomised controlled trial. Methods: Based on an a priori power calculation, 51 patients with IC will be allocated to 24 weeks of twice-weekly pain-free (PF), moderate pain (MOD-P) or maximal pain (MAX-P) exercise. The PF group will cease exercise at the onset of claudication (1 on the 0–4 IC rating scale), the MOD-P group will stop once moderate pain is reached (2 on the rating scale) and the MAX-P group will stop once maximal pain is reached (4 on the rating scale). Analysis: Outcome measures will be assessed at baseline, 12 and 24 weeks adopting an analysis of covariance (ANCOVA) to compare MWD across three time points. The primary outcome for the trial will be change in maximal treadmill walking distance at 12 and 24 weeks. Registration: Trial registration number: NCT04370327.

Why we are undertaking the research: Peripheral artery disease is a common problem where the blood vessels in the legs are narrowed by fatty deposits. Supervised exercise programmes are recommended to help treat this condition, as they can reduce leg pain and improve fitness. However, not many people are able to access these programmes typically because of barriers including travel burdens, time constraints or other commitments. As an alternative, researchers are developing home-based programmes which do not require people to travel to centres for their sessions. In the UK and to the author’s knowledge, there are not many well researched home-based programmes available for people living with peripheral artery disease. What we aim to do: We plan to undertake a study to see how feasible our home-based programme is. People with peripheral artery disease will either be asked to continue with their normal routine or will be prescribed an exercise programme, with an activity watch to monitor physical activity. This programme will include increasing the number of steps walked each day, an exercise circuit (twice a week) and a telephone support call with a member of the research team to discuss their progress or lack of progress. Questionnaire responses, blood samples, walking ability, muscle strength and the amount of daily exercise will be compared between the two groups at the start of the 12-week programme, at the end, and 12 weeks after the programme has finished. By doing this study, we will be able to refine our home-based exercise programme so that it can be tested on a larger scale to see if it is a good option for people with peripheral artery disease who may not be able to attend a supervised exercise programme.

Intermittent claudication (IC) is a classic symptom of peripheral artery disease, with first line treatment being supervised exercise therapy (SET). Despite this, SET is frequently underutilised, and adherence is often poor. An alternative option are home-based exercise programmes (HBEP). Although HBEPs are well tolerated, to the authors' knowledge, no research has assessed their safety. The aim of this review was to assess the safety of HBEPs in people living with IC. We performed an electronic search of the MEDLINE, CINAHL, and Cochrane Library databases. The main parameter of interest was complication rate, calculated as the number of related adverse events per patient-hours. Subanalysis was undertaken to determine differences in safety for studies that did and did not include pre-exercise cardiac screening, and for studies with exercise at low, moderate, and high levels of claudication pain. Our search strategy identified 8693 results, of which 27 studies were included for full review. Studies included 1642 participants completing 147,810 patient-hours of home-based exercise. Four related adverse events were reported, three of which were cardiac in origin, giving an all-cause complication rate of one event per 36,953 patient-hours. Three of these events occurred following exercise to high levels of claudication pain, and one occurred with pain-free exercise. One event occured in a study without cardiac screening. Based on the low number of related adverse events, HBEPs appear to be a safe method of exercise prescription for people with IC. Our results strengthen the rationale for providing alternative exercise options for this population. PROSPERO Registration No.: CRD42021254581.

Cardiovascular disease is the major cause of death worldwide. Extensive cardiovascular biomarkers are available using blood tests but very few, if any, investigations have described non-invasive tests for cardiovascular biomarkers based on readily available hair samples. Here we show, first, that human hair proteins are post-translationally modified by arginine methylation (ArgMe). Using western blot, proteomic data mining and mass spectrometry, we identify several ArgMe events in hair proteins and we show that keratin-83 is extensively modified by ArgMe in the human hair. Second, using a preliminary cohort (n = 18) of heterogenous healthy donors, we show that the levels of protein ArgMe in hair correlate with serum concentrations of a well-established cardiovascular biomarker, asymmetric dimethylarginine (ADMA). Compared to blood collection, hair sampling is cheaper, simpler, requires minimal training and carries less health and safety and ethical risks. For these reasons, developing the potential of hair protein ArgMe as clinically useful cardiovascular biomarkers through further research could be useful in future prevention and diagnosis of cardiovascular disease.

Objectives Supervised exercise programmes (SEPs) are a vital treatment for people with intermittent claudication, leading improvements in walking distance and quality of life and are recommended in multiple national and international guidelines. We aimed to evaluate the use and structure of SEPs in the United Kingdom (UK). Design We conducted an anonymous online survey using the Jisc platform comprising of 40 questions. The survey was designed to address key areas such as access, provision, uptake and delivery of SEPs in the United Kingdom. Ethical approval was obtained from Coventry University (P108729). Methods The list of trusts providing vascular services was obtained from the National Vascular Registry (NVR) report. The survey was disseminated via social media, The Vascular Society of Great Britain and Ireland and the Society for Vascular Technology. Data were exported to a Microsoft Excel document and analysed using simple descriptive statistics. Results Of 93 vascular units identified, we received response from 48. Of these, 23 had access to an exercise programme (48%). The majority of SEPs were exclusively for PAD patients (77%), with 21% using integrated services. 67% of respondents were providing a circuit-based programme, and 5 out of 23 were meeting the dose recommendations in the UK National Institute for Health and Care Excellence (NICE) guidelines. Respondents felt that programmes were moderately to extremely important to patients, slightly to very important to clinicians and not at all important to slightly important to commissioning/funding bodies. Conclusion SEPs are a well-established first-line treatment for patients with IC and they are recommended by NICE guidelines. Despite this, many patients still do not have access to an exercise programme, and clinicians do not feel that they have support from commissioning/funding bodies to develop them. There is an urgent need for funding, development and delivery of SEPs in the United Kingdom.

The authors regret that citation [[39]Khushhal A. Nichols S. Carroll S. Ingle L. Insufficient exercise intensity for clinical benefit? Monitoring and quantification of a community-based Phase III cardiac rehabilitation programme: a United Kingdom perspective.Plos One. 2019; 14e0217654https://doi.org/10.1371/journal.pone.0217654"Crossref PubMed Google Scholar] was incorrectly referenced. Reference [[39]Khushhal A. Nichols S. Carroll S. Ingle L. Insufficient exercise intensity for clinical benefit? Monitoring and quantification of a community-based Phase III cardiac rehabilitation programme: a United Kingdom perspective.Plos One. 2019; 14e0217654https://doi.org/10.1371/journal.pone.0217654"Crossref PubMed Google Scholar] should read: The authors would like to apologise for any inconvenience caused. DOI of original article: doi:https://doi.org/10.1016/j.ijcard.2020.01.044 Funding was received from the Hull and East Riding Cardiac Trust Fund , United Kingdom (No grant ID). Funding was used to analyse blood samples for the CARE CR study. The authors declare that there are no conflicts of interest. Routine exercise-based cardiac rehabilitation does not increase aerobic fitness: A CARE CR studyInternational Journal of CardiologyVol. 305PreviewRecent evidence suggests that routine exercise-based cardiac rehabilitation (CR) may not lead to a substantial increase in estimated peak oxygen uptake (V̇O2peak). This could reduce the potential benefits of CR and explain why CR no longer improves patient survival in recent studies. We aimed to determine whether routine exercise-based CR increases V̇O2peak using gold-standard maximal cardiopulmonary exercise testing (CPET), and to quantify the exercise training stimulus which might be insufficient in patients undertaking CR. Full-Text PDF Open Access

Background: Current guidelines for intermittent claudication advocate exercise at moderate to maximal claudication pain. However, adherence rates to supervised exercise programmes (SEP) remain poor and claudication pain is a contributing factor. Limited evidence suggests that moderate or pain-free exercise may be just as beneficial and may be better tolerated. However, it remains unclear what 'level' of claudication pain is optimal for improving functional outcomes. We therefore conducted a systematic review to synthesise the evidence for exercise prescribed at different levels of claudication pain. Methods: The CENTRAL, MEDLINE, Embase and CINAHL databases were searched up to October 2020. Randomized controlled trials (RCTs) that directly compared at least 2 different intensities of claudication pain were included. Outcome measures included walking performance, adherence, quality of life and vascular function. Results: Of 1,543 search results, 2 studies were included. Maximal walking distance improved by 100-128% in the moderate-pain SEP groups, and by 77-90% in the pain-free SEP groups. Importantly, there were no significant differences between the moderate-pain and pain-free SEP groups in either study for improvements in walking performance, though comparison to a maximal-pain SEP group was not made. Conclusions: The efficacy of SEPs for patients with intermittent claudication is irrefutable, though there is no consensus on the optimal level of pain. Therefore, adequately powered RCTs are required to compare the effect of pain-free SEPs, moderate-pain SEPs and maximal-pain SEPs on functional outcomes.

Background: There is wide discrepancy in how published research defines and reports home-based exercise programmes. Studies consisting of fundamentally different designs have been labelled as home-based, making searching for relevant literature challenging and time consuming. This issue has been further highlighted by an increased demand for these programmes following the COVID-19 pandemic and associated government-imposed lockdowns. Purpose: To examine what specifically constitutes home-based exercise by: (1) developing definitions for a range of terms used when reporting exercise and physical activity programmes and (2) providing examples to contextualise these definitions for use when reporting exercise and physical activity programmes. Methods: A literature search was undertaken to identify previous attempts to define home-based exercise programmes. A working document, including initial definitions and examples were developed, which were then discussed between six experts for further refinement. Results: We generated definitions for universal key terms within three domains (and subdomains) of programme design: location (home-based, community/centre-based, or clinical setting), prescription (structured or unstructured) and delivery (supervised, facilitated, or unsupervised). Examples for possible combinations of design terms were produced. Conclusions: Definitions will provide consistency when using reporting tools and the intention is to discuss the issues presented as part of a Delphi study. This is of paramount importance due to the predicted increase in emerging research regarding home-based exercise.

A systematic review was conducted to identify the range of terminology used in studies to describe maximum walking distance and the exercise testing protocols, and testing modalities used to measure it in patients with intermittent claudication. A secondary aim was to assess the implementation and reporting of the exercise testing protocols. CINAHL, Medline, EMBASE and Cochrane CENTRAL databases were searched. Randomised controlled trials whereby patients with intermittent claudication were randomised to an exercise intervention were included. The terminology used to describe maximal walking distance was recorded, as was the modality and protocol used to measure it. The implementation and reporting quality was also assessed using pre-specified criteria. Sixty-four trials were included in this review. Maximal walking distance was reported using fourteen different terminologies. Twenty-two different treadmill protocols and three different corridor tests were employed to assess maximal walking distance. No single trial satisfied all the implementation and reporting criteria for an exercise testing protocol. Evidence shows that betweenstudy interpretation is difficult given the heterogenous nature of the exercise testing protocols, test endpoints and terminology used to describe maximal walking distance. This is further compounded by poor test reporting and implementation across studies. Comprehensive guidelines need to be provided to enable a standardised approach to exercise testing in patients with intermittent claudication.

High-intensity interval training (HIIT) and circuit training (CT) are popular methods of exercise, eliciting improvements in cardiorespiratory fitness (CRF). However, direct comparisons of these two training methods are limited. We investigated the effects of HIIT and CT on CRF. Thirty-nine apparently healthy middle-aged participants [HIIT; mean age: 42.5 ± 12.3; $$\dot{V}{\text{O}}_{2\hbox{max} }$$ 31.5 ± 7.1 (ml kg−1 min−1); 52% males; CT; mean age: 41.2 ± 12.9; $$\dot{V}{\text{O}}_{2\hbox{max} }$$ 31.4 ± 6.8 (ml kg−1 min−1); 57% males] were randomly allocated to two sessions per week of HIIT or CT over 8 weeks. HIIT performed ten 1-min cycle-ergometry intervals at > 85% HRmax, separated by ten 1-min intervals of active recovery. The CT group performed up to 40-min of CT at 60–80% HRmax. CRF was measured using maximum oxygen uptake ( $$\dot{V}{\text{O}}_{2\hbox{max} }$$ ), ventilatory anaerobic threshold ( $$\dot{V}{\text{O}}_{2}$$ at VAT) and maximum oxygen pulse ( $$\dot{V}{\text{O}}_{2}$$ /HR). $$\dot{V}{\text{O}}_{2\hbox{max} }$$ increased by 12% following HIIT (mean difference 3.9 ml kg−1 min−1; 95% CI: 2.8–4.9; P < 0.001), and 3% in CT (mean difference 1.0 ml kg−1 min−1; 95% CI: − 0.4 to 2.0; P = 0.060). $$\dot{V}{\text{O}}_{2}$$ at VAT increased by 16% following HIIT (mean difference 2.4 ml kg−1 min−1; 95% CI: 1.6–3.1; P < 0.001) and 4% in CT (mean difference 0.7 ml kg−1 min−1; 95% CI: − 0.1 to 1.4; P = 0.085). $$\dot{V}{\text{O}}_{2}$$ /HR increased by 11% following HIIT (mean difference 1.4 ml beat−1; 95% CI: 0.9–2.0; P < 0.001) and 1% after CT (mean difference 0.3 ml beat−1; 95% CI: − 0.3 to 0.8; P = 0.318). Our study demonstrated that HIIT led to greater improvements in CRF when compared to CT. ClinicalTrials.gov Identifier: NCT03700671.

Background In the United Kingdom (UK), exercise intensity is prescribed from a fixed percentage range (% heart rate reserve (%HRR)) in cardiac rehabilitation programmes. We aimed to determine the accuracy of this approach by comparing it with an objective, threshold-based approach incorporating the accurate determination of ventilatory anaerobic threshold (VAT). We also aimed to investigate the role of baseline cardiorespiratory fitness status and exercise testing mode dependency (cycle vs. treadmill ergometer) on these relationships. Design and methods A maximal cardiopulmonary exercise test was conducted on a cycle ergometer or a treadmill before and following usual-care circuit training from two separate cardiac rehabilitation programmes from a single region in the UK. The heart rate corresponding to VAT was compared with current heart rate-based exercise prescription guidelines. Results We included 112 referred patients (61 years (59–63); body mass index 29 kg·m–2 (29–30); 88% male). There was a significant but relatively weak correlation ( r = 0.32; p = 0.001) between measured and predicted %HRR, and values were significantly different from each other ( p = 0.005). Within this cohort, we found that 55% of patients had their VAT identified outside of the 40–70% predicted HRR exercise training zone. In the majority of participants (45%), the VAT occurred at an exercise intensity <40% HRR. Moreover, 57% of patients with low levels of cardiorespiratory fitness achieved VAT at <40% HRR, whereas 30% of patients with higher fitness achieved their VAT at >70% HRR. VAT was significantly higher on the treadmill than the cycle ergometer ( p < 0.001). Conclusion In the UK, current guidelines for prescribing exercise intensity are based on a fixed percentage range. Our findings indicate that this approach may be inaccurate in a large proportion of patients undertaking cardiac rehabilitation.