682123

research-article2016
CNU0010.1177/1474515116682123European Journal of Cardiovascular NursingKorzeniowska-Kubacka et al.

EUROPEAN
SOCIETY OF
Original Article CARDIOLOGY ®

European Journal of Cardiovascular Nursing

The impact of exercise-only-based

2017, Vol. 16(5) 390­–396
© The European Society of Cardiology 2016
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rehabilitation on depression and anxiety sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1474515116682123
https://doi.org/10.1177/1474515116682123

in patients after myocardial infarction journals.sagepub.com/home/cnu

Iwona Korzeniowska-Kubacka1, Maria Bilińska2, Dorota

Piotrowska1, Monika Stepnowska1 and Ryszard Piotrowicz1

Abstract
Aim: The aim of the study was to assess the effectiveness of exercise training on depression, anxiety, physical capacity
and sympatho-vagal balance in patients after myocardial infarction and compare differences between men and women.
Methods: Thirty-two men aged 56.3±7.6 years and 30 women aged 59.2±8.1 years following myocardial infarction
underwent an 8-week training programme consisting of 24 interval trainings on cycloergometer, three times a week.
Before and after completing the training programme, patients underwent: depression intensity assessment with the Beck
depression inventory; anxiety assessment with the state–trait anxiety inventory; a symptom-limited exercise test during
which were analysed: maximal workload, duration, double product.
Results: In women the initial depression intensity was higher than in men, and decreased significantly after the
training programme (14.8±8.7 vs. 10.5±8.8; P<0.01). The anxiety manifestation for state anxiety in women was higher
than in men and decreased significantly after the training programme (45.7±9.7 vs. 40.8±0.3; P<0.01). Of note, no
depression and anxiety manifestation was found in men. Physical capacity improved significantly after the training
programme in all groups, and separately in men and in women. Moreover, an 8-week training programme favourably
modified the parasympathetic tone.
Conclusions: Participating in the exercise training programme contributed beneficially to a decrease in depression
and anxiety manifestations in women post-myocardial infarction. Neither depression nor anxiety changed significantly
in men. The impact of exercise training on physical capacity and autonomic balance was beneficial and comparable
between men and women.

Keywords
Exercise only-based rehabilitation, coronary artery disease, depression, anxiety

Date received: 9 May 2016; revised: 25 October 2016; accepted: 10 November 2016

Introduction
The benefits of comprehensive cardiac rehabilitation (CR) after myocardial infarction (MI) and are also strong pre-
and supervised exercise training for patients with coronary dictors of mortality.5–9 Approximately 65% of patients
artery disease (CAD) have been known to be very good for
many years. Published studies have shown that CR reduced
1Department of Cardiac Rehabilitation and Noninvasive
the rates of all-cause and cardiac mortality, the incidence
Electrocardiology, Institute of Cardiology, Warsaw, Poland
of acute cardiac events, hospital readmission, and miti- 2Department of Arrhythmia, Institute of Cardiology, Warsaw, Poland

gated cardiovascular disease progression.1–4

Corresponding author:
Apart from improving physical capacity, the effects of
Iwona Korzeniowska-Kubacka, Department of Cardiac Rehabilitation
CR include the modification of the symphato-vagal bal- and Noninvasive Electrocardiology, Institute of Cardiology, Alpejska 42,
ance and improving mental competence. Anxiety and 04-628 Warsaw, Poland.
depression are commonly observed risk factors in patients Email: drkubacka@wp.pl
Korzeniowska-Kubacka et al. 391
Figure 1.  Flow chart of the study patients.
CR: cardiac rehabilitation.
with acute MI report symptoms of depression. Major
depressive disorder is present in 15–20% of these patients,
the remainder have moderate depression.8 The manifesta-
tion of major depression should be treated with psycho-
logical therapy and, if necessary, with pharmacotherapy.9
Most post-MI patients, especially women, present with
moderate depressive disorder associated with the disease.8
Participating in comprehensive CR improves depression
and anxiety manifestations.10–15 The question arises: can
exercise-only-based rehabilitation without the psychologi-
cal therapy element decrease depression and anxiety mani-
festations in post-MI patients. The literature available
contains no reports on this issue.
The aim of the study was to assess the effectiveness of
exercise training on depression, anxiety, physical capacity
and sympatho-vagal balance in patients after MI and com-
pare differences between men and women.
Methods
Between January and December 2014, 225 consecutive
patients (158 men and 67 women), three months after MI,
referred to the ambulatory part of the Department of
Cardiac Rehabilitation, were screened for inclusion in the
study. Inclusion criteria were: sinus rhythm, preserved left
ventricular function (ejection fraction >50%), clinical sta-
bility for at least two weeks prior to entry to the study plus
optimal and stable medical treatment. Exclusion criteria
were: unstable angina, congestive heart failure, uncon-
trolled hypertension, valvular heart disease, impaired renal
or hepatic function.
After exclusions, 62 patients were enrolled into the
study protocol (see Figure 1).
Study protocol
At entry, eligible patients underwent clinical examination,
ECG, echocardiography, exercise stress test on a cycloer-
gometer (EST) and baseline psychological evaluation.
After initial investigation, patients underwent an
8-week training programme (TP) consisting of 24 inter-
val trainings three times a week, started on average three
months after MI.
The study protocol was approved by the Institutional
Ethics Committee on Human Research, and each partici-
pant gave their written informed consent.
392 European Journal of Cardiovascular Nursing 16(5)
Psychological evaluation
Before the TP each patient filled out the state–trait anxiety
inventory (STAI) including assessment of state-anxiety
(A-state) and trait-anxiety (A-trait) and the Beck depression
inventory (BDI), which assessed depression intensity. As
A-trait is known to be a constant for each individual, only
A-state and BDI were analysed after completion of the TP.16
Depressive disorders were diagnosed in patients whose
BDI outcome was 10 points or more.17,18 However, accord-
ing to the STAI standards for post-MI patients, the criterion
of dividing the anxiety level into low and high was 44 points
for the A-state subscale and 46 for the A-trait subscale.17,19
Exercise stress test
All patients underwent a symptom-limited EST performed
on a cycloergometer with the workload increased every 3
minutes by 50 Watts using a computerised system Case
8000 (Marquette Electronics, Milwaukee, WI, USA).
A 3-lead ECG was monitored continuously before, dur-
ing and for 10 minutes after the test. The test was discon-
tinued in the case of fatigue, arterial blood pressure (BP)
increase over 230/120 mmHg, ST segment depression by
at least 2 mm and/or anginal pain. The test was considered
positive when ST segment depression of at least 1 mm was
horizontal or down-sloping, 80 ms beyond the J point. The
following parameters were analysed: maximal workload
(W), duration (minutes), double product (DP, mmHg/min),
heart rate (HR, bpm) at rest and at peak effort and HR
recovery in the first (HRR1) and second minute (HRR2) of
the recovery period, which is thought to reflect the reacti-
vation of the parasympathetic nervous system after effort.
Exercise training
Interval training was planned according to the guidelines
on exercise prescription in CAD patients.1 Patients were
qualified for the TP on the basis of their EST results. The
limit of training HR was calculated as the sum of resting
HR and 60–80% of HR reserve, i.e. the difference between
maximal and resting HR. All of them underwent 24 inter-
val trainings on a cycloergometer three times a week. Each
training session lasted 40 minutes and included a 2-minute
warm-up, six 4-minute exercise bouts separated by 2-
minute rests in between with gradually increased workload
until the HR limit achieved during EST was reached.
During each session ECG, HR and BP were measured at
baseline, at the end of each interval and at recovery. The
training was documented by a written protocol.
Statistical analysis
Statistical analysis was performed using SAS statistical
software (version 8.2; Cary, NC, USA). All data were
expressed as mean±SD or as percentages. Student’s
t-test for matched pairs or the analysis of variance were
used to compare the parameters of a continuous type in
the groups studied, when the distribution of variables did
not differ significantly from the normal distribution;
when it did, a non-parametric rank test was used. In
order to assess the differences of categorised parameters
in the groups, the chi-square test was used when the
number was high enough or Fisher’s exact test when it
was not significant.
Multivariate regression analysis with stepwise method
selection of variables was done to assess the association
between exercise-induced changes in anxiety and depres-
sion and such variables as: age, sex, hypertension, time to
CR after MI and physical capacity.
A P value less than 0.05 was considered statistically
significant.
Results
Of the 225 patients referred for CR, we analysed 62
patients: 32 men aged 56.3±7.6 years and 30 women aged
59.2±8.1 years, with stable angina pectoris (Canadian
Cardiovascular Society class I or II) and preserved left
ventricular function (Figure 1).
The clinical characteristics of the patients studied are
listed in Table 1. Most of them had hypertension and
hypercholesterolemia. There were no differences between
men and women in terms of age, coronary risk factors,
clinical status and concomitant medication. Our female
patients were waiting for CR longer, however non-signifi-
cantly, than men.
In all studied heterogenic groups depression intensity
decreased significantly after the TP.
As at entry male patients were depression-free and its
intensity was higher in women than in men, this beneficial
effect after the TP was caused by a significant decrease in
depression manifestations in women (Figure 2).
The anxiety manifestation for A-trait was found to be
45±9.3 points for all groups and was significantly higher in
women than in men (48.4±8.6 vs. 41.8±9.0 points;
P<0.01). Although the initial anxiety level for A-state
decreased significantly after the TP (42.8±10.8 vs.
40.1±8.9 points; P<0.01) in all study groups, it was mainly
caused by a decrease of higher anxiety manifestations
observed in women than in men before the TP (45.7±9.8
vs. 40.1±11.3; P<0.05) (Figure 3).
Physical capacity improved significantly after the TP in
all studied group and separately in men and in women
(Figure 4). In all groups, an increase in EST duration
amounted to 23.6% and in workload to 23.7%, whereas in
men they amounted to 22.8% and 29.0%, respectively, and
in women to 26.2% and 22.4%, respectively. DP at rest
was significantly lower after the TP in all groups, and sep-
arately in men and women too. Moreover, DP at peak
Korzeniowska-Kubacka et al. 393

Table 1.  Clinical characteristics of the study group.

All groups (n=62) Men (n=32) Women (n=30) P value

Age, years 58.1 ± 7.4 56.3 ± 7.6 59.2 ± 8.1 NS
History of MI, n (%) 62 (100) 32 (100) 30 (100) NS
Hypertension, n (%) 37 (59.7) 19 (59.4) 18 (60) NS
Type 2 DM, n (%) 8 (12.9) 5 (15.6) 3 (10) NS
Hypercholesterolemia, n (%) 43 (70) 28 (87.5) 15 (51.7) NS
Time to cardiac rehabilitation, days 91.5 ± 108.2 72.2 ± 69.3 98.7 ± 128.0 NS
LVEF (%) 53.3 ± 9.0 53.2 ± 9.3 52.8 ± 8.6 NS
Medications
Β-blockers, n (%) 61 (98.4) 31 (96.9) 30 (100) NS
ACE-I, n (%) 50 (80.6) 27 (84.4) 23 (79.3) NS
Statins, n (%) 62 (100) 32 (100) 30 (100) NS
Clopidogrel, n (%) 62 (100) 32 (100) 30 (100) NS
Aspirin, n (%) 61 (98.4) 32 (100) 29 (96.6) NS

Data are expressed as mean ± SD or number (percentage).

ACE-I: angiotensin-converting enzyme inhibitors; LVEF: left ventricular ejection fraction; MI: myocardial infarction; DM: diabetes mellitus.

Figure 2.  Depression manifestations in all studied groups and separately in men and women before and after the training
programme. See Table 1 for numbers in each group. All values are mean±SD.
*P<0.05, **P<0.01 vs. baseline.

effort increased in all groups by 17.9%, and was caused
mainly by a significantly greater increase in men than in
women (26.4% vs. 8.0 %; P<0.01).
In addition, an 8-week TP resulted in a significant
improvement in such variables of parasympathetic activity
as HRR2 in men and HR at rest in women. The remaining
parameter, i.e. HRR1 also improved but without signifi-
cant differences.
Of note, multivariate logistic regression analysis did
not show associations between exercise-induced changes
in anxiety and depression and such variables as: age,
sex, hypertension, time to CR after MI and physical
capacity.
The health status was stable in all patients during the
study, and in none of them were any adverse effects of
exercise training observed. Moreover, there were no drop-
outs from our study.
Discussion
To the best of our knowledge, our study was the first which
assessed the influence of exercise training alone on depres-
sion and anxiety in post-MI patients.
We found that exercise-only-based CR without profes-
sional psychological intervention decreased depression
and state anxiety levels in the whole heterogenic group and
in the subgroup of women. It should be emphasised that
women in our study presented with higher levels of depres-
sion and both state and trait anxiety than men, which con-
curs with the literature.7 One of the reasons might be that
394 European Journal of Cardiovascular Nursing 16(5)

Figure 3.  Anxiety as state in all studied groups and separately in men and women before and after the training programme. See
Table 1 for numbers in each group. All values are mean±SD.
*P<0.05, **P<0.01 vs. baseline.

Figure 4.  Changes in the results of exercise stress tests in all studied groups and separately in men and women before and after
the training programme. Percentage changes from the results of the baseline EST are plotted. See Table 1 for numbers in each
group. All values are mean±SD.
*P<0.05, **P<0.01, #P<0.001 vs baseline.

the length of time spent on the waiting list before CR,
despite being non-significantly longer than in men, influ-
enced the psychological status in our female patients.
Depression is highly prevalent in cardiac patients, but is
also a risk factor for cardiac morbidity and mortality, inde-
pendent of traditional risk factors.5,6 Importantly, the
reduction in depressive symptoms was related not only to
lower mortality, but also to an improvement in physical
capacity.10–12
To date, there have been only a few studies assessing
the effects of comprehensive CR on anxiety and depres-
sion in heterogenous groups of patients with CAD.11–15
Korzeniowska-Kubacka et al. 395
Literature reports say that approximately 80% of CAD
patients present with a moderate level of depression and
anxiety.7 In addition, not all patients can undergo compre-
hensive CR with psychological support. Therefore, the
question arises whether exercise-only-based CR might be
a sufficient intervention in reducing such negative psycho-
logical symptoms as depression and anxiety.
A number of factors can contribute to the benefits of
exercise training, including a reduction in inflammation,
improvement of endothelial function, and more favourable
fibrinolytic and sympatho-vagal balance.1,7,8,10 The sys-
temic review performed by Jolliffe et al. and updated by
Anderson et al. revealed that exercise-only-based CR or
comprehensive CR similarly reduced total and cardiovas-
cular mortality and hospital admissions but not non-fatal
MI when compared with usual care.20,21 Nevertheless, these
meta-analyses failed to show whether exercise-only-based
CR or comprehensive CR had any effect on the revasculari-
sation rate, BP, smoking behaviour or quality of life.
As mentioned above, we found that an 8-week TP not
only favourably influenced depression and anxiety mani-
festations but also led to a significant improvement in
physical capacity in all trained patients and separately in
men and women. The positive effects of exercise training
on physical capacity have been well documented. Yet,
most studies have been performed on men or heterogenic
groups.1–4 Women are still underrepresented in many car-
diovascular clinical trials, while important gender differ-
ences are present within most areas of heart disease.22
Moreover, women are less likely to be referred for CR.
This disparity occur despite the documentation that both
genders receive equal benefit from participation in CR,
which included exercise training.23,24
Beyond the beneficial impact of regular exercise training
on physical capacity a shift of the sympatho-vagal balance
toward parasympathetic dominance has been observed.
The literature shows that parasympathetic activity is
higher in people who do exercises than in those who do
not. Such parasympathetic parameters as HR, HRR and
HR variability have been shown to improve in people
undergoing exercise training.25–27 On the other hand,
increased sympathetic activity is associated with an
increased risk of cardiac events and death.28 Importantly,
the activity of the autonomic nervous system can be
easily obtained during the standard EST using the HR
profile.23 In our study we assessed such variables of par-
asympathetic activity as HRR and HR and found that
an 8-week exercise training resulted in a significant
improvement in HRR2 in men and HR at rest in women.
Similarly, Giallauria et al. found that a three-month TP
favourably modified HRR in post-MI patients and HRR
response correlated with the improvement in cardiopul-
monary EST parameters.29
Taking into account that HR response in the first and
second minute after EST ending is known to be a strong
predictor of mortality in patients after MI, regular exercise
training should be advised for patients with known cardio-
vascular diseases.
In summary, we found that depression and anxiety were
present only in our female patients and decreased signifi-
cantly after exercise-only-based CR. Moreover, exercise
training as the basic element of post-MI CR resulted in an
improvement of physical capacity and sympatho-vagal
balance, i.e. parameters for good prognosis in CAD
patients, in both men and women. Undergoing exercise
training within CR may be considered a sort of life insur-
ance policy in post-MI patients. Further studies are needed
to confirm the long-term clinical utility of exercise therapy
on psychological status.
Limitations
An acknowledged limitation of this study is the lack of a
non-exercised control group; however, at present it was
considered unethical to suggest that post-MI patients avoid
physical activity. Moreover, small patient numbers limit
the generalisability of our results.
Conclusions
Participating in an exercise TP beneficially contributed to
a decrease in depression and anxiety manifestations in
post-MI women. Neither depression nor anxiety changed
significantly in men. The impact of exercise training on
physical capacity and autonomic balance was beneficial
and comparable between men and women.
Implications for practice
•• Anxiety and depression are commonly observed
in post-myocardial infarction patients, especially
in women.
•• Regular exercise training should be advised for
post-myocardial infarction women to reduce
such negative psychological symptoms as
depression and anxiety.
•• Exercise-only-based rehabilitation is helpful in
obtaining better physical capacity and sympatho-
vagal balance, which are thought to influence
prognosis favourably in post-myocardial infarc-
tion patients.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support from any funding
agency in the public, commercial, or not-for-profit sectors for the
research, authorship, and/or publication of this article.
396 European Journal of Cardiovascular Nursing 16(5)
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