EURO PEAN

SO CIETY O F
Original scientific paper CARDIOLOGY ®

European Journal of Preventive

Cardiology

Insufficient control of exercise 19(3) 436–443

! The European Society of
Cardiology 2011
intensity by heart rate monitoring Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
in cardiac patients DOI: 10.1177/1741826711406832
ejpc.sagepub.com

Falko Frese, Philipp Seipp, Susanne Hupfer, Peter Bärtsch and

Birgit Friedmann-Bette

Abstract
Objectives: To test the reliability of heart rate (HR) recommendations for cardiac rehabilitation training obtained from
different treadmill tests.
Background: For training in cardiac rehabilitation, HR recommendations are derived from cardio-pulmonary tests.
Exercise intensity is often controlled through self-monitoring HR by the cardiac patients.
Design: Non-randomized clinical trial.
Methods: 25 patients of a cardiac sports group (six women, 19 men, age 68.3  5 years, height 171  10 cm, weight
82  12.8 kg) performed a stepwise increasing treadmill test according to a modified Stanford protocol (S) and a ramp
treadmill test according to the Balke–Ware protocol (B) until volitional exhaustion. In 16 patients, HR was assessed with
a HR monitor and compared with HR obtained by self-monitoring through pulse palpation during three training sessions.
Results: Similar peak cardiopulmonary responses were obtained with the two exercise protocols of significantly
(p < 0.001) different duration (S 22:05  7:11 min, B 13:31  4:20 min). During the training sessions, HR exceeded the
upper HR limit set at 85% HRpeak in 15 patients and in nine patients, higher HRpeak than in the exercise tests was observed.
Five participants did not accurately measure their HR by pulse palpation.
Conclusions: All but one patient of the cardiac sports group did not adhere to the HR recommendations derived from
incremental treadmill testing, most likely because volitional exhaustion occurred in both treadmill tests before maximal
cardiopulmonary responses were reached. In about 30% of the patients, training intensity could not be controlled by self-
monitoring because of inaccurate pulse palpation.

Keywords
Heart rate monitor, rehabilitation, training, treadmill protocol
Received 15 November 2010; accepted 18 March 2011

Introduction endurance training are usually provided as HR ranges

Exercise training plays an important role in cardiac
rehabilitation.1–3 In Germany, about 100,000 cardiac
patients participate in outpatient cardiac sports
groups during phase III of cardiac rehabilitation.4
The training in these groups aims at an improvement
in aerobic capacity (VO2max), endurance performance,
strength, and coordination. For regular continuous
endurance training in cardiac patients, an exercise
intensity of 40–80% VO2peak, has been recommended
for decades4–10 and positive effects of such training
were shown in many studies.11 Only recently, high-
intensity interval training has been discussed as alter-
native form of exercise in patients with coronary heart
disease.12–14 Intensity recommendations for the
on the basis of cardiopulmonary testing. In patients
with an exercise stress test performed without measure-
ment of gas exchange, the HR ranges are often set at
50–85% HRpeak or 40–80% of heart rate reserve
(HRR).6–10 If ergospirometry is performed target HR
can be derived from HR (VO2) at the anaerobic
Department of Sports Medicine, Medical Clinic, University Hospital
Heidelberg, Germany.
Corresponding author:
Falko Frese, Medical Clinic, Department of Sports Medicine,
University Hospital Heidelberg, Im Neuenheimer Feld 710, 69120
Heidelberg, Germany
Email: f.frese@web.de

Downloaded from cpr.sagepub.com at CARLETON UNIV on May 6, 2015

Frese et al.
threshold (AT).5,15 Usually, 85% of HRpeak obtained
by an exercise test to volitional exhaustion is regarded
as the upper and relatively safe limit.9,16
For several years, a modified Stanford protocol for
treadmill testing17 has been applied in our exercise lab-
oratory. Cardiac patients, who exercise until volitional
exhaustion, are given an upper heart rate limit at 85%
HRpeak for their training in the cardiac sports group
and for any further exercises. For HR control during
the cardiac sports sessions, patients are repeatedly
asked to palpate their carotid or radial pulse for
10–15 seconds. Preliminary observations indicated
HR above the 85% HRpeak limit in the absence of
symptoms or incidents. Therefore, we wondered: (a)
whether patients might not be able to reach HRpeak
during treadmill testing with the modified Stanford
protocol and might be given a too low upper HR
limit; and (b) if the patients were able to reliably mea-
sure their HR during training in the heart sport groups.
In the present study, we tested the hypothesis that
the cardiac patients might reach higher HRpeak and
VO2peak during the more often applied ramp test
according to the Balke–Ware protocol compared to
the modified Stanford protocol. Furthermore, to objec-
tify HR during typical cardiac sports sessions, HR was
recorded with HR monitors and compared to the
results of self-monitoring through palpation of the car-
otid or radial pulse.
Methods
Subjects
Twenty-five patients of the cardiac sports group (six
women, 19 men, age 68.3  5 years, height
171  10 cm, weight 82  12.8 kg, body mass index
27.9  3.4 kg/m2), which is supervised by our depart-
ment, volunteered to perform two different treadmill
exercise tests with respiratory gas analysis in random-
ized order, one test according to a stepwise increasing
exercise protocol (modified Stanford protocol)17 and
the other one according to a ramp exercise protocol
(Balke–Ware protocol).10,17 Written informed consent
was obtained in each case. The study was approved by
the Ethics Committee of the Medical Faculty of the
University of Heidelberg, Germany, and conformed
to the standards set by the Declaration of Helsinki.
Only patients with stable coronary heart disease, with-
out change of medication within the preceding 3
months, used to exercise testing in our laboratory,
able to perform the incremental testing to volitional
exhaustion without any other indication for terminat-
ing the exercise, and regularly participating in the
weekly sessions of the cardiac sports group were
included in the study.
Downloaded from cpr.sagepub.com at CARLETON UNIV on May 6, 2015
437
Exercise testing
The modified Stanford protocol (S)17 starts with 4 km
h1, 0% grade, followed by 5 km h1, 2.5% grade and
an increase of 2.5% grade every 3 min with 30 s of rest
(standing) in between the stages and a 5 min recovery
stage at 5 km h1, 0% grade. The Balke–Ware protocol
(B)10,17 has a steady treadmill speed of 5 km h1 while
grade (starting with 0%) is increased by 1% every
minute with also a 5 min recovery stage at 5 km h1,
0% grade. The two treadmill tests were conducted on a
motor-driven treadmill (Woodway, Weil am Rhein,
Germany) at the same time of day, about 2 hours
after a light meal and under the patient’s ordinary med-
ication, in randomized order within 2–6 days. During
the tests, the patients were verbally encouraged to
exercise until volitional exhaustion was reached.
12-lead-electrocardiogram (ECG) was monitored con-
tinuously throughout the test. Blood pressure was mea-
sured every 3 minutes. HR was recorded during the last
10 s of each exercise step from the continuously regis-
tered ECG (Custo Med, Ottobrunn, Germany). VO2,
VCO2, and ventilation (VE) were measured and
recorded continuously with an automated computer-
ized analysis system (Metalyzer 3; Cortex, Leipzig,
Germany). Before each test, gas sensors were calibrated
with known gas concentrations and the volume sensor
with a 3 l syringe according to the manufacturer’s
instructions. Peak values were calculated as 30 s aver-
age at the last step. Two independent investigators
determined the AT in the ramp exercise test applying
the V-slope method.18 For HR recommendations, the
upper limit was determined from the results of both
ergospirometries at 85% HRpeak. Furthermore, HR at
AT (from B) was determined.
HR monitoring during exercise in the cardiac
sports group
For comparing the exercise results with HR during the
cardiac sports sessions, patients were equipped with
HR monitors during three representative cardiac
sports sessions lasting 1 hour each. As HR was contin-
uously monitored and recorded wirelessly with a com-
puter (BlueRobin; BM Wireless, Högertshausen,
Germany) patients could not check their HR from the
HR monitor. They were repeatedly asked (five or six
times a session) to take their carotid or radial pulse for
10–15 seconds after certain exercises. Patients were
instructed by specially educated coaches and were
supervised by a medical doctor from our department.
Each session consisted of a warm-up phase, exercises
for invigoration and coordination, different game forms
with or without ball, and a game for about 10 min at
the end of the lesson. Because of technical malfunction
438 European Journal of Preventive Cardiology 19(3)

of the HR monitor or obvious patient’s inability to HRpeak. The total exercise time, however, was signifi-
palpate his or her own pulse, reliable results from cantly (p < 0.001) reduced with B compared with S
these cardiac sport sessions could only be assessed (Table 1).
from 16 patients. To compare the HR recorded by a
HR monitor with the HR assessed by self-monitoring HR monitoring during exercise in the cardiac
(palpation of the carotid or radial pulse, the recorded
HR was averaged over the same 10–15 seconds within
sports group
which the pulse was taken manually. Monitoring with a HR recorder revealed HR exceeding
Statistical analysis was performed with the software the upper limit set at 85% HRpeak in 15 patients (95%)
programs SigmaStat 3.5 and SigmaPlot 10.0 (Figure 2). Nine patients (56%) even reached higher
for Windows (Jandel Scientific, San Rafael, CA, HRpeak during 5–6 intervals on the average with an
USA). Data are presented as mean  standard devia- average interval duration of 5–20 s in the cardiac
tion. Differences between means of variables were eval- sports sessions compared with the exercise tests. With
uated with the Student’s paired t-test after normality different types of exercises performed during the car-
test had passed. The level of significance was set at diac sports sessions, HR varied considerably. We also
p  0.05. observed a high inter-individual variation for the fre-
quency (from 1–2 intervals to 15–18 intervals) and
duration (from 5 s to 6 min) of the intervals during
Results which 85% HRpeak of the exercise test was exceeded
(Figure 3). RERpeak in the nine patients with higher
Exercise testing
HRpeak in the cardiac sports sessions than in the exer-
The HRpeak (Figure 1), VO2peak, VCO2peak, and VEpeak cise tests was not significantly different from RERpeak
obtained with the two protocols, B and S, did not differ of the remaining seven patients (0.98  0.10 vs.
significantly. RERpeak and oxygen pulse were not sig- 0.99  0.07). The difference between HRpeak observed
nificantly different either (Table 1). Accordingly, simi- in the cardiac sports sessions and HRpeak in the exercise
lar upper heart rate limits at 85% HRpeak were assessed tests (
HRpeak) was not significantly correlated with
from both tests (B 112  19 bpm, S 115  18 bpm.). HR RERpeak (R ¼ 0.350, p ¼ 0.183). Analysis of HR simul-
at AT could only be determined in 17 out of the 25 taneously assessed with the HR monitor and by self-
patients (68%). It averaged 103  23 bpm (approxi- monitoring showed that five out of 16 (31%) partici-
mately 60% VO2peak) and was significantly lower pants of the cardiac sports group did not accurately
(p ¼ 0.006) than the upper heart rate limit at 85% measure their HR by palpation of the carotid or
radial pulse (Figure 4).

40
Discussion
One major finding of this study was that peak cardio-
pulmonary responses in elderly cardiac patients were
20 similar during treadmill testing when a ramp (B) or a
D HRBalke-stanford (bpm)

stepwise increasing exercise protocol (S) was applied in

spite of the significantly longer total exercise time
0
during S. Consequently, the upper HR limit for exercis-
ing in the cardiac sports group derived from the two
–20
exercise tests did not differ significantly. However, HR
assessment with heart rate monitors revealed HR well
above the upper HR limit in 95% of the patients during
–40 the ball games performed in the cardiac sports group.
90 100 110 120 130 140 150 160 170
Five of 16 (31%) patients were unable to accurately
Average HRpeak (bpm)
palpate their exercise pulses.
Mean difference Treadmill testing is commonly accepted for assessing
95% Limits of agreement
cardiopulmonary function and for determining exercise
prescription in young healthy people as well as in
Figure 1. Bland–Altman plot: difference between peak heart patients with chronic heart failure.19 Various maximal
rate (
HR) obtained from treadmill testing according to the exercise protocols are used10,17 and only few of them
Balke protocol (HRBalke) and according to the modified Standford have been compared. In three investigations,20–22 the
protocol (HRStandford) vs. average of HRBalke and HRStandford. Balke–Ware protocol, also applied in the present

Downloaded from cpr.sagepub.com at CARLETON UNIV on May 6, 2015

Frese et al. 439

Table 1. Peak cardiopulmonary responses during the exercise tests

Stanford protocol Balke–Ware protocol

Total exercise time (min) 22:05  7:11 13:31  4:20 (p < 0.001)
HRpeak (bpm) 135  21 132  22
VO2peak (ml/kgmin1) 28.4  5.9 28.4  6.1
VO2peak (l/min) 2.30  0.44 2.20  0.62
VCO2peak (l/min) 2.26  0.47 2.27  0.47
VEpeak (l/min) 84.0  21.8 81.2  21.2
RERpeak 0.98  0.07 0.99  0.06
VO2/HR (ml/bpm) 17.2  3.2 17.6  3.4
Values are mean  standard deviation.

HRmax in exercise test, sport lesson & upper HR limit

180

160

140
HR (bpm)

120

100

80
1 2 3 4 7 8 9 11 12 14 15 18 19 20 24 25

Subject-No.

HRmax assessed from stepwise exercise test

85%HRmax assessed from stepwise exercise test
Monitored HRmax in coronary sport lessons

Figure 2. Peak heart rate (HRpeak) and the upper heart rate limits determined at 85% HRpeak in the stepwise increasing exercise test
as well as HRpeak recorded by a HR monitor during cardiac sports sessions in 16 patients.

study, was compared to different stepwise increasing
protocols in healthy men and women. In all these stud-
ies, a significantly lower VO2peak was observed with the
Balke protocol compared to one of the stepwise
increasing protocols (Taylor, Bruce, modified
Astrand); however, no significant differences were
observed for HRpeak. To our knowledge, there are
only two investigations with elderly cardiac patients.
Comparison of the Bruce protocol and a modified
Bruce protocol with an individualized ramp protocol
(increase in step and grade every 30 s)23 and compari-
son of Bruce, Balke, and individualized ramp proto-
cols24 did not reveal any significant difference in
VO2peak and HRpeak between the treadmill protocols
applied in the respective study. Our results with similar
peak cardiopulmonary responses during the exercise
tests according to B and S are in agreement with
these previously reported findings.
Besides peak cardiopulmonary responses, the critical
power is regarded a useful parameter to assess the

Downloaded from cpr.sagepub.com at CARLETON UNIV on May 6, 2015

440 European Journal of Preventive Cardiology 19(3)

150
HR HR
HR HR
140 HR

130
HR
Upper HR limit
120
HR (bpm)

HR
110

100

90

80
Warmup Gymnastics Football
70
0 500 1000 1500 2000 2500 3000 3500
Time (s)

180
HR
160 HR
HR HR HR

140
Upper HR limit
HR
120
HR (bpm)

100

80
s
ni
n

n
io

en

io

ll
at

ba
t
l-t
up

ra

60
in

et
al

go
rd
m

sk
ftb
oo
ar

vi

Ba
So

In
W

40
0 500 1000 1500 2000 2500 3000 3500
Time (s)

Figure 3. Heart rate (HR) recorded with a HR monitor in two representative patients during two difference cardiac sports
sessions The arrows indicate the time points when the recorded HR was compared to the HR obtained by palpation of the carotid
or radial pulse.

functional status of patients with cardiovascular dis-
ease.15,25 It is often determined as the AT according
to the V-slope method.5,18 In the present study, AT
could not be determined in eight of 25 patients
(32%). This percentage is higher than the finding of
16.4% indeterminate AT in a multicentre study, in
which 1679 treadmill exercise tests of patients with
chronic heart failure were evaluated,25 and might be
explained by the much lower subject number of the
present investigation. HR determined at AT in the 17
patients of our study was equivalent to only about 60%
VO2peak. Such relatively low intensity is in accordance
with the observation that patients with chronic heart
failure can perform their habitual activities at absolute
and relative intensities higher than the AT.15,26
Therefore, it seems reasonable to assess an upper HR

Downloaded from cpr.sagepub.com at CARLETON UNIV on May 6, 2015

Frese et al.
100
50
D HRpalp-monitor (bpm)
10
0
–10
–50
–100
40 60
Figure 4. Bland–Altman plot: difference between HR obtained by palpation of the carotid or radial pulse (HRpalp) and recorded HR
(HRmonitor) (
HR) in 16 patients during 3 representative cardiac sports sessions vs. average of HRpalp and HRmonitor. The symbols
represent the values of different patients.
limit for training recommendations at a higher intensity
than the AT, around 85% HRpeak.6,10,15
The findings of some few investigations suggest a
tendency for cardiac patients to underestimate their
heart rate during exercise rehabilitation.27 In a study
investigating the self-regulation of cardiac patients
during 20 min of exercise on aerobic equipment (tread-
mill, bicycle, stairmaster, rower), only 16% of the par-
ticipants exercised within their target heart rates, 9%
exceeding their target heart rate by up to 20 bpm.28
In the present study, 15 of the 16 patients (95%),
whose HR could be assessed with a HR monitor
during cardiac sports sessions, exceeded the upper
heart rate limit of 85% HRpeak and nine patients
(56%) even exceeded HRpeak (21  17 bpm; 3–49
bpm) obtained in the treadmill tests during periods of
marked ambition and high group dynamics.
Apparently, volitional exhaustion during both tread-
mill tests had occurred before the maximum cardiopul-
monary response was achieved although similar peak
cardiopulmonary responses were reached on different
days in different tests. RERpeak of about 1.0 also
points into this direction. However, relatively lower
RERpeak did not indicate greater
HRpeak (HRpeak
recorded during the cardiac sports session minus
HRpeak reached in the treadmill test). No inverse
Downloaded from cpr.sagepub.com at CARLETON UNIV on May 6, 2015
441
95% limit of agreement
Preset clinical acceptance limit
80 100 120 140 160 180
Average HR (bpm)
correlation between RERpeak and
HRpeak was
observed and RERpeak measured in the nine patients
with higher HRpeak during the cardiac sports sessions
than in the treadmill tests was not significantly different
from RERpeak of the remaining seven patients.
With regard to the observation that high-intensity
interval training is more efficient for an improvement
of aerobic capacity in patients with coronary heart dis-
ease than moderate endurance training,13,14 ball games
with short periods of high-intensity exercise might be
recommended for supervised cardiac sports sessions.
To our experience, these games are highly accepted by
cardiac patients. Carefully designed and supervised,
ball games might be a means to subject stable cardiac
patients to high-intensity training. Nevertheless, testing
of cardiac patients should be adapted individually, e.g.
for the patients with increased HRpeak during the car-
diac sports sessions, treadmill tests with higher speed
(running) might be applied to reach exhaustion, moni-
tor the ECG during high intensities, and adjust training
recommendations.
Self-monitoring with the palpation of the carotid or
radial pulse seems to be an important instrument. In
contrast to the findings of Kosiek et al.28 who reported
that cardiac rehabilitation participants could accurately
palpate their exercise pulse rates, we observed wide
442
individual discrepancies between HR assessed with a
heart rate monitor and HR assessed by self-monitoring.
In only nine patients (69%), HR obtained with a HR
monitor and through palpation of the carotid or radial
pulse was within 10 bpm, what we regarded as
acceptable.
In conclusion, treadmill testing with a ramp protocol
(B) is time-saving compared with a stepwise increasing
protocol (S) to obtain similar cardiovascular responses
in cardiac patients. It seems that many of the patients
(56% in the present study) might not reach their max-
imal HR during the applied walking treadmill tests with
increasing grade and that alternative protocols have to
be chosen. As high HR is observed in short intervals
during ball games, such games might be included in
cardiac sports sessions as a form of high-intensity train-
ing. However, training HR should regularly be con-
trolled with objective methods as self-monitoring HR
is inaccurate in quite a number of the cardiac patients.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
None to declare.
References
1. Corra U, Piepoli MF, Carre F, Heuschmann P, Hoffmann
U, Verschuren M, et al. Secondary prevention through
cardiac rehabilitation: physical activity counselling and
exercise training: key components of the position paper
from the Cardiac Rehabilitation Section of the European
Association of Cardiovascular Prevention and
Rehabilitation. Eur Heart J 2010; 31(16): 1967–1974.
2. Hambrecht R. [Sports as therapy]. Herz 2004; 29(4):
381–390.
3. Piepoli MF, Corra U, Benzer W, Bjarnason-Wehrens B,
Dendale P, Gaita D, et al. Secondary prevention through
cardiac rehabilitation: from knowledge to implementation.
A position paper from the Cardiac Rehabilitation Section
of the European Association of Cardiovascular Prevention
and Rehabilitation. Eur J Cardiovasc Prev Rehabil 2010;
17(1): 1–17.
4. Schmidt-Trucksäss A and Herz-Kreislauf-Erkrankungen.
In: Dickhuth HH, Mayer F, Röcker K and Berg A (eds)
Sportmedizin für Ärzte. Köln: Deutscher Ärzte-Verlag,
2007. pp.421–429.
5. Carvalho VO and Mezzani A. Aerobic exercise training
intensity in patients with chronic heart failure: principles
of assessment and prescription. Eur J Cardiovasc Prev
Rehabil, Prepublished May 13, 2010; DOI: 10.1097/
HJR.0b013e32833a9c63.
6. Lavie CJ, Thomas RJ, Squires RW, Allison TG and
Milani RV. Exercise training and cardiac rehabilitation
Downloaded from cpr.sagepub.com at CARLETON UNIV on May 6, 2015
European Journal of Preventive Cardiology 19(3)
in primary and secondary prevention of coronary heart
disease. Mayo Clin Proc 2009; 84(4): 373–383.
7. Papathanasiou G, Tsamis N, Georgiadou P and
Adamopoulos S. Beneficial effects of physical training
and methodology of exercise prescription in patients with
heart failure. Hellenic J Cardiol 2008; 49(4): 267–277.
8. Selig SE, Levinger I, Williams AD, Smart N, Holland DJ,
Maiorana A, et al. Exercise & Sports Science Australia
Position Statement on exercise training and chronic heart
failure. J Sci Med Sport 2010; 13(3): 288–294.
9. Stilgenbauer F, Reißnecker S and Steinacker JM.
Herzfrequenzvorgaben für Ausdauertraining von
Herzpatienten. Dtsch Z Sportmed 2003; 54(10): 295–296.
10. Thompson WR, Gordon NF and Pescatello LS. Exercise
prescription for patients with cardiac disease.
In: Thompson WR, Gordon NF and Pescatello LS
(eds) ACSM’s guidelines for exercise testing and prescrip-
tion. Philadelphia: Lippincott Williams & Wilkins, 2010,
pp.207–224.
11. Lloyd-Williams F, Mair FS and Leitner M. Exercise
training and heart failure: a systematic review of current
evidence. Br J Gen Pract 2002; 52(474): 47–55.
12. Guiraud T, Juneau M, Nigam A, Gayda M, Meyer P,
Mekary S, et al. Optimization of high intensity interval
exercise in coronary heart disease. Eur J Appl Physiol
2010; 108(4): 733–740.
13. Rognmo O, Hetland E, Helgerud J, Hoff J and Slordahl
SA. High intensity aerobic interval exercise is superior to
moderate intensity exercise for increasing aerobic capac-
ity in patients with coronary artery disease. Eur J
Cardiovasc Prev Rehabil 2004; 11(3): 216–222.
14. Warburton DE, McKenzie DC, Haykowsky MJ, Taylor
A, Shoemaker P, Ignaszewski AP, et al. Effectiveness of
high-intensity interval training for the rehabilitation of
patients with coronary artery disease. Am J Cardiol
2005; 95(9): 1080–1084.
15. Mezzani A, Agostoni P, Cohen-Solal A, Corra U, Jegier
A, Kouidi E, et al. Standards for the use of cardiopulmo-
nary exercise testing for the functional evaluation of car-
diac patients: a report from the Exercise Physiology
Section of the European Association for Cardiovascular
Prevention and Rehabilitation. Eur J Cardiovasc Prev
Rehabil 2009; 16(3): 249–267.
16. Steinacker JM, Liu Y and Reißnecker S.
Abbruchkriterien bei der Ergometrie. Dtsch Z Sportmed
2002; 53(7): 228–229.
17. Balady GJ, Berra KA, Golding LA, Gordon NF, Mahler
DA, Myers DA, et al. Exercise prescription for cardiac
patients. In: Franklin BA, Whaley MH and Howley ET
(eds) ACSM’s guidelines for exercise testing and prescrip-
tion. Philadelphia, Baltimore, New York, London,
Buenos Aires, Hong Kong, Sydney, Tokyo: Lippincott
Williams & Wilkins, 2000, pp.165–199.
18. Beaver WL, Wasserman K and Whipp BJ. A new method
for detecting anaerobic threshold by gas exchange. J Appl
Physiol 1986; 60(6): 2020–2027.
19. Fletcher GF, Balady GJ, Amsterdam EA, Chaitman B,
Eckel R, Fleg J, et al. Exercise standards for testing and
training: a statement for healthcare professionals from
Frese et al.
the American Heart Association. Circulation 2001;
104(14): 1694–1740.
20. Froelicher Jr. VF, Brammell H, Davis G, Noguera I,
Stewart A and Lancaster MC. A comparison of the
reproducibility and physiologic response to three maxi-
mal treadmill exercise protocols. Chest 1974; 65(5):
512–517.
21. Pollock ML, Bohannon RL, Cooper KH, Ayres JJ, Ward
A, White SR, et al. A comparative analysis of four pro-
tocols for maximal treadmill stress testing. Am Heart J
1976; 92(1): 39–46.
22. Pollock ML, Foster C, Schmidt D, Hellman C, Linnerud
AC and Ward A. Comparative analysis of physiologic
responses to three different maximal graded exercise test
protocols in healthy women. Am Heart J 1982; 103(3):
363–373.
23. Bader DS, Maguire TE and Balady GJ. Comparison
of ramp versus step protocols for exercise testing in
patients > or ¼ 60 years of age. Am J Cardiol 1999;
83(1): 11–14.
Downloaded from cpr.sagepub.com at CARLETON UNIV on May 6, 2015
443
24. Myers J, Buchanan N, Walsh D, Kraemer M, McAuley
P, Hamilton-Wessler M, et al. Comparison of the ramp
versus standard exercise protocols. J Am Coll Cardiol
1991; 17(6): 1334–1342.
25. Myers J, Goldsmith RL, Keteyian SJ, Brawner CA,
Brazil DA, Aldred H, et al. The ventilatory anaerobic
threshold in heart failure: a multicenter evaluation of reli-
ability. J Card Fail 2010; 16(1): 76–83.
26. Tabet JY, Meurin P, Teboul F, Tartiere JM, Weber H,
Renaud N, et al. Determination of exercise training level
in coronary artery disease patients on beta blockers. Eur
J Cardiovasc Prev Rehabil 2008; 15(1): 67–72.
27. Ekkekakis P. Let them roam free? Physiological and psy-
chological evidence for the potential of self-selected exer-
cise intensity in public health. Sports Med 2009; 39(10):
857–888.
28. Kosiek RM, Szymanski LM, Lox CL, Kelley G and
MacFarlane PA. Self-regulation of exercise intensity in
cardiac rehabilitation participants. Sports Med Train
Rehabil 1999; 8(4): 359–368.