344 Original article
Routine initial exercise stress testing for treatment
stratification in comprehensive cardiac rehabilitation
Annett Salzwedela, Angelika Riecka, Rona K. Reibisb and Heinz Völlera,c
There is evidence of substantial benefit of cardiac
rehabilitation (CR) for patients with low exercise capacity at
admission. Nevertheless, some patients are not able to
perform an initial exercise stress test (EST). We aimed to
describe this group using data of 1094 consecutive patients
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after a cardiac event (71 ± 7 years, 78% men) enrolled in nine
centres for inpatient CR. We analysed sociodemographic and
clinical variables (e.g. cardiovascular risk factors,
comorbidities, complications at admission), amount of
therapy (e.g. exercise training, nursing care) and the results
of the initial and the final 6-min walking test (6MWT) with
respect to the application of an EST. Fifteen per cent of
patients did not undergo an EST (non-EST group). In
multivariable analysis, the probability of obtaining an EST
was higher for men [odds ratio (OR) 1.89, P = 0.01], a 6MWT
(per 10 m, OR 1.07, P < 0.01) and lower for patients with
diabetes mellitus (OR 0.48, P < 0.01), NYHA-class III/IV (OR
0.27, P < 0.01), osteoarthritis (OR 0.39, P < 0.01) and a longer
hospital stay (per 5 days, OR 0.87, P = 0.02). The non-EST
group received fewer therapy units of exercise training, but
more units of nursing care and physiotherapy than the EST
Introduction
Comprehensive inpatient cardiac rehabilitation (CR) should
be considered a part of integrated healthcare for patients
after an acute cardiac event including coronary artery disease
and heart valve surgery. According to German and European
Guidelines, CR consists of cardiovascular risk factor man-
agement, life style counselling, psychological support and
vocational advice as core components (Bjarnason-Wehrens
et al., 2007a, 2007b; Corrà et al., 2010; Piepoli et al., 2010).
A symptom-limited exercise testing at admission to CR is
recommended to determine individual exercise capacity,
blood pressure pattern and training heart rate (Bjarnason-
Wehrens et al., 2009; Vanhees et al., 2012). There is con-
sistent evidence that patients with low exercise capacity at
admission benefit from CR as well (Pollock et al., 2000;
Pasquali et al., 2001; Leon et al., 2005). This includes patients
with coronary artery disease as well as patients with inter-
ventionally treated heart valve diseases, predominantly after
transcatheter aortic valve implantation, who are mostly older
and in a generally weakened condition. A considerable pro-
portion of these patients are unable to perform an exercise
stress test (EST) at admission (Russo et al., 2014). This
growing population is largely under-represented in the recent
literature and consequently has not been satisfactorily
described as yet.
0342-5282 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
group. However, there were no significant differences
between both groups in the increase of the 6MWT during CR
(123 vs. 108 m, P = 0.122). The present study confirms the
feasibility of an EST at the start of CR as an indicator of
disease severity. Nevertheless, patients without EST benefit
from CR even if exercising less. Thus, there is a justified
need for individualized, comprehensive and
interdisciplinary CR. International Journal of Rehabilitation
Research 38:344–349 Copyright © 2015 Wolters Kluwer
Health, Inc. All rights reserved.
International Journal of Rehabilitation Research 2015, 38:344–349
Keywords: disease severity, exercise stress test,
multimodal cardiac rehabilitation, rehabilitation outcome, therapy volume
a
Centre of Rehabilitation Research, University of Potsdam, bCardiological
Outpatient Clinic Am Park Sanssouci, Potsdam and cKlinik am See, Rehabilitation
Centre for Internal Medicine, Rüdersdorf, Germany
Correspondence to Annett Salzwedel, Centre of Rehabilitation Research,
University of Potsdam, Am Neuen Palais 10, D-14469 Potsdam, Germany
Tel: + 49 331 977 4063; fax: + 49 331 977 4081;
e-mail: annett.salzwedel@uni-potsdam.de
Received 24 July 2015 Accepted 30 July 2015
In the present study, we aimed to identify socio-
demographic and clinical predictors for the feasibility of
an initial EST in a consecutive cohort of older in-hospital
CR patients.
In addition, we examined to what extent rehabilitative
procedures including exercise training, psychological
counselling and nursing were applied during CR in this
patient subgroup in comparison with those who were able
to perform EST. Finally, the rehabilitation outcome
measured by the increase in the 6-min walking test
(6MWT) was also investigated with respect to the feasi-
bility of EST.
Methods
Patients and cardiac rehabilitation
We analysed data of 1094 patients after an acute coronary
event (aged 71 ± 7 years, 78% men), insured by a German
health insurance company (Techniker Krankenkasse,
Hamburg), who were consecutively enrolled in nine
centres for inpatient CR between 2009 and 2010. All
patients underwent a standardized comprehensive in-
patient CR programme of 3–4 weeks’ duration starting
9.9 ± 22.4 days after discharge from the hospital. The
rehabilitation programme includes individualized physi-
cal training, disease information and structured teaching
DOI: 10.1097/MRR.0000000000000133

programmes to reduce cardiovascular risk factors and
psychological support. In all participating centres, a
symptom-limited bicycle EST on a cycle ergometer at
admission was usually performed for determining toler-
able exercise intensity (W), training heart rate and blood
pressure regulation. The EST was carried out under the
supervision of a physician using a stepwise stress proto-
col, starting with 25 W (or 50 W depending on clinical
stability) and increasing the workload in 25 (or 50) W
increments every second minute until the patient was
exhausted or clinical reasons that result in premature
termination of EST (arrhythmias, ischaemia). During the
exercise test, a 12-lead ECG was recorded continuously.
In addition, blood pressure was controlled every 2 min.
During CR, sociodemographic variables (e.g. age, sex, liv-
ing alone or in family, level of education), indication for
CR, cardiovascular risk factors, relevant comorbidities (such
as peripheral artery disease, chronic obstructive pulmonary
disease, congestive heart failure, stroke, chronic back pain,
cancer, osteoarthritis including arthrosis, rheumatic and
nonrheumatic arthritis), complications at the beginning of
CR (including wound-healing impairment, pleural or
pericardial effusion), duration of hospital stay, as well as
echocardiographic data and laboratory parameters were
documented and merged in a central database.
A standardized 6MWT was performed according to the
guidelines of the American Thoracic Society (ATS
Committee on Proficiency Standards for Clinical Pulmonary
Function Laboratories, 2002) using a wheel roll tachometer
or a corridor of defined length depending on the local
situation. Patients were asked to walk continuously at a
steady pace for 6 min to quantify the maximum walking
distance (m). 6MWT was performed at admission and dis-
charge of CR to register both the maximum and the dif-
ference between the tests (Δm). In addition, we considered
the therapeutic volume (total minutes) in different cate-
gories (e.g. physical training, nursing care, patient educa-
tion). All variables were examined as a function of the
application of an EST (EST or non-EST group).
Only patients who had fully completed the CR pro-
gramme were enrolled; patients who died or were
retransferred to hospital during the rehabilitation period
were excluded.
Statistical analysis
Continuous variables are expressed as means ± SD and
categorical variables as frequencies and percentages.
Comparisons between groups were performed using the
χ2 test and the t-test. The initially large set of patient
characteristics was reduced to a reasonable number of
predictor variables for the application of an EST. To
achieve this, theoretically meaningful variables and
variables found to be significant in bivariate analysis
(P ≤ 0.1) were entered into multivariable logistic regres-
sion. In stepwise processes, variables were included in
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Exercise stress test in cardiac rehabilitation Salzwedel et al. 345
and excluded from the model according to their P-values
and their contribution to measures of model fit (Cox and
Snell’s as well as Nagelkerke’s pseudo R2). Thus, vari-
ables with independent influences on EST were retained
in the model. Age was considered basic and retained in
the model even if not significant. In addition to main
effects, potential interactions between pairs of covariates
were assessed. Effects with a P-value of less than 0.05
(two-sided) were considered significant. The effect-size
estimates [odds ratios (OR)] of the independent predictor
variables of the final model are shown with 95% con-
fidence intervals and P-values. Calculations were carried
out using SPSS 22.0 (IBM, Chicago, Illinois, USA).
Results
In the 1094 patients analysed, the most common indi-
cations for CR were coronary artery bypass grafting
(33%), percutaneous coronary intervention (21%) with or
without acute coronary syndrome and heart valve repla-
cement or reconstruction (14%). Detailed patient char-
acteristics are shown in Table 1.
For 166 patients (15%), no baseline values for the EST
were available. These patients (non-EST group) were
significantly older and more often female than patients of
the EST group. Moreover, they had a longer hospital stay
for the index event, showed complications more often at
the start of CR, had a higher proportion of NYHA-class
III/IV and a higher number of comorbidities. In bivariate
analysis, significant group differences were found for
variables such as diabetes mellitus, pulmonary hyper-
tension (maximum systolic pulmonary arterial
pressure ≥ 30 mmHg), atrial fibrillation, stroke, peripheral
artery disease, osteoarthritis and chronic back pain. In
contrast, smoking behaviour, obesity, left ventricular
ejection fraction or pericardial effusion at admission were
comparable between the EST and the non-EST group
(Table 1).
In multivariable regression, adjusted for the centre effect,
the probability of obtaining an EST was significantly
higher for male patients (OR 1.89, P = 0.013), a longer
maximum walking distance at admission to CR (per 10 m,
OR 1.07, P < 0.001) and a higher level of education (OR
2.85, P = 0.004) (Fig. 1). Diabetes mellitus (OR 0.48,
P = 0.004), NYHA-class III/IV (OR 0.27, P < 0.001), pre-
sence of osteoarthritis (OR 0.39, P = 0.008) and a longer
hospital stay (OR 0.97, P = 0.023) were associated with a
lower probability for the EST. Age at admission failed to
achieve significance in the multivariable analysis
(P = 0.669). Nagelkerke’s pseudo R2 for the final model
was 0.77 (Fig. 1).
Patients of the non-EST group received significantly less
therapeutic units of exercise training (428 vs. 761 min,
P < 0.001) and education (694 vs. 751 min, P = 0.019)
during CR, but more units of nursing care (554 vs.
60 min, P < 0.001), physiotherapy/physical therapy (768
346 International Journal of Rehabilitation Research 2015, Vol 38 No 4

Table 1 Baseline characteristics and bivariate associations in the class III/IV. This combination of variables describes a
application of exercise stress test (n = 1094)
specific subgroup of patients with a generally higher
Overall EST performed severity of disease irrespective of the underlying cardio-
Mean ± SD
vascular disease.
or % Yes (n = 928) No (n = 166) P-value
In multivariable analysis, the level of education showed a
Age (years) 70.9 ± 7.0 70.4 ± 6.8 73.3 ± 7.8 < 0.001
Sex (male) 78.4 81.4 62.0 < 0.001
high predictive impact on the feasibility of EST. The
Educational 29.2 31.2 18.1 0.001 probability to perform an EST was much greater for
achievement (higher higher educated patients (university degree or equiva-
education)
CR indication (after 61.4 62.3 56.6 0.169 lent) than for those with a lower level of education
surgery) (OR =2.85). This variable showed stable patterns
Duration of hospital 12.5 ± 8.2 11.9 ± 7.2 15.8 ± 11.6 < 0.001
stay (days)a
throughout the statistical modelling and should therefore
Risk factors not be ignored.
Diabetes mellitus 26.2 24.3 36.7 0.001
Arterial hypertension 83.6 83.1 86.1 0.330 A Canadian study in CR enrollees described a positive
Pulmonary 13.1 10.8 25.9 < 0.001
hypertension
correlation between greater education and higher disease-
Smokers and former 13.9 14.4 10.8 0.219 related knowledge at admission to CR. Besides, knowl-
smokers (< 5 years edge was associated positively with physical activity and
abstinence)
Obesity 16.5 16.4 17.5 0.728 nutrition in this study (Ghisi et al., 2015). In addition, a
(BMI ≥ 30 kg/m2) higher level of education appears to have a huge effect on
Clinical characteristics
Complications at CR 5.6 5.0 9.0 0.035
the treatment adherence of adult patients with somatic
startb chronic conditions (Mathes et al., 2014). Furthermore, a
LVEF ≤ 50% 29.1 28.3 33.7 0.157 low educational level was found to be an independent
Atrial fibrillation 14.1 12.2 24.7 < 0.001
Pericardial effusion 4.7 4.7 4.8 0.963 predictor of a poor self-reported health status, even after
Pleural effusiona 30.4 29.9 33.6 0.364 controlling for comorbidities, in a Norwegian cohort study
NYHA class III/IV 11.8 9.0 27.1 < 0.001
Comorbid conditions
of patients after aortic valve replacement with or without
Number 0.7 ± 1.0 0.7 ± 0.9 1.0 ± 1.1 < 0.001 concomitant bypass surgery (Oterhals et al., 2014). Finally,
Stroke 5.4 4.7 9.0 0.024 secondary and postsecondary education were verified as
PAD 6.7 5.9 12.7 0.001
Osteoarthritis 8.6 7.4 15.1 0.001 independent predictors for smoking cessation in an ana-
Chronic back pain 12.1 11.1 17.5 0.020 lysis of data from the Canadian Community Health
CR, cardiac rehabilitation; EST, exercise stress test; LVEF, left ventricular ejection
Survey involving more than 170 000 patients with cere-
fraction; NYHA, New York Heart Association; PAD, peripheral artery disease. brovascular diseases (Edjoc et al., 2015).
a
Duration of hospital stay was missing in 92 patients. Pleural effusion was missing
in 197 patients. Consequently, it can be assumed that higher educated
b
The most frequent condition was impairment of wound healing (n = 50, 4.6%).
patients show better health behaviours already before
rehabilitation and thereby a better state of health.
vs. 554 min, P < 0.001) and occupational therapy (40 vs. However, a patient’s level of education appears to be a
14 min, P = 0.001). For sociomedical support, psycholo- complex measure that also encompasses physical and
gical interventions and therapy units for lifestyle change, behavioural factors.
there were no differences between the groups (Fig. 2).
Female patients entering CR frequently show a reduced
One hundred and twenty-two patients (73.5%) of the aerobic exercise capacity (Ades et al., 2006; Barth et al.,
non-EST group underwent the initial 6-min walk test 2009). Sex differences in terms of the acceptance, utiliza-
compared with 850 patients (91.5%) of the EST group. tion and intensity of CR programmes have been described
The maximum distance in the non-EST group was widely (Sanderson and Bittner, 2005; Bjarnason-Wehrens
shorter at the start (204.8 ± 169.4 vs. 369.8 ± 135.9 m, et al., 2007a, 2007b). Compared with men, women are older
P < 0.001) and at the end of CR (325.8 ± 175.9 vs. and more often affected by multimorbidity at the time of
469.6 ± 133.7 m, P < 0.001). Nevertheless, these patients myocardial infarction. In addition, women show a higher
increased their maximum walking distance during CR as prevalence of psychological distress such as depressive
much as the patients who performed the EST symptoms in the acute post-infarction phase (Sanderson
(123.0 ± 129.9 vs. 102.8 ± 103.8 m, P = 0.122). and Bittner, 2005; Bjarnason-Wehrens et al., 2007a, 2007b,
2008; Grande, 2008; Barth et al., 2009). Furthermore,
Discussion women of advanced age with coexisting metabolic dis-
Out of 1094 patients, 166 (15%) patients were unable to orders frequently present with motivational problems in
perform an initial EST. According to bivariate analysis, physical activity (Bjarnason-Wehrens et al., 2007a, 2007b).
these patients were older, had an increased number of Thus, in the present investigation, it must be considered
comorbidities, had a higher complication rate at admis- that women may have rejected the EST because of per-
sion, a longer in-hospital stay and a higher rate of NYHA sonal sensitivities.

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 Exercise stress test in cardiac rehabilitation Salzwedel et al. 347

Fig. 1

Parameters OR (95% CI) P-value

Sex (male) 1.89 (1.14−3.12) 0.013

Educational achievement
2.85 (1.40−5.84) 0.004
(higher education)
Duration of hospital stay
0.87 (0.78−0.98) 0.023
(5 days)
NYHA class III/IV
0.27 (0.14−0.53) <0.001
(yes vs. no)
Osteoarthritis
0.39 (0.20−0.78) 0.008
(yes vs. no)
Diabetes mellitus
0.48 (0.29−0.79) 0.004
(yes vs. no)
6MWD at the start of CR
1.14 (1.10−1.17) <0.001
(20 m)

0.1 1.0

Predictors of feasibility of the exercise stress test. CI, confidence interval; CR, cardiac rehabilitation; 6MWT, 6-min walking test; NYHA, New York
Association; logistic regression model, adjusted for age and cardiac rehabilitation centre effect; OR, odds ratio.

Fig. 2

P-value
30
Sociomedical support Initial exercise stress test NS
32
Performed
78
Nutrition/lifestyle change Not performed NS
91

147
Psycological interventions NS
176

694
Patient education 0.019
751

40
Occupational therapy 0.001
14

428
Exercise training <0.001
761

768
Physiotherapy/physical therapy <0.001
554

554
Nursing care <0.001
60
0 200 400 600 800 Total minutes

Therapy volume (total minutes) during cardiac rehabilitation with respect to feasibility of an initial exercise stress test.

In accordance with earlier findings, other identified
negative predictors of feasibility of an initial EST (higher
NYHA-class, osteoarthritis, diabetes mellitus, a longer
duration of hospital stay and a lower maximum walking
distance at the start of CR) describe a generally impaired
health status (Cowper et al., 1997; Cacciatore et al., 2012;
Reibis et al., 2012; Oterhals et al., 2014). It is remarkable
that factors such as pleural effusion or wound healing,
which are often perceived as prejudicial by physicians
and patients, did not have a predictive effect in multi-
variable analysis. Moreover, age at admission failed to
achieve a significant independent impact. Our results

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348 International Journal of Rehabilitation Research 2015, Vol 38 No 4
suggest that age-related decline of functional mobility
and comorbid conditions, not numerical age, are crucial
for the execution of an EST (Listerman et al., 2011;
Pasquini et al., 2015).
However, the usual CR programme focusing on exercise
training and physical activity might be unsuitable for the
patient group characterized. In a previously published sepa-
rate study, using a composite measure of 13 variables (incor-
porating key aspects such as cardiovascular risk factors,
exercise capacity and subjective health), a poorer rehabilita-
tion outcome was observed for patients who did not perform
an initial EST (Salzwedel et al., 2015). The comparison of the
therapeutic measures during CR between the patient groups
with and without an EST at admission indicates different
approaches to patient management. Although patients who
were able to perform an EST received significantly more
units in exercise training, the complementary group received
more units in physiotherapy, physical therapy and particularly
nursing care. Nevertheless, even with a poorer general health
condition at admission, the non-EST group benefited from
CR as much as the EST group. This underlines the impor-
tance of rehabilitation programmes that are better tailored to
the needs of particular patient groups.
It can be assumed that the patient population described will
increase because of demographic development and imple-
mentation of new intervention techniques in heart valve
diseases. New concepts for CR programmes focusing on
functional health and patients characteristics as well as other
restrictions according to the International Classification of
Functioning, Disability and Health should be developed.
Limitations
The present investigation is a retrospective analysis of data
from the pilot phase of the EVA-Reha (evaluation of reha-
bilitation) Cardiology Registry. The aim of this registry was
to develop a composite measurement of holistic rehabilita-
tion outcome and to compare centres of CR. Centres in
which an initial EST was generally not performed were
excluded. Nevertheless, it is possible that – because of the
study design – patients did not receive an EST because of
the personal decision of the patients or for institutional
reasons. Furthermore, the prescription of an EST is based
on physician–patient interaction. Consequently, a perfor-
mance bias because of personal preference or psychological
factors cannot be excluded. However, the authors assume
that the bias is negligible, given the comparably high degree
to which the variables investigated explain the feasibility of
EST (as measured by Nagelkerke’s pseudo R2 of 0.77).
Conclusion
The results of the present study show that the non-
feasibility of an EST at admission to CR, in large part,
can be attributed to a poor health status of the patient.
Female as well as diabetic patients, patients with pro-
longed hospital stay or reduced general capacity are fre-
quently unable to perform an EST and require a high
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
level of nursing care. However, patients without EST
comparably benefit from CR even though they receive
fewer exercise training sessions than patients with a
better health status. Thus, there is a justified need not
only for exercise-based programmes but also for the
comprehensive, interdisciplinary CR and individualized
CR programmes for a broad spectrum of patients.
Acknowledgements
This study was supported by an unrestricted grant from
the Techniker Krankenkasse health insurance company
in Hamburg, Germany. The authors are grateful to
Medical Advisory Service of Statutory Health Insurance
Funds in Rhineland-Palatinate (Alzey, Germany) for data
management and to the physicians, nurses and patients at
the participating rehabilitation centres.
Conflicts of interest
There are no conflicts of interest.
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