Journal of Sports Sciences

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The effects of 12-months supervised periodized

training on health-related physical fitness in
coronary artery disease: a randomized controlled
trial

Rita Pinto, Xavier Melo, Vitor Angarten, Madalena Lemos Pires, Mariana
Borges, Vanessa Santos, Ana Abreu & Helena Santa-Clara

To cite this article: Rita Pinto, Xavier Melo, Vitor Angarten, Madalena Lemos Pires, Mariana
Borges, Vanessa Santos, Ana Abreu & Helena Santa-Clara (2021): The effects of 12-months
supervised periodized training on health-related physical fitness in coronary artery disease: a
randomized controlled trial, Journal of Sports Sciences, DOI: 10.1080/02640414.2021.1907062

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JOURNAL OF SPORTS SCIENCES
https://doi.org/10.1080/02640414.2021.1907062

PHYSICAL ACTIVITY, HEALTH AND EXERCISE

The effects of 12-months supervised periodized training on health-related physical

fitness in coronary artery disease: a randomized controlled trial
Rita Pinto a, Xavier Melo b,c, Vitor Angarten d
, Madalena Lemos Pires a
, Mariana Borges a
, Vanessa Santos b
,
Ana Abreu a and Helena Santa-Clara b
a
Serviço de Cardiologia, Departamento Coração E Vasos, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina,
Universidade de Lisboa, Lisboa, Portugal; bExercise and Health Laboratory, CIPER, Faculdade de Motricidade Humana, Universidade de Lisboa, Cruz
Quebrada, Portugal; cGinásio Clube Português, Research & Development Department, GCP Lab, Lisboa, Portugal; dFaculdade de Motricidade
Humana, Universidade de Lisboa, Cruz Quebrada, Portugal

ABSTRACT ARTICLE HISTORY

We compared the impact of a one-year periodized exercise training versus a non-periodized exercise Accepted 19 March 2021
training on health-related physical fitness (HRPF) including body composition, cardiorespiratory and
KEYWORDS
muscular fitness in patients with coronary artery disease (CAD). Fifty CAD patients (60.4 ± 9.9 years) were Coronary artery disease;
randomized to either a periodized training group (PG) (n = 25) or a non-periodized training group (NPG) cardiorespiratory fitness;
(n = 25). Both consisted of a combined training programme, performed 3 days/week for 12 months. body composition; muscular
Thirty-six CAD patients (PG: n = 18, NPG: n = 18) successfully completed the exercise regimes. In both fitness; training model
groups, a favourable main effect for time was evident for peak VO2, peak workload, anaerobic threshold
and respiratory compensation point workloads and VO2, whole body skeletal muscle mass and quality
index at 12 months.
In conclusion, a periodized model is as effective as a non-periodized model in promoting increases in
HRPF outcomes following a one-year intervention. These findings indicate that health-professionals can
add variation to cardiac rehabilitation workouts without compromising effectiveness.

Introduction a 6-month CR programme, and this percentage drops down

to 20–50% following 12 months (Dolansky et al., 2010; De
The clinical and health benefits of exercise training in second­
Smedt et al., 2016). Variety and novelty in training are impor­
ary prevention in patients with coronary artery disease (CAD)
tant factors that could help to enhance adherence to exercise
are well established (Ambrosetti et al., 2020; Anderson et al.,
training in those who lack motivation to train (Baz-Valle et al.,
2016; Piepoli et al., 2016). Greater cardiorespiratory fitness and
2019). As implicit in its definition, periodization is a planning
muscle strength are associated with lower cardiovascular and
process that implies variation to maximize training adapta­
total mortality, better prognosis and better functional perfor­
tions, and a selected body of work in short-term physical
mance in patients with CAD (Katzmarzyk & Craig, 2002;
fitness has provided support for periodization in clinical
Kavanagh et al., 2002). Regarding body composition, abdom­
populations (Klijn et al., 2013; Macedo et al., 2018;
inal obesity is associated with increased risk of myocardial
Strohacker et al., 2015). However, its effectiveness remains
infarction (Yusuf et al., 2005) and worse clinical outcomes in
questionable in apparently healthy older adults, especially in
patients with CAD (Dagenais et al., 2005). However, most stu­
untrained subjects with low initial physical fitness (Conlon
dies were conducted in the early stages following the acute
et al., 2016, 2017; DeBeliso et al., 2005), but also in those with
cardiovascular event, with interventions lasting 4–16 weeks
CAD (Boidin et al., 2020). Still, these were all short-term inter­
(Anderson et al., 2016; Gielen et al., 2015).
ventions (≤22 weeks), and it is known that results from short-
The importance of a long-term (up to 12 months) out­
term research on periodization should not be transposed into
patient supervised exercise-based cardiac rehabilitation (CR)
longer-term periods (Afonso et al., 2017; Harries et al., 2015).
programme on improving health-related physical fitness
Thus, the impact of variation workouts strategies to promote
(HRPF) has been recognized over the last years (Belardinelli
greater HRPF in patients with CAD, on long-term basis and
et al., 2012; Hamm et al., 2004; Nishitani et al., 2013; Reich
adherence have not yet been tested.
et al., 2020; Santa-Clara et al., 2003, 2002). However, CR may
Therefore, the purpose of this one-year randomized con­
be a monotonous treatment, especially when the most
trolled study is to evaluate the effects of a periodized workout
recommended types of exercise within CR programmes are
variation exercise training regime versus a non-periodized
walking or cycling at a moderate intensity without significant
constant load exercise training regime on HRPF outcomes in
variations over time. Thus, it is not surprising that only
patients with CAD.
30–60% of patients remain physically active following

CONTACT Rita Pinto mrpinto@campus.ul.pt Serviço de Cardiologia, Departamento Coração E Vasos, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL,
Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa, 1649-028, Portugal
Supplemental data for this article can be accessed online https://doi.org/10.1080/02640414.2021.1907062
© 2021 Informa UK Limited, trading as Taylor & Francis Group
2 R. PINTO ET AL.
We hypothesize that a periodized workout variation exercise
training regime will lead to superior improvements in VO2peak,
muscle strength and body composition compared to
a constant load regime in patients with CAD.
Materials and methods
Study design
This is a longitudinal randomized controlled trial designed to
compare the effects of a periodized versus non-periodized
training regime on HRPF including cardiorespiratory fitness,
body composition and muscular fitness in patients with CAD
(clinicaltrials.gov ID: NCT03335319). Detailed randomization
procedures, recruitment processes, ethical approval and elig­
ibility criteria, are outlined in the published study protocol
(Pinto et al., 2019). Briefly, patients with CAD were randomized
1:1 and stratified (sex, age and peak VO2) to either a periodized
training group (PG) or a non-periodized training control group
(NPG). Both regimes were matched for training impulse (TRIMP)
and consisted of a combination of aerobic and resistance train­
ing, performed 3 days/week for 12 months. The primary out­
come was the change in peak VO2 at 12 months and the
secondary outcomes included body composition and muscular
fitness outcomes. Measurements of the primary and secondary
Figure 1. Study flow chart.
outcomes took place at baseline, 6 months and 12 months after
starting the exercise training in 3 non-consecutive days. Sample
size was calculated for the primary outcome (peak VO2) (Pinto
et al., 2019). Power and sample size calculations (G-Power,
Version 3.1.3) were based on peak VO2 with a standard devia­
tion of 3.5 ml/kg/min, α = 0.05, 1-β = 0.80 and an expected
dropout rate at 12 months of 37% (Dolansky et al., 2010). The
study was carried out in accordance with the recommendations
of the Declaration of Helsinki for Human Studies and was
approved by the Ethics Committee. Informed consent was
obtained from all participants included in the study.
Participants
Sixty patients with CAD who underwent a hospital-based CR
programme (phase II) in any hospital within the Lisbon district
were recruited (Figure 1). The study was conducted at the
Cardiovascular Rehabilitation Center of the University of
Lisbon (CRECUL) (phase III) at the University Stadium of
Lisbon, clinically supervised by the Faculty of Medicine from
the University of Lisbon. Inclusion criteria were as follows:
patients aged over 18 years, who had angiographically docu­
mented CAD in at least one major epicardial vessel, clinical
evidence of CAD in the form of previous myocardial infarction,
coronary revascularization (coronary artery bypass grafting

[CABG] or percutaneous coronary intervention [PCI]), or angina
pectoris and had completed 12 weeks of an early outpatient CR
programme. Exclusion criteria included: heart failure, cardiac
implantable defibrillators or resynchronizing devices; and
inability to comply with guidelines for participation in exercise
testing and training (Riebe et al., 2017).
Compliance with the exercise training and adherence was
determined by the number of training sessions attended and
successfully completed in accordance to the exercise protocol.
Sessions were deemed completed when at least 90% of the
prescribed exercises had been successfully performed. To verify
the safety on both training groups, adverse and serious adverse
events were carefully monitored, recorded and reported in line
with the principles of Good Clinical Practice.
Exercise training
A more detailed description of the exercise programme has
been published elsewhere (Pinto et al., 2019). Briefly, both
intervention groups were provided with supervised exercise
sessions by an exercise physiologist on three non-consecutive
days per week for 48 weeks; these sessions were monitored
using a heart rate polar band (H7 Polar, Electro, Kempele,
Finland). TRIMP was used to ensure similar training loads
between exercise groups. The quantification of the training
load in the aerobic component was performed according to
the methods by Edwards (Edwards, 1993). The volume load of
the resistance training was calculated as the number of repeti­
tions multiplied by the percentage of 1-RM (Haff, 2010). All
sessions included 10 minutes standardized warm-up and cool-
down for both groups.
The PG consisted of a periodization method which gradually
progressed through various combinations of duration and/or
intensity of training as described in Figure 2.
Over the first 15 exercise sessions, 20 minutes of continuous
exercise on an ergometer (cycle ergometer or treadmill) was
prescribed with the intensity set on the first anaerobic thresh­
old determined from the cardiopulmonary exercise testing
(CPET); followed by 2 sets of 15–20 repetitions of resistance
Figure 2. PG and NPG exercise prescription on the aerobic and resistance component for 12 months.
JOURNAL OF SPORTS SCIENCES 3
training on major muscle groups at 50% of 1-RM. From the 16th
to the 30th session, consisting of high-intensity interval train­
ing, followed by 2 sets 8–12 repetitions of resistance training on
major muscle groups at 60% 1-RM. From the 31st to the 45th
exercise session, it was prescribed 20 minutes of moderate
intensity continuous training with the intensity of 60–70%
heart rate reserve, followed by 2 sets of 6–8 repetitions of
resistance training on major muscle groups at 80% 1-RM.
From the 46th to the 60th exercise sessions, high-intensity
interval training was prescribed, followed by 2 sets 8–12 repeti­
tions of resistance training on major muscle groups at
60% 1-RM.
The NPG consisted of a combined exercise training regime
(aerobic and resistance training) according to the recommen­
dations from the American College of Sports Medicine (Riebe
et al., 2017) (Figure 2). Moderate intensity continuous training
was prescribed at an intensity of 50%-70% heart rate reserve,
for 20 minutes per session, using available ergometers (cycle
ergometer or treadmill). The resistance training was performed
after the aerobic component. Patients started with
a progression from 1 to 2 sets of 10–15 repetitions at 50% of
1-RM for the firsts 15 sessions. After completing the first 15
sessions, it was prescribed 2 sets of 8–12 repetitions with 60%
1-RM with a rest interval of 2–3 min between sets.
For the resistance training, the following resistance
machines were used for both groups (Life Fitness, Rosemont,
IL, USA): leg curl, leg press, leg extension, chest press, vertical
traction and low row.
Cardiorespiratory fitness
A symptom-limited ramp incremental CPET was performed on
a cycle ergometer (CardioWise Ergo Fit, Germany) with mea­
surement of inspired and expired gases (Ergostik, Geratherm
Respiratory GmbH, Germany). Each patient was encouraged to
exercise to exhaustion, as defined by intolerance, leg fatigue or
dyspnoea unless clinical criteria for test termination occurred.
Peak oxygen capacity was considered the highest 30 seconds
value for peak oxygen consumption (ml/kg/min) attained in the
4 R. PINTO ET AL.
last minute of exercise, anaerobic threshold (AT) was estimated
by the V-slope method and respiratory compensation point
(RCP) was defined as the point at which the ratio of ventilation
to VCO2 started to increase after a period of decrease or stasis
(Beaver et al., 1986).
Those tests were performed with the subject in a non-fasting
condition and under regular medication. All patients achieved
a respiratory exchange ratio of >1.1, an indicator of maximal effort
in the CPET. All CPET were performed by the same technician and
cardiologist, both blinded to the randomization schedule.
Body composition
Height and weight were measured using an electronic
scale with stadiometer (SECA, Hamburg, Germany). Whole
and regional body mass (bone mineral content, lean soft
tissue and fat mass) were estimated using dual energy
radiographic absorptiometry (DXA) (Hologic Explorer-W,
fan-beam densitometer, software QDR for windows version
12.4, Hologic, USA). Whole body skeletal muscle mass
(SMM) was calculated based on the equation: [1.19
x appendicular lean soft tissue (kg)] – 1.65 (Kim et al.,
2004). Whole body fat index and whole body SMM index,
were calculated by dividing the whole body fat and whole
body SMM by the square of the height (kg/m2).
Muscular fitness
Maximal dynamic strength
Maximal dynamic strength was assessed by one repetition max­
imum (1-RM) test for each of the same six weight exercises used
on the exercise training prescription. The protocol test of 1RM
was determined as described previously (Santa-Clara et al., 2002).
The whole body muscle quality index (MQI) was determined
as the ratio of total strength 1-RM (sum of the six resistance
machines) by whole body SMM (Barbat-Artigas et al., 2012). For
the lower body MQI, it was calculated by the ratio of lower
strength 1-RM (sum of the leg press, leg curl and leg extension)
by whole body SMM and, for the upper body MQI, it was
calculated by the ratio of upper strength 1-RM (sum of the
chest press, low row and vertical traction).
Objective measured physical activity
Physical activity was assessed by accelerometery
(ActiGraph, GT3X+, Florida). Each participant was asked to
wear the accelerometer ActiGraph GT3X+ attached to an
elastic waist belt and placed in line with the axillary line of
the right iliac crest for 7 days. A valid day was defined as
600 minutes (10 hours) or more of monitored wear time,
and all participants with at least 3 valid days (including
one weekend day) were included in the analyses. The
devices were activated on raw mode with a 100 Hz fre­
quency, and posteriorly downloaded into 15-s epochs
(Actilife v.6.9.1). Troiano et al. (Troiano et al., 2008), cut-
off points and wear time validation criteria were used to
define the time spent in each intensity period and to
define the valid register.
Data analysis
Primary and secondary outcome variables were presented as
means ± standard deviation. Normality was tested using Q–Q
plots. Comparisons between groups at baseline were per­
formed using independent sample t-test or, when not normally
distributed, the non-parametric Mann–Whitney–Wilcoxon
approach. Generalized estimating equations, followed by
Bonferroni post hoc test, were used to estimate the between-
group and within-group effects at 6 and 12 months on primary
and secondary outcomes, while allowing to control for poten­
tial confounders (i.e. sex and age). Missing data points were
assessed for random occurrence using Little’s Missing
Completely at Random (MCAR) and then imputed using expec­
tation-maximization algorithms. For primary and secondary
outcomes, an intention-to-treat analysis (ITTA) was performed
including all patients who were initially randomized at baseline.
An additional per-protocol analysis (PPA) was performed
including only the patients that completed the whole 12-
month intervention. Statistical analyses were conducted using
Statistical Package for the Social Sciences (SPSS) 24.0 (IBM SPSS
Statistics, Chicago, IL, USA). Statistical significance was set at an
alpha level of 0.05.
Results
Baseline descriptive characteristics of patients by allocation
group are presented in Table 1. All participants had
a previous myocardial infarction. The average time since the
last CAD event was 6.7 months in the PG and 6.9 months in the
NPG. There were no significant differences between groups
regarding CABG/PCI and time since last CAD event. Amongst
the 50 randomized patients, 80% were males, 52% were classi­
fied as overweight and 18% classified as obese. No significant
differences between groups were found at baseline for cardior­
espiratory fitness values, body composition, muscular fitness
and physical activity. Ninety-four per cent of the patients met
the WHO recommendations for physical activity and 60% of the
sample population attained more than 300 minutes per week
of moderate to vigorous physical activity. Physical activity levels
did not change during intervention within and between
groups. No adverse events were experienced during maximum
exercise testing or training sessions. Thirty-six patients com­
pleted all the scheduled tests, and the mean attendance rate of
the training sessions was 84.8% in the PG and 81.2% in the NPG.
There were no significant differences in attendance rate
between groups. Patients did not change their medication
during the study period. Dropout rates for both groups were
28% (Figure 1). Tables 2 and 3 summarize the exercise training
data for all patients in the ITTA, and Table 4 and 5 (Supplement)
presents the results from the PPA.
Cardiorespiratory fitness
Peak VO2 increased in both groups from baseline values to
6- (PG: 3.7 ± 9.8%, p < 0.001; NPG: 7.4 ± 13.6%, p = 0.002)
and 12-months (PG: 6.9 ± 10.0%, p < 0.001; NPG:
8.7 ± 15.9%, p = 0.001) (Figure 3a). Changes in time were
not different between groups in peak VO2 (p = 0.346). In
 JOURNAL OF SPORTS SCIENCES 5

Table 1. Baseline characteristics of the patients by allocation group.

PG NPG All sample
(n = 25) (n = 25) (n = 50) p value
Females/Males 5/20 5/20 10/40 1.000
Age (years) 60.4 ± 11.2 60.3 ± 8.6 60.4 ± 9.9 0.955
Baseline VO2 peak (ml/kg/min) 21.4 ± 4.5 20.7 ± 5.1 21.1 ± 4.8 0.632
BMI (kg/m2) 27.5 ± 3.5 27.0 ± 4.4 27.2 ± 3.9 0.639
Whole body fat index (kg/m2) 8.8 ± 2.5 8.2 ± 3.6 8.5 ± 3.1 0.501
Whole body SMM index (kg/m2) 9.0 ± 1.2 9.0 ± 1.2 9.0 ± 1.2 0.821
Android fat index (kg/m2) 0.83 ± 0.26 0.80 ± 0.31 0.82 ± 0.3 0.671
MVPA (min/week) 353 ± 156 386 ± 183 369 ± 169 0.500
Treatment (%)
PCI 76.0 76.0 76.0 1.000
CABG 28.0 32.0 30.0 0.548
Risk factors (%)
Family history 40.0 53.3 46.7 0.573
Hypertension 56.0 40.0 48.0 0.262
Diabetes mellitus 0 0 0 1.000
Dyslipidaemia 20.0 32.0 26.0 0.338
Ex-smoker 56.0 64.0 60.0 0.625
Smoker 12.0 12.0 12.0 1.000
Medications (%)
Βeta Blockers 84.0 80.0 82.0 0.716
Statins 84.0 93.3 88.7 0.162
Diuretics 20.0 12.0 16.0 0.445
ACE inhibitors 68.0 52.0 60.0 0.253
Anti-platelets 100.0 100.0 100.0 1.000
Abbreviations: ACE, angiotensin-converting enzyme; BMI, body mass index; CABG, coronary artery bypass graft; MVPA, moderate to vigorous physical
activity periodized group; NPG, non-periodized group; PCI, percutaneous coronary intervention; PG, periodized group; SMM, skeletal muscle mass;
VO2 peak, peak oxygen uptake.
Data are mean ± SD.

Table 2. Cardiorespiratory parameters at rest, peak exercise, anaerobic threshold and respiratory compensation point at baseline, 6 and 12 months: intention-to-treat
analysis.
PG (n = 25) NPG (n = 25) PGaNPG
Baseline 6 months 12 months Baseline 6 months 12 months β (95% CI)
Resting measurements
HR (bpm) 61 ± 9 60 ± 11 61 ± 10 63 ± 10 62 ± 10 64 ± 11 −0.73 (−2.92, 1.45)
Systolic BP (mmHg) 114 ± 13 115 ± 12 115 ± 14 116 ± 11 115 ± 12 119 ± 15 −0.25 (−3.68, 3.18)
Diastolic BP (mmHg) 70 ± 9 68 ± 7 67 ± 8 69 ± 7 66 ± 15 70 ± 10 −1.29 (−3.72, 1.14)
Peak Exercise
Workload (Watts) 142 ± 40 153 ± 45a 162 ± 48a,b 135 ± 37 148 ± 45a 152 ± 52a 1.02 (−5.42, 7.45)
HR (bpm) 127 ± 19 128 ± 21 129 ± 89 130 ± 16 131 ± 17 128 ± 18 2.11 (−0.75, 4.96)
VO2 (ml/kg/min) 21.4 ± 4.5 22.0 ± 4.6 22.7 ± 4.3a 20.7 ± 5.1 22.3 ± 5.0a 22.8 ± 5.4a −0.39 (−1.20, 0.42)
VO2 (l/min) 1.68 ± 0.46 1.73 ± 0.48a 1.78 ± 0.46a,b 1.59 ± 0.41 1.69 ± 0.43a 1.71 ± 0.47a −0.01 (−0.07, 0.05)
RER 1.17 ± 0.05 1.17 ± 0.07 1.17 ± 0.06 1.17 ± 0.08 1.16 ± 0.08 1.16 ± 0.06 0.00 (−0.02, 0.02)
VE/VCO2 slope 36.7 ± 5.2 37.3 ± 5.5 36.5 ± 5.1 35.6 ± 4.0 35.2 ± 4.9 35.1 ± 4.8 0.24 (−0.61, 1.09)
O2 pulse (mL/beat) 13.3 ± 2.8 13.6 ± 3.0 13.9 ± 2.9a 12.5 ± 3.2 13.1 ± 3.3a 13.6 ± 3.4a,b −0.23 (−0.65, 0.18)
ΔVO2/ΔWL (ml/min/W) 11.9 ± 0.9 11.5 ± 1.3 11.2 ± 1.2a 11.9 ± 1.6 11.6 ± 1.5 11.5 ± 1.4 −0.15 (−0.52, 0.23)
AT
Workload (Watts) 92 ± 30 101 ± 37 103 ± 34a 88 ± 30 95 ± 30a 102 ± 37a −1.49 (−6.84, 3.85)
HR (bpm) 95 ± 15 97 ± 16 94 ± 13 99 ± 13 97 ± 13 99 ± 16 −0.68 (−3.27, 1.91)
VO2, (ml/kg/min) 14.3 ± 4.0 15.1 ± 3.7 15.2 ± 3.4 14.6 ± 4.1 15.4 ± 3.7 15.9 ± 3.9a −0.20 (−0.90, 0.51)
% of peak oxygen uptake 66.6 ± 9.9 68.5 ± 6.9 66.9 ± 8.3 70.4 ± 8.5 69.4 ± 6.7 70.2 ± 9.1 0.65 (−2.21, 3.50)
RER 0.95 ± 0.03 0.95 ± 0.04 0.94 ± 0.05 0.95 ± 0.04 0.94 ± 0.05 0.96 ± 0.04 −0.01 (−0.02, 0.01)
RCP
Workload (Watts) 128 ± 35 138 ± 42a 148 ± 46a,b 123 ± 35 135 ± 43a 139 ± 48a,b 0.53 (−5.63, 6,68)
HR (bpm) 115 ± 16 117 ± 21 118 ± 21 119 ± 15 119 ± 15 119 ± 17 1.68 (−1.06, 4.42)
VO2, (ml/kg/min) 19.3 ± 4.1 20.0 ± 4.5 20.4 ± 4.3a 18.8 ± 4.8 20.6 ± 4.9a 20.8 ± 4.6a −0.40 (−1.08, 0.29)
% of peak oxygen uptake 90.5 ± 4.7 90.0 ± 4.9 89.9 ± 5.3 89.9 ± 6.0 92.2 ± 6.0 91.5 ± 6.7 −0.76 (−2.52, 1.00)
RER 1.10 ± 0.06 1.10 ± 0.06 1.10 ± 0.06 1.10 ± 0.06 1.09 ± 0.05 1.10 ± 0.05 0.00 (−0.02, 0.02)
Abbreviations: AT, anaerobic threshold; BP, blood pressure; bpm, beats per minute; HR, heart rate; NPG, non-periodized group; PG, periodized group; RCP, respiratory
compensation point RER, respiratory exchange ratio; VE/VCO2, minute ventilation/carbon dioxide production; VO2, oxygen uptake; WL, workload. Data are mean ±
SD.
a
Within-group changes compared with baseline, significant at p < 0.05.
b
Within-group changes compared with 6 months, significant at p < 0.05.

both groups, a favourable main effect for time was evident Figure 3b. Additionally, peak O2 pulse increased in both
for peak workload following 6- (PG: p < 0.001; NPG: groups from baseline to 12 months (PG: p = 0.009; NPG:
p = 0.002) and 12-months (PG: p < 0.001; NPG: p = 0.001), p = 0.002). At the AT and RCP, both groups increased their
6 R. PINTO ET AL.

Table 3. Body composition and muscular fitness at baseline, 6 and 12 months: intention-to-treat analysis.
PG (n = 25) NPG (n = 25) PGaNPG
Baseline 6 months 12 months Baseline 6 months 12 months β (95% CI)
Body composition
BMI (kg/m2) 27.48 ± 3.46 27.53 ± 3.59 27.50 ± 3.61 26.95 ± 4.41 27.02 ± 4.63 27.24 ± 4.73 −0.14 (−0.38, 0.11)
Whole body fat (%) 32.09 ± 5.33 31.12 ± 5.45a 31.31 ± 5.50a 29.96 ± 8.15 29.53 ± 8.19 29.54 ± 7.86 −0.18 (−0.67, 0.31)
Whole body fat index (kg/m2) 8.79 ± 2.46 8.55 ± 2.54a 8.60 ± 2.56 8.20 ± 3.59 8.11 ± 3.65 8.18 ± 3.63 −0.08 (−0.26, 0.10)
Android fat index (kg/m2) 0.83 ± 0.26 0.81 ± 0.25 0.81 ± 0.26 0.80 ± 0.31 0.78 ± 0.30 0.80 ± 0.31 −0.01 (−0.03, 0.01)
Whole body SMM index (kg/m2) 8.95 ± 1.20 9.14 ± 1.25a 9.15 ± 1.28a 9.03 ± 1.20 9.14 ± 1.20a 9.29 ± 1.26a,b −0.04 (−0.11, 0.04)
Maximal dynamic strength
Upper body MQI 6.76 ± 1.04 7.04 ± 0.83a 7.07 ± 0.83a 6.87 ± 1.29 7.04 ± 1.20a 7.03 ± 1.31 0.07 (−0.09, 0.23)
Lower body MQI 10.02 ± 1.94 10.95 ± 1.53a 11.37 ± 1.39a,b 9.80 ± 2.18 10.41 ± 2.35a 10.76 ± 2.47a,b 0.16 (−0.27, 0.59)
Whole body MQI 16.78 ± 2.67 18.04 ± 1.91a 18.52 ± 1.77a,b 16.68 ± 3.12 17.45 ± 3.18a 17.80 ± 3.44a,b 0.26 (−0.26, 0.79)
Abbreviations: BMI, body mass index; MQI, muscle quality index; NPG, non-periodized group; PG, periodized group; SMM, skeletal muscle mass. Data are mean ± SD.
a
Within-group changes compared with baseline, significant at p < 0.05.
b
Within-group changes compared with 6 months, significant at p < 0.05.

Figure 3. Changes in peak VO2 (a); peak workload (b); whole body SMM Index (c) and whole body MQI (d) using the intention-to-treat analysis at 6 and 12 months.
Dashed lines represent mean values for each intervention group. * statistically different from baseline (p < 0.05) # statistically different from 6 months (p < 0.05)
changes in each variable were only analysed to show graphically the magnitude of gains.

VO2 (AT, PG: p = 0.006; NPG: p = 0.009 and RCP, PG:
p = 0.004; NPG, p = 0.001) and workload (AT, PG:
p = 0.002; NPG: p = 0.001 and RCP, p < 0.001 in both
groups) from baseline to 12-months (Table 2). Increments
in the peak workload and peak VO2 from 6- to 12-months
were only observed in the PG (p < 0.001, in both variables),
whereas increases in the AT workload and O2 pulse were
only observed in the NPG at 6-months (p = 0.047 and
p = 0.025, respectively). The VO2-Workload relationship
only decreased in the PG from baseline to 12 months
(p = 0.006).
Changes in time were not different between groups regard­
ing all the outcomes presented in Table 2.
Similar results were found in the PPA (Supplement
Table 4) except for peak VO2 that did not differ from 6 to
12 months at the PG group. There were no changes in
resting heart rate and blood pressure, VE/VCO2 and peak

heart rate within- or between-groups from baseline to
follow-up in ITTA and PPA.
Body composition
A main effect of time was observed in whole body SMM index
in both groups at 12-months (p < 0.001, in both groups) (Figure
3c), although these increases were already observed at
6-months in both groups (PG: p < 0.001; NPG, p = 0.035). The
whole body fat only decreased in the PG from baseline to 6-
and 12-months (p < 0.001 and p = 0.002, respectively). There
were no changes in BMI and android fat index either within- or
between-groups from baseline to 6- and 12-months follow-up
(Table 3). And, changes in time were not different between
groups regarding all the outcomes presented in Table 3.
When considering the PPA, the results were similar (Table 5 –
Supplement).
Muscular fitness
Lower body and whole body MQI increased during the exercise
training intervention in both groups at 6- (PG: p < 0.001 in both
variables; NPG: p = 0.018 and p = 0.001, respectively) and 12-
months (PG: p < 0.001 in both variables; NPG: p = 0.005 and
p = 0.001, respectively), Figure 3d. Upper body MQI increased in
both groups at 6-months (PG: p = 0.016; NPG: p = 0.011),
whereas increases in upper body MQI were only observed in
the PG at 12-months (p = 0.018), Table 3. In both groups, lower
and whole body MQI increased from 6- to 12-month follow-up
(PG: p = 0.005 and p = 0.013; NPG: p = 0.001 and p = 0.010,
respectively). In muscular fitness outcomes, changes in time
were not different between groups from baseline to 6- and 12-
months follow-up. Similar results were found in the PPA (Table
5 – Supplement).
Discussion
To our knowledge, this is the first study to compare the effects
of a 12-month periodized high-intensity training model on
HRPF in patients with CAD. Contrary to our hypothesis, results
showed that periodized and non-periodized training models
were equally effective in promoting increases in peak VO2,
whole body SMM, and whole body strength in patients with
CAD. This suggests that patients with CAD are likely to experi­
ence positive benefits in HRPF in response to any supervised
training model, also encouraging health professionals to add
variation to CR workouts without compromising long-term
effectiveness.
It is common among CR studies to establish a minimum
training attendance of 75% (Beauchamp et al., 2013). In the
present study, we found exercise adherence to be in line with
literature (PG: 84.8%; NPG: 81.2%). However, contrary to what
was reported by Baz-Valle et al. (2019), variety and novelty in
training did not improve exercise training adherence or drop-
out prevention when compared to a constant load training.
There were no adverse events during the trial, suggesting that
periodized training can be prescribed to patients with CAD over
the course of 12 months without compromising safety, as long
JOURNAL OF SPORTS SCIENCES 7
as pre-exercise screening assessment and maximal tests are
ensured.
Limited data are available regarding the use of periodization
models in patients with CAD. The study by Macedo et al. (2018)
included 62 patients with CAD that were randomized to a PG
(n = 29) or a NPG (n = 33). The main finding of this study was
that improvements in peak VO2 were superior in the PG com­
pared the NPG (4% vs 1.7%, p < 0.001). However, instead of an
organized cyclic programme that uses planned variations in
intensity, volume and specificity, the authors limited their inter­
vention to progressive increases in the intensity of resistance
training. Recently, Boidin et al. (2020) compared two isoener­
getic aerobic training periodization protocols (non-linear vs.
linear periodization) on CPET variables. The authors found
that more variation in aerobic training does not increase more
cardiopulmonary adaptations in patients with CAD when com­
pared to the traditional method. However, these were all short-
term interventions (12 weeks), which makes it difficult to draw
conclusions regarding its long-term effectiveness (Afonso et al.,
2017; Harries et al., 2015). It is expected that exercise training
increases peak VO2 in around 2.3 ml/kg/min following 3 to
12 months of exercise training in patients with CAD, with the
greatest improvements amongst the most unfit (Martin et al.,
2013). In our study, the small increase in peak VO2 (PG: 1.3 ml/
kg/min and NPG: 2.1 ml/kg/min) could be explained by the
characteristics of the patients enrolled. These had been physi­
cally active (>300 mins/week) (Table 1) for at least 3 months
(length of the phase II CR programme) before the beginning of
phase III CR programme and had their baseline cardiorespira­
tory fitness values above 5 METS. That is evident in the small
magnitude of the increases in peak VO2, falling short from
those previously published in unfit patients with low cardior­
espiratory fitness levels (<5 METS) (Martin et al., 2013). The AT is
considered to be an important exercise parameter in patients
with CAD (Digenio et al., 1997; Santa-Clara et al., 2002). In our
study, VO2 at the AT changed in both groups at 12 months, but
significant improvements were already observed at 6 months in
NPG. Those improvements were probably due to the type of
aerobic training prescribed in the NPG that reached intensities
in-between AT and RCP, inducing faster and better physiologi­
cal efficiency.
Increased lower body muscle mass in CR helps fighting the
age-related decline in lower body muscle mass after the fifth
decade (Janssen et al., 2000) and sarcopenia in older adults
(Morley et al., 2014). In the present study, whole body SMM
index increased in both groups after completion of the
6-month exercise training. Again, increases in lower body
SMM were already evident by the 6th month in both groups,
positively influencing functional impairment and disability on
performing activities of daily living at an early stage (Janssen
et al., 2002). The increase in SMM is consistent with data from
supervised long-term studies conducted in patients with CAD
(Santa-Clara et al., 2003) and older individuals (Snijders et al.,
2019). There are no universal findings regarding body weight
and BMI, wherein some studies show a benefit of exercise
training (Lavie & Milani, 1996; Savage et al., 2003), whereas
others, including ours, show no effect (Pimenta et al., 2013;
Santa-Clara et al., 2003). Although favourable changes in body
fat percentage have been reported in patients with CAD
8 R. PINTO ET AL.
enrolled in exercise-based CR interventions of shorter duration
(Brochu et al., 2000; Savage et al., 2003), longer interventions
seem to struggle to keep those benefits (Madssen et al., 2014;
Nishitani et al., 2013). In our study, only the PG group decreased
the percentage of body fat. This might be explained by the
intermittent nature of the training stimulus and the higher
intensities prescribed in the PG (Dun et al., 2019; Villelabeitia-
Jaureguizar et al., 2019).
Our data suggest that both exercise training models were
equally effective in promoting improvements in overall muscle
strength. These strength improvements are in line with pre­
vious literature (Conlon et al., 2016) and are expected to have
an impact on reducing the risk of injury from falls; maintaining
functional independence for a greater period of time; and
improving quality of life as it allows individuals to perform
activities of daily living easier (Schaap et al., 2013; Trombetti
et al., 2016). The shared benefits might be explained by the
prescription exercise sets to the momentary muscular failure in
both groups, conferring greater adaptations in strength and
hypertrophy compared to other methods (Fisher et al., 2013).
This study is not without limitations. Considering that most
subjects were predominantly males, and all patients had pre­
vious history of myocardial infarction, our results cannot be
directly extrapolated to females, or other patients with CAD,
respectively. In this study, caloric intake was not assessed and it
is possible that some results may be influenced to a certain
extent by the subjects’ diet. Nevertheless, all patients received
the same dietary recommendations as part of their standard
care follow-up. All subjects were also involved in a prior phase II
CR which included some aerobic exercise for 3 months. This
could have had some impact on the results as some of the
adaptations to exercise including cardiorespiratory fitness
adaptations could have already taken place (Murias et al., 2010).
Concepts of periodization and variation are being used
interchangeably in research, while they actually represent two
distinct constructs. More variation does not provide the basis
for a periodized programme (Kiely, 2012), as acknowledged by
mainstream definitions of periodization (Harries et al., 2015).
Conclusion
This study demonstrates that 12 months periodized and non-
periodized training models were equally effective in promoting
increases in peak VO2, whole body SMM, and whole body
muscle strength in patients with CAD. These findings suggest
that, in the future, prescribing a periodized training model may
be an effective option to be added in supervised long-term CR
programmes.
Acknowledgments
The authors would like to thank all the participants in this study for their
dedication to the training programmes and associated assessments. We thank
the cardiopulmonary technician Paula Sousa for performing all the CPET, and
we are also grateful to Machado Rodrigues for all the support provided.
Disclosure statement
The authors declare that they have no competing interests.
Funding
R. P. was supported by a scholarship from the Universidade de Lisboa, grant
number 545. The current work was partly supported by the Portuguese
Foundation for Science and Technology, under grant UIDB/00447/2020 to
CIPER – Centro Interdisciplinar para o Estudo da Performance Humana (unit
447).
ORCID
Rita Pinto http://orcid.org/0000-0003-0925-4245
Xavier Melo http://orcid.org/0000-0003-3934-3986
Vitor Angarten http://orcid.org/0000-0002-6916-0737
Madalena Lemos Pires http://orcid.org/0000-0002-4449-4597
Mariana Borges http://orcid.org/0000-0003-2829-1703
Vanessa Santos http://orcid.org/0000-0003-2540-2826
Ana Abreu http://orcid.org/0000-0003-0786-7830
Helena Santa-Clara http://orcid.org/0000-0003-3134-3893
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