Clinical Sciences
Cardiovascular Responses to Different Resistance Exercise
­Protocols in Elderly
Authors
Amanda Veiga Sardeli1, 2, Lucas do Carmo Santos2, Marina Lívia Venturini Ferreira2, Arthur Fernades Gáspari2,
Bruno Rodrigues2, Cláudia Regina Cavaglieri1, 2, Mara Patricia Traina Chacon-Mikahil1, 2
Affiliations
1 Gerontology Program – Faculty of Medical Sciences,
University of Campinas – UNICAMP, Campinas, Brazil
2 Laboratory of Exercise Physiology – FISEX, University of
Campinas – UNICAMP, Campinas, Brazil
Key words
strength exercise, aging, autonomic modulation, hemody-
namic, cardiovascular response, Kaatsu training
accepted 07.06.2017
Bibliography
DOI https://doi.org/10.1055/s-0043-115737
Published online: 2017
Int J Sports Med
© Georg Thieme Verlag KG Stuttgart · New York
ISSN 0172-4622
Correspondence
Ms. Amanda Veiga Sardeli, PhD student
University of Campinas – UNICAMP
Faculty of Physical Education
Rua Érico Veríssimo, 701
13.083-851 Campinas
Brazil
Tel.: + 55/19/35216 625, Fax: + 55/19/3521 6750
amandaveigasardeli@yahoo.com.br
Introduction
Muscle strength has been recognized as an important capacity to
keep good health, functional independence and avoid falls in aging
[5, 20]. Thus, training with resistance exercise (RE) has been high-
ly recommended for healthy purposes in the elderly [5]. Yet the vig-
orous exertion involved in the recommended RE protocols acutely
disturbs the cardiovascular system, theoretically overly increasing
blood pressure (BP), cardiac sympathetic modulation, and central
arterial stiffness as well as limiting venous return [17, 26, 48, 52].
This disturbance facilitates atherosclerotic plaques and aneurysm
rupture and leads to myocardial electrical instability during exer-
cise recovery, increasing risk of sudden death [1, 48]. The magni-
tude of cardiovascular risks varies among different individuals as
well as among RE protocols, hence they can encompass different
Sardeli AV et al. Cardiovascular Responses to Different … Int J Sports Med
Thieme
Abstract
Increase in muscle mass and strength through resistance exer-
cise (RE) has been highly recommended for healthy aging. On
the other hand, RE could lead to acute cardiovascular risks
prompted mainly by intense blood pressure elevations and
cardiac autonomic imbalance. We compared the cardiovascu-
lar responses to three different RE protocols performed by 21
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healthy elderly on a leg press machine. The protocols tested
were high load (80 % 1RM) until muscular failure (HL); low load
(30 % 1RM) until muscular failure (LL); low load, 30 repetitions
followed by 3 sets of 15 repetitions, with 50 % blood flow
­r estriction (LL-BFR); and a control session (CON). Based on
heart rate variability analysis, only LL kept parasympathetic
indexes lower than CON at 30 min recovery. By finger photop-
lethysmography, LL-BFR prompted higher systolic and mainly
diastolic blood pressure increments in many sets. The heart
rate and cardiac output increase, and total peripheral resistance
reduction following exercise were not different among RE
­protocols. There was no significant post-exercise hypotension
and carotid arterial compliance changes. HL seems to be the
safer protocol to be recommended for the healthy elderly,
­because it induces lower blood pressure increments and faster
parasympathetic recovery compared to LL and LL-BFR.
muscle groups, intensities, volumes, execution speed, and time in-
tervals between sets [28, 50].
Three types of RE protocols have gained ground in the exercise
training field due to their potential to increase muscle mass and
strength: the traditional RE at high load (HL) and low volume, the
low-load RE (LL) with high volume, and the LL with blood flow re-
striction (LL-BFR) [5, 28, 50]. LL-BFR has been addressed as a good
option to obtain similar benefits to traditional RE protocols with-
out higher loads [41]. Nevertheless, this type of exercise has shown
exacerbated increases in sympathetic modulation and BP because
of its higher exercise metaboreflex and pressor reflex stimulation
[43, 44, 47]. LL, when performed until the muscular failure, is also
effective for increasing muscle mass and strength, independent of
BFR [2]. On the other hand, the high volume of LL would also in-
 Clinical Sciences
crease sympathetic modulation and BP to exacerbated levels
[27, 30, 39].
Although these RE protocols are efficient at improving muscle
mass and strength, the safer protocol for the elderly as regards car-
diovascular risks is still unknown. Thus, the aim of the present study
is to compare the effect of these three RE protocols performed on
a leg press machine on hemodynamics, central arterial stiffness,
and cardiac autonomic modulation during exercise and recovery.
We hypothesized that LL-BFR would prompt higher cardiovascular
stress and a slower recovery due to the higher chemoreflex stimu-
lus even during rest intervals. The identification of the safer RE pro-
tocol will pave the way for precise training prescription, reducing
the risks during the post-exercise period.
Materials and Methods
Subjects
The 24 participants selected had not been engaged in regular ex-
ercise programs (less than 2 times per week) during the previous
6 months. Anamneses, clinical and laboratory assessments were
used to identify the limitations for engaging in the experimental
protocols. Volunteers were excluded if they had cardiovascular,
metabolic, pulmonary or limiting osteoarticular diseases, obesity
(body mass index > 30 kg/m2), if they were smokers, or if they used
any medication that could influence the cardiovascular responses
investigated herein (e. g., antidepressants, neuroleptics or antiar-
rhythmic medications). A clinical examination was carried out by a
cardiologist and included an electrocardiogram during rest and
during effort to ensure the participants’ safety. All participants
signed the informed consent approved by the research ethics com-
mittee from our university and the study was carried out accord-
ing to declaration of Helsinki. The study met the ethical standards
of the International Journal of Sports Medicine [16].
Experimental design
After the previously described clinical evaluations, participants un-
derwent one familiarization session in which experimental sessions
were simulated on the leg press machine with no additional load
and with 60 mmHg BFR. Participants went to the laboratory two
more days for a one-repetition maximum (1RM) test and retest.
Participants performed the experimental sessions in a cross-over
design (Latin square), always at the same time in the morning, be-
tween 7 a.m. and 12 p.m., in a temperature- controlled (23 ° Cel-
sius) environment with at least a one-week interval in between.
Every day session participants were instructed to: avoid drink-
ing alcohol, coffee or other caffeinated beverages for 12 h; remain
fasted for 2 h preceding sessions; sleep well; and refrain from exer-
cise for at least 72 h before assessments. Furthermore, participants
were instructed to eat the same diet 24 h before the experimental
sessions and take their medicines at the same time. On the day be-
fore their tests, a member of our group called the participants to
check whether they were following all recommended procedures.
On the day of the experimental sessions, conditions related to the
subject's health status were self-reported by means of three sim-
ple questions: 1. Is your health good? 2. Did you sleep well? Is some-
Thieme
thing bothering you? The experimental sessions were postponed
whenever necessary.
In each experimental session when participants arrived at the
laboratory, they were instructed to use the toilet, drink a cup of
water and turn off their cell phones. A heart rate monitor was then
attached and the subjects were instructed to lie in the supine po-
sition for a 5 min rest for leg BP gauging. Subsequently, participants
remained seated in a 45 ° leg press machine for all pre-, intra- and
post-session assessments. Outcome assessors were blinded to ex-
perimental session allocation for data analysis (BP, between R waves
interval – RRi and carotid arterial compliance – CAC) and partici-
pants knew only which session they should perform after the base-
line rest data collection.
Experimental protocols
Experimental sessions were performed on a 45 ° leg press machine
(Nakagym, São Paulo, Brasil). During the CON session, all the same
data was collected as during the exercise session, with subjects re-
maining seated in a 45 ° leg press machine for 10 min to replicate the
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time in the exercise sessions. The exercise protocols were: high load
resistance exercise (HL), with 4 sets until voluntary failure at 80 %
1RM; low load resistance exercise (LL), with 4 sets until voluntary fail-
ure at 30 % 1RM; low load resistance exercise with BFR (LL-BFR), with
1 × 30 + 3 × 15 repetitions at 30 % 1RM and 50 % BFR maintained
throughout the exercise session, until the last repetition when BFR
was immediately released. Exercise protocols were preceded by 10
repetitions at 30 % 1RM for warm-up and all protocols included a
1- min rest interval between sets (feet resting on the ground).
Determination of individual blood flow restriction
After subjects rested in the supine position for 5 min, a vascular
Doppler probe (DV-600; Martec, São Paulo, Brazil) was placed over
the tibial artery to capture its auscultatory pulse. To determine leg
BP (mmHg), a BP cuff (175 mm wide and 920 mm long) was at-
tached in the quadriceps inguinal fold and inflated up to ausculta-
tory pulse interruption (arterial occlusion pressure). Following com-
plete occlusion, the cuff was deflated until the first pulse ausculta-
tion and the systolic BP was determined at 2 mmHg above this point
[23].
Maximum strength test
Maximal strength was measured by a one-repetition maximum
(1RM) test on a leg press machine (Nakagym, Brazil) as described
by Brown et al. [3]. Participants performed a general 5-min low-
load warm-up on a cycle ergometer. After 3 min, participants per-
formed a specific warm-up composed of 8 repetitions at 50 % of
their estimated 1RM and 3 repetitions at 70 % of their estimated
1RM, interspersed by 3 min rest [35]. The test consisted of 5 trials
of 1RM, with 3 to 5 min of rest between trials. Participants were
tested in two separate sessions (test-retest) with at least 72 h rest
between them. The value of the highest load obtained after the
test-retest was recorded for the purpose of exercise prescription.
Cardiac autonomic modulation
Continuous RR intervals were acquired throughout the 15-min
baseline rest (9–22 breaths per minute) and 15-min recovery seat-
ed on a leg press machine (from 15 min to 30 min exercise recov-
Sardeli AV et al. Cardiovascular Responses to Different … Int J Sports Med
ery), using a Polar RS800CX heart rate monitor (Polar Electro, Kem-
pele, Finland) and Polar ProTrainer 5 software (version 4.0. Kem-
pele, Finland) [19, 32]. A 5-min stationary and noise-free interval
was analyzed following linear interpolation of adjacent beats in
Kubios HRV software (Version 2.1, Biosignal Analysis and Medical
Imaging Group, Kuopio, Finland) [31].
Heart rate variability (HRV) time and frequency domain were
analyzed. Among time domain indices, mean RR interval (RRi),
standard deviation of all normal RR intervals (SDNN), and square
root of the mean squared differences of successive RR intervals
(RMSSD) were analyzed as representatives of parasympathetic
modulation. Frequency domain indices were derived by a fast Fou-
rier transform, which included low frequency (LF: 0.04–0.15 Hz)
and high frequency (HF:0.15–0.4 Hz), expressed in absolute units
(LFms2 and HFms2), normalized units (LFnu and HFnu), and the ratio
between the bands (LF/HF) [11]. HF is a good indicator of cardiac
vagal modulation, while LFnu better expresses sympathetic mod-
ulation and LF/HF the sympathovagal balance [11].
Hemodynamic assessments
Beat-to-beat BP waveforms were continuously recorded during all
experimental sessions by photoplethysmography (Finometer Pro®,
Finapres Medical Systems, Arnhem, The Netherlands), with the cuff
positioned on the medial phalanx of the middle finger of the right
hand [15]. Prior to the experimental procedures, the participants
remained at rest for physiological calibration of BP values (physio-
cal) and correction from finger arterial BP by brachial BP values
(reBAP) [15]. All participants were instructed to remain at rest seat-
ed on a 45 ° leg press machine in silence and awake. Brachial BP was
estimated from the finger blood pressure waveform and analyzed
using BeatScope® software (Finapres Medical Systems, Amster-
dam, The Netherlands), with a hydrostatic height correction sys-
tem to compensate hand position according to the heart’s position
[10]. Throughout all data recording, the physiological calibration
system remained turned off and the precise begin and end of each
RE set were indicated in the data record. For pre-exercise BP and
HR analysis, a average of 300 beats at the end of 15-min baseline
rest, the average of 5 beats at the end of each set during RE ses-
sions and post 30-min recovery were selected for analysis [49].
Heart rate (HR), stroke volume (SV), cardiac output (CO) and total
peripheral resistance (TPR) were derived from finger BP waves using
the Modelflow method incorporating age, sex, height and body
mass (BeatScope®, Finapres Medical Systems, Amsterdam, The
Netherlands) [45, 46].
Carotid artery compliance
Carotid arter y images were acquired by linear transducer
(10–5 MHz) coupled in an ultrasound machine (Nanomaxxtm, Son-
oSite, USA), at the middle third left common carotid artery, always
by the same assessor (AVS). It was recorded before exercise and
after three and 30 min recovery. Systolic and diastolic carotid di-
ameters were acquired by M-mode during 5 s image-recording. Si-
multaneously with M-mode acquisition, the BP recording was ex-
tracted from photoplethysmography previously described. CAC
was calculated based on the difference between maximum and
minimum diameters related to moment BP, using the following
equation: CAC = ([Sd − Dd]/Dd)/(SBP − DBP), where Sd is maximum
Sardeli AV et al. Cardiovascular Responses to Different … Int J Sports Med
▶Table 1   Sample features.
N 21 (9♂/12♀)
Age (years) 64.3 (SD 5.04)
Anthropometry
Body mass (Kg) 67.19 ± 12.53
Standing height (m) 1.63 ± 0.08
BMI (kg.m-2) 25.31 ± 3.05
Strength
1RM leg press 45 ° (kg) 161.67 ± 63.01
Cardiovascular parameters
Systolic blood pressure (mmHg) 128.82 ± 14.50
Diastolic blood pressure (mmHg) 69.57 ± 6.06
Mean blood pressure (mmHg) 92.17 ± 8.00
Heart rate (bpm) 67.32 ± 7.60
Note: Data are presented in mean (SD). BMI: body mass index; 1RM:
one repetition maximum.
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diameter (systolic), Dd is the minimum diameter (diastolic), SBP is
the systolic blood pressure and DBP is the diastolic blood pressure
[21]. Image J software was used to measure Sd and Dd, and the
mean values of three heart cycles were registered.
Rating of perceived exertion
We evaluate the rating of perceived exertion (RPE) in each exercise
session to address the participant’s degree of effort. The partici-
pants chose the score from the Borg scale (6–20) that best fit their
perception right after each exercise set [12].
Statistical analysis
Characteristics of RE protocols such as exercise duration, number
of repetitions, load, and ratio of perceived exertion (RPE) were not
normally distributed according to the Shapiro-Wilk test. Thus, for
these analyses we applied Friedman test comparisons, followed by
Wilcoxon post hoc and present data as median (25th; 75th). For our
main data, the Shapiro-Wilk test showed normal distribution after
transformation by 1/x (CAC), In (x) (SBP and DBP) and log (other
variables). Mixed models for repeated measures were applied to
compare the four experimental protocols (CON, HL, LL, LL-BFR) and
three moments (pre, post, post 30-min) followed by Bonferroni
post-hoc test, when session * time interaction was found for all
study variables. For HRV we performed the mixed models with just
two moments (pre and post 30-min), because the data were not
stationary at the post-exercise moment, precluding their analyses.
The delta of variation for exercise hemodynamics was compared
among protocols by one-way ANOVA at each moment. We consid-
ered significant a P value < 0.05. PASW Statistics 18.0 software
(SPSS Inc., Chicago, USA) was used for statistical analyses.
Results
After randomization, three participants dropped out, leaving 21.
Participants’ features are described in ▶ Table 1. Regarding RE
­protocol features, the load was significantly different between HL
and the others; the number of total repetitions was higher for LL
than LL-BFR, which in turn was higher than HL; LL time duration was
 Clinical Sciences Thieme

▶Table 2   Resistance exercise protocol features.

HL LL LL-BFR p value (Friedman test)

Exercise duration (s) b,c 428.4 (406.5; 439.5) 511 (469.5; 565.8) 436.8 (429.3; 448.2) < 0.001
RPE 19.0 (17.0; 20.0) 19.3 (19.0; 20.0) 19.0 (17.5; 20.0) 0.454
Number of repetitions (mean) b,c 9.6 (8.6; 11.4) 23.4 (19.9; 29.4) 17.0 (17.0; 17.0) < 0.001
Exercise load (Kg) a,b 132.0 (82.0;174.0) 49.5 (31.5; 62.2) 49.5 (31.5; 65.2) < 0.001
Note: Data are presented in median (25th; 75th); RPE: rate of perceived exertion; HL: high intensity resistance exercise; LL: low intensity resistance
exercise; LL-BFR: low intensity resistance exercise with blood flow restriction; a: HL ≠ LL-BFR; b: HL ≠ LL; c: LL ≠ LL-BFR (p< 0.008 for Wilcoxon test).

▶Table 3a   Hemodynamic responses to different resistance exercise protocols in elderly.

SBP (mmHg) CON HL LL LL-BFR P session * time

Pre 128.7 (SD 16.84) 128.4 (SD 13.61) 129.0 (SD 13.87) 129.0 (SD 14.52) 0.93
Post 134.1 (SD 19.09) 129. 6 (SD 14.11) 130.0 (SD 19.30) 135.5 (SD 21.20)
Post 30 min. 131.2 (SD 17.83) 127.4 (SD 17.13) 128.8 (SD 16. 93) 129.8 (SD 14.20)
DBP (mmHg)
pre 69.9 (SD 6.68) 67.9 (SD 6.08) 69.4 (SD 6.10) 70.8 (SD 5.36) 0.69
post 72.3 (SD 9.64) 67.5 (SD 7.16) 69.0 (SD 7.26) 72.5 (SD 9.27)

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post 30 min. 7.6 (SD 7.30) 70.4 (SD 8.34) 72.2 (SD 6.79) 74.1 (SD 9.02)
MBP (mmHg)
Pre 92.3 (SD 9.28) 90.8 (SD 7.69) 92.5 (SD 7.12) 92.9 (SD 8.12) 0.90
Post 95.8 (SD 12.28) 90.1 (SD 8.07) 91.9 (SD 9.94) 96.3 (SD 13.09)
Post 30 min. 94.2 (SD 10.52) 91.9 (SD 10. 79) 93.3 (SD 9.92) 94.7 (SD 9.34)
HR (bpm)
Pre 67.8 (SD 7.65) 65.9 (SD 7.70) 68.2 (SD 7.79) 67.3 (SD 7.61) < 0.001
Post 66.5 (SD 7.92) 78.5 (SD 11.18) * † 86.6 (SD 11.83) * † 80.3 (SD 10.19) * †
Post 30 min. 68.3 (SD 8.14) 75.6 (SD 10.24) * ‡ 79.6 (SD 10.66) * §‡ 77. 6 (SD 12.42) * ‡
VS (ml)
Pre 74.7 (SD 14.80) 77.4 (SD 17.54) 70.3 (SD 18.13) 72.9 (SD 15.58) 0.54
Post 73.7 (SD 16.08) 81.5 (SD 21.65) 74.7 (SD 22.11) 75.4 (SD 17.81)
Post 30 min. 68.9 (SD 13.00) 67.6 (SD 19.95) 60.6 (SD 19.12) 65.3 (SD 17.36)
CO (l/min)
Pre 5.03 (SD 0.98) 5.05 (SD 1.03) 4.75 (SD 1.17) 4.88 (SD 1.10) < 0.001
Post 4.87 (SD 1.14) 6.33 (SD 1.71) * † 6.49 (SD 2.22) * † 6.04 (SD 1.62) * †
Post 30 min. 4.69 (SD 0.93) 5.01 (SD 1.29) * 4.80 (SD 1.49) * 4.93 (SD 1.11) *
TPR (mmHg.min/l)
Pre 1.16 (SD 0.30) 1.13 (SD 0.3) 1.25 (SD 0.38) 1.20 (SD 0.30) < 0.001
Post 1.25 (SD 0.38) 0.90 (SD 0.22) * 0.92 (SD 0.28) * 1.03 (SD 0.33) *
Post 30 min. 1.26 (SD 0.32) 1.20 (SD 0.49)§ 1.31 (SD 0.56)§ 1.22 (SD 0.32)§
CAC ( %/10 mmHg)
Pre 0.82 (SD 1.22) 0.62 (SD 0.79) 0.59 (SD 0.72) 0.43 (SD 0.29) 0.34
Post 0.87 (SD 1.20) 0.55 (SD 0.68) 0.64 (SD 0.68) 0.59 (SD 0.68)
Post 30 min. 0.64 (SD 0.95) 0.62 (SD 0.97) 0.58 (SD 0.69) 0.64 (SD 0.95)
Note: Data are presented in mean (SD). CON: CON session; HL: high intensity resistance exercise; LL: low intensity resistance exercise; LL-BFR: low
intensity resistance exercise with blood flow restriction; SBP: systolic blood pressure; DBP: diastolic blood pressure; MBP: mean blood pressure; HR:
heart rate; CO: cardiac output; TPR: total peripheral resistance; CAC: Carotid arterial Compliance; * different of pre within the same protocol; † different
of post CON; ‡ different of post 30-min CON; § different of post within the same protocol.

longer than others; and rate of perceived exertion was the same
for all RE protocols (▶ Table 2). The basal leg SBP was maintained
stable throughout all days of the experimental protocols, without
significant pre-value differences among the sessions.
There was no difference among experimental protocol pre-val-
ues for all variables. There was no session * time interaction for SBP,
DBP, MBP, SV and CAC at pre, post and post 30-min comparisons
although some differences were observed in HR, CO and TPR be-
tween the CON and RE protocols, without differences among RE
protocols (▶Table 3a).
Regarding HRV time domain, there was a post 30-min reduction
in RRi and SDNN after all RE protocols, with a difference only be-
tween CON and LL. Besides the difference for LL in time domain in-
dices, in the HRV frequency domain, the difference of CON also ap-

Sardeli AV et al. Cardiovascular Responses to Different … Int J Sports Med

▶Table 3b   Cardiovascular autonomic modulation responses to different resistance exercise protocols in the elderly.

RRi mean CON HL LL LL-BFR P value

session * time
Pre 887 (SD 99) 917 (SD 105) 881 (SD 95) 909 (SD 101) < 0.001
Post 30 min 917 (SD 93) 813 (SD 105) * 766 (SD 94) * ‡ 804 (SD 96) *
HRV SDNN
Pre 29 (SD 12) 33 (SD 20) 34 (SD 18) 30 (SD 11) < 0.001
Post 30 min 32 (SD 15) 26 (SD 10) * 22 (SD 10) * ‡ 24 (SD 10) *
HRV RMSSD
Pre 22 (SD 13) 27 (SD 24) 24 (SD 16) 23 (SD 12) < 0.001
Post 30 min 26 (SD 15) 17 (SD 13) * ‡ 13 (SD 7) * ‡ 15 (SD 9) * ‡
HRV LF (ms2)
Pre 190 (SD 144) 402 (SD 619) 281 (SD 246) 229 (SD 204) 0.012
Post 30 min 292 (SD 304) 187 (SD 158) 129 (SD 100) * 170 (SD 205) *
HRV HF (ms2)
Pre 228 (SD 276) 369 (SD 522) 330 (SD 545) 250 (SD 282) < 0.001
Post 30 min 336 (SD 413) 177 (SD 284) * ‡ 80 (SD 75) * ‡ 106 (SD 114) * ‡

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HRV LF nu
Pre 54 (SD 22) 52 (SD 16) 55 (SD 20) 53 (SD 19) 0.296
Post 30 min 49 (SD 20) 63 (SD 22) 64 (SD 22) 61 (SD 22)
HRV HF nu
Pre 46 (SD 22) 47 (SD 16) 44 (SD 20) 47 (SD 19) 0.006
Post 30 min 51 (SD 20) 37 (SD 22) 36 (SD 22) 39 (SD 22)
HRV LF/HF
Pre 2 (SD 2) 2 (SD 1) 2 (SD 2) 2 (SD 2) 0.032
Post 30 min 1 (SD 1) 3 (SD 3) * ‡ 3 (SD 4) * 3 (SD 3) *
HRV TP
Pre 770 (SD 534) 1303 (SD 1814) 1187 (SD 1427) 941 (SD 653) 0.001
Post 30 min 1300 (SD 1371) 682 (SD 441) 476 (SD 354) * ‡ 596 (SD 513) *
Note: Data are presented in mean (SD). CON: CON session; HL: high intensity resistance exercise; LL: low intensity resistance exercise; LL-BFR: low
intensity resistance exercise with blood flow restriction; RRi: RR interval; SDNN: standard deviation of all RR normal intervals; RMSSD: root mean square
standard deviation; LFms2: absolute values low frequency; HFms2: absolute values high frequency; LFnu: normalized units low frequency; HFnu:
normali­zed units high frequency; LF/HF: sympathovagal balance. * different of pre within the same protocol; ‡ different of post 30-min CON.

peared for HL (▶Table 3b). Considering the more sensible index of
time and frequency domain, such as RMSSD and HF (ms2), all RE
protocols differed from CON in post 30-min.
Regarding hemodynamic changes, LL-BFR prompted higher SBP,
DBP and MBP increases than HL along different RE sets (▶Fig. 1).
LL leads to higher MBP values than HL and lower than LL-BFR, at the
2nd and 4th sets, respectively (▶Fig. 1).
Discussion
The aim of the present study was to compare the cardiovascular
responses during exercise and recovery among RE protocols in
healthy elderly. Although LL-BFR prompted higher BP peaks, car-
diac vagal withdrawal (considering RRi, SDNN, LF/HF, HFnu, TP) was
normalized (same as CON) 30-min post LL-BFR, whereas it was still
high post-LL for most HRV indexes and post-HL for the LF/HF index.
Similar to our findings, Okuno et al. [33] found a greater mag-
nitude of reduction in vagal withdrawal and delayed recovery after
HL (80 % 1RM) than LL-BFR (40 % 1RM and 100 mmHg BFR) per-
formed until muscle failure, also on the leg press machine, in young
individuals. Since a higher RE load prompts higher sympathetic in-
creases and parasympathetic decreases [25], Okuno et al. [33]
equalized the volume and load of LL-BFR based on LL repetitions,
confirming the same cardiac autonomic changes in both groups
[33]. In the present study, LL-BFR was not performed until failure
like the others protocols were, which might be the reason for fast-
er vagal recovery in LL-BFR. In fact, a single squat exercise prompts
higher vagal withdrawal when performed until muscular failure,
compared to equalized volume and load without muscular failure
in young individuals [27]. Thus the efficacy of LL depends on suffi-
cient volume, whereas LL-BFR has shown effective strength and
muscle mass increments in elderly, independent of muscular fail-
ure [50].
Despite the efficient vagal recovery from LL-BFR herein, Spranger
et al. [43] have cited cardiovascular risks from exacerbated pressor
reflex stimulation (overly increasing sympathetic modulation)
through BFR exercises. They argued that the muscle adaptations
prompted by BFR exercise are due to the metabolic accumulation
stimulating fast-twitch glycolytic fibers even in low-load exercise,
which elicits a much larger pressor response and chemoreflex than
slow-twitch oxidative fibers [43]. In the present study, we confirmed
the expected higher BP peaks in LL-BFR. Nonetheless, compared to

Sardeli AV et al. Cardiovascular Responses to Different … Int J Sports Med

Clinical Sciences Thieme

the other RE protocols, LL-BFR did not delay vagal recovery, suggest-
150 ing whether or not the higher stimulation of pressor and metabore-
flex happened during exercise, it was not enough to impair the fast-
a a er cardiac vagal autonomic recovery until post 30-min.
100 In young individuals, Takano et al. [47] found higher BP and HR
Δ SBP (mmHg)

after LL-BFR (20 % 1RM with 1.3 times baseline SBP BFR) performed
until muscular failure compared to LL without BFR, on bilateral leg
50 extension. Staunton et al. [44] also showed higher hemodynamic
stress after LL-BFR (1 × 30 + 3 × 15 with 20 % 1RM and 60 % SBP BFR)
than after LL in young and older individuals. These studies did not
0
compare LL-BFR to HL, which is important for practical applicabil-
ity because LL without large muscle fiber recruitment (higher type
t.

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t.
t.
p

s
st
t1

t3
t2

t4
in

in
in
in
-u

15
po
se

se
se

se II fiber activation), from BFR or high volume stimulus, would not

m
ar
w

60 increase muscle mass and strength [4]. In any case, Pinto and Polito
a a a
a [36], in comparing LL-BFR with HL and LL not until failure, in hyper-
tensive women, also found higher BP and HR peaks after LL-BFR. A
40
similar study with young men compared the effects of the same
Δ DBP (mmHg)

a
protocols we investigated on BP during exercise. In contrast to our
20 findings in elderly, they found higher increments in HL than LL-BFR

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[24]. Perhaps the dependence of limb muscle mass size to really
0
occlude venous return was greater in our thinner and weaker elder-
ly [15], leading to higher pressor reflex stimulation than the young
men from the Libardi et al. study [24]. Someone could conclude
– 20
the higher BP propensity in the elderly would lead to exacerbated
t.

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in

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15
po

metaboreflex BP stimulation through BFR (metabolic accumula-

se

se
se

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m
ar
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80
tion) as is the case for hypertensive individuals [14, 36, 37, 42]. On
a
a, b a a, c the other hand, it is noteworthy that the delta BPs found by Libardi
60 et al. [24] in young men during LL-BFR were very similar to our find-
ings in the normotensive elderly, whereas the delta BP for HL in their
Δ MBP (mmHg)

40 study seems to be higher than we found. In other words, our op-

posite results might be due to HL effects on BP because of the high-
20 er volume performed by young men during HL (they did not find a
significant difference between HL and LL-BFR, as we did). Corrobo-
0 rating such a hypothesis, Vieira et al. [51] suggest that young and
normotensive elderly individuals do not differ regarding LL-BFR-in-
– 20
duced BP and HR increments. Thus we concluded the differences
t.

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15

between our elderly and the young men from the Libardi et al. study
po
se

se
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stem from different HL volumes.

60
We are not aware of any study that investigated the acute effect
of RE on elderly CAC. In young individuals, many studies have
shown a reduction in CAC after RE protocols [6, 8, 17, 22], which
40
may be deleterious. Nevertheless, no change was observed in
Δ HR (bpm)

healthy elderly CAC with the RE protocols tested herein. Because

the elderly have higher arterial stiffness, it is possible their more
20
calcified arteries are not affected by only one session of RE, or per-
haps the practice of only the leg press exercise is not enough to
prompt the changes observed after a whole-body RE session [18].
0 Post-exercise hypotension (PEH) has also been shown after RE,
t.

t.
t.
t.

including the LL-BFR type, in young normotensive individuals

p

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se

se
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ar

[29, 30, 40], and in comparison with HL and LL, LL-BFR has shown
w

HL LL LL-BFR
higher PEH effects [30]. Here, we did not find PEH. On the other
hand, it is known that the PEH magnitude is sometimes insignifi-
▶Fig. 1. Acute hemodynamic changes comparisons among RE cant in normotensive individuals [38] and the volume of just the
protocols. HL: high load resistance exercise; LL: low load resistance leg press exercise might be insufficient to stimulate PEH in the
exercise; LL-BFR: low load resistance exercise with blood flow restric-
healthy elderly [9].
tion; a: HL ≠ LL-BFR (p < 0.05); a HL ≠ LL-BFR (p < 0.1); b HL ≠ LL
(p < 0.05); c LL ≠ LL-BFR (p < 0.05).

Sardeli AV et al. Cardiovascular Responses to Different … Int J Sports Med

 It is important to remember that despite acute hemodynamic
changes after RE protocols, 5 min of recovery were enough to
­return to baseline values in the healthy elderly, with no difference
among protocols. These findings are similar to the Ozaki et al.
­investigation in young men [34]. Ozaki compared post-exercise
effects of LL-BFR (1 × 30 + 3 × 15 with 30 % 1RM and 160 mmHg
BFR) to HL (3 × 10 repetitions with 75 % 1RM) in the bench press
exercise and did not show any difference in the young men’s BP.
Thus, even though major cardiovascular changes occur during ex-
ercise, the healthy elderly returned to basal levels in the majority
of the hemodynamic parameters right after the end of RE proto-
cols. In addition, despite a significant reduction in parasympathet-
ic modulation (HF ms2) after all RE sessions (different from CON),
the increase in sympathetic modulation was smaller, likely due to
the reduction of total power, because the reduction in LFnu and
HFnu was not significant but there was an increase in the LF/HF
ratio (▶ Table 3b).
One limitation of the present study was the indirect BP record-
ing during exercise. Nonetheless, we solved this problem by report-
ing delta BP values, because the finger photoplethysmography-de-
rived delta BP is highly correlated with the gold standard intra-ar-
terial BP measurement [13]. Estimation of SV, CO and TPR has
underlying assumptions derived from interrelationships between
aortic impedance, arterial compliance and total systemic periph-
eral resistance that could be influenced by peripheral circulatory
factors [7], which varied during exercise, thus we compared only
the effect of RE protocols on these hemodynamic parameters dur-
ing rest. Another limitation of the present study was the determi-
nation of individual BFR in the supine position, whereas the RE and
CON were performed in a seated position. However, besides the
possible differences between the supine and seated positions, the
cross-over design could annul these effects because the orthostat-
ic differences in each participant were kept in all experimental ses-
sions.
Conclusions
Taking all findings together, HL is the safer RE protocol for the el-
derly. HL leads to lower BP peak during exercise and its parasym-
pathetic withdrawal seemed to recover as quickly as in the LL-BFR
protocol, which was equal to CON post 30-min recovery for most
HRV indexes, different from LL. Although HL and LL were performed
until muscle failure and LL-BFR had a limited number of repetitions,
the latter prompted higher BP peaks, suggesting potential risks
with LL-BFR exercise in the elderly. Thus, our data shows it is better
prescribe a high load with low volume resistance exercise than a
high volume and low load when considering acute cardiovascular
risk in the elderly.
Acknowledgements
AVS and MLVF were supported by Coordenação de Aperfeiçoamen-
to de Pessoal de Nível Superior (Capes) Foundation. LCS, AFG, BR,
CRC and MPTCM were recipient of Conselho Nacional de Desen-
volvimento Científico e Tecnológico (CNPq) Fellowship. We thank
the support of FISEX research group members and LabFEF techni-
Sardeli AV et al. Cardiovascular Responses to Different … Int J Sports Med
cians from Physical Education Faculty at University of Campinas
(Brazil).
Conflicts of interest
The authors declare there is no conflict of interest.
References
[1] Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson
JE. Triggering of sudden death from cardiac causes by vigorous
exertion. N Engl J Med 2000; 343: 1355–1361
[2] Barcelos LC, Nunes PR, de Souza LR, de Oliveira AA, Furlanetto R,
Marocolo M, Orsatti FL. Low-load resistance training promotes
muscular adaptation regardless of vascular occlusion, load, or volume.
Eur J Appl Physiol 2015; 115: 1559–1568
[3] Brown LE, Weir JP. Procedures recommendation I: Accurate assessment
of muscular strength and power. J Exerc Physiol Online 2001; 4: 1–21
[4] Burd NA, Mitchell CJ, Churchward-Venne TA, Phillips SM. Bigger
Downloaded by: Purdue University Libraries. Copyrighted material.
weights may not beget bigger muscles: evidence from acute muscle
protein synthetic responses after resistance exercise. Appl Physiol Nutr
Metab 2012; 37: 551–554
[5] Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, Minson CT, Nigg
CR, Salem GJ, Skinner JS. American College of Sports Medicine position
stand. Exercise and physical activity for older adults. Med Sci Sports
Exerc 2009; 41: 1510–1530
[6] DeVan AE, Anton MM, Cook JN, Neidre DB, Cortez-Cooper MY, Tanaka
H. Acute effects of resistance exercise on arterial compliance. J Appl
Physiol 2005; 98: 2287–2291
[7] Dyson KS, Shoemaker JK, Arbeille P, Hughson RL. Modelflow estimates
of cardiac output compared with Doppler ultrasound during acute
changes in vascular resistance in women. Exp Physiol 2010; 95:
561–568
[8] Fahs CA, Heffernan KS, Fernhall B. Hemodynamic and vascular
response to resistance exercise with L-arginine. Med Sci Sports Exerc
2009; 41: 773–779
[9] Figueiredo T, Willardson JM, Miranda H, Bentes CM, Reis VM, Simao R.
Influence of load intensity on postexercise hypotension and heart rate
variability after a strength training session. J Strength Cond Res 2015;
29: 2941–2948
[10] FMS. Finometer User’s Guide. Amsterdam: Finapres medical systems
BV. In. Amsterdam: 2005: 221
[11] Force T. Heart rate variability. Standards of measurement, physiologi-
cal interpretation, and clinical use. Task force of the european society
of cardiology and the north american society of pacing and electro-
physiology. Eur Heart J 1996; 17: 354–381
[12] G. B. Borg’s Perceived Exertion and Pain Scales. 1st ed. United States:
Human Kinetics; 1998
[13] Gomides RS, Dias RM, Souza DR, Costa LA, Ortega KC, Mion D Jr.,
Tinucci T, de Moraes Forjaz CL. Finger blood pressure during leg
resistance exercise. Int J Sports Med 2010; 31: 590–595
[14] Greaney JL, Matthews EL, Boggs ME, Edwards DG, Duncan RL, Farquhar
WB. Exaggerated exercise pressor reflex in adults with moderately
elevated systolic blood pressure: role of purinergic receptors. Am J
Physiol 2014; 306: H132–H141
[15] Guelen I, Westerhof BE, van der Sar GL, van Montfrans GA, Kiemeneij
F, Wesseling KH, Bos WJ. Validation of brachial artery pressure
reconstruction from finger arterial pressure. J Clin Hypertens 2008; 26:
1321–1327
 Clinical Sciences
[16] Harriss DJ, Atkinson G. Ethical Standards in Sport and Exercise Science
Research: 2016 Update. Int J Sports Med 2015; 36: 1121–1124
[17] Heffernan KS, Collier SR, Kelly EE, Jae SY, Fernhall B. Arterial stiffness
and baroreflex sensitivity following bouts of aerobic and resistance
exercise. Int J Sports Med 2007; 28: 197–203
[18] Heffernan KS, Rossow L, Jae SY, Shokunbi HG, Gibson EM, Fernhall B.
Effect of single-leg resistance exercise on regional arterial stiffness. Eur
J Appl Physiol 2006; 98: 185–190
[19] Hernando D, Garatachea N, Almeida R, Casajus JA, Bailon R. Validation
of heart rate monitor Polar RS800 for heart rate variability analysis
during exercise. J Strength Cond Res 2016 ahead of print
[20] Ishigaki EY, Ramos LG, Carvalho ES, Lunardi AC. Effectiveness of muscle
strengthening and description of protocols for preventing falls in the
elderly: A systematic review. Braz J Phys Ther 2014; 18: 111–118
[21] Juonala M, Järvisalo MJ, Mäki-Torkko N, Kähönen M, Viikari JSA,
Raitakari OT. Risk factors identified in childhood and decreased carotid
artery elasticity in adulthood the cardiovascular risk in young finns
study. Circulation 2005; 112: 1486–1493
[22] Kingsley JD, Mayo X, Tai YL, Fennell C. Arterial Stiffness and autonomic
modulation after free-weight resistance exercises in resistance trained
individuals. J Strength Cond Res 2016; 30: 3373–3380
[23] Laurentino G, Ugrinowitsch C, Aihara AY, Fernandes AR, Parcell AC,
Ricard M, Tricoli V. Effects of strength training and vascular occlusion.
Int J Sports Med 2008; 29: 664–667
[24] Libardi CA, Catai AM, Miquelini M, Borghi-Silva A, Minatel V, Alvarez IF,
Milan-Mattos JC, Roschel H, Tricoli V, Ugrinowitsch C. Hemodynamic
responses to blood flow restriction and resistance exercise to muscular
failure. Int J Sports Med 2017; 38: 134–140
[25] Lima AH, Forjaz CL, Silva GQ, Meneses AL, Silva AJ, Ritti-Dias RM. Acute
effect of resistance exercise intensity in cardiac autonomic modulation
after exercise. Arq Bras Cardiol 2011; 96: 498–503
[26] MacDougall JD, Tuxen D, Sale DG, Moroz JR, Sutton JR. Arterial blood
pressure response to heavy resistance exercise. J Appl Physiol 1985;
58: 785–790
[27] Mayo X, Iglesias-Soler E, Farinas-Rodriguez J, Fernandez-Del-Olmo M,
Kingsley JD. Exercise type affects cardiac vagal autonomic recovery
after a resistance training session. J Strength Cond Res 2016; 30:
2565–2573
[28] Mitchell CJ, Churchward-Venne TA, West DW, Burd NA, Breen L, Baker SK,
Phillips SM. Resistance exercise load does not determine training-mediat-
ed hypertrophic gains in young men. J Appl Physiol 2012; 113: 71–77
[29] Moraes MR, Bacurau RF, Ramalho JD, Reis FC, Casarini DE, Chagas JR,
Oliveira V, Higa EM, Abdalla DS, Pesquero JL, Pesquero JB, Araujo RC.
Increase in kinins on post-exercise hypotension in normotensive and
hypertensive volunteers. Biol. Chem 2007; 388: 533–540
[30] Neto GR, Sousa MS, Costa PB, Salles BF, Novaes GS, Novaes JS.
Hypotensive effects of resistance exercises with blood flow restriction.
J Strength Cond Res 2015; 29: 1064–1070
[31] Niskanen JP, Tarvainen MP, Ranta-Aho PO, Karjalainen PA. Software for
advanced HRV analysis. Comp Methods Programs Biomed 2004; 76:
73–81
[32] Nunan D, Donovan G, Jakovljevic DG, Hodges LD, Sandercock GR,
Brodie DA. Validity and reliability of short-term heart-rate variability
from the Polar S810. Med Sci Sports Exerc 2009; 41: 243–250
[33] Okuno NM, Pedro RE, Leicht AS, Ramos SP, Nakamura FY. Cardiac
autonomic recovery after a single session of resistance exercise with
and without vascular occlusion. J Strength Cond Res 2014; 28:
1143–1150
[34] Ozaki H, Yasuda T, Ogasawara R, Sakamaki-Sunaga M, Naito H, Abe T.
Effects of high-intensity and blood flow-restricted low-intensity
resistance training on carotid arterial compliance: role of blood pressure
during training sessions. Eur J Appl Physiol 2013; 113: 167–174
Thieme
[35] Pierce GL, Schofield RS, Casey DP, Hamlin SA, Hill JA, Braith RW. Effects
of exercise training on forearm and calf vasodilation and proinflamma-
tory markers in recent heart transplant recipients: A pilot study. Eur J
Cardiovasc Prev Rehab 2008; 15: 10–18
[36] Pinto RR, Polito MD. Haemodynamic responses during resistance
exercise with blood flow restriction in hypertensive subjects. Clin
Physiol Funct Imaging 2016; 36: 407–413
[37] Poton R, Polito MD. Hemodynamic response to resistance exercise
with and without blood flow restriction in healthy subjects. Clin
Physiol Funct Imaging 2014; 36: 231–236
[38] Queiroz AC, Sousa JC, Cavalli AA, Silva ND Jr., Costa LA, Tobaldini E,
Montano N, Silva GV, Ortega K, Mion D Jr., Tinucci T, Forjaz CL.
Post-resistance exercise hemodynamic and autonomic responses:
Comparison between normotensive and hypertensive men. Scand J
Med Sci Sports 2015; 25: 486–494
[39] Rezk CC, Marrache RC, Tinucci T, Mion D Jr., Forjaz CL. Post-resistance
exercise hypotension, hemodynamics, and heart rate variability:
Influence of exercise intensity. Eur J Appl Physiol 2006; 98: 105–112
[40] Rossow LM, Fahs CA, Sherk VD, Seo DI, Bemben DA, Bemben MG. The
effect of acute blood-flow-restricted resistance exercise on post
exercise blood pressure. Clin Physiol Funct Imaging 2011; 31: 429–434
Downloaded by: Purdue University Libraries. Copyrighted material.
[41] Slysz J, Stultz J, Burr JF. The efficacy of blood flow restricted exercise: A
systematic review & meta-analysis. J Sci Med Sport 2016; 19: 669–675
[42] Smolander J, Aminoff T, Korhonen I, Tervo M, Shen N, Korhonen O,
Louhevaara V. Heart rate and blood pressure responses to isometric
exercise in young and older men. Eur J Appl Physiol 1998; 77: 439–444
[43] Spranger MD, Krishnan AC, Levy PD, O'Leary DS, Smith SA. Blood flow
restriction training and the exercise pressor reflex: A call for concern.
Am J Physiol 2015; 309: H1440–H1452
[44] Staunton CA, May AK, Brandner CR, Warmington SA. Haemodynamics
of aerobic and resistance blood flow restriction exercise in young and
older adults. Eur J Appl Physiol 2015; 115: 2293–2302
[45] Stok WJ, Baisch F, Hillebrecht A, Schulz H, Meyer M, Karemaker JM.
Noninvasive cardiac output measurement by arterial pulse analysis
compared with inert gas rebreathing. J Appl Physiol 1993; 74:
2687–2693
[46] Sugawara J, Tanabe T, Miyachi M, Yamamoto K, Takahashi K, Iemitsu
M, Otsuki T, Homma S, Maeda S, Ajisaka R, Matsuda M. Non-invasive
assessment of cardiac output during exercise in healthy young
humans: Comparison between Modelflow method and Doppler
echocardiography method. Acta Physiol Scand 2003; 179: 361–366
[47] Takano H, Morita T, Iida H, Asada K, Kato M, Uno K, Hirose K,
Matsumoto A, Takenaka K, Hirata Y, Eto F, Nagai R, Sato Y, Nakajima T.
Hemodynamic and hormonal responses to a short-term low-intensity
resistance exercise with the reduction of muscle blood flow. Eur J Appl
Physiol 2005; 95: 65–73
[48] Thompson PD, Franklin BA, Balady GJ, Blair SN, Corrado D, Estes NA
3rd, Fulton JE, Gordon NF, Haskell WL, Link MS, Maron BJ, Mittleman
MA, Pelliccia A, Wenger NK, Willich SN, Costa F.American Heart
Association Council on Nutrition PA, Metabolism, American Heart
Association Council on Clinical C, American College of Sports M.
Exercise and acute cardiovascular events placing the risks into
perspective: a scientific statement from the American Heart
Association Council on Nutrition, Physical Activity, and Metabolism
and the Council on Clinical Cardiology. Circulation 2007; 115:
2358–2368
[49] van der Velde N, van den Meiracker AH, Stricker BH, van der Cammen
TJ. Measuring orthostatic hypotension with the Finometer device: Is a
blood pressure drop of one heartbeat clinically relevant? Blood Press
Moni 2007; 12: 167–171
Sardeli AV et al. Cardiovascular Responses to Different … Int J Sports Med
[50] Vechin FC, Libardi CA, Conceicao MS, Damas FR, Lixandrao ME, Berton
RP, Tricoli VA, Roschel HA, Cavaglieri CR, Chacon-Mikahil MP,
Ugrinowitsch C. Comparisons between low-intensity resistance training
with blood flow restriction and high-intensity resistance training on
quadriceps muscle mass and strength in elderly. J Strength Cond Res
2015; 29: 1071–1076
[51] Vieira PJ, Chiappa GR, Umpierre D, Stein R, Ribeiro JP. Hemodynamic
responses to resistance exercise with restricted blood flow in young
and older men. J Strength Cond Res 2013; 27: 2288–2294
Sardeli AV et al. Cardiovascular Responses to Different … Int J Sports Med
[52] Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V, Franklin
BA, Gulanick M, Laing ST, Stewart KJ. Resistance exercise in individuals
with and without cardiovascular disease: 2007 update: A scientific
statement from the American Heart Association Council on Clinical
Cardiology and Council on Nutrition, Physical Activity, and Metabo-
lism. Circulation 2007; 116: 572–584
Downloaded by: Purdue University Libraries. Copyrighted material.