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Enquiry Article

Effects of Moderate Aerobic Exercise Training on Hemorheological and Laboratory Parameters in Ischemic Heart Disease Patients

• Barbara Sandor,
• Alexandra Nagy,
• Andras Toth,
• Miklos Rabai,
• Bela Mezey,
• Arpad Csatho,
• Istvan Czuriga,
• Kalman Toth,
• Eszter Szabados

x

• Published: October 27, 2014
• https://doi.org/10.1371/journal.pone.0110751

Figures

Abstract

Background and Design

In this study we gear up out to determine the effects of long-term physical training on hemorheological, laboratory parameters, exercise tolerability, psychological factors in cardiac patients participating in an convalescent rehabilitation program.

Methods

Before physical training, patients were examined by echocardiography, tested on treadmill by the Bruce protocol, and blood was drawn for laboratory tests. The enrolled 79 ischemic heart disease patients joined a 24-calendar week cardiac rehabilitation grooming program. Claret was fatigued to measure out hematocrit (Hct), plasma and whole claret viscosity (PV, WBV), red blood cell (RBC) assemblage and deformability. Hemorheological, clinical chemistry and psychological measurements were repeated 12 and 24 weeks later, and a treadmill test was performed at the cease of the plan.

Results

Later on 12 weeks Hct, PV, WBV and RBC aggregation were significantly decreased, RBC deformability exhibited a pregnant increase (p<0.05). Laboratory parameters (triglyceride, uric acid, hsCRP and fibrinogen) were significantly decreased (p<0.05). Later 24 weeks the significant results were still observed. Past the finish of the written report, IL-6 and TNF-α levels displayed decreasing trends (p<0.06). There was a significant improvement in MET (p<0.001), and the BMI decrease was also meaning (p<0.05). The vital exhaustion parameters measured on the fatigue bear on scale indicated a significant improvement in two areas of the daily activities (p<0.05).

Conclusions

Regular physical training improved the do tolerability of patients with ischemic heart illness. Previous publications accept demonstrated that decreases in Hct and PV may reduce cardiovascular chance, while a decrease in RBC aggregation and an increase in deformability improve the capillary menses. Positive changes in laboratory parameters and body weight may indicate better oxidative and inflammatory circumstances and an improved metabolic state. The psychological findings point to an improvement in the quality of life.

Citation: Sandor B, Nagy A, Toth A, Rabai K, Mezey B, Csatho A, et al. (2014) Effects of Moderate Aerobic Exercise Training on Hemorheological and Laboratory Parameters in Ischemic Heart Disease Patients. PLoS ONE 9(10): e110751. https://doi.org/x.1371/periodical.pone.0110751

Editor: Paula A. da Costa Martins, Maastricht University Faculty of Health, Medicine, and Life Sciences, Netherlands

Received: May 1, 2014; Accustomed: September 24, 2014; Published: October 27, 2014

Copyright: © 2014 Sandor et al. This is an open up-admission article distributed under the terms of the Creative Eatables Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The authors ostend that all information underlying the findings are fully bachelor without restriction. All relevant data are within the paper and its Supporting Information files.

Funding: The authors accept no funding or back up to report.

Competing interests: The authors have declared that no competing interests exist.

Introduction

In the past few decades, bloodshed due to coronary avenue disease (CAD) has decreased substantially in the industrialized countries thanks to the improved medical care, simply it remains the leading cause of death worldwide. In add-on to the optimal pharmacological therapies and modern revascularization procedures, a number of preventive strategies have been created with a view to the farther reduction of the morbidity and bloodshed of CAD [ane].

The contempo guidelines of the European Lodge of Cardiology (ESC) and the American Heart Association/American College of Cardiology (AHA/ACC) indicate that physical action has a pivotal role in the primary prevention in healthy subjects [1], and moreover information technology reduces the all-cause and cardiovascular (CV) mortality also [1], [2], [3], [four], [5], [6], [7]. Moderate aerobic do preparation in patients with CAD improves myocardial perfusion, muscular endurance and psychosocial well-being leading to enhanced flexibility, ameliorated symptoms, improve cardiorespiratory fitness and a reduced CV risk [i]. Training from 2.five to 5 hours a week can upshot in a 20–30% CV and all-cause mortality risk reduction. In summary, moderate physical activeness reduces the CV take a chance in a dose-dependent manner in both male and female person healthy subjects, and fifty-fifty in patients with known CAD [1]. Physical action conducted by physiotherapists and supervised by a cardiologist in a cardiac rehabilitation (CR) program is an excellent possibility for secondary prevention, where effective take chances factor management tin be achieved through long-term life fashion changes [1].

Impaired hemorheological parameters, including reduced erythrocyte deformability and increased erythrocyte aggregation, may have a deleterious effect on the vascular organization leading to the evolution of various CV, cerebrovascular and peripheral arterial diseases [8], [9], [10], [11], [12]. Whereas publications from the last 25 years have clearly revealed a relationship between hemorheological factors and concrete training, those studies involved healthy volunteers or a small numbers of CV patients participating in short-term (ten–12 weeks) exercise preparation. Furthermore, the possible connections betwixt hemorheology and long-term, moderate aerobic physical activity have non been investigated in a relatively large population with ischemic heart illness.

Our study had the aim of determining the benign effects of aerobic concrete training on ischemic heart affliction patients participating in a long-term (24 weeks) convalescent CR program.

Methods

79 non-smoker patients with stable ischemic heart disease (39 males and 40 females, mean age: 65.3±five.68 years) were selected for the report; their co-morbidities are presented in Table 1. The patients received their medication in accordance with electric current guidelines for the secondary prevention of CAD [13] and with their co-morbidities (Tabular array 2). Modifications in either agent or dose were not made during the trial. Patients with an ejection fraction <40%, and MET <5 or a significant ST depression during a treadmill-based exercise tolerance test using the Bruce protocol were excluded from the study [14], [15]. ST depression was accustomed significant in thoracic leads by 1 mm and in limb leads by 2 mm. There were neither arrhythmias nor AV blocks detected among our patients.

The investigation was approved by the Regional Ethics Commission (licence number: 4378) of the Academy of Pecs and written informed consent was signed past all subjects.

Study design

At baseline, the following measurements were performed: psychological tests, resting electrocardiography (ECG), resting echocardiography (Table three), treadmill-based exercise tolerance testing using the Bruce protocol, clinical chemical science (fasting total cholesterol, triglyceride, loftier-density lipoprotein (HDL), low-density lipoprotein (LDL), uric acrid, hsCRP, fasting glucose, total plasma protein, albumin, blood cell counts, fibrinogen, cytokines (TNF-α and IL-six) and hemorheological measurements (Hct, whole blood viscosity (WBV), the ratio Hct/WBV, plasma viscosity (PV), red blood jail cell aggregation and ruddy blood cell deformability).

The patients participated in a 24-weeks concrete grooming programme lasting for 1 hour iii times weekly, designed and conducted by a physiotherapist and supervised by a cardiologist. Later 12 weeks, the hemorheological measurements, clinical chemical science (except cytokines) and psychological tests were repeated. At the end of the 24 weeks, the resting ECG measurements, the treadmill tests with the Bruce protocol, the clinical chemistry, the hemorheological measurements and the psychological tests were repeated.

Aerobic practise preparation program

The present aerobic exercise training program was preceded and concluded with blood pressure and pulse measurements. The patients began with warm-up exercises (breathing exercises, and stretching of the big joints) for 5–ten minutes. In the 2nd stage, they participated in a moderate-intensity training. Intensity was defined as fifty–seventy% of peak VO₂ (starting at 50% and gradually increasing to seventy% of VO_2max). The intensity was assessed by the Borg scale (13–fifteen/twenty) [16] and pulse measurements. The training involved static (exercises with medicine ball, half-squats, toe raisis, body flexions) and dynamic (walking, jogging, ball games due east.g. basketball game, football) practise elements. The aerobic phase lasted 35–40 minutes. Finally, relaxation exercises were performed (stretching and breathing exercises) for ten minutes.

Blood collecting

Blood samples were obtained from the antecubital vein at baseline, after 12 weeks and afterward 24 weeks. The claret was nerveless into 2 lithium heparin-coated (12 ml), one jell activator-coated and gel-containing (v ml), one potassium EDTA-coated (3 ml) and ane sodium fluoride and potassium oxalate-coated (ii ml) Vacutainer tube with a 21-gauge Eclipse Blood Collection butterfly needle fix, using a minimal tourniquet.

Hemorheological measurements

Hemorheological measurements were performed within 2 hours after blood sampling. Hct was measured past using a micro-Hct centrifuge (Haemofuge Heraeus Instr., Germany). WBV and PV were determined at a shear rate of 90 s^−ane with a Hevimet 40 capillary viscometer (Hemorex Ltd., Budapest, Hungary). Plasma was prepared by a 10-minute centrifugation of whole blood at 1500 one thousand. Measurements were made at 37°C. The ratio Hct/WBV was utilized to narrate RBC oxygen ship effectiveness [11].

Scarlet blood cell aggregation was measured with LORCA (Laser-assisted Optical Rotational Cell Analyzer; R&R Mechatronics, Hoorn, The Netherlands) [17], [18] aggregometer, using blood samples with standard xl% Hct. RBC assemblage index (AI) was adamant at 37°C via syllectometry (i.e., light amplification by stimulated emission of radiation backscatter versus time). The RBC disaggregation threshold (γ), i.e., the minimal shear rate needed to preclude RBC aggregation or to breakup existing RBC aggregates, was adamant using a re-iteration procedure. Measurements were fabricated at 37°C.

Erythrocyte deformability was characterized with a LORCA ektacytometer [nineteen] at 37°C, which provided nine values of elongation index (EI) in the shear stress range from 0.3 to xxx Pa. The deformability results were analyzed by ways of the Lineweaver-Shush nonlinear equation, with calculation of the maximal EI (EI_max) at infinite shear, and the shear stress value (SS_1/ii) required for half of this maximal elongation [20]. For deformability measurements, claret samples were suspended in a highly viscous (32.six mPas) polyvinylpyrrolidone solution.

Cytokine measurements

Cytokines were determined with an automated chemiluminescence immunoassay system (Immulite g, Siemens). For TNF-α, a solid-phase chemiluminescent immunometric assay (cat. no. LKNF1), and for IL-6, a solid-stage chemiluminescent sequential immunometric assay (cat. no. LK6P1) was used. Master scale and bi-level cytokine controls were applied during the runs.

Psychological surveys

In order to examine the effects of the 24-calendar week physical training on the patients' subjective experience with fatigue, we practical the Fatigue Impact Scale (FIS) [21], [22]. The FIS consists of 40 items which evaluate the impact of fatigue on 3 aspects of daily life: physical (10 items), cerebral (10 items) and psychosocial (20 items) functions. In addition, nosotros monitored patients' low severity by the short version of the Beck Depression Inventory (9 items).

Statistics

Data are shown as means ± SD. Differences were evaluated past a one-way repeated ANOVA statistical test (Tamhane post-hoc exam) afterwards using the Kolmogorov–Smirnov test to check on the normality of the data distribution. Multivariate linear regression and stepwise analyses of the data were performed with regard to differences betwixt the baseline and the 24-calendar week MET values for whole blood and plasma viscosity, LORCA aggregation index, LORCA erythrocyte deformability at 5,33 Pa shear stress and BMI.

A sample size and ability analysis was performed for the overall population using PS program version 3.ane.2. For the sample size of n = 79 patients needed to detect a truthful departure of δ = i.94 in MET with 92.6% power, where type I error probability is α = 0.05.

The psychological data revealed a significant departure from the normal distribution, and; the nonparametric Friedman examination was therefore applied to analyze potential changes in psychological functioning. The analyses of the psychological information was restricted to those patients who had no missing surveys and gave no indication of moderate to severe low at any of the three measurements. Five patients indicated moderate to severe low during the rehabilitation catamenia, and half dozen of them had missing surveys. These patients were excluded from the psychological data analyses, which included 68 patients' data (86% of the total sample).

Significance level was divers as p<0.05. SPSS statistical software, version 11.0.ane. was used to carry descriptive analyses and to describe the sample.

Results

As concerns the hemorheological results, the Hct displayed a decreasing tendency during the investigated period, while the WBV exhibited a significant reduction (p<0.05), resulting in a significantly increased Hct/WBV ratio (p<0.05). The PV was significantly decreased after 12 weeks and remained significantly lower relative to the baseline at the finish of the program (p<0.001) (Table four). The ruby blood cell aggregation parameters of LORCA aggregometer likewise demonstrated pregnant reductions. The LORCA parameter (AI) decreased significantly during the 24-calendar week training programme (p<0.05) (Table five), while the LORCA EIs of erythrocyte deformability increased significantly (p<0.001), supported by the Lineweaver-Burke nonlinear equation analyses showing a significantly higher EI_max and a significantly lower SS_1/ii (Table 6).

Tabular array 4. Changes in certain hemorheological parameters (hematocrit (Hct), whole claret viscosity (WBV), plasma viscosity (PV) and the Hct/WBV ratio) later the 12- and 24-week ambulatory exercise preparation of ischemic heart affliction patients.

https://doi.org/10.1371/periodical.pone.0110751.t004

Table 6. Changes in erythrocyte deformability parameters EI_max and SS_1/2 calculated by the Lineweaver-Burke nonlinear equation afterward the 12- and 24-calendar week ambulatory exercise training of ischemic heart affliction patients.

https://doi.org/ten.1371/periodical.pone.0110751.t006

The clinical chemical science parameters relating to uric acrid, triglycerides, hsCRP and fibrinogen decreased significantly during the training period (Table seven).

The cytokine measurements did not indicate a significant decrease (p<0.05), but simply a falling trend as compared with the baseline values (Table 7).

As expected, the functional capacity described by the MET significantly improved (p<0.001), and the treadmill fourth dimension likewise increased significantly, by 17.4% (p<0.001), during the training program. Moreover, the patients lost weight, with the body mass index (BMI) undergoing a significant decrease during the trial (p<0.001), all the same lean body mass index calculated past the Hume formula [23], showed a slight merely not significant increase at the end of the 24 week (Table viii).

Table viii. Changes in exercise tolerability parameters (MET and treadmill time) and BMI also equally lean body mass index later on the 24-calendar week ambulatory exercise training of ischemic heart affliction patients.

https://doi.org/10.1371/journal.pone.0110751.t008

For the Δ values betwixt the baseline and 24-week measurements were calculated from every parameter showing a pregnant deviation to the baseline. The Δ parameters, which were in positive or negative correlation to the MET were used for the multivariate linear regression analyses: five independent variables were investigated in association with the departure in MET (ΔMET was regarded as the dependent variable). Regression assay showed that the predictive model provided a good fit to the data with a significant F value (F(five), p<0.001), and the v predictors explained 76% of the difference in MET values (R² = 0.76). The results in Table 9 indicated that the change in red blood cell aggregation index (LORCA) (standardized β = −0.337), WBV (standardized β = 0.406) and red claret cell deformability at 5,33 Pa shear stress (standardized β = −0.197) values were significant independent variables of the regression model and the most strongly related to the variation of the MET values. Furthermore, the analyses revealed a strong independent predictive association betwixt the ΔAI (LORCA), ΔWBV equally well as Δdeformability and the dependent variables.

Although gender specific subgroup analyses was made regarding hemorheological, laboratory chemical science and exercise tolerance parameters, merely no differences were observed. Data are not shown.

In the course of the study, there was no drop out, and no noteworthy CV event or unplanned hospitalization occurred. Analysis of the FIS data revealed a meaning refuse in the symptoms of fatigue in the physical [chi²(ii)  = half dozen.12, p<0.05], the psycho-social [chi²(2)  = seven.09, p<0.05] and in the cognitive domain [chi²(two)  = viii.85, p<0.05]. More specifically, patients' perception of their physical, cognitive, and social functional limitations caused by fatigue declined significantly over the course of the physical training period.

Discussion

The fundamental trouble of CAD patients can not be solved completely via revascularization techniques (percutaneous coronary intervention or a coronary artery bypass graft), effective and long-term lifestyle changes are at least as vital as other therapeutic procedures [24]. Contempo studies such as EuroAction [25] and GOSPEL [26] accept indicated that regular long-term physical activeness results in more do good than short-term training programs as regards the prognosis of cardiac patients. A physical training program is strongly recommended by the ESC and the AHA/ACC also [i], [2], [3].

Aerobic exercise training is defined as a sub-category of concrete activity in which planned, structured, and repetitive bodily movements are performed to maintain or better physical fettle [1]. Co-ordinate to the recommendations of ESC guidelines regarding physical activeness and CAD prevention [1], [2], patients with previous astute myocardial infarction, CABG, PCI, stable angina pectoris, or stable chronic heart failure should undergo exercise training (I (A) stiff evidence) [27], which should be performed at least xxx minutes long (preferably 45–60 minutes) and 3–5 times weekly, in form of an aerobic exercise training (I (B) evidence) [1], [2], at 70–85% of the superlative heart rate [2] or 40–60% of eye rate reserve [2] or 10/20–xiv/twenty of the Borg Scale [16].

Information technology is a long revealed fact that impaired hemorheological factors are CV risk factors, and the improvement of these could effect in lower CV adventure and mortality [8]–[12]. The triphasic association of hemorheology and physical exercise is besides identified by at present. Even so, the possible connections between hemorheology and long-term aerobic physical preparation in a relatively large ischemic heart disease population have not been investigated previously. A systematic literature search in PubMed with the keywords hemorheology, physical action, physical exercise, cardiovascular diseases and atherosclerosis, identified but 14 nonrandomized controlled studies from the by 25 years in which original data were used to make up one's mind changes in hemorheological parameters, mostly in healthy volunteers and athletes (9 publications), but too partially in patients with CV diseases (five publications), participating in short-term (10–12 weeks) practise preparation [28] (Tables S1 in File S1, Table S2 in File S2, Tabular array S3 in File S3). Investigations involving healthy volunteers have proven that short-term physical action has acute effects on the hemorheological parameters, including increases in Hct and WBV due to the fluid shift, water loss and release of sequestered scarlet claret cells from the spleen [29]–[31]. In contrast, long-term training causes autohemodilution, resulting in reduction of PV and WBV [29]. On the other hand, the findings of red claret cell assemblage and deformability studies are not concordant. Some investigations dealing with long-term physical activity performed by healthy volunteers, suggested the deterioration of rheological factors [32]–[34], whereas others reached the reverse decision [35]–[37]. These discrepancies might exist explained by differences in training periods (short,- or long-term), study designs [29], [31], [35], methods [32], [33], [36], [37], the selected populations [31], [33], [34] and the exercise performed (cycling vs. running) [29], [31].

Only few studies take focused on the furnishings of exercise on hemorheological factors in CV patients [28]. Several investigations have shown that acute training evokes increases in PV and fibrinogen [38]. Levine et al. were unable to demonstrate any hemorheological furnishings after a 10-week CR preparation [39], merely Church et al. reported reductions in WBV and PV after a 12-week CR program [40]. In our present study, we investigated whether we could demonstrate any hemorheological changes in ischemic heart disease patients participating in a 24-calendar week convalescent CR training program. The results pointed to a slight subtract in Hct, while meaning decreases were observed in WBV and PV, resulting in a significantly increased Hct/WBV ratio. The carmine blood cell aggregation indices and the measured deformability parameters were besides significantly enhanced at the end of the training program.

Although the blood flow of the coronary vessel system is primarily determined by hemodynamic factors (i.e. continuous changes in flow, extravascular pressure, perfusion force per unit area and shear charge per unit during a cardiac cycle), nether certain conditions (e.grand. a menstruum decrease acquired by vessel stenosis, especially in ischemic heart illness patients) the role of rheological parameters becomes of import. The observed beneficial changes in the macrorheological parameters presented in this investigation (e.g. Hct and viscosity) presumably reduce the CV risk of ischemic heart disease patients [11], [12], [41], [42].

In addition to the positive findings among macrorheological parameters, microrheological changes could also accept a pivotal role in the development of amend physical fitness. The diameter of the narrowest capillaries in the body (iii–v µm), found in the myocardium, is appreciably less than the resting diameter of a normal red blood cell (seven–viii µm), which highlights the importance of the microrheological parameters (due east.g. erythrocyte aggregation and deformability). Decreased red blood cell assemblage and improved deformability observed in our trial back up capillary flow, especially in patients suffering from ischemic heart disease. In the groundwork of increased deformability we could assume recently published data, which have stated that aerobic preparation with low lactate levels (as aerobic practice) could enhance RBC deformability [43], which together with an increased Hct/WBV ratio indicate a amend RBC oxygen transport effectiveness leads to a better oxygen supply of the myocardiocytes, and the working muscles (43, 44). According to a lately observed miracle, cerebral and muscle tissue oxygenation indicis (TOI) measured past NIRS are positively correlated with Hct/WBV ratio in sickle-cell patients (SC and SS patients) comparing to salubrious volunteers, which could also support our findings [45]. Thus, our results may advise that cardiac patients could achieve a condition of "hemorheological fitness" characterized by improved tissue perfusion, better oxygen delivery and lower vascular resistance [28], [43], [44], [45] by participating in a physical training program for 24 weeks.

Furthermore, all hemorheological alterations may likewise contribute to the ameliorate exercise tolerability proved by the treadmill test parameter MET and the treadmill fourth dimension. Moreover, the multivariate linear regression analyses showed that changes in red blood jail cell deformability, assemblage and WBV are independent predictors of the positive changes in MET. These results are in accordance with the higher up mentioned findings nigh improving RBC deformability and Hct/WBV ratio since they accept a pivotal part in the enhancement of capillary blood period, every bit well as in the oxygen supply of the myocardiocytes and the working muscles during exercise [43], [44], [45]. Beneath improve physical tolerance, the improvement of MET by ane value could reduce the risk of all-cause and CV mortality by 13% and 15%, respectively [46], [47].

Of the clinical chemistry indicators, uric acrid, triglyceride, hsCRP and fibrinogen underwent significant decreases during our study. Although we are enlightened that these biomarkers are considered to display only depression specificity in a CV risk cess and are easily influenced by common inflammatory diseases, our data advise that regular long-term physical activity might exert a favorable upshot on the inflammation status of patients with CAD. Further overproduction of proinflammatory cytokines such as IL-6 or TNF-α could exist a marking of chronic inflammation leading to provoked and accelerated atherosclerosis [48], [49], with a higher risk of CV events and mortality [50]. Our information demonstrated an almost significant decreases in IL-vi and TNF-α levels, suggesting that a longer preparation program might be required to achieve pregnant reductions in these parameters.

Interestingly, no significant change was observed in the fasting glucose. Our findings in instance of glucose levels are supported by recent publication; authors did not observed any effect on the glycemic control caused by exercise training in 16 aged, female patients with blazon 2 diabetes mellitus neither with weekly 2 times for hour nor with weekly 4 times for 30 minutes [51]. Although the same paper described the benign hemorheological effects (decreased RBC aggregation and increased RBC deformability) of the mentioned training protocol [51].

However total cholesterol and LDL cholesterol levels did not modify during the trial, triglyceride and uric acid levels decreased significantly by the cease of the training programme. It is well known that hypertriglyceridemia is a pregnant contained CV adventure factor [52], [53] and a recently published metaanalysis concluded that an elevated serum uric acid level should be considered as a risk factor for CV bloodshed [54]. The pregnant reductions in triglyceride and uric acid levels in our report may reverberate a better metabolic state evoked past regular concrete activity.

Beside laboratory parameters, both overweight and obesity are associated with an elevated chance of death in CAD and of all-cause mortality [55]–[57]. The BMI was significantly decreased by the stop of the 24-week practice preparation in our study. Although the results of the multivariate linear regression model indicated that the positive change in functional chapters is non influenced by the reduction in BMI. Accordingly, the better physical exercise tolerance can not be explained merely by the decreases in BMI and obesity. The beneficial furnishings of the physical activity generally on all the measured CV risk factors, including the hemorheological factors, must besides be involved.

Moreover, CAD is frequently accompanied by an increased subjective feeling of fatigue (i.e. a feeling of physical tiredness and a lack of free energy) and this might accept a serious detrimental impact on a broad variety of everyday functions, including physical, mental and social operation [58]. Our psychological results showed a significant amelioration every bit concerns the FIS physical and psycho-social aspects, indicating an comeback in the quality of life among our ischemic heart affliction patients.

Our study was designed as a self-control study, equally our working group accept already proved the worsening of the hemorheological factors in patients with stable CAD, fifty-fifty if these patients have received correct drug therapy, merely have not attended at whatever CR plan [41], [42]. Kesmarky et al. have observed meaning deterioration in WBV and Hct as well equally in fibrinogen levels, along with an increase of PV, half-dozen months after a percutaneous coronary angioplasty [41]. In accord, Marton et al. described the aforementioned meaning increase in WBV, Hct and PV in ischemic heart affliction patients 1 year after their myocardial infarction [42].

Conclusions

Our written report has revealed new information regarding the furnishings of a long-term ambulatory CR training programme on stable CAD patients. Also the anticipated improvement in functional capacity and the reduction in BMI, the regular, moderate-intensity, long-term concrete activity led to favorable hemorheological changes, decreased level of inflammation and improvements in sure metabolic parameters, such as the triglyceride and uric acid contents, suggesting that these parameters may play important part in the positive effects of regular physical activity in patients with CAD.

Supporting Information

Author Contributions

Conceived and designed the experiments: BS AN BM AC KT ES. Performed the experiments: BS AN AT MR BM AC. Analyzed the information: BS AN Air conditioning. Contributed reagents/materials/analysis tools: IC KT ES. Wrote the paper: BS MR AC IC KT ES.

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