Search tips
Search criteria 


Logo of aryaathArchiveInstruction for AuthorsSubmit OnlineCurrent IssueSearchFarzanegan Radandish Co.
ARYA Atheroscler. 2012 Summer; 8(2): 55–58.
PMCID: PMC3463993

Comparing the effects of a cardiac rehabilitation program on functional capacity of obese and non-obese women with coronary artery disease



Obesity and sedentary lifestyle are known as important risk factors of coronary artery disease. The prevalence of obesity has increased among both men and women in the world. Therefore, the present study tried to evaluate the effectiveness of a cardiac rehabilitation program on functional capacity and body mass index (BMI) in obese and non-obese women with coronary artery disease.


In an observational study during 2000-11, we evaluated a total of 205 women with coronary artery disease who referred to the cardiac rehabilitation unit of Isfahan Cardiovascular Research Institute, Isfahan, Iran. BMI and functional capacity of each patient were assessed before and after the program. The patients were categorized as obese or non-obese based on their BMI. All participants completed the full course of the program. Data was analyzed by independent t-test and paired t-test in SPSS15.


Our finding showed that an 8-week cardiac rehabilitation program had significant effects on functional capacity in obese and non-obese female patients (P < 0.01 for both). The program also resulted in BMI improvements in both groups (P < 0.01 for both). Comparing the changes in the two groups did not reveal any significant differences in functional capacity. However, the two groups were significantly different in terms of BMI changes.


Cardiac rehabilitation programs are a major step in restoration of functional capacity and improvement of BMI in obese and non-obese women with coronary artery disease.

Keywords: Cardiac Rehabilitation Program, Coronary Artery Disease, Obesity, Functional Capacity, Body Mass Index


Obesity and sedentary lifestyle are parallel important risk factors that increase the risk of coronary artery disease (CAD) in women.1 The prevalence of obesity has risen among both men and women throughout the world.2,3 Obesity is identified based on body mass index (BMI). It is defined as a BMI ≥ 30 kg/m2 and thus means an excess body weight for a particular height.2,4,5

On the other hand, functional capacity (FC) is a strong predictor of mortality and morbidity in patients with CAD.6 Such patients usually suffer from cardiopulmonary and musculoskeletal limitations that greatly lessen their ability to exercise and daily physical tasks.6,7 Most studies have implied significant reductions in risks among active CAD patients compared to sedentary patients.8-10

According to previous research, cardiac rehabilitation programs (CRPs), as an established treatment including the combined and coordinated use of medical, physical, psychosocial, and educational measures to return CAD patients to an active and satisfying lifestyle, are an essential way for improving FC and fitness level of cardiac patients.11-13

Despite the numerous reports about the beneficial effects of CRP and exercise training on FC, limited data is available about the usefulness of CRP in obese cardiac patients, particularly women. Therefore, the purpose of this investigation was to evaluate the effectiveness of CRP on FC and weight reduction in obese female patients with CAD compared to non-obese female patients.

Materials and Methods

In an observational study during 2000-11, we evaluated a total of 205 female patients with CAD who referred to the phase II of cardiac rehabilitation unit at Isfahan Cardiovascular Research Institute (Isfahan, Iran). CAD was defined as a history of myocardial infarction (MI), coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or chronic stable angina. Before entering the CRP, written informed consents were obtained from all patients. Height (without shoes) and weight of each patient were then measured by a nurse after an overnight fast and after voiding. BMI was calculated by dividing weight to height squared (kg/m2). According to BMI, patients were allocated into obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) groups. Moreover, the Naughton protocol was used to perform exercise test on each patient under supervision of a cardiologist. Exercise test provided an opportunity to determine body reaction and FC by indicating hemodynamic responses and metabolic equivalent (MET). Afterwards, both groups participated in a CRP for 2 months. The program consisted of 24 sessions, i.e. 3 times a week for 8 weeks. It included exercise training sessions, nutritional and psychological consultation, and risk factor management. Exercise sessions were similar for obese and non-obese patients and consisted of combined aerobic and resistance training. The sessions were held in the cardiac rehabilitation center under the supervision of a physician, an exercise physiologist, and a nurse. Patients were supposed to use treadmills, stationary cycles, stationary steppers, and some resistance devices. Stair climbing, rowing, and jogging were also included. Each session lasted up to 90 minutes and comprised a 10-minute warm-up followed by 60 minutes of aerobic and resistance training, a 10-minute cool-down, and 10 minutes of relaxation. The intensity of training was established according to patients' linical conditions and calculated as 60-85% of maximum heart rate. Dietitians provided all participants with dietary instructions. The patients were encouraged to complete the course of CRP by the physicians, exercise physiologists, and dietitians. Angina treatments were continued at the prescribed dose while no weight reduction medication was used. After 2 months and completing the CRP, all tests were carried out for each patient again. The research was conducted under the medical ethics standards and approved in the Ethics Committee of Isfahan Cardiovascular Research Institute. Independent sample t-test was used to identify baseline differences. On the other hand, paired t-test was employed to investigate the changes caused by the CRP. The results were expressed as mean ± standard deviation (SD) and the level of significance was set at P < 0.05. All analyses were performed in SPSS15 (SPSS Inc., Chicago, IL, USA).


Overall, 205 women with CAD were evaluated. They were divided into two groups of obese (BMI ≥ 30;n = 84; mean age: 57.6 ± 7.94 years) and non-obese (BMI < 30; n = 121; mean age: 58.09 ± 8.95 years). Independent sample t-test showed that at baseline, obese patients had lower FC than non-obese patients (P = 0.001) (Table 1).

Table 1
Changes in functional capacity and weight within and between groups following the cardiac rehabilitation program (CRP)

In addition, paired t-tests revealed that the CRP significantly improved FC and BMI in both groups (P = 0.03). Independent sample t-test was also used to compare the 2 groups after the CRP. Although no significant difference was observed in FC between the two groups, the two groups were significantly different in terms of BMI changes.


In this study, we demonstrated that 8 weeks of CRP and regular exercise training had beneficial effects on FC and BMI in obese and non-obese women with CAD. Moreover, comparing the changes in the two groups showed that following the CRP, obese patients had a relative improvement in BMI compared to non-obese patients. FC, which is a main indicator in CAD, was notably affected by obesity. In fact, at baseline, obese patients had lower FC than non-obese patients. However, after the period of the CRP and performing regular physical activity, they enjoyed a higher, but statistically insignificant, level of fitness. It can thus be concluded that lower levels of FC at baseline may predict improvement in obese patients. In addition, greater improvements in BMI could also explain the greater development in FC in our obese female patients.

Most previous studies were consistent with our results.10,11,14,15 Ades found exercise capacity to constantly improve after cardiac rehabilitation. Therefore, exercise tolerance on the treadmill and peak oxygen consumption increased and everyday activities, such as climbing stairs and carrying groceries, improved in cardiac patients. Ades also reported that weight reduction was the goal of CRP in these patients and that a combination of dietary interventions and exercise training resulted in reduced BMI.16 Likewise, Kennedy et al. suggested CRP to play an important role in improving functional independence in all age groups of women. They also indicated increased exercise capacity to be associated with improvements in the ability to perform everyday activities and to feel less fatigue while doing routine tasks.17 A previous article proposed that high calorie expenditure exercise for overweight coronary patients resulted in greater weight loss compared to standard cardiac rehabilitation.8 Similarly, Bocalini et al. recommended supervised physical exercise as a safe method with the potential to improve FC in patients with heart failure.11,12 weeks of resistance training improved muscle strength and exercise capacity in patients with stable chronic heart failure.9 Lavie and Milani demonstrated that despite improvements in BMI among obese patients with CAD, statistically significant changes in BMI were not observed in non-obese patients.18 Another study used 6-minute walking test and reported CRP to be useful in improving FC and enhancing muscle strength in patients after CABG.19

On the other hand, in contrast to our results, a study showed obese patients to have lower work capacity at both baseline and follow-up. These patients also gained smaller work capacity from baseline to follow-up than non-obese and overweight patients. In fact, their results implied that obese patients benefited less from the CRP than did normal-weight patients.20 Another study detected that CRP had short-term efficiency on FC and BMI in obese patients with coronary heart disease.21 Kiat et al. revealed that a CRP did not affect weight loss but enhanced FC level in patients with CAD.22

Generally, it should be noticed that cardiac adaptations result in increased cardiac dimensions, stroke volume, and cardiac output which in turn increase the blood flow to skeletal muscles and allow the tissues to receive adequate oxygen. Finally, a growing difference in oxygen content between arterial and venous blood occurs during exercise. This process would ultimately lead to increased aerobic capacity in the exercised muscle. On the other hand, vascular adaptations increase the density of skeletal muscle capillaries and improve endothelial-dependent vasodilatation in both epicardial and coronary arteries and thus help these progressions.7,23 These physiological adaptations increase exercise tolerance and fitness level and reduce cardiorespiratory symptoms in women with CAD.


According to the findings of this study and similar research, we can notify a CRP, carried out by cardiac patients under the supervision of a physician and an exercise physiologist, to play a major role in management of obesity and FC in both obese and non-obese female patients.


We thank all physicians and nurses and the staff of Isfahan Cardiovascular Research Institute who kindly helped us in this study.


Conflicts of Interest

Authors have no conflict of interests.


1. Ades PA, Savage PD, Harvey-Berino J. The treatment of obesity in cardiac rehabilitation. J Cardiopulm Rehabil Prev. 2010;30(5):289–98. [PMC free article] [PubMed]
2. Mosca L, Manson JE, Sutherland SE, Langer RD, Manolio T, Barrett-Connor E. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Writing Group. Circulation. 1997;96(7):2468–82. [PubMed]
3. Bahrami H, Sadatsafavi M, Pourshams A, Kamangar F, Nouraei M, Semnani S, et al. Obesity and hypertension in an Iranian cohort study; Iranian women experience higher rates of obesity and hypertension than American women. BMC Public Health. 2006;6:158. [PMC free article] [PubMed]
4. Canoy D, Boekholdt SM, Wareham N, Luben R, Welch A, Bingham S, et al. Body fat distribution and risk of coronary heart disease in men and women in the European Prospective Investigation Into Cancer and Nutrition in Norfolk cohort: a population-based prospective study. Circulation. 2007;116(25):2933–43. [PubMed]
5. Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, Pi-Sunyer FX, et al. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2006;113(6):898–918. [PubMed]
6. Jehn M, Schmidt-Trucksass A, Schuster T, Weis M, Hanssen H, Halle M, et al. Daily walking performance as an independent predictor of advanced heart failure: Prediction of exercise capacity in chronic heart failure. Am Heart J. 2009;157(2):292–8. [PubMed]
7. Ades PA, Waldmann ML, Meyer WL, Brown KA, Poehlman ET, Pendlebury WW, et al. Skeletal muscle and cardiovascular adaptations to exercise conditioning in older coronary patients. Circulation. 1996;94(3):323–30. [PubMed]
8. Manson JE, Lee IM. Exercise for women-how much pain for optimal gain? N Engl J Med. 1996;334(20):1325–7. [PubMed]
9. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273(5):402–7. [PubMed]
10. Manzoni GM, Villa V, Compare A, Castelnuovo G, Nibbio F, Titon AM, et al. Short-term effects of a multi-disciplinary cardiac rehabilitation programme on psychological well-being, exercise capacity and weight in a sample of obese in-patients with coronary heart disease: a practice-level study. Psychol Health Med. 2011;16(2):178–89. [PubMed]
11. Bocalini DS, dos SL, Serra AJ. Physical exercise improves the functional capacity and quality of life in patients with heart failure. Clinics (Sao Paulo) 2008;63(4):437–42. [PMC free article] [PubMed]
12. Leon AS, Franklin BA, Costa F, Balady GJ, Berra KA, Stewart KJ, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111(3):369–76. [PubMed]
13. Thompson PD, Buchner D, Pina IL, Balady GJ, Williams MA, Marcus BH, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107(24):3109–16. [PubMed]
14. Balady GJ, McInnis KJ. Cardiac rehabilitation in obese patients. Chest. 1996;109(1):3–4. [PubMed]
15. Binder RK, Barth J, Schmid JP, Saner H. Burden of abdominal obesity in cardiac rehabilitation patients: Results from the Swiss CaRe study. Swiss Med Wkly. 2011;141:w13153. [PubMed]
16. Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med. 2001;345(12):892–902. [PubMed]
17. Kennedy MD, Haykowsky M, Daub B, Van LK, Knapik G, Black B. Effects of a comprehensive cardiac rehabilitation program on quality of life and exercise tolerance in women: A retrospective analysis. Curr Control Trials Cardiovasc Med. 2003;4(1):1. [PMC free article] [PubMed]
18. Lavie CJ, Milani RV. Effects of cardiac rehabilitation and exercise training in obese patients with coronary artery disease. Chest. 1996;109(1):52–6. [PubMed]
19. Steki Ghashghaei, Taghian F, Najafian J, Marandi M, Ramezani MA, Moastafavi S, et al. Effect of cardiac rehabilitation on functional capacity of patients after cardiac surgery by assessing 6-minute walking test. ARYA Atheroscler J. 2009;5:147–51.
20. Gunstad J, Luyster F, Hughes J, Waechter D, Rosneck J, Josephson R. The effects of obesity on functional work capacity and quality of life in phase II cardiac rehabilitation. Prev Cardiol. 2007;10(2):64–7. [PubMed]
21. Gondoni LA, Titon AM, Nibbio F, Caetani G, Augello G, Mian O, et al. Short-term effects of a hypocaloric diet and a physical activity programme on weight loss and exercise capacity in obese subjects with chronic ischaemic heart disease: a study in everyday practice. Acta Cardiol. 2008;63(2):153–9. [PubMed]
22. Kiat A, Cook E, Kiat H. Weight Loss And Fitness In Patients With Coronary Artery Disease Through Cardiac Rehabilitation - A Long Term Follow-Up. The Internet Journal of Cardiovascular Research. 2011;7(1)
23. Hambrecht R, Wolf A, Gielen S, Linke A, Hofer J, Erbs S, et al. Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med. 2000;342(7):454–60. [PubMed]

Articles from ARYA Atherosclerosis are provided here courtesy of Farzanegan Radandish Co.