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Effect of exercise on upper and lower extremity endothelial function in patients with coronary artery disease

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Abstract

Aerobic exercise training improves endothelial vasomotor function in the coronary circulation of patients with coronary artery disease (CAD), an effect that has been attributed to local repetitive increases in shear stress on the endothelium. To study the effects of exercise on endothelial function in the peripheral circulation, we used vascular ultrasound to examine flow-mediated dilation and nitroglycerin-mediated dilation in the brachial and posterior tibial arteries of 58 subjects with CAD. Studies were performed at baseline and after 10 weeks in 40 subjects (aged 59 ± 10 years) who participated in a supervised cardiac rehabilitation program that predominantly involved moderate intensity leg exercise (three 30-minute sessions/week), and 18 matched patients who did not exercise and maintained a sedentary lifestyle. Exercise was associated with a 29% increase in functional capacity (7.3 ± 2.2 vs 9.4 ± 2.7 METs, p <0.001), and significant improvement in endothelium-dependent, flow-mediated dilation in a conduit artery of the leg, but not the arm. Nitroglycerin-mediated dilation in the upper arm and lower extremity was unaffected. These findings suggest that exercise improves endothelial function in peripheral conduit arteries of patients with CAD and that the beneficial effect may be more marked in the vascular beds of the exercised limbs.

Section snippets

Research subjects

Patients referred for management of CAD, including cardiac rehabilitation, were eligible to participate in the study. All had angiographically documented CAD (at least 1 coronary stenosis >50%). Subjects were excluded if they had unstable angina, acute myocardial infarction within 1 week, uncontrolled systemic hypertension, claudication, clinically significant valvular disease, decompensated congestive heart failure, or any condition that would preclude safely withholding vasoactive medications

Clinical characteristics

A total of 58 subjects were studied, and their baseline characteristics are listed in Table 1. Subjects in the exercise and control groups had similar characteristics with regard to age, traditional cardiac risk factors, prior revascularization, gender distribution, and medical therapy.

As expected, a program of regular endurance training was associated with a significant increase in exercise tolerance in the exercise group. Mean exercise capacity was 7.3 ± 2.2 METs at baseline, and increased to

Discussion

This is the first prospective study to evaluate the effects of endurance exercise as prescribed in cardiac rehabilitation on vascular function in both the upper and lower limbs of patients with documented CAD. This present study demonstrated the salient finding that a supervised, 10-week endurance training program characterized by lower extremity exercise improves flow-mediated dilation of the posterior tibial artery in patients with CAD. A nonsignificant increase in brachial artery

Acknowledgements

We are grateful to Helene Glassberg, Thomas Maguire, and Cheryl Spahn for their assistance with data collection for this study.

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    Although considered the “gold standard” for non-invasive assessment of the endothelium-dependent vasodilation in different populations (Allen et al., 2003; Green et al., 2010; Rakobowchuk et al., 2008; Doerschug et al., 2007), this technique does not provide a direct measurement of downstream microvascular function, which is also impaired in the obese state and has been indicated as a predecessor of more overt vascular dysfunction (Bender and Laughlin, 2015; Bagi et al., 2012). Additionally, as aforementioned, studies have shown that differences in shear stress exposure can induce differences in endothelial cell phenotype expression throughout the vasculature (Bender and Laughlin, 2015; Gokce et al., 2002). Therefore, being able to assess microvascular function in the lower limb is also important.

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