High-intensity interval aerobic exercise improved endothelial function by 3.47% (95% CI: 2.02–4.92) versus usual care and was superior to moderate-intensity aerobic exercise.
Does exercise modality and intensity (specifically high-intensity interval aerobic exercise) improve endothelial function measured by flow-mediated dilation in adults with coronary artery disease or chronic heart failure compared to usual care?
High-intensity interval aerobic exercise is the most robust and evidence-based exercise modality for improving endothelial function in patients with coronary artery disease or heart failure.
Abstract Aims Endothelial dysfunction is a hallmark of cardiovascular disease (CVD). Exercise effectively improves endothelial function, yet the impact of different modalities and intensities remains unclear. This study evaluated the effect of aerobic (AE), resistance (RE), and combined exercise (CE), on endothelial function measured by flow-mediated dilation (FMD). Methods A systematic review and frequentist network meta-analysis of randomised and non-randomised trials in adults with coronary artery disease or chronic heart failure was conducted. Electronic databases were searched up to April 2025. Interventions were classified as usual care (UC), moderate-intensity AE (MAE), high-intensity interval AE (HIIE), moderate-intensity RE (MRE), high-intensity RE (HRE), moderate-intensity CE (MCE), and high-intensity CE (HCE). Mean differences (MD) with 95% confidence intervals (CI) were used as effect size index, and interventions ranked using surface under the cumulative ranking curve (SUCRA). Results Thirty-seven studies (80 groups; n = 6818) were included. Compared with UC, MAE (2.04%; 95% CI: 1.01–3.07), HIIE (3.47%; 95% CI: 2.02–4.92), MCE (2.71%; 95% CI: 0.05–5.36), and HCE (8.25%; 95% CI: 3.18–13.32) significantly improved brachial FMD, whereas MRE did not. HIIE outperformed MAE (1.43%; 95% CI: 0.09–2.78). Although HCE showed the highest surface under the cumulative ranking curve (SUCRA: 98.2%), this relied on a single group. Crucially, sensitivity analyses confirmed HIIE as the most robust high-performing intervention (84.0%) compared to MRE (61.6%) and MCE (61.3%). Conclusion Exercise significantly enhances endothelial function in in patients with CVD. HIIE emerged as the most robust and evidence-based modality, demonstrating superior efficacy over moderate continuous exercise. While high-intensity combined protocols (HCE) show significant theoretical potential, randomised trials are urgently needed to confirm their efficacy. Current evidence supports HIIE as a primary strategy for vascular adaptation in cardiac rehabilitation.
Fuertes-Kenneally et al. (2026) studied this question. High-intensity interval aerobic exercise improved endothelial function by 3.47% (95% CI: 2.02–4.92) versus usual care and was superior to moderate-intensity aerobic exercise.