High-intensity combined exercise significantly improved endothelial function compared to usual care in patients with cardiovascular disease (MD 8.25%; 95% CI 3.18-13.32).
Meta-Analysis (n=6,818)
Does aerobic, resistance, and combined exercise at different intensities improve endothelial function in adults with cardiovascular disease?
High-intensity exercise protocols, particularly high-intensity combined exercise, are the most effective modalities for improving endothelial function in patients with cardiovascular disease.
Mean Difference: 8.25 (95% CI 3.18–13.32)
Abstract Background and aim Endothelial dysfunction is a hallmark of cardiovascular disease (CVD). Exercise is an effective non-pharmacological strategy to restore endothelial function; however, the relative efficacy of different modalities and intensities remains uncertain. Therefore, the aim was to compare the effects of aerobic, resistance, and combined exercise—at different intensities—on endothelial function, as assessed by flow-mediated dilation (FMD), in adults with CVD, specifically coronary artery disease and heart failure. Methods A systematic review and frequentist network meta-analysis of randomised and non-randomised trials was performed following PRISMA-NMA guidelines. Electronic databases were searched up to April 2025. Interventions were classified as usual care (UC), moderate-intensity aerobic (MAE), high-intensity interval aerobic (HIIE), moderate-intensity resistance (MRE), high-intensity resistance (HRE), and combined exercise at either moderate (MCE) or high intensity (HCE). A secondary classification distinguished long-HIIE (1 min) from short-HIIE (1 min) protocols. Mean differences (MD, 95% CI) were calculated, and interventions ranked using the surface under the cumulative ranking curve (SUCRA). Results Thirty-seven studies (80 groups; N = 6,818; 84% males) were included. MAE was the most common modality (39%), typically performed under supervision (62%), with training duration ranging from 4-48 weeks. Compared with UC, significant improvements in FMD were observed after MAE (MD 2.04%, 95% CI 1.01–3.07), HIIE (3.47%, 2.02–4.92), MCE (2.71%, 0.05–5.36) and HCE (8.25%, 3.18–13.32), whereas MRE showed no benefit (based on 3 studies) (Figure 2; A and C). HIIE outperformed MAE (1.43%, 0.09–2.78). According to SUCRA ranking, HCE was most effective (98.2%), followed by HIIE (67.5 %), MAE (46.4%), and MCE (44.7%) (Figure 2; B). Long-interval HIIE (5.69%; 95% CI: 0.02–11.37) and MCE (1.59%; 95% CI: 0.04–3s.15) were superior to MAE, although no significant difference was observed between long and short HIIE. High methodological heterogeneity in exercise protocols was identified. Conclusions Exercise enhances endothelial function in CVD, with high-intensity protocols -particularly HCE - being most effective. Multimodal approaches like HCE may offer additive benefits. The duration of HIIE bouts appears relevant, as long-HIIE outperformed MAE. These findings support incorporating high-intensity training into cardiac rehabilitation to optimise endothelial recovery. Future studies should address underrepresented modalities (HRE, HCE) and directly compare short- vs long-HIIE.
Rocamora et al. (Mon,) conducted a meta-analysis in Cardiovascular disease (coronary artery disease and heart failure) (n=6,818). High-intensity combined exercise (HCE) vs. Usual care was evaluated on Endothelial function assessed by flow-mediated dilation (FMD) (MD 8.25%, 95% CI 3.18-13.32). High-intensity combined exercise significantly improved endothelial function compared to usual care in patients with cardiovascular disease (MD 8.25%; 95% CI 3.18-13.32).