Validation of rate of perceived exertion-based exercise training in

patients with heart failure: Insights from autonomic nervous

system adaptations
Ferdinando Iellamo
a,b,
, Vincenzo Manzi
a
, Giuseppe Caminiti
a
, Cristiana Vitale
a
, Michele Massaro
b
,
Anna Cerrito
a
, Giuseppe Rosano
a
, Maurizio Volterrani
a
a
Istituto di Ricovero e Cura a Carattere Scientico San Raffaele Pisana, Roma, Italy
b
Dipartimento di Medicina dei Sistemi, Universit Tor Vergata, Roma, Italy
a b s t r a c t a r t i c l e i n f o
Article history:
Received 16 March 2014
Received in revised form 29 May 2014
Accepted 24 July 2014
Available online xxxx
Keywords:
Heart failure
Exercise training
Rate of perceived exertion
Baroreex sensitivity
Heart rate variability
Cardiac rehabilitation
Background: Exercise prescription in cardiac patients is based on heart rate (HR) response to exercise. How to
prescribe long-term exercise training outside medically-supervised settings also considering changes in individ-
ual physical capacity over time is unknown. In this study we hypothesizedthat inpatients with chronic heart fail-
ure (CHF) the session-rate of perceived exertion (RPE), a subjective-based training methodology, provides
autonomic and functional capacity changes superimposable to those observed with HR-based Training Impulses
(TRIMPi) method.
Methods: Twenty patients with stable CHF were randomized to either aerobic continuous training (ACT) or aer-
obic interval training (AIT) for 12 weeks. For each TRIMPi-guidedexercise session, the session-RPE was recorded.
By this method, internal training load (TL) is quantied by multiplying the RPE of the whole training session,
using the Borg CR10-scale, by its duration. Heart rate variability (HRV), and baroreex sensitivity (BRS) were
assessed at baseline and at 3 weeks intervals.
Results: Signicant correlations were found between TRIMP
i
and individual session-RPE, for both ACT and
AIT (r = 0.63 to 0.81), (P b 0.05). The same occurred when ACT and AIT groups were pooled together (r =
0.72; P b 0.01). RR interval, HRV and BRS were signicantly and very highly correlated with weekly RPE-
session (r
2
rangedfrom0.77 to 0.97; P b 0.001). Asignicant relationship between session-RPE and performance
at the 6MWT was also found.
Conclusions: Session-RPE is an easy-to-use, inexpensive and valid method for exercise prescription and health
maintenance, consistent with objective physiological indices of training, that could be used for long-term phys-
ical activity in patients with CHF.
2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Exercise training, is currently recommended in combination with
pharmacological therapy in patients with chronic heart failure (CHF)
at a class 1 level [1,2]. It is well established that to be effective over
time, exercise training should be maintained all-life long. This would
imply the need of a continuous adaptation of exercise prescription, in
terms of volume and intensity, especially in aging individuals. Current
guidelines for exercise prescription commonly utilize HR as target
tool, namely percentages of maximum heart rate (HRmax), and heart
rate reserve (HRR) [3], or little bit more sophisticated measures that
take into account also the lactate prole and individual internal training
load [4]. These types of exercise prescription are usually done in clinical
rehabilitation, centers, where patients are followed as in- or outpatients
for a limited period of time. The issue thus exists as to how prescribing
long-term exercise training taking into account: 1) the need of practis-
ing regular physical activity outside medically-supervised settings and
2) the physiological aging processes with the attendant changes in indi-
vidual physical capacity over time. Hence, a more practical and user-
friendly method of exercise prescription would be mandatory.
A simple method to quantify internal training load has been ad-
vanced by Foster et al. [5] and referred to as session-RPE. By this
method, internal training load (TL) is quantied by multiplying the
whole training session rating of perceived exertion (RPE) using the
Borg category ratio scale [6] (CR10-scale) by its duration. This prod-
uct represents in a single number the magnitude of internal TL in ar-
bitrary units (AU) and has been used and validated in athletes of
different sport disciplines [5,7,8]. Borg's CR10 is considered a global
indicator of exercise intensity including physiological (oxygen
International Journal of Cardiology xxx (2014) xxxxxx
Corresponding author at: IRCCS San Raffaele Pisana, Dipartimento di Medicina dei
Sistemi, Universit di Roma Tor Vergata, Via Montpelier, 1, 00173 Roma, Italy.
Tel.: +39 06 20900560; fax: +39 06 72594263.
E-mail address: iellamo@med.uniroma2 (F. Iellamo).
IJCA-18395; No of Pages 5
http://dx.doi.org/10.1016/j.ijcard.2014.07.076
0167-5273/ 2014 Elsevier Ireland Ltd. All rights reserved.
Contents lists available at ScienceDirect
International Journal of Cardiology
j our nal homepage: www. el sevi er . com/ l ocat e/ i j car d
Please cite this article as: Iellamo F, et al, Validation of rate of perceived exertion-based exercise training in patients with heart failure: Insights
from autonomic nervous system adaptations, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.076
uptake, HR, ventilation, beta endorphin, circulating glucose concen-
tration, and glycogen depletion) and psychological factors [9] and
as such it could be considered an accurate indicator of global internal
TL. The RPE-session method might potentially be used by cardiac pa-
tients for long-term, self-selected physical activity management.
However, whether this easy-to-use training method would provide
similar physiological adaptations as with the more usual HR-
targeted training methodologies is patients with cardiac diseases is
not known.
We recently reported in patients with chronic heart failure (CHF),
that exercise training programs guided by the TRIMPi method [10], a
measure of internal TL which integrates in a single term both the vol-
ume and intensity of exercise, i.e., the dose, by utilizing the relation-
ship that exists between increase in HR and lactate production at
individual level, induced a dose-dependent curvilinear response in sev-
eral parameters exploring autonomic nervous systemcardiac regulation
while simultaneously increasing functional capacity [10].
In the present study we sought to test the hypothesis that in the
same patients, the session-RPE method provides similar autonomic ad-
aptations and improvement in functional capacity as those observed
with the more complex HR-based TRIMPi method.
2. Methods
2.1. Patients and study design
We enrolled 20 consecutive male patients with post-infarction heart failure referred
to our center for a cardiac rehabilitation program. Subject eligibility was determined at
the initial screening visit. Patients were included in the study if they had left ventricular
ejection fraction (LVEF) b 40% at echocardiographic examination, symptomatic heart fail-
ure with functional New York Heart Association (NYHA) class II or III, clinical stability
without hospital admission for HF in the previous 3 months, sinus rhythm and were on
optimal medical treatment. Patients were excluded if they had unstable angina or recent
acute myocardial infarction (less than 6 months), frequent atrial or ventricular premature
beats, conduction defects, pacemaker, uncontrolledhypertension, history of severe kidney
diseases, signicant pulmonary disease, severe lower extremities vascular or other dis-
eases which could prevent a symptom limited exercise test, coexisting valvular disease
and insulin-dependent diabetes. Medications were not altered throughout the study.
The patients reported in the present study were the same of other investigations having
different purposes [4,10].
Patients were randomly assigned on 1:1 basis to a 12-week aerobic continuous
training (ACT) or aerobic interval training (AIT), both programmed according to the
TRIMPi method [4,10]. For each TRIMPi-guided exercise session, the RPE-session ac-
cording to Foster [5] was also recorded. To validate the session-RPE method we
used the correlation between session-RPE responses with those observed with the
TRIMPi method, the latter assumed as criterion validity. Reliability of the session-
RPE method was assessed before the beginning of the study as intraclass correlation
coefcient and coefcient of variation. The corresponding values were 0.96 and 1%,
respectively.
ACT and AIT programs guided by TRIMPi have been reported in detail elsewhere
[4,10,11]. Shortly, for all patients, the exercise training program consisted of uphill
treadmill walking, 2 days a week for the rst three weeks, 3 days a week for the sec-
ond three weeks, 4 days a week for the third three weeks, 5 days a week for the last
three weeks. Specically, patients in the ACT group walked continuously at a moder-
ate training intensity, ~4560% of HRR for 3045 min, according to the training peri-
odization. Patients in the AIT group warmed-up for 9 min with calisthenics and
stretching exercise, before walking four 4-minute intervals by 24 times at ~75
80% of HRR, with active pauses of 3 min of walking at 4550% of HRR. The treadmill
running velocity and inclination were adjusted continuously to ensure that every
training session was carried out at the assigned HRR throughout the training period.
Heart rates were recorded (5-second sampling rate) using short-range telemetry
(Polar Team System, Polar Electro Oy, Kempele, Finland). Heart rates were recorded
(5-second sampling rate) using short-range telemetry (Polar Team System, Polar
Electro Oy, Kempele, Finland). All training sessions were performed in the morning
as it was for the 6 minute walking test (6MWT) and cardiopulmonary exercise test
performed before and after training. Data from 42 training sessions were collected
for each patient. Each training session was supervised by a physical therapist.
To allowfor TRIMPi-guided trainings, at baseline, all patients underwent progres-
sive incremental treadmill test until volitional fatigue with monitoring of gas ex-
change (Vmax 29 C, SensorMedics) using a modied Bruce protocol for the
assessment of individual blood-lactate concentration prole, maximal HR and func-
tional capacity. Capillary blood samples were taken from the earlobe each 3 min
and immediately analyzed to assess blood-lactate concentration using an
electroenzymatic technique (YSI 1500 Sport, Yellow Springs Instruments, Yellow
Springs, OH, USA). The highest HR measured during the maximal incremental test
was used as maximum reference value (HRmax
). Blood lactate concentrations were
plotted against running speeds and fractional HR elevation (HR), and individual
blood-lactate concentration proles were identied via exponential interpolation
[4,7,8].
2.2. RPE determination
The subjective perception of effort as session-RPE and HR were assessed in each
patient, for each training session, during 12 different weekly training periodizations.
The session-RPE was determined by multiply the training duration (minutes) by ses-
sion RPE. Individual RPE was assessed using the Borg 10-point scale modied by Fos-
ter [5]. This product represents in a single number the magnitude of internal training
load (TL) in arbitrary units (AU).
Patients were educatedand familiarized withthe use of the Borg 10-point scale before
the beginning of the experiment. To ensure that the perceived effort was referred to the
whole training session rather than the most recent exercise intensity, each patient was
asked to provide a rating of the overall difculty of the exercise bout, and each individual
RPE was recorded about 30 min after completion of eachtraining session. We explained to
the patients that we wanted a global rating of the entire training bout using whatever cues
they felt to be appropriate. Each patient reported the perception of training session effort
by indicating the number on the Borg 10-point scale.
2.3. Autonomic assessment
BRS and Heart rate Variability (HRV) were investigated in each patient at baseline
and 3 weeks apart on 4 subsequent occasions, according to the training periodization.
BRS was assessed by means of the sequences technique [12] by analyzing simulta-
neous recordings of non-invasive nger beat-by-beat BP (Finapres, Ohmeda 2350,
Englewood, CO, USA) and the electrocardiographic trace from a precordial lead at a
sampling rate of 250 Hz (REP 10, Marazza, Italy), as described in details previously
[10,11]. HRV considered in the present study was the standard deviation of mean
RR interval, inasmuch as this is the HRV parameter more consistently reported to
be impaired in CHF. All assessments were made in the morning. After instrumenta-
tion, the subjects lay supine for 15 min before experiments to relax in the room
made dark and noiseless; thereafter, blood pressure (BP) was measured twice,
5 min apart by sphygmomanometer, and the measurements were averaged. After
BP measurements, continuous data acquisition was performed for 10 min.
After ANS assessment, on the same days, patients also performed a 6MWT, as a
measure of functional capacity, according to standardized procedures [13].
All patients gave written informed consent to participate in the study, which was
approved by the local Ethics Committee.
3. Statistics
The results are expressed as means SD and 95% condence inter-
vals (95% CI). Before using parametric tests, the assumption of normal-
ity was veried using the ShapiroWilk W test. Pearson product
moment correlation coefcients with linear regression analysis were
calculated to determine whether there was a signicant relationship
between session-RPE and the HR-based method. Qualitative magnitude
of associations was reported according to Hopkins [14] as follow: trivial
r b 0.1, small r b 0.1 to b0.3, moderate r 0.3 to b0.5, large r 0.5 to b0.7,
very large r 0.7 to b0.9, nearly perfect r N 0.9 and perfect r = 1. To ex-
press the doseresponse relationship between the exercise stimulus
and changes in ANS parameters, correlations between the mean weekly
session-RPE and ANS parameters at baseline, 3, 6, 9 and 12 weeks were
estimated from a second order regression [10,11,15,16]. A multivariate
between-within subject analysis of variance was conducted to assess
the impact of the two different training programs on mean weekly
session-RPE and ANS parameters. The effect size (
2
) was calculated
to assess meaningfulness of differences. Effect sizes values of 0.01,
0.06, and 0.14 were considered small, moderate and large, respectively.
Statistical signicance was set at P b 0.05.
4. Results
Out of 20 patients, 16 completed the study: 2 patients in the ACT
group and 2 in the AIT group discontinued the study. The reason for dis-
continuation was in 1 case the development of permanent atrial brilla-
tion, which prevented HRV and BRS assessment, and in 3 cases the
willingness of the patient to discontinue in the study, not related to
medical reasons. Baseline characteristics of the patients are reported
in Table 1. There were no signicant differences between the ACT and
2 F. Iellamo et al. / International Journal of Cardiology xxx (2014) xxxxxx
Please cite this article as: Iellamo F, et al, Validation of rate of perceived exertion-based exercise training in patients with heart failure: Insights
from autonomic nervous system adaptations, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.076
AIT groups with respect to all variables. All patients were on beta-
blockers and medications were not altered throughout the study.
Adherence to the specic training paradigm in each training session
and compliance with the program was 100%, as inferred from the HR
monitoring device that recorded, in addition to HR, the date of each
training session. The TRIMPi- and session-RPE-based TL were calculated
from 672 training sessions. Individual correlations were determined
from 42 training sessions. Signicant correlations were found between
TRIMP
i
and the individual session-RPE, for both ACT and AIT, with r
values ranging from 0.63 to 0.81; (P b 0.05) (Table 2). Additionally,
a signicant correlation between TRIMP
i
and session-RPE were ob-
served when both ACT and AIT patients groups were pooled together
(r = 0.72; P b 0.01; 95% CI = 0.54 to 0.84) (Fig. 1). The weekly
session-RPE training load steadily increased during the training peri-
od in both ACT and AIT groups (P b 0.001,
2
= 0.99). No signicant
differences were found in mean weekly session-RPE TL score or in
total session-RPE TL score between ACT and AIT group. The mean
weekly RPE-session TL for ACT and AIT groups (weekly periodization)
is shown in Fig. 2. As expected, a progressive increase in the distance
walked was observed with the increase in RPE-session score frombase-
line throughout the study, as observed with the TRIMPi method [4,7],
with a signicant linear relationship between session-RPE score and
the distance walked at the 6MWT (r = 0.85, P b 0.01; 95% CI = 0.38
to 0.97) (Fig. 3).
RR interval, HRV, and BRS increased signicantly with increase in
TL with both training protocols (P b 0.01,
2
= 0.65,
2
= 0.45,
2
=
0.52 for each variable, respectively) and were signicantly and very
highly correlated with weekly RPE-session score with a second-order
regression model (r
2
ranged from 0.77 to 0.97; P b 0.001), resembling
a bell-shaped curve in the ACT and an asymptotic-shaped curve in the
AIT groups, respectively (Fig. 4).
5. Discussion
The main nding of this study is the demonstration that a simple
method of training prescription/monitoring (i.e., session-RPE) provides
superimposable outcomes, in terms of autonomic adaptations and func-
tional capacity, as those provided by an objective, HR-based method
(i.e., TRIMPi) in patients with CHF. The consistency of results during dif-
ferent exercise modalities (i.e., ACT and AIT) suggests that the session-
RPE method may be useful for long-term prescription of varying
exercise-based rehabilitation programs in cardiac patients.
The present study is the rst to apply the session-RPE based ap-
proach to quantify internal TL in patients with CHF and to demon-
strate signicant correlations between this subjective method of
training monitoring and the more objective TRIMP
i
method, based
on the HR and lactate responses to exercise, with individual correla-
tions ranging from 0.63 to 0.81 between weekly TRIMP
i
and weekly
session-RPE TL in both ACT and AIT groups. This nding is similar
to those previously reported in endurance athletes of different
sport disciplines [5,7,8], but, to date, there are no published studies
validating this practical, simple, and inexpensive method of quanti-
fying internal TL in cardiac patients undergoing exercise-based car-
diac rehabilitation programs.
Indeed, the session-RPE score resulted strongly related to TRIMP
i
,
considered as reference standard in assessing training load in the
present investigation. The regression equations describing the relation-
ship between session-RPE with RR interval, HRV and BRS for ACT and
AIT showed superimposable shapes with those using the TRIMPi meth-
od [10] and indicate that to obtain benecial effects in ANS parameters,
patients would need to accumulate at least 400 AU during the weekly
training. From a practical point of view, to reach weekly training load
in the range of 400 AU the exercise training program would need 4
days a week of training with a training session duration of 4050 min
at RPE score from 3 to 5 on the Borg 10-point scale.
Table 1
Baseline characteristics and medications.
ACT AIT
Age, y 62.6 9 62.2 8
BMI, kg/m
2
27.2 3 27.8 2
HR, bmin
1
55.6 5 60.9 5
SAP, mm Hg 110 10 113 11
DAP, mm Hg 70.0 7.6 76.9 5.9
Beta-blockers 8/8 8/8
ACE inhibitors 7/8 8/8
Diuretics 5/8 4/8
Aldosterone receptors blockers 8/8 8/8
Digoxin 1/8 1/8
Antiplatelet agents 8/8 8/8
Statins 8/8 8/8
Data are mean SDor number of patients. ACT, aerobic continuous training; AIT, aerobic
interval training; HR, heart rate; SAP, systolic arterial pressure; and DAP, diastolic arterial
pressure.
Table 2
Individual correlations between RPE-based training load (session-RPE) and TRIMPi train-
ing load in the continuous and intermittent training groups; all individual correlations
were statistically signicant (P b 0.01).
Continuous training Interval training
Subjects TRIMP Subjects TRIMP
S1 0.71 S1 0.71
S2 0.80 S2 0.66
S3 0.66 S3 0.69
S4 0.74 S4 0.81
S5 0.67 S5 0.68
S6 0.66 S6 0.77
S7 0.63 S7 0.64
S8 0.78 S8 0.70
Min 0.63 Min 0.64
Max 0.80 Max 0.81
Fig. 1. Relationship between session-RPE training load and TRIMP
i
method.
Fig. 2. Comparison between the AIT (black bars) and ACT (open bars) groups in mean
weekly session-RPE training load score.
3 F. Iellamo et al. / International Journal of Cardiology xxx (2014) xxxxxx
Please cite this article as: Iellamo F, et al, Validation of rate of perceived exertion-based exercise training in patients with heart failure: Insights
from autonomic nervous system adaptations, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.076
This critical session-RPE training load may be utilized during the
long-term, post-hospital, exercise training, to improve/maintain
functional capacity and ANS parameters on the basis of a subjective,
yet objectively validated, tool. This information might have a huge
impact on training prescription in patient with CHF. Furthermore,
the knowledge of threshold-like values grants practical guidelines
to the development of a structured ergonomic exercise model in pa-
tients with CHF.
The perceived exertion method which uses RPE as a marker of
training intensity within the TRIMP concept [5] has a physiological
basis, inasmuch as it has been shown to be related to both HR and
blood lactate markers of exercise intensity and to the percent of HR
reserve (HRR) during steady-state running and to the time spent at
different intensities corresponding to HR at lactate thresholds (2.5
and 4.0 mmolL
1
) during continuous and interval running [17].
The present data provide support for the use of the session-RPE
method as a subjective estimate of TL also during non-steady state
exercise, like interval training. As such, this very simple method
may be a useful technique for quantitating TL in a variety of training
programs in cardiac patients.
In this regard, the present data suggest that the session-RPE method
may be representative, in a single term, of combined intensity and
duration of training sessions (i.e., the dose of exercise) like the
more sophisticated TRIMPi methodology.
As RPE represents the patient's own perception of training stress,
which can include both physical and psychological stresses, the
session-RPE method may provide a valuable measure of internal TL,
particularly in elderly patients with CHF and other cardiac diseases.
It needs to be recognized and outlined that contributions document-
ed at the level of a patient's group may not fully apply to each mem-
ber of that group even when all patients of the exercising group are
exposed to the same volume/intensity of physical activity adjusted
for their own tolerance level. Hence, a group of CHF patients exercis-
ing at, for example, 4070% HRR may be working at individually dif-
ferent relative intensities. For this reason, exercise training programs
based solely on percentage of HRR or HRmax are likely to impose
variable cardiovascular and metabolic demands in CHF patients [18,
19] as a consequence of differences in individual internal training
load. According to this concept, Scharhag-Rosenberger et al. [20] re-
cently reported a wide inter-subjects variability in lactate response
Fig. 3. Relationship between the sum of the weekly session-RPE training load scores and
the distance walked at the 6 minute walking test. Black circles, ACT group, and black
squares, AIT group.
Fig. 4. Doseresponse relationship betweenweekly RPE-session score andautonomic cardiovascular parameters during interval training (left panel) and continuous training (right panel).
HRV, heart rate variability; and BRS, baroreex sensitivity. *P b 0.05 versus pre-training baseline values.
4 F. Iellamo et al. / International Journal of Cardiology xxx (2014) xxxxxx
Please cite this article as: Iellamo F, et al, Validation of rate of perceived exertion-based exercise training in patients with heart failure: Insights
from autonomic nervous system adaptations, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.076
in individuals with similar aerobic capacity while exercising at the
same percentage of VO
2
max. This study ts well with the general
consensus that exercise training should be individually tailored to
the patient's clinical and functional status [21,22].
Obviously, our results should not be viewed as a substitute of the
current guidelines, which utilize HR, VO
2
or TRIMP methodologies
for exercise prescription. Exercise prescriptions based on these
methods provided fundamental concepts on the effect of exercise
training in cardiac patients. However, they are usually done in clini-
cal rehabilitation centers and need expensive instruments and high
professional skill. Rather, our results would add a further tool in
the armamentarium of exercise prescription methods, particularly
apt to long-term, out-of-hospital, physical activity of cardiac pa-
tients, with a high benet also in terms of cost-effectiveness in com-
parison to TRIMPi or HR and VO
2
-based training methodologies,
especially in the elderly.
5.1. Study limitations
The main limitation of the present investigation is the small sample
size, furtherly penalized by unexpected drop-outs (e.g., willingness of 3
patients to discontinue the study, not related to medical reasons). This
limitation is compensated, in part, by the high consistency of data be-
tween RPE-session and TRIMPi methods and by the use of effect size
analyses, which makes statistical analysis more robust, particularly in
small samples.
Also, we cannot comment on possible gender-related differences,
since patients involved in the study were only males. Finally, our
ndings cannot be extrapolated to CHF patients with preserved EF.
In conclusion, the present study in CHF patients, along with pre-
vious experience in healthy subjects, suggests that the session-RPE
is an easy to use, inexpensive and valid method for exercise prescrip-
tion and health maintenance, consistent with objective physiological
indices of exercise training, that can be used for long-term, out-of-
hospital, physical activity programs in patients with CHF. Further
studies are clearly warranted examining the optimal weekly
session-RPE to be provided in the setting of cardiac rehabilitation
to maximize training responses in ANS parameters and in aerobic
tness.
Conict of interest
The authors report no relationships that could be construed as a
conict of interest.
References
[1] Piepoli MF, Corr U, Benzer W, et al. Secondary prevention through cardiac rehabil-
itation: from knowledge to implementation. A position paper from the cardiac reha-
bilitation section of the European Association of cardiovascular prevention and
rehabilitation. Eur J Cardiovasc Prev Rehabil 2010;17:117.
[2] Pina IL, Apstein CS, Balady GJ, et al. Exercise and heart failure. A statement from the
American Heart Association Committee on Exercise, Rehabilitation, and Prevention.
Circulation 2003;107:121025.
[3] Carvalho VO, Mezzani A. Aerobic exercise training intensity in patients with chronic
heart failure: principles of assessment and prescription. Eur J Cardiovasc Prev
Rehabil 2011;18:514.
[4] Iellamo F, Manzi V, Caminiti G, et al. Matched dose interval and continuous exercise
training induce similar cardiorespiratory and metabolic adaptations in patients with
heart failure. Int J Cardiol 2013;167:25615.
[5] Foster C, Florhaug A, Franklin J, et al. A new approach to monitoring exercise train-
ing. J Strength Cond Res 2001;15:10915.
[6] Borg G, Hassmn P, LagerstrmM. Perceived exertion related to heart rate and blood
lactate during arm and leg exercise. Eur J Appl Physiol 1987;56:67985.
[7] Impellizzeri FM, Rampinini E, Coutts A, Sassi A, Marcora SM. Use of RPE-based train-
ing load in soccer. Med Sci Sports Exerc 2004;36:10427.
[8] Manzi V, D'Ottavio S, Impellizzeri FM, Chaouachi A, Chamari K, Castagna C. Prole of
weekly training load in elite male professional basketball players. J Strength Cond
Res 2010;24:1399406.
[9] Morgan WP. Psychological components of effort sense. Med Sci Sports Exerc 1994;
26:10717.
[10] Iellamo F, Manzi V, Caminiti G, et al. Doseresponse relationship of baroreex sensi-
tivity and heart rate variability to individually-tailored exercise training in patients
with heart failure. Int J Cardiol 2013;166:3349.
[11] Manzi V, Castagna C, Padua E, et al. Doseresponse relationship of autonomic ner-
vous system responses to individualized training impulse in marathon runners.
Am J Physiol 2009;296:H173340.
[12] Bertinieri G, Di Rienzo M, Cavallazzi A, Ferrari AV, Pedotti A, Mancia G. Evaluation of
baroreceptor reex by blood pressure monitoring in unanesthetized cats. AmJ Phys-
iol 1988;254:H37783.
[13] American Thoracic Society. ATS statement: guidelines for the six-minute walk test.
Am J Respir Crit Care Med 2002;166:1117.
[14] Hopkins WG. A scale of magnitudes for effect statistics. Available at: http://www.
sportsci.org/resource/stats/index.htm; 2002.
[15] Iwasaki K, Zhang R, Zuckerman JH, Levine BD. Doseresponse relationship of the car-
diovascular adaptation to endurance training in healthy adults: how much training
for what benet? J Appl Physiol 2003;95:157583.
[16] Okazaki K, Iwasaki K, Prasad A, et al. Doseresponse relationship of endurance train-
ing for autonomic circulatory control in healthy senior. J Appl Physiol 2005;99:
10419.
[17] Foster C, Hector L, Welsh R, Schrager M, Green MA, Snyder AC. Effects of specic ver-
sus cross training on running performance. Eur J Appl Physiol 1995;70:36772.
[18] Dwyer J. Metabolic character of exercise at traditional training intensities in cardiac
patients and healthy persons. J Cardpulm Rehabil 1994;14:18996.
[19] Beale L, Carter H, Doust J, Brickley G, Silberbauer J, Lloyd G. Exercise heart rate guide-
lines overestimate recommended intensity for chronic heart failure patients. Br J
Cardiol 2010;17:1337.
[20] Scharhag-Rosenberger F, Meyer T, Gssler N, Faude O, Kindermann W. Exercise at
given percentages of VO2max: heterogeneous metabolic responses between indi-
viduals. J Sci Med Sport 2010;13:749.
[21] Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advi-
sory Committee Report, 2008. Washington, DC: U.S. Department of Health and
Human Services; 2008.
[22] Kokkinos P, Myers J. Exercise and physical activity. Clinical outcomes and applica-
tions. Circulation 2010;122:163748.
5 F. Iellamo et al. / International Journal of Cardiology xxx (2014) xxxxxx
Please cite this article as: Iellamo F, et al, Validation of rate of perceived exertion-based exercise training in patients with heart failure: Insights
from autonomic nervous system adaptations, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.076