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Exercise Standards for Testing and Training: A Scientific Statement From the American Heart Association
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“The American College of Cardiology/American Heart Association recommend exercise testing before engaging in moderate- or vigorous-intensity exercise when the risk of CVD is increased but recognize that these recommendations are based on conflicting evidence and divergent expert opinions (15).”
From Updating ACSM's Recommendations for Exercise Preparticipation Health Screening (2015) · cites this paper as [15]
In the citing paper
“The American College of Cardiology/American Heart Association recommend exercise testing before engaging in moderate- or vigorous-intensity exercise when the risk of CVD is increased but recognize that these recommendations are based on conflicting evidence and divergent expert opinions (15).”
From Updating ACSM's Recommendations for Exercise Preparticipation Health Screening (2015) · cites this paper as [15]
In the citing paper
“Manual auscultation remains the recommended approach [15,42] although there are automated, motion-tolerant devices in widespread clinical use that have shown reasonable concordance with manual or invasive exercise BP measures [47,48].”
From The Identification and Management of High Blood Pressure Using Exercise Blood Pressure: Current Evidence and Practical Guidance (2022) · cites this paper as [42]
In the citing paper
“Guidelines recommend that BP measurement should take place before the exercise test, at every stage of exercise (including peak/maximal intensity if such a test is performed), and in recovery from an exercise test [15,42].”
From The Identification and Management of High Blood Pressure Using Exercise Blood Pressure: Current Evidence and Practical Guidance (2022) · cites this paper as [42]
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“[17] Because maximal exercise testing including measurement of maximal oxygen uptake had not been administered previously to persons with SMA, the feasibility was uncertain at the start of the study.”
BackgroundPopulation Health Management for Older Adults
Tkatch, R., Musich, S. A., MacLeod, S., Alsgaard, K., Hawkins, K., & Yeh, C. S. (2016) · Gerontology and Geriatric Medicine · doi:10.1177/2333721416667877 · Cited by 67
“The program provides a supervised exercise program, education, and counseling to improve health and prevent further cardiac events (Fletcher et al., 2013).”
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“However, additional benefits occur with more PA [4, 5].”
BackgroundKaminsky, L. A., Myers, J., & Arena, R. (2019) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2018.10.003 · Cited by 59
Gjellesvik, T. I., Becker, F., Tjønna, A. E., Indredavik, B., Nilsen, H. O., Brurok, B., Tørhaug, T., Busuladzic, M., Lydersen, S., & Askim, T. (2020) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2020.02.006 · Cited by 57
JCS 2021 Guideline on the Clinical Application of Echocardiography
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Cardiorespiratory Fitness and Reclassification of Risk for Incidence of Heart Failure
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Cardiovascular Biomarkers and Imaging in Older Adults
Forman, D. E., de Lemos, J. A., Shaw, L. J., Reuben, D. B., Lyubarova, R., Peterson, E. D., Spertus, J. A., Zieman, S. J., Salive, M. E., & Rich, M. W. (2020) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2020.07.055 · Cited by 57
“, Balke or Naughton) when appropriate (107).”
Bench-to-Bedside Approaches for Personalized Exercise Therapy in Cancer
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Using Exercise to Fight Depression in Older Adults
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“As such, we only invited patients with stable CHF to participate in the study and observed exercise testing contraindications in line with recommended standards.(31) Telerehabilitation assessment may best be suited for patients with some experience in using telerehabilitation technologies, such as those who have compl…”
MethodCardiopulmonary Exercise Test in Hypertrophic Cardiomyopathy
Magrì, D., & Santolamazza, C. (2017) · Annals of the American Thoracic Society · doi:10.1513/annalsats.201611-884fr · Cited by 54
The relationship between cardiorespiratory fitness, cardiovascular risk factors and atherosclerosis
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Exercise Testing in Chest Pain Units: Rationale, Implementation, and Results
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“Although this equation was limited in predicting the accurate HRmax, with a high variability of 12 bpm among subjects of identical age, it was still recommended in clinical settings and published in resources by well-established organizations in the field (Fletcher et al., 2013).”
Broderick, J. M., Guinan, E. M., Kennedy, M., Hollywood, D. P., Courneya, K. S., Culos-Reed, S. N., Bennett, K., Donnell, D. M. O., & Hussey, J. M. (2013) · Journal of Cancer Survivorship · doi:10.1007/s11764-013-0294-6 · Cited by 55
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Exercise Blood Pressure Response, Albuminuria, and Arterial Stiffness in Hypertension
Tsioufis, C. P., Dimitriadis, K. S., Thomopoulos, C., Tsiachris, D., Selima, M., Stefanadi, E., Tousoulis, D. M., Kallikazaros, I. E., & Stefanadis, C. (2008) · The American Journal of Medicine · doi:10.1016/j.amjmed.2008.05.035 · Cited by 51
Accuracy of 5 Common Age-Predicted Maximal Heart Rate Equations
Shookster, D., Lindsey, B., Cortés, N., & Martin, J. R. (2020) · International journal of exercise science · doi:10.70252/xfsj6815 · Cited by 73
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Infectious endocarditis and infection of intracardiac devices in adults. Clinical guidelines 2021
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“most adults with CVD can safely perform physical activity and exercise(59); restrictions to intensity and duration of exercise may be necessary according to the type and severity of disease, and the American Heart Association recommends that adults with CVD consult with their physician before initiating an exercise pr…”
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“Resistance training is categorized into anaerobic exercise, in which a muscle contraction is opposed by force, leading to increased lactate levels, blood pressure, and oxygen consumption (Fletcher et al. 2013; Spurway 1992).”
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“1,13 In general, absolute contraindications for CPET encompass :”
BackgroundPhysical function and exercise training in older patients with heart failure
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“Among them, the Q, R, and S waves compose the QRS-complex, which contains precious clinical information relates to cardiac health [1].”
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Is Ultra-Short-Term Heart Rate Variability Valid in Non-static Conditions?
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Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I
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Quantifying QRS changes during myocardial ischemia: Insights from high frequency electrocardiography
Amit, G., Granot, Y., & Abboud, S. (2014) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2014.03.006 · Cited by 47
“The microvolt highfrequency components of the QRS are typically filtered out by ECG devices, despite the wealth literature on their properties and their potential diagnostic value [2].”
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“However, an exercise training prescription based only on heart rate peak has been shown to overestimate exercise intensity [8,47].”
BackgroundAdvanced ECG in 2016: is there more than just a tracing?
Reichlin, T., Abächerli, R., Twerenbold, R., Kühne, M., Schaer, B. A., Mueller, C. E., Sticherling, C., & Osswald, S. (2016) · Swiss Medical Weekly · doi:10.4414/smw.2016.14303 · Cited by 49
Inflammation and oxidative stress in heart failure: effects of exercise intensity and duration
Ribeiro-Samora, G. A., Rabelo, L. A., Ferreira, A. C., Favero, M., Guedes, G. D. S., Pereira, L. S. M., Parreira, V., & Britto, R. R. (2017) · Brazilian Journal of Medical and Biological Research · doi:10.1590/1414-431x20176393 · Cited by 49
“The subjects were instructed to continue their usual medication, to refrain from cigarettes and caffeinated food or drinks for 3 h prior to the test, and to avoid physical exercise for 12 h prior to the test (17,18).”
MethodImboden, M. T., Harber, M. P., WHALEY, M. H., Finch, W. H., Bishop, D. L., Fleenor, B. S., & Kaminsky, L. A. (2019) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2019.01.049 · Cited by 48
Effects of Exercise Intensity on Acute Circulating Molecular Responses Poststroke
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“4 CABG 10 (42) 29 (55) PCI 7 (29) 17 (32) Valve 7 (29) 9 (17) Comorbidity, no.”
Cardiac rehabilitation in patients with pacemakers and implantable cardioverter defibrillators
Iliou, M. C., Blanchard, J. C., Tanguy, A. L., Cristofini, P., & Ledru, F. (2016) · Monaldi Archives for Chest Disease · doi:10.4081/monaldi.2016.756 · Cited by 45
“International guidelines [1,2] are now available for exercise training and rehabilitation in cardiac patients.”
BackgroundSartor, F., Bonato, M., Papini, G. B., Bosio, A., Mohammed, R. A., Bonomi, A., Moore, J. P., Merati, G., Torre, A. L., & Kubis, H. (2016) · PLoS ONE · doi:10.1371/journal.pone.0168154 · Cited by 45
“Moreover, lack of motivation, general discomfort, reduced exercise tolerance, and the occurrence of symptoms can hamper its correct assessment [2].”
BackgroundFrançois, M. E., Durrer, C. G., Pistawka, K. J., Halperin, F. A., Chang, C. R., & Little, J. P. (2017) · Frontiers in Physiology · doi:10.3389/fphys.2017.00528 · Cited by 45
“Beginning at 30W, the test increased by 1W every 4 s (15W/min) until volitional exhaustion or contraindication (Fletcher et al., 2013).”
BackgroundVogel, J., Auinger, A., Riedl, R., Kindermann, H., Helfert, M., & Ocenasek, H. (2017) · PLoS ONE · doi:10.1371/journal.pone.0186261 · Cited by 51
Steinhaus, D. A., Lubitz, S. A., Noseworthy, P. A., & Kramer, D. B. (2019) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0000000000000389 · Cited by 51
Ehrman, J. K., Fernández, A. B., MYERS, J. N., OH, P. I., Thompson, P. D., & Keteyian, S. J. (2020) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0000000000000521 · Cited by 45
Aerde, N. V., Meersseman, P., Debaveye, Y. A., Wilmer, A. P., Casaer, M. P., Gunst, J., Wauters, J., Wouters, P. J., Goetschalckx, K., Gosselink, R., et al. (2021) · Intensive Care Medicine · doi:10.1007/s00134-021-06541-9 · Cited by 44
Cardiorespiratory fitness, physical activity and cancer mortality in men
Vainshelboim, B., Müller, J., Lima, R. M., Nead, K. T., Chester, C., Chan, K., Kokkinos, P. F., & MYERS, J. N. (2017) · Preventive Medicine · doi:10.1016/j.ypmed.2017.04.014 · Cited by 45
“Standard criteria for test termination were used (American College of Sports Medicine., 2014; Fletcher et al., 2013).”
MethodMcAuley, P. A., Keteyian, S. J., Brawner, C. A., Dardari, Z., Rifai, M. A., Ehrman, J. K., Al-Mallah, M. H., Whelton, S. P., & Blaha, M. J. (2018) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2018.01.026 · Cited by 44
Salokari, E., Laukkanen, J. A., Lehtimäki, T. J., Kurl, S., Kunutsor, S. K., Zaccardi, F., Viik, J., Lehtinen, R., Nikus, K. C., Kööbi, T., et al. (2018) · European Journal of Preventive Cardiology · doi:10.1177/2047487318804618 · Cited by 44
“The exercise time in minutes was approximated from the maximal METs using a linear approach derived from the scientific statement of the American Heart Association regarding exercise standards for testing and training.(7) The following equation was used: exercise time1⁄4 (METs – 1)/1.”
MethodAntidiabetic Effects of Physical Activity: How It Helps to Control Type 2 Diabetes
Wake, A. D. (2020) · Diabetes Metabolic Syndrome and Obesity · doi:10.2147/dmso.s262289 · Cited by 58
A Message From Modern-Day Healthcare to Physical Activity and Fitness: Welcome Home!
Arena, R. A., Harrington, R. A., & Després, J. (2014) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2014.11.001 · Cited by 44
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Hautala, A. J., Kiviniemi, A. M., Mäkikallio, T. H., Koistinen, P., Ryynänen, O., Martikainen, J. A., Seppänen, T., Huikuri, H. V., & Tulppo, M. P. (2016) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.12738 · Cited by 45
“Despite the proven clinical effectiveness of ECR (Fletcher et al., 2013), many patients faced with a coronary artery disease (CAD) do not become or remain regularly active, mainly due to low cardiac rehabilitation referral, uptake, and adherence rates (Kotseva et al., 2013).”
BackgroundMethodKitai, T., Shimogai, T., Tang, W. H. W., IWATA, K., Xanthopoulos, A. V., Otsuka, S., Nakada, F., Yokoyama, R., Kamiya, K., Saito, H., et al. (2021) · European Heart Journal Open · doi:10.1093/ehjopen/oeab006 · Cited by 43
Codima, A., das Neves, W., Borges, A. P. D. S., & de Castro, G. (2020) · Supportive Care in Cancer · doi:10.1007/s00520-020-05499-6 · Cited by 47
The pulmonary artery wedge pressure response to sustained exercise is time-variant in healthy adults
Wright, S. P., Esfandiari, S., Gray, T., Fuchs, F. C., Chelvanathan, A., Chan, W., Sasson, Z., Granton, J. T., Goodman, J. M., & Mak, S. S. (2016) · Heart · doi:10.1136/heartjnl-2015-308592 · Cited by 42
Physical Activity Prescription
Thornton, J. S., Frémont, P., Khan, K., Poirier, P., Fowles, J. R., Wells, G. D., & Frankovich, R. J. (2016) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0000000000000363 · Cited by 43
Stable ischemic heart disease in the older adults
Alexander, K. P., Dai, X., Busby‐Whitehead, J., & Forman, D. E. (2020) · PubMed Central · doi:10.17615/gdsp-rx11 · Cited by 45
Aerobic Training Effect on Arterial Stiffness in Metabolic Syndrome
Slivovskaja, I., Ryliškytė, L., Šerpytis, P., Navickas, R., Badarienė, J., Čelutkienė, J., Puronaitė, R., Ryliškienė, K., Čypienė, A., Rinkūnienė, E., et al. (2017) · The American Journal of Medicine · doi:10.1016/j.amjmed.2017.07.038 · Cited by 44
A 3-minute test of cardiorespiratory fitness for use in primary care clinics
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Einsatz von Kraftausdauertraining und Muskelaufbautraining in der kardiologischen Rehabilitation
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Effects of exercise training modality on skeletal muscle fatigue in men with coronary heart disease
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“The design of endurance exercise intervention is based on guidelines of the American Heart Association for endurance exercise.(101) Furthermore, recommendations from comparative metaanalyses in MDD regarding duration, frequency, and content of exercises were taken into account.”
MethodExercise-based cardiac rehabilitation for people with implantable ventricular assist devices
Yamamoto, S., Hotta, K., Ota, E., Matsunaga, A., & Mori, R. (2018) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012222.pub2 · Cited by 39
“Fletcher 2013 Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association.”
BackgroundMethodInfluentialBlood Pressure Responses During Exercise: Physiological Correlates and Clinical Implications
Nayor, M. G., Gajjar, P., Murthy, V. L., Miller, P. E., Velagaleti, R. S., Larson, M. G., Vasan, R. S., Lewis, G. D., Mitchell, G. F., & Shah, R. V. (2022) · Arteriosclerosis Thrombosis and Vascular Biology · doi:10.1161/atvbaha.122.318512 · Cited by 40
The role of exercise training in the management of chronic kidney disease
Howden, E. J., Coombes, J. S., & Isbel, N. M. (2015) · Current Opinion in Nephrology & Hypertension · doi:10.1097/mnh.0000000000000165 · Cited by 40
Walter, J. E., Honegger, U., Puelacher, C., Mueller, D. L., Wagener, M., Schaerli, N., Strebel, I., Twerenbold, R., Boeddinghaus, J., Nestelberger, T., et al. (2017) · Clinical Chemistry · doi:10.1373/clinchem.2017.277210 · Cited by 40
The safety of isometric exercise
Wiles, J. D., Taylor, K. A., Coleman, D. A., Sharma, R., & O’Driscoll, J. M. (2018) · Medicine · doi:10.1097/md.0000000000010105 · Cited by 45
“consumption (MVO2) is known to affect the risk of physical exertion.([31]) The RPP, calculated as HR sBP, provides a good index of MVO2 during upright exercise regardless of distinct differences in the proportional rise in these variables during aerobic and IE.”
MethodHuckstep, O. J., Burchert, H. H., Williamson, W., Telles, F., Tan, C., Bertagnolli, M., Arnold, L., Mohamed, A. B., McCormick, K. P., Hanssen, H., et al. (2020) · European Heart Journal - Cardiovascular Imaging · doi:10.1093/ehjci/jeaa060 · Cited by 41
“Workload then incremented by 15 watts each minute and participants cycled continuously until exhaustion prevented them from maintaining at least 50 revolutions per minute or safety termination criteria were met.(18) Participants then completed a 2-min cool-down period at 50 watts and the revolutions per minute of thei…”
BackgroundCosta, V. A. B., Midgley, A. W., Carroll, S., Astorino, T. A., de Paula, T., Farinatti, P., & da Cunha, F. A. (2021) · PLoS ONE · doi:10.1371/journal.pone.0247057 · Cited by 43
Wilms, B., Ernst, B., Thurnheer, M., Weisser, B., & Schultes, B. (2014) · International Journal of Obesity · doi:10.1038/ijo.2014.22 · Cited by 41
Zafrir, B., Aker, A., Asaf, Y., & Saliba, W. (2022) · Journal of Hypertension · doi:10.1097/hjh.0000000000002991 · Cited by 42
“Exercise stress testing Treadmill EST was performed using a Bruce protocol in all patients [1].”
BackgroundMethodInfluentialAntoniou, V., Xanthopoulos, A. V., Giamouzis, G., Davos, C. H., Baťalík, L., Stavrou, V. T., Gourgoulianis, K. I., Kapreli, E., Skoularigis, J. S., & Pepera, G. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-059945 · Cited by 41
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“Exercise measurements involved participants cycling for 2–3 min at a low cadence (30–50 rpm) and low work rate (20– 40 W) (warmup period), before increasing to a cadence of 60 rpm and work rates of 80 W for males and 50 W for females (exercise period), corresponding to z30%– 35% of the participants’ maximumworkload on…”
MethodEhrman, J. K., Brawner, C. A., Al-Mallah, M. H., Qureshi, W., Blaha, M. J., & Keteyian, S. J. (2017) · The American Journal of Medicine · doi:10.1016/j.amjmed.2017.02.036 · Cited by 41
Effects of circuit exercise training on vascular health and blood pressure
Getty, A. K., Wisdo, T. R., Chavis, L. N., Derella, C. C., McLaughlin, K. C., Perez, A. N., DiCiurcio, W. T., Corbin, M. E., & Feairheller, D. L. (2018) · Preventive Medicine Reports · doi:10.1016/j.pmedr.2018.02.010 · Cited by 39
“The treadmill test was terminated according to guidelines, and VO2max was calculated using the Bruce protocol test time formula (Fletcher et al., 2013; Foster et al., 1984).”
MethodEgbe, A. C., Qureshi, M. Y., & Connolly, H. M. (2020) · Circulation Heart Failure · doi:10.1161/circheartfailure.119.006651 · Cited by 39
Cho, H., & Lee, J. H. (2015) · Journal of Medical Systems · doi:10.1007/s10916-015-0279-2 · Cited by 40
Cardiorespiratory fitness and cancer in women: A prospective pilot study
Vainshelboim, B., Lima, R. M., & MYERS, J. N. (2019) · Journal of sport and health science/Journal of Sport and Health Science · doi:10.1016/j.jshs.2019.02.001 · Cited by 38
“A 12-lead electrocardiogram, heart rate, blood pressure, and Borg 6-20 perceived exertion rating were continuously recorded throughout the tests, and standard criteria for test termination were used.(11,28) CRF (in metabolic equivalents (METs)) was calculated from the peak treadmill speed and grade using established m…”
MethodCheng, Y., Chen, C.-M., Huang, W.-C., Chiang, S., Hsieh, P.-C., Lin, K., Chen, Y., Fu, T., Huang, S.-C., Chen, S., et al. (2020) · Journal of the Formosan Medical Association · doi:10.1016/j.jfma.2020.08.015 · Cited by 39
“Patients who had not undergone formal exercise testing can exercise at a rated perceived exertion of 4e6 on a 0e10 scale.(21) However, a formal exercise test should still be considered in patients with advanced CVD with proper clinical disinfection following CDC(11) and WHO(12) recommendations.”
BackgroundSunde, S., Hesseberg, K., Skelton, D. A., Ranhoff, A. H., Pripp, A. H., Aarønæs, M., & Brovold, T. (2021) · European Geriatric Medicine · doi:10.1007/s41999-021-00525-0 · Cited by 45
Metadata
- Authors
- Fletcher, G. F., Ades, P. A., Kligfield, P., Arena, R., Balady, G. J., Bittner, V. A., Coke, L. A., Fleg, J. L., Forman, D. E., Gerber, T. C., Gulati, M., Madan, K., Rhodes, J., Thompson, P. D., & Williams, M. A.
- Affiliations
- Mayo Clinic (US)
- ORCID
- Venue
- Circulation
- Published
- 2013-08-20
- Volume
- 128
- Issue
- 8
- Pages
- 873-934
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2120888944
- Cited by
- 2,235
- References
- 823
- Citations by year
- 2026: 163 · 2025: 181 · 2024: 165 · 2023: 218 · 2022: 192 · 2021: 223 · 2020: 209 · 2019: 184 · 2018: 152 · 2017: 141 · 2016: 127 · 2015: 99 · 2014: 68 · 2013: 13
- FWCI
- 241.91
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Physiology (medical) › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Physical Education and Training Studies
- Keywords
- exercise testing, exercise training, exercise prescription, aerobic exercise
- MeSH terms
- Cardiovascular Diseases, Exercise Test, Exercise Therapy, Humans, Exercise, Resistance Training
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