Land versus water exercise in patients with coronary artery disease: effects on body composition, blood lipids, and physical fitness Konstantinos A. Volaklis, PhD, Apostolos Th. Spassis, PhD, and Savvas P. Tokmakidis, PhD Komotini, Greece Background We examined the effects of combined resistance and aerobic training on land versus combined resistance and aerobic training in water in patients with coronary artery disease. Methods Thirty-four patients were randomly assigned to land exercise (LE, n = 12), water exercise (WE, n = 12), and control (n = 10) groups. The LE group trained 4 times per week, twice with aerobic exercise and twice with resistance training. The WE program included aquatic aerobic activities 2 times per week and resistance exercise at the same frequency carried out in water. The duration of the training programs was 4 months. Body composition measurements, blood lipids, exercise stress testing, and muscular strength were obtained at the beginning and at the end of the training period. Results After 4 months of training, analysis of covariance revealed that body weight and sum of skinfolds were lower for WE and LE groups than for the control group. Patients who trained in water improved exercise time (+11.7% vs +8.1%) and maximum strength (+12.8% vs +12.9%) in a similar manner compared to the patients who trained on land. Total cholesterol (WE -4.4%, LE -3.3%) and triglycerides (WE -10.2%, LE -11.8%) decreased significantly for both exercise groups but not for the control group. Conclusions Exercise programs that combine resistance and aerobic exercise performed either on land or in water can both improve exercise tolerance and muscular strength in patients with coronary artery disease. Furthermore, both programs induce similar favorable adaptations on total cholesterol, triglycerides, and body composition. (Am Heart J 2007;154:560.e1-560.e6.) Exercise training, the major component of cardiac rehabilitation, reduces risk factors, improves functional capacity and prognosis, and enhances psychosocial well- being and quality of life in patients suffering from coronary artery disease (CAD). 1-3 Traditionally, the type of physical training that has been undertaken in cardiac rehabilitation programs was aerobic in nature, mainly walking, jogging, stationary cycling, and arm cranking. In recent years, resistive training was also found to be a significant component in cardiac rehabilitation programs for the improvement of muscular strength and endur- ance, 4-6 whereas the combination of both resistance and aerobic exercise seems to induce better adaptations than aerobic training alone. 7-9 Recently, the American Heart Association recommended that resistance training be implemented in cardiac rehabilitation programs 2 times per week. 4,6 For many decades, patients with CAD were told to avoid swimming because it was associated with undesirable cardiorespiratory alterations such as increased left ventricular volume and ventricular irrit- ability. Furthermore, it has been reported that even comfortable swimming can elicit high V̇O 2 and heart rate responses, especially for those patients with poor swimming skills. 10,11 Based on recent scientific evidence, however, activities with the head out of water such as water-walking, adapted water games, and aqua-aerobic performed in thermoneutral temperatures could be a feasible alter- native of physical training for low-risk patients with CAD to improve their motivation and compliance and to optimize the expected exercise-induced cardiovascular adaptations. 12-14 Water-based exercise (not swimming), as prescribed above, performed in upright position and according to the main principles of interval training is safe and elicits appropriate hemodynamic responses. Indeed, McMurray et al 15 and Fernhall et al 16 indicated that there are no differences in angina, ST depression, and From the Department of Physical Education and Sport Science, Democritus University of Thrace, Komotini, Greece. Sponsorship: The study was funded by PYTHAGORAS II (2.2.3.στ) and cofinanced by Hellenic (25%) and European Community (75%) funds. Submitted March 6, 2007; accepted June 17, 2007. Reprint requests: Savvas P. Tokmakidis, PhD, Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece. E-mail: stokmaki@phyed.duth.gr 0002-8703/$ - see front matter © 2007, Mosby, Inc. All rights reserved. doi:10.1016/j.ahj.2007.06.029