What are the optimal exercises to improve cardiovascular health in generally healthy adults?

Best Exercises for Heart Health

For optimal cardiovascular health, adults should perform at least 150 minutes per week of moderate-intensity aerobic exercise (such as brisk walking, cycling, or swimming) or 75 minutes of vigorous-intensity aerobic activity, combined with resistance training 2-3 days per week targeting all major muscle groups. 1

Aerobic Exercise: The Foundation

Aerobic exercise is the cornerstone of cardiovascular disease prevention and provides the strongest mortality benefit. 1

Specific Recommendations:

• Moderate-intensity aerobic activity: 150-300 minutes per week at 40-59% of heart rate reserve (equivalent to brisk walking where you can talk but not sing) 1
• Vigorous-intensity aerobic activity: 75-150 minutes per week at 60-85% of heart rate reserve (jogging, running, swimming laps, cycling uphill) 1
• Frequency: Distribute activity across most days of the week; even 1-2 sessions weekly meeting total volume targets reduces cardiovascular mortality by 40% 1
• Duration per session: Bouts of at least 10 minutes count toward weekly totals, though longer continuous sessions provide additional benefits 1

Mortality Impact:

• Aerobic exercise reduces all-cause mortality by 20-30% and cardiovascular mortality by 30-35% in a dose-response fashion 1, 2
• Each 1-MET increase in cardiorespiratory fitness produces an 11% reduction in all-cause death and 18% reduction in cardiovascular death 2
• Continuous aerobic exercise specifically reduces cardiovascular mortality by 44% (RR 0.56) in patients with coronary disease 3

Best Aerobic Modalities:

High-intensity interval training (HIIT) produces the greatest improvements in cardiorespiratory fitness (4.5 mL/kg/min increase in peak VO2), followed by moderate-intensity continuous training (3.0 mL/kg/min increase) 3. However, moderate-intensity continuous training is the most feasible and cost-effective option for most adults and provides equivalent mortality benefits when total energy expenditure is matched 1.

Alternative effective modalities include: walking, jogging, cycling, swimming, rowing, cross-country skiing, stair climbing, and water-based exercises 1, 3

Resistance Training: Essential Complement

Resistance training must be added to aerobic exercise for comprehensive cardiovascular protection, improving physical function, glycemic control, and potentially blood pressure. 1

Specific Prescription:

• Frequency: 2-3 non-consecutive days per week 1
• Sets and repetitions: 1 set of 8-12 repetitions for adults under 50-60 years; 10-15 repetitions at lower resistance (40-60% of 1-repetition maximum) for older adults 1
• Muscle groups: Minimum 8-10 exercises covering all major muscle groups: chest press, shoulder press, triceps extension, biceps curl, pull-down, lower-back extension, abdominal crunch, leg press or quadriceps extension, leg curls, calf raise 1
• Tempo: Moderate to slow controlled speed (3 seconds concentric, 3 seconds eccentric) through full range of motion 1
• Breathing: Exhale during exertion phase, inhale during relaxation—never hold breath to avoid Valsalva maneuver 1

Mortality Impact:

Resistance exercise combined with aerobic training reduces all-cause mortality by 42% (RR 0.58) in patients with coronary disease, superior to aerobic exercise alone 3. Single-set programs performed twice weekly provide nearly identical strength gains as multiple-set programs during initial training, promoting adherence 1.

Combined Exercise: Maximum Benefit

Combined aerobic and resistance exercise produces superior outcomes compared to either modality alone for cardiovascular risk reduction. 3, 4

Implementation Strategy:

• Perform aerobic exercise first (ensuring adequate warm-up), followed by resistance training 1
• Total session duration: 60 minutes, 3 times per week 5
• Aerobic component: 30-40 minutes at 50-80% of maximum intensity 1, 5
• Resistance component: 15-20 minutes covering 8-10 exercises 1

Evidence for Combined Training:

Combined exercise improves peak oxygen consumption by 3.4 mL/kg/min, quality of life (SMD 1.2), and reduces all-cause mortality by 42% in coronary disease patients 3. A minimum dose of 310 MET-minutes per week produces measurable cardiorespiratory improvements, with benefits increasing progressively up to 600+ MET-minutes per week 4.

Flexibility Training: Supportive Component

Flexibility exercises should complement aerobic and resistance training but are not sufficient alone for cardiovascular protection. 1

• Frequency: 2-3 days per week 1
• Technique: Static stretching of major muscle-tendon groups, holding each stretch 15-30 seconds, 2-4 repetitions per stretch 1
• Timing: Perform after aerobic or resistance exercise when muscles are warm 1

Critical Fitness Thresholds

Target peak VO2 >22 mL/kg/min (approximately >6 METs) to achieve mortality rates lower than sedentary individuals without cardiovascular disease. 2

Risk Stratification by Fitness Level:

• <15 mL/kg/min (<5 METs): Highest mortality risk; begin with 75-150 minutes/week moderate-intensity activity 2, 6
• 15-22 mL/kg/min (5-7 METs): Intermediate risk (HR 0.62-0.66 for mortality); target 150-300 minutes/week 2
• >22 mL/kg/min (>6 METs): Optimal protection (HR 0.39-0.45 for mortality); maintain with ≥300 minutes/week moderate or ≥150 minutes vigorous activity 2, 6

Progression for Sedentary Individuals

Sedentary adults must start at lower intensity and duration, progressing gradually to avoid injury and promote adherence. 1

Safe Progression Algorithm:

1. Weeks 1-4: Begin with 10-minute bouts of slow walking or light activity, 3-5 days per week 1
2. Weeks 5-8: Increase to 15-20 minute sessions, adding 5 minutes per week until reaching 30 minutes 1
3. Weeks 9-12: Progress to 30-40 minute sessions at moderate intensity, 5 days per week 1
4. Month 4+: Add resistance training 2 days per week, starting with 1 set of 10-15 repetitions at 40% 1-RM 1

Even 1.5 hours per week of moderate-to-vigorous activity produces a 20% mortality reduction—the largest marginal benefit occurs when transitioning from inactive to minimally active. 2, 6

Special Populations

Older Adults (≥60 years):

• Use lower resistance (40-60% 1-RM) with higher repetitions (10-15) for resistance training 1
• Emphasize functional exercises: sit-to-stand, stair climbing, balance training 1
• Target moderate intensity (3.2-4.7 METs) rather than vigorous intensity 1
• Highest fitness level reduces all-cause mortality by 41% and cardiovascular death by 43% compared to lowest fitness 2

Cardiac Patients:

• Reduce resistance to 40% 1-RM with 10-15 repetitions to minimize cardiovascular strain 1
• Avoid traditional upper-body resistance exercises for 8-12 weeks post-coronary bypass surgery 1
• Supervised cardiac rehabilitation produces 30-35% reduction in cardiovascular mortality when sustained ≥3 months 2
• Exercise testing (stress test) recommended before starting vigorous training programs 1

Hypertensive Patients:

• Focus on aerobic activities using large muscle groups 1
• Exercise 30-60 minutes, 3-7 days per week (daily may be most effective for blood pressure reduction) 1
• Use lower resistance (40-70% 1-RM) with proper breathing technique to prevent Valsalva maneuver 1
• Achieve minimum 5.1-7.0 METs to eliminate excess mortality from hypertension 2

Common Pitfalls to Avoid

Do not perform high-intensity resistance training (>80% 1-RM) to exhaustion, as this causes excessive blood pressure elevations. 1

Do not hold your breath during resistance exercises—this Valsalva maneuver dramatically increases cardiovascular strain. 1

Do not start vigorous exercise without gradual progression if you are sedentary—this increases acute myocardial infarction risk during the exercise bout itself. 1, 7

Do not rely solely on resistance training for cardiovascular protection—aerobic exercise provides the primary mortality benefit. 1

Do not exercise affected joints during arthritis flare-ups or continue if joint pain persists >1 hour post-exercise. 1

Practical Implementation

Weekly Schedule Example (150 minutes moderate + resistance):

• Monday: 30 minutes brisk walking + 20 minutes resistance training (upper body)
• Wednesday: 40 minutes cycling
• Friday: 30 minutes swimming + 20 minutes resistance training (lower body)
• Saturday: 50 minutes hiking or recreational sports

Intensity Monitoring:

• Moderate intensity: Can talk but not sing; Rate of Perceived Exertion (RPE) 5-6 on 0-10 scale 1
• Vigorous intensity: Cannot say more than a few words without pausing for breath; RPE 7-8 1
• Heart rate targets: Moderate = 40-59% heart rate reserve; Vigorous = 60-85% heart rate reserve 1

The evidence overwhelmingly supports that any exercise is better than none, but meeting minimum thresholds (150 minutes moderate or 75 minutes vigorous weekly) plus resistance training 2-3 days per week provides optimal cardiovascular protection and mortality reduction. 1, 2