BACKGROUND: Despite the rational expectation for a survival benefit produced by exercise training among post-myocardial infarction (MI) patients, direct evidence remains elusive. Clinically, changes in autonomic balance toward lower vagal activity have consistently been associated with increased mortality risk; conversely, among both control and post-MI dogs, exercise training improved vagal reflexes and prevented sudden death. Accordingly, we tested the hypothesis that exercise training, if accompanied by a shift toward increased vagal activity of an autonomic marker such as baroreflex sensitivity (BRS), could reduce mortality in post-MI patients. METHODS AND RESULTS: Ninety-five consecutive male patients surviving a first uncomplicated MI were randomly assigned to a 4-week endurance training period or to no training. Age (51 +/- 8 versus 52 +/- 8 years), site of MI (anterior 41% versus 43%), left ventricular ejection fraction (52 +/- 13 versus 51 +/- 14%), and BRS (7.9 +/- 5.4 versus 7.9 +/- 3.4 ms/mmHg) did not differ between the two groups. After 4 weeks, BRS improved by 26% (p = 0.04) in trained patients, whereas it did not change in nontrained patients. During a 10-year follow-up, cardiac mortality among the 16 trained patients who had an exercise-induced increase in BRS >= 3 ms/mmHg (responders) was strikingly lower compared with that of the trained patients without such a BRS increase (nonresponders) and that of the nontrained patients (0 of 16 versus 18 of 79 (23%), p = 0.04). Cardiac mortality was also lower among responders irrespective of training (4% versus 24%, p = 0.04). CONCLUSIONS: Post-MI exercise training can favorably modify long-term survival, provided that it is associated with a clear shift of the autonomic balance toward an increase in vagal activity.
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