High-intensity interval training (HIIT) has emerged as an attractive alternative to traditional continuous exercise training (CT) programs for clinical and healthy populations who find that they can achieve equal or greater fitness benefits in less time. Land-based HIIT may not be an appropriate choice for some participants. Few studies have explored the acute responses and chronic adaptations of HIIT in an aquatic environment, and no study has compared the cardiometabolic responses of an aquatic-based program to a land-based HIIT program. Shallow-water aquatic exercise (AE) programs utilizing HIIT have elicited comparable and, in some cases, greater physiological responses compared with constant-intensity or continuous AE regimens. Factors that may explain why HIIT routines evoke greater cardiometabolic responses than CT protocols may be based on the types of exercises and how they are cued to effectively manipulate hydrodynamic properties for greater intensities. Favorable aquatic HIIT protocols such as the S.W.E.A.T. system may serve as a beneficial alternative to land-based HIIT programs for clinical, and athletic populations, potentially reducing the likelihood of associated musculoskeletal and orthopedic complications. Hence, the purpose of this review is to examine the role of AE as an alternative safe and effective HIIT modality.