Exercise Training in Pulmonary Arterial and Chronic Thromboembolic Pulmonary Hypertension

Quick Takes

  • A low-intensity standardized exercise training program was safe and feasible in patients with pulmonary hypertension (PAH) and chronic thromboembolic PH.
  • This trial, in conjunction with prior reports, suggests a role for exercise therapy in PAH patients moving forward.
  • Future work is needed before exercise therapy can be used in routine clinical practice.

Study Questions:

What is the safety and feasibility of standardized exercise training in precapillary pulmonary hypertension (PAH) and inoperable or recurrent chronic thromboembolic PH (CTEPH)?


A total of 116 patients (98 with PAH and 18 with CTEPH) were studied across 10 European centers. They were randomized to either an exercise training group or control/usual care group. The previously validated low-intensity Heidelberg exercise training program was administered in the exercise training group. Change in 6-minute walk distance (6MWD) was the primary endpoint. Changes in quality of life (QoL), World Health Organization (WHO) functional class (FC), and peak oxygen consumption were secondary endpoints.


At baseline, most patients were either WHO FC II (53%) or III (46%) and mean pulmonary arterial pressure was 46.6 ± 15.1 mm Hg. Participants in the training group performed a standardized in-hospital rehabilitation with mean duration of 25 days, which was continued at home. The primary endpoint, change of 6MWD, improved by 34.1 ± 8.3 m in the training compared with the control group (p < 0.01) at a median follow-up of 14.4 weeks. Exercise training was feasible, safe, and well-tolerated. Secondary endpoints showed improvements in quality of life (Short Form-36 mental health 7.3 ± 2.5, p = 0.004), WHO FC, and peak oxygen consumption (0.9 ± 0.5 ml/min/kg, p = 0.05) compared with the control group.


A low-intensity specialized exercise training program is safe and feasible in patients with precapillary PH and CTEPH.


This is the first randomized multicenter trial of exercise training in patients with precapillary PH and CTEPH. The improvements in 6MWD, WHO FC, QoL, and peak oxygen consumption are clinically meaningful and in line with prior smaller studies on exercise training in PH. They should, however, be interpreted in an appropriate context. Most participants were WHO FC II or III at enrollment; severely deconditioned patients (WHO FC IV) with very restricted mobility range were largely excluded in this study due to safety concerns. Similarly, patients who are willing to undertake an exercise intervention may reflect a more motivated and adherent group. Given the same 25/58 participants in the training group and 26/58 in the control group had 6MWD values >440 m at baseline, the improvement of walking distance in such participants may well be limited by a ceiling effect. Future work should focus on establishing efficacy and extending these findings to patients with WHO FC IV symptoms.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Acute Heart Failure, Pulmonary Hypertension, Exercise

Keywords: Exercise, Exercise Therapy, Heart Failure, Hypertension, Pulmonary, Oxygen Consumption, Pulmonary Embolism, Quality of Life, Rehabilitation, Walking

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