Supervised Exercise Training for Chronic HFpEF: Key Points

Sachdev V, Sharma K, Keteyian SJ, et al., on behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and American College of Cardiology.
Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2023;March 21:[Epub ahead of print].

The following are key points to remember from an American Heart Association and American College of Cardiology Scientific Statement on supervised exercise training for chronic heart failure with preserved ejection fraction (HFpEF):

  1. Comorbid conditions (including hypertension, obesity, diabetes, coronary artery disease, pulmonary hypertension, chronic kidney disease, sarcopenia, frailty) are common in patients with HFpEF and contribute to the underlying pathophysiology.
  2. Patients with HFpEF in a compensated state often experience exercise intolerance and exertional symptoms. Reducing symptoms and improving physical function are important endpoints to consider in HF trials. Pharmacologic and device therapy are advancing but still have overall limited benefit for this patient population.
  3. Aerobic exercise capacity of patients with HFpEF, as assessed by 6-minute walk distance (6MWD) or peak VO2, is reduced compared to control patients and similar to patients with HF with reduced EF (HFrEF).
  4. Many factors contribute to the reduced exercise capacity in patients with HFpEF, including cardiac (blunted stroke volume augmentation, chronotropic incompetence, exaggerated increase in filling pressures), pulmonary (pulmonary vascular remodeling, impaired gas exchange, pulmonary hypertension), vascular (central artery stiffness, reduced peripheral artery vasodilator response, microvascular dysfunction), and skeletal muscle (reduced mass, excess adipose infiltration, mitochondrial dysfunction) limitations.
  5. A meta-analysis of randomized controlled trials of the effects of supervised exercise training (SET) on exercise capacity in patients with HFpEF demonstrate that SET improves baseline peak VO2 by 14% (increase of 2.2 mL/kg/min) compared to a reduction in baseline peak VO2 by 0.2% (decrease of 0.3 mL/kg/min) in the control group (p = 0.002). For comparison, in patients with HFrEF, an increase in peak VO2 of 6-7% is considered clinically meaningful.
  6. Effects of SET on quality-of-life measures have been mixed, with some studies demonstrating no benefit and others demonstrating improved quality of life.
  7. Effects of SET on cardiovascular and peripheral parameters have been mixed. Some studies have demonstrated improvements in diastolic cardiac function and others have indicated no change. Evidence suggests no significant change to central artery stiffness, but positive changes in the periphery (increased mitochondrial density/function, myoglobin content, capillary density, blood flow redistribution). Effects of exercise training in patients with HFpEF are likely pleiotropic.
  8. While better exercise capacity is correlated with reduced cardiovascular events and mortality in larger populations, this has not been adequately studied and correlated in the HFpEF population. This remains a critical area for future research.
  9. SET is safe for select patients with HFpEF. Factors to consider are clinical stability, degree of frailty, and stability of comorbid conditions.
  10. It is important to note that SET trials are mostly short-term and the issue of long-term adherence to exercise remains a challenge and may attenuate benefit.
  11. Home-based and hybrid exercise training programs have been studied but the data are limited for patients with HFpEF. These may prove to be useful strategies, although more evidence is need regarding efficacy and safety.
  12. In clinical practice, exercise training comes in several forms. Self-directed exercise training based on guideline recommendations can be performed by individuals but has unclear efficacy and safety. SET can be prescribed as a stand-alone therapy for a set number of sessions and time. SET can also be a part of an exercise-based cardiac rehabilitation program that also includes disease and risk factor management education.
  13. Third-party payer and Medicare coverage for SET and cardiac rehabilitation for patients with HFpEF have been barriers to implementation. When compared to conditions such as HFrEF and peripheral artery disease, which are generally covered by insurance for exercise therapies, SET in HFpEF has a similar or possibly greater benefit. Future efforts need to focus on extending coverage to patients with HFpEF.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Chronic Heart Failure, Pulmonary Hypertension, Exercise, Hypertension

Keywords: Cardiac Rehabilitation, Comorbidity, Exercise, Frail Elderly, Geriatrics, Heart Failure, Heart Failure, Diastolic, Hypertension, Pulmonary, Patient Care Team, Peripheral Arterial Disease, Quality of Life, Secondary Prevention, Stroke Volume, Vascular Diseases

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