Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology
Why the study?
Most pharmacological trials for HFpEF have yielded neutral primary outcomes, whereas exercise-based interventions show meaningful clinical improvements, prompting an examination of the evidence, mechanisms, and implementation gaps for exercise-based therapies in chronic stable HFpEF.
Does supervised exercise training improve exercise capacity in patients with chronic stable heart failure with preserved ejection fraction?
Key Points
- Supervised exercise training delivers clinically meaningful improvements in aerobic exercise capacity and quality of life for patients with preserved ejection fraction.
- More than 3 million Americans live with heart failure with preserved ejection fraction, where exercise intolerance and exertional dyspnea drive debilitating functional decline.
- Scientific statement analysis demonstrates therapeutic benefits matching heart failure with reduced ejection fraction, yet Medicare reimbursement remains unavailable.
Study Design
Type
Meta-Analysis (n=503)
Blinding
Single-blind
Structured PICO
Does supervised exercise training improve exercise capacity in patients with chronic stable heart failure with preserved ejection fraction?
P
Population
503 patients with chronic stable heart failure with preserved ejection fraction from 8 single-blinded randomized controlled trials evaluating the effects of supervised exercise training.
I
Intervention
Supervised exercise training (SET) including aerobic training (e.g., walking, stationary cycling, high-intensity interval training, or moderate-intensity continuous training), typically 3 sessions per week for 1 to 8 months.
C
Comparator
Control group (no supervised exercise training).
O
Outcome
Aerobic exercise capacity, quantified as peak oxygen uptake (VO2) by expired gas analysis.surrogate
Main Result
Mean Difference: 2.8
Absolute Event Rate: 2.2% vs -0.3%
p-value: p=0.002
Supervised exercise training produces clinically meaningful improvements in exercise capacity (peak VO2) for patients with chronic stable HFpEF, highlighting the critical role of lifestyle interventions in managing exercise intolerance.
Limitations
- Variation in baseline characteristics and exclusion of common comorbidities like atrial fibrillation, COPD, and CAD limits generalizability.
- Underrepresentation of older adults, women, and diverse racial and ethnic groups.
- Most included trials were short-term, lacking data on long-term adherence and long-term clinical events such as hospitalizations and mortality.
- Exclusions of common HFpEF comorbidities (e.g., atrial fibrillation, COPD, CAD) limit generalizability.
- Underrepresentation of older adults, women, and individuals of lower socioeconomic status.
- Lack of large-scale, longer-term studies to examine effects on clinical events.
- Small sample sizes in most individual trials.
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Implication
Supports incorporating supervised exercise training into chronic stable HFpEF management; reinforces lifestyle interventions amid neutral pharmacologic trials.
Abstract
Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities—peripheral vascular, skeletal muscle, and cardiovascular—that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research.
JACC · AHA/ACC statement. AHA/ACC now backs supervised exercise training for chronic stable HFpEF. Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology 503 patients: Pooled from 8 RCTs in chronic stable HFpEF. Training vs control: Supervised exercise vs No supervised training. How supervised aerobic training ran: Walking or cycling → Interval or continuous → 3 sessions per week → 1 to 8 months. 2.8 mL/kg/min gain in peak VO2. MD 2.8, P=0.002. Pooled effect 2.5 to 2.8 mL/kg/min over control. Bottom line: Supervised exercise belongs in chronic stable HFpEF care; clinical-event data still lacking.
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Cite This Study
Sachdev et al. (2023) conducted a meta-analysis in Chronic Heart Failure with Preserved Ejection Fraction (HFpEF) (n=503). Supervised Exercise Training (SET) vs. Control (usual care) was evaluated on Change in peak oxygen uptake (peak VO2) (MD 2.8 mL/kg/min, p=0.002). Supervised exercise training significantly improved peak oxygen uptake by an absolute treatment effect of 2.5 to 2.8 mL/kg/min compared to control in patients with chronic stable HFpEF.