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July 9, 2026Circulation
Exercise Training in High-Risk Populations: A Scientific Statement From the American Heart Association
Why the study?
Certain high-risk populations warrant special considerations regarding exercise training, requiring a summary of the present state, modifications needed for safety and efficacy, and future directions.
Key Points
- Tailored aerobic exercise training matches or exceeds standard functional gains in high-risk groups, despite widespread barriers and low baseline cardiorespiratory fitness.
- Scientific statement synthesizes evidence on advanced heart failure therapies and cardiac implantable electronic devices, evaluating program adjustments to ensure safety.
- Highlights the urgent need for equitable delivery of patient-centered training regimens to address clinical deficits across conditions like genetic cardiomyopathies.
Structured PICO
P
Population
High-risk populations including those with frailty, stroke, spinal cord injury, rheumatological conditions, genetic cardiomyopathies, and recipients of advanced heart failure therapies or cardiac implantable electronic devices
I
Intervention
Exercise training (including aerobic, strength, balance, and flexibility training with necessary modifications and supervision)
This AHA scientific statement highlights the safety, efficacy, and necessity of tailored exercise training programs for high-risk cardiovascular populations to improve functional capacity and quality of life.
Discussion
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Exercise training has demonstrated clinical benefit in diverse populations, including patients with frailty, stroke, SCI, rheumatologic conditions, CIEDs, and some inherited cardiomyopathies and recipients of advanced HF therapies. Despite evidence to support the efficacy and safety of exercise training in the majority of conditions reviewed, these programs remain vastly underused. Additional research is urgently needed to identify a patient-centered approach to exercise training that accounts for patients' unique needs, with a focus on implementation to equitably increase access to such programs for all individuals with the potential for benefit.”
“Functional and quality-of-life gains in response to appropriately designed exercise programs match or exceed those in more traditional populations.”
Implication
Warrants individualized exercise regimens for high-risk groups; leaves open optimal protocols pending targeted trials.
Abstract
There is broad consensus on the benefits of aerobic exercise training in patients with cardiovascular disease to improve cardiorespiratory fitness and lower the risk of adverse cardiovascular events. However, certain high-risk populations such as those with frailty, stroke, spinal cord injury, rheumatological conditions, or genetic cardiomyopathies and recipients of advanced heart failure therapies or cardiac implantable electronic devices warrant special considerations with regard to exercise training. This scientific statement summarizes the present state and future directions of exercise training for these high-risk populations, including functional deficits, responses to exercise training, modifications in training programs required to maximize safety and efficacy, and knowledge gaps in this field. Key findings common across most of these high-risk populations include (1) increased barriers to participation in exercise training at multiple levels; (2) low baseline cardiorespiratory fitness, creating heightened need for exercise interventions; (3) modifications to exercise prescription, frequently emphasizing strength, balance, and flexibility in addition to aerobic training, as well as accommodations with enhanced supervision and specialized equipment as needed; and (4) functional and quality-of-life gains in response to appropriately designed exercise programs that match or exceed those in more traditional populations. Future research is needed to further develop patient-centered training regimens designed to address the unique and heterogeneous needs of these populations, evaluate their impact on clinical and patient-centered outcomes, and advance scalable and equitable delivery of exercise therapies proven safe and effective.
Cite This Study
Fleg et al. (2026) conducted a review in High-risk populations with cardiovascular disease (e.g., frailty, stroke, spinal cord injury, genetic cardiomyopathies). Exercise training was evaluated. Appropriately designed exercise training programs in high-risk cardiovascular populations yield functional and quality-of-life gains that match or exceed those in more traditional populations.