Exercise-Based Cardiac Rehabilitation in Heart Failure with Preserved Ejection Fraction: Mechanisms, Evidence, and Exercise Prescription

Heart failure with preserved ejection fraction (HFpEF) accounts for approximately half of all heart failure cases and is increasing rapidly, yet effective pharmacological options remain limited. Because its hallmark symptom, exercise intolerance, is fundamentally functional in nature, exercise-based cardiac rehabilitation holds particular importance in HFpEF management. Rather than central cardiac limitations, peripheral factors such as skeletal muscle myopathy, reduced capillary density, and mitochondrial dysfunction, predominate, with peripheral adaptation accounting for the majority of exercise-induced improvement of peak oxygen uptake in HFpEF. Several randomized trials demonstrate that exercise training reproducibly improves peak oxygen uptake, physical function, and quality of life in HFpEF. Notably, HFpEF patients may respond to rehabilitation even more favorably than those with HFrEF. Exercise prescription in HFpEF differs from that in HFrEF, emphasizing the essential inclusion of resistance training, a multidomain approach addressing frailty and balance, careful monitoring of blood pressure responses, and individualization for comorbidities. Given that high-intensity interval training has not proven superior to moderate continuous training, gradual progression favoring duration and adherence is preferred, and caloric restriction combined with resistance training is recommended to preserve lean mass in obese HFpEF patients. In conclusion, exercise-based cardiac rehabilitation is an effective strategy targeting peripheral mechanisms in HFpEF. Under Korean National Health Insurance, which covers cardiac rehabilitation regardless of ejection fraction, broader clinical application alongside the accumulation of long-term outcome evidence is warranted.