New Paradigms to Address Long-Term Exercise Adherence, An Achilles Heel of Lifestyle Interventions

Regular physical activity is widely recommended for the primary and secondary prevention of cardiovascular disease (CVD), and formal cardiac rehabilitation (CR) programs are indicated for a range of cardiovascular and post-surgical conditions.Heart failure (HF) is one of the conditions for which multi-component CR and even exercise training (ET) alone improve both exercise capacity and clinical outcomes 1,2 As a result, CR (including ET, medication education, dietary recommendations, and psychosocial support) and ET alone are codified in US and European guidelines for management of patients with HF regardless of ejection fraction, as class 1 to 2a recommendations.Of note, the efficacy of exercise intervention is significantly impacted by adherence.2 Short-term adherence rates of up to ~80% can be achieved in rigorous clinical trials of exercise interventions, 2 but longer-term sustainability remains either poor or untested globally.This is particularly true once individuals transition out of in-person supervised sessions to the home environment.Several clinical factors are associated with adherence, but these account for very little of the variance in individual adherence.2 This leaves an enormous gap in the knowledge base necessary to sustain exercise therapy in this high-risk population.Traditional efforts to improve adherence (as detailed below) have demonstrated important, albeit modest benefits.3 For HF in particular, there are relatively few recent or ongoing clinical trials investigating adherence to exercise.Increased efforts through alternative paradigms may be necessary to reduce the knowledge gap around effective methods to enhance adherence (including in diverse populations).From this perspective, we briefly review traditional methods to optimize adherence in exercise for CVD, with HF as a case study, and discuss innovative strategies to overcome barriers to long-term adherence.