Exercise Training in Pulmonary Hypertension: Current Evidence and Clinical Practice

Pulmonary hypertension (PH) is characterized by progressive dyspnea, exercise intolerance, and impaired quality of life (QOL).[1][2][3] Although advances in PH-specific therapies have substantially improved survival, optimizing functional capacity and QOL has become an increasingly important therapeutic goal.1,3,4 Exercise intolerance results not only from pulmonary vascular disease and right ventricular dysfunction but also from skeletal muscle dysfunction and physical deconditioning, providing a strong rationale for exercise rehabilitation.Over the past two decades, substantial evidence has established exercise training as an effective adjunct to optimized medical therapy (Fig. 1).[5][6][7][8][9][10][11][12][13][14] A landmark European multicenter randomized controlled trial demonstrated significant improvements in the 6-minute walk distance (6MWD), peak oxygen uptake (peak VO 2 ), WHO functional class, and health-related QOL following supervised exercise training.13 Meta-analyses have consistently confirmed improvements in 6MWD and peak VO 2 , with a very low incidence of serious adverse events in experienced centers.[15][16][17][18] More recently, home-based and tele-rehabilitation programs have shown comparable benefits, suggesting that remote rehabilitation may broaden access to care.19,20 Exercise rehabilitation should be initiated only after optimization of PH-specific therapy and confirmation of clinical stability.Suitable candidates are generally patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) who are clinically stable and receiving optimized medical therapy.Baseline evaluation should include the 6-minute walk test or cardiopulmonary exercise testing (CPET), together with assessment of muscle strength, physical performance, and QOL to guide individualized exercise prescription and monitor treatment response.Aerobic and resistance exercise, combined with respiratory muscle training and patient education, constitute the core components of rehabilitation, typically beginning with a supervised in-hospital phase of low-intensity interval training followed by a home-based maintenance phase.Exercise intensity should be tailored according to CPET findings, Borg perceived exertion score, heart rate, oxygen saturation, and clinical symptoms.3,[15][16][17][18] Although exercise training is generally safe, patients with PH remain vulnerable to hypoxemia, right ventricular decompensation, arrhythmias, and syncope during exertion.3 Accordingly, rehabilitation should be delivered by multidisciplinary teams experienced