AHA/ACC Release Scientific Statement on Benefits of Exercise Training in Persons with HFpEF

A joint scientific statement from the American Heart Association (AHA) and the American College of Cardiology (ACC) issued March 21 states that supervised exercise therapy is safe and may improve symptoms and quality of life (QoL) for patients with chronic heart failure with preserved ejection fraction (HFpEF). According to the statement, the improvements observed may even surpass those achieved with medication.

Based on examination of research published since 2010, statement authors found that results of exercise therapy for persons with preserved EF were comparable to or better than for those with HF with reduced EF (HFrEF) and other cardiovascular conditions, evidence that argues for Medicare and other insurers to expand coverage of cardiac rehabilitation to those with HFpEF.

“The prevalence of HFpEF continues to increase due to aging of the population and the growing prevalence of risk factors such as obesity and Type 2 diabetes,” said Vandana Sachdev, MD, chair of the scientific statement writing committee and director of the Echocardiography Laboratory in the Division of Intramural Research at the National Heart, Lung, and Blood Institute. “Improved management of this large population of patients who have HFpEF, many of whom may be undertreated, represents an urgent unmet need.”

“The prevalence of HFpEF continues to increase due to aging of the population and the growing prevalence of risk factors such as obesity and Type 2 diabetes. Improved management of this large population of patients who have HFpEF, many of whom may be undertreated, represents an urgent unmet need.”

While the prevalence of HFpEF is increasing, outcomes are worsening, according to the statement. Associated symptoms include severe exertional dyspnea and incapacitating fatigue, frequent hospitalizations, and elevated mortality rate.

Primary outcomes from most HFpEF pharmacotherapy intervention studies have, until recently, been neutral. Studies of exercise interventions, on the other hand, have consistently returned large, significant, and clinically meaningful improvements in HFpEF symptoms, exercise capacity, and often, QoL, according to authors, setting the stage for the critical review of literature on which the current statement is based.

In April 2022, the AHA/ACC published recommendations for supervised exercise training for people with HF, regardless of type. Medicare, however, currently only reimburses cardiac rehabilitation program for persons with HFrEF. In its review, the writing committee vetted research on the impact of exercise-based therapies for patients with chronic, stable HFpEF, how these data compared with exercise therapy for other cardiovascular conditions (ie, HFrEF, peripheral artery disease [PAD]), as well as potential mechanisms for improving exercise capacity and symptoms.

Review of evidence

The studies reviewed for the current statement evaluated various approaches for exercise training including walking, stationary cycling, high-intensity interval training (HIIT), strength training, and dancing, both in facility settings and home-based training programs. Sessions of supervised exercise therapy were typically 3 times per week across studies while exercise program duration ranged from 1 to 8 months.

Peak oxygen uptake (VO₂) among persons with HFpEF is often up to 30% lower than that of a healthy person, a level considered below the threshold required for functional independence. Change in peak VO₂ was one of several outcomes measured in the studies reviewed.

The ACC/AHA writing committee suggests in the final statement that supervised exercise training may lead to:

• Increased baseline peak VO2 by 12% to 14%
• Increased total exercise time by 21%
• Improved QoL scores by 4 to 9 points (Minnesota Living with Heart Failure questionnaire)

Limitations, future research

Limitations in the data acknowledged by the writing committee include variations in baseline characteristics of study participants, exclusion of persons with certain comorbidities, and underrepresentation in some studies of several groups known for high prevalence of HF, ie, older adults, women, persons of low socioeconomic status, and persons from diverse racial and ethnic groups. Small study size, single-center design, and short study duration leave open questions regarding long-term adherence with supervised exercise training, a topic the writing committee suggests for future research.

Other data-poor areas considered critical for future trials include exercise settings, specific modalities, combination with other lifestyle interventions, and cost.

“Improved management of the large, inadequately treated population of patients with HFpEF represents an urgent unmetneed,” the committee writes in the statement’s conclusion. “Future research should focus on maximizing the benefits and accessibility of supervised exercise training for chronic HFpEF; extending its availability to medically supervised group, home-based, and hybrid cardiac rehabilitation settings; and addressing common barriers to long-term adherence. Implementation efforts will need to include coverage by Medicare and other insurers.”

The statement was prepared by a volunteer writing group on behalf of the AHA/ACC and endorsed by the Heart Failure Society of America, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the American Association of Heart Failure Nurses.

Reference: Sachdev V, Sharma K, Keteyian SJ, et al. AHAACC Scientific Supervised exercise training for chronic heart failure with preserved ejection fraction: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. Published online March 21, 2023. doi:10.1161/CIR.0000000000001122