AHA/ACC Scientific Statement Reports Benefit of Supervised Exercise Training for HFpEF

Vandana Sachdev, MD

Courtesy of the National Heart, Lung, and Blood Institute

A new joint scientific statement from the American Heart Association (AHA) and the American College of Cardiology (ACC) suggests supervised exercise therapy is safe and could improve symptoms for patients with chronic heart failure with preserved ejection fraction (HFpEF).¹

According to the statement, exercise therapy had comparable or better results on improving exercise capacity for people with preserved EF compared to those who have heart failure with reduced ejection fraction (HFrEF). Based on these findings, the writing committee advised that Medicare and other insurers expand the coverage of cardiac rehabilitation to include people 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 Echocardiography Laboratory in the Division of Intramural Research at the National Heart, Lung, and Blood Institute.² “Improved management of this large population of patients who have HFpEF, many of whom may be undertreated, represents an urgent unmet need.”

Alongside the increasing prevalence of HFpEF, patient outcomes are additionally worsening, with those affected experiencing severe exertional dyspnea and fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Data from most pharmacological intervention trials for HFpEF indicated neutral primary outcomes. However, exercise-based intervention trials have indicated significant, clinically meaningful improvements in symptoms, exercise capacity, and often, quality of life.

Recommendations were released by the AHA/ACC in April 2022 for supervised exercise training for people with heart failure, regardless of type. However, currently, Medicare only reimburses cardiac rehabilitation for patients with HFrEF. Members of the current writing committee critically examined research since 2010 on the impact of exercise-based therapies for HfpEF, as well as potential mechanisms for improving exercise capacity and symptoms, and how these data compared with exercise therapy for other cardiovascular conditions.

The studies included in the statement evaluated several exercise types, including walking, stationary cycling, high-intensity interval training, strength training, and dancing in both facility settings and home-based training. Moreover, in the studies, supervised exercise therapy often occurred three times per week and program duration ranged from 1 to 8 months. Investigators in the studies measured peak oxygen uptake to better assess exercise capacity, but measured the total amount of oxygen able to be taken into the lungs during physical exercise.

Individuals with HfpEF often have a peak oxygen uptake approximately 30% lower than that of a healthy person and considered below the threshold required for functional independence and performing daily living activities. Ultimately, the reviewed data indicated a comparable or larger magnitude in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with HFrEF.

In the statement, based on the data, the writing committee suggested that supervised exercise training could lead to:

• Increased peak oxygen uptake 12 - 14%
• Increased total exercise time by 21%
• Improved quality-of-life scores by 4 – 9 points on the Minnesota Living with Heart Failure questionnaire

The writing committee noted variations in the baseline characteristics of people in the reviewed trials and some excluded participants with co-existing health conditions. Additionally, many heart failure groups with prevalent disease, including older adults, women, those in low socioeconomic status, and people from diverse racial and ethnic groups, were underrepresented in some research. Studies were noted to be smaller, single-center and mostly short-term, leading to a lack of information addressing long-term adherence.

Critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise settings, training modalities, diet and medications, and long-term adherence, were additionally highlighted to help provide guidance for future research. Overall, however, the writing committee suggested supervised exercise training is safe and could provide substantial improvement in exercise capacity and quality of life in heart failure

“Future work is needed to improve referral of appropriate patients to supervised exercise programs, and better strategies to improve long-term adherence to exercise training is needed,” Sachdev said.² “Hybrid programs combining supervised and home-based training may also be beneficial. Further, 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.

References

1. Sachdev, V., Sharma, K., Keteyian, S. J., Alcain, C. F., Desvigne-Nickens, P., Fleg, J. L., Florea, V. G., Franklin, B. A., Guglin, M., Halle, M., Leifer, E. S., Panjrath, G., Tinsley, E. A., Wong, R. P., & Kitzman, D. W. (2023). 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. https://doi.org/10.1161/cir.0000000000001122
2. Exercise therapy is safe, may improve quality of life for many people with heart failure. American Heart Association. (2023, March 21). Retrieved March 22, 2023, from https://newsroom.heart.org/news/exercise-therapy-is-safe-may-improve-quality-of-life-for-many-people-with-heart-failure