Exercise as Treatment: New Horizons for Heart Failure with Preserved Ejection Fraction

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Introduction 

This article provides synthesized and up-to-date information on Heart Failure with Preserved Ejection Fraction (HFpEF)—one of the most common and socially significant issues in cardiovascular medicine. The information is derived from the scientific publication "Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology," published in 2023 in the Journal of the American College of Cardiology (Vol. 81, Issue 15, pp. 1524–1542).

The authoring team includes leading specialists and researchers in cardiology, rehabilitation, and medical science: Dr. Vandana Sachdev (chair of the working group), Dr. Kavita Sharma, Dr. Steven Keteyian, Dr. Patrice Desvigne-Nickens, Dr. Jerome Fleg, Dr. Maya Guglin, Dr. Martin Halle, Dr. Dalane Kitzman, among others. These experts represent the American Heart Association (AHA), the American College of Cardiology (ACC), as well as heart failure and rehabilitation associations. This scientific document is recognized as an official statement and reflects the consensus of the international scientific community.

The purpose of the following questions and answers is to clearly guide patients and their families on what they need to know about HFpEF—from symptoms and associated conditions to the role of exercise and the outlook for future treatments.

"Physical activity is the most effective way to improve symptoms and daily life in heart failure with preserved ejection fraction."

Current Understanding of HFpEF and the Role of Exercise

Heart Failure with Preserved Ejection Fraction (HFpEF) is a condition that affects millions of people worldwide, including a significant number of women and older adults. It leads to severe fatigue, shortness of breath, and a marked decline in quality of life. While most drug therapies have limited impact on HFpEF, growing evidence shows that structured and medically supervised physical activity offers substantial and clinically meaningful benefits. Below, we highlight five key expert and scientific opinions from the latest consensus by the American Heart Association and American College of Cardiology to help patients and families understand the most current and important information on this condition.

1. What is the greatest clinical benefit of exercise for HFpEF? Expert Question: "What are the proven effects of supervised physical training in patients with HFpEF?" 

Quote:

“...patients who undergo training show large, statistically significant, and clinically meaningful improvements in symptoms, objectively measured physical performance, and typically in quality of life... This is likely due to the pleiotropic effects of exercise, which favorably impact all abnormalities—vascular, skeletal muscle, and cardiac—that contribute to exercise intolerance in HFpEF.”

Explanation: Patients with HFpEF often cannot perform simple daily activities without experiencing shortness of breath and fatigue. Research shows that exercise significantly enhances the ability to be physically active and reduces symptoms, thereby improving everyday life.

2. Why is medication alone not enough? Researcher Question: "Are there any medications that significantly improve physical performance in HFpEF?" 

Quote:

“Almost all pharmacological trials... have shown disappointing results in improving physical capacity. For example, differences between drug and placebo groups in peak oxygen uptake or six-minute walk distance are minimal and statistically insignificant.”

Explanation: Even the most modern drugs rarely lead to meaningful improvements in physical activity levels. This means patients should not rely solely on medications but should consider combined approaches in which exercise plays a central role.

3. What are the specific results of exercise on physical performance capacity? Cardiologist Question: "How much does physical capacity improve after an exercise program for HFpEF?" 

Quote:

“A meta-analysis of 8 RCTs (randomized controlled trials) found that patients with HFpEF undergoing supervised training showed a 14% increase in peak VO₂... representing a clinically significant improvement.”

Explanation: Peak VO₂ is a measure of physical endurance and is directly related to quality of life. A 14% increase is especially impressive for chronically ill patients and shows that the benefits of exercise are real and measurable—not just theoretical.

4. How safe is exercise for older adults and people with HFpEF? Safety Expert Question: "Is it safe for patients with HFpEF to start a structured exercise program?" 

Quote:

“The safety of supervised training in HFpEF patients has been confirmed: in a meta-analysis of 276 patients across 6 studies, no serious exercise-related adverse events were reported...”

Explanation: Patients often fear that physical exertion could worsen their condition. The data shows that for those with stable and compensated HFpEF, supervised programs carry minimal risk when monitored by professionals.

5. What does the future hold, and what questions remain unanswered? Scientific Consensus

Question: "What are the key scientific and practical questions for future research?" Quote:

“Major unresolved questions include: how to ensure long-term patient adherence to exercise programs, which types of exercise are optimal, how best to combine them with other interventions such as diet and medication, and how to make programs accessible across all social groups.”

Explanation: Although the benefits are clear, challenges remain in maintaining long-term activity. It's important for patients to talk to their doctor about creating a personalized, supervised exercise plan.

Q&A

1. How do I know if I have HFpEF and what are the symptoms? 

Answer: HFpEF (Heart Failure with Preserved Ejection Fraction) is diagnosed when you have symptoms of heart failure (such as shortness of breath during exertion, rapid fatigue, easy exhaustion, fluid retention), while your heart is still pumping blood with a normal ejection fraction (usually EF ≥ 50%). HFpEF is common in older adults, especially women, and is marked by severely limited exercise tolerance, frequent hospitalizations, and reduced quality of life.

2. What other conditions often accompany HFpEF? 

Answer: Patients with HFpEF often have additional comorbidities:

• High blood pressure (hypertension) – the most common risk factor

• Obesity – more than 80% of patients are overweight

• Type 2 diabetes – found in 25% to 50% of cases

• Coronary artery disease

• Kidney disease

• Sarcopenia and frailty – loss of muscle mass and overall physical condition

These conditions complicate treatment and worsen prognosis.

3. What happens in my body with HFpEF – why do I get tired so easily? 

Answer: The main reason for fatigue and breathlessness in HFpEF is that the heart cannot increase blood flow adequately during exertion. Additionally, the peripheral organs (blood vessels, skeletal muscles) and lungs undergo changes that limit oxygen delivery to tissues. Often, there's impaired ability of muscles to use oxygen, decreased elasticity of blood vessels, and sometimes lung problems, all contributing to poor exercise tolerance.

4. How is physical performance measured in HFpEF and why does it matter? 

Answer: Physical capacity is measured using peak VO₂—the maximum amount of oxygen the body can use during exertion. This is an objective and reliable indicator strongly linked to prognosis and quality of life. In HFpEF, peak VO₂ is typically reduced by about 30% compared to healthy individuals. The six-minute walk test (6MWD) is also commonly used, measuring the distance walked in six minutes.

5. What should I expect from different types of exercise, and where are training programs offered? 

Answer: Supervised training programs typically include aerobic exercises (walking, stationary biking, even dancing), strength training, and interval workouts. These are conducted in medical centers under supervision or at home with remote monitoring. Most programs are prescribed three times per week, lasting anywhere from 1 to 8 months. All models studied have shown improvements in physical capacity and often in quality of life, with minimal risk when conducted in a controlled environment.

Conclusion

Heart Failure with Preserved Ejection Fraction remains a major challenge for patients, clinicians, and healthcare systems around the world. As shown in the scientific publication by Sachdev and colleagues (2023)—based on multiple randomized clinical trials and expert consensus—supervised exercise, proper diagnosis, and understanding of associated conditions are key to improving both prognosis and quality of life. While science continues to search for new therapies and more effective strategies, the most important thing for patients today is to stay informed, engaged, and proactive in their care—with the support of a multidisciplinary team.

We hope that the answers presented here, grounded in the authoritative scientific position of the American Heart Association and American College of Cardiology, will give you the knowledge and confidence to make informed decisions about your health.

Source Sachdev V, Sharma K, Keteyian SJ, et al. "Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology." Journal of the American College of Cardiology, Vol. 81, No. 15, 2023, pp. 1524–1542. https://doi.org/10.1016/j.jacc.2023.02.012