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. 2024 Mar 7;3(3):CD003331.
doi: 10.1002/14651858.CD003331.pub6.

Exercise-based cardiac rehabilitation for adults with heart failure

Cal Molloy  1 , Linda Long  2 , Ify R Mordi  3 , Charlene Bridges  4 , Viral A Sagar  5 , Edward J Davies  6 , Andrew Js Coats  7 , Hasnain Dalal  8   9 , Karen Rees  10 , Sally J Singh  11 , Rod S Taylor  12
Affiliations

Exercise-based cardiac rehabilitation for adults with heart failure

Cal Molloy et al. Cochrane Database Syst Rev. .

Abstract

Background: People with heart failure experience substantial disease burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous 2018 Cochrane review reported that exercise-based cardiac rehabilitation (ExCR) compared to no exercise control shows improvement in HRQoL and hospital admission amongst people with heart failure, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane review include the following: (1) most trials were undertaken in patients with heart failure with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with heart failure with preserved (≥ 45%) ejection fraction (HFpEF) were under-represented; and (2) most trials were undertaken in a hospital or centre-based setting.

Objectives: To assess the effects of ExCR on mortality, hospital admission, and health-related quality of life of adults with heart failure.

Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and Web of Science without language restriction on 13 December 2021. We also checked the bibliographies of included studies, identified relevant systematic reviews, and two clinical trials registers.

Selection criteria: We included randomised controlled trials (RCTs) that compared ExCR interventions (either exercise only or exercise as part of a comprehensive cardiac rehabilitation) with a follow-up of six months or longer versus a no-exercise control (e.g. usual medical care). The study population comprised adults (≥ 18 years) with heart failure - either HFrEF or HFpEF.

Data collection and analysis: We used standard Cochrane methods. Our primary outcomes were all-cause mortality, mortality due to heart failure, all-cause hospital admissions, heart failure-related hospital admissions, and HRQoL. Secondary outcomes were costs and cost-effectiveness. We used GRADE to assess the certainty of the evidence.

Main results: We included 60 trials (8728 participants) with a median of six months' follow-up. For this latest update, we identified 16 new trials (2945 new participants), in addition to the previously identified 44 trials (5783 existing participants). Although the existing evidence base predominantly includes patients with HFrEF, with New York Heart Association (NYHA) classes II and III receiving centre-based ExCR programmes, a growing body of trials includes patients with HFpEF with ExCR undertaken in a home-based setting. All included trials employed a usual care comparator with a formal no-exercise intervention as well as a wide range of active comparators, such as education, psychological intervention, or medical management. The overall risk of bias in the included trials was low or unclear, and we mostly downgraded the certainty of evidence of outcomes upon GRADE assessment. There was no evidence of a difference in the short term (up to 12 months' follow-up) in the pooled risk of all-cause mortality when comparing ExCR versus usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.71 to 1.21; absolute effects 5.0% versus 5.8%; 34 trials, 36 comparisons, 3941 participants; low-certainty evidence). Only a few trials reported information on whether participants died due to heart failure. Participation in ExCR versus usual care likely reduced the risk of all-cause hospital admissions (RR 0.69, 95% CI 0.56 to 0.86; absolute effects 15.9% versus 23.8%; 23 trials, 24 comparisons, 2283 participants; moderate-certainty evidence) and heart failure-related hospital admissions (RR 0.82, 95% CI 0.49 to 1.35; absolute effects 5.6% versus 6.4%; 10 trials; 10 comparisons, 911 participants; moderate-certainty evidence) in the short term. Participation in ExCR likely improved short-term HRQoL as measured by the Minnesota Living with Heart Failure (MLWHF) questionnaire (lower scores indicate better HRQoL and a difference of 5 points or more indicates clinical importance; mean difference (MD) -7.39 points, 95% CI -10.30 to -4.77; 21 trials, 22 comparisons, 2699 participants; moderate-certainty evidence). When pooling HRQoL data measured by any questionnaire/scale, we found that ExCR may improve HRQoL in the short term, but the evidence is very uncertain (33 trials, 37 comparisons, 4769 participants; standardised mean difference (SMD) -0.52, 95% CI -0.70 to -0.34; very-low certainty evidence). ExCR effects appeared to be consistent across different models of ExCR delivery: centre- versus home-based, exercise dose, exercise only versus comprehensive programmes, and aerobic training alone versus aerobic plus resistance programmes.

Authors' conclusions: This updated Cochrane review provides additional randomised evidence (16 trials) to support the conclusions of the previous 2018 version of the review. Compared to no exercise control, whilst there was no evidence of a difference in all-cause mortality in people with heart failure, ExCR participation likely reduces the risk of all-cause hospital admissions and heart failure-related hospital admissions, and may result in important improvements in HRQoL. Importantly, this updated review provides additional evidence supporting the use of alternative modes of ExCR delivery, including home-based and digitally-supported programmes. Future ExCR trials need to focus on the recruitment of traditionally less represented heart failure patient groups including older patients, women, and those with HFpEF.

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Conflict of interest statement

Rod Taylor*: no relevant interests; former Editor for the Cochrane Heart Group (closed March 2023), with no role in the editorial decision‐making of this review update.

Cal Molloy: none known

Linda Long: none known

Ify Mordi: no relevant interests; site PI for REACH‐HFpEF trial at Ninewells Hospital (led by Rod Taylor), funded by NIHR

Charlene Bridges: no relevant interests; former Information Specialist for the Cochrane Heart Group (closed March 2023), with no role in the editorial decision‐making of this review update.

Viral Segar: no relevant interests; Cardiology fellow, Guy's and St Thomas' Hospital, London, UK

Edward Davies: none known

Andrew Coats: no relevant interests; published opinions/review articles about exercise

Karen Rees: no relevant interests; former Editor for the Cochrane Heart Group (closed March 2023), with no role in the editorial decision‐making of this review update

Sally Singh: no relevant interests; health professional at the University of Leicester; co‐applicant (not a recruiting site) University Hospitals of Leicester NHS Trust for a study that is eligible for inclusion in the work, funded by NIHR

Hasnain Dalal*: no relevant interests; published BMJ Clinical Reviews in 2015 and 2021 on Cardiac Rehabilitation; chief investigator for the Cornwall Heart Attack Rehabilitation Management Study (CHARMS); Dalal HM, Evans PH, Campbell JL, Taylor RS, Watt A, Read KL, et al. Home‐based versus hospital‐based rehabilitation after myocardial infarction: a randomized trial with preference arms ‐ Cornwall Heart Attack Rehabilitation Management Study (CHARMS). International Journal of Cardiology 2007;119(2):202‐11. Taylor RS, Watt A, Dalal HM, Evans PH, Campbell JL, Read KL, et al. Home‐based cardiac rehabilitation versus hospital‐based rehabilitation: a cost‐effectiveness analysis. International Journal of Cardiology 2007;119(2):196‐201; funded by National Institute for Health Research (NIHR) Programme Grants for Applied Research (RP‐PG‐1210‐12004).

*RT and HD are co‐lead investigators on an ongoing National Institute for Health Research (NIHR) Programme Grants for Applied Research‐funded study ‐ Rehabilitation Enablement in Chronic Heart Failure (REACH‐HF) ‐ to develop and evaluate the costs and outcomes of a home‐based self‐help heart failure exercise rehabilitation manual (RP‐PG‐1210‐12004). Several review authors are also authors of included studies – Dalal 2018; Jolly 2009; Lang 2018. They did not extract data from their own studies. Instead, another author extracted these data and checked the interpretation against the study report.

Figures

1
1
2
2
Risk of bias graph: review authors' judgements about each risk‐of‐bias domain presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk‐of‐bias domain for each included study.
1.1
1.1. Analysis
Comparison 1: Exercise‐based rehabilitation versus usual care, Outcome 1: All‐cause mortality up to 12 months' follow‐up
1.2
1.2. Analysis
Comparison 1: Exercise‐based rehabilitation versus usual care, Outcome 2: All‐cause mortality more than 12 months' follow‐up
1.3
1.3. Analysis
Comparison 1: Exercise‐based rehabilitation versus usual care, Outcome 3: Hospital admissions (all‐cause) up to 12 months' follow‐up
1.4
1.4. Analysis
Comparison 1: Exercise‐based rehabilitation versus usual care, Outcome 4: Hospital admissions (all‐cause) more than 12 months' follow‐up
1.5
1.5. Analysis
Comparison 1: Exercise‐based rehabilitation versus usual care, Outcome 5: Hospital admissions (heart failure only) up to 12 months' follow‐up
1.6
1.6. Analysis
Comparison 1: Exercise‐based rehabilitation versus usual care, Outcome 6: Hospital admissions (heart failure only) more than 12 months' follow‐up
1.7
1.7. Analysis
Comparison 1: Exercise‐based rehabilitation versus usual care, Outcome 7: Health‐related quality of life (MLWHF) up to 12 months' follow‐up
1.8
1.8. Analysis
Comparison 1: Exercise‐based rehabilitation versus usual care, Outcome 8: Health‐related quality of life (all scales) up to 12 months' follow‐up
1.9
1.9. Analysis
Comparison 1: Exercise‐based rehabilitation versus usual care, Outcome 9: Health‐related quality of life (MLWHF) more than 12 months' follow‐up
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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HF ACTION 2009 {published data only}
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Norman 2012 {published data only}
    1. Norman JF, Pozehl BJ, Duncan KA, Hertzog MA, Krueger SK. Effects of exercise training versus attention on plasma B-type natriuretic peptide, 6-minute walk test and quality of life in individuals with heart failure. Cardiopulmonary Physical Therapy Journal 2012;23:19-25. - PMC - PubMed
    1. Pozehl B, Duncan K, Hertzog M, Norman JF. Heart failure exercise and training camp: effects of a multicomponent exercise training intervention in patients with heart failure. Heart & Lung 2010;39:S1-13. - PMC - PubMed
Passino 2006 {published data only}
    1. Passino C, Severino S, Poletti R, Piepoli MF, Mammini C, Clerico A, et al. Aerobic training decreases B-type natriuretic peptide expression and adrenergic activation in patients with heart failure. Journal of the American College of Cardiology 2006;47:1835-9. - PubMed
Peng 2018 {published data only}
    1. Peng X, Su Y, Hu Z, Sun X, Li X, Dolansky MA. Home-based telehealth exercise training program in Chinese patients with heart failure. A randomized controlled trial. Medicine (Baltimore) 2018;97(35):e12069. [PMID: ] - PMC - PubMed
Pozehl 2008 {published data only}
    1. Pozehl B, Duncan K, Hertzog M. The effects of exercise training on fatigue and dyspnea in heart failure. European Journal of Cardiovascular Nursing 2008;7(2):127-32. - PubMed
Reeves 2017 {published data only}
    1. Reeves GR, Whellan DJ, O'Conner CM, Duncan P, Eggebeen JD, Morgan TM, et al. A novel rehabilitation intervention for older patients with acute decompensated heart failure: the REHAB-HF pilot study. JACC: Heart Failure 2014;5(5):361. - PMC - PubMed
Ricca‐Mallada 2017 {published data only}
    1. Ricca-Mallada R, Migliaro ER, Silvera G, Chiappella L, Frattini R, Ferrando-Castagnetto F. Functional outcome in chronic heart failure after exercise training: possible predictive value of heart rate variability. Annals of Physical and Rehabilitation Medicine 2017;60(2):87-94. [DOI: 10.1016/j.rehab.2016.12.003] [PMID: ] - DOI - PubMed
Ryu 2018 {published data only}
    1. Ryu HY, Kim KS, Jeon IC. Influence of home based exercise intensity on the aerobic capacity and 1 year re-hospitalization rate in patients with chronic heart failure. Journal of Korean Physical Therapy 2018;30(5):181-6. [DOI: ]
Santa‐Clara 2019 {published data only}
    1. Santa-Clara H, Abreu A, Melo X, Santos V, Cunha P, Oliveira M, et al. High‑intensity interval training in cardiac resynchronization therapy: a randomized control trial. European Journal of Applied Physiology 2019;119:1757-67. [DOI: ] - PubMed
TELEREH‐HF 2020 {published data only}
    1. Główczyńska R, Piotrowicz E, Szalewska D, Piotrowicz R, Kowalik I, Pencina MJ, et al. Efects of hybrid comprehensive telerehabilitation on cardiopulmonary capacity in heart failure patients depending on diabetes mellitus: subanalysis of the TELEREH-HF randomized clinical trial. Cardiovasular Diabetology 2021;20:106. [PMID: ] - PMC - PubMed
    1. Niewada M, Tabor B, Piotrowicz E, Piotrowicz R, Opolski G, Banach M, et al. Cost-effectiveness of telerehabilitation in patients with heart failure in Poland: an analysis based on the results of Telerehabilitation in the Heart Failure Patients (TELEREH-HF) randomized clinical trial. Kardiologia Polska 2021;79(5):510-6. [PMID: ] - PubMed
    1. Orzechowski P, Piotrowicz R, Zareba W, Pencina MJ, Kowalik I, Komar E, et al. Antiarrhythmic effect of 9-week hybrid comprehensive telerehabilitation and its influence on cardiovascular mortality in long-term follow-up - subanalysis of the TELEREHabilitation in Heart Failure Patients randomized clinical trial. Archives of Medical Science 2021;18(2):293-306. [PMID: ] - PMC - PubMed
    1. Piotrowicz E, Pencina MJ, Opolski G, Zareba W, Banach M, Kowalik I, et al. Antiarrhythmic effect of 9-week hybrid comprehensive telerehabilitation and its influence on cardiovascular mortality in long-term follow-up – subanalysis of the TELEREHabilitation in Heart Failure Patients randomized clinical trial. Archives of Medical Science 2021;18(2):293-306. [PMID: ] - PMC - PubMed
    1. Piotrowicz E, Pencina MJ, Opolski G, Zareba W, Banach M, Kowalik I, et al. Effects of a 9-week hybrid comprehensive telerehabilitation program on long-term outcomes in patients with heart failure the Telerehabilitation in Heart Failure Patients (TELEREH-HF) randomized clinical trial. JAMA Cardiology 2019;5(3):300-8. [PMID: ] - PMC - PubMed
Wall 2010 {published data only}
    1. Wall HK, Ballard J, Troped P, Njike VY, Katz DL. Impact of home-based, supervised exercise on congestive heart failure. International Journal of Cardiology 2010;145:267-70. - PubMed
Wang 2021 {published data only}PMC8290646
    1. Wang Y, Cao J, Kong X, Wang S, Meng L, Wang Y. The effects of CPET-guided cardiac rehabilitation on the cardiopulmonary function, the exercise endurance, and the NT-proBNP and hscTnT levels in CHF patients. American Journal of Translational Research 2021;13(6):7104-14. [PMID: ] - PMC - PubMed
Willenheimer 2001 {published data only}
    1. Willenheimer R, Rydberg E, Cline C, Broms K, Hillberger B, Oberg L, et al. Effects on quality of life, symptoms and daily activity 6 months after termination of an exercise training programme in heart failure patients. International Journal of Cardiology 2001;77(1):25-31. - PubMed
Witham 2005 {published data only}
    1. Witham MD, Gray JM, Argo IS, Johnston DW, Struthers AD, McMurdo ME. Effect of a seated exercise program to improve physical function and health status in frail patients > or = 70 years of age with heart failure. American Journal of Cardiology 2005;95(9):1120-4. [PMID: ] - PubMed
Witham 2012 {published data only}
    1. Witham MD, Fulton RL, Greig CA, Johnston DW, Lang CC, Van der Pol M, et al. Efficacy and cost of an exercise program for functionally impaired older patients with heart failure: a randomized controlled trial. Circulation: Heart Failure 2012;5:209-16. - PubMed
Yeh 2011 {published data only}
    1. Yeh GY, McCarthy EP, Wayne PM, Stevenson LW, Wood MJ, Davis RB, et al. Tai Chi exercise in patients with chronic heart failure: a randomized clinical trial. Archives of Internal Medicine 2011;171:750-7. - PMC - PubMed

References to studies excluded from this review

Abdelbasset 2019 {published data only}
    1. Abdelbasset WK, Alqahtani BA. A randomized controlled trial on the impact of moderate-intensity continuous aerobic exercise on the depression status of middle-aged patients with congestive heart failure. Medicine 2019;98(17):e15344. [DOI: 10.1097/MD.0000000000015344] - DOI - PMC - PubMed
Abolahrari‐Shirazi 2018 {published data only}
    1. Sara A, Javad K, Zahra, Zahra R. Efficacy of combined endurance-resistance training versus endurance training in patients with heart failure after percutaneous coronary intervention: a randomized controlled trial. Journal of Isfahan University of Medical Sciences 2018;23:12. [DOI: ] - PMC - PubMed
Alonso 2021 {published data only}
    1. Windy W, Alonso KA, Kupzyk JF, Norman SW, Lundgren AF. The HEART The HEART Camp Exercise Intervention improves exercise adherence, physical function, and patient-reported outcomes in adults with preserved ejection fraction heart failure. Journal of Cardiac Failure 2021;28(3):431-42. [DOI: ] - PMC - PubMed
Arjunan 2020 {published data only}
    1. Arjunan P, Trichur RV. The impact of nurse-led cardiac rehabilitation on quality of life and biophysiological parameters in patients with heart failure: a randomized clinical trial. Journal of Nursing Research 2020;29(1):e130. [PMID: ] - PMC - PubMed
Ayad 2021 {published data only}
    1. Ayad S, Hassanein M, El Dabe F, El Amrawy A. Impact of cardiac rehabilitation on patients with heart failure with preserved ejection fraction. JACC 2021;77(18):574.
Bahrami 2019 {published data only}
    1. Bahrami H, Homaei H, Maleki M, Naderi N. Study design: The effects of photobiomodulation therapy combined with exercise training on functional capacity and quality of life in patients with heart failure (double-blind randomized). Research in Cardiovascular Medicine Journal of the American College of Cardiology;8(4):114-7. [DOI: 10.4103/rcm.rcm_27_19] - DOI
Bangen 2020 {published data only}
    1. Redwine LS, Pung MA, Wilson K, Bangen KJ, Delano-Wood L, Hurwitz B. An exploratory randomized sub-study of light-to-moderate intensity exercise on cognitive function, depression symptoms and inflammation in older adults with heart failure. Journal of Psychosomatic Research 2020;128:109883. [PMID: ] - PMC - PubMed
Bortzova 2018 {published data only}
    1. Bortsova M, Sitnikova M, Demchenko E, Lelyavina T, Babich O, Galenko V, et al. Efficiency and safety of physical rehabilitation in patients with chronic heart failure III-IV class NYHA candidates for heart transplantation. European Journal of Heart Failure 2018;20:86. [DOI: 10.1002/ejhf.1197] - DOI
Brubaker 2020 {published data only}
    1. Brubaker PH, Avis T, Rejeski WJ, Mihalko SE, Tucker WJ, Kitzman DW. Exercise training effects on the relationship of physical function and health-related quality of life among older heart failure patients with preserved ejection fraction. Journal of Cardiopulmonary Rehabilitation and Prevention 2020;40(6):427-33. [PMID: ] - PMC - PubMed
Chaveles 2021 {published data only}
    1. Chaveles I, Papazachou O, Shamari MA, Delis D, Ntalianis A, Panagopoulou N, et al. Effects of exercise training on diastolic and systolic dysfunction in patients with chronic heart failure. World Journal of Cardiology 2021;13(9):514-25. [PMID: ] - PMC - PubMed
Chen 2017 {published data only}
    1. Chen DM, Yu WC, Hung HF, Tsai JC, Wu HY, Chiou AF. The effects of Baduanjin exercise on fatigue and quality of life in patients with heart failure: a randomized controlled trial. European Journal of Cardiovascular Nursing 2018;17(5):456-66. [PMID: ] - PubMed
Chinh 2019 {published data only}
    1. Redwine LS, Wilson K, Pung MA, Chinh K, Rutledge T, Mills PJ, Smith B. A randomized study examining the effects of mild-to-moderate group exercises on cardiovascular, physical, and psychological well-being in patients with heart failure. Journal of Cardiopulmonary Rehabilitation and Prevention 2019;39(6):403-8. [PMID: ] - PMC - PubMed
Davis 2018 {published data only}
    1. Luberto CM, Coey CA, Davis RB, Wayne PM, Crute S, Yeh GY. Exploring correlates of improved depressionsymptoms and quality of life following tai chi exercisefor patients with heart failure. ESC Heart Failure 2020;7(6):4206-12. [DOI: 10.1002/ehf2.13046] - DOI - PMC - PubMed
Deka 2019 {published data only}
    1. Deka P, Pozehl B, Williams MA, Norman JF, Khazanchi D, Pathak D. MOVE-HF: an internet-based pilot study to improve adherence to exercise in patients with heart failure. European Journal of Cardiovascular Nursing 2019;18(2):122-31. [PMID: ] - PubMed
Delgado 2020 {published data only}
    1. Delgado BM, Lopes I, Gomes B, Novo A. Early rehabilitation in cardiology – heart failure: The ERIC-HF protocol, a novel intervention to decompensated heart failure patients rehabilitation. European Journal of Cardiovascular Nursing 2020;19(7):592–9. [DOI: ] - PubMed
Deng 2020 {published data only}
    1. Deng H. One-dimensional nanomaterials on prognosis and sports rehabilitation of elderly patients with chronic heart failure. Ferroelectrics 2021;580(1):298-301. [DOI: ]
Galenko 2018a {published data only}
    1. Galenko VL, Lelyavina TA, Sitnikova MY. P2178 Non-response predictors to physical rehabilitation in heart failure patients. European Journal of Heart Failure 2018;20 Suppl 1:582.
Galenko 2018b {published data only}
    1. Galenko VL, Lelyavina TA, Sitnikova MY. P2180 Physical rehabilitation efficiency in heart failure patients. European Journal of Heart Failure 2018;20 Suppl 1:583. [DOI: 10.1002/ejhf.1197] - DOI
Gary 2020 {published data only}
    1. Gary R, Dunbar SB, Higgins M, Butts B, Corwin E, Hepburn K, et al. An intervention to improve physical function and caregiver perceptions in family caregivers of persons with heart failure. Journal of Applied Gerontology 2020;39(2):181-91. [PMID: ] - PMC - PubMed
Gasser 2021 {published data only}
    1. Gasser B, Boesing M, Schoch R, Brighenti-Zogg S, Kröpfl J, Thesenvitz E, et al. High-intensity interval training for heart failure patients with preserved ejection fraction (HIT-HF)-rational and design of a prospective, randomized, controlled trial. Frontiers in Physiology 2021;12:734111. [PMID: ] - PMC - PubMed
Gevaert 2021 {published data only}
    1. Gevaert AB, Witvrouwen I, Van Craenenbroeck AH, Van Laere SJ, Boen JR, Van de Heyning CM, et al. miR-181c level predicts response to exercise training in patients with heart failure and preserved ejection fraction: an analysis of the OptimEx-Clin trial. European Journal of Preventive Cardiology 2021;28(15):1722-33. [PMID: ] - PubMed
Guimaraes 2018 {published data only}
    1. Guimaraes GV, Alves LS, Sara MG, Chizzola PR, Castro RE, Bocchi EA. P6236 Permanent atrial fibrillation in heart failure: impact of exercise training on biomarkers. A randomized controlled trial. European Heart Journal 2018;39 Suppl 1:2018.
Guimaraes 2021 {published data only}
    1. Guimarães GV, Ribeiro F, Castro RE, Roque JM, Machado ADT, Antunes-Correa LM, et al. Effects of the exercise training on skeletal muscle oxygen consumption in heart failure patients with reduced ejection fraction. International Journal of Cardiology 2021;343:73-9. [PMID: ] - PubMed
Guo 2018 {published data only}
    1. Guo D. Improvement of cardiac function and quality of life in elderly patients with chronic heart failure by exercise rehabilitation. Journal of the American Geriatrics Society 2018;66:S511. [DOI: 10.1111/jgs.15550] - DOI
Halle 2018 {published data only}
    1. Halle M, Prescott E, Linke A, Ellingsen Ø. Exercise training of different intensities in heart failure with ischemic and non-ischemic etiology -results from the smartex trial. Circulation 2018;138 Suppl 1:A12099.
Hearon 2020 {published data only}
    1. Hearon CM Jr, Dias KA, Samels M, Morris M, Palmer D, Livingston SA, et al. Effects of 1-year of high intensity interval training and omega-3 fatty acid supplementation in stage A HFpEF: A randomized controlled trial. Circulation 2020;142 Suppl 3:A14518.
Hieda 2019 {published data only}
    1. Hieda M, Hearon CM Jr, Dias KA, Rakushumimarika H, Yogamaya M, MacNamara JP, et al. Effect of stage B HFpEF on diastolic peak filling rates in obese individuals, and the impact of 1 year of exercise training. Circulation 2019;140 Suppl 1:A10958. [DOI: 10.1161/circ.140.suppl_1.10958] - DOI
Hooglugt 2018 {published data only}
    1. Hooglugt JQ, Van Dissel AC, De Haan FH, Blok IM, Jorstad HR, Mulder BJ, et al. Efficacy and compliance of long-term, individualised exercise training in adults with congenital heart disease and heart failure symptoms: a randomized controlled trial. European Heart Journal 2018;39:245. [DOI: 10.1093/eurheartj/ehy565.P1240] - DOI
Hu 2021 {published data only}
    1. Hu T, Xiong H, Zhou H, Song Y, Zhang Z, Wan J, et al. Effect of acupoint meridian therapeutic exercise on cardiac function in patients with chronic heart failure. Acupuncture & Electro-Therapeutics Research 2021;46(3):177-89. [DOI: ]
Hua 2019 {published data only}
    1. Yin H, Tan C, Li X, Wang J, Wu Z. Effects of continuous weight intervention on cardiac function and quality of life in chronic congestive heart failure. Chinese Nursing Research 2019;33(6):911-6. [DOI: 10.12102/j.issn.1009-6493.2019.06.001] - DOI
Jin 2016 {published data only}
    1. Jin H, Lee H. The effects of reinforced walking exercise on dyspnea-fatigue symptoms, daily activities, walking ability, and health related quality of life in heart failure patients. Korean Journal of Adult Nursing 2016;28(3):266-78. [DOI: ]
Jones 2019 {published data only}
    1. Jones AV, Evans RA, Esliger DW, Sherar LB, Singh SJ. Protocol for a feasibility trial to inform the development of a breathlessness rehabilitation programme for chronic obstructive pulmonary disease and chronic heart failure (the COHERE trial). BMJ Open 2019;16(9):e029387. [PMID: ] - PMC - PubMed
Karaman 2020 {published data only}
    1. Karaman E, Fadiloglu C, Yildirim Y, Zoghi M, Sahin YG, Aykar FS. The effects of an exercise empowerment programme for older patients with heart failure: a randomized controlled trial. International Journal of Caring Sciences 2020;13(3):1835.
Kim 2016 {published data only}
    1. Kim C, Choi HE, Lim YJ. The effect of cardiac rehabilitation exercise training on cardiopulmonary function in ischemic cardiomyopathy with reduced left ventricular ejection fraction. Annals of Rehabilitation Medicine 2016;40(4):647-56. [PMID: ] - PMC - PubMed
Lan 2020 {published data only}
    1. Lan NS, Lam K, Naylor LH, Green DJ, Minaee NS, Dias P, Maiorana AJ. The impact of distinct exercise training modalities on echocardiographic measurements in patients with heart failure with reduced ejection fraction. Journal of the American Society of Echocardiography 2020 ;33(2):148-56. [PMID: ] - PubMed
Li 2020 {published data only}
    1. Li J, Yang P, Fu D, Ye X, Zhang L, Chen G, et al. Effects of home-based cardiac exercise rehabilitation with remote electrocardiogram monitoring in patients with chronic heart failure: a study protocol for a randomised controlled trial. BMJ Open 2019;9:e023923. [PMID: ] - PMC - PubMed
Limpens 2021 {published data only}
    1. Limpens MA, Gürgöze MT, Lenzen MJ, Roest S, Voortman T, Kavousi M, et al. Heart failure and promotion of physical activity before and after cardiac rehabilitation (HF-aPProACH): a study protocol. ESC Heart Failure 2021;8(5):3621-7. [PMID: ] - PMC - PubMed
Mendes 2020 {published data only}
    1. Mendes Fde S, Sousa AS, Souza FC, Pinto VL, Silva PS, Saraiva RM, et al. Effect of physical exercise training in patients with Chagas heart disease: study protocol for a randomized controlled trial (PEACH study). Trials 2016;17:433. [PMID: ] - PMC - PubMed
Mudge 2011 {published data only}
    1. Mudge AM, Denaro CP, Scott AC, Atherton JJ, Meyers DE, Marwick TH, et al. Addition of supervised exercise training to a post-hospital disease management program for patients recently hospitalized with acute heart failure: the EJECTION-HF randomized phase 4 trial. JACC: Heart Failure 2018;6(2):143-52. - PubMed
    1. Mudge AM, Denaro CP, Scott AC, Atherton JJ, Meyers DE, Marwick TH, et al. Exercise training in recently hospitalized heart failure patients enrolled in a disease management programme: design of the EJECTION-HF randomized controlled trial. European Journal of Heart Failure 2011;13:1370-5. - PubMed
Mudge 2018 {published data only}
    1. Mudge AM, Denaro CP, Scott AC, Meyers D, Adsett JA, Mullins RW, et al. Addition of supervised exercise training to a post-hospital disease management program for patients recently hospitalized with acute heart failure: The EJECTION-HF Randomized Phase 4 Trial. JACC Heart Failure 2018;6(2):143-52. [PMID: ] - PubMed
Murad 2019 {published data only}
    1. Murad S, Siddiqi FA, Tariq MI, Butt MW. Effects of cardiovascular conditioning exercises on quality of life in patients with dilated ardiomyopathy in Pakistan. Journal of Ayub Medical College Abbottabad 2019;31:S651-5. [PMID: ] - PubMed
Nakaya 2021 {published data only}
    1. Nakaya Y, Akamatsu M, Ogimoto A, Kitaoka H. Early cardiac rehabilitation for acute decompensated heart failure safely improves physical function (PEARL study): a randomized controlled trial. European Journal of Physics 2021;57(6):985-93. [PMID: ] - PubMed
Ngengo 2020 {published data only}
    1. Ngeno GT, Barasa FA, Kwobah E, Kamano J, Vedanthan R, Knettel B, et al. Outcomes of a randomized controlled trial of integrated cardiac rehabilitation among heart failure patients in Kenya. Circulation 2020;142:A16597. [DOI: ]
Norman 2020 {published data only}
    1. Norman JF, Kupzyk KA, Artinian NT, Keteyian SJ, Alonso WS, Bills SE, et al. The influence of the HEART Camp intervention on physical function, health-related quality of life, depression, anxiety and fatigue in patients with heart failure. European Journal of Cardiovascular Nursing 2020;19(1):64-73. [PMID: ] - PMC - PubMed
Omidi 2020 {published data only}
    1. Omidi S, Delavar SH, Amiripour A, Heydarpoor B. Effects of eight weeks of aerobic exercises on the cardiac function and inflammatory markers of male patients with heart failure after coronary artery bypass grafting. Journal of Kermanshah University of Medical Sciences 2020;24(1):e98429. [DOI: 10.5812/jkums.98429] - DOI
Orwelius 2020 {published data only}
    1. Orwelius L, Jaarsma T, Klompstra L, Thylen I, Stromberg A. Evaluate efficacy of tele-yoga on multiple outcomes after a period of critical illness. Intensive Care Medicine Experimental 2020;8 Suppl 2. [DOI: 10.1186/s40635-020-00354-8] - DOI
Papathanasiou 2017 {published data only}
    1. Papathanasiou J, Boyadjiev N, Dimitrova D, Kasnakova P, Tsakris Z, Tsekoura D, et al. The effect of group-based cardiac rehabilitation models on the quality of life and exercise capacity of patients with chronic heart failure. Hellenic Journal of Cardiology 2017;58(6):432-5. [PMID: ] - PubMed
Papathanasiou 2020 {published data only}
    1. Papathanasiou JV. Are the group-based interventions improving the functional exercise capacity and quality of life of frail subjects with chronic heart failure? Journal of Frailty, Sarcopenia and Falls 2020;5(4):102-8. [PMID: ] - PMC - PubMed
Pourhabib 2018 {published data only}
    1. Pourhabib A, Fotokian Z, Nasiri M, Abrotan S. Effects of a group-based aerobic and resistance exercise program on physiological-psychological adaptation in elderly with heart failure. Journal of Clinical Gerontology & Geriatrics 2018;9(1):59-66.
Pourhabib 2019 {published data only}
    1. Pourhabib A, Fotokian Z. Effects of aerobic and resistance exercise program on physical adaptation in the elderly men patients with heart failure. Journal of Shahid Sadoughi University of Medical Sciences 2019;27(7):0. [DOI: ]
Pozehl 2018 {published data only}
    1. Pozehl BJ, McGuire R, Duncan K, Kupzyk K, Norman J, Artinian NT, et al. Effects of the HEART Camp Trial on adherence to exercise in patients with heart failure. Journal of Cardiac Failure 2018;24(10):654-60. [PMID: ] - PMC - PubMed
Sayegh 2019 {published data only}
    1. Sayegh AL, Dos Santos MR, Rondon E, Oliveira P, Souza FR, Salemi VM, et al. Exercise rehabilitation improves cardiac volumes and functional capacity in patients with endomyocardial fibrosis: a randomized controlled trial. Journal of Cardiopulmonary Rehabilitation and Prevention 2019;39(6):373-80. [PMID: ] - PubMed
Scuffham 2019 {published data only}
    1. Maru S, Mudge AM, Suna JM, Scuffham PA. One-year cost-effectiveness of supervised center-based exercise training in addition to a post-discharge disease management program for patients recently hospitalized with acute heart failure: The EJECTION-HF study. Heart & Lung 2019;48(5):414-20. [PMID: ] - PubMed
Sengupta 2021 {published data only}
    1. Sengupta SP, Masram S, Sawarkar S, Okwose NC, Macgowan GA, Jakovljevic DG. Haemodynamic effects of a personalized, home-based physical activity intervention for heart failure with preserved ejection fraction. European Journal of Heart Failure 2021;23 Suppl 2:25-6. [DOI: 10.1002/ejhf.2297] - DOI
Sinikova 2019 {published data only}
    1. Леляϑина T, Sinikova M, Galenko V. Predictors of reverse myocardial remodeling in heart failure patients undergoing aerobic exercise, designed with individualized method based on lactate threshold definition. Chest 2019;155(6, Supplement):A340.
Smyrnova 2018 {published data only}
    1. Smyrnova G, Babkina T, Taradin G, Vatutin M. Influence of pulmonary rehabilitation on clinical characteristics in patients with chronic heart failure and chronic obstructive pulmonary disease. International Journal of Cardiovascular Sciences 2018;31(5):499-504. [DOI: 10.5935/2359-4802.20180051] - DOI
Song 2019 {published data only}
    1. Tsai E, Mouhayar E, Lenihan D, Song J, Durand JB, Fadol A, et al. Feasibility and outcomes of an exercise intervention for chemotherapy-induced heart failure. Journal of Cardiopulmonary Rehabilitation and Prevention 2019;39(3):199-203. [PMID: ] - PMC - PubMed
Spee 2020 {published data only}
    1. Spee RF, Niemeijer VM, Schoots T, Tuinenburg A, Houthuizen P, Wijn PF, et al. High intensity interval training after cardiac resynchronization therapy: an explorative randomized controlled trial. International Journal of Cardiology 2020;299:169-74. [PMID: ] - PubMed
Turri‐Silva 2021 {published data only}
    1. Turri-Silva N, Vale-Lira A, Verboven K, Quaglioti Durigan JL, Hansen D, Cipriano G Jr. High-intensity interval training versus progressive high-intensity circuit resistance training on endothelial function and cardiorespiratory fitness in heart failure: a preliminary randomized controlled trial. PLoS One 2021;16(10):e0257607. [PMID: ] - PMC - PubMed
Yu 2020 {published data only}
    1. Yu J, Wang M, Fang J, Lin Z. The effects of cardiac exercise rehabilitation training on the cardiopulmonary function and quality of life in patients with chronic stable heart failure. International Journal of Clinical and Experimental Medicine 2020;13(8):5983-90.
Zhang 2021 {published data only}
    1. Zhang ZY, Sun XG, Xi JN, Feng J, Sun XJ, Liu YL. The impacts of outpatient vs inpatient holistic management based on exercise training on cardiac rehabilitation efficacy among patients with chronic heart failure. Zhongguo Ying Yong Sheng Li Xue Za Zhi 2021;37(1):89-95. [PMID: ] - PubMed

References to ongoing studies

Bobenko 2019 {published data only}
    1. Bobenko A, Schoenrath F, Knierim JH, Friede T, Verheyen N, Mehra MR, et al. Exercise training in patients with a left ventricular assist device (Ex-VAD): rationale and design of a multicentre, prospective, assessor-blinded, randomized, controlled trial. European Journal of Heart Failure 2019;21(9):1152-59. [PMID: ] - PubMed
Koifman 2014 {published data only}
    1. Koifman E, Grossman E, Elis A, Dicker D, Koifman B, Mosseri M, et al. Multidisciplinary rehabilitation program in recently hospitalized patients with heart failure and preserved ejection fraction: rationale and design of a randomized controlled trial. American Heart Journal 2014;168(6):830-7. - PubMed
Vetrovsky 2017 {published data only}
    1. Vetrovsky T, Siranec M, Parenica J, Griva M, Stastny J, Precek J, et al. Effect of a 6-month pedometer-based walking intervention on functional capacity in patients with chronic heart failure with reduced (HFrEF) and with preserved (HFpEF) ejection fraction: study protocol for two multicenter randomized controlled trials. Journal of Translational Medicine 2017;15:153. - PMC - PubMed
Zuazagoitia 2010 {published data only}
    1. Zuazagoitia A, Grandes G, Torcal J, Lekuona I, Echevarria P, Gómez MA, et al. Rationale and design of a randomised controlled trial evaluating the effectiveness of an exercise program to improve the quality of life of patients with HF in primary care: the EFICAR study protocol. BMC Public Health 2010;10:33. - PMC - PubMed

Additional references

ACCF/AHA 2013
    1. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 2013;15:e147-239. - PubMed
AHA/ACC/HFSA 2022
    1. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022;145(18):e895–e1032. [DOI: ] - PubMed
Anker 2021
    1. Anker SD, Butler J, Filippatos G, Ferreira JP, Bocchi E, Böhm M, et al. EMPEROR-Preserved Trial Investigators. Empagliflozin in heart failure with a preserved ejection fraction. New England Journal of Medicine 2021;14:1451-61.
BACPR 2017
    1. British Association for Cardiovascular Prevention and Rehabilitation (BACPR). The BACPR standards and core components for cardiovascular disease prevention and rehabilitation, 3rd edition, 2017. http://www.bacpr.com/resources/6A7_BACR_Standards_and_Core_Components_20... (accessed 2 May 2018).
Belardinelli 1998
    1. Belardinelli R, Georgiou D, Ginzton L, Cianci G, Purcaro A. Effects of moderate exercise training on thallium uptake and contractile response to low-dose dobutamine of dysfunctional myocardium in patients with ischemic cardiomyopathy. Circulation 1998;97:553-61. - PubMed
Bjarnason‐Wehrens 2010
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