In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.

Exercise training as therapy for chronic heart failure

Heart failure (HF) is associated with undermining physical symptoms, resulting in a markedly decreased quality of life. Exercise intolerance, with pronounced fatigue and dyspnoea are key characteristics of the HF syndrome. Contra-intuitively at first sight, exercise training is one of the most efficacious ways to improve physical performance and quality of life, and to reduce morbidity and mortality. The recently launched 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure have incorporated a recommendation for regular aerobic exercise in patients with HF to improve functional capacity and symptoms and to reduce the risk of HF hospitalisation (Class I recommendation). However, there remains a considerable knowledge gap between these firm recommendations and the lack of practical guidelines on the prescription of exercise training. Either way, it is essential to tailor the prescribed exercise regimen to the patient’s HF phenotype and abilities, as well as to take their preferences into account.  Active measures should be taken to increase dissemination of efficacy, safety and practical modalities for exercise training in HF to cardiologists, physiotherapists, regulatory organisations and patients. In such a way, more patients, including the elderly and frail HF patients, will find their way to cardiac rehabilitation centres.

Heart Failure


More than 14 million Europeans suffer from heart failure (HF). Despite significant improvements in the treatment of HF, morbidity and mortality remain unacceptably high [1]. In addition, the costs for HF care approach 2% of the healthcare expenditure in Western Europe. One of the hallmarks of HF is severe exercise intolerance with pronounced fatigue and dyspnoea, even at low workloads, resulting in a markedly decreased quality of life. However, the severity of exercise limitation in HF is not correlated to the extent of cardiac dysfunction alone. Peripheral disturbances such as impaired vasoreactivity, impaired skeletal muscle energy metabolism and functional iron deficiency are as important as cardiac function to determine exercise capacity [2].

Because exercise training tackles both central and peripheral disturbances, it is an attractive therapy from a pathophysiological point of view. Indeed, 25 years of research have demonstrated the numerous physiologic, musculoskeletal and psychosocial benefits of exercise training. These benefits are clinically translated into improved exercise capacity, improved quality of life and improved outcome in patients with HF. This article provides general information on the clinical evidence of exercise training in HF and includes practical advice on how to prescribe exercise to HF patients.

Benefits of exercise training

In contrast to the former belief, exercise training in HF patients has proven to be safe and has no adverse effect on left ventricular remodelling [3].

Exercise capacity and quality of life

With regard to benefit on exercise capacity, a meta-analysis of 29 randomised controlled trials (RCT) including 848 patients revealed a mean improvement of VO2peak of 2.16 ml/kg/min [4].  Although modest in absolute terms, this means an increase of 13% which translates into a considerably better quality of life [5]. VO2peak is a strong and independent prognosticator in HF, and even small changes in VO2peak are associated with significantly improved outcomes [6]. In addition to VO2peak, exercise training has positive effects on health-related quality of life. A meta-analysis of 13 RCT demonstrated that exercise training results in a clinically important improvement in the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) (mean difference: -5.8 points) [3].  

Hospitalisations and mortality

The HF-ACTION trial randomised 2,331 patients (median age 59 yrs, 27-30% women) suffering from HF with reduced ejection fraction (HFrEF) either to three months of supervised aerobic exercise training at moderate intensity (three days/week, exercise capacity at 60-70% of heart rate reserve) or to usual care [7]. This study showed in an intention-to-treat analysis that exercise training was associated with an 11% lower adjusted risk for all-cause mortality or all-cause hospitalisation and a 15% lower adjusted risk for cardiovascular mortality or HF hospitalisation.

The most recent Cochrane review of exercise training included 33 trials with 4,740 patients with HF (mainly HFrEF) with the HF-ACTION trial contributing approximately 50% [3]. There was a trend towards a reduction in mortality with exercise in trials with >1 year of follow-up. Exercise training, when compared to usual care alone, reduced the rate of overall (25%) and HF-specific hospitalisation (39%).

Indications and contraindications

The 2016 European Society of Cardiology heart failure guidelines [8] firmly recommend that:

  • Regular aerobic exercise is encouraged in patients with HF to improve functional capacity and symptoms (Class I indication, level of evidence A); and
  • Regular aerobic exercise is encouraged in patients with HF to reduce the risk of HF hospitalisation (Class I indication, level of evidence A).

Contraindications for participation in an exercise training programme are listed in Table 1 [9].


Table 1. Contraindications for exercise training in HF.



Early after acute coronary syndrome (2 days)

Acute systemic illness, fever

Untreated life-threatening cardiac arrhythmias

Uncontrolled diabetes mellitus or thyroid dysfunction

Acute heart failure

Severe COPD

High degree atrioventricular block

Cerebrovascular or musculoskeletal disease preventing exercise testing or training

Acute myocarditis and pericarditis


Symptomatic aortic stenosis


Severe hypertrophic obstructive cardiomyopathy


Intracardiac thrombus


Progressive worsening of heart failure symptoms in previous 3-5 days, NYHA Class IV


Significant myocardial ischaemia or arrhythmia during low-intensity exercise



Exercise prescription

  • It is mandatory that (sub)maximal exercise capacity is measured with a symptom-limited cardiopulmonary exercise test (CPET). A CPET will give information on the degree of cardiac impairment and will objectively measure VO2peak and other prognostic factors (VE/VCO2slope, oscillatory ventilation). Based on the results of CPET, one can
    • Determine training intensity and perform training adjustments
    • Determine risk and prognosis
    • Re-test after exercise training programme to objectify improvement in exercise capacity
  • A universal agreement on the best training modality in heart failure does not exist. Rather, an individualised approach is recommended, based on clinical evaluation and personal preferences. Training protocols vary in a number of ways: intensity (aerobic and anaerobic), type (endurance, resistance) and method (continuous and interval).
    • Continuous endurance training is the best described form of exercise training and, because of its well-demonstrated efficacy and safety, is highly recommended in the guidelines. It is characterised by a moderate-to-high exercise intensity at steady-state condition of aerobic energetic yield, allowing the patient to perform prolonged training sessions (45-60 min duration). The exercise is usually performed on a bicycle or treadmill.
    • Interval training is characterised by short bouts (10-30 sec) of moderate-to-high intensity (50-100% VO2peak), with a recovery phase performed at low or no workload. High intensity interval training (HIIT) was studied in the SMARTEX trial [10]. In this study, patients performed 4x4 min bouts of high-intensity exercise (90-95% VO2peak), interspersed with 4 min recovery periods at low intensity. The authors showed that HIIT was not superior to moderate continuous training in changing aerobic capacity or left ventricular remodelling. As such, HIIT is a valuable option in selected HFrEF patients.
    • Resistance/strength training has been proposed to prevent the wasting syndrome and to incorporate upper body exercise, which is important to complete daily life tasks. It is important to prescribe dynamic resistive exercise training of small muscle groups and to avoid Valsalva manoeuvres.
  • Setting: it is recommended to initiate exercise training in a structured, supervised, centre-based programme. This can be either in-hospital or in a specialised private facility, as long as close supervision and direct monitoring of heart rate and blood pressure are available, especially when HF symptoms are severe. Most centre-based programmes offer an eight to 12-week training programme. Thereafter, a gradual transition to a home-based programme - with or without telemonitoring tools - is encouraged, stimulating the patient to remain active for a longer time period and to adhere to the exercise training.
  • To increase long-term adherence to exercise training, the patient’s preferences should be taken into account [11].

The main characteristics of the most frequently applied training schemes in HF are shown in Table 2.


Table 2. Main characteristics of the most frequently applied training schemes in HF.

Training schemes




Optimal intensity


Continuous endurance training


Intensity 40-50% VO2peak until exercise duration of 10-15 minutes is achieved

Increase  gradually to  intensity 50-70-80% VO2peak.

Then increase session duration to 15-20-30 minutes

RPE <15.

Session duration: 45-60 min

3-5 sessions/week

Interval endurance training


Start low intensity, e.g., 50% of VO2peak during 10 sec, for 5-10 min

Increase gradually the duration of the high-intensity interval (10-30 sec), and then increase the intensity (60-100%). Session duration: 15-30 min

RPE <15

3 sessions/week

Resistance training

Muscle mass

Intensity <30% 1-RM.

Repetitions: 5-10

Intensity: 30-50% 1-RM.

Repetitions: 15-25

Intensity 40-60% 1-RM.

Repetitions: 8-15

2-3 sessions/week


Patients with ICD and CRT devices

Special heart failure populations

The potential benefits of exercise training after ICD implantation include acquaintance with device settings, instruction about physical activity (including arm movements), psychological support and improvement of exercise capacity. One single-centre study showed that exercise training on top of CRT doubled the improvement in exercise capacity and further improved haemodynamic measures and quality of life [12].

ICD and CRT-D patients should start exercise training under medical supervision and monitoring of heart rate. Exercise level and ICD programming should be adapted to keep the maximal heart rate 20 beats below the ICD intervention zone. The following patient information should be readily available to reduce the risk of incidents: 1) underlying heart disease and indication of ICD implantation; 2) triggers for arrhythmia (e.g., ischaemia) and the arrhythmic substrate; 3) the ICD intervention heart rate; 4) the tachy-therapy that will be delivered.

Heart failure with preserved ejection fraction (HFpEF)

So far, only small single-centre trials have been performed in which exercise training has been evaluated as treatment for HFpEF. From a recent meta-analysis of eight intervention trials of exercise training in HFpEF [13], we learn that endurance training, either alone or in combination with strength training, has several benefits, including improvements in exercise capacity, as measured objectively by VO2peak [14], quality of life [15] and diastolic dysfunction [16].  


It is worrying that women with HF are severely underrepresented in exercise intervention trials. Only four RCT (a total of 84 women), with the most recent study dating from 2005 [17], have specifically studied the efficacy of exercise training on health-related outcomes in women. Despite the low sample, and the single-centre design of these trials, the data indicate that aerobic exercise training and strength training significantly improve VO2peak, health-related quality of life and muscle strength, similarly to men. When it comes to hard endpoints, the sub-analysis of the HF-ACTION trial - stratified according to sex - is of particular interest [18]. Aerobic training was associated with a 26% reduction in the combined endpoint in women (n=290 in exercise group), whereas there was no decrease in men (n=682 in exercise group).

This subanalysis provides proof of concept that women, although they achieved lower VO2peak at baseline and their training adherence was lower compared to men, may benefit even more from exercise training than men with regard to outcome.

Future directions

A joint effort from clinicians and researchers should be made to achieve the following goals in the future:

  • Aim to enhance long-term maintenance of exercise training for HF, e.g., by home-based cardiac rehabilitation and telemonitoring-assisted programmes.
  • Aim to improve adherence to exercise training, e.g., by defining causes for non-adherence, development of motivational tools, design of personalised training programmes.
  • Aim to “fit” the training programme to the patient’s phenotype, with patient variables including age, gender, comorbidities, type of HF. Ideally, a biomarker that would distinguish responders from non-responders to exercise training could guide in this personalised approach.
  • Aim to increase dissemination of efficacy of exercise training in HF to cardiologists, physiotherapists, regulatory organisations and patients. According to the ExtraHF survey, non-implementation of an exercise training programme was, in 20% of the centres, due to scientific underestimation of the utility and safety of exercise training [19].


  • Exercise training is an evidence-based adjunct treatment modality for patients with heart failure.
  • The benefits of exercise training entail both central and peripheral adaptations and are clinically translated into anti-remodelling effects, increased exercise capacity and reduced morbidity and mortality.
  • Cardiopulmonary exercise testing is mandatory to objectify exercise capacity objectively and to define training intensity.
  • Ideally, a patient-tailored exercise training programme is prescribed instead of a “one size fits all” approach.
  • Increasing long-term adherence and reaching the frailest patients are challenging goals for future initiatives in the field.


  1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P; Authors/Task Force Members. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016 Jul 14;37(27):2129-200. 
  2. Conraads VM, Van Craenenbroeck EM, De Maeyer C, Van Berendoncks AM, Beckers PJ, Vrints CJ. Unraveling new mechanisms of exercise intolerance in chronic heart failure: role of exercise training. Heart Fail Rev. 2013 Jan;18(1):65-77. 
  3. Taylor RS, Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal H, Lough F, Rees K, Singh S. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014 Apr 27;(4):CD003331. 
  4. Rees K, Taylor RS, Singh S, Coats AJ, Ebrahim S. Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev. 2004;(3):CD003331.
  5. van Tol BA, Huijsmans RJ, Kroon DW, Schothorst M, Kwakkel G. Effects of exercise training on cardiac performance, exercise capacity and quality of life in patients with heart failure: a meta-analysis. Eur J Heart Fail. 2006 Dec;8(8):841-50. 
  6. Swank AM, Horton J, Fleg JL, Fonarow GC, Keteyian S, Goldberg L, Wolfel G, Handberg EM, Bensimhon D, Illiou MC, Vest M, Ewald G, Blackburn G, Leifer E, Cooper L, Kraus WE; HF-ACTION Investigators. Modest increase in peak VO2 is related to better clinical outcomes in chronic heart failure patients: results from heart failure and a controlled trial to investigate outcomes of exercise training. Circ Heart Fail. 2012 Sep 1;5(5):579–85. 
  7. O'Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, Leifer ES, Kraus WE, Kitzman DW, Blumenthal JA, Rendall DS, Miller NH, Fleg JL, Schulman KA, McKelvie RS, Zannad F, Piña IL; HF-ACTION Investigators. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009 Apr 8;301(14):1439-50.
  8. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P; Authors/Task Force Members; Document Reviewers. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016 Aug;18(8):891-975. 
  9. Piepoli MF, Conraads V, Corrà U, Dickstein K, Francis DP, Jaarsma T, McMurray J, Pieske B, Piotrowicz E, Schmid JP, Anker SD, Solal AC, Filippatos GS, Hoes AW, Gielen S, Giannuzzi P, Ponikowski PP. Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Heart Fail. 2011 Apr;13(4):347-57. 
  10. Støylen A, Conraads V, Halle M, Linke A, Prescott E, Ellingsen Ø. Controlled study of myocardial recovery after interval training in heart failure: SMARTEX-HF--rationale and design. Eur J Prev Cardiol. 2012 Aug;19(4):813-21. 
  11. Conraads VM, Deaton C, Piotrowicz E, Santaularia N, Tierney S, Piepoli MF, Pieske B, Schmid JP, Dickstein K, Ponikowski PP, Jaarsma T. Adherence of heart failure patients to exercise: barriers and possible solutions: a position statement of the Study Group on Exercise Training in Heart Failure of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2012 May;14(5):451-8. therapy in chronic heart failure: higher cardiac output does not acutely improve exercise performance: a pilot trial. Eur J Cardiovasc Prev Rehabil. 2008 Apr;15(2):197-202. 
  12. Van Thielen G, Paelinck BP, Beckers P, Paul B, Vrints CJ, Conraads VM. Rate response and cardiac resynchronisation therapy in chronic heart failure: higher cardiac output does not acutely improve exercise performance: a pilot trial. Eur J Cardiovasc Prev Rehabil. 2008 Apr;15(2):197-202.
  13. Chan E, Giallauria F, Vigorito C, Smart NA. Exercise training in heart failure patients with preserved ejection fraction: a systematic review and meta-analysis. Monaldi Arch Chest Dis. 2016 Oct 14;86(1-2):759. 
  14. Haykowsky MJ, Brubaker PH, Stewart KP, Morgan TM, Eggebeen J, Kitzman DW. Effect of endurance training on the determinants of peak exercise oxygen consumption in elderly patients with stable compensated heart failure and preserved ejection fraction. J Am Coll Cardiol. 2012 Jul 10;60(2):120-8. 
  15. Nolte K, Herrmann-Lingen C, Wachter R, Gelbrich G, Düngen HD, Duvinage A, Hoischen N, von Oehsen K, Schwarz S, Hasenfuss G, Halle M, Pieske B, Edelmann F. Effects of exercise training on different quality of life dimensions in heart failure with preserved ejection fraction: the Ex-DHF-P trial. Eur J Prev Cardiol. 2015 May;22(5):582-93. 
  16. Edelmann F, Gelbrich G, Düngen HD, Fröhling S, Wachter R, Stahrenberg R, Binder L, Töpper A, Lashki DJ, Schwarz S, Herrmann-Lingen C, Löffler M, Hasenfuss G, Halle M, Pieske B. Exercise training improves exercise capacity and diastolic function in patients with heart failure with preserved ejection fraction: results of the Ex-DHF (Exercise training in Diastolic Heart Failure) pilot study. J Am Coll Cardiol. 2011 Oct 18;58(17):1780-91. 
  17. Haykowsky M, Vonder Muhll I, Ezekowitz J, Armstrong P. Supervised exercise training improves aerobic capacity and muscle strength in older women with heart failure. Can J Cardiol. 2005 Dec;21(14):1277-80. 
  18. Piña IL, Bittner V, Clare RM, Swank A, Kao A, Safford R, Nigam A, Barnard D, Walsh MN, Ellis SJ, Keteyian SJ; HF-ACTION Investigators. Effects of exercise training on outcomes in women with heart failure: analysis of HF-ACTION (Heart Failure-A Controlled Trial Investigating Outcomes of Exercise TraiNing) by sex. JACC Heart Fail. 2014 Apr;2(2):180-6. 
  19. Piepoli MF, Binno S, Corrà U, Seferovic P, Conraads V, Jaarsma T, Schmid JP, Filippatos G, Ponikowski PP; Committee on Exercise Physiology & Training of the Heart Failure Association of the ESC. ExtraHF survey: the first European survey on implementation of exercise training in heart failure patients. Eur J Heart Fail. 2015 Jun;17(6):631-8.

Notes to editor


Emeline M. Van Craenenbroeck, MD, PhD

Cardiology Department, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium


Address for correspondence:

Prof Dr Emeline M. Van Craenenbroeck

Cardiology Department, Antwerp University Hospital, Wilrijkstraat 10

B-2650 Edegem, Belgium


Tel: +32 3 8214672


Conflict of interest

The author has no conflicts of interest to declare.


The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.