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Exercise your heart - importance of physical activity in patients with HFpEF

By Marcus Dörr - EBTR Section

Risk Factors and Prevention

Sufficient physical activity (PA) represents a key component of a healthy lifestyle. The beneficial effects of PA are well know in healthy subjects while the impact on the outcome of patients with heart failure with preserved ejection fraction (HFpEF) still needs closer investigation. A recent publication of Hedge et al. makes a significant contribution to this research question by reporting very interesting findings from a post-hoc analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial [1]. Based on data from 1751 subjects they showed strong associations between self-reported PA at baseline and several outcomes. Thus, participants reporting a both poor and intermediate PA had a nearly two-fold higher risk of heart failure hospitalization (HR 1.93; CI, 1.16-3.22, and HR 1.84; CI, 1.02-3.31), a four-fold higher risk of CV mortality (HR 4.36; CI, 1.37-13.83, and HR 4.05; CI 1.17-14.04), and a two- to three-fold higher risk of all-cause mortality (HR 2.95; CI, 1.44-6.02, and HR 2.05; CI 0.90, 4.67) after adjustment for other confounding factors compared to those with ideal PA levels.

During the last years several smaller studies have demonstrated that exercise training improves cardiorespiratory fitness and increases quality of life in HFpEF patients [2-5], but evidence for beneficial effects on clinical outcomes such as hospitalization rates or mortality is still lacking. Although, the associations reported in this study are only of observational nature, they give very important and novel insights on the potential impact of PA in these type of patients. In face of still missing therapeutic interventions for patients for HFpEF, these data should give us optimism that lifestyle modifications with a focus on increased PA and/or exercise training might be a valuable option to improve the clinical outcome of patients with HFpEF. Furthermore, the findings of this study underline the need for additional trials that evaluate exercise training in more detail (i.e. regarding different types and intensities of exercise).

We are therefore especially looking forward to the findings of the Ex-DHF trial [6], that investigated whether a 12 month supervised exercise training can improve a composite outcome score (all-cause mortality, hospitalizations, NYHA functional class, global self-rated health, maximal exercise capacity, and diastolic function) in HFpEF patients. In total, 320 patients with stable HFpEF were randomized 1:1 to supervised exercise training in addition to usual care or to usual care alone for 12 months. The results of the Ex-DHF trial will be presented at the „Late-Breaking Clinical Trials 4“ hot line session on August 29th 2017 during the upcoming ESC congress in Barcelona.


Note: 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


Marcus Dörr commented on this article:

Physical Activity and Prognosis in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) Trial, Hegde S et al.

Circulation. 2017;CIRCULATIONAHA.117.028002

additional references:

1. Physical Activity and Prognosis in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) Trial. Hegde S, Claggett B, Shah AM, Lewis EF, Anand IS, Shah SJ, Sweitzer NK, Fang JC, Pitt B, Pfeffer MA, Solomon SD. Circulation. 2017 Jun 21. pii: CIRCULATIONAHA.117.028002. doi: 10.1161/CIRCULATIONAHA.117.028002. [Epub ahead of print]

2. Effect of Endurance Exercise Training on Endothelial Function and Arterial Stiffness in Older Patients With Heart Failure and Preserved Ejection Fraction: A Randomized, Controlled, Single-Blind Trial. Kitzman DW, Brubaker PH, Herrington DM, Morgan TM, Stewart KP, Hundley WG, Abdelhamed A, Haykowsky MJ. J Am Coll Cardiol. 2013;62:584– 592.

3. 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. Edelmann F, Gelbrich G, Düngen H-D, 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. J Am Coll Cardiol. 2011;58:1780–1791.

4. Exercise Training in Older Patients With Heart Failure and Preserved Ejection Fraction A Randomized, Controlled, Single-Blind Trial. Kitzman DW, Brubaker PH, Morgan TM, Stewart KP, Little WC. Circ Heart Fail. 2010;3:659–667.
5. Effects of exercise training for heart failure with preserved ejection fraction: A systematic review and meta-analysis of comparative studies. Taylor RS, Davies EJ, Dalal HM, Davis R, Doherty P, Cooper C, Holland DJ, Jolly K, Smart NA. Int J Cardiol. 2012;162:6–13.

6. Exercise training in Diastolic Heart Failure (Ex-DHF): rationale and design of a multicentre, prospective, randomized, controlled, parallel group trial. Edelmann F, Bobenko A, Gelbrich G, Hasenfuss G, Herrmann-Lingen C, Duvinage A, Schwarz S, Mende M, Prettin C, Trippel T, Lindhorst R, Morris D, Pieske-Kraigher E, Nolte K, Düngen HD, Wachter R, Halle M, Pieske B. Eur J Heart Fail. 2017 May 17. doi: 10.1002/ejhf.862. [Epub ahead of print]