In heart failure, the heart is no longer able to supply enough blood – and therefore enough oxygen and nutrients – to the body. Doctors distinguish between two types of heart failure, regardless of the cause: when the heart muscle can no longer pump hard enough, this is called heart failure with reduced ejection fraction: HFrEF. In contrast, about half of people with heart failure have preserved ejection fraction: HFpEF. This means that the relative ejection capacity of the heart is still within the normal range, but the heart cannot relax properly between heartbeats and therefore cannot receive blood well. HFpEF has similar symptoms and risks to HFrEF, but there are far fewer treatment options for this form of heart failure.
Impact of exercise on the syndrome and quality of life
How does targeted physical training affect the course of the syndrome and the patient’s quality of life? This question was investigated by a research team led by Professor Frank Edelmann (senior physician at the Clinic for Cardiology, Angiology and Intensive Care Medicine on the Virchow-Klinikum campus of the German Heart Centre at Charité (DHZC) and Professor of Cardiovascular Prevention), Professor Rolf Wachter (Professor of Clinical and Interventional Cardiology at Leipzig University and Deputy Director of the Department of Cardiology at the University of Leipzig Medical Center), Professor Burkert Pieske (Head of the Heart Failure Unit at the Department of Cardiology, University Medicine Rostock) and Professor Martin Halle (Medical Director of Preventive Sports Medicine and Sports Cardiology at the TUM University Hospital in Munich).
The Exercise Training in Diastolic Heart Failure (Ex-DHF) study, funded by the German Research Foundation (DFG), was conducted at eleven sites in Germany and Austria and included 322 patients with HFpEF who were randomised to receive either a one-year structured exercise programme or usual medical care. “This is the most comprehensive study on this topic in the world in terms of the number of people involved and the length of time over which it was conducted,” says Professor Frank Edelmann from the Charité in Berlin.
Structure of the training programme
The training programme consisted of a combination of endurance and resistance training, with participants exercising three times a week under supervision. Initially, the training consisted of 30 minutes of moderate cycling, which was gradually increased to 60 minutes over three months. After four weeks, resistance training for the large muscle groups was added. The patients trained for a total of one year.
Training success was primarily measured using the modified Packer score, which combines various parameters such as symptoms, resilience, hospitalisation and general well-being. The NYHA class and peak oxygen consumption (VO₂) were also recorded. The NYHA class categorises patients according to the severity of their heart failure. Peak oxygen consumption (VO₂) indicates how much oxygen the body can absorb during exercise.
The scientists have just published their findings in Nature Medicine, one of the world’s leading medical research journals. In summary, after one year of training, most patients did not show a significant improvement in the modified Packer score as a combination of different health parameters. However, there were significant improvements in two of the five components: peak oxygen consumption (VO₂) and NYHA class, indicating increased exercise tolerance and reduced symptoms.
Exercise as a valuable adjunct therapy
“The results of our study show that exercise training improves exercise tolerance but does not prevent hospitalisation for heart failure, at least within the first year,” concludes Professor Rolf Wachter, cardiologist at the University of Leipzig Medical Center. Professor Burkert Pieske, cardiologist at University Medicine Rostock, adds: “Based on these results, we can recommend structured exercise training to our patients with heart failure and preserved ejection fraction, as it is safe and improves performance and symptoms.” Over the course of the one-year study, only 48 per cent of patients in the exercise group exercised at least twice a week; this group had the greatest benefit in the study. “The study shows us very clearly where the problem lies with training interventions: we need to do a better job of ensuring that patients maintain their training over a longer period of time,” says Professor Martin Halle from the Technical University of Munich.
Original publication in Nature Medicine:
“Combined endurance and resistance exercise training in heart failure with preserved ejection fraction: a randomized controlled trial”, DOI: https://doi.org/10.1038/s41591-024-03342-7