Impact of exercise on the 21^st century epidemic of heart failure

Heart failure (HF) poses a serious threat to public health in an aging population. HF with reduced ejection fraction (HFrEF) historically was the focus for developing prevention and management strategies, including exercise training in HFrEF patients. However, HF with preserved ejection fraction (HFpEF) is increasingly common among older adults. There are no well-established treatment options making its primary prevention critical. This article reviews the role of exercise in the prevention and management of HF. Selected published articles informed discussion of HF etiology, evidence for the role of exercise in HF, and the biologic mechanisms linking exercise with HF development and prognosis. HF is a complex syndromic condition that manifests with severe exercise intolerance. Several causes of HF-related exercise intolerance respond to exercise training and two randomized controlled exercise interventions in HFrEF patients have demonstrated safety and efficacy for improved physical work capacity, quality of life, and mortality endpoints in medically stable HF patients. At present, only epidemiological cohort data are available for HFpEF outcomes, but the data are generally consistent in supporting lower risk of HFpEF development with levels of lifestyle physical activity meeting recommended amounts. Clinical trial evidence is needed to support this observation in HFpEF. Exercise training is established as part of guideline directed treatment of HFrEF patients. Lifestyle physical activity at guideline recommended amounts appears to be associated with lower risk of developing both HFrEF and HFpEF. There has yet to be a definitive clinical trial on exercise training and HFpEF treatment.