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5.2.5 Heart failure with preserved ejection fraction Exercise-based cardiac rehabilitation programmes are a cornerstone in the holistic prevention and management of HFpEF.260,285 Exercise intervention for 1224 weeks increases functional capacity and quality of life.286292 The beneficial effects seem to be mediated by improvement in oxidative muscle metabolism and vascular function.293 In obese patients, weight reduction has been shown to have similar effects to exercise alone,288 therefore a stable weight reduction of 10% over 24 years is recommended.294

5.2.5.1 Exercise modalities and sports participation Higher endurance intensities such as HIIT (4  4 min at 8590% peak heart rate, with 3 min active recovery) have revealed positive effects on myocardial function, but data are limited to a small group of patients with diabetes.295 HIIT performed over 4 weeks significantly improved VO2peak and LV diastolic function.296 Higherintensity exercise should be limited to stable patients and could be gradually introduced after 4 weeks of MCE. Exercise sessions should start with short phases of 10 min of endurance and 10 min of resistance exercises, which should gradually be extended in time over a period of 4 weeks. The final aim should be at least 3045 min for >_3 days per week. Depending on the patient’s symptomatic status and functional capacity, intervals of higher intensity may be introduced. Duration of intervention seems to be important for inducing functional and structural CV changes in HFpEF. Interventions over 2 years in healthy individuals reversed early signs of diastolic dysfunction.297,298 Regarding sports participation refer to section 5.2.3. 5.2.6 Exercise in individuals after heart transplantation The exercise capacity in heart transplantation (HTx) recipients is reduced by 5060% compared with healthy age and sex-matched individuals in the general population,300302 due to several factors (Table 13).303 Exercise reduces CV risk induced by posttransplantation immunosuppressive medical therapy,304 and increases physical performance,305 enabling HTx patients to achieve levels comparable to age-matched controls.306 HTx recipients participating in exercise-based cardiac rehabilitation programmes reveal a favourable outcome with respect to hospital readmission and longterm survival.305,307,308

Improvements in exercise capacity are primarily dependent on the volume of exercise. Increased functional capacity is primarily due to peripheral adaptations in the skeletal muscle including increased oxidative capacity and capillary conductance. Cardiac allograft neural reinnervation also contributes to improved functional capacity in the first year.304,309,310 If these occur, training can be performed at high levels, enabling selected HTx patients to perform marathon runs or triathlons.304,309,310

5.2.6.1 Exercise modalities and sports participation A combination of endurance and resistance exercise is considered to be the preferred exercise programme. Mean endurance exercise intensity should start at a moderate intensity (60% VO2peak), which can later be increased to 80% of VO2peak, a regimen level applied in the majority of exercise intervention studies in HTx.305 In uncomplicated cases these intensities can be increased to maximum levels. It is recommended that individuals should perform up to five bouts of 30 min of exercise per week; however, exercise duration and frequency have ranged from 30 min to 90 min for 2 to 5 times per week, in previous HTx studies.305,311 Both endurance and resistance training is included in these training sessions; however, an additional 23 sessions of resistance training may be performed each week. Resistance exercise should focus on large muscle groups using own body weight exercises or exercises on weight machines. Upper body resistance exercise should start at least 3 months after surgery, and intensity should gradually increase from low to moderate but can

Non-competitive (low-intensity recreational skill-related sports) may be considered (when tolerated) in stable, optimally treated individuals with HFrEF. IIb C High-intensity power and endurance sports are not recommended in patients with HFrEF irrespective of symptoms. III C

HFmrEF = heart failure with mid-range ejection fraction; HFrEF = heart failure with reduced ejection fraction; NYHA = New York Heart Association. aClass of recommendation. bLevel of evidence.

Recommendations for exercise and participation in sport in individuals with heart failure with preserved ejection fraction

Recommendations Classa Levelb

Moderate endurance and dynamic resistance exercise, together with lifestyle intervention and optimal treatment of cardiovascular risk factors (i.e. arterial hypertension and type 2 diabetes) are recommended.287,289292,299 I C Competitive sports may be considered in selected stable patients without abnormalities on maximal exercise testing. IIb C

aClass of recommendation. bLevel of evidence. Refer also to the recommendation in section 5.2.5. Table 13 Factors influencing decreased exercise capacity (peak VO2) and reduced cardiac output in individuals with heart transplants

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