A statement released by the American Heart Association (AHA) and the American College of Cardiology (ACC) advocates use of supervised exercise training in patients with heart failure with preserved ejection fraction (HFpEF), as well as coverage for these services by third party payers.

The authors hope to boost the stature of supervised exercise training (SET) in HFpEF among practitioners and show Medicare and insurers that it deserves reimbursement. Currently, they note, clinicians tend to recognize exercise as therapy more in heart failure with reduced ejection fraction (HFrEF). And Medicare covers exercise training within broader cardiac rehabilitation programs for patients with HFrEF but not HFpEF.

Yet exercise has been broadly effective in HFpEF clinical trials, as outlined in the document. And there are good mechanistic reasons to believe that patients with the disorder can gain as much or more from SET than those with HFrEF.

"The signals for improvement from exercise training, in symptoms and objective measures of exercise capacity, are considerably larger for HFpEF than for HFrEF," Dalane W. Kitzman, MD, Wake Forest University School of Medicine, Winston-Salem, North Carolina, told theheart.org | Medscape Cardiology.

So, it's a bit of a paradox that clinicians don't prescribe it as often in HFpEF, probably because of the lack of reimbursement but also from less "awareness" and understanding of the disease itself, he proposed.

Kitzman is senior author on the statement sponsored by the AHA and the ACC. It was published March 21 in the societies' flagship journals Circulation and the Journal of the American College of Cardiology. The statement was also endorsed by the Heart Failure Society of America, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the American Association of Heart Failure Nurses.  

Carefully Chosen Words

The statement makes its case in HFpEF specifically for SET rather than cardiac rehabilitation, the latter typically a comprehensive program that goes beyond exercise, Kitzman noted. And SET is closer to the exercise interventions used in the supportive HFpEF trials.

"Also, Medicare in recent years has approved something called 'supervised exercise training' for other disorders, such as peripheral artery disease." So, the document specifies SET "to be fully aligned with the evidence base," he said, as well as "align it with a type of treatment that Medicare has a precedent for approving for other disorders."

Data and Physiologic Basis

Core features of the AHA/ACC statement is its review of HFpEF exercise physiology, survey of randomized trials supporting SET in the disease, and characterization of exercise as an especially suitable pleiotropic therapy.

Increasingly, "HFpEF is now accepted as a systemic disorder that affects and impacts all organs," Kitzman observed. "With a systemic multiorgan disorder, it would make sense that a broad treatment like exercise might be just the right thing. We think that's the reason that its benefits are really quite large in magnitude."

The document notes that exercise seems "potentially well suited for the treatment of both the cardiac and, in particular, the extracardiac abnormalities that contribute to exercise intolerance in HFpEF."

Its effects in the disorder are "anti-inflammatory, rheological, lipid-lowering, antihypertensive, positive inotropic, positive lusitropic, negative chronotropic, vasodilation, diuretic, weight-reducing, hypoglycemic, hypnotic, and antidepressive," the statement notes. It achieves them via multiple pathways involving the heart, lungs, vasculature and, notably, the skeletal muscles.

"It's been widely overlooked that at least 50% of low exercise capacity and symptoms in HFpEF are due to skeletal muscle dysfunction," said Kitzman, an authority on exercise physiology in heart failure.

"But we've spent about 95% of our attention trying to modify and understand the cardiac component." Skeletal muscles, he said, "are not an innocent bystander. They're part of the problem. And that's why we should really spend more time focusing on them."

Kitzman discloses receiving consulting fees from Bayer, Medtronic, Corvia Medical, Boehringer Ingleheim, Keyto, Rivus, NovoNordisk, AstraZeneca, and Pfizer; holding stock in Gilead; and receiving grants to his institution from Bayer, NovoNordisk, AstraZeneca, Rivus, and Pfizer. Disclosures for the other authors are in the reports.

J Am Coll Cardiol. Published online March 21, 2023. Full Text

Circulation. Published online March 21, 2023. Full Text

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