Author + information
- Received December 11, 2019
- Revision received March 4, 2020
- Accepted March 5, 2020
- Published online July 27, 2020.
- Matthew Nayor, MD, MPHa,
- Nicholas E. Houstis, MD, PhDa,
- Mayooran Namasivayam, MBBS, PhDa,
- Jennifer Rouvina, NPb,
- Charles Hardin, MDb,
- Ravi V. Shah, MDa,
- Jennifer E. Ho, MDa,c,
- Rajeev Malhotra, MDa,c and
- Gregory D. Lewis, MDa,b,c,∗ (, )@GLewisCardiol
- aCardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- bPulmonary Critical Care Unit, Massachusetts General Hospital, Boston, Massachusetts
- cCardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Gregory D. Lewis, Heart Failure and Cardiac Transplantation Unit, Massachusetts General Hospital, Bigelow 800, 55 Fruit Street, Boston, Massachusetts 02114.
• Exercise intolerance is a cardinal feature of HFpEF, whether or not patients are experiencing congestion while at rest.
• Cardiac and extracardiac reserve capacity impairments contribute to exertional intolerance in HFpEF.
• Exercise testing can identify and rank-order multiorgan system limitations responsible for a person’s exertional intolerance.
• Targeting specific physiological abnormalities underlying exercise intolerance in HFpEF may aid in identifying effective therapies.
Exercise intolerance is a principal feature of heart failure with preserved ejection fraction (HFpEF), whether or not there is evidence of congestion at rest. The degree of functional limitation observed in HFpEF is comparable to patients with advanced heart failure and reduced ejection fraction. Exercise intolerance in HFpEF is characterized by impairments in the physiological reserve capacity of multiple organ systems, but the relative cardiac and extracardiac deficits vary among individuals. Detailed measurements made during exercise are necessary to identify and rank-order the multiorgan system limitations in reserve capacity that culminate in exertional intolerance in a given person. We use a case-based approach to comprehensively review mechanisms of exercise intolerance and optimal approaches to evaluate exercise capacity in HFpEF. We also summarize recent and ongoing trials of novel devices, drugs, and behavioral interventions that aim to improve specific exercise measures such as peak oxygen uptake, 6-min walk distance, heart rate, and hemodynamic profiles in HFpEF. Evaluation during the clinically relevant physiological perturbation of exercise holds promise to improve the precision with which HFpEF is defined and therapeutically targeted.
Dr. Nayor is supported by National Institutes of Health grant K23-HL138260. Dr. Lewis is supported by grants 1R01HL131029 from the National Heart, Lung, and Blood Institute and 15GPSGC24800006 from the American Heart Association. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Heart Failure author instructions page.
- Received December 11, 2019.
- Revision received March 4, 2020.
- Accepted March 5, 2020.
- 2020 American College of Cardiology Foundation
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