AHA: Exercise can benefit even the highest-risk patients

Clinical takeaway: High-risk populations should not be excluded from exercise training because of their diagnosis alone. Instead, clinicians should individualize programs with condition-specific modifications, emphasizing strength, balance, flexibility, and appropriate supervision in addition to aerobic training. Appropriately designed programs can improve fitness, function, quality of life, and, in some groups, reduce hospitalizations and mortality.

In this new American Heart Association scientific statement, experts review evidence supporting exercise training (ET) for patients traditionally considered challenging or high risk, including older adults with frailty, stroke survivors, patients with spinal cord injury, severe arthritis, cardiac implantable electronic devices (CIEDs), left ventricular assist devices (LVADs), heart transplantation, and inherited cardiomyopathies.

A central message is that these patients often have the lowest baseline cardiorespiratory fitness and the greatest barriers to participation, yet they may derive some of the largest relative benefits from structured exercise programs. Across populations, successful programs typically require adaptations such as slower progression, enhanced supervision, specialized equipment, and a greater focus on strength, balance, and flexibility training.

Among frail older adults, multicomponent programs emphasizing lower-extremity strength, balance, mobility, and endurance are recommended, often with protein-rich nutritional support. For stroke survivors, the statement supports regular aerobic exercise (20–60 minutes, 3–5 days weekly), resistance training, flexibility exercises, and neuromuscular training once medically stable.

For patients with CIEDs, supervised exercise is generally safe and improves fitness without increasing ICD shocks, hospitalizations, or mortality. The statement recommends maintaining exercise heart rate below device therapy thresholds and optimizing pacemaker rate-response settings when appropriate.

In advanced heart failure, exercise training and cardiac rehabilitation are supported for both LVAD recipients and heart transplant recipients. Heart transplant recipients may benefit from moderate-intensity exercise and strength training, and emerging evidence suggests high-intensity interval training can produce greater improvements in peak oxygen uptake after recovery.

For inherited cardiomyopathies, the authors note a shift away from blanket exercise restrictions. Moderate-intensity exercise appears safe for most patients with hypertrophic cardiomyopathy after appropriate evaluation, whereas vigorous exercise remains discouraged in arrhythmogenic cardiomyopathy because of increased arrhythmic risk and disease progression. Patients with long-QT syndrome may also be able to exercise safely when receiving optimal medical therapy, including beta-blockers and/or ICD protection when indicated.

“Functional and quality-of-life gains in response to appropriately designed exercise programs match or exceed those in more traditional populations,” the authors write, while emphasizing the need for broader access, referrals, and reimbursement for exercise-based rehabilitation services.

Source: Fleg JL, et al. (2026 July 9) Circulation. Exercise Training in High-Risk Populations: A Scientific Statement From the American Heart Association