Impact of different exercise training modalities on patient-reported outcomes in heart failure with reduced and preserved ejection fraction

Background

Exercise training improves exercise capacity in heart failure (HF), but effects on patient-reported outcomes remain less clear.

Purpose

In this randomized controlled trial, patients with heart failure with reduced (HFrEF) or preserved ejection fraction (HFpEF) were assigned to supervised high-intensity interval training (HIIT) or moderate-intensity continuous training (MCT). The primary outcome was change in Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OSS) at 3 months and 1 year. Prespecified subgroup analyses were conducted according to ejection fraction phenotype and sex.

Methods

We performed a pooled analysis of two randomised controlled trials. SMARTEX-HF enrolled HFrEF-patients with left ventricular ejection fraction (LVEF) ≤35% on optimal HF therapy; OptimEx-CLIN included HFpEF patients with LVEF ≥50% and increased left ventricular filling pressure (E/e′ 8–15 with elevated natriuretic peptides, or E/e′ >15). Both trials compared HIIT, MICT and standard care. Changes in KCCQ-OSS from baseline to 3 months and 1 year were analysed using linear mixed models.

Results

In total, 367 patients were analysed at 3 months (210 HFrEF: mean age 61 years, 19% women, mean LVEF 28%; 157 HFpEF: mean age 67 years, 70% women, mean LVEF 62%). KCCQ-OSS improved modestly across all groups, without differences in change over time between training modalities (p for time*group=0.53). HFrEF patients had higher overall KCCQ-OSS values than HFpEF (p=0.0006), and men had higher scores than women (p=0.002). Although greater improvements over time were observed in women and in patients with HFpEF, these differences were not statistically significant (p for time*HF type=0.11 and p time*sex=0.10).

At 1 year, 337 patients were available for analysis (194 HFrEF, 143 HFpEF). KCCQ-OSS increased modestly across all groups at 1 year, again without differences in change between exercise modalities (p for time*group=0.82). Overall scores were higher in HFrEF than in HFpEF (p for HF type=0.02), and the change over time differed significantly between HF types (p for time*HF type=0.005), with a greater improvement observed in HFpEF. Men had higher overall scores than women (p=0.005). While women showed greater changes over time compared with men, this difference did not reach statistical significance (p for time*sex=0.07). Also, in HFpEF and in women, the change in KCCQ-OSS did not differ significantly between training groups and controls (p>0.05). Changes in KCCQ clinical summary score (KCCQ-CSS) did not differ significantly according to sex or HF type. Detailed results are summarized in Figure 1.

Conclusion

KCCQ-OSS improved modestly over time in all patients with HF. Meaningful and sustained long-term improvements were larger in HFpEF than HFrEF but did not differ significantly between controls and training modalities.Figure_ESCCongres2026_FD