The effect of exercise training and physiotherapy on diastolic function, exercise capacity and quality of life in patients with heart failure with preserved ejection fraction: a systematic review and meta-analysis

Background: Exercise and physiotherapy are accepted as an important contribution to the rehabilitation of patients with heart failure with preserved ejection fraction (HFpEF). But the previous results are unclear partly because of their limited power and small sample sizes. Aims: We aimed to understand better the effects of two exercise training interventions and two modalities of physiotherapies on exercise capacity, quality of life (QoL), and diastolic dysfunction in HFpEF patients. Methods: The Cochrane Library, EMBASE, and MEDLINE via PubMed were searched for randomized controlled trials from their inception to May 2021. The effect size was estimated as mean differences (MD) with 95% confidence intervals (CI). Results: A total of 14 articles on 13 trials were included in this meta-analysis with 673 HFpEF patients. The pooling revealed that peak oxygen uptake was improved by endurance training, functional electrical stimulation (FES), and inspiratory muscle training (IMT). Similar results were observed for a 6-minute walk test and QoL. A combination of endurance and resistance training (combined exercise) was beneficial to the ratio of peak early to late diastolic mitral inflow velocities (MD [95% CI]: –2.90 [–4.97, –0.83]; P = 0.006) and the early diastolic mitral annual velocity (MD [95% CI]: 1.40 [0.68, 2.12]; P = 0.006]. IMT improved the ventilation/carbon dioxide ratio slope (MD [95% CI]: –3.36 ml/kg/min [–6.17, –0.54]; P = 0.019]. Conclusions: FES and IMT improve functional capacity and QoL without a change in diastolic function in HFpEF patients, and the outcomes are similar to endurance training. Notably, combined exercise may improve diastolic function. Key words: diastolic function, exercise training, functional electrical stimulation, heart failure with preserved ejection fraction, inspiratory muscle training