What exercise regimen is recommended for maintaining good heart health in adults with or without pre-existing heart conditions?

Exercise Recommendations for Heart Health

Adults should engage in at least 150 minutes per week of moderate-intensity aerobic exercise or 75 minutes per week of vigorous-intensity aerobic exercise, combined with muscle-strengthening activities at least 2 days per week, to reduce cardiovascular disease risk and mortality. 1

Core Exercise Prescription for All Adults

Aerobic Exercise Requirements

• Minimum target: 150-300 minutes per week of moderate-intensity OR 75-150 minutes per week of vigorous-intensity aerobic activity 1
• Equivalent combinations of moderate and vigorous intensity are acceptable to meet weekly targets 1
• Exercise can be accumulated throughout the week in any pattern—even 1-2 sessions weekly meeting total volume targets reduces all-cause mortality (HR 0.66), cardiovascular mortality (HR 0.60), and cancer mortality (HR 0.83) 1
• Bouts of any duration count: Even activity lasting less than 10 minutes provides cardiovascular benefits, contradicting older recommendations requiring 10-minute minimum bouts 1

Resistance Training Requirements

• Frequency: At least 2-3 days per week targeting all major muscle groups 1
• Prescription: 1-3 sets of 8-12 repetitions at 60-80% of one-repetition maximum 1
• Resistance training improves glycemic control in diabetes, lowers blood pressure, and enhances physical functioning 1

Intensity Definitions for Practical Application

• Moderate intensity: 50-70% maximum heart rate, 3-6 METs, or perceived exertion 13-14 on Borg scale 1
• Vigorous intensity: >70% maximum heart rate, >6 METs, or perceived exertion ≥15 on Borg scale 1
• Moderate-intensity examples: Brisk walking, slow cycling, recreational swimming, dancing 2

Special Considerations for Pre-Existing Heart Conditions

Chronic Coronary Syndromes (Stable CAD)

• Exercise is therapy, not just prevention: Exercise training reduces hospitalizations, adverse cardiovascular events, and mortality in patients with established coronary disease 1
• Prescription follows FITT model: Frequency of 3-7 days/week at moderate to moderate-high intensity based on percentage of VO2max, percentage of maximum heart rate, or ventilatory thresholds 1
• Moderate-intensity continuous training is the most feasible and cost-effective modality for most patients with coronary disease 1
• High-intensity interval training can be prescribed in selected patients to specifically increase VO2 peak, though insufficient evidence exists to recommend it over moderate-intensity continuous training 1
• Resistance exercise (1-3 sets of 8-12 repetitions at 60-80% one-repetition maximum, 2-3 days/week) is associated with lower risks of total cardiovascular events and all-cause mortality when added to aerobic training 1

Hypertrophic Cardiomyopathy (HCM)

• Moderate-intensity exercise is safe and beneficial: Adults with HCM following moderate-intensity exercise prescriptions showed significant improvements in peak oxygen consumption and physical functioning without major adverse events or increased arrhythmias 1
• Target: 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity aerobic exercise weekly 1
• Supervised exercise initially warranted for patients with abnormal blood pressure response to exercise, history of exercise-triggered ventricular arrhythmias, or advanced heart failure 1
• Avoid Valsalva maneuver as it can acutely worsen left ventricular outflow obstruction 1
• Children with HCM can participate in physical education at school without being graded, timed, or scored for performance 1

Hypertension

• Moderate-intensity aerobic exercise: ≥150 minutes/week (30 minutes, 5-7 days/week) OR 75 minutes of vigorous exercise weekly over 3 days 1
• Add resistance training: Low- or moderate-intensity dynamic or isometric resistance training 2-3 times weekly provides additional blood pressure reduction 1
• Exercise can reduce medication requirements in patients whose blood pressure is responsive to antihypertensive effects of physical activity 1

Critical Safety Principles

Starting Exercise in Sedentary Individuals

• Initiate at lower intensity and duration: Sedentary individuals should begin with slow walking and progress gradually to recommended levels 1
• Gradual progression of exercise intensity and volume reduces cardiovascular risks 1

Upper Limits of Exercise

• No clear upper threshold for harm: The largest cohort (661,137 subjects) demonstrated mortality benefits up to 3-5 times current guidelines with no harm at levels 10+ times the recommended minimum 1
• Very high levels of physical activity (>10 times minimum) apply to only a small fraction of the population 1

Reducing Sedentary Behavior

• Decreasing sedentary time may reduce cardiovascular disease risk, even in physically active adults 1
• High levels of sedentary time are associated with increased risk for chronic diseases and mortality 1
• Intersperse frequent, short bouts of standing and physical activity between sedentary periods 1

Healthcare Provider Role

Counseling and Assessment

• Routine counseling in healthcare visits to optimize physically active lifestyle is a Class I recommendation 1
• Physical activity assessment during clinical visits using simple tools can be recorded in the electronic health record alongside weight and blood pressure 1
• Number needed to counsel: As low as 12 patients for one individual to achieve recommended physical activity levels 1

Patients Unable to Meet Minimum Targets

• Some activity is better than none: Even physical activity below 150 minutes weekly provides cardiovascular disease risk reduction 1
• Light-intensity physical activity, even as little as 15 minutes daily, produces benefits in inactive adults 1

Common Pitfalls to Avoid

• Do not require 10-minute minimum bouts: This outdated recommendation has been removed; activity of any duration counts toward weekly totals 1
• Do not prescribe fixed percentages of maximum heart rate universally: Individual variability in metabolic thresholds (ventilatory and lactate thresholds) means fixed percentages do not acknowledge individual boundaries 3
• Do not overlook resistance training: It provides independent cardiovascular benefits beyond aerobic exercise alone 1
• Do not discourage patients who cannot meet full targets: Partial adherence still provides substantial mortality reduction 1