What are the limitations on sitting, standing, or walking for a patient with Heart Failure with Reduced Ejection Fraction (HFrEF) and an ejection fraction of 31 percent?

Activity Limitations in HFrEF with 31% Ejection Fraction

Patients with HFrEF and an ejection fraction of 31% should NOT be restricted from sitting, standing, or walking—in fact, regular physical activity and exercise training are strongly recommended and safe to improve functional status, reduce hospitalizations, and potentially reduce mortality. 1

Evidence-Based Exercise Recommendations

Core Guideline Recommendations

Multiple international guidelines provide Class I, Level A recommendations for exercise training in HFrEF patients who are clinically stable:

• The AHA/ACC guidelines state that exercise training (or regular physical activity) is safe and effective for patients with HF who are able to participate to improve functional status (Class I, Level A). 1

• The European Society of Cardiology encourages regular aerobic exercise in patients with HF (Class I, Level A), with most evidence specifically from HFrEF patients. 1

• The Australian and New Zealand guidelines recommend regular moderate-intensity continuous exercise (breathing more quickly but able to hold a conversation) for patients with stable chronic HF, particularly those with reduced LVEF, to improve physical functioning, quality of life, and reduce hospitalizations (Strong recommendation, High quality evidence). 1

Specific Activity Guidance

For a patient with 31% ejection fraction who is clinically stable, the following activities are appropriate:

• Walking: Regular walking at moderate intensity is encouraged and beneficial. 1

• Standing: No specific restrictions on standing duration, though patients may experience fatigue or dyspnea with prolonged standing due to their underlying cardiac dysfunction. 2

• Sitting: No restrictions on sitting, though prolonged sedentary behavior should be avoided in favor of regular physical activity. 1

Critical Prerequisite: Clinical Stability

The key limitation is NOT the activity itself, but rather the patient's clinical stability status:

• Exercise training should only be offered to patients with stable chronic HF—those with unstable HF should not participate until stabilized. 1

• Clinical stability assessment should include evaluation for signs of congestion or inadequate perfusion, including dyspnea on exertion and decreased exercise tolerance. 1

• Patients should be assessed to ensure the exercise program is suitable before participation. 1

Structured Exercise Program Recommendations

Rather than restricting activity, patients should be referred to a supervised exercise training program:

• Cardiac rehabilitation with exercise training can improve functional capacity, exercise duration, health-related quality of life, and mortality in clinically stable HF patients (Class IIa, Level B). 1

• The ACC/AHA recommends that patients with HFrEF who have not participated in an exercise training program should be referred to outpatient cardiac rehabilitation. 1

• Programs should be personalized, exercise-based, and can be delivered at home, in the community, or in the hospital setting. 1

• The program should include psychological and educational components alongside the exercise training. 1

Expected Functional Limitations (Not Restrictions)

Patients with HFrEF at 31% ejection fraction commonly experience the following symptoms during physical activity, but these are targets for improvement through exercise training, not reasons to avoid activity:

• Difficulty walking up steep inclines, up steps, and long distances. 2
• Limited walking speed and difficulty standing for long periods. 2
• Dyspnea, tiredness/fatigue, and potentially peripheral edema during exertion. 2
• Reduced peak oxygen consumption (VO2) compared to healthy individuals. 1

These limitations improve with regular exercise training—they are not contraindications to activity. 1

Mechanisms of Benefit

Exercise training in HFrEF patients with ejection fractions like 31% provides multiple physiological benefits:

• Reverses cardiac remodeling with decreased LV dimensions and volumes after 6 months of training. 1
• Improves LV ejection fraction with long-term training interventions (at least 6 months). 1
• Increases peak exercise stroke volume and cardiac output. 1
• Improves skeletal muscle mitochondrial function, which is a major contributor to exercise intolerance in HFrEF. 1
• Enhances peripheral vascular function and oxygen utilization. 1

Common Pitfalls to Avoid

Do not confuse symptomatic limitations with activity restrictions:

• Patients may adapt to symptoms by taking rests, doing activities more slowly, or initially avoiding certain activities—this is expected and should be addressed through gradual exercise progression, not permanent restriction. 2

• The goal is to improve functional capacity through structured exercise, not to limit activity based on the ejection fraction number alone. 1

Do not delay exercise referral:

• Automatic referral systems with strong professional guidance significantly improve cardiac rehabilitation enrollment. 1
• Exercise training should be initiated as part of comprehensive guideline-directed medical therapy, which also includes SGLT2 inhibitors, ARNI/ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists. 3, 4

Contraindications (When to Restrict Activity)

Activity should be restricted or modified only in these specific circumstances:

• Acute decompensated heart failure with signs of congestion or hemodynamic instability—wait until clinical stabilization. 1
• Active myocarditis or pericarditis. 1
• Severe symptomatic aortic stenosis. 1
• Uncontrolled arrhythmias causing symptoms or hemodynamic compromise. 1
• Recent acute coronary syndrome (within 2 days). 1

Once these acute conditions resolve and the patient is stabilized, exercise training should be resumed. 1