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. 2026 Mar 26;7:1800669. doi: 10.3389/fragi.2026.1800669

Effects of exercise training on frail older adults with heart failure: a systematic-review

C Sáez-Nieto 1,†, P Pérez-Rodríguez 2,†, P Matovelle 3, L Rodríguez-Mañas 4,5, H J Coelho-Júnior 6,7, I Rodríguez-Sánchez 8,9,10,*
PMCID: PMC13062297  PMID: 41969362

Abstract

Introduction and objectives

Heart failure (HF) is highly prevalent in older adults and is frequently associated with frailty, leading to increased morbidity, hospitalization, disability, and mortality. Exercise training (ET) has demonstrated benefits in HF and frailty separately, but its effects in frail older adults with HF have not been extensively evaluated. This systematic review aimed to synthesize the evidence on the effects of ET on health outcomes in frail older patients with HF.

Methods

A systematic review of interventional studies was conducted following PRISMA and Cochrane Handbook guidelines. MEDLINE (PubMed), SCOPUS, and Scielo were searched up to March 2026. Inclusion criteria were: (a) intervention studies involving frail adults aged ≥60 years with HF, (b) evaluation of chronic effects of ET on health outcomes, and (c) publication in English. Study selection and data extraction were performed independently by four reviewers, with a fifth reviewer resolving disagreements. Methodological quality of randomized controlled trials was assessed using the PEDro scale.

Results

Six investigations were included. Overall quality assessment results ranged from 4 to 7. Studies were conducted in Japan and the United States. All were randomized controlled trials with sample sizes ranging from 30 to 337 participants (mean age 72.5 years). Frailty was assessed using the Frailty Phenotype, Frailty Index, and Short Physical Performance Battery. ET interventions varied in duration and modality, and were mostly characterized by multicomponent (e.g., resistance, endurance, flexibility) exercise training protocols. Adverse events were infrequent; one study reported musculoskeletal pain in 25% of participants. ET significantly improved HF symptoms, frailty status, physical function (mobility, muscle strength, aerobic capacity), physical activity levels, quality of life, and depressive symptoms. Improvements in hemoglobin and cholesterol were also observed. Meta-analysis was not performed due to heterogeneity in interventions and outcome measures.

Conclusion

Cardiac rehabilitation programs based on ET protocols appear to improve clinical and functional outcomes in frail older adults with HF. However, evidence is limited by the small number of studies, variability in intervention protocols, and heterogeneity in outcome assessment. Further high-quality randomized trials are needed to confirm these findings and establish optimal ET strategies for this vulnerable population.

Keywords: cardiac rehabilitation, exercise training, frailty, heart failure, older adults, physical function, systematic review

1. Introduction

World Health Organization projections indicate that individuals aged 60+ years will reach nearly two billion people by 2050 worldwide, suppressing the young population. Although this demographic phenomenon represents decades of advances in medical care, the aging process is associated with the development of chronic conditions (e.g., cardiovascular diseases), which characterize an important challenge for health systems (James et al., 2018; Salomon et al., 2012). For instance, a significant reduction in physiological reserve accompanied by an increased vulnerability to stressors events is frequently observed in people with advanced age, a condition called frailt y (Fried et al., 2001).

Frailty is acknowledged as a geriatric syndrome that contributes to the development of diseases and increases the risk for many adverse outcomes, including falls, sarcopenia, hospitalization, disability, institutionalization, and death (Fried et al., 2001; Morley et al., 2013; Rodríguez-Mañas et al., 2013; Afilalo et al., 2014). Furthermore, several studies have shown that frailty represents a stronger predictor of these negative events than other well-established conditions (e.g., multimorbidity, sarcopenia) (Davies et al., 2022).

Another prevalent condition observed in people with advanced age is heart failure (HF) (Khan et al., 2024). Current estimations indicate that nearly 2 in each 10 old individuals have HF (Khan et al., 2024). These data are concerning, as HF is a major cause of poor quality of life, functional decline, hospitalization, and death among older people, reflecting in exacerbated healthcare costs (Khan et al., 2024; Darbà et al., 2025). Notably, numerous studies have found that HF commonly coexist with frailty (Denfeld et al., 2017).

Indeed, frailty is very common in older adults with HF, affecting nearly 80% of this population, according to individuals’ characteristics (Altimir et al., 2005; Lupón et al., 2008; McNallan et al., 2013; Denfeld et al., 2017). This relationship has serious health implications (Veronese et al., 2017; Yang et al., 2018; Prokopidis et al., 2025), with studies indicating numerous negative outcomes, including reducing exercise tolerance (Kato, 2013; Springer et al., 2017; Suzuki et al., 2018; Yin et al., 2019), increased risk of hospital admission (Chaudhry et al., 2010; Vidán et al., 2016), and death (Vidán et al., 2016; Yang et al., 2018). As such, the prompt implementation of therapeutic strategies to avoid the progression and harmful consequences of frailty among people with HF is mandatory to preserve the quality of life and independence of these individuals.

Exercise training (ET) is globally acknowledged as a first-line therapy to counteract frailty (Hoogendijk et al., 2019), with studies supporting its effectiveness in frail older adults from different contexts (Nagata et al., 2023; Yang et al., 2024). Similarly, ET is a cardinal strategy to contribute to the rehabilitation of HF patients. In fact, international organizations responsible for the care of HF patients have instructed the use of ET to maintain or even improve multiple health aspects in individuals with this condition. These recommendations are grounded in the numerous randomized controlled trials (RCT) that showed improvements in cardiac function (e.g., ejection fraction), physical performance, and quality of life, among other domains. Investigations have also examined the effects of ET on HF patients with frailty (Papathanasiou, 2020; Pandey et al., 2023). However, to the best of our knowledge, no systematic reviews have been conducted so far.

Based on these premises, the present study aimed at investigating the effects of ET on health-aspects of older adults with HF and frailty.

2. Methods

We conducted a systematic review of interventional studies to quantify the effects of ET on frail older adults with HF. The study was fully performed by investigators, and no librarian was part of the team. This study complies with the criteria of the Primary Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement (Liberati et al., 2009) and Cochrane Handbook for Systematic Reviews and Interventions (Green and Higgins, 2005). All data are available in the open Science Framework (https://osf.io/c25nj).

2.1. Eligibility criteria

The inclusion criteria of the present study consisted of: (a) investigations that studied the chronic effects (≥4 weeks) of ET protocols on any health parameter; (b) examined frail older adults with HF aged ≥60 years; (c) published studies in English language. Studies analyzing exclusive nutritional or pharmacological strategies were excluded. We also excluded studies examining multidomain strategies where ET was not the main intervention. No limitations were set regarding the frailty assessment tools used.

2.2. Search strategy and selection criteria

Studies published on or before March 2026 were retrieved by five investigators from MEDLINE (PubMed interface), SCOPUS, and SciELO. Reference lists for reviews and retrieved articles for additional studies were checked and citation searches in key articles were performed on Google Scholar and ResearchGate for additional reports. Initially, a search strategy was designed using keywords such as “exercise”, “frail older adults”, and “heart failure”. Additionally, keywords and subject headings were exhaustively combined using Boolean operators. Only eligible full texts in English and Spanish were considered for review.

2.3. Data extraction and quality assessment

Titles and abstracts of retrieved articles were screened for eligibility by four researchers. Full-text articles were retrieved when abstracts did not provide sufficient information for evaluation. Four reviewers independently extracted study characteristics and methodological data using a standardized coding form. A fifth researcher was consulted to resolve any disagreements.

The methodological quality of each included intervention trial was assessed using the PEDro scale (de Morton, 2009). This assessment tool evaluates key aspects of trial design and reporting, including random and concealed allocation, baseline comparability, blinding, follow-up adequacy, intention-to-treat analysis, and reporting of between-group statistical comparisons. Four reviewers performed the assessment independently, and discrepancies were resolved by discussion or consultation with a fifth researcher. The inter-rater agreement for PEDro scoring was high (κ = 0.99).

3. Results

3.1. Search results

A detailed summary of the literature search is provided in Figure 1. A total of 258 records were retrieved: 212 from PubMed and hand searching and 46 from Scopus. No records were retrieved from SciELO. Of these, 195 records were excluded after screening titles and abstracts. Two records were identified in both PubMed and Scopus and were therefore merged. Sixty-one full-text articles were assessed for eligibility, and 55 were excluded, leaving a total of six articles (n = 708 participants).

FIGURE 1.

Flowchart of the article selection for this review: 258 records identified, 195 excluded, 61 full-text articles assessed, 55 excluded for various reasons, and 6 articles included in the review.

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Selection process of studies.

3.2. Participants’ characteristics

The main characteristics of the studies included are shown in Table 1. All the studies included were RCTs. Investigations were published from 2005 to 2023, and conducted in the United States of America (n = 2), Japan (n = 1), Australia (n = 1), Bulgaria (n = 1), and Spain (n = 1). Nearly 700 participants (n = 708) with a mean age of 72.5 years were examined. Frailty was identified using original and modified versions of the Frailty Phenotype (n = 2), the Frailty Index (n = 1), and the Short Physical Performance Battery (SPPB) (n = 1). Overall quality assessment results ranged from 4 to 7. The incidence of adverse events during exercise interventions across the studies was generally low, with most interventions proving to be safe and well-tolerated by participants.

TABLE 1.

Main characteristics of the study participants of the included studies.

First author Year Country Design Sample size Mean participants’ age Frailty assessment method Intervention Quality assessment (0–10) Results
Dobarro D. 2023 Spain RCT single-blinded 48 83.0 SPPB VIVIFRAIL 6 ↑ HF symptoms; ↑ PA
Pandey A. 2023 United States RCT 337 72.0 Frailty phenotype Progressive multidomain physical rehabilitation intervention 5 ↑ SPPB, ↑ Aerobic capacity; ↑ Mobility, ↑ Muscle strength; ↑ QoL, ↓ Depressive symptoms
Nagatomi Y. 2022 Japan RCT 30 63.7 Japanese cardiovascular health study Comprehensive cardiac rehabilitation program focused on exercise training 4 ↑ Aerobic capacity and mobility; ↑ Muscle strength; ↑ PA; ↑ Hemoglobin; ↑ Cholesterol
Mudge A. M. 2021 Australia RCT 91 >70 Frailty index Multicomponent exercise training 5 ↑ Frailty index
Papathanasiou J. V. 2020 Bulgaria RCT 120 63.7 — Moderate and HIIT 5 ↑ Aerobic capacity; ↑ Mobility; ↑ QoL
Witham M. D. 2005 United States RCT 82 80.0 — Exercise training 7 ↑ PA; ↓ Depressive symptoms
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HF, heart failure; HIIT, High-intensity interval training; PA, physical activity; QoL = quality of life; RCT, randomized controlled trial; SPPB, Short Physical Performance Battery. ↑ = Improvement; ↓ = Reduction.

3.3. Effects of exercise intervention on symptom-limited exercise tolerance

The effect of ET on exercise tolerance was examined in one study. Dobarro et al. (Dobarro et al., 2023) investigated the effects of a 6-month VIVIFRAIL program on the severity of HF symptoms. The authors found that 47.6% of participants in the ET program showed improvements of at least one point in the New York Heart Association (NYHA) classification, a gold-standard instrument to assess functional limitation due to HF, compared to only 22.2% in the control group.

3.4. Effects of exercise intervention on frailty status

The effect of ET on frailty status was examined in one study. Mudge et al. (Mudge et al., 2021) proposed a 6-month ET-based cardiac rehabilitation program composed of both home- and center-based resistance, aerobic, and balance exercises. Participants of the intervention group exhibited significant improvements (∼60%) in the results of the frailty index, compared to 20% in the non-exercised group.

3.5. Effects of exercise intervention on physical performance

The effect of ET on physical performance was investigated in three studies. Papathanasiou (Papathanasiou, 2020) investigated the effects of a group-based intervention on the aerobic capacity and mobility of frail patients with HF. The ET involved moderate- and high-intensity interval training (HIIT) protocols, performed 5 times a week, over 12 weeks. A significant 20%–30% and 11%–17% increase in aerobic capacity and mobility, respectively, were observed after interventions. These findings were expanded by Nagatomi et al. (Nagatomi et al., 2022), after investigating the effects of a home-based cardiac rehabilitation involving stretching, resistance, and aerobic exercises. Authors found significant improvements in mobility and aerobic capacity—assessed using the 6-min walking test (6MWT) — and lower-limb muscle strength. More recently, Pandey et al. (Pandey et al., 2023) conducted a secondary analysis of the REHAB-HF trial. The intervention encompassed 36 sessions over 12 weeks and focused on strength, balance, mobility, and endurance exercises. Results indicated a significant improvement of nearly 80% in SPPB results among frailty participants, in contrast to an 18% increase in the control group. Furthermore, significant increases in 6MWT, walking speed, lower-limb muscle strength, and balance were observed.

3.6. Effects of exercise intervention on physical activity levels

The effects of ET on PA were investigated in three studies. Witham et al. (Witham et al., 2005) proposed a two-phase 6-month ET protocol, which involved a 3-month supervised program and a 3-month home-based intervention. Authors found significant improvements in everyday PA levels, evaluated using a validated accelerometer. Findings of Nagatomi et al. (Nagatomi et al., 2022) are in line with these results, as a significant increase of nearly 700 steps/day was noted after ET. Significant increases were also observed when PA was estimated using self-reported instruments. Indeed, Dobarro et al. (Dobarro et al., 2023) reported a 6.4 improvement in the physical activity scale for the elderly (PASE) score in the intervention group, compared to a reduction of 12.5 in the control group.

3.7. Effects of exercise intervention on secondary outcomes

Secondary outcomes included QoL, depressive symptoms, hemoglobin, and cholesterol. Significant improvements in QoL and depressive symptomatology were observed in two studies (Papathanasiou, 2020; Pandey et al., 2023). Additionally, Nagatomi et al. (Nagatomi et al., 2022) found that ET increased cholesterol and hemoglobin levels.

4. Discussion

The main findings of the present study indicate that cardiac rehabilitation programs based on ET protocols significantly improved health aspects in frailty patients with HF. Specifically, symptom-limited exercise tolerance, frailty severity, and depressive symptoms were reduced, whereas the performance in multiple physical function tests (i.e., mobility, lower-limb muscle strength, aerobic capacity), PA levels, and QoL were significantly increased. Furthermore, changes in hemoglobin and cholesterol levels were observed.

These results underscore the importance of ET as a complementary strategy to pharmacological treatment in the recovery and improvement of health status in frail HF patients. Specifically, while these findings need further confirmation in additional studies, the observation that ET improved HF severity in approximately 50% of frail older adults who participated in the program (Dobarro et al., 2023) is promising and encouraging. Indeed, the fact that increased HF severity is independently associated with QoL, multimorbidity, malnutrition, major clinical events (e.g., hospitalization), and all-cause and cause-specific mortality (Liang et al., 2011; Demant et al., 2014; Agra Bermejo et al., 2017; Shuvy et al., 2020), suggests that ET may serve as a valuable tool to help reduce the overall burden of frail older adults with HF.

These premises regarding the usability of ET as a strategy to reduce HF and frailty burden in older adults are further supported by our observations on the safety and tolerability of the exercise protocols. Most intervention trials, including the one involving a HIIT protocol, did not report significant adverse events related to exercise. These findings likely reflect the efforts of study groups to align their intervention programs with established ET principles (e.g., overload, individualization) and to integrate trained movement therapists (e.g., exercise physiologists, physiotherapists) into the intervention design and supervision processes (Kraemer and Ratamess, 2004; American College of Sports Medicine, 2009). For instance, the HIIT protocol was supervised and conducted in a specialized center for rehabilitation using validated tools to monitor exercise intensity and progression (Papathanasiou, 2020).

Another important finding of the present study is that ET significantly improved frailty status and physical function. These observations have clinical implications because frailty, sarcopenia, and physical impairments are highly prevalent among patients with HF compared to the general population (Pandey et al., 2019; Zhang et al., 2021) and exacerbate the risk of adverse outcomes in this population (Pandey et al., 2019; Zhang et al., 2021). For instance, frailty may contribute to the worsening of cardiac cachexia, a condition that further complicates the management of heart failure (Lavie et al., 2014).

Furthermore, frailty, sarcopenia, and physical impairments are independent risk factors for a wide range of adverse outcomes in the older population, such as falls, fractures, institutionalization, disability, dementia, hospitalization, and death (Studenski et al., 2011; Hirani et al., 2015; Kojima, 2016; 2017b, 2017a; 2018b, 2018a; Beeri et al., 2021). These conditions have also been consistently linked to cognitive decline, multimorbidity, and polypharmacy (Auyeung et al., 2008; Huang et al., 2016; Coelho-Júnior et al., 2018; Bai et al., 2020; Beeri et al., 2021; Dai et al., 2023), further complicating the health of older adults and reinforcing the importance of ET. This complex scenario often leads to the need for increased healthcare interventions, culminating in high healthcare costs (Janssen et al., 2004; García-Nogueras et al., 2017; Hajek et al., 2018).

The practice of PA, simultaneously with ET and pharmacological treatment, is important in patients with HF because it enhances cardiovascular function, improves muscle strength, and increases exercise tolerance, which can help reduce symptoms like fatigue and dyspnea (LaMonte, 2018; Jordan et al., 2023). This combined approach helps mitigate the detrimental effects of sedentary behavior, which is common in HF patients and contributes to physical deconditioning, frailty, and poor prognosis (LaMonte, 2018; Jordan et al., 2023). Furthermore, engaging in regular PA alongside pharmacological treatment can improve overall functional capacity, reduce hospitalizations, and enhance QoL, addressing both the physical and psychological challenges of living with heart failure (LaMonte, 2018; Jordan et al., 2023).

The combination of the significant improvements in physical function, frailty status, and HF symptomatology likely explains the changes in QoL and depressive symptomatology observed in the present study. Improved physical function and reduced frailty contribute to increased independence and a greater sense of wellbeing, which directly impacts mental health and reduces feelings of depression. Furthermore, the reduction in HF symptoms, such as breathlessness and fatigue, enables patients to engage more actively in daily activities, leading to a better QoL. The positive impact on physical health can therefore foster a more optimistic outlook, helping to alleviate the psychological burden often experienced by frail HF patients.

A surprising result of this systematic review relies on significant changes in blood markers observed after intervention. In the study of Nagatomi et al. (Nagatomi et al., 2022) serum hemoglobin and blood cholesterol levels significantly increased in the ET group, whereas no changes were found in the control group. Although these results might be controversial, a detailed analysis should be conducted to avoid misunderstanding.

Notably, although these results might be interpreted as increases in blood markers, they probably reflect the maintenance of serum hemoglobin and blood cholesterol values in the ET group. Indeed, blood concentrations remained virtually stable in the ET group, whereas reductions were observed in the control group. These observations might be more indicative of changes in nutritional status in the control group than unexpected increases in the ET group, as the intervention of Nagatomi et al. (Nagatomi et al., 2022) involves nutritional counselling to provide adequate calories and protein intake. Furthermore, the slight increases found in the ET group were within normal ranges for these markers and are likely a product of diet adjustments.

Findings of the present study have clinical implications. The exercise interventions analyzed were generally multicomponent, adaptable, and feasible within routine cardiac rehabilitation settings, suggesting that their implementation does not require highly specialized infrastructure. Given that frail older adults with HF are frequently underrepresented in clinical trials yet commonly encountered in daily clinical care, the observed improvements in functional status, symptoms, and QoL support the integration of structured exercise programs into standard management. Rather than replacing pharmacological therapy, ET should be considered a complementary and patient-centered strategy aimed at preserving independence, reducing functional decline, and potentially lowering healthcare utilization in this high-risk population.

The present study has limitations. First, the relatively small sample size of the included studies limits the generalizability of the findings to the broader population of frail HF patients. Second, while the studies were conducted in multiple countries, the majority were from the United States and Japan, which may restrict the applicability of results to other cultural or healthcare contexts. Third, although the studies employed RCT designs, there was variability in the duration and intensity of ET interventions, making it difficult to draw firm conclusions about the optimal protocols for frail HF patients. Fourth, there was heterogeneity in the methods used to assess frailty and physical performance across studies, potentially introducing bias or inconsistencies in the interpretation of the results. Fifth, the assessment of secondary outcomes, such as QoL and depressive symptoms, varied between studies, and some studies relied on self-reported measures, which are subject to recall bias. Sixth, studies examining strategies ground exclusively on nutritional interventions were not included in the present systematic review. This scenario deserves attention because it might influence the results of the present study (Lorenzo-Lopez et al., 2017; Fard et al., 2019). Hence, this aspect should be examined in future pooled analyses. Seventh, meta-analysis could not be performed due to the variability in outcome measures and intervention protocols across the studies. Eight, no librarian or information specialist was involved in the development of the search strategy. Although the search terms and strategy were carefully designed and discussed among the authors, the absence of a trained librarian may have limited the comprehensiveness and optimization of the search process. The involvement of an information specialist could have further refined the selection of databases, controlled vocabulary (e.g., MeSH terms), and search syntax, potentially increasing the sensitivity and specificity of the search and reducing the risk of missing relevant studies.

Finally, no limitations were set regarding the frailty assessment tools used. This approach was adopted to include as many relevant articles as possible, given that this is the first review addressing this topic. Notably, although the SPPB has demonstrated good accuracy in identifying individuals with frailty (Sanchez-Sanchez et al., 2022), it has not been frequently mentioned in the major guidelines for frailty assessment. Therefore, more studies are needed to confirm the accuracy of the SPPB in identifying frailty, as well as investigations that further validate the results observed with SPPB, such as Symptom-Limited Exercise Tolerance and PA.

5. Conclusion

Findings of the present study indicate that cardiac rehabilitation programs based on ET protocols significantly improve health outcomes in frail patients with HF. Specifically, symptomatology of HF, frailty severity, and depressive symptoms were reduced, while performance on multiple physical function tests (i.e., mobility, lower-limb muscle strength, aerobic capacity), PA levels, and QoL were significantly increased. These results highlight the need for additional RCTs to provide further evidence and enable more detailed pooled analyses, which would contribute to a more comprehensive understanding of the benefits of ET in this patient population.

Funding Statement

The author(s) declared that financial support was not received for this work and/or its publication.

Footnotes

Edited by: Caroline Sarah Stokes, Humboldt University of Berlin, Germany

Reviewed by: Yasuhiro Ikeda, Yamaguchi Prefectural Grand Medical Center, Japan

Ahmed Atallah, Abdelhamid Ibn Badis University of Mostaganem, Algeria

Author contributions

CS-N: Conceptualization, Data curation, Investigation, Methodology, Writing – original draft, Writing – review and editing. PP-R: Conceptualization, Data curation, Investigation, Methodology, Writing – original draft, Writing – review and editing. PM: Conceptualization, Data curation, Investigation, Methodology, Writing – original draft, Writing – review and editing. LR-M: Writing – original draft, Writing – review and editing. HC-J: Data curation, Formal Analysis, Investigation, Methodology, Writing – original draft, Writing – review and editing. IR-S: Conceptualization, Data curation, Formal Analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review and editing.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author HC-J declared that they were an editorial board member of Frontiers at the time of submission. This had no impact on the peer review process and the final decision.

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