Should Cardiac Rehabilitation Be Part of GDMT for Heart Failure?

When we talk about GDMT for heart failure, we immediately think of the four pillars:

ARNI/ACEi/ARB + Beta Blocker + MRA + SGLT2 inhibitor

But heart failure is not simply a disease of the heart. It is also a disease of physical function and fitness.

Two patients can have the same EF of 30%—one can walk several miles while the other becomes exhausted crossing a parking lot. Same EF. Very different functional reserve and prognosis.

Heart failure can lead to:

Skeletal-muscle weakness and deconditioning

Impaired peripheral oxygen utilization

Reduced endurance

Loss of lower-extremity strength

Frailty and impaired mobility

GDMT improves cardiac biology. Diuretics restore euvolemia. But neither automatically restores physical function.

That is where cardiac rehabilitation (CR) becomes important.

The 2022 AHA/ACC/HFSA guidelines give exercise training a Class I recommendation for appropriate HF patients to improve functional status, exercise performance and quality of life.

CR can improve:

Peak VO₂ and aerobic fitness

Functional capacity and endurance

Lower-extremity strength

Balance and mobility

Quality of life

HF hospitalization risk

Importantly, cardiac rehab is much more than a treadmill. Modern rehabilitation incorporates aerobic conditioning, resistance training, mobility, balance, education and long-term lifestyle change.

Making CR part of our CHF pathway

At Sharp Chula Vista, every appropriate hospitalized CHF patient is referred for cardiac rehabilitation.

Our philosophy is simple:

If rehabilitation is important enough to recommend, it should be built into the system of care—not left as an afterthought.

As part of our New Frontiers HF initiative, we are looking to take this further:

Identify frailty and functional limitations earlier

Emphasize lower-extremity strength, balance and mobility

Improve the transition from hospital → cardiac rehab → community exercise

Develop community partnerships for continued physical activity

Track functional recovery alongside EF, weight and laboratory values

Perhaps we should expand how we think about comprehensive HF therapy:

GDMT → improve cardiac biology and survival

Diuresis → restore euvolemia

Devices/procedures → address structural and electrical disease

Cardiac rehabilitation → rebuild functional reserve

We measure EF, BNP, creatinine, potassium and weight.

Maybe we should also measure whether our patients can walk farther, get out of a chair more easily and regain their independence.

Successful heart failure treatment shouldn't simply help patients live longer—it should help them live better.

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