Heart Failure Reviews

, Volume 23, Issue 4, pp 537–545 | Cite as

Heart rate during exercise: mechanisms, behavior, and therapeutic and prognostic implications in heart failure patients with reduced ejection fraction

  • Stefania Paolillo
  • Piergiuseppe Agostoni
  • Fabiana De Martino
  • Francesca Ferrazzano
  • Fabio Marsico
  • Paola Gargiulo
  • Elisabetta Pirozzi
  • Caterina Marciano
  • Santo Dellegrottaglie
  • Pasquale Perrone Filardi


Exercise intolerance is a typical manifestation of patients affected by heart failure with reduced ejection fraction (HFrEF); however, the relationship among functional capacity, mortality, and exercise-induced heart rate response during exercise remains unclear in either sinus rhythm or atrial fibrillation subjects. Heart rate increase during incremental load exercise has a typical pattern in normal subjects, whereas it is commonly compromised in HFrEF patients, mainly due to the imbalance of the autonomic nervous system. In the present review, we aim to describe the behavior of heart rate during exercise in normal subjects and in HFrEF patients in sinus rhythm and atrial fibrillation, understanding and explaining the mechanism leading to a different exercise performance and functional limitation. Moreover, the role of chronotropic incompetence and the need of standardizing the cutoff criteria are also discussed in order to clarify the clinical importance, the prognostic relevance, and the potential therapeutic implications of this condition. Looking into the relative contribution and interaction of heart rate response during exercise might represent an important issue to guide individualized therapeutic interventions and prognostic assessment in HFrEF patients.


Heart failure Heart rate Exercise Chronotropic incompetence 


Funding information

Dr. Paolillo is financed by the Italian Ministry of Health (Project Code: GR-2011-02354285).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Stefania Paolillo
    • 1
  • Piergiuseppe Agostoni
    • 2
    • 3
  • Fabiana De Martino
    • 4
  • Francesca Ferrazzano
    • 4
  • Fabio Marsico
    • 4
  • Paola Gargiulo
    • 1
  • Elisabetta Pirozzi
    • 4
  • Caterina Marciano
    • 5
  • Santo Dellegrottaglie
    • 6
    • 7
  • Pasquale Perrone Filardi
    • 4
  1. 1.IRCCS SDNNaplesItaly
  2. 2.Centro Cardiologico MonzinoIRCCSMilanItaly
  3. 3.Dipartimento di Scienze Cliniche e di Comunità, Sezione CardiovascolareUniversità di MilanoMilanItaly
  4. 4.Department of Advanced Biomedical Sciences, Section of CardiologyFederico II University of NaplesNaplesItaly
  5. 5.Istituto Diagnostico VarelliNaplesItaly
  6. 6.Division of CardiologyOspedale Accreditato Villa dei FioriNaplesItaly
  7. 7.Mount Sinai Medical SchoolNew York CityUSA

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