Top Things to Know: Exercise in High-Risk Populations

Updated: July 09, 2026

Prepared by Jerome L. Fleg, MD, Chair and Jessica R. Golbus, MD, MS, FAHA, Vice Chair of the Writing Group

Although the health-related benefits of higher fitness and exercise training in both healthy individuals and patients with major comorbidities are widely recognized, participation in regular exercise and exercise training (ET) remains underutilized, especially in high-risk individuals.
The current Scientific Statement summarizes the present state and future directions of ET for specific high-risk populations, including their functional deficits, training modifications required to maximize efficacy and safety, and important knowledge gaps in this field.
In frail older adults with cardiovascular disease, ET begins with a multidimensional functional assessment, progresses through an individualized multicomponent prescription, and targets outcomes that resonate with older persons.
In stable post-stroke individuals, ET programs of 8 weeks or longer that include both aerobic and strength components produce substantial improvement in exercise capacity, physical and cognitive function, and cardiometabolic profile.
Persons with spinal cord injury often require significant training modifications, but benefit from resistance training across all levels of injury to improve strength and balance, and aerobic training to increase their typically low peak oxygen consumption.
In persons with activity-limiting arthritis, multicomponent ET improves aerobic fitness and strength irrespective of age and baseline functional deficits, with minimal adverse effects.
Although many individuals with implantable cardioverter-defibrillators (ICD) may be reluctant to exercise vigorously, multiple studies have demonstrated the safety and efficacy of aerobic ET in this population, with low risk of ICD shock or anti-tachycardia pacing.
In patients with implanted pacemakers undergoing ET, the heart rate response mode should be turned on, and the upper tracking rate set to a heart rate achievable during exercise.
Patients with a left ventricular assist device and heart transplant recipients both have low exercise capacity and benefit substantially from aerobic ET. The blunted and delayed heart rate response to exercise in the latter group may require the use of perceived exertion ratings to help monitor relative exercise intensity.
Recent studies have demonstrated the efficacy and safety of vigorous aerobic exercise in individuals with hypertrophic cardiomyopathy. However, those with genotype PKP2 arrhythmogenic cardiomyopathy should generally be discouraged from high intensity exercise due to their increased risk for ventricular arrhythmias and disease progression.

View the summary for Exercise Training in High-Risk Populations

Citation

Fleg JL, Golbus JR, Afilalo J, Cornwell WK III, Cuccurullo S, Dougherty CM, Forman DE, Huffman KM, Khadanga S, Mancini D, Nytrøen K, Reeves GR, Taylor JA; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Sports Cardiology Science Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Quality of Care and Outcomes Research; and Stroke Council. Exercise in high-risk populations: a scientific statement from the American Heart Association. Circulation. Published online July 9, 2026. doi: 10.1161/CIR.0000000000001456