Guidelines in Practice | Cardiology · Preventive Medicine · Cardiac Rehabilitation
An evidence-based clinical guide to prescribing exercise for cardiovascular prevention, coronary artery disease, heart failure, hypertension and other cardiovascular conditions.
The 2026 American College of Cardiology (ACC) Scientific Statement establishes exercise prescription as an essential component of cardiovascular prevention and disease management. Rather than simply advising patients to become more active, clinicians should provide structured, individualised exercise recommendations based on functional capacity, cardiovascular risk, symptoms and treatment goals.
An important message is that the greatest cardiovascular benefit occurs when physically inactive individuals begin even modest levels of activity. Exercise is beneficial across the cardiovascular disease spectrum, although intensity, progression and supervision must be tailored to clinical circumstances.
1. How Much Exercise Should Adults Perform?
The ACC statement reinforces established physical activity targets while emphasising achievable, sustainable progression.
| Exercise component | Recommended prescription |
|---|---|
| Moderate-intensity aerobic activity | 150–300 minutes/week |
| Vigorous-intensity aerobic activity | 75–150 minutes/week |
| Resistance training | At least 2 days/week |
| Balance and functional training | At least 3 days/week for individuals at risk of falls |
| Sedentary behaviour | Reduce prolonged sitting and introduce regular movement breaks |
The minimum target is 150 minutes of moderate activity or 75 minutes of vigorous activity weekly, with additional benefits from greater activity volumes.
However, these targets should not discourage inactive patients. Even small increases in daily movement produce meaningful benefits.
What about daily step counts?
The statement highlights emerging evidence suggesting that 10,000 steps daily is not necessary to achieve cardiovascular benefits.
- Approximately 7,000 steps/day is associated with substantial reductions in cardiovascular and all-cause mortality.
- A practical target of 4,000–8,000 steps/day may be appropriate for many healthy adults.
- Benefits occur at considerably lower step counts, particularly among previously sedentary individuals.
These associations are predominantly based on observational evidence and should not be interpreted as a rigid therapeutic threshold.
2. How to Prescribe Exercise: The FITT Principle
A structured exercise prescription should specify frequency, intensity, time, type and progression.
| Component | Practical approach |
|---|---|
| Frequency | Aerobic activity 3–5 days/week |
| Intensity | Moderate to vigorous, according to clinical tolerance |
| Time | Typically 20–60 minutes/session |
| Type | Walking, cycling, swimming, rowing or other rhythmic activity |
| Progression | Gradually increase duration and subsequently intensity according to tolerance |
Exercise intensity assessment
Exercise intensity may be determined using heart rate, workload, perceived exertion or cardiopulmonary exercise testing (CPET).
For patients with stable cardiovascular disease, a Borg perceived exertion score of approximately 12–14 on the 6–20 scale generally represents a well-tolerated training intensity.
Perceived exertion is particularly useful when heart rate responses are altered by beta-blockers or other rate-limiting medications.
Resistance training
Resistance training should complement aerobic exercise.
A typical prescription includes:
- 1–3 sets of 8–12 repetitions involving major muscle groups.
- Beginners may start at approximately 40–60% of one-repetition maximum.
- Progression towards 60–80% may be considered as tolerated.
- Older or deconditioned adults may benefit from 10–15 repetitions per set.
Resistance training improves muscular strength, functional capacity, blood pressure and body composition, while helping preserve muscle mass during ageing or weight loss.
3. Exercise in Specific Cardiovascular Conditions
Coronary artery disease
Cardiac rehabilitation (CR) remains first-line management for eligible patients following myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft surgery and spontaneous coronary artery dissection, as well as patients with stable angina.
Exercise-based rehabilitation improves exercise capacity and quality of life and reduces cardiac mortality and hospital admissions in selected populations.
Patients unable to attend formal rehabilitation should be encouraged to progress towards at least 150 minutes of moderate-intensity activity weekly.
For stable angina, exercise should remain below the intensity that provokes chest discomfort. Appropriate pre-exercise antianginal therapy may improve exercise tolerance.
Peripheral artery disease
Supervised or structured walking exercise is a first-line treatment for intermittent claudication.
The recommended approach involves repeated walking bouts until moderate or near-maximal claudication discomfort occurs, followed by rest and subsequent repetition.
When walking is not feasible, cycling, arm ergometry or recumbent stepping may be considered. Exercise therapy remains valuable before and after selected revascularisation procedures.
Heart failure
Exercise training is beneficial in clinically stable heart failure, but the strength of evidence differs by phenotype.
| Heart failure phenotype | Expected benefit |
|---|---|
| HFrEF | Improved exercise capacity, symptoms and quality of life, with evidence supporting reductions in clinical events |
| HFpEF | Improved exercise capacity and quality of life; impact on clinical events remains uncertain |
| Recent decompensated HF | Establish clinical stability before structured training; rehabilitation may require individualised functional assessment |
In the HF-ACTION trial involving 2,331 patients with HFrEF, exercise training was associated with an 11% reduction in the adjusted composite outcome of all-cause death or hospitalisation.
Hypertension
Aerobic and resistance exercise should accompany pharmacological treatment.
A network meta-analysis cited in the statement demonstrated reductions in ambulatory blood pressure of approximately:
| Exercise modality | Mean BP reduction (SBP/DBP) |
|---|---|
| Aerobic training | 4.7/2.8 mmHg |
| High-intensity interval training | 5.7/4.6 mmHg |
| Combined aerobic and resistance training | 6.2/3.9 mmHg |
No significant differences in blood-pressure reduction were identified between modalities.
Important safety threshold: Exercise should not be performed when resting systolic blood pressure exceeds 200 mmHg or diastolic pressure exceeds 110 mmHg. Breath-holding and Valsalva manoeuvres during resistance exercise should be avoided.
Hypertrophic and other cardiomyopathies
Contemporary evidence supports mild-to-moderate recreational exercise in many appropriately evaluated patients with hypertrophic cardiomyopathy (HCM).
However, exercise recommendations should consider ventricular function, symptoms, arrhythmic risk and potential outflow tract obstruction.
Arrhythmogenic cardiomyopathy requires particular caution because high-volume or endurance exercise may accelerate disease progression and increase arrhythmic risk.
In symptomatic acute myocarditis, strenuous exercise is generally restricted for 3–6 months, followed by appropriate clinical reassessment before return.
Overweight and obesity
Exercise provides cardiovascular benefits independently of weight loss, but exercise alone usually produces relatively modest reductions in body weight.
Combining aerobic exercise with dietary treatment is more effective for weight reduction. Resistance training is particularly valuable for preserving lean muscle mass, including during GLP-1 receptor agonist therapy or following bariatric surgery.
Moderate-intensity, low-impact activities should be prioritised to support adherence and reduce musculoskeletal injury.
Older adults and frailty
Exercise prescriptions should reflect functional ability rather than chronological age alone.
For frail individuals, prioritise strength, balance, mobility and flexibility before progressing towards conventional endurance training.
Useful assessment tools include the six-minute walk test, Timed Up and Go and Sit to Stand tests. Initial sessions may need to be limited to 10 minutes or less, with gradual progression.
4. When Is Exercise Testing Necessary?
A major practical message of the statement is that routine exercise testing is not required before prescribing physical activity to most asymptomatic or clinically stable adults.
Unnecessary testing can create barriers to exercise initiation.
Exercise testing should be considered when clinical circumstances warrant additional risk assessment, particularly in patients with unexplained exertional symptoms, recent clinical deterioration, significant coronary disease, heart failure or planned vigorous exercise.
CPET is especially informative in heart failure, adult congenital heart disease and selected cardiomyopathies.
| Assessment | Principal clinical application |
|---|---|
| Exercise treadmill test | Exercise capacity, inducible ischaemia, arrhythmias and blood pressure responses |
| Six-minute walk test | Functional capacity and response to rehabilitation |
| CPET | Peak oxygen uptake, ventilatory efficiency, physiological limitations and risk stratification |
5. Contraindications and Exercise Safety
Exercise should be deferred until appropriate stabilisation in the presence of conditions such as:
- Acute myocardial infarction within the preceding two days.
- Unstable angina or haemodynamically significant uncontrolled arrhythmias.
- Severe symptomatic aortic stenosis.
- Uncontrolled symptomatic heart failure.
- Acute pulmonary embolism, myocarditis, pericarditis or aortic dissection.
Relative contraindications, including severe resting hypertension and certain arrhythmias, require individualised assessment and potentially supervised or modified exercise.
Patients developing new exertional symptoms, particularly those suggestive of myocardial ischaemia, should stop exercise and seek medical evaluation.
Although vigorous exertion transiently increases the relative risk of acute cardiovascular events, the absolute risk remains very low in the general population.
6. Cardiac Rehabilitation and Digital Exercise Monitoring
The ACC statement highlights the need to expand access to cardiac rehabilitation through centre-based, home-based, hybrid and virtual programmes.
Regardless of delivery model, rehabilitation should preserve its multidisciplinary components, including exercise training, cardiovascular risk reduction, education and psychosocial support.
Wearable activity trackers and smartwatches may support exercise prescription through self-monitoring, feedback and goal setting.
A meta-analysis cited in the statement found that wearable interventions increased physical activity by approximately 1,850 steps/day among healthy adults. In populations with cardiometabolic disease, improvements of approximately 2,592 steps/day and 36 additional minutes of moderate-to-vigorous activity per week were reported.
Nevertheless, wearables should be considered adjuncts rather than replacements for clinical supervision. Cost, digital literacy, accessibility and long-term adherence remain important limitations.
7. Monitoring the Response to Exercise
Objective functional assessment can help clinicians document improvements and adjust prescriptions.
The statement identifies several useful measures:
| Outcome measure | Interpretation |
|---|---|
| Exercise capacity increase ≥1 MET | Generally indicates a meaningful training effect |
| Six-minute walk distance increase greater than 50 metres | Generally suggests improved functional performance |
| Reduced heart rate at equivalent workload | Supports improved cardiovascular training adaptation |
| CPET-derived peak VO₂ | Useful for quantifying functional improvement and risk in selected cardiovascular populations |
Follow-up should also assess symptoms, adherence, treatment tolerance and changes in clinical status.
8. Practical Clinical Exercise Prescription Pathway
Assess cardiovascular status
Symptoms · Functional capacity · Comorbidities · Medications · Patient goals
Clinically stable / low risk
Initiate individualised aerobic and resistance exercise; routine stress testing usually unnecessary
Symptoms / elevated risk
Evaluate contraindications, consider exercise testing or CPET, and arrange specialist-supervised training as indicated
Individualised FITT prescription
Progress towards ≥150 minutes/week of moderate activity, plus resistance exercise at least twice weekly, where clinically appropriate
Reassess adherence, symptoms and functional capacity; adjust exercise intensity and duration
Practical pathway synthesised from the 2026 ACC scientific statement; not a reproduced ACC algorithm.
Clinical Takeaways
The 2026 ACC statement reinforces exercise as a core therapeutic intervention rather than an optional lifestyle recommendation. The most important clinical priorities are to encourage previously inactive patients to begin moving, prescribe activity using a structured and individualised approach, refer eligible patients for cardiac rehabilitation, avoid unnecessary pre-exercise testing and monitor functional improvements over time.
The central principle is straightforward: exercise should be prescribed with the same clinical attention to individualisation, safety, progression and follow-up as other cardiovascular treatments.
Original Scientific Statement
Myers, J., Beckie, T.M., Chastin, S., Fleg, J.L., Kitzman, D.W., Thompson, P.D. and Wasfy, M.M. (2026) ‘Exercise Prescriptions for Cardiovascular Health in Adults: 2026 ACC Scientific Statement’, Journal of the American College of Cardiology.
DOI: 10.1016/j.jacc.2026.09.008
This article is a clinical interpretation of the ACC scientific statement, not a replacement for the original document. The ACC document is a scientific statement containing consensus recommendations rather than a new graded clinical practice guideline.