Related Experiment Video

Updated: Mar 22, 2026

Tachycardia-Induced Cardiomyopathy As a Chronic Heart Failure Model in Swine

Tachycardia-Induced Cardiomyopathy As a Chronic Heart Failure Model in Swine

Published on: February 17, 2018

Chronotropic Incompetence Does Not Limit Exercise Capacity in Chronic Heart Failure

Haqeel A Jamil¹, John Gierula², Maria F Paton¹

¹Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.

Journal of the American College of Cardiology

|April 23, 2016

Insights

Chronotropic incompetence (CI) in chronic heart failure (CHF) does not limit exercise capacity. Adjusting heart rate (HR) with pacemakers or ivabradine does not improve or worsen exercise tolerance in CHF patients.

Area of Science:

Cardiology
Exercise Physiology
Heart Failure Management

Background:

Limited heart rate rise (HRR) during exercise, termed chronotropic incompetence (CI), is common in chronic heart failure (CHF).
The relationship between CI and exercise intolerance in CHF remains unclear.
CHF is characterized by workload limitations, impacting HRR.

Purpose of the Study:

To investigate the role of heart rate (HR) in exercise capacity among patients with CHF.
To determine if CI is a cause or consequence of exercise intolerance in CHF.
To assess the impact of manipulating HR on exercise performance in CHF.

Main Methods:

A retrospective cohort study and two randomized crossover trials were conducted.
Assessed the correlation between HRR and exercise capacity in CHF patients.
Evaluated the effects of increasing and decreasing HR on peak oxygen consumption during treadmill tests in CHF.

Main Results:

The association between exercise capacity and HRR is weaker in severe CHF compared to normal left ventricular function.
Rate-adaptive pacing to increase HRR did not enhance peak exercise capacity in CHF.
Lowering HR with pacemaker adjustments and ivabradine did not impair exercise capacity in CHF patients.

Conclusions:

Chronotropic incompetence does not contribute to impaired exercise capacity in CHF.
Findings suggest revised pacemaker programming strategies for CHF patients.
The use of heart-rate lowering agents in CHF warrants re-evaluation based on these results.

Read full analysis

Abstract

Background:

Limited heart rate (HR) rise (HRR) during exercise, known as chronotropic incompetence (CI), is commonly observed in chronic heart failure (CHF). HRR is closely related to workload, the limitation of which is characteristic of CHF. Whether CI is a causal factor for exercise intolerance, or simply an associated feature remains unknown.

Objectives:

This study sought to clarify the role of the HR on exercise capacity in CHF.

Methods:

This series of investigations consisted of a retrospective cohort study and 2 interventional randomized crossover studies to assess: 1) the relationship between HRR and exercise capacity in CHF; and 2) the effect of increasing and lowering HR on exercise capacity in CHF as assessed by symptom-limited treadmill exercise testing and measurement of peak oxygen consumption in patients with CHF due to left ventricular systolic dysfunction.

Results:

The 3 key findings were: 1) the association of exercise capacity and HRR is much weaker in severe CHF compared to normal left ventricular function; 2) increasing HRR using rate-adaptive pacing (versus fixed-rate pacing) in unselected patients with CHF does not improve peak exercise capacity; and 3) acutely lowering baseline and peak HR by adjusting pacemaker variables in conjunction with a single dose of ivabradine does not adversely affect exercise capacity in unselected CHF patients.

Conclusions:

The data refute the contention that CI contributes to impaired exercise capacity in CHF. This finding has widespread implications for pacemaker programming and the use of heart-rate lowering agents. (The Influence of Heart Rate Limitation on Exercise Tolerance in Pacemaker Patients [TREPPE]; NCT02247245).

Keywords:

chronotropic incompetence exercise capacity heart failure heart rate

More Related Videos

Author Spotlight: Investigating HR-Dependent Cardiac Function in Mouse Models Through a Novel Atrial-Pacing Approach

Author Spotlight: Investigating HR-Dependent Cardiac Function in Mouse Models Through a Novel Atrial-Pacing Approach

Published on: July 21, 2023

Integration of Brain Tissue Saturation Monitoring in Cardiopulmonary Exercise Testing in Patients with Heart Failure

Integration of Brain Tissue Saturation Monitoring in Cardiopulmonary Exercise Testing in Patients with Heart Failure

Published on: October 1, 2019

Related Concept Videos

Imbalances in Cardiac Output

Imbalances in Cardiac Output

The heart's primary function is to pump blood throughout the body, maintaining a balance between blood sent out (cardiac output) and blood returning (venous return). If this balance is disrupted, it can result in congestive heart failure (CHF), a severe condition where the heart becomes an inefficient pump, leading to inadequate blood circulation.
CHF can occur due to the failure of either side of the heart. Left-side failure leads to pulmonary congestion—the right side continues to send...

Exercise and Cardiovascular Response

Exercise and Cardiovascular Response

Exercise significantly impacts cardiovascular response, which is crucial for understanding patient health and designing effective treatment plans.
Light to moderate physical activity initiates a series of interconnected responses in the body. The heart rate modestly increases in anticipation of the workout, followed by widespread vasodilation as oxygen consumption by skeletal muscles increases. This results in decreased peripheral resistance, increased capillary blood flow, and accelerated...

Heart Failure Drugs: Inotropic Agents

Heart Failure Drugs: Inotropic Agents

Positive inotropic agents are commonly used as the first line of treatment for heart failure. One such agent is digoxin, derived from the genus Digitalis, which has been known for centuries but effectively utilized since 1785. However, these cardiac glycosides can have potentially toxic effects due to their mechanism of action, which involves inhibiting Na+/K+-ATPase and increasing contractility. Digoxin is absorbed orally and distributed in various tissues, including the CNS. It has a long...

Heart Failure Drugs: β-Blockers

Heart Failure Drugs: β-Blockers

β-adrenergic antagonists, commonly known as β-blockers, block the effects of sympathetic neurotransmitters such as noradrenaline (NA) and adrenaline (ADR). They have several beneficial effects in heart failure treatment. They reduce heart rate, the force of contraction, and cardiac muscle relaxation. They also slow the atrial-ventricular conduction rate and raise the threshold for arrhythmias. The concentration of β-blockers determines their effects on bronchodilation,...

Pathophysiology of Cardiac Performance

Pathophysiology of Cardiac Performance

Typical heart performance is influenced by heart rate, rhythm, myocardial contraction, and metabolism or blood flow. The cardiac muscle exhibits distinct electrophysiological features, including pacemaker activity and calcium channel control, which play a vital role in the heart's response to various drugs. The autonomic nervous system, comprising the sympathetic and parasympathetic branches, regulates heart rate. Sympathetic activation increases heart rate, while parasympathetic activation...

Pathophysiology of Heart Failure

Pathophysiology of Heart Failure

Heart failure (HF) is a progressive syndrome involving ventricles that leads to inadequate cardiac output. It can be classified based on location and output or ejection fraction. Ejection fraction (EF) is an essential measurement in the diagnosis and surveillance of HF. Reduced EF corresponds to systolic heart failure (HFrEF). However, HF with preserved ejection fraction (HFpEF) is becoming increasingly prevalent. Also known as diastolic HF, this form of HF is related to aging. The...

Articles linked to this work by shared authors, journal, and citation graph.

Conduction system pacing: what emerging evidence and what indications?

Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology·2026

Artificial intelligence in echocardiography: a position statement from the British Society of Echocardiography.

Echo research and practice·2026

Prevalence and incidence of left ventricular systolic dysfunction and adverse outcomes in patients receiving de novo and replacement pacemaker therapy for bradycardia.

European heart journal open·2026

Safety and Performance of INVICTA DF4 Ventricular Defibrillation Lead: Results From APOLLO Prospective Multicenter Study.

Pacing and clinical electrophysiology : PACE·2026

Incidence and type of recurrent ventricular arrhythmia in patients with arrhythmic mitral valve prolapse and implantable cardioverter defibrillator for secondary prevention.

Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology·2026

Blood Cancer Clinical Trials Long-term Follow-up Using Integrated Healthcare Systems Data (BLISS): protocol for a data-linkage study integrating randomised clinical trials with national healthcare systems data.

BMJ open·2026

See all related articles