Ahpra registration PHY0002298174
How these guides are written and reviewed →
A heart transplant replaces a failing heart with a donated one. The new heart works well, but it is not connected to the body’s nerves, so it responds to exercise more slowly than a normal heart — it takes longer to speed up at the start and longer to settle afterwards. It also cannot produce the chest pain that normally warns of a problem. This page explains what that means for exercise and rehabilitation.
Who is transplanted
Heart transplantation is offered for advanced heart failure refractory to medical and device therapy, most commonly from dilated or ischaemic cardiomyopathy, and in younger patients from congenital heart disease.1 Candidates are increasingly bridged with mechanical circulatory support — a left ventricular assist device — while waiting, which means many arrive at transplant having already been through major cardiac surgery.
Peak oxygen uptake on cardiopulmonary exercise testing is a core listing variable, which places cardiopulmonary exercise testing (CPET) and the physiotherapy interpretation of it directly in the assessment pathway.
The denervated heart
The donor heart is surgically disconnected from the autonomic nervous system. Both vagal and sympathetic supply are lost, and the consequences are consistent and clinically important.
| Feature | Consequence |
|---|---|
| Loss of vagal tone | Resting heart rate is high, typically 90–110 bpm. This is normal, not a sign of instability. |
| Delayed heart-rate rise | Rate increases only as circulating catecholamines accumulate, so it lags the start of exercise by minutes. Early exercise output depends on stroke volume via preload. |
| Delayed recovery | Heart rate falls slowly after exercise. An abrupt stop can cause hypotension — a prolonged cool-down is mandatory. |
| Blunted peak heart rate | Chronotropic incompetence limits peak output; target heart rates derived from age are meaningless. |
| No angina | Ischaemia is silent. The usual warning symptom does not exist. |
| Preload dependence | Adequate warm-up and hydration matter more than usual; sudden postural change is less well tolerated. |
| Partial reinnervation | Sympathetic reinnervation occurs in some recipients over years, improving chronotropic response — variable and unpredictable. |
Heart rate is unusable as a prescription variable in the early years after transplant. Use rating of perceived exertion and the talk test. Build in an extended warm-up of at least 10 minutes and an equally extended cool-down — stopping suddenly in a preload-dependent, slowly-responding circulation is the main avoidable adverse event in this population.
Cardiac allograft vasculopathy
A diffuse, accelerated obliterative arteriopathy of the graft's coronary arteries, and the principal cause of late graft loss. Because the heart is denervated, it produces no angina — it presents instead as silent ischaemia, arrhythmia, heart failure or sudden death. Recipients undergo routine surveillance angiography for this reason.2
For physiotherapy, this means new exertional breathlessness, unexplained fatigue, a fall in exercise tolerance or a new arrhythmia in a recipient is a cardiac presentation until proven otherwise, and warrants escalation rather than progression of training.
Rejection and immunosuppression
Acute rejection is monitored with endomyocardial biopsy and non-invasive surveillance, most intensively in the first year. Rejection may be asymptomatic or present with fatigue, breathlessness, arrhythmia or fluid retention.
Long-term immunosuppression brings a predictable cluster that shapes rehabilitation: corticosteroid myopathy affecting proximal muscle, osteoporosis, diabetes, hypertension, renal impairment and increased malignancy risk. As after lung transplantation, exercise limitation is substantially peripheral — muscle rather than pump.
Exercise training — the strongest evidence in this population
Exercise-based rehabilitation after heart transplantation improves exercise capacity, and Cochrane review supports it as standard care.3 More striking is the evidence for intensity: several randomised trials have shown that high-intensity interval training is superior to moderate continuous training for peak oxygen uptake in stable recipients, and appears to improve chronotropic response — suggesting a training effect on the denervated heart itself.4,5,6
This is a genuinely counterintuitive result. The instinct with a transplanted heart is caution; the evidence supports the opposite, in stable, medically cleared recipients working within a transplant service's protocols.
Practical prescription
- Extended warm-up and cool-down, 10 minutes or more at each end, without exception.
- RPE-guided intensity; use heart rate for trend monitoring only.
- Interval training in stable recipients, once cleared — typically from around three to six months, per the transplant service.
- Progressive resistance training for steroid myopathy and bone density, with attention to sternal status early on — see Sternal Precautions and Cardiac Surgery.
- Blood pressure monitoring; hypertension is near-universal on calcineurin inhibitors.
- Infection precautions in shared gym environments.
Heart–lung transplantation
Now uncommon, and reserved mainly for Eisenmenger syndrome and complex congenital disease with irreversible pulmonary vascular disease. These recipients carry both sets of consequences — a denervated heart and a denervated lung. In practice that means RPE-based prescription with prolonged warm-up and cool-down, and scheduled airway clearance independent of symptoms, and spirometric surveillance for allograft dysfunction. See Lung Transplantation for the pulmonary half.
Role of the physiotherapist
Understand the denervated physiology before prescribing anything. Abandon heart-rate targets. Never allow an abrupt stop. Train hard once cleared, because the evidence supports intensity and the limitation is peripheral. Treat new breathlessness, fatigue or arrhythmia as possible vasculopathy or rejection rather than deconditioning — there will be no chest pain to warn you. And work inside the transplant service's protocols throughout.
Related: Heart Failure, Cardiomyopathies, Cardiorespiratory Rehabilitation.
Evidence summary
Framing. Heart transplantation produces a physiology that invalidates the standard cardiac rehabilitation toolkit: heart-rate-based prescription, angina as a warning symptom, and normal heart-rate recovery all fail simultaneously. At the same time, this is one of the few populations where randomised evidence favours higher training intensity than conventional practice would suggest.4,5,6
Evidence — exercise trainingCochrane review supports exercise-based rehabilitation for improving exercise capacity after heart transplantation.3 Hermann and Dall's randomised and crossover work demonstrated superiority of high-intensity interval training over moderate continuous training for peak VO2, with associated improvement in chronotropic response; Nytrøen's trial replicated the peak VO2 and muscular capacity findings.4,5,6 The consistency across groups is the reason this has changed practice.
Evidence — surveillanceInternational Society for Heart and Lung Transplantation (ISHLT) guidance defines the surveillance framework for rejection and cardiac allograft vasculopathy, including the rationale for routine angiography in an asymptomatic population.1,2 The absence of angina is the single most important safety fact for anyone prescribing exercise to these patients.
Physiotherapy implicationsPrescribe by RPE; use heart rate only as a trend. Mandate prolonged warm-up and cool-down. Escalate new exertional symptoms rather than modifying the programme around them. Address proximal myopathy and bone density with resistance training. Progress to interval training once the transplant service has cleared it — under-dosing is the more common error than over-dosing.
Evidence gapsOptimal timing for commencing high-intensity training after transplant is not established, and trials have generally recruited stable recipients well beyond the first year. There is little evidence guiding rehabilitation in recipients with established allograft vasculopathy, or in the growing group bridged with durable mechanical circulatory support. Heart–lung recipients are too few to have been studied separately, and their management is extrapolated from both single-organ populations.
References & evidence base
- Mehra MR, Canter CE, Hannan MM, et al. The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: a 10-year update. J Heart Lung Transplant 2016;35(1):1–23.
- Velleca A, Shullo MA, Dhital K, et al. The International Society for Heart and Lung Transplantation (ISHLT) guidelines for the care of heart transplant recipients. J Heart Lung Transplant 2023;42(5):e1–e141.
- Anderson L, Nguyen TT, Dall CH, Burgess L, Bridges C, Taylor RS. Exercise-based cardiac rehabilitation in heart transplant recipients. Cochrane Database Syst Rev 2017;(4):CD012264.
- Hermann TS, Dall CH, Christensen SB, Goetze JP, Prescott E, Gustafsson F. Effect of high intensity exercise on peak oxygen uptake and endothelial function in long-term heart transplant recipients. Am J Transplant 2011;11(3):536–541.
- Dall CH, Snoer M, Christensen S, et al. Effect of high-intensity training versus moderate training on peak oxygen uptake and chronotropic response in heart transplant recipients: a randomized crossover trial. Am J Transplant 2014;14(10):2391–2399.
- Nytrøen K, Rustad LA, Aukrust P, et al. High-intensity interval training improves peak oxygen uptake and muscular exercise capacity in heart transplant recipients. Am J Transplant 2012;12(11):3134–3142.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
More than one of our services applies here, and which combination suits you depends on what your assessment shows.
Corrections: If something on this page is wrong, out of date or unclear, we want to know. Email reception@inspireclinic.au with the page name and what you believe is incorrect. Substantive corrections are made promptly, and the guide’s version and last-updated date are changed to reflect it.