IPM Take
Cardiology has spent decades getting better at prescribing medicines, devices and procedures while one of its most powerful interventions has often remained compressed into two words at the end of an appointment: exercise more.
The American College of Cardiology now wants to make that much harder to defend.
Its new scientific statement argues that exercise should be prescribed as deliberately as other elements of cardiovascular care, with attention to frequency, intensity, duration, type and progression rather than relying on generic advice to “be more active”.
The most important part of the statement may be its rejection of the idea that meaningful cardiovascular benefit begins only after patients reach an ideal exercise target. The steepest gains occur when someone moves from being inactive to doing something, meaning the people who may have the most to gain are often those furthest from conventional fitness goals.
That has implications for prevention programmes, cardiac rehabilitation and health inequalities. A recommendation built around 10,000 steps, gym memberships or highly structured programmes may unintentionally make movement look harder than it needs to be.
The ACC points instead toward achievable progression, including evidence that roughly 5,000 to 7,000 daily steps can already be associated with substantial reductions in cardiovascular and all-cause mortality for many adults.
The statement also exposes a more uncomfortable health-system problem. Exercise is widely accepted as treatment, yet clinicians often receive little training in how to prescribe it, reimbursement for cardiac rehabilitation remains a barrier, and access to supervised programmes is uneven.
The evidence problem is therefore no longer whether exercise works.
It is whether healthcare systems are organised to deliver it as care.
Executive Summary
The American College of Cardiology published a new scientific statement in JACC on 15 October 2026 calling for structured exercise prescription to become a routine component of cardiovascular prevention and disease management.
The statement describes physical activity and cardiorespiratory fitness as major determinants of cardiovascular outcomes and notes that low cardiorespiratory fitness has prognostic importance comparable to, and in some settings greater than, traditional risk factors including smoking, hypertension, hyperlipidaemia and diabetes.
Rather than giving all patients the same target, the ACC recommends tailoring exercise to the individual’s cardiovascular condition, functional capacity, symptoms, medications, comorbidities, treatment goals and preferences.
For most adults, including many patients with stable cardiovascular disease, the statement supports aerobic activity alongside resistance training, with the familiar overall target of at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity per week while recognising that benefits begin below those thresholds.
The largest absolute reductions in cardiovascular risk occur when inactive individuals become even modestly active.
The statement also challenges several assumptions that can create unnecessary barriers. Most asymptomatic people and many patients with stable cardiovascular disease do not require maximal exercise testing before beginning physical activity, although testing can be useful when clinicians need more precise information about functional capacity, safety or exercise intensity.
Cardiac rehabilitation remains a first-line intervention for many patients with established cardiovascular disease, but the ACC acknowledges persistent access barriers and argues that patients unable to participate in formal programmes should still receive individualised exercise prescriptions.
Wearable devices, home-based programmes and virtual rehabilitation are positioned as tools that may support adherence rather than replacements for clinical judgement.
Why it matters
- HTA bodies: Exercise illustrates the challenge of assessing interventions that are highly effective but difficult to package like conventional technologies. Evidence extends across physical activity, supervised training and cardiac rehabilitation, but implementation varies widely. Assessment may increasingly need to consider delivery models, digital support and adherence strategies alongside the intervention itself.
- Payers: The statement strengthens the argument that exercise and cardiac rehabilitation should be considered components of cardiovascular treatment rather than optional wellness services. Coverage decisions around supervised, home-based and hybrid rehabilitation may determine whether evidence-based exercise remains available primarily to patients who can afford the time, travel and programme costs.
- Industry / innovation partners: Wearables, remote monitoring platforms and digital rehabilitation tools have an expanding role in cardiovascular care, but the opportunity is not simply to count steps. Technologies that help clinicians prescribe appropriate intensity, monitor progress and sustain long-term participation could become increasingly relevant as exercise moves further into formal care pathways.
Exercise has occupied a strange position in cardiovascular medicine for years. Few cardiologists would dispute that regular physical activity can prevent disease, improve fitness and help patients live better after a cardiovascular diagnosis, yet exercise is often treated very differently from the other interventions that appear in a treatment plan.
A prescription for hypertension specifies a drug, dose and schedule. A cardiac rehabilitation programme comes with structured sessions and progression. Advice about exercise, by contrast, can still end with a broad instruction to walk more, lose weight or become active.
The American College of Cardiology’s new scientific statement is an attempt to close that gap by making exercise prescription more concrete, more individualised and more recognisably clinical.
The document begins from a strong evidence base. Regular physical activity is associated with lower cardiovascular risk, while structured exercise among people with established cardiovascular disease can improve functional capacity, reduce hospitalisation and improve quality of life. Cardiorespiratory fitness has also emerged as a powerful predictor of future outcomes, with prognostic importance comparable to traditional cardiovascular risk factors.
Despite that evidence, physical activity counselling remains inconsistent in routine care, partly because clinicians may receive little formal training in exercise prescription and partly because the healthcare system has historically been better designed to prescribe medicines than movement.
The ACC’s response is to bring exercise closer to the logic already used elsewhere in medicine.
Instead of simply telling a patient to exercise, clinicians are encouraged to consider frequency, intensity, time and type, together with gradual progression. A prescription should also reflect the patient’s underlying cardiovascular disease, functional capacity, symptoms, medications, other conditions and preferences.
That last element matters more than it might appear.
An exercise plan that is physiologically perfect but impossible to sustain is not an effective treatment.
This is why the statement repeatedly emphasises achievable activity rather than fitness perfection. One of the most consistent findings in physical-activity research is that the risk curve is not linear. The largest improvement often occurs when someone who does almost nothing begins doing something.
For a sedentary patient, that can make the difference between being told to meet an intimidating national exercise target and being told that even a modest increase matters.
The ACC highlights step-count research suggesting that many adults can achieve clinically meaningful cardiovascular benefit at around 5,000 to 7,000 steps per day, well below the 10,000-step target that has become embedded in consumer culture despite never functioning as a universal clinical threshold.
That does not mean 7,000 steps is a new prescription for everyone, because the relationship varies with age, fitness, disease and baseline activity. What it does mean is that the cardiovascular value of movement starts before someone reaches an arbitrary milestone.
The same principle applies to formal exercise targets. Adults are still encouraged to work toward at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous activity each week, but the statement is careful not to turn those recommendations into an all-or-nothing boundary between useful and useless activity.
This is particularly important for patients with cardiovascular disease, older adults and people who have been inactive for years. The distance between no exercise and guideline-level exercise can be large, and asking patients to cross it immediately may undermine adherence before treatment has really begun.
The ACC instead argues for progression.
For many adults with stable cardiovascular disease, aerobic exercise can be performed three to five days each week for around 20 to 60 minutes per session at moderate to vigorous intensity, with the programme adjusted according to tolerance and symptoms.
Resistance training should generally be added rather than treated as separate from cardiovascular care. Beyond increasing muscle strength, resistance exercise can improve insulin sensitivity, blood pressure, body composition and functional capacity while helping older adults preserve independence.
The statement also challenges the assumption that extensive medical testing must precede exercise.
For most asymptomatic individuals, and many clinically stable patients, maximal exercise testing is not required before beginning physical activity. Testing remains useful when clinicians need to establish functional capacity, clarify risk or define exercise intensity more precisely, particularly in patients with established disease or more complex symptoms.
That is a meaningful policy point because unnecessary testing can itself become a barrier.
If every sedentary person believes they need a stress test before walking regularly, cardiovascular prevention becomes harder rather than safer. At the same time, a blanket “everyone can exercise” message would be equally inappropriate for patients with unstable disease or significant symptoms.
The goal is risk-based personalisation rather than either extreme.
Cardiac rehabilitation sits at the more structured end of that spectrum and remains one of the clearest examples of exercise functioning as treatment. For eligible patients after myocardial infarction, coronary intervention, cardiac surgery and several other cardiovascular conditions, rehabilitation can improve recovery, fitness and quality of life while supporting secondary prevention.
Yet participation remains far below eligibility.
Geography, transport, work obligations, cost, referral practices and insurance coverage can all determine whether a patient receives an intervention that clinicians already know is beneficial.
The ACC therefore places substantial emphasis on home-based, hybrid and virtual models, not because digital delivery should replace supervised rehabilitation for everyone, but because a treatment that patients cannot access has limited population value.
Wearable technology enters the same conversation.
Step counters, smartwatches and heart-rate monitors can help patients track progress, set goals and maintain motivation. They can also extend rehabilitation beyond the clinic by giving patients and clinicians information about activity in everyday life.
But the statement does not turn wearables into treatment by themselves.
Collecting activity data is easier than changing activity behaviour, and digital tools still depend on engagement, health literacy, access and the ability of clinicians to interpret the information meaningfully.
The deeper issue is implementation.
Cardiovascular medicine already possesses a sophisticated infrastructure for cholesterol management, blood-pressure treatment and pharmacological prevention. Risk is measured, thresholds are defined and prescriptions can be adjusted over time.
Physical inactivity rarely receives the same systematic response even though poor cardiorespiratory fitness carries substantial prognostic information.
Closing that gap would require more than asking doctors to mention exercise more often. Clinicians need training in how to prescribe activity safely. Electronic records could make physical activity assessment more routine. Referral pathways need to connect appropriate patients with rehabilitation and exercise professionals. Payers need to decide how home-based and digital programmes fit into coverage. Patients need options that work outside specialised urban centres.
Without those pieces, “exercise is medicine” risks remaining a slogan rather than a care model.
The new ACC statement pushes the debate in a more practical direction by asking clinicians to stop treating exercise as an optional piece of lifestyle advice and start treating it as an intervention that needs a dose, a plan and follow-up.
That does not mean every patient needs to become an athlete, and the statement’s most important message may be precisely the opposite.
A patient who moves from inactivity to regular walking may gain more than someone already highly active gains by optimising another few minutes of training. For cardiovascular prevention, the priority is therefore not to create perfect exercisers but to make inactivity less normal.
Medicine already knows that movement can prevent and treat cardiovascular disease. The unresolved question is why something considered powerful enough to improve outcomes is still so often delivered as advice instead of prescribed as care.
