Pilates for heart failure: cardiac rehab first, what's safe, breathing and strength, what the evidence shows, and a class
Gentle Pilates can be a good way to build strength, balance and flexibility with stable heart failure, as long as you keep breathing, keep holds short and don't lie flat if it makes you breathless. But it has been tested in only one small trial, it isn't a treatment for heart failure, and it never replaces your medicines or cardiac rehabilitation (rehab), which has the evidence for fewer hospital stays and a better quality of life.
This guide covers where Pilates fits after your rehab assessment, what the one Pilates trial found and what it didn't, safe effort and breathing, lying flat and bending forward, the moves to skip, medicines and devices, a sitting-and-standing class, and the warning signs that need help. Our exercise with heart failure guide covers walking, strength work, fluid and medicines in full, and our Pilates for heart health guide covers other heart conditions.
NICE (the National Institute for Health and Care Excellence) says to offer everyone with heart failure "a personalised, exercise-based cardiac rehabilitation programme", after an assessment, and the NHS says "Everyone diagnosed with heart failure should be offered cardiac rehabilitation." In 60 trials, rehab probably meant fewer hospital stays overall and a better quality of life. Start Pilates after your rehab assessment, or once your heart failure team agrees.
"In the past, people with heart failure were told they needed rest.", the British Heart Foundation (BHF) says; the 2026 European guideline recommends exercise training for all stable patients, inside rehab and long term. Exercise doesn't cure heart failure or replace medicines: the BHF says it's "not reversible with exercise".
In Brazil, 16 people with mild heart failure did aerobic exercise and then either mat Pilates or usual rehab exercises for 16 weeks; fitness rose only in the Pilates group. We could read only the summary, the gain reported is larger than 20 minutes of mat work seems likely to produce, and the trial has never been repeated.
A typical class is light to moderate work, and the BHF says to combine Pilates with 150 minutes a week of moderate activity such as walking. It fits the strength, balance and flexibility part of your week.
Keep breathing: no breath holds, no straining, no planks
The BHF says to avoid "lifting heavy weights", "holding your breath" and "using your whole body as a weight, such as press-ups or planks." In 17 people with severe heart failure, a short leg contraction with normal breathing was fine, while holding the breath and bearing down changed the pressures in the heart and lungs far more.
Sit, stand or lie on your side, and check yourself first
Trouble lying flat can be a sign of fluid building up, and UK rehab standards keep lying exercises out of the main part of a session. Don't exercise on a day you're unwell or more tired or breathless than normal, and weigh yourself if your team asks you to: sudden weight gain can mean fluid is building up.
Heart failure, and what a Pilates class asks of it
What heart failure is
In the NHS's words: "Heart failure is when your heart cannot pump blood properly. It does not mean your heart has stopped working or is about to stop working. There's no cure, but treatment and lifestyle changes can help." Our exercise with heart failure guide explains the types, stages and medicines.
When the heart pumps less well, muscles get less oxygen, and losing fitness adds to the breathlessness. Training mainly improves the muscles and blood vessels rather than the heart muscle itself: in trials, fitness and quality of life improved without changes in how the heart pumped. In frail older people after a hospital stay, "A key goal was to increase endurance (walking time), but doing this safely required first addressing deficits in balance, strength, and mobility.", the kind of work Pilates includes.
Much of mat Pilates is lying on your back, and the BHF's guide says "You may also find it difficult to lie flat." Roll-downs and forward folds bend the trunk, and breathlessness on bending forward is a listed heart failure symptom: it affected 28% of 102 people in one study. Planks, long holds and the Hundred invite holding the breath. Getting up from the floor quickly can make you dizzy, and a class is light to moderate work, so it doesn't replace walking or cycling.
Beta blockers slow the heart, so heart rate targets mislead. Water tablets (diuretics) can leave you dehydrated or needing the toilet mid-class. Several heart failure medicines lower blood pressure, so stand up slowly. Newer medicines called SGLT2 inhibitors, now used in every type of heart failure, change blood pressure only a little.
Offered to everyone, after an assessmentStrong evidence
NICE says the rehab programme "should be preceded by an assessment to ensure that it is suitable for the person". UK rehab standards make heart failure a priority group. Ask your heart failure nurse or GP to refer you if you haven't been offered it.
In Cochrane's 2024 review (60 trials, 8,728 people), rehab probably cut hospital stays for any reason within a year (15.9% against 23.8%) and improved quality of life by about 7 points, where 5 is a meaningful change. It made no clear difference to deaths. Since the 2019 version, the estimate for hospital stays for heart failure itself has shrunk and is no longer clearly different from usual care, so the honest summary is fewer hospital stays overall, and a better quality of life.
Exercise is safe when you're stableStrong evidence
In HF-ACTION (2,331 people), exercise training was "well-tolerated and safe". In 6 trials in people with preserved ejection fraction, there were no major adverse events linked to exercise, helped by careful choice of stable patients and supervision. The European guideline lists times not to exercise, such as heart failure that is getting worse, unstable angina and an active infection.
It recommends personalised exercise training within rehab for all stable patients, unless there's a specific reason not to, and says "Personalized exercise training outside exercise-based cardiac rehabilitation is recommended for all stable patients on a long-term basis". The change in its evidence level from 2021 partly reflects a new grading system, not weaker evidence. US guidelines give exercise their strongest recommendation too.
In the UK, a home programme with chair-based exercise or progressive walking improved quality of life at 12 months (216 people). In 349 people aged 60 and over in hospital with heart failure, a strength, balance, mobility and endurance programme improved physical function, and the frailest gained most, though hospital stays and deaths didn't fall.
Searches in English, Portuguese, Spanish and Turkish on 3 November 2026 found one trial: 16 people with mild symptoms in São Paulo did 30 minutes of aerobic exercise and then 20 minutes of mat Pilates or usual rehab exercises for 16 weeks. Exercise time rose in both groups and fitness rose only with Pilates. But there were 8 people in each group, the full paper was blocked so we read only the summary, harms weren't reported in it, the fitness gain reported is implausibly large for 20 minutes of mat work, and nobody has repeated it in 14 years. We leave its figures out for that reason.
Reviews of mind-body exercise in heart failure count one Pilates trial, and a 2026 network analysis says Pilates was "evaluated in a small number of studies". Any ranking that puts Pilates above other mind-body exercise rests on those 16 people, so it shouldn't be relied on.
UK, European, US and Brazilian heart failure and rehab guidelines don't mention Pilates. The Brazilian guideline, from the country with the most Pilates trials, says patients "should always be instructed on how to correctly perform movement and breathing, avoiding the Valsalva maneuver" (holding the breath and bearing down).
Across 6 studies, Pilates exercises were light to moderate work, about 3 times the energy of resting. It complements walking or cycling rather than replacing them.
In the best-run trial, tai chi twice a week for 12 weeks improved quality of life and mood in 100 people with heart failure, but not walking distance or fitness. Yoga trials are small and mostly low quality; our yoga for heart failure guide covers them.
Keep breathing, and breathe out on the effortStrong evidence
UK rehab standards leave out "sustained breath holding and isometric exercises", and the BHF says to avoid holding your breath. In 17 people with severe heart failure, a short leg contraction with normal breathing didn't upset the pressures in the heart and lungs, while holding the breath and bearing down did. Muscle work isn't the problem; holding the breath and straining are.
No planks, floor push-ups or long holdsStrong evidence
The BHF says avoid "using your whole body as a weight, such as press-ups or planks." A wall push-up is the swap. Keep holds short and reformer springs light, because heavy springs make it easy to strain (our suggestion, following the BHF's advice not to lift heavy weights).
European guidance says strength training "may complement, but not substitute, aerobic exercise training". UK rehab standards suggest 2 to 3 sessions a week, 48 hours apart, starting with 1 set of 8 to 10 repetitions and building to 3. In trials, light strength training raised strength, fitness and walking distance without harming the heart, with one serious event across 18 trials, and adding it to aerobic training helped more than aerobic training alone. Standing and side-lying Pilates moves fit this light end.
Moderate effort means "you'll feel a bit warmer and breathe a bit more heavily, but you should still be able to talk", the BHF says, and a few 5 to 10-minute sessions a day count.
Beta blockers slow your heartbeat and may make you feel more tired or less energetic. Use the talk test or the Borg scale rather than heart rate. If a beta blocker makes you dizzy, the NHS says not to drive, ride a bike or use machinery until the dizziness stops. Talk to your doctor if you want to change your exercise routine, and don't change your dose yourself.
Feeling fine doesn't override warning signs: in 14 men on beta blockers, some had warning signs on testing while the effort still felt light.
Warm up for 15 minutes, cool down for 10Strong evidence
UK cardiac rehab standards ask for a graded warm-up of about 15 minutes and a cool-down of at least 10, and keep floor work until after the cool-down. Our class below follows this.
Slow breathing with no holds suits a cool-down. Leave out breathing patterns with long breath-holds, because the BHF advises against holding your breath when you exercise.
The BHF's guide says "You may also find it difficult to lie flat." and "Being propped up by pillows at night can help.", and the NHS lists feeling breathless when lying down among the heart failure signs to act on. Do Pilates sitting, standing or on your side, or propped up on pillows. New or worse breathlessness lying flat is a reason to call your team or NHS 111, not to push on (our suggestion).
The 2026 European guideline lists "Breathlessness on bending forward/flexing the body." as a heart failure symptom; in 102 people with heart failure, 28% had it, after about 8 seconds of bending. Keep forward bends small and short, and sit up if you get breathless.
UK rehab standards say avoid "rapid changes in position", and heart failure medicines often lower blood pressure. Sit for a few breaths after side-lying or floor work before you stand, and stand with a hand on the chair or wall.
Breathing-muscle training uses a hand-held device that you breathe in through against a set load. In 17 trials (510 people), it improved breathing strength, walking distance and quality of life, at low to very low certainty, and European guidance suggests it first for the most deconditioned people. The classic dose, 30 minutes a day for 12 weeks at 30% of your maximum breathing strength, needs your rehab team's device and settings.
No trial has tested Pilates breathing as a substitute. Slow breathing, at about 6 breaths a minute, raised oxygen levels and eased breathlessness in a small, old study, and suits a cool-down with no holds.
An implantable cardioverter defibrillator (ICD) isn't a reason to avoid exercise: in HF-ACTION, shocks were no more common with training (20% against 22%), and the authors say exercise training shouldn't be withheld from people with heart failure who have an ICD. European device experts advise no strength training for the first 4 to 6 weeks after an implant, because it may dislodge new leads, and keeping your heart rate at least 10 to 20 beats a minute below your ICD's cut-off. Follow your device clinic's arm limits; our exercise with a pacemaker or ICD guide has more.
Tell your heart failure team if you notice any of these. On those days, don't exercise (our suggestion, following the BHF's advice not to exercise when you're unwell or more breathless than normal).
Use your own team's figure for sudden weight gain. If you take a water tablet such as furosemide, check with your doctor how much you can drink, and plan a toilet break around your class.
Sudden weight gain.
Swollen legs, ankles or feet.
Shoes or clothes feeling tighter.
Feeling more breathless.
A bloated or full feeling in your tummy.
Needing extra pillows at night to breathe comfortably.
The seated march (3 min, three times through the warm-up, building to the last 4 minutes), the breath reach (3 breaths) and thoracic rotation (5 each side, seated) from our heart failure exercises at home; shoulder circles (10 each way), lateral breathing (5 breaths, sitting, no holds) and hip circles (2 slow circles each leg, holding the wall) from our heart health class.
Light, breathing out on the effort: sit to stand (8 to 10) and the seated knee extension (8 each leg) from our heart failure exercises at home; the wall side leg lift (10 each side) and the slow calf raise (10 to 15 slow) from our heart health class; the wall push-up and band row (8 to 10 each, a light band) from both classes.
The side kick (8 each side) and the clamshell (10 each side), from our heart health class, with your head on a pillow, never flat on your back; sit for a few breaths before you stand.
Cool down sitting, and breathe (at least 10 minutes)
The seated march (3 min, gradually slower), seated cat-cow (6 slow rounds, head level), the seated upper-back lift (5 holds of 3 to 5 s, keep breathing), the mermaid on a chair (3 each direction, each side) and slow breathing (5 min, about 4 in and 6 out, no holds), from our heart health class; the seated calf raise (10 slow) from our heart failure exercises at home.
Planks, floor push-ups, long holds and the wall sit
Leave out the forearm and straight-arm planks, the leg pull front and back, the Pilates push-up, long knee hovers and the wall sit: the BHF says avoid press-ups and planks, and our move cautions say "with heart failure, avoid planks". Use the wall push-up instead.
The Hundred's pumping breath has no hold, but done with the head and legs lifted it invites straining: leave it out, or do the arm beats sitting up with normal breathing (our suggestion). Leave out box breathing and 4-7-8 holds.
Lying flat on your back
The bridge, knee folds, leg circles and chest lift: only if lying flat is comfortable and your team agrees; otherwise propped up or on your side (our suggestion).
Legs overhead
Leave out the roll-over, jack knife, control balance and boomerang, which take your legs over your head. No trial has tested them in heart disease: this is a precaution, as our yoga for heart health guide leaves out the plough and shoulder stand.
Arms overhead on the device side
In the first weeks after a pacemaker, ICD or CRT (cardiac resynchronisation therapy) device, follow your device clinic's arm limits, as our heart health class says.
Classes to follow
Our upright class is new and untested as a whole: it keeps everything sitting, standing or side-lying, with a 15-minute warm-up, a stop point on low days and a 10-minute seated cool-down. Our heart failure exercises at home do the cardio part Pilates doesn't. The 40-minute heart health class fits too, without its mat block if lying flat makes you breathless, and the chair classes suit low days if your team is happy for you to exercise.
Low blood pressure, dizziness on standing or atrial fibrillation
Sit for a few breaths before standing. Our Pilates for low blood pressure and Pilates for atrial fibrillation guides go further.
Warning signs: when to stop and when to get help
This is general information, not a diagnosis. A&E means accident and emergency; in the US, call 911 for 999, and use your doctor's urgent line or urgent care for NHS 111.
Call 999 now
Call 999 (911 in the US) if:
You have chest pain that feels tight or like squeezing on your chest.
You have chest pain that spreads to your arms, neck or jaw.
You're having severe difficulty breathing: you're gasping, choking or not able to get words out.
Your lips or skin are pale, blue or grey. On brown or black skin, this may be easier to see on the palms of the hands.
Someone has passed out and is not responding normally.
Don't drive yourself to A&E. Sit and rest on the floor with your knees bent and your back supported. Take a 300 mg aspirin if you have one and aren't allergic to aspirin, and use your GTN if you have angina. If someone stops responding and stops breathing, start CPR (cardiopulmonary resuscitation).
Call 999 or go to A&E if palpitations don't go away, or come with chest pain, shortness of breath, feeling faint or fainting. With a fast or irregular heartbeat, the NHS also lists sweating, feeling or being sick, dizziness, a severe headache, weakness or numbness on one side, blurred vision, and confusion or difficulty speaking as reasons to call 999. If palpitations have stopped, ask for an urgent GP appointment or call NHS 111.
Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.
Stop if you get palpitations (your heart pounding or skipping a beat), extreme shortness of breath or light-headedness, and stop if you run out of energy. The BHF says stop immediately and contact your GP if you feel unwell, very short of breath, or get chest pain, dizziness or palpitations while exercising. Call 999 for the signs above.
You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.
Your heart failure nurse or team first, then your GP or rehab team. The BHF Heart Helpline (0808 802 1234, Monday to Friday, 9am to 5pm) answers questions, and the NHS links to the heart failure charity Pumping Marvellous for more information.
Call 999 if you or someone else has fallen and may have injured the head, back, neck or hip, or cannot get up.
Get help from NHS 111 if you or someone else has fallen and may be in pain, injured or unwell.
See a GP if you're worried about your balance or mobility, or you've had a fall. You may be able to refer yourself to a falls service, which can include strength and balance training.
The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.
"With heart failure, you should rest, not exercise"Strong evidence
The BHF says "we now know keeping active can help to improve your symptoms and quality of life." Rehab probably means fewer hospital stays overall, and European guidance recommends exercise for all stable patients.
"Pilates can reverse heart failure or strengthen the heart muscle"Strong evidence
No. The BHF says heart failure is "not reversible with exercise". Exercise trials improved fitness without changing how the heart pumped, and the one Pilates trial measured fitness, not the heart.
"Pilates can replace cardiac rehab"Strong evidence
No. NICE and the NHS say everyone with heart failure should be offered rehab, and the Pilates trial added Pilates to aerobic rehab rather than replacing it.
"Planks and long holds are fine as long as you don't hold your breath"Strong evidence
The BHF says avoid press-ups and planks, UK rehab avoids long held contractions as well as breath-holding, and long holds make holding the breath likely.
"If you get breathless, Pilates isn't for you"Emerging evidence
Getting a little more breathless is expected: stay at a talking pace, and in one trial the frailest people gained most from a supervised programme. Breathlessness lying flat, or out of proportion to what you're doing, is different: it is a warning sign.
It can be a good addition once you're stable and your heart failure team agrees, as the strength, balance and flexibility part of your week. But the evidence is one small trial of 16 people, where Pilates was added to aerobic rehab, and Pilates isn't a treatment for heart failure.
Can I do Pilates with heart failure?
Most people with stable heart failure can, with changes: sitting, standing or side-lying moves, no breath holds, no planks or floor push-ups, and a long warm-up. Do your cardiac rehab assessment first, as NICE advises.
Should I do cardiac rehab or Pilates?
Rehab first. In 60 trials, exercise-based rehab probably meant fewer hospital stays overall and a better quality of life, and NICE says everyone with heart failure should be offered it. Pilates can come alongside it or afterwards.
Which Pilates moves should I avoid with heart failure?
Planks, floor push-ups and long holds; moves where you might hold your breath, such as the Hundred done hard; legs-overhead moves; and lying flat if it makes you breathless. Bending forward brings on breathlessness in some people with heart failure, so keep forward bends small.
Can I lie on my back for Pilates?
Only if it's comfortable and your team is happy. Difficulty lying flat can be a sign of fluid building up, and UK rehab keeps lying exercises out of the main part of a session. Prop yourself up, or work sitting, standing or on your side.
How hard should Pilates feel?
Moderate at most: a bit warmer and breathing a bit more heavily, but still able to talk. On a beta blocker, go by how it feels rather than your heart rate.
How often should I do Pilates with heart failure?
Two or three times a week is reasonable alongside walking or cycling, with a few short sessions a day counting towards 150 minutes a week. Skip a session on a day you feel unwell or more tired or breathless than normal.
Will Pilates breathing help my breathlessness?
It may help you breathe calmly, but it isn't the same as breathing-muscle training with a hand-held device, which improved breathing strength and walking in small trials. Ask your rehab team about that, and keep Pilates breathing slow, with no holds.
Is reformer Pilates OK with heart failure?
It can be, with light springs and no straining; heavy springs make it easy to hold your breath and push too hard. Tell the teacher about your heart failure and any device.
I have an ICD or pacemaker. Can I do Pilates?
Yes, once your device clinic agrees; shocks were no more common with exercise in a large trial. Avoid strength work and heavy arm work for the first 4 to 6 weeks after an implant, and follow your clinic's arm limits.
When should I stop?
Stop for chest pain, palpitations, extreme breathlessness, light-headedness or if you run out of energy, and get help for the warning signs on this page. Contact your heart failure team if light activities are getting harder or you notice swelling or sudden weight gain.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
