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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e927 CLINICAL STATEMENTS AND GUIDELINES

Synopsis Exercise training in patients with HF is safe and has numerous benefits. In a major trial of exercise and HF, exercise training was associated with a reduction in CVD mortality or hospitalizations in the exercise training group after adjustment for risk factors.1 Meta-analyses show that cardiac rehabilitation improves functional capacity, exercise duration, and health-related QOL. A cardiac rehabilitation program for patients with HF usually includes a medical evaluation, education regarding the importance of medical adherence, dietary recommendations, psychosocial support, and an exercise training and physical activity counseling program. Patients with HF on optimal GDMT, who are in stable medical condition and are able to participate in an exercise program, are candidates for an exercise rehabilitation program.10,11

Recommendation-Specific Supportive Text

1.	 Evidence from RCTs indicates that exercise training improves functional status, exercise performance, and QOL in patients with HFrEF and HFpEF. In HF-ACTION, the largest randomized trial with exercise training in patients with HF,1 2331 patients with LVEF ≤35% (NYHA class II and III) were randomized to usual care versus supervised exercise training plus usual care. There were modest reductions in all-cause mortality and hospitalization rates that did not reach significance by primary analysis but, after prespecified adjustment, were associated with reductions in cardiovascular mortality or HF hospitalizations.1 Many RCTs of exercise training in HF have been conducted, but the statistical power of most was low.2–5,9–13 Meta-analyses suggest that exercise training is associated with improvement in functional capacity, exercise duration, healthrelated QOL, and reduction in HF hospitalizations in patients with HFrEF as well as HFpEF.2–6,8,11,14,15 Most studies and meta-analyses have not shown significant changes in all-cause mortality.2,12,14–22 except for a few showing mortality benefit with longer follow-up6,7 Other benefits of exercise training include improved endothelial function, blunted catecholamine spillover, increased peripheral oxygen extraction, and improvement in peak oxygen consumption.2–5,8,10–12,21 2.	 A formal cardiac rehabilitation program usually includes a medical evaluation, education regarding the importance of medical adherence, dietary recommendations, psychosocial support, and an exercise training and physical activity counseling program. Exercise-based cardiac rehabilitation has been associated with an improvement in functional capacity, exercise tolerance, the rate of overall and HF-specific hospitalization, and improved QOL.3,4,6,7,11,16,17 In a diverse population of older patients who were hospitalized for acute decompensated HF, an early, transitional, tailored, progressive rehabilitation intervention that included multiple physical-function domains (strength, balance, mobility, and endurance) initiated during, or early after hospitalization for HF, and continued after discharge, resulted in greater improvement in physical function than usual care.9

7.2 Diuretics and Decongestion Strategies in

Patients With HF Recommendations for Diuretics and Decongestion Strategies in Patients With HF Referenced studies that support the recommendations are summarized in the Online Data Supplements.

COR LOE Recommendations

1 B-NR 1.	 In patients with HF who have fluid retention, diuretics are recommended to relieve congestion, improve symptoms, and prevent worsening HF.1–5

1 B-NR 2.	 For patients with HF and congestive symptoms, addition of a thiazide (eg, metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderateor high-dose loop diuretics to minimize electrolyte abnormalities.6

Synopsis Bumetanide, furosemide, and torsemide inhibit reabsorption of sodium or chloride at the loop of Henle, whereas thiazide and thiazide-like diuretics act in the distal convoluting tubule and potassium-sparing diuretics (eg, spironolactone) in the collecting duct.7,8 Loop diuretics are the preferred diuretic agents for use in most patients with HF. Thiazide diuretics such as chlorthalidone or hydrochlorothiazide may be considered in patients with hypertension and HF and mild fluid retention. Metolazone or chlorothiazide may be added to loop diuretics in patients with refractory edema unresponsive to loop diuretics alone. Diuretics should be prescribed to patients who have evidence of congestion or fluid retention. In any patient with a history of congestion, maintenance diuretics should be considered to avoid recurrent symptoms. The treatment goal of diuretic use is to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia. With the exception of MRAs, the effects of diuretics on morbidity and mortality are uncertain.1–5 As such, diuretics should not be used in isolation but always combined with other GDMT for HF that reduces hospitalizations and prolongs survival. Table 12 lists oral diuretics recommended for use in the treatment of chronic HF. Hyponatremia complicates HF management. If reversing potential causes and free water restriction do not improve hyponatremia, vasopressin antagonists may be helpful in the acute management of

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