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.................................................................................. The exercise session should be individually tailored for several weeks, according to symptoms and objective findings during exercise testing such as maximal exercise capacity, heart rate response, or arrhythmias. In atrial fibrillation (AF), exercise can only be monitored by power or Borg’s RPE. High-risk patients should be counselled more frequently during the initial phases. Ideally exercise should be supervised through an exercisebased cardiac rehabilitation programme while non-supervised homebased sessions should be gradually added.260 When all these measures are followed, the overall risk of exercise is low, even during higherintensity exercises and in patients with more severe HF.268,269 Follow-up examinations for exercise recommendations should be scheduled at least every 36 months. Intervals between examinations should depend on disease severity and comorbidities, setting of the sessions (supervised vs. home-based), patient’s age and adherence. 5.2.3 Exercise modalities and sports participation in heart failure Following risk factor control and therapy optimization, the individual with HF should be encouraged to start exercise programmes without delay.242,244,270 Initially home-based exercise programmes may also be prescribed and monitored.270,271 In uncomplicated cases low to moderate-intensity recreational sporting activities may be considered in parallel to the structured exercise programme. When prescribed, maximal exercise intensities should be monitored, for example, by heart rate monitors. If monitoring does not reveal any exercise-induced arrhythmias or other abnormalities, then all types of recreational sports activities are permitted (see Figure 2, section 4.1.2). 5.2.3.1 Aerobic/endurance exercise Aerobic exercise is recommended for stable patients [New York Heart Association (NYHA) class IIII], because of its welldemonstrated efficacy and safety.260 Recommendations on optimal exercise dose have been previously described in ESC and AHA Guidelines.242,270272 The most commonly evaluated exercise mode is moderate continuous exercise (MCE).242,270272 In patients in NYHA functional class III, exercise intensity should be maintained at a lower intensity (<40% of VO2peak), according to perceived symptoms and clinical status during the first 12 weeks. This should be followed by a gradual increase in intensity to 5070% VO2peak, and if tolerated, up to 85% VO2peak as the primary aim.270,271 Recently, high-intensity interval training (HIIT) programmes have been considered as an alternative exercise modality for low-risk patients.269 The most recent meta-analysis showed that HIIT was superior to MCE in improving VO2peak in individuals with HF with reduced (<40%) ejection fraction (HFrEF) in the short term.273 However, this superiority disappeared in subgroup analysis of isocaloric protocols. HITT programmes may be recommended initially to prepare low risk patients with stable HF who want to return to high intensity aerobic and mixed endurance sports (Figure 2, section 4.1.2). 5.2.3.2 Resistance exercise Resistance exercise training may complement, but not substitute, aerobic exercise training because it reverses skeletal muscle mass loss and deconditioning without excessive stress on the heart.270,274 The training intensity can preferably be set at the level of resistance at which the patient can perform 1015 repetitions at 15 on Borg’s RPE scale (Table 12).242,270 In patients with altered skeletal muscle function and muscle wasting, exercise training should focus initially on increasing muscle mass by using resistance programmes.275,276 Resistance programmes may specifically be considered for lowrisk stable patients, who want to return to strength-related power sports, e.g. weightlifting (Figure 2, section 4.1.2). A meta-analysis showed that resistance exercise as a single intervention has the capacity to increase muscle strength, aerobic capacity, and quality of life in HFrEF patients who are unable to participate in aerobic exercise programmes.277 Also, in advanced HF or in patients with very low exercise tolerance, resistance exercise can be safely applied if small muscle groups are trained.270,277,278 5.2.3.3 Respiratory exercise Inspiratory muscle training improves VO2peak, dyspnoea, and muscle strength,279282 and it typically involves several sessions per week with intensity ranging from 30% to 60% of maximal inspiratory pressure, and duration from 1530 min for an average of 1012 weeks.279 This training modality should be recommended to the most severely deconditioned individuals as an initial alternative who may then transition to conventional exercise training and sports participation, to optimize cardiopulmonary benefits.280 5.2.3.4 Aquatic exercise Aquatic exercise has not been recommended for individuals with HF, due to concerns that the increase in central blood Table 12 Optimal exercise training dose for patients with chronic heart failure ©ESC 2020 1 RM = one repetition maximum; RPE = rating of perceived exertion; VO2peak = peak oxygen consumption. 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