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.......................................................................................................................................... QOL or prognosis; however, providing this information has become a key component of education for self-care.

General educational approaches include: • Providing information in a variety of formats that take into account educational grade and health literacy. Consider approaches with active roles for patients and caregivers such as ‘ask-tell-ask’, ‘teach back’, or motivational interviewing. Reinforce messages at regular time intervals. • Recognizing barriers to communication (language, social skills, cognition, anxiety/depression, hearing or visual challenges). • Recommending ‘HFmatters.org’. Offer help and guidance to use it and offer discussion of questions arising. • Inviting patients to be accompanied by a family member or friend. Key topics to include are recommended in Table 12.

9.4 Exercise rehabilitation

There is consistent evidence that physical conditioning by exercise training improves exercise tolerance, and health-related QOL in patients with HF. Clinical trials and meta-analyses in people with HFrEF show that exercise rehabilitation improves exercise capacity and QOL. Several meta-analyses also show that it reduces all-cause and HF hospitalizations, although uncertainty persists about its effects on mortality.322328 The effect on hospitalization is seen in those who are highly adherent to the exercise programme.329 Highintensity interval training, in patients who are able and willing, may improve peak oxygen consumption (VO2).330,331 Supervised exercise-based rehabilitation should be considered in those who are frail, who have more severe disease or comorbidities.95

Physical conditioning also improves exercise capacity and QOL.332335 No data on HFmrEF are available, but benefits observed in the other groups of HF should also apply to this group.

9.5 Follow-up of chronic heart failure

9.5.1 General follow-up This is a relatively understudied area. Patients with HF, even if symptoms are well controlled and stable, require follow-up to ensure continued optimization of therapy, to detect asymptomatic progression of HF or its comorbidities and to discuss any new advances in care. These guidelines recommend follow-up at intervals no longer than 6 months to check symptoms, heart rate and rhythm, BP, full blood count, electrolytes, and renal function. For patients recently discharged from hospital, or in those undergoing uptitration of medication, follow-up intervals should be more frequent. Whether such stable patients need to be followed-up by cardiologists is uncertain. Some studies suggest that follow-up in primary care may be appropriate.303,339 However, uptake of evidence-based interventions is poor in many settings340,104 and several studies suggest that care and follow-up provided by HF specialists, and use of quality improvement registries can lead to higher rates of optimal therapy and improved outcomes.341343

An ECG should be done annually to detect QRS prolongation344 as such patients may become candidates for CRT. Furthermore, it may identify conduction disturbances and AF. Serial echocardiography is generally not necessary, although an echocardiogram should be repeated if there has been a deterioration in clinical status. An echocardiogram is also advised 36 months after optimization of standard therapies for HFrEF to determine the need for addition of newer pharmacological agents and implanted devices.

9.5.2 Monitoring with biomarkers Trials investigating the use of biomarkers (particularly BNP and/or NT-proBNP) to guide pharmacotherapy for HFrEF have produced conflicting results.345352 They are undoubtedly good prognostic markers.72,353,354 Conceptually, it is not clear what a biomarkersupported strategy might offer in addition to assiduous application of guideline-recommended therapy. Current evidence, therefore, does not support the routine measurement of BNP or NT-proBNP to guide titration of therapy.

9.6 Telemonitoring

Telemonitoring enables patients to provide, remotely, digital health information to support and optimize their care. Data such as

Table 12 Continued

Education topic Goal for the patient and caregiver Professional behaviour and educational tools

To recognise that the carer or family members may be

greatly affected and need to seek help.

Family and informal caregivers To be able to ask for support. Discuss the preference of caregiver/family involvement.

Involve patients and caregivers in a respectful way.

CMP = cardiomyopathy; CV = cardiovascular; HF = heart failure. a1 unit is 10 mL of pure alcohol (e.g., 1 glass of wine, 1=2 pint of beer, 1 measure of spirit).

Recommendations for exercise rehabilitation in patients with chronic heart failure

Recommendations Classa Levelb

Exercise is recommended for all patients who are able in order to improve exercise capacity, QOL, and reduce HF hospitalization.c 324328,335337 I A A supervised, exercise-based, cardiac rehabilitation programme should be considered in patients with more severe disease, frailty, or with comorbidities.95,324327,338 IIa C

HF = heart failure; QOL = quality of life. aClass of recommendation. bLevel of evidence. cIn those who are able to adhere to the exercise programme. ESC 2021

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