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11.2 Patient education, self-care, and

lifestyle advice Education, self-care, and lifestyle advice empower patients and their caregivers in managing HF and engage in shared decisionmaking. Self-care incorporates education and strategies to support maintenance, monitoring, and management of HF.973 The aim is to ensure people with HF and their caregivers are equipped with knowledge and skills and be partners in their care and not simply recipients of information and treatments. The benefits of self-care are described in a meta-analysis of 20 RCTs including 5624 patients.977 Self-management interventions on the background of usual HF care improved QoL and reduced time to HFH or all-cause death. There may be some barriers to self-care, but these can be overcome by careful design of programmes982,983 (see Supplementary data online, Section S8.2). Effective self-care enhances QoL, reduces symptom severity, and lowers the risk of hospitalization. It is essential that HF professionals collaborate with patients and caregivers, using shared decision-making to develop personalized self-care plans (Supplementary data online, Table S24).

11.3 Implementation and adherence to

therapy 11.3.1. Implementation and optimization Implementation of HF therapies should be individualized, based on available evidence, and involve the HF-MDT and patients and caregivers. Yet, there remain delays to implementation and optimization of treatments.984–986 Multivariable adjusted large observational studies suggest that among the strongest factors associated with improved FMT, AMT, and GDIT use is access to cardiologist specialists.987–990 For barriers and facilitators to improved implementation of HF therapies, including clinical inertia, impact of race, ethnicity, gender, and health literacy, see Supplementary data online, Table S25. Evidence supports the role of HF nurses and pharmacists in the implementation and optimization of HF therapies and avoidance of unnecessary side effects of polypharmacy.991–994 Pharmacists play a key role in ensuring safe and effective use of medicines, including medication reconciliation and the optimization of therapies for comorbidities. Development of the HF-MDT to support the implementation and optimization of HF and to address the barriers that exist is key to improving outcomes for patients.

11.3.2 Long-term adherence

Adherence to self-care strategies and therapies is essential to control symptoms, limit disease progression, and reduce hospitalization and death.981 Factors that impact adherence and affect clinical outcomes include health literacy, polypharmacy, and managing multiple health conditions.978,979,995 Strategies to improve adherence in the context of HF have been described elsewhere and provide guidance on the use of education tailored to the individual, communication skills, polypharmacy review, and co-ordinated care.980,996 Central to these is the importance of the HF-MDT recognizing the barriers to adherence, assessing those barriers, and utilizing other members of the health and social care team to address them. 11.4 Exercise training and cardiac

rehabilitation 11.4.1. Benefits of exercise training according to heart failure stage and phenotype There is consistent evidence that exercise training improves exercise tolerance and health-related QoL in patients with HF.94 HF-ACTION was the largest RCT on exercise training in HF including 2331 patients with LVEF ≤35% (NYHA classes II–IV). Compared with usual care, supervised exercise training plus usual care showed modest, non-significant reductions in allcause death and hospitalizations. However, prespecified adjustments revealed significant reductions in CV death and HFH.997 A systematic review of 60 trials with 8728 patients (mean age 63 years, mean LVEF 32%) confirmed improvements in functional capacity, QoL, and reductions in HFH with exercise training but found no reduction in death.998 Similar findings were reported by another systematic review focusing on HFrEF (LVEF <40%).94,999 In HFpEF, exercise training is safe and significantly enhances exercise capacity and QoL, with no significant impact on diastolic function, arterial stiffness, or vascular function, and insufficient data exist to assess its impact on clinical events, such as death and hospital admissions, due to small sample sizes and short follow-up times.1000,1001 Most trials in HF, except for HF-ACTION, are too small to reliably evaluate the effects of exercise rehabilitation across subgroups (see Supplementary data online, Section S8.4).1002,1003 In patients with long-term mechanical support, the benefit of exercise training on functional capacity has been demonstrated.1004,1005 The Rehab-VAD trial showed that moderate intensity aerobic training was safe in patients with continuousflow LVADs and yielded significantly improved health status, treadmill time, and leg strength, without significant improvements in peak oxygen consumption.1006 If a patient with advanced HF can tolerate physical activity, exercise training can improve QoL.1007 Exercise training before and after heart transplantation should follow recommendations according to the consensus document.1008

11.4.2 Safety and contraindications

No major adverse effects of exercise training were reported in the included studies of above systematic reviews and meta-analyses.1001,1009 However, exercise interventions should only be initiated in stable individuals after initiation of FMT. Exercise training is contraindicated in patients with refractory/unstable angina and other high-risk CV conditions (e.g. high-grade arrhythmias, DHF, active thromboembolic disease) and in any other unstable non-cardiac condition (e.g. active infection, uncontrolled diabetes, end-stage cancer, COPD exacerbation).94

11.4.3 Exercise prescription

A personalized training programme, with the mode of delivery, type, and intensity tailored to the patient’s preferences, risk level, and comorbidities, is recommended to improve uptake of exercise-based cardiac rehabilitation. Exercise training should be started as part of cardiac rehabilitation and be individually prescribed according to the FITT model (frequency, intensity, Downloaded from academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehag100/8766302 by guest on 31 August 2026