For patients with stable New York Heart Association class II to III HF (table 3) who do not have advanced arrhythmias and who do not have other limitations to exercise, we recommend offering a cardiac rehabilitation program. The beneficial effects of exercise are seen with high or low levels of training, and are apparent as early as three weeks after training. There are not enough data at present to recommend cardiac rehabilitation for patients with advanced HF.
Lifestyle modification — Recommendations for lifestyle modification are largely based upon observational studies and physiologic rationale, as there have been scant randomized trials on the effects of lifestyle modification:
●Cessation of smoking.
●Restriction of or abstinence from alcohol consumption, including the use of support groups such as Alcoholics Anonymous; avoidance of illicit drug use (eg, cocaine). (See "Alcoholic cardiomyopathy".)
●Based on expert opinion and limited evidence, we advise our patients with HF to restrict sodium intake to 3 g/day. This level of sodium restriction is likely sufficient for most patients with HF, and there is limited evidence of harm with more restrictive sodium intake. The 2013 ACC/AHA HF guidelines suggest some degree (eg, <3 g/day) of sodium restriction in patients with symptomatic HF [13]. The 2016 ESC HF guidelines suggest avoiding excessive salt intake (>6 g/day) [3]. (See "Heart failure self-management", section on 'Sodium restriction'.)
●We suggest fluid restriction (eg, 1.5 to 2 L/day) only in patients with refractory (stage D, class IV) HF or symptomatic or severe hyponatremia (serum sodium <120 meq/L) [13]. (See "Heart failure self-management", section on 'Fluid restriction' and "Hyponatremia in patients with heart failure", section on 'Treatment' and "Overview of the treatment of hyponatremia in adults", section on 'Fluid restriction'.)
●Avoidance of obesity. (See "Obesity in adults: Overview of management".)
●Daily weight monitoring is recommended to detect fluid accumulation before it becomes symptomatic.
We avoid the use of any NSAIDs in patients with established HF because of the increased risk of death and cardiovascular morbidity associated with their use; the possibility of drug-induced disease should be considered in patients without a prior history of HF if symptoms or signs of HF develop during use of any selective cyclooxygenase (COX)-2 inhibitor or nonselective NSAID. These drugs should be used with caution and in the lowest dose necessary if required in this setting.
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