These recommendations reflect recommendations in the National Institute for Health and Clinical Excellence (NICE) guideline Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010], as well as guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2007] and European Society of Cardiology guidelines [European Society of Cardiology, 2008].

Recognizing the symptoms of heart failure

• The recommendation to teach people how to recognize the symptoms of heart failure is largely based on expert opinion [European Society of Cardiology, 2008].

How to monitor body weight

• The recommendation to teach people to monitor their weight is largely based on expert opinion [SIGN, 2007; European Society of Cardiology, 2008].
• Evidence from one study indicates that increases in body weight are not always associated with a deterioration of symptoms of heart failure and fluid retention [Lewin et al, 2005].

Keeping active and fit

• Keeping active and fit is generally recommended — see the CKS topic on CVD risk assessment and management. This may be even more important for people with heart failure and is widely recommended by experts on the basis of experience and evidence of benefit that is not always consistent [ICSI, 2007; SIGN, 2007; European Society of Cardiology, 2008; National Clinical Guideline Centre for Acute and Chronic Conditions, 2010].
• Older systematic reviews found small studies providing evidence that exercise reduces mortality and hospitalization, and improves exercise tolerance and health-related quality of life [Piepoli et al, 2004; Rees et al, 2004; Smart and Marwick, 2004].
• Two more recent randomized controlled trials (RCTs) in people with chronic heart failure suggest that intensive aerobic exercise may be more effective than less intensive exercise and weight training [Feiereisen et al, 2007; Wisloff et al, 2007].
• A small RCT found that 6 years after participation in a residential rehabilitation programme, people with chronic heart failure had slightly better outcomes than the control group, maintained exercise capacity, and engaged in activities that exceed the minimal amount recommended by guidelines for cardiovascular health [Mueller et al, 2007].
• A large RCT (1159 participants) found that exercise training resulted in a nonsignificant reduction in the risk of death (from any cause) or hospitalization, and a small but statistically significant improvement in self-reported health status [Flynn et al, 2009; O'Connor et al, 2009].
• A systematic review on the effects of moderate- to high-intensity resistance training in people with chronic heart failure found 10 trials, all with methodological flaws [Spruit et al, 2009]. The review concluded that the evidence on benefits was weak and inconsistent and that there was no evidence of harm.

Stopping smoking

• Stopping smoking is recommended for everyone — see the CKS topic on Smoking cessation. It may be even more important for people with heart failure.
• The effect of smoking cessation in people with heart failure has not been studied in clinical trials. However, current smoking was an independent predictor of readmissions for heart failure in two observational studies [Evangelista et al, 2000; Suskin et al, 2001].

Prudent use of alcohol

• Prudent use of alcohol is generally recommended — see the CKS topic on Alcohol - problem drinking. It may be even more important for people with heart failure.
• A recent review [Djousse and Gaziano, 2008] found:
• Good evidence that heavy alcohol use is associated with cardiomyopathy and that abstinence leads to improved survival.
• Limited evidence that moderate alcohol use reduces the risk of heart failure compared with abstinence.
• No evidence on the type of beverage and heart failure, or on drinking patterns (binge drinking versus frequent light to moderate drinking) and heart failure.

Losing excess weight and maintaining weight loss

• Losing excess weight and maintaining weight loss are generally recommended — see the CKS topic on Obesity.
• Losing excess weight is thought to be important for people with heart failure, although there is little evidence to support this assumption [Kenchaiah et al, 2007; Abdulla et al, 2008; Shirley et al, 2008].

Restricting salt consumption

• The recommendation to restrict salt consumption is largely based on expert opinion and extrapolation from evidence of the effects of salt consumption on hypertension [SIGN, 2007; European Society of Cardiology, 2008].
• Two RCTs of low-salt diets in people with heart failure found weak evidence for modest benefits in terms of weight loss, oedema, fatigue, quality of life, and New York Heart Association classification of heart failure [Alvelos et al, 2004; Colin Ramirez et al, 2004].

Restricting fluid intake

• The recommendation to restrict fluid intake in people with severe symptoms of heart failure is largely based on expert opinion [SIGN, 2007; European Society of Cardiology, 2008].
• One open-label RCT in people hospitalized for severe heart failure symptoms failed to find evidence of benefit from fluid restriction [Travers et al, 2007]. Nevertheless, there is no concern that fluid restriction to 1.5–2 L per day could be harmful.

Diarrhoea and vomiting

• The recommendation to stop treatment with an ACE inhibitor, AIIRA, diuretic, or spironolactone for a short time (1–2 days) is based on concern that continued treatment may increase the risk of acute renal failure [Stirling et al, 2003; McGuigan et al, 2005], and CKS expert reviewers (based on pharmacological and physiological knowledge of drug effects on the kidney).

Immunizations

• The recommendation for influenza and pneumococcal immunization is largely based on expert opinion and extrapolation from the benefits of these immunizations in other populations at risk — see the CKS topics on Immunizations - seasonal influenza and Immunizations - pneumococcal.
• A large epidemiological study in elderly people found that immunization against influenza was associated with reductions in the risk of hospitalization for heart disease, cerebrovascular disease, and pneumonia or influenza, as well as the risk of death from all causes during influenza seasons [Nichol et al, 2003].