Exercise is safe and beneficial for heart failure patients and should be recommended even in patients awaiting heart transplant surgery. The statement includes a lengthy literature review on exercise in heart failure patients and concludes that exercise increases exercise capacity and quality of life and shows benefits in muscle structure, vascular flow, and endothelial function. Since there is no agreement in the literature about what training regimen should be used, the committee recommends an individualized approach for each patient, with a rough guideline of 20 to 30 minutes 3 to 5 times a week, with an additional warm-up and cool-down period. The committee recommends supervised exercise, particularly during the early stages of the training, with home training possible for healthier patients and frequent follow-up in all cases. The authors note that exercise intolerance is not strongly related to lower indices of resting ventricular function such as ejection fraction. There are, however, many peripheral factors that seem to be involved, such as abnormalities in blood flow and vascular endothelial function, neurohormonal response, and skeletal muscle metabolism. These peripheral effects seem to be ameliorated by increased exercise training. The statement also specifies areas that merit future research. Of importance is determining whether the short-term benefits of exercise training translate into long-term effects and a resulting drop in hospitalization and morbidity of heart failure. There is also a need to determine whether there is a patient population with heart failure that does not benefit from or is even put at risk by exercise training. Some of these questions will be answered by an upcoming trial, A Congestive Heart Failure Trial Investigating Outcomes of Exercise Training (ACTION). That trial, which is beginning to enroll patients this month, will enroll 3000 patients with stage 2 to stage 4 heart failure and randomly assign them to a formal exercise program at a cardiac center or to education on the importance of exercise but without entry into a formal program. This will hopefully give us the answers we are seeking, Pina said. If exercise is shown to have a beneficial impact on survival and hospitalization rates, it will really be a cost-effective, low-tech approach to helping these patients.