A newly published correspondence in The Lancet takes issue with a recent Seminar on heart failure with reduced ejection fraction, or HFrEF, for leaving out what the authors describe as guideline-recommended regular physical activity counselling and supervised exercise training. The letter, written in response to the Seminar by Antonio Cannata and colleagues on novel diagnosis and management approaches, argues that exercise-based interventions deserve a place alongside drug therapy in the standard care of these patients.
The correspondents say they read the Seminar with great interest but were surprised by the omission. Their central point is that physical activity counselling and supervised exercise training are not optional extras. They are recommended in clinical guidelines and, when combined with pharmacotherapy, offer benefits that patients with HFrEF would otherwise miss. The letter does not dispute the value of the pharmacological advances discussed in the original Seminar. Instead, it positions exercise as a complementary pillar of management that should be addressed in any comprehensive review of how the condition is treated.
HFrEF is a form of heart failure in which the heart muscle is unable to pump enough blood forward because its ejection fraction — the share of blood leaving the ventricle with each beat — is reduced. It is a common and serious condition, and its management typically involves a combination of medications, lifestyle measures, and in some cases devices or surgery. The correspondence highlights that regular physical activity and structured exercise programmes are part of that landscape, particularly when supervised by clinicians who can tailor the intensity and format to the patient's capacity.
The letter's authors frame their intervention as a corrective rather than a rebuttal. They note that supervised exercise training has been recommended in guidelines, and they emphasize its benefits in combination with pharmacotherapy. That phrasing matters: the argument is not that exercise should replace drugs, but that the two approaches work together. For patients living with reduced pumping function, a care plan that includes both medical therapy and a structured activity programme may address symptoms, functional capacity, and overall cardiovascular risk more fully than either approach alone.
The correspondence also draws attention to the role of counselling. Recommending regular physical activity is one thing; helping patients adopt and maintain it is another. The letter points to guideline-recommended counselling as a distinct clinical task, suggesting that clinicians should discuss activity levels with patients and, where appropriate, refer them to supervised training. That kind of support can be especially relevant for people who are deconditioned, anxious about exertion, or unsure how much activity is safe after a heart failure diagnosis.
By raising the issue in the pages of a major medical journal, the correspondents are pushing for exercise to be treated as a standard element of HFrEF care rather than an afterthought. The exchange reflects a broader conversation in cardiology about how to integrate lifestyle and rehabilitation services into routine practice, particularly as pharmacological and device-based therapies continue to evolve. The letter does not present new trial data of its own. Its contribution is to remind readers of the original Seminar — and the wider clinical community — that guideline-recommended activity counselling and supervised exercise training belong in the discussion.
For patients and families, the practical takeaway is that movement remains part of the medical conversation about heart failure with reduced ejection fraction. The correspondence urges clinicians not to let that part of care drop out of view, even as attention focuses on novel diagnostic and treatment strategies. The authors close by underscoring the benefits of exercise when it is combined with pharmacotherapy, a message they say should have been included in the original review.
