Initially, exercise should be supervised to educate the patient on heart rate response and level of exercise and to gradually increase exercise duration and intensity. The exercise goal is 30 minutes of moderate activity 5 d/wk with warm-up and cool-down periods (Strength of In the European Society of Cardiology guidelines, it is recommended that regular aerobic exercise be encour- aged to improve functional capacity and symptoms.317 The 2013 ACCF/AHA HF guidelines indicate that exer- cise training (or regular physical activity) is recommend- ed as safe and effective for patients with HF who are able to participate to improve functional status8,230,319,320 (Level of Evidence A). Stage A or B HF 1. Exercise or regular physical activity is ben- eficial in prevention of CVD and HF (Class I; Level of Evidence B).193,311 316 Stage C HF 1. Exercise training (or regular physical activ- ity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status8,230,319,320 (Class I; Level of Evidence A). Summary and Future Directions As addressed in the earlier sections, lifestyle modifica- tion and the management of comorbidities remain chal- lenging in patients with HF. Despite intensive lifestyle and medical interventions, the prevention and optimal treatment of hypertension, diabetes mellitus, obesity, and metabolic syndrome have often proved difficult in patients with HF. These comorbidities are highly prevalent and are associated with the development of incident HF in the general population. However, in patients with established HF, their contributory roles to clinical outcomes are para- doxical; that is, patients with HF with diabetes mellitus, obesity, and hypertension usually are associated with better outcomes than patients without those comorbidities individually, making their management targets and treatment reasons quite challenging. 