Rule of 2’s

So today, we are going to focus on the role PTs and PTAs need to be filling in the treatment and management of congestive heart failure. The first thing you need to address is the rule of twos. Don’t assume someone else had ever educated your patient about this. I cannot tell you how many patients I have seen on their 3rd or 4th exacerbation who have never been educated on fluid restrictions or daily weights (FYI, its all of them).

Obviously there are different stages of heart failure and the patients you are seeing may not be as advanced as some of the patients I am seeing, but that doesn’t mean they don’t need to be managing their condition. The different stages of heart failure all have different needs, no let’s take a look:

Stage A: Pre-Heart Failure. This basically means that the patient is at higher risk of developing heart failure, but they aren’t quite there yet. They probably already have CAD, CKD, DM, HTN or some other set of comorbidities that is leading them down this path. Probably starting some beta blockers and/or ACE inhibitors here. This is the stage we HOPE to see them in because exercise can make a huge different here!

Stage B: Heart Failure. This is the real deal. Cardiac dysfunction is starting to show its ugly face here. Beta blockers and ACE inhibitors continue, and there will likely be a few other medications added like spironolactone or a different kind of diuretic like hydrochlorothiazide (HCTZ). All of these have some nasty side effects. Patients may start showing a reduced ejection fraction if they have HFrEF (reduced ejection fraction). Cardiac valve repairs/replacements and coronary stenting are common here. The disease manifests here as structural changes to the heart. Of note, HIIT style-exercise has shown significant evidence for promoting left ventricular remodeling in an effort to stop or reverse this process! Intensities up in the 90-95% HRmax range are necessary.

Stage C: Heart Failure with active symptoms. These patients tend to show the symptoms regularly, and have now experienced significant changes to their heart morphology. Shortness of breath is common along with fatigue, edema, and nocturia. This is the stage at which we start implementing the Rule of 2s. Pacemakers and/or ICDs make their appearance here if rhythm drugs fail. These are the patients I see often and I still have them doing HIIT programs with great success!

Stage D: End Stage. These are the patients I also see often. If the patient has HFrEF (reduced Ejection Fraction) we are talking about VADs and transplants or continuous milrinone infusion. If they have HFpEF (preserved Ejection Fraction), we have to increase the treatment of all the things that cause heart failure like A-Fib, obesity, diabetes, and hypertension. Even still, exercise can make a huge impact here.

When it comes to End Stage, I tend to see a fair share of VAD patients. Ventricular Assist Devices are mechanical motors installed in the heart (either in the left or right ventricle, or both if you have my patients) to circulate blood. These can be used as a bridge to transplant or as a terminal device and are typically used for patients with a poor ejection fraction (EF). As you could imagine, people with VADs don’t have pulses or blood pressures because they don’t have a pulse… I had the rare opportunity to treat a patient in the home long term who had a Left VAD (EF 21%). It took two years of regular exercise but, you guys, his heart began to recover. The VAD offloaded him enough that his heart began to heal and remodel. By the end of my time with him, I was actually able to take a manual blood pressure and auscultate Korotkoff sounds over the sound of the motor. This is the magic of exercise prescription at work! But I digress…

Photo by Mike on

Overall, general heart failure management is simple:

The Rule of 2
2 Grams of Sodium
2 Liters of Fluid
2 Pounds of Weight Gain

I’ll break that down:

  • Your patient may only have 2000mg of sodium per day in their diet. This is tough for many patients with HF because much of the food they regularly eat (which is part of what lead them to having HF) comes from a box or a deli counter and is, therefore, HIGH in sodium as a preservative. It’s the American way.
  • Your patient may only have 2000mL of fluid intake in a day. This sounds simple, but I promise you that it is not. Four of those single serving water bottles are equal to 2000mL (they are each 500mL). But patients drink more than water. They drink coffee, soup, juice, and tea. They eat ice chips (really, I promise). So, this does actually become tough to measure.
  • They cannot gain more than 2 pounds in a day (or five pounds in a week). This means that they have to weigh themselves at the same time every day and record this weight for further reflection. This is the practical method of watching for the beginnings of fluid overload. This can be treated if it is caught early and we can avoid an exacerbation and hospitalization.

First step: Refer to a dietician! Let’s be real, we aren’t experts at this stuff. And heart failure comes with its own diet plan! So why not get them directly to the person with that info! The dietician will help them with the sodium part particularly.
Second step: Figure out a method of measuring fluid intake that works for the patient. My favorite is to have a 2 liter bottle on the kitchen counter next to the sink. Every time they want a drink, they fill their cup with that amount of water from the sink, dump it into the 2 liter bottle, and then fill their cup with that same amount of whatever they are drinking. That way, they can watch the bottle fill up over the course of the day and know exactly how much they have to go.
Third Step: Safely getting up on to and down from the scale for daily weights. It always amazes me that no one ever thinks to use their walker. Walk the walker right over the scale and step up on it, let go for a second to measure weight, then grab the walker and keep walking right back down off the scale. Done. Keep the weight log right next to the scale with a pen so they always remember to write it down.

Ongoing Step: Monitor symptoms (lower extremity swelling, shortness of breath, crackles with lung auscultation which could lead to oxygen desaturation with activity, abdominal distention) and check vitals. This we should really be doing anyway! You can use this super handy Red/Yellow/Green light handout for your patient (and yourself) so that everyone knows whats the plan is and what to watch out for! I love that the language is super patient friendly.

Source: Heart Failure Zones from the American Association of Heart Failure Nurses

It’s also important to remember that these guidelines are general. A patient may have more specific restrictions like only being allowed 1.5 liters of fluid intake per day or only 1500mg of sodium per day. Those orders come from the physician so if you don’t see it stated, be sure to check. There is also a caveat to the weight gain/loss rule. If you are exercising your patient to a sufficient intensity, you may see weight gain over time due to gain of muscle mass. You may also see significant weight gain if a patient is recovering from a severe exacerbation that left them unable to eat for a time. Still notify the doctor, that’s their call.

And for the final and most important step in the process….. EXERCISE! You can view the BRAND SPANKING NEW Clinical Practice Guidelines for Physical Therapists in the Treatment of Heart Failure for all the information you’ll need on that! You can read about more specifics HERE.

What is your method of teaching patients how to monitor their fluid intake? Tell me about it in the comments!

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Cleveland Clinic. (2020). Heart Failure: Understanding Heart Failure: Management and Treatment. Retrieved from

Shoemaker, M. J., Dias, K. J., Lefebvre, K. M., Heick, J. D., & Collins, S. M. (2020). Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure. Physical therapy100(1), 14–43.

American Association of Heart Failure Nurses. (2017). Zone Tool for Heart Failure. Retrieved from

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