ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Content 1. Introduction .........................................................................................946 1.1. Strengths (Grades) of Recommendation ...........................................947 1.2. Levels of Evidence ............................................................................947 2. Structure of a Cardiovascular Rehabilitation Program ..........................947 2.1. Staffing and Individual Responsibilities ............................................947 2.1.1. Primary Physician .........................................................................947 2.1.2. Lead Physician of Cardiovascular Rehabilitation Program ...........947 2.1.3. Other Health Care Workers ..........................................................947 2.1.4. Physical Therapists and Physical Educators .................................947 2.1.5. Nurses ...........................................................................................947 2.2. Physical Infrastructure of a Rehabilitation Service ............................948 2.2.1. General Aspects ............................................................................948 2.2.2. Fitness and Exercise Equipment ....................................................948 2.2.2.1. Aerobic Exercise .........................................................................948 2.2.2.2. Strength Training ........................................................................948 2.2.2.3. Other Exercise Modalities ..........................................................948 2.2.3. Monitoring ....................................................................................948 2.2.4. Safety ............................................................................................948 3. Phases of Cardiovascular Rehabilitation and Risk Stratification ..........949 3.1. High Clinical Risk ..............................................................................949 3.2. Intermediate Clinical Risk .................................................................950 3.3. Low Clinical Risk ...............................................................................951 4. Cost-Effectiveness of Cardiovascular Rehabilitation .............................951 5. Home-Based Cardiovascular Rehabilitation .........................................952 6. Integration of Cardiovascular Rehabilitation into Optimized Clinical Care of Cardiovascular Diseases ......................................................................953 6.1. General Guidance for Increasing Physical Activity and Engagement in Physical Exercise .....................................................................................953 6.2. Hypertension ....................................................................................955 6.2.1. Therapeutic Benefits of Physical Exercise .....................................955 6.2.2. Indications for Physical Exercise in Hypertension ........................955 6.2.3. Pre-Exercise Evaluation .................................................................956 6.2.4. Special Considerations for the Prescription and Follow-Up of Physical Exercise Programs .....................................................................956 6.3. Stable Coronary Artery Disease after an Acute Event or Revascularization ................................................................................957 6.3.1. Therapeutic Benefits of Physical Exercise .....................................957 6.3.2. When Is Rehabilitation Indicated? ................................................957 6.3.3. Pre-Exercise Evaluation and Exercise Prescription .......................958 6.3.4. Special Considerations for the Prescription and Follow-Up of Physical Exercise Programs .....................................................................959 6.3.4.1. Refractory Angina .......................................................................959 6.3.4.2. Exercise Training with Myocardial Ischemia ..............................959 6.3.4.3. Drug Adjustments in Response to Physical Exercise ..................959 6.4. Heart Failure .....................................................................................960 6.4.1. Pre-Exercise Evaluation and Exercise Prescription .......................960 6.4.2. Final Considerations on Heart Failure ..........................................962 6.5. Heart Transplantation .......................................................................962 6.5.1. Benefits of Physical Exercise .........................................................962 6.5.2. Pre-Exercise Evaluation and Unique Features ..............................963 6.5.3. Exercise Prescription .....................................................................963 6.5.4. Home-Based Cardiovascular Rehabilitation .................................963 6.5.5. Recommendations ........................................................................964 6.6. Cardiomyopathies .............................................................................964 6.6.1. Hypertrophic Cardiomyopathy .....................................................964 6.6.1.1. Therapeutic Benefits of Physical Exercise ...................................965 6.6.1.2. When Is Physical Exercise Indicated? .........................................966 6.6.1.3. Pre-Exercise Evaluation ..............................................................966 6.6.1.4. Unique Features in the Prescription and Follow-Up of Physical Exercise Programs ...................................................................................966 6.6.2. Myocarditis ...................................................................................967 6.6.3. Other Cardiomyopathies ..............................................................967 6.6.3.1. Arrhythmogenic Right Ventricular Cardiomyopathy ..................967 6.6.3.2. Noncompaction Cardiomyopathy ..............................................968 6.7. Valvular Heart Disease ......................................................................968 6.7.1. Pre-Intervention Phase .................................................................968 6.7.2. Post-Intervention Phase ................................................................968 6.7.3. Pre-Exercise Evaluation .................................................................969 6.7.4. Special Considerations for the Prescription and Follow-Up of Physical Exercise Programs .....................................................................969 6.8. Patients with Artificial Pacemakers or Implantable Cardioverter‑Defibrillators ........................................................................970 6.8.1. Therapeutic Benefits of Physical Exercise .....................................970 6.8.2. When Is Cardiovascular Rehabilitation Indicated? .......................971 6.8.3. Pre-Exercise Evaluation .................................................................971 6.8.4. Special Considerations for the Prescription and Follow-Up of Physical Exercise Programs .....................................................................971 6.8.5. Resistance Training .......................................................................973 6.8.6. Neuromuscular Electrical Stimulation ..........................................973 6.9. Peripheral Arterial Occlusive Disease ................................................973 References ..............................................................................................975 1. Introduction It is common sense—and has been scientifically proven – that physical activity helps to preserve and restore the health of both body and mind. The favorable effects of cardiovascular rehabilitation (CVR), with an emphasis on physical exercise, include significant reductions in cardiovascular and overall morbidity and mortality, 1 reductions in hospitalization rate, 1,2 and significant gains in quality of life, 1,2 as consistently documented in the literature, including in meta-analyses of randomized clinical trials. These effects justify the consensual, emphatic recommendation of CVR by major medical societies worldwide. 3-6 Sedentary behavior, which is highly prevalent in Brazil and elsewhere, is strongly associated with cardiovascular disease (CVD) and early mortality. 7,8 Conversely, higher levels of physical activity are positively associated with better quality of life and longer life expectancy. 9-13 In addition, there is a strong, inverse association of the various components of physical fitness with all-cause mortality and with occurrence of adverse cardiovascular events: the lower the level of physical fitness, the higher the mortality rate. 14-21 Therefore, the main objective of CVR, with an emphasis on physical exercise, is to improve the various components of physical fitness, both aerobic and non-aerobic (muscle strength/endurance, flexibility, balance). This requires a combination of different exercise modalities and types of training. In this view, beyond rehabilitation, CVR aims to provide the highest achievable level of physical fitness – in order to reduce the risk of further cardiovascular events – and to promote all of the other benefits derived from regular physical exercise. 14-21 However, despite its documented benefits and excellent cost-effectiveness, 22,23 CVR is underutilized worldwide. In Brazil, considering the size of the country and the diversity of its population, several barriers limit access to RCV, 24,25 such as a scarcity of structured services, limited urban mobility, and high rates of violence in cities. 26,27 Within this context, so-called home-based cardiovascular rehabilitation (HBCR) programs, 946