ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 2.2. Physical Infrastructure of a Rehabilitation Service 2.2.1. General Aspects A CVR program can be run out of various types of facilities, depending on its objectives and on the available resources. Most often, CVR programs are carried out indoors, in air‑conditioned environments, although exercise sessions can be held in outdoor venues such as running tracks, courts, gymnasiums, parks, or public recreation spaces. 29 Indoor venues should be adequately sized and appointed, with dimensions and characteristics varying according to local resources and service capacity. The space should be large enough for patients to exercise in, ideally with a ceiling height not less than 2.5 meters. It should also be properly lit, well ventilated, and climate-controlled so as to maintain a temperature of 22–25°C and a relative humidity of 40–65% during sessions. The exercise area per se, not considering changing rooms, restrooms, and the reception area or waiting room, varies greatly – from 20 m 2 to a several hundred square meters. Proper changing rooms and restrooms are essential. To minimize the risk of accidental falls, slip-resistant flooring is mandatory. 29 2.2.2. Fitness and Exercise Equipment 2.2.2.1. Aerobic Exercise The most commonly used aerobic exercise equipment are treadmills and stationary bicycles (cycle ergometers), but upper-body ergometers, rowing machines, cross-country ski machines, and elliptical trainers can be used, among countless others. 29 Treadmills must be electric, with a nominal capacity of at least 100 kg body weight, front and side supports for the hands, and a safety key. They must also allow individualized adjustments of speed and slope over a wide range. Cycle ergometers can be mechanical or electromagnetically braked. There are specific models for the upper body, and even some models which allow all four limbs to be exercised simultaneously. Conventional (lower body) models may be upright or recumbent. Ideally, the cycle ergometer should provide a readout of cadence or speed and, most importantly, power (in watts). Some cycle ergometers allow the user to program the intensity directly in watts, so that the resistance of the pedals increases when the cadence decreases and vice versa. Rowing machines, ski machines, and elliptical trainers can be particularly useful for patients with a lower degree of functional limitation or who have had previous experience with such equipment. These devices provide the advantage of allowing simultaneous exercise of the upper and lower limbs. 2.2.2.2. Strength Training Several types of equipment can be used for strength training. Bodyweight exercises, which require no equipment at all, are often sufficient in the most debilitated patients. One representative and functional example is rising from a seated position, which requires only a chair or bench. Ropes or straps, firmly attached to the ceiling or high on a wall, can also be used to facilitate a wide range and variety of bodyweight exercises. Free weights, dumbbells, or ankle weights are often adopted in CVR programs, as they allow patients to execute a wide range of movements and provide appropriate stimulation of different muscle groups. Specific devices consisting of weights connected to cables and pulleys, known as cable machines or stack machines, can also be used. Other useful equipment includes workout bars, weighted exercise balls (also known as medicine balls), stability balls (also known as Swiss balls), and elastic bands or tubes (also known as exercise bands or resistance bands) with varying degrees of resistance. 29 During all exercises, attention must be paid to proper posture and execution of the prescribed movements, so as to prevent musculoskeletal injuries. Attention when handling exercise equipment is also important to prevent accidents and potential injury. 2.2.2.3. Other Exercise Modalities With a view to overall health, considering heart disease and associated conditions, patients may benefit from or even require other types of exercise, such as isometric handgrip training, inspiratory muscle training, and exercises designed to improve balance and flexibility. 2.2.3. Monitoring Several modalities are available for patient monitoring, including heart monitors, mobile applications for monitoring heart rate (HR), glucometers, pulse oximeters, and conventional devices such as sphygmomanometers and stethoscopes. Depending on the clinical complexity and the risk of unfavorable cardiovascular events, continuous electrocardiographic monitoring (at rest or during exercise) may be convenient. This can be achieved by conventional ECG (connected directly to the patient) or by telemetry systems. Rapid access to monitoring equipment is of fundamental importance for proper detection and subsequent management of potential cardiovascular events. 2.2.4. Safety Although serious cardiovascular events – such as cardiac arrest, which, in most adults, results from ventricular fibrillation or pulseless ventricular tachycardia – are extremely uncommon during CVR, it is essential that all programs have a plan in place to respond appropriately to these events if they do occur. Therefore, a defibrillator (whether manual or automated) is mandatory safety equipment. Other basic and advanced life support supplies must also be available, such as laryngoscopes, orotracheal tubes of various sizes, masks, a bag-valve-mask manual resuscitator, and supplemental oxygen. For more detailed guidance on techniques, equipment, and recommended drugs, readers are advised to check subject- specific guidelines. 35,36 948