ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 3. Phases of Cardiovascular Rehabilitation and Risk Stratification Traditionally, CVR is divided into time-bound phases, with phase 1 occurring in hospital and phases 2 to 4 in the outpatient setting. In the early days of CVR, phase 1 was intended for recovery after acute myocardial infarction (AMI) or coronary artery bypass surgery (CABG). Subsequently, in the context of what is now known as cardiopulmonary and metabolic rehabilitation, phase 1 was expanded to include hospitalized patients who underwent percutaneous coronary intervention (PCI), valve replacement or repair surgery, procedures for congenital heart disease, and heart transplantation (HTx), in addition to those with heart failure (HF), coronary artery disease (CAD), diabetes, hypertension, and chronic lung and kidney disease (once clinically stable). Therefore, CVR should begin immediately once the patient is considered clinically stable as a result of clinical and/or interventional treatment. 31 In phase 1 of CVR, the aim is for the patient to be discharged from the hospital in the best possible physical and psychological condition and with guidance to pursue a healthy lifestyle, especially with regard to physical exercise. A combination of low-intensity physical exercise, techniques for stress control, and education on risk factors and heart disease is recommended. The team must be composed of at least one physician, one physical therapist, and one nurse. All should be trained specifically in CVR, but full-time dedication to the rehabilitation program is not required; team members are free to perform other duties in the hospital. 31 Upon discharge from hospital, patients must be referred to the outpatient phases of CVR. Phase 2 begins immediately after hospital discharge and lasts, on average, 3 months. Phase 3 usually lasts 3 to 6 months, and phase 4 is quite prolonged. In all phases, the goal is to obtain progressive benefits from RCV or at least maintain any gains obtained. A strict division of CVR into time-bound phases may fail to take into account that some very symptomatic, debilitated patients with severe heart disease will remain in long-term “phase 2” rehabilitation, as they continue to require direct supervision of physical exercise, while other low-risk patients may be fit for phase 3 or even phase 4 programs straight away, and are thus candidates for home-based CVR (in which most sessions take place under indirect, remote supervision). 31 Therefore, stratification of clinical risk is recommended to enable a more rational use of CVR programs, with individualized targeting of phases and modalities. In this context, high-risk patients, those with less physical capacity, and those most symptomatic should participate in supervised sessions indefinitely, while those at lower risk, with greater physical capacity and fewer or less severe symptoms can engage in a wider range of more intense exercises without direct supervision (Figure 1). Stratification of clinical risk as high, intermediate, or low is based on existing recommendations, 4,28,37 while the cut‑off points for this classification are based on expert opinion (level C evidence), and can thus be modified according to the experience of the CVR team and the discretion and judgment of the clinician in response to the pre-exercise evaluation and subsequent evaluations (Table 1). 3.1. High Clinical Risk The duration of CVR can vary according to the patient’s clinical picture and progress of physical training. The initial classification, maintenance, and reclassification of risk profile must be based on the pre-exercise evaluation and on subsequent revaluations, carried out by the physician and other CVR team members. This evalution may vary according to the logistics, infrastructure and experience of each CVR service, but must at least consist of a clinical history, physical examination, resting electrocardiogram (ECG), and cardiopulmonary exercise test (CPET) or treadmill exercise test (TMET). High-risk patients will often need immediate or short‑term medical attention during CVR (hospital readmission, intervention, or adjustment of drug therapy). Therefore, they require closer monitoring by the team, which must be able to identify signs and symptoms of high-risk events and act immediately if such an event arises, providing basic and advanced life support, including with use of a manual or automated external defibrillator as necessary. It is preferable that this equipment be present in the room at all times. The medical team must be readily available on site to attend to the patient in the event of any serious complications. It should be noted that the best way to prevent cardiovascular events during a rehabilitation program, and especially after events and interventions, is to conduct systematic pre-exercise evaluation and revaluations. Figure 1 – General characteristics of patients undergoing outpatient cardiovascular rehabilitation stratified by clinical risk. MET: metabolic equivalent; VO 2 : oxygen consumption Clinical risk High Lower Less Less Greater Greater Greater Intermediate Low Physical capacity (MET, VO 2 ) Symptoms Need for supervision during exercise 949