ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Table 1 – Clinical risk stratification of patients undergoing outpatient cardiovascular rehabilitation Risk High Intermediate Low Features Cardiovascular event, cardiovascular intervention, or clinical decompensation Less than 8 to 12 weeks 12 weeks or longer 6 months or longer Physical functioning TMET: < 5 MET CPET: Weber C/D or VO 2 peak < 60% of predicted TMET: 5–7 MET CPET: Weber B or VO 2 peak 60–85% of predicted TMET: > 7 MET CPET: Weber A or VO 2 peak > 85% of predicted Signs and symptoms of myocardial ischemia (ischemic threshold) At low loads TMET: at < 6 MET CPET: at < 15 ml.kg -1 .min -1 TMET: at > 6 MET CPET: at > 15 ml.kg -1 .min -1 Absent Symptoms HF: NYHA III and IV Angina: CCS III and IV HF: NYHA I and II Angina: CCS I and II Absent Other clinical features: Dialytic CKD; oxygen desaturation on exertion; complex ventricular arrhythmia. At clinician’s discretion and judgment during pre-exercise evaluation At clinician’s discretion and judgment during pre-exercise evaluation CCS: Canadian Cardiovascular Society; CKD: chronic kidney disease; CPET: cardiopulmonary exercise test; HF: heart failure; MET: metabolic equivalent; NYHA: New York Heart Association functional class; TMET: treadmill exercise test; VO 2 : oxygen consumption. The exercise program must be individualized in terms of intensity, duration, frequency, training modality, and progression, according to the functional testing performed at the start of the program and subsequently. Proper measurement of HR and BP at rest and during exercise are mandatory; measurement of oxygen saturation, capillary blood glucose, and electrocardiographic monitoring should also be available. The rehabilitation program should also include an educational program aimed at lifestyle modification, with an emphasis on dietary re-education and strategies for smoking cessation, if necessary. It is essential that patients acquire knowledge about their illness and learn to self-monitor, both while exercising and in terms of red-flag signs and symptoms which may signal unstable or high-risk clinical situations. The clinical characteristics of patients who would initially be classified as high clinical risk (presence of at least one such feature) are: • Hospitalization due to recent (< 8–12 weeks) cardiovascular events: AMI or unstable angina; surgical or percutaneous revascularization; complex arrhythmias; cardiac arrest; acute decompensated HF. • Chronic heart disease with or without recent cardiovascular events and/or interventions but with significant functional changes on physical exertion, i.e.: – Low functional capacity on TMET (< 5 MET) or CPET (Weber C/D classification or VO 2 peak < 60% of predicted for age and sex). – Signs and symptoms of myocardial ischemia at low loads (< 6 MET or at a VO 2 of < 15 ml.kg -1 .min -1 ). – Exacerbated symptoms (HF with NYHA functional class III or IV, or angina with CCS functional class III and IV). • Other clinical characteristics of patients at increased risk during physical exercise include dialytic chronic kidney disease (CKD), oxygen desaturation on exertion, and complex ventricular arrhythmias at rest or exertion. Considering that high-risk patients often need frequent readjustment of drug therapy and reassessment and occasionally need advanced intervention (revascularization or other procedures), constant communication between the CVR team and the patient’s primary physician(s) is essential. It is also important to note that some patients who experience intercurrent events during exercise or unfavorable findings on follow-up evaluations may remain in the high-risk classification (i.e., requiring direct supervision of physical exercise) indefinitely. 3.2. Intermediate Clinical Risk Patients may have completed previous stages of CVR and been reclassified; may be classified directly into this category despite no previous engagement in exercise; or may have been referred from other exercise programs. The duration of CVR under this classification can also be variable, depending on the clinical status and progress achieved with physical training as demonstrated in follow-up evaluations. Exercises should be supervised by a physical therapist or physical educator, and the service should (ideally) rely on the coordination of a physician with experience in CVR. Devices for measurement of HR and BP at rest and during exercise are recommended; measurement of oxygen saturation, capillary blood glucose, and electrocardiographic monitoring should also be available as necessary. If there is no on-site physician, one must be readily on call. Basic life support material must be available on site and all team members must be trained in cardiopulmonary resuscitation, including use of an automated external defibrillator, which must also be present on site. It is essential that pre-exercise evaluation be carried out by the CVR team, with appropriate risk stratification. Regular medical follow-up and revaluations as necessary must be carried out to ensure the safety of the exercise regimen. 950