ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 The clinical characteristics of patients who would initially be classified as intermediate risk (presence of at least one such feature) are: • Longer than 12 weeks since the latest cardiovascular event or intervention and currently stable clinical condition. • Chronic heart diseasewith some loss of functiononexertion: – Moderate functional capacity on TMET (5–7 MET) or CPET (Weber B classification or VO 2 peak 60–85% of predicted for age and sex). – Signs and symptoms of myocardial ischemia at loads > 6 MET or at a VO 2 > 15 ml.kg -1 .min -1 . – Mild to moderate symptoms (HF with NYHA functional class I or II, or angina with CCS functional class I and II). • Any other clinical features judged by the physician responsible for pre-exercise evalution to pose intermediate cardiovascular risk on exertion. The main objective of CVR in patients with this risk profile remains the improvement of physical fitness, both aerobic and non-aerobic (muscle strength, flexibility, balance, body composition), as well as superior disease control. The need to promote wellness and improved quality of life, in addition to other procedures that contribute to reducing the risk of clinical complications, such as strategies for smoking cessation, dietary reeducation, and weight control, should all be considered. An emphasis on maintaining and adhering to prescribed drug therapy is also essential to preventing the progression or instability of CVD. Acquisition of knowledge about the disease itself, allowing for better self-management, increases the accuracy in identifying signs and symptoms of disease progression or red flags of unstable clinical situations, which may require interruption of the exercise program and medical revaluation. Patients in this category, after an initial period of guidance and knowledge acquisition about physical exercise and self-monitoring, may be able to adapt to home-based CVR, in which physical exercise is performed under the indirect supervision of team members. Such supervision, as well as adjustments to the exercise prescription or patient education to clarify any questions, should take place during periodic face-to-face or remote follow-up sessions. 3.3. Low Clinical Risk Patientsmay have completed previous stages of CVR and been reclassified; may be classified directly into this category despite no previous engagement in CVR; or may have been referred from other physical exercise programs. Training for these patients is a long-term endeavor, aimed at maintaining overall health and achieving the greatest possible gains in physical fitness, with the objective of reaching the highest attainable standard of health. Depending on availability and individual preferences, exercises can be carried out under direct (face-to-face) or remote supervision. However, given their lower clinical risk and reduced need for supervision, patients at this stage are a perfect fit for home-based rehabilitation models, so that the CVR team can devote on-site resources to patients at higher clinical risk. Patients must nevertheless undergo periodic reevaluation by their primary physician and by the CVR team, including CPET or TMET. In principle, the time between follow-up revaluations should not exceed 12 months. The purpose of follow-up is to readjust the exercise prescription and identify any deterioration of the underlying disease or red flags for clinical decompensation or cardiovascular events, thus allowing preemptive adjustment of drug therapy and/or surgical or percutaneous intervention as needed. Patients receiving home-based programs should be periodically reevaluated and receive guidance on exercise. These occasions are advised to serve as opportunities for participation in supervised exercise sessions, especially for less-experienced patients, as well as for readjustment of the exercise prescription as needed and to answer any questions. Periodic remote assessment by the CVR team (through virtual and/or telephone contact), at least once every 6 months, is recommended to encourage continued adherence to the physical exercise program. The clinical characteristics of stage 4 patients are (all of the following must be present): • Longer than 6months since the latest cardiovascular event or intervention and currently stable clinical condition. • Chronic heart disease with little or no loss of function on exertion. • Patients in this classification usually exhibit the following: – Good functional capacity on TMET (> 7 MET) or CPET (Weber A classification or VO 2 peak > 85% of predicted for age and sex). – No signs or symptoms of myocardial ischemia and no unusual symptoms on physical exertion. 4. Cost-Effectiveness of Cardiovascular Rehabilitation According to theWorld Health Organization, between 2000 and 2016, the rise in global health expenditures outpaced the global economy, reaching USD 7.5 trillion in 2016. 38 In 2010 alone, USD 863 billion were spent worldwide on CVD, a figure estimated to reach USD 1.04 trillion by 2030. 39 In Brazil, where nearly 50% of health expenditures are borne by the government, 40 the situation is no different. CVD accounts for the largest share of expenditure on inpatient care within the Brazilian Unified Health System, and is the leading reason for disability benefits. 41-45 It is estimated that, in 2015, public expenses on inpatient and outpatient care of CVD exceeded R$ 5 billion, while the cost of temporary sick leave or disability exceeded R$ 380 million. 40 Therefore, the economic impact of CVD, coupled with the need for rational use of financial resources, requires the large-scale implementation of low-cost models to ensure the feasibility of caring for a greater number of patients. CVR is a strategy that, in patients with stable CAD, is more cost‑effective than procedures used much more widely, such as percutaneous coronary intervention. 46,47 In addition, its use on a larger scale would reduce health care expenditures due to a decrease in new cardiovascular events, 951