ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 hospital readmissions, and interventional treatment. 48,49 Therefore, wider dissemination of CVR should be considered a priority public health strategy. Assessment of cost-effectiveness, which is done through a combined analysis of clinical consequences (effectiveness) and health-system expenditures, is essential in evaluating the relevance of large-scale implementation of a given treatment. 50-52 According to Georgiou et al., 53 measures that require investments of less than USD 20,000 per life-year saved (LYS) are considered to have excellent cost-effectiveness, whereas those that require investments of USD 20,000– 40,000/LYS are acceptable and those requiring investments of USD > 40,000/LYS are unacceptable. According to 1985–2004 data, CVR can be considered an intervention with an excellent cost-effectiveness ratio, as its addition to conventional treatment resulted in an increase in expenditures fromUSD 2,193 to USD 28,193 per LYS. In 2005, Papadakis et al. 23 published the first systematic review of studies on the cost-effectiveness of CVR as a secondary prevention strategy in patients with CAD and HF. In a 2018 evaluation of studies published after 2001, 54 the cost-effectiveness ratio was very similar to that described by Papadakis; the addition of CVR to conventional treatment resulted in an increase in expenditure of USD 2,555 to USD 23,598 per LYS. It is worth mentioning that, although more than 75% of CVD deaths occur in low- and middle-income countries, 55 there is a lack of data on the cost-effectiveness of CVR in these settings. 56 Most of the information available comes from high-income nations, such as the United States, Canada, and European countries, which hinders extrapolation of results to the Brazilian reality. However, those few studies which are available from lower-income nations show a similar trend. In Brazil, the addition of rehabilitation to conventional treatment of patients with HF resulted in an increase in expenditures of USD 21,169 per LYS. 57 Despite the clear clinical and economic benefits of CVR, the percentage of eligible patients who effectively receive this type of care is far short of desired levels. According to international data, only around 30% of patients attend a CVR program; in Brazil, this number is estimated to be well below 15%. 26,58,59 In fact, most Brazilian states – including most capitals and large cities – lack even a single cardiac rehabilitation service. As a result, the use of home-based models has grown. Initially, concerns about the safety of physical exercise meant that HBCR was intended only for low-risk patients. However, with growing evidence of noninferiority in terms of safety and similar clinical benefits in relation to the conventional strategy, 60-62 in addition to advances in technology that now allow remote monitoring, the use of HBCR has been expanded to patients with a higher risk profile. Recent studies show that HBCR has effectiveness similar to traditional CVR, as demonstrated by Ades et al., 60 who compared the effects of a 3-month program of either model in low- and moderate-risk CAD patients after an acute coronary event. Although the group of patients who attended the traditional program performed a higher volume of exercise, there was no difference in increase in functional capacity or quality of life between the two groups. Jolly et al. 62 compared cardiovascular risk outcomes between patients undergoing traditional and home-based rehabilitation for longer periods, with 6, 12, and 24 months of follow-up, and also observed no differences. A recent systematic review by Anderson et al. of studies enrolling patients with a history of AMI, CABG, or HF 61 also found no significant differences between conventional and home-based rehabilitation across a series of outcomes (death, cardiac events, functional capacity, quality of life, and modifiable risk factors) in the short term (3 to 12 months) or long term (up to 24 months). Thus, HBCR programs should be considered as a strategy to facilitate access, adherence, and wider use of rehabilitation. Despite the aforementioned evidence of noninferiority in outcomes, comparatively few studies have demonstrated that the cost of HBCR is comparable to that of traditional CVR programs. 61,63,64 This major research gap precludes comparison of the two models in terms of cost-effectiveness. 65-67 Given the facts, it is unsustainable that countries of all income levels – and, most worryingly, lower-incomes – continue to provide high-cost therapeutic interventions massively, without stricter indications and criteria, while they continue to neglect the highly effective, economically viable, and readily applicable intervention that is CVR. There is an urgent need for public health policies to expand the availability of, participation in, and adherence of eligible patients to both traditional and home-based CVR programs. Finally, considering the relevance of CVR given its broad clinical benefit and excellent cost-effectiveness, strategies must be implemented to change medical culture and stances toward it and facilitate the dissemination of structured rehabilitation programs. In this context, it is particularly relevant that specialty cardiology services offer CVR to their patients both during hospitalization and after discharge. The availability of a CVR service should be considered as a mandatory prerequisite for a medical institution to be recognized or accredited as having excellence in cardiology. 5. Home-Based Cardiovascular Rehabilitation There are several barriers to patient access and adherence to conventional CVR, 24-27,68 which, compounded by the scarcity of referral to CVR programs and the limited availability of services, lead to very low levels of actual participation in supervised exercise programs. In this context, programs of indirectly supervised exercise carried out in the home, known as home-based cardiovascular rehabilitation (HBCR), are an attractive alternative or supplement to conventional, on-site CVR. Given its inherently greater availability, HBCR should be considered the main modality of CVR intervention when it comes to public health strategies, aiming at mass engagement of the CVD population in rehabilitation programs. A Cochrane review 61 of 23 studies including 2,890 patients with heart disease (post-AMI, post-CABG, angina or HF) compared the effects of conventional CVR and HBCR. No differences were found in mortality, physical capacity, or quality of life. Therefore, the decision to participate in conventional (on-site) or home-based programs depends on the availability of services and patients’ individual preference. 952