ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 HBCR is understood as the practice of physical exercise without face-to-face supervision, but with guidance and follow‑up from the CVR team. It is thus also known as semi‑supervised rehabilitation, or rehabilitation under indirect or remote supervision. The indications and objectives of HBCR are the same as those of conventional CVR; the same care is required regarding pre-exercise evaluation and exercise prescription. Most sessions are held under indirect supervision, but participation in some on-site classes, especially at the start of the program, is of fundamental importance to ensure that patients understand the exercise prescription, consolidate guidance and clarity doubts. Exercise can be done at home, in parks, on public roads, gyms, sports centers, and health clubs, among others, with patients self-monitoring and following the guidance received. Therefore, in order to achieve HBCR as a viable population strategy, it is first necessary to expand the availability and capacity of conventional CVR programs, in order to enable initial evaluation, guidance, exercise prescription, and follow‑up of home sessions (with periodic reassessment for any adjustments). Thus, the home strategy must be aligned with that of conventional CVR. The two modalities may be used in parallel, including patients with different risk profiles, or in sequence, with the same patient engaging in conventional or home-based CVR depending on clinical status. Just as in conventional CVR, the first step of HBCR is referral by the primary physician, followed by evaluation by the rehabilitation physician and other team members, ideally including a stress test (CPET or TMET) or other physical fitness tests. After the pre-exercise evaluation, patients defined as high risk can be prioritized for conventional, face-to-face CVR. Those at lower risk, who are capable of self-monitoring and according to individual preference, can be routed to the HBCR component of the program. After receiving instruction on the prescribed exercises, patients perform the sessions on their own. The exercises may be documented in printouts or spreadsheets, with the aid of resources such as cardiac monitors, pedometers, or fitness trackers. Smartphone apps can mediate this exchange of information between patients and the health care team. In some cases, a combined CVR program – with both on-site and home-based sessions – may be an option for moderate-risk patients who are still learning to self-monitor or find it difficult to attend face-to-face sessions due to social issues or reduced mobility. The proportion of on-site versus home-based sessions will vary according to the patient's clinical characteristics and the logistics and infrastructure of the CVR service. The overall focus is always to make patients more physically active; a reduction in sedentary behavior and its harmful consequences is the imperative. It is essential that all available resources – whether alone or in combination, whether informal physical activity, home rehabilitation, or conventional CVR – be deployed toward this goal. 6. Integration of Cardiovascular Rehabilitation into Optimized Clinical Care of Cardiovascular Diseases CVR must be integrated with full clinical treatment of CVD, which consists of a synergistic combination of structured lifestyle changes and optimized drug therapy. For instance, in patients with stable coronary disease – even those with moderate and severe ischemia – interventional treatments have not been shown to be superior in reducing major outcomes (cardiovascular mortality, all-cause mortality, AMI, HF). 69,70 To increase the efficacy and safety of CVR, it is important that drug therapy of CVD be properly optimized. The aim is to increase exercise tolerance and thus facilitate engagement in physical exercise while reducing the risk of further events. 3,5,71-73 In this context, it may be necessary to adjust current drugs or prescribe additional agents prior to the start of the physical exercise program. Once CVR has been initiated and adequate adherence has been achieved, some patients may require dose reduction or even discontinuation of some drugs due to adaptations to physical training, e.g., patients who develop hypotension, marked bradycardia, or symptomatic hypoglycemia. 74,75 6.1. General Guidance for Increasing Physical Activity and Engagement in Physical Exercise There is an association between sedentary lifestyle (e.g., screen time), and higher all-cause and cardiovascular mortality. 76 Therefore, for health promotion and CVD prevention, medical guidelines have recommended the practice of moderate-intensity physical activity for at least 150 minutes per week or high-intensity for at least 75 minutes per week (grade 1B recommendation). 77-83 Engagement in more than 300 minutes/week of moderate- to high-intensity exercise can confer additional benefit, as has already been demonstrated in patients with CAD. 84 According to the results of individual evaluation, the exercise prescription may vary in terms of type (aerobic, endurance, flexibility), modality (walking, running, cycling, dancing, etc.) and duration; weekly frequency and intensity should also be considered (Tables 2 and 3). Sedentary patients should start exercising at the lower limit of the exercise prescription and progress gradually over the following weeks. Progression should initially be based on the duration of each session and, later, on exercise intensity. Physically active patients can perform exercises at a more intense level from the outset, aiming at a minimum duration of 75 minutes divided into two or more weekly sessions. Resistance training of localized muscle groups (whether strength or endurance training) has proven quite beneficial for overall health and for the cardiovascular and musculoskeletal systems, and is particularly important – in fact, essential – in patients with sarcopenia and/or osteopenia. Resistance training should be performed at least twice a week, favoring the large muscle groups of the upper limbs, lower limbs, and core. Exercise can be done against the individual’s own body weight or using implements such as free weights, ankle weights, bands, or weight machines. The load (or weight) for each exercise or movement must be individually adjusted, and particular attention should be paid to proper posture and technique. Several protocols for resistance training are available, with variations in parameters such as the number of exercises per session (e.g., 6 to 15), the number of sets per exercise (usually 1 to 3), and the number of repetitions 953