ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Table 2 – Classifications of physical exercise Classification Features By predominant metabolic pathway Alactic anaerobic High intensity, very short duration Lactic anaerobic High intensity, short duration Aerobic Low or medium intensity, prolonged duration By pace Fixed, constant, or continuous No change of pace over time Variable, intermittent, or interval Pace changes over time By relative intensity* Low or light Easy to breathe, barely short of breath (Borg < 4) Medium or moderate Breathing faster and labored, but still controlled. Can speak a sentence (Borg 4–7) High or heavy Breathing very rapid and labored; short or out of breath. Barely able to speak (Borg > 7) By muscle mechanics Static There is no movement; mechanical work is zero Dynamic Involves movement; mechanical work is positive or negative *A Borg scale of 0 to 10 was considered. Table 3 – Methods for prescription of moderate-intensity aerobic exercise Method Description Rating of perceived exertion (Borg) Exercises yielding a rating of perceived exertion of 2–4 on the 0–10 Borg scale or 10–13 on the 6–20 Borg scale Speech test Exercise intensity maintained so that breathing is labored but still controlled, and the patient is still able to speak a complete sentence without pause Percent peak HR Exercise intensity titrated to an HR target of 70–85% of peak HR* Target HR = peak HR x desired percentage HR reserve (Karvonen) Exercise intensity titrated to an HR target of 50–85% of reserve HR (peak HR – resting HR). Target HR = resting HR + (peak HR – resting HR) x desired percentage Cardiopulmonary exercise test thresholds Exercise intensity titrated to remain between ventilatory threshold 1 (anaerobic threshold) and ventilatory threshold 2 (respiratory compensation point) *Peak HR preferably measured during a maximal exercise stress test, as interindividual variability can cause errors in the prediction of HR by age, especially in patients who are on medications with negative chronotropic effect. HR: heart rate. per set (6 to 20). The intensity of resistance training can be adjusted according to the relative intensity of the maximum force, and can be expressed as a function of the maximum load that can be borne during a single repetition (one repetition maximum test or 1RM). Light intensity would be up to 30% of 1RM; medium intensity, between 30 and 60–70% of 1RM; and high intensity, above 60–70% of 1RM. Resistance exercises may also be prescribed subjectively, on the basis of perceived exertion alone (see Table 2). A practical approach is the variable repetitionmethod, which aims to perform a range of repetitions (e.g., 10 to 15 repetitions). If the patient is unable to perform the movement correctly for the minimum number of repetitions prescribed, the applied load is too high. On the other hand, if the patient reaches the maximum prescribed number of repetitions easily, the load is insufficient. Thus, the load will be adjusted so that training takes place within the proposed range of repetitions. This method can be applied to a wide range of localized exercises and can be altered as the patient progresses; the repetition ranges can also be modified depending on the desired objective (strength, hypertrophy, or endurance). Flexibility exercises can also provide musculoskeletal benefits, improve health-related quality of life, and prevent falls in the elderly. By facilitating and increasing the efficiency of joint movement, they reduce oxygen demand during motion, thus enhancing cardiovascular performance. The aim of these exercises is to reach the maximum range of motion (point of mild discomfort) and remain static for 10 to 30 seconds. Depending on the age group, clinical condition, and objectives of the exercise program for a given patient, other types of exercise can be included in the prescription, such as motor coordination and balance exercises. The countless benefits of more playful, social-based forms of exercise, such as dance and other modalities, should also be considered. 85,86 Assessment of aerobic and non-aerobic physical fitness enables a more individualized exercise prescription, with the objective of achieving the best outcomes while minimizing hazard to the patient through proper risk stratification and a thorough search for possible abnormalities. In general, the initial evaluation is based on a thorough history, physical examination, and ECG. More detailed assessments should be individualized to include CPET or TMET, anthropometric measurements, and evaluation of muscle strength/endurance and flexibility. The initial evaluation allows quantification of the patient’s functional deficit in relation to the desired level of function, as well as goal setting. Even those patients with poor baseline physical fitness can benefit 954