ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Table 5 – Indications for cardiovascular rehabilitation in coronary artery disease Indication Recommendation Level of evidence CVR to reduce myocardial ischemia 132-140,158 I A CVR to increase physical capacity 132,134,140 I A CVR to reduce mortality 1,154,155 I A CVR after coronary events or revascularization 140,157 I A Early CVR (1 week after an acute event) 159,160 IIa A CVR in patients with refractory angina 161,162 IIb C CVR: cardiovascular rehabilitation. Although widely endorsed by the medical literature for their beneficial effects and cost-effectiveness, CVR programs are only attended by a minority of eligible patients. Multiple barriers can explain this, such as a lack of programs, difficulty in accessing existing services, few referrals, and poor urban mobility; women, the elderly, and ethnic minorities are most affected. 165-168 Therefore, political, social, and structural changes – as well as a shift in medical culture – are needed to change this scenario. 6.3.3. Pre-Exercise Evaluation and Exercise Prescription Both in patients with stable CAD and after a coronary event and/or revascularization, risk stratification for CVR is essential and should be based on a targeted clinical evaluation focused on detailed knowledge of the patient’s CVD and treatment history, whether clinical or interventional. Presence of symptoms, ventricular function, functional capacity, arrhythmias, and the possibility of residual ischemia all aid in stratification and should queried during the initial assessment. Ideally, this evaluation should be carried out by a CVR team member (rehabilitation physician). The profile of a patient referred to CVR can vary widely, from individuals receiving elective treatment to patients with a complicated acute coronary syndrome and history of prolonged hospitalization. A broader assessment, including nutritional, psychological and musculoskeletal issues, should be part of the clinical history and examination, as these factors can directly impact the CVR process. In patients who have undergone percutaneous or surgical revascularization, examination of the arterial puncture site (especially of femoral access sites) or surgical wound (especially regarding sternal stability and wound infection) should always be performed. Any abnormalities or complex medical needs identified during the pre-exercise evaluation must be relayed to the CVR team members who will be involved in the patient’s exercise sessions. During pre-exercise evaluation for CVR, the purpose of functional tests is to gain better insight into functional capacity, identification of residual ischemia and stress-induced arrhythmias. Myocardial ischemia on exertion is identified by detection of symptoms such as angina pectoris and/or by ECG changes. The ischemic threshold can be identified during TMET by the onset of these clinical and/or ECG changes and expressed as the load and/or HR at which ischemia initiate. This information is essential to guide the exercise prescription. When used for exercise prescription purposes, TMET should be performed on all of the patient’s usual medications, especially those that may affect HR. This is important to reproduce the conditions that will be present during training sessions. If patients on beta blockers have their dose adjusted during rehabilitation, ideally a new TMET would be performed for adjustment of the exercise prescription. If this is impossible, a subjective (perceived exertion) test may assist in adjusting the prescription until a new test can be performed. In some cases, patients entering CVR may have clinical limitations precluding a maximal exercise test. In these patients, the initial exercise prescription can be guided by a submaximal test, and a maximal test performed once there has been sufficient clinical improvement and/or optimization of drug therapy. Considering the possibility of serious error due to marked individual variation in chronotropic response, formulas that consider age as a parameter to define peak HR should never be used. The error is even greater in patients who are on beta blockers. When rehabilitation is initiated without functional testing, the prescription may be based on the Borg scale of perceived exertion (a score of 11–15 on the 6–20 scale) and on arbitrary limitation of HR during training, i.e., the use of a resting HR + 20 bpm for patients who have had an acute coronary syndrome or resting HR+ 30 bpm for those who have undergone elective surgical or interventional revascularization. 131 The target exercise intensity can also be determined by subjective assessment of breathing; moderate-intensity activity leaves the patient only slightly short of breath, but still able to speak complete sentences without interruption (see Table 3). When a TMET is performed, the intensity of the prescribed exercise should lie between 40 and 80%of HR reserve (Karvonen formula: [Peak HR – resting HR] x percent intensity + resting HR). In such cases, the initial exercise prescription usually targets the lower limit of HR, progressing from there according to the patient’s clinical course and improvement in functional capacity. Most patients will be prescribed an exercise intensity between 50 and 70% of their HR reserve. Those that are more functionally limited or have significant ventricular dysfunction may be prescribed at lower intensities (40–60%), while those who were previously active and still retain better functional capacity may be prescribed at a higher andwider range (50–80%). Percentages of peak HR can also be used, with moderate-intensity exercise corresponding to 70–85% of HR peak (see Table 3). 958