ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Table 6 – Indications for cardiovascular rehabilitation in heart failure Indication Recommendation Level of evidence Regular aerobic exercise in patients with HF to increase functional capacity, reduce symptoms, and improve quality of life 2,195-199,205 I A Regular aerobic exercise in patients with reduced LVEF to decrease HF hospitalization 2,198 I A Aerobic exercise in patients with preserved LVEF to increase functional capacity and improve diastolic function 203,205,206 IIa B Low-intensity aerobic exercises with noninvasive ventilation during the hospital phase of HF 201 IIb B/C HF: heart failure; LVEF: left ventricular ejection fraction. published to date, Smartex-HF, 211 compared MICT versus HIIT. The authors found similar benefit, with no superiority of one modality over the other in any respect. Therefore, the choice of protocol will depend on team experience, clinical conditions, physical capacity, and patient preferences. In addition, HIIT protocols can vary widely; several have been described. 212 One consists of 4 min of high-intensity exercise (90 to 95% of maximum HR) alternating with 3 min of low-intensity exercise (70% of maximum HR). 209 Protocols with much shorter durations of high-intensity load (30 or 90s) have already been described, and the tolerance to different HIIT protocols may vary according to patient preference and physical capacity. 213 Therefore, the use of this modality will depend on the patient’s clinical picture and choices, as well as on the experience and preferences of the CVR team. The addition of localized muscle resistance exercises to aerobic training has been suggested as a means of obtaining additional benefit. 214 These exercised can be prescribed as percentages of maximum voluntary contraction or according to subjective perceived exertion. The recommended loads and repetitions may vary according to the patient’s functional limitations and must be individualized, progressing as rehabilitation itself progresses. The addition of breathing exercises has been recommended for patients with respiratorymuscleweakness. 215 In ameta‑analysis by Smart et al. 216 which evaluated 11 studies including 287 participants with HF, 148 of whom underwent inspiratory muscle training (IMT) compared with 139 sedentary controls, significant gains in VO 2 peak, distance walked in the 6-minute test, quality of life, PImax, and VE/VCO 2 slope were observed. Thus, IMT provided gains in cardiorespiratory fitness and quality of life of a similar magnitude to those obtainedwith conventional training, and should be considered a valid alternative for severely deconditioned and debilitated HF patients, perhaps as a bridge to conventional physical exercise. Figure 2 – Flow diagram of cardiovascular rehabilitation in patients with heart failure. Stable heart failure Optimized drug therapy Functional assessment Cardiopulmonary exercise test (CPET) Selection of exercise modalities Rehabilitation: grade Ia evidence Aerobic (continuous) Aerobic (interval) Resistance training Inspiratory muscle training 6-minute walk test or Treadmill test (if CPET is unavailable) 961