ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Another study, 260 with an equivalent aerobic training protocol but a longer duration (five times a week for 6 months), documented improvements in VO 2 peak, workload, and BP in individuals after HTx. In addition, there were signs of cardiac sympathetic reinnervation and restoration of arterial sensitivity to autonomic modulation, with no changes in the control group. Even beyond 5 years after HTx, HBCR can still improve functional capacity, as demonstrated by a study in which 21 patients were instructed to follow a home-based physical training program consisting of cycle ergometer exercises for 1 year. Nine patients served as controls. To ensure adequate control, patients received a smart card programmed for a 6-min warm-up and 20 min at a constant workload, with load adjustment according to the exercise prescription and HR monitoring. At the end of 12 months, there was a modest improvement in VO 2 peak. 261 Karapolat et al. 262 compared the effects of home-based and hospital-based exercise programs on exercise capacity and chronotropic variables in 28 patients after HTx and observed significant improvements in VO 2 peak and HR reserve only in the traditional CVR group. However, new studies, with the inclusion of a larger number of patients, are necessary to better elucidate this superiority of the hospital-based program observed in this study. 6.5.5. Recommendations Based on the evidence reviewed above, physical training has an unequivocal beneficial effect after HTx, is safe and feasible, and can be performed in the hospital or home environment (Table 7). However, although both strategies are effective in promoting an increase in functional capacity, the magnitude of the effect is greater when training is performed in supervised environments. CVR should be started 6 to 8 weeks after the HTx, with referral at hospital discharge. In selected cases and after careful evaluation by the CVR team, rehabilitation may begin earlier. As in any post-sternotomy situation, special care must be taken not to prescribe exercises that might overload the chest muscles and lead to sternal traction, especially in the first 90 days after transplant. The ideal prescription will include exercises that promote different components of physical fitness, always maintaining an emphasis on specific recommendations for each condition. After HTx, just as in other indications for CVR, aerobic exercise should be the main component of training sessions, supplemented by resistance and flexibility training within an individualized, periodically reassessed program. Sessions should always start with a warm-up period and end with a controlled cooldown period. This strategy aims not only to warm up the skeletal muscles but also to provide an adequate time for adjustments of HR and BP to exercise, as the exertion response in these patients is affected by denervation of the heart, especially in the early stages of the training program after transplant. Aerobic exercise may consist of walking or cycling, whether indoors (using treadmills and/or cycle ergometers) or outdoors. A weekly frequency of three to five sessions, each lasting 20 to 40 minutes, is recommended. The frequency and duration of these sessions will be adjusted according to the patient’s preexisting condition and should progress over time with training. Control of exercise intensity is essential; given the larger evidence base, MICT (between the first and second ventilatory thresholds) is recommended, with a perceived exertion no greater than 11 to 13 on the modified Borg Scale. In selected cases, interval training can be adopted to add variety and, potentially, to enhance functional gain. Resistance training is essential, especially in the early phase after transplantation. Many HTx recipients had longstanding HF, endured prolonged hospitalizations, and have been exposed to massive surgical stress. In this regard, a resistance exercise program can be particularly useful. At the start of training, activities performed against body weight alone are considered sufficient for these patients. Over time, elastic bands, dumbbells, ankle weights, and weight machines can be added to the training program. Greater than usual care is needed during upper body exercises, considering that corticosteroid therapy may make for slower healing of the thoracotomy scar. Further information and examples of training protocols for these patients are available elsewhere. 263-265 6.6. Cardiomyopathies This section will address hypertrophic cardiomyopathy (HCM), myocarditis, and other cardiomyopathies. The indications for CVR in this setting are listed in Table 8. 6.6.1. Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy (HCM) is a disease characterized by left ventricular hypertrophy, usually without dilatation of the ventricular chambers, in the absence of another cardiac or systemic disease capable of explaining themagnitude of hypertrophy observed. 271 It is the most common hereditary Table 7 – Indications for cardiovascular rehabilitation in heart transplant recipients Indication Recommendation Level of evidence CVR consisting of moderate aerobic exercise is recommended for patients after HTx 234,239,241,243 I A CVR consisting of high-intensity aerobic exercise is recommended for patients after HTx 233,238,244 IIa B CVR consisting of resistance training is recommended for patients after HTx 235,236 I B CVR: cardiovascular rehabilitation, Htx: heart transplant (HTx). 964