ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Therefore, the inclusion of a patient with ARVC in CVR programs should only be carried out after a thorough pre‑exercise evaluation and rigorous evaluation of the risk‑benefit balance of physical exercises. Options should be discussed with the patient, exposing the absence of proven benefits versus the potential risks of physical inactivity and low physical fitness. It is then up to the patient to choose according to their own personal preferences. In the context of CVR, extrapolating findings from athletes, a restriction on higher training intensities is also suggested. Patients with ARVC could thus perform supervised physical exercises of light to moderate intensity. 6.6.3.2. Noncompaction Cardiomyopathy Noncompaction cardiomyopathy (NCM) is a heart disease that occurs due to embryonic interruption of myocardial compaction. It is characterized by segmental thickening of the left ventricular walls, consisting of two layers: a compacted epicardial one and an endocardial one with marked trabeculation and deep intratrabecular recesses, where spaces are filled by blood flow. 295,296 Its incidence and prevalence are uncertain, ranging from 0.02 to 0.05% according to some echocardiographic records. 297 Clinically, it can be asymptomatic or present with symptoms of HF, ventricular and/or atrial arrhythmias, pre-excitation, thromboembolic events, or SCD. There are no universally accepted criteria for morphological diagnosis; however, a ratio between noncompacted/compacted myocardium greater than 2.1:1 at the end of systole on echocardiography or 2.3:1 at the end of systole on MRI has become the most widely accepted proposed criterion. 298 It is not yet established how physical training can influence NCM, nor is the frequency of development of noncompaction morphology in the population known. 299,300 In recent studies, athletes have shown a high prevalence of increased ventricular trabeculation when compared to a control group (18.3 versus 7%). It is believed that the increase in ventricular trabeculation or the presence of isolated echocardiographic criteria for cardiomyopathy is probably of little significance, and may be part of the spectrum of athlete’s heart. 300,301 Therefore, not all athletes with isolated ventricular compaction are diagnosed with NCM. Therefore, functional parameters (such as ejection fraction) must also be considered to guide management. 301 To date, there is no evidence from studies of CVR or training in NCM. Therefore, patients with left ventricular dysfunction should follow the same exercise recommendations as those with chronic HF (see Table 6). 6.7. Valvular Heart Disease Patients with valvular heart disease represent a very heterogeneous group with major variability in terms of age, etiology, affected valves, and severity of involvement, whether due to stenosis, regurgitation/insufficiency, or mixed lesions. However, most valvular heart diseases share a common feature in their clinical manifestations induced by exertion, which include chest pain, dyspnea, and/or functional limitations. The severity of these symptoms in patients with severe valvular heart disease can be used as one of several criteria to indicate surgical or percutaneous intervention. In addition, the identification of reduced aerobic fitness, as documented by CPET or TMET, is also a criteria used to define whether interventions are indicated. 302-304 One major issue in the clinical follow-up of patients with valvular heart disease is the prolonged natural history of these conditions. The onset and progression of symptoms and functional limitations is often slow, which may lead patients to spontaneously reduce their engagement in physical activity due to symptoms on exertion. This sedentary lifestyle can contribute to further reductions in aerobic physical fitness and worsen symptoms. Thus, doubts may arise regarding the clinical management and need for interventions when the patient undergoes a CPET or TMET, namely: are limitations in physical fitness identified on exercise testing a result of progressive valvular heart disease, a sedentary lifestyle, or both? In this context, the regular practice of physical exercise and the consequent maintenance or even improvement of physical fitness are important to elucidate these questions in the follow-up of patients with valvular heart disease. Participation of these patients in CVR programs has been the subject of a single cost-effectiveness study. 305 However, increases in the functional capacity of individuals referred for CVR have been demonstrated consistently, 306,307 which justifies referral to exercise-programs (level of evidence C). Rehabilitation in the setting of valvular heart disease can be subdivided into two phases: pre- and post-intervention (surgical or percutaneous). 6.7.1. Pre-Intervention Phase Patients with moderate to severe valvular heart disease in the pre-intervention phase are rarely enrolled in CVR programs. Training is carried out mainly in asymptomatic cases, in whom there is still no indication for valve repair or correction. CVR can be useful to keep the patient physically active while waiting for future intervention; after all, a sedentary lifestyle can deteriorate functional capacity and, thus, increase the risk of postoperative complications, especially when the intervention is performed in older adults with multiple comorbidities and established frailty. 308-310 In addition, monitoring during supervised CVR sessions can be useful to observe changes in symptoms and physical fitness, which can indicate progression of valvular heart disease and suggest the need for medical reevaluation. 6.7.2. Post-Intervention Phase Post-intervention patients are more common in CVR programs, as structured and supervised exercise is a useful means of observing the hemodynamic behavior of a patient’s new (or newly repaired) valve. Information on a patient’s response to physical exercise can help their primary physician adjust drug therapy and/or review valve function. In addition, supervised exercise provides a greater measure of safety for the patient to return to his or her activities of daily living, leisure, and sports. 968