ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Although there is no consensually defined time limit for referral to CVR in the setting of valvular heart disease, the earlier the patient starts exercise, the less function he or she will lose from inactivity. 305-307,310 The exchange of information between the patient’s primary physician and the rehabilitation physician is the best strategy for defining the optimal timing of referral, and the pre-exercise evaluation has a fundamental role in consolidating this shared decision. 6.7.3. Pre-Exercise Evaluation The pre-exercise evaluation should always consist of a thorough history, physical examination, and evaluation of laboratory tests and imaging. The clinical history must include: length of hospital stay; complications related to the procedure, such as pleural or pericardial effusion, mediastinitis, and infections; type and size of prosthetic valve; surgical technique; and whether CABG was performed concomitantly, in addition to other clinical information that may be relevant regarding other comorbidities. Onphysical examination, cardiac andpulmonary auscultation are particularly important. In addition, attention should be paid to the surgical scar, which should be examined for signs of inflammation and infection, sternal instability, and pain or discomfort on palpation. If concomitant revascularization was performed, the saphenectomy and/or radial artery donor site must be examined. If valve repair or replacement was performed percutaneously, the access site should be checked for signs of peripheral vascular complications. It is important that the clinician look for signs of anemia on physical examination and laboratory tests, because this is a common complication and can have a negative impact on functional capacity. 311 Laboratory evaluation of coagulation is relevant in patients who received a mechanical valve and were started on anticoagulants. Achieving the correct level of anticoagulation is important in preventing complications. A resting ECG should be obtained to check for any arrhythmias and disturbances in rhythm or conduction. The most commonly used imaging modality in the evaluation of valvular heart disease is Doppler echocardiography, which allows assessment of ventricular function and cavity dimensions, measurement of transvalvular pressure gradients, estimation of pulmonary artery systolic pressure, and measurement of blood flow, which provides a good overview of valve function and cardiac function at rest. Echocardiography should always be performed before the start of a CVR program, to assess the risk of exercise-related complications. 312 It is important to evaluate functional capacity by CPET or TMET. 313-316 These tests, especially CPET, provide extremely useful information regarding aerobic fitness and the hemodynamic repercussions of valvular heart disease, which may be underestimated by assessments performed at rest. In addition, treadmill tests identify parameters that are used to guide exercise prescription and restrictions. When TMET and CPET are unavailable, the use of functional tests, such as the 6-minute walk test and the step test, should be considered. 317-320 It is important to emphasize that CPET and TMET pose greater risk in patients with stenotic lesions; therefore, they should only be carried out by experienced physicians and in a safe setting with the necessary infrastructure to respond in case of emergency. 321 Functional tests are indicated not only in pre-exercise evaluation, but also to elucidate any doubts regarding the symptoms of patients in the pre-intervention phase of valvular heart disease. The combination of functional tests with echocardiography helps assess the response of the transvalvular pressure gradient and pulmonary artery systolic pressure to exertion, especially when there is a discrepancy between echocardiogram findings at rest and clinical signs and symptoms. 304,322,323 Another relevant issue is the evaluation of elderly patients, who are frequently affected by valvular heart disease and have a high prevalence of risk factors and comorbidities. 324 Due to their high surgical risk, such patients are now considered candidates for percutaneous repair or replacement of the aortic 325 and mitral valves. 326 In this scenario, CVR can be considered before the intervention, with the aim of decreasing complication rates, length of hospital stay, and mortality and morbidity associated with the frailty syndrome. 327 After the intervention, CVR then provides an opportunity for monitoring and optimization of the outcomes of the procedure in all its aspects. 328-331 The use of frailty syndrome assessment instruments is still a controversial subject in the literature; there is no consensus regarding the best protocol to assess CVR outcomes. The assessment should include objective tests and instruments to address risk in several domains: mobility, muscle mass and strength, independence in activities of daily living, cognitive function, nutrition, anxiety, and depression. 304,308,332 6.7.4. Special Considerations for the Prescription and Follow-Up of Physical Exercise Programs This section will only address guidelines and recommendations for exercise in patients with moderate or severe valvular heart disease, as there are no restrictions to exercise in patients with mild involvement. Participation in competitive sports should follow the recommendations of the specific literature on the subject. 276,333,334 Scientific evidence is scarce as to the impact of regular exercise on the progression of valvular heart disease and its complications; therefore, recommendations are based on expert opinion alone (level of evidence C). Acutely, exercise causes an increase in adrenergic tone and in the hemodynamic load imposed on the cardiovascular system, which raises concerns regarding the potential for deleterious cardiovascular effects in patients with valvular heart disease, including progression of aortic disease, functional deterioration, pulmonary hypertension, cardiac remodeling, myocardial ischemia, and arrhythmias. Patients with valvular heart disease who will start a CVR program must undergo a stress test to guide exercise prescription. Table 9 summarizes recommendations for asymptomatic patients, who have not undergone any intervention, with moderate or severe valvular heart disease. In general, training will consist of a combination of aerobic and resistance exercise. When there are no restrictions, the recommendations for exercise prescription will be the same as those for individuals without heart disease. 969