ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 For symptomatic patients in whom surgical correction is not indicated or who do not have the characteristics described in Table 9, the intensity of exercise should be limited by the occurrence of abnormalities observed during the CPET or TMET, as it is assumed that repeated insults at this intensity could increase the risk of exercise and induce potential deleterious effects in the long term. The exercise prescription should be limited to an intensity of exertion corresponding to 10 bpm below the HR at which the abnormality occurred during the CPET or TMET. Relative loads and subjective perceived exertion can be used to guide exercise prescription when HR is not a good indicator, such as in patients with atrial fibrillation or an artificial pacemaker (Table 10). In patients who have undergone surgical correction of valvular heart disease, the exercise prescription will depend on the underlying disease, the outcome of the procedure, the presence of residual lesions, ventricular function, and the response to the exercise test (TMET or CPET). Therefore, each case must be assessed individually, and the limits of exercise prescription defined by the pre-exercise assessment and the results of physical examination and any other tests performed. 6.8. Patients with Artificial Pacemakers or Implantable Cardioverter-Defibrillators This section describes particulars involving implantable devices: artificial pacemakers and implantable cardioverter- defibrillators (ICD). Artificial pacemakers are indicated in the management of electrical abnormalities, which may be isolated – sick sinus syndrome, advanced atrioventricular (AV) block – or associated with structural heart diseases. ICDs are indicated for the primary or secondary prevention of SCD in patients with severe electrical and/or structural heart disease. Depending on the underlying heart condition, the recommendations on CVR described elsewhere in this guideline apply. One of the main concerns of physical exercise in patients with an artificial pacemaker or ICD is the risk of device-related complications, especially in high-impact activities. In patients with ICDs, there is the added fear of inadvertent activation, which can cause behavioral changes, such as reduced physical activity and participation in moderate-intensity exercise. 335,336 Health care providers also share these fears, 337 which may limit their exercise prescribing practices. However, studies have shown that physical exercise is safe and is not associated with an increased risk of shocks or other adverse events. 338-342 In addition, ICD-related complications have not been observed even in competitive athletes. 343,344 Nevertheless, before clearing a patient for exercise, the clinician must be aware of the reasons for device placement and become familiar the device’s programming parameters and settings, ideally during the pre-exercise evaluation. 6.8.1. Therapeutic Benefits of Physical Exercise A meta-analysis 342 of 14 studies enrolling 2,681 patients with ICDs showed a beneficial effect of physical exercise on functional capacity in this population, with an average increase in VO 2 of 2.4 ml.kg -1 .min -1 . In another meta-analysis, which included five randomized trials and one nonrandomized study in patients with HF and ICDs, 341 a similar improvement in physical capacity was observed, with an increase in VO 2 peak of 1.98 ml.kg -1 .min -1 in relation to the control group. As for the concern of inadvertent ICD activation during physical training, one meta-analysis found no significant differences. The rate of exercise-associated shocks ranged from 0 to 20% across studies, with an average of 2.2%, similar to the rate of shocks during an exercise-free follow-up period. 342 Thus, despite widespread fear of this phenomenon, physical training was not associated with increased ICD activation and proved safe. Table 9 – Physical exercise in asymptomatic individuals with valvular heart disease Valvular heart disease Aerobic exercise Resistance exercise Aortic insufficiency Moderate or severe (normal ventricular function; LVESD < 50 mm in men or < 40 mm in women; good functional capacity) No restrictions Moderate or severe Avoid high intensity Aortic stenosis Moderate or severe (normal ventricular function; good functional capacity; absence of myocardial ischemia, complex ventricular arrhythmias, or plateau response/fall in SBP) Avoid high intensity Moderate Avoid high intensity Severe Limited to low intensity (enough to maintain activities of daily living) Mitral insufficiency Moderate or severe (normal ventricular function; LVEDD < 60 mm; PASP < 30 mmHg) No restrictions Moderate or severe Avoid high intensity Mitral stenosis Moderate or severe (good functional capacity) Avoid high intensity Moderate or severe (good functional capacity) Avoid high intensity LVEDD: left ventricular end-diastolic diameter; LVESD: left ventricular end-systolic diameter; SBP: systolic blood pressure; PASP: pulmonary artery systolic pressure. 970