ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 6.8.5. Resistance Training Resistance training is an important component of CVR for several heart diseases. However, after implantation of a pacemaker of ICD, some care is required until healing is complete, to prevent vascular injury, displacement of the device, and electrode fracture. For instance, caution is recommended when performing weight training and any exercise which involves raising the arms during the first 6 weeks after the implant procedure. In addition, repetitive and intense movements of the limb ipsilateral to the device should be avoided. However, such guidelines are geared more at patients involved in sports, and are unlikely to be relevant to the exercises carried out in CVR programs. A study of early, supervised shoulder mobilization immediately after artificial pacemaker implantation did not observe any device complications. 353 6.8.6. Neuromuscular Electrical Stimulation The use of neuromuscular electrical stimulation (NMES) in patients with HF has become widespread, especially for those unable to exercise due to disease severity. NMES can improve aerobic capacity, muscle strength, and cross-sectional area of the quadriceps muscles, and is an effective passive exercise modality in this population. 354-356 However, the use of electronic devices in these patients (ICDs, artificial pacemakers, resynchronization devices) is also increasing, which raises concerns of the possibility of electromagnetic interference. A systematic review 349 demonstrated that NMES of the quadriceps muscles appears to be safe and feasible in patients with HF and a bipolar sensing ICD. However, the review itself notes that the number of studies and patients included is too small to allow more comprehensive conclusions, and concludes that NMES can be used provided the following conditions are met: 1) If individual hazards (pacemaker dependence, acute HF, unstable angina, ventricular arrhythmia in the last 3 months) have been excluded before starting NMES. 2) If NMES is performed only on the quadriceps and gluteal muscles. 3) If treatment is regularly supervised by a doctor, and the device is analysed after every NMES session. Therefore, at the present time, although NMES seems safe to use in patients with bipolar-sensing implantable devices when performed on muscles far from the implant, there is still a need for studies with a larger number of patients to confirm that use is safe and feasible without the need for repeated, detailed device evaluation after sessions. 6.9. Peripheral Arterial Occlusive Disease Stroke has been correctly viewed and addressed as a serious disease with massive impact on public health. However, peripheral artery disease, which is also highly prevalent worldwide and carries high morbidity and mortality rates, affecting more than 40 million individuals in Europe alone, have not been properly addressed, hindering prevention, diagnosis, and effective treatment. 357,358 In this context, peripheral arterial occlusive disease (PAOD) of the lower limbs is particularly concerning, as, at its most severe stage (critical ischemia), it is associated with a high risk of cardiovascular events, lower limb amputation, and death. With the growth of risk factors such as age, diabetes, and smoking, critical ischemia of the lower limbs has become more prevalent, and currently affects about 2 million individuals in the United States alone. 359 The presence of PAOD is suspected when there is pain in the lower limbs on exertion, with no apparent musculoskeletal etiology, and the ankle-brachial index (ABI) is <0.90 at rest. 360,361 The ABI has been recommended as a diagnostic resource prior to use of imaging. 362 Functional tests during exertion effort may be necessary to establish the diagnosis, especially when the ABI is greater than 0.91, as well as for functional classification and exercise prescription in CVR. Gait can be assessed by means of field tests, which allow the diagnosis of intermittent claudication and determination of the distance walked until onset of symptoms (initial claudication) and until development of total loss of function (absolute claudication). A TMET with measurement of the ABI at rest and after exercise has also been proposed as a diagnostic test. The presence of PAOD is suggested by a greater than 20% reduction in post-exercise ABI as compared to resting values, or a decrease in post-exercise BP greater than 30 mmHg as compared to the resting state. 363 Another study reported lower cut-off scores, with PAOD being suggested when there is a greater than 18.5% reduction in ABI and a greater than 15 mmHg decrease in BP after exercise. 364 Considering the overall cardiovascular risk of these patients, optimized clinical treatment should always be instituted. In addition, smoking cessation and drug therapy with statins and antiplatelet agents must be considered, as well as adequate blood glucose and BP control. Regarding the use of cilostazol, there is no consensus among the guidelines of different medical societies. 362,363 In symptomatic patients, exercise has the potential to influence morbidity and mortality, reducing symptoms, improving quality of life, and increasing the maximum walking distance (Table 12). 365 Physical activities performed under direct supervision have been shown to be more effective than unsupervised exercise. 366 In 14 clinical trials (1,002 participants), with an intervention duration from 6 weeks to 12 months, pain- free walking increased about 180 meters more in training under direct supervision when compared to training under indirect supervision. Physical training is safe; in most studies, the sole exercise was walking to claudication, at least three times a week, for at least 3 months. 367 In patients with PAOD, training under direct supervision is also superior in terms of cost-effectiveness, 368 although indirect supervision (HBCR) is a good alternative, with positive effects on quality of life and significantly greater improvement in walking tolerance as compared to a simple recommendation to walk. 369,370 When walking is not feasible, other activities, such as cycling, resistance training, and use of an upper body 973