ABC | Volume 115, Nº2, August 2020

Statement Grossman et al. Position Statement of the Brazilian Society of Cardiology Department of Exercise Testing, Sports Exercise, Nuclear Cardiology, and Cardiovascular Rehabilitation (DERC/SBC) on Activities Within its Scope of Practice During the COVID-19 Pandemic Arq Bras Cardiol. 2020; 115(2):284-291 • An order for a TMET or CPET must be preceded by a thorough physical examination of the patient to determine whether the test is truly indicated. Thus, such tests cannot be ordered or requested via telemedicine. 5 • Examination rooms should be large and well-ventilated. Natural ventilation is preferred; common climate-control systems (fans and HVAC) should be avoided due to the potential for environmental dispersal of contaminants. 6 • It is well established that TMET and CPET pose a theoretical risk of contamination for the performing clinician and team. The physician and auxiliary staff (technicians, paramedics, nurses) are advised to wear a respirator (FFP2/ N95-equivalent filtration efficiency or higher), goggles, and procedure gloves throughout the test. Staff are to remain at least 2 meters away from the patient for as long as possible. Institutional recommendations and the advice of municipal and state health departments should be followed. • Patients must wear an FFP1-equivalent medical mask (such as a surgical mask) upon entering the testing area of the facility. Patients must wash their hands with soap and water and apply hand sanitizer (containing at least 70% alcohol) before contact with any equipment or any other surface in the examination room. • In the clinic and hospital setting, before the test begins, staff are to confirm that potentially contaminating devices and surfaces have been properly cleaned and sanitized. Institutional protocols should incorporate the recommendations of health authorities regarding these procedures and must be followed. 6 If a test is to be performed in an office setting or at a clinic that has no environmental services protocols in place, the following actions are recommended: • Clean the ECG cables with a 70% alcohol wipe. • Clean and perform high-level disinfection for transmissible pathogens of the ergometer support bar, treadmill mat, cycle ergometer saddle, sphygmomanometer cuff, stethoscope, and other high-touch surfaces using one or more of the following recommended products: 1,7 • Active chlorine-based (0.5% sodium hypochlorite solution). • Quaternary ammonium (“quat”)-based (final concentration no higher than 0.8%). • Accelerated hydrogen peroxide-based (concentration no higher than 0.5%). • Alcohol-based (concentration no lower than 70%) or alcohol plus a quaternary ammonium (“quat”) compound. • Disposable materials—especially monitoring electrodes— are preferred when performing TMET and CPET. Dispose of all materials properly and in an appropriate container. • In case of CPET, the physician in charge of the test must confirm there is capacity to sterilize the entire system effectively, including the expired gases circuit and analyzer, and that institutional protocols which incorporate the recommendations of health authorities are followed. • The physician in charge of the test is to assess and update the crash cart/trolley and all other emergency equipment so as to ensure it is adapted to the latest recommendations for resuscitation and treatment of complications during the COVID-19 pandemic. 8,9 • Facilities which offer TMET and CPET are to update their protocols for patient transfer in the event of complications and emergencies in concert with the availability and guidelines of insurers, health management organizations, and local emergency medical services. 10 • Professionals (including the physician and auxiliary staff) with a suspected or confirmed diagnosis of COVID-19 are to be relieved of their duties and follow current recommendations for treatment and self-isolation. 6 • The usual criteria for selection of ergometers and exercise protocols, the classic diagnostic and prognostic criteria for TMET and CPET, and the conventional pre- and post-test probabilities still apply. We suggest that the test report describe the behavior of the QT interval during exertion and at the fourth minute of recovery. 11,12 • At the present time, it is reasonable to consider postponing TMET and CPET whenever the test is unlikely to have a direct impact on care or clinical outcome in the following months. 3 3. Cardiopulmonary and Metabolic Rehabilitation The COVID-19 pandemic has had a profound impact on health services, including cardiopulmonary and metabolic rehabilitation (CPMR) services, which play a fundamental role in the clinical management of patients with cardiovascular, pulmonary, and metabolic diseases, providing significant reductions in hospitalization and overall mortality rates. 13-17 However, to date, isolation and social distancing have been the cornerstone of COVID-19 control, especially for patients at higher risk of hospitalization, respiratory complications, and mortality—precisely those with indications for CPMR programs. 18,19 Therefore, in line with the recommendations of global and national health authorities, CMR services involving face-to-face activities have been suspended due to the risk of contagion. Within the context of COVID-19, considering that CPMR is essential for the process of recovery of functional capacity of patients with heart failure 17,20 or after cardiovascular events and interventions, and that the time to initiation of an exercise program after hospital discharge can influence functional recovery, disease management, and mortality rates, we believe that home-based CPMR programs—delivered at a distance with the support of digital technologies—should be prioritized. Such programs have been adopted to good effect by many services in Brazil and elsewhere. 17,21 Home-based exercises should follow the usual recommendations for conventional CPMR. The exercise prescription should be individualized and based on prior evaluation whenever possible. 17,21 For safety purposes, it is recommended that the scale of perceived exertion be used during physical exercise, which should be of light and/or moderate intensity at most. At the present time, we suggest that high-intensity, exhausting exercises with a very high rating of perceived exertion be avoided. 287