IJCS | Volume 32, Nº5, September/October 2019

491 1. Gomes Neto M, Oliveira FA, Reis HF, de Sousa Rodrigues- E Jr, Bittencourt HS, Oliveira Carvalho V. Effects of Neuromuscular Electrical Stimulation on Physiologic and Functional Measurements in Patients With Heart Failure: A Systematic ReviewWith Meta-Analysis. J Cardiopulm Rehabil Prev. 2016;36(3):157-66. 2. Cerqueira TC, Neto ML, Carvalho AJ, Oliveira GU, Filho AA, Carvalho VO, et al. Neuromuscular Electrical Stimulation on Hemodynamic and Respiratory Response in Patients Submitted to Cardiac Surgery: Pilot Randomized Clinical Trial. Int J Cardiovasc Sci. 2019;32(5):483-489. 3. Forestieri P, BolzanDW, Santos VB, Moreira RSL, de Almeida DR, Trimer R, et al. Neuromuscular electrical stimulation improves exercise tolerance in patients with advanced heart failure on continuous intravenous inotropic support use-randomized controlled trial. Clin Rehabil. 2018 Jan;32(1):66-74. 4. Hainaut K, Duchateau J. Neuromuscular electrical stimulation and voluntary exercise. Sports Med. 1992;14(2):100-13. 5. Sbruzzi G, Ribeiro RA, Schaan BD, Signori LU, Silva AM, Irigoyen MC, et al. Functional electrical stimulation in the treatment of patients with chronic heart failure: a meta-analysis of randomized controlled trials. Eur J Cardiovasc Prev Rehabil. 2010;17(3):254-260. 6. HerdyAH,López-JiménezF,TerzicCP,MilaniM,SteinR,CarvalhoT,etal. Sociedade Brasileira de Cardiologia. Diretriz Sul-Americana de prevenção e reabilitação cardiovascular. Arq Bras Cardiol. 2014;103(2):1-31. 7. Zanini M, Nery R, Lima J, Buhler R, Silveira R, Stein R. effects of different rehabilitation protocols in inpatient cardiac rehabilitation after coronary arterybypassgr aftsurgery:arandomizedclinicaltrial.JCardiopulmRehabil Prev. 2019 Jul . doi: 10.1097/HCR.0000000000000431. [Epub ahead of print] 8. Spiroski D, Andjić M, Stojanović O, Lazović M, Dikić AD, Ostojić M, et al. Very short/short-term benefit of inpatient /outpatient cardiac rehabilitation programs after coronary artery bypass grafting surgery. Clin Cardiol. 2017;40(5):281-6. 9. Nobrega AC. The subacute effects of exercise: concept, characteristics, and clinical implications. Exerc Sport Sci Rev. 2005;33(2):84-7. 10. Dias DW, Marchese LD, Muradas MC, Mascarenhas C, Ferreira BA, Branco WD, et al. Efeito agudo de uma sessão de eletroestimulação neuromuscular sobre as variáveis hemodinâmicas em pacientes com insuficiência cardíaca. Rev Bras Cardiol. 2014;27(Suppl A):1-5. References Chermont & Quintão Neuromuscular electrical stimulation in cardiac surgery Int J Cardiovasc Sci. 2019;32(5):490-491 Editorial protocol, even when done briefly, is safe and effective for these patients. 8 However, evidence such as this one does not make it impossible for NMES to be used as an adjuvant treatment or in patients with no functional capacity to perform dynamic exercises. Therefore, the indication and prescription of the modality to be performed should be analytical and precise, considering that most of the progress in research studies showing the benefits of NMES converge to the scenario of patients with HF who cannot perform conventional dynamic exercises. 1,5 NMES does not yet have a well-defined role in the postoperative period of cardiac surgery, and little is known about whether it would play an important role in early physiological adaptations in an intrahospital CVR protocol. The intensity of acute physiological responses to exercise involves increasedHR, ventilation, catecholamine release, and autonomic responses, which reflect an individual’s ability to undergo repetitive and regular adjustments that determine physiological adaptations which promote increased performance and exercise capacity. 9 Cerqueira et al., 2 found that the absence of hemodynamic abnormalities could be an indication of a safety parameter. However, in the scenario of phase I CVR, in order to use NMES as an adjuvant technique, hemodynamic abnormalities must exist to ensure progressive adaptations to exertion. 9 Otherwi se , the inves t i ga t i on of res t r i c t ed hemodynamic parameters may not reflect the true extent of response to NMES. It is important to measure other hemodynamic parameters both for patient safety and to infer physiological adaptations, such as systolic volume, cardiac output and peripheral vascular resistance response, etc., which could provide guidance in the immediate postoperative period of cardiac surgery, especially in the presence of vasopressor use. 3 Unlike Cerqueira et al., 2 a recent study demonstrated changes in both systolic volume, cardiac output and systemic vascular resistance fromusingNMES in patients with HF and reduced ejection fraction. 10 The design and methodology applied in the study by Cerqueira et al., 2 were careful and sufficient to confirm the hypothesis, but measurements of other more complex hemodynamic and autonomic responses may actually ensure feasibility and safety and provide more information about the mechanism of benefit and usefulness of this technique as an adjuvant resource for intrahospital CVR. Although the intensity of NMES used is compatible withmost studies, other intensities can also be tested and compared to measure the magnitude of their responses. Further studies are needed to pave the way for the implementation and corroboration of new protocols with NMES. This is an open-access article distributed under the terms of the Creative Commons Attribution License