ASSOBRAFIR clinical practice guidelines in cardiovascular physical therapy: Exercise-based interventions in outpatient rehabilitation programs for heart failure

Abstract

Background: Exercise training is a core component of cardiovascular rehabilitation programs for patients with heart failure (HF). In Brazil, physical therapists frequently deliver rehabilitation interventions. Given heart failure clinical management advancements and varied rehabilitation approaches, standardizing exercise training within cardiovascular rehabilitation programs is essential. Objective: To provide evidence-based recommendations for structuring exercise training (ET) in outpatient cardiovascular rehabilitation with HF, whether with preserved or reduced left ventricular ejection fraction. Methods: The Guideline Panel followed the principles of the Guidelines International Network (GIN) and the Appraisal of Guidelines for Research & Evaluation (AGREE-II) to ensure methodological rigor. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence (CoE) and to formulate recommendations for key questions regarding supervised ET in clinically stable outpatients with HF. Treatment effects were assessed through meta-analyses of randomized clinical trials published since 2009. Results: The Guideline Panel suggests: 1. High-intensity interval training and moderate-intensity continuous training are equivalent (conditional recommendation [CoR], low CoE); 2. Moderate-intensity resistance training is more effective than low-intensity resistance training (CoR, very low CoE); 3. High-intensity inspiratory muscle training (IMT) is more effective than low-intensity IMT (CoR, very low CoE); 4a. Neuromuscular electrical stimulation (NMES) is more effective than NMES placebo or usual activities (CoR, low CoE). 4b. NMES, in addition to aerobic training, is not more effective than aerobic training alone (CoR, low CoE). Conclusion: These recommendations provide valuable guidance for delivering exercise-based interventions to outpatient cardiovascular rehabilitation programs in heart failure patients.