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Arquivos Brasileiros de Cardiologia

Print version ISSN 0066-782XOn-line version ISSN 1678-4170

Arq. Bras. Cardiol. vol.105 no.6 São Paulo Dec. 2015 


Cardiac Rehabilitation: Far Beyond Coronary Artery Disease

Claudio Gil Soares de Araújo1 

1Instituto do Coração Edson Saad – Universidade Federal do Rio de Janeiro - Rio de Janeiro, RJ; Clínica de Medicina do Exercício – CLINIMEX – Rio de Janeiro, RJ – Brazil

Keywords: Cardiovascular Diseases; Physical Exercise; Exercise Training; Exercise Programs; Flexibility

Palavras-chave: Doenças Cardiovasculares; Exercício Físico; Treinamento Físico; Programas de Exercício; Flexibilidade

Cardiac rehabilitation (CR), as originally proposed in the mid of last century, was primarily aimed at returning life back to normal, with emphasis on aspects of physical, mental and professional plenitude. At that time, a few paradigms were modified. Instead of four to six weeks of bed rest and immobilization following acute myocardial infarction, patients were oriented to sit on chairs, which was described as "armchair treatment"; right after, studies began to show the favorable results of early ambulation.1 This has evolved and currently the Brazilian Society of Cardiology guidelines proposing and advising how to implement and to start supervised exercise programs for CR.2 Those guidelines comprise aerobic, muscle strengthening and flexibility exercises to be started as soon as clinical stability is reached after myocardial infarction. Currently CR is aimed at providing patients with better or much better conditions than those prior to the cardiac event or the diagnosis of cardiovascular disease.

Although CR is a frequent and recurring theme of several presentations in scientific meetings of the specialty, being thus known by clinical cardiologists, there is worldwide consensus that only a very small part of patients with coronary artery disease is usually referred by their physicians for CR programs. Several are the reasons for that insufficient referral and they will not be addressed in this editorial.

The present editorial is aimed at alerting to another aspect, certainly less known to clinical cardiologists. CR and especially supervised exercise programs should be recommended not only to patients with coronary artery disease, but also to a wide range of cardiovascular disorders and, thus, to almost all patients with heart disease.

As highlighted in an article recently published in the Arquivos Brasileiros de Cardiologia,3 aerobic fitness has long been known to be one of the best, if not the best marker of the health status and prognosis of not only healthy individuals, but also those with heart disease. Aerobic fitness is expressed as the maximal oxygen uptake, preferentially measured through expired gas analysis during a cardiopulmonary exercise testing. Although the aerobic fitness is highly influenced by genetics, there is consensus that optimal levels can only be achieved via regular physical exercise, predominantly aerobics. Thus, for both primary and secondary prevention of cardiovascular diseases, being physically active is fundamental to optimize the aerobic fitness. Nevertheless, that is seen neither in daily clinical practice nor in the epidemiological data of the Brazilian population, and most patients with heart disease remain sedentary or insufficiently physically active.

Based on the increasing knowledge on physiological responses and adaptations to physical exercise of individuals from different populations and with different clinical characteristics, several researchers and CR services have recently explored other possibilities of indications and care for 'non-coronary heart patients'. Thus, the risks and benefits of interventions with regular physical exercise can be better known in a wide range of 'non-coronary heart patients', some considered as having absolute contraindications until recently. Those patients can be then referred to CR programs.

The Chart 1 lists 22 cardiovascular disorders,4-25 except for coronary artery disease, on which there are studies and scientific evidence suggesting the lack of harm or of important risk and presence of significant benefit resulting from the participation in CR programs and regular physical exercise sessions with or without medical supervision.

Chart 1 List of 22 non-coronary cardiovascular conditions that have been shown to clinically benefit from physical exercise intervention 

Number Cardiovascular condition Reference PubMed URL
1 Heart failure (all functional classes) (4)
2 Heart failure with preserved ejection fraction (5)
3 Dilated cardiomyopathy (6)
4 Heart transplantation (post-surgery) (7)
5 Heart valve surgery (post-event) (8)
6 Peripheral artery disease (9)
7 Systemic arterial hypertension (10)
8 Stroke (post-event) (11)
9 Transient ischemic attack (post-event) (12)
10 Pulmonary arterial hypertension (13)
11 Chagas disease (14)
12 Congenital heart diseases (15)
13 Catecholaminergic polymorphic ventricular tachycardia (16)
14 Erectile dysfunction (vascular etiology) (17)
15 Neurocardiogenic syncope (18)
16 Postural orthostatic tachycardia syndrome (19)
17 Abdominal aortic aneurysm (< 55 mm) (20)
18 Asymmetric hypertrophic cardiomyopathy (21)
19 Left ventricular assistance device (post-implantation) (22)
20 Transposition of the great vessels (adults, post-surgery) (23)
21 Atrial fibrillation (post-ablation) (24)
22 Transcatheter aortic valve implantation (25)

The disorders are listed in a decreasing order according to evidence level, level of knowledge available and clinical experience regarding the benefits of regular physical exercise. Each indication is based on a qualified and recent scientific reference, whose abstract in PubMed can be obtained via the hyperlink provided.

In fact, this list should actually be understood as open and not restrictive, because, except for arrhythmogenic right ventricular dysplasia,26,27 end-stage heart failure and acute myocardial or heart valve infections, some benefit can almost always be obtained from participating in CR programs or supervised physical exercise sessions, as long as the patient with heart disease is stable from the clinical, hemodynamic and electrocardiographic viewpoint.

I hope this editorial helps clinical cardiologists to definitively incorporate, as major priority, regular physical exercise into the treatment of patients with heart disease, not only the already known 'coronary heart patient', but also and with great emphasis on the 'non-coronary heart patient'. In parallel, public and private hospitals and clinics of Cardiology and Exercise Medicine should prepare to properly approach this new demand.


1 Brummer P, Linko E, Kasanen A. Myocardial infarction treated by early ambulation. Am Heart J. 1956;52(2):269-72. [ Links ]

2 Araujo CG, Carvalho T, Castro CL, Costa RV, Moraes RS, Oliveira Filho JA, et al. Standardization of equipment and technics for supervised cardiovascular rehabilitation. Arq Bras Cardiol. 2004;83(5):448-52. [ Links ]

3 Araujo CG, Herdy AH, Stein R. Maximum oxygen consumption measurement: valuable biological marker in health and in sickness. Arq Bras Cardiol. 2013;100(4):e51-3. [ Links ]

4 Taylor RS, Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal H, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014 Apr 27;4:CD003331. [ Links ]

5 Pandey A, Parashar A, Kumbhani DJ, Agarwal S, Garg J, Kitzman D, et al. Exercise training in patients with heart failure and preserved ejection fraction: meta-analysis of randomized control trials. Circ Heart Fail. 2015;8(1):33-40. [ Links ]

6 Holloway CJ, Dass S, Suttie JJ, Rider OJ, Cox P, Cochlin LE, et al. Exercise training in dilated cardiomyopathy improves rest and stress cardiac function without changes in cardiac high energy phosphate metabolism. Heart. 2012;98(14):1083-90. [ Links ]

7 Dall CH, Gustafsson F, Christensen SB, Dela F, Langberg H, Prescott E. Effect of moderate- versus high-intensity exercise on vascular function, biomarkers and quality of life in heart transplant recipients: a randomized, crossover trial. J Heart Lung Transplant. 2015;34(8):1033-41. [ Links ]

8 Kiel MK. Cardiac rehabilitation after heart valve surgery. PM R. 2011;3(10):962-7. [ Links ]

9 Murphy TP, Cutlip DE, Regensteiner JG, Mohler ER 3 rd , Cohen DJ, Reynolds MR, et al. Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease: the CLEVER study. J Am Coll Cardiol. 2015;65(10):999-1009. [ Links ]

10 Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc. 2013;2(1):e004473. [ Links ]

11 Saunders DH, Sanderson M, Brazzelli M, Greig CA, Mead GE. Physical fitness training for stroke patients. Cochrane Database Syst Rev. 2013 Oct 21;10:CD003316. [ Links ]

12 Faulkner J, Lambrick D, Woolley B, Stoner L, Wong LK, McGonigal G. The long-term effect of exercise on vascular risk factors and aerobic fitness in those with transient ischaemic attack: a randomized controlled trial. J Hypertens. 2014;32(10):2064-70. [ Links ]

13 Ehlken N, Lichtblau M, Klose H, Weidenhammer J, Fischer C, Nechwatal R, et al. Exercise training improves peak oxygen consumption and haemodynamics in patients with severe pulmonary arterial hypertension and inoperable chronic thrombo-embolic pulmonary hypertension: a prospective, randomized, controlled trial. Eur Heart J. 2015 Jul 31. [Epub ahead of print]. [ Links ]

14 Nascimento BR, Lima MM, Nunes MC, Alencar MC, Costa HS, Pinto Filho MM, et al. Effects of exercise training on heart rate variability in Chagas heart disease. Arq Bras Cardiol. 2014;103(3):201-8. [ Links ]

15 Duppen N, Takken T, Hopman MT, ten Harkel AD, Dulfer K, Utens EM, et al. Systematic review of the effects of physical exercise training programmes in children and young adults with congenital heart disease. Int J Cardiol. 2013;168(3):1779-87. [ Links ]

16 Manotheepan R, Saberniak J, Danielsen TK, Edvardsen T, Sjaastad I, Haugaa KH, et al. Effects of individualized exercise training in patients with catecholaminergic polymorphic ventricular tachycardia type 1. Am J Cardiol. 2014;113(11):1829-33. [ Links ]

17 Lamina S, Agbanusi E, Nwacha RC. Effects of aerobic exercise in the management of erectile dysfunction: a meta analysis study on randomized controlled trials. Ethiop J Health Sci. 2011;21(3):195-201. [ Links ]

18 Takahagi VC, Costa DC, Crescencio JC, Gallo Junior L. Physical training as non-pharmacological treatment of neurocardiogenic syncope. Arq Bras Cardiol. 2014;102(3):288-94. [ Links ]

19 Fu Q, Levine BD. Exercise in the postural orthostatic tachycardia syndrome. Auton Neurosci. 2015;188:86-9. [ Links ]

20 Myers J, McElrath M, Jaffe A, Smith K, Fonda H, Vu A, et al. A randomized trial of exercise training in abdominal aortic aneurysm disease. Med Sci Sports Exerc. 2014;46(1):2-9. [ Links ]

21 Klempfner R, Kamerman T, Schwammenthal E, Nahshon A, Hay I, Goldenberg I, et al. Efficacy of exercise training in symptomatic patients with hypertrophic cardiomyopathy: results of a structured exercise training program in a cardiac rehabilitation center. Eur J Prev Cardiol. 2015;22(1):13-9. [ Links ]

22 Marko C, Danzinger G, Kaferback M, Lackner T, Muller R, Zimpfer D, et al. Safety and efficacy of cardiac rehabilitation for patients with continuous flow left ventricular assist devices. Eur J Prev Cardiol 2015;22(11):1378-84. [ Links ]

23 Shafer KM, Janssen L, Carrick-Ranson G, Rahmani S, Palmer D, Fujimoto N, et al. Cardiovascular response to exercise training in the systemic right ventricle of adults with transposition of the great arteries. J Physiol. 2015;593(11):2447-58. [ Links ]

24 Pathak RK, Elliott A, Middeldorp ME, Meredith M, Mehta AB, Mahajan R, et al. Impact of CARDIOrespiratory FITness on Arrhythmia Recurrence in Obese Individuals With Atrial Fibrillation: The CARDIO-FIT Study. J Am Coll Cardiol. 2015;66(9):985-96. [ Links ]

25 Zanettini R, Gatto G, Mori I, Pozzoni MB, Pelenghi S, Martinelli L, et al. Cardiac rehabilitation and mid-term follow-up after transcatheter aortic valve implantation. J Geriatr Cardiol. 2014;11(4):279-85. [ Links ]

26 Rojas A, Calkins H. Present understanding of the relationship between exercise and arrhythmogenic right ventricular dysplasia/cardiomyopathy. Trends Cardiovasc Med. 2015;25(3):181-8. [ Links ]

27 Sawant AC, Calkins H. Relationship between arrhythmogenic right ventricular dysplasia and exercise. Card Electrophysiol Clin. 2015;7(2):195-206. [ Links ]

Received: September 15, 2015; Revised: September 15, 2015; Accepted: September 15, 2015

Mailing Address: Claudio Gil Soares de Araújo , Clínica de Medicina do Exercício – CLINIMEX. Rua Siqueira Campos, 93/101, Copacabana. Postal Code 22071-030, Rio de Janeiro, RJ – Brazil. E-mail:

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