Exercise Prescriptions for Heart Failure Validated in New Brazilian Clinical Guidelines

Heart failure (HF) affects millions globally and carries high morbidity, mortality, and reduced quality of life. Exercise-based cardiac rehabilitation is a cornerstone of management, yet variability in how programs are structured — particularly in Brazil, where physical therapists often lead rehabilitation — has created a need for standardized, evidence-based guidance. ASSOBRAFIR (Brazilian Association of Cardiorespiratory Physical Therapy) convened a multidisciplinary expert panel to address this gap.

The guideline panel followed the Guidelines International Network (GIN) and AGREE-II frameworks for methodological rigor. Evidence was synthesized through meta-analyses of randomized clinical trials published from 2009 onward, and certainty of evidence (CoE) and recommendation strength were graded using the GRADE approach. Four clinical questions were addressed, covering aerobic, resistance, inspiratory muscle, and neuromuscular electrical stimulation (NMES) modalities in clinically stable outpatients with either reduced or preserved ejection fraction (HFrEF and HFpEF).

For aerobic training, the panel found high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) to be equivalent in outcomes (conditional recommendation, low CoE). This equivalence gives clinicians flexibility to individualize training based on patient preference, tolerance, and functional capacity. For resistance training, moderate-intensity resistance training (MIRT) was found to be more effective than low-intensity resistance training (LIRT), particularly in HFpEF patients (conditional recommendation, very low CoE). This distinction is clinically meaningful, as HFpEF has historically lacked strong evidence-based exercise prescriptions.

Regarding inspiratory muscle training (IMT), high-intensity IMT was superior to low-intensity IMT for improving inspiratory muscle strength and endurance (conditional recommendation, very low CoE). This supports targeting higher training loads when prescribing IMT, a modality particularly relevant for HF patients who exhibit respiratory muscle weakness. For NMES, two sub-recommendations emerged: NMES is more effective than NMES placebo or usual activities (conditional recommendation, low CoE), but adding NMES to aerobic training confers no additional benefit over aerobic training alone (conditional recommendation, low CoE).

All recommendations were conditional rather than strong, reflecting low to very low certainty of evidence — a limitation inherent to the current trial landscape in HF rehabilitation. The guidelines nonetheless provide a structured framework that can guide clinical decision-making while highlighting where future research investment is most needed. These recommendations are especially relevant for middle- and low-income healthcare settings where resource allocation and protocol standardization can meaningfully impact patient outcomes.