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BACKGROUND: Evidence on the safety and anti-ischemic effects of exercise-based cardiac rehabilitation (ECR) in patients with refractory angina (RA) remains limited. OBJECTIVE: To evaluate the safety and efficacy of a 12-week ECR program in patients with RA, focusing on improvements in symptoms, functional capacity, and ischemic burden assessed by exercise stress echocardiography (ESE). METHODS: This was a prospective, single-center, randomized controlled trial evaluating a 12-week ECR program in patients with RA. Forty-five patients were randomized to either the rehabilitation group (RG), receiving ECR, or the control group (CG), receiving medical treatment (MT) alone. Outcomes included mortality, cardiovascular events, anginal symptoms, and parameters from ESE and cardiopulmonary exercise testing (CPET). Statistical significance was set at p < 0.05. RESULTS: In ESE, exercise duration was significantly greater in RGpost (after ECR) compared to RGpre (before ECR) (∆ = 63.24 ± 19.87 s; p < 0.01). Angina quantification was lower in RGpost than in RGpre, CGpost (after MT alone), and CGpre (before MT alone) (∆ = -1.64 ± 0.48 n, p < 0.01; -3.10 ± 0.97 n, p < 0.01; and -2.73 ± 0.92 n, p = 0.01, respectively). The angina threshold was higher in RGpost than in RGpre and CGpost (∆ = 89.66 ± 33.16 s, p = 0.04; and 111.76 ± 42.25 s, p = 0.04, respectively). Improvement in ischemic burden on ESE was demonstrated by increased time to ischemic threshold in RGpost compared to RGpre, CGpost, and CGpre (∆ = 83.23 ± 21.84 s, p < 0.01; 98.44 ± 35.11 s, p = 0.03; and 109.34 ± 34.00 s, p < 0.01, respectively). In CPET, RGpost showed increased exercise duration (∆ = 104.54 ± 28.09 s, p < 0.01) and distance covered (∆ = 131.23 ± 30.48 m, p < 0.01) compared to RGpre. No significant differences in VO2 were observed between groups. Two patients in the CG group died. One patient in the RG group experienced prolonged angina during training. No significant differences in major cardiovascular events were observed between groups. CONCLUSION: The 12-week ECR-program was safe and effective in improving exercise duration, distance covered and ischemic burden on ESE in patients with RA. FUNDAMENTO: As evidências sobre a segurança e os efeitos anti-isquêmicos da reabilitação cardíaca baseada em exercício (RCE) em pacientes com angina refratária (AR) ainda são limitadas. OBJETIVO: Avaliar a segurança e a eficácia de um programa de RCE de 12 semanas em pacientes com AR, com foco na melhora dos sintomas, da capacidade funcional e da carga isquêmica avaliada por ecocardiografia de estresse com exercício (EEE). M&#xc9;TODOS: Estudo prospectivo, randomizado, controlado, e unicêntrico, que avaliou um programa de RCE de 12 semanas em pacientes com AR. Quarenta e cinco pacientes foram randomizados para o grupo de reabilitação (GR), que recebeu RCE, ou para o grupo controle (GC), que recebeu apenas tratamento médico. Os desfechos avaliados incluíram mortalidade, eventos cardiovasculares, sintomas anginosos e parâmetros da EEE e do teste cardiopulmonar de exercício (TCPE). O nível de significância estatística adotado foi p < 0,05. RESULTADOS: Na EEE, a duração do exercício foi significativamente maior no GRpós (após a RCE) em comparação com GRpré (antes da RCE) (∆ = 63,24 ± 19,87 s; p < 0,01). A quantificação de angina foi menor no GRpós em comparação ao GRpré, ao GCpós (após tratamento médico isolado) e ao GCpré (antes do tratamento médico isolado) (∆ = –1,64 ± 0,48 n, p < 0,01; -3,10 ± 0,97 n, p < 0,01; e -2,73 ± 0,92 n, p = 0,01, respectivamente). O limiar de angina foi maior em GRpós em comparação ao GRpré e ao GRpós (∆ = 89,66 ± 33,16 s, p = 0,04; e 111,76 ± 42,25 s, p = 0,04, respectivamente). A melhora na carga isquêmica na EEE foi demonstrada pelo aumento do tempo até o limiar isquêmico GRpós em comparação ao GCpré, e ao GCpré e GRpós (∆ = 83,23 ± 21,84 s, p < 0,01; 98,44 ± 35,11 s, p = 0,03; e 109,34 ± 34,00 s, p < 0,01, respectivamente). No TCPE, o GRpós apresentou aumento na duração do exercício (∆ = 104,54 ± 28,09 s; p < 0,01) e na distância percorrida (∆ = 131,23 ± 30,48 m; p < 0,01) em comparação ao GRpré. Não foram observadas diferenças significativas no VO2 entre os grupos. Dois pacientes do grupo CG faleceram. Um paciente do GR apresentou angina prolongada durante o treinamento. Não houve diferenças significativas nos eventos cardiovasculares maiores entre os grupos. CONCLUS&#xc3;O: O programa de RCE de 12 semanas foi seguro e eficaz na melhora da duração do exercício, da distância percorrida e da carga isquêmica na EEE em pacientes com AR. BACKGROUND: Evidence on the safety and anti-ischemic effects of exercise-based cardiac rehabilitation (ECR) in patients with refractory angina (RA) remains limited. OBJECTIVE: To evaluate the safety and efficacy of a 12-week ECR program in patients with RA, focusing on improvements in symptoms, functional capacity, and ischemic burden assessed by exercise stress echocardiography (ESE). METHODS: This was a prospective, single-center, randomized controlled trial evaluating a 12-week ECR program in patients with RA. Forty-five patients were randomized to either the rehabilitation group (RG), receiving ECR, or the control group (CG), receiving medical treatment (MT) alone. Outcomes included mortality, cardiovascular events, anginal symptoms, and parameters from ESE and cardiopulmonary exercise testing (CPET). Statistical significance was set at p < 0.05. RESULTS: In ESE, exercise duration was significantly greater in RGpost (after ECR) compared to RGpre (before ECR) (∆ = 63.24 ± 19.87 s; p < 0.01). Angina quantification was lower in RGpost than in RGpre, CGpost (after MT alone), and CGpre (before MT alone) (∆ = –1.64 ± 0.48 n, p < 0.01; –3.10 ± 0.97 n, p < 0.01; and –2.73 ± 0.92 n, p = 0.01, respectively). The angina threshold was higher in RGpost than in RGpre and CGpost (∆ = 89.66 ± 33.16 s, p = 0.04; and 111.76 ± 42.25 s, p = 0.04, respectively). Improvement in ischemic burden on ESE was demonstrated by increased time to ischemic threshold in RGpost compared to RGpre, CGpost, and CGpre (∆ = 83.23 ± 21.84 s, p < 0.01; 98.44 ± 35.11 s, p = 0.03; and 109.34 ± 34.00 s, p < 0.01, respectively). In CPET, RGpost showed increased exercise duration (∆ = 104.54 ± 28.09 s, p < 0.01) and distance covered (∆ = 131.23 ± 30.48 m, p < 0.01) compared to RGpre. No significant differences in VO2were observed between groups. Two patients in the CG group died. One patient in the RG group experienced prolonged angina during training. No significant differences in major cardiovascular events were observed between groups. CONCLUSION: The 12-week ECR-program was safe and effective in improving exercise duration, distance covered and ischemic burden on ESE in patients with RA.