Cardiac rehabilitation

CR services can be provided in hospital, in an outpatient setting such as a community center, or remotely at home using the phone and other technologies. Hybrid programs are also increasingly being offered.{{cite journal | vauthors = Keteyian SJ, Ades PA, Beatty AL, Gavic-Ott A, Hines S, Lui K, Schopfer DW, Thomas RJ, Sperling LS | display-authors = 6 | title = A Review of the Design and Implementation of a Hybrid Cardiac Rehabilitation Program: AN EXPANDING OPPORTUNITY FOR OPTIMIZING CARDIOVASCULAR CARE | journal = Journal of Cardiopulmonary Rehabilitation and Prevention | volume = 42 | issue = 1 | pages = 1–9 | date = January 2022 | pmid = 34433760 | doi = 10.1097/HCR.0000000000000634 | s2cid = 237306143 | doi-access = }}{{cite journal | vauthors = Heindl B, Ramirez L, Joseph L, Clarkson S, Thomas R, Bittner V | title = Hybrid cardiac rehabilitation - The state of the science and the way forward | journal = Progress in Cardiovascular Diseases | volume = 70 | pages = 175–182 | date = 2022-01-01 | pmid = 34958846 | doi = 10.1016/j.pcad.2021.12.004 | s2cid = 245480348 }} There appears to be no difference in outcomes between supervised and home-based CR programs, and both cost about the same.{{Cite journal |last1=McDonagh |first1=Sinead Tj |last2=Dalal |first2=Hasnain |last3=Moore |first3=Sarah |last4=Clark |first4=Christopher E. |last5=Dean |first5=Sarah G. |last6=Jolly |first6=Kate |last7=Cowie |first7=Aynsley |last8=Afzal |first8=Jannat |last9=Taylor |first9=Rod S. |date=2023-10-27 |title=Home-based versus centre-based cardiac rehabilitation |journal=The Cochrane Database of Systematic Reviews |volume=2023 |issue=10 |pages=CD007130 |doi=10.1002/14651858.CD007130.pub5 |issn=1469-493X |pmc=10604509 |pmid=37888805}} Home-based cardiac rehabilitation is generally considered to be a safe alternative to traditional CR.{{cite journal |display-authors=6 |vauthors=Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, Franklin BA, Keteyian SJ, Kitzman DW, Regensteiner JG, Sanderson BK, Whooley MA |date=July 2019 |title=Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology |url=https://escholarship.org/content/qt4774x846/qt4774x846.pdf?t=rvfmqe |journal=Circulation |volume=140 |issue=1 |pages=e69–e89 |doi=10.1161/CIR.0000000000000663 |pmid=31082266 |s2cid=153312127 |doi-access=free}} Home-based programs with technology are similarly shown to be effective.{{cite journal |vauthors=Chong MS, Sit JW, Karthikesu K, Chair SY |date=December 2021 |title=Effectiveness of technology-assisted cardiac rehabilitation: A systematic review and meta-analysis |journal=International Journal of Nursing Studies |volume=124 |pages=104087 |doi=10.1016/j.ijnurstu.2021.104087 |pmid=34562846 |s2cid=237636685}}{{cite journal |vauthors=Ramachandran HJ, Jiang Y, Tam WW, Yeo TJ, Wang W |date=May 2022 |title=Effectiveness of home-based cardiac telerehabilitation as an alternative to Phase 2 cardiac rehabilitation of coronary heart disease: a systematic review and meta-analysis |journal=European Journal of Preventive Cardiology |volume=29 |issue=7 |pages=1017–1043 |doi=10.1093/eurjpc/zwab106 |pmc=8344786 |pmid=34254118}}{{cite journal |display-authors=6 |vauthors=Jin K, Khonsari S, Gallagher R, Gallagher P, Clark AM, Freedman B, Briffa T, Bauman A, Redfern J, Neubeck L |date=April 2019 |title=Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review and meta-analysis |url=https://napier-repository.worktribe.com/file/1488219/1/Telehealth%20interventions%20for%20the%20secondary%20prevention%20of%20coronary%20heart%20disease |journal=European Journal of Cardiovascular Nursing |volume=18 |issue=4 |pages=260–271 |doi=10.1177/1474515119826510 |pmid=30667278 |s2cid=58601002}} In a typical cardiac rehabilitation setting, the patient is cared for by a team of professionals that is typically led by a cardiologist. In home-based cardiac rehabilitation programs, patients are supported by a similar team of professionals, but the patient is responsible for completing the program without direct supervision.{{Cite journal |last1=Besnier |first1=Florent |last2=Gayda |first2=Mathieu |last3=Nigam |first3=Anil |last4=Juneau |first4=Martin |last5=Bherer |first5=Louis |date=2020-06-27 |title=Cardiac Rehabilitation During Quarantine in COVID-19 Pandemic: Challenges for Center-Based Programs |journal=Archives of Physical Medicine and Rehabilitation |volume=101 |issue=10 |pages=1835–1838 |doi=10.1016/j.apmr.2020.06.004 |issn=1532-821X |pmc=7319913 |pmid=32599060}} While CR is generally considered to be cost effective{{Cite journal |last1=Shields |first1=Gemma E. |last2=Wells |first2=Adrian |last3=Doherty |first3=Patrick |last4=Heagerty |first4=Anthony |last5=Buck |first5=Deborah |last6=Davies |first6=Linda M. |date=2018-04-13 |title=Cost-effectiveness of cardiac rehabilitation: a systematic review |journal=Heart (British Cardiac Society) |volume=104 |issue=17 |pages=1403–1410 |doi=10.1136/heartjnl-2017-312809 |issn=1468-201X |pmc=6109236 |pmid=29654096}}, it is worth noting that many insurances, including Medicare, do not cover home-based cardiac rehabilitation programs{{Cite web |title=Cardiac Rehabilitation Program Coverage |url=https://www.medicare.gov/coverage/cardiac-rehabilitation |access-date=2025-04-18 |website=www.medicare.gov |language=en}}

CR is useful for those who are recovering from a recent cardiac emergency, those who need assistance managing their chronic stable angina symptoms, those who have recently undergone cardiac surgeries, and in many other cases.{{Citation |last1=Tessler |first1=Joseph |title=Cardiac Rehabilitation |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK537196/ |access-date=2025-04-18 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30725881 |last2=Ahmed |first2=Intisar |last3=Bordoni |first3=Bruno}} However, traditional CR is not an option for some individuals. Some patients are discouraged from participating in the typical exercise component of CR, including those with unstable angina, intracavitary thrombus, and more.

{{expand section|date=January 2012}}

Engaging in CR before leaving the hospital can hasten patient’s recovery, as well as facilitate a smoother return to activities of daily living and roles once they return home. Many patients express anxiety about their recovery, especially after a severe illness or surgery, so Phase I CR provides an opportunity for patients to test their abilities in a safe, supervised setting.

Where available, patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms. Heart rate and blood oxygen levels are closely monitored by a therapist as the patient begins to walk, or exercise using a stationary bicycle. The therapist ensures that the level of aerobic and strength training are appropriate for the patient’s current status, and gradually progresses their therapeutic exercises.{{cite journal | vauthors = Wang TJ, Chau B, Lui M, Lam GT, Lin N, Humbert S | title = Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19 | journal = American Journal of Physical Medicine & Rehabilitation | volume = 99 | issue = 9 | pages = 769–774 | date = September 2020 | pmid = 32541352 | pmc = 7315835 | doi = 10.1097/PHM.0000000000001505 }}

Phase I is also an ideal time for the patient and their family to receive information regarding what is to be expected after their release. This includes information regarding their ADLs (activities of daily life) and the importance of stress management. During this time, patients are also assessed to determine if they will need assistive devices following their release from the inpatient program.

In order to participate in an outpatient program, the patient generally must first obtain a physician's referral. It is recommended patients begin outpatient CR within 2–7 days following a percutaneous intervention, and 4–6 weeks after cardiac surgery.{{cite journal | vauthors = Zhang Y, Cao H, Jiang P, Tang H | title = Cardiac rehabilitation in acute myocardial infarction patients after percutaneous coronary intervention: A community-based study | journal = Medicine | volume = 97 | issue = 8 | pages = e9785 | date = February 2018 | pmid = 29465559 | pmc = 5841979 | doi = 10.1097/MD.0000000000009785 }}{{cite journal | vauthors = Shajrawi A, Granat M, Jones I, Astin F | title = Physical Activity and Cardiac Self-Efficacy Levels During Early Recovery After Acute Myocardial Infarction: A Jordanian Study | journal = The Journal of Nursing Research | volume = 29 | issue = 1 | pages = e131 | date = November 2020 | pmid = 33136697 | pmc = 7808357 | doi = 10.1097/JNR.0000000000000408 }}{{cite journal | vauthors = Dafoe W, Arthur H, Stokes H, Morrin L, Beaton L | title = Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation | journal = The Canadian Journal of Cardiology | volume = 22 | issue = 11 | pages = 905–911 | date = September 2006 | pmid = 16971975 | pmc = 2570237 | doi = 10.1016/s0828-282x(06)70309-9 }} This period is often very difficult for patients due to fears of over-exertion or a recurrence of heart issues.{{cite journal | vauthors = Astin F, Closs SJ, McLenachan J, Hunter S, Priestley C | title = Primary angioplasty for heart attack: mismatch between expectations and reality? | journal = Journal of Advanced Nursing | volume = 65 | issue = 1 | pages = 72–83 | date = January 2009 | pmid = 19032516 | doi = 10.1111/j.1365-2648.2008.04836.x }} Shorter time to start is associated with better outcomes.{{Cite web |title=Cardiac rehabilitation wait times and relation to patient outcomes - European Journal of Physical and Rehabilitation Medicine 2015 June;51(3):301-9 |url=https://www.minervamedica.it/en/journals/europa-medicophysica/article.php?cod=R33Y2015N03A0301 |access-date=2023-04-05 |website=www.minervamedica.it |language=en}}

Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipids, blood pressure, body composition, depression / anxiety, and tobacco use. A functional capacity test is usually performed both to determine if exercise is safe and to support development of a customized exercise program.

Risk factors are addressed and patients goals are established; a "case-manager" who may be a cardiac-trained registered nurse, physiotherapist, or an exercise physiologist works to help patients achieve their targets. During exercise, the patient's heart rate and blood pressure may be monitored to check the intensity of activity.{{cite journal | vauthors = Supervia M, Turk-Adawi K, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, Bjarnason-Wehrens B, Derman W, Abreu A, Babu AS, Santos CA, Jong SK, Cuenza L, Yeo TJ, Scantlebury D, Andersen K, Gonzalez G, Giga V, Vulic D, Vataman E, Cliff J, Kouidi E, Yagci I, Kim C, Benaim B, Estany ER, Fernandez R, Radi B, Gaita D, Simon A, Chen SY, Roxburgh B, Martin JC, Maskhulia L, Burdiat G, Salmon R, Lomelí H, Sadeghi M, Sovova E, Hautala A, Tamuleviciute-Prasciene E, Ambrosetti M, Neubeck L, Asher E, Kemps H, Eysymontt Z, Farsky S, Hayward J, Prescott E, Dawkes S, Santibanez C, Zeballos C, Pavy B, Kiessling A, Sarrafzadegan N, Baer C, Thomas R, Hu D, Grace SL | display-authors = 6 | title = Nature of Cardiac Rehabilitation Around the Globe | language = English | journal = eClinicalMedicine | volume = 13 | pages = 46–56 | date = August 2019 | pmid = 31517262 | pmc = 6733999 | doi = 10.1016/j.eclinm.2019.06.006 | doi-access = free }}

The duration of CR varies from program to program, and can range from six weeks to several years. Globally, a median of 24 sessions are offered,{{cite journal | vauthors = Chaves G, Turk-Adawi K, Supervia M, Santiago de Araújo Pio C, Abu-Jeish AH, Mamataz T, Tarima S, Lopez Jimenez F, Grace SL | display-authors = 6 | title = Cardiac Rehabilitation Dose Around the World: Variation and Correlates | journal = Circulation: Cardiovascular Quality and Outcomes | volume = 13 | issue = 1 | pages = e005453 | date = January 2020 | pmid = 31918580 | doi = 10.1161/CIRCOUTCOMES.119.005453 | s2cid = 210133397 | doi-access = free }} and it is well-established that the more the better.{{cite journal | vauthors = Santiago de Araújo Pio C, Marzolini S, Pakosh M, Grace SL | title = Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis | journal = Mayo Clinic Proceedings | volume = 92 | issue = 11 | pages = 1644–1659 | date = November 2017 | pmid = 29101934 | doi = 10.1016/j.mayocp.2017.07.019 | hdl-access = free | s2cid = 40193168 | hdl = 10315/38072 }}

Immediately following phase II, patients are encouraged to continue their recovery from home. While it is recommended that patients continue to attend follow-up visits with their physicians, phase III is predominantly carried out by the patients themselves. During this phase, the patient is expected to continue taking their medications as prescribed, to continue the exercises that they have been taught, and to ensure that they make the appropriate lifestyle changes to avoid another cardiac event.{{Citation |last1=Tessler |first1=Joseph |title=Cardiac Rehabilitation |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK537196/ |access-date=2025-03-29 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30725881 |last2=Bordoni |first2=Bruno}} Challenges persist for optimizing and maintaining cardiovascular health among people with CVD and this includes a need for longer term support and care rather than a time-limited traditional rehabilitation program{{Cite journal |last1=Redfern |first1=Julie |last2=Gallagher |first2=Robyn |last3=Maiorana |first3=Andrew |last4=Candelaria |first4=Dion |last5=Hollings |first5=Matthew |last6=Gauci |first6=Sarah |last7=O’Neil |first7=Adrienne |last8=Chaseling |first8=Georgia K. |last9=Zhang |first9=Ling |last10=Thomas |first10=Emma E. |last11=Ghisi |first11=Gabriela L. M. |last12=Gibson |first12=Irene |last13=Hyun |first13=Karice |last14=Beatty |first14=Alexis |last15=Briffa |first15=Tom |date=2024-09-30 |title=Cardiac rehabilitation and secondary prevention of CVD: time to think about cardiovascular health rather than rehabilitation |journal=npj Cardiovascular Health |language=en |volume=1 |issue=1 |page=22 |doi=10.1038/s44325-024-00017-7 |pmid=39359645 |pmc=11442299 |issn=2948-2836}}{{Cite journal |last1=Redfern |first1=Julie |last2=Gallagher |first2=Robyn |last3=O’Neil |first3=Adrienne |last4=Grace |first4=Sherry L. |last5=Bauman |first5=Adrian |last6=Jennings |first6=Garry |last7=Brieger |first7=David |last8=Briffa |first8=Tom |date=2022-04-27 |title=Historical Context of Cardiac Rehabilitation: Learning From the Past to Move to the Future |journal=Frontiers in Cardiovascular Medicine |language=English |volume=9 |doi=10.3389/fcvm.2022.842567 |doi-access=free |pmid=35571195 |issn=2297-055X|pmc=9091441 }}.

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Participation in CR may be associated with many benefits.{{cite journal | vauthors = Taylor RS, Dalal HM, McDonagh ST | title = The role of cardiac rehabilitation in improving cardiovascular outcomes | journal = Nature Reviews. Cardiology | volume = 19 | issue = 3 | pages = 180–194 | date = March 2022 | pmid = 34531576 | pmc = 8445013 | doi = 10.1038/s41569-021-00611-7 }} Cardiac rehabilitation decreases the risk that patients will have further complications due to heart disease, with studies showing that CR decreases the chance of dying from heart complications in the next five years by about 35%.. The potential benefit in all-cause mortality is not as clear, however there is some supportive evidence.{{cite journal |display-authors=6 |vauthors=Kabboul NN, Tomlinson G, Francis TA, Grace SL, Chaves G, Rac V, Daou-Kabboul T, Bielecki JM, Alter DA, Krahn M |date=December 2018 |title=Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis |journal=Journal of Clinical Medicine |volume=7 |issue=12 |pages=514 |doi=10.3390/jcm7120514 |pmc=6306907 |pmid=30518047 |doi-access=free}}

CR is associated with improved quality of life, improved psychosocial well-being, and functional capacity,{{cite journal | vauthors = Francis T, Kabboul N, Rac V, Mitsakakis N, Pechlivanoglou P, Bielecki J, Alter D, Krahn M | display-authors = 6 | title = The Effect of Cardiac Rehabilitation on Health-Related Quality of Life in Patients With Coronary Artery Disease: A Meta-analysis | journal = The Canadian Journal of Cardiology | volume = 35 | issue = 3 | pages = 352–364 | date = March 2019 | pmid = 30825955 | doi = 10.1016/j.cjca.2018.11.013 | s2cid = 73474249 }} and is cost-effective.{{cite journal | vauthors = Shields GE, Wells A, Doherty P, Heagerty A, Buck D, Davies LM | title = Cost-effectiveness of cardiac rehabilitation: a systematic review | journal = Heart | volume = 104 | issue = 17 | pages = 1403–1410 | date = September 2018 | pmid = 29654096 | pmc = 6109236 | doi = 10.1136/heartjnl-2017-312809 }} In addition, cardiac rehabilitation has been shown to reduce negative symptoms, help foster positive lifestyle changes, and encourage patients to continue taking their medications on a daily basis.{{Cite web |last=CDC |date=2024-05-24 |title=How Cardiac Rehabilitation Can Help Heal Your Heart |url=https://www.cdc.gov/heart-disease/about/cardiac-rehabilitation-treatment.html |access-date=2025-04-01 |website=Heart Disease |language=en-us}} There are specific reviews on benefits of CR in patients with specific health conditions such as valve issues,{{cite journal | vauthors = Abraham LN, Sibilitz KL, Berg SK, Tang LH, Risom SS, Lindschou J, Taylor RS, Borregaard B, Zwisler AD | display-authors = 6 | title = Exercise-based cardiac rehabilitation for adults after heart valve surgery | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 5 | pages = CD010876 | date = May 2021 | pmid = 33962483 | pmc = 8105032 | doi = 10.1002/14651858.CD010876.pub3 }} atrial fibrillation,{{Cite journal |last1=Buckley |first1=Benjamin JR |last2=van Hout |first2=Liz |last3=Fitzhugh |first3=Charlotte |last4=Lip |first4=Gregory YH |last5=Taylor |first5=Rod S |last6=Thijssen |first6=Dick HJ |date=2025-03-14 |title=Exercise-based cardiac rehabilitation for patients with atrial fibrillation: a narrative review |url=https://academic.oup.com/ehjopen/article/5/2/oeaf025/8078332 |journal=European Heart Journal Open |volume=5 |issue=2|pages=oeaf025 |doi=10.1093/ehjopen/oeaf025 |pmid=40161304 |pmc=11953005 }} heart transplant recipients,{{cite journal | vauthors = Anderson L, Nguyen TT, Dall CH, Burgess L, Bridges C, Taylor RS | title = Exercise-based cardiac rehabilitation in heart transplant recipients | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | issue = 4 | pages = CD012264 | date = April 2017 | pmid = 28375548 | pmc = 6478176 | doi = 10.1002/14651858.CD012264.pub2 }} and heart failure.{{cite journal | vauthors = Dibben GO, Dalal HM, Taylor RS, Doherty P, Tang LH, Hillsdon M | title = Cardiac rehabilitation and physical activity: systematic review and meta-analysis | journal = Heart | volume = 104 | issue = 17 | pages = 1394–1402 | date = September 2018 | pmid = 29654095 | pmc = 6109237 | doi = 10.1136/heartjnl-2017-312832 }}

While CR is generally considered safe and effective, there are rare cases in which patients undergoing cardiac rehabilitation experience physical complications as they complete the exercise aspect of these programs.{{Cite web |date=2022-03-24 |title=Heart Treatments - Heart Treatments {{!}} NHLBI, NIH |url=https://www.nhlbi.nih.gov/health/heart-treatments-procedures#:~:text=The%20heart-healthy%20lifestyle%20changes,life-threatening%20heart%20rhythm%20problems |access-date=2025-04-19 |website=www.nhlbi.nih.gov |language=en}}

Poor psychological health has been shown to have a negative impact on patients' recovery process as well as their willingness and ability to complete rehabilitation.{{Cite journal |last1=Brown |first1=Todd M. |last2=Pack |first2=Quinn R. |last3=Aberegg |first3=Ellen |last4=Brewer |first4=LaPrincess C. |last5=Ford |first5=Yvonne R. |last6=Forman |first6=Daniel E. |last7=Gathright |first7=Emily C. |last8=Khadanga |first8=Sherrie |last9=Ozemek |first9=Cemal |last10=Thomas |first10=Randal J. |last11=on behalf of the American Heart Association Exercise, Cardiac Rehabilitation and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Lifestyle and Cardiometabolic Health; and Council on Quality of Care and Outcomes Research |date=2024-10-29 |title=Core Components of Cardiac Rehabilitation Programs: 2024 Update: A Scientific Statement From the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation |url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000001289#T2 |journal=Circulation |volume=150 |issue=18 |pages=e328–e347 |doi=10.1161/CIR.0000000000001289|pmid=39315436 |url-access=subscription }} Unresolved depression and anxiety have also been shown to increase the risk of mortality following the completion of rehabilitation programs.{{Cite journal |last1=Kachur |first1=Sergey |last2=Menezes |first2=Arthur R. |last3=Schutter |first3=Alban De |last4=Milani |first4=Richard V. |last5=Lavie |first5=Carl J. |date=2016-12-01 |title=Significance of Comorbid Psychological Stress and Depression on Outcomes After Cardiac Rehabilitation |url=https://www.amjmed.com/article/S0002-9343(16)30731-8/fulltext |journal=The American Journal of Medicine |language=English |volume=129 |issue=12 |pages=1316–1321 |doi=10.1016/j.amjmed.2016.07.006 |issn=0002-9343 |pmid=27480388|url-access=subscription }} Because of this, psychological intervention is a common practice in CR.

Additionally, research suggests that screening for psychological distress is a helpful way to assess a patient's risk of further cardiovascular complications due to the negative effects of psychological distress on CVD outcomes.{{Cite journal |last1=Gaffey |first1=Allison E. |last2=Gathright |first2=Emily C. |last3=Fletcher |first3=Lauren M. |last4=Goldstein |first4=Carly M. |date=2022-11-01 |title=Screening for Psychological Distress and Risk of Cardiovascular Disease and Related Mortality: A SYSTEMATIZED REVIEW, META-ANALYSIS, AND CASE FOR PREVENTION |journal=Journal of Cardiopulmonary Rehabilitation and Prevention |volume=42 |issue=6 |pages=404–415 |doi=10.1097/HCR.0000000000000751 |issn=1932-751X |pmc=9646240 |pmid=36342683}} However, this type of psychological health screening is still underutilized in modern cardiac rehabilitation programs.

CR is significantly under-used globally.{{cite journal |display-authors=6 |vauthors=Santiago de Araújo Pio C, Beckie TM, Varnfield M, Sarrafzadegan N, Babu AS, Baidya S, Buckley J, Chen SY, Gagliardi A, Heine M, Khiong JS, Mola A, Radi B, Supervia M, Trani MR, Abreu A, Sawdon JA, Moffatt PD, Grace SL |date=January 2020 |title=Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement |journal=International Journal of Cardiology |volume=298 |pages=1–7 |doi=10.1016/j.ijcard.2019.06.064 |pmid=31405584 |doi-access=free |hdl-access=free |hdl=10034/622555}} Rates vary widely.{{cite journal |vauthors=Grace SL, Kotseva K, Whooley MA |date=July 2021 |title=Cardiac Rehabilitation: Under-Utilized Globally |journal=Current Cardiology Reports |volume=23 |issue=9 |pages=118 |doi=10.1007/s11886-021-01543-x |pmid=34269894 |s2cid=235916856 |hdl-access=free |hdl=10315/38989}}

Under-use is caused by multi-level factors.{{Cite journal |last1=Grace |first1=Sherry L. |last2=Ghanbari |first2=Mahdieh |last3=Cruz |first3=Mayara Moura Alves da |last4=Vanderlei |first4=Luiz Carlos Marques |last5=Ghisi |first5=Gabriela Lima de Melo |date=2024-10-01 |title=Psychometric validation of the Cardiac Rehabilitation Barriers Scale Revised (CRBS-R) for hybrid delivery |url=https://bmjopen.bmj.com/content/14/10/e090261.long |journal=BMJ Open |language=en |volume=14 |issue=10 |pages=e090261 |doi=10.1136/bmjopen-2024-090261 |issn=2044-6055 |pmc=11481153 |pmid=39414267}}{{cite book |title=International Handbook of Behavioral Health Assessment |vauthors=Stewart C, Ghisi GL, Davis EM, Grace SL |date=2023 |publisher=Springer International Publishing |isbn=978-3-030-89738-3 |veditors=Krägeloh CU, Alyami M, Medvedev ON |place=Cham |pages=1–57 |language=en |chapter=Cardiac Rehabilitation Barriers Scale (CRBS) |doi=10.1007/978-3-030-89738-3_39-1}} At the health system level, this includes lack of available programs.{{cite journal |display-authors=6 |vauthors=Turk-Adawi K, Supervia M, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, Bjarnason-Wehrens B, Derman W, Abreu A, Babu AS, Santos CA, Jong SK, Cuenza L, Yeo TJ, Scantlebury D, Andersen K, Gonzalez G, Giga V, Vulic D, Vataman E, Cliff J, Kouidi E, Yagci I, Kim C, Benaim B, Estany ER, Fernandez R, Radi B, Gaita D, Simon A, Chen SY, Roxburgh B, Martin JC, Maskhulia L, Burdiat G, Salmon R, Lomelí H, Sadeghi M, Sovova E, Hautala A, Tamuleviciute-Prasciene E, Ambrosetti M, Neubeck L, Asher E, Kemps H, Eysymontt Z, Farsky S, Hayward J, Prescott E, Dawkes S, Santibanez C, Zeballos C, Pavy B, Kiessling A, Sarrafzadegan N, Baer C, Thomas R, Hu D, Grace SL |date=August 2019 |title=Cardiac Rehabilitation Availability and Density around the Globe |journal=eClinicalMedicine |volume=13 |pages=31–45 |doi=10.1016/j.eclinm.2019.06.007 |pmc=6737209 |pmid=31517261}} At the provider level, low referral rates are a major barrier.{{cite journal |vauthors=Ghisi GL, Polyzotis P, Oh P, Pakosh M, Grace SL |date=June 2013 |title=Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review |journal=Clinical Cardiology |volume=36 |issue=6 |pages=323–335 |doi=10.1002/clc.22126 |pmc=3736151 |pmid=23640785}}{{cite journal |display-authors=6 |vauthors=Ghanbari-Firoozabadi M, Mirzaei M, Nasiriani K, Hemati M, Entezari J, Vafaeinasab M, Grace SL, Jafary H, Sadrbafghi SM |date=2020-01-01 |title=Cardiac Specialists' Perspectives on Barriers to Cardiac Rehabilitation Referral and Participation in a Low-Resource Setting |journal=Rehabilitation Process and Outcome |volume=9 |pages=1179572720936648 |doi=10.1177/1179572720936648 |pmc=8282146 |pmid=34497466 |doi-access=free}} At the patient level, factors such as lack of awareness, transportation, distance, cost, competing responsibilities, and other health conditions are responsible,{{cite journal |vauthors=Shanmugasegaram S, Gagliese L, Oh P, Stewart DE, Brister SJ, Chan V, Grace SL |date=February 2012 |title=Psychometric validation of the cardiac rehabilitation barriers scale |journal=Clinical Rehabilitation |volume=26 |issue=2 |pages=152–164 |doi=10.1177/0269215511410579 |pmc=3351783 |pmid=21937522}} but most can be mitigated.{{cite journal |vauthors=Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL |date=February 2019 |title=Interventions to promote patient utilisation of cardiac rehabilitation |journal=The Cochrane Database of Systematic Reviews |volume=2019 |issue=2 |pages=CD007131 |doi=10.1002/14651858.CD007131.pub4 |pmc=6360920 |pmid=30706942}} Women,{{cite journal |vauthors=Samayoa L, Grace SL, Gravely S, Scott LB, Marzolini S, Colella TJ |date=July 2014 |title=Sex differences in cardiac rehabilitation enrollment: a meta-analysis |journal=The Canadian Journal of Cardiology |volume=30 |issue=7 |pages=793–800 |doi=10.1016/j.cjca.2013.11.007 |pmid=24726052 |doi-access=free |hdl-access=free |hdl=10315/27523}}{{Cite journal |last1=Ghisi |first1=Gabriela Lima de Melo |last2=Kim |first2=Won-Seok |last3=Cha |first3=Seungwoo |last4=Aljehani |first4=Raghdah |last5=Cruz |first5=Mayara Moura Alves |last6=Vanderlei |first6=Luiz Carlos Marques |last7=Pepera |first7=Garyfallia |last8=Liu |first8=Xia |last9=Xu |first9=Zhimin |last10=Maskhulia |first10=Lela |last11=Venturini |first11=Elio |last12=Chuang |first12=Hung-Jui |last13=Pereira |first13=Danielle Gomes |last14=Trevizan |first14=Patricia Fernandes |last15=Kouidi |first15=Evangelia |date=2023-11-01 |title=Women's Cardiac Rehabilitation Barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation's First Global Assessment |journal=Canadian Journal of Cardiology |series=The Third Jim Pattison-Mazankowski Alberta Heart Institute Cardiac Rehabilitation Symposium |volume=39 |issue=11, Supplement |pages=S375–S383 |doi=10.1016/j.cjca.2023.07.016 |issn=0828-282X |pmid=37747380 |doi-access=free}} ethnocultural minorities,{{cite journal |vauthors=Midence L, Mola A, Terzic CM, Thomas RJ, Grace SL |date=November–December 2014 |title=Ethnocultural diversity in cardiac rehabilitation |journal=Journal of Cardiopulmonary Rehabilitation and Prevention |language=en-US |volume=34 |issue=6 |pages=437–444 |doi=10.1097/HCR.0000000000000089 |pmid=25357126 |doi-access=free}}{{cite journal |vauthors=Koehler Hildebrandt AN, Hodgson JL, Dodor BA, Knight SM, Rappleyea DL |date=September 2016 |title=Biopsychosocial-Spiritual Factors Impacting Referral to and Participation in Cardiac Rehabilitation for African American Patients: A Systematic Review |journal=Journal of Cardiopulmonary Rehabilitation and Prevention |volume=36 |issue=5 |pages=320–330 |doi=10.1097/HCR.0000000000000183 |pmid=27496250 |s2cid=10829735 |doi-access=free}} older patients,{{cite journal |vauthors=Grace SL, Shanmugasegaram S, Gravely-Witte S, Brual J, Suskin N, Stewart DE |date=2009 |title=Barriers to cardiac rehabilitation: DOES AGE MAKE A DIFFERENCE? |journal=Journal of Cardiopulmonary Rehabilitation and Prevention |volume=29 |issue=3 |pages=183–187 |doi=10.1097/HCR.0b013e3181a3333c |pmc=2928243 |pmid=19471138}} those of lower socio-economic status, with comorbidities, and living in rural areas{{cite journal |vauthors=Leung YW, Brual J, Macpherson A, Grace SL |date=November 2010 |title=Geographic issues in cardiac rehabilitation utilization: a narrative review |journal=Health & Place |volume=16 |issue=6 |pages=1196–1205 |doi=10.1016/j.healthplace.2010.08.004 |pmc=4474644 |pmid=20724208}} are less likely to access CR, despite the fact that these patients often need it most.{{cite journal |display-authors=6 |vauthors=Ruano-Ravina A, Pena-Gil C, Abu-Assi E, Raposeiras S, van 't Hof A, Meindersma E, Bossano Prescott EI, González-Juanatey JR |date=November 2016 |title=Participation and adherence to cardiac rehabilitation programs. A systematic review |journal=International Journal of Cardiology |volume=223 |issue= |pages=436–443 |doi=10.1016/j.ijcard.2016.08.120 |pmid=27557484 |s2cid=205234011}}

Strategies are now established on how we can mitigate these barriers to CR use.{{cite journal |vauthors=Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL |date=February 2019 |title=Interventions to promote patient utilisation of cardiac rehabilitation |journal=The Cochrane Database of Systematic Reviews |volume=2019 |issue=2 |pages=CD007131 |doi=10.1002/14651858.cd007131.pub4 |pmc=6360920 |pmid=30706942}}{{cite journal |vauthors=Aljehani R, Grace SL, Aburub A, Turk-Adawi K, Ghisi GL |date=April 2023 |title=Translation, Cross-Cultural Adaptation and Psychometric Validation of the Arabic Version of the Cardiac Rehabilitation Barriers Scale (CRBS-A) with Strategies to Mitigate Barriers |journal=Healthcare |volume=11 |issue=8 |pages=1196 |doi=10.3390/healthcare11081196 |pmc=10138187 |pmid=37108029 |doi-access=free}} It is important for inpatient units treating cardiac patients to institute automatic/systematic or electronic referral to CR (see: https://www.ahrq.gov/takeheart/index.html).{{cite journal |display-authors=6 |vauthors=Grace SL, Russell KL, Reid RD, Oh P, Anand S, Rush J, Williamson K, Gupta M, Alter DA, Stewart DE |date=February 2011 |title=Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study |journal=Archives of Internal Medicine |volume=171 |issue=3 |pages=235–241 |doi=10.1001/archinternmed.2010.501 |pmid=21325114 |doi-access=}} It is also key for healthcare providers to promote CR to patients at the bedside.{{cite journal |vauthors=Santiago de Araújo Pio C, Gagliardi A, Suskin N, Ahmad F, Grace SL |date=August 2020 |title=Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course |journal=BMC Health Services Research |volume=20 |issue=1 |pages=768 |doi=10.1186/s12913-020-05619-2 |pmc=7439558 |pmid=32819388 |doi-access=free}} The National Institute for Health and Care Excellence offer helpful recommendations on encouraging patients to attend [https://www.nice.org.uk/guidance/ng185/chapter/Recommendations#cardiac-rehabilitation-after-an-mi CR].

Training more healthcare professionals to deliver CR can also help.{{cite journal |display-authors=6 |vauthors=Babu AS, Heald FA, Contractor A, Ghisi GL, Buckley J, Mola A, Atrey A, Lopez-Jimenez F, Grace SL |date=May 2022 |title=Building Capacity Through ICCPR Cardiovascular Rehabilitation Foundations Certification (CRFC): Evaluation of Reach, Barriers, and Impact |journal=Journal of Cardiopulmonary Rehabilitation and Prevention |volume=42 |issue=3 |pages=178–182 |doi=10.1097/hcr.0000000000000655 |pmid=34840246 |s2cid=244714261 |hdl-access=free |hdl=10315/40874}} CR programs can also join a registry to assess and improve their utilization—among other quality indicators.{{cite journal |display-authors=6 |vauthors=Grace SL, Elashie S, Sadeghi M, Papasavvas T, Hashmi F, de Melo Ghisi G, Vargas JL, Al-Hashemi M, Turk-Adawi K |date=July 2023 |title=Pilot testing of the International Council of Cardiovascular Prevention and Rehabilitation Registry |journal=International Journal for Quality in Health Care |volume=35 |issue=3 |doi=10.1093/intqhc/mzad050 |pmc=10329404 |pmid=37421311}}{{cite journal |vauthors=Turk-Adawi K, Ghisi GL, Tran C, Heine M, Raidah F, Contractor A, Grace SL |date=May 2023 |title=First report of the International Council of Cardiovascular Prevention and Rehabilitation's Registry (ICRR) |url=https://figshare.com/articles/journal_contribution/22573542 |journal=Expert Review of Cardiovascular Therapy |volume=21 |issue=5 |pages=357–364 |doi=10.1080/14779072.2023.2199154 |pmid=37024997 |s2cid=258008458 |hdl-access=free |hdl=10315/41813}}{{Cite journal |last1=Grace |first1=Sherry L |last2=Hagström |first2=Emil |last3=Harrison |first3=Alexander S |last4=Phillips |first4=Samara |last5=Bovin |first5=Ann |last6=Yokoyama |first6=Miho N |last7=Niebauer |first7=Josef |last8=Makita |first8=Shigeru |last9=Raidah |first9=Fabbiha |last10=Back |first10=Maria |last11=on behalf of the ICRR Investigators |date=2024-11-01 |title=Cardiac rehabilitation registries around the globe: current status and future needs |url=https://academic.oup.com/eurjpc/article/31/16/e117/7679727?login=true |journal=European Journal of Preventive Cardiology |volume=31 |issue=16 |pages=e117–e121 |doi=10.1093/eurjpc/zwae182 |issn=2047-4873 |pmc=11571179 |pmid=38775788}} Offering programs tailored to under-served groups such as women may also facilitate program participation.{{cite journal |vauthors=Mamataz T, Ghisi GL, Pakosh M, Grace SL |date=June 2022 |title=Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis |journal=Maturitas |volume=160 |pages=32–60 |doi=10.1016/j.maturitas.2022.01.008 |pmid=35550706 |s2cid=246424701 |hdl-access=free |hdl=10315/40875}}{{cite journal |vauthors=Mamataz T, Ghisi GL, Pakosh M, Grace SL |date=September 2021 |title=Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review |journal=BMC Cardiovascular Disorders |volume=21 |issue=1 |pages=459 |doi=10.1186/s12872-021-02267-0 |pmc=8458788 |pmid=34556036 |doi-access=free}}{{cite journal |vauthors=Ghisi GL, Kin SM, Price J, Beckie TM, Mamataz T, Naheed A, Grace SL |date=December 2022 |title=Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline |journal=The Canadian Journal of Cardiology |language=English |volume=38 |issue=12 |pages=1786–1798 |doi=10.1016/j.cjca.2022.06.021 |pmid=36085185 |s2cid=251967685 |doi-access=free |hdl-access=free |hdl=10315/40876}}{{Cite journal |last1=Ghisi |first1=Gabriela Lima de Melo |last2=Supervia |first2=Marta |last3=Turk-Adawi |first3=Karam |last4=Beleigoli |first4=Alline |last5=Contractor |first5=Aashish |last6=Mampuya |first6=Warner M. |last7=Grace |first7=Sherry L. |date=2024-02-01 |title=Women-Focused Cardiac Rehabilitation Delivery Around the World and Program Enablers to Support Broader Implementation |journal=CJC Open |series=Why Her Heart Matters: Evidence-Based Practice and Practice-Based Evidence |volume=6 |issue=2, Part B |pages=425–435 |doi=10.1016/j.cjco.2023.10.008 |issn=2589-790X |pmid=38487061 |pmc=10935990 |hdl-access=free |hdl=10576/53081}} Global experts have proposed the 5 P’s for umproving quality and uptake of cardiac rehabilitation programs as follows (1) personalization, (2) processes and systems, (3) patient-centered care, (4) parlance, and (5) partnership and unity{{Cite journal |last1=Redfern |first1=Julie |last2=Gallagher |first2=Robyn |last3=Maiorana |first3=Andrew |last4=Candelaria |first4=Dion |last5=Hollings |first5=Matthew |last6=Gauci |first6=Sarah |last7=O’Neil |first7=Adrienne |last8=Chaseling |first8=Georgia K. |last9=Zhang |first9=Ling |last10=Thomas |first10=Emma E. |last11=Ghisi |first11=Gabriela L. M. |last12=Gibson |first12=Irene |last13=Hyun |first13=Karice |last14=Beatty |first14=Alexis |last15=Briffa |first15=Tom |date=2024-09-30 |title=Cardiac rehabilitation and secondary prevention of CVD: time to think about cardiovascular health rather than rehabilitation |journal=npj Cardiovascular Health |language=en |volume=1 |issue=1 |page=22 |doi=10.1038/s44325-024-00017-7 |pmid=39359645 |pmc=11442299 |issn=2948-2836}}. United groups are driving new approaches and data driven-approaches to care such as [https://solvechd.org.au/ SOLVE-CHD].

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CR professionals work together in many countries to optimize service delivery and increase awareness of CR.{{Cite journal |last=Grace |first=Sherry L |date=2023-01-02 |title=Evidence is indisputable that cardiac rehabilitation provides health benefits and event reduction: time for policy action |url=http://dx.doi.org/10.1093/eurheartj/ehac690 |journal=European Heart Journal |volume=44 |issue=6 |pages=470–472 |doi=10.1093/eurheartj/ehac690 |pmid=36746185 |issn=0195-668X|url-access=subscription }} The [https://globalcardiacrehab.com/ International Council of Cardiovascular Prevention and Rehabilitation] (ICCPR),[https://globalcardiacrehab.com/] a member of the World Heart Federation, is composed of formally-named Board members of CR societies globally. Through cooperation across most CR-related associations,{{cite journal | vauthors = Turk-Adawi K, Supervia M, Ghisi G, Cuenza L, Yeo TJ, Chen SY, Anchique-Santos C, Grace SL | display-authors = 6 | title = The impact of ICCPR's Global Audit of Cardiac Rehabilitation: where are we now and where do we need to go? | journal = eClinicalMedicine | volume = 61 | pages = 102092 | date = July 2023 | pmid = 37528847 | doi = 10.1016/j.eclinm.2023.102092 | pmc = 10388569 | doi-access = free }} ICCPR seeks to promote CR in low-resource settings,{{Cite journal |last1=Grace |first1=Sherry L. |last2=Taylor |first2=Rod S. |last3=Gaalema |first3=Diann E. |last4=Redfern |first4=Julie |last5=Kotseva |first5=Kornelia |last6=Ghisi |first6=Gabriela |date=July 2023 |title=Cardiac Rehabilitation |journal=JACC: Advances |volume=2 |issue=5 |pages=100412 |doi=10.1016/j.jacadv.2023.100412 |issn=2772-963X|doi-access=free |pmid=38938991 |pmc=11198422 |url=https://eprints.gla.ac.uk/305174/1/305174.pdf }} among other aims outlined in their Charter.{{cite journal | vauthors = Grace SL, Warburton DR, Stone JA, Sanderson BK, Oldridge N, Jones J, Wong N, Buckley JP | display-authors = 6 | title = International Charter on Cardiovascular Prevention and Rehabilitation: a call for action | language = en-US | journal = Journal of Cardiopulmonary Rehabilitation and Prevention | volume = 33 | issue = 2 | pages = 128–131 | date = March–April 2013 | pmid = 23399847 | pmc = 4559455 | doi = 10.1097/HCR.0b013e318284ec82 }} CR societies offer registries, clinician certification,{{Cite journal |last1=Babu |first1=Abraham Samuel |last2=Heald |first2=Fiorella A. |last3=Contractor |first3=Aashish |last4=Ghisi |first4=Gabriela L. M. |last5=Buckley |first5=John |last6=Mola |first6=Ana |last7=Atrey |first7=Alison |last8=Lopez-Jimenez |first8=Francisco |last9=Grace |first9=Sherry L. |date=May 2022 |title=Building Capacity Through ICCPR Cardiovascular Rehabilitation Foundations Certification (CRFC): EVALUATION OF REACH, BARRIERS, AND IMPACT |url=https://journals.lww.com/jcrjournal/abstract/2022/05000/building_capacity_through_iccpr_cardiovascular.6.aspx |journal=Journal of Cardiopulmonary Rehabilitation and Prevention |language=en-US |volume=42 |issue=3 |pages=178–182 |doi=10.1097/HCR.0000000000000655 |pmid=34840246 |hdl=10315/40874 |issn=1932-7501|hdl-access=free }} and program certification,{{Cite journal |last1=Turk-Adawi |first1=Karam I. |last2=Elshaikh |first2=Usra |last3=Contractor |first3=Aashish |last4=Hashmi |first4=Farzana Amir |last5=Thomas |first5=Emma |last6=Raidah |first6=Fabbiha |last7=Grace |first7=Sherry L. |date=2023-11-09 |title=Development and Evaluation of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) Program Certification for Low-Resource Settings |journal=International Journal of General Medicine |language=English |volume=16 |pages=5199–5214 |doi=10.2147/IJGM.S423209|doi-access=free |pmid=38021048 |pmc=10643168 |hdl=10576/52666 |hdl-access=free }} among other resources.

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Category:Rehabilitation medicine