BackgroundDespite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density.MethodsA survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed.FindingsCR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < .001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35–1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04–1.06), and significantly lower with private (OR = .92, 95%CI = .91–.93) or public (OR = .83, 95%CI = .82–84) funding compared to hybrid sources.Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25-Q75 = 150–390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally.InterpretationCR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation.

Cardiac rehabilitation (CR) services improve various clinical outcomes in patients with cardiovascular disease, but such services are underutilized, particularly in women. The aim of this study was to identify evidence-based barriers and solutions for CR participation in women. A literature search was carried out using PubMed, EMBASE, Cochrane, OVID/Medline, and CINAHL to identify studies that have assessed barriers and/or solutions to CR participation. Titles and abstracts were screened, and then the full-text of articles that met study criteria were reviewed. We identified 24 studies that studied barriers to CR participation in women and 31 studies that assessed the impact of various interventions to improve CR referral, enrollment, and/or completion of CR in women. Patient-level barriers included lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. We found support for the use of automatic referral and assisted enrollment to improve CR participation. A small number of studies suggest that incentive-based strategies, as well as home-based programs, may contribute to improving CR attendance and completion rates. A systematic approach to CR referral, including automatic CR referral, may help overcome barriers to CR referral in women and should be implemented in clinical practice. However, more studies are needed to help identify the best methods to improve CR attendance and completion of CR rates in women.

BackgroundCardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region.MethodsIn this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models.Findings111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ± 2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p < 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ± 1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p < 0.01). All regions met ≥ 16/20 quality indicators, but quality was < 75% for tobacco cessation and return-to-work counseling (lower in Americas, p = < 0.05).InterpretationThis first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes.

ObjectiveCardiac rehabilitation (CR) availability, programme characteristics and barriers are not well-known in low/middle-income countries (LMICs). In this study, they were compared with high-income countries (HICs) and by CR funding source.MethodsA cross-sectional online survey was administered to CR programmes globally. Need for CR was computed using incident ischaemic heart disease (IHD) estimates from the Global Burden of Disease study. General linear mixed models were performed.ResultsCR was identified in 55/138 (39.9%) LMICs; 47/55 (85.5% country response rate) countries participated and 335 (53.5% programme response) surveys were initiated. There was one CR spot for every 66 IHD patients in LMICs (vs 3.4 in HICs). CR was most often paid by patients in LMICs (n=212, 65.0%) versus government in HICs (n=444, 60.2%; p<0.001). Over 85% of programmes accepted guideline-indicated patients. Cardiologists (n=266, 89.3%), nurses (n=234, 79.6%; vs 544, 91.7% in HICs, p=0.001) and physiotherapists (n=233, 78.7%) were the most common providers on CR teams (mean=5.8±2.8/programme). Programmes offered 7.3±1.8/10 core components (vs 7.9±1.7 in HICs, p<0.01) over 33.7±30.7 sessions (significantly greater in publicly funded programmes; p<0.001). Publicly funded programmes were more likely to have social workers and psychologists on staff, and to offer tobacco cessation and psychosocial counselling.ConclusionCR is only available in 40% of LMICs, but where offered is fairly consistent with guidelines. Governments should enact policies to reimburse CR so patients do not pay out-of-pocket.

Background: Cardiac Rehabilitation (CR) is a recommendation in international clinical practice guidelines given its' benefits, however use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrolment and adherence into implementable recommendations. Methods: The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology, and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy-makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patient utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A web call was

Herein, 28 publications describing cardiac rehabilitation (CR) delivery in 50 of the 113 countries globally suspected to deliver it are reviewed, to characterize the nature of services. Government funding was the main source of CR reimbursement in most countries (73%), with private and patient funding in about ¼ of cases.Myocardial infarction patients and those having revascularization were commonly served. The main professions delivering CR were physicians, nurses, and physiotherapists. Programs offered a median of 20 sessions, although this varied. Most programs offered the core components of exercise training, patient education and nutrition counselling. Alternative models were not commonly offered. Lack of human and/or financial resources as well as space constraints were reported as the major barriers to delivery. Overall, CR delivery has been characterized in less than half of the countries where it is offered. The nature of services delivered is fairly consistent with major CR guidelines and statements.Keywords: cardiac rehabilitation, global health, secondary prevention Alphabetical List of Abbreviations: AS= administrative support CABG = coronary artery bypass graft CB = community-based A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT2 CR = cardiac rehabilitation CPR= cardiopulmonary resuscitation CVD = cardiovascular disease ECG = electrocardiogram EQ= equipment ET = exercise training FR= financial resources HB = home-based HF = heart failure HR= human resources IA = initial assessment IB = internet-based IHD = ischemic heart disease LMIC = low-and middle-income country MI = myocardial infarction NC = nutrition counseling NZ = New Zealand PAW= patient awareness PCI = percutaneous coronary intervention PE = patient education PR= patient referral RF = risk factor management SC = smoking cessation SM = stress management and/or psychosocial support/counselling TI = transportation issues UAE = United Arab Emirates VAD = ventricular assist device A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT3 By 2030, it is expected 84 million individuals will be diagnosed with cardiovascular disease (CVD) 1 .Moreover, it is among the leading causes of disability around the world, and contributes to 10% of disabilityadjusted life years lost world-wide 2 . With improved survival (in high-income countries 3 ), clearly there is a great need for secondary prevention, such as is offered in cardiac rehabilitation (CR) programs.Many meta-analyses demonstrate that participation in CR is associated with improved quality of life, as well as decreased morbidity and mortality [4][5][6][7] . CR is also cost-effective 8 . Accordingly, it is a class 1 level A recommendation in clinical practice guidelines for CVD patients 9,10 . 19 , have established guidelines to ensure consistent provision and quality of CR delivery in order to achieve the greatest population health benefits. They all outline the nature of patients indicated for services, and make recommendations regarding the composition of a multi-disciplinary...

BackgroundPrognosis based on body fat percentage (BF%) in patients with coronary artery disease has not been extensively studied. We tested the hypothesis that patients with coronary artery disease and increased BF% have a higher risk for major adverse cardiovascular events (MACEs) and that fat‐free mass is associated with better prognosis.Methods and ResultsWe included 717 patients referred to cardiac rehabilitation after coronary artery disease events or procedures who underwent air displacement plethysmography to assess BF%; 75% were men, with a mean age 61.4±11.4 years and a mean body mass index of 30±5.4 kg/m2. Follow‐up was performed using a record linkage system. Patients were classified in sex‐specific quartiles of BF% and fat‐free mass index. The composite outcome of MACEs included acute coronary syndromes, coronary revascularization, stroke, or death from any cause. After a median follow‐up of 3.9 years, 201 patients had a MACE. After adjusting for covariates, body mass index was not associated with MACEs (P=0.12). However, the risk of MACEs for those in the highest BF% quartile was nearly double when compared with those in the lowest quartile (hazard ratio, 1.89; 95% confidence interval, 1.30–2.77; P=0.0008). In contrast, fat‐free mass was inversely associated with MACEs. The risk of MACEs for those in the fourth fat‐free mass quartile was lower (adjusted hazard ratio, 0.53; 95% confidence interval, 0.35–0.82; P=0.004), when compared with those in the first quartile.ConclusionsIn patients with coronary artery disease, there is no obesity paradox when measuring BF% instead of body mass index. BF% is associated with a higher risk of MACEs, whereas fat‐free mass is associated with a lower risk of MACEs. Body mass index was not associated with MACEs.

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