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.

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A 10-year longitudinal population-based study, entitled the Isfahan Cohort Study (ICS) is being conducted. The ICS commenced in 2001, recruiting individuals aged 35 þ living in urban and rural areas of three counties in central Iran, to determine the individual and combined impact of various risk factors on the incidence of cardiovascular events. After 24379 person-years of follow-up with a median follow-up of 4.8 years, we documented 219 incident cases of ischemic heart disease (IHD) (125 in men and 94 in women) and 57 incident cases of stroke (28 in men and 29 in women). The absolute risk of IHD was 8.9 (7.8-10.2) per 1000 person-years for all participants, 10.6 (8.8-12.5) per 1000 person-years for men and 7.4 (6.0-9.0) per 1000 person-years for women. The respective risk of ischemic stroke was 2.3 (1.7-3.0), 2.3 (1.6-3.3) and 2.3 (1.5-3.2) per 1000 person-years. The risk of IHD was approximately 3.5-fold higher in the presence of hypertension, followed by diabetes mellitus and hypercholesterolemia with near 2.5-and twofold higher risk, respectively. This cohort provides confirmatory evidence of the ethnic differences in the magnitude of the impact of various risk factors on cardiovascular events. The differences may be due to varying absolute risk levels among populations and the existing ethnic disparities for using western risk equations to local requirements.

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.