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Cardiovascular Rehabilitation & Prevention, University Health Network, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada (K.T.‑A.). Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Seddigheh Tahereh Research and Treatment Hospital, Khorram Ave, PO Box 81465‑1148, Isfahan, Iran (N.S.). School of Kinesiology and Health Science, Bethune 368, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada (S.L.G.).

Correspondence to: N.S. nsarrafzadegan@ gmail.com

Global availability of cardiac rehabilitationKaram Turk-Adawi, Nizal Sarrafzadegan and Sherry L. Grace

Abstract | Cardiovascular disease (CVD) is the most‑prevalent noncommunicable disease and leading cause of death globally. Over 80% of deaths from CVD occur in low‑income and middle‑income countries (LMICs). To limit the socioeconomic impact of CVD, a comprehensive approach to health care is needed. Cardiac rehabilitation delivers a cost‑effective and structured exercise, education, and risk reduction programme, which can reduce mortality by up to 25% in addition to improving a patient’s functional capacity and lowering rehospitalization rates. Despite these benefits and recommendations in clinical practice guidelines, cardiac rehabilitation programmes are grossly under‑used compared with revascularization or medical therapy for patients with CVD. Worldwide, only 38.8% of countries have cardiac rehabilitation programmes. Specifically, 68.0% of high‑income and 23% of LMICs (8.3% for low‑income and 28.2% for middle‑income countries) offer cardiac rehabilitation programmes to patients with CVD. Cardiac rehabilitation density estimates range from one programme per 0.1 to 6.4 million inhabitants. Multilevel strategies to augment cardiac rehabilitation capacity and availability at national and international levels, such as supportive public health policies, systematic referral strategies, and alternative models of delivery are needed.

Turk‑Adawi, K. et al. Nat. Rev. Cardiol. 11, 586–596 (2014); published online 15 July 2014; doi:10.1038/nrcardio.2014.98

IntroductionCardiovascular disease (CVD) is the most prevalent non-communicable disease and the leading cause of death globally.1 The burden of CVD is growing, particularly in low-income and middle-income countries (LMICs); >80% of deaths related to CVD occur in LMICs.1–3 By 2030, 23 million people per year are predicted to die from CVD.4 According to the World Economic Forum, in 2010, 62.5 million new cases of CVD were reported, of which 24.2 million were attributed to ischaemic heart disease (Table 1).4 By 2030, this number is expected to grow to 84 million individuals diagnosed with CVD, of whom up to 32.3 million will have ischaemic heart disease.4

Patients with established CVD have a high risk of adverse cardiovascular events, such as fatal and non-fatal myocardial infarction.5 Consequently, CVD is also the leading cause of disability,6 accounting for 10% of d isability-adjusted life years (DALYs; Box 17) lost world-wide, 10% of DALYs lost in LMICs, and 18% of DALYs lost in high-income countries.8 Worldwide, 47 million DALYs were lost in 1990 due to coronary heart disease (CHD), a figure that is expected to rise to 82 million DALYs by 2020.8

In 2010, an estimated 111.7 million individuals—that is 1.62% of the total world’s population—had angina due to ischaemic heart disease, as reported in the Global Burden of Disease Study.9 In response to the emerging economic and social burden of noncommunicable dis-eases, the WHO has set a global target for reduction of “premature deaths from noncommunicable diseases by

25% by 2025”.10 All 194 WHO Member States endorsed this target during the 65th World Health Assembly in 2012.10 In the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020, the WHO underlines the need for rehabilitation, including cardiac rehabilitation, to combat the burden of CVD.11 Cardiac rehabilitation is a strategy to reduce CVD risk factors, such as obesity and physical inactivity, restore heart function, and limit health deterioration owing to CVD, as well as expedite hospital discharge, and improve patient quality of life.11 Given the current and expected increases in rates of CVD, cardiac rehabilitation capacity will need to be high to meet such demand.

In this Review we describe the availability of cardiac rehabilitation both in high-income countries and in LMICs, and highlight the varying density of this treat-ment in these countries. We consider rates of physician referral to cardiac rehabilitation and the availability of cardiac rehabilitation compared with other evidence-based prevention therapies. The reasons for low avail-ability of cardiac rehabilitation and approaches to increase provision at the health-care policy and pro-gramme level are also explored. Cardiac rehabilitation is a secondary and tertiary prevention strategy for future CVD events and we focus on this treatment as delivered in the outpatient setting.

Cardiac rehabilitationCardiac rehabilitation is a multidisciplinary approach designed to stabilize, slow, or promote regression of CVD.12 The WHO defines cardiac rehabilitation as the “sum of activities required to influence favourably the

Competing interestsThe authors declare no competing interests.

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underlying cause of the disease, as well as to provide the best possible physical, mental, and social conditions, so that the patients may, by their own efforts, preserve or resume when lost, as normal a place as possible in the community”.13

National and international associations, such as the American Association of Cardiovascular and Pulmon-ary Rehabilitation and the European Association of Cardiovascular Prevention and Rehabilitation have established the core components of cardiac rehabilita-tion.14,15 These include an initial assessment of patients to identify cardiovascular risk factors and comorbidi-ties, physical activity training, nutritional advice, man-agement of risk factors (for example, dyslipidaemia, hypertension, obesity, diabetes mellitus, and smoking),

Key points

■ Cardiac rehabilitation services are poorly implemented worldwide, with only 38.8% of countries having such a programme

■ Cardiac rehabilitation services are available in only 23% of low‑income and middle‑income countries, which have the greatest cardiovascular disease burden and highest cardiovascular mortality

■ Cardiac rehabilitation density is greatest in the USA where one programme per 102,000 inhabitants is provided; middle‑income countries have approximately one programme per 1–6 million individuals

■ Worldwide <50% of eligible patients are referred to cardiac rehabilitation programmes

■ Cardiac rehabilitation services are less‑often implemented, despite costing much less to implement, than other evidence‑based secondary prevention therapies

■ More research is required to evaluate effectiveness of affordable and feasible cardiac rehabilitation models that utilize new technologies, in both high‑income and low‑to‑middle‑income countries

psychosocial interventions, and counselling.14 These components promote and maintain healthy behaviour, active lifestyles, and can improve quality of life and reduce disability.14

Robust evidence demonstrates that participation in a cardiac rehabilitation programme reduces mortality by up to 25% over an average of 5 years when compared with usual care, such as medical therapy alone.16–21 The only risks of cardiac rehabilitation are potential adverse cardiac events while exercising, such as arrhythmia. However, rates of these adverse events are low in cardiac rehabili-tation programmes. For example, in a French study, the rate of severe cardiac events was one per ~50,000 patient-hours of exercise training, with a cardiac arrest rate of 1.3 per million patient-hours of exercise.22

According to clinical practice guidelines, cardiac rehabil itation is recommended for patients with a pri-mary diagnosis of myocardial infarction, angina, or heart failure, and who have undergone CABG surgery, percutaneous coronary intervention (PCI), or a heart or lung transplant.15,23–25

Global availabilityWe identified all those countries recognized by the World Bank with an active cardiac rehabilitation pro-gramme and classified them according to income (Box 1; Figure 1). Cardiac rehabilitation availability in many high-income countries has been described in national and regional surveys, such as the CARINEX Survey,26 and the European Cardiac Rehabilitation Inventory Survey.27 Of the 75 high-income countries defined by the World Bank, cardiac rehabilitation services are available in only 51 (68.0%; Figure 1).26–63

The most-comprehensive data on the availability of cardiac rehabilitation in middle-income countries were published in two regional surveys: a survey of Latin America and Caribbean with 14 participating countries,64 and a South American survey of nine countries.36 The authors of a 2013 review reported that cardiac rehabili-tation services are available in only 22.1% of LMICs.65 Cardiac rehabilitation services exist in 29 (28.2%) of the 103 World Bank defined middle-income countries (Figure 1).36,37,64–78 Of the 36 low-income countries, cardiac rehabilitation services were available in only three (8.3%)—Afghanistan,79 Bangladesh,80 and Kenya.81

Overall, cardiac rehabilitation is available in only 38.8% countries worldwide. More specifically and of concern, cardiac rehabilitation services are available in only 23% of the LMICs, where >80% of CVD deaths occur,82 under-lining the insufficient supply of such interventions in c ountries with the greatest cardiovascular burden.

DensityThe number of cardiac rehabilitation programmes per inhabitant (which we refer to as cardiac rehabilitation density), is a crude estimate of the number of patients who might have access to cardiac rehabilitation in each country. Although the number of patients who are indi-cated for cardiac rehabilitation per programme might be more informative to assess provision of this treatment;36,45

Table 1 | Worldwide CVD incidence and cost

Year Total cost (US$, billions)

CHF incidence

IHD incidence

Stroke incidence

2010 863 10,072 24,167 28,299

2015 906 10,821 25,933 30,370

2020 957 11,830 28,284 33,122

2025 1,002 12,754 30,369 35,571

2030 1,044 13,637 32,339 37,886

Abbreviations: CHF, chronic heart failure; CVD, cardiovascular disease; IHD, ischaemic heart disease. Permission obtained from World Economic Forum © Bloom et al. The global economic burden of non‑communicable diseases (2011).4

Box 1 | World Bank and WHO definitions

Countries by incomeCountries are classified according to 2012 Gross National Income per capita (US$).3

■ Low income: ≤$1,035 ■ Middle income: $1,036–12,615 ■ Lower middle income: $1,036–4,085 ■ Upper middle income: $4,086–12,615 ■ High income: ≥$12,616

DALYSThe WHO defines DALYs as “The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.”7

Abbreviation: DALY; Disability‑adjusted life year.

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unfortunately, data on CVD prevalence are not avail-able for many countries. Moreover, using the number of patients indicated for a programme is limited by the variation in the number of patients treated across cardiac rehabilitation programmes, which can range from 75 to 232 patients per programme according to one study conducted in the USA.83 However, no accepted density threshold that indicates sufficient cardiac rehabilitation capacity has been established. A position statement rec-ommends a benchmark of 70% enrolment for cardiac rehabilitation;33 however, the translation of this recom-mendation into a density value has yet to be under-taken. In line with previous research,36 the density of cardiac rehabilitation is presented and for the first time, c ompared across regions of the world (Table 2).

High-income countriesBased on national and regional surveys in high-income countries, cardiac rehabilitation density ranges from one programme per 100,000 to one programme per 300,000 inhabitants (Table 2).36,45,84 An exception is Chile, which was only classified as a high-income country in 2013 and, consequently, has a lower density of programmes

consistent with the density found in middle-income coun-tries.85 In the USA, which has the highest cardiac rehabili-tation programme density worldwide, one programme per 102,000 inhabitants was available in 2003, with a range of one programme per 23,000–261,000 inhabi tants depend-ing on region (the highest density was in Nebraska and the lowest in California).84

LMICsIn middle-income countries, cardiac rehabilitation density is lower than in high-income countries, ranging from 0.9 to 6.4 million inhabitants per programme (Table 2).36 Cardiac rehabilitation density in the USA was almost 23-fold greater than that reported in South America, which has an estimated 2.3 million inhabitants per programme.36 Furthermore, although cardiac rehabilitation density was one programme per <500,000 inhabitants in high-income countries,36,45,84 in middle-income countries, the density was one programme per 1–6 million inhabitants.36

The density of cardiac rehabilitation programmes in low-income countries has not been reported. Our extensive search identified only one programme per country in the three low-income countries where cardiac

Countries by income group

Middle Low Unde�nedCountries with an active cardiac rehabilitation programmeHigh

Figure 1 | Global availability of cardiac rehabilitation. High‑income countries: Australia, Austria, Bahrain, Barbados, Belgium, Bermuda, Brunei Darussalam, Canada, Channel Islands, Chile, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Isle of Man, Israel, Italy, Japan, Kuwait, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Norway, Poland, Portugal, Puerto Rico, Qatar, Russian Federation, Singapore, Slovak Republic, Slovenia, South Korea, Spain, Sweden, Switzerland, Trinidad and Tobago, United Arab Emirates, UK, USA, Uruguay, and the US Virgin Islands. Middle‑income countries: Algeria, Argentina, Belarus, Bosnia and Herzegovina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Ecuador, Egypt, India, Indonesia, Iran, Malaysia, Mexico, Pakistan, Panama, Paraguay, Peru, Philippines, Romania, South Africa, Sri Lanka, Thailand, Tunisia, Turkey, and Venezuela. Low‑income countries: Afghanistan, Bangladesh, and Kenya. Countries in white are not in the World Bank’s income‑group list as of January 2014.

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rehabilitation was found to exist—Afghanistan,79,86 Bangladesh,80,86 and Kenya.81,86

Patient accessPhysician referralPatient referral to a cardiac rehabilitation programme by a physician is a prerequisite step for participation in most countries. In high-income countries, low or no physi-cian referral to cardiac rehabilitation is a key barrier to patients enrolling in a programme, according to several studies.33,36,87–91 For example, in some studies, 71% of eligible patients were not referred and were, therefore, unable to access to cardiac rehabilitation (Table 3). In the EUROASPIRE III Survey,50 conducted in 22 European countries (19 classed as high-income), only 44.8% of 8,845 patients eligible for cardiac rehabilitation were advised by physicians or other health-care professionals to attend a programme. However, whether this advice was a formal referral or verbal recommendation was not stated in the study. Therefore, the true rate of referral from completion and transmission to the cardiac rehabili tation programme is not known and the rate is likely to be an overestimate.

In LMICs, physician referral to cardiac rehabilitation has been investigated in very few studies, and in these countries, where reported, referral rates are even lower than those in high-income countries. For example, in a survey undertaken in Iran, cardiologists reported that <15% of patients are referred.92 In a review on cardiac rehabilitation in Brazil, low cardiac rehabilitation refer-ral was reported as a barrier to enrolment.67 In several m iddle-income countries of Europe, car diac rehabilita-tion ‘advice’ rates (that is, patients advised to seek a cardiac rehabilitation programme) in the EUROASPIRE III survey50 were reported to range from 7.3% in Turkey to 57.0% in Hungary (Table 3). Again, these percentages are likely to be overestimates of true referral rates.

Disparities in patient accessVariability in cardiac rehabilitation use has been docu-mented in high-income countries.12,89,90 For example, certain patient groups are less likely to be referred and, therefore, to participate in cardiac rehabilitation.12,89,90 These groups include women, elderly patients, individu-als from ethnic minorities, patients of low socio economic status, and those with comorbidities.62,89,90,93 These patients often have a greater need for cardiac rehabilitation, as dem-onstrated by evidence of poorer outcomes and greater disease management complexity in these individuals than in other patients. However, patients at greatest need face multiple barriers to participation including low health lit-eracy, lack of proficiency in the language in which cardiac rehabilitation is offered, or lack of transportation. In middle-income countries, women are under-represented compared with men, representing <30% of patients partici-pating in cardiac rehabilitation programmes.70,73,94,95 In one study from Brazil, no women attended the cardiac rehabili-tation programme.96 Given that no evidence has been pre-sented that these patient groups derive less clinical benefit from cardiac rehabilitation, efforts to ensure patient access is equal for all socioeconomic groups are needed.

Comparison with other interventionsThe WHO states that “cardiac rehabilitation should be an integral component of the long-term, comprehen-sive care of cardiac patients”.97 However, in high-income countries, governments allocate more resources to acute CVD treatment than less expensive, long-term disease management strategies, such as cardiac rehabilitation (Box 2).46,64 In a national survey, only 6.5% of 1,059 sur-veyed hospitals in Japan were approved for reimburse-ment of cardiac rehabilitation services by the Japanese health insurance system.46 Whereas, 61.8% and 58.8% of hospitals in Japan implement coronary angiography and PCI, respectively, following myocardial infarction.46

Although acute revascularization strategies such as CABG surgery and PCI confer benefit for patients, cardiac rehabilitation is also considered a Class IA indi-cation in clinical practice guidelines (that is the treat-ment is useful and effective).25,98 CABG surgery reduces mortality by 39% (OR 0.61, 95% CI 0.48–0.77) at 5-year follow-up99 and PCI by 20% (OR 0.80, 95% CI 0.64–0.99) at an average of 4-year follow-up.100 In a review of 34 different trials, cardiac rehabilitation had comparable mortality reductions to the invasive procedures of 26%, over 3 months to 5-year follow-up (OR 0.74, 95% CI 0.58–0.95).101 Moreover, in a study conducted in the USA, out of the 10 known effective treatments for myo-cardial infarction and their degree of implementation, cardiac rehabilitation ranked second, after revasculari-zation, as the treatment which would prevent or post-pone the greatest number of deaths.102 In the same study, cardiac rehabilitation pro vision was estimated to prevent or postpone the greatest number of deaths in patients with unstable angina and heart failure compared with other treatments.102

Table 2 | Density of cardiac rehabilitation programmes

Country Population (million)

Number of programmes

Density (million inhabitants per programme)

High-income

Chile*36 15.1 9 1.7

Italy45 57.0 190 0.3

Uruguay*36 3.3 12 0.3

USA84 267.4 2621 0.1

Middle-income

Brazil36 192.4 39 4.9

Colombia36 46.4 49 0.9

Ecuador36 14.5 5 2.9

Paraguay36 6.5 1 6.4

Peru36 28.2 9 3.1

Venezuela36 27.2 8 3.3

Low-income‡

Afghanistan79 29.1 1 29.1

Bangladesh80 164.4 1 164.4

Kenya81 40.9 1 40.9

*Classified as high‑income country in 2014.85 ‡Extrapolated estimate.

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Health-care systems in middle-income countries are starting to provide expensive revascularization proce-dures.64 Although such procedures are appropriate given the epidemic of CVD, resources are still very limited and where possible alternatives might be more suitable than revascularization in these countries.64 As in high-income countries, the cost of cardiac rehabilitation provision in LMICs is likely to be much less than that of acute revas-cularization, although no specific data are currently available. In patients at low-risk of a cardiovascular event (for example, those with a Thrombolysis In Myocardial Infarction risk score of 1 or 2), revascularization at the time of acute care admission is unlikely to change clini-cal outcome103 and, therefore, is not only costly but futile. Mortality reductions can be achieved with noninvasive medical therapy and cardiac rehabilitation in low-risk patients.99,104 If revascularization was discontinued in low-risk individuals, and the associated financial costs diverted to cardiac rehabilitation, resources for such pro-grammes would greatly increase. Cardiac rehabilitation should, therefore, be developed in combination with the building of operating theatres and cardiac catheterization facilities. However, a survey of centres offering cardiac catheterization in 13 countries in Latin America revealed that only 56% had cardiac rehabilitation programmes.64

Cardiac rehabilitation is also used less often than other guideline-recommended secondary prevention therapies, such as medical therapy.105 For example, in a study on implementation of the AHA ‘Get with the Guidelines’ programme, multiple hospitals reported that they were

able to achieve high rates of aspirin (94%), β-blocker (92.5%), and angiotensin-converting enzyme inhibitor (84.8%) use.106 These figures are in stark contrast to the rates of inpatient cardiac rehabilitation referral (56%) using the same guidelines programme.88 For outpatient care, data from the ACC Practice Innovation and Clinical Excellence (PINNACLE) programme similarly reveal greater provision of evidence-based therapies, such as drug therapies, smoking cessation, and blood pressure and lipid measurement and control, than for cardiac reha-bilitation.103 In a sample of 8,132 patients with coronary artery disease, cardiac rehabilitation referral was only 18.1%.103 Only screening for diabetes had a lower referral rate (13.3%) in this study. The most common practice recommendations implemented were blood pressure measurement (94.0%), smoking a ssessment (83.8%), and annual lipid assessment (74.3%).103

LMICs have higher provision of noncardiac reha-bilitation secondary prevention recommendations than cardiac rehabilitation.37,107 For instance, across 10 LMICs (Brazil, Egypt, India, Indonesia, Iran, Pakistan, Russian Federation, Sri Lanka, Tunisia, and Turkey), 81.2% of patients with CHD received aspirin, 48.1% β-blockers, 39.8% angiotensin-converting enzyme inhibitors, and 29.8% statins.107 Unfortunately, the average rate of cardiac rehabilitation use in LMICs has yet to be reported.

Reasons for under-useMuch research has been conducted in high-income countries to identify reasons for under-use of cardiac rehabilitation despite its benefits. For example, the authors of one systematic review associated 253 differ-ent patient-related factors with the uptake of lifestyle change programmes, including cardiac rehabilitation.108 The reasons can be characterized at three inter-related levels: patient, provider, and health-care system.

The most-commonly reported patient-related cardiac rehabilitation barriers included old age, low socio economic status, employment obligations and subsequent time con-flicts, patient disinterest in attending a programme, and comorbidities.12,74,87,89,90,105–111 Despite the relative scarcity of studies on barriers to cardiac rehabilitation from middle-income countries, the barriers that have been reported are similar to those in high-income countries.74,89,92,96 In low-income countries, no studies on b arriers to cardiac r ehabilitation programmes were identified.

In high-income and middle-income countries, physi-cians have an important role in the use of cardiac rehabili-tation.12,92,110,112 Inadequate physician knowledge about the benefits of cardiac rehabilitation, a lack of incentives to refer a patient, and low physician endorsement of pro-grammes have been often described.92,110 Low physician referral rates might be compounded by a subjective assess-ment of a patient’s ability (or inability) to participate, and a lack of implementation of systematic cardiac rehabilitation referral strategies at patient discharge.34,112,113 Moreover, financial compensation for physicians to provide car-diac rehabilitation is either nonexistent or negli gible. For example, in Iran, cardiologists attributed a low phy-sicians’ fee among other factors for low referral rates.92

Table 3 | Patients referred to cardiac rehabilitation by country

Country Procedure or diagnosis Patients (n) Referred (%)

High-income

Australia147 Cardiac event 15,186 29

Australia, Canada, USA111 Coronary artery disease 30,333 34

Canada90 CABG surgery, PCI 3,739 52

UK148

England Wales Northern Ireland

Myocardial infarction, unstable angina, or after revascularization

146,00045–6759–8125–36

USA88 Myocardial infarction, PCI, CABG surgery

72,817 56

USA89 PCI 145,661 60

LMICs

Hungary50 CABG surgery, PCI, myocardial infarction, acute myocardial ischaemia without infarction

452 57*

Iran92 NS NA 15‡

Romania50 CABG surgery, PCI, myocardial infarction, acute myocardial ischaemia without infarction

516 26.4*

Turkey50 CABG surgery, PCI, myocardial infarction, acute myocardial ischaemia without infarction

329 7.3*

*Patients were advised by physicians or health‑care professionals to attend cardiac rehabilitation. ‡Based on the opinion of 122 physicians. Abbreviations: LMIC, low‑to‑middle‑income country; NA, not applicable; NS, not specified; PCI percutaneous coronary intervention.

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Furthermore, in Latin America, catheterization centre administrators and physician leaders suggest that financial constraints and low profitability are barriers to availability of cardiac rehabilitation.64 The most-common explanation for lower availability of cardiac rehabilitation compared with expensive cardiac procedures in Latin America was that cardiac rehabilitation is not viewed as an investment priority for health-care institutions.64 This lack of funding leads to low human resource capacity to deliver cardiac rehabilitation and, in turn, a lack of programmes to which physicians can refer their patients. Limited availability of programmes, financial constraints, distance, transpor-tation problems, and a lack of insurance coverage are some of the most frequently-reported system-level bar-riers to cardiac rehabilitation access in high-income and middle-income countries.12,92,96,108,110

The barriers to cardiac rehabilitation programmes have only been investigated in the middle-income countries of Brazil, Iran, and Pakistan.74,92,96 In Iran, physicians perceive that low patient referral is due to limited knowledge about cardiac rehabilitation and its benefits, limited knowledge about methods of financial reimbursement, and a lack of insurance coverage.92 In Brazil, distance, cost, lack of patient knowledge, and work and family responsibilities were all cited by physicians as barriers to cardiac reha-bilitation participation.96,114 Similarly, employment con-flicts and distance were reported by physicians as the main limits to participation in cardiac rehabilitation p rogrammes in Pakistan.74

Increasing provisionIn high-income countries, societies such as the AHA strongly advocate an increase in cardiac rehabilitation provision,115 and these calls should also be emphasized in LMICs. Implementation of evidence-based care is highly dependent on policy-makers, health-care pro-fessionals, and patients.116,117 The Theoretical Domains Framework116 integrates 33 theories of behaviour change into 12 domains including skills, professional role and identity, reinforcements, cognition, and environmental context and resources, to address complex implementa-tion problems.116 Although no study has yet reported on the effectiveness of the Theoretical Domains Framework in cardiac rehabilitation, these theories have been suc-cessfully applied in other areas of health care.118 The Theoretical Domains Framework might be useful for developing interventions that overcome the gap in cardiac rehabilitation implementation, through its consideration of theory, evidence, and logistical barriers.

Strategies to improve rehabilitation service deliv-ery worldwide have been described by the WHO.119 These strategies include reforming health-care policies, increasing research, developing funding mechanisms to address barriers, increasing human resources in health care, expanding and decentralizing service delivery, and increasing the use and affordability of technology.

Policies to increase capacityTo address the inadequate availability of cardiac rehabili-tation worldwide, co-ordinated efforts at national and

international levels are required.120 Surveys of cardiac rehabilitation programme directors in high-income and middle-income countries have confirmed the need for national policies to support provision and comprehensive reimbursement.64,121 Results from the European Cardiac Rehabilitation Inventory Survey27 indicate that only 46% of the 28 participating countries had national legislation regarding cardiac rehabilitation, 57% had national profes-sional guidelines, and 75% had government funding.27 In a survey of Latin America and the Caribbean, lack of health insurance coverage for cardiac rehabilitation, and lack of regulatory health policies were highlighted among the reasons for poor implementation of cardiac rehabilitation by programme directors and physician leaders.64

Although sufficient evidence exists to support the pro-vision of cardiac rehabilitation in high-income countries, few randomized controlled trials of such treatments have been undertaken in LMICs.68,122,123 However, improve-ments in clinical outcomes are expected in LMICs in response to cardiac rehabilitation programmes, given the low rates of screening and control of CVD risk factors.124 With expanded, context-specific research evidence, gov-ernment health ministries might then implement public-health policies that acknowledge, promote, and prioritize resources to support cardiac rehabilitation.64

In LMICs, a major discrepancy between the pro vision of expensive coronary interventions and inexpensive alternative therapies highlights the need for novel funding models to promote more cost-effective strategies such as cardiac rehabilitation in these resource-poor regions.64 For instance, the British Association for Cardiovascular Prevention and Rehabilitation cardiac rehabilitation stand-ards suggest that cardiac rehabilitation should be part of the “integrated cardiology service”.125 As cardiology services are developed in LMICs, cardiac rehabilitation should be a required service after a cardiovascular disease-related event or procedure. Such low-cost programmes might, therefore, reduce the need for repeat r evascularization and other downstream medical care utilization.

Expanding human resources and service delivery in health care, as recommended by the WHO, is likely to have a substantive impact in increasing cardiac rehabili-tation supply. Cardiac rehabilitation should be incorpor-ated into the training and education of future health-care providers, from community health-workers to physi-cians. The provision of core cardiac rehabilitation ele-ments, such as self-management education for patients,

Box 2 | Cost of CVD therapies in high‑income countries

UK149

■ Cardiac rehabilitation: UK£427 ■ CABG surgery for chronic angina (elective): £4,956 ■ PCI for chronic angina (elective): £2,369

USA ■ Cardiac rehabilitation150: US$1,728 ■ CABG surgery151: $133,247 ■ PCI151: $67,086 ■ Diagnostic cardiac catheterization151: $39,264

All figures are mean hospital charge per patient. Abbreviations: CVD, cardiovascular disease; PCI, percutaneous coronary intervention.

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could be allocated to nurses rather than physicians. Other approaches, such as increasing the hours of operation of existing programmes to enable an increased number of patients to attend, and the development of satellite sites based on well-established programmes could also greatly increase cardiac rehabilitation capacity.

Health-care systemsIf physicians increase patient referral rates for cardiac reha-bilitation, the pressure to expand provision in health-care systems will also increase. In a systematic review, three randomized controlled trials of interventions to increase patient uptake of cardiac rehabilitation were identified.126 These studies were conducted in high-income countries, and all were successful in increasing patient participa-tion in the programme. One trial was low-cost, which simply involved a motivational letter to patients.127 The other two trials were more complex and human resource-intensive. For example, one involved liaison nurses who co-ordinated the transfer of care between hospital and general practice, and encouraged general practice nurses to prompt and guide structured follow-up.128 In the other trial, the intervention included an in-hospital visit from a social worker and a motivational telephone call 4 weeks after hospital discharge.129 The investigators of a further study, published in 2013, also detailed that the provision of a theory-based invitation letter aimed at changing patient behaviour improved attendance at cardiac rehabilita-tion.130 These low-cost, simple methods should be adapted and tested in middle-income countries.

Systematic cardiac rehabilitation referral is a policy that demonstrably increases programme participa-tion.131 Several associations have endorsed cardiac rehabilitation referral as a care quality metric,33 includ-ing the American Association of Cardiovascular and Pulmonary Rehabilitation,132 the European Association for Cardiovascular Prevention and Rehabilitation,15 and the Canadian Association of Cardiovascular Prevention and Rehabilitation.133 The American Association of Cardiovascular and Pulmonary Rehabilitation is close to achieving ‘pay-for-performance’ for cardiac rehabili-tation referral, a funding reform that represents a dis-ruptive innovation to increase programme participation rates.134 Pay-for-performance describes the use of finan-cial rewards or penalties to encourage the provision of high-quality care. Hospitals or health-care providers are required to report on a core set of performance indicators. If a hospital fails to report, a financial penalty is initiated; financial rewards are given to hospitals for achievement of the measures. Along with other performance meas-ures, such as prescription of statins, inpatient cardiac rehabilitation referral would be linked to payment or full r eimbursement for a patient’s care.134

Alternative models of deliveryOwing to the challenges of delivering traditional h ospital-based cardiac rehabilitation, such as cost and accessibility, alternative models have now been developed. For example, in high-income and middle-income countries, home and community-based cardiac rehabilitation programmes

have been established.72,96,123,135 These programmes are as effective as traditional hospital-based cardiac rehabilita-tion at reducing CVD risk factors and mortality accord-ing to systematic literature reviews.70,136,137 Unfortunately, owing to rigid approaches towards re imbursement for these models, such as lack of payment for health-care provider time in delivering cardiac rehabilitation sessions over the phone, on the internet, or at a community centre, their implementation has not been widespread. The UK, however, is a notable exception.138

Another alternative model for cardiac rehabilitation implementation is provision within the primary health-care setting,139,140 which is much more broadly available globally than specialty care. Integration of chronic and primary health care in low-resource settings has been successful, such as for diabetes and hypertension.141 How ever, although such findings are promising, the time available to primary health-care providers to engage in preventive care is often limited. Allied health-care profes-sionals, such as physiotherapists or occupational thera-pists, trained in the core elements of cardiac rehabili tation might, therefore, support cardiac re habilitation p rovision in this context.

Finally, internet-based, telephone-based, and mobile device-based delivery modalities are an increasingly active area of cardiac rehabilitation research.136,142 These programme models have advantages in terms of cost, time (they are less likely to conflict with work or family obligations, and no transportation is required), privacy (no group embarrassment), and in overcoming logistical barriers, such as infrastructure and human resource con-straints. According to our own literature review, internet-based models incorporating, for example, a web-based recording system of vital signs such as heart rate or blood pressure, online tutorials and educational modules on all the core components of cardiac rehabilitation, online discussion groups with peers and cardiac rehabilitation professionals, or a combination of these approaches have only been tested in high-income countries to date.136,142 Owing to wide variation in internet-based interven-tions, a direct comparison between the effectiveness of internet-based and hospital-based cardiac rehabilitation programmes was not possible in a systematic review.142 How ever, the authors reported that internet-based inter-ventions have positive effects on health behaviour, as well as psychosocial and clinical outcomes (such as blood pressure, cholesterol levels, and hospital visits).142 Cardiac rehabilitation delivered on mobile devices, such as moni-tored exercise training via smartphone appli cations, text messages, voice calls, or mobile-based questionnaires on health behaviour, are emerging in high-income countries. These strategies have shown promising results, including improvement in exercise capacity and risk factors (blood pressure, glycated haemoglobin level, and BMI).136,143 Although data on the effectiveness of cardiac rehabilita-tion delivered on a mobile device has yet to be reported from LMICs, one study is under way in Jordan.143,144 Given the penetrance of mobile technology in many LMICs, with rates of ownership as high as 45% in low-income countries and 76% in lower-middle-income countries,

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mobile-based strategies have great potential to increase delivery of cardiac rehabilitation.145

In terms of interventions based on social media, the authors of a 2014 meta-analysis reported that such strate-gies for promoting healthy diet and exercise behaviours had no effect in the general population.146 Whether this delivery approach will be effective in the area of cardiac rehabilitation remains to be determined.

ConclusionsAlthough the global burden of CVD and cardio vascular death are increasing, the global availability of cardiac rehabilitation is very low. In our review of the pub-lished literature and internet searches, only 38.8% of countries have cardiac rehabilitation programmes. The problem is most severe in LMICs, where only 23% of countries have cardiac rehabilitation programmes. Some m iddle-income countries have as few as one programme per 6 million inhabitants, yet LMICs have the greatest burden of CVD.

Cardiac rehabilitation use has increased in the USA and much of Western Europe, countries that have estab-lished, but diverse, health-care system delivery models.

We must now focus on tailoring these approaches for LMICs to improve cardiac rehabilitation participation. Novel delivery modalities for cardiac rehabilitation are very promising, particularly given the penetrance of mobile phones in LMICs. Cardiac rehabilitation is equally effective as more-invasive and expensive inter-ventions for improving quality of life and clinical out-comes in low-risk patients. Therefore, as cardiology services are developed in LMICs, cardiac rehabilitation should be at the forefront of care.

Review criteria

MEDLINE, EMBASE, and Google Scholar were searched for relevant articles published between database inception and October 2013 using the following terms: “heart diseases”, “heart failure”, “angioplasty”, “rehabilitation”, “recovery of function”, “physical therapy modalities”, “secondary prevention”, and “physical medicine”. The authors’ also used their personal collections of journal articles and references from key articles to write the Review. Internet search engines were queried with “cardiac rehabilitation” by country, and for services provided by hospitals within those countries.

1. Mendis, S. & Alwan, A. (Eds) Prioritized Research Agenda for Prevention and Control of Noncommunicable Diseases (WHO, 2011).

2. Gaziano, T. A. & Pagidipati, N. Scaling up chronic disease prevention interventions in lower‑ and middle‑income countries. Annu. Rev. Public Health 34, 317–335 (2013).

3. The World Bank. Countries and lending groups [online], http://data.worldbank.org/about/country‑classifications (2013).

4. Bloom, D. E. et al. The World Economic Forum and Harvard School of Public Health. The global economic burden of non-communicable diseases [online], http://www3.weforum.org/docs/ WEF_Harvard_HE_GlobalEconomicBurdenNon CommunicableDiseases_2011.pdf (2011).

5. Balady, G. et al. Cardiac rehabilitation programs. A statement for healthcare professionals from the American Heart Association. Circulation 90, 1602–1610 (1994).

6. WHO. The global burden of disease: 2004 update [online], http://www.who.int/healthinfo/ global_burden_disease/2004_report_update/en/ (2008).

7. WHO. Mental Health DALYs/YLD definition. [online], http://www.who.int/mental_health/management/depression/daly/en (2013).

8. Mackay, J., Mensah, G. A., Mendis, S. & Greenlund, K. WHO. The atlas of heart disease and stroke [online], http://www.who.int/cardiovascular_diseases/resources/atlas/en/ (2004).

9. Vos, T. et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2163–2196 (2012).

10. World Heart Federation. Global Health Agenda. Targets and indicators. [online], http:// www.worldheartfederation.org/what‑we‑do/advocacy/global‑health‑agenda/un‑summit‑on‑ncds/targets‑and‑indicators (2013).

11. WHO. Global action plan for the prevention and control of noncommunicable diseases 2013–2020 [online], http://www.who.int/nmh/events/ ncd_action_plan/en/ (2013).

12. Balady, G. J. et al. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation 124, 2951–2960 (2011).

13. WHO. Needs and Action Priorities in Cardiac Rehabilitation and Secondary Prevention in Patients with CHD (WHO, 1993).

14. Balady, G. J. et al. Core Components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 115, 2675–2682 (2007).

15. Piepoli, M. F. et al. Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the Cardiac Rehabilitation Section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur. J. Prev. Cardiol. 21, 664–681 (2012).

16. Clark, A. M., Hartling, L., Vandermeer, B. & McAlister, F. A. Meta‑analysis: secondary prevention programs for patients with coronary artery disease. Ann. Intern. Med. 143, 659–672 (2005).

17. Jolliffe, J. A. et al. Exercise‑based rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews, Issue 1. Art No.: CD001800 http://dx.doi.org/10.1002/ 14651858.CD001800.

18. Taylor, R. et al. Exercise‑based rehabilitation for patients with coronary heart disease: systematic review and meta‑analysis of randomized controlled trials. Am. J. Med. 116, 682–692 (2004).

19. Martin, B.‑J. et al. Cardiac rehabilitation attendance and outcomes in coronary artery disease patients. Circulation 126, 677–687 (2012).

20. Heran, B. S. et al. Exercise‑based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews, Issue 7. Art No.: CD001800 http://dx.doi.org/ 10.1002/14651858.CD001800.pub2.

21. Alter, D., Oh, P. & Chong, A. Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system. Eur. J. Cardiovasc. Prev. Rehabil. 16, 102–113 (2009).

22. Pavy, B. et al. French Society of Cardiology guidelines for cardiac rehabilitation in adults. Arch. Cardiovasc. Dis. 105, 309–328 (2012).

23. Hillis, L. D. et al. ACCF/AHA Guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 124, 2610–2642 (2011).

24. Levine, G. et al. ACCF/AHA/SCAI Guideline for percutaneous coronary intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 124, 2574–2609 (2011).

25. Smith, S. et al. AHA/ACCF Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 124, 2458–2473 (2011).

26. Vanhees, L. et al. A representative study of cardiac rehabilitation activities in European Union Member States: the Carinex survey. J. Cardiopulm. Rehabil. 22, 264–272 (2002).

27. Bjarnason‑Wehrens, B. et al. Cardiac rehabilitation in Europe: Results from the European Cardiac Rehabilitation Inventory Survey. Eur. J. Cardiopulm. Prev. Rehabil. 17, 410–418 (2010).

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28. Fletcher, S. M., Burley, M. B., Thomas, K. E. & Mitchell, E. K. Feeling supported and abandoned: mixed messages from attendance at a rural community cardiac rehabilitation program in Australia. J. Cardiopulm. Rehabil. Prev. 34, 29–33 (2014).

29. Nooruddin, T., Matooq, A., Mansoor, F., Alaswamy, Z. & Khalil., H. Effectiveness of cardiac rehabilitation program in reducing cardiovascular risk factor and improving functional capacity among cardiac patients in Kingdom of Bahrain. Presented at the 23rd Australian Annual Cardiovascular Health and Rehabilitation Conference.

30. Heart and Stroke Foundation of Barbados. Cardiac disease prevention & rehabilitation programme—CDP&R [online], http://www.hsfbarbados.org/%28S% 28fknmqa454jp2nranjahcb4fk%29%29/GymCDPR.aspx (2014).

31. Bermuda Hospitals Board. Cardiac rehabilitation services. [online], http:// www.bermudahospitals.bm/cardiac‑care/cardiac_rehabilitation_services.asp (2013).

32. The Brunei Times. Ripas designs exercise regimen for patients in cardiac rehabilitation. [online], http://www.bt.com.bn/classification/news/home_news/2007/05/16/ripas_ designs_exercise_regimen_for_patients_ in_cardiac_rehabilitation (2007).

33. Grace, S. L. et al. Systematizing inpatient referral to cardiac rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society joint position paper. J. Cardiopulm. Rehabil. Prev. 31, E1–E8 (2011).

34. Grace, S. L., Bennett, S., Ardern, C. I. & Clark, A. M. Cardiac rehabilitation series: Canada. Prog. Cardiovasc. Dis. 56, 530–535 (2014).

35. States of Jersey. Specialist help for cardiac patients. [online], http://www.gov.je/News/ 2011/Pages/HelpForCardiacPatients.aspx (2011).

36. Cortes‑Bergoderi, M. et al. Availability and characteristics of cardiovascular rehabilitation programs in South America. J. Cardiopulm. Rehabil. Prev. 33, 33–41 (2013).

37. Stewart, R. et al. Physical activity in patients with stable coronary heart disease: an international perspective. Eur. Heart J. 34, 3286–3293 (2013).

38. Zwisler, A. D. O., Traeden, U., Videbaek, J. & Madsend, M. Cardiac rehabilitation services in Denmark: still room for expansion. Scand. J. Public Health 33, 376–383 (2005).

39. Cottin, Y. et al. Specific profile and referral bias of rehabilitated patients after an acute coronary syndrome. J. Cardiopul. Rehabil. 24, 38–44 (2004).

40. Karoff, M., Held, K. & Bjarnason‑Wehrens, B. Cardiac rehabilitation in Germany. Eur. J. Cardiovasc. Prev. Rehabil. 14, 18–27 (2007).

41. Antonakoudis, H. et al. Cardiac rehabilitation effects on quality of life in patients after acute myocardial infarction. Hippokratia 10, 176–181 (2006).

42. Chan, D. S. K., Chau, J. P. C. & Chang, A. M. Acute coronary syndromes: cardiac rehabilitation programmes and quality of life. J. Adv. Nurs. 49, 591–599 (2005).

43. The Official Isle of Man Government. Cardiac services [online], https://www.gov.im/categories/health‑and‑wellbeing/hospitals‑ and‑emergency‑treatment/noble’s‑hospital/ cardiac‑services (2014).

44. Gendler, Y. et al. A multicenter intervention study on referral to cardiac rehabilitation after coronary artery bypass graft surgery: a 1‑year follow‑up of rehabilitation rates among

USSR‑born and veteran Israeli patients [Hebrew]. Harefuah 151, 511–517 (2012).

45. Tramarin, R. et al. The Italian Survey on cardiac rehabilitation‑2008 (ISYDE‑2008). Part 3. National availability and organization of cardiac rehabilitation facilities. Official report of the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (IACPR‑GICR). Monaldi. Arch. Chest Dis. 70, 175–205 (2008).

46. Goto, Y. et al. Poor implementation of cardiac rehabilitation despite broad dissemination of coronary interventions for acute myocardial infarction in Japan. a nationwide survey. Circ. J. 71, 173–179 (2007).

47. Goto, Y. Current state of cardiac rehabilitation in Japan. Prog. Cardiovasc. Dis. 56, 557–562 (2014).

48. Kim, Y. J. et al. Beneficial effects of cardiac rehabilitation and exercise after percutaneous coronary intervention on hsCRP and inflammatory cytokines in CAD patients. Pflugers Arch. 455, 1081–1088 (2008).

49. Four Square. Cardiac Rehabilitation Center —CDH Medical Center Alsabah, Kuwait. [online], https://foursquare.com/v/cardiac‑rehabilitation‑ center—cdh/51b40915498e614915ba6b01 (2013).

50. Kotseva, K., Wood, D., Backer, G. D. & Bacquer, D. D. Use and effects of cardiac rehabilitation in patients with coronary heart disease: Results from the EUROASPIRE III survey. Eur. J. Prev. Cardiol. 20, 817–826 (2013).

51. Briffa, T. et al. Exposure to evidence‑based secondary prevention after acute coronary syndrome (ACS) in Australia and New Zealand [abstract]. Circulation 128, A11996 (2013).

52. Otterstad, J. E. Influence on lifestyle measures and five‑year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease. Eur. J. Cardiovasc. Prev. Rehabil. 10, 429–437 (2003).

53. Padró, C. & Correa‑Pérez, M. A clinical study of a cardiac rehabilitation program (phase II). P. R. Health Sci. J. 16, 245–250 (1997).

54. Heart Hospital, Doha‑Qatar. Cardiac Rehabilitation [online], http://hh.hamad.qa/ en/hospital_services/clinical_departments/cardiac_rehabilitation/cardiac_rehabilitation.aspx (2013).

55. Blair, J., Corrigall, H., Angus, N., Thompson, D. & Leslie, S. Home versus hospital‑based cardiac rehabilitation: A systematic review. Rural Remote Health 11, 1532 (2011).

56. G‑movement. Life-enhancing movement for health [online], http://www.g‑movement.org/programmes.html (2013).

57. Stauber, S. et al. Psychosocial outcome in cardiovascular rehabilitation of peripheral artery disease and coronary artery disease patients. Vasc. Med. 18, 257–262 (2013).

58. WellnessConnect. Total Rehab Centre: holistic health [online], http://www.ttwellnessconnect.com/ total‑rehab‑centre‑holistic‑health (2013).

59. Sheikh Khalifa Medical City. Cardiac sciences. [online], http://www.skmc.ae/en‑us/medicalservices/SpecialistCare/CardiacSciences/Pages/default.aspx (2013).

60. Bethell, H. et al. Outpatient cardiac rehabilitation attendance in England: variability by region and clinical characteristics. J. Cardiopulm. Rehabil. Prev. 28, 386–391 (2008).

61. Suaya, J. et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 116, 1653–1662 (2007).

62. Menezes, A. R. et al. Cardiac rehabilitation in the United States. Prog. Cardiovasc. Dis. 56, 522–529 (2014).

63. Juan F. Luis Hospital & Medical Center. Virgin Islands Cardiac Center at JFLH. [online], http://www.jflusvi.org/cardiac_center.php (2013).

64. Korenfeld, Y. et al. Current status of cardiac rehabilitation in Latin America and the Caribbean. Am. Heart J. 158, 480–487 (2009).

65. Shanmugasegaram, S., Perez‑Terzic, C., Jiang, X. & Grace, S. L. Cardiac rehabilitation services in low‑ and middle‑income countries: a scoping review. J. Cardiovasc. Nurs. http://dx.doi.org/ 10.1097/JCN.0b013e31829c1414.

66. Adghar, D., Bougherbal, R., Hanifi, R. & Khellaf, N. Cardiac rehabilitation: first experience in Algeria [French]. Ann. Cardiol. Angeiol. (Paris) 57, 44–47 (2008).

67. Borghi‑Silva, A., Mendes, R. G., Trimer, R. & Cipriano, G. Jr. Current trends in reducing cardiovascular disease risk factors from around the world: focus on cardiac rehabilitation in Brazil. Prog. Cardiovasc. Dis. 56, 536–542 (2014).

68. Jiang, X., Sit, J. W. & Wong, T. K. A nurse‑led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China. J. Clin. Nurs. 16, 1886–1897 (2007).

69. Tantaewy, N. M., Shebl, A. M., Shereif, W. I. & Weheda, S. M. Effect of cardiac rehabilitation program on lifestyle pattern of patients with myocardial infarction. Journal of Biology, Agriculture & Healthcare 3, 9–21 (2013).

70. Chakraborty, K. et al. A comparative study on the effects of comprehensive rehabilitation in uncomplicated coronary artery bypass grafting patients from rural and urban India. Indian J. Physical Med. Rehabil. 18, 34–40 (2007).

71. Madan, K. et al. Cardiac rehabilitation in India. Prog. Cardiovasc. Dis. 56, 543–550 (2014).

72. Radi, B. S36–3 Cardiac rehabilitation in Indonesia. [abstract] CVD Prev. Cont. 4 (Suppl. 1), S49 (2009).

73. Sarrafzadegan, N. et al. Gender differences in risk factors and outcomes after cardiac rehabilitation. Acta Cardiol. 63, 763–770 (2008).

74. Ali, M. et al. Factors affecting outpatient cardiac rehabilitation attendance after acute myocardial infarction and coronary revascularization —a local experience. J. Pak. Med. Assoc. 62, 347–351 (2012).

75. Avram, A. et al. EUROASPIRE III Romania —the need to reinforce cardiac rehabilitation in patients with coronary artery disease. Timisoara Med. J. 60, 299–304 (2010).

76. Digenio, A. G. et al. The Johannesburg Cardiac Rehabilitation Programme: a 5 year evaluation. J. Cardiopulm. Rehabil. Prev. 17, 340 (1997).

77. Nahali, R. M. et al. Place of cardiac rehabilitation in coronary patients. Presented at the 26th Congress of SOFMER: Physical and Rehabilitation Medicine.

78. Ciftçi, C., Duman, B., Cagatay, P., Demiroglu, C. & Aytekin, V. The effects of phase II cardiac rehabilitation programme on patients undergone coronary bypass surgery. Anadolu. Kardiyol. Derg. 5, 116–121 (2005).

79. Kabul Medical University Cardiac Research Centre. Rehabilitation services. [online], http://www.kcrc‑af.ca/rehabilitation‑services (2012).

80. Zahan, R. Exercise-based cardiac rehabilitation program: Status in Bangladesh. Thesis, Friedrich‑Alexander University Erlangen‑Nuremberg, Germany (2013).

81. The Aga Khan University Hospitals. News 2011. Aga Khan University Hospital opens cardiac rehabilitation unit [online], http://hospitals.aku.edu/nairobi/aboutus/newsandevents/Pages/Opens‑A‑Cardiac‑Rehabilitation‑Unit.aspx (2011).

REVIEWS

© 2014 Macmillan Publishers Limited. All rights reserved

NATURE REVIEWS | CARDIOLOGY VOLUME 11 | OCTOBER 2014 | 595

82. Laslett, L. J. et al. The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology. J. Am. Coll. Cardiol. 60 (25 Suppl.), S1–S49 (2012).

83. Pack, Q. R. et al. What is the potential capacity for increasing cardiac rehabilitation utilization in the United States? [abstract]. Circ. Cardiovasc. Qual. Outcomes. 6, A180 (2013).

84. Curnier, D. Y., Savage, P. D. & Ades, P. A. Geographic distribution of cardiac rehabilitation programs in the United States. J. Cardiopulm. Rehabil. 25, 80–84 (2005).

85. The World Bank. New country classifications [online], http://data.worldbank.org/news/ new‑country‑classifications (2014).

86. World Atlas. Countries of the World [online], http://www.worldatlas.com/aatlas/populations/ctypopls.htm#.Uqyqv‑IuehI (2014).

87. Clark, A. M. et al. Factors influencing referral to cardiac rehabilitation and secondary prevention programs: a systematic review. Eur. J. Prev. Cardiol. 20, 692–700 (2013).

88. Brown, T. M. et al. Predictors of cardiac rehabilitation referral in coronary artery disease patients: findings from the American Heart Association’s Get With The Guidelines program. J. Am. Coll. Cardiol. 54, 515–521 (2009).

89. Aragam, K. G. et al. Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention. Am. Heart J. 161, 544–551 (2011).

90. Brady, S., Purdham, D., Oh, P. & Grace, S. Clinical and sociodemographic correlates of referral for cardiac rehabilitation following cardiac revascularization in Ontario. Heart Lung 42, 320–325 (2013).

91. Beckstead, J. W. et al. Physicians’ tacit and stated policies for determining patient benefit and referral to cardiac rehabilitation. Med. Decis. Making 34, 63–74 (2014).

92. Moradi, B., Maleki, M., Esmaeilzadeh, M. & Abkenar, H. B. Physician‑related factors affecting cardiac rehabilitation referral. J. Tehran. Heart Cent. 6, 187–192 (2011).

93. Leung, Y. W., Brual, J., Macpherson, A. & Grace, S. L. Geographic issues in cardiac rehabilitation utilization: a narrative review. Health Place 16, 1196–1205 (2010).

94. Rajendran, A., Manoj, S., Karthikeyan, D. & Davis, S. Cardiac rehabilitation for CABG patients in South Indian setup: a prospective study. Indian J. Physical Med. Rehabil. 15, 23–33 (2004).

95. Moradi, B., Esmaeilzadeh, M., Maleki, M. & Sari, L. Factors associated with failure to complete phase II cardiac rehabilitation: survey registry in Rajaie Cardiovascular Medical and Research Center. Int. Cardiovasc. Res. J. 5, 139–142 (2011).

96. Ghisi, G. L. et al. Perceptions of barriers to cardiac rehabilitation use in Brazil. Vasc. Health Risk Manag. 9, 485–491 (2013).

97. Goble, A. J. & Worcester, M. Department of Human Services Victoria, Australia. Best practice guidelines for cardiac rehabilitation and secondary prevention [online], http:// www.health.vic.gov.au/nhpa/downloads/bestpracticecardiacrehab.pdf (1999).

98. Oldridge, N. Exercise‑based cardiac rehabilitation in patients with coronary heart disease: Meta‑analysis outcomes revisited. Future Cardiol. 8, 729–751 (2012).

99. Yusuf. S. et al. Effect of coronary artery bypass graft surgery on survival: overview of 10‑year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 344, 563–570 (1994).

100. Wijeysundera, H. C. & Ko, D. T. Does percutaneous coronary intervention reduce mortality in patients with stable chronic angina: Are we talking about apples and oranges? Circ. Cardiovasc. Qual. Outcomes 2, 123–126 (2009).

101. Lawler, P., Filion, K. & Eisenberg, M. Efficacy of exercise‑based cardiac rehabilitation post‑myocardial infarction: a systematic review and meta‑analysis of randomized controlled trials. Am. Heart J. 162, 571–584.e2 (2011).

102. Kottke, T. E. et al. The comparative effectiveness of heart disease prevention and treatment strategies. Am. J. Prev. Med. 36, 82–88 (2009).

103. Chan, P. S. et al. Cardiac performance measure compliance in outpatients: The American College of Cardiology and National Cardiovascular Data Registry’s PINNACLE (Practice Innovation And Clinical Excellence) Program. J. Am. Coll. Cardiol. 56, 8–14 (2010).

104. Morris, A. C., Caesar, D., Gray, S. & Gray, A. TIMI risk score accurately risk stratifies patients with undifferentiated chest pain presenting to an emergency department. Heart 92, 1333–1334 (2006).

105. Mendis, S. et al. The availability and affordability of selected essential medicines for chronic diseases in six low‑ and middle‑income countries. Bull. World Health Organ. 85, 279–288 (2007).

106. Eagle, K. A., Koelling, T. M. & Montoye, C. K. Primer: implementation of guideline‑based programs for coronary care. Nat. Clin. Pract. Cardiovasc. Med. 3, 163–171 (2006).

107. Mendis, S. et al. WHO study on prevention of recurrences of myocardial infarction and stroke (WHO‑PREMISE). Bull. World Health Organ. 83, 820–829 (2005).

108. Murray, J., Craigs, C., Hill, K., Honey, S. & House, A. A systematic review of patient reported factors associated with uptake and completion of cardiovascular lifestyle behaviour change. BMC Cardiovasc. Disord. 12, 120 (2012).

109. Sarrafzadegan, N. et al. Drop‑out predictors in cardiac rehabilitation programmes and the impact of sex differences among coronary heart disease patients in an Iranian sample: a cohort study. Clin. Rehab. 21, 362–372 (2007).

110. Neubeck, L. et al. Participating in cardiac rehabilitation: a systematic review and meta‑synthesis of qualitative data. Eur. J. Prev. Cardiol. 19, 494–503 (2012).

111. Cortés, O. & Arthur, H. M. Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review. Am. Heart J. 151, 249–256 (2006).

112. Ghisi, G. L. M., Polyzotis, P., Oh, P., Pakosh, M. & Grace, S. L. Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review. Clin. Cardiol. 36, 323–335 (2013).

113. Boyden, T., Rubenfire, M. & Franklin, B. Will increasing referral to cardiac rehabilitation improve participation? Prev. Cardiol. 13, 198–202 (2010).

114. Mair, V., Breda, A. P., Nunes, M. E. & Matos, L. D. Evaluating compliance to a cardiac rehabilitation program in a private general hospital. Einstein (São Paulo) 11, 278–284 (2013).

115. Arena, R. et al. Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings: a science advisory from the American Heart Association. Circulation 125, 1321–1329 (2012).

116. Michie, S. et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual. Saf. Health Care 14, 26–33 (2005).

117. Cane, J., O’Connor, D. & Michie, S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement. Sci. 7, 37 (2012).

118. Islam, R. et al. A cross‑country comparison of intensive care physicians’ beliefs about their transfusion behaviour: a qualitative study using the theoretical domains framework. Implement. Sci. 7, 93 (2012).

119. WHO. World Report: Disability [online], http://www.who.int/disabilities/world_report/2011/en/ (2011).

120. Smith, S. C. et al. Our time: a call to save preventable death from cardiovascular disease (heart disease and stroke). Circulation 126, 2769–2775 (2012).

121. Zwisler, A.‑D. O. & Schou, L. in Cardiac Rehabilitation: Basic Principles (eds Zwisler, A.‑D. O, Schou, L. & Sorensen, L. V.) 17–28 (H:S Bispebjerg Hospital and National Institute of Public Health, 2004).

122. Charoenkul, P., Khuangsirikul, W., Jalayondeja, W. & Krittayaphong, R. Improvement in quality of life with phase II cardiac rehabilitation home program after coronary artery bypass surgery at Siriraj Hospital. Thai Heart J. 20, 165–170 (2007).

123. Karapolat, H. et al. Effects of cardiac rehabilitation program on exercise capacity and chronotropic variables in patients with orthotopic heart transplant. Clin. Res. Cardiol. 97, 449–456 (2008).

124. Salim, Y. et al. Use of secondary prevention drugs for cardiovascular disease in the community in high‑income, middle‑income, and low‑income countries (the PURE Study): a prospective epidemiological survey. Lancet 378, 1231–1243 (2011).

125. Buckley, J. P. et al. BACPR scientific statement: British standards and core components for cardiovascular disease prevention and rehabilitation. Heart 99, 1069–1071 (2013).

126. Davies, P. et al. Promoting patient uptake and adherence in cardiac rehabilitation. Cochrane Database of Systematic Reviews Issue 7. Art. No.: CD007131 http://dx.doi.org/ 10.1002/14651858.CD007131.pub2.

127. Wyer, S. et al. Increasing attendance rates at a cardiac rehabilitation programme: an intervention study using the Theory of Planned Behaviour. Coronary Health Care 5, 154–159 (2001).

128. Jolly, K. et al. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group. BMJ 318, 706–711 (1999).

129. Hillebrand, T., Frodermann, H., Lehr, D. & Wirth, A. Increased participation in coronary groups by means of an outpatient care program [German]. Herz Kreislauf 27, 346–349 (1995).

130. Mosleh, S. M., Bond, C. M., Lee, A. J., Kiger, A. & Campbell, N. C. Effectiveness of theory‑based invitations to improve attendance at cardiac rehabilitation: A randomized controlled trial. Eur. J. Cardiovasc. Nurs. 13, 201–210 (2014).

131. Gravely‑Witte, S. et al. Effects of cardiac rehabilitation referral strategies on referral and enrollment rates. Nat. Rev. Cardiol. 7, 87–96 (2010).

132. Thomas, R. et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac

REVIEWS

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rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing committee to develop clinical performance measures for cardiac rehabilitation). Circulation 122, 1342–1350 (2010).

133. Grace, S. L. et al. Pan‑Canadian development of cardiac rehabilitation and secondary prevention quality indicators. Can. J. Cardiol. http:// dx.doi.org/10.1016/j.cjca.2014.04.003.

134. Mead, H., Grantham, S. & Siegel, B. Improving cardiovascular care through outpatient cardiac rehabilitation: an analysis of payment models that would improve quality and promote use. J. Cardiovasc. Nurs. 29, 158–164 (2014).

135. Mandic, S. et al. Effects of community‑based cardiac rehabilitation on body composition and physical function in individuals with stable coronary artery disease: 1.6‑year follow up. Biomed Res. Int. 2013, 903604 (2013).

136. Clark, R. A. et al. Alternative models of cardiac rehabilitation: a systematic review. Eur. J. Prev. Cardiol. http://dx.doi.org/10.1177/ 2047487313501093.

137. Dalal, H. M., Zawada, A., Jolly, K., Moxham, T. & Taylor, R. S. Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta‑analysis. BMJ 340, b5631 (2010).

138. Dalal, H. et al. Home‑based versus hospital‑based rehabilitation after myocardial infarction: a randomized trial with preference arms —Cornwall Heart Attack Rehabilitation Management study (CHARMS) Int. J. Cardiol. 19, 202–211 (2007).

139. Márquez‑Calderóna, S. et al. Incorporation of cardiac rehabilitation programs and their characteristics in the Spanish National Health Service [Spanish]. Rev. Esp. Cardiol. 56, 775–782 (2003).

140. Cupples, M. E., Reader, C. & Tully, M. A. Cardiac rehabilitation uptake following myocardial infarction: cross‑sectional study in primary care. Br. J. Gen. Pract. 60, 431–435 (2010).

141. Esterson, Y. B., Carey, M., Piette, J. D., Thomas, N. & Hawkins, M. A systematic review of innovative diabetes care models in low‑and middle‑income countries (LMICs). J. Health Care Poor Underserved 25, 72–93 (2014).

142. Munro, J., Angus, N. & Leslie, S. J. Patient focused Internet‑based approaches to cardiovascular rehabilitation—a systematic review. J. Telemed. Telecare 19, 347–353 (2013).

143. Beatty, A. L., Fukuoka, Y. & Whooley, M. A. Using mobile technology for cardiac rehabilitation: a review and framework for development and evaluation. J. Am. Heart Assoc. 2, e000568 (2013).

144. Alsaleh, E., Blake, H. & Windle, R. Behavioural intervention to increase physical activity among patients with coronary heart disease: protocol for a randomised controlled trial. Int. J. Nurs. Stud. 49, 1489–1493 (2012).

145. United Nations Development Programme. Mobile technologies and empowerment: enhancing human development through participation and innovation [online], https://www.undpegov.org/mgov‑primer.html (2011).

146. Williams, G., Hamm, M. P., Shulhan, J., Vandermeer, B. & Hartling, L. Social media interventions for diet and exercise behaviours: a systematic review and meta‑analysis of randomised controlled trials. BMJ Open 4, e003926 (2014).

147. Scott, I. A., Lindsay, A. & Harden, H. E. Utilisation of outpatient cardiac rehabilitation in Queensland. Med. J. Aust. 179, 341–345 (2003).

148. Beswick, A. D. et al. Provision, uptake and cost of cardiac rehabilitation programmes: improving services to under‑represented groups. Health Technol. Assess. 8, 1–152 (2004).

140. Fidan, D., Unal, B., Critchley, J. & Capewell, S. Economic analysis of treatments reducing coronary heart disease mortality in England and Wales, 2000–2010. QJM 100, 277–289 (2007).

150. Carlson, J. J., Johnson, J. A., Franklin, B. A. & VanderLaan, R. L. Program participation, exercise adherence, cardiovascular outcomes, and program cost of traditional versus modified cardiac rehabilitation. Am. J. Cardiol. 86, 17–23 (2000).

151. Go, A. S. et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation 127, e6–e245 (2013).

AcknowledgementsThe authors gratefully acknowledge the assistance of information specialist Ms Maureen Pakosh (University Health Network, Toronto Rehabilitation Institute, Toronto, Canada) in conducting the electronic database searches. N.S. also acknowledges the University of British Columbia School of Population and Public Health, Vancouver, Canada where she was undertaking sabbatical while writing this manuscript.

Author contributionsK.T.‑A. reviewed data for the article. N.S. and S.L.G. made substantial contributions to the content. All authors wrote, reviewed, and edited the manuscript before submission.

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