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  • Review Article
  • Published:

Global availability of cardiac rehabilitation

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

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.

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Figure 1: Global availability of cardiac rehabilitation.

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References

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

    Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  3. The World Bank. Countries and lending groups [online], (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], (2011).

    Google Scholar 

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

    Article  Google Scholar 

  6. WHO. The global burden of disease: 2004 update [online], (2008).

  7. WHO. Mental Health DALYs/YLD definition. [online], (2013).

  8. Mackay, J., Mensah, G. A., Mendis, S. & Greenlund, K. WHO. The atlas of heart disease and stroke [online], (2004).

    Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  10. World Heart Federation. Global Health Agenda. Targets and indicators. [online], (2013).

  11. WHO. Global action plan for the prevention and control of noncommunicable diseases 2013–2020 [online], (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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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], (2014).

  31. Bermuda Hospitals Board. Cardiac rehabilitation services. [online], (2013).

  32. The Brunei Times. Ripas designs exercise regimen for patients in cardiac rehabilitation. [online], (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).

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  35. States of Jersey. Specialist help for cardiac patients. [online], (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).

    Article  PubMed  Google Scholar 

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

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  Google Scholar 

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

    Article  PubMed  Google Scholar 

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

    CAS  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  43. The Official Isle of Man Government. Cardiac services [online], (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).

    PubMed  Google Scholar 

  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).

    PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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).

    Article  CAS  PubMed  Google Scholar 

  49. Four Square. Cardiac Rehabilitation Center—CDH Medical Center Alsabah, Kuwait. [online], (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).

    Article  PubMed  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    PubMed  Google Scholar 

  54. Heart Hospital, Doha-Qatar. Cardiac Rehabilitation [online], (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).

    PubMed  Google Scholar 

  56. G-movement. Life-enhancing movement for health [online], (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).

    Article  PubMed  Google Scholar 

  58. WellnessConnect. Total Rehab Centre: holistic health [online], (2013).

  59. Sheikh Khalifa Medical City. Cardiac sciences. [online], (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).

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  63. Juan F. Luis Hospital & Medical Center. Virgin Islands Cardiac Center at JFLH. [online], (2013).

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

    Article  PubMed  Google Scholar 

  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).

    Article  CAS  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Google Scholar 

  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).

    Google Scholar 

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

    Article  PubMed  Google Scholar 

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

    Article  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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).

    PubMed  Google Scholar 

  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).

    Google Scholar 

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

    Article  Google Scholar 

  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., Cag˘atay, P., Demirog˘lu, C. & Aytekin, V. The effects of phase II cardiac rehabilitation programme on patients undergone coronary bypass surgery. Anadolu. Kardiyol. Derg. 5, 116–121 (2005).

    PubMed  Google Scholar 

  79. Kabul Medical University Cardiac Research Centre. Rehabilitation services. [online], (2012).

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

    Google Scholar 

  81. The Aga Khan University Hospitals. News 2011. Aga Khan University Hospital opens cardiac rehabilitation unit [online], (2011).

  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).

    Article  PubMed  Google Scholar 

  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).

    Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  85. The World Bank. New country classifications [online], (2014).

  86. World Atlas. Countries of the World [online], (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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Google Scholar 

  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).

    Article  Google Scholar 

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

    Article  PubMed  Google Scholar 

  97. Goble, A. J. & Worcester, M. Department of Human Services Victoria, Australia. Best practice guidelines for cardiac rehabilitation and secondary prevention [online], (1999).

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

    Article  CAS  PubMed  Google Scholar 

  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).

    Article  CAS  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed Central  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

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

    Article  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  119. WHO. World Report: Disability [online], (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).

    Article  PubMed  Google Scholar 

  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).

    Google Scholar 

  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).

    Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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).

    Google Scholar 

  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).

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  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).

    Article  PubMed  PubMed Central  Google Scholar 

  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).

    Article  PubMed  Google Scholar 

  145. United Nations Development Programme. Mobile technologies and empowerment: enhancing human development through participation and innovation [online], (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).

    Article  PubMed  PubMed Central  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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).

    Article  Google Scholar 

  149. 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).

    Article  CAS  PubMed  Google Scholar 

  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).

    Article  CAS  PubMed  Google Scholar 

  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).

    PubMed  Google Scholar 

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Acknowledgements

The 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.

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K.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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Correspondence to Nizal Sarrafzadegan.

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Turk-Adawi, K., Sarrafzadegan, N. & Grace, S. Global availability of cardiac rehabilitation. Nat Rev Cardiol 11, 586–596 (2014). https://doi.org/10.1038/nrcardio.2014.98

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