Cardiac rehabilitation is a vastly underutilized Class IA recommendation, and cardiovascular nurses are uniquely positioned to bridge the implementation gap through advocacy, education, and innovative care models.
Introduction Cardiovascular disease (CVD) remains the leading cause of death globally, accounting for an estimated 17.9 million deaths in 2019 (over one-third of all global deaths)1 and nearly 1 million deaths in the United States in 2020.2 Although advancements in diagnostic and acute treatment strategies have reduced mortality rates over recent decades, the burden of CVD remains high. Hospital readmission rates after an initial cardiac event are concerning, with up to 14% of patients readmitted within 30 days,3 and as high as 50% within 1 year.4 Given that CVD is largely a preventable disease, secondary prevention strategies including physical activity, healthy eating, adequate sleep, tobacco cessation, and improved lipid and blood pressure control are critical for reducing recurrent events and CVD-related deaths. What Is Cardiac Rehabilitation and Why It Matters Cardiac rehabilitation (CR) is a class IA guideline–recommended secondary prevention program designed to support comprehensive recovery after a cardiac event.5,6 It includes structured exercise training, patient education, and psychosocial support, delivered by a multidisciplinary team of healthcare professionals. CR benefits patients recovering from myocardial infarction, heart failure, and revascularization procedures, with strong evidence demonstrating reductions in mortality and recurrent events, and improvements in functional capacity and mental well-being.7–9 Despite these benefits and in the face of strong international recommendations, CR remains underused. Global trends show that only 20%–30% of eligible patients are referred, and an even smaller proportion complete the full program.10 This underuse is not a reflection of evidence but rather of persistent challenges in implementation. The Role of Cardiovascular Nurses in Bridging the Cardiac Rehabilitation Gap Cardiovascular nurses are often the first point of contact as patients transition from acute care to recovery. However, awareness of CR and its benefits remains variable, even among health professionals. Many nurses outside dedicated CR programs may be unfamiliar with referral pathways, program content, or the extensive evidence base supporting CR.11 This lack of awareness potentially hinders nurses' ability to advocate effectively for patients and contributes to the persistent underuse of CR services. Strengthening CR education and engagement across nursing roles empowers nurses to advocate for patients and champion secondary prevention throughout the continuum of care. As part of a multidisciplinary team, nurses play a vital role in ensuring coordinated, person-centered care, working alongside physicians, physiotherapists, clinical exercise physiologists, dietitians, and psychologists to support patients in achieving long-term recovery and improved cardiovascular health. The barriers to CR are multifaceted and exist at the system, healthcare professional, and patient levels.12,13 System-level issues include the absence of automatic referral mechanisms, limited program capacity, and insufficient funding. Healthcare professionals may be uncertain about eligibility criteria or the referral process. Barriers to CR attendance and participation also exist at the individual level; some patients may underestimate the importance of CR or fear that engaging in physical activity could worsen their condition.13,14 Patients often face psychosocial, cultural, or logistical barriers such as transportation difficulties, caregiving responsibilities, or language differences.14 Nurses are uniquely positioned to address these issues by educating patients and families, identifying and mitigating barriers to participation, facilitating timely referrals, and leading the development of flexible, culturally appropriate models of care. Strengthening nurses' knowledge and engagement with CR is essential not only to close the knowledge-to-practice gap but also to ensure equitable access to this life-saving intervention across diverse healthcare settings. From Evidence to Implementation The evidence supporting CR is robust; however, the real challenge lies in making these programs part of routine, equitable care. Many patients are never referred after hospital discharge, whereas others are unable to attend because of costs, transport limitations, or scheduling conflicts. Participation in CR also remains disproportionately low among women, older adults, rural populations, and racial/ethnic minority groups and communities.14 Therefore, addressing these gaps requires models of care that are flexible and responsive to individual needs.13 Home-based and hybrid CR programs, culturally tailored approaches, and digital health tools can expand reach and improve accessibility while ensuring that these solutions do not inadvertently widen disparities.15 Unfortunately, significant variability within the current US CR infrastructure limits the flexible implementation of home-based and hybrid models, largely because of inconsistent insurance coverage and individual CR program constraints. This is where implementation science becomes vital. Although efficacy is established in controlled research settings, implementation studies provide insights into how CR can be adapted, scaled, and sustained in real-world environments.16 Empowering cardiovascular nurses to participate in clinical research enables nurses to translate and integrate evidence into usual care practices, narrowing the research and practice gap. Engagement in implementation science also reaffirms nurses' roles as critical thinkers, problem solvers, and champions of high-quality, evidence-based care. Embracing research empowers nurses to influence the future of cardiovascular health, maintaining person-centered care that is both innovative and evidence based.17 Looking ahead, nurses' contributions in clinical research continuously play a critical role in advancing healthcare, improving patient outcomes, and establishing nursing as a cornerstone of healthcare innovation and excellence. Nurses must engage with this growing evidence base to ensure that CR programs are both clinically effective and contextually relevant.18 Without deliberate, evidence-informed implementation, even the most promising interventions will fall short of their potential. Reframing Cardiac Rehabilitation as Part of Core Cardiovascular Care To fully integrate CR into the continuum of cardiovascular care, it must be reframed not as an optional service but as an essential component of secondary prevention.9 Ideally, every eligible patient should be automatically referred to CR at hospital discharge, clinical teams should treat it as a shared responsibility, and health systems should track enrolment, participation, and outcomes as indicators of quality care.14 Achieving this vision requires coordinated, system-level change. Referral to CR should be embedded into standard discharge protocols, ideally through automated systems. Care pathways must include CR as a fundamental step in recovery. Investment in scalable models such as home-based and hybrid CR is crucial, especially for underserved populations. Participation and completion rates should be captured in quality improvement and audit frameworks. Clinician education, particularly for nurses, must be prioritized to ensure the entire care team understands and champions the value of CR. Positioned at the intersection of acute care and recovery, cardiovascular nurses are critical in this transformation. Expanding Cardiac Rehabilitation Access Through Innovation Despite clinicians' best efforts to refer patients to CR, a large proportion of eligible individuals still may not participate because of persistent barriers. A national study of CR programs estimated that even if all existing programs operated at full capacity, only up to 47% of eligible patients could be accommodated (range, 32%–67%), primarily because of facility limitations and staffing shortages.19 From the perspective of program administrators and staff, many of these challenges are systems related and potentially modifiable.19 Practical strategies to address CR capacity issues include expanding the number of programs, improving reimbursement models, and implementing new delivery approaches.19 Importantly, cardiovascular nurses are well positioned to lead and support these innovations. Beyond expanding existing CR programs, there is a growing need to reimagine secondary prevention to meet the diverse needs of patients, ranging from those at highest risk after acute cardiovascular events, such as open-heart surgery, to individuals newly diagnosed with a form of CVD.9 A tailored, accessible alternative program to CR is urgently needed, particularly for patients facing logistical, geographic, or socioeconomic barriers. Digital health technologies (eg, mobile apps, text messaging, wearable devices) offer promising tools to complement CR in supporting behavior change and sustained risk factor management.20 Although digital solutions may not address every barrier, there is growing consensus among CR stakeholders that a shift or “rebranding” of CR is necessary to reach more patients. Nurses play a pivotal role in this transformation, advocating for and codesigning person-centered, technology-enabled approaches that broaden access, personalize care, and improve outcomes for people living with CVD. Conclusion CR is not an optional add-on in cardiovascular care. It is a life-saving, evidence-based component of cardiovascular care. Yet, it remains underused, in part because of persistent systemic challenges. As the burden of CVD continues to rise, particularly among aging and diverse populations, addressing the gaps in CR access and participation must become a health system priority. Nurses, given their proximity to patients and integral role across the continuum of care, are uniquely positioned to drive this change. By advocating for equitable access, leading implementation efforts, reshaping clinical practice, and developing innovative, person-centered strategies, cardiovascular nurses can ensure that CR becomes a fundamental part of every cardiac patient's recovery journey.
Candelaria et al. (Thu,) studied this question.