Editorial: Reviews in cardiac rehabilitation

availability of CR programs in China, the growth has been slow. China, not unlike other countries, have more men and younger patients enrolling in CR [15][16][17][18] . China also has similar system and personal barriers to getting patients referred and enrolled into CR programs. And, the "CR deserts" are quite prominent in the rural areas of China with most CR programs being offered at tertiary care centers. These issues have resulted in the majority of the Chinese patients diagnosed with CVD being unable to heed the benefits of CR. These disparities will result in a haves and have-not implementation and participation in CR 14 .Compared to traditional CR programs, hybrid models of CR offer several potential advantages. They facilitate eligible patients who are unable to visit rehabilitation centers for various reasons (eliminating the "CR deserts"), decrease medical costs, and improve patient satisfaction and adherence to CR.There are various components to a CR program which includes exercise, nutrition, psycho-social issues, CV risk factor modification, and education. The exercise regimen does not fit all. Patients who find themselves inflicted with a CV disease range from elite athletes to, respectfully, exercise adverse individuals. Yet, exercise is a key component to primary and secondary prevention, it must be embraced, and must meld into the individual patient's lifestyle. Therefore, various exercises must be made available to individualize the exercise regimen. High intensity interval training (HIIT) is specifically embraced by more elite athletes and women 19 . Strength training to rebuild lost skeletal muscle is key for heart failure (HF) patients 20 . Furthermore, exercises must be culturally varied in order to embrace our patient's needs.Traditional Chinese Exercises (TCE) such as Tai Chi, Qi Gong and Ba Duan Jin have become increasingly popular around the world because of their gentle movements, low-risk, easy training, and long-term adherence 21 . As a mild musclestrengthening sport, TCE combines spiritual meditation with moderate postures, musculoskeletal stretching, and deep breathing 22,23 . TCE has been shown in numerous studies to be an effective exercise for CR and to enhance cardiorespiratory health 24,25 . J. Zhang, et al performed a meta-analysis of 21 studies which utilized TCE and found that the use of TCE was an effective form of exercise in patients after a myocardial infarction (MI) to prevent subsequent CV events and improve patient's emotions and quality of life (QoL). 26 Heart failure (HF) incidence is increasing 20,26 . HF with reduced ejection fraction (HFrEF) < 35% is a qualifying diagnosis that for many is covered by insurance and Medicare. Unfortunately, Medicaid coverage for CR is quite variable from state to state within the United States (US) with very limited CR coverage. Despite heart failure with preserved ejection fraction (HFpEF) increasing, especially, in the elderly and women, HFpEF is not covered for CR 20,26 .As a set of Tai Chi exercises designed specifically for elderly patients with chronic heart failure, Fu Yang Tai Chi exercises are ideal. Fu Yang Tai Chi stems from the traditions of Tai Chi and incorporates a holistic approach melding the body, mind, and breath, "emphasizing the importance of spiritual care in moderate exercise, realizing the combination of "exercise prescription" and "psychological prescription." The whole set of movements is even and slow, combining movement and stillness, and is a unique connotation of aerobic physical and mental exercise" 27 . However, there are no clinical trials to confirm the effectiveness and safety of the exercises; therefore, the Q. Jiao, et al designed a single-center, open label, randomized controlled trial (RCT) to study the effects of Fu Yang Tai Chi as an adjunctive therapy on the quality of life of elderly patients with HF. If the results are positive, this therapy could become a good way for older people with HF to exercise at home that is also affordable 27 .Globally, the lack of utilization of CR for patients with CVD as a resource to prevent disease is adding insult to injury, salt to the wound. The knowledge is abounding for the benefits of CR to prevent subsequent events in patients with CVD. The COVID pandemic brought to the surface the great need, benefit, efficacy, and safety of alternative options of traditional CR to expand the benefit to the masses of patients with CVD. This global awareness is occurring now. The effects and outcomes will decrease CV events, reduce the barriers to receive CR, and improve CV morbidity and mortality.