Barriers to Participation in Cardiac Rehabilitation

Cardiac rehabilitation (CR) is a proven secondary-prevention strategy that improves exercise capacity, quality of life, and survival in cardiovascular disease patients. Despite numerous efforts, the participation rate in cardiac rehabilitation remains low. In Korea, reimbursement for CR was implanted later than in other countries with advanced health-care systems, and CR participation rates are reported to be even lower. Accordingly, systematically identifying the barriers that disturb CR participation and devising targeted countermeasures are essential to effective cardiovascular disease management. Patient-level obstacles include female sex, advanced age, low socioeconomic status, limited geographic access to CR centers, and a high burden of comorbid conditions. On the healthcare provider and hospital aspect, insufficient awareness of CR, weak physician endorsement, and the high fixed and operating costs required to maintain programs hinder uptake. Despite robust evidence supporting the cost-effectiveness of CR, policy-level support for wider implementation remains inadequate. This gap is especially evident for emerging, evidence-based digital and hybrid CR models, for which technological advances have not been matched by commensurate reimbursement or regulatory frameworks. A thorough appraisal of these limitations and the development of context-specific strategies to address them are urgently needed. All-cause and cardiac mortality and enhances functional capacity and quality of life, yet uptake remains poor-about 30-40 % of eligible patients in high-income nations and < 10 % in Korea attend. To clarify this evidence-to-practice gap, we reviewed English and Korean literature (2010-2024) on barriers to CR engagement and synthesised findings using the 2024 revised Cardiac Rehabilitation Barriers Scale (CRBS-R). Patient-level impediments include female sex, older age, low socioeconomic status, travel times exceeding 60 minutes, multimorbidity (e.g., diabetes, chronic kidney disease) and heart-failure diagnosis-all consistently associated with lower referral and enrolment. Provider and hospital barriers comprise limited physician awareness or endorsement, cumbersome referral workflows and restricted programme capacity; high start-up costs, space constraints and staffing shortages confine CR services to tertiary centres, exacerbating rural inequities. Policy barriers involve inadequate insurance coverage, residual out-of-pocket expenses despite reimbursement, and the absence of distinct fees for remote or hybrid CR, even though meta-analyses confirm such models are cost-effective and clinically non-inferior. These patient, institutional and systemic factors interact to suppress CR uptake; recognising their interplay is essential for designing multifaceted, context-specific strategies that can expand equitable access and optimise cardiovascular secondary prevention.