Barriers to participation in cardiac rehabilitation

This editorial refers to ‘Socio-geographical factors associated with cardiac rehabilitation participation after percutaneous coronary intervention: a registry-based cohort study from France’, by F. Quattrone et al., https://doi.org/10.1093/eurjpc/zwaf087. Cardiac rehabilitation (CR) is a comprehensive, multidisciplinary intervention grounded in evidence-based practice, designed to improve cardiovascular outcomes, attenuate disease progression, and enhance patients’ quality of life. Core components include structured exercise training, nutritional counselling, psychological support, and education in self-management.1 While exercise therapy remains central to CR, patients with comorbidities—such as stroke—benefit significantly from integrated, cross-disciplinary rehabilitation approaches. Nutritional guidance plays a pivotal role in the early detection and management of frailty and sarcopenia, particularly in patients with advanced heart failure. Multimodal nutritional assessments and individualized interventions are essential in these populations. Psychological support and educational initiatives further promote patient self-efficacy and long-term adherence to healthy behaviours.1 Cardiac rehabilitation is typically delivered across three sequential phases: acute, recovery, and chronic.1 Early initiation—ideally beginning during the acute hospitalization phase—is critical, even in high-risk conditions such as severe aortic stenosis, where low-intensity resistance training has demonstrated safety and efficacy.2–4 A seamless transition from inpatient to outpatient care is necessary to ensure continuity and maximize benefit. Despite advances in pharmacotherapy for acute myocardial infarction and heart failure, a substantial proportion of patients continue to experience impaired cardiac function post-discharge. Coupled with a rapidly ageing population, this has contributed to what is often referred to as a ‘heart failure pandemic’, underscoring the importance of robust post-acute care systems. Cardiac rehabilitation has proven effective in reducing hospital readmissions and improving quality of life.5–7 In older adults, structured exercise and tailored nutritional interventions are indispensable in addressing frailty and sarcopenia. Comprehensive disease management programmes that include risk factor modification, medication adherence, and psychosocial support have shown improvements in both physical function and psychological well-being.1 Developed countries face unique challenges due to its rapidly ageing population and increasing prevalence of multimorbidity, including chronic kidney disease, atrial fibrillation, and dementia. Compounding these issues is the limitation of CR insurance coverage—posing a significant barrier to long-term rehabilitation, particularly for homebound patients.1 Meta-analyses support the efficacy of home-based CR in reducing hospital readmissions in elderly heart failure patients, and its relevance is expected to increase.8 Multiple barriers impede the widespread implementation of CR. These include low patient motivation, environmental limitations, dietary habits that conflict with nutritional guidance, inadequate healthcare infrastructure in some regions, and disparities in health literacy.1 In the current issue of European Journal of Preventive Cardiology, Quattrone et al.9 have reported that geographic and socio-economic disparities remain prominent; distance from CR centres and lower income correlate with reduced participation. In France, only 33% of patients with acute coronary syndrome and 15% with chronic coronary syndrome participated in CR, with particularly low rates observed in rural and socio-economically disadvantaged areas. Similarly, Canadian data reveal sex-based disparities in enrolment—particularly among women—as well as limited data on quality indicators.10 In the USA, inadequate broadband access in rural and low-income regions presents a major obstacle to implementing telehealth-based CR models.11 Despite these challenges, telemedicine and remote CR (tele-CR) are emerging as viable alternatives for patients unable to attend centre-based programmes.11 Telemedicine and remote CR have demonstrated cost-effectiveness and practical utility, particularly for elderly or mobility-limited patients. However, accurate assessment of exercise intensity and validation of remote programmes remain necessary. Insurance coverage is a critical step towards broader adoption, with potential cost savings for healthcare systems. In Japan, efforts are underway to integrate tele-CR into clinical practice and achieve reimbursement, though the development of robust safety protocols and exercise monitoring systems remains a priority. Telemedicine and remote may also hold promise for patients with implantable ventricular assist devices, especially in home-care settings.1 Globally, CR remains underutilized. In Turkey, for instance, educational interventions increased participation from 0 to 29.4%, with transportation and scheduling issues identified as major barriers.12 Standardized referral systems, including automated referrals and integration of telehealth platforms, may enhance uptake. Policy initiatives should focus on reducing inequities in access by addressing geographic and socio-economic determinants. The future of CR lies in its integration with emerging technologies. Robotic-assisted rehabilitation, digital platforms, and information and communication technologies have the potential to enhance personalization, accessibility, and adherence (Figure 1). As the complexity of cardiovascular care continues to increase, there is an urgent need to establish adaptive, patient-centred CR systems capable of addressing the diverse needs of contemporary populations. Community-based cardiac rehabilitation supported by integrated care and advanced technologies. The goal of community-based rehabilitation in the chronic phase is to enable patients and their families to live safely, vibrantly, and in a manner true to themselves within their familiar environments throughout life. Achieving this requires collaboration across all sectors involved in daily living—including public health, medical care, welfare, long-term care services, and local residents. A seamless continuum of rehabilitation across the acute, recovery, and chronic phases must be provided to prevent physical and psychological decline, social isolation, and institutionalization among patients, older adults, and their caregivers. To support this objective, administrative bodies, regional rehabilitation support institutions, and community volunteers must work in close coordination to establish a comprehensive support network. The model illustrated incorporates advanced technologies as needed, such as robotic-assisted therapy and remote monitoring systems, with participation from specialized medical institutions in chronic phase cardiac rehabilitation. AI, artificial intelligence; ECG, electrocardiography, SpO₂, peripheral oxygen saturation. None declared. No new data were generated or analysed in this editorial.