Sex Differences in Cardiac Rehabilitation Access and Utilization: A Systematic Review of Barriers and Facilitators in Cardiovascular Care

Cardiac rehabilitation (CR) is central to secondary prevention, but women remain less likely than men to access and fully utilize CR. This systematic review examined sex differences across the CR utilization continuum, separating referral, enrollment, attendance or session exposure, and program completion, and evaluated barriers and facilitators at each stage. PubMed was searched for studies published from January 1, 2000 through March 2025 reporting sex-specific CR utilization outcomes. Supplementary citation searching was undertaken to improve completeness. Outcomes were classified as referral, enrollment, attendance or session exposure, and completion or dropout. Forty-six unique study cohorts, including over one million patients, met the inclusion criteria. Women were most consistently disadvantaged at referral and initial access. In several cohorts, sex differences narrowed after referral or after adjustment for clinical, psychosocial, and structural factors. A large multicentre referral-strategy cohort reported lower overall referral (57.8% vs. 67.2%) and enrollment (49.3% vs. 58.6%) in women than men, but among referred patients, subsequent enrollment was similar (82% vs. 85%). Across studies, transport, caregiving, comorbidity, financial constraints, and lower CR awareness disproportionately affected women, while work and time conflicts were more prominent among men. The largest completion analysis (n = 5922) found that sex was not an independent predictor of withdrawal after adjustment (OR 0.89, 95% CI 0.76-1.05). Automatic or systematic referral, liaison-supported referral, geographic matching to nearer programs, flexible delivery models, and targeted navigation were identified as facilitators of access and utilization. Sex disparities in CR are stage-specific rather than a single "adherence" phenomenon. The strongest and most consistent gap occurs at referral and initial access, while differences may narrow once patients are referred or when systematic referral pathways are used. Equity-focused CR services should combine system-level referral strategies with interventions addressing transport, caregiving, comorbidity, financial, and program-fit barriers.