Cardiac rehab (CR) remains one of the most underutilized interventions in cardiovascular medicine despite overwhelming evidence that it saves lives, improves quality of life and is cost effective. While ACC/AHA performance measures and numerous clinical practice guidelines consistently recommend cardiac rehab as a Class I indication for patients following acute coronary syndromes, cardiac procedures and heart failure (HF) diagnoses, referral rates fail to reach even 25% among Medicare beneficiaries.¹ This gap represents a significant missed opportunity to improve patient outcomes and reduce health care costs.

Modern CR programs employ a multidisciplinary approach that addresses the complex interplay of factors contributing to cardiovascular risk, creating synergistic effects that exceed the sum of individual components. Importantly, they should be tailored to each patient's needs.

"Good cardiac rehab today is individualized to the patient. This means that you do something different for the 80-year-old woman who just had her chest cracked, who's frail and has a bad hip and needs to optimize her recovery, compared to the 35-year-old spontaneous coronary artery dissection patient who was running a few weeks ago and now needs some help to regain confidence in her body," says Sharonne N. Hayes, MD, FACC, a cardiologist from the Mayo Clinic in Rochester, MN and the founder of their Women's Heart Clinic. "But if the patients aren't referred, they get none of that."

Why do we consistently fall short in connecting our patients to this lifesaving intervention? And how can we bridge this implementation gap to ensure our patients receive the comprehensive care they deserve?

The Evidence Base: Beyond Question

The research supporting the benefits of exercise-based CR is well established. A contemporary update of the evidence base in 2023 by Dibben, et al., included 85 randomized controlled trials involving 23,430 participants with a median 12-month follow-up in a meta-analysis.² They showed that, overall, exercise-based CR was associated with a significant 26% risk reduction in cardiovascular mortality (number needed to treat [NNT], 37), a 23% risk reduction in hospitalizations (NNT, 37) and an 18% risk reduction in myocardial infarction (MI) (NNT, 100).

There was also some evidence that CR improved health-related quality of life and was cost-effective. No significant difference in treatment effects was found across different patient groups, CR delivery models, doses, follow-up, or risk of bias.

"Some cardiologists still think of rehab as something needed to get patients back on their feet and moving after the procedural burden of CABG, but not as something truly fundamental to treating coronary artery disease, especially compared to a stent, antiplatelets and a statin," opines Daniel E. Forman, MD, FACC, a geriatrician-cardiologist at the University of Pittsburgh Medical Center and VA Pittsburgh Healthcare System. Forman, who has directed CR programs for two decades in Pittsburgh and Boston, notes that referral rates are worse after PCI than cardiac surgery.

This perception represents a fundamental underestimation of contemporary CR's scope and purpose. "I would argue the rationale for cardiac rehab is greater than ever, even if a preceding cardiovascular procedure or event is not debilitating, says Forman.

"We're not just having them walk on a treadmill and reviewing their medications – it's more about opportunities to address cardiometabolic issues, risk factor management and nutritional counseling. It's also addressing the emotional impact of having heart disease, and it's maintaining strength," he notes.

Emphasizing this point, a recently published randomized trial showed a relative risk reduction of 43% for the composite of cardiovascular death or unplanned hospitalization for cardiovascular causes within one year with multidomain CR compared to usual care in elderly patients (median age, 80 years) with MI and impaired physical performance (12.6% vs. 20.6%; hazard ratio [HR], 0.57; p=0.01).³

Patients in the control group received a single in-person visit at one month after hospital discharge, which included a 30-minute counseling session that was supported by educational materials.

"If you want to provide holistic and effective care, you can't not think of cardiac rehab, because the acute care setting simply does not give you the time to do even half of what's needed," says Forman.

This comprehensive approach is illustrated in the 2024 AHA/AACVPR core components framework for CR programs (Table).⁴ Standard programs involve 12 weeks of sessions, with most insurance plans covering 36 sessions over this period. Importantly, the model emphasizes how modern CR can be delivered through center-based, virtual or remote methods – or hybrid combinations of these approaches.

Forman suspects that GLP-1 receptor inhibitors may ironically be exacerbating this issue. "Recently, many studies are demonstrating the utility of GLP-1s to reduce cardiac disease. So, many clinicians assume that adding GLP-1s to the regimens of overweight cardiac patients is mostly what's needed."

"However, if GLP-1s are not paired with CR, I fear we may see an epidemic of muscle loss [and associated frailty] down the line. We know that muscle is crucial for healthy aging and that GLP-1s without exercise can worsen muscle loss," says Forman, who was the inaugural chair of ACC's Geriatric Cardiology Section.

The evolution toward comprehensive and individualized care is particularly relevant as patient demographics shift. "Early on, cardiac rehab primarily served middle-aged White men. Now, we are more aware of social disparities in care and are reaching a broader patient spectrum," notes Forman. "Cardiac rehab is a multicomponent approach that can help us bridge the gaps in care that we see in some groups because it focuses on a broader perspective of management, truly treating the patient holistically."

Breaking Down Referral Barriers

Multiple systemic barriers contribute to suboptimal CR utilization, including inadequate program capacity, geographic accessibility challenges and insufficient insurance coverage. Yet, the problem often begins with physician assumptions about patient suitability.

"If it's extra work, if it's not in the process or if the clinicians don't understand the benefits of rehab, it very often simply doesn't happen," notes Hayes. She regularly sees patients who were treated elsewhere and hears either that they weren't referred to CR at all after their event or they were told CR wasn't necessary and they should "just do your own thing," she says.

"The most successful programs," Hayes says, are those that implement automated referral protocols, integrated into electronic health records, which eliminate provider-dependent decision-making and eliminate both neglect and bias. Some institutions have implemented "opt-out" rather than "opt-in" models, which can also dramatically improve referral rates.

Financial disincentives compound the challenges of clinician and patient inertia. Unlike procedural interventions, CR generates minimal direct physician revenue, creating perverse incentives that prioritize acute interventions over long-term outcomes. "There's no cardiologist billing for someone to come to cardiac rehab. It's a hospital-based program, so it doesn't really generate as much physician engagement as it might in that respect," Forman explains.

A systematic review that included 19 studies showed that CR was cost-effective compared to no CR, with incremental cost-effectiveness ratios ranging from $1,065 to $71,755 per quality-adjusted life-year.⁵

For Forman, HF represents a particularly poignant missed opportunity. "It's ironic to me that referral rates for HF are so low," Forman observes. "There are impediments and comorbidity and complexities of care that have been well described, but HF is a disease that really responds to cardiac rehab."

Historically, patients with HF were assumed to be at risk to exercise and were commonly discouraged from participating in physical activity.⁶ Yet, despite evidence of outcome benefits and safety, as well as cost-effectiveness and strong practice guideline recommendations, patients still aren't referred, particularly older patients and women. "Being sedentary because you're fearful of exercising is really the kiss of death spiral down," Forman warns.

Age and impairment also should not be reasons for not referring a patient to CR, he adds. In a just-published Italian trial, 512 elderly patients (median age, 80 years) with impaired physical performance one month after an MI were randomized to either a multidomain rehab intervention (cardiovascular risk factor control, dietary counseling and exercise training) or usual care in a 2:1 ratio.³

The intervention group had significantly fewer primary composite events of cardiovascular death or unplanned cardiovascular hospitalization at one year compared to usual care (12.6% vs. 20.6%; HR, 0.57; p=0.01), driven primarily by reduced hospitalizations (9.1% vs. 17.6%).

"We have data to show that the sicker the patient, the more they benefit from rehab, so not referring because it seems too little or too late is incorrect," says Hayes.

Of course, it's not all on clinicians. Patient-level obstacles are equally significant. Transportation difficulties, work schedule conflicts, costs and family caregiving responsibilities create practical barriers to participation. Cultural factors, including stigma around exercise programs and misconceptions about the purpose of CR, further limit engagement.

Post-discharge support systems have proven crucial for improving participation rates. There have been several studies that have shown that simply having a nurse call within a few days of discharge to ask about medications, symptoms and rehab plans can have a significant impact on completion rates, explains Hayes. This simple intervention addresses the gap between hospital discharge and program enrollment when patients often feel overwhelmed by competing priorities.

Expanding the Paradigm

Innovative delivery models are addressing traditional barriers to participation. Several trials have looked at the effectiveness and feasibility of home-based CR as an alternative to traditional center-based programs.

In the single-center EXIT-HF noninferiority trial, 120 patients were randomly assigned to either standard CR (24 supervised sessions) or home-based CR (four supervised sessions plus 20 home sessions monitored via smartwatch and telephone).⁷ Home-based CR was noninferior to center-based CR, with no significant differences in peak oxygen uptake improvement (primary endpoint), 6-minute walk distance, quality of life scores or exercise adherence at 12 weeks.

Another study (iATTEND) randomized 282 patients to hybrid CR (combining one to 12 in-facility sessions with virtual sessions via audiovisual technology) vs. traditional CR.⁸ Hybrid delivery did not improve attendance or completion rates, nor did it significantly improve exercise capacity or health status, but the study demonstrated that hybrid CR with virtually supervised exercise is a safe and acceptable alternative to traditional facility-based programs.

Hayes thinks the future of CR lies in creating flexible, individualized programs that meet patients where they are. "I think we're going to see an explosion in remote cardiac rehab, although we still need more data showing it has the same outcomes or at least some good outcomes."

Either way, the evidence supporting CR is unequivocal, she adds. "I talk about it as lifesaving. The data absolutely supports rehab, and the referral and completion rates are poor, so we must do better than this for our patients."

References

1. Ritchey MD, Maresh S, McNeely J, et al. Tracking cardiac rehabilitation participation and completion among medicare beneficiaries to inform the efforts of a national initiative. Circ Cardiovasc Qual Outcomes 2020;13:e005902.
2. Dibben GO, Faulkner J, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease: a meta-analysis. Eur Heart J 2023;44:452-69.
3. Tonet E, Raisi A, Zagnoni S, et al. Multidomain rehabilitation for older patients with myocardial infarction. N Engl J Med 2025;393:973-82.
4. Brown TM, Pack QR, Aberegg E, et al. Core components of cardiac rehabilitation programs: 2024 update: A Scientific Statement from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2024;150:e328-e347.
5. Shields GE, Wells A, Doherty P, et al. Cost-effectiveness of cardiac rehabilitation: a systematic review. Heart 2018;104:1403-10.
6. Bozkurt B, Fonarow GC, Goldberg LR, et al. Cardiac rehabilitation for patients with heart failure. JACC 2021;77:1454-69.
7. Schmidt C, Magalhães S, Gois Basilio P, et al. Center- vs home-based cardiac rehabilitation in patients with heart failure. JACC Heart Fail 2025;13:695-706.
8. Keteyian SJ, Grimshaw C, Ehrman JK, et al. The iATTEND Trial: a trial comparing hybrid versus standard cardiac rehabilitation. Am J Cardiol 2024;221:94-101.

Clinical Topics: Cardiovascular Care Team

Keywords: Cardiology Magazine, ACC Publications, Health Care Costs, Quality of Life, Cardiac Rehabilitation, Medicare