PR O GRE S S I N C ARDI O VAS CU L AR D I S EAS E S 5 7 ( 2 0 14 ) 26 8–2 75

Available online at www.sciencedirect.com

ScienceDirect
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Cardiac Rehabilitation in Latin America

Claudia Victoria Anchique Santosa,⁎, Francisco Lopez-Jimenezb , Briseida Benaimc ,

Gerard Burdiatd , Rosalia Fernandez Coronadoe , Graciela Gonzalezf , Arthur Herdyg ,
Jose Medina-Inojosab , Claudio Santibañezh , Juan E. Uriona Villarroeli , Cecilia Zeballosi, j
a
Division of Cardiovascular Diseases, Cardiac Rehabilitation, Mediagnóstica Duitama, Colombia
b
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
c
Division of Cardiovascular Diseases, Cardiac Rehabilitation and Secondary Prevention (ASCARDIO),Venezuela
d
Department of Cardiology, Spanish Association's Quality of Life Center, Montevideo, Uruguay
e
Cardiac Rehabilitation Unit, National Cardiovascular Institute “Carlos Alberto Pashchiera”, Lima, Peru
f
Cardiovascular Prevention and Rehabilitation program, Central Hospital Institute of Social Welfare, Asuncion, Paraguay
g
Institute of Cardiology of Santa Catarina, Universidad e do Sulde Santa Catarina, Brazil
h
Prevention department, Chilean Society of Cardiology, Austral University of Chile, Chile
i
Cardiac Rehabilitation Service, Boliviano Belga Surgical Medical Center, Cochabamba, Boliviano, Bolivia
j
Cardiac Rehabilitation Service, Cardiovascular Institute of Buenos Aires, Argentinian Institute of Diagnostic and Treatment, Argentina

A R T I C LE I N FO AB S T R A C T

Keywords: This article provides a description of the status of cardiovascular (CV) rehabilitation (CVR)
Cardiac rehabilitation in Latin America (LA) and the potential impact on CV disease in the region. We discuss
Latin America the insufficient number of CVR programs in the region and describe the components of CVR
South America that are more commonly available, like exercise interventions, medical assessment and
Cardiovascular diseases patient education. Additionally, we discuss the heterogeneity in other components,
Prevention like the evaluation of depression, sleep apnea, and smoking cessation programs. Lastly,
we provide a brief review on the main characteristics of the health systems of each country
regarding access to CVR programs and compare the average cost of CV procedures and
treatments with CVR.
© 2014 Elsevier Inc. All rights reserved.

Cardiovascular disease (CVD) is the leading cause of morbidity
and mortality worldwide. According to the World Health
Organization (WHO) approximately one third of annual deaths
in the world are due to CVD.1–3 In Latin America (LA), mortality
secondary to CVD is 30%, resulting in 11 million deaths in 2010,
23% of whom represented people younger than 60 years of
age.2,4 The impact of CVD in LA is clear with an alarming
increase in morbidity and mortality and the disturbing effects
of secondary disability, decreased quality of life, and elevated
health and social costs.
The CV field has shown spectacular advances in the last
several decades. From being historically a clinical field with

Statement of Conflict of Interest: see page 273.

⁎ Address reprint requests to Claudia Victoria Anchique Santos, M.D., Division of Cardiovascular Diseases and Cardiovascular
Rehabilitation, Mediagnostica, Carrera #16 14-68, Duitama, Colombia.
E-mail addresses: claudia.anchiquesantos@gmail.com (C.V. Anchique Santos), lopez@mayo.edu (F. Lopez-Jimenez),
benaimbriseida@gmail.com (B. Benaim), gburdiat@mednet.org.uy (G. Burdiat), rosafernco@hotmail.com (R. Fernandez Coronado),
cardiograciela@yahoo.com.ar (G. Gonzalez), arherdy@cardiosport.com.br (A. Herdy), medinainojosa.jose@mayo.edu (J. Medina-Inojosa),
csanti4@yahoo.com (C. Santibañez), urionajuan@gmail.com (J.E. Uriona Villarroel), ceciliazeballos@hotmail.com (C. Zeballos).

http://dx.doi.org/10.1016/j.pcad.2014.09.006
0033-0620/© 2014 Elsevier Inc. All rights reserved.
 PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S 5 7 (2 0 1 4) 26 8–2 7 5 269

Abbreviations and Acronyms few diagnostic tools,

it has evolved to the
AACVPR = American Association present day with so- Cardiac Rehabilitation in Latin America
of Cardiovascular and
phisticated diagnostic
Pulmonary Rehabilitation
tests, drugs and Despite evidence supporting CVR as an effective intervention
CV = cardiovascular invasive treatment to reduce CVD events and mortality, the establishment of
methods available. In CVR programs in LA has been slow, with very few programs
CVD = cardiovascular disease
contrast to this, the available, not matching the needs of the region. The models
CVR = cardiovascular progress achieved re- and structure of health systems in LA are complex and quite
rehabilitation garding preventative heterogeneous, making comparison extremely challenging.
measures has been less Table 1 lists some general characteristics of healthcare
IASC = Inter-American Society
impressive, considering systems in LA and whether CVR is covered by the national
of Cardiology
that the main risk fac- universal healthcare system. In all countries of LA, healthcare
ICCPR = International Council in tors for CVD disability systems generally include two distinct models: the public
Cardiovascular Prevention are preventable and and the private. Public systems, generally represented by a
and Rehabilitation modifiable and that national universal healthcare program, offer 100% coverage
LA = Latin America shifting management for CVR in some countries as is the case of Bolivia, Venezuela,
or Latin American towards a healthy life- Peru and Argentina, meaning that patients who qualify for CVR
style has proven to be have full coverage for CVR services when available. In other
PAHO = Pan American of greatest impact on countries, coverage for CVR in the public system is only partial,
Health Organization
reducing morbidity and where the patient pays out of pocket a percentage of the total
SA = South America mortality.5 Because of cost and the public healthcare insurance pays for the rest.
this, CV rehabilitation CVR coverage by private insurance companies is also
SSCARDIO = South American
(CVR) is a key preventa- variable in LA. In some countries private insurance companies
Society of Cardiology
tive strategy in CV med- provide full coverage while in others coverage is partial and the
UN = United Nations icine, with supporting cost of CVR services is shared between the patient and the
evidence of benefit in insurance company. Unfortunately, many and perhaps the
WHO = World Health
terms of reduced adverse majority of private insurance companies offer no coverage for
Organization
outcomes and being CVR in LA.22,23 It is noteworthy that in some countries like
cost-effective.6–8 Some Uruguay, there is only partial coverage for CVR regardless of
reports have shown that CVR can reduce CVD mortality by 20% or whether the insurance is private or if covered by the universal
even 40%, and achieve a 30% reduction in re-hospitalization (public) healthcare program. The irony is that coverage for
and re-infarction 9–12 after myocardial infarction. Preventa- any costly diagnostic or invasive cardiac procedure such as
tive strategies stem from current knowledge of the evolution open-heart surgery, coronary angiography, pacemaker implan-
of CVD from its molecular and cellular level when the athero- tation or implantation of a defibrillator is covered at 100%,
sclerotic process begins at an early age, until when clinical regardless of the health system to which the patient belongs.
manifestations become evident, usually in more advanced stages If coverage for CVR services is a major problem, access to
of the disease.6–10 CVR represents another major barrier for the universal
This knowledge has helped build the foundation of implementation of CVR in the region, given the small number
what is known as CVR, which is an integrated concept of of CVR programs available in LA. South America (SA) has an
comprehensive care that focuses on several key aspects like estimated population of 393 million,23 and only about 172 CVR
intervention and risk modification, management of risk programs, equivalent to one CVR program for every 2,285,768
factors including psychological support, promotion of (Table 2).24 For example, in 2009, the availability of CVR
healthy lifestyles, gender-specific issues, interventions ad- programs per inhabitants, a concept we have coined as CVR
justed for socio-economic status, and evaluation of inter- programs' density, is highly variable in LA. Mexico registered
ventions (Fig 1). Moreover, CVR programs must include a 17 CVR programs for a population of 106.6 million25 while
competent, multidisciplinary group of professionals who Costa Rica registered 1 CVR program for a population of
implements the program, monitors progress and obtains 4,451,205.26 Because each CVR program sees an average of 180
feedback of all necessary activities and strategies. It is a new patients each year, it is obvious that the number of CVR
process with short, medium and long-term goals that are programs is insufficient for the current needs of the region.
quantifiable, measurable, and susceptible to improvement, Another limitation for the use of CVR services is their
always with the end goal of rehabilitating the individual to geographic distribution within each country and whether the
his/her pre-events functional level. 13–19 In addition, CVR CVR program is public versus private. Examples of challenges
follows the objectives and strategies set by United Nations, to access to CVR despite being covered by the public
the World Health Organization and the Pan-American healthcare system are Argentina and Venezuela. Data from
Health Organization, aiming to reduce premature CVD 2010 indicate that only one out of 28 centers in Argentina and
mortality by 25% by the year 2025 and to increase health only six centers in Venezuela belong to the public sector
promotion, CVD prevention, and achieve an integrated responsible for providing CVR services to the entire population
control of chronic diseases. 20,21 covered.27,28 Chile has one of the lowest CVR referral rates (5%),
270 PR O GRE S S I N C ARDI O VAS CU L AR D I S EAS E S 5 7 ( 2 0 14 ) 26 8–2 75
Fig 1 – Comprehensive model of care of cardiac rehabilitation.
with 9 centers through the country, mostly located in large
urban areas.29 Paraguay reported a single CVR program in 2010
and had the lowest density of CVR center per inhabitants.24,30
Similarly, Bolivia has 9 CVR centers concentrated in 3 areas,
while in Peru all registered centers in 2010 were located in the
capital city of Lima, of which 3 were eventually closed down due
to insufficient funds and low patient referral.30 Brazil, the
largest and most populated country in LA, provides partial
coverage by both the public and private healthcare systems.
Brazil also has significant difficulties to provide access to CVR to
those who need it, not only because of its size but also because
of the distribution of CVR centers. The highest concentration
of CVR centers is located in the south and southeast areas of
the country, regions with the highest economic development,
compared with the poorer north and northeastern areas of the
country where CVR centers are barely available.31,32 The
different barriers to get CVR have been described in several
publications, showing that, in addition to poor physician
referral patterns, factors like distances to the CVR centers,
limited financial support, and poorly trained personnel, also
affect access to appropriate CVR.32–35 Restrictions in the referral
process probably impact the availability of CVR in LA. In most
countries of LA, the physician referring the patient to CVR needs
to be a specialist (cardiologist, interventional cardiologist, cardio-
vascular surgeon, physiatrist, sports medicine physician), while
the general practitioner or any other specialist cannot refer
patients to CVR programs.
Many physicians and healthcare systems in LA consider
CVR as “workout sessions”, not as a comprehensive program,
but it is highly likely that it is the comprehensive approach
that provides a meaningful medical intervention with the
potential to improve quality of life and health. However,
to date no LA country has a specific guideline in terms of
the necessary components to call CVR “complete”, nor are
there institutions regulating, monitoring or certifying CVR
programs and their quality of care. The Latin American
Cardiovascular Rehabilitation and Secondary Prevention
Working Group has recently published a document called
Consensus for CVR and Prevention for Latin America.36 This
document and the Brazilian Cardiac and Pulmonary Rehabil-
itation Society Consensus are the only documents describing
the components, competencies and expectations for CVR
programs. Thus, not all components of CVR are the same
among all centers, something expected given the heteroge-
neity of healthcare systems. However, some aspects of CVR
are commonly available like prescribing and performing
 PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S 5 7 (2 0 1 4) 26 8–2 7 5 271

Table 1 – Coverage of CVR services by country in south america.

Is CVR Covered
by the Public
Healthcare
System?

COUNTRY Yes No Coverage of CVR

Venezuela X The entire population is covered by the public healthcare system
that assumes100% of the cost of CVR in public hospitals where the
service exists (6 hospitals); the rest should attend private institutions
or non-profit associations. The patient would then rely on private
insurance or absorb the cost of CVR.
Colombia X The public healthcare system covers 96% of the population.
The CVR is included within the benefits of this mandatory healthcare plan.
In some cases the coverage is 100% of the cost, and in others the patient must
pay a percentage of the cost. Some private insurance policies have partial coverage
for CVR and others are not covered.
Peru X 60% of the population is covered by the public healthcare system and it covers
100% of the cost of CVR. 10% of the population has private
insurance where the patient pays a deductible.
Bolivia X The public healthcare system covers 40% of the population and it pays 100% of CVR cost.
The private sector insures 10% of the population and provides no coverage for CVR.
The rest of the population (50%) does not have any type of health coverage.
Chile X The public healthcare system covers 70% of the population and the private 30%.
There is no concept of CVR but rather homologates physical therapy (kinesiology).
Public and private sector cover between 25 and 50% of the cost
and the rest is covered by the patient.
Uruguay X The medical care coverage includes prepaid medical assistance systems (majority),
free medical assistance (public health) and medical insurance (minority).
CVR is partially covered by the public system (37% of the population) and
is not covered by prepayment private insurance or system and policies.
Brasil X 75% of the population is covered by the public sector and has
full CVR coverage in public hospitals.
The remaining 25% is covered by the private sector with very limited coverage for CVR.
Paraguay X 16% of the population is covered by public health insurance,
which covers all costs of CVR while private insurance provides partial coverage.
Argentina X The population coverage varies, with three sectors: public, private and binding.
The public sector covers 35% of the population and covers all the cost of CVR,
while the other two sectors can cover the CVR totally or partially depending on each case.

*Coverage: proportion of the population with health needs and that receives specific intervention.

supervised exercises, monitoring, control and follow up of an
exercise plan, medical evaluations, risk factor education, as
well as monitoring of blood glucose and lipids.24,25,26,29,37–39
Other program components convey significant heterogeneity
like smoking cessation interventions and risk assessment
for depression and sleep apnea, which are all evaluations of
risk factors affecting the prognosis and treatment of several
cardiovascular conditions.30,37–39 Exercise stress test with
oxygen consumption assessment and specific CV health
programs aimed at women are performed by less than 20% of
centers. Moreover, tests like Apo lipoprotein B and screening for
coronary calcification by computer tomography are performed
in a handful of CVR programs in the region.24 Only a minority
of CVR centers in LA offer all phases; however, 90% of the
programs offer phases II and III, while 57% offer phase IV and
less than 50% offer the inpatient phase I.24
Cardiac procedures and treatments in LA countries
have variable costs and are generally expensive as they
include the use of pricey technology. For example, a cardiac
catheterization with coronary angioplasty and stent place-
ment costs about $3000 with an additional cost of $1000 for
each stent implanted. For an implantable defibrillator or heart
transplant, the costs would be around $40,000 to $60,000. In
contrast, the cost of CVR sessions varies around $5 to $30 per
session. This means that with the money spent in one of the
common cardiac procedures, dozens or hundreds of patients
in any LA country could get a full CVR program paid. Table 3
describes this comparative assessment in more detail.
Actions and Progress
There is a significant opportunity to improve and strengthen
CVR programs in LA. In 2010 the South American Society
of Cardiology (SSCARDIO), the Inter-American Society of
Cardiology (IASC), the Venezuelan Society of Cardiology, the
Asociacion Cardiovascular Centroccidental (ASCARDIO), and
272 PR O GRE S S I N C ARDI O VAS CU L AR D I S EAS E S 5 7 ( 2 0 14 ) 26 8–2 75

Table 2 – Density of cardiovascular rehabilitation programs in latin america per inhabitants.

Mayo Clinic designed an action plan to train leaders in the the Latin American Working Group in CVR and prevention,
field of CVR in LA to promote international collaborative the publication of the consensus as CVR36 and other publica-
work. The results of this effort include the creation of tions promoting education and research in CVR Fig 2.

Table 3 – Approximate costs in US dollars for common cardiac procedures and cost of CVR sessions in south america.
Cost of One CVR Cost of One CVR
Session Covered Session When Coronary Permanent Implantable
by the Public Paid Out Cardiac Angioplasty Artery Bypass Pacemaker Cardiac
Healthcare System of Pocket Catheterization and Stent Graft Surgery Implantation Defibrillator

Country USD USD USD USD USD USD USD

Venezuela 4 6 2500 12,000 23,000 3300 48,000

Colombia 10 22 500 3400 23,000 4500 42,000
Peru 9 12 42,000 4800 2800 38,000
Bolivia 6 7 1400 3600 13,500 1500 55,000
Chile 25 20 1000 4000 20,000–60,000 2000–3000 50,000
Uruguay 5 11 1500 3500 5000 1500 5000
Brasil 10 30 500 1500 10,000-20,000 3000–5000 20,000
Paraguay 25 17 1000 2500 15,000 4000 35,000
Argentina 7 8 700 3900 11,000 1500 40,000
 PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S 5 7 (2 0 1 4) 26 8–2 7 5
Fig 2 – Action plan and progress of the Latin American Cardiovascular Rehabilitation and Secondary Prevention Working Group.
Current Challenges
Current challenges to improve CVR in LA include the following:
• Promoting knowledge and sharing the scientific evidence
of the benefits of CVR to improve referral rates.
• Promoting collaborative research in the region to identify
and solve problems specific to the execution of CVR in LA.
• Achieving standardization of CVR services, identifying
the core components with the highest benefit per dollar
but also promoting the use of comprehensive CVR strate-
gies, if possible.
• Increasing coverage of CVR services for patients who need
it the most by lobbying leaders in the healthcare systems,
policy members, and insurance companies.
Conclusions
CVR is a cost effective strategy in secondary prevention
of CVD proposed by the United Nations, the WHO, and the
Pan-American Health Organization (PAHO). However, CVR
remains underutilized not only because of the low patient
referral, which is as low as 10% of those who need it, but also
273
because of the scarcity of existing programs. The urgency
to improve the current situation of CVR in LA is based on the
current and growing local needs, backed by the scientific
evidence showing the cost-saving nature of CVR. Those
changes, however, will need to be individualized country by
country. Strengthening of CVR requires the participation and
coordination of professionals in the healthcare sector and
policymakers in each country. More and better CVR programs
are needed to expand the access, and improvements in the
coverage of CVR services on the other hand will lead to
increased demand and to the creation of more CVR centers.
This will certainly lead to better CV health in the LA region.
Acknowledgments
Francisco Lopez-Jimenez is supported by the European Regional
Development Fund—Project FNUSA-ICRC (No. Z.1.05/1.1.00/
02.0123).
Statement of Conflict of Interest
All authors declare that there are no conflicts of interest.
274 PR O GRE S S I N C ARDI O VAS CU L AR D I S EAS E S 5 7 ( 2 0 14 ) 26 8–2 75
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