European Journal of Preventive Cardiology (2023) 30, 758–768 FULL RESEARCH PAPER

https://doi.org/10.1093/eurjpc/zwad024 Cardiac rehabilitation

Overview of Cardiac Rehabilitation following

post-acute myocardial infarction in European
Society of Cardiology member countries
1 2 1
Jorge Ruivo *, Trine Moholdt , and Ana Abreu

Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023

1
Cardiovascular Exercise & Rehabilitation, Centro Cardiovascular da Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028 Lisbon, Portugal; and 2Department of Circulation and Medical
Imaging, Faculty of Medicine and Health Sciences, Norwegian Institute of Science and Technology (NTNU), Trondheim, Norway

Received 7 November 2022; revised 20 January 2023; accepted 26 January 2023; online publish-ahead-of-print 1 February 2023

See the editorial comment for this article ‘To believe or not to believe in cardiac rehabilitation? Answer for success’, by F. I. Gambarin
et al., https://doi.org/10.1093/eurjpc/zwad061.

Aims Cardiovascular disease (CVD) is still a leading cause of death and morbidity in Europe and must be addressed through ap­
proaches beyond therapeutic interventions and pharmacological management. Cardiac rehabilitation (CR) is a comprehen­
sive, individualized, and patient-tailored programme, comprising multidisciplinary interventions. Despite its clinical benefits,
cost-effectiveness, and existing guidelines, CR uptake in Europe remains suboptimal and detailed information on its current
state is lacking. This centralized pan-European study (Overview of Cardiac Rehabilitation—OCRE) aimed to characterize
and advance the knowledge about European Society of Cardiology (ESC) affiliated national CR settings.
............................................................................................................................................................................................
Methods An online survey about provision and quality indicators from CR was sent to the network of National CVD Prevention
and results Coordinators of ESC member states, whose answers were supported by published evidence and/or national experts.
The OCRE study had a high participation rate (82%). Current positive aspects of CR include low dropout rates and short
average start time after myocardial infarction, as well as public funding being standard practice. However, the uptake rate and
average duration of CR are still suboptimal, and several countries lack CR mandatory rotation in Cardiology training, guid­
ance documents, national accreditation, and electronic database registries. We also found several barriers to CR guideline
implementation, at patient, staff, and healthcare levels.
............................................................................................................................................................................................
Conclusions This study provides a comprehensive characterization of CR in Europe, generating important insight on the current provi­
sion and quality of CR in Europe, highlighting its sucesses and shortcomings, and discussing important strategies to overcome
current obstacles.
-Lay
- - - - - summary
--------------------------------------------------------------------------------------------------------------------------------------------------------
Since cardiovascular disease (CVD) is a leading cause of mortality and morbidity, this work sought to characterize the cur­
rent state of cardiac rehabilitation (CR), an important therapeutic tool comprising multidisciplinary interventions to manage
cardiovascular risk, in Europe. Current positive aspects of CR in Europe include low dropout rates and short average start
time after myocardial infarction, as well as public funding being standard practice. Suboptimal aspects of CR in Europe in­
clude low uptake rates and short average duration, a lack of CR mandatory rotation in cardiology training, guidance docu­
ments, lack of national accreditation, and electronic database registries. Although provision of CR is at an encouraging level in
Europe, it often is of suboptimal quality, signalling the need for improvement in the allocation of human and monetary re­
sources. This study also highlighted the following major barriers to the implementation and use of the cardiovascular pre­
vention and rehabilitation guidelines: low socioeconomic status and educational level, older age, lack of benefit awareness,
presence of comorbidities, transportation problems and financial concern (at patient level), lack of automatic referral, no
financial incentives, lack of multidisciplinary teams and time consumption (at staff level), and reimbursement issues, lack
of preventive culture, lack of specialized locations, and geographical issues (at healthcare level).
-Keywords
-------------------------------------------------------------------------------------------------------------------------------------------------------------
Cardiac rehabilitation • Cardiovascular diseases • Secondary prevention • Surveys and questionnaires • Europe

* Corresponding author. Tel: +35 1210517285, Email: jorgearsenioruivo@gmail.com

© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
OCRE in ESC Member Countries
Introduction
Although recent data show a decline in cardiovascular disease (CVD)
mortality in some European countries, it is still a leading cause of death
and morbidity in Europe.1 The development and availability of en­
hanced diagnostic and therapeutic approaches has increased patient
survival and rendered CVD a chronic condition, representing a major
health, social, and economic burden on individuals and healthcare sys­
tems.2 Moreover, CVD is often the result of risk factors and health be­
haviours which must be addressed through approaches beyond
therapeutic interventions and pharmacological management, in ways
that promote disability-free survival, focusing on physical capacity,
changes in lifestyle, risk factor management, improved well-being, and
social and vocational participation.3,4 Cardiac rehabilitation (CR) is a
multidisciplinary approach to achieve these goals, being defined by
the World Health Organization (WHO) as ‘the sum of activity and in­
terventions required to ensure the best possible physical, mental, and
social conditions so that patients with chronic or post-acute cardiovas­
cular disease may, by their own efforts, preserve or resume their prop­
er place in society and lead an active life.’5
Cardiac rehabilitation is a comprehensive, individualized, and patient-
tailored programme that comprises multidisciplinary intervention,
including as core components: patient assessment, management and
control of cardiovascular risk factors, structured exercise training, diet­
ary advice, psychosocial counselling, vocational support, and pharmaco­
logical optimization.6,7 It is an established model for secondary
prevention, which is cost-effective8–10 and has been shown to reduce
all-cause11–16 and cardiovascular10,11 mortality and morbidity, reduce
risk of (cardiac) hospital readmissions,10,11,14 and increase quality of
life,10,14,17 remaining an important and effective therapeutic intervention
even upon adherence to recommended drugs or modern surgical pro­
cedures. Due to its wide-ranging benefits, CR has been classified by the
European Society of Cardiology (ESC) as a therapeutic intervention with
the highest level of recommendation (A-1) in the treatment of multiple
cardiac conditions.18 CR’s core components, standards, and outcome
measures have equally been revisited in a position paper from the
Secondary Prevention and Rehabilitation Section of the European
Association of Preventive Cardiology (EAPC).6
Despite its clinical benefits, cost-effectiveness and existing guidelines,
CR uptake in Europe remains suboptimal,3,17,19,20 and insufficient con­
trol of cardiovascular risk factors remains a major issue.4 Moreover, de­
tailed information of the current state of CR services throughout
Europe remains unsatisfactory. After a first review in the Carinex study
in 2002,19 several efforts have been made to provide broader knowl­
edge within this matter,3,20 but in the latest survey published in
2019,21 data from <30% of all centres providing CR were accessible,
and this study comprised data collected between June 2016 and
December 2017, likely not being representative of CR’s current status
and quality across Europe.
To overcome the reporting bias related to centre selection, EAPC
has pursued a centralized pan-European characterization of the delivery
of preventive cardiology with the collaboration of its network of
National CVD Prevention Coordinators (NCPCs).22 These are cham­
pion physicians appointed by ESC National Cardiac Societies, with
comprehensive awareness and deep understanding of their national
CR state, as well as easy access to CR centres for information gathering.
The main aims of our Overview of Cardiac Rehabilitation (OCRE) in
ESC member countries project were to broadly compare the national
CR Phase II services, to reveal contrasting strategies, and to describe fea­
tures unique to certain countries, advancing the knowledge about
ESC-affiliated national CR settings. This was accomplished in two different
stages. Part 1, in which the ‘Country of the Month’ (CoM) reports from
ESC member countries, extensively described Phase II programmes in
Europe (discussed elsewhere23) evaluating six CR components (the
team, the patient, the place, the programme, the cost and control, and
759
the future). However, the comparison of countries regarding CR services
was limited by a relative lack of homogeneity regarding published data
(since the reports were in open format) and by a wide reporting period.
Moreover, only 28 CoM reports were available at the time. Hence, a
Part 2 was envisioned, consisting of an online survey sent to the NCPCs
of the ESC member states. Our paper focuses on the latter, aiming at un­
derstanding the pulse of European CR as a whole, and at highlighting suc­
cessful and efficient strategies to overcome common obstacles.
Methods
Design and procedures
To provide an integrated overview of CR practices, the EAPC Prevention
Implementation Committee released a web-based survey to ESC member
Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023
countries in March 2019, containing 13 core questions (Table 1) about pro­
vision and quality indicators from the 6 CR components, with full comple­
tion mandatory to validate the participation. Although Table 1 displays the
provision and quality questions separately (for better viewing and interpret­
ation), the questionnaire sent to the NPCs contained mixed provision and
quality questions to limit fatigue by the responders. The questionnaire was
sent to the NPCs in English, due to feasibility reasons and to the risk of los­
ing key semantic elements in translation.
National CVD Prevention Coordinators were asked to support their an­
swers with published evidence or the best estimate following national con­
sensus of their national cardiology societies and other national experts in the
field, as published data might not always be available. The statement sent to
the NPCs, containing instructions for the completion of the questionnaire
read as follows: ‘Dear National CVD Prevention Coordinator (NCPC),
the following are a set of 13 core hard-thought questions believed to
make the most accurate snapshot of European cardiovascular disease
(CVD) prevention and cardiac rehabilitation (CR) reality. All answers and
sources are mandatory to validate the questionnaire. Results, participating
countries and its representatives will be published on the EAPC website.
Please, gather the necessary information concerning the year of 2018 al­
ways citing the latest national data (provide URL if published). If there is
no available data to reply to a specific question, please provide the best es­
timate possible as an alternative, based on gathered representative national
consensus or your personal judgement’. Each NPC completed the survey
as they best saw fit. Supplementary material online, Table S1 details the
published evidence and additional comments of each country’s NPC for
each question, providing extra insight into how the NPCs selected the in­
formation, some of the challenges they faced, updates on the current state
of CR in each country (e.g. some countries do not presently have guide­
lines/guidance documents, but these are being drafted), and other clarifica­
tions overall.
Data from the CoM reports were sometimes used as complementary in­
formation to the survey. If conflicting data were present, the most recent
were preferred.
Sample and measures
The present cross-sectional study was pursued using a web-based survey
sent to 51 ESC member countries comprising a total of 53 NCPCs, due
to duplicate delegates from Romania and The Netherlands. This study cov­
ered relevant demographic, structural, and quality control topics, including
adopted CVD prevention and rehabilitation guidelines; major barriers to
their implementation; guidance documents used in each country; CR
Phase II provision after myocardial infarction (MI; namely uptake rate, drop­
out rate, start time, duration of the programme, and percentage of pro­
grammes that rely on inpatient/residential services); percentage of CR
programmes which are medically coordinated by a cardiologist; whether
there is a CR mandatory rotation in cardiology training; which CR pro­
grammes are mainly provided by public funding; and if a national accredit­
ation programme and electronic database registry exist. These data are
presented in map format.
Data analysis
A descriptive analysis was conducted for all variables of interest and data
were presented as frequency (and percentages). An exploratory analysis
760 J. Ruivo et al.

Table 1 Questions contemplated in the Overview of Cardiac Rehabilitation 3.0 Questionnaire

Provision
(1) What are the major barriers to implementation and use of cardiovascular prevention and rehabilitation guidelines in your country? Multiple clicks
possible*
(2) After a myocardial infarction what is the average uptake rate for Phase II CR programmes?
(3) After a myocardial infarction what is the average dropout rate from CR programmes?
(4) After a myocardial infarction what is the average time between hospital discharge and the start of the CR Phase II programme?
(5) After a myocardial infarction what is the average length of Phase II CR programmes?
(6) What is the percentage of CR programmes mainly provided by public funding (no significant payment from the patient; minor fees)?
Quality
(1) Which cardiovascular prevention and rehabilitation guidelines are in place in your country?
(2) Do you have implementation guidance documents in place in your country, based on the cardiovascular prevention guidelines mentioned in the answer

Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023

to Question 1?
(3) In some country CR Phase II is conducted in specialized institutes. What is the national percentage of programmes which rely on inpatient/residential
services at this stage for myocardial infarction?
(4) What is the national percentage of Phase II CR programmes which are medically coordinated by a cardiologist?
(5) Is CR mandatory rotation in training a cardiologist?
(6) Is there a national accreditation platform set in place for licensing CR programmes?
(7) Is there a national CR electronic database registry?
.........................................................................................................................................................
Patient level Staff level Healthcare level
........................................................................................................................................................
Older age Unaware of locations/teams Lack of preventive culture
Gender inequality Lack of training/guidelines Lack of specialized locations
Multiple comorbidities Lack of awareness Geographical issues
Low socioeconomic status Lack of automatic referral system Reimbursement issues
Professional responsibilities Lack of liaison referral protocol Lack of alternative program models
Unemployment Time-consuming Lack of governance legislation
Lack of benefit awareness No financial incentives Others: –
Education level Lack of multidisciplinary teams
Negative belief concerning prevention/rehabilitation Prohibitive reimbursement systems
Expected negative perceptions during exercise Others: –
Transportation problems
Family obligations at home
Lack of support system (friends, family)
Financial concern
Cultural
Other(s): –
The * refers to the options at patient/Staff/Healthcare level portrayed below in the same table.
The questions are presented here separated in terms of provision and quality, for easier interpretation. However, this does not reflect the order of the questions that were sent to the
NPCs, which contained mixed provision and quality issues in order to avoid fatigue by the responders.

was conducted and associations between all categorical variables of interest
were performed, using a χ2 independence test. The strength of the associ­
ation between each pair of nominal variables was conducted using Cramers’
V. The level of significance was set to 0.05. All statistical analyses were per­
formed using SPSS (v25; IBM Corporation 2017) and R Statistical Software
(v4.0.2; R Core Team 2020).
Results
A summary of the results of this survey (henceforth termed OCRE sur­
vey or simply OCRE) was previously published in the EAPC website22
after validation by all participating NCPCs. Herein, we present the full
extension of OCRE’s findings.
Out of the 51 ESC member countries invited to participate in OCRE
(henceforth referred to as OCRE countries), 42 yielded valid survey an­
swers, resulting in an 82% participation rate (Figure 1).
We present our results in sections CR provision and CR quality.
Cardiac rehabilitation provision
Major barriers to guideline implementation: patient, staff,
and healthcare levels
Collected data showed that the four major patient-level barriers to
guidelines’ use and implementation were: low economic status (re­
ported by 41% of the OCRE countries), older age (31%), lack of
benefit awareness (37%), and multiple comorbidities (31%). Other
important patient-level barriers were education level (31%), trans­
portation problems (29%), and financial concern (29%), among
others.
Data indicated that the four major staff-level barriers to the implemen­
tation and use of the guidelines were: lack of an automatic referral system
(reported by 49% of the OCRE countries), lack of financial incentives (49%),
lack of multidisciplinary teams (37%), and that CR was time-consuming
(29%). Other relevant staff-level barriers were lack of awareness (27%)
and lack of training/guidelines (22%), among others.
OCRE in ESC Member Countries
Figure 1 Countries participating in Overview of Cardiac Rehabilitation Part 2 survey (map). Out of 51 invited European Society of Cardiology mem­
ber countries with appointed National Cardiovascular Disease Prevention Coordinators, 42 provided valid survey answers resulting in an 82% partici­
pation rate.
Lastly, our data showed that the major healthcare-level barriers to
the implementation and use of the guidelines were: reimbursement is­
sues (reported by 47% of the OCRE countries), lack of preventive cul­
ture (41%), lack of specialized locations (33%), geographical issues
(27%), lack of alternative programme models (22%), and lack of govern­
ance legislation (14%).
Cardiac rehabilitation Phase II provision after myocardial
infarction
Regarding the provision of CR Phase II after MI, the OCRE survey inves­
tigated the uptake rate, dropout rate, the average start time, the aver­
age duration of the programme, which percentage of CR national
programmes relied on inpatient/residential services, and the amount
of public funding of the CR programmes in each country. This informa­
tion is summarized in Supplementary material online, Table S2.
Collected data revealed that the uptake rate of CR Phase II after MI
was: 0–25% in 17 countries, 25–50% in 14 countries, 50–75% in 7 coun­
tries, and 75–100% in 4 countries (Figure 2, Supplementary material
761
Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023
online, Table S2). The uptake rate was higher in Northern Europe.
Data indicated that the dropout rate of CR Phase II after MI was: 0–
25% in 22 countries, 25–50% in 16 countries, 50–75% in 2 countries,
and 75–100% in 2 countries (see Supplementary material online,
Figure S1A and Table S2). The dropout rate was lower in western
European countries.
Our data also showed that in 12 countries, the average start time for
CR Phase II after MI was 0–2 weeks, in 23 countries it was 2–6 weeks, in
5 countries 6–12 weeks, and only in 2 country more than 12 weeks (see
Supplementary material online, Figure S1B and Table S2). The average
start time was shorter in northern Europe. Regarding the average
duration of a CR Phase II programme after MI, data revealed that: in
14 countries, it was 0–12 sessions; in 23 countries, it was 13–24
sessions; in 4 countries, it was 25–35 sessions; and in 1 country, >36
sessions (see Supplementary material online, Figure S2A and Table S2).
Lastly, concerning reliance by CR Phase II national programmes on
inpatient/residential services after MI, our survey found it to be: 0–
25% in 28 countries, 25–50% in 5 countries, 50–75% in 4 countries,
and 75–100% in 5 countries (see Supplementary material online,
762
Figure 2 Cardiac rehabilitation Phase II uptake rate after myocardial infarction (map).
Figure S2B and Table S2). Northern and eastern European countries
relied more often on inpatient/residential services, whereas data
suggest that in the remaining countries outpatient settings were
preferred.
Potential associations influencing cardiac rehabilitation
Phase II uptake rate after myocardial infarction
An exploratory data analysis was conducted to establish associations
between the uptake rate of CR Phase II after MI and other factors in­
vestigated in OCRE, such as patient level barriers to the implementa­
tion of guidelines, the dropout rate, start time, and percentage of
programmes that rely on inpatient/residential services.
Considering the most relevant patient-level barriers to the im­
plementation and use of these guidelines (particularly older age,
low economic status, and lack of benefit awareness), the uptake
rate was found to associate, moderately (0.44) yet significantly,
with older age (Figure 3A). The uptake rate of CR Phase II after
MI was also associated, moderately (0.39) yet significantly, with
the proportion of inpatient/residential programmes (Figure 3B).
No associations were found between the uptake rate and the
J. Ruivo et al.
Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023
income of the participating countries, the dropout rate, and the
start time for CR Phase II after MI.
Cardiac rehabilitation funding
The OCRE survey also investigated which percentage of CR pro­
grammes was mainly provided by public funding. Data revealed that
in 10 countries, 0–25% of the programmes were publicly funded,
in 5 countries 25–50%, in 1 country 50–75%, and in 26 countries
75–100% (see Supplementary material online, Figure S3 and Table S2).
In this regard, eastern European countries and Portugal were lagging com­
paring to other OCRE countries, suggesting privately or out-of-pocket
funded CR programmes.
Cardiac rehabilitation quality
Regarding the CR Phase II quality, the OCRE survey investigated: the
guidelines in use in each country, the percentage of CR programmes
that were coordinated by a cardiologist, which countries had manda­
tory rotation in cardiology training, and the presence/absence of guid­
ance documents, national accreditation, and electronic database
OCRE in ESC Member Countries
Figure 3 Cardiac rehabilitation uptake is significantly associated with older age (A) and inpatient/residential programmes after myocardial infarction (B).
registries. This information is summarized in Supplementary material
online, Table S3.
Cardiovascular prevention and rehabilitation guidelines
and guidance documents
Data revealed that 67% of the inquired OCRE countries, followed
European cardiovascular prevention and rehabilitation guidelines (45%
following ESC guidelines, 10% following ESC-based guidelines, and 11%
following ESC translated guidelines), whereas 19% of the OCRE coun­
tries, mostly comprising central and northern European countries, fol­
lowed national guidelines (see Supplementary material online, Figure S4A
and Table S3). Additionally, data from the survey revealed that only
43% of the OCRE countries had implemented guidance documents based
in CVD prevention guidelines, mostly in western and northern Europe
(see Supplementary material online, Figure S4B and Table S3).
Phase II cardiac rehabilitation programmes which are
medically coordinated by a cardiologist and cardiac
rehabilitation mandatory rotation in cardiology training
Data from OCRE indicated that the national percentage of Phase II CR
programmes which were medically coordinated by a cardiologist was:
0–25% in 9 countries, 25–50% in 8 countries, 50–75% in 8 countries,
and 75–100% in 17 countries (see Supplementary material online,
Figure S5A and Table S3). Interestingly, countries such as the UK,
Ireland, The Netherlands, and Finland showed a low rate of medical co­
ordination by cardiologists (0–25% in the UK; and 25–50% in Ireland,
The Netherlands, and Finland).
Regarding CR mandatory rotation in cardiology training: 8 countries
reported that it is mandatory, 13 countries as non-existent, and 21 coun­
tries as optional (see Supplementary material online, Figure S5B and
763
Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023
Table S3). In this domain, Eastern European countries, Ireland, The
Netherlands, and Germany (reporting non-existent CR mandatory rota­
tion) were lagging when compared with the remaining OCRE countries.
National accreditation and cardiac rehabilitation electronic
database registry
Survey data identified that 15 countries (mostly central Europe and the
UK) had a national accreditation platform set in place for licensing CR
programmes, whereas 28 countries reported they did not (see
Supplementary material online, Figure S6A and Table S3). As for a national
CR electronic database registry, 8 countries reported to have 1, and 22
reported to have none (see Supplementary material online, Figure S6B
and Table S3). However, some countries also reported that such regis­
tries existed in the past but had to be discontinued due to financial rea­
sons (The Netherlands), registry deadline (Spain), or an unspecified
reason (Estonia, Finland). In Ireland and Israel, such a registry existed
but its completion was voluntary—the Irish NCPC considered that
this qualified as having a registry whereas the one from Israel did not.
Discussion
Overall appreciation of the study:
innovation, importance, and opportunities
The OCRE study was the most comprehensive characterization of the
content and quality of CR programmes in ESC member states per­
formed to date, with the important advantage of having a high partici­
pation rate (82%) and comprising of answers provided by the NCPCs,
as well as supported by published evidence and/or national cardiology
societies and/or national experts. Moreover, the OCRE survey was
764
designed for objective assessment of key provision and quality indica­
tors of Phase II CR. A concise overview of CR practices across
Europe has remarkable potential for cardiologists, other health care
professionals, and decision-makers alike since a comparison between
countries may inspire improvement of local programmes.
Furthermore, this overview may have effects at national level by im­
proving CR provision and quality, drawing from best international prac­
tices, and informing political decisions in order to provide the resources
required for CR to effectively reach the patients ultimately benefiting
from it.
Importantly, the authors decided to limit the CR provision character­
ization to the post-ischaemic setting which is the not only the most
prevalent indication European-wide but also one of the few with
more extensive published reporting.
Cardiac rehabilitation provision and
quality across Europe: overall findings
To summarize the findings from the OCRE study, we assigned partici­
pating countries based on their provision of CR (Figure 4,
Supplementary material online, Table S2) and their CR quality
(Figure 5, Supplementary material online, Table S3), to three different
categories: lacking, average, and good.
Overall, most countries displayed average or good Phase II CR pro­
vision, with Cyprus and Moldova lacking (Figure 4). This positive evalu­
ation was mostly due to the low dropout rates and short average start
time for CR after MI, as well as public funding being standard practice in
most OCRE countries (see Supplementary material online, Table S2).
However, the uptake rate and average duration of Phase II CR were still
suboptimal and will need to be improved to shift the ‘average’ countries
to ‘good’ in terms of CF provision.
As for CR quality, our results were less encouraging, as several coun­
tries were lacking (Figure 5), resulting from absence/optional CR man­
datory rotation in cardiology training, and/or absence of guidance
documents, national accreditation, and electronic database registries
(see Supplementary material online, Table S3).
These data suggest that although provision of CR is at an encouraging
level in Europe (Figure 4), it often is of suboptimal quality (Figure 5), sig­
nalling the need for improvement in the allocation of human and mon­
etary resources. This is most common in eastern European countries,
but not necessarily in exclusivity, with Germany being a striking example,
where CR provision is ‘good’, but its overall quality is lagging according to
the set criteria for the self-reported data. Some simple and cost-
effective steps, such as a national accreditation platforms for licensing
CR programmes, CR mandatory rotations in Cardiology training, and
the implementation of national guidance documents based in CVD
guidelines (only occurring in 43% of OCRE countries), could greatly im­
prove the quality of these services. This is in line with the important role
found of physicians on patient enrolment in CR, particularly their en­
dorsement, referral, and attitude towards CR.24 Better training and
guidance documents would likely improve CR quality, which would po­
tentially translate into improved uptake rates and average duration of
Phase II CR, two of the major CR provision issues identified in this study.
Accordingly, a cultural change in how CR is viewed by both staff and pa­
tients, prompted by better educational programmes (e.g. during univer­
sity studies for staff and during CR for patients) would be essential for a
more extensive application of CR and its higher quality in Europe.
Cardiac rehabilitation provision:
comparison with other pan-European
studies
The OCRE study confirmed that CR programme provision and quality
remains heterogeneous among different CR centres in ESC affiliated
countries. It seems particularly worrisome that in most ESC member
J. Ruivo et al.
countries investigated (31 in 42), the uptake rate of CR Phase II after
MI was below 50%, consistent with previous reports of suboptimal
use of CR in Europe (the Carinex, ECRIS, and EuroCaReD studies
equally reported that fewer than half of the eligible cardiovascular pa­
tients benefited from CR in most European countries3,19,20). More en­
couraging was the finding that in 38 of the 42 countries, the dropout
rate was below 50% (and below 25% in 22 countries). This is consistent
with the 15% dropout rate found by the EuroCaReD study20 and sug­
gests that although CR Phase II uptake is still low and suboptimal after
MI, most of the patients who enrol in the programmes complete it.
Thus, addressing the obstacles to CR programmes’ uptake is likely to
impact patients’ overall benefits.
Considering the guidelines’ recommendation of CR’s early start,25
40 countries reported an average start of the CR Phase II programme
within 12 weeks from MI (35 reporting it within 6 weeks). The average
Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023
duration of CR Phase II programmes after MI was 13–24 sessions in
most countries, being <13 sessions in 14 countries. These data are in
line with the overall CR dose of 24.8 ± 26.0 h (median of 16 h) pre­
scribed to patients in a recent global CR survey,21 and constitutes a me­
dium dose of CR, which has been shown to be sufficient to reduce
all-cause mortality.26 However, the data differ from the mean total
number of sessions offered during CR reported in the EuroCaReD
study20 (43.5 h), which is likely due to variations in the concept of ses­
sion between studies (since the EuroCaReD study counted exercise
sessions and counselling sessions separately).
Lastly, inpatient/residential services after MI seem to be few in OCRE
countries, being <50% in 33 countries. Northern and eastern European
countries relied more on inpatient/residential services, whereas data
suggested that the remaining countries may prefer outpatient settings.
This is in line with the findings from EuroCaReD, which reported most
European countries as now preferring outpatient settings offered over
a longer period.20 However, according to the same study, in some
countries such as Austria and Germany, short in-patient CR settings
have emerged, where patients at higher risk can be quickly admitted
to CR programmes to start their recovery.20 Accordingly, we found
a moderate association between CR uptake and proportion of in­
patient/residential programmes, where the best uptake rates occurred
in countries providing 25–50% and/or 50–75% of inpatient/residential
programmes. These data suggest that a mixed model might be the
best solution to improve CR uptake. It might be important to promote
early uptake of CR with inpatient/residential settings (particularly with
high-risk patients), but outpatient settings offered over a longer period
also allow patients (at least partially) to remain in CR programmes,
maintaining an active life and their daily routines over time.
Barriers to implementation and use of
cardiovascular prevention and
rehabilitation guidelines
The major barriers identified by OCRE to the implementation and use
of the cardiovascular prevention and rehabilitation guidelines were: low
socioeconomic status and educational level, older age, lack of benefit
awareness, presence of comorbidities, transportation problems and fi­
nancial concern (at patient level), lack of automatic referral, no financial
incentives, lack of multidisciplinary teams and time-consumption (at
staff level), and reimbursement issues, lack of preventive culture, lack
of specialized locations, and geographical issues (at healthcare level).
These barriers, particularly lower education level, low income, co­
morbid conditions, lack of referral, long travel time, and/or dependency
for transport, have equally been identified by a systematic review of
prospective cohort studies investigating which factors associated with
non-participation in and dropout from CR programmes.27 The
EUROASPIRE IV cross-sectional survey also reported that older pa­
tients, those at low socioeconomic status, and those presenting
OCRE in ESC Member Countries
Figure 4 Overview of Cardiac Rehabilitation evaluation of the cardiac rehabilitation provision in Europe (map). Participating countries were assigned
to three different categories—lacking, average, and good —according to their cardiac rehabilitation provision indicators (see Supplementary material
online, Table S1 for details).
comorbidities (among others) were less likely to be advised to attend a
CR programme and, if advised, less educated patients were less likely to
participate.17 However, interestingly, the OCRE study showed a mod­
erate association between older age and CR uptake, suggesting that the
‘age paradigm’ might be changing, with more doctors referring older pa­
tients to CR programmes.
Successful identification of these obstacles to the implementation of
CVD secondary prevention, particularly those identified by several
studies, constitute unique opportunities, since interventions targeting
these barriers will greatly increase the likelihood of successfully con­
ducting CR programmes. As examples, patients with lesser socio­
economic status and/or lower education levels should receive
particular attention from healthcare professionals as well as specific re­
commendations from physicians to attend CR programmes.
Physician factors have a great impact on patient enrolment in CR,
particularly physician endorsement, referral, and attitude towards
CR.24 Concomitantly, higher rates of CR referral were achieved in stud­
ies implementing automatic referral of all eligible patients, a strategy
which is likely to decrease rates of non-participation in CR.28
765
Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023
Regarding the geographical/travel challenges faced by patients, some
strategies to improve participation are possible, such as: availability of
proximity sites, home-based CR delivery, CR programmes in primary
care settings27 and telehealth CR programmes (which have been shown
to be at least as beneficial as centre-based CR29).
Strategies for secondary prevention and
cardiac rehabilitation
As part of the CoM reports, participating NCPCs were asked to pro­
pose strategies for secondary prevention and CR. Israel proposed the
use of CR delivery as an established national health system quality indi­
cator, as well as the referral of non-classical CR indications. Germany
recommended risk factor counselling reimbursement by insurance
companies, and Italy suggested continued reinforced intervention up
to 3 years after rehabilitation. The Netherlands and Slovenia proposed
the development of tele- and web-based programmes, and Slovenia
added full establishment of appropriate registries. Sweden recom­
mended the establishment of individualized models of CR, and
766
Figure 5 Overview of Cardiac Rehabilitation evaluation of the cardiac rehabilitation quality in Europe (map). Participating countries were assigned to
three different categories—lacking, average, and good—according to their cardiac rehabilitation quality indicators (see Supplementary material online,
Table S2 for details).
Georgia suggested setup of local EAPC masterclasses for CR training.
The UK suggested payment by results and centre certification to in­
corporate improvement in exercise capacity/risk reduction outcomes.
Finally, Portugal proposed the setup of an educational programme for
pupils and their parents, and France advocated for the support of lag­
ging programmes by the top performing programmes. Frailty-tailored
CR programmes were also proposed.
Funding
Data from OCRE revealed that in 26 OCRE countries 75–100% of CR
programmes were publicly funded, Eastern European countries and
Portugal lagging in this regard, with less than 50% of CR programmes
paid by public funding. These results are slightly different from the
most recent global CR survey, which found 59.5% of the European
CR programmes to be funded by social security.21 Despite this dispar­
ity, it seems likely that many patients are at least partially paying
out-of-pocket for CR programmes, which is problematic, since recent
data show that that funding sources can impact delivery costs, pro­
gramme capacity, patients per session, number and nature of healthcare
J. Ruivo et al.
Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023
providers on the team, and types of functional testing used.30
Moreover, elevated costs to the patient will likely discourage participa­
tion. It is essential to advocate for improved reimbursement of CR ser­
vices so that patients are less likely to cover their costs.31
Implementation protocols: accreditation,
registry, and guidelines
The OCRE survey revealed very heterogeneous implementation pro­
tocols. Regarding CVD prevention and rehabilitation guidelines, 67%
of the OCRE countries reported to following ESC, ESC-based or
ESC-translated guidelines, and 19% reported following national guide­
lines. However, only 43% of these countries had implemented guidance
documents based on the guidelines. Likewise, only 15 countries re­
ported having a national accreditation platform set in place for licensing
CR programmes, and as few as 8 countries stated having a national CR
electronic database registry (although some countries reported previ­
ous existence and discontinuation of such registries).
Setting up pan-European implementation protocols, either for ac­
creditation, electronic registries, and CR guidelines, would be beneficial.
OCRE in ESC Member Countries
Recently, an EAPC CR Phase II accreditation programme has been de­
veloped by the EAPC Secondary Prevention and Rehabilitation (SP/CR)
Section, aiming to acknowledge CR centres providing high-level quality
of care, and encourage European CR centres to improve their standard
of care delivery.25 This programme also described the minimal and op­
timal CR quality standards that European CR centres should achieve to
provide evidence-based, cost-effective, and safe interventions. A recent
position paper from the EAPC SP/CR Section, updating the practical re­
commendations on the core components and goals of CR intervention
also provided up-to-date guidelines for European countries.6 Efforts
should thus be made to apply all these recent and relevant resources
across ESC member states. Moreover, national registries would be an
important strategy to oversee the implementation of CR guidelines
and accreditation programmes, being an important strategy to charac­
terize service delivery, quality, and outcomes, establishing comparisons
and stimulating improvements. A pan-European multinational registry
would be ideal in structuring programme data, providing important na­
tional and global benchmarking.32
Strengths and limitations
In terms of strengths, the OCRE study provides an up-to-date report
on the content and quality of CR programmes in ESC member states,
achieving a high participation rate comprising of 42 countries, many of
which were absent or underrepresented in previous studies. Moreover,
due to the design of this study, the questionnaire employed focused on
objective quality and provision indicators, and the answers from each
country considered a national consensus ponderation factor. These
qualities were efficient in finding both similarities and heterogeneity
within CR programmes, contributing to the robustness of the findings
and an accurate representation of the current cardiovascular preven­
tion and rehabilitation care across Europe.
However, this study also presents some limitations. Some of the ques­
tions in the OCRE survey may have led to different interpretations, thus
having been misinterpreted in some countries. Although NCPCs were in­
structed to attempt to provide evidence-based answers, the results re­
vealed that suboptimal rates of evidence-based answers were present,
which should imply caution in final data interpretation. A reporting bias
may be present in this study since only one NPC per country was selected,
which may induce subjectivity (although these are very well-connected pro­
fessionals with a clear notion of the reality of their country who were in­
structed to rely on consensus from their national society). Additional
possible biases of the study (identified by the NPCs in the observations
in Supplementary material online, Table S1) include absence of accurate
data, insufficient data, and differences in the national centres and pro­
grammes which create regional variations of data. Moreover, the character­
ization of the CR provision was limited to the post-ischaemic indication,
since this is the indication with the highest prevalence and most reported
data. Lastly, the data presented here are prior to COVID-19 pandemic,
which may have induced changes in the present situation of CR in Europe.
Conclusions
Cardiac rehabilitation, a cost-effective strategy of secondary prevention
with the potential to reduce cardiovascular mortality and morbidity, is
certainly in need of expansion in ESC-affiliated countries, as illustrated
by the different reports of several countries presented here. This
work confirmed a great heterogeneity in CR across Europe, although
ESC countries appear to face shared obstacles, for which a joint strategy
might prove important and effective. We consider that this work iden­
tified real-world challenges faced by CR in Europe, for which we present
possible concerted strategies. Particularly, we consider that European
CR programmes need to be based upon the same minimal quality stan­
dards and aim towards the same quality indicators. However, we
767
acknowledge the differences in economy, culture, religion, health sys­
tem, climate, and literacy across the different countries. These need
to be considered and respected, and a shared CR plan should contem­
plate this diversity and promote adjustments for each country while also
preventing it from falling short of the common set goals.
The wide range of responses received in selected performance indi­
cators probably reflects, in our perspective, the suboptimal application
of CR programme guidelines6 be it for different patient, staff, or health­
care reasons across countries. Irrespective of the documented obsta­
cles, what is clear to the authors is that there is (still) remarkable
heterogeneity among countries when it comes to adopting fundamen­
tal provision and quality raising aspects related to CR, warranting un­
doubtfully a centralized CR standardization approach.
Understanding the extent of any variation in practice should lead to a
process of review and redesign at the site level and cumulatively at the
Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023
national level, ideally in the light of a strategic centralized accreditation.
Accreditation enables centres to document that the point of care pro­
vided is reliable and based on the latest guidelines, that infrastructure
and resources are in place and well-trained, and that protocols are
used in an adequate standardized way.
The recently announced EAPC certification system25 based on sound
guideline CR implementation recommendations6 aims exactly at raising
the quality of CR service, by optimizing patient selection, defining ‘min­
imum’ standard protocol/duration and by suggesting common key indi­
cators upon which to measure performance, providing a fair balance
between feasibility of its application and effectiveness of CR delivery.
Presently, only 17 European centres hold EAPC accreditation.33 It
will certainly be worthwhile to take another OCRE snapshot in a few
years once the certification system becomes widely established, hope­
fully to find a more homogenous quality service level across Europe.
Authors’ contributions
Study concept and design: A.A., J.R. Data analysis and interpretation:
A.A., J.R. Manuscript and figures preparation: A.A., J.R. Manuscript re­
view and editing: A.A., J.R., T.M. All authors approved the final version
of the manuscript.
Supplementary material
Supplementary material is available at European Journal of Preventive
Cardiology.
Acknowledgements
The authors acknowledge Britta Ettelt, Coordinator of the EAPC. The
authors also thank the EAPC National CVD Prevention Coordinators for
completing the survey and providing Country of the Month reports, and
the EAPC Prevention Implementation Committee for coordinating this ini­
tiative. Particularly, the authors thank Johan De Sutter (Belgium), Lambros
Kypris (Cyprus), Ann Bovin (Denmark), Margus Viigimaa (Estonia), Seppo
Lehto (Finland), Iliou (France), Stephen Gielen (Germany), Eszter
Szabados (Hungary), Karl Andersen (Iceland), Angie Brown (Ireland),
Salvatore Novo (Italy), Vilnis Dzerve (Latvia), Rimvydas Slapikas
(Lithuania), Jean Beissel and Charles Delagardelle (Luxembourg), Madoka
Sunamura and Roderik Kraaijenhagen (The Netherlands), Henrik
Schirmer (Norway), Piotr Jankowski (Poland), Ana Abreu (Portugal),
Myra Tilney (Republic of Malta), Marina Foscoli (Republic of San Marino),
Zlatko Fras (Slovenia), Regina Dalmau (Spain), Barak Zafrir (State of
Israel), Anna Kiessling (Sweden), Philippe Meyer (Switzerland), Joe Mills
(United Kingdom), Tigran Astvatsatryan (Armenia), Gamela Nasr (Egypt),
Zurab Klimiashvili (Georgia), Victor Rudi (Republic of Moldova),
Mohamed Alami (Morocco), Professor Elena Nesukay (Ukraine), Rahima
Gabulova (Azerbaijan), Olga Pavlova (Belarus), Mirza Dilic (Bosnia and
768
Herzegovina), Evgeniy Goshev (Bulgaria), Georges (Lebanon), Dr Omar
Msalam (Libya), Aneta Boskovic (Montenegro), Iulia Kulcsar and Dan
Gaita (Romania), Vojislav Giga (Serbia), and Emre Aslanger (Turkey). The
authors dedicate this paper to Professor Joep Perk, who passed during its
preparation, and whose leadership in EAPC made it possible for preventive
cardiology to become an integrative field in cardiology, championing cardiac
rehabilitation. Professor Joep Perk worked in ESC as a spokesperson for
CVD prevention and was one of the founders of EAPC. In recent years,
he worked tirelessly in the EAPC Prevention Implementation Committee
trying to implement the 2021 ESC Guidelines on CVD Prevention in
European countries with the highest incidence of CVD deaths. He will re­
main in our hearts as a true legend in preventive cardiology.
Funding
The authors received no financial support for the research, authorship, and/
or publication of this article.
Conflict of interest: None declared.
Data availability
The data underlying this article are available in the article and in its online
supplementary material. Previous presentations of the work presented in
the article: not performed on its final iteration.
References
1. Wilkins E, Wilson L, Wickramasinghe K, Bhatnagar P, Leal J, Luengo-Fernandez R, Burns
R, Rayner M, Townsend N. European Cardiovascular Disease Statistics 2017. Brussels:
European Heart Network; 2017.
2. Timmis A, Townsend N, Gale CP, Torbica A, Lettino M, Petersen SE, et al. European
Society of Cardiology: Cardiovascular Disease Statistics 2019. Eur Heart J 2020;41:
12–85.
3. Bjarnason-Wehrens B, McGee H, Zwisler AD, Piepoli MF, Benzer W, Schmid JP, et al.
Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation
Inventory Survey. Eur J Cardiovasc Prev Rehabil 2010;17:410–418.
4. Kotseva K, De Backer G, De Bacquer D, Rydén L, Hoes A, Grobbee D, et al. Lifestyle
and impact on cardiovascular risk factor control in coronary patients across 27 coun­
tries: results from the European Society of Cardiology ESC-EORP EUROASPIRE V
registry. Eur J Prev Cardiol 2019;26:824–835.
5. WHO Expert Committee on Rehabilitation after Cardiovascular Diseases, with Special
Emphasis on Developing Countries. Rehabilitation after cardiovascular diseases, with
special emphasis on developing countries: report of a WHO expert committee.
Geneva. 1993.
6. Ambrosetti M, Abreu A, Corrà U, Davos CH, Hansen D, Frederix I, et al. Secondary
prevention through comprehensive cardiovascular rehabilitation: from knowledge to
implementation. 2020 update. A position paper from the Secondary Prevention and
Rehabilitation Section of the European Association of Preventive Cardiology. Eur J
Prev Cardiol2021;28:460–495.
7. Cuomo G, di Lorenzo A, Tramontano A, Iannone FP, D’Angelo A, Pezzella R, et al.
Exercise Training in Patients with Heart Failure: From Pathophysiology to Exercise
Prescription. Vol. 23, Reviews in Cardiovascular Medicine. Singapore: IMR Press Limited;
2022.
8. Shields GE, Wells A, Doherty P, Heagerty A, Buck D, Davies LM. Cost-effectiveness of
cardiac rehabilitation: a systematic review. Heart 2018;104:1403–1410.
9. Edwards K, Jones N, Newton J, Foster C, Judge A, Jackson K, et al. The cost-effectiveness
of exercise-based cardiac rehabilitation: a systematic review of the characteristics and
methodological quality of published literature. Health Econ Rev 2017;7:37.
10. Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin N, et al.
Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database
Syst Rev 1996;2016:1–196.
11. Janssen V, De Gucht V, Dusseldorp E, Maes S. Lifestyle modification programmes for
patients with coronary heart disease: a systematic review and meta-analysis of rando­
mized controlled trials. Eur J Prev Cardiol 2013;20:620–640.
12. Rauch B, Davos CH, Doherty P, Saure D, Metzendorf MI, Salzwedel A, et al. The prog­
nostic effect of cardiac rehabilitation in the era of acute revascularisation and statin ther­
apy: a systematic review and meta-analysis of randomized and non-randomized studies
—The Cardiac Rehabilitation Outcome Study (CROS). Eur J Prev Cardiol 2016;23:
1914–1939.
J. Ruivo et al.
13. Salzwedel A, Jensen K, Rauch B, Doherty P, Metzendorf MI, Hackbusch M, et al.
Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease pa­
tients treated according to contemporary evidence based medicine: update of the
Cardiac Rehabilitation Outcome Study (CROS-II). Eur J Prev Cardiol 2020;27:
1756–1774.
14. Long L, Mordi IR, Bridges C, Sagar VA, Davies EJ, Coats AJ, et al. Exercise-based cardiac
rehabilitation for adults with heart failure. Cochrane Database Syst Rev 2019;2019:
1–173.
15. Scalvini S, Grossetti F, Paganoni AM, Teresa La Rovere M, Pedretti RFE, Frigerio M.
Impact of in-hospital cardiac rehabilitation on mortality and readmissions in heart fail­
ure: a population study in Lombardy, Italy, from 2005 to 2012. Eur J Prev Cardiol
2019;26:808–817.
16. Goel K, Pack QR, Lahr B, Greason KL, Lopez-Jimenez F, Squires RW, et al. Cardiac re­
habilitation is associated with reduced long-term mortality in patients undergoing com­
bined heart valve and CABG surgery. Eur J Prev Cardiol 2015;22:159–168.
17. Kotseva K, Wood D, De Bacquer D. Determinants of participation and risk factor con­
trol according to attendance in cardiac rehabilitation programmes in coronary patients
Downloaded from https://academic.oup.com/eurjpc/article/30/9/758/7018700 by guest on 13 July 2023
in Europe: EUROASPIRE IV survey. Eur J Prev Cardiol 2018;25:1242–1251.
18. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, et al. 2021 ESC
guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021;42:
3227–3337.
19. Vanhees L, McGee HM, Dugmore LD, Schepers D, van Daele P. A representative study
of cardiac rehabilitation activities in European Union member states. J Cardiopulm
Rehabil 2002;22:264–272.
20. Benzer W, Rauch B, Schmid JP, Zwisler AD, Dendale P, Davos CH, et al. Exercise-based
cardiac rehabilitation in twelve European countries results of the European cardiac re­
habilitation registry. Int J Cardiol 2017;228:58–67.
21. Abreu A, Pesah E, Supervia M, Turk-Adawi K, Bjarnason-Wehrens B, Lopez-Jimenez F,
et al. Cardiac rehabilitation availability and delivery in Europe: how does it differ by re­
gion and compare with other high-income countries? Eur J Prev Cardiol 2019;26:
1131–1146.
22. Overview of Cardiac Rehabilitation (OCRE) in ESC Member Countries: Highlights
and comparisons of phase II programmes according to the “Country of the
Month” reports of National CVD Prevention Coordinators [Internet]. Available
from: https://www.escardio.org/Sub-specialty-communities/European-Association-
of-Preventive-Cardiology-(EAPC)/Advocacy/Prevention-in-your-country/overview-
of-cardiac-rehabilitation (19 January 2023).
23. Overview of Cardiac Rehabilitation—Part 1 Derived from ‘Country of the month’
reports (comparison by topics) [Internet]. Available from: https://www.escardio.
org/Sub-specialty-communities/European-Association-of-Preventive-Cardiology-
(EAPC)/Advocacy/Prevention-in-your-country/overview-of-cardiac-rehabilitation-part-
one (19 January 2023).
24. Ghisi GLM, Polyzotis P, Oh P, Pakosh M, Grace SL. Physician factors affecting cardiac
rehabilitation referral and patient enrollment: a systematic review. Clin Cardiol 2013;
36:323–335.
25. Abreu A, Frederix I, Dendale P, Janssen A, Doherty P, Piepoli MF, et al. Standardization
and quality improvement of secondary prevention through cardiovascular rehabilitation
programmes in Europe: the avenue towards EAPC accreditation programme: a position
statement of the Secondary Prevention and Rehabilitation Section of the European
Association of Preventive Cardiology (EAPC). Eur J Prev Cardiol 2021;28:496–509.
26. Santiago de Araújo Pio C, Marzolini S, Pakosh M, Grace SL. Effect of cardiac rehabilita­
tion dose on mortality and morbidity: a systematic review and meta-regression analysis.
Mayo Clin Proc 2017;92:1644–1659.
27. Resurrección DM, Moreno-Peral P, Gómez-Herranz M, Rubio-Valera M, Pastor L,
Caldas de Almeida JM, et al. Factors associated with non-participation in and dropout
from cardiac rehabilitation programmes: a systematic review of prospective cohort
studies. Eur J Cardiovasc Nurs 2019;18:38–47.
28. Gravely-Witte S, Leung YW, Nariani R, Tamim H, Oh P, Chan VM, et al. Effects of car­
diac rehabilitation referral strategies on referral and enrollment rates. Nat Rev Cardiol
2010;7:87–96.
29. Rawstorn JC, Gant N, Direito A, Beckmann C, Maddison R. Telehealth exercise-based
cardiac rehabilitation: a systematic review and meta-analysis. Heart 2016;102:1183–1192.
30. Moghei M, Pesah E, Turk-Adawi K, Supervia M, Jimenez FL, Schraa E, et al. Funding
sources and costs to deliver cardiac rehabilitation around the globe: drivers and barriers.
Int J Cardiol 2019;276:278–286.
31. Babu AS, Lopez-Jimenez F, Thomas RJ, Isaranuwatchai W, Herdy AH, Hoch JS, et al.
Advocacy for outpatient cardiac rehabilitation globally. BMC Health Serv Res 2016;16:1–9.
32. Poffley A, Thomas E, Grace SL, Neubeck L, Gallagher R, Niebauer J, et al. A systematic
review of cardiac rehabilitation registries. Eur J Prev Cardiol 2017;24:1596–1609.
33. EAPC Preventive Cardiology Centre Accreditation. https://www.escardio.org/Education/
Career-Development/Accreditation/EAPC-centre-accreditation (19 January 2023).