Karam Turk-Adawi

Objective: Cardiac rehabilitation (CR) is an outpatient model of secondary prevention that improves patient outcomes, yet use remains limited. Hybrid/alternative CR addresses these challenges, but global availability, structure, and volumes have not been characterized since the pandemic. Methods: The International Council of Cardiovascular Prevention and Rehabilitation’s (ICCPR) 2025 Audit Update is a cross-sectional survey of phase II CR programs worldwide. After member Associations supported identification of countries with CR, program data were collected via REDCap between May-September/2025. Data were compared by country income classification, and with prior ICCPR Audits where possible. Results: Of 6,905 CR programs identified globally, 1,505 initiated a survey (median program response rate = 62.3% per country) from 90/113 (79.6%) countries with CR. Globally, 286 (23.2%) programs in 40 (35.4%) countries reported reimbursement for hybrid/alternative models, varying significantly by country income class (p < 0.001); this was higher than 2016 (14.5%), but not significantly different from the pandemic (21.0%). 285 (31.1%) programs reported offering a hybrid/alternative CR model, in 57 (50.4% with CR) countries (higher in lower-middle income countries, then upper-middle income countries [UMICs]). This was not higher than previous Audits. Programs were staffed by exercise professionals, nurses and physicians (more in UMICs). Dose was a median of 10 sessions (one/week over 8 weeks), lower than centre-based, but consistent across income classes and over time. Patients were allocated to model based on clinical criteria, choice (69.5%), but also cost (30.2%; higher in middle-income countries and than 2016). Hybrid/alternative models served a median of 50 (P25-P75 = 10–100) patients/program annually, lower than centre-based (median = 135; p < 0.001); volumes were higher in UMICs. 160 (45.8%) programs perceived insufficient capacity to meet demand, most commonly due to staffing and funding. Conclusions: Hybrid/alternative CR availability has not increased since 2016, and decreased since the pandemic. Reimbursement drives availability, but remains limited and inadequate, frequently shifting costs to patients, constraining services and limiting equitable scale-up.

Background: Cardiovascular disease (CVD) remains a leading global health burden. Cardiac rehabilitation (CR) is essential to reducing morbidity and improving patient outcomes. Since the COVID-19 pandemic, CR delivery worldwide has evolved, yet these changes have not been systematically charactemkjrized. The objective of this study was to characterize globally: (1) the delivery of core CR components, including risk factors assessed, patient education practices, and program resources; (2) differences in these elements by country income classification and relative to the initial 2016 Global CR Audit. Methods and findings: A cross-sectional Audit update was conducted. Program-level data were collected from May 1st to September 1st 2025 using a REDCap survey adapted from previous Audits. Eligible respondents were leads of phase II/post-discharge CR programs providing at least an initial assessment, structured aerobic exercise, and ≥1 additional core component. ICCPR associations and local leaders supported program identification. Main outcomes were core components delivered (10 assessed), risk factors assessed (14 assessed), patient education dose (hours/patient/program), and program resources (17 assessed). Generalized linear mixed models (GLMM) tested differences by income classification and (when applicable) changes since 2016. Of 7,025 programs identified globally, 1,505 (62% median country response rate) initiated a survey from 90/113 (80%) countries with CR. The median number of core components offered was 8/program (p25, p75 = 6, 10), with upper-middle income countries offering significantly more components overall (median = 9), and also high-income countries offering more than low-income countries (8 versus 6, p < 0.001; decade change not tested). Programs assessed 11 risk factors/program (median; p25, p75 = 8, 12). This significantly differed by country income class (GLMM p < 0.001), with programs in lower-middle income countries assessing fewer risk factors than those in both upper-middle-income (mean difference = 2.2; p < 0.001) and high-income countries (mean difference = 1.6, p < 0.001). There were significant increases in 2025 for glucose, sleep apnea and sedentariness, among others (ps < 0.01). Patient education dose was 3 hours/supervised program (median; p25, p75 = 1, 7), a significant reduction in many high-income countries since 2016 ( p = 0.01). Globally, gym space, resistance training equipment, and individual assessment/counseling space were the most common resources (all >90%; median = 11; p25, p75 = 8, 14). Resource availability differed significantly by country income class (GLMM p < 0.001), with programs in upper-middle-income countries reporting more resources than those in high-income (mean difference = 1.5), lower-middle-income (mean difference = 2.6), and low-income countries (mean difference = 4.8; all p < 0.001). While there were no significant differences in total resources, resistance training equipment, electronic patient charts, body composition analyzers, and stress testing with O ₂ were more available in 2025, and the availability of administrative office space and group education room less so (ps < .01). Limitations include potential selection and ascertainment bias from incomplete program identification as well as variable, modest program response rates, limited representation from low-income settings, reliance on self-reported survey data, as well as measurement differences across Audit cycles, which may affect generalizability and precision of findings. Conclusions: CR programs worldwide continue to deliver guideline-concordant care, with education potentially shifting modality. However, modest inequities persist for resource-constrained programs.

Background: Cardiac rehabilitation supports recovery after cardiac events, but it is unclear whether outcomes differ by socioeconomic characteristics in low‐resource settings. This study aimed to identify whether pre‐program socioeconomic characteristics (financial strain, age, education, employment) were associated with cardiac rehabilitation completion, and–among completers–to examine associations with changes in depressive symptoms and quality of life from pre‐ to post‐program. Methods: Individuals with pre‐program data (2021‐May 2024) in the ICRR (International Cardiac Rehab Registry), from 17 programs in low‐resource settings across 11 countries, were included. Outcomes were changes in Patient Health Questionnaire‐2 depressive symptoms and Cantril's Ladder quality of life scores. Among completers, associations were examined using robust linear mixed‐effects models, adjusting for characteristics, with a random intercept for site. Results: Among 3520 individuals (mean age 59 years [SD=12], 79% men), 2190 (62%) completed cardiac rehabilitation. Completion was more common among those without financial strain (20% versus 10%, P 12 years of education (57% versus 44%, P P P =0.021), while employment was associated with smaller improvement (β=0.297, 95% CI=0.104, 0.489, P =0.019). Age and education were not associated with change in depressive symptoms. No socioeconomic characteristics were associated with change in quality of life. Conclusions: These findings suggest socioeconomic pressures are associated with differences in recovery. Flexible cardiac rehabilitation models may support individuals in low‐resource settings.

Cardiovascular disease involves complex molecular, cellular, and physiological derangements that present challenges for traditional diagnostic and therapeutic approaches. Precision medicine is an evolving field that seeks to tailor interventions according to an individual's genetic, molecular, and physiological characteristics. By leveraging advanced omics approaches, including genomics, proteomics, metabolomics, and microbiomics, precision medicine may enable more comprehensive patient phenotyping and support the development of more individualized strategies. The emerging concept of precision cardiac rehabilitation (CR) could provide a more tailored approach to cardiac care by integrating artificial intelligence (AI) with multimodal data, including clinical, imaging, physiological, and omics information. In this context, AI has been explored as a tool to support risk assessment, exercise prescription, and monitoring during CR. However, current evidence remains limited and heterogeneous. Omics-based approaches are primarily confined to research and translational settings, and their role in guiding individualized exercise prescription or clinical decision making in CR remains unestablished. Similarly, while AI shows promise for improving adherence, remote monitoring, and data integration, its effectiveness for optimizing clinical outcomes in CR requires further validation. Overall, precision CR represents a promising but still evolving paradigm. Future progress will depend on well-designed clinical trials, real-world data integration, standardized methodologies, and interdisciplinary collaboration to determine whether these technologies can be safely and effectively integrated into routine clinical practice.

Aims: To characterize global variation in cardiac rehabilitation (CR) staffing, indications, and prescribed dose by country income classification and compare findings with the International Council of Cardiovascular Prevention and Rehabilitation’s 2016 Global Audit. Methods and results: Cross-sectional REDCap survey of Phase II/post-discharge CR programmes (May–September 2025). Outcomes were multidisciplinary team size/composition, accepted cardiac and non-cardiac indications, and centre-based CR dose. Comparisons were made across World Bank country income classifications and Audit decade (2016 vs. 2025). Of 7025 programmes identified globally, 1505 (median programme response rate = 62%/country) initiated a survey, from 90/113 (80%) countries with CR. CR was delivered by a multidisciplinary team of 7 (median; P25–P75 = 5–8; nurses, physiotherapists, cardiologists, and dietitians most common); teams were smaller in low-income countries (median = 4; P < 0.001), and physician specialty varied. Non-low-income programmes consistently accepted (≥90%) patients with acute coronary syndrome, with programmes in low-income countries less often accepting related interventions (e.g. surgery: low-income 0% vs. high-income 97%; P < 0.01), but non-cardiac indications were more frequently accepted (e.g. primary prevention, diabetes, and lung disease). Acceptance of heart failure increased compared with the previous Audit (70% vs. 87%; P < 0.001). Centre-based programmes prescribed a median of 20 h (P25–P75 = 12–30), typically two sessions/week over 8 weeks. Globally, 65 (72%) countries prescribed a median ≥12 sessions/programme. Programmes in upper-middle-income countries prescribed more sessions (median = 24, P25–P75 = 12–36; P < 0.001). Dose did not differ meaningfully between Audits (P = 0.07). Conclusion: CR programmes globally are offered by small, but multidisciplinary teams. They accept guideline-indicated patients, with applicable variation by context. Insufficient dose in one-quarter of countries underscores investment need.

Purpose: Cardiovascular disease is a leading cause of morbidity globally, particularly in low-resource settings. The effectiveness of cardiac rehabilitation (CR) is well-established; however, the nature of services in low-resource settings differs. This study sought to investigate program characteristics associated with lower all-cause morbidity among CR participants from low-resource settings. Methods: This was a prospective observational study analyzing the International Council of Cardiovascular Prevention and Rehabilitation’s International CR Registry. Programs with annual assessment data at the time of study were included, and their characteristics were assessed in a survey. Self and program-reported patient morbidity included all- and cardiac-cause hospitalization, emergency department visits, cardiovascular disease events, and procedures 1 year from initial assessment. A multilevel modified Poisson regression model was used to account for clustering of patients within CR programs, estimating the adjusted incidence rate ratios (IRR) for morbidity. Results: Of the 690 patients from programs in 6 countries across 4 regions (Colombia, Iran, Malaysia, Mexico, Pakistan, and Qatar), 637 (92%) were retained, of which 479 (75%) had morbidity data. Seven patients died and 93 suffered morbidity; this was most commonly noncardiac hospitalization (29 events) and emergency department visits (18 events). The regression analysis revealed a significantly lower incidence of morbidity associated with the following program factors: higher number of risk factors assessed (IRR = 0.55: 95% CI, 0.39-0.77), greater number of CR health care professionals (IRR = 0.76: 95% CI, 0.65-0.89), and CR located in academic/tertiary care institution (IRR = 0.61: 95% CI, 0.50-0.75). Conclusion: Globally, CR programs could benefit from prioritizing comprehensive risk assessment and strengthening CR teams to potentially reduce morbidity.

As the burden of Heart failure (HF) continues to rise, effective management strategies are essential. Multidisciplinary disease management programs (DMPs)

Objective Heart failure clinics (HFCs) are associated with increased survival rates, lower hospitalisation and improved quality of life. This study investigated factors influencing patient access to multidisciplinary outpatient HFCs from the perspective of patients and cardiologists. Design This was a qualitative study. A trained researcher conducted semistructured face-to-face interviews with patients and online interviews with cardiologists. Interviews, conducted between March and October 2023, were audio-recorded. Transcripts were cleaned (deidentification, translation verification) and analysed by two trained researchers independently using systematic text condensation in NVivo v12. Codes were derived from the transcripts and grouped and organised into themes. Two authors independently coded data, reconciling disagreements with the senior author, followed by respondent validation. Member checking ensued. Setting Outpatient multidisciplinary HFCs in Qatar. Participants A purposive sample of patients diagnosed with heart failure who had attended at least one HFC appointment at Qatar’s Heart Hospital were approached in person or via phone, and cardiologists with the authority to make referrals to these clinics via the electronic medical record system were emailed; interviews ensued until theme saturation was achieved. Results 26 individuals (14 patients and 12 cardiologists) participated in the interviews. Four major themes were identified: health system organisation (subthemes: benefits, HFC triage criteria, need/capacity), HFC referral processes (subthemes: electronic record system, patient communication and education), care continuity and communication (subthemes: patient navigators, clinician preferences) and access challenges (subthemes: transportation, costs). Conclusions Resources are needed to expand HFC capacity and coverage, leverage electronic medical record tools as well as telehealth, educate physicians and patients on referral guidelines and processes and engage primary care to ultimately improve patient outcomes.

Dove Press is a member of the Open Access Initiative, specializing in peer reviewed Medical Journals. View articlesor submit your research for publishing