Gabriela Lima de Melo Ghisi

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.

Purpose: To identify and prioritize key considerations for culturally adapting the Mediterranean diet for diverse populations participating in cardiac rehabilitation (CR) programs outside the Mediterranean region. Methods: This modified, 2-round Delphi consensus study (September to December 2025) included 3 phases. Phase 1 involved online focus groups with dietitians from Canada and Brazil. Phase 2 comprised in-person and virtual focus groups with adults enrolled in a Canadian CR program. Data from Phases 1 and 2 were analyzed using thematic analysis to generate candidate recommendations. Phase 3 consisted of a 2-round Delphi process with CR health care professionals and patients from 31 countries across all 6 World Health Organization regions, who rated recommendation importance using a 5-point Likert scale. Consensus was assessed using descriptive statistics. Results: Focus groups with dietitians (n = 27) and CR participants (n = 15) generated 26 recommendations across 7 thematic categories. In the 2-round Delphi process (N = 102), 15 recommendations reached consensus in round 1 and were refined, while 11 were excluded or merged. Twelve recommendations progressed to round 2, yielding a final set of 11 consensus-based recommendations. Key priorities included flexibility, cultural and religious relevance, affordability, local food availability, individualized counseling, and emphasis on heart-healthy behaviors over weight loss. Alcohol was considered nonessential, with support for excluding it from educational materials. Conclusions: This international, stakeholder-informed study established 11 consensus recommendations to guide culturally responsive adaptation of the Mediterranean diet in CR. Findings support flexible, patient-centered dietary approaches that maintain cardioprotective principles while enhancing feasibility and relevance across diverse global settings.

With an ageing population and the persistence of unhealthy lifestyle behaviours, health-care systems are challenged by a growing number of individuals living longer with cardiovascular disease and its sequelae. The evolution of cardiac rehabilitation, from a group exercise-based programme to encompassing all aspects of secondary prevention, has led to the ultimate objective of achieving lifelong cardiovascular health for all. In this World Heart Federation Roadmap, we present a united and forward-looking vision to consolidate global and collaborative efforts that enhance equitable access, improve patient outcomes and ensure value-based health care. The Roadmap outlines a reframing of terminology and interconnected solutions founded on unity, person-centredness and being future-focused. The five key roadblocks and widely applicable solutions are interlinked and include having a greater emphasis on lifelong cardiovascular health, better engagement among patients and clinicians, a greater emphasis on new models of care, workforce strengthening and support for strong advocacy and policy. We present a series of practical solutions and successful international case studies. The next steps are to facilitate local and regional implementation and evaluation strategies. A shift to systems, policy and advocacy thinking is crucial for the sector, with a view to long-term investment to meet growing demands. This World Heart Federation Roadmap is endorsed by the International Council of Cardiovascular Prevention and Rehabilitation.