Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease

INTRODUCTION — Lack of physical activity is among the risk factors that have adverse effects on atherosclerotic cardiovascular events. Numerous observational studies in both males and females have demonstrated that regular exercise and physical fitness are both associated with a reduced risk of coronary events and coronary death. (See "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease".)

Many patients who are eligible for and require exercise training as part of their recovery do not receive such therapy, often because of lack of awareness by healthcare professionals, by patients and their families, and by healthcare insurers of the appropriateness and effectiveness of an exercise intervention [1].

Based upon these observations and the demonstrated benefit of risk factor reduction, cardiac rehabilitation programs were developed to provide exercise training and counseling on risk factor modification for the secondary prevention of coronary heart disease [2-6]. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk".)

Cardiac rehabilitation programs are comprehensive, long-term services involving medical evaluation, supervised exercise, cardiac risk factor modification, education, and counseling. They limit the physiologic and psychologic effects of cardiac illness, reduce the risk of sudden death or reinfarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients. Cardiac rehabilitation improves risk factors, exercise capacity, medication adherence to secondary preventive therapies, and survival after percutaneous coronary intervention and coronary artery bypass graft surgery [7,8].

The efficacy and safety of cardiac rehabilitation programs will be reviewed here. The details of these programs are discussed separately. (See "Cardiac rehabilitation programs".)

INDICATIONS — For all patients with an acute coronary syndrome, recent myocardial revascularization, systolic heart failure, stable angina pectoris, heart valve repair or replacement, heart transplant or left ventricular assist device, or symptomatic peripheral artery disease, we recommend referral to a cardiac rehabilitation program [1,9,10].

There has been wide acceptance of the benefits of supervised exercise programs for patients with stable angina, recent myocardial infarction (MI), and recent coronary artery bypass surgery (CABG) for decades.

In the United States, healthcare insurers have recognized these benefits and approved payment for them.

Other candidates for cardiac rehabilitation/secondary prevention programs include those with diabetes, pulmonary artery hypertension, heart failure with preserved ejection fraction, and congenital heart disease [6].

Many studies presented in this topic focus on the efficacy of cardiac rehabilitation in patients with recent MI or acute coronary syndrome. However, there has been wide acceptance of the benefits of supervised exercise programs for most patients with coronary heart disease. Rehabilitation services for patients with coronary artery revascularization procedures using either percutaneous coronary intervention or coronary artery bypass surgery and for patients with stable angina are covered by Medicare and third party payers in the United States [11,12]. Referral for cardiac rehabilitation is recommended in clinical practice guidelines, including those for ST-segment elevation MI, unstable angina/non-ST segment elevation MI, chronic stable ischemic heart disease, percutaneous coronary intervention, heart failure, peripheral artery disease, and CABG.

Indications for exercise in older patients is discussed separately. (See "Cardiac rehabilitation in older adults", section on 'Exercise in older adults'.)

EVIDENCE OF BENEFIT — Participation in a cardiac rehabilitation program improves outcomes such as survival or recurrent MI in patients with acute MI or prior revascularization. The evidence of benefit is less robust in patients with stable angina pectoris. While all components of cardiac rehabilitation programs are important for long-term benefit, the relative strengths of the components are not known. Exercise training is the best studied, and it is reasonable to assume it is a major important component.

Exercise training — Exercise-based cardiac rehabilitation programs are associated with improved survival and a lower rate of MI in patients with acute MI or prior revascularization. Several meta-analyses have evaluated exercise rehabilitation alone or as a component of multifactorial rehabilitation with risk-factor education and counseling [13-18]

Duration and type of benefit

●Cardiovascular disease outcomes – In a meta-analysis of 85 randomized controlled trials (RCTs) of cardiac rehabilitation with 23,430 people with coronary heart disease, exercise-based cardiac rehabilitation improved short-, medium- and long-term outcomes, although the specific beneficial effects differed depending on length of follow-up period [18].

•Short-term (6 to 12 months) – At short‐term follow‐up, exercise‐based cardiac rehabilitation resulted in a reduction in MI (risk ratio [RR] 0.72, 95% CI 0.55-0.93; number needed to treat for an additional beneficial outcome [NNTB] 75, 95% CI 47-298) and a reduction in all‐cause hospitalization (RR 0.58, 95% CI 0.43-0.77; NNTB 12, 95% CI 9-21). Exercise‐based cardiac rehabilitation resulted in little to no difference in risk of all-cause mortality, cardiovascular mortality, coronary artery bypass graft surgery (CABG), or percutaneous coronary intervention (PCI).

•Medium-term (>12 to 36 months) – At medium‐term follow‐up, those randomized to exercise-based cardiac rehabilitation had a reduction in cardiovascular mortality (RR 0.77, 95% CI 0.63-0.93). Exercise‐based cardiac rehabilitation resulted in no difference in all‐cause mortality, MI, PCI, CABG, or all‐cause hospitalization.

•Long-term (>3 years) – At long‐term follow‐up, exercise‐based cardiac rehabilitation was associated with a reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43-0.78) and MI (RR 0.67, 95% CI 0.50-0.90). There was no clear benefit in all‐cause mortality (RR 0.91, 95% CI 0.75-1.10), CABG (RR 0.66, 95% CI 0.34-1.27), or PCI (RR 0.76, 95% CI 0.48-1.20).

●Activity and quality of life – Exercise rehabilitation may have benefits in addition to reductions in recurrent MI and/or mortality [13,14]. Improvement in functional capacity, including an increase in the activity threshold before the onset of ischemia, and a reduction in symptoms can enable return to work and leisure and recreational activities. For elderly patients, moderate increases in functional capacity can help maintain independent living [19].

●Dose response – One study suggested a dose-response relationship between number of cardiac rehabilitation sessions attended and reduction in cardiac events and death [20]. Among 2345 patients attending cardiac rehabilitation (average of 12 sessions attended), 695 experienced a cardiac event or death over six years of follow-up. Cardiac rehabilitation dose was inversely associated with a cardiac event or death (hazard ratio [HR] 0.98, 95% CI 0.97-0.99), as was greater session frequency (HR 0.74, 95% CI 0.58-0.94).

●In a recent meta-analysis of contemporary management for coronary heart disease, exercise-based cardiac rehabilitation was associated with a risk reduction in cardiovascular mortality, hospitalizations, and myocardial infarction. There was some evidence of improved health-related quality of life, and cardiac rehabilitation was cost effective [21].

●Specific patient groups – For patients with stable coronary disease, the evidence to support its use is weaker. A 2018 systematic review of seven studies (n = 581) that compared cardiac rehabilitation with no exercise control found no clear evidence of benefit in all-cause mortality (RR 1.01, 95% CI 0.18-5.67), acute MI (RR 0.33, 95% CI 0.07-1.63), or cardiovascular-related hospital admissions (RR 0.14, 95% C I 0.02-1.1) [22]. The authors articulated their concerns about the small sample size, the risk of bias, and the possibility of imprecision.

Patients who have undergone CABG benefit from cardiac rehabilitation. In a community-based analysis of 846 individuals who underwent CABG between 1996 and 2007, and who survived at least six months, those who participated in a cardiac rehabilitation program (compared with those who had not) had a lower incidence of all-cause mortality (adjusted) at 10 years (23.0 versus 35.7 percent; adjusted HR 0.54, 95% CI 0.40-0.74) [23]. In patients who had CABG, a comprehensive rehabilitation and intensive education program had a favorable effect on anxiety, depression, quality of life, and major adverse coronary events [24].

Mechanisms of benefit — A number of factors may contribute to the benefit of exercise rehabilitation. Well-described effects include improvement in the lipid profile, a reduction in blood pressure, and treatment and prevention of type 2 diabetes. (See "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease".)

In a randomized trial of 74 overweight patients with coronary artery disease, high-calorie expenditure exercise (3000 to 3500 kcal/week), compared with standard cardiac rehabilitation exercise (700 to 800 kcal/week), was associated with a significantly greater weight loss and a more favorable cardiometabolic risk profile with the high-calorie expenditure approach [25].

Other factors also may contribute. These include a reduction in inflammation, as manifested by a decrease in serum C-reactive protein concentration that is independent of weight loss and other medical therapies [26], and possibly ischemic preconditioning. Exercise is also associated with improved endothelial function and a more favorable fibrinolytic balance. (See "Myocardial ischemic conditioning: Clinical implications".)

Exercise training has beneficial hemodynamic effects in patients following MI, including a lower heart rate and blood pressure for a given level of exertion and improvement in aerobic capacity averaging 20 percent. Resistance (strength) training, when superimposed on aerobic training, improves skeletal muscle strength and endurance. More important are reductions in both mortality and recurrent MI.

Abnormal heart rate recovery predicts mortality. In a study of 544 patients with abnormal baseline heart rate recovery before a Phase II Cardiac Rehabilitation Program, heart rate recovery improved in 41 percent [27]. There was a strong association of abnormal heart rate recovery at program exit with all-cause mortality; however, patients with an abnormal heart rate recovery at baseline who normalized their heart rate recovery with exercise training had mortality similar to that of individuals with baseline normal heart recovery.

Exercise training after MI also may improve left ventricular function and attenuate remodeling. These benefits were demonstrated in the Exercise in Left Ventricular Dysfunction (ELVD) trial in which the efficacy of exercise was evaluated in patients with a first Q wave MI and a left ventricular ejection fraction below 40 percent [28]. A six-month exercise training program increased both exercise capacity and the left ventricular ejection fraction (from 34 to 38 percent), while left ventricular end systolic and diastolic volumes were unchanged compared to increased volumes in the control group. In a 2011 systematic review, a beneficial effect of exercise training on left ventricular remodeling was shown in clinically stable patients following MI [29]. The greatest benefit occurred when training started earlier following MI (from one week) and lasted longer than three months.

Exercise-based cardiac rehabilitation had favorable effects on cardiovascular risk factors, including smoking, blood pressure, body weight, and lipid profile [15]

Psychosocial intervention — The possible benefit of reducing emotional distress and depression in patients with cardiovascular disease is discussed in detail elsewhere. (See "Psychosocial factors in acute coronary syndrome", section on 'Depression after acute coronary syndrome' and "Psychosocial factors in coronary and cerebral vascular disease", section on 'Interventions'.)

The following studies have attempted to evaluate the role of stress management in patients enrolled in cardiac rehabilitation programs or those with recent MI:

●In a study of individuals with coronary heart disease, 151 individuals were randomly assigned to 12 weeks of comprehensive cardiac rehabilitation or cardiac rehabilitation combined with stress management training [30]. After a median follow-up of 3.2 years, patients in the cardiac rehabilitation plus stress management training group had greater reduction in composite stress levels (p = 0.02). In addition, the stress management group had a lower rate of clinical events (18 versus 33 percent; hazard ratio 0.49, 95% CI 0.25-0.95), although the number of events was small.

●In the randomized ENRICHD trial of psychosocial interventions in 2481 patients after MI, patients receiving psychosocial intervention had less depression and better levels of perceived social support, but there was no reduction in mortality (24 percent in both groups at a mean follow-up of 29 months) [31].

●In a randomized trial of 134 patients with stable coronary heart disease (57 percent with a prior MI) and exercise-induced ischemia, the patients were assigned to usual medical care alone, with exercise training for 35 minutes three times per week, or with 1.5 hours of stress management training for 16 weeks [32]. Compared to usual care, exercise and stress management were associated with significant reductions in general distress and depressive symptoms (without between-group differences in hostility or anxiety measures), and with significant improvements in markers of cardiovascular risk, such as a smaller reduction in left ventricular ejection fraction during mental stress testing and a lower mean wall motion abnormality score in patients with significant stress-induced wall motion abnormalities at baseline.

●Depressive symptoms were assessed by questionnaire and mortality was evaluated at 40 months in over 500 consecutive coronary patients completing versus not completing rehabilitation [33]. Depressed patients had an over fourfold increase in mortality, 22 versus 5 percent, versus nondepressed patients; depressed patients completing rehabilitation had a substantially lower mortality, 8 versus 30 percent. Decreased depressive symptoms and decreased mortality were associated with improved fitness, with only modest improvement in fitness levels needed to produce these benefits.

Intensive cardiac rehabilitation — As an alternative to traditional cardiac rehabilitation, intensive cardiac rehabilitation includes exercise, extensive nutrition education, stress management, and group support. In the United States, two intensive programs are active: Ornish Lifestyle Medicine program and the Pritikin program [34]. A recent retrospective cohort study of over 15,000 participants enrolled in 46 Ornish intensive cardiac rehabilitation programs across the United States compared outcomes in males (46 percent) and females (44 percent). Of the participants who completed the program, females had greater depression and quality-of-life improvements compared with males. Program completion rates were approximately 65 percent for both males and females, showing an improvement in completion rate among females, which is often lower than males in traditional cardiac rehabilitation programs [35].

A recent study showed that the most frequent barriers to participation in cardiac rehabilitation were age; comorbidities; lack of support from friends, family, and health workers; distance or time traveled; cost; and economic status [36].

Role of program completion — Benefits of cardiac rehabilitation occur only if the patient attends and completes an appropriate program. A study suggested that mailouts plus telephone support increased the likelihood of completing cardiac rehabilitation by enhancing goal priority, self-efficacy, and outcome expectancies [37].

A prospective cohort study focused on 5886 patients following coronary angiography (70 percent after an ACS) subsequently referred for cardiac rehabilitation between 1996 and 2009 [38]. Of these, 2432 did not start, 554 started but did not complete, and 2900 completed a program. The median length of follow-up was 5.4 years and the median time to enrollment (among those who participated) was 84 days. The patients who completed cardiac rehabilitation, compared to the combination of non-completers and non-enrollers, had a lower risk of death (adjusted hazard ratio [HR] 0.59, 95% CI 0.49-0.84) and all-cause hospitalization (adjusted HR 0.77, 95% CI 0.71-0.84). The rate of survival was similar between non-enrollers and non-completers. In a propensity-matched analysis, patients who attended 36 sessions had a 22 percent lower risk of death than those who completed 12 sessions (HR, 0.78; 95% CI, 0.71 to 0.87). Similar findings have been noted in other studies [39].

Conversely, another meta-analysis showed that participation in cardiac rehabilitation in patients with acute myocardial infarction was the highest in those characterized as male, with an education level of university or above, with ST segment elevation myocardial infarction, and a higher economic level, while patients with acute myocardial infarction over the age of 60 with decreased left ventricular ejection fraction, a history of coronary heart disease, smoking, combined hypertension, and combined hyperlipidemia were less likely to participate [40].

COMPREHENSIVE RISK FACTOR INTERVENTION — Comprehensive risk factor intervention refers to the sustained use by the patient of all evidence-based therapies (including medications, exercise, diet, smoking cessation, and counseling). However, many cardiac rehabilitation programs support the patient for one or two of these, such as exercise and medications, and many do not offer long-term care.

Magnitude of benefit — The magnitude of benefit when all major aspects of secondary prevention are followed derives from the findings of observational studies [41-45], of which the following two epidemiologic studies are representative.

●The magnitude and causes of the reduction in coronary heart disease (CHD) mortality was evaluated in adults between the ages 25 and 84 in the United States from 1980 to 2000 [44]. The age-adjusted death rate for CHD in males and females fell from 543 to 267 and from 263 to 134 per 100,000 population, respectively. Approximately one-half of this effect was due to improvements in therapy, including secondary preventive measures or revascularization after myocardial infarction (MI).

●Temporal trends in mortality after hospitalization for acute myocardial infarction (MI) were evaluated in over 21,000 elderly patients (average age 80 years) between 1995 and 2004 who survived at least 30 days [45]. Mortality decreased significantly over time by about 3 percent per year and was entirely explained by the combined use of statins, beta blockers, angiotensin converting enzyme inhibitors or angiotensin II receptor blockers, and antiplatelet drugs.

Short-term comprehensive intervention — Direct evidence of benefit from short-term comprehensive rehabilitation programs comes from the EUROACTION trial, which randomly assigned 12 hospitals to deliver either a comprehensive risk factor intervention program or usual care (no cardiac rehabilitation) to over 1800 patients with established CHD [46]. The intervention patients and their partners received at least eight sessions of a hospital-based, nurse-coordinated, multidisciplinary program in which dietary instruction, exercise training, smoking cessation support, and monitoring of the use of cardioprotective drugs and risk factors were performed.

Compared with patients who received usual care, patients in the intervention programs who either smoked or had hypertension at baseline had significantly higher rates of smoking cessation (58 versus 47 percent) or achievement of the blood pressure target of <140/90 mmHg (65 versus 55 percent) at one year. Significant improvements in multiple recommended dietary components were also seen in patients in the intervention groups, but there was no significant difference in other end points such as achievement of lipid or body mass index goals.

Long-term comprehensive intervention — The effect on prognosis of a long-term intensive rehabilitation strategy was evaluated in the Italian GOSPEL trial in which 3241 patients with a recent MI were randomly assigned to either a three-year intensive, multifactorial, continuous educational and behavioral program or to usual care [47]. All patients received standard post-MI, one-month cardiac rehabilitation.

The primary combined end point (cardiovascular mortality, nonfatal MI, nonfatal stroke, or hospitalization for angina pectoris) was not significantly improved by intensive intervention (16.1 versus 18.2 percent for usual care). However, intensive intervention significantly decreased several secondary end points, including the combination of cardiovascular mortality plus nonfatal MI and stroke (3.2 versus 4.8 percent) and cardiac death plus nonfatal MI (2.5 versus 4.0 percent).

SAFETY — A number of studies have documented the safety of cardiac rehabilitation in supervised programs; many antedated current beneficial medical and revascularization therapies [48-51]. In a more contemporary study of over 25,000 patients enrolled in 65 cardiac rehabilitation centers in 2003, there was one cardiac event for every 8484 exercise tests performed, one cardiac event for every 50,000 patient hours of exercise training, and 1.3 cardiac arrests for every million patient hours of exercise [51].

The 2007 American Heart Association scientific statement on exercise and acute cardiovascular events estimated that the risk of any major cardiovascular complication (cardiac arrest, death, or MI) is one event in 60,000 to 80,000 hours of supervised exercise [52]. The 2023 European Society of Cardiology Guidelines for the Management of Acute Coronary Syndromes provides a strong recommendation for cardiac rehabilitation [53].

Additional information is available in a related topic. (See "Cardiac rehabilitation programs", section on 'Risk stratification for exercise'.)

RECOMMENDATIONS OF OTHERS — The 2011 American Heart Association/American College of Cardiology Foundation secondary prevention and risk reduction guideline (and other guidelines) makes a strong recommendation for referral to a cardiac rehabilitation program for patients with recent myocardial infarction or unstable angina, chronic stable angina, heart failure, or recent myocardial revascularization [1,3].

The 2017 European Society of Cardiology (ESC) guidelines for the management of acute MI in patients presenting with ST-segment elevation [54] and the 2019 ESC guidelines on the diagnosis and management of chronic coronary syndromes [55] strongly recommend referral to cardiac rehabilitation programs [56].

UTILIZATION RATES — Despite the benefits of cardiac rehabilitation described above, only 10 to 33 percent of eligible patients following myocardial infarction participate in formal structured cardiac rehabilitation in the United States and the United Kingdom [57-63]. The primary reason is likely low rates of referral (20 to 30) [2,9,10,64,65]. Females, patients over age 65 (and particularly older than 75), and racially or ethnically underrepresented groups have particularly low rates [58,59,66,67]. In addition, patients with less medical insurance coverage and with geographic accessibility limitations to program sites are less likely to be referred and to participate [1]. Other predictors of suboptimal participation include poor functional status, higher body mass index, tobacco use, depression, long-distance to facilities, low health literacy, and inflexible work schedules [1,68,69]. (See "Cardiac rehabilitation programs", section on 'Summary'.)

Unfortunately, low utilization rates were substantiated in a recent study of 366,000 Medicare fee-for-service beneficiaries eligible for outpatient cardiac rehabilitation; only approximately one-fourth (24.4 percent) participated. Among patients who participated, 24.3 percent began the program within 21 days, and 26.9 percent completed 36 or more sessions. Similar to older studies, participation decreased with increasing age, was lower among females compared with males, and was lower among Hispanic individuals and non-Hispanic Black compared with non-Hispanic White individuals [70].

Duncan and colleagues sought to determine how access to cardiac rehabilitation centers impacts the initiation of cardiac rehabilitation in Medicare beneficiaries. Density of cardiac rehabilitation programs accounted for 23.5 percent of geographic variation in the initiation of cardiac rehabilitation at the Hospital Referral Region level, whereas the average distance to the nearest cardiac rehabilitation center accounted for only 7.4 percent of geographic variation. Furthermore, a geospatial analysis was conducted to identify where cardiac rehabilitation was particularly limited. Of the 3006 counties nationwide, 39 were identified as cardiac rehabilitation deserts with disproportionately low access to cardiac rehabilitation services. Cardiac rehabilitation deserts had a higher proportion of Hispanic residents (30 versus 9 percent for all counties) and Black residents (12 versus 9 percent for all counties) aged 65 years or older [71].

HOME-BASED AND HYBRID CARDIAC REHABILITATION — Home-based cardiac rehabilitation is an option for clinically stable low-to-moderate-risk patients who cannot attend center-based rehabilitation [72,73]. Technology has made it possible to provide key components of facility-based cardiac rehabilitation (supervised exercise training, education, and outcome assessment) through a secure connection to the patient using a personal mobile device [74]. A randomized controlled trial pilot study demonstrated the feasibility, acceptability, and clinical effectiveness of a technology-enabled remotely-monitored, home-based program of cardiac rehabilitation [75]. In a pragmatic trial, coronary patients enrolled in home-based cardiac rehabilitation appeared to derive equivalent benefit in efficient exercise capacity and overall program efficacy to facility-based cardiac rehabilitation [76].

Attendance and safety appear comparable. Virtual rehabilitation during the COVID-19 pandemic requires long-term assessment [77].

A recent systematic review of 24 randomized controlled trials compared the effects of home-based versus supervised center-based cardiac rehabilitation on several outcomes, with up to 12 months of follow-up. No difference was observed between home- and center-based cardiac rehabilitation for total mortality or exercise capacity. No difference was observed in health-related quality of life at up to 24 months of follow-up [78].

Cardiac rehabilitation is evolving to include in-person synchronous, virtual, and remote modes of delivery, which have the scope to broaden geographic access to improve patient outcomes and address health inequities [79]. Research is ongoing to develop optimal hybrid cardiac rehabilitation programming [80]. In a randomized controlled trial in coronary patients, home-based exercise using telemonitoring was equally effective to a center-based program [81]. Also, a virtual-rehabilitation-based video game program as an adjunct to cardiac rehabilitation showed improvement in ergometry, METs, resistance to fatigue, and health-related quality of life [82].

A recent science advisory by the American Heart Association facilitates the development and implementation of digital strategies for cardiac rehabilitation that can be readily translated into clinical care, improve health outcomes, and support health equity. The digital components that can be integrated into a cardiac rehabilitation telehealth program are described along with inherent challenges [83].

A recent report from the University of Michigan, using SCOREPAD-identified patients at low risk, studied patients suitable for participation in alternative models of cardiac rehabilitation. Patients derived substantial benefit, and the study concluded that their training expertise showed a substantial percentage of such patients [84].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Primary prevention of cardiovascular disease" and "Society guideline links: Secondary prevention of cardiovascular disease" and "Society guideline links: Lifestyle management and cardiac rehabilitation".)

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●Basics topics (see "Patient education: Heart attack recovery (The Basics)" and "Patient education: Recovery after coronary artery bypass graft surgery (The Basics)")

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SUMMARY AND RECOMMENDATIONS

●Benefit – Cardiac rehabilitation improves risk factors, exercise capacity, and survival after percutaneous coronary intervention and coronary artery bypass graft surgery and prevents recurrent myocardial infarction. (See 'Evidence of benefit' above.)

●Indications – For all patients with coronary artery disease, including those with an acute coronary syndrome, recent myocardial revascularization, or stable angina pectoris, we recommend referral to a cardiac rehabilitation program (Grade 1A). (See 'Indications' above.)

Other patients who will likely benefit from participation in a cardiac rehabilitation program include those with chronic heart failure, prior heart or heart-lung transplantation, heart valve repair or replacement, and symptomatic peripheral arterial disease. (See 'Indications' above.)

●Comprehensive risk factor intervention – Many cardiac rehabilitation programs include not only an exercise component, but also comprehensive risk factor management, including help with medications, diet, smoking cessation, and psychosocial counseling. (See 'Comprehensive risk factor intervention' above.)

●Utilization rates – Utilization remains low, particularly among females and Hispanic and Black people as compared with White people. Low physician referral is the primary reason for low referral rates.

●Home-based and hybrid rehabilitations – These programs can be effective and can be a way to overcome geographic and time-based limitations to patient participation.