Women and cardiac rehabilitation: Moving beyond barriers to solutions?

The prognostic benefit of cardiac rehabilitation, even in the contemporary era of advances in treatment for cardiovascular disease, is well-established. Indeed, we might argue that fully realising the benefit of primary percutaneous coronary intervention for myocardial infarction (MI), new cardiovascular surgical procedures and drug therapy is not possible unless patients are supported to recover physiologically and psychologically, adhere to prescribed treatment and change unhealthy behaviours. Research shows that we still fail to achieve good control of risk factors in women and men with cardiovascular disease across Europe. Thus, comprehensive cardiac rehabilitation is more important than ever, and must continue to evolve to keep up with innovation in treatment and to address the challenges of patients with different needs and preferences, and the world’s ageing population. Cardiac rehabilitation has already evolved from its roots in early ambulation post-MI in the 1960s to the comprehensive programme of exercise-based rehabilitation and secondary prevention of today. And yet, despite demonstrated benefit, evidence indicates that only 20–50% of eligible patients participate in cardiac rehabilitation. The problem is especially acute in certain groups, with women, older patients and minorities having much lower participation rates. A recent Cochrane review of the effectiveness of exercise-based cardiac rehabilitation versus no exercise control on core outcomes (mortality, morbidity and quality of life) found that women accounted for fewer than 15% of the patients recruited within the included trials. Numerous papers have reviewed the barriers to low participation rates overall and specifically to high risk groups such as women. Innovative models of delivery such as home-based programmes and telehealth interventions have similar outcomes to traditional centre-based rehabilitation, with the caveat that patients participating tend to be younger and healthier. Unfortunately the uptake of innovative delivery remains limited. In the recent audit of cardiac rehabilitation in the UK, group-based supervised cardiac rehabilitation remained the dominant mode of delivery (77%) with home-based (8%) and telephone supported (17%) infrequently provided. Other groups have evaluated in-hospital cardiac rehabilitation programmes as a means to address the needs of high-risk groups such as those with heart failure and high comorbidity burden. In a narrative review in this issue, Vidal-Almela and colleagues remind us that for women, barriers to cardiac rehabilitation participation are multiple and complex, traversing all levels of the ecological model of health. They also highlight the gender gap observed in cardiac rehabilitation and the dearth of research focusing exclusively on women or alternative modes of delivery that may better suit women. What differentiates this review from previous endeavours is the authors’ willingness to look beyond strictly cardiovascular disease (CVD) focused programmes for insights into how we may improve appeal, uptake, completion and ongoing adherence. The rationale for looking to allied disciplines for solutions is clear: community and home-based physical activity and primary prevention programmes appear to attract substantial numbers of women, deliver high satisfaction levels and some achieve high rates of adherence and completion. What do these community-based activity programmes offer women that cardiac rehabilitation may not? Such programmes tended to be embedded in the local community or convenient locations, much more