We investigated impacts of COVID-19 on cardiac rehabilitation (CR) delivery around the globe, including virtual delivery, as well as effects on providers and patients. In this cross-sectional study, a piloted survey was administered to CR programs globally via REDCap from April to June 2020. The 50 members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) and personal contacts facilitated program identification. Overall, 1062 (18.3% program response rate) responses were received from 70/111 (63.1% country response rate) countries in the world with existent CR programs. Of these, 367 (49.1%) programs reported they had stopped CR delivery, and 203 (27.1%) stopped temporarily (mean = 8.3 ± 2.8 weeks). Alternative models were delivered in 322 (39.7%) programs, primarily through low-tech modes (n = 226,19.3%). Furthermore, 353 (30.2%) respondents were re-deployed, and 276 (37.3%) felt the need to work due to fear of losing their job, despite the perceived risk of contracting COVID-19 (mean = 30.0% ± 27.4/100). Also, 266 (22.5%) reported anxiety, 241(20.4%) were concerned about exposing their family, 113 (9.7%) reported increased workload to transition to remote delivery, and 105 (9.0%) were juggling caregiving responsibilities during business hours. Patients were often contacting staff regarding grocery shopping for heart-healthy foods (n = 333, 28.4%), how to use technology to interact with the program (n = 329, 27.9%), having to stop their exercise because they have no place to exercise (n = 303, 25.7%), and their risk of death from COVID-19 due to pre-existing cardiovascular disease (n = 249, 21.2%). Respondents perceived staff (n = 488, 41.3%) and patient (n = 453, 38.6%) personal protective equipment, as well as COVID-19 screening (n = 414, 35.2%), and testing (n = 411, 35.0%) as paramount to in-person service resumption. Given the estimated number of CR programs globally, these results suggest approximately 4400 CR programs globally have ceased or temporarily stopped service delivery. Those that remain open are implementing new technologies to ensure their patients receive CR safely, despite the challenges.

Cardiac rehabilitation (CR) programs are underutilized globally, especially by women. In this study we investigated sex differences in CR barriers across all world regions, to our knowledge for the first time, the characteristics associated with greater barriers in women, and women's greatest barriers according to enrollment status. In this cross-sectional study, the English, Simplified Chinese, Arabic, Portuguese, or Korean versions of the Cardiac Rehabilitation Barriers Scale was administered to CR-indicated patients globally via Qualtrics from October 2021 to March 2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated participant recruitment. Mitigation strategies were provided and rated. Participants were 2163 patients from 16 countries across all 6 World Health Organization regions; 916 (42.3%) were women. Women did not report significantly greater total barriers overall, but did in 2 regions (Americas, Western Pacific) and men in 1 (Eastern Mediterranean; all P < 0.001). Women's barriers were greatest in the Western Pacific (2.6 ± 0.4/5) and South East Asian (2.5 ± 0.9) regions (P < 0.001), with lack of CR awareness as the greatest barrier in both. Women who were unemployed reported significantly greater barriers than those not (P < 0.001). Among nonenrolled referred women, the greatest barriers were not knowing about CR, not being contacted by the program, cost, and finding exercise tiring or painful. Among enrolled women, the greatest barriers to session adherence were distance, transportation, and family responsibilities. Mitigation strategies were rated as very helpful (4.2 ± 0.7/5). CR barriers-men's and women's-vary significantly according to region, necessitating tailored approaches to mitigation. Efforts should be made to mitigate unemployed women's barriers in particular.

Alternative models of cardiac rehabilitation (CR) delivery, such as home or community-based programs, have been developed to overcome underutilization. However, their availability and characteristics have never been assessed globally. In this cross-sectional study, a piloted survey was administered online to CR programs globally. CR was available in 111/203 (54.7%) countries globally; data were collected in 93 (83.8% country response rate). 1082 surveys (32.1% program response rate) were initiated. Globally, 85 (76.6%) countries with CR offered supervised programs, and 51 (45.9%; or 25.1% of all countries) offered some alternative model. Thirty-eight (34.2%) countries with CR offered home-based programs, with 106 (63.9%) programs offering some form of electronic CR (eCR). Twenty-five (22.5%) countries with CR offered community-based programs. Where available, programs served a mean of 21.4% ± 22.8% of their patients in home-based programs. The median dose for home-based CR was 3 sessions (Q25−Q75 = 1.0–4.0) and for community-based programs was 20 (Q25–Q75 = 9.6–36.0). Seventy-eight (47.0%) respondents did not perceive they had sufficient capacity to meet demand in their home-based program, for reasons including funding and insufficient staff. Where alternative CR models are offered, capacity is insufficient half the time. Home-based CR dose is insufficient to achieve health benefits. Allocation to program model should be evidence-based.

Although patient education is considered a core component of cardiac rehabilitation (CR) programs, to our knowledge, no educational program designed for CR has been standardized in Canada. This absence of standardization may be due to a lack of reliable resources to educate these patients. The objective of this study was to assess the effectiveness of an education intervention in improving knowledge and health behaviours among CR patients in 3 sites in Canada. CR patients were exposed to an evidence- and theoretically based comprehensive education intervention. Patients completed surveys assessing knowledge, physical activity, food intake, self-efficacy, and health literacy. All outcomes were assessed pre- and post-CR. Paired t tests were used to investigate variable changes between pre- and post-CR, Pearson correlation coefficients were used to determine the association between knowledge and behaviours, and linear regression models were computed to investigate differences in overall post-CR knowledge based on participant characteristics. A total of 252 patients consented to participate, of whom 158 (63.0%) completed post-CR assessments. There was a significant improvement in patients’ overall knowledge pre- to post-CR, as well as in exercise, food intake, and self-efficacy (P < 0.05). Results showed a significant positive correlation between post-CR knowledge and food intake (r = 0.203; P = 0.01), self-efficacy (r = 0.201; P = 0.01), and health literacy (r = 0.241; P = 0.002). Education level (unstandardized beta = −2.511; P = 0.04) and pre-CR knowledge (unstandardized beta = 0.433; P < 0.001) were influential in changing post-CR knowledge. In this first-ever multi-site study focusing on patient education for CR patients in Canada, the benefits of an education intervention have been supported.