Key messages
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Interventions to promote the use of cardiac rehabilitation (CR) programmes may increase enrolment of patients.
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The interventions probably lead to small increases in patients' attendance of CR programmes and patients are probably more likely to complete a CR programme.
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More high-quality trials are needed to confirm which strategies work best to improve the use of CR. As most participants were men, more research is needed on women, older adults, and other under-represented groups to help ensure CR programmes are effective and accessible to everyone.
What is cardiac rehabilitation (CR)?
CR is a therapy programme delivered by healthcare professionals that helps people recover and improve their heart health after a heart attack, heart surgery, or other heart problems including heart failure. CR helps improve recovery, prevent future heart problems, and support overall well-being. It is strongly recommended for people with these heart conditions.
What is the problem?
Despite its benefits, only a small number of people who are eligible worldwide take part in CR programmes. Also, if people do attend CR, many do not fully participate or complete the programme.
What did we want to find out?
We wanted to find out whether interventions to promote use of CR programmes can help more people:
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enrol into a CR programme;
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attend a CR programme; and
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complete a CR programme.
We also wanted to know if these interventions could cause any unwanted effects.
What did we do?
We searched for studies that tested different methods for increasing CR use. Only studies in which people were assigned randomly to two or more treatment groups were included. This is the best way to ensure that groups of participants are similar, and that investigators and participants don’t know who is in which group. We considered studies in all languages. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found a total of 47 studies (58 comparisons) with 10,803 people. Included studies were mainly done in North America and Europe, or other high-income countries. No studies from low- and middle-income country settings were included. The participants had conditions like heart attacks, angina, heart failure, or had undergone procedures such as bypass surgery or stent placement. Most participants were men. The studies tested a wide range of interventions, such as starting CR earlier, using digital tools, offering CR in different locations (such as at home), providing peer or healthcare professional support, tailoring programmes for women, and creating shorter or more flexible options.
Main results
In people with heart disease, interventions to promote the use of CR programmes:
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may increase CR enrolment of patients (27 studies, 726 people);
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probably lead to small increases in patients' attendance of CR (18 studies, 3024 people);
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probably make it more likely that patients will complete a CR programme (19 studies, 5432 people); and
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probably do not increase the number of serious unwanted effects (6 studies, 716 people).
What are the limitations of the evidence?
Our confidence in the evidence ranged from low to moderate, as the included studies used different ways of delivering interventions to increase CR use. While the results are promising, more high-quality studies are needed to confirm which strategies work best, especially for helping patients complete CR programmes. Little information was available on the costs or cost-effectiveness of interventions to promote CR use. Also, more research is needed on other groups, such as women, older adults, and people living in low- and middle-income countries. This may help to ensure CR programmes are useful and accessible for everyone.
How up‐to‐date is this evidence?
This review updates our 2019 review. The evidence is up‐to‐date to March 2025.
Read the full abstract
International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation.
Objectives
Primary objective
To assess the effects of interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation (CR) for people with myocardial infarction (MI), with angina, following coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI), or with heart failure (HF) who were eligible for CR in an inpatient or outpatient setting.
Secondary objectives
To assess intervention costs and associated harms with interventions intended to promote CR utilisation.
Search strategy
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (Wiley), MEDLINE (Ovid), Embase (OVID), CINAHL Cumulative Index to Nursing and Allied Health Literature (EBSCO), and Conference Proceedings Citation Index - Science (CPCI-S) via Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and searched two clinical trial registers. We did not apply any language restrictions. The date of search was 02 March 2025.
Selection criteria
We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity.
Data collection and analysis
Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random-effects meta-regression for each outcome and explored prespecified study characteristics.
Main results
Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation.
Low-quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta-regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face-to-face; P = 0.01) were influential in increasing enrolment. Low-quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home-based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate-quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi-centre studies were less effective than those given in single-centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient studies to test for this in the other outcomes).
With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women-tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment.
Authors' conclusions
This updated Cochrane review shows that a range of interventions may increase utilisation of CR in terms of CR enrolment, and likely increase CR adherence and completion. The certainty of the evidence was low to moderate due to high statistical heterogeneity across trials, which was likely due to the range of included interventions and the differences in outcome collection and reporting.
Funding
This Cochrane review was funded by the National Institute for Health Research (NIHR) under its Research and Innovation for Global Health Transformation (RIGHT) Programme (Grant reference: NIHR205540). LL, RST, and VW undertook this research as University of Glasgow-funded staff.
Registration
Protocol (2008): DOI 10.1002/14651858.CD007131/full
Original review (2010): DOI 10.1002/14651858.CD007131.pub2
Review updates (2014): DOI 10.1002/14651858.CD007131.pub3; (2019): DOI 10.1002/14651858.CD007131.pub4
