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Review of Recent Cardiac Rehabilitation Research Related to Enrollment/Adherence, Mental Health, and Other Populations

Ozemek, Cemal PhD; Lavie, Carl J. MD; Kaminsky, Leonard A. PhD

Author Information
Journal of Cardiopulmonary Rehabilitation and Prevention: September 2021 - Volume 41 - Issue 5 - p 302-307
doi: 10.1097/HCR.0000000000000649

The Journal of Cardiopulmonary Rehabilitation (JCRP) is dedicated to improving multidisciplinary clinical practice and expanding research evidence specific to both cardiovascular rehabilitation (CR) and pulmonary rehabilitation. This year an editorial subgroup of JCRP met to evaluate what have been the topic areas that have received the most attention in CR-related research in the recent time frame. In this review, we will overview three topic areas we observed as highly active in the CR research literature published in 2019 and 2020. We will provide a similar review for pulmonary rehabilitation in the near future.

First, we provide an overview of studies related to enrollment or adherence in CR programs. Despite the well-documented health benefits associated with CR participation, programs have historically faced challenges enrolling qualifying patients. However, there are growing examples of effective strategies institutions can take to increase the CR enrollment and adherence that are highlighted in this review. Next, we review the recent reports related to mental health, particularly, depression, stress, and anxiety of patients participating in CR programs. It is encouraging to see more attention on these important mental health topics related to patients in CR programs in the research literature. Finally, we summarize key findings from patients participating in CR programs with diagnoses other than coronary artery bypass graft (CABG), myocardial infarction (MI), or percutaneous coronary interventions (PCI). As JCRP is the only journal with a primary focus on CR, it was looked to first to identify the topic areas that have received the most attention in CR-related research literature. Each of these topic areas had multiple publications in JCRP these past 2 yr and also had reports published in other major journals that include some reports on CR, which we included in this review.



The first evaluation of CR enrollment data of Medicare beneficiaries in 2007 identified that <15% of patients with MI and 31% of patients who had undergone CABG surgery had received CR services.1 Further examination of patient characteristics identified that women, non-White, older patients, those with a lower mean income, lower education, and higher prevalence of disability had lower use rates.1 Consequently, well-coordinated campaigns, such as the Million Hearts initiative, were introduced to promote evidence-based strategies in overcoming common barriers to enrollment in CR.2 Although national CR participation rates have not yet reached the target goal of 70%, the cadre of recent publications provides reassurance that a move in the right direction is occurring with effective strategies to increase patient enrollment and adherence at the institutional level.

Information on the number of institutions that provided inpatient CR services and the proportion of patients who received the service has been lacking. An analysis of inpatient hospital service codes through the Premier Healthcare Alliance Inpatient Database, which represented >500 hospitals in the United States and accounted for 15-20% of US hospitalizations, found that only half offered inpatient CR and just >20% of patients used the service.3 Patients having undergone cardiac surgery had the highest utilization (43.3%) and the lowest was seen in those with medically managed MI (15.6%) or heart failure (HF;10.6%).

The latest national estimate of CR enrollment among Medicare beneficiaries demonstrated that only a quarter of qualifying patients took part in ≥1 CR session,4 well below the 70% goal identified by the Million Hearts initiative.2 In that sample, only 16.5% of patients with an MI participated in CR; however, MI patients receiving a cardiac procedure enrolled at a 34.5% rate compared with 7.1% without a procedure. The influence of undergoing a procedure was evident as 55.3% of beneficiaries without an MI undergoing CABG and 23.1% having a PCI participated in CR.4 Because referral rate data and level of CR endorsement were not available in this study, it is not possible to identify the reason why those without a procedure enrolled at lower rates. These data should, however, prompt clinics to evaluate whether similar trends exist within their system and promote CR referral/enrollment for all patients with a qualifying diagnosis, particularly those without a procedure.

One consistent observation over the existence of CR programs is men enrolling more readily than women.5 Cossette et al6 expanded this observation by exploring sex and gender-related factors associated with CR enrollment. These included contextual factors (eg, living near a CR center), sex-related factors (eg, age ≥65 yr), and gender-related factors (eg, education level). Comparatively, women had a greater number of sex- and gender-related factors (see Supplemental Digital Content Table 1, available at: that were associated with CR enrollment. Previously, active men (n = 207) living near a CR center were positively associated with enrolling in CR, while key themes for women (n = 35) included age, anxiety, emotional representations of their illness, and sense of control over their treatment. Unfortunately, there still is a lack of research related to participation of women in CR.7 Indeed, an attempt to perform a meta-analysis of the effects of CR in women was deemed inappropriate due to a lack of trials that involved women.8 It is important to note that additional investigations are needed due to the relatively low number of women in the study; however, these additional sex- and gender-related factors may help practitioners identify patients who are less likely to participate in CR and provide the appropriate attention to encourage their participation.

Although progress in improving enrollment rates at the national level is slow, recent examples of effective strategies at the state or institutional level suggest some viable models to follow. For instance, Frechette and colleagues9 reported a 98% CR referral rate among individuals undergoing PCI, CABG, or valve surgery across a system of 41 CR centers. Of these patients, 84% and 60% of patients participated in ≥1 session of CR at the institution where they received their surgical intervention or a regional CR program closer to their residence, respectively. The authors attributed their success to allocating CR nurses on the inpatient care team who identified patients qualifying for CR and strongly advocated for the service. Moreover, having had a dedicated staff member for this purpose extended beyond the benefits of having an automated referral system as they forged a personal connection and high-level trust between the patient and the practitioner.


The delivery of CR exercise services may be provided using a variety of different program designs. However, many, if not all, CR programs deliver service in group settings with multiple patients to one practitioner and offer exercise sessions either at set times or in an “open gym” model, which allows patients to arrive within a large time block (eg, 4-hr window). Whited et al10 provided an assessment of patient attendance and clinical outcomes in response to traditional CR scheduling and the open gym concept. This report could help programs considering one model over another.10 There were no differences observed between the number of CR sessions patients attended (traditional = 22, open gym = 20) and the proportion of patients completing CR (64 and 65%, respectively) between the two models. However, in the case of key clinical outcome measures representing cardiorespiratory fitness (CRF), both the 6-min walk distance (traditional +82.1 ± 57.5 m, open gym +57.2 ± 59.8 m) and peak metabolic equivalents of task (METs) (traditional +1.5 ± 1.4 vs open gym +1.0 ± 1.4 METs) improved to a greater extent in the traditional model of scheduling CR sessions. Although the authors were not able to statistically explore contributing factors for greater clinical improvements in the traditional model, they speculated that consistent scheduling may have facilitated regular interactions with a specific practitioner that fostered a greater familiarity with patients and led to more effective progression of the exercise intervention. An open gym model may increase the number of different practitioners a patient interacts with and reduce rapport.

Experimental strategies aimed at bolstering CR attendance, such as incorporating escalating financial incentives, have received much attention.11 Patients with a lower socioeconomic status were randomized to receive financial incentives and were shown to attend more sessions (22.4) compared with traditional CR participation (14.7) and nearly twice as likely to complete the program.12 However, both groups similarly improved CRF and quality of life. Perhaps the most prominent question surrounding the use of financial incentives relates to its cost-effectiveness. The initial analysis by Gaalema and colleagues12 revealed that their intervention was inexpensive in relation to its expected health gains. With this being the first study to investigate the effects of financially incentivizing graded CR participation, additional research is needed to determine its long-term health effects and cost-effectiveness. Financial considerations were also found to be important in a report by Farah et al.13 They found that for CR patients with some form of cost sharing (copays), higher cost sharing was associated with lower attendance.

Harris et al14 reported that neither anxiety nor depression alone was related to CR adherence; however, higher anxiety when coupled with greater will to live was associated with poorer attendance. Bennett et al15 evaluated CR attendance in safety net hospitals and noted that those with access to insurance and perceived lack of time were predictors of lower attendance. Additional recommendations on evidence-based interventions that increase CR enrollment and adherence are provided in the recent position statement on outpatient CR promotion and utilization.16


A comprehensive overview of home-based CR (HBCR) was recently summarized in a Scientific Statement from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), the American Heart Association, and the American College of Cardiology.17 A recent comparison between two Veterans Affairs CR programs, one providing center-based and one HBCR, found enrollment times in HBCR to be significantly shorter and patients were more likely to complete >85% of sessions compared with center-based CR.18 Similarly, Schopfer et al19 reported shorter time to enrollment and, interestingly, greater functional improvement gains at 3 mo. Uddin and colleagues20 also found the delivery of HBCR in CABG patients to be feasible and safe when providing monthly phone calls over a 12-mo intervention period. Others have similarly reported on the feasibility of HBCR in CABG patients and have even shown these patients to be twice as likely to complete HBCR compared with PCI patients.21 When possible, providing the option of a hybrid model that allows patients to attend center-based CR either for their initial sessions, followed by HBCR or periodically attending center-based CR to serve as boosters is encouraged. A recent meta-analysis revealed that hybrid CR contributed to a 9.7 mL/kg/min (2.8 METs) increase in peak oxygen consumption (V˙o2peak) over usual care.22 This is especially meaningful when considering the robust adverse event risk reduction experienced with a 1 MET improvement in CRF.23

Recent technological advancements (eg, smartphones and software enabling the delivery of virtual home exercise) and their increasing availability have expanded opportunities to provide real-time virtual exercise sessions and consultations for HBCR, thus increasing the feasibility of patients enrolling in an outpatient CR program and adhering to the prescribed number of sessions that may have otherwise been difficult due to transportation and work-associated barriers. Prior to the coronavirus disease 2019 (COVID-19) pandemic, telemedicine real-time monitoring of patients was limited mostly to clinical trials, with fewer CR programs pursuing its clinical application due to reimbursement limitations. Prior to the pandemic, Berry et al24 provided two clinical case studies that outlined the procedural methods of delivering real-time virtual CR sessions in addition to considerations related to billing. Subsequent recommendations to temporarily pause outpatient CR led to states approving virtual health services. Although published data characterizing the adoption of virtual CR services are not yet available, regular webinars provided through the AACVPR have likely contributed to programs contemplating the adoption of this platform.


Considerable evidence suggests that lifestyle factors play a major role in cardiovascular diseases (CVD), and among these lifestyle factors, various psychological risk factors have significant impacts. These include anxiety, hostility, and, especially, depression, which play a major role in the pathogenesis and progression of major CVD and may be involved in the prognosis of patients after major CVD events.25–29 In fact, the INTERHEART study showed that psychosocial factors were similar to smoking and second only to lipids in the population attributable risk for MI.30 Not surprisingly, considerable evidence has focused on the importance of various psychological factors in preventive cardiology and CR.25,26,29


Certainly, one of the most important psychological risk factors is depression. Milani and Lavie31 at the John Ochsner Heart and Vascular Institute in New Orleans demonstrated many years ago that patients with depression who complete CR have four- to fivefold higher mortality rates than do those without depression, and patients with depression who do not attend CR have mortality rates during the next 3 yr almost threefold higher than those who attend CR. Improvements in CRF assessed by gas exchange and V˙o2peak were associated with reductions in depression and depression-related increased mortality risk. Many patients with depression also have other psychological risk factors, including anxiety and hostility, and these additional comorbid conditions add somewhat to the risks imposed by depression.32 However, most of the mortality related to psychological stress seems to be explained statistically by depression as demonstrated in the recent study by Kachur et al,32 suggesting that depression should be emphasized.

Several recent articles in JCRP have focused on depression (see Supplemental Digital Content Table 2, available at: Gonzáles-Roz and colleagues33 assessed several depression instruments in terms of the capability to accurately identify depression among the patients in CR and to determine the sensitivity to determine major changes in depression after CR. They noted that the Beck Depression Inventory-II and the Hospital Anxiety Depression Scale are among the most widely used, although the prior mentioned Ochsner data were collected and validated with a less frequently used older scale, the Kellner Questionnaire, which utilized 92 questions and provided scores for depression, anxiety, hostility and somatization.25,29,31,32 Based on their data, Gonzáles-Roz et al33 recommended that the Beck Depression Inventory-II should be used whenever possible, but that a brief two-step procedure (the two-item Patient Health Questionnaire) could be performed followed by the BTI-II, if positive.

A study of 135 patients from China used the Patient Health Questionnaire-9 and demonstrated that depression was associated with major unhealthy lifestyle behaviors in post–acute coronary syndrome/MI, suggesting that reducing depression should be emphasized.34 Importantly, Gathright et al35 in the study of 637 CR attendees demonstrated that depression symptoms and affect improve with improvements in vitality and social support following CR. Clearly, depression is critical in CR, as Edwards and Sydeman36 reviewed 17 studies in 19 independent samples of more than 30 000 CR patients in a meta-analysis and showed that depression was strongly associated with lower CR completion rates, suggesting that potentially the patients who need CR the most do not seem to be completing these programs possibly due to their underlying depression.


Several other articles in JCRP studied various aspects of mental and psychosocial stress. Gecaite and colleagues37 studied 116 patients with coronary artery disease and showed that mental stress was associated with adverse cardiovascular stress–related reactions independent of other factors, suggesting dysregulation psychological reactivity to acute stress, which could potentially be lessened with higher physical activity (PA) and exercise. In fact, in the study of 1101 patients hospitalized with MI, Peersen et al38 showed that insufficient PA was associated with several unhealthy lifestyle habits, including smoking, obesity, poor quality diet, and depression. In addition, an aerobic PA and exercise training program conferred significant effects on depression and quality of life (QoL) in patients with an implantable cardioverted defibrillator (ICD).39

Patients with spontaneous coronary artery dissection are perceived to have higher psychological stress, but the incidence of post-traumatic stress disorder in these patients is suspected but has not been well documented. In a pilot study of 14 female spontaneous coronary artery dissection patients, post-traumatic stress disorder was present in 43%.40 Potentially, CR and exercise training could also help alleviate these symptoms.


Although most of the mortality benefits of CR programs can be explained statistically by improvements in exercise capacity, including those assessed by estimated workload, gas exchange and V˙o2peak, and even 6-min walk test, 25,29,41,42 it seems likely that improvements in psychological risk factors, particularly, depression, play a major role in the improvements in prognosis and also QoL following formal CR.


This section will focus on different patient characteristics or diagnoses that have received notable attention in the recently published literature related to CR. Specifically, findings from reports concerning diagnoses of HF, arrhythmias, older individuals, and women related to participation in CR are summarized (see Supplemental Digital Content Table 3, available at:


Heart failure is the most recently added diagnosis eligible for CR reimbursement, although currently only HF with reduced ejection fraction (HFrEF) is covered. As such, there has been a notable increase in research of patients with HF participating in CR. For example, in JCRP alone, there were six such reports in 2019 and eight in 2020. A number of reports evaluated the effectiveness of CR for patients with either HFrEF or with preserved ejection fraction (HFpEF). Three reviews that reported little or no difference in mortality for patients with HF participating in CR, however, differed in their findings of reduction in hospital admissions.43–45 A more recent study from Japan did observe significant reductions in both mortality and hospitalizations.46 Improvements in QoL were observed for patients with HF participating in CR or exercise training programs; however, the effects differed in some regards due to the type of program (home-base or hybrid),22 instrument used to assess QoL,45 the type of HF,47 or if patients experienced a stressful life event.48 Findings remain consistent for observing improvement in CRF for patients with HF participating in CR. Braga et al49 showed this for patients with varying levels of left ventricle systolic function, the review by Araújo et al50 reported greater CRF improvements with high-intensity interval training versus continuous training, and Tucker et al51 reviewed that these changes are also seen in patients with HFpEF. Chirico et al52 demonstrated that the 6-min walk test was not able to capture the changes in CRF. One finding that may influence some of the equivocal findings was that from a large sample in New York, where Bostrom et al53 reported that one in five patients with HFrEF had early termination of his or her participation in CR. Another was reported by Adsett et al,54 who showed that a new HF diagnosis was predictive of improved adherence to an exercise training program.

Left-ventricular assistance devices can be used in patients with end-stage HF and as a bridge to transplantation. Patients with left-ventricular assistance devices can participate in CR; however, this can be challenging for programs. A retrospective analysis by Hildebrandt et al55 identified that these patients have a high degree of impairment, particularly in body function, and PA and participation. They proposed that an individualized approach of CR is needed for this patient population. Ferrario and Panzeri56 reported that these patients, along with their caregivers, showed improvement in the emotional state following CR participation.

Atrial fibrillation (AF) is the most common arrhythmia seen in clinical practice and is more prevalent in older populations. A typical treatment for AF is an ablation. Risom et al57 reported that patients treated for AF or atrial flutter experienced decreased mental and physical health and had high hospital readmission rates in the subsequent 6-12 mo. They suggested that CR programs could be useful in the care of these patients. Kato et al58 actually enrolled patients treated with a catheter ablation in a CR program. They observed that patients with AF who attended CR had improved CRF, indicated by 6-min walk test, and did not have any increased risk for AF reoccurrence compared with the usual care group. An excellent summary of the value of exercise CR for patients with AF was provided by Keteyian et al.59 It seems clear that the evidence base is developing for considering referring patients with AF to CR.

Patients at high risk for ventricular arrhythmias are commonly recommended to receive an ICD. Often, these patients have limited their PA due to the concerns related to triggering a ventricular arrhythmia. Tripp et al60 demonstrated that patients experienced an improvement in PA levels over the first 90 d of wearing an ICD. Patients with ICDs can benefit from participation in exercise-training programs. Dougherty et al39 demonstrated that patients with ICD had significant improvement in depression and self-efficacy following 8 wk of exercise training. In addition, in a review by Steinhaus et al,61 they noted that there was significantly improved CRF and lower ICD shocks in patients participating in exercise interventions.


Enrollment and participation in CR programs are known to be lower in women versus men and also for older (≥75 yr) patients compared with those of younger age. As noted previously, Cossette et al6 identified a number of reasons participation of women in CR was different than that for men. In addition, Rengo et al62 showed that women who participated in CR had a significantly lower rate of CRF improvement than men, with 24% of women failing to have any improvement in CRF (compared with 16% for men).

Challenges faced by the elderly have often been a deterrent for referral to CR or for adherence and completion of CR. Flint et al63 provided an excellent review on issues related to frail elderly participation in CR. They advocated for the inclusion of physical frailty measures as a part of the CR intake to guide the programming. The value of this approach was further supported by Kellar et al,64 who noted including a functional risk stratification added significant prognostic information that would be useful to guiding CR programming for these patients. Lutz et al65 demonstrated that CR was associated with significant improvement in multiple physical function domains and this was true of even those considered the most frail. Also, a review of 32 851 Medicare beneficiaries, who were MI survivors and participated in CR, had reduced rates of CVD and all-cause hospital admissions.66


The importance of CR is well established.67,68 The evolvement of the CR profession and the AACVPR was recently summarized.69 The evidence base for CR continues to expand.70 This review summarized recent contribution to the literature related to enrollment and adherence challenges for CR programs, mental health factors associated with participation in CR, and other clinical populations that could benefit from CR programming, possibly most importantly through the use of HBCR and CR in HFpEF.


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49. Braga M, Nascimento H, Nunes A, et al. Role of left ventricle function in cardiac rehabilitation outcomes in stage B heart failure patients. J Cardiopulm Rehabil Prev. 2020;40(1):E5–E9.
50. Araújo BTS, Leite JC, Fuzari HKB, et al. Influence of high-intensity interval training versus continuous training on functional capacity in individuals with heart failure: a systematic review and meta-analysis. J Cardiopulm Rehabil Prev. 2019;39(5):293–298.
51. Tucker WJ, Angadi SS, Haykowsky MJ, Nelson MD, Sarma S, Tomczak CR. Pathophysiology of exercise intolerance and its treatment with exercise-based cardiac rehabilitation in heart failure with preserved ejection fraction. J Cardiopulm Rehabil Prev. 2020;40(1):9–16.
52. Chirico D, Davidson TW, Terada T, et al. Using the 6-min walk test to monitor peak oxygen uptake response to cardiac rehabilitation in patients with heart failure. J Cardiopulm Rehabil Prev. 2020;40(6):378–382.
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adherence; cardiac rehabilitation; depression; enrollment; heart failure

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