1. Ghisi, Gabriela Lima de Melo PhD
  2. Taylor, Rod S. PhD
  3. Seron, Pamela PhD
  4. Grace, Sherry L. PhD, CRFC, FAACVPR

Article Content

Cardiovascular diseases are among the leading causes of death and disability globally, with the greatest burden in low- and middle-income countries (LMIC).1 Cardiac rehabilitation (CR) mitigates this growing epidemic.2 Despite this, CR is underutilized.3 This is particularly so in LMIC where it is needed most, availability is scant, and there are greater challenges to implementation.4


Barriers to CR delivery are multifactorial, with factors at play at the health system, referring provider, CR program, as well as patient levels.3 These have been well-characterized in high-resource settings, with some review in LMIC,4 although the latter is dated given recent contextual changes.


One of the main recommendations to improve CR use has been availability of unsupervised (ie, remote, home-based) models.5 Given the high penetrance of mobile phones in LMIC, programs have more recently initiated technology that is quite advanced and patient-friendly. In response to the COVID-19 pandemic in these countries, there has been a great shift to online CR care,6 with need for more.


While characterized for high-resource settings,7,8 factors hindering CR availability and utilization that are unique to, or more problematic in, LMIC have not been described, particularly by level and setting. Based on a rapid review of literature and the expertise of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR; 43 member associations and 17 "friends," of which 52% are from LMIC), this Infographic illustrates these factors. This brief version, as well as the full version (see Supplemental Digital Content, available at:, separately displays factors hindering supervised and unsupervised CR delivery in LMIC, at the societal, referring clinician, CR program, and patient levels.


Ideally, unsupervised CR models do involve some in-person sessions at least at the start of a program, to enable full assessment, risk stratification, plan of care development, and therapeutic rapport. There is now burgeoning research on hybrid CR (ie, combining supervised center-based and remote/unsupervised) in high-resource settings, with corresponding best practice recommendations for implementation.9 While there are also sound recommendations to promote supervised CR implementation in LMIC,4 and some training available from the ICCPR on supervised and unsupervised delivery,10 it is hoped strategies to overcome barriers to unsupervised CR delivery in LMIC will be identified as well. Ultimately, we must support CR champions in LMIC to address these multilevel barriers to CR delivery, to realize availability of CR in all settings, based on context and patient need, in both high and LMIC.




1. Bowry AD, Lewey J, Dugani SB, Choudhry NK. The burden of cardiovascular disease in low- and middle-income countries: epidemiology and management. Can J Cardiol. 2015;31(9):1151-1159. [Context Link]


2. Dibben G, Faulkner J, Oldridge N, et al Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2021;11(11):CD001800. [Context Link]


3. Grace SL, Kotseva K, Whooley MA. Cardiac rehabilitation: under-utilized globally. Curr Cardiol Rep. 2021;23(9):118. [Context Link]


4. Ragupathi L, Stribling J, Yakunina Y, Fuster V, McLaughlin MA, Vedanthan R. Availability, use, and barriers to cardiac rehabilitation in LMIC. Glob Heart. 2017;12(4):323-334.e10. [Context Link]


5. Thomas RJ, Beatty AL, Beckie TM, et al Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. J Cardiopulm Rehabil Prev. 2019;39(4):208-225. [Context Link]


6. Ghisi GLM, Xu Z, Liu X, et al Impacts of the COVID-19 pandemic on cardiac rehabilitation delivery around the world. Glob Heart. 2021;16(1):43. [Context Link]


7. Shanmugasegaram S, Oh P, Reid RD, McCumber T, Grace SL. A comparison of barriers to use of home- versus site-based cardiac rehabilitation. J Cardiopulm Rehabil Prev. 2013;33(5):297-302. [Context Link]


8. Vanzella LM, Oh P, Pakosh M, Ghisi GLM. Barriers and facilitators to virtual education in cardiac rehabilitation: a systematic review of qualitative studies. Eur J Cardiovasc Nurs. 2022;21(5):414-429. [Context Link]


9. Keteyian SJ, Ades PA, Beatty AL, et al A review of the design and implementation of a hybrid cardiac rehabilitation program: an expanding opportunity for optimizing cardiovascular care. J Cardiopulm Rehabil Prev. 2022;42(1):1-9. [Context Link]


10. Babu AS, Heald FA, Contractor A, et al Building capacity through ICCPR Cardiovascular Rehabilitation Foundations Certification (CRFC): evaluation of reach, barriers, and impact. J Cardiopulm Rehabil Prev. 2022;42(3):178-182. [Context Link]