The accessibility and effectiveness of health services for people with coronary heart disease (CHD) have never been more important: more people are living longer with symptomatic CHD in high-income, middle-income and low-income countries.1 Healthy behaviours can reduce likelihood of premature death in people with CHD by threefold.2 Yet, despite the existence of guidelines for cardiac rehabilitation for over 20 years, around 60%–70% of patients do not receive optimal secondary prevention.3 Possibly, as few as 1 in 10 eligible patients are referred to, participate in and then complete cardiac rehabilitation.4

Trials and meta-analyses support the general benefits to life expectancy and quality of cardiac rehabilitation interventions of various lengths, formats and delivery settings.5–8 Yet, recent trial findings9 have led to questions about the benefits of traditional centre-based cardiac rehabilitation and disagreement over whether these findings reflect true effects, confounded interventions or methodological weaknesses. Scepticism over the benefits of these interventions is not new—anecdotally many clinicians have expressed doubts that long-term behavioural change from time-limited cardiac rehabilitation is realistic for patients with CHD. These concerns are then reflected in clinicians’ interactions with patients and referral behaviours.

Doubts have also arisen less from the inherent effectiveness of cardiac rehabilitation interventions than their poor accessibility—particularly to groups in greater need of …