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Consensus statement
Cardiac rehabilitation delivery model for low-resource settings
  1. Sherry L Grace1,
  2. Karam I Turk-Adawi2,
  3. Aashish Contractor3,
  4. Alison Atrey4,
  5. Norm Campbell5,
  6. Wayne Derman6,
  7. Gabriela L Melo Ghisi7,
  8. Neil Oldridge8,
  9. Bidyut K Sarkar9,
  10. Tee Joo Yeo10,
  11. Francisco Lopez-Jimenez11,
  12. Shanthi Mendis12,
  13. Paul Oh13,
  14. Dayi Hu14,
  15. Nizal Sarrafzadegan15
  1. 1Faculty of Health, School of Kinesiology and Health Science, York University, and Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
  2. 2School of Health Policy and Management, York University, Toronto, Ontario, Canada
  3. 3Rehabilitation and Sports Medicine, Sir H. N. Reliance Foundation Hospital, Mumbai, India
  4. 4Imperial College, Cambridgeshire, UK
  5. 5Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
  6. 6Institute of Sport and Exercise Medicine (SEM), Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
  7. 7Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
  8. 8College of Health Sciences, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
  9. 9Research Division, Public Health Foundation of India, ISID Campus, New Delhi, India
  10. 10Department of Cardiology, National University Heart Centre Singapore, Singapore
  11. 11Cardiovascular Health Clinic and Cardiometabolic Program, Mayo Clinic, Rochester, Minnesota, USA
  12. 12Chronic Diseases Prevention and Management, NCD, WHO, Geneva, Switzerland
  13. 13UHN Cardiovascular Prevention and Rehabilitation Program, Toronto, Ontario, Canada
  14. 14Heart Center, People Hospital of Peking University, Beijing, China
  15. 15Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  1. Correspondence to Dr Sherry L Grace, Faculty of Health, School of Kinesiology and Health Science, Bethune 368, York University, 4700 Keele Street, Toronto, Ontario, Canada M3J 1P3; sgrace{at}


Objective Cardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries.

Methods A literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (2) medical risk factor management (eg, lipid control, blood pressure control), (3) education for self-management and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not.

Results Available data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in low-resource settings were summarised in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by non-physician healthcare workers, in non-clinical settings.

Conclusions Advocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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