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Original research article
Cardiac rehabilitation delivery in low/middle-income countries
  1. Ella Pesah1,
  2. Karam Turk-Adawi2,
  3. Marta Supervia3,4,
  4. Francisco Lopez-Jimenez4,
  5. Raquel Britto5,
  6. Rongjing Ding6,
  7. Abraham Babu7,
  8. Masoumeh Sadeghi8,
  9. Nizal Sarrafzadegan8,16,
  10. Lucky Cuenza9,
  11. Claudia Anchique Santos10,
  12. Martin Heine11,
  13. Wayne Derman11,
  14. Paul Oh12,
  15. Sherry L Grace12
  1. 1 School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
  2. 2 Department of Public Health, Qatar University, Doha, Qatar
  3. 3 Department of Physical Medicine and Rehabilitation, Gregorio Marañón General University Hospital, Madrid, Spain
  4. 4 Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
  5. 5 Department of Physiotherapy, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
  6. 6 Department of Cardiology, Peiking University People’s Hospital, Beijing, China
  7. 7 Department of Physiotherapy, Manipal University, Manipal, Karnataka, India
  8. 8 Department of Cardiology, Isfahan University of Medical Sciences, Isfahan, Iran
  9. 9 Department of Adult Cardiology, Philippine Heart Center, Quezon City, Philippines
  10. 10 Division of Cardiovascular Diseases, Cardiac Rehabilitation, Mediagnóstica Duitama, Boyacá, Colombia
  11. 11 Institute of Sports and Exercise Medicine and Department of Physiotherapy, Stellenbosch University, Stellenbosch, South Africa
  12. 12 Cardiovascular Rehabilitation, University Health Network – Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada
  13. 16 School of Population and Public Health, University of British Columbia, Vancouver, Canada
  1. Correspondence to Dr Sherry L Grace, Faculty of Health, York University, Toronto, Ontario M3J 1P3, Canada; sgrace{at}


Objective Cardiac rehabilitation (CR) availability, programme characteristics and barriers are not well-known in low/middle-income countries (LMICs). In this study, they were compared with high-income countries (HICs) and by CR funding source.

Methods A cross-sectional online survey was administered to CR programmes globally. Need for CR was computed using incident ischaemic heart disease (IHD) estimates from the Global Burden of Disease study. General linear mixed models were performed.

Results CR was identified in 55/138 (39.9%) LMICs; 47/55 (85.5% country response rate) countries participated and 335 (53.5% programme response) surveys were initiated. There was one CR spot for every 66 IHD patients in LMICs (vs 3.4 in HICs). CR was most often paid by patients in LMICs (n=212, 65.0%) versus government in HICs (n=444, 60.2%; p<0.001). Over 85% of programmes accepted guideline-indicated patients. Cardiologists (n=266, 89.3%), nurses (n=234, 79.6%; vs 544, 91.7% in HICs, p=0.001) and physiotherapists (n=233, 78.7%) were the most common providers on CR teams (mean=5.8±2.8/programme). Programmes offered 7.3±1.8/10 core components (vs 7.9±1.7 in HICs, p<0.01) over 33.7±30.7 sessions (significantly greater in publicly funded programmes; p<0.001). Publicly funded programmes were more likely to have social workers and psychologists on staff, and to offer tobacco cessation and psychosocial counselling.

Conclusion CR is only available in 40% of LMICs, but where offered is fairly consistent with guidelines. Governments should enact policies to reimburse CR so patients do not pay out-of-pocket.

  • cardiac rehabilitation
  • health care delivery
  • global health
  • acute myocardial infarction

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  • Contributors SLG, FL-J, KT-A and MS conceived and designed the research. EP and SLG preformed statistical analysis and drafted the manuscript. SLG handled funding and supervision. All authors contributed to the acquisition of the data and made critical revisions to the manuscript. All gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.

  • Funding This project was supported by a research grant from York University’s Faculty of Health. Funding was used to translate the survey into Spanish and Chinese characters.

  • Competing interests WD received research grants from the International Olympic Committee and International Paralympic Committee and personal fees from the Adcock Ingram Pain Advisory Board and the Ossur South Africa Advisory Board.

  • Ethics approval The study was approved by York University’s Office of Research Ethics (Toronto, Canada; e2014-078) and Mayo Clinic’s Institutional Review Board (Rochester, United States; 16-001110). All participants gave informed consent before initiating the survey.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data will be available upon request and approval of the corresponding author SLG (

  • Patient consent for publication Not required.