Despite clear evidence that cardiac rehab saves lives, most women never enroll. The American Heart Association’s new statement explains why and outlines guidelines to ensure heart recovery is fair and accessible for all women.
Study: Cardiac Rehabilitation in Women: A Scientific Statement From the American Heart Association. Image credit: PeopleImages/Shutterstock.com
The American Heart Association has published a scientific statement in the journal Circulation to increase women’s participation in cardiac rehabilitation and improve cardiovascular health and quality of life.
Why cardiac rehab matters
Cardiac rehabilitation (CR) is a lifestyle management program through which a team of professionals with different expertise provides personalized exercise and behavioral counselling to patients with cardiovascular disease.
Although traditional CR services involve in-person sessions, these services can also be delivered through virtual or remote sessions. In virtual sessions, CR components are delivered through audio-visual communication between patients and clinicians in different locations. In remote sessions, patients exercise independently without supervision and then share their data with clinicians.
Regarding health benefits, evidence suggests that CR improves cardiovascular risk factors, including smoking cessation, blood pressure, cholesterol levels, and fasting glucose levels.
Practicing in CR over a period of 6-12 months has been found to reduce the risk of hospital readmission by 42 %. Similarly, long-term CR sessions have been found to reduce the risks of myocardial infarction and cardiovascular mortality.
Overall, these benefits have led professional societies, including the American College of Cardiology and the AHA, to recommend CR as a key component of secondary prevention in cardiovascular disease.
Specific health benefits of CR in women
CR and physical activity can benefit women in several ways. Evidence indicates that mortality risk reduction through CR is relatively more pronounced in women than in men. In women with cardiovascular complications, CR has been found to improve exercise capacity, metabolism, and mental health.
Regarding physical activity, evidence suggests that women who regularly practice aerobic and resistance exercises experience greater benefits than men, including improvements in hypertension and a reduction in the risk of all-cause mortality.
For example, the AHA notes that women who achieved 300 minutes of aerobic activity per week had a 24% reduction in all-cause mortality, compared to 18% in men. Additionally, three weekly resistance sessions lowered mortality by 28% in women, compared to 14% in men.
Factors restricting CR access for women
Several factors can potentially restrict women's participation in CR, including lower CR referral rates, lack of insurance, transportation issues, lower educational backgrounds, social isolation, limited self-care opportunities, and family responsibilities.
Inequalities in the CR referral rate are considered the dominant factor restricting CR participation among women. Such inequalities may result from a lack of cardiovascular diagnosis in women who qualify them for CR. Clinician bias may be another potential factor, because women who are eligible for CR tend to be older and have more medical and psychological comorbidities.
Like participation rates, completion rates of CRs are also lower in women compared to those in men. In this context, evidence indicates that even after referral, women are less likely to enroll in, attend, and complete CR. The AHA highlights that women from underrepresented racial or ethnic groups, including non-Hispanic Black, Hispanic, and Asian women, have particularly low participation rates, often below 12%, and face additional barriers related to financial constraints, discrimination, and lack of culturally tailored programs.
Strategies for improving CR participation in women
Addressing inequalities in CR participation requires a multifaceted, intersectional approach that recognizes and responds to the diverse needs of women. The lack of CR referral is one of the major modifiable risk factors for non-participation in CR. The implementation of automated referral systems could be a solution, which has been found to increase CR participation by more than 10 times in women and up to 25 times when combined with case management strategies.
A case management or liaison strategy is another approach that addresses several challenges related to CR enrollment and improves CR awareness. This strategy, in combination with automated electronic referrals, has been found to improve CR participation among women.
Personalized CR programs designed explicitly for women could be promising interventions to increase CR participation, as these interventions have the potential to target behavioral, clinical, and psychosocial factors unique to women.
Emerging evidence suggests that support from peers and family plays a crucial role in improving self-efficacy, quality of life, mental health, and therapeutic adherence in patients with cardiovascular disease, ultimately improving CR participation and attendance. Routine incorporation of peer support programs and mental health services throughout the CR process may enhance women’s participation in CR.
Remote or virtual CR sessions, powered by digital technologies, could be effective in improving CR participation among women, as these sessions can eliminate or reduce the need for transportation and allow for the flexible delivery of CR in patients’ preferred locations. However, in-depth research is necessary to determine the safety and clinical effectiveness of such CR sessions, particularly in women.
It is emphasized that research on nontraditional delivery models, such as hybrid, community-based, or virtual CR, remains limited by small sample sizes and underrepresentation of women, underscoring the need for large, sex-specific studies to determine the safety, efficacy, and equity of access. There is also a need for the implementation of culturally sensitive and equity-focused programs that address the needs of women from diverse racial, ethnic, and socioeconomic backgrounds.
Special considerations in CR for women
Cardiorespiratory improvement in women
The maximum rate of oxygen consumption attainable during physical exercise (peak V̇O2) is the gold standard assessment for cardiorespiratory fitness. It is also a vital prognostic indicator for cardiovascular outcomes.
In women with cardiovascular disease, moderate-to-vigorous or high-intensity exercise training has been found to improve peak V̇O2. Existing evidence also indicates that high-intensity interval training is superior to moderate-intensity continuous training for improving peak V̇O2 in women with coronary artery dissection. Tailored, high-intensity or combined aerobic–resistance regimens may be particularly effective for improving fitness and leg strength among women in CR programs.
Women-focused CR programs
Women-focused CR programs address the preferences of women, such as a broader range of exercise choices, greater social interaction and psychosocial support, and concerns about insecurity. These kinds of programs have been found to increase women’s participation in exercise and educational sessions.
Guidelines have been developed for CR clinicians when implementing women-focused programs. These guidelines address sex-specific challenges in CR participation and delivery, providing a roadmap to increase the inclusion and effectiveness of CR for women across various settings globally.
However, the benefits from women-only CR programs remain mixed, and integrating women-focused approaches, such as motivational interviewing, flexible scheduling, and staff training in women’s cardiovascular health, within existing mixed-gender programs may be the most practical approach.
Spontaneous coronary artery dissection
Spontaneous coronary artery dissection (SCAD) most commonly occurs in women. Both traditional CR programs and SCAD-focused CR programs have been shown to improve physical and emotional fitness in patients with SCAD.
According to experts’ recommendations, patients participating in CR after SCAD should engage in moderate-intensity aerobic exercise, avoid intense straining, and receive personalized psychosocial support to address mental health concerns.
Disease-specific CR models should also address other conditions that disproportionately affect women, including ischemia or myocardial infarction with nonobstructive coronary arteries (INOCA and MINOCA), breast or gynecologic cancers, and stress-induced cardiomyopathy.
Enhancing CR participation in women
The American Heart Association has proposed specific strategies to improve CR access and participation in women.
These strategies primarily focus on increasing CR awareness and implementing automated referrals; exploring alternative CR delivery methods; incorporating peer-support and mental health-support programs in CR; developing culturally sensitive programs; and promoting research and innovation to develop disease-specific CR interventions that address conditions disproportionately affecting women, including SCAD, ischemia with nonobstructive coronary arteries, breast or gynecologic cancers, and stress-induced cardiomyopathy.
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