PLoS Med. 2026 Jun 23;23(6):e1005151. doi: 10.1371/journal.pmed.1005151. eCollection 2026 Jun.
ABSTRACT
BACKGROUND: Cardiovascular disease (CVD) remains a leading global health burden. Cardiac rehabilitation (CR) is essential to reducing morbidity and improving patient outcomes. Since the COVID-19 pandemic, CR delivery worldwide has evolved, yet these changes have not been systematically charactemkjrized. The objective of this study was to characterize globally: (1) the delivery of core CR components, including risk factors assessed, patient education practices, and program resources; (2) differences in these elements by country income classification and relative to the initial 2016 Global CR Audit.
METHODS AND FINDINGS: A cross-sectional Audit update was conducted. Program-level data were collected from May 1st to September 1st 2025 using a REDCap survey adapted from previous Audits. Eligible respondents were leads of phase II/post-discharge CR programs providing at least an initial assessment, structured aerobic exercise, and ≥1 additional core component. ICCPR associations and local leaders supported program identification. Main outcomes were core components delivered (10 assessed), risk factors assessed (14 assessed), patient education dose (hours/patient/program), and program resources (17 assessed). Generalized linear mixed models (GLMM) tested differences by income classification and (when applicable) changes since 2016. Of 7,025 programs identified globally, 1,505 (62% median country response rate) initiated a survey from 90/113 (80%) countries with CR. The median number of core components offered was 8/program (p25, p75 = 6, 10), with upper-middle income countries offering significantly more components overall (median = 9), and also high-income countries offering more than low-income countries (8 versus 6, p < 0.001; decade change not tested). Programs assessed 11 risk factors/program (median; p25, p75 = 8, 12). This significantly differed by country income class (GLMM p < 0.001), with programs in lower-middle income countries assessing fewer risk factors than those in both upper-middle-income (mean difference = 2.2; p < 0.001) and high-income countries (mean difference = 1.6, p < 0.001). There were significant increases in 2025 for glucose, sleep apnea and sedentariness, among others (ps < 0.01). Patient education dose was 3 hours/supervised program (median; p25, p75 = 1, 7), a significant reduction in many high-income countries since 2016 (p = 0.01). Globally, gym space, resistance training equipment, and individual assessment/counseling space were the most common resources (all >90%; median = 11; p25, p75 = 8, 14). Resource availability differed significantly by country income class (GLMM p < 0.001), with programs in upper-middle-income countries reporting more resources than those in high-income (mean difference = 1.5), lower-middle-income (mean difference = 2.6), and low-income countries (mean difference = 4.8; all p < 0.001). While there were no significant differences in total resources, resistance training equipment, electronic patient charts, body composition analyzers, and stress testing with O2 were more available in 2025, and the availability of administrative office space and group education room less so (ps < .01). Limitations include potential selection and ascertainment bias from incomplete program identification as well as variable, modest program response rates, limited representation from low-income settings, reliance on self-reported survey data, as well as measurement differences across Audit cycles, which may affect generalizability and precision of findings.
CONCLUSIONS: CR programs worldwide continue to deliver guideline-concordant care, with education potentially shifting modality. However, modest inequities persist for resource-constrained programs.
PMID:42335042 | DOI:10.1371/journal.pmed.1005151