Cardiovascular disease (CVD) is a significant cause of morbidity and mortality.1,2 Although significant advances have been made in terms of prevention, diagnosis, and overall management, leading to improved outcomes, CVD still represents an important healthcare burden.1–4 As such, optimized prevention measures across the cardiovascular continuum are of pivotal importance.3,4 In this context, cardiac rehabilitation (CR) programs play a central role in contemporary cardiovascular medicine.3,4 Although exercise training (ET) is a critical component of this intervention, over the years CR programs have evolved into a broadly multidisciplinary and multi-layered framework, providing a holistic and integrative approach to the complex cardiovascular patient.4–7 As well as ET, some of the core components of these structured programs presently include the identification and control of cardiovascular (CV) risk factors as well as overall therapeutic optimization and counseling regarding adherence, nutritional assessment, smoking cessation counseling, psychological assessment and intervention, and educational sessions, as well as other ancillary interventions such as socioeconomic support and vocational advice.5,6,8

Several publications have reported extensively on the plethora of beneficial effects associated with structured CR programs in terms of morbidity and mortality, especially in the setting of ischemic heart disease (IHD),9–11 and also on parameters such as control of CV risk factors, functional capacity and quality of life.12–15 Given these data, current guidelines on different CV diseases such as IHD and heart failure (HF) strongly support the use of CR, which is a class I, level A recommendation in these two settings, as a pivotal aspect of optimal patient management.3,4,16–18 While their role across a broad range of CVD is presently consensual, several obstacles to the optimal application of CR programs have also been described. Among these are differences in program design, as well as suboptimal patient representation (particularly among certain subgroups such as the elderly, women, and those living far from healthcare centers) and adherence.4,10,19,20

Over the course of the last two decades, the Working Group on Exercise Physiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology (SPC) has periodically assessed the state of CR in Portugal, by performing a national survey.8,21–23 Initially carried out in 1998 and subsequently updated in 2004, 2007 and 2013-14, this survey has enabled the growth of this intervention in Portugal to be analyzed and tracked, as well as providing an important and pragmatic insight into its most central challenges. This paper presents the results of the 2019 national survey on CR, and compares some of its indicators with previous results, in order to provide an overview of the current state of CR in Portugal.

In December 2019 a voluntary questionnaire was sent to all centers offering CR programs, including the following items: general information on the center, including name, location, type (public or private institution), and year of CR program inception, composition of the team and its coordinators, description of the CR phases offered (i.e. phases I, II and III), program components, total number of participants and distribution by diagnosis in 2019, drop-out rate, and associated reasons for lack of adherence. In addition, a description of the main factors concerning patient enrollment and maintenance in the program was also requested.

The responses were analyzed and compared with the results of the previous surveys.

The present study reports on a pragmatic and contemporary survey on the state of CR in Portugal. Overall, 25 centers provided structured CR programs in 2019. Of these, 12 provided phase I, 22 phase II and 13 phase III interventions. A total of 2182 patients were included in phase II CR programs (1076 in the setting of ACS), while 606 were included in phase III programs.

This study provides important data on the current state of CR in Portugal. Compared to the 2014 data, there was an increase of 33% in the number of centers providing phase I and of 5% in the number of centers providing phase II programs.8 For phase II programs, there was an increase of 13% in the total number of patients included, which translates to an estimated 9.3% coverage of ACS survivors.24 These results are in agreement with the previously reported progressive increase in CR uptake, a finding which is supported by the rise in the number of centers providing these structured interventions and the improvements in terms of the geographical area covered (Table 1).8,21–23 In addition, the Portuguese Registry on ACS (ProACS) showed an increase in the referral rate for phase II programs (scheduled or planned at discharge), which may also be related to this increase (although published data only cover the period up to 2016).25 Nevertheless, overall coverage was still not at an ideal level. Moreover, both the variation in the number of centers (compared to the estimated number expected to provide a broad coverage for the Portuguese population)6 and the reduction in phase III participation should be stressed. Indeed, for structured phase III programs, there was a 37% decrease in the number of patients represented compared to the previous survey.8 These findings should be acknowledged and explored, in order to help develop strategies to promote increases in CR uptake in this setting. Of note, some centers, while not offering structured phase III programs (those including formal ET sessions), nonetheless focused on counseling, especially relating to CV risk factors, thus reinforcing the importance of long-term follow-up and optimization in this patient population.3

Worldwide, the availability and characteristics of CR programs present significant differences.19,26–28 Data from a seminal study by Bjarnason-Wehrens et al., based on the European Cardiac Rehabilitation Inventory Survey, illustrate these variations in different European countries.28 In this study, the proportion of eligible patients included in phase II interventions ranged from <3% to 90%, but was ≤30% in 54% of countries.28 Recent data from the EUROASPIRE V registry further stressed this notion, reporting on 46% of patients advised to undergo CR.29 In the US, studies report participation rates of 20-30%, also with differences among regions and subgroups.30,31 The present survey confirms the sustained increase in the number of centers and patients treated (from 638 in 2007 to 1927 in 2013, and to 2182 in 2019) for phase II programs (Figure 1), which translates into an increased (estimated – see below) coverage after ACS.8,23 Although this improvement should be acknowledged, the 9.3% estimated coverage is still below the optimal value for this intervention.5,6,8,25,28 Several factors have been reported as influencing suboptimal patient representation.6,8,19,20,28,32,33 These include lack of specific facilities and limited capacity to accommodate the number of patients, distance to CR centers, lack of knowledge concerning the intervention (on the part of both healthcare professionals – thus affecting referral rates – and patients), financial constraints, and differences in legislation.6,8,19,20,28,32,33 As expected, several of these were reported by the centers responding to this survey as being associated with lower adherence, as well as affecting patient entry in CR programs (see Results). The present survey thus reinforces the need to address these diverse issues, related to different factors, as tackling some of these challenges could assist in optimizing the uptake of this pivotal intervention. Notably, although drop-out rates ranged from 0 to 68%, most centers (91%) had rates under 25%, which is a proposed quality indicator in a recent statement by the European Association of Preventive Cardiology (EAPC).5 In this context, as the number of CR centers continues to rise (although it is still insufficient given the overall needs, as clearly indicated in previous reports),6,19,34 other parameters should also be recognized as potential obstacles to optimal patient enrollment and adherence.

As in the previous survey, HF presented the second most frequent indication for both phase II (with an increase of 1.8%) and phase III CR programs.8 This is in line with current epidemiological data demonstrating the healthcare burden associated with HF.17,35 Interestingly, referrals after implantation of cardiac resynchronization therapy devices and/or implantable cardioverter-defibrillators also increased (by 3.1%). While the improvement in the number of patients undergoing CR in the setting of HF, albeit small, is encouraging, given the estimated prevalence of this entity efforts should be undertaken to improve referrals.17,35,36 Importantly, different studies have highlighted the cost-effectiveness of this intervention in different patient populations.10,37–39 Given the figures for phase III programs, with fewer patients (Table 5), this is also relevant in this setting.28,40 Of note, the European Cardiac Rehabilitation Inventory Survey has also reported on the broad range of enrollment for these programs, and some of the factors that can hamper their optimization.28

All centers reported having multidisciplinary teams, although frameworks varied (Tables 2 and 4). In this regard, all programs included nutritional counseling, while most offered CV risk factor management, and a large proportion included smoking cessation counseling and psychosocial assessments. Furthermore, access to consultations with different healthcare professionals was also reported for most programs. Although improvements should be made in order to increase the number of programs including these components, the present results reinforce the current notion of CR as a comprehensive and cohesive intervention.5,6 Importantly, recent guidance from both the SPC and EAPC on the components comprising structured CR programs provide a benchmark for the design and tailoring of this intervention.5,6 In this regard, the present results highlight some of the areas where improvement is most needed, as well as presenting some of the potential barriers to their application. Also, the possibility of a national CR registry (as proposed in the current guidelines from the SPC) could further build on the legacy of the present survey, to improve benchmarking concerning various domains of CR.6

As discussed above, the central role of CR programs in CVD has been extensively discussed, and is presently consensual.3–5,9,11,41,42 Although questions concerning the optimal design of such programs, in terms of both efficacy and cost-effectiveness, have still not been fully addressed,4,5,37,43–46 their overall beneficial effects are well established, as supported by the current guidelines.3/4/16-18 The present results are in line with these concepts, with most patients undergoing CR due to IHD and HF, two of the classical indications for these programs.3,17 Although, as previously discussed, efforts should be made to increase the number of patients undergoing CR in the setting of these two entities, as well as improving and streamlining the operative framework (design and scope) of these interventions, future prospects should also be the focus of further research. In this context, the potential role of home-based CR programs should be assessed, particularly given some of the challenges associated with patient adherence and enrollment.5,6,45,47,48 Furthermore, careful consideration should be given to the optimal framework of these programs in the setting of other indications, such as patients with cancer (encompassing the frontier field of cardio-oncology rehabilitation) or left ventricular assist devices.49,50

Several limitations of the present study should be acknowledged. Firstly, this was a voluntary survey conducted with a pragmatic design. Several variables which could have been of interest, such as patient age and gender, time between discharge and program initiation (for phase II programs), medication adherence and control of CV risk factors (including specific values for the different CV risk factors, in accordance with the current guidelines), and differences in functional capacity, were not available for the present analysis.3–6,41,42 Secondly, an important limitation is the fact that specific data on the total number of ACS in 2019 were, to the best of our knowledge, not available at the time of data assessment. An estimate was accordingly provided based on the latest available data.24 Moreover, the questionnaire sent to centers in the present survey specified as an indication “acute myocardial infarction/ACS (with or without percutaneous coronary intervention)” (in order to provide a description that reflected the guidelines).3,51,52 Hence, when 2019 data were compared to those of the previous survey (reporting on MI) and to the DGS data (also on MI), it is possible that some cases of unstable angina were categorized in this section. Finally, some of the data (as specified in the above tables) were not available for all centers. Although these caveats should be borne in mind when assessing the present results, they should not hinder the overall interpretation of the data, which provide a comprehensive report on the state of CR in Portugal in 2019.

The present survey shows an overall increase in the number of CR centers and of patients participating in phase II CR programs, with an estimated coverage of 9.3% after an ACS. Although these results are significant, they still highlight an important unmet need in terms of CR enrollment and overall patient participation. Furthermore, the reduction in the number of patients enrolled in phase III CR programs should also prompt reflection, in order to improve patient referral and uptake.

As personalized medicine evolves against the background of increasingly sophisticated diagnostic and therapeutic interventions, bringing about major advances while also leading to new challenges, the pivotal and time-tested role of CR as a holistic framework able to provide major improvements in overall health status across different stages of the cardiovascular continuum should be seen as an integral component of the optimal contemporary standard of care.

The author has no conflicts of interest to declare.