Alternative Models of Cardiac Rehabilitation Delivery Urgently Needed to Improve Access for Heart Failure Patients.

We read with interest the study by Pandey et al (1) who show that only 2.2%-4.3% of patients with heart failure (HF) participated in cardiac rehabilitation (CR) within 6 months of discharge from hospital or outpatient visit. In this letter, we share recent European experience that underscore the importance of these findings.

The National Health Service in England has set the ambitious target of increasing CR participation for patients with HF from <10% to 33% by 2023 (2). However, a two-thirds decrease in HF patients’ CR attendance in the United Kingdom has been seen between the 6-month periods before coronavirus disease-2019 (COVID-19) (August 2019 to January 2020; n = 3,612 [6.8%]) and after COVID-19 (February 2020 to July 2020; n = 1,935 [5.4%]) (3). With national public measures of lockdown, there was an increase in the proportion of patients enrolling in home-based CR programs (22.2%-72.4%) in this same period We are working with National Health Service providers to roll out the home-based REACH-HF program to enhance access for patients with HF (4).

We recently undertook an analysis of all patients in Denmark with incident HF (N = 33,257) from 2010 to 2018 (5). Although focused on referral (≤120 days of hospital admission) rather than CR participation, it still shows the problem of CR access in that only 1 in 2 HF patients in Denmark are referred to CR. Subgroups of patients with HF found to be with highest risk of poor access were those who were older, unemployed/retired, living alone, non-Danish, of lower education, and multimorbid.

In closing, despite robust evidence of benefit, global participation in CR for HF remains stubbornly low. The challenge of the COVID-19 pandemic offered us a unique opportunity to “fast-track” the development/implementation of home-based CR to improve CR access for people with HF and their families.