Key takeaways:
- Cardiac rehabilitation (CR) significantly reduces hospitalization, cardiovascular mortality, and myocardial infarction risk, yet women remain underreferred and underenrolled.
- Women who do participate in CR experience substantial benefits, including improved exercise capacity and greater reductions in all-cause mortality compared with men.
- Barriers to CR for women include clinical bias, lower likelihood of diagnostic qualification, time constraints, transportation challenges, caregiving responsibilities, and discomfort with group settings.
- Automated referral systems and sex-tailored exercise prescriptions are evidence-based strategies shown to increase CR participation and completion.
- Breast arterial calcification detected on routine mammograms may provide an additional pathway for early cardiovascular risk identification in women.
Researchers have identified poor attendance to cardiac rehabilitation (CR) despite key benefits, publishing their findings in Circulation.1
Short- and long-term recovery following heart surgery or a major cardiovascular event are significantly improved by CR, but researchers have highlighted low rates of referral and other barriers to enrollment. This indicates the need for a multi-faceted approach to reduce this disparity.
“Even when women do participate, the research tells us that they are still less likely to complete cardiac rehabilitation as compared to men,” said Jessica Golbus, MD, a cardiologist at the University of Michigan Health Frankel Cardiovascular Center. “There are several barriers that women face to accessing cardiac rehabilitation.”
Clinical benefits of CR
The investigators from the American Heart Association highlighted the benefits of CR in a scientific statement.2 These include:
- 42% reduction in hospitalization risk
- Risk ratio of 0.58 for cardiovascular mortality
- Risk ratio of 0.67 for myocardial infarction
CR has also been linked to improved quality of life and fasting glucose levels, leading the American Heart Association to recommend CR as a secondary prevention of many cardiovascular diseases. Experts have also noted more significant benefits from CR in women vs men.
Exercise capacity without adverse events has also been reported following CR in women with spontaneous coronary artery dissection. Additionally, a 24% reduction in all-cause mortality has been reported in women completing at least 300 minutes of aerobic physical activity per week, vs an 18% reduction in men.
Barriers to CR referral and enrollment
Despite these benefits, research has indicated reduced odds of receiving a cardiovascular diagnosis needed to quality for CR among women vs men. Investigators have hypothesized clinical bias as a source of these reduced rates, as increased medical and psychological comorbidities alongside an older age are often seen in women eligible for CR.
One meta-analysis reported this disparity in CR enrollment among women vs men is 36%. Additionally, reduced odds of CR referral have been reported in Black and Hispanic women vs White women, at 34%, 15%, and 48%, respectively.
CR completion is also reduced among women vs men. Barriers linked to this disparity include time constraints, language barriers, perception of exercise as unpleasant, work-related conflicts, challenges with transportation, limited support systems, discomfort with group sessions, cost, and preference to alternative forms of exercise.
Investigators have also hypothesized characteristics often associated with feminine gender traits such as caregiving responsibilities and family obligations may increase dropout rates among this population. Based on the information currently available, the American Heart Association has suggested increasing recognition to other rehabilitative needs beyond exercise.
Strategies to improve CR access and engagement
Evidence-based strategies to increase CR participation have been highlighted, such as automatization of the referral process, which has been linked to an over 10-fold increase in CR referrals. To increase engagement, experts recommended sex-tailored exercise prescriptions, with CR staff adapting protocols based on the preference of each participant.
“Implementation of these strategies can facilitate access to CR programs for women, promoting their quality of life and long-term cardiovascular health,” wrote investigators.
Cardiovascular outcomes may also be identified in women through breast arterial calcification (BAC) seen on mammograms, as discussed by Lori Daniels, MD, FACC, professor of cardiovascular medicine at UC San Diego, in an interview with Contemporary OB/GYN.3
In a study by Daniels, adverse cardiovascular outcomes were significantly more likely in women with increased BAC. Therefore, Daniels stated that recognizing BAC on mammograms may be a key factor of early risk detection.
“This is a relatively easy finding to incorporate, because the data’s already there,” said Daniels. “We’re not requiring additional testing, a lot of women starting at age 40 get annual mammograms anyway.”
