ICCPR Women-Focused CR Clinical Practice Guideline
Dear Cardiac Rehabilitation (CR) Community:
Please find on this page links to high-quality reviews and seminal articles on women in CR (or sex/gender differences in CR), so we can learn to better engage them and improve their outcomes. If you have some suggestions for additional resources to display that are high-quality, please email us at globalcardiacrehab@gmail.com.
Women are an under-represented patient group in cardiac rehab, despite great need. Once enrolled, women are more likely to dropout and often don’t improve to the same degree as men. Therefore ICCPR embarked on a rigorous process to develop the first clinical practice guideline on women-focused CR: Ghisi, G.L.M., Marzolini, S., Price, J., Beckie, T., Mamataz, T.*, Naheed, A., & Grace, S.L. (2022). Women-focused cardiovascular rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline. Canadian Journal of Cardiology; 38:1786-1798. December.
Click here to view the guideline
Click here to download the Supplementary Material (including Supplemental Methods, Supplemental Results, Supplemental Discussion, Supplemental References, Initial Recommendations with Delphi Ratings and Panel Decisions and Implementation Tools)
Women’s CR Preferences
Sex differences in CR preferences and degree to which they are met: Moore SM, Kramer FM. Women's and men's preferences for cardiac rehabilitation program features. J Cardiopulm Rehabil. 1996;16(3):163-168.
Women’s CR Utilization
Sex differences in CR barriers (quantitative): Grace SL, Gravely-Witte S, Kayaniyil S, Brual J, Suskin N, Stewart DE. A multisite examination of sex differences in cardiac rehabilitation barriers by participation status. J Womens Health (Larchmt). 2009;18(2):209-216.
Review on sex differences in CR referral: Colella TJ, Gravely S, Marzolini S, et al. Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis. Eur J Prev Cardiol. 2015;22(4):423-441.
Review on sex differences in CR enrolment: Samayoa L, Grace SL, Gravely S, Scott LB, Marzolini S, Colella TJ. Sex differences in cardiac rehabilitation enrollment: a meta-analysis. Can J Cardiol. 2014;30(7):793-800.
Review on sex differences in CR adherence: Oosenbrug E, Marinho RP, Zhang J, et al. Sex Differences in Cardiac Rehabilitation Adherence: A Meta-analysis. Can J Cardiol. 2016;32(11):1316-1324.
Women’s top CR barriers around the world: Ghisi GLM, Kim WS, Cha S, et al. Women's Cardiac Rehabilitation Barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation's First Global Assessment [published online ahead of print, 2023 Sep 13]. Can J Cardiol. 2023;S0828-282X(23)01552-0.
Women’s CR Outcomes
Meta-analysis on impacts of tailored CR for women on quality of life, showing importance of psychosocial component: Chung, Sherrie MN; Candelaria, Dion; Gallagher, Robyn. Women's Health-Related Quality of Life Substantially Improves With Tailored Cardiac Rehabilitation, Journal of Cardiopulmonary Rehabilitation and Prevention: July 2022 - Volume 42 - Issue 4 - p 217-226.
Meta-analysis attempt re mortality and morbidity: Ghisi, Gabriela Lima de Melo; Chaves, Gabriela Suéllen da Silva; Bennett, Amanda; Lavie, Carl J; Grace, Sherry L. The Effects of Cardiac Rehabilitation on Mortality and Morbidity in Women, Journal of Cardiopulmonary Rehabilitation and Prevention: January 2019 - Volume 39 - Issue 1 - p 39-42.
Registry data showing lower mortality in women with CR: Örjan Ekblom, Åsa Cider, Kristina Hambraeus, Maria Bäck, Margrét Leosdottir, Amanda Lönn, Mats Börjesson, Participation in exercise-based cardiac rehabilitation is related to reduced total mortality in both men and women: results from the SWEDEHEART registry, European Journal of Preventive Cardiology, Volume 29, Issue 3, February 2022, Pages 485–492.
Narrative review on women’s exercise response: Witvrouwen I, Van Craenenbroeck EM, Abreu A, Moholdt T, Kränkel N. Exercise training in women with cardiovascular disease: Differential response and barriers - review and perspective [published online ahead of print, 2019 Mar 19]. Eur J Prev Cardiol. 2019;2047487319838221.
Review of women’s CR outcomes by area / component: Smith JR, Thomas RJ, Bonikowske AR, Hammer SM, Olson TP. Sex Differences in Cardiac Rehabilitation Outcomes [published correction appears in Circ Res. 2022 Mar 18;130(6):e22]. Circ Res. 2022;130(4):552-565.
Sex differences in METs: Duggal NA, Scalzitti DA, Watkins S, Hecht O , Johnson SJ, et al. (2021) Sex-Based Differences in Metabolic Equivalents (METs) After Cardiac Rehabilitation: A Systematic Review. J Card Pulm Rehabil 5: 143.
Registry data on sex differences in risk factor target attainment: Turk-Adawi KI, Oldridge NB, Vitcenda MJ, Tarima SS, Grace SL. Secondary Prevention Recommendation Attainment with Cardiac Rehabilitation: Is There a Gender Disparity?. Womens Health Issues. 2016;26(3):278-287.
WHAT TO DO ABOUT IT?
Here is a 1-hr ICCPR webinar on engaging women in CR and implementing women-focused CR
Interventions to Increase Women’s CR Use
Automatic / systematic CR referral: Gravely S, Anand SS, Stewart DE, Grace SL; CRCARE Investigators. Effect of referral strategies on access to cardiac rehabilitation among women. Eur J Prev Cardiol. 2014;21(8):1018-1025. doi:10.1177/2047487313482280
Review of women’s CR barriers and suggested solutions to overcome them: Supervía M, Medina-Inojosa JR, Yeung C, et al. Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions [published online ahead of print, 2017 Mar 13]. Mayo Clin Proc. 2017;S0025-6196(17)30026-5. doi:10.1016/j.mayocp.2017.01.002
Review of women’s preferred features for non-clinical CR delivery: Vidal-Almela S, Czajkowski B, Prince SA, et al. Lessons learned from community- and home-based physical activity programs: A narrative review of factors influencing women's participation in cardiac rehabilitation [published online ahead of print, 2020 Mar 6]. Eur J Prev Cardiol. 2020;2047487320907748.
CR for Cardiac Conditions More Common in Women
Review regarding SCAD, stress as well as peripartum cardiomyopathy, MINOCA: Sawan MA, Calhoun AE, Fatade YA, Wenger NK. Cardiac rehabilitation in women, challenges and opportunities. Prog Cardiovasc Dis. 2022;70:111-118.
Review regarding TAVI, PAD: Galati A, Piccoli M, Tourkmani N, et al. Cardiac rehabilitation in women: state of the art and strategies to overcome the current barriers. J Cardiovasc Med (Hagerstown). 2018;19(12):689-697. doi:10.2459/JCM.0000000000000730
Women-Focused CR / CR Especially for Women (CREW) Specifically
Randomized trial on model for women: Andraos C, Arthur HM, Oh P, Chessex C, Brister S, Grace SL. Women's preferences for cardiac rehabilitation program model: a randomized controlled trial. Eur J Prev Cardiol. 2015;22(12):1513-1522. doi:10.1177/2047487314559275
Review on what is women-focused CR: Mamataz T, Ghisi GLM, Pakosh M, Grace SL. Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review. BMC Cardiovasc Disord. 2021;21(1):459. doi:10.1186/s12872-021-02267-0
Review on outcomes of women-focused CR: Mamataz T, Ghisi GL, Pakosh M, Grace SL. Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis. Maturitas. 2022;160:32-60. doi:10.1016/j.maturitas.2022.01.008
Global availability of women-focused CR: Turk-Adawi K, Supervia M, Lopez-Jimenez F, Adawi A, Sadeghi M, Grace SL. Women-Only Cardiac Rehabilitation Delivery Around the World. Heart Lung Circ. 2021;30(1):135-143. doi:10.1016/j.hlc.2020.01.015
Women-focused cardiac rehabilitation delivery around the world and program enablers to support broader implementation: Ghisi GLM, Supervia M, Turk-Adawi K, Beleigoli A, Contractor A, Mampuya WM, Grace SL. Women-focused cardiac rehabilitation delivery around the world and program enablers to support broader implementation. CJC Open. 2023;6(2Part B):425-435. doi:10.1016/j.cjco.2023.10.008
IMPLEMENTATION TOOLS
Interventions to Improve Women’s Outcomes (Clinical and Other)
Review on alternative forms of exercise (forthcoming)
Appendix from Women-Focused CR Clinical Practice Guideline : List of Women-Focused CR Implementation Tools. Click here
Cardiac College for Women: open access comprehensive women-focused patient education curriculum for CR that is co-created, evidence-based and theoretically-informed.
- Types of heart diseases, tests and treatments for women: click here
- Exercise for women: click here
- Nutrition for women: click here
- Psychosocial well-being for women: click here
POTPOURRI – Narrative Reviews on Women and CR, etc
Review about underutilization of CR in women: Khadanga S, Gaalema DE, Savage P, Ades PA. Underutilization of Cardiac Rehabilitation in Women: BARRIERS AND SOLUTIONS. J Cardiopulm Rehabil Prev. 2021;41(4):207-213.
Joint British Cardiovascular Societies’ consensus document: Tayal U, Pompei G, Wilkinson I, et al. Advancing the access to cardiovascular diagnosis and treatment among women with cardiovascular disease: a joint British Cardiovascular Societies' consensus document. Heart. 2024 Oct 28;110(22):e4.