Exercise training is fundamental in CR, improving functional capacity, QoL, and reducing recurrent cardiac events in CAD patients. Aerobic training involves improving cardiovascular endurance through activities like treadmill walking, cycling, and rowing. Moderate-intensity continuous training is standard care, involving sustained aerobic activities at 50% to 70% maximum heart rate and improving VO ₂ peak by approximately 9% to 19% over a 12-week period in post-ACS patients.

Resistance training, incorporating the use of weights or resistance bands, confers robust and quantifiable physiological and prognostic benefits in patients with CAD participating in CR. Evidence from randomized controlled trials (RCTs) and meta-analyses consistently demonstrates that resistance training, either as a standalone intervention or integrated with aerobic modalities, elicits clinically significant improvements in cardiorespiratory fitness, muscular strength, functional performance, and patient-reported outcomes. ^,,,

Specifically, resistance training has been shown to increase upper and lower limb muscle strength with standardized mean differences (SMDs) ranging from 0.65 to 0.73 in middle-aged adults and up to 1.18 in older cohorts. ^, Improvements in VO₂ peak, a key prognostic indicator of survival in CAD, range from 0.70 to 0.92 ml·kg⁻¹·min⁻¹ compared with control interventions. In elderly populations, mobility and functional capacity are also significantly enhanced (SMD = 0.61). Combined aerobic and resistance training regimens are superior to aerobic training alone and standard care in augmenting VO₂ peak, exercise time, and muscular strength. For example, recent pooled analyses show combined modalities yield greater improvements in maximal aerobic capacity, muscle hypertrophy, and strength, with session durations of ≥50 minutes and 3 sets of 10 to 12 repetitions per major muscle group being optimal.

Flexibility training supports joint mobility and reduces the risk of musculoskeletal injuries during CR. While less extensively studied than aerobic and resistance training, flexibility exercises complement other modalities by enhancing overall mobility, reducing muscular stiffness, and decreasing fall risks, particularly in elderly patients.

The incorporation of structured exercise interventions, encompassing aerobic, resistance, and flexibility training, across the various phases of CR is crucial in patients with CAD. Tailoring these interventions to individual patient needs and clinical status ensures maximal benefit for recovery and long-term outcomes.

Effective risk factor modification is central to CR, with programs focusing on smoking cessation, blood pressure (BP) control, lipid management, and diabetes care. CR offers unique opportunities for behavioral intervention, as patients are often more receptive to lifestyle changes following a major cardiovascular event. However, the EUROASPIRE V survey of over 7,000 CAD patients across Europe found that only 18.6% of current smokers received structured support to quit smoking, underscoring a critical area for improvement in CR programs. This is despite evidence that persistent smoking following an ACS event doubles the risk of recurrent myocardial infarction (MI) and cardiac death. ^, Intensive cessation strategies combining pharmacotherapy and cognitive-behavioral counselling are more effective than minimal interventions or advice alone. A meta-analysis of RCTs in cardiac patients demonstrated that behavioral counselling increases sustained smoking abstinence at 6 to 12 months compared to usual care (odds ratio 2.40, 95% confidence interval [CI] 1.58 to 3.64); the efficacy of comprehensive behavioral interventions rivals that of pharmacotherapy such as bupropion or nicotine replacement therapy. Motivation-based strategies and multisession interventions, particularly when coupled with nurse or specialist support within CR, have shown quit rates of up to 51% at 12 months in post-ACS patients, significantly higher than brief interventions or self-guided quit attempts.

Integration of these intensive strategies into CR is critical: a systematic review of 18 studies demonstrated that comprehensive CR programs, especially those with group-based support and combined physical exercise, facilitate the highest smoking cessation rates (76% to 99%) at 1 year. These findings strongly support not only the inclusion, but the prioritization, of intensive, multicomponent smoking cessation interventions within modern, guideline-concordant CR for CAD patients

CR programs facilitate BP reduction through both lifestyle interventions and medication adherence. Key lifestyle interventions include dietary sodium restriction, reducing alcohol consumption, smoking cessation, stress management and weight loss. Structured exercise training within CR, particularly moderate-intensity aerobic activity, can lower systolic and diastolic BP by approximately 5 to 10 mm Hg in hypertensive patients, representing a clinically meaningful reduction in cardiovascular risk.

Dyslipidemia management within CR for CAD patients is grounded in rigorous evidence and guideline-concordant practice, centering on education, dietary intervention, and pharmacotherapy. Comprehensive risk factor modification, including optimization of lipid profiles, is linked to improved survival, reduced recurrent events, and favorable clinical trajectories in CR cohorts.

Intensive lipid-lowering therapy with statins remains the mainstay for post-ACS management, with meta-analyses demonstrating significant reductions in major adverse cardiovascular events (MACE) and all-cause mortality. For instance, a meta-analysis of 9 trials (n = 38,640) revealed early intensive statin therapy reduces 3-point MACE by 12% and recurrent ACS by 18% over standard or delayed lipid-lowering strategies. CR programs employing systematic lipid management protocols, such as nurse-led interventions, significantly increase the proportion of patients achieving lipid goals, improve LDL cholesterol levels (p = 0.01), and enhance medication adherence (up to 84% vs 49% in usual care).

Dietary modification within CR, including adoption of Mediterranean or low-fat dietary model, synergistically contributes to lipid optimization. In a biomarker-based study of 313 CAD patients in CR, diet-centric interventions facilitated significant reductions in total cholesterol and LDL, and additive improvement in the 10-year cardiovascular mortality risk (mean drop: 3.7%). Although, large-scale randomized trials directly testing dietary interventions within CR programs are limited, landmark secondary prevention studies such as the CORDIOPREV provide complementary evidence for the role of nutrition in improving cardiovascular outcomes. In this 7-year RCT involving 1,002 patients with established CAD, adherence to a Mediterranean diet significantly reduced the incidence of MACE compared with a low-fat diet (adjusted HR 0.72, 95% CI 0.54 to 0.96). These findings demonstrate the importance of structured dietary counselling as a core component of comprehensive CR programmes. Recent studies have begun to bridge this gap by evaluating the integration of Mediterranean dietary principles into structured CR settings. In a study by Novaković et al. 121 post-MI patients underwent a 12-week comprehensive CR program incorporating exercise, behavioral counselling, and structured Mediterranean lifestyle education. The intervention led to significant improvements in Medlife Index scores among participants with low baseline adherence (13.8 to 16.7, p < 0.001), accompanied by favorable changes in triglycerides, HDL cholesterol, and glucose levels , highlighting the potential of CR as a vehicle for sustained lifestyle transformation. Building upon this framework, the ongoing DIABEPIC-1 trial is evaluating the feasibility and metabolic efficacy of an enhanced CR paradigm that integrates structured exercise training with Mediterranean dietary counselling, reduction of ultra-processed food intake, and time-restricted eating in patients with established CAD and prediabetes. The trial is designed to determine whether this multimodal intervention can facilitate partial or complete remission of prediabetes, improve glycemic control, and modulate cardiometabolic risk markers, thereby addressing residual metabolic vulnerability frequently observed after conventional CR.

Nutritional counseling and weight management are key for targeting atherosclerosis risk factors. Excess weight, particularly visceral adiposity, is independently associated with increased cardiovascular mortality, while poor dietary patterns contribute to dyslipidemia, hypertension, and insulin resistance. Evidence consistently demonstrates superior outcomes when nutrition interventions are delivered by registered dietitians using multiple sessions with individualized goal setting. Programs should routinely include formal dietary assessment, personalized meal planning, and scheduled follow-up extending beyond the traditional CR window to support long-term behavior change.

For instance, participation in CR programs is linked to increased long-term adherence to dietary recommendations, a benefit observed in the prospective study by Froger-Bompas et al. which showed sustained improvement in diet quality among patients post-MI. This aligns with a Swedish multicenter analysis of 5,248 patients, where structured dietary education delivered by trained staff in a supportive team environment predicted healthier eating patterns at 1-year post-MI. The Dietary Approaches to Stop Hypertension (DASH) diet specifically has demonstrated significant reductions in BP (systolic −5.2 mm Hg, diastolic −2.6 mm Hg) and LDL cholesterol (−0.1 mmol/L) in controlled trials, translating to approximately 2% reduction in major cardiovascular events based on cholesterol-outcome relationships. ^, While not specific to CR, incorporating the DASH diet into CR programs has been associated with improved BP and lipid control. The DISCO-CT trial, specifically evaluating intensive DASH counseling in 97 patients with nonobstructive CAD, demonstrated that during the 12-month intervention period, the DASH group lost an average of 3.6 ± 4.2 kg and reduced total body fat by 4.2 ± 4.8 kg compared to 1.1 ± 2.9 kg and 0.3 ± 4.1 kg in the control group (both p < 0.01). Notably, the DASH intervention resulted in sustained reduction of the proatherogenic chemokine CXCL4 (decreasing by 4.3 ± 3.0 ng/ml during intervention and remaining suppressed at 6-year follow-up, (p < 0.001 between groups), a biomarker of atherothrombotic risk. Longer-term outcome data are particularly compelling. In a 5-year RCT by Plüss et al., patients receiving extended CR including additional nutritional counseling saw cardiac events reduced from 60% to 48% compared to standard care, with corresponding reductions in nonfatal MI and hospitalizations (risk ratio 0.69). DISCO-CT trial’s 6-year follow-up, despite weight regain and increased visceral fat in both groups, the Mediterranean DASH-counseled cohort experienced only 1 major adverse cardiovascular event compared with 4 events (including 1 fatal MI) in the control group (p = 0.575), suggesting that sustained systemic reinforcement of dietary behaviors confers persistent cardiovascular protection even when anthropometric gains are partially lost.

A systematic review by Kocanda et al. analyzing 11 RCTs evaluating nutrition interventions within CR identified substantial heterogeneity and poor methodological reporting across studies. The review, encompassing 1,542 participants and evaluating 29 distinct dietary intake outcomes across 10 countries, found that only 5 of 11 studies (45%) reported statistically significant dietary changes. This modest effectiveness rate is particularly concerning given the evidence base, yet even more problematic is the consistent failure of included trials to report intervention details with sufficient precision to enable clinical replication or implementation. Most studies inadequately described intervention components according to the Template for Intervention Description and Replication (TIDieR) checklist, omitting critical elements such as intervention dosage, fidelity measures, protocol deviations, and the qualifications of personnel delivering nutritional education. This reporting opacity limits the capacity to identify best-practice features, hampers evidence synthesis, and undermines confidence in applying research findings to routine CR practice.

Several studies have shown that multicomponent lifestyle interventions delivered during CR yield clinically significant weight loss. The EuroAction trial, which evaluated lifestyle-focused CR across several European centers, found that patients in intervention groups achieved greater weight reduction, improved diet quality, and better lipid control compared with usual care. Calorie restriction, typically targeting a 500 to 1,000 kcal/d deficit, remains central to weight loss in CR. Programs that combine this with frequent dietary feedback, weigh-ins, and goal setting tend to have higher success rates. Weight regain following initial successful weight reduction represents a pervasive and clinically significant limitation in CR populations. In a landmark RCT by Ades et al. 74 overweight patients with CAD randomized to high-calorie-expenditure exercise (3,000 to 3,500 kcal/wk) versus standard CR exercise (700 to 800 kcal/wk) demonstrated striking short-term results: participants in the intensive exercise arm achieved double the weight loss (8.2 ± 4 kg vs 3.7 ± 5 kg, p < 0.001) and fat mass reduction (5.9 ± 4 kg vs 2.8 ± 3 kg, p < 0.001) at 5 months. Critically, this weight loss was largely maintained at 1 year, with modest regain of 1.3 kg in the high-expenditure group and 0.9 kg in the standard group. However, such intensive supervised programs are resource-demanding and not universally scalable, highlighting tensions between efficacy and feasibility.

A systematic review by Vanzella et al. identified multilevel barriers affecting adherence to dietary recommendations in CR participants, categorized across individual, provider, and system/environmental domains. At the individual level, lack of nutritional knowledge was the most frequently reported barrier (56% of studies), followed by financial constraints, personal food preferences and habits, time limitations, and psychological factors including low motivation and depression. At the provider level, inadequate detail in dietary counselling, language barriers, and absence of translation services hindered patient understanding. At the system/environmental level, lack of family support (37% of studies) and poor availability of recommended foods, including limited healthy restaurant options, scarcity of fish markets, and seasonal unavailability of fresh produce, were consistently identified.

Cultural factors represent particularly complex barriers. South Asian patients participating in CR programs reported cultural norms where meals are prepared by specific family members (typically women), making individualized dietary modifications socially and practically challenging without family engagement. Religious and fatalistic beliefs also influenced health prioritization and attendance at CR sessions among ethnic minority populations.

Integration of motivational interviewing, a patient-centered counseling technique designed to enhance intrinsic motivation and resolve ambivalence toward behavior change, has demonstrated effectiveness in promoting lifestyle modification among cardiovascular patients. Systematic reviews indicate motivational interviewing increases physical activity and supports dietary adherence when incorporated into multicomponent interventions. ^, Group-based education sessions, family involvement, and culturally tailored resources addressing specific ethnic and socioeconomic needs are critical facilitators that should be systematically incorporated.

Telehealth-based dietary interventions, increasingly utilized during and after the COVID-19 pandemic, offer scalability and accessibility advantages. A systematic review and meta-analysis of 13 RCTs (3,013 participants) evaluating telehealth dietary interventions for cardiovascular disease demonstrated significant reductions in systolic BP and improvements in weight and lipid profiles compared to usual care. Emerging technologies including mobile applications, text messaging, wearable devices, and remote coaching platforms hold promise for sustaining engagement and accountability during the vulnerable postrehabilitation period when weight regain is most likely.

Education and psychosocial support are necessary to address the psychological and behavioral responses that follow ACS and which can worsen prognosis. Anxiety, depression, and post-traumatic stress are common after MI and are linked to poor medication adherence, reduced lifestyle adherence, and poorer follow-up, increasing reinfarction and mortality risk.

Several studies have highlighted the benefits of CR-based education. The EUROACTION study, a multicenter European trial, incorporated patient and partner education as a core part of its CR program. Participants in these sessions improved knowledge and lifestyle behaviors and were more likely to stay active and follow dietary advice at 1 year. The incorporation of family-based CR within conventional center-based programs may mitigate key barriers to CR efficacy and represents a potentially effective, personalized approach for specific populations, such as individuals of South Asian descent. ^, Similarly, the Coronary Health Improvement Project (CHIP) incorporated structured educational modules for individuals at elevated risk of CAD and reported significant improvements in BP, weight, and triglyceride levels. Holistic management of post-ACS patients includes effectively addressing psychological and psychiatric disorders. The Enhancing Recovery in Coronary Heart Disease Patients trial found cognitive behavioral therapy significantly reduced depressive symptoms post-MI but did not impact all-cause mortality, potentially due to adherence challenges and the variability of treatment intensity.

Traditional CR often follows a one-size-fits-all approach, which fails to address the specific clinical, psychological, and socio-cultural needs of diverse patient groups. Growing recognition of these limitations has led to a growing emphasis on personalized and population-sensitive CR strategies.

Gender-specific barriers to CR participation in women with CAD have been documented in multiple studies. ^,, Family and caregiving responsibilities represent a significant and well-established barrier, with quantitative studies demonstrating that women rate family responsibilities higher than men as obstacles to CR enrollment (p = 0.039) and are more likely to withdraw from CR due to family obligations. While depression and anxiety are more prevalent in women with CVD, the relationship between these conditions and CR participation is complex and inconsistent across studies, with some large post-MI cohorts showing depression associated with higher CR attendance, possibly reflecting increased referral patterns. Atypical symptom presentation, though more common in women, primarily influences CR participation indirectly through lower referral rates and delayed diagnosis rather than as a direct patient-level barrier.

Despite agreement on this gap there has been limited research on methods to mitigate sex disparity in CR. One systematic review and meta-analysis found that systematic CR referral resulted in significantly improved enrollment among women compared to nonsystematic referral. A retrospective study by Heald et al. compared outcomes in women, predominantly with CAD, participating in mixed-sex, women-only, or home-based CR (HBCR) and found no advantage to participation in women-only CR. Ultimately, there is a critical need for research into effective methods to improve referral, enrollment, and retention of women with CR.

Addressing the well-documented gender disparities in CR participation among women with CAD requires implementation of multifaceted, evidence-based strategies targeting both systemic and individual-level barriers. Automatic referral systems combined with liaison-facilitated enrollment represent the most effective approach to overcoming referral bias and improving access; a multisite study of 452 women with CAD demonstrated that combined systematic and liaison-facilitated referral resulted in 84.2% referral and 70.0% enrollment rates compared to 29.1% referral and 26.2% enrollment with usual care (p < 0.001), translating to 10-fold greater odds of referral (OR 10.26, 95% CI 4.11 to 25.58) and 6.5-fold greater odds of enrollment (OR 6.56, 95% CI 4.34 to 9.92). Women-tailored interventions incorporating motivational interviewing, flexible scheduling, and psychosocial support components have demonstrated superior outcomes; a RCT of 225 women with CAD comparing tailored versus traditional CR showed significant improvements in QoL scores at postintervention (MDT scores 37.9 vs 35.9, p < 0.05) and sustained benefits at 6-month follow-up.

Older adults (≥65 years) represent a majority of patients with acute MI, yet their inclusion in CR is often limited by age-related factors including functional and cognitive decline, frailty, polypharmacy, and multimorbidity. Despite these challenges, evidence supports the efficacy of CR in this demographic, with improvements in exercise capacity, cardiorespiratory fitness, and mortality that are comparable to younger cohorts. ^,, The generalizability of evidence from major CR trials is often limited by the exclusion of frail patients. This highlights the critical role of studies, such as the meta-analysis by MacEachern et al. in understanding CR outcomes in this population. Their analysis confirms that while frailty at program entry is a significant predictor of mortality (p = 0.0001), CR participation yields substantial and sustained improvements in frailty status over a median follow-up of 4 to 6 months (p < 0.0001). Therefore, although frail individuals are underrepresented in clinical trials, data indicate they are a high-risk cohort that derives significant benefit from CR interventions.

Optimizing CR for frail older adults necessitates a personalized approach. Baseline functional assessments, such as cardiopulmonary exercise testing (CPET), are crucial for prescribing safe and effective exercise intensities. Emerging evidence supports the integration of hybrid and telemonitoring strategies to enhance safety and adherence. While the CR-AGE trial highlighted age-related exclusion from independent home-based exercise due to safety concerns, it underscored the need for more inclusive CR models. The HYCARET trial, in turn, demonstrated the potential of a hybrid approach among older adults. Collectively, these findings advocate for the development of structured, hybrid CR programs that incorporate individualized exercise prescriptions to improve cardiovascular outcomes whilst simultaneously improving muscle strength. In corroboration with previous trials, the recently published Physical Activity Intervention in Elderly Patients with MI (PIpELINe) trial demonstrates that tailored multidomain rehabilitation initiated 1-month post-MI substantially reduces adverse outcomes in older patients with impaired physical performance. This multicenter randomized trial enrolled 512 patients (median age 80 years, 36% women, SPPB 4 to 9) to receive comprehensive intervention combining cardiovascular risk factor optimization, personalized dietary counseling, and individualized exercise training versus usual care. The primary composite endpoint of cardiovascular death or unplanned cardiovascular hospitalization at 1 year occurred in 12.6% of intervention patients versus 20.6% controls (HR 0.57, 95% CI 0.36 to 0.89, p = 0.01), driven predominantly by a 52% reduction in cardiovascular hospitalizations (HR 0.48, 95% CI 0.29 to 0.79) and striking 80% reduction in heart failure hospitalizations (HR 0.20, 95% CI 0.07 to 0.56). The open-label design introduces performance bias, selection bias excludes the most vulnerable (only 40% of screened patients enrolled), and inability to disaggregate intervention components precludes identification of which elements drive benefit. Adherence was 71% overall, with substantial unreported variability by frailty severity. One-year follow-up is insufficient to establish durability, and the exclusively Italian healthcare setting raises external validity concerns regarding generalizability to lower-participation-rate settings.

Ethnic disparities in CR utilization and outcomes are also well documented. Black, South Asian, and Hispanic populations face higher cardiovascular risk yet are less likely to be referred or to adhere to CR. Contributing factors include language barriers, cultural differences, mistrust, and socioeconomic constraints. ^, Research on culturally adapted cardiovascular interventions offers insights for adapting CR. The South Asian Health Lifestyle Intervention (SAHELI) trial randomized participants to either printed educational materials or a 16-week group-based program led by South Asian coaches, with sessions conducted in relevant languages including Gujarati, Hindi, and Urdu. The program addressed culturally specific influences on lifestyle in South Asian communities—family dynamics, values, norms, and illness perceptions. However, at 12 months, no significant difference in CVD risk factor reduction was observed between groups. Though underpowered, the study suggests that language and cultural adaptation alone may not be sufficient to drive engagement in ethnic communities. In contrast, community-based approaches in African American populations have shown promise. The Heart 2 Heart pilot study, which included peer mentoring and church-based education, improved attendance and reduced systolic BP mainly by increasing timeliness of medication refills. Tailoring CR programs to incorporate trusted community members or take place in familiar settings could boost patient engagement while easing demands on clinical staff.

Center-based CR (CBCR) remains the gold standard and is characterized by real-time clinician-patient interactions in outpatient, hospital or community settings. Despite proven clinical efficacy, global participation remains suboptimal, with enrollment rates consistently below 50%. ^, Barriers to attendance are multifactorial and include inadequate transportation infrastructure, caregiving responsibilities, cost, competing familial obligations, and geographical inaccessibility. ^,,,,, These barriers disproportionately affect women and older adults, exacerbating disparities in CR.

HBCR has emerged as an effective alternative to address barriers inherent to CBCR models. HBCR leverages telehealth infrastructure, wearable biosensors, smartphone applications, and asynchronous remote monitoring to enable patient self-management while providing clinical oversight via videoconferencing, automated prompts, and telemetric data transmission ^, (See Table 1 ). Mobile Health (mHealth) platforms expand the scope of HBCR by facilitating virtual clinician contact and tracking metrics such as heart rate, BP, and VO₂ peak. ^, In an RCT of 120 post-MI patients, Varnfield et al. evaluated a smartphone-based HBCR model incorporating weekly 15-minute phone consultations and daily logging of weight, BP, sleep, stress, diet, and substance use. These entries, synced to a secure digital diary, enabled clinicians to review data and offer personalized feedback aligned with patient goals. As such, the HBCR model of care yielded a significant improvement in adherence (94% vs 68%) and completion (80% vs 47%) rates compared with center-based care.

The evidence base for HBCR’s efficacy continues to grow. A meta-analysis of 13 RCTs evaluating mHealth-enabled CR found significant improvements in functional capacity over 6 to 24 weeks, as measured by VO₂ peak and 6-Minute Walk Test. Another meta-analysis of 14 RCTs in patients with CAD compared HBCR with conventional CBCR. The findings revealed an equivalent effect across functional capacity, physical activity levels, exercise adherence, depressive symptoms, and HRQoL. These findings illustrate not only the efficacy of HBCR but also its potential to address barriers to geographic isolation and logistical constraints, which affect CBCR attendance. ^,,

A key concern of HBCR is safety of unsupervised physical activity in high-risk patients. However, data from Rognmo et al. have demonstrated that the incidence of exercise-related cardiac complications is low, with only 1 event per 23,182 hours of high-intensity exercise. Preparticipation screening interventions, including CPET, can be implemented to guide safe home-based program initiation. CPET has been shown to aid in establishing safe and effective exercise intensity thresholds and optimize HBCR protocol through continuous monitoring of ECG activity, BP response, and gas exchange. Finally, devices such as wrist-worn heart monitors and hip-mounted accelerometers have been increasingly adopted within HBCR. These devices allow clinicians to adjust exercise prescriptions based on exertional intensity in real-time or retrospectively, enhancing safety without compromising therapeutic benefit. However, high costs and a lack of widespread availability are a key barrier to the utilization of CPET and wearable devices, especially in under-resourced communities. ^,,,

Hybrid CR (HCR) models combine supervised, in-person sessions with a subsequent phase of remote HBCR. Hybrid models leverage components of HBCR, such as telemonitoring and tele-coaching, to sustain engagement and compliance. The rationale for this approach lies in building early confidence and skill acquisition through direct supervision, while fostering long-term behavioral adherence through remote, structured reinforcement. This may be particularly beneficial for populations in which CR is historically underutilized, such as racial and ethnic minorities, older adults, and those in resource-limited settings.

In the Hybrid CR Trial (HYCARET), Marzuca-Nassr et al. evaluated a hybrid CR model in adults ≥60 years with CAD. The intervention comprised an initial 6-week phase of 10 supervised outpatient sessions, including aerobic and resistance training with self-directed counseling, followed by a 6-week HBCR phase. The home-based component replicated the exercise prescription and incorporated behavioral reinforcement via “nudging” interventions—biweekly phone calls and thrice-weekly text messaging. The trial demonstrated a statistically significant improvement in functional capacity, with no significant difference observed between the groups. These results highlight HCR’s viability, especially in older adults, supporting its role as an alternative strategy to engage underutilized populations.

Although the HYCARET trial was limited by attrition and underpowered, its findings are supported by an expanding body of prospective, randomized studies demonstrating the comparable clinical benefits of HCR in CAD. ^,,, Nevertheless, further adequately powered studies are required to establish the long-term effectiveness of technology-enabled HCR programs. Ongoing trials such as the mTECH-Rehab study (NCT05238103) will evaluate the Corrie HBCR program in patients eligible for CR, including those recovering from acute MI, coronary artery bypass grafting, PCI, valvular heart surgery, and transcatheter aortic valve replacement. Its outcomes will inform scalability, safety, and population-specific impacts of HCR. A summary of the components of cardiac telerehabilitation is presented in Table 2 .

CR is a proven cornerstone of secondary cardiovascular prevention, reducing mortality, recurrence, and improving QoL for patients with CAD. Yet, gaps in referral, enrolment, and adherence have limited its population-level impact. The emergence of digital health tools and artificial intelligence (AI) offer promising opportunities to personalize, streamline and scale CR. Advanced machine learning and deep learning algorithms can analyze complex datasets from wearables, apps, and remote monitoring platforms to generate actionable insights for both patients and clinicians.

Digital applications have emerged as an efficacious solution to enhance patient engagement in CR. One prospective cohort study examined Heart Track , a gamified mobile application with wearable sensors, in patients following coronary revascularization. Features included self-directed, individualized exercise programs and incorporated gamification elements, including achievement trophies and ranking systems. Participants reported increased exercise frequency, highlighting that gamified platforms can help improve adherence. Similarly, an RCT of eMOTIVA , an mHealth intervention, assessed the platform over 6 months in 300 patients post-PCI for ACS. The intervention employed behavior modification strategies including weekly digital prompts promoting healthy lifestyle, a color-coded goal-tracking system for dietary adherence, physical activity levels, smoking cessation, and medication compliance. The study found significant improvements in physical activity engagement and exercise capacity. Furthermore, participants demonstrated improved knowledge of cardiovascular risk factors and higher satisfaction, affirming mHealth interventions to inform patients and reinforce healthy behaviors.

Despite these advances, limitations remain for HBCR and mHealth interventions. Low digital literacy and reduced confidence with mobile technologies can hinder uptake, particularly among older adults. ^, However, recent evidence suggests a growing receptivity to digital health interventions among older adults, particularly in the aftermath of the SARS-CoV-2 pandemic. ^,, Telemonitoring and motivational tele-support could mitigate usability concerns and enhance adherence. One multicenter RCT of patients ≥65 years with CAD found that an mHealth-facilitated HBCR program supplemented with motivational tele-counselling led to significant improvements in VO₂ peak. These findings substantiate the viability of digital CR interventions in older cohorts when augmented by synchronous clinical support and counselling.

A pivotal role for AI in CR will be shifting traditional care paradigms from reactive to proactive through continuous physiological monitoring. In an RCT by Widmer et al. a digital health intervention for 80 post-PCI patients used an AI-generated health score from biometric data (BP, lipids, glucose) to trigger clinical alerts. This led to improved weight loss and trends toward reduced CVD-related hospitalizations compared with standard CR (8.1% vs 26.6%, p = 0.054). Unlike conventional CR, which often implements care after clinical decline, AI models can be trained to detect subtle, presymptomatic changes and prompt earlier intervention. The principle of these models is readily extrapolated to wearables, where continuous ECG data could help AI detect risk in real-time for individuals undertaking HBCR. Forthcoming studies, such as the trial by Lee et al. utilizing an AI-enabled smartwatch ECG for early prediction of rehospitalization due to ischemic events during CR, are poised to elucidate the real-world feasibility and potential impact of these technologies. ^,

Another use of AI in CR is to tailor exercise prescriptions for individual patients that can adapt to evolving physiological status. Algorithms integrating biometric data, exertion scores, and adherence logs can dynamically adjust intensity to mitigate the risks of over-exertion or suboptimal training. The RECAP trial is a single-center feasibility study investigating an AI model that automates exercise prescription in HBCR. The algorithm synthesizes patient demographics, activity history, and exertion ratings to generate personalized weekly exercise goals. Such automation confers significant advantages in scalability, reducing dependency on direct clinical supervision, and facilitates an adaptive system that learns from the patient over time.

Suboptimal participation remains a major barrier in CR. AI-driven chatbots and virtual coaches may offer a novel modality to boost engagement by providing tailored education, 24/7 support, and motivational feedback. ^, Preliminary findings from a cross-sectional study by Genes et al. showed ChatGPT-4 could generate guideline-concordant CR recommendations and patient-specific strategies. However, limitations were noted in tailoring regimens for high-intensity interval training and resistance training in elderly or frail patients, underscoring the need for caution and clinical oversight. Prospective studies are needed to evaluate the impact of AI-powered health coaching on key patient behaviors, specifically medication adherence, completion of CR, and clinical outcomes.

Language barriers and a lack of culturally relevant information are also significant hurdles to equitable CR access. Studies have shown that CR participation can be improved by educating patients about the CR program, and its respective benefits and therefore providing information to patients in their native language may prove to be beneficial. ^,,, AI-powered translation technologies such as real-time speech-to-text translations and text-to-text systems leveraging large-language models present a novel approach to overcoming linguistic barriers. Embedding cultural competence into AI tools by incorporating values, customs, social norms of the patient may enhance relevance and uptake. For instance, home-based AI tools could deliver CR in a format that is family-centered (valued by many ethnic communities). ^, While promising, this remains conceptual, requiring thoughtful design and real-world testing.