We read with great interest the article by Vadlakonda et al. evaluating patient outcomes from home-based virtual cardiac rehabilitation (CR) within a large integrated healthcare system. The authors should be commended for addressing one of the most persistent gaps in secondary cardiovascular prevention, limited access and participation in conventional center-based CR programs. Their findings suggesting that participation in virtual CR was associated with lower hospitalization rates and improved 1-year survival provide important real-world evidence supporting telehealth-enabled rehabilitation models.

Nevertheless, several aspects warrant further consideration. Although the authors used propensity-weighted analyses to mitigate selection bias, the observational design may still be subject to residual confounding. Factors such as patient motivation, socioeconomic status, baseline health literacy, and digital access could influence both the likelihood of enrolling in a virtual CR program and subsequent outcomes. In addition, the overall participation rate among eligible patients remained relatively modest, indicating that barriers to CR uptake persist even when rehabilitation programs are delivered remotely.

The expansion of remote CR programs is supported by previous investigations showing that telehealth-based rehabilitation can achieve comparable clinical outcomes and adherence compared with facility-based programs. For example, another study demonstrated that remote cardiac rehabilitation delivered through a digital platform enabled faster enrollment, higher completion rates, and similar clinical outcomes compared with traditional facility-based CR, while maintaining comparable overall healthcare costs.

Importantly, adherence remains a key determinant of the effectiveness of rehabilitation interventions. Barriers such as transportation difficulties, work obligations, low motivation, comorbidities, and limited social support have long been recognized as major contributors to poor participation in cardiac rehabilitation programs. Strategies aimed at improving adherence, including individualized exercise prescriptions, behavioral support, remote monitoring, and digital health tools, may therefore play a crucial role in maximizing the benefits of virtual CR programs.

Patient characteristics and comorbidities may also influence rehabilitation participation and outcomes. Obesity, for instance, is a frequent condition among patients with cardiovascular disease and may significantly affect functional capacity, risk stratification, and clinical prognosis. Recent evidence has highlighted the complex relationship between obesity and cardiovascular outcomes, emphasizing the importance of individualized risk assessment when evaluating patient populations in cardiovascular studies.

Finally, the increased rate of emergency department visits observed among virtual CR participants in the present study deserves further exploration. This finding may reflect improved symptom awareness, earlier healthcare engagement, or proactive clinical monitoring rather than deterioration in clinical status. Prior research has also demonstrated that patients with cardiovascular disease often experience substantial long-term healthcare utilization following hospitalization, particularly those with complex comorbidities. Additional contemporary studies in cardiovascular cohorts further confirm the importance of structured follow-up and multidisciplinary management strategies to improve long-term outcomes in high-risk cardiac populations.

Overall, the study adds meaningful evidence to the growing literature supporting virtual cardiac rehabilitation as an effective strategy to expand access to guideline-recommended secondary prevention. Future investigations should further explore determinants of adherence, patient-reported outcomes, and long-term functional capacity, while also addressing digital inequities that may influence participation in virtual care models.