Europe Expands Cardiac Rehabilitation Guidance

The European Society of Cardiology has published its first guidelines specifically dedicated to cardiac rehabilitation, which should now be considered earlier in the course of care — in some cases, as early as the hospital stay itself. The goal is to encourage wider implementation, including through home-based cardiac rehabilitation — particularly where resources are limited — using digital tools.The guidelines were presented at the European Society of Cardiology (ESC) Congress 2026 in Munich, Germany, and published simultaneously in the European Heart Journal.Until now, cardiac rehabilitation had been covered in separate sections of various guidelines and played a particularly important role in the management of acute coronary syndrome and heart failure. The document now proposes a comprehensive, patient-centered approach, with specific adaptations for each cardiovascular disease.Expansion of IndicationsBeyond acute coronary syndrome and heart failure, rehabilitation now covers a broader spectrum of heart diseases, including valvular heart disease, congenital heart disease, atrial fibrillation, cardio-oncology, pulmonary arterial hypertension, and certain cardiomyopathies. These new guidelines also allow rehabilitation to be tailored to patients’ comorbidities.“Cardiac rehabilitation is one of the most effective treatments in cardiology, with benefits that go beyond those of medication or surgery,” emphasized Maria Bäck, researcher and clinician at Sahlgrenska University Hospital in Gothenburg, Sweden, who co-led the development of these guidelines. “Despite the rise in the number of people living with cardiovascular disease, cardiac rehabilitation remains underutilized.”“There is a real problem with access to cardiac rehabilitation,” confirmed Marie Christine Iliou, MD, Paris Saint-Joseph Hospital, Paris, France, who helped review the document, in an interview with Medscape’s French edition. “In France, 25% of patients with acute coronary syndrome and 10% of patients with heart failure receive rehabilitation. Among those with chronic coronary syndrome, the rate drops to 5%.”The lack of specialized centers and the broadening of indications partly explain this difficulty in access to care. To address this shortage and improve participation, telerehabilitation is presented for the first time as an alternative to in-center programs in certain situations, with a Class IIa recommendation, particularly in a hybrid approach combining in-person sessions and remote monitoring, always under the supervision of a cardiac rehabilitation center.“These recommendations also reflect a push to standardize practices, which differ widely from one country to another, and to revisit the indications and contraindications,” said the cardiologist specializing in cardiac rehabilitation. “They also represent recognition of the specialty.”A key point, the authors emphasized, is that rehabilitation is patient-centered. It is not about offering a standardized program. Instead, care is individualized to reflect each patient’s medical circumstances, needs, and expectations, with the goal of improving quality of life. To that end, patient organizations were extensively consulted during development of the guidelines.More Muscle Strengthening“Shared decision-making is essential for defining the key components of cardiac rehabilitation and how it is delivered,” said Matthias Wilhelm, MD, of University Hospital Bern in Bern, Switzerland, during his presentation. He also co-led the drafting process. “Combined with new technologies, this approach can help patients follow their rehabilitation program wherever it works best for them, especially at home.”In these recommendations, cardiac and vascular rehabilitation is no longer presented as a simple physical exercise program but as a set of individualized measures aimed at improving patients’ recovery and overall health.In addition to physical training, it incorporates treatment optimization, management of risk factors and comorbidities, nutrition, weight management, as well as psychological support and therapeutic education. “Even though evidence of its impact on prognosis is still limited, appropriate psychological support should be offered based on the patient’s profile,” Iliou explained. Psychoeducational interventions or cognitive behavioral therapy are specifically suggested.The guidelines also devote entire chapters to sexuality and returning to work — two important aspects of recovery following a cardiovascular event.For physical activity, the guidelines generally call for endurance and strength-training exercises in most patients. The recommendations are individualized based on frequency, intensity, duration, exercise type, volume, and progression. Strength training, which receives greater emphasis in these guidelines, is particularly important for patients with heart failure and older adults.Specified Timelines for ImplementationAn important new feature: The recommendations specify adjustments based not only on the specific condition but also on the patient’s profile and goals. “The document provides very clear guidance on how to adapt physical exercises based on comorbidities, such as high blood pressure or obesity,” emphasized Iliou.Another new feature is that the guidelines set specific time frames for starting rehabilitation. In general, early initiation is recommended to improve adherence and functional outcomes, with a Class I/C recommendation.After an acute coronary syndrome, cardiac rehabilitation should begin within the first 14 days and no later than 30 days. After coronary artery bypass grafting, it should begin within 28 days and not be delayed beyond 42 days. After these time frames, however, it is never too late to start, the cardiologist noted.Early initiation of cardiac rehabilitation should be considered in hospitalized patients with decompensated heart failure to reduce in-hospital mortality, with a Class IIa/B2 recommendation. It can begin soon after decongestion and hemodynamic stabilization have been achieved.In certain high-risk patients — such as those with advanced heart failure, New York Heart Association Class IV, complex ventricular arrhythmias, or severe coronary stenosis — telemetric monitoring during exercise may be considered to detect potential arrhythmias, ischemia, or hemodynamic abnormalities, with a Class IIb/C recommendation.Cardiac rehabilitation is particularly recommended following acute coronary syndrome and in the management of chronic coronary syndrome, with or without percutaneous coronary intervention or coronary artery bypass grafting. It is associated with a reduced risk for cardiovascular mortality and myocardial infarction, with a Class I/A recommendation. It also helps reduce hospitalizations and improve physical capacity and quality of life.The same is true for patients with heart failure and reduced ejection fraction, defined as less than 50%, for whom rehabilitation carries a Class I/B1 recommendation. It should also be considered as soon as possible in cases of decompensated heart failure, with a Class IIa/B1 recommendation. Rehabilitation is likewise indicated in patients with preserved ejection fraction, defined as 50% or greater, to improve physical capacity and quality of life, also with a Class I/B1 recommendation.The recommendations extend cardiac rehabilitation to several other cardiovascular conditions. It is recommended for patients with valvular heart disease treated by transcatheter aortic valve implantation or surgery, adults with congenital heart disease, or those following implantation of a defibrillator or cardiac resynchronization device, with a Class I/B1 recommendation.With regard to rehabilitation in atrial fibrillation, this is the first time it has been the subject of recommendations. It should be considered to “reduce the severity of atrial fibrillation-related symptoms, the symptom burden, the frequency and duration of episodes, as well as recurrences,” with a Class IIa/B1 recommendation. Following radiofrequency catheter ablation, rehabilitation should also be considered to improve physical capacity and quality of life, with a Class IIa/B1 recommendation.It should also be considered in cases of pulmonary arterial hypertension, as well as in patients with certain cancers, particularly when there is associated heart disease and/or to limit the cardiotoxic effects of cancer treatments, with a Class IIa/B1 recommendation.Overall, the experts specify that frailty or the presence of comorbidities should not lead to the exclusion of a patient with an indication for cardiac rehabilitation, with a Class III recommendation.Recognition of TelerehabilitationTo remove barriers to participation, hybrid models are proposed to supplement care provided in hospitals or specialized centers by combining in-person sessions with remote monitoring. These new recommendations thus mark a recognition of telerehabilitation, which should now be considered, particularly for low-risk patients limited by geographic, family, or work-related constraints.More broadly, the recommendations indicate that remote consultations should be considered for patients undergoing cardiac rehabilitation to improve referral, adherence, and full participation in the program, with a Class IIa/B2 recommendation.The initial assessment, risk stratification, and pre-exercise screening must be conducted in person to determine a program that can then be implemented remotely via specific online platforms. AI is also mentioned as a tool that can contribute to the personalization and optimization of rehabilitation programs.The standard outpatient program consists of 24 rehabilitation sessions spread over approximately 12 weeks. “In general, for cardiac rehabilitation, there are between 20 and 40 sessions, with weekly frequencies varying depending on the specific condition,” Iliou explained. In France, reimbursement for telerehabilitation is expected to begin in 2027, she noted.Experts emphasized that, for certain selected patients, at-home cardiac rehabilitation incorporating digital tools — particularly remote monitoring and teleconsultations with health professionals — can reduce healthcare costs and be more convenient to implement than standard hospital-based programs.This story was translated from Medscape’s French edition.