IPM Take
Cardiac rehabilitation has an unusual problem. The intervention works, but many eligible patients never receive enough of it.
The updated Cochrane evidence confirms that exercise-based rehabilitation after coronary heart disease reduces myocardial infarction and hospital admissions and improves aspects of quality of life. What has changed is the delivery model. Newer studies increasingly include rehabilitation delivered at home, through apps, video consultations and hybrid programmes rather than exclusively inside specialist centres.
That matters because attendance is one of cardiac rehabilitation’s persistent weaknesses. Travel, work, caring responsibilities, mobility and geography can all turn a guideline-recommended intervention into one that is practically inaccessible.
But remote care should not be confused with unsupervised exercise for everyone. The 2026 ESC cardiac rehabilitation guidelines support patient-centred combinations of face-to-face, virtual and remote delivery, while home-based rehabilitation without digital support is positioned as an option particularly for patients who are not high risk.
The emerging model is therefore not “hospital or home.”
It is the right rehabilitation intensity, supervision and setting for the right patient.
Executive Summary
The updated Cochrane review assessed exercise-based cardiac rehabilitation in adults with coronary heart disease, including people following myocardial infarction, percutaneous coronary intervention or bypass surgery and those with angina or coronary artery disease. Programmes ranged from structured exercise alone to exercise combined with education or psychosocial support.
At 6 to 12 months, exercise-based rehabilitation produced a 28% relative reduction in myocardial infarction compared with no structured exercise, with a risk ratio of 0.72. It also reduced all-cause hospitalisation and was associated with improvements in several dimensions of health-related quality of life. Longer-term follow-up suggested reductions in cardiovascular mortality and recurrent MI.
The evidence base increasingly reflects modern delivery. Twenty-seven studies in the Cochrane public summary involved exercise performed at home, with some programmes delivered through mobile apps or online platforms. Cochrane concluded that newer home-based and digitally supported approaches can be effective alternatives to conventional delivery.
However, women remain underrepresented, accounting for only around 17% of participants in the public summary, and implementation evidence remains less mature for patients with complex or high-risk disease.
Why it matters
- HTA bodies: Cardiac rehabilitation should increasingly be assessed as a service model rather than a fixed location. Digital platforms, remote supervision, exercise prescription and clinical escalation all contribute to value.
- Payers: If home and hybrid rehabilitation can achieve comparable outcomes for appropriate patients, reimbursement models that only fund centre attendance may create unnecessary access barriers. Savings from reduced travel and infrastructure need to be weighed against monitoring, technology and workforce costs.
- Industry / innovation partners: Remote monitoring, wearables, video-based rehabilitation and digital adherence tools could become increasingly embedded in secondary cardiovascular prevention, but products will need to demonstrate that they improve participation and clinical outcomes rather than simply digitising existing workflows.
For decades, cardiac rehabilitation has been treated as a place patients go after a heart attack.
The evidence increasingly suggests it should be thought of as something patients receive.
An updated Cochrane review published in September reinforces one of the strongest arguments for structured rehabilitation in coronary heart disease. Compared with no structured exercise programme, exercise-based cardiac rehabilitation reduced recurrent myocardial infarction, lowered hospitalisation and improved several measures of health and wellbeing.
At 6 to 12 months, the pooled risk ratio for myocardial infarction was 0.72, corresponding to a 28% relative reduction. Cochrane’s public summary estimates that approximately one heart attack is prevented for every 71 people participating in exercise-based rehabilitation.
The intervention was not built around one specific workout.
Trials included walking, stationary cycling, circuit training and other forms of aerobic exercise, delivered at different intensities and frequencies. Some programmes combined exercise with education, behavioural support or psychological interventions.
What is becoming more interesting is where those interventions happen.
Traditional rehabilitation often requires patients to travel repeatedly to a hospital or specialist centre. That model can work well for patients who need close supervision, but it can also exclude people whose jobs, transport, caring responsibilities or geography make frequent attendance unrealistic.
Home-based and digital delivery offer another route.
Cochrane’s update included a growing number of studies testing rehabilitation at home, including programmes delivered through apps and online support. The review authors concluded that newer digital models can produce benefits comparable to conventional programmes, opening the possibility of reaching patients who would otherwise never complete rehabilitation.
European guidance is moving in the same direction.
The 2026 ESC Guidelines on cardiac rehabilitation recommend considering patient-centred programmes that combine face-to-face, virtual or remote delivery to improve participation and better match individual needs. They also state that home-based rehabilitation without digital technology may be considered as an alternative to centre-based rehabilitation for patients who are not at high risk.
But another major 2026 study provides an important warning against turning that flexibility into a blanket replacement strategy.
The Remote Exercise SWEDEHEART programme tested remote exercise rehabilitation after myocardial infarction. At ESC Congress 2026, investigators reported that adding access to remotely supervised exercise produced similar numbers of completed sessions and similar improvements in exercise capacity to conventional centre-based care. Serious exercise-related adverse events were uncommon. The investigators’ conclusion was deliberately cautious: remote delivery should be viewed as an additional patient-centred option, not a universal replacement for centre-based rehabilitation.
Earlier real-world results from the same Swedish programme showed why the model is attractive. Among 232 post-MI patients using remotely supervised exercise, 83% said the programme improved healthcare access, 94% found the technology easy to use and 95% found the exercise delivery and interaction acceptable.
That makes cardiac rehabilitation an increasingly useful case study for digital health.
Technology does not need to replace clinicians to change care delivery. Sometimes its value is simply allowing the same clinical intervention to reach patients somewhere else.
The next challenge is implementation.
Health systems need criteria for identifying who can safely rehabilitate remotely, mechanisms for escalation when symptoms or monitoring data raise concern, reimbursement that does not favour one location over another, and alternatives for patients without reliable internet, devices or digital confidence.
Cardiac rehabilitation already has the evidence to justify its place in secondary prevention.
The emerging question is whether health systems can finally stop making access to that evidence-based care depend on a patient’s ability to repeatedly walk through the hospital door.
