IPM Take
Cardiac rehabilitation is not a wellness extra. It is secondary prevention. It combines exercise, education, risk-factor control, medicines support and psychosocial care after a cardiac event. Yet Australia’s new data show the brutal implementation gap: evidence exists, benefit exists, services exist, but most patients still do not get there. For personalised medicine, this is the uncomfortable lesson: precision does not matter if the care pathway breaks immediately after discharge.
Executive Summary
A Monash-led study published in the International Journal of Cardiology linked data from the Victorian Cardiac Outcomes Registry and the Victorian Integrated Non-Admitted Health dataset, covering patients across 13 public hospitals from 2019 to 2021. The study found that cardiac rehabilitation attendance after PCI was low, with only 19.3% of linked patients attending at least one session.
At 12 months, cardiac rehabilitation attendees had lower mortality and fewer unplanned readmissions. The study also found a dose-response relationship: patients attending six or more sessions had the lowest mortality, while non-attenders had worse outcomes.
Monash University reports that almost 400,000 Australians each year fail to access cardiac rehabilitation after conditions such as heart attack. In Victoria, more than 80% of eligible cardiac patients reportedly do not access these programmes after a major heart event.
The policy issue is not only Australian. Cardiac rehabilitation remains underused worldwide. Global audit evidence has shown that cardiac rehabilitation is available in only around half of countries, with large gaps in low-resource settings. The United States has set a national goal of 70% participation, while Europe has mapped major variation in uptake, funding, quality control and registry infrastructure across countries.
Australia’s problem is especially revealing because it has strong hospitals, strong cardiac care and high procedural capacity, but no national cardiac rehabilitation registry. That means the post-discharge patient journey remains poorly tracked, poorly governed and too easy to ignore.
Why it matters
- Policymakers and public authorities: Cardiac rehabilitation should be treated as a mandatory component of secondary prevention, not an optional outpatient add-on after discharge.
- Hospitals and providers: Referral cannot depend on individual clinician behaviour. Automatic referral, bedside endorsement and closed-loop follow-up should become standard after eligible cardiac events.
- Payers: Cardiac rehabilitation is cost-effective and linked to reduced mortality and readmissions. Underfunding it is not savings. It is delayed spending.
- Clinicians: A stent is not the end of care. Without rehabilitation, medication optimisation, exercise support and risk-factor management, the system leaves preventable risk untreated.
- Patients and advocates: Patients need to know that cardiac rehab is not “exercise class”. It is structured, evidence-based survival care after a heart attack or cardiac procedure.
Cardiac rehabilitation should be one of the least controversial interventions in cardiology.
It saves lives. It reduces readmissions. It improves quality of life. It supports exercise, education, medication adherence, risk-factor control and psychosocial recovery after a heart attack or cardiac procedure.
And still, most patients do not get it.
That is the uncomfortable message from a new Monash-led Australian study. Researchers linked data from the Victorian Cardiac Outcomes Registry with the Victorian Integrated Non-Admitted Health dataset, examining more than 7,100 linked patients across 13 public hospitals between 2019 and 2021. Only 19.3% attended cardiac rehabilitation.
The outcome difference was not marginal. At 12 months, cardiac rehabilitation attendees had lower mortality and fewer unplanned readmissions. Mortality was lowest among patients who attended six or more sessions. In Monash’s summary, patients who did not attend cardiac rehabilitation after a serious cardiac event were four times more likely to die from another attack compared with those who completed the full six-week programme.
That should be a policy scandal.
Because this is not a new drug waiting for approval. It is not a futuristic AI tool. It is not an experimental procedure. It is basic secondary prevention, already supported by decades of evidence and clinical guidelines.
Yet Monash reports that almost 400,000 Australians each year fail to access cardiac rehabilitation after conditions such as heart attack. In Victoria, more than 80% of eligible cardiac patients reportedly do not access these programmes after a major heart event.
The failure point is not just patient behaviour. It is system design.
According to the Monash report, lack of attendance is driven by weak referral, poor patient understanding of why rehabilitation matters, and fragmented inpatient-to-outpatient care. Less than half of eligible Australians are referred to cardiac rehabilitation after an acute cardiac event. Even among PCI patients, where previous registry work showed referral can be high, actual attendance remained poor.
This is the classic implementation gap: the hospital saves the patient, then the health system loses them.
Australia is not alone. Cardiac rehabilitation is underused globally. The International Council of Cardiovascular Prevention and Rehabilitation’s global audit found that cardiac rehabilitation was available in only 111 of 203 countries. The World Heart Federation previously warned that only one in 12 ischemic heart disease patients globally could access rehabilitation to prevent another event, with more than 18 million additional programme spots needed each year.
In the United States, Million Hearts reports that participation remains low, around 19% to 34% in a national analysis, despite a national goal of reaching 70% participation among eligible patients. In Europe, the European Society of Cardiology has mapped wide variation across member countries in cardiac rehabilitation uptake after myocardial infarction, dropout rates, start times, funding, accreditation and national registry infrastructure.
The global pattern is obvious. Health systems invest heavily in acute cardiac care, procedures and medicines, then underinvest in the recovery pathway that turns survival into long-term prevention.
That is bad medicine and bad economics.
Cardiac rehabilitation is a bridge between hospital and life. It is where patients learn how to exercise safely, manage symptoms, understand medicines, stop smoking, improve diet, address stress, regain confidence and reduce recurrent risk. It is also where clinicians can identify depression, frailty, poor adherence, uncontrolled blood pressure, diabetes risk and social barriers that may otherwise remain invisible.
For personalised care, cardiac rehabilitation should be a perfect delivery model. It can be tailored by risk, comorbidity, functional capacity, age, language, culture, geography and patient preference. Centre-based programmes will work for some. Hybrid and home-based models will work better for others. Digital tools may help monitor progress, but they cannot replace human support for patients with complex needs.
The policy challenge is to make rehabilitation impossible to miss.
That means automatic referral for eligible patients before discharge. It means clear communication from cardiologists that rehabilitation is part of treatment, not a lifestyle suggestion. It means follow-up calls, transport support, culturally appropriate education, flexible scheduling, tele-rehabilitation options and shared data between hospitals, primary care and rehabilitation providers.
It also means registries.
Australia’s lack of a national cardiac rehabilitation registry is not a technical detail. It is a governance failure. Without a registry, policymakers cannot properly see who is referred, who attends, who drops out, who benefits and which groups are being left behind. Countries such as Austria, Canada, Denmark, the UK and the USA already have national or established cardiac rehabilitation registry infrastructure. Australia’s gap makes accountability harder.
Data should not be optional in secondary prevention.
The equity implications are serious. Patients who are older, live alone, have lower health literacy, face transport barriers, live in rural areas, cannot take time off work, or do not receive strong clinician endorsement are more likely to miss rehabilitation. These are often the same patients who face higher recurrent cardiovascular risk. A passive referral model will always favour the patients already best equipped to navigate care.
The solution is not to blame patients for non-attendance. It is to build systems that assume recovery is difficult and design around that reality.
Cardiac rehabilitation should be commissioned as a core cardiovascular service. Hospitals should be measured on referral and completion. Payers should reimburse flexible delivery models. Digital health should support continuity, not become a cheap substitute. Registries should track access and outcomes by sex, age, geography, ethnicity, socioeconomic status and comorbidity.
The bigger lesson goes beyond Australia. Cardiovascular medicine has become very good at the dramatic rescue. The ambulance. The catheter lab. The stent. The discharge letter.
But preventing the next event is less dramatic, less profitable and easier to neglect.
That is where patients die.
The Monash study should force a policy rethink. If cardiac rehabilitation lowers mortality and readmissions, then failure to connect patients to it is not a minor service gap. It is a preventable failure in the care pathway.
The heart attack is only the first crisis.
The second crisis is what happens after the patient goes home.
