IPM Take
For years, cardiac rehabilitation has occupied an uncomfortable position in cardiovascular medicine: strongly supported by evidence, routinely recommended after major cardiac events, yet still treated in many health systems as an optional service that patients may or may not reach.
The first dedicated ESC guidelines on cardiac rehabilitation challenge that model by defining rehabilitation as an individualised component of cardiovascular care rather than a generic exercise programme after discharge. The recommendations combine exercise training with psychosocial support, education, medication adherence, lifestyle management and shared decision-making, while expanding rehabilitation beyond traditional post-MI and heart-failure populations to people with atrial fibrillation, congenital heart disease, valve replacement and selected patients exposed to cardiotoxic cancer therapies.
That is a meaningful step toward personalised medicine because the intervention is supposed to change according to the person rather than merely the diagnosis.
The policy contradiction is that Europe can now recommend tailored rehabilitation while still leaving access dependent on where a patient lives, whether a programme exists locally and whether someone is willing to reimburse it. The guidelines themselves identify absent reimbursement and poor participation as continuing barriers in parts of Europe.
Personalised medicine does not become equitable simply because the guideline uses the word individualised.
Executive Summary
The European Society of Cardiology published its first dedicated guidelines on cardiac rehabilitation in the European Heart Journal. Until now, rehabilitation recommendations were distributed across disease-specific ESC documents. The new guideline brings the evidence together across cardiovascular conditions and provides recommendations on indications, Phase II rehabilitation, infrastructure, staffing, core components, delivery models, goal setting and outcome assessment.
The central model is explicitly patient-centred. Rehabilitation should be tailored according to each patient’s medical, functional, psychosocial and lifestyle needs, together with their preferences and personal circumstances. Programmes should be developed through shared decision-making and delivered by multidisciplinary teams, combining exercise with emotional support and personalised education on sustainable lifestyle changes and medication adherence.
Eligibility is also broader than the familiar post-heart-attack pathway. The ESC highlights potential benefit after acute coronary syndromes and in heart failure, but also after surgical or transcatheter aortic valve replacement, in atrial fibrillation and congenital heart disease, and among patients with cancer undergoing or recovering from potentially cardiotoxic therapy. Older age, frailty and comorbidity should not automatically exclude patients from rehabilitation.
The guidelines also address implementation. The ESC identifies absent reimbursement, poor referral and low attendance as persistent barriers, while digitally enhanced home-based programmes incorporating remote monitoring and teleconsultation are positioned as possible alternatives for appropriately selected patients.
Why it matters
- HTA bodies: Cardiac rehabilitation should be evaluated as a multicomponent intervention rather than exercise alone. Assessment will increasingly need to capture hospitalisations, functional recovery, quality of life, mental health and long-term adherence, while determining whether digital and hybrid delivery models produce comparable outcomes for different patient groups.
- Payers: The guidelines make reimbursement part of the clinical implementation debate. Refusing or restricting access to rehabilitation may save money at the service level while shifting costs toward recurrent cardiovascular events, hospital use and poorer long-term functioning.
- Industry / innovation partners: Personalised and hybrid rehabilitation creates opportunities for remote monitoring, wearable technologies, digital coaching and patient-reported outcomes, but technology will need to support clinical individualisation rather than reproduce a standard programme on a smartphone.
Cardiac rehabilitation has often been presented as the final step after the important cardiology has already happened. The artery has been opened, the valve replaced, the heart failure stabilised or the patient discharged after myocardial infarction, and rehabilitation is then offered as a programme of supervised exercise and lifestyle advice.
The new ESC guidelines argue for a much broader interpretation.
For the first time, the European Society of Cardiology has produced a dedicated clinical guideline bringing cardiac rehabilitation across multiple conditions into a single framework. Its scope extends beyond whether patients should exercise after a cardiac event and addresses how rehabilitation services should be structured, who should deliver them, which patients should be considered and how programmes should adapt to individual needs. The guideline is endorsed by the European Society of Physical and Rehabilitation Medicine and the World Organization of Family Doctors, underscoring that rehabilitation is expected to extend beyond specialist cardiology clinics.
That shift is particularly important for personalised medicine because patients recovering from cardiovascular disease are not clinically interchangeable. One person may principally need improvement in exercise capacity, while another is limited by frailty, anxiety, multimorbidity, medication burden or loss of confidence following a major cardiac event. The same diagnosis can therefore produce very different rehabilitation needs.
The ESC explicitly describes cardiac rehabilitation as a multicomponent intervention. Exercise remains central, but programmes also incorporate psychosocial care, education, medication adherence and support for sustainable lifestyle change. Comprehensive assessment is intended to identify each patient’s medical, functional, psychosocial and lifestyle needs, while shared decision-making is used to shape goals and the mode of delivery.
This is personalised cardiology in a form that does not depend on genomics or an expensive molecular test. The relevant phenotype may instead be a combination of functional capacity, mental health, comorbidities, social circumstances and what the patient is realistically able to sustain after leaving hospital.
The eligible population is becoming much wider
The second major change is who cardiac rehabilitation is for.
Its role after myocardial infarction and in heart failure is well established, but the new guideline brings other populations more clearly into the rehabilitation framework, including people with atrial fibrillation, congenital heart disease, patients recovering from valve replacement and people with cancer receiving or recovering from therapies associated with cardiovascular toxicity.
That expansion matters because it moves rehabilitation away from a narrow post-event service toward a broader model of chronic cardiovascular management.
The inclusion of cardio-oncology patients is particularly revealing. Cancer survivors may be dealing simultaneously with cardiovascular toxicity, deconditioning, fatigue, psychological distress and the consequences of cancer treatment. A conventional exercise prescription alone is unlikely to capture that complexity, which is precisely why an individualised multidisciplinary model becomes relevant.
The guideline also states that older age, frailty and comorbidity should not in themselves be reasons to withhold cardiac rehabilitation.
That sounds straightforward, but it confronts a common weakness in real-world implementation. Patients who are older, less mobile or medically complex may theoretically have much to gain from rehabilitation while simultaneously being the least able to travel several times a week to a hospital-based programme.
Personalisation therefore has to include how care is delivered, not only what happens during the session.
The ESC dedicates attention to telehealth, telemedicine and mobile-health approaches, including digitally enhanced home-based rehabilitation using remote monitoring and teleconsultation. For selected patients, these models may offer greater convenience and can potentially reduce healthcare costs compared with exclusively centre-based delivery.
That does not mean remote rehabilitation should automatically replace face-to-face programmes. Some patients may need supervised exercise, direct multidisciplinary support or more intensive monitoring, while others may prefer and safely use home-based care. A genuinely personalised system would offer several validated modes and match them to clinical need and patient preference instead of assuming that digital delivery is universally superior.
Europe now has the guideline. It still needs the service.
This is where the clinical document becomes a health-policy document.
The ESC openly acknowledges that cardiac rehabilitation remains underused and that reimbursement is absent in some European countries, while referral and attendance remain poor in others. The EMJ summary of the guidelines similarly highlights reimbursement as a major barrier to implementation and digital rehabilitation as one possible route to wider access.
This creates an uncomfortable mismatch between evidence and delivery.
A clinician cannot engage in meaningful shared decision-making if the patient has only one programme available, located two hours away. A rehabilitation plan cannot be tailored to psychosocial needs if psychological support is not funded. A home programme is not equitable if the patients expected to use it lack appropriate technology, digital literacy or reliable connectivity.
The guideline therefore raises questions that extend well beyond cardiology departments. Who commissions rehabilitation? Which professional groups are funded to deliver it? Are digital programmes reimbursed alongside hospital programmes? Which outcomes determine whether a service is considered successful, attendance, exercise capacity, readmission, patient-reported health or all of them?
These are not implementation details added after the science. They determine whether the science reaches patients at all.
The ESC notes that rehabilitation can reduce hospitalisations while improving physical and mental functioning and quality of life, and cites evidence supporting its cost-effectiveness. If health systems accept those benefits, continuing to treat rehabilitation as an optional add-on becomes increasingly difficult to justify.
The new guideline gives European cardiology a much clearer definition of what modern cardiac rehabilitation should look like: multidisciplinary, individualised, flexible in delivery and shaped with patients rather than simply prescribed to them.
The next test is political rather than scientific.
Europe has defined personalised cardiac rehabilitation. It now has to decide whether personalised access will follow.
