title: Narrative review comparing the benefits of and participation in cardiac rehabilitation in high-, middle- and low-income countries.
abstract: BACKGROUND
  Cardiovascular disease is a leading cause of morbidity worldwide. Cardiac rehabilitation (CR) is a comprehensive secondary prevention approach, with established benefits in reducing morbidity in high-income countries (HICs). The objectives of this review were to summarise what is known about the benefits of CR, including consideration of cost-effectiveness, in addition to rates of CR participation and adherence in high-, as well as low- and middle-income countries (LMICs).
  
  
  METHODS
  A literature search of Medline, Excerpta Medica Database (EMBASE), and Google Scholar was conducted for published articles from database inception to October 2013. The search was first directed to identify meta-analyses and reviews reporting on the benefits of CR. Then, the search was focussed to identify articles reporting CR participation and dropout rates. Full-text versions of relevant abstracts were summarised qualitatively.
  
  
  RESULTS
  Based on meta-analysis, CR significantly reduced all-cause mortality by 13%-26%, cardiac mortality by 20%-36%, myocardial re-infarction by 25%-47%, and risk factors. CR is cost-effective in HICs. In LMICs, CR is demonstrated to reduce risk factors, with no studies on mortality or cost-effectiveness. Based on available data, CR participation rates are <50% in the majority of countries, with documented dropout rates up to 56% and 82% in high- and middle-income countries, respectively.
  
  
  CONCLUSIONS
  CR is a beneficial intervention for heart patients in high and LMICs, but is underutilised with low participation and adherence rates worldwide. While more research is needed in LMICs, strategies shown to increase participation and program adherence should be implemented.
authors.affiliation: School of Health Policy and Management, York University, Toronto, Ontario, Canada; College of Health Professions, Al-Quds University, Jerusalem, Palestinian Authority. Electronic address: karamturk2000@yahoo.com.
authors.forename: Karam I
authors.initials: KI
authors.lastname: Turk-Adawi
authors.affiliation: School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; Cardiovascular Rehabilitation & Prevention, University Health Network, Toronto, Ontario, Canada.
authors.forename: Sherry L
authors.initials: SL
authors.lastname: Grace
mesh_terms: D000072038:Cardiac Rehabilitation; D002318:Cardiovascular Diseases / Q000401:mortality*; D019049:Developed Countries; D003906:Developing Countries; D005260:Female; D006801:Humans; D008297:Male; D012307:Risk Factors; D012959:Socioeconomic Factors
keywords: Adherence; Cardiac rehabilitation; Cost-effectiveness; Myocardial infarction; Participation; Secondary prevention