title: Availability, Use, and Barriers to Cardiac Rehabilitation in LMIC.
abstract: Cardiac rehabilitation (CR) is a cornerstone of secondary prevention of ischemic heart disease. It is critically important in low- and middle-income countries (LMIC), where the burden of ischemic heart disease is substantial and growing. However, the availability and utilization of CR in LMIC is not systematically known.
  
  
  
  This study sought to characterize the availability, use, and barriers to the use of CR.
  
  
  
  Electronic databases (Cochrane Library, EMBASE, PubMed, Web of Science) were searched from January 1, 1980 to May 31, 2013 for articles on CR in LMIC. Citations on availability, use, and/or barriers to CR were screened for inclusion by title, abstract, and full text. Data were summarized by region or country to determine the characteristics of CR in LMIC and gaps in the peer-reviewed biomedical publications.
  
  
  
  Our search yielded a total of 5,805 citations, of which 34 satisfied full inclusion and exclusion criteria. The total number of CR programs available ranged from 1 in Algeria and Paraguay to 51 in Serbia. Referral rates for CR ranged from 5.0% in Mexico to 90.3% in Lithuania. Attendance rates ranged from 31.7% in Bulgaria to 95.6% in Lithuania, and CR attendance was correlated with higher educational background. The most commonly cited barrier to CR in LMIC was lack of physician referral.
  
  
  
  Our results illustrate that the published reports reflects heterogeneity of CR availability and use in LMIC. Overall, CR is insufficiently available and underutilized. Further characterization of CR in LMIC, especially in Asia and Africa, is necessary to develop targeted strategies to improve availability and utilization. Patient, physician, and systems factors must be addressed to overcome barriers to participation in CR in LMIC.
authors.affiliation: Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: loheetha.ragupathi@jefferson.edu.
authors.forename: Loheetha
authors.initials: L
authors.lastname: Ragupathi
authors.affiliation: Samuel J. Wood Library, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Judy
authors.initials: J
authors.lastname: Stribling
authors.affiliation: Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Yuliya
authors.initials: Y
authors.lastname: Yakunina
authors.affiliation: Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain.
authors.forename: Valentin
authors.initials: V
authors.lastname: Fuster
authors.affiliation: Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: McLaughlin
authors.affiliation: Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA. Electronic address: rajesh.vedanthan@mssm.edu.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Vedanthan
mesh_terms: D000072038:Cardiac Rehabilitation / Q000706:statistics & numerical data*; D003906:Developing Countries; D014943:Global Health; D006801:Humans; D009017:Morbidity / Q000639:trends; D017202:Myocardial Ischemia / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control; D011203:Poverty; D018570:Risk Assessment; D055502:Secondary Prevention / Q000458:organization & administration*