According to recent estimates, heart failure (HF) affects an estimated 6 million Americans, and 870,000 people in the United States are newly diagnosed with HF each year. The disease accounts for more than 1 million hospitalizations and over $30 billion in direct costs annually. Several clinical trials have shown that HF patients who undergo a rigorous 36-week cardiac rehabilitation (CR) program that focuses on aerobic exercise training are more capable of controlling shortness of breath symptoms and are better able to perform daily activities, such as walking and climbing stairs.

In 2007, a landmark study called the Heart Failure and A Controlled Trial Investigating Outcomes of Exercise Training (HF–ACTION) revealed that patients who underwent exercise training after being hospitalized for HF improved their ability to perform normal daily living tasks, were less likely to be rehospitalized, and had a lower mortality rate. “After data from HF–ACTION were released, the American College of Cardiology and American Heart Association (ACC/AHA) issued guidelines recommending CR for medically stable HF patients,” explains Gregg C. Fonarow, MD. “Recently, CMS approved CR for eligible patients with HF with reduced ejection fraction, making it available to a broader group of Medicare patients.”


Assessing CR Trends

Current guidelines recommend CR in medically stable outpatients with HF, but few studies have examined temporal trends and factors associated with CR referral among these patients in real-world practices. To explore this issue further, Dr. Fonarow and colleagues conducted a study to assess the use, trends, and hospital factors associated with CR referral at discharge among patients admitted with decompensated HF. The study, published in the Journal of the American College of Cardiology, is among the first since the ACC/AHA guidelines were issued to assess how often physicians refer patients to CR programs upon hospital discharge and the factors associated with these referrals.

Using data from a national Get With The Guidelines–Heart Failure registry, Dr. Fonarow and colleagues assessed temporal trends in CR referral among eligible patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Data were drawn from a national database of more than 105,000 people with HF who were discharged from hospitals between 2005 and 2014 and were eligible for CR programs.


Few Patients Receive Referrals

According to the study results, just 10.4% of eligible patients were referred to a CR program when they were discharged. Of these patients, CR referral rates were 12.2% for those with HFrEF and 8.8% for those with HFpEF. The research team noted that a significant increase in CR referral rates was observed among both HFpEF and HFrEF patients over the study period; Dr. Fonarow notes that that these rates were still low overall.

“It was alarming to see that only one in 10 eligible HF patients received CR referrals at discharge after being hospitalized with HF,” says Dr. Fonarow. “Physicians who were more likely to incorporate state-of-the-art therapies in the management of HF were also more likely to refer patients to CR programs. This suggests that raising awareness about the benefits of these programs may be an effective strategy for increasing referrals.”

When compared with patients who were discharged with CR referrals, those who were not referred to these programs tended to be older, were predominantly women, and were less likely to receive evidence-based, guideline-recommended HF therapies at discharge. In a multivariable analysis, the authors found that younger age, fewer comorbid conditions, and in-hospital procedures—such as CABG, PCI, and cardiac valve surgery—were most strongly associated with CR referral (Figure).


More Efforts Needed

Dr. Fonarow says that clinicians need to develop strategies to improve physician and patient awareness about the benefits of CR to increase referrals to these programs when managing patients with HF. “These trends occurred despite strong evidence that CR improves quality of life and reduces the likelihood of future hospitalizations and mortality,” he says. “We need better strategies to increase physician and patient awareness on the individual and public health benefits of CR programs. This is especially important considering the escalating healthcare expenditures that have been associated with HF hospitalizations.”

It is equally important to increase insurance coverage and reduce copayments for CR programs, according to the study. The investigators also recommend increasing access to community-based CR. “These efforts are paramount to reducing the burden of HF to society and improving patient outcomes,” Dr. Fonarow says.


Golwala H, Pandey A, Ju C, et al. Temporal trends and factors associated with cardiac rehabilitation referral among patients hospitalized with heart failure: findings from Get With The Guidelines–Heart Failure Registry. J Am Coll Cardiol. 2015;66:917-926. Available at:

Creaser JW, DePasquale EC, Vandenbogaart E, Rourke D, Chaker T, Fonarow GC. Team-based care for outpatients with heart failure. Heart Fail Clin. 2015;11:379-405.

Cheng RK, Cox M, Neely ML, et al. Outcomes in patients with heart failure with preserved, borderline, and reduced ejection fraction in the Medicare population. Am Heart J. 2014;168:721-730.

Taylor RS, Sagar VA, Davies EJ, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014;4:CD003331.

O’Connor CM, Whellan DJ, Lee KL, et al; HF-ACTION Investigators. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301:1439-1450.