Cardiovascular diseases are among the leading causes of death and disability globally, with the greatest burden in low- and middle-income countries (LMIC).1 Cardiac rehabilitation (CR) mitigates this growing epidemic.2 Despite this, CR is underutilized.3 This is particularly so in LMIC where it is needed most, availability is scant, and there are greater challenges to implementation.4

Barriers to CR delivery are multifactorial, with factors at play at the health system, referring provider, CR program, as well as patient levels.3 These have been well-characterized in high-resource settings, with some review in LMIC,4 although the latter is dated given recent contextual changes.

One of the main recommendations to improve CR use has been availability of unsupervised (ie, remote, home-based) models.5 Given the high penetrance of mobile phones in LMIC, programs have more recently initiated technology that is quite advanced and patient-friendly. In response to the COVID-19 pandemic in these countries, there has been a great shift to online CR care,6 with need for more.

While characterized for high-resource settings,7,8 factors hindering CR availability and utilization that are unique to, or more problematic in, LMIC have not been described, particularly by level and setting. Based on a rapid review of literature and the expertise of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR; 43 member associations and 17 "friends," of which 52% are from LMIC), this Infographic illustrates these factors. This brief version, as well as the full version (see Supplemental Digital Content, available at: http://links.lww.com/JCRP/A457), separately displays factors hindering supervised and unsupervised CR delivery in LMIC, at the societal, referring clinician, CR program, and patient levels.

Ideally, unsupervised CR models do involve some in-person sessions at least at the start of a program, to enable full assessment, risk stratification, plan of care development, and therapeutic rapport. There is now burgeoning research on hybrid CR (ie, combining supervised center-based and remote/unsupervised) in high-resource settings, with corresponding best practice recommendations for implementation.9 While there are also sound recommendations to promote supervised CR implementation in LMIC,4 and some training available from the ICCPR on supervised and unsupervised delivery,10 it is hoped strategies to overcome barriers to unsupervised CR delivery in LMIC will be identified as well. Ultimately, we must support CR champions in LMIC to address these multilevel barriers to CR delivery, to realize availability of CR in all settings, based on context and patient need, in both high and LMIC.

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