Cardiac Rehabilitation and Secondary Prevention in Women

  • Lene Rørholm PedersenEmail author
  • Eva Prescott


Physical inactivity is more strongly associated with risk of acute coronary syndromes (ACS) in women than in men. Despite, women and ethnic minorities are less likely to participate in cardiac rehabilitation (CR) programs. Goals for secondary prevention are also less often achieved in women. They also have more depression and anxiety and experience lower quality of life and social support than men. This has an important negative effect on outcomes in ischemic heart disease (IHD). Barriers to CR may be overcome by offering individualized rehabilitation programs that also encompasses home-based cardiac rehabilitation and tele-health based cardiac rehabilitation.


Cardiac rehabilitation (CR) Depression Diet eHealth Ethnic minorities Exercise Gender bias Ischemic heart disease (IHD) Lifestyle Physical activity Secondary prevention 


  1. 1.
    Chow CK, Jolly S, Rao-Melacini P, Fox KAA, Anand SS, Yusuf S. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation. 2010;121:750–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. J Am Coll Cardiol. 2016;67:1–12.CrossRefPubMedGoogle Scholar
  3. 3.
    Doll JA, Hellkamp A, Thomas L, Ho PM, Kontos MC, Whooley MA, Boyden TF, Peterson ED, Wang TY. Effectiveness of cardiac rehabilitation among older patients after acute myocardial infarction. Am Heart J. 2015;170:855–64.CrossRefPubMedGoogle Scholar
  4. 4.
    Sagar VA, Davies EJ, Briscoe S, Coats AJS, Dalal HM, Lough F, Rees K, Singh S, Taylor RS. Exercise-based rehabilitation for heart failure: systematic review and meta-analysis. Open Heart. 2015;2:e000163.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Doll JA, Hellkamp A, Ho PM, Kontos MC, Whooley MA, Peterson ED, Wang TY. Participation in cardiac rehabilitation programs among older patients after acute myocardial infarction. JAMA Intern Med. 2015;175:1700–2.CrossRefPubMedGoogle Scholar
  6. 6.
    Colella TJ, Gravely S, Marzolini S, Grace SL, Francis JA, Oh P, Scott LB. Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis. Eur J Prev Cardiol. 2015;22:423–41.CrossRefPubMedGoogle Scholar
  7. 7.
    De Smedt D, De Bacquer D, De Sutter J, Dallongeville J, Gevaert S, De Backer G, Bruthans J, Kotseva K, Reiner Ž, Tokgözoğlu L, Clays E. The gender gap in risk factor control: effects of age and education on the control of cardiovascular risk factors in male and female coronary patients. The EUROASPIRE IV study by the European Society of Cardiology. Int J Cardiol. 2016;209:284–90.CrossRefPubMedGoogle Scholar
  8. 8.
    Dallongevillle J, De Bacquer D, Heidrich J, De Backer G, Prugger C, Kotseva K, Montaye M, Amouyel P, EUROASPIRE Study Group. Gender differences in the implementation of cardiovascular prevention measures after an acute coronary event. Heart. 2010;96:1744–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Hambraeus K, Tydén P, Lindahl B. Time trends and gender differences in prevention guideline adherence and outcome after myocardial infarction: data from the SWEDEHEART registry. Eur J Prev Cardiol. 2016;23:340–8.CrossRefPubMedGoogle Scholar
  10. 10.
    European Association of Cardiovascular Prevention and Rehabilitation Committee for Science Guidelines, EACPR, Corrà U, Piepoli MF, Carré F, Heuschmann P, Hoffmann U, Verschuren M, Halcox J, Document Reviewers, Giannuzzi P, Saner H, Wood D, Piepoli MF, Corrà U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, McGee H, Mendes M, Niebauer J, Zwisler AD, Schmid JP. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the cardiac rehabilitation section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J. 2010;31:1967–74.CrossRefGoogle Scholar
  11. 11.
    Kavanagh T, Mertens DJ, Hamm LF, Beyene J, Kennedy J, Corey P, Shephard RJ. Peak oxygen intake and cardiac mortality in women referred for cardiac rehabilitation. J Am Coll Cardiol. 2003;42:2139–43.CrossRefPubMedGoogle Scholar
  12. 12.
    Kotseva K, Wood D, De Bacquer D, De Backer G, Ryden L, Jennings C, Gyberg V, Amouyel P, Bruthans J, Castro Conde A, Cifkova R, Deckers JW, De Sutter J, Dilic M, Dolzhenko M, Erglis A, Fras Z, Gaita D, Gotcheva N, Goudevenos J, Heuschmann P, Laucevicius A, Lehto S, Lovic D, Miličić D, Moore D, Nicolaides E, Oganov R, Pajak A, Pogosova N, et al. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol. 2016;23(6):636–48.CrossRefPubMedGoogle Scholar
  13. 13.
    Anand SS, Islam S, Rosengren A, Franzosi MG, Steyn K, Yusufali AH, Keltai M, Diaz R, Rangarajan S, Yusuf S. Risk factors for myocardial infarction in women and men: insights from the INTERHEART study. Eur Heart J. 2008;29:932–40.CrossRefPubMedGoogle Scholar
  14. 14.
    Vanhees L, Rauch B, Piepoli M, van Buuren F, Takken T, Borjesson M, Bjarnason-Wehrens B, Doherty P, Dugmore D, Halle M, Börjesson M, Bjarnason-Wehrens B, Doherty P, Dugmore D, Halle M, Writing Group, EACPR. Importance of characteristics and modalities of physical activity and exercise in the management of cardiovascular health in individuals with cardiovascular disease (Part III). Eur J Prev Cardiol. 2012;19:1333–56.CrossRefPubMedGoogle Scholar
  15. 15.
    Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen M-L, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2016;37(29):2315–81.Google Scholar
  16. 16.
    Smith SC, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation World Heart Federation and the Preventive Cardiovascular Nurses Association. J Am Coll Cardiol. 2011;58:2432–46.CrossRefPubMedGoogle Scholar
  17. 17.
    Borg G. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377–81.CrossRefPubMedGoogle Scholar
  18. 18.
    Pischon T, Boeing H, Hoffmann K, Bergmann M, Schulze MB, Overvad K, van der Schouw YT, Spencer E, Moons KGM, Tjønneland A, Halkjaer J, Jensen MK, Stegger J, Clavel-Chapelon F, Boutron-Ruault MC, Chajes V, Linseisen J, Kaaks R, Trichopoulou A, Trichopoulos D, Bamia C, Sieri S, Palli D, Tumino R, Vineis P, Panico S, PHM P, May AM, Bueno-de-Mesquita HB, van Duijnhoven FJB, et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med. 2008;359:2105–20.CrossRefPubMedGoogle Scholar
  19. 19.
    Coutinho T, Goel K, Corrêa de Sá D, Carter RE, Hodge DO, Kragelund C, Kanaya AM, Zeller M, Park JS, Kober L, Torp-Pedersen C, Cottin Y, Lorgis L, Lee SH, Kim YJ, Thomas R, Roger VL, Somers VK, Lopez-Jimenez F. Combining body mass index with measures of central obesity in the assessment of mortality in subjects with coronary disease: role of ‘normal weight central obesity’. J Am Coll Cardiol. 2013;61:553–60.CrossRefPubMedGoogle Scholar
  20. 20.
    Lemieux S, Prud’homme D, Bouchard C, Tremblay A, Després JP, Pud’homme D, Bouchard C, Tremblay A, Despres JP. Sex differences in the relation of visceral adipose tissue accumulation to total body fatness. Am J Clin Nutr. 1993;58:463–7.PubMedGoogle Scholar
  21. 21.
    Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Pina IL, Roger VL, Shaw LJ, Zhao D, Beckie TM, Bushnell C, D’Armiento J, Kris-Etherton PM, Fang J, Ganiats TG, Gomes AS, Gracia CR, Haan CK, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore A, Nussmeier NA, Ofili E, Oparil S, Ouyang P, Pinn VW, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243–62.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Romero-Corral A, Montori VM, Somers VK, Korinek J, Thomas RJ, Allison TG, Mookadam F, Lopez-Jimenez F. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet. 2006;368:666–78.CrossRefPubMedGoogle Scholar
  23. 23.
    Goel K, Thomas RJ, Squires RW, Coutinho T, Trejo-Gutierrez JF, Somers VK, Miles JM, Lopez-Jimenez F. Combined effect of cardiorespiratory fitness and adiposity on mortality in patients with coronary artery disease. Am Heart J. 2011;161:590–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Pack QR, Rodriguez-Escudero JP, Thomas RJ, Ades PA, West CP, Somers VK, Lopez-Jimenez F. The prognostic importance of weight loss in coronary artery disease: a systematic review and meta-analysis. Mayo Clin Proc. 2014;89:1368–77.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Todaro JF, Shen BJ, Niaura R, Tilkemeier PL, Roberts BH. Do men and women achieve similar benefits from cardiac rehabilitation? J Cardpulm Rehabil. 2004;24:45–51.CrossRefGoogle Scholar
  26. 26.
    Osler M, Mårtensson S, Wium-Andersen IK, Prescott E, Andersen PK, Jørgensen TSH, Carlsen K, Wium-Andersen MK, Jørgensen MB. Depression after first hospital admission for acute coronary syndrome: a study of time of onset and impact on survival. Am J Epidemiol. 2016;183:218–26.CrossRefPubMedGoogle Scholar
  27. 27.
    Rugulies R. Depression as a predictor for coronary heart disease: a review and meta-analysis. Am J Prev Med. 2002;23:51–61.CrossRefPubMedGoogle Scholar
  28. 28.
    Whooley MA, de Jonge P, Vittinghoff E, Otte C, Moos R, Carney RM, Ali S, Dowray S, Na B, Feldman MD, Schiller NB, Browner WS. Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. JAMA. 2008;300:2379–88.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Cooney G, Dwan K, Mead G. Exercise for depression. JAMA. 2014;311:2432–3.CrossRefPubMedGoogle Scholar
  30. 30.
    Lichtman JH, Bigger JT, Blumenthal JA, Kaufmann PG, Lespérance F, Mark DB, Sheps DS, Taylor CB, Froelicher ES. Recommendations for screening, referral, and treatment a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation. 2008;118(17):1768–75.CrossRefPubMedGoogle Scholar
  31. 31.
    Celano CM, Millstein RA, Bedoya CA, Healy BC, Roest AM, Huffman JC. Association between anxiety and mortality in patients with coronary artery disease: a meta-analysis. Am Heart J. 2015;170:1105–15.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Remes O, Brayne C, van der Linde R, Lafortune L. A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain Behav. 2016;6:e00497.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Richardson S, Shaffer JA, Falzon L, Krupka D, Davidson KW, Edmondson D. Meta-analysis of perceived stress and its association with incident coronary heart disease. Am J Cardiol. 2012;110:1711–6.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Appels A, Höppener P, Mulder P. A questionnaire to assess premonitory symptoms of myocardial infarction. Int J Cardiol. 1987;17:15–24.CrossRefPubMedGoogle Scholar
  35. 35.
    Frestad D, Prescott E. Vital exhaustion and coronary heart disease Risk: a systematic review and meta-analysis. Psychosom Med. 2017;79(3):260–72.Google Scholar
  36. 36.
    Schnohr P, Marott JL, Kristensen TS, Gyntelberg F, Grønbæk M, Lange P, Jensen MT, Jensen GB, Prescott E. Ranking of psychosocial and traditional risk factors by importance for coronary heart disease: the Copenhagen City Heart Study. Eur Heart J. 2015;36:1385–93.CrossRefPubMedGoogle Scholar
  37. 37.
    Prescott E, Holst C, Grønbaek M, Schnohr P, Jensen G, Barefoot J, Grønbæk M, Schnohr P, Jensen G, Barefoot J, Grønbaek M, Schnohr P, Jensen G, Barefoot J, Grønbæk M, Schnohr P, Jensen G, Barefoot J. Vital exhaustion as a risk factor for ischaemic heart disease and all-cause mortality in a community sample. a prospective study of 4084 men and 5479 women in the Copenhagen City Heart Study. Int J Epidemiol. 2003;32:990–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Sherwood A, Blumenthal JA, Trivedi R, Johnson KS, O’Connor CM, Adams KF, Dupree CS, Waugh RA, Bensimhon DR, Gaulden L, Christenson RH, Koch GG, Hinderliter AL. Relationship of depression to death or hospitalization in patients with heart failure. Arch Intern Med. 2007;167:367–73.CrossRefPubMedGoogle Scholar
  39. 39.
    Blumenthal JA, Smith PJ, Hoffman BM. Opinion and evidence: is exercise a viable treatment for depression? ACSM’s Heal Fit J. 2012;16:14–21.Google Scholar
  40. 40.
    Blumenthal JA, Sherwood A, Babyak MA, Watkins LL, Waugh R, Georgiades A, Bacon SL, Hayano J, Coleman RE, Hinderliter A. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease. J Cardpulm Rehabil. 2005;25:235.CrossRefGoogle Scholar
  41. 41.
    Gulliksson M, Burelle G, Vessby B, Lundin L, Toss H, Svardsudd K. Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease. Arch Intern Med. 2014;171:134–40.Google Scholar
  42. 42.
    Orth-Gomer K, Schneiderman N, Wang HX, Walldin C, Blom M, Jernberg T. Stress reduction prolongs life in women with coronary disease: the Stockholm Women’s Intervention Trial for Coronary Heart Disease (SWITCHD). Circ Cardiovasc Qual Outcomes. 2009;2:25–32.CrossRefPubMedGoogle Scholar
  43. 43.
    Taylor RS, Dalal H, Jolly K, Zawada A, Dean SG, Cowie A, Norton RJ. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2015;1:CD007130.Google Scholar
  44. 44.
    Mead H, Ramos C, Grantham SC. Drivers of racial and ethnic disparities in cardiac rehabilitation use: patient and provider perspectives. Med Care Res Rev. 2016;73:251–82.CrossRefPubMedGoogle Scholar
  45. 45.
    Mochari H, Lee JR, Kligfield P, Mosca L. Ethnic differences in barriers and referral to cardiac rehabilitation among women hospitalized with coronary heart disease. Prev Cardiol. 2006;9:8–13.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of CardiologyBispebjerg University HospitalCopenhagenDenmark

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