2025+AHA科学声明：女性心脏康复

BENEFITS OF CR

CR results in improvement of CVD risk factors, includ-ing higher rates of tobacco cessation, lowering of blood pressure and cholesterol levels,4,5 and improvements in

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Table 1. Core Components of Traditional Cardiac Rehabilitation Programs

|Patient assessment|| |---|---| |Nutrition counseling|| |Weight and body composition management|| |Cardiovascular disease and risk factor management|| |Psychosocial management|| |Aerobic exercise training|| |Strength training|| |Physical activity counseling|| |Program quality||

Adapted from Brown et al.' Copyright©2024,American Heart Association,Inc.

fasting glucose levels.6 Over a period of 6 to 12 months,patients who participate in CR are 42% less likely to be readmitted to the hospital.5 In the long term, patients attending CR have lower rates of cardiovascular mortal-ity(risk ratio, 0.58[95% CI, 0.43-0.78]) and myocardial infarction(MI; risk ratio, 0.67[95% CI, 0.50-0.90]).7 Quality of life also improves as a result of CR.7 As such,American College of Cardiology/American Heart As-sociation performance measures and numerous clinical practice guidelines support CR for the secondary pre-vention of a broad array of CVDs.8-11

# SPECIFIC BENEFITS OF CR AND PHYSICAL ACTIVITY IN WOMEN

Although CR provides benefits regardless of the patient's sex, large retrospective cohort studies have found that women in CR experience a relatively greater mortality risk reduction as compared to men(Figure 1).12,13 Further-more, women with spontaneous coronary artery dissec-tion(SCAD) who undergo CR experience improvements in exercise capacity without adverse events, as well as a

modest improvement in mental health scores. ${}^{14}$ Another study found significant improvement in exercise capacity,metabolic measures, and psychosocial variables among women with microvascular angina who attended CR. ${}^{15}$ A recent prospective study of $\approx 400000$ US adults(55%female) observed greater benefits from regular aerobic and resistance exercise in women than men. Among people who achieved 300 minutes per week of aerobic physical activity, women experienced a 24% reduction in all-cause mortality rates, compared with 18% reduction in men. In addition, 3 sessions of resistance training per week were associated with a 28% reduction in all-cause mortality rates in women, and only a 14% reduction in men. Furthermore, engagement in physical activity was associated with lower odds of hypertension in women,but not in men. ${}^{16}$

# BARRIERS TO CR ACCESS FOR WOMEN

# Gaps in CR Referral and Enrollment

Despite its proven benefits, CR remains underutilized overall, particularly among women. Specific barriers to CR(Table 2) vary widely according to region of the world,necessitating location-specific solutions.17 The under-representation of women in CR is partially attributable to lower CR referral rates, which affects CR participation.18 In the United States, women are less likely than men to have a cardiovascular diagnosis qualifying them for CR.19 The lower referrallates may also be due in part to clini-cian bias, because women who are eligible for CR tend to be older and to have more medical and psychological comorbidities.20,21 In a meta-analysis of 297719 individu-als eligible for CR, the rate of enrollment was 36% lower for women than for men.22 In addition, previous studies have identified lack of insurance, transportation issues,lower educational attainment, and social isolation as bar-riers to CR participation that are more prevalent among

# Benefits of Cardiac Rehabilitation in Women

 Figure 1. Benefits of cardiac rehabilitation in women.

CABG indicates coronary artery bypass graft; and MI, myocardial infarction.

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women. $^{18,20,23}$ Women often serve as caregivers, and this role may interfere with self-care. Therefore, women are more likely than men to report family responsibilities as a barrier to CR attendance. ${ }^{24}$

The low enrollment in and attendance at CR among women is magnified among women from underrep-resented racial or ethnic groups. Non-Hispanic Black,Hispanic, or Asian women have particularly low rates of participation, ranging between 10% and 12%.19 One study examined racial or ethnic differences in CR referral among women(34% Black, 15% Hispanic, and 48% White), and found that individuals from underrepresented racial or ethnic groups were less likely to receive physician recom-mendations about CR and more likely to cite financial bar-riers compared with White women.25 Given the numerous benefits of CR, specific efforts should be directed toward increasing enrollment and participation among women from underrepresented racial or ethnic groups.

Gaps in CR Engagement and Completion

Similar to participation rates, sex differences are seen with respect to CR completion. In the United States, dis-parities in CR referral may be a dominant factor preclud-ing CR participation in women. In a single-center study of 450 CR participants, once women were adequately referred to CR and supported with facilitation or case management, the disparities in participation rates based on sex diminished significantly.26 However, even after re-ferral, women may be less likely to enroll in, attend, and complete CR.27 Low CR participation rates have been at-tributed to a number of factors, which include Individual interpersonal, societal, and program-related or health system-related factors.1728.29

Individual factors include multiple medical comorbid conditions, self-reported poor health status, time con-straints, language barriers, and the perception of exer-cise as being unpleasant, all of which negatively affect CR participation. For instance, women who are<55 years of age, have obesity, are active smokers, or have diagnoses other than coronary artery disease are less likely to engage in or complete CR.30

Interpersonal or societal factors span work-related conflicts, challenges with transportation and distance to CR facilities, and limited family and social support sys-tems. Characteristics that are often associated with femi-nine gender traits, such as family obligations, caregiving responsibilities, or lower physical function, may contrib-ute to the higher dropout rates. ${ }^{18}$

Program-related or health system-related factors con-sist of cost(eg, high copayments),31 discomfort with group sessions or formats due to a desire for privacy, interest in alternatives to facility-based CR(eg, community-based or home-based options), dissatisfaction with the duration and number of sessions, inconvenient timing or inflexible schedule, unappealing exercise routines (eg, weights,

treadills, cycle-only exercise), and preference for alter-nate forms of exercise (eg, yoga). ${ }^{17}$ In addition, women are less likely than men to receive a physician recommen-dation, which is a strong predictor of CR attendance. ${ }^{30}$

Gaps in CR Achievements

Women entering CR tend to be older and have a greater number of comorbidities than men entering CR. Even when adjusting for age, women have lower cardiorespi-ratory fitness as measured by peak oxygen level. Among 3925 patients entering CR, at program completion wom-en's VO(strong predictor of mortality) improved less than men's, when expressed as either absolute VO(peak 14 versus 19% improvement, respectively; P<0.001) or relative VO(peak accounting for body weight(13 versus 17% improvement, respectively; P<0.001).32 Women in CR also self-report lower levels of physical function and have less muscle strength than men.30 It is therefore per-tinent to not only engage women in CR, but also to as-sess ways to optimize their exercise training to improve cardiorespiratory fitness and strength.

ADDITIONAL REHABILITATIVE NEEDS FOR WOMEN: MENTAL HEALTH AND SOCIAL SUPPORT

Addressing other relevant rehabilitative needs in addi-tion to exercise is increasingly recognized as an impor-tant component of CR to improve both cardiovascular outcomes and psychosocial well-being.33 Women with CVD are more likely to experience depression,34 to have lower health-related quality of life, and to exhibit higher levels of psychosocial distress than men.35 Furthermore,women attending CR after coronary revascularization have poorer psychosocial health at baseline and show smaller improvements in health-related quality of life after CR, as compared to men.36 The presence of these fac-tors is significantly associated with a low likelihood of CR adherence and completion.37 Mental stress is also an es-tablished trigger for SCAD,38 which predominantly affects women, and for myocardial ischemia, particularly in wom-en39 and people without obstructive coronary disease.40 The presence of mental health-induced ischemia nearly quintuples the risk for cardiovascular events.41 As such,there is a crucial need to systematically address mental health factors within CR programs, especially for women.

Another potential reason for a deficit in CR enrollment and adherence in women may relate to a lack of system-atic inclusion of social support programming as part of conventional CR. Social support, which influences indi-viduals' behaviors, beliefs, and attitudes through inter-personal relationships, is a primary rehabilitative need of women,42 with direct links to health status and depres-sive symptoms after MI.43 Women with CVD express

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Table 2. Barriers to Cardiac Rehabilitation Participation for Women and Potential Solutions

|Category|Barrier|Potential solutions and actionable items| |---|---|---| |Individual|Medical and psychologic comorbid conditions|Assess safety and tailor exercise prescription accordingly. Integrate mental health supports, including stress management, into CR programs. Provide individualized programming addressing both physical and mental health, including tailored support for managing comorbidities.| |Individual|Self-reported poor health status|Train staff in sensitivity and empathy. Educate staff to pay careful attention to function and mobility and tailor exercise routines to patients' needs and preferences.| |Individual|Lack of awareness|Enhance patient education about CR benefits to improve engagement and understanding, which may occur as part of usual clinical care, hospital discharge lectures, online materials, or use of a CR liaison.| |Individual|Time constraints|Provide alternative options to traditional CR (eg, virtual, hybrid, community-based) and flexible scheduling options.| |Individual|Cultural and language barriers|Ensure educational content is available in various languages to meet the needs of the local population. Provide culturally sensitive CR programs with multilingual options, interpreter availability, and culturally relevant content. Consider innovative CR delivery models that incorporate the patient's community setting.| |Individual|Variability in underlying pathogenesis|Provide disease-specific, tailored patient education, exercise guidance, and mental health or peer support for patients with SCAD, SIC, INOCA, or MINOCA. Incorporate specific education for patients with breast cancer participating in CR programs.| |Intrapersonal or societal|Work-related conflicts|Offer flexible options for timing and program design (including women-only, community-based, and virtual and remote CR).| |Intrapersonal or societal|Transportation challenges and distance to CR facilities|Offer flexible program options that reduce travel requirements, such as hybrid, virtual, and community-based CR and peer-support groups.| |Intrapersonal or societal|Family obligations and caregiving responsibilities|Offer flexible options for timing and program design (including women-only, community-based, and virtual CR). Consider offering childcare services concurrently with CR sessions based on successful models adopted by gyms and recreation centers.| |Social isolation and limited support|Assess psychosocial needs and ensure measures are put in place to address these. Provide referral to a specialist, such as a social worker, occupational therapist, or vocational counselor, when appropriate. Incorporate peer-support programs or women-only CR groups to foster a supportive environment and improve engagement.|| |Program- or health system-related|Low CR referral rates|Implement automatic CR referral systems and case management strategies to ensure consistent CR referral.| |Program- or health system-related|Lack of CR recommendation|Educate health care professionals on the benefits of CR for women.| |Program- or health system-related|Financial constraints|Offer hybrid or virtual-only education programs and exercise sessions. Explore alternative payment models to reduce cost and improve CR uptake. Advocate for broader insurance coverage of in-person and telehealth CR and financial assistance programs. Explore transportation assistance to decrease the cost burden of transportation to and from CR centers.| |Program- or health system-related|Unappealing exercise routines|Provide alternate forms of exercise as options, such as dancing, yoga, or tai chi (recognizing that the effect of these alternate exercise routines on CVD outcomes are largely unknown).| |Program- or health system-related|Inconvenient timing or inflexible schedule|Offer flexible options for timing (eg, early morning, evening, weekend).|

CR indicates cardiac rehabilitation; INOCA, ischemia with nonobstructive coronary arteries; MINOCA, myocardial infarction with nonobstructive coronary arteries;SCAD, spontaneous coronary artery dissection; and SIC, stress-induced cardiomyopathy.

concerns over their dual role as supporters and needing support after MI,44 as well as a need and desire to return quickly to their daily routines.45 A systematic review of qualitative studies found that women who perceived themselves as the primary family caregiver had reduced ability to attend CR.45

IDEENCE-BASED SOLUTIONS FOR CR IMPLEMENTATION AMONG WOMEN

The aforementioned gaps between CR participation among men and women, summarized in Figure 2, high-light a need for focused interventions to augment CR

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 Figure 2. Sex-based comparison of cardiac rehabilitation: eligibility, referral, enrollment, adherence, and support needs.

CR indicates cardiac rehabilitation.

participation among women to optimize their cardio-vascular outcomes. Despite consistent research dem-onstrating sex and gender disparities along the CR continuum from referral to completion, a limited number of interventions have been evaluated in a sex-specific manner. A recent global survey of 223 CR programs across 52 countries comprehensively described barriers and enablers to women-focused CR.46 Several evidence-based solutions have been shown to improve CR partici-pation broadly and, in select cases, in women specifically(Table 2). Because women experience a heterogenous set of barriers to CR participation, a multifaceted and in-tersectional approach is required to meet the unique and varied needs of women.

Increasing Referrals and Enrollment

The absence of a referral to CR remains one of the clearest and most modifiable risk factors for nonpar-ticipation. Automatization is one of the most effective strategies for increasing CR referrals, particularly when deployed as part of a larger strategy of care coordina-tion.47 In women specifically, a combination of systematic,automatic referrals and case management resulted in a nearly 25 times increase in CR referrals after account-ing for clinical and demographic factors, and automatic referrals alone resulted in a>10x increase in referrals.48 Whereas the observational nature of the study and con-duct within the context of a universal health care system limits generalizability, the study overall supports automat-ic referrals among women, which have been shown to be

<EndOfPara>effective irrespective of sex, and a broader strategy of care coordination.49

A combination of automatic electronic referrals with a case management or liaison strategy also appears to increase CR enrollment among women. ${ }^{30,48}$ The lat-ter addresses multiple barriers to CR enrollment and facilitates enhanced education around the benefits of CR, because lack of awareness of CR is often cited by women as a reason for CR nonparticipation. ${ }^{24}$ A second strategy for increasing enrollment includes targeted edu-cation to patients and clinicians. Among women, strength of physician recommendation is associated with CR par-ticipation, ${ }^{30}$ although physicians are less likely to rec-ommend CR to women due to a combination of patient and clinician-level factors. ${ }^{50}$ Strategies demonstrated to be broadly successful for increasing enrollment remain salient for women, and include early postdischarge appointments and contact with the health system, cultur-ally sensitive programming, and flexible delivery hours. ${ }^{51}$

Increasing Participation and Engagement

In general, strategies that increase CR referral and en-rollment have also been shown to improve CR adher-ence. Specific to CR participation, women's tailored CR programs remain an area of investigation given their potential to target behavioral, clinical, and psychosocial factors unique to women(see Women-Focused CR Pro-grams section below). A second potential strategy for increasing CR participation includes sex-tailored exer-cise prescriptions. In a randomized controlled trial of 56

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women, intensive strength training combined with high-intensity interval training was safe and improved peak VO, and leg strength to a greater extent than moderate-intensity aerobic exercise.52 In this context, CR staff may need to adapt high-intensity interval training protocols to the preferences of each specific participant to en-hance acceptability and generalizability among women.Financial incentives53 and nontraditional delivery models using digital technologies(see Nontraditional Delivery Models Using Digital Technologies section below) have shown promise in other populations, although research is needed to understand the effects of these strategies in women specifically.

Peer Support Programming

Emerging evidence highlights the benefits of peer sup-port after a cardiovascular diagnosis. In a systematic review of 12 clinical trials, peer support after MI led to increased self-efficacy, self-care, quality of life, and ther-peutic adherence, lower depression and anxiety scores,and lower rates of rehospitalization and health care use compared with controls.54 Specific to women, support from peers and family leads to improved coping mecha-nisms for participating in CR, which leads to improved CR attendance.45 Among women with CVD who partici-pated in peer-led support groups, those who were at or above the median for social support measures experi-enced higher odds of high-level health activation,55 which may ultimately contribute to CR participation. As such,routinely incorporating peer support programing may en-hance women's participation in CR. Although evidence for virtual-based peer support as part of CR is lacking,further research in this field has the potential to enhance use of CR by removing barriers to access and offering support from peers outside usual geographic boundaries.

Mental Health Support

Studies have evaluated the efficacy of mental health treatments in patients with CVD, predominantly in pa-tients with coronary heart disease(CHD). In a Cochrane meta-analysis of randomized trials, psychologic treat-ment delivered by trained staff to patients with CHD led to small-to-moderate improvements in depression and anxiety, and small but significant effects on cardiac mor-tality rates.56 Sex-specific effects were not reported. In a systematic review of psychologic interventions that in-cluded 1587 women with CVD, interventions were most successful at reducing stress, with lesser effects on de-pression and anxiety.57 As such, existing evidence sup-ports incorporating mental health interventions as part of CR,although further research is needed to determine the sex- and disease-specific benefits of these interventions.Routine incorporation of mental health services through-out the CR process would include structured psychologic

counseling, support groups, and stress management pro-grams tailored to the needs of each patient.

Nontraditional Delivery Models Using Digital Technologies

There is emerging evidence to suggest that remote or virtual CR incorporating digital technologies(eg, vir-tual conferencing, remote physiologic monitoring, activ-ity tacking), either in isolation or as part of hybrid CR programs, achieves similar improvements in functional capacity as in-person CR.58 A single-center, real-world cohort study compared outcomes across in-person, hy-brid, and virtual CR.59 A second study randomized patients to in-person CR or a hybrid model(32% women).60 The number of completed CR sessions was similar between the 2 groups, as was exercise capacity and health status at 6 months. Studies of nontraditional delivery models using digital health technologies have been limited by their heterogenous designs and underrepresentation of women, limiting sex-specific inferences. One study ran-domized women to in-person mixed-gender, in-person women-only, or a hybrid program, with 3 in-person vis-its followed by home-based exercise supported by tele-phone calls.61 There were no differences in adherence to CR or functional capacity, although the study was limited by the small number of participants each arm, as well as by significant crossover.

Advantages of nontraditional delivery models include the potential to improve access by eliminating or reduc-ing the need for transportation and by facilitating the flexible delivery of CR in patients' preferred locations.Because transportation issues and family obligations are more often cited by women as barriers to CR par-ticipation, these models may be attractive alternatives to women who are eligible for CR.62 Potential disadvan-tages of these models that are particularly salient for women include lower levels of peer support and focus on moderate-intensity aerobic exercise.30,52 In addition,whereas studies of virtual and remote CR have increas-ingly enrolled patients at higher cardiovascular risk,data are lacking on the safety of these delivery mod-els in unique populations, such as those with SCAD or stress-induced cardiomyopathy(SIC). Thus, additional research is needed in women specifically to understand the effects of nontraditional delivery models using digital technologies on important clinical and patient-centered outcomes, with a focus on diverse, large studies. There is evidence of sex-based differences in sedentary time and behaviors, whereby older men generally accumu-late more total sedentary time, and older women tend to have more frequent but shorter bouts of sedentary behavior.63 As such, future nontraditional delivery models of CR should consider tailored interventions to reduce sedentary time on the basis of sex-specific patterns and behaviors.

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SPECIAL CONSIDERATIONS IN CR FOR WOMEN

Improving Cardiorespiratory Fitness in Women

Peak VO2 is the gold standard assessment for cardiore-spiratory fitness, and an important prognostic indicator for cardiovascular outcomes.64,65 In women-only studies,exercise training at moderate-to-vigorous or high inten-sities improved peak VO2 in patients with CHD,52 non-obstructive coronary disease with stable angina,66 and cardiotoxicity.67 A recent meta-analysis(63% women)also demonstrated that exercise training improves peak VO2 in patients with heart failure with preserved ejection fraction(a condition affecting more women than men),68 although regional differences in CR eligibility for patients with heart failure with preserved ejection fraction ex-ist. With respect to exercise modality, Khadanga et al52 found that high-intensity interval training was superior to moderate-intensity continuous training for improving peak VO2 in women with CAD. Recent meta-analyses have found that high-intensity interval training among patients with CAD69 and combined moderate-to-vigorous aerobic training with resistance training among patients with atrial fibrillation70 led to similar relative improve-ments in peak VO2 across genders. There are limited data on the effects of exercise training on peak VO2 in women with SCAD.

Women-Focused CR Programs

Women-focused CR programs address preferences of women, such as a broader range of exercise choices (eg,dance, yoga, tai chi), greater social interaction and psy-chosocial support, and insecurity concerns.2029,72 In a trial of women with CHD, those randomized to a motivational-ly enhanced, sex-tailored CR program attended a greater number of exercise and educational sessions than those randomized to a traditional mixed-sex CR program.73 A second trial randomized women to mixed-gender, women only, or home-based CR programs, and found no differ-ences in adherence to CR or functional capacity in the per-protocol analysis.61 In aggregate, the evidence re-mains mixed with respect to the potential benefits of sex-tailored CR programs, 61,73-76 and may reflect differences in the use of motivational interviewing and the resource-intensive nature of women's-only CR programs, with a limited availability of offerings.61,74,77

Guidelines have been developed for CR clinicians when implementing women-focused programs, with emphasis on systematic referral; patient choice of set-ting; staff expertise; approach to exercise training; pro-gram design features, such as psychosocial support,tailored exercise prescription, and patient education,empowerment, and self-management; and CR outcome evaluation. ${}^{78}$ By addressing sex-specific challenges in CR participation and delivery, the document outlines a

road map to enhance the inclusion and effectiveness of CR for women across various settings globally. Given the resource-intensive nature of women-focused CR,strategies may be needed to aid in the optimization of efficiencies and scaling of such interventions,46 includ-ing leveraging existing resources and infrastructure from current CR programs rather than creating separate facili-ties, expanding virtual and asynchronous education with recorded videos and online courses, providing alternative exercise modalities to enhance adherence, and training current CR staff in women's cardiovascular health topics to maximize efficiency and efficacy.

CR After a SCAD Event

SCAD is caused by intramural hematoma rather than atherothrombosis, and can be triggered by exercise.38 Patients with SCAD are most commonly female, 40 to 50 years of age on average(although all adult age groups are encountered), and usually healthy and active before the event. SCAD can be a traumatic event, and although the desire to return to vigorous exercise is often strong, so are patient concerns about exercise risks.79,80 Traditional CR programs have both physical and emo-tional benefits for patients with SCAD,81 but fewer than half of eligible patients participate even in specialized centers that frequently care for patients with SCAD.82 Dropout rates are high for women with SCAD and reflect shared barriers with other women, as well as unique bar-riers related to their young age, higher level of fitness,and perceived lack of value from traditional CR materi-als due to the unique pathophysiology of their disease.83 SCAD-focused CR is safe and has been well received by patients.83 Observational studies have reported no major adverse cardiac events, arrhythmias, or exercise-induced complications related to CR participation.14,81,83 Tradi-tional CR can be adapted to meet the specific needs of patients with SCAD with appropriate modifications.84 Although clinical trials are lacking, experts recommend that patients participating in CR after SCAD engage in moderate-intensity aerobic exercise, avoid intense straining(ie, Valsalva maneuver) to limit arterial shear stress, and receive tailored psychosocial support to ad-dress mental health concerns.84-86 Additional research is needed to inform CR models that are most applicable to patients with SCAD, including appropriate exercise test-ing protocols; exercise targets, modalities, and intensity;and form of CR delivery.

CR in Ischemia With Nonobstructive Coronary Arteries and MI With Nonobstructive Coronary Arteries

Ischemia with nonobstructive coronary arteries(INOCA)is caused by coronary microvascular dysfunction, coro-nary artery spasm, or both. Quality of life and functional

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status among patients with INOCA are similar to or worse than in those with obstructive CAD.87,88 A chal-lenge to CR delivery for patients with INOCA is the frequent occurrence of resting symptoms, which can result in interruptions in CR. Close collaboration be-tween exercise physiologists and cardiologists is neces-sary. Published studies of CR in INOCA are small but encouraging, with high adherence and improvements in quality of life and functional capacity reported.15,66 A randomized controlled pilot trial of 62 women with mi-crovascular angina and body mass index>25 Kg/m2 demonstrated that patients randomized to a weight loss,exercise, and risk factor management intervention expe-rienced greater improvements in anginal and depressive symptoms, weight loss, serum lipid levels, and HgbA1c levels compared with patients receiving usual care.89 In another trial of 30 patients with INOCA(50% women)randomized to CR or usual care, those participating in CR experienced improvements in exercise duration and cardiorespiratory fitness.90

MI with nonobstructive coronary arteries(MINOCA)has various causes, with atherothrombosis being the most common.91 Thus, CR after MINOCA can follow usual exercise and secondary prevention protocols,92 including education of the CR team to ensure all are aware that MINOCA is an ML to avoid mixed messaging to patients. Whereas clinical trial data for CR in MINOCA are lacking, in an observational study of patients with MINOCA, exercise-based CR improved physical health quality of life scores and reduced all-cause mortality and major adverse cardiovascular event rates,93 suggesting the importance of CR for this population. Future clinici-cal trials of CR in MINOCA are necessary to definitively quantify CR benefits in this population.

Preventative Strategies for Women With Breast or Gynecologic Malignancies

Women with a history of breast or gynecologic cancers often have elevated cardiovascular risk, and CVD com-petes with malignancy as the leading cause of death in this population.94,95 Shared risk factors and pathophysi-ologic mechanisms of breast or gynecologic cancers and CVD are recognized as potential mediators of the increased risk.96-98 In addition, adverse cardiovascular ef-fects of certain cancer therapies contribute to increased risk during and after treatment.99-101 In this context, CVD preventative strategies in this population need to be con-sidered in the continuum of cancer treatment, based on individual risk. Women with breast cancer who partici-pate in CR programs have unique educational needs that may go beyond the typical CR topics.102 This highlights a need for supplemental education of CR health care pro-fessionals on these particular needs.

Exercise training mitigates the decline in cardiorespi-ratory fitness, cardiac function, and biomarkers of cardiac

injury in this population, although with notable effect het-erogeneity.103,104 The implementation of exercise as part of comprehensive prevention strategies, including smok-ing cessation, weight control, and a healthy diet, has been recommended by the American Heart Association scientific statement on cardio-oncology rehabilitation.

Stress-Induced Cardiomyopathy

SIC is a transient cardiac condition typically triggered by physical or emotional stress, which is characterized by sudden regional or global left ventricular dysfunction and often mimics a Ml. Approximately 90% of patients with SIC are female, and many are postmenopausal. Although thought to be a relatively benign and self-resolving con-dition, SIC can have persistent emotional and physical effects, such as impaired exercise capacity.106 Two small observational studies.107,108 have demonstrated the safety and benefits(eg, increase in exercise capacity by 1.2 METs on average108) of CR in SIC. Given these findings,along with clinical parallels to conditions like SCAD and MINOCA for which CR is recommended, there is a grow-ing rationale to consider CR for individuals with SIC.

HEALTH EQUITY IN CR

Disparities in referrals to, access to and delivery of CR result in particularly low participation rates among people from underrepresented racial or ethnic groups, people with lower socioeconomic status, uninsured or underin-sured individuals, older patients, and people residing in areas with limited or no CR programs.31,109 People from underrepresented racial or ethnic groups bear a large burden of several multilevel risk factors and adverse so-cial determinants of health, which plays a major role in driving CR disparities.110 Other unique obstacles to CR participation include perceived discrimination, lack of trust in the health care system, and poor patient-phy-sician relationship.110 Multiple studies have documented evidence of these disparities, but fewer have evaluated interventions to ensure equitable access to and partici-pation in CR. A few studies suggest peer support and early postdischarge follow-up are associated with higher CR completion among women≥50 years of age. ${}^{111}$ Part-nerships with community organizations(eg, recreation centers, churches) to provide alternative CR delivery op-tions for people from underrepresented racial or ethnic groups have been shown to improve access to CR and enhance trust by providing culturally sensitive program-ming.110 Novel CR delivery methods, such as the use of a virtual world(an immersive computer-based environ-ment that simulates in-person experiences and allows for social engagement and interaction with others), are also being evaluated as tools to advance health equity.112,113 Although more complex to implement, financial incen-tives and case management have also been shown to

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improve CR adherence, especially among people with lower socioeconomic status.53 Programs should be cul-turally competent and tailored to address the needs of women from underrepresented racial or ethnic groups,considering cultural attitudes toward chronic disease and rehabilitation and providing educational materials in multiple languages.114 Implementation of health equity metrics in CR is essential to highlight program-specific inequities and address logistical barriers to improve par-ticipation rates.

OPPORTUNITIES TO ENHANCE CR FOR WOMEN: NEXT STEPS

Based on CR needs, gaps, and evidence-based ap-proaches specific to women outlined in this scientific statement, we propose the following steps to increase CR referral, participation, and completion among women,with the goal of improving their cardiovascular outcomes(Figure 3 and Table 2). Key areas for action include the following:

● Increase awareness and referrals: educate women on CR benefits, empower them to participate

<EndOfPara>actively in their health care and recovery, and imple-ment automatic referral systems combined with case management to ensure all eligible women receive a CR recommendation.

• Expand access:enhance accessibility through flex-ible CR schedules and hybrid CR models(in-person and virtual), which may address conflicts with work or caregiving as well as barriers to transportation;advocate for insurance coverage for alternative,flexible models of CR; and strive to achieve a pro-portion of women in CR that reflects the proportion of women with the CVDs being addressed in the program.

● Provide gender- and culturally sensitive program-ming: adapt CR programs to address specific needs and preferences of women. Develop community partnerships to deliver CR programs that are inclu-sive of women from underrepresented racial or ethnic groups and tailored to cultural and socioeco-nomic contexts.

● Provide tailored support: incorporate mental health interventions and peer support programs to meet the specific emotional and social needs of women with CVD. Administer tailored exercise prescriptions

  Figure 3. Enhancing cardiac rehabilitation participation in women.

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that may best address patients' preferences while contributing to improvements in their cardiorespira-tory fitness and overall function. Consider patients'unique diagnoses(eg, SCAD, INOCA, MINOCA,heart failure with preserved ejection fraction, atrial fibrillation, history of breast cancer or gynecologic malignancies) and comorbid conditions that may affect adaptation to exercise when tailoring CR components to address the participants' needs effi-caciously and safely.

● Promote research and innovation: explore non-traditional CR models with a focus on their safety and effectiveness for women. Develop and test CR protocols that address women's unique needs,including targeted exercise regimens, mental health support, and educational interventions.115 Ensure adequate, proportional participation of women in CR clinical trials and observational research. Enhance research funding to test alternative delivery mod-els to improve CR access in women, determine the best protocols to improve cardiorespiratory fitness in women with CVD, address women-predominant CR needs(eg, mental health and peer support inter-ventions), and develop disease-specific CR inter-ventions that address conditions disproportionately affecting women(eg, SCAD, MINOCA, INOCA,breast or gynecologic malignancies).

Implementation of these strategies can facilitate access to CR programs for women, promoting their qual-ity of life and long-term cardiovascular health.

Disclosures

Writing Group Disclosures

|Writing group member|Employment|Research grant|Other research support|Speakers bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Thais Coutinho|Mayo Clinic Rochester|None|None|None|None|None|None|None| |Sherrie Khadanga|University of Vermont Medical Center|NIH(received R01 funding from NIA)*|None|None|None|None|None|None| |Demilade Adedinsewo|Mayo Clinic Florida|Mayo Clinic Women's Health Research Center; Miami Heart Foundationt|None|None|None|None|None|None| |Ana Barac|Inova Heart and Vascular Institute|None|None|None|None|None|None|None| |Todd M. Brown|University of Alabama at Birmingham|None|None|None|None|None|None|None| |Christi Deaton|University of Cambridge School of Clinical Medicine (United Kingdom)|National Institute of Health Research(coinvestigator on grants funded by NIHR)*|None|None|None|None|None|None| |Jessica R. Golbus|University of Michigan|NIH(Pl)÷PCORI (coinvestigator)*|None|None|None|None|None|None| |Harmony Reynolds|New York University Grossman School of Medicine|NHLBl'; American Heart Association*|None|None|None|None|None|None|

(Continued)

Coutinho et al

Cardiac Rehabilitation in Women

Writing Group Disclosures Continued

|Writing group member|Employment|Research grant|Other research support|Speakers& bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Garima Sharma|Inova Heart and Vascular Institute|None|None|None|None|None|None|None| |Jenna L. Taylor|The University of Queensland School of Human Movement and Nutrition Sciences (Australia)|None|None|None|None|None|None|None|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives ≥$5000 during any 12-month period, or≥5% of the person's gross income; or (b) the person owns ≥5% of the voting stock or share of the entity, or owns ≥$5000 of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.

*Modest.

tSignificant.

Reviewer Disclosures

|Reviewer|Employment|Research grant|Other research support|Speakers' bureau/honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Gabriela Lima de Melo Ghisi|Toronto Rehabilitation Institute, University Health Network (Canada)|None|None|None|None|None|None|None| |Paul I.Oh|Toronto Rehabilitation Institute, University Health Network (Canada)|None|None|None|None|None|None|None| |Quinn R. Pack|Baystate Medical Center|NIH,NHLBI/ NIA*|None|None|None|None|An|None| |Paul Porier|Université Laval, Faculté de Pharmacie Institut Universitaire de Cardiologie et de Pneumologie de Québec(Canada)|None|None|None|None|None|None|None|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-tomnaire, which all reviewers are required to complete and submit A relationship is considered to be significant if a the person receives≥$5000 during any 12-month period, or≥5% of the person's gross income; or(b) the person owns≥5% of the voting stock or share of the entity, or owns≥$5000 of the fair market value of the entity.A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.

*Modest.

tSignificant.

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