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Engaging Women in Cardiovascular Rehabilitation

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Why do Women Often Need Cardiovascular Rehabilitation More Than Men?

Gender bias in society leads to a greater burden of risk factors in women. Lower socioeconomic status is associated with less access to healthy food and transportation issues. Informal caregiving responsibilities lead to added stress and less time for self-care and less time for physical activity which is an added risk factor. 

Throughout a woman’s life there are hormonal issues such as pregnancy and menopause which increase risk. Later detection of cardiovascular disease and less well-studied forms of cardiovascular disease such as Spontaneous Coronary Artery Dissection (SCAD) and Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA). 

There are more comorbidities for women, less aggressive treatment and a lack of information on medication in women such as dosing and adverse events. All these contribute to poorer outcomes than men and increased risk of depression, anxiety and consequently the increased need for cardiovascular rehabilitation.1

A Canadian study shows that while there is less data in women, women may actually benefit more from cardiovascular rehabilitation.2, 3

Despite the clear benefits of cardiovascular rehabilitation, unfortunately, there are barriers to participation. Men were approximately 1.5 times more likely to be referred to cardiovascular rehabilitation than women. Certain patient groups such as women are less likely to access and complete cardiovascular rehabilitation despite their greater need.4,5

  • Lack of referral and encouragement
  • Distance
  • Transportation (and related costs)
  • Comorbidities
  • Symptoms of pain, fatigue during exercise
  • Family responsibilities and other time constraints
  • Depression, anxiety

For these reasons, many cardiovascular rehabilitation programs have developed women-focused models that offer at least one of the following three options.7,8

Doctor assisting patient on exercise equipment.

Women-only, "mostly women" sessions, or full programs

  • Some staff educated on women and cardiovascular disease
  • Patient-centered care 
Two people chatting online with messages.

Accessible mode

  • Choice of home or center-based and timing of sessions
Diverse group of women standing together.

Content tailored to women

  • Women prefer exercise modes such as yoga, dance, walk outside, aqua aerobics
  • Peer-support
  • Psychosocial component
  • Educational content

The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) set out a process to develop the first clinical practice guideline for women-focused cardiovascular rehabilitation and to give some tangible recommendations to the cardiovascular rehabilitation community on how to deliver women-focused cardiovascular rehabilitation.9

Women-focused cardiovascular rehab guidelines overview

Presented by members of the CWHHA, this webinar targets cardiovascular rehabilitation (CR) staff and reviews the following: 

  1. Describes the importance of CR for women; 
  2. Reviews women-focused CR; 
  3. Reviews the 15 recommendations from the Women-Focused CR Clinical Practice Guideline; and 
  4. Describes how to feasibly tailor CR to women at your program. 

    1. Kim I, Field TS, Wan D, Humphries K, Sedlak T. Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes. Canadian Journal of Cardiology. 2022 Sept Vol: 38(2)12,1865-1880. DOI: https://doi.org/10.1016/j.cjca.2022.09.009

    2. Colbert JD, Martin BJ, Haykowsky MJ, Hauer TL, Austford LD, Arena RA, Knudtson ML, Meldrum DA, Aggarwal SG, Stone JA. Cardiac rehabilitation referral, attendance and mortality in women. Eur J Prev Cardiol. 2015 Aug;22(8):979-86. doi: 10.1177/2047487314545279. Epub 2014 Oct 2. PMID: 25278001.

    3. de Souza E Silva CG, Nishijuka FA, de Castro CLB, Franca JF, Myers J, Laukkanen JA, de Araújo CGS. Women Have Lower Mortality Than Men After Attending a Long-Term Medically Supervised Exercise Program. J Cardiopulm Rehabil Prev. 2022 Mar 1;42(2):120-127. doi: 10.1097/HCR.0000000000000623. PMID: 34117185.

    4. 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 Apr;22(4):423-41. doi: 10.1177/2047487314520783. Epub 2014 Jan 28. PMID: 24474091.

    5. Samayoa L, Grace SL, Gravely S, Scott LB, Marzolini S, Colella TJ. Sex differences in cardiac rehabilitation enrollment: a meta-analysis. Can J Cardiol. 2014 Jul;30(7):793-800. doi: 10.1016/j.cjca.2013.11.007. Epub 2013 Nov 12. PMID: 24726052.

    6. Grace SL, Gravely-Witte S, Kayaniyil S, Brual J, Suskin N, Stewart DE. A multisite examination of sex differences in cardiac rehabilitation barriers by participation status. J Womens Health (Larchmt). 2009 Feb;18(2):209-16. doi: 10.1089/jwh.2007.0753. PMID: 19183092; PMCID: PMC2927522.

    7. Supervía M, Medina-Inojosa JR, Yeung C, Lopez-Jimenez F, Squires RW, Pérez-Terzic CM, Brewer LC, Leth SE, Thomas RJ. Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions. Mayo Clin Proc. 2017 Mar 13:S0025-6196(17)30026-5. doi: 10.1016/j.mayocp.2017.01.002. Epub ahead of print. PMID: 28365100; PMCID: PMC5597478.

    8. Mamataz, T, Ghisi, GLM., Pakosh, M et al. Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review. BMC Cardiovasc Disord 21, 459 (2021). https://doi.org/10.1186/s12872-021-02267-0

    9. Ghisi GLM, Kin SMR, Price J, Beckie TM, Mamataz T, Naheed A, Grace SL. Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline. Can J Cardiol. 2022 Dec;38(12):1786-1798. doi: 10.1016/j.cjca.2022.06.021. Epub 2022 Aug 30. PMID: 36085185.