7th June 2019, Volume 132 Number 1496

Brendon H Roxburgh, Marta Supervia, Karam Turk-Adawi, Jocelyne R Benatar, Francisco Lopez Jimenez, Sherry L Grace

Cardiovascular diseases (CVD) account for approximately 10,000 deaths per annum (31.2% of all deaths) in New Zealand.1 Patients afflicted with CVD are at increased risk of recurrent cardiovascular events and…

Subscriber content

The full contents of this page is only available to subscribers.

To view this content please login or subscribe


Cardiac rehabilitation (CR) is a cost-effective service to improve risk factors after a heart attack and/or cardiac surgery, reducing mortality and risk of rehospitalisation. We compared the nature of CR programs in New Zealand and with those of countries with similar incomes and health systems. We found New Zealand CR programmes had fewer types and number of staff, provided fewer sessions and were less comprehensive, compared to those in other high-income countries. New Zealand did well in providing alternate forms of CR, such as community based.



To compare the nature and delivery of cardiac rehabilitation (CR) services within New Zealand by island (North vs South; NI, SI), and to other high-income countries (HICs).


In this cross-sectional study, secondary analysis of an online survey of CR programmes globally was undertaken. Results from New Zealand were compared to data from other HICs with CR.


Twenty-seven (62.7%) out of 43 CR programmes in New Zealand (n=18/31, 66.7% respondents from NI) and 619 (43.1%) from 28 other HICs completed the survey. New Zealand CR programmes offered a median of 16.0 sessions/patient (interquartile range (IQR)=12.0–36.0; vs 21.6 sessions in other HICs, IQR=12.0–36.0, p=0.016), delivered by a team of 6.0 staff (IQR=5.5–7.0; vs 7.0 staff; IQR=5.0–9.0, p=0.012). New Zealand programmes were significantly less comprehensive than other HICs (p=0.002); within New Zealand, NI programmes were more likely to provide an initial and end-of-programme assessment, supervised exercise training and depression screening, compared to SI programmes (all p<0.05). New Zealand more often offered CR in an alternative setting (n=14, 58.3%), compared to other HICs (n=190, 36.5%), p=0.03).


CR programmes in New Zealand offer fewer sessions and have fewer elements compared to other HICs, and disparity exists in programmes across New Zealand. More investment is needed to ensure CR in New Zealand meets international guidelines.

Author Information

Brendon H Roxburgh, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin; Marta Supervia, Department of Physical Medicine and Rehabilitation, Gregorio Marañón General University Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain; Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States; Karam Turk-Adawi, Department of Public Health, QU Health, Qatar University, Doha, Qatar; Jocelyne R Benatar, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland; Francisco Lopez Jimenez, Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States; Sherry L Grace, School of Kinesiology and Health Science, York University; University Health Network, University of Toronto, Toronto, Ontario, Canada.


On behalf of the International Council of Cardiovascular Prevention and Rehabilitation through which this study was undertaken, the Global CR Program Survey Investigators are grateful to all other national champions who collaborated to identify and reach programmes in other HICs, namely Drs Karl Andersen, Birna Bjarnason Wehrens, Vilnis Dzerve, Stefan Farsky, Hareld Kemps, Anna Kiessling, Evangelia Kouidi, Maria Mooney, Lis Neubeck, Bruno Pavy, Attila Simon, Eliska Sovova, Juan Castillo Martin, Jacqueline Cliff, Susan Dawkes, Eva Prescott and Egle Tamuleviciute-Prasciene. We also thank the CSANZ Secondary Prevention Working Group for assisting with programme identification and the World Heart Foundation who formally endorsed the study protocol.


Prof Sherry L Grace, School of Kinesiology and Health Science, York University; University Health Network, University of Toronto, 4700 Keele Street, Toronto, ON, Canada.

Correspondence Email


Competing Interests



  1. Ministry of Health. 2016 Mortality data tables (provisional) 2018 [Available from: http://www.health.govt.nz/publication/mortality-2016-data-tables-provisional
  2. Westin L, Carlsson R, Israelsson B, et al. Quality of life in patients with ischaemic heart disease: a prospective controlled study. J Intern Med. 1997; 242(3):239–47.
  3. Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016; 37(29):2315–81.
  4. Shields G, Wells A, Doherty P, et al. Cost-effectiveness of cardiac rehabilitation: a systematic review. Heart. 2018; 104(17):1403–10.
  5. Smith SC, Benjamin EJ, Bonow RO, et al. 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 endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. J Am Coll Cardiol. 2011; 58(23):2432–46.
  6. Piepoli MF, Corra U, Adamopoulos S, et al. Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Card. 2014; 21(6):664–81.
  7. Balady GJ, Ades PA, Bittner VA, et al. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation. 2011; 124(25):2951–60.
  8. Balady G, Williams M, Ades P, et al. American Heart Association Exercise CR. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardpulm Rehabil Prev. 2007; 27(3):121–9.
  9. Kira G, Doolan-Noble F, Humphreys G, et al. A national survey of cardiac rehabilitation services in New Zealand: 2015. N Z Med J. 2016; 129(1435):50–8.
  10. Pesah E, Supervia M, Turk-Adawi K, et al. A review of cardiac rehabilitation delivery around the world. Prog Cardiovasc Dis. 2017; 60(2):267–80.
  11. Supervia M, Turk-Adawi K, Lopez Jimenez F, et al. Nature of cardiac rehabilitation around the globe. EClinicalMedicine. 2018; Under revision.
  12. World Bank. High income data http://data.worldbank.org/income-level/high-income 2017 [Available from: http://data.worldbank.org/income-level/high-income.
  13. Polyzotis P, Tan Y, Prior P, et al. Cardiac rehabilitation services in Ontario: components, models and underserved groups. J Cardiovasc Med. 2012; 13(11):727–34.
  14. Bjarnason-Wehrens B, McGee H, Zwisler A-D, et al. Cardiac rehabilitation in Europe: Results from the European cardiac rehabilitation inventory survey. Eur J Cardiovasc Prev Rehabil. 2010; 17(4):410–8.
  15. Cortes-Bergoderi M, Lopez-Jimenez F, Herdy AH, et al. Availability and characteristics of cardiovascular rehabilitation programs in South America. J Cardpulm Rehabil Prev. 2013; 33(1):33–41.
  16. Liew TV, McLachlan A, Roxburgh BH, et al. New Zealand Cardiac Support and Secondary Prevention (Cardiac Rehabilitation) Core Components. http://cardiacsociety.org.nz/; 2018.
  17. Woodruffe S, Neubeck L, Clark RA, et al. Australian Cardiovascular Health and Rehabilitation Association (ACRA) core components of cardiovascular disease secondary prevention and cardiac rehabilitation 2014. Heart Lung Circ. 2015; 24(5):430–41.
  18. Benatar J, Doolan-Noble F, McLachlan A. Cardiac rehabilitation in New Zealand-moving forward. N Z Med J. 2016; 129(1435):68–74.
  19. Russell K, Holloway T, Brum M, et al. Cardiac rehabilitation wait times: effect on enrollment. J Cardpulm Rehabil Prev. 2011; 31(6):373–7.
  20. Fell J, Dale V, Doherty P. Does the timing of cardiac rehabilitation impact fitness outcomes? An observational analysis. Open Heart. 2016; 3(1):e000369.
  21. Doherty P, Petre C, Onion N, et al. National Audit of Cardiac Rehabilitation (NACR): Annual Statistical Report 2017. http://www.bhf.org.uk/informationsupport/publications/statistics/national-audit-of-cardiac-rehabilitation-annual-statistical-report-2017; 2018.
  22. de Araújo Pio CS, Marzolini S, Pakosh M, et al. Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis. Mayo Clin Proc. 2017; 92(11):1644–59.
  23. Chaves G, Turk-Adawi K, Supervia M, Santiago Pio C, Mamataz T, Abdel-Hadi R, Lopez-Jimenez F, El-Heneidi AA, Grace SL. Cardiac rehabilitation dose around the globe: Variation and drivers. Circ Cardiovasc Qual Outcomes. 2019; Under revision.
  24. Turk-Adawi K, Supervia M, Lopez Jimenez F, et al. Cardiac rehabilitation availability and density around the globe. EClinicalMedicine. 2019; Under revision.
  25. Stewart R. More flexible approaches are needed to improve cardiac rehabilitation. N Z Med J. 2016; 129(1435):7–9.
  26. Dale L, Whittaker R, Jiang Y, et al. Effects of an mHealth cardiac rehabilitation intervention on lifestyle change: results from the Text4Heart randomised controlled trial. Heart Lung Circ. 2015; 24:S77.
  27. Maddison R, Rawstorn JC, Stewart RA, et al. Effects and costs of real-time cardiac telerehabilitation: randomised controlled non-inferiority trial. Heart. 2018:heartjnl-2018-313189.
  28. Roxburgh BH, Elliott T, Reading S. Community-based cardiac rehabilitation led by CEPs improves physical and mental health of Phase 2 patients. Med Sci Sports Exerc. 2016; 48(5S):658–9.
  29. Mandic S, Body D, Barclay L, et al. Community-based cardiac rehabilitation maintenance programs: Use and effects. Heart Lung Circ. 2015; 24(7):710–8.
  30. Gasparini C, Johansen Y, Reed S, et al. A Community Exercise Program in Partnership with Te Hononga o Tamaki Me Hoturoa-a Holistic Approach to Exercise Rehabilitation. Heart Lung Circ. 2016; 25:S36.


The downloadable PDF version of this article is only available to subscribers.

To view this content please login or subscribe