This sub-analysis of ICCPR’s 2025 Global CR Audit Update was cross-sectional and observational in design. The study protocol was approved by the ICCPR Executive and publicly posted prior to study initiation (https://globalcardiacrehab.com/2025/26-Audit-Update). Ethics approval was obtained from the York University Research Ethics Board (Toronto, Canada; e2025–057). This study was conducted in accordance with the ethical principles of the Declaration of Helsinki of the World Medical Association. Global findings related to CR coverage,14 access and referrals,15 core components offered,16 as well as dose, indications and staffing17 are reported elsewhere.

Detailed methods for the global Audit are reported elsewhere.16 In brief, the World Health Organization’s (WHO) country list served as the basis for this Audit. All countries listed as LAC as per World Bank (WB) regional groupings were the focus for this paper, to enable comparison with the initial Audit LAC results, and considering that the context in the United States and Canada is much different and more well-known than that in LAC.18 Countries were also income classified based on the WB (note there is no classification for Venezuela).18

For each country, national cardiovascular societies or identified local CR leaders were contacted to: (a) confirm the presence of any CR programs, and (b) provide contact information for each program identified.

From May 1st to September 1st, 2025, leads of identified programs were invited via email to provide electronic informed consent and complete the confidential online survey. REDCap was used for survey administration (SurveyMonkey in China). Up to two reminder emails were issued at two-week intervals to non-responders.

The study population comprised all Phase 2 CR programs identified worldwide. The inclusion criterion was programs offering post-discharge services delivering at least: (1) an initial patient assessment; (2) structured aerobic exercise training, whether supervised or unsupervised (± technology); and (3) at least one additional core component aimed at controlling cardiovascular risk factors (e.g., patient education, psychosocial or dietary counselling, tobacco cessation intervention).5 Programs operating solely for research purposes were excluded.

For the purposes of this study, data from the 35 WB LAC countries were considered.18 Aruba and Bermuda were accordingly considered as individual countries. Note that the British territories were not considered separately (e.g., Cayman Islands). Puerto Rico and the United States Virgin Islands were grouped with the United States, and therefore were only considered in the Global estimates for the purposes of this sub-study (Table 1).

CR need (number of CR-indicated patients/year) was computed using Global Burden of Disease Study 2023 estimates,19 as described in the Supplemental Methods. Operationalization of CR availability (≥1 program; yes/no), volume (number of patients served per year), service levels (shortfall(-)/surplus(+) patients/year), and coverage (%) are described in full there as well.

The survey instrument was adapted from the 2016 Global CR Audit,10,11 with updates invited from the global CR community, as described elsewhere.16 Items relevant to this sub-study assessed: service volumes, referral and access (including funding practices), multidisciplinary team composition, delivery of core CR components, and CR dose. Skip logic was applied to minimize respondent burden (therefore valid percentages are reported throughout). For instance, most questions pertained to supervised models, with a specific subsection on hybrid models and alternative settings. Hybrid CR was defined as offering patients both supervised on-site, and remote or unsupervised sessions (with latter being alternative model/setting).23,24

Programs were asked to specify whether the phase II CR service was located within a hospital and, if so, whether an inpatient cardiology ward was present. For hospital-based programs, respondents further indicated the nature of any referral systems linking inpatient and outpatient CR. Information on program funding sources were queried; for sites where patients paid, program respondents estimated the average proportion of program cost covered by patients.

Respondents were also asked to estimate the total cost to deliver one complete supervised program per patient. To enable valid comparison of program delivery costs across countries and time, all cost estimates were standardized following international health-economic methods20; full details are provided in the Supplemental Methods.

Multidisciplinary team composition was assessed through a list of relevant disciplines, considering also part-time staff. Total program staff size was computed by summing 1.0 full-time equivalent (FTE) for each full-time and 0.5 FTE for each part-time staff member.

Delivery of core CR components was captured using a standardized list aligned with major CR society recommendations.5,21,22 Respondents also indicated which cardiovascular risk factors were assessed at initial evaluation (e.g., blood pressure, lipids, glycemia, physical activity, tobacco use, diet, and psychosocial factors), and about their patient education component.

CR dose was calculated as the product of program duration (weeks) by sessions per week (frequency), for total sessions per patient per program. Dose was reported separately for center-based versus hybrid or alternative delivery settings/models.

Data were analyzed using SPSS version 31.25 All initiated surveys were included in the analysis. Descriptive statistics were computed for all variables, with continuous variables presented as medians with corresponding 25th-75th percentiles (P25-P75), and categorical variables as frequencies and valid percentages.

Data distributions were assessed for normality using the Shapiro-Wilk test. As most continuous variables were not normally distributed, non-parametric tests were applied. Where comparable variables were available, 2025 Audit data were compared with published 2016 Audit results to characterize changes in CR delivery over time.9–11 For continuous variables reported as medians with interquartile ranges, differences between 2016 and 2025 were assessed using the Mann-Whitney U test. For categorical variables, comparisons of proportions were conducted using the chi-square test (or Fisher’s exact test, as applicable). When raw data from the 2016 Audit were not available in the same format, decade comparisons were conducted using available summary statistics with Welch’s t-test applied in MedCalc for variables reported as means with standard deviations.26 In addition, regional estimates were compared with global estimates of program characteristics, patient costs, and service delivery patterns using the same inferential approach, as applicable. Statistical significance was set at p < 0.05.

As detailed elsewhere,14 113/199 (56.8%) countries in the world were confirmed to have CR available; in LAC countries specifically 25/35 (71.4%) had any phase II CR (Fig. 1). With regard to responses received, globally, at least one survey was initiated by a program from 90/113 (79.6%) of these countries with CR available. In LAC countries, ≥1 surveys were received from programs in 19/25 (76.0%) with available CR (Table 1, left-most column).

Fig. 1.

Phase II cardiac rehabilitation availability and coverage in Latin American countries.

Note: 0% coverage (red) indicates no CR availability.

In total, 6905 CR programs were confirmed globally. Overall, 1505 (21.4%) programs initiated a survey, with a median program response rate across countries of 62.3% (P25-P75: 24.1–100.0%).14 In LAC, 337 programs were confirmed, of which 255 (75.7%) programs responded (shown by country in Table 1); percentage of responses received per LAC country ranged from 14.3–100.0% of programs, with a median program response rate of 83.1% across countries in the region.

The proportion of LAC countries represented in this ICCPR Audit were similar to that in the first,9,10 where CR was identified in 68.6% of LAC countries, and data were similarly obtained from 20 (57.1%) countries. The number of program responses was higher in the current Audit (255 vs. 139, respectively; see Table 1 for response by country for both Audits). In 2025, all responding CR programs in the 19 LAC countries were located in urban areas (n = 189, 100.0%; 92.8% in 20169). The majority of responding CR programs were situated in a hospital (n = 105, 59.0%), though this proportion declined from 68.1% in 2016,9 suggesting increasing diversification of delivery settings such as community or private clinics (38.8% in 2025).

CR availability is shown in Fig. 1, and number of programs per country in Table 2. The 10 countries without CR available are: Bahamas, Belize, Ecuador, Guyana, Haiti, Nicaragua, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Trinidad and Tobago. Since the last Audit,9–11 Ecuador as well as Trinidad and Tobago (n = 2 countries) no longer report any CR availability, while Antigua and Barbuda, Bolivia, Dominica, as well as Suriname (n = 4 countries) newly report programs.

In the initial Audit9,10 it was estimated there were a total of 255 programs across the LAC region, and 337 in the Audit update. As shown in Table 2, the number of programs per country with available CR in 2025 ranged from 1 in several smaller nations (e.g., Barbados, Bermuda, Honduras, Paraguay) to a maximum of 65 in Mexico, with a median of 1 program/country (P25-P75:0–8). Since the last Global CR Audit,10 there was an increase in the number of programs - notably in Mexico (from 24 to 65 programs), Chile (10 to 46), Cuba (8 to 21), Uruguay (12 to 21), and Costa Rica (6 to 11). Countries with notable reductions in the number of CR programs from 201610 included Brazil (75 to 59 programs), Ecuador (5 to 0), Colombia (50 to 46), Venezuela (9 to 5), as well as Trinidad and Tobago (2 to 0). Program capacity (patients that could be treated/year) is shown in Supplemental Table S1 by Audit decade and LAC country. The median of 198 in the region is greater than that of 160 globally.

Median annual supervised or unsupervised program volume in LAC countries ranged from 0 (i.e., no CR available) to 500 patients annually (median=56.5, P25-P75=0–120). There was a median national volume of 200 patients treated/country/year (P25-P75=0–1075; not comparable globally given lower population in many LAC countries). The total volume was 48,736 patients/year in the region.

As shown in Table 2, there were CR service shortfalls in 31/34 (91.2%; could not be computed for Aruba) LAC countries. Note that in all 3/3 countries that reported a service surplus (i.e., Antigua and Barbuda [n = 121 patients/year], Bermuda [n = 89 patients/year], and Dominica [n = 6 patients/year]; all island nations, where geographic isolation and relatively small populations may also have contribute to the observed service surpluses), the regional median capacity was applied for the service level computation, so caution is warranted in over-interpreting those results.

The greatest CR service shortfall was observed in Brazil (259,308 patients/year), followed by Mexico (132,791) and Argentina (37,642). As also shown in Table 1, the median shortfall per LAC country was −4939 (mean of −18,704). The total estimated service shortfall across the LAC region was −635,945 patients/year, or two-thirds of a million indicated patients who could not be treated due to insufficient services.

With regard to CR service coverage (Table 2), for countries with CR with insufficient service volumes, coverage ranged from 0.9% (Brazil) to 65.3% (Grenada), with a national median of 9.6% CR coverage across the LAC; this is however more favourable than the global median country coverage of 2.9%. By global ranking (Table 2), disregarding countries where the income-class median was imputed due to missing data (e.g., Antigua and Barbuda, Dominica), Barbados (20th best globally), followed by Colombia (22nd), as well as Cuba (23rd) had among the best CR coverage in the region; no other countries ranked under 25th; Other than Colombia, this is potentially partially explained by their island status. Disregarding ranks of 114 reflecting ties for no CR available, Brazil (97th), Dominican Republic (96th), Bolivia (94th), Jamaica (85th), and Venezuela (83rd) had the poorest global rankings.

Among programs in hospitals, for 119 (83.2%), the hospitals had an inpatient cardiology service (90.3% in 2016).9 Among these programs, they estimated that 49.6 ± 32.6% of inpatients were directly referred to CR prior to discharge (58.2 ± 34.3% globally in 2025). The most common referral strategies were discussion at the bedside (n = 59, 23.1%), followed by scheduling an initial appointment before discharge (n = 45, 17.6%), and providing informative materials to all inpatients (n = 39, 15.3%); systematic inpatient referral was rarely applied (Fig. 2, by country, region and globally). When compared to inpatient CR referral practices globally, LAC programs significantly less commonly applied systematic referral, CR discussion at the bedside, and provision of informational materials to inpatients (Fig. 2).

Fig. 2.

Phase II cardiac rehabilitation referral practices in programs situated in hospitals with inpatient cardiology services by Latin American and Caribbean Country vs Globally, n = 119.

Note: for each practice, the estimated proportion per year is reported.

ǁCountry-level data in Barbados, Bermuda, Jamaica, Paraguay and Suriname are not shown to protect program privacy (i.e., only 1 program in country); country-level data in Cuba, Dominican Republic, Guatemala, Honduras and Panama not shown due to small cell sizes rendering estimates unreliable (≤3 programs responding). Any values are included in regional row, to optimize generalizability.

*physician, non-physician clinician, peer, or volunteer.

§caution warranted in interpreting results due to small number of responding programs situated in hospitals with inpatient units.

Acronyms: CR, cardiac rehabilitation; LAC, Latin America and the Caribbean.

^LAC vs global: ^p<.05; ^^p<.01; ^^^p<.001.

Alternative models, including home-based or hybrid CR, and community-based settings which can be more accessible, were available in 42 (16.5%) programs across the region (Table 3), representing no substantive difference from 27 (19.4%) programs in 2016.9 This is lower than global availability (29.5%).

The under-availability of CR represents a major missed opportunity to improve secondary prevention outcomes and reduce the burden of CVD. Given robust evidence demonstrating the low healthcare cost to the system (not for patients in the region) and cost-effectiveness of CR,28 morbidity and mortality reduction,29 as well as quality-of-life benefits,30 the lack of sufficient services contributes to preventable disability and death across LAC. While CR program capacity has expanded in some countries in the last decade, the magnitude of service shortfalls underscores the urgent need for health systems to integrate CR into national CVD and non-communicable disease management policies.31

Despite relatively robust multidisciplinary staffing17 and a comprehensive suite of core components offered,16 participation continues to be constrained by limited referral systems, persistent out-of-pocket costs, and sparse availability of alternative or community-based models that could improve reach. The high patient cost burden may exacerbate socioeconomic inequities in access and undermine the potential of CR to mitigate CVD burden region-wide. Expanding CR coverage and optimizing delivery require coordinated action between Ministries of Health, health governance bodies at all levels, professional Associations, and community organizations. Professional Societies, including the ICCPR and local cardiovascular organizations, should continue to champion CR inclusion in policy, accreditation standards, and workforce training initiatives. Strategic investment is needed to expand coverage, particularly in underserved areas, and to include hybrid/alternative CR models within existing reimbursement structures (only reimbursed for 18.1% programs currently). Integrating CR into publicly-funded health benefit packages, establishing referral mandates within hospital discharge processes and leveraging digital technologies represent actionable opportunities to reduce unmet need and increase utilization.

Several limitations warrant consideration. Although the country response rate was high, challenges in program identification (e.g., private sector programs not linked to Societies, programs that re-branded post-COVID) may have introduced bias. It is unknown how non-identified programs differ from responding programs. Moreover, the number of programs in many countries was small, which may limit the stability and generalizability of country-level estimates.

Caution is warranted in interpretation of PPP costing values, given PPP compression effects in MICs, public-sector subsidization of CR staff and infrastructure when compared to privately-funded health care, internalization of costs in public health systems, and inflation instability in some countries.

As with prior Audits,9 heterogeneity in health system structures, economic conditions, and data completeness across countries may affect the generalizability of results. Findings should thus be interpreted with caution and viewed as exploratory, emphasizing trends rather than definitive inter-country comparisons. Similar caution is warranted when interpreting changes from 2016 due to measurement modifications and the repeated cross-sectional design.

In this 2025 Audit Update, CR availability and delivery in LAC show areas of important progress, yet substantial inequities and service gaps persist. While several countries have expanded program numbers, strengthened multidisciplinary teams, and maintained delivery of most guideline-recommended core components, referral practices remain inconsistent, alternative models are under-available, and patient out-of-pocket costs continue to pose major barriers to access. Comparison with global estimates and the initial Audit reveals modest improvements in some domains but persistent or widening shortfalls in others, resulting in an annual service shortfall reaching well over 600,000 indicated patients. Taken together, these findings highlight the urgent need for coordinated regional policies, sustainable funding mechanisms, improved referral systems, and wider adoption of hybrid or home-based models to ensure equitable, scalable CR services capable of addressing the growing secondary prevention needs across the region.