Cardiac rehabilitation and socioeconomic variation: Bibliometric, systematic, and registry analyses across multiple contexts

Abstract

Background: Cardiac rehabilitation is a core model of secondary prevention that supports recovery after cardiac and vascular events through structured exercise, education, and psychosocial support. Despite well-established clinical efficacy, cardiac rehabilitation remains underutilised and inequitably accessed.

This thesis examined how socioeconomic characteristics were associated with cardiac rehabilitation participation and outcomes across international, national, and local contexts. Five interrelated aims were addressed.

Methods and results: Chapter 2 presents a bibliometric review of 8,729 publications, showing growth in research output, predominantly from high-income countries, with socioeconomic characteristics and equity considerations underrepresented. Chapter 3 reports a systematic review of six observational studies, showing that participation was associated with lower mortality and hospital readmission, with some evidence of lower return to work among disadvantaged groups. Chapter 4 reports analysis of the CONCORDANCE national registry, finding that participation was associated with a lower risk of major adverse cardiovascular events and mortality, with no variation by area-level socioeconomic status. Chapter 5 reports analysis of the International Cardiac Rehab Registry, finding that depressive symptoms improved overall, with greater improvements among those reporting financial strain and smaller improvements among those employed, while no socioeconomic differences were observed in quality of life. Chapter 6 reports analysis of the Westmead Hospital program, finding that health-related quality of life improved overall, although improvements were more modest among individuals who were unemployed or retired, those born overseas, and those residing in regional areas.

Conclusion: While cardiac rehabilitation delivers consistent clinical benefits across socioeconomic groups, participation and psychosocial recovery remain unequally distributed.