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........................................................................................................... 4.11. Cardiac rehabilitation and prevention programmes CR is a comprehensive, multidisciplinary intervention not just including exercise training and PA counselling, but also education, risk factor modification, diet/nutritional counselling, and vocational and psychosocial support.358 Prevention and rehabilitation programmes after ASCVD events or revascularization reduce CV hospitalizations, myocardial infarction, CV mortality and, in some programmes, allcause mortality.638,640642 They may also reduce depressive/anxiety symptoms.649 In patients with chronic HF (mainly HFrEF), exercisebased cardiac rehabilitation (EBCR) may improve all-cause mortality, reduce hospital admissions, and improve exercise capacity and quality of life.639,650 CR is generally cost-effective.651 Clinical trials and registries are highly heterogeneous, which influences national guidelines, legislation, and reimbursement.652,653 The results of recent reviews provide clinicians with minimal requirements for successful CR after ACS or coronary artery bypass graft: • CR is a comprehensive multidisciplinary intervention466,649,654,655 • CR is supervised and carried out by adequately trained health professionals, including cardiologists649 • CR starts as soon as possible after the initial CV event649 • EBCR includes aerobic and muscular resistance exercise, which should be individually prescribed based on pre-exercise screening and exercise testing656 • The dose of EBCR (number of weeks of exercise training average number of sessions/week average duration of session in minutes) exceeds 1000638 • The number of EBCR sessions needs to exceed 36641 • During CR, all individually recognized CV risk factors need to be addressed and treated.642 Recently, the European Association of Preventive Cardiology (EAPC) proposed minimal and optimal standards for improvement of secondary prevention through CR programmes in Europe.657 Although exercise training prescription should adopt the FITT (frequency, intensity, time duration, and type of exercise) model, interclinician variance and disagreement exists.658 To optimize exercise training, the EAPC has introduced a digital, interactive decision support tool; the EXPERT (EXercise Prescription in Everyday practice & Rehabilitation Training) Tool (https://www.escardio.org/Education/ Practice-Tools/CVD-prevention-toolbox/expert-tool).659 No single exercise component is a significant predictor of mortality; only adherence to the full intervention improves outcome.660 Despite proven benefits, rates of referral, participation, and implementation are low.653,660,661 Uptake seems lower in women, but a variety of other intrapersonal, interpersonal, clinical, logistical, health system, and CR programme-related factors affect participation and adherence.662 CR enrolment is higher if trained nurses or allied healthcare providers intervene face-to-face, whereas adherence may be higher when remote interventions are implemented (i.e. homebased).643 Nurse-coordinated programmes can increase effectiveness.644646 Home-based CR with or without telemonitoring may increase participation and appear similarly effective as centre-based CR.647 Telehealth interventions are more effective than no intervention,648 but may also complement conventional CR. Also, mobile device-based healthcare (mHealth) delivery through smartphones may be as effective as traditional centre-based CR, showing significant improvements in health-related quality of life.663 These novel interventions may support the patient to maintain long-term healthy behaviours after specialized CR programmes.664 5 Policy interventions at the population level Recommendations for cardiac rehabilitation Recommendations Classa Levelb Participation in a medically supervised, structured, comprehensive, multidisciplinary EBCR and prevention programme for patients after ASCVD events and/or revascularization, and for patients with HF (mainly HFrEF), is recommended to improve patient outcomes.638642 I A Methods to increase CR and prevention referral and uptake should be considered (i.e. electronic prompts or automatic referrals, referral and liaison visits, structured follow-up by nurses or health professionals, and early programme initiation after discharge).643646 IIa B Home-based CR, telehealth, and mHealth interventions may be considered to increase patient participation and long-term adherence to healthy behaviours.647,648 IIb B ASCVD = atherosclerotic cardiovascular disease; CR = cardiac rehabilitation; EBCR = exercise-based cardiac rehabilitation; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; mHealth = mobile device-based healthcare. aClass of recommendation. bLevel of evidence. Recommendations for policy interventions at the population level Recommendations Classa Levelb,c Policies and population approaches to PA, diet, smoking and tobacco use, and alcohol in governmental restrictions and mandates, media and education, labelling and information, economic incentives, schools, worksites, and community settings follow different levels of recommendations (see specific tables in the supplementary material for section 5). Putting in place measures to reduce air pollution, including reducing PM emission and gaseous pollutants, reducing the use of fossil fuels, and limiting carbon dioxide emissions, are recommended, to reduce CVD mortality and morbidity. I C CVD = cardiovascular disease; PA = physical activity; PM = particulate matter. aClass of recommendation. bLevel of evidence. cLevel of evidence applies less well to policy interventions, and the type of empirical evidence varies widely across the separate approaches suggested. 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