Barriers to Cardiac Rehabilitation in Saudi Arabia: A Scoping Review
DOI:
https://doi.org/10.62464/jvsx4y69Keywords:
Cardiac Rehabilitation; CR; Barriers; Saudi Arabia; Cardiovascular Disease; Scoping Review.Abstract
Background: Cardiac rehabilitation (CR) is considered a cornerstone of secondary prevention for cardiovascular disease (CVD); however, it remains underutilized and underdeveloped in Saudi Arabia. Objective: This scoping review aimed to analyze the existing evidence on barriers affecting the implementation and participation in CR programs across Saudi Arabia. Methods: A comprehensive search was conducted in MEDLINE, PubMed, Google Scholar, and ScienceDirect for studies published between 2015 and 2025. Eight national studies were included, examining perspectives from physicians, nurses, physiotherapists, and patients. Data were thematically analyzed and categorized into four domains—service delivery and policy, workforce and training, awareness and culture, and patient-related factors—classified under two levels: system and personal. Results: Findings from eight included studies revealed system-level barriers, including a shortage of CR centers, insufficient workforce training, fragmented policies, and limited funding. Personal-level barriers included low awareness, cultural constraints, and patient-related factors such as fatigue, anxiety, comorbidities, and limited access. Together, these challenges delay the normalization of CR within cardiac care pathways. Conclusions: A coordinated national framework is needed to integrate CR into post-cardiac care, supported by professional training, sustainable funding, and culturally sensitive public engagement. The most urgent priorities include establishing national CR guidelines, expanding workforce development pathways, and improving awareness of CR among patients and healthcare providers. Addressing these barriers is essential to expanding CR services, enhancing patient outcomes, and aligning healthcare priorities with Saudi Arabia’s Vision 2030 goal of an equitable and prevention-oriented healthcare system.
References
AACVPR. (2020). Guidelines for cardiac rehabilitation programs (6th ed.). Human Kinetics.
Adam, T., Al Sharif, A. I., Alamri, T. S. M., Al-Nashri, R. A. O., Alluwimi, A. I. M., Samkri, A. Y., Alharthi, M. A., Moafa, A. Y., Alsaadi, N. A., & Alraimi, A. M. S. (2023). The state of cardiac rehabilitation in Saudi Arabia: Barriers, facilitators, and policy implications. Cureus, 15(11), e48279. https://doi.org/10.7759/cureus.48279
Al-Ajlouni, Y. A., Tanashat, M., Basheer, A. A., Al Ta’ani, O., Alhuneafat, L., Deepak, F., Bilgin-Badur, N., & Etienne, M. (2024). Exploring cardiopulmonary rehabilitation in the Middle East and North Africa: A narrative review of challenges and opportunities. Current Problems in Cardiology, 49(12), 102829. https://doi.org/10.1016/j.cpcardiol.2024.102829
Aldhahir, A. M. (2022). Nurses’ perception of, and barriers to, delivering cardiopulmonary rehabilitation for heart failure patients: A national survey in Saudi Arabia. International Journal of Environmental Research and Public Health, 19(20), 13586. https://doi.org/10.3390/ijerph192013586
Aldhahir, A. M., Alhotye, M., Alqahtani, J. S., AlDraiwiesh, I. A., Alghamdi, S. M., Alsulayyim, A. S., Alqarni, A. A., Alzahrani, E. M., Siraj, R. A., & Alwafi, H. (2022a). Physiotherapists’ attitudes and barriers toward delivering cardiopulmonary rehabilitation for heart failure patients in Saudi Arabia. Journal of Multidisciplinary Healthcare, 15, 2353–2361. https://doi.org/10.2147/JMDH.S386519
Aldhahir, A. M., Alhotye, M., Alqahtani, J. S., Alghamdi, S. M., Alsulayyim, A. S., Alqarni, A. A., Alzahrani, E. M., Siraj, R. A., & Alwafi, H. (2022b). Physicians’ perceptions of and barriers to cardiopulmonary rehabilitation for heart failure patients in Saudi Arabia. International Journal of Environmental Research and Public Health, 19(22), 15208. https://doi.org/10.3390/ijerph192215208
Alhabeeb, W., Elasfar, A., Kinsara, A. J., Aljizeeri, A., Jelaidan, I., Alghalayini, K., AlKheraiji, M. F., Akbar, M., Lawand, S., & Alyousif, S. M. (2024). A Saudi Heart Association position statement on cardiovascular diseases and diabetes mellitus. Journal of the Saudi Heart Association, 36(4), 385–400. https://doi.org/10.37616/2212-5043.1407
Aljabri, N. Q., Bulkeley, K., & Cusick, A. (2021). Telerehabilitation in the Middle East and North Africa region: A structured review. International Journal of Telerehabilitation, 13(2), e6401. https://doi.org/10.5195/ijt.2021.6401
Aljefree, N., & Ahmed, F. (2015). Prevalence of cardiovascular disease and associated risk factors among adults in the Gulf region: A systematic review. Advances in Public Health, 2015, 235101. https://doi.org/10.1155/2015/235101
Alqahtani, A. S. (2023). A review of the scope, future, and effectiveness of using artificial intelligence in cardiac rehabilitation: A call to action for the Kingdom of Saudi Arabia. Applied Artificial Intelligence, 37(1), 2175111. https://doi.org/10.1080/08839514.2023.2175111
Alqahtani, B. A., & Alenazi, A. M. (2024). A national perspective on cardiovascular diseases in Saudi Arabia. BMC Cardiovascular Disorders, 24, 184. https://doi.org/10.1186/s12872-024-03845-8
Alsaidan, A. A. (2025). Cardiovascular disease management and prevention in Saudi Arabia: Strategies, risk factors, and targeted interventions. International Journal of Clinical Practice, 2025, 7233591. https://doi.org/10.1155/ijcp/7233591
Althumiri, N. A., Basyouni, M. H., AlMousa, N., AlJuwaysim, M. F., Almubark, R. A., BinDhim, N. F., Alkhamaali, Z., & Alqahtani, S. A. (2021). Obesity in Saudi Arabia in 2020: Prevalence, distribution, and its association with health conditions. Healthcare, 9(3), 311. https://doi.org/10.3390/healthcare9030311
Altowaijri, A., Alshehri, N., Balkhi, B., & Alghamdi, A. (2020). Economic burden of major cardiovascular diseases and ischemic stroke in Saudi Arabia: A cost-of-illness study. Value in Health, 23(Suppl. 2), S495–S496. https://doi.org/10.1016/j.jval.2020.08.541
Anderson, L., Oldridge, N., Thompson, D. R., Zwisler, A.-D., Rees, K., Martin, N., & Taylor, R. S. (2016). Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane review and meta-analysis. Journal of the American College of Cardiology, 67(1), 1–12. https://doi.org/10.1016/j.jacc.2015.10.044
Babgi, M. F., Albar, H. M., Miny, M. H., Alzahrani, H., Ahmad, M. S., Shaik, R. A., & Ahmed, E. O. (2023). Disparity analysis for cardiac surgical outcomes: The citizenship factor. Journal of Cardiovascular Development and Disease, 10(7), 292. https://doi.org/10.3390/jcdd10070292
Brown, T. M., Pack, Q. R., Aberegg, E., Brewer, L. C., Ford, Y. R., Forman, D. E., Khadanga, S., Ozemek, C., Thomas, R. J., & American Heart Association. (2024). Core components of cardiac rehabilitation programs: 2024 update. Circulation, 150(18), e328–e347. https://doi.org/10.1161/CIR.0000000000001289
Buckley, B. J. R., Harrison, S. L., Fazio-Eynullayeva, E., Underhill, P., Sankaranarayanan, R., Wright, D. J., Thijssen, D. H. J., & Lip, G. Y. H. (2021). Cardiac rehabilitation and all-cause mortality in heart failure patients. European Journal of Preventive Cardiology, 28(15), 1704–1710. https://doi.org/10.1093/eurjpc/zwab035
Chindhy, S., Taub, P. R., Lavie, C. J., & Shen, J. (2020). Current challenges in cardiac rehabilitation: Overcoming social and attendance barriers. Expert Review of Cardiovascular Therapy, 18(11), 777–789. https://doi.org/10.1080/14779072.2020.1816464
Gaalema, D. E., Dube, S., Potter, A., Elliott, R. J., Mahoney, K., Sigmon, S. C., Higgins, S. T., & Ades, P. A. (2019). The effect of executive function on adherence to cardiac secondary prevention. Preventive Medicine, 128, 105865. https://doi.org/10.1016/j.ypmed.2019.105865
Giri, B., Dey, S., Das, T., Sarkar, M., Banerjee, J., & Dash, S. K. (2018). Chronic hyperglycemia–mediated physiological alteration and metabolic distortion leads to organ dysfunction, infection, cancer progression and other pathophysiological consequences: An update on glucose toxicity. Biomedicine & Pharmacotherapy, 107, 306–328. https://doi.org/10.1016/j.biopha.2018.07.157
Global Burden of Cardiovascular Diseases Collaborators. (2025). Global, regional, and national burden of cardiovascular diseases and risk factors in 204 countries and territories, 1990–2023. Journal of the American College of Cardiology, 0(0). https://doi.org/10.1016/j.jacc.2025.08.015
Hadi Ahmed, R., & Bugis, B. A. (2023). Implementation and importance of cardiac rehabilitation in Saudi Arabia: A systematic review. Current Vascular Pharmacology, 21(4), 224–233. https://doi.org/10.2174/1570161121666230623115529
Jegier, A., Szalewska, D., Mawlichanów, A., Bednarczyk, T., Eysymontt, Z., Gałaszek, M., Mamcarz, A., Mierzyńska, A., Piotrowicz, E., & Piotrowicz, R. (2021). Comprehensive cardiac rehabilitation as the keystone in the secondary prevention of cardiovascular disease. Kardiologia Polska, 79(7–8), 901–916. https://doi.org/10.33963/KP.a2021.0066
Khushhal, A., & Alsubaiei, M. (2023). Barriers to establishing outpatient cardiac rehabilitation in the Western Region of Saudi Arabia: A cross-sectional study. Journal of Multidisciplinary Healthcare, 16, 653–661. https://doi.org/10.2147/JMDH.S398687
King Fahad Medical City. (2016). 20,000 catheterization and open-heart surgeries performed in KSHC.https://www.kfmc.med.sa/EN/Media/News/Pages/NewsArchived/20%2C000-Catheterization-and-Open-Heart-Surgeries-Performed-in-KSHC.aspx
Kinsara, A. J., Aljehani, R., Wolszakiewicz, J., Staron, A., & Alsulaimy, M. A. (2023). Recommendations for establishing cardiac rehabilitation services in Saudi Arabia. Journal of the Saudi Heart Association, 35(3), 205–212. https://doi.org/10.37616/2212-5043.1346
Middleton, W. A., Savage, P. D., Khadanga, S., Rengo, J. L., Ades, P. A., & Gaalema, D. E. (2022). Benchmarking depressive symptoms in cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention, 42(3), 163–171. https://doi.org/10.1097/HCR.0000000000000657
Ministry of Health. (2020). Cardiovascular diseases: Prevention and treatment. https://www.moh.gov.sa/en/HealthAwareness/EducationalContent/Diseases/Heartcirculatory/Pages/004.aspx
Neubeck, L., Freedman, S. B., Clark, A. M., Briffa, T., Bauman, A., & Redfern, J. (2012). Participating in cardiac rehabilitation: A qualitative meta-synthesis. European Journal of Preventive Cardiology, 19(3), 494–503. https://doi.org/10.1177/1741826711409326
Osailan, A. M. (2024). Cardiac rehabilitation in Saudi Arabia: Current status and future directions. Current Cardiology Reports, 26(10), 1077–1083. https://doi.org/10.1007/s11886-024-02105-7
Piepoli, M. F., Hoes, A. W., Agewall, S., Albus, C., Brotons, C., Catapano, A. L., Cooney, M.-T., Corrà, U., Cosyns, B., & Deaton, C. (2016). European guidelines on cardiovascular disease prevention in clinical practice. Kardiologia Polska, 74(9), 821–936. https://doi.org/10.5603/KP.2016.0120
Rashed, M., Theruvan, N., Gad, A., Shaheen, H., & Mosbah, S. (2020). Cardiac rehabilitation in Saudi Arabia: A perceptual view. World Journal of Cardiovascular Diseases, 10(9), 666–677. https://doi.org/10.4236/wjcd.2020.109064
Ritchey, M. D., Maresh, S., McNeely, J., Shaffer, T., Jackson, S. L., Keteyian, S. J., Brawner, C. A., Whooley, M. A., Chang, T., & Stolp, H. (2020). Tracking cardiac rehabilitation participation and Completion among Medicare beneficiaries. Circulation: Cardiovascular Quality and Outcomes, 13(1), e005902. https://doi.org/10.1161/CIRCOUTCOMES.119.005902
Ruano-Ravina, A., Pena-Gil, C., Abu-Assi, E., Raposeiras, S., van’t Hof, A., Meindersma, E., Prescott, E. I. B., & González-Juanatey, J. R. (2016). Participation and adherence to cardiac rehabilitation programs: A systematic review. International Journal of Cardiology, 223, 436–443. https://doi.org/10.1016/j.ijcard.2016.08.120
Schopfer, D. W., Nicosia, F. M., Ottoboni, L., & Whooley, M. A. (2020). Patient perspectives on declining to participate in home-based cardiac rehabilitation: A mixed-methods study. Journal of Cardiopulmonary Rehabilitation and Prevention, 40(5), 335–340. https://doi.org/10.1097/HCR.0000000000000493
Shah, N. P., AbuHaniyeh, A., & Ahmed, H. (2018). Cardiac rehabilitation: Current review of the literature and its role in patients with heart failure. Current Treatment Options in Cardiovascular Medicine, 20, Article 12. https://doi.org/10.1007/s11936-018-0611-5
Smith, S. C., Benjamin, E. J., Bonow, R. O., Braun, L. T., Creager, M. A., Franklin, B. A., … & World Heart Federation. (2011). AHA/ACCF guideline for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2011 update. Journal of the American College of Cardiology, 58(23), 2432–2446. https://doi.org/10.1016/j.jacc.2011.10.824
Suaya, J. A., Shepard, D. S., Normand, S.-L. T., Ades, P. A., Prottas, J., & Stason, W. B. (2007). Use of cardiac rehabilitation by Medicare beneficiaries. Circulation, 116(15), 1653–1662. https://doi.org/10.1161/CIRCULATIONAHA.107.701466
Sumner, J., Harrison, A., & Doherty, P. (2017). The effectiveness of modern cardiac rehabilitation: A systematic review of recent observational studies. PLOS ONE, 12(5), e0177658. https://doi.org/10.1371/journal.pone.0177658
Supervia, M., Medina-Inojosa, J. R., Pérez-Terzic, C. M., Sharma, S., Goel, K., Vickers Douglas, K., Salz, K., & Thomas, R. J. (2021). Impact of musculoskeletal limitations on cardiac rehabilitation participation. Frontiers in Cardiovascular Medicine, 8, 688483. https://doi.org/10.3389/fcvm.2021.688483
Turk-Adawi, K., Supervia, M., Pesah, E., Lopez-Jimenez, F., Afaneh, J., El-Heneidy, A., Sadeghi, M., Sarrafzadegan, N., Alhashemi, M., Papasavvas, T., & Grace, S. L. (2019). Availability and delivery of cardiac rehabilitation services in the Eastern Mediterranean Region: Findings from the Global Cardiac Rehabilitation Atlas. International Journal of Cardiology, 285, 147–153. https://doi.org/10.1016/j.ijcard.2019.02.065
Virani, S. S., Newby, L. K., Arnold, S. V., Bittner, V., Brewer, L. C., Demeter, S. H., Dixon, D. L., Fearon, W. F., Hess, B., Johnson, H. M., … Williams, M. S. (2023). 2023 ACC/AHA guideline for the management of patients with chronic coronary disease. Circulation, 148(9), e9–e119. https://doi.org/10.1161/CIR.0000000000001168
Whitmarsh, A., Koutantji, M., & Sidell, K. (2003). Illness perceptions, mood and coping in predicting attendance at cardiac rehabilitation. British Journal of Health Psychology, 8(2), 209–221. https://doi.org/10.1348/135910703321649178
World Health Organization. (2021). Cardiovascular diseases (CVDs). https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
Downloads
Published
Issue
Section
License
Copyright (c) 2025 International Journal of Physical Therapy Research & Practice
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
