European coronary centres achieve almost universal guideline-based prescribing at discharge, but only 48% cardiac rehabilitation completion: a paired within-centre “handoff gap” survey across Europe
M Gallego Llorente, L Y Rekker, L C Kieviet, D Breucker, L Tjon, M von Scheidt, G Pasterkamp, M I F J Oerlemans, P van der HarstAbstract
Background
Exercise-based cardiac rehabilitation (CR) is a Class I recommendation after acute myocardial infarction (AMI), yet participation remains suboptimal across Europe. Whether this shortfall reflects discrete pathway deficits or a broader failure in the acute-to-chronic transition is unclear.
Purpose
To quantify the within-centre gap between guideline-based secondary prevention prescribing at discharge and CR completion, and to characterise referral, timing, and reimbursement features of CR delivery.
Methods
We conducted a cross-sectional, web-based survey of coronary artery disease centres across 13 European countries (29 centres analysed; one excluded for an implausible screening value). Respondents reported centre-level proportions for AMI risk factor screening, ESC guideline-based prescribing at discharge, CR enrolment delay (weeks), and CR completion, alongside pathway characteristics (automatic referral and reimbursement coverage). The primary analysis was a within-centre paired t-test of prescribing at discharge versus CR completion, which controls for institutional differences. Associations between enrolment delay and completion were explored using Pearson correlation; categorical pathway features were assessed by non-parametric tests. Results are reported as means with 95% confidence intervals (CI).
Results
Acute-care discharge processes were near universal: mean AMI risk factor screening was 96.7% (95% CI 94.8–98.6) and mean guideline-based prescribing at discharge was 93.9% (95% CI 91.4–96.3). In contrast, mean CR completion was 48.4% (95% CI 37.9–58.8; range 5–90%), substantially below guideline expectations. The within-centre paired gap averaged 45.5 percentage points (95% CI 35.8–55.2; p<0.001); 28 of 29 centres showed a positive gap, with no reversals. Mean enrolment delay was 4.2 weeks (95% CI 3.2–5.2; range 0–9), and longer delay was associated with lower completion (r=−0.52, 95% CI −0.75 to −0.16; p=0.007). Referral was automatic for all eligible patients in only 28% of centres, and 24% reported no CR reimbursement. Neither was significantly associated with CR completion (all p>0.10).
Conclusion
Despite near-universal prescribing at discharge, only half of patients complete CR, revealing a pronounced "handoff gap" at the acute-to-chronic transition consistent across centres and countries. This gap represents a major point of value leakage: the clinical investment made during hospitalisation is not carried through to long-term secondary prevention. Importantly, no single structural lever (automatic referral or reimbursement alone) was sufficient to close this gap, suggesting a systemic transition-of-care failure rather than any single missing component. Coordinated strategies (e.g. potentially including earlier CR scheduling and systematic patient navigation) are needed to convert acute-phase excellence into sustained chronic-phase outcomes.Panel A: Prescribing vs completionPanel B: CR completion vs time to enrolment