Symposium Article| Volume 348, ISSUE 2, P146-152, August 2014

Gender, Race and Cardiac Rehabilitation in the United States: Is There a Difference in Care?

  • Arthur R. Menezes
    From the Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
    Search for articles by this author
  • Carl J. Lavie
    Correspondence: Carl j. Lavie, MD, Cardiac Rehabilitation and Prevention, Exercise Laboratories, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121–2483
    From the Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
    Search for articles by this author
  • Alban DeSchutter
    From the Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
    Search for articles by this author
  • Richard V. Milani
    From the Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
    Department of Preventive Cardiology, Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana
    Search for articles by this author


      Coronary heart disease is the leading cause of death within the United States, involving both genders and among all races and ethnic populations. Cardiac rehabilitation (CR) has been shown to significantly improve morbidity and mortality, and these benefits extend to individuals of both genders and all ages with coronary heart disease. Despite this, referral and participation rates remain surprisingly low. Furthermore, women and minorities have even lower referral rates than do their male and white counterparts. over the course of this article, we will review CR referral and participation among women, as well as racial and ethnic minorities in the United States. We will also examine barriers to CR participation among these subgroups.

      Key Indexing Terms

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of the Medical Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Go A.S.
        • Mozaffarian D.
        • Roger V.L.
        • et al.
        Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
        Circulation. 2013; 127: e6-e245
        • Leon A.S.
        • Franklin B.A.
        • Costa F.
        • et al.
        Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
        Circulation. 2005; 111: 369-376
        • Williams M.A.
        • Ades P.A.
        • Hamm L.F.
        • et al.
        Clinical evidence for a health benefit from cardiac rehabilitation: an update.
        Am Heart J. 2006; 152: 835-841
        • Witt B.J.
        • Jacobsen S.J.
        • Weston S.A.
        • et al.
        Cardiac rehabilitation after myocardial infarction in the community.
        J Am Coll Cardiol. 2004; 44: 988-996
        • Thomas R.J.
        • King M.
        • Lui K.
        • et al.
        AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists. Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2007; 50: 1400-1433
        • Menezes A.R.
        • Lavie C.J.
        • Milani R.V.
        • et al.
        Cardiac rehabilitation in the United States.
        Prog Cardiovasc Dis. 2014; 56: 522-529
        • Cruz-Flores S.
        • Rabinstein A.
        • Biller J.
        • et al.
        Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2011; 42: 2091-2116
        • Day J.C.
        Population Projections of the United States by Age, Sex, Race and Hispanic Origin: 1995 to 2050. US Government Printing Office, Washington, DC1996: 25-1130 (US Bureau of the Census, Current Population Reports, Available at:) (Accessed July 5, 2014)
        • Roger V.L.
        • Go A.S.
        • Lloyd-Jones D.M.
        • et al.
        Heart disease and stroke statistics—2011 update: a report from the American Heart Association.
        Circulation. 2011; 123: e18-e209
        • Cardiovascular Health Branch, Division ofChronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC
        Trends in ischemic heart disease mortality—United States, 1980–1988.
        Morb Mortal Week Rep. 1992; 41: 548-556
        • Levy R.I.
        The decline in cardiovascular disease mortality.
        Annu Rev Public Health. 1981; 2: 49-70
        • Rosamond W.D.
        • Chambless L.E.
        • Heiss G.
        • et al.
        Twenty-two-year trends in incidence of myocardial infarction, coronary heart disease mortality, and case fatality in 4 US communities, 1987–2008.
        Circulation. 2012; 125: 1848-1857
        • Yeh R.W.
        • Sidney S.
        • Chandra M.
        • et al.
        Population trends in the incidence and outcomes of acute myocardial infarction.
        N Engl J Med. 2010; 362: 2155-2165
        • Safford M.M.
        • Brown T.M.
        • Muntner P.M.
        • et al.
        Association of race and sex with risk of incident acute coronary heart disease events.
        JAMA. 2012; 308: 1768-1774
      1. Smedley B.D. Stith A.Y. Nelson A.R. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, Washington, DC2003 (Available at:) (Accessed July 5, 2014)
        • Dunlay S.M.
        • Witt B.J.
        • Allison T.G.
        • et al.
        Barriers to participation in cardiac rehabilitation.
        Am Heart J. 2009; 158: 852-859
        • Shippee T.P.
        • Ferraro K.F.
        • Thorpe R.J.
        Racial disparity in access to cardiac intensive care over 20 years.
        Ethn Health. 2011; 16: 145-165
        • Valencia H.E.
        • Savage P.D.
        • Ades P.A.
        Cardiac rehabilitation participation in underserved populations. Minorities, low socioeconomic, and rural residents.
        J Cardiopulm Rehabil Prev. 2011; 31: 203-210
        • Menezes A.R.
        • Lavie C.J.
        • Milani R.V.
        • et al.
        Cardiac rehabilitation and exercise therapy in the elderly: should we invest in the aged?.
        J Geriatr Cardiol. 2012; 9: 68-75
        • Suaya J.A.
        • Stason W.B.
        • Ades P.A.
        • et al.
        Cardiac rehabilitation and survival in older coronary patients.
        J Am Coll Cardiol. 2009; 54: 25-33
        • Hammill B.G.
        • Curtis L.H.
        • Schulman K.A.
        • et al.
        Relationship between cardiac rehabilitation and long-term risks ofdeath and myocardial infarction among elderly Medicare beneficiaries.
        Circulation. 2010; 121: 63-70
        • Medina R.A.
        • Aranda E.
        • Verdugo C.
        • et al.
        The action of ovarian hormones in cardiovascular disease.
        Biol Res. 2003; 36: 325-341
        • Lamon-Fava S.
        Complete and selective estrogenic effects on lipids and cardiovascular disease.
        Curr Atheroscler Rep. 2000; 2: 72-75
        • Shwaery G.T.
        • Vita J.A.
        • Keaney Jr., J.F.
        Antioxidant protection of LDL by physiologic concentrations of estrogens is specific for 17-beta-estradiol.
        Atherosclerosis. 1998; 138: 255-262
        • Rich-Edwards J.W.
        • Manson J.E.
        • Hennekens C.H.
        • et al.
        The primary prevention of coronary heart disease in women.
        N Engl J Med. 1995; 332: 1758-1766
        • Savage P.D.
        • Brochu M.
        • Ades P.A.
        Gender alters the high-density lipoprotein cholesterol response to cardiac rehabilitation.
        J Cardiopulm Rehabil. 2004; 24: 248-254
        • Lavie C.J.
        • Milani R.V.
        Benefits of cardiac rehabilitation and exercise training in elderly women.
        Am J Cardiol. 1997; 79: 664-666
        • Lavie C.J.
        • Milani R.V.
        High-dose atorvastatin in acute coronary and cerebrovascular syndromes.
        JACC Cardiovasc Interv. 2010; 3: 340-342
        • Lavie C.J.
        • Milani R.V.
        • O’Keefe J.H.
        Statinwars: Emphasis on potency vs event reduction and safety?.
        Mayo Clin Proc. 2007; 82: 539-542
        • Warner Jr., J.G.
        • Brubaker P.H.
        • Zhu Y.
        • et al.
        Long-term (5-year) changes in HDL cholesterol in cardiac rehabilitation patients. Do sex differences exist?.
        Circulation. 1995; 92: 773-777
        • Artham S.M.
        • Lavie C.J.
        • Milani R.V.
        Value of weight reduction in patients with cardiovascular disease.
        Curr Treat Options Cardiovasc Med. 2010; 12: 21-35
        • Bader D.S.
        • Maguire T.E.
        • Spahn C.M.
        • et al.
        Clinical profile and outcomes of obese patients in cardiac rehabilitation stratified according to National Heart, Lung, and Blood Institute criteria.
        J Cardiopulm Rehabil. 2001; 21: 210-217
        • Lavie C.J.
        • Milani R.V.
        Effects of cardiac rehabilitation, exercise training, and weight reduction on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in obese coronary patients.
        Am J Cardiol. 1997; 79: 397-401
        • Lavie C.J.
        • Milani R.V.
        • Artham S.M.
        • et al.
        The obesity paradox, weight loss, and coronary disease.
        Am J Med. 2009; 122: 1106-1114
        • Ades P.A.
        • Savage P.D.
        • Harvey-Berino J.
        The treatment of obesity in cardiac rehabilitation.
        J Cardiopulm Rehabil Prev. 2010; 30: 289-298
        • Lavie C.J.
        • Morshedi-Meibodi A.
        • Milani R.V.
        Impact of cardiac rehabilitation on coronary risk factors, inflammation, and the metabolic syndrome in obese coronary patients.
        J Cardiometab Syndr. 2008; 3: 136-140
        • Sierra-Johnson J.
        • Romero-Corral A.
        • Somers V.K.
        • et al.
        Prognostic importance of weight loss in patients with coronary heart disease regardless of initial body mass index.
        Eur J Cardiovasc Prev Rehabil. 2008; 15: 336-340
        • Pearson T.A.
        • Mensah G.A.
        • Alexander R.W.
        • Centers for Disease Control and Prevention
        • Association American Heart
        • et al.
        Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Center for Disease Control and Prevention and the American Heart Association.
        Circulation. 2003; 107: 499-511
        • Zebrack J.S.
        • Anderson J.L.
        • Maycock C.A.
        • Intermountain Heart Collaborative (IHC) Study Group
        • et al.
        Usefulness of high-sensitivity C-reactive protein in predicting long-term risk of death or acute myocardial infarction in patients with unstable or stable angina pectoris or acute myocardial infarction.
        Am J Cardiol. 2002; 89: 145-149
        • Milani R.V.
        • Lavie C.J.
        • Mehra M.R.
        Reduction in C-reactive protein through cardiac rehabilitation and exercise training.
        J Am Coll Cardiol. 2004; 43: 1056-1061
        • Kim Y.J.
        • Shin Y.O.
        • Bae J.S.
        • et al.
        Beneficial effects of cardiac rehabilitation and exercise after percutaneous coronary intervention on hsCRP and inflammatory cytokines in CAD patients.
        Pflugers Arch. 2008; 455: 1081-1088
        • Caulin-Glaser T.
        • Falko J.
        • Hindman L.
        • et al.
        Cardiac rehabilitation is associated with an improvement in C-reactive protein levels in both men and women with cardiovascular disease.
        J Cardiopulm Rehabil. 2005; 25: 332-336
        • Shepherd C.W.
        • While A.E.
        Cardiac rehabilitation and quality of life: a systematic review.
        Int J Nurs Stud. 2012; 49: 755-771
        • Johnston M.
        • MacDonald K.
        • Manns P.
        • et al.
        Impact of cardiac rehabilitation on the ability of elderly cardiac patients to perform common household tasks.
        J Cardiopulm Rehabil Prev. 2011; 31: 100-104
        • Yusuf S.
        • Hawken S.
        • Ounpuu S.
        • et al.
        Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 937-952
        • Menezes A.R.
        • Lavie C.J.
        • Milani R.V.
        • et al.
        Psychological risk factors and cardiovascular disease: is it all in your head?.
        Postgrad Med. 2011; 123: 165-176
        • Lavie C.J.
        • Milani R.V.
        Adverse psychological and coronary risk profiles in young patients with coronary artery disease and benefits of formal cardiac rehabilitation.
        Arch Intern Med. 2006; 166: 1878-1883
        • McGrady A.
        • McGinnis R.
        • Badenhop D.
        • et al.
        Effects of depression and anxiety on adherence to cardiac rehabilitation.
        J Cardiopulm Rehabil Prev. 2009; 29: 358-364
        • Hazelton G.
        • Williams J.W.
        • Wakefield J.
        • et al.
        Psychosocial benefits of cardiac rehabilitation among women compared with men.
        J Cardiopulm Rehabil Prev. 2014; 34: 21-28
        • Milani R.V.
        • Lavie C.J.
        Impact of cardiac rehabilitation on depression and its associated mortality.
        Am J Med. 2007; 120: 799-806
        • Milani R.V.
        • Lavie C.J.
        • Mehra M.R.
        • et al.
        Impact of exercise training and depression on survival in heart failure due to coronary heart disease.
        Am J Cardiol. 2011; 107: 64-68
        • Yu C.M.
        • Lau C.P.
        • Chau J.
        • et al.
        A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention.
        Arch Phys Med Rehabil. 2004; 85: 1915-1922
        • Lavie C.J.
        • Milani R.V.
        Prevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training.
        Mayo Clin Proc. 2005; 80: 335-342
        • Kochanek K.D.
        • Xu J.
        • Murphy S.L.
        • et al.
        Deaths: final data for 2009.
        Natl Vital Stat Rep. 2011; 60: 1-116
        • Christian A.
        • Mills T.
        • Simpson S.
        • et al.
        Quality of cardiovascular disease preventive care and physician/practice characteristics.
        J Gen Intern Med. 2006; 21: 231-237
        • Mosca L.
        • Linfante A.H.
        • Benjamin E.J.
        • et al.
        National study of physician awareness and adherence to cardiovascular disease prevention guidelines.
        Circulation. 2005; 111: 499-510
        • Halm M.
        • Penque S.
        • Doll N.
        • et al.
        Women and cardiac rehabilitation: referral and compliance patterns.
        J Cardiovasc Nurs. 1999; 13: 83-92
        • Ades P.A.
        • Waldmann M.L.
        • Polk D.M.
        • et al.
        Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years.
        Am J Cardiol. 1992; 69: 1422-1425
        • Allen J.K.
        • Scott L.B.
        • Stewart K.J.
        • et al.
        Disparities in women’s referral to and enrollment in outpatient cardiac rehabilitation.
        J Gen Intern Med. 2004; 19: 747-753
        • Ghisi G.L.
        • Polyzotis P.
        • Oh P.
        • et al.
        Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review.
        Clin Cardiol. 2013; 36: 323-335
        • Covello V.T.
        • Peters R.G.
        Women’s perceptions of the risks of age-related diseases, including breast cancer: reports from a 3-year research study.
        Health Commun. 2002; 14: 377-395
        • Pilote L.
        • Hlatky M.A.
        Attitudes ofwomen toward hormone therapy and prevention of heart disease.
        Am Heart J. 1995; 129: 1237-1238
        • Mosca L.
        • Mochari-Greenberger H.
        • Dolor R.J.
        • et al.
        Twelve-year follow-up of American women’s awareness of cardiovascular disease risk and barriers to heart health.
        Circ Cardiovasc Qual Outcomes. 2010; 3: 120-127
        • Sanderson B.K.
        • Shewchuk R.M.
        • Bittner V.
        Cardiac rehabilitation and women: what keeps them away?.
        J Cardiopulm Rehabil Prev. 2010; 30: 12-21
        • Lieberman L.
        • Meana M.
        • Stewart D.
        Cardiac rehabilitation: gender differences in factors influencing participation.
        J Womens Health. 1998; 7: 717-723
        • King K.M.
        • Humen D.P.
        • Smith H.L.
        • et al.
        Psychosocial components of cardiac recovery and rehabilitation attendance.
        Heart. 2001; 85: 290-294
        • Norrman S.
        • Stegmayr B.
        • Eriksson M.
        • et al.
        Depressive mood after a cardiac event: gender inequality and participation in rehabilitation programme.
        Eur J Cardiovasc Nurs. 2004; 3: 295-302
        • Turner S.C.
        • Bethell H.J.
        • Evans J.A.
        • et al.
        Patient characteristics and outcomes of cardiac rehabilitation.
        J Cardiopulm Rehabil. 2002; 22: 253-260
        • Marcuccio E.
        • Loving N.
        • Bennet S.
        • Hayes S.
        A survey of attitudes and experiences of women with heart disease.
        Womens Health Issues. 2003; 13: 23-31
        • Parashar S.
        • Spertus J.A.
        • Tang F.
        • et al.
        Predictors of early and late enrollment in cardiac rehabilitation, among those referred, after acute myocardial infarction.
        Circulation. 2012; 126: 1587-1595
        • Barber K.
        • Stommel M.
        • Kroll J.
        • et al.
        Cardiac rehabilitation for community-based patients with myocardial infarction: factors predicting discharge recommendation and participation.
        J Clin Epidemiol. 2001; 54: 1025-1030
        • Jones C.A.
        • Valle M.
        • Manring S.
        Using survival analysis to explore female cardiac rehabilitation programme adherence.
        Appl Nurs Res. 2001; 14: 179-186
        • Conn V.S.
        • Taylor S.G.
        • Abele P.B.
        Myocardial infarction survivors: age and gender differences in physical health, psychosocial state and regimen adherence.
        J Adv Nurs. 1991; 16: 1026-1034
        • Gregory P.C.
        • LaVeist T.A.
        • Simpson C.
        Racial disparities in access to cardiac rehabilitation.
        Am J Phys Med Rehabil. 2006; 85: 705-710
        • Aragam K.G.
        • Moscucci M.
        • Smith D.E.
        • et al.
        Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention.
        Am Heart J. 2011; 161: 544-551
        • Thomas R.J.
        • Miller N.H.
        • Lamendola C.
        • et al.
        National Survey on Gender Differences in Cardiac Rehabilitation Programs. Patient characteristics and enrollment patterns.
        J Cardiopulm Rehabil. 1996; 16: 402-412
        • Prince D.Z.
        • Sobolev M.
        • Gao J.
        • et al.
        Racial disparities in cardiac rehabilitation initiation and the effect on survival.
        PM R. 2014; 6: 486-492
        • Mazzini M.J.
        • Stevens G.R.
        • Whalen D.
        • et al.
        Effect of an American Heart Association Get With the Guidelines program-based clinical pathway on referral and enrollment into cardiac rehabilitation after acute myocardial infarction.
        Am J Cardiol. 2008; 101: 1084-1087
        • Cortés O.
        • Arthur H.M.
        Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review.
        Am Heart J. 2006; 151: 249-256
        • Ferguson J.A.
        • Weinberger M.
        • Westmoreland G.R.
        • et al.
        Racial disparity in cardiac decision making: results from patient focus groups.
        Arch Intern Med. 1998; 158: 1450-1453
        • Maly R.C.
        • Umezawa Y.
        • Ratliff C.T.
        • et al.
        Racial/ethnic group differences in treatment decision-making and treatment received among older breast carcinoma patients.
        Cancer. 2006; 106: 957-965
        • Wilkinson-Lee A.
        • Rohrbaugh M.J.
        • Schoenfeld J.
        • et al.
        Mexican- and Anglo-Americans in Cardio Rehabilitation: Do Cultural Differences Make a Difference?.
        Vancouver, BC, National Council on Family Relations2003
        • Mochari H.
        • Lee J.R.
        • Kligfield P.
        • et al.
        Ethnic differences in barriers and referral to cardiac rehabilitation among women hospitalized with coronary heart disease.
        Prev Cardiol. 2006; 9: 8-13
        • Gravely-Witte S.
        • Leung Y.W.
        • Nariani R.
        • et al.
        Effects of cardiac rehabilitation referral strategies on referral and enrollment rates.
        Nat Rev Cardiol. 2010; 7: 87-96
        • Grace S.L.
        • Scholey P.
        • Suskin N.
        • et al.
        A prospective comparison of cardiac rehabilitation enrollment following automatic vs usual referral.
        J Rehabil Med. 2007; 39: 239-245
        • Grace S.L.
        • Russell K.L.
        • Reid R.D.
        • et al.
        Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study.
        Arch Intern Med. 2011; 171: 235-241
        • Grewal K.
        • Leung Y.W.
        • Safai P.
        • et al.
        Access to cardiac rehabilitation among South-Asian patients by referral method: a qualitative study.
        Rehabil Nurs. 2010; 35: 106-112
        • Cossette S.
        • Frasure-Smith N.
        • Dupuis J.
        • et al.
        Randomized controlled trial of tailored nursing interventions to improve cardiac rehabilitation enrollment.
        Nurs Res. 2012; 61: 111-120
        • Balady G.J.
        • Ades P.A.
        • Bittner V.A.
        • et al.
        Referral, enrollment, and delivery ofcardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association.
        Circulation. 2011; 124: 2951-2960
        • Zutz A.
        • Ignaszewski A.
        • Bates J.
        • et al.
        Utilization of the internet to deliver cardiac rehabilitation at a distance: a pilot study.
        Telemed J E Health. 2007; 13: 323-330
        • Clark R.A.
        • Conway A.
        • Poulsen V.
        • et al.
        Alternative models of cardiac rehabilitation: a systematic review.
        Eur J Prev Cardiol. 2013; ([Epub ahead of print; August 13, 2013])
        • Poortaghi S.
        • Baghernia A.
        • Golzari S.E.
        • et al.
        The effect of home-based cardiac rehabilitation program on self efficacy of patients referred to cardiac rehabilitation center.
        BMC Res Notes. 2013; 6: 287
        • Scalvini S.
        • Zanelli E.
        • Comini L.
        • et al.
        Home-based versus in-hospital cardiac rehabilitation after cardiac surgery: a nonrandomized controlled study.
        Phys Ther. 2013; 93: 1073-1083
        • Budnick K.
        • Campbell J.
        • Esau L.
        • et al.
        Cardiac rehabilitation for women: a systematic review.
        Can J Cardiovasc Nurs. 2009; 19: 13-25
        • Rolfe D.E.
        • Sutton E.J.
        • Landry M.
        • et al.
        Women’s experiences accessing a women-centered cardiac rehabilitation program: a qualitative study.
        J Cardiovasc Nurs. 2010; 25: 332-341
        • Beckie T.M.
        • Mendonca M.A.
        • Fletcher G.F.
        • et al.
        Examining the challenges of recruiting women into a cardiac rehabilitation clinical trial.
        J Cardiopulm Rehabil Prev. 2009; 29: 13-21