www.npjournal.org The Journal for Nurse Practitioners - JNP 399 H ealth care costs for cardiovascular disease (CVD) accounted for over $503 billion in the United States in 2010. 1 CVD includes coronary heart disease (CHD), stroke, hypertension, and heart failure. These diseases resulted in over 79 million health care visits in 2007. Approximately 81 million US adults have some type of CVD, and 34% of deaths in 2006 were caused by this disorder. Since 1900, CVD has caused more US deaths annually than any other source, with the exception of the influenza pandemic of 1918. 1 Cardiac rehabilitation (CR) is an evidence-based, sec- ondary-prevention treatment that assists and guides patients in developing healthier lifestyles after a cardiac event and may prevent future coronary episodes. 2-4 CR is constantly evolving to reflect updates in cardiac treat- ment that offer optimal patient outcomes. 3 CR programs typically consist of 4 phases. 2,5 The first phase is initiated when the patient is hospitalized after an acute cardiac episode. During this phase, the patient is initially screened and counseled for unhealthy lifestyle behaviors, such as smoking and poor diet and exercise behaviors. The patient is also assessed for readiness to participate in exer- cise (eg, walking). Emotional support for the patient is important at this time and is also implemented. 5 Phase 2, which occurs after the patient has been dis- charged from acute care, involves evaluating and treating his or her emotional needs regarding the illness. Phase 3 engages the patient in an individually prescribed exercise regimen. 2 The final phase (4) of CR emphasizes maintain- ing healthy behaviors, such as proper nutrition and weight control, for long-term maintenance of cardiac health. 2,5 The ultimate goal of CR is to produce optimal func- tioning in individuals who have suffered a cardiac event. 5 Mortality rate has been reduced by 25% as a result of CR, 6 and participants have been reported to enjoy a 35% greater survival rate than non-participants after 5 years. 7 Hence, the World Health Organization (WHO) recom- mends CR as a cost-effective intervention. 2 ABSTRACT Too many patients with cardiovascular disease do not elect recommended cardiac rehabilitation (CR). This integrative literature review includes 16 peer-reviewed arti- cles and describes factors associated with the use of CR. The Health Promotion Model guided synthesis of findings. Barriers and facilitators to participating in CR, characteristics of typical CR clients, and clinical implications of findings for the advanced practice nurse (APN) are presented. The most common factors related to CR use/nonuse were knowledge, income, depression, referral and access, and age. Recognizing how these factors influence CR and health behavior decisions can help patients and health care providers manage cardiovascular disease. Keywords: barriers, cardiac rehabilitation, facilitators, noncompliance © 2011 American College of Nurse Practitioners Facilitators and Barriers in Cardiac Rehabilitation Participation: An Integrative Review Melanie Rose, MSN, Shirley M. Timmons, PhD, Roxanne Amerson, PhD, Elaine Reimels, PhD, and Rosanne H. Pruitt, FNP-BC