Abstract
Cardiac rehabilitation (CR) is a cornerstone of secondary prevention in coronary heart disease, supported by robust evidence and classified as a Class I recommendation in international guidelines. Despite its proven benefits in reducing morbidity, mortality, and improving quality of life, CR remains strikingly underutilized worldwide, revealing a paradox of high-level evidence with low-level implementation. The INTERASPIRE study highlights this global gap, showing that many patients are neither referred nor adhere to CR programs, and that profound inequities persist across regions and socioeconomic groups. These findings underscore systemic failures in translating guideline recommendations into practice, driven not only by structural limitations but also by physician referral patterns, patient awareness, and health system priorities. Addressing this gap requires investment in infrastructure, equitable referral strategies, standardization of program content, and innovative delivery models such as telehealth. Ensuring universal access to CR is both a clinical imperative and a matter of health equity, with the potential to transform outcomes for patients with cardiovascular disease worldwide.