Preamble

Review and Monograph
Exercise-Based Cardiac Rehabilitation in Acute Myocardial Infarction Management: Global Perspectives, Multimodal Interventions, and Personalized Strategies

Kaiyuan Cen¹,², Fatimah Ahmedy²,³*, Hong Chen⁴, Mingchen Shao⁵, Mexmollen Marcus², Mohd Fadzli Shukor²

¹Cardiovascular Department, Guidong People's Hospital of Guangxi Zhuang Autonomous Region, Wuzhou 543000, China
²Faculty of Medicine and Health Sciences, University Malaysia Sabah, UMS, Kota Kinabalu, Sabah 88400, Malaysia
³Sabah Rehabilitation Research and Service Group, Universiti Malaysia Sabah, UMS, Kota Kinabalu, Sabah 88400, Malaysia
⁴Institute of Medicine, University of Tsukuba, Tsukuba 3050005, Japan
⁵Department of Cardiovascular Surgery, I.M. Sechenov First Moscow State Medical University, Moscow 119991, Russia

*Corresponding author: FATIMAH AHMEDY; E-mail: fatimahmedy@ums.edu.my

[Abstract] Acute myocardial infarction (AMI) remains one of the leading causes of mortality and disability from cardiovascular disease worldwide, making the optimization of long-term post-procedural management strategies a critical focus in the medical community. As a core intervention recommended by evidence-based medicine, exercise-based cardiac rehabilitation (EBCR) demonstrates significant efficacy in improving cardiopulmonary function, alleviating psychological stress, and enhancing quality of life through the integration of diversified exercise modalities and personalized management strategies. With the deep integration of precision medicine, smart technologies, and psychosocial interventions, EBCR implementation in resource-limited regions faces new development opportunities. However, global dissemination of EBCR continues to encounter multiple barriers, particularly in areas with scarce medical resources where service accessibility, economic burden, and patient adherence significantly constrain its application scope. This study comprehensively reviews the global implementation landscape of EBCR, regional disparities, and multidimensional interventions and personalized strategies, while exploring development pathways including intelligent technology applications, policy support system construction, and interdisciplinary collaborative innovation, aiming to provide more targeted theoretical support and practical guidance for AMI rehabilitation management.

[Keywords] Acute myocardial infarction; Exercise-based cardiac rehabilitation; Multimodal intervention; Personalized management; Precision medicine; Smart technology; Psychosocial intervention; Adherence; Global implementation

[Chinese Library Classification] R 542.22 [Document Code] A DOI: 10.12114/j.issn.1007-9572.2025.0028

1. Global Status and Disparities in Exercise-Based Cardiac Rehabilitation

Acute myocardial infarction (AMI) represents a major global cardiovascular disease with high mortality and disability rates. Although treatment strategies such as percutaneous coronary intervention (PCI) have significantly improved short-term survival, long-term management of these patients remains challenging. Post-PCI patients frequently experience ventricular remodeling and recurrent cardiovascular events, substantially affecting long-term prognosis and reducing quality of life [1-2]. Guidelines recommend cardiac rehabilitation (CR) as an essential intervention, with exercise-based cardiac rehabilitation (EBCR) serving as the core component that effectively reduces cardiovascular event incidence, improves cardiopulmonary function, and extends survival [3-4]. Psychosocial disorders such as anxiety and depression commonly afflict AMI patients, acting as "roadblocks" in the CR process and increasing the risk of adverse cardiovascular events [5]. Meta-analyses have demonstrated that EBCR reduces all-cause mortality and hospitalization rates while improving mental health and health-related quality of life (HRQoL) in AMI patients [6]. Advancing research in CR has driven the development of multimodal exercise protocols including aerobic exercise, resistance training, low-intensity training, moderate-intensity continuous training (MICT), and high-intensity interval training (HIIT), significantly expanding individualized adaptation options for patients [7-9]. Rehabilitation pathway design must precisely match patient age characteristics, psychological assessment data, and baseline fitness levels, as this individualized adaptation mechanism directly influences EBCR's long-term prognostic outcomes [10]. Technological innovations such as wearable biosensors and remote rehabilitation platforms are reshaping rehabilitation medicine models, with real-time physiological parameter tracking combined with dynamic protocol optimization mechanisms effectively improving treatment adherence and reducing CR risk event incidence [11-14]. Global EBCR implementation shows significant regional disparities: lower-middle-income countries (LMICs) face constraints from weak medical infrastructure and professional talent shortages, while high-income countries (HICs) grapple with dual challenges of healthcare cost pressures and insufficient patient subjective participation [9]. During CR implementation, effectively integrating the synergistic operational mechanisms between diversified intervention modes and customized strategies to meet the differential needs of patient populations has become a core scientific challenge requiring urgent breakthroughs [4,14-15]. Clinical practice urgently needs to address the systematic integration of multidimensional intervention methods, with dynamic optimization of individualized rehabilitation pathways gradually emerging as an important breakthrough in CR research transformation.

1.1 Differences in Global Participation Rates and Contributing Factors

EBCR maintains important clinical value in the comprehensive treatment system for coronary heart disease (CHD), significantly improving prognosis in AMI patients. Multiple studies [6,16] demonstrate that this intervention not only effectively reduces all-cause mortality and readmission risk but also shows clear advantages in cardiovascular risk factor management including blood pressure regulation, lipid control, and weight management, with its secondary prevention role achieving broad consensus. Consequently, EBCR's role in cardiovascular disease secondary prevention has gained widespread recognition. Nevertheless, despite its significant clinical benefits, global EBCR participation rates remain low. Data show [17-18] that pre-pandemic participation in Europe was less than 15%; in the United States, participation over the past 15 years has been only 5%, with the pandemic exacerbating healthcare resource constraints and further compressing rehabilitation service accessibility. Although HICs have relatively健全的康复体系, service utilization remains limited; in LMICs, constrained by medical resource gaps, weak infrastructure, and patient awareness factors, over 50% of rehabilitation needs remain unmet [19].

The stark disparities in rehabilitation participation rates stem from complex and intertwined causes, with imbalanced regional medical resource allocation and insufficient grassroots service accessibility constituting major bottlenecks. Rural populations show urgent rehabilitation needs, yet limited transportation conditions and infrastructure result in relatively low participation willingness and rates compared to urban residents. A study including 1,809 patients found that rehabilitation participation among rural populations was only 11.9%, with rehabilitation barrier scores significantly higher than urban residents (P<0.01), highlighting the substantial rehabilitation challenges faced by rural patients [20]. A multinational multicenter study across eight countries involving 1,213 patients indicated that geographic isolation severely constrains rehabilitation service accessibility, with patients in medically underserved areas struggling to access rehabilitation services in a timely manner [21]. Even in HICs with well-established healthcare systems, geographic factors impact rehabilitation participation rates. Canada has established approximately 170 CR programs, yet the northern region remains virtually blank, with geographic imbalance in medical resource distribution significantly increasing patient difficulty in accessing services [22]. Economic burden represents another barrier to participation. In some countries, citizens may need to spend more than half their annual income to complete a full CR program, whereas in HICs this expenditure is typically less than 10% of annual income. Approximately 2.41 billion people globally urgently need CR services; resource allocation imbalances, particularly in LMICs, funding shortages, and lack of medical reimbursement mechanisms greatly constrain EBCR accessibility [23-24]. Patients also face hidden costs such as transportation and accommodation, which further exacerbate economic burden and weaken rehabilitation willingness. Cognitive biases also hinder rehabilitation participation. Many patients harbor misconceptions about EBCR, mistakenly believing rehabilitation training will increase cardiac burden, thus avoiding it. Each rehabilitation session attended reduces mortality or readmission probability by 2%, with risk decreasing by 10% after completing five CR sessions [17,25-26]. Cultural concepts and social environments also influence CR普及情况, with some patients fearing rehabilitation training may cause disease recurrence and consequently resisting EBCR [18].

1.2 Innovative Models and Technical Approaches

In recent years, community-based cardiac rehabilitation (CBCR) has enhanced EBCR accessibility and patient adherence. A total of 65.3% of patients successfully participated in CBCR, with only 5.3% withdrawing during follow-up [27]. CBCR improves patient HRQoL, psychological status, and exercise endurance; anxiety and depression levels decreased, with 6-minute walk test distance improving by an average of 57.42 meters [22,24,27]. In resource-scarce regions, CBCR similarly reduces cardiovascular event recurrence risk by effectively decreasing transportation and economic burdens while increasing rehabilitation program participation rates [28]. The CBCR model promotes widespread health intervention application, proving particularly suitable for low-income populations. In sub-Saharan Africa, telemedicine reduced patient waiting times by 30% and medical costs by 20%, improving local residents' probability of accessing medical services [29]. Iterative innovation in telemedicine technology is breaking through traditional geographic limitations. In Uganda, 40% of rural patients obtained professional services through telemedicine, reducing long-distance medical needs by 50% [30]. Wearable technology significantly improves patient adherence. Medical institutions can monitor patient exercise volume, heart rate, and other data in real-time, enabling precise remote management that allows AMI patients' maximal oxygen uptake (VO₂max) to be significantly improved through remote rehabilitation, thereby supporting subsequent treatment [31].

1.3 Policy Support and Education Promotion

Medical insurance policy adjustments profoundly impact EBCR participation, with out-of-pocket expenses directly affecting rehabilitation adherence. If initial rehabilitation assessment costs exceed $25.40, participation rates drop sharply by 30.9%; for every additional $10 in out-of-pocket expenses, average rehabilitation participation frequency decreases by 0.41 sessions [25]. Alleviating economic burden is crucial for patient rehabilitation participation. Improving EBCR participation rates requires policy intervention, with optimizing medical insurance policies, promoting remote rehabilitation, and reducing patients' financial burdens all contributing to enhanced accessibility.

Multinational practices have validated the effectiveness of policy interventions in improving CR participation. The U.S. "Million Hearts" program increased EBCR participation from less than 20% to 70% through financial assistance and free rehabilitation services [23]. Such policy models demonstrate diverse practice forms in Commonwealth countries: the United Kingdom adopts joint action between healthcare systems and non-profit organizations, Australia establishes a bidirectional collaboration mechanism between the Heart Foundation and government, while Ontario, Canada addresses low-income group needs through public insurance plans. Important strategies for improving adherence also include health education. Systematic health education increases patient rehabilitation adherence rates by 30%, with online education platforms breaking geographic restrictions and driving participation growth of 25% in remote areas [32]. Educational lectures for new patients can effectively alleviate their anxiety and accelerate integration into the rehabilitation environment [33]. Cultural adaptation concepts demonstrate unique value in LMICs; Pakistan's "Getting Better Bite by Bite" project improved rehabilitation knowledge acceptance and significantly enhanced participation sustainability by integrating traditional religious elements with modern medical cognition through本土化心理干预方案设计 [34]. Uneven medical resource allocation limits EBCR program普及, urgently requiring breakthroughs in establishing standardized intervention pathways and optimizing regionalized implementation plans [6].

2. Multimodal Interventions in Exercise-Based Cardiac Rehabilitation

2.1 Aerobic Exercise: The Foundation of EBCR

Aerobic exercise improves cardiovascular health and reduces adverse cardiovascular event incidence, establishing it as the core EBCR intervention. Multiple clinical trials confirm [6,35-37] that CR reduces mortality risk by 63% and 38% in acute coronary syndrome and coronary artery bypass grafting patients respectively, while decreasing reinfarction risk by 47%, cardiovascular-related mortality by 36%, and all-cause mortality by 26%. Aerobic exercise significantly enhances myocardial functional adaptation, manifested by increased stroke volume, improved cardiac systolic and diastolic function, and reduced ventricular remodeling [36]. Mechanistic studies reveal that myocardial infarction patients show significantly improved heart rate variability after a 4-week EBCR protocol; following 6 months of continuous intervention, muscle sympathetic nerve activity decreases, arterial systolic pressure declines, and autonomic blood pressure regulation capacity enhances, promoting hemodynamic parameters toward physiological states [38-39]. Exercise-mediated anti-inflammatory effects constitute another key mechanism. Research shows that exercise-induced cytokine responses are specific, not causing significant elevation of classic pro-inflammatory factors such as tumor necrosis factor-α and interleukin (IL)-1β, but instead temporarily increasing IL-6 concentration to activate IL-10 secretion and IL-1 receptor antagonist release pathways, forming an anti-inflammatory protective barrier that alleviates pathological inflammatory damage to the cardiovascular system [40]. In practical application, guidelines recommend exercise intensity be controlled at 40%-80% of peak oxygen uptake (VO₂peak): frail or elderly patients should adopt low-intensity training at 40%-50% VO₂peak, while those with excellent physical fitness may apply MICT or HIIT to maintain VO₂peak at 60%-80% [41]. For patients constrained by insufficient facilities or poor adherence, wearable device applications become an effective solution for remote CR. Real-time monitoring of heart rate and exercise volume through wearable devices to optimize individualized training protocols can improve aerobic exercise adherence and training effectiveness [33,42].

2.2 Resistance Training and Aerobic Intensity Graded Training: Key Supplements to EBCR

Resistance training occupies a crucial position in EBCR protocols, enhancing exercise tolerance and optimizing skeletal health indices by strengthening muscle power in AMI patients. Research evidence shows EBCR interventions produce multifaceted functional improvements, with strategies combining resistance training and multi-intensity aerobic training demonstrating more significant clinical effects [41-43]. Comparing rehabilitation responses between PCI-post-HF AMI patients and other populations reveals that AMI patients show faster improvements in muscle strength recovery and training adaptation, suggesting pathological type differences may affect intervention responsiveness. Additionally, this study found moderate correlation between postoperative patient muscle torque growth and peak oxygen uptake (r=0.51, P<0.01), suggesting muscle strength enhancement may participate in cardiopulmonary function recovery mechanisms. Systematic review results further support these findings. Yamamoto et al.'s meta-analysis [44] showed resistance training produced moderate-to-large effect size improvements across multiple dimensions: middle-aged patients demonstrated lower and upper limb strength improvements of 0.65 (95%CI=0.35-0.95) and 0.73 (95%CI=0.48-0.99) standardized mean differences (SMD) respectively, with peak oxygen uptake increasing by 0.92 (95%CI=0.12-1.72) mL·kg⁻¹·min⁻¹; elderly patients showed significant improvements in upper limb strength (1.18 SMD, 95%CI=0.56-1.80) and daily activity capacity (0.61 SMD, 95%CI=0.21-1.01). These results suggest EBCR combined with resistance training can synergistically promote muscle reconstruction and cardiopulmonary function recovery in coronary artery disease patients across different age groups and pathological types. Early research controversies regarding resistance training's potential cardiovascular risks and effects on lipoprotein (P=0.04) and blood glucose levels (P=0.02) have been addressed by recent evidence indicating that medically supervised low-to-moderate intensity training (40%-60% one-repetition maximum) produces blood pressure changes essentially equivalent to same-intensity aerobic exercise. Studies confirm that hemodynamically stable CHD patients can not only improve cardiovascular adaptability but also enhance metabolic indices and mental health status through low-to-moderate intensity resistance training [45]. Low-intensity training and MICT protocols introduced during AMI early rehabilitation demonstrate good safety, with heart failure patients receiving 2-week interventions showing significantly reduced cardiac mortality and readmission rates compared to conventional rehabilitation groups [46]. In-depth analysis of this training mode's positive effects on heart failure patients with different ejection fractions reveals that compared to control groups, heart failure with reduced ejection fraction (HFrEF) patients showed decreased cardiac mortality (31.3% vs 0.0%, P=0.002), while heart failure with mid-range ejection fraction (HFmrEF) patients showed reduced readmission rates (22.1% vs 3.6%, P=0.008). Furthermore, in AMI patients undergoing cardiopulmonary exercise testing, when end-tidal carbon dioxide partial pressure (PETCO₂) at anaerobic threshold ≤ 3.5 mmHg (1 mmHg=0.133 kPa), readmission risk significantly increases (OR=0.635, 95%CI=0.463-0.871, P=0.005), suggesting this indicator's important application value in early EBCR efficacy assessment and prognosis prediction while validating resistance training's clinical safety and effectiveness as a rehabilitation intervention.

Aerobic exercise intensity grading continues to generate research attention in EBCR. HIIT can achieve synergistic improvement in ventricular structure and function by inhibiting progressive ventricular wall thinning and improving ventricular diastolic function [47]. During 16-week training periods, its effects on ventricular remodeling show volume-dependency with clear dose-dependent characteristics. Additionally, short-duration HIIT protocols (single session ≤ 20 minutes, with high-intensity phases ≤ 10 minutes) demonstrate unique therapeutic value in clinical practice. Under safety-assured conditions, short-duration HIIT effectively delays pathological ventricular remodeling progression by optimizing training duration, providing important evidence-based support for individualized CR prescription formulation. Studies on elderly populations [48] show that compared with non-exercise control groups, resistance training, HIIT, and combined training significantly improved BMI (P≤0.0001), body fat percentage (P=0.03), aerobic endurance (P=0.03), low-density lipoprotein (P=0.04), and blood glucose levels (P=0.02). However, how to optimally combine resistance training with HIIT requires further investigation. A major future EBCR development focus concerns training modes with superior patient adaptability, necessitating integration of resistance training into aerobic exercise to find balance between HIIT's efficiency and MICT's high adherence.

2.3 Aerobic and Mind-Body Balance: Synergistic Effects of EBCR

Swimming, as a low-impact, whole-body exercise, demonstrates significant potential benefits in EBCR, particularly in improving exercise capacity, enhancing muscle strength, and improving HRQoL. Related research indicates swimming training can effectively improve cardiovascular function and promote cardiac functional recovery, providing AMI patients with stable heart failure and CHD an exercise form combining entertainment and functionality [49-50]. Swimming training's multidimensional health benefits give it auxiliary intervention potential within EBCR systems, though implementation requires strict adherence to personalized exercise prescriptions under medical supervision. Meanwhile, yoga's mind-body integration characteristics show broad application space in CR. Related studies demonstrate yoga intervention can optimize physiological indices, regulate emotions, alleviate psychological stress, reduce 10-year cardiovascular disease risk, and improve Framingham risk scores, providing comprehensive health management strategies for EBCR [51]. Yoga's regulatory function on the autonomic nervous system has been confirmed. In AMI patients receiving standardized medical treatment, regular yoga training can effectively reestablish dynamic balance between sympathetic and parasympathetic nerves, not only enhancing parasympathetic nerve activity and heart rate variability parameters but also significantly reducing adverse cardiovascular event incidence through enhanced stress adaptation capacity while synchronously improving HRQoL and psychosocial function [52]. Swimming emphasizes strengthening cardiopulmonary endurance while yoga excels at promoting neural regulation and mental health—both possessing distinctive features and complementary advantages in EBCR. The potential synergistic effects of swimming and yoga may enable more comprehensive and personalized treatment strategies for CR patients. Integrating cardiopulmonary endurance training with mind-body regulation may more effectively promote dual improvement in cardiovascular health and quality of life, jointly building CR bridges.

2.4 Combined Training and Multidimensional Intervention: Comprehensive Strategy for EBCR

Combined training, integrating aerobic and resistance exercise, is recognized as an effective strategy for maximizing cardiovascular health improvements. Related research confirms that compared with single aerobic exercise modes, combined training can significantly improve cardiorespiratory fitness, increase muscle strength, and optimize body composition [53]. Meta-analysis further confirms it can reduce body fat percentage (SMD=-2.30, 95%CI=-3.59 to -1.02), decrease trunk fat (SMD=-0.56, 95%CI=-0.96 to -0.15), and promote fat-free mass increase (SMD=0.90, 95%CI=0.39-1.36) [54]. Resistance training shows clear advantages in improving upper and lower limb muscle strength, with SMDs of 1.07 (95%CI=0.51-1.63) and 0.77 (95%CI=0.21-1.33) respectively [55]. Short-term intervention studies reveal that 8-week combined training can reduce diastolic blood pressure, increase lean body mass, and significantly improve cardiopulmonary health, with superior effects in hypertensive and high cardiovascular risk populations [55]; long-term intervention studies show that 8 months of continuous training can stabilize blood pressure and improve exercise capacity, while oxidative stress level regulation requires longer intervention periods for consolidation [56]. Elderly patients also benefit from combined training, showing muscle strength enhancement (SMD=0.60, 95%CI=0.43-0.77), aerobic capacity improvement (SMD=2.71, 95%CI=1.96-3.45), and HRQoL improvement (SMD=-5.71, 95%CI=-9.85 to -1.56) [57]. PRIME-HF study data show that the 8-week PRIME training protocol significantly improved VO₂peak by 2.4 mL·kg⁻¹·min⁻¹ (P=0.004), demonstrating superior efficacy compared to traditional interventions [57]. Recent research progress indicates that multidimensional intervention strategies based on resistance training systems combined with aerobic exercise intensity grading standards for selecting low-intensity, MICT, or HIIT are gradually developing into emerging rehabilitation models, opening comprehensive treatment options for clinical practice [7-9].

Exercise intervention is not the sole core of combined training; systematic integration of nutritional management and psychological support has become a key pathway for optimizing multidimensional rehabilitation effects. Depression incidence in AMI patients is significantly higher than in the general population (15%-20% vs 4.8%), and insufficient intervention worsens adverse cardiovascular outcomes. Cognitive behavioral therapy (CBT) has been proven to alleviate 25%-30% of depressive symptoms and improve rehabilitation adherence [58]; at the dietary strategy level, the Mediterranean diet can reduce major cardiovascular event risk by 31% (RR=0.69, 95%CI=0.53-0.91) and 28% (RR=0.72, 95%CI=0.54-0.95) in high cardiovascular risk populations [59]. The synergistic effect of psychological support and nutritional intervention enables EBCR protocols to achieve multidimensional benefits in HRQoL improvement and long-term prognosis optimization. Expanding multidimensional intervention models based on the EBCR framework has become an inevitable trend for optimizing coordinated development of cardiopulmonary fitness and muscle function, with underlying mechanisms involving multidimensional integration effects of the bio-psycho-social medical model.

3.1 Customized Exercise Intervention: Precision Exercise Prescription Design

In EBCR, meticulous design of personalized pathways constitutes a key success factor. Elderly AMI patients receiving individualized exercise training showed significant improvements in heart rate recovery, VO₂peak, and ventilatory efficiency (P<0.001), while those receiving only conventional exercise advice showed no similar benefits [60]. The American College of Sports Medicine strongly recommends progressive personalized exercise strategies for elderly patients to enhance muscle strength and endurance while minimizing injury risk and improving adherence [61]. After 8 weeks of comprehensive CR, elderly patients showed significantly decreased LDL-C levels (P<0.001), improved exercise capacity (P<0.001), and enhanced quality of life scores, with both physical and emotional dimension scores significantly decreasing [62]. Even when elderly patients have lower CR participation rates, individualized training can produce health benefits comparable to younger patients, significantly optimizing overall health status [63]. For physically fit younger populations, HIIT demonstrates unique advantages in VO₂max gains. Research results show that 8-week HIIT intervention can increase VO₂max by an average of (6.5%±2.4%) (P<0.001), exceeding the increase from sprint interval training (SIT) 8×20s protocol (3.3%±2.4%) (P<0.001) but not significantly different from SIT 10×30s group; in 3,000m endurance tests, the HIIT group achieved improvement of (5.9%±3.2%) (P<0.001), significantly higher than SIT 10×30s group's (2.2%±2.2%) (P<0.05), providing evidence for HIIT's clinical application in improving cardiopulmonary fitness [64].

Longitudinal studies reveal that after 16 weeks of aerobic interval training, subjects' VO₂peak improvement was accompanied by visceral adipose tissue reduction (P<0.01), with significant negative correlation between the two changes; improvements in metabolic syndrome core indicators (waist circumference, diastolic blood pressure, triglyceride levels) showed negative associations with both VO₂peak increase and visceral fat reduction (P<0.05) [64-65], confirming synergistic effects of cardiopulmonary function optimization on metabolic regulation. Compared with continuous moderate exercise, intermittent training HIIT and MICT demonstrate superior biological effects in metabolic sensitivity, BMI regulation, and insulin resistance mitigation, providing evidence-based support for developing EBCR protocols for younger individuals.

For patients with metabolic syndrome and heart failure, the roles of HIIT and MICT in EBCR have also received extensive attention. A meta-analysis showed HIIT was superior to MICT in improving VO₂peak (MD=1.78, 95%CI=0.80-2.76), left ventricular ejection fraction (LVEF, MD=3.13, 95%CI=1.25-5.02), 6-minute walk distance (MD=28.13, 95%CI=14.56-41.70), and HRQoL (MD=-4.45, 95%CI=-6.25 to -2.64) [66]. Taylor et al.'s study [67] showed that 4-week HIIT training significantly improved flow-mediated dilation (1.5% vs 0.1%, P=0.004), revealing its potential for short-term vascular function improvement. However, after 12 months of follow-up, no significant differences existed between HIIT and MICT in vascular function, arterial stiffness, or blood pressure improvement, indicating HIIT has short-term advantages, thus requiring consideration of timeliness characteristics in short-term rehabilitation protocol design while establishing dynamic assessment mechanisms for long-term management strategies. For rehabilitation challenges in AMI female patients, psychological factors have been confirmed as key variables affecting prognosis. Jug et al.'s study [68] indicated that female patients have significantly higher psychological support needs than males, with increased psychological intervention effectively improving CR participation rates. Turner et al.'s study [69] further confirmed that targeted psychological counseling and peer support can enhance patients' confidence in overcoming disease and improve long-term cardiovascular disease prognosis. The synergistic effect of EBCR protocols and psychological interventions essentially constructs a novel treatment paradigm with dual bio-psycho action targets.

3.2 Integration of Psychological and Behavioral Factors: Improving Rehabilitation Adherence and Effectiveness

Psychological and behavioral factors play crucial roles in AMI patient rehabilitation. The overall prevalence of kinesiophobia among cardiac disease patients reaches 61.0% (95%CI=49.4%-72.6%), with CHD patients showing 63.2% prevalence (95%CI=45.2%-81.3%), significantly affecting exercise adherence and highlighting the clinical importance of early psychological intervention in CR [70]. AMI patients commonly experience comorbid psychological issues such as depression and anxiety after the acute phase, which not only increase disease burden but may also become key barriers constraining rehabilitation progress [5]. CBT significantly improves patient self-efficacy by correcting erroneous beliefs and establishing positive coping mechanisms; motivational interviewing techniques enhance individual intrinsic motivation for behavior change through goal-oriented dialogue patterns [71-72]. From a behavioral medicine perspective, exercise avoidance behaviors often originate from risk cognition biases and rehabilitation knowledge deficiencies, requiring intervention protocols to address both physiological and psychological dimensions. Systematic health education strategies significantly improve patient acceptance of exercise therapy by analyzing rehabilitation mechanisms and clarifying cognitive misconceptions. Research confirms structured educational interventions reduce kinesiophobia scale scores and double the proportion of patients regularly participating in rehabilitation training [73-74]. Constructing an intervention system integrating psychological and behavioral dimensions has become an important research direction for breaking through traditional CR model bottlenecks.

3.3 Technology Integration and Innovation: Driving Precision in Personalized Rehabilitation

EBCR is maturing through technological innovation, enabling realization of personalized rehabilitation protocols. Medical teams can optimize rehabilitation protocols using detailed data such as heart rate, step count, and exercise intensity monitored in real-time through smartwatches and other wearable devices, making rehabilitation processes more precise and manageable. Studies show [75] that smart device-based remote rehabilitation protocols can improve AMI patients' VO₂peak by 1.56 mL·kg⁻¹·min⁻¹ after 3 months of intervention, with efficacy comparable to traditional offline rehabilitation. For patients with poorer baseline functional capacity, VO₂peak improvement is more significant at 2.46 mL·kg⁻¹·min⁻¹, accompanied by 60m increase in 6-minute walk distance (P=0.045), further validating the clinical value of remote personalized CR in high-risk subgroups. Technology empowerment gives rehabilitation processes data-driven characteristics, with enhanced patient autonomy and sense of security directly promoting treatment adherence. Remote medical systems break geographic barriers, enabling quality resources to cover remote and medically underserved areas and achieve universal rehabilitation services, with remote monitoring combined with real-time guidance constructing continuous management loops. A meta-analysis showed remote CR can significantly improve patient VO₂peak and HRQoL, with intervention completion rates reaching 80%, demonstrating excellent feasibility and adherence [76]. During the pandemic prevention and control period, low-contact rehabilitation protocols effectively avoided nosocomial infection risks, while continuous home-based interventions alleviated subjects' medical environment anxiety [77]. The era wave of artificial intelligence (AI) is surging forward, profoundly transforming the CR field. Cardiovascular event risk assessment, previously limited by traditional methods, now achieves precise risk prediction and personalized intervention through AI's deep mining of massive data and construction of advanced algorithm models. Exercise prescriptions optimized through machine learning (ML) technology can substantially improve patient treatment compliance and rehabilitation effectiveness [78]. Home-based rehabilitation models, long constrained by lack of professional guidance and immediate feedback, have seen new dawn for patient behavior management and treatment adherence through the organic integration of telemedicine and AI, ushering in a new development stage for EBCR long-term management [79].

3.4 Socioeconomic and Cultural Adaptation: Improving Rehabilitation Accessibility and Participation

Social resource allocation patterns and cultural cognition models jointly shape CR service accessibility characteristics. Economically underdeveloped regions commonly experience structural medical resource imbalances, urgently requiring establishment of differential intervention frameworks based on community ecology. Precise economic support deployment must advance synergistically with cultural adaptation mechanisms, integrating community medical resource networks to construct CR service delivery systems covering different social strata. Economically disadvantaged groups face dual dilemmas: CR participation directly affects health reconstruction processes, while medical expenditure pressures may exacerbate family economic vulnerability. Cultural concept-level cognitive biases manifest as some patients equating rehabilitation training with "markers of weakness," with this symbolic cognition causing significant regional differences in service utilization. Economic incentive measures increased CR completion rates from 11% to 42% in low socioeconomic status patients, rising further to 62% with combined interventions, significantly improving adherence [80]. Remote areas constrained by transportation conditions and medical resource insufficiency have long-stagnated CR implementation effects at 11.2%. Telemedicine significantly reduces CR non-completion risk (OR=0.26), while rehabilitated patients' readmission and mortality risks decrease by approximately 35% (HR=0.65) within 12 months, demonstrating technology's important potential in improving adherence and outcomes [81]. The synergistic application of economic assistance and technological means not only breaks through regional medical resource limitations but also alleviates economic pressure and expands service accessibility through dual pathways, effectively improving CR implementation effects. Cultural background differences directly constrain clinical adoption depth of CR protocols. Culturally adapted CR programs have proven to have good acceptability and safety, effectively improving cardiovascular risk factors, with success dependent on community-led design, cultural sensitivity training, and organic integration of traditional practices [82]. Culturally adapted CR interventions for minority ethnic communities help improve patient participation and program completion rates, with integration of religious and cultural elements in rehabilitation environments enhancing emotional identification and acceptance willingness toward treatment protocols among traditional community patients [83]. Residence distance >16 km from rehabilitation centers is the strongest predictor of non-participation in EBCR (OR=1.75), with smoking, chronic disease comorbidities, male gender, and retirement status also being significant influencing factors, suggesting that optimizing resource layout and social-cultural adaptation are key pathways for improving rehabilitation accessibility and participation rates [84]. Cultural inclusivity reconstruction of healthcare systems and socioeconomic support are becoming key pathways for optimizing CR outcomes.

4.1.1 Personalized Initiation Time Optimization Strategy: EBCR can significantly reduce all-cause mortality and reinfarction risk in AMI patients [6,26,85]. When extending follow-up periods, all-cause mortality shows no statistical difference (RR=0.91, 95%CI=0.75-1.10), but the intervention strategy demonstrates significant effects on cardiovascular-specific mortality (RR=0.58, 95%CI=0.43-0.78) and MI incidence (RR=0.67, 95%CI=0.50-0.90) [85]. Determining optimal initiation timing directly affects intervention effectiveness, prompting academic efforts to construct precise individualized implementation models. Initiating EBCR within 2 weeks post-AMI is safe and beneficial, not impairing LVEF and myocardial function while promoting cardiac functional recovery [86]. Feasibility of early exercise intervention is also corroborated by other studies; in a 6-week follow-up study, patients receiving exercise intervention showed significantly improved LVEF without observed exercise-related adverse events [87]. Left ventricular systolic and diastolic function can also be significantly improved through exercise training beginning within 1 week post-AMI. Another retrospective analysis found that compared with conventional rehabilitation, early home-based exercise intervention resulted in lower postoperative complication rates (3.45% vs 17.54%, P<0.05) and significantly improved LVEF and HRQoL scores [88]. Existing evidence reveals positive effects of early EBCR on cardiac structural remodeling and functional recovery [89]. Subsequent meta-analysis validated these conclusions, finding that EBCR intervention during the acute phase (within 1 week) showed advantages over the recovery phase (2-4 weeks) in improving LVEF, left ventricular end-systolic diameter, and increasing VO₂peak [89]. However, myocardial healing processes accompany rehabilitation benefit attenuation phenomena; implementing EBCR beyond 4 weeks not only reduces cardiac functional recovery magnitude but may also trigger cardiac adaptive disorders [86]. Clinical observations show early EBCR does not significantly increase cardiovascular adverse event risk [90]; age, comorbidities, and economic factors cause some groups to miss optimal intervention windows, while continuous lifelong EBCR training can effectively maintain left ventricular systolic function and delay post-AMI structural abnormalities [91]. Zhang et al.'s meta-analysis [92] found that AMI patient rehabilitation needs to break through single exercise training modes, integrating physiological status assessment, psychological adaptability analysis, and personalized goal setting to form multidimensional intervention systems, suggesting clinical need to establish dynamic EBCR implementation frameworks that precisely regulate intervention timing based on pathological staging and tolerance thresholds to achieve long-term prognosis optimization through adherence management under safety-assured conditions.

4.1.2 Exploration of Optimal Exercise Mode and Intensity Combinations: Optimization of exercise modes and intensities represents an important direction in EBCR research and practice. Different implementation mode interventions produce multidimensional impacts on patient health outcomes. EBCR protocols improve Minnesota Heart Failure Questionnaire scores by 7.11 points (95%CI=-10.49 to -3.73) and relatively reduce all-cause hospitalization risk by 30% (RR=0.70, 95%CI=0.60-0.83) [93], with clinical value reflected in dual dimensions of quality of life optimization and medical resource consumption reduction. Central rehabilitation, home-based scenarios, and digital platform implementation pathways show convergence in HRQoL improvement effects, providing empirical basis for personalized rehabilitation mode selection. Exercise prescription intensity control shows significant individual differences: HIIT strategies improve VO₂peak by up to 25% [66,76,93], but higher training loads in heart failure populations may cause psychological stress and adherence issues [94]; MICT protocols, with intensity controllability advantages, produce relatively lower exercise endurance improvements but higher long-term participation rates reaching 80% [65,93]. Complementary characteristics of the two strategies suggest training parameters should be dynamically adjusted based on patient cardiopulmonary function baseline levels. In EBCR mode selection processes, precise intervention strategies must be implemented considering comprehensive factors including patient physical status, psychological adaptation level, and rehabilitation progression. MICT has universal advantages, while HIIT specifically enhances rehabilitation effects in individuals with higher cardiopulmonary function reserves. Hybrid exercise models integrating HIIT's efficiency with MICT's adherence advantages are emerging as new directions in EBCR. Through dynamic exercise load regulation, these protocols can match rehabilitation needs across different tolerance threshold populations, enhancing rehabilitation confidence while ensuring training safety to achieve sustained execution of medium-to-long-term exercise prescriptions [95].

Remote monitoring and smart devices have greatly advanced refined implementation of EBCR in individualized rehabilitation. Studies show that combining remote CR monitoring with personalized feedback improved patient adherence from 29.2% to 80.8%, with interventions significantly improving metabolic indices including increased high-density lipoprotein levels and decreased BMI, while also reducing anxiety and depression levels, demonstrating comprehensive potential for remote CR in improving multidimensional health indicators [96].

4.1.3 Challenges and Strategies for Long-term Adherence and Behavior Change: EBCR effectiveness hinges on patient long-term adherence, yet patients face numerous challenges in practice. Even though short-term rehabilitation substantially improves HRQoL, only 30%-50% of patients maintain initial exercise levels after 12 months [97]. Reduced treatment adherence is constrained by multiple factors: weak patient cognition of rehabilitation value, incomplete social support networks, and complex psychological mechanisms; economically disadvantaged groups and female patients face triple pressures from economic burden, family caregiving demands, and social role conflicts, presenting significant challenges to rehabilitation plan sustainability [98]; severe homogenization of exercise prescriptions and lack of personalized guidance cause continuous decay in patient participation enthusiasm, particularly prominent during long-term rehabilitation. Smart monitoring devices and remote support systems can effectively overcome traditional rehabilitation model limitations, with research confirming this strategy provides alternative pathways for groups unable to participate in offline CR, not only improving treatment adherence but also significantly improving multiple physiological indices [27,30]. Real-time data tracking combined with dynamic incentive mechanisms breaks geographic restrictions and assists patients in establishing continuous rehabilitation behavior patterns. Intervention models combining CBT strategies with community support provide practical directions for improving long-term adherence in elderly patients and populations with weak social support [71,98].

4.2.1 Integration of Psychological Support and Nutritional Intervention: Depression and anxiety are common in CHD patients, increasing mortality probability and reducing HRQoL [108-109]. CBT can significantly improve mental health in CHD, heart failure, and atrial fibrillation patients, providing positive support for rehabilitation, as confirmed by related systematic meta-analyses [110-111]. Integration of mental health and nutritional intervention is key to future EBCR development. CBT rehabilitation models can effectively reduce patient depression and improve HRQoL [112]. Patients with major depression should receive regular depression screening, and according to primary care guidelines, may adopt CBT combined with selective serotonin reuptake inhibitor intervention strategies when necessary to improve mental status, rehabilitation adherence, and long-term efficacy [113-114]. Additionally, individualized nutritional intervention holds important significance in cardiovascular health improvement. Related studies show that increased dietary fiber intake can effectively reduce cardiovascular risk, while ω-3 fatty acid supplementation helps reduce inflammatory responses, stabilize heart rhythm, and shows significant effects in preventing and adjuvantly treating cardiovascular diseases [115-116]. Although EBCR demonstrates significant effects in improving mental health and quality of life, current EBCR-related research remains insufficient, with many areas awaiting in-depth investigation.

4.3.1 Integration of Psychological Support and Nutritional Intervention: Depression and anxiety are common in CHD patients, increasing mortality probability and reducing HRQoL [108-109]. CBT can significantly improve mental health in CHD, heart failure, and atrial fibrillation patients, providing positive support for rehabilitation, as confirmed by related systematic meta-analyses [110-111]. Integration of mental health and nutritional intervention is key to future EBCR development. CBT rehabilitation models can effectively reduce patient depression and improve HRQoL [112]. Patients with major depression should receive regular depression screening, and according to primary care guidelines, may adopt CBT combined with selective serotonin reuptake inhibitor intervention strategies when necessary to improve mental status, rehabilitation adherence, and long-term efficacy [113-114]. Additionally, individualized nutritional intervention holds important significance in cardiovascular health improvement. Related studies show that increased dietary fiber intake can effectively reduce cardiovascular risk, while ω-3 fatty acid supplementation helps reduce inflammatory responses, stabilize heart rhythm, and shows significant effects in preventing and adjuvantly treating cardiovascular diseases [115-116]. Although EBCR demonstrates significant effects in improving mental health and quality of life, current EBCR-related research remains insufficient, with many areas awaiting in-depth investigation.

4.3.2 Integration of Precision Medicine and Molecular Diagnostics: Rapid development in genomics and metabolomics provides new technical support for individualized and precision rehabilitation intervention strategies in cardiovascular disease patients. Research shows that gene variants such as PNPLA3 I148M (rs738409) are not only closely related to metabolic disorders but may also increase individual cardiovascular death risk, holding important reference value for rehabilitation pathway design [117]. Meanwhile, metabolomics-level research indicates that short-chain fatty acids (such as propionic acid, butyric acid, etc.) play key roles in maintaining cardiovascular system homeostasis and regulating immune function, with their levels serving as important indicators for measuring rehabilitation progress and effectiveness [118]. Multi-omics joint analysis-based research further reveals extensive effects of exercise intervention at multiple tissue levels, with systematic changes occurring in protein expression, metabolic pathways, and mitochondrial function in skeletal muscle, liver, and myocardium. Integration of such multidimensional biological data improves rehabilitation effect prediction accuracy, providing theoretical basis for precise individualized exercise prescription formulation [119]. Additionally, for complex pathological states such as chronic inflammation and viral infections, amino acid metabolism abnormalities are considered key intervention targets, particularly metabolic pathways such as tryptophan, glutamine, and arginine, which are increasingly recognized for their roles in immune regulation, membrane repair, and cellular stress, holding important significance for advancing precision rehabilitation intervention models [120].

4.3.3 Construction of Ecosystem-Based Rehabilitation Models: Ecosystem rehabilitation models are receiving increasing attention in cardiac rehabilitation applications. This model emphasizes multidisciplinary collaboration and individual-environment interaction, integrating physiological, psychological, and social factors to construct patient-centered rehabilitation pathways [121]. Digital means, particularly serious games, show good effects in improving rehabilitation adherence and possess feasibility and promotion value even in low-resource environments [121]. Intervention strategies based on use-dependent plasticity mechanisms help improve motor function in chronic musculoskeletal pain patients. Research finds that long-term exercise experience can reduce persistent pain's inhibitory effect on motor cortex, providing neural regulation basis for individualized rehabilitation [122]. Additionally, cardiac rehabilitation models integrating health technology have been proven to provide effective support in improving HRQoL and achieving remote intervention, and help improve rehabilitation service accessibility [123]. In home-based rehabilitation scenarios, the ecosystem perspective emphasizes continuity and adaptability, promoting optimal allocation of rehabilitation resources and sustainable development of rehabilitation management through multi-stakeholder collaboration and environmental factor integration [124]. These findings further corroborate the applicability of ecosystem models, particularly in resource-limited situations or with diverse patient needs, potentially becoming an effective approach for EBCR implementation.

5. Conclusion and Outlook

EBCR serves as a core intervention in long-term management of AMI patients, demonstrating significant effects in reducing recurrent cardiovascular event risk, improving cardiopulmonary function reserve, and enhancing HRQoL. However, clinical practice still faces multiple challenges in its promotion and application, including insufficient patient treatment adherence, uneven medical resource allocation, and socioeconomic condition constraints, particularly prominent in LMICs. With deepening rehabilitation medicine research, individualized exercise prescription has become an important research direction in this field, with multidimensional intervention schemes combining aerobic exercise intensity grading and resistance training providing more precise rehabilitation strategies for patients with different clinical characteristics. Notably, the synergistic application of psychological intervention and nutritional support further enhances overall rehabilitation effectiveness. Meanwhile, technological innovation is reshaping traditional rehabilitation models, with wearable device and remote monitoring technology applications significantly improving rehabilitation service accessibility and patient adherence.

Looking forward, EBCR development will focus on three dimensions: precision rehabilitation, resource integration, and intelligent application. Through developing individualized rehabilitation protocols, constructing multidisciplinary collaboration systems, and applying digital health tools, EBCR widespread promotion will be powerfully advanced. Essentially, EBCR has transcended simple medical intervention to become an important model of proactive health management. Through continuous optimization of rehabilitation strategies, integrating technological innovation and medical resources, more quality rehabilitation services will be provided for AMI patients, thereby effectively reducing the global disease burden of cardiovascular disease.

Author Contributions: Kaiyuan Cen was responsible for research material collection and organization, manuscript writing, and conceptualization/design; Mingchen Shao was responsible for manuscript organization; Hong Chen, Mexmollen Marcus, and Mohd Fadzli Shukor provided article revision suggestions; Kaiyuan Cen and Fatimah Ahmedy were responsible for article conceptualization, final version revision, and overall responsibility for the paper.

Conflict of Interest: The authors declare no conflict of interest.

ORCID: Kaiyuan Cen https://orcid.org/0009-0006-7947-2909

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(Received: March 31, 2025; Revised: June 22, 2025)
(Editor: Zou Lin)