ESC · 2026

Cardiac Rehabilitation — Management Guideline

Source: 2026 ESC Guidelines on cardiac rehabilitation, European Heart Journal

✓ Edition checked 3 Oct 2026 — ESC 2026 is the current edition as of this date.

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Cardiac rehabilitation is indicated for patients with established cardiovascular disease, for example after an acute coronary syndrome, with chronic coronary syndromes, with stable chronic heart failure, or with a left ventricular assist device. The 2026 ESC guideline is the first ESC guideline dedicated entirely to cardiac rehabilitation. Programmes are individualized after assessment of the patient's cardiovascular risk, physical function, comorbidities, and clinical profile.

⚠ Alarm features (investigate before diagnosing)

Contraindications to exercise testing or training (ESC 2026 Table 4 lists the clinical conditions); the guideline recommends exercise training unless these are present
Clinical instability or worsening symptoms during exercise
Frailty or marked comorbidity that needs a modified programme

Initial workup

Test	When to order
Initial patient assessment	Before the programme starts: cardiovascular risk, physical function, comorbidities, and clinical profile, to personalize exercise training and the other components.
Cardiopulmonary exercise testing	To prescribe exercise intensity. When it is unavailable and training is at lower intensity, a submaximal exercise test may be considered as an alternative.

Decision Points

❓ What is the main indication for rehabilitation?

Recent ACS or chronic coronary syndromes → After acute coronary syndrome or with chronic coronary syndromes

Stable chronic heart failure or an LVAD → Chronic heart failure or LVAD

Hypertension, frailty, or planning to return to work → Special situations: hypertension, frailty, return to work

Treatment

After acute coronary syndrome or with chronic coronary syndromes

1 Multidisciplinary exercise-based cardiac rehabilitation with endurance plus resistance training Strong (Guideline recommendation) — resistance plus endurance training in patients after ACS or with CCS (Class I, level B1)

Dose: ESC 2026 Table 8 reference frame for ACS and CCS: endurance sessions of 30-60 minutes; resistance training at 30-70% of 1RM for the upper limbs and 40-80% of 1RM for the lower limbs, added on top of the endurance exercise (about one-third of the bout is given as an example, not as a fixed rule). Frequency is given in Table 8
Duration: Outpatient programme: minimum standard of 24 sessions, typically over 12 weeks with two sessions per week (ESC 2026)
Evidence level: High
Avoid if: Specific contraindications to exercise training; clinical instability
If no response: Add the other core components (education, risk-factor control, psychosocial and nutritional management)

2 Other core components alongside exercise Guideline recommendation — these are listed as core components of cardiac rehabilitation

Dose: Patient education and self-management, optimization of cardiovascular drugs, physical activity and sedentary-behaviour counselling, nutrition and body composition, smoking cessation, psychosocial management, sexual counselling
Duration: Throughout the programme
Evidence level: High
Avoid if: —

Chronic heart failure or LVAD

1 Personalized exercise training in stable heart failure Strong (Guideline recommendation) — recommended for all stable patients in exercise-based cardiac rehabilitation or outside it, unless contraindicated, to improve exercise capacity and quality of life and reduce all-cause hospitalization (ESC 2026 heart failure guideline)

Dose: ESC 2026 Table 8 for chronic heart failure: endurance sessions up-titrating from 15-30 to 45-60 minutes; resistance training up-titrating to 40-60% of 1RM; inspiratory muscle training of 20-30 minutes up-titrating from 30% to 60% of maximal inspiratory pressure, when tolerated
Duration: Long-term
Evidence level: High
Avoid if: Specific contraindications to exercise training

2 Cardiac rehabilitation for patients with an LVAD Guideline recommendation — to improve functional capacity and quality of life (ESC 2026 heart failure guideline)

Dose: —
Duration: Per programme
Evidence level: Moderate
Avoid if: Per LVAD team advice

Special situations: hypertension, frailty, return to work

1 Arterial hypertension: aerobic exercise first Guideline recommendation

Dose: Aerobic training as the first choice, with sessions longer than 30 minutes that can be split into shorter parts with short breaks; isometric resistance exercise may complement it
Duration: Long-term
Evidence level: Moderate
Avoid if: Uncontrolled blood pressure at rest (stabilize first)

2 Frailty: add resistance training Guideline recommendation

Dose: Resistance training of the large muscle groups, at least of moderate intensity, next to endurance exercise
Duration: Long-term
Evidence level: Moderate
Avoid if: Specific contraindications to exercise training

3 Return to work: combined counselling and exercise Guideline recommendation (should be considered)

Dose: Counselling combined with exercise training to support timely and successful reintegration into the workforce
Duration: During and after the programme
Evidence level: Low
Avoid if: —

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.