1. Introduction Cardiovascular disease remains a major contributor to morbidity and mortality worldwide [ 1]. Consequently, effective secondary prevention is a prime goal in reducing long-term disability, overall disease burden, and the recurrence of cardiovascular events [ 1, 2]. A major component of current programmes for the management of coronary artery disease and recovery after major cardiac events or revascularisation is exercise-based cardiac rehabilitation (CR). Cardiac rehabilitation is not simply an exercise programme; it is a multifaceted approach that combines physical exercise with comprehensive patient education, identification and modification of risk factors, and behavioural support [ 2, 3]. Evidence from a variety of sources indicates that CR has been associated with improved survival, reduced hospitalisations and recurrent cardiovascular events, and better health-related quality of life [ 3, 4]. Despite such encouraging evidence, levels of CR participation remain low across the world [ 2, 5]. From referral through enrolment on programmes and continued participation, gaps persist across the care pathway [ 2, 6]. International mapping studies show that CR services are not widely available and, where they are available, are often insufficient for the populations they are intended to serve [ 5]. The crucial issue around CR, therefore, is less its effectiveness than the practical challenges involved in implementing it, particularly limitations in access, service organisation, and system-level delivery [ 2, 6]. Strategies such as systematic referral processes and alternative modes of delivery, including remote, home-based, and hybrid models, have been proposed to address barriers such as long travel distance and limited service reach; however, equitable access remains difficult to achieve [ 7, 8]. Accordingly, this review aimed to map the availability and geographic distribution of CR services across countries of the World Health Organization Eastern Mediterranean Region (WHO EMR), characterise delivery models, programme characteristics, and multidisciplinary involvement, and summarise reported referral and participation metrics, including enrolment, adherence, completion, and attrition where available. It also aimed to identify multilevel barriers and enablers to CR implementation and participation, and to provide a Saudi Arabia-focused synthesis highlighting context-specific evidence gaps and priorities for service development and future research. The Saudi Arabia-focused synthesis was planned in the registered protocol. It was included because six of the included studies were from Saudi Arabia, and the findings may be useful for national CR service planning. 2. Methods 2.1. Study Design The purpose of this study was to characterise the contemporary evidence on CR across WHO EMR countries, with particular attention to Saudi Arabia as a planned component of the registered protocol [ 13, 14]. The scoping methodology was chosen in light of the heterogeneity of the existing literature, which encompasses observational studies, service evaluations, surveys, qualitative research, and intervention-based designs [ 14]. Rather than seeking to generate pooled effect estimates, the review aimed to describe the breadth, nature, and distribution of evidence, as well as how CR has been reported in relation to service availability, delivery models, referral and participation pathways, and barriers and enablers to participation and completion [ 13, 14]. This national synthesis was intended to place the Saudi evidence within the regional map and to identify context-specific service gaps and planning priorities. The protocol was registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols on 15 January 2026 (INPLASY202610048), before the formal database searches began on 20 January 2026; reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and the completed PRISMA-ScR checklist is provided as Supplementary Material S1 [ 16]. 2.3. Information Sources and Search Strategy To access regional research sources, the literature search was conducted in MEDLINE (via PubMed), Scopus, Web of Science Core Collection, CINAHL, Embase, and the WHO Index Medicus for the Eastern Mediterranean Region (IMEMR) [ 14]. The publication date range was from 1 January 2000 to 14 January 2026. No language restrictions were applied at the search stage. No potentially eligible non-English full-text articles requiring translation were identified. 2.4. Study Selection Records were deduplicated in Zotero using its duplicate-detection function and checked before screening in Covidence [ 16]. Study selection was led by the author using the predefined eligibility criteria. A second reviewer with health research experience independently verified all title/abstract screening decisions (108/108, 100%) and all full-text eligibility decisions (88/88, 100%). Any uncertainties were resolved through discussion and rechecking against the predefined eligibility criteria. Formal inter-reviewer agreement statistics were not calculated for this verification step. Reasons for excluding full-text articles were recorded, and the overall selection process was summarised using a PRISMA-ScR flow diagram [ 16]. 2.5. Critical Appraisal In line with scoping review objectives, which focus on charting the breadth and characteristics of the evidence rather than creating pooled estimates, no formal methodological quality assessment was conducted. However, key methodological characteristics of the included studies were recorded and considered in the interpretation of the findings [ 14]. 2.6. Data Charting and Extraction A structured charting form, specifically created for the study, was used to extract data and was piloted on a subset of studies before full implementation. Data charting was conducted by the author. A second reviewer independently verified the charted data for all included studies (25/25, 100%). Any uncertainties were resolved through discussion and rechecking against the source articles and the predefined charting framework. Formal inter-reviewer agreement statistics were not calculated for this verification step. Extracted variables consisted of bibliographic information, including author, year, country, and design, as well as population and setting features and details on the study objectives [ 14]. 2.7. Data Synthesis In order to synthesise the data relating to evidence on CR within the WHO EMR, a descriptive and narrative approach was employed. The quantitative findings were recorded as frequencies, proportions, and ranges; meta-analysis was not conducted. The domains around which the synthesis was organised were: availability and geographic distribution of CR services delivery models and programme characteristics referral pathways and participation-related outcomes, including enrolment, adherence, completion, and attrition where reported barriers and enablers influencing implementation and participation Tabular summaries and narrative synthesis were used to present the findings for the overall region, while additional attention was given to data on Saudi Arabia in order to detail context-specific gaps and service implications [ 14]. 3. Results 3.1. Study Selection A total of 631 records were retrieved from the database searches. After removal of 523 duplicate records, 108 titles and abstracts were screened, of which 20 were excluded. Full-text eligibility was assessed for 88 reports, and 63 were excluded for prespecified reasons. The final synthesis included 25 studies, as shown in the PRISMA-ScR flow diagram ( Figure 1). 3.2. Overview of the Included Evidence 3.3. Availability and Geographic Distribution of CR Evidence Saudi Arabia, Iran, Qatar, the United Arab Emirates, Pakistan, and Algeria provided more comprehensive programme- and service-level descriptions, whereas data from Lebanon and Morocco were more limited and consisted mainly of survey-based studies focusing on awareness, preferences, attitudes, referral barriers, and implementation challenges, rather than detailed descriptions of established CR services. An EMR audit showed that CR is available only in a subset of countries, with programme density and capacity remaining low relative to population needs in those settings ( Table 2). Overall, most detailed programme-level data were generated by only a few countries, as illustrated in Table 1. Table 2. Programme characteristics and delivery models. Table 2. Programme characteristics and delivery models. Study/Country Delivery Model Key Programme Characteristics Team/Service Features Main Relevance to Review EMRO regional audit (2019) Mixed regional picture Assessed availability, density, capacity, and delivery of CR across EMRO System-level mapping Demonstrated limited regional availability and low capacity Saudi Arabia: post-CABG RCT (2022) Home-based vs. outpatient-based vs. usual care Compared structured home-based and outpatient CR after CABG Rehabilitation intervention Showed home-based CR was effective and may sustain gains Saudi Arabia: home-based CR trial (2012) Home-based Education, follow-up phone calls, workshops, family involvement Multicomponent home programme Demonstrated feasibility and benefit of home-based CR UAE: Abu Dhabi registry (2023) Centre-based outpatient Exercise-based outpatient CR registry from 2015–2022 Physical therapist-led programme Provided direct Gulf programme description and completion factors Qatar first CR programme (2021) Centre-based outpatient Sole national CR programme with engagement and outcome data Established programme service Demonstrated feasibility and high completion in a national service Qatar hybrid phase II programme (2023) Hybrid Hybrid CR delivery during COVID-19 with safety and cost data Programme adaptation model Showed hybrid CR was feasible, safe, and lower cost Iran provincial audit (2023) Mainly centre-based, some home-based National/provincial mapping; median supervised dose 14 sessions; about one-third offered home-based services Mostly multidisciplinary Documented programme distribution and service characteristics Iran registry experience (2023) Centre-based, home-based, hybrid Phased CR workflow with long-term registry follow-up Registry-supported multidisciplinary model Highlighted registry-based quality improvement and model flexibility Iran Yazd programme report (2019) Multi-phase centre-based with alternatives Four phases; outpatient phase 36 sessions over 3 months Multidisciplinary team Provided detailed service-level description in a developing-country context Pakistan local experience (2012) Centre-based outpatient 6-week outpatient CR after AMI/CABG/PCI Service access-oriented Identified attendance/completion patterns in routine practice Pakistan qualitative home-based design study (2025 VOR) Contextual home-based model Explored patient needs to inform locally tailored home-based CR Patient-informed model design Supported need for contextualized home-based CR Pakistan MCard trial (2022) Digitally supported/mHealth-augmented mHealth added to standard post-ACS care Technology-supported care Suggested scalable low-cost extension of CR services Algeria first experience (2008) Early centre-based programme First Algerian CR centre and early outcomes in coronary patients Early implementation report Demonstrated initial feasibility of CR establishment This table focuses on studies that described CR delivery pathways, programme/service architecture, or intervention characteristics relevant to the review objectives. Delivery models were categorized as centre-based, home-based, hybrid, or digitally supported in accordance with the protocol. 3.4. Delivery Models and Programme Characteristics Table 2 indicates the range of CR delivery models across the included studies; these encompassed centre-based, home-based, hybrid, and digitally supported approaches. The programmes most frequently described were centre-based outpatient programmes, with most of the reported studies coming from Iran, Qatar, the United Arab Emirates, Pakistan, and Algeria [ 11, 12, 21, 22, 24, 25, 26, 29]. These reports and audits provided useful insights into how services were organised. Saudi Arabia provided most of the information on home-based CR, especially in relation to patients after coronary artery bypass grafting; data from Iran and Pakistan were also included [ 25, 26, 31, 33, 34]. Qatar provided information on hybrid models, while Iran contributed information on registry- or service-based pathways. A Pakistani mHealth-enhanced model described digitally supported delivery [ 27]. Although there was variation across settings, the core components tended to include supervised or prescribed exercise, patient education, risk factor management, follow-up support, and multidisciplinary involvement [ 12, 20, 21, 22, 24, 25, 26, 27, 29, 31, 34]. Teams also tended to be multidisciplinary, with an Abu Dhabi centre being described as having a physical therapist-led outpatient CR programme [ 21]. In general, the findings reveal growing interest in flexible delivery models in order to help address capacity constraints within the region [ 11, 20, 22, 24, 25, 26, 27, 31]. 3.5. Referral, Uptake, Adherence, Completion, and Attrition Table 3. Participation metrics across key studies. Table 3. Participation metrics across key studies. Country/Study Referral Uptake/Enrolment/Attendance Completion/Attrition Notes SAUDI ARABIA: POST-PCI PATIENT SURVEY (2024) 10.6% referred 36.4% of those referred attended Not fully reported Home-based CR preferred by 58.7% IRAN: WEST OF IRAN POST-CABG (2014) 44.6% referred 18.7% enrolled 16.5% completed Systematic referral improved participation IRAN: YAZD PROGRAMME REPORT (2019) 60% referral by inpatient CR team Participation 6.9%; enrolment 55% 57% completed Only CR programme in Yazd province IRAN: KERMANSHAH COMPLETION STUDY (2015) Not reported CR attendees analyzed 49% completed; 51% dropped out Failure to complete linked to social/psychological factors QATAR FIRST CR PROGRAMME (2021) Not reported 77.6% of prescribed sessions attended 81.2% completed High engagement within established service QATAR HYBRID PHASE II (2023) Not reported 51 enrolled in hybrid model 84.3% completed No major adverse events reported PAKISTAN LOCAL EXPERIENCE (2012) Not reported 36.2% enrolled and attended 73.4% completed >6 weeks Attendance associated with easier access UAE ABU DHABI REGISTRY (2023) Not uniformly reported Registry attendees described Completion pragmatically defined as ≥10 sessions Completion associated with geography, BMI, depression Definitions varied across studies; metrics are presented descriptively and should not be interpreted as directly comparable. In general, the data suggest that the more important influences on participation may lie in service access, referral systems, and early enrolment pathways rather than in within-programme retention once patients have entered CR. Given the variability in reporting across studies, however, these findings should be interpreted with caution. 3.6. Barriers and Enablers Table 4. Multi-level matrix of barriers and enablers. Table 4. Multi-level matrix of barriers and enablers. Level Recurring Barriers Recurring Enablers Patient level Transport burden, long travel distance, out-of-pocket costs, low awareness, low motivation, anxiety/depression, comorbidities, work or family constraints Home-based CR, hybrid models, tailored education, telephonic/remote support, family involvement Provider level Limited CR knowledge, inconsistent referral practices, low awareness of CR phases/benefits, insufficient trained personnel Provider education, stronger endorsement by specialists, simplified/automated referral systems, increased professional exposure to CR Organisational/health-system level Limited number of CR centres, geographic maldistribution, concentration in major cities/capitals, fragmented referral pathways, workforce/resource shortages Multidisciplinary service development, wider regional coverage, programme standardisation, registry-based monitoring, flexible delivery pathways Policy/financing level Weak insurance coverage, funding limitations, lack of structured national implementation pathways, insufficient strategic support Leadership support, reimbursement reform, Arabic/local guidance, institutional coordination, service scale-up planning Themes were mapped to the four implementation domains prespecified in the protocol: patient, provider, organisational/health-system, and policy/financing. 3.7. Saudi Arabia–Focused Synthesis Table 5. Saudi Arabia-specific cardiac rehabilitation evidence included in the review. Table 5. Saudi Arabia-specific cardiac rehabilitation evidence included in the review. Study/Saudi Evidence Area Design/Population CR Focus or Programme Type Referral/Uptake/Completion Metrics Main Findings/Barriers Key Limitations This table summarises the Saudi Arabia-specific studies included in the review. Themes were mapped to the four implementation domains prespecified in the protocol: patient, provider, organisational/health-system, and policy/financing. 4. Discussion Across EMR countries, the central pattern was that inconsistent uptake of CR appeared to reflect access and implementation barriers rather than uncertainty about its clinical value. This pattern is consistent with global CR availability studies and the EMR-specific audit, which show that CR remains unevenly available and that service capacity is often insufficient for population needs. Because participation metrics were defined and reported heterogeneously, these findings should be interpreted cautiously; nevertheless, the available data indicate that fragmented referral and enrolment processes may contribute to low initial uptake. Regardless of delivery model, CR services should retain core components such as exercise, education, risk-factor management, and behavioural support. Recent literature on CR in other cardiac populations, including atrial fibrillation, also supports the value of multidisciplinary rehabilitation beyond exercise alone [ 42]. Nevertheless, the current evidence base remains weighted toward observational and survey-based research, with relatively limited representation of implementation-focused evaluations, registry-based monitoring, qualitative research, and interventional designs [ 31, 36]. This pattern suggests that, particularly in low- and middle-income settings, the field is shifting from demonstrating the value of CR to understanding how it can be implemented effectively in real-world health systems [ 5, 43]. Future research in the EMR should therefore prioritise strategies to improve referral, enrolment, and sustained participation, especially where access remains limited. This review has several strengths relevant to interpretation. It was conducted using a prospectively registered protocol and a clearly defined scoping methodology, which allowed a heterogeneous body of evidence to be mapped systematically. Through the inclusion of multiple study designs, including audits, programme reports, registry-based studies, surveys, qualitative research, and interventional studies, CR could be examined as both a clinical and a service-delivery intervention. Additionally, the use of structured evidence-mapping tables enabled synthesis across country, programme, participation, and implementation domains, thereby strengthening the practical and policy relevance of the findings. The results should, however, be interpreted in light of certain limitations. First, the evidence was unevenly distributed, with Iran and Saudi Arabia contributing substantially more than other EMR countries. This uneven distribution of published evidence should not necessarily be interpreted as the absence of CR services in other EMR countries, but may also reflect limited publication, indexing, or accessible programme-level reporting. Because the search included service and implementation terms, studies reporting clinical outcomes without describing CR delivery, referral, participation, or barriers may have been missed. Second, observational and survey-based studies were more common, whereas detailed service evaluations, qualitative implementation studies, and controlled trials were less frequently represented. Third, participation-related metrics varied in both definition and reporting, including referral, uptake, enrolment, adherence, completion, and attrition, which limited straightforward comparison across studies. Fourth, although a second reviewer verified all screening decisions and charted data, the review process was primarily author-led and formal agreement statistics were not calculated. This differed from the duplicate independent screening process anticipated in the registered protocol and is therefore acknowledged as a methodological limitation. Accordingly, the possibility of selection or charting error cannot be fully excluded. Finally, as a scoping review, this study was designed to capture the breadth and nature of the available evidence rather than to generate pooled estimates or support comparative effectiveness conclusions. The findings should therefore be viewed as an overview of the current evidence landscape rather than as a basis for direct cross-context comparison. 5. Conclusions This scoping review suggests that evidence on CR in the WHO EMR is growing, but geographic coverage, service access, and depth of evidence remain fragmented. The central theme in the literature is not uncertainty about the value of CR, but the limited translation of this value into effective referral pathways, accessible services, and sustained participation. Saudi Arabia reflects a similar pattern, with stakeholders recognising the need for CR while continuing to face challenges in achieving equitable access. Future priorities should include strengthening referral practices, expanding service capacity, and supporting flexible delivery models across the EMR. Supplementary Materials The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/jcm15124413/s1, Supplementary Material S1: Completed PRISMA-ScR checklist; Supplementary Material S2: Full database-specific search strategies; Supplementary Table S1: Characteristics of the included studies. Funding This research received no external funding. Institutional Review Board Statement Not applicable. Informed Consent Statement Not applicable. Data Availability Statement All data generated or analysed during this scoping review are included in this article and its Supplementary Materials. Acknowledgments The author thanks Abdullah Alzahrani for independently verifying the screening decisions and charted data, and for providing methodological feedback during the review process. 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Country/Region No. of Included Studies Main Evidence Types EMRO region 1 Regional audit Saudi Arabia 6 Qualitative, cross-sectional surveys, randomized trials United Arab Emirates 1 Registry-based retrospective study Qatar 2 Retrospective cohort, quality improvement Lebanon 2 Survey/preference studies Iran 8 Audit, registry report, programme report, cross-sectional, retrospective observational Pakistan 3 Cross-sectional, qualitative, randomized trial Morocco 1 Cross-sectional survey Algeria 1 Early programme report Counts refer to the primary country or region reported for each included study; the EMRO regional audit was counted separately. Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. © 2026 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license. MDPI and ACS Style Alghamdi, W. Cardiac Rehabilitation in the WHO Eastern Mediterranean Region: A Scoping Review with a Saudi Arabia–Focused Synthesis. J. Clin. Med. 2026, 15, 4413. https://doi.org/10.3390/jcm15124413 AMA Style Alghamdi W. Cardiac Rehabilitation in the WHO Eastern Mediterranean Region: A Scoping Review with a Saudi Arabia–Focused Synthesis. Journal of Clinical Medicine. 2026; 15(12):4413. https://doi.org/10.3390/jcm15124413 Chicago/Turabian Style Alghamdi, Wael. 2026. "Cardiac Rehabilitation in the WHO Eastern Mediterranean Region: A Scoping Review with a Saudi Arabia–Focused Synthesis" Journal of Clinical Medicine 15, no. 12: 4413. https://doi.org/10.3390/jcm15124413 APA Style Alghamdi, W. (2026). Cardiac Rehabilitation in the WHO Eastern Mediterranean Region: A Scoping Review with a Saudi Arabia–Focused Synthesis. Journal of Clinical Medicine, 15(12), 4413. https://doi.org/10.3390/jcm15124413
