Cardiac Rehabilitation in Heart Failure: Evidence, Coverage, and Implementation.

Cardiac rehabilitation (CR) is a multicomponent secondary prevention intervention that improves functional capacity and quality of life across cardiac diagnoses, yet remains markedly underused in heart failure (HF). Existing reviews treat efficacy, coverage, delivery, and equity separately; this narrative review integrates them to clarify why uptake in HF remains low despite an established evidence base. We searched PubMed/MEDLINE and the Cochrane Library from January 2009 through December 2025, prioritizing clinical practice guidelines, landmark trials, systematic reviews, registry analyses, and U.S. policy documents, with narrative synthesis across efficacy, coverage, delivery, and equity. In heart failure with reduced ejection fraction (HFrEF), exercise-based CR consistently improves peak oxygen consumption by roughly 15 to 17 percent, improves health status, and reduces short-term all-cause hospitalization. In heart failure with preserved ejection fraction (HFpEF), supervised exercise improves functional capacity and quality of life, but a large pragmatic outcome trial and Medicare coverage remain lacking. In appropriately selected, clinically stable patients, hybrid and virtual delivery produce comparable short-term functional and quality-of-life gains, with more limited direct evidence for hard clinical endpoints. Closing the HFpEF coverage gap, automating HFrEF referral, diversifying delivery, and embedding equity across the CR pipeline are actionable priorities for realizing CR's potential in HF.