Cardiac rehabilitation in overweight and obese patients: Challenges, strategies, and the role of emerging anti-obesity therapies.

Overweight and obesity are highly prevalent among patients with cardiovascular disease and are associated with reduced functional capacity, increased cardiometabolic risk, and worse clinical outcomes. Cardiac rehabilitation (CR) is a cornerstone of secondary prevention, yet its implementation and optimization in patients with obesity remain challenging. This review summarizes current evidence on the role and effectiveness of CR in overweight and obese individuals, focusing on clinical outcomes, participation barriers, tailored intervention strategies, and the emerging role of anti-obesity pharmacotherapies. Available data show that CR significantly improves functional capacity, cardiovascular risk factors, and quality of life in patients with obesity, although weight loss during CR is generally modest and heterogeneous. Importantly, improvements in cardiorespiratory fitness and physical activity-rather than weight reduction alone-appear to be the main drivers of prognostic benefit and help explain the attenuation of the obesity paradox after adjustment for fitness. Patients with obesity face multiple barriers to CR participation and adherence, including musculoskeletal limitations, comorbidities, psychological factors, and structural constraints, and remain underrepresented in clinical trials. Tailored CR programs integrating individualized exercise prescription, nutritional and behavioral support, and extended follow-up show short-term benefits, but long-term weight maintenance remains difficult. Novel incretin-based and multi-agonist anti-obesity agents produce substantial weight loss and cardiometabolic improvements and may enhance CR participation and outcomes, although potential effects on lean mass and muscle function warrant careful monitoring. A personalized, fitness-centered, multidisciplinary CR model that integrates exercise training, lifestyle intervention, body composition assessment, and selected pharmacotherapy may optimize long-term results beyond weight loss alone.