Low-density lipoprotein cholesterol (LDL-C) is causal in atherosclerotic cardiovascular disease (ASCVD), still the leading causes of global morbidity and mortality. The 2025 update of the ESC/EAS guidelines for the management of dyslipidemia recommends increasingly stringent, risk-based LDL-C targets. Beyond achieved LDL-C targets, cumulative exposure over time has emerged as a key determinant of ASCVD risk. Accordingly, treatment strategies should evolve from a traditional stepwise approach toward a more proactive, personalized, and target-oriented model; the recognized impact of cumulative LDL-C exposure further reinforces the importance of early, intensive, and sustained lipid lowering therapies (LLT). Despite this awareness and the availability of effective therapies, LDL-C control in clinical practice remains suboptimal. This gap is largely driven by the so called "therapeutic inertia", involving physician-related factors, patient barriers, and healthcare system constraints; accordingly, fewer than one-third of patients in secondary prevention achieve recommended LDL-C goals. A significant improvement in this situation requires structured treatment algorithms, multidisciplinary care, improved patient education, and integration of digital decision-support tools. A pragmatic framework to improve goal attainment is the estimation of "distance to target", which enables selection of LLT based on the required percentage reduction from baseline LDL-C levels. This approach facilitates alignment between the expected efficacy of available treatments and individual patient needs. While statins remain first-line therapy, combination regimens are frequently required-particularly in very high-risk patients-including ezetimibe, bempedoic acid, PCSK9 inhibitors, and inclisiran.

The gut microbiota has emerged as a key regulator of cardiovascular health, influencing metabolic, inflammatory, and vascular pathways. Growing evidence indicates that gut dysbiosis, characterized by reduced microbial diversity, depletion of beneficial short-chain fatty acid-producing bacteria, and enrichment of pro-inflammatory taxa, is associated with major cardiovascular risk factors and disease progression. Microbial-derived metabolites, including trimethylamine/trimethylamine N-oxide, short-chain fatty acids, amino acids and bile acids, may play a central role in modulating lipid metabolism, endothelial function, inflammation, and thrombosis, although the underlying mechanisms remain incompletely understood. Recent multi-omics approaches have expanded this understanding by identifying personalized microbiome-metabolome signatures linked to cardiovascular risk, supporting a shift toward precision medicine. In this review, we summarize current evidence on the composition and functional role of the gut microbiota in cardiovascular disease and critically discuss emerging microbiota-targeted strategies. These include dietary interventions, prebiotics, probiotics, synbiotics, antibiotics, enzyme inhibitors, and fecal microbiota transplantation, which may contribute to both the prevention and adjunctive treatment of cardiovascular conditions. In addition, we address the challenges of integrating gut microbiota management into clinical practice and highlight the importance of tailored strategies, including exercise-based interventions, microbial enzyme inhibitors, and postbiotics. Despite promising preclinical and early clinical data, the translation of microbiome-based therapies into routine practice remains limited by heterogeneity in study design, the lack of standardized protocols, and incomplete mechanistic understanding. Overall, targeting the gut microbiota represents a novel and potentially complementary approach for cardiovascular disease prevention and management, warranting further well-designed clinical studies.

Therapeutic inertia in lipid-lowering treatment remains a striking paradox of modern cardiovascular medicine: at a time when the causal role of LDL-cholesterol in atherosclerotic disease is unequivocal and potent therapies are widely available, a substantial proportion of high- and very-high-risk patients still fail to receive timely treatment intensification. Contemporary European and international data consistently show fewer than one in three patients in secondary prevention achieve guideline-recommended LDL-C targets, revealing a persistent and unacceptable gap between scientific evidence and clinical reality. This narrative review examines therapeutic inertia as a key explanatory framework for this gap, describing its epidemiology, mechanisms, and clinical consequences in secondary cardiovascular prevention. We summarize the main physician-, patient-, and system-level determinants and propose recurrent clinician "phenotypes" of inertia that may help explain why opportunities are missed even in the highest-risk patients. The consequences are profound: therapeutic inertia contributes to what we propose as the conceptual framework of an "avoidable atherosclerotic burden", the cumulative vascular injury that accrues each period in which LDL-C remains above target, translating into higher rates of avoidable cardiovascular events, and increased healthcare costs. Emerging strategies such as upfront combination therapy, decision-support systems, structured lipid pathways, and the integration of artificial intelligence offer practical tools to shift lipid management from reactive to proactive care. Overcoming therapeutic inertia is therefore not merely a matter of improving process metrics, but a clinical and ethical imperative. Closing the gap between evidence and practice requires transforming optimal lipid management from an exception into a system-level default, ensuring that every patient receives the full benefit of therapies proven to save lives. This work proposes a novel characterization of clinician 'phenotypes' and the concept of 'avoidable atherosclerotic burden' as a framework to understand and address this gap.

Hospital discharge is a pivotal stage in the continuum of care, marking the transition from the acute clinical episode to subsequent therapeutic management. Rather than being a purely administrative procedure, discharge is a multifaceted process that requires structured planning, clear communication, and the coordinated participation of all healthcare stakeholders, with the patient playing a central role. Inadequate discharge processes may adversely affect clinical outcomes and increase hospital readmission rates, resulting in sub-optimal utilization of healthcare resources. This issue is particularly relevant in the context of an ageing and increasingly frail population, characterized by a high burden of comorbidities and complex clinical needs. In this setting, discharge planning should be treated as an integral component of the care pathway, embedded within a comprehensive, coordinated model of care. This document proposes an updated, practical framework for hospital discharge management, grounded in current scientific evidence and multidisciplinary expertise. Its primary objective is to enhance continuity of care, support individualized treatment strategies, and ultimately improve patient outcomes. Specifically, this paper aims to provide clinical cardiologists with a structured reference tool for discharge management, including actionable recommendations to strengthen physician-patient communication, optimize therapeutic regimens, and promote better health outcomes.

È noto che una quota consistente di pazienti non riesce a raggiungere determinati obiettivi terapeutici, in particolare in ambito preventivo o nel trattamento di condizioni croniche. Una delle cause è l’inerzia terapeutica, quale risultato di un’interazione complessa tra molteplici fattori, che comprendono non solo il medico ma anche il paziente, con la sua attitudine all’aderenza, e i vincoli organizzativi del sistema sanitario. La letteratura scientifica suggerisce una ripartizione del peso della responsabilità dell’inerzia terapeutica attribuendolo per il 50% a fattori correlati al medico, per il 30% a fattori correlati al paziente e per il restante 20% a barriere del sistema sanitario. Questa visione a compartimenti stagni risulta fuorviante perché non è in grado di cogliere la profonda interconnessione dei diversi elementi e come essi si vadano ad autoalimentare in un circolo vizioso che condiziona l’agire terapeutico. Il processo decisionale del medico è tutt’altro che razionale e algoritmico, è influenzato da bias cognitivi, scorciatoie mentali e pressioni di contesto che possono condurre a errori sistematici. Il paziente non è mai un attore passivo: le sue paure, percezioni e comportamenti, giocano un ruolo cruciale nel determinare dinamiche relazionali che influenzano il ragionamento clinico e danno origine a interazioni in cui per il curante evitare il conflitto determina una perdita di opportunità terapeutiche. L’inerzia che origina dal clinico è un comportamento composito, che può consentire di identificare almeno quattro profili ricorrenti, definibili “fenotipi di inerzia terapeutica”: disinformato, esitante, rigido, sopraffatto. Ogni fenotipo è caratterizzato da un diverso livello di consapevolezza ed è sostenuto da bias cognitivi oltre che da specifiche difficoltà relazionali con le diverse tipologie di pazienti. Non esistono soluzioni univoche per sostenere le modifiche dei comportamenti, tuttavia alcuni profili risultano essere più suscettibili al cambiamento di altri. Identificare i fenotipi di inerzia è quindi solo il primo passo, in quanto per la pratica clinica è decisamente rilevante se e come possono essere modificati. Si tratta quindi di sviluppare una griglia interpretativa per riconoscere i pattern ricorrenti di inerzia e quali potrebbero costituire le più efficaci strategie correttive.

Acute coronary syndromes (ACSs) remain a major cause of mortality and morbidity across Europe, with long-term outcomes still sub-optimal despite advances in acute care. Current clinical guidelines primarily focus on the immediate post-event phase, providing limited direction on extended follow-up and integrated care strategies. Furthermore, there is considerable heterogeneity across European healthcare systems regarding the implementation of post-ACS services, resulting in disparities in patient outcomes and access to preventive care. The aim of this clinical consensus statement, developed by the European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology, is to define an optimal, lifelong roadmap for patients following an ACS. It proposes a structured, phased model of care that supports evidence-informed, equitable, and patient-centred management strategies adaptable to national and local contexts. The roadmap targets multiple patient phenotypes, promoting continuity of care, collaboration among healthcare professionals, and integration of technological solutions. The methodology employed involved a multidisciplinary expert group nominated by the EAPC. Through structured literature review, expert consensus, and iterative discussions, the panel defined key components of post-ACS care across different phases of recovery. The final roadmap integrates best available evidence, clinical expertise, and practical considerations to support implementation across diverse healthcare settings.

Background and aims:To provide a contemporary description of patients referred to cardiac rehabilitation (CR) in Italy after hospitalization for acute heart failure (HF), focusing on the use and optimization of guideline-directed medical therapy (GDMT) across the spectrum of left-ventricular ejection fraction (LVEF). Methods:PROMETEO is a prospective, multicentre Italian registry enrolling consecutive adult patients admitted to CR after acute HF. Patients were stratified as HFrEF (LVEF <40%) or HFmrEF/HFpEF (LVEF ≥40%). Results:Among 263 patients with available LVEF, median age was 68.7 years, 21.7% were female, and 74.9% had HFrEF. Compared with HFmrEF/HFpEF, HFrEF were younger, less frequently female and with higher NT-proBNP levels. At CR admission, 72.1% of HFrEF patients received ACEi/ARB/ARNI, 91.9% beta-blockers, 79.2% MRAs, and 66.0% SGLT2 inhibitors, with a median GDMT score of 6 (IQR 4-8). At discharge, ARNI use increased significantly (58.9%) and the median GDMT score increased to 7 (IQR 4-8; p = 0.013), alongside higher beta-blocker dosing and reduced loop diuretic use. Chronic kidney disease and higher baseline GDMT score were negatively associated with GDMT optimization, while higher BMI showed a positive association. In HFmrEF/HFpEF patients, SGLT2 inhibitor use increased from 28.8% to 47.0% (p = 0.010), with a concomitant reduction in loop diuretic prescription and dose. Conclusion:Patients referred to CR after acute HF are mainly male with HFrEF and show substantial comorbidity and treatment complexity. Residential CR represents a key opportunity for GDMT optimization across the HF spectrum.

Therapeutic inertia is the result of a complex interaction between multiple factors. In the recent years, some authors suggested that the burden of responsibility for therapeutic inertia is shared, with 50% due to physician-related factors, 30% to patient-related factors, and the remaining 20% to healthcare system barriers. This view is misleading because it fails to capture the deep interconnection between the various elements and how they feed into each other in a vicious circle that influences therapeutic action. The physician's decision-making is influenced by cognitive biases, mental shortcuts, and contextual pressures that can lead to systematic errors. Within the different care settings, the patient is never a passive actor; their fears, perceptions and behaviors play a crucial role in factors that influence clinical reasoning and give rise to interactions in which avoiding conflict leads to a loss of therapeutic opportunities. At least four recurring clinical profiles can be identified, which can be defined as "phenotypes of therapeutic inertia": uninformed, hesitant, rigid, overwhelmed. Each phenotype is characterized by a different level of self-awareness and is supported by cognitive biases as well as specific relational difficulties with different types of patients. Identifying the phenotypes of inertia is only the first step: the crucial question for clinical practice is whether and how they can be modified. There are no single solutions: it is therefore a matter of developing an interpretative grid to recognize recurring patterns of inertia in clinical practice and identify the most effective corrective strategies.

Introduction Nutritional literacy enables the proper management of information about food and diet, promoting adequate nutritional habits. Diet plays a central role in the prevention and management of cardiovascular diseases. In centres dedicated to cardiovascular prevention and cardiac rehabilitation, dietitian-led nutritional care is essential, but all team members contribute to patient education, requiring continuous knowledge updates. The DEMETRA survey assessed the nutritional knowledge of the cardiology teams members, their adherence to the Mediterranean Diet, and the relationship between knowledge and adherence. Methods The DEMETRA survey, promoted by ASAND and ITACARE-P, involved healthcare professionals of cardiovascular prevention and rehabilitation teams (cardiologists, resident physicians, psychologists, nurses, and physiotherapists), excluding dietitians. The online questionnaire collected demographic data, presence of a dietitian in the team, nutritional knowledge (Moynihan questionnaire), and adherence to the Mediterranean Diet (QueMD questionnaire). Results A total of 153 healthcare professionals participated. Nutritional knowledge and Mediterranean Diet adherence were similar between medical and non-medical professionals ( p > 0.05). Higher knowledge did not consistently correspond to greater dietary adherence. Only participants with high adherence to the Mediterranean model reported a mean score consistent with high nutritional knowledge. Conclusions Nutritional knowledge and Mediterranean Diet adherence were moderate but below optimal levels. A possible positive relationship emerged between high adherence to the Mediterranean model and greater nutritional knowledge. These findings highlight the need for targeted educational strategies and reinforce the strategic role of dietitians in strengthening nutrition competencies within multidisciplinary cardiovascular teams.

The Italian Association for Cardiovascular Rehabilitation and Prevention (ITACARE-P) together with the Società Italiana di Gerontologia e Geriatria (SIGG); Società Italiana di Geriatria Ospedale e Territorio (SIGOT); SICGE, Società Italiana di Cardiologia Geriatrica (SICGE) released a joint position paper to guide referrals of elderly cardiovascular patients discharged from Geriatric wards to Cardiac Rehabilitation (CR) facilities. The document provides rationale and operative recommendations for appropriateness (i.e. qualifying diagnosis) and priority criteria to overcome mismatch between potential demand and effective supply of CR programmes. In case of no-referral due to logistic restraints, the document recommends the adoption of best alternatives to CR for disability reduction, better prognosis, and improvement of quality of life. The joint position paper is also aimed at promoting the consideration of Geriatric Medicine as a potential stakeholder of CR.

Background: Atherothrombosis is a systemic disease that may affect one or more than one vascular bed. Data on the impact of polyvascular disease (PVD) on the long-term prognosis of patients with coronary artery disease (CAD) are still scarce. Aim: To assess the prevalence of symptomatic PVD in a cohort of patients with a new episode of acute coronary syndrome (ACS) and to investigate the impact of multiple vascular beds involvement on long-term outcomes. Methods: We analysed a nationwide, comprehensive administrative database of consecutive patients aged ≥ 40 years admitted for a new episode of ACS in Italy in 2017-2018. Patients with ACS were stratified according to the presence of peripheral artery disease (PAD) only; cerebrovascular disease (CeVD) only; PAD+CeVD; or neither (no PAD/noCeVD, i.e., ACS only). A multivariate Cox proportional hazards model was used to assess the impact of PAD only; CeVD only and PAD+CeVD on 5-year MACCE. Results: A total of 342,052 patients hospitalised with ACS were identified. Among them, 24,727 (7.2%) were patients with PAD only, 16,887 (4.9%) with CeVD only, and 5810 (1.7%) with PAD+CeVD. After adjusting for age, sex, and comorbidities, the hazard ratio (HR) for 5-year MACCE was 1.37 (95% CI: 1.35-1.40), 1.36 (95% CI: 1.33-1.39), and 1.45 (95% CI: 1.40-1.50) in patients with PAD only, CeVD only, and PAD+CeVD, respectively, compared with patients with ACS only. Conclusions: In patients with ACS, the involvement of a second vascular bed increases the risk of long-term outcomes; the simultaneous involvement of three vascular beds further increases the risk of long-term outcomes.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous chronic lung condition often accompanied by comorbidities and systemic manifestations that affect the person’s clinical condition and prognosis and often require specific treatment. Therefore, the management of COPD extends beyond treatment for the lungs per se. Pulmonary rehabilitation (PR) should be considered as part of person-centered management, and supervised exercise training is a core component of this intervention. PR exercise training parameters (e.g., frequency, intensity, time, and type) should be individualized to maximize each individual’s functional gains while targeting systemic manifestations and comorbidities. This manuscript presents evidence-based tailored recommendations for optimizing exercise interventions for people with COPD and comorbidities that significantly affect prognosis (e.g., mortality, hospitalizations) including cardiovascular disease (CVD) (e.g., chronic coronary syndrome, heart failure), CVD risk factors (e.g., type 2 diabetes mellitus [T2DM], hypertension), and sarcopenia. To achieve these goals, existing guidelines and evidence for exercise training in COPD, CVD, CVD risk factors, and sarcopenia have been reviewed to identify synergies between PR and cardiac rehabilitation, as well as the treatment of T2DM and sarcopenia. In addition, we provided clinical cases to illustrate how PR can be adapted to accommodate specific comorbidities. These examples offer practical guidance for tailoring exercise prescriptions within PR programs to address the unique needs of people with COPD and clinically relevant comorbidities, thereby enhancing overall treatment effectiveness and optimizing health outcomes.

BACKGROUND:Despite the intensive approach recommended by the 2019 European Society of Cardiology/European Atherosclerosis Society guidelines, low-density lipoprotein cholesterol (LDL-C) target attainment (<55 mg/dL or <40 mg/dL for patients with recurrent events within 2 years) in atherosclerotic cardiovascular disease (ASCVD) patients remains low, with clinical inertia and lack of lipid-lowering therapy (LLT) optimization as major barriers. METHODS:We analyzed real-world LLT patterns in the ITACARE-P registry, enrolling 1909 Italian ASCVD patients referred to cardiovascular rehabilitation or secondary prevention programs. Baseline LLT and LDL-C levels were recorded. For patients not at LDL-C target, a Monte Carlo simulation with 10,000 iterations was performed using efficacy data from pivotal randomized trials to model sequential addition of ezetimibe, bempedoic acid, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, and inclisiran to estimate potential LDL-C goal attainment rates. RESULTS:Among 1909 patients (mean age 66 ± 10 years, 26% women), 41.3% were at LDL-C target. Most (90%) were on statins, predominantly at moderate or high intensity, whereas only 3% were untreated. Among patients not at LDL-C target, the Monte Carlo simulation predicted a stepwise increase in goal attainment from 43% to 50% after ezetimibe, 63% after bempedoic acid, 95% after PCSK9 inhibitors, and 90% after inclisiran. A baseline percentage distance of 23.66% from the LDL-C target was identified as a threshold beyond which the addition of bempedoic acid alone was rarely sufficient (<5% success), supporting direct escalation to injectables. CONCLUSION:A structured, guideline-based intensification strategy in secondary prevention could close the treatment gap and enable near-universal LDL-C target achievement, supporting early implementation of combination therapy.

Patients with chronic kidney disease are at high and very high risk of cardiovascular disease. As estimated glomerular filtration rate declines, the incidence and severity of risk factors, complications, and atherosclerotic cardiovascular events increase. In this scenario, tailored assessment is the key to evaluate the severity of chronic kidney disease and estimate cardiovascular disease risk. Personalized stratification differentiates patients with chronic kidney disease without diabetes mellitus or established atherosclerotic cardiovascular disease in their management and beneficial treatment. Exercise intensity assessment and prescription is suggested to propose specific and safe recommendations for physical activity, training, and cardiac rehabilitation. Programs are based on a combination of endurance and resistance exercise and should be adapted to very high risk chronic kidney disease and haemodialysis patients and after kidney transplantation. Appropriate management of cardiovascular complications in these patients, such as risk factors, heart failure, arrhythmias, and coronary artery disease, is essential to ensure the best treatment and improve the prognosis. Therefore, we propose a critical and comprehensive review to suggest how to manage patients with chronic kidney disease in clinical practice and, specifically, with regard to cardiovascular risk assessment, exercise training prescription, and management of complications.

Hospital discharge is a crucial moment in the continuity of care, acting as a bridge between the acute phase and the treatment pathway that follows. Far from being a simple administrative act, it is a complex process requiring careful planning, effective communication, and the active involvement of all the stakeholders of the healthcare system, including the patient. Poor discharge management can have a negative impact on clinical outcomes, resulting in a higher risk of hospital readmission and inefficient use of healthcare resources. Taking into account the increasingly old, fragile population showing a high prevalence of comorbidities and complex care needs, it is essential to consider discharge as a comprehensive and integrated approach to the care continuum. This document arises from the necessity to share an updated and practical model for the management of hospital discharge, based on the latest scientific evidence and multidisciplinary experience, its aim being to promote continuity of care and personalized treatment as well as to improve health outcomes. The authors intend to provide clinical cardiologists with a unified tool for the management of patient discharge, offering concrete proposals to improve communication between physicians and patients, optimize therapies, and positively impact health outcomes.

Cardiac rehabilitation should be suggested after mitral valve intervention. Physical exercise is associated with improved cardiorespiratory fitness and clinical outcome and reduced rehospitalization and mortality in patients after heart valve surgery. Tailored assessment is the first step before starting a cardiac rehabilitation program. Physical examination, electrocardiogram, echocardiography, and peak exercise capacity stratify the risk of these patients when prescribing appropriate supervised aerobic and resistance exercise training. Cardiac rehabilitation participation impacts physical capacity, psychosocial function, and prognosis in patients after mitral valve surgery and transcatheter edge-to-edge repair. However, further evidence is needed on the efficacy and safety of cardiac rehabilitation programs, as well as standardization. In this review, we provide a contemporary and comprehensive update on the role of cardiac rehabilitation in patients after mitral valve intervention, after both mitral valve surgery and transcatheter mitral valve implantation. Specifically, we focus our review on the tailored assessment and management of these patients from post-operative to cardiac rehabilitation.

Background/Objectives: This study assessed the proportion of secondary cardiovascular prevention patients who achieved low-density lipoprotein (LDL) cholesterol targets as per the 2019 ESC/EAS Dyslipidemia Guidelines. We also evaluated whether lipid-lowering therapies (LLTs) were adjusted in patients not meeting targets and analyzed the likelihood of these modifications achieving recommended levels. Methods: A multicenter, cross-sectional observational study retrospectively reviewed medical records of 1909 outpatients in 9 Italian cardiac rehabilitation/secondary prevention clinics from January 2023 to June 2024. Inclusion criteria included prior atherosclerotic cardiovascular disease (ASCVD) and recent LDL-cholesterol levels. Data included demographics, ASCVD presentation, lipid profiles, and LLTs. Patients at very high risk had LDL targets of ≤55 mg/dL, or ≤40 mg/dL for recurrent events within 2 years. Clinicians’ approaches to LLT modification in patients not at target were recorded, with LLT efficacy estimated based on percentage distance from LDL-cholesterol targets. Results: Of the 1909 patients, 41.3% met the LDL-cholesterol target. Predictors of achieving targets included male gender, cardiac rehabilitation, recent acute coronary syndrome, diabetes, and triple therapy (statin + ezetimibe + PCSK9 inhibitors). Conversely, a target of ≤40 mg/dL, lack of therapy, and monotherapy were negative predictors. Among 1074 patients not at target, LLT modifications were proposed for 48.6%. Predictors of LLT modification included recent ASCVD events, cardiac rehabilitation, and greater percentage distance from the LDL target, while advanced age and an LDL target of ≤40 mg/dL were negative predictors. However, only 42.3% of modified therapies were predicted to be effective in reaching LDL targets. Conclusions: Despite 2019 ESC/EAS guidelines, a significant proportion of high-risk patients did not achieve LDL targets, and proposed LLT modifications were often insufficient. More intensive LLT regimens are needed to improve outcomes in this population.

Residential phase II Cardiac Rehabilitation (RCR) is characterized by frequent referral of patients with low functional capacity and higher residual risk, as compared to those engaged in out-patient programs. In this specific setting, usually covering the first period after a major cardiovascular event (MACE), training programs could be underpowered due to clinical instability and related comorbidities, despite strong need for rapid functional recovery and cardiovascular risk profile modification. To evaluate 1) the number of training sessions usually completed during RCR according to referral groups, and 2) its association with improvements of exercise capacity and lipid profile. Prospective single-centre observational study of consecutive patients directly tracked from acute facilities RCR after MACE. A minimal clinically important difference of +5% for functional capacity was considered. Lipid targets were derived from current ESC guidelines. The correlation between number of training sessions and functional capacity/lipid profile was evaluated by the Pearson correlation coefficient (r). A total number of 472 patients were considered, 86 of whom were excluded due to lack of program completion (i.e. death, emergency relocation, or voluntary discharge). Out of 386 evaluated (298/88 (77%/23%) M/F; age 69±12 years), 172 (45%), 106 (27%), 34 (9%), and 74 (19%) started RCR after acute coronary syndrome/primary angioplasty, acute heart failure, coronary surgery, and valve/great vessels surgery respectively, with an average time distance from MACE of 14±10 days and a RCR course of 24±9 days. Direct testing for functional capacity as an indicator of RCR outcomes was performed by means of short physical performance battery (SPPB), six minutes walking test (6MWT), and ergometry stress test (ET) in 135 (35%), 247 (64%), and 4 (1%) cases respectively. Globally, the number of completed training sessions was 31.2±12.1 (i.e. 29.3±12.1, 34.7±13.4, 30.3±9.7, and 31.0±10.3 among the four referral groups respectively). The improvement of functional capacity was displayed in 330 (86%) patients, while lipid target was achieved in 243 (63%) patients. A linear correlation between number of completed training sessions and better functional capacity (r= 0.175; p<0.05) was found in the whole study group, without significant differences between different testing methods (data for 6MWT in figure). Positive correlation was also found for achievement of individual lipid target (r= 0.150; p<0.05) but not for the absolute level of LDL-cholesterol at discharge (r= 0.052; p= 0.366). During RCR it seems difficult to reach the recommended training volume of 36 sessions, nevertheless a positive outcome is often displayed for functional capacity, with a "more sessions, more gain" dynamic. The achievement of lipid target seems to be influenced by total training volume also.

A growing body of evidence underscores the importance of investigating the patient journey in managing systemic disorders. This is particularly relevant in heart failure (HF), a condition in which achieving long-term outcomes requires advancements in the early detection, accurate diagnosis, and comprehensive treatment of HF throughout the patient's care experience. Addressing this challenge necessitates tackling critical barriers, including workforce shortages, insufficient funding, and limited awareness of HF care among both healthcare providers and patients. Cardiac rehabilitation (CR) plays a pivotal role within the continuum of care, serving as a cornerstone for engaging and motivating patients and caregivers. Despite its recognized value, gaps persist in the integration of CR into interconnected care networks and the broader healthcare system. This paper seeks to highlight the essential role of CR as a "bridging tool" to promote patient stabilization, emphasizing the implementation of guideline-directed medical therapy, as well as fostering patient education and empowerment. Achieving this integration requires embedding CR as a central component within the comprehensive management pathway for patients with HF.