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A Cross-Sectional Examination of Sex-Based Differences in Cardiac Rehabilitation Participation From the Behavioral Risk Factor Surveillance System.

S. Gore,Amol M Karmarkar,Lin-Na Chou,S. Mily,Amit Kumar

Published 2026 in Journal of Cardiopulmonary Rehabilitation and Prevention

ABSTRACT

PURPOSE Following an acute myocardial infarction (AMI), females often experience worse outcomes than males. However, sex-specific disparities in cardiac rehabilitation (CR) participation, along with the roles of income and education, have not been thoroughly investigated. This study examined sex-specific differences in CR participation following AMI and how education and income mediate this association. METHODS We analyzed cross-sectional data from the Behavioral Risk Factor Surveillance System for adults aged ≥45 years with a history of AMI who responded to a CR participation question in 2009 (n = 1289) and 2017 (n = 1383), across 4 states and Washington, DC. The study outcome was participation in CR following AMI. Mediation and moderation analyses were performed to examine the effects of sex, education, and income on CR participation. RESULTS Females were significantly less likely to participate in CR than males. Mediation analysis revealed a negative association between sex and CR participation, mediated by income and education (β = -.135, SE = 0.024, P <.001), along with a significant direct effect (β = -.383, SE = 0.083, P <.001). Moderation analysis showed that females were less likely to participate in CR across several subgroups: White females compared with White males (OR = 0.70: 95% CI, 0.58-0.85), married females compared with married males (OR = 0.50: 95% CI, 0.38-0.67), and significantly lower among females across both age groups. CONCLUSIONS Female participation in CR remains significantly lower than males, partially mediated by lower education and income levels. These findings underscore the need for targeted strategies to enhance CR awareness, accessibility, and adherence among females.

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