Understanding Frailty in Cardiac Rehabilitation: A Scoping Review of Prevalence, Measurement, Sex and Gender Considerations, and Barriers to Completion

Abstract

Background/Objectives: Frailty is a multifactorial clinical syndrome characterized by diminished physiological reserves and increased vulnerability to stressors. It is increasingly recognized as a predictor of poor outcomes in cardiac rehabilitation (CR). However, how frailty is defined, assessed, and addressed across outpatient CR programmes remains unclear. This scoping review aimed to map the extent, range, and nature of research examining frailty in the context of outpatient CR, including how frailty is measured, its impact on CR participation and outcomes, and whether sex and gender considerations or participation barriers are reported. Methods: Following the PRISMA-ScR guidelines, we conducted a comprehensive search across six electronic databases (from inception to 15 May 2025). Eligible peer-reviewed studies included adult participants assessed for frailty using validated tools and enrolled in outpatient CR programmes. Two reviewers independently screened citations and extracted data. Results were synthesized descriptively and narratively across three domains: frailty assessment, sex and gender considerations, and barriers to CR participation. The protocol was registered with the Open Science Framework. Results: Thirty-nine studies met inclusion criteria, all conducted in the Americas, Western Pacific, or Europe. Frailty was assessed using 26 distinct tools, most commonly the Kihon Checklist, Fried's Frailty Criteria, and Frailty Index. The median pre-CR frailty prevalence was 33.5%. Few studies (n = 15; 38.5%) re-assessed frailty post-CR. Sixteen studies reported sex or gender data, but none applied sex- or gender-based analysis (SGBA) frameworks. Only eight studies examined barriers to CR participation, identifying physical limitations, emotional distress, cognitive concerns, healthcare system-related factors, personal and social factors, and transportation as key barriers. Conclusions: The literature on frailty in CR remains fragmented, with heterogeneous assessment methods, limited global representation, and inconsistent attention to sex, gender, and participation barriers. Standardized frailty assessments and individualized CR programme adaptations are urgently needed to improve accessibility, adherence, and outcomes for frail individuals.

Keywords: access to care; barriers to care; cardiac rehabilitation; frailty; gender identity; health equity; older adults; participation; secondary prevention; sex differences.

Figure 1

PRISMA flow diagram.