Affordable Cardiac Rehabilitation: An Outreach Inter-disciplinary Strategic Study (ACROSS)

What is the ACROSS collaboration?
Who is the collaboration?
Need for the ACROSS programme
Public & patient involvement
Research activities & outputs
Capacity building & training
Our partners 

What is the ACROSS collaboration? | Home

“Ensuring global access to affordable and effective rehabilitation for people with heart disease to enable them to lead longer & healthier lives”

Working with partners in Bangladesh, Pakistan and India, the ‘Affordable Cardiac Rehabilitation: An Outreach Inter Disciplinary Strategic Study’ (ACROSS) programme will develop the infrastructure for development and delivery of clinically effective, affordable and culturally appropriate model of home-based CR. ACROSS is organised in four work packages to be undertaken in the three low and middle income countries (LMICs) - Bangladesh, Pakistan, and India:

  • Work Package 1: Intervention development: culturally adapt a home-based cardiac rehabilitation (CR) programme developed in United Kingdom.
  • Work Package 2: Feasibility study: pilot study in each country to determine the feasibility/acceptability of trial design and adapted rehabilitation intervention.
  • Work Package 3: Full trial: a multi-country full randomised trial to assess the clinical and cost-effectiveness of home-based CR plus usual care versus usual care alone in 3000 patients with coronary heart disease and/or heart failure with depression and/or anxiety with nested economic/process evaluation (trial design).
  • Work Package 4: Capacity development: build sustainable research and CR delivery capacity and enhance knowledge.


Evaluate the impact of a culturally-adapted, affordable, inter-disciplinary CR programme in three LMICs of Southeast Asia (Bangladesh, Pakistan, and India).


  1. Evaluate the impact of patient outcomes (survival, rehospitalisation rates, health-related quality of life, depression/anxiety) through delivery of a culturally-adapted, multidisciplinary CR programme on cardiac patients with co-morbidities.
  2. Evaluate the cost-effectiveness and feasibility of establishing a multidisciplinary CR programme in three LMICs of Southeast Asia,


Is the implementation of a culturally-adapted, multidisciplinary, home-based CR programme for patients diagnosed with CVDs and modifiable risk factors, as compared to usual care, is clinically effective and cost-effective when delivered within LMICs of Southeast Asian of Pakistan, India, and Bangladesh?

Who is the collaboration? | Home

The ACROSS collaboration brings together researchers and clinicians from Bangladesh, India, Pakistan, and United Kingdom


  • List of co-applicants and collaborators 


 United Kingdom


Need for the ACROSS programme | Home

 Global pattern of cardiovascular disease

Cardiovascular diseases (CVDs) are the number one cause of death globally, with an estimated 17.9 million people dying each year. By 2030, more than 80% of global CVD related disability and death are in middle-income countries especially South Asia, including Bangladesh, Pakistan, and India. (LMICs) by 2030 (Figure 3A). The economic burden of CVD is estimated to decrease LMIC gross domestic product by ~7% (ref). Burden is further accentuated by the increasing global prevalence of multimorbidity, driven by the ageing population, especially within a common multimorbidity cluster of cardiovascular disease and mental health disorders, including depression and anxiety. Depression is a global public health problem and when present in patients with heart disease, depression and anxiety are associated with poorer health related quality of life and higher costs.

 Current global provision of cardiac rehabilitation

Cardiac rehabilitation (CR) is an essential part of cardiovascular care, that reduces mortality, hospital admissions (with concomitant reductions in health & societal costs), and improves the health-related quality of life of patients. Key components are exercise, lifestyle change, medication management, psychological support (ref 1 | ref 2).

CR is a strong recommendation in clinical practice guidelines of HICs for management of post-myocardial, revascularisation, and heart failure patients (refs). However, our knowledge of CR has almost exclusively been developed in high-income settings and little is known about the potential effectiveness and cost-consequences of its delivery low- and middle-income countries (ref).  Furthermore, there is little or no guidance on how to deliver this treatment practically and affordably in low- and middle-income countries, especially for cardiac patients with multimorbidity.

Benefits of CR include reductions of mortality and unplanned hospitalisation and improvements in health-related quality of patients following post-myocardial infarction, revascularisation, and with heart failure (ref 1 | ref 2). However, a recent global survey has shown CR is grossly under-used, particularly in LMICs where CVD is at its’ worst, including South Asia (Figure 3B) (ref). This unmet need is illustrated by a recent global survey of CR identifying only one CR programme across the country of Bangladesh for an estimated 409,210 incidence of CHD per year (ref). In contrast in England there are 500 CR programme, estimated CHD incidence of 318,284 (ref).

Establishment of evidence based culturally appropriate, acceptable, and cost-effective models of CR for people with CHD or heart failure and depression or anxiety offers the opportunity for substantive patient, health service and socio-economic benefits in Bangladesh, Pakistan, and India. CR is comprised of several core components that include.

There is a therefore an urgent need to develop effective and cost-effective CR services in Bangladesh, India, and Pakistan. However, our knowledge of CR has almost exclusively been developed in HICs and little is known about the potential effectiveness, cost-consequences and acceptability of its delivery in LMICs. Furthermore, there is little or no guidance on how to deliver this treatment practically and affordably in low and middle-income countries, especially for cardiac patients with multimorbidity. The urgent need for accessible and affordable rehabilitation in LMICs is a current strategic objective of the World Health Organisation (ref).