Long-Term Attrition in a 12-Month Adapted Physical Activity Program After Cardiac Rehabilitation: A Real-World Longitudinal Study

Background: Exercise-based cardiac rehabilitation (CR) is a cornerstone of secondary cardiovascular prevention and improves functional capacity, quality of life, and clinical outcomes. However, maintaining long-term participation remains a major challenge in routine clinical practice. Adapted Physical Activity (APA) programs represent a community-based strategy to promote continued exercise after outpatient cardiac disease, although evidence regarding long-term retention and functional outcomes in real-world settings remains limited. The aim of this study was to evaluate attrition patterns during a 12-month APA follow-up pathway following cardiac rehabilitation and to explore longitudinal changes in functional outcomes among participants who remained under follow-up. Methods: This retrospective longitudinal observational study included 78 consecutive patients referred to an APA program following outpatient cardiac rehabilitation for myocardial infarction or other cardiovascular conditions. Assessments were performed at baseline (T0), 2 months (T1), 6 months (T2), and 12 months (T3). The primary outcome was attrition, operationally defined as failure to attend scheduled follow-up assessments. Secondary outcomes included walking speed during the 1 km Treadmill Walk Test, lower-limb functional performance, handgrip strength, balance, pain, and self-reported physical activity. Longitudinal changes were analyzed using linear mixed-effects models adjusted for age and sex. Results: Seventy-eight patients were enrolled (48 men, 29 women, one participant with missing sex data; mean age 64 ± 11 years). Follow-up attendance progressively declined from 81% at 2 months to 27% at 6 months and 18% at 12 months. Among participants with available follow-up data, significant improvements were observed in walking speed, lower-limb performance, balance, and motor pain during the early supervised phase of the program, with the most robust changes evident at the 2-month assessment (all p < 0.001). Although favorable values were also observed at later assessments, the marked loss to follow-up substantially limited interpretation of the 6- and 12-month estimates. Handgrip strength showed no significant longitudinal changes, while self-reported physical activity increased at 6 months but remained highly variable across participants. Conclusions: In this real-world APA follow-up pathway after cardiac rehabilitation, substantial attrition was observed, with fewer than one-fifth of participants attending follow-up assessments at 12 months. The most robust secondary finding was the short-term improvement in functional outcomes during the initial supervised phase. Long-term functional estimates should be considered exploratory because of the high attrition rate and potential survivor/selection bias. These findings highlight long-term retention as a key outcome for future community-based exercise programs and support the development of strategies aimed at improving sustained participation after cardiac rehabilitation.