Short title: Cardiac Rehabilitation in Brazil

Background: Brazil has insufficient cardiac rehabilitation (CR) capacity, yet density and regional variation in unmet need is unknown. Moreover, South America has CR guidelines, but whether delivery conforms has not been characterized. This study aimed to establish: (1) CR volumes and density, and (2) the nature of programs, and (3) compare these by: (a) Brazilian region and (b) to other upper middle-income countries (upper-MICs). Methods: In this cross-sectional study, a survey was administered to CR programs globally. Cardiac associations were engaged to facilitate program identification. Density was computed using Global Burden of Disease study ischemic heart disease (IHD) incidence estimates. Results were compared to data from the 29 upper-MICs with CR (N=249 programs). Results: CR was available in all 5 regions (only one program in North), with 30/75 programs initiating a survey (40.0% program response rate). There was only one CR spot for every 99 IHD patient. Most programs were funded by government/hospital sources (n=16, 53.3%), but in 11 programs (36.7%) patients depended on private health insurance. Guideline-indicated conditions were accepted in ≥70% of programs. Programs had a team of 3.8±1.9 staff (versus 5.9±2.8 in other upper-MICs, p<0.05), offering 4.0±1.6/10core components (versus 6.0±1.5in other upper-MICs, p<0.01; more tobacco cessation and return-to-work counselling needed in particular) over 44.5 sessions/patient (Q25-75=29-65) vs 32 sessions/patient (Q25-75=15-40) in other upper-MICs (p