This highlights the importance of CR programs to help patients achieve their goals and to improve long-term outcomes.212 Multiple barriers exist to the adoption of preventive therapies, including knowledge defi- cit, ambivalence, comorbidities, preconceived beliefs, lack of support, employment, and readiness for change.347 349 For example, older patients with comorbidities who live alone are more likely after 1 year to remain sedentary and to have poor medication and diet compliance.350 Interventions for self-management of risk factors should be individualized to meet specific sex concerns. Women in par- ticular have difficulty with self-management of heart disease because of fatigue, anxiety, and depression, as well as feel- ings of guilt that home and family responsibilities are being Adherence to physical activity remains a challenging issue; 35% of women are no longer exercising 3 months after discharge from CR.353 In contrast, men experi- ence different barriers to secondary prevention compared with women. Some of the obstacles to compliance among men include comprehension of disease, dietary barriers (depen- dence on others for meals), and activity barriers (such as employment superseding CR).354 Participation in a hospital-based outpatient CR program compared with a home-based program helps improve exer- cise adherence for both men and women, increases knowledge about the condition for men, and improves stress control for Continuation of the secondary prevention education after discharge from CR can improve adherence to long-term self-management. Secondary prevention programs should be individualized, considering the patient s knowledge deficit. 