With an aging population in many Western countries and increases in risk factors such as obesity, the number of patients with cardiovascular diseases (CVDs) is increasing. 1 These patients are at greater risk of subsequent events, comorbidities, and premature mortality, therefore effective and ongoing management is needed to reduce this risk. Cardiac rehabilitation programs (CRPs) are effective at improving lifestyle behaviors and reducing risk factors in patients with CVD, as well as reducing CVD events and premature mortality, while being cost-effective.2-5 As a result, the American Heart Association, and others, have highlighted participation in CRP as an essential element of secondary prevention in patients with CVD. [6][7][8] Despite the known benefits of CRP, as little as 10% to 30% of eligible patients attend these programs. [9][10][11][12][13] The majority of these programs are limited to hospitals in large urban areas with geographical accessibility as one of the main barriers to attendance.14,15 Lack of access is more pronounced for patients in rural areas that do not have CRP, 16,17 although risk factors such as smoking and obesity are higher in rural populations 18 resulting in a greater rate of hospitalizations than urban populations.19 Home-based CRP have been developed to address the accessibility issue, and a review of these studies found no difference to hospital-based CRP with respect to improvements in CVD risk. 20 However, these programs generally consist of a mix of on-site exercise sessions, clinic or home visits, telephone calls from staff, and diaries, which still require patients to attend some sort of clinic and therefore do not accommodate patients in outlying areas.The proliferation of low-cost communications technology, such as the Internet, has opened up an array of opportunities for patient communication while bridging geographic distance. The Internet holds great promise in improving access to healthcare services as it is ubiquitous, requires little infrastructure and cost, and is readily scalable to large populations. Despite the enthusiasm for technology supported healthcare services, the evidence to support such use in cardiac rehabilitation is limited to pilot studies. [21][22][23][24] As a result, a recent American Heart Association Presidential Advisory has called for more robust research to test the feasibility and effectiveness of Internet-based CRP. 25 Our goal therefore, was to test the clinical effectiveness of a virtual CRP (vCRP) delivered exclusively using Internet-based technology. Local Challenges in ImplementationA common challenge to the implementation of CRP is the cost of their implementation despite having been demonstrated to be cost-effective.5 This challenge also holds true for technology-based solutions. Although several communication technology mediums exist (telephone, video-conferencing, and telemonitoring), we chose to use a web-based program delivered through the Internet as it is (1) commonly available in people's homes, (2) requires less capital exp...

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