Aim The purpose of this study was to describe the proportions of patients referred to and attending cardiac rehabilitation programmes in Europe and to compare lifestyle and risk factor targets achieved according to participation in a cardiac rehabilitation programme. Methods The EUROASPIRE IV cross-sectional survey was undertaken in 78 centres from 24 European countries. Consecutive patients aged <80 years with acute coronary syndromes and/or revascularization procedures were interviewed at least six months after their event. Results A total of 7998 patients (24% females) were interviewed. Overall, 51% were advised to participate in a cardiac rehabilitation programme and 81% of them attended at least half of the sessions; being 41% of the study population. Older patients, women, those at low socio-economic status or enrolled with percutaneous coronary intervention and unstable angina, as well as those with a previous history of coronary disease, heart failure, hypertension or dysglycaemia were less likely to be advised to follow a cardiac rehabilitation programme. People smoking prior to the recruiting event were less likely to participate. The proportions of patients achieving lifestyle targets were higher in the cardiac rehabilitation programme group as compared to the non-cardiac rehabilitation programme group: stopping smoking (57% vs 47%, p < 0.0001), recommended physical activity levels (47% vs 38%, p < 0.0001) and body mass index<30 kg/m (65% vs 61%, p=0.0007). However, there were no differences in the blood pressure, lipids and glucose control. Patients who attended a cardiac rehabilitation programme had significantly lower anxiety and depression scores and better medication adherence. Conclusions Only half of all coronary patients were referred and a minority attended a cardiac rehabilitation programme. Those attending were more likely to achieve lifestyle targets, had lower depression and anxiety, and better medication adherence. There is still considerable potential to further reduce cardiovascular risk by increasing uptake and fully integrating secondary prevention and cardiac rehabilitation to provide a modern preventive cardiology programme.