666781

research-article2016
CNU0010.1177/1474515116666781European Journal of Cardiovascular NursingBertelsen et al.

EUROPEAN
SOCIETY OF
Original Article CARDIOLOGY ®

European Journal of Cardiovascular Nursing

Cardiac rehabilitation after acute

2017, Vol. 16(4) 334­–343
© The European Society of Cardiology 2016
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DOI: 10.1177/1474515116666781
https://doi.org/10.1177/1474515116666781

adherence and risk factor modification journals.sagepub.com/home/cnu

in a community-based shared care model

versus hospital-based care in a randomised
controlled trial with 12 months of follow-up

Jannik B Bertelsen1, Jens Refsgaard2, Helle Kanstrup1,

Søren P Johnsen3, Ina Qvist4, Bo Christensen5
and Kent L Christensen1

Abstract
Aim: To investigate whether phase II cardiac rehabilitation (CR) conducted by a community model of shared care CR
(SC-CR) including health care centres and general practice was feasible and provided acceptable results and to compare
SC-CR to hospital-based CR (H-CR) in a randomised controlled trial.
Methods: Patients were randomised to H-CR or SC-CR after admission for acute coronary syndrome. In SC-CR, the
general practitioner took over the responsibility of the remaining rehabilitation, pharmacological treatment and risk
factor management after the initial visit to the hospital outpatient clinic. The Municipal Health Care Centres provided
courses on smoking cessation, nutrition, and exercise training and contributed to disease education and psychosocial
support. The main endpoint was adherence to the CR programme and compliance with lifestyle modifications.
Results: In total, 1364 patients were screened, 327 (24%) were eligible, and 212 (65%) accepted participation. Phase II
CR was completed by 192 (91%) of the participants. Full adherence to the CR programme was seen in 53% in SC-CR
versus 54% in H-CR (relative risk (RR): 0.98, 95% confidence interval: 0.73–1.32). In H-CR, patients had higher rates of
adherence to dietary advice and health education. In SC-CR, 12% of patients did not attend the risk factor evaluation and
clinical assessment with their general practitioner. No difference in risk factor improvement was found. Exercise training
was declined by 25% in both groups.
Conclusion: Adherence to phase II CR was high in both groups. SC-CR did not improve adherence and efficacy, but
had comparable effects on medication and risk factors. Thus, SC-CR was safe and effective.

Keywords
Ischaemic heart disease, secondary prevention, cardiac rehabilitation, acute coronary syndrome, shared care,
community-based, randomised controlled trial, health care organisation

Date received: 12 February 2016; revised: 11 May 2016; accepted: 9 August 2016

1Department of Cardiology, Aarhus University Hospital,
Denmark
2Department of Cardiology, Viborg Regional Hospital, Denmark
3Department of Clinical Epidemiology, Aarhus University Hospital,
Denmark
4Department of Medicine, Silkeborg Regional Hospital, Denmark
5Instituteof Public Health, Section for General Practice, Aarhus
University, Denmark
Corresponding author:
Jannik B Bertelsen, Department of Cardiology, Aarhus University
Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
Email: jannik.bertelsen@auh.rm.dk
Bertelsen et al. 335
Introduction
Multifactorial cardiac rehabilitation (CR) in ischaemic
heart disease has a proven benefit on survival, on risk of
cardiovascular death, on adherence to drug therapy, and on
lifestyle modification.1,2 CR is recommended for all
patients after acute coronary syndrome (ACS) (myocardial
infarction and unstable angina pectoris) with stable angina,
with heart failure, and after bypass or valvular surgery.
However, not all patients are systematically offered or
referred to CR. Frequently reported barriers for referral
and attending CR programmes were logistics due to the
distance to the CR centre, patients’ beliefs that they could
handle their own problems, and simply a lack of time.3,4
After discharge, phase II CR has been carried out in
hospital outpatient clinics, after which the general practi-
tioner (GP) takes over secondary prevention from phase
III. In Denmark, CR is financed from taxes and is hence
free of charge, and transportation times are generally
short. Despite these favourable circumstances, adherence
to CR does not appear to be higher in Denmark than in
other countries (i.e. 50–79%).5,6 Primary care providers
have now been made more responsible than they previ-
ously were for the education, control, and treatment of
patients with chronic diseases (Danish Health Reform Act
of 2007). The GPs are supported in this task by the newly
established public Municipal Health Care Centres
(MHCCs). In the MHCCs, patients with chronic diseases,
including heart disease referred from a GP, are encour-
aged to adopt lifestyle modification through programmes
involving exercise, smoking cessation, health education,
and nutrition.
The aim of this study was to establish a phase II model
of shared care CR (SC-CR) between hospitals, GP, and
municipalities and to compare adherence and efficacy con-
cerning risk factor management and pharmacological
treatment in SC-CR with hospital-based CR (H-CR) after
ACS in a randomised controlled trial.
Materials and methods
Trial design
The study was designed as an open 1:1 randomised con-
trolled trial for comparing H-CR with SC-CR. Detailed
information on the trial protocol has previously been
published.7
Participants
Patients who were hospitalised due to ACS in the four
coronary units within Aarhus University Hospital, the
Central Hospital Unit, Viborg, and Silkeborg Regional
Hospitals were screened by study nurses. Eligible patients
were informed before discharge by the cardiologist and
enrolled in the trial by the study nurses.
Inclusion criteria
•• Angiographically documented coronary thrombosis
or stenosis
•• Resident in one of the participating municipalities:
Aarhus, Viborg, Silkeborg, Skive, Samsø, Favrskov,
or Skanderborg
•• No previous cardiac rehabilitation
•• ⩾18 but <80 years of age
•• Written informed consent, including acceptance of
both models of rehabilitation before randomisation
Exclusion criteria
•• Myocardial infarction on a non-thrombotic basis
•• Ejection fraction ⩽40% as evaluated by echocardi-
ography
•• Lack of physical or mental ability to participate in a
complete CR course evaluated by at least two mem-
bers of the project staff based on an evaluation of
the physical and mental function of the patient
•• Resuscitation from cardiac arrest if ergotherapy was
needed after discharge
•• Inability to write and understand Danish without help
•• Any other disease causing severe disability, includ-
ing pulmonary disease (Forced Expiratory Volume 1
second <1 L/second), neurological disease (cerebro-
vascular insult), severe kidney disease (uraemia,
serum creatinine >300 µM/L), hepatic cirrhosis, or
cancer
Interventions
SC-CR.  In SC-CR, the GP played a more prominent role in
phase II CR than in the hospital-based model, but with the
same level of lifestyle moderating being offered, as seen in
Figure 1. Details on the components of SC-CR are shown
in Table 1. The first visit was in the outpatient clinic at 1–2
weeks after discharge. A specialised nurse and a cardiolo-
gist conducted a clinical assessment, and a Watt max bike
exercise test was performed. Then, the patient was referred
to the GP. Individualised optimal treatment goals were
noted on each patient’s chart by the cardiologist, including
targets for blood pressure, cholesterol, and body mass
index (BMI)/weight. This information was communicated
to the GP as part of the discharge document. Risk factor
management and pharmacological treatment were then
managed by the GP. All patients were encouraged to con-
sult their GP a few weeks after discharge, and again at the
end of the phase II CR programme.
The discharge chart was also made available to the
MHCC, which provided courses on smoking cessation,
nutrition, and exercise training and contributed to disease
education and psychosocial support. The patient was con-
tacted by the MHCC (by phone or letter), and an individual
meeting was scheduled as an introduction to the MHCC
CR programme.
336 European Journal of Cardiovascular Nursing 16(4)
Figure 1.  Components in the Danish randomised controlled
trial ‘Shared care rehabilitation after acute coronary syndrome’,
conducted in the Danish Central Region, 2011–2014.
CR: cardiac rehabilitation.
H-CR.  The H-CR was performed entirely within hospital
outpatient clinics, as seen in Figure 1. Details on the com-
ponents of H-CR are shown in Table 2. The H-CR pro-
gramme terminated with a consultation with a cardiologist
concerning risk factors and future medication. A discharge
note was then sent to the GP, who took over future risk
factor management from phase III of the CR. Further
details have been published in the protocol article.
Outcomes
The primary outcome was defined as adherence to the CR
programme, measured as a composite of the participation
in the different components of the programme8:
•• Smoking cessation, if a smoker
•• Dietary advice
•• Exercise training
•• Clinical assessment by a doctor
•• Patient education
Participation in one component was defined as attending
50% or more of the sessions in the component. Full partici-
pation involved participation in all components (five of
five if a smoker, four of four if a non-smoker).
Efficacy was evaluated by changes in the listed second-
ary outcomes: 24-hour ambulatory blood pressure meas-
urement, weight, abdominal circumference, cholesterol
levels, fasting blood glucose, haemoglobin A1C, pre-
scribed cardiovascular medicine, and compliance with
lifestyle modifications.
Sample size
Using Danish Heart Association data, we hypothesised
that SC-CR would improve the rate of full attendance by
20% up to 55%.9 This was considered realistic because a
previous Danish study reported that 58.5% of all patients
participated fully or partially in the CR component of
health education at the hospital.5 The expected sample size
of 208 participants would enable us to identify such an
increase in the attendance rate with a power of 0.80 and a
two-sided p-value of <0.05. The proportion of patients
who dropped out or withdrew was expected to be 10%.
Randomisation
Computer randomisation was performed after consent was
obtained, stratified by hospital and municipality, ensuring
an equal distribution of H-CR and SC-CR in each hospital.
Blinding was not possible.
Ethical considerations
The study was conducted in accordance with good clinical
practice and the ethical standards described in the Helsinki
Declaration. The Central Denmark Region Committees on
Biomedical Research Ethics j.nr. M-20110135 and the
Danish Data Protection Agency approved the study proto-
col j.nr. 2011-41-6533, which was changed to 2014-41-
3342 in 2014.
Statistical analysis
Data analysis was performed according to the intention-to-
treat principal. Patients leaving the trial due to medical
reasons at the first rehabilitation visit were censored as
excluded. Patients withdrawing from the study before the
baseline visit were censored as withdrawals. Patients lost
to follow-up were censored as dropouts. Comparison of
the SC-CR and H-CR groups in the primary endpoint of
full adherence to CR was analysed using relative risk with
95% confidence intervals (CIs). In the efficacy evaluation,
changes in the secondary outcomes were analysed by
Student’s paired t-tests when data were parametrically
distributed. Non-parametric data were analysed by
Wilcoxon signed rank test. Data analysis was performed
in STATA 12.1.
Results
Inclusion lasted from 10 October 2011 to 24 March 2013.
Four-month follow-up occurred between 2 February 2012
and 31 August 2013 as soon as phase 2 CR was completed,
or 5 months after admission if CR was delayed or if a
bypass operation was needed. One patient experienced a
rupture of the Achilles tendon during exercise; otherwise,
no major events were reported throughout the trial. The
trial flowchart is shown in Figure 2.
Bertelsen et al. 337

Table 1.  Components of shared-care cardiac rehabilitation in different municipalities.

Municipality Initial and end of Physical exercise Health education Smoking Dietary advice Risk and clinical
course cessation evaluation
Aarhus Individually Group-based (10 Group-based (10 Individually Individually Individually
2 sessions, each 30 patients) patients) 2 sessions, 2 sessions, each 45 1 session, 15
minutes 30 sessions, each 60 7 sessions, each 45 each 15 minutes minutes
By physiotherapist minutes minutes minutes By nurse or By general
or nurse By physiotherapist By rehabilitation nurse By nurse dietician practitioner
Viborg Individually Group-based Group-based (10–12 Individually Group-based Individually
2 sessions, each 30 (10–12 patients) patients) 1 session, 15 (10–12 patients) 1 session, 15
minutes 12 sessions, 60 7 sessions, each 45 minutes 2 sessions, 60 minutes
By physiotherapist minutes and 12 minutes By nurse minutes and 2 By general
or nurse sessions, 90 minutes By rehabilitation nurse sessions, 150 practitioner
By physiotherapist minutes
By nurse or
dietician
Silkeborg Individually Group-based (10 Group-based (10 Individually Group-based (10 Individually
2 sessions, each 30 patients) patients) 2 sessions, patients) 1 session, 15
minutes 12 sessions, 60 8 sessions, each 60 each 15 2 sessions, 60 minutes
By physiotherapist minutes and 12 minutes minutes minutes and 2 By general
or nurse sessions, 90 minutes By nurse By nurse sessions, 150 practitioner
By physiotherapist minutes
and nurse By nurse or
dietician
Skive Individually Group-based (10 Group-based (5 Individually Group-based (10 Individually
2 sessions, each 30 patients) patients) 2 sessions, patients) 1 session, 15
minutes 16 sessions, each 60 7 sessions, each 60 each 15 2 sessions, 90 minutes
By physiotherapist minutes minutes minutes minutes By general
or nurse By physiotherapist, By rehabilitation By nurse By dietician practitioner
nurse and specialist, nurse and
ergonomist ergonomist
Favrskov Individually Group-based (10 Individually Individually Individually Individually
2 sessions, each 30 patients) 2 sessions, each 45 2 sessions, 2 sessions, each 30 1 session, 15
minutes 30 sessions, each 90 minutes each 15 minutes minutes
By physiotherapist minutes By rehabilitation nurse minutes By dietician By general
or nurse By physiotherapist By nurse practitioner
and nurse
Skanderborg Individually Group-based (10 Group-based (10 Individually Group-based (10 Individually
2 sessions, each 30 patients) patients) 2 sessions, patients) 1 session, 15
minutes 12 sessions, 60 7 sessions, each 45 each 15 2 sessions, 60 minutes
By physiotherapist minutes and 12 minutes minutes minutes and 2 By general
or nurse sessions, 90 minutes By rehabilitation nurse By nurse sessions, 150 practitioner
By physiotherapist minutes
and nurse By nurse or
dietician
Samsø Individually Group-based (5 Group-based (5 Individually Group-based (5 Individually
2 sessions, each 30 patients) patients) 2 sessions, patients) 1 session, 15
minutes 24 sessions, each 60 3 sessions, each 45 each 15 2 sessions, 45 minutes
By physiotherapist minutes minutes minutes minutes By general
or nurse By physiotherapist By nurse By nurse By nurse or practitioner
and nurse dietician

Table 3 shows patient baseline characteristics at the
time of randomisation. Women constituted 25% of the
patients, forming 21% in H-CR and 29% in SC-CR
(p = 0.09). The mean transportation time between the home
and the rehabilitation facility to the MHCC was 19 min-
utes (range: 4–150) and to the hospitals was 26 minutes
(range 5–120) (p = 0.54).
Adherence to phase II CR is shown in Table 4. No dif-
ference was seen in terms of full adherence to the combined
CR programme (SC-CR vs. H-CR, RR: 0.98, 95% CI:
0.73–1.32). Adherence to the individual components of the
programmes varied. Adherence rates to dietary advice (RR:
0.61, 95% CI: 0.46–0.80) and health education (RR: 0.63,
95% CI: 0.48–0.83) were significantly lower in the SC-CR
338 European Journal of Cardiovascular Nursing 16(4)

Table 2.  Components of hospital-based cardiac rehabilitation in different hospitals.

Hospital Initial rehabilitation Physical exercise Health Smoking cessation Dietary Risk and clinical
education advice evaluation at end
of rehabilitation
Aarhus Individually Group-based (12 Individually Individually Individually Individually
University By rehabilitation patients) 1–3 sessions, 1–3 sessions, each 30 2 sessions, 75 By nurse for
Hospital nurse for 60 minutes 24 sessions, each each 30 minutes minutes – included in minutes and 30 minutes and
and with cardiologist 75 minutes By rehabilitation health education 25 minutes cardiologist for
for 45 minutes By physiotherapist nurse By rehabilitation nurse By dietician 30 minutes
Viborg Individually Group-based (10 Group-based Individually Group-based Individually
Regional By rehabilitation patients) (20 patients) 3 sessions, each 15 (20 patients) By nurse for
Hospital nurse for 45 minutes 16 sessions, each 7 sessions, each minutes 1 session, 45 30 minutes and
and cardiologist for 60 minutes 45 minutes By nurse minutes cardiologist for
30 minutes By physiotherapist By rehabilitation By nurse 15 minutes
and nurse nurse
Silkeborg Individually Group-based (10 Group-based (8 Individually Group-based Individually
Regional By rehabilitation patients) patients) 3 sessions, each 30 (8 patients) By nurse for
Hospital nurse for 60 minutes 24 sessions, each 3 sessions, each minutes 1 session, 45 30 minutes and
Cardiologist available 60 minutes 90 minutes By nurse minutes cardiologist for
By physiotherapist By nurse By dietician 15 minutes

arm. In SC-CR, risk factor evaluation and clinical assess-
ment at the end of CR were to be performed by the GP;
however, 12% did not attend, whereas all patients in H-CR
attended the evaluation and clinical assessment by the car-
diologist at the hospital. Exercise training was declined by
approximately 25% of the patients in both groups.
Table 5 shows the percentages of patients achieving the
recommended treatment targets and the prescribed cardio-
vascular medicine at discharge, at the end of phase II CR,
and at 12 months after ACS. No differences were found
regarding total cholesterol, low-density lipoprotein choles-
terol, daily exercise, blood pressure, smoking status, waist
circumference, or BMI. Overall, the percentage of patients
achieving the target blood pressure seemed to decline from
baseline to follow-up, but while an increasing percentage
of patients in SC-CR achieved the recommended blood
pressure target, the percentage was decreasing in H-CR. In
general, all patients were treated with statins and aspirin,
and most were also given a second platelet inhibitor.
Approximately 80% received a beta-blocker. Close to a
third had a renin–angiotensin–aldosterone system (RAAS)
inhibitor prescribed. At the end of phase II, CR RAAS
inhibition increased in both groups to approximately 40%.
At 12 months after ACS, adherence to statins was signifi-
cantly higher in H-CR, but otherwise only small differ-
ences were observed.
Discussion
The shared care model did not improve the adherence to
and efficacy of the SC-CR programme compared with
H-CR, which was our primary outcome, but we found no
indication that SC-CR was not safe. In the H-CR arm,
significantly more patients had risk factor evaluation,
dietary advice, and clinical assessment performed at the
end of CR. Adherence to dietary advice and health
education was better in H-CR. Several participants in
both treatment arms chose not to take part in exercise
training.
CR adherence was similar to the adherence rates
reported in other trials.3,6,10 One of the main differences in
the two CR models was the location of the rehabilitation
facilities. However, the median difference in transporta-
tion time between the hospital and the MHCC turned out
to be too small for evaluating a superior effect of transpor-
tation time on adherence.
Achievement of lifestyle targets seemed difficult to
obtain, which corresponds to the findings from the
EUROASPIRE IV survey.11 Chow et al. found that a ben-
efit from adherence to behavioural advice (smoking, diet,
and exercise) was seen after 6 months.2 The finding of
smoking cessation in approximately 50% is similar to
that which has been found in other studies; however, the
percentage fulfilling the recommendation of 30 minutes
of exercise on ⩾5 days a week declined in both groups
during the phase II CR period. Similar effects have been
reported previously.12 Recently, a dose–response rela-
tionship between the number of CR sessions attended and
mortality was reported, and long-term survival benefits
in patients joining a comprehensive CR programme has
also made the effort of increasing adherence to CR even
more advantageous, and hence a relevant measure of
exercise in particular.10,13 However, the shared care model
did increase adherence to exercise training.
Adherence to the recommended medication was high,
being almost complete to dual antiplatelet therapy and
statins and at approximately 80% to beta-blockers.
However, only 40% received RAAS inhibition medica-
tion. Approximately 80% in a Dutch study and 65% in a
French study received this type of medication.12,14
Bertelsen et al. 339

Figure 2.  Flowchart of the Danish randomised controlled trial ‘Shared care rehabilitation after acute coronary syndrome’
conducted in the Danish Central Region, 2011–2014. Three of the 99 in the hospital-based cardiac rehabilitation group did not
complete the questionnaires at the 4-month follow-up. CAG: Coronary Angiography; CABG: Coronary Artery Bypass Grafting.

Approximately 75% of our patients were normoten-
sive at the first clinical examination. Strangely, the per-
centage of patients achieving the recommended blood
pressure values decreased from baseline to follow-up in
H-CR and increased in H-CR. An Austrian study found
that 91% achieved the target blood pressure after CR, but
this study included heart failure patients.15 Potentially,
the percentage achieving the target blood pressure may
have been higher if RAAS inhibitors had been prescribed
more aggressively. There is no very obvious explanation
for this, but according to the PEACE study, the useful-
ness of angiotensin-converting enzyme inhibitors in
patients with ACS and normal blood pressure is not nec-
essarily very high.16
Participation in the trial was rejected by 35% of poten-
tial candidates. The patients declining to participate had,
on average, a higher mean age and more frequently were
more women, and the main reason they provided was a
lack of surplus energy due to uncertainty related to the ran-
domisation and the possibility of facing a new model of
340 European Journal of Cardiovascular Nursing 16(4)

Table 3.  Baseline data from the randomised controlled trial ‘Shared care rehabilitation after acute coronary syndrome’, conducted
in the Danish Central Region, 2011–2014.

Variable Outcome Shared care (n = 106) Hospital (n = 106) p-value

Sex male/female (%)   71/29 79/21 0.085
Age, years (mean; range)   60; 40–79 60; 30–78 0.71
Diagnosis (%) 0.63
  STEMI 41 46  
  NSTEMI 36 35  
  UAP 24 19  
Hospital (%) 1.00
  Aarhus University Hospital 50 50  
  Central Hospital Unit 50 50  
Municipality (%) 0.87
  Aarhus 46 46  
  Viborg 27 30  
  Skive 15 12  
  Other municipalities 12 12  
Transportation time, minutes (mean; range)
  Hospital 25; 4–150 26; 5–120 0.54
  Health Care Centre 20; 5–50 20; 5–75 0.74
Chronic diseases (%)  
  None 34 42 0.32
  Diabetic disease 10 8 0.82
  Metabolic disease 1 2 0.50
  Pulmonary disease 10 4 0.11
  Kidney disease 4 4 1.00
  Rheumatologic disease 8 8 1.00
  Hypertension 41 34 0.39
  Hypercholesterolaemia 44 33 0.12
Daily smoking at admission (%)   34 42 0.24
Living alone (%)   14 19 0.34
No children (%)   8 7 0.79
Education (%) 0.33
  None 25 12  
  Skilled 40 42  
  Short (⩽3 years) 8 9  
  Intermediate 17 24  
  Long (⩾5 years) 7 9  
  Other education 3 3  
Living alone, no education or 59 51 0.26
age <55 years (%)
Retired (%)   43 42 0.89

STEMI: ST-elevation myocardial infarction; NSTEMI: non-ST-elevation myocardial infarction; UAP: unstable angina pectoris.

Table 4.  Participation in the different elements of phase II cardiac rehabilitation at the 4-month follow-up in percentages.

  Shared care (%) (n = 93) Hospital care (%) (n = 99) RR 95% CI

  ⩾50% <50% Declined ⩾50% <50% Declined

Exercise lessons 54 16 30 65 11 24 0.80 0.60–1.06
Dietary advice 70 9 21 88 1 11 0.61 0.46–0.80*
Education 59 37 4 80 5 15 0.63 0.48–0.83*
Smoking cessation 12 0 88 10 0 90 1.14 0.40–3.28
General practitioner 88 0 12 67 0 33 2.22 1.30–3.77*
Physician at cardiac rehabilitation end 88 0 12 100 0 0 0.45 0.39–0.53*
Full adherence 53 54 0.98 0.73–1.32
One component missing 17 33 0.61 0.39–0.93*

The physician at the end of cardiac rehabilitation was a general practitioner in the shared care arm and a cardiologist in the hospital arm. Full adher-
ence was found in all components of the combined cardiac rehabilitation programme.
RR: relative risk for participation in ⩾50% of a component of shared care compared to hospital care; CI: confidence interval. * Statistical significant.
Table 5.  Percentages of patients achieving the recommended treatment goals at baseline and after phase II cardiac rehabilitation and at the 12-month follow-up.
Bertelsen et al.

Treatment goal Achieving treatment goal Achieving treatment Shared care vs. Achieving treatment goal Shared care vs. hospital
at baseline (%) goal after phase II (%) hospital after phase II after 12 months (%) after 12 months

Hospital Shared care Hospital Shared care RR 95% CI Hospital Shared care RR 95% CI
(n = 100) (n = 100) (n = 99) (n = 93) (n = 97) (n = 93)
Total cholesterol <4 mmol/L 13 22 64 63 1.00 0.74–1.35 75 57 0.67 0.51–0.89*
LDL cholesterol <1.8 mmol/L 6 14 48 41 0.86 0.63–1.16 47 36 0.80 0.58–1.09
Exercise daily minimum 30 minutes/5 54 49 49 45 0.93 0.69–1.24 58 55 0.93 0.68–1.25
days/week
Daily smokers 44 39 20 17 0.98 0.60–1.59 – – – –
Smoke reduction ⩾50% at follow-up  – –  75 63 0.73 0.36–1.51 – – – –
BP ⩽130/80 mmHg 65 54 57 53 0.92 0.69–1.24 44 41 0.93 0.68–1.27
BP <135/85 mmHg 83 69 73 73 1.00 0.71–1.39 64 72 1.21 0.86–1.71
Waist circumference
Males <94 cm, Females <80 cm 21 21 27 26 0.97 0.69–1.36 28 28 0.99 0.72–1.37
Males 94–102 cm 36 24 33 25 0.80 0.56–1.14 33 24 0.77 0.54–1.11
Females 80–88 cm
Males >102 cm 43 55 39 49 1.22 0.91–1.63 39 48 1.12 0.84–1.48
Females >88 cm
BMI
<25 kg/m2 36 33 29 24 0.87 0.61–1.24 29 24 0.87 0.61–1.24
25–30 kg/m2 48 41 51 42 0.81 0.60–1.10 51 42 0.81 0.60–1.10
>30 kg/m2 15 26 20 34 1.45 1.08–1.93 20 34 1.45 1.08–1.93*
HbA1c <6.5% 16 18 9 13 1.26 0.85–1.87 9 13 1.26 0.85–1.87
Acetyl salicylic acid 100 99 98 96 0.72 0.40–1.29 96 95 0.88 0.48–1.60
Clopidogrel/ticagrelor 93 93 94 91 0.84 0.52–1.35 61 66 1.11 0.82–1.52
Statins 99 98 96 95 0.87 0.47–1.58 99 92 0.54 0.40–0.73*
Beta-blockade 81 77 77 84 1.28 0.84–1.96 70 75 1.15 0.81–1.62
RAAS inhibitor 34 33 40 41 1.01 0.75–1.36 40 46 1.13 0.85–1.51
Diuretics 12 22 13 17 1.17 0.81–1.68 12 15 1.12 0.76–1.65
Other antihypertensives 21 16 19 23 1.11 0.79–1.56 24 27 1.09 0.79–1.50

Target treatment goals are carefully communicated to the general practitioner at discharge in cases of shared care rehabilitation at the 4-month follow-up.
* Statistically significant. LDL: low-density lipoprotein; BP: daytime average ambulatory blood pressure; RAAS: renin–angiotensin–aldosterone system; RR: relative risk reported as shared care versus
hospital-based cardiac rehabilitation; CI: confidence interval.
341
342 European Journal of Cardiovascular Nursing 16(4)
CR. Due to the rejection rate and a sample size of 212,
caution must be exerted when generalising our findings.
The data did not allow for subgroup analysis of transporta-
tion time or comorbidity.
The objective of this trial was to evaluate adherence to
CR in a new setting with primary care in charge. The trial
results could be extrapolated to other hospitals and munici-
palities in Denmark, since the model is based on exploiting
existing resources that are now present in all Danish
municipalities, but high attention to inter-sectoral coordi-
nation in the CR course is important. A model with nurses
coordinating the course between sectors has been described
as a useful measure.17
The Organisation for Economic Co-operation and
Development report on Danish Health quality from
2013 emphasises the need for specific quality initiatives
focused on coordination between primary and secondary
care.18 This can be accomplished with the SC-CR model.
However, the model has to be further developed, and ideas
for promoting greater programme adherence and lifestyle
modifications are still needed, but the model provides an
opportunity to offer CR to a broader group of patients in
the local community, hopefully with high-quality and good
outcomes for the patients in a health care system, thereby
meeting future requirements of quality and productivity at
a reduced cost.
Conclusion
We report the first randomised trial investigating whether
implementing a shared care programme between the spe-
cialised hospital unit, the community-based MHCC and
the GP could increase adherence to CR. We succeeded in
describing and implementing this type of care sharing, but
the shared care model was not associated with improved
programme adherence. The achievement of targets for
cholesterol, smoking cessation, blood pressure, and other
medical therapies was equal just after CR, and SC-CR was
found to be safe.
Implications for practice
•• The shared care model of cardiac rehabilitation
between the specialised hospital unit, the com-
munity-based Municipal Health Care Centre and
the general practitioner is described and could be
implemented.
•• The shared care model was not associated with
improved programme adherence compared to
hospital-based cardiac rehabilitation.
•• The achievement of targets for cholesterol,
smoking cessation, blood pressure, and other
medical therapies was equal just after cardiac
rehabilitation.
Trial registration: clinicaltrials.gov identifier: NTC
01522001.
Acknowledgement
The staff of the Municipal Health Care Centres of Aarhus,
Viborg, Skive, Silkeborg, Favrskov, Skanderborg, and Samsø
and the cardiac rehabilitation staff of the Department of
Cardiology, Aarhus University Hospital and Viborg and
Silkeborg Regional Hospitals are thanked.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
The trial is funded by the Central Region Denmark as a part of
the chronic care programme.
References
1. Bramlage P, Messer C, Bitterlich N, et al. The effect of
optimal medical therapy on 1-year mortality after acute
myocardial infarction. Heart 2010; 96: 604–609.
2. Chow CK, Jolly S, Rao-Melacini P, et al. Association of
diet, exercise, and smoking modification with risk of early
cardiovascular events after acute coronary syndromes.
Circulation 2010; 121(6): 750–758.
3. Brown TM, Hernandez AF, Bittner V, et al. Predictors of
cardiac rehabilitation referral in coronary artery disease
patients: Findings from the American Heart Association’s
Get With The Guidelines Program. J Am Coll Cardiol 2009;
54(6): 515–521.
4. De Vos C, Li X, Van Vlaenderen I, et al. Participating or
not in a cardiac rehabilitation programme: Factors influenc-
ing a patient’s decision. Eur J Prev Cardiol 2013; 20(2):
341–348.
5. Larsen KK, Vestergaard M, Søndergaard J, et al.
Rehabilitation status three months after first-time myo-
cardial infarction. Scand J Prim Health Care 2011; 29(4):
210–215.
6. Zwisler A-DO, Soja AMB, Rasmussen S, et al. Hospital-
based comprehensive cardiac rehabilitation versus usual
care among patients with congestive heart failure, ischemic
heart disease, or high risk of ischemic heart disease:
12-month results of a randomized clinical trial. Am Heart J
2008; 155(6): 1106–1113.
7. Bertelsen JB, Refsgaard J, Kanstrup H, et al. Hospital-based
versus community-based shared care cardiac rehabilitation
after acute coronary syndrome: Protocol for a randomized
clinical trial. Dan Med J 2013; 60(9): A4699.
8. Wurgler MW, Sonne LT, Kilsmark J, et al. Danish heart
patients’ participation in and experience with rehabilitation.
Scand J Public Health 2012; 40: 126–132.
9. Bøgelund M. Hjertepatienters brug og oplevelse af rehabili-
tering 2010.
10. Suaya JA, Stason WB, Ades PA, et al. Cardiac rehabilitation
and survival in older coronary patients. J Am Coll Cardiol
2009; 54: 25–33.
11. Kotseva K, Wood D, De Bacquer D, et al. EUROASPIRE
IV: A European Society of Cardiology survey on the
Bertelsen et al. 343
lifestyle, risk factor and therapeutic management of coro-
nary patients from 24 European countries. Eur J Prev
Cardiol 2016; 23: 636–648.
12. Jorstad HT, von Birgelen C, Alings MW, et al. Effect of a
nurse-coordinated prevention programme on cardiovascular
risk after an acute coronary syndrome: Main results of the
RESPONSE randomised trial. Heart 2013; 99: 1421–1430.
1 3. Beauchamp A, Worcester M, Ng A, et al. Attendance at
cardiac rehabilitation is associated with lower all-cause
mortality after 14 years of follow-up. Heart 2013; 99(9):
620–625.
14. Cohen A, Assyag P, Boyer-Chatenet L, et al. An education
program for risk factor management after an acute coronary
syndrome: A randomized clinical trial. JAMA Intern Med
2014; 174(1): 40–48.
15. Niebauer J, Mayr K, Harpf H, et al. Long-term effects
of outpatient cardiac rehabilitation in Austria: A nation-
wide registry. Wien Klin Wochenschr 2014; 126(5–6):
148–155.
16. Lewis EF, Solomon SD, Jablonski KA, et al. Predictors of
heart failure in patients with stable coronary artery disease:
A PEACE study. Circ Heart Fail 2009; 2(3): 209–216.
17. Hansen VB and Maindal HT. Cardiac rehabilitation with
a nurse case manager (GoHeart) across local and regional
health authorities improves risk factors, self-care and psy-
chosocial outcomes. A one-year follow-up study. JRSM
Cardiovasc Dis 2014; 3: 2048004014555922.
18. OECD. OECD Reviews of Health Care Quality: Denmark
2013. Raising Standards. http://dx.doi.org/10.1787/97892641
91136-en (2013).