P2518Failure of completion of post-myocardial infarction rehabilitation programme - Who and why? Single center experience with novel Coordinated Comprehensive Care program in Poland

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
W Telec ◽  
P Kalmucki ◽  
H Krysztofiak ◽  
A Szyszka ◽  
A Baszko
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiac Rehabilitation ◽  
Laboratory Data ◽  
Care Program ◽  
Rehabilitation Programme ◽  
Comprehensive Care ◽  
Invasive Treatment ◽  
Laboratory Test Results ◽  
Number Of Patients

Abstract Background Rehabilitation after acute myocardial infarction is a well-proven strategy to improve outcomes and reduce complications rate. Poland recently introduced a novel, fully-reimbursed Coordinated Comprehensive Care (CCC) program after myocardial infarction, a significant portion of which comprises access to free-of-charge cardiac rehabilitation. Purpose The purpose of the study was to analyze all patients qualified for the Coordinated Comprehensive Care Program and evaluate reasons for not completing rehabilitation. We compared two groups of patients - those who completed the rehabilitation and those that did not - in terms of clinical, demographic and laboratory characteristics. Methods All patients (n=169) referred from the cardiology department for the CCC program were included in the study. They were divided into two groups, depending on single, strict criterium of completion or non-completion of the rehabilitation program. Demographic, clinical and laboratory data were collected and analyzed. Results The majority of the patients (n=100, 59.2%) did not undergo cardiac rehabilitation. 61 of them were not qualified for rehabilitation programme by the consortium of doctors: 33 of them due to the need for further invasive treatment, the remainder 28 were disqualified due to severe comorbidities. 32 patients did not commence the program despite referral and encouragement, mostly (n=25) due to personal reasons, 7 patients did not specify reasons for not participating in the rehabilitation. 7 patients were lost to follow-up. Patients who completed rehabilitation (n=69, 40.8%) were younger that those who did not (64.4±9.8 vs. 67.1±9.5 years, respectively; p=0.076), had significantly higher baseline LVEF (49.1±9.4 vs. 44.7±11.9%, p<0.03), and had lower serum creatinine level (0.99±0.28 vs. 1.15±0.59 mg/dl; p<0.03). There were more patients with LVEF<35% (n=23; 23%) in the no-rehabilitation, than in the other group (n=5; 7.25%; p<0.01). Rehabilitation completed (n=69) Rehabilitation NOT completed (n=100) p Gender – male 40 (35.4%) 73 (64.6%) <0.05 LVEF- % 49.12 (±9.43) 44.69 (±11.97) <0.03 No. of patients with EF <35% 5 (7.25%) 23 (23%) <0.01 Conclusion Although fully-reimbursed cardiac rehabilitation is provided for all patients following acute myocardial infarction, there is a significant number of patients who fail to complete the programme. This group comprises more male patients with worse clinical and laboratory test results, especially LVEF and renal function. Efforts should be made to address the problem and modify the programme accordingly.

scholarly journals Post-myocardial transitional care in Poland - single centre experience with novel Coordinated Comprehensive Care programme – clinical and laboratory follow-up

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
W Telec ◽  
H Krysztofiak ◽  
P Kalmucki ◽  
A Baszko ◽  
A Szyszka
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Transitional Care ◽  
Laboratory Data ◽  
Rehabilitation Program ◽  
Comprehensive Care ◽  
Invasive Treatment ◽  
Care Programme ◽  
The Impact

Abstract Background Cardiac rehabilitation (CR) is an inherent part of the transitional care after acute myocardial infarction (AMI). Polish health care system has created a novel Coordinated Comprehensive Care Program after AMI, which ensures outpatient follow-ups, further invasive treatment and free-of-charge CR for all patients after acute MI. Purpose The aim of the study was to analyze the impact of CR on clinical and laboratory characteristics of the patients who completed the recommended programme. Methods 118 participants were enrolled. They were divided into two groups, depending on the criterium of completion (rehabilitation group) or non-completion (no rehabilitation group) of the CR. The clinical and laboratory data at discharge and after 12 months were collected and analyzed in both groups. Results The majority of the patients (n=83, 70,3%) underwent CR. This group was younger in comparison to patients who did not participate in CR (63.0±8.6 vs. 69.8±8.7 years; p&lt;0.01). Index hospitalization was significantly shorter in rehabilitation group (7 vs. 8 days, respectively; p&lt;0,04). LDL-C reduction was observed in both groups, but only rehabilitation group presented statistically significant reduction (median LDL at discharge 108,5 vs. 67,0 mg/dl at follow-up; p&lt;0.01). No rehabilitation group had LDL-C non-significantly decreased (p=0.16). NT-proBNP decreased in both groups over 12 months, but only rehabilitation group had significant reduction (median 590,0 pg/ml at discharge vs. 199,0 at follow-up; p&lt;0.01). Laboratory follow-up is summarized in Figure 1. BMI increased in both groups, with statistical importance in rehabilitation group (p&lt;0,01). Conclusions Post-myocardial rehabilitation is more frequently prescribed to younger patients with shorter index hospitalisation. Clinical and laboratory parameters improve more in the group that underwent CR programme and this might warant more effort on increasing CR accessibility and patient enrollement. The phenomenon of weight gain in patients after acute myocardial infarction independently from undergoing rehabilitation program or not needs further research. Figure 1. 12-month laboratory follow-up. Funding Acknowledgement Type of funding source: None

Feasibility of hybrid telerehabilitation as component of a novel comprehensive care program after acute myocardial infarction in a one-year follow-up preliminary experience of a single center

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
E Piotrowicz ◽  
P Orzechowski ◽  
I Kowalik ◽  
R Piotrowicz
Keyword(s):  
Myocardial Infarction ◽  
Blood Pressure ◽  
Acute Myocardial Infarction ◽  
Heart Rate ◽  
Functional Capacity ◽  
Care Program ◽  
Comprehensive Care ◽  
Monitoring Center ◽  
One Year

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): National Health Fund Background. A novel comprehensive care program after acute myocardial infarction (AMI) „KOS-zawał" was implemented in Poland. It includes acute intervention, complex revascularization, implantation of cardiovascular electronic devices (in case of indications), rehabilitation or hybrid telerehabilitation (HTR) and scheduled outpatient follow-up. HTR is a unique component of this program. The purpose of the pilot study was to evaluate a feasibility, safety and patients’ acceptance of HTR as component of a novel care program after AMI and to assess mortality in a one-year follow-up. Methods The study included 55 patients (LVEF 55.6 ± 6.8%; aged 57.5 ± 10.5 years). Patients underwent a 5-week HTR based on Nordic walking, consisting of an initial stage (1 week) conducted within an outpatient center and a basic stage (4-week) home-based telerehabilitation five times weekly. HTR was telemonitored with a device adjusted to register electrocardiogram (ECG) recording and to transmit data via mobile phone network to the monitoring center. The moments of automatic ECG registration were pre-set and coordinated with exercise training. The influence on physical capacity was assessed by comparing changes in functional capacity (METs) from the beginning and the end of HTR. Patients filled in a questionnaire in order to assess their acceptance of HTR at the end of telerehabilitation. Results HTR resulted in a significant improvement in functional capacity and workload duration in exercise test (Table). Safety: there were neither deaths nor adverse events during HTR. Patients accepted HTR, including the need for interactive everyday collaboration with the monitoring center. Prognosis all patients survived in a one-year follow-up. Conclusions Hybrid telerehabilitation is a feasible, safe form of rehabilitation, well accepted by patients. There were no deaths in a one-year follow-up. Outcomes before and after HTR Before telerehabilitation After telerehabilitation P Exercise time [s] 381.5 ± 92.0 513.7 ± 120.2 &lt;0.001 Maximal workload [MET] 7.9 ± 1.8 10.1 ± 2.3 &lt;0.001 Heart rate rest [bpm] 68.6 ± 12.0 66.6 ± 10.9 0.123 Heart rate max effort [bpm] 119.7 ± 15.9 131.0 ± 20.1 &lt;0.001 SBP rest [mmHg] 115.6 ± 14.8 117.7 ± 13.8 0.295 DBP rest [mmHg] 74.3 ± 9.2 76.2 ± 7.3 0.079 SBP max effort [mm Hg] 159.5 ± 25.7 170.7 ± 25.5 0.003 DBP max effort [mm Hg] 84.5 ± 9.2 87.2 ± 9.3 0.043 SBP systolic blood pressure, DBP diastolic blood pressure.

scholarly journals Can inflammatory biomarkers play a role in the inclusion of patients with acute myocardial infarction in cardiac rehabilitation programs?

2021 ◽  
Vol 12 (3) ◽  
pp. 255-260
Author(s):  
Alexandra DĂDÂRLAT-POP ◽  
Horea ROȘIANU ◽  
Renaldo POPTILE ◽  
Raluca TOMOAIA ◽  
Ruxandra BEYER ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiac Rehabilitation ◽  
Systolic Function ◽  
Laboratory Data ◽  
Inflammatory Biomarkers ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Rehabilitation Programs ◽  
St Segment

Introduction: In spite of the enormous progress made over the last decades, acute coronary syndromes remain the leading cause of death globally. Inflammation plays an important role in coronary artery disease development. Although the role of inflammatory biomarkers in acute obstructive myocardial infarction is well established, there is no data regarding the potential differences between acute myocardial infarction (AMI) with ST segment elevation, AMI without ST segment elevation (NON-STEMI) and non-obstructive acute myocardial infarction (MINOCA), respectively. Also, it is well known that cardiac rehabilitation of acute myocardial infarction survivors significantly improves their long-term prognosis. Aim of the study: To asses the possible existing differences between patients with STEMI, NON-STEMI and MINOCA in terms of clinical and paraclinical parameters, especially inflammatory biomarkers. A second objective of our study was to describe the relationship between inflammatory, cardiac necrosis enzymes and left ventricle systolic function. Material and methods: The study included 35 adult patients admitted in the Cardiology service of the Niculae Stăncioiu Heart Institute, Cluj-Napoca with acute myocardial infarction. Demographic, clinical, echocardiographic and laboratory data were analyzed. Patients were divided into 3 groups, 19 patients (54.2%) were diagnosed with STEMI- group 1, 9 patients (25.7%) with NON-STEMI- group 2 and 7 patients (20%) with MINOCA- group 3, respectively. Dosage of serum inflammatory markers was performed on the day of admission. Results and conclusion: The most common associated cardiovascular risk factor was arterial hypertension (65.7% of patients). Markers of myocardial necrosis (CK, CK-MB, hs Troponin) were significantly higher in patients with STEMI (p <0.05) in comparison with NON-STEMI and MINOCA patients. Congestive heart failure was most frequently encountered in STEMI patients. hsCRP value was higher among patients with STEMI. The value of ESR was significantly higher among patients with NON-STEMI. Serial dosage of inflammation biomarkers in patients with recent acute myocardial infarction may serve as valuable risk stratification instruments and also for functional capacity and recovery status assessment in patients included in cardiac rehabilitation programs. Keywords: acute coronary syndrome; inflammatory biomarkers; non-obstructive acute myocardial infarction,

scholarly journals Current status of cardiac rehabilitation among representative hospitals treating acute myocardial infarction in South Korea

PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0261072
Author(s):  
Myung Soo Park ◽  
Sunki Lee ◽  
Taehoon Ahn ◽  
Doyoung Kim ◽  
Mi-Hyang Jung ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
South Korea ◽  
Cardiac Rehabilitation ◽  
Administrative Support ◽  
Artery Bypass ◽  
Current Status ◽  
Rehabilitation Services ◽  
Invasive Treatment ◽  
Medical Centers

Cardiac rehabilitation services are mostly underutilized despite the documentation of substantial morbidity and mortality benefits of cardiac rehabilitation post-acute myocardial infarction. To assess the implementation rate and barriers to cardiac rehabilitation in hospitals dealing with acute myocardial infarction in South Korea, between May and July 2016, questionnaires were emailed to cardiology directors of 93 hospitals in South Korea; all hospitals were certified institutes for coronary interventions. The questionnaires included 16 questions on the hospital type, cardiology practice, and implementation of cardiac rehabilitation. The obtained data were categorized into two groups based on the type of the hospital (secondary or tertiary) and statistically analysed. Of the 72 hospitals that responded (response rate of 77%), 39 (54%) were tertiary medical centers and 33 (46%) were secondary medical centers. All hospitals treated acute myocardial infarction patients and performed emergency percutaneous coronary intervention; 79% (57/72) of the hospitals performed coronary artery bypass grafting. However, the rate of implementation of cardiac rehabilitation was low overall (28%, 20/72 hospitals) and even lower in secondary medical centers (12%, 4/33 hospitals) than in tertiary centers (41%, 16/39 hospitals, p = 0.002). The major barriers to cardiac rehabilitation included the lack of staff (59%) and lack of space (33%). In contrast to the wide availability of acute-phase invasive treatment for AMI, the overall implementation of cardiac rehabilitation is extremely poor in South Korea. Considering the established benefits of cardiac rehabilitation in patients with acute myocardial infarction, more administrative support, such as increasing the fee for cardiac rehabilitation services by an appropriate level of health insurance coverage should be warranted.

scholarly journals Innovative Managed Care May Be Related to Improved Prognosis for Acute Myocardial Infarction Survivors

2021 ◽  
Author(s):  
Piotr Jankowski ◽  
Roman Topór-Mądry ◽  
Mariusz Gąsior ◽  
Urszula Cegłowska ◽  
Zbigniew Eysymontt ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Managed Care ◽  
Cardiac Rehabilitation ◽  
Care Program ◽  
Cardiac Resynchronization ◽  
Cardiac Care ◽  
Cardioverter Defibrillator ◽  
End Point

Background: Mortality following discharge in myocardial infarction survivors remains high. Therefore, we compared outcomes in myocardial infarction survivors participating and not participating in a novel, nationwide managed care program for myocardial infarction survivors in Poland. Methods: We used public databases. We included all patients hospitalized due to acute myocardial infarction in Poland between October 1, 2017 and December 31, 2018. We excluded from the analysis all patients aged <18 years as well as those who died during hospitalization or within 10 days following discharge from hospital. All patients were prospectively followed. The primary end point was defined as death from any cause. Results: The mean follow-up was 324.8±140.5 days (78 034.1 patient-years; 340.0±131.7 days in those who did not die during the observation). Participation in the managed care program was related to higher odds ratio of participating in cardiac rehabilitation (4.67 [95% CI, 4.44–4.88]), consultation with a cardiologist (7.32 [6.83–7.84]), implantable cardioverter-defibrillator (1.40 [1.22–1.61]), and cardiac resynchronization therapy with cardioverter-defibrillator implantation (1.57 [1.22–2.03]) but lower odds of emergency (0.88 [0.79–0.98]) and nonemergency percutaneous coronary intervention (0.88 [0.83–0.93]) and coronary artery bypass grafting (0.82 [0.71–0.94]) during the follow-up. One-year all-cause mortality was 4.4% among the program participants and 6.0% in matched nonparticipants. The end point consisting of all-cause death, myocardial infarction, or stroke occurred in 10.6% and 12.0% ( P <0.01) of participants and nonparticipants respectively, whereas all-cause death or hospitalization for cardiovascular reasons in 42.2% and 47.9% ( P <0.001) among participants and nonparticipants, respectively. The difference in outcomes between patients participating and not participating in the managed care program could be explained by improved access to cardiac rehabilitation, cardiac care, and cardiac procedures. Conclusions: Managed care following myocardial infarction may be related to improved prognosis as it may facilitate access to cardiac rehabilitation and may provide a higher standard of outpatient cardiac care.

scholarly journals Cardiac rehabilitation after acute myocardial infarction in Sweden – evaluation of programme characteristics and adherence to European guidelines: The Perfect Cardiac Rehabilitation (Perfect-CR) study

2019 ◽  
Vol 27 (1) ◽  
pp. 18-27 ◽  
Author(s):  
Halldora Ögmundsdottir Michelsen ◽  
Ingela Sjölin ◽  
Mona Schlyter ◽  
Emil Hagström ◽  
Anna Kiessling ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiac Rehabilitation ◽  
Patient Outcomes ◽  
National Level ◽  
Rehabilitation Programme ◽  
Cardiac Rehabilitation Programme ◽  
Rehabilitation Team ◽  
European Guidelines

Background While patient performance after participating in cardiac rehabilitation programmes after acute myocardial infarction is regularly reported through registry and survey data, information on cardiac rehabilitation programme characteristics is less well described. Aim The aim of this study was to evaluate Swedish cardiac rehabilitation programme characteristics and adherence to European Guidelines on Cardiovascular Disease Prevention. Method Cardiac rehabilitation programme characteristics at all 78 cardiac rehabilitation centres in Sweden in 2016 were surveyed using a web-based questionnaire (100% response rate). The questions were based on core components of cardiac rehabilitation as recommended by European Guidelines. Results There was a wide variation in programme duration (2–14 months). All programmes reported offering an individual post-discharge visit with a nurse, and 90% ( n = 70) did so within three weeks from discharge. Most programmes offered centre-based exercise training ( n = 76, 97%) and group educational sessions ( n = 61, 78%). All programmes reported to the national audit, SWEDEHEART, and 60% ( n = 47) reported that performance was regularly assessed using audit data, to improve quality of care. Ninety-six per cent ( n = 75) had a core team consisting of a cardiologist, a physiotherapist and a nurse and 76% ( n = 59) reported having a medical director. Having other allied healthcare professionals included in the cardiac rehabilitation team varied. Forty per cent ( n = 31) reported having regular team meetings where nurses, physiotherapists and cardiologist could discuss patient cases. Conclusion The overall quality of cardiac rehabilitation programmes provided in Sweden is high. Still, there are several areas of potential improvement. Monitoring programme characteristics as well as patient outcomes might improve programme quality and patient outcomes both at a local and a national level.

scholarly journals See You in 7: improving acute myocardial infarction follow-up care

2018 ◽  
Vol 7 (2) ◽  
pp. e000296
Author(s):  
Alex Batten ◽  
Cassie Jaeger ◽  
David Griffen ◽  
Paula Harwood ◽  
Karen Baur
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiac Rehabilitation ◽  
Hospital Discharge ◽  
Recovery Process ◽  
Appointment Scheduling ◽  
Academic Medical Centre ◽  
Number Of Patients ◽  
Follow Up Care

Acute myocardial infarction (AMI) follow-up care is a crucial part of the AMI recovery process. The American College of Cardiology’s ‘See You in 7 Challenge’ advocates that all patients discharged with a diagnosis of AMI have a cardiac rehabilitation referral made and outpatient cardiac rehabilitation appointment scheduled to occur within 7 days of hospital discharge. A streamlined AMI cardiac rehabilitation referral and appointment scheduling process was not in place at this urban academic medical centre. To develop the streamlined processes, a Six Sigma project was initiated. Four months before the intervention, 1/38 patients with AMI (2.6%) were scheduled to have the initial outpatient cardiac rehabilitation appointment occur within 7 days of hospital discharge, with an average 18.7 days from hospital discharge to the scheduled initial outpatient cardiac rehabilitation appointment. To reduce the time to this initial appointment, availability of outpatient cardiac rehabilitation appointments was increased, additional staff were trained in appointment scheduling and insurance verification processes and appointments were scheduled prior to hospital discharge. After intervention, the number of patients scheduled to attend an outpatient cardiac rehabilitation appointment within 7 days of hospital discharge improved to 72/79 (91.1%) (two-proportion test, p<0.001). Days from hospital discharge to first scheduled outpatient cardiac rehabilitation appointment were reduced from 18.7 days to 6.3 days (a 66.3% reduction) (Mann-Whitney U test, p<0.01). Initial outpatient cardiac rehabilitation attendance within 7 days of hospital discharge increased from 1/38 (2.6%) to 42/79 (53.2%) (a 50.6% increase) (two-proportion test, p<0.001).

P631Socioeconomic status; how does it influence referral to cardiac rehabilitation after acute myocardial infarction?

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
C B Graversen ◽  
M B Johansen ◽  
S P Johnsen ◽  
S Riahi ◽  
T Holmberg ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Socioeconomic Status ◽  
Cardiac Rehabilitation ◽  
Low Socioeconomic Status ◽  
Occupational Status ◽  
University Hospital ◽  
Referral Process ◽  
Willingness To Participate ◽  
Number Of Patients

Abstract Background The number of patients with low socioeconomic status who are referred to cardiac rehabilitation (CR) has been documented to be relative lower than patients with high SES among all patients hospitalised with acute myocardial infarction (AMI). Purpose The aims of this study were to evaluate the referral process to CR and how it is influenced by socioeconomic variables. Methods In 2011–2014, 1229 patients were hospitalised with AMI at Department of Cardiology of our University Hospital, Denmark. All were evaluated for participation to CR. Socioeconomic status was measured by personal income, educational level, marital status, and employment and obtained from national registers. Multiple logistic regression assessed socioeconomic determinants in three phases of the referral process to CR: 1. information about CR, 2. wish to participate in CR, and 3. referral to specialiced- or municipality-based CR. All analyses were adjusted for sex, age, and comorbidities. Results A total of 1123 (91.4%) patients received information regarding CR. Of these, 854 (69.5%) patients wished to participate in the programme. Income was the most important socioeconomic variable when looking at who were informed about CR (OR 2.17, 95%-CI: 1.0- 4.64) and who wished to participate in CR (OR 1.55, 95%-CI: 1.02–2.35). Characteristics of study participants Characteristics All participants STEMI NSTEMI UAP n=1229 n=402 n=711 n=116 Male (n, %) 907 (73.8) 322 (80.1) 503 (70.7) 82 (70.7) Age Group (yrs)   <65 591 (48.1) 227 (56.5) 308 (43.3) 56 (48.3)   65–74 371 (30.2) 116 (28.9) 215 (30.2) 40 (34.5)   ≥75 267 (21.7) 59 (14.7) 188 (26.4) 20 (17.2) Baseline Comorbidity   Hypertension 241 (19.6) 62 (15.4) 148 (20.8) 31 (26.7)   Diabetes 14 (1.1) <5 (<1) 8 (1.1) <5 (<1) Charlson Comorbidity Index   Low (0 points) 1088 (88.5) 358 (89.1) 630 (88.6) 100 (86.2)   Moderate/High (>0) 141 (11.5) 44 (10.9) 81 (11.4) 16 (13.8) Civil status (n, %)   Married/Partnership 793 (64.5) 253 (62.9) 449 (63.2) 91 (78.4)   Divorced/Unmarried/Widow 436 (35.5) 149 (37.1) 262 (36.8) 25 (21.6) Occupational status (n, %)   Employed 479 (39.0) 195 (48.5) 240 (33.8) 44 (37.9)   Unemployed/Retired 750 (61.0) 207 (51.5) 471 (66.2) 72 (62.1) Educational status (n, %)   Low 516 (42.0) 144 (35.8) 322 (45.3) 50 (43.1)   Medium 539 (43.9) 201 (50.0) 293 (41.2) 45 (38.8)   High 174 (14.2) 57 (14.2) 96 (13.5) 21 (18.1) Gross income, tertile (n, %)   Low 405 (33.0) 113 (28.1) 251 (35.3) 41 (35.3)   Medium 406 (33.0) 124 (30.8) 247 (34.7) 35 (30.2)   High 418 (34.0) 165 (41.0) 213 (30.0) 40 (34.5) STEMI: ST-elevated myocardial infarction; NSTEMI: non-ST-elevated myocardial infarction; UAP: unstable angina pectoris. Conclusion Two out of three patients received referral to CR. However, higher income was proportional with the likelihood of receiving information about CR and willingness to participate in the programme. Acknowledgement/Funding the Danish Heart Foundation

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