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Nana Brochmann,1 Esben Meulengracht Flachs,2 Anne Illemann Christensen,3 Marie Bak,1 Christen Lykkegaard Andersen,1 Knud Juel,3 Hans Carl Hasselbalch,1 Ann-Dorthe Zwisler,4 Nina Rottmann4–6 1Department of Hematology, Zealand University Hospital, University of Copenhagen, Roskilde, Denmark; 2Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark; 3National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark; 4Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, University of Southern Denmark, Nyborg, Denmark; 5Department of Psychology, University of Southern Denmark, Odense, Denmark; 6Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark Objective: We sought to determine the prevalence and severity of anxiety and depression among patients with Philadelphia-negative myeloproliferative neoplasms (MPNs) and respective associations of anxiety and depression with demographic and lifestyle factors, comorbidity burden, duration of MPN disease, financial difficulties, and health-related quality of life (QoL). Methods: This study used data from a nationwide, population-based, cross-sectional survey of health-related QoL in MPN patients in Denmark called the MPNhealthSurvey. Individuals with a diagnosis of MPN in the National Patient Register were invited. The Hospital Anxiety and Depression Scale was used to assess the prevalence and severity of anxiety and depression. The associations of anxiety and depression with age, sex, education, body mass index (BMI), smoking, alcohol intake, physical activity, comorbidity burden, duration of MPN disease, financial difficulties, symptom burden, sexual problems, fatigue, functioning, and global health/QoL were examined. Results: In total, 2,029 patients completed the Hospital Anxiety and Depression Scale. The prevalence of anxiety, depression, and both was 21%, 12%, and 8%, respectively. Many participants who reported anxiety or depression exhibited mild symptoms. Middle-aged and elderly participants had lower odds of experiencing anxiety and depression when compared to younger participants, and females had higher odds of anxiety compared to males. Participants with higher education had lower odds of anxiety compared to those with lower education. Current smokers and ex-smokers had higher odds of anxiety and depression compared to those who had never smoked, and sedentary participants and participants with a lower level of physical activity had higher odds of anxiety and depression compared to participants who performed hard training several times a week. Higher comorbidity burden increased the odds of depression, and greater financial difficulties increased the odds of anxiety and depression. Higher total symptom burden and fatigue burden and higher level of sexual problems increased the odds of anxiety and depression. Finally, lower functional level and global health/quality of life increased the odds of anxiety and depression. BMI, alcohol intake, comorbidity burden, and duration of disease were not substantially associated with anxiety, whereas sex, educational level, and duration of MPN disease were not substantially associated with depression. Conclusion: There may be an unmet need in handling psychological distress in MPN patients. Future research might explore the utility of screening for psychological distress and the effectiveness of lifestyle interventions, rehabilitation, and MPN-symptom reduction in preventing and treating psychological distress. Keywords: myeloproliferative neoplasm, anxiety, depression, health-related quality of life, patient-reported outcomes

Nana Brochmann,1 Esben Meulengracht Flachs,2 Anne Illemann Christensen,3 Christen Lykkegaard Andersen,1 Knud Juel,3 Hans Carl Hasselbalch,1 Ann-Dorthe Zwisler4 1Department of Hematology, Zealand University Hospital, University of Copenhagen, Roskilde, 2Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, 3National Institute of Public Health, University of Southern Denmark, Copenhagen, 4Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark and Odense University Hospital, Odense, Denmark Objective: The Department of Hematology, Zealand University Hospital, Denmark, and the National Institute of Public Health, University of Southern Denmark, created the first nationwide, population-based, and the most comprehensive cross-sectional health-related quality of life (HRQoL) survey of patients with myeloproliferative neoplasms (MPNs). In Denmark, all MPN patients are treated in public hospitals and treatments received are free of charge for these patients. Therefore, MPN patients receive the best available treatment to the extent of its suitability for them and if they wish to receive the treatment. The aims of this article are to describe the survey design and the characteristics of respondents and nonrespondents. Material and methods: Individuals with MPN diagnoses registered in the Danish National Patient Register (NPR) were invited to participate. The registers of the Danish Civil Registration System and Statistics Denmark provided information regarding demographics. The survey contained 120 questions: validated patient-reported outcome (PRO) questionnaires and additional questions addressing lifestyle. Results: A total of 4,704 individuals were registered with MPN diagnoses in the NPR of whom 4,236 were eligible for participation and 2,613 (62%) responded. Overall, the respondents covered the broad spectrum of MPN patients, but patients 70–79 years old, living with someone, of a Danish/Western ethnicity, and with a higher level of education exhibited the highest response rate. Conclusion: A nationwide, population-based, and comprehensive HRQoL survey of MPN patients in Denmark was undertaken (MPNhealthSurvey). We believe that the respondents broadly represent the MPN population in Denmark. However, the differences between respondents and nonrespondents have to be taken into consideration when examining PROs from the respondents. The results of the investigation of the respondents’ HRQoL in this survey will follow in future articles. Keywords: survey design, cross-sectional survey, nationwide survey, patient-reported outcomes, health-related quality of life, myeloproliferative neoplasms

Ann-Dorthe Zwisler,1 Henriette Knold Rossau,1 Anne Nakano,2,3 Sussie Foghmar,4 Regina Eichhorst,5 Eva Prescott,6 Charlotte Cerqueira,7 Anne Merete Boas Soja,4 Gunnar H Gislason,8–10 Mogens Lytken Larsen,5 Ulla Overgaard Andersen,11 Ida Gustafsson,4 Kristian K Thomsen,12 Lene Boye Hansen,13 Signe Hammer,14 Lone Viggers,15 Bo Christensen,16 Birgitte Kvist,17 Cecilie Lindström Egholm,18 Ole May19 On behalf of the Working Group of Preventive Cardiology and Rehabilitation, Danish Society of Cardiology, and the Working Group of Cardiac Clinical Registries, Danish Society of Cardiology 1Danish Centre for Rehabilitation and Palliative Care, Odense University Hospital and University of Southern Denmark, Odense, 2Department of Clinical Epidemiology, Aarhus University Hospital, 3Registry Support Centre (West) – Clinical Quality Improvement & Health Informatics, Aarhus, 4Department of Cardiology, Copenhagen University Hospital, Hvidovre, 5Department of Cardiology, Aalborg University Hospital, Aalborg, 6Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, 7Registry Support Centre (East) – Epidemiology and Biostatistics, Research Centre for Prevention and Health, the Capital Region of Denmark, Glostrup, 8Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, 9The Danish Heart Foundation, Copenhagen, 10The National Institute of Public Health, University of Southern Denmark, 11Department of Cardiology, Holbaek Hospital, University of Copenhagen, Copenhagen, 12Department of Cardiology, Hospital of Southwest Jutland, Esbjerg, 13Department of Cardiology, Gentofte Hospital, Gentofte, 14Department of Occupational Therapy and Physiotherapy, Herlev Hospital, Herlev, 15Department of Nutrition, Regional Hospital West Jutland, Holstebro, 16Department of General Medicine, School of Public Health, Aarhus University, Aarhus, 17Department of Health Care and Prevention, Municipality of Frederikshavn, Frederikshavn, 18The Regional Research Unit, Region Zealand, Roskilde, 19Department of Medicine, Cardiovascular Research Unit, Regional Hospital Herning, Herning, Denmark Aim of database: The Danish Cardiac Rehabilitation Database (DHRD) aims to improve the quality of cardiac rehabilitation (CR) to the benefit of patients with coronary heart disease (CHD).Study population: Hospitalized patients with CHD with stenosis on coronary angiography treated with percutaneous coronary intervention, coronary artery bypass grafting, or medication alone. Reporting is mandatory for all hospitals in Denmark delivering CR. The database was initially implemented in 2013 and was fully running from August 14, 2015, thus comprising data at a patient level from the latter date onward.Main variables: Patient-level data are registered by clinicians at the time of entry to CR directly into an online system with simultaneous linkage to other central patient registers. Follow-up data are entered after 6 months. The main variables collected are related to key outcome and performance indicators of CR: referral and adherence, lifestyle, patient-related outcome measures, risk factor control, and medication. Program-level online data are collected every third year.Descriptive data: Based on administrative data, approximately 14,000 patients with CHD are hospitalized at 35 hospitals annually, with 75% receiving one or more outpatient rehabilitation services by 2015. The database has not yet been running for a full year, which explains the use of approximations.Conclusion: The DHRD is an online, national quality improvement database on CR, aimed at patients with CHD. Mandatory registration of data at both patient level as well as program level is done on the database. DHRD aims to systematically monitor the quality of CR over time, in order to improve the quality of CR throughout Denmark to benefit patients. Keywords: secondary prevention, coronary heart disease, cardiovascular prevention, clinical quality registry, clinical database, quality improvement

Aims: Patients with heart failure (HF) often experience delayed identification of palliative care needs. While communication with HF patients and their caregivers is increasingly stressed, systematic conversations about end-of-life care wishes remain a gap. This study explores a dyad experience of Advance Care Planning (ACP) conversations in an HF outpatient clinic., Methods and Results: A qualitative interview study with 15 patients diagnosed with end-stage HF and 14 caregivers. Through qualitative content analysis and investigator triangulation, three subthemes emerged: 'ACP as a harsh reality', 'ACP as a catalyst for crucial conversations', and 'ACP conversations help appreciating life's small moments and adjusting hope'. Despite significant symptom burden, many patients lacked awareness of their end-stage HF prognosis. Following an initial 'reality shock', ACP conversations facilitated open discussions about end-of-life care wishes. Especially spousal caregivers experienced a significant caregiving load, generating complex emotions for both patients and their families. Notably, patients prioritized self-care, daily activities, and social interaction for maintaining quality of life., Conclusion: This study highlights a gap between patients with end-stage HF disease status and their comprehension of disease severity. Early integration of ACP may address knowledge gaps, enable informed decision-making, and alleviate caregiver burden. The study also emphasizes the patient-and family-centred care to support self-care, daily life activities, and social connections for improved quality of life throughout the disease trajectory., Registration: ClinicalTrials.gov: NCT05269875., Competing Interests: Conflict of interest: The authors declare no conflict of interest with respect to the research, authorship, and/or publication of this article and that they all agree with the final versions of this manuscript., (© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Context: Heart failure (HF) is considered a multifaceted and life-threatening syndrome characterized by high symptom-burden and significant mortality., Objectives: To describe the symptom-burden in patients with HF and identify their palliative care needs. In this respect, symptom burden related to sex, age and classification of HF using New York Heart Association Functional Classification (NYHA) were analyzed., Methods: A cross-sectional questionnaire survey included adult HF patients according to NYHA II, III, and IV. Palliative care needs were assessed using validated patient reported outcomes measures; SF-36v1, HeartQoL, EORTC- QLQ-C15-PAL, MFI-20 and HADS. Patients were recruited from the Department of Cardiology, North Zealand Hospital, Denmark., Results: In total, 314 patients (79%) completed the questionnaire (233 men). Mean age = 74 years (range 35-94 years). In all, 42% had NYHA III or IV and 53% self-rated their health to be fair or poor. In all, 19% NYHA II and 67% NYHA III/IV patients had ≥4 severe palliative symptoms according to EORTC-QLQ-C15-PAL. In addition, NYHA III/IV had a mean of 8.9 symptoms and a mean of 5.4 severe symptoms. Women, older patients, and those with NYHA III/IV had worse outcomes regarding health-related quality of life, functional capacity, and symptom burden., Conclusions: Patients with HF have a high prevalence of symptoms and, thus, potential palliative care needs. Predominantly, women, older patients, and those with higher severity of disease have the highest symptom burden. PROMs can help cardiologists address the palliative care needs and systematic assessment may be a prerequisite to integrate symptom-modifying and palliative care interventions., (Copyright © 2024 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Cardiac arrest (CA) survivorship is associated with risk of cognitive deficits, emotional and social consequences. Early recognition of these symptoms and referral to rehabilitation is considered to be the fifth link in the chain of survival. This review highlights the need for a national standardized care plan for CA survivors based on a multidisciplinary approach. A patient-tailored law-bound rehabilitation form is essential to proper services in Denmark and should be mandatory. Further research within different rehabilitation areas following CA is warranted to support clinical practice., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Background: Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, disrupts the heart's rhythm through numerous small re-entry circuits in the atrial tissue, leading to irregular atrial contractions. The condition poses significant health risks, including increased stroke risk, heart failure, and reduced quality of life. Given the complexity of AF and its growing incidence globally, exercise-based cardiac rehabilitation (ExCR) may provide additional benefits for people with AF or those undergoing routine treatment for the condition., Objectives: To assess the benefits and harms of ExCR compared with non-exercise controls for people who currently have AF or who have been treated for AF., Search Methods: We searched the following electronic databases: CENTRAL in the Cochrane Library, MEDLINE Ovid, Embase Ovid, PsycINFO Ovid, Web of Science Core Collection Thomson Reuters, CINAHL EBSCO, LILACS BIREME, and two clinical trial registers on 24 March 2024. We imposed no language restrictions., Selection Criteria: We included randomised clinical trials (RCTs) that investigated ExCR interventions compared with any type of non-exercise control. We included adults 18 years of age or older with any subtype of AF or those who had received treatment for AF., Data Collection and Analysis: Five review authors independently screened and extracted data in duplicate. We assessed risk of bias using Cochrane's RoB 1 tool as outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed clinical and statistical heterogeneity by visual inspection of the forest plots and by using standard Chi² and I² statistics. We performed meta-analyses using random-effects models for continuous and dichotomised outcomes. We calculated standardised mean differences where different scales were used for the same outcome. We used the GRADE approach to assess the certainty of the evidence., Main Results: We included 20 RCTs involving a total of 2039 participants with AF. All trials were conducted between 2006 and 2024, with a follow-up period ranging from eight weeks to five years. We assessed the certainty of evidence as moderate to very low. Five trials assessed comprehensive ExCR programmes, which included educational or psychological interventions, or both; the remaining 15 trials compared exercise-only cardiac rehabilitation with controls. The overall risk of bias in the included studies was mixed. Details on random sequence generation, allocation concealment, and use of intention-to-treat analysis were typically poorly reported. Evidence from nine trials (n = 1173) suggested little to no difference in mortality between ExCR and non-exercise controls (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.76 to 1.49; I² = 0%; 101 deaths; low-certainty evidence). Based on evidence from 10 trials (n = 825), ExCR may have little to no effect on SAEs (RR 1.30, 95% CI 0.63 to 2.67; I² = 0%; 28 events; low-certainty evidence). Evidence from four trials (n = 378) showed that ExCR likely reduced AF recurrence (measured via Holter monitoring) compared to controls (RR 0.70, 95% CI 0.56 to 0.88; I² = 2%; moderate-certainty evidence). ExCR may reduce AF symptom severity (mean difference (MD) -1.59, 95% CI -2.98 to -0.20; I² = 61%; n = 600; low-certainty evidence); likely reduces AF symptom burden (MD -1.61, 95% CI -2.76 to -0.45; I² = 0%; n = 317; moderate-certainty evidence); may reduce AF episode frequency (MD -1.29, 95% CI -2.50 to -0.07; I² = 75%; n = 368; low-certainty evidence); and likely reduces AF episode duration (MD -0.58, 95% CI -1.14 to -0.03; I² = 0%; n = 317; moderate-certainty evidence), measured via the AF Severity Scale (AFSS) questionnaire. Moderate-certainty evidence from six trials (n = 504) showed that ExCR likely improved the mental component summary measure in health-related quality of life (HRQoL) of the 36-item Short Form Health Survey (SF-36) (MD 2.66, 95% CI 1.22 to 4.11; I² = 2%), but the effect of ExCR on the physical component summary measure was very uncertain (MD 1.75, 95% CI -0.31 to 3.81; I² = 52%; very low-certainty evidence). ExCR also may improve individual components of HRQoL (general health, vitality, emotional role functioning, and mental health) and exercise capacity (peak oxygen uptake (VO 2peak ) and 6-minute walk test) following ExCR. The effects of ExCR on serious adverse events and exercise capacity were consistent across different models of ExCR delivery: centre compared to home-based, exercise dose, exercise only compared to comprehensive programmes, and aerobic training alone compared to aerobic plus resistance programmes. Using univariate meta-regression, there was evidence of significant association between location of trial and length of longest follow-up on exercise capacity., Authors' Conclusions: Due to few randomised participants and typically short-term follow-up, the impact of ExCR on all-cause mortality or serious adverse events for people with AF is uncertain. ExCR likely improves AF-specific measures including reduced AF recurrence, symptom burden, and episode duration, as well as the mental components of HRQoL. ExCR may improve AF symptom severity, episode frequency, and VO 2peak . Future high-quality RCTs are needed to assess the benefits of ExCR for people with AF on patient-relevant outcomes including AF symptom severity and burden, AF recurrence, AF-specific quality of life, and clinical events such as mortality, readmissions, and serious adverse events. High-quality trials are needed to investigate how AF subtype and clinical setting (i.e. primary and secondary care) may influence ExCR effectiveness., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: Knowledge about caregiver strain among relatives of out-of-hospital cardiac arrest (OHCA) survivors is limited. Thus, the objectives were to i) describe differences in self-reported mental well-being, mental health, and caregiver strain at different time points (1-5 years) post-OHCA and ii) investigate characteristics associated with caregiver strain., Methods: A national cross-sectional survey (DANCAS) from October 2020 to March 2021 with OHCA survivors and their closest relatives. The relative survey included the WHO-5 Well-being Index (WHO-5), the Hospital Anxiety and Depression Scale (HADS) and the Modified Caregiver Strain Index (M-CSI). Differences in scores between time groups were explored using descriptive statistics. Associations between characteristics and caregiver strain were investigated with multivariable logistic regression models, presented as odds ratios (OR) with 95% confidence intervals (CI), adjusted for gender, age, education status, relative affiliation, and time after OHCA., Results: Of 561 relatives, 24% (n = 137) experienced caregiver strain, with no significant differences in the relatives' mental well-being, mental health, or caregiver strain with time since OHCA. In the adjusted analyses, older age (OR 0.98 95% CI 0.96;0.99) and several self-reported outcomes, including reduced mental well-being (WHO-5 OR 7.27 95% CI 4.86;11.52), symptoms of anxiety (HADS-A OR 6.01 95% CI 3.89;9.29) and depression (HADS-D OR 15.03 95% CI 7.33;30.80) were significantly associated with worse caregiver strain., Conclusion: Nearly one-quarter of relatives of OHCA survivors experience caregiver strain, with this proportion remaining unchanged with time. Several outcomes were associated with caregiver strain, emphasising the need to identify relatives at greater risk of burden following OHCA., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background and Aims: A heart-healthy diet is an important component of secondary prevention in ischemic heart disease. The Danish Health Authority recommends using the validated 19-item food frequency questionnaire HeartDiet in cardiac rehabilitation practice to assess patients' need for dietary interventions, and HeartDiet has been included in national electronic patient-reported outcome instruments for cardiac rehabilitation. This study aims to evaluate challenges and benefits of its use. The objectives are to: 1) describe HeartDiet responses of patients with ischemic heart disease and discuss HeartDiet's suitability as a screening tool, 2) discuss whether an abridged version should replace HeartDiet., Methods and Results: A cross-sectional study using data from a national feasibility test. HeartDiet was sent electronically to 223 patients with ischemic heart disease prior to cardiac rehabilitation. Data were summarised with descriptive statistics, and Spearman's rank correlations, explorative factor analysis, and Cohen's kappa coefficient were used to derive and evaluate abridged versions. The response rate was 68 % (n = 151). Evaluated with HeartDiet, no respondents had a heart-healthy diet. There was substantial agreement between HeartDiet and an abridged 9-item version (kappa = 0.6926 for Fat Score, 0.6625 for FishFruitVegetable Score), but the abridged version omits information on milk products, wholegrain, nuts, and sugary snacks., Conclusion: With the predefined cut-offs, HeartDiet's suitability as a screening tool to assess needs for dietary interventions was limited, since no respondents were categorised as having a heart-healthy diet. An abridged version can replace HeartDiet, but the tool's educational potential will be compromised, since important items will be omitted., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aim: Long-term cognitive decline after out-of-hospital cardiac arrest (OHCA) is still poorly understood. This study describes long-term observer-reported cognitive decline among Danish OHCA survivors, including differences in years since the event, and investigates characteristics and self-reported outcomes associated with observer-reported cognitive decline., Methods: Adults who survived an OHCA from 2016 to 2019, and their relatives, completed the national DANish Cardiac Arrest Survivorship survey. Relatives completed the Informant Questionnaire on Cognitive Decline in the Elderly, Cardiac Arrest version (IQCODE-CA), the Hospital Anxiety and Depression Scale (HADS) and the World Health Organisation-Five Well-being index; and survivors completed the Two Simple Questions (everyday activities and mental recovery), the Modified Fatigue Impact Scale, HADS, and the Short World Health Organisation Disability Assessment Schedule 2.0. Potential associations between survivor characteristics and the IQCODE-CA were investigated using a multivariable logistic regression model. Self-reported outcomes among survivors and relatives, and the association with IQCODE-CA scores were investigated using separate logistic regression models., Results: Total median IQCODE-CA score was 3.04 (IQR: 3.00-3.27), with 47% having possible cognitive decline (score ≥ 3.04), consistent across time groups. Increasing age (OR 0.98, 95% CI: 0.97-0.99) and worse self-reported mental and physical outcomes for survivors and relatives, except 'everyday activities' were significantly associated with possible cognitive decline among survivors., Conclusions: Nearly half of OHCA survivors may suffer long-term cognitive decline. Worse self-reported mental and physical outcomes among survivors and their relatives are associated with potential cognitive decline emphasising the need for post-OHCA care to include systematic neurocognitive assessment, tailored support and effective rehabilitation., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: Existing estimates of PD prevalence in Denmark are lower than those in the rest of Europe and are based on identification via single registries. Hence, are aim was to use a combined registry/self-report survey approach to identify people with PD and also investigate whether using different registry methods led to differences in the accuracy, completeness and characteristics of the identified cohorts., Methods: This study had a cross-sectional design using routinely collected health registry data to identify adults, ≥18 years of age and resident in Denmark, with PD from either the Danish National Patient (DNP) registry or Danish Prescription Medicines (DPM) registry. Those identified were asked to confirm their PD diagnosis using a national self-report survey., Results: 13,433 people were identified potentially as having PD via the DNP or DPM registry and sent a survey. Of these, 9094 responded (68 %) of which 85 % confirmed they had PD (n = 7763; 194/100,000; 95%CI:7650-7876). When adjusting for non-respondents, assuming an equal rate of confirmation in respondents and non-respondents, estimated Danish PD population was 11,467 (198.4/100,000; 95 % CI:197.2-199.6). Identification of people using those found in both registries led to 98 % confirming they had PD versus using one registry: DNP 93 % and DPM 88 %. No clear differences in sociodemographic characteristics were found between different registry identification methods., Conclusions: Estimated PD population in Denmark was significantly higher than previous Danish estimates and close to existing estimates in other European countries. The most accurate PD population was identified when including those found in both the DNP and DPM registries., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jette Theusen reports financial support was provided by the Danish Parkinson's Association., (Copyright © 2024. Published by Elsevier Ltd.)

The 12-item version of the Kansas City Cardiomyopathy Questionnaire (KCCQ-12) was originally developed for patients with heart failure but has been used and tested among patients with severe aortic stenosis (AS) who underwent transcatheter aortic valve implantation. Whether the instrument is suitable for patients with AS who underwent surgical aortic valve replacement (SAVR) is currently unknown. Thus, we aimed to investigate the psychometric properties of the KCCQ-12 before and after SAVR among patients with severe AS. We conducted a prospective cohort of 184 patients with AS who completed the KCCQ-12 and the EuroQol 5 Dimension 5 Levels before and 4 weeks after surgery. Construct validity was investigated with hypothesis testing and an analysis of Spearman's correlation between the two instruments. Structural validity was investigated with explorative and confirmatory factor analyses and reliability with Cronbach's α. All analyses were conducted on data from the two time points (preoperatively and four weeks after surgery). The hypothesis testing revealed how the New York Heart Association class was significantly correlated with the preoperative KCCQ-12 total score (higher New York Heart Association class, worse score). A longer length of hospital stay and living alone were significantly associated with poorer postoperative KCCQ-12 total score. KCCQ-12 and EuroQol 5 Dimension 5 Levels were moderately correlated in most domains/the total score/Visual Analogue Scale score. Principal component analyses revealed two 3-factor structures. The confirmatory factor analyses did not support the original model at any time point. Cronbach's α ranged from 0.22 to 0.84 in three preoperative factors and from 0.39 to 0.76 in the postoperative factors. The total Cronbach's α was 0.83 for the suggested preoperative 3-factor model and 0.83 for the postoperative model. In conclusion, the Danish version of the KCCQ-12 tested in a population of patients with AS who underwent SAVR appears to have acceptable construct validity, whereas structural validity cannot be confirmed for the original four-factor model. Overall reliability is good., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

This study examined whether patients attending cardiac rehabilitation (CR) based on the pedagogical strategy learning and coping (LC) led to improved health-related quality of life (HRQL), reduced symptoms of anxiety and depression and improved self-management 6 and 12 months after the completion of CR compared with patients attending CR based on the pedagogical strategy 'Empowerment, Motivation and Medical Adherence' (EMMA). A pragmatic cluster-controlled trial of two pedagogical strategies, LC and EMMA, including 10 primary health care settings and 555 patients diagnosed with ischaemic heart disease and referred to CR between August 2018 and July 2019 was conducted. In total, 312 patients replied to the questionnaires collected at baseline, 12 weeks, 6 months and 12 months after completing CR. Linear regression analyses adjusted for potential confounder variables and cluster effects were performed. We found clinically relevant and statistically significant improvements in HRQL, anxiety, depression and self-management after completing CR. The improvements were sustained at 6 and 12 months after the completion of CR. We found no differences between the two evidence-based patient education strategies. In conclusion, this study supports the use of evidence-based patient education strategies, but there is no evidence to suggest that one pedagogical strategy is superior to the other., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Allocating resources to increase survival after cardiac arrest requires survivors to have a good quality of life, but long-term data are lacking., Objective: To determine the quality of life of survivors of out-of-hospital cardiac arrest from 2001 to 2019., Design, Setting, and Participants: This survey study used the EuroQol Health Questionnaire, 12-Item Short Form Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) to assess the health-related quality of life of all adult survivors of out-of-hospital cardiac arrest included in the Danish Cardiac Arrest Registry between June 1, 2001, and August 31, 2019, who were alive in October 2020 (follow-up periods, 0-1, >1-2, >2-4, >4-6, >6-8, >8-10, >10-15, and >15-20 years since arrest). The survey was conducted from October 1, 2020, through May 31, 2021., Exposure: All patients who experienced an out-of-hospital cardiac arrest., Main Outcome and Measures: Self-reported health was measured using the EuroQol Health Questionnaire index (EQ index) score and EQ visual analog scale. Physical and mental health were measured using the SF-12, and anxiety and depression were measured using the HADS. Descriptive statistics were used for the analysis., Results: Of 4545 survivors, 2552 (56.1%) completed the survey, with a median follow-up since their event of 5.5 years (IQR, 2.9-8.9 years). Age was comparable between responders and nonresponders (median [IQR], 67 [58-74] years vs 68 [56-78] years), and 2075 responders (81.3%) were men and 477 (18.7%) women (vs 1473 male [73.9%] and 520 female [26.1%] nonresponders). For the shortest follow-up (0-1 year) and longest follow-up (>15-20 years) groups, the median EQ index score was 0.9 (IQR, 0.7-1.0) and 0.9 (0.8-1.0), respectively. For all responders, the mean (SD) SF-12 physical health score was 43.3 (12.3) and SF-12 mental health score, 52.9 (8.3). All 3 scores were comparable to a general Danish reference population. Based on HADS scores, a low risk for anxiety was reported by 73.0% (54 of 74) of 0- to 1-year survivors vs 89.3% (100 of 112) of greater than 15- to 20-year survivors; for symptoms of depression, these proportions were 79.7% (n = 59) and 87.5% (n = 98), respectively. Health-related quality of life was similar in survivor groups across all follow-up periods., Conclusions and Relevance: Among this survey study's responders, who comprised more than 50% of survivors of out-of-hospital cardiac arrest in Denmark, long-term health-related quality of life up to 20 years after their event was consistently high and comparable to that of the general population. These findings support resource allocation and efforts targeted to increasing survival after out-of-hospital cardiac arrest.

Aims: The aim of this study was to evaluate if a combination of World Health Organization-5 (WHO-5), Anxiety Symptom Scale-2 (ASS-2), and Major Depression Inventory-2 (MDI-2) can replace the Hospital Anxiety and Depression Scale (HADS) as screening tool for anxiety and depression in cardiac patients across diagnoses and whether it is feasible to generate crosswalks (translation tables) for use in clinical practice., Methods and Results: We used data from the Danish 'Life with a heart disease' survey, in which 10 000 patients with a hospital contact and discharge diagnosis of ischaemic heart disease, heart failure, heart valve disease, or atrial fibrillation in 2018 were invited. Potential participants received an electronic questionnaire including 51 questions on health, well-being, and evaluation of the health care system. Crosswalks between WHO-5/ASS-2 and HADS anxiety dimension (HADS-A) and between WHO-5/MDI-2 and HADS depression dimension (HADS-D) were generated and tested using item response theory (IRT). A total of 4346 patients responded to HADS, WHO-5, ASS-2, and MDI-2. Model fit of the bi-factor IRT models illustrated appropriateness of a bi-factor structure and thus of essential uni-dimensionality [root mean square error of approximation (RMSEA) (P value) range 0.000-0.053 (0.0099-0.7529) for anxiety and 0.033-0.061 (0.0168-0.2233) for depression]. A combination of WHO-5 and ASS-2 measured the same trait as HADS-A, and a combination of WHO-5 and MDI-2 measured the same trait as HADS-D. Consequently, crosswalks (translation tables) were generated., Conclusions: Our study shows that it is feasible to use crosswalks between HADS-A and WHO-5/ASS-2 and HADS-D and WHO-5/MDI-2 for screening cardiac patients across diagnoses for anxiety and depression in clinical practice., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Equal access to healthcare is a fundamental principle in the fully tax-financed Danish healthcare system. This study reveals whether this system lives up to the principle of equal access when it comes to the rehabilitation of patients who have major lower extremity amputations., Methods: With the aim of exploring possible inequality in rehabilitation for patients having major lower extremity amputation in Denmark, a nationwide electronic survey was conducted in the autumn of 2020, which included all hospitals and municipalities in Denmark., Results: Eighty six percent of hospitals (n = 19) and 97% (n = 95) of municipalities responded. Of the 32% (n = 6) of hospitals and 78% (n = 74) of municipalities that provided prosthesis rehabilitation, the majority (hospitals 50% /municipalities 91%) provided prostheses for <10 patients in 2019, and 36% reported having competencies at only a general level among physiotherapists performing prosthetic training. Psychosocial rehabilitation modalities were lacking overall., Conclusions: This national study documents pronounced geographic inequality in access to qualified rehabilitation services for the relatively few patients undergoing lower extremity amputations in Denmark. The decentralised organisation of amputation rehabilitation makes it difficult to build and maintain specialist competencies among healthcare professionals. Inconsistent availability of psychosocial rehabilitation modalities of all kinds found in this study points to a need for action particularly among patients not in prosthetic rehabilitation where palliative needs should also be considered., (© 2023 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.)

Cardiac rehabilitation remains the 'Cinderella' of treatments for heart failure. This state-of-the-art review provides a contemporary update on the evidence base, clinical guidance, and status of cardiac rehabilitation delivery for patients with heart failure. Given that cardiac rehabilitation participation results in important improvements in patient outcomes, including health-related quality of life, this review argues that an exercise-based rehabilitation is a key pillar of heart failure management alongside drug and medical device provision. To drive future improvements in access and uptake, health services should offer heart failure patients a choice of evidence-based modes of rehabilitation delivery, including home, supported by digital technology, alongside traditional centre-based programmes (or combinations of modes, 'hybrid') and according to stage of disease and patient preference., Competing Interests: Conflict of interest None of the authors have any conflict of interest or relationships with industry that could have influenced this manuscript. R.S.T., H.D., and A.D.Z. are active cardiac rehabilitation researchers that include systematic reviews/meta-analyses and clinical trials of cardiac rehabilitation in patients with heart failure. The authors declare that all illustrations and figures in the manuscript are entirely original and do not require reprint permission., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Caring for an out-of-hospital cardiac arrest (OHCA) survivor may impact family caregivers' lives due to the sudden onset of the illness and possible secondary cognitive, emotional, and physical challenges. However, experiences of caring for an OHCA survivor are sparsely described. Thus, this study aimed to explore how family caregivers of OHCA survivors experience the potential burden., Methods and Results: Using an explorative qualitative approach, six focus group interviews were conducted with a sample of 25 family caregivers of OHCA survivors and analysed using a phenomenological hermeneutic approach inspired by the philosophy of Ricoeur. The OHCA survivors attended a rehabilitation course, and the family caregivers were interviewed as part of the course.Based on the analysis, three themes emerged: (i) feeling unexpectedly alone and invisible; the family caregivers experienced an emotional burden that could not be shared-leading to caregiving being a lonely experience, (ii) fear of loss; the fear of losing a loved one was a constant companion contributing to the burden, and (iii) adjusting to a new everyday life; the family caregivers had difficulties adjusting to living their lives on the premise of the survivors' needs., Conclusion: The findings of this study emphasize the burden experienced by family caregivers and how they can be trapped in competing emotions and tensions. The possible caregiver burden following OHCA should be acknowledged. Interventions to reduce the burden should be tested and implemented as part of the clinical care of OHCA survivors and their families., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Aims: Coronary heart disease is the most common reason for referral to exercise-based cardiac rehabilitation (CR) globally. However, the generalizability of previous meta-analyses of randomized controlled trials (RCTs) is questioned. Therefore, a contemporary updated meta-analysis was undertaken., Methods and Results: Database and trial registry searches were conducted to September 2020, seeking RCTs of exercise-based interventions with ≥6-month follow-up, compared with no-exercise control for adults with myocardial infarction, angina pectoris, or following coronary artery bypass graft, or percutaneous coronary intervention. The outcomes of mortality, recurrent clinical events, and health-related quality of life (HRQoL) were pooled using random-effects meta-analysis, and cost-effectiveness data were narratively synthesized. Meta-regression was used to examine effect modification. Study quality was assessed using the Cochrane risk of bias tool. A total of 85 RCTs involving 23 430 participants with a median 12-month follow-up were included. Overall, exercise-based CR was associated with significant risk reductions in cardiovascular mortality [risk ratio (RR): 0.74, 95% confidence interval (CI): 0.64-0.86, number needed to treat (NNT): 37], hospitalizations (RR: 0.77, 95% CI: 0.67-0.89, NNT: 37), and myocardial infarction (RR: 0.82, 95% CI: 0.70-0.96, NNT: 100). There was some evidence of significantly improved HRQoL with CR participation, and CR is cost-effective. There was no significant impact on overall mortality (RR: 0.96, 95% CI: 0.89-1.04), coronary artery bypass graft (RR: 0.96, 95% CI: 0.80-1.15), or percutaneous coronary intervention (RR: 0.84, 95% CI: 0.69-1.02). No significant difference in effects was found across different patient groups, CR delivery models, doses, follow-up, or risk of bias., Conclusion: This review confirms that participation in exercise-based CR by patients with coronary heart disease receiving contemporary medical management reduces cardiovascular mortality, recurrent cardiac events, and hospitalizations and provides additional evidence supporting the improvement in HRQoL and the cost-effectiveness of CR., Competing Interests: Conflict of interest: N.O. declares being an author of a study that is eligible for inclusion in the work (funding source: European Society of Cardiology & European Association of Preventive Cardiology). D.R.T. declares being an author of a study that is eligible for inclusion in the work. A.D.Z. declares being an author of a study that is eligible for inclusion in the work., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Out-of-hospital cardiac arrest (OHCA) survivors may suffer short-term fatigue, psychological, cognitive and disability problems, but we lack information on the proportion of survivors with these problems in the long-term. Hence, we investigated these problems in survivors 1-5 years post-OHCA and whether the results are different at different time points post-OHCA., Methods: All adults who survived an OHCA in Denmark from 2016 to 2019 were identified using the Danish Cardiac Arrest Registry and invited to participate in a survey between October 2020 and March 2021. The survey included the Modified Fatigue Impact Scale, Hospital Anxiety and Depression Scale, "Two simple questions" (everyday activities and mental recovery), and the 12-item World Health Organisation Disability Assessment Schedule 2.0. To investigate results at different time points, survivors were divided into four time-groups (12-24, 25-36, 37-48 and 49-56 months post-OHCA). Differences between time-groups were determined using the Kruskall-Wallis test for the mean scores and Chi-square test for the proportion of survivors with symptoms., Results: Total eligible survey population was 2116, of which 1258 survivors (60 %) responded. Overall, 29 % of survivors reported fatigue, 20 % anxiety, 15 % depression, and 27 % disability. When survivors were sub-divided by time since OHCA, no significant difference was found on either means scores or proportion between time groups (p = 0.28 to 0.88)., Conclusion: Up to a third of survivors report fatigue, anxiety, depression, reduced mental function and disability 1-5 years after OHCA. This proportion is the same regardless of how much time has passed supporting early screening and tailored post-OHCA interventions to help survivors adapt to their new situation., (Copyright © 2022. Published by Elsevier B.V.)

Introduction: Multidisciplinary Team Conferences (MDTs) are complex interventions in the modern healthcare system and they promote a model of coordinated patient care and management. However, MDTs within chronic diseases are poorly defined. Therefore, the aim of this scoping review was to summarise the current literature on physician-led in-hospital MDTs in chronic non-malignant diseases., Method: Following the PRISMA-ScR guideline for scoping reviews, a search on MDT interventions in adult patients, with three or more medical specialties represented, was performed., Results: We identified 2790 studies, from which 8 studies were included. The majority of studies were non-randomised and focused on a single disease entity such as infective endocarditis, atrial fibrillation, IgG4-related disease, or arterial and venous thrombosis. The main reason for referral was confirmation or establishment of a diagnosis, and the MDT members were primarily from medical specialties gathered especially for the MDT. Outcomes of the included studies were grouped into process indicators and outcome indicators. Process indicators included changes in diagnostic confirmation as well as therapeutic strategy and management. All studies reporting process indicators demonstrated significant changes before and after the MDT., Conclusion: MDTs within chronic diseases appeared highly heterogeneous with respect to structure, reasons for referral, and choice of outcomes. While process indicators, such as change in diagnosis, and treatment management/plan seem improved, such have not been demonstrated through outcome indicators., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Aims . The CopenHeart VR trial found positive effects of cardiac rehabilitation (CR) on physical capacity at 4 months. The long-term effects of CR following valve surgery remains unclear, especially regarding readmission and mortality. Using data from he CopenHeart VR Trial we investigated long-term effects on physical capacity, mental and physical health and effect on mortality and readmission rates as prespecified in the original protocol. Methods . A total of 147 participants were included after heart valve surgery and randomly allocated 1:1 to 12-weeks exercise-based CR including a psycho-educational programme (intervention group) or control. Physical capacity was assessed as peak oxygen uptake (VO 2 peak) measured by cardiopulmonary exercise testing, mental and physical health by Short Form-36 questionnaire, Hospital Anxiety and Depression Scale, and HeartQol. Mortality and readmission were obtained from hospital records and registers. Groups were compared using mixed regression model analysis and log rank test. Results . No differences in VO 2 peak at 12 months or in self-assessed mental and physical health at 24 months (68% vs 75%, p  = .120) was found. However, our data demonstrated reduction in readmissions in the intervention group at intermediate time points; after 3, 6 (43% vs 59%, p  = .03), and 12 (53% vs 67%, p  = .04) months, respectively, but no significant effect at 24 months. Conclusions . Exercise-based CR after heart valve surgery reduces combined readmissions and mortality up to 12 months despite lack of improvement in exercise capacity, physical and mental health long-term. Exercise-based CR can ensure short-term benefits in terms of physical capacity, and lower readmission within a year, but more research is needed to sustain these effects over a longer time period. These considerations should be included in the management of patients after heart valve surgery.

Aims: To examine the temporal trends and factors associated with national cardiac rehabilitation (CR) referral and compare the risk of hospital readmission and mortality in those referred for CR versus no referral., Methods and Results: This cohort study includes all adult patients alive 120 days from incident heart failure (HF) identified by the Danish Heart Failure Registry (n = 33 257) between 2010 and 2018. Multivariable logistic regression models were used to assess the association between CR referral and patient factors and acute all-cause hospital readmission and mortality at 1 year following HF admission. Overall, 46.7% of HF patients were referred to CR, increasing from 31.7% in 2010 to 52.2% in 2018. Several factors were associated with lower odds of CR referral: male sex [odds ratio (OR): 0.85; 95% confidence interval: 0.80-0.89], older age, unemployment, retirement, living alone, non-Danish ethnic origin, low educational level, New York Heart Association (NYHA) class IV vs. I (OR: 0.75; 0.60-0.95), left ventricular ejection fraction >40%, and comorbidity (stroke, chronic kidney disease, atrial fibrillation/flutter, and diabetes). Myocardial infarction, arthritis, coronary artery bypass grafting, percutaneous coronary intervention, valvular surgery, NYHA class II, and use of angiotensin-converting enzyme inhibitors were associated with higher odds of CR referral. CR referral was associated with lower risk of acute all-cause readmission (OR: 0.92; 0.87-0.97) and all-cause mortality (OR: 0.65; 0.58-0.72)., Conclusion: Although increased over time, only one in two HF patients in Denmark were referred to CR in 2018. Strategies are needed to reduce referral disparities, focusing on subgroups of patients at highest risk of non-referral., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Cardiovascular patients with low socioeconomic status and non-western ethnic background have worse prognostic outcomes. The aim of this nationwide study was first to address whether short-term effects of hospital-based outpatient cardiac rehabilitation (CR) are similar across educational level and ethnic background, and secondly to study whether known disparity in long-term prognosis in patients with cardiovascular disese is diminished by CR participation., Methods: All patients with myocardial infarction and/or coronary revascularization from August 2015 until March 2018 in the Danish national patient registry or the Danish cardiac rehabilitation database (DHRD) were included. We used descriptive statistics to address disparity in achievement of quality indicators in CR, and Cox proportional hazard regression to examine the association between the disparity measures and MACE (cardiovascular hospitalization and all-cause mortality) with adjustment for age, gender, index-diagnose and co-morbidity., Results: We identified 34,511 patients of whom 19,383 had participated in CR and 9,882 provided information on CR outcomes from the DHRD. We demonstrated a socioeconomic gradient in improvements in VO2peak, and non-western patients were less often screened for depression or receive dietary consulting. We found a strong socioeconomic gradient in MACE irrespective of CR participation, medication, and risk factor control (adjusted HR 0.65 (95% CI 0.56-0.77) for high versus low education). Non-western origin was associated with higher risk of MACE (adjusted HR 1.2 (1.1-1.4))., Conclusion: We found only minor socioeconomic and ethnic differences in achievement of CR quality indicators but strong differences in CHD prognosis indication that conventional risk factor control and medical treatment following CR do not diminish the socioeconomic and ethnical disparity in CHD prognosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Kjesbu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Adherence and completion of programmes in educational and physical exercise sessions is essential in cardiac rehabilitation (CR) to obtain the known benefits on morbidity, mortality, risk factors, lifestyle, and quality of life. The patient education strategy "Learning and Coping" (LC) has been reported to positively impact adherence and completion in a hospital setting. It is unknown if LC has impact on adherence in primary healthcare settings, and whether LC improves self-management. The aim of this pragmatic primary healthcare-based study was to examine whether patients attending CR based on LC had a better adherence to patient education and physical exercise, higher program completion rate, and better self-management compared to patients attending CR based on a consultation program Empowerment, Motivation and Medical Adherence (EMMA)., Method: A pragmatic cluster-controlled trial of two types of patient education LC and EMMA including ten primary healthcare settings and 514 patients (LC, n = 266; EMMA, n = 248) diagnosed with ischaemic heart disease discharged from hospital and referred to CR between August 1, 2018 and July 31, 2019. Adherence was defined as participation in ≥ 75% of provided sessions. Completion was defined as patients attended the final interview at the end of the 12-weeks programme. Patient Activation Measure (PAM) was used to obtain information on a person's knowledge, skills and confidence for self-management. PAM questionnaire was completed at baseline and 12-weeks follow-up. Multiple and Linear regression analyses adjusted for potential confounder variables and cluster effect were performed., Result: Patients who followed CR based on LC had a higher adherence rate to educational and physical exercise sessions compared to patients who followed CR based on EMMA (p < 0.01). High-level of completion was found at the end of CR with no statistically significant between clusters (78.9% vs. 78.2%, p > 0.05). At 12-weeks, there was no statistical differences in PAM-score between clusters (p > 0.05)., Conclusion: This study indicates that the LC positively impacts adherence in CR compared to EMMA. We found non-significant difference in completing CR and in patient self-management between the two types of patient education. Future studies are needed to investigate if the higher adherence rate achieved by LC in primary healthcare settings translates into better health outcomes., (© 2022. The Author(s).)

Aims: Systematic screening for anxiety and depression is widely recommended as a core component of cardiac rehabilitation in ischemic heart disease, however, recommendation-practice gaps are common and limited knowledge exists about factors hindering and supporting implementation. The study aimed to assess adherence to national clinical guideline recommendations and to gain a greater understanding of the implementation of screening in real-world practice., Methods: An observational, longitudinal mixed-methods design including hospitals and municipalities in Denmark. We retrieved nationwide survey data from 2013, 2015, 2018 and 2021 to assess adherence to screening on programme level, and clinical quality registry data from 2016 to 2020 to assess proportion of patients screened. Data were analysed descriptively. Semi-structured interviews with healthcare professionals were conducted in 2015 (n = 11) and 2020 (n = 11) to explore how screening was conducted and factors supporting implementation. Normalization Process Theory guided interviews and content analysis., Results: Screening on programme level increased from 61% to 88% in hospitals and 20% to 89% in municipalities. The individual proportion of patients screened remained relatively stable in both hospitals and municipalities overall, however with considerable inter-site differences. Screening practices became more aligned to guidelines, pushed by formal recommendations and monitoring, and pulled by activities strengthening the knowledge and motivation among staff., Conclusion: Screening for anxiety and depression improved considerably over the seven-year period, from a scattered practice driven by individuals to a movement where healthcare professionals had a feeling of going with the flow. Nationwide implementation of screening requires national and local supporting activities and a continuous effort., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Aim: The benefits of cardiac rehabilitation (CR) after acute coronary syndrome (ACS) are well established. However, the relative benefit of CR in those with comorbidities, including diabetes, is not well understood. This systematic review and meta-analysis examined the benefit of CR on exercise capacity and secondary outcomes in ACS patients with a co-diagnosis of diabetes compared to those without., Methods: Five databases were searched in May 2021 for randomised controlled trials (RCTs) and observational studies reporting CR outcomes in ACS patients with and without diabetes. The primary outcome of this study was exercise capacity expressed as metabolic equivalents (METs) at the end of CR and ≥ 12-month follow-up. Secondary outcomes included health-related quality of life, cardiovascular- and diabetes-related outcomes, lifestyle-related outcomes, psychological wellbeing, and return to work. If relevant/possible, studies were pooled using random-effects meta-analysis., Results: A total of 28 studies were included, of which 20 reported exercise capacity and 18 reported secondary outcomes. Overall, the studies were judged to have a high risk of bias. Meta-analysis of exercise capacity was undertaken based on 18 studies (no RCTs) including 15,288 patients, of whom 3369 had diabetes. This analysis showed a statistically significant smaller difference in the change in METs in ACS patients with diabetes (standardised mean difference (SMD) from baseline to end of CR: - 0.15 (95% CI: - 0.24 to - 0.06); SMD at the ≥ 12-month follow-up: - 0.16 (95% CI: - 0.23 to - 0.10, four studies))., Conclusion: The benefit of CR on exercise capacity in ACS patients was lower in those with diabetes than in those without diabetes. Given the small magnitude of this difference and the substantial heterogeneity in the results of the study caused by diverse study designs and methodologies, further research is needed to confirm our findings. Future work should seek to eliminate bias in observational studies and evaluate CR based on comprehensive outcomes., (© 2022. The Author(s).)

Objective: Psychosocial risk factors are common in patients with ischemic heart disease (IHD) and linked to poor prognosis. Psychosocial healthcare is recommended in international guidelines and has demonstrated positive effects, primarily on psychosocial symptoms. We examined the association between patient-reported psychosocial healthcare and hospital readmissions and mortality in patients with IHD., Methods: A population-based cohort study with register-based follow-up. Patient-reported psychosocial healthcare was measured by seven items in a survey sent to a random sample of patients with incident IHD in Denmark in 2014. We used multivariable Cox proportional hazards models and Poisson regression to examine the association between psychosocial healthcare and readmissions and all-cause mortality., Results: In total, 1083 (57%) patients were followed up to 4½ years. Low psychosocial support was reported by 53.4%, medium by 26.2% and high by 20.4% patients. The hazard of acute cardiac readmission for patients reporting low psychosocial healthcare was 2.08 higher than for patients reporting high psychosocial healthcare (95%CI:1.01-4.30). No association was found with time to first all-cause readmission. The acute cardiac readmission rate was 3.24 (95%CI:1.66-6.29) and 4.23 (95%CI:2.15-8.33) times higher among patients reporting low and medium psychosocial healthcare compared to high, and the all-cause readmission rate was 1.30 (95%CI:1.16-1.46) and 1.32 (95%CI:1.17-1.49) times higher. The hazard of death was 2.86 (95%CI:1.23-6.69) and 2.88 (95%CI:1.18-7.04) times higher among patients reporting low and medium psychosocial healthcare compared to high., Conclusion: In patients with IHD, a high level of patient-reported psychosocial healthcare was significantly associated with reduced hospital readmissions and all-cause mortality., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Aims: Infective endocarditis is a complex and highly mortal disease requiring lengthy treatment. Physical and mental deconditioning is common. Nonetheless, rehabilitation is virtually unexplored in this population. The aim of this trial was therefore to investigate the effects of cardiac rehabilitation in patients following endocarditis., Methods and Results: In a randomized trial, adults with left-sided or cardiac device endocarditis were randomized 1:1 to 12 weeks of physical exercise training and five psycho-educational consultations (cardiac rehabilitation) vs. usual care without rehabilitation (control). Primary outcome was mental health measured by SF-36 Mental Component Summary (MCS) at 6 months. Secondary outcome was physical capacity measured by peak oxygen uptake (VO2) at 4 months. Exploratory outcomes were investigated. Low inclusion rate resulted in trial termination before reaching the target sample size. A total of 117 participants (mean age: 60 years, 81% male) were randomized to cardiac rehabilitation (n = 58) or to control (n = 59). Mental health and physical capacity at baseline were generally poor (MCS: 38.9-42.2 points, VO2 peak: 16.1-16.6 mL/kg/min). Cardiac rehabilitation compared with control showed no effect on mental health (MCS: 44.6 points vs. 48.8 points, P = 0.41) or physical capacity (VO2 peak: 19.9 mL/kg/min vs. 18.0 mL/kg/min, P = 0.09). Effects favouring the intervention were identified in exploratory outcomes including general fatigue (P = 0.005), and physical capacity as maximal power (W) (P = 0.005). Adherence to the intervention was 28%., Conclusions: Results indicate no effect of cardiac rehabilitation in patients following endocarditis; however, lack of statistical power and poor adherence render findings inconclusive. Valuable insight into patients' capabilities and safety was gained, and further investigations into rehabilitation needs and modes of delivery in this high-need population should be a future priority., Registration: The trial is registered at ClinicalTrials.gov, NCT01512615., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aims: This study investigated the feasibility and potential effect of SCARF (Survivors of Cardiac ARest focused on Fatigue) a multidisciplinary residential rehabilitation intervention focused on fatigue and the secondary psychological and physical consequences of cardiac arrest (CA)., Methods: This was a prospective one-armed feasibility study. Six progression criteria were identified related to the feasibility of the intervention and viability of a future effect study in terms of: participant recruitment (1), participant retention (2,3,4), and completeness of outcomes (5,6). Data on participant/clinician satisfaction with the intervention was also collected along with self-reported outcomes: fatigue, quality of life, anxiety, depression, function and disability, and physical activity (at baseline, 12 weeks and 6 months) and physical capacity (baseline and 12 weeks)., Results: Four progression criteria were met including retention (87.5%) and completion of baseline outcomes (97.5%). Two criteria were not met: recruitment rate was 2.9 participants per month (estimated rate needed 6.1) and completion of final outcomes was 65% (estimated proportion needed 75%). Participant/clinician satisfaction with the intervention was high. Three months after the SCARF intervention small to moderate effect size changes of r = 0.18-0.46 were found for self-reported fatigue, quality of life, anxiety, depression, function and disability and for two of the physical capacity tests (d = 0.46-0.52)., Conclusion: SCARF was found to be a feasible intervention with high participant/clinician satisfaction, high participant retention and the possible potential to improve self-reported and physical capacity outcomes. Procedures for study recruitment and collection of final outcomes should be modified before a fully powered randomised controlled trial is conducted., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016., Objectives: To assess the clinical effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD., Search Methods: We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021., Selection Criteria: We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease., Data Collection and Analysis: We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point).  MAIN RESULTS: This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years. In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years). At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials;  NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I 2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes. At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials). At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials). Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias. There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs)., Authors' Conclusions: This updated Cochrane Review supports the conclusions of the previous version, that exercise-based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all-cause mortality, and a large reduction in all-cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well-designed, adequately-reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer-term follow-up, and assess costs and cost-effectiveness., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Aims: Due to an ageing population and increasing survival from concurrent diseases, the burden of left-sided degenerative valvular heart disease is expected to increase over time. This study aims at determining the temporal trends in incidence rates at the population level and examines whether there are socioeconomic differences., Methods and Results: A total of 133 209 patients were identified with a first-time diagnosis of aortic stenosis (AS), mitral regurgitation (MR), or aortic regurgitation (AR) in the Danish National Patient Registry in the 2000-17 period. Incidence rates (per 100 000 person-years) doubled over the period for AS (57 in 2000-02; 114 in 2015-17) and for AR (22 in 2000-02; 41 in 2015-17) and remained the same for MR (38 in both 2000-02 and 2015-17). Incidence rates increased rapidly with increasing age, most markedly for AS. Men had a higher risk of being affected [relative risk (RR) 1.69 for AS, 1.19 for MR, 1.35 for AR]. Compared to high-level education, patients with medium- and low-level education had a higher risk of being affected (RR 1.18 for AS medium level and 1.47 for AS low level; 1.03 for MR medium level and 1.14 for MR low level; 1.03 for AR medium level and 1.18 for AR low level)., Conclusions: For AS and AR, the incidence rates doubled, while the incidence rates remained at the same level for MR. The risk of being affected increased with advanced age and male gender. Patients with low-level education had a higher risk of being affected compared to patients with high-level education, especially among patients with AS., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aim: The aim of this systematic review was to assess the effectiveness of rehabilitation interventions on the secondary physical, neurological and psychological consequences of cardiac arrest (CA) for adult survivors., Methods: A literature search of electronic databases (MEDLINE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica database, Psychological Information Database, Web of Science and Cochrane Central Register of Controlled trials) was conducted for randomised controlled trials (RCTs) and observational studies up to 18 April 2021. The primary outcome was health-related quality of life (HRQoL) and main secondary outcome was neurological function with additional secondary outcomes being survival, rehospitalisation, safety (serious and non-serious adverse events), psychological well-being, fatigue, exercise capacity and physical capacity. Two authors independently screened studies for eligibility, extracted data and assessed risk of bias., Results: Three RCTs and 11 observational studies were included (total 721 participants). Study duration ranged from 8 weeks to 2 years. Pooled data from two RCTs showed low-quality evidence for no effect on physical HRQoL (standardised mean difference (SMD) 0.19, (95% CI: -0.09 to 0.47)) and no effect on mental HRQoL (SMD 0.27 (95% CI: -0.01 to 0.55)).Regarding secondary outcomes, very low-quality evidence was found for improvement in neurological function associated with inpatient rehabilitation for CA survivors with acquired brain injury (SMD 0.71, (95% CI: 0.45 to 0.96)) from five observational studies. Two small observational studies found exercise-based rehabilitation interventions to be safe for CA survivors, reporting no serious or non-serious events., Conclusions: Given the overall low quality of evidence, this review cannot determine the effectiveness of rehabilitation interventions for CA survivors on HRQoL, neurological function or other included outcomes, and recommend further high-quality studies be conducted. In the interim, existing clinical guidelines on rehabilitation provision after CA should be followed to meet the high burden of secondary consequences suffered by CA survivors., Prospero Registration Number: CRD42018110129., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

COVID-19 can lead to a long-term loss of functioning, which may affect activities and participation in daily living in various ways. The extent and characteristics of post-COVID-19 persistent symptoms are currently being studied extensively worldwide. The purpose of this exploratory study is to explore functioning and rehabilitation needs among persons with self-reported disability following COVID-19. This mixed methods study is based on data from patient-reported outcome measures (PRO), tests of body functions, visual drawings and focus groups among persons with self-reported disability after having suffered from COVID-19. PRO covered quality of life, activity and participation. Tests of body functions targeted strength and endurance. Focus groups and visual drawings elaborated on how post COVID-19 persistent symptoms affected functioning, activities and daily living. Data was collected in August and September 2020. The study sample consisted of 11 women, nine men, aged 35-79 years. Self-reported PRO data showed low quality of life and disability among the participants primarily related to fatigue, energy and drive, breathing and concentration. Tests of body functions showed low strength in lower extremities but otherwise no striking limitations on a group level. Analysis of the focus groups generated the following four themes: (1) Persistent symptoms , particularly in regards to concentration, memory, lack of energy, fatigue and headaches. (2) Balancing activities in daily living with fluctuating symptoms. (3) Uncertainty and Powerlessness , which included a need for directional guidance in order to regain functioning and unmet needs regarding further clinical assessment of persistent symptoms, referral to rehabilitation and returning to work. (4) Hope associated with the experiences of recovery - and for the future. This study highlights that persons with persistent symptoms after COVID-19 may experience a range of limitations in their daily living. This points toward a need for individual assessment and guidance to tailor relevant rehabilitation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Backmann, Maribo, Zwisler, Davidsen and Rottmann.)

Aims: This study aims at determining the temporal trends and the socioeconomic differences in treatment and mortality following a diagnosis of aortic stenosis., Methods and Results: A total of 45,026 patients with a first-time diagnosis of aortic stenosis were identified in the Danish National Patient Registry in the period 2000-17. The risk of AVR within the first year after diagnosis decreased (OR = 1.84 in 2000-02 compared to 2015-16) and the risk was lower in the low-level educational group (OR = 0.85) and in the medium-level group (OR = 0.94) compared to high-level education. The risk of death after AVR within the first year decreased (OR = 2.25 in 2000-02 compared to 2015-16) and the risk was higher in the low-level educational group (OR = 1.32) and in the medium-level group (OR = 1.28) compared to high-level education. The risk of death within the first year after diagnosis, for those patients who did not get an AVR during the follow-up, decreased (OR = 3.08 in 2000-02 compared to 2015-16) and the risk was higher in the low-level educational group (OR = 1.21) and in the medium-level group (OR = 1.10) compared to high-level education., Conclusion: Since 2000 there has been a decrease in both AVR treatment rate, mortality rate after AVR and mortality rate in patients not receiving AVR. For patients with lower-level education there is lower AVR treatment rate, higher mortality rate after AVR and higher mortality rate in patients not receiving AVR., Competing Interests: Declaration of competing interest None declared., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The impact of exercise-based cardiac rehabilitation (CR) following heart valve surgery is uncertain. We conducted an update of this systematic review and a meta-analysis to assess randomised controlled trial evidence for the use of exercise-based CR following heart valve surgery., Objectives: To assess the benefits and harms of exercise-based CR compared with no exercise training in adults following heart valve surgery or repair, including both percutaneous and surgical procedures. We considered CR programmes consisting of exercise training with or without another intervention (such as an intervention with a psycho-educational component)., Search Methods: We searched the Cochrane Central Register of Clinical Trials (CENTRAL), in the Cochrane Library; MEDLINE (Ovid); Embase (Ovid); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO); PsycINFO (Ovid); Latin American Caribbean Health Sciences Literature (LILACS; Bireme); and Conference Proceedings Citation Index-Science (CPCI-S) on the Web of Science (Clarivate Analytics) on 10 January 2020. We searched for ongoing trials from ClinicalTrials.gov, Clinical-trials.com, and the World Health Organization International Clinical Trials Registry Platform on 15 May 2020., Selection Criteria: We included randomised controlled trials that compared exercise-based CR interventions with no exercise training. Trial participants comprised adults aged 18 years or older who had undergone heart valve surgery for heart valve disease (from any cause) and had received heart valve replacement or heart valve repair. Both percutaneous and surgical procedures were included., Data Collection and Analysis: Two review authors independently extracted data. We assessed the risk of systematic errors ('bias') by evaluating risk domains using the 'Risk of bias' (RoB2) tool. We assessed clinical and statistical heterogeneity. We performed meta-analyses using both fixed-effect and random-effects models. We used the GRADE approach to assess the quality of evidence for primary outcomes (all-cause mortality, all-cause hospitalisation, and health-related quality of life)., Main Results: We included six trials with a total of 364 participants who have had open or percutaneous heart valve surgery. For this updated review, we identified four additional trials (216 participants). One trial had an overall low risk of bias, and we classified the remaining five trials as having some concerns. Follow-up ranged across included trials from 3 to 24 months. Based on data at longest follow-up, a total of nine participants died: 4 CR versus 5 control (relative risk (RR) 0.83, 95% confidence interval (CI) 0.26 to 2.68; 2 trials, 131 participants; GRADE quality of evidence very low). No trials reported on cardiovascular mortality. One trial reported one cardiac-related hospitalisation in the CR group and none in the control group (RR 2.72, 95% CI 0.11 to 65.56; 1 trial, 122 participants; GRADE quality of evidence very low). We are uncertain about health-related quality of life at completion of the intervention in CR compared to control (Short Form (SF)-12/36 mental component: mean difference (MD) 1.28, 95% CI -1.60 to 4.16; 2 trials, 150 participants; GRADE quality of evidence very low; and SF-12/36 physical component: MD 2.99, 95% CI -5.24 to 11.21; 2 trials, 150 participants; GRADE quality of evidence very low), or at longest follow-up (SF-12/36 mental component: MD -1.45, 95% CI -4.70 to 1.80; 2 trials, 139 participants; GRADE quality of evidence very low; and SF-12/36 physical component: MD -0.87, 95% CI -3.57 to 1.83; 2 trials, 139 participants; GRADE quality of evidence very low).  AUTHORS' CONCLUSIONS: Due to lack of evidence and the very low quality of available evidence, this updated review is uncertain about the impact of exercise-CR in this population in terms of mortality, hospitalisation, and health-related quality of life. High-quality (low risk of bias) evidence on the impact of CR is needed to inform clinical guidelines and routine practice., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Aims: Anxiety and depression are prevalent in 20% of patients with ischaemic heart disease (IHD); however, treatment of psychological conditions is not commonly integrated in cardiac rehabilitation (CR). Internet-based psychological treatment holds the potential to bridge this gap. To examine the feasibility of an eHealth intervention targeting anxiety and depression in patients with IHD attending CR., Methods and Results: We used a mixed-methods design, including quantitative methods to examine drop-out and change in anxiety and depression scores, and qualitative methods (thematic analysis) to evaluate patients' and nurses' experiences with the intervention. The therapist-guided intervention consisted of 12 modules provided via a web-based platform. The primary outcome was drop-out, with a drop-out rate <25% considered acceptable. Patients were considered as non-drop-out if they completed ≥5 modules. Out of 60 patients screened positive for anxiety and/or depression, 29 patients were included. The drop-out rate was 24% (7/29). Patients had a mean improvement in anxiety and depression scores of 5.5 and 4.6, respectively. On average, patients had 8.0 phone calls with their therapist and 19.7 written messages. The qualitative analysis of patients' experiences identified four themes: treatment platform, intervention, communication with therapist, and personal experience. Patients were positive towards the intervention, although some found the assignments burdensome. From the nurses, we identified three themes: intervention, inclusion procedure, and collaboration with study team. The nurses were positive, however, due to limited time some struggled with the inclusion procedure., Conclusion: Integrating an eHealth intervention in CR is feasible and the drop-out rate acceptable., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Introduction: The number of out-of-hospital cardiac arrest (OHCA) survivors is increasing. However, there remains limited knowledge on the long-term physical and psychological problems suffered by survivors and their relatives. The aims of the DANCAS (DANish cardiac arrest survivorship) survey are to describe the prevalence of physical and psychological problems, identify predictors associated with suffering them and to determine unmet rehabilitation needs in order to make recommendations on the timing and content of future rehabilitation interventions., Methods and Analysis: The DANCAS survey has a cross-sectional design involving a survey of OHCA survivors and their relatives. OHCA survivors will be identified through the Danish Cardiac Arrest Registry as having suffered an OHCA between 1 January 2016 and 31 December 2019. Each survivor will be asked to identify their closest relative to complete the relatives' survey. Contents of survivor survey: EQ-5D-5Level, Hospital Anxiety and Depression Scale, Two Simple Questions, Modified Fatigue Impact Scale, 12-item WHO Disability Assessment Scale 2.0, plus questions on unmet rehabilitation and information needs. Contents of relatives' survey: World Health Organisation-Five Well-Being Index, Hospital Anxiety and Depression Scale, Informant Questionnaire on Cognitive Decline in the Elderly-Cardiac Arrest and the Modified Caregiver Strain Index. Self-report outcome data collected through the surveys will be enriched by data from Danish national registries including demographic characteristics, circumstances of cardiac arrest and comorbidities. The survey will be completed either electronically or by post December 2020-February 2021., Ethics and Dissemination: The study will be conducted in accordance with the Declaration of Helsinki. Surveys and registry-based research studies do not normally require ethical approval in Denmark. This has been confirmed for this study by the Region of Southern Denmark ethics committee (20192000-19). Results of the study will be disseminated via several peer-reviewed publications and will be presented at national and international conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The objectives were to assess the short- and long-term effect of the patient education strategy 'Learning and Coping' (LC) in cardiac rehabilitation (CR) on health-related quality of life, patient education impact, cardiac risk factors and lifestyle. In total, 825 patients hospitalized with ischaemic heart disease or heart failure were randomized to either LC-CR or standard CR at three Danish hospitals. Teaching approach in LC-CR was situational, inductive and reflective, with experienced patients as co-educators and supplemental interviews. Teaching approach in standard CR was structured and deductive. Outcomes were assessed immediately after CR, and after 3 months (short term), and after 3 years (long term). Between-arm differences in favour of LC-CR were SF-12 'role emotional' (3.7, 95% CI: 0.6-6.8) and MDI depression score (0.9, 0.1-1.8) immediately after CR, exercise capacity (4 W, 1-9) at 3 months and SF-12 'role physical' (4.6, 0.1-9.0) (long term). Between-arm differences in favour of controls were waist circumference (-1.7 cm, -2.3 to -1.0) immediately after CR and HeiQ domain 'Constructive attitudes and approaches' (0.11, 0.04-0.18), triglycerides (-0.12 mmol/l, -0.21 to -0.02), systolic blood pressure (-3.12 mmHg, -5.66 to -0.58) at 3 months. Adding LC strategies to CR provides inconsistent short-term results but improves 'role physical' long term., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)