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Chapter 1


Ann-Dorthe Zwisler

Cardiac rehabilitation today targets people with ischaemic heart disease, congestive heart failure and people with a high risk of developing ischaemic heart disease (1).

The short-term goals of cardiac rehabilitation are to stabilize heart disease, to limit the physical and mental effects of heart disease, to improve the functioning of the people with heart disease and to improve their quality of life. The long-term goals are to reduce patients’ long-term risk of heart disease, to stop the progression of heart disease and to reduce morbidity and mortality (1).

According to current evidence, these goals can best be realized through comprehensive cardiac rehabilitation programmes based on exercise training, patient education, lifestyle intervention, risk factor management and clinical assessment, psychosocial support and optimizing the pharmaceutical treatment of symptoms. Pharmaceutical treatment comprises an important part of overall rehabilitation (1).

1.1 Health Benefits

Studies (2–6) have shown that comprehensive cardiac rehabilitation can substantially improve the health of people with ischaemic heart disease.

The results of health economics studies (7–10) further show that comprehensive cardiac rehabilitation is cost-effective. Chapters 5–11 document the individual components of cardiac rehabilitation.

1.2 Guidelines and Recommendations

In 1997, the Danish Heart Foundation and the Danish Society of Cardiology published clinical guidelines for cardiac rehabilitation in Denmark (11). These guidelines closely follow the current international recommendations (1;12;13). The role of cardiac rehabilitation in the treatment of people with ischaemic heart disease has subsequently been emphasized in Denmark among professionals (14–16) and among politicians and administrators (17–21). Nevertheless, hospital-based comprehensive cardiac rehabilitation still needs to be expanded in Denmark (22;23).

Health benefits of cardiac rehabilitation
31% reduction in total mortality
16–36% reduction in the number of admissions
Reduction in symptoms of heart disease
Long-term changes in lifestyle (smoking, diet and exercise)
Improvement of the health-related quality of life
Improved physical functioning

1.3 From idea to project

In 1997, few hospitals in Denmark offered cardiac rehabilitation services that complied with the newly published guidelines (24;25).The heads of the Department of Cardiology at Bispebjerg Hospital appointed an interprofessional working group in spring 1997 (Annex 1) to assess whether the rehabilitation services in the Department complied with the guidelines. The working group indicated that the existing rehabilitation services needed to be reorganized and prepared a local report on this reorganization (26). The heads of the Department, the management of Bispebjerg Hospital and external partners reacted positively to the report. Evaluating the reorganization was given high priority, since Denmark has little experience with cardiac rehabilitation. A three-year project (described at www.CardiacRehabilitation.dk) was initiated with support from foundations and research funds (Annex 2).

1.4 Guidance for the reader

This book is a practical manual on organizing and developing a cardiac rehabilitation programme. The book describes how the Cardiac Rehabilitation Unit currently organizes clinical practice, the rationale on which the efforts are based and the experience of staff in developing and implementing the programme. The experience is based on treating 389 patients who received comprehensive cardiac rehabilitation, most the full programme.

The target group for this book is health professionals and health planners in the fields of heart health or rehabilitation. In addition, the book is suitable for medical and other health degree programmes.

The book is divided into three sections: rationale, methods and experience. Chapter 2, which covers the key concepts in the comprehensive cardiac rehabilitation programme at Bispebjerg Hospital, introduces the components of cardiac rehabilitation described in the second section. The third section describes the experience with the methods.

Chapter 11 on type 2 diabetes mellitus is very extensive, since the Cardiac Rehabilitation Unit has especially focused on this area as part of a PhD study.

We have attempted to use the latest knowledge in this field and mostly refer to the most recent relevant reviews and original research. Each chapter is designed so that it can be read independently, and the chapters may therefore overlap. Each chapter has a reference list.

The cardiac rehabilitation team (Annex 4) prepared the book collectively. Individual contributors wrote most of the individual chapters; Ann-Dorthe Olsen Zwisler wrote the sections on evidence in Chapters 4–11. The editors edited the text for consistency. The material used in teaching, interview guides, descriptions of functions and other purposes is available (in Danish) at www.CardiacRehabilitation.dk to inspire other people in clinical practice and administration. In addition, the comprehensive cardiac rehabilitation programme is described in more detail in English at:


High-risk patients are defined as patients at high risk for developing ischaemic heart disease. The field of rehabilitation uses several terms for the person who needs rehabilitation, including patient, user and client. We have chosen to use the word patient because cardiac rehabilitation in this context is part of an overall programme for hospital patients.We also use the word patient for people at high risk of developing ischaemic heart disease. These people have all been admitted to a department of cardiology because of symptoms that caused the admission.

The health professionals involved are called professionals or practitioners here. The term cardiac rehabilitation team includes all the staff of the Cardiac Rehabilitation Unit, and the clinical team covers solely practitioners.

The book uses the most commonly known words and abbreviations used within cardiology. Annex 6 is a glossary of words and abbreviations used within cardiology. Reference books within cardiology and medical dictionaries may also be useful.

The book uses the present tense although it refers to a project that ended in January 2004. The comprehensive cardiac rehabilitation programme at Bispebjerg Hospital is now permanent.

The project and its process of development have been described (27), and the results of the evaluation are being published in scientific journals.


(1) Giannuzzi P, Saner H, Bjornstad H, Fioretti P, Mendes M, Cohen-Solal A et al. Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003; 24(13): 1273–1278.

(2) Jolliffe JA, Rees K,Taylor RS,Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease (Cochrane review). The Cochrane Library. Issue 1, 2004. Chichester: John Wiley & Sons.

(3) Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease.N Engl J Med 2001; 345(12): 892–902.

(4) McAlister FA, Lawson FM,Teo KK,Armstrong PW. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 2001; 323: 957–962.

(5) Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ 1998; 316(7142): 1434–1437.

(6) Stewart KJ, Badenhop D, Brubaker PH, Keteyian SJ, King M. Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery, and for chronic heart failure. Chest 2003; 123(6): 2104–2111.

(7) Brown A,Taylor R, Noorani H, Stone J, Skidmore B. Exercise-based cardiac rehabilitation programs for coronary artery disease: a systemic clinical and economic review. 3. Ottawa, Canadian Coordinating Office for Health Technology Assessment, 2003.

(8) Lowensteyn I, Coupal L, Zowall H, Grover SA. The cost-effectiveness of exercise training for the primary and secondary prevention of cardiovascular disease. J Cardiopulm Rehabil 2000; 20(3): 147–155.

(9) Ades PA, Pashkow FJ, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil 1997; 17(4): 222–231.

(10) Oldridge N, Furlong W, Feeny D, Torrance G, Guyatt G, Crowe J et al. Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction. Am J Cardiol 1993; 72(2): 154–161.

(11) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(12) Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention. Atherosclerosis 1998; 140(2): 199–270.

(13) Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA et al. Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin 1995; (17): 1–23.

(14) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(15) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(16) Larsen ML, Sjøl A, Videbæk J. Hjerterehabilitering på sygehuse [Hospital-based cardiac rehabilitation]. Copenhagen, National Network of Health Promoting Hospitals in Denmark and Danish Society of Cardiology, 2003.

(17) Government of Denmark. Government Programme on Public Health and Health Promotion, 1999–2008. Copenhagen, Ministry of Health, 1999.

(18) Government of Denmark. Healthy throughout life – the targets and strategies for public health policy of the Government of Denmark, 2002–2010. Copenhagen, Ministry of the Interior and Health, 2002.

(19) National Association of Local Authorities in Denmark, Danish Regions and Ministry of Finance. Udfordringer og muligheder – den kommunale økonomi frem mod 2010 [Challenges and opportunities – local government finances towards 2010]. Copenhagen, Schultz Information, 2002.

(20) Klarlund Pedersen B, Saltin B. Fysisk aktivitet – håndbog om forebyggelse og behandling [Physical activity handbook on prevention and treatment]. Copenhagen, National Board of Health, Centre for Health Promotion and Disease Prevention, 2003.

(21) Cardiac Follow-up Group, National Board of Health. Det fremtidige behov for revaskulariserende behandling af iskæmisk hjertesygdom – herunder PCI-behandling [The future need for revascularization treatment of ischaemic heart disease – including percutaneous coronary intervention]. Copenhagen, National Board of Health, 2003.

(22) Ischiel Træden U, Olsen Zwisler AD, Møller L, Tønnesen H. Forebyggelse på danske sygehuse. En kortlægning [Disease prevention and health promotion at hospitals in Denmark. A survey]. Copenhagen, Unit of Preventive Medicine and Health Promotion, Bispebjerg Hospital and National Network of Health Promoting Hospitals in Denmark, 2003.

(23) Zwisler ADO, Traeden UI, Videbaek J, Madsen M. Implementing cardiac rehabilitation services in Denmark – room for expansion. Presented at the 19th Nordic Congress of Cardiology, 4–6 June 2003, Odense, Denmark.

(24) Danish Heart Foundation. Kardial rehabilitering i Danmark 1994 [Cardiac rehabilitation in Denmark, 1994]. Copenhagen, Danish Heart Foundation, 1994 (Hjertenyt 1994).

(25) Brinksby L. A questionnaire study on cardiac rehabilitation at Danish hospitals. IV Nordic Conference on Cardiac Rehabilitation, June 1996, Copenhagen, Denmark.

(26) Olsen AD, Degn L, Sigurd B. Hjerterehabilitering og -forebyggelse på Bispebjerg Hospital [Cardiac rehabilitation and prevention of heart disease at Bispebjerg Hospital]. Copenhagen, Bispebjerg Hospital, 1997.

(27) Zwisler ADO. DANREHAB-studiet. Efterbehandlingstilbud til patienter udskrevet fra en hjerteafdeling. Status [The DANREHAB study. Rehabilitation services for patients discharged from a department of cardiology]. Copenhagen, Bispebjerg Hospital and National Institute of Public Health, 2002.

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© Cardiac Rehabilitation, Department of Cardiology Y, H:S Bispebjerg Hospital