International Journal of Cardiology 386 (2023) 134–140

Contents lists available at ScienceDirect

International Journal of Cardiology

journal homepage: www.elsevier.com/locate/ijcard

Optimal outcomes from cardiac rehabilitation are associated with

longer-term follow-up and risk factor status at 12 months: An observational
registry-based study☆
Lars Hermann Tang a, b, c, *, Patrick Doherty c, Søren T. Skou a, d, Alexander Harrison a, b, c
a
The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Denmark
b
The Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
c
Department of Health Sciences, University of York, England, United Kingdom
d
Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense,
Denmark

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: The purpose of Cardiac Rehabilitation (CR) is to promote and reduce risk factors in the short and long term,
Maintenance however, the latter has, to date, been poorly evaluated. We explored characteristics associated with provision
Rehabilitation and outcomes of a long-term assessment in CR.
Heart disease
Method: Data from the UK National Audit of CR between April 2015 and March 2020 was used. Programmes were
Exercise
selected if they had an established mechanism and routine methodology to collect the 12-month assessments.
Risk factors pre and post phase II CR and at the 12-month assessment were explored; BMI ≤30, ≥150 min of
physical activity per week, hospital anxiety and depression scale (HADS) scores <8. The data came from 32
programmes, 24,644 patients with coronary heart disease. Patients being in at least one optimal risk factor stage
throughout phase II CR (OR = 1.43 95% CI 1.28 to 1.59) or successfully reaching an optimal stage during phase II
CR (OR = 1.61 95% CI 1.44 to 1.80) had an increased likelihood of being assessed at 12 months compared to
those who did not. Patients being in the optimal stage upon completion of phase II CR had an increased like­
lihood of still being in the optimal stage at 12 months. Most prominent was BMI; (OR = 14.6 (95% CI 11.1 to
19.2) for patients reaching an optimal stage throughout phase II CR.
Conclusion: Being in an optimal stage upon routine CR completion could be an overlooked predictor in the
provision of a long-term CR service and prediction of longer-term risk factor status.

1. Introduction develop personalised goals [3,4].

In randomised controlled trials (RCT), a reduction in the risk of
Routine exercise-based phase II cardiac rehabilitation (CR) services cardiovascular mortality and myocardial infarction has been found
are well implemented in most European countries [1,2]. These services three years after participation in CR [1]. Notwithstanding these positive
facilitate lifestyle behaviour change and risk factor management. implications, a translation of the benefits seen in RCTs to routine prac­
A key objective of CR is to improve the cardiovascular prognosis by tice data is difficult due to substantial differences in patients’ charac­
reducing cardiovascular risk factors – e.g. lowering body mass index teristics e.g. younger patients with fewer comorbidities have tended to
(BMI), increasing the level of physical activity and promoting psycho­ be recruited to clinical trials compared to routine clinical practice [5,6].
social wellbeing [3,4]. Phase II CR programmes typically have a dura­ Furthermore, a skewed distribution in referral, participation and
tion of 3–6 months [3]. After the completion of phase II CR, clinical completion rates exists in routine CR. This has the potential to consid­
standards recommend that patients undergo a post-assessment CR ses­ erably impact the provision of long-term CR services and associated
sion and formulate a long-term health behaviour management plan and longer-term health behaviour [7,8].

This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
☆

* Corresponding author at: Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Fælledvej 2c, DK-4200 Slagelse,
Denmark.
E-mail address: [email protected] (L.H. Tang).

https://doi.org/10.1016/j.ijcard.2023.05.028
Received 14 December 2022; Received in revised form 8 May 2023; Accepted 14 May 2023
Available online 17 May 2023
0167-5273/© 2023 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
L.H. Tang et al. International Journal of Cardiology 386 (2023) 134–140

Moreover, maintaining or continuing long-term health behaviour 2.3. Outcomes

change is challenging. As an example, only about 40% of patients remain
physically active one year after CR, even though it is likely to reduce the Following the BACPR [4] and European Society of Cardiology core
risk of a poor cardiovascular prognosis [9,10]. In addition, evaluations components [3] for phase II CR, patients are assessed prior to and at the
of interventions applied in everyday life show that very few intensive end of the rehabilitation programme. These pre and post assessments
and short-term health interventions result in long-term behaviour assess different risk factors, which can be a target of the CR intervention.
changes [11]. For this study, we were only able to assess these risk factors available in
Historically, the delivery and recording of long-term CR services the NACR database at pre and post assessment and again at the 12-
have been underutilised. Thus, to date, there is a sparsity of evidence month assessment; including body mass index (BMI), physical activity
and knowledge of how long-term services work in the routine setting level, psychosocial wellbeing measure using the Hospital Anxiety and
[3,12]. Yet, the prevalence of people living with a cardiovascular disease Depression Scale (HADS) [19]. Physical activity was self-reported and
has increased drastically over the last decade [13,14]. This, in turn, has based on the UK chief medical officers’ guidelines for physical activity
increased the need for the healthcare system to prioritise the provision [20]. All four risk factors are stated to be of importance for phase II CR
of routine long-term CR services to support long-term health behaviour by the BACPR [4] and European Society of Cardiology core components
[15]. So far, it is unknown to what extent patients post CR attend and [3].
complete this long-term assessment and, moreover, to what degree any For each risk factor, clearly defined optimal risk factor stages were
behaviour change is achieved through risk factor reduction. used as clinical benchmarks in the data analysis; The World Health
This paper will explore patients’ characteristics associated with the Organization (WHO) classification of obesity in adults; a BMI lower than
provision of a long-term risk factor assessment in CR service and assess 30 [21]. Adhering to WHO guidelines for physical activity; equal to or
the associated level of long-term risk factor status in the population >150 min per week [22]. HADS anxiety and depression scores <8 [19].
completing CR.
2.4. Covariates
2. Method
Patient characteristics included in the analysis were: age (mean
This study is reported following the Strengthening the Reporting of centred), gender (male/female), ethnicity (white/non-white), partner­
Observational Studies in Epidemiology (STROBE) guideline [16]. ship status (partnered/single), medical treatment status (none/ percu­
taneous coronary intervention (PCI)/coronary artery bypass graft
2.1. Data (CABG)/Other treatment), comorbidity status (none/one/two or more).
A measure of deprivation was included according to where patients
Data for this project is from the National Audit of Cardiac Rehabil­ lived, this was divided into five quintiles (Indices of Multiple Depriva­
itation (NACR) - a UK registry with data entered by over 180 CR pro­ tion (IMD)) [23].
grammes (over 90% coverage of all programmes) [6]. The audit’s goal is
to monitor programmes to improve the quality-of-service delivery and 2.5. Data analysis
outcomes in CR centres. Data entered into the audit covers the early,
phase II and long-term stages of the CR pathway. In the UK, phase II CR Descriptive statistics of mean and standard deviation (SD) were used
(equal to core CR in UK) stage is an 8 to 12-week long multimodal for continuous variables and percentages and counts for the categorical
intervention that includes exercise, education and sets goals for lifestyle variables. Independent samples t-tests were used to examine differences
change [17]. Phase II includes a pre and post assessment (at either end of in patient characteristics between being assessed or not at 12 months
phase II) where varieties of risk factor measurements are taken. after CR for continuous variables, whereas Pearson Chi-square tests (or
Although not a standardised part of routine practice, a third assessment equivalent) were used for categorical variables. A p-value <0.05 was
point measuring the long-term improvement, maintenance and change considered as statistically significant.
in these measures 12 months after completing CR is available. Currently, Two sets of binary logistic regressions were built to study the asso­
of all programmes in the UK, only 11% of all patients assessed at CR ciation between patient characteristics and being assessed at 12 months
entry have long-term assessment recorded in NACR. and the likelihood of being in the optimal stage for the four outcome
The recording of data into the audit is covered under section 251 of measures, accounting for patient characteristics.
the NHS Act 2006 and submitted into the NHS Digital data storage In the first model, a factor was created based on patients’ achieve­
system. Data for this study was collected for the period April 2015 to ment during phase II CR. A three-category variable was made based on
March 2020 to include the most recent data up to the emergence of the four outcomes (BMI, Physical activity, HADS anxiety and depres­
COVID-19 that has altered the recording and standard running of the CR sion), patients were either “never in an optimal stage”, “In at least one
services in the UK [18]. optimal stage but never improved” and “made at least one improvement
during CR”. This allowed the analysis to account for the patient’s
2.2. Cohort of programmes achievement during CR in the likelihood for attending 12-month
assessment.
Within this study, the selection of patients was based on programmes In the second set of models, association with each of the four out­
with an established mechanism and methodology to collect the 12- comes was assessed. For each model, a new status of their achievement
month assessment. This mechanism was defined as; 1) programmes was created for that outcome, e.g. BMI at 12 months had achievement
rehabilitating at least 100 patients per year or 500 over the last 5 years for BMI pre and post CR. Patients in the optimal stage during both up­
and 2) having a total of at least 200 or more 12-month assessments over take and completion of phase II CR were categorised as “Always in the
the term. These two criteria allowed for a sufficient sample within the optimal stage”. Whereas patients first reaching the optimal stage upon
programmes for clustering but also ensured that patients with 12 months completion were categorised as “Improved throughout CR”. Patients never
follow-up were standard care patients and not outliers or unique and being in the optimal stage throughout phase II CR were categorised as
complex individual patient pathways. Based on the inclusion criteria, 32 “Never in optimal stage”.
programmes were included (18% of all programmes). The independent variables were entered in the models via a back­
ward selection method involving a repeated elimination of variables
with p-value >0.05. After model testing, estimated margins were
generated to show, based on the model, the distributions of patients in

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the three optimal stages for each of the four outcomes at the 12-month Table 4 shows the actual distribution of patients for the four out­
assessment. Estimated margins are useful to interpret the results beyond comes and the estimated margins generated based on the regression
the odds ratio by showing the expected proportion of change for an models to illustrate the expected proportion of change for an adjusted
adjusted and averaged population which allows for a substantive and and averaged population. From the actual distribution, around 75%
practical presentation of the findings [24]. were in the optimal stage for BMI, physical activity and anxiety at 12
months. For depression, this was 85%.
3. Results Based on the model and averaging the patient population, the esti­
mated margins showed that <8% of patients who were in the optimal
During the five-year period, the 32 programmes that met the inclu­ stage during phase II CR had moved out of that stage at 12 months
sion criteria had 62,697 patients starting CR and 42,616 that had pre (range 4.1–7.8%). For BMI, however, 83% were still expected outside of
and post CR assessments (68%). Study flow is illustrated in Fig. 1. Fig. 2 the optimal stage at 12 months, if patients never reached the optimal
shows the proportion of patients in the three optimal stage categories stage during phase II CR. This was 42%, 50% and 56% for physical ac­
upon CR completion for each of the four risk factors. The majority of tivity, anxiety and depression, respectively.
patients across all four risk factors were always in the optimal stages
(range across the four risk factors: 43 to 81%). A 25% improvement, 4. Discussion
meaning the largest improvement during phase II CR, was found for the
physical activity level. This was the first study investigating the association between CR
In Table 1, patient characteristics have been divided into whether the completion and risk factor status at 12 months post discharge. Patients
patient underwent long-term assessment at 12 months or not. All undergoing an invasive treatment procedure or living with comorbidity
investigated variables, beside marital status (p = 0.076), were statisti­ were more likely to be assessed at 12 months whereas highly deprived
cally significantly different between those being assessed and those not. patients were less likely to be assessed. Being in the optimal stage for
Table 2 shows the association of being assessed at 12 months and four common cardiovascular risk factors, (BMI, physical activity level,
patient characteristics – all insignificant factors have been removed after psychosocial wellbeing, anxiety and depression), upon CR completion
the backward selection process. Invasive treatment procedure and a was the only variable consistently associated with undergoing a 12-
higher number of comorbidities increased the likelihood of being month assessment and, in addition, associated with long-term
assessed at 12 months. Being in the fifth IMD reduced the likelihood of a improved cardiovascular risk factors. Our findings provide insight and
12-month assessment by 18% (OR = 0.82 95% CI 0.77 to 0.88). Patients evidence that will help inform the provision of long-term services and
always being in the optimal stage in one of the four risk factors during associated research.
phase II CR (OR = 1.43 95% CI 1.28 to 1.59) or patients reaching an An interesting finding of this work was that, in the routine popula­
optimal stage during phase II CR (OR = 1.61 95% CI 1.44 to 1.80) had an tion, over 90% of patients were always in the optimal stage and 70%
increased likelihood of being assessed at 12 months compared to pa­ who made improvements during phase II CR retained their stage at 12
tients never being in any of the optimal risk factors stages. months. Interestingly, between 43 and 58% of patients not in the
The likelihood of being in an optimal risk factor stage at 12 months optimal stage for depression, anxiety and physical activity had made
upon CR completion is shown in Table 3. Patients were more likely still improvements at 12 months assessment. These findings correlate with
to be in the optimal stage at 12 months assessment if they reached an trial evidence that shows that over a longer term (3 years), CR is
optimal stage during phase II CR compared to patients still not in the beneficial at achieving and maintaining secondary prevention goals
optimal stage upon completion (Table 3). This was most prominent for [1,25,26].
BMI (OR = 14.6 (95% CI 11.1 to 19.2). Always being in an optimal stage Our findings are in line with The European Association of Preventive
during phase II CR showed the same pattern with BMI again being the Cardiology stating that phase II CR can be extended to support long-term
most prominent (OR = 134.0 (95% CI 112.4 to 159.8). Having higher care needs – when appropriately selected and modulated [3]. Evidence
levels of comorbidities, specifically three or more was the only other and knowledge about the content of such routine intervention and to
consistent variable across the four optimal stages (OR ranging 0.4 to whom it should be provided are sparse [3,12]. Most trials testing in­
0.8). terventions to maintain or increase patients’ health behaviour after
phase II CR are provided shortly after CR completion, include various
components and have a short duration (<1 year) [15]. In a review by
Graham et al. [15], 19 RCTs were reviewed, with twelve supporting the
use of post-phase II CR interventions. These were physical activity and
cognitive-behavioural components, e.g. counselling, coaching, diary
logs, to change physical activity behaviour [15]. In routine CR, sup­
porting personal goals and health benefits through long-term health
behaviour management plans is also a central component [3,4]. Patients
must implement the plans into regular life themselves, sometimes with
only very limited support from healthcare professionals. Yet, our results
suggest that what is being delivered routinely is sufficient for some
patients to maintain health status a year after completion of phase II CR.
Additional evidence and clinical tools are called for to better identify
both those patients who can continue a long-term healthy lifestyle
themselves and, in particular, those who cannot [27]. Inclusion of
additional outcomes like physical function and quality of life is sug­
gested to strengthen such classification [27].
Current evidence from interventions investigating maintenance of
physical activity after completion of Phase II CR [15] suggests that
implementing a 12-month assessment into all routine CR services may
not necessarily be the most appropriate strategy in facilitating long-term
health behaviour change. The approach is not offered shortly after
Fig. 1. Study flow. completion [15], does not directly build on a theoretical framework, e.g.

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Fig. 2. The proportion of patients in each optimal stages for the four risk factors 12 weeks post core cardiac rehabilitation (CR).

Table 1
Patient characteristics and services-level factors between patients being assessed and not at 12 months after Cardiac rehabilitation (CR).
Assessed at 12 months

No Yes Total

Count Row % Count Row % Count

Total Patients 17,952 42% 24,664 58% 42,616

Mean (SD) Min -Max Mean (SD) Min -Max Mean (SD) Min -Max P-value
Age at admission(years) 65 (12) 18–100 66 (11) 18–101 66 (11) 18–101 <0.001
Waiting time from Referral to Start (days) 36 (37) 1–365 37 (35) 1–365 37 (36) 1–365 0.018
Duration of Core CR (days) 102 (61) 7–365 91 (57) 7–364 96 (59) 7–365 <0.001
Count Row % Count Row % Count p-value
Male 12,951 41.7% 18,101 58.3% 31,052
Gender 0.016
Female 4917 43.0% 6514 57.0% 11,431
White 13,836 41.3% 19,683 58.7% 33,519
Ethnicity <0.001
Ethnic Minority 4116 45.2% 4981 54.8% 9097
Employed/Retired 11,033 38.0% 17,972 62.0% 29,005
Employment Status <0.001
Unemployed 2708 49.1% 2805 50.9% 5513
Single 2751 42.5% 3725 57.5% 6476
Marital Status 0.076
Partnered 9747 41.3% 13,879 58.7% 23,626
None 2069 50.4% 2037 49.6% 4106
PCI 7963 39.6% 12,149 60.4% 20,112
Cardiovascular Treatment <0.001
CABG 2286 41.2% 3266 58.8% 5552
Other Treatment 5634 43.9% 7212 56.1% 12,846
Lowest Quintile 2340 43.1% 3083 56.9% 5423
Second Quintile 2441 37.9% 4008 62.1% 6449
IMD Quintiles Third Quintile 3292 40.8% 4783 59.2% 8075 <0.001
Fourth Quintile 3554 39.3% 5484 60.7% 9038
Fifth Quintile 4009 43.3% 5240 56.7% 9249

Abbreviations: SD: Standard deviation, PCI: Percutaneous coronary intervention, CABG: Coronary artery bypass graft, IMD; Indices of multiple deprivation.

a behaviour change theory that has been found superior to support pa­ thought to provide an opportunity to screen and prevent inadequate risk
tients to meet their own health behaviour goals [28–30], or take account factor behaviour in deprived cardiovascular patient groups – but its
for potential individual barriers and facilitators known to support health impact needs validation in forthcoming research [27].
behaviour throughout the CR pathway [31–33]. Yet, the American Heart Being in an optimal stage for at least one of the four risk factors
Association calls for more pragmatic and sustainable assessment models yielded the highest likelihood for undergoing a 12-month assessment.
successfully integrated in CR [27] and stresses that risk factor assess­ One explanation could be that a positive assessment upon phase II CR
ment is of high priority - particularly in patients with a high risk profile completion facilitates positive physiological attributes, e.g. optimism,
[34]. Our results highlight the relevance of this, as patients with a poor positive affect, self-discipline and health believes reported in several
prognosis due to e.g. comorbidity [35] were more likely to be assessed studies to be associated with positive cardiac outcomes, risk factor
12 months after CR completion. Unfortunately, highly deprived patients behaviour and treatment adherence [38,39]. Clinical decision making
were less likely to undergo a 12-month assessment. Inequalities in has various pitfalls [40], and it may be possible that clinicians are less
behaviour related to risk factors, the cardiovascular prognosis and likely to offer a long-term assessment to patients not being in an optimal
development of additional chronic conditions are highly associated with stage upon CR completion to protect them from another
deprivation [36,37]. A systematic provision of long-term assessment is disappointment.

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Table 2 services is possible – knowledge sought for by the European Associa­

The statistically significant likelihoods of being assessed at 12 months in relation tion of Preventive Cardiology [3].
to patient characteristics from a backward selection with removed factors.
Odds ratio 95% confidence interval p-value 5. Limitations
Status Post CR (base never
improved) The long-term assessment at 12 months is not performed systemat­
ically by all programmes in the UK. Despite this, we identified 32 pro­
1. At least one improvement 1.61 1.44 1.80 <0.001
2. In at least one optimal grammes with sufficient size conducting 12-month assessments.
1.43 1.28 1.59
stage, but never improved
<0.001
However, only a small sample were eligible (47%). Thus, caution should
IMD Quintile (base First be taken in interpreting the results widely as they may not be general­
quintile) isable to the entire cardiac population. In addition, only 18% of the
1. Second Quintile 1.22 1.13 1.33
NACR database programmes had a well-established mechanism and
<0.001
2. Fifth Quintile 0.82 0.77 0.88 <0.001
Cardiac Treatment (base no methodology to collect the 12-month assessment. The results may,
treatment) therefore, be based on data for high performing programmes [41].
PCI 1.37 1.23 1.52 <0.001 We used clearly defined optimal stages as benchmarks for health and
CABG 1.25 1.11 1.42 <0.001
risk factor in people with cardiac conditions. The disadvantage is that
Other Treatment 1.12 1.00 1.25 0.04
Employment Status (Base some information of within group changes above or below a certain
Unemployed) optimal stage was not accounted for in our analysis. CR targets other risk
Employed/Retired 1.73 1.60 1.86 <0.001 factors than those available in the NACR data, e.g. lipids profile and
Marital Status (base Single) blood pressure [3]. Therefore, further investigations with other risk
Partnered 1.07 1.00 1.15 0.04
Comorbidities (base None)
factors are needed before a conclusion can be made concerning other
One 1.26 1.17 1.35 <0.001 risk factors than the four risk factors present in this study.
Two or More 1.41 1.29 1.55 <0.001 Another limitation of this study is that service-level factors, known to
Constant 0.7560354 0.6482922 0.881685 <0.001 influence CR provision [42], were not included. As this information is
Abbreviations: SD: Standard deviation, PCI: Percutaneous coronary interven­ not available for many patients, we were unable to include such factors
tion, CABG: Coronary artery bypass graft, IMD; Indices of multiple deprivation. in our regression models. Finally, we were unable to collect data on CR-
adherence to address if our finding related to the fact that adherent
Being in an optimal stage upon CR completion was not only associ­ patients also were more likely to be adherent at 12 months.
ated with undergoing a 12-month assessment but also the level of long-
term risk factor and health behaviour. Based on our data, we cannot 6. Conclusion
determine if this is a consequence of patients with a healthier risk factor
behaviour profile being more likely to attend a 12-month assessment. It Using routine CR service data, we found large variation across pa­
could simply be that those patients in the optimal stage upon CR tient characteristics in the provision of long-term service assessments in
completion are those with the highest adherence level to their CR pro­ the UK. Patients undergoing invasive treatment procedures or having
gramme and have higher likelihood to retain status at 12 months. Yet comorbidities were more likely to be assessed at 12 months. However,
other patient related outcomes are also likely to interact with our find­ patients from highly deprived areas were less likely to be assessed. Being
ings as several barriers for sustaining adequate risk factor behaviours are in an optimal stage upon CR completion for the four common cardio­
known for patients living with cardiovascular diseases [32,33,38,39]. vascular risk factors was also associated with attending the 12-month
Our results, however, suggest that one of the most important predictors assessment. Moreover, this variable was the only one consistently
for long-term health behaviour is to reach an optimal stage upon routine associated with maintaining a positive long-term risk factor status. Thus,
phase II CR completion. However, further research that can confirm the the conclusions of this work are that being in an optimal stage upon
findings of this study, and which includes additional risk factors, is routine CR completion should be an important assessment and predictor
needed before a qualified selection of patients to include in long-term in the provision of a long-term CR service. Additional work should seek

Table 3
The likelihood of being in an optimal stage at 12 months after phase II cardiac rehabilitation completion.
Under 30 in BMI ≥ 150 min of physical activity HADS - Anxiety score below 8 HADS - Depression score below 8

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Age (years) 1.0 (1.0–1.0) 0.9 (09–0.9) 1.0 (1.0–1.0) not sign
Gender (Female) 0.7 (0.6–0.8) not sign. not sign not sign
Employment Status (Unemployed) not sign. not sign. 1.4 (1.2–1.8) 1.4 (1.1–1.8)
Marital Status (Partnered) not sign. 1.1 (1.0–1.3) not sign not sign
Post CR status
Never in the optimal stage Reference Reference Reference Reference
Improved upon completion 14.6 (11.1–19.2) 2.6 (2.3–3.0) 3.3 (2.6–4.1) 3.3 (2.6–4.3)
Always in the optimal stage 134. 0 (112.4–159.8) 8.7 (7.6–10.0) 16.6 (14.0–19.6) 21.0 (17.0–25.8)
Comorbidities
No Comorbidities Reference Reference Reference Reference
One to Two comorbidities 0.6 (0.5–0.8) not sign. not sign not sign
Three or more comorbidities 0.4 (0.3–0.6) 0.7 (0.6–0.8) 0.8 (0.6–0.9) 0.7 (0.6–0.9)
Cardiovascular Treatment
No Cardiac Treatment Reference Reference Reference Reference
PCI 1.4 (1.2–1.7) not sign. not sign not sign
CABG not sign. 1.4 (1.2–1.7) not sign not sign
Other Treatment not sign. not sign. not sign not sign

Abbreviations: BMI: Body mass index, HADS: Hospital Anxiety and Depression Scale, OR: Odds ratio, CI: Confidence interval, CABG: Coronary Artery Bypass Graft, not
sign: Not Significant and omitted in backwards model, PCI: Percutaneous Coronary Intervention.

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Table 4 Acknowledgments
The actual distributions of patients and estimated margins distributing the
percentages of patients in the three optimal risk factor stages for each of the four The authors acknowledge the support of the NHS England to
outcomes at 12 months. continue to fund and support the NACR. In addition, the authors thank
Total Always in Improved Not in optimal all programmes and clinicians for the entering and engagement of data,
optimal throughout stage upon without the data the service evaluation would not be possible.
stage completion completion

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