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Grzyb C, Du D, Mahesh B, Nair N. Mental Health and Substance Use Disorders in Transplant Waitlist, VAD, and Heart Transplant Patients: A TriNetX Database Analysis. J Clin Med 2024; 13:3151. [PMID: 38892862 PMCID: PMC11172532 DOI: 10.3390/jcm13113151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/22/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: Mental health and substance use disorders (MHDs and SUDs) affect cardiac allograft and VAD recipients and impact their quality of life and compliance. Limited research currently exists on MHDs and SUDs in this population. Methods: This study compares the incidence of MHDs and SUDs in the transplant list, VAD, and post-transplant patients with that in heart failure patients. Study cohorts were derived from the TriNetX database using ICD-10 codes. Differences in incidence were examined using the log-rank test. Adults with MHDs and SUDs before the window of time were excluded. All comparisons were made between propensity-matched cohorts. Statistical significance was set at p < 0.05. Results: Transplant waitlist patients showed a significant increase in the incidence of anxiety, depression, panic, adjustment, mood, alcohol use, and eating disorders. Post-transplant patients showed a significant increase in depression and opioid use. VAD patients showed a significant increase in depression and a decrease in panic disorder and anxiety. These results allow for further investigations on prevention and coping strategies. Conclusions: The deterioration of mental health can significantly impact medication compliance, survival, and quality of life. Opioid use for pain management in the early postoperative period should be further investigated to assess its impact on long-term substance use and addiction.
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Affiliation(s)
- Chloe Grzyb
- Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA;
| | - Dongping Du
- Department of Industrial, Manufacturing, and Systems Engineering, Texas Tech University, Lubbock, TX 79409, USA;
| | - Balakrishnan Mahesh
- Division of Cardiothoracic Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA;
| | - Nandini Nair
- Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA;
- Division of Cardiology, Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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Impact of Age on Emergency Resource Utilization and Outcomes in Pediatric and Young Adult Patients Supported with a Ventricular Assist Device. ASAIO J 2021; 68:1074-1082. [PMID: 34743138 PMCID: PMC9061895 DOI: 10.1097/mat.0000000000001603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
There are minimal data describing outcomes in ambulatory pediatric and young adult ventricular assist device (VAD)-supported patient populations. We performed a retrospective analysis of encounter-level data from 2006 to 2017 Nationwide Emergency Department Sample (NEDS) to compare emergency department (ED) resource utilization and outcomes for pediatric (≤18 years, n = 494) to young adult (19-29 years, n = 2,074) VAD-supported patient encounters. Pediatric encounters were more likely to have a history of congenital heart disease (11.3% vs. 4.8%). However, Pediatric encounters had lower admission/transfer rates (37.8% vs. 57.8%) and median charges ($3,334 (IQR $1,473-$19,818) vs. $13,673 ($3,331-$45,884)) (all p < 0.05). Multivariable logistic regression modeling revealed that age itself was not a predictor of admission, instead high acuity primary diagnoses and medical complexity were: (adjusted odds ratio; 95% confidence intervals): cardiac (3.0; 1.6-5.4), infection (3.4; 1.7-6.5), bleeding (3.9; 1.7-8.8), device complication (7.2; 2.7-18.9), and ≥1 chronic comorbidity (4.1; 2.5-6.7). In this largest study to date describing ED resource use and outcomes for pediatric and young adult VAD-supported patients, we found that, rather than age, high acuity presentations and comorbidities were primary drivers of clinical outcomes. Thus, reducing morbidity in this population should target comorbidities and early recognition of VAD-related complications.
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Tigges-Limmer K, Sitzer M, Gummert J. Perioperative Psychological Interventions in Heart Surgery. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:339-345. [PMID: 34180796 DOI: 10.3238/arztebl.m2021.0116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/14/2020] [Accepted: 12/17/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Heart surgery is a source of high levels of emotional distress for the patient. If the stress experience is not adequately compensated, it can have a negative impact on postoperative recovery, as can untreated comorbid mental disorders. METHODS A selective literature review on emotional distress and mental comorbidities in heart surgery patients and a scoping review on the spectrum and effectiveness of perioperative psychological interventions to compensate and reduce the stress experience. RESULTS Mental factors such as depressive symptoms or anxiety disorders are associated with an elevated risk of postoperative morbidity and mortality in patients treated for heart disease. Mental comorbidities occur more frequently in these patients than in the general population. Following the manifestation of chronic heart disease (CHD), for example, 15-20% of the patients display severe depressive disorders. A few psychotherapeutic interventions to reduce anxiety and depression, emotional distress, consumption of analgesics, and extubation time have been found effective, with low to moderate evidence quality. Many different psychological interventions have proved useful in clinical practice, including multimodal, multiprofessional interventions incorporating medications, education, sports, and exercise as well as psychosocial therapy including stress management. Individual psychotherapy during the period of acute inpatient treatment after myocardial infarction is also effective. CONCLUSION Because psychosocial factors are important, the current guidelines recommend systematic screening for mental symptoms and comorbidities in advance of heart transplantation or the implantation of ventricular assist devices (VAD). Acute psychotherapeutic interventions to reduce mental symptoms can be offered in the perioperative setting.
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A systematic review of psychosocial design considerations for the next generation of mechanical circulatory support. Heart Lung 2021; 50:397-406. [PMID: 33621838 DOI: 10.1016/j.hrtlng.2021.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/13/2021] [Accepted: 01/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Biomedical engineers are developing new mechanical circulatory support pumps. Clinicians are generating and analysing new evidence for their prescription and management. Industrial designers are generating usable solutions for wearable components and controllers. However, psychosocial considerations may be falling between the cracks of the three disciplines because of their multi-faceted nature. OBJECTIVES This article seeks to identify psychosocial needs raised in previous work, re-frame them as needs for future products and services, and discuss routes to solutions. METHODS SLR extracted 225 statements on psychosocial considerations from 42 included articles. 23 codes were inductively generated and applied to relevant datapoints. Codes were consolidated under 4 main themes and re-framed as solvable problems. RESULTS Identified themes: expanded remote care, improved multidisciplinary management tools, creating easier interactions; and extending patient engagement. CONCLUSIONS Design-driven methods have been used to solve analogous problems in other contexts and can address the identified psychosocial problems if implemented fully.
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Fuchs M, Schibilsky D, Zeh W, Berchtold-Herz M, Beyersdorf F, Siepe M. Does the heart transplant have a future? Eur J Cardiothorac Surg 2020; 55:i38-i48. [PMID: 31106338 PMCID: PMC6537946 DOI: 10.1093/ejcts/ezz107] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/29/2019] [Accepted: 02/15/2019] [Indexed: 12/11/2022] Open
Abstract
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Heart failure has remained the leading cause of death globally for the last 15 years—and its prevalence will continue to rise. Fifty years ago, heart failure management was enriched by the possibility of a heart transplant. Despite impressive improvements in medical treatment for heart failure, a heart transplant remains the most effective long-lasting treatment for advanced heart failure in terms of mortality and quality of life. However, donor and recipient characteristics have changed dramatically in recent years, leading to more complex decision-making regarding organ acceptance and to more demanding operations and postoperative management. With improving pathophysiological understanding in the last decades, today’s scientific interest still focuses on basic knowledge. How to retrieve and conserve organs to minimize ischaemic injury; how best to allocate them, considering the likelihood of success (developing a heart-allocation scoring system similar to that for lung allocation); how to match donor/recipient characteristics (ABO blood-group antigen compatibility versus incompatibility); and how to avoid graft failure, rejection and secondary morbidities such as malignomas and cardiac allograft vasculopathy after the heart transplant—all these factors remain fundamental challenges in today’s transplant medicine. The use of ex vivo perfusion (e.g. via the Organ Care System®, TransMedics, Andover, MA, USA) may play an important role in this change. Remarkably, there are huge regional divergences in current transplant practices: Whereas the number of transplants continues to rise in most Eurotransplant countries and other major transplant networks, there are some countries in which transplant numbers are static or even dropping (as in Germany). This difference results in wide variations across different countries as to how advanced heart failure is treated using mechanical circulatory-assist devices.
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Affiliation(s)
- Matthias Fuchs
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Corresponding author. Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Südring 15, 79189 Bad Krozingen, Germany. Tel: +49-7633-4020; fax: +49-7633-4029909; e-mail: (M. Fuchs)
| | - David Schibilsky
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Zeh
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Okam NA, Ahmad W, Rana D, Torrilus C, Jahan N, Sedrakyan S. Psychological Spectrum Experienced by Heart Failure Patients After Left Ventricular Assist Device Implantation. Cureus 2020; 12:e9671. [PMID: 32923266 PMCID: PMC7485994 DOI: 10.7759/cureus.9671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/11/2020] [Indexed: 11/06/2022] Open
Abstract
Depression and anxiety disorders are prevalent in patients with heart failure. They are associated with adverse effects such as rapid disease progression, poor medication compliance, low quality of life and increased mortality rate. The current literature review aims to provide an overview of the overall rate of depression in patients who receive left ventricular assist device (LVAD) implantation and identify the psychological phases that these individuals experienced peri- and post-LVAD implantation. A PubMed search using regular and Medical Subject Headings (MeSH) keywords identified 239 articles. After applying inclusion/exclusion criteria, removal of duplicate studies, and careful review of articles, 40 studies provided relevant information on our primary end-point. These 40 studies selected include 13 paid articles with abstracts and 27 free full-text articles comprising eight prospective cohort studies, five retrospective cohort studies, six cross-sectional studies, one qualitative study, one randomized clinical trial, one systematic review, four literature reviews, and one practice guide. Our review shows that patients experienced different psychological phases after LVAD implantation. However, as the time from implantation progressed, these patients showed a significant improvement in depression, anxiety, and health-related quality of life.
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Affiliation(s)
- Nkechi A Okam
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Wiqas Ahmad
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Dibyata Rana
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Chenet Torrilus
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nusrat Jahan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Surik Sedrakyan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Suarez L, Dunlay SM, Schettle SD, Stulak JM, Staab JP. Associations of depressive symptoms with outcomes in patients implanted with left ventricular assist devices. Gen Hosp Psychiatry 2020; 64:93-98. [PMID: 32008725 DOI: 10.1016/j.genhosppsych.2019.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/11/2019] [Accepted: 12/30/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We examined characteristics of depressive symptoms in patients who received left ventricular assist devices (LVAD) to assess their effects on negative outcomes post-implantation. METHODS We retrospectively identified 203 adults with pre-operative PHQ-9 scores who underwent LVAD placement as bridge to transplant (BTT) or destination therapy (DT). We analyzed effects of PHQ-9 total, somatic, and cognitive/affective scores and proportion of patients with clinical depression on all-cause mortality, rehospitalization, major bleeding, and neurologic events post-implantation, controlling for demographics and other medical comorbidities. RESULTS Mean total PHQ-9 scores did not differ between 81 BTT and 122 DT patients (BTT 6.4 vs. DT 7.5, p = 0.12). A higher proportion of DT patients had clinical depression (BTT 22% vs. DT 39%, p = 0.015). Somatic symptoms accounted for three-quarters of total scores in both groups. PHQ-9 domains were not associated with negative outcomes post-implantation. CONCLUSION Depression severity did not differ based on implant strategy, but more DT patients had clinical depression. Somatic symptoms were the biggest contributor to depressive symptoms. Pre-implantation PHQ-9 scores were not associated with outcomes, possibly because depression was mild in both groups. Additional work is needed in LVAD patients to better characterize depressive symptoms and their unique effects on clinical course and well-being.
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Affiliation(s)
- Laura Suarez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America; Department of Health Sciences Research, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
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Tosto C, Adamo L, Craddock H, Di Blasi M, Girgenti R, Clemenza F, Carney RM, Ewald G. Relationship between device acceptance and patient-reported outcomes in Left Ventricular Assist Device (LVAD) recipients. Sci Rep 2019; 9:10778. [PMID: 31346241 PMCID: PMC6658659 DOI: 10.1038/s41598-019-47324-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/08/2019] [Indexed: 11/10/2022] Open
Abstract
The number of Left Ventricular Assist Devices (LVADs) implanted each year is rising. Nevertheless, there are minimal data on device acceptance after LVAD implant, and on its relationship with patient-reported outcomes. We designed a cross-sectional study to address this knowledge gap and test the hypothesis that low device acceptance is associated with poorer quality of life, depression and anxiety. Self-report questionnaires were administered to assess quality of life (12-item Kansas City Cardiomyopathy Questionnaire quality of life subscale), level of anxiety (7-item Generalized Anxiety Disorder; GAD-7), level of depression (9-item Patient Health Questionnaire; PHQ-9) and device acceptance (Florida Patient Acceptance Survey; FPAS) to 101 consecutive patients presenting to LVAD clinic. Regression analysis showed a strong correlation between device acceptance and both psychological distress (p < 0.001) and quality of life (p < 0.001). Analysis of the sub-scales of the FPAS showed that patients had significant body image concerns, but return to function and device-related distress were the main drivers of the observed correlation between device acceptance and patient well-being. Younger age was associated with lower device acceptance (r = 0.36, p < 0.001) and lower quality of life (r = 0.54, p < 0.001). These findings suggest that interventions targeting device acceptance should be explored to improve outcomes in LVAD recipients.
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Affiliation(s)
- Crispino Tosto
- From the University of Palermo, Department of Psychological and Educational Sciences, Palermo, Italy
| | - Luigi Adamo
- From the Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Heidi Craddock
- From the Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Maria Di Blasi
- From the University of Palermo, Department of Psychological and Educational Sciences, Palermo, Italy
| | | | | | - Robert M Carney
- From the Department of Psychiatry, Washington University School of Medicine, St Louis, MO, USA
| | - Gregory Ewald
- From the Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Trevizan FB, Miyazaki MCDOS, Silva YLW, Roque CMW. Quality of Life, Depression, Anxiety and Coping Strategies after Heart Transplantation. Braz J Cardiovasc Surg 2017; 32:162-170. [PMID: 28832793 PMCID: PMC5570391 DOI: 10.21470/1678-9741-2017-0029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/06/2017] [Indexed: 12/20/2022] Open
Abstract
Introduction Heart transplantation is the therapeutic procedure indicated to increase the
survival of patients with refractory heart failure. Improvement in overall
functioning and quality of life are expected factors in the postoperative
period. Objective To identify and evaluate mental disorders and symptoms, such as depression
and anxiety, quality of life and coping strategies in the post-surgical
situation of heart transplantation. Methods A cross-sectional, quantitative study with patients who have undergone heart
transplantation. Participants answered to the Sociodemographic
Questionnaire, Beck Depression Inventory (BDI-II), Beck Anxiety Inventory
(BAI), MINI International Neuropsychiatric Interview, Escala Modos de
Enfrentamento de Problemas (Ways of Coping Scale) (EMEP) and World Health
Organization Quality of Life-BREF (WHOQOL-BREF). For data analysis, the
significance level was considered P≤0.05. Results A total of 33 patients participated in the study. The BDI-II results
indicated that 91% (n=30) of the patients presented a minimal level. In BAI,
94% (n=31) of the patients demonstrated minimal level of anxiety symptoms.
WHOQOL-BREF showed a perception of quality of life considered good in all
domains. The EMEP data have registered a problem-focused coping strategy.
According to MINI, a single case of major depressive episode, current and
recurrent was recorded. Conclusion Although most participants in the sample had symptoms of depression and
anxiety, only one patient was identified with moderate symptoms in both
domains. The most used strategy was coping focused on the problem. Patients
have classified the perceptions of quality of life as 'good', pointing out
satisfaction with their health.
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Affiliation(s)
| | | | | | - Christiane Maia Waetman Roque
- Fundação Faculdade Regional de Medicina de São José do Rio Preto (FUN-FARME), São José do Rio Preto, SP, Brazil.,Hospital de Base (HB), São José do Rio Preto, SP, Brazil
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Berg SK, Rasmussen TB, Thrysoee L, Lauberg A, Borregaard B, Christensen AV, Ekholm O, Juel K, Svanholm JR. DenHeart: Differences in physical and mental health across cardiac diagnoses at hospital discharge. J Psychosom Res 2017; 94:1-9. [PMID: 28183396 DOI: 10.1016/j.jpsychores.2017.01.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/22/2016] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To describe: (i) differences in patient reported physical and mental health outcomes at hospital discharge between a) cardiac diagnostic groups and b) cardiac patients and a national representative reference population and to describe (ii) in-hospital predicting factors for patient reported outcomes. METHODS A national cross-sectional survey combined with national register data. From April 2013 to April 2014 all patients (n=34,564) discharged or transferred from one of five Danish Heart Centres were invited to participate. 16,712 patients (51%) responded; 67% male and mean age 64years. All diagnostic groups were represented similar to real life proportions. Patient reported outcome measures included: SF-12, Hospital Anxiety and Depression Scale, EQ-5D, Brief Illness Perception Questionnaire, HeartQoL and Edmonton Symptom Assessment Scale. RESULTS Statistically significant differences were found in all patient reported outcomes across diagnostic groups. Listed from worst to best outcomes were heart failure, heart valve disease, ischemic heart disease, infectious heart disease, arrhythmia, congenital heart disease and heart transplant. Also "observation for cardiac disease" scored poorly on some aspects such as anxiety and treatment control. Compared to the reference population, cardiac patients had lower physical and mental health scores. Predicting factors for worse outcomes across diagnoses were female sex, older age, being unmarried, planned admission, longer hospital stay, and higher co-morbidity score. CONCLUSIONS This large nationwide study finds significant differences in patient reported outcomes across cardiac diagnostic groups, however the differences were small and did not reach minimal important difference. The total population of cardiac patients had significant and clinically relevant poorer scores on mental and physical health than the reference population. Predicting factors for poor outcomes were identified. It is the first study comparing all diagnostic groups within cardiology and it provides important benchmarks between diagnostic groups and future comparisons. This knowledge may help clinicians make better decisions about post-hospital care and prevention.
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Affiliation(s)
- Selina Kikkenborg Berg
- Department of Cardiology, Gentofte University Hospital, Niels Andersens Vej 65, 2900 Hellerup, Denmark; Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Trine Bernholdt Rasmussen
- Department of Cardiology, Gentofte University Hospital, Niels Andersens Vej 65, 2900 Hellerup, Denmark
| | - Lars Thrysoee
- Department of Cardiology, Odense University Hospital, University of Southern Denmark, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - Astrid Lauberg
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark; Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Britt Borregaard
- Cardiothoracic- and Vascular Department, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - Anne Vinggaard Christensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Ola Ekholm
- National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5A, 1353 Copenhagen, Denmark
| | - Knud Juel
- National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5A, 1353 Copenhagen, Denmark
| | - Jette Rolf Svanholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, 8200 Aarhus N, Denmark
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