Correspondence to Tom Briffa; [email protected]
STRENGTHS AND LIMITATIONS OF THIS STUDY
This is a large-scale, randomised controlled trial comparing personalised cardiac rehabilitation with usual care.
The trial utilises an opt-out approach, minimising bias in patient selection.
Secondary endpoints include patient-reported quality of life.
12-months follow-up will allow an understanding of the effects of participation in a personalised cardiac rehabilitation programme.
The generalisability may be limited given recruitment within Australia.
Introduction
Annually, an estimated 49 329 Australians aged 25 and over experience a non-fatal myocardial infarction (MI) at a rate of 135 events every day.1 Notwithstanding advances in care, 15% of MI survivors have a new MI, stroke or die within 12 months, with 8.9% of these unexpectedly rehospitalised within a year.
Type 1 myocardial infarction (type 1 MI) national guidelines recommend adopting healthy behaviours, as well as initiation and adherence to pharmacotherapy for preventing new events.2 Interventions are best initiated at discharge from hospital through prescription of dual antiplatelet therapy, statins, beta-blockers (when indicated) and a renin–angiotensin antagonist and referral to cardiac rehabilitation. A recent national audit of cardiac rehabilitation found delivery was predominately outpatient hospital-based group exercise, education, counselling and pharmacy services;3 a format essentially unchanged since last century.4
Despite the acknowledged benefits of cardiac rehabilitation in reducing new clinical events and bettering quality of life,5 participation rates remain low. Outpatient rehabilitation services averaging 11 sessions (range 1–36) over 7 weeks (range 1–12) are vastly underused with low referral, low enrolment, low completion rates and are associated with considerable disparities in access.6 Among the patient barriers to participation are transport difficulties, work and social commitments, lack of perceived need and functional impairments, calling into question the relevance of current established approaches.7 There have been repeated calls for more flexible, individualised prevention strategies to improve the acceptability, reach and completion of cardiac rehabilitation within the changing social profile of MI survivors.8 9
This has seen the emergence of personalised secondary prevention models, mostly supplementary to or infrequently, instead of outpatient rehabilitation.9 10 Yet such innovations require investment. Importantly, robust evidence of effectiveness is needed to justify such a shift in costs and to ensure that personalised models deliver meaningful benefits to patients. Secondary prevention for all in need (SPAN) is a developed, published, flexible framework for providing a more personalised approach to cardiac rehabilitation.4 The aim of this study is to test whether an approach of personalised cardiac rehabilitation after type 1 MI results in better completion rates than standard outpatient cardiac rehabilitation. The hypothesis is that those randomised to personalised rehabilitation will have higher completion rates at 3 months compared with those randomised to the standard outpatient rehabilitation model.
Methods
Design
SPAN is a prospective multisite single-blind comparative effectiveness RCT of personalised rehabilitation versus outpatient rehabilitation evaluating the primary endpoint of rehabilitation completion at 3 months. Secondary endpoints include changes in quality of life at 3 months and 5-point major adverse cardiovascular events (MACE; defined as cardiovascular death, non-fatal MI, non-fatal stroke, new/worsening heart failure and unplanned coronary artery revascularisation) at 12 months. An overview of the trial is shown in figure 1.
Setting
Cardiology Departments in four Australian Metropolitan public hospitals; Royal Perth Hospital (WA), Flinders Medical Centre (SA), Concord Repatriation and General Hospital (NSW) and Royal Brisbane and Women’s Hospital (Qld).
Patient population
Target patients are aged 18 years or over with a hospital diagnosis of type 1 MI by the fourth Universal definition11 and deemed to be suitable for cardiac rehabilitation. Exclusions have been kept to a minimum and consist of conditions that increase the risk to the participant and would introduce confounding to the study or interfere with a participant’s ability to comply. The full list of inclusion and exclusion criteria is listed in box 1. Patients will be enrolled using an opt-out approach. Eligible patients who do not actively opt out will be included in the trial. The opt-out form is included in the online supplemental file 1
Box 1SPAN eligibility criteria
Participant inclusion criteria
Persons aged >18 years.
Inpatient diagnosis of suspected ST-segment elevation MI (STEMI), or non-STEMI (NSTEMI) acute coronary syndrome by ACS Guidelines and fourth universal definition of MI; specifically, a rise and/or fall in troponin from at least two samples defined as follows:
Hs-Troponin T: a rise and/or fall in the absolute troponin level of 2.5 ng/L/hour (ie, a change of 15 ng/L in 6 hours) between any troponin results before randomisation or a relative change in troponin 20% between earlier and later samples (ie, 100*(hs−TnT [later] − hs−TnT [earlier]/hs−TnT [earlier]) 20%) documented on any troponin results before randomisation.
Hs-Troponin I: an absolute elevation of >10 times the upper limit of normal specific for that assay, using gender-specific cut-points if implemented locally or change in troponin 20% between earlier and later samples (ie, 100*(hs−TnI [later] − hs−TnI [earlier]/hs−TnI [earlier]) 20% documented on any troponin results before randomisation.
Regarded by the treating team to be suitable for cardiac rehabilitation.
Participant exclusion criteria
May include conditions that increase the risk to the participant, that introduce confounding to the study or interfere with a participant’s ability to comply.
Prior cardiac rehabilitation.
Clinical diagnosis of uncompensated severe heart failure (NYHA class IV).
Uncontrolled arrhythmia or angina.
Severe or symptomatic aortic stenosis.
Coexisting clinical diagnosis of non-cardiac condition that would rule out participation; for example, advanced dementia, severe rheumatoid arthritis, severe frailty, terminal illness.
NYHA, New York Heart Association; SPAN, secondary prevention for all in need.
Screening, baseline assessment and data collection
Potential participants for SPAN will be identified by their medical team and assessed for trial eligibility using prespecified inclusion/exclusion criteria (see box 1). They will be provided with an opt-out form to consider. Patients who are deemed ineligible for SPAN will not be randomised into SPAN and will instead receive usual care. A screening log at all centres of patients with type 1 MI will be maintained to identify trends in patients approached and screen failures. Individuals will not be identifiable from the screening log. Patients who are deemed to be eligible for the trial and who do not opt out will be randomised. The study will randomise 532 patients with type 1 MI to either allocated standard outpatient rehabilitation (n=266) or personalised rehabilitation (n=266). Participants randomised to the personalised rehabilitation arm may also elect to engage with the standard outpatient services offered by their hospital’s cardiac rehabilitation team.
There are well-developed mechanisms at all centres for identifying patients with type 1 MI and channelling them into cardiovascular studies. Participants will be identified from daily admissions to coronary care and general medical units.
Randomisation
There is a well-controlled randomisation for allocation to either standard outpatient rehabilitation or personalised rehabilitation. Randomisation is at the level of the individual. It will be performed centrally utilising a computer-generated random allocation sequence in a uniform 1:1 allocation ratio and will be concealed from the primary analyst throughout the life of the trial.
Intervention
Outpatient cardiac rehabilitation
Patients randomised into the outpatient rehabilitation arm will follow the standard programme offered at their participating site. Outpatient rehabilitation typically commences within 2–4 weeks of leaving hospital, providing on average 11 sessions (range 1–42) over 7 weeks (range 1–12);3 however, the start times, duration and services offered will be variable across participating sites. Outpatient rehabilitation typically incorporates disease education, generic lifestyle counselling, psychosocial support and supervised exercise. Outpatient rehabilitation services will be performed by usual hospital cardiac rehabilitation staff.
Personalised rehabilitation (includes access to full outpatient model where requested)
Trial sites will employ a specialised nurse to administer personalised rehabilitation for the trial.
Personalised rehabilitation is bookended by a face-to-face, telephone or video call induction contact (median 45 min, IQR 30–60 min) and a face-to-face/telephone/video call close-out contact (median duration 20 min; range 5–50 min). In between, participants will be able to receive optional choice of disease and lifestyle education and psychosocial support.
Participants will be offered modules targeting the four key risk factors of elevated blood pressure, elevated low-density lipoprotein cholesterol, physical inactivity and cigarette smoking, as applicable. They may choose to target any combination or all modules, depending on their individual circumstances.
At the induction contact, the participant and site personalised rehabilitation coordinator will review the participant’s medical history and lifestyle behaviours. They will then mutually agree with the participant on suitable modules to address and goals to set. The participant will assign a personal confidence rating for achieving each goal. The strategy for addressing each module is also flexible. In SPAN, strategies are categorised as medical, flexible, home-based or self-directed and range from primary supervision by their usual general practitioner (medical) to a totally self-directed approach (see table 1 for details of each strategy).
Table 1Description of SPAN strategies for addressing selected risk factor modules
| SPAN strategy | Approach for addressing selected modules |
| Medical | Visiting usual doctor and following their advice (doctors fee may apply/Medicare) |
| Flexible | Taking part in free facilitated sessions to address risk factor online/in the local community/at hospital site |
| Home-based | Participating in a home-based programme to address risk factor supported by the site personalised rehabilitation co-ordinator |
| Self-directed | Managing own risk factors with or without support of personalised rehabilitation co-ordinator |
SPAN strategies for addressing the selected modules of the personalised cardiac rehabilitation modules (lowering blood pressure, reducing LDL cholesterol levels, increasing activity levels and quitting smoking).
LDL, low-density lipoprotein; SPAN, secondary prevention for all in need.
Regardless of the approach chosen, participants can elect to engage in up to three 20 min phone calls with the personalised rehabilitation co-ordinator outside of induction and close-out contacts, to provide support and monitor progress. Additional ad-hoc contacts may also take place. The personalised rehabilitation co-ordinator may also provide assistance with sourcing and/or co-ordination of hospital, community or online services.
At the induction visit and throughout the rehabilitation process, participants will nominate specific contacts they plan to make to address the selected risk factors. Examples of this may include calling the Quitline, visiting a fitness facility or attending a scheduled education session. These planned contacts will be recorded on a rehabilitation plan. Throughout the rehabilitation process and at the close-out visit, details of the specific contacts undertaken will be recorded on a rehabilitation attendance log. By comparing the planned activities with those performed, a participant’s completion rate for their rehabilitation will be ascertained.
In the standard rehabilitation arm, data will be extracted from the local system used to record cardiac rehabilitation. Completion rates will be determined through attendance records based on the standard programme provided.
Patients will typically receive lipid-lowering and other evidence-based drugs (subject to contraindication and intolerance); however, this would be at the discretion of their treating clinician and independent of their trial intervention.
At baseline, participants in both treatment arms will complete the EuroQol 5 Dimension 5 Level (EQ-5D-5L) quality of life questionnaire and the Specific Activity Questionnaire (SAQ). The EQ-5D-5L is a reasonably valid, reliable and responsive quality of life measure for patients with acute coronary syndrome,12 while the SAQ provides a moderately good measure of functional capacity in cardiac patients.13 Both questionnaires are low-burden. Participants will repeat these measures at the conclusion of the rehabilitation intervention. Both questionnaires are included in the online supplemental file 2 (EQ-5D-5L) and file 3 (Specific Activity Questionnaire). A timeline of intervention is provided in figure 2.
Enlarge this image.Figure 2. Timeline of interventions in SPAN. EQ-5D-5L, EuroQol 5 Dimension 5 Level; MACE, major adverse cardiovascular event.
Outcomes
The primary outcome is the proportion of patients completing at least 80% of all scheduled contacts for their assigned rehabilitation strategy at 3 months follow-up. In both treatment arms, this will be calculated from attendance records of planned activities, determined at induction visit or pre-outpatient rehabilitation contact.
Secondary outcomes are 5-point MACE (composite of non-fatal stroke, non-fatal MI, cardiovascular death, heart failure hospitalisation and coronary/peripheral artery revascularisation). These will be collected directly in-trial by the study trial coordinator at each site and thereafter indirectly from linkage of administrative health data collections at completion of 12 month follow-up for all participants.
Responses to the EQ-5D-5L and SAQ will also be used to calculate changes in quality of life and physical activity from baseline and compared across the two treatment arms.
Statistical considerations
The trial will be reported according to Consolidated Standards of Reporting Trials (CONSORT) guidelines.14 Summary statistics including means and SDs (or medians and IQRs where appropriate) or counts and percentages will be calculated for all baseline characteristics by treatment arm, as well as for the number of scheduled and attended contacts for each study arm.
The primary analysis will be based on the intention-to-treat principle. The primary outcome of meeting at least 80% participation of all scheduled sessions (yes/no) for personalised rehabilitation versus standard outpatient rehabilitation will be assessed using logistic regression with stratification by site.
For all time to event secondary endpoints, including the composite of readmission to hospital for MACE, treatment groups will be compared using a two-sided log-rank test with stratification by site and visualised using cumulative incidence curves. Subsequently, Cox proportional hazards regression models, with stratification by site, will be performed. HRs of personalised rehabilitation versus standard outpatient rehabilitation, with corresponding 95% CIs, will be calculated.
All other binary and continuous outcomes will be analysed using logistic regression and linear regression, respectively, with stratification by site. A modified intent-to-treat analysis will also be performed where only those who achieved a minimum exposure to outpatient rehabilitation, defined as attendance at one or more sessions after pre-outpatient rehabilitation contact and a minimum exposure to personalised rehabilitation, defined as one contact; that is, induction session, with the personalised co-ordinator will be included.
Two-tailed p-values<0.05 will be considered statistically significant; however, given the limited number of secondary endpoints and therefore the chance of increasing the family-wise error rate is low and they are exploratory in nature, we contend formal adjustments for multiple comparisons are not necessary. However, results will be interpreted with caution.
A detailed statistical analysis plan will be finalised prior to closure of the trial and before any data analysis begins. Once finalised, this will be made publicly available.
Sample size
The participating tertiary centres report aggregated annual admissions for MI, ranging from 720 to 950/hospital. All eligible participants will be identified by study personnel from daily admissions to coronary care and general medical units.
Study power and significance
Assuming a power of 90% and an overall type 1 error of 5%, we expect that 50% of those randomised to usual care will meet the primary endpoint compared with 65% of those on personalised rehabilitation. To detect this difference of 15%, we require a sample size of 478 participants (239 per arm). Accounting for a conservative attrition rate of 10%, the total sample size required is 532. The sample size calculation for the primary outcome was performed using PS: Power and Sample Size software (V.3.1.6).
As indicated in the protocol, the primary outcome will be tested at a 5% significance level; however, given the limited number of secondary endpoints and therefore the chance of increasing the family-wise error rate is low and they are exploratory in nature, we contend formal adjustments for multiple comparisons are not necessary. However, results will be interpreted with caution.
Trial oversight and governance
The SPAN trial is sponsored by the University of Western Australia (UWA). The trial received ethical approval from the Southern Adelaide Clinical Human Research Ethics Committee on 19 September 2022 (Project ID 2022/HRE00071).
Patient and public involvement and engagement
The trial was developed with extensive input from two community consumers with lived cardiac experience. Recommendations were implemented into the final trial design, such as the inclusion of patient-reported outcome measures, as well as the development of participant-facing documentation.
Trial progress
The first participant was randomised on 23 August 2023. As of the date of submission, there have been 253 participants randomised to the trial, across four sites. The trial is planned to continue to recruit until July 2026 and complete all cardiac rehabilitation follow-ups by 31 December 2026.
Discussion
The SPAN trial will address the established evidence-practice gap that 7/10 MI survivors in Australia are not accessing guideline-advocated secondary prevention measures.4 Barriers to improving reach, completion and outcomes are complex and well documented but can be addressed by studying more personalised ways of delivering prevention. This trial, where patients have an equal chance of receiving preventive treatment options, will evaluate the implementation of a published and flexible framework for improving secondary prevention among MI survivors.4
By taking a disruptive approach to innovation in this area of care, the SPAN strategy seeks to establish the effectiveness of moving to a personalised precision model of rehabilitation compared with the traditional model of outpatient rehabilitation after type 1 MI. Pilot work15 16 has demonstrated potential benefits in reach (uptake by >50% of non-outpatient rehabilitation attenders); high completion (93%), sustainability (68% at 4 years) and estimated cost-savings of $30 million annually in Australia alone, by avoiding potentially preventable hospital admissions and procedures through more personalised and simplified models of post-type 1 MI care.17 18
The SPAN trial involves comparing personalised rehabilitation with standard outpatient, group-based rehabilitation. The SPAN framework offers a flexible, targeted and sustainable approach for risk factor control and disease management through shared decision-making and goal attainment. The trial will report on the differences between the two rehabilitation strategies in terms of completion defined as participation in ≥80% of scheduled contacts as established at the initial engagement, and subsequently all admissions to hospital and death identified from administrative records at 12 months.
SPAN will determine if there is an absolute increase of at least 15% in the proportion of MI survivors who complete personalised versus outpatient rehabilitation, that is, 65% versus 50% at 3 months follow-up, respectively. If successful, this personalised rehabilitation strategy could be rapidly and widely implemented and would be expected to reduce the risk of recurrent cardiovascular events and unplanned readmissions to hospital nation-wide.
Limitations and contingencies
Given the subjective nature of the primary effectiveness outcome, we have mitigated against detection bias and between group contamination by collection of comprehensive workflow records, trial monitoring and exclusion of patients with prior cardiac rehabilitation experience. The possibility of a cluster randomised trial to address the potential for between-group contamination was not pursued due to the larger sample size requirements for this approach and the modest number of participating sites in the SPAN trial.19
All available participant data, including from those who withdraw from the trial, will be used to derive the primary endpoint of participation in ≥80% of all scheduled sessions according to the intention-to-treat principle. Finally, should the proposed number of sites fail to recruit the required number of participants, a reserve list of potential sites will be engaged.
Ethics and dissemination
The trial received ethical approval from the Southern Adelaide Clinical Human Research Ethics Committee (ref. 2022/HRE00071) in September 2022, with an opt-out approach. The findings will be disseminated through peer-reviewed journals.
We thank cardiac rehabilitation units and SPAN research staff at all participating hospitals.
Ethics statements
Patient consent for publication
Not applicable.
X @JRedHeart
Contributors TB, JRe, GH, JA, JRa, CB, DPC, DB, AM, AC, TR, SN and TG contributed to the initial conception and study design and developed the study protocol. TG drafted the initial manuscript. All authors critically reviewed the manuscript. TB is the guarantor of the manuscript.
Funding This work was supported by the National Heart Foundation of Australia, grant number 105531.
Competing interests JA declares receiving grants or contracts from American Regent, Bayer, Merck Sharp and Dome, Novo Nordisk; consulting fees from AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly and Novo Nordisk; payment for presentations from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly and Novo Nordisk; support attending meetings from Bayer, Bristol-Myers Squibb, Novo Nordisk, Vifor Pharma; leadership or board positions with the Cardiac Society of Australia and New Zealand (CSANZ), National Heart Foundation of Australia (NHFA) Research Committee, Medicare Benefits Schedule Advisory Committee and the Australian Government’s Department of Health and Ageing. TB declares support for attending NHFA meetings. DC declares receiving consulting fees from CSL Sequiris, Novartis and Abbott. JRe declares receiving a peer-reviewed grant from the NHFA and a peer-reviewed fellowship from the National Health and Medical Research Council (NHMRC), and unpaid committee memberships to the World Heart Federation, CSANZ and the Australian Cardiovascular Alliance. All other authors have no completing interest to declare.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
1 Heart, stroke and vascular disease: Australian facts. Australian Institute of Health and Welfare; 2023. Available: https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/hsvd-facts/contents/summary-of-coronary-heart-disease-and-stroke/coronary-heart-disease
2 Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2016; 205: 128–33. doi:10.5694/mja16.00368
3 Abell B, Glasziou P, Briffa T, et al. Exercise training characteristics in cardiac rehabilitation programmes: a cross-sectional survey of Australian practice. Open Heart 2016; 3: e000374. doi:10.1136/openhrt-2015-000374
4 Redfern J, Maiorana A, Neubeck L, et al. Achieving coordinated secondary prevention of coronary heart disease for all in need (SPAN). Int J Cardiol 2011; 146: 1–3. doi:10.1016/j.ijcard.2010.08.046
5 Dibben G, Faulkner J, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2021; 11: CD001800. doi:10.1002/14651858.CD001800.pub4
6 Ritchey MD, Maresh S, McNeely J, et al. Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative. Circ Cardiovasc Qual Outcomes 2020; 13: e005902. doi:10.1161/CIRCOUTCOMES.119.005902
7 Scott IA, Lindsay KA, Harden HE. Utilisation of outpatient cardiac rehabilitation in Queensland. Med J Aust 2003; 179: 341–5. doi:10.5694/j.1326-5377.2003.tb05588.x
8 Briffa TG, Kinsman L, Maiorana AJ, et al. An integrated and coordinated approach to preventing recurrent coronary heart disease events in Australia. Med J Aust 2009; 190: 683–6. doi:10.5694/j.1326-5377.2009.tb02636.x
9 Astley CM, Neubeck L, Gallagher R, et al. Cardiac Rehabilitation: Unraveling the Complexity of Referral and Current Models of Delivery. J Cardiovasc Nurs 2017; 32: 236–43. doi:10.1097/JCN.0000000000000332
10 Woodruffe S, Neubeck L, Clark RA, et al. Australian Cardiovascular Health and Rehabilitation Association (ACRA) core components of cardiovascular disease secondary prevention and cardiac rehabilitation 2014. Heart Lung Circ 2015; 24: 430–41. doi:10.1016/j.hlc.2014.12.008
11 Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction (2018). Circulation 2018; 138: e618–51. doi:10.1161/CIR.0000000000000617
12 Schweikert B. Validation of the EuroQol questionnaire in cardiac rehabilitation. Heart 2006; 92: 62–7. doi:10.1136/hrt.2004.052787
13 Rankin SL, Briffa TG, Morton AR, et al. A specific activity questionnaire to measure the functional capacity of cardiac patients. Am J Cardiol 1996; 77: 1220–3. doi:10.1016/s0002-9149(97)89157-6
14 Schulz KF, Altman DG, Moher D, et al. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010; 340: c332. doi:10.1136/bmj.c332
15 Redfern J, Briffa T, Ellis E, et al. Choice of secondary prevention improves risk factors after ACS: 1-year follow-up randomised controlled trial. Heart 2009; 95: 468–75.
16 Neubeck L, Freedman SB, Briffa T, et al. Four year follow-up of the CHOICE randomised controlled trial. Eur J Prev Cardiol 2011; 18: 278–86. doi:10.1097/HJR.0b013e32833cca66
17 Anderson L, Oldridge N, Thompson DR, et al. Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease. J Am Coll Cardiol 2016; 67: 1–12. doi:10.1016/j.jacc.2015.10.044
18 Briffa TG, Eckermann SD, Griffiths AD, et al. Cost-effectiveness of rehabilitation after an acute coronary event: a randomised controlled trial. Med J Aust 2005; 183: 450–5. doi:10.5694/j.1326-5377.2005.tb07121.x
19 Giraudeau B, Weijer C, Eldridge SM, et al. Why and when should we cluster randomize? J Epidemiol Popul Health 2024; 72: 202197. doi:10.1016/j.jeph.2024.202197
© 2025 Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. http://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ . Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.
Details
; Redfern, Julie 2
; Chew, Derek P 3 ; Atherton, John 4 ; Hillis, Graham 5
; Nicholls, Stephen 6 ; Brieger, David 7 ; Rankin, Jamie 8 ; Lehman, Sam 9 ; Maiorana, Andrew 10
; Budgeon, Charley 11
; Cordingley, Anne 12 ; Robinson, Teagan 12 ; Briffa, Tom 11
1 UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
2 Bond University Institute for Evidence-Based Healthcare, Robina, Queensland, Australia; Sydney Nursing School, University of Sydney, Glebe, New South Wales, Australia
3 Victorian Heart Hospital, Monash University, Melbourne, Victoria, Australia
4 School of Medicine, University of Queensland, Brisbane, Queensland, Australia
5 UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
6 Monash University, Clayton, Victoria, Australia
7 Department of Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
8 Department of Cardiology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
9 College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
10 Physical Activity and Well-Being Research Group, enAble Institute, Curtin University, Perth, Western Australia, Australia; Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia; Exercise Physiology Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
11 Cardiovascular Epidemiology Research Centre, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
12 Consumer and Community Advisory Council, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia