European Journal of Cardiovascular Nursing 9 (2010) 118 – 125

www.elsevier.com/locate/ejcnurse

Coping, sense of coherence and the dimensions of affect in patients with

chronic heart failure
Catarina Nahlén a,⁎, Fredrik Saboonchi b,c
a
Department of Cardiology Danderyd Hospital AB, S-182 88 Stockholm, Sweden
b
Sophiahemmet University College, Stockholm, Sweden
c
Department of Clinical Sciences Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
Received 26 June 2009; received in revised form 19 November 2009; accepted 23 November 2009
Available online 21 December 2009

Abstract

Background: Living with chronic heart failure has an impact on several important dimensions of an individual's life. A patient's use of
coping strategies may influence his or her health condition and emotional well-being.
Aim: To investigate factors that may relate to the coping strategies used by individuals with chronic heart failure and how the coping
strategies are associated with positive and negative affect.
Methods: A cross-sectional research design was used. The participants provided demographic data and filled out three questionnaires: Sense
of Coherence scale, Brief COPE and Positive Affect Negative Affect Schedule.
Results: No differences in relation to coping strategies were found with regard to New York Heart Association class. Substance use was
associated with gender and age. Sense of coherence was negatively associated with denial, behavioural disengagement, venting and self-
blame, and positively associated with acceptance. It was found that avoidant coping positively and sense of coherence negatively, predicted
negative affect. Problem focused coping positively predicted positive affect. Socially supported coping predicted both negative and positive
affect.
Conclusion: The present study found that the employment of different coping strategies and sense of coherence had an impact on affect and
therefore also the emotional well-being among patients with chronic heart failure.
© 2009 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Keywords: Chronic heart failure; Coping; Coping strategy; Affect; Sense of coherence

1. Introduction of diagnosis. Forty percent of patients admitted to hospital

Chronic heart failure (CHF) is a syndrome that involves
characteristic symptoms such as breathlessness and fatigue,
at rest or during exertion, or peripheral oedema. The
prevalence of CHF in the European population is estimated
to vary between 2 and 3% and the prevalence increases with
age. Half of the patients living with CHF die within 4 years
⁎ Corresponding author. Tel.: +46 86555496; fax: +46 87532294.
E-mail address: catarina.nahlen@ds.se (C. Nahlén).
1474-5151/$ - see front matter © 2009 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcnurse.2009.11.006
with CHF die, or are readmitted, within 1 year [1].
The severity of symptoms in CHF is divided into four
different functional classes according to the New York Heart
Association Classification (NYHA-Class) [1].
Class I No limitation of physical activity. Ordinary phys-
ical activity does not cause undue fatigue, palpita-
tion, or dyspnoea.
Class II Slight limitation of physical activity. Comfortable
at rest, but ordinary physical activity results in
fatigue, palpitation, or dyspnoea.
Class III Marked limitation of physical activity. Comfortable

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 C. Nahlén, F. Saboonchi / European Journal of Cardiovascular Nursing 9 (2010) 118–125
at rest, but less than ordinary activity results in
fatigue, palpitation, or dyspnoea.
Class IV Unable to carry out any physical activity without
discomfort. Symptoms at rest. If any physical
activity is undertaken, discomfort is increased.
Living with CHF affects several dimensions of the
individual's life [2–6], especially the physical dimension.
Individuals with CHF experience many symptoms of which
the most distressing are lack of energy, difficulty sleeping,
breathlessness and waking up breathless at night [7]. Greater
functional impairment has been found to be associated with a
worse quality of life [7,8]. Patients with CHF experience
worse health-related quality of life (HRQL) compared with
healthy individuals [9]. Decreased energy and the need to
slow down are particularly distressing for a younger
individual with CHF [10]. Living with CHF requires
fundamental adjustments for the individual such as gradually
taking on a new identity and making lifestyle changes, and
putting the new life situation into context and meaning [10].
The overall purpose of the present study is to examine
how patients with CHF cope with these adjustments, what
the outcomes of their coping are, and what factors influence
the patient's coping strategies.
1.1. Theoretical framework
According to Moos crisis theory [11] the outcome of any
health crisis such as living with a chronic illness is
influenced by the patient's coping process, which in its
turn is influenced by a number of factors including illness-
related factors and personal factors. The present study
applies Moos crisis theory to chronic heart failure as it is
displayed in Fig. 1.
1.2. Coping
Coping has been defined by Lazarus and Folkman as:
“constantly changing cognitive and behavioural efforts to
manage specific external and/or internal demands that are
appraised as taxing or exceeding the resources of the person”
[12]. Coping strategies are the specific ways in which
individuals respond to stressful situations [13]. Individuals
Fig. 1. Overview of the theoretical framework of the present study: segments
of Moos crisis theory are applied to CHF. Negative and positive affect are
viewed as outcomes of a health crisis. Arrows in the figure denote the flow
of the hypothesised influence of the variables. NYHA-class = New York
Heart Association Classification; SOC = sense of coherence.
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119
with CHF use strategies including active, problem-solving
coping to change their environment and to seek information
[14–16]. They also use specific coping strategies to ease
their emotional burden, i.e. emotional coping strategies such
as avoidance, healthy denial, acceptance [17], hopefulness
and spirituality [6,18,19]. A study has shown that the higher
the NYHA-class the more likely a patient with CHF tends to
use symptom-focused coping (i.e., lying down or resting;
taking medicine) and work towards accepting their limita-
tions [8]. Avoidant coping is more prevalent among patients
older than 70 years and patients with moderate to severe
limitation in physical capacity [17]. Blunting, a measure of
threat avoidance, has been found to be negatively associated
with both optimism and emotional well-being among cardiac
patients [20]. Studies have shown that some coping
strategies result in negative consequences for health [17,21].
Men and women can experience living with CHF
differently and consequently use different coping strategies
[2,3,22]. There are, for example, indications that women
display a higher health perception and construct a more
positive meaning to their illness than men do [2,3,22].
Interestingly, actual health does not predict health percep-
tions considering that the women in that study had lower
functional status [22].
1.3. Sense of Coherence
Sense of coherence (SOC) is theoretically viewed as an
internal resource towards coping with stress and demands in
life [23]. Antonovsky defined the concept of SOC as: “a
global orientation that expresses the extent to which one has
a pervasive, enduring though dynamic feeling of confidence
that one's internal and external environments are predictable
and that there is a high probability that things will work out
as well as can reasonably be expected” [24]. SOC consists of
three components; comprehensibility, manageability, and
meaningfulness. Individuals with strong SOC are more
likely to judge a situation as controllable and to select
adequate coping strategies [25].
Chronically ill patients with low SOC are at risk of having
poor self-management. [26]. SOC has also been suggested to
be a strong predictor of quality of life in persons with
coronary heart disease [27]. The associations between SOC
and HRQL are, however, not necessarily straightforward. In
a group of patients with coronary artery disease, those who
had poor or moderate SOC had lower HRQL than the
patients with strong SOC [28]. On the contrary, despite
differences in experienced HRQL between a healthy
population and a group of patients with CHF, the patients
with CHF still displayed high or similar SOC as the controls
[9]. Another study examining SOC in individuals with heart
failure suggested that patients with CHF with high SOC
tended to have high levels of coping resources (i.e.,
emotional, social, and spiritual) [29]. A Swedish study
indicated that low SOC among a group of patients with CHF
affected their mental fatigue in a negative way [30].
120 C. Nahlén, F. Saboonchi / European Journal of Cardiovascular Nursing 9 (2010) 118–125
1.4. Affect
Affect comprises different states of mood and is modelled
as a two-dimensional structure consisting of positive affect
(PA) and negative affect (NA). These two factors represent
the major dimensions of emotional experience [31]. High
positive affect is a state of high energy, full concentration,
and pleasurable engagement, whereas low positive affect is
characterized by sadness and lethargy. Negative affect is a
general dimension of subjective distress and non-pleasurable
engagement that subsumes a variety of aversive mood states,
including anger, contempt, disgust, guilt, fear and nervous-
ness, with low negative affect being a state of calmness and
serenity [32]. Positive and negative affect are associated with
the emotional aspect of well-being [33]. Positive emotions
can trigger an upward spiral toward emotional well-being
[34]. Positive affect can occur during chronic stress and can
have significant adaptive functions, both under stressful
situations and under normal conditions [35].
An important factor in chronic disease is affect since both
positive and negative affect influence the adjustment to
chronic illness [36]. Higher affective states of depression,
anxiety and hostility have been associated with lower quality
of life in men with heart failure [37]. Depressive symptoms
in patients with CHF have been shown to be a strong
predictor of short-term worsening of CHF symptoms [38]
and mortality [39]. In a study comprising patients with CHF
it was found that maladaptive coping styles such as denial,
self-distraction, behavioural disengagement, venting of
emotions, and self-blame were negatively associated with
quality of life and positively associated with depressive
symptoms [40]. In patients with advanced heart failure
avoidant coping style has been found to be significantly
associated with higher negative emotional states such as
anxiety, anger, depression, confusion and fatigue [41].
Another study indicated that greater active/acceptance
coping was significantly associated with lower depression
among patients with CHF. Patients who had more depressive
symptoms also reported greater negative mood and lower
positive mood [8].
The aim of the current study is to investigate whether
functional status, demographic variables and sense of
coherence may be related to the coping strategies used by
patients with CHF. Another main objective of the study was
to examine how coping strategies may be associated with
different dimensions of affect, considered as a main pillar of
emotional well-being for these patients.
1.5. Hypotheses
In the present study, it was hypothesised that NYHA-
class, gender, age and SOC are associated with the coping
strategies used by patients with CHF. Furthermore, that the
employment of coping strategies predicts different dimen-
sions of affect.
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2. Methods
A cross-sectional research design was utilized.
2.1. Sample
Patients enrolled in the study met the following criteria:
patients diagnosed with CHF hospitalized at a heart failure
ward or a nurse-led heart failure outpatient clinic at Danderyd
Hospital, Sweden, were classified in NYHA-class II-IV and
were aged over 18 years.
Exclusion criteria were cognitive dysfunction and/or life
threatening disease such as cancer or primary organ failure
and not being able to understand the Swedish language. Data
of cognitive dysfunction were obtained from medical
records.
All patients who met the above criteria were asked by the
research nurse to participate in the study. Of the 143 patients
who met the inclusion criteria, 94 participated. Fourteen
patients were excluded due to incomplete response to the
questionnaires or no response at all, hence 80 patients were
included in the study. For socio-demographic and clinical
data of the participants, see Table 1.
2.2. Instruments
Three questionnaires were used in the present study. The
participants were also asked to fill in a form with
demographic data such as age and gender and the research
nurse complemented it with information from the medical
record.
For measuring SOC, the shorter version of the Sense of
Coherence scale was used. It includes 13 items measuring
comprehensibility, manageability and meaningfulness. The
participant was asked to select a number from 1 to 7 with two
anchoring responses (e.g. never and very often) which best
represented the statement. The possible scores range from 13
to 91 and a high score indicates a strong sense of coherence.
The Swedish short version of the Sense of Coherence scale
has been validated by Langius and Björvell and Chronbach's
alpha was 0.77 [42]. In the present study Cronbach's α for
the total SOC was also 0.77.
Brief COPE was used to measure different coping
strategies. Brief COPE is a shorter version of the 60-item
COPE inventory and has been designed with the purpose of
being less time-consuming for research participants. Brief
COPE contains 28 items, which measure 14 conceptually
differentiable coping strategies: active coping, planning,
positive reframing, acceptance, humour, religion, using
emotional support, using instrumental support, self-distrac-
tion, denial, venting of emotions, substance use, behavioural
disengagement and self-blame. The participant was asked to
think of what he or she usually does and feel in a stressful
situation. Each item is ranged from 1 (not right at all) to 4
(exactly right) and consists of different statements. This
 C. Nahlén, F. Saboonchi / European Journal of Cardiovascular Nursing 9 (2010) 118–125 121

Table 1 Table 2
Socio-demographic and clinical variables (n = 80). The four-factor model of the Brief COPE and the related coping strategies
included in each factor. Self-distraction and self-blame are not included in
n (%)
this model since the items are not part of the original COPE inventory.
Age (mean ± S.D.) 72.1 ± 10.5 (range 39–90)
Problem focused Avoidant Socially supported Emotion focused
Sex
coping coping coping coping
Male 58 (72.5)
Female 22 (27.5) Active coping Behavioural Using emotional Positive
Marital status disengagement support reframing,
Married/cohabitate 48 (60.0) Planning Denial Using instrumental Acceptance
Single 32 (40.0) support
Education Substance-use Venting of emotions Humour
Nine-year compulsory school 28 (35.0) Religion
(ages 7–16)
Upper secondary school (age 17–19) 31 (38.8)
University 21 (26.2)
Occupation describe PA and NA separately. The participant was asked to
Working 15 (18.8) fill in how much he or she has experienced each feeling and
Pensioner 62 (77.5) emotion the past few weeks. Each item is ranked from 1 (not
Other occupation 3 (3.7)
NYHA a
at all) to 5 (extremely). The score for each subscale is
Class II 39 (48.75) summarized to a total score. This instrument has been
Class III 39 (48.75) developed and validated by Watson, Clark & Tellegen;
Class IV 2 (2.5) Chronbach's alpha was 0.87 for both PA and NA [32]. The
Time since diagnosis of heart failure internal consistency of PANAS in the present study was for
Less than 6 months 15 (18.8)
6 months to 1 year 14 (17.5)
PA, α = 0.86 and NA, α = 0.85.
1 year to 2 years 9 (11.2)
2 years to 5 years 18 (22.5) 2.3. Statistical analysis
More than 5 years 24 (30.0)
Heart failure medication Data analysis was carried out using SPSS (version 16).
Diuretics 74 (92.5)
ACEi b 49 (61.3)
Missing values were accounted for by using mean
ARB c 28 (35.0) substitution procedure. For NYHA-class analysis, patients
Beta-adrenoceptor antagonists 77 (96.3) with NYHA-class IV were excluded due to the small sample
Aldosterone receptor antagonists 43 (53.8) consisting of only two individuals.
Left ventricular ejection fraction (LVEF) Upon screening the data, departure from normality was
Normal (LVEF N 50%) 13 (16.2)
Mildly reduced (LVEF 40–49%) 12 (15.0)
detected for the variables religion (skewness = 1.68 and
Moderately reduced (LVEF 30–39%) 28 (35.0) kurtosis = 2.13), and substance use (skewness = 2.12 and
Severely reduced (LVEF b 30%) 27 (33.8) kurtosis = 3.72). The corresponding values for all other
a
NYHA = New York Heart Association Class. variables were acceptable (skewness b.72 and kurtosis
b
ACEi = angiotensin-converting enzyme inhibitor. ranging from − 1.05 to.56). Further examination of normal
c
ARB = angiotensin II receptor blocker. Q & Q plots corroborated the departure from normality for
religion and substance use, whereby non-parametric tests
were applied for these variables.
instrument has been validated by Carver; Chronbach's alpha For examining differences with respect to the choice of
ranged from 0.50 to 0.90 for the subscales [43]. coping strategies between NYHA-classes II and III, as well
The conceptually differentiable coping strategies included as gender groups, t-tests and Mann–Whitney U-tests were
in the Brief COPE can be grouped into 4 subgroups of related carried out. For examining the associations between age and
coping strategies according to previous research [44] (see SOC with coping strategies, a series of Pearson and
Table 2). This grouping of related coping strategies, into Spearman Correlation analyses were performed. Correlation
subgroups of coping, reduces the large number of subscales analysis was also done to explore associations between SOC
in Brief COPE and has been suggested to be theoretically and dimensions of affect.
sound by previous research [45] For further analysis, the In order to investigate whether specific coping strategies
subscales of Brief COPE were divided into this four-factor and SOC may be able to predict different dimensions of
model. The four-factor model of Brief COPE in our study affect, a series of correlation analyses were performed.
showed α coefficients as follows: problem focused coping, The subgroups of coping strategies that had a significant
α = 0.53; avoidant coping, α = 0.71; socially supported correlation with affect were included in two regression
coping, α = 0.82 and emotion focused coping, α = 0.65. analyses, one to predict the degree of negative affect and
To measure affect, the Positive Affect Negative Affect another for predicting the degree of positive affect.
Schedule (PANAS) was used. PANAS consists of 20 words A preliminary power analysis, in line with Cohen's [45]
that describe different feelings and emotions. Ten words recommendations, indicated that to obtain a power of 0.80

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122 C. Nahlén, F. Saboonchi / European Journal of Cardiovascular Nursing 9 (2010) 118–125

assuming an explained variance of r2 = 0.15, a sample size of Table 4

76 participants was needed. Pearson correlation coefficients between subgroups of Brief COPE and SOC
with PA and NA.
Problem Avoidant Socially Emotion SOC
2.4. Ethical consideration focused coping supported focused total
coping coping coping
The investigation conforms to the principles outlined in the PA .35** −.03 .29** .22 −.02
Declaration of Helsinki and the Research Ethics Committee at NA .19 .39** .32** .16 −.42**
Karolinska Institutet, Stockholm approved the study. ** = p b .01.
PA = positive affect, NA = negative affect, and SOC = sense of coherence.
3. Results
3.3. Predictors of positive and negative affect
3.1. NYHA-class, gender, age, SOC and coping strategies
As shown in Table 4, problem focused coping and
There were no significant differences between NYHA- socially supported coping had significant correlations with
class II and III concerning coping strategies. With regard to PA, and were subsequently included as predicators in a
gender, the results showed that men had a significantly regression analysis for PA. Avoidant coping, socially
higher mean rank score for substance use than women did in supported coping and SOC total, correlated significantly
this sample (Mann–Whitney U = 428.5, p b 0.01). No other with NA (see Table 4), and were included as predicators for
significant differences in coping strategies between the this dimension of affect. The regression analyses were
genders were found. Furthermore, there were no significant performed on data from the whole sample. As displayed in
correlations between age and any of the coping strategies as Table 5, problem focused coping significantly predicted PA,
outlined by the subscale of Brief COPE with the exception of however the total variance explained by this regression
substance use which showed a negative significant correla- analysis was limited to 14%. All three correlates of NA:
tion with age (ρ = − 0.35, p b 0.01). avoidant coping, socially supported coping and SOC,
Significant negative correlations were also found between significantly predicted NA and accounted for 31% of the
total score of SOC and venting, r = − 0.35, p b 0.01, and with total variance in this dimension of affect.
self-blame, r = − 0.40, p b 0.01.
4. Discussion
3.2. Correlations between coping strategies and positive
and negative affect The present study examined the possible role of NYHA-
class, gender, age, and sense of coherence in the way patients
Correlations between coping strategies and different with CHF use coping strategies and how coping strategies
dimensions of affect, as measured by Brief COPE and influence the emotional well-being of patients with CHF.
PANAS, are shown in Table 3. Active coping, positive Neither age nor gender emerged as significant differentiating
reframing, and emotional support correlated significantly factors in the magnitude of the outlined coping strategies in
with positive affect. Venting, behavioural disengagement, this study with the exception of substance use, which showed
substance use and self-blame correlated significantly with a higher mean rank score for men and a decrease with age.
negative affect. This demographic pattern regarding substance use is also
The correlations between the four-factor model (see seen in the general Swedish adult population [46]. The
Table 2) subgroups of Brief COPE, SOC scale and PANAS present findings further motivate a more detailed assessment
were calculated in order to identify hypothetical predictors of substance use, especially in younger male patients,
for further regression analysis of PANAS (see Table 4). considering the adverse effects of substance use such as

Table 3
Correlations between subscales of Brief COPE and PANAS. The coefficients in the table denote Pearson product moment r, and Spearman ρ for variables which
depart from normality.
Pearson product moment r Spearman ρ
Active Planning Pos. Accept. Humour Emot. Instr. Self- Denial Venting Behav. Self- Relig Subst.
coping refr support support distr. diseng. blame use
PA .32** .28 .30** −.02 .25 .32** .25 .07 .01 .15 −.08 .11 .02 .03
NA .04 .27 .15 −.16 .17 .25 .18 .27 .25 .39** .40** .38** .24 .31**
**p b .01.
PA = positive affect, NA = negative affect, Pos. refr = positive reframing, Accept. = acceptance, Emot. support = emotional support, Instr. support = instrumental
support, Self-distr. = self-distraction, Behav. diseng. = behavioural disengagement, Relig = religion, Subst. use = substance use. For a more detailed description
of the coping strategies listed see Carver [43].

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 C. Nahlén, F. Saboonchi / European Journal of Cardiovascular Nursing 9 (2010) 118–125
Table 5
Regression analysis of PA and NA. Each dimension of affect is a dependent
variable regressed separately on its predictors.
Independent variable Standardised betas ( β )
Dependent variable: PA
Problem focused coping .28
Socially supported coping .13
r² = 0.14, F(2,77) = 6.00, p b 0.01
Dependent variable: NA
Avoidant coping .26
Socially supported coping .24
SOC total −.32
r² = 0.31, F(3.76) = 11.58, p b 0.001
PA = positive affect, NA = negative affect, and SOC = sense of coherence.
⁎ p b 0.05.
⁎⁎ p b 0.01.
alcoholic cardiomyopathy (ACM) and the major negative
impact of alcohol use on the prognosis [47].
SOC has been widely considered as an important personality
factor with regard to health and disease [9,26–28,30]. In the
present study, it was found that SOC was negatively associated
with venting of emotions, and self-blame, both of which are
generally viewed as maladaptive coping strategies [43]. This
result indicates that patients with higher degrees of SOC tend not
to engage in maladaptive coping behaviour and further
corroborates the theoretical notion about sense of coherence as
a buffering factor against life stress [23].
Concerning illness-related factors, no significant differ-
ences could be established concerning the employment of
coping strategies between the NYHA-classes. Although
patients with higher NYHA-class generally experience a
worse quality of life [7,8], the results suggest that they cope
with their life situation in much the similar way as patients
with lower NYHA-class. The range of NYHA-classes in this
study was, however, limited to NYHA-class II and III.
Subsequently, this restriction may be a possible explanation
for not detecting differences in coping strategies which may
exist between NYHA-class I and IV.
During the last decade, a growing number of studies have
focused on affect as an important factor in the adjustment to
chronic illness [48]. Affect is considered to be an essential
aspect of the emotional well-being in, amongst others, patients
with CHF [8,33,34]. The results of the present study suggest
that specific coping strategies are differentially associated with
positive and negative affect. Considering the impact of affect in
adjustment to chronic illness in general, and prognosis of CHF
in particular [36,38,39], these results show the importance of
assessment of the coping strategies used by the patients.
Negative affect was, in the present study, partially
predicted by avoidant coping. Avoidant coping is considered
unhealthy in a number of populations [20,49–52]. Oddly,
even socially supported coping appeared as a significant
predictor of negative affect. This finding is not consistent
with previous research [49] indicating that seeking social
support decreases depressive symptoms in patients with
CHF. This may be partly explained by the inclusion of
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123
venting in the definition of socially supported coping
according to the four-factor model of the COPE inventory
[44]. Venting of emotions and to some degree the self-
t focused attention it implies may be related to a magnification
of depressive affect and emotional distress [53,54]. This
2.13 ⁎ finding, however, encourages a more detailed examination
0.96
of the exact nature of how different components of social
support seeking coping strategies affect the emotional well-
2.53 ⁎ being in patients with CHF. Demographic variables and
2.47 ⁎ illness-related factors have been shown to contribute to
−3.23 ⁎⁎ depressive symptomology [49,55]. Our results suggest that
this may be partially due to use of avoidant coping strategies.
As expected, sense of coherence emerged as a negative
predictor for negative affectivity in patients with CHF,
indicating that higher SOC acts as a buffer for the adverse
emotional effect of life stress. Positive affect was, however,
only predicted by problem focused coping.
Since the present study had a cross-sectional design the
causality of the variables cannot be empirically determined.
In the present study, in line with Moos crisis theory [11],
affect was considered an outcome measure of coping
strategies and SOC. Physical and social environmental
factors can also influence the coping process according to
Moos crisis theory [11]. A limitation of the present study
may be the lack of assessment of these factors.
There has traditionally been a focus on negative affectivity
and depressive symptoms concerning chronic illness as it is
widely recognized how the chronicity and the difficulties of
living with severe chronic conditions tax the individual's
psychological and emotional resources. Positive affect,
however, is becoming increasingly recognized as an important
aspect of a person´s health and well-being [56]. The findings of
the present study suggest that promoting active coping
strategies in patients with CHF should be considered as a
possible approach to interventions. A review [57] of patient
education for patients with CHF presents a number of
approaches to patient education interventions to promote
quality of life. The findings of the present study may contribute
to a theoretical basis of such a nurse-led patient education
intervention where active coping could be a target variable.
Acknowledgements
We would like to thank the participants in the study. This
research was financially supported by the Department of
Cardiology at Danderyds Hospital, Stockholm and Sophiahemmet
University College, Stockholm.
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