Usual care patients will continue with the hospital follow-up plan and routine preventive care after hospital discharge.

Intervention patients will receive a disease management program in addition to the usual care.

The components of our DMP include:

1. Intensive post-discharge education
2. Home surveillance of signs and symptoms will be reviewed (weekly in the first month and monthly thereafter) in a telehealth consultation with patient and/or carer.
3. Medical treatment involves a planned up-titration of cardioprotective medications that will proceed in the absence of advice from the general practitioner (GP) to the contrary. Close observation and frequent appointments are organised by the nurse with the patient's GP during up-titration period.
4. Exercise program delivered by an exercise physiologist
5. Maintenance phase of the DMP: During this maintenance phase, Intervention patients should have been fully transitioned to home care where they are managed by their GP at optimal doses of their medications. Repeated education and exercise guidance will continue with the carer, supported by our cardiac nurse and exercise physiologist via telehealth consultation bimonthly.

Greater Montreal Cognitive Assessment (MOCA) score (ranging 0-30) is better

Cardiac function will be measured by echocardiography. Left ventricular global longitudinal strain will be the primary measure of cardiac function.