OBJECTIVES: In Denmark, the local and regional health authorities share responsibility for cardiac rehabilitation (CR). The objective was to assess effectiveness of CR across sectors coordinated by a nurse case manager (NCM). DESIGN: A one-year follow-up study. SETTING: A CR programme (GoHeart) was evaluated in a cohort at Lillebaelt Hospital Vejle, DK from 2010 to 2011. PARTICIPANTS: Consecutive patients admitted to CR were included. The inclusion criteria were the event of acute myocardial infarction or stable angina and invasive revascularization (left ventricular ejection fraction (LVEF) ≥45%). MAIN OUTCOME MEASURES: Cardiac risk factors, stratified self-care and self-reported psychosocial factors (SF12 and Hospital Anxiety and Depression Scale (HADS)) were assessed at admission (phase IIa), at three months at discharge (phase IIb) and at one-year follow-up (phase III). Intention-to-treat and predefined subgroup analysis on sex was performed. RESULTS: Of 241 patients, 183 (75.9%) were included (mean age 63.8 years). At discharge improvements were found in total-cholesterol (p < 0.001), low density lipoprotein (LDL; p < 0.001), functional capacities (metabolic equivalent of tasks (METS), p < 0.01), self-care management (p < 0.001), Health status Short Form 12 version (SF12; physical; p < 0.001 and mental; p < 0.01) and in depression symptoms (p < 0.01). At one-year follow-up these outcomes were maintained; additionally there was improvement in body mass index (BMI; p < 0.05), and high density lipoprotein (HDL; p < 0.05). There were no sex differences. CONCLUSION: CR shared between local and regional health authorities led by a NCM (GoHeart) improves risk factors, self-care and psychosocial factors. Further improvements in most variables were at one-year follow-up.