Long-term effects of lifestyle behavior change in coronary artery disease: effects on recurrent coronary events after percutaneous coronary intervention

[Effects of Non-Pharmacological Interventions on Major Adverse Cardiac Events in Patients Underwent Percutaneous Coronary Intervention: Systematic Review and Meta-Analysis]

PURPOSE

In this study a systematic review and meta-analysis investigated the impact of non-pharmacological interventions on major adverse cardiac events (MACE) in patients with coronary artery disease who underwent percutaneous coronary intervention (PCI).

METHODS

A literature search was performed using PubMed, Cochrane Library, EMBASE, and Cumulative Index to Nursing & Allied Health Literature databases up to November 2023. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. Effect sizes and 95% confidence intervals were calculated using R software (version 4.3.2).

RESULTS

Eighteen randomized studies, involving 2,898 participants, were included. Of these, 16 studies with 2,697 participants provided quantitative data. Non-pharmacological interventions (education, exercise, and comprehensive) significantly reduced the risk of angina, heart failure, myocardial infarction, restenosis, cardiovascular-related readmission, and cardiovascular-related death. The subgroup meta-analysis showed that combined interventions were effective in reducing the occurrence of myocardial infarction (MI), and individual and group-based interventions had significant effects on reducing the occurrence of MACE. In interventions lasting seven months or longer, occurrence of decreased by 0.16 times, and mortality related to cardiovascular disease decreased by 0.44 times, showing that interventions lasting seven months or more were more effective in reducing MI and cardiovascular disease-related mortality.

CONCLUSION

Further investigations are required to assess the cost-effectiveness of these interventions in patients undergoing PCI and validate their short- and long-term effects. This systematic review underscores the potential of non-pharmacological interventions in decreasing the incidence of MACE and highlights the importance of continued research in this area (PROSPERO registration number: CRD42023462690).

Percutaneous coronary intervention outcomes based on American College of Cardiology/American Heart Association coronary lesion classification over 14 years - Melbourne interventional group (MIG) registry

BACKGROUND

The American College of Cardiology / American Heart Association (ACC/AHA) introduced a coronary lesion classification in 1988 to stratify coronary lesions for probability of procedural success and complications after coronary angioplasty. Our aim is to assess the validity of the ACC/AHA lesion classification in predicting outcomes of percutaneous coronary intervention (PCI) in a contemporary cohort of patients.

METHODS

Consecutive PCI procedures performed between 2005 and 2018, were divided into three periods. At each period, the ACC/AHA lesion classification (A, B1, B2, C) was analysed with respect to procedural characteristics, in-hospital and 30-day outcomes, as well as long-term mortality by linkage to the National Death Index (NDI).

RESULTS

In total, 21,437 lesions were included with 7399 lesions (2005-2009), 6917 lesions (2010-2014) and 7121 lesions (2015-2018). There was a progressive increase in the number of complex lesions treated over time with ACC/AHA type C (15 %, 21 % and 26 %, p < 0.01). The rate of PCI procedural success decreased with increase in the complexity of lesions treated across all three periods (p < 0.01). Further, in-hospital and 30-day major adverse cardiovascular events (MACE), major adverse cardiac and cerebrovascular events (MACCE) increased across all three time periods (all p < 0.05).

CONCLUSIONS

Our study validates the ACC/AHA lesion classification as a meaningful tool for prediction of PCI outcomes. Despite advances in PCI techniques and technology, complex lesion PCI defined by this classification continues to be associated with adverse outcomes.

Behavioural and psychological telehealth support for people with cardiac conditions: randomized trial of the 'back on track' self-management programme

AIMS

Behaviour modification and mood management are essential to recovery after a cardiac event. Recent times have seen a major shift to remote delivery of cardiac services. This study assessed behavioural and psychological outcomes of the Back on Track online self-management programme, comparing the programme undertaken alone (self-directed) vs. with telephone support (supported). Relevance for people with depression was also assessed.

METHODS AND RESULTS

Participants with cardiac conditions (n = 122) were randomly assigned to self-directed or supported groups and given access to the online programme for 2 months. The programme addressed depression, anxiety, physical activity, and healthy eating. Supported group participants also received two telephone sessions facilitated by a trained counsellor to further enhance their self-management skills and engagement with the online modules. The Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Active Australia Survey and Diet Quality Tool were administered at baseline, 2, and 6 months. χ2 tests were used to compare self-directed and supported groups. Cochrane's Q tests assessed changes over time in depression, anxiety, and physical activity (PA) and healthy diet guideline achievement. Participants in both groups showed reduced depression rates (self-directed, P < 0.05) and increased PA after programme completion (both groups, P < 0.05). Amongst those classified as depressed at baseline, significantly fewer were classified as depressed over time (P < 0.001) and significantly more were achieving the PA guidelines (P < 0.01) compared to those who were not depressed at baseline.

CONCLUSIONS

The Back on Track telehealth programme was effective in assisting with behavioural and emotional recovery after a cardiac event. The programme may be particularly beneficial for those who are depressed early in their recovery period.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12620000102976.

Psychological interventions aiming for changing dietary habits in patients with cardiovascular disease: A systematic review and meta-analysis

BACKGROUND

Diet is a critical component of healthy lifestyle, especially in cardiac rehabilitation. Psychological interventions, as well as mix-treatment interventions, such as psychological components, appear promising approaches in the adoption and maintenance of a healthy diet in patients with cardiovascular disease (CVD). Given the variety of clinical intervention programmes available, we aimed to determine whether psychological interventions and interventions that incorporate psychological components provide better lifestyle outcomes than traditional care, specifically targeting dietary outcomes, and what types of psychological or mix-treatment interventions are more likely to benefit patients with CVD.

METHODS

A systematic literature search was performed using MEDLINE (PubMed), Scopus, Cochrane Library and PsycINFO to identify interventional studies, published from 2012 to 2022, written in English, evaluating psychological and mix-treatment intervention programmes for dietary outcomes in patients with CVD. In total, 33 intervention studies (n = 5644 patients) were retrieved and analysed using fixed and random effects models.

RESULTS

No significant effect of the psychological intervention was observed regarding fruit and vegetable intake (Hedge's g = +1.06, p = 0.766), whereas a significant reduction was observed in alcoholic beverage consumption in the intervention group, as compared to the control group (Hedge's g = -7.33, p < 0.001). However, based on both our qualitative and quantitative analyses, psychological and mix-treatment interventions were more effective than traditional models in dietary modification. Also, the majority of effective interventions were psychological over mixed-treatment interventions.

CONCLUSIONS

Findings add to the growing evidence suggesting that specific psychological interventions may be effective approaches in dietary modification for patients with CVD, potentially forming part of public health agenda.

Getting "Back on Track" After a Cardiac Event: Protocol for a Randomized Controlled Trial of a Web-Based Self-management Program

Background

After a cardiac event, a large majority of patients with cardiac conditions do not achieve recommended behavior change targets for secondary prevention. Mental health issues can also impact the ability to engage in health behavior change. There is a need for innovative, flexible, and theory-driven eHealth programs, which include evidence-based strategies to assist patients with cardiac conditions with their recovery, especially in behavioral and emotional self-management.

Objective

The aim of this study is to determine the short- and longer-term behavioral and emotional well-being outcomes of the Back on Track web-based self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counselor, over and above benefit obtained through completing the web-based program alone.

Methods

People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either “self-directed” completion of the Back on Track program (without assistance) or “supported” completion of the Back on Track program (additional 2 telephone sessions with a lifestyle counselor). All participants will have access to the web-based Back on Track program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2 and 6 weeks post enrollment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all 3 timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change, and self-efficacy in relation to behavioral and emotional self-management, quality of life, and self-rated health and well-being. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only.

Results

Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022, and data analysis and publication of results will be completed by June 2022. A total of 122 participants were enrolled in this study.

Conclusions

The Back on Track trial will enable us to quantify the behavioral and emotional improvements obtained and maintained for patients with cardiac conditions and, in particular, to compare two modes of delivery: (1) fully self-directed delivery and (2) supported by a lifestyle counselor. We anticipate that the web-based Back on Track program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible, and easily accessible adjunct to center-based rehabilitation programs.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000102976; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/34534

Retrospective Analysis and Forecasted Economic Impact of a Virtual Cardiac Rehabilitation Program in a Third-Party Payer Environment

Background: Participation in cardiac rehabilitation (CR) is recommended for all patients with coronary artery disease (CAD) following hospitalization for acute coronary syndrome or stenting. Yet, few patients participate due to the inconvenience and high cost of attending a facility-based program, factors which have been magnified during the ongoing COVID pandemic. Based on a retrospective analysis of CR utilization and cost in a third-party payer environment, we forecasted the potential clinical and economic benefits of delivering a home-based, virtual CR program, with the goal of guiding future implementation efforts to expand CR access. Methods: We performed a retrospective cohort study using insurance claims data from a large, third-party payer in the state of Pennsylvania. Primary diagnostic and procedural codes were used to identify patients admitted for CAD between October 1, 2016, and September 30, 2018. Rates of enrollment in facility-based CR, as well as all-cause and cardiovascular hospital readmission and associated costs, were calculated during the 12-months following discharge. Results: Only 37% of the 7,264 identified eligible insured patients enrolled in a facility-based CR program within 12 months, incurring a mean delivery cost of $2,922 per participating patient. The 12-month all-cause readmission rate among these patients was 24%, compared to 31% among patients who did not participate in CR. Furthermore, among those readmitted, CR patients were readmitted less frequently than non-CR patients within this time period. The average per-patient cost from hospital readmissions was $30,814 per annum. Based on these trends, we forecasted that adoption of virtual CR among patients who previously declined CR would result in an annual cost savings between $1 and $9 million in the third-party healthcare system from a combination of increased overall CR enrollment and fewer hospital readmissions among new HBCR participants. Conclusions: Among insured patients eligible for CR in a third-party payer environment, implementation of a home-based virtual CR program is forecasted to yield significant cost savings through a combination of increased CR participation and a consequent reduction in downstream healthcare utilization.

Effectiveness and equity evaluation of an insurance-wide telephone-counseling program for self-management of chronic diseases: The Health Coach Study

Trajectories of chronic illnesses depend on patient socioeconomic status (SES). This study examines main and equity effects (age, gender, education, region of residence) of a brief telephone self-management intervention on self-rated health and depressive symptoms of health insurance clients with chronic illnesses. Randomized invitation design (n = 2628) with predominantly male (82%) older individuals (modal age = 65-74) with one or more chronic illnesses. Primary outcomes: Self-rated health and depressive symptoms. Intervention: Brief CBT-based telephone counseling. Propensity score matching was used to equate intervention and control groups (n = 1314 pairs). Change score models were used to analyze changes in health-related outcome measures. The intervention resulted in improvements in self-rated health (d = .37) and fewer depressive symptoms (d = .17) over 4 and 6 months. There were comparable effects across education and regions, but younger and female participants profited more from the intervention compared with older and male participants. A brief telephone-based intervention led to improved self-rated health and well-being in a large sample of participants with chronic health conditions. This effect was observed over and above regular medical care. The intervention was equitable with respect to education and region, but not age and gender.

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD.

SEARCH METHODS

We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease.

DATA COLLECTION AND ANALYSIS

We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point).  MAIN RESULTS: This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years. In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years). At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials;  NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes. At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials). At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials). Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias. There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs).

AUTHORS' CONCLUSIONS

This updated Cochrane Review supports the conclusions of the previous version, that exercise-based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all-cause mortality, and a large reduction in all-cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well-designed, adequately-reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer-term follow-up, and assess costs and cost-effectiveness.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1

BACKGROUND

Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases.

METHODS

The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation.

RESULTS

Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs.

CONCLUSIONS

These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

Combined lifestyle factors, all-cause mortality and cardiovascular disease: a systematic review and meta-analysis of prospective cohort studies

INTRODUCTION

Unhealthy lifestyles caused a huge disease burden. Adopting healthy lifestyles is the most cost-effective strategy for preventing non-communicable diseases. The aim was to perform a systematic review and meta-analysis to quantify the relationship of combined lifestyle factors (eg, cigarette smoking, alcohol consumption, physical activity, diet and overweight/obesity) with the risk of all-cause mortality, cardiovascular mortality and incident cardiovascular disease (CVD).

METHODS

PubMed and EMBASE were searched from inception to April 2019. Cohort studies investigating the association between the combination of at least three lifestyle factors and all-cause mortality, cardiovascular mortality or incidence of CVD were filtered by consensus among reviewers. Pairs of reviewers independently extracted data and evaluated study quality. Random-effects models were used to pool HRs. Heterogeneity and publication bias were tested.

RESULTS

In total, 142 studies were included. Compared with the participants with the least-healthy lifestyles, those with the healthiest lifestyles had lower risks of all-cause mortality (HR=0.45, 95% CI 0.41 to 0.48, 74 studies with 2 584 766 participants), cardiovascular mortality (HR=0.42, 95% CI 0.37 to 0.46, 41 studies with 1 743 530 participants), incident CVD (HR=0.38, 95% CI 0.29 to 0.51, 22 studies with 754 894 participants) and multiple subtypes of CVDs (HRs ranging from 0.29 to 0.45). The associations were largely significant and consistent among individuals from different continents, racial groups and socioeconomic backgrounds.

CONCLUSIONS

Given the great health benefits, comprehensively tackling multiple lifestyle risk factors should be the cornerstone for reducing the global disease burden.

Interventions to increase the pharmacological adherence on arterial hypertension in Latin America: a systematic review

OBJECTIVES

This review aims to summarize evidence on the effectiveness of interventions to improve antihypertensive drug adherence in Latin America and the Caribbean.

METHODS

A systematic search from January 2000 to October 2018 was conducted through LILACS, SciELO, MEDLINE, Health Evidence, Cochrane Library and Embase. Search terms were in English, Portuguese and Spanish through the MeSH and DECS.

RESULTS

Seven articles were included in the study. The main discoveries indicate that implemented interventions to increase the adherence are very varied. Likewise, a high variability in levels of adherence was found (46-94%) and we could evidence that indirect measurements were used. Lastly, it was evidenced that the obstacles for adherence were mainly associated with the adverse effects of antihypertensive medication, the dosage and forgetfulness of the medication intake given the age of the patients.

CONCLUSIONS

There is no single strategy to increase pharmacological adherence in Latin America since the studies used different strategies. Additional efforts are required to standardize cost-effective interventions to increase pharmacological adherence in Latin America.

Effects of Exercise-Based Cardiac Rehabilitation in Patients with Acute Coronary Syndrome: A Meta-Analysis

BACKGROUND Acute coronary syndrome (ACS) has become an important cause of death from cardiovascular disease. Cardiac rehabilitation (CR) plays an essential role in ACS patients after treatment. Therefore, in order to detect the impact of CR on mortality and major adverse cardiac events in patients with ACS, we conducted this meta-analysis. MATERIAL AND METHODS We searched PubMed, Web of science, and EMBASE databases to obtain published research results from 2010 to August 2018 to determine the relevant research. Random-effects model or fixed-effects model were used to calculate relative risk (RR) and 95% confidence interval (CI). RESULTS Overall, a total of 25 studies with 55 035 participants were summarized in our meta-analysis. The results indicated that the hazard ratio (HR) of mortality significantly lower in the CR group than in the non-CR group (HR=-0.47; 95% CI=(-0.56 to -0.39; P<0.05). Fourteen studies on mortality rate showed exercise was associated with reduced cardiac death rates (RR=0.40; 95% CI=0.30 to 0.53; P<0.05). We found the risk of major adverse cardiac events (MACE) was lower in the rehabilitation group (RR=0.49; 95% CI=0.44 to 0.55; P<0.05). In 11 articles on CR including 8098 participants, the benefit in the CR group was greater than in the control group concerning revascularization (RR=0.69, 95% CI: 0.53 to 0.88; P=0.003). The recurrence rate of MI was reported in 13 studies, and the risk was lower in the CR group (RR=0.63, 95% CI: 0.57-0.70; P<0.05). CONCLUSIONS Our meta-analysis results suggest that CR is clearly associated with reductions in cardiac mortality, recurrence of MI, repeated PCI, CABG, and restenosis.

Lifestyle determinants of behavioural outcomes triggered by direct-to-consumer advertising of prescription medicines: a cross-sectional study

OBJECTIVE

Direct-to-consumer advertising of prescription medicines encourages individuals to search for or request advertised medicines, can stimulate taking medications rather than making lifestyle behaviour changes, and may target individuals with poorer demographic and socioeconomic status and riskier health-related behaviours. This study thus explored whether responses to medicine advertising vary as a function of lifestyle behaviours, and demographic and socioeconomic factors.

METHODS

Data were collected through an online survey of a nationally representative sample of 2,057 adults in New Zealand. Multivariate binary logistic regressions were used to explore whether lifestyle behaviours, including nutritional habits, alcohol consumption, illegal drug consumption, physical activity, attitudes towards doing exercise, as well as demographic and socioeconomic status were associated with self-reported behavioural responses to medicine advertising.

RESULTS

Individuals who had unhealthier lifestyle behaviours were more likely to respond to medicine advertising.

CONCLUSIONS

The findings raise concerns regarding the misuse or overuse of medications for diseases that may otherwise be improved by a healthier lifestyle. Implications for public health: To improve public health and wellbeing of society, we call for regulatory changes regarding advertising of medicines. Where applicable, lifestyle changes should be advertised as potential substitutes for the advertised medicines. Interprofessional collaboration is also recommended to educate individuals and convey the value of health behaviour changes.

The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression

BACKGROUND

While the clinical benefits of exercise-based cardiac rehabilitation are well established, there is extensive variation in the interventions used within these trials. It is unknown whether variations in individual components of these exercise interventions provide different relative contributions to overall clinical outcomes. This study aims to systematically examine the relationship between individual components of the exercise intervention in cardiac rehabilitation (such as intensity and frequency) and clinical outcomes for people with coronary heart disease.

METHODS

In this systematic review, eligible trials were identified via searches of databases (PubMed, Allied and Complementary Medicine, EMBASE, PEDro, Science Citation Index Expanded, CINAHL, The Cochrane Library, SPORTDiscus) from citation tracking and hand-searching. Studies were included if they were randomised trials of a structured exercise intervention (versus usual care) for participants with coronary heart disease and reported at least one of cardiovascular mortality, total mortality, myocardial infarction or revascularisation outcomes. Each included trial was assessed using the Cochrane Risk of Bias Tool. Authors were also contacted for missing intervention details or data. Random effects meta-analysis was performed to calculate a summary risk ratio (RR) with 95% confidence interval (CI) for the effect of exercise on outcomes. Random effects meta-regression and subgroup analyses were conducted to examine the association between pre-specified co-variates (exercise components or trial characteristics) and each clinical outcome.

RESULTS

Sixty-nine trials were included, evaluating 72 interventions which differed markedly in terms of exercise components. Exercise-based cardiac rehabilitation was effective in reducing cardiovascular mortality (RR 0.74, 95% CI 0.65 to 0.86), total mortality (RR 0.90, 95% CI 0.83 to 0.99) and myocardial infarction (RR 0.80, 95% CI 0.70 to 0.92). This effect generally demonstrated no significant differences across subgroups of patients who received various types of usual care, more or less than 150 min of exercise per week and of differing cardiac aetiologies. There was however some heterogeneity observed in the efficacy of cardiac rehabilitation in reducing total mortality based on the presence of lipid lowering therapy (I 2 = 48%, p = 0.15 for subgroup treatment interaction effect). No single exercise component was identified through meta-regression as a significant predictor of mortality outcomes, although reductions in both total (RR 0.81, p = 0.042) and cardiovascular mortality (RR 0.72, p = 0.045) were observed in trials which reported high levels of participant exercise adherence, versus those which reported lower levels. A dose-response relationship was found between an increasing exercise session time and increasing risk of myocardial infarction (RR 1.01, p = 0.011) and the highest intensity of exercise prescribed and an increasing risk of percutaneous coronary intervention (RR 1.05, p = 0.047).

CONCLUSIONS

Exercise-based cardiac rehabilitation is effective at reducing important clinical outcomes in patients with coronary heart disease. While our analysis was constrained by the quality of included trials and missing information about intervention components, there appears to be little differential effect of variations in exercise intervention, particularly on mortality outcomes. Given the observed effect between higher adherence and improved outcomes, it may be more important to provide exercise-based cardiac rehabilitation programs which focus on achieving increased adherence to the exercise intervention.

Patient education in the management of coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and improve prognosis. Cardiac rehabilitation is a complex multifaceted intervention which aims to improve the health outcomes of people with CHD. Cardiac rehabilitation consists of three core modalities: education, exercise training and psychological support. This is an update of a Cochrane systematic review previously published in 2011, which aims to investigate the specific impact of the educational component of cardiac rehabilitation.

OBJECTIVES

1. To assess the effects of patient education delivered as part of cardiac rehabilitation, compared with usual care on mortality, morbidity, health-related quality of life (HRQoL) and healthcare costs in patients with CHD.2. To explore the potential study level predictors of the effects of patient education in patients with CHD (e.g. individual versus group intervention, timing with respect to index cardiac event).

SEARCH METHODS

We updated searches from the previous Cochrane review, by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 6, 2016), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) in June 2016. Three trials registries, previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied.

SELECTION CRITERIA

1. Randomised controlled trials (RCTs) where the primary interventional intent was education delivered as part of cardiac rehabilitation.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with a diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on the above inclusion criteria. One author extracted study characteristics from the included trials and assessed their risk of bias; a second review author checked data. Two independent reviewers extracted outcome data onto a standardised collection form. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. Heterogeneity amongst included studies was explored qualitatively and quantitatively. Where appropriate and possible, results from included studies were combined for each outcome to give an overall estimate of treatment effect. Given the degree of clinical heterogeneity seen in participant selection, interventions and comparators across studies, we decided it was appropriate to pool studies using random-effects modelling. We planned to undertake subgroup analysis and stratified meta-analysis, sensitivity analysis and meta-regression to examine potential treatment effect modifiers. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of the evidence and the GRADE profiler (GRADEpro GDT) to create summary of findings tables.

MAIN RESULTS

This updated review included a total of 22 trials which randomised 76,864 people with CHD to an education intervention or a 'no education' comparator. Nine new trials (8215 people) were included for this update. We judged most included studies as low risk of bias across most domains. Educational 'dose' ranged from one 40 minute face-to-face session plus a 15 minute follow-up call, to a four-week residential stay with 11 months of follow-up sessions. Control groups received usual medical care, typically consisting of referral to an outpatient cardiologist, primary care physician, or both.We found evidence of no difference in effect of education-based interventions on total mortality (13 studies, 10,075 participants; 189/5187 (3.6%) versus 222/4888 (4.6%); random effects risk ratio (RR) 0.80, 95% CI 0.60 to 1.05; moderate quality evidence). Individual causes of mortality were reported rarely, and we were unable to report separate results for cardiovascular mortality or non-cardiovascular mortality. There was evidence of no difference in effect of education-based interventions on fatal and/or non fatal myocardial infarction (MI) (2 studies, 209 participants; 7/107 (6.5%) versus 12/102 (11.8%); random effects RR 0.63, 95% CI 0.26 to 1.48; very low quality of evidence). However, there was some evidence of a reduction with education in fatal and/or non-fatal cardiovascular events (2 studies, 310 studies; 21/152 (13.8%) versus 61/158 (38.6%); random effects RR 0.36, 95% CI 0.23 to 0.56; low quality evidence). There was evidence of no difference in effect of education on the rate of total revascularisations (3 studies, 456 participants; 5/228 (2.2%) versus 8/228 (3.5%); random effects RR 0.58, 95% CI 0.19 to 1.71; very low quality evidence) or hospitalisations (5 studies, 14,849 participants; 656/10048 (6.5%) versus 381/4801 (7.9%); random effects RR 0.93, 95% CI 0.71 to 1.21; very low quality evidence). There was evidence of no difference between groups for all cause withdrawal (17 studies, 10,972 participants; 525/5632 (9.3%) versus 493/5340 (9.2%); random effects RR 1.04, 95% CI 0.88 to 1.22; low quality evidence). Although some health-related quality of life (HRQoL) domain scores were higher with education, there was no consistent evidence of superiority across all domains.

AUTHORS' CONCLUSIONS

We found no reduction in total mortality, in people who received education delivered as part of cardiac rehabilitation, compared to people in control groups (moderate quality evidence). There were no improvements in fatal or non fatal MI, total revascularisations or hospitalisations, with education. There was some evidence of a reduction in fatal and/or non-fatal cardiovascular events with education, but this was based on only two studies. There was also some evidence to suggest that education-based interventions may improve HRQoL. Our findings are supportive of current national and international clinical guidelines that cardiac rehabilitation for people with CHD should be comprehensive and include educational interventions together with exercise and psychological therapy. Further definitive research into education interventions for people with CHD is needed.

Psychological interventions for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

SEARCH METHODS

We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

MAIN RESULTS

This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

AUTHORS' CONCLUSIONS

This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with usual care on mortality, morbidity and HRQL in patients with CHD.To explore the potential study level predictors of the effectiveness of exercise-based CR in patients with CHD.

SEARCH METHODS

We updated searches from the previous Cochrane review, by searching Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 6, 2014) from December 2009 to July 2014. We also searched MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and Science Citation Index Expanded (December 2009 to July 2014).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with a no exercise control. The study population comprised men and women of all ages who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or who have angina pectoris, or coronary artery disease. We included RCTs that reported at least one of the following outcomes: mortality, MI, revascularisations, hospitalisations, health-related quality of life (HRQL), or costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on the above inclusion and exclusion criteria. One author extracted data from the included trials and assessed their risk of bias; a second review author checked data. We stratified meta-analysis by the duration of follow up of trials, i.e. short-term: 6 to 12 months, medium-term: 13 to 36 months, and long-term: > 3 years.

MAIN RESULTS

This review included 63 trials which randomised 14,486 people with CHD. This latest update identified 16 new trials (3872 participants). The population included predominantly post-MI and post-revascularisation patients and the mean age of patients within the trials ranged from 47.5 to 71.0 years. Women accounted for fewer than 15% of the patients recruited. Overall trial reporting was poor, although there was evidence of an improvement in quality of reporting in more recent trials.As we found no significant difference in the impact of exercise-based CR on clinical outcomes across follow-up, we focused on reporting findings pooled across all trials at their longest follow-up (median 12 months). Exercise-based CR reduced cardiovascular mortality compared with no exercise control (27 trials; risk ratio (RR) 0.74, 95% CI 0.64 to 0.86). There was no reduction in total mortality with CR (47 trials, RR 0.96, 95% CI 0.88 to 1.04). The overall risk of hospital admissions was reduced with CR (15 trials; RR 0.82, 95% CI 0.70 to 0.96) but there was no significant impact on the risk of MI (36 trials; RR 0.90, 95% CI 0.79 to 1.04), CABG (29 trials; RR 0.96, 95% CI 0.80 to 1.16) or PCI (18 trials; RR 0.85, 95% CI 0.70 to 1.04).There was little evidence of statistical heterogeneity across trials for all event outcomes, and there was evidence of small study bias for MI and hospitalisation, but no other outcome. Predictors of clinical outcomes were examined across the longest follow-up of studies using univariate meta-regression. Results show that benefits in outcomes were independent of participants' CHD case mix (proportion of patients with MI), type of CR (exercise only vs comprehensive rehabilitation) dose of exercise, length of follow-up, trial publication date, setting (centre vs home-based), study location (continent), sample size or risk of bias.Given the heterogeneity in outcome measures and reporting methods, meta-analysis was not undertaken for HRQL. In five out of 20 trials reporting HRQL using validated measures, there was evidence of significant improvement in most or all of the sub-scales with exercise-based CR compared to control at follow-up. Four trial-based economic evaluation studies indicated exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years.The quality of the evidence for outcomes reported in the review was rated using the GRADE method. The quality of the evidence varied widely by outcome and ranged from low to moderate.

AUTHORS' CONCLUSIONS

This updated Cochrane review supports the conclusions of the previous version of this review that, compared with no exercise control, exercise-based CR reduces the risk of cardiovascular mortality but not total mortality. We saw a significant reduction in the risk of hospitalisation with CR but not in the risk of MI or revascularisation. We identified further evidence supporting improved HRQL with exercise-based CR. More recent trials were more likely to be well reported and include older and female patients. However, the population studied in this review still consists predominantly of lower risk individuals following MI or revascularisation. Further well conducted RCTs are needed to assess the impact of exercise-based CR in higher risk CHD groups and also those presenting with stable angina. These trials should include validated HRQL outcome measures, explicitly report clinical event outcomes including mortality and hospital admissions, and assess costs and cost-effectiveness.

Mind-Body Medicine in the Secondary Prevention of Coronary Heart Disease

BACKGROUND

In mind-body medicine (MBM), conventional lifestyle modification measures such as dietary counseling and exercise are supplemented with relaxation techniques and psychological motivational elements. This review studied the effect of MBM on cardiac events and mortality in patients with coronary heart disease (CHD).

METHODS

This review is based on publications up to and including January 2015 that were retrieved by a systematic search in PubMed, the Cochrane Library, and Scopus. Randomized controlled trials of the effect of MBM programs (versus standard treatment) on cardiac events, overall mortality, and/or cardiac mortality were analyzed. Atherosclerosis, blood pressure, LDL cholesterol, and the body mass index (BMI) were chosen as secondary outcomes. Random-effects meta-analyses were performed. The risk of bias was assessed with the Cochrane tool.

RESULTS

Twelve trials, performed on a total of 1085 patients, were included in the analysis. Significant differences between groups were found with respect to cardiac events (odds ratio [OR]: 0.38; 95% confidence interval [CI]: 0.23-0.61; p<0.01; heterogeneity [I2]: 0%), but not overall mortality (OR: 0.82; 95% CI: 0.46-1.45; p = 0.49; I2: 0%) or cardiac mortality (OR: 0.98; 95% CI: 0.43-2.25; p = 0.97; I2: 0%). Significant differences between groups were also found with respect to atherosclerosis (mean difference [MD] = -7.86% diameter stenosis; 95% CI: -15.06-[-0.65]; p = 0.03; I2: 0%) and systolic blood pressure (MD = -3.33 mm Hg; 95% CI: -5.76-[-0.91]; p<0.01; I2: 0%), but not with respect to diastolic blood pressure, LDL cholesterol, or BMI.

CONCLUSION

In patients with CHD, MBM programs can lessen the occurrence of cardiac events, reduce atherosclerosis, and lower systolic blood pressure, but they do not reduce mortality. They can be used as a complement to conventional rehabilitation programs.

Use of Nutrition Standards to Improve Nutritional Quality of Hospital Patient Meals: Findings from New York City's Healthy Hospital Food Initiative

BACKGROUND

Most hospital patient meals are considered regular-diet meals; these meals are not required to meet comprehensive nutrition standards for a healthy diet. Although programs exist to improve nutrition in hospital food, the focus is on retail settings such as vending machines and cafeterias vs patient meals. New York City's Healthy Hospital Food Initiative (HHFI) provides nutrition standards for regular-diet meals that hospitals can adopt, in addition to retail standards.

OBJECTIVE

This study was undertaken to describe regular-diet patient menus before and after implementation of the HHFI nutrition standards.

DESIGN

The study involved pre- and post- menu change analyses of hospitals participating in the HHFI between 2010 and 2014.

PARTICIPANTS/SETTING

Eight New York City hospitals, selected based on voluntary participation in the HHFI, were included in the analyses.

MAIN OUTCOME MEASURES

Nutritional content of regular-diet menus were compared with the HHFI nutrition standards.

STATISTICAL ANALYSES PERFORMED

Nutrient analysis and exact Wilcoxon signed-rank tests were used for the analysis of the data.

RESULTS

At baseline, no regular-diet menu met all HHFI standards, and most exceeded the daily limits for percentage of calories from fat (n=5), percentage of calories from saturated fat (n=5), and milligrams of sodium (n=6), and they did not meet the minimum grams of fiber (n=7). Hospitals met all key nutrient standards after implementation, increasing fiber (25%, P<0.01) and decreasing sodium (-19%, P<0.05), percentage of calories from fat (-24%, P<0.01), and percentage of calories from saturated fat (-21%, P<0.05). A significant increase was seen in fresh fruit servings (667%, P<0.05) and decreases in full-fat and reduced-fat milk servings (-100%, P<0.05), refined grain servings (-35%, P<0.05), and frequency of desserts (-92%, P<0.05).

CONCLUSIONS

Regular diet menus did not comply with the HHFI nutrition standards at baseline. Using the HHFI framework, hospitals significantly improved the nutritional quality of regular-diet patient menus. The standards were applied across hospitals of varying sizes, locations, menu types, and food service operations, indicating feasibility of this framework in a range of hospital settings.

Efficiency of rehabilitation after acute myocardial infarction

The purpose of this study was to evaluate the recurrence rate and medical expenses of acute myocardial infarction (AMI) following inpatient cardiac rehabilitation. A total of 834 patients with AMI were divided into Group 1 (with inpatient cardiac rehabilitation) and Group 2 (without inpatient cardiac rehabilitation). The results showed that Group 1 had a lower AMI recurrence rate (a 0.640-fold lower hazards ratio) than Group 2 [95% confidence interval (CI) = 0.197-1.863; p = 0.004]. Compared with the medical costs of Group 2, Group 1 also had lower medical costs (a 0.947-fold lower hazards ratio) than Group 2 (95% CI = 0.934-0.981; p = 0.042). These findings have implications for the decision making of clinicians and health policymakers attempting to provide adequate services for patients with AMI.

When it comes to lifestyle recommendations, more is sometimes less: a meta-analysis of theoretical assumptions underlying the effectiveness of interventions promoting multiple behavior domain change

A meta-analysis of 150 research reports summarizing the results of multiple behavior domain interventions examined theoretical predictions about the effects of the included number of recommendations on behavioral and clinical change in the domains of smoking, diet, and physical activity. The meta-analysis yielded 3 main conclusions. First, there is a curvilinear relation between the number of behavioral recommendations and improvements in behavioral and clinical measures, with a moderate number of recommendations producing the highest level of change. A moderate number of recommendations is likely to be associated with stronger effects because the intervention ensures the necessary level of motivation to implement the recommended changes, thereby increasing compliance with the goals set by the intervention, without making the intervention excessively demanding. Second, this curve was more pronounced when samples were likely to have low motivation to change, such as when interventions were delivered to nonpatient (vs. patient) populations, were implemented in nonclinic (vs. clinic) settings, used lay community (vs. expert) facilitators, and involved group (vs. individual) delivery formats. Finally, change in behavioral outcomes mediated the effects of number of recommended behaviors on clinical change. These findings provide important insights that can help guide the design of effective multiple behavior domain interventions.

Reduction in 2-year recurrent risk score and improved behavioral outcomes after participation in the "Beating Heart Problems" self-management program: results of a randomized controlled trial

PURPOSE

While behavior change can improve risk factor profiles and prognosis after an acute cardiac event, patients need assistance to achieve sustained lifestyle changes. We developed the "Beating Heart Problems" cognitive-behavioral therapy and motivational interviewing program to support patients to develop behavioral and cognitive self-management skills. We report the results of a randomized controlled trial of the program.

METHODS

Patients (n = 275) consecutively admitted to 2 Melbourne hospitals after acute myocardial infarction (32%), coronary artery bypass graft surgery (40%), or percutaneous coronary intervention (28%) were randomized to treatment (T; n = 139) or control (C; n = 136). T group patients were invited to participate in the 8-week group-based program. Patients underwent risk factor screening 6 weeks after hospital discharge (before randomization) and again 4 and 12 months later. At both the followups, T and C groups were compared on 2-year risk of a recurrent cardiac event and key behavioral outcomes, using both intention-to-treat and "completers only" analyses.

RESULTS

Patients ranged in age from 32 to 75 years (mean = 59.0 years; SD - 9.1 years). Most patients (86%) were men. Compared with the C group patients, T group patients tended toward greater reduction in 2-year risk, at both the 4- and 12-month followups. Significant benefits in dietary fat intake and functional capacity were also evident.

CONCLUSIONS

The "Beating Heart Problems" program showed modest but important benefit over usual care at 4 and, to a lesser extent, 12 months. Modifications to the program such as the inclusion of booster sessions and translation to online delivery are likely to improve outcomes.

Development of a behaviour change communication tool for medical students: the 'Tent Pegs' booklet

OBJECTIVE

To describe the development and validation of a behaviour change communication tool for medical students.

METHODS

Behaviour change techniques (BCTs) were identified within the literature and used to inform a communication tool to support medical students in discussing health-related behaviour change with patients. BCTs were organized into an accessible format for medical students (the 'Tent Pegs' booklet) and validated using discriminant content validity methods with 11 expert judges.

RESULTS

One-sample t-tests showed that judges reliably mapped BCTs onto six of the seven Tent Pegs domains (confidence rating means ranged from 4.0 to 5.1 out of 10, all p≤0.002). Only BCTs within the 'empowering people to change' domain were not significantly different from the value zero (mean confidence rating=1.2, p>0.05); these BCTs were most frequently allocated to the 'addressing thoughts and emotions' domain instead.

CONCLUSION

BCTs within the Tent Pegs booklet are reliably allocated to corresponding behaviour change domains with the exception of those within the 'empowering people to change' domain.

PRACTICE IMPLICATIONS

The existing evidence-base on BCTs can be used to directly inform development of a communication tool to support medical students facilitate health behaviour change with patients.

Effects of a psychoeducational intervention for secondary prevention in Korean patients with coronary artery disease: a pilot study

This intervention study was designed to examine whether a 12-week psychoeducational intervention influenced recurrent cardiac events, symptom experience and treatment adherence of patients with coronary artery disease. Fifty-eight patients were randomized to either the intervention or the control group. Measures were taken at baseline, after intervention, and at 6-month follow-up. Recurrent cardiac events included revascularization, rehospitalization, emergency room visits and mortality. Symptom experiences were measured using the Seattle Angina Questionnaire-Korean and Hospital Anxiety and Depression Scale. Treatment adherence included health behaviours, routine check-up and medication adherence. At 6-month follow-up, the intervention group had significantly better physical functions and lower anxiety and depressive symptoms. Treatment adherence was also significantly higher in the intervention group than the control group. No significant difference was noticed in the incidence of recurrent cardiac events between the groups. A longer follow-up study is needed to determine the long-term effects on the prevention of recurrent cardiac events.

Effectiveness of health education programs on exercise behavior among patients with heart disease: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Regular exercise has been shown to be beneficial to patients with heart disease. Previous studies have indicated that health education can effectively increase participants' physical activity. However, no systematic review was conducted to evaluate the effectiveness of health education programs on changing exercise behavior among patients with heart disease. The aim of this study was to examine the effectiveness of health education programs on exercise behavior among heart disease patients.

METHOD

Potential studies were retrieved in the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMbase, PsycINFO, the British Nursing Index and Archive, Science Direct, and ERIC via EBSCOhost. Meta-analysis was done using the random-effect model.

RESULTS

Thirty-seven studies were identified. Only 12 studies delivered health education based on various theories/models. Twenty-eight studies were included in the meta-analyses. The results showed that health education had significantly positive effects on exercise adherence (risk ratio = 1.35 to 1.48), exercise duration (SMD = 0.25 to 0.69), exercise frequency (MD = 0.54 to 1.46 session/week), and exercise level (SMD = 0.25), while no significant effects were found on exercise energy expenditure and cognitive exercise behavior.

CONCLUSION

Health education has overall positive effects on changing exercise behavior among heart disease patients. Few theoretical underpinning studies were conducted for changing exercise behavior among heart disease patients. The findings suggest that health education improves exercise behavior for heart disease patients. Health professionals should reinforce health education programs for them.

Telephone-based health coaching for chronically ill patients: study protocol for a randomized controlled trial

Background

The rising prevalence of chronic conditions constitutes a major burden for patients and healthcare systems and is predicted to increase in the upcoming decades. Improving the self-management skills of patients is a strategy to steer against this burden. This could lead to better outcomes and lower healthcare costs. Health coaching is one method for enhancing the self-management of patients and can be delivered by phone. The effects of telephone-based health coaching are promising, but still inconclusive. Economic evaluations and studies examining the transferability of effects to different healthcare systems are still rare. Aim of this study is to evaluate telephone-based health coaching for chronically ill patients in Germany.

Methods/Design

The study is a prospective randomized controlled trial comparing the effects of telephone-based health coaching with usual care during a 4-year time period. Data are collected at baseline and after 12, 24 and 36 months. Patients are selected based on one of the following chronic conditions: diabetes, coronary artery disease, asthma, hypertension, heart failure, COPD, chronic depression or schizophrenia. The health coaching intervention is carried out by trained nurses employed by a German statutory health insurance. The frequency and the topics of the health coaching are manual-based but tailored to the patients’ needs and medical condition, following the concepts of motivational interviewing, shared decision-making and evidence-based-medicine. Approximately 12,000 insurants will be enrolled and randomized into intervention and control groups. Primary outcome is the time until hospital readmission within two years after enrolling in the health coaching, assessed by routine data. Secondary outcomes are patient-reported outcomes like changes in quality of life, depression and anxiety and clinical values assessed with questionnaires. Additional secondary outcomes are further economic evaluations like health service use as well as costs and hospital readmission rates. The statistical analyses includes intention-to-treat and as-treated principles. The recruitment will be completed in September 2014.

Discussion

This study will provide evidence regarding economic and clinical effects of telephone-delivered health coaching. Additionally, this study will show whether health coaching is an adequate option for the German healthcare system to address the growing burden of chronic diseases.

Trial registration

German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS) DRKS00000584.

Validation of persuasive messages for the promotion of physical activity among people with coronary heart disease

OBJECTIVE

to validate the content of persuasive messages for promoting walking among patients with coronary heart disease (CHD). The messages were constructed to strengthen or change patients' attitudes to walking.

METHOD

the selection of persuasive arguments was based on behavioral beliefs (determinants of attitude) related to walking. The messages were constructed based in the Elaboration Likelihood Model and were submitted to content validation.

RESULTS

the data was analyzed with the content validity index and by the importance which the patients attributed to the messages' persuasive arguments. Positive behavioral beliefs (i.e. positive and negative reinforcement) and self-efficacy were the appeals which the patients considered important. The messages with validation evidence will be tested in an intervention study for the promotion of the practice of physical activity among patients with CHD.

Efficacy of multifactorial lifestyle interventions in patients with established cardiovascular diseases and high risk groups

BACKGROUND

Lifestyle modification is recommended for patients with established cardiovascular diseases (CVD) or at high risk of CVD. In recent years, risk factor interventions in which multiple risk factors are addressed simultaneously are increasingly conducted.

AIM

To determine, and if possible quantify, the efficacy of multifactorial lifestyle interventions (without drug therapy) in patients with established CVD or in high risk groups.

METHODS

A literature search was conducted using 'Pubmed', to identify articles of randomized controlled trials (RCTs) or reviews of RCTs, published between 1990 and 2007.

RESULTS

In patients with established CVD, multifactorial lifestyle interventions can reduce the occurrence of cardiovascular diseases and/or mortality, even many years after the end of the intervention. Further, in both patients and high risk groups, multifactorial lifestyle interventions have favorable effects on biological risk factors and lifestyle and are able to reduce the incidence of diabetes. In the long-term, in particular lifestyle changes seem to persist, such as improved dietary habits and increased physical activity, while the favorable effects on biological risk factors, such as body weight and blood pressure, are no longer different from the control group. Regular contact with the participants seems to be part of the "success factor".

CONCLUSION

It can be recommended to offer patients with established CVD as well as individuals at high risk of CVD a comprehensive lifestyle advice, as part of their medical treatment, combined with intensive counseling.

Effect of patient education in the management of coronary heart disease: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

To assess the effects of patient education on mortality, morbidity, health-related quality of life (HRQoL), and healthcare costs in people with coronary heart disease (CHD).

DESIGN

Systematic review and meta-analysis.

METHODS

Data sources were Cochrane Library, Medline, Embase, PsycINFO, CINAHL, and ongoing trial registries until August 2010. We also checked study references. The study selection was based on design (randomized controlled trials with follow up of at least 6 months, published from 1990 onwards), population (adults with CHD), intervention (patient education stated to be the primary intervention), and comparators (usual care or no educational intervention).

RESULTS

Thirteen studies (68,556 people with CHD) were included. Educational interventions ranged from two visits to a 4-week residential stay with 11 months of reinforcement sessions. Compared to no educational intervention, there was weak evidence that education reduced all-cause mortality (pooled relative risk (RR) 0.79, 95% CI 0.55 to 1.13) and cardiac morbidity outcomes: myocardial infarction (pooled RR 0.63, 95% CI 0.26 to 1.48), revascularization (pooled RR 0.58, 95% CI 0.19 to 1.71), and hospitalization (pooled RR 0.83, 95% CI 0.65 to 1.07) at median 18-months follow up. There was evidence to suggest that education can improve HRQoL and decrease healthcare costs by reductions in downstream healthcare utilization.

CONCLUSIONS

Our review had insufficient power to exclude clinically important effects of education on mortality and morbidity. Nevertheless it supports the practice of CHD secondary prevention and rehabilitation programmes including education as an intervention. Further research is needed to determine the most effective and cost-effective format, duration, timing, and methods of education delivery.

Randomized controlled trial on the long-term efficacy of a multifaceted, interdisciplinary lifestyle intervention in reducing cardiovascular risk and improving lifestyle in patients at risk of cardiovascular disease

The objective of the study was to evaluate the efficacy of an interdisciplinary intervention known as Educoeur in reducing cardiovascular risk and improving health behaviors in people without evidence of cardiovascular disease and to compare the Educoeur program to interventions in a specialized clinic and in usual care family practice. In a parallel, randomized, controlled trial of 185 adults with at least two modifiable cardiovascular risk factors, patients were randomly assigned to either Educoeur, specialized clinic or usual care. Cardiovascular risk, biological and lifestyle measures were assessed at baseline and at 2 years. In Educoeur, measurements were also taken before and after the lifestyle group treatment program. In 12 weeks, patients in Educoeur significantly lowered their cardiovascular risk, weight, body mass index, waist circumference, systolic blood pressure, kilocalories intake and improved their VO2 Max and mental health. Changes remained significant at 2 years. Between group comparisons at 2 years demonstrated that Educoeur was significantly better in reducing cardiovascular risk than interventions in usual care. Together, these results highlight the importance of providing interdisciplinary programs that optimize cardiovascular risk reduction and promote active lifestyles in patients at risk of cardiovascular disease.

Beyond resolutions? A randomized controlled trial of a self-regulation lifestyle programme for post-cardiac rehabilitation patients

BACKGROUND

As lifestyle adherence and risk factor management following completion of cardiac rehabilitation (CR) have been shown to be problematic, we developed a brief self-regulation lifestyle programme for post-CR patients.

DESIGN

Randomized-controlled trial.

METHODS

Following completion of CR 210 patients were randomized to receive either a lifestyle maintenance programme (n = 112) or standard care (n = 98). The programme was based on self-regulation principles and consisted of a motivational interview, seven group sessions, and home assignments. Risk factors and health behaviours were assessed at baseline (end of CR) and 6 months thereafter.

RESULTS

ANCOVAs showed a significant effect of the lifestyle programme after 6 months on blood pressure, waist circumference, and exercise behaviour.

CONCLUSION

This trial indicates that a relatively brief intervention based on self-regulation theory is capable of instigating and maintaining beneficial changes in lifestyle and risk factors after CR.

Psychoeducational rehabilitation for health behavior change in coronary artery disease: a systematic review of controlled trials

PURPOSE

Psychoeducation is a recommended component of cardiac rehabilitation, but to date, evidence from high quality trials examining behavior change has not been synthesized. The primary aim of this systematic review was to examine the effectiveness of psychoeducation on behavior change in adults with coronary artery disease participating in cardiac rehabilitation; and to identify if changes in health behavior had an effect on modifiable physiological risk factors.

METHODS

A search of electronic databases was conducted for randomized controlled trials involving adults with a primary diagnosis of myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, stable angina, or coronary artery disease defined by angiography. Trials comparing psychoeducational programs to exercise only, standard cardiac rehabilitation or medical care were included. Primary outcomes were smoking status, physical activity, dietary habits, supplemental oxygen, or medication use. Included trials were assessed for quality with the PEDro scale, and data synthesized descriptively or with meta-analysis.

RESULTS

Six randomized controlled trials and 1 quasiexperimental trial were included, a total of 536 participants. A meta-analysis from 213 participants showed psychoeducational interventions produced a significant positive effect on physical activity levels over the medium term (6-12 months) when compared with exercise and risk factor education, (δ = .62, 95% CI 0.3-0.94). However, there was limited positive evidence for change in smoking and dietary behavior. No effect was found on physiological risk factors.

CONCLUSIONS

Psychoeducational interventions produce a significant positive effect on physical activity levels and potentially on dietary habits and smoking. Strategies such as goal setting, problem solving, self-monitoring, and role modeling appear to be influential in this change.

Patient education in the management of coronary heart disease

BACKGROUND

Cardiac rehabilitation (CR) is a complex multifaceted intervention consisting of three core modalities: education, exercise training and psychological support. Whilst exercise and psychological interventions for patients with coronary heart disease (CHD) have been the subject of Cochrane systematic reviews, the specific impact of the educational component of CR has not previously been investigated.

OBJECTIVES

1. Assess effects of patient education on mortality, morbidity, health-related quality of life (HRQofL) and healthcare costs in patients with CHD.2. Explore study level predictors of the effects of patient education (e.g. individual versus group intervention, timing with respect to index cardiac event).

SEARCH METHODS

The following databases were searched: The Cochrane Library, (CENTRAL, CDSR, DARE, HTA, NHSEED), MEDLINE (OVID), EMBASE (OVID), PsycINFO (EBSCOhost) and CINAHL (EBSCOhost). Previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied.

SELECTION CRITERIA

1. Randomised controlled trials (RCTs) where the primary interventional intent was education.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies and extracted data. Attempts were made to contact all study authors to obtain relevant information not available in the published manuscript. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. For continuous variables, mean differences and 95% CI were calculated for each outcome.

MAIN RESULTS

Thirteen RCTs involving 68,556 subjects with CHD and follow-up from six to 60 months were found. Overall, methodological quality of included studies was moderate to good. Educational 'dose' ranged from a total of two clinic visits to a four-week residential stay with 11 months of follow-up sessions. Control groups typically received usual medical care. There was no strong evidence of an effect of education on all-cause mortality (Relative Risk (RR): 0.79, 95% CI 0.55 to 1.13), cardiac morbidity (subsequent myocardial infarction RR: 0.63, 95% CI 0.26 to 1.48, revascularisation RR: 0.58, 95% CI 0.19 to 1.71) or hospitalisation (RR: 0.83, 95% CI:0.65 to 1.07). Whilst some HRQofL domain scores were higher with education, there was no consistent evidence of superiority across all domains. Different currencies and years studies were performed making direct comparison of healthcare costs challenging, although there is evidence to suggest education may be cost-saving by reducing subsequent healthcare utilisation.This review had insufficient power to exclude clinically important effects of education on mortality and morbidity of patients with CHD.

AUTHORS' CONCLUSIONS

We did not find strong evidence that education reduced all cause mortality, cardiac morbidity, revascularisation or hospitalisation compared to control. There was some evidence to suggest that education may improve HRQofL and reduce overall healthcare costs. Whilst our findings are generally supportive of current guidelines that CR should include not only exercise and psychological interventions, further research into education is needed.

Evidence of improved shooting precision in biathlon after 10 weeks of combined relaxation and specific shooting training

The aim of this study was to test the hypothesis that a combined relaxation (applied tension release, ATR) and specific shooting training regimen may enhance shooting ability of biathlon athletes. Seven biathletes of high national level were randomized into an experimental group (age 20 ± 5 years; Vo2max 60 ± 8 mL kg(-1) min(-1)) and were asked to add this special training intervention to their regular training for 10 weeks, while five other biathletes served as controls (age 19 ± 2 years; Vo2max 57 ± 10 mL kg(-1) min(-1)). The shooting ability of the subjects was assessed before and after the intervention at rest and after roller skiing on a treadmill in a laboratory-based competition simulating assessment. After the intervention period, the experimental group demonstrated a significantly enhanced shooting performance compared to the control group. No changes in Vo2max or in heart rate and Vo2 responses were observed before and after the intervention in either group and there were no differences between the groups in these parameters. Thus, the preliminary conclusion is that a combination of ATR and specific shooting training seems to be instrumental in enhancing the shooting performance in biathlon.

Psychological interventions for coronary heart disease

BACKGROUND

Psychological symptoms are strongly associated with coronary heart disease (CHD), and many psychological treatments are offered following cardiac events or procedures.

OBJECTIVES

Update the existing Cochrane review to (1) determine the independent effects of psychological interventions in patients with CHD (principal outcome measures included total or cardiac-related mortality, cardiac morbidity, depression, and anxiety) and (2) explore study-level predictors of the impact of these interventions.

SEARCH STRATEGY

The original review searched Cochrane Controleed Trials Register (CCTR, Issue 4, 2001), MEDLINE, EMBASE, PsycINFO, and CINAHL to December 2001. This was updated by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, PsycINFO and CINAHL from 2001 to January 2009. In addition, we searched reference lists of papers, and expert advice was sought for the original and update review.

SELECTION CRITERIA

Randomised controlled trials of psychological interventions compared to usual care, administered by trained staff. Only studies estimating the independent effect of the psychological component with a minimum follow-up of six months. Adults with specific diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Titles and abstracts of all references screened for eligibility by two reviewers independently; data extracted by the lead author and checked by a second reviewer. Authors contacted where possible to obtain missing information.

MAIN RESULTS

There was no strong evidence that psychological intervention reduced total deaths, risk of revascularisation, or non-fatal infarction. Amongst a smaller group of studies reporting cardiac mortality there was a modest positive effect of psychological intervention (relative risk: 0.80 (95% CI 0.64 to 1.00)). Furthermore, psychological intervention did result in small/moderate improvements in depression, standardised mean difference (SMD): -0.21 (95% CI -0.35, -0.08) and anxiety, SMD: -0.25 (95% CI -0.48 to -0.03). Results for mortality indicated some evidence of small-study bias, though results for other outcomes did not. Meta regression analyses revealed four significant predictors of intervention effects on depression were found: (1) an aim to treat type-A behaviours (ß = -0.32, p = 0.03) were more effective than other interventions. In contrast, interventions which (2) aimed to educate patients about cardiac risk factors (ß = 0.23, p = 0.03), (3) included client-led discussion and emotional support as core therapeutic components (ß = 0.31, p < 0.01), or (4) included family members in the treatment process (ß = 0.26, p < 0.01) were significantly less effective.

AUTHORS' CONCLUSIONS

Psychological treatments appear effective in treating psychological symptoms of CHD patients. Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

The burden of coronary heart disease (CHD) worldwide is one of great concern to patients and healthcare agencies alike. Exercise-based cardiac rehabilitation aims to restore patients with heart disease to health.

OBJECTIVES

To determine the effectiveness of exercise-based cardiac rehabilitation (exercise training alone or in combination with psychosocial or educational interventions) on mortality, morbidity and health-related quality of life of patients with CHD.

SEARCH STRATEGY

RCTs have been identified by searching CENTRAL, HTA, and DARE (using The Cochrane Library Issue 4, 2009), as well as MEDLINE (1950 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), and Science Citation Index Expanded (1900 to December 2009).

SELECTION CRITERIA

Men and women of all ages who have had myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA), or who have angina pectoris or coronary artery disease defined by angiography.

DATA COLLECTION AND ANALYSIS

Studies were selected and data extracted independently by two reviewers. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

This systematic review has allowed analysis of 47 studies randomising 10,794 patients to exercise-based cardiac rehabilitation or usual care. In medium to longer term (i.e. 12 or more months follow-up) exercise-based cardiac rehabilitation reduced overall and cardiovascular mortality [RR 0.87 (95% CI 0.75, 0.99) and 0.74 (95% CI 0.63, 0.87), respectively], and hospital admissions [RR 0.69 (95% CI 0.51, 0.93)] in the shorter term (< 12 months follow-up) with no evidence of heterogeneity of effect across trials. Cardiac rehabilitation did not reduce the risk of total MI, CABG or PTCA. Given both the heterogeneity in outcome measures and methods of reporting findings, a meta-analysis was not undertaken for health-related quality of life. In seven out of 10 trials reporting health-related quality of life using validated measures was there evidence of a significantly higher level of quality of life with exercise-based cardiac rehabilitation than usual care.

AUTHORS' CONCLUSIONS

Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality (in medium to longer term studies) and hospital admissions (in shorter term studies) but not total MI or revascularisation (CABG or PTCA). Despite inclusion of more recent trials, the population studied in this review is still predominantly male, middle aged and low risk. Therefore, well-designed, and adequately reported RCTs in groups of CHD patients more representative of usual clinical practice are still needed. These trials should include validated health-related quality of life outcome measures, need to explicitly report clinical events including hospital admission, and assess costs and cost-effectiveness.

Fears, feelings, and facts: interactively communicating benefits and risks of medical radiation with patients

OBJECTIVE

As public awareness of medical radiation exposure increases, there has been heightened awareness among patients and physicians of the importance of holistic benefit-and-risk discussions in shared medical decision making.

CONCLUSION

We examine the rationale for informed consent and risk communication, draw on the literature on the psychology of radiation risk communication to increase understanding, examine methods commonly used to communicate radiation risk, and suggest strategies for improving communication about medical radiation benefits and risk.

Effectiveness of small-group interactive education vs. lecture-based information-only programs on motivation to change and lifestyle behaviours. A prospective controlled trial of rehabilitation inpatients

OBJECTIVE

Although patient education may promote motivation to change health behaviours, the most effective method has not yet been determined.

METHODS

This prospective, controlled trial compared an interactive, patient-oriented group program with lectures providing only information. We evaluated motivational stages of change and self-reported behaviours in three domains (sports, diet, relaxation) at four times up to one year (60% complete data) among 753 German rehabilitation inpatients (mean age 50 years, 52% male) with orthopaedic (59%) or cardiologic disorders (10%) or diabetes mellitus (31%).

RESULTS

We found improvements between baseline and follow up regarding each outcome (p<.001) in both groups. At the end of rehabilitation, participants of the interactive group, as compared to the lectures, showed more advanced motivation regarding diet (p<.10) and sports (p=.006). Interactive group patients reported healthier diets both after 3 months (p=0.013) and 12 months (p=0.047), more relaxation behaviours (p=.029) after 3 months and higher motivation for sports after 12 months (p=.08).

CONCLUSIONS

The superior effectiveness of the interactive group was only partly confirmed.

PRACTICE IMPLICATIONS

This short, 5-session interactive program may not be superior to lectures to induce major sustainable changes in motivation.

Systematic review of the effect of diet and exercise lifestyle interventions in the secondary prevention of coronary heart disease

The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease (CHD) remains unclear. This systematic review aimed to determine their effectiveness and included randomized controlled trials of lifestyle interventions, in primary care or community settings, with a minimum follow-up of three months, published since 1990. 21 trials with 10,799 patients were included; the interventions were multifactorial (10), educational (4), psychological (3), dietary (1), organisational (2), and exercise (1). The overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes but no overall effect on smoking outcomes. In trials that examined mortality and morbidity, significant benefits were reported for total mortality (in 4 of 6 trials; overall risk ratio (RR) 0.75 (95% confidence intervals (CI) 0.65, 0.87)), cardiovascular mortality (3 of 8 trials; overall RR 0.63 (95% CI 0.47, 0.84)), and nonfatal cardiac events (5 of 9 trials; overall RR 0.68 (95% CI 0.55, 0.84)). The heterogeneity between trials and generally poor quality of trials make any concrete conclusions difficult. However, the beneficial effects observed in this review are encouraging and should stimulate further research.

Living with heart disease after angioplasty: A qualitative study of patients who have been successful or unsuccessful in multiple behavior change

OBJECTIVE

To document values, attitudes, and beliefs that influence behavior change among a diverse group of patients post-angioplasty.

METHODS

Purposive and maximum-variation sampling were used to assemble a demographically diverse patient cohort (N=61) who had been successful or unsuccessful at post-angioplasty multibehavior change. Semistructured interviews and grounded theory methods were used to collect and analyze qualitative data.

RESULTS

Themes showed the following: a) Patients reported surviving a life-threatening event and feared disease recurrence and death; b) the perception of a turning point and self-determination facilitated behavior change; c) social support and spiritual beliefs promoted coping with the uncertainty of living with heart disease; and d) unsuccessful behavior change was related to physical limitations, a sense that "nothing helps," and the belief that angioplasty "cures" heart disease.

CONCLUSION

Lifestyle interventions should be culturally relevant and adapted to physical abilities. Fostering self-determination and social support may promote successful behavior change.

Long-term effect of rehabilitation in coronary artery disease patients: randomized clinical trial of the impact of exercise volume

OBJECTIVE

To assess whether exercise volume during phase II rehabilitation affects long-term clinical benefits in patients with coronary artery disease.

DESIGN

Prospective randomized clinical trial with long-term follow-up.

SETTING

Hospital outpatient clinic.

SUBJECTS

Coronary artery disease patients (age 65 +/- 9 years, 82% males) attending a phase II rehabilitation programme were randomized into two groups of exercise volumes: 40- versus 60-minute training sessions. Patients exercised for three days per week for seven weeks, at 65% of baseline oxygen uptake capacity. Next, they were followed up for 18 months. Out of 165 patients with coronary artery disease who completed the exercise intervention, 119 attended the 18-month follow-up assessment.

MAIN MEASUREMENTS

Body anthropometrics, resting haemodynamics, blood lipid profile, glycaemia, and C-reactive protein level, smoking behaviour, habitual physical activity, cardiovascular disease incidence and mortality.

RESULTS

In total population, a significant worsening of various cardiovascular disease risk factors was found at 18 months follow-up (P<0.05), and few patients (27% of total group) adhered to the recommended minimal physical activity level. No difference in change of body anthropometrics, resting haemodynamics, blood lipid profile, glycaemia, and C-reactive protein level, and smoking behaviour was seen between different exercise volumes (P>0.05). In addition, total cardiovascular disease incidence (13% versus 22% in 40- versus 60-minute group, respectively) and habitual physical activity were not different between groups (P>0.05).

CONCLUSION

In patients with coronary artery disease following cardiac rehabilitation, the cardiovascular disease risk profile worsened significantly during long-term follow-up. A smaller exercise volume during phase II rehabilitation generated equal long-term clinical benefits compared to a greater exercise volume.