Lifestyle changes in secondary prevention of coronary heart disease: breaking the chains of unhealthy habits
R. J. G. Peters
) Department of Cardiology
Academic Medical Center, University of Amsterdam
, PO Box 22660, 1100 DD Amsterdam,
The management of patients with acute coronary complications
includes three components: short-term local therapy for
clinically significant coronary obstructions, cardiac
rehabilitation (CR) and long-term treatment of the underlying
atherosclerotic process. Of these, the last mentioned appears
to be the most challenging.
There is little question as to which factors should be
addressed to inhibit progression of the disease, and
guidelines on this topic are clear and consistent around the world.
Changing unhealthy lifestyles may lead to reductions in the
risk of mortality that are greater than the benefits of some of
the acute treatments for coronary disease . Unfortunately,
the success of these lifestyle changes in practice is limited. In
general, drug treatments and the achievement of their target
values are relatively adequate . However, the widely
recommended healthy lifestyles are frequently not achieved. In
a recent observation from 17 countries, nearly 1 in 5 individuals
continued to smoke, only 1 in 3 individuals reported high levels
of physical activity and 2 in 5 reported a healthy diet . As
these proportions are based on self reports, true numbers may in
fact be lower. Thus, a large gap exists between guidelines and
their implementation in reality. The causes for this discrepancy
are multiple and complex.
On the patients side, it is challenging to change habits that
have been in place for many decades, that are shared with their
partner and with their social environment, and that are generally
associated with short-term quality of life. In addition, the
concept of long-term prevention is complex: the sacrifices are
clear and instant whereas the rewards are uncertain and distant.
Some of the lifestyle changes may be costly to the patient, such
as healthy food choices and engaging in exercise.
On the physicians side, the short-term treatment of
coronary disease is rewarding, in medical, psychological and
financial terms, whereas the management of long-term risk
is less rewarding and not infrequently frustrating. In recent
years, the management of secondary prevention has
increasingly been transferred to paramedical personnel. Nurses,
physiotherapists and dieticians now play an important role,
particularly in addressing the lifestyle-related components.
Nonetheless, overall results are suboptimal and new
approaches are needed to promote healthy lifestyles and thus
achieve better outcomes.
The OPTICARE study is designed to test two strategies to
improve implementation of guideline-based secondary
prevention, in addition to a standard program of CR, in patients
with a recent coronary incident . In the COACH arm, a
previously explored approach of telephone coaching is
added, with five contacts in the first 6 months after hospital
discharge. Coaches are trained nurses in a single, central
facility who encourage the patients to adopt healthy lifestyles
and to adhere to their medication.
In the CAPRI arm, more group sessions are added to the
regular program, pedometers are issued to provide feedback
on activities and additional long-term sessions are included
in the first year after hospital discharge. In this study arm,
medications for low-density lipoprotein (LDL) and blood
pressure control are titrated to target levels by study personnel,
in collaboration with the treating physician.
The control group will receive CR as it is currently offered
(usual care). The primary outcome of the study is an
overall estimate of the 10-year risk of cardiovascular morbidity
and mortality, the Systematic Coronary Risk Evaluation
(SCORE) calculation. Secondary outcomes include risk factors
separately and clinical events. In addition, cost-effectiveness
will be analysed.
As outlined above, the OPTICARE study addresses a very
important subject, and if completed as planned may
contribute to real improvements in secondary prevention. The tested
interventions are widely applicable, if proven successful.
The goals of the study are ambitious and include
improvements in virtually all components of secondary prevention,
ranging from improved achievement of target values for LDL
cholesterol and blood pressure to improved physical activity
and cessation of smoking. Since self-reported outcome
measures may not be reliable, the outcomes of the study at
12 months follow-up are measured by objective assessments,
such as accelerometry and breath carbon monoxide.
In studies on long-term prevention, an overall
quantification of risk is the preferred outcome parameter. The primary
outcome of the OPTICARE study, the SCORE risk estimate,
is validated only in primary prevention. For secondary
prevention, no such risk function is available. In secondary
prevention, the absolute SCORE estimate is not a
meaningful metric. However, for comparisons among groups and
between baseline and 12-month outcome, SCORE can be
used as a relative measure. A similar approach was selected
in the RESPONSE 1 study . Another limitation of this
primary outcome parameter in the OPTICARE study is that it
does not reflect a number of important risk factors that are
addressed in the interventions, including physical activity
and healthy food choices. Any favourable change in these
parameters will be missed in the SCORE function. The
authors describe the study as featuring a PRospective Open,
Blinded Endpoint (PROBE) design. However, this reflects
only the secondary outcome parameter of clinical events, for
which the study is not powered statistically.
Cost-effectiveness is an important component of the study.
If improvements are achieved only at great cost,
implementation into practice is not likely to occur. The time span of this
analysis, of 12 months, is likely to lead to underestimation of
cost effectiveness. If successful adoption of healthy lifestyles
is indeed achieved, the benefits may, ideally, persist in the
patients remaining lifetime and thus lead to better results at
the same cost.
In the interventions tested in OPTICARE, personal
attention by (para)medical professionals stands out as one of the
most important components. A single advice given in an
outpatient visit has little impact, particularly in the long term.
In fact, most patients are aware of the traditional risk factors
and the recommendation to improve on them hardly provides
new information. Repeated personal attention from
professionals, in addition to group pressure and partner support,
may be required to achieve permanent changes in lifestyle.
Based on similar concepts in secondary prevention in
patients with coronary artery disease, the RESPONSE 2 study
is currently underway in the Netherlands. In this study,
external commercial parties are involved in addressing the
three most important lifestyle components: overweight and
obesity (Weight Watchers), physical inactivity (Philips
DirectLife activity program) and smoking (Luchtsignaal).
In the future, combinations of the interventions described in
studies such as OPTICARE and RESPONSE 2 will hopefully
assist our patients in adopting a healthy lifestyle and thus
prevent recurrences of their disease.
Open Access This article is distributed under the terms of the Creative
Commons Attribution License which permits any use, distribution, and
reproduction in any medium, provided the original author(s) and the
source are credited.