Michael V. Jelinek

The COACH Program Produces Sustained Improvements in Cardiovascular Risk Factors and Adherence to Recommended Medications—Two Years Follow-up

PURPOSE To assess whether The COACH Program could sustain its favourable impact on coronary risk factors (CRFs) and adherence to recommended medication for 18 months after the completion of The COACH Program. METHOD A clinical audit of a secondary prevention program performed in three teaching hospitals in Melbourne, Victoria for patients with coronary heart disease (CHD). The CRF targets were based on recommendations from the National Heart Foundation of Australia between 2003 and 2007. RESULTS 656 patients were followed by telephone every 6 months from recruitment in hospital for 2 years. There was a substantial improvement in all CRF from discharge from hospital to the completion of active coaching 6 months after hospital discharge. There was also a significant increase in the proportion of patients taking statins and renin-angiotensin system antagonists in the same period of time. There was a small deterioration in CRF status in the 6 months after exit from The COACH Program but thereafter CRF status was maintained and substantially better than that on entry to The COACH Program. The use of the recommended cardio-protective medications remained at the levels achieved at exit from The COACH Program. CONCLUSION The changes in CRF status and adherence to cardiac medications achieved at 6 months in The COACH Program are sustained for at least 18 months after cessation of The COACH Program.

A randomised, feasibility trial of a tele-health intervention for Acute Coronary Syndrome patients with depression ('MoodCare'): Study protocol

BackgroundCoronary heart disease (CHD) and depression are leading causes of disease burden globally and the two often co-exist. Depression is common after Myocardial Infarction (MI) and it has been estimated that 15-35% of patients experience depressive symptoms. Co-morbid depression can impair health related quality of life (HRQOL), decrease medication adherence and appropriate utilisation of health services, lead to increased morbidity and suicide risk, and is associated with poorer CHD risk factor profiles and reduced survival. We aim to determine the feasibility of conducting a randomised, multi-centre trial designed to compare a tele-health program (MoodCare) for depression and CHD secondary prevention, with Usual Care (UC).MethodsOver 1600 patients admitted after index admission for Acute Coronary Syndrome (ACS) are being screened for depression at six metropolitan hospitals in the Australian states of Victoria and Queensland. Consenting participants are then contacted at two weeks post-discharge for baseline assessment. One hundred eligible participants are to be randomised to an intervention or a usual medical care control group (50 per group). The intervention consists of up to 10 × 30-40 minute structured telephone sessions, delivered by registered psychologists, commencing within two weeks of baseline screening. The intervention focuses on depression management, lifestyle factors (physical activity, healthy eating, smoking cessation, alcohol intake), medication adherence and managing co-morbidities. Data collection occurs at baseline (Time 1), 6 months (post-intervention) (Time 2), 12 months (Time 3) and 24 months follow-up for longer term effects (Time 4). We are comparing depression (Cardiac Depression Scale [CDS]) and HRQOL (Short Form-12 [SF-12]) scores between treatment and UC groups, assessing the feasibility of the program through patient acceptability and exploring long term maintenance effects. A cost-effectiveness analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government.DiscussionThis manuscript presents the protocol for a randomised, multi-centre trial to evaluate the feasibility of a tele-based depression management and CHD secondary prevention program for ACS patients. The results of this trial will provide valuable new information about potential psychological and wellbeing benefits, cost-effectiveness and acceptability of an innovative tele-based depression management and secondary prevention program for CHD patients experiencing depression.Trial Registration NumberAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000386235

Impact of Coaching Patients on Coronary Risk Factors: Lessons from The COACH Program

It is well recognized that there is a treatment gap in the management of risk factors in patients with coronary heart disease (CHD) — a gap between what is known from published evidence and what is actually practiced.Strategies to address the treatment gap have usually been aimed at the physician and these have often been ineffective. Few strategies have been directed at the patient. Patient-targeted strategies can be subdivided into those that permit the prescribing of medication by allied health professionals and those where allied health staff do not have prescribing rights. Although intuitively it may appear that any program providing attention to patients would result in improvements in risk-factor levels, published work shows that the programs that allow the prescription of drugs have all resulted in significant improvement in coronary risk factor status. By contrast, all but one of the non-drug prescribing programs failed to improve the risk factor status. The COACH (Coaching patients On Achieving Cardiovascular Health) Program is a novel program using non-drug prescribing health professionals to achieve the target levels for all of the modifiable risk factors in patients with CHD.The COACH Program is a training program for patients with CHD in which a health professional coach trains patients to aggressively pursue the target levels for their particular coronary risk factors. The coach is hospital-based and uses the telephone and mailouts to provide regular coaching sessions to patients after discharge from hospital. Coaching is directed at the patient and not at the treating doctor. Patients are coached to know their risk-factor levels, the target levels for their risk factors, and how to achieve the target levels for their risk factors. Patients are persuaded to go to their own doctor(s) and ask for appropriate prescription of medication(s). Coaching also trains patients to follow appropriate lifestyle measures.The COACH Program has been validated by two randomized controlled trials. The first was a pilot, single-center study in which one coach targeted serum cholesterol as an outcome. Having established the success of the method, a definitive multicenter study was performed in six hospitals, each with its own trained coach, which aimed to improve lipid and other risk factors. This study confirmed that coaching was an independent and significant factor in lowering total and low-density lipoprotein cholesterol. In addition, coaching resulted in a lower blood pressure, lower intake of dietary saturated fat, lower bodyweight, less anxiety, improved self-perception of health, and lesser symptoms of chest pain and breathlessness at 6-month follow-up. The COACH Program is a proven, highly effective method of using health professionals, who do not have the authority to prescribe medication, to improve risk status in patients with CHD.

Psychosocial interventions for patients with coronary heart disease and depression: A systematic review and meta-analysis

Introduction: Depression is common in patients with coronary heart disease, and together these conditions significantly affect health outcomes. Impaired social support is also considered an important predictor of coronary heart disease prognosis and, as there is a complex interplay between social isolation and depression, interventions to address both may be required. This review aimed to assess the effectiveness of psychosocial interventions addressing both depression and social support for people with coronary heart disease and depression. Methods: PRISMA guidelines were used to search major health databases to identify randomised controlled trials that evaluated psychosocial interventions compared with usual care in patients with coronary heart disease and depression; the primary outcome was depressive symptoms and secondary outcomes were mortality (all-cause and cardiac), myocardial infarction, revascularisation, anxiety, social support and quality of life. Data, when suitable, were pooled using a random-effects meta-analysis model. Results: Five studies (n=1358 participants) were eligible and included. The psychosocial intervention group had significantly lower levels of depressive symptoms (standardised mean difference (SMD) –0.15, 95% confidence interval (CI) −0.27 to −0.03; P=0.02) and higher levels of social support (SMD 0.17; 95% CI 0.04 to 0.30; P=0.01) but no differences were found for mortality (all-cause and cardiac), myocardial infarction, revascularisation, anxiety or quality of life. Conclusions: Psychosocial interventions for patients with coronary heart disease and depression result in modest reductions in depressive symptoms and improvements in social support. However, caution is warranted in view of the small number of studies included in the review and potential heterogeneity in outcomes and in differences in treatment.

Efficacy and feasibility of a tele-health intervention for acute coronary syndrome patients with depression: results of the "MoodCare" randomized controlled trial

BackgroundDepression is common after a cardiac event, yet there remain few approaches to management that are both effective and scalable.PurposeWe aimed to evaluate the 6-month efficacy and feasibility of a tele-health program (MoodCare) that integrates depression management into a cardiovascular disease risk reduction program for acute coronary syndrome patients with low mood.MethodsA two-arm, parallel, randomized design was used comprising 121 patients admitted to one of six hospitals for acute coronary syndrome.ResultsSignificant treatment effects were observed for Patient Health Questionnaire 9 (PHQ9) depression (mean difference [change] = −1.8; p = 0.025; effect size: d = 0.36) for the overall sample, when compared with usual medical care. Results were more pronounced effects for those with a history of depression (mean difference [change] = −2.7; p = 0.043; effect size: d = 0.65).ConclusionsMoodCare was effective for improving depression in acute coronary syndrome patients, producing effect sizes exceeding those of some face-to-face psychotherapeutic interventions and pharmacotherapy. (Trial Registration Number: ACTRN1260900038623.)

Preoperative cardiac evaluation and management of patients undergoing elective non-cardiac surgery

Perioperative cardiac complications are a common cause of death and major morbidity in patients undergoing non‐cardiac surgery. Preoperative evaluation and medical optimisation can improve outcomes, although the evidence base is limited. Evidence of effectiveness is strongest for prophylactic use of β‐blockers in high‐risk patients and aspirin in patients with coronary artery disease. Particular challenges arise among patients with heart failure or valvular heart disease or those receiving antithrombotic therapy for coronary artery stents or atrial fibrillation. Close liaison between general practitioners, surgeons, anaesthetists and cardiologists is needed for optimising preoperative management and subsequent clinical outcomes in high‐risk patients.

Reversing social disadvantage in secondary prevention of coronary heart disease

BACKGROUND To compare and contrast the coronary heart disease (CHD) risk factors of lower socio-economic status public hospital patients with those of privately insured CHD patients before and after six months of telephone delivered coaching using The COACH Program. METHODS A retrospective observational study which contrasts the lifestyle and biomedical coronary risk factor status of 2256 public hospital patients with the same risk factors of 3278 patients who had private health insurance. All patients received an average of 5 coach sessions over 6 months. RESULTS The public hospital patients were four years younger and had multiple measures confirming their lower socio-economic status than their private hospital counterparts. At entry to the program, the public hospital patients had worse risk factor levels than the privately insured patients for total and LDL-cholesterol, triglycerides, fasting glucose, smoking and physical activity levels (P<0.0001) but better status for systolic and diastolic blood pressures and alcohol intake. At exit from the program, many of these differences had diminished or disappeared. The public hospital patients had greater improvements in their risk factor status for total and LDL-cholesterol, fasting glucose, body weight, smoking status and physical activity level than did the privately insured patients (P<0.05). CONCLUSIONS This paper demonstrates that a program of initiating contact with patients with CHD, identifying treatment gaps in their management and coaching to achieve guideline recommended risk factor targets can help reduce health inequalities in such patients and thus benefit all patients in the context of ongoing secondary prevention.

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes [SMART-REHAB Trial]: a randomized controlled trial protocol

BackgroundThere are well-documented treatment gaps in secondary prevention of coronary heart disease and no clear guidelines to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps. This paper describes the study design of a randomized controlled trial assessing whether a smartphone-based secondary prevention program can facilitate early physical activity and improve cardiovascular health in patients with ACS.MethodsWe have developed a multi-faceted, patient-centred smartphone-based secondary prevention program emphasizing early physical activity with a graduated walking program initiated on discharge from ACS admission. The program incorporates; physical activity tracking through the smartphone’s accelerometer with interactive feedback and goal setting; a dynamic dashboard to review and optimize cardiovascular risk factors; educational messages delivered twice weekly; a photographic food diary; pharmacotherapy review; and support through a short message service. The primary endpoint of the trial is change in exercise capacity, as measured by the change in six-minute walk test distance at 8-weeks when compared to baseline. Secondary endpoints include improvements in cardiovascular risk factor status, psychological well-being and quality of life, medication adherence, uptake of cardiac rehabilitation and re-hospitalizations.DiscussionThis randomized controlled trial will use a smartphone-phone based secondary prevention program to emphasize early physical activity post-ACS. It will provide evidence regarding the feasibility and utility of this innovative platform in closing the treatment gaps in secondary prevention.Trial registrationThe trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) on April 4, 2016. The registration number is ACTRN12616000426482.

‘FIT FOR PURPOSE’. The COACH program improves lifestyle and biomedical cardiac risk factors

The ‘Rehabilitation after Myocardial Infarction Trial’ (RAMIT) showed that cardiac rehabilitation in the UK failed to impact on total mortality, cardiac morbidity, health related quality of life and behavioural risk factors.1 These results were met with indignation. David Wood actually questioned whether cardiac rehabilitation as performed in the UK was ‘fit for purpose’.2 Which raises the question: what is the purpose of cardiac rehabilitation? We believe that the immediate objectives of cardiac rehabilitation are to improve the physical fitness of cardiac patients after acute illness or cardiac procedures and to initiate secondary prevention by improving lifestyle and biomedical risk factors. Nowadays, patients spend 2–4 days in hospital after an acute coronary syndrome. They are not deconditioned. They are fit to return to work 2–4 weeks after the acute event. They are unlikely to attend a cardiac rehabilitation …

Reconciling systematic reviews of exercise-based cardiac rehabilitation and secondary prevention programmes for coronary heart disease

Findings of systematic reviews incorporating metaanalysis are by nature hypothesis generating and should be carefully and judiciously interpreted. This need is epitomized by two of the largest reviews of interventions to support risk factor reduction after a diagnosis of coronary heart disease (Table 1). These reviews both included randomized trials published in a similar timeframe (up to 2003 or 2004) that compared the effects of various risk factor reduction programmes for patients with confirmed coronary heart disease to usual care. In 2004, a Cochrane review found that supervised and unsupervised exercise-based cardiac rehabilitation provided to patients with different forms of coronary heart disease lowered all cause total mortality by 20% and cardiac mortality by 26% in 48 trials of 8940 patients. The reviewers concluded that there was ‘no difference in mortality effect between exercise-only cardiac rehabilitation and comprehensive cardiac rehabilitation, or by exercise dose or duration of followup’. Also, the exercise-based programmes did not reduce recurrent myocardial infarction and the need for repeat coronary revascularization to statistically significant levels. Around the same time, a second review of 63 trials involving 21,295 patients who had undergone secondary cardiac prevention programmes found reductions of total mortality of 15% and of acute myocardial infarction of 17%. However, in contrast to the previous review, the secondary prevention programmes significantly reduced the rate of recurrent heart attacks. Also, benefits did not differ between programmes ‘that incorporated education and counselling about coronary risk factors with a supervised exercise programme, those that included risk factor education or counselling but no exercise component, and those that consisted of only a structured exercise programme’. On first reading, these reviews appear to offer different conclusions on effects on cardiovascular morbidity and regarding the benefits of supervised exercise. Either could be cited selectively to support or refute the benefits of exercise programmes for morbidity or to support or refute the incorporation of supervised exercise into services. Why might these different conclusions have come about and how should they be interpreted? Firstly, it is unlikely that the different conclusions arise from differences in quality as both reviews were of high quality as defined by PRISMA criteria and included many of the same trials: 37 of the 48 (77%) exercise-based trials were included in the 63 (59%) secondary prevention trials. Rather, issues of statistical power can explain the differences noted in morbidity. The forest plot analyses showed that, although exercise-based programmes in the Cochrane review did not reach statistically significant headline ‘effect sizes’, there was a tendency towards reduced recurrent myocardial infarction and the need for repeat coronary revascularization. The larger review of secondary prevention programmes considered over twice the number of events in the analysis of recurrent myocardial infarction and found that secondary prevention programmes significantly reduced the rate of recurrent heart attacks. Hence, focusing only on the presence or absence of statistical