Examination of a Nurse-led Community-based Education and Coaching Intervention for Coronary Heart Disease High-risk Individuals in China. A randomised, feasibility trial of a tele-health intervention for Acute Coronary Syndrome patients with depression ('MoodCare'): Study protocol Treatment with Atorvastatin to the National Cholesterol Educational Program Goal Versus 'Usual' Care in Secondary Coronary Heart Disease Prevention The health-related quality of life and cost implications of falls in elderly women Cost-effectiveness of varenicline compared with nicotine patches for smoking cessation--results from four European countries. The Effect of Education and Counselling on Knowledge, Attitudes and Beliefs about Responses to Acute Myocardial Infarction Symptoms Cost effectiveness of personal health education in primary care for people with angina in the greater Belfast area of Northern Ireland. Measuring health-related quality of life in population-based studies of coronary heart disease: comparing six generic indexes and a disease-specific proxy score Cost-effectiveness of a coronary heart disease secondary prevention program in patients with myocardial infarction: results from a randomised controlled trial (ProActive Heart) [Patient education in the management of coronary heart disease]. The WRITTEN-HEART study (expressive writing for heart healing): rationale and design of a randomized controlled clinical trial of expressive writing in coronary patients referred to residential cardiac rehabilitation A pilot randomised controlled trial of personalised care for depressed patients with symptomatic coronary heart disease in South London general practices: the UPBEAT-UK RCT protocol and recruitment Nurse-led telecoaching of people with type 2 diabetes in primary care: rationale, design and baseline data of a randomized controlled trial Enhancing the quality of care for patients with coronary heart disease: the design and baseline results of the hastening the effective application of research through technology (HEART) trial. The important role of modifiable dietary and behavioral characteristics in the causation and prevention of coronary heart disease hospitalization and mortality: the prospective NHANES I follow-up study. Life-course socioeconomic position and incidence of coronary heart disease: the Framingham Offspring Study. The impact of angina and cardiac history on health-related quality of life and depression in coronary heart disease patients Integrating depression and chronic disease care among patients with diabetes and/or coronary heart disease: the design of the TEAMcare study. Cost-effectiveness of pravastatin in secondary prevention of coronary heart disease: comparison between Belgium and the United States of a projected risk model. Antidepressant use and risk of incident cardiovascular morbidity and mortality among postmenopausal women in the Women's Health Initiative study.
PURPOSE Early detection and management of coronary heart disease ( CHD ) are embedded into many community health service and primary care practice s in western countries . The Framingham CHD risk score has been used to predict CHD and mortality for nearly 20 years , and it has predicted CHD event risk accurately in multiethnic population s. The aim of this study was to access the effect of a 6-month community-based intervention on CHD risk in individuals at high risk . METHODS A r and omized controlled trial of individuals with a high 10-year CHD risk were recruited from two communities in China . Individuals in the intervention group ( n = 53 ) received a 3-month group education and a 3-month coaching session . Physical examination and self-report question naires were used to collect both pre- and postintervention data on blood pressure , glucose , cholesterol , body mass index , smoking , depression , and health-related quality of life ( HRQoL ) . RESULTS A total of 102 participants ( 85.0 % ) completed the 6-month study . Compared with the usual care group , the intervention group had a 5 mmHg greater reduction in systolic blood pressure ( t = 2.01 , p = .047 ) , larger declines in glucose ( t = -2.49 , p = .015 ) , cholesterol ( t = -2.44 , p = .017 ) , body mass index ( t = -2.58 , p = .011 ) , and depression ( t = -2.05 , p = .043 ) , and better reports of HRQoL ( t = 3.36 , p = .001 ) . No significant group differences in smoking behaviors were reported . CONCLUSION A 6-month  community-based intervention in a CHD high-risk population improved disease-related risk factors , depression , and HRQoL. Results provide preliminary evidence for primary prevention of cardiovascular disease risk in a community high-risk population Background Coronary heart disease ( CHD ) and depression are leading causes of disease burden globally and the two often co-exist . Depression is common after Myocardial Infa rct ion ( 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 r and omised , multi-centre trial design ed to compare a tele-health program ( MoodCare ) for depression and CHD secondary prevention , with Usual Care ( UC ) . Methods Over 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 Queensl and . Consenting participants are then contacted at two weeks post-discharge for baseline assessment . One hundred eligible participants are to be r and omised 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 . Discussion This manuscript presents the protocol for a r and omised , 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 Zeal and Clinical Trials Register ( ANZCTR ) : Summary Background : Atorvastatin is very effective in reducing plasma low-density lipoprotein cholesterol ( LDL-C ) levels . However , there is no long-term survival study that evaluated this statin . Patients − Methods : To assess the effect of atorvastatin on morbidity and mortality ( total and coronary ) of patients with established coronary heart disease ( CHD ) , 1600 consecutive patients were r and omised either to  atorvastatin  or to  ' usual ' medical care . The dose of atorvastatin was titrated from 10 to 80mg/day , in order to reach the National Cholesterol Education Program ( NCEP ) goal of LDL-C < 100mg/dl ( 2.6mmol/l ) . All patients were followed up for a mean period of 3 years . Main Outcome Measures : Primary endpoints of the study were defined as death , non-fatal myocardial infa rct ion , unstable angina , congestive heart failure , revascularisation ( coronary morbidity ) and stroke . Secondary endpoints were the safety and efficacy of the hypolipidaemic drugs as well as the cost-effectiveness of atorvastatin . Results : The mean dosage of atorvastatin was 24 mg/day . This statin reduced total cholesterol by 36 % , LDL-C by 46 % , triglycerides by 31 % , and non-high-density lipoprotein cholesterol ( non-HDL-C ) by 44 % , while it increased HDL-C by 7 % ; all these changes were significant . The NCEP LDL-C and non-HDL-C treatment goals were reached by 95 % ( n = 759 ) and 97 % ( n = 776 ) , respectively , of patients on atorvastatin . Only 14 % of the ' usual ' care patients received any hypolipidaemic drugs throughout the study and 3 % of them reached the NCEP LDL-C treatment goal . The cost per quality -adjusted life-year gained with atorvastatin was estimated at $ US 8350 . During this study 196 ( 24.5 % ) CHD patients on ' usual ' care had a CHD recurrent event or died vs. 96 ( 12 % ) CHD patients on atorvastatin ; risk ratio ( RR ) 0.49 , confidence interval ( CI ) 0.27 - 0.73 , p < 0.0001 . In detail , atorvastatin reduced , in comparison to ' usual ' care , total mortality ( RR 0.57 , CI 0.39 - 0.78 , p = 0.0021 ) , coronary mortality ( RR 0.53 , CI 0.29 - 0.74 , p = 0.0017 ) , coronary morbidity ( RR 0.46 , CI 0.25 - 0.71 , p < 0.0001 ) , and stroke ( RR 0.53 , CI 0.30 - 0.82 , p = 0.034 ) . All subgroups of patients ( women , those with diabetes mellitus , arterial hypertension , age 60 to 75 years , congestive heart failure , recent unstable angina or prior revascularisation ) benefited from treatment with atorvastatin . Withdrawal of patients because of side-effects from the atorvastatin group was low ( 0.75 % ) and similar to that of the ' usual ' care group ( 0.4 % ) . Conclusions : Long-term treatment of CHD patients with atorvastatin  to achieve NCEP lipid targets significantly reduces total and coronary mortality , coronary morbidity and stroke , in comparison to patients receiving ' usual ' medical care . Treatment with atorvastatin is well tolerated and cost-effective Summary Fractures and falls are serious cause of morbidity and cost to society . Our results suggest that the main burden to morbidity , measured as impact on health-related quality of life , is due to fear of falling rather than falls or their sequelae , such as fractures . Introduction Fractures and falls are serious cause of morbidity and cost to society . We investigated the impact on health-related quality of life ( HRQoL ) associated with  falls , fractures and fear of falling and falls and fractures cost . Methods Three data sets providing longitudinal data on fear of falling , HRQoL and a common set of baseline risk factors for fracture ( smoking status , weight and age ) were analysed . Multilevel r and om effects models were used to estimate the long-term impact on HRQoL associated with falls , fractures and fear of falling . Healthcare re source use primary data were collected to estimate falls and fractures cost . Results Older , low weight and smoking women reported lower HRQoL. The impact on HRQoL of a fracture was at least twice as large as that associated with falls . The largest negative effect on HRQoL was associated with self-reported fear of falling . The cost of falls was £ 1088 . Similarly , the cost of falls leading to a fracture was £ 15,133 , £ 2,753 , £ 1,863 , £ 1,331 and £ 3,498 for hip , wrist , arm , vertebral and other fractures , respectively . Discussion The main burden to morbidity is due to fear of falling . Interventions aim ed at reducing fear of falling may produce larger gains in BACKGROUND The aim of this study was to evaluate and compare the cost-effectiveness of varenicline with nicotine replacement therapy ( NRT ) for smoking cessation in four European countries ( Belgium , France , Sweden and the UK ) . METHODS Markov simulations , using the Benefits of Smoking Cessation on Outcomes ( BENESCO ) model , were performed . We simulated the incidence of four smoking-related morbidities : lung cancer , chronic obstructive pulmonary disease , coronary heart disease and stroke . The model computes quality -adjusted life-years gained and incremental cost-effectiveness ratios . Incremental cost-utility ratios were calculated , adopting a lifetime perspective . Efficacy data were obtained from a r and omized open-label trial : Week 52 continuous abstinence rates were 26.1 % for varenicline and 20.3 % for NRT . RESULTS The analyses imply that for countries analysed , smoking cessation using varenicline versus NRT was associated with reduced smoking-related morbidity and mortality . The number of morbidities avoided , per 1000 smokers attempting to quit , ranged from 9.7 in Belgium to 6.5 in the UK . The number of quality -adjusted life-years gained , per 1000 smokers , was 23 ( Belgium ) ; 19.5 ( France ) ; 29.9 ( Sweden ) ; and 23.7 ( UK ) . In all base-case simulations ( except France ) , varenicline dominated ( more effective and cost saving ) NRT regarding costs per quality -adjusted life-year gained ; for France the incremental cost-effectiveness ratio was 2803 . CONCLUSION This cost-effectiveness analysis demonstrated that since varenicline treatment was more effective , the result was increased healthcare cost savings in Belgium , Sweden and the UK . Our results suggest that funding varenicline as a smoking cessation aid is justifiable from a healthcare re source allocation perspective The time that elapses from the onset of symptoms of acute myocardial infa rct ion ( AMI ) to treatment has a significant effect on mortality and morbidity . This study reports the effectiveness of an education and counselling intervention on knowledge , attitudes and beliefs about AMI symptoms and the appropriate response to symptoms . The intervention was tested in a r and omised controlled trial of 200 people with a history of coronary heart disease ( CHD ) . The groups were equivalent at baseline on study outcomes , clinical history and sociodemographic characteristics with the exception of more women in the intervention group ( 38 % vs. 24 % ) . The results of repeated measures ANOVA showed that the intervention result ed in improved knowledge of CHD , AMI symptoms and the appropriate response to symptoms that was sustained to 12 months ( p = 0.02 ) . There were no differences between groups ' attitudes and beliefs over time . It is concluded that a short individual teaching and counselling intervention result ed in improved knowledge of CHD , AMI symptoms and the appropriate response to symptoms in people at risk of AMI sustained to 12 months STUDY OBJECTIVE : To investigate the cost effectiveness of personal health education for angina patients being treated in general practice . DESIGN : A r and omised controlled trial in which people were r and omised to intervention and control groups . All were assessed at the start and end of the study , with details recorded of disease status , coronary heart disease risk factors , and self assessed quality of life . A note was taken of their current use of drugs and over the course of the study their use of all health services . Those in the intervention group had three visits per year from a health visitor , whose brief was discuss ways of living more easily with their disease and in which risks of further events might be reduced . PATIENTS : Altogether 688 patents in the Greater Belfast area aged less than 75 years and known to have angina for at least six months . MAIN RESULTS : Significant improvements in survival and self assessed quality of life were found between the study and control groups . The intervention was associated with a reduction in drug usage and there was no significant difference between the intervention and control groups in terms of their use of other health services . CONCLUSION : Given the improvement in survival and self assessed quality of life and no significant differences in costs to the health service between the two groups , the intervention was deemed to be cost effective Purpose To compare HRQoL differences with CHD in generic indexes and a proxy CVD-specific score in a nationally representative sample of U.S. adults . Methods The National Health Measurement Study , a cross-sectional r and  om-digit-dialed telephone survey  of adults aged 35–89 , administered the EQ-5D , QWB-SA , HUI2 , HUI3 , SF-36v2 ™ ( yielding PCS , MCS , and SF-6D ) , and HALex . Analyses compared 3,350 without CHD ( group 1 ) , 265 with CHD not taking chest pain medication ( group 2 ) , and 218 with CHD currently taking chest pain medication ( group 3 ) , with and without adjustment for demographic variables and comorbidities . Data on 154 patients from heart failure clinics were used to construct a proxy score utilizing generic items probing CVD symptoms . Results Mean scores differed between CHD groups for all indexes with and without adjustment ( P < 0.0001 for all except MCS P = 0.018 ) . Unadjusted group 3 versus 1 differences were about three times larger than for group 2 versus 1 . St and ardized differences for the proxy score were similar to those for generic indexes , and were about 1.0 for all except MCS for group 3 versus 1 . Conclusions Generic indexes capture differences in HRQoL in population -based studies of CHD similarly to a score constructed from questions probing CVD-specific symptoms Background Participation in coronary heart disease ( CHD ) secondary prevention programs is low . Telephone-delivered CHD secondary prevention programs may overcome the treatment gap . The telephone-based health coaching ProActive Heart trial intervention has previously been shown to be effective for improving health-related quality of life , physical activity , body mass index , diet , alcohol intake and anxiety . As a secondary aim , the current study evaluated the cost-effectiveness of the ProActive Heart intervention compared to usual care . Methods 430 adult myocardial infa rct ion patients were r and omised to a six-month  CHD secondary prevention ‘ health coaching ’ intervention or ‘ usual care ’ control group . Primary outcome variables were health-related quality of life ( SF-36 ) and physical activity ( Active Australia Survey ) . Data were collected at baseline , six-months ( post-intervention ) and 12 months ( six-months post-intervention completion ) for longer term effects . Cost-effectiveness data [ health utility ( SF-6D ) and health care utilisation ] were collected using self-reported ( general practitioner , specialist , other health professionals , health services , and medication ) and cl aims data ( hospitalisation rates ) . Intervention effects are presented as mean differences ( 95 % CI ) , p-value . Results Improvements in health status ( SF-6D ) were observed in both groups , with no significant difference between the groups at six [ 0.012 ( -0.016 , 0.041 ) , p = 0.372 ] or 12 months [ 0.011 ( -0.028 , 0.051 ) p = 0.738 ] . Patients in the health coaching group were significantly more likely to be admitted to hospital due to causes unrelated to cardiovascular disease ( p = 0.042 ) . The overall cost for the health coaching group was higher ( $ 10,574 vs. $ 8,534 , p = 0.021 ) , mainly due to higher hospitalisation ( both CHD and non-CHD ) costs ( $ 6,841 vs. $ 4,984 , p = 0.036 ) . The incremental cost-effectiveness ratio was $ 85,423 per QALY . Conclusions There was no intervention effect measured using the SF-36/SF-6D and ProActive Heart result ed in significantly increased costs . The cost per QALY gained from ProActive Heart was high and above acceptable limits compared to usual care The aim of the review was to assess the effect of patient education in ischaemic heart disease . Thirteen r and omised controlled trials of moderate to good quality including 68,556 patients were selected . The effect on mortality , cardiac morbidity , hospitalisation and health-related quality of life was assessed and only non-significant tendencies of effect were found . The authors of the review nevertheless conclude that the review supports current rehabilitation programmes that include patient education . Further research in patient education , especially concerning the most effective methods of education delivery , is needed Background Coronary heart disease ( CHD ) is typically associated with many cardiovascular risk factors ( e.g. , elevated blood pressure ) , low health-related quality of life , depression , anxiety and psychological stress . Expressive writing ( EW ) has shown beneficial effects on such variables in both people from the community and in patients with a variety of chronic illnesses . However , no study to date has evaluated the physical and psychological effects of the expressive writing procedure on coronary patients referred to cardiac rehabilitation ( CR ) . Methods The clinical effectiveness of a 2-week disease-related expressive writing procedure ( writing about one 's deepest thoughts and feelings regarding the experience with heart disease ) compared with the st and ard writing task ( writing about one 's deepest thoughts and feelings about the most traumatic or negative event experienced in the life ) , a neutral writing condition ( writing about the facts regarding heart disease and its treatment ) and an empty control condition will be evaluated in a r and omized controlled clinical trial ( RCT ) with repeated follow-up measurements at 3 , 6 and 12 months after discharge from CR . The primary outcome is health-related quality of life ( SF-12 ) . Secondary outcome measures are depression ( BDI-II ) , anxiety ( BAI ) and post-traumatic growth ( PTGI ) . Furthermore , the study will explore the moderating effects of coping styles , type D personality , perceived emotional support and participants ' evaluative ratings of the writing interventions on the main experimental effects in order to identify sub-groups of patients showing different results . Discussion The WRITTEN-HEART study aims to explore and exp and the frontiers of the expressive writing research enterprise by investigating the feasibility , safety and clinical efficacy of brief and cost-effective  expressive writing interventions in patients with CHD referred to CR.Trial registration Clinical Trials.gov Background Community studies reveal people with coronary heart disease ( CHD ) are twice as likely to be depressed as the general population and that this co-morbidity negatively affects the course and outcome of both conditions . There is evidence for the efficacy of collaborative care and case management for depression treatment , and whilst NICE guidelines recommend these approaches only where depression has not responded to psychological , pharmacological , or combined treatments , these care approaches may be particularly relevant to the needs of people with CHD and depression in the earlier stages of stepped care in primary care setting s. Methods This pilot r and omised controlled trial will evaluate whether a simple intervention involving a personalised care plan , elements of case management and regular telephone review is a feasible and acceptable intervention that leads to better mental and physical health outcomes for these patients . The comparator group will be usual general practitioner ( GP ) care.81  participants have been recruited from CHD registers of 15 South London general practice s. Eligible participants have probable major depression identified by a score of ≥8 on the Hospital Anxiety and Depression Scale depression subscale ( HADS-D ) together with symptomatic CHD identified using the Modified Rose Angina Question naire . Consenting participants are r and omly allocated to usual care or the personalised care intervention which involves a comprehensive assessment of each participant ’s physical and mental health needs which are documented in a care plan , followed by regular telephone review s by the case manager over a 6-month period . At each review , the intervention participant ’s mood , function and identified problems are review ed and the case manager uses evidence based behaviour change techniques to facilitate achievement of goals specified by the patient with the aim of increasing the patient ’s self efficacy to solve their problems . Depressive symptoms measured by HADS score will be collected at baseline and 1 , 6- and 12 months post r and omisation . Other outcomes include CHD symptoms , quality of life , wellbeing and health service utilisation . Discussion This practical and patient-focused intervention is potentially an effective and accessible approach to the health and social care needs of people with depression and CHD in primary care . Trial registration IS RCT N21615909 Background Despite the efforts of the healthcare community to improve the quality of diabetes care , about 50 % of people with type 2 diabetes do not reach their treatment targets , increasing the risk of future micro- and macro-vascular complications . Diabetes self-management education has been shown to contribute to better disease control . However , it is not known which strategies involving educational programs are cost-effective . Telehealth applications might support chronic disease management . Transferability of successful distant patient self-management support programs to the Belgian setting needs to be confirmed by studies of a high method ological quality . “ The COACH Program ” was developed in Australia as target driven educational telephone delivered intervention to support people with different chronic conditions . It proved to be effective in patients with coronary heart disease after hospitalization . Clinical and cost-effectiveness of The COACH Program in people with type 2 diabetes in Belgium needs to be assessed . Methods / Design R and omized controlled trial in patients with type 2 diabetes . Patients were selected based on their medication consumption data and were recruited by their sickness fund . They were r and omized to receive either usual care plus “ The COACH Program ” or usual care alone . The study will assess the difference in outcomes between groups . The primary outcome measure is the level of HbA1c . The secondary outcomes are : Total Cholesterol , LDL-Cholesterol , HDL-Cholesterol , Triglycerides , Blood Pressure , body mass index , smoking status ; proportion of people at target for HbA1c , LDL-Cholesterol and Blood Pressure ; self-perceived health status , diabetes-specific emotional distress and satisfaction with diabetes care . The follow-up period is 18 months . Within-trial and modeled cost-utility analyses , to project effects over life-time horizon beyond the trial duration , will be undertaken from the perspective of the health care system if the intervention is effective . Discussion The study will enhance our underst and ing of the potential of telehealth in diabetes management in Belgium . Research on the clinical effectiveness and the cost-effectiveness is essential to support policy makers in future reimbursement and implementation decisions . Trial registration Belgian number : B322201213625 . Clinical Trials.gov Identifier : BACKGROUND Effective therapies exist for reducing mortality in persons with coronary heart disease ( CHD ) , but they remain underused . OBJECTIVE To report the design and baseline results of a quality improvement project design ed to increase the use of hydroxymethyl glutaryl coenzyme A ( HMG-CoA ) reductase inhibitors , beta-adrenergic blocking agents , and angiotensin-converting enzyme ( ACE ) inhibitors in patients with CHD in a network-model managed care setting . METHODS Patients with CHD were identified by search ing a cl aims data base . Use of therapies was assessed by linkage with a pharmacy benefits data base . A survey was mailed to primary care physicians to collect information related to attitudes and behavioral intentions regarding aggressive management of CHD . An intervention , consisting of a guideline summary , performance feedback , and medical chart reminders , was evaluated in a r and omized , practice -based trial . RESULTS Among 1189 patients with CHD , the median prevalence of receipt of  HMG-CoA reductase inhibitors , beta-adrenergic blocking agents , and ACE inhibitors across practice s at baseline ( the first 3 months of 1999 ) was 50.0 % , 35.0 % , and 18.8 % , respectively . Reported barriers included a perception that aggressive management of CHD is thought to be unimportant by support staff yet to require significant staff time . Aggressive management of CHD was perceived to incur non-reimbursable costs , to be unimportant in their patient population , to require a great deal of patient education and self-management , and to be limited because many patients do not adhere to therapy . CONCLUSIONS Opportunities exist for enhancing the quality of care provided to patients with CHD . Our experience to date supports the logistical feasibility of implementing network-level quality enhancement efforts in managed care networks OBJECTIVE Our specific aim in the prospect i ve , longitudinal assessment of 8,251 subjects in the National Health and Nutrition Examination Survey , NHANES I , followup study was to assess the important roles of modifiable dietary and behavioral characteristics in the causation and prevention of coronary heart disease ( CHD ) . METHODS Using NHANES I prospect i ve 10 year followup data , we studied 8,251 subjects ; 492 with cardiovascular events and 7,759 without events during the followup period ( 1971 - 75 to 1982 - 84 ) . Using general linear models and logistic regression , we assessed the relationships of CHD risk factors to CHD morbidity and mortality . RESULTS By logistic regression , the following factors were independently , significantly , and inversely associated with coronary heart and vascular disease deaths and hospitalizations : alcohol intake , dietary riboflavin , dietary iron , serum magnesium , leisure time exercise , habitual physical activity , and female gender . Positive significant independent determinants of CHD events included cigarette smoking , sedimentation rate , Quetelet index , maximum body weight , and age . CONCLUSIONS These associations emphasize the important role of modifiable dietary and behavioral characteristics in the causation and prevention of CHD Cumulative exposure to socioeconomic disadvantage across the life course may be inversely associated with coronary heart disease ( CHD ) ; the mechanisms are not fully clear . An objective of this study was to determine whether cumulative life-course socioeconomic position ( SEP ) is associated with CHD incidence in a well-characterized US cohort that had directly assessed childhood and adulthood measures of SEP and prospect ively measured CHD incidence . Furthermore , analyses aim ed to evaluate whether adjustment for CHD risk factors reduces the association between cumulative life-course SEP and CHD . The authors examined 1,835 subjects who participated in the Framingham Heart Study Offspring Cohort from 1971 through 2003 ( mean age , 35.0 years ; 52.4 % women ) .  Childhood SEP  was measured as father 's education ; adulthood SEP  was assessed as own education and occupation .  CHD incidence included myocardial infa rct ion , coronary insufficiency , and coronary death . Cox proportional hazards analyses indicated that cumulative SEP was associated with incident CHD after adjustment for age and sex ( hazard ratio = 1.82 , 95 % confidence interval : 1.17 , 2.85 for low vs. high cumulative SEP score ) . Adjustment for CHD risk factors reduced that magnitude of association ( hazard ratio = 1.29 , 95 % confidence interval : 0.78 , 2.13 ) . These findings underscore the potential importance of CHD prevention and treatment efforts for those whose background s include low SEP throughout life Objective : To prospect ively examine the contribution of angina and cardiac history to health-related quality of life ( HRQoL ) and depression in cardiac patients , over 6 months post-hospitalization . Methods : Participants were myocardial infa rct ion ( MI ) , percutaneous coronary intervention ( PCI ) or coronary artery bypass graft ( CABG ) out patients under the age of 70 years . One hundred and seventy-one patients consented to participate , with 121 patients being retained 6 months later ( 71 % response rate ) . The impact of the patient 's cardiac history and the presence of angina on physical , social and emotional HRQoL and depression was examined . Results : At baseline , cardiac history was not significantly related to any of the dimensions of HRQoL or depression . At 6-month follow-up , cardiac history significantly predicted a higher level of depression , and angina was predictive of a significantly worse emotional , physical and social HRQoL and a higher level of depression . Discussion : The presence of a cardiac history is associated with depression 6 months post-cardiac event , and angina is associated with both an adverse HRQoL and higher levels of depression . As past research has demonstrated that depression is a risk factor for mortality in patients with established heart disease , it is important from both a clinical and a research perspective to address these issues Diabetes and coronary heart disease ( CHD ) are two of the most prevalent medical illnesses in the US population and comorbid depression occurs in up to 20 % of these patients . Guidelines for management of diabetes and CHD overlap for healthy lifestyle and disease-control recommendations . However , the majority of patients with these medical illnesses have been shown to have inadequate control of key risk factors such as blood pressure , LDL cholesterol , or blood sugar . Comorbid depression has been shown to adversely affect self-care of diabetes and CHD , and is associated with an increased risk of complications and mortality . Interventions that have improved quality and outcomes of depression care alone in patients with diabetes and CHD have not demonstrated benefits in self-care , improved disease control or morbidity and mortality . This paper describes the design and development of a new biopsychosocial intervention ( TEAMcare ) aim ed at improving both medical disease control and depression in patients with poor control of diabetes and /or CHD who met the criteria for comorbid depression . A team approach is used with a nurse interventionist who receives weekly psychiatric and primary care physician caseload supervision in order to enhance treatment by the primary care physician . This intervention is being tested in an NIMH-funded r and omized controlled trial in a large integrated health plan Method ological differences and variations in health care regulations among countries often preclude direct comparisons of cost-effectiveness studies . A projected risk model was applied , design ed to determine the economic value in the United States of pravastatin in the secondary prevention of coronary heart disease ( CHD ) , to Belgium using local health care costs . A Markov process was used to model the effectiveness of treatment for 3 years with pravastatin versus placebo in 1000 male CHD patients aged 60 years and clinical ly similar to those in the pravastatin limitation of atherosclerosis in the coronary arteries ( PLAC I ) and pravastatin , lipids and atherosclerosis in the carotid arteries ( PLAC II ) studies . The PLAC I and II trials have shown that pravastatin treatment for 3 years at a weighted mean dose of 36.64 mg daily significantly reduced the incidence of non-fatal myocardial infa rct ion in patients with CHD . Framingham data were used to project the risk of mortality 10 years post-myocardial infa rct ion . The incremental cost per life year gained ( LYG ) , after discounting costs and benefits by 5 % annually , in the setting of Belgian health care regulations , was Belgian francs ( BEF ) 720794 ( US$ 24359 ) for CHD patients with one additional risk factor ; BEF 526464 ( US$ 17792 ) for those with two additional risk factors ; and BEF 392765 ( US$ 13274 ) for those with three or more additional risk factors . The cost per LYG in Belgium appeared to be more sensitive to drug acquisition cost than to costs of medical interventions . The cost-effectiveness ratios of pravastatin monotherapy for 3 years in secondary prevention of CHD , obtained with the same projected risk model , are from 86 to 92 % higher in Belgium than in the United States , due to differences in medical patterns of practice and in intervention costs BACKGROUND Antidepressants are commonly prescribed medications , but their effect on cardiovascular morbidity and mortality remains unclear . METHODS Prospect i ve cohort study of 136 293 community-dwelling postmenopausal women in the Women 's Health Initiative ( WHI ) . Women taking no antidepressants at study entry and who had at least 1 follow-up visit were included . Cardiovascular morbidity and all-cause mortality for women with new antidepressant use at follow-up ( n = 5496 ) were compared with those characteristics for women taking no antidepressants at follow-up ( mean follow-up , 5.9 years ) . RESULTS Antidepressant use was not associated with coronary heart disease ( CHD ) .  Selective serotonin reuptake inhibitor ( SSRI ) use was associated with increased stroke risk ( hazard ratio [HR],1.45 , [ 95 % CI , 1.08 - 1.97 ] ) and all-cause mortality ( HR,1.32 [ 95 % CI , 1.10 - 1.59 ] ) . Annualized rates per 1000 person-years of stroke with no antidepressant use and SSRI use were 2.99 and 4.16 , respectively , and death rates were 7.79 and 12.77 . Tricyclic antidepressant ( TCA ) use was associated with increased risk of all-cause mortality ( HR,1.67 [ 95 % CI , 1.33 - 2.09 ] ; annualized rate , 14.14 deaths per 1000 person-years ) . There were no significant differences between SSRI and TCA use in risk of any outcomes . In analyses by stroke type , SSRI use was associated with incident hemorrhagic stroke ( HR , 2.12 [ 95 % CI , 1.10 - 4.07 ] ) and fatal stroke ( HR , 2.10 [ 95 % CI , 1.15 - 3.81 ] ) . CONCLUSIONS In postmenopausal women , there were no significant differences between SSRI and TCA use in risk of CHD , stroke , or mortality . Antidepressants were not associated with risk of CHD .  Tricyclic antidepressants and SSRIs may be associated with increased risk of mortality , and SSRIs with increased risk of hemorrhagic and fatal stroke , although absolute event risks are low . These findings must be weighed against quality of life and established risks of cardiovascular disease and mortality associated with untreated depression
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 clinical ly important effects of education on mortality and morbidity .
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 ) .