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 Effectiveness of a self-management intervention with personalised genetic and lifestyle-related risk information on coronary heart disease and diabetes-related risk in type 2 diabetes (CoRDia): study protocol for a randomised controlled trial The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411] Integrating depression and chronic disease care among patients with diabetes and/or coronary heart disease: the design of the TEAMcare study. 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 TrueBlue study: Is practice nurse-led collaborative care effective in the management of depression for patients with heart disease or diabetes? Screening for Coronary Heart Disease: Recommendation Statement Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the American Heart Association. Costs of a Community Pharmacist-Led Medicines Management Service for Patients with Coronary Heart Disease in England Dietary prevention of coronary heart disease: the Finnish Mental Hospital Study. Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial Prospective study of coronary heart disease incidence in relation to fasting total homocysteine, related genetic polymorphisms, and B vitamins: the Atherosclerosis Risk in Communities (ARIC) study. Examining the link between coronary heart disease and the elimination of chronic dental infections. [Community nursing intervention in population with high-risk coronary heart disease in Hengyang]. Information and Risk Modification Trial (INFORM): design of a randomised controlled trial of communicating different types of information about coronary heart disease risk, alongside lifestyle advice, to achieve change in health-related behaviour Assessment and Treatment of Depression in Patients With Cardiovascular Disease: National Heart, Lung, and Blood Institute Working Group Report Heart rate variability biofeedback as a behavioral neurocardiac intervention to enhance vagal heart rate control. Quality of care for secondary prevention for patients with coronary heart disease: results of the Hastening the Effective Application of Research through Technology (HEART) trial. 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 randomised, feasibility trial of a tele-health intervention for Acute Coronary Syndrome patients with depression ('MoodCare'): Study protocol Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease Mindfulness-based stress reduction program in coronary heart disease: A randomized control trial The relationship of psychosocial factors to coronary heart disease in the Framingham Study. III. Eight-year incidence of coronary heart disease. Exercise training improves activity in adolescents with congenital heart disease Risk of New Myocardial Infarction in Middle‐aged Men with Manifest Coronary Heart Disease Proactive Multifactorial Intervention Strategy Reduces the Risk of Cardiovascular Disease Estimated with Region-Specific Risk Assessment Models in Pacific Asian Patients Participating in the CRUCIAL Trial Lifestyle Interventions Reduce Coronary Heart Disease Risk: Results From the PREMIER Trial Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Nurse case management of hypercholesterolemia in patients with coronary heart disease: results of a randomized clinical trial. The UPBEAT Nurse-Delivered Personalized Care Intervention for People with Coronary Heart Disease Who Report Current Chest Pain and Depression: A Randomised Controlled Pilot Study Alcohol intake and mortality in middle aged men with diagnosed coronary heart disease ALPHA LIPOPROTEIN (HDL) CHOLESTEROL IN THE SERUM AND THE RISK OF CORONARY HEART DISEASE AND DEATH Sweetened beverage consumption and risk of coronary heart disease in women. Increased Framingham Coronary Heart Disease Risk Score in Dementia Caregivers Relative to Non-Caregiving Controls Secondary prevention of coronary heart disease: patient beliefs and health-related behaviour. The joint effects of physical activity and body mass index on coronary heart disease risk in women. Prediction of coronary heart disease using risk factor categories. Quantity and variety in fruit and vegetable intake and risk of coronary heart disease. Effects of a stress management program on vital exhaustion and depression in women with coronary heart disease: a randomized controlled intervention study. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey. Effects of the mediterranean lifestyle program on multiple risk behaviors and psychosocial outcomes among women at risk for heart disease The Lipid Research Clinics Coronary Primary Prevention Trial results. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. Life style intervention in general practice: Effects on psychological well-being and patient satisfaction Systematic Review of the Effect of Diet and Exercise Lifestyle Interventions in the Secondary Prevention of Coronary Heart Disease Improving coronary heart disease self-management using mobile technologies (Text4Heart): a randomised controlled trial protocol Effort-Reward Imbalance at Work and Recurrent Coronary Heart Disease Events: A 4-Year Prospective Study of Post-Myocardial Infarction Patients Case-Based Training of Evidence-Based Clinical Practice in Primary Care and Decreased Mortality in Patients With Coronary Heart Disease Job strain and risk of acute recurrent coronary heart disease events. C-Reactive Protein, Interleukin-6, and Fibrinogen as Predictors of Coronary Heart Disease: The PRIME Study Examination of a Nurse-led Community-based Education and Coaching Intervention for Coronary Heart Disease High-risk Individuals in China. The Women's Health Initiative postmenopausal hormone trials: overview and baseline characteristics of participants. Effects of exercise training on coronary heart disease risk factors in renal transplant recipients.
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 Many patients with type 2 diabetes fail to achieve good glycaemic control . Poor control is associated with complications including coronary heart disease ( CHD ) . Effective self-management and engagement in health behaviours can reduce risks of complications . However , patients often struggle to adopt and maintain these behaviours . Self-management interventions have been found to be effective in improving glycaemic control . Recent developments in the field of genetics mean that patients can be given personalised information about genetic- and lifestyle-associated risk of developing CHD . Such information may increase patients ’ motivation to engage in self-management . The Coronary Risk in Diabetes ( CoRDia ) trial will compare the effectiveness of a self-management intervention , with and without provision of personalised genetic- and lifestyle-associated risk information , with usual care , on clinical and behavioural outcomes , the cognitive predictors of behaviour , and psychological wellbeing . Methods / Design Participants will be adults aged 25–74 years registered with general practice s in the East of Engl and , diagnosed with type 2 diabetes , with no history of heart disease , and with a glycated haemoglobin level of ≥6.45 % ( 47 mmol/mol ) . Consenting participants will be r and omised to one of three arms : usual care control , group self-management only , group self-management plus personalised genetic- and lifestyle-associated risk information . The self-management groups will receive four weekly 2-hour group sessions , focusing on knowledge and information sharing , problem solving , goal setting and action planning to promote medication adherence , healthy eating , and physical activity . Primary outcomes are glycaemic control and CHD risk . Clinical data will be collected from GP records , including HbA1c , weight , body mass index , blood pressure , and HDL and total cholesterol . Self-reported health behaviours , including medication adherence , healthy eating and physical activity , and cognitive outcomes will be assessed by question naire . Measures will be taken at baseline , 3 months ( question naire only ) , 6 months and 12 months post-baseline . Discussion This study will determine whether the addition of personalised genetic- and lifestyle-associated CHD risk information to a group self-management intervention  improves diabetes control and CHD risk compared with group self-management and usual care . Effectiveness of the combined intervention on health behaviours cognitions theorised to predict them , and psychological outcomes will also be investigated . Trial registration This study has been registered at Clinical Trials.gov ; registration identifier NCT01891786 , registered 28 June 2013 Background The aim of the SPHERE study is to design , implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease ( CHD ) in general practice across two different health systems on the isl and of Irel and .CHD is a common cause of death and a significant cause of morbidity in Irel and . Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives . Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the isl and of Irel and . The review literature recommends structured programmes with continued support and follow-up of patients ; the provision of training , tailored to practice needs of access to evidence of effectiveness of secondary prevention ; structured recall programmes that also take account of individual practice needs ; and patient-centred consultations accompanied by attention to disease management guidelines . Methods SPHERE is a cluster r and omised controlled trial , with practice -level r and omisation to intervention and control groups , recruiting 960 patients from 48 practice s in three study centres ( Belfast , Dublin and Galway ) . Primary outcomes are blood pressure , total cholesterol , physical and mental health status ( SF-12 ) and hospital re-admissions . The intervention takes place over two years and data is collected at baseline , one-year and two-year follow-up . Data is obtained from medical charts , consultations with practitioners , and patient postal question naires . The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice . It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients . General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD . Patients are invited to attend regular four-monthly consultations over two years , during which targets and goals for secondary prevention are set and review ed . The analysis will be strengthened by economic , policy and qualitative components 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 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 Background In the presence of type 2 diabetes ( T2DM ) or coronary heart disease ( CHD ) , depression is under diagnosed and under treated despite being associated with worse clinical outcomes . Our earlier pilot study demonstrated that it was feasible , acceptable and affordable for practice nurses to extend their role to include screening for and monitoring of depression alongside biological and lifestyle risk factors . The current study will compare the clinical outcomes of our model of practice nurse-led collaborative care with usual care for patients with depression and T2DM or CHD . Methods This is a cluster-r and omised intervention trial . Eighteen general practice s from regional and metropolitan areas agreed to join this study , and were allocated r and omly to an intervention or control group . We aim to recruit 50 patients with co-morbid depression and diabetes or heart disease from each of these practice s. In the intervention group , practice nurses ( PNs ) will be trained for their enhanced roles in this nurse-led collaborative care study . Patients will be invited to attend a practice nurse consultation every 3 months prior to seeing their usual general practitioner . The PN will assess psychological , physiological and lifestyle parameters then work with the patient to set management goals . The outcome of this assessment will form the basis of a GP Management Plan document . In the control group , the patients will continue to receive their usual care for the first six months of the study before the PNs undergo the training and switch to the intervention protocol . The primary clinical outcome will be a reduction in the depression score . The study will also measure the impact on physiological measures , quality of life and on patient attitude to health care delivered by practice nurses . Conclusion The strength of this programme is that it provides a sustainable model of chronic disease management with monitoring and self-management assistance for physiological , lifestyle and psychological risk factors for high-risk patients with co-morbid depression , diabetes or heart disease . The study will demonstrate whether nurse-led collaborative care achieves better outcomes than usual care Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) recommends against routine screening with resting electrocardiography ( ECG ) , exercise treadmill test ( ETT ) , or electron-beam computerized tomography ( EBCT ) scanning for coronary calcium for either the presence of severe coronary artery stenosis ( CAS ) or the prediction of coronary heart disease ( CHD ) events in adults at low risk for CHD events . This is a grade D recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) The USPSTF found at least fair evidence that ECG or ETT can detect some asymptomatic adults at increased risk for CHD events independent of conventional CHD risk factors ( see Clinical Considerations ) and that ETT can detect severe CAS in a small number of asymptomatic adults . Similar evidence for EBCT is limited . In the absence of evidence that such detection by ECG , ETT , or EBCT among adults at low risk for CHD events ultimately results in improved health outcomes , and because false-positive tests are likely to cause harm , including unnecessary invasive procedures , overtreatment , and labeling , the USPSTF concluded that the potential harms of routine screening for CHD in this population exceed the potential benefits . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Appendix Table 1 . U.S. Preventive Services Task Force Grade s and Recommendations Appendix Table 2 . U.S. Preventive Services Task Force Strength of Overall Evidence The USPSTF found insufficient evidence to recommend for or against routine screening with ECG , ETT , or EBCT scanning for coronary calcium for either the presence of severe CAS or the prediction of CHD events in adults at increased risk for CHD events . This is a grade I recommendation . The USPSTF found inadequate evidence to determine the extent to which the added detection offered by ECG , ETT , or EBCT ( beyond that obtained by ascertainment of conventional CHD risk factors ) ( see Clinical Considerations ) would result in interventions that lead to improved CHD-related health outcomes among adults at increased risk for CHD events . Although there is limited evidence to determine the magnitude of harms from screening this population , harms from false-positive tests ( that is , unnecessary invasive procedures , overtreatment , and labeling ) are likely to occur . As a result , the USPSTF could not determine the balance between benefits and harms of screening this population for CHD . Clinical Considerations Several factors are associated with a higher risk for CHD events ( the major ones are nonfatal myocardial infa rct ion and coronary death ) , including older age , male gender , high blood pressure , smoking , abnormal lipid levels , diabetes , obesity , and sedentary lifestyle . A person 's risk for CHD events can be estimated on the basis of the presence of these factors . Calculators are available to ascertain a person 's risk for a CHD event ; for example , a calculator to estimate a person 's risk for a CHD event in the next 10 years can be accessed at hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof . Although the exact risk factors that constitute each of these categories ( low or increased risk ) have not been established , younger adults ( that is , men<50 years of age and women<60 years of age ) who have no other risk factors for CHD ( < 5 % to 10 % 10-year risk ) are considered to be at low risk . Older adults , or younger adults with one or more risk factors ( > 15 % to 20 % 10-year risk ) , are considered to be at increased risk . Screening with ECG , ETT , and EBCT could potentially reduce CHD events in 2 ways : either by detecting people at high risk for CHD events who could benefit from more aggressive risk factor modification or by detecting people with existing severe CAS whose life could be prolonged by coronary artery bypass grafting ( CABG ) surgery . However , the evidence is inadequate to determine the extent to which people detected through screening in either situation would benefit from either type of intervention . The consequences of false-positive tests may potentially outweigh the benefits of screening . False-positive tests are common among asymptomatic adults , especially women , and may lead to unnecessary diagnostic testing , overtreatment , and labeling . Because the sensitivity of these tests is limited , screening could also result in false-negative results . A negative test does not rule out the presence of severe CAS or a future CHD event . For people in certain occupations , such as pilots and heavy equipment operators ( for whom sudden incapacitation or sudden death may endanger the safety of others ) , considerations other than the health benefit to the individual patient may influence the decision to screen for CHD . Although some exercise programs initially screen asymptomatic participants with ETT , there is not enough evidence to determine the balance of benefits and harms of this practice . Discussion Coronary heart disease is the leading cause of death in the United States ; more than 700000 of the deaths in 2000 were due to heart disease ( 1 ) . The overall costs of CHD and stroke in 2003 are estimated to be greater than $ 350 billion ( 2 ) . Many clinicians ascertain a person 's overall risk for CHD events by screening for cardiac risk factors and incorporating that information into risk prediction equations derived from the Framingham or other cohort studies ( 3 , 4 ) . Asymptomatic adults clearly benefit from risk factor modification proportional to their degree of CHD risk ( that is , more intensive risk factor modification for people at higher risk ) ( 5 ) . Since those at high risk for CHD may already be receiving interventions to maximally reduce their risk for CHD events , screening may potentially be of greatest benefit to those presumed to be at intermediate risk for CHD who could be reclassified as being at high risk ( and thus treated more aggressively ) after additional testing . In addition to risk factor reduction , persons with symptoms of CHD who have severe CAS ( defined as either triple-vessel or left main coronary artery atherosclerotic disease with poor left ventricular function ) clearly benefit from CABG or percutaneous transluminal coronary angioplasty ( 6 - 8 ) . Among the asymptomatic population , those at higher risk for CHD events have a higher prevalence of severe CAS ; thus , the yield of screening is expected to be greater in this population . However , it is uncertain whether this increased yield increases the detection of people with severe CAS to an important degree and whether invasive revascularization procedures would benefit those who are asymptomatic as much as those who have symptoms of CAS . The USPSTF review ed the evidence as to whether supplementing the conventional CHD risk ascertainment strategy with additional screening using ECG , ETT , or EBCT , or using these 3 tests to identify people with severe CAS earlier , would lead to improved health outcomes in asymptomatic persons . The USPSTF found no r and omized , controlled trials with health outcomes that examined the extent to which  ECG , ETT , or EBCT scanning for coronary calcium provided additional prognostic information beyond the currently used risk factor calculations . The Task Force further found that the 3 screening testsECG , ETT , and EBCThave poor to fair accuracy in predicting CHD events . Systematic review s have reported that the sensitivity of resting ECG abnormalities for CHD events is low ( 3 , 9 ) . The prevalence of the most common ECG abnormalities ( Q waves , left ventricular hypertrophy , bundle-branch blocks , and ST-segment depression ) ranges from 1 % to 10 % ( 3 ) . Only a few studies have examined ECG abnormalities in the black population . Although major ECG abnormalities may be more prevalent in black men than in white men , these abnormalities may not confer the same risk for CHD death in black men ( relative risk , 1.95 [ 95 % CI , 0.93 to 4.11 ] ) as in white men ( relative risk , 2.72 [ CI , 1.47 to 5.04 ] ) ( 10 ) . The sensitivity of ETT  for the prediction of CHD events 3 to 12 years in the future ranges from 40 % to 62 % ; the positive predictive value ( PPV ) ranges from 6 % to 48 % . The higher sensitivity of ETT  reported in older studies may not be accurate because of the possibility of spectrum bias ( 11 , 12 ) . The prevalence of an abnormal ETT ( ST-segment depression 1 mm ) reportedly ranges from 5 % to 25 % ( 3 ) . The yield of ETT  in detecting severe CAS in asymptomatic middle-aged men is estimated to be 0.5 % ( 3 , 13 ) . The PPV for future CHD in recent cohort studies ( most of them conducted with asymptomatic men ) is low ( range , 6 % to 48 % ) ( 3 ) . Adding nuclear perfusion to ECG analysis may increase sensitivity somewhat ; however , the low PPV of ETT is due mainly to the low prevalence of CHD in asymptomatic persons and can not be corrected simply by improving test accuracy . For patients with symptoms of CHD , EBCT has a sensitivity of 80 % and a specificity of 40 % for detecting angiographically demonstrated CAS ( 14 ) ; similar data for those who have no symptoms are lacking . A systematic review reported that higher calcium scores on EBCT were associated with higher risk for CHD events ( 3 ) . This review concluded that EBCT may have a role in better defining risk for CHD events in those who have been identified as being at intermediate risk based on traditional risk factors , but no study has examined the effect of EBCT data on clinical decision making ( 3 ) . Potential harms of screening asymptomatic patients for CHD include unnecessary invasive testing ( for example , coronary angiography ) and labeling of those who have had false-positive test results . In low-risk asymptomatic population s , most positive ECG test results occur in those who will not have a CHD event in the next 5 to 10 years ( 3 ) . One study reported that 71 % of those without symptoms who had an abnormal ETT had no angiographically demonstrable CAS ( 15 ) . While the yield of screening is low in those at low risk for CHD , the potential for Substantial progress has been made in the awareness , treatment , and prevention of  cardiovascular disease ( CVD ) in women since the first women-specific clinical recommendations for the prevention of CVD were published by the American Heart Association ( AHA ) in 1999.1 The myth that heart disease is a “ man 's disease ” has been debunked ; the rate of public awareness of CVD as the leading cause of death among US women has increased from 30 % in 1997 to 54 % in 2009.2 The age-adjusted death rate result ing from  coronary heart disease ( CHD ) in females , which accounts for about half of all CVD deaths in women , was 95.7 per 100 000 females in 2007 , a third of what it was in 1980.3,4 Approximately 50 % of this decline in CHD deaths has been attributed to reducing major risk factors and the other half to treatment of CHD including secondary preventive therapies.4 Major r and omized controlled clinical trials such as the Women 's Health Initiative have changed the practice of CVD prevention in women over the past decade.5 The investment in combating this major public health issue for women has been significant , as have the scientific and medical achievements . Despite the gains that have been made , considerable challenges remain . In 2007 , CVD still caused ≈1 death per minute among women in the United States.6 These represent 421 918 deaths , more women 's lives than were cl aim ed by cancer , chronic lower respiratory disease , Alzheimer disease , and accidents combined.6 Reversing a trend of the past 4 decades , CHD death rates in US women 35 to 54 years of age now actually appear to be increasing , likely because of the effects of the obesity epidemic.4 CVD rates in the United States are significantly higher for black females compared with their white counterparts ( 286.1/100 000 versus Background Coronary heart disease ( CHD ) is the most common cause of death in the UK . CHD cost the UK National Health Service ( NHS ) £ 3.5 billion in 2003 . The economic impact of community pharmacists providing a medicines management service for patients with CHD has not been rigorously evaluated ; the full economic costs of such interventions are rarely presented in the literature . Objective To examine the incremental costs of a 1-year community pharmacistled medicines management service for patients with CHD in the UK , from a healthcare system and patient perspective . Methods and participants A cost-minimisation analysis was conducted alongside a multicentre r and omised controlled trial . The primary study participants were patients with CHD identified from general practice computer records . Patients ( intervention , n = 980 ; control , n = 500 ) from 38 general practice s in nine geographical areas in the UK were included in the study .Intervention and outcomes measures The intervention consisted of a review of pharmaceuticals and lifestyle advice by pharmacists in their premises , with recommendations communicated to the patient ’s GP . The main outcome measure was the incremental cost per patient in the intervention group compared with the control group . Annual costs ( £ , 2003/4 values ) included the costs of the intervention ( training and delivery costs ) , the usual costs of NHS treatment ( costs of pharmaceuticals , GP and hospital visits ) and costs borne by patients . Data were collected in the 12 months before and 12 months after the intervention . Results The total NHS cost increased between baseline and follow-up in both groups ( from £ 1243 to £ 1286 [ 3 % ] in the control group and from £ 1410 to £ 1433 [ 2 % ] in the intervention group).The greater cost in the intervention group largely reflects the additional cost of the pharmacist training and the time taken to deliver the intervention ; the difference in costs between the intervention and control groups , after controlling for differences in costs at baseline at follow-up , was statistically significant ( p = 0.001 ) . The costs of pharmaceuticals was higher in the intervention group ( £ 769.20 vs £ 742.3 ; p = 0.04).According to the sensitivity analysis , the intervention cost would need to decrease by 35 % to achieve equivalence between costs in each arm of the trial . Difference to costs of patients and their carers at follow-up were not statistically significant . Conclusions The introduction of a 1-year pharmacist-led medicines management service is likely to increase the total cost of CHD treatment and prevention from the healthcare perspective , as the cost of the intervention outweighed the observed reduction in the cost of drugs in the intervention group . No changes in costs from the patient perspective were found A controlled intervention trial , with the purpose of testing the hypothesis that the incidence of coronary heart disease ( CHD ) could be decreased by the use of serum-cholesterol-lowering ( SCL ) diet , was carried out in 2 mental hospitals near Helsinki in 1959 - -71 . The subjects were hospitalized middle-aged men . One of the hospitals received the SCL diet , i.e. a diet low in saturated fats and cholesterol and relatively high in polyunsaturated fats , while the other served as the control with a normal hospital diet . Six years later the diets were reversed , and the trial was continued another 6 years . The use of the SCL diet was associated with markedly lowered serum-cholesterol values . The incidence of CHD , as measured by the appearance of certain electrocardiographic patterns and by the occurrence of coronary deaths , was in both hospitals during the SCL-diet periods about half that during the normal-diet periods . An examination of a number of potential confounding variables indicated that the changes in them were small and failed to account for the considerable reduction in the incidence of CHD . It is concluded that the use of the serum-cholesterol-lowering diet exerted a substantial preventive effect on CHD Aims : To evaluate the effect of a disease management programme for patients with coronary heart disease ( CHD ) and chronic heart failure ( CHF ) in primary care . Methods : A cluster r and omised controlled trial of 1316 patients with CHD and CHF from 20 primary care practice s in the UK was carried out . Care in the intervention practice s was delivered by specialist nurses trained in the management of patients with CHD and CHF . Usual care was delivered by the primary healthcare team in the control practice s. Results : At follow up , significantly more patients with a history of myocardial infa rct ion in the intervention group were prescribed a beta-blocker compared to the control group ( adjusted OR 1.43 , 95 % CI 1.19 to 1.99 ) . Significantly more patients with CHD in the intervention group had adequate management of their blood pressure ( < 140/85 mm Hg ) ( OR 1.61 , 95 % CI 1.22 to 2.13 ) and their cholesterol ( < 5 mmol/l ) ( OR 1.58 , 95 % CI 1.05 to 2.37 ) compared to those in the control group . Significantly more patients with an unconfirmed diagnosis of CHF had a diagnosis of left ventricular systolic dysfunction confirmed ( OR 4.69 , 95 % CI 1.88 to 11.66 ) or excluded ( OR 3.80 , 95 % CI 1.50 to 9.64 ) in the intervention group compared to the control group . There were significant improvements in some quality -of-life measures in patients with CHD in the intervention group . Conclusions : Disease management programmes can lead to improvements in the care of patients with CHD and presumed CHF in primary care BACKGROUND Elevated plasma total homocysteine ( tHcy ) , low B-vitamin intake , and genetic polymorphisms related to tHcy metabolism may play roles in coronary heart disease ( CHD ) . More prospect i ve studies are needed . METHODS AND RESULTS We used a prospect i ve case-cohort design to determine whether tHcy-related factors are associated with incidence of CHD over an average of 3.3 years of follow-up in a biracial sample of middle-aged men and women . Age- , race- , and field center-adjusted CHD incidence was associated positively ( P<0.05 ) with tHcy in women but not men , and CHD was associated negatively ( P<0.05 ) with plasma folate ( women only ) , plasma pyridoxal 5'-phosphate ( both sexes ) , and vitamin supplementation ( women only ) . However , after accounting for other risk factors , only plasma pyridoxal 5'-phosphate was associated with CHD incidence ; the relative risk for the highest versus lowest quintile of pyridoxal 5'-phosphate was 0.28 ( 95 % CI=0.1 to 0.7 ) . There was no association of CHD with the C677 T mutation of the methylenetetrahydrofolate reductase gene or with 3 mutations of the cystathionine beta-synthase gene . CONCLUSIONS Our prospect i ve findings add uncertainty to conclusions derived mostly from cross-sectional studies that tHcy is a major , independent , causative risk factor for CHD . Our findings point more strongly to the possibility that vitamin B6 offers independent protection . R and omized trials , some of which are under way , are needed to better clarify the interrelationships of tHcy , B vitamins  , and cardiovascular disease BACKGROUND While it has been suggested that periodontal disease may be associated with coronary heart disease , or CHD , there are no data to suggest that the elimination of chronic dental infections actually lowers the risk of developing chronic CHD . The goal of this study was to determine whether people with a definitive elimination of all potential dental infections -- edentulous people , who are at the optimum endpoint of dental infection elimination from a CHD perspective -- lower their CHD risk over time when compared with people who have a specific dental infection , periodontitis . METHODS The authors examined data from a prospect i ve cohort of 4,027 people who participated in the First National Health and Nutrition Examination Survey , or NHANES I , Epidemiologic Follow-up Study . The primary outcome measure was the first CHD event . RESULTS During a mean follow-up of 17 years , there were 1,238 CHD events ( 538 fatal ) . The confirmed elimination of chronic dental infections did not lead to a decreased risk of experiencing a CHD event ( relative risk , 1.02 ; 95 percent confidence interval , 0.86 - 1.21 ) . The CHD risk among people with and without chronic dental infections remained constant over time with respect to each other ( test for increasing or decreasing trend over time : not significant , chi2(1 ) = 0.48 ; P = .93 ) . CONCLUSIONS People who had a complete , definitive and long-term elimination of all potential dental infections through extraction of all teeth did not have lower CHD risk when compared with people with diagnosed periodontitis . CLINICAL IMPLICATION S Until evidence is found to the contrary , the authors suggest that prevention of CHD should not be used as the basis for recommending treatment to eliminate chronic dental infections OBJECTIVE To explore the effect of community nursing intervention on awareness regarding primary prevention knowledge , self-management , and risk factors for coronary heart disease ( CHD ) in Hengyang City , Hunan Province . METHODS A total of 120 individuals at high risk of CHD were recruited and divided into a control group and an intervention group . The intervention group was given the health knowledge lecture and individual community nursing intervention . The control group was given the routine management . Before and after the intervention , all of the recruiters were evaluated by the awareness on primary prevention knowledge , self-management and risk factors for CHD . RESULTS Before the intervention , there was no significant difference in the demographic data , the cognitive levels regarding primary prevention knowledge , the self-management and the risk factors for CHD between the 2 groups ( P>0.05 ) . After the intervention , the cognitive levels regarding primary prevention knowledge , the self-management and the risk factors for CHD between the 2 groups changed . In the intervention group , the cognitive level was significantly increased ( P<0.05 ) ; the self management score was improved ; the systolic blood pressure , BMI , and the levels of fasting glucose , TC and low density lipoprotein-cholesterol were significantly decreased and the level of high density lipoprotein-cholesterol was significantly increased ( P<0.05 ) . There was no significant difference in the above-mentioned parameters between before and after intervention in the control group ( P>0.05 ) . CONCLUSION The cognitive levels regarding primary prevention knowledge and self-management for CHD can be improved effectively by community nursing intervention in high-risk population of CHD , and the risk factors for CHD can also be reduced Background Cardiovascular disease ( CVD ) remains the leading cause of death globally . Primary prevention of CVD requires cost-effective strategies to identify individuals at high risk in order to help target preventive interventions . An integral part of this approach is the use of CVD risk scores . Limitations in previous studies have prevented reliable inference about the potential advantages and the potential harms of using CVD risk scores as part of preventive strategies . We aim to evaluate short-term effects of providing different types of information about coronary heart disease ( CHD ) risk , alongside lifestyle advice , on health-related behaviours . Methods / Design In a parallel-group , open r and omised trial , we are allocating 932 male and female blood donors with no previous history of CVD aged 40–84 years in Engl and to either no intervention ( control group ) or to one of three active intervention groups : i ) lifestyle advice only ; ii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic characteristics ; and iii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic and genetic characteristics . The primary outcome is change in objective ly measured physical activity . Secondary outcomes include : objective ly measured dietary behaviours ; cardiovascular risk factors ; current medication and healthcare usage ; perceived risk ; cognitive evaluation of provision of CHD risk scores ; and psychological outcomes . The follow-up assessment takes place 12 weeks after r and omisation . The experiences , attitudes and concerns of a subset of participants will be also studied using individual interviews and focus groups . Discussion The INFORM study has been design ed to provide robust findings about the short-term effects of providing different types of information on estimated 10-year CHD risk and lifestyle advice on health-related behaviours . Trial registration Current Controlled Trials IS RCT N17721237 . Registered 12 January 2015 Objective : The National Heart , Lung , and Blood Institute convened an interdisciplinary working group of experts to develop recommendations for the assessment and treatment of depression in patients with coronary heart disease ( CHD ) . Method : Consensus of experts . Results : Our current recommendations are that the Beck Depression Inventory-I be employed for epidemiological studies of depression and CHD , that the Patient Health Question naire 2-item version be employed for screening for trial eligibility , that the Depression Interview and Structured Hamilton ( DISH ) be employed for diagnostic ascertainment for trial inclusion , and that the Hamilton rating scale , which is part of the DISH , be employed for both depression symptom reduction and the remission criterion in any trial . We further recommend that a r and omized controlled trial be undertaken to determine whether selective serotonin reuptake inhibitors , psychotherapy , or combined treatment can reduce the risk of CHD events and mortality associated with depression in CHD patients . Conclusions : This report summarizes the recommendations made by the working group and discusses the rationale for each recommendation , the strengths and weaknesses of alternative approaches to assessment and treatment , and the implication s for future research in this area . ACS = acute coronary syndrome ; BDI = Beck Depression Inventory ; CBASP = Cognitive Behavioral Analysis System of Psychotherapy ; CBT = cognitive behavior therapy ; CIDI = Composite International Diagnostic Interview ; CHD = coronary heart disease ; CVD = cardiovascular disease ; DISH = Depression Interview and Structured Hamilton ; ENRICHD = Enhancing Recovery in Coronary Heart Disease ; HAM-D = Hamilton Rating Scale for Depression ; IDS-SR = Inventory of Depressive Symptomatology , self-report ; IMPACT = Improving Mood – Promoting Access to Collaborative Treatment ; IPT = interpersonal therapy ; MI = myocardial infa rct ion ; NHLBI = National Heart , Lung , and Blood Institute ; PHQ = Patient Health Question naire ; RCT = r and omized controlled trial ; SADHART = Sertraline Antidepressant Heart Attack R and omized Trial ; SCID = Structured Clinical Interview for DSM-IV ; SSRI = selective serotonin reuptake inhibitor ; STAR*D = Sequenced Treatment Alternatives to Relieve Depression BACKGROUND Patients with coronary heart disease ( CHD ) who experience depressed mood or psychological stress exhibit decreased vagal control of heart rate ( HR ) , as assessed by spectral analysis of HR variability ( HRV ) . Myocardial infa rct ion and sudden cardiac death are independently associated with depression and stress , as well as impaired vagal HR control . This study examined whether a behavioral neurocardiac intervention to reduce stress or depression can augment cardiovagal modulation in CHD patients . We hypothesized that ( 1 ) cognitive-behavioral training with HRV biofeedback would augment vagal recovery from acute stress , and ( 2 ) vagal regulation of HR would be inversely associated with stress and depression after treatment . METHODS This r and omized controlled trial enrolled 46 CHD patients from 3 clinics of CHD risk reduction in Toronto and Vancouver , Canada . Subjects were r and omized to five 1.5-hour sessions of HRV biofeedback or an active control condition . Outcome was assessed by absolute and normalized high-frequency spectral components ( 0.15 - 0.50 Hz ) of HRV , and by the Perceived Stress Scale and Centre for Epidemiologic Studies in Depression scale . RESULTS Both groups reduced symptoms on the Perceived Stress Scale ( P = .001 ) and Centre for Epidemiologic Studies in Depression scale ( P = .004 ) . Hierarchical linear regression determined that improved psychological adjustment was significantly associated with the high-frequency index of vagal HR modulation only in the HRV biofeedback group . Adjusted R 2 was as follows : HRV biofeedback group , 0.86 for stress ( P = .02 ) and 0.81 for depression ( P = .03 ) ; versus the active control group , 0.04 ( P = .57 ) and 0.13 ( P = .95 ) , respectively . CONCLUSION A novel behavioral neurocardiac intervention , HRV biofeedback , can augment vagal HR regulation while facilitating psychological adjustment to CHD BACKGROUND Effective therapies for reducing mortality rates in persons with coronary heart disease ( CHD ) remain underused . We report the results of an effectiveness trial of a quality improvement effort to increase the use of 3-hydroxy-3methylglutaryl coenzyme A ( HMG CoA ) reductase inhibitors , beta-blockers , 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 . The use of therapies was assessed by linkage with a pharmacy data base . An intervention , consisting of a guideline summary , peer comparison performance feedback , and patient specific chart reminders was evaluated in a r and omized , practice -based effectiveness trial . RESULTS Data were available for > 700 patients per year ( 1999 - 2002 ) in 131 practice s. At baseline ( 1999 ) , 55 % of patients were receiving HMG CoA reductase inhibitors , 39 % of patients were receiving beta-blockers , and 24 % of patients were receiving ACE inhibitors . The use of all 3 types of medications increased steadily with time , with the exception of a decrease in the use of HMG CoA reductase inhibitors in the final year ( 2002 ) . No difference in medication use was observed between r and omized groups . CONCLUSIONS The observed pattern of care supports the contention that the quality of outpatient care for secondary prevention of CHD improved from 1999 to 2002 in this setting . The basis for the inconsistent pattern of use of HMG CoA reductase inhibitors is not certain , but may relate to concerns about toxicity . Central ized mailings of guideline summaries , performance feedback reports , and chart reminders had no observable impact on quality of care in this setting . More intensive intervention may be required to improve the quality of outpatient care for the secondary prevention of CHD 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 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 ) : Background Lifestyle measures of coronary heart disease ( CHD ) prevention have been overshadowed by the efficacy of drug treatments . This is particularly the case in the setting of secondary prevention where the benefits of lipid lowering , anti-platelet and anti-hypertensive drugs have been emphasised in numerous trials . Lifestyle measures address several CHD risk factors at once and are generally free of serious side effects . Objectives The objective of the present study was to determine whether a comprehensive programme of lifestyle modification could favourably influence dietary and exercise habits in addition to smoking cessation over two years . In addition , an attempt was made to evaluate if this programme could favourably influence the five-year CHD-risk in the male population included in the study . Design A total of 197 patients with proven coronary heart disease were included and r and omised to a lifestyle intervention programme or to usual care . Follow-up was after a period of two years . Methods Intervention comprised a low fat diet , regular exercise , smoking cessation , psychosocial support and education , delivered by nurses on the rationale for pharmacological and lifestyle measures . Usual care comprised follow-up in the routine outpatient clinic . Both groups were given the same comprehensive medication according to recent guidelines . Results Patients in the lifestyle intervention group reduced the intake of saturated fat , sugar and cholesterol ( P<0.001 ) , increased their exercise level ( P<0.01 ) and stopped smoking ( P<0.05 ) when compared with the usual care group . A sub analysis of the influence of five-year CHD calculated risk in males result ed in a relative risk reduction of 22 % ( 95 % confidence intervals 9 - 35 ) . Although significant , this result must be interpreted with caution due to poor statistical power and reproducibility of the method . Conclusions In the presence of modern drug treatments for secondary cardiovascular disease prevention it remains possible through a favourable diet , exercise and smoking cessation to show an additional reduction in the five-year risk for CHD in males BACKGROUND Psychological risk factors such as anxiety and depression have been associated with coronary heart disease ( CHD ) . Stress can have an impact on the risk factors for the disease , such as high blood pressure ( BP ) , physical inactivity and being overweight . AIMS Examine the effect of the Mindfulness-Based Stress Reduction ( MBSR ) program on symptoms of anxiety and depression , perceived stress , BP and body mass index ( BMI ) in patients with CHD . SETTING S AND DESIGN Intervention was carried out at an Outpatient clinic . Parallel group - MBSR group ; and treatment-as-usual group ( TAU ) - r and omized control design with pre- ( baseline ) , post-intervention and follow-up assessment s was adopted . MATERIAL S AND METHODS Thirty male patients , age range ( 30 - 65 years ) with CHD were r and omly allocated to either group . The therapeutic program comprised of eight weekly sessions of structured MBSR intervention for the MBSR group and one health education session for the TAU group . Regular medical intervention and monthly consultations with the cardiologist were consistent for both groups . The main outcome measures were : Hospital Anxiety and Depression Scale , Perceived Stress Scale ( perceived stress ) , BP and BMI . STATISTICAL ANALYSIS Independent sample t-tests , chi square test and paired sample t-test were used . RESULTS All patients completed intervention in the MBSR group . Significant reduction was observed in symptoms of anxiety and depression , perceived stress , BP and BMI in patients of the MBSR group after the completion of intervention assessment . At 3-month follow-up , therapeutic gains were maintained in patients of the MBSR group . CONCLUSION The MBSR program is effective in reducing symptoms of anxiety and depression , perceived stress , BP and BMI in patients with CHD An extensive psychosocial question naire was administered to 1674 coronary free individuals participating in the Framingham Heart Study between 1965 and 1967 . The respondents were followed for the development of coronary heart disease ( CHD ) over an eight-year period . Women ( aged 45 - 64 years ) who developed CHD scored significantly higher on the Framingham Type A behavior ,  suppressed hostility  ( not showing or discussing anger ) , tension , and anxiety symptoms scales than women remaining free of CHD . Type A women developed twice as much CHD and three times as much angina as Type B women . In a multivariate analysis , Framingham Type A behavior and not discussing anger were independent predictors of CHD incidence when controlled for the st and ard coronary risk factors and other psychosocial scales . Men exhibiting Framingham Type A behavior , work overload , suppressed hostility ( not showing anger ) , and frequent job promotions were at increased risk of developing CHD ( especially in the age group 55 - 64 years ) . Among men aged 45 - 64 years , Type A behavior was associated with a twofold risk of angina , myocardial infa rct ion , and CHD in general , as compared to Type B behavior . The association was found only among white-collar workers and was also independent of the st and ard coronary risk factors and other psychosocial scales . This prospect i ve study suggests that Type A behavior and suppressed hostility may be involved in the pathogenesis of CHD in both men and women Objectives To ascertain if motivational techniques and a structured exercise programme can increase activity in adolescents afflicted with congenital heart disease ( CHD ) . Design Prospect i ve r and omised controlled trial . Setting One hundred and forty-three patients aged 12–20 years attending the tertiary centre for paediatric cardiology in Northern Irel and . Main outcome measures Increase in exercise capacity as assessed by duration of exercise stress test , and number of minutes spent in moderate to vigorous physical activity ( MVPA ) per day . Results Eighty-six patients were men ( 60 % ) , mean age was 15.60±2.27 years . Seventy-three percent were considered to have major CHD . Seventy-two participants were r and omised to the intervention group . Following intervention , duration of exercise test increased by 1 min 5 s for the intervention group ( p value 0.02 ) along with increase in predicted VO2Max ( p value 0.02 ) . There was a significant increase in minutes of MVPA per day for the intervention group from baseline to re assessment ( p value < 0.001 ) while MVPA remained much the same for the control group . Fourteen patients met the current recommendation for more than 60 min MVPA per day at baseline . This doubled to 29 participants at re assessment . There were no adverse effects or mortalities reported . Conclusions Exercise training  is safe , feasible and beneficial in adolescents with CHD . Psychological techniques can be employed to maximise the impact of interventions . Trial Registration Number IS RCT N27986270 Men incurring coronary heart disease ( CHD ) during surveillance of an employed population were studied for risk factors associated with additional myocardial infa rct ions . The coronaryprone Type A behavior pattern measured by a  test score , number of cigarettes smoked daily , and serum cholesterol  were significant discriminators between the 67 men with recurrent CHD and the 220 with but a single clinical CHD event .  Diastolic blood pressure and fasting serum triglycerides were not significant discriminators . Statistical analyses directed to possible sources of bias occasioned by the combined retrospective- prospect i ve study design revealed that these problems are negligible and do not alter the findings observed . Type A score appears relatively unaffected by whether the measure was made before or after the initial CHD event . Multivariable discriminant function equations showed Type A score to be the strongest single predictor of recurrent CHD among the variables available . Number of cigarettes smoked and serum cholesterol accounted for additional variance . Future field trials for the secondary prevention of myocardial infa rct ion would be strengthened by consideration of the possible role of Type A behavior Despite race , ethnic , and regional differences in cardiovascular disease risk , many worldwide hypertension management guidelines recommend the use of the Framingham coronary heart disease ( CHD ) risk equation to guide treatment decisions . This sub analysis of the recently published CRUCIAL trial compared the treatment-related reductions in calculated CHD and stroke risk among Pacific Asian ( PA ) patients using a variety of region-specific risk assessment models . As a result , greater reductions in systolic and diastolic blood pressure , low-density lipoprotein cholesterol , and triglycerides were observed in the proactive multifactorial intervention ( PMI ) arm compared with the usual care arm at Week 52 for PA patients . The relative percentage change in 10-yr CHD risk between baseline and Week 52 in the PMI versus usual care arms was greatest using the NIPPON DATA 80 fatal CHD model ( LS [ least square ] mean difference -42.6 % ) , and similar in the SCORE fatal CHD and Framingham total CHD models ( LS mean difference -29.4 % and -30.8 % , respectively ) . The single-pill based PMI approach is consistently effective in reducing cardiovascular disease risk , evaluated using a variety of risk assessment models . ( Clinical Trials.gov registration number : NCT00407537 Background — Although trials of lifestyle interventions generally focus on cardiovascular disease risk factors rather than hard clinical outcomes , 10-year coronary heart disease ( CHD ) risk can be estimated from the Framingham risk equations . Our objectives were to study the effect of 2 multicomponent lifestyle interventions on estimated CHD risk relative to advice alone and to evaluate whether differences can be observed in the effects of the lifestyle interventions among subgroups defined by baseline variables . Methods and Results — A total of 810 healthy adults with untreated prehypertension or stage I hypertension were r and omized to 1 of 3 intervention groups : An “ advice-only ” group , an “ established ” group that used established lifestyle recommendations for blood pressure control ( sodium reduction , weight loss , and increased physical activity ) , or an “ established-plus-DASH ” group that combined established lifestyle recommendations with the DASH ( Dietary Approaches to Stop Hypertension ) diet . The primary outcome was 10-year CHD risk , estimated from follow-up data collected at 6 months . A secondary outcome was 10-year CHD risk at 18 months . Of the 810 participants , 62 % were women and 34 % were black . Mean age was 50 years , mean systolic/diastolic blood pressure was 135/85 mm Hg , and median baseline Framingham risk was 1.9 % . The relative risk ratio comparing 6-month to baseline Framingham risk was 0.86 ( 95 % confidence interval 0.81 to 0.91 , P<0.001 ) in the established group and 0.88 ( 95 % confidence interval 0.83 to 0.94 , P<0.001 ) in the established-plus-DASH group relative to advice alone . Results were virtually identical in sensitivity analyses , in each major subgroup , and at 18 months . Conclusions — The observed reductions of 12 % to 14 % in estimated CHD risk are substantial and , if achieved , should have important public health benefits BACKGROUND Several studies have suggested an increased risk of fatal coronary heart disease ( CHD ) among patients with panic disorder , phobic anxiety , and other anxiety disorders . We prospect ively examined this association in the Normative Aging Study . METHODS AND RESULTS An anxiety symptoms scale was constructed out of five items from the Cornell Medical Index , which was administered to the cohort at baseline . During 32 years of follow-up , we observed 402 cases of incident coronary heart disease ( 137 cases of nonfatal myocardial infa rct ion , 134 cases of angina pectoris , and 131 cases of fatal CHD : made up of 26 cases of sudden cardiac death and 105 cases of nonsudden death ) . A nested case-control design ( involving 1869 control subjects who remained free of diagnosed CHD ) was used to assess the association between anxiety and risk of CHD . Compared with men reporting no symptoms of anxiety , men reporting two or more anxiety symptoms had elevated risks of fatal CHD ( age-adjusted odds ratio [ OR ] = 3.20 , 95 % confidence interval [ CI ] : 1.27 to 8.09 ) , and sudden death ( age-adjusted OR = 5.73 , 95 % CI : 1.26 to 26.1 ) . The multivariate OR after adjusting for a range of potential confounding variables was 1.94 ( 95 % CI : 0.70 - 5.41 ) for fatal CHD and 4.46 ( 95 % CI : 0.92 - 21.6 ) for sudden death . No excess risks were found for nonfatal myocardial infa rct ion or angina . CONCLUSIONS These data suggest an association between anxiety and fatal coronary heart disease , in particular , sudden cardiac death BACKGROUND Despite the large body of evidence confirming the effectiveness of lipid lowering for the secondary prevention of coronary heart disease ( CHD ) events , undertreatment of hyperlipidemia is common . This study tested the effectiveness of a nurse case management program to lower blood lipids in patients with CHD . METHODS A total of 228 consecutive , eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization . Patients were r and omized to receive lipid management , including individualized lifestyle modification and pharmacologic intervention , from a nurse practitioner for 1 year after discharge in addition to their usual care ( NURS ) , or to usual care enhanced with feedback on lipids to their primary provider and /or cardiologist ( EUC ) . RESULTS Significantly more patients in the NURS group than in the EUC group achieved low-density lipoprotein cholesterol ( LDL-C ) levels < 2.59 mmol/dL ( 100 mg/dL , 65 % vs 35 % , P = .0001 ) . Favorable changes in lipids and lipoproteins were accompanied by significant improvements in dietary and exercise patterns in the NURS group . In a multivariate analysis adjusting for other covariates , being assigned to the NURS group ( P = .0001 ) and being on a lipid-lowering medication ( P = .001 ) were significant independent predictors of LDL-C level . CONCLUSIONS Control of hypercholesterolemia in patients who have undergone coronary revascularization can be improved by a nurse case-management program . Because the National Cholesterol Education Program Adult Treatment Panel III guidelines have broadened the definition of high-risk population s that warrant aggressive treatment , nurse case-management programs may offer key opportunities to enhance appropriate application of new treatment paradigms Background Depression is common in people with coronary heart disease ( CHD ) and associated with worse outcome . This study explored the acceptability and feasibility of procedures for a trial and for an intervention , including its potential costs , to inform a definitive r and omized controlled trial ( RCT ) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression . Methods Multi-centre , outcome assessor-blinded , r and omized parallel group study . CHD patients reporting chest pain and scoring 8 or more on the HADS were r and omized to personalized care ( PC ) or treatment as usual ( TAU ) for 6 months and followed for 1 year . Primary outcome was acceptability and feasibility of procedures ; secondary outcomes included mood , chest pain , functional status , well being and psychological process variables . Result 1001 people from 17 General Practice CHD registers in South London consented to be contacted ; out of 126 who were potentially eligible , 81 ( 35 % female , mean age = 65 SD11 years ) were r and omized .  PC  participants ( n = 41 ) identified wide ranging problems to work on with nurse-case managers . Good acceptability and feasibility was indicated by low attrition ( 9 % ) , high engagement and minimal nurse time used ( mean/SD = 78/19 mins assessment , 125/91 mins telephone follow up ) . Both groups improved on all outcomes . The largest between group difference was in the proportion no longer reporting chest pain  ( PC 37 % vs TAU 18 % ; mixed effects model OR 2.21 95 % CI 0.69 , 7.03 ) . Some evidence was seen that self efficacy ( mean scale increase of 2.5 vs 0.9 ) and illness perceptions ( mean scale increase of 7.8 vs 2.5 ) had improved in PC vs TAU participants at 1 year . PC appeared to be more cost effective up to a QALY threshold of approximately £ 3,000 . Conclusions Trial and intervention procedures appeared to be feasible and acceptable . PC allowed patients to work on unaddressed problems and appears cheaper than TAU . Trial Registration Controlled-Trials.com IS RCT OBJECTIVE To examine the effects of alcohol on risk of mortality from coronary heart disease ( CHD ) , cardiovascular disease , and all causes in men with established CHD . METHODS AND RESULTS In a population based prospect i ve study of 7169 men aged 45–64 years followed for a mean of 12.8 years , 655 men ( 9.1 % ) had a physician diagnosis of CHD ( myocardial infa rct ion 455 , angina only 200 ) . In these 655 men , there were 294 deaths from all causes including 175 CHD deaths . Ex-drinkers had the highest risk of CHD , cardiovascular mortality , and all cause mortality even after adjustment for lifestyle characteristics and pre-existing disease . Using occasional drinkers as the reference group , lifelong teetotallers , occasional drinkers , and light drinkers all showed similar risks of mortality from CHD , cardiovascular disease , and all causes . Moderate/heavy drinkers showed increased risk of mortality from CHD , cardiovascular disease , and all causes compared to occasional drinkers . The adverse effect of moderate/heavy drinking was confined to the 455 men with previous myocardial infa rct ion ( adjusted relative risk for all cause mortality 1.50 , 95 % confidence interval 1.01 to 2.23 ) . In contrast to lighter drinking , giving up smoking within five years of the start of follow up was associated with a considerable reduction in risk of all cause and cardiovascular mortality compared to those who continued to smoke . CONCLUSION Compared to occasional drinking , regular light alcohol consumption ( 1–14 units per week ) in men with established coronary heart disease is not associated with any significant benefit or deleterious effect for CHD , cardiovascular disease or all cause mortality . Higher levels of intake ( ⩾ 3 drinks per day ) are associated with increased mortality in men with previous myocardial infa rct ion . In contrast , smoking cessation in men with established CHD substantially reduces the risk of mortality The Minnesota Prospect i ve Study on coronary heart disease ( CHD ) in 284 business and professional men began in 1947 . In 1953 and 1955 measurements were made of  serum alpha-lipoprotein ( HDL ) cholesterol  on the men . The mean was 45 . 2 mg/dl , the same as reported for HDL cholesterol in men of that age at Framingham . As with HDL at Framingham and elsewhere , alpha cholesterol was not correlated with age , blood-pressure , total cholesterol , or smoking habit , but was negatively correlated ( r=-0.37 ) with relative body-weight . In the next 25 years 133 men died , 55 from CHD . Mean alpha cholesterol of those who died from CHD was lower than that of men dying from other causes but was not significantly different from the mean of the 120 men alive in 1978 . Of all groups classified by 25-year outcome , the 32 men who died from neoplasms had the highest mean alpha cholesterol at entry , differing significantly from survivors . Multivariate analysis did not change the relationships . Consideration of CHD only and follow-up of only a few years may greatly distort evaluation of the overall long-term significance of HDL cholesterol concentration in the plasma BACKGROUND Previous studies have linked full-calorie sugar-sweetened beverages ( SSBs ) with greater weight gain and an increased risk of type 2 diabetes . OBJECTIVE We prospect ively examined the association between consumption of SSBs and the risk of coronary heart disease ( CHD ) in women . DESIGN Women ( n = 88,520 ) from the Nurses ' Health Study aged 34 - 59 y , without previously diagnosed coronary heart disease ( CHD ) , stroke , or diabetes in 1980 , were followed from 1980 to 2004 . Consumption of SSBs was derived from 7 repeated food-frequency question naires administered between 1980 and 2002 . Relative risks ( RRs ) for CHD were calculated by using Cox proportional hazards models and adjusted for known cardiovascular disease risk factors . RESULTS During 24 y of follow-up , we ascertained 3105 incident cases of CHD  ( nonfatal myocardial infa rct ion and fatal CHD ) . After st and ard and dietary risk factors were adjusted for , the RRs ( and 95 % CIs ) of CHD according to categories of cumulative average of SSB consumption ( < 1/mo , 1 - 4/mo , 2 - 6/wk , 1/d , and > or = 2 servings/d ) were 1.0 , 0.96 ( 0.87 , 1.06 ) , 1.04 ( 0.95 , 1.14 ) , 1.23 ( 1.06 , 1.43 ) , and 1.35 ( 1.07 , 1.69 ) ( P for trend < 0.001 ) . Additional adjustment for body mass index , energy intake , and incident diabetes attenuated the associations , but they remained significant . Artificially sweetened beverages were not associated with CHD . CONCLUSION Regular consumption of SSBs is associated with a higher  risk of CHD in women , even after other unhealthful lifestyle or dietary factors are accounted for Background : Elderly individuals who provide care to a spouse suffering from dementia bear an increased risk of coronary heart disease ( CHD ) . Objective : To test the hypothesis that the Framingham CHD Risk Score would be higher in  dementia caregivers  relative to non-caregiving controls . Methods : We investigated 64 caregivers providing in-home care for their spouse with Alzheimer ’s disease and 41 gender-matched non-caregiving controls . All subjects ( mean age 70 ± 8 years , 75 % women , 93 % Caucasian ) had a negative history of CHD and cerebrovascular disease . The original Framingham CHD Risk Score was computed adding up categorical scores for age , blood lipids , blood pressure , diabetes , and smoking with adjustment made for sex . Results : The average CHD risk score was higher in caregivers than in controls even when co-varying for socioeconomic status , health habits , medication , and psychological distress ( 8.0 ± 2.9 vs. 6.3 ± 3.0 points , p = 0.013 ) . The difference showed a medium effect size ( Cohen ’s d = 0.57 ) . A relatively higher blood pressure in caregivers than in controls made the greatest contribution to this difference . The probability ( area under the receiver operator curve ) that a r and omly selected caregiver had a greater CHD risk score than a r and omly selected non-caregiver was 65.5 % . Conclusions : Based on the Framingham CHD Risk Score , the potential to develop overt CHD in the following 10 years was predicted to be greater in dementia caregivers than in non-caregiving controls . The magnitude of the difference in the CHD risk between caregivers and controls appears to be clinical ly relevant . Clinicians may want to monitor caregiving status as a routine part of st and ard evaluation of their elderly patients ’ cardiovascular risk OBJECTIVE Coronary heart disease ( CHD ) is a leading cause of illness and death in Western society . The present study was design ed to evaluate the utility of illness perceptions and medication beliefs in predicting secondary preventive behaviour among patients with CHD . An extended version of Leventhal 's self-regulatory model ( SRM ) was used as a theoretical framework for this study [ Leventhal H , Nerenz DR , Steele DJ . Illness perceptions and coping with health threat . In : Baum A , Taylor SE , Singer JE , editors . H and book of psychology and health , Volume IV : social psychological aspects of health . Hillsdale ( NJ ) : Erlbaum , 1984 . pp . 219 - 52 ; Horne R , Weinman J. Self-regulation and self-management in asthma : exploring the role of illness perceptions and treatment beliefs in explaining non-adherence to preventer medication . Psychol Health 2002;17(1):17 - 32 ] . METHOD Medical and demographic data were gathered from the medical charts of 1611 patients with established CHD from 35 r and omly selected general practice s.  Self-report data about patients ' lifestyles ( diet , exercise , smoking , alcohol consumption and medication adherence ) and information on illness and medication beliefs were provided from postal question naire ( 1084 patients responded ; 69 % response rate ) . The relationship between patients ' beliefs and their secondary preventive behaviour was examined using regression analyses . RESULTS Illness perceptions appeared to be only weak predictors of smoking , exercise , diet , alcohol consumption and medication adherence , accounting for about 2 % of the variance in these behaviours . Medication beliefs were moderately related to medication adherence , accounting for about 7 % of the variance in scores . A strong belief in the necessity of one 's medication and a lower level of concern about one 's medication were associated with higher levels of adherence . CONCLUSIONS An illness perception approach did not prove helpful in predicting secondary preventive behaviour among this group of patients . However , beliefs about medications appear to be reasonable predictive of medication adherence BACKGROUND Physical activity and body mass index ( calculated as weight in kilograms divided by height in meters squared ) independently alter the risk of coronary heart disease ( CHD ) ; however , their combined effect on CHD is not established . Our objective was to study the combined association of physical activity and body mass index on CHD . METHODS Prospect i ve cohort study of 38,987 women free of cardiovascular disease , cancer , and diabetes at baseline in the Women 's Health Study , with 10.9 mean years of follow-up .  Weight , height , and recreational activities were reported on entry . Body mass index was categorized as normal weight ( < 25 ) , overweight ( 25 to < 30 ) , and obese ( > or = 30 ) . Active was defined as 1000 kilocalories or more expended on recreational activities weekly . Six joint body weight-physical activity categories were defined . The main outcome measure was the occurrence of incident CHD during follow-up , defined as a cardiovascular event including nonfatal myocardial infa rct ion , coronary artery bypass graft , percutaneous transluminal coronary angioplasty , or CHD death . RESULTS A total of 948 cases of incident CHD occurred during follow-up . Higher body mass index and physical inactivity were individual predictors of CHD . In joint analyses , compared with active normal-weight individuals , the multivariate-adjusted hazard ratios ( 95 % confidence intervals ) were 1.54 ( 1.14 - 2.08 ) for overweight-active ; 1.87 ( 1.29 - 2.71 ) for obese-active ; 1.08 ( 0.84 - 1.39 ) for normal weight-inactive ; 1.88 ( 1.46 - 2.42 ) for overweight-inactive ; and 2.53 ( 1.94 - 3.30 ) for obese-inactive . Increasing levels of walking also result ed in significant reductions in CHD risk for overweight and obese individuals . CONCLUSIONS The risk of CHD associated with elevated body mass index is considerably reduced by increased physical activity levels . However , the risk is not completely eliminated , reinforcing the importance of being lean and physically active BACKGROUND The objective of this study was to examine the association of Joint National Committee ( JNC-V ) blood pressure and National Cholesterol Education Program ( NCEP ) cholesterol categories with coronary heart disease ( CHD ) risk , to incorporate them into coronary prediction algorithms , and to compare the discrimination properties of this approach with other noncategorical prediction functions . METHODS AND RESULTS This work was design ed as a prospect i ve , single-center study in the setting of a community-based cohort . The patients were 2489 men and 2856 women 30 to 74 years old at baseline with 12 years of follow-up . During the 12 years of follow-up , a total of 383 men and 227 women developed  CHD , which was significantly associated with categories of blood pressure , total cholesterol , LDL cholesterol , and HDL cholesterol ( all P<.001 ) . Sex-specific prediction equations were formulated to predict CHD risk according to age , diabetes , smoking , JNC-V blood pressure categories , and NCEP total cholesterol and LDL cholesterol categories . The accuracy of this categorical approach was found to be comparable to CHD prediction when the continuous variables themselves were used . After adjustment for other factors , approximately 28 % of CHD events in men and 29 % in women were attributable to blood pressure levels that exceeded high normal ( > or = 130/85 ) . The corresponding multivariable-adjusted attributable risk percent associated with elevated total cholesterol ( > or = 200 mg/dL ) was 27 % in men and 34 % in women . CONCLUSIONS Recommended guidelines of blood pressure , total cholesterol , and LDL cholesterol effectively predict CHD risk in a middle-aged white population sample . A simple coronary disease prediction algorithm was developed using categorical variables , which allows physicians to predict multivariate CHD risk in patients without overt CHD BACKGROUND Dietary guidelines recommend increasing fruit and vegetable intake and , most recently , have also suggested increasing variety . OBJECTIVE We prospect ively examined the independent roles of quantity and variety in fruit and vegetable intake in relation to  incident coronary heart disease ( CHD ) .  DESIGN We prospect ively followed 71,141 women from the Nurses ' Health Study ( 1984 - 2008 ) and 42,135 men from the Health Professionals Follow-Up Study ( 1986 - 2008 ) who were free of diabetes , cardiovascular diseases , and cancer at baseline .  Diet was assessed by using a vali date d question naire and up date d every 4 y. Variety was defined as the number of unique fruit and vegetables consumed at least once per week . Potatoes , legumes , and fruit juices were not included in our definition of fruit and vegetables . RESULTS During follow-up , we documented 2582 CHD cases in women and 3607 cases in men . In multivariable analyses , after adjustment for dietary and nondietary covariates , those in the highest quintile of fruit and vegetable intake had a 17 % lower risk ( 95 % CI : 9 % , 24 % ) of CHD . A higher consumption of  citrus fruit , green leafy vegetables  , and  β-carotene- and vitamin C-rich fruit and vegetables was associated with a lower CHD risk . Conversely , quantity-adjusted variety was not associated with CHD . CONCLUSIONS Our data suggest that absolute quantity , rather than variety , in fruit and vegetable intake is associated with a significantly lower risk of CHD . Nevertheless , consumption of specific fruit and vegetable subgroups was associated with a lower CHD risk OBJECTIVES Psychosocial factors , including depression and vital exhaustion ( VE ) are associated with adverse outcome in coronary heart disease ( CHD ) . Women with CHD are poor responders to psychosocial treatment and knowledge regarding which treatment modality works in them is limited . This r and omized controlled clinical study evaluated the effect of a 1-year stress management program , aim ed at reducing symptoms of depression and VE in CHD women . DESIGN Patients were 247 women , < or = 75 years , recruited consecutively after a cardiac event and r and omly assigned to either stress management ( 20 2-h sessions ) and medical care by a cardiologist , or to obtaining usual health care as controls . Measurements at ; baseline ( 6 - 8 weeks after r and omization ) , 10 weeks ( after 10 intervention sessions ) , 1 year ( end of intervention ) and 1 - 2 years follow-up . RESULTS For VE , intention to treat analysis showed effects for time ( P < 0.001 ) and time x treatment interaction ( P = 0.005 ) , reflecting that both groups improved over time , and that the decrease of VE was more pronounced in the intervention group . However , the level of VE was higher in the intervention group than amongst controls at baseline , 22.7 vs. 19.4 ( P = 0.036 ) but it did not differ later . The change in depressive symptoms did not differ between the groups . CONCLUSIONS CHD women attending our program experienced a more pronounced decrease in VE than controls . However , as they had higher baseline levels , due to regression towards the mean we can not attribute the decrease in VE to the intervention . Whether the program has long-term beneficial effects needs to be evaluated BACKGROUND Although primary care is the major target of coronary heart disease ( CHD ) clinical recommendations , little is known of how community physicians view guidelines and their implementation . The REACT survey was design ed to assess the views , and perceived implementation , of CHD and lipid treatment guidelines among primary care physicians . METHODS Semi-structured vali date d telephone interviews were conducted , in the relevant native tongue , with 754 r and omly selected primary care physicians ( GPs and family doctors ) in five European countries ( France , Germany , Italy , Sweden and the UK ) . RESULTS Most physicians ( 89 % ) agreed with the content of current guidelines and reported use of them ( 81 % ) . However , only 18 % of physicians believed that guidelines were being implemented to a major extent . Key barriers to greater implementation of guidelines were seen as lack of time ( 38 % of all physicians ) , prescription costs ( 30 % ) , and patient compliance ( 17 % ) . Suggestions for ways to improve implementation centred on more education , both for physicians themselves ( 29 % ) and patients ( 25 % ) ; promoting , publicizing or increasing guideline availability ( 23 % ) ; simplifying the guidelines ( 17 % ) ; and making them clearer ( 12 % ) . Physicians perceived diabetes to be the most important risk factor for CHD , followed by hypertension and raised LDL-C. Most physicians ( 92 % ) believe their patients do associate high cholesterol levels with CHD . After establishing that a patient is ' at risk ' of CHD , physicians reported spending an average of 16.5 minutes discussing risk factors and lifestyle changes or treatment that is required . Factors preventing this included insufficient time ( 42 % ) , having too many other patients to see ( 27 % ) and feeling that patients did not listen or underst and anyway ( 21 % ) . CONCLUSIONS Primary care physicians need more information and support on the implementation of CHD and cholesterol guideline recommendations . This need is recognized by clinicians Background : The Mediterranean Lifestyle Program was evaluated for its effects on multiple behavioral risk factors for coronary heart disease ( CHD )  among postmenopausal women with diabetes . Purpose : Our purpose is to test a comprehensive lifestyle management intervention to reduce CHD risk in postmenopausal women with type 2 diabetes . Methods : Participants ( N = 279 ) were r and omized to usual care ( UC ) or Mediterranean Lifestyle Program , a lifestyle change intervention aim ed at the behavioral risk factors ( eating patterns , physical activity , stress management , and social support ) affecting risk for CHD in postmenopausal women with type 2 diabetes . Results : In original and intent-to-treat analyses ,  Mediterranean Lifestyle Program participants showed significantly greater improvement in dietary behaviors , physical activity , stress management , perceived support , and weight loss at 6 months compared to UC . Conclusions : This study demonstrated the effectiveness of the Mediterranean Lifestyle Program in improving self-care among women with type 2 diabetes , showed that postmenopausal women could make comprehensive lifestyle changes , and provided evidence that a program using social-cognitive strategies and peer support can be used to modify multiple lifestyle behaviors In the Lipid Research Clinics Coronary Primary Prevention Trial ( LRC-CPPT ) , a 19 % lower incidence of coronary heart disease ( CHD ) in  cholestyramine-treated men was accompanied by mean falls of 8 % and 12 % in plasma total ( TOTAL-C ) and low-density lipoprotein ( LDL-C ) cholesterol levels relative to levels in  placebo-treated men . When the cholestyramine treatment group was analyzed separately , a 19 % reduction in CHD risk was also associated with each decrement of 8 % in TOTAL-C or 11 % in LDL-C levels ( P less than .001 ) . Moreover , CHD incidence in men sustaining a fall of 25 % in TOTAL-C or 35 % in LDL-C levels , typical responses to the prescribed dosage ( 24 g/day ) of cholestyramine resin , was half that of men who remained at pretreatment levels . Adherence to medication was associated with reduced incidence of CHD only when accompanied by falls in TOTAL-C and LDL-C levels . Small increases in high-density lipoprotein cholesterol levels , which accompanied cholestyramine treatment , independently accounted for a 2 % reduction in CHD risk . Thus , the reduction of CHD incidence in the cholestyramine  group seems to have been mediated chiefly by reduction of TOTAL-C and LDL-C levels The objectives of this study were to : ( 1 ) study if an opportunistic screening of coronary heart disease ( CHD ) risk factors among male attenders in general practice ( GP ) influenced the overall subjective satisfaction with life of persons labelled ‘ high risk ’ compared to other screened persons ; ( 2 ) compare psychological well-being and patient satisfaction in a patient centred and self-directive ( PCSD ) intervention with conventional care ( CC ) ; and ( 3 ) evaluate patient satisfaction and psychological well-being among subjects with high CHD risk during a one year intervention study . Effects of ‘ labelling ’ were evaluated in 115 subjects with high CHD risk in comparison with a low risk reference population . The 22 participating GP centres were r and omly allocated to follow either a PCSD intervention or a CC approach . An overall satisfaction with life question was employed and psychological well-being were measured using the General Health Question naire ( 20 item version ) . Satisfaction measures on health care aspects were also included . No difference of change between the high risk and the reference population was found concerning satisfaction with life after screening . No significant difference of change was found within or between the PCSD and the CC group concerning emotional well-being or overall satisfaction with life during one year intervention . Satisfaction with the care received was significantly better in the CC group as compared with the PCSD group ( p=0.02 ) . Satisfaction with own efforts for improving health was , however , more pronounced in the PCSD group ( p=0.01 ) . A substantial number ( n=61 ) of the participants reported distaste of being reminded of the risk of heart disease and no more than 60 of the participants were satisfied with their own efforts for improving health . Although no significant change of satisfaction with life and emotional well-being due to screening or intervention could be detected , clinicians should be aware that encouraging patients to change life style may lead to patients ' annoyance of being reminded of the risk of disease and dissatisfaction with their own efforts . Increasing patient responsibility and self-determination may improve their satisfaction with their own efforts , but reduce satisfaction with medical care The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease ( CHD ) remains unclear . This systematic review aim ed to determine their effectiveness and included r and omized controlled trials of lifestyle interventions , in primary care or community setting s , 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 Background Cardiac rehabilitation ( CR ) is a secondary prevention program that offers education and support to assist patients with coronary heart disease ( CHD ) make lifestyle changes . Despite the benefits of CR , attendance at centre-based sessions remains low . Mobile technology ( mHealth ) has potential to reach more patients by delivering CR directly to mobile phones , thus providing an alternative to centre-based CR . The aim of this trial is to evaluate if a mHealth comprehensive CR program can improve adherence to healthy lifestyle behaviours ( for example , physically active , fruit and vegetable intake , not smoking , low alcohol consumption ) over and above usual CR services in New Zeal and adults diagnosed with CHD . Methods / design A two-arm , parallel , r and omised controlled trial will be conducted at two Auckl and hospitals in New Zeal and . One hundred twenty participants will be r and omised to receive a 24-week evidence - and theory-based personalised text message program and access to a supporting website in addition to usual CR care or usual CR care alone ( control ) . The primary outcome is the proportion of participants adhering to healthy behaviours at 6 months , measured using a composite health behaviour score . Secondary outcomes include overall cardiovascular disease risk , body composition , illness perceptions , self-efficacy , hospital anxiety/depression and medication adherence . Discussion This study is one of the first to examine an mHealth-delivered comprehensive CR program . Strengths of the trial include quality research design and in-depth description of the intervention to aid replication . If effective , the trial has potential to augment st and ard CR practice s and to be used as a model for other disease prevention or self-management programs . Trial registryAustralian New Zeal and Clinical Trials Registry : Objective : Prospect i ve studies have shown that effort-reward imbalance ( ERI ) at work is associated with the incidence of a first coronary heart disease ( CHD ) event . However , it is unknown whether ERI at work increases the risk of recurrent CHD events . The objective of this study was to determine whether ERI at work and its components ( effort and reward ) increase the risk of recurrent CHD in post-myocardial infa rct ion ( post-MI ) workers . Methods : We carried out a prospect i ve cohort study of 669 men and 69 women who returned to work after a first MI .  ERI at work was assessed by telephone interview using vali date d scales of reward and psychological dem and s. The outcome was a composite of fatal CHD , nonfatal MI , and unstable angina . CHD risk factors were documented in medical files and by interview . The participants were followed up for a mean period of 4.0 years ( 1998 - 2005 ) . Results : During the follow-up , 96 CHD events were documented . High ERI and low reward were associated with recurrent CHD ( respective adjusted hazard ratios [ HRs ] = 1.75 , 95 % confidence interval [ CI ] = 0.99 - 3.08 , and HR = 1.77 , 95 % CI = 1.16 - 2.71 ) . There was a gender interaction showing stronger effects among women ( respective adjusted HRs for high ERI and low reward : HR = 3.95 , 95 % CI = 0.93 - 16.79 , and HR = 9.53 , 95 % CI = 1.15 - 78.68 ) . Conclusions : Post-MI workers holding jobs that involved ERI or low reward had increased risk of recurrent CHD . BMI = body mass index ; CHD = coronary heart disease ; CI = confidence interval ; ERI = effort-reward imbalance ; HR = hazard ratio ; MI = myocardial infa rct ion PURPOSE We investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aim ed at reducing the gap between evidence -based goals and clinical practice in patients with coronary heart disease ( CHD ) . METHODS A prospect i ve r and omized controlled pragmatic trial was undertaken in a primary care setting . New evidence -based guidelines , with intensified lipid-lowering recommendations in CHD , were mailed to all general practitioners in the region and presented at a lecture in 1995 . General practitioners ( n = 54 ) and patients with CHD ( n = 88 ) were assigned according to their primary health care center to 2 balanced groups and r and omly allocated to usual care as a control or to an active intervention . General practitioners in the intervention group participated in repeated case-based training during a 2-year period . Patients whose CHD was treated by specialists ( n = 167 ) served as an internal specialist comparison group . Altogether , 255 consecutive patients were included .  Cox regression analysis was used to detect any survival benefit of the intervention . RESULTS At 10 years , 22 % of the patients in the intervention group had died as compared with 44 % in the control group ( P = .02 ) , with a hazard ratio of 0.45 ( 95 % confidence interval , 0.20–0.95 ) . This difference was mainly due to reduced cardiovascular mortality in the intervention group ( P = .01 ) . In addition , the mortality rate of 22 % in the intervention group was comparable to the rate of 23 % seen in patients treated by a specialist . CONCLUSIONS Use of case-based training to implement evidence -based practice in primary care was associated with decreased mortality at 10 years in patients with CHD CONTEXT There is evidence that job strain increases the risk of a first coronary heart disease ( CHD ) event . However , little is known about its association with the risk of recurrent CHD events after a first myocardial infa rct ion ( MI ) . OBJECTIVE To determine whether job strain increases the risk of recurrent CHD events . DESIGN , SETTING , AND PATIENTS Prospect i ve cohort study of 972 men and women aged 35 to 59 years who returned to work after a first MI and were then followed up between February 10 , 1996 , and June 22 , 2005 . Patients were interviewed at baseline ( on average , 6 weeks after their return to work ) , then after 2 and 6 years subsequently . Job strain , a combination of high psychological dem and s and low decision latitude , was evaluated in 4 quadrants : high strain ( high dem and s and low latitude ) , active ( high dem and s and high latitude ) , passive ( low dem and s and low latitude ) , and low strain . A  chronic job strain  variable was constructed based on the first 2 interviews , and patients were divided into those exposed to high strain at both interviews and those unexposed to high strain at 1 or both interviews . The survival analyses were presented separately for 2 periods : before 2.2 years and at 2.2 years and beyond . MAIN OUTCOME MEASURE The outcome was a composite of fatal CHD , nonfatal MI , and unstable angina . RESULTS The outcome was documented in 206 patients . In the unadjusted analysis , chronic job strain was associated with recurrent CHD in the second period after 2.2 years of follow-up ( hazard ratio [ HR ] , 2.20 ; 95 % CI , 1.32 - 3.66 ; respective event rates for patients exposed and unexposed to chronic job strain , 6.18 and 2.81 per 100 person-years ) . Chronic job strain remained an independent predictor of recurrent CHD in a multivariate model adjusted for 26 potentially confounding factors ( HR , 2.00 ; 95 % CI , 1.08 - 3.72 ) . CONCLUSION Chronic  job  strain after a first MI was associated with an increased risk of recurrent CHD Objective —This study was undertaken to examine the association of plasma inflammatory markers such as C-reactive protein ( CRP ) , interleukin-6 , and fibrinogen with the incidence of coronary heart disease within the prospect i ve cohort study on myocardial infa rct ion ( PRIME study ) . Methods and Results —Multiple risk factors were recorded at baseline in 9758 men aged 50 to 59 years who were free of coronary heart disease ( CHD ) on entry . Nested case-control comparisons were carried out on 317 participants who suffered myocardial infa rct ion (MI)-coronary death ( n=163 ) or angina ( n=158 ) as an initial CHD event during a follow-up for 5 years . After adjustment for traditional risk factors , incident MI-coronary death , but not angina , was significantly associated with CRP , interleukin-6 , and fibrinogen , but only interleukin-6 remained significantly associated with MI-coronary death when the 3 inflammatory markers were included in the model . The different interleukin-6 levels in Northern Irel and and France partly explained the difference in risk between these countries . Interleukin-6 appeared as a risk marker of MI-coronary death , and it improved the definition of CHD risk beyond LDL cholesterol . Conclusions —This association may reflect the underlying inflammatory reaction located in the atherosclerotic plaque or a genetic susceptibility on the part of CHD subjects to answer a proinflammatory stimulus and subsequent increase in hepatic CRP gene expression 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 The postmenopausal hormone therapy ( PHT ) component of the Women ’s Health Initiative ( WHI ) is composed of two r and omized , placebo-controlled , double-blind trials in postmenopausal women aged 50 to 79 years at initial screening , testing the effects of estrogen alone ( E-alone ) and estrogen plus progestin ( E P ) on coronary heart disease ( CHD ) as the primary outcome , hip and other fractures and colorectal cancer as secondary outcomes , and pulmonary embolism , breast and endometrial cancers as potential risks . The design and rationale of the PHT trials , including general eligibility and exclusion criteria and considerations regarding sample size and statistical power , have been described previously ( 1 ) . Postmenopausal hormones have been initiated in menopausal women for the treatment of vasomotor symptoms , mood disturbances , vaginal dryness , and prevention of rapid bone loss for several decades . Despite a paucity of data on effects of initiating hormone use in older women , postmenopausal hormones have also been promoted for the prevention of CHD , osteoporotic fractures , and other diseases that occur years after menopause ( 2 ) . It is generally recommended ( 2 ) that women with a uterus be prescribed a combination of estrogen and progestin to prevent BACKGROUND Multiple risk-factor interventions that include lifestyle changes have been proved to be effective in reducing risk profile in persons at high risk for developing coronary heart disease ( CHD ) . There have not been similar studies involving transplant recipients . The purpose of this study is to examine effects of exercise training on cardiovascular risk profile during the first year after renal transplantation . We used traditional CHD risk factors and the Framingham CHD prediction methods . METHODS Ninety-six transplant recipients were r and omly assigned to 2 groups at 1 month posttransplantation : the exercise training ( EX group ; n = 51 ) and usual care groups ( UC group ; n = 45 ) . Testing was performed at baseline and 12 months posttransplantation and included maximal exercise testing and evaluation of CHD risk factors and risk-factor categories , determined by means of the Framingham equations . RESULTS Overall 10-year CHD risk score did not change in either group . All patients showed increases in total cholesterol ( TC ) level , high-density lipoprotein fraction of cholesterol ( HDL-C ) , and body mass index over time . No differences were observed between groups , except for a trend toward greater improvement in HDL cholesterol levels in the EX group ( P = 0.07 ) . Significantly more patients in the EX group moved out of the high-risk category in TC-HDL ratio . All patients remained in the high-risk category for physical fitness . There was a significant negative correlation of CHD risk and maximal exercise capacity ( r = -0.406 ; P < 0.001 ) . CONCLUSION Exercise training alone does not reduce CHD risk during the first year after transplantation . Research to determine the effects of multiple risk interventions during a longer period in transplant recipients is warranted
Conclusions We found that psychological intervention  improved psychological symptoms and reduced cardiac mortality for people with CHD .
However , there remains considerable uncertainty regarding the magnitude of these effects and the specific techniques most likely to benefit people with different presentations of CHD
Background Although psychological interventions are recommended for the management of coronary heart disease ( CHD ) , there remains considerable uncertainty regarding their effectiveness .