Nurse-coordinated referral to lifestyle programs benefits patients with CAD

NEW ORLEANS — Nurse-coordinated referral of patients with CAD and their partners to a comprehensive set of community based lifestyle programs to achieve weight loss, improve physical activity and encourage smoking cessation yielded significant improvements in lifestyle-related risk factors compared with usual care, according to results of the RESPONSE 2 study.

Moreover, “this strategy can be easily implemented into daily practice to improve secondary prevention of CAD,” Ron Peters, MD, PhD, from the department of cardiology at the Academic Medical Center Amsterdam, the Netherlands, said during a presentation at the American Heart Association Scientific Sessions.

The randomized trial was conducted at 15 sites in the Netherlands and enrolled 824 patients with CAD and at least one lifestyle-related risk factor. Patients — and their partners, if applicable — in the intervention group were referred by nurses to available community based programs targeting weight reduction (Weight Watchers), physical activity (Philips DirectLife) and smoking cessation (Luchtsignaal telephone coaching). Each patient also received usual care based on current guidelines; this included cardiac rehabilitation and outpatient care by cardiologists and specialized nurses, according to the study details.

In total, 824 patients underwent randomization from April 2013 to July 2015. The mean age was 59 years, one-fifth were women and the majority were white. Forty-eight percent of patients reported smoking, 62% reported inadequate physical activity and 87% had a BMI exceeding 25 kg/m². Most patients were also using antiplatelet agents, lipid-lowering drugs, beta-blockers and ACE inhibitors or angiotensin receptor blockers.

The primary outcome was proportion of patients who had improvement in at least one lifestyle-related risk factor, without deterioration in the other two risk factors, at 1 year.

According to results presented here, the proportion of successful patients at 1 year was 37% in the intervention group vs. 26% in the control group (RR = 1.43; 95% CI, 1.14-1.78; P = .002).

Peters also reported improvements in the intervention group in secondary outcomes including improvement in just one lifestyle-related risk factor (60% vs. 50%; RR = 1.2; 95% CI, 1.05-1.37), weight reduction of 5% or more (27% vs. 14%; RR = 1.97; 95% CI, 1.44-2.7; P < .001), 10% or greater improvement in walk test distance (45% vs. 40%; RR = 1.15; 95% CI, 0.97-1.36; P = .13), negative urinary cotinine (76% vs. 74%; RR = 1.03; 95% CI, 0.94-1.12; P = .55) and systolic BP < 140 mm Hg (72% vs. 67%; RR = 1.08; 95% CI, 0.98-1.19; P = .12). The proportion of patients with LDL < 70 mg/dL was higher, but not significantly so, in the control group (34% vs. 38%; RR = 0.88; 95% CI, 0.72-1.07; P = .23).

Valentin Fuster

Partner participation was also associated with a higher rate of success, according to Peters.

During a discussion of the trial, Valentin Fuster, MD, PhD, director of Mount Sinai Heart and physician-in-chief of The Mount Sinai Hospital, brought up several questions related to the results, including the number of patient drop-outs, insufficient data on worsening risk factors and use of the 6-minute walk test. He also questioned the cost of the program studied, but noted that “we should look at the science first, and then look at the economics.” – by Dave Quaile

Reference:

Peters R, et al. Clinical Science Special Reports 3. Presented at: American Heart Association Scientific Sessions; Nov. 12-16, 2016; New Orleans.

Disclosure: Peters reports receiving research grants from the Möller Foundation, Phillips and Weight Watchers.