Comparación critica con la literatura existente

In addition to interventions undertaken to improve survival and prevent cardiovascular complications, therapy also is

prescribed to improve patients’health status,a general term

that incorporates many facets, including severity of symp-

toms, functional limitations, and quality of life. Assessment of health status is often unstructured and exclusively quali- tative, but efforts to standardize this assessment are recom- mended, beginning with a structured inventory of activity, symptoms, and quality of life, supplemented by the use of simple, semiquantitative scales such as the CCS and New York Heart Association classifications (432,433).

The CCS and New York Heart Association classifica- tions are limited, however, because they quantify health status from the physicians’ perspective, rather than directly reporting patients’ experiences, and they are known to have limited reproducibility and sensitivity to important clinical changes. Furthermore, even these simple classifications of health status are recorded infrequently in health records (432,434). One approach to directly eliciting perceptions of health status from patients with IHD is to use the self- administered Seattle Angina Questionnaire (SAQ), a valid, sensitive, and prognostically important questionnaire, to quantify the symptoms, functional limitations, and quality

of life of patients with SIHD (246,247,435). Although such

instruments typically are used in research trials, they are readily applicable to clinical practice and can be used serially to assess and monitor the effectiveness of therapy, including

antianginal medications and revascularization (434). The

formal assessment of a patient’s disease-specific health status, through either the CCS or the SAQ, has been endorsed as a performance measure of healthcare quality (436).

4.3. Patient Education: Recommendations CLASS I

1. Patients with SIHD should have an individualized education plan to optimize care and promote wellness, including:

a. education on the importance of medication adherence for man- aging symptoms and retarding disease progression (437–439) (Level of Evidence: C);

b. an explanation of medication management and cardiovascular risk reduction strategies in a manner that respects the patient’s level of understanding, reading comprehension, and ethnicity (8,440–444)(Level of Evidence: B);

c. a comprehensive review of all therapeutic options (8,441–444) (Level of Evidence: B);

d. a description of appropriate levels of exercise, with encourage- ment to maintain recommended levels of daily physical activity (8,445–448)(Level of Evidence: C);

e. introduction to self-monitoring skills (445,447,448)(Level of Evidence: C);and

f. information on how to recognize worsening cardiovascular symp- toms and take appropriate action.(Level of Evidence: C)

2. Patients with SIHD should be educated about the following lifestyle elements that could influence prognosis: weight control, mainte- nance of a BMI of 18.5 to 24.9 kg/m2

, and maintenance of a waist circumference less than 102 cm (40 inches) in men and less than 88 cm (35 inches) in women (less for certain racial groups) (8,440,449–452); lipid management (18); BP control (17,453); smoking cessation and avoidance of exposure to secondhand smoke (8,454,455); and individualized medical, nutrition, and life-

style changes for patients with diabetes mellitus to supplement diabetes treatment goals and education (456).(Level of Evidence: C)

CLASS IIa

1. It is reasonable to educate patients with SIHD about:

a. adherence to a diet that is low in saturated fat, cholesterol, and transfat; high in fresh fruits, whole grains, and vegetables; and reduced in sodium intake, with cultural and ethnic preferences incorporated (8,17,18,457,458)(Level of Evidence: B); b. common symptoms of stress and depression to minimize stress-

related angina symptoms (459)(Level of Evidence: C); c. comprehensive behavioral approaches for the management of

stress and depression (237,460–462)(Level of Evidence: C); and d. evaluation and treatment of major depressive disorder when indicated (237,238,437,461,463,464,467,468). (Level of Evi- dence: B)

Multiple risk factors for heart disease, vascular disease, and stroke are typically present in persons with SIHD, including hypertension, smoking, dyslipidemia, diabetes mellitus, overweight, and physical inactivity (27,392). At a national level, in 2000, only 5% of individuals without IHD and 7% of those with IHD were fully adherent to recom- mendations for physical activity, fruit and vegetable con- sumption, and nonsmoking.

The approach to managing risk factors usually requires partnerships among the healthcare team, the patient, their family, and their community. The goal of this partnership is to assure an effective exchange of information, sharing of concerns, and an improved understanding of treatments, with the aim of improving quality of life and health outcomes. The American Academy of Family Physicians defines patient education as “the process of influencing patient behavior through the provision of information and counseling that is designed to produce changes in knowl- edge, attitudes, and skills necessary to maintain or improve

health” (469). The Joint Commission mandates patient

education as a principal guiding policy to improve health outcomes. Effective patient education and counseling are based on a collaborative approach that acknowledges indi- vidual patient needs through an understanding of cognitive, behavioral, and sociodemographic factors. Patients actively involved in care decisions are more likely to follow a treatment plan and engage in behaviors that can improve their health.

When educating patients, it is important to communicate an understanding of a specific disease process, the need for laboratory testing, medication management and adherence, reporting of efficacy and side effects, and behavioral lifestyle

change (8). Unfortunately, the type, intensity, frequency,

and duration of educational programs are not well estab- lished for individual risk factors. For example, the Ask, Advise, Assess, Assist, and Arrange algorithm for smoking cessation often is used, although supporting data from

RCTs are lacking (470). In addition, who should deliver

education programs and how to evaluate efficacy are not well studied. In smoking cessation, the most effective interven- tion continues to be a physician’s recommendation for the

patient “to quit.” However, quit rates for smoking are also dependent on the appropriate use of medical therapies and

group support programs (442,471). In diabetes care, patient

education has the potential to be as effective as or more

effective than medical therapies (472). The management of

hypertension, heart failure, dyslipidemia, type 2 diabetes mellitus, weight loss, and physical activity is enhanced by ongoing health education and support in addition to phy- sician office visits.

Factors that complicate effective patient education in- clude low literacy, adverse sociodemographic factors (e.g., poverty, social isolation, and emotional disorders such as depression), cultural beliefs and language barriers, environ- mental factors, advanced age, and the presence of complex comorbidities. These factors and others play an important role in the adoption of healthy lifestyles and adherence to recommended medical therapies. In addition, how to best provide cost-effective educational strategies remains a chal-

lenge in today’s healthcare environment (473). The lack of

payment for these activities remains an important barrier. Clinic-based education generally consists of the following: 1. Individual counseling.This educational format commonly is used in the context of a routine clinic visit. It tends to be directive and didactic, generally not interactive or behaviorally oriented, relatively brief, and sometimes supported with written materials. Follow-up to ascertain effectiveness is not commonly practiced.

2. Group education. Group care or shared office visits have been tested in multispecialty group practices. They offer the benefit of providing education to larger numbers of patients with similar diagnoses (e.g., type 2 diabetes mellitus), combined with an individualized physician visit. They tend to be behaviorally oriented with planned follow-up for effectiveness and outcomes.

3. Self-monitoring. Self-monitoring skills enhance patient education and behavior change. Examples such as home BP and blood glucose monitoring and tracking daily calories and physical activity minutes can support impor- tant lifestyle change. Review of self-monitoring logs by patient and provider at subsequent clinic visits supports the continued importance of and attention to behavior change. In some healthcare plans, these data can be entered via web portals for patients (474).

4. Internet- and computer-based education.A growing num- ber of health plans provide health information via web- sites and special programs. This approach is often low in cost to the patient but requires adequate computer access and skills, higher reading levels, and self-motivation to

change behavior (e.g., AHA Choose to Move) (475).

5. Hand-held computer devices, smartphones, and other porta- ble devices.Portable devices have the potential to provide motivational reminders and prompts for lifestyle change but have not yet been thoroughly tested.

Present efforts to improve the effectiveness of patient education and lifestyle interventions integrate key constructs

related to behavior change theory. A summary of the most common models is provided below:

1. Motivational interviewing,a social learning theory, pro- motes behavioral change through empathetic and reflec- tive listening, encouraging patients to determine their reasons for change, helping healthcare professionals deal with resistance, and supporting self-efficacy (476). 2. Self-efficacy theoryposits that the ability to change behav-

ior depends upon one’s self-confidence to perform a specific action (such as walking 30 minutes daily) and the belief that one can persist with this action. Low self- efficacy predicts poor ability to achieve a specified life- style change. Improving one’s self-efficacy will improve the ability to change a particular lifestyle (477).

3. The Transtheoretical Modelof behavior change is based

on “stages of change.” The theory relies on the observa- tion that many individuals traverse 5 distinct temporal processes in achieving permanent change. These include precontemplation, contemplation, preparation, action, and maintenance. Application of this model of change entails categorizing an individual’s progress in the pro- cess of change and recognizing that cycling through phases is common in the process of achieving permanent change (478).

The interventions described above should be provided within a medical environment that provides coordinated, team-based care. Data accumulating from interventions that incorporate principles of the chronic care model (479), such as the patient-centered medical home, have demonstrated beneficial effects not only on intermediate outcomes such as glycemic and BP but also on cost, utilization, and mortality

rate (480,481). This approach depends on the active partic-

ipation of an engaged, informed patient, which in turn relies on the patient’s understanding of his or her condition, ability to adhere safely to complex medical therapies, and willingness to communicate on a regular basis with the healthcare team. In addition to counseling about the ap- proach to management of SIHD and risk reduction, pa- tients often seek information about other aspects of their health, particularly issues that are often not directly ad- dressed by healthcare providers.

One such topic that commonly arises is possible restric- tions on sexual activity. Regrettably, there are relatively limited scientific data on the cardiovascular demands and potential risks of sexual activity in patients with heart disease, some of it dating back 3 or 4 decades and nearly all of it dealing with men. In general, sexual activity is equivalent to mild to moderate physical activity requiring 3 to 5 METs (i.e., the equivalent of climbing 2 flights of stairs or walking briskly) (482). The few available studies suggest that AMI within 1 to 2 hours of sexual activity is associated with an average RR of 2.7 among middle-aged men, with

the greatest risk among those who are sedentary (483– 486).

Because the overall incidence of AMI is low in the popu- lation and periods of exposure relatively infrequent, it has

been postulated that the absolute risk is exceedingly low for

any individual (487). However, ECG monitoring during

sexual activity in 1 study of men with IHD revealed that nearly a third developed ST depression and nearly half developed arrhythmias. It appeared, however, that these findings also were found during similarly stressful activities that did not involve sex, and the arrhythmias were largely benign. Moreover, these patients were not initially on anti-ischemic medications, and it was reported that the ischemic changes on ECG resolved when subjects took beta blockers. Thus, it seems that sexual activity should not necessarily be regarded as appreciably different from other types of physical activity that impose equivalent metabolic demands. Needless to say, patients should be treated to maximize their capacity for physical activity, as described subsequently in this guideline.

Patients often express concerns that medications given to treat symptoms or reduce cardiovascular risk could cause erectile dysfunction. Although these perceptions are often firmly and widely held, studies and reviews have not delineated a clear association between these drugs, including beta blockers, and sexual dysfunction (488 – 492).

A related issue that could arise is use of phosphodiesterase 5 inhibitors, such as sildenafil, vardenafil, or tadalafil, to improve erectile function. Although, as discussed in the section on treatment of SIHD, current evidence has shown that these drugs do not raise the risk of adverse cardiovas-

cular events in men with SIHD (493,494), there is a clear

risk of serious hypotension when they are taken in conjunc- tion with nitrates, and the combination is absolutely con- traindicated. There are also potential drug– drug interac- tions with alpha-blockers that are sometimes used to treat hypertension (495).

4.4. Guideline-Directed Medical Therapy