Ebpppt

Impact of an Intensive Lifestyle Change on Coronary Artery

Disease.

Lissah DunstonChristine Lutz

Amanda Werner &

Kimberly Werner

PICO Summary

P- Patients with CAD (Coronary Artery Disease) or high risk for CAD

I- Intensive lifestyle change of exercise, diet (low-fat/plant based diet), stress reduction measures, and psychosocial support.

C- Standard medical intervention and no lifestyle/support changes.

O- A statistically significant change in emerging cardiac biomarkers, clinical measurements of weight, blood pressure, lipoproteins.

Significance of the Problem

Coronary Artery Disease (CAD) is a leading cause of death in the United states.

CAD kills approximately 380,000 people per year.

Annual Cost: $108.9 BILLION DOLLARS

this includes health are services, medications, and lost wages.

Significance of the Problem (Continued)

Risk Factors of CAD include:

HTN

smoking

increased LDL cholesterol levels

diabetes

obesity

poor diet

lack of exercise

heavy ETOH use

Search Strategies

Search terms used:

“Coronary Artery Disease”

“Plant-based diet”

“lifestyle change”

Using terms alone produced too many results, combining “CAD and Plant-based diet” yielded the most appropriate results.

We used the two articles selected because interventions and hypothesized outcomes were closely related.

First Article:Preventive cardiology: Effect of Intensive Lifestyle Changes on Endothelial

Function and on Inflammatory Markers of Atherosclerosis

Dod, H. S., Bhardwaj, R., Sajja, V., Weidner, G., Hobbs, G. R., Konat, G. W., & ... Jain, A. C. (2010). Preventive cardiology: Effect of Intensive Lifestyle Changes on Endothelial Function and on Inflammatory Markers of Atherosclerosis. The American Journal Of Cardiology, 105362-367. doi:10.1016/j.amjcard.2009.09.038

Summary of First Article

Intervention: Multisite Cardiac Lifestyle Intervention Program

Design: Experimental; pre-test, post-test

Sample: Convenience.

Inclusion Criteria: ALL participants diagnosed with stable coronary artery disease (CAD) and/or risk factors for CAD; at least 18 years old; mentally competent; stable medication and physical health for more than 4 months.

The participants in the experimental group were currently enrolled in the Multisite Cardiac Lifestyle Intervention Program sponsored by insurance companies.

The control group was selected from individuals enrolled in outpatient clinics. The type of sampling was convenience. The following exclusion criteria were used:

Exclusion Criteria: Smokers. individuals not completing lifestyle changes and changes/additions of medication/doses during the study.

Summary of First Article

Data Collection/Measurement Tools: Endothelial function was measured at baseline and 12 weeks.

flow-mediated dilitation via Doppler vascular imaging

inflammatory endothelial dysfunction markers including high-sensitivity C-reactive protein (CRP), and human vascular endothelial growth factor.

T and chi-square tests were used to measure baseline characteristics. Matched-pair t tests were used to assess the changes between the baseline and 3 month measurements.

Summary of First Article

Findings:

Significant improvement in FMD, C-reactive protein, and interleukin-6 in the intervention group.

These results support previous research that theorizes that intensive lifestyle changes can regress atherosclerosis, and improve cardiac health.

Summary of First Article

Strengths & Threats to internal validity:

Strength: Consistent measurement intervals for all groups and the

Strength: Biomarkers as a measurement tool.

Weaknesses: Alpha level was not defined, however, given statistically significant p-values, we could assume that the alpha level was 0.05.

Weakness: Many potential confounding variables including variations in the experimental group and a wide variety of interventions.

Weakness: No randomization

Weakness: small and homogenous sample, and inconsistent oversight of interventions.

Second Article:Changes in emerging cardiac biomarkers after an intensive lifestyle

intervention

Chainani-Wu, N., Weidner, G., Purnell, D., Frenda, S., Merritt-Worden, T., Pischke, C., &... Ornish, D. (2011). Changes in emerging cardiac

biomarkers after an intensive lifestyle intervention. American Journal Of Cardiology, 108(4), 498-507.

Summary of Second Article

Intervention: Multisite Cardiac Lifestyle Intervention Program

Design: Cohort, Prospective Design

Sample: Convenience. Participants were selected from the Multisite Cardiac Lifestyle Intervention Program.

Inclusion Criteria:All participants met the following criteria: Diagnosed with CHD (or at high risk for CHD), or type 1 or type 2 diabetes mellitus (Cite page 504).

Exclusion Criteria: Exclusion criteria: 9 primary factors including current smokers, coronary artery bypass graft surgery within 4 weeks, unstable angina pectoris, and impaired cognitive function (Cite page 504).

Summary of Second Article (cont.)

Data Collection/Measurement Tools:

Demographic information and medical history were obtained for baseline data by interview.

Other values were taken at baseline and at 12 weeks including:

Blood samples for cardiac markers including a fasting blood sample and nuclear magnetic resonsance Lipoprofile assays.

Clinical measurements (height, weight, abdominal and hip circumference, and blood pressure).

Questionnaires were used to asses exercise habits, quality of life, stress management, social support.

Paired t tests were used to compare baseline means to the means calculated after 3 months of the group at high risk of CHD and the group already diagnosed with CHD.

Summary of Second Article (cont.)

Findings:

Improvements were seen in all targeted health behaviors in both groups (all p<0.001) at 12 weeks including

reduced BMI, systolic and diastolic blood pressure, waist/hip ratio, c-reactive protein, insulin, LDL and total cholesterol, etc.

Quality of life, cognitive function, and social support measures also improved.

As with the previous study, the results of this study support the theory lifestyle changes can result in favorable changes in coronary heart disease biomarkers.

Summary of Second Article (cont.)

Strengths & Threats to internal validity:

Strength: Generalizable. Participants were selected from multiple states.

Strength: Biomarkers as a measurement tool.

Strength: Large sample a potential strength. Weakness: No power analysis completed.

Weakness: No randomization, which is a threat to external validity.

Weakness: multiple interventions and interrelated outcome measurements.

Weakness: Cognitive function measured using a subjective pre-test/post-test self-report. Threat to internal validity.

Rating the Evidence

The recommended strength for these articles is level II: quasi-experimental study.

The recommended quality is B - good.

The studies contained an intervention and control but no randomization.

Results were consistent with definitive conclusions, and had reasonably consistent results with some control.

There was an evaluation of strengths and limitations and fairly definitive conclusions.

Conclusions and Recommendations

Use this evidence to guide our nursing practice.

Results indicated significant changes in some of the biomarkers and clinical measurements.

Our recommendation: Include all aspects of the interventions (low-fat/plant-based diet, exercise, stress reduction, and psychosocial support). The individual impact of each intervention cannot be isolated in the results.

RESOURCES:

The American Heart Association: http://www.heart.org/HEARTORG/

Preventative Medicine Research Institute: http://www.pmri.org/dean_ornish.html

References:

Chainani-Wu, N., Weidner, G., Purnell, D., Frenda, S., Merritt-Worden, T., Pischke, C., &... Ornish, D. (2011). Changes in emerging cardiac biomarkers after an intensive lifestyle intervention. American Journal Of Cardiology, 108(4), 498-507.

Dod, H. S., Bhardwaj, R., Sajja, V., Weidner, G., Hobbs, G. R., Konat, G. W., & ... Jain, A. C. (2010). Preventive cardiology: Effect of Intensive Lifestyle Changes on Endothelial Function and on Inflammatory Markers of Atherosclerosis. The American Journal Of Cardiology, 105362-367. doi:10.1016/j.amjcard.2009.09.038

Heart Disease. (n.d.). American Heart Association. Retrieved May 4, 2014, from Conditions_UCM_001087_SubHomePage.jsp

Heart Disease Facts. (2014, February 19). Centers for Disease Control and Prevention. Retrieved April 27, 2014, from

http://www.cdc.gov/heartdisease/facts.htm