Interview #1:

'Targeting Multiple Risks'

Robert F. DeBusk, MD, is a cardiologist and professor of medicine at the Stanford University School of Medicine, Stanford, California. Dr. DeBusk has conducted research on the management of heart disease and other chronic illnesses for more than two decades, and he has pioneered the use of nurse case-managers to assist physicians in helping patients adhere to exercise, medication, and other medical advice.

Q: How serious a problem is heart disease?

A: It affects tens of millions of Americans in one way or another. There are 10 to 12 million people with angina, chest pain that occurs when the heart muscle does not receive enough blood. There are a 1.5 million heart attacks each year and in excess of 750,000 coronary revascularization procedures, such as bypass surgery and angioplasty. As the population ages, heart disease stands to become an even larger problem. African Americans and Native Americans are more likely than other groups to suffer from hypertension and diabetes -- two conditions that increase the risk for heart disease. Contrary to popular belief, women have about the same rate of death from coronary artery disease as men do. Women acquire the disease somewhat later in life, but they also tend to live longer than men do.

Q: Is heart disease preventable?

A: Studies show that there is a 25 to 33 percent reduction in mortality from coronary events among patients treated with medications to lower blood cholesterol. Other studies show a similar reduction among people who stop smoking or get their blood pressure under control. Unfortunately, many patients never begin therapy, and most never achieve the same sustained benefit achieved in clinical trials. That’s because in clinical trials, there is a delivery system that ensures that patients take their medicines, exercise, or keep on their diets. But once patients’ active participation in the research study is over, there's no system to make sure patients follow treatment recommendations. This gap is at the very root of the problem in prevention of heart disease and other chronic health problems today.

Q: How would you reduce that gap, for example, in getting people to quit smoking?

A: Smoking cessation is the single most powerful intervention in terms of its impact on coronary mortality, but logistically it is very difficult to encourage within the framework of a standard medical practice. Physicians have about a 5 percent success rate in helping their patients who smoke quit over any given year. But specialized programs in hospitals and other settings have quit rates that can range from 40 to 75 percent. Most physicians simply are not in the position to follow up with the kind of behaviorally oriented treatment protocol that could help their patients stop smoking.

Q: So consistent and frequent follow-up is key to behavior change?

A: Exactly. And it doesn't need to be face to face. In a number of clinical trials, we’ve employed nurse case-managers to follow up with heart patients by phone to see how they were doing with their medicines, exercise, diet, or smoking.[16] There's a standard repertoire of issues that are quite easy to lay out for the patient and find out where any problems may lie. With smoking cessation, for example, the nurses work with patients to anticipate situations where they are likely to smoke again and come up with strategies on how they can avoid smoking in those situations.

Q: You've also studied ways to promote exercise. What have you found?

A: We started out looking at patients who were recovering from a heart attack. Many were concerned that they would be unable to resume their usual activities. We started them on an exercise program as early as two weeks after their attack. Once we demonstrated that they could resume activity safely, it wasn’t difficult to motivate them to continue exercising. They were delighted to be able to do as much as they were doing, and they felt they were contributing to their long-term health.

In a later series of studies, we worked with sedentary middle-aged individuals without heart disease.[12] We demonstrated that it really is quite easy for them to undertake a home-based exercise program. In fact, patients who exercised at home spent more time on their exercise bicycles than patients who were randomized to the gym program spent in their cars, driving to and from the gym. Many people do not have access to gyms or do not like group exercise programs. For them, exercise training at home is a very attractive alternative.

Q: Many people have more than one risk factor for heart disease. How do you work with them?

A: One of our most important clinical trials, called MULTIFIT(SM) for Multiple Risk Factor Intervention Trial, focused simultaneously on exercise training, smoking cessation, and diet and drug management for high cholesterol among patients who had their first heart attack.[8] The approach used in that study was innovative because it had three simultaneous objectives. The teaching to that point had been that each goal would need to be introduced over time in a gradual fashion, but we found that was not the case. Patients had no difficulty beginning changes in various areas of their lives if the changes made sense to them, if they had regular contact with the nurse case-manager coordinating their care, and if they could see their progress.

Q: So if people are willing to make one change for their health, they frequently are willing to make others at the same time?

A: Absolutely. One needs to strike while the iron is hot, which often is after a coronary event or instability in the patient's life that focuses his or her attention on the problem. But it needn’t wait for something drastic to happen. We try to get patients at risk to begin to focus their efforts and show them with timely feedback that their efforts are having an immediate effect on their blood pressure or cholesterol, instead of focusing on a distant goal, such as preventing a heart attack. That way they are more likely to stick with their medicines, exercise, and diet over the longer term. We think that such feedback will become more mainstream over time with use of e-mail, the Internet, and the like.

Q: How does the nurse case-manager approach work in the real world?

A: I've had the good fortune to work with Kaiser Permanente over the last 15 years, and they have implemented a number of programs based on the MULTIFIT(SM) model. Experience has shown that when the nurse case-managers are given access to information about the patient and their illness -- when they are given a clear-cut series of objectives, they can become extremely adept at managing patients with chronic conditions such as hypertension and diabetes, and in particular, with heart failure.[27]

Many physicians get uneasy about this incursion on their turf, but I think if they are honest, they will acknowledge that there are limits to what they can accomplish alone. We find that there can be a very close integration between what the nurses do in these areas and how the physician manages the overall care of the patient. But it requires a collaborative and cooperative effort -- one that is still comparatively new. I think the next large step in chronic disease management in America will be an explicit development and acknowledgement that these kinds of cooperative efforts are highly effective in addressing chronic illnesses.

Interview #2:

'Stress Takes a Deadly Toll'

James A. Blumenthal, PhD, is a professor of medical psychology in the Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC. Much of his research over the past two decades has focused on the effects of mental stress on the cardiovascular system.

Q: Much of your recent work deals with the effects of mental stress on the heart, particularly a phenomenon called myocardial ischemia. What is myocardial ischemia?

A: Myocardial ischemia is a condition in which there is an inadequate supply of blood to the heart. Ischemia usually occurs in the context of some degree of coronary atherosclerosis -- that is, some narrowing of the blood vessels. Most episodes of ischemia are "silent" and without symptoms. Exercise is the most well-studied trigger of ischemic episodes. People with exercise-induced ischemia are more likely to show increasing symptoms of heart disease and are at increased risk to have a heart attack, to require cardiac surgery, or to suffer from sudden cardiac death.

Q: What have you learned from your studies of ischemia induced by mental stress?

A: The first thing we found is that mental stress in the laboratory was associated with increased risk of having ischemia during daily life.[3] The second thing we found is that people who have mental stress-induced ischemia in the laboratory also show the largest blood pressure changes in response to mental stress. In our field studies, we learned that mental stress during daily life can also be a potent trigger of ischemia.[10] When we monitored people and had them complete diaries about their emotional state throughout the day, people were more likely to report feeling angry, frustrated, or sad in the hour preceding ischemic episodes than at other times. Finally, we know that people who have ischemia in response to mental stress have a worse prognosis over and above what we see with exercise stress testing.[11]

Q: Do we know how mental stress causes myocardial ischemia?

A: In exercise-induced ischemia, heart rate increases significantly -- it may increase two- to three-fold, reflecting increased demand for oxygen. Ischemia occurs when this increased demand for blood exceeds the supply. In ischemia induced by mental stress, the problem is not just increased demand -- and heart rate elevations are usually lower than what is typically seen with exercise -- but reduced blood supply. Reduced supply is likely to result from abnormal constriction of the blood vessels. We think it may be related to the motion of coronary and other blood vessels. We know that in individuals with coronary artery disease, the endothelium -- the lining of the blood vessels -- does not respond to stress and other stimuli in the same way as normal healthy blood vessels do.[25] Rather than dilating or opening up, the vessels may stay the same or even constrict.

Q: You've also studied interventions for people with mental stress-induced myocardial ischemia. What did you find?

A: We randomly assigned a group of patients to receive stress management training, exercise training, or their usual care.[5] We saw a 74 percent reduction in the risk of cardiac events among patients in the stress management group compared with the usual care group and a 34 percent reduction among those who received the exercise training. Interestingly, those in the stress management group were more likely to see reductions in ischemia induced by mental stress while those in the exercise group had less ischemia induced by exercise. So there is some specificity to the treatments.

Q: And the stress management program, what does it include?

A: There are three components: education, group support, and skills training. First, we teach patients about heart disease risk factors and the role of stress and its effects on the body. The second component is social support. All of our stress management training is done in groups where people can share their frustrations and their successes and see they are not alone in facing these challenges. The third component includes a variety of different skills to cope with stress, ranging from relaxation training to teaching people different cognitive behavioral strategies to help them respond differently to situations that previously were regarded as very stressful.

Q: What do you mean by cognitive behavioral strategies?

A: Cognitive behavioral strategies refer to techniques for modifying the ways in which individuals perceive and interpret various situations. We teach people to monitor their thought patterns, to recognize when their thinking is not realistic, and to challenge their unrealistic thought patterns and substitute them with more appropriate, realistic, and adaptive cognitions.

Q: So we know mental stress is a significant risk factor for heart attack. What other psychological states are important?

A: The most widely studied psychological risk factor for heart disease is Type A personality. People who have Type A personalities tend to be impatient and irritable. They also feel a real sense of time urgency, and they get easily angered. Many studies suggest this last component -- the propensity toward anger or hostility -- might be particularly important as a risk factor for heart disease.

Q: What possible mechanism would account for this link between Type A and hostility and heart disease?

A: Numerous studies have shown that people with Type A behavior and high levels of hostility show greater heart rate and blood pressure changes and a greater release of certain stress hormones in response to stress.

Q: How about the role of depression in heart disease?

A: Well, we know that in individuals who have had a heart attack, perhaps 30 to 40 percent have symptoms of major or minor depression. Studies have shown that people who are depressed after a heart attack have three to four times increased risk of having additional heart problems, including death. We are currently participating in a multi-center study sponsored by the National Heart, Lung, and Blood Institute to see if heart patients who are depressed or socially isolated can benefit from cognitive behavioral therapy.[4]

Q: Do depressed patients simply take poorer care of themselves or is there some other factor related to depression that increases their risk of additional cardiac events?

A: There are several potential mechanisms including behavioral factors. For example, studies have shown that depressed patients may indeed be less compliant with medications and may be more sedentary than non-depressed patients. There are also a number of physiologic mechanisms that could contribute to the increased risk of cardiac events in depressed individuals. There have been several studies in patients without heart disease showing there are differences in certain clotting factors among depressed patients compared with those who are not depressed. Some researchers suggest that depression may be associated with a greater propensity to develop blood clots and this may be responsible for additional heart attacks and other cardiovascular complications. Depressed people also exhibit an imbalance between the sympathetic and parasympathetic nervous system that may be a marker that their hearts are impaired in the ability to respond to a host of stimuli.

Q: You mentioned targeting people who are socially isolated. What is the role of social support in heart disease?

A: A number of studies have demonstrated that people who perceive themselves as having good social support systems are at lower risk of heart problems and those who see themselves as socially isolated are at increased risk. One of the challenges in our current study is to increase people’s perceptions of social support.

Q: So it isn’t just a matter of the number of relatives, friends, and others that people see on a regular basis? They have to believe that there are other people who can offer them support?

A: Yes. We work with many people who have low perceived social support, and yet when you speak with them, you find out they’ve received many get-well cards and have family members who care about them. I think it's probably related to depression, because if you are depressed, even though you may have family members who care about you, you may not feel that they care or you feel you are not worth caring about. That’s where the cognitive therapy can make a difference, to counter some of these misperceptions of reality.

Are Women Missing Out?

Do women miss out on needed cardiac care?

Numerous studies over the past decade have documented significant differences in the cardiac care received by women and men. Studies have shown that women with suspected coronary artery disease have fewer additional diagnostic tests, such as cardiac catheterization, than men do [24] and that women hospitalized with heart disease are less likely to receive coronary artery bypass surgery, angioplasty procedures, [2] or clot-busting thrombolytic drugs to restore blood flow to the heart.[13]

Some investigators, like Duke University’s Daniel B. Mark, MD, argue that these differences in care can largely be explained by the fact that differences in presentation and sensitivity of tests make heart disease harder to diagnose in women. Also, women frequently have less severe disease despite being generally older and having more diabetes, hypertension, and other complicating conditions than men at onset of CHD, Mark says in a recent editorial in the Journal of the American Medical Association.[15]

But Mark acknowledges that a bias against women may still be operating, as seen in the results of a study by Kevin A. Schulman, MD, then at Georgetown University Medical Center, and colleagues.

Schulman and colleagues used actors to portray patients with symptoms of coronary artery disease.[23] Even when women and men displayed identical histories, primary care physicians judged the women significantly less likely to have heart disease than men, and black women were significantly less likely to be referred for cardiac catheterization than were white women and black or white men. Race and sex had no effect on referrals for exercise stress testing.

Some real-world evidence also suggests that under identical circumstances, women may get less aggressive care, leading to poorer outcomes. For example, Peter J. Kudenchuk, MD, and colleagues at the University of Washington, Seattle examined records on more than 1,000 men and women with a confirmed heart attack.[13] Although men and women differed little in their symptoms or electrocardiogram findings, or in time before receiving treatment, women were half as likely as men to receive thrombolytic drugs or undergo catheterization, angioplasty, or bypass surgery. Even after adjusting for the effects of age and other baseline characteristics, women were twice as likely to die while in the hospital than were men.

Survival May Be a Matter of Time

The longer patients delay in seeking treatment after experiencing heart attack symptoms, the higher the likelihood they will experience further disability or death. That’s because methods to open clogged arteries -- usually by using clot-busting medications, anticoagulants, and other medications or balloon angioplasty -- have their maximal effect if administered within an hour of the onset of symptoms. Yet many patients wait much longer before seeking medical care.

In their study of 360,000 heart attack cases, Robert J. Goldberg, PhD, of the University of Massachusetts Medical School, and colleagues found that patients took 5.5 hours, on average, after symptoms began before seeking care at an emergency room.[9] As has been shown in previous studies, women delayed significantly longer than men (6.2 hours vs. 5.4 hours), blacks delayed longer than whites (6.3 hours vs. 5.6 hours), and older patients delayed longer than younger patients (6.1 hours for those over 75 vs. 4.8 hours for those under 55).

Other research has shown that the severity of symptoms people experience affects how quickly they seek care. People who have sudden severe chest pain seek care most quickly, but those with severe pain that increases over time delay just as long as those with less severe pain.[18]

Educational efforts to reduce treatment delays should focus first on detailing the range of possible heart attack symptoms, concluded a panel convened by the National Heart, Lung, and Blood Institute (NHLBI). Although many patients expect a heart attack to be accompanied by crushing chest pain and unconsciousness, symptoms can be intermittent or come on gradually. And while chest pain is the most common symptom in women as well as men, both men and women with heart attacks often complain of back pain, shortness of breath, or nausea and vomiting alone.[21] Symptoms among women and the elderly may be even more non-specific.

The second focus of educational efforts, according to the NHLBI panel, should be on what to do when a heart attack is suspected. Dialing 911 is the preferred strategy. People who contact their physician first can double the delay in receiving appropriate emergency care.

Emotional issues are also important. Patients frequently attempt to downplay the severity of their symptoms and allay their anxiety by attributing heart attack symptoms to indigestion or other causes. Emphasizing the rewards of acting quickly is likely to be more effective than stressing the risks of sudden death, the panel concluded.

Finally, these messages should be conveyed to partners, spouses, and family members, since people tend to consult those close to them about suspected heart attack symptoms.

These and other strategies are being tested in an NHLBI-sponsored trial that has just been completed in 20 U.S. communities.[22] Led by James M. Raczynski, PhD, at the University of Alabama, the educational campaign is targeting patients at high risk of heart attack, health care providers, and community members and organizations to increase knowledge and awareness of the need for action in the event of heart attack symptoms. Investigators expect the findings will prove valuable in designing national efforts to reduce heart disease illness and death.

Know Your Risks: A Web Guide

The Internet is awash with information on cardiovascular disease, but the American Heart Association (AHA) is betting that its soon-to-be launched interactive Web site can dramatically reduce heart attack and stroke risk among those who use it.

Visitors to the site, called "One of A Kind," complete a questionnaire about their diet, exercise habits, and health history. The program then creates a personal risk profile and action plan to help individuals reduce their heart disease and stroke risk.

"I could go anywhere and read something about smoking, high cholesterol, or high blood pressure," says Kathryn Taubert, PhD, AHA’s director of cardiovascular science. "But if I have all three risks, here [on the One of a Kind Web site] I’ll get a message back that is tailored to me and explains why I am at particular risk. And the message may be different if I am a 60-year-old woman, or a 40-year-old man, or if I also have diabetes."

Tailoring information to each individual is key to the program, Taubert says. Research has shown that people who hear health messages individually tailored for them are more likely to quit smoking [26] or reduce fat in their diets,[6] she says.

Information is also tailored to each individual’s readiness to make changes in their lives, as indicated by their responses on the questionnaire. "If someone says they are not ready to quit smoking, you come back at them with messages about smoking, but you don’t try to ram it down their throats," Taubert says. "A person might be more willing to work on their diet. If you can get them off the dime on one thing, they very often will go ahead and try to make a change in another area."

Participants update their health status as needed and complete follow-up questionnaires periodically throughout the year, allowing the program to assess their progress and highlight the positive changes they’ve made and the areas they still need to work on.

The AHA is marketing One of a Kind to large employers for use in their work-site health promotion programs. The organization hopes it also will be incorporated by several other health Web sites on the Internet. People will also be able to access the program through AHA’s Web site at http://www.americanheart.org this spring.

Steps to Collaborative Management of Chronic Conditions:

Once a chronic condition has been identified, patients do best if there is on-going commitment by patients, their families, and their health care providers to work together over time. There is strong evidence that the following simple steps taken by providers and patients can significantly improve health and well-being.

1. Define the problem jointly: Providers often define problems in terms of medical diagnoses and treatments, while patients define them in terms of the impact that symptoms have on their lives. Patients are more likely to benefit when these two perspectives are harmonized in a shared definition of the problem.

2. Develop common action plan: Managing chronic conditions is more successful when providers and patients focus on a few specific concerns, identify realistic goals, and commit to a joint plan of action in which the responsibilities of both parties are clear.

3. Explore possible programs and services: Many chronic conditions are better managed when patients are referred by providers to special support services or behavior change programs tailored to their priorities, needs, and preferences.

4. Track progress and anticipate course corrections: Scheduled, on-going communication between providers and patients is critical to tracking progress in achieving goals, identifying potential barriers and complications, and making needed adjustments in the joint plan of action.

For more information on the Behavior Change in Managed Care Settings project, visit our Web site http://www.cfah.org

The Research:

1. American Heart Association. (2000). 2000 Heart and Stroke Statistical Update. Dallas, TX. http://www.americanheart.org/statistics/index.html.
2. Ayanian JZ & Epstein AM. (1991). Differences in the use of procedures between women and men hospitalized for coronary heart disease. New England Journal of Medicine, 325(4):221-225.
3. Blumenthal JA, et al. (1995). Mental stress-induced ischemia in the laboratory and ambulatory ischemia during daily life. Association and hemodynamic features. Circulation, 92(8):2102-2108.
4. Blumenthal JA, et al. (1997). Psychosocial factors and coronary disease. A multicenter clinical trial (ENRICHD) with a North Carolina focus. North Carolina Medical Journal, 58(6):440-444.
5. Blumenthal JA, et al. (1997). Stress management and exercise training in cardiac patients with myocardial ischemia. Archives of Internal Medicine, 157:2213-2223.
6. Campbell MK, et al. (1994). Improving dietary behavior: The effectiveness of tailored messages in primary care settings. American Journal of Public Health, 84(5):783-787.
   
   
7. DeBusk RF, et al. (1994). A case-management system for coronary risk factor modification after acute myocardial infarction. Annals of Internal Medicine, 120:721-729.
8. DeBusk RF. (1996).MULTIFIT: A new approach to risk factor modification. Cardiology Clinics, 14(1):143-157.
9. Goldberg RJ, et al. (1999). Duration of, and temporal trends (1994-1997) in, prehospital delay in patients with acute myocardial infarction. Archives of Internal Medicine, 159:2141-2147.
10. Gullette ECD, et al. (1997). Effects of mental stress on myocardial ischemia during daily life. Journal of the American Medical Association, 277(19):1521-1526.
11. Jiang W, et al. (1996). Mental stress-induced myocardial ischemia and cardiac events. Journal of the American Medical Association, 275(21):1651-1656.
12. King AC, et al. (1991). Group- vs. home-based exercise training in healthy older men and women. A community-based clinical trial. Journal of the American Medical Association, 266(11):1535-42.
13. Kudenchuk PJ, et al. (1996). Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (The myocardial infarction triage and intervention registry). American Journal of Cardiology, 78:9-14.
14. Linden W, et al. (1996). Psychosocial interventions for patients with coronary artery disease. A meta-analysis. Archives of Internal Medicine, 156:745-752.
15. Mark DB. (2000). Sex bias in cardiovascular care. Should women be treated more like men? Journal of the American Medical Association, 283(5):659-661.
16. Miller NH, et al. (1997). Smoking cessation in hospitalized patients. Results of a randomized trial. Archives of Internal Medicine, 157(4):409-415.
17. Milner KA. (1999). Gender differences in symptom presentation associated with coronary heart disease. American Journal of Cardiology, 84:396-399.
18. National Heart, Lung, and Blood Institute. (1997). Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction. Bethesda, MD. http://www.nhlbi.nih.gov/about/nhaap/highrisk.htm.
19. National Heart, Lung, and Blood Institute. (2000). Healthy Heart Handbook for Women. Bethesda, MD. http://www.nhlbi.nih.gov/health/public/heart/other/hhw/index.htm.
20. Ornish D, et al. (1998). Intensive lifestyle changes for reversal of coronary heart disease. Journal of the American Medical Association, 280(23):2001-2007.
21. Penque S. (1998). Women and coronary disease: Relationship between descriptors of signs and symptoms and diagnostic and treatment course. American Journal of Critical Care, 7(3):175-182.
22. Raczynski JM, et al. (1999). REACT theory-based intervention to reduce treatment-seeking delay for acute myocardial infarction. American Journal of Preventive Medicine, 16(4):325-334.
23. Schulman KA, et al. (1999). The effect of race and sex on physicians’ recommendations for cardiac catheterization. New England Journal of Medicine, 340(8):618-626.
24. Shaw LJ, et al. (1994). Gender differences in the noninvasive evaluation and management of patients with suspected coronary artery disease. Annals of Internal Medicine, 120(7):559-566.
25. Sherwood A, et al. (1999). Endothelial function and hemodynamic responses during mental stress. Psychosomatic Medicine, 61(3):365-370.
26. Strecher VJ, et al. (1994). The effects of computer-tailored smoking cessation messages in family practice settings. The Journal of Family Practice, 39(3):262-270.
27. West JA, et al. (1997). A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. American Journal of Cardiology, 79(1):58-63.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
College on Problems of Drug Dependence
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, , a nonprofit institute, promotes the science that explores health as a complex and dynamic system of relationships among biology, behavior, psychology, and social context and works to integrate this knowledge into public awareness, health care policy, and health care practice. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding.

Funding for this series was provided by the Robert Wood Johnson Foundation.

For more information contact:
Petrina Chong Director of Communications
phone: 202.387.2829
To e-mail Petrina Chong