Lifestyle interventions reduce cardiovascular risk in patients with coronary artery disease: A randomized clinical trial

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1 5396CNU / European Journal of Cardiovascular NursingSaffi et al. Original Article Lifestyle interventions reduce cardiovascular risk in patients with coronary artery disease: A randomized clinical trial EUROPEAN SOCIETY OF CARDIOLOGY European Journal of Cardiovascular Nursing 2014, Vol. 13(5) The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalspermissions.nav DOI: / cnu.sagepub.com Marco Aurélio Lumertz Saffi 1,2, Carisi Anne Polanczyk 1,2 and Eneida Rejane Rabelo-Silva 1 3 Abstract Background: Nurse-led interventions have proven beneficial to reduce estimated cardiovascular risk. Aim: The purpose of this study was to evaluate the effect of systematic, nurse-led individual lifestyle counseling sessions on the reduction of 10-year cardiovascular risk scores in patients with coronary artery disease (CAD). Methods: This was a randomized clinical trial of CAD patients treated at a tertiary referral hospital. The intervention group received nurse-led guidance by means of five face-to-face sessions and telephone contact over the course of one year, starting three months after hospital discharge. Exercise and dietary goals were set for each patient and monitored at each session. The control group received standard medical advice. Patients were stratified by Framingham risk score and compared at the end of the follow-up period. Results: The final sample comprised 74 patients, 38 in the intervention group and 36 in the control group. Mean age was 58±9 years; 74% of patients were male. A 1.7 point ( 13.6%) reduction in risk score was recorded in the intervention group, vs a 1.2 point increase in risk score (+11%) in the control group (p=0.011). Significant between-group differences were detected for weight (intervention, 78±14 kg at baseline vs 77±14 kg at study end; control, 78±15 kg vs 79±15 kg; p=0.04), systolic blood pressure (intervention, 136±22 mm Hg vs 124±15 mm Hg; control, 126±15 mm Hg vs 129±16 mm Hg; p=0.005), and diastolic blood pressure (intervention, 82±10 mm Hg vs 77±09 mm Hg; control, 79±09 mm Hg vs 80±10 mm Hg; p=0.02). Conclusion: Structured and systematic nurse-led lifestyle counseling effectively reduced cardiovascular risk score. Keywords Risk factors, coronary artery disease, patient education, nursing, secondary prevention, intervention studies Received 6 March 2013; revised 20 August 2013; accepted 27 August 2013 Introduction Despite a worldwide increase in the absolute number of cardiovascular events, cardiovascular deaths have remained constant in many countries, possibly as a result of new therapeutic approaches to prevent and treat atherosclerosis, 1 a condition associated with cardiovascular risk factors (RFs) such as smoking and sedentary behavior. Among these therapeutic approaches, behavioral changes have proved to be safe and effective. Interventions such as education and behavioral counseling and support have been reported to be effective in patients with coronary artery disease (CAD) and heart failure (HF). However, attempts to implement lifestyle changes are difficult and require substantial time and effort. 2 Some patients may require more intensive behavior change counseling and others a specialist method such as motivational interviewing. Establishing rapport, setting 1 Graduate Program in Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul, Brazil 2 Cardiovascular Division, Hospital de Clínicas de Porto Alegre, Brazil 3 Nursing School, Federal University of Rio Grande do Sul, Brazil Corresponding author: Eneida Rejane Rabelo-Silva, Escola de Enfermagem da UFRGS, Rua São Manoel, 963-Santa Cecília, Porto Alegre, RS , Brazil. eneidarabelo@gmail.com

2 Saffi et al. 437 agendas and assessing importance and confidence to change are integral to this approach. 3 Patients should remain motivated to implement behavioral changes in their daily lives, and so should health care professionals to implement the interventions. 4 So far, strategies and programs for cardiovascular risk prevention and reduction have tended to be multidisciplinary and geared to specific RFs. Even though they employ evidence-based recommendations for management of RFs such as hypertension, dyslipidemia, obesity, sedentary behavior, smoking, diabetes, alcohol intake, and psychosocial factors, 5,6 they are neither intensive nor systematic, and follow-up is usually short. 6,7 As a result, the optimal strategy, duration, and intensity of interventions for cardiovascular risk reduction remains unknown. 8 To address this gap, the present study was designed to test whether systematic, nurse-led lifestyle counseling consisting of individualized patient encounters reduces the estimated 10-year cardiovascular risk in patients with CAD. Furthermore, as a secondary outcome, we assessed whether these interventions improved laboratory and anthropometric parameters. Methods Study participants This parallel-group, randomized clinical trial (RCT) was designed to evaluate the impact of systematic educationbased nursing interventions on estimated cardiovascular risk in a sample of CAD patients recruited from a teaching hospital in Southern Brazil. Patients were recruited by a nurse member of the research team. Inclusion criteria were: age 18 years, diagnosis by catheterization, treatment of acute coronary syndrome at our institution between January 2008 December Patients with cognitive deficit or neurological sequelae, participating in other intervention studies, those who had a new cardiac event or who died before randomization were excluded. A patient was classified as having cognitive deficit or neurological sequelae if available records mentioned any mental impairment/confusion or any motor impairments, respectively. Participants who had difficulty in answering the items in the survey instruments or required additional explanation after answering the questions were considered to have some degree of cognitive decline and were also excluded to avoid potential bias in the analysis due to mistakes in data completion. The study was approved by the local institutional review board and is registered at ClinicalTrials.gov (NCT ). This study was approved by the Hospital de Clínicas de Porto Alegre Research Ethics Committee with judgment number 06/570. Study protocol and intervention The study intervention consisted of systematic, nurse-led lifestyle counseling sessions. Patients who met the inclusion criteria, agreed to take part in the study, and provided written informed consent were scheduled to attend the first counseling session three months after the acute event or hospital discharge. At three months, prior to the first counseling session, all study subjects participated in the baseline assessment and responded to the survey instruments. After all measurements had been made, the patients were randomly allocated to the intervention group (IG) or control group (CG) by an external investigator using PEPI 4.0 software (random sampling). The recruiting nurse did not participate in the random allocation process. The external investigator then informed the nurse of the group to which the patient was allocated (IG or CG). During the first session, patients in the IG had their next four consecutive encounters scheduled to take place within a 12-month period. Controls were scheduled to return only after 12 months for the final assessment, but received the standard one-year conventional medical follow-up consisting of two encounters within a one-year period. Data collected during each counseling session were evaluated by the principal investigator. Participants in the IG attended five individual counseling sessions with the recruiting nurse over a period of one year. The first session took place three months after the acute event or hospital discharge. Session 2 took place at six months, session 3 at nine months, session 4 at 12 months and session 5 at 15 months. During these encounters, patients were assessed, counseled, and monitored as to management of cardiovascular RF and lifestyle changerelated parameters. Information was provided on cardiovascular disease (acute myocardial infarction, percutaneous or surgical intervention, and pharmacological treatment), RFs, and the need for regular physical activity, smoking cessation, dietary control and management of weight, blood pressure, blood sugar, and lipid profile. The counseling sessions included audiovisual materials to help contextualize the cardiovascular disease, as well as handbooks explaining about the cardiovascular RFs. Between visits, IG participants also received once-monthly counseling by means of telephone calls lasting approximately 15 min each. Lifestyle goals were set for each patient according to their specific needs (for example, focus on weight loss or on antismoking strategies). Patients were instructed to walk at moderate intensity three to five times a week for min daily. To control weight and blood pressure, participants were advised to reduce intake of sodium and alcohol and increase consumption of fresh fruit, vegetables and low-fat dairy products. 9 At each visit, these goals were reviewed. Barriers to the implementation of exercise and dietary goals, to drug therapy adherence and to smoking cessation were discussed. Participants in the CG received standard one-year follow-up, consisting of two encounters with the recruiting nurse (visit 1 taking place three months after discharge or the acute event and visit 2 at month 15). CG participants received conventional medical follow-up, including general, unstructured lifestyle counseling. In these encounters,

3 438 European Journal of Cardiovascular Nursing 13(5) medical advice was focused on the pharmacological management of disease and optimization of medication for relief of clinical symptoms. Although cardiovascular RFs were addressed during standard medical encounters, there was no emphasis on the patient s individual RFs or lifestyle. Framingham Risk Scores, which estimate 10-year cardiovascular risk and mortality by taking into account non modifiable (age, gender) and modifiable (blood pressure, lipid profile, smoking status) RFs, were calculated for participants in both groups during the first and last encounters, using the variables age, gender, High-density lipoprotein cholesterol (HDL-C) level, total cholesterol level, systolic blood pressure, and smoking status. 10,11 Demographic and clinical data were collected for all participants and updated throughout the study period. Lipid profile, triglycerides, blood glucose, and glycated hemoglobin were measured at enrollment (month 3) and at the end of one year in both groups. Weight, body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), capillary blood glucose, and blood pressure (BP) were measured during all visits in both groups. Measurements were recorded and classified according to Brazilian Society of Cardiology guidelines. 12,13 The study also included the Morisky scale, a four-item adherence measure designed to evaluate medication adherence. The questions were as follows: Do you forget to take your medications? Are you careless about the time of taking your medications? Do you stop taking your medications when you feel better? Do you stop taking your medications when you feel worse? To score the questionnaire, each yes response is given a score of 1, and each no response is given a score of 0 (range 0 4). According to the Morisky classification, adherence is divided into three groups: high for those scoring 0, medium for those scoring 1 or 2, and low for those scoring 3 or 4, when scoring one point for each yes answer. 14 Study outcomes The primary outcome was the reduction of estimated 10-year cardiovascular risk, as calculated by the Framingham Risk Score, at the end of the lifestyle intervention. Secondary outcomes were improvement in laboratory (lipid profile, blood glucose, glycated hemoglobin) and anthropometric parameters (weight, BMI, WC, WHR), BP, capillary blood glucose measurements, and adherence to pharmacological treatment. Sample size calculation Taking into account a significance level of 5% (α=0.05), a statistical power of 80%, an absolute difference of 4% and a standard deviation of 6% in Framingham Risk Scores between the intervention and control groups, and a loss to follow-up of 15%, a minimum sample size of 80 patients (40 patients per group) was required to achieve statistical significance at the end of one year of follow-up. 15 Statistical analysis Continuous variables were expressed as means and standard deviations when normally distributed or median and interquartile range otherwise. The categorical variables were expressed in percentages and as absolute numbers. Pearson s chi-square test and Student s t-test were used for between-group comparison of sample characteristics. Analysis of variance (ANOVA) for repeated measures and analysis of covariance (ANCOVA) with adjustment for baseline measurements were performed for between-group comparison of study variables. A generalized estimating equation was used to assess long-term variation at 3, 6, 9, 12, and 15 months in the intervention group. Two-tailed p-values <0.05 were considered statistically significant. Results Of 552 eligible patients, 335 did not agree to participate, mainly because they lived far from the hospital (out of town), 53 patients had a cognitive deficit and 32 neurological sequelae, 37 participated in other intervention studies and 15 had a new cardiac event or died before randomization. Therefore, 80 patients were randomized, 43 to IG and 37 to CG. After one year of follow-up, 38 patients in IG and 36 in CG remained for analysis (Figure 1). The reason for dropout: the patients did not attend 1st visit (five patients in the IG and one patient in the CG). Baseline characteristics were similar in both groups. The mean cardiovascular risk score was 12.5 for the IG and 10.9 for the CG. Considering the 74 patients who completed the study, mean age was 58±9 years in IG and 59±9 years in CG. Table 1 describes the main characteristics of the sample. At the end of 1 year, the mean cardiovascular risk score declined 1.7 points (-13.6%) in the IG and increased 1.2 points (+11%) in the CG (P=0.011) (Table 2). Regarding cardiovascular risk stratification, 10 patients in the IG (26%) and two patients in the CG (6%) changed to a lower risk class (p=0.016). Relative risk was 4.7 (95% confidence interval (CI): ). The changes in laboratory variables at the end of one year were not statistically different between the groups, before or after adjustment for covariance, except for change in LDL-C (p=0.03) (Table 3). Conversely, between-group differences in variables such as weight, SBP, and DBP were statistically significant at the end of one year before and after adjustment for covariance (Table 4). Adherence to pharmacological treatment, as measured by the Morisky scale, improved to high adherence in 10 patients in the IG (26%) and five patients in the CG (14%) (p=0.15).

4 Saffi et al. 439 Assessed for eligibility (n=552) Excluded (n=472) Declined to participate (n=335) Cognitive deficit (n=53) Neurological sequelae (n=32) Participating in other intervention studies (n=37) Randomized (n=80) New event or death (n=15) Allocated to intervention group (n=43) - Received allocated intervention (n=38) - Did not receive allocated intervention (n=5) Allocated to control group (n=37) - Received allocated control (n=36) - Did not receive allocated control (n=1) Lost to follow-up (did not attend 1st visit) (n=5) Deaths (n=1) Coronary artery bypass grafting (n=1) Acute myocardial infarction/percutaneous coronary transluminal angioplasty (n=1) Lost to follow-up (did not attend 1st visit) (n=1) Deaths (n=3) Coronary artery bypass grafting (n=2) Acute myocardial infarction/percutaneous coronary transluminal angioplasty (n=2) Analyzed (n=38) Analyzed (n=36) Figure 1. Consolidated Standards of Reporting Trials (CONSORT) flow diagram of allocated patients. Discussion In the present study, 10-year cardiovascular risk score decreased by 1.7 points in a group receiving lifestyle counseling, while increasing 1.2 points in a CG receiving traditional medical advice following acute coronary syndrome. Furthermore, there was significant improvement in secondary outcomes such as weight, systolic and diastolic BP in the IG. To the best of our knowledge, this is the first study to demonstrate that a systematic, nurse-led lifestyle counseling intervention had a positive impact on estimated 10-year cardiovascular risk as compared to traditional medical advice. In a review of the literature, we found no conclusive studies that define an effective intervention strategy, duration or intensity related to cardiovascular risk reduction. 8,16 Our study is the first carried out in Latin America using an intervention model for secondary prevention of cardiovascular disease characterized as systematic, as it was methodical in procedure and marked by regularity. Patients in the IG attended pre-scheduled one-on-one counseling sessions and received guidance tailored to their cardiovascular RFs during one year of follow-up. At each visit, the topics were reviewed and patients were encouraged to change their behavior related to lifestyle modifications. The main distinguishing features of this study are the individualized intervention model used, which was associated with reinforcement of instructions by once-monthly telephone calls, and the one-year follow-up period. The predetermined three-month interval between counseling sessions (guidance and management of RFs) and the yearlong trial period proved to be effective and probably helped establish a stronger bond with the patients, thus promoting a stronger commitment to their goals and hence improving clinical outcomes. Holding one-on-one encounters, combined with extra counseling by telephone between visits, was an important factor in this study, because, although patients have a

5 440 European Journal of Cardiovascular Nursing 13(5) Table 1. Sample profile. Characteristics Overall (n=74) IG (n=38) CG (n=36) n= (157) p a Framingham Risk Score b 11.7± ±9 10.9± Age (years) b 58±9 58±9 59± Gender (male) c 55 (74) 28 (74) 27 (75) 0.89 Income ( 3 minimum wage) c 43 (58) 25 (66) 18 (50) 0.39 Educational attainment (years) d 5 (4 9) 6 (5 10) 5 (4 8) 0.07 Risk factors and comorbidities c Hypertension 71 (96) 36 (95) 35 (97) 0.52 Dyslipidemia 49 (66) 26 (68) 23 (64) 0.43 Family history 45 (61) 22 (58) 23 (64) 0.38 Smoking (former) 33 (45) 17 (45) 16 (44) 0.19 Hypertriglyceridemia 45 (61) 15 (39) 14 (39) 0.57 Diabetes mellitus 28 (38) 14 (37) 14 (39) 0.52 Physically active ( 3 /week) 24 (32) 14 (37) 10 (28) 0.68 Smoking (current) 11 (15) 6 (16) 5 (14) 0.19 Alcohol intake ( 2 units/week) 11 (15) 5 (13) 6 (17) 0.47 Percutaneous coronary 51 (69) 26 (68) 25 (69) 0.56 intervention Acute coronary syndrome 42 (57) 22 (58) 20 (56) 0.51 Coronary artery bypass graft 26 (35) 11 (29) 15 (42) 0.18 Current medications c Statins 73 (99) 37 (97) 36 (100) 0.51 Aspirin 68 (92) 34 (89) 34 (94) 0.36 Beta blockers 67 (90) 32 (84) 35 (97) 0.06 ACE inhibitors 52 (70) 26 (68) 26 (72) 0.45 Diuretics 35 (47) 18 (47) 17 (47) 0.58 Oral antidiabetics 26 (35) 14 (37) 12 (33) 0.47 Nitrates 22 (30) 11 (29) 11 (31) 0.54 ACE: angiotensin-converting-enzyme; CG: control group; IG: intervention group. a t-test for independent samples; b expressed as mean±standard deviation; c categorical data expressed as n (%); d expressed as median (interquartile range). Table 2. Cardiovascular risk score (Framingham Risk Score). Group (n=74) Baseline (%) One-year (%) Absolute difference p a Intervention (n=38) Control (n=36) a t-test. Table 3. Laboratory variables. Laboratory variables Baseline 1 year Delta (p) a Delta (p) b IG (n=38) CG (n=36) IG (n=38) CG (n=36) Total cholesterol (mg/dl) c 180±50 170±43 175±53 173± LDL-C (mg/dl) c 105±46 93±27 99±47 96± HDL-C (mg/dl) c 43±9 42±9 43±8 42± Triglycerides (mg/dl) d 148 ( ) 140 ( ) 145 (90 224) 164 ( ) Blood glucose (mg/dl) c 118±54 111±36 114±50 113± Glycated hemoglobin (%) c 6.7±1 6.8±1 6.9±2 6.9± CG: control group; IG: intervention group; LDL-C: low-density lipoprotein cholesterol; HDL-C: high-density lipoprotein cholesterol. a Analysis of variance (ANOVA); b analysis of covariance (ANCOVA) with adjustment for baseline measurement; c expressed as mean±standard deviation; d expressed as median (interquartile range).

6 Saffi et al. 441 Table 4. Measured variables. Measured variables a Baseline 1 year Delta (p) b Delta (p) c IG (n=38) CG (n=36) IG (n=38) CG (n=36) Weight (kg) 78±14 78±15 77±14 79± Body mass index (kg/m 2 ) 28±4 28±4 28±4 29± Waist circumference (cm) 99±10 101±11 99±10 102± Waist-to-hip ratio 0.97± ± ± ± Capillary blood glucose (mg/dl) 120±51 129±56 114±47 128± Systolic blood pressure (mm Hg) 136±22 126±15 124±15 129± Diastolic blood pressure (mm Hg) 82±10 79±9 77±9 80± CG: control group; IG: intervention group. a Expressed as mean±standard deviation; b analysis of variance (ANOVA); c analysis of covariance (ANCOVA) with adjustment for baseline measurement). disease in common, RFs vary from individual to individual and the possibility to tailor each session according to the individual s needs allowed the reduction of estimated 10-year cardiovascular risk. A recent meta-analysis of patients who had undergone myocardial revascularization evaluated the importance of telephone follow-up in this scenario. The studies analyzed showed that telephone follow-up after hospital discharge helped improve quality of life and clinical symptoms, such as pain, anxiety, mood symptoms, knowledge about self-care measures, and lipid profile. 17 Also, counseling and disease management by a health care provider is known to contribute to a beneficial effect on the process of care and quality of life, in addition to reducing hospital admissions. 18 In our study, this combined strategy, one-on-one face-to-face encounters plus reinforcement by telephone, proved to be a feasible strategy for application in clinical practice, being of great benefit to patients in the intervention group. A similar reduction in risk scores was reported by the Lifestyle Interventions for Blood Pressure Control (PREMIER) study, which sought to assess the impact of two lifestyle change interventions on predicted cardiovascular risk. Key findings were a 14% reduction (p<0.001) in Framingham Risk Score in patients who received cardiovascular RF counseling, and a 12% reduction (p<0.001) in those who were also advised to follow the Dietary Approaches to Stop Hypertension (DASH) as compared to the control group. 19 Another randomized clinical trial published in 2007 sought to assess cardiovascular risk reduction, as expressed by reductions in Framingham Risk Score, after a one-year telephone-based intervention with separate analyses of a primary prevention and a secondary prevention group. The primary prevention group experienced a significant reduction in risk score, of 3.10 points (95% CI: 3.98 to 2.22), as compared to 1.30 points in the CG (95% CI: 2.18 to 0.42) (p<0.001). Furthermore, there was significant improvement in secondary outcomes such as total cholesterol, systolic BP, and nutrition level. No significant changes in outcome variables were found in the secondary prevention group compared to its own control group. 16 The Extensive Lifestyle Management Intervention (ELMI) study was conducted with the objective of achieving changes in cardiovascular RFs after one year of follow-up in patients with established CAD. Key findings showed no statistically significant differences in Framingham Risk Score reduction between the intervention and control groups ( 0.34±2.46 vs 0.09±2.08) (p=0.138) and no significant differences in secondary outcomes such as RFs and lifestyle modification. 6 Regarding secondary outcomes, an RCT assessed intervention strategies based on nurse-led counseling in patients with diagnosed CAD over 1 4 years of follow-up. During year 1, the IG improved in terms of adherence to pharmacological treatment, BP management, lipid profile, physical activity, and diet: that is, all components except smoking cessation. After four years, the intervention group had further or sustained improvement in all components except smoking cessation and diet. On adjusted analysis, the relative risk (RR) was 0.75 (95% CI: ) for overall mortality and 0.76 (95% CI: ) for coronary events. 20 Lifestyle interventions often lead to impressive rates of early behavioral change, but these modifications frequently do not persist over the long term. Changing behaviors is a challenge not only to patients receiving the intervention, but also to the health care providers applying it. 21 A systematic review published in 2010 describes key components that need to be considered in the planning of intervention strategies: cognitive and behavioral aspects, psychological aspects, self-efficacy, length of follow-up, frequency of contact, and motivation. There is no conclusive evidence on these issues, particularly regarding length of interventions and of follow-up. However, it is suggested that initial interventions take place over six weeks, with maintenance and monitoring of RFs at 3, 6, 9, and 12 months 9. This is consistent with the strategy used in the present study. Our findings suggest that nurse-led intervention strategies for reduction of cardiovascular risk scores can be used

7 442 European Journal of Cardiovascular Nursing 13(5) in clinical practice. When applied and evaluated systematically, these interventions play a major role in the promotion of lifestyle changes and reduction of cardiovascular events. Limitations Participants in both groups may have received additional dietary and pharmacological guidance provided by other health care providers. Smoking was assessed, but because of the small number of smokers in our sample (n=11), we did not report degree of dependence or change after intervention. A large number of patients declined to participate in our study because they lived far from the hospital and found it hard to come back for the counseling sessions. Conclusions In this study, a one-year-long program of systematic nurseled lifestyle counseling reduced cardiovascular risk scores, estimated effects over 10 years, by 1.7 points in a sample of CAD patients. Furthermore, there was significant improvement in secondary outcomes such as weight and systolic and diastolic blood pressure. Implications for practice Patients with CAD benefit from cardiovascular risk reduction when counseled by nurses as to lifestyle modifications. Therefore, lifestyle counseling should be incorporated into clinical nursing practice regardless of setting. New studies should be carried out to ascertain the extent to which this risk reduction improves endpoints such as myocardial infarction and death. Acknowledgements The authors would like to thank all participants of this study for their contribution. Funding This work was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE) do Hospital de Clínicas de Porto Alegre (HCPA). Conflict of interest The authors declare that they have no conflict of interests. References 1. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 2004; 364: Thompson DR, Chair SY, Chan SW, et al. Motivational interviewing: A useful approach to improving cardiovascular health? J Clin Nurs 2011; 20: Rubak S, Sandbaek A, Lauritzen T, et al. Motivational interviewing: A systematic review and meta-analysis. Br J Gen Pract 2005; 55: Martins RK and McNeil DW. Review of motivational interviewing in promoting health behaviors. Clin Psychol Rev 2009; 29: Gordon NF, Salmon RD, Franklin BA, et al. Effectiveness of therapeutic lifestyle changes in patients with hypertension, hyperlipidemia, and/or hyperglycemia. Am J Cardiol 2004; 94: Lear SA, Ignaszewski A, Linden W, et al. The Extensive Lifestyle Management Intervention (ELMI) following cardiac rehabilitation trial. Eur Heart J 2003; 24: Wing RR, Goldstein MG, Acton KJ, et al. Behavioral science research in diabetes: Lifestyle changes related to obesity, eating behavior, and physical activity. Diabetes Care 2001; 24: Allen JK and Dennison CR. Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure: Systematic review. J Cardiovasc Nurs 2010; 25: Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation 2010; 122: Grundy SM, Pasternak R, Greenland P, et al. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: A statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 1999; 100: Fox CS, Evans JC, Larson MG, et al. Temporal trends in coronary heart disease mortality and sudden cardiac death from 1950 to 1999: The Framingham Heart Study. Circulation 2004; 110: Sposito AC, Caramelli B, Fonseca FA, et al. [IV Brazilian Guideline for Dyslipidemia and Atherosclerosis prevention: Department of Atherosclerosis of Brazilian Society of Cardiology]. Arq Bras Cardiol 2007; 88: S2 S Cardiologia SBd, Hipertensão SBd and Nefrologia SBd. [VI Brazilian Guidelines on Hypertension]. Arq Bras Cardiol 2010; 95: Morisky DE, Green LW and Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986; 24: Lovibond SH, Birrell PC and Langeluddecke P. Changing coronary heart disease risk-factor status: The effects of three behavioral programs. J Behav Med 1986; 9: Wister A, Loewen N, Kennedy-Symonds H, et al. One-year follow-up of a therapeutic lifestyle intervention targeting cardiovascular disease risk. CMAJ 2007; 177: Furuya RK, Mata LR, Veras VS, et al. Original research: Telephone follow-up for patients after myocardial revascularization: A systematic review. Am J Nurs 2013; 113:

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