Issues in cardiovascular nursingCardiovascular risk reductions associated with aggressive lifestyle modification and cardiac rehabilitation
Introduction
For most patients with cardiovascular disease (CVD) current management in the United States usually involves intensive pharmacological therapy and/or invasive interventions with little lifestyle modification. Medical interventions have demonstrated clinical benefits but also carry a substantial risk of side effects. Surgical interventions also have demonstrated benefits but carry risks of early mortality and surgical complications. Percutaneous interventions, though less invasive than open surgical procedures, have not been shown to alter the natural history of the disease.1
In the early 1970s, the need for lifestyle modification as an adjunct to cardiac treatment spawned the development of cardiac rehabilitation programs that encouraged aerobic exercise, weight control, smoking cessation, and dietary modifications. These programs were designed to limit the physiologic and psychologic effects of cardiac illness, stabilize or reverse the atherosclerotic process, and enhance the psychosocial status of cardiac patients. Today, despite the benefits of cardiac rehabilitation programs, there are several barriers that keep many patients from participating. Rehabilitation participants are required to pay additional out-of-pocket expenses in the form of insurance copays, and bear cost of additional time and travel commitments. Lack of motivation may also be a barrier.
Though most cardiac rehabilitation programs focus on exercise participation, other programs offer assistance in lowering cardiac risks associated with poor nutrition, hypertension, hypercholesterolemia, stress, hostility, depression, and social isolation. One such program is the Ornish Heart Disease Reversing Program.2
The Ornish Program is divided into 3 distinct stages. The first stage is 12 weeks long and begins with an intensive week-long orientation. During the first week, participants meet 3 times for 4 hours each session. During these sessions, participants are introduced to each aspect of the program and taught how to integrate recommended changes into their lifestyle. During weeks 2 through 11, participants meet twice weekly for 4 hours each session. Each session consists of supervised group exercise, stress management, group support meetings, and a communal meal. Program participants are encouraged to adopt a vegetarian diet, which can include egg whites and non-fat dairy products. The diet consists of less than 10% of total calories from fat, 15% of calories from protein, and 75% of calories from complex carbohydrates. Participants are instructed to have no more than 10 mg of cholesterol per day and less than 2 ounces of alcohol per day. No caffeine is allowed, and salt intake is restricted for those with hypertension, heart failure, or kidney disease.
Stage 2 of the Program lasts an additional 3, 6, or 9 months depending on the patients' medical status and adherence. Stage 2 is a continuation of stage 1, however participants meet only once a week for 4 hours. Stage 3 is an alumni association. Participants are encouraged to join a self-directed community to reinforce long-term lifestyle changes and maximize self-reliance.
Early within-group evaluations of the program reported a 62% increase in treadmill time and decreases in systolic and diastolic blood pressure, premature ventricular beats, plasma cholesterol, and plasma triglycerides.2 Controlled, 1-year trials of the program revealed a 55% average improvement in treadmill time, a 20% average decrease in plasma cholesterol levels, a 91% average reduction in frequency of anginal episodes, and significant reductions in anxiety and depression.3 Other 1-year findings have shown that 82% of patients in the Ornish Program showed measurable regression of stenotic lesions, whereas 53% of patients in the control group had documented progression of their stenoses.4 Among Ornish Program participants, improvement in myocardial perfusion has also been demonstrated with positron emission tomography scans for as many as 5 years of follow-up.5
These findings suggest that intensive lifestyle change programs are capable of reducing a variety of CVD risks in patients who already have advanced stages of CVD. The purpose of this study was to compare the 6-month changes in cardiovascular risks experienced by patients who participated in the Ornish Heart Disease Reversing Program (Ornish Program), those who participated in a traditional cardiac rehabilitation program, and a control group that did not participate in any formal cardiac risk-reduction program.
Section snippets
Participants
Data were obtained from cardiac patients recruited from the Swedish American Hospital in Rockford, Illinois. All patients lived within 40 minutes of the study center and had clinically confirmed acute myocardial infarction as defined by the presence of at least 2 of the following 3 criteria: 1) continuous chest pain lasting at least 30 minutes, 2) electrocardiogram changes typical of an evolving myocardial infarction, and 3) elevated levels of cardiac enzymes as determined by a physician. All
Ornish program
Cardiac patients who participate in the Ornish program eat a low-fat vegetarian diet; regularly practice stress management techniques (including stretching, progressive relaxation, imagery, breathing techniques, and meditation); and participate in moderate aerobic exercise and group support meetings. Additional detail about the program is provided in the introduction.
Traditional cardiac rehabilitation
The traditional cardiac rehabilitation program is divided into 4 phases.10, 11 Phase I takes place while the patient is still in
Results
In all, 141 patients agreed to participate, 28 selected the Ornish Program, 58 entered cardiac rehabilitation, and 55 elected no formal rehabilitation. To control for a possible income-related selection bias, each of the 28 Ornish participants was stratified by income with each group and was then randomly matched by income with a patient in the rehabilitation group and a patient in the control group. These income-matched triplets were used in all analyses. The final study design included 84
Discussion
Several studies examining the effects of the Ornish Program on modifiable risk factors have reported significant improvements in blood lipids, blood glucose, percent body fat, blood pressure, nutrition, anginal pain outcome, functional capacity, and reversal of atherosclerosis.2, 3, 4, 5, 15, 16, 17 The findings reported here demonstrate that participants in the Ornish Program are able to experience similar reductions in cardiovascular disease risks and can reduce the frequency, duration, and
Conclusion
Results of this study suggest that the Ornish Program may be more effective at improving modifiable risk factors such as weight, BMI, systolic blood pressure, glucose, total cholesterol, and LDL-cholesterol than traditional cardiac rehabilitation programs or no rehabilitation. Ornish Program participants also demonstrated significant improvements in intake of dietary fat and complex carbohydrates when compared with the other 2 groups. Regardless of group membership, all participants experienced
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