The worldwide epidemic of cardiovascular disease (CVD) poses a significant challenge to the implementation of interventions shown to improve patient outcomes.1 Initiation of and adherence to lifesaving therapies is complex and challenging for medical care systems, health care professionals, and patients. To improve patient outcomes through adherence to national guidelines, a multidisciplinary team-based approach has been proposed.2-4 Significant evidence exists supporting a systematic approach to CVD risk reduction through team-based, nurse-directed case management.5-8 A team-based approach requires the expertise of multiple health care professionals, including nurses, nutritionists, physicians, pharmacists, psychologists, social workers, and other allied health care professionals.
The Role of Nurses
Nurses are ideal health care professionals to direct the CVD risk reduction team and to deliver multifactorial risk reduction in hospital settings, outpatient clinics, and community-based facilities. The ideal nurse case manager has an in-depth knowledge of medicine, psychology, and behavior change. Most importantly, a skilled nurse case manager must have an interest in and commitment to the unique differences in patient populations based on age, race, ethnicity, culture, sociodemographics, and literacy. Bodenheimer and colleagues,9-11 in their evaluation of ways to improve primary care in the United States, called attention to the pivotal role of nurses in the health care reform necessary to address the growing needs of chronic disease management and in improving care for chronic diseases.
In a meta-analysis of secondary CVD prevention programs, Clark and colleagues12 demonstrated a reduction in all-cause mortality and acute myocardial infarction (MI). Of note, 45% of the studies included in the analysis were nurse led or nurse managed. In the early 1990s, the Stanford Coronary Risk Intervention Study (SCRIP) assessed whether nurse-directed, multifactorial risk reduction could improve cardiovascular outcomes compared with usual care in men and women with baseline coronary artery disease (CAD) documented by angiography. The primary outcome was angiographic progression of CAD from baseline to 4 years following the intervention; secondary outcomes were all CVD events. Following a nurse-directed team-based case management protocol, after 4 years, 45% fewer clinical events and a regression in angiographically measured atherosclerosis was seen in the intervention group compared with control.5 The MULTIFIT study, also undertaken by investigators at Stanford University, was designed to determine the effect of modifying multiple risk factors in post-MI patients.6 Operating primarily by telephone, nurse case managers offered education and counseling and titrated medications under guideline-based protocols. At the end of 1 year, significant changes in dietary scores, lipid levels, functional status as measured by exercise testing, and biochemically confirmed smoking cessation rates were superior in patients assigned to the treatment arm, compared with usual care.
In 2004, the Cardiac Hospitalization Atherosclerosis Management Program undertaken at the University of California at Los Angeles focused on the initiation of guideline-based therapies for CVD risk reduction in hospitalized patients with CAD.8 The Cardiac Hospitalization Atherosclerosis Management Program demonstrated a significant reduction in morbidity and mortality (P < .05) in patients receiving nurse-directed case management compared with usual care 1 year after hospital discharge. This trial became the cornerstone for the American Heart Association's "Get With the Guidelines" national initiative.13 More recently, a major study undertaken in Europe demonstrated that a nurse-directed program for multifactor risk reduction improved blood pressure (BP) and lipid goals compared with usual care in high-risk hospitalized coronary heart disease patients and those seen in general practice.7 In hospitalized patients, statin use increased from 80% at baseline to 86% at 12 months (P = .04) compared with no change in usual care. Findings were similar in general practice patients: statin use increased from 15% to 38% at 1 year (P = .03), and usual care also increased, from 18% to 23% (not statistically significant). Both statins and hypertension medications were prescribed suboptimally in general-practice high-risk patients.7
Nurse-directed case management has been shown to be effective not only in individuals with multiple risk factors, but also in treating single risk factors in young and older populations, in diverse ethnic groups, and in individuals with comorbidities.14 The greater than 10 million nurses worldwide represent the largest group of health care providers with the requisite education and position in their communities required to take on the role of case managers for CVD risk reduction.15 Nurses are highly respected and valued by patients, patients' families, and the health care community and thus are ideal to fill this important role.
Successful Models of Care-An International Perspective
Although the scientific evidence for CVD prevention in clinical practice is compelling, translating that evidence into effective models of care remains a challenge. The nurse-led case management approach is characterized by individual goal setting between the patient and nurse to achieve lifestyle change. In addition, adherence to national guidelines for medical management by nurse case managers has been shown to be effective in lowering blood lipids, BP, blood glucose, and smoking cessation.2,5,7,8 Key principles for an effective practice model are proposed, based on supporting evidence from successful case management trials (Figure).5,7,16,17 These studies were selected because they applied a multifactorial approach, were undertaken in different parts of the world, and lend support for understanding key concepts critical to nurse-led case management.
Key Principles of a Nurse-Led Case Management Approach
- 1. Preventive care should be implemented according to evidence-based guidelines for CVD prevention.
Evidence-based guidelines should be locally adapted for everyday clinical practice in the country where they are to apply, and goals for treatment should be set to reduce global CVD risk. The SCRIP program (Table) chose to use a stricter approach than the National Cholesterol Education Program in the United States by setting its low-density lipoprotein cholesterol goal lower and using more aggressive guidelines for saturated fat and dietary cholesterol intake.5 In the MULTIFIT program (Table), the goal for low-density lipoprotein cholesterol was based on the mean post-treatment level achieved in clinical trials. Both the Extensive Lifestyle Management Intervention (ELMI) and EUROACTION studies (Table) aimed to demonstrate in everyday clinical practice that evidence-based guidelines can be implemented.7,16 The primary outcomes of the EUROACTION study were the European lifestyle, risk factor, and therapeutic goals for CVD prevention in clinical practice.7
- 2. Preventive efforts should be targeted at those who will benefit the most, that is, patients with vascular disease, those at high risk of developing disease, and the close family members of these patients, and should take into account groups in which the prevalence of CVD and risk factors is highest.
Targeting those at risk and with vascular disease is known as a high-risk strategy, but it can also accompany a strategy for CVD risk reduction that includes a population approach. Population strategies have the potential to achieve substantially larger reductions in risk in an entire population as the result of relatively small modifications in risk factors by many individuals, not just those at highest risk.
All of the selected studies shown in the Table targeted patients with coronary disease for secondary prevention: those with angiographically determined atherosclerosis, those immediately post-MI, those who completed a cardiac rehabilitation program, and those with heart disease seen in primary care clinics.5-7,16,17 The EUROACTION study addressed all priority groups for CVD prevention as defined by the Joint European Societies at the time-such as those with established coronary disease and those at high risk of developing CVD. Thus, the EUROACTION study embraced primary as well as secondary prevention.7,18
To reach those at highest risk in general practice, the EUROACTION primary care study used the European SCORE risk estimation charts and electronic HeartScore risk estimation and management system, which uses European regional mortality data to predict the probability of a fatal cardiovascular event over a 10-year period.19
- 3. The families of high-risk patients should be included in preventive efforts and not just the patient alone.
Close family members of vascular and high-risk patients are at increased risk of developing CVD due, in part, to genetic factors, but principally to a shared family lifestyle and in spouses, to assortative mating.20-24 The EUROACTION study included partners and close relatives in the prevention program and actively managed cardiovascular risk in these family members.7 Partners made lifestyle changes in the same direction as patients. Significant concordance for change was seen between patients and partners participating in the intervention arm of the hospital study for body mass index (r = 0.21), waist circumference (r = 0.22), BP (systolic BP: r = 0.13, and diastolic BP: r = 0.15), and total cholesterol (r = 0.21), which reflected the dietary and physical activity changes these couples made together.
- 4. Preventive programs should have an appropriate setting and a flexible approach that allows easy access to the people from the community targeted for the intervention, especially when that community includes vulnerable and deprived groups.
Among the selected studies in the Table, 4 were hospital-based programs, one was based in general practice, and one had both hospital and general practice programs.5-7,16,17 Three of the hospital-based programs (SCRIP, MULTIFIT, and ELMI) adopted a flexible approach using primarily mail and telephone contact with patients.5,6,16 In addition, both the SCRIP and MULTIFIT programs utilized a home-based exercise program, further reducing the need for attendance at a specialized center.5,6 All 3 programs achieved participation rates between 82% to 86% of eligible patients. However, even though the EUROACTION hospital program required more frequent attendance over a shorter period, it also achieved a participation rate of nearly 90%.7
Although the EUROACTION hospital program was offered to 67% of all eligible consecutively identified patients, making it better than reported survey data of one-third in 15 countries in Europe, it was even better for high-risk individuals in the EUROACTION general practice program, at 94%.7 Many patients who chose not to participate in the EUROACTION hospital program reported distance from their home (29.5%) and time required (25.5%) as limiting factors.
A new nurse-led case management approach called MYACTION,25 which evolved from EUROACTION, locates programs in the community, using leisure facilities or other community centers. This model addresses health inequalities by targeting deprived and vulnerable populations, where the prevalence of CVD and risk factors can be high.
- 5. The focus of preventive efforts should be on promoting healthy lifestyle habits to address total cardiovascular risk.
Cardiovascular risk is driven by poor dietary habits, sedentary behavior, and tobacco smoking. These risk factors lead to overweight and central obesity, increased BP, abnormal lipid levels, and diabetes. The long-term effects of these risk factors are seen in higher rates of CAD, stroke, peripheral arterial disease, cancer, and lung diseases. Addressing and managing complex lifestyle behaviors require expertise from a variety of health care professionals. Preventive efforts should therefore be based on a lifestyle program that incorporates the expertise of the disciplines of nursing, medicine, dietetics, physical activity, and psychology.
A defined behavioral strategy is essential and will determine the quality and impact of an intervention, together with intensity and frequency of contact and the involvement of health care professionals. A behavioral strategy characterized by a theoretical framework, individualized goal setting, and intensive support from health care professionals is described for each of the study programs included in the Table. For example, in the MULTIFIT program, the behavioral intervention was derived from social learning theory, which is designed to improve perceptions of self-efficacy by teaching self-management and enhancing motivation.26 For example, when setting goals, nurse case managers and patients initially set attainable subgoals, whereas recommended study goals remained the final, optimal end point. Regular follow-up by the case managers allowed feedback on progress. In the ELMI and EUROACTION programs, self-monitoring of progress was facilitated by the use of a patient-held personal record card to track progress at every contact with a nurse or other member of the program team.7,16 The EUROACTION program also incorporated motivational interviewing techniques into its behavioral strategy.27 These techniques included using appropriate tools to assess motivation, for example, asking patients and partners to rate the importance of changing a particular behavior to stopping smoking. Their confidence in the ability to achieve the change was measured. Decisional balance was assessed and provided the means to promote motivation and explore ambivalence toward addressing a particular behavior change. The health professionals involved were trained to avoid rigidly dichotomizing patients into isolated stages of change as defined by the Transtheoretical Model, but rather to use this model to tailor the use of motivational techniques. The family approach adopted by the EUROACTION program added an important source of social support for behavior change.
In addition to being trained to understand and apply behavioral strategies, health care professionals involved in the delivery of a multifactor program need expert knowledge and training in smoking cessation, implementing a cardioprotective diet, adapting physical activity and exercise (taking functional capacity and physical limitation into account), and reducing weight. To achieve this, dedicated time to provide follow-up and support is critical. In the MULTIFIT program, the nurse case managers had 80 hours of multidisciplinary training from specialists, which covered exercise testing and training, diet and drug management of hyperlipidemia, smoking cessation, and psychosocial interventions.6 The intervention required approximately 9 hours per patient throughout the year of the program, of which 6 were direct patient contact, usually by telephone or mail; the rest were allocated to liaison with primary care, hospital and study center personnel. This is in contrast to the Grampian study of secondary prevention in primary care, which used existing nursing personnel in 19 practices, fitting the program into usual work routines.17 In Grampian, nurses received a day and a half of training in clinic protocols and techniques to facilitate behavior change. The program lasted 1 year for each patient and included an initial visit of 45 minutes and subsequent 20-minute follow-up visits (number not specified). Both studies reported reductions in self-reported fat intake at 1 year. In the Grampian study, an additional 7.5% of patients adopted a low-fat diet in intervention, compared with no increase in patients receiving usual care, as measured by the Dietary Instrument for Nutrition Education questionnaire.17,28 In the MULTIFIT study, there was a reduction from 322 to 124 in a food frequency score for a diet low in saturated fat and dietary cholesterol, compared with a reduction from 307 to 140 in usual care; both of these surpassed the National Cholesterol Education Program Step 2 goal of a score between 160 and 210.6 In the Grampian study, 4.4% of patients became more physically active, compared with −1.1% of patients in usual care.17 In the MULTIFIT study, self-reported increases in physical activity and adherence to a home-based exercise program were validated by exercise treadmill testing of functional capacity, which was significantly higher in intervention (9.3 METs) compared with usual care (8.4 METs) (P = .001). This measure of functional capacity in the MULTIFIT study represents a rigorous validation of the increase in physical activity, superior to self-report.6
Of note is the highly significant smoking cessation result in the MULTIFIT study, 70% in intervention compared with 53% in usual care, compared with the absence of any effect in the Grampian study.6,17 However, MULTIFIT recruited patients 3 days after MI and focused primarily on relapse prevention, whereas the Grampian study recruited patients with a diagnosis of coronary heart disease from the practice registers, regardless of the date of their acute event. The authors point out that it is possible that coronary patients who continue to smoke in the weeks, months, and years following their event may be more resistant to change. Although nicotine replacement therapy was available to support smoking cessation at that time, it was not widely used, and no other options, such as bupropion or varenicline, were available.
Each EUROACTION hospital program had a dedicated multidisciplinary team of specialist nurses (1.75 full-time equivalents [FTEs]), a dietitian (0.5 FTE), and a physiotherapist or physical activity expert (0.5 FTE).7 This team had 40 hours of training from a central multidisciplinary team. The training included how to carry out an individualized assessment, deliver smoking cessation, perform dietary management, run a supervised exercise program, and advise on appropriate physical activity. Lifestyle interventions were based on national guidelines as well as patient-specific physical limitations. Team members were available at the weekly program sessions, which lasted 2 to 3 hours and included one-on-one tracking of progress toward attainment of lifestyle (smoking cessation, adoption of a cardioprotective diet, increasing physical activity, working toward achieving a healthy weight and shape) and risk factor management goals. In the general practice program, a full-time dedicated nurse was trained by the same central team to deliver all aspects of the lifestyle program (see above) and to follow risk factor management protocols. The EUROACTION primary care program structure was more flexible than the hospital program, which required attendance for the 16-week program. Patients and partners in the primary care program were enrolled for 1 year and were managed by the nurse on a one-to-one basis, attending meetings when required.
In the ELMI study, despite quite a large investment in a lifestyle intervention, a 4-year program, and intensive support, the results for diet, physical activity, and weight management were disappointing. However, patients in both intervention and usual care had been through an initial cardiac rehabilitation program, thus reducing the study's potential to show a difference.16
The duration of the programs under examination varied from 16 weeks for EUROACTION (hospital program)7 to 4 years for SCRIP and ELMI.5,16 Is duration important, and if so, how do we decide on the optimum length for a program? It could be argued that support and follow-up should be provided indefinitely, although this may be realistic only in a primary care setting, where people register with a general practitioner for all their chronic disease management. The results of the 4-year studies are in many ways similar to studies whose programs lasted between 16 weeks and 1 year. However, are the immediate results of these programs sustained? In the case of the EUROACTION 16-week hospital program, the published results are at 1 year after the program started, representing results sustained without the support of the team for an 8-month period.7 The Grampian study authors demonstrated in their 4-year follow-up study of a 1-year program that lifestyle and risk-factor changes were sustained, with the exception of physical activity.28 If the aim of such initiatives is to promote self-management, then expanding programs for longer-term duration may be an unnecessary burden on health care services.
- 6. There should be an effective mechanism for prescribing cardioprotective medications, and protocols should be available to facilitate the management of BP, lipids, and diabetes to achieve guideline-based goals.
High-risk patients often require adjunctive drug therapies in addition to lifestyle interventions to optimize the management of risk factors. All the studies in the Table had some degree of success in modifying risk factors. All were characterized by a goal-oriented approach, with protocols in place to facilitate and guide management. In the MULTIFIT program, nurse case managers prescribed lipid-lowering medications under protocols.6
In the EUROACTION program, the hospital team and the nurse in general practice met weekly with a physician who had dedicated time for the program to prescribe and titrate cardioprotective medications. Nurses did not prescribe, as legislation in all of the European countries involved in the study at the time did not support nurse prescribing.7 Since the completion of the study, the United Kingdom has introduced legislation to support independent nurse prescribing (2005), and this is a feature of the newly evolved MYACTION model.25
There were no differences in the percentage of BP-lowering medications prescribed between intervention and usual care in the hospital arm of the EUROACTION study (β-blockers: 76% in intervention compared with 80% in usual care; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers [ARBs]: 52% in intervention compared with 56% in usual care), yet BP control was superior in the intervention arm compared with usual care (proportions reaching goal 65% in intervention compared with 55% in usual care P = .04).7 A number of possible explanations for this include (1) a professional lifestyle program that included a dietitian and physical activity specialist who focused on assessing diet and physical activity and negotiating tailored changes. These tailored changes positively influenced BP by reducing salt, increasing fruit and vegetable consumption, increasing activity levels, and managing weight loss; (2) improved compliance with medication; and (3) correct doses. Although prescribing in the general practice arm for individuals at high risk of developing CVD was generally much lower than in the hospital arm, there were significant increases in prescribing for angiotensin-converting enzyme inhibitors/ARBs (29% in intervention compared with 20% in usual care), diuretics (32.5% in intervention compared with 18.3% in usual care), and statins (37.7% in intervention compared with 22.1% in usual care).7
In the ELMI study, significant changes between baseline and 4 years were seen in mean systolic BP (128 to 126 mm Hg in intervention, compared with 125 to 131 mm Hg in usual care) and mean total cholesterol (4.43 to 4.21 mmol/L in intervention, compared with no change from 4.54 mmol/L in usual care).16 In this program, the nurse case managers consulted a dedicated cardiologist who recommended prescriptions to general practitioners of participating patients. Forty-four percent of these recommendations were acted upon, resulting in significant increases in prescribing of diuretics from 16% to 28% and in ARBs from 3% to 12%.
A few key principles have been identified that can be applied to a working model for practice. An example of such a model is shown in the Figure. This model reflects the MYACTION community-based model of vascular prevention and embraces both primary and secondary prevention, eliminating the artificial barrier between the two.25 Asymptomatic individuals with at high CVD risk require the same preventive care as symptomatic patients who have already developed vascular disease, and so do their families. These families are also likely to be at a high CVD risk and will thus benefit from a program as shown in the EUROACTION study.7
The Success of Nurse Case Managers
As indicated by the models shown in the Table, nurse case managers have helped to educate and motivate individuals to manage numerous lifestyle changes pertinent to CVD prevention. The majority of programs of case management for CVD risk reduction have been shown to be effective in improving overall patient care.29 Effectiveness has been measured by an improvement in the achievement of goals such as BP, smoking cessation, and dyslipidemia; improvement in quality of life; an increase in short-term adherence; and reductions in medical resource utilization, including fewer emergency room visits and hospitalizations for some populations.30
A review of educational interventions for CVD risk reduction conducted by Mullen and colleagues31 in the early 1990s found that the success of education programs was more highly related to skill building rather than simply imparting knowledge. Two- thirds of the programs evaluated were directed by nurses who used a range of behavioral skills such as contracting, goal-setting, self-monitoring, feedback, and problem solving to facilitate change.31 Theories such as stages of change, social learning theory, and relapse prevention training have guided nurses' efforts to provide education and behavioral interventions to patients.27,32,33 The success of nurse case managers has resulted from designing educational interventions specific to the needs of patients, such as audio, video, or written materials. In addition, a wide variety of formats such as face-to-face education and counseling, education by telephone, and home visits were designed for those in greatest need.34 Nurses' success in intervening with large populations attempting to change multiple cardiovascular risk factors is dependent on providing more intensive education and counseling for those who need to make the greatest changes and those who lack motivation to adhere without such support.35
Nurse case managers have also played a significant role in helping individuals to manage pharmacological therapies for primary and secondary prevention of CVD. Guidelines developed by international organizations represent only a starting point for key decisions about pharmacotherapy. They are currently insufficient to support the mission of managing dose titration and long-term adherence. Implementation of guideline based treatment protocols (eg, such as drug choice and dose titration tables) by nurse practitioners and nurses under nurse practice acts has supported physicians' efforts to manage all aspects of pharmacological therapy. A major focus for nurse case managers is helping individuals adhere to well-known lifesaving pharmacotherapies.
Having additional time devoted to counseling during office visits or through telephone contacts or the Internet with a focus on tailoring interventions to the needs of patients has enabled nurse case managers to help individuals with acquisition of lifesaving behavioral skills. Developing skills such as prompting and cueing, reminders, and enlisting the support of family members to support medication-taking behaviors provides a basis for successful change.29
Self-care is essential for lifelong success in reducing cardiovascular risk and managing chronic conditions such as diabetes and heart failure. Self-care has been defined as a naturalistic decision-making approach that patients use in the choice of behaviors that maintain physiological stability (symptom monitoring and treatment adherence) and the response to symptoms when they occur.36,37 Unlike adherence, self-care involves the tactical and situational skills for managing various disease conditions.37 Acquisition of skills to modify behaviors is often gained through involvement and support from family members and friends and practice over time. However, nurses can assist individuals in acquiring skills to perform routine behaviors such as meal preparation and can teach them how to order various diets in restaurants to master changes in their diet. It is important to convey an understanding that self-care involves the tactical (eg, how to) and situational skills (eg, what to do when) for managing the risk factors and disease conditions. For example, following a low-salt diet for BP control requires the skills of reading labels, preparing foods, menu planning, and perhaps managing multiple diets. Identifying deficiencies, finding trusted resources for support, and role playing are helpful in focusing on skill building. Although nurses in some settings, such as cardiac rehabilitation programs, offer unique support by facilitating tactical skills training, additional research is needed to guide the activities of nurses and other health care professionals in supporting individuals to succeed with self-care.
Challenges for Nurse Case Managers and Future Research
Many challenges confront nurses involved in care management. One is the nurses' ability to simultaneously manage multiple risk factors and comorbid diseases in patients at risk for or with established CVD. This challenge is confounded by barriers associated with language and literacy, especially in individuals who may be at highest risk for CVD. Defining specific roles (such as ensuring the availability of staff with language skills and cultural knowledge/sensitivity) of all health care providers and identifying programs with high success rates that can be easily disseminated are critical in supporting implementation of nurse case management programs. Although fewer programs of nurse case management in lower-literacy individuals have been conducted to date, early analysis suggests that risk factors have been improved and appropriate outcomes achieved in these populations.38,39
Additional challenges relate to the choice of intervention components and the length of follow-up. Large variations in the frequency of contact, the type of content, the information provided, and the length of follow-up to ensure ongoing maintenance of risk-factor changes exist in multiple risk factor intervention programs. Few programs involving nurses have prioritized the various components of their programs or combinations of components within programs or settings. Programs already found to be successful in achieving improved CVD outcomes need to be replicated and disseminated. Additional studies are needed to determine not only the cost-effectiveness of such programs but also how these programs influence overall quality of life.
Electronic communication provides the opportunity for nurses to manage larger numbers of patients over an extended period, yet reimbursement in the United States remains based primarily on face-to-face visits. Reimbursement is needed to support time spent by nurses in education, counseling, and follow-up of individuals at high risk. This is particularly important in those who experience difficulty with adherence and those faced with managing multiple risk factors and chronic medical conditions. Addressing these issues will require changes in the way both physicians and nurses are reimbursed. It is very likely that future innovations in technology will support the dissemination of nurse case management systems of care. Electronic medication monitoring, home BP monitors, blood glucose meters, and voice-recognition technology all facilitate the data-gathering process for health care professionals. Real-time online analysis of data linked to patient reminders will enable case managers to individualize care. Future research is needed to determine the best approach for integrating and using technology in the management of patients who would benefit from case management for CVD risk reduction.
In summary, a significant role exists for nurses as leaders in CVD prevention. Research has documented that nurse case management improves cardiovascular risk factors, lifestyle, and, most importantly, outcomes. Although continued research is needed, the time is now for an international expansion of nurse-based CVD prevention to reduce death and disability from this worldwide epidemic.
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