Lifestyle changes in secondary prevention of coronary heart disease: breaking the chains of unhealthy habits

The management of patients with acute coronary complications includes three components: short-term local therapy for clinically significant coronary obstructions, cardiac rehabilitation (CR) and long-term treatment of the underlying atherosclerotic process. Of these, the last mentioned appears to be the most challenging. There is little question as to which factors should be addressed to inhibit progression of the disease, and guidelines on this topic are clear and consistent around the world. Changing unhealthy lifestyles may lead to reductions in the risk of mortality that are greater than the benefits of some of the acute treatments for coronary disease [1]. Unfortunately, the success of these lifestyle changes in practice is limited. In general, drug treatments and the achievement of their target values are relatively adequate [2]. However, the widely recommended healthy lifestyles are frequently not achieved. In a recent observation from 17 countries, nearly 1 in 5 individuals continued to smoke, only 1 in 3 individuals reported high levels of physical activity and 2 in 5 reported a healthy diet [3]. As these proportions are based on self reports, true numbers may in fact be lower. Thus, a large gap exists between guidelines and their implementation in reality. The causes for this discrepancy are multiple and complex. On the patient's side, it is challenging to change habits that have been in place for many decades, that are shared with their partner and with their social environment, and that are generally associated with short-term quality of life. In addition, the concept of long-term prevention is complex: the sacrifices are clear and instant whereas the rewards are uncertain and distant. Some of the lifestyle changes may be costly to the patient, such as healthy food choices and engaging in exercise. On the physician's side, the short-term treatment of coronary disease is rewarding, in medical, psychological and financial terms, whereas the management of long-term risk is less rewarding and not infrequently frustrating. In recent years, the management of secondary prevention has increasingly been transferred to paramedical personnel. Nurses, physiotherapists and dieticians now play an important role, particularly in addressing the lifestyle-related components. Nonetheless, overall results are suboptimal and new approaches are needed to promote healthy lifestyles and thus achieve better outcomes. The OPTICARE study is designed to test two strategies to improve implementation of guideline-based secondary prevention , in addition to a standard program of CR, in patients with a recent coronary incident [4]. In …