**8. Summary: Implications for research and practice**

**7. Overall effectiveness of angina SMT programs: Results of meta-analyses**

We first summarized the effectiveness of angina SMT interventions in a 2008 meta-analysis [84]. The results of 7 trials, involving 949 CSA patients in total, were included. In each case, the effects of a SMT intervention were compared to usual medical and/or nursing care as described [74-77,79-81]. We found that those who underwent angina SMT experienced significant reductions in the frequency of angina (nearly 3 less angina episodes per week) as well as SL nitroglycerin use (approximately 4 times less per week) up to 6 months postintervention [84]. Significant, pooled effects were also found for angina-induced physical limitation and HRQL-related disease perception, but we were uncertain of the stability of these estimates due to broad confidence intervals [84]. At the time, we were unable to generate an estimate of the effect of SMT on psychological well-being due to the heterogeneity of measures used across trials to measure these HRQL dimensions. We signaled caution with respect to the interpretation of our results due to the wide range (low to high) of methodological quality

New, robust trial data contributed by Zetta et al. [82] and Furze et al. [83] allowed us to update our meta-analysis in 2012 [85]; nine trials including 1282 CSA patients in total were included. Outcome measures were more homogenous with the inclusion of these new data which allowed us to examine the impact of angina SMT on psychological outcomes. Consistent with our 2008 review [84], we found that angina SMT reduced the frequency of angina symptoms and the use of SL nitrates. Self-management training also reduced physical limitation for CSA patients. Our pooled estimates of effect for the impact on SMT for emotional well-being were less certain. We did find a significant improvement in depression scores, but there was considerable statistical heterogeneity for this outcome across trials [85]. Initially, we found no impact on anxiety, but, sensitivity analysis—via removal of 1 trial [83] with the widest confidence interval for this outcome—suggested that anxiety scores [85] are improved up to

Based on our systematic reviews [84,85], evidence is clear that SMT consistently improves angina with respect to the frequency of symptoms and reduces the need for SL nitrates. The positive effect of SMT on physical limitations imposed by angina also appears stable. What is less certain is the potential for SMT to improve the psychological burden of CSA, particularly anxiety. Noteworthy is the fact that the overall improvements we observed in depression scores were yielded by the Angina Plan [78,79,82,83], suggesting that perhaps individualized

Some key questions about the effectiveness of SMT for CSA management remain. A critical element contributing to the effectiveness of intervention programs to date is the provision of an array of self-management strategies that can be tailored to individual problems, needs and preferences, in the context of living with chronic angina. This much is clear and entirely consistent with the broader chronic disease-self-management literature [42-48], as well as underlying principles of self-efficacy theory [52-54]. What is less clear is the ideal intervention design—or particular elements thereof—that would yield maximum symptom benefits and much needed improvements in HRQL for this heavily burdened population. For example,

SMT programs my yield greater benefits in terms of emotional well-being.

across trials included in this review [84].

226 Current Trends in Atherogenesis

six months following SMT.

Without question, SMT interventions are gaining momentum in the arena of CSA manage‐ ment. Their positive impact on symptoms and aspects of HRQL is unequivocal. Relatively speaking, as a class of interventions, SMT programs have not seen the widespread uptake in cardiology as they have in other fields, such as rheumatology. Historically, this may be explained by the overarching dominance of surgical and interventional strategies as mainstays of effective treatment. But the culture is changing and the need to employ adjunctive secondary prevention approaches, to help offset the burden of CAD, has been recognized worldwide [1, 87-91]. The recent incorporation of angina SMT into national clinical practice guidelines for CAD management in both the UK [87] and Canada [88] speaks to this emerging cultural shift.

In order to more fully integrate angina SMT across health systems, funding support for continued research, development and dissemination of these programs is crucial. Some outstanding issues have major implications for the widespread uptake of angina SMT training. As discussed, there are the critical questions which remain about optimal intervention design (to yield maximal benefits) and cost effectiveness. These questions could perhaps be addressed best via robust, multi-national trials with long-term follow up [85]. There must also be however, a focused effort toward both integrated and end-of-study knowledge translation strategies with the overall goal of mainstreaming angina SMT.

Typically, self-management interventions are developed and tested within academic centres or research institutes, and formally (or informally) linked with a variety of hospital and community-based settings [68]. Dissemination of these programs therefore depends on strong partnerships between researchers and key stakeholder representatives, such as leaders in regional health authorities. Ideally, these players should be involved at the onset of angina SMT research programs and implementation to maximize the success of integrating these programs into existing and diverse health system infrastructures [68]. The widespread success of the Angina Plan in the UK [78,79,82,83] is an excellent example of the benefits of such an integrated approach.

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Policy makers and the general public also require timely notification of future developments in angina SMT research, in accessible language. In the clinical arena, broader uptake of angina SMT could be facilitated by the development of key competencies to adequately prepare health care professionals to educate and consult with their CSA patients about the effectiveness of SMT programs [88]. Akin to clinician preparation for patient counseling, there is also the important question of patient readiness to engage in angina SMT. Patient preparedness for self-management is an emerging field, not yet taken up by CSA researchers. Emerging evidence suggests that one's beliefs and perceptions about a) influential others contributing to his or her overall state of health, and b) his or her own internal locus of control, may be key factors in the pre-contemplation, or intention to engage in self-management practices [92]. Advancements in this area will be important to developing a better understanding of factors that drive one's readiness for angina self-management, and ultimately, who is likely to benefit most from angina SMT training.
