**4. Self-management training: Angina-specific models**

Angina-specific SMT programs emerged in the early 1990s [74-76] and have been documented as recently as 2012 [82]. The majority of RCT evidence to date includes individual counseling or small-group interventions (i.e. 6-15 patients) employing varying combinations of educa‐ tional materials on CAD and medications, risk factor identification and modification, planned exercise/physical activity, and cognitive-behavioural techniques targeted at lifestyle and angina symptom self-management, relaxation training and/or stress reduction, or enhance‐ ment of physical activity. Intervention durations, formats, and processes have varied [74-82]. A range of outcomes have been used to examine the effectiveness of angina SMT, including: angina symptom profile (e.g. frequency, severity, stability) and related sublingual (SL) nitrate use, objective measures of ischemia such as treadmill stress tests, and self-report measures of HRQL and psychological well-being.

nurse, the LAMP intervention did not significantly reduce the frequency of angina symptoms; it was hypothesized that this may have been a function of effective medication regimens for both groups [83]. Those in the intervention group did report significantly improved depression (6 months), anxiety (3 and 6 months) and HRQL scores (3 and 6 months), compared to controls. Significant improvements in hip-to-waist ratio were also found. The cost utility of the LAMP was assessed in terms of quality-adjusted life years (QALY). A significant difference in average QALY per patient of 0 045 (confidence interval [CI], 0 005-0 085) was found. Based on their cost utility model, Furze et al. [83] estimated the average net benefit of the LAMP intervention (over controls) at £354-360; there was some uncertainty around this estimate however due to a lack of coefficient significance (from zero) [83]. While the LAMP was deemed cost-effective, improvements in angina symptoms per se were not observed. Notably, this finding was in

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contrast to evaluations of the nurse-facilitated version of the Angina Plan [79,82].

The CASMP [17,81] is a disease-specific adaptation of the generic Stanford Chronic Disease Self-Management Program (CDSMP). To develop the CASMP, McGillion et al. conducted a qualitative evaluation of the self-management learning needs of individuals living with CSA; perspectives from both patients and clinicians were solicited [19]. Based on this study, adaptations of the CDSMP curriculum were made to address the following angina-specific learning needs: safe exercise planning; relaxation and stress management; symptom monitor‐ ing, interpretation, and management techniques; CAD and related medication review; decision making about seeking emergency medical assistance; diet; and, managing emotional responses to angina [17,81]. The self-efficacy enhancing process elements of the original

The CASMP follows the CDSMP standardized 6-week, community small-group based format (i.e. 2-hour sessions weekly, groups of 8-12 patients), but the program is delivered by nurse facilitators rather than lay leaders. The program is delivered according to a facilitator manual and participants receive a workbook to reinforce educational content. In a 2008 RCT (n=130), the CASMP was found to significantly improve the frequency and stability of angina symp‐ toms compared to usual care at 3 months post-intervention. Significant improvements in selfreported physical functioning, perceived self-efficacy, and general health status were also found [81]. The CASMP did not reduce the financial burden of CSA on participants (estimated

Concomitant to the RCT [81], qualitative evaluation of the CASMP found positive shifts in the perceived meaning of cardiac pain following self-management training [17]. CSA was initially described by participants as a major negative life change characterized by fear, frustration, limitations and anger [19]. Following the CASMP, chronic angina was interpreted more constructively as a broad, ongoing health problem requiring continual self-management in order to retain desired life goals and optimal levels of functioning [17]. Based on these positive evaluations, plans to implement the CASMP at select cardiac centres in Canada are underway.

from a societal perspective), perhaps due to the short time frame of the study [81].

**6. The chronic angina self-management program**

CDSMP were retained [17,81].

This review of the evidence will focus first on two more recent angina SMT models with clear underpinnings in self-efficacy theory: *The Angina Plan* [78,79,82,83] and the *Chronic Angina Self-Management Program* [17,81]. Second, results of meta-analyses [84,85] of the overall effective‐ ness of angina SMT will be discussed.
