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

group-based SMT interventions are efficient and have been found to be equally effective as individualized approaches for arresting chronic disease progression and managing symptoms across populations; people with diabetes are one such example [86]. Yet, the available data suggest that this may not be the case for CSA patients when it comes to psychological outcomes;

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There is also the question of whether angina SMT programs should be delivered by health professionals or lay peers. Indeed, lay-led SMT models have been demonstrated widely to be effective and cost-saving [42-48,82]. Such models are also idyllic in the sense that they embrace the concept of patients as active self-managers and experts in terms of the chronic illness experience [45]. However, in the case of CSA patients, Furze et al. [82] observed a high refusal

Other key questions pertain to the overall cost-effectiveness of angina SMT implementation as well as the ability of these programs to reduce the financial burden of CSA. The trial by McGillion et al. [81] showed no impact on cost illness but the follow up period was brief. To date, Furze et al.'s trial is the only study to [82] to examine comprehensively the cost utility of angina SMT. While the cost results of this trial are certainly promising, they pertain to the

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

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

an individualized approach could be more effective.

rate (46%) in the RCT of their lay-led SMT program.

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

strategies with the overall goal of mainstreaming angina SMT.

training and employ of lay leaders only.

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 across trials included in this review [84].

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 six months following SMT.

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

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, group-based SMT interventions are efficient and have been found to be equally effective as individualized approaches for arresting chronic disease progression and managing symptoms across populations; people with diabetes are one such example [86]. Yet, the available data suggest that this may not be the case for CSA patients when it comes to psychological outcomes; an individualized approach could be more effective.

There is also the question of whether angina SMT programs should be delivered by health professionals or lay peers. Indeed, lay-led SMT models have been demonstrated widely to be effective and cost-saving [42-48,82]. Such models are also idyllic in the sense that they embrace the concept of patients as active self-managers and experts in terms of the chronic illness experience [45]. However, in the case of CSA patients, Furze et al. [82] observed a high refusal rate (46%) in the RCT of their lay-led SMT program.

Other key questions pertain to the overall cost-effectiveness of angina SMT implementation as well as the ability of these programs to reduce the financial burden of CSA. The trial by McGillion et al. [81] showed no impact on cost illness but the follow up period was brief. To date, Furze et al.'s trial is the only study to [82] to examine comprehensively the cost utility of angina SMT. While the cost results of this trial are certainly promising, they pertain to the training and employ of lay leaders only.
