**5. The angina plan**

The Angina Plan, developed by Lewin, Furze et al. [78,79] is the most widely evaluated and disseminated angina SMT program to date; over 20,000 patients have been enrolled [83]. The Angina Plan is recognized in the United Kingdom [86] as a form of home-based cardiac rehabilitation geared toward debunking common misconceptions about angina, promoting relaxation, increasing physical activity and role functioning, and making positive changes in lifestyle (e.g. nutrition). Risk factor identification, and educational materials on CAD, medi‐ cations, as well as seeking emergency medical assistance (as appropriate) are also key com‐ ponents [78,79]. The program materials are provided in a workbook and relaxation tape which patients are oriented to by a nurse intervener during a structured, individualized interview process [78,79]; this initial session is followed by a 12-week course of telephone-based support to facilitate incremental goal setting and pacing of activities [78,79]. A 2002 RCT of the Angina Plan (n=142), found that at 6 months follow-up, those assigned to the intervention group had significant reductions in angina frequency, anxiety and depression, and SL nitrate usage, as compared to controls who received standard education and counseling by a nurse [79]. Those who received the Angina Plan also demonstrated significant improvements in physical limitation scores, daily walking, and dietary habits [79]. A pragmatic RCT by Zetta et al. (n= 218) [82] found similar results for patients admitted to hospital for acute exacerbation of angina. Angina Plan recipients reported significant improvements in knowledge and cardiac miscon‐ ceptions, social and leisure activities, perceived general health, and physical limitation. Improvements in cardiac risk factors including body-mass index and exercise were also found [82]. However, no significant improvements in anxiety and depression scores were found based on intention-to-treat analyses; extracardiac depression was proposed as a potential confounding factor diluting the treatment effect [82].

Recently, Furze et al. [83] evaluated (n= 142) a lay, peer-led adaptation of the Angina Plan in response to healthcare resource constraints as well as increasing interest in lay-facilitated SMT interventions. The Lay-facilitated Angina Management Program (LAMP) was delivered by people who had experience with CAD either as patients or caregivers [83]; outcomes were evaluated at 3 and 6 months post intervention. Compared to standard advice from a specialist 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 contrast to evaluations of the nurse-facilitated version of the Angina Plan [79,82].
