**1. Introduction**

#### **1.1. The societal burden of chronic stable angina**

Chronic stable angina (CSA) is a cardinal symptom of coronary artery disease (CAD), charac‐ terized by pain or discomfort in the precordium, shoulder, back, arm, or jaw [1]. Angina pain symptoms—or equivalents such as shortness of breath, fatigue, and nausea—are considered stable if they are experienced over several weeks in the absence of major deterioration [1-3]. Those affected by CSA typically have CAD involving one or more large epicardial arteries, although individuals diagnosed with hypertrophic cardiomyopathy, hypertension, endothe‐ lial dysfunction, or valvular stenosis/deficiencies may also exhibit angina [1]. Symptoms usually occur predictably upon physical exertion and are relieved by rest or nitroglycerin [1]. The severity of symptoms experienced can vary, typically ranging from Canadian Cardiovas‐ cular Society [CCS] class I to class III angina. A number of factors can also aggravate symptoms including heightened emotional states, diet, smoking, and weather [1,4].

As CAD survival rates increase, the global incidence and prevalence of CSA are also on the rise. Prevalence estimates suggest that CSA affects more than 10 million Americans [5] and nearly ½ million Canadians over the age of 12 [6]. In Scotland, CSA affects 2.6% of the general population, with 28 per 1000 men and 25 per 1000 women diagnosed, respectively [7]. The agestandardized annual incidence of angina, per 100 population in Finland, 2006 was 2.03 among men and 1.89 among women [8].

Chronic stable angina poses significant risk for acute myocardial infarction, congestive heart failure, atrial fibrillation, and stroke [9], as well as increased risk of cardiovascular-related mortality or hospitalization (men: RR 1.62, women: RR 1.48) [10]. Moreover, multiple studies have shown that people living with CSA are among the more severely debilitated across several chronic illness populations including sciatica, arthritis, low back pain, diabetes and

© 2013 McGillion et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

stroke [11-15]. Many of these patients suffer persistent pain episodes, poor general health, sleep disturbance, impaired social role functioning, activity restriction, and reduced ability to selfcare [16-27].

as specific angina SMT models developed in the United Kingdom and Canada. The overall effectiveness of SMT for angina will also be reviewed with respect to impact on symptoms, HRQL outcomes, and cost. Implications for future research and practice will also be discussed.

Self-Management Training for Chronic Stable Angina: Theory, Process, and Outcomes

http://dx.doi.org/10.5772/54635

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Self-management training emerged as a priority for health systems in the 1980's and 90's, following a surge of population-based research on the prevalence of chronic illness in the 1960's and 70's [42]. The realization of the global prevalence of divergent chronic illnesses, without cure, led to major critiques of standard health care delivery models as too poorly integrated and siloed to address the consequences of chronic illness and related therapies [42]. Similarly, traditional patient education models have been critiqued as lacking adequate scope and complexity to address an ageing population, multiple co-morbidities, and the complex needs of individuals who must manage their chronic illnesses daily [42]. Traditional acute care models and related patient education focus on diagnosis and cure, technological interventions, and the imparting of specific disease-related information to inexperienced patients who act as passive recipients of health teaching. Within this paradigm, the health care professional is understood to be the knowledgeable, experienced authority on the patient's care priorities [42-44]. Thus, a fundamental premise of traditional models of care is that patient compliance with specific direction and principles taught will lead to improved health behaviours and

In contrast, SMT interventions espouse the tenets of Wagner et al.'s Chronic Care Model (CCM) [45]. According to the CCM, chronic disease management refers to a system of health care that supports individuals with chronic illness to remain as healthy and independent as possible. The process of disease management is conceptualized as patient-centered, with health care professionals, the health care system, and the community at large collaborating with the patient to facilitate optimum health and well-being. Implicit within the CCM is the concept that patients should be well-informed about their illness, and should be active participants in their

The emphasis of SMT, therefore, is the role of the patient as an active player engaged in preventive and therapeutic health activities in partnership with health care professionals [46]. At the crux of such partnerships are patients' everyday problems as a result if living with chronic illnesses. As D'Zurilla [47] Lorig and Holman [44], and others [46] have argued, effective SMT is fundamentally problem-oriented. A common starting ground for SMT interventions in practice is identification, crystallization, and prioritization of patients' chief concerns [44-47]. Care is generally taken during this process to harmonize perspectives through deliberative discussion—as health care professionals will often conceptualize the issues in terms of diagnosis and/or risk factor modification, whereas patients will think in practical terms about the day-to-day difficulties their illnesses present [19,48]. The problem

list generated dictates the direction and scope of intervention for each patient [44-48].

Along with collaborative problem identification, additional key elements of SMT, which are typical [45,48,49], include a) *targeted goal setting:* identifying meaningful, realistic goals in the

**2. Self-Management training: Overview**

outcomes [42-44].

care [45].

As Lewin [28,29] and others [30] have argued, angina seems to have a disproportionately severe impact on one's self-perceived health status relative to other chronic illnesses. Extensive work in the field to date has shown that negative emotional states, such as anxiety and depression, are well-documented corollaries of CSA. For example, as part of a larger clinical trial, Ketterer et al. [31] (n= 196) examined the psychological profile of patients with stable CAD, angina symptoms during daily activities, and positive exercise stress tests. Anxiety and depression were strongly associated with recent angina, as well as angina in the presence of ischemia invoked by treadmill testing. Gravely-Witte et al. [32] found similar results in a prospective study of 121 patients following surgical and percutaneous revascularization procedures. Angina symptoms were predictive of higher levels of depression and lower levels of emotional and social functioning [32].

The central role of emotional distress in CSA may be explained, in part, by the fact that angina sufferers tend to hold erroneous and maladaptive beliefs about their condition. In Wynn's widely cited observational study (1967) [30], 23% of post-myocardial infarction patients (n=400) reported being anxious due to the misconception that each angina episode reflected further damage to the heart. In 40% of cases, failure to return to work was attributed to fear of immanent death [30]. Since the time of Wynn's seminal work, multiple studies have shown that CSA patients routinely interpret their angina symptoms as 'mini heart attacks' [19,22-24, 30,33]. Consequently, many patients adopt sedentary lifestyles, relinquish their normal routines, and/or retire early as means to avoid angina attacks [19,22-24,34,35]. Unfortunately, out of concern, family members, peers [17,19,36], and health care professionals [37] alike often reinforce such maladaptive coping behaviours which can evoke unintentional deconditioning as well as reductions in coronary blood flow, sheer stress, and impetus for healthy collateral coronary vessel formation [38].

Considering the high prevalence and major negative psychological impact of CSA, the cost implications are significant. The total costs associated with CSA management in the United States have been estimated to exceed 15 billion dollars per annum [1]. In the United Kingdom, the direct cost of chronic angina in 2000, including prescriptions, repeated emergency depart‐ ment visits and other hospital admissions, outpatient referrals, and procedures, was estimated at ₤669,000,000, accounting for 1.3% of the total National Health Service expenditure [39]. At the patient level, a Canadian study [40] estimated the mean cost RFA-related disability (2003 – 2005) from a societal perspective including direct out-of-pocket costs to patients, indirect costs expressed as forgone income and leisure time, and system-related costs paid by public and private insurers. The total estimated annualized cost of CSA per patient was \$19,209 [40].

In recent years, increasing attention has been given to angina self-management training [SMT] interventions as a means to offset the societal burden of CSA. These interventions are multimodal educational packages that employ learning materials and cognitive-behavioural strategies to achieve changes in knowledge and behaviour for effective disease self-manage‐ ment [41]. This chapter provides a brief overview of the concept of self-management and discussion of background theory, key elements of intervention structure and process, as well as specific angina SMT models developed in the United Kingdom and Canada. The overall effectiveness of SMT for angina will also be reviewed with respect to impact on symptoms, HRQL outcomes, and cost. Implications for future research and practice will also be discussed.
