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

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

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‐

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

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

HRQL and psychological well-being.

ness of angina SMT will be discussed.

confounding factor diluting the treatment effect [82].

**5. The angina plan**

224 Current Trends in Atherogenesis

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 CDSMP were retained [17,81].

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

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.
