Patients with angina also have increased anxiety and depression, and experience reduced quality of life. The Angina Plan was developed in Great Britain to provide significant rehabilitative services in the community, using a self-management model in which the patient and family are supported by trained primary care facilitators and specialized materials (www.cardiacrehabilitation.org.uk). The program is estimated to be used by more than 6,000 British survivors of myocardial infarction and is being introduced in several other European countries. Lewin and colleagues evaluated the Angina Plan in a randomized controlled trial in the city of York.

General practitioners were asked to identify patients for whom nitrates had been prescribed for the first time within the previous year. Patients who agreed to participate in the study were screened for angina lasting longer than one year, life-threatening comorbidity, or mental illness. Patients were also screened by exercise tolerance test to verify that they were not in need of urgent treatment. After obtaining baseline data, participants were assigned to attend conventional education sessions or participate in the Angina Plan. All patients received standard advice on risk factors, medication, and appropriate action to take if symptoms occurred.

Participants in the Angina Plan received a workbook and audiotaped relaxation programs. Patients and their partners were oriented to the plan by specialist nurses during a 30- to 40-minute structured interview that included identifying and addressing the patient's specific beliefs and concerns about their cardiac condition. Patients were also assisted with setting goals for lifestyle changes, particularly in nutrition and exercise, and were asked to use the audio cassette to practice relaxation for 20 minutes each day. The nurses contacted each patient by telephone at the end of weeks 1, 4, 8, and 12, and conducted a structured review, including adjustment of goals as appropriate.

Patients assigned to the educational sessions discussed risk factors with a specialist nurse and were encouraged to discuss their concerns about angina and how it affected their quality of life. Patient questions were answered by the nurse, and patients received informational materials from leading expert groups.

The 68 patients assigned to the Angina Plan were comparable with the 74 assigned to the educational sessions in demographic variables and measures of severity of illness. The average age in both groups was 67 years, and more than one half were men. After six months, results were available for 91 percent of participants. The Angina Plan was associated with significantly greater improvement in scores for anxiety and depression on standardized assessments, reduction in number of anginal episodes per week, use of trinitrates, and physical limitation, as assessed by the Seattle Angina Questionnaire.

Most patients using the Angina Plan reported a 50 percent reduction in anginal episodes, from a mean of seven to three per week, but the reduction in other patients was equivalent to less than one episode every two weeks. Patients in the Angina Plan were significantly more likely to report changing their diet (31.5 percent compared with 16.2 percent) and increasing their daily walking (23.3 percent compared with 1.6 percent). Nevertheless, significant differences in diet and exercise were not apparent on standardized questionnaires, and the groups did not differ in changes in body mass index after six months. No differences were significant in changes in blood pressure, smoking, use of medication other than nitrates, or duration and severity of angina episodes.

The authors conclude that the Angina Plan improves the psychologic, symptomatic, and functional status of patients with new-onset angina. This finding correlates with other interventions led by practice-based nurses and suggests that these programs could significantly benefit patients with new-onset angina in primary care.

editor's note: According to the Lewin article, the average family doctor in Great Britain sees four patients with new angina per year. The rate is likely to be similar in the United States, and it is expected to rise in both countries as the population ages and cardiopathic diets and habits take their toll. Medical advances mean that these patients are less likely to die in the early years of their cardiovascular disease, so the emphasis, for increasing numbers of patients, has to be on enhanced quality and enjoyment of life with heart disease. This is the latest in a series of articles demonstrating that nurse-led supportive and educational programs can improve outcomes such as lipid profiles, blood pressure rates, hospital admission (Campbell, et al.), compliance, exercise, and quality of life (Cupples ME, McKnight A). Is it time to prepare practice nurses for this role? In view of the nursing shortage, could we obtain the same results if the programs were provided by well-trained volunteers, including patients? Patient counselors have proved to be highly effective in several areas of medicine: a study using non-nursing staff to implement the Angina Plan would be fascinating. The plan, however, might require some adaptation for U.S. populations to account for cultural and other differences.—a.d.w.