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Am Fam Physician. 2004;70(2):383-384

Reduced mortality in patients with coronary heart disease can be achieved through lowered cholesterol levels, improved hypertension control, and regular exercise. Studies have shown that these options are being applied only partially in clinical practice. Strategies aimed at physicians have proved to be ineffective. Another strategy is to target patients through disease management programs. Some of these programs have been established to improve compliance with lowering cholesterol levels to goal levels. Unfortunately, most of these programs included nurses and dietitians who were able to provide prescriptions directly to patients. Other programs, which did not allow direct prescription writing, showed no improvement in coronary risk profiles despite improving patients’ health behaviors. The Coaching patients On Achieving Cardiovascular Health (COACH) program was developed to see if nonprescribing health professionals are helpful in coaching. Vale and associates assessed the effectiveness of the COACH program in modifying coronary risk profiles in patients with known coronary artery disease.

The trial was a multicenter, randomized controlled study of patients with known coronary artery disease. Patients were selected from those admitted with various coronary heart disease diagnoses at six university hospitals. Once enrolled, patients were randomly assigned to receive usual care alone or in combination with participation in the COACH program. The COACH program was directed at the patient and performed by hospital-based staff. Patients were coached about risk factors, ways to achieve target levels appropriate for individual risk factors, and appropriate lifestyle measures. The coaching process was aimed at achieving and maintaining target levels for each patient’s risk factors. The coaching was performed by telephone and mail. The primary outcome measurement was the change in total cholesterol level six months after hospital discharge. Other outcome measurements included a wide range of physical, nutritional, and psychologic factors.

There were 394 patients assigned to the usual-care group and 398 to the usual-care plus COACH group. Those who participated in the COACH program had significantly greater reductions in total cholesterol levels at six months, with a mean reduction that was 14 mg per dL (0.36 mmol per L) greater than the reduction in the usual-care group. Those participating in the COACH program also had a significant reduction in low-density lipoprotein cholesterol level compared with the usual-care group.

Other outcomes in the COACH group included greater reduction in body weight, body mass index, and dietary intake of fats, and an increase in dietary fiber. Patients in the COACH group were more likely to initiate a walking program. More patients in the COACH group reported better general health and mood at six months. The COACH program had no effect on smoking behavior, glucose control, or depression scores compared with usual care. A significant number of patients in each group who claimed to have stopped smoking had high cotinine levels in their blood system, indicating that they were still smoking.

The authors conclude that the COACH program is highly effective in reducing total cholesterol levels and improving coronary risk factors in patients with coronary heart disease. They add that the program succeeds even without the additional services of dietitians or nurses who are able to prescribe medications. The COACH program is a potential adjuvant tool in the management of patients with coronary heart disease and could be integrated into existing health care systems.

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