Effects of Cardiac Rehabilitation 3 and Behavioral Interventions In this guideline, “education” is defined as systematic instruction, and "counseling" is defined as providing advice, support, and consultation. "Behavioral interventions" refer to systematic instruction in techniques to modify health-related behaviors. This chapter discusses the effects of cardiac rehabilitation education, counseling, and behavioral interventions on smoking, lipids, body weight, blood pressure, exercise tolerance, symptoms, return to work, stress and psychological well-being, morbidity, and mortality. Smoking RECOMMENDATION A combined approach of education, counseling, and behavioral interventions in cardiac rehabilitation results in smoking cessation and relapse prevention and is recommended for cardiac risk reduction. Scientific Evidence (Strength of Evidence = B) Seven reports in the cardiac rehabilitation literature focused on education, counseling, and behavioral interventions designed to reduce cigarette smoking. Five were randomized controlled trials,36,108,152,267,269 one was a nonrandomized controlled study,221 and one was an observational report. 196 The randomized controlled trials are summarized in Table 9. A randomized controlled trial in patients after myocardial infarction compared an exercise-only group, an exercise plus education/counseling group, and a control group. At the 3- and 6-month followups after hospital discharge, no significant differences were noted among the three groups in self-reported smoking cessation or smoking reduction to 10 or fewer cigarettes. 108 A second randomized controlled trial evaluated the effects of a nurse-managed educational-behavioral intervention on smoking cessation after acute myocardial infarction.269 This study was initiated in the hospital, and the intervention was maintained thereafter primarily through telephone contact. At the 12-month followup, significant reduction in biochemically verified smoking cessation occurred in intervention patients compared with control patients-71 percent versus 45 percent, (p = .01). A third study of multifactorial rehabilitation, which included exercise training and education, involved men under 65 years of age following CABG;152 smoking at the 12-month followup was significantly lower in rehabilitation patients compared with control patients—12 percent versus 15 percent (p < .01). Another randomized controlled trial in patients = National Cholesterol Note: CABG = coronary artery bypass graft surgery; CCU = coronary care unit; LDL = low-density lipoprotein; MD physician; MI = myocardial infarction; NCEP Education Program. = following myocardial infarction compared informational mailings supplemented by telephone contact with the rehabilitation staff versus a control group of patients that received usual care.267 At the 6-month followup by questionnaire assessment, there were no significant differences in rates of cigarette smoking. The final randomized controlled trial involved men and women following myocardial infarction and compared nurse-managed home-based multifactorial cardiac rehabilitation with usual care.36 Concurrent pharmacologic intervention with nicotine patches was reported in 10 percent of the intervention and in 2 percent of the control group. At the 12-month followup, biochemically confirmed smoking cessation rates were 70 percent in the intervention patients compared with 53 percent in the control patients, a 17 percent difference favoring the intervention group (p = .03). A nonrandomized controlled trial in patients following PTCA compared multifactorial exercise and education-counseling versus usual care. Selfreported smoking cessation differences between intervention and control patients were 18 percent at both the 3- and 18-month followups (p < .01).221 A single observational study described a self-reported smoking reduction from 59 percent to 7 percent. 196 Conclusions Well-designed education and behavioral interventions (relapse prevention) reduce cigarette smoking. Between 17 and 26 percent of patients can be expected to stop smoking.36,269 These findings supplement prior reports on the spontaneously high cessation rates in most populations soon after myocardial infarction. 36,108 One effective model includes nurse-managed smoking cessation-behavioral intervention with biochemical verification of smoking status. Whether biochemical verification should be recommended for clinical practice is unclear. Scientific evidence, consensus papers, and other scientific reviews in nonrehabilitation settings, including the Surgeon General's messages since 1965, lend strong support that education, counseling, and behavioral interventions are beneficial for smoking cessation.268,270–272 Lipids RECOMMENDATION Intensive nutritional education, counseling, and behavioral interventions improve dietary fat and cholesterol intake. Education, counseling, and behavioral interventions about nutrition-with and without pharmacologic lipid-lowering therapy-result in significant imxprovement in blood lipid levels and are recommended as components of cardiac rehabilitation. Scientific Evidence (Strength of Evidence = B) Eighteen reports provided information on the effect of education, counseling, and behavioral intervention, either alone or as part of multifactorial cardiac rehabilitation, on dietary change, and/or blood lipid levels. Twelve were randomized controlled trials; 22,36,39,41,108,149,152,267,273-276 these are described in Table 10. Three were nonrandomized controlled studies, 163,221,277 and three were observational reports. 196,198,235 Seven of the 12 randomized controlled trials reported changes in measures of dietary fat and cholesterol intake. Five of these seven studies reported statistically significant differences favoring intervention groups compared with control groups;39,41,267,273,275 two reported no significant differences |