Advances in Usual Care of Coronary Artery Disease: Mechanisms and Outcome of Cardiologic, Exercise, and Psychosocial Studies

Dear Colleagues,

Many intervention studies of coronary artery disease (CAD) have found health benefits for patients in the “treatment as usual” or basic care group. In this series, we invite clinicians and scientists to present and discuss the role and reasons for those effects. In a health care perspective it seems necessary and beneficial to examine effective mechanisms of cardiologic – behavioral interactions on a basic care level. Especially, we invite to focus on the therapeutic alliance between patient and care professional and their efficacy on patients cardiac, behavioral and psychological outcome. In non-selected or psychodiagnostic defined subgroups of CAD (depressive, anxious, non-adherence patients or other) the optimizing of usual care or the efficacy of psychosocial treatment, coronary exercise groups or other interventions with behavioral therapeutic techniques should be demonstrated.

The effectiveness of usual care in cardiologic, exercise and psychosocial outcome studies is impressive and influenced by various factors.  Intense medical attention, additional counselling, and teaching of therapeutic techniques with clinical competence (1) may guide to a satisfactory outcome and strengthen the therapeutic alliance between patient and care giver. These factors may be moderators of efficacy related to a better adherence, to deminish cardiac risk factors and to optimize drug intake.

1. Regarding the therapeutic quality of usual care, it it possible for the physician to give the symptom a name, or a diagnosis, which is in line with the subjective theory of the patient and convinced him or her, inspired confidence and positive expectation? Do the physician take the patient seriously, do he or she inform the patient about the next diagnostic steps and the procedure of therapy? Do he or she assure him/herselfs that the patient cooperates?
2. The course of usual care covers interactions generated by the patient himself and by care professionals. A remission of disease or sedentary lifestyle, psychological symptoms could be evoked by increased hope and stronger resistance of an individual. If patients obtained higher medical and social support from their cardiologists, this experience can lead to the reduction in psychological symptoms and risk factors.
3. In which way the well-known mediators of treatment outcomeg., therapeutic alliance, expressed empathy or dysfunctional thinking, in individual physician-patient contacts, which give support for enhanced cardiological and psychological usual care in CAD patients, are effective and may influence adherence to medication, or progress of coronary disease. It seems necessary to examine and understand several effective cardiologic, hormonal, autonomic and inflammatory therapeutic mechanisms. This knowledge should present as a basic condition for additional behavioural therapeutic activities on a primary care level (1).
4. In this perspective different patient groups, related to gender, low SES or immigrant status need different interactive activities and communicative skills of the care provider.
5. What therapeutic dose of usual care is necessary in cardiac patients to stabilize the cardiologic and psychologic individual situation of a patient? In the ENRICHD trial the control participants received usual care, education, and on demand anti-depressant medication, psychotherapy and participated in cardiac rehabilitation. [2].

Selection: Specified psychotherapeutic interventions, coronary exercise groups have shown an additional independent effects on morbidity and mortality. There is a need to identify patients at risk for a sedentary lifestyle of remaining depressed, anxious or under severe stress during usual care (3). These patients may require additional attention and therapeutic actions. These provide in a greater extend of physical activity, reduction of depressive and anxiety symptoms and enable additionally a decrease in cardiovascular events and mortality.

Prof. Hans-Christian Deter
Guest Editor

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• coronary artery disease
• basic care
• depression
• anxiety
• adherence
• physical activity
• exercise
• mechanisms
• individual and group interventions