Doctors End

Assessment of symptoms and habits

Personal and family information was obtained. Exertional dyspnea and chest pain were
graded according to the New York Heart Association (NYHA) functional classification
and the Canadian Cardiovascular Society (CCS) classification, respectively. History
of known coronary artery disease and/or diabetes mellitus was documented.

Prevalence of parameters of cardiovascular health metrics, as defined by the American
Heart Association’s (AHA) 2020 Strategic Impact Goals Committee was assessed, and
ideal, intermediate or poor levels were calculated⁵. Relative change after education to a healthy
lifestyle was estimated for each of the 4 health behaviors (smoking, diet, physical
activity and body mass) and 3 health factors (plasma glucose, cholesterol levels and
blood pressure).

Smoking habit was extensively interrogated. However, only the aspects defined by the
American Heart Association’s 2020 Strategic Impact Goals Committee⁵ were considered for analysis. Current
smokers were classified as being in the group with a poor level of cardiovascular
health; those who quit smoking < 12 months, as intermediate; and non-smokers as well as those who quit smoking ≥ 12 months, as ideal.

Dietary behavior was defined qualitatively according to the daily intake of three
groups of foods: meats/animal fats, vegetables/fruits and sugar/carbohydrates. The
degree of consumption was assessed for each group as “none”, “low”, “moderate” or
“high”. A simple healthy diet score was built accordingly, and scores from 1-3 points
were considered as “poor”, from 4-6 points as “intermediate”, and from 7-9 points as
“ideal”.

The level of daily physical activity was classified as sedentary behavior, when not
even a short recreational-type walk was achieved; moderate, when at least 30 minutes
of a recreational-type walk at moderate intensity was achieved daily; and important,
when ≥ 30 minutes of vigorous recreational walk or sports were achieved.
Participants were classified as having a poor, intermediate or ideal level,
correspondingly.

The daily level of psychological stress was classified subjectively as mild or
absent, moderate or important.

Assessment of anthropometric and laboratory parameters

All parameters were assessed at inclusion and at every follow-up visit. Body weight,
height, body mass index (BMI), abdominal circumference and blood pressure, as well as
standard laboratory parameters including triglycerides, total cholesterol, HDL and
LDL cholesterol and fasting plasma glucose were assessed as described in another
report¹². In addition, the
prevalence of AHA parameters of cardiovascular health metrics was assessed⁵.

Education to a healthy lifestyle

All participants attended one educational workshop at the beginning, and were
encouraged to participate in similar workshops at every visit during follow-up.
Informative material was compiled from recommendations published in another
report¹³.

Basic knowledge on cardiovascular diseases and risk factors was addressed. Targets
were directed to quit smoking, switching to a healthy diet, avoiding sedentary
lifestyle and working on reducing daily psychological stress. The following
strategies were undertaken to reach these goals: 1) tips on how to quit smoking; 2)
aspects concerning a healthy diet, with suggestions for everyday life; 3) suggestions
on how to implement a daily physical exercise program; and 4) useful strategies for
reducing daily psychological stress.

Smoking cessation: patients were advised of the value of stopping and
the risks to health of continuing smoking. It was suggested to set a date to stop and
stop completely on that day, to review experiences concerning measures that helped or
that hindered, and to ask family members and friends for their support. No nicotine
replacement drugs were used¹².

Healthy diet: patients were asked to eat moderately; to reduce
consumption of meats, especially red meats; to avoid consumption of animal fats and
hydrogenated vegetable oils; to switch to daily meals with emphasis on vegetables and
fruits; to reduce daily salt intake; and to reduce consumption of sugar and refined
wheat products, switching to whole-wheat products instead.

Physical activity: patients given suggestions to avoid a sedentary
lifestyle by accomplishing at least a 30-minute recreational daily walk. They were
motivated to start at a moderate pace, and to increase speed progressively to a level
as vigorous as possible. Furthermore, they were stimulated to practice aerobic sports
according to their possibilities¹³.

Psychological stress: physicians in charge of the study addressed coping
with daily psychological stress. Possible causes such as occupational, familial
and/or social were examined and helpful measures were suggested. A professional
psychological support was provided as required.

Workshops were conducted by physicians and nurses trained for this purpose. A close
supervision and coaching was done by physicians in charge of this study. Treatment
was further managed by the corresponding referring physician. No change in
medications was made as part of the study. Patients were merely told to follow
strictly the indications of their treating physician. Further written material, as
well as current information related to the study were posted on the website:
http://asuriesgo.de.

Baseline characteristics of the patient population

Anthropometric characteristics, personal and familial disease history and symptoms
are presented in . Female prevalence
in this population was high – more than double that of males.

The prevalence of known coronary artery disease and diabetes mellitus was low, and
family history of coronary heart disease was present in 5.4% of the study population.
Patients stated having shortness of breath on exertion, with a NYHA functional
classification grade II in approximately 18% and NYHA grade III in approximately 13%
of patients. The prevalence of angina pectoris on exertion was lower, with
approximately 8% of patients being classified as CCS II and 5% as CCS III.

Dropout of participants during follow-up

Patients were requested to attend a follow-up visit by telephone or
Short-Message-Service (SMS) if they did not come spontaneously to the visit scheduled
for 6 months after the first assessment. However, although striving efforts were
undertaken, a large dropout rate could be documented throughout the first 5 visits,
80% between the first and second assessments, 55.6% between the second and third,
43.6% between the third and fourth, and 38% between the fourth and fifth assessments.
The median time span between the first and second assessments was 10 months
(25^th, 75^th percentiles, 7 to 21 months). Patient flow and
dropout rate during follow-up throughout the first five assessments were documented
().

Flow of participants during the study. Only the first 5 visits considered for
dropout analysis are shown here. Changes in parameters were analyzed between
the first and second assessments.

Change in parameters after education to a healthy lifestyle

Comparative analysis between the first and second assessments was carried out in
patients for whom the information on medical history and habits, physical examination
and laboratory tests had been assessed at both visits (n = 3,009).

Anthropometrics, symptoms and habits

A slight but significant decrease in weight (from 76.6 ± 15.3 kg to 76.4
± 15.3 kg, p = 0.002) and body mass index (from 30.2 ± 5.6 kg/m² to
30.1 ± 5.6 kg/m², p=0.004) could be documented at the second assessment after
education to a healthy lifestyle ().
The proportion of patients with dyspnea on exertion NYHA grade II and grade III was
also lower at the second visit (from 23.4% to 21.0%, and from 15.8% to 14.0%,
respectively). The proportion of patients with angina pectoris on exertion decreased
as well, but the differences were not statistically significant.

The proportion of current active smokers decreased (from 3.6% to 2.9%, p = 0.002).
There were also fewer passive smokers, but the difference here was not statistically
significant. The proportion of former smokers increased correspondingly (from 22.2%
to 23.3%). The proportion of patients with a sedentary lifestyle decreased (from
54.0% to 49.2%), while an increase in daily physical activities could be documented
correspondingly (from 45.8% to 50.5%). Although the level of psychological stress in
patients who described it as “important” increased slightly after education to a
healthy lifestyle (from 12.9% to 13.4%); the level of stress improved in the group of
patients with “mild or absent” (from 42.1% to 46.5%) and with “moderate” intensity
(from 45.0% to 40.1%).

ATP III criteria for metabolic syndrome and LDL cholesterol

The proportion of patients with any particular parameters for metabolic syndrome
showed minimal, but statistically not significant differences at the second
assessment (; for brevity, subgroups
are not shown). However, significant improvement in lipid profiles could be
documented, with a decrease in the proportion of patients with triglycerides > 150
mg/dL (from 46.3% to 42.4%, p < 0.001), especially in patients ≥ 60 years old. Additionally, a mild improvement in HDL-cholesterol levels could be observed in men, with a significant decrease in the prevalence of HDL < 40 mg/dL in the age group between 40 and 49 years of age (from 29.7% to 20.4%, p = 0.009). Tendency to a lower prevalence of low HDL levels was found only in the group of female patients between 60 and 69 years of age (from 46.5% to 43.4%, p = 0.084).

Improvement was also found in LDL-cholesterol levels > 100 mg/dL (from 69.3% to
65.5%, p < 0.001). This decrease was statistically significant in the age groups between 50-59 years of age (p = 0.03) and 60-69 years of age (p = 0.004).