SCIENTIFIC REVIEW
Primary and Secondary Prevention of Cardiovascular Disease IS THERE A PLACE FOR INTERNET-BASED INTERVENTIONS?
Eva Pietrzak, PhD; Cristina Cotea, BSc (Hons); Stephen Pullman, RAN
■ PURPOSE:
Internet-based interventions to manage and prevent chronic diseases are becoming increasingly popular, especially for those with limited access to health services. This article reviews Internet-based interventions for the prevention of cardiovascular disease (CVD) and reduction of cardiovascular risk factors.
■ METHODS:
MEDLINE, EMBASE, and Cochrane databases were searched using terms for telemedicine and CVD (heart disease* OR myocardial infarction OR cardiac event* OR heart attack* OR cardiovascular disease* OR cardiovascular risk factor* OR blood pressure OR hypertension OR cholesterol OR LDL-C OR HDL-C OR cardiac rehabilitation) AND (telemonitor* OR tele-monitor* OR teleconsult* OR tele-consult* OR telemanagement OR tele-management OR telerehab* OR telerehab* OR Internet-based intervention OR internet based intervention OR Internet intervention* OR web based or web-based). Studies that investigated Internet-based interventions delivered directly to patients and resulted in improvement of cardiovascular-related health outcomes were included.
■ RESULTS:
Studies were identified (N = 23) investigating the reduction of cardiovascular risk factors. Five studies investigated patients diagnosed with CVD, 6 targeted participants with diabetes, 6 targeted participants with increased cardiovascular risk, and 6 investigated the general population. The majority of studies reported improvement in blood pressure and HbA1c levels in participants diagnosed with type 2 diabetes. Other outcomes included a decreased number of cardiovascular events, improved lipid profile and eating habits, decreased weight, and increased physical activity.
■ CONCLUSIONS:
There is emerging evidence that Internet-based interventions may reduce cardiovascular risk in cardiac patients and in populations with a heightened risk of CVD. Such interventions may also represent an alternative method of providing CVD prevention strategies.
Cardiovascular disease (CVD) is the leading cause of death in the United States. Approximately 600 000 people die of CVD in the United States every year, 1 in every 4 deaths.1 Cardiovascular disease is responsiwww.jcrpjournal.com
K E Y
W O R D S
cardiovascular disease risk factors hypertension prevention telehealth telemanagement
Author Affiliation: Centre for Military and Veterans’ Health, The University of Queensland, Mayne Medical School, Herston, QLD, Australia. The authors declare no potential conflicts of interest. Correspondence: Eva Pietrzak, PhD, Centre for Military and Veterans’ Health, The University of Queensland, Mayne Medical School, Herston Rd, Herston, QLD 4006, Australia (epietrzak@bigpond .com). DOI: 10.1097/HCR.0000000000000063
ble for 17% of national health expenditures. Coronary heart disease alone costs the United States $108.9 billion each year. This total includes the cost of health care services, medications, and lost productivity.2 Internet-Based CVD Pvrevention / 303
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-13-00100_LR 303
8/11/14 8:42 AM
Although some main risk factors associated with CVD, such as a positive family history, are nonmodifiable, CVD can be moderated through the reduction of key modifiable risk factors such as high blood pressure (BP), high blood cholesterol, physical inactivity, high body mass, tobacco smoking, low fruit and vegetable consumption, and excessive alcohol consumption, and through controlling diseases such as diabetes.3 Usually, interventions that delay the onset of a disease are defined as primary prevention and those that delay the progression of the disease by treatment and rehabilitation are defined as secondary prevention. However, in the context of CVD, the distinction between primary and secondary prevention is blurred because the reduction of modifiable CVD risk factors is effective for both the prevention of the disease in a general population and the delay of its progress in patients diagnosed with the disease, and similar interventions may be used for both.4 Important interventions to reduce CVD risk include advice and treatment for (1) smoking cessation; (2) maintenance of normal BP; (3) lowering serum cholesterol concentration and changing the lipid profile to within guideline levels; (4) lowering serum glucose to within guideline levels; and (5) providing information on lifestyle risk factors, such as physical activity, diet, obesity, and alcohol consumption, and how they can be reduced.4 These strategies are used for both primary and secondary prevention of CVD. Cardiac rehabilitation is designed for people with heart problems, such as myocardial infarction, heart failure, and stable angina, as well as after surgical interventions for coronary heart disease such as heart transplant, coronary artery bypass, or angioplasty. It includes an exercise training and strategies aimed at reducing modifiable risk factors for CVD.5 An increasing proportion of the population uses the Internet for accessing health information.6 Internetbased interventions delivered directly to patient homes have been found to produce clinically beneficial outcomes in areas as diverse as mental health7 and rehabilitation after knee surgery.8 Long-term care through telemedicine services was found effective in reducing rehospitalizations and improving quality of life in high-risk cardiac patients with heart failure.9 This type of tertiary prevention, avoidance of hospitalizations, and other catastrophic events in chronically ill patients through disease management and remote monitoring have been studied extensively.9-11 However, the feasibility and effectiveness of the application of Internet-based interventions for primary and secondary prevention of CVD remain to be clarified. The aim of this article was to review published literature on the effectiveness of Internet-based interven-
tions for the prevention of CVD occurring or recurring and the reduction of CVD risk factors.
METHODS Studies were identified by searching MEDLINE, EMBASE, and Cochrane databases, using synonyms and MeSH (Medical Subject Headings) terms for Internet-based intervention and CVD risk factors. Text and reference lists of relevant articles were searched for other relevant articles. The search was performed in September 2013. The following search terms were used: (heart disease* OR myocardial infarction OR cardiac event* OR heart attack* OR cardiovascular disease* OR cardiovascular risk factor* OR blood pressure OR hypertension OR cholesterol OR LDL-C OR HDL-C OR cardiac rehabilitation) AND (telemonitor* OR tele-monitor* OR teleconsult* OR tele-consult* OR telemanagement OR tele-management OR telerehab* OR tele-rehab* OR Internet-based intervention OR internet based intervention OR Internet intervention* OR web based or web-based).
Inclusion/Exclusion Criteria Studies were included if they investigated Internetbased interventions for the reduction of cardiovascular health outcomes and CVD risk factors in adult populations and delivered directly to participants. Specifically, outcomes and populations of interest were as follows: 1. Direct clinical outcomes such as mortality or CVD events; intermediate clinical outcomes such as lipid profile and BP, which affect CVD outcomes in a dose-response manner12,13; and health behaviors regarding statin therapy, such as commencing the medication and adjusting the dose when required, with conclusive evidence of decreasing blood cholesterol concentration and preventing CVD events,14 regardless of the health status of investigated population. 2. Improvements in lifestyle–dependent CVD risk factors, such as nutrition, body weight, physical activity, smoking, and drinking habits, if they were performed in populations with diagnosed CVD or heightened CVD risks. With the exception of case studies, studies of all design (randomized controlled trials [RCT], observational, and pilot studies) that contained the original data were included. Discussion articles and reviews were excluded. We included 4 studies that used Web-based intervention combined with mobile phone short message
304 / Journal of Cardiopulmonary Rehabilitation and Prevention 2014;34:303-317
www.jcrpjournal.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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service (SMS). Mobile phones were used to upload self-monitoring data to the server, and SMSs sent to mobile phones were generated by the server. There was no direct telephone communication between participants and researchers in the studies. Therefore, mobile phones in these studies fulfilled the role of mobile extension of the participants’ computers.
Study Quality Assessment The quality of the studies was analyzed by the Qualitative Assessment Tool for Quantitative Studies.15 The study quality was assessed on the basis of study components that included (1) selection bias, (2) study design, (3) confounders, (4) blinding procedures, (5) data collection methods, and (6) withdrawals and dropouts. Each study component received a quality score (QS) of weak, moderate, or strong. A study that received 4 strong ratings with no weak ratings in any of the components mentioned earlier was rated as “strong.” Studies with fewer than 4 strong ratings with 1 weak rating were rated as “moderate,” and those with 2 or more weak ratings were rated as “weak.”
RESULTS A total of 1074 studies were identified with the database search. After reviewing the abstracts and removing duplicate publications, 53 full-text articles were retrieved for consideration. Of these, 21 articles reporting original data on Internet-based preventive interventions aimed at reducing clinical CVD risk factors fulfilled all the inclusion/exclusion criteria and were included in the review. An additional 3 included articles were found manually. The investigated populations included patients diagnosed with CVD,16-20 type 2 diabetes,21-27 increased CVD risk,28-33 and general population samples.34-39 Investigated outcomes included CVD events (n = 1), the Framingham CVD risk score (n = 1), BP (n = 21), lipid profile (n = 17), blood glucose or glycolysated hemoglobin (HbA1c) (n = 12), medication adherence (n = 2), body weight parameters (n = 14), eating habits (n = 4), physical activity (n = 5), exercise capacity (n = 1), and smoking status (n = 2). Fifteen studies were RCTs, 3 studies were comparative, with nonrandomized control group and pre-/postcomparison, and 5 studies were observational, with pre-/postcomparisons. The quality of 9 RCTs was assessed as “strong.” There were 10 “moderate” studies (4 RCTs, 4 comparative, and 2 observational) and 4 “weak” studies (1 RCT and 3 observational). The duration of the studies generally ranged between 3 and 12 months; there were 7 studies each with followup of 12, 6, and 3 months, www.jcrpjournal.com
and 1 study with a 24-month followup. One study was completed in 1 day. The sample sizes were generally relatively large, numbering more than 300 participants in 9 studies and 100 to 300 in 8 studies; only 4 studies had 50 to 100 participants, and 3 had
Primary and Secondary Prevention of Cardiovascular Disease IS THERE A PLACE FOR INTERNET-BASED INTERVENTIONS?
Eva Pietrzak, PhD; Cristina Cotea, BSc (Hons); Stephen Pullman, RAN
■ PURPOSE:
Internet-based interventions to manage and prevent chronic diseases are becoming increasingly popular, especially for those with limited access to health services. This article reviews Internet-based interventions for the prevention of cardiovascular disease (CVD) and reduction of cardiovascular risk factors.
■ METHODS:
MEDLINE, EMBASE, and Cochrane databases were searched using terms for telemedicine and CVD (heart disease* OR myocardial infarction OR cardiac event* OR heart attack* OR cardiovascular disease* OR cardiovascular risk factor* OR blood pressure OR hypertension OR cholesterol OR LDL-C OR HDL-C OR cardiac rehabilitation) AND (telemonitor* OR tele-monitor* OR teleconsult* OR tele-consult* OR telemanagement OR tele-management OR telerehab* OR telerehab* OR Internet-based intervention OR internet based intervention OR Internet intervention* OR web based or web-based). Studies that investigated Internet-based interventions delivered directly to patients and resulted in improvement of cardiovascular-related health outcomes were included.
■ RESULTS:
Studies were identified (N = 23) investigating the reduction of cardiovascular risk factors. Five studies investigated patients diagnosed with CVD, 6 targeted participants with diabetes, 6 targeted participants with increased cardiovascular risk, and 6 investigated the general population. The majority of studies reported improvement in blood pressure and HbA1c levels in participants diagnosed with type 2 diabetes. Other outcomes included a decreased number of cardiovascular events, improved lipid profile and eating habits, decreased weight, and increased physical activity.
■ CONCLUSIONS:
There is emerging evidence that Internet-based interventions may reduce cardiovascular risk in cardiac patients and in populations with a heightened risk of CVD. Such interventions may also represent an alternative method of providing CVD prevention strategies.
Cardiovascular disease (CVD) is the leading cause of death in the United States. Approximately 600 000 people die of CVD in the United States every year, 1 in every 4 deaths.1 Cardiovascular disease is responsiwww.jcrpjournal.com
K E Y
W O R D S
cardiovascular disease risk factors hypertension prevention telehealth telemanagement
Author Affiliation: Centre for Military and Veterans’ Health, The University of Queensland, Mayne Medical School, Herston, QLD, Australia. The authors declare no potential conflicts of interest. Correspondence: Eva Pietrzak, PhD, Centre for Military and Veterans’ Health, The University of Queensland, Mayne Medical School, Herston Rd, Herston, QLD 4006, Australia (epietrzak@bigpond .com). DOI: 10.1097/HCR.0000000000000063
ble for 17% of national health expenditures. Coronary heart disease alone costs the United States $108.9 billion each year. This total includes the cost of health care services, medications, and lost productivity.2 Internet-Based CVD Pvrevention / 303
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-13-00100_LR 303
8/11/14 8:42 AM
Although some main risk factors associated with CVD, such as a positive family history, are nonmodifiable, CVD can be moderated through the reduction of key modifiable risk factors such as high blood pressure (BP), high blood cholesterol, physical inactivity, high body mass, tobacco smoking, low fruit and vegetable consumption, and excessive alcohol consumption, and through controlling diseases such as diabetes.3 Usually, interventions that delay the onset of a disease are defined as primary prevention and those that delay the progression of the disease by treatment and rehabilitation are defined as secondary prevention. However, in the context of CVD, the distinction between primary and secondary prevention is blurred because the reduction of modifiable CVD risk factors is effective for both the prevention of the disease in a general population and the delay of its progress in patients diagnosed with the disease, and similar interventions may be used for both.4 Important interventions to reduce CVD risk include advice and treatment for (1) smoking cessation; (2) maintenance of normal BP; (3) lowering serum cholesterol concentration and changing the lipid profile to within guideline levels; (4) lowering serum glucose to within guideline levels; and (5) providing information on lifestyle risk factors, such as physical activity, diet, obesity, and alcohol consumption, and how they can be reduced.4 These strategies are used for both primary and secondary prevention of CVD. Cardiac rehabilitation is designed for people with heart problems, such as myocardial infarction, heart failure, and stable angina, as well as after surgical interventions for coronary heart disease such as heart transplant, coronary artery bypass, or angioplasty. It includes an exercise training and strategies aimed at reducing modifiable risk factors for CVD.5 An increasing proportion of the population uses the Internet for accessing health information.6 Internetbased interventions delivered directly to patient homes have been found to produce clinically beneficial outcomes in areas as diverse as mental health7 and rehabilitation after knee surgery.8 Long-term care through telemedicine services was found effective in reducing rehospitalizations and improving quality of life in high-risk cardiac patients with heart failure.9 This type of tertiary prevention, avoidance of hospitalizations, and other catastrophic events in chronically ill patients through disease management and remote monitoring have been studied extensively.9-11 However, the feasibility and effectiveness of the application of Internet-based interventions for primary and secondary prevention of CVD remain to be clarified. The aim of this article was to review published literature on the effectiveness of Internet-based interven-
tions for the prevention of CVD occurring or recurring and the reduction of CVD risk factors.
METHODS Studies were identified by searching MEDLINE, EMBASE, and Cochrane databases, using synonyms and MeSH (Medical Subject Headings) terms for Internet-based intervention and CVD risk factors. Text and reference lists of relevant articles were searched for other relevant articles. The search was performed in September 2013. The following search terms were used: (heart disease* OR myocardial infarction OR cardiac event* OR heart attack* OR cardiovascular disease* OR cardiovascular risk factor* OR blood pressure OR hypertension OR cholesterol OR LDL-C OR HDL-C OR cardiac rehabilitation) AND (telemonitor* OR tele-monitor* OR teleconsult* OR tele-consult* OR telemanagement OR tele-management OR telerehab* OR tele-rehab* OR Internet-based intervention OR internet based intervention OR Internet intervention* OR web based or web-based).
Inclusion/Exclusion Criteria Studies were included if they investigated Internetbased interventions for the reduction of cardiovascular health outcomes and CVD risk factors in adult populations and delivered directly to participants. Specifically, outcomes and populations of interest were as follows: 1. Direct clinical outcomes such as mortality or CVD events; intermediate clinical outcomes such as lipid profile and BP, which affect CVD outcomes in a dose-response manner12,13; and health behaviors regarding statin therapy, such as commencing the medication and adjusting the dose when required, with conclusive evidence of decreasing blood cholesterol concentration and preventing CVD events,14 regardless of the health status of investigated population. 2. Improvements in lifestyle–dependent CVD risk factors, such as nutrition, body weight, physical activity, smoking, and drinking habits, if they were performed in populations with diagnosed CVD or heightened CVD risks. With the exception of case studies, studies of all design (randomized controlled trials [RCT], observational, and pilot studies) that contained the original data were included. Discussion articles and reviews were excluded. We included 4 studies that used Web-based intervention combined with mobile phone short message
304 / Journal of Cardiopulmonary Rehabilitation and Prevention 2014;34:303-317
www.jcrpjournal.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-13-00100_LR 304
8/11/14 8:42 AM
service (SMS). Mobile phones were used to upload self-monitoring data to the server, and SMSs sent to mobile phones were generated by the server. There was no direct telephone communication between participants and researchers in the studies. Therefore, mobile phones in these studies fulfilled the role of mobile extension of the participants’ computers.
Study Quality Assessment The quality of the studies was analyzed by the Qualitative Assessment Tool for Quantitative Studies.15 The study quality was assessed on the basis of study components that included (1) selection bias, (2) study design, (3) confounders, (4) blinding procedures, (5) data collection methods, and (6) withdrawals and dropouts. Each study component received a quality score (QS) of weak, moderate, or strong. A study that received 4 strong ratings with no weak ratings in any of the components mentioned earlier was rated as “strong.” Studies with fewer than 4 strong ratings with 1 weak rating were rated as “moderate,” and those with 2 or more weak ratings were rated as “weak.”
RESULTS A total of 1074 studies were identified with the database search. After reviewing the abstracts and removing duplicate publications, 53 full-text articles were retrieved for consideration. Of these, 21 articles reporting original data on Internet-based preventive interventions aimed at reducing clinical CVD risk factors fulfilled all the inclusion/exclusion criteria and were included in the review. An additional 3 included articles were found manually. The investigated populations included patients diagnosed with CVD,16-20 type 2 diabetes,21-27 increased CVD risk,28-33 and general population samples.34-39 Investigated outcomes included CVD events (n = 1), the Framingham CVD risk score (n = 1), BP (n = 21), lipid profile (n = 17), blood glucose or glycolysated hemoglobin (HbA1c) (n = 12), medication adherence (n = 2), body weight parameters (n = 14), eating habits (n = 4), physical activity (n = 5), exercise capacity (n = 1), and smoking status (n = 2). Fifteen studies were RCTs, 3 studies were comparative, with nonrandomized control group and pre-/postcomparison, and 5 studies were observational, with pre-/postcomparisons. The quality of 9 RCTs was assessed as “strong.” There were 10 “moderate” studies (4 RCTs, 4 comparative, and 2 observational) and 4 “weak” studies (1 RCT and 3 observational). The duration of the studies generally ranged between 3 and 12 months; there were 7 studies each with followup of 12, 6, and 3 months, www.jcrpjournal.com
and 1 study with a 24-month followup. One study was completed in 1 day. The sample sizes were generally relatively large, numbering more than 300 participants in 9 studies and 100 to 300 in 8 studies; only 4 studies had 50 to 100 participants, and 3 had
