|Among a sample of 7,519 individuals with self-reported atherosclerotic cardiovascular disease, 19% continued to smoke cigarettes, just 35% undertook recommended levels of moderate-to-vigorous physical activity, and only 39% had healthy diets (60). Moreover, a substantial percentage of patients receiving percutaneous coronary intervention do not achieve lifestyle and risk factor goals at 1 year after procedure and therefore remain at increased risk for recurrent cardiac events or coronary revascularization procedures (61). Early referral and long-term follow-up should help to improve program access and compliance with lifestyle modification.|
|Conventional cardiac rehabilitation (CR) programs routinely emphasize structured exercise and use of continuous electrocardiographic monitoring for reimbursement, yet the primary beneficiaries of structured exercise programs are those at the bottom of the fitness/activity chain, patients in the least fit, least active cohort (i.e., the bottom 20%) (62). Contemporary CR programs should prioritize low-fit patients and increasingly focus on facilitating long-term behavior change (e.g., promoting lifestyle physical activity) and comprehensive risk reduction by incorporating new modalities such as home-based, internet-based, and telephone-based CR programs.|
|Although nearly 90% of patients are discharged with appropriate medications after acute myocardial infarction, most patients receive doses prescribed substantially below those with proven efficacy in clinical trials (63). For a variety of reasons (e.g., cost, adverse effects, apathy) many patients also report inconsistent long-term use of beta-blockers, lipid-lowering therapy, or combinations of these potentially lifesaving drugs (64). In multivariate analysis, medication nonadherence remained significantly associated with increased all-cause mortality risk in patients with coronary artery disease (65). A potential solution that will maximize the outcomes of patients with coronary disease is to target medication dosing and nonadherence for quality improvement initiatives in CR.|
|Because patients with chronic disease typically spend ≥5,000 h each year independent of medical providers, it is critical to arm them with research-based behavior change strategies that they can implement in their immediate environment (e.g., home, work, community) (66). Tailoring messages about lifestyle counseling to patients’ individual readiness to change will increase the likelihood of behavioral transformation (67), as will motivational interviewing as a form of talk therapy during patient encounters (68,69).|
|More than 80% of adults currently have an established source of healthcare services, and this percentage is expected to appreciably increase with implementation of the Affordable Care Act. This shift will enable vulnerable subsets of the population, who are more often plagued by unhealthy lifestyle practices, to seek medical evaluation and care, empowering medical providers with heightened opportunities to facilitate behavioral improvements in population health over time (70). The 5As approach can be used to elicit significant improvements in a variety of health behaviors, including smoking cessation, dietary choices, and physical activity (71,72).|
|Self-responsibility (e.g., meeting certain health metrics) will become a greater priority in the new healthcare coverage environment. For example, completing health habit surveys and/or serial risk factor profiles, along with regular physical examinations, and attaining certain risk factor ranges will be increasingly mandated by insurers and employers, orchestrated in part by financial incentives and penalties.|
CR = cardiac rehabilitation.