Multiple risk factor counseling to promote heart healthy lifestyles in the chest pain observation unit: pilot randomized controlled trial

BACKGROUND: Admission to the chest pain observation unit (CPOU) may be an advantageous time for patients to consider heart‐healthy lifestyle changes while undergoing diagnostic evaluation to rule out myocardial ischemia. The aim of this pragmatic trial was to assess the effectiveness of a multiple risk factor intervention in changing CPOU patients' health beliefs and readiness to change health behaviors. A secondary aim is to obtain preliminary estimates of the intervention's effect on diet, physical activity, and smoking. METHODS: We conducted a pilot randomized controlled trial (RCT) of a moderate intensity counseling intervention in 140 adult patients with at least one modifiable cardiovascular risk factor (CRF) who were admitted to the CPOU of an academic emergency department (ED) with symptoms of possible acute coronary syndrome (ACS). Study patients were randomly assigned to full counseling (face‐to‐face cardiovascular risk assessment and personalized counseling on nutrition, physical activity, and smoking cessation in the ED, plus two telephone follow‐up sessions) or minimal counseling (brief instruction on benefits of modifying cardiovascular risk factors (<5 min) and informational handout) by a cardiac rehabilitation specialist. We measured Health Belief Model constructs for ischemic heart disease, stage of change, and self‐reported CRF‐related behaviors during 6‐month follow‐up using previously validated measures. We used linear mixed models and logistic regression (with generalized estimating equations) to compare continuous and dichotomous behavioral outcomes across treatment arms, respectively. RESULTS: In both treatment arms combined, patients showed significant increases in the perceived benefits of improving CRF‐related behaviors (27.7 vs. 26.6, p = .0001) and increased readiness to change dietary behavior and PA during follow‐up: intake of saturated fat (83 vs. 49%), fruit and vegetable consumption (83 vs 56%), and regular exercise (34 vs. 14%) at 6‐months and baseline, respectively (p < .0001 for all comparisons). Although roughly 20% more patients in the full counseling arm reported having received counseling on diet and physical activity during CPOU admission, there were no significant differences between treatment arms for any cardiovascular health beliefs, stages of change, or CRF‐related behaviors during longitudinal follow‐up. CONCLUSIONS: Patients admitted to the CPOU demonstrate sustained changes in several cardiovascular health beliefs and risk‐related behaviors during follow‐up; this provides further evidence that the CPOU visit is a “teachable moment” for cardiovascular risk reduction. A multiple risk factor intervention that aimed to build motivation to change and problem‐solving skills did not significantly improve behavioral outcomes, compared to minimal counseling. Future studies should evaluate more intensive ED‐initiated counseling interventions to engage patients in changing cardiovascular risk behaviors, in coordination with primary care.