The document summarizes two studies on the impact of an intensive lifestyle change program on coronary artery disease (CAD) and related risk factors. Both studies found statistically significant improvements in biomarkers and clinical measurements like blood pressure and cholesterol levels in patients who underwent lifestyle changes including a plant-based diet, exercise, stress reduction, and social support, compared to standard medical care. Specifically, the lifestyle changes were associated with reduced inflammation, improved endothelial function, lower BMI and waist-hip ratio, and better quality of life. The results provide further evidence that comprehensive lifestyle interventions can positively impact CAD.

1. Impact of an Intensive Lifestyle
Change on Coronary Artery
Disease.
Lissah Dunston
Christine Lutz
Amanda Werner
&
Kimberly Werner

2. PICO Summary
P- Patients with CAD (Coronary Artery Disease) or high risk for CAD
I- Intensive lifestyle change of exercise, diet (low-fat/plant based diet),
stress reduction measures, and psychosocial support.
C- Standard medical intervention and no lifestyle/support changes.
O- A statistically significant change in emerging cardiac biomarkers,
clinical measurements of weight, blood pressure, lipoproteins.

3. Significance of the
Problem
Coronary Artery Disease (CAD) is a leading cause of
death in the United states.
CAD kills approximately 380,000 people per year.
Annual Cost: $108.9 BILLION DOLLARS
this includes health are services, medications, and
lost wages.

4. Significance of the Problem
(Continued)
Risk Factors of CAD include:
HTN
smoking
increased LDL cholesterol levels
diabetes
obesity
poor diet
lack of exercise
heavy ETOH use

5. Search Strategies
Search terms used:
“Coronary Artery Disease”
“Plant-based diet”
“lifestyle change”
Using terms alone produced too many results, combining “CAD and Plant-
based diet” yielded the most appropriate results.
We used the two articles selected because interventions and hypothesized
outcomes were closely related.

6. First Article:
Preventive cardiology: Effect of Intensive Lifestyle Changes on Endothelial Function and
on Inflammatory Markers of Atherosclerosis
Dod, H. S., Bhardwaj, R., Sajja, V., Weidner, G., Hobbs, G. R., Konat, G. W., & ...
Jain, A. C. (2010). Preventive cardiology: Effect of Intensive Lifestyle Changes on
Endothelial Function and on Inflammatory Markers of Atherosclerosis. The American
Journal Of Cardiology, 105362-367. doi:10.1016/j.amjcard.2009.09.038

7. Summary of First Article
Intervention: Multisite Cardiac Lifestyle Intervention Program
Design: Experimental; pre-test, post-test
Sample: Convenience.
Inclusion Criteria: ALL participants diagnosed with stable coronary artery disease (CAD) and/or risk factors for
CAD; at least 18 years old; mentally competent; stable medication and physical health for more than 4 months.
The participants in the experimental group were currently enrolled in the Multisite Cardiac Lifestyle Intervention
Program sponsored by insurance companies.
The control group was selected from individuals enrolled in outpatient clinics. The type of sampling was
convenience. The following exclusion criteria were used:
Exclusion Criteria: Smokers. individuals not completing lifestyle changes and changes/additions of
medication/doses during the study.

8. Summary of First Article
Data Collection/Measurement Tools:
Endothelial function was measured at baseline and 12 weeks.
flow-mediated dilitation via Doppler vascular imaging
inflammatory endothelial dysfunction markers including high-sensitivity C-
reactive protein (CRP), and human vascular endothelial growth factor.
T and chi-square tests were used to measure baseline characteristics.
Matched-pair t tests were used to assess the changes between the baseline
and 3 month measurements.

9. Summary of First Article
Findings:
Significant improvement in FMD, C-reactive protein,
and interleukin-6 in the intervention group.
These results support previous research that
theorizes that intensive lifestyle changes can regress
atherosclerosis, and improve cardiac health.

10. Summary of First Article
Strengths & Threats to internal validity:
Strength: Consistent measurement intervals for all groups and the
Strength: Biomarkers as a measurement tool.
Weaknesses: Alpha level was not defined, however, given statistically significant p-values, we
could assume that the alpha level was 0.05.
Weakness: Many potential confounding variables including variations in the experimental
group and a wide variety of interventions.
Weakness: No randomization
Weakness: small and homogenous sample, and inconsistent oversight of interventions.

11. Second Article:
Changes in emerging cardiac biomarkers after an intensive lifestyle
intervention
Chainani-Wu, N., Weidner, G., Purnell, D., Frenda, S., Merritt-Worden, T., Pischke,
C., &... Ornish, D. (2011). Changes in emerging cardiac biomarkers after an
intensive lifestyle intervention. American Journal Of Cardiology, 108(4), 498-507.

12. Summary of Second
Article
Intervention: Multisite Cardiac Lifestyle Intervention Program
Design: Cohort, Prospective Design
Sample: Convenience. Participants were selected from the Multisite Cardiac
Lifestyle Intervention Program.
Inclusion Criteria:All participants met the following criteria: Diagnosed with CHD
(or at high risk for CHD), or type 1 or type 2 diabetes mellitus (Cite page 504).
Exclusion Criteria: Exclusion criteria: 9 primary factors including current
smokers, coronary artery bypass graft surgery within 4 weeks, unstable angina
pectoris, and impaired cognitive function (Cite page 504).

13. Summary of Second
Article (cont.)
Data Collection/Measurement Tools:
Demographic information and medical history were obtained for baseline data by interview.
Other values were taken at baseline and at 12 weeks including:
Blood samples for cardiac markers including a fasting blood sample and nuclear magnetic
resonsance Lipoprofile assays.
Clinical measurements (height, weight, abdominal and hip circumference, and blood pressure).
Questionnaires were used to asses exercise habits, quality of life, stress management, social
support.
Paired t tests were used to compare baseline means to the means calculated after 3 months of the
group at high risk of CHD and the group already diagnosed with CHD.

14. Summary of Second
Article (cont.)
Findings:
Improvements were seen in all targeted health behaviors in both groups (all
p<0.001) at 12 weeks including
reduced BMI, systolic and diastolic blood pressure, waist/hip ratio, c-reactive
protein, insulin, LDL and total cholesterol, etc.
Quality of life, cognitive function, and social support measures also improved.
As with the previous study, the results of this study support the theory lifestyle
changes can result in favorable changes in coronary heart disease biomarkers.

15. Summary of Second
Article (cont.)
Strengths & Threats to internal validity:
Strength: Generalizable. Participants were selected from multiple states.
Strength: Biomarkers as a measurement tool.
Strength: Large sample a potential strength. Weakness: No power analysis completed.
Weakness: No randomization, which is a threat to external validity.
Weakness: multiple interventions and interrelated outcome measurements.
Weakness: Cognitive function measured using a subjective pre-test/post-test self-report.
Threat to internal validity.

16. Rating the Evidence
The recommended strength for these articles is level II: quasi-
experimental study.
The recommended quality is B - good.
The studies contained an intervention and control but no randomization.
Results were consistent with definitive conclusions, and had reasonably
consistent results with some control.
There was an evaluation of strengths and limitations and fairly definitive
conclusions.

17. Conclusions and
Recommendations
Use this evidence to guide our nursing practice.
Results indicated significant changes in some of the
biomarkers and clinical measurements.
Our recommendation: Include all aspects of the interventions
(low-fat/plant-based diet, exercise, stress reduction, and
psychosocial support). The individual impact of each
intervention cannot be isolated in the results.

18. RESOURCES:
The American Heart Association:
http://www.heart.org/HEARTORG/
Preventative Medicine Research Institute:
http://www.pmri.org/dean_ornish.html

19. References:
Chainani-Wu, N., Weidner, G., Purnell, D., Frenda, S., Merritt-Worden, T., Pischke, C., &... Ornish, D.
(2011). Changes in emerging cardiac biomarkers after an intensive lifestyle intervention. American
Journal Of Cardiology, 108(4), 498-507.
Dod, H. S., Bhardwaj, R., Sajja, V., Weidner, G., Hobbs, G. R., Konat, G. W., & ... Jain, A. C. (2010).
Preventive cardiology: Effect of Intensive Lifestyle Changes on Endothelial Function and on Inflammatory
Markers of Atherosclerosis. The American Journal Of Cardiology, 105362-367.
doi:10.1016/j.amjcard.2009.09.038
Heart Disease. (n.d.). American Heart Association. Retrieved May 4, 2014, from
Conditions_UCM_001087_SubHomePage.jsp
Heart Disease Facts. (2014, February 19). Centers for Disease Control and Prevention.
Retrieved April 27, 2014, from
http://www.cdc.gov/heartdisease/facts.htm