Current Cardiology Reports

, Volume 14, Issue 3, pp 265–275 | Cite as

Role of Self-Care in the Patient with Heart Failure

Congestive Heart Failure (J Lindenfeld, Section Editor)

Abstract

Optimal outcomes and quality of life for patients with heart failure depend on engagement in effective self-care activities. Self-care is a complex set of activities and most clinicians are not adequately prepared to assist their patients to engage in effective self-care. In this paper, we provide an overview of self-care that includes definitions, the importance of self-care to outcomes, the physiologic basis for better outcomes with good self-care, cultural perspectives of self-care, and recommendations for the improvement of self-care. Promotion of effective self-care by all clinicians could substantially reduce the economic and personal burden of repeated rehospitalizations among patients with heart failure.

Keywords

Self-care Heart failure Outcomes Self-management 

References

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. 1.
    Lee WC, Chavez YE, Baker T, Luce BR. Economic burden of heart failure: a summary of recent literature. Heart Lung. 2004;33(6):362–71.PubMedCrossRefGoogle Scholar
  2. 2.
    Linne AB, Liedholm H, Jendteg S, Israelsson B. Health care costs of heart failure: results from a randomised study of patient education. Eur J Heart Fail. 2000;2(3):291–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Liao L, Jollis JG, Anstrom KJ, Whellan DJ, Kitzman DW, Aurigemma GP, Mark DB, Schulman KA, Gottdiener JS. Costs for heart failure with normal vs reduced ejection fraction. Arch Intern Med. 2006;166(1):112–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Liao L, Anstrom KJ, Gottdiener JS, Pappas PA, Whellan DJ, Kitzman DW, Aurigemma GP, Mark DB, Schulman KA, Jollis JG. Long-term costs and resource use in elderly participants with congestive heart failure in the Cardiovascular Health Study. Am Heart J. 2007;153(2):245–52.PubMedCrossRefGoogle Scholar
  5. 5.
    Formiga F, Chivite D, Manito N, Casas S, Llopis F, Pujol R. Hospitalization due to acute heart failure. Role of the precipitating factors. Int J Cardiol. 2007;120(2):237–41.PubMedCrossRefGoogle Scholar
  6. 6.
    Opasich C, Rapezzi C, Lucci D, Gorini M, Pozzar F, Zanelli E, Tavazzi L, Maggioni AP. Precipitating factors and decision-making processes of short-term worsening heart failure despite “optimal” treatment (from the IN-CHF Registry). Am J Cardiol. 2001;88(4):382–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Tsuyuki RT, McKelvie RS, Arnold JM, Avezum Jr A, Barretto AC, Carvalho AC, Isaac DL, Kitching AD, Piegas LS, Teo KK, et al. Acute precipitants of congestive heart failure exacerbations. Arch Intern Med. 2001;161(19):2337–42.PubMedCrossRefGoogle Scholar
  8. 8.
    Michalsen A, Konig G, Thimme W. Preventable causative factors leading to hospital admission with decompensated heart failure. Heart. 1998;80(5):437–41.PubMedGoogle Scholar
  9. 9.
    Rogers A, Addington-Hall JM, McCoy AS, Edmonds PM, Abery AJ, Coats AJ, Gibbs JS. A qualitative study of chronic heart failure patients’ understanding of their symptoms and drug therapy. Eur J Heart Fail. 2002;4(3):283–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Rogers AE, Addington-Hall JM, Abery AJ, McCoy AS, Bulpitt C, Coats AJ, Gibbs JS. Knowledge and communication difficulties for patients with chronic heart failure: qualitative study. BMJ. 2000;321(7261):605–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Evangelista LS, Dracup K, Doering LV. Treatment-seeking delays in heart failure patients. J Heart Lung Transplant. 2000;19(10):932–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Ghali JK. Heart failure and noncompliance in the elderly. Arch Intern Med. 1994;154(18):2109–10.PubMedCrossRefGoogle Scholar
  13. 13.
    Bennett SJ, Huster GA, Baker SL, Milgrom LB, Kirchgassner A, Birt J, Pressler ML. Characterization of the precipitants of hospitalization for heart failure decompensation. Am J Crit Care. 1998;7(3):168–74.PubMedGoogle Scholar
  14. 14.
    Schiff GD, Fung S, Speroff T, McNutt RA. Decompensated heart failure: symptoms, patterns of onset, and contributing factors. Am J Med. 2003;114(8):625–30.PubMedCrossRefGoogle Scholar
  15. 15.
    Chin MH, Goldman L. Correlates of early hospital readmission or death in patients with congestive heart failure. Am J Cardiol. 1997;79(12):1640–4.PubMedCrossRefGoogle Scholar
  16. 16.
    Struthers AD, Anderson G, MacFadyen RJ, Fraser C, MacDonald TM. Nonadherence with ACE inhibitors is common and can be detected in clinical practice by routine serum ACE activity. Congest Heart Fail. 2001;7(1):43–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Moser DK, Doering LV, Chung ML. Vulnerabilities of patients recovering from an exacerbation of chronic heart failure. Am Heart J. 2005;150(5):984.PubMedCrossRefGoogle Scholar
  18. 18.
    Friedman MM. Older adults’ symptoms and their duration before hospitalization for heart failure. Heart Lung. 1997;26(3):169–76.PubMedCrossRefGoogle Scholar
  19. 19.
    Riegel B, Dickson VV. A situation-specific theory of heart failure self-care. J Cardiovasc Nurs. 2008;23(3):190–6.PubMedGoogle Scholar
  20. 20.
    Riegel B, Lee CS, Dickson VV. Self care in patients with chronic heart failure. Nat Rev Cardiol. 2011;8(11):644–54.PubMedCrossRefGoogle Scholar
  21. 21.
    •• Lainscak M, Blue L, Clark AL, Dahlstrom U, Dickstein K, Ekman I, McDonagh T, McMurray JJ, Ryder M, Stewart S, et al. Self-care management of heart failure: practical recommendations from the Patient Care Committee of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2011;13(2):115–26. This article provides foundational evidence-based material for including self-care into practice. PubMedCrossRefGoogle Scholar
  22. 22.
    Klein G. Naturalistic decision making. Hum Factors. 2008;50(3):456–60.PubMedCrossRefGoogle Scholar
  23. 23.
    Kim YJ, Soeken KL. A meta-analysis of the effect of hospital-based case management on hospital length-of-stay and readmission. Nurs Res. 2005;54(4):255–64.PubMedCrossRefGoogle Scholar
  24. 24.
    McDonald K. Disease management programs for heart failure. Curr Treat Options Cardiovasc Med. 2010;12(6):578–86.PubMedCrossRefGoogle Scholar
  25. 25.
    Savard LA, Thompson DR, Clark AM. A meta-review of evidence on heart failure disease management programs: the challenges of describing and synthesizing evidence on complex interventions. Trials. 2011;12:194.PubMedCrossRefGoogle Scholar
  26. 26.
    Whellan DJ, Hasselblad V, Peterson E, O’Connor CM, Schulman KA. Metaanalysis and review of heart failure disease management randomized controlled clinical trials. Am Heart J. 2005;149(4):722–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Yu DS, Thompson DR, Lee DT. Disease management programmes for older people with heart failure: crucial characteristics which improve post-discharge outcomes. Eur Heart J. 2006;27(5):596–612.PubMedCrossRefGoogle Scholar
  28. 28.
    Jovicic A, Holroyd-Leduc JM, Straus SE. Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials. BMC Cardiovasc Disord. 2006;6:43.PubMedCrossRefGoogle Scholar
  29. 29.
    Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure: a systematic review of randomized trials. Arch Intern Med. 2008;168(7):687–94.PubMedCrossRefGoogle Scholar
  30. 30.
    Gohler A, Januzzi JL, Worrell SS, Osterziel KJ, Gazelle GS, Dietz R, Siebert U. A systematic meta-analysis of the efficacy and heterogeneity of disease management programs in congestive heart failure. J Card Fail. 2006;12(7):554–67.PubMedCrossRefGoogle Scholar
  31. 31.
    Konstam MA, Konstam V. Heart failure disease management a sustainable energy source for the health care engine. J Am Coll Cardiol. 2010;56(5):379–81.PubMedCrossRefGoogle Scholar
  32. 32.
    Ferrante D, Varini S, Macchia A, Soifer S, Badra R, Nul D, Grancelli H, Doval H. Long-term results after a telephone intervention in chronic heart failure: DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure) follow-up. J Am Coll Cardiol. 2010;56(5):372–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Wu JR, Moser DK, Chung ML, Lennie TA. Objectively measured, but not self-reported, medication adherence independently predicts event-free survival in patients with heart failure. J Card Fail. 2008;14(3):203–10.PubMedCrossRefGoogle Scholar
  34. 34.
    Wu JR, Moser DK, De Jong MJ, Rayens MK, Chung ML, Riegel B, Lennie TA. Defining an evidence-based cutpoint for medication adherence in heart failure. Am Heart J. 2009;157(2):285–91.PubMedCrossRefGoogle Scholar
  35. 35.
    Wu JR, Corley DJ, Lennie TA, Moser DK. Effect of a medication-taking behavior feedback theory-based intervention on outcomes in patients with heart failure. J Card Fail. 2012;18(1):1–9.PubMedCrossRefGoogle Scholar
  36. 36.
    van der Wal MH, van Veldhuisen DJ, Veeger NJ, Rutten FH, Jaarsma T. Compliance with non-pharmacological recommendations and outcome in heart failure patients. Eur Heart J. 2010;31(12):1486–93.PubMedCrossRefGoogle Scholar
  37. 37.
    •• Lee CS, Moser DK, Lennie TA, Riegel B. Event-free survival in adults with heart failure who engage in self-care management. Heart Lung. 2011;40(1):12–20. Among the first data-based papers to demonstrate that better self-reported self-care results in better event-free survival. PubMedCrossRefGoogle Scholar
  38. 38.
    Buck HG, Lee CS, Moser DK, Albert NM, Lennie T, Bentley B, Worrall-Carter L, Riegel B. Relationship between self-care and health-related quality of life in older adults with moderate to advanced heart failure. J Cardiovasc Nurs. 2012;27(1):8–15.PubMedGoogle Scholar
  39. 39.
    Wang SP, Lin LC, Lee CM, Wu SC. Effectiveness of a self-care program in improving symptom distress and quality of life in congestive heart failure patients: a preliminary study. J Nurs Res. 2011;19(4):257–66.PubMedCrossRefGoogle Scholar
  40. 40.
    Seto E, Leonard KJ, Cafazzo JA, Masino C, Barnsley J, Ross HJ. Self-care and quality of life of heart failure patients at a multidisciplinary heart function clinic. J Cardiovasc Nurs. 2011;26(5):377–85.PubMedGoogle Scholar
  41. 41.
    •• Riegel B, Moser DK, Anker SD, Appel LJ, Dunbar SB, Grady KL, Gurvitz MZ, Havranek EP, Lee CS, Lindenfeld J, et al. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation. 2009;120(12):1141–63. First evidence-based consensus statement dedicated to self-care in patients with HF. PubMedCrossRefGoogle Scholar
  42. 42.
    Lee CS, Tkacs NC, Riegel B. The influence of heart failure self-care on health outcomes: hypothetical cardioprotective mechanisms. J Cardiovasc Nurs. 2009;24(3):179–87. quiz 188–179.PubMedGoogle Scholar
  43. 43.
    Packer M. The neurohormonal hypothesis: a theory to explain the mechanism of disease progression in heart failure. J Am Coll Cardiol. 1992;20(1):248–54.PubMedCrossRefGoogle Scholar
  44. 44.
    Seta Y, Shan K, Bozkurt B, Oral H, Mann DL. Basic mechanisms in heart failure: the cytokine hypothesis. J Card Fail. 1996;2(3):243–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Felker GM, Whellan D, Kraus WE, Clare R, Zannad F, Donahue M, Adams K, McKelvie R, Pina IL, O’Connor CM. N-terminal pro-brain natriuretic peptide and exercise capacity in chronic heart failure: data from the Heart Failure and a Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) study. Am Heart J. 2009;158(4 Suppl):S37–44.PubMedCrossRefGoogle Scholar
  46. 46.
    Adamopoulos S, Parissis J, Kroupis C, Georgiadis M, Karatzas D, Karavolias G, Koniavitou K, Coats AJ, Kremastinos DT. Physical training reduces peripheral markers of inflammation in patients with chronic heart failure. Eur Heart J. 2001;22(9):791–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Gielen S, Adams V, Mobius-Winkler S, Linke A, Erbs S, Yu J, Kempf W, Schubert A, Schuler G, Hambrecht R. Anti-inflammatory effects of exercise training in the skeletal muscle of patients with chronic heart failure. J Am Coll Cardiol. 2003;42(5):861–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Niebauer J. Effects of exercise training on inflammatory markers in patients with heart failure. Heart Fail Rev. 2008;13(1):39–49.PubMedCrossRefGoogle Scholar
  49. 49.
    Nichol KL, Nordin J, Mullooly J, Lask R, Fillbrandt K, Iwane M. Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. N Engl J Med. 2003;348(14):1322–32.PubMedCrossRefGoogle Scholar
  50. 50.
    Gundogdu F, Bozkurt E, Kiziltunc A, Sevimli S, Arslan S, Gurlertop Y, Senocak H, Karakelleoglu S. The effect of beta-blocker (carvedilol) therapy on N-terminal pro-brain natriuretic peptide levels and echocardiographic findings in patients with congestive heart failure. Echocardiography. 2007;24(2):113–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Gullestad L, Aukrust P, Ueland T, Espevik T, Yee G, Vagelos R, Froland SS, Fowler M. Effect of high-versus low-dose angiotensin converting enzyme inhibition on cytokine levels in chronic heart failure. J Am Coll Cardiol. 1999;34(7):2061–7.PubMedCrossRefGoogle Scholar
  52. 52.
    Fliser D, Buchholz K, Haller H. Antiinflammatory effects of angiotensin II subtype 1 receptor blockade in hypertensive patients with microinflammation. Circulation. 2004;110(9):1103–7.PubMedCrossRefGoogle Scholar
  53. 53.
    Sola S, Mir MQ, Rajagopalan S, Helmy T, Tandon N, Khan BV. Statin therapy is associated with improved cardiovascular outcomes and levels of inflammatory markers in patients with heart failure. J Card Fail. 2005;11(8):607–12.PubMedCrossRefGoogle Scholar
  54. 54.
    Ambardekar AV, Fonarow GC, Hernandez AF, Pan W, Yancy CW, Krantz MJ. Characteristics and in-hospital outcomes for nonadherent patients with heart failure: findings from Get With The Guidelines-Heart Failure (GWTG-HF). Am Heart J. 2009;158(4):644–52.PubMedCrossRefGoogle Scholar
  55. 55.
    Fitzgerald AA, Powers JD, Ho PM, Maddox TM, Peterson PN, Allen LA, Masoudi FA, Magid DJ, Havranek EP. Impact of medication nonadherence on hospitalizations and mortality in heart failure. J Card Fail. 2011;17(8):664–9.PubMedCrossRefGoogle Scholar
  56. 56.
    Lennie TA. Nutrition self-care in heart failure: state of the science. J Cardiovasc Nurs. 2008;23(3):197–204.PubMedGoogle Scholar
  57. 57.
    •• Rathman LD, Lee CS, Sarkar S, Small RS. A critical link between heart failure self-care and intrathoracic impedance. J Cardiovasc Nurs. 2011;26(4):E20–6. Demonstrates the potential for implanted impedance monitoring to detect adequate and failed self-care. PubMedGoogle Scholar
  58. 58.
    Gheorghiade M, Zannad F, Sopko G, Klein L, Pina IL, Konstam MA, Massie BM, Roland E, Targum S, Collins SP, et al. Acute heart failure syndromes: current state and framework for future research. Circulation. 2005;112(25):3958–68.PubMedCrossRefGoogle Scholar
  59. 59.
    Felker GM, Leimberger JD, Califf RM, Cuffe MS, Massie BM, Adams Jr KF, Gheorghiade M, O’Connor CM. Risk stratification after hospitalization for decompensated heart failure. J Card Fail. 2004;10(6):460–6.PubMedCrossRefGoogle Scholar
  60. 60.
    Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P, Rouleau JL, Tendera M, Castaigne A, Roecker EB, et al. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med. 2001;344(22):1651–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Patel J, Smith M, Heywood JT. Optimal use of diuretics in patients with heart failure. Curr Treat Options Cardiovasc Med. 2007;9(4):332–42.PubMedCrossRefGoogle Scholar
  62. 62.
    Peschel T, Schonauer M, Thiele H, Anker SD, Schuler G, Niebauer J. Invasive assessment of bacterial endotoxin and inflammatory cytokines in patients with acute heart failure. Eur J Heart Fail. 2003;5(5):609–14.PubMedCrossRefGoogle Scholar
  63. 63.
    Lee CS, Moser DK, Lennie T, Margulies KB, Tkacs NC, Riegel B. Biomarkers of myocardial stress and systemic inflammation in patients who engage in heart failure self-care management. J Cardiovasc Nurs. 2011;26(4):321–8.PubMedGoogle Scholar
  64. 64.
    Moser DK, Watkins JF. Conceptualizing self-care in heart failure: a life course model of patient characteristics. J Cardiovasc Nurs. 2008;23(3):205–18. quiz 219–220.PubMedGoogle Scholar
  65. 65.
    Riegel B, Lee CS, Albert N, Lennie T, Chung M, Song EK, Bentley B, Heo S, Worrall-Carter L, Moser DK. From novice to expert: confidence and activity status determine heart failure self-care performance. Nurs Res. 2011;60(2):132–8.PubMedCrossRefGoogle Scholar
  66. 66.
    Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53(15):e1–e90.PubMedCrossRefGoogle Scholar
  67. 67.
    Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, et al. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010;16(6):e1–e194.PubMedCrossRefGoogle Scholar
  68. 68.
    Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA, Stromberg A, van Veldhuisen DJ, Atar D, Hoes AW, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail. 2008;10(10):933–89.PubMedCrossRefGoogle Scholar
  69. 69.
    van der Wal MH, Jaarsma T, Moser DK, van Gilst WH, van Veldhuisen DJ. Unraveling the mechanisms for heart failure patients’ beliefs about compliance. Heart Lung. 2007;36(4):253–61.PubMedCrossRefGoogle Scholar
  70. 70.
    Riegel B, Driscoll A, Suwanno J, Moser DK, Lennie TA, Chung ML, Wu JR, Dickson VV, Carlson B, Cameron J. Heart failure self-care in developed and developing countries. J Card Fail. 2009;15(6):508–16.PubMedCrossRefGoogle Scholar
  71. 71.
    Hebert K, Lopez B, Horswell R, Tamariz L, Palacio A, Li H, Arcement LM. The impact of a standardized disease management program on race/ethnicity and gender disparities in care and mortality. J Health Care Poor Underserved. 2010;21(1):264–76.PubMedCrossRefGoogle Scholar
  72. 72.
    Riegel B, Carlson B, Glaser D, Romero T. Randomized controlled trial of telephone case management in Hispanics of Mexican origin with heart failure. J Card Fail. 2006;12(3):211–9.PubMedCrossRefGoogle Scholar
  73. 73.
    Dickson V, McCarthy M, Howe A, Schipper J, Katz S: Socio-cultural influences on heart failure self-care among an ethnic minority black population. J Cardiovasc Nurs. in pressGoogle Scholar
  74. 74.
    Khalsa S, Rudrauf D, Tranel D. Interoceptive awareness declines with age. Psychophysiology. 2009;46(6):1130–6.PubMedCrossRefGoogle Scholar
  75. 75.
    Woo M, Macey P, Fonarow G, Hamilton M, Harper R. Regional brain gray matter loss in heart failure. J Appl Physiol. 2003;95:677–84.PubMedGoogle Scholar
  76. 76.
    Riegel B, Dickson VV, Cameron J, Johnson JC, Bunker S, Page K, Worrall-Carter L. Symptom recognition in elders with heart failure. J Nurs Scholarsh. 2010;42(1):92–100.PubMedCrossRefGoogle Scholar
  77. 77.
    Patel H, Shafazand M, Schaufelberger M, Ekman I. Reasons for seeking acute care in chronic heart failure. Eur J Heart Fail. 2007;9:702–8.PubMedCrossRefGoogle Scholar
  78. 78.
    Bekelman DB, Havranek EP, Becker DM, Kutner JS, Peterson PN, Wittstein IS, Gottlieb SH, Yamashita TE, Fairclough DL, Dy SM. Symptoms, depression, and quality of life in patients with heart failure. J Card Fail. 2007;13(8):643–8.PubMedCrossRefGoogle Scholar
  79. 79.
    •• Dickson VV, Buck H, Riegel B. A qualitative meta-analysis of heart failure self-care practices among individuals with multiple comorbid conditions. J Card Fail. 2011;17(5):413–9. Large qualitative analysis of why self-care fails. PubMedCrossRefGoogle Scholar
  80. 80.
    van Veldhuisen DJ, Braunschweig F, Conraads V, Ford I, Cowie MR, Jondeau G, Kautzner J, Aguilera RM, Lunati M, Yu CM, et al. Intrathoracic impedance monitoring, audible patient alerts, and outcome in patients with heart failure. Circulation. 2011;124(16):1719–26.PubMedCrossRefGoogle Scholar
  81. 81.
    McDonagh TA, Blue L, Clark AL, Dahlstrom U, Ekman I, Lainscak M, McDonald K, Ryder M, Stromberg A, Jaarsma T. European Society of Cardiology Heart Failure Association Standards for delivering heart failure care. Eur J Heart Fail. 2011;13(3):235–41.PubMedCrossRefGoogle Scholar
  82. 82.
    Dickson VV, Riegel B. Are we teaching what patients need to know? Building skills in heart failure self-care. Heart Lung. 2009;38(3):253–61.PubMedCrossRefGoogle Scholar
  83. 83.
    White M, Howie-Esquivel J, Caldwell M. Improving heart failure symptom recognition: a diary analysis. J Cardiovasc Nurs. 2010;25(1):7–12.PubMedGoogle Scholar
  84. 84.
    Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van Horn L, Lichtenstein AH, Kumanyika S, Kraus WE, Fleg JL, Redeker NS, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 2010;122(4):406–41.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Debra K. Moser
    • 1
  • Victoria Dickson
    • 2
  • Tiny Jaarsma
    • 3
  • Christopher Lee
    • 4
  • Anna Stromberg
    • 5
    • 6
  • Barbara Riegel
    • 7
  1. 1.University of Kentucky, College of NursingLexingtonUSA
  2. 2.New York University College of NursingNew YorkUSA
  3. 3.Department of Social and Welfare Studies, Faculty of Health SciencesLinköping UniversityLinköpingSweden
  4. 4.Oregon Health & Science UniversityPortlandUSA
  5. 5.Division of Nursing Science, Department of Medicine and Health Sciences, Faculty of Health SciencesLinköping UniversityLinköpingSweden
  6. 6.Department of Cardiology, UHLCounty Council of ÖstergötlandLinköpingSweden
  7. 7.University of Pennsylvania, School of NursingPhiladelphiaUSA

Personalised recommendations