The Design and Implementation of a Heart Disease Reversal Program in the Veterans Health Administration: Before and During the COVID-19 Pandemic
Background: Heart disease continues to be the leading cause of death in the US, and the number of people with cardiovascular disease (CVD) is rising. CVD is more prevalent among military veterans than nonveterans, and veteran status is associated with higher risk of incident heart disease after controlling for socioeconomic status, other medical diseases, depression, and lifestyle. Many patients seeking care in the Veterans Health Administration, including those who undergo cardiac catheterization, meet the criteria for multimorbidity (defined as ≥ 2 chronic diseases).
Observations: The Heart Disease Reversal Program (HDRP) is a novel interdisciplinary, multicomponent lifestyle program at the US Department of Veterans Affairs (VA) Sacramento VA Medical Center. This program is a streamlined adaptation of behavioral/lifestyle interventions aimed at promoting partial reversal (regression) of atherosclerotic heart disease and achievement of comprehensive cardiovascular risk reduction. HDRP was developed and implemented within a VA behavioral medicine clinic and successfully adapted for delivery through videoconferencing during the COVID-19 pandemic. Patient satisfaction survey data indicate a very high level of patient acceptability. We found direct-to-patient clinical outreach an effective method for launching a disease reversal program.
Conclusions: Beyond the clinical benefits to patients, there is significant value and benefit added to the health care system by offering an intervention within the disease reversal paradigm. Efforts of the health care team to reverse a disease can be considered the highest aim of medicine and health care.
A psychologist delivers the physical activity component. Patients are encouraged to meet the American Heart Association/American College of Cardiology recommendations for aerobic exercise (at least 150 minutes of moderate intensity physical activity per week) through a walking program.35 Patients with medical contraindications (eg, severe pain, mobility restrictions) are encouraged to follow the exercise/activity recommendations they had been given by their primary care provider (PCP), physical therapist, or other HCP.
A psychologist provides evidence-based cognitive behavioral stress management (CBSM) training, adapted from models developed for patients with stable ischemic heart disease, HIV/AIDS, and cancer.36-38 CBSM is a psychotherapy grounded in stress/coping theory and cognitive behavioral theory of psychopathology that integrates cognitive restructuring, coping skills training, communication/assertiveness training, anger management, and mindfulness/acceptance-based approaches. Additional emphasis is placed on assisting patients’ adjustment to the lifestyle challenges for following a plant-based diet, dealing with food cravings and emotional eating, and connecting lifestyle change to patients’ deepest values and goals.
A clinical pharmacist conducts a medication reconciliation for each patient at baseline. The pharmacist consults with each patient’s PCP, cardiologist, and HDRP consulting physician, as needed, to ensure safe adjustments to medications. Pharmacists also provide education on medications at group sessions.
After completion of the 12-week core program, graduates are encouraged to attend the monthly graduates’ group indefinitely, and as often as they desire to promote maintenance of the disease reversal lifestyle. Patients are encouraged to complete our recommended fasting laboratory work every 3 to 6 months to facilitate maintenance of treatment gains.
Program Evaluation
Patients frequently reported that the group format was vital to their success. Patients requested a cooking class, yet we lacked a full teaching kitchen. Integrating plant-based meal samples at every session and cooking videos helped. Patients reported that 100% adherence to the WFPB diet led to significant changes in their food preferences, including a loss of interest in meat.39 Patients encouraged us to keep the “disease reversal” language and focus. One veteran stated: “Disease reversal, that is the reason I called you when I got your letter.” Showing before and after images of coronary angiograms and cardiac positron emission tomography scans depicting regression of atherosclerotic plaque and restored myocardial perfusion were described as highly motivating and generated willingness to commit to a more aggressive lifestyle change.31
Patients routinely stated that they lacked understanding of their laboratory test results, which HDRP remedied. Some patients reported their adult children followed a plant-based diet, and our program resulted in a new commonality and source of bonding that was highly valued. Some patients reported that HDRP was helpful for controlling their COVID-19 anxiety and feeling in control of their health. Satisfaction surveys were completed by participants at the end of the core program, which demonstrated very high satisfaction with and acceptability of HDRP (Table 3).
The program also has received positive feedback from HCPs when we alert them to improvements in outcome measures for their patients. These HCPs expressed satisfaction with having a program to refer patients to that can help with chronic illness in more depth.
