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6 Long-term follow-up and care

6.1 Voice of the patient

A diagnosis of CCS can have an impact on self-identity, lifestyle, employment, and cause anxiety, depression, and burdensome treatment. Patients are experts in their own conditions, and their voices and preferences are integral to decisions about treatment. Health outcomes improve with better patient involvement, and shared decision-making is central to future patient care.1113

6.1.1 Communication

Communication is essential to support patients’ understanding, adherence, and engagement in decision-making.1114 Good communication requires providing information at an appropriate level, active listening, assessing patient understanding, and determining patient perspectives and priorities. A meta-analysis summarizing a total of 127 studies of communication training concluded that patients were 19% more likely to be non-adherent when physicians had poor communication, and 12% more likely to be non-adherent when their physicians had not received communication training.1115 Communication and shared decision-making can be particularly challenging when patients have comorbidities, low health literacy, language differences, cognitive impairment, depression, or anxiety, and when evidence for treatment is less robust. Patient reported outcome measures can be useful to improve assessment and communication of symptoms, function, and QoL, and can highlight problems that may not have been previously discussed. Under- and overestimation of symptoms can lead to a lack of or inappropriate treatment.1116,1117 The routine use of PROMs in clinical practice is hampered by the challenge of interpretation of scores and their integration into routine clinical processes.1116 Although quality of communication can be improved through training, meta-analyses have not found evidence of significant impact on outcomes such as physical or mental health, satisfaction, QoL, or specific risk factors in patients with cancer, diabetes, and hypertension.1115,1118,1119 Structured tools and a flexible range of resources (including videos, workbooks, and health-literacy materials) that provide individualized information and decision aids can be adjuncts to better communication and shared decision-making.443 A systematic review of 17 RCTs of tools to support decision-making in severe illness concluded that they improved patient knowledge and readiness to make decisions.1120 Communicating the risk of future CVD events and how risk can be lowered through lifestyle and medications is best presented using visual or imaging approaches, natural frequencies rather than percentages, and positive framing (focusing on risk-reduction benefits).1121–1125 Relative risk reduction is more persuasive than either absolute risk reduction or the number needed to treat.1122 The use of risk prediction estimates may have an impact on individuals’ health when their information (i.e. predicted risk stratification) changes individuals’ behaviour, self-management decisions, and even treatment decisions.446 This enables patients to gain insights into their cardiovascular prognosis and to empower them to take part in the decision-making process.1126 This approach may increase self-motivation for therapy adherence and lifestyle changes, including changes in nutrition, physical activity, relaxation training, weight management, and participation in smoking cessation programmes for resistant smokers.446 Previous unsuccessful attempts to change to a healthy lifestyle or take guidelinerecommended treatment can be addressed to set realistic goals.446 Communication should be clear regarding symptoms, even if not cardiac. Patients with CCS experiencing non-cardiac chest pain experience uncertainty about the cause and actions to take. A multidisciplinary approach and evaluation of non-cardiac aetiology with an appropriate referral are advocated to ensure that appropriate treatment is initiated.1127,1128

6.1.2 Depression and anxiety

Depression is common (15%–20% prevalence) in CVD, and associated with poor adherence and worse outcomes, including MACE and premature death.1129 Coronary microvascular dysfunction (prevalent in INOCA) is linked with psychological stress and depression.946 Unfortunately, depression and psychological stress are often unrecognized due to a lack of systematic screening using validated tools.1129 For anxiety, a recent meta-analysis involving 16 studies reported a prevalence in post-MI between 5.5% and 58%, and a 27% greater risk of poor clinical outcomes in anxious patients compared with those without anxiety.1130 In contrast, in a 15-year follow-up of 1109 patients with CCS moderate anxiety did not increase the risk of cardiovascular events compared with low anxiety levels. Patients on a high but decreasing anxiety trajectory had an HR of 1.72 (95% CI, 1.11–2.68) for cardiovascular events.1131 Treatment of psychosocial factors, depression, and anxiety with pharmacotherapy, psychotherapy, and/or exercise can improve symptoms and QoL in some patients, and there is some evidence for improvement in cardiac outcomes.472,1132–1134 Stepped care (initial therapy based on patient preferences) and a combination of therapies may be more efficacious.1129,1135 First-line treatment with selective serotonin reuptake inhibitors (recommended in CCS) or non-pharmacological interventions and a multidisciplinary collaborative approach are recommended.1129

6.2 Adherence and persistence

Earlier analyses reported that adherence to long-term therapies in chronic conditions in Western countries averaged 50% and was lower in developing countries.1136 Pooled prevalence of non-adherence from a recent meta-analysis of eight studies (n = 3904 patients with multimorbidity) was 42.63% (95% CI, 34%–51%).1137 Data from the ESC-EORP EUROASPIRE V registry indicate that many CCS patients still have unhealthy lifestyles in terms of smoking, diet, and sedentary behaviour.1138 Poor adherence and persistence (duration of time in which medications and healthy behaviours are continued) have a profound effect on effective management, patient safety, and outcomes. The World Health Organization (WHO) advocates training in adherence for healthcare professionals, a multidisciplinary approach, support rather than blame, tailored interventions based on illness-related demands for each patient, and viewing adherence as a dynamic process.1136 The five dimensions of adherence are patient, disease, provider, therapy, and healthcare system (Figure 16).1139 Therefore, identifying patients at risk of non-adherence, addressing all five dimensions, developing a multidisciplinary pathway to support sustained adherence, and a follow-up strategy are essential steps.1139

6.2.1 Adherence to healthy lifestyle behaviours

Different strategies may help improve long-term adherence to a healthy lifestyle (Figure 17).

6.2.1.1 Why behavioural changes are difficult

Making changes to unhealthy lifestyles and controlling risk factors can be a daunting task as these are usually longstanding habits and patterns

ESC Guidelines                                                                                                                                                                                          3489

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