Reliability and Validity of the State-Trait Hopelessness Scale in a Primarily Rural Population of Adults With Ischemic Heart Disease in the US Great Plains.

PURPOSE: Hopelessness and rurality are each independently associated with increased mortality in adults with ischemic heart disease (IHD), yet there is no known research examining hopelessness in rural patients with IHD. The authors of this study evaluated the reliability and validity of the State-Trait Hopelessness Scale (STHS) in a primarily rural population of adults with IHD living in West North Central United States (US Great Plains). METHODS: Reliability, concurrent validity, and convergent validity were evaluated for 115 adults hospitalized for IHD. Rural-Urban Commuting Area codes were used to stratify participants by rurality level, with 66% categorized as rural. Principal component analysis was used to examine potential factor structure of the STHS. FINDINGS: Cronbach α for the State and Trait Hopelessness subscales were 0.884 and 0.903, respectively. Concurrent validity was supported for the State and Trait subscales using the Patient Health Questionnaire-8 (State: r = 0.50, P < .001; Trait: r = 0.35, P < .001). Convergent validity was supported for the State subscale using the Duke Activity Status Index ( r = -0.23, P = .013). Principal component analysis showed 2 factors (hopelessness present and hopelessness absent) for the State and Trait subscales, accounting for 63% and 58% of variance, respectively. CONCLUSIONS: Findings support the reliability and validity of the STHS for evaluation of hopelessness in rural adults with IHD in clinical and research settings. Results replicated the same factor structure found in testing of the STHS in a primarily urban sample. Because of the prevalence of hopelessness in rural adults with IHD and association with increased mortality, hopelessness should be assessed during hospitalization and in the recovery period.

There is little association between prehospital delay, persistent symptoms, and post-discharge healthcare utilization in patients evaluated for acute coronary syndrome.

AIMS: Test for an association between prehospital delay for symptoms suggestive of acute coronary syndrome (ACS), persistent symptoms, and healthcare utilization (HCU) 30-days and 6-months post hospital discharge. BACKGROUND: Delayed treatment for ACS increases patient morbidity and mortality. Prehospital delay is the largest factor in delayed treatment for ACS. METHODS: Secondary analysis of data collected from a multi-center prospective study. Included were 722 patients presenting to the Emergency Department (ED) with symptoms that triggered a cardiac evaluation. Symptoms and HCU were measured using the 13-item ACS Symptom Checklist and the Froelicher's Health Services Utilization Questionnaire-Revised instrument. Logistic regression models were used to examine hypothesized associations. RESULTS: For patients with ACS (n = 325), longer prehospital delay was associated with fewer MD/NP visits (OR, 0.986) at 30 days. Longer prehospital delay was associated with higher odds of calling 911 for any reason (OR, 1.015), and calling 911 for chest related symptoms (OR, 1.016) 6 months following discharge. For non-ACS patients (n = 397), longer prehospital delay was associated with higher odds of experiencing chest pressure (OR, 1.009) and chest discomfort (OR, 1.008) at 30 days. At 6 months, longer prehospital delay was associated with higher odds of upper back pain (OR, 1.013), palpitations (OR 1.014), indigestion (OR, 1.010), and calls to the MD/NP for chest symptoms (OR, 1.014). CONCLUSIONS: There were few associations between prehospital delay and HCU for patients evaluated for ACS in the ED. Associations between prolonged delay and persistent symptoms may lead to increased HCU for those without ACS.

Negative Attitudes, Self-efficacy, and Relapse Management Mediate Long-Term Adherence to Exercise in Patients With Heart Failure.

BACKGROUND: Exercise is safe and provides considerable benefits for patients with heart failure (HF) including improved function, quality of life, and symptoms. However, patients with HF have difficulty initiating and adhering to an exercise regimen. To improve adherence, our team developed Heart Failure Exercise and Resistance Training (HEART) Camp, a multicomponent, theory-driven intervention that was efficacious in a randomized controlled trial of long-term adherence to exercise in patients with HF. Identifying active components of efficacious interventions is a priority. PURPOSE: The purpose of this study is to use mediation analysis to determine which interventional components accounted for long-term adherence to exercise in patients with HF. METHODS: This study included 204 patients with HF enrolled in a randomized controlled trial. Instruments measuring interventional components were completed at baseline, 6, 12, and 18 months. Hierarchical linear models generated slope estimates to be used as predictors in logistic regression models. Significant variables were tested for indirect effects using path analyses with 1,000 bootstrapped estimates. RESULTS: Significant mediation effects were observed for the interventional components of negative attitudes (ß NA = 0.368, s.e. = 0.062, p < .001), self-efficacy (ß SE = 0.190, s.e. = 0.047, p < .001), and relapse management (ß RM = 0.243, s.e. = 0.076, p = .001). CONCLUSIONS: These findings highlight improving attitudes, self-efficacy, and managing relapse as key interventional components to improve long-term adherence to exercise in patients with HF. Future interventions targeting adherence to exercise in patients with HF and other chronic illnesses should consider the incorporation of these active components.

Suicide Risk Management Protocol for a Randomized Controlled Trial of Cardiac Patients Reporting Hopelessness.

BACKGROUND: Investigators conducting studies that include potentially suicidal individuals are obligated to develop a suicide risk management (SRM) protocol. There is little available in the literature to guide researchers in SRM protocol development. OBJECTIVES: The aim of the study was to describe an SRM protocol developed for a randomized controlled trial (RCT) currently enrolling cardiac patients who report moderate to severe levels of hopelessness. METHODS: The SRM protocol identifies suicidal ideation and measures ideation severity through use of the Columbia-Suicide Severity Rating Scale risk factor questions. Based on responses, study participants are deemed safe or at low, moderate, or high risk for suicide. The SRM protocol guides research staff through a plan of action based on risk level. The protocol further guides staff through a plan over the course of this prospective study-from hospital enrollment to home-based visits. RESULTS: Research staff are well trained to identify suicidal ideation risk factors, initiate specific questioning about suicidal intent, determine level of risk, identify protective factors and a safe environment, and make referrals if needed. Of the 51 patients hospitalized with cardiac disease who reported moderate to severe hopelessness, 43 scored at a safe suicide risk level and 8 scored at low risk. Thirty-five of the 51 patients enrolled in the RCT. Of the 35 participants who received home visits to date, there have been three instances of low and one instance of moderate suicide risk. The SRM protocol has been consistently and accurately used by research personnel in both hospital and home settings. One modification has been made to the protocol since study activation, namely, the addition of an assessment of counseling history and encouragement of continued counseling. Booster training sessions of research staff will continue throughout the course of the RCT. DISCUSSION: Use of the SRM protocol identifies study participants who are safe or at risk for suicide in both hospital and home settings, and research staff can refer participants accordingly. CONCLUSION: The SRM protocol developed for this RCT can serve as a model in the development of SRM protocols for future research in acute care, community, or home-based settings.

ActiGraph and Short-term Heart Rate Variability Study Protocol: Amended for the COVID-19 Pandemic.

BACKGROUND: ActiGraph accelerometry is widely used in nursing research to estimate daily physical activity. Heart rate variability (HRV), a measure of autonomic modulation, can be assessed in conjunction with the ActiGraph using a Polar H7 Bluetooth heart rate monitor. There is a paucity of nursing literature to guide nurse researchers' protocol development when using the ActiGraph to assess both physical activity and short-term HRV via its Bluetooth capabilities. OBJECTIVES: The aim of this study was to describe a standardized research ActiGraph and HRV (ActiGraph HRV) protocol for an ongoing randomized controlled trial to measure physical activity and short-term HRV in patients with ischemic heart disease who report hopelessness. METHODS: We outline the study protocol for the standardization of reliable and rigorous physical activity and HRV data collection using the ActiGraph wGT3X-BT and Polar H7 Bluetooth heart rate monitor, and data analysis using ActiLife and Kubios software programs. RESULTS: Sixty-four participants enrolled in the randomized controlled trial to date, and 45 (70.3%) have completed or are actively participating in the study. Heart rate variability data have been collected on 43 of the 45 participants (96%) to date. During the first data collection time point, 42 of 44 participants (95.5%) wore the ActiGraph for a minimum of 5 valid days, followed by 28 of 31 participants (90.3%) and 25 of 26 participants (96.2%) at subsequent data collection time points. The intraclass correlation for physical activity in this study is 0.95 and 0.98 for HRV. DISCUSSION: Revisions to the protocol were successfully implemented at the onset of the COVID-19 pandemic for data collection using social distancing. The protocol was additionally amended in response to an unanticipated problem with ActiGraph battery life using Bluetooth technology. Use of the ActiGraph HRV protocol has led to a reliable and rigorous measurement of physical activity and HRV for patients with ischemic heart disease who report hopelessness in this randomized controlled trial. CONCLUSION: We provide an ActiGraph HRV protocol that can be adapted as a model in the development of ActiGraph HRV protocols for future nursing research in community and home-based settings while maximizing social distancing in the current and future pandemics.

Heart up! RCT protocol to increase physical activity in cardiac patients who report hopelessness: Amended for the COVID-19 pandemic.

Hopelessness is associated with decreased physical activity (PA) and increased adverse events and death in patients with ischemic heart disease (IHD). Rates of PA in patients with IHD continue to be low in both hospital-based cardiac rehabilitation and home settings. While researchers have investigated strategies to increase PA among patients with IHD, interventions to promote PA specifically in IHD patients who report hopelessness are lacking. We describe the protocol for a NIH-funded randomized controlled trial designed to establish the effectiveness of a 6-week intervention (Heart Up!) to promote increased PA in IHD patients who report hopelessness. Participants (n = 225) are randomized to one of three groups: (1) motivational social support (MSS) from a nurse, (2) MSS from a nurse plus significant other support (SOS), or (3) attention control. Aims are to: (1) test the effectiveness of 6 weeks of MSS and MSS with SOS on increasing mean minutes per day of moderate to vigorous PA; (2) determine the effects of change in moderate to vigorous PA on hopelessness; and (3) determine if perceived social support and motivation (exercise self-regulation) mediate the effects of the intervention on PA. A total of 69 participants have been enrolled to date. The protocol has been consistently and accurately used by research personnel. We address the protocol challenges presented by the COVID-19 pandemic and steps taken to maintain fidelity to the intervention. Findings from this study could transform care for IHD patients who report hopelessness by promoting self-management of important PA goals that can contribute to better health outcomes.

Reliability and Validity of the State-Trait Hopelessness Scale in Patients With Heart Disease and Moderate to Severe Hopelessness.

OBJECTIVE: The aim of this study was to evaluate the reliability and validity of the State-Trait Hopelessness Scale (STHS) in patients with heart disease who report moderate to severe state hopelessness. METHODS: Reliability, concurrent validity, and convergent validity were evaluated for 20 patients. RESULTS: Cronbach's α for the State and Trait subscales were .81 and .79, respectively. Strong correlations between the State Hopelessness Subscale and Patient Health Questionnaire-9 (r = 0.77, P < .001), State Hope Scale (r = -0.75, P < .001), EQ-5D-5L (r = 0.59, P < .005), and PROMIS-29 domains of depression (P = .72, P < .001), fatigue (P = .61, P < .001), and social roles (P = .45, P = .047) were found. There were strong correlations between the Trait Hopelessness Subscale and Trait Hope Scale (r = -0.58, P < .005), State Hope Scale (r = -0.49, P = .03), and PROMIS-29 fatigue domain (r = 0.54, P = .015). CONCLUSIONS: Findings support the reliability and validity of the STHS for evaluation of hopelessness in patients with heart disease.

Lack of perceived social support in patients with ischemic heart disease is associated with hopelessness.

OBJECTIVE: To evaluate perceived social support (PSS) in ischemic heart disease (IHD) patients who report hopelessness. METHODS: Using a cross-sectional design, 156 patients were screened during their hospitalization for moderate to severe state hopelessness. Twenty patients who reported hopelessness during hospitalization and maintained hopelessness one week after hospital discharge were included. RESULTS: A moderately strong negative correlation was identified between PSS and state hopelessness (r = -0.54, p = .014). PSS was significantly higher in married/partnered patients (26.7 ± 4.85) compared to unmarried/unpartnered patients (18 ± 9.18; t = 2.45, p = .035). CONCLUSIONS: Social support may help reduce hopelessness in vulnerable cardiac patients, especially those who are unpartnered.

Ethnic minority members may be at risk for state hopelessness following hospitalization for ischemic heart disease.

OBJECTIVE: To examine differences in state and trait hopelessness between ethnic minority and White patients hospitalized with ischemic heart disease (IHD). METHODS: A descriptive cross-sectional design was used to enroll 517 patients at one Midwestern U.S. hospital. The State-Trait Hopelessness Scale measured hopelessness. RESULTS: State hopelessness was higher in ethnic minority patients compared to Whites. Ethnic minority patients who had never been married had higher state hopelessness than those who were married or separated/divorced. There were no differences in trait hopelessness. CONCLUSIONS: Ethnic minority patients with IHD, who have never been married, may be at higher risk for state hopelessness.

Dog Ownership and Dog Walking: The Relationship With Exercise, Depression, and Hopelessness in Patients With Ischemic Heart Disease.

BACKGROUND: Dog ownership has been associated with increased physical activity in the general adult population. OBJECTIVE: The objective of this study was to examine dog ownership and dog walking and their relationship with home-based and phase II cardiac rehabilitation exercise, depression, and hopelessness in patients with ischemic heart disease. METHODS: A total of 122 patients with ischemic heart disease were included in this prospective observational study. Patients completed dog ownership/walking questions during their hospitalization. The Cardiac Rehabilitation Exercise Participation Tool, Patient Health Questionnaire-9, and State-Trait Hopelessness Scale were completed by mail at 3, 8, or 12 months later. Regression modeling was used to evaluate the significance of dog ownership/walking on exercise, depression and hopelessness. RESULTS: The sample was 34.4% female and had a mean age of 64.7 ± 9.1 years. Forty-two patients (34.4%) reported owning a dog. Patients who owned but did not walk their dog reported significantly lower levels of home exercise compared with patients who walked their dogs at least 1 day per week (36.8% for non-dog walkers vs 73.9% for dog walkers, P = .019). The odds of participating in home exercise were significantly higher for dog walkers compared with non-dog walkers (odds ratio, 8.1 [1.7, 38.5] vs 1.0). There were no differences in phase II cardiac rehabilitation exercise, depression, or hopelessness between dog owners and non-dog owners or between dog walkers and non-dog walkers. CONCLUSIONS: These findings show a beneficial effect on home-based exercise for those who dog-walk at least 1 day per week. Healthcare professionals should encourage dog walking to increase dog owners' physical activity levels.

Carbon Monoxide Poisoning from Portable Electrical Generators.

BACKGROUND: Portable electrical generators have been responsible for over 800 accidental carbon monoxide (CO) poisoning deaths in the United States from 1999-2012. OBJECTIVES: Because mortality figures are typically the only data reported with regard to the adverse effects of generators, we describe a nonfatal segment of the poisoned population to further emphasize the significance of the problem. METHODS: Unidentifiable information about patients treated in the United States with hyperbaric oxygen for acute CO poisoning was prospectively reported by participating centers. Those patients poisoned by portable generators were selected for analysis. RESULTS: Of 1604 patients reported from August 1, 2008 to July 31, 2011, there were 264 accidentally poisoned by portable generators. Exposures occurred in 151 incidents in 33 states. In 99 incidents, poisoning occurred in a residence. Average patient age was 37 ± 20 years (range 1 to 90+ years). Of those poisoned, 146 (55%) were non-Hispanic white, 57 (22%) were black, 52 (20%) were Hispanic white, 4 (2%) were Asian, and 4 (2%) were Native American. English was spoken by 96%. The most common symptoms included headache (62%), dizziness (52%), and loss of consciousness (50%). Blood carboxyhemoglobin levels averaged 22.7 ± 9.0% (range 2.3-48.3%). Thirty-six patients demonstrated evidence of cardiac ischemia. CONCLUSIONS: Acute, severe CO poisoning from portable electric generators is common in the United States, likely affecting an estimated 4000 individuals annually, occurring predominantly in residential settings, and affecting English language-speaking individuals.

Relationships Among Heart Rate Variability, Perceived Social Support, and Hopelessness in Adults With Ischemic Heart Disease.

BACKGROUND: Lower perceived social support is associated with hopelessness in patients with ischemic heart disease (IHD). Higher perceived social support is associated with higher heart rate variability (HRV) in adults following a stressful event, but the relationship between HRV and hopelessness has not been examined in patients with IHD. The purpose of this research was to evaluate the relationships among HRV, perceived social support, and hopelessness in patients with IHD. METHODS AND RESULTS: Ninety-four participants were enrolled while hospitalized for an IHD event at a large hospital in the United States. Data collection occurred 2 weeks after hospital discharge and included the State-Trait Hopelessness Scale, ENRICHD Social Support Inventory, Patient Health Questionnaire-9, a demographic form, and a short-term HRV measurement taken at rest. Linear models were used to assess associations between variables in unadjusted and adjusted models. Most participants were men (67%), married (75%), and non-Hispanic White (96%) and underwent coronary artery bypass surgery (57%). There were inverse correlations between high frequency HRV and state hopelessness (r=-0.21, P=0.008) and root mean square of successive differences between normal heartbeats HRV and state hopelessness (r=-0.20, P=0.012) after adjusting for important covariates. High frequency and root mean square of successive differences between normal heartbeats did not show evidence of mediating the relationship between perceived social support and hopelessness. CONCLUSIONS: There were significant inverse correlations between parasympathetic measures of HRV and hopelessness. Assessing high frequency and root mean square of successive differences between normal heartbeats during early recovery following an IHD event could provide promising evidence for understanding a possible precursor to hopelessness and targets for future interventions. Registration Information: clinicaltrials.gov. Identifiers: NCT03907891, NCT05003791.

Comorbidities are associated with state hopelessness in adults with ischemic heart disease.

BACKGROUND: In adults with ischemic heart disease (IHD), comorbidities and hopelessness are independently associated with increased risk of mortality. OBJECTIVES: To determine if comorbidities were associated with state and trait hopelessness and explore the influence of specific conditions and hopelessness in individuals hospitalized for IHD. METHODS: Participants completed the State-Trait Hopelessness Scale. Charlson Comorbidity Index (CCI) scores were generated from the medical record. A chi-squared test was used to examine differences in 14 diagnoses included in the CCI by CCI severity. Unadjusted and adjusted linear models were used to explore the relationship between hopelessness levels and the CCI. RESULTS: Participants (n=132) were predominantly male (68.9%), with a mean age of 62.6 years, and majority white (97%). The mean CCI was 3.5 (range 0-14), with 36.4% having a score of 1-2 (mild), 41.2% with a score of 3-4 (moderate) and 22.7% with a score of ≥5 (severe). The CCI was positively associated with both state (ß=0.03; 95% CI 0.01, 0.05; p=0.002) and trait (ß=0.04; 95% CI 0.01, 0.06; p=0.007) hopelessness in unadjusted models. The relationship for state hopelessness remained significant after adjusting for multiple demographic characteristics (ß=0.03; 95% CI 0.01, 0.05; p=0.02), while trait hopelessness did not. Interaction terms were evaluated, and findings did not differ by age, sex, education level, or diagnosis/type of intervention. CONCLUSION: Hospitalized individuals with IHD with a higher number of comorbidities may benefit from targeted assessment and brief cognitive intervention to identify and ameliorate state hopelessness which has been associated with worse long-term outcomes.

Symptoms of carbon monoxide poisoning do not correlate with the initial carboxyhemoglobin level.

BACKGROUND: Symptoms in carbon monoxide (CO) poisoned patients have traditionally been described as being related to corresponding carboxyhemoglobin (COHb) levels without substantive support for the relationship. This study sought to determine whether prospectively collected symptoms correlate with specific COHB level ranges in a large population of CO-poisoned patients. METHODS: Data from patients reported in the initial two years of operation of the joint UHMS/CDC CO Poisoning Surveillance System were used to compare presenting COHb levels with symptoms collected with a standardized questionnaire. RESULTS: Data from 1,323 CO-poisoned patients referred for hyperbaric oxygen therapy from August 2008 to July 2010 were analyzed with regard to initial COHb level and symptoms. Of approximately 50 categories of symptoms reported, none was associated with a specific range of COHb levels. CONCLUSIONS: While symptoms are common in acute CO poisoning, none can be directly correlated to COHb levels, even in a population of more than 1,000 patients. The concept of a table relating specific symptoms to specific COHb levels is invalid. One such table that has often been published comes from a 1923 U.S. government publication and appears to be based at least in part upon the symptoms experienced by three men in a total of 10 low-level laboratory CO exposures.

Partnering with a medical specialty society to perform online public health surveillance.

While accidental carbon monoxide (CO) poisoning is common, it is felt to be largely preventable through targeted public education. Development of effective education programs requires accurate epidemiologic information about the condition. Many acute, severe cases of CO poisoning are treated with hyperbaric oxygen (HBO2) at hospital-based facilities staffed by members of the Undersea and Hyperbaric Medical Society (UHMS). In 2008, the Centers for Disease Control and Prevention (CDC) began sponsoring a UHMS proposal to use online reporting by UHMS members of cases treated with HBO2. This report describes development and implementation of the internet-based surveillance system, as well as its first year of operation. From August 2008 to July 2009, a total of 740 cases were reported by the 82 hyperbaric facilities participating nationwide. Extensive epidemiologic information about CO poisoning in the United States has been collected, and the utility of partnering with a medical specialty society for disease-specific surveillance demonstrated.

Perceived Social Support and Heart Rate Variability: An Integrative Review.

The purpose of this integrative review is to explore and synthesize literature about the relationship between perceived social support and cardiac vagal modulation, measured by heart rate variability (HRV), during phases of an acute stress response to assess this potential relationship underlying the stress-buffering effects of perceived social support. A systematic search of seven databases was conducted, including MEDLINE, CINAHL, PsychINFO, Embase, ProQuest, medRxiv, and clinicaltrials.gov. Eight studies met the inclusion criteria and were systematically synthesized. A quality appraisal was completed for each included study. Majority of studies focused on time and frequency domain measures of HRV thought to reflect parasympathetic modulation of heart rate and identified them as positively associated with perceived social support during rest, stress induction, and recovery from an acute stressor. Results highlight the importance for nurses and other health care professionals to assess patients' perceived social support, as increased perceived social support may contribute to an adaptive stress response.

Investigating Rurality as a Risk Factor for State and Trait Hopelessness in Hospitalized Patients With Ischemic Heart Disease.

Background Rurality and hopelessness are each associated with increased mortality in adults with ischemic heart disease (IHD), yet there is no known research examining rurality as a risk factor for hopelessness in patients with IHD. This study evaluated rurality as a risk factor for state and trait hopelessness in adults hospitalized with IHD in samples drawn from the Great Lakes and Great Plains regions of the United States. Methods and Results A descriptive cross-sectional design was used. Data were collected from 628 patients hospitalized for IHD in the Great Lakes (n=516) and Great Plains (n=112). Rural-Urban Commuting Area codes were used to stratify study participants by level of rurality. Levels of state hopelessness (measured by the State-Trait Hopelessness Scale) were higher in rural patients (58.8% versus 48.8%; odds ratio [OR], 1.50; 95% CI, 1.03-2.18), a difference that remained statistically significant after adjusting for demographics, depression severity (measured by the Patient Health Questionnaire-8), and physical functioning (measured by the Duke Activity Status Index; OR, 1.59; 95% CI, 1.06-2.40; P=0.026). There was evidence of an interaction between marital status and rurality on state hopelessness after accounting for covariates (P=0.02). Nonmarried individuals had an increased prevalence of state hopelessness (nonmarried 72.0% versus married 52.0%) in rural areas (P=0.03). Conclusions Rural patients with IHD, particularly those who are nonmarried, may be at higher risk for state hopelessness compared with patients with IHD living in urban settings. Understanding rurality differences is important in identifying subgroups most at risk for hopelessness. Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT04498975.

Does outpatient telephone coaching add to hospital quality improvement following hospitalization for acute coronary syndrome?

BACKGROUND: Telephone counseling in chronic disease self-management is increasing, but has not been tested in studies that control for quality of medical care. OBJECTIVE: To test the effectiveness of a six-session outpatient telephone-based counseling intervention to improve secondary prevention (behaviors, medication) in patients with acute coronary syndrome (ACS) following discharge from hospital, and impact on physical functioning and quality of life at 8 months post-discharge. DESIGN: Patient-level randomized trial of hospital quality improvement (QI-only) versus quality improvement plus brief telephone coaching in three months post-hospitalization (QI-plus). DATA: medical record, state vital records, patient surveys (baseline, three and eight months post-hospitalization). ANALYSIS: pooled-time series generalized estimating equations to analyze repeated measures; intention-to-treat analysis. PARTICIPANTS: Seven hundred and nineteen patients admitted to one of five hospitals in two contiguous mid-Michigan communities enrolled; 525 completed baseline surveys. MEASUREMENTS: We measured secondary prevention behaviors, physical functioning, and quality of life. RESULTS: QI-plus patients showed higher self-reported physical activity (OR = 1.53; p = .01) during the first three months, with decline after active intervention was withdrawn. Smoking cessation and medication use were not different at 3 or 8 months; functional status and quality of life were not different at 8 months. CONCLUSIONS: Telephone coaching post-hospitalization for ACS was modestly effective in accomplishing short-term, but not long-term life-style behavior change. Previous positive results shown in primary care did not transfer to free-standing telephone counseling as an adjunct to care following hospitalization.