Our research examined the associations between longitudinal changes in cardiovascular risk factors and satisfaction with life among cardiovascular disease patients, 5 years after coronary angiography. With regard to our major findings, first, a lower LS was observed when obesity or physical inactivity was already apparent or became so in 2013/14. Second, the same trend was not seen in patients with diabetes that was recorded in 2008/9, but only when it appeared in 2013/14. Third, the decrease in LS was lower when obesity and physical inactivity disappeared in 2013–2014. We will develop these findings point by point.
One of our most interesting findings was that the lowest LS was more likely when failure to exercise was declared in 2013/14. Although our results did not investigate gender differences, we propose to underline the conclusions of a study  which examined the change in physical activity-mediated gender-related satisfaction with life over a 2-year period. It showed that higher physical activity levels impact on satisfaction with life positively, but observed that males were engaged in more physical activity than were females. A systematic review of the impact of lifestyle interventions in the secondary prevention of coronary heart disease follow-up of 3 months  confirmed that the overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes. Hypotheses could be proposed to better understand the link between non adhesion to physical activity and satisfaction with life. Some of the patients probably had little motivation to adopt healthy behaviours or were not able to change , when they declared their inactivity 5 years after their event; they perceived their satisfaction with life negatively. In another study , data sets predicting behaviours in the health domain (smoking, applying universal precautions, exercising) were examined. Patients whose intentions were more aligned with the norms of the society were more likely to report healthy behaviours than were participants whose intentions differed . Other suggestions that concerned reducing TV or computer time as well as targeting other healthy behaviours (eg. increasing physical activity levels, improving dietary intake) might prove useful . In contrast, the more patients waste time by not becoming active, the more cardiovascular risk factors appear. In a Luxembourgish study , higher weekday sitting time was related to poorer cardiovascular health; time spent watching television was inversely associated with this score on both workdays and days off. Physical activity has been associated with improved physical fitness, social functioning, self-esteem, body image, mood, stress response; and a decreased risk of heart disease, and diabetes . A longitudinal study of older people demonstrated that more time watching television was associated with incident central obesity after adjustment for covariables including physical activity, but not with total obesity when measured by BMI .
A second finding showed the same low trend on life satisfaction as previously when the risk of obesity was present in 2008/9 and in 2013/14, and when obesity appeared in 2013/14. In light of the previous hypothesis, and such proposals as those by Sheeran , we would suggest that during the 5 years after coronary angiography, these patients probably had most difficulty adapting their lifestyle and their life satisfaction had been perceived negatively because their intentions were questionable concerning medical advice and secondary prevention. Some authors  tried to account for the gap between knowledge of risk factors and change in unhealthy behaviour. Their conclusions indicated that intention is a moderate predictor of behaviour and that the gap between intention and behaviour is caused by high intenders not taking action. It is also necessary to recall that with long-term cardiovascular disabilities, social and familial repercussions on daily life, restrictions in routine, leisure and work activities, and socioeconomic impact, a proportion of patients go through a phase of depression and anxiety .
Another finding concerned longitudinal modifications in diabetes. The relationship with life satisfaction was deleterious, whereas lifestyle was more beneficial when obesity and physical inactivity disappeared in 2013/14. Patients who adjusted their lifestyles during the 5 years following a coronary angiography, are, we suppose, probably motivated, but are likely to have changed their behaviour against their will. They perceived adopting healthy behaviours as unpleasant, which may impact negatively on their life satisfaction. Effectively, patients who follow the strict regime prescribed and hence go from diabetes in 2008/9, to at least less severe diabetes in 2013/14, experienced a difficult period during which they maintained unpleasant lifestyle behaviours. In addition, eating carbohydrate-rich food is part of a ‘good life’ , but also a form of dependency. To abandon that and to limit ones diet and adopt physical activity could be devastating. Adherence to therapeutic advice and adjustment in lifestyle, including healthy eating and reducing the sugar intake in the diet, can reduce cardiovascular risk factors, and modify the satisfaction with life. For example, patients who must adopt a behaviour that is perceived as unpleasant, such as a diabetic regime, are affected emotionally because the gap between what they currently do and what they must do is likely to precipitate psychological difficulties. A better comprehension of the cognitive aspects of cardiovascular disease in relation to the affective aspects [33, 34] makes clear that what happens in the mind has to be taken into account if we want to understand how adapted lifestyles are adopted and how the ability to adhere to medication can be developed. Knowledge of the emotional impact of adherence may be useful for policy interventions aimed at improving the health and daily life of patients. Non-adherence is complex and remains difficult to define. In addition, the ability of providers to accurately identify at-risk patients is limited. Improved screening tools are needed to detect them and thereby facilitate appropriate targeting of interventions. Given the rapidly expanding global population with coronary heart disease and emerging clinical and cost-benefits of adherence, addressing non-adherence to prescribed therapies is a top priority .
Lastly, two other findings are worthy of a brief mention; the facts that being a woman and/or having a low income affect satisfaction with life. Firstly, in accord with this finding, in the presence of coronary artery disease, female-patients with co-morbidities such as diabetes, hypertension and obesity, presented greater impairment of their wellbeing. The unfavorable outcomes months after percutaneous coronary intervention were associated with female sex, a previous event, or procedure failure . Another example, the rates of obesity and overweight vary according to educational level and socioeconomic status, and these disparities are significant among women, but less clear among men . Secondly, the lower the income of study patients, the lower the life satisfaction. Lack of income would be greater already due to facing lifestyle disadvantages, and the consequences of CVD-related behaviours would be greater when they are confronted with new socioeconomic disadvantages like wages for domestic helpers. A study over time found that life satisfaction is lower when all the years of poverty are together rather than split up into periods in and out of poverty. This ties in with the idea that individuals may have the resources (financial or otherwise) to deal with relatively short-term poverty but not when it lasts too long .
Furthermore, our results showed that hypertension and hypercholesterolemia were not discriminant factors of the life satisfaction between patients with or without these risk factors. In other words, the link between the constraints related to treatments and to lifestyle changes of these risk factors, and the life satisfaction would be less strong than those associated to diabetes or obesity. Regarding the lack of a link between the evolution of tobacco consumption and LS, we can conclude that stopping smoking in a situation of medical stress can be experienced with difficulty.
Strengths and limitations
The strength of the survey
resides in the population sample; the small size of the country made it possible to organize data collection at a national level. Our participation rate of 35.5% is similar to that of two previous studies (32.2% vs. 28%) in Luxembourg [28, 38]. Such study protocols are rare because they are very expensive and difficult to organise. Some patients died, moved to institutions, changed their residential arrangements (for example to live with a son or daughter), or failed to respond.
Some limitations might be indicated
Based on monitoring data from a cohort of patients five years after coronary angiography, a potential risk exists due to the current composition of the respondents of the follow-up group compared to the non-respondents regarding certain individual characteristics, except age, and certain cardiovascular risk factors: diabetes, hypertension, BMI, tobacco consumption and physical inactivity. Such limitations are inherent to most follow-up studies, particularly with cohorts of patients (mean age 64 years). Another limitation is the fact that life satisfaction was not measured at baseline at the time of examination of coronary angiography. It was not possible to measure satisfaction with life change during the study interval as well as the evolution of changes in cardiovascular risk factors. As a result, the relationship between life satisfaction and the evolution of risk factors cannot be interpreted as causality. [The follow-up surveys have not considered at the beginning of the design of the study to collect information concerning the presence of other pathologies, comorbidity, clinical and mental health variables (such as depression, anxiety and psychological distress), which could explain, at least to some extent, the differences obtained, for example in comorbid depression . Therefore for further research, a control could be required of the consequence of the emotional state of CVD patients to be careful about the interpretation of the links between each cardiovascular risk factor and the satisfaction with life.
Practical and clinical implications
A hypothesis can be suggested to explain the minimal positive relationship with life satisfaction observed in 2013/14 when obesity and physical inactivity disappeared. Attempts to understand behaviour among patients who took part in a secondary preventive program and medical follow-up should explore further the importance of internalized norms and self-expectations in the development of motivation and the ability to adopt a given behaviour .
Intensive diet and physical activity interventions have been found to reduce CVD risk, but are resource intensive. The American Heart Association recently recommended motivational interviewing (MI) as an effective low-intensity intervention to promote health-related outcomes such as weight loss. In a UK primary-care setting, low-intensity MI counselling was effective in bringing about long-term changes in some, but not all, health-related outcomes (walking, cholesterol levels) associated with CVD risk. Intervention was particularly effective for patients with elevated levels of CVD risk factors at baseline .
Taken together, other aspects probably intervened in longitudinal modifications in diabetes, obesity and/or physical activity, and associations with patient LS. A previous study  looked at the impact of the patient’s communication with the medical practitioner on adherence to preventive behaviours. It showed that good doctor-patient communication was related to nutrition, particularly increased consumption of fresh fruits and vegetables. Accurate perception of CVRF by both patient and medical practitioner is essential for CV protection. The aim of instructing patients is to encourage them to make informed decisions about how to change their lifestyle.
Cardiovascular secondary prevention with nurse-based telephone follow-up was more effective than usual care in improving low-density lipoprotein cholesterol levels 12 months after discharge for patients with diabetes mellitus or chronic kidney disease . In the same time, to improve anxiety outcomes of patients following myocardial infarction, a telephone service can help patients and their family caregivers to adapt. Delivered by trained health and social professionals and comprising up to 10 telephone-delivered ‘health coaching’ sessions (ProActive Heart)  and combined with psychologically-specific treatment, this programme could impact on anxiety of greater intensity in a clinically meaningful way. Furthermore, therapeutic coaching provides reassurance about secondary treatment effects, improves adherence to prescriptions, and provides information about medical-social services . In addition, for some patients, internet mobile application can help increase healthy behaviour in nutrition, such as vegetable consumption .