Who this is for
Adults 18+ with elevated cardiovascular risk who do NOT have an active acute coronary syndrome (unstable angina, active MI, decompensated heart failure). Those members are stabilized clinically before joining. AHA risk stratification (low / moderate / high) tunes touchpoint intensity, not eligibility.
What brings people here
Biometric screening with elevated inflammatory markers (hs-CRP), abnormal lipid panel, or BP >=130/80; self-reported family history of premature CVD; member request following a primary care recommendation; or Functional Medicine Assessment Cardiometabolic domain in elevated range.
Clinical framework
American Heart Association - Center for Health Technology & Innovation.
How the 24 weeks run
Baseline assessments, your first SMART goal, and the 1:1 that sets up everything after it.
Specialist coaches rotate in, and sessions come thickest here. One change at a time, in the domains your baseline flagged.
Re-score, refresh the care plan, and check in 1:1 on what is and is not working.
The remaining domains, at a lighter cadence, and the work of making the early weeks hold under pressure.
Final re-score, relapse prevention, and the plan for what happens next.
When your sessions fall
The program is built in four-week modules. Sessions come thickest at the start, when what you decide matters most, and step down as things settle. That is 16 sessions of 45 minutes across 24 weeks, counting the visit before week 1.
That is the schedule this pathway is being built to. The sessions you can book today are the ones in the written weeks listed below.
| Module | Weeks | Sessions | Cadence |
|---|---|---|---|
| Module 1 | Weeks 1 to 4 | 3 | weekly to every 10 days |
| Module 2 | Weeks 5 to 8 | 3 | weekly to every 10 days |
| Module 3 | Weeks 9 to 12 | 3 | weekly to every 10 days |
| Module 4 | Weeks 13 to 16 | 2 | every other week |
| Module 5 | Weeks 17 to 20 | 2 | every other week |
| Module 6 | Weeks 21 to 24 | 2 | every other week |
Week by week
- Before you beginBefore you begin
Your baseline across the eight cardiovascular health factors, your medication list, and a week of activity as it actually is. Bring your most recent numbers if you have them, and the fact that you do not if you do not.
- Week 1Cardiac rehabilitation
The single best-evidenced intervention available to you, and the one most often skipped. What it is, what the trials show, and how to find out whether you have been referred.
- Week 2Movement, safely
How much, how hard, and what the warning signs are. Your physical therapist builds a progression that accounts for your heart and your medications, because a beta blocker makes target heart rate a poor guide to effort.
- Week 3Eating for a heart
The dietary pattern that changed events rather than only cholesterol numbers, plus sodium and potassium. Where sodium actually comes from, which is mostly not the salt shaker.
- Week 4Mid-program: the eight factors again
Re-score the eight factors from week 0 and compare. Then the question nobody asks directly: are you actually taking every medication, every day, as prescribed?
- Week 5Sleep, and why it was added
Sleep joined the eight factors in 2022 on the evidence. What short sleep does, and the one thing worth escalating: sleep apnea is common after a cardiac event and treating it changes the other seven factors.
- Week 6Stress, mood and the heart
What the evidence supports and what is overstated. Depression after a cardiac event is common and associated with worse outcomes, and it is treatable.
- Week 7Your numbers and your medications
The list to take to your next appointment: your personal blood pressure target, your LDL target, kidney function, and anything you have quietly stopped taking.
- Week 8Making it hold
Score the eight factors one last time and put all three points side by side. Then the plan for week 9: who you contact, at what point, and what your maintenance week actually looks like.
Who you will work with
Your Whole Health Coach takes your first visit and closes every module, so it is the same person from the first session to the last. The specialists below lead the weeks where their work is the focus.
Professionally, Cindy has been a clinical nurse for nearly a decade. She served in both clinical and administrative capacities throughout her career and holds a Master's degree in Nursing Leadership. As a staff nurse, nurse leader, and quality improvement specialist, she led multidisciplinary teams in academic medical settings throughout Boston, New York, and Ohio to deliver high-quality care to patients across complex diagnoses.
Tonia is a Doctor of Physical Therapy, Integrative Nutrition Health Coach, and Certified McKenzie Spine Specialist with over 25 years of experience helping clients heal from pain, injury, and chronic conditions. She specializes in spine care, orthopedic rehabilitation, and restoring strength and vitality through personalized, science-based treatment.
Meet Lucy Paulise, who is a career and stress management coach, book writer, and Forbes contributor. Her passion lies in helping people discover and reach their full potential. She specializes in coaching individuals on how to manage stress, anxiety, imposter syndrome, perfectionism, or any other challenges they may face in their work or personal lives that can lead to feeling overwhelmed.
What we work on
| Domain | What this pathway does |
|---|---|
| Nutrition & Metabolism | DASH or Mediterranean pattern. Saturated fat <7% of calories, sodium <2g/day, soluble fiber 10-25g, alcohol <1 drink/day women, <2 men. Plant-forward where possible. |
| Movement & Mobility | 150 min/wk moderate aerobic + 2x/wk resistance training. Zone-2 cardio prioritized. Cap intensity until stress-test cleared if high-risk. |
| Sleep & Recovery | 7-9 hr/night, consistent wake time. STOP-BANG >=5 + ESS >=10 triggers same-day RN Navigator referral for polysomnography. |
| Stress & Resilience | PSS-10 down >=4 pts. Daily relaxation practice (breathwork, walks, journaling) 4+ days/week. |
| Mind & Mood | PHQ-9 baseline; q4 weeks. Depression doubles cardiac mortality risk - never optional in this pathway. |
| Preventive care | Annual physical, lipid panel, A1c, BP record. CT calcium scoring if intermediate risk. |
How progress is measured
These are the validated tools this pathway uses: at your first visit, at the mid-program review, and at the end.
| Tool | Cadence | Owned by |
|---|---|---|
| AHA Life's Essential 8 | Baseline, Wk 12-13, quarterly | WHC |
| Home BP series (7-day avg) | Daily in Build phase; biweekly maintenance | WHC + member |
| Lipid panel | Baseline, Wk 12-13, quarterly | RN Nav coordinates |
| STOP-BANG + ESS | Onboard; PRN | Sleep Coach |
| PHQ-9 + GAD-7 | Onboard, q4 weeks | WHC; LCSW reads |
| Med-Diet Adherence Screener | Onboard, q4 weeks | Nutrition Coach |
| PAR-Q+ | Before any exercise prescription | Exercise Coach |
The research behind this pathway
Your clinician playbook was built from the guidelines and studies below. They are listed so you can read them yourself: every one is a real, published paper and the number at the end of each line is its PubMed ID.
Guidelines this pathway follows
- Life's Essential 8 · American Heart Association
The eight measures of cardiovascular health scored at baseline, mid-program and exit. PMID 35766027
- 2025 AHA/ACC High Blood Pressure Guideline · American Heart Association and American College of Cardiology
Blood pressure targets and the home-monitoring routine. PMID 40811516
- Depression as a risk factor after acute coronary syndrome · American Heart Association
Why mood screening is a standing part of a cardiac pathway rather than an add-on. PMID 24566200
Key studies
- Lloyd-Jones DM et al. (2022). CirculationLife's Essential 8: Updating and Enhancing the American Heart Association's Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association
Defines Life's Essential 8, the eight measures of cardiovascular health this pathway scores you on at baseline, mid-program and exit. PMID 35766027
- Estruch R et al. (2018). N Engl J MedPrimary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts
7,447 people at high cardiovascular risk, randomized to a Mediterranean diet or a low-fat control. The Mediterranean groups had about 30 percent fewer major cardiovascular events. PMID 29897866
- Dibben G et al. (2021). Cochrane Database Syst RevExercise-based cardiac rehabilitation for coronary heart disease
Cochrane's review of exercise-based cardiac rehabilitation. It cut heart attacks, produced a large reduction in all-cause hospital admission, and improved quality of life out to 12 months. PMID 34741536
- Lichtman JH et al. (2014). CirculationDepression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association
The American Heart Association's statement that depression after a heart event predicts worse outcomes. It is why mood screening is not optional on this pathway. PMID 24566200
- SPRINT Research Group (2015). N Engl J MedA Randomized Trial of Intensive versus Standard Blood-Pressure Control
9,361 people randomized to a systolic target under 120 rather than under 140. The tighter target cut cardiovascular events and deaths. PMID 26551272
- Cholesterol Treatment Trialists' Collaboration (2010). LancetEfficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials
170,000 people across 26 trials. Every further 1 mmol/L drop in LDL cholesterol cut major vascular events by about a fifth, with no threshold below which it stopped helping. PMID 21067804
Why this pathway runs 24 weeks
Your playbook names both halves: sixteen structured weeks and an eight-week step-down. Twenty-four weeks is exactly that, and it puts sixteen coach contacts in the six-month window the dose trials measure.
Your clinician playbook says: 16 weeks structured + 8-week step-down to maintenance.
Length and cadence are set from the evidence on how much coaching contact actually changes anything. Below roughly one session a month, programs stop reliably beating no program at all; above about sixteen to twenty-four sessions in the first six months, more sessions stop adding. That is why sessions here are front-loaded and then step down, rather than spread evenly.
- Bauman V et al. (2019). BMJ Open Diabetes Res CareEffect of dose of behavioral weight loss treatment on glycemic control in adults with prediabetes
Randomized 287 adults with obesity and prediabetes to 8, 16 or 24 coaching sessions over six months. More sessions meant more weight lost, and the curve flattened between 16 and 24. PMID 31245006
- Perri MG et al. (2014). Obesity (Silver Spring)Comparative effectiveness of three doses of weight-loss counseling: two-year findings from the rural LITE trial
Randomized 612 adults to 16, 32 or 48 sessions over two years. The 16-session arm was barely better than education alone; 32 and 48 were the same as each other. PMID 25376396
- Ely EK et al. (2017). Diabetes CareA National Effort to Prevent Type 2 Diabetes: Participant-Level Evaluation of CDC's National Diabetes Prevention Program
Followed 14,747 people through the CDC's National Diabetes Prevention Program. Every additional session attended was worth another 0.3 percent of body weight. PMID 28500215
- Wadden TA et al. (2020). Am PsycholLifestyle modification approaches for the treatment of obesity in adults
The review behind the obesity guideline standard: six months of 14 or more counseling sessions for an active phase, then at least monthly for the year that follows. PMID 32052997
- Cannon MJ et al. (2020). Diabetes CareRetention Among Participants in the National Diabetes Prevention Program Lifestyle Change Program, 2012-2017
Tracked 41,203 people through a year-long program. People dropped out fastest at exactly the point where sessions went from weekly to monthly, which is why our step-downs land on a module boundary and get their own check-in. PMID 32616617
- Hartmann-Boyce J et al. (2021). BMJAssociation between characteristics of behavioural weight loss programmes and weight change after programme end: systematic review and meta-analysis
Pooled 249 trials and 59,081 people. Weight comes back after a program ends, but the gap against people who never did one was still there five years later. PMID 34404631
- Wadden TA et al. (2019). Obesity (Silver Spring)A Protocol to Deliver Intensive Behavioral Therapy (IBT) for Obesity in Primary Care Settings: The MODEL-IBT Program
The protocol that turned the 14-session standard into a real schedule: 14 visits in the first 24 weeks, then monthly. It is the front-load-then-step-down shape this pathway uses. PMID 31544345