• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

Meta-Analysis: Secondary Prevention Programs for Patients With Coronary Artery Disease

Posted on: Friday, 11 November 2005, 03:02 CST

By Clark, Alexander M; Hartling, Lisa; Vandermeer, Ben; McAlister, Finlay A

Background: Although supervised exercise programs reduce mortality in survivors of myocardial infarction, the effects of other types of cardiac secondary prevention programs are unknown.

Purpose: To determine the effectiveness of secondary cardiac prevention programs with and without exercise components.

Data Sources: The authors searched MEDLINE (1966-2004), the Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, SIGLE, and the Cochrane Effective Practice and Organization of Care Study Registry. They also contacted primary study authors and hand- searched bibliographies provided by the Centers for Medicare & Medicaid Services.

Study Selection: Randomized clinical trials.

Data Extraction: Two reviewers chose studies and extracted data independently; random-effects summary risk ratios were calculated.

Data Synthesis: The authors identified 63 randomized trials (21 295 patients with coronary disease). The summary risk ratio was 0.85 (95% CI, 0.77 to 0.94) for all-cause mortality, but this result differed over time with a risk ratio of 0.97 (CI, 0.82 to 1.14) at 12 months and 0.53 (CI, 0.35 to 0.81) at 24 months. The summary risk ratio was 0.83 (CI, 0.74 to 0.94) for recurrent myocardial infarction over a median follow-up of 12 months. Effects were similar for programs that included risk factor education or counseling with a structured exercise component (risk ratio, 0.88 [CI, 0.74 to 1.04] for mortality and 0.62 [CI, 0.44 to 0.87] for myocardial infarction), for programs that included risk factor education or counseling without an exercise component (risk ratio, 0.87 [CI, 0.76 to 0.99] for mortality and 0.86 [CI, 0.72 to 1.03] for myocardial infarction), and for programs that were solely exercisebased (risk ratio, 0.72 [CI, 0.54 to 0.95] for mortality and 0.76 [CI, 0.57 to 1.01] for myocardial infarction). Most of these programs improved quality of life or functional status, but effect sizes were small.

Limitations: Although these programs may reduce total health care costs, published data on the costs of the programs are inadequate to conclusively comment on their cost-effectiveness.

Conclusions: A wide variety of secondary prevention programs improve health outcomes in patients with coronary disease.

Ann Intern Med. 2005;143:659-672. www.annals.org

Cardiovascular disease remains the most common cause of office visits, hospitalizations, and death in the United States: More than 13 million Americans have documented coronary artery disease (CAD), and costs for CAD are expected to exceed $393 billion in 2005 (1). Control of the CAD epidemic requires a multifaceted strategy targeting the currently recognized modifiable risk factors for CAD that account for more than 90% of risk, regardless of sex, age, or region (2). This strategy should include primary prevention maneuvers (for the general population and high-risk individuals) and secondary prevention programs (for patients with established CAD). Despite the abundant evidence base for CAD prevention (3), health outcomes studies consistently demonstrate gaps in applying this evidence to clinical practice; these gaps contribute to suboptimal patient outcomes (4).

Secondary prevention programs are often proposed as a way to improve management and outcomes. Although several reviews have shown that cardiac rehabilitation reduces mortality in survivors of myocardial infarction (MI) (5-8), these conclusions are informed largely by trials that tested supervised exercise programs versus no exercise postinfarction. Since exercise training confers substantial physiologic and clinical benefits and activity levels are inversely proportional to cardiovascular mortality (9), it is not surprising that trials of exercise programs found positive effects on survival.

However, few trials included in these reviews evaluated secondary prevention programs that were not primarily exercise-based. In an earlier review (10), we identified 12 randomized trials (9803 patients) of non-exercise-based secondary prevention programs in patients with established CAD. We demonstrated improvements in risk factor profiles and processes of care (particularly the prescription of proven efficacious therapies) but indeterminate effect on rates of death or recurrent MIs (10).

Because current guidelines recommend that secondary prevention programs should not be restricted to supervised exercise programs but should address the full range of modifiable risk factors (11), we conducted a systematic review to update earlier work and to determine the effects of different types of secondary prevention programs (particularly those with a structured exercise component versus those without).

METHODS

Data Sources

We searched MEDLINE (1966-2004); the Cochrane Central Register of Controlled Trials, Issue 4, 2004; EMBASE (1980-2004); CINAHL (1982- 2004); SIGLE (1980-2004); and PubMed (January 2004-December 2004). We also conducted a cited reference search for our previous review (10) in Web of Science (1999-2004). We based the searches on the following terms: case management, comprehensive health care, disease management, health services research, home can services, clinical protocols, patient care planning, quality of health care, rehabilitation, nurse led clinics, special clinics, and myocardial ischemia. We handsearched reference lists of all identified studies, review articles, and references provided by the Centers for Medicare & Medicaid Services and content experts (search strategy available upon request). We limited our search to Englishlanguage publications (no abstracts), and the search extends from 1966 to 2004 (we completed the search on 16 December 2004).

Study Selection

Two investigators independendy reviewed the titles and abstracts of all citations to identify studies reporting die effect of secondary prevention programs on mortality, MI, or hospitalization rates in patients with CAD. Both investigators obtained the full text of potentially relevant articles and reviewed them by using prestandardized data abstraction forms and eligibility criteria defined a priori. Any discrepancies were resolved by consensus.

We excluded studies if they were not randomized, if they did not include a "usual care" group, if the outcomes for CAD patients were not reported or were not obtainable from the study investigators, if they evaluated single-modality interventions except exercise (such as telephone follow-up), if they tested interventions delivered to inpatients, or if the interventions were not provided by health professionals (for example, mailed reminders, self-help groups, or self-directed interventions).

Data Extraction and Quality Assessment

Two investigators extracted all outcome data independendy, and a third investigator checked the data. We assigned outcomes according to the intention-to-treat principle and by using the definitions from the primary studies. When necessary, we contacted original investigators to clarify the data for any trial published in the past decade. Authors for 10 of these 21 studies provided further data.

Two investigators independendy assigned each intervention to 1 of 3 groups: 1) programs that incorporated education and counseling about coronary risk factors with a supervised exercise program (either in a group setting, per traditional comprehensive cardiac rehabilitation programs, or individually delivered), 2) programs that included education and counseling about coronary risk factors but had no exercise component (either delivered in a group setting or individually), and 3) supervised exercise programs only.

Data Synthesis and Analysis

We performed analyses by using RevMan 4.2 (Update Software, Oxford, Uniced Kingdom). Our outcomes of interest were all-cause mortality and recurrent MIs. Because the outcomes were relatively common, we calculated risk ratios and used the I^sup 2^ statistic to assess for heterogeneity in each outcome of interest. We combined studies by using the DerSimonian and Laird random-effects model. For the primary analysis, we used data from the longest follow-up period reported in each trial. In a priori sensitivity analyses, we pooled data for 3 follow-up periods (12, 24, and 60 months). To evaluate whether different types of secondary prevention programs had different effects, we calculated the summary risk ratio for each program type and used adjusted indirect comparisons to compare different types of interventions, according to the method of Song and colleagues (12).

Role of the Funding Source

An earlier version of this evidence report was produced under contract to the Agency for Healthcare Research and Quality, Rockvillc, Maryland (contract no. 290-02-0023). The funding source had no role in the collection, analysis, or interpretation of the data or in the decision to submit the manuscript for publication.

RESULTS

Study Selection and Evaluation

We identified 6345 citations from electronic databases (n = 6207), reference lists (n = 45), and the Centers for Medicare & Medicaid Services (n = 93). After the initial screening, we reviewed 254 full manuscripts and excluded 179 of these studies after detailed evaluation (Figure 1).

Sixteen disagreements among the reviewers about eligibility \of the studies occurred for a κ value of 0.81. All disagreements were resolved by consensus.

Of the randomized trials that were eligible for inclusion (13- 87), 9 were reported in more than I publication. The second publication reported different end points in 2 cases (13-16), results from different follow-up periods in 5 cases (13, 17-26), and results from the subgroup of patients with cardiac disease in 1 case (27, 28). The ninth trial (the World Health Organization [WHO] trial) (29) included 24 collaborating centers; however, the original investigators excluded 7 sites because of poor participant follow- up and 4 sites because of statistically significant differences between the intervention and control groups at baseline. We included the outcome data from the remaining 13 sites as 1 trial for our analysis, an approach validated by die nonsignificant test results for statistical heterogeneity for all-cause mortality and MI. While the 2 Finnish centers in the WHO trial published their results separately (and for several follow-up periods), we included only their 3-year outcome data with the other 11 WHO sites for consistency of data presentation (30-32).

Figure 1. Flow of trials through the selection process.

Studies Included in the Systematic Review

Table 1 presents summary data from the 63 unique randomized trials that were eligible for our systematic review (13-87). Our search retrieved 51 trials that were not included in our previous systematic review (which was limited to literature published before 1999 and excluded any studies with exercise components) (10) and 26 trials that were not included in a more recent systematic review of cardiac rehabilitation (which was limited to literature published before 2003 and included few "individual counseling" programs) (8).

Qualitative Data Synthesis

In all trials, patients who were randomly assigned to the control groups received usual care (this was generally undefined). Table 1 describes the types of secondary prevention programs; few trials described the intensity of the interventions. Almost all trials enrolled highly selected study samples: Forty-five trials recruited patients after acute MI or a coronary revascularization procedure. Thirty-five trials excluded elderly patients, and 19 trials excluded women (Table 1). Indeed, women constituted fewer than 50% of study participants in all but 2 trials.

No trial was double-blind (which is not surprising, considering the nature of the intervention), and very few trials described randomization procedures or accounted for discrepancies between sample sizes at recruitment and follow-up. As a result, Jadad quality scores clustered around 2 (Table 2). Furthermore, only 15 (24%) trial reports described adequate allocation concealment.

No trial reported side effects with the secondary prevention programs beyond the adverse clinical outcomes described later.

Quantitative Data Synthesis

All-Cause Mortality

Only 1 of the 40 trials reporting this outcome found a statistically significant survival benefit with the intervention (Figure 2). The summary risk ratio for all 40 trials reporting all- cause mortality (16 142 patients) was 0.85 (95% CI, 0.77 to 0.94; P for heterogeneity = 0.96; I^sup 2^ = 0%). The treatment effects did not statistically significantly differ among the 3 types of secondary prevention programs (Figure 2), even if all exercise- based programs were combined (27 trials, 6940 patients) (summary risk ratio, 0.83 [CI, 0.72 to 0.96]) and compared with non-exercise- based programs (14 trials, 9202 patients) (summary risk ratio, 0.87 [CI, 0.76 to 0.99]; P = 0.64).

Table 1. Description of Included Studies*

Table 1. Description of Included Studies*

Table 1. Description of Included Studies*

However, the effects of secondary prevention programs differed over time, while the risk ratio for allcause mortality was 0.97 (CI, 0.82 to 1.14) in the 20 trials (9462 patients) reporting 12-month outcome data (P for heterogeneity = 0.97; I^sup 2^ = 0%) and 0.53 (CI. 0.35 to 0.81) in the 6 trials (1780 patients) reporting 24- month outcome data (P for heterogeneity = 0.58; I^sup 2^ = 0%). Furthermore, pooling the data from the 7 trials (2477 patients) reporting follow-up data from at least 5 years after initiation of the intervention program demonstrated that these programs had a sustained beneficial effect: The risk ratio for all-cause mortality at 5 years was 0.77 (CI, 0.63 to 0.93; P for heterogeneity = 0.72; I^sup 2^ = 0%).

Table 2. Methodologic Quality of Included Studies*

Table 2. Methodologic Quality of Included Studies*

Recurrent MI Kate

Two of the 27 trials reporting this end point (Figure 3) detected a statistically significant difference between intervention and control patients, and the summary risk ratio for reinfarction for all 11 723 patients over a median follow-up of 12 months was 0.83 (CI, 0.74 to 0.94; P for heterogeneity = 0.55; I^sup 2^ = 0%). The treatment effects did not appreciably differ over various follow-up periods among the 3 types of programs (Figure 3), among all programs that incorporated exercise (22 trials, 6194 patients) (summary risk ratio, 0.73 [CI, 0.60 to 0.89]), and among non-exercise-based programs (6 trials, 5529 patients) (summary risk ratio, 0.86 [CI, 0.72 to 1.03]; P = 0.23).

Processes of Care

Details on these outcomes in each trial are available at www.cms.hhs.gov/mcacyidl44a.pdf. In brief, 35 trials reported effects on cardiovascular risk factors, with 26 trials demonstrating better cholesterol profiles in patients who were randomly assigned to the intervention programs, although the differences were statistically significant in only 17 trials and the effect sizes were generally small to moderate. Of the 22 trials that assessed the use of proven efficacious medications, 8 trials demonstrated statistically significantly better application of at least 1 therapy in the intervention patients, 3 trials demonstrated better prescribing in intervention patients but did not achieve statistical significance, and 11 trials did not demonstrate any appreciable difference between intervention and control patients. In many cases, improved processes of care were not seen with the intervention because of improved risk factor management in control patients. For example, 55% of control patients in 1 study were exposed to comprehensive secondary prevention clinics by the end of follow-up (19).

Other End Points

Twenty-four of the 42 trials evaluating quality of life or functional status reported statistically significantly better scores in patients exposed to the intervention programs, although the effect sizes were generally small. Only 7 of these trials (17, 27, 47, 50, 52, 53, 88) described the costs of the intervention. Of these, 2 trials (27, 53) reported that their intervention was cost- saving and only 1 trial (88) performed formal cost-effectiveness analyses (demonstrating incremental cost per quality-adjusted life- year of 1097). Another 2 trials did not report costs but did report fewer physician visits, fewer emergency department visits, less laboratory testing, and fewer total hospital days in intervention patients than control patients (Vale M. Personal communication; 63, 65).

Publication Bias

There was no evidence of publication bias (Egger test; P = 0.51).

DISCUSSION

Secondary prevention programs positively affect processes of care (risk factor profiles and use of proven efficacious therapies) and functional status or quality of life for participants and reduce MIs by 17% over a median follow-up of 12 months. The mortality benefit derived from participation in secondary prevention programs (15% overall and 47% at 2 years) became apparent with longer follow-up and was of similar magnitude in recently published trials and in trials published more than 2 decades ago (before the widespread use of contemporary medical therapies). Benefits did not differ among the 3 types of programs: those that incorporated education and counseling about coronary risk factors with a supervised exercise program, those that included risk factor education or counseling but no exercise component, and those that consisted of only a structured exercise program.

Many reasons may explain why the mortality benefit was not evident at 12 months despite a rapid effect on processes of care linked to CAD outcomes (89). First, 12 months is probably too short to show a clear effect on mortality given the natural history of atherosclerotic CAD (that is, changes in coronary risk factors would not be expected to produce immediate improvements in atherosclerotic plaque stability or coronary artery diameter). The 2 trials that evaluated coronary angiographic lesions reported statistically significant regression rates in patients who adhered to comprehensive lifestyle modifications within 12 months even without statistically significant changes in metabolic profiles or medication use (22, 25). Second, the patients included in these studies were at sufficiently low risk over the first year after enrollment that the likelihood of detecting a beneficial effect was remote. Third, the incremental benefit of secondary prevention programs over usual care may be very small in the settings in which the trials were performed (where management in the "usual care" group was probably close to optimal already-as witnessed by the low control event rates). Secondary prevention programs are likely to be most beneficial in settings where usual care is less optimal.

Figure 2. All-cause mortality in trials evaluating secondary prevention programs.

Figure 3. Recurrent myocardial infarctions in trials evaluating secondary prevention programs.

Limitations

As with all systematic reviews, our study has some potential limitations. There was a lack of blinding in outcome ascertainment and insufficient detail on whether randomization was conducted properly or whether allocation concealment was achieved in most trials\. These weaknesses arise from the primary data and, because all tend to result in overestimation of any treatment effect, these factors should be considered when interpreting our summary estimates. Our interpretations of programs were hampered by imprecise descriptions of the interventions and the lack of data to "open the black box" and determine the incremental benefits of the various components of each intervention. Finally, we could not make a definitive comment on the cost-effectiveness and economic effect of the programs tested in these trials because of the paucity of long-term data in all but 1 trial (88). Although some trials reported costs and outcomes after 1 year, this time horizon is undoubtedly too short to fully evaluate the cost-effectiveness of secondary prevention programs, and studies with 5- and 10-year time horizons are clearly needed.

Generalizability of Findings

Translation of the benefits demonstrated in these trials into clinical practice depends on suitable patients being referred to, accessing, and completing the secondary prevention programs. However, studies have consistently demonstrated that, even in publicly funded health care systems (where access is free), fewer than 50% of patients with CAD access rehabilitation programs (90- 92). Moreover, those groups that are less likely to be referred, to attend, and to complete these programs are often those in greatest need (such as women, elderly people, low-income groups, and ethnic minorities) (90). Indeed, these groups were underrepresented in the trials published thus far (Table 1). While selection bias in trial enrollment always raises concerns about generalizability, elderly patients and women have been shown to derive similar benefits after secondary prevention programs as younger men (93-96).

Furthermore, as with any intervention proven efficacious in trial settings, applying this evidence to clinical practice, where adherence is often lower than that observed in trial participants, is a potential concern. While some people may conclude that our results should be viewed as a "best-case scenario" for the effect of secondary prevention programs, we disagree because trial participants assigned to the control groups also received better care than usual care. Indeed, while the incremental benefit of secondary prevention programs over usual care may be very small in the settings in which these trials were performed (where management in the "usual care" group was often close to optimal), secondary prevention programs will probably be more beneficial in other settings (perhaps more akin to the "real world" of current clinical practice) where usual care is less optimal.

Conclusion

In summary, although the interventions tested in these trials varied substantially and the trials enrolled highly selected study samples, secondary prevention programs improve processes of care, coronary risk factor profiles, and functional status or quality of life. Although the optimal mix of interventions, including frequency and duration, is unclear, secondary prevention programs also reduce subsequent MI and mortality in patients with coronary disease. While these programs reduce health care resource use and thus will probably reduce total health care expenditures, the costs of the program components and their cost-effectiveness have been inadequately evaluated thus far in the literature. Thus, while the implementation of secondary prevention programs on a wide scale for patients with coronary disease is justified, it should be accompanied by plans to rigorously evaluate long-term clinical and economic outcomes in participants and nonparticipants.

References

1. American Heart Association. Heart Disease and Stroke Statistics-2005 Update. Dallas, TX: American Heart Association; 2004.

2. Yusuf S, Hawken S, Ounpuu S, Dam T. Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case- control study. Lancet. 2004;364:937-52. [PMID: 15364185]

3. Yusuf S. Two decades of progress in preventing vascular disease. Lancet. 2002; 360:2-3. [PMID: 12114031]

4. Majumdar SR, McAlister FA, Furberg CD. From knowledge to practice in chronic cardiovascular disease a long and winding road. J Am Coll Cardiol. 2004;43:1738-42. [PMID: 15145092]

5. O'Conoor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS Jr, et al. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation. 1989;80:234-44. (PMID: 2665973)

6. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA. 1988;260:945-50. [PMID: 3398199]

7. Dinnes J, Kleijnen J, Leitner M, Thompson D. Cardiac rehabilitation. Qual Health Care. 1999;8:65-71. [PMID: 10557673]

8. Taylor RS, Brown A. Ebrahim S. Jolliffe J. Noorani H, Rees K. et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116: 682-92. [PMID: 15121495]

9. Shephard RJ, Balady GJ. Exercise as cardiovascular therapy. Circulation. 1999;99:963-72. [PMID: 10027821]

10. McAlister FA, Lawson FM, Teo KK. Armstrong PW. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ. 2001;323:957-62. [PMID: 11679383]

11. Ballady GJ, Ades PA, Comoss P. Limacher M, Pina IL, Southard D. et al Core components of cardiac rehabilitation/secondary prevention programs: a statement for healihcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation. 2000;102:1069-73. [PMID: 10961975]

12. Song F, Altman DG, Glenny AM, Deeks JJ. Validity of indirect comparison for estimating efficacy of competing interventions: empirical evidence from published meta-analyses. BMJ. 2003326:472. [PMID: 12609941]

13. Campbell NC, Thain J, Deans HG, Ritchie LD. Rawles JM. Squair JL Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ. 1998;316:1434-7. [PMID: 9572758]

14. Campbell NC Ritchie LD, Thain J. Deans HG, Rawles JM. Squair JL. Secondary prevention in coronary heart disease: a randomised trial of nurse led dinics in primary care. Heart. 1998:80:447-52. [PMID: 9930042]

15. Engblom E, Rnnemaa T. Hmlinen H, Kallio V, Vnninen E, Knuts LR. Coronary hean disease risk factors before and after bypass surgery: results of a controlled trial on multifactorial rehabilitation. Eur Heart J. 1992;13:232-7. [PMID: 1348226]

16. Engblom E, Korpilahti K, Hmlinen H, Rnnemaa T, Puukka P. Quality of life and return to work 5 years after coronary artery bypass surgery. Long-term results of cardiac rehabilitation. J Cardiopulm Rehabil. 1997;17:29-36. [PMID: 9041068]

17. DeBusk RF, Miller NH, Superko HR, Dennis CA, Thomas RJ. Lew HT, et al. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med. 1994;120:721-9. [PMID: 8147544]

18. Taylor CB, Miller NH, Smith PM, DeBunk RF. The effect of a homebated. Gee-managed, multifactorial risk-reduction program on reducing psychological distress in patients with cardiovascular disease. J Cardiopulm Rehabil. 1997;17:157-62. [PMID: 9187981]

19. Murchie P. Campbell NC, Ritchie LD, Simpson JA, Thain J. Secondary prevention dinks for coronary heart disease four year follow up of a randomised controlled trial in primary care. BMJ. 2003;326:84 [PMID: 12521974]

20. Murchie P. Campbell NC, Ritchie LD, Deans HG, Thain J. Effects of secondary prevention dinks on health status in patients with coronary heart disease: 4 year follow-up of a randomized trial in primary care. Fam Pracr. 2004; 21:567-74. [PMID: 15367480]

21. Schuler G. Hambrecht R. Schlierf G. Niebauer J. Hauer K. Neumann J. et al. Regular physical exercise and low-rat diet. Effects on progression of coronary artery disease. Circulation. 1992:86:1-11. [PMID: 1617762]

22. Niebauer J. Hambrachi R. Velich T. Hauer K. Marburger C Kberer B, et al. Attenuated progression of coronary artery disease after 6 years of mularactohal risk intervention: role of physical exercise. Circulation. 1997;96:2534-41. [PMID: 9355890]

23. Cupples ME, McKnight A. Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk. BMJ. 1994;309:993-6. (PMID: 7950723)

24. Cupples ME, McKnight A, Five year follow up of patients at high cardiovascular risk who took part in randomised controlled trial of health promotion. BMJ. 1999;319:687-8. [PMID: 10480826]

25. Ornish D. Brawn SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet. 1990;336:129-33. [PMID: 1973470]

26. Ornish D. Scherwitz LW. Billings JH, Brawn SE, Gould KL, Merrirr TA, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:2001-7. [PMID: 9863851]

27. Naylor MD. Brooten D. Campbell R. Jacobsen BS, Mezey MD. Passly MV, et al. Comprehensive discharge planning and home follow- up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-20. [PMID: 10029122]

28. Naylor MD. McCauley KM. The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. J Cardiovasc Nurs. 1999;14:44-54. [PMID: 10533691]

29. Dorossiev D. Rehabilitation and Comprehensive Secondary Prevention after Acute Myocardial Infarction. Report on a Study. EURO Reports and Studies No. 84. Copenhagen: World Health Organization: 1983.

30. Kallio V, Hmlinen H, Hakkila J, Laurila OJ. Reduction in sudden deaths by a multifactorial intervention programme after acute myocardial infarction. Lancet. 1979;21:1091-4. [PMID: 91836]

31. Hmlinen \H. Luurila OJ. Kallio V. Knuts LR. Arstila M. Hakkila J. Long-term reduction in sudden deaths after a multifaciorial intervention programme in patients with myocardial infarction: 10-year results of a controlled investigation. Eur Heart J. 1989:10:55-62. [PMID: 2564823]

32. Hmlinen H. Luurila OJ, Kallio V. Knuts LR. Reduction in sudden deaths and coronary mortality in myocardial infarction patients after rehabilitation. 15 year follow-up study. Eur Heart J. 1995;16:1839-44. [PMID: 8682016]

33. Sivarajan ES, Bruce RA, Lindskog BD. Almes MJ. Belanger L, Green B, Treadmill test responses to an carry exercise program after myocardial infarction: a randomized study. Circulation. 1982;65:1420- 8. [PMID: 7074797]

34. Vermeulen A, Lie KI, Durrer D. Effects of cardiac rehabilitation after myocardial infarction: changes in coronary risk factors and long-term prognosis. Am Heart J. 1983;105:798-801. [PMID: 6846123]

35. Bengtsson K. Rehabilitation after myocardial infarction. A controlled study. Scand J Rehabil Med. 1983;15:1-9. [PMID: 6828827]

36. Oldridge N. Guyatt G. Jones N. Crowe J. Singer J. Feery D. et aL Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction. Am J Cardiol. 1991;67:1084-9. [PMID: 2024598]

37. Comparison of a rehabilitation programme, a counselling programme and usual care after an acute myocardial infarction: results of a long-term randomized trial. P.RE.COR. Group. Eur Heart J. 1991:12:612-6. [PMID: 1874262]

38. Fridlund B, Hgstedt B, Lidell E, Larsson PA. Recovery after myocardial infarction. Effects of a caring rehabilitation programme. Scand J Caring Sci. 1991;5:23-32. [PMID: 2011669]

39. Bell JM. A Comparison of a Multi-Disciplinary Home Based Cardiac Rehabilitation Programme with Comprehensive Conventional Rehabilitation in Post-Myocardial Infarction Patients [PhD thesis]. London: University of London; 1998.

40. Johnston M, Foulkes J, Johnston DW, Pollard B, Gudmundsdottir H. Impact on patients and partners of inpatient and extended cardiac counseling and rehabilitation: a controlled trial. Psychosom Med. 1999;61:225-33. [PMID: 10204976]

41. Lisspers J, Sundin O, Hofman-Bang C, Nordlander R, Nygren A, Rydn L, et al. Behavioral effects of a comprehensive, multifactorial program for lifestyle change after percutaneous transluminal coronary angioplasty: a prospective, randomized controlled study. J Psychosom Res. 1999;46:143-54. [PMID: 10098823]

42. Toobert DJ, Glasgow RE, Radcliffe JL. Physiologic and related behavioral outcomes from the Women's Lifestyle Heart Trial. Ann Behav Med. 2000;22: 1-9. [PMID: 10892523]

43. Sundin O, Lisspers J, Hofman-Bang C, Nygren A, Rydn L, Ohman A. Comparing multifactorial lifestyle interventions and stress management in coronary risk reduction. Int J Behav Med. 2003;10:191- 204. [PMID: 14525716]

44. Seki E, Watanabe Y, Sunayama S, Iwama Y, Shimada K, Kawakami K, et al. Effects of phase III cardiac rehabilitation programs on health-related quality of life in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP). Circ J. 2003;67:73-7. [PMID: 12520156]

45. Yu CM, Li LS, Ho HH, Lau CP. Long-term changes in exercise capacity, quality of life, body anthropometry, and lipid profiles after a cardiac rehabilitation program in obese patients with coronary heart disease. Am J Cardiol. 2003;91: 321-5. [PMID: 12565088]

46. Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease. Eur J Cardiovasc Prev Rehabil. 2003:10:429- 37. [PMID: 14671465]

47. Marchionni N, Fattirolli F, Fumagalli S, Oldridge N, Del Lungo F, Morosi L, et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial. Circulation. 2003:107:2201-6. [PMID: 12707240]

48. Stern MJ, Gorman PA, Kaslow L. The group counseling v exercise therapy study. A controlled intervention with subjects following myocardial infarction. Arch Intern Med. 1983;143:1719-25. [PMID: 6615094]

49. Jones DA, West RR. Psychological rehabilitation after myocardial infarction: multicentre randomised controlled trial. BMJ. 1996;313:1517-21. [PMID: 8978226]

50. Masley S, Phillips S, Copeland JR, Group office visits change dietary habits of patients with coronary artery disease-the dietary intervention and evaluation trial (D.I.E.T.). J Fam Pract. 2001;50:235-9. [PMID: 11252212]

51. Ornish D, Scherwitz LW, Doody RS, Kesten D, McLanahan SM, Brown SE, et al. Effects of stress management training and dietary changes in treating ischemic heart disease. JAMA. 1983;249:54-9. [PMID: 6336794]

52. Fitzgerald JF, Smith DM, Martin DK, Freedman JA, Katz BP. A case manager intervention to reduce readmissions. Arch Intern Med. 1994;154:1721-9. [PMID: 8042889]

53. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med. 1994;120:999- 1006. [PMID: 8185149]

54. Frasure-Smith N, Lesperance F, Prince RH, Verrier P, Garber RA, Juneau M, et al. Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction. Lancet. 1997;350:473-9. [PMID: 9274583]

55. Carlsson R. Serum cholesterol, lifestyle, working capacity and quality of life in patients with coronary artery disease. Experiences from a hospital-based secondary prevention programme. Scand Cardiovasc J Suppl. 1998;50:1-20. [PMID: 9802147]

56. Jolly K, Bradley F, Sharp S, Smith H, Thompson S, Kinmonth AL, et al. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group. BMJ. 1999;318: 706-11. [PMID: 10074017]

57. Allison TG, Farkouh ME, Smars PA, Evans RW, Squires RW, Gabriel SE, et al. Management of coronary risk factors by registered nurses versus usual care in patients with unstable angina pectoris (a chest pain evaluation in the emergency room [CHEER] substudy). Am J Cardiol. 2000;86:133-8. [PMID: 10913471]

58. Moher M, Yudkin P, Wright L, Turner R, Fuller A, Schofield T, et al. Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care. BMJ. 2001;322: 1338. [PMID: 11387182]

59. McHugh F, Lindsay GM, Hanlon P, Hutton I, Brown MR, Morrison C, et al. Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: a randomised controlled trial. Heart. 2001;86:317-23. [PMID: 11514487]

60. Higgins HC, Hayes RL, McKenna KT. Rehabilitation outcomes following percutaneous coronary interventions (PCI). Patient Educ Couns. 2001;43:219-30. [PMID: 11384820]

61. Allen JK, Blumenthal RS, Margolis S, Young DR, Miller ER 3rd, Kelly K. Nurse case management of hypercholesterolemia in patients with coronary heart disease: results of a randomized clinical trial. Am Heart J. 2002;144:678-86. [PMID: 12360165]

62. Vale MJ, Jelinek MV, Best JD, Santamaria JD. Coaching patients with coronary heart disease to achieve the target cholesterol: a method to bridge the gap between evidence-based medicine and the "real world"-randomized controlled trial. J Clin Epidemiol. 2002;55:245-52. [PMID: 11864795]

63. Vale MJ, Jelinek MV, Best JD, Dart AM, Grigg LE, Hare DL, et al. Coaching patients On Achieving Cardiovascular Health (COACH): a multicenter randomized trial in patients with coronary heart disease. Arch Intern Med. 2003;163:2775-83. [PMID: 14662633]

64. Lear SA, Ignaszewski A, Linden W, Brozic A, Kiess M, Spinelli JJ, et al. The Extensive Lifestyle Management Intervention (ELMI) following cardiac rehabilitation trial. Eur Heart J. 2003;24:1920- 7. [PMID: 14585250]

65. Young W, Rewa G, Goodman SG, Jaglal SB, Cash L, Lefkowitz C, et al. Evaluation of a community-based inner-city disease management program for postmyocardial infarction patients: a randomized controlled trial. CMAJ. 2003; 169:905-10. [PMID: 14581307]

66. Lichtman JH, Amatruda J, Yaari S, Cheng S, Smith GL, Matteta JA, et al. Clinical trial of an educational intervention to achieve recommended cholesterol levels in patients with coronary artery disease. Am Heart J. 2004;147:522-8. [PMID: 14999204]

67. Haskell WL, Alderman EL, Fair JM, Maron DJ, Mackey SF, Superko HR, et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Circulation. 1994; 89:975-90. [PMID: 8124838]

68. Carlsson R, Lindberg G, Westin L, Israelsson B. Influence of coronary nursing management follow up on lifestyle after acute myocardial infarction. Heart. 1997;77:256-9. [PMID: 9093045]

69. Allison TG, Squires RW, Johnson BD, Gau GT. Achieving National Cholesterol Education Program goals for low-density lipoprotein cholesterol in cardiac patients: importance of diet, exercise, weight control, and drug therapy. Mayo Clin Proc. 1999;74:466-73. [PMID: 10319076]

70. Stagmo M, Westin L, Carlsson R, Israelsson B. Long-term effects on cholesterol levels and the utilization of lipid-lowering drugs of a hospital-based programme for secondary prevention of coronary artery disease. J Cardiovasc Risk. 2001;8:243-8. [PMID: 11551003]

71. Wilhelmsen L, Sanne H, Elmfeldt D, Grimby G, Tibblin G, Wedel H. A controlled trial of physical training after myocardial infarction. Effects on risk factors, nontatal reinfarction, and death. Prev Med. 1975;4:491-508. [PMID: 1208362]

72. Shaw LW. Effects of a prescribed supervised exercise program on mortality and cardiovascular morbidity in patients after myocardial infarction. The National Exercise and Heart Disease Project. Am J Cardiol. 1981;48:39-46. [PMID: 6972693]

73. Carso\n P, Phillips R, Lloyd M, Tucker H, Neophytou M, Buch NJ, et al. Exercise after myocardial infarction: a controlled trial. J R Coll Physicians Lond. 1982;16:147-51. [PMID: 7050369]

74. Ballantyne FC, Clark RS, Simpson HS, Ballantyne D. The effect of moderate physical exercise on the plasma lipoprotein subfractions of male survivors of myocardial infarction. Circulation. 1982;65:913- 8. [PMID: 7074752]

75. Miller NH, Haskell WL, Berra K, DeBusk RF. Home versus group exercise training for increasing functional capacity after myocardial infarction. Circulation. 1984;70:645-9. [PMID: 6478567]

76. Roviaro S, Holmes DS, Holmsten RD. Influence of a cardiac rehabilitation program on the cardiovascular, psychological, and social functioning of cardiac patients. J Behav Med. 1984;7:61-81. [PMID: 6609243]

77. Erdman RA, Duivenvoorden HJ, Verhage F, Kazemier M, Hugenhoitz PG. Predictability of beneficial effects in cardiac rehabilitation: a randomized clinical trial of psychosocial variables. J Cardiopulm Rehabil. 1986;6:206-13.

78. Agren B, din C, Casicnfbn J, Nilsfon-Ehle P. Improvements of Ae lipoprotcin profile after coronary bypass surgery; additional effects of an OCTOSC training program. Eur Heart J. 1989:10:451-8. [PMlD; 2788085]

79. Bethel! HJ, Mullee MA. Λ controlled trial of mmunity based ronary rehabilitation. Br Mean J. 1990^4:370-5. (PMID: 2271343)

80. Bertie J. King A, Reed N. Manhall AJ, Ricken C Benefits and weaknesses of ι cardiac rehabilitation programme. J R Coll Phvudaru Lond. 1992^26:14751. [PMID: 1588521)

81. Hetcher BJ, Dunbar SB, Feiner JM, Jemen BE, Almon L, Couonii G, β L Exercise testing and training in physically disabled men with clinical evidence of coronary arten disease. Am J Cardiol. 1994:73:170-4. [PMlD: 8296738]

82. Holmbadc AM. Sawe U, Faghcr B. Training after myocardial infarction: lade of long-term effects on physical capacity and psychological variables. Arch Phys Mcd Rehabil. 1994:75:551-4. (PMID: 8185448]

83. Wotomu D, Bedford D. Ballantyne D. Λ comparison of the effects of strength and aerobic exercise training on exercise capacity and Upids after coronary artery bypass surgery. Eur Heart J. 19%: 17:854-63. (PMID: 8781824]

84. Dugmore LD, Tipmn RJ. PhOUp. MH. Flint EJ. Stenriford NH. Bone MF, et aL Changes in caniiorcspiraiory fitness, psychological wellbeing. qualin of life, and vocational sums following a 12 month cardiac exercise rehabilitation programme. Heart. 1999;81:359-66. [PMlD: 10092561]

85. HeUaI M, Site S, Dale J. Randomised training after myocardial infarction: short and long-term effects of exercise training after myocardial infarction in patients on beta-blocker treatment. A randomized, controlled study. Scand Caidiovasc J. 2000-34:59-64. [PMlD: 10816062]

86. Stihle A, Ijiylqiiig 1, Mansion E. Important factors for physical activity among elderly patients one year after an acute myocardial infarction. Scand J Rehabil Mcd 200OJiI 11-6. (PNiID: 11028795)

87. miJinlli R. Paolini I, Cianci G. Prva R. Georgiou D, Purcaro A. Exercise training intervention after coronary angwpbny: the ETICA treu. J Am CaU Oidiol. 200137:1891-900. (PMID: 11401128)

88. Rafary JP. Yao GU Murchie P. Camphefl NC Rrtdue LO. Cost cBcanc ness of nuise led secondary prevention dinks for coronary bean disease in primary arc follow up of a randomised controlled trot BMJ. 2005330:707. IPMID: 157162891

89. Mant J. Hida N. Detecting differences in quality of care the sensitivity of measures of process and outcome in treating acute myocardial infarction. BMJ. 1995311:793-6. IPMID: 7580444]

90. Cooper AF, Jadtaon G, Weinman J, Home R. Factors associated with cardiac rehabilitation attendance: a systematic review of the literature, din Rehabil. 2002416:541-52. [PMID: 12194625)

91. Wm BJ, Jacob SJ, Weston SA. Killian JM, Meverden RA. AKaan TG, et aL Cardiac rehabilitation after myocardial infarction in die community. J Am Coll CardioL 2004:44:988-%. (PMlD: 15337208)

92. Oliver S, Oarkr-Jooes L, Rm R. Milne R. Buchanan P, GaUMyJ, aL Involving consumers in research and development agenda setting for the NHS: developing an evidence-based approach. Health Techno! Assess. 2004 A1-148, IH-IV. [PMID: 15080866]

93. Milan! RV, Lavie CJ. Prevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease. Am J Cardiol 1998Λ1: 1233-6. [PMID: 9604957)

94. Majecd FA. Cook DG. Age and sex difference in the management of bdvaemic heart disease. Public Health. 1996:110:7-12. (PMID: 8685314]

95. Lavie CJ, Milan! RV. Cardiac rehabilitation and preventive cardiology in the elderly. Cardiol CUn. 1999:17:233-42. [PMID: 10093776]

96. Mosca L Appel LJ. Benjamin EJ. Bern K. Chandra-Strobos N. Fabunmi RP, a aL Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004:109:672-93. (PMID: 14761900)

Alexander M. Clark, PhD, BA, RN; Lisa Hartling, MSc; Ben Vandermeer, BSc, MSc; and Finlay A. McAlister, MD, MSc

From the University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada.

Disclaimer: No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human Services.

Acknowledgments: The authors thank Dr. N.C. Campbell (13, 14), Dr. R. West (49), Dr. M. Naylor (27, 53), Dr. N. Marchionni (47), Drs. Vale and Sundararajan (63), Dr. Otterstad and Ms. Peersen (46), Dr. W. Young (65), and Dr. K. Jolly (39) for providing further details about their studies. The authors also thank the staff of the University of Alberta Evidence-based Practice Center who participated in generating this report: C. Friesen, J. Russell, M. Joseisson, N. Wiebe, M. Tubman, and K. Bond.

Grant Support: This evidence report was produced by the University of Alberta Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (contract no. 290- 02-0023). Drs. Clark and McAlister hold salary awards from the Alberta Heritage Foundation for Medical Research. Dr. McAlister also holds a Canadian Institutes of Health Research New Investigator Award and the Merck Frosst/Aventis Chair in Patient Health Management at the University of Alberta.

Potential Financial Conflicts of Interest None disclosed.

Requests for Single Reprints: Finley A. McAlister, MD, MSc, Division of General Internal Medicine, 2E3.24 WMC, University of Alberta Hospital, 8440 112th Street, Edmonton T6G 2R7, Alberta, Canada: e-mail, Finlay. McAlister@ualberta.ca.

Current author addresses are available at www.annals.org.

Copyright American College of Physicians Nov 1, 2005

Source: Annals of Internal Medicine

More News in this Category