SAGE-Hindawi Access to ResearchCardiology Research and PracticeVolume 2011, Article ID 232351, 25 pagesdoi:10.4061/2011/232351

Review Article

Systematic Review of the Effect of Diet and ExerciseLifestyle Interventions in the Secondary Prevention ofCoronary Heart Disease

Judith A. Cole,1 Susan M. Smith,2 Nigel Hart,1 and Margaret E. Cupples1

1 UKCRC Centre of Excellence for Public Health (Northern Ireland), Queen’s University Belfast, Dunluce Health Centre,1 Dunluce Avenue, Belfast BT9 7HR, UK

2 Department of Public Health and Primary Care, Trinity College Centre for Health Sciences, AMNCH, Tallaght, Dublin 24, Ireland

Correspondence should be addressed to Judith A. Cole, jcole04@qub.ac.uk

Received 15 October 2010; Accepted 3 November 2010

Academic Editor: Demosthenes Panagiotakos

Copyright © 2011 Judith A. Cole et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease (CHD) remains unclear. Thissystematic review aimed to determine their effectiveness and included randomized controlled trials of lifestyle interventions, inprimary care or community settings, with a minimum follow-up of three months, published since 1990. 21 trials with 10,799patients were included; the interventions were multifactorial (10), educational (4), psychological (3), dietary (1), organisational(2), and exercise (1). The overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes butno overall effect on smoking outcomes. In trials that examined mortality and morbidity, significant benefits were reported for totalmortality (in 4 of 6 trials; overall risk ratio (RR) 0.75 (95% confidence intervals (CI) 0.65, 0.87)), cardiovascular mortality (3 of8 trials; overall RR 0.63 (95% CI 0.47, 0.84)), and nonfatal cardiac events (5 of 9 trials; overall RR 0.68 (95% CI 0.55, 0.84)). Theheterogeneity between trials and generally poor quality of trials make any concrete conclusions difficult. However, the beneficialeffects observed in this review are encouraging and should stimulate further research.

1. Introduction

The World Health Organisation has stated that, since 1990,more people worldwide have died from coronary heartdisease (CHD) than any other cause [1]. Further, theyreported that 80% to 90% of people dying from CHD hadone or more major risk factors associated with lifestyle.

In the UK, more than 90,000 deaths per year are dueto CHD, and although death rates are falling they are stillamong the highest in western Europe [2].

Cardiac rehabilitation (CR) programmes were initiatedin the 1960s when the benefits of mobilisation and physicalactivity (PA) following lengthy hospital stays for CHDbecame known [3]. Since then, secondary prevention hasbecome an essential aspect of care of the patient with CHD[4]. Research has shown that lifestyle change, including PA,a healthy diet, and smoking cessation, alters the courseof CHD [5–7], and so disease prevention measures have

been designed to focus on a range of lifestyle factors.Indeed, cardiac rehabilitation and secondary preventionprogrammes have developed from focusing on exercise aloneto becoming multidisciplinary and encompassing baselinepatient assessments, nutritional counselling, risk factor man-agement (i.e., lipids, hypertension, weight, diabetes, andsmoking), psychosocial and vocational counselling, and PAadvice and exercise training, in addition to the appropriateuse of cardioprotective drugs [4].

Multidisciplinary measures are advocated by govern-ments around the world, and in the UK the National Institutefor Clinical Excellence (NICE) set out a series of guidelines in2007 for care of patients who had had a myocardial infarction(MI) [8]. The guidelines covered secondary prevention inprimary and secondary care and were not focused solelyon lifestyle interventions. They did, however, incorporatePA, diet, smoking, and drug therapy and were based onsystematic reviews of the best available evidence. Priority

2 Cardiology Research and Practice

recommendations, considered to have the most importanteffect on patient care and outcomes, included that ondischarge from hospital every MI patient should have hada confirmed diagnosis of acute MI, results of investigations,future management plans, and advice on secondary preven-tion. Also, NICE highlighted the importance of advice beinggiven regarding regular PA in the form of 20–30 minutes ofexercise per day to the point of slight breathlessness. Patientsshould also be advised to stop smoking, eat a Mediterraneanstyle diet rich in fibre, fruit, vegetables, and fish, and follow atreatment regime with a combination of ACE (angiotensin-converting enzyme) inhibitors, aspirin, beta-blockers, andstatins.

However, despite the evidence that positive lifestylechanges bring about improved outcomes, results froma number of secondary prevention initiatives have beendisappointing. In a systematic review of multidisciplinarysecondary prevention programmes McAlister et al. [9]reported that although some beneficial impact was achievedon processes of care, morbidity, and mortality, questionsremained regarding the duration and frequency of inter-ventions and the best combination of disciplines within anintervention.

The EUROASPIRE (European Action on Secondary andPrimary Prevention by Intervention to Reduce Events) sur-veys by the European Society of Cardiology have shown thatthe adoption of cardiovascular disease prevention measuresas part of daily clinical practice was wholly inadequate[10] and that unhealthy lifestyle trends are continuing. Theauthors commented on the difficulty experienced by adultsin changing behaviour despite having a life threatening dis-ease and that continued professional support was imperativeif this was to be achieved.

Few previous reviews of secondary prevention inter-ventions have been published. McAlister et al. [9] carriedout a systematic review of RCTs of secondary preventioninterventions, published in 2001, and analysed 12 studies.Jolliffe et al. [11] analysed only exercise interventions insecondary prevention, and Rees et al. [12] reviewed psycho-logical interventions. To our knowledge no comprehensivesystematic review has been undertaken since 2001 of theeffects of diet, exercise, and other lifestyle factors in thesecondary prevention of CHD. We therefore performeda systematic review of randomised controlled trials todetermine the effectiveness of lifestyle interventions for thesecondary prevention of CHD.

2. Methods

This was a systematic review carried out using CochraneCollaboration methodology [13].

2.1. Participants. We included male and female adults ofall ages (aged 18+) with a diagnosis of CHD. Patientsincluded those who had experienced a myocardial infarction(MI), coronary artery bypass graft (CABG), or percutaneoustransluminal coronary angioplasty (PTCA) and those withangina pectoris and coronary artery disease defined by

angiography. For the purposes of this review we excludedpatients who had had a heart transplant, heart valve surgery,or heart failure, unless it was clearly specified that the causerelated to CHD.

2.2. Interventions. We have included interventions with alifestyle and/or behaviour change focus designed for thesecondary prevention of CHD, incorporating one or acombination of exercise and diet. Interventions may becategorized as follows.

(1) Dietary.

(2) Exercise.

(3) Psychological.

(4) Educational.

(5) Multifactorial.

(6) Organisational (e.g., case management).

2.3. Exclusions. We have excluded from this review studieswhich were not randomized controlled trials, focused onprimary prevention, involved patients with multiple diseasesand/or outcomes which were related to diseases other thanCHD, involved patients in a hospital in-patient setting,focused on drug therapy, had short (less than three months)or no follow-up, or reported outcomes which were notthe focus of this review (see “Types of outcome measures”section) such as depression, cost-effectiveness, or servicedelivery.

2.4. Study Duration. Trials were included in this review ifthey reported a minimum postintervention follow-up ofthree months to allow some change to take place.

2.5. Settings. For the purposes of this review, interventionshave been considered to have been delivered in primarycare according to the definition of primary care as statedby the Committee on the Future of Primary Care at theInstitute of Medicine in the United States: “Primary careis the provision of integrated, accessible healthcare servicesby clinicians who are accountable for addressing a largemajority of personal healthcare needs, developing a sustainedpartnership with patients, and practicing in the context offamily and community” [14]. Interventions are delivered inprimary care by clinicians who are “generally considered tobe physicians, nurse practitioners and physical assistants”and “a broader array of individuals in a primary care team”[14]. In the care of CHD patients, the primary care team mayinclude general practitioners, practice nurses, communitypharmacists, community and public health nurses, dieti-cians, occupational therapists, and physiotherapists.

(i) Interventions have been included in the review if theyhave been delivered in primary care or communitysettings by primary care clinicians or clinicians whosenormal roles may be within secondary care, forexample, community hospitals, or tertiary care, forexample, general hospitals.

Cardiology Research and Practice 3

(ii) We have excluded from this review studies of inter-ventions undertaken primarily within secondary ortertiary care settings by clinicians or care teamswhose relationship with patients is not long term orongoing.

2.6. Comparators. In the included studies, the comparatorsare “normal care” or “usual care,” meaning standard clinicalcare or standard care given by a general practitioner (GP).

2.7. Types of Outcome Measures. All or any number of thefollowing.

Primary Outcomes

(i) All-cause mortality.

(ii) Cardiac mortality.

(iii) Nonfatal cardiac events.

(iv) Hospital admissions (cardiac related/and all-cause ifavailable).

Secondary Outcomes

(i) Diet (e.g., measured by fibre, fruit, and veg quantity).

(ii) Exercise (e.g., frequency, duration).

(iii) Blood pressure (BP); systolic BP (SBP); diastolic BP(DBP).

(iv) Blood lipid levels (high density lipoprotein choles-terol (HDL-chol), low density lipoprotein cholesterol(LDL-chol)).

(v) Smoking behavior.

(vi) Health related quality of life (QOL).

(vii) Self efficacy.

(viii) Medication adherence.

Only outcomes measured using a validated instrument wereincluded.

2.8. Search Methods for Identification of Studies. We searchedelectronic databases Medline, Cinahl, and Embase forEnglish language randomized trials in humans publishedsince 1990. The search method for Medline is detailed below;it was modified as appropriate for Cinahl and Embase.Reference lists of review articles were also searched.

2.9. Medline Search Method. Selecting an Advanced Ovidsearch, the keyword “lifestyle” was inserted and the boxticked to select “Map term to subject heading.” After selecting“Search” a new page was presented entitled “MappingDisplay.” Options indicating the Subject Headings “LifeStyle” and “lifestyle.mp. search as keyword” were chosen and“Continue” selected. This allowed further keywords to beentered.

The same process was followed for the keywords “exer-cise,” “physical activity,” and “diet.” In each case only thekeyword as a subject heading and as a keyword were selectedon the Mapping Display page.

A fifth search was commanded by using all four keywordsabove separated by the Boolean operator “OR.” This wasdone by selecting “click to expand” the “Search History” box,ticking each of the four boxes relating to the keywords, andselecting “Combine selections with OR.”

A sixth search term “secondary prevention” was addedas a keyword in same way as above. A seventh “coronaryheart disease” was inserted, then its abbreviation “CHD”and four conditions related to it and their abbreviations,where appropriate, all as separate keywords: “myocardialinfarction,” “MI,” “coronary artery bypass graft,” “CABG,”“percutaneous transluminal coronary angioplasty,” “PTCA,”and “angina pectoris.” This group incorporating coronaryheart disease and related conditions involved a total of nineseparate searches, and they were together inserted as a 16thsearch, with each term separated by “OR.” This was done, asabove, by expanding the search history, selecting the relevantboxes beside keywords and selecting “Combine selectionswith OR.”

The three components of the search were put together inthe following way.

On the search history page, search five was selected byclicking on the box beside it (Lifestyle.mp. or Life Style/ORExercise.mp. or Exercise/OR Physical activity.mp. OR Diet/ordiet.mp.). Search six was then selected (Secondary preven-tion.mp. or Secondary Prevention/), and search 16 (Coro-nary heart disease.mp. or Coronary Disease/OR CHD.mp.OR Myocardial infarction.mp. or Myocardial Infarction/ORMI.mp OR Coronary Artery Bypass/or coronary arterybypass graft.mp. OR CABG.mp. OR Percutaneous trans-luminal coronary angioplasty.mp. or Angioplasty, Translu-minal, Percutaneous Coronary/OR PTCA.mp. OR Anginapectoris.mp. or Angina Pectoris/). The option “Combineselections with AND” was selected.

This gave search 17. Search 17 was selected by tickingthe box, and limits were imposed in an effort to narrowthe search. Below the search results, within the “Limits”options, “English language,” “Humans,” and “PublicationYear-1990 to Current” were selected. “Additional Limits” wasthen selected, search 17 was selected, and in the “Age Groups”options “All Adult (19 plus years)” was selected. No otherlimits were imposed. Then, “Limit A Search” was selected.

To refine the search further, terms relating to a ran-domized controlled trial study design were inserted. Theterms entered were randomized controlled trial.mp. orRandomized Controlled Trial/, controlled clinical trial.mp.or Controlled Clinical Trial/, random allocation.mp. orRandom Allocation/, double blind method.mp. or Double-Blind Method/, single blind method.mp. or Single-BlindMethod. Each of these terms was combined with “OR,”giving search 24.

Selecting search 18 and search 24, and combining themwith “AND” gave the final selection. The Medline searchstrategy is detailed in the Appendix.

2.10. Data Analysis. From the searching, titles and abstractswere screened by two reviewers (MC, JC), and potentiallyrelevant references were retrieved. The two reviewers (MC,

4 Cardiology Research and Practice

screening reference lists of

(n = 227)

Records identified through database searching (n =

Titles and abstracts of articles

screened and assessed for

eligibility (n = 266)

266)

Articles identified for

inclusion in review (n = 39)

Records excluded,

Scre

enin

gfo

rel

igib

ility

Incl

ude

d

Not CHD specific: 15

Drug therapy: 57

Not lifestyle: 13

Not RCT: 85

Follow-up short : 3

Setting: 4

Outcomes not of interest: 25

Duplicate: 25

Articles excluded after full text

review, with reasons (n = 12)

Final selection of articlesfor review (30 papersdescribing 21 studies)

Not lifestyle: 2

Setting: 1

Not RCT: 2

Comparator: 1

Duplicate: 4

Initial results of trial

(included paper on final

results): 1

Setting: 11 article added (from sametrial but different outcomes to

an excluded article)

2 articles added after

relevant systematic reviews

Iden

tifi

cati

on

Figure 1: Screening and selection of studies of interventions for secondary prevention of coronary heart disease.

JC) then independently selected trials to be included in thereview. Reference lists of relevant systematic reviews werealso screened for potential papers to include.

After the final selection of trials was agreed upon,data including study characteristics, outcome measures andresults were extracted.

In addition, the quality of trials was assessed in relation torandomization method, loss to follow up, intention to treatanalyses, and blinding measures.

Dichotomous outcomes for each study have beenexpressed as risk ratios, where appropriate, and 95% confi-dence intervals (CIs). Meta-analyses were performed usingrandom effects models, and data were presented as forest

plots using Revman software [15]. We were only able toperform meta-analysis on three outcomes—total mortality,cardiovascular mortality, and nonfatal cardiac events.

Continuous variables have been expressed as the dif-ference between intervention and control groups at studycompletion and the standard deviation difference wherereported.

3. Results

3.1. Study Selection and Evaluation. Figure 1 shows theselection, screening, and identification of studies for thisreview. Of the 266 papers originally identified through

Cardiology Research and Practice 5

searching the three electronic databases, we identified 39that were potentially eligible for inclusion, and full textversions of these studies were retrieved and assessed. Twelveof the 39 papers were excluded because they included diseasesother than CHD, were drug trials, did not focus on lifestyle,were not randomized controlled trials, had a short follow-up period, were conducted within a hospital in-patientsetting, had outcomes which were not of interest, or wereretrieved more than once from the three search engines. Twopapers were added after screening reference lists of relevantsystematic reviews, and one trial was added which reporteddifferent outcomes of an identical study which emerged inour searches (Figure 1).

3.2. Description of Studies. Table 1 shows summary dataof 30 papers from the 21 randomised controlled trials(RCTs) found to be eligible for this review [16–45]. Wehave presented them in the six categories described in the“Methods” section (exercise, dietary, psychological, edu-cational, multifactorial, and organisational). The categorywhich had the largest number of trials was multifactorial (10in total). We also found one which focused on exercise only,one dietary intervention, three which had a psychologicalapproach, four educational, and two organisational.

In all the trials except where stated, patients randomisedto the control group received usual care, which was notdefined by every study but usually meant standard clinicalcare or standard care given by a GP.

3.2.1. Study Characteristics. The studies varied greatly interms of sample size, duration, and intervention elements;however all involved patients of a similar age group (olderadults) with CHD.

The sample size of trials ranged from 48 [41] to 3241[21], and study duration ranged from three months [19, 43]to four [33] and five years [41]. Follow-up analyses variedtoo, ranging from three months [19] to 15 years [45].

3.2.2. Settings. We found much variation in study setting.Astengo et al. [16] reported a home-based exercise interven-tion while two studies incorporated initial short residentialstays to deliver an intensive educational programme. Lissperset al. [26] conducted a four-week stay at an interventionunit located in a rural part of northern Sweden, followedby a structured 11-month programme consisting of self-recording of lifestyle behaviours and contact with thepatients’ personal coaches. It was not clear whether theintervention unit was part of a hospital. Ornish et al. [41]organised a week-long residential stay at a hotel to educatepatients on diet, exercise, and stress, followed by twice-weekly group support meetings for five years. The VestfoldHeartcare Study Group [28] conducted an initial six-week“Heart School” at a hospital rehabilitation centre, althoughit was unclear whether this was residential. Heart Schoolinvolved physiotherapist-led PA, stress reduction educationand lifestyle counselling followed by nine weeks of twice-weekly exercise, and then meetings every three months fortwo years. No other trial contained a residential element.

3.2.3. Intervention Intensity. Some studies were of intensiveinterventions. Salminen et al. [25] delivered nurse-led lec-tures, lasting up to two hours each, once a month for 16months. In addition, eight group meetings were organisedthroughout this period, six exercise sessions, and three socialevents.

Less intensive programmes, in which patients wereencouraged to self-manage their lifestyle behaviour change,included those reported by Murphy et al. [17] and Cupplesand McKnight [22, 23], in which patients were seen everyfour months.

Another less intensive intervention, the Lyon Diet HeartStudy [32, 33], involved a one-hour education session with acardiologist and dietician, followed by a repeat visit at eightweeks and annually thereafter.

3.2.4. Professional Involvement. The interventions includedin this review involved a range of clinical and otherhealthcare staff including doctors, nurses, physiotherapists,psychologists, dieticians, and social workers. Seven of the21 trials were led by nurses, mainly based in primary care.De Lorgeril et al. [32, 33] reported a trial conducted bya cardiologist and dietician. Four studies were GP-led, oneconducted by a physiotherapist and one nutritionist-led.Other studies involved a variety of professional input.

3.3. Risk of Bias in Included Studies. The methodologicalquality of the included studies is presented in Table 2. Thequality of the trials, in terms of the method of randomisation,whether groups were similar at baseline, losses to follow up,whether intention to treat analyses were used and blinding ofoutcome assessors, is as reported in the papers.

In seven of the 21 original studies (excluding follow-up papers), the randomisation method was not clearlydescribed. In six of these trials, the method was not statedat all [16, 25, 26, 39, 43, 45]. The majority of the remain-ing studies described various randomisation techniquesincluding the use of computer-generated random numbers,random numbers tables, and sealed envelopes. Lewin et al.[29] used block randomisation, while Carlsson [42] allocatedpatients in groups of 20. Murphy et al. [17] used clusterrandomisation because their intervention was aimed toalter practitioners’ behaviour which could contaminate theirinteractions with control patients.

Loss to follow up was not reported by some authors.Where it was reported, it was defined differently. Someauthors included as losses to follow up deaths and with-drawals due to poor health, while others defined it as peoplewho could not be accounted for or contacted at follow-up.Follow-up as a quality marker relates only to original studiesand varied considerably for longer-term follow-up studies aswould be expected.

Thirteen of the 21 studies stated that analyses wereconducted using intention to treat principles. The VestfoldHeartcare Study Group [28] used the last recorded value of avariable from the previous visit if there were missing data.

Only seven out of 21 studies reported that outcomeassessors were blind to group allocation. Overall, the quality

6 Cardiology Research and Practice

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Cardiology Research and Practice 7

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)%

Men

Ou

tcom

esFo

llow

-up

Inte

rven

tion

Salm

inen

etal

.[2

5](2

005)

,Fi

nla

nd

227

pati

ents

wit

hC

HD

.

I(n=

118)

:m

ales

72.5

(5.3

),fe

mal

es75

.5(6

.6);

C(n=

109)

:m

ales

72.6

(5.5

),fe

mal

es75

.3(6

.5).

I:49

%;

C:5

0%.

Die

t(p

atie

nt

inte

rvie

ws)

,PA

(sel

fre

port

),sm

okin

g(p

atie

nt

inte

rvie

ws)

,B

P,to

tal,

LDL

and

HD

Lch

oles

tero

l.

At

com

plet

ion

of16

-mon

thin

terv

enti

on.

16-m

onth

inte

rven

tion

:n

urs

e-le

d.16

lect

ure

s:90

–120

min

ute

sea

ch;p

reve

nti

onof

CH

D,d

iet

and

wei

ght

con

trol

,exe

rcis

ing,

fin

anci

alco

nce

rns.

8gr

oup

disc

uss

ion

s:sm

allg

rou

ps,8

mee

tin

gs90

–120

min

ute

sea

ch;t

reat

men

tof

elev

ated

seru

mlip

ids,

hea

lthy

eati

ng,

CH

Dri

skfa

ctor

s.6

ligh

tex

erci

sese

ssio

ns:

60–9

0m

inu

tes

each

;w

alki

ng,

gym

nas

tics

,rel

axat

ion

.3

soci

alac

tivi

ties

:pic

nic

atn

atio

nal

park

,vis

itto

spa,

24-h

our

cru

ise.

Edu

cati

onal

Car

lsso

net

al.

[42,

43]

(199

7),

Swed

en

50–7

0ye

ars

wit

hac

ute

MI,

CA

BG

orP

TC

Ale

ssth

an2

wee

ksbe

fore

stu

dy.

Car

lsso

nA

[42]

:12

1A

MI

pati

ents

:I=

61;

C=

60;m

ean

age

62.1

.56

CA

BG

pati

ents

:I=

27;

C=

29;m

ean

age

61.5

.Car

lsso

nB

[42]

:142

AM

Ipa

tien

ts:I

=75

;C=

67;m

ean

age

62.0

.63

CA

BG

pati

ents

:I=

31;

C=

32;m

ean

age

61.3

.C

arls

son

C[4

3]:

168

pati

ents

wit

hA

MI:

I(n=

87):

62.2

;C

(n=

81):

61.9

.

A:A

MI

pati

ents

:75

%;

CA

BG

pati

ents

:84

%.

B:A

MI

pati

ents

:77

%;

CA

BG

pati

ents

:84

%.

C:7

5%

Die

t(q

ues

tion

nai

re),

PA(q

ues

tion

nai

re),

smok

ing

(qu

esti

onn

aire

),to

tal,

LDL

and

HD

Lch

oles

tero

l,u

seof

dru

gs.

At

com

plet

ion

of1-

year

inte

rven

tion

.

3-m

onth

nu

rse-

led

edu

cati

onpr

ogra

mm

e:in

divi

dual

and

grou

pco

un

selli

ng:

9h

ours

/pat

ien

t:1.

5h

ours

smok

ing

cess

atio

n,5

.5h

ours

diet

,2h

ours

PA.E

xerc

ise

trai

nin

g:2/

3ti

mes

/wee

kfo

r10

–12

wee

ks,4

0m

inu

tes

PAin

clu

din

gin

terv

altr

ain

ing

wit

hcy

clin

gan

djo

ggin

g.E

duca

tion

con

tin

ued

byn

urs

efo

r1

year

.In

divi

dual

exer

cise

sch

edu

les.

Cu

pple

san

dM

cKn

igh

t[2

2](1

994)

,U

K

688

pati

ents

wh

oh

adh

adan

gin

afo

r≥6

mon

ths.

I(n=

342)

:m

ean

age

62.7

(7.1

).C

(n=

346)

:63

.6(6

.8).

I:59

.4%

C:5

9.2%

All-

cau

sean

dC

Vm

orta

lity,

diet

(Dep

artm

ent

ofH

ealt

han

dSo

cial

Serv

ices

),PA

(pat

ien

tin

terv

iew

s),s

mok

ing

(pat

ien

tin

terv

iew

s),

BP,

chol

este

rol,

QO

L,u

seof

dru

gs.

At

com

plet

ion

of2-

year

inte

rven

tion

.C

upp

les

and

McK

nig

ht

[23]

(199

9):

5ye

ars

from

base

line.

Pati

ents

give

npr

acti

cala

dvic

ere

lati

ng

toC

Vri

skfa

ctor

san

dre

view

edby

hea

lth

visi

tors

atfo

ur

mon

thly

inte

rval

sfo

rtw

oye

ars.

8 Cardiology Research and Practice

Ta

ble

1:C

onti

nu

ed.

Sou

rce

Stu

dypo

pula

tion

Mea

nag

e(y

ears

)%

Men

Ou

tcom

esFo

llow

-up

Inte

rven

tion

Hel

ler

etal

.[4

4](1

993)

,A

ust

ralia

450

subj

ects

adm

itte

dto

hos

pita

lwit

hsu

spec

ted

MI.

I(n=

213)

:59

(8);

C(n=

237)

:58

(8).

I:76

%C

:68%

Non

fata

lCV

even

ts,

hos

pita

ladm

issi

ons,

diet

(fat

inta

ke),

PA(q

ues

tion

nai

re),

tota

lch

oles

tero

l,Q

OL

(Old

ridg

eet

al.1

989)

,u

seof

dru

gs.

At

com

plet

ion

of6-

mon

thin

terv

enti

on.

6-m

onth

inte

rven

tion

:G

P-de

liver

eded

uca

tion

alin

terv

enti

on.I

nit

iall

ette

rto

GP

onbe

nefi

tsof

aspi

rin

and

beta

-blo

cker

spl

us

firs

tof

3p

oste

dpa

ckag

esfo

rpa

tien

t.Pa

ckag

e1:

Step

1of

“Fac

tson

Fat”

kit;

quiz

,pat

ien

tta

rget

for

fat

redu

ctio

n;w

alki

ng

prog

ram

me

and

smok

ing

cess

atio

nad

vice

.Pa

ckag

e2:

Step

s2

and

3;qu

esti

ons

onpr

evio

us

wee

k’s

PA.

Pack

age

3:St

eps

4an

d5;

info

rmat

ion

onlo

calw

alki

ng

grou

ps.

Mon

thly

new

slet

ters

post

edov

ern

ext

4m

onth

sco

nta

inin

gre

cipe

s,di

etar

yan

dPA

info

rmat

ion

,an

dN

atio

nal

Hea

rtFo

un

dati

onbo

okle

t.Tw

ote

leph

one

calls

atte

mpt

ed,p

atie

nts

urg

edto

tele

phon

eif

requ

irin

gin

form

atio

n.

Sou

thar

det

al.

[31]

(200

3),

USA

104

subj

ects

wit

hC

HD

,con

gest

ive

hea

rtfa

ilure

orbo

th.

I(n=

53):

61.8

(10.

6);

C(n=

51):

62.8

(10.

6).

I:68

%C

:82%

Non

fata

lCV

even

ts,

diet

(ME

DFI

CT

Sdi

etar

ysu

rvey

),PA

(min

/wk)

,BP,

tota

l,LD

Lan

dH

DL

chol

este

rol,

trig

lyce

ride

s.

At

com

plet

ion

of6-

mon

thin

terv

enti

on.

6-m

onth

inte

rven

tion

:In

tern

etba

sed

edu

cati

onal

prog

ram

me

for

nu

rse

case

man

ager

sto

prov

ide

risk

fact

orm

anag

emen

ttr

ain

ing

and

advi

ce.

Pati

ents

acce

ssed

inte

rnet

prog

ram

me

atle

ast

once

aw

eek

for

30m

inu

tes,

com

mu

nic

atin

gw

ith

case

man

ager

via

web

site

’sin

tern

alem

ails

yste

m,c

ompl

etin

ged

uca

tion

alm

odu

les

(wit

hin

tera

ctiv

em

ult

iple

choi

cese

lf-t

ests

),en

teri

ng

data

(at

any

tim

e)to

mon

itor

prog

ress

.Opt

ion

aldi

scu

ssio

ns

wit

hot

her

part

icip

ants

,rew

ards

give

n(w

orth

$0.5

0to

$1.5

0)fo

rac

tive

part

icip

atio

non

web

site

.Die

tici

anav

aila

ble

toan

alys

e24

hou

rdi

etre

calls

.C

ase

man

ager

san

ddi

etic

ian

also

avai

labl

evi

ate

leph

one

and

post

ifn

eces

sary

.

Mul

tifa

ctor

ial

Alle

net

al.

[30]

(200

2),

USA

228

pati

ents

wit

hhy

per

chol

este

ro-

laem

iaw

ho

had

CA

BG

orP

CI.

I(n=

115)

:61

.1(1

0.3)

;C

(n=

113)

:59

.6(9

.6).

I:70

%;

C:7

3%.

Die

t(B

lock

Hea

lth

Hab

its

and

His

tory

),PA

(Aer

obic

sC

entr

equ

esti

onn

aire

),to

tal,

HD

L,an

dLD

Lch

oles

tero

l,tr

igly

ceri

des.

At

com

plet

ion

of1-

year

inte

rven

tion

.

1-ye

arin

terv

enti

on:

nu

rse

case

man

agem

ent:

plan

devi

sed

4–6

wee

ksaf

ter

hos

pita

ldi

sch

arge

incl

udi

ng

lifes

tyle

cou

nse

llin

gan

dre

view

ofdr

ug

ther

apy.

Follo

w-u

pte

leph

one

calls

tore

info

rce

cou

nse

llin

gan

dad

just

dru

gth

erap

y(e

ach

pati

ent

con

tact

edav

erag

e7

tim

esdu

rin

gfo

llow

-up

year

);on

goin

gpl

anse

nt

regu

larl

yto

doct

or.D

iet

advi

ce:<

30%

ofto

tale

ner

gyas

fat,<

7%sa

tura

ted

fat,

<20

0m

gp

erda

ych

oles

tero

l;PA

:par

tici

pati

onin

mod

erat

ein

ten

sity

hom

e-ba

sed

exer

cise

prog

ram

me;

refe

rral

toC

R;

smok

ing

cess

atio

nad

vice

and

rela

pse

prev

enti

on.

Cardiology Research and Practice 9T

abl

e1:

Con

tin

ued

.

Sou

rce

Stu

dypo

pula

tion

Mea

nag

e(y

ears

)%

Men

Ou

tcom

esFo

llow

-up

Inte

rven

tion

Cam

pbel

let

al.[

34]

(199

8)A

(Hea

rt)

1343

pati

ents

wit

hC

HD

.A

t1

yr:I

=59

3;C=

580.

6658

.2%

Die

t(D

ieta

ryIn

stru

men

tfo

rN

utr

itio

nE

duca

tion

(DIN

E)

ques

tion

nai

re),

PA(H

ealt

hP

ract

itio

ner

sIn

dex

Qu

esti

onn

aire

),sm

okin

g(H

ealt

hP

ract

itio

ner

sIn

dex

Qu

esti

onn

aire

),B

P,lip

idm

anag

emen

t,as

piri

nm

anag

emen

t.

At

com

plet

ion

of1-

year

inte

rven

tion

.

1-ye

arin

terv

enti

on:

Nu

rse-

led

clin

ics

topr

omot

em

edic

alan

dlif

esty

leas

pect

sof

seco

nda

rypr

even

tion

.Clin

ics:

4st

ages

:(1)

Rev

iew

ofsy

mpt

oms

toid

enti

fypo

orco

ntr

olan

dre

fer

acco

rdin

gly.

(2)

Rev

iew

ofdr

ug

trea

tmen

t;en

cou

rage

aspi

rin

use

.(3)

BP

and

lipid

asse

ssm

ent.

(4)

Ass

essm

ent

ofex

erci

se,d

iet,

smok

ing,

and

beh

avio

ur

chan

ges

sugg

este

d.Fo

llow

-up

visi

tsev

ery

2–6

mon

ths;

20m

inu

tes.

Mu

rch

ieet

al.[

36]

(200

3)A

:at

4-ye

arfo

llow

-up:

I=

564;

C=

534.

I:65

.4(8

.2);

C:6

5.7

(8.6

).A

sab

ove

As

abov

epl

us:

All-

cau

sem

orta

lity,

CV

even

ts.

4ye

ars

from

base

line.

As

abov

e.

Cam

pbel

let

al.[

35]

(199

8)B

:as

Cam

pbel

lAA

sC

ampb

ellA

As

Cam

p-be

llA

QO

L(S

hor

tFo

rm(S

F)36

ques

tion

nai

re)

At

com

plet

ion

of1-

year

inte

rven

tion

.

As

Cam

pbel

lA

Mu

rch

ieet

al.[

37]

(200

4)B

:as

Mu

rch

ieA

As

Mu

rch

ieA

As

Mu

rch

ieA

QO

L(S

F36

)4

year

sfr

omba

selin

e

Del

aney

etal

.[38

](2

008)

:at

10-y

ear

follo

w-u

p53

1of

1343

orig

inal

coh

ort

had

died

.

All-

cau

sem

orta

lity

and

coro

nar

yev

ents

(non

fata

lMIs

and

coro

nar

yde

ath

s).

10ye

ars

from

base

line.

Gia

llau

ria

etal

.[18

](2

009)

,Ita

ly

52pa

tien

tsw

ith

acu

tem

yoca

rdia

lin

farc

tion

(AM

I).

I(n=

26):

58.2

(7.8

);C

(n=

26):

57.4

(9.7

).

I:85

%;

C:8

5%.

Non

fata

lCV

even

ts,

PA(c

ycle

ergo

met

erte

st),

BP,

tota

l,LD

Lan

dH

DL

chol

este

rol,

trig

lyce

ride

s.

At

com

plet

ion

of2-

year

inte

rven

tion

.

2-ye

arin

terv

enti

on:

edu

cati

onal

and

beh

avio

ura

l;in

divi

dual

and

grou

p.E

ach

pati

ent

give

nbo

okle

ton

exer

cise

,die

tan

dsm

okin

gce

ssat

ion

,an

did

ealt

arge

ts.M

onth

lyh

ospi

talv

isit

s:di

etar

yad

vice

,re

info

rcem

ent

ofh

ealt

hylif

esty

les,

exer

cise

trai

nin

gse

ssio

nto

60–7

0%of

VO

2p

eak.

Gia

nu

zzie

tal

.[2

1](2

008)

,It

aly

3241

pati

ents

wit

hre

cen

tM

I(w

ith

inpa

st3

mon

ths)

.57

.9(9

.2)

86.3

%

All-

cau

sean

dC

Vm

orta

lity,

non

fata

lC

Vev

ents

,die

t(k

now

ledg

e/h

abit

s),

PA(q

ues

tion

nai

re),

smok

ing

(qu

esti

onn

aire

),B

P,to

tal,

HD

Lan

dLD

Lch

oles

tero

l,se

lf/s

tres

sm

anag

emen

t,u

seof

dru

gs.

At

com

plet

ion

of3-

year

inte

rven

tion

;D

ata

colle

cted

at6

mon

ths,

1,2

and

3ye

ars.

3-ye

arin

terv

enti

on:

mu

ltif

acto

rial

,con

tin

ued

edu

cati

onal

and

beh

avio

ura

l;m

onth

lyse

ssio

ns

from

mon

ths

1to

6,th

enev

ery

6m

onth

sfo

r3

year

s.E

ach

sess

ion

:30

min

ute

ssu

perv

ised

aero

bic

exer

cise

;lif

esty

lean

dri

skfa

ctor

cou

nse

llin

gla

stin

gat

leas

t1h

our;

rein

forc

emen

tof

prev

enti

vein

terv

enti

ons.

Boo

klet

onh

owto

deal

wit

hex

erci

se,d

iet,

smok

ing

cess

atio

n,a

nd

stre

ssm

anag

emen

t.Ta

rget

s:ce

ase

smok

ing,

adop

tM

edit

erra

nea

ndi

et,i

ncr

ease

PAto

atle

ast

3hou

rs/w

eek

at60

–75%

ofm

ean

max

hea

rtra

te,m

ain

tain

BM

Iof

<25

,BP

140/

85,t

otal

chol

este

rol<

200

mg/

dL,L

DL

chol<

100

mg/

dL,b

lood

glu

cose

<11

0m

g/dL

.Dru

gtr

eatm

ents

pos

itiv

ely

reco

mm

ende

d.

10 Cardiology Research and Practice

Ta

ble

1:C

onti

nu

ed.

Sou

rce

Stu

dypo

pula

tion

Mea

nag

e(y

ears

)%

Men

Ou

tcom

esFo

llow

-up

Inte

rven

tion

Ham

alai

nen

etal

.[45

](1

995)

,Fi

nla

nd

375

subj

ects

wit

hM

I.

I(n=

188)

:m

ean

age

men

53.4

,wom

en58

.8.

C(n=

187)

:m

ean

age

men

53.0

,wom

en58

.4.

I:80

%C

:80%

All-

cau

sean

dC

Vm

orta

lity,

PA(c

ycle

ergo

met

erte

st),

smok

ing

(pat

ien

tin

terv

iew

s),B

P,ch

oles

tero

l,tr

igly

ceri

des.

15ye

ars

from

base

line.

3-ye

arin

terv

enti

on:

opti

mal

med

ical

care

,phy

sica

lact

ivat

ion

,an

tism

okin

g,di

etar

y,ps

ych

osoc

ialc

oun

selli

ng

led

byso

cial

wor

ker,

psyc

hol

ogis

t,di

etic

ian

,phy

siot

her

apis

t,an

ddo

ctor

s.In

terv

enti

onm

ost

inte

nsi

vefo

r3

mon

ths

afte

rA

MI,

clos

eco

nta

cts

wit

hte

amm

ain

tain

edov

er3

year

s.

Mu

rphy

etal

.[1

7](2

009)

,N

orth

ern

Irel

and

and

Rep

ubl

icof

Irel

and

903

subj

ects

wit

hC

HD

recr

uit

edfr

om48

gen

eral

prac

tice

s.

I(n=

444)

:68

.5(9

.3);

C(n=

459)

:66

.5(9

.9).

I:70

%;

C:7

0%.

BP,

tota

lch

oles

tero

l,h

ospi

tala

dmis

sion

s,Q

OL

(SF

12),

diet

(DIN

Equ

esti

onn

aire

),PA

(God

inqu

esti

onn

aire

),sm

okin

g(S

lan

Nat

ion

alSu

rvey

ofH

ealt

han

dLi

fest

yles

inIr

elan

d).

At

com

plet

ion

of18

-mon

thin

terv

enti

on.

GP

and

nu

rse-

led

tailo

red

care

plan

sfo

rpr

acti

ces:

trai

nin

gin

pres

crib

ing

and

beh

avio

ur

chan

ge,a

dmin

istr

ativ

esu

ppor

t,qu

arte

rly

new

slet

ter;

Tailo

red

care

plan

sfo

rpa

tien

ts:m

otiv

atio

nal

inte

rvie

win

g,go

alse

ttin

g,ta

rget

sett

ing

for

lifes

tyle

chan

ge,i

nfo

book

let

give

nto

each

pati

ent,

prog

ress

revi

ewed

ever

y4

mon

ths.

(Soc

ialc

ogn

itiv

eth

eory

use

dto

deve

lop

trai

nin

gin

beh

avio

ur

chan

ge,d

esig

npa

tien

tin

fobo

okle

t,an

din

form

deve

lopm

ent

ofta

ilore

dpa

tien

tca

repl

ans.

)

Orn

ish

etal

.[4

1](1

998)

,U

SA

48pa

tien

tsw

ith

mod

erat

eto

seve

reC

HD

.

I(n=

20):

57.4

(6.4

);C

(n=

15):

61.8

(7.5

).

I:10

0%C

:80%

CV

mor

talit

y,n

onfa

talC

Vev

ents

,h

ospi

tala

dmis

sion

s,di

et(d

iari

es),

PA(q

ues

tion

nai

reon

typ

e,fr

equ

ency

,du

rati

on),

BP,

tota

l,LD

Lan

dH

DL

chol

este

rol,

trig

lyce

ride

s,ap

olip

opro

tein

s.

At

com

plet

ion

of5-

year

inte

rven

tion

.

5-ye

arin

terv

enti

on:

wee

klo

ng

edu

cati

onal

resi

den

tial

stay

ath

otel

(Orn

ish

etal

.,19

90).

Gro

up

supp

ort

mee

tin

gs,4

hou

rstw

ice

aw

eek.

Die

t:lo

wfa

tve

geta

rian

,for

atle

ast

aye

ar:f

ruit

,veg

etab

les,

grai

ns,

legu

mes

,soy

bean

prod

uct

s;n

oan

imal

prod

uct

sex

cept

egg

wh

ite

and

1cu

p/da

yof

non

fat

milk

oryo

ghu

rt.S

tres

sm

anag

emen

tte

chn

iqu

es;a

dvis

edat

leas

t1

hou

r/da

y;au

dioc

asse

tte

tape

toas

sist

.E

xerc

ise:

indi

vidu

alpr

escr

ipti

onac

cord

ing

toba

selin

etr

eadm

illte

stre

sult

s,m

ain

lyw

alki

ng;

atle

ast

3h

ours

/wee

k,30

min

ute

sp

erse

ssio

n.

Clin

ical

psyc

hol

ogis

t-le

dgr

oup

disc

uss

ion

s:so

cial

supp

ort

toen

cou

rage

adh

eren

ce.

Red

fern

etal

.[1

9](2

008)

A,

Au

stra

lia

144

acu

teco

ron

ary

syn

drom

e(A

CS)

surv

ivor

sn

otac

cess

ing

stan

dard

card

iac

reh

abili

tati

on(C

R).

I(n=

72):

62(1

.6);

C(n=

72):

67(1

.3).

I:74

%;

C:7

5%.

PA(P

hysi

calA

ctiv

ity

Rea

din

ess

Qu

esti

onn

aire

(PA

RQ

)),s

mok

ing

(sel

frep

ort/

Air

met

Scie

nti

fic

Mic

ro-s

mok

anal

yser

),B

P,to

talc

hol

este

rol.

At

com

plet

ion

of3-

mon

thin

terv

enti

on.

Red

fern

etal

.[2

0](2

009)

B:1

2m

onth

sfr

omba

selin

e

GP-

led

beh

avio

ur

chan

gein

terv

enti

on;1

hou

rin

itia

lco

nsu

ltat

ion

,3m

onth

sof

5ph

one

calls

(Red

fern

etal

.,20

06)

for

risk

fact

ored

uca

tion

,ass

erti

ven

ess

trai

nin

gan

das

sess

men

tof

lifes

tyle

goal

s.M

anda

tory

chol

este

roll

ower

ing

mod

ule

,in

clu

din

gh

ealt

hyea

tin

gan

dph

arm

acol

ogic

alad

vice

,an

dch

oice

of2

oth

erm

odu

les

incl

udi

ng

BP

low

erin

g,sm

okin

gce

ssat

ion

,an

dPA

;ch

oice

ofm

anag

emen

top

tion

sfo

rri

skfa

ctor

sin

clu

din

gdo

ctor

-dir

ecte

d,su

chas

aPA

“scr

ipt”

from

GP,

hos

pita

lpro

gram

me,

for

exam

ple,

exer

cise

clas

s,in

divi

dual

prog

ram

me,

orse

lf-h

elp.

Cardiology Research and Practice 11

Ta

ble

1:C

onti

nu

ed.

Sou

rce

Stu

dypo

pula

tion

Mea

nag

e(y

ears

)%

Men

Ou

tcom

esFo

llow

-up

Inte

rven

tion

Ves

tfol

dH

eart

care

Stu

dyG

rou

p[2

8](2

003)

,N

orw

ay

197

subj

ects

wit

hac

ute

MI,

hos

pita

lisat

ion

for

un

stab

lean

gin

a,P

CI,

orC

AB

G.

I(n=

98):

54(8

);C

(n=

99):

55(8

).

I:81

%;

C:8

3%.

Hos

pita

ladm

issi

ons,

diet

(FFQ

),PA

(sel

f-re

port

/dia

ries

),sm

okin

g(s

elf-

repo

rt),

BP,

tota

lan

dH

DL

chol

este

rol,

QO

L(S

F36

),u

seof

dru

gs.

At

com

plet

ion

of2-

year

inte

rven

tion

.

2-ye

arin

terv

enti

on:

6-w

eek

“hea

rtsc

hoo

l”in

hos

pita

l:PA

wit

hph

ysio

ther

apis

t:15

min

ute

sw

arm

-up,

20m

inu

tes

wal

kin

g,10

min

ute

sco

ol-d

own

,10

min

ute

sst

retc

hin

g;ad

vise

dto

exer

cise

onth

eir

own

ever

yda

y.E

duca

tion

sess

ion

s:tw

ice

aw

eek,

2h

ours

each

;die

tary

advi

ce,

smok

ing

cess

atio

n,P

Aco

un

selli

ng,

risk

fact

orm

anag

emen

t,ps

ych

osoc

ialm

anag

emen

t,m

edic

atio

n,s

tres

sre

duct

ion

;in

divi

dual

cou

nse

llin

g.Fo

llow

edby

9w

eeks

’org

anis

edPA

twic

ea

wee

kat

gym

supe

rvis

edby

phys

ioth

erap

ist;

leve

lin

crea

sed

tojo

ggin

g;gr

oup

mee

tin

gsev

ery

3rd

mon

thth

rou

ghou

t2

year

follo

w-u

p.

Wal

lner

etal

.[3

9](1

999)

,A

ust

ria

60pa

tien

ts<

70ye

ars

wit

han

giog

raph

ical

lydo

cum

ente

dC

AD

and

stab

lean

gin

ape

ctor

is;r

ecru

ited

afte

rsu

cces

sfu

lel

ecti

veP

TC

A.

I(n=

28):

58(8

).C

(n=

32):

60(7

)

I:89

%;

C:6

9%.

Non

fata

lCV

even

ts,

diet

(7-d

ayw

eigh

ted

food

reco

rds)

,PA

(Min

nes

ota

Leis

ure

Tim

equ

esti

onn

aire

),B

P,LD

Lan

dH

DL

chol

este

rol.

Mea

n26

mon

ths

(ran

ge18

–31)

afte

rba

selin

e.

12-m

onth

inte

rven

tion

:n

utr

itio

nis

t-le

d.A

llpa

tien

tsat

base

line:

diet

ary

and

lifes

tyle

advi

ce:c

hol

este

rol1

00–1

50m

g/da

y,fi

bre≥2

5g/

day,

PA≥3

tim

es/w

eek

for

30m

inu

tes,

smok

ing

cess

atio

n.I

grou

p:1-

hou

rdi

etar

yad

vice

sess

ion

sw

ith

nu

trit

ion

ist

wee

kly

duri

ng

firs

tm

onth

,eve

ry2

wee

ksu

nti

lmon

th3

then

mon

thly

un

til

end

ofin

terv

enti

on.

Org

anis

atio

nal

Jolly

etal

.[40

](1

999)

,UK

597

pati

ents

;422

wit

hM

Ian

d17

5w

ith

new

diag

nos

isof

angi

na.

I(n=

277)

:63

(10)

;C

(n=

320)

:64

(10)

.

I:68

%;

C:7

4%.

Tota

lch

oles

tero

l,B

P,PA

(qu

esti

onn

aire

,w

alki

ng

test

),sm

okin

g(q

ues

tion

nai

re),

BM

I.

At

com

plet

ion

of1-

year

inte

rven

tion

.

Led

by3

spec

ialis

tca

rdia

clia

ison

nu

rses

resp

onsi

ble

for

coor

din

atin

gfo

llow

-up

care

,esp

ecia

llytr

ansf

erof

resp

onsi

bilit

yfo

rca

rebe

twee

nh

ospi

tala

nd

GP.

Liai

son

nu

rses

prov

ided

supp

ort

topr

acti

cest

affby

phon

ean

dvi

sits

topr

acti

ceev

ery

3–6

mon

ths.

Pra

ctic

en

urs

esen

cou

rage

dto

atte

nd

trai

nin

gon

beh

avio

ur

chan

geba

sed

onst

ages

ofch

ange

mod

el.E

ach

pati

ent

was

give

na

pati

ent

hel

dre

cord

,w

hic

hpr

ompt

edan

dgu

ided

follo

w-u

p(a

tap

prox

imat

ely

4to

6m

onth

inte

rval

s).

Mu

noz

etal

.[2

4](2

007)

,Sp

ain

983

subj

ects

wit

hM

I,an

gin

a,or

isch

aem

iaw

ith

inpr

evio

us

6ye

ars.

I(n=

515)

:64

.2(9

.8);

C(n=

468)

:63

.6(1

0.3)

.

I:76

.1%

;C

:73.

2%.

Tota

lmor

talit

y,C

Vm

orta

lity,

non

fata

lC

Vev

ents

,PA

(sel

fre

port

),B

P,to

tal,

LDL

and

HD

Lch

oles

tero

l,Q

OL

(SF

12),

use

ofdr

ugs

.

At

com

plet

ion

of3-

year

inte

rven

tion

oru

nti

lan

endp

oin

toc

curr

ed.

3-ye

arin

terv

enti

on:

Post

alre

min

ders

tose

eG

Pev

ery

3m

onth

sdu

rin

g3-

year

follo

w-u

p.G

Psst

rict

lyfo

llow

edm

ost

rece

nt

guid

elin

eson

CV

prev

enti

on,p

rovi

depa

tien

tsw

ith

hea

lthy

lifes

tyle

advi

cein

clu

din

gM

edit

erra

nea

ndi

et,P

Aan

dsm

okin

gce

ssat

ion

;ad

just

edtr

eatm

ents

.

I:in

terv

enti

on;C

:con

trol

12 Cardiology Research and Practice

of many trials was poor with a majority not having blindedoutcome assessors and many not describing the method ofrandomisation.

3.4. Effects of Interventions

3.4.1. All-Cause Mortality. Six studies reported total mor-tality and are presented in Figure 2. Overall, four studiesshowed benefits for intervention patients compared tocontrols in relation to total mortality. Because of the largedifferences in follow-up periods, we have used data fromthe studies which range from 3 to 5 years to allow easiercomparison of studies. For all interventions except two, thisconstituted their study endpoint.

Murchie et al. [36] reported a significant survival effectfor intervention patients compared to controls at their 4.7year follow-up. Within the same study, Delaney et al. [38]reported that, at 10 years, the observed difference was nolonger significant between the groups.

Hamalainen et al. [45] reported a significant survivaleffect for intervention patients compared to controls at their4.7 year follow-up.

The I2 test for heterogeneity combined with the Chi2

nonsignificant P value suggests that the level of heterogeneitybetween studies is not important.

3.4.2. Cardiovascular Mortality. Eight studies reported car-diovascular mortality and are presented in Figure 3. Threestudies showed significant survival effects. Data were col-lected at times ranging from 2 to 5 years. Delaney et al. [38]reported a 10-year follow-up study but we have presentedtheir data collected at 4.7 years to allow for easier comparisonwith other studies. For the same reason we have used datareported by Hamalainen et al. [45] at three years of follow-up instead of the authors’ results at 15 years.

The three studies reporting significant survival effectswere Cupples and McKnight [22], two-year follow-up resultsfrom an educational intervention, De Lorgeril et al. [33],a Mediterranean diet study with four-year follow-up, andHamalainen et al. [45], a trial of a multifactorial intervention.

Hamalainen et al. [45], who reported coronary mortality,also reported significant survival effects for interventionpatients compared to controls in their 15-year follow-up study. Delaney et al. [38] reported CV and coronarydeaths at both 4.7- and 10-year follow-up points. However,the mortality figures were combined with nonfatal MI tocalculate a proportional hazard ratio. Murchie et al. [36],a paper from the same study at 4.7 years of follow-up,reported an adjusted hazard ratio of 0.76 for coronary events(coronary deaths plus nonfatal MIs) (0.58 to 1.00, P = .049).

The I2 test for heterogeneity indicated a moderate levelof heterogeneity across studies.

3.4.3. Nonfatal Cardiac Events. This was reported by ninestudies. In Figure 4, we have presented data for majornonfatal events (MI, CABG, PCI, coronary angioplasty).Significant benefits for intervention patients compared tocontrols were shown by five studies. Four studies reported

nonfatal events separately [21, 33, 41, 44] while five reportedthe number of patients who had an event.

Lisspers et al. [27] included mortality in “event” results,therefore although they reported figures for various eventsand mortality they did not report a separate statistic fornonfatal events. Delaney et al. [38] reported coronary eventswhich included coronary deaths and nonfatal MIs; howeverseparate figures for each variable were not reported.

Gianuzzi et al. [21] reported nonfatal stroke, heart fail-ure, and angina data but none of the values was significant.

Lewin et al. [29] reported the frequency of angina attackin number of episodes per week. Intervention group patientshad a reduction of three attacks per week compared to areduction of 0.4 attacks among control subjects (P = .016).

In addition to nonfatal MI and coronary revascularisa-tion, De Lorgeril et al. [33] reported a number of major andminor secondary endpoints. They calculated risk ratios fornonfatal AMI combined with CV deaths, major secondaryendpoints (periprocedural infarction, unstable angina, heartfailure, stroke, pulmonary embolism, peripheral embolism)combined with primary endpoints, and primary and majorsecondary endpoints combined with minor secondary end-points (stable angina, post-PCTA restenosis, and throm-bophlebitis). Separate risk ratios for nonfatal CV events werenot reported.

In addition to MI, PTCA, and CABG, Ornish et al. [41]reported the frequency, duration, and severity of angina chestpain at one year and five years. One significant value out ofthree outcomes reported at the two different time points eachwas reported: chest pain severity (scale 1–7, baseline to oneyear: intervention group 1.5 (1.5) to 0.7 (1.2); control group0.6 (0.8) to 1.4 (1.2); P < .001).

The I2 test for heterogeneity indicated that there maybe substantial heterogeneity across studies so results of thismeta-analysis have to be interpreted with caution.

3.4.4. Hospital Admissions. Five studies reported resultsrelating to hospital admissions. While there was an overalltrend to reduced admissions in intervention groups, onlyone of these studies reported a significant reduction inintervention patients [17]. The data are presented in Table 3.

3.4.5. Lifestyle Risk Factors. Data relating to lifestyle riskfactors for CHD–diet, PA, and smoking are presented inTable 4.

Table 5 shows a summary of lifestyle risk findings fromour included studies. For each of the three areas of diet,exercise, and smoking, we have presented the number ofstudies reporting each outcome, the number of outcomes,and the numbers of significant and nonsignificant values.

Diet. Fifteen studies reported diet as an outcome, witha total of 51 outcomes. Of these, 39 showed significantbenefits for intervention patients compared to controls inrelation to dietary consumption. These included significantimprovement in specific food intake, such as fat, fibre, sugar,and cholesterol [28, 30, 33, 34, 39, 41], diet score, diet

Cardiology Research and Practice 13T

abl

e2:

Met

hod

olog

ical

qual

ity

ofin

clu

ded

stu

dies

.

Sou

rce

Ran

dom

isat

ion

met

hod

Gro

ups

sim

ilar

atba

selin

eL

oss

tofo

llow

up

Inte

nti

onto

trea

tan

alys

es?

Ass

esso

rsbl

ind?

Exe

rcis

e

Ast

engo

etal

.[1

6](2

010)

Un

clea

r.M

eth

odof

ran

dom

isat

ion

not

stat

ed.A

uth

ors

stat

era

ndo

mis

ed“t

otr

ain

ing

grou

por

con

trol

.”

Yes

On

lysi

gnifi

can

tdi

ffer

ence

was

fast

ing

glu

cose

leve

l(h

igh

erin

inte

rven

tion

(I)

grou

pth

anco

ntr

ol(C

)).

Non

e.Si

xpa

tien

ts(9

.7%

)h

adm

ajor

clin

ical

com

plic

atio

ns

and

did

not

com

plet

est

udy

.U

ncl

ear

Un

clea

r

Die

tary

De

Lorg

eril

etal

.[32

,33]

(199

6,19

99)

Cle

ar.

Con

secu

tive

pati

ents

wit

hfi

rst

MI

ran

dom

ised

.In

clu

sion

base

don

mod

ified

Zel

ende

sign

.

Yes

Exc

ept:

smok

ers

(mor

ein

Igr

oup)

.

Not

clea

r.R

ate

ofw

ith

draw

alfr

omfo

llow

-up

rep

orte

d:I

=8%

C=

7%(D

eLo

rger

ilet

al.[

46],

1994

)Ye

sYe

s

Psyc

holo

gica

l

Lew

inet

al.

[29]

(200

2)

Cle

ar.

Elig

ible

pati

ents

allo

cate

dto

Ior

Cgr

oup

bybl

ock

ran

dom

isat

ion

,str

atif

yin

gfo

rag

ean

dse

x.

Yes

Not

clea

r.9

drop

outs

(6.3

%),

1di

dn

otre

turn

ques

tion

nai

res

(0.7

%),

and

2di

ed(1

.4%

).Ye

sYe

s

Liss

pers

etal

.[2

6](1

999)

Un

clea

r.M

eth

odn

otst

ated

/des

crib

ed.

Yes;

Exc

ept

Cgr

oup:

sign

ifica

ntl

yh

igh

erpr

opor

tion

taki

ng

beta

bloc

kers

.

Dat

am

issi

ng

from

exer

cise

test

s(4

Ipa

tien

ts,4

Cs)

,an

dqu

esti

onn

aire

s(n

um

bers

not

stat

ed).

5-ye

arfo

llow

-up

(Lis

sper

set

al.[

27],

2005

):da

taav

aila

ble

from

28in

terv

enti

onpa

tien

ts(3

9%lo

ss)

and

27co

ntr

ol(3

4%lo

ss).

Furt

her

deta

iln

otre

port

ed.

Un

clea

rU

ncl

ear

Salm

inen

etal

.[2

5](2

005)

Un

clea

r.M

eth

odn

otst

ated

/des

crib

ed.A

uth

ors

stat

edth

atpa

tien

tsid

enti

fied

from

lon

gitu

din

alst

udy

data

and

ran

dom

lydi

vide

din

toin

terv

enti

onan

dco

ntr

olgr

oups

.

Yes

Non

e.12

did

not

wis

hto

take

part

inst

udy

afte

rra

ndo

mis

atio

n(4

.5%

);29

died

(10.

8%).

Un

clea

rU

ncl

ear

Edu

cati

onal

Car

lsso

net

al.

[42,

43]

(199

7,19

98)

Un

clea

r.C

arls

son

Aan

dB

[42]

:pat

ien

tsra

ndo

mis

edin

grou

psof

20;n

ofu

rth

erde

tail

onm

eth

odgi

ven

.Car

lsso

nC

[43]

:pat

ien

tsad

mit

ted

toco

ron

ary

care

un

itw

ho

fulfi

lled

incl

usi

oncr

iter

iaw

ere

ran

dom

ised

.

Car

lsso

nA

,B,a

nd

C:y

es

Car

lsso

nA

,B,a

nd

C:u

ncl

ear.

Car

lsso

nC

:4(4

.9%

)of

usu

alca

repa

tien

tslo

stto

follo

wu

p;n

oda

tagi

ven

for

inte

rven

tion

pati

ents

.Au

thor

sre

port

edfi

gure

sfo

rm

issi

ng

data

rela

tin

gto

spec

ific

vari

able

s.

Car

lsso

nA

,B,

and

C:

un

clea

r.

Car

lsso

nA

,B,a

nd

C:

un

clea

r.

Cu

pple

san

dM

cKn

igh

t[2

2](1

994)

.

Cle

ar.

Pati

ents

ran

dom

ised

toon

eof

two

grou

ps.A

hea

lth

visi

tor

open

edan

opaq

ue,

seal

ed,a

nd

nu

mbe

red

enve

lope

con

tain

ing

the

allo

cati

onw

hic

hh

adbe

enge

ner

ated

bya

com

pute

rpr

ogra

mm

eu

sin

gra

ndo

mpe

rmu

ted

bloc

ks.

Yes

2ye

ars:

I:25

/342

(7.3

%).

C:4

6/34

6(1

3.3%

);re

ason

sgi

ven

5ye

ars

[23]

:I:

92/3

42(2

9.9%

).C

:109

/346

(31.

5%);

reas

ons

give

n.

Yes

Yes

14 Cardiology Research and PracticeT

abl

e2:

Con

tin

ued

.

Sou

rce

Ran

dom

isat

ion

met

hod

Gro

ups

sim

ilar

atba

selin

eL

oss

tofo

llow

up

Inte

nti

onto

trea

tan

alys

es?

Ass

esso

rsbl

ind?

Hel

ler

etal

.[4

4](1

993)

Cle

ar.

Pati

ents

allo

cate

dto

Ior

Cgr

oups

acco

rdin

gto

nam

eof

GP.

Gen

eral

prac

tice

sst

rati

fied

byn

um

ber

ofdo

ctor

san

dra

ndo

mly

allo

cate

dto

Ior

C.

Yes

I=

213,

C=

237:

nos

.not

sim

ilar

beca

use

ran

dom

isat

ion

was

byG

P.

Did

not

retu

rnfo

llow

-up

ques

tion

nai

res:

I:45

/213

(21.

1%)

C:3

0/23

7(1

2.7%

)(n

ofu

rth

erde

tail

give

n)

Un

clea

rU

ncl

ear

Sou

thar

det

al.

[31]

(200

3)

Cle

ar.

Pati

ents

stra

tifi

edby

eth

nic

grou

p,C

Rpa

rtic

ipat

ion

,an

dac

ute

stat

us,

then

allo

cate

dto

Ior

Cgr

oups

byco

mpu

ter

gen

erat

edra

ndo

mn

um

ber.

Yes

4(3

.84%

);re

ason

sst

ated

.Ye

sU

ncl

ear

Mul

tifa

ctor

ial

Alle

net

al.

[30]

(200

2)

Cle

ar.

Con

secu

tive

pati

ents

ran

dom

ised

wit

hco

mpu

teri

sed

sch

ema.

Yes

Un

clea

r.15

8ou

tof

228

com

plet

edfo

llow

-up

(31%

loss

);re

ason

sfo

rth

ese

loss

esgi

ven

.Ye

sU

ncl

ear

Cam

pbel

let

al.[

34]

(199

8)

Cle

ar.

Ran

dom

nu

mbe

rsta

bles

use

dto

cen

tral

lyra

ndo

mis

epa

tien

ts(b

yin

divi

dual

afte

rst

rati

fica

tion

byag

e,se

x,an

dpr

acti

ce)

toI

and

Cgr

oups

.

Yes

Un

clea

r.A

vaila

ble

at1-

year

anal

ysis

:I:5

93(8

8%)

out

ofor

igin

alto

tal6

73;C

:580

(87%

)ou

tof

670;

reas

ons

for

loss

give

n.

Yes

Un

clea

r

Mu

rch

ieet

al.[

36]

(200

3):a

vaila

ble

at4-

year

follo

w-u

pan

alys

is:I

:500

(74%

);C

:461

(69%

);re

ason

sfo

rlo

ssgi

ven

.D

elan

eyet

al.[

38]

(200

8):a

vaila

ble

at10

-yea

rfo

llow

-up:

I:38

5(5

7%);

C:3

65(5

4%).

Th

ese

figu

res

incl

ude

deat

hs

but

loss

tofo

llow

up

was

repo

rted

as62

pati

ents

(4.6

%).

Gia

llau

ria

etal

.[18

](2

009)

Cle

ar.

Pati

ents

ran

dom

ised

1:1

usi

ng

com

pute

rge

ner

ated

ran

dom

isat

ion

.Ye

sN

one

Un

clea

rU

ncl

ear

Gia

nu

zzie

tal

.[2

1](2

008)

Cle

ar.

Pati

ents

ran

dom

ised

1-to

-1;r

ando

mis

atio

nce

ntr

ally

dete

rmin

edby

fax

atco

ordi

nat

ing

secr

etar

iat

usi

ng

com

pute

rise

dal

gori

thm

.

Yes

154

(4.7

%).

Yes

Yes

Ham

alai

nen

etal

.[45

](1

995)

Un

clea

r.C

onse

cuti

vepa

tien

tsh

ospi

talis

edfo

rA

MI

allo

cate

dto

Ior

Cgr

oup

byst

rati

fied

ran

dom

isat

ion

.No

furt

her

deta

ilon

met

hod

give

n.

Yes

Un

clea

rU

ncl

ear

Un

clea

r

Mu

rphy

etal

.[1

7](2

009)

Cle

ar.

Pra

ctic

es:c

ompu

ter

gen

erat

edra

ndo

mn

um

bers

;pat

ien

ts:r

ando

mly

sele

cted

atre

mot

esi

te,s

ent

invi

tati

onin

sequ

ence

from

lists

inra

ndo

mor

der.

Yes

Exc

ept:

diff

eren

tpr

opor

tion

sin

con

trol

and

inte

rven

tion

grou

psad

mit

ted

toh

ospi

tali

npr

evio

us

12m

onth

s.T

his

was

adju

sted

for

inan

alys

is.

Non

eYe

sYe

s

Cardiology Research and Practice 15T

abl

e2:

Con

tin

ued

.

Sou

rce

Ran

dom

isat

ion

met

hod

Gro

ups

sim

ilar

atba

selin

eL

oss

tofo

llow

up

Inte

nti

onto

trea

tan

alys

es?

Ass

esso

rsbl

ind?

Orn

ish

etal

.[4

1](1

998)

Un

clea

r.M

eth

odst

ated

;not

fully

desc

ribe

d.A

fter

angi

ogra

phy

pati

ents

ran

dom

ised

usi

ng

invi

tati

onal

desi

gnto

min

imis

ecr

osso

ver,

eth

ical

con

cern

s,n

oceb

oeff

ects

,an

ddr

opou

t.

Yes

Exc

ept

Cgr

oup

had

sign

ifica

ntl

yh

igh

erle

vels

ofH

DL-

chol

and

apol

ipop

rote

inA

-I.

20(7

1%)

inte

rven

tion

pati

ents

com

plet

ed5-

year

follo

w-u

p;15

(75%

)co

ntr

olpa

tien

ts.

Yes

Yes

Red

fern

etal

.[1

9](2

008)

Cle

ar.

Con

secu

tive

pati

ents

ran

dom

ised

follo

win

gbl

inde

dba

selin

eas

sess

men

t.C

ompu

ter

gen

erat

edra

ndo

mal

loca

tion

sequ

ence

was

impl

emen

ted

usi

ng

con

secu

tive

lyn

um

bere

den

velo

pes

.

Of1

5de

mog

raph

ican

dcl

inic

alch

arac

teri

stic

s,gr

oups

wer

esi

mila

rin

9.St

atis

tica

llydi

ffer

ent

wer

eE

uro

pea

nan

dA

sian

/Afr

ican

orig

in,

empl

oym

ent

stat

us,

CV

Dh

isto

ry,a

nd

CA

BG

stat

us.

1(u

nco

nta

ctab

le).

(4w

ith

drew

,3di

ed).

Yes

Yes

Ves

tfol

dH

eart

care

Stu

dyG

rou

p[2

8](2

003)

Cle

ar.

Pati

ents

ran

dom

ised

byu

seof

prep

repa

red

seal

edop

aqu

een

velo

pes

con

tain

ing

deta

ilson

grou

pal

loca

tion

.Pat

ien

tsop

ened

enve

lope

sso

that

thei

rgr

oup

allo

cati

onw

asre

veal

edto

them

wit

hou

tpr

evio

us

know

ledg

eof

stu

dyin

vest

igat

ors.

Yes

Un

clea

r.Pe

rcen

tage

sat

ten

din

gfo

llow

-up

mee

tin

gs,

keep

ing

diar

ies

and

adh

erin

gto

PAle

vels

only

give

nfo

rI

grou

p.

Un

clea

r:w

her

eth

ere

wer

em

issi

ng

data

at6

mon

ths

and

2ye

ars,

the

last

reco

rded

valu

eof

the

vari

able

from

prev

iou

svi

sit

was

use

d.

Un

clea

r

Wal

lner

etal

.[3

9](1

999)

Un

clea

r.M

eth

odof

ran

dom

isat

ion

not

stat

ed/d

escr

ibed

.

Yes

Exc

ept:

stat

isti

cally

sign

ifica

nt

diff

eren

ces

inn

um

ber

wit

hpr

evio

us

MI

(Igr

oup

mor

e),S

BP

(Igr

oup

hig

her

),ex

erci

se/d

ay(I

grou

pm

ore)

.

Un

clea

r.Pa

tien

tsra

ndo

mis

ed:I

=28

,C=

32.A

t12

mon

ths,

anal

yses

per

form

edin

25I

pati

ents

(89%

),13

C(4

0%)

(on

lypa

tien

tsw

ith

com

plet

eda

tafo

r12

mon

ths

wer

ein

clu

ded

atba

selin

e)be

cau

seal

lpat

ien

tsdi

dn

otag

ree

toco

mpl

ete

len

gthy

ques

tion

nai

res.

Car

diol

ogic

alfo

llow

-up

was

com

plet

edin

allp

atie

nts

recr

uit

ed.

Yes

Un

clea

r

Org

anis

atio

nal

Jolly

etal

.[40

](1

999)

Cle

ar.

Pra

ctic

esra

ndo

mis

ed(b

efor

eco

nse

nt

sou

ght)

toI

orC

afte

rst

rati

fica

tion

bysi

zeof

prac

tice

and

dist

ance

from

dist

rict

gen

eral

hos

pita

l.

Yes

10%

inbo

thgr

oups

;rea

son

sgi

ven

.Ye

sU

ncl

ear

Mu

noz

etal

.[2

4](2

007)

.C

lear

.P

rim

ary

care

faci

litie

sal

loca

ted

toI

orC

byra

ndo

mse

quen

cege

ner

ated

byco

mpu

ter

prog

ram

me.

Yes

Exc

ept:

Cgr

oup

hig

her

prop

orti

onha

dpr

evio

us

hype

rten

sion

,per

iph

eral

vasc

ula

rdi

seas

e;h

igh

erpr

opor

tion

taki

ng

beta

bloc

kers

,AC

Ein

hib

itor

s;h

igh

erB

P;I

grou

ph

igh

erH

DL-

chol

.

11(1

.1%

).A

lso:

Wit

hdr

ew:2

8(2

.8%

);U

nwill

ing:

2(0

.2%

);D

ied:

59(6

%).

Yes

Un

clea

r

I:in

terv

enti

on;C

:con

trol

.

16 Cardiology Research and Practice

Study or Subgroup

Cupples and McKnight 1999

De Lorgeril 1999

Giannuzzi 2008

Hamalainen 1995

Munoz 2007

Murchie 2003

Total (95% CI)

Total events

Heterogeneity: Tau² = 0.00; Chi² = 1.22, df = 5 (P = .94); I² = 0%

Test for overall effect: Z = 3.89 (P = .0001)

Events

47

14

34

41

31

100

267

Total

342

219

1620

188

515

673

3557

Events

65

24

43

56

36

128

352

Total

346

204

1621

187

468

670

3496

Weight

18.2%

5.4%

10.9%

17.7%

10.0%

37.8%

100.0%

M-H, Random, 95% CI

0.73 [0.52, 1.03]

0.54 [0.29, 1.02]

0.79 [0.51, 1.23]

0.73 [0.51, 1.03]

0.78 [0.49, 1.24]

0.78 [0.61, 0.99]

0.75 [0.65, 0.87]

Intervention Control Risk Ratio Risk Ratio

M-H, Random, 95% CI

0.01 0.1 1 10 100Favours intervention Favours control

Figure 2: Effect of interventions on all-cause mortality: comparison of intervention versus control groups.

Study or Subgroup

Cupples and McKnight 1994

De Lorgeril 1999

Delaney 2008

Giannuzzi 2008

Hamalainen 1995

Lisspers 2005

Munoz 2007

Ornish 1998

Total (95% CI)

Total events

Heterogeneity: Tau² = 0.06; Chi² = 11.51, df = 7 (P = .12); I² = 39%

Test for overall effect: Z = 3.12 (P = .002)

Events

10

6

74

18

35

1

17

2

163

Total

342

219

673

1620

188

46

515

28

3631

Events

28

19

90

24

55

6

17

1

240

Total

346

204

670

1621

187

41

468

20

3557

Weight

11.6%

8.1%

27.2%

14.1%

23.1%

1.8%

12.7%

1.5%

100.0%

M-H, Random, 95% CI

0.36 [0.18, 0.73]

0.29 [0.12, 0.72]

0.82 [0.61, 1.09]

0.75 [0.41, 1.38]

0.63 [0.44, 0.92]

0.15 [0.02, 1.18]

0.91 [0.47, 1.76]

1.43 [0.14, 14.70]

0.63 [0.47, 0.84]

Intervention Control Risk Ratio Risk Ratio

M-H, Random, 95% CI

0.01 0.1 1 10 100

Favours intervention Favours control

Figure 3: Effect of interventions on cardiovascular mortality: comparison of intervention versus control groups.

knowledge, and habits [21, 27, 44, 47], and for concern aboutdietary habits [43].

PA. Twenty-one studies incorporated PA, with 37 out-comes. Of these, 20 showed significant improvements forintervention patients compared to controls. These includedsignificant improvements in maximal workload and VO2peak

[16, 18, 27]. Eleven studies used validated questionnaires orpatient diaries [17, 20, 23–25, 28, 30, 34, 36, 39, 41]. Fourconducted patient interviews or used questionnaires whichwere not reported as validated [21, 40, 43, 44]. Of these, eightstudies reported significant improvements [20, 21, 23, 27, 28,30, 34, 39].

Smoking. While all studies reported proportions of thestudy populations that smoked, only 13 studies reportedsmoking as an outcome and five of these reported significantreductions in smoking behaviours in the intervention groups[20, 21, 27, 28, 45]. Hamalainen et al. [45] reported anonsignificant difference between intervention and controlgroups at one year, but significant at two and three years.

BP. Thirteen studies reported BP as an outcome, and fivereported significant benefits for intervention compared tocontrol patients [18, 20, 34, 39, 45]. Giallauria et al. [18]reported significant improvements in SBP and DBP at 12months and 24 months. Redfern et al. [20] reported signifi-cant difference in SBP among intervention compared to con-trol patients at three months and 12 months. Campbell et al.[34] collected BP data from medical records and classified itas being managed according to British Hypertension Societyrecommendations if the last recorded measurement was lessthan 160/90 mmHg or receiving attention. The significantdifference between intervention and control groups at oneyear was no longer observed at four-year follow-up [36].

Wallner et al. [39] found significant improvements inSBP and DBP in intervention patients compared to controls.Hamalainen et al. [45] reported significant benefits forintervention compared to control patients relating to SBPand DBP at one, two, and three years but not at six or 10years.

Total Cholesterol and/or Lipid Levels. These outcomes werereported by 19 studies and 12 demonstrated significant

Cardiology Research and Practice 17

Study or Subgroup

DeLorgeril1999 MIRevasc

DeLorgeril1999 nonfatalMI

Giallauria 2009

Giannuzzi2008 CABG

Giannuzzi2008 nonfatal MI

Giannuzzi2008 PCI

Heller1993 C/angioplasty

Heller1993 CABG

Heller1993 cardcatheter

Lisspers 2005

Munoz 2007Ornish1998 CABG

Ornish1998 nonfatal MI

Ornish1998 PTCA

Southard 2003

Wallner 1999

Total (95% CI)

Total events

Heterogeneity: Tau² = 0.08; Chi² = 35.36, df = 15 (P = .002); I² = 58%

Test for overall effect: Z = 3.66 (P = .0003)

Events

37

8

3

45

23

144

11

29

60

10

922

2

8

2

3

479

Total

219

219

26

1620

1620

1620

213

213

213

46

51528

28

28

53

28

6689

Events

45

25

7

50

44

159

17

35

73

19

735

4

14

8

14

592

Total

204

204

26

1621

1621

1621

237

237

237

41

46820

20

20

51

32

6660

Weight

9.3%

4.7%

2.3%

9.2%

7.7%

12.2%

5.0%

8.3%

11.0%

6.0%

11.1%1.6%

1.5%

5.8%

1.7%

2.6%

100.0%

M-H, Random, 95% CI

0.77 [0.52, 1.13]

0.30 [0.14, 0.65]

0.43 [0.12, 1.48]

0.90 [0.61, 1.34]

0.52 [0.32, 0.86]

0.91 [0.73, 1.12]

0.72 [0.35, 1.50]

0.92 [0.58, 1.45]

0.91 [0.69, 1.22]

0.47 [0.25, 0.89]

1.15 [0.87, 1.52]0.29 [0.06, 1.33]

0.36 [0.07, 1.76]

0.41 [0.21, 0.78]

0.24 [0.05, 1.08]

0.24 [0.08, 0.77]

0.68 [0.55, 0.84]

Intervention Control Risk Ratio Risk Ratio

M-H, Random, 95% CI

0.01 0.1 1 10 100Favours intervention Favours control

Figure 4: Effect of interventions on nonfatal cardiac events: comparison of intervention versus control groups. MIRevasc = electivemyocardial revascularisation, CABG = coronary artery bypass graft, PCI = percutaneous coronary intervention, C/angioplasty = coronaryangioplasty, Cardcatheter = cardiac catheter, PTCA = percutaneous transluminal coronary angioplasty.

benefits for intervention patients. Seven of these 12 studiesreported significant improvements in total cholesterol forintervention patients compared to controls [18, 20, 21, 30,41, 42, 45]. Another study found a significant difference intotal cholesterol between female intervention and controlgroups but not male [25].

Low-Density Lipoprotein Cholesterol (LDL-chol). Five studiesreported significant improvements in levels of LDL-cholamong intervention patients compared to controls [18, 30,39, 41, 42]. Salminen et al. [25] found significant improve-ments between female intervention and control groups butnot male.

Only one study, that by Giallauria et al. [18], found asignificant improvement in levels of high-density lipoproteincholesterol (HDL-chol) among intervention patients com-pared to controls.

QOL. 10 studies reported quality of life, and four reportedsignificant benefits for intervention patients—including for“physical activity factor” [26], physical function [28], andemotional [44]. Campbell et al. [35] reported five significantresults out of the eight health status domains (physical,social, role physical, role emotional, and pain).

Self Efficacy. This was reported by only one study. Gianuzziet al. [21] reported a significantly better score in interventionpatients compared to controls relating to self/stress manage-ment at six month follow-up and throughout their study.

Medication. Nine studies reported use of medications, andsix reported significant improvements among interventionpatients compared to controls.

Lewin et al. [29] reported the number of glyceryltrinitrate pills or puffs of sublingual spray taken per daywhich were self-reported in a diary by patients. Interventionpatients reported a significant reduction in doses per weekcompared to control group patients.

Campbell et al. [34] reported proportions taking aspirinwhich was ascertained by postal questionnaire. A signifi-cantly greater number of intervention patients at one-yearfollow-up was taking aspirin compared to controls.

Carlsson [42] found significant differences betweenintervention and control patients in use of statins andcholestyramine; however it was unclear how this data wascollected.

In the study by Cupples and McKnight [22, 23] trainedhealth visitors assessed the use of prophylactic drugs forangina by interviewing patients. At the two- and five-yearfollow-ups, a significantly higher number of interventionpatients were using prophylactic medication than controls.

4. Discussion

We have conducted a systematic review of lifestyle inter-ventions for the secondary prevention of CHD usingCochrane Collaboration methodology. The review indicatesthat lifestyle interventions have mixed effects with somebenefits in relation to total mortality, CV mortality, and

18 Cardiology Research and Practice

Table 3: Impact of interventions on hospital admissions.

Study Intervention Control Risk ratio

Murphy∗Overall:

P = .03Baseline to 18 months:

0.3 (0.6) to0.4 (0.7)

0.4 (0.8) to0.5 (1.0)

CV:

P = .04At 18 months:

0.14 (0.50) 0.23 (0.7)

Other:P = .22

0.24 (0.6) 0.32 (0.7)

Vestfold∗∗ 20 33 NS (not significant)

Ornish∗∗∗ 23 440.685 (0.012–13.2),P = .81

Heller∗∗∗∗ 47 600.253∗∗∗∗∗

Diff -0.8%(−10.0–8.4); NS

Delaney∗∗∗∗∗ 7647 8642 P = .998∗Mean number of admissions per patient (at 18 months).∗∗20 admissions related to chest pain without evidence of ischaemia among11 patients in intervention group, 33 admissions among 14 patients incontrol group (at 2 years).∗∗∗Cardiac hospitalisations (at 5 years).∗∗∗∗Patients with ≥1 hospital readmission (at 6 months).∗∗∗∗∗Total number of admissions (at 10 years).

nonfatal CV events as well as PA, diet, blood pressure,cholesterol, QOL, and medication adherence. The reviewwas restricted to the period after 1990 because the conceptof secondary prevention and methods to promote it area relatively recent development in healthcare. Nonetheless,we found trials of interventions which were heterogeneous,and this was evidenced by the range of categories intowhich they could be classified. Few trials evaluated a singlecomponent of lifestyle, while many assessed the effects ofa complex, multifactorial intervention. Other differencesbetween studies included trial quality, intervention setting,intensity, duration, and length of follow-up.

For all trials the control group was usual medical care.We excluded trials which evaluated the intervention against adifferent intervention or other programme which could notbe defined as usual care.

4.1. Effectiveness of Interventions. Overall, a small numberof studies showed a significant reduction in deaths andnonfatal MIs while several reported positive results relatingto adherence to lifestyle change. Regarding total mortality,four studies out of the six reporting this outcome showedsignificant benefits in the relatively short time scale studied(3–5 years). The Lyon Diet Heart Study [33] showed asignificant impact on All-cause mortality and fewer deathsfrom CV causes among intervention patients comparedto controls. The protective effect of the intervention wasmaintained for up to four years. This was a noteworthy resultbecause patients were seen annually, indicating that they

were able to maintain the diet for long periods alone andwithout professional motivation. The other trials showingsignificant benefits were of an educational intervention [22]and two multifactorial [36, 45]. Only three out of eightstudies showed significant results for cardiovascular mortal-ity. These were a dietary intervention [33], educational [22]and multifactorial ones [45], all of which had also shownsignificant effects on total mortality.

Concerning nonfatal CV events, we presented 16 out-comes from nine studies. There were significant improve-ments in five of these trials, which were of dietary [33],psychological [27], and multifactorial [21, 39, 41] interven-tions. Of the five studies which reported hospital admissions,only one, Murphy et al. [17], reported significant benefit forintervention patients compared to controls, both for overalland CV admissions.

In terms of risk factors for CHD, these were assessed bygreatly differing methods which made comparison difficult.Diet, PA, smoking status, blood pressure, and cholesterolwere widely reported, with varying results. In relationto diet, significant results were reported for the dietaryintervention, one psychological, three educational, and sixmultifactorial interventions. Significant results relating to PAwere reported for one exercise trial, one educational, twopsychological, and seven multifactorial. Of the five studieswhich showed significant benefits for intervention patientscompared to controls in relation to smoking, four were mul-tifactorial and one psychological. All five interventions whichshowed significant results relating to BP were multifactorial.Concerning cholesterol and lipid levels, the interventionswhich showed significant results were one psychological, oneeducational, and eight multifactorial.

In relation to quality of life, one psychological trialreported a significant benefit for intervention patientscompared to controls, as did one educational and twomultifactorial.

Few trials reported medication intake or adherence.However, as appropriate therapy is a key aspect of secondaryprevention of CHD [8], this should surely be given greaterconsideration. The trials which reported significant resultsrelating to medication were classified as psychological (one),multifactorial (two), and educational (three).

Likewise, self-efficacy, a patient’s ability, and confidenceto manage their own condition, was only reported in onestudy. This multifactorial intervention reported a significantoutcome for intervention patients compared to controls.

4.2. Relevance of Lifestyle and Risk Factor Modification.Recent evidence has shown the importance of focusing onlifestyle to effect positive changes relating to CHD. Bennettet al. [48] used the IMPACT CHD model to examine thedecline in CHD mortality in Ireland between 1985 and 2000,and possible reasons for this. The mortality rate fell duringthis period by some 47%, representing 3673 fewer observedCHD deaths. The authors found that 48% of this decreasewas due to a reduction in major risk factors includingsmoking and cholesterol levels. Conversely, an upward trendwas seen in obesity, diabetes, and PA which were said to

Cardiology Research and Practice 19T

abl

e4:

Impa

ctof

inte

rven

tion

son

lifes

tyle

risk

fact

ors.

Sou

rce

Die

tE

xerc

ise

Smok

ing

Exe

rcis

e

Ast

engo

etal

.[1

6](2

010)

NR

Max

imu

mw

orkl

oad:P=.0

2.Se

lf-r

epor

ted

trai

nin

g(d

ays/

wee

k):P

valu

efo

rdi

ffer

ence

betw

een

grou

ps<

.001

.Se

lfre

port

edtr

ain

ing

(min

ute

s/se

ssio

n):P<

.001

.M

axim

um

hea

rtra

te:N

S.

NR

Die

tary

%ca

lori

esco

nsu

med

:

NR

NR

Tota

llip

ids:P=.0

02.

Satu

rate

dfa

ts:P=.0

001.

Poly

un

satu

rate

dfa

ts:P=.0

001.

Ole

ic:P=.0

001.

De

Lorg

eril

etal

.[32

](1

996)

.Li

nol

eic:P=.0

001.

Lin

olen

ic:P=.0

001.

Alc

ohol

:NS.

Pro

tein

s:N

S.

Fibr

e:P=.0

04.

Ch

oles

tero

l:P=.0

001.

Psyc

holo

gica

l

Lew

inet

al.

[29]

(200

2)N

RSe

attl

eA

ngi

na

Qu

esti

onn

aire

:phy

sica

llim

itat

ion

ssc

ore

for

Igr

oup

redu

ced;

for

Cgr

oup

incr

ease

d:P<.0

01.

NR

Die

tkn

owle

dge

inde

x:P<.0

005.

PAfr

equ

ency

:P<.0

25.

Max

imu

mw

orkl

oad:P<.0

025.

Ch

est

pain

rati

ngs

duri

ng

exer

cise

test

s:P<.0

25.

Self

rate

dsm

oker

sP<.0

1.Li

sspe

rset

al.

[26]

(199

9).

Self

rate

ddi

etar

yh

abit

s:P<.0

005.

Liss

pers

etal

.[27

](2

005)

calc

ula

ted

over

alll

ifes

tyle

scor

esin

corp

orat

ing

diet

,PA

,sm

okin

g,an

dst

ress

:Igr

oup

sign

ifica

ntl

yh

igh

ersc

ore

than

Cgr

oup

at12

,24,

36,a

nd

60m

onth

s.P

valu

esn

otgi

ven

for

indi

vidu

alco

mpo

nen

tsof

scor

e.

Salm

inen

etal

.[2

5](2

005)

Type

ofm

ilk/t

ype

offa

tco

nsu

med

:NS

(dat

an

otre

port

ed).

PAfr

equ

ency

:NS

(dat

an

otre

port

ed).

NS

(dat

an

otre

port

ed).

Edu

cati

onal

Car

lsso

net

al.

[42,

43]

(199

7,19

98).

A:N

RA

:wor

kca

paci

ty:N

S(A

MI

pati

ents

:P=.0

8;C

AB

Gpa

tien

ts:P=.7

5).

B:N

R.

A:N

R

B:N

RC

:PA

:fre

quen

cy:N

S.St

opp

edB

:NR

C:C

once

rnab

out

food

hab

its:P=.0

08ph

ysic

altr

ain

ing:P=.4

3;st

arte

dph

ysic

altr

ain

ing:

P=

0.50

.C

:sm

okin

gce

ssat

ion

:NS.

20 Cardiology Research and PracticeT

abl

e4:

Con

tin

ued

.

Sou

rce

Die

tE

xerc

ise

Smok

ing

Cu

pple

san

dM

cKn

igh

t[2

2](1

994)

.

Inta

keof

pou

ltry

(P=.0

2),g

reen

vege

tabl

es(P=.0

02),

hig

hfi

bre

food

(P=.0

1),r

edm

eat

(P=.0

05),

frie

dfo

od(P=.0

45),

bisc

uit

san

dsw

eets

(P=.0

001)

,sat

ura

ted

fat

(P=.0

13).

PAfr

equ

ency

:P<.0

001.

Smok

ing

cess

atio

nra

te:

NS

(P=.8

2).

Cu

pple

san

dM

cKn

igh

t[2

3](1

999)

Die

tsc

ore:

diff

eren

cebe

twee

ngr

oups

:NS

PAfr

equ

ency

:P<.0

5.Sm

okin

gce

ssat

ion

rate

:di

ffer

ence

betw

een

grou

ps:

NS.

Hel

ler

etal

.[4

4](1

993)

Mea

nfa

tsc

ore:P=.0

02.

Pro

port

ion

exer

cisi

ng

3ti

mes

wee

kly:

diff

eren

cebe

twee

ngr

oups

NS.

Cu

rren

tsm

oker

:diff

eren

cein

prop

orti

ons

betw

een

grou

ps:N

S

Sou

thar

det

al.

[31]

(200

3)M

ED

FIC

TS

diet

ary

scor

e:N

SC

anad

ian

An

gin

aG

rade

,Du

keA

ctiv

ity

Stat

us

Scor

e:N

S.PA

dura

tion

:NS.

NR

Mul

tifa

ctor

ial

1ye

ar:

ME

T,h

r/w

k≥6

1ye

ar:P=.0

2.N

RFa

t:P=.0

09;

Alle

net

al.

[30]

(200

2).

Satu

rate

dfa

t:P=.0

04;

Ch

oles

tero

l:P=.0

06;

Fibr

e:N

S.

Cam

pbel

let

al.[

34]

(199

8)A

Low

fat

diet

:eff

ect

size

:OR

1.47

,CI

1.10

to1.

96,

P=.0

09.

Mod

erat

ePA

:eff

ect

size

:OR

1.67

,CI

1.23

to2.

26,

P=.0

01.

Pro

por

tion

ofn

on-s

mok

ers:

OR

0.78

,P=.3

22.

Gia

llau

ria

etal

.[18

](2

009)

.

NR

VO

2pea

k(i

ncr

ease

inox

ygen

atp

eak

exer

cise

):

NR

3,12

,an

d24

mon

ths:P<.0

01.

VO

2AT

(an

aero

bic

thre

shol

d):3

,12

and

24m

onth

s:P<.0

01.

Wat

t max

:3,1

2an

d24

mon

ths:P<.0

01.

Gia

nu

zzie

tal

.[2

1](2

008)

Die

tary

scor

e3.

9%h

igh

erin

Igr

oup

(P<.0

01);

mai

nta

ined

thro

ugh

out

stu

dy.

Mea

nsc

ore:

6m

onth

s:P<.0

1;m

ain

tain

edth

rou

ghou

tst

udy

.A

t6

mon

ths:P=.0

2.3

year

s:N

S(P=.6

0).

NR

Freq

uen

cyof

PAan

dw

ork

capa

city

:NS

(dat

an

otre

port

ed).

No.

ciga

rett

essm

oked

/day

:

1ye

ar:N

S;

Ham

alai

nen

etal

.[45

](1

995)

.2

year

s:P=.0

2;

3ye

ars:P=.0

02;

Year

s6

and

10:N

S.

Mu

rch

ieet

al.

[36]

(200

3)A

NS

Igr

oup

impr

ovem

ents

sust

ain

edin

alla

reas

but

at4

year

sC

grou

pim

prov

edan

ddi

ffer

ence

sn

olo

nge

rsi

gnifi

can

t.

NS

NS

Cardiology Research and Practice 21

Ta

ble

4:C

onti

nu

ed.

Sou

rce

Die

tE

xerc

ise

Smok

ing

Mu

rphy

etal

.[1

7](2

009)

.D

INE

fibr

e:N

S(P=.0

6)D

INE

fat:

NS

(P=.8

6).

God

inex

erci

sesc

ore:

NS

(P=

0.67

).Se

lfre

port

edsm

oker

:NS

(P=.2

3).

Fat

inta

ke,g

per

day:

Adh

eren

ceto

exer

cise

:N

R1

year

:P<.0

01.

5ye

ars:P<.0

01.

Orn

ish

etal

.[4

1](1

998)

.Fa

tin

take

,%of

ener

gyin

take

:

1ye

ar:P

<.0

01.

1ye

ar:N

S.5

year

s:P<.0

01.

Die

tary

chol

este

rol:

1ye

ar:P

<.0

01.

5ye

ars:P=.0

02.

5ye

ars:

NS.

En

ergy

inta

ke:

1ye

ar:P=.6

4.5

year

s:P=.8

6.R

edfe

rnet

al.

[19]

(200

8)A

Bas

elin

eto

3m

onth

s

NR

ME

TS/

kg/m

in:P=.0

1.Sm

oker

s:P

<0.

01.

Red

fern

etal

.[2

0](2

009)

BN

RM

ET

S/kg

/min

,P=.0

01.

NR

Ves

tfol

d[2

8](2

003)

.6

mon

ths:

Ipa

tien

tssi

gnifi

can

tly

low

erin

take

satu

rate

dan

dm

onou

nsa

tura

ted

fat,

suga

r,an

dch

oles

tero

l,h

igh

erfi

bre

than

C.

PAfr

equ

ency

:6

mon

ths:P<.0

01.

6m

onth

s:P<.0

5.2

year

s:P<.0

5.

2ye

ars:

Igr

oup

sign

ifica

ntl

ylo

wer

tota

lfat

inta

ke,

satu

rate

dfa

tan

dm

onou

nsa

tura

ted,

sign

ifica

ntl

yh

igh

erfi

bre,

low

ersu

gar

and

chol

este

rol.

2ye

ars:P<.0

1.

Tota

lfat

:P=.0

01;

Kca

l/da

y:P=.0

01.

NR

SFA

:P=.0

5;M

UFA

:P=.0

4;C

arbo

hydr

ate:P=.0

01;

Wal

lner

etal

.[3

9](1

999)

.Fi

bre:P=.0

06;

Ch

oles

tero

l:P=.0

3;V

itam

inC

:P=.0

06;

En

ergy

inta

ke(k

cal)

,PU

FA,p

rote

in,v

itam

inE

:NS.

Org

anis

atio

nal

Jolly

etal

.[40

](1

999)

NR

Fitn

ess

test

(dis

tan

cew

alke

din

6m

inu

tes,

met

res)

:NS.

Qu

itra

te(p

ropo

rtio

nw

ho

stop

ped

smok

ing)

:NS.

Mu

noz

etal

.[2

4](2

007)

NR

PA(a

mou

nt

ofex

erci

se):

both

grou

psin

crea

sed

but

diff

eren

cebe

twee

ngr

oups

NS.

NR

NR

:not

repo

rted

;NS:

not

sign

ifica

nt;

I:in

terv

enti

on;C

:con

trol

.

22 Cardiology Research and Practice

Table 5: Summary of lifestyle risk findings.

Outcome

Numberof studieswith thisoutcome

Number ofoutcomes

Numbersignificantlyimproved

Number ofoutcomes withno significantdifference

Exercise 21 37 20 17

Diet 15 51 39 12

Smoking 13 20 7 13

Note: we counted Campbell and Murchie as separate studies as the patientsin each were not necessarily the same. Other follow-up studies, Cupples,Ornish, Vestfold, and Redfern we counted as one study but counted theoutcomes from each time point as different outcomes (hence the 20outcomes for the 13 studies reporting smoking outcomes).

contribute an additional 500 deaths in 2000. These resultswere similar to those found by Palmieri et al. [49], whoalso used the IMPACT model and investigated the declinein CHD mortality in Italy between 1980 and 2000. Theyconcluded that over half of the mortality fall was due torisk factors, mainly blood pressure and cholesterol, and justunder half was due to medical therapies.

The Lyon Diet Heart Study [33] was the first clinicaltrial evidence in support of the Mediterranean diet, whichcomprises a high intake of fruit, vegetables, nuts, legumes,and grains. Other recent evidence has been found supportingthe Mediterranean diet’s protective effect in the secondaryprevention of CHD [50–52]. O’Connor et al. [6] examinedRCTs of cardiac rehabilitation with exercise and found amoderate reduction of 20% in total and CV mortality afterone year, with a reduced risk maintained for three years afterinfarction. In a recent review of interventions incorporatingexercise as part of a cardiac rehabilitation programme, Jolliffeet al. [11] also observed a reduction in total mortality.Exercise-only interventions resulted in a 27% reduction intotal mortality and 31% reduction in cardiac mortality whilecomprehensive rehabilitation reduced mortality to a lesserextent (26%).

The psychological interventions included in this reviewshowed small beneficial effects. This is in keeping with sim-ilar findings in a recent review of 36 RCTs of psychologicalinterventions by Rees et al. [12] which showed no evidenceof effect on total or cardiac mortality, but found smallreductions in anxiety and depression.

We included two organisational interventions in thisreview, and both reported disappointing results. Jolly et al.[40] investigated a programme to improve communicationbetween hospital and GP practices using liaison nurses. Theprogramme was effective in promoting follow-up care ofpatients in general practice; however health outcomes werenot improved. Munoz et al. [24] examined an interventioninvolving postal reminders sent to patients to encouragethem to visit their GP. Blood pressure and HDL-cholesterollevels were improved, but no effect was observed on mortal-ity or morbidity.

4.3. Limitations of the Review. This review has a number ofpotential limitations. The relatively small number of studies

which included mortality as an outcome, the heterogeneitybetween trials, and poor quality of reporting all arise fromthe primary data. Further, imprecise descriptions of theinterventions and the limited data have made it difficultto determine the benefits of various components of theinterventions. The majority of the population of the inter-ventions was male and relatively low risk; however greaterbenefit could have been derived from the interventions byhigher risk patients who were excluded on the basis ofcomorbidity.

The broad range of trials included, and the subsequentlarge number discovered in our search, may have madecomparisons difficult. Nonetheless this reflects the currentlack of clarity in respect of the optimal components ofeffective interventions for CHD secondary prevention.

4.4. Implications for Practice. We have found that lifestyleinterventions promoting regular PA, a healthy diet, andadherence to medication have beneficial effects amongpatients with CHD. It is therefore reasonable to promotesuch a healthy lifestyle to patients similar to those includedin the RCTs we investigated—mainly older adults who hadsuffered a coronary event. As practitioners endeavour toachieve target levels of blood pressure and cholesterol byaltering their patients’ prescribed medication, the potentialvalue of their advice regarding exercise and diet should notbe overlooked.

4.5. Implications for Future Research. Overall, the currentevidence suggests that lifestyle interventions have somebeneficial effects on total and cardiac mortality, morbid-ity, and on behaviour change in relation to modifiablecardiac risk factors. Even where little or no effect wasobserved relating to mortality or morbidity, some trialsreported benefits in terms of lifestyle behaviour change. Thathealthcare education and even small-scale interventions canlead to healthier lifestyle choices, as shown in this reviewand others, should be an encouragement to professionalsin practice. Future studies should be designed carefully,with attention given to aspects of study quality, which weaddressed in Table 2. For example, RCTs of a cluster designhelp to avoid contamination of control patients. Further,outcomes should be matched to intervention elements.In addition, it is important to incorporate concealmentof allocation and blinding of outcomes. Maximal follow-up should be ensured and more consideration given tothe underlying theoretical foundation for the interven-tion.

However, the fact that more profound and wide reachingbenefits were not seen in our review is surprising consideringthat all guidelines focus on the importance of lifestyleinterventions. Future research should perhaps focus on thecomponents of interventions and what the ideal combinationof measures, intervention intensity, and duration should be.In addition, investigations into the barriers to lifestyle changeamong patients with CHD may shed new light on why somewell-designed and executed interventions have not resultedin expected benefits.

Cardiology Research and Practice 23

Appendix

Medline Search Strategy

(1) Lifestyle.mp. or Life Style/

(2) Exercise.mp. or Exercise/

(3) Physical activity.mp.

(4) Diet/ or diet.mp.

(5) 1 OR 2 OR 3 OR 4.

(6) Secondary prevention.mp. or Secondary Prevention/

(7) Coronary heart disease.mp. or Coronary Disease/

(8) CHD.mp.

(9) Myocardial infarction.mp. or Myocardial Infarction/

(10) MI.mp.

(11) Coronary Artery Bypass/or coronary artery bypassgraft.mp.

(12) CABG.mp.

(13) Percutaneous transluminal coronary angioplasty.mp.or Angioplasty, Transluminal, Percutaneous Coro-nary/

(14) PTCA.mp.

(15) Angina pectoris.mp. or Angina Pectoris/

(16) 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR15.

(17) 5 AND 6 AND 16.

(18) Limit search 17 by English language, humans, 1990-current and adults all ages (19 plus).

(19) randomized controlled trial.mp. or RandomizedControlled Trial/

(20) controlled clinical trial.mp. or Controlled ClinicalTrial/

(21) random allocation.mp. or Random Allocation/

(22) double blind method.mp. or Double-Blind Method/

(23) single blind method.mp. or Single-Blind Method/

(24) 19 OR 20 OR 21 OR 22.

(25) 18 AND 24.

Acknowledgments

M. Cupples and J. Cole gratefully acknowledge fundingfrom the Centre of Excellence for Public Health (North-ern Ireland), a UKCRC Public Health Research Centreof Excellence, funded by the British Heart Foundation,Cancer Research UK, Economic and Social Research Council,Medical Research Council, Research and Development Officefor the Northern Ireland Health and Social Services, andthe Wellcome Trust, under the auspices of the UK ClinicalResearch Collaboration.

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