A randomized non-pharmacological intervention study for prevention of ischaemic heart disease: baseline results Inter99 (1) A randomized multifactorial intervention study for prevention of ischaemic heart disease (Inter99): The long-term effect on physical activity Selection bias in enrollment to a programme aimed at the secondary prevention of ischaemic heart disease in general practice: a cohort study. A cluster randomized trial to assess the impact of opinion leader endorsed evidence summaries on improving quality of prescribing for patients with chronic cardiovascular disease: rationale and design [ISRCTN26365328] Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial An educational intervention to improve data recording in the management of ischaemic heart disease in primary care. The effectiveness of a comprehensive reminder system in the secondary prevention of hypertensive ischaemic stroke: randomized controlled trial protocol. No excess 12-year mortality in men with impaired glucose tolerance who participated in the Malmö Preventive Trial with diet and exercise A randomised controlled trial of senior Lay Health Mentoring in older people with ischaemic heart disease: The Braveheart Project. Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia Comparing the effectiveness of two cardiovascular prevention programmes for highly educated professionals in general practice: a randomised clinical trial A mobile phone intervention increases physical activity in people with cardiovascular disease: Results from the HEART randomized controlled trial Psychosocial distress and impaired quality of life - targets neglected in the secondary prevention in women with ischaemic heart disease The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411] Secondary prevention of cardiovascular disease: a randomised trial of training in information management, evidence-based medicine, both or neither: the PIER trial. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events). Secondary Prevention of New Vascular Events with Lifestyle Intervention in Patients with Noncardioembolic Mild Ischemic Stroke: A Single-Center Randomized Controlled Trial
Background Various strategies have been used to induce lifestyle changes to reduce ischaemic heart disease ( IHD ) with various successes . The aim of Inter99 is to assess the effect on IHD incidence of individually tailored non-pharmacological intervention on lifestyle using a newly developed computer-based health educational tool . The article describes the study and baseline results . Methods From a population of 61,301 individuals two r and om sample s ( high intensity intervention group ( A ) , n = 11,708 ; low intensity intervention group ( B ) , n = 1308 ) are screened to assess their absolute risk of IHD . Those at high risk receive individual lifestyle counselling . Individuals in group A are furthermore offered lifestyle counselling in groups on smoking cessation or physical activity/diet over a 6-month period . Individuals in group B are referred to their GP . High-risk persons are re-counselled after 1 and 3 years and the whole group is re-invited after 5 years . The remaining 48,285 ( group C ) are followed by question naire . The total population is followed through central registers . Intermediate end-points are changes in lifestyle , cholesterol , blood pressure and body mass index . Final end-point is reduction in incidence of IHD . Results The r and omization leads to comparable groups . Participation rate was 52.5 % . A total of 60 % fulfilled the predetermined criteria for being at high risk for developing IHD . After an individual lifestyle counselling 41 % accepted group-based counselling . Conclusion This large r and omized population based trial discloses a noticeable need for and acceptance of lifestyle intervention in the general population . Eur J Cardiovasc Prevention Rehab 10:377 - 386 © 2003 Lippincott Williams & Wilkins Aim : To examine the effect of a r and omized multiple risk factor intervention study for prevention of ischaemic heart disease ( IHD ) on the development in physical activity over a 36-month period . Methods : Two r and om sample s ( high intensity intervention , group A , n=11,708 ; low intensity intervention , group B , n=1,308 ) were invited for a health examination , an assessment of absolute risk of developing IHD , and an individualized lifestyle intervention . The participation rate was 52.5 % . High-risk persons in group A were also offered diet/physical activity and /or smoking cessation group counselling . High-risk persons in group B were referred to their GP . High-risk persons were re-counselled after 12 and 36 months . The  control group ( group C , n=5,264 , response rate=61.3 % ) answered a mailed question naire . Data were analysed using longitudinal linear regression models with r and om effects . Main outcome : Change in physical activity from baseline to 12- and 36-month follow-up . Results : In men , the high-intensity ( group A ) intervention had a beneficial effect at 12-month follow-up , whereas after 36 months both the high-intensity and the low-intensity ( group B ) intervention had a beneficial effect on the development in physical activity when compared with group C. This was regardless of baseline physical activity level . At 36-month follow-up there was no significant difference between groups A and B. There was no intervention effect among women . Conclusions : Only men seemed to benefit from the intervention OBJECTIVE To evaluate differences between adults who participated in a secondary prevention of ischaemic heart disease ( IHD ) programme and those who did not . DESIGN Population -based cohort study . SETTING A r and om selection of 12 Irish general practice s. PARTICIPANTS A total of 493 adults with IHD identified in 2000/2001 . INTERVENTION Medical records search and postal question naires in 2000/2001 and 2005/2006 . MAIN OUTCOME MEASURES Differences in demographic characteristics and indicators of process of care and risk factor management between participants and non- participants . RESULTS Multiple logistic regression confirmed that female gender was associated with a reduced likelihood of participation in the secondary prevention programme [ odds ratio ( OR ) 0.53 ( 95 % CI : 0.32 - 0.87 ) ] , while an adequately controlled total cholesterol level was associated with an increased likelihood of enrollment [ OR 1.82 ( 95 % CI : 1.18 - 2.80 ) ] . CONCLUSIONS There is limited evidence that biases , which have been shown to affect participation in research , also affect participation in care programmes in everyday practice . A gender bias appears to have affected the enrollment of participants for the secondary preventive programme considered by this study , with enrollment favouring men with well-managed cholesterol . Reimbursement dependent upon patient adherence may incentivise the enrollment of adherent patients , although the influence of patient choice is unclear : the need to maintain records relating to patients who opt out of such interventions is thus highlighted Background Although much has been written about the influence of local opinion leaders on clinical practice , there have been few controlled studies of their effect , and almost none have attempted to change prescribing in the community for chronic conditions such as heart failure ( HF ) or ischemic heart disease ( IHD ) . These two conditions are common and there is very good evidence about how to best prevent morbidity and mortality – and good evidence that quality of care is , in general , suboptimal . Practice audits have demonstrated that about one-half of eligible HF patients are prescribed ACE inhibitors ( with fewer still reaching appropriate target doses ) and less than one-third of patients with established IHD are prescribed statins ( with many fewer reaching recommended cholesterol targets ) . It is apparent that interventions to improve quality of prescribing are urgently needed . We hypothesized that an intervention that consisted of patient-specific one-page evidence summaries , generated and then endorsed by local opinion leaders , would be able to change prescribing practice s of community-based primary care physicians . Methods ( study design ) A pragmatic single-centre cluster r and omized controlled trial comparing an opinion leader-based intervention to usual care for patients with HF or IHD . R and omization will be clustered at the level of the primary care physician ; as the design effect is anticipated to be negligible , the unit of analysis will be the patient . Patients with HF or IHD ( not receiving ACE inhibitors or statins , respectively ) will be recruited from community pharmacies and allocated to intervention or usual care  based on the r and omization status of their primary care physician . The primary outcome is improvement in prescription of proven efficacious therapies for HF ( ACE inhibitors ) or IHD ( statins )  within 6 months of the intervention . Conclusion If the methods used in this intervention are found to improve prescribing practice s , similar interventions could be design ed for other chronic conditions dealt with in the outpatient setting Background Coronary Heart Disease and Cerebrovascular Disease share many predisposing , modifiable risk factors ( hypertension , abnormal blood lipids and lipoproteins , cigarette smoking , physical inactivity , obesity and diabetes mellitus ) . Lifestyle interventions and pharmacological therapy are recognised as the cornerstones of secondary prevention . Cochrane review has proven the benefits of programmes incorporating exercise and lifestyle counselling in the cardiac disease population . A Cochrane review highlighted as priority , the need to establish feasibility and efficacy of exercise based interventions for Cerebrovascular Disease . Methods A single blind r and omised controlled trial is proposed to examine a primary care cardiac rehabilitation programme for adults post transient ischemic attack ( TIA ) and stroke in effecting a positive change in the primary outcome measures of cardiac risk scores derived from Blood Pressure , lipid profile , smoking and diabetic status and lifestyle factors of habitual smoking , exercise and healthy eating participation . Secondary outcomes of interest include health related quality of life as measured by the Hospital Anxiety and Depression Scale , the Stroke Specific Quality of Life scale and WONCA COOP Functional Health Status charts and cardiovascular fitness as measured by a sub-maximal fitness test .  A total of 144 patients , over 18 years of age with confirmed diagnosis of ischaemic stroke or TIA , will be recruited from Dublin community stroke services and two tertiary T.I.A clinics . Exclusion criteria will include oxygen dependence , unstable cardiac conditions , uncontrolled diabetes , major medical conditions , claudication , febrile illness , pregnancy or cognitive impairment . Participants will be block-statified , r and omly allocated to one of two groups using a pre-prepared computer generated r and omisation schedule . Both groups will receive a two hour education class on  risk reduction  post stroke  .  The intervention group will receive a 10 week programme of supervised aerobic exercises ( twice weekly ) and individually tailored brief intervention lifestyle counselling . Both groups will be tested on week one and week ten of the programme . Follow-up at 1 year will assess longer term benefits . Analysis will test for significant changes in the key variables indicated . Discussion Application of the Cardiac Rehabilitation paradigm to patients with ischaemic stroke or TIA has not been explored despite the obvious overlap in aetiology . It is hoped the anticipated improvement in vascular risk factors and fitness result ing from such a programme will enhance health and social gain in this population .Trial Registration Current Controlled Trials ISCTRN90272638 BACKGROUND Gaps in computerized medical records and a lack of a systematic approach to data recording make progress towards achieving quality st and ards in primary care difficult to demonstrate . The aim of this study was to examine the effect of an educational intervention on data quality in primary care . METHODS A before- and -after study of key data quality measures was carried out in 87 general practice s in eight primary care organizations in Engl and in phase 1 and 84 general practice s in phase 2 . The subjects were 19,470 patients with ischaemic heart disease in phase 1 and 19,784 patients in phase 2 . The main outcome measures were improvement in the completeness and quality of the computerized medical record . Anonymized data were extracted from clinical information systems and processed to produce comparative information on each practice . Data quality workshops were arranged , in which reflection can take place , backed up by summary statistics . Practice visits provided training and personalized feedback of patients needing intervention . RESULTS In the patients with heart disease , nearly 16,000 new clinical entries were made in the key improvement areas . The percentage of patients advised to quit smoking increased by 49.3 per cent , from 23.6 per cent to 61.9 per cent . There were also significant improvements in many other aspects of management . CONCLUSION Focused interventions that provide targeted and relevant clinical information can be implemented in primary care . Such interventions can lead to a rise in data quality in primary care , but their effectiveness needs to be further tested in more rigorous research setting s such as r and omized controlled trials AIM The aim of this study was to determine whether the Comprehensive Reminder System based on the Health Belief Model improves health belief , health behaviours , medication adherence and blood pressure control as a means of decreasing the rate of stroke recurrence among hypertensive ischaemic stroke . BACKGROUND Hypertensive patients having experienced recent ischaemic strokes are at high risk for stroke recurrence . Several trials attempted to improve secondary stroke prevention via patient education , however , patient outcomes remained poor . Long-term follow-up studies regarding secondary stroke prevention are limited . DESIGN A multi-centre , 12-month , assessor-blinded , parallel-group , r and omized controlled longitudinal trial . METHODS Hypertensive patients having experienced an ischaemic stroke are the target population . The intervention consists of health belief education , a calendar h and book , a weekly automated short-message service and four telephone follow-up interviews . Outcomes will be assessed at baseline and at 3 , 6 and 12 months following discharge . The primary outcome is blood pressure control . The secondary outcomes include health belief , health behaviours and medication adherence . The clinical endpoint is the rate of stroke recurrence . DISCUSSION Although many efforts to improve secondary stroke prevention have been undertaken , research indicates that improvements remain possible and warranted . This research protocol based on the Health Belief Model will improve our underst and ing of stroke education and transitional care needed in China and with the world-wide target population Summary Impaired glucose tolerance ( IGT ) is associated with increased mortality due to ischaemic heart disease ( IHD ) , but as it is not known whether this excess mortality can be reduced by preventing or delaying the development of non-insulin-dependent diabetes mellitus ( NIDDM ) , a long-term NIDDM prevention trial of dietary counselling and physical exercise was launched at Malmö , Sweden , the 12-year follow-up of which is reported here . At 12-year follow-up of 6956 men who underwent health screening at 48 years of age , an IGT intervention group ( n = 288 ) who participated in a long-term NIDDM prevention programme were compared with an IGT non-r and omised routine treatment group ( n = 135 ) , a diabetic group ( n = 144 ) , and the remainder , the normal glucose tolerance ( NGT ) group ( n = 6389 ) . The variables studied included the levels of blood glucose , plasma insulin , blood pressure , blood lipids , lung function and maximum oxygen uptake .  Subjects with IGT were characterised by overweight , poor vital capacity , hypertension , hypertriglyceridaemia and hyperinsulinaemia . The mortality rate in the IGT intervention group was similar to that in the NGT group ( 6.5 vs 6.2 per 1000 person years at risk ) and lower than that in the IGT routine treatment group ( 6.5 vs 14.0 , p = 0.009 ) . In the two IGT groups taken together , intervention but not body mass index , systolic blood pressure , smoking , cholesterol or the 2-h glucose level predicted mortality . Systolic blood pressure was a predictor of IHD mortality among IGT subjects ; and in the cohort as a whole , body mass index , systolic blood pressure , hypercholesterolaemica , diabetes and smoking were predictors of IHD mortality . The findings suggest that a long-term intervention programme , with an emphasis on lifestyle changes , including dietary counselling and physical exercise , will reduce mortality in subjects with IGT who are at an increased risk of both developing NIDDM and of premature death due to IHD and other causes . [ Diabetologia ( 1998 ) 41 : 1010–1016 OBJECTIVE to examine the effects and feasibility of educating and empowering older people with ischaemic heart disease using trained senior lay health mentors . DESIGN r and omised controlled trial with blinded evaluation . SETTING Falkirk and District Royal Infirmary . PARTICIPANTS in patients and out patients aged 60 or over attending secondary care with a diagnosis of angina or acute myocardial infa rct ion . Three-hundred and nineteen entered and 289 completed exit assessment s. The intervention group took part in mentoring groups for 1 year , meeting monthly for 2 hours , each led by two trained lay health mentors in addition to st and ard care . MAIN OUTCOME MEASURES primary outcome measures were changes in coronary risk factors , medication usage and actual use of secondary care health services . Secondary outcomes were total and cardiovascular events ; changes in medication compliance , non-medical support requirement , health status and psychological functioning , and social inclusion . RESULTS there were significant improvements in a reported current exercise score ( mean + 0.33 , + 0.02 to + 0.52 ) , in the average time spent walking per week by 72 minutes ( + 1 to + 137 minutes ) , and in the SF36 Physical Functioning Score ( + 6.1 , + 2.4 to + 9.5 ) . There was a 1.0 % reduction in total fat ( 95 % CI -3.0 % to -0.6 % ) and a 0.6 % reduction in saturated fat ( 95 % CI -1.5 % to -0.03 % ) . The intervention group showed reduced outpatient attendance for coronary heart disease ( -0.25 appointments , -0.61 to -0.08 ) . Attendance rates were high . Socio-economic grouping did not affect participation . CONCLUSIONS Lay Health Mentoring is feasible , practical and inclusive , positively influencing diet , physical activity , and health re source utilisation in older subjects with ischaemic heart disease without causing harm Rationale PROTECT DC examines whether stroke navigators can improve cardiovascular risk factors in urban underserved individuals newly hospitalized for stroke or ischemic attack . Within one-year of hospital discharge , up to one-third of patients no longer adhere to secondary prevention behaviors . Adherence rates are lower in minority-underserved groups , contributing to health disparities . In-hospital programs increase use of stroke prevention therapies but may not be as successful in underserved individuals . In these groups , low literacy , limited healthcare access , and sparse community re sources may reduce adherence . Lay community health workers ( navigators ) improve adherence in other illnesses through education and assisting in overcoming barriers to achieving desired health behaviors and obtaining needed healthcare services . Aims and design PROTECT DC is a Phase II , single-blind , r and omized , controlled trial comparing in-hospital education plus stroke navigators to usual care .  Atherogenic ischemic stroke and transient ischemic attack survivors are recruited from Washington , DC hospitals .  Navigators meet with participants during the index hospitalization , perform home visits , and meet by phone . They focus on stroke education , medication compliance , and overcoming practical barriers to adherence . The interventions are driven by the theories of reasoned action and planned behavior . Study outcomes The primary dependent measure is a summary score of four objective measures of stroke risk factor control : systolic blood pressure , low-density lipoprotein , hemoglobin Hb A1C , and antiplatelet agent pill counts . Secondary outcomes include stroke knowledge , exercise , dietary modification , and smoking cessation . Conclusion PROTECT DC will determine whether a Phase III trial of stroke navigation for urban underserved individuals to improve adherence to secondary stroke prevention behaviors is warranted Background Cardiovascular disease is a major cause of mortality and morbidity and its prevalence is set to increase . While the benefits of medical and lifestyle interventions are established , the effectiveness of interventions which seek to improve the way preventive care is delivered in general practice is less so . The aim was to study and to compare the effectiveness of 2 intervention programmes for reducing cardiovascular risk factors within general practice . Methods A r and omised controlled trial was conducted in Belgium between 2007 - 2010 with 314 highly educated and mainly healthy professionals allocated to a medical ( MP ) or a medical + lifestyle ( MLP ) programme . The MP consisted of medical assessment s ( screening and follow-up ) and the MLP added a tailored lifestyle change programme ( web-based and individual coaching ) to the MP . Primary outcomes were total cholesterol , blood pressure , and body mass index ( BMI ) . The secondary outcomes were smoking status , fitness-score , and total cardiovascular risk . Results The mean age was 41 years , 95 ( 32 % ) participants were female , 7 had a personal cardiovascular event in their medical history and 3 had diabetes . There were no significant differences found between MP and MLP in primary or secondary outcomes . In both study conditions decreases of cholesterol , systolic blood pressure , and diastolic blood pressure were found . Unfavourable increases were found for BMI ( p < .05 ) . A significant decrease of the overall cardiovascular risk was reported ( p < .001 ) . Conclusions Both interventions are effective in reducing cardiovascular risk . In our population the combined medical and lifestyle programme was not superior to the medical programme . Trial registration IS RCT Aim To determine the effectiveness and cost-effectiveness of a mobile phone intervention to improve exercise capacity and physical activity behaviour in people with ischaemic heart disease ( IHD ) . Methods and results In this single-blind , parallel , two-arm , r and omized controlled trial adults ( n = 171 ) with IHD were r and omized to receive a mobile phone delivered intervention  ( HEART ; n = 85 ) plus usual care , or usual care alone ( n = 86 ) . Adult participants aged 18 years or more , with a diagnosis of IHD , were clinical ly stable as out patients , able to perform exercise , able to underst and and write English , and had access to the Internet . The HEART ( Heart Exercise And Remote Technologies ) intervention involved a personalized , automated package of text messages and a secure website with video messages aim ed at increasing exercise behaviour , delivered over 24 weeks . All participants were able to access usual community-based cardiac rehabilitation , which involves encouragement of physical activity and an offer to join a local cardiac support club . All outcomes were assessed at baseline and 24 weeks and included peak oxygen uptake ( PVO2 ; primary outcome ) , self-reported physical activity , health-related quality of life , self-efficacy and motivation ( secondary outcomes ) . Results showed no differences in PVO2 between the two groups ( difference −0.21 ml kg−1 min−1 , 95 % CI : −1.1 , 0.7 ; p = 0.65 ) at 24 weeks . However significant treatment effects were observed for selected secondary outcomes , including leisure time physical activity ( difference 110.2 min/week , 95 % CI : −0.8 , 221.3 ; p = 0.05 ) and walking ( difference 151.4 min/week , 95 % CI : 27.6 , 275.2 ; p = 0.02 ) . There were also significant improvements in self-efficacy to be active ( difference 6.2 % , 95 % CI : 0.2 , 12.2 ; p = 0.04 ) and the general health domain of the SF36 ( difference 2.1 , 95 % CI : 0.1 , 4.1 ; p = 0.03 ) at 24 weeks . The HEART programme was considered likely to be cost-effective for leisure time activity and walking . Conclusions A mobile phone intervention was not effective at increasing exercise capacity over and above usual care . The intervention was effective and probably cost-effective for increasing physical activity and may have the potential to augment existing cardiac rehabilitation services Background Secondary prevention in patients with ischaemic heart disease ( IHD ) focusing on classical risk factors has been less successful in women than in men . Previous studies have suggested that psychosocial factors may be new targets for secondary prevention . In the present study , psychosocial factors have been compared in women with and without IHD . Methods and subjects Using a cross-sectional comparison , classical cardiovascular risk factors and self-rated stress behaviour , vital exhaustion , stressful life events and quality of life  were assessed in 198 women ( age 35–77 years ) who had IHD and a population -based sample of 206 women ( age 45–74 years ) without IHD . Results Control of classical risk factors was most often adequate in women with IHD . The prevalence of smoking was 9 % in women with versus 18 % in women without IHD ( P < 0.001 ) , blood pressure levels were similar , and a very large share of women with IHD were on treatment with anti-thrombotic , anti-hypertensive and /or lipid-lowering drugs ( P < 0.001 compared with women free of IHD ) . In contrast , women with IHD scored significantly worse than women without IHD in self-rated stress behaviour ( P = 0.003 after adjustment for other possible determinants ) , and in vital exhaustion ( P = 0.003 ) . In univariate analyses , quality of life was significantly worse in women with IHD . Stressful life events did not differ between the two groups . Conclusions In this group of women with IHD , control of classical risk factors was good , whereas control of psychosocial risk factors was clearly inadequate . Secondary prevention by psychosocial intervention in women with IHD should be evaluated in r and omized controlled trials . Eur J Cardiovasc Prevention Rehab 10:258–266 © 2003 Lippincott Williams & Wilkins Background The aim of the SPHERE study is to design , implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease ( CHD ) in general practice across two different health systems on the isl and of Irel and .CHD is a common cause of death and a significant cause of morbidity in Irel and . Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives . Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the isl and of Irel and . The review literature recommends structured programmes with continued support and follow-up of patients ; the provision of training , tailored to practice needs of access to evidence of effectiveness of secondary prevention ; structured recall programmes that also take account of individual practice needs ; and patient-centred consultations accompanied by attention to disease management guidelines . Methods SPHERE is a cluster r and omised controlled trial , with practice -level r and omisation to intervention and control groups , recruiting 960 patients from 48 practice s in three study centres ( Belfast , Dublin and Galway ) . Primary outcomes are blood pressure , total cholesterol , physical and mental health status ( SF-12 ) and hospital re-admissions . The intervention takes place over two years and data is collected at baseline , one-year and two-year follow-up . Data is obtained from medical charts , consultations with practitioners , and patient postal question naires . The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice . It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients . General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD . Patients are invited to attend regular four-monthly consultations over two years , during which targets and goals for secondary prevention are set and review ed . The analysis will be strengthened by economic , policy and qualitative components BACKGROUND Sub-optimal management of cardiovascular disease ( CVD ) patients is widespread in primary and secondary care , with risk factors frequently unrecorded or untreated . AIM To investigate the effectiveness of educational interventions developed in primary care , on recording , prescribing and control of risk factors among all patients recorded by their general practitioner as having CVD . DESIGN OF STUDY Factorial , duster-r and omised controlled trial . SETTING Primary care teams representing the range of practice development in a geographically defined area in inner London . METHOD Participating practice s were r and omly allocated to one of the four intervention groups : information , evidence , both or neither . Interventions were tailored to suit individual practice needs . At a mean of 19 months after baseline , and three months after the end of intervention , practice s carried out the follow-up assessment of recording , treatment , and control of risk factors in the same CVD patients . RESULTS Adequate recording of all three risk factors , found inapproximately a third of patients at baseline , increased non-significantly by 10.5 % ( 95 % confidence interval [ CI ] = 3.9 to 24.9 ) in the information ( versus not information ) group and by 6.6 % ( 95 % [ CI ] = 8.9 to 22.0 ) in the evidence ( versus not evidence ) group . Factorial improvements in prescribing and control of risk factors tended not to be significant . Adequate recording of an three risk factors showed the greatest improvement in the information plus evidence group ( 19.9 % increase , P for heterogeneity across the four groups < or = 0.001 ) . Mean change from baseline to follow-up within the four intervention groups suggested improvements in the combined information plus evidence group in cholesterol recording ( 22.5 % increase ) , prescribing of lipid lowering drugs ( 4.4 % increase ) and mean cholesterol ( 0.7 mmol/l decrease ) . CONCLUSIONS Adequate risk factor recording did not differ between the information ( versus not information ) or the evidence ( versus not evidence ) intervention groups . Combined training in information systems and evidence -based medicine should be considered in the design of future interventions , to improve secondary prevention of CVD OBJECTIVE : To measure the potential for secondary prevention of coronary disease in the United Kingdom . DESIGN : Cross sectional survey of a representative sample of coronary patients from a retrospective review of hospital medical records and patient interview and examination . SETTING : Stratified r and om sample of 12 specialist cardiac centres and 12 district general hospitals drawn from 34 specialist cardiac centres and 261 district general hospitals in 12 geographic areas in the United Kingdom . SUBJECTS : 2583 patients < or = 70 yr ; 25 consecutive males and 25 consecutive females identified retrospectively in each of four diagnostic categories : coronary artery bypass grafting , percutaneous transluminal coronary angioplasty , acute myocardial infa rct ion , and acute myocardial ischaemia without evidence of infa rct ion . MAIN OUTCOME MEASURES : Risk factor recording and management in medical records ; the prevalence and control of risk factors at interview six months after the procedure or event . RESULTS : Recording of coronary risk factors in patient 's records was incomplete and this varied by risk factor . Smoking habit and blood pressure were most completely recorded , whereas a history of hyperlipidaemia and blood cholesterol concentrations were least complete . Risk factor records were more likely to be complete in cardiac centres than in district hospitals . At interview 10 % to 27 % of patients were still smoking cigarettes and 75 % remained overweight , females more severely so . Up to a quarter of patients remained hypertensive , males more severely so than females . Over three quarters had a total cholesterol > 5.2 mmol/l . In patients on medication for blood pressure , cholesterol or glucose , risk factor profiles were little better than in those who were not . Only about one patient in three was taking a beta blocker after infa rct ion . Up to a fifth of patients who had had acute myocardial ischaemia were not taking aspirin at follow up . CONCLUSIONS : There is considerable potential to reduce the risk of a further major ischaemic event in patients with established coronary disease . This can be achieved by effective lifestyle intervention , the rigorous management of blood pressure and cholesterol , and the appropriate use of prophylactic drugs Background : Lifestyle modification is associated with a substantially decreased risk of cardiovascular events . However , the role of lifestyle intervention for secondary prevention in patients with noncardioembolic ischemic stroke is inadequately defined . We assessed the hypothesis that lifestyle intervention can reduce the onset of new vascular events in patients with noncardioembolic mild ischemic stroke . Methods : We conducted an observer-blind r and omized controlled trial that enrolled 70 patients ( 48 men , mean age 63.5 years ) with acute noncardioembolic mild ischemic stroke . The patients were allocated in equal numbers to a lifestyle intervention group or a control group . We performed lifestyle interventions , which comprised exercise training , salt restriction and nutrition advice for 24 weeks . Then all patients were prospect ively followed up for occurrence of the primary endpoints , including hospitalization due to stroke recurrence and the onset of other vascular events . We also evaluated systolic blood pressure ( SBP ) at the clinic and at home , low-density lipoprotein cholesterol ( LDL-C ) , high-density lipoprotein cholesterol ( HDL-C ) , hemoglobin A1c ( HbA1c ) and high-sensitivity C-reactive protein ( hs-CRP ) to compare the efficacy of the lifestyle interventions . Results : This trial was terminated earlier than expected because of the prespecified early stopping rule for efficacy . After the 24-week intervention period , the intervention group showed a significant increase in daily physical activity and a significant decrease in salt intake ( physical activity , p = 0.012 ; salt intake , p < 0.001 ) , with a significant difference between the r and omized groups ( physical activity , p < 0.001 ; salt intake , p = 0.018 ) . Similarly , blood pressure was decreased and the HDL-C levels were increased in the intervention group ( SBP , p < 0.001 ; HDL-C , p = 0.018 ) , with significant differences between the r and omized groups ( SBP , p < 0.001 ; HDL-C , p = 0.022 ) . In contrast , LDL-C , HbA1c and hs-CRP tended to decrease in the intervention group , but this decrease did not achieve significance . After a median follow-up period of 2.9 years , 12 patients allocated to the control group and 1 patient in the lifestyle intervention group experienced at least 1 vascular event . A sequential plans analysis indicated the superiority of the lifestyle intervention in interim analysis . Kaplan-Meier survival curves after the log-rank test showed a significant prognostic difference between the r and omized groups ( p = 0.005 ) . Conclusions : Lifestyle intervention with appropriate medication is beneficial for reducing the incidence of new vascular events and improving vascular risk factors in patients with noncardioembolic mild ischemic stroke
There were no significant effects of interventions on mean blood pressure or cholesterol levels , prescribing , smoking status or body mass index .
There was some suggestion of a " ceiling effect " whereby interventions have a diminishing beneficial effect once certain levels of risk factor management are reached .
There is weak evidence that regular planned recall of patients for appointments , structured monitoring of risk factors and prescribing , and education for patients can be effective in increasing the proportions of patients within target levels for cholesterol control and blood pressure .
BACKGROUND Ischaemic heart disease ( IHD ) is a major cause of mortality and morbidity and its prevalence is set to increase .
Secondary prevention aims to prevent subsequent acute events in people with established IHD .
While the benefits of individual medical and lifestyle interventions is established , the effectiveness of interventions which seek to improve the way secondary preventive care is delivered in primary care or community setting s is less so .
OBJECTIVES To assess the effectiveness of service organisation interventions , identifying which types and elements of service change are associated with most improvement in clinician and patient adherence to secondary prevention recommendations relating to risk factor levels and monitoring ( blood pressure , cholesterol and lifestyle factors such as diet , exercise , smoking and obesity ) and appropriate prophylactic medication .