Systematic Review of the Effect of Diet and Exercise Lifestyle Interventions in the Secondary Prevention of Coronary Heart Disease Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease A comparison of live counseling with a web-based lifestyle and medication intervention to reduce coronary heart disease risk: a randomized clinical trial. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care Evaluating the efficacy of an education and treatment program for patients with coronary heart disease. Lifestyle Interventions Reduce Coronary Heart Disease Risk: Results From the PREMIER Trial Community-based comprehensive lifestyle programs in patients with coronary artery disease: Objectives, design and expected results of Randomized Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2 trial (RESPONSE 2). Randomised controlled trial of a secondary prevention program for myocardial infarction patients ('ProActive Heart'): study protocol. Secondary prevention program for myocardial infarction patients Text Message and Internet Support for Coronary Heart Disease Self-Management: Results From the Text4Heart Randomized Controlled Trial Rationale and design of a randomized controlled trial evaluating community health worker-based interventions for the secondary prevention of acute coronary syndromes in India (SPREAD). Effectiveness of two preventive interventions for coronary heart disease in primary care. A randomized trial of an intervention to improve use and adherence to effective coronary heart disease prevention strategies A pharmacist-led follow-up program for patients with established coronary heart disease in North Norway – a randomized controlled trial Quality of care for secondary prevention for patients with coronary heart disease: results of the Hastening the Effective Application of Research through Technology (HEART) trial. Case-Based Training of Evidence-Based Clinical Practice in Primary Care and Decreased Mortality in Patients With Coronary Heart Disease [Effectiveness of the cooperative program of multifactorial prevention of ischemic heart disease (results of the 3-year study)]. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care
The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease ( CHD ) remains unclear . This systematic review aim ed to determine their effectiveness and included r and omized controlled trials of lifestyle interventions , in primary care or community setting s , with a minimum follow-up of three months , published since 1990 . 21 trials with 10,799 patients 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 but no overall effect on smoking outcomes . In trials that examined mortality and morbidity , significant benefits were reported for total mortality ( in 4 of 6 trials ; overall risk ratio ( RR ) 0.75 ( 95 % confidence intervals ( CI ) 0.65 , 0.87 ) ) , cardiovascular mortality ( 3 of 8 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 ) ) . The heterogeneity between trials and generally poor quality of trials make any concrete conclusions difficult . However , the beneficial effects observed in this review are encouraging and should stimulate further research Background Lifestyle measures of coronary heart disease ( CHD ) prevention have been overshadowed by the efficacy of drug treatments . This is particularly the case in the setting of secondary prevention where the benefits of lipid lowering , anti-platelet and anti-hypertensive drugs have been emphasised in numerous trials . Lifestyle measures address several CHD risk factors at once and are generally free of serious side effects . Objectives The objective of the present study was to determine whether a comprehensive programme of lifestyle modification could favourably influence dietary and exercise habits in addition to smoking cessation over two years . In addition , an attempt was made to evaluate if this programme could favourably influence the five-year CHD-risk in the male population included in the study . Design A total of 197 patients with proven coronary heart disease were included and r and omised to a lifestyle intervention programme or to usual care . Follow-up was after a period of two years . Methods Intervention comprised a low fat diet , regular exercise , smoking cessation , psychosocial support and education , delivered by nurses on the rationale for pharmacological and lifestyle measures . Usual care comprised follow-up in the routine outpatient clinic . Both groups were given the same comprehensive medication according to recent guidelines . Results Patients in the lifestyle intervention group reduced the intake of saturated fat , sugar and cholesterol ( P<0.001 ) , increased their exercise level ( P<0.01 ) and stopped smoking ( P<0.05 ) when compared with the usual care group . A sub analysis of the influence of five-year CHD calculated risk in males result ed in a relative risk reduction of 22 % ( 95 % confidence intervals 9 - 35 ) . Although significant , this result must be interpreted with caution due to poor statistical power and reproducibility of the method . Conclusions In the presence of modern drug treatments for secondary cardiovascular disease prevention it remains possible through a favourable diet , exercise and smoking cessation to show an additional reduction in the five-year risk for CHD in males IMPORTANCE Most primary care clinicians lack the skills and re sources to offer effective lifestyle and medication ( L&M ) counseling to reduce coronary heart disease ( CHD ) risk . Thus , effective and feasible CHD prevention programs are needed for typical practice setting s. OBJECTIVE To assess the effectiveness , acceptability , and cost-effectiveness of a combined L&M intervention to reduce CHD risk offered in counselor-delivered and web-based formats . DESIGN , SETTING , AND PARTICIPANTS A comparative effectiveness trial in 5 diverse family medicine practice s in North Carolina . Participants were established patients , aged 35 to 79 years , with no known cardiovascular disease , and at moderate to high risk for CHD ( 10-year Framingham Risk Score [ FRS ] , ≥10 % ) . INTERVENTIONS Participants were r and omized to counselor-delivered or web-based format , each including 4 intensive and 3 maintenance sessions . After r and omization , both formats used a web-based decision aid showing potential CHD risk reduction associated with L&M risk-reducing strategies . Participants chose the risk-reducing strategies they wished to follow . MAIN OUTCOMES AND MEASURES The primary outcome was within-group change in FRS at 4-month follow-up . Other measures included st and ardized assessment s of blood pressure , blood lipid levels , lifestyle behaviors , and medication adherence . Acceptability and cost-effectiveness were also assessed . Outcomes were assessed at 4 and 12 months . RESULTS Of 2274 screened patients , 385 were r and omized ( 192 counselor ; 193 web ) : mean age , 62 years ; 24 % African American ; and mean FRS , 16.9 % . Follow-up at 4 and 12 months included 91 % and 87 % of the r and omized participants , respectively . There was a sustained reduction in FRS at both 4 months ( primary outcome ) and 12 months for both counselor-based ( -2.3 % [ 95 % CI , -3.0 % to -1.6 % ] and -1.9 % [ 95 % CI , -2.8 % to -1.1 % ] , respectively ) and web-based groups ( -1.5 % [ 95 % CI , -2.2 % to -0.9 % ] and -1.7 % [ 95 % CI , -2.6 % to -0.8 % ] respectively ) . At 4 months , the adjusted difference in FRS between groups was -1.0 % ( 95 % CI , -1.8 % to -0.1 % ) ( P = .03 ) , and at 12 months , it was -0.6 % ( 95 % CI , -1.7 % to 0.5 % ) ( P = .30 ) . The 12-month costs from the payer perspective were $ 207 and $ 110 per person for the counselor- and web-based interventions , respectively . CONCLUSIONS AND RELEVANCE Both intervention formats reduced CHD risk through 12-month follow-up . The web format was less expensive . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01245686 Abstract Objectives : To evaluate the effects of nurse led clinics in primary care on secondary prevention , total mortality , and coronary event rates after four years . Design : Follow up of a r and omised controlled trial by postal question naires and review of case notes and national data sets . Setting : Stratified , r and om sample of 19 general practice s in north east Scotl and . Participants : 1343 patients ( 673 intervention and 670 control ) under 80 years with a working diagnosis of coronary heart disease but without terminal illness or dementia and not housebound . Intervention : Nurse led secondary prevention clinics promoted medical and lifestyle components of secondary prevention and offered regular follow up for one year . Main outcome measures : Components of secondary prevention ( aspirin , blood pressure management , lipid management , healthy diet , exercise , non-smoking ) , total mortality , and coronary events ( non-fatal myocardial infa rct ions and coronary deaths ) . Results : Mean follow up was at 4.7 years . Significant improvements were shown in the intervention group in all components of secondary prevention except smoking at one year , and these were sustained after four years except for exercise . The control group , most of whom attended clinics after the initial year , caught up before final follow up , and differences between groups were no longer significant . At 4.7 years , 100 patients in the intervention group and 128 in the control group had died : cumulative death rates were 14.5 % and 18.9 % , respectively ( P=0.038 ) . 100 coronary events occurred in the intervention group and 125 in the control group : cumulative event rates were 14.2 % and 18.2 % , respectively ( P=0.052 ) . Adjusting for age , sex , general practice , and baseline secondary prevention , proportional hazard ratios were 0.75 for all deaths ( 95 % confidence intervals 0.58 to 0.98 ; P=0.036 ) and 0.76 for coronary events ( 0.58 to 1.00 ; P=0.049 ) Conclusions : Nurse led secondary prevention improved medical and lifestyle components of secondary prevention and this seemed to lead to significantly fewer total deaths and probably fewer coronary events .  Secondary prevention clinics should be started sooner rather than later . What is already known on this topic Several effective interventions exist for the secondary prevention of coronary heart disease , but implementing them in practice has proved difficult Secondary prevention programmes for coronary heart disease have improved short term outcomes such as processes of care and quality of life What this study adds Short term improvements in uptake of secondary prevention produced by nurse led clinics are maintained in the longer term Improved medical and lifestyle components of secondary prevention produced by nurse led clinics seem to lead to fewer total deaths and coronary BACKGROUND Until now , there has not been any evaluated , disease-specific education and treatment program for patients with coronary heart disease ( CHD ) in Germany . It is thought that education can improve these patients ' physical activity and quality of life and teach them how to lessen their risk factors , what to do in case of an emergency , and how to assess their own medical treatment . METHODS A r and omized controlled open intervention trial was carried out from February 2010 to September 2011 . 196 patients were assigned to receive the intervention ( patient education ) , while 199 were assigned to a control group .  In an intention-to-treat analysis , baseline and follow-up data were compared after a mean interval of 220 days . The evaluative instruments included the Freiburg Question naire of Physical Activity , the MacNew Heart Disease Quality of Life Question naire , question naires regarding knowledge about CHD , ergometric performance ability , and the body-mass index . RESULTS The patients in the intervention group reported having increased their physical activity by a mean of 9.3 MET/week ( MET = metabolic equivalent of task ) , compared to 2.5 MET/week in the control group ; the difference of 6.8 MET/week was statistically significant ( p = 0.015 ) . The patients in the intervention group also rated their quality of life higher than those in the control group ( 0.2 ± 0.56 vs. 0.09 ± 0.53 [ mean ± st and ard deviation ] , p = 0.056 ) . They were significantly better informed than patients in the control group about risk factors and about what to do in an emergency . CONCLUSION Persistently unhealthy lifestyle is a common problem of CHD patients ; the education and treatment program presented here may be a suitable means of improving patients ' lifestyle for secondary prevention . Further studies will be needed to document long-term efficacy and to determine whether occasional refresher courses will be needed as well Background — Although trials of lifestyle interventions generally focus on cardiovascular disease risk factors rather than hard clinical outcomes , 10-year coronary heart disease ( CHD ) risk can be estimated from the Framingham risk equations . Our objectives were to study the effect of 2 multicomponent lifestyle interventions on estimated CHD risk relative to advice alone and to evaluate whether differences can be observed in the effects of the lifestyle interventions among subgroups defined by baseline variables . Methods and Results — A total of 810 healthy adults with untreated prehypertension or stage I hypertension were r and omized to 1 of 3 intervention groups : An “ advice-only ” group , an “ established ” group that used established lifestyle recommendations for blood pressure control ( sodium reduction , weight loss , and increased physical activity ) , or an “ established-plus-DASH ” group that combined established lifestyle recommendations with the DASH ( Dietary Approaches to Stop Hypertension ) diet . The primary outcome was 10-year CHD risk , estimated from follow-up data collected at 6 months . A secondary outcome was 10-year CHD risk at 18 months . Of the 810 participants , 62 % were women and 34 % were black . Mean age was 50 years , mean systolic/diastolic blood pressure was 135/85 mm Hg , and median baseline Framingham risk was 1.9 % . The relative risk ratio comparing 6-month to baseline Framingham risk was 0.86 ( 95 % confidence interval 0.81 to 0.91 , P<0.001 ) in the established group and 0.88 ( 95 % confidence interval 0.83 to 0.94 , P<0.001 ) in the established-plus-DASH group relative to advice alone . Results were virtually identical in sensitivity analyses , in each major subgroup , and at 18 months . Conclusions — The observed reductions of 12 % to 14 % in estimated CHD risk are substantial and , if achieved , should have important public health benefits UNLABELLED Patients with coronary artery disease ( CAD ) are at high risk of recurrent events . A healthy lifestyle can significantly reduce this risk . A previous trial , R and omized Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists ( RESPONSE ) , demonstrated that nurse-coordinated outpatient clinics improve drug treatment of cardiovascular risk factors . However , lifestyle-related risk factors , including smoking , overweight , and physical inactivity , were common and remained largely unchanged at follow-up in most patients ( 66 % ) . The aim of the current study is to evaluate the impact of 3 community-based lifestyle programs in patients after hospitalization for CAD . We are conducting a multicenter ( n = 15 ) , r and omized trial that will recruit 800 patients to test the efficacy of up to 3 widely available commercial lifestyle programs , aim ed at patients and their partners , on top of usual care . These programs are aim ed at smoking cessation ( Luchtsignaal ( ® ) ) , weight loss ( Weight Watchers ( ® ) ) , and improving physical activity ( Philips DirectLife ( ® ) ) . OUTCOMES The primary outcome at 12months is the proportion of patients in whom at least 1 lifestyle risk factor is improved without deterioration in any of the other 2 , and a relative increase of at least 30 % in this proportion is considered clinical ly relevant Background Coronary heart disease ( CHD ) is a significant cause of health and economic burden . Secondary prevention programs play a pivotal role in the treatment and management of those affected by CHD although participation rates are poor due to patient , provider , health system and societal-level barriers . As such , there is a need to develop innovative secondary prevention programs to address the treatment gap . Telephone-delivered care is convenient , flexible and has been shown to improve behavioural and clinical outcomes following myocardial infa rct ion ( MI ) . This paper presents the design of a r and omised controlled trial to evaluate the efficacy of a six-month telephone-delivered secondary prevention program for  MI patients ( ProActive Heart ) . Methods 550 adult MI patients have been recruited over a 14 month period ( December 2007 to January 2009 ) through two Brisbane metropolitan hospitals , and r and omised to an intervention or control group ( n = 225 per group ) . The intervention commences within two weeks of hospital discharge delivered by study -trained health professionals ( ' health coaches ' ) during up to 10 × 30 minute scripted telephone health coaching sessions . Participants also receive a ProActive Heart h and book and an educational re source to use during the health coaching sessions . The intervention focuses on appropriate modification of CHD risk factors , compliance with pharmacological management , and management of psychosocial issues . Data collection occurs at baseline or prior to commencement of the intervention ( Time 1 ) , six months follow-up or the completion of the intervention ( Time 2 ) , and at 12 months follow-up for longer term outcomes ( Time 3 ) . Primary outcome measures include quality of life ( Short Form-36 ) and physical activity ( Active Australia Survey ) . A cost-effective analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government . Discussion The results of this study will provide valuable new information about an innovative telephone-delivered cost-effective secondary prevention program for MI patients .Trial Registration Background Mobile technology has the potential to deliver behavior change interventions ( mHealth ) to reduce coronary heart disease ( CHD ) at modest cost . Previous studies have focused on single behaviors ; however , cardiac rehabilitation ( CR ) , a component of CHD self-management , needs to address multiple risk factors . Objective The aim was to investigate the effectiveness of a mHealth-delivered comprehensive CR program ( Text4Heart ) to improve adherence to recommended lifestyle behaviors ( smoking cessation , physical activity , healthy diet , and nonharmful alcohol use ) in addition to usual care ( traditional CR ) . Methods A 2-arm , parallel , r and omized controlled trial was conducted in New Zeal and adults diagnosed with CHD . Participants were recruited in-hospital and were encouraged to attend center-based CR ( usual care control ) . In addition , the intervention group received a personalized 24-week mHealth program , framed in social cognitive theory , sent by fully automated daily short message service ( SMS ) text messages and a supporting website . The primary outcome was adherence to healthy lifestyle behaviors measured using a self-reported composite health behavior score ( ≥3 ) at 3 and 6 months . Secondary outcomes included clinical outcomes , medication adherence score , self-efficacy , illness perceptions , and anxiety and /or depression at 6 months . Baseline and 6-month follow-up assessment s ( unblinded ) were conducted in person . Results Eligible patients ( N=123 ) recruited from 2 large metropolitan hospitals were r and omized to the intervention ( n=61 ) or the control ( n=62 ) group . Participants were predominantly male ( 100/123 , 81.3 % ) , New Zeal and European ( 73/123 , 59.3 % ) , with a mean age of 59.5 ( SD 11.1 ) years . A significant treatment effect in favor of the intervention was observed for the primary outcome at 3 months ( AOR 2.55 , 95 % CI 1.12 - 5.84 ; P=.03 ) , but not at 6 months ( AOR 1.93 , 95 % CI 0.83 - 4.53 ; P=.13 ) . The intervention group reported significantly greater medication adherence score ( mean difference : 0.58 , 95 % CI 0.19 - 0.97 ; P=.004 ) . The majority of intervention participants reported reading all their text messages ( 52/61 , 85 % ) . The number of visits to the website per person ranged from zero to 100 ( median 3 ) over the 6-month intervention period . Conclusions A mHealth CR intervention plus usual care showed a positive effect on adherence to multiple lifestyle behavior changes at 3 months in New Zeal and adults with CHD compared to usual care alone . The effect was not sustained to the end of the 6-month intervention . A larger study is needed to determine the size of the effect in the longer term and whether the change in behavior reduces adverse cardiovascular events . Trial Registration ACTRN 12613000901707 ; https://www.anzctr.org.au/Trial/ Registration /Trial Review .aspx?id=364758&is Review = true ( Archived by WebCite at http://www.webcitation.org/6c4qhcHKt BACKGROUND There is a need to evaluate and implement cost-effective strategies to improve adherence to treatments in coronary heart disease . There are no studies from low- to middle income countries ( LMICs ) evaluating trained community health worker (CHW)-based interventions for the secondary prevention of coronary heart disease . METHODS We design ed a hospital-based , open r and omized trial of CHW-based interventions versus st and ard care .  Patients after an acute coronary syndrome ( ACS ) were r and omized to an intervention group ( a CHW-based intervention package , comprising education tools to enhance self-care and adherence , and regular follow-up by the CHW ) or to st and ard care for 12 months during which study outcomes were recorded . The CHWs were trained over a period of 6 months . The primary outcome measure was medication adherence . The secondary outcomes were differences in adherence to lifestyle modification , physiological parameters ( blood pressure [ BP ] , body weight , body mass index [ BMI ] , heart rate , lipids ) , and major adverse cardiovascular events . RESULTS We recruited 806 patients stabilized after an ACS from 14 hospitals in 13 Indian cities . The mean age was 56.4 ( ± 11.32 ) years , and 17.2 % were females . A high prevalence of risk factors such as hypertension ( 43.4 % ) , diabetes ( 31.9 % ) , tobacco consumption ( 35.4 % ) , and inadequate physical activity ( 70.5 % ) was documented . A little over half had ST-elevation myocardial infa rct ion ( 53.7 % ) , and 46.3 % had non-ST-elevation myocardial infa rct ion or unstable angina . CONCLUSION The CHW interventions and training for SPREAD have been developed and adapted for local use . The results and experience of this study will be important to counter the burden of cardiovascular diseases in low- to middle income countries OBJECTIVES 1 . To compare a patient-centred , self-directive intervention with conventional care ; 2 . To evaluate longitudinal within-group changes of coronary heart disease risk . METHODS Risk factor changes were evaluated in 110 men with high coronary heart disease risk attending a one year intervention study in general practice . The 22 participating general practice centres were r and omly allocated to follow either a patient-centred , self-directive intervention or a conventional approach . RESULTS No significant between-group differences were found in any single risk factor or in the combined risk of coronary heart disease . The improvement of total risk from screening time to conclusion of the study corresponded with changes of relative risks of CHD to 0.64 ( 95 % CI : 0.54 - 0.77 ) and 0.65 ( 0.54 - 0.77 ) in the patient-centred , self-directive and the conventional care group respectively ( p < 0.0001 in both groups ) . CONCLUSION Everyday general practice clinical work seems as efficacious as a specific intervention method based on currently advocated behaviour change principles Background Efficacious strategies for the primary prevention of coronary heart disease ( CHD ) are underused , and , when used , have low adherence . Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice . Methods We conducted a r and omized trial of a CHD prevention intervention ( including a computerized decision aid and automated tailored adherence messages ) at one university general internal medicine practice . After obtaining informed consent and collecting baseline data , we r and omized patients ( men and women age 40 - 79 with no prior history of cardiovascular disease ) to either the intervention or usual care . We then saw them for two additional study visits over 3 months . For intervention participants , we administered the decision aid at the primary study visit ( 1 week after baseline visit ) and then mailed 3 tailored adherence reminders at 2 , 4 , and 6 weeks . We assessed our outcomes ( including the predicted likelihood of angina , myocardial infa rct ion , and CHD death over 10 years ( CHD risk ) and self-reported adherence ) between groups at 3 month follow-up . Data collection occurred from June 2007 through December 2009 . All study procedures were IRB approved . Results We r and omized 160 eligible patients ( 81 intervention ; 79 control ) and followed 96 % to study conclusion . Mean predicted CHD risk at baseline was 11.3 % . The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points ( 95 % CI 8 % to 42 % ) , with the biggest effect for aspirin . It also changed predicted CHD risk by -1.1 % ( 95 % CI -0.16 % to -2 % ) , with a larger effect in a pre-specified subgroup of high risk patients . Conclusion A computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk . Clinical trials registration number Clinical Trials.gov : Objectives : The aim of the study was twofold ; 1 ) to develop a clinical pharmacist-led 12 month lasting follow-up program for patients with established coronary heart disease ( CHD ) discharged from the University Hospital of North Norway , and 2 ) to explore the impact of the program with regards to adherence to a medication assessment tool for secondary prevention of CHD and change in biomedical risk factors . Methods : A total of 102 patients aged 18 - 82 years were enrolled in a non-blinded r and omized controlled trial with an intervention group and a control group . The intervention comprised medication reconciliation , medication review and patient education during three meetings ; at discharge , after three months and after twelve months . The control group received st and ard care from their general practitioner . Primary outcomes were adherence to clinical guideline recommendations concerning prescription , therapy goal achievement and lifestyle education  defined in the medication assessment tool for secondary prevention of CHD ( MAT-CHDSP ) . Secondary outcomes included changes in the biomedical risk factors cholesterol , blood pressure and blood glucose . Results : Ninety-four patients completed the trial , 48 intervention group patients and 46 controls . Appropriate prescribing was high , but therapy goal achievement was low in both groups . Overall adherence to MAT-CHDSP criteria increased in both groups and was significantly higher in the intervention group at study end , 78.4 % vs. 62.0 % , p<0.001 . The difference was statistically significant for the documented lifestyle advices in intervention group patients . No significant improvements in biomedical risk factors were observed in favor of the intervention group . Conclusions : The study showed an increased guideline adherence in both study groups . This indicates that attention to clinical practice guideline recommendations in itself increases adherence – which may be a clinical pharmacist task . A larger adequately powered study is needed to show a significant difference in biomedical risk factor improvements in favor of the intervention . Amendments to the follow-up program are suggested before implementation in st and ard patient care can be recommended BACKGROUND Effective therapies for reducing mortality rates in persons with coronary heart disease ( CHD ) remain underused . We report the results of an effectiveness trial of a quality improvement effort to increase the use of 3-hydroxy-3methylglutaryl coenzyme A ( HMG CoA ) reductase inhibitors , beta-blockers , and angiotensin-converting enzyme ( ACE ) inhibitors in patients with CHD in a network-model managed-care setting . METHODS Patients with CHD were identified by search ing a cl aims data base . The use of therapies was assessed by linkage with a pharmacy data base . An intervention , consisting of a guideline summary , peer comparison performance feedback , and patient specific chart reminders was evaluated in a r and omized , practice -based effectiveness trial . RESULTS Data were available for > 700 patients per year ( 1999 - 2002 ) in 131 practice s. At baseline ( 1999 ) , 55 % of patients were receiving HMG CoA reductase inhibitors , 39 % of patients were receiving beta-blockers , and 24 % of patients were receiving ACE inhibitors . The use of all 3 types of medications increased steadily with time , with the exception of a decrease in the use of HMG CoA reductase inhibitors in the final year ( 2002 ) . No difference in medication use was observed between r and omized groups . CONCLUSIONS The observed pattern of care supports the contention that the quality of outpatient care for secondary prevention of CHD improved from 1999 to 2002 in this setting . The basis for the inconsistent pattern of use of HMG CoA reductase inhibitors is not certain , but may relate to concerns about toxicity . Central ized mailings of guideline summaries , performance feedback reports , and chart reminders had no observable impact on quality of care in this setting . More intensive intervention may be required to improve the quality of outpatient care for the secondary prevention of CHD PURPOSE We investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aim ed at reducing the gap between evidence -based goals and clinical practice in patients with coronary heart disease ( CHD ) . METHODS A prospect i ve r and omized controlled pragmatic trial was undertaken in a primary care setting . New evidence -based guidelines , with intensified lipid-lowering recommendations in CHD , were mailed to all general practitioners in the region and presented at a lecture in 1995 . General practitioners ( n = 54 ) and patients with CHD ( n = 88 ) were assigned according to their primary health care center to 2 balanced groups and r and omly allocated to usual care as a control or to an active intervention . General practitioners in the intervention group participated in repeated case-based training during a 2-year period . Patients whose CHD was treated by specialists ( n = 167 ) served as an internal specialist comparison group . Altogether , 255 consecutive patients were included .  Cox regression analysis was used to detect any survival benefit of the intervention . RESULTS At 10 years , 22 % of the patients in the intervention group had died as compared with 44 % in the control group ( P = .02 ) , with a hazard ratio of 0.45 ( 95 % confidence interval , 0.20–0.95 ) . This difference was mainly due to reduced cardiovascular mortality in the intervention group ( P = .01 ) . In addition , the mortality rate of 22 % in the intervention group was comparable to the rate of 23 % seen in patients treated by a specialist . CONCLUSIONS Use of case-based training to implement evidence -based practice in primary care was associated with decreased mortality at 10 years in patients with CHD The paper provides the results obtained in the course of the cooperative All-Union programme on multifactor prevention of coronary heart disease ( CHD ) , which has been implemented over 3 years to examine the efficiency of preventive actions aim ed at correcting the levels of CHD risk factors . The study was conducted in 6 centers of the country among a non-organized male population aged 40 - 59 years . The outcome of the preventive measures , largely nonpharmacological ones , made during 3 years suggests that the prevalence of the major CHD risk factors may be reduced in the population . The preventive actions are the most beneficial in arterial hypertension and smoking Objective To evaluate whether  nurse run clinics in general practice improve secondary prevention in patients with coronary heart disease . Design R and omised controlled trial . Setting A r and om sample of 19 general practice s in northeast Scotl and . Patients 1173 patients ( 685 men and 488 women ) under 80 years with working diagnoses of coronary heart disease , but without terminal illness or dementia and not housebound .  Intervention Nurse run clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow up . Main outcome measures Components of secondary prevention assessed at baseline and one year were : aspirin use ; blood pressure management ; lipid management ; physical activity ; dietary fat ; and smoking status . A cumulative score was generated by counting the number of appropriate components of secondary prevention for each patient . Results There were significant improvements in aspirin management ( odds ratio 3.22 , 95 % confidence interval 2.15 to 4.80 ) , blood pressure management ( 5.32 , 3.01 to 9.41 ) , lipid management ( 3.19 , 2.39 to 4.26 ) , physical activity ( 1.67 , 1.23 to 2.26 ) and diet ( 1.47 , 1.10 to 1.96 ) . There was no effect on smoking cessation ( 0.78 , 0.47 to 1.28 ) . Of six possible components of secondary prevention , the baseline mean was 3.27 . The adjusted mean improvement attributable to intervention was 0.55 of a component ( 0.44 to 0.67 ) . Improvement was found regardless of practice baseline performance . Conclusions  Nurse run clinics proved practical to implement in general practice and effectively increased secondary prevention in coronary heart disease . Most patients gained at least one effective component of secondary prevention and , for them , future cardiovascular events and mortality could be reduced by up to a third
The overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes but no overall effect on smoking outcomes .
The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease ( CHD ) remains unclear .
This systematic review aim ed to determine their effectiveness and included r and omized controlled trials of lifestyle interventions , in primary care or community setting s , with a minimum follow-up of three months , published since 1990 .