Systematic Review of the Effect of Diet and Exercise Lifestyle Interventions in the Secondary Prevention of Coronary Heart Disease

Table 1

Studies (all RCTs) included in analysis of secondary prevention programmes in coronary heart disease.

Source	Study population	Mean age (years)	% Men	Outcomes	Follow-up	Intervention
Exercise
Astengo et al. [16] (2010), Sweden	62 patients with stable angina who had percutaneous coronary intervention (PCI).	Intervention (I) group (𝑛=32): 62 (SD 7);  Control (C) group (𝑛=29): 65 (8).	I: 79%; C: 76%	PA (cycle ergometer test), glucose, and lipid metabolism.	At completion of 8-month intervention.	8-month intervention: I group patients exercised at home on a bicycle ergometer for ≥30 minutes on ≥5 days/week of 250 day (eight months) study period; resistance exercises; monthly motivational meetings with physiotherapist.
Dietary
De   Lorgeril et al. [32] (1996), France	605 subjects <70 years who had survived a MI within 6 months of enrolment.	I (𝑛=302): 53.5. C (𝑛=303): 53.5.	I: 89.4%; C: 92.1%	All-cause and cardiovascular (CV) mortality, nonfatal CV events, diet (24 hour diet recall, Food Frequency Questionnaire).	27 months.; De Lorgeril et al. [33] (1999): 46 months	5-year intervention: initial 1-hour advice session from research cardiologist and dietician to adopt Mediterranean type diet of more bread, root and green vegetables, more fish, less meat, fruit every day and butter and cream replaced with margarine; patients seen at 8 weeks from baseline and annually thereafter.
Psychological
Lewin et al. [29]  (2002), UK	142 patients with angina diagnosed within previous 12 months randomised to Angina Plan or educational session.	I (𝑛=68): 66.7 (9.4); C (𝑛=74): 67.6 (9).	I: 57%; C: 62%.	Frequency of angina attacks, physical limitations (Seattle Angina questionnaire), anxiety, depression, use of drugs.	At completion of 6-month intervention.	6-month intervention: nurse-led Angina Plan: 70 page “workbook” and audio-taped relaxation programme introduced to patient and partner during a 30–40 minute structured interview; nurse sought to correct any misunderstanding of illness. Risk factors discussed; how to reduce these through goal setting and pacing; patients asked to practice relaxation using the tape each day.; Nurse contacted patient by phone at end of weeks 1, 4, 8, and 12 and praised the achievement of reaching goals, discussed extending goals.
Lisspers et al. [26] (1999), Sweden	87 patients with at least 1 significant coronary stenosis suitable for PCI and at least 1 additional clinically insignificant coronary lesion.	I (𝑛=46): 53 (7); C (𝑛=41): 53 (7).	I: 80%; C: 88%.	CV mortality, nonfatal CV events, diet (questionnaire), PA (questionnaire), smoking (questionnaire), QOL (questionnaire:AP-QLQ).	At completion of 12-month intervention.; Lisspers et al. [27] (2005): 24, 36 and 60 months from baseline.	12-month intervention: nurse-led. 4-week residential stay at intervention unit: intense group and individual health education and training; stress management, diet, exercise, smoking; followed by 11-month structured maintenance phase; regular contact with specially assigned nurse through mail and phone calls. Personal lifestyle goals set, diaries kept of everyday lifestyle behaviour.
Salminen et al. [25] (2005), Finland	227 patients with CHD.	I (𝑛=118): males 72.5 (5.3), females 75.5 (6.6); C (𝑛=109): males 72.6 (5.5), females 75.3 (6.5).	I: 49%; C: 50%.	Diet (patient interviews), PA (self report), smoking (patient interviews), BP, total, LDL and HDL cholesterol.	At completion of 16-month intervention.	16-month intervention: nurse-led. 16 lectures: 90–120 minutes each; prevention of CHD, diet and weight control, exercising, financial concerns.; 8 group discussions: small groups, 8 meetings 90–120 minutes each; treatment of elevated serum lipids, healthy eating, CHD risk factors. 6 light exercise sessions: 60–90 minutes each; walking, gymnastics, relaxation.; 3 social activities: picnic at national park, visit to spa, 24-hour cruise.
Educational
Carlsson et al. [42, 43] (1997), Sweden	50–70 years with acute MI, CABG or PTCA less than 2 weeks before study.	Carlsson A [42]: 121 AMI patients: I = 61; C = 60; mean age 62.1.56 CABG patients: I = 27; C = 29; mean age 61.5. Carlsson B [42]: 142 AMI patients: I = 75; C = 67; mean age 62.0. 63 CABG patients: I = 31; C = 32; mean age 61.3.; Carlsson C [43]: 168 patients with AMI: I (𝑛=87): 62.2; C (𝑛=81): 61.9.	A: AMI patients: 75%; CABG patients: 84%.; B: AMI patients: 77%; CABG patients: 84%.; C: 75%	Diet (questionnaire), PA (questionnaire), smoking (questionnaire), total, LDL and HDL cholesterol, use of drugs.	At completion of 1-year intervention.	3-month nurse-led education programme: individual and group counselling: 9 hours/patient: 1.5 hours smoking cessation, 5.5 hours diet, 2 hours PA. Exercise training: 2/3 times/week for 10–12 weeks, 40 minutes PA including interval training with cycling and jogging. Education continued by nurse for 1 year.; Individual exercise schedules.
Cupples and McKnight [22] (1994), UK	688 patients who had had angina for ≥6 months.	I (𝑛=342): mean age 62.7 (7.1).; C (𝑛=346): 63.6 (6.8).	I: 59.4%; C: 59.2%	All-cause and CV mortality, diet (Department of Health and Social Services), PA (patient interviews), smoking (patient interviews), BP, cholesterol, QOL, use of drugs.	At completion of 2-year intervention.; Cupples and McKnight [23] (1999): 5 years from baseline.	Patients given practical advice relating to CV risk factors and reviewed by health visitors at four monthly intervals for two years.
Heller et al. [44] (1993), Australia	450 subjects admitted to hospital with suspected MI.	I (𝑛=213): 59 (8); C (𝑛=237): 58 (8).	I: 76%; C: 68%	Nonfatal CV events, hospital admissions, diet (fat intake), PA (questionnaire), total cholesterol, QOL (Oldridge et al. 1989), use of drugs.	At completion of 6-month intervention.	6-month intervention: GP-delivered educational intervention. Initial letter to GP on benefits of aspirin and beta-blockers plus first of 3 posted packages for patient.; Package 1: Step 1 of “Facts on Fat” kit; quiz, patient target for fat reduction; walking programme and smoking cessation advice.; Package 2: Steps 2 and 3; questions on previous week’s PA.; Package 3: Steps 4 and 5; information on local walking groups.; Monthly newsletters posted over next 4 months containing recipes, dietary and PA information, and National Heart Foundation booklet.; Two telephone calls attempted, patients urged to telephone if requiring information.
Southard et al. [31] (2003), USA	104 subjects with CHD, congestive heart failure or both.	I (𝑛=53): 61.8 (10.6); C (𝑛=51): 62.8 (10.6).	I: 68%; C: 82%	Nonfatal CV events, diet (MEDFICTS dietary survey), PA (min/wk), BP, total, LDL and HDL cholesterol, triglycerides.	At completion of 6-month intervention.	6-month intervention: Internet based educational programme for nurse case managers to provide risk factor management training and advice.; Patients accessed internet programme at least once a week for 30 minutes, communicating with case manager via website’s internal email system, completing educational modules (with interactive multiple choice self-tests), entering data (at any time) to monitor progress. Optional discussions with other participants, rewards given (worth $0.50 to $1.50) for active participation on website. Dietician available to analyse 24 hour diet recalls.; Case managers and dietician also available via telephone and post if necessary.
Multifactorial
Allen et al. [30] (2002), USA	228 patients with hypercholesterolaemia who had CABG or PCI.	I (𝑛=115): 61.1 (10.3); C (𝑛=113): 59.6 (9.6).	I: 70%; C: 73%.	Diet (Block Health Habits and History), PA (Aerobics Centre questionnaire), total, HDL, and LDL cholesterol, triglycerides.	At completion of 1-year intervention.	1-year intervention: nurse case management: plan devised 4–6 weeks after hospital discharge including lifestyle counselling and review of drug therapy.; Follow-up telephone calls to reinforce counselling and adjust drug therapy (each patient contacted average 7 times during follow-up year); ongoing plan sent regularly to doctor. Diet advice: <30% of total energy as fat, <7% saturated fat, <200 mg per day cholesterol; PA: participation in moderate intensity home-based exercise programme; referral to CR; smoking cessation advice and relapse prevention.
Campbell et al. [34] (1998)A (Heart)	1343 patients with CHD.; At 1 yr: I = 593; C = 580.	66	58.2%	Diet (Dietary Instrument for Nutrition Education (DINE) questionnaire), PA (Health Practitioners Index Questionnaire), smoking (Health Practitioners Index Questionnaire), BP, lipid management, aspirin management.	At completion of 1-year intervention.	1-year intervention: Nurse-led clinics to promote medical and lifestyle aspects of secondary prevention. Clinics: 4 stages: (1) Review of symptoms to identify poor control and refer accordingly. (2) Review of drug treatment; encourage aspirin use. (3) BP and lipid assessment. (4) Assessment of exercise, diet, smoking, and behaviour changes suggested. Follow-up visits every 2–6 months; 20 minutes.
	Murchie et al. [36] (2003) A: at 4-year follow-up: I = 564; C = 534.	I: 65.4 (8.2); C: 65.7 (8.6).	As above	As above plus: All-cause mortality, CV events.	4 years from baseline.	As above.
	Campbell et al. [35] (1998) B: as Campbell A	As Campbell A	As Campbell A	QOL (Short Form (SF) 36 questionnaire)	At completion of 1-year intervention.	As Campbell A
	Murchie et al. [37] (2004) B: as Murchie A	As Murchie A	As Murchie A	QOL (SF 36)	4 years from baseline
	Delaney et al. [38] (2008): at 10-year follow-up 531 of 1343 original cohort had died.			All-cause mortality and coronary events (nonfatal MIs and coronary deaths).	10 years from baseline.
Giallauria et al. [18] (2009), Italy	52 patients with acute myocardial infarction (AMI).	I (𝑛=26): 58.2 (7.8); C (𝑛=26): 57.4 (9.7).	I: 85%; C: 85%.	Nonfatal CV events, PA (cycle ergometer test), BP, total, LDL and HDL cholesterol, triglycerides.	At completion of 2-year intervention.	2-year intervention: educational and behavioural; individual and group. Each patient given booklet on exercise, diet and smoking cessation, and ideal targets. Monthly hospital visits: dietary advice, reinforcement of healthy lifestyles, exercise training session to 60–70% of VO2 peak.
Gianuzzi et al. [21] (2008), Italy	3241 patients with recent MI (within past 3 months).	57.9 (9.2)	86.3%	All-cause and CV mortality, nonfatal CV events, diet (knowledge/habits), PA (questionnaire), smoking (questionnaire), BP, total, HDL and LDL cholesterol, self/stress management, use of drugs.	At completion of 3-year intervention; Data collected at 6 months, 1, 2 and 3 years.	3-year intervention: multifactorial, continued educational and behavioural; monthly sessions from months 1 to 6, then every 6 months for 3 years. Each session: 30 minutes supervised aerobic exercise; lifestyle and risk factor counselling lasting at least 1hour; reinforcement of preventive interventions. Booklet on how to deal with exercise, diet, smoking cessation, and stress management. Targets: cease smoking, adopt Mediterranean diet, increase PA to at least 3hours/week at 60–75% of mean max heart rate, maintain BMI of <25, BP 140/85, total cholesterol <200 mg/dL, LDL chol <100 mg/dL, blood glucose <110 mg/dL. Drug treatments positively recommended.
Hamalainen et al. [45] (1995), Finland	375 subjects with MI.	I (𝑛=188): mean age men 53.4, women 58.8.; C (𝑛=187): mean age men 53.0, women 58.4.	I: 80%; C: 80%	All-cause and CV mortality, PA (cycle ergometer test), smoking (patient interviews), BP, cholesterol, triglycerides.	15 years from baseline.	3-year intervention: optimal medical care, physical activation, antismoking, dietary, psychosocial counselling led by social worker, psychologist, dietician, physiotherapist, and doctors. Intervention most intensive for 3 months after AMI, close contacts with team maintained over 3 years.
Murphy et al. [17] (2009), Northern Ireland and Republic of Ireland	903 subjects with CHD recruited from 48 general practices.	I (𝑛=444): 68.5 (9.3); C (𝑛=459): 66.5 (9.9).	I: 70%; C: 70%.	BP, total cholesterol, hospital admissions, QOL (SF 12), diet (DINE questionnaire), PA (Godin questionnaire), smoking (Slan National Survey of Health and Lifestyles in Ireland).	At completion of 18-month intervention.	GP and nurse-led tailored care plans for practices: training in prescribing and behaviour change, administrative support, quarterly newsletter; Tailored care plans for patients: motivational interviewing, goal setting, target setting for lifestyle change, info booklet given to each patient, progress reviewed every 4 months. (Social cognitive theory used to develop training in behaviour change, design patient info booklet, and inform development of tailored patient care plans.)
Ornish et al. [41] (1998), USA	48 patients with moderate to severe CHD.	I (𝑛=20): 57.4 (6.4); C (𝑛=15): 61.8 (7.5).	I: 100%; C: 80%	CV mortality, nonfatal CV events, hospital admissions, diet (diaries), PA (questionnaire on type, frequency, duration), BP, total, LDL and HDL cholesterol, triglycerides, apolipoproteins.	At completion of 5-year intervention.	5-year intervention: week long educational residential stay at hotel (Ornish et al., 1990).Group support meetings, 4 hours twice a week.; Diet: low fat vegetarian, for at least a year: fruit, vegetables, grains, legumes, soybean products; no animal products except egg white and 1 cup/day of nonfat milk or yoghurt. Stress management techniques; advised at least 1 hour/day; audiocassette tape to assist.; Exercise: individual prescription according to baseline treadmill test results, mainly walking; at least 3 hours/week, 30 minutes per session.; Clinical psychologist-led group discussions: social support to encourage adherence.
Redfern et al. [19] (2008) A, Australia	144 acute coronary syndrome (ACS) survivors not accessing standard cardiac rehabilitation (CR).	I (𝑛=72): 62 (1.6); C (𝑛=72): 67 (1.3).	I: 74%; C: 75%.	PA (Physical Activity Readiness Questionnaire (PARQ)), smoking (self report/Airmet Scientific Micro-smokanalyser), BP, total cholesterol.	At completion of 3-month intervention.; Redfern et al. [20] (2009) B: 12 months from baseline	GP-led behaviour change intervention; 1 hour initial consultation, 3 months of 5 phone calls (Redfern et al., 2006) for risk factor education, assertiveness training and assessment of lifestyle goals. Mandatory cholesterol lowering module, including healthy eating and pharmacological advice, and choice of 2 other modules including BP lowering, smoking cessation, and PA; choice of management options for risk factors including doctor-directed, such as a PA “script” from GP, hospital programme, for example, exercise class, individual programme, or self-help.
Vestfold Heartcare Study Group [28] (2003), Norway	197 subjects with acute MI, hospitalisation for unstable angina, PCI, or CABG.	I(𝑛=98): 54 (8); C (𝑛=99): 55 (8).	I: 81%; C: 83%.	Hospital admissions, diet (FFQ), PA (self-report/diaries), smoking (self-report), BP, total and HDL cholesterol, QOL (SF 36), use of drugs.	At completion of 2-year intervention.	2-year intervention: 6-week “heart school” in hospital: PA with physiotherapist: 15 minutes warm-up, 20 minutes walking, 10 minutes cool-down, 10 minutes stretching; advised to exercise on their own every day.; Education sessions: twice a week, 2 hours each; dietary advice, smoking cessation, PA counselling, risk factor management, psychosocial management, medication, stress reduction; individual counselling.; Followed by 9 weeks’ organised PA twice a week at gym supervised by physiotherapist; level increased to jogging; group meetings every 3rd month throughout 2 year follow-up.
Wallner et al. [39] (1999), Austria	60 patients <70 years with angiographically documented CAD and stable angina pectoris; recruited after successful elective PTCA.	I (𝑛=28): 58 (8).; C (𝑛=32): 60 (7)	I: 89%; C: 69%.	Nonfatal CV events, diet (7-day weighted food records), PA (Minnesota Leisure Time questionnaire), BP, LDL and HDL cholesterol.	Mean 26 months (range 18–31) after baseline.	12-month intervention: nutritionist-led. All patients at baseline: dietary and lifestyle advice: cholesterol 100–150 mg/day, fibre ≥25 g/day, PA ≥3 times/week for 30 minutes, smoking cessation. I group: 1-hour dietary advice sessions with nutritionist weekly during first month, every 2 weeks until month 3 then monthly until end of intervention.
Organisational
Jolly et al. [40] (1999), UK	597 patients; 422 with MI and 175 with new diagnosis of angina.	I (𝑛=277): 63 (10); C (𝑛=320): 64 (10).	I: 68%; C: 74%.	Total cholesterol, BP, PA (questionnaire, walking test), smoking (questionnaire), BMI.	At completion of 1-year intervention.	Led by 3 specialist cardiac liaison nurses responsible for coordinating follow-up care, especially transfer of responsibility for care between hospital and GP. Liaison nurses provided support to practice staff by phone and visits to practice every 3–6 months. Practice nurses encouraged to attend training on behaviour change based on stages of change model. Each patient was given a patient held record, which prompted and guided follow-up (at approximately 4 to 6 month intervals).
Munoz et al. [24] (2007), Spain	983 subjects with MI, angina, or ischaemia within previous 6 years.	I (𝑛=515): 64.2 (9.8); C (𝑛=468): 63.6 (10.3).	I: 76.1%; C: 73.2%.	Total mortality, CV mortality, nonfatal CV events, PA (self report), BP, total, LDL and HDL cholesterol, QOL (SF 12), use of drugs.	At completion of 3-year intervention or until an endpoint occurred.	3-year intervention: Postal reminders to see GP every 3 months during 3-year follow-up. GPs strictly followed most recent guidelines on CV prevention, provide patients with healthy lifestyle advice including Mediterranean diet, PA and smoking cessation; adjusted treatments.

I: intervention; C: control