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

Alexander M. Clark, PhD, BA, RN; Lisa Hartling, MSc; Ben Vandermeer, BSc, MSc; and Finlay A. McAlister, MD, MSc
[+] Article and Author Information

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


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

Acknowledgments: The authors thank Dr. N.C. Campbell (1314), Dr. R. West (49), Dr. M. Naylor (27, 53), Dr. N. Marchionni (47), Drs. Vale and Sundararajan (63), Dr. Otterstad and Ms. Peersen (46), Dr. W. Young (65), and Dr. K. Jolly (39) for providing further details about their studies. The authors also thank the staff of the University of Alberta Evidence-based Practice Center who participated in generating this report: C. Friesen, J. Russell, M. Josefsson, N. Wiebe, M. Tubman, and K. Bond.

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

Potential Financial Conflicts of Interest: None disclosed.

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

Current Author Addresses: Dr. Clark: Fourth Floor, Faculty of Nursing, Clinical Sciences Building, University of Alberta, Edmonton TGR 2G3, Alberta, Canada.

Ms. Hartling and Mr. Vandermeer: Alberta Research Centre for Child Health Evidence, Aberhart Building, University of Alberta, 11402 University Avenue, Edmonton T6G 2J3, Alberta, Canada.

Dr. McAlister: Division of General Internal Medicine, 2E3.24 WMC, University of Alberta Hospital, 8440 112th Street, Edmonton T6G 2R7, Alberta, Canada.


Ann Intern Med. 2005;143(9):659-672. doi:10.7326/0003-4819-143-9-200511010-00010
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Background: Although supervised exercise programs reduce mortality in survivors of myocardial infarction, the effects of other types of cardiac secondary prevention programs are unknown.

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

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

Study Selection: Randomized clinical trials.

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

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

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

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

Figures

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Figure 1.
Flow of trials through the selection process.

CAD = coronary artery disease.

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

Note that P.RE.COR. had 2 intervention groups and 1 control group. The control group data have been included only once in the total pooled estimate. COACH = Coaching patients On Achieving Cardiovascular Health; ELMI = Extensive Lifestyle Management Intervention; ETICA = Exercise Training Intervention after Coronary Angioplasty; M-HART = Montreal Heart Attack Readjustment Trial; NEHDP = National Exercise and Heart Disease Project; RR = risk ratio; SCRIP = Stanford Coronary Risk Intervention Project; WHO = World Health Organization.

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

Note that P.RE.COR. had 2 intervention groups and 1 control group. The control group data have been included only once in the total pooled estimate. Data for all trials are for the combined end point of nonfatal and fatal myocardial infarction, except for data from Campbell et al., 1998 (13); DeBusk et al., 1994 (17); Allison et al., 2000 (57); Bertie et al., 1992 (80); Carson et al., 1982 (73); Dugmore et al., 1999 (84); Erdman et al., 1986 (77); and Holmbäck et al., 1994 (82). These 8 trials collected data on nonfatal reinfarction rate. ETICA = Exercise Training Intervention after Coronary Angioplasty; M-HART = Montreal Heart Attack Readjustment Trial; NEHDP = National Exercise and Heart Disease Project; RR = risk ratio; SCRIP = Stanford Coronary Risk Intervention Project; WHO = World Health Organization.

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Summary for Patients

The Effectiveness of Cardiac Rehabilitation Programs with and without Exercise Components

The summary below is from the full report titled “Meta-Analysis: Secondary Prevention Programs for Patients with Coronary Artery Disease.” It is in the 1 November 2005 issue of Annals of Internal Medicine (volume 143, pages 659-672). The authors are A.M. Clark, L. Hartling, B. Vandermeer, and F.A. McAlister.

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