Lifestyle modification programmes for coronary heart disease patients have been shown to effectively improve risk factors and related health behaviours, quality of life, reincidence, and mortality. However, improvements in routine cardiac care over the recent years may offset the incremental benefit associated with older programmes.
Purpose
To determine the efficacy of lifestyle modification programmes for coronary heart disease patients developed over the last decade (1999–2009) by means of a systematic review and meta-analysis.
Results
The study included 23 trials (involving 11,085 randomized patients). Lifestyle modification programmes were associated with reduced all-cause mortality (summary OR 1.34, 95% CI 1.10–1.64), cardiac mortality (summary OR 1.48, 95% CI 1.17–1.88), and cardiac readmissions and non-fatal reinfarctions (summary OR 1.35, 95% CI 1.17–1.55). Furthermore, lifestyle modification programmes positively affected risk factors and related lifestyle behaviours at posttreatment (M = 10.2 months), and some of these benefits were maintained at long-term follow up (M = 33.7 months). Improvements in dietary and exercise behaviour were greater for programmes incorporating all four self-regulation techniques (i.e. goal setting, self-monitoring, planning, and feedback techniques) compared to interventions that included none of these techniques.
Conclusion
The evidence summarized in this meta-analysis confirms the benefits of lifestyle modification programmes – over and above benefits achieved by routine clinical care alone.
AllenderSScarboroughPPetoV. European cardiovascular disease statistics, Brussels: European Heart Network, 2008.
2.
PiepoliMFCorràUBenzerW. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil2010; 17(1): 1741–8267.
3.
BethellHLewinRDalalH. Cardiac rehabilitation in the United Kingdom. Heart2009; 95(4): 271–275.
FranklinBACushmanM. Recent advances in preventive cardiology and lifestyle medicine: a themed series. Circulation2011; 123(20): 2274–2283.
6.
IestraJAKromhoutDvan der SchouwYT. Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review. Circulation2005; 112(6): 924–934.
7.
DusseldorpEMeulmanJKraaijV. A meta-analysis of psychoeduational programs for coronary heart disease patients. Health Psychol1999; 18(5): 506–519.
TaylorRSBrownAEbrahimS. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med2004; 116(10): 682–692.
10.
ClarkAMHartlingLVandermeerB. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Am J Med2005; 143(9): 659–672.
11.
LindenWPhillipsMJLeclercJ. Psychological treatment of cardiac patients: a meta-analysis. Eur Heart J2007; 28(24): 2972–2984.
12.
ClarkAMMacIntyrePDCruickshankJ. A critical realist approach to understanding and evaluating heart health programmes. Health2007; 11(4): 513–539.
13.
MichieSAbrahamCWhittingtonC. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol2009; 28(6): 690–701.
14.
Van AchterbergTHuisman-de WaalGGJKetelaarNBM. How to promote healthy behaviours in patients? An overview of evidence for behaviour change techniques. Health Promot Int2011; 26(2): 148–162.
15.
ChaseJ-AD. Systematic review of physical activity intervention studies after cardiac rehabilitation. J Cardiovasc Nurs2011; 26(5): 351–358.
16.
FebbraroGARClumGA. Meta-analytic investigation of the effectiveness of self-regulatory components in the treatment of adult problem behaviors. Clin Psychol Rev1998; 18(2): 143–161.
17.
MaesSKarolyP. Self-regulation assessment and intervention in physical health and illness: a review. Appl Psychol2005; 54(2): 267–299.
18.
CarverCSScheierMF. On the self-regulation of behavior, New York: Cambridge University Press, 1998.
19.
KnittleKMaesSde GuchtV. Psychological interventions for rheumatoid arthritis: examining the role of self-regulation with a systematic review and meta-analysis of randomized controlled trials. Arthritis Care Res2010; 62(10): 1460–1472.
LancasterT. Review: secondary prevention programmes with and without exercise reduce all cause mortality and recurrent MI. Evid Based Med2006; 11(3): 87–87.
22.
de BruinMViechtbauerWHospersHJ. Standard care quality determines treatment outcomes in control groups of HAART-adherence intervention studies: implications for the interpretation and comparison of intervention effects. Health Psychol2009; 28(6): 668–674.
23.
BaladyGJWilliamsMAAdesPA. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. A scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation2007; 115(20): 2675–2682.
24.
MaesSDe GuchtVGoudR. Is the MacNew quality of life questionnaire a useful diagnostic and evaluation instrument for cardiac rehabilitation?Eur J Cardiovasc Prev Rehabil2008; 15(5): 516–520.
25.
YusufSAvezumAPaisP. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet2004; 364(9438): 937–952.
26.
JadadA. Assessing the quality of reports of randomized clinical trials: is blinding necessary?Control Clin Trials1996; 17(1): 1–12.
27.
AuerRGaumeJRodondiN. Efficacy of in-hospital multidimensional interventions of secondary prevention after acute coronary syndrome: a systematic review and meta-analysis. Circulation2008; 117(24): 3109–3117.
28.
KraemerHCGardnerCBrooksJOIII. Advantages of excluding underpowered studies in meta-analysis: inclusionist versus exclusionist viewpoints. Psychol Meth1998; 3(1): 23–31.
29.
CoyneJCLeporeSJ. Rebuttal: the black swan fallacy in evaluating psychological interventions for distress in cancer patients. Ann Behav Med2006; 32(2): 115–118.
30.
Borenstein LH, Higgins J and Rothstein H. Comprehensive Meta-analysis Version 2, Biostat, Englewood NJ, 2005.
31.
NordmannAMartinaBBattegayE. A case-management program of medium intensity does not improve cardiovascular risk factor control in coronary artery disease patients: the Heartcare I trial. Am J Med2001; 110(7): 543–550.
32.
DelaneyEKMurchiePLeeAJ. Secondary prevention clinics for coronary heart disease: a 10-year follow-up of a randomized controlled trial in primary care. Heart2008; 94(11): 1419–1423.
33.
Murchie P, Campbell NC, Ritchie LD, et al. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care. BMJ 326(7380): 84.
34.
CupplesMEMcKnightA. Five year follow up of patients at high cardiovascular risk who took part in randomized controlled trial of health promotion. BMJ1999; 319(7211): 687–688.
35.
LearSAPritchardPHFrohlichJJ. Extensive lifestyle management intervention following cardiac rehabilitation: pilot study. Rehabil Nurs2002; 26(6): 227–232.
36.
LisspersJRydnLNygrenA. Multifactorial evaluation of a program for lifestyle behavior change in rehabilitation and secondary prevention of coronary artery disease. Scand Cardiovasc J1999; 33(1): 9–16.
37.
MildestvedtTMelandEEideG. No difference in lifestyle changes by adding individual counseling to group-based rehabilitation RCT among coronary heart disease patients. Scand J Public Health2007; 35(6): 591–598.
38.
PischkeCRScherwitzLWeidnerG. Long-term effects of lifestyle changes on well-being and cardiac variables among coronary heart disease patients. Health Psychol2008; 27(5): 584–592.
39.
ToobertDJGlasgowRERadcliffeJL. Physiologic and related behavioral outcomes from the Women’s Lifestyle Heart Trial. Ann Behav Med2000; 22(1): 1–9.
40.
ZwislerA-DOSchouLSojaAMB. A randomized clinical trial of hospital-based, comprehensive cardiac rehabilitation versus usual care for patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease (the DANREHAB trial) – design, intervention, and population. Am Heart J2005; 150(5): 899e8–899e16.
41.
JeongHSChaeJSMoonJS. An individualized teaching program for atherosclerotic risk factor reduction in patients with myocardial infarction. Yonsei Med J2002; 43(1): 93–100.
42.
WallnerSWatzingerNLindschingerM. Effects of intensified lifestyle modification on the need for further revascularization after coronary angioplasty. Eur J Clin Invest1999; 29(5): 372–379.
43.
GiannuzziPTemporelliPLMarchioliR. Global secondary prevention strategies to limit event recurrence after myocardial infarction: results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network. Arch Intern Med2008; 168(20): 2194–2204.
44.
ZwislerA-DOSojaAMBRasmussenS. Hospital-based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12-month results of a randomized clinical trial. Am Heart J2008; 155(6): 1106–1113.
45.
The Vestfold Heartcare Study Group. Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease. Eur J Cardiovasc Prev Rehabil2003; 10(6): 429–437.
46.
CupplesMEMcKnightA. Randomized controlled trial of health promotion in general practice for patients at high cardiovascular risk. BMJ1994; 309(6960): 993–996.
47.
LisspersJHofman-BangCRydnL. Long-term effects of lifestyle behavior change in coronary artery disease: effects on recurrent coronary events after percutaneous coronary intervention. Health Psychol2005; 24(1): 41–48.
48.
OrnishDScherwitzLWBillingsJH. Intensive lifestyle changes for reversal of coronary heart disease. JAMA1998; 280(23): 2001–2007.
49.
MurphyAW. Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomized controlled trial. BMJ2009; 339: b4220–b4220.
50.
Rosenthal R. The ‘file drawer problem’ and tolerance for null results. Psychol Bull 1979; 86(3): 638–641.
51.
DuvalSTweedieR. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics2000; 56(2): 455–463.
52.
ColeJaSmithSMHartN. Systematic review of the effect of diet and exercise lifestyle interventions in the secondary prevention of coronary heart disease. Cardiol Res Prac2011; 2011(Mi): 232351–232351.
53.
McAlisterFALawsonFMETeoKK. Randomized trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ2001; 323(7319): 957–962.
54.
YusufSAvezumAPaisP. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet2004; 364(9438): 937–952.
55.
KotsevaKWoodDABacquer DDeHeidrichJBacker GDe. Cardiac rehabilitation for coronary patients: lifestyle, risk factor and therapeutic management. Results from the EUROASPIRE II survey. Eur Heart J Supplements2004; 6(J): J17–J26.
56.
KotsevaK. Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries. Lancet2009; 373(9667): 929–940.
57.
LiberatiAAltmanDGTetzlaffJ. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clini Epidemiol2009; 62(10): e1–e34.
58.
LeporeSJCoyneJC. Psychological interventions for distress in cancer patients: a review of reviews. Ann Behav Med2006; 32(2): 85–92.
59.
NüeschEJüniP. Commentary: which meta-analyses are conclusive?Int J Epidemiol2009; 38(1): 298–303.
60.
MichieSAshfordSSniehottaFF. A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE taxonomy. Psychol Health2011; 26(11): 1–20.
61.
SchaalmaHKokG. Decoding health education interventions: the times are a-changin’. Psychol Health2009; 24(1): 5–9.
62.
SchulzRCzajaS. Intervention Taxonomy (ITAX): describing essential features of interventions (HMC). Am J Health Behav2010; 34(6): 811–821.
63.
PoppeKKDoughtyRNYuC-M. Understanding differences in results from literature-based and individual patient meta-analyses: an example from meta-analyses of observational data. Int J Cardiol2011; 148(2): 209–213.
64.
RileyRD. Commentary: like it and lump it? Meta-analysis using individual participant data. Int J Epidemiol2010; 39(5): 1359–1361.
65.
AldanaRSalbergAMerrillR. The effects of an intensive lifestyle modification program on carotid artery intima-media thickness: a randomized trial. Am J Health Promot2007; 21(6): 510–516.
66.
AllisonTGEvansRWKopeckySL. Management of coronary risk factors by registered nurses versus usual care in patients with unstable angina pectoris (a chest pain evaluation in the emergency room [CHEER] substudy). Am J Cardiol2000; 86(2): 133–138.
67.
BrugemannJ. A randomised controlled trial of cardiac rehabilitation after revascularisation. Int J Cardiol2007; 119(1): 59–64.
68.
CampbellNCRitchieLDThainJ. Secondary prevention in coronary heart disease: a randomized trial of nurse led clinics in primary care. Heart1998; 80(5): 447–452.
69.
CampbellNCThainJDeansHG. Secondary prevention clinics for coronary heart disease: randomized trial of effect on health. BMJ1998; 316(7142): 1434–1437.
70.
MurchiePDeansHGThainJ. Effects of secondary prevention clinics on health status in patients with coronary heart disease: 4 year follow-up of a randomized trial in primary care. Fam Pract2004; 21(5): 567–574.
JiangX. A nurse-led cardiac rehabilitation programme improves health behaviors and cardiac physiological risk parameters: evidence from Chengdu, China. J Clin Nurs2007; 16(10): 1886–1897.
73.
LearSABrozicAHaydn PritchardP. The Extensive Lifestyle Management Intervention (ELMI) following cardiac rehabilitation trial. Eur Heart J2003; 24(21): 1920–1927.
74.
LearSABrozicAPritchardPH. A randomized controlled trial of an extensive lifestyle management intervention (ELMI) following cardiac rehabilitation: study design and baseline data. Curr Control Trials Cardiovasc Med2005; 3(1): 9–9.
75.
LearSASpinelliJJLindenW. The Extensive Lifestyle Management Intervention (ELMI) after cardiac rehabilitation: a 4-year randomized controlled trial. Am Heart J2006; 152(2): 333–339.
76.
LisspersJNordlanderROhmanA. Behavioral effects of a comprehensive, multifactorial program for lifestyle change after percutaneous transluminal coronary angioplasty: a prospective, randomized controlled study. J Psychosom Res1999; 46(2): 143–154.
77.
McHughFHuttonIWheatleyDJ. Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: a randomized controlled trial. Heart2001; 86(3): 317–323.
78.
MildestvedtT. How important are individual counseling, expectancy beliefs and autonomy for the maintenance of exercise after cardiac rehabilitation?Scand J Public Health2008; 36(8): 832–840.
79.
OrnishDBrownSEBillingsJH. Can lifestyle changes reverse coronary heart disease?Lancet1990; 336(8708): 129–133.
80.
SalminenMOjanlatvaAVahlbergT. Effects of health advocacy, counseling, and activation among older coronary heart disease (CHD) patients. Aging Clin Exp Res2006; 17(6): 472–478.
81.
SmeuldersESTFvan HaastregtJCMAmbergenT. The impact of a self-management group programme on health behaviour and healthcare utilization among congestive heart failure patients. Eur J Heart Fail2009; 11(6): 609–616.
82.
ToobertDJGlasgowRENettekovenLA. Behavioral and psychosocial effects of intensive lifestyle management for women with coronary heart disease. Patient Educ Couns1998; 35(3): 177–188.
83.
WoodDAKotsevaKConnollyS. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomized controlle. Lancet2008; 371(9629): 1999–2012.
84.
Hofman-BangCNygrenARydnL. Two-year results of a controlled study of residential rehabilitation for patients treated with percutaneous transluminal coronary angioplasty. A randomized study of a multifactorial programme. Eur Heart J1999; 20(20): 1465–1474.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
