title: An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Regular Physical Exercise and Low‐Fat Diet: Effects on Progression of Coronary Artery Disease Improved Exercise Tolerance and Quality of Life With Cardiac Rehabilitation of Older Patients After Myocardial Infarction: Results of a Randomized, Controlled Trial Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction Secondary prevention clinics for coronary heart disease: randomised trial of effect on health Physiologic and related behavioral outcomes from the Women’s Lifestyle Heart Trial Can lifestyle changes reverse coronary heart disease?: The Lifestyle Heart Trial Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care Treadmill test responses to an early exercise program after myocardial infarction: a randomized study. Attenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: role of physical exercise. Serum cholesterol, lifestyle, working capacity and quality of life in patients with coronary artery disease. Experiences from a hospital-based secondary prevention programme. Evaluation of a community-based inner-city disease management program for postmyocardial infarction patients: a randomized controlled trial. Effects of cardiac rehabilitation after myocardial infarction: changes in coronary risk factors and long-term prognosis. Rehabilitation outcomes following percutaneous coronary interventions (PCI). Impact on patients and partners of inpatient and extended cardiac counseling and rehabilitation: a controlled trial. The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. Comparing multifactorial lifestyle interventions and stress management in coronary risk reduction Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk Intensive lifestyle changes for reversal of coronary heart disease. Psychological rehabilitation after myocardial infarction: multicentre randomised controlled trial Coaching patients with coronary heart disease to achieve the target cholesterol: a method to bridge the gap between evidence-based medicine and the "real world"--randomized controlled trial. Behavioral effects of a comprehensive, multifactorial program for lifestyle change after percutaneous transluminal coronary angioplasty: a prospective, randomized controlled study. Influence of coronary nursing management follow up on lifestyle after acute myocardial infarction. Effects of phase III cardiac rehabilitation programs on health-related quality of life in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP). 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). The group counseling v exercise therapy study. A controlled intervention with subjects following myocardial infarction. Rehabilitation after myocardial infarction. A controlled study. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. Long-Term Effects on Cholesterol Levels and the Utilization of Lipid-Lowering Drugs of a Hospital-Based Programme for Secondary Prevention of Coronary Artery Disease A case manager intervention to reduce readmissions. Five year follow up of patients at high cardiovascular risk who took part in randomised controlled trial of health promotion Recovery after myocardial infarction. Effects of a caring rehabilitation programme. Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: a randomised controlled trial Nurse case management of hypercholesterolemia in patients with coronary heart disease: results of a randomized clinical trial. Quality of life and return to work 5 years after coronary artery bypass surgery. Long-term results of cardiac rehabilitation. Group office visits change dietary habits of patients with coronary artery disease-the dietary intervention and evaluation trial (D.I.E.T.). Achieving National Cholesterol Education Program goals for low-density lipoprotein cholesterol in cardiac patients: importance of diet, exercise, weight control, and drug therapy. Effects of stress management training and dietary changes in treating ischemic heart disease.
abstract: Of 22 r and omized trials of rehabilitation with exercise  after myocardial infa rct ion ( MI ) , one trial had results that achieved conventional statistical significance . To determine whether or not these studies , in the aggregate , show a significant benefit of rehabilitation after myocardial infa rct ion , we performed an overview of all r and omized trials , involving 4,554 patients ; we evaluated total and cardiovascular mortality , sudden death , and fatal and nonfatal reinfa rct ion . For each endpoint , we calculated an odds ratio ( OR ) and 95 % confidence interval ( 95 % CI ) for the trials combined . After an average of 3 years of follow-up , the ORs were significantly lower in the rehabilitation than in the comparison group : specifically , total mortality ( OR = 0.80 [ 0.66 , 0.96 ] ) , cardiovascular mortality ( OR = 0.78 [ 0.63 , 0.96 ] ) , and fatal reinfa rct ion ( OR = 0.75 [ 0.59 , 0.95 ] ) . The OR for sudden death was significantly lower in the rehabilitation than in the comparison group at 1 year ( OR = 0.63 [ 0.41 , 0.97 ] ) . The data were compatible with a benefit at 2 ( OR = 0.76 [ 0.54 , 1.06 ] ) and 3 years ( OR = 0.92 [ 0.69 , 1.23 ] ) , but these findings were not statistically significant . For nonfatal reinfa rct ion , there were no significant differences between the two groups after 1 ( OR = 1.09 [ 0.76 , 1.57 ] ) , 2 ( OR = 1.10 [ 0.82 , 1.47 ] ) , or 3 years ( OR = 1.09 [ 0.88 , 1.34 ] ) of follow-up . The observed 20 % reduction in overall mortality reflects a decreased risk of cardiovascular mortality and fatal reinfa rct ion throughout at least 3 years and a reduction in sudden death during the 1st year after infa rct ion and possibly for 2 - 3 years . With respect to the independent effects of the physical exercise component of cardiac rehabilitation , the relatively small number of " exercise only " trials , combined with the possibility that they may have had a formal or informal nonexercise component precludes the possibility of reaching any definitive conclusion . To do so would require a r and omized trial of sufficient size to distinguish between no effect and the most plausible effect based on the results of this overview BACKGROUND Recent clinical trials have shown that modification of plasma lipoprotein concentrations can favorably alter progression of coronary atherosclerosis , but no data exist on the effects of a comprehensive program of risk reduction involving both changes in lifestyle and medications . This study tested the hypothesis that intensive multiple risk factor reduction over 4 years would significantly reduce the rate of progression of atherosclerosis in the coronary arteries of men and women compared with subjects r and omly assigned to the usual care of their physician .  METHODS AND RESULTS Three hundred men ( n = 259 ) and women ( n = 41 ) ( mean age , 56 + /- 7.4 years ) with angiographically defined coronary atherosclerosis were r and omly assigned to usual care ( n = 155 ) or multifactor risk reduction ( n = 145 ) . Patients assigned to risk reduction were provided individualized programs involving a low-fat and -cholesterol diet , exercise , weight loss , smoking cessation , and medications to favorably alter lipoprotein profiles . Computer-assisted quantitative coronary arteriography was performed at baseline and after 4 years . The main angiographic outcome was the rate of change in the minimal diameter of diseased segments . All subjects underwent medical and risk factor evaluations at baseline and yearly for 4 years , and reasons for all hospitalizations and deaths were documented . Of the 300 subjects r and omized , 274 ( 91.3 % ) completed a follow-up arteriogram , and 246 ( 82 % ) had comparative measurements of segments with visible disease at baseline and follow-up . Intensive risk reduction result ed in highly significant improvements in various risk factors , including low-density lipoprotein cholesterol and apolipoprotein B ( both , 22 % ) , high-density lipoprotein cholesterol ( + 12 % ) , plasma triglycerides ( -20 % ) , body weight ( -4 % ) , exercise capacity ( + 20 % ) , and intake of dietary fat ( -24 % ) and cholesterol ( -40 % ) compared with relatively small changes in the usual-care group . No change was observed in lipoprotein(a ) in either group . The risk-reduction group showed a rate of narrowing of diseased coronary artery segments that was 47 % less than that for subjects in the usual-care group ( change in minimal diameter , -0.024 + /- 0.066 mm/y versus -0.045 + /- 0.073 mm/y ; P < .02 , two-tailed ) . Three deaths occurred in each group . There were 25 hospitalizations in the risk-reduction group initiated by clinical cardiac events compared with 44 in the usual-care group ( rate ratio , 0.61 ; P = .05 ; 95 % confidence interval , 0.4 to 0.9 ) . CONCLUSIONS Intensive multifactor risk reduction conducted over 4 years favorably altered the rate of luminal narrowing in coronary arteries of men and women with coronary artery disease and decreased hospitalizations for clinical cardiac events Background Significant regression of coronary and femoral atherosclerotic lesions has been documented by angiographic studies using aggressive lipid-lowering treatment . This study tested the applicability and effects of intensive physical exercise and low-fat diet on coronary morphology and myocardial perfusion in nonselected patients with stable angina pectoris . Methods and Results Patients were recruited after routine coronary angiography for stable angina pectoris ; they were r and omized to an  intervention group ( n = 56 ) and a  control group on “ usual care ” ( n = 57 ) . Treatment comprised intensive physical exercise in group training sessions ( minimum , 2 hr/wk ) , daily home exercise periods ( 20 min/d ) , and low-fat , low-cholesterol diet ( American Heart Association recommendation , phase 3 ) . No lipid-lowering agents were prescribed . After 12 months of participation , repeat coronary angiography was performed ; relative and minimal diameter reductions of coronary lesions were measured by digital image processing . Change in myocardial perfusion was assessed by 201TI scintigraphy . In patients participating in the intervention group , body weight decreased by 5 % ( p<0.001 ) , total cholesterol by 10 % ( p<0.001 ) , and triglycerides by 24 % ( p<0.001 ) ; high density lipoproteins increased by 3 % ( p = NS ) . Physical work capacity improved by 23 % ( p<0.0001 ) , and myocardial oxygen consumption , as estimated from maximal rate-pressure product , by 10 % , ( p<0.05 ) . Stress-induced myocardial ischemia decreased concurrently , indicating improvement of myocardial perfusion . Based on minimal lesion diameter , progression of coronary lesions was noted in nine patients ( 23 % ) , no change in 18 patients ( 45 % ) , and regression in 13 patients ( 32 % ) . In the control group , metabolic and hemodynamic variables remained essentially unchanged , whereas progression of coronary lesions was noted in 25 patients ( 48 % ) , no change in 18 patients ( 35 % ) , and regression in nine patients ( 17 % ) . These changes were significantly different from the intervention group ( p<0.05 ) . Conclusions In patients participating in regular physical exercise and low-fat diet , coronary artery disease progresses at a slower pace compared with a control group on usual care Background —Whether cardiac rehabilitation ( CR ) is effective in patients older than 75 years , who have been excluded from most trials , remains unclear . We enrolled patients 46 to 86 years old in a r and omized trial and assessed the effects of 2 months of post-myocardial infa rct ion ( MI ) CR  on total work capacity ( TWC , in kilograms per meter ) and health-related quality of life ( HRQL ) . Methods and Results —Of 773 screened patients , 270 without cardiac failure , dementia , disability , or contraindications to exercise were r and omized to outpatient , hospital-based CR ( Hosp-CR ) , home-based CR ( Home-CR ) , or no CR within 3 predefined age groups ( middle-aged , 45 to 65 years ; old , 66 to 75 years ; and very old , > 75 years ) of 90 patients each .  TWC and HRQL were determined with cycle ergometry and Sickness Impact Profile at baseline , after CR , and 6 and 12 months later . Within each age group , TWC improved with Hosp-CR and Home-CR and was unchanged with no CR . The improvement was similar in middle-aged and old persons but smaller , although still significant , in very old patients . TWC reverted toward baseline by 12 months with Hosp-CR but not with Home-CR .  HRQL improved in middle-aged and old CR and control patients but only with CR in very old patients . Complications were similar across treatment and age groups . Costs were lower for Home-CR than for Hosp-CR . Conclusions —Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group . However , with lower costs and more prolonged positive effects , Home-CR may be the treatment of choice in low-risk older patients BACKGROUND Increases in life stress have been linked to poor prognosis , after myocardial infa rct ion ( MI ) . Previous research suggested that a programme of monthly screening for psychological distress , combined with supportive and educational home nursing interventions for distressed patients , may improve post-MI survival among men . Our study assessed this approach for both men and women . We aim ed to find out whether the programme would reduce 1-year cardiac mortality for women and men . METHODS We carried out a r and omised , controlled trial of 1376 post-MI patients ( 903 men , 473 women ) assigned to the intervention programme ( n = 692 ) or usual care ( n = 684 ) for 1 year . All patients completed a baseline interview that included assessment of depression and anxiety . Survivors were also interviewed at 1 year . FINDINGS The programme had no overall survival impact . Preplanned analyses showed higher cardiac ( 9.4 vs 5.0 % , p = 0.064 ) and all-cause mortality ( 10.3 vs 5.4 % , p = 0.051 ) among women in the intervention group . There was no evidence of either benefit or harm among men ( cardiac mortality 2.4 vs 2.5 % , p = 0.94 ; all-cause mortality 3.1 vs 3.1 % , p = 0.93 ) . The programme 's impact on depression and anxiety among survivors was small . INTERPRETATION Our results do not warrant the routine implementation of programmes that involve psychological-distress screening and home nursing intervention for patients recovering from MI . The poorer overall outcome for women , and the possible harmful impact of the intervention on women , underline the need for further research and the inclusion of adequate numbers of women in future post-MI trials Abstract Objective : To evaluate the effects of secondary prevention clinics run by nurses in general practice on the health of patients with coronary heart disease . Design : R and omised controlled trial of clinics over one year with assessment by self completed postal question naires and audit of medical records at the start and end of the trial . Setting : R and om sample of 19 general practice s in northeast Scotl and . Subjects : 1173 patients ( 685 men and 488 women ) under 80 years with working diagnoses of coronary heart disease who did not have terminal illness or dementia and were not housebound . Intervention : Clinic staff promoted medical and lifestyle aspects of secondary prevention and offered regular follow up . Main outcome measures : Health status measured by the SF-36 question naire , chest pain by the angina type specification , and anxiety and depression by the hospital anxiety and depression scale . Use of health services before and during the study . Results : There were significant improvements in six of eight health status domains ( all functioning scales , pain , and general health ) among patients attending the clinic . Role limitations attributed to physical problems improved most ( adjusted difference 8.52 , 95 % confidence interval 4.16 to 12.9 ) . Fewer patients reported worsening chest pain ( odds ratio 0.59 , 95 % confidence interval 0.37 to 0.94 ) . There were no significant effects on anxiety or depression . Fewer intervention group patients required hospital admissions ( 0.64 , 0.48 to 0.86 ) , but general practitioner consultation rates did not alter . Conclusions : Within their first year secondary prevention clinics improved patients ' health and reduced hospital admissions . Key messages Nurse led clinics in general practice were used to promote secondary prevention to patients with coronary heart disease Within the first year the health of patients invited to the clinics improved Most benefit was in functional status , but chest pain improved too There was no effects on anxiety or depression There were significant reductions in hospital admissions in the first The Women ’s Lifestyle Heart Trial was a small ( N=28 ) r and omized controlled trial to evaluate the effects of a comprehensive lifestyle self-management program ( very low-fat vegetarian diet , stress-management training , exercise , group support , and smoking cessation ) on reduction of cardiovascular risk factors in postmenopausal women with coronary heart disease ( CHD ) . Women assigned to the treatment condition ( Prime Time ) participated in a week-long retreat followed by twice-weekly 4-hour meetings . Endpoints were program adherence ; changes in lipid profiles , body mass , blood pressure , hypolipidemic and antihypertensive medications ; and quality of life . Risk factor and psychosocial evaluations were conducted at baseline and at 4 , 12 , and 24 months . Repeated measures analyses of covariance revealed that the dietary , stress management , and physical activity changes made by intervention women were dramatic and lasting . There were significantly greater improvements in the Prime Time condition compared to the usual care control group on body mass , angina symptoms , and quality of life , and a tendency for a greater reduction in blood pressure-lowering medications . Similar patterns were seen in lipids , blood pressure , and lipid-lowering medications , but did not reach significance . These results demonstrate that postmenopausal CHD women can make lasting lifestyle changes , and that these changes may reduce the need for cardiac medications and improve CHD risk factors and quality of life In a prospect i ve , r and omised , controlled trial to determine whether comprehensive lifestyle changes affect coronary atherosclerosis after 1 year , 28 patients were assigned to an experimental group ( low-fat vegetarian diet , stopping smoking , stress management training , and moderate exercise ) and 20 to a usual-care control group . 195 coronary artery lesions were analysed by quantitative coronary angiography  . The average percentage diameter stenosis regressed from 40.0 ( SD 16.9)% to 37.8 (16.5)% in the experimental group yet progressed from 42.7 (15.5)% to 46.1 (18.5)% in the control group . When only lesions greater than 50 % stenosed were analysed , the average percentage diameter stenosis regressed from 61.1 (8.8)% to 55.8 (11.0)% in the experimental group and progressed from 61.7 (9.5)% to 64.4 (16.3)% in the control group . Overall , 82 % of experimental-group patients had an average change towards regression .  Comprehensive lifestyle changes may be able to bring about regression of even severe coronary atherosclerosis after only 1 year , without use of lipid-lowering drugs 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 effects of an exercise program started early after myocardial infraction and the added effects of an outpatient teaching-counseling program were studied . At r and om , 84 patients were allocated to a control group ( A ) , 88 patients to an exercise group ( B1 ) and 86 patients to an exercise and teaching-counseling group ( B2 ) . The same exercise program was prescribed for patients in groups B1 and B2 and was started about 4.5 days after myocardial infa rct ion and continued for 3 months . The outpatient teaching-counseling program consisted of eight group sessions pertaining to risk factor reduction and psychosocial adjustment to myocardial infraction . A low-level treadmill test and an exercise test were performed at 3 months and the exercise test was repeated at 6 months . The clinical , hemodynamic and electrocardiographic responses to these tests were not different among the three groups . However , by the end of 3 months , patients in group B1 and B2 reported walking greater distances than patients in group A. The incidence of morbidity and mortality was not different between the groups . No deleterious or beneficial physiologic effects of an exercise program either by itself or combined with a teaching-counseling program were demonstrated . Routine medical care and our interventions were equally effective in permitting the spontaneous hemodynamics improvements after myocardial infraction . More than 3 months after myocardial infa rct ion , the group as a whole manifested spontaneous recovery in the form of a significant decrease in resting heart rate ( p less than 0.001 ) and a significant increase in systolic and diastolic blood pressure at rest and with submaximal exercise ( p less than 0.001 ) . No further improvements were observed between 3 and 6 months BACKGROUND It was the aim of this study to assess the long-term effects of physical exercise and low-fat diet on the progression of coronary artery disease . At the beginning of the study , 113 male patients with coronary artery disease were r and omized to an intervention group ( n=56 ) or a control group ( n=57 ) ; 90 patients ( 80 % ) could be reevaluated after 6 years . METHODS AND RESULTS Patients in the intervention group ( n=40 ) showed a reduction in total serum cholesterol ( 6.03+/-1.03 versus 5.67+/-1.01 mmol/L ; P<.03 ) and triglyceride levels ( 1.94+/-0.8 versus 1.6+/-0.89 mmol/L ; P<.005 ) and maintained their initial body mass index ( 26+/-2 versus 27+/-2 kg/m2 ; P = NS ) , but results were not statistically different from the control group ( n=50 ) ( total serum cholesterol , 6.05+/-1.02 versus 5.79+/-0.88 mmol/L ; triglycerides , 2.25+/-1.28 versus 1.85+/-0.96 mmol/L [ both P = NS ] ; body mass index , 26+/-2 versus 28+/-3 kg/m2 [ P<.0001 ] ) . In the intervention group , there was a significant 28 % increase in physical work capacity ( 166+/-59 versus 212+/-89 W ; P<.001 ) , whereas values remained essentially unchanged in the control group ( 165+/-51 versus 170+/-60 W ; P = NS ; between groups , P<.05 ) . In the intervention group , coronary stenoses progressed at a significantly slower rate than in the control group ( P<.0001 ) . Energy expenditure during exercise was assessed in a subgroup ; patients with regression of coronary stenoses spent an average of 1784+/-384 kcal/wk ( approximately 4 hours of moderate aerobic exercise per week ) . Multivariate regression analysis identified only physical work capacity as independently contributing to angiographic changes . CONCLUSIONS After 6 years of multifactorial risk intervention , there is significant and persistent improvement in lipoprotein levels and physical work capacity , which results in a significant retardation of disease progression . These beneficial effects appear to be largely due to chronic physical exercise Coronary artery diseases ( CAD ) are main causes of morbidity and hospitalisation in western countries and CAD patients are at considerable risk of suffering further cardiac events . The development and evaluation of secondary prevention programmes therefore an important task . This thesis includes investigations on CAD patients admitted to a secondary prevention programme at Malmö University Hospital , Malmö , Sweden . Four weeks after discharge from the hospital , consecutive male and female patients aged 50 - 70 years with acute myocardial infa rct ion ( AMI ) or treated with coronary artery bypass grafting ( CABG ) surgery  were r and omised to a hospital organised preventive intervention or to usual follow-up at their general practitioners . In the three studies using this r and omised design , 87 ( study II ) , 90 ( study IV ) , and 106 ( study V ) intervention patients were available for evaluation . In addition , without r and omisation , lipid levels at four weeks after the event was compared with levels estimated within 24 hours after onset of symptoms in 141 AMI patients ( study I ) , and quality of life ( QL ) were estimated by question naire at one month and at one year after the event in 266 AMI , 94 CABG , and 16 percutaneous transluminal coronary angioplasty ( PTCA ) patients ( study III ) . The prevention programme was effective in improving food habits but showed no impact on smoking habits or physical exercise in AMI patients ( study II ) . The intervention also did not show any significant improvement in working capacity in AMI and CABG patients . However , working capacity improved in both intervention and reference CABG patients , most probably due to improved coronary circulation from the surgery ( study IV ) . Cholesterol levels decreased significantly in AMI and CABG intervention patients as compared to the corresponding reference patients . This difference most likely was due to a higher frequency of lipid lowering drugs used in the intervention patients ( study V ) . The prevention programme also decreased body mass index significantly in AMI but not in CABG patients ( study V ) . In AMI patients receiving thrombolysis , cholesterol levels estimated within 24 hours after onset of symptoms and at four weeks after the event were virtually equal . In AMI patients not receiving thrombolysis , the lipid estimates from four weeks after the event were slightly , but significantly , above the within 24 hours from onset of symptoms estimates ( study I ) . One month after the event , both somatic and psychological aspects of QL were negatively affected in AMI and CABG patients compared to population controls . One year after the event , patients differed from controls mainly in somatic symptoms ( study III ) . Thus , the intervention programme was most successful in affecting lipid levels and food habits in AMI patients .  QL was considerably affected in patients following an cardiac event , especially during the initial recovery phase . In addition , in patients receiving thrombolysis , cholesterol levels estimated four weeks after an AMI are reasonably valid estimates of baseline values and may be used to decide about lipid lowering interventions BACKGROUND Disease management programs ( DMPs ) that use multidisciplinary teams and specialized clinics reduce hospital admissions and improve quality of life and functional status . Evaluations of cardiac DMPs delivered by home health nurses are required . METHODS Between August 1999 and August 2000 we identified consecutive patients admitted to hospital with elevated cardiac enzymes . Patients who agreed were r and omly assigned to participate in a DMP or to receive usual care .  The DMP included 6 home visits by a cardiac-trained nurse , a st and ardized nurses ' checklist , referral criteria for specialty care , communication with the family physician and patient education . We measured readmission days per 1000 follow-up days for angina , congestive heart failure ( CHF ) and chronic obstructive pulmonary disease ( COPD ) ; all-cause readmission days ; and provincial cl aims for emergency department visits , physician visits , diagnostic or therapeutic services and laboratory services . RESULTS We screened 715 consecutive patients admitted with elevated cardiac markers between August 1999 and August 2000 . Of those screened 71 DMP and 75 usual care patients met the diagnostic criteria for myocardial infa rct ion , were eligible for visits from a home health nurse and consented to participate in the study . Readmission days for angina , CHF and COPD per 1000 follow-up days were significantly higher for usual care patients than for DMP patients ( incidence density ratio [ IDR ] = 1.59 , 95 % confidence interval [ CI ] 1.27 - 2.00 , p < 0.001 ) . All-cause readmission days per 1000 follow-up days were significantly higher for usual care patients than for DMP patients ( IDR = 1.53 , 95 % CI 1.37 - 1.71 , p < 0.001 ) . The difference in emergency department encounters per 1000 follow-up days was significant ( IDR = 2.08 , 95 % CI 1.56 - 2.77 , p < 0.001 ) . During the first 25 days after discharge , there were significantly fewer provincial cl aims su bmi tted for DMP patients than for usual care patients for emergency department visits ( p = 0.007 ) , diagnostic or therapeutic services ( p = 0.012 ) and laboratory services ( p = 0.007 ) . INTERPRETATION The results provide evidence that an appropriately developed and implemented community-based inner-city DMP delivered by home health nurses has a positive impact on patient outcomes Prognosis during 5 years of follow-up after first myocardial infa rct ion ( MI ) in a group of men ( aged 40 to 55 years ) was related to risk factors determined at the time of MI . Progression of coronary artery disease ( CAD ) was measured by the occurrence of severe angina pectoris , recurrent myocardial infa rct ion , and cardiac death . Only smoking and serum cholesterol level influenced prognosis . It was possible to identify a subgroup ( patients smoking less than 20 cigarettes/day and having a cholesterol level of less than 7.0 mmoles/L ) with low risk for progression of CAD . A r and omly applied 6-week rehabilitation program shortly after MI was associated with a 50 % decrease in progressive CAD when compared to the control group . Since only a slight decrease in cholesterol levels was found in the rehabilitation group , a direct effect of the rehabilitation program could thus not be excluded because the second important risk factor , smoking , did not show differences between the two groups . The smoking habits at the time of MI determined the continuation of cigarette smoking and rehabilitation did not influence smoking habits This prospect i ve study evaluated the effect of an individualized , comprehensive , home-based cardiac rehabilitation program combining exercise training with risk factor modification and psychosocial counseling on risk factors , psychological well-being , functional capacity , and work resumption in 99 post-percutaneous coronary interventions ( PCI ) patients r and omized to control ( st and ard care plus telephone follow-up  , n=49 ) or intervention ( individualized , comprehensive , home-based cardiac rehabilitation , n=50 ) groups . Data were collected at time 1 ( T(1 ) ) during hospital admission , time 2 ( T(2 ) ) approximately 2 months post-PCI , and time 3 ( T(3 ) ) approximately 12 months post-PCI . Results suggest that the allocation to an individualized , comprehensive , home-based cardiac rehabilitation program provided more advantageous outcomes . At both follow-ups , the intervention group showed within-group improvement in serum cholesterol levels ( P<0.02 ; P<0.01 ) and exercise participation ( P<0.001 ; P<0.001 ) with differences in exercise participation favoring the intervention group ( P<0.01 ) at T(2 ) . Repeated measures ANOVA showed significant improvements over time in body mass index ( BMI ) ( P<0.01 ) , psychological well-being ( P<0.001 ) , and functional capacity ( P<0.001 ) for both groups . More patients in the intervention group had returned to work at T(2 ) ( P<0.001 ) and did so more quickly ( P<0.01 ) . These findings suggest that an individualized , comprehensive , home-based cardiac rehabilitation program improves risk factor profiles and work resumption patterns for patients following PCI OBJECTIVES This study evaluated the effectiveness of cardiac counseling and rehabilitation programs led by a nurse counselor , compared with normal care on outcomes for myocardial infa rct ion ( MI ) patients and their partners . METHODS A r and omized controlled trial with follow-up to 1 year was conducted with 100 patients recruited within 72 hours of a first MI and their partners : a Control group received normal care ; an Inpatient group received cardiac rehabilitation from a nurse counselor while in hospital ; and an Extended group received the same cardiac rehabilitation as the Inpatient group , but with additional sessions continuing up to 6 weeks after discharge from hospital . The scales for main outcome measures were 1 ) knowledge of heart disease and treatment ( correct , misconceptions , and uncertainty ) ; 2 ) mood ( Hospital Anxiety and Depression Scale ) ; 3 ) satisfaction ; 4 ) disability ( Functional Limitations Profile ) . RESULTS Inpatient cardiac counseling and rehabilitation result ed in more knowledge , less anxiety , less depression , and greater satisfaction with care in both patients and partners and in less disability in patients , with effects enduring to 1 year . There was some evidence of additional benefit from the Extended program . Both nurse counselors achieved benefits on all outcome variables . CONCLUSIONS This Inpatient cardiac counseling and rehabilitation program result ed in significant and enduring benefits of clinical value . It is likely that it would be acceptable to most post-MI patients , many of whom are not offered or are unable to accept outpatient cardiac rehabilitation This study was a secondary analysis of data collected on 202 patients hospitalized with common medical or surgical cardiac conditions who completed a 24-week postdischarge follow-up program as part of a large-scale r and omized clinical trial . Subjects were age 65 years or older , admitted from their homes with one of the following diagnosis-related groups : heart failure , angina , myocardial infa rct ion , coronary artery bypass graft surgery , or cardiac valve replacement . The intervention consisted of comprehensive discharge planning and home follow-up by an advanced practice nurse ( APN ) for 4 weeks after discharge . Control subjects received usual care . Findings indicated that medical patients in the intervention group had fewer multiple readmissions during the 24 weeks of follow-up and a reduced total number of days of rehospitalization . There were fewer hospital readmissions in the surgical group when measured from discharge to 6 weeks . There were no differences in functional status between intervention and control groups for either population . The findings of this study suggest that high-risk elders with significant cardiac problems may benefit from a care program that emphasizes collaborative , coordinated discharge planning and home follow-up that includes telephone and home visits by APNs The aim of this study was to compare the effects of residential multifactorial cardiac rehabilitation , outpatient multifactorial rehabilitation , stress management , and st and ard coronary rehabilitation , on cardiac risk reduction . Out of 144 eligible male patients recently treated with percantaneous transluminal coronary angiography ( PTCA ) , coronary artery bypass graft ( CABG ) , or acute myocardial infa rct ion ( AMI ) , 132 were r and omized into this study . All interventions covered a 12-month active intervention , intense during the first months and subsequently leveled out . Main assessment s were performed before r and omization and after the intervention . Patients offered behavioral rehabilitation showed improved selfreported healthy diet habits and exercise frequency , and higher internal locus of control . Although blood lipids , exercise capacity , body mass , anxiety , depression , and Type A scores were changed in the expected direction , no significant difference emerged between active intervention and the st and ard care condition . St and ard care of today appears to have great potential in particular if supplemented with some kind of stress management Abstract Objective : To assess the value of health education for patients with angina in reducing risk factors for cardiovascular disease and lessening the effect of angina on everyday activities . Design : R and omised controlled trial of personal health education given every four months . Setting : 18 general practice s in the greater Belfast area . Subjects : 688 patients aged less than 75 years and known to have had angina for at least six months ; 342 r and omised to receive education and 346 to no education .  Main outcome measures : Restriction of everyday activities , dietary habit , smoking habit , frequency of physical exercise ; blood pressure , body mass index , and serum total cholesterol concentration at entry to trial and after two years . Results : 317 in the intervention group and 300 in the control group completed the trial . At the two year review more of the intervention group ( 140 , 44 % ) reported taking daily physical exercise than the control group ( 70 , 24 % ) . The intervention group also reported eating a healthier diet than the control group and less restriction by angina in any everyday activity . No significant differences were found between the groups in smoking habit , systolic or diastolic blood pressure , cholesterol concentration , or body mass index . Conclusion : Despite having no significant effect on objective cardiovascular risk factors , personal health education of patients with angina seems to increase exercise and improve dietary habits and is effective in lessening the restriction of everyday activities CONTEXT The Lifestyle Heart Trial demonstrated that intensive lifestyle changes may lead to regression of coronary atherosclerosis after 1 year . OBJECTIVES To determine the feasibility of patients to sustain  intensive lifestyle changes  for a total of 5 years and the effects of these lifestyle changes ( without lipid-lowering drugs ) on coronary heart disease . DESIGN R and omized controlled trial conducted from 1986 to 1992 using a r and omized invitational design . PATIENTS Forty-eight patients with moderate to severe coronary heart disease were r and omized to an  intensive lifestyle change group  or to a  usual-care control group  , and 35 completed the 5-year follow-up quantitative coronary arteriography . SETTING Two tertiary care university medical centers . INTERVENTION Intensive lifestyle changes ( 10 % fat whole foods vegetarian diet , aerobic exercise , stress management training , smoking cessation , group psychosocial support ) for 5 years . MAIN OUTCOME MEASURES Adherence to intensive lifestyle changes , changes in coronary artery percent diameter stenosis , and cardiac events . RESULTS Experimental group patients ( 20 [ 71 % ] of 28 patients completed 5-year follow-up ) made and maintained comprehensive lifestyle changes for 5 years , whereas control group patients ( 15 [ 75 % ] of 20 patients completed 5-year follow-up ) made more moderate changes . In the experimental group , the average percent diameter stenosis at baseline decreased 1.75 absolute percentage points after 1 year ( a 4.5 % relative improvement ) and by 3.1 absolute percentage points after 5 years ( a 7.9 % relative improvement ) . In contrast , the average percent diameter stenosis in the control group increased by 2.3 percentage points after 1 year ( a 5.4 % relative worsening ) and by 11.8 percentage points after 5 years ( a 27.7 % relative worsening ) ( P=.001 between groups . Twenty-five cardiac events occurred in 28 experimental group patients vs 45 events in 20 control group patients during the 5-year follow-up ( risk ratio for any event for the control group , 2.47 [ 95 % confidence interval , 1.48 - 4.20 ] ) . CONCLUSIONS More regression of coronary atherosclerosis occurred after 5 years than after 1 year in the experimental group . In contrast , in the control group , coronary atherosclerosis continued to progress and more than twice as many cardiac events occurred Abstract Objective : To evaluate rehabilitation  after myocardial infa rct ion . Design : R and omised controlled trial of rehabilitation in unselected myocardial infa rct ion patients in six centres , baseline data being collected on admission and by structured interview ( of patients and spouses ) shortly after discharge and outcome being assessed by structured interview at six months and clinical examination at 12 months . Setting : Six district general hospitals . Subjects : All 2328 eligible patients admitted over two years with confirmed myocardial infa rct ion and discharged home within 28 days . Interventions : Rehabilitation programmes comprising psychological therapy , counselling , relaxation training , and stress management training over seven weekly group outpatient sessions for patients and spouses . Main outcome measures : Anxiety , depression , quality of life , morbidity , use of medication , and mortality . Results : At six months there were no significant differences between rehabilitation patients and controls in reported anxiety ( prevalence 33 % ) or depression ( 19 % ) . Rehabilitation patients reported a lower frequency of angina ( median three versus four episodes a week ) , medication , and physical activity . At 12 months there were no differences in clinical complications , clinical sequelae , or mortality . Conclusions : Rehabilitation programmes based on psychological therapy , counselling , relaxation training , and stress management seem to offer little objective benefit to patients who have experienced myocardial infa rct ion compared with previous reports of smaller trials . Key messages In this series there were no important differences by age , sex , hospital , or baseline anxiety or depression At six months the prevalence rates of clinical anxiety and depression remained high ( 33 % and 19 % respectively ) Patients and spouses rated programmes highly , which suggests a “ quality of care ” role for Community studies have demonstrated suboptimal achievement of lipid targets in the management of patients with coronary heart disease ( CHD ) . An effective strategy is required for the application of evidence -based prevention therapy for CHD . The objective of this study was to test coaching as a technique to assist patients in achieving the target cholesterol level of < 4.5 mmol/L. Patients with established CHD ( n = 245 ) underwent a stratified r and omization by cardiac procedure ( coronary artery bypass graft surgery or percutaneous coronary intervention ) to receive either the coaching intervention ( n = 121 ) or usual medical care ( n = 124 ) . The primary outcome measure was fasting serum total cholesterol ( TC ) , serum triglyceride ( TG ) , high-density lipoprotein cholesterol ( HDL-C ) , and calculated low-density lipoprotein cholesterol ( LDL-C ) level , measured at 6 months post-r and omization . At 6 months , the serum TC and LDL-C levels were significantly lower in the coaching intervention group ( n = 107 ) than the usual care group ( n = 112 ) : mean TC ( 95%CI ) 5.00 ( 4.82 - 5.17 ) mmol/L versus 5.54 ( 5.36 - 5.72 ) mmol/L ( P < .0001 ) ; mean LDL-C ( 95%CI ) 3.11 ( 2.94 - 3.29 ) mmol/L versus 3.57 ( 3.39 - 3.75 ) mmol/L ( P < .0004 ) , respectively . Coaching had no impact on TG or on HDL-C levels . Multivariate analysis showed that being coached ( P < .001 ) had an effect of equal magnitude to being prescribed lipid-lowering drug therapy ( P < .001 ) . The effectiveness of the coaching intervention is best explained by both adherence to drug therapy and to dietary advice given . Coaching may be an appropriate method to reduce the treatment gap in applying evidence -based medicine to the " real world . A group of 93 coronary patients recently treated with percutaneous transluminal coronary angioplasty ( PTCA ) were r and omly assigned to either an intervention or a control group . Subjects in the intervention group participated in a comprehensive behaviorally oriented program aim ed at achieving significant long-term changes in risk factor-related lifestyle behavior . Assessment s of lifestyle behaviors , psychological factors , biological risk factors , and rehabilitation as well as secondary prevention endpoints were carried out , at inclusion and after 12 months . Results showed that the intervention patients , as compared with controls , improved significantly on measures assessing smoking , exercise , and diet habits . These self-rated changes were confirmed by weight reductions and improved exercise capacity , as well as by between-group differences in sub clinical chest pain during an exercise test . However , few effects were found on the different psychological variables , as well as on morbidity or return to work OBJECTIVE : To examine the ability of a secondary prevention programme to improve the lifestyle in myocardial infa rct ion patients aged 50 - 70 years . DESIGN : Habitual physical activity , food habits , and smoking habits were assessed from question naires at admission to hospital and at the one year follow up . Initially , all patients were invited to join an exercise programme and were informed about cardiovascular risk factors . Four weeks after discharge from the hospital , 87 patients were r and omised to follow up at the coronary prevention unit by a special trained nurse ( the intervention group )  , and 81 to follow up by their general practitioners (  the  usual care group ) . After r and omisation , the intervention group was educated about the effects of smoking cessation , dietary management , and regular physical activity . The intervention group also participated in a physical training programme two to three times weekly for 10 - 12 weeks . MAIN RESULTS : 89 % of the patients referred to the intervention group improved their food habits compared with 62 % of the patients referred to the usual care group ( P = 0.008 ) . Furthermore , 50 % of the smokers referred to the intervention group stopped smoking compared to 29 % in the usual care group ( P = 0.09 ) . Changes in physical activity did not differ between the groups . CONCLUSIONS : This secondary prevention programme based on a nurse rehabilitator was successful in improving food habits in patients with acute myocardial infa rct ion . Initiating the smoking cessation programme during the hospital stay followed by repeated counselling during follow up might have improved the results . The exercise programme had no advantage in supporting physical activity compared to usual care The purpose of this prospect i ve r and omized controlled trial was to assess the impact of phase III comprehensive cardiac rehabilitation ( CR ) on health-related quality of life ( HRQOL ) in elderly patients with coronary artery disease ( CAD ) . Thirty-eight elderly males ( mean age , 70 years ) with CAD were stratified as the intervention group ( n=20 ) and the control group ( n=18 ) . In the intervention group , patients participated in CR for 6 months , whereas in the control group , they received st and ard care . Vali date d question naires were obtained to evaluate HRQOL using the Medical Outcome Study Short-Form 36 Health Status Survey ( SF-36 ) , State-trait anxiety inventory question naire ( STAI ) and Self-rating Depression Scale ( SDS ) at baseline and after 6 months . At baseline , scores of SF-36 except for general health , STAI and SDS were not different in either group . After 6 months , in the intervention group , scores of bodily pain , general health , vitality and mental health of SF-36 improved significantly compared with baseline . State anxiety scores also improved significantly ( p<0.01 ) , but SDS depression scores were not improved . In the control group , none of the parameters significantly changed . These results indicate that elderly patients with CAD should be vigorously encouraged to pursue CR even in chronic phase III This study examined whether  nurses  could manage coronary risk factors in patients with unstable angina more effectively than physicians practicing usual care . Three hundred twenty-six patients were r and omized in the emergency room to a 6-month program of risk factor management by a registered nurse versus participation in usual care . The nurse intervention consisted of a 30-minute counseling visit at 6 to 10 days after the chest pain episode and a second 30-minute session 1 month later . Multiple risk factors were assessed and addressed : smoking , blood lipids , blood pressure , blood glucose , physical inactivity , weight , psychological stress , and social isolation . Compared with usual care , nurse intervention patients significantly reduced both triglycerides ( -29 + /- 8 vs 5 + /- 6 mg/dl ; p < 0.0004 ) and weight ( -0.9 + /- 3.3 vs + 0.1 + /- 2.1 kg ; p = 0.0071 ) , and had corresponding improvements in self-reported diet compliance and exercise ( + 34 + /- 106 vs + 9 + /- 98 minutes , p = 0.0491 ) . No significant differences between groups were observed in terms of 6-month changes in total , high-density lipoprotein , or low-density lipoprotein cholesterol , blood pressure , fasting blood glucose , percent body fat or waist-hip ratio , or psychological distress scores . The 6-month rate of recurrent events ( cardiac death , out-of-hospital cardiac arrest , myocardial infa rct ion ) and /or revascularizations ( coronary artery bypass surgery or coronary angioplasty ) was lower in the nurse intervention group ( 1 % vs 9 % ; p = 0.002 ) . We conclude that a nurse-delivered risk factor intervention program for patients with chest pain is feasible and more effective than usual care in terms of fostering lifestyle changes that may lower coronary risk One hundred six postmyocardial infa rct ion subjects who either achieved a mean work load of less than seven mets on treadmill testing , who were rated as anxious and /or depressed , or who met both criteria , participated in a controlled study comparing the rehabilitation effectiveness of exercise therapy and group counseling . Each intervention lasted 12 weeks . Follow-up evaluations were scheduled at three months , six months and one year . Exercise substantially increased mean work capacity , decreased fatigue , lessened anxiety and depression , and promoted independence and sociability .  Counseling substantially reduced depression and promoted a sense of friendliness , and decreased interpersonal friction as well as greater independence and sociability . The control group reported no substantial change on any measured factor . Neither counseling nor exercise had an effect on mortality though subjects in the exercise group reported fewer major cardiovascular sequelae The effects of a rehabilitation programme  one year after myocardial infa rct ion ( MI ) were investigated in 171 patients under 65 years of age . These patients were allocated at r and om to rehabilitation and control groups before discharge from hospital . The groups were comparable with regard to age , sex and clinical data . The programme included physical exercise , counselling of patients and relatives , and social measures over a 3-month period during the convalescent stage . One year after MI patients in the rehabilitation group showed lower systolic blood pressure at rest and lower diastolic pressure on submaximal exercise than controls . No differences were found with regard to mean work capacity , days off work , return to work , psychological status , and underst and ing of the illness . At 12 months all patients were less physically and socially active than before MI , they were more dependent on their relatives than before , and they had poor underst and ing of their illness R and omized clinical trials of cardiac rehabilitation following myocardial infa rct ion have typically demonstrated a lower mortality in treated patients , but with a statistically significant reduction in only one trial . To overcome the problem of not being able to detect small but clinical ly important benefits in mortality in r and omized clinical trials of exercise and risk factor rehabilitation after myocardial infa rct ion with small numbers of patients , we carried out a meta- analysis on the combined results of ten r and omized clinical trials that included 4347 patients ( control , 2145 patients ; rehabilitation , 2202 patients ) . The pooled odds ratios of 0.76 ( 95 % confidence intervals , 0.63 to 0.92 ) for all-cause death and of 0.75 ( 95 % confidence intervals , 0.62 to 0.93 ) for cardiovascular death were significantly lower in the rehabilitation group than in the control group , with no significant difference for nonfatal recurrent myocardial infa rct ion . These results suggest that , for appropriately selected patients , comprehensive cardiac rehabilitation has a beneficial effect on mortality but not on nonfatal recurrent myocardial infa rct ion Background The study was design ed to determine whether a 1-year hospital-based secondary prevention programme would have any long-term effects on serum lipid levels and the use of lipid-lowering drugs in patients with coronary artery disease 4 years after referral to primary care facilities for follow-up . Design / methods After acute myocardial infa rct ion or coronary bypass surgery , 241 consecutive patients were r and omly assigned to conventional care ( CC ) by the primary health care facilities or to a 1-year hospital-based secondary prevention programme ( SPP ) with target levels for serum cholesterol ( < 5.2 mmol/l ) and triglycerides ( < 1.5 mmol/l ) . After 1 year all patients were referred to the primary care sector for a further 4-year follow-up . Results At the 1-year follow-up there was a significant decrease in serum cholesterol , LDL-cholesterol and triglyceride levels in the SPP group but no change in the CC group , and lipid-lowering drugs were used more frequently in the SPP group . These changes were maintained after 5 years . The proportion of patients achieving target serum cholesterol and triglyceride levels were larger in the SPP group . Conclusions Initiatives regarding cholesterol lowering and drug treatment taken by specialists within a structured hospital-based SPP have long-term impact . Accordingly , drug treatment should be initiated and adjusted to adequate doses before patients are referred to primary care for follow-up BACKGROUND Acute hospitalizations represent substantial financial liability to closed health care systems . Among hospitalized patients , those with repeated admissions are high-cost users . Most managed care plans employ case management to control hospital use . This technique attempts to detect and fulfill unmet medical and social needs , intensify postdischarge care , identify and mobilize effective community services , and enhance primary care access . Despite the popularity of case management to control hospital use , few trials have examined its efficacy . METHODS We conducted a r and omized controlled trial of an intervention of  case managers at a university-affiliated Veterans Affairs medical center . Six hundred sixty-eight patients aged 45 years or older who were discharged from the general medicine inpatient service , who had access to a telephone , and who received primary care at the hospital 's clinics were r and omized to the intervention ( N = 333 ) and control ( N = 335 ) groups . Within 24 hours of discharge , case managers mailed educational material s and access information to intervention patients , and within 5 days they called to review and resolve unmet needs , early warning signs , barriers to keeping appointments , and any readmissions . Case managers contacted intervention patients if they made no visits for 30 days . This result ed in a total of 6260 patient-case manager contacts . Control and intervention patients were followed up for 12 months . RESULTS Intervention patients had more frequent visits per patient per month to the general medicine clinic ( 0.30 + /- 0.23 vs 0.26 + /- 0.22 , P = .008 ) , but we detected no significant differences between groups in nonelective readmissions , readmission days , or total readmissions . CONCLUSIONS Frequent contacts for education , care , and accessibility by case managers using protocol s were ineffective in reducing nonelective readmissions Health promotion programmes for patients with coronary heart disease are valuable,1 2 but there is little evidence on their lasting effect.3 A r and omised controlled trial in which patients who received personalised health promotion for two years showed significant benefits in lifestyle and quality of life.2 4 We investigated whether the differences in lifestyle , quality of life , and risk factors persisted between the two groups five years after enrolment . Patients aged under 75 who had had angina ( all grade s included ) for at least six months and no other concurrent serious illness were identified by 18 general practice s in Belfast . Their diagnosis was confirmed at interview , and they were r and omly allocated to receive either usual NHS care and personal health promotion from a trained nurse every four months for two years or usual NHS care alone . Sealed envelopes opened at interview showed group allocations . Both groups were review ed The aim of the study was to evaluate a multifactorial rehabilitation programme based on interdisciplinary caring efforts for myocardial infa rct ion ( MI ) patients . R and omly chosen MI- patients participated , either in a six-month rehabilitation programme ( intervention group = 53 ) or in routine cardiac follow-ups ( control group = 63 ) . Subjective and objective instruments were used for measuring their health recovery . Biophysical improvements were showed as an increased physical capacity ( p less than 0.001 ) using a submaximal exercise test six months after MI , and less reinfa rct ions ( p less than 0.024 ) twelve months after MI , to the intervention patients ' advantage . Psychological improvements were demonstrated in a higher life satisfaction ( p less than 0.001 ) six months and ( 0.1 greater than p greater than 0.05 ) twelve months after MI to the intervention patients ' advantage . Social improvements were indicated as a better leisure situation ( p less than 0.004 ) six months after MI , and as a better partner situation ( p less than 0.010 ) , including a less influenced sex life ( p less than 0.017 ) , twelve months after MI to the intervention patients ' advantage . As to the overall view , the caring rehabilitation programme appeared to be required for the MI- patients ' health recovery . In order to be able to reach an optimal state of human health , an even more individualised programme seems to be necessary OBJECTIVE To evaluate the effectiveness of a nurse led shared care programme to improve coronary heart disease risk factor levels and general health status and to reduce anxiety and depression in patients awaiting coronary artery bypass grafting ( CABG ) . DESIGN R and omised controlled trial . SETTING Community , January 1997 to March 1998 . STUDY GROUPS 98 ( 75 male ) consecutive patients were recruited to the study within one month of joining the waiting list for elective CABG at Glasgow Royal Infirmary University NHS Trust . Patients were r and omly assigned to  usual care ( control ; n = 49 ) or a  nurse led intervention programme  ( n = 49 ) . INTERVENTION A shared care programme consisting of health education and motivational interviews , according to individual need , was carried out monthly . Care was provided in the patients ' own homes by the community based cardiac liaison nurse alternating with the general practice nurse at the practice clinic . OUTCOME MEASURES Smoking status , obesity , physical activity , anxiety and depression , general health status , and proportion of patients exceeding target values for blood pressure , plasma cholesterol , and alcohol intake . RESULTS Compared with patients who received usual care , those participating in the nurse led programme were more likely to stop smoking ( 25 % v 2 % , p = 0.001 ) and to reduce obesity ( body mass index > 30 kg/m2 ) ( 16.3 % v 8.1 % , p = 0.01 ) . Target systolic blood pressure improved by 19.8 % compared with a 10.7 % decrease in the control group ( p = 0.001 ) and target diastolic blood pressure improved by 21.5 % compared with 10.2 % in the control group ( p = 0.000 ) . However , there was no significant difference between groups in the proportion of patients with cholesterol concentrations exceeding target values . There was a significant improvement in general health status scores across all eight domains of the 36 item short form health survey with changes in difference in mean scores between the groups ranging from 8.1 ( p = 0.005 ) to 36.1 ( p < 0.000 ) . Levels of anxiety and depression improved ( p < 0.000 ) and there was improvement in time spent being physically active ( p < 0.000 ) . CONCLUSIONS This nurse led shared care intervention was shown to be effective for improving care for patients on the waiting list for CABG BACKGROUND Despite the large body of evidence confirming the effectiveness of lipid lowering for the secondary prevention of coronary heart disease ( CHD ) events , undertreatment of hyperlipidemia is common . This study tested the effectiveness of a nurse case management program to lower blood lipids in patients with CHD . METHODS A total of 228 consecutive , eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization . Patients were r and omized to receive lipid management , including individualized lifestyle modification and pharmacologic intervention , from a nurse practitioner for 1 year after discharge in addition to their usual care ( NURS ) , or to usual care enhanced with feedback on lipids to their primary provider and /or cardiologist ( EUC ) . RESULTS Significantly more patients in the NURS group than in the EUC group achieved low-density lipoprotein cholesterol ( LDL-C ) levels < 2.59 mmol/dL ( 100 mg/dL , 65 % vs 35 % , P = .0001 ) . Favorable changes in lipids and lipoproteins were accompanied by significant improvements in dietary and exercise patterns in the NURS group . In a multivariate analysis adjusting for other covariates , being assigned to the NURS group ( P = .0001 ) and being on a lipid-lowering medication ( P = .001 ) were significant independent predictors of LDL-C level . CONCLUSIONS Control of hypercholesterolemia in patients who have undergone coronary revascularization can be improved by a nurse case-management program . Because the National Cholesterol Education Program Adult Treatment Panel III guidelines have broadened the definition of high-risk population s that warrant aggressive treatment , nurse case-management programs may offer key opportunities to enhance appropriate application of new treatment paradigms BACKGROUND Rehabilitation is an important part of the treatment of patients with ischemic heart disease . Therefore , many patients undergoing coronary artery bypass surgery ( CABS ) also participate in cardiac rehabilitation programs . This study was conducted to investigate whether rehabilitation influences quality of life and work status after CABS . METHODS Consecutive patients undergoing elective CABS were r and omly assigned to a rehabilitation group ( R , N = 119 ) and a hospital-treatment group ( H N = 109 ) . All patients received usual medical care .  Group R participated in a rehabilitation program based on exercise and counseling . The follow-up time was 5 years . The measured domains of health-related quality of life were heart symptoms , functional class , exercise capacity , use of medication , depression , the patients ' perception of health , and overall life situation . The Nottingham Health Profile as a measure of perceived distress was used . RESULTS Symptoms , use of medication , exercise capacity , and depression scores did not differ between groups R and H. Five years after the CABS , the patients in group R reported less restriction in physical mobility on the Nottingham Health Profile than patients in group H ( P = 0.005 ) , and more patients in group R than in group H perceived their health ( P = 0.03 ) and overall life situation ( P = 0.02 ) as good . The increase in the proportion of subjects working was higher in group R than group H at 3 years after the CABS ( P = 0.02 ) , but not at other follow-up times . CONCLUSION A cardiac rehabilitation program in conjunction with usual medical care after CABS may induce a perception of improved health . The influence on return to work is limited BACKGROUND We evaluated the effectiveness of a low-cost group visit intervention for changing the dietary intake and lipid levels of patients with known coronary artery disease ( CAD ) . METHODS We performed a controlled r and om group assignment trial in 4 community outpatient clinics . The Dietary Intervention and Evaluation Trial r and omized 97 patients with CAD to either a control group that followed the National Cholesterol Education Program 's Step II-III diet plan ( n=48 ) or an experimental group that received meal plans , recipes , and nutritional information during monthly group office sessions ( n=49 ) . Both groups received lipid-lowering medications and were followed-up over 12 months . We assessed dietary intake , fasting lipid profiles , hemoglobin A1C levels , and per member per month ( PMPM ) expense data . RESULTS Food frequency data showed that eating fruits and vegetables and cooking with monounsaturated fat increased significantly in the experimental group compared with the control group at 1 year ( P=.0072 ; P=.0001 ; P=.0004 ) . The total PMPM expenses decreased for both groups ( 38 % for the experimental group and 10 % for the control group ) , but the cost difference was statistically nonsignificant ( P=.2975 ) . Both groups noted low-density lipoprotein reductions , significant only in the experimental group ( P=.0035 ) . CONCLUSIONS Our study suggests that using group office visits for patients with CAD was an effective method for helping subjects make dietary changes and for improving lipid levels .  Patients with known CAD and elevated lipid levels were willing to make significant lifestyle changes when offered a program that emphasizes healthy foods in a group visit format OBJECTIVE To determine how frequently the National Cholesterol Education Program ( NCEP ) goal of a low-density lipoprotein ( LDL ) cholesterol level of 100 mg/dL or less is achieved in clinical practice in patients with coronary artery disease and what fraction of patients can achieve this goal without drug therapy . DESIGN We examined the results of lipid management in 152 consecutive patients who had completed cardiac rehabilitation after an acute coronary event . Patients were r and omized to follow-up by specially trained nurses or by preventive cardiologists , and they were not receiving  lipid-lowering drugs at the start of the study . MATERIAL AND METHODS Patients were given aggressive diet and exercise recommendations and lipid-lowering drugs in accordance with NCEP guidelines . Follow-up was continued for a mean of 526 days after the first lipid assessment subsequent to the coronary event . Multiple logistic regression analysis was used to identify independent predictors of a final LDL cholesterol level of 100 mg/dL or less . RESULTS Of the study group , 39 % achieved the NCEP goal LDL cholesterol level of 100 mg/dL or less . Characteristics of the patients with LDL cholesterol levels of 100 mg/dL or less in comparison with those with LDL cholesterol levels of more than 100 mg/dL included a greater frequency of drug therapy ( 65 % versus 38 % ) , more rigorous dietary compliance , longer follow-up ( 586 + /- 317 days versus 493 + /- 264 days ) , more favorable weight change ( -0.3 + /- 4.9 kg versus + 1.7 + /- 5.0 kg ) , and more extensive weekly exercise ( 183 + /- 118 minutes versus 127 + /- 107 minutes ) . CONCLUSION The registered nurses managed the lipids of these patients as effectively as did the preventive cardiologists . Appropriate drug therapy was the most important factor in achieving an LDL cholesterol level of 100 mg/dL or less , but 35 % of patients attaining this NCEP goal were not receiving drug therapy . Exercise , dietary compliance , and weight loss were also important factors To evaluate the short-term effects of an intervention that consists of stress management training and dietary changes in patients with ischemic heart disease ( IHD ) , we compared the cardiovascular status of 23 patients who received this intervention with a r and omized control group of 23 patient who did not . After 24 days , patients in the experimental group demonstrated a 44 % mean increase in duration of exercise , a 55 % mean increase in total work performed , somewhat improved left ventricular regional wall motion during peak exercise , and a net change in the left ventricular ejection fraction from rest to maximum exercise of + 6.4 % . Also , we measured a 20.5 % mean decrease in plasma cholesterol levels and a 91.0 % mean reduction in frequency of anginal episodes . In this selected sample , short-term improvements in cardiovascular status seem to result from these adjuncts to conventional treatments of IHD
target: Other characteristics , including specialist versus generalist provision , did not appreciably impact programme effectiveness .
  Conclusions Shorter secondary prevention programmes , those based in general practice , and those staffed by generalists are at least as effective in reducing all cause mortality in patients with coronary heart disease as longer programmes , hospital-based programmes , and programmes staffed by specialists
background: Background The aim of this study was to determine which programme characteristics influence the effectiveness of secondary prevention programmes for Coronary Heart Disease .