title: An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Early Protection Against Sudden Death by n-3 Polyunsaturated Fatty Acids After Myocardial Infarction: Time-Course Analysis of the Results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI)-Prevenzione Mortality in relation to smoking: 50 years' observations on male British doctors The impact of body mass index on short- and long-term outcomes inpatients undergoing coronary revascularization. Insights from the bypass angioplasty revascularization investigation (BARI). Adherence to a Mediterranean diet and survival in a Greek population. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial Low intake of fruits, berries and vegetables is associated with excess mortality in men: the Kuopio Ischaemic Heart Disease Risk Factor (KIHD) Study. Is intake of breakfast cereals related to total and cause-specific mortality in men? A prospective study of variety of healthy foods and mortality in women. Results of a multicenter randomized clinical trial of exercise and long-term survival in myocardial infarction patients: the National Exercise and Heart Disease Project (NEHDP). A prospective study of diet quality and mortality in women. Alcohol intake and mortality in middle aged men with diagnosed coronary heart disease Lack of benefit of dietary advice to men with angina: results of a controlled trial Intensive lifestyle changes for reversal of coronary heart disease. High fruit intake may reduce mortality among middle-aged and elderly men. The Study of Men Born in 1913 Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients (Indo-Mediterranean Diet Heart Study): a randomised single-blind trial Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. Effect of age on excess mortality in obesity. No inverse association between fish consumption and risk of death from all-causes, and incidence of coronary heart disease in middle-aged, Danish adults. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. Mortality in relation to consumption of alcohol: 13 years' observations on male British doctors Randomised controlled trial of cardioprotective diet in patients with recent acute myocardial infarction: results of one year follow up. EFFECTS OF CHANGES IN FAT, FISH, AND FIBRE INTAKES ON DEATH AND MYOCARDIAL REINFARCTION: DIET AND REINFARCTION TRIAL (DART) Urinary sodium excretion and cardiovascular mortality in Finland: a prospective study Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease Epidemiologic studies on dietary fats and coronary heart disease. Alcohol consumption and mortality among middle-aged and elderly U.S. adults.
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 —Our purpose was to assess the time course of the benefit of n-3 polyunsaturated fatty acids ( PUFAs ) on mortality documented by the GISSI-Prevenzione trial in patients surviving a recent ( <3 months ) myocardial infa rct ion . Methods and Results —In this study , 11 323 patients were r and omly assigned to supplements of n-3 PUFAs , vitamin E ( 300 mg/d ) , both , or no treatment ( control ) on top of optimal pharmacological treatment and lifestyle advice . Intention-to-treat analysis adjusted for interaction between treatments was carried out . Early efficacy of n-3 PUFA treatment for total , cardiovascular , cardiac , coronary , and sudden death ; nonfatal myocardial infa rct ion ; total coronary heart disease ; and cerebrovascular events was assessed by right-censoring follow-up data 12 times from the first month after r and omization up to 12 months . Survival curves for n-3 PUFA treatment diverged early after r and omization , and total mortality was significantly lowered after 3 months of treatment ( relative risk [ RR ] 0.59 ; 95 % CI 0.36 to 0.97;P = 0.037 ) . The reduction in risk of sudden death was specifically relevant and statistically significant already at 4 months ( RR 0.47 ; 95 % CI 0.219 to 0.995;P = 0.048 ) . A similarly significant , although delayed , pattern after 6 to 8 months of treatment was observed for cardiovascular , cardiac , and coronary deaths . Conclusions —The early effect of low-dose ( 1 g/d ) n-3 PUFAs on total mortality and sudden death supports the hypothesis of an antiarrhythmic effect of this drug . Such a result is consistent with the wealth of evidence coming from laboratory experiments on isolated myocytes , animal models , and epidemiological and clinical studies Abstract Objective To compare the hazards of cigarette smoking in men who formed their habits at different periods , and the extent of the reduction in risk when cigarette smoking is stopped at different ages . Design Prospect i ve study that has continued from 1951 to 2001 . Setting United Kingdom . Participants 34 439 male British doctors . Information about their smoking habits was obtained in 1951 , and periodically thereafter ; cause specific mortality was monitored for 50 years . Main outcome measures Overall mortality by smoking habit , considering separately men born in different periods . Results The excess mortality associated with smoking chiefly involved vascular , neoplastic , and respiratory diseases that can be caused by smoking . Men born in 1900 - 1930 who smoked only cigarettes and continued smoking died on average about 10 years younger than lifelong non-smokers . Cessation at age 60 , 50 , 40 , or 30 years gained , respectively , about 3 , 6 , 9 , or 10 years of life expectancy . The excess mortality associated with cigarette smoking was less for men born in the 19th century and was greatest for men born in the 1920s . The cigarette smoker versus non-smoker probabilities of dying in middle age ( 35 - 69 ) were 42 % ν24 % ( a twofold death rate ratio ) for those born in 1900 - 1909 , but were 43 % ν 15 % ( a threefold death rate ratio ) for those born in the 1920s . At older ages , the cigarette smoker versus non-smoker probabilities of surviving from age 70 to 90 were 10 % ν 12 % at the death rates of the 1950s ( that is , among men born around the 1870s ) but were 7 % ν 33 % ( again a threefold death rate ratio ) at the death rates of the 1990s ( that is , among men born around the 1910s ) . Conclusion A substantial progressive decrease in the mortality rates among non-smokers over the past half century ( due to prevention and improved treatment of disease ) has been wholly outweighed , among cigarette smokers , by a progressive increase in the smoker ν non-smoker death rate ratio due to earlier and more intensive use of cigarettes . Among the men born around 1920 , prolonged cigarette smoking from early adult life tripled age specific mortality rates , but cessation at age 50 halved the hazard , and cessation at age 30 avoided almost all of it OBJECTIVES We sought to investigate the impact of body mass index ( BMI ) on short- and long-term outcomes after initial revascularization with percutaneous transluminal coronary angioplasty ( PTCA ) or coronary artery bypass graft surgery ( CABG ) .  BACKGROUND Equivocal results exist on the impact of BMI on the risk of in-hospital complications after PTCA or CABG , and no long-term mortality data exist from a large series of revascularized patients . METHODS From the r and omized series and observational registry of the Bypass Angioplasty Revascularization Investigation ( BARI ) , 2,108 patients who had PTCA and 1,526 patients who had CABG were evaluated by taking their BMI at study entry . They were classified as follows : low ( < 20 kg/m(2 ) ) , normal ( 20 to 24.9 kg/m(2 ) ) , overweight ( 25 to 29.9 kg/m(2 ) ) , class I obese ( 30 to 34.9 kg/m(2 ) ) and class II/III obese ( greater-than-or-equal 35 kg/m(2 ) ) . In-hospital complications and short- and long-term mortalities were compared between levels of BMI within each mode of initial revascularization . RESULTS Among patients who had PTCA , each unit increase in BMI was associated with a 5.5 % lower adjusted risk of a major in-hospital event ( death , myocardial infa rct ion , stroke , coma ) ; among patients who had CABG , no difference in the in-hospital outcome was observed according to BMI . In contrast , BMI was not associated with five-year mortality in the PTCA group ; among the CABG group , adjusted relative risks of five-year cardiac mortality according to levels of BMI were 0.0 ( low ) , 1.0 ( normal ) , 2.02 ( overweight ) , 3.16 ( class I obese ) and 4.85 ( class II/III obese ) ( linear p < 0.001 ) . CONCLUSIONS Body mass index appears to have a differential impact on short- and long-term outcomes after coronary revascularization . These results underscore the need for further research to identify factors responsible for the apparent short-term protective effect of a higher BMI in patients undergoing PTCA and to study the impact of weight reduction on the long-term survival of obese patients undergoing CABG BACKGROUND Adherence to a Mediterranean diet may improve longevity , but relevant data are limited . METHODS We conducted a population -based , prospect i ve investigation involving 22,043 adults in Greece who completed an extensive , vali date d , food-frequency question naire at base line .  Adherence to the traditional Mediterranean diet was assessed by a 10-point Mediterranean-diet scale that incorporated the salient characteristics of this diet ( range of scores , 0 to 9 , with higher scores indicating greater adherence ) . We used proportional-hazards regression to assess the relation between adherence to the Mediterranean diet and total mortality , as well as mortality due to coronary heart disease and mortality due to cancer , with adjustment for age , sex , body-mass index , physical-activity level , and other potential confounders . RESULTS During a median of 44 months of follow-up , there were 275 deaths . A higher degree of adherence to the Mediterranean diet was associated with a reduction in total mortality ( adjusted hazard ratio for death associated with a two-point increment in the Mediterranean-diet score , 0.75 [ 95 percent confidence interval , 0.64 to 0.87 ] ) . An inverse association with greater adherence to this diet was evident for both death due to coronary heart disease ( adjusted hazard ratio , 0.67 [ 95 percent confidence interval , 0.47 to 0.94 ] ) and death due to cancer ( adjusted hazard ratio , 0.76 [ 95 percent confidence interval , 0.59 to 0.98 ] ) . Associations between individual food groups contributing to the Mediterranean-diet score and total mortality were generally not significant . CONCLUSIONS Greater adherence to the traditional Mediterranean diet is associated with a significant reduction in total mortality BACKGROUND The Lyon Diet Heart Study is a r and omized secondary prevention trial aim ed at testing whether a Mediterranean-type diet may reduce the rate of recurrence  after a first myocardial infa rct ion . An intermediate analysis showed a striking protective effect after 27 months of follow-up . This report presents results of an extended follow-up ( with a mean of 46 months per patient ) and deals with the relationships of dietary patterns and traditional risk factors with recurrence . METHODS AND RESULTS Three composite outcomes ( COs ) combining either cardiac death and nonfatal myocardial infa rct ion ( CO 1 ) , or the preceding plus major secondary end points ( unstable angina , stroke , heart failure , pulmonary or peripheral embolism ) ( CO 2 ) , or the preceding plus minor events requiring hospital admission ( CO 3 ) were studied . In the  Mediterranean diet group , CO 1 was reduced ( 14 events versus 44 in the prudent Western-type diet group , P=0.0001 ) , as were CO 2 ( 27 events versus 90 , P=0.0001 ) and CO 3 ( 95 events versus 180 , P=0 . 0002 ) . Adjusted risk ratios ranged from 0.28 to 0.53 . Among the traditional risk factors , total cholesterol ( 1 mmol/L being associated with an increased risk of 18 % to 28 % ) , systolic blood pressure ( 1 mm Hg being associated with an increased risk of 1 % to 2 % ) , leukocyte count ( adjusted risk ratios ranging from 1.64 to 2.86 with count > 9x10(9)/L ) , female sex ( adjusted risk ratios , 0.27 to 0 . 46 ) , and aspirin use ( adjusted risk ratios , 0.59 to 0.82 ) were each significantly and independently associated with recurrence . CONCLUSIONS The protective effect of the Mediterranean dietary pattern was maintained up to 4 years after the first infa rct ion , confirming previous intermediate analyses . Major traditional risk factors , such as high blood cholesterol and blood pressure , were shown to be independent and joint predictors of recurrence , indicating that the Mediterranean dietary pattern did not alter , at least qualitatively , the usual relationships between major risk factors and recurrence . Thus , a comprehensive strategy to decrease cardiovascular morbidity and mortality should include primarily a cardioprotective diet . It should be associated with other ( pharmacological ? ) means aim ed at reducing modifiable risk factors . Further trials combining the 2 approaches are warranted BACKGROUND There is conflicting evidence on the benefits of foods rich in vitamin E ( alpha-tocopherol ) , n-3 polyunsaturated fatty acids ( PUFA ) , and their pharmacological substitutes . We investigated the effects of these substances as supplements in patients who had myocardial infa rct ion . METHODS From October , 1993 , to September , 1995 , 11,324 patients surviving recent ( < or = 3 months ) myocardial infa rct ion were r and omly assigned supplements of n-3 PUFA ( 1 g daily , n=2836 ) , vitamin E ( 300 mg daily , n=2830 ) , both ( n=2830 ) , or none ( control , n=2828 ) for 3.5 years . The primary combined efficacy endpoint was death , non-fatal myocardial infa rct ion , and stroke . Intention-to-treat analyses were done according to a factorial design ( two-way ) and by treatment group ( four-way ) . FINDINGS Treatment with n-3 PUFA , but not vitamin E , significantly lowered the risk of the primary endpoint ( relative-risk decrease 10 % [ 95 % CI 1 - 18 ] by two-way analysis , 15 % [ 2 - 26 ] by four-way analysis ) . Benefit was attributable to a decrease in the risk of death ( 14 % [ 3 - 24 ] two-way , 20 % [ 6 - 33 ] four-way ) and cardiovascular death ( 17 % [ 3 - 29 ] two-way , 30 % [ 13 - 44 ] four-way ) . The effect of the combined treatment was similar to that for n-3 PUFA for the primary endpoint ( 14 % [ 1 - 26 ] ) and for fatal events ( 20 % [ 5 - 33 ] ) . INTERPRETATION Dietary supplementation with n-3 PUFA led to a clinical ly important and statistically significant benefit . Vitamin E had no benefit . Its effects on fatal cardiovascular events require further exploration Diets rich in fruits and vegetables have been of interest because of their potential health benefits against chronic diseases such as cardiovascular disease ( CVD ) and cancer . The aim of this work was to assess the association of the dietary intake of a food group that includes fruits , berries and vegetables with all-cause , CVD-related and non-CVD-related mortality .  The subjects were Finnish men aged 42 - 60 y examined in 1984 - 1989 in the prospect i ve Kuopio Ischaemic Heart Disease Risk Factor ( KIHD ) Study .  Dietary intakes were assessed by 4-d food intake record during the baseline phase of the KIHD Study . The risk of all-cause and non-CVD-related deaths was studied in 2641 men and the risk of CVD-related death in 1950 men who had no history of CVD at baseline . During a mean follow-up time of 12.8 y , cardiovascular as well as noncardiovascular and all-cause mortality were lower among men with the highest consumption of fruits , berries and vegetables . After adjustment for the major CVD risk factors , the relative risk for men in the highest fifth of fruit , berry and vegetable intake for all-cause death , CVD-related and non-CVD-related death was 0.66 [ 95 % confidence interval ( CI ) 0.50 - 0.88 ] , 0.59 ( 0.33 - 1.06 ) , and 0.68 ( 0.46 - 1.00 ) , respectively , compared with men in the lowest fifth . These data show that a high fruit , berry and vegetable intake is associated with reduced risk of mortality in middle-aged Finnish men . Consequently , the findings of this work indicate that diets that are rich in plant-derived foods can promote longevity BACKGROUND Prospect i ve studies suggested that substituting whole-grain products for refined-grain products lowers the risks of type 2 diabetes and cardiovascular disease ( CVD ) in women . Although breakfast cereals are a major source of whole and refined grains , little is known about their direct association with the risk of premature mortality . OBJECTIVE We prospect ively evaluated the association between whole- and refined-grain breakfast cereal intakes and total and CVD-specific mortality in a cohort of US men . DESIGN We examined 86,190 US male physicians aged 40 - 84 y in 1982 who were free of known CVD and cancer at baseline . RESULTS During 5.5 y , we documented 3114 deaths from all causes , including 1381 due to  CVD  ( 488 myocardial infa rct ions and 146 strokes ) . Whole-grain breakfast cereal intake was inversely associated with total and CVD-specific mortality , independent of age ; body mass index ; smoking ; alcohol intake ; physical activity ; history of diabetes , hypertension , or high cholesterol ; and use of multivitamins . Compared with men who rarely or never consumed whole-grain cereal , men in the highest category of whole-grain cereal intake ( > or = 1 serving/d ) had multivariate-estimated relative risks of total and CVD-specific mortality of 0.83 ( 95 % CI : 0.73 , 0.94 ; P for trend < 0.001 ) and 0.80 ( 0.66 , 0.97 ; P for trend < 0.001 ) , respectively . In contrast , total and refined-grain breakfast cereal intakes were not significantly associated with total and CVD-specific mortality . These findings persisted in analyses stratified by history of type 2 diabetes , hypertension , and high cholesterol . CONCLUSIONS Both total mortality and CVD-specific mortality were inversely associated with whole-grain but not refined-grain breakfast cereal intake . These prospect i ve data highlight the importance of distinguishing whole-grain from refined-grain cereals in the prevention of chronic diseases BACKGROUND To assess the overall influence of diet on health and disease in epidemiological studies , the habitual diet of the study participants has to be captured as a pattern rather than individual foods or nutrients . The simplest way to describe dietary preferences is to separate foods considered beneficial to health from foods considered to promote disease , and separate individuals on the basis of their regular consumption of these foods . METHODS We used data from 59 038 women participating in the prospect i ve Mammography Screening Cohort in Sweden to investigate the influence of variety of healthy and less healthy foods on all-cause and cause-specific mortality . RESULTS Women who followed a healthy diet defined as consumption of a high variety of fruits , vegetables , whole grain breads , cereals , fish , and low fat dairy products had a significantly lower mortality than women who consumed few of these foods ( 3710 deaths total ) . Women who reported regularly consuming 16 - 17 healthy foods had a 42 % lower all-cause mortality ( 95 % CI : 32 - 50 % ) compared to women reporting consumption of 0 - 8 healthy foods with any regularity ( P for trend < 0.0001 ) . For each additional healthy food consumed the risk of death was about 5 % lower ( 95 % CI : 4 - 6 % ) . Cardiovascular mortality was particularly low among women who reported consuming a high variety of healthy foods . A less healthy diet defined as consumption of a high variety of red meats , refined carbohydrates and sugars , and foods high in saturated or trans fats was not directly associated with a higher overall mortality . However , women who reported consuming many less healthy foods were significantly more likely to die from cancer than those who consumed few less healthy foods . CONCLUSIONS A healthy diet can affect longevity . It appears more important to increase the number of healthy foods regularly consumed than to reduce the number of less healthy foods regularly consumed BACKGROUND This study examined whether a supervised exercise program improved 19-year survival in 30- to 64-year-old male myocardial infa rct ion patients . METHODS AND RESULTS The men ( n=651 ) were participants in the National Exercise and Heart Disease Project , a 3-year multicenter r and omized clinical trial conducted in the United States ( 1976 - 1979 ) . The treatment group ( n=315 ) exercised for 8 weeks in a laboratory . Thereafter , they jogged , cycled , or swam in a gymnasium/pool setting guided by an individualized target heart rate . Participants in the control group ( n=319 ) were to maintain normal routines but not participate in any regular exercise program . Participants were followed up until their death or December 31 , 1995 . Cox proportional hazards analysis revealed the all-cause mortality risk estimates ( 95 % CIs ) in the exercise group compared with controls to be 0.69 ( 0.39 to 1.25 ) after an average follow-up of 3 years , 0.84 ( 0.55 to 1.28 ) after 5 years , 0.95 ( 0.71 to 1.29 ) after 10 years , 1.02 ( 0.79 to 1.32 ) after 15 years , and 1.09 ( 0.87 to 1 . 36 ) after 19 years . Cardiovascular disease ( CVD ) mortality risk estimates ( 95 % CI ) for the same follow-up periods were 0.73 ( 0.37 to 1.43 ) , 0.98 ( 0.60 to 1.61 ) , 1.21 ( 0.79 to 1.60 ) , 1.14 ( 0.84 to 1.54 ) , and 1.16 ( 0.88 to 1.52 ) . However , each 1-MET increase in work capacity from baseline to the end of the original trial result ed in consistent reductions in all-cause and CVD mortality risk at each follow-up period , regardless of initial work-capacity level . CONCLUSIONS These findings indicate exercise-program participation result ed in nonsignificantly reduced mortality risks early in the follow-up period . Benefits diminished as time since participation increased , which suggests that the protective mechanisms associated with the program may be short term . Contamination between groups over time could also explain the diminished effects , because increased work capacity provided survival benefits up to 19 years CONTEXT Most studies of diet and health care have focused on the role of single nutrients , foods , or food groups in disease prevention or promotion . Few studies have addressed the health effects of dietary patterns , which include complex mixtures of foods containing multiple nutrients and nonnutrients . OBJECTIVE To examine the association of mortality with a multifactorial diet quality index . DESIGN AND SETTING Data from phase 2 ( 1987 - 1989 ) of a prospect i ve cohort study of breast cancer screening , the Breast Cancer Detection Demonstration Project , with a median follow-up of 5.6 years . PARTICIPANTS A total of 42,254 women ( mean age , 61.1 years ) who completed the food frequency question naire portion of the survey .  MAIN OUTCOME MEASURE All-cause mortality by quartile of Recommended Food Score ( RFS ; the sum of the number of foods recommended by current dietary guidelines [ fruits , vegetables , whole grains , low-fat dairy , and lean meats and poultry ] that were reported on the question naire to be consumed at least once a week , for a maximum score of 23 ) . RESULTS There were 2065 deaths due to all causes in the cohort . The RFS was inversely associated with all-cause mortality . Compared with those in the lowest quartile , subjects in the upper quartiles of the RFS had relative risks for all-cause mortality of 0.82 ( 95 % confidence interval [ CI ] , 0.73 - 0.92 ) for quartile 2 , 0.71 ( 95 % CI , 0.62 - 0.81 ) for quartile 3 , and 0.69 ( 95 % CI , 0.61 - 0.78 ) for quartile 4 adjusted for education , ethnicity , age , body mass index , smoking status , alcohol use , level of physical activity , menopausal hormone use , and history of disease ( chi2 for trend = 35.64 , P<.001 for trend ) . CONCLUSIONS These data suggest that a dietary pattern characterized by consumption of foods recommended in current dietary guidelines is associated with decreased risk of mortality in women OBJECTIVE To examine the effects of alcohol on risk of mortality from coronary heart disease ( CHD ) , cardiovascular disease , and all causes in men with established CHD . METHODS AND RESULTS In a population based prospect i ve study of 7169 men aged 45–64 years followed for a mean of 12.8 years , 655 men ( 9.1 % ) had a physician diagnosis of CHD ( myocardial infa rct ion 455 , angina only 200 ) . In these 655 men , there were 294 deaths from all causes including 175 CHD deaths . Ex-drinkers had the highest risk of CHD , cardiovascular mortality , and all cause mortality even after adjustment for lifestyle characteristics and pre-existing disease . Using occasional drinkers as the reference group , lifelong teetotallers , occasional drinkers , and light drinkers all showed similar risks of mortality from CHD , cardiovascular disease , and all causes . Moderate/heavy drinkers showed increased risk of mortality from CHD , cardiovascular disease , and all causes compared to occasional drinkers . The adverse effect of moderate/heavy drinking was confined to the 455 men with previous myocardial infa rct ion ( adjusted relative risk for all cause mortality 1.50 , 95 % confidence interval 1.01 to 2.23 ) . In contrast to lighter drinking , giving up smoking within five years of the start of follow up was associated with a considerable reduction in risk of all cause and cardiovascular mortality compared to those who continued to smoke . CONCLUSION Compared to occasional drinking , regular light alcohol consumption ( 1–14 units per week ) in men with established coronary heart disease is not associated with any significant benefit or deleterious effect for CHD , cardiovascular disease or all cause mortality . Higher levels of intake ( ⩾ 3 drinks per day ) are associated with increased mortality in men with previous myocardial infa rct ion . In contrast , smoking cessation in men with established CHD substantially reduces the risk of mortality Objective : To see whether mortality among men with angina can be reduced by dietary advice . Design : A r and omized controlled factorial trial . Setting : Male patients of general practitioners in south Wales . Subjects : A total of 3114 men under 70 y of age with angina . Interventions : Subjects were r and omly allocated to four groups : ( 1 ) advised to eat two portions of oily fish each week , or to take three fish oil capsules daily ; ( 2 ) advised to eat more fruit , vegetables and oats ; ( 3 ) given both the above types of advice ; and ( 4 ) given no specific dietary advice .  Mortality was ascertained after 3–9 y. Results : Compliance was better with the fish advice than with the fruit advice . All-cause mortality was not reduced by either form of advice , and no other effects were attributable to fruit advice . Risk of cardiac death was higher among subjects advised to take oily fish than among those not so advised ; the adjusted hazard ratio was 1.26 ( 95 % confidence interval 1.00 , 1.58 ; P=0.047 ) , and even greater for sudden cardiac death ( 1.54 ; 95 % CI 1.06 , 2.23 ; P=0.025 ) . The excess risk was largely located among the subgroup given fish oil capsules . There was no evidence that it was due to interactions with medication . Conclusion : Advice to eat more fruit was poorly complied with and had no detectable effect on mortality . Men advised to eat oily fish , and particularly those supplied with fish oil capsules , had a higher risk of cardiac death . This result is unexplained ; it may arise from risk compensation or some other effect on patients ' or doctors ' behaviour . Sponsorship : British Heart Foundation , Seven Seas Limited , Novex Pharma Limited , The Fish Foundation 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 Objective : A number of long-term population -based studies have tried to study fruit and vegetable consumption in relation to cardiovascular disease , cancer and total mortality . Few of these studies are based on r and omly selected population sample s. The aim of the study was to investigate the long-term effect of fruit and vegetable consumption on mortality , cardiovascular disease , cardiovascular death , cancer morbidity and cancer death among middle-aged and elderly men . Design : Prospect i ve cohort study . Setting : General community . The Study of Men Born in 1913.Subjects : 792 men at age 54 who participated in a screening examination in 1967.Main outcome measures : A  food frequency question naire was used to obtain information of the dietary habits in 730 of the men ( 92 % ) . All men were followed up with repeated examinations until the age of 80 . Results : Cardiovascular as well as total mortality was significantly lower among men with high fruit consumption in univariate analysis . There was no correlation between fruit or vegetable consumption in relation to cancer incidence , cancer death and cardiovascular disease . In multivariate survival analysis where smoking , cholesterol and hypertension were taken into account , there was a significantly lower mortality among men with a high fruit consumption during 16 y follow up until the age of 70 ( P=0.042 ) , but this finding was no longer statistically significant during 26 y follow-up at the age of 80 ( P=0.051 ) . Conclusions . Daily fruit consumption seems to have positive effect on long-term survival independently of other traditional cardiovascular risk factors like smoking , hypertension and cholesterol . Sponsorship : This study was supported by grants from the Swedish Medical Research Council ( K98 - 274 - 06276 - 17 ) King Gustav V and Queen Victoria ’s Foundation , and the Göteborg University . European Journal of Clinical Nutrition ( 2000 ) 54 , BACKGROUND The rapid emergence of coronary artery disease ( CAD ) in south Asian people is not explained by conventional risk factors . In view of cardioprotective effects of a Mediterranean style diet rich in alpha-linolenic acid , we assessed the benefits of this diet for patients at high risk of CAD . METHODS We did a r and omised , single-blind trial in 1000 patients with angina pectoris , myocardial infa rct ion , or surrogate risk factors for CAD . 499 patients were allocated to a diet rich in whole grains , fruits , vegetables , walnuts , and almonds . 501 controls consumed a local diet similar to the step I National Cholesterol Education Program ( NCEP ) prudent diet . FINDINGS The intervention group consumed more  fruits , vegetables , legumes , walnuts , and almonds  than did controls ( 573 g [ SD 127 ] vs 231 g [ 19 ] per day p<0.001 ) . The intervention group had an increased intake of whole grains and mustard or soy bean oil . The mean intake of alpha-linolenic acid was two-fold greater in the intervention group ( 1.8 g [ SD 0.4 ] vs 0.8 g [ 0.2 ] per day , p<0.001 ) . Total cardiac end points were significantly fewer in the intervention group than the controls ( 39 vs 76 events , p<0.001 ) . Sudden cardiac deaths were also reduced ( 6 vs 16 , p=0.015 ) , as were non-fatal myocardial infa rct ions ( 21 vs 43 , p<0.001 ) . We noted a significant reduction in serum cholesterol concentration and other risk factors in both groups , but especially in the intervention diet group . In the treatment group , patients with pre-existing CAD had significantly greater benefits compared with such patients in the control group . INTERPRETATION An Indo-Mediterranean diet that is rich in alpha-linolenic acid might be more effective in primary and secondary prevention of CAD than the conventional step I NCEP prudent diet CONTEXT Dietary sodium is positively associated with blood pressure , and ecological and animal studies both have suggested that high dietary sodium intake increases stroke mortality . OBJECTIVE To examine the risk of cardiovascular disease associated with dietary sodium intake in overweight and nonoverweight persons . DESIGN Prospect i ve cohort study . SETTING The first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study , conducted in 1982 - 1984 , 1986 , 1987 , and 1992 . PARTICIPANTS Of those aged 25 to 74 years when the survey was conducted in 1971 -1975 ( 14407 participants ) , a total of 2688 overweight and 6797 nonoverweight persons were included in the analysis . MAIN OUTCOME MEASURES  Dietary sodium and energy intake  were estimated at baseline using a single 24-hour dietary recall method .  Incidence and mortality data for cardiovascular disease were obtained from medical records and death certificates . RESULTS For overweight and nonoverweight persons , over an average of 19 years of follow-up , the total number of documented cases were as follows : 680 stroke events ( 210 fatal ) , 1727 coronary heart disease events ( 614 fatal ) , 895 cardiovascular disease deaths , and 2486 deaths from all causes . Among overweight persons with an average energy intake of 7452 kJ , a 100 mmol higher sodium intake was associated with a 32 % increase ( relative risk [ RR ] , 1.32 ; 95 % confidence interval [ CI ] , 1.07 - 1.64 ; P = .01 ) in stroke incidence , 89 % increase ( RR , 1.89 ; 95 % CI , 1.31 - 2.74 ; P<.001 ) in stroke mortality , 44 % increase ( RR , 1.44 ; 95 % CI , 1.14 - 1.81 ; P = .002 ) in coronary heart disease mortality , 61 % increase ( RR , 1.61 ; 95 % CI , 1.32 - 1.96 ; P<.001 ) in cardiovascular disease mortality , and 39 % increase ( RR , 1.39 ; 95 % CI , 1.23 - 1.58 ; P<.001 ) in mortality from all causes . Dietary sodium intake was not significantly associated with cardiovascular disease risk in nonoverweight persons . CONCLUSIONS Our analysis indicates that high sodium intake is strongly and independently associated with an increased risk of cardiovascular disease and all-cause mortality in overweight persons CONTEXT The effect of age on excess mortality from all causes associated with obesity is controversial . Few studies have investigated the association between body mass index ( BMI , calculated as weight in kilograms divided by the square of height in meters ) , age , and mortality , with sufficient numbers of subjects at all levels of obesity . OBJECTIVE To assess the effect of age on the excess mortality associated with all degrees of obesity . DESIGN Prospect i ve cohort study . SETTING AND PARTICIPANTS A total of 6193 obese patients with mean ( SD ) BMI of 36.6 ( 6.1 ) kg/m2 and mean ( SD ) age of 40.4 ( 12.9 ) years who had been referred to the obesity clinic of Heinrich-Heine University , Düsseldorf , Germany , between 1961 and 1994 . Median follow-up time was 14.8 years . MAIN OUTCOME MEASURE All-cause mortality through 1994 among 6053 patients for whom follow-up data were available ( 1028 deaths ) analyzed as st and ardized mortality ratios ( SMRs ) using the male-female population of the geographic region ( North Rhine Westphalia ) as reference . RESULTS The cohort was grouped into approximate quartiles according to age ( 18 - 29 , 30 - 39 , 40 - 49 , and 50 - 74 years ) and BMI ( 25 to < 32 , 32 to < 36 , 36 to < 40 , and > or = 40 kg/m2 ) at baseline . The SMRs showed a significant excess mortality with an SMR for men of 1.67 ( 95 % confidence interval , 1.51 - 1.85 ; P<.001 ) and an SMR for women of 1.45 ( 95 % confidence interval , 1.34 - 1.57 ; P<.001 ) . The excess mortality associated with obesity declined with age . For men , the SMRs of the 4 age groups were 2.46 , 2.30 , 1.99 , and 1.31 , respectively ; for women , they were 1.81 , 2.10 , 1.70 , and 1.26 , respectively ( Poisson trend test , P<.001 ) . The SMRs increased with BMI but , within each BMI group , the SMRs decreased with age . The lowest SMRs ( for men , 1.01 ; for women , 0.91 ) were obtained for patients older than 50 years with BMI s of 25 to less than 32 kg/m2 . Thus , older men and women at a BMI range of 25 to less than 32 kg/m2 had no excess mortality . The highest SMRs ( for men , 4.22 ; for women , 3.79 ) were calculated for the patients aged 18 to 29 years with a BMI of 40 kg/m2 or higher . CONCLUSIONS In this large cohort of obese persons , risk of death increased with body weight , but obesity-related excess mortality declined with age at all levels of obesity This study investigate the relation between fish consumption  , all-cause mortality , and incidence of coronary heart disease ( CHD ) .  A total of 4,513 men and 3,984 women aged 30 - 70 years , sample d r and omly from the population in Copenhagen County , Denmark , with initially examination in 1982 - 1992 was followed until 2000 for all-cause mortality and until 1997 for first admission to hospital or death from CHD . Information on fish consumption was obtained from a self-administered food-frequency question naire . Cox proportional hazard analysis gave no evidence for an inverse association between fish consumption and all-cause mortality or incident CHD after adjustment for confounders . Among subjects with a priory-defined high risk of CHD there was a nonsignificant inverse relation between fish intake and CHD morbidity ( Hazard Ratio 1.28 ( 0.92 - 1.80 ) for a consumption of fish of less than two times per month or less compared with once a week ) , but there was relatively few cases in this subgroup . These data provides no evidence for a protective effect of fish consumption on all-cause mortality or incident CHD in the population as a whole , but it can not be excluded that frequent consumption of fish benefits those at high risk for CHD 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 Abstract Objective : To assess the risk of death associated20with various patterns of alcohol consumption .  Design - Prospect i ve study of mortality in relation to alcohol drinking habits in 1978 , with causes of death sought over the next 13 years ( to 1991 ) . Subjects : 12 321 British male doctors born between 1900 and 1930 ( mean 1916 ) who replied to a postal question naire in 1978 . Those written to in 1978 were the survivors of a long running prospect i ve study of the effects of smoking that had begun in 195120 and was still continuing . Results - Men were divided on the basis of their response to the 1978 question  naire into two groups according to whether or not they had ever had any type of vascular disease , diabetes , or “ life threatening disease ” and into seven groups according to the amount of alcohol they drank . By 1991 almost a third had died . All statistical analyses of mortality were st and ardised for age , calendar year , and smoking habit . There was a U shaped relation between all cause mortality and the average amount of alcohol reportedly drunk ; those who reported drinking 8 - 14 units of alcohol a week ( corresponding to an average of one to two units a day ) had the lowest risks . The causes of death were grouped into three main categories : “ alcohol augmented ” causes ( 6 % of all deaths : cirrhosis , liver cancer , upper aerodigestive ( mouth , oesophagus , larynx , and pharynx ) cancer , alcoholism , poisoning , or injury ) , ischaemic heart disease ( 33 % of all deaths ) , and other causes . The few deaths from alcohol augmented causes showed , at least among regular drinkers , a progressive trend , with the risk increasing with dose . In contrast , the many deaths from ischaemic heart disease showed no significant trend among regular drinkers , but there were significantly lower rates in regular drinkers than in non-drinkers . The aggregate of all other causes showed a U shaped dose-response relation similar to that for all cause mortality . Similar differences persisted irrespective of a history of previous disease , age ( under 75 or 75 and older ) , and period of follow up ( first five and last eight years ) . Some , but apparently not much , of the excess mortality in non-drinkers could be attributed to the inclusion among them of a small proportion of former drinkers . Conclusion : The consumption of alcohol appeared to reduce the risk of ischaemic heart disease , largely irrespective of amount . Among regular drinkers mortality from all causes combined increased progressively with amount drunk above 21 units a week . Among British men in middle or older age the consumption of an average of one or two units of alcohol a day is associated with significantly lower all cause mortality than is the consumption of no alcohol , or the consumption of substantial amounts . Above about three units ( two American20units ) of alcohol a day , progressively greater levels of consumption are associated with progressively higher all cause mortality OBJECTIVE --To test whether a fat reduced diet rich in soluble dietary fibre , antioxidant vitamins , and minerals reduces complications and mortality after acute myocardial infa rct ion . DESIGN --R and omised , single blind , controlled trial . SETTING -- Primary and secondary care research centre for patients with myocardial infa rct ion . SUBJECTS--505 patients with suspected acute myocardial infa rct ion . Those with definite or possible acute myocardial infa rct ion and unstable angina based on World Health Organisation criteria were assigned to diet A ( n = 204 ) or diet B ( n = 202 ) within 24 - 48 hours of infa rct ion . INTERVENTIONS --Both groups were advised to follow a fat reduced diet . Group A was also advised to eat more fruit , vegetables , nuts , and grain products . MAIN OUTCOME MEASURES --Mortality from cardiac disease and other causes . Serum lipid concentrations and compliance with diet . RESULTS --Blood lipoprotein concentrations and body weight fell significantly in patients in group A compared with those in group B ( cholesterol fell by 0.74 mmol/l in group A v 0.32 mmol/l in group B , 95 % confidence interval of difference 0.14 to 0.70 , and weight by 7.1 v 3.0 kg , 0.52 to 7.68 ) . The incidence of cardiac events was significantly lower in group A than group B ( 50 v 82 patients , p less than 0.001 ) . Group A also had lower total mortality ( 21 v 38 died , p less than 0.01 ) than group B. CONCLUSIONS --Comprehensive dietary changes in conjunction with weight loss immediately after acute myocardial infa rct ion may modulate blood lipoproteins and significantly reduce complications and mortality after one year A r and omised controlled trial with a factorial design was done to examine the effects of dietary intervention in the secondary prevention of myocardial infa rct ion ( MI ) . 2033 men who had recovered from MI were allocated to receive or not to receive advice on each of three dietary factors : a reduction in fat intake and an increase in the ratio of polyunsaturated to saturated fat , an increase in fatty fish intake , and an increase in cereal fibre intake . The advice on fat was not associated with any difference in mortality , perhaps because it produced only a small reduction ( 3 - 4 % ) in serum cholesterol . The subjects advised to eat fatty fish had a 29 % reduction in 2 year all-cause mortality compared with those not so advised . This effect , which was significant , was not altered by adjusting for ten potential confounding factors . Subjects given fibre advice had a slightly higher mortality than other subjects ( not significant ) . The 2 year incidence of reinfa rct ion plus death from ischaemic heart disease was not significantly affected by any of the dietary regimens . A modest intake of fatty fish ( two or three portions per week ) may reduce mortality in men who have recovered from MI BACKGROUND The evidence that high salt intake increases the risk of cardiovascular disease has been challenged . We aim ed to find out whether salt intake , measured by 24 h urinary sodium excretion , is an independent risk factor for cardiovascular disease frequency and mortality , and all-cause mortality . METHODS We prospect ively followed 1173 Finnish men and 1263 women aged 25 - 64 years with complete data on 24 h urinary sodium excretion and cardiovascular risk factors . The endpoints were an incident coronary and stroke event , and death from coronary heart disease , cardiovascular disease , and any cause . Each endpoint was analysed separately with the Cox proportional hazards model . FINDINGS The hazards ratios for coronary heart disease , cardiovascular disease , and all-cause mortality , associated with a 100 mmol increase in 24 h urinary sodium excretion , were 1.51 ( 95 % CI 1.14 - 2.00 ) , 1.45 ( 1.14 - 1.84 ) , and 1.26 ( 1.06 - 1.50 ) , respectively , in both men and women . The frequency of acute coronary events , but not acute stroke events , rose significantly with increasing sodium excretion . When analyses were done separately for each sex , the risk ratios were significant in men only . There was a significant interaction between sodium excretion and body mass index for cardiovascular and total mortality ; sodium predicted mortality in men who were overweight . Correction for the regression dilution bias increased the hazards ratios markedly . INTERPRETATION High sodium intake predicted mortality and risk of coronary heart disease , independent of other cardiovascular risk factors , including blood pressure . These results provide direct evidence of the harmful effects of high salt intake in the adult population In a prospect i ve , r and omised single-blinded secondary prevention trial we compared the effect of a Mediterranean alpha-linolenic acid-rich diet to the usual post-infa rct prudent diet .  After a first myocardial infa rct ion , patients were r and omly assigned to the experimental ( n = 302 ) or control group ( n = 303 ) . Patients were seen again 8 weeks after r and omisation , and each year for 5 years . The experimental group consumed significantly less lipids , saturated fat , cholesterol  , and  linoleic acid  but more  oleic  and  alpha-linolenic acids  confirmed by measurements in plasma . Serum lipids , blood pressure , and body mass index remained similar in the 2 groups . In the experimental group , plasma levels of albumin , vitamin E , and vitamin C were increased , and granulocyte count decreased . After a mean follow up of 27 months , there were 16 cardiac deaths in the control and 3 in the experimental group ; 17 non-fatal myocardial infa rct ion in the control and 5 in the experimental groups : a risk ratio for these two main endpoints combined of 0.27 ( 95 % CI 0.12 - 0.59 , p = 0.001 ) after adjustment for prognostic variables . Overall mortality was 20 in the control , 8 in the experimental group , an adjusted risk ratio of 0.30 ( 95 % CI 0.11 - 0.82 , p = 0.02 ) . An alpha-linolenic acid-rich Mediterranean diet seems to be more efficient than presently used diets in the secondary prevention of coronary events and death The results of large prospect i ve epidemiologic investigations support the hypothesis that coronary disease risk depends on the quality rather than quantity of dietary fat . Whereas saturated fat and cholesterol appear to increase the risk of coronary heart disease ( CHD ) as predicted by their effects on blood lipids , strong evidence has emerged that the deleterious effects of trans unsaturated fatty acids ( trans fatty acids ) extend beyond those predicted by their well-known adverse influence on the ratio of low-density lipoprotein to high-density lipoprotein cholesterol . On the other h and , increased consumption of the polyunsaturated fats , linoleic acid and linolenic acid , appears to reduce the risk of CHD BACKGROUND Alcohol consumption has both adverse and beneficial effects on survival . We examined the balance of these in a large prospect i ve study of mortality among U.S. adults . METHODS Of 490,000 men and women ( mean age , 56 years ; range , 30 to 104 ) who reported their alcohol and tobacco use in 1982 , 46,000 died during nine years of follow-up . We compared cause-specific and rates of death from all causes across categories of base-line alcohol consumption , adjusting for other risk factors , and related drinking and smoking habits to the cumulative probability of dying between the ages of 35 and 69 years . RESULTS Causes of death associated with drinking were cirrhosis and alcoholism ; cancers of the mouth , esophagus , pharynx , larynx , and liver combined ; breast cancer in women ; and injuries and other external causes in men . The mortality from breast cancer was 30 percent higher among women reporting at least one drink daily than among nondrinkers ( relative risk , 1.3 ; 95 percent confidence interval , 1.1 to 1.6 ) . The rates of death from all cardiovascular diseases were 30 to 40 percent lower among men ( relative risk , 0.7 ; 95 percent confidence interval , 0.7 to 0.8 ) and women ( relative risk , 0.6 ; 95 percent confidence interval , 0.6 to 0.7 ) reporting at least one drink daily than among nondrinkers , with little relation to the level of consumption . The overall death rates were lowest among men and women reporting about one drink daily . Mortality from all causes increased with heavier drinking , particularly among adults under age 60 with lower risk of cardiovascular disease . Alcohol consumption was associated with a small reduction in the overall risk of death in middle age ( ages 35 to 69 ) , whereas smoking approximately doubled this risk . CONCLUSIONS In this middle-aged and elderly population , moderate alcohol consumption slightly reduced overall mortality . The benefit depended in part on age and background cardiovascular risk and was far smaller than the large increase in risk produced by tobacco
target: Available studies show convincingly the health benefits of lifestyle changes in CAD patients .
  Effect estimates of combined dietary changes look promising .
background: BACKGROUND Guidelines for lifestyle and dietary modification in patients with coronary artery disease ( CAD ) are mainly supported by evidence from general population studies .
  CAD patients , however , differ from the general population in age ( older ) and treatment with preventive drugs .
  This review seeks to provide evidence for a prognostic benefit of lifestyle and dietary recommendations from studies in CAD patients .