title: 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). A randomized clinical trial of hospital-based, comprehensive cardiac rehabilitation versus usual care for patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease (the DANREHAB trial)--design, intervention, and population. [The Belgian project for the prevention of cardiovascular diseases: a model of multifactorial prevention]. The Lowering of Vascular Atherosclerotic Risk (LOVAR) program: an approach to modifying cerebral, cardiac, and peripheral vascular disease. Multifactorial trial in the prevention of coronary heart disease: 3. Incidence and mortality results. Attenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: role of physical exercise. Lifestyle modification program in management of patients with coronary artery disease: the clinical experience in a tertiary care hospital. [Patient education in the management of coronary heart disease]. All-cause mortality of patients with dyslipidemia up to 19 years after a multidisciplinary lifestyle modification programme: a randomized trial Evaluation of a community-based inner-city disease management program for postmyocardial infarction patients: a randomized controlled trial. [Comparative efficiency of a course of multi-factor physiotherapeutic treatment and a complex of instrumental physiotherapy technics for medical rehabilitation of patients with stable angina pectoris]. Possibilities of multifactorial cardiovascular disease prevention in patients aged 75 and older: a randomized controlled trial: Drugs and Evidence Based Medicine in the Elderly (DEBATE) Study. Two-year results of a controlled study of residential rehabilitation for patients treated with percutaneous transluminal coronary angioplasty. A randomized study of a multifactorial programme. [Cardiovascular morbimortality reduction after an acute cardiovascular event through multifactorial and intensive cardiovascular risk factors management (MIRVAS project)]. Comparing multifactorial lifestyle interventions and stress management in coronary risk reduction A multidimensional integrative medicine intervention to improve cardiovascular risk Hospital-based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12-month results of a randomized clinical trial. The Belgian Heart Disease Prevention Project: 10-year mortality follow-up. Effects of an expanded cardiac rehabilitation programme in patients treated for an acute myocardial infarction or a coronary artery by-pass graft operation Psychological effects of a short behavior modification program in patients with acute myocardial infarction or coronary artery bypass grafting. A randomized controlled trial. Summer and follow-up interventions to affect adiposity with mothers and daughters. 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). Comparison of standard- and extended-length participation in cardiac rehabilitation on body composition, functional capacity, and blood lipids. The Multifactor Primary Prevention Trial in Göteborg, Sweden Reduction in sudden deaths and coronary mortality in myocardial infarction patients after rehabilitation. 15 year follow-up study. Global secondary prevention strategies to limit event recurrence after myocardial infarction: results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network. Recovery after myocardial infarction. Effects of a caring rehabilitation programme. Multifactorial cardiovascular disease prevention in patients aged 75 years and older: A randomized controlled trial: Drugs and Evidence Based Medicine in the Elderly (DEBATE) Study. GlObal Secondary Prevention strategiEs to Limit event recurrence after myocardial infarction: the GOSPEL study. A trial from the Italian Cardiac Rehabilitation Network: rationale and design The Extensive Lifestyle Management Intervention (ELMI) following cardiac rehabilitation trial. Two-year multicomprehensive secondary prevention program: favorable effects on cardiovascular functional capacity and coronary risk profile after acute myocardial infarction Prolonged effects of a home-based intervention in patients with chronic illness. EUROPEAN COLLABORATIVE TRIAL OF MULTIFACTORIAL PREVENTION OF CORONARY HEART DISEASE: FINAL REPORT ON THE 6-YEAR RESULTS Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older: the Drugs and Evidence-Based Medicine in the Elderly (DEBATE) study: a randomized, controlled trial. REDUCTION IN SUDDEN DEATHS BY A MULTIFACTORIAL INTERVENTION PROGRAMME AFTER ACUTE MYOCARDIAL INFARCTION
abstract: 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 Current guidelines broadly recommend comprehensive cardiac rehabilitation ( CR ) , although evidence for this is still limited . It is not known whether evidence from before 1995 is still valid . STUDY DESIGN The DANish Cardiac ReHABilitation ( DANREHAB ) trial was design ed as a central ly r and omized clinical trial to clarify whether hospital-based comprehensive CR is superior to usual care for patients with congestive heart failure , ischemic heart disease , or high risk for ischemic heart disease . A combined primary outcome measure included total mortality , myocardial infa rct ion , or readmissions due to heart disease based on linkage to public registries . The CR was an individually tailored , multidisciplinary program ( 6 weeks of intensive CR and 12 months of follow-up ) including patient education , exercise training , dietary counseling , smoking cessation , psychosocial support , risk factor management , and clinical assessment . STUDY POPULATION Of 5060 discharged patients , 1614 ( 32 % ) were eligible for the trial and 770 patients were r and omized ( 47 % of those eligible ) . Participants were younger ( P < .001 ) and had less comorbidity than non participants ( P < .03 ) . CONCLUSION Our trial shows that a large-scale , central ly r and omized clinical trial on comprehensive CR can be conducted among a broadly defined patient group , but reaching the stipulated number of 1800 patients was difficult . Although the study included relatively many women and older people , elderly patients and patients with high comorbidity were underrepresented , which may influence the external validity Résults are presented from the " belgian heart disease prevention project , part of the WHO european collaborative trial in the multifactorial prevention of coronary heart disease ( CHD ) " . 19.409 men aged 40 - 59 yr took part ; they were employed in thirty factories which formed the allocation units for a r and omised controlled trial lasting 5 - 6 yr . The intervention package consisted largely of health education promoting a cholesterol-lowering diet , smoking cessation , weight control , physical activity , and treatment of arterial hypertension . A programme of information was supplemented by face-to-face counselling at the workplace by two physicians attached to the project . The coronary risk profile was reduced in the intervention group , compared with that in the control group , especially during the first 4 yr , by effects on serum cholesterol , number of cigarettes smoked daily , and arterial blood-pressure . Total mortality was 17.5 % lower in the intervention group than in the control group ( p = 0.038 ) ; coronary mortality was reduced by a non-significant 20.8 % whereas CHD incidence ( non-fatal myocardial infa rct ion plus fatal myocardial infa rct ion plus sudden deaths ) was reduced by 24.5 % , ( P = 0.031 ) . Non-fatal myocardial infa rct ion ( not a major end-point ) was similarly reduced by 26.1 % ( p = 0.030 ) More than 1 million US citizens die of cerebral , cardiac , and peripheral vascular disease ( collectively , CVD ) each year . Basic science and clinical outcome research aim ed at reducing the burden of this illness is widespread , but the knowledge gleaned from controlled trials has not fully translated into everyday clinical practice and care of patients with CVD and their inherent risk factors . The Lowering of Vascular Atherosclerotic Risk ( LOVAR ) program was a 5-year observational study that evaluated the feasibility of a high-intensity multidisciplinary program of risk factor reduction in a population with known symptoms of CVD . The population comprised patients with documented clinical ly symptomatic cerebral , cardiac , or peripheral vascular disease and at least two modifiable risk factors for stroke , myocardial infa rct ion , or peripheral vascular occlusive disease . Final outcomes were evaluated by comparing primary and secondary end points and quality of life .  A total of 271 patients were enrolled in the intervention group , and 242 were enrolled in the st and ard care group ( control ) .  At 3 years , significant improvements in several risk factors were seen in the intervention group , with no significant improvements for the control group . The rate of patient retention was 95 % at 3 years , and overall rates of physician and patient satisfaction were high . We believe that the Lowering of Vascular Atherosclerotic Risk program is generalizable to a sufficiently motivated population targeted as high risk for vascular disease Incidence and mortality results are presented from an international controlled trial of multifactorial prevention of coronary heart disease , involving r and omization of 66 factories ( 49 781 men ) in U.K. , Belgium , Italy and Pol and ( Cracow ) . Results for Pol and ( Warsaw ) are not yet complete . Net average reductions in risk factors ( all subjects ) were 1.2 % for plasma cholesterol , 8.9 % for daily cigarettes , 0.4 % for weight , 2.0 % for systolic blood pressure , and 11.1 % for a combined risk estimate . Greater reductions occurred in high-risk subjects ( 19.4 % for the combined estimate ) . The net overall reduction in CHD rates was 7.4 % ( 95 % confidence interval -29 to + 15 % ) for deaths ( 722 cases ) , and 3.9 % ( 95 % confidence interval -10 to + 2 % ) for fatal CHD + non-fatal myocardial infa rct ion ( 1502 cases ) . Among men aged 40 - 49 the reduction for this end-point was 15 % ; at ages 50 - 59 there was a small net increase . All-causes deaths after an early adverse trend showed 2.7 % reduction overall . There were large differences between centres , ranging from a 5 % net increase in CHD for U.K. to a decrease of 24 % in Belgium . In Belgium the decrease both in CHD and in all deaths was significant at the 5 % level . The effect on CHD in the different centres correlated broadly with their changes in risk factors . It is concluded that reduction in major coronary risk factors in industrial population s is possible , but it depends on adequate re sources ; the results support the hypotheses that CHD risk in middle-aged men is reversible and that community intervention can be beneficial 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 OBJECTIVES The authors examined clinical outcomes in 71 male and female patients with coronary atherosclerosis who enrolled in a 2-year , independent-living , lifestyle modification program . The findings in 43 patients who completed the program were compared with those in 28 patients who dropped out of the program . BACKGROUND Clinical studies suggest that lifestyle modification of risk factors for coronary atherosclerosis reduces subsequent cardiac events but there are very few reports of the effect of these programs in patients living independently . METHODS Patients with diagnosed coronary atherosclerosis were managed for a 2-year period in a structured multidisciplinary program by a team that included two cardiologists , a nurse , a dietitian , an exercise physiologist , and a clinical psychologist . The overall aim of the program was to normalize or control all major reversible cardiovascular risk factors . Patients were required to participate in several weekly sessions for exercise , meditation/stress reduction training , dietary education and counseling , and participatory dinners . There was a strong emphasis on patient 's self care , inclusion of support members , and regular monitoring of and feedback to patients . RESULTS Data comparing baseline and 2-year outcomes showed a significant reduction in body weight , dietary intake of total/saturated fat and cholesterol , serum low- and high-density lipoprotein concentration , and an increase in exercise capacity . In the compliant group , the incidence of cardiac events was 2.3 % over 2 years . CONCLUSION Multidisciplinary lifestyle modification programs addressing cardiovascular risk factors are known to have a significant impact upon cardiac risk factors in patients with coronary atherosclerosis . Data show that these changes can be accomplished in independent-living patients in a program offered through a routine cardiology service . However , compliance is an important issue in these self-regulated programs The aim of the review was to assess the effect of patient education in ischaemic heart disease . Thirteen r and omised controlled trials of moderate to good quality including 68,556 patients were selected . The effect on mortality , cardiac morbidity , hospitalisation and health-related quality of life was assessed and only non-significant tendencies of effect were found . The authors of the review nevertheless conclude that the review supports current rehabilitation programmes that include patient education . Further research in patient education , especially concerning the most effective methods of education delivery , is needed Background : Many studies have shown that individual lifestyle factors are associated with cardiovascular mortality and all-cause mortality . Observational studies of comprehensive programmes have reported risk reductions . The objectives were to assess the long-term all-cause mortality by diagnosis in patients referred to a lifestyle modification programme  , aim ed at combating coronary heart disease and stroke . Methods : A r and omized trial with 325 patients referred to the centre between 1988 and 1989 for dyslipidemia , hypertension , type 2 diabetes and coronary heart disease ; 239 patients were r and omized to the programme , 86 r and omized to usual care . Cases were admitted to the centre in groups of 30 for a 4-week residential comprehensive activity , in total 114 full-time hours , focusing on food preferences and selection s , and physical exercise . The activities were repeated during a 4-day revisit to the centre 1 year and 5 years after the 4-week intervention . Controls were referred back to their doctors , mainly in primary care , for usual care . Main outcome measure was all-cause mortality during 11–12 and 18–19 years after intervention . Results : At follow-up 11–12 years after referral , the relative risk reduction ( RRR ) was 76 % with the intention-to-treat analysis among cases admitted for dyslipidemia ( hazards ratio 0.24 , confidence interval 0.06–0.89 , P = 0.033 ) . After 18–19 years , the RRR was 66 % ( hazards ratio 0.34 , confidence interval 0.13–0.88 , P = 0.026 ) . No RRR was found for the other three diagnoses . Conclusion : Patients admitted for dyslipidemia reached a real long-term RRR of all-cause mortality . They had by definition a need for this programme 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 Examination of comparable groups of patients with angina of efforts has demonstrated identical clinical efficiency of multi-factor therapeutic modalities and methods of instrumental physiotherapy for medical rehabilitation of patients with stable angina of effort . The results of this study suggest the possibility to avoid polypragmasia when prescribing physiotherapeutic treatment AIMS The effectiveness of multifactorial cardiovascular disease prevention in patients aged 75 years or older is uncertain , because these patients have often been excluded from trials . The aim of this pre-planned , first-year analysis of the Drugs and Evidence -Based Medicine in the Elderly ( DEBATE ) Study was to determine the feasibility of prevention efforts in elderly cardiovascular patients . METHODS AND RESULTS For DEBATE , home-dwelling individuals aged 75 years and over with cardiovascular diseases ( n=400 , mean age 80 years , 65 % women ) were recruited from the community . These high-risk participants were r and omly assigned to the intervention group  ( n=199 ) where both lifestyle modification and pharmacological cardiovascular treatments are individualized by a geriatrician according to current European guidelines . The control group ( n=201 ) receives the usual care . Interim analysis of the study groups at one year shows that intervention has succeeded in increasing the use of statins , aspirin , beta-blockers , and ACE inhibitors  , and decreasing serum cholesterol ( p<0.0001 ) , LDL-cholesterol ( p<0.0001 ) , and hsCRP ( p=0.04 ) . Body mass index , blood pressure , and blood glucose were similar at one year in both groups . No safety problems or adverse effects on health-related quality of life were observed and compliance was good . CONCLUSIONS It is possible and safe to institute evidence -based cardiovascular treatments in the 75 + cardiovascular patients in a real life setting , but only serum cholesterol and hsCRP are significantly decreased AIMS In a multifactorial lifestyle behaviour programme , of 2 years duration , to study the maintenance of achieved behaviour and risk factor-related changes . METHODS AND RESULTS Out of a consecutive population of 151 patients treated with percutaneous transluminal angioplasty under 65 years of age , 87 were r and omly allocated to an intervention group ( n=46 ) or to a control group ( n=41 ) . The programme started with a 4 week residential stay , which was focused on health education and the achievement of  behaviour change .  During the first year of follow-up , a maintenance programme included regular contacts with a nurse , while no further rehabilitative efforts were offered during the second year . One patient died ( control ) . During the second year the proportion of hospitalized patients was lower in the intervention group ( 4 % vs 20%;P<0.05 ) . Patients in the intervention group improved several lifestyle dependent behaviours : diet ( index at 0 , 12 and 24 months ) : 10.5+/-3 . 4 , 12.9+/-2.5 and 12.4+/-2.6 in the intervention group ( I ) vs 10 . 1+/-3.2 , 10.7+/-3.0 and 11.8+/-3.2 in the control group (C);P<0.05 , exercise sessions per week : 2.5+/-2.3 , 4.5+/-1.9 and 4.4+/-2.1 ( I ) vs 3.1+/-2.2 , 3.5+/-2.3 and 3.7+/-2.7 (C);P<0.05 , and smoking ; 18 % , 6 % and 9 % ( I ) vs 12 % , 21 % and 18 % (C);P<0.05 . This corresponded to improvement in exercise capacity ( 0 , 12 and 24 months ) : 156+/-42 , 174+/-49 and 165+/-47 W ( I ) vs 164+/-40 , 163+/-49 and 156+/-48 watts (C);P<0.05 . There were no significant differences between the two groups with regard to serum cholesterol levels at 0 and 24 months : 5 . 4+/-0.8 and 5.2+/-0.9 mmol . l(-1)(I ) vs 5.4+/-1.0 and 4.9+/-0.9 mmol . l(-1)(C ) ; ns , low density lipoprotein cholesterol level : 3.6+/-0.8 and 3.4+/-0.8 mmol . l(-1)(I ) vs 3.7+/-0.9 and 3.3+/-0.7 mmol . l(-1)(C ) ; ns , triglyceride level : 2.2+/-1.6 and 1.8+/-1.3 mmol . l(-1)(I ) vs 2.2+/-1.4 and 1.6+/-0.6 mmol . l(-1)(C ) ; ns , body mass index ( 0 , 12 and 24 months ) : 27.5+/-4.5 , 27.0+/-4.3 and 27.4+/- 4.5 kg . m(-2)(I ) vs 26.8+/-2.8 , 26.9+/-2.7 and 26.9+/- 3.2 kg . m(-2)(C ) ; ns , waist/hip ratio or blood pressure . The two groups did not differ in quality of life , or psychological factors . Return to work after 12 and 24 months was 74 % and 78 % ( I ) vs 68 % and 61 % ( C ) ; ns . CONCLUSION This rehabilitation programme influenced important lifestyle behaviour and reduced some , but not all , important risk BACKGROUND AND OBJECTIVE In spite of publication of many guidelines , management of patients on secondary prevention of cardiovascular disease is still not appropriated . We design a r and omized trial , in usual clinical practice conditions , to compare the results in cardiovascular morbimortality of intensive and integral management of cardiovascular risk factors ( CVRF ) management versus conventional care . PATIENTS AND METHOD We selected patients discharged between October 2002 and January 2004 who suffered an acute coronary syndrome with or without ST-segment elevation or a stroke , 247 patients that met inclusion s criteria were r and omized to intensive care of CVRF  in a specific Internal Medicine outpatient clinic ( n = 121 ) or usual care according to National Health Service recommendations ( n = 126 ) . A year after r and omization , the percentage of patients who met CVRF control , treatment received and the number of cardiovascular events ( cardiovascular death , acute coronary syndrome with or without ST-segment elevation , stroke , transient ischemic attack , revascularization , lower limb amputation , heart failure admission and sudden death ) were revised . RESULTS CVRF control was greater in patients assigned to intensive care . 74.1 % of hypertensive patients assigned to this treatment were controlled vs 41.7 % in the usual care group ( relative risk [ RR ] = 1.78 ; 95 % confidence interval [ CI ] , 1.27 - 2 - 49 ) ; 70.2 % of patients had low-densi-tiy lipoprotein cholesterol lower than 100 mg/dl vs 55.8 % ( RR = 1.26 ; 95 % CI , 1.00 - 1.58 ) of patients in usual care group ; 93.1 % of diabetic patients had glycosylated haemoglobin lower than 7 % vs. 57.1 % ( RR = 1.63 ; 95 % CI , 1.11 - 2.39 ) in the usual care group . There were 12 cardiovascular events in the intensive care group vs 35 in the usual care group . CONCLUSIONS Intensive management of CVRF leads to a better control of them and a reduction of the morbimortality one year after an acute cardiovascular event 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 BACKGROUND : Integrative medicine is an individualized , patient-centered approach to health , combining a whole-person model with evidence -based medicine . Interventions based in integrative medicine theory have not been tested as cardiovascular risk-reduction strategies . Our objective was to determine whether personalized health planning ( PHP ) , an intervention based on the theories and principles underlying integrative medicine , reduces 10-year risk of coronary heart disease ( CHD ) . METHODS : We conducted a r and omized , controlled trial among 154 out patients age 45 or over , with 1 or more known cardiovascular risk factors . Subjects were enrolled from primary care practice s near an academic medical center , and the intervention was delivered at a university Center for Integrative Medicine . Following a health risk assessment , each subject in the intervention arm worked with a health coach and a medical provider to construct a personalized health plan . The plan identified specific health behaviors important for each subject to modify ; the choice of behaviors was driven both by cardiovascular risk reduction and the interests of each individual subject . The coach then assisted each subject in implementing her/his health plan . Techniques used in implementation included mindfulness meditation , relaxation training , stress management , motivational techniques , and health education and coaching .  Subjects r and omized to the comparison group received usual care ( UC ) without access to the intervention  . Our primary outcome measure was 10-year risk of CHD , as measured by a st and ard Framingham risk score , and assessed at baseline , 5 , and 10 months . Differences between arms were assessed by linear mixed effects modeling , with time and study arm as independent variables . RESULTS : Baseline 10-year risk of CHD was 11.1 % for subjects r and omized to UC ( n=77 ) , and 9.3 % for subjects r and omized to PHP ( n=77 ) . Over 10 months of the intervention , CHD risk decreased to 9.8 % for UC subjects and 7.8 % for intervention subjects . Based on a linear mixed-effects model , there was a statistically significant difference in the rate of risk improvement between the 2 arms ( P=.04 ) . In secondary analyses , subjects in the PHP arm were found to have increased days of exercise per week compared with UC ( 3.7 vs 2.4 , P=.002 ) , and subjects who were overweight on entry into the study had greater weight loss in the PHP arm compared with UC ( P=.06 ) . CONCLUSIONS : A multidimensional intervention based on integrative medicine principles reduced risk of CHD , possibly by increasing exercise and improving weight loss BACKGROUND Current guidelines broadly recommend comprehensive cardiac rehabilitation ( CCR ) , although evidence for this is still limited . We investigated the 12-month effect of hospital-based CCR versus usual care ( UC ) for a broadly defined group of cardiac patients within the modern therapeutic era of cardiology . METHODS We conducted a central ly r and omized single-center clinical trial with blinded assessment of the primary outcome : registry-based composite of total mortality , myocardial infa rct ion , or acute first-time readmission due to heart disease . Other outcomes were hospitalization , risk profile , and quality of life . The trial included 770 participants ( 20 - 94 years ) with congestive heart failure ( 12 % ) , ischemic heart disease ( 58 % ) , or high risk of ischemic heart disease ( 30 % ) .  Comprehensive cardiac rehabilitation is composed of 6 weeks of intensive intervention and systematic follow-up for 10.5 months . RESULTS We r and omized 380 patients to CCR versus 390 to UC . R and omization was well balanced . The primary outcome occurred in 31 % of both groups ( relative risk 0.96 , 95 % confidence interval 0.78 - 1.26 ) . Compared with the UC group , CCR significantly reduced length of stay by 15 % ( 95 % confidence interval 1.1%-27.1 % , P = .04 ) , mean number of cardiac risk factors above target ( 4.5 vs 4.1 , P = .01 ) , patients with systolic blood pressure below target ( P = .003 ) , physically inactivity ( P = .01 ) , and unhealthy dietary habits ( P = .0003 ) . Short-Form-36 and Hospital Anxiety and Depression Scale did not differ significantly . CONCLUSION At 12 months , the CCR and UC groups did not differ regarding the primary composite outcome . Comprehensive cardiac rehabilitation significantly reduced length of hospital stay and improved cardiac risk factors The Belgian Heart Disease Prevention Project was a controlled , r and omized multifactorial intervention trial in middle-aged men which lasted 6 years . Significant net differences between intervention and control groups were observed in change in risk profile , in total mortality and in CHD incidence . The net difference in risk profile change was greatest at two years , intermediate at four years and minimal at six years . Total and cause-specific mortality rates were systematic ally followed from the 6th to the 10th year . Follow-up at 10 years was 99.3 % complete . The differences between intervention and control groups in total , coronary and cardiovascular mortality reduced from the 6th to the 10th year . The results suggest that changes in risk profile are rapidly followed by changes in cardiovascular mortality , but this applies in both directions . Thus risk reduction should be maintained in order to achieve a long-lasting preventive effect Objective : To investigate the effects of exp and ed cardiac rehabilitation with multifactorial interventions on metabolic and inflammatory markers , exercise performance and on established cardiovascular risk factors . Design : Single-centre prospect i ve r and omized controlled trial . Setting : A university hospital . Subjects : Two hundred and twenty-four patients with an acute myocardial infa rct ion or patients undergoing coronary artery by-pass grafting . Intervention : Patients were r and omized to exp and ed cardiac rehabilitation including stress management , increased physical training , staying at a ' patient hotel ' and cooking sessions , or to usual cardiac rehabilitation Main measures : Biochemical risk markers and exercise performance ; follow-up was one year . Results : There were no significant differences between the two treatment groups in the changes of biochemical risk markers or in exercise performance . Thus , low-density lipoprotein (LDL)-cholesterol levels decreased from 3.00 ( 0.97 ) to 2.54 ( 0.66 ) mmol/L in the intervention group and from 3.20 ( 0.85 ) to 2.54 ( 0.63 ) mmol/L in the control group , fibrinogen levels decreased from 5.30 ( 2.00 ) to 4.25 ( 1.01 ) g/L in the intervention group and from 5.29 ( 1.89 ) to 4.33 ( 0.83 ) g/L in the control group and C-reactive protein ( CRP ) levels decreased from 3.04 ( 2.79 ) to 2.09 ( 2.13 ) mg/L in the intervention group and from 4.01 ( 3.49 ) to 2.39 ( 2.49 ) mg/L in the control group . Total workload ( W ) improved from 118 ( 35 ) to 136 ( 34 ) in the intervention group and from 117 ( 36 ) to 133 ( 39 ) in the control group . Conclusion : There was no further significant benefit in biochemical risk markers or in exercise performance among patients undergoing the exp and ed rehabilitation as compared to the control group which received usual cardiac rehabilitation OBJECTIVE The effects of a short intervention on behavioral risk factor modification in patients with coronary artery disease ( CAD ) on Type A behavior , vital exhaustion , and depression were studied in a r and omized controlled trial . METHODS Acute myocardial infa rct ion patients or patients who underwent coronary artery bypass grafting ( CABG ) were r and omly assigned to an 8-week multiple risk modification group program ( n = 94 ) or to a control group ( n = 90 ) that received usual care with st and ard physical exercise training . Patients were assessed before intervention , directly after intervention , and at 9-month follow-up . RESULTS The intervention was effective in reducing hostility and total Type A behavior at postintervention ( P = .01 ) and at 9-month follow-up ( P = .03 ) . The intervention had no overall impact on vital exhaustion and depression , measured by the Beck Depression Inventory ( BDI ) , whereas we unexpectedly found that the percentage of patients with major depression was reduced in the control group but not in the intervention group . CONCLUSION The results indicate that a short behavioral intervention for coronary patients can result in relatively large and persistent reductions in cognitive aspects of Type A behavior and hostility , in particular . In view of the unwanted findings on the diagnosis of depression , however , we do not unequivocally advise the intervention to the general population of AMI and CABG patients BACKGROUND The development of effective obesity interventions to reduce adiposity indicators in Latina girls is a public health priority because of their increased risk for becoming overweight . Research indicates that the summer season may be a critical time to intervene because summer exacerbates children 's risk for excessive weight gain and increased body fat development . PURPOSE The purpose of this study was twofold : ( 1 ) to determine if summer and follow-up interventions reduce adiposity in Latina girls ; ( 2 ) to assess if such interventions reduce adiposity in Latina girls after controlling for their mothers ' adiposity measures . DESIGN This study had a non-experimental ( one-group pre- and multiple post-intervention assessment ) design . Following a 4-week healthy-lifestyle summer program , each mother-daughter pair participated in 12 weekly follow-up sessions . SETTING / PARTICIPANTS The sample consisted of 61 pairs of Latina girls and their mothers ( N=122 ) . Daughters ' average age was 10.9 years ( ± 1.6 years ) and mothers ' average age was 38.0 years ( ± 1.6 years ) . All daughters and 92 % of the mothers were categorized as overweight/obese . MAIN OUTCOME MEASURES Percent body fat ( % BF ) , abdominal fat , and height and weight measurements to calculate BMI were conducted at pre-intervention ( M1 [ baseline ] ) and three post-intervention time points ( M2 [ Month 2 ] ; M3 [ Month 3 ] ; and M4 [ Month 6 ] ) . Paired sample t-tests were used to assess the differences in adiposity among the daughters from M1 to M4 . Repeated- measures ANCOVA tests were used to control for mother 's adiposity . RESULTS Reductions of % BF ( p<0.001 ) ; abdominal fat ( p<0.05 ) ; and BMI ( p<0.001 ) at M2 were found for the summer intervention , but no effects were found at M4 . Maternal % BF , abdominal fat , and BMI did not have an impact on the daughters ' adiposity indicators . CONCLUSIONS Results from this study revealed that a summer intervention appears to be effective in reducing adiposity in Latina girls , but the follow-up sessions did not result in sustaining continued reductions . Maternal measures did not influence their daughters ' adiposity measures 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 Participation in a st and ard-length outpatient cardiac rehabilitation program ( CRP ) for 3 months is known to result in positive changes in body composition , functional capacity , and blood lipids in patients with coronary artery disease . However , there has been little attempt to compare patients who remain active in a formal CRP for an extended length of > 1 year with patients who exit after a st and ard length of 3 months . Consequently , 50 patients underwent a series of tests including a maximal grade d exercise treadmill test , assessment of body composition , and  fasting blood lipid analysis  , at entry to CRP and after a follow-up period that ranged from 1 to 5 years . All patients participated in a st and ard multidisciplinary cardiac rehabilitation program for 3 months . Twenty-five patients discontinued participation after 3 months and received no other contact from the program staff until follow-up , whereas 25 patients remained active in the program until follow-up . After statistically adjusting for baseline differences between the groups , significant differences were observed between the extended- and st and ard-length groups at follow-up for body weight ( 177 vs 183 lbs ) , percent fat ( 22 % vs 24 % ) , METS ( 10.5 vs 8.4 ) , high-density lipoprotein level cholesterol ( 44 vs 39 mg/dl ) , total cholesterol/high-density lipoprotein ratio ( 5.2 vs 6.1 ) , and triglycerides ( 134 vs 204 mg/dl ) , respectively . No significant differences in the adjusted means were observed between the groups at follow-up for total cholesterol ( 209 vs 219 mg/dl ) and low-density lipoprotein cholesterol ( 136 vs 138 mg/dl ) . Data from this study demonstrate the efficacy of extended participation in CRP on body composition , functional capacity , and blood lipids . Greater efforts need to be directed at retaining patients in low-cost , center-based maintenance programs and at extending monitoring of patients exiting st and ard length CRPs Summary All male inhabitants of the city of Göteborg , who were born between 1915–1922 and 1924–1925 were included in the trial , and were 47 to 55 years of age on entry to the study in 1970 to 1973 . One-third of these men were r and omly allocated to an intervention group , whilst the other two-thirds acted as controls  . Men of all social classes , employed as wellas unemployed , health conscious as well as careless , were invited , with 75 % of these responding to the invitation . The intervention group contained 10,000 men and the control group 20,000 men . The intervention group were given advice on diet , both individually and in groups , the type of advice depending upon serum cholesterol level . Smokers were advised to stop smoking , and men with elevated blood pressure were treated with antihypertensive drugs . Due to the large size of the groups and because they formed a r and om population sample , it was assumed that they had similar characteristics at the start of the trial . Risk factors were only measured in the intervention group at this time , followed by intervention . This design feature solved several ethical problems with regard to no treatment in the control group . These men were , however , subjected to health examinations and treatment as well as general health advice . Risk factor levels were measured in the intervention group , and also in r and om sub sample s ( 11 % ) of the control group after 4 and 10 years . Serum cholesterol , blood pressure and smoking decreased among men in both groups , and only slightly more in the intervention group . Antihypertensive drug treatment was given to 26 % of the intervention group and 20 % of the control group participants after 10 years . No significant effect on total or cardiovascular mortality , or on the incidence of myocardial infa rct ion or stroke was found . However , the effect of this intensive antihypertensive treatment on mortality and morbidity is indicated when the present results are compared to those of a previous population study in the same city . A markedly higher mortality in the group of non- participants diluted the results considerably , and some characteristics of this group will be discussed in view of future possibilities of prevention efforts in the whole community The study was set up to evaluate the long-term effects on mortality of a comprehensive rehabilitation and secondary prevention programme lasting 3 years after acute myocardial infa rct ion . The study group consisted of 375 consecutive , non-selected patients under 65 years of age r and omly allocated to an intervention group ( 188 patients ) or a control group ( 187 patients ) . After 15 years follow-up significantly lower incidence of sudden death ( 16.5 % vs 28.9 % , P = 0.006 ) and coronary mortality ( 47.9 % vs 58.5 % , P = 0.04 ) were seen in the intervention group compared with controls . Total mortality was 64.4 % and 66.8 % , respectively ( ns ) . The incidence of cancer death was 16 in the intervention group and three in the controls . Cardiac failure , enlarged heart , New York Heart Association functional class II or more and membership in the control group were significantly associated with coronary mortality during the first 3 years , and after 3 years enlarged heart , diabetes and reinfa rct ion were associated with late coronary death . Thus , comprehensive multifactorial intervention after acute myocardial infa rct ion had favourable long-term effects on coronary mortality and sudden death but no effect on total mortality BACKGROUND Secondary prevention is not adequately implemented after myocardial infa rct ion ( MI ) . We assessed the effect on quality of care and prognosis of a long-term , relatively intensive rehabilitation strategy after MI . METHODS We conducted a multicenter , r and omized controlled trial in patients following st and ard post-MI cardiac rehabilitation  , comparing a long-term , reinforced , multifactorial educational and behavioral intervention with usual care . A total of 3241 patients with recent MI were r and omized to a 3-year multifactorial continued educational and behavioral program ( intervention group ; n = 1620 ) or usual care ( control group ; n = 1621 ) . The combination of cardiovascular ( CV ) mortality , nonfatal MI , nonfatal stroke , and hospitalization for angina pectoris , heart failure , or urgent revascularization procedure was the primary end point . Other end points were major CV events , major cardiac and cerebrovascular events , lifestyle habits , and drug prescriptions . RESULTS End point events occurred in 556 patients ( 17.2 % ) . Compared with usual care , the intensive intervention did not decrease the primary end point significantly ( 16.1 % vs 18.2 % ; hazard ratio [ HR ] , 0.88 ; 95 % confidence interval [ CI ] , 0.74 - 1.04 ) . However , the intensive intervention decreased several secondary end points : CV mortality plus nonfatal MI and stroke ( 3.2 % vs 4.8 % ; HR , 0.67 ; 95 % CI , 0.47 - 0.95 ) , cardiac death plus nonfatal myocardial infa rct ion ( 2.5 % vs 4.0 % ; HR , 0.64 ; 95 % CI , 0.43 - 0.94 ) , and nonfatal MI ( 1.4 % vs 2.7 % ; HR , 0.52 ; 95 % CI , 0.31 - 0.86 ) . A marked improvement in lifestyle habits ( ie , exercise , diet , psychosocial stress , less deterioration of body weight control ) and in prescription of drugs for secondary prevention was seen in the intervention group . CONCLUSION The GOSPEL Study is the first trial to our knowledge to demonstrate that a multifactorial , continued reinforced intervention up to 3 years after rehabilitation following MI is effective in decreasing the risk of several important CV outcomes , particularly nonfatal MI , although the overall effect is small . TRIAL REGISTRATION Clinical Trials.gov Identifier : NCT00421876 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 BACKGROUND The number of patients aged 75 + years with cardiovascular diseases ( CVD ) is increasing , but few studies of secondary prevention in this age group exist . The aim of the Drug and Evidence Based Medicine in the Elderly ( DEBATE ) study is to test the applicability and effectiveness of established CVD treatments in elderly patients . METHODS From 1998 to 2000 , population -based postal surveys were performed in Helsinki , Finl and , including the age groups 75 , 80 , 85 , 90 , and 95 years ( n = 4821 ) . Of the 812 individuals reporting any atherosclerotic disease , 400 patients ( 66 % of those eligible ) were included in a r and omized trial . In the intervention group , CVD treatments will be individualized according to current guidelines . A control group will receive the usual care . The trial period will last 2 years with a 3-year extension . The primary end point will be a composite of major CVD . In addition , a number of secondary end points will be recorded , including permanent institutionalization , decline in cognitive and physical function , and quality of life . RESULTS During 2000 , 400 home-dwelling patients were r and omized to the intervention ( n = 199 ) and control ( n = 201 ) groups . The mean age is 80.2 years and 65.3 % are women . Of the participants , 82 % have coronary heart disease ( 41 % with history of myocardial infa rct ion ) , 37 % history of stroke , 19 % non-insulin-dependent diabetes mellitus , and 45 % hypertension , and 6 % are current smokers . Before r and omization , 67 % used aspirin , 40 % b-blockers , 14 % angiotensin-converting enzyme inhibitors , 36 % nitrates , and 20 % lipid-lowering drugs . The groups were well balanced at baseline . CONCLUSION We have successfully r and omized elderly patients with a high degree of comorbidity into a multifactorial CVD prevention trial Background Cardiac rehabilitation programmes are a proven treatment for individuals with recent myocardial infa rct ion , result ing in reduced morbidity and mortality compared to usual care . Unfortunately , following completion of a cardiac rehabilitation programme , risk factors and lifestyle behaviours may deteriorate . The GlObal Secondary Prevention strategiEs to Limit event recurrence after myocardial infa rct ion ( GOSPEL ) study investigates the benefits of a programme of continued educational and behavioural interventions to achieve optimal long-term secondary prevention goals . Design This will be a multicentre , r and omized , controlled study carried out in 78 Italian cardiac rehabilitation centres . Methods After completion of an initial cardiac rehabilitation programme , patients with recent ( <3 months ) myocardial infa rct ion were r and omized to either a long-lasting ( over 3 years ) multifactorial continued educational and behavioural programme ( intensive approach ) or usual care ( control ) group . Intensive approach patients participated in extensive cardiac rehabilitation sessions , monthly from months 1 to 6 , then every 6 months for 3 years . Each session consisted of aerobic exercise , comprehensive lifestyle and risk factor counselling , and clinical assessment Usual care patients returned to their family physicians ’ care , and attended the reference centre only for the 6-month and then annual scheduled assessment . The efficacy of the two different strategies will be evaluated in terms of morbidity and mortality as primary endpoint . Results From January 2001 through December 2002 , 3241 patients were enrolled . Results will be available in mid 2006 . Conclusions The GOSPEL trial , the rationale and design of which we present here , was design ed to test a new strategy of secondary prevention delivery and to raise st and ards of long-term secondary prevention in Italy . With a cohort of over 3200 patients , GOSPEL is the largest r and omized , multifactorial lifestyle and risk factor intervention trial after myocardial infa rct ion conducted so far AIM Previous studies have reported lifestyle and risk factor deterioration following completion of a cardiac rehabilitation program ( CRP ) . We report the results of a one-year Extensive Lifestyle Management Intervention ( ELMI ) aim ed at preventing these adverse changes . METHODS AND RESULTS A total of 302 men and women with ischaemic heart disease were recruited following completion of a CRP and r and omized to either the  ELMI  ( consisting of exercise sessions , telephone follow-ups and risk factor and lifestyle counselling ) or  usual care . The primary outcome was global cardiovascular risk using the Framingham and Procam risk scores . Secondary outcomes included risk factors and lifestyle behaviours . Baseline characteristics were similar between the two groups . Adherence to the ELMI was high . There was a non-significant trend in favour of the ELMI between for both the Framingham ( 6.6+/-3.1 to 6.2+/-2.9 vs 6.6+/-3.2 to 6.7+/-3.2 , P=0.138 ) and Procam ( 20.0+/-20.0 to 20.6+/-19.5 vs 19.1+/-18.7 to 21.8+/-19.1 , P=0.089 ) scores . There were no differences in secondary outcomes . CONCLUSIONS A one-year multi-factorial post-CRP intervention results in modest , non-significant benefits to global risk compared to usual care . The absence of deterioration in the usual care group may be due to improved practice s in usual care Background Cardiac rehabilitation includes interventions aim ed at facilitating physical , psychological and emotional recovery following the acute phase of myocardial infa rct ion ( AMI ) . To date , optimal cardiac rehabilitation program duration and frequency of patient contact has yet to be identified . Objective The present study was performed to evaluate the effects of two different strategies of secondary prevention ( 2 years , multifactorial continued educational and behavioral intervention versus usual care ) implemented into a cardiac rehabilitation setting on several cardiovascular endpoints indicating cardiovascular functional exercise capacity and coronary risk profile in patients with recent AMI . Methods This was a prospect i ve r and omized study including 52 postinfa rct ion patients . Initially , all patients were enrolled in a 3-month outpatient cardiac rehabilitation program .  Thereafter , they were r and omly subdivided into two groups ( I = intervention group ; C = control group ) , each composed of 26 patients , and followed for 24 months . Results At the end of the 3-month outpatient cardiac rehabilitation program , both groups showed a significant ( P < 0.05 ) improvement in cardiopulmonary parameters ( maximal oxygen consumption , maximal workload ) and in cardiovascular risk profile ( BMI , lipid profile ) . During the 24-month study period , group I showed stabilization or even improvement ( P < 0.05 ) of both cardiopulmonary parameters and cardiovascular risk profile , whereas group C patients showed a deterioration or significant impairment ( P < 0.05 ) of the same parameters . Clinical events occurred in 27 % of patients in the control group ( n = 7 ) and in 11 % in the training group ( n = 3 ) ( P < 0.05 ) . Conclusion Long-term , multifactorial educational and behavioral intervention maintained for 2 years in a multicomprehensive cardiac rehabilitation setting represents a valid strategy for improving long-term cardiovascular functional capacity and cardiovascular risk profile in postinfa rct ion patients BACKGROUND Data on the long-term benefits of nonspecific disease management programs are limited . We performed a long-term follow-up of a previously published r and omized trial . METHODS We compared all-cause mortality and recurrent hospitalization during median follow-up of 7.5 years in a heterogeneous cohort of patients with chronic illness initially exposed to a multidisciplinary , home-based intervention ( HBI ) ( n = 260 ) or to usual postdischarge care ( n = 268 ) . RESULTS During follow-up , HBI had no impact on all-cause mortality ( relative risk , 1.04 ; 95 % confidence interval , 0.80 - 1.35 ) or event-free survival from death or unplanned hospitalization ( relative risk , 1.03 ; 95 % confidence interval , 0.86 - 1.24 ) . Initial analysis suggested that HBI had only a marginal impact in reducing unplanned hospitalization , with 677 readmissions vs 824 for the usual care group ( mean + /- SD rate , 0.72 + /- 0.96 vs 0.84 + /- 1.20 readmissions/patient per year ; P = .08 ) . When accounting for increased hospital activity in  HBI patients with chronic obstructive pulmonary disease during follow-up for 2 years , post hoc analyses showed that HBI reduced readmissions by 14 % within 2 years in patients without this condition ( mean + /- SD rate , 0.54 + /- 0.72 vs 0.63 + /- 0.88 readmission/patient per year ; P = .04 ) and by 21 % in all surviving patients within 3 to 8 years ( mean + /- SD rate , 0.64 + /- 1.26 vs 0.81 + /- 1.61 readmissions/patient per year ; P = .03 ) . Overall , recurrent hospital costs were significantly lower ( 14 % ) in the HBI group ( mean + /- SD , 823 dollars + /- 1642 dollars vs 960 dollars + /- 1376 dollars per patient per year ; P = .045 ) . CONCLUSION This unique study suggests that a nonspecific HBI provides long-term cost benefits in a range of chronic illnesses , except for chronic obstructive pulmonary disease In a r and omised controlled evaluation of multifactorial prevention of coronary heart disease ( CHD ) among 60 881 men employed in 80 factories in Belgium , Italy , Pol and , and the UK intervention was associated with reductions of 10.2 % in total CHD , 6.9 % in fatal CHD , 14.8 % in non-fatal myocardial infa rct ion , and 5.3 % in total deaths , with a neutral result for non-CHD deaths . Benefit was significantly related to the extent of risk factor change . The observed reduction in total CHD was 62 % of that predicted by means of a multiple logistic function summary of risk factor changes . Advice on risk factor reduction in middle-aged men is effective to the extent that it is accepted and it appears to be safe OBJECTIVE We aim ed to examine whether better use of preventive methods and treatments of cardiovascular disease would reduce recurrent events in home-dwelling patients 75 years or older . METHODS This was a r and omized , controlled trial ( a practical clinical trial , the DEBATE ) , conducted in 2000 to 2003 in Helsinki , Finl and . We recruited 400 vascular patients with mean age of 80 years from the community , and they were r and omly assigned to the intervention group ( n = 199 ) where both nonpharmacological and pharmacological cardiovascular treatments were optimized by a geriatrician according to current guidelines . The control group ( n = 201 ) received the usual care . Main outcome measures were major cardiovascular disease events and total mortality and changes in risk factors and medications . RESULTS The groups were balanced at baseline . Mean duration of follow-up was 3.4 years . At 3 years , drug treatments had become more evidence -based in the intervention group . Consequently , total and low-density lipoprotein cholesterol levels ( P < .0001 ) and systolic ( P = .005 ) and diastolic ( P = .009 ) blood pressure were significantly improved in the intervention group . However , neither primary end points ( 52 and 53 events in the intervention and control groups , respectively ) nor total mortality ( 36 and 35 deaths ) were significantly different between the two groups . No special adverse effects were encountered . CONCLUSION It was possible and safe to institute evidence -based cardiovascular treatments and improve risk factors in patients 75 years or older in a pragmatic setting . During 3.4 years , however , this was not converted to clinical benefits 375 consecutive patients below 65 years who had an acute myocardial infa rct ion ( AMI ) took part in a r and omised rehabilitation and secondary prevention trial ( part of a W.H.O.-coordinated project ) design ed to study the effects of a multifactorial intervention programme on morbidity , mortality , return to work , & c. After three years ' follow-up the cumulative coronary mortality was significantly smaller in the intervention group than in the controls ( 18.6 % versus 29.4 % , p = 0.02 ) . This difference was mainly due to a reduction of sudden deaths in the intervention group ( 5.8 % versus 14.4 % , p less than 0.01 ) . The reduction was greatest during the first six months after AMI . 18.1 % in the intervention group and 11.2 % in the controls ( p less than 0.10 ) presented with non-fatal reinfa rct ions . The number of patients with new Q-QS findings at the end of the three years was , however , almost the same in both groups . The results suggest that organised aftercare during the first six months after AMI with special emphasis on optimum medical control and health education contributes significantly to a reduction in the number of sudden deaths
target: Multifactorial lifestyle interventions aim ed at improving modifiable risk factors in patients with established CHD reduce the risk for fatal cardiovascular events .
  Therefore , they may have added value in secondary prevention of CHD
background: CONTEXT Coronary heart disease ( CHD ) is responsible for about 15 % of all deaths worldwide and is identified as a top priority for decision makers .
  Both primary and secondary prevention are considered key strategies in the prevention of CHD .
  The aim of this study was to assess the efficacy of nonpharmacologic interventions with multiple lifestyle components in patients with established CHD in comparison to usual care .