Secondary prevention clinics for coronary heart disease: Four year follow up of a randomised controlled trial in primary care

Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Aberdeen AB25 2AY, UK.
BMJ (online) (Impact Factor: 17.45). 02/2003; 326(7380):84.
Source: PubMed


To evaluate the effects of nurse led clinics in primary care on secondary prevention, total mortality, and coronary event rates after four years.
Follow up of a randomised controlled trial by postal questionnaires and review of case notes and national datasets.
Stratified, random sample of 19 general practices in north east Scotland.
1343 patients (673 intervention and 670 control) under 80 years with a working diagnosis of coronary heart disease but without terminal illness or dementia and not housebound. Intervention: Nurse led secondary prevention clinics promoted medical and lifestyle components of secondary prevention and offered regular follow up for one year.
Components of secondary prevention (aspirin, blood pressure management, lipid management, healthy diet, exercise, non-smoking), total mortality, and coronary events (non-fatal myocardial infarctions and coronary deaths).
Mean follow up was at 4.7 years. Significant improvements were shown in the intervention group in all components of secondary prevention except smoking at one year, and these were sustained after four years except for exercise. The control group, most of whom attended clinics after the initial year, caught up before final follow up, and differences between groups were no longer significant. At 4.7 years, 100 patients in the intervention group and 128 in the control group had died: cumulative death rates were 14.5% and 18.9%, respectively (P=0.038). 100 coronary events occurred in the intervention group and 125 in the control group: cumulative event rates were 14.2% and 18.2%, respectively (P=0.052). Adjusting for age, sex, general practice, and baseline secondary prevention, proportional hazard ratios were 0.75 for all deaths (95% confidence intervals 0.58 to 0.98; P=0.036) and 0.76 for coronary events (0.58 to 1.00; P=0.049)
Nurse led secondary prevention improved medical and lifestyle components of secondary prevention and this seemed to lead to significantly fewer total deaths and probably fewer coronary events. Secondary prevention clinics should be started sooner rather than later.

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    • "Moderate to large effect sizes have been reported in studies that investigated secondary prevention strategies included in the nurse practitioner intervention, such as guidelinebased care and nurse case management on lipids, diet and exercise (e.g., Allen et al., 2002; DeBusk et al., 1994; Goessens et al., 2006; Murchie et al., 2003). To account for an anticipated 10% attrition rate 6 additional participants (3 in each group) were recruited, for a total of 66 (33 in each group). "
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    ABSTRACT: Background Patients with acute myocardial infarction (AMI) are at high risk for reinfarction and death. Therapies that have been shown to reduce these risks (secondary prevention) continue to be underutilized. Nurse practitioners are well positioned to provide secondary prevention during and following hospitalization Objectives The purpose of this study was to evaluate the effects of NP care on the rate of provider implementation and patient achievement of evidence-based secondary prevention target goals. Design A prospective cohort design was used, which compared achievement of target goals between patients who received secondary prevention care from an NP to those who received usual care. Participants The sample consisted of 65 patients with AMI, admitted to a large community hospital. Patients meeting eligibility criteria were recruited consecutively Methods The intervention was delivered by the NP before discharge from hospital and one week, two weeks, six weeks and 3 months after discharge. Data on patients’ achievement of goals were obtained before discharge from hospital and 3 months after discharge from both groups. Results This study's results provide preliminary evidence that an NP delivered secondary prevention intervention can significantly improve achievement of the following target goals when compared to usual care: smoking cessation (OR 5), blood pressure (OR 15), attendance at cardiac rehabilitation (OR 7), physical activity five days a week (OR 17), physical activity ≥ five days a week (OR 34), achieving a glycated hemoglobin < 7% in those with diabetes (OR 10), triglyceride levels (p = 02), statin use at follow-up (p = .05), and number of weeks to cardiac rehabilitation (p .05). Conclusion NP-led interventions such as this warrant duplication to evaluate reproducibility of the intervention and to determine if short-term improvements in secondary prevention goals translate into morbidity and mortality benefits.
    The Canadian journal of cardiology 12/2014; 51(12). DOI:10.1016/j.ijnurstu.2014.04.004 · 3.71 Impact Factor
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    • "Patients need clear, consistent information. Regular review is associated with improved uptake of secondary prevention [29,33]. Regular monitoring of individuals’ lifestyles may give professionals opportunities to identify difficulties patients are experiencing and facilitate lifestyle change. "
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    ABSTRACT: Healthy lifestyles help to prevent coronary heart disease (CHD) but outcomes from secondary prevention interventions which support lifestyle change have been disappointing. This study is a novel, in-depth exploration of patient factors affecting lifestyle behaviour change within an intervention designed to improve secondary prevention for patients with CHD in primary care using personalised tailored support. We aimed to explore patients' perceptions of factors affecting lifestyle change within a trial of this intervention (the SPHERE Study), using semi-structured, one-to-one interviews, with patients in general practice. Interviews (45) were conducted in purposively selected general practices (15) which had participated in the SPHERE Study. Individuals, with CHD, were selected to include those who succeeded in improving physical activity levels and dietary fibre intake and those who did not. We explored motivations, barriers to lifestyle change and information utilised by patients. Data collection and analysis, using a thematic framework and the constant comparative method, were iterative, continuing until data saturation was achieved. We identified novel barriers to lifestyle change: such disincentives included strong negative influences of social networks, linked to cultural norms which encouraged consumption of 'delicious' but unhealthy food and discouraged engagement in physical activity. Findings illustrated how personalised support within an ongoing trusted patient-professional relationship was valued. Previously known barriers and facilitators relating to support, beliefs and information were confirmed. Intervention development in supporting lifestyle change in secondary prevention needs to more effectively address patients' difficulties in overcoming negative social influences and maintaining interest in living healthily.
    BMC Family Practice 08/2013; 14(1):126. DOI:10.1186/1471-2296-14-126 · 1.67 Impact Factor
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    • "However, the mortality figures were combined with nonfatal MI to calculate a proportional hazard ratio. Murchie et al. [36], a paper from the same study at 4.7 years of follow-up, reported an adjusted hazard ratio of 0.76 for coronary events (coronary deaths plus nonfatal MIs) (0.58 to 1.00, P = .049). "
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    ABSTRACT: The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease (CHD) remains unclear. This systematic review aimed to determine their effectiveness and included randomized controlled trials of lifestyle interventions, in primary care or community settings, with a minimum follow-up of three months, published since 1990. 21 trials with 10,799 patients were included; the interventions were multifactorial (10), educational (4), psychological (3), dietary (1), organisational (2), and exercise (1). The overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes but no overall effect on smoking outcomes. In trials that examined mortality and morbidity, significant benefits were reported for total mortality (in 4 of 6 trials; overall risk ratio (RR) 0.75 (95% confidence intervals (CI) 0.65, 0.87)), cardiovascular mortality (3 of 8 trials; overall RR 0.63 (95% CI 0.47, 0.84)), and nonfatal cardiac events (5 of 9 trials; overall RR 0.68 (95% CI 0.55, 0.84)). The heterogeneity between trials and generally poor quality of trials make any concrete conclusions difficult. However, the beneficial effects observed in this review are encouraging and should stimulate further research.
    Cardiology Research and Practice 01/2011; 2011(3):232351. DOI:10.4061/2011/232351
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