Secondary Prevention Program May Reduce Risks After Heart Attack

An intensive, comprehensive, long-term secondary prevention program lasting up to three years after cardiac rehabilitation appears to reduce the risk of a second non-fatal heart attack and other cardiovascular events, according to a report in the November 10 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Cardiac rehabilitation programs after a heart disease diagnosis have evolved over two decades from solely exercise-based interventions, according to background information in the article. Now, rehabilitation includes helping patients with smoking cessation, diet, risk factors, and lifestyle habits. However, current rehabilitation procedures rely on short-term interventions that are unlikely to yield long-term benefits because patients never reach therapeutic goals.

Pantaleo Giannuzzi, M.D., of the Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy, and colleagues conducted the Global Secondary Prevention Strategies to Limit Event Recurrence After Myocardial Infarction (GOSPEL) study, in which they randomly assigned 1,620 patients who had a heart attack to receive a long-term, reinforced, multifactorial educational and behavioral intervention after a standard period of rehabilitation.

“The intervention was aimed at individualizing risk factor and lifestyle management, and pharmacological treatments were based on current guidelines,” the authors write. Comprehensive sessions with one-on-one support were held monthly for six months, then once every six months for three years. Results of patients in this program were compared with those of 1,621 who were randomly assigned to receive usual care.

Overall, 556 patients (17.2 percent) experienced a cardiovascular event. The intervention did not significantly reduce the risk of combined heart events (which occurred in 261 [16.1 percent] of patients in the intervention group and 295 [18.2 percent] in the usual care group), including cardiovascular death, non-fatal heart attack, non-fatal stroke and hospitalization for chest pain, heart failure or an urgent revascularization procedure to restore blood flow. However, the program did significantly decrease incidence of individual heart events and some combinations of outcomes, including a 33 percent reduction in cardiovascular death plus non-fatal heart attack and stroke (3.2 percent in the intervention group vs. 4.8 percent in the usual care group), a 36 percent reduction in cardiac death plus non-fatal heart attack (2.5 percent vs. 4 percent) and a 48 percent reduction in non-fatal heart attack (1.4 percent vs. 2.7 percent).

“A marked improvement in lifestyle habits (i.e., exercise, diet, psychosocial stress, less deterioration of body weight control) and in prescription of drugs for secondary prevention was seen in the intervention group,” the authors write.

“After three years, the integrated, multifactorial, reinforced approach proved effective in countering the risk factors and medication adherence deterioration over time and was able to induce a considerable improvement in lifestyle habits,” the authors conclude. “In line with such results, all the clinical end points were reduced by the intensive intervention.” The results reinforce previous findings that gains achieved with short-term cardiac rehabilitation are not maintained over time and suggest that a more comprehensive, sustained intervention is needed to reduce cardiovascular risks after a heart attack.(Arch Intern Med. 2008;168[20]:2194-2204. Available pre-embargo to the media at jamamedia.org.)