The prognostic value of heart rate recovery in patients with coronary artery disease: A systematic review and meta-analysis.

BACKGROUND: Routine outpatient care of patients with coronary artery disease (CAD) lacks a simple measure of physical fitness and risk of mortality. Heart rate recovery (HRR) is noninvasive and easily obtainable in outpatient settings. Prior studies have suggested that delayed postexercise HRR in the first minutes is associated with mortality in several types of populations. However, a comprehensive overview of the prognostic value of delayed HRR for time to mortality specifically in CAD patients is not available. The purpose of the current meta-analysis is to evaluate the prognostic value of delayed HRR in CAD patients. METHODS: We conducted a systematic search in OVID MEDLINE and OVID EMBASE to identify studies reporting on HRR and risk of incident cardiovascular events or mortality in CAD patients. Hazard ratios for delayed versus nondelayed HRR were pooled using random-effects meta-analysis. RESULTS: Four studies were included, comprising 2,428 CAD patients. The study quality of the included studies was rated moderate (n = 2) to high (n = 2). Delayed HRR was defined by ≤12 to ≤21 beat/min in the recovery period. During follow-up (range 2.0-9.8 years), 151 patients died (6.2% [range 2.5%-19.5%]). Only data on mortality could be pooled. Heterogeneity was limited (I2 = 32%; P = .23); pooled unadjusted hazard ratio for mortality, based on 3 studies, was 5.8 (95% CI 3.2-10.4). CONCLUSIONS: In CAD patients, delayed HRR is significantly associated with all-cause mortality. As exercise testing is performed routinely in CAD patients, HRR can be considered in monitoring exercise; still, further research must investigate the addition of HRR in current risk scores.

Community-based comprehensive lifestyle programs in patients with coronary artery disease: Objectives, design and expected results of Randomized Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2 trial (RESPONSE 2).

UNLABELLED: Patients with coronary artery disease (CAD) are at high risk of recurrent events. A healthy lifestyle can significantly reduce this risk. A previous trial, Randomized Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists (RESPONSE), demonstrated that nurse-coordinated outpatient clinics improve drug treatment of cardiovascular risk factors. However, lifestyle-related risk factors, including smoking, overweight, and physical inactivity, were common and remained largely unchanged at follow-up in most patients (66%). The aim of the current study is to evaluate the impact of 3 community-based lifestyle programs in patients after hospitalization for CAD. We are conducting a multicenter (n = 15), randomized trial that will recruit 800 patients to test the efficacy of up to 3 widely available commercial lifestyle programs, aimed at patients and their partners, on top of usual care. These programs are aimed at smoking cessation (Luchtsignaal(®)), weight loss (Weight Watchers(®)), and improving physical activity (Philips DirectLife(®)). OUTCOMES: The primary outcome at 12months is the proportion of patients in whom at least 1 lifestyle risk factor is improved without deterioration in any of the other 2, and a relative increase of at least 30% in this proportion is considered clinically relevant.

Weight management and determinants of weight change in patients with coronary artery disease.

OBJECTIVE: To study the effects of a comprehensive secondary prevention programme on weight loss and to identify determinants of weight change in patients with coronary artery disease (CAD). METHODS: We performed a secondary analysis focusing on the subgroup of overweight CAD patients (BMI ≥27 kg/m2) in the Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists-2 (RESPONSE-2) multicentre randomised trial. We evaluated weight change from baseline to 12-month follow-up; multivariable logistic regression with backward elimination was used to identify determinants of weight change. RESULTS: Intervention patients (n=280) lost significantly more weight than control patients (n=257) (-2.4±7.1 kg vs -0.2±4.6 kg; p<0.001). Individual weight change varied widely, with weight gain (≥1.0 kg) occurring in 36% of interventions versus 41% controls (p=0.21). In the intervention group, weight loss of ≥5% was associated with higher age (OR 2.94), lower educational level (OR 1.91), non-smoking status (OR 2.92), motivation to start with weight loss directly after the baseline visit (OR 2.31) and weight loss programme participation (OR 3.33), whereas weight gain (≥1 kg) was associated with smoking cessation ≤6 months before or during hospitalisation (OR 3.21), non-Caucasian ethnicity (OR 2.77), smoking at baseline (OR 2.70), lower age (<65 years) (OR 1.47) and weight loss programme participation (OR 0.59). CONCLUSION: The comprehensive secondary prevention programme was, on average, effective in achieving weight loss. However, wide variation was observed. As weight gain was observed in over one in three participants in both groups, prevention of weight gain may be as important as attempts to lose weight. TRIAL REGISTRATION NUMBER: NTR3937.

Lifestyle modification in older versus younger patients with coronary artery disease.

OBJECTIVE: To compare the treatment effect on lifestyle-related risk factors (LRFs) in older (≥65 years) versus younger (<65 years) patients with coronary artery disease (CAD) in The Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2 (RESPONSE-2) trial. METHODS: The RESPONSE-2 trial was a community-based lifestyle intervention trial (n=824) comparing nurse-coordinated referral with a comprehensive set of three lifestyle interventions (physical activity, weight reduction and/or smoking cessation) to usual care. In the current analysis, our primary outcome was the proportion of patients with improvement at 12 months follow-up (n=711) in ≥1 LRF stratified by age. RESULTS: At baseline, older patients (n=245, mean age 69.2±3.9 years) had more adverse cardiovascular risk profiles and comorbidities than younger patients (n=579, mean age 53.7±6.6 years). There was no significant variation on the treatment effect according to age (p value treatment by age=0.45, OR 1.67, 95% CI 1.22 to 2.31). However, older patients were more likely to achieve ≥5% weight loss (OR old 5.58, 95% CI 2.77 to 11.26 vs OR young 1.57, 95% CI 0.98 to 2.49, p=0.003) and younger patients were more likely to show non-improved LRFs (OR old 0.38, 95% CI 0.22 to 0.67 vs OR young 0.88, 95% CI 0.61 to 1.26, p=0.01). CONCLUSION: Despite more adverse cardiovascular risk profiles and comorbidities among older patients, nurse-coordinated referral to a community-based lifestyle intervention was at least as successful in improving LRFs in older as in younger patients. Higher age alone should not be a reason to withhold lifestyle interventions in patients with CAD.

Smoking cessation after nurse-coordinated referral to a comprehensive lifestyle programme in patients with coronary artery disease: a substudy of the RESPONSE-2 trial.

OBJECTIVE: The objective of this study was to investigate the characteristics of successful quitters, their use of a smoking cessation programme and the use of other lifestyle interventions to improve lifestyle-related risk factors, within a nurse-coordinated care programme. METHODS: We used data from the multicentre randomised controlled RESPONSE-2 trial ( n=824, The Netherlands). The trial was designed to assess the efficacy of nurse-coordinated referral to a comprehensive set of up to three community-based interventions, based on smoking cessation, healthy food choices and physical activity to improve lifestyle-related risk factors in coronary artery disease patients, compared to usual care. Smoking status was assessed using urinary cotinine at baseline and 12 months follow-up. RESULTS: At 12 months follow-up, there was no statistically significant difference in cessation rates (50% intervention group vs. 46% usual care group, P=0.45). The majority of successful quitters in both groups quit immediately after hospitalisation (72% intervention group vs. 86% usual care group, P=0.29). Only 19% of successful quitters in the intervention group participated in the smoking cessation programme. However, successful quitters participated more frequently in other lifestyle programmes compared with persistent smokers (65% vs. 37%, P<0.01). CONCLUSION: The majority of patients who successfully quit smoking are those who quit immediately after hospitalisation, without a need to participate in a smoking cessation programme. Moreover, this programme was attended by only a minority of successful quitters. Successful quitters were motivated to attend other lifestyle programmes addressing healthy food choices and physical activity. Our findings support a tailored, comprehensive approach to lifestyle interventions in the secondary prevention of coronary artery disease.

Impact of physical activity on the risk of cardiovascular disease in middle-aged and older adults: EPIC Norfolk prospective population study.

Background There is broad consensus that regular physical activity yields major health benefits. However, current guidelines on physical activity are mainly aimed at middle-aged adults. It is unclear whether physical activity also translates into cardiovascular health benefits in older adults. Therefore, we aimed to compare the association between different levels of physical activity and the risk of cardiovascular disease (CVD) in elderly to middle-aged individuals. Methods We analysed data from the EPIC Norfolk prospective population study. Cox proportional hazards models were used to analyse the association between physical activity levels and time to CVD events in three age categories (<55, 55-65 and >65 years). Interaction between age categories and physical activity levels was assessed. Results Analyses were based on 24,502 study participants aged 39-79 years. A total of 5240 CVD events occurred during 412,954 person-years follow-up (median follow-up was 18.0 years). Among individuals aged over 65 years, hazard ratios for CVD were 0.86 (95% confidence interval (CI) 0.78-0.96), 0.87 (95% CI 0.77-0.99) and 0.88 (95% CI 0.77-1.02) in moderately inactive, moderately active and active people, respectively, compared to inactive people. Among people aged 55-65 and less than 55 years, the associations were directionally similar, but not statistically significant. The interaction term between physical activity levels and age categories was not significant ( P = 0.38). Conclusion The inverse association between physical activity and the risk of CVD was significant in elderly and comparable with middle-aged individuals. In addition, we observed that modest levels of physical activity confer benefits in terms of CVD risk, compared to being completely inactive.

Community-Based Lifestyle Intervention in Patients With Coronary Artery Disease: The RESPONSE-2 Trial.

BACKGROUND: Among patients with coronary artery disease (CAD), improvement of lifestyle-related risk factors (LRFs) reduces cardiovascular morbidity and mortality. However, modification of LRFs is highly challenging. OBJECTIVES: This study sought to evaluate the impact of combining community-based lifestyle programs with regular hospital-based secondary prevention. METHODS: The authors performed a randomized controlled trial of nurse-coordinated referral of patients and their partners to 3 widely available community-based lifestyle programs, in 15 hospitals in the Netherlands. Patients admitted for acute coronary syndrome and/or revascularization, with ≥1 LRF (body mass index >27 kg/m2, self-reported physical inactivity, and/or smoking) were included. All patients received guideline-based usual care. The intervention was based on 3 lifestyle programs for weight reduction, increasing physical activity, and smoking cessation. The primary outcome was the proportion of success at 12 months, defined as improvement in ≥1 qualifying LRF using weight (≥5% reduction), 6-min-walking distance (≥10% improvement), and urinary cotinine (200 ng/ml detection limit) without deterioration in the other 2. RESULTS: The authors randomized 824 patients. Complete data on the primary outcome were available in 711 patients. The proportion of successful patients in the intervention group was 37% (133 of 360) compared with 26% (91 of 351) in the control group (p = 0.002; risk ratio: 1.43; 95% confidence interval: 1.14 to 1.78). In the intervention group, partner participation was associated with a significantly greater success rate (46% vs. 34%; p = 0.03). CONCLUSIONS: Among patients with coronary artery disease, nurse-coordinated referral to a comprehensive set of community-based, widely available lifestyle interventions, with optional partner participation, leads to significant improvements in LRFs. (RESPONSE-2: Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2; NTR3937).

Ideal cardiovascular health and risk of cardiovascular events in the EPIC-Norfolk prospective population study.

BACKGROUND: The American Heart Association has prioritised seven cardiovascular health metrics to reduce the cardiovascular burden, including: body mass index, healthy diet, physical activity, smoking status, blood pressure, glycated haemoglobin A1c and total cholesterol. The aim of the current study was to assess the association between the American Heart Association-defined health metrics and the risk of cardiovascular events in the EPIC-Norfolk prospective study. DESIGN: Prospective cohort study. METHODS: An overall cardiovascular health score was calculated based on the number of health metrics including ideal, intermediate or poor. Cox proportional hazards models were used to describe the association of the seven metrics separately and the overall health score with risk of coronary heart disease, stroke and cardiovascular disease. A total of 10,043 participants was included in the analysis (follow-up 1993-2008). For all individual health metrics a more ideal status was associated with a lower risk of cardiovascular events. RESULTS AND CONCLUSION: As for the overall cardiovascular health score, those in the highest (i.e. healthiest) category (score 12-14) had an adjusted hazard ratio for coronary heart disease of 0.07 (95% confidence interval (CI) 0.02-0.29, P < 0.001), for stroke of 0.16 (95% CI 0.02-1.37, P = 0.09) and for cardiovascular disease of 0.07 (95% CI 0.02-0.23, P < 0.001), compared to people in the lowest (i.e. unhealthiest) category (score 0-2). The overall cardiovascular health score was strongly and inversely associated with risk of coronary heart disease, stroke and cardiovascular disease. Our data suggest that even small improvements in modifiable risk factors may lead to substantial reductions in the risks of cardiovascular events.