Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease Designing and implementing a comparative effectiveness study of two strategies for delivering high quality CHD prevention: methods and participant characteristics for the Heart to Health study. The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411] The effect of a smartphone-based coronary heart disease prevention (SBCHDP) programme on awareness and knowledge of CHD, stress, and cardiac-related lifestyle behaviours among the working population in Singapore: a pilot randomised controlled trial Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial Information and Risk Modification Trial (INFORM): design of a randomised controlled trial of communicating different types of information about coronary heart disease risk, alongside lifestyle advice, to achieve change in health-related behaviour Improving coronary heart disease self-management using mobile technologies (Text4Heart): a randomised controlled trial protocol Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease Text Message and Internet Support for Coronary Heart Disease Self-Management: Results From the Text4Heart Randomized Controlled Trial A randomised, feasibility trial of a tele-health intervention for Acute Coronary Syndrome patients with depression ('MoodCare'): Study protocol A Web-Based Program Improves Physical Activity Outcomes in a Primary Care Angina Population: Randomized Controlled Trial Costs of a Community Pharmacist-Led Medicines Management Service for Patients with Coronary Heart Disease in England Randomised controlled trial of a secondary prevention program for myocardial infarction patients ('ProActive Heart'): study protocol. 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Background Lifestyle measures of coronary heart disease ( CHD ) prevention have been overshadowed by the efficacy of drug treatments . This is particularly the case in the setting of secondary prevention where the benefits of lipid lowering , anti-platelet and anti-hypertensive drugs have been emphasised in numerous trials . Lifestyle measures address several CHD risk factors at once and are generally free of serious side effects . Objectives The objective of the present study was to determine whether a comprehensive programme of lifestyle modification could favourably influence dietary and exercise habits in addition to smoking cessation over two years . In addition , an attempt was made to evaluate if this programme could favourably influence the five-year CHD-risk in the male population included in the study . Design A total of 197 patients with proven coronary heart disease were included and r and omised to a lifestyle intervention programme or to usual care . Follow-up was after a period of two years . Methods Intervention comprised a low fat diet , regular exercise , smoking cessation , psychosocial support and education , delivered by nurses on the rationale for pharmacological and lifestyle measures . Usual care comprised follow-up in the routine outpatient clinic . Both groups were given the same comprehensive medication according to recent guidelines . Results Patients in the lifestyle intervention group reduced the intake of saturated fat , sugar and cholesterol ( P<0.001 ) , increased their exercise level ( P<0.01 ) and stopped smoking ( P<0.05 ) when compared with the usual care group . A sub analysis of the influence of five-year CHD calculated risk in males result ed in a relative risk reduction of 22 % ( 95 % confidence intervals 9 - 35 ) . Although significant , this result must be interpreted with caution due to poor statistical power and reproducibility of the method . Conclusions In the presence of modern drug treatments for secondary cardiovascular disease prevention it remains possible through a favourable diet , exercise and smoking cessation to show an additional reduction in the five-year risk for CHD in males BACKGROUND Although lifestyle and medications are effective for coronary heart disease ( CHD ) risk reduction , few studies have examined the comparative effectiveness of various strategies for delivering high quality CHD risk reduction . In this paper , we report on the design and baseline characteristics of participants for just such a trial . METHODS We conducted a r and omized trial of the same lifestyle and medication intervention delivered in two alternate formats : counselor-delivered or web-based . The trial was conducted at 5 diverse practice s in a family medicine research network and included men and women age 35 - 79 who were at high risk of CHD events based on 10-year predicted Framingham risk of ≥10 % or a known history of cardiovascular disease . After individual-level r and omization , participants in both arms received a decision aid plus four intensive intervention visits and 3 maintenance visits over 12 months . The primary outcome was change in 10-year predicted CHD risk among patients without prior cardiovascular disease . Secondary outcomes , measured among all participants , included changes in CHD risk factors , cost-effectiveness , and acceptability at 4 and 12-month follow-up . RESULTS We r and omized 489 eligible patients : 389 without and 100 with a known history of cardiovascular disease . Mean age was 62.3 . 75 % were white , 25 % African-American . 45 % had a college education . 88 % had health insurance . Mean 10-year predicted CHD risk was 16.9 % . CONCLUSION We have successfully recruited a diverse sample of practice s and patients that will provide a rich sample in which to test the comparative effectiveness of two strategies to implement high quality CHD prevention Background The aim of the SPHERE study is to design , implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease ( CHD ) in general practice across two different health systems on the isl and of Irel and .CHD is a common cause of death and a significant cause of morbidity in Irel and . Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives . Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the isl and of Irel and . The review literature recommends structured programmes with continued support and follow-up of patients ; the provision of training , tailored to practice needs of access to evidence of effectiveness of secondary prevention ; structured recall programmes that also take account of individual practice needs ; and patient-centred consultations accompanied by attention to disease management guidelines . Methods SPHERE is a cluster r and omised controlled trial , with practice -level r and omisation to intervention and control groups , recruiting 960 patients from 48 practice s in three study centres ( Belfast , Dublin and Galway ) . Primary outcomes are blood pressure , total cholesterol , physical and mental health status ( SF-12 ) and hospital re-admissions . The intervention takes place over two years and data is collected at baseline , one-year and two-year follow-up . Data is obtained from medical charts , consultations with practitioners , and patient postal question naires . The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice . It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients . General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD . Patients are invited to attend regular four-monthly consultations over two years , during which targets and goals for secondary prevention are set and review ed . The analysis will be strengthened by economic , policy and qualitative components Abstract Background Coronary heart disease ( CHD ) is the most prevalent type of cardiac disease among adults worldwide , including those in Singapore . Most of its risk factors , such as smoking , physical inactivity and high blood pressure , are preventable . mHealth has improved in the last decade , showing promising results in chronic disease prevention and health promotion worldwide . Our aim was to develop and examine the effect of a 4-week Smartphone-Based Coronary Heart Disease Prevention ( SBCHDP ) programme in improving awareness and knowledge of CHD , perceived stress as well as cardiac-related lifestyle behaviours in the working population of Singapore . Methods The smartphone app “ Care4Heart ” was developed as the main component of the programme . App content was review ed and vali date d by a panel of experts , including two cardiologists and two experienced cardiology-trained nurses . A pilot r and omised controlled trial was conducted . Eighty working people were recruited and r and omised to either the intervention group ( n = 40 ) or the control group ( n = 40 ) . The intervention group underwent a 4-week SBCHDP programme , whereas the control group were offered health promotion websites only . The participants ’ CHD knowledge , perceived stress and behavioural risk factors were measured at baseline and on the 4th week using the Heart Disease Fact Question naire-2 , Perceived Stress Scale , and Behavioural Risk Factor Surveillance System . Results After the SBCHDP programme , participants in the intervention group had a better awareness of CHD being the second leading cause of death in Singapore ( X2 = 6.486 , p = 0.039 ) , a better overall CHD knowledge level ( t = 3.171 , p = 0.002 ) , and better behaviour concerning blood cholesterol control ( X2 = 4.54 , p = 0.033 ) than participants in the control group . Conclusion This pilot study partially confirmed the positive effects of the SBCHDP programme in improving awareness and knowledge of CHD among the working population . Due to the small sample size and short follow-up period , this study was underpowered to detect significant differences between groups . A full-scale longitudinal study is required in the future to confirm the effectiveness of the SBCHDP programme Aims : To evaluate the effect of a disease management programme for patients with coronary heart disease ( CHD ) and chronic heart failure ( CHF ) in primary care . Methods : A cluster r and omised controlled trial of 1316 patients with CHD and CHF from 20 primary care practice s in the UK was carried out . Care in the intervention practice s was delivered by specialist nurses trained in the management of patients with CHD and CHF . Usual care was delivered by the primary healthcare team in the control practice s. Results : At follow up , significantly more patients with a history of myocardial infa rct ion in the intervention group were prescribed a beta-blocker compared to the control group ( adjusted OR 1.43 , 95 % CI 1.19 to 1.99 ) . Significantly more patients with CHD in the intervention group had adequate management of their blood pressure ( < 140/85 mm Hg ) ( OR 1.61 , 95 % CI 1.22 to 2.13 ) and their cholesterol ( < 5 mmol/l ) ( OR 1.58 , 95 % CI 1.05 to 2.37 ) compared to those in the control group . Significantly more patients with an unconfirmed diagnosis of CHF had a diagnosis of left ventricular systolic dysfunction confirmed ( OR 4.69 , 95 % CI 1.88 to 11.66 ) or excluded ( OR 3.80 , 95 % CI 1.50 to 9.64 ) in the intervention group compared to the control group . There were significant improvements in some quality -of-life measures in patients with CHD in the intervention group . Conclusions : Disease management programmes can lead to improvements in the care of patients with CHD and presumed CHF in primary care Background Cardiovascular disease ( CVD ) remains the leading cause of death globally . Primary prevention of CVD requires cost-effective strategies to identify individuals at high risk in order to help target preventive interventions . An integral part of this approach is the use of CVD risk scores . Limitations in previous studies have prevented reliable inference about the potential advantages and the potential harms of using CVD risk scores as part of preventive strategies . We aim to evaluate short-term effects of providing different types of information about coronary heart disease ( CHD ) risk , alongside lifestyle advice , on health-related behaviours . Methods / Design In a parallel-group , open r and omised trial , we are allocating 932 male and female blood donors with no previous history of CVD aged 40–84 years in Engl and to either no intervention ( control group ) or to one of three active intervention groups : i ) lifestyle advice only ; ii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic characteristics ; and iii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic and genetic characteristics . The primary outcome is change in objective ly measured physical activity . Secondary outcomes include : objective ly measured dietary behaviours ; cardiovascular risk factors ; current medication and healthcare usage ; perceived risk ; cognitive evaluation of provision of CHD risk scores ; and psychological outcomes . The follow-up assessment takes place 12 weeks after r and omisation . The experiences , attitudes and concerns of a subset of participants will be also studied using individual interviews and focus groups . Discussion The INFORM study has been design ed to provide robust findings about the short-term effects of providing different types of information on estimated 10-year CHD risk and lifestyle advice on health-related behaviours . Trial registration Current Controlled Trials IS RCT N17721237 . Registered 12 January 2015 Background Cardiac rehabilitation ( CR ) is a secondary prevention program that offers education and support to assist patients with coronary heart disease ( CHD ) make lifestyle changes . Despite the benefits of CR , attendance at centre-based sessions remains low . Mobile technology ( mHealth ) has potential to reach more patients by delivering CR directly to mobile phones , thus providing an alternative to centre-based CR . The aim of this trial is to evaluate if a mHealth comprehensive CR program can improve adherence to healthy lifestyle behaviours ( for example , physically active , fruit and vegetable intake , not smoking , low alcohol consumption ) over and above usual CR services in New Zeal and adults diagnosed with CHD . Methods / design A two-arm , parallel , r and omised controlled trial will be conducted at two Auckl and hospitals in New Zeal and . One hundred twenty participants will be r and omised to receive a 24-week evidence - and theory-based personalised text message program and access to a supporting website in addition to usual CR care or usual CR care alone ( control ) . The primary outcome is the proportion of participants adhering to healthy behaviours at 6 months , measured using a composite health behaviour score . Secondary outcomes include overall cardiovascular disease risk , body composition , illness perceptions , self-efficacy , hospital anxiety/depression and medication adherence . Discussion This study is one of the first to examine an mHealth-delivered comprehensive CR program . Strengths of the trial include quality research design and in-depth description of the intervention to aid replication . If effective , the trial has potential to augment st and ard CR practice s and to be used as a model for other disease prevention or self-management programs . Trial registryAustralian New Zeal and Clinical Trials Registry : Background : The CardioFit internet-based expert system was design ed to promote physical activity in patients with coronary heart disease ( CHD ) who were not participating in cardiac rehabilitation . Design : This r and omized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes . Methods : A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and r and omly assigned to either  CardioFit  ( n = 115 ) or  usual care ( n = 108 ) . The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking . They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist . Usual care consisted of physical activity guidance from an attending cardiologist .  Physical activity was measured by pedometer and self-reported over a 7-day period , 6 and 12 months after r and omization . Results : The CardioFit internet-based physical activity expert system significantly increased objective ly measured ( p = 0.023 ) and self-reported physical activity ( p = 0.047 ) compared to usual care . Emotional ( p = 0.038 ) and physical ( p = 0.031 ) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care . Conclusions : Patients with CHD using an internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care . Use of the CardioFit program could extend the reach of rehabilitation and secondary -prevention services Background Mobile technology has the potential to deliver behavior change interventions ( mHealth ) to reduce coronary heart disease ( CHD ) at modest cost . Previous studies have focused on single behaviors ; however , cardiac rehabilitation ( CR ) , a component of CHD self-management , needs to address multiple risk factors . Objective The aim was to investigate the effectiveness of a mHealth-delivered comprehensive CR program ( Text4Heart ) to improve adherence to recommended lifestyle behaviors ( smoking cessation , physical activity , healthy diet , and nonharmful alcohol use ) in addition to usual care ( traditional CR ) . Methods A 2-arm , parallel , r and omized controlled trial was conducted in New Zeal and adults diagnosed with CHD . Participants were recruited in-hospital and were encouraged to attend center-based CR ( usual care control ) . In addition , the intervention group received a personalized 24-week mHealth program , framed in social cognitive theory , sent by fully automated daily short message service ( SMS ) text messages and a supporting website . The primary outcome was adherence to healthy lifestyle behaviors measured using a self-reported composite health behavior score ( ≥3 ) at 3 and 6 months . Secondary outcomes included clinical outcomes , medication adherence score , self-efficacy , illness perceptions , and anxiety and /or depression at 6 months . Baseline and 6-month follow-up assessment s ( unblinded ) were conducted in person . Results Eligible patients ( N=123 ) recruited from 2 large metropolitan hospitals were r and omized to the intervention ( n=61 ) or the control ( n=62 ) group . Participants were predominantly male ( 100/123 , 81.3 % ) , New Zeal and European ( 73/123 , 59.3 % ) , with a mean age of 59.5 ( SD 11.1 ) years . A significant treatment effect in favor of the intervention was observed for the primary outcome at 3 months ( AOR 2.55 , 95 % CI 1.12 - 5.84 ; P=.03 ) , but not at 6 months ( AOR 1.93 , 95 % CI 0.83 - 4.53 ; P=.13 ) . The intervention group reported significantly greater medication adherence score ( mean difference : 0.58 , 95 % CI 0.19 - 0.97 ; P=.004 ) . The majority of intervention participants reported reading all their text messages ( 52/61 , 85 % ) . The number of visits to the website per person ranged from zero to 100 ( median 3 ) over the 6-month intervention period . Conclusions A mHealth CR intervention plus usual care showed a positive effect on adherence to multiple lifestyle behavior changes at 3 months in New Zeal and adults with CHD compared to usual care alone . The effect was not sustained to the end of the 6-month intervention . A larger study is needed to determine the size of the effect in the longer term and whether the change in behavior reduces adverse cardiovascular events . Trial Registration ACTRN 12613000901707 ; https://www.anzctr.org.au/Trial/ Registration /Trial Review .aspx?id=364758&is Review = true ( Archived by WebCite at http://www.webcitation.org/6c4qhcHKt Background Coronary heart disease ( CHD ) and depression are leading causes of disease burden globally and the two often co-exist . Depression is common after Myocardial Infa rct ion ( MI ) and it has been estimated that 15 - 35 % of patients experience depressive symptoms . Co-morbid depression can impair health related quality of life ( HRQOL ) , decrease medication adherence and appropriate utilisation of health services , lead to increased morbidity and suicide risk , and is associated with poorer CHD risk factor profiles and reduced survival . We aim to determine the feasibility of conducting a r and omised , multi-centre trial design ed to compare a tele-health program ( MoodCare ) for depression and CHD secondary prevention , with Usual Care ( UC ) . Methods Over 1600 patients admitted after index admission for Acute Coronary Syndrome ( ACS ) are being screened for depression at six metropolitan hospitals in the Australian states of Victoria and Queensl and . Consenting participants are then contacted at two weeks post-discharge for baseline assessment . One hundred eligible participants are to be r and omised to an intervention or a usual medical care control group ( 50 per group ) . The intervention consists of up to 10 × 30 - 40 minute structured telephone sessions , delivered by registered psychologists , commencing within two weeks of baseline screening . The intervention focuses on depression management , lifestyle factors ( physical activity , healthy eating , smoking cessation , alcohol intake ) , medication adherence and managing co-morbidities . Data collection occurs at baseline ( Time 1 ) , 6 months ( post-intervention ) ( Time 2 ) , 12 months ( Time 3 ) and 24 months follow-up for longer term effects ( Time 4 ) . We are comparing depression ( Cardiac Depression Scale [ CDS ] ) and HRQOL ( Short Form-12 [ SF-12 ] ) scores between treatment and UC groups , assessing the feasibility of the program through patient acceptability and exploring long term maintenance effects . A cost-effectiveness analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government . Discussion This manuscript presents the protocol for a r and omised , multi-centre trial to evaluate the feasibility of a tele-based depression management and CHD secondary prevention program for ACS patients . The results of this trial will provide valuable new information about potential psychological and wellbeing benefits , cost-effectiveness and acceptability of an innovative tele-based depression management and secondary prevention program for CHD patients experiencing depression . Trial Registration NumberAustralia and New Zeal and Clinical Trials Register ( ANZCTR ) : Background Angina affects more than 50 million people worldwide . Secondary prevention interventions such as cardiac rehabilitation are not widely available for this population . An Internet-based version could offer a feasible alternative . Objective Our aim was to examine the effectiveness of a Web-based cardiac rehabilitation program for those with angina . Methods We conducted a r and omized controlled trial , recruiting those diagnosed with angina from general practitioners ( GPs ) in primary care to an intervention or control group . Intervention group participants were offered a 6-week Web-based rehabilitation program ( “ ActivateYourHeart ” ) . The program was introduced during a face-to-face appointment and then delivered via the Internet ( no further face-to-face contact ) . The program contained information about the secondary prevention of coronary heart disease ( CHD ) and set each user goals around physical activity , diet , managing emotions , and smoking . Performance against goals was review ed throughout the program and goals were then reset/modified . Participants completed an online  exercise diary and communicated with rehabilitation specialists through an email link/synchronized chat room . Participants in the control group continued with GP treatment as usual , which consisted of being placed on a CHD register and attending an annual review . Outcomes were measured at 6-week and 6-month follow-ups during face-to-face assessment s. The primary outcome measure was change in daily steps at 6 weeks , measured using an accelerometer . Secondary outcome measures were energy expenditure ( EE ) , duration of sedentary activity ( DSA ) , duration of moderate activity ( DMA ) , weight , diastolic/systolic blood pressure , and body fat percentage . Self-assessed question naire outcomes included fat/fiber intake , anxiety/depression , self-efficacy , and quality of life ( QOL ) . Results A total of 94 participants were recruited and r and omized to the intervention ( n=48 ) or the usual care  ( n=46 ) group ; 84 and 73 participants completed the 6-week and 6-month follow-ups , respectively . The mean number of log-ins to the program was 18.68 ( SD 13.13 , range 1 - 51 ) , an average of 3 log-ins per week per participant . Change in daily steps walked at the 6-week follow-up was + 497 ( SD 2171 ) in the intervention group and –861 ( SD 2534 ) in the control group ( 95 % CI 263 - 2451 , P=.02 ) . Significant intervention effects were observed at the 6-week follow-up in EE ( + 43.94 kcal , 95 % CI 43.93 - 309.98 , P=.01 ) , DSA ( –7.79 minutes , 95 % CI –55.01 to –7.01 , P=.01 ) , DMA ( + 6.31 minutes , 95 % CI 6.01 - 51.20 , P=.01 ) , weight ( –0.56 kg , 95 % CI –1.78 to –0.15 , P=.02 ) , self-efficacy ( 95 % CI 0.30 - 4.79 , P=.03 ) , emotional QOL score ( 95 % CI 0.01 - 0.54 , P=.04 ) , and angina frequency ( 95 % CI 8.57 - 35.05 , P=.002 ) . Significant benefits in angina frequency ( 95 % CI 1.89 - 29.41 , P=.02 ) and social QOL score ( 95 % CI 0.05 - 0.54 , P=.02 ) were also observed at the 6-month follow-up . Conclusions An Internet-based secondary prevention intervention could be offered to those with angina . A larger pragmatic trial is required to provide definitive evidence of effectiveness and cost-effectiveness . Trial Registration International St and ard R and omized Controlled Trial Number ( IS RCT N ) : 90110503 ; http://www.controlled-trials.com/IS RCT N90110503/IS RCT N90110503 ( Archived by WebCite at http://www.webcitation.org/6RYVOQFKM ) Background Coronary heart disease ( CHD ) is the most common cause of death in the UK . CHD cost the UK National Health Service ( NHS ) £ 3.5 billion in 2003 . The economic impact of community pharmacists providing a medicines management service for patients with CHD has not been rigorously evaluated ; the full economic costs of such interventions are rarely presented in the literature . Objective To examine the incremental costs of a 1-year community pharmacistled medicines management service for patients with CHD in the UK , from a healthcare system and patient perspective . Methods and participants A cost-minimisation analysis was conducted alongside a multicentre r and omised controlled trial . The primary study participants were patients with CHD identified from general practice computer records . Patients ( intervention , n = 980 ; control , n = 500 ) from 38 general practice s in nine geographical areas in the UK were included in the study .Intervention and outcomes measures The intervention consisted of a review of pharmaceuticals and lifestyle advice by pharmacists in their premises , with recommendations communicated to the patient ’s GP . The main outcome measure was the incremental cost per patient in the intervention group compared with the control group . Annual costs ( £ , 2003/4 values ) included the costs of the intervention ( training and delivery costs ) , the usual costs of NHS treatment ( costs of pharmaceuticals , GP and hospital visits ) and costs borne by patients . Data were collected in the 12 months before and 12 months after the intervention . Results The total NHS cost increased between baseline and follow-up in both groups ( from £ 1243 to £ 1286 [ 3 % ] in the control group and from £ 1410 to £ 1433 [ 2 % ] in the intervention group).The greater cost in the intervention group largely reflects the additional cost of the pharmacist training and the time taken to deliver the intervention ; the difference in costs between the intervention and control groups , after controlling for differences in costs at baseline at follow-up , was statistically significant ( p = 0.001 ) . The costs of pharmaceuticals was higher in the intervention group ( £ 769.20 vs £ 742.3 ; p = 0.04).According to the sensitivity analysis , the intervention cost would need to decrease by 35 % to achieve equivalence between costs in each arm of the trial . Difference to costs of patients and their carers at follow-up were not statistically significant . Conclusions The introduction of a 1-year pharmacist-led medicines management service is likely to increase the total cost of CHD treatment and prevention from the healthcare perspective , as the cost of the intervention outweighed the observed reduction in the cost of drugs in the intervention group . No changes in costs from the patient perspective were found Background Coronary heart disease ( CHD ) is a significant cause of health and economic burden . Secondary prevention programs play a pivotal role in the treatment and management of those affected by CHD although participation rates are poor due to patient , provider , health system and societal-level barriers . As such , there is a need to develop innovative secondary prevention programs to address the treatment gap . Telephone-delivered care is convenient , flexible and has been shown to improve behavioural and clinical outcomes following myocardial infa rct ion ( MI ) . This paper presents the design of a r and omised controlled trial to evaluate the efficacy of a six-month telephone-delivered secondary prevention program for  MI patients ( ProActive Heart ) . Methods 550 adult MI patients have been recruited over a 14 month period ( December 2007 to January 2009 ) through two Brisbane metropolitan hospitals , and r and omised to an intervention or control group ( n = 225 per group ) . The intervention commences within two weeks of hospital discharge delivered by study -trained health professionals ( ' health coaches ' ) during up to 10 × 30 minute scripted telephone health coaching sessions . Participants also receive a ProActive Heart h and book and an educational re source to use during the health coaching sessions . The intervention focuses on appropriate modification of CHD risk factors , compliance with pharmacological management , and management of psychosocial issues . Data collection occurs at baseline or prior to commencement of the intervention ( Time 1 ) , six months follow-up or the completion of the intervention ( Time 2 ) , and at 12 months follow-up for longer term outcomes ( Time 3 ) . Primary outcome measures include quality of life ( Short Form-36 ) and physical activity ( Active Australia Survey ) . A cost-effective analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government . Discussion The results of this study will provide valuable new information about an innovative telephone-delivered cost-effective secondary prevention program for MI patients .Trial Registration IMPORTANCE Most primary care clinicians lack the skills and re sources to offer effective lifestyle and medication ( L&M ) counseling to reduce coronary heart disease ( CHD ) risk . Thus , effective and feasible CHD prevention programs are needed for typical practice setting s. OBJECTIVE To assess the effectiveness , acceptability , and cost-effectiveness of a combined L&M intervention to reduce CHD risk offered in counselor-delivered and web-based formats . DESIGN , SETTING , AND PARTICIPANTS A comparative effectiveness trial in 5 diverse family medicine practice s in North Carolina . Participants were established patients , aged 35 to 79 years , with no known cardiovascular disease , and at moderate to high risk for CHD ( 10-year Framingham Risk Score [ FRS ] , ≥10 % ) . INTERVENTIONS Participants were r and omized to counselor-delivered or web-based format , each including 4 intensive and 3 maintenance sessions . After r and omization , both formats used a web-based decision aid showing potential CHD risk reduction associated with L&M risk-reducing strategies . Participants chose the risk-reducing strategies they wished to follow . MAIN OUTCOMES AND MEASURES The primary outcome was within-group change in FRS at 4-month follow-up . Other measures included st and ardized assessment s of blood pressure , blood lipid levels , lifestyle behaviors , and medication adherence . Acceptability and cost-effectiveness were also assessed . Outcomes were assessed at 4 and 12 months . RESULTS Of 2274 screened patients , 385 were r and omized ( 192 counselor ; 193 web ) : mean age , 62 years ; 24 % African American ; and mean FRS , 16.9 % . Follow-up at 4 and 12 months included 91 % and 87 % of the r and omized participants , respectively . There was a sustained reduction in FRS at both 4 months ( primary outcome ) and 12 months for both counselor-based ( -2.3 % [ 95 % CI , -3.0 % to -1.6 % ] and -1.9 % [ 95 % CI , -2.8 % to -1.1 % ] , respectively ) and web-based groups ( -1.5 % [ 95 % CI , -2.2 % to -0.9 % ] and -1.7 % [ 95 % CI , -2.6 % to -0.8 % ] respectively ) . At 4 months , the adjusted difference in FRS between groups was -1.0 % ( 95 % CI , -1.8 % to -0.1 % ) ( P = .03 ) , and at 12 months , it was -0.6 % ( 95 % CI , -1.7 % to 0.5 % ) ( P = .30 ) . The 12-month costs from the payer perspective were $ 207 and $ 110 per person for the counselor- and web-based interventions , respectively . CONCLUSIONS AND RELEVANCE Both intervention formats reduced CHD risk through 12-month follow-up . The web format was less expensive . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01245686 Background Participation in coronary heart disease ( CHD ) secondary prevention programs is low . Telephone-delivered CHD secondary prevention programs may overcome the treatment gap . The telephone-based health coaching ProActive Heart trial intervention has previously been shown to be effective for improving health-related quality of life , physical activity , body mass index , diet , alcohol intake and anxiety . As a secondary aim , the current study evaluated the cost-effectiveness of the ProActive Heart intervention compared to usual care . Methods 430 adult myocardial infa rct ion patients were r and omised to a six-month  CHD secondary prevention ‘ health coaching ’ intervention or ‘ usual care ’ control group . Primary outcome variables were health-related quality of life ( SF-36 ) and physical activity ( Active Australia Survey ) . Data were collected at baseline , six-months ( post-intervention ) and 12 months ( six-months post-intervention completion ) for longer term effects . Cost-effectiveness data [ health utility ( SF-6D ) and health care utilisation ] were collected using self-reported ( general practitioner , specialist , other health professionals , health services , and medication ) and cl aims data ( hospitalisation rates ) . Intervention effects are presented as mean differences ( 95 % CI ) , p-value . Results Improvements in health status ( SF-6D ) were observed in both groups , with no significant difference between the groups at six [ 0.012 ( -0.016 , 0.041 ) , p = 0.372 ] or 12 months [ 0.011 ( -0.028 , 0.051 ) p = 0.738 ] . Patients in the health coaching group were significantly more likely to be admitted to hospital due to causes unrelated to cardiovascular disease ( p = 0.042 ) . The overall cost for the health coaching group was higher ( $ 10,574 vs. $ 8,534 , p = 0.021 ) , mainly due to higher hospitalisation ( both CHD and non-CHD ) costs ( $ 6,841 vs. $ 4,984 , p = 0.036 ) . The incremental cost-effectiveness ratio was $ 85,423 per QALY . Conclusions There was no intervention effect measured using the SF-36/SF-6D and ProActive Heart result ed in significantly increased costs . The cost per QALY gained from ProActive Heart was high and above acceptable limits compared to usual care BACKGROUND Effective therapies for reducing mortality rates in persons with coronary heart disease ( CHD ) remain underused . We report the results of an effectiveness trial of a quality improvement effort to increase the use of 3-hydroxy-3methylglutaryl coenzyme A ( HMG CoA ) reductase inhibitors , beta-blockers , and angiotensin-converting enzyme ( ACE ) inhibitors in patients with CHD in a network-model managed-care setting . METHODS Patients with CHD were identified by search ing a cl aims data base . The use of therapies was assessed by linkage with a pharmacy data base . An intervention , consisting of a guideline summary , peer comparison performance feedback , and patient specific chart reminders was evaluated in a r and omized , practice -based effectiveness trial . RESULTS Data were available for > 700 patients per year ( 1999 - 2002 ) in 131 practice s. At baseline ( 1999 ) , 55 % of patients were receiving HMG CoA reductase inhibitors , 39 % of patients were receiving beta-blockers , and 24 % of patients were receiving ACE inhibitors . The use of all 3 types of medications increased steadily with time , with the exception of a decrease in the use of HMG CoA reductase inhibitors in the final year ( 2002 ) . No difference in medication use was observed between r and omized groups . CONCLUSIONS The observed pattern of care supports the contention that the quality of outpatient care for secondary prevention of CHD improved from 1999 to 2002 in this setting . The basis for the inconsistent pattern of use of HMG CoA reductase inhibitors is not certain , but may relate to concerns about toxicity . Central ized mailings of guideline summaries , performance feedback reports , and chart reminders had no observable impact on quality of care in this setting . More intensive intervention may be required to improve the quality of outpatient care for the secondary prevention of CHD Community studies have demonstrated suboptimal achievement of lipid targets in the management of patients with coronary heart disease ( CHD ) . An effective strategy is required for the application of evidence -based prevention therapy for CHD . The objective of this study was to test coaching as a technique to assist patients in achieving the target cholesterol level of < 4.5 mmol/L. Patients with established CHD ( n = 245 ) underwent a stratified r and omization by cardiac procedure ( coronary artery bypass graft surgery or percutaneous coronary intervention ) to receive either the coaching intervention ( n = 121 ) or usual medical care ( n = 124 ) . The primary outcome measure was fasting serum total cholesterol ( TC ) , serum triglyceride ( TG ) , high-density lipoprotein cholesterol ( HDL-C ) , and calculated low-density lipoprotein cholesterol ( LDL-C ) level , measured at 6 months post-r and omization . At 6 months , the serum TC and LDL-C levels were significantly lower in the coaching intervention group ( n = 107 ) than the usual care group ( n = 112 ) : mean TC ( 95%CI ) 5.00 ( 4.82 - 5.17 ) mmol/L versus 5.54 ( 5.36 - 5.72 ) mmol/L ( P < .0001 ) ; mean LDL-C ( 95%CI ) 3.11 ( 2.94 - 3.29 ) mmol/L versus 3.57 ( 3.39 - 3.75 ) mmol/L ( P < .0004 ) , respectively . Coaching had no impact on TG or on HDL-C levels . Multivariate analysis showed that being coached ( P < .001 ) had an effect of equal magnitude to being prescribed lipid-lowering drug therapy ( P < .001 ) . The effectiveness of the coaching intervention is best explained by both adherence to drug therapy and to dietary advice given . Coaching may be an appropriate method to reduce the treatment gap in applying evidence -based medicine to the " real world . OBJECTIVE Primary prevention of Coronary Heart Disease ( CHD ) in diabetic patients should be based on absolute CHD risk calculation . This study was aim ed to determine the levels of 10-year CHD risk in Caribbean type 2 diabetic patients using the diabetes specific United Kingdom Prospect i ve Diabetes Study ( UKPDS ) risk engine calculator . SUBJECTS AND METHODS Three hundred and twenty-five ( 106 males , 219 females ) type 2 diabetic patients resident in two Caribbean Isl and s of Tobago and Trinidad met the UKPDS risk engine inclusion criteria . Records of their sex , age , ethnicity , smoking habit , diabetes duration , systolic blood pressure , total cholesterol , HDL-cholesterol and glycated haemoglobin were entered into the UKPDS risk engine calculator programme and the absolute 10-year CHD and stroke risk levels were computed . The 10-year CHD and stroke risks were statistically stratified into < 15 % , 15 - 30 % and > 30 % CHD risk levels and differences between patients of African and Asian-Indian origin were compared . RESULTS In comparison with patients in Tobago , type 2 diabetic patients in Trinidad , irrespective of gender , had higher proportion of 10-year CHD risk ( 10.4 vs. 23.6 % , P<0.001 ) whereas the overall 10-year stroke risk prediction was higher in patients resident in Tobago ( 16.9 vs. 11.4 % , P<0.001 ) . Ethnicity-based analysis revealed that irrespective of gender , higher proportion of patients of Indian origin scored > 30 % of absolute 10-year CHD risk compared with patients of African descent ( 3.2 vs. 28.2 % , P<0.001 ) . CONCLUSIONS The results of the study identified diabetic patients resident in Trinidad and patients of Indian origin as the most vulnerable groups for CHD . These groups of diabetic patients should have priority in primary or secondary prevention of coronary heart disease BACKGROUND Despite the large body of evidence confirming the effectiveness of lipid lowering for the secondary prevention of coronary heart disease ( CHD ) events , undertreatment of hyperlipidemia is common . This study tested the effectiveness of a nurse case management program to lower blood lipids in patients with CHD . METHODS A total of 228 consecutive , eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization . Patients were r and omized to receive lipid management , including individualized lifestyle modification and pharmacologic intervention , from a nurse practitioner for 1 year after discharge in addition to their usual care ( NURS ) , or to usual care enhanced with feedback on lipids to their primary provider and /or cardiologist ( EUC ) . RESULTS Significantly more patients in the NURS group than in the EUC group achieved low-density lipoprotein cholesterol ( LDL-C ) levels < 2.59 mmol/dL ( 100 mg/dL , 65 % vs 35 % , P = .0001 ) . Favorable changes in lipids and lipoproteins were accompanied by significant improvements in dietary and exercise patterns in the NURS group . In a multivariate analysis adjusting for other covariates , being assigned to the NURS group ( P = .0001 ) and being on a lipid-lowering medication ( P = .001 ) were significant independent predictors of LDL-C level . CONCLUSIONS Control of hypercholesterolemia in patients who have undergone coronary revascularization can be improved by a nurse case-management program . Because the National Cholesterol Education Program Adult Treatment Panel III guidelines have broadened the definition of high-risk population s that warrant aggressive treatment , nurse case-management programs may offer key opportunities to enhance appropriate application of new treatment paradigms CONTEXT Coronary heart disease ( CHD ) mortality has declined substantially in Canada since 1994 . OBJECTIVE To determine what proportion of this decline was associated with temporal trends in CHD risk factors and advancements in medical treatments . DESIGN , SETTING , AND PATIENTS Prospect i ve analytic study of the Ontario , Canada , population aged 25 to 84 years between 1994 and 2005 , using an up date d version of the vali date d IMPACT model , which integrates data on population size , CHD mortality , risk factors , and treatment uptake changes . Relative risks and regression coefficients from the published literature quantified the relationship between CHD mortality and ( 1 ) evidence -based therapies in 8 distinct CHD sub population s ( acute myocardial infa rct ion [ AMI ] , acute coronary syndromes , secondary prevention post-AMI , chronic coronary artery disease , heart failure in the hospital vs in the community , and primary prevention for hyperlipidemia or hypertension ) and ( 2 ) population trends in 6 risk factors ( smoking , diabetes mellitus ,  systolic blood pressure ,  plasma cholesterol level , exercise , and obesity  ) . MAIN OUTCOME MEASURES The number of deaths prevented or delayed in 2005 ; secondary outcome measures were improvements in medical treatments and trends in risk factors . RESULTS Between 1994 and 2005 , the  age-adjusted CHD mortality rate  in Ontario decreased by 35 % from 191 to 125 deaths per 100,000 inhabitants , translating to an estimated 7585 fewer CHD deaths in 2005 . Improvements in medical and surgical treatments were associated with 43 % ( range , 11 % to 124 % ) of the total mortality decrease , most notably in AMI ( 8 % ; range , -5 % to 40 % ) , chronic stable coronary artery disease ( 17 % ; range , 7 % to 35 % ) , and heart failure occurring while in the community ( 10 % ; range , 6 % to 31 % ) . Trends in risk factors accounted for 3660 fewer CHD deaths prevented or delayed ( 48 % of total ; range , 28 % to 64 % ) , specifically , reductions in total cholesterol ( 23 % ; range , 10 % to 33 % ) and systolic blood pressure ( 20 % ; range , 13 % to 26 % ) . Increasing diabetes prevalence and body mass index had an inverse relationship associated with higher CHD mortality of 6 % ( range , 4 % to 8 % ) and 2 % ( range , 1 % to 4 % ) , respectively . CONCLUSION Between 1994 and 2005 , there was a decrease in CHD mortality rates in Ontario that was associated primarily with trends in risk factors and improvements in medical treatments , each explaining about half of the decrease Background Case management has emerged as a promising alternative approach to supplement traditional one-on-one sessions between patients and doctors for improving the quality of care in chronic diseases such as coronary heart disease ( CHD ) . However , data are lacking in terms of its efficacy and cost-effectiveness when implemented in ethnic and low-income population s. Methods The Stanford and San Mateo Heart to Heart ( HTH ) project is a r and omized controlled clinical trial design ed to rigorously evaluate the efficacy and cost-effectiveness of a multi-risk cardiovascular case management program in low-income , primarily ethnic minority patients served by a local county health care system in California . R and omization occurred at the patient level . The primary outcome measure is the absolute CHD risk over 10 years . Secondary outcome measures include adherence to guidelines on CHD prevention practice . We documented the study design , methodology , and baseline sociodemographic , clinical and lifestyle characteristics of 419 participants . Results We achieved equal distributions of the sociodemographic , biophysical and lifestyle characteristics between the two r and omization groups . HTH participants had a mean age of 56 years , 63 % were Latinos/Hispanics , 65 % female , 61 % less educated , and 62 % were not employed . Twenty percent of participants reported having a prior  cardiovascular event . 10-year CHD risk averaged 18 % in men and 13 % in women despite a modest low-density lipoprotein cholesterol level and a high on-treatment percentage at baseline . Sixty-three percent of participants were diagnosed with diabetes and an additional 22 % had metabolic syndrome . In addition , many participants had depressed high-density lipoprotein ( HDL ) cholesterol levels and elevated values of total cholesterol-to-HDL ratio , triglycerides , triglyceride-to-HDL ratio , and blood pressure . Furthermore , nearly 70 % of participants were obese , 45 % had a family history of CHD or stroke , and 16 % were current smokers . Conclusion We have recruited an ethnically diverse , low-income cohort in which to implement a case management approach and test its efficacy and cost-effectiveness . HTH will advance the scientific underst and ing of better strategies for CHD prevention among these priority sub population s and aid in guiding future practice that will reduce health disparities BACKGROUND Until now , there has not been any evaluated , disease-specific education and treatment program for patients with coronary heart disease ( CHD ) in Germany . It is thought that education can improve these patients ' physical activity and quality of life and teach them how to lessen their risk factors , what to do in case of an emergency , and how to assess their own medical treatment . METHODS A r and omized controlled open intervention trial was carried out from February 2010 to September 2011 . 196 patients were assigned to receive the intervention ( patient education ) , while 199 were assigned to a control group .  In an intention-to-treat analysis , baseline and follow-up data were compared after a mean interval of 220 days . The evaluative instruments included the Freiburg Question naire of Physical Activity , the MacNew Heart Disease Quality of Life Question naire , question naires regarding knowledge about CHD , ergometric performance ability , and the body-mass index . RESULTS The patients in the intervention group reported having increased their physical activity by a mean of 9.3 MET/week ( MET = metabolic equivalent of task ) , compared to 2.5 MET/week in the control group ; the difference of 6.8 MET/week was statistically significant ( p = 0.015 ) . The patients in the intervention group also rated their quality of life higher than those in the control group ( 0.2 ± 0.56 vs. 0.09 ± 0.53 [ mean ± st and ard deviation ] , p = 0.056 ) . They were significantly better informed than patients in the control group about risk factors and about what to do in an emergency . CONCLUSION Persistently unhealthy lifestyle is a common problem of CHD patients ; the education and treatment program presented here may be a suitable means of improving patients ' lifestyle for secondary prevention . Further studies will be needed to document long-term efficacy and to determine whether occasional refresher courses will be needed as well Objectives : The aim of the study was twofold ; 1 ) to develop a clinical pharmacist-led 12 month lasting follow-up program for patients with established coronary heart disease ( CHD ) discharged from the University Hospital of North Norway , and 2 ) to explore the impact of the program with regards to adherence to a medication assessment tool for secondary prevention of CHD and change in biomedical risk factors . Methods : A total of 102 patients aged 18 - 82 years were enrolled in a non-blinded r and omized controlled trial with an intervention group and a control group . The intervention comprised medication reconciliation , medication review and patient education during three meetings ; at discharge , after three months and after twelve months . The control group received st and ard care from their general practitioner . Primary outcomes were adherence to clinical guideline recommendations concerning prescription , therapy goal achievement and lifestyle education  defined in the medication assessment tool for secondary prevention of CHD ( MAT-CHDSP ) . Secondary outcomes included changes in the biomedical risk factors cholesterol , blood pressure and blood glucose . Results : Ninety-four patients completed the trial , 48 intervention group patients and 46 controls . Appropriate prescribing was high , but therapy goal achievement was low in both groups . Overall adherence to MAT-CHDSP criteria increased in both groups and was significantly higher in the intervention group at study end , 78.4 % vs. 62.0 % , p<0.001 . The difference was statistically significant for the documented lifestyle advices in intervention group patients . No significant improvements in biomedical risk factors were observed in favor of the intervention group . Conclusions : The study showed an increased guideline adherence in both study groups . This indicates that attention to clinical practice guideline recommendations in itself increases adherence – which may be a clinical pharmacist task . A larger adequately powered study is needed to show a significant difference in biomedical risk factor improvements in favor of the intervention . Amendments to the follow-up program are suggested before implementation in st and ard patient care can be recommended OBJECTIVE Coronary heart disease ( CHD ) is a leading cause of illness and death in Western society . The present study was design ed to evaluate the utility of illness perceptions and medication beliefs in predicting secondary preventive behaviour among patients with CHD . An extended version of Leventhal 's self-regulatory model ( SRM ) was used as a theoretical framework for this study [ Leventhal H , Nerenz DR , Steele DJ . Illness perceptions and coping with health threat . In : Baum A , Taylor SE , Singer JE , editors . H and book of psychology and health , Volume IV : social psychological aspects of health . Hillsdale ( NJ ) : Erlbaum , 1984 . pp . 219 - 52 ; Horne R , Weinman J. Self-regulation and self-management in asthma : exploring the role of illness perceptions and treatment beliefs in explaining non-adherence to preventer medication . Psychol Health 2002;17(1):17 - 32 ] . METHOD Medical and demographic data were gathered from the medical charts of 1611 patients with established CHD from 35 r and omly selected general practice s.  Self-report data about patients ' lifestyles ( diet , exercise , smoking , alcohol consumption and medication adherence ) and information on illness and medication beliefs were provided from postal question naire ( 1084 patients responded ; 69 % response rate ) . The relationship between patients ' beliefs and their secondary preventive behaviour was examined using regression analyses . RESULTS Illness perceptions appeared to be only weak predictors of smoking , exercise , diet , alcohol consumption and medication adherence , accounting for about 2 % of the variance in these behaviours . Medication beliefs were moderately related to medication adherence , accounting for about 7 % of the variance in scores . A strong belief in the necessity of one 's medication and a lower level of concern about one 's medication were associated with higher levels of adherence . CONCLUSIONS An illness perception approach did not prove helpful in predicting secondary preventive behaviour among this group of patients . However , beliefs about medications appear to be reasonable predictive of medication adherence Objectives : To evaluate the effects of nurse-led secondary prevention clinics for coronary heart disease ( CHD ) in primary care on total mortality and coronary event rates after 10 years . Design : Follow-up of a r and omised controlled trial by review of national data sets . Setting : Stratified r and om sample of 19 general practice s in northeast Scotl and . Participants : Original study cohort of 1343 patients , aged < 80 years , with a working diagnosis of CHD , but without dementia or terminal illness and not housebound . Intervention : Nurse-led secondary prevention clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow-up for 1 year , Main outcome measures : Total mortality and coronary events ( non-fatal myocardial infa rct ions ( MIs ) and coronary deaths ) . Results : Mean ( SD ) follow-up was at 10.2 ( 0.19 ) years . No significant differences in total mortality or coronary events were found at 10 years . 254 patients in the intervention group and 277 patients in the control group had died : cumulative death rates were 38 % and 41 % , respectively ( p = 0.177 ) . 196 coronary events occurred in the intervention group and 195 in the control group : cumulative event rates were 29.1 % and 29.1 % , respectively ( p = 0.994 ) . When Kaplan – Meier survival analysis , adjusted for age , sex and general practice , was used , proportional hazard ratios were 0.88 ( 0.74 to 1.04 ) for total mortality and 0.96 ( 0.79 to 1.18 ) for coronary death or non-fatal MI . No significant differences in the distribution of cause of death classifications was found at either 4 or 10 years . Conclusions : After 10 years , differences between groups were no longer significant . Total mortality survival curves for the intervention and control groups had not converged , but the coronary event survival curves had . Possibly , therefore , the earlier that secondary prevention is optimised , the less likely a subsequent coronary event is to prove fatal CONTEXT Observational studies have found lower rates of coronary heart disease ( CHD ) in postmenopausal women who take estrogen than in women who do not , but this potential benefit has not been confirmed in clinical trials . OBJECTIVE To determine if estrogen plus progestin therapy alters the risk for CHD events in postmenopausal women with established coronary disease . DESIGN R and omized , blinded , placebo-controlled secondary prevention trial . SETTING Outpatient and community setting s at 20 US clinical centers . PARTICIPANTS A total of 2763 women with coronary disease , younger than 80 years , and postmenopausal with an intact uterus . Mean age was 66.7 years . INTERVENTION Either 0.625 mg of conjugated equine estrogens plus 2.5 mg of medroxyprogesterone acetate in 1 tablet daily ( n = 1380 ) or a placebo of identical appearance ( n = 1383 ) . Follow-up averaged 4.1 years ; 82 % of those assigned to hormone treatment were taking it at the end of 1 year , and 75 % at the end of 3 years . MAIN OUTCOME MEASURES The primary outcome was the occurrence of nonfatal myocardial infa rct ion ( MI ) or CHD death . Secondary cardiovascular outcomes included coronary revascularization , unstable angina , congestive heart failure , resuscitated cardiac arrest , stroke or transient ischemic attack , and peripheral arterial disease . All-cause mortality was also considered . RESULTS Overall , there were no significant differences between groups in the primary outcome or in any of the secondary cardiovascular outcomes : 172 women in the hormone group and 176 women in the placebo group had MI or CHD death ( relative hazard [ RH ] , 0.99 ; 95 % confidence interval [ CI ] , 0.80 - 1.22 ) . The lack of an overall effect occurred despite a net 11 % lower low-density lipoprotein cholesterol level and 10 % higher high-density lipoprotein cholesterol level in the hormone group compared with the placebo group ( each P<.001 ) . Within the overall null effect , there was a statistically significant time trend , with more CHD events in the hormone group than in the placebo group in year 1 and fewer in years 4 and 5 . More women in the hormone group than in the placebo group experienced venous thromboembolic events ( 34 vs 12 ; RH , 2.89 ; 95 % CI , 1.50 - 5.58 ) and gallbladder disease ( 84 vs 62 ; RH , 1.38 ; 95 % CI , 1.00 - 1.92 ) . There were no significant differences in several other end points for which power was limited , including fracture , cancer , and total mortality ( 131 vs 123 deaths ; RH , 1.08 ; 95 % CI , 0.84 - 1.38 ) . CONCLUSIONS During an average follow-up of 4.1 years , treatment with oral conjugated equine estrogen plus medroxyprogesterone acetate did not reduce the overall rate of CHD events in postmenopausal women with established coronary disease . The treatment did increase the rate of thromboembolic events and gallbladder disease . Based on the finding of no overall cardiovascular benefit and a pattern of early increase in risk of CHD events , we do not recommend starting this treatment for the purpose of secondary prevention of CHD . However , given the favorable pattern of CHD events after several years of therapy , it could be appropriate for women already receiving this treatment to continue OBJECTIVES To evaluate whether lipid-lowering therapy with xuezhikang reduces the risk of coronary events and total mortality in patients with coronary heart disease ( CHD ) aged 65 and older . DESIGN Subgroup analysis of the China Coronary Secondary Prevention Study , a r and omized , double-blind , placebo-controlled , clinical trial . SETTING Sixty-six hospitals in China . PARTICIPANTS A total of 1,445 patients , aged 65 to 75 , were chosen from 4,780 patients with a history of myocardial infa rct ion . INTERVENTION The patients were r and omized to the xuezhikang ( n=735 ) or the placebo ( n=710 ) group and followed for a mean of 4 years . MEASUREMENTS The primary endpoint was recurrent coronary events ; the secondary endpoint was all-cause mortality and other clinical events , including adverse effects . RESULTS Elderly patients were at greater risk for coronary events , death from coronary events , all-cause mortality , and malignancies than younger patients .  Xuezhikang therapy reduced the incidence of coronary events 36.9 % ( P=.001 ) , death from coronary heart disease 31.0 % ( P=.04 ) , all-cause mortality 31.9 % ( P=.01 ) , stroke 44.1 % ( P=.04 ) , the need for a percutaneous coronary intervention or coronary artery bypass graft 48.6 % ( P=.07 ) , and malignancies 51.4 % ( P=.03 ) . Based on the treatment of elderly patients with xuezhikang for an average of 4 years , the number needed to treat ( NNT ) to prevent one coronary event , one coronary death , and one mortality due to all causes was estimated to be 18 , 33 , and 23 , respectively . In a like manner , the estimated NNT to prevent one coronary event , one coronary death , and one mortality due to all causes in younger patients was 23 , 82 , and 51 , respectively . There was not a significantly greater number of adverse effects in the xuezhikang group than in the placebo group . CONCLUSION This is the first study demonstrating that treatment with xuezhikang capsules is safe and effective for the secondary prevention of CHD in older Chinese people 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 Weight reduction limits disease progression in obese people with coronary heart disease ( CHD ) and /or type 2 diabetes mellitus ( T2DM ) . Purpose To test a 16-week group-based weight reduction intervention combining exercise , diet and behaviour change strategies aim ed to increase self-efficacy  ( Healthy Eating and Exercise Lifestyle Program — HEELP ) on weight , body mass index ( BMI ) , waist circumference and exercise . Methods Participants with CHD and /or T2DM and BMI between 27 to 39 kg/m2 were r and omised to HEELP  ( n = 83 ) or usual care ( n = 65 ) . Results Participants were aged a mean 63.47 years ( SD 8.9 ) , male ( 58 % ) and Caucasian ( 79 % ) . HEELP participants lost significantly more weight , BMI and waist circumference and exercised more days/week for a longer duration /week than usual care . Clinical ly significant weight loss ( ≥5 % ) was more common in HEELP than usual care . Conclusion The HEELP result ed in weight loss and improved exercise behaviour in obese people with CHD and T2DM PURPOSE To determine whether baseline serum uric acid ( UA ) levels and estrogen-progestin (E+P)-associated change in serum UA in postmenopausal women with coronary disease are associated with recurrent coronary heart disease ( CHD ) events . METHODS 2763 postmenopausal women enrolled in the Heart and Estrogen-Progestin Replacement Study ( HERS ) were r and omly assigned to take conjugated E+P or placebo in a secondary CHD prevention study . The primary outcome for these analyses was nonfatal myocardial infa rct ion or CHD death during a mean follow up of 4.1 years . RESULTS The baseline serum UA for the cohort was 5.4 mg/dl and , compared with placebo , E+P on average lowered serum UA levels slightly ( 0.2 mg/dl ) at one year of follow up ( p<0.0001 ) . Baseline serum UA levels were associated in simple proportional hazards models with CHD events ; each st and ard deviation increase ( 1.3 mg/dl ) was associated with a 22 % increased risk of primary CHD events ( p=.0001 ) . This association , however , was no longer statistically significant after multivariable adjustment ( p=0.36 ) . There was no association between on- study change in serum UA level and any CHD outcome . CONCLUSION Treatment with E+P lowered serum UA levels slightly , but neither baseline UA nor change in UA affected CHD risk OBJECTIVE To explore the effect of community nursing intervention on awareness regarding primary prevention knowledge , self-management , and risk factors for coronary heart disease ( CHD ) in Hengyang City , Hunan Province . METHODS A total of 120 individuals at high risk of CHD were recruited and divided into a control group and an intervention group . The intervention group was given the health knowledge lecture and individual community nursing intervention . The control group was given the routine management . Before and after the intervention , all of the recruiters were evaluated by the awareness on primary prevention knowledge , self-management and risk factors for CHD . RESULTS Before the intervention , there was no significant difference in the demographic data , the cognitive levels regarding primary prevention knowledge , the self-management and the risk factors for CHD between the 2 groups ( P>0.05 ) . After the intervention , the cognitive levels regarding primary prevention knowledge , the self-management and the risk factors for CHD between the 2 groups changed . In the intervention group , the cognitive level was significantly increased ( P<0.05 ) ; the self management score was improved ; the systolic blood pressure , BMI , and the levels of fasting glucose , TC and low density lipoprotein-cholesterol were significantly decreased and the level of high density lipoprotein-cholesterol was significantly increased ( P<0.05 ) . There was no significant difference in the above-mentioned parameters between before and after intervention in the control group ( P>0.05 ) . CONCLUSION The cognitive levels regarding primary prevention knowledge and self-management for CHD can be improved effectively by community nursing intervention in high-risk population of CHD , and the risk factors for CHD can also be reduced Method ological differences and variations in health care regulations among countries often preclude direct comparisons of cost-effectiveness studies . A projected risk model was applied , design ed to determine the economic value in the United States of pravastatin in the secondary prevention of coronary heart disease ( CHD ) , to Belgium using local health care costs . A Markov process was used to model the effectiveness of treatment for 3 years with pravastatin versus placebo in 1000 male CHD patients aged 60 years and clinical ly similar to those in the pravastatin limitation of atherosclerosis in the coronary arteries ( PLAC I ) and pravastatin , lipids and atherosclerosis in the carotid arteries ( PLAC II ) studies . The PLAC I and II trials have shown that pravastatin treatment for 3 years at a weighted mean dose of 36.64 mg daily significantly reduced the incidence of non-fatal myocardial infa rct ion in patients with CHD . Framingham data were used to project the risk of mortality 10 years post-myocardial infa rct ion . The incremental cost per life year gained ( LYG ) , after discounting costs and benefits by 5 % annually , in the setting of Belgian health care regulations , was Belgian francs ( BEF ) 720794 ( US$ 24359 ) for CHD patients with one additional risk factor ; BEF 526464 ( US$ 17792 ) for those with two additional risk factors ; and BEF 392765 ( US$ 13274 ) for those with three or more additional risk factors . The cost per LYG in Belgium appeared to be more sensitive to drug acquisition cost than to costs of medical interventions . The cost-effectiveness ratios of pravastatin monotherapy for 3 years in secondary prevention of CHD , obtained with the same projected risk model , are from 86 to 92 % higher in Belgium than in the United States , due to differences in medical patterns of practice and in intervention costs Background Cardiac rehabilitation is very important for the recovery and the secondary prevention of cardiovascular disease , and one of its main strategies is to increase the level of physical activity . Internet and mobile phone based interventions have been successfully used to help people to achieve this . One of the components that are related to the efficacy of these interventions is tailoring of content to the individual . This trial is study ing the effect of a longitudinally tailored Internet and mobile phone based intervention that is based on models of health behaviour , on the level of physical activity and the adherence to the intervention , as an extension of a face-to-face cardiac rehabilitation stay . Methods / Design A parallel group , cluster r and omized controlled trial . The study population is adult participants of a cardiac rehabilitation programme in Norway with home Internet access and mobile phone , who in monthly clusters are r and omized to the control or the intervention condition . Participants have access to a website with information regarding cardiac rehabilitation , an online discussion forum and an online activity calendar . Those r and omized to the intervention condition , receive in addition tailored content based on models of health behaviour , through the website and mobile text messages . The objective is to assess the effect of the intervention on maintenance of self-management behaviours after the rehabilitation stay . Main outcome is the level of physical activity one month , three months and one year after the end of the cardiac rehabilitation programme . The r and omization of clusters is based on a true r and om number online service , and participants , investigators and outcome assessor are blinded to the condition of the clusters . Discussion The study suggests a theory-based intervention that combines models of health behaviour in an innovative way , in order to tailor the delivered content . The users have been actively involved in its design , and because of the use of Open- Source software , the intervention can easily and at low-cost be reproduced and exp and ed by others . Challenges are the recruitment in the elderly population and the possible underrepresentation of women in the study sample . Funding by Northern Norway Regional Health Authority . Trial registration Trial registry http://www . clinical trials.gov : NCT01223170 Guidelines have recommended that a family history of premature coronary heart disease ( CHD ) warrants screening and preventive efforts , including lifestyle change . The objective of this study was to evaluate the effects of a lifestyle modification program on lipids and novel risk markers in young relatives of patients with premature CHD . In a parallel , r and omized , intervention trial , intensified support to quit smoking and dietary modification was compared with general lifestyle advice in 172 men and women aged 18 to 39 years with a total cholesterol of 5 to 8 mmol/L and > or=1 lipid abnormality ( high low-density lipoprotein [ LDL ] cholesterol , triglycerides or lipoprotein(a ) , or low high-density lipoprotein cholesterol ) . All had a first-degree relative with premature CHD or with hyperlipidemia and other relative(s ) with premature CHD , and 40 % were daily smokers . After a mean of 8 months , the intervention group reduced the dietary intake of saturated fat and cholesterol compared with controls ( p = < 0.01 ) . Ten smokers in the intervention group quit , whereas 2 subjects in the control group started and none quit . LDL cholesterol ( p = 0.007 ) , oxidized LDL ( p = 0.03 ) , and E-selectin ( p = 0.02 ) concentrations were reduced in the intervention group compared with controls . In subjects who quit smoking , concentrations of intercellular adhesion molecule-1 decreased ( 261 + /- 66 to 228 + /- 30 ng/ml ) compared with that in continuing smokers ( 308 + /- 106 ng/ml to 304 + /- 109 ng/ml ) ( p = 0.05 between groups ) . These findings indicate that dietary modification and smoking cessation are feasible in young adults with familial premature CHD and document novel mechanisms by which lifestyle modification may reduce CHD risk Background and aims : Coronary heart disease ( CHD ) is common and the maprity of CHD patients are 65 years or older . There exist only a few r and omized , controlled intervention studies on secondary prevention of CHD among elderly CHD patients . Our study assessed the effects of health advocacy , counseling , and activation programs with outcome variables of changes in the use of fats , lipid-lowering medications , frequency of exercise , cigarette smoking , serum cholesterol and triglyceride concentrations , blood pressure , and symptoms of late-life CHD among CHD patients of the Lieto Study . Methods : R and omized , controlled intervention study . Late-life ( > 65 yrs ) CHD patients were r and omized into intervention group ( IG ) ( n=118 ) and control group ( CG ) ( n=109 ) . Intervention consisted of 16 lectures by experts , eight group discussion s , six group exercise sessions , and three social activity events . Results : The use of lipid-lowering medications became more common in IG than in CG among men ( p=0.041 ) , with a similar tendency among women . Among women , decreases in the means of total serum cholesterol ( p=0.009 ) and LDL-cholesterol ( p=0.049 ) were greater in IG than in CG . Conclusions : The program produced no positive effects on health behavior . Positive effects were gained by the increase in lipid-lowering medications , which reduced mean total serum cholesterol and LDL-cholesterol concentrations . More intensive counseling on health behavior should be planned , implemented , and evaluated BACKGROUND Many dementia and cardiovascular disease ( CVD ) cases in older adults are attributable to modifiable vascular and lifestyle-related risk factors , providing opportunities for prevention . In the Healthy Aging Through Internet Counselling in the Elderly ( HATICE ) r and omized controlled trial , an internet-based multidomain intervention is being tested to improve the cardiovascular risk ( CVR ) profile of older adults . OBJECTIVE To design a multidomain intervention to improve CVR  , based on the guidelines for CVR management , and administered through a coach-supported , interactive , platform to over 2500 community-dwellers aged 65 + in three European countries . METHODS A comparative analysis of national and European guidelines for primary and secondary CVD prevention was performed . Results were used to define the content of the intervention . RESULTS The intervention design focused on promoting awareness and self-management of hypertension , dyslipidemia , diabetes mellitus , and overweight , and supporting smoking cessation , physical activity , and healthy diet . Overall , available guidelines lacked specific recommendations for CVR management in older adults . The comparative analysis of the guidelines showed general consistency for lifestyle-related recommendations . Key differences , identified mostly in methods used to assess the overall CVR , did not hamper the intervention design . Minor country-specific adaptations were implemented to maximize the intervention feasibility in each country . CONCLUSION Despite differences in CVR management within the countries considered , it was possible to design and implement the HATICE multidomain intervention . The study can help define preventative strategies for dementia and CVD that are applicable internationally Summary Irel and has one of the highest death rates in the world from coronary heart disease ( CHD ) and has not shared in the rapid decline in mortality which has occurred in other countries . The Kilkenny Health Project was established as a community-based research and demonstration programme for cardiovascular disease prevention in County Kilkenny and as a pilot project for future national initiatives . The first phase of the health promotion programme in Kilkenny is being carried out between 1985 and 1990 . Changes in behaviour and in factors associated with CHD will be estimated by the difference in changes over time between Kilkenny and the reference area , as measured by independent r and om sample surveys of men and women aged 35 to 64 years .  CHD and stroke events , fatal and non-fatal , will be registered in both areas from 1987–1992.The Project has studied attitudes to CHD and its prevention . Health behaviours have been studied in adults and in post- primary school pupils . Risk factors for CHD have been measured in adults in accordance with the methods of the international MONICA Project . It has been demonstrated that health and education professionals can incorporate preventive activities and health education into everyday practice Introduction Internet-delivered psychological interventions among people with chronic pain have the potential to overcome environmental and economic barriers to the provision of evidence -based psychological treatment in the Irish health service context . While the use of internet-delivered cognitive – behavioural therapy programmes has been consistently shown to have small-to-moderate effects in the management of chronic pain , there is a paucity in the research regarding the effectiveness of an internet-delivered Acceptance and Commitment Therapy ( ACT ) programme among people with chronic pain . The current study will compare the clinical -effectiveness and cost-effectiveness of an online ACT intervention with a waitlist control condition in terms of the management of pain-related functional interference among people with chronic pain . Methods and analysis Participants with non-malignant pain that persists for at least 3 months will be r and omised to one of two study conditions . The experimental group will undergo an eight-session internet-delivered ACT programme over an 8-week period . The control group will be a waiting list group and will be offered the ACT intervention after the 3-month follow-up period . Participants will be assessed preintervention , postintervention and at a 3-month follow-up . The primary outcome will be pain-related functional interference . Secondary outcomes will include : pain intensity , depression , global impression of change , acceptance of chronic pain and quality of life . A qualitative evaluation of the perspectives of the participants regarding the ACT intervention will be completed after the trial . Ethics and dissemination The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Irel and Galway Research Ethics Committee ( 12/05/05 ) . The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer- review ed journals . Trial registration number IS RCT N18166896 BACKGROUND While it has been suggested that periodontal disease may be associated with coronary heart disease , or CHD , there are no data to suggest that the elimination of chronic dental infections actually lowers the risk of developing chronic CHD . The goal of this study was to determine whether people with a definitive elimination of all potential dental infections -- edentulous people , who are at the optimum endpoint of dental infection elimination from a CHD perspective -- lower their CHD risk over time when compared with people who have a specific dental infection , periodontitis . METHODS The authors examined data from a prospect i ve cohort of 4,027 people who participated in the First National Health and Nutrition Examination Survey , or NHANES I , Epidemiologic Follow-up Study . The primary outcome measure was the first CHD event . RESULTS During a mean follow-up of 17 years , there were 1,238 CHD events ( 538 fatal ) . The confirmed elimination of chronic dental infections did not lead to a decreased risk of experiencing a CHD event ( relative risk , 1.02 ; 95 percent confidence interval , 0.86 - 1.21 ) . The CHD risk among people with and without chronic dental infections remained constant over time with respect to each other ( test for increasing or decreasing trend over time : not significant , chi2(1 ) = 0.48 ; P = .93 ) . CONCLUSIONS People who had a complete , definitive and long-term elimination of all potential dental infections through extraction of all teeth did not have lower CHD risk when compared with people with diagnosed periodontitis . CLINICAL IMPLICATION S Until evidence is found to the contrary , the authors suggest that prevention of CHD should not be used as the basis for recommending treatment to eliminate chronic dental infections STUDY OBJECTIVE : To investigate differences between smokers and non-smokers in health behaviour , cardiovascular risk factors , coronary heart disease ( CHD ) risks , health knowledge , health attitudes , and compliance with a CHD prevention programme . DESIGN : Differences between smokers and non-smokers were studied via medical examinations , question naires , physical exercise activity logs , and food record sheets . Data were analysed using univariate and multivariate analyses . The five and 10 year CHD risks were assessed using the Framingham CHD risk estimate . SETTING : The Karolinska Hospital , Stockholm , and Sollentuna Primary Health Centre , Sollentuna , Sweden . PARTICIPANTS : The analyses were based on 158 healthy smoking and non-smoking men aged 35 - 60 years with raised cardiovascular risk factors who enrolled in controlled , r and omised six month diet and exercise programmes .  MAIN RESULTS : Discriminant analysis suggested that smokers , compared with non-smokers , were characterised by a higher alcohol energy percent , lower HDL cholesterol concentration , lower systolic blood pressure , and a higher plasminogen activator inhibitor-1 ( PAI-1 ) value . Knowledge of the risk factors for CHD was not a discriminating factor . Both smokers and non-smokers increased the exercise taken , improved their diet , and lowered their CHD risk . Before , as well as after the intervention , smokers had a higher CHD risk than non-smokers . CONCLUSIONS : The best CHD prevention action that could be taken by smokers would of course be to quit smoking . Those who can not stop should be encouraged to improve their diet and increase the amount of  physical exercise  they take in order to reduce the health hazards of their smoking behaviour BACKGROUND Secondary prevention improves survival , yet implementation is suboptimal . We tested the impact of a systematic hospital-based educational intervention vs. usual care to improve rates of adherence to secondary prevention guidelines among women hospitalized with coronary heart disease ( CHD ) , according to their ethnic status . METHODS Women ( n = 304 , 52 % minorities ) hospitalized with CHD were r and omly assigned to a systematic secondary prevention educational intervention vs. usual care . Adherence to goals for smoking cessation , weight management , physical activity , blood pressure < 140/90 mm Hg , low-density lipoprotein cholesterol ( LDL-C ) < 100 mg/dL ( 2.59 mmol/L ) , and use of aspirin/anticoagulants , beta-blockers , and angiotensin-converting enzyme ( ACE ) inhibitors were assessed at 6 months . RESULTS On admission , minority women were less likely than white women to meet the goals for blood pressure ( OR = 0.46 , 95 % CI 0.26 - 0.80 ) , LDL-C ( OR = 0.57 , CI 0.33 - 0.94 ) , and weight management ( OR = 0.40 , 95 % CI 0.20 - 0.82 ) . There was no difference between the intervention and usual care groups in a summary score of goals met at study completion ; however , minority women in the intervention group were 2.4 times more likely ( 95 % CI 1.13 - 5.03 ) to reach the blood pressure goal at 6 months compared with minority women in usual care . White women in the intervention group were 2.86 times more likely ( 95 % CI 1.06 - 7.68 ) to report use of beta-blockers at 6 months compared with white women in usual care . In a logistic regression model , the interaction term for ethnic status and group assignment was significant for achieving the blood pressure goal ( p = 0.009 ) . CONCLUSIONS A healthcare systems approach to educate women about secondary prevention and blood pressure control may differentially benefit ethnic minority women compared with white women Background Efficacious strategies for the primary prevention of coronary heart disease ( CHD ) are underused , and , when used , have low adherence . Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice . Methods We conducted a r and omized trial of a CHD prevention intervention ( including a computerized decision aid and automated tailored adherence messages ) at one university general internal medicine practice . After obtaining informed consent and collecting baseline data , we r and omized patients ( men and women age 40 - 79 with no prior history of cardiovascular disease ) to either the intervention or usual care . We then saw them for two additional study visits over 3 months . For intervention participants , we administered the decision aid at the primary study visit ( 1 week after baseline visit ) and then mailed 3 tailored adherence reminders at 2 , 4 , and 6 weeks . We assessed our outcomes ( including the predicted likelihood of angina , myocardial infa rct ion , and CHD death over 10 years ( CHD risk ) and self-reported adherence ) between groups at 3 month follow-up . Data collection occurred from June 2007 through December 2009 . All study procedures were IRB approved . Results We r and omized 160 eligible patients ( 81 intervention ; 79 control ) and followed 96 % to study conclusion . Mean predicted CHD risk at baseline was 11.3 % . The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points ( 95 % CI 8 % to 42 % ) , with the biggest effect for aspirin . It also changed predicted CHD risk by -1.1 % ( 95 % CI -0.16 % to -2 % ) , with a larger effect in a pre-specified subgroup of high risk patients . Conclusion A computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk . Clinical trials registration number Clinical Trials.gov : The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease ( CHD ) remains unclear . This systematic review aim ed to determine their effectiveness and included r and omized controlled trials of lifestyle interventions , in primary care or community setting s , 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 The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ( ALLHAT ) was a r and omized , double-blind , active , controlled clinical trial conducted to determine whether newer antihypertensive agents , including doxazosin , an alpha-blocker , differ from chlorthalidone , a diuretic , with respect to coronary heart disease ( CHD ) and other cardiovascular disease ( CVD ) events in hypertensive patients at high risk of CHD . In February 2000 , the doxazosin treatment arm was discontinued , and findings through December 1999 were reported . This report includes an additional 9232 participant-years and 939 CVD events . At 623 clinical centers , patients ( aged > or=55 years ) with hypertension and at least 1 other CHD risk factor were r and omly assigned to either chlorthalidone or doxazosin . The primary outcome measure was the combined occurrence of fatal CHD or nonfatal myocardial infa rct ion ( MI ) , analyzed by intent to treat ; prespecified secondary outcome measures included all-cause mortality , stroke , combined CHD ( fatal CHD , nonfatal MI , hospitalized angina , and coronary revascularization ) , and combined CVD ( combined CHD , stroke , angina treated outside the hospital , heart failure , and peripheral arterial disease ) . Mean follow-up was 3.2 years . There was no difference in primary outcome between the arms ( relative risk [ RR ] , 1.02 ; 95 % confidence interval [ CI ] , 0.92 to 1.15 ) . All-cause mortality also did not differ ( RR , 1.03 ; 95 % CI , 0.94 to 1.13 ) . However , the doxazosin arm compared with the chlorthalidone arm had a higher risk of stroke ( RR , 1.26 ; 95 % CI , 1.10 to 1.46 ) and combined CVD ( RR 1.20 ; 95 % CI , 1.13 to 1.27 ) . These findings confirm the superiority of diuretic-based over alpha-blocker-based antihypertensive treatment for the prevention of CVD BACKGROUND Low intakes or blood levels of eicosapentaenoic and docosahexaenoic acids ( EPA + DHA ) are independently associated with increased risk of death from coronary heart disease ( CHD ) . In r and omized secondary prevention trials , fish or fish oil have been demonstrated to reduce total and CHD mortality at intakes of about 1 g/day . Red blood cell ( RBC ) fatty acid ( FA ) composition reflects long-term intake of EPA + DHA . We propose that the RBC EPA + DHA ( hereafter called the Omega-3 Index ) be considered a new risk factor for death from CHD . METHODS We conducted clinical and laboratory experiments to generate data necessary for the validation of the Omega-3 Index as a CHD risk predictor . The relationship between this putative marker and risk for CHD death , especially sudden cardiac death ( SCD ) , was then evaluated in several published primary and secondary prevention studies . RESULTS The Omega-3 Index was inversely associated with risk for CHD mortality . An Omega-3 Index of > or = 8 % was associated with the greatest cardioprotection , whereas an index of < or = 4 % was associated with the least . CONCLUSION The Omega-3 Index may represent a novel , physiologically relevant , easily modified , independent , and grade d risk factor for death from CHD that could have significant clinical utility Background — Although trials of lifestyle interventions generally focus on cardiovascular disease risk factors rather than hard clinical outcomes , 10-year coronary heart disease ( CHD ) risk can be estimated from the Framingham risk equations . Our objectives were to study the effect of 2 multicomponent lifestyle interventions on estimated CHD risk relative to advice alone and to evaluate whether differences can be observed in the effects of the lifestyle interventions among subgroups defined by baseline variables . Methods and Results — A total of 810 healthy adults with untreated prehypertension or stage I hypertension were r and omized to 1 of 3 intervention groups : An “ advice-only ” group , an “ established ” group that used established lifestyle recommendations for blood pressure control ( sodium reduction , weight loss , and increased physical activity ) , or an “ established-plus-DASH ” group that combined established lifestyle recommendations with the DASH ( Dietary Approaches to Stop Hypertension ) diet . The primary outcome was 10-year CHD risk , estimated from follow-up data collected at 6 months . A secondary outcome was 10-year CHD risk at 18 months . Of the 810 participants , 62 % were women and 34 % were black . Mean age was 50 years , mean systolic/diastolic blood pressure was 135/85 mm Hg , and median baseline Framingham risk was 1.9 % . The relative risk ratio comparing 6-month to baseline Framingham risk was 0.86 ( 95 % confidence interval 0.81 to 0.91 , P<0.001 ) in the established group and 0.88 ( 95 % confidence interval 0.83 to 0.94 , P<0.001 ) in the established-plus-DASH group relative to advice alone . Results were virtually identical in sensitivity analyses , in each major subgroup , and at 18 months . Conclusions — The observed reductions of 12 % to 14 % in estimated CHD risk are substantial and , if achieved , should have important public health benefits OBJECTIVES To estimate the impact of small reductions in the population distribution of diastolic blood pressure ( DBP ) , such as those potentially achievable by population -wide lifestyle modification , on incidence of coronary heart disease ( CHD ) and stroke . DESIGN Published data from the Framingham Heart Study , a longitudinal cohort study , and from the National Health and Nutrition Examination Survey II , a national population survey , were used to examine the impact of a population -wide strategy aim ed at reducing DBP by an average of 2 mm Hg in a population including normotensive subjects . SETTING / PARTICIPANTS White men and women aged 35 to 64 years in the United States . MAIN OUTCOME MEASURES Incidence of CHD and stroke , including transient ischemic attacks ( TIAs ) . RESULTS Data from overviews of observational studies and r and omized trials suggest that a 2-mm Hg reduction in DBP would result in a 17 % decrease in the prevalence of hypertension as well as a 6 % reduction in the risk of CHD and a 15 % reduction in risk of stroke and TIAs . From an application of these results to US white men and women aged 35 to 64 years , it is estimated that a successful population intervention alone could reduce CHD incidence more than could medical treatment for all those with a DBP of 95 mm Hg or higher . It could prevent 84 % of the number prevented by medical treatment for all those with a DBP of 90 mm Hg or higher . For stroke ( including TIAs ) , a population -wide 2-mm Hg reduction could prevent 93 % of events prevented by medical treatment for those with a DBP of 95 mm Hg or higher and 69 % of events for treatment for those with a DBP of 90 mm Hg or higher . A combination strategy of both a population reduction in DBP and targeted medical intervention is most effective and could double or triple the impact of medical treatment alone . Adding a population -based intervention to existing levels of hypertension treatment could prevent an estimated additional 67,000 CHD events ( 6 % ) and 34,000 stroke and TIA events ( 13 % ) annually among all those aged 35 to 64 years in the United States . CONCLUSIONS A small reduction of 2 mm Hg in DBP in the mean of the population distribution , in addition to medical treatment , could have a great public health impact on the number of CHD and stroke events prevented . Whether such DBP reductions can be achieved in the population through lifestyle interventions , in particular through sodium reduction , depends on the results of ongoing primary prevention trials as well as the cooperation of the food industry , government agencies , and health education professionals Background : Little is known about statins in the prevention of  dyslipidaemia induced renal function decline . The secondary coronary heart disease ( CHD ) prevention GREACE study suggested that dose titration with atorvastatin ( 10–80 mg/day , mean dose 24 mg/day ) achieves the national cholesterol educational programme treatment goals and significantly reduces morbidity and mortality , compared with usual care . Aims : To report the effect of statin on renal function compared with untreated dyslipidaemia in both treatment groups . Methods / Results : All patients had plasma creatinine values within the reference range < 115 µmol/litre ( 13 mg/litre ) .  The on study creatinine clearance ( CrCl ) , as estimated ( for up to 48 months ) by the Cockroft-Gault formula , was compared within and between treatment groups using analysis of variance to assess differences over time . Patients from both groups not treated with statins ( 704 ) showed a 5.2 % decrease in CrCl ( p < 0.0001 ) . Usual care patients on various statins ( 97 ) had a 4.9 % increase in CrCl ( p = 0.003 ) . Structured care patients on atorvastatin ( 783 ) had a 12 % increase in CrCl ( p < 0.0001 ) . This effect was more prominent in the lower two quartiles of baseline CrCl and with higher atorvastatin doses . After adjustment for 25 predictors of all CHD related events , multivariate analysis revealed a hazards ratio of 0.84 ( confidence interval 0.73 to 0.95 ; p = 0.003 ) with every 5 % increase in CrCl . Conclusions : In untreated dyslipidaemic patients with CHD and normal renal function at baseline , CrCl declines over a period of three years . Statin treatment prevents this decline and significantly improves renal function , potentially off setting an additional factor associated with CHD risk The primary aim of this study was to estimate the relation between cholesterol reduction and total mortality and coronary heart disease ( CHD ) incidence . Secondarily , the clinical issues of whether the efficacy of cholesterol lowering is dependent on the treatment modality , presence of CHD at baseline , or the simultaneous introduction of other interventions was explored . All r and omized clinical intervention trials of cholesterol reduction were used in an overview analysis of total mortality rate and CHD incidence ; analysis was performed with weighted linear regression . The trials include those that used primary and secondary intervention , diet and drugs , and single or multifactor design .  Nineteen trials were analyzed for total mortality , and of the 19 , 16 were analyzed for CHD incidence rate .  Net difference in cholesterol change between study groups was used as the independent variable , and the three previously mentioned dichotomous design characteristics were used as additional independent variables . For every 1 % reduction in cholesterol , an estimated 2.5 % reduction in CHD incidence is indicated ( 95 % CL : 1.1 , 3.9 ) . With regard to CHD drug trials tended toward better efficiency in cholesterol lowering than did dietary trials . With regard to total mortality , this efficiency was higher in secondary than in primary preventive trials . The efficiency was also somewhat dependent on the baseline cholesterol level . This study shows that cholesterol reduction is effective in lowering CHD incidence , but cholesterol reduction must be at least 8 - 9 % to be effective in lowering total mortality Background Depression is common in people with coronary heart disease ( CHD ) and associated with worse outcome . This study explored the acceptability and feasibility of procedures for a trial and for an intervention , including its potential costs , to inform a definitive r and omized controlled trial ( RCT ) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression . Methods Multi-centre , outcome assessor-blinded , r and omized parallel group study . CHD patients reporting chest pain and scoring 8 or more on the HADS were r and omized to personalized care ( PC ) or treatment as usual ( TAU ) for 6 months and followed for 1 year . Primary outcome was acceptability and feasibility of procedures ; secondary outcomes included mood , chest pain , functional status , well being and psychological process variables . Result 1001 people from 17 General Practice CHD registers in South London consented to be contacted ; out of 126 who were potentially eligible , 81 ( 35 % female , mean age = 65 SD11 years ) were r and omized .  PC  participants ( n = 41 ) identified wide ranging problems to work on with nurse-case managers . Good acceptability and feasibility was indicated by low attrition ( 9 % ) , high engagement and minimal nurse time used ( mean/SD = 78/19 mins assessment , 125/91 mins telephone follow up ) . Both groups improved on all outcomes . The largest between group difference was in the proportion no longer reporting chest pain  ( PC 37 % vs TAU 18 % ; mixed effects model OR 2.21 95 % CI 0.69 , 7.03 ) . Some evidence was seen that self efficacy ( mean scale increase of 2.5 vs 0.9 ) and illness perceptions ( mean scale increase of 7.8 vs 2.5 ) had improved in PC vs TAU participants at 1 year . PC appeared to be more cost effective up to a QALY threshold of approximately £ 3,000 . Conclusions Trial and intervention procedures appeared to be feasible and acceptable . PC allowed patients to work on unaddressed problems and appears cheaper than TAU . Trial Registration Controlled-Trials.com IS RCT Background Cardiovascular disease ( CVD ) is the leading cause of death worldwide . Secondary prevention is essential , but participation rates for cardiac rehabilitation are low . Furthermore , current programmes do not accomplish that patients with CVD change their lifestyle in a way that their individual risk factors for recurrent events decrease , therefore more effective interventions are needed . In this study , the effectiveness of the Hartcoach-programme , a telephonic secondary prevention program focussing on self management , is studied . Methods / design A multicenter , r and omised parallel-group study is being conducted . Participants are 400 patients with acute myocardial infa rct ion ( STEMI , NSTEMI , ) and patients with chronic or unstable angina pectoris ( IAP ) . Patients are recruited through the participating hospitals and r and omly assigned to the experimental group ( Hartcoach-programme plus usual care ) or the control group ( usual care).The Hartcoach-programme consists of a period of six months during which the coach contacts the patient every four to six weeks by telephone . Coaches train patients to take responsibility for the achievement and maintenance of the defined target levels for their particular individual modifiable risk factors . Target levels and treatment goals are agreed by the nurse and patient together . Data collection is blinded and occurs at baseline and after 26 weeks ( post-intervention ) . Primary outcome is change in cardiovascular risk factors ( cholesterol , body mass index , waist circumference , blood pressure , physical activity and diet ) . Secondary outcomes include chances in glucose , HbA1c , medication adherence , self-management and quality of life . Discussion This study evaluates the effects of the Hartcoach-programme on the reduction of individual risk factors of patients with CVDs . Patients who are not invited to follow a hospital based rehabilitation programme or patients who are unable to adhere to such a programme , may be reached by this home based Hartcoach-programme . If positive results are found , the implementation of the Hartcoach-programme will be extended , having implication s for the management of many people with CVD.Trial registration BACKGROUND The America on the Move ( AOM ) Family Intervention Program has been shown to prevent excess weight gain in overweight children . Providing intervention material s via the internet would have the potential to reach more families but may increase sedentary behavior . The purpose was to evaluate whether delivering the AOM Family Intervention via the internet versus printed workbook would have a similar impact on sedentary behaviors in children . METHODS 131 children ( age 8 - 12 ) were r and omized to receive the AOM Family Intervention via the internet or workbook for 12 weeks . Changes in objective ly measured sedentary time and moderate-to vigorous physical activity ( MVPA ) as well as self-reported screen time were compared between groups . RESULTS There were no significant differences between groups in screen time , sedentary time , or MVPA at the end of the 12 week intervention . Families receiving the intervention via the internet were more likely to remain in the study ( 98 % vs. 82 % , P = .016 ) . CONCLUSIONS Using the internet to deliver the lifestyle intervention did not increase  sedentary behavior in children . Attrition rates were lower when the program was delivered by internet versus via printed material s. These results provide support for using the internet to deliver healthy lifestyle programs for children Abstract Objectives : To evaluate the effects of nurse led clinics in primary care on secondary prevention , total mortality , and coronary event rates after four years . Design : Follow up of a r and omised controlled trial by postal question naires and review of case notes and national data sets . Setting : Stratified , r and om sample of 19 general practice s in north east Scotl and . Participants : 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 . Main outcome measures : Components of secondary prevention ( aspirin , blood pressure management , lipid management , healthy diet , exercise , non-smoking ) , total mortality , and coronary events ( non-fatal myocardial infa rct ions and coronary deaths ) . Results : 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 ) Conclusions : 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 . What is already known on this topic Several effective interventions exist for the secondary prevention of coronary heart disease , but implementing them in practice has proved difficult Secondary prevention programmes for coronary heart disease have improved short term outcomes such as processes of care and quality of life What this study adds Short term improvements in uptake of secondary prevention produced by nurse led clinics are maintained in the longer term Improved medical and lifestyle components of secondary prevention produced by nurse led clinics seem to lead to fewer total deaths and coronary Background Decision aids offer promise as a practical solution to improve patient decision making about coronary heart disease ( CHD ) prevention medications and help patients choose medications to which they are likely to adhere . However , little data is available on decision aids design ed to promote adherence . Methods In this paper , we report on secondary analyses of a r and omized trial of a CHD adherence intervention ( second generation decision aid plus tailored messages ) versus usual care in an effort to underst and how the decision aid facilitates adherence . We focus on data collected from the primary study visit , when  intervention participants presented 45 minutes early to a previously scheduled provider visit ; viewed the decision aid , indicating their intent for CHD risk reduction after each decision aid component ( individualized risk assessment and education , values clarification , and coaching ) ; and filled out a post-decision aid survey assessing their knowledge , perceived risk , decisional conflict , and intent for CHD risk reduction . Control participants  did not present early and received usual care from their provider . Following the provider visit , participants in both groups completed post-visit surveys assessing the number and quality of CHD discussion s with their provider , their intent for CHD risk reduction , and their feelings about the decision aid . Results We enrolled 160 patients into our study ( 81 intervention , 79  control ) . Within the decision aid group , the decision aid significantly increased knowledge of effective CHD prevention strategies ( + 21 percentage points ; adjusted p<.0001 ) and the accuracy of perceived CHD risk ( + 33 percentage points ; adjusted p<.0001 ) , and significantly decreased decisional conflict ( -0.63 ; adjusted p<.0001 ) . Comparing between study groups , the decision aid also significantly increased CHD prevention discussion s with providers ( + 31 percentage points ; adjusted p<.0001 ) and improved perceptions of some features of patient-provider interactions . Further , it increased participants ’ intentions for any effective CHD risk reducing strategies ( + 21 percentage points ; 95 % CI 5 to 37 percentage points ) , with a majority of the effect from the educational component of the decision aid . Ninety-nine percent of participants found the decision aid easy to underst and and 93 % felt it easy to use . Conclusions Decision aids can play an important role in improving decisions about CHD prevention and increasing patient-provider discussion s and intent to reduce CHD risk Internet delivered primary prevention interventions for HIV risk reduction present significant challenges . Changing lifestyle behaviors , such as beginning to use condoms , is difficult and men seeking date s on line may want to avoid thinking about HIV risk which may lead to low initiation and high dropout rates . Many Internet delivered HIV risk reduction programs have mimicked face-to-face outreach programs , failing to take advantage of the Internet ’s capabilities or did not conduct evaluation . This study focuses on examining the feasibility , acceptability , and efficacy of an Internet delivered HIV risk reduction program for rural men who have sex with men ( MSM ) . The program included online recruiting , three intervention modules , each with two sessions , online question naires . The intervention was developed based on iterative research and the Information-Motivation-Behavioral skills model . Participants ( N = 475 ) were r and omly assigned to one of six module orders and data were collected automatically at pre-test and after each module . Data supports the feasibility and acceptability of the program as demonstrated by good retention and rapid program completion . Knowledge , self-efficacy , outcome expectancies and motivation increase in a dose response fashion . Post-intervention behavior changes included reduced anal sex and significant increases in condom use . Limitations include a short follow-up period , a predominantly young white rural sample , and the lack of an attention control . Overall the results of the study provide support for the efficacy of Internet-based interventions to reduce risk of HIV infection . Results also support traditional research methods to evaluate HIV prevention programs delivered exclusively through the Internet Coronary heart disease , hypertension , and dyslipidemia are highly prevalent and commonly coexist in people who are middle-aged and older . Previous data suggested that lowering cholesterol concentrations in individuals at high risk of cardiovascular disease improved clinical outcomes . Xuezhikang , a partial extract of red yeast rice containing statin , has a marked impact on lipids . The purpose of this study , therefore , was to evaluate the impact of Xuezhikang on reducing cardiovascular events and mortality in elderly Chinese hypertensive patients with a history of myocardial infa rct ion ( MI ) enrolled in the Chinese Coronary Secondary Prevention Study . In this r and omized trial , 1530 elderly hypertensive patients ( > or = 65-years-old ) with previous MI were assigned either to placebo ( n = 758 ) or to Xuezhikang ( n = 772 ) daily for an average of 4.5 years . The primary endpoint was recurrent coronary events ; the secondary endpoint was all-cause mortality and other clinical events , including adverse effects . There were 68 cases of coronary events ( 8.8 % ) detected in the Xuezhikang group and 108 cases ( 14.3 % ) in the placebo group ( 38.2 % risk reduction by Xuezhikang therapy ) . Death from coronary heart disease ( CHD ) totaled 49 cases in the Xuezhikang group ( 6.4 % ) and 68 cases in the placebo group ( 9.0 % ) , indicating that Xuezhikang significantly decreased the risk of CHD death by 29.2 % . Our study demonstrated that Xuezhikang therapy could effectively and safely reduce cardiovascular events and all-cause death in Chinese elderly hypertensive patients with previous MI . This finding may have an important implication for the treatment of elderly hypertensive patients with CHD BACKGROUND Pulse pressure ( PP ) has been shown to predict risk for cardiovascular events in men ; however , this association has not been well established in women .  Hormone replacement therapy may improve arterial compliance , but findings from cross-sectional and prospect i ve studies report inconsistent results . We sought to examine the relationship between PP and risk for cardiovascular events , and to determine the effect of hormone therapy on PP in postmenopausal women with coronary heart disease ( CHD ) . METHODS AND RESULTS A total of 2,763 postmenopausal women ( mean age , 66 + /- 7 years [ + /- SD ] ) with CHD in the Heart and Estrogen/Progestin Replacement Study , a r and omized , placebo-controlled , secondary CHD prevention trial of estrogen plus progestin , were followed up on average for 4.1 years . BP was measured at baseline and annually . Mean baseline PP was 62 + /- 16 mm Hg . There were 361 myocardial infa rct ions ( MIs ) or CHD deaths , 265 hospitalizations for congestive heart failure ( CHF ) , and 215 strokes or transient ischemic attacks ( TIAs ) . Women in the highest quartile of PP at baseline had a 47 % increase in risk for MI or CHD death and more than a twofold increase in risk for stroke and TIA events or hospitalization for CHF ( p < 0.01 for each outcome ) . After adjustment for other cardiovascular risk factors and mean arterial pressure , PP remained significantly associated with incident stroke or TIA events ( odds ratio , 1.25 ; p = 0.02 ) and hospitalizations for CHF ( odds ratio , 1.31 ; p < 0.01 ) but not with MI or CHD death . After adjustment for diastolic BP , systolic BP was similarly associated with stroke or TIA ( odds ratio , 1.30 ; p < 0.01 ) and hospitalized CHF ( odds ratio , 1.30 ; p < 0.01 ) and was also weakly associated with risk for MI and CHD death ( odds ratio , 1.18 ; p = 0.02 ) . Mean PP was 1- to 2-mm Hg higher in women r and omized to hormone replacement therapy vs those receiving placebo ( p < 0.01 ) . CONCLUSIONS PP had predictive value for CHF and stroke or TIA , but not MI or CHD death in this cohort of postmenopausal women with CHD . Use of hormone replacement therapy produced a small , statistically significant increase in PP . Further research is necessary to determine the clinical utility of PP as a potential therapeutic target Background : Exercise training is beneficial , but most persons with multiple sclerosis ( MS ) are sedentary and physically inactive . This has prompted a new focus on the promotion of lifestyle physical activity in MS . We previously design ed , tested , and refined a behavioral intervention delivered through the Internet that successfully increased lifestyle physical activity in MS , but have not evaluated the effects on secondary symptomatic and health-related quality of life ( HRQOL ) outcomes . Objective : We conducted a 6-month r and omized controlled trial ( RCT ) that examined the efficacy of an Internet-delivered , behavioral intervention for improving outcomes of fatigue , depression , anxiety , pain , sleep quality , and HRQOL in 82 ambulatory persons with MS . The secondary aim was to replicate previous results regarding change in free-living physical activity . Results : There was a significant and positive effect of the intervention on fatigue severity ( p=.001 , ηρ2=.15 ) and its physical impact ( p=.008 , ηρ2=.09 ) , depression ( p=.006 , ηρ2=.10 ) , and anxiety ( p=.006 , ηρ2=.10 ) . There were non-significant improvements in pain ( p=.08 , ηρ2=.04 ) , sleep quality ( p=.06 , ηρ2=.05 ) , and physical HRQOL ( p=.06 , ηρ2=.05 ) . We replicated our previous results by demonstrating an increase in self-reported physical activity ( p=.001 , ηρ2=.13 ) . Conclusions : Our results support behavioral interventions targeting lifestyle physical activity as an alternative approach for managing symptoms in MS Background : The Mediterranean Lifestyle Program was evaluated for its effects on multiple behavioral risk factors for coronary heart disease ( CHD )  among postmenopausal women with diabetes . Purpose : Our purpose is to test a comprehensive lifestyle management intervention to reduce CHD risk in postmenopausal women with type 2 diabetes . Methods : Participants ( N = 279 ) were r and omized to usual care ( UC ) or Mediterranean Lifestyle Program , a lifestyle change intervention aim ed at the behavioral risk factors ( eating patterns , physical activity , stress management , and social support ) affecting risk for CHD in postmenopausal women with type 2 diabetes . Results : In original and intent-to-treat analyses ,  Mediterranean Lifestyle Program participants showed significantly greater improvement in dietary behaviors , physical activity , stress management , perceived support , and weight loss at 6 months compared to UC . Conclusions : This study demonstrated the effectiveness of the Mediterranean Lifestyle Program in improving self-care among women with type 2 diabetes , showed that postmenopausal women could make comprehensive lifestyle changes , and provided evidence that a program using social-cognitive strategies and peer support can be used to modify multiple lifestyle behaviors OBJECTIVES Cardiovascular diseases are the most frequent cause of death in industrialized countries . Non-adherence with prescribed medication and recommended lifestyle changes significantly increases the risk of major cardiovascular events . The telemonitoring programme MyCor ( Myokardinfarkt und Koronarstent Programm in Tirol ) is a multi-modal intervention programme to improve lifestyle and medication management of patients with coronary heart disease ( CHD ) . It includes patient education , self-monitoring with goal - setting and feedback , and regular clinical visits . We evaluated the MyCor telemonitoring programme regarding technical feasibility , user acceptance , patient adherence , change in health status , and change in quality of life . METHODS A 4½-month study was conducted with two telemonitoring phases and one interim phase . The study comprised patient surveys , st and ardized assessment of quality of life using the MacNew question naire at study entry and after 4 and 18 weeks , analysis of adherence to medication and physical activity during the two telemonitoring phases , and analysis of reached goals regarding health conditions during the telemonitoring phases . RESULTS Twenty-five patients ( mean age : 63 years ) participated in the study . Patients showed a high acceptance of the MyCor telemonitoring programme . Patients reported feelings of self-control , motivation for lifestyle changes , and improved quality of life . Adherence to daily measurements was high with 86 % and 77 % in the two telemonitoring phases . Adherence to medication was also high with up to 87 % and 80 % . Pre-defined goals for physical activity were reached in up to 86 % and 73 % of days , respectively . Quality of life improved from 5.5 at study entry to 6.3 at the end ( p < 0.01 ; MacNew question naire ) . Reductions in blood pressure and heart rate or an improvement in reaching defined goals could not be observed . CONCLUSIONS The MyCor telemonitoring programme Tirol for CHD patients has a high rate of acceptance among included patients . Critical evaluation revealed subjective benefits regarding quality of life and health status as well as high adherence rates to medication and lifestyle changes . Achieving long-term adherence and verifying clinical outcomes , however , remains an open issue . Our findings will promote further studies , addressing different strategies for an optimal mix of patient education , telemonitoring , feedback , and clinical follow-ups Background Cardiovascular disease is the leading cause of morbidity and mortality in the world , including China . Cardiac rehabilitation ( CR ) has been demonstrated to be beneficial in reducing cardiovascular mortality , myocardial infa rct ion , and cerebrovascular events . This pilot study seeks to assess the feasibility of aerobic-exercise-based CR in Chinese patients with coronary heart disease ( CHD ) and outcomes of aerobic metabolism capacity and molecular biomarkers . Methods / design This study is a single-center , pilot , r and omized , controlled study that is currently being carried out at a regional hospital in Shanghai . Forty patients with CHD who underwent percutaneous coronary intervention will be r and omly allocated into either the intervention group or control group . Participants in the intervention group will undergo 8 weeks of aerobic exercise with targeted intensity and participants in the control group will undergo 8 weeks of leisure exercise . The primary measurement is the feasibility of the trial ; the secondary measurement is the capacity of aerobic metabolism and the exploratory measurement includes additional molecular biomarkers underlying cardiovascular function . Discussion This is the first prospect i ve r and omized and controlled clinical study in China that assesses the parameters of aerobic metabolism and comprehensively screens for substantial blood biomarkers to reveal the molecular mechanisms underlying changes in cardiovascular function after aerobic exercise with targeted intensity in participants with CHD . The success of this study will contribute to guide the design of future CR studies in patients with CHD in China . Trial registration Chinese Clinical Trial Registry , ChiCTR-IPR-17010556 . Registered on 1 June 2016 AIMS To establish the long-term efficacy of a universal internet-based alcohol and cannabis prevention programme in schools . METHODS A cluster-r and omized controlled trial was conducted to assess the effectiveness of the Climate Schools : Alcohol and Cannabis Course . The evidence -based course , aim ed at reducing alcohol and cannabis use , is facilitated by the internet and consists of 12 novel and curriculum consistent lessons delivered over 6 months . PARTICIPANTS A total of 764 year 8 students ( 13 years ) from 10 Australian secondary schools were allocated r and omly to the  internet-based prevention programme  ( n = 397 , five schools ) , or to their usual health classes  ( n = 367 , five schools ) . MEASURES Participants were assessed at baseline , immediately post , and 6 and 12 months following completion of the intervention , on measures of alcohol and cannabis knowledge , attitudes , use and related harms . RESULTS This paper reports the final results of the intervention trial , 12 months following the completion of the Climate Schools : Alcohol and Cannabis Course . The effectiveness of the course 6 months following the intervention has been reported previously . At the 12-month follow-up , compared to the control group , students in the intervention group showed significant improvements in alcohol and cannabis knowledge , a reduction in average weekly alcohol consumption and a reduction in frequency of drinking to excess . No differences between groups were found on alcohol expectancies , cannabis attitudes or alcohol- and cannabis-related harms . The course was found to be acceptable by teachers and students as a means of delivering drug education in schools . CONCLUSIONS Internet-based prevention programs for school-age children can improve student 's  knowledge about alcohol and cannabis , and may also reduce alcohol use twelve months after completion Objective To investigate whether an internet based , nurse led vascular risk factor management programme promoting self management on top of usual care is more effective than usual care alone in reducing vascular risk factors in patients with clinical ly manifest vascular disease . Design Prospect i ve r and omised controlled trial . Setting Multicentre trial in secondary and tertiary healthcare setting . Participants 330 patients with a recent clinical manifestation of atherosclerosis in the coronary , cerebral , or peripheral arteries and with at least two treatable risk factors not at goal . Intervention Personalised website with an overview and actual status of patients ’ risk factors and mail communication via the website with a nurse practitioner for 12 months ; the intervention combined self management support , monitoring of disease control , and drug treatment . Main outcome measures The primary endpoint was the relative change in Framingham heart risk score after 1 year . Secondary endpoints were absolute changes in the levels of risk factors and the differences between groups in the change in proportion of patients reaching treatment goals for each risk factor . Results Participants ’ mean age was 59.9 ( SD 8.4 ) years , and most patients ( n=246 ; 75 % ) were male . After 1 year , the relative change in Framingham heart risk score of the intervention group compared with the usual care group was −14 % ( 95 % confidence interval −25 % to −2 % ) . At baseline , the Framingham heart risk score was higher in the intervention group than in the usual care group ( 16.1 ( SD 10.6 ) v 14.0 ( 10.5 ) ) , so the outcome was adjusted for the separate variables of the Framingham heart risk score and for the baseline Framingham heart risk score . This produced a relative change of −12 % ( −22 % to −3 % ) in Framingham heart risk score for the intervention group compared with the usual care group adjusted for the separate variables of the score and −8 % ( −18 % to 2 % ) adjusted for the baseline score . Of the individual risk factors , a difference between groups was observed in low density lipoprotein cholesterol ( −0.3 , −0.5 to −0.1 , mmol/L ) and smoking ( −7.7 % , −14.9 % to −0.4 % ) . Some other risk factors tended to improve ( body mass index , triglycerides , systolic blood pressure , renal function ) or tended to worsen ( glucose concentration , albuminuria ) . Conclusion An internet based , nurse led treatment programme on top of usual care for vascular risk factors had a small effect on lowering vascular risk and on lowering of some vascular risk factors in patients with vascular disease . Trial registration Clinical trials NCT00785031 BACKGROUND Low-density lipoprotein (LDL)-based guidelines are currently used to initiate and monitor cholesterol-lowering therapy . METHODS Using stratified analyses , data from the Framingham Heart Study and the Coronary Primary Prevention Trial were evaluated to determine whether ( 1 ) cholesterol levels  ( total cholesterol [ TC ] or LDL [ low-density lipoprotein ] ) better discriminated risk for coronary heart disease ( CHD ) than cholesterol ratios ( LDL/HDL [ high-density lipoprotein ] or TC/HDL ) ; and ( 2 ) whether changes in ratios better predicted risk reduction than changes in levels . RESULTS Individuals with similar LDL/HDL ratios had similar risks for CHD regardless of whether they had high LDL levels or low LDL levels ( 23 % vs 23 % for the CPPT , 13.8 % vs 14 % for FHS men , and 8.6 % vs 10.9 % for FHS women ) . Among men with similar initial LDL/HDL ratios  and similar changes in LDL/HDL ratios , risks for CHD did not differ ( 20.3 % compared with 21.0 % ; p = 0.96 ) between those with the largest and smallest reductions in LDL levels ( 21.3 % compared with 6.5 % ) . Among men with similar initial LDL levels  and similar LDL reductions  , a 20 % reduction in risk for CHD was seen ( 19.5 % compared with 24.5 % ; p = 0.005 ) between those with the largest and smallest reductions in LDL/HDL ratios ( 23 % compared with 4.6 % ) . TC/HDL had predictive ability similar to LDL/HDL . CONCLUSIONS Cholesterol levels do not provide incremental predictive value over cholesterol ratios in identifying people at risk for CHD . Changes in ratios are better predictors of successful CHD risk reduction than changes in levels . Future guidelines should consider incorporating ratios in initiating and monitoring successful lipid-lowering therapy BACKGROUND The beneficial effects of statins on cardiovascular mortality in secondary prevention have been established in several long-term , placebo-controlled trials . However , the value of statin therapy in reduction of overall mortality in patients without coronary heart disease ( CHD ) is question able . This study evaluated the effect of statin therapy in subjects with no indication of cardiovascular disease ( primary prevention ) and patients with known CHD ( secondary prevention ) . METHODS This retrospective cohort study included 229 918 adult enrollees in a health maintenance organization in Israel who initiated statin treatment from 1998 through 2006 ( mean age , 57.6 years ; 50.8 % female ) .  Proportion of days covered ( PDC ) with  statins  was measured by the number of dispensed  statin prescriptions during the interval between the date of the first statin prescription and the end of follow-up . RESULTS During a mean of 4.0 and 5.0 years of follow-up , there were 4259 and 8906 deaths among the primary prevention and secondary prevention cohorts , respectively . In both cohorts , continuity of treatment with statins ( PDC , > or = 90 % ) conferred at least a 45 % reduction in risk of death compared with patients with a PDC of less than 10 % . A stronger risk reduction was calculated among patients with high baseline low-density lipoprotein cholesterol level and patients initially treated with high-efficacy statins . CONCLUSIONS Better continuity of statin treatment provided an ongoing reduction in mortality among patients with and without a known history of CHD . The observed benefits from statins were greater than expected from r and omized clinical trials BACKGROUND Although primary care is the major target of coronary heart disease ( CHD ) clinical recommendations , little is known of how community physicians view guidelines and their implementation . The REACT survey was design ed to assess the views , and perceived implementation , of CHD and lipid treatment guidelines among primary care physicians . METHODS Semi-structured vali date d telephone interviews were conducted , in the relevant native tongue , with 754 r and omly selected primary care physicians ( GPs and family doctors ) in five European countries ( France , Germany , Italy , Sweden and the UK ) . RESULTS Most physicians ( 89 % ) agreed with the content of current guidelines and reported use of them ( 81 % ) . However , only 18 % of physicians believed that guidelines were being implemented to a major extent . Key barriers to greater implementation of guidelines were seen as lack of time ( 38 % of all physicians ) , prescription costs ( 30 % ) , and patient compliance ( 17 % ) . Suggestions for ways to improve implementation centred on more education , both for physicians themselves ( 29 % ) and patients ( 25 % ) ; promoting , publicizing or increasing guideline availability ( 23 % ) ; simplifying the guidelines ( 17 % ) ; and making them clearer ( 12 % ) . Physicians perceived diabetes to be the most important risk factor for CHD , followed by hypertension and raised LDL-C. Most physicians ( 92 % ) believe their patients do associate high cholesterol levels with CHD . After establishing that a patient is ' at risk ' of CHD , physicians reported spending an average of 16.5 minutes discussing risk factors and lifestyle changes or treatment that is required . Factors preventing this included insufficient time ( 42 % ) , having too many other patients to see ( 27 % ) and feeling that patients did not listen or underst and anyway ( 21 % ) . CONCLUSIONS Primary care physicians need more information and support on the implementation of CHD and cholesterol guideline recommendations . This need is recognized by clinicians Background In the presence of type 2 diabetes ( T2DM ) or coronary heart disease ( CHD ) , depression is under diagnosed and under treated despite being associated with worse clinical outcomes . Our earlier pilot study demonstrated that it was feasible , acceptable and affordable for practice nurses to extend their role to include screening for and monitoring of depression alongside biological and lifestyle risk factors . The current study will compare the clinical outcomes of our model of practice nurse-led collaborative care with usual care for patients with depression and T2DM or CHD . Methods This is a cluster-r and omised intervention trial . Eighteen general practice s from regional and metropolitan areas agreed to join this study , and were allocated r and omly to an intervention or control group . We aim to recruit 50 patients with co-morbid depression and diabetes or heart disease from each of these practice s. In the intervention group , practice nurses ( PNs ) will be trained for their enhanced roles in this nurse-led collaborative care study . Patients will be invited to attend a practice nurse consultation every 3 months prior to seeing their usual general practitioner . The PN will assess psychological , physiological and lifestyle parameters then work with the patient to set management goals . The outcome of this assessment will form the basis of a GP Management Plan document . In the control group , the patients will continue to receive their usual care for the first six months of the study before the PNs undergo the training and switch to the intervention protocol . The primary clinical outcome will be a reduction in the depression score . The study will also measure the impact on physiological measures , quality of life and on patient attitude to health care delivered by practice nurses . Conclusion The strength of this programme is that it provides a sustainable model of chronic disease management with monitoring and self-management assistance for physiological , lifestyle and psychological risk factors for high-risk patients with co-morbid depression , diabetes or heart disease . The study will demonstrate whether nurse-led collaborative care achieves better outcomes than usual care 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 Pharmacologic treatment for secondary prevention of coronary heart disease ( CHD ) is critical to prevent adverse clinical outcomes . In a r and omized controlled trial , we compared antiplatelet and statin adherence among patients with CHD who received : ( 1 ) text messages ( TM ) for medication reminders and education , ( 2 ) educational TM only , or ( 3 ) No TM .  METHODS A mobile health intervention delivered customized TM for 30 days . We assessed and analyzed medication adherence with electronic monitoring devices [ Medication Event Monitoring System ( MEMS ) ] by one-way ANOVA and Welch tests , two-way TM response rates by t-tests , and self-reported adherence ( Morisky Medication Adherence Scale ) by Repeated Measures ANOVA . RESULTS Among 90 patients ( 76 % male , mean age 59.2 years ) , MEMS revealed patients who received TM for antiplatelets had a higher percentage of correct doses taken ( p=0.02 ) , percentage number of doses taken ( p=0.01 ) , and percentage of prescribed doses taken on schedule ( p=0.01 ) .  TM response rates were higher for antiplatelets than statins ( p=0.005 ) . Self-reported adherence revealed no significant differences among groups . CONCLUSION TM increased adherence to antiplatelet therapy demonstrated by MEMS and TM responses . PRACTICE IMPLICATION S Feasibility and high satisfaction were established . Mobile health interventions show promise in promoting medication adherence A definitive model for predicting absolute risk of coronary heart disease ( CHD ) in male and female people with Type II diabetes is not yet available . This paper provides an equation for estimating the risk of new CHD events in people with Type II diabetes , based on data from 4540 U.K. Prospect i ve Diabetes Study male and female patients . Unlike previously published risk equations , the model is diabetes-specific and incorporates  glycaemia , systolic blood pressure and lipid levels  as risk factors , in addition to age , sex , ethnic group , smoking status and time since diagnosis of diabetes . All variables included in the final model were statistically significant ( P<0.001 , except smoking for which P=0.0013 ) in likelihood ratio testing . This model provides the estimates of CHD risk required by current guidelines for the primary prevention of CHD in Type II diabetes Background Even though there is convincing evidence that self-care , such as regular exercise and /or stopping smoking , alters the outcomes after an event of coronary heart disease ( CHD ) , risk factors remain . Outcomes can improve if core components of secondary prevention programmes are structurally and pedagogically applied using adult learning principles e.g. problem-based learning ( PBL ) . Until now , most education programs for patients with CHD have not been based on such principles . The basic aim is to discover whether PBL provided in primary health care ( PHC ) has long-term effects on empowerment and self-care after an event of CHD . Methods / Design A r and omised controlled study is planned for patients with CHD . The primary outcome is empowerment to reach self-care goals . Data collection will be performed at baseline at hospital and after one , three and five years in PHC using quantitative and qualitative method ologies involving question naires , medical assessment s , interviews , diaries and observations . R and omisation of 165 patients will take place when they are stable in their cardiac condition and have optimised cardiac medication that has not substantially changed during the last month . All patients will receive conventional care from their general practitioner and other care providers . The intervention consists of a patient education program in PHC by trained district nurses ( tutors ) who will apply PBL to groups of 6–9 patients meeting on 13 occasions for two hours over one year . Patients in the control group will not attend a PBL group but will receive home-sent patient information on 11 occasions during the year . Discussion We expect that the 1-year PBL-patient education will improve patients ’ beliefs , self-efficacy and empowerment to achieve self-care goals significantly more than one year of st and ardised home-sent patient information . The assumption is that PBL will reduce cardiovascular events in the long-term and will also be cost-effective compared to controls . Further , the knowledge obtained from this study may contribute to improving patients ’ ability to h and le self-care , and furthermore , may reduce the number of patients having subsequent CHD events in Sweden . Trial registration Background Many patients with type 2 diabetes fail to achieve good glycaemic control . Poor control is associated with complications including coronary heart disease ( CHD ) . Effective self-management and engagement in health behaviours can reduce risks of complications . However , patients often struggle to adopt and maintain these behaviours . Self-management interventions have been found to be effective in improving glycaemic control . Recent developments in the field of genetics mean that patients can be given personalised information about genetic- and lifestyle-associated risk of developing CHD . Such information may increase patients ’ motivation to engage in self-management . The Coronary Risk in Diabetes ( CoRDia ) trial will compare the effectiveness of a self-management intervention , with and without provision of personalised genetic- and lifestyle-associated risk information , with usual care , on clinical and behavioural outcomes , the cognitive predictors of behaviour , and psychological wellbeing . Methods / Design Participants will be adults aged 25–74 years registered with general practice s in the East of Engl and , diagnosed with type 2 diabetes , with no history of heart disease , and with a glycated haemoglobin level of ≥6.45 % ( 47 mmol/mol ) . Consenting participants will be r and omised to one of three arms : usual care control , group self-management only , group self-management plus personalised genetic- and lifestyle-associated risk information . The self-management groups will receive four weekly 2-hour group sessions , focusing on knowledge and information sharing , problem solving , goal setting and action planning to promote medication adherence , healthy eating , and physical activity . Primary outcomes are glycaemic control and CHD risk . Clinical data will be collected from GP records , including HbA1c , weight , body mass index , blood pressure , and HDL and total cholesterol . Self-reported health behaviours , including medication adherence , healthy eating and physical activity , and cognitive outcomes will be assessed by question naire . Measures will be taken at baseline , 3 months ( question naire only ) , 6 months and 12 months post-baseline . Discussion This study will determine whether the addition of personalised genetic- and lifestyle-associated CHD risk information to a group self-management intervention  improves diabetes control and CHD risk compared with group self-management and usual care . Effectiveness of the combined intervention on health behaviours cognitions theorised to predict them , and psychological outcomes will also be investigated . Trial registration This study has been registered at Clinical Trials.gov ; registration identifier NCT01891786 , registered 28 June 2013 This cost-benefit analysis attempts to translate the clinical findings of the Helsinki Heart Study ( HHS ) and published results regarding additional cardiovascular conditions into economic terms meaningful to US managed care providers . The study has the following 3 key objectives : to define the cost effectiveness of gemfibrozil in the prevention of coronary  heart disease ( CHD ) ; to assess the net impact of gemfibrozil on total treatment costs for CHD ; and to identify those patient groups for whom gemfibrozil therapy is most cost effective . In order to reach these findings a cost-effectiveness model was constructed based on original clinical data provided by the HHS , published findings for CHD risk and cost of treatment in the US , expert opinion and extension of HHS to other cardiovascular conditions , and documented costs and treatment protocol s of US Medicaid and privately managed health care programmes . The model was applied to the California Medicaid ( Medi-Cal ) programme to estimate costs of hyperlipidaemia therapy using gemfibrozil . In parallel , savings to Medi-Cal from averted coronary events were estimated . From these data , the net expected savings to Medi-Cal were calculated . The probability of experiencing CHD varies with cholesterol level , age , sex and risk factors such as smoking , hypertension and diabetes . Therefore , it is possible to use risk-factor profiles to define groups of individuals with low , moderate or high risk of experiencing acute myocardial infa rct ion ( AMI ) or sudden cardiac death . The probability of a cardiac event within 5 years ranges from 1.1 % in a 45-year-old low risk male to over 36 % in a 55-year-old high risk male . The average total cost of CHD care was found to be US$ 22,271 within 5 years . Using the probability of a CHD event to calculate the expected 5-year cost of CHD care produces a range from US$ 242 in the 45-year-old low risk male to US$ 8084 in the 55-year-old high risk male . Treatment with gemfibrozil reduces the probability of AMI and sudden cardiac death events by 34 % , as demonstrated in the HHS . Therefore , the corresponding probability ranges are reduced to 0.7 % in the 45-year-old low risk male and 27.3 % in the 55-year-old high risk male after treatment with gemfibrozil . The expected cost of a coronary event is reduced by US$ 82 and US$ 1997 , respectively . ( ABSTRACT TRUNCATED AT 400 WORDS Aims We assessed whether a novel programme to evaluate/communicate predicted coronary heart disease ( CHD ) risk could lower patients ' predicted Framingham CHD risk vs. usual care . Methods The Risk Evaluation and Communication Health Outcomes and Utilization Trial was a prospect i ve , controlled , cluster-r and omised trial in nine European countries , among patients at moderate cardiovascular risk . Following baseline assessment s , physicians in the intervention group calculated patients ' predicted CHD risk and were instructed to advise patients according to a risk evaluation/communication programme . Usual care physicians did not calculate patients ' risk and provided usual care only . The primary end-point was Framingham 10-year CHD risk at 6 months with intervention vs. usual care . Results Of 1103 patients across 100 sites , 524 patients receiving intervention , and 461 receiving usual care , were analysed for efficacy . After 6 months , mean predicted risks were 12.5 % with intervention , and 13.7 % with usual care [ odds ratio = 0.896 ; p = 0.001 , adjusted for risk at baseline ( 17.2 % intervention ; 16.9 % usual care ) and other covariates ] . The proportion of patients achieving both blood pressure and low-density lipoprotein cholesterol targets was significantly higher with intervention ( 25.4 % ) than usual care ( 14.1 % ; p < 0.001 ) , and 29.3 % of smokers in the intervention group quit smoking vs. 21.4 % of those receiving usual care ( p = 0.04 ) . Conclusions A physician-implemented CHD risk evaluation/communication programme improved patients ' modifiable risk factor profile , and lowered predicted CHD risk compared with usual care . By combining this strategy with more intensive treatment to reduce residual modifiable risk , we believe that substantial improvements in cardiovascular disease prevention could be achieved in clinical practice BACKGROUND Secondary prevention is an important goal of cardiac rehabilitation in patients with coronary heart disease ( CHD ) . Dyslipidemia is one of the major risk factors that is important to control to reduce the incidence of future ischemic coronary events . The aim of the present study was to assess whether control of dyslipidemia , in secondary prevention , could be improved by a comprehensive cardiac rehabilitation program . METHODS Fifty-two newly diagnosed hyperlipidemic men , who had experienced a recent CHD event , were separated in two equal groups of 26 patients : group CR+ , in which patients were included in a 2-month cardiac rehabilitation program including an extensive educational program on cardiovascular risk factors , lipids , and diet , and group CR-without any cardiac rehabilitation . Mean age , body mass index , initial levels of total cholesterol , triglycerides , high-density lipoprotein ( HDL ) cholesterol , low-density lipoprotein ( LDL ) cholesterol , and LDL/HDL ratio were not significantly different between the 2 groups . In both groups , each patient was referred to a dietitian and to the same lipidologist to start an appropriate hypolipidemic treatment . Treatment of coronary event , type of hyperlipidemia , and hypolipidemic treatment were not different between the two groups . RESULTS Lipid measurements , performed 3 months after the beginning of the hypolipidemic treatment , showed that patients from the CR+ group , compared with those from the CR-group , had a significantly greater reduction of total cholesterol ( 23 % versus 13 % ; P < 0.001 ) , of LDL cholesterol ( 28 % versus 12 % ; P < 0.001 ) , of LDL/HDL ratio ( 34 % versus 13 % ; P < 0.01 ) and of triglycerides ( 33 % versus 21 % ; P = 0.05 ) . CONCLUSIONS Patients with CHD included in a comprehensive cardiac rehabilitation program showed a significantly better response to the hypolipidemic treatment than patients without cardiac rehabilitation . These results could be attributable to the extensive educational program on secondary prevention performed during cardiac rehabilitation , leading to optimized knowledge on lipid-lowering diet and to improved diet and drug adherence . A secondary prevention educational program must be an important part of any comprehensive cardiac rehabilitation program in patients with CHD OBJECTIVES Assess the risk of ischaemic events associated with psychosocial stress in patients with stable coronary heart disease ( CHD ) . METHODS Psychosocial stress was assessed by a question naire  in 14 577 patients ( median age 65.0 , IQR 59 , 71 ; 81.6 % males ) with stable CHD on optimal secondary preventive therapy in the prospect i ve r and omized STABILITY clinical trial . Adjusted Cox regression models were used to assess associations between individual stressors , baseline cardiovascular risk factors and outcomes . RESULTS After 3.7 years of follow-up , depressive symptoms , loss of interest and financial stress were associated with increased risk ( hazard ratio , 95 % confidence interval ) of CV death ( 1.21 , 1.09 - 1.34 ; 1.15 , 1.05 - 1.27 ; and 1.19 , 1.08 - 1.30 , respectively ) and the primary composite end-point of CV death , nonfatal MI or nonfatal stroke ( 1.21 , 1.13 - 1.30 ; 1.19 , 1.11 - 1.27 ; and 1.17 , 1.10 - 1.24 , respectively ) . Living alone was related to higher risk of CV death ( 1.68 , 1.38 - 2.05 ) and the primary composite end-point ( 1.28 , 1.11 - 1.48 ) , whereas being married as compared with being widowed , was associated with lower risk of CV death ( 0.64 , 0.49 - 0.82 ) and the primary composite end-point ( 0.81 , 0.67 - 0.97 ) . CONCLUSIONS Psychosocial stress , such as depressive symptoms , loss of interest , living alone and financial stress , were associated with increased CV mortality in patients with stable CHD despite optimal medical secondary prevention treatment . Secondary prevention of CHD should therefore focus also on psychosocial issues both in clinical management and in future clinical trials Background Evidence suggests people with axial spondyloarthritis ( axial SpA ) should exercise up to five times per week but lack of time , symptoms , cost and distance are barriers to regular exercise in axial SpA. Personalised exercise programmes delivered via the internet might support people with axial SpA to reach these exercise targets . The aim of this study is to investigate the effect of , and adherence to , a 12 month personalised web-based physiotherapy programme for people with axial SpA. Methods Fifty people with axial SpA will be recruited to this prospect i ve , interventional cohort study . Each participant will be assessed by a physiotherapist and an individualised exercise programme set up on www.webbasedphysio.com . Participants will be asked to complete their programme five times per week for 12 months . With the exception of adherence , data will be collected at baseline , 6 and 12 months . Discussion The primary outcome measure is adherence to the exercise programme over each four week cycle ( 20 sessions maximum per cycle ) and over the 12 months . Secondary measures include function ( BASFI ) , disease activity ( BASDAI ) , work impairment ( WPAI : SpA ) , quality of life ( ASQoL , EQ5D ) , attitude to exercise ( EMI-2 , EAQ ) , spinal mobility ( BASMI ) , physical activity and the six minute walk test . Participants will also be interviewed to explore their adherence , or otherwise , to the intervention . This study will determine the adherence and key clinical outcomes of a targeted web-based physiotherapy programme for axial SpA. This data will inform clinical practice and the development and implementation of similar programmes . Trial registration Clinical Trials.gov : NCT02666313 , 20th January BACKGROUND The Heart and Estrogen/Progestin Replacement Study ( HERS ) is the first large clinical trial design ed to test the efficacy of postmenopausal estrogen/progestin therapy for secondary prevention of coronary heart disease ( CHD ) . To examine the representativeness of the HERS cohort to the general population of postmenopausal women with CHD , we compared the baseline cardiovascular risk factor data from HERS with similar data from women presumed to have CHD from the National Health and Nutrition Examination Survey ( NHANES ) III . METHODS Age , race , and cardiovascular disease risk factors were compared in the 2763 postmenopausal women younger than 80 years old , with a uterus , and with documented CHD in HERS versus 145 similarly aged women with clinical or electrocardiographic evidence of CHD from phase I of NHANES III . RESULTS There were fewer current smokers in HERS ( 13 % ) than in the NHANES cohort ( 21.7 % , p = 0.05 ) . Similarly , a history of hypertension was less prevalent in HERS ( 58.6 % ) than in the NHANES cohort ( 69.3 % , p = 0.03 ) . Women with fasting triglyceride levels > 3.39 mmol/L or fasting glucose levels > 16.6 mmol/L were excluded from HERS , result ing in fewer diabetics ( 22.9 % vs 29.5 % , p = 0.26 ) and lower serum triglyceride levels ( 1.88 mmol/L vs 2.25 mmol/L , p = 0.19 ) in HERS versus the NHANES cohort . Systolic and diastolic blood pressure , body mass index , physical activity , and total LDL and HDL cholesterol were not significantly different between the two groups . CONCLUSIONS The HERS cohort had fewer CHD risk factors than women with myocardial infa rct ion or angina in NHANES III , although comparison is hindered by differences in selection criteria . The many women with diabetes and hypertriglyceridemia in the NHANES cohort emphasizes the importance of testing strategies for secondary prevention of CHD in this high-risk subgroup The paper provides the results obtained in the course of the cooperative All-Union programme on multifactor prevention of coronary heart disease ( CHD ) , which has been implemented over 3 years to examine the efficiency of preventive actions aim ed at correcting the levels of CHD risk factors . The study was conducted in 6 centers of the country among a non-organized male population aged 40 - 59 years . The outcome of the preventive measures , largely nonpharmacological ones , made during 3 years suggests that the prevalence of the major CHD risk factors may be reduced in the population . The preventive actions are the most beneficial in arterial hypertension and smoking
Similarly , there was no clear evidence of effect for cardiovascular risk factors , although again the number of studies reporting these was small .
There was some evidence for beneficial effects on HRQOL , dietary outcomes , and physical activity , although firm conclusions can not yet be made .
The effects on healthcare utilisation and cost-effectiveness are also inconclusive , and trials are yet to measure the impact of  Internet interventions on compliance with medication .
BACKGROUND The Internet could provide a means of delivering secondary prevention programmes to people with coronary heart disease ( CHD ) .
OBJECTIVES To determine the effectiveness of Internet-based interventions targeting lifestyle changes and medicines management for the secondary prevention of CHD .