Article Text

Review: secondary prevention programmes with and without exercise reduced all cause mortality and recurrent myocardial infarction
  1. Patricia Harbman, RN(EC), MN/ACNP, PhD student
  1. University of Toronto
 Toronto, Ontario, Canada

    Statistics from

 Q In patients with coronary artery disease (CAD), what is the effectiveness of secondary prevention programmes with and without exercise components?


    Embedded ImageData sources:

    Medline, PubMed, CINAHL, EMBASE/Excerpta Medica, SIGLE, Web of Science, and the Cochrane Central Register of Controlled Trials (all to 2004); reference lists; and references provided by the Centers for Medicare and Medicaid Services and content experts.

    Embedded ImageStudy selection and assessment:

    randomised controlled trials (RCTs) that were fully published in English, included a usual care group, and reported outcomes for patients with CAD. Exclusion criteria: single modality interventions (except exercise), inpatients, or interventions not delivered by health professionals. 63 studies met the selection criteria. 45 RCTs included patients after acute myocardial infarction (MI) or a coronary revascularisation procedure. Follow up ranged from 3 weeks to 72 months. Most studies had a quality score of 2 on the Jadad scale. Interventions were classified into 3 groups: (1) education and counselling about CAD risk factors with a supervised exercise programme, (2) education and counselling without an exercise programme, and (3) supervised exercise programme only.

    Embedded ImageOutcomes:

    all cause mortality and recurrent MI.


    Secondary prevention programmes reduced all cause mortality (40 RCTs, 16 142 patients) and recurrent MI (27 RCTs, 11 723 patients) (table).

    Secondary prevention programmes v usual care for coronary artery disease*


    In patients with coronary artery disease, secondary prevention programmes reduced all cause mortality and recurrent myocardial infarction.

    A modified version of this abstract appears in Evidence-Based Medicine.


    The systematic review by Clark et al builds on previous reviews of secondary cardiac prevention programmes1,2 by comparing the effectiveness of programmes with and without exercise components. It exemplifies the power of meta-analysis in pooling the findings of many studies (n = 63), some with small sample sizes, and only 3 of which, on their own, identified statistically significant benefits. The programmes reduce the risk of all cause mortality by 47% at 24 months, with a sustained benefit after 5 years, and reduce the risk of recurrent MI by 17% after a median of 12 months.

    The review was based on a comprehensive search of studies, although it was limited to trials that were published in English. Many studies in the review had limitations, including lack of blinding of outcome assessment and selection bias (eg, many trials excluded women or elderly patients).

    Reviewing the components of the programmes evaluated in the individual trials is clinically informative. Other than programmes that were restricted to exercise alone, all other interventions included risk factor education or counselling. The most common features of the 23 programmes without exercise included nurses leading or managing the programme (n = 19), individual counselling and education (n = 19), and frequent telephone follow up (n = 7). In the 24 programmes with exercise, common features were nurses leading or managing the programme (n = 6), relaxation or stress management (n = 6), and individual counselling (n = 4).

    The review by Clark et al provides strong evidence that programmes that include risk factor education or counselling, with or without exercise, are important for secondary prevention of CAD. Nurses have pivotal roles in risk factor education and counselling. Next steps include unravelling the multicomponent interventions to determine the incremental benefit of each component and their required intensity, and conducting long term economic evaluations.


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    • For correspondence: Dr F A McAlister, University of Alberta Hospital, Edmonton, Alberta, Canada. finlay.mcalister{at}

    • Source of funding: Agency for Healthcare Research and Quality.

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