Coronary artery disease: secondary prevention programmes reduce hospital admission with heart disease and increase prescription of appropriate medication

Clinical bottom line (level 1a)

  1. Patients with coronary artery disease who take part in a secondary prevention programme compared with usual care are not clearly less likely to die or have a recurrent myocardial infarction, but are less likely to be admitted to hospital.
  2. Patients who take part in a secondary prevention programme are more likely to be prescribed lipid-lowering drugs, beta-blockers and antiplatelet agents.
McAlister et al: BMJ 2001; 323 : 957-962
Expires April 2004

The study

Systematic review of all randomised controlled trials of
  • Patients:
  • Intervention: secondary prevention programmes compared with usual care
  • Outcome: death, myocardial infarction, admission to hospital with heart disease
Articles found in all languages using Medline, Embased, CINAHL, SIGLE, the Cochrane controlled trial register, the Cochrane effective practice and organisation of care study register, 1966 to 2000 (search terms: textwords and MeSH headings: case management, comprehensive health care, disease management, health services research, home care services, clinical protocols, patient care planning, quality of health care, rehabilitation, nurse led clinics, special clinics and myocardial ischemia ) and searching bibliographies of retrieved articles and contacting experts in the field.

Selection criteria: by 2 independent reviewers - discrepanices were resolved by consensus. Authors were contacted to retrieve missing data.
Appraisal criteria: by 2 independent reviewers using a standardised form
Articles excluded if:
  • not randomised
  • primary prevention
  • tested inpatient interventions
  • enrolled fewer than 50 patients


12 RCTs found involving 10357 patients receiving multidisciplinary interventions, usually nurse managed education and counselling with telephone or clinic follow-up for 1-48 months, commonly 12 months

The evidence

Outcome Time to outcome CER OR
(95% CI)		 NNT
(95% CI)
admission to hospital with heart disease months /
(%)		 0.84
(0.76 to 0.94)
recurrent myocardial infarction months 290/3702
(7.8%)		 0.94
(0.80 to 1.1) 		230
(NNT = 68 to infinity;
NNH = 140 to infinity)
death months 393/4855
(8.1%)		 0.91
(0.79 to 1.04) 		150
(NNT = 63 to infinity;
NNH = 340 to infinity)
prescribed lipid-lowering drugs months /
(%)		 2.14
(1.92 to 2.38)
prescribed beta-blockers months /
(%)		 1.19
(1.07 to 1.32)
prescribed anti-platelet drugs weeks /
(%)		 1.07
(1.03 to 1.11)

  • 3 of 8 studies evaluating quality-of-life or functional outcomes found small but statistically significant improvements in patients who took part in a disease management programme.
  • No formal cost-effectiveness analysis were performed.

Comments

  1. There were too few studies to indicate which components of the interventions were statistically beneficial.
  2. Control rates were not reported for all outcomes, so NNTs could not be calculated.

Citation

  1. McAlister FA, Lawson FE, Teo KK, et al: randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 2001; 323 : 957-962
Search Terms: from ACP Journal Club
Contributor: Chris Ball, April 2002
Reviewer:

Clinical Question.
Patient coronary artery disease
Intervention or Exposure secondary prevention programme
Comparison usual care
Outcome death, myocardial infarction, admission to hospital with heart disease, drug prescription