Role of Long-term Secondary Prevention after MI
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP, Assistant Professor, Department of Internal Medicine, Meharry Medical College Nashville, TN; Assistant Clinical Professor, Division of General Internal Medicine and Public Health, Vanderbilt University Medical School, Nashville, TN. Dr. Gupta reports no financial relationship to this field of study.
Synopsis: This first known study of the effects of a 3-year cardiac rehabilitation program following a myocardial infarction (MI) included a continuous reinforced educational and behavioral intervention and proved effective in decreasing the risk of several important secondary cardiovascular (CV) outcomes.
Source: Giannuzzi P, et al. Global secondary prevention strategies to limit event recurrence after myocardial infarction. Arch Intern Med 2008;168:2194-2204.
The most significant question that arises immediately after survival from a myocardial infarction (MI) is the same whether you are the treating physician or the suffering patient: What can I do to prevent the next one? Current guidelines by the American Heart Association/American College of Cardiology recommend a host of actions in risk factor modification for secondary prevention in patients with coronary and other atherosclerotic disease.1 These include stopping smoking (complete cessation), blood pressure control (< 130/80 mm Hg if diabetes or chronic kidney disease, < 140/90 mm Hg otherwise), lipid management (LDL < 100 mg/dL, but most likely should be < 70 mg/dL), physical activity (30 min, 7 days/wk), weight management (BMI 18.5-24.9 kg/m2), diabetes management (A1c < 7%), aspirin, ACE inhibitors, beta-blockers, and influenza vaccination. Current cardiac rehabilitation programs (CRPs) contain these specific core components that aim to optimize cardiovascular risk reduction, foster healthy behaviors and adherence to these behaviors, reduce disability, and promote an active lifestyle for patients with cardiovascular (CV) disease.2 This includes a baseline patient assessment, nutritional counseling, risk factor management, psychosocial interventions, and physical activity counseling with exercise training. An important consideration of these recommendations is the understanding that successful risk factor modification and the maintenance of a physically active lifestyle is a lifelong process. However, most of the existing CRPs are short-term and therefore remain short-sighted in achieving their benefits. The short-term use of these benefits would not be expected to lead to long-term benefits.3 Medications like aspirin, statins, beta-blockers, and ACE inhibitors used for secondary prevention are often stopped shortly after hospital discharge.4,5
The current study (The Global Secondary Prevention Strategies to Limit Event Recurrence After Myocardial Infarction or GOSPEL) was undertaken to assess the effect on quality of care and prognosis of a long-term, relatively intensive rehabilitation strategy after MI. Giannuzzi et al conducted a multicenter, prospective, randomized, open-label, blinded controlled trial at 78 Italian cardiac rehabilitation centers. Following a standard post-MI cardiac rehabilitation program, a total of 3241 patients were randomized in a 1:1 fashion to either an intensive, 3-year-long, multifactorial intervention and behavioral program (intervention group; n = 1620) or usual care (control group; n = 1621). The combination of CV mortality, nonfatal MI, nonfatal stroke, and hospitalization for angina pectoris, heart failure, or urgent revascularization procedure was the primary endpoint. Other endpoints were major CV events, major cardiac and cerebrovascular events, lifestyle habits, and drug prescriptions.
Endpoint events occurred in 556 patients (17.2%). Compared with usual care, the intensive intervention did not decrease the primary endpoint significantly (16.1% vs 18.2%; hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.74-1.04). However, the intensive intervention decreased several secondary endpoints: CV mortality plus nonfatal MI and stroke (3.2% vs 4.8%; HR, 0.67; 95% CI, 0.47-0.95), cardiac death plus nonfatal myocardial infarction (2.5% vs 4.0%; HR, 0.64; 95% CI, 0.43-0.94), and nonfatal MI (1.4% vs 2.7%; HR, 0.52; 95% CI, 0.31-0.86). In addition, a marked improvement in lifestyle habits and in prescription of drugs for secondary prevention was seen in the intervention group. For example, the overall Mediterranean-like dietary habits increased from 26.1% at baseline to 59.6% at 6 months with the intervention group doing better; the 6-month score for physical activity was 6.1% (P < 0.01) higher in the intervention group; and the 6-month score for self/stress management adjusted for baseline was 3.8% lower (or better results) in the intervention group (P < 0.001). All results were maintained throughout the study.
Commentary
In an era where we allow researchers to develop a new paradigm for defining terms like prevention, it would be an immense disappointment if we prematurely discarded the current meaning of prevention. I will illustrate my point as follows: Results of two significant prevention trials were reported in the same week of November 2008. The GOSPEL study as discussed above was the largest one of its kind evaluating the role of a 3- year multifactorial comprehensive cardiac rehabilitation program in secondary prevention of coronary heart disease. Results from a separate primary prevention study (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin or JUPITER) was also reported in the same time period.6 The JUPITER trial enrolled healthy subjects who did not have high cholesterol levels or coronary heart disease but elevated high-sensitivity C-reactive protein. This trial of nearly 18,000 patients was stopped early, with only 1.9 of its proposed 4 years of follow-up concluded, when the data and safety monitoring board noted a significant reduction in the primary endpoint among participants assigned to receive rosuvastatin. This trial obviously received a lot of media coverage, largely because the authors were able to demonstrate that a pill could prevent a heart attack or stroke, even if you were healthy with good cholesterol. This is despite the traditional definition of primary prevention, which involves the use of health promotion activities including immunization to prevent specific diseases. Wouldn't a prudent lifestyle modification program achieve similar results without the unknown long-term risks of rosuvastatin? In this regard, even though the GOSPEL trial is a secondary prevention study, it highlights the point that we must continue to put emphasis on a comprehensive lifestyle modification program for our post-MI patients, not just in the short term but as a long-term strategy.
References
1. Smith SC Jr, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: Endorsed by the National Heart, Lung, and Blood Institute. Circulation 2006;113:2363-2372.
2. Balady GJ, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: A scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115:2675-2682.
3. Willich SN, et al. Cardiac risk factors, medication, and recurrent clinical events after acute coronary disease; a prospective cohort study. Eur Heart J 2001;22:307-313.
4. Lear SA, et al. The Extensive Lifestyle Management Intervention (ELMI) following cardiac rehabilitation trial. Eur Heart J 2003;24:1920-1927.
5. Newby LK, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation 2006;113:203-212.
6. Ridker PM, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008 Nov 9; Epub ahead of print. Available at: http://content.nejm.org/cgi/content/full/NEJMoa0807646v1. Accessed Nov. 16, 2008.
This first known study of the effects of a 3-year cardiac rehabilitation program following a myocardial infarction (MI) included a continuous reinforced educational and behavioral intervention and proved effective in decreasing the risk of several important secondary cardiovascular (CV) outcomes.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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