Effect Size Estimates of Lifestyle and Dietary Changes on All-Cause Mortality in Coronary Artery Disease Patients
http://www.100md.com
《循环学杂志》
the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (J.A.I., Y.T.v.d.S., D.E.G., W.A.v.S.)
Nutrition and Consumer Safety Division, RIVM, Bilthoven (D.K.)
Division of Nutrition, Wageningen University Research Center, Wageningen (D.K., W.A.v.S.)
Public Health Division, RIVM, Bilthoven (H.C.B.), the Netherlands.
Abstract
Background— Guidelines for lifestyle and dietary modification in patients with coronary artery disease (CAD) are mainly supported by evidence from general population studies. CAD patients, however, differ from the general population in age (older) and treatment with preventive drugs. This review seeks to provide evidence for a prognostic benefit of lifestyle and dietary recommendations from studies in CAD patients.
Methods and Results— A literature search was performed on the effect of lifestyle and dietary changes on mortality in CAD patients. Prospective cohort studies and randomized controlled trials of patients with established CAD were included if they reported all-causes mortality and had at least 6 months of follow-up. The effect estimates of smoking cessation (relative risk [RR], 0.64; 95% CI, 0.58 to 0.71), increased physical activity (RR, 0.76; 95% CI, 0.59 to 0.98), and moderate alcohol use (RR, 0.80; 95% CI, 0.78 to 0.83) were studied most extensively. For the 6 dietary goals, data were too limited to provide reliable effect size estimates. Combinations of dietary changes were associated with reduced mortality (RR, 0.56; 95% CI, 0.42 to 0.74).
Conclusions— Available studies show convincingly the health benefits of lifestyle changes in CAD patients. Effect estimates of combined dietary changes look promising. Future studies should confirm these findings and assess the contribution of the individual dietary factors.
Key Words: coronary disease ; diet ; lifestyle ; mortality ; patients
Introduction
More than 40 years ago, Ancel Keys1 was the first to explore the relationship between coronary artery disease (CAD) and environmental factors. Since then, several lifestyle and dietary factors have been found to be associated with the risk of cardiovascular morbidity and mortality.2 This knowledge has been translated into recommendations for the general population (primary prevention) and clinical guidelines for those with manifest cardiovascular diseases (secondary prevention).
Patients with CAD, ie, myocardial infarction (MI) or angina pectoris (AP), are the largest of the secondary prevention groups. This group is characterized by older age (80% are older than 50 years) and a minority of women (30%).3 Although the prognosis of CAD patients has improved considerably during the last decades,4 they still carry a high absolute risk for future CAD events (10-year absolute risk from 20% to 80%).5 International guidelines6 defined this patient group as top priority for preventive strategies.
This study seeks to summarize the evidence that the individual lifestyle and dietary goals formulated in Table 1 can improve prognosis in CAD patients. Second, we want to provide estimates of the magnitude of the effects on survival for each individual lifestyle and dietary goal based on the available studies in CAD patients.
Methods
We conducted a systematic review of the literature on benefits of the recommended lifestyle and dietary changes in CAD patients applying the following selection criteria.
Study Population
Studies had to investigate a population of at least 50% patients diagnosed with CAD. CAD patients were defined as patients with a history of MI or AP or who underwent coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA).
Determinants and Interventions
We excluded studies on nutrient supplements if the dosage of the nutrient they provide goes beyond the amount that can reasonably be achieved by changing food habits without the use of supplements. For each lifestyle and dietary recommendation (Table 1), we defined the following determinants or interventions to be accepted in our study.
Smoking Cessation
Studies reporting smoking cessation after the diagnosis of CAD were accepted.
Physical Activity
Time spent on moderate intensive activity is the best example of operationalization of the current recommendations.11 Moderately intensive activities are those with an absolute intensity of 4 to 6 METs or a relative intensity of 40% to 60% of O2max.12 We also accepted studies on total energy expenditure, habitual daily activity scores, time spent in vigorous intensive physical activity, physical fitness, or participation in structured exercise programs.
Alcohol Consumption
Alcohol consumption had to be reported in the number of units or grams of alcohol per day. Studies reporting only alcohol intake as a percentage of total energy intake were excluded.
Energy Balance
The recommendation to maintain or attain a healthy body weight refers to both the actual as well as the previous history of the balance between energy intake and energy expenditure (physical activity). Accepted were studies on body weight maintenance after the first manifestation of CAD and studies on intentional body weight reduction in overweight or obese CAD patients in relation to survival. Studies on the association between body weight status (body mass index [BMI]) at time of event and survival were excluded because BMI at time of diagnosis does not reflect lifestyle and dietary habits after the first manifestation of CAD.
Saturated Fat and Trans–Fatty Acids
We accepted all studies investigating a reduced intake of saturated fat and/or trans–fatty acids without a substantial restriction of total fat intake. Interventions on total fat intake restrictions beyond 25 energy% were excluded because of supposed detrimental effects on HDL and triglyceride levels.13 Given the mean intake of saturated fat in most Western countries at 15 energy%, we defined a reduction of 5 energy% as a relevant difference.
Regular Fish (Oil) Consumption
The recommended 2 portions (400 g) of oily fish per week are equivalent to a daily dose of 500 to 1000 mg -3 fatty acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]).14 We accepted all studies on fish consumption and on fish oil supplements to a maximum increase of 1000 mg -3 fatty acids per day. We excluded studies with higher doses because it is unlikely that these levels can be achieved by increasing fish consumption alone.
Fruits and Vegetables
We included studies that examined the effect of the daily intake of fruits and vegetables in all available forms (fresh, canned, frozen, dried, or as juice).
Whole Grains, Legumes, and Nuts
We included studies on the effect of the daily intake of whole grains, legumes, and nuts or that studied the effect of intake of fiber from these products.
Salt
We included all studies examining the effect of sodium restriction. Because the recommended maximal salt intake is 6 g/d15 (2400 mg or 100 mmol sodium) and current intake in Western societies is 9 g, a restriction was defined as a reduction of at least 30% or 50 mmol sodium.
Combined Lifestyle and Dietary Interventions or Combined Determinant Scores
We also included studies that examined a combination of 2 of the aforementioned individual factors.
Outcome Measures
We only included studies that reported an effect on all-causes mortality.
Study Design and Follow-Up Period
Studies had to have a prospective design, being either a cohort study or a randomized controlled trial, and the follow-up period had to be at least 6 months. If available, meta-analyses of prospective studies were preferred and replaced the individual studies that they described.
Search Strategy
Data for this review were identified by searches in PubMed (1966 to May 2004) with the Medical Subject Heading (MeSH) terms coronary artery disease and patients in combination with the MeSH terms or text words lifestyle, smoking, physical activity, physical fitness, exercise, alcohol drinking, body weight, weight control, diet, saturated fat, trans–fatty acids, cholesterol, fish, fruit, vegetables, whole grains, cereals, legumes, nuts, fiber, salt, sodium, mortality, survival, and death. There was a restriction on English language. Relevant articles not identified by this strategy, but referenced in the bibliographies of these selected articles, were also included.
Data Extraction and Standardization
Summary Effect Estimates
We decided that an effect estimate per lifestyle or dietary goal could only be provided if a meta-analysis was available or if at least 2 randomized controlled trials or 2 cohort studies were available meeting the following quality criteria: in case of cohort studies, the effect estimate should be based on findings that were adjusted for confounders, at least for age and gender; in case of randomized trials, information should be given that compliance with the intervention under study was checked and considered satisfactory; and the effect estimate of each study should be based on at least 20 mortality cases to guarantee that the power of the study allowed meaningful effect estimation.
Results
Goals With Sufficient Studies to Calculate a Pooled Effect Estimate
Smoking Cessation
Two meta-analyses of cohort studies were found on smoking cessation. Duration of follow-up ranged from 2 to 20 years. All included studies consistently showed a protective effect of smoking cessation. Wilson et al16 performed a meta-analyses of 12 studies in patients with MI and found a pooled RR for all-causes mortality of 0.54 (95% CI, 0.46 to 0.62) for those who had quit smoking. Critchley and Capewell17 published a meta-analysis of 20 studies in patients with previous MI or AP and reported a pooled RR of 0.64 (95% CI, 0.58 to 0.71). Half of the studies were the same as in the first analysis. On the basis of these 2 meta-analyses, we conservatively estimate the effect size of smoking cessation in CAD patients as a 35% mortality risk reduction.
Habitual Physical Activity
We found no studies on the effect of increased physical activity on mortality in CAD patients. The effect of participation in a structured exercise program after a cardiac event (MI, AP, CABG, or PTCA) on morbidity and mortality has been evaluated in several meta-analyses.18–22 Reported effect size estimates of mortality reduction varied between 20% and 25%. Here we review the analysis by Brown et al,21 which is a 2003 update from earlier meta-analyses and which studied exercise-based rehabilitation programs separately from the comprehensive rehabilitation programs that also included educational and psychosocial interventions. In this study mortality data were available of 2585 patients in 12 randomized controlled trials. The interventions varied widely from gym-based aerobic exercise twice a week for 4 weeks to interventions lasting for 30 months with inpatient stays. Mean follow-up time was 24 months (range, 6 to 60 months). The study showed a significant beneficial effect of an exercise program. The effect on all-causes mortality was estimated as 25% risk reduction (RR, 0.76; 95% CI, 0.59 to 0.98).
Moderate Alcohol Consumption
Saturated Fat Reduction
Four28–31 randomized controlled trials and 1 cohort study32 met our criteria for fat modification. They all concerned saturated fat intake reduction. No studies were detected on the relation between trans–fatty acid intake and mortality in CAD patients. The randomized controlled trials were performed between 1960 and 1988 and intended to study a reduction of 5 energy% in saturated fat intake during 2 to 5 years of follow-up. The resulting reduction in serum cholesterol was 15% in 2 studies28,29 and only 5% in the other 2,31 raising doubts on adherence to the regimen in the latter 2 studies.30 Only in the 2 studies with the largest serum cholesterol reductions was total mortality reduced (12% and 25%), but the power of the studies was too limited to show statistically significant reductions. The probability value for heterogeneity was 0.18 for the 4 studies and 0.63 when the 2 studies with unsatisfying serum cholesterol reductions were excluded. The pooled effect estimates were not statistically significant for either the 4 or the 2 studies (Table 3). The cohort study32 in 400 Finnish CAD patients was supportive of a beneficial effect of a lower saturated fat intake. For every 4 energy% reduction in saturated fat, intake RR for all-causes mortality was 0.64 (95% CI, 0.46 to 0.88). However, this study on its own is not sufficient to be conclusive. Because the pooled effects are not statistically significant, we provide no summary effect estimate for saturated fat restriction.
Regular Fish (Oil) Consumption
We found 3 randomized controlled trials31,33–35 and 2 cohort studies32,36 fulfilling our selection criteria. The trials tested either the effect of advice to increase fatty fish consumption up to 200 to 400 g/wk31,33 or the effect of a fish oil supplement containing 900 mg EPA and DHA per day.34,35 Two of them31,34,35 showed a significant mortality reduction, but the trial in AP patients33 found a nonsignificant mortality increase in the intervention group.
Remaining Goals
Combined Interventions
Discussion
Although many of the commonly provided lifestyle and dietary recommendations (Table 1) are supported with evidence from surrogate end point studies and studies in the general population, there is only limited evidence from studies in CAD patients that these recommendations indeed improve their life expectancy. The available studies show significant effects for 3 lifestyle recommendations on prognosis of CAD patients. Effects for smoking cessation, increased physical activity, and moderate alcohol consumption vary from a 20% to 35% reduction in all-causes mortality. For individual dietary goals, evidence from studies in CAD patients was not available or was too limited to provide reliable effect estimates. A few studies on combinations of dietary changes show promising results, with mortality reductions of 45%.
In this review we included both experimental and observational studies. Randomized controlled trials are generally rated as a higher level of evidence than prospective cohort studies because they exclude self-selection and confounding by indication as a source of bias. Randomized clinical trials, however, have their own drawbacks: their inclusion criteria often limit generalization to the average patient population in routine care, their costs often limit the duration of the study, in the case of lifestyle or dietary interventions double blinding is often impossible, or the intervention itself is unethical (eg, smoking or alcohol consumption). Prospective cohort studies, on the other hand, may be confounded by unknown prognostic factors associated with lifestyle or dietary habits, but they have the advantage of giving a better reflection of the "real-life" situation with long-term exposure and mostly a mixed patient population. The advantages and disadvantages of each design do not outweigh those of the other. In this review we reported effect sizes of both study designs (if available) separately and did not make an attempt to rank one above the other.
This review has several potential limitations. Most evidence was available for studies on lifestyle changes in CAD patients. Studies on dietary changes are scarce, and several are of poor methodological quality. Confounding due to clustering of lifestyle and dietary factors as well as bias because of unblinding or poor compliance with the intervention or changes in habits of the control group is more common in lifestyle and dietary studies than in drugs trials. Many of the studies included in this review were underpowered to assess effects on total mortality. This problem may be solved by pooling the results of individual studies, but, even if tests for heterogeneity are not significant, this operation may be problematic because of the heterogeneity of studies with respect to background habits, intervention characteristics, exposure (time and dose), and length of follow-up. Sometimes the point estimates are impressive, but the wide CIs indicate a high degree of uncertainty. Therefore, caution is needed in interpreting the results and particularly in translating the effect size estimates to the individual patient.
Nevertheless, most of the presented effect estimates are in accord with results from studies performed in the general population. Table 4 compares the effect estimates in CAD patients with results from cohort studies in the general population.
Smoking Cessation
Our effect estimate of 35% risk reduction is similar to findings from population-based cohort studies indicating that quitters before age 50 have a 50% lower risk of dying than continuing smokers.41,42
Physical Activity Level
An effect estimate of 25% mortality risk reduction for an increased level of physical activity was obtained from a meta-analysis on the effect of exercise-based revalidation. Although the best available, this is not a good estimate for adherence to the guideline11 to increase habitual physical activity level to a daily amount of at least 30 minutes of moderately intensive activity. Participation in a program is not necessarily related to a higher physical activity level in the long run.43,44 However, the estimated 25% mortality risk reduction compares well with estimates from other populations. A review45 of 44 population-based cohort studies reported that adherence to the guideline was associated with a 20% to 30% reduction in all-causes mortality. Further reductions were observed at higher volumes of energy expenditure. Not only high baseline levels but also increments in physical activity level later in life are shown to be associated with lower mortality.46,47
Alcohol
Although the protective effect of moderate alcohol consumption on cardiovascular risk has been sufficiently demonstrated in the general population cohorts,48 for CAD patients there was concern about the adverse effects on the cardiovascular system, such as hypertension, arrhythmias, hemorrhagic stroke, and cardiomyopathy.49 The presented studies are consistent in their finding that moderate alcohol consumption can improve the prognosis in CAD patients, even in patients with associated heart failure,23 as long as the alcohol intake is moderate (2 to 3 U/d). The estimate of 20% mortality risk reduction in CAD patients is in range with a pooled estimate of 15% mortality reduction in cohort studies in middle-aged populations.50 Of course, the benefits of moderate alcohol consumption should always be mentioned in relation to the potential risks of excessive alcohol consumption because there are still more deaths caused by alcohol than prevented.51
Saturated Fat
Reliable effect estimates could be provided for none of the individual dietary factors.
The pooled effect estimates for saturated fat reduction were not statistically significant (for the 4 studies: RR, 0.98; 95% CI, 0.81 to 1.18) but agreed with the findings of 2 meta-analyses on fat modification combining the results of both primary and secondary prevention trials: RR, 0.94 (95% CI, 0.89 to 0.99; 17 trials)52 and RR, 0.98 (95% CI, 0.86 to 1.12; 11 trials).53 In contrast to our study, these meta-analyses also included studies on total fat restriction, which might have attenuated the effect. They confirm our finding that a trend was seen toward a greater risk reduction in trials in which better adherence to the intervention is shown by a greater reduction in serum cholesterol.
Regular Fish (Oil) Consumption
There was heterogeneity between the studies, but the calculated pooled effect estimates for the trials (12% to 23% mortality risk reduction) are in agreement with an estimate of 20% all-causes mortality reduction in a meta-analysis by Bucher et al54 based on 9 trials in CAD patients on the effects of dietary fish or fish oil supplementation in doses up to 10 g of -3 fatty acids per day. The pooled effect estimate from the cohort studies in CAD patients was also 20%. Data on fish and all-causes mortality from population-based cohorts are inconsistent and vary from 0% to 30%.55–60 Null findings in some of the studies can possibly be explained by the adverse effects of the high mercury content of fish in some geographic areas56,61 or by the fact that the protective effect is specific for fatty fish and not for total fish consumption.62 The association with CAD mortality is more frequently studied than all-causes mortality, and significant risk reductions are reported.63–65
For the remaining individual goals, studies on mortality were too few to provide effect estimates. This should not be interpreted as a lack of scientific support for these recommendations. The evidence from surrogate end point or clinical end point studies is reviewed elsewhere.66–77 Studies on all-causes mortality, however, are scarce, not only in CAD patients but also in other populations. Given the alarming signals78,79 on a high prevalence (80%) of overweight and obesity in CAD patients, it is surprising that no studies were found on the effect of intentional weight loss on mortality in CAD patients. Weight loss might be one of the mechanisms through which other lifestyle or dietary changes (eg, regular exercise or increased intake of whole grains and vegetables) might exert their protective effect, but few authors report on body weight changes.40 Cohort studies in the general population have shown that mortality is 30% to 50% lower in normal-weight individuals than in their obese peers,80 although this difference decreases with age.81 The effect that can be expected from weight reduction in patients already treated with preventive drugs is unclear. Some studies in CAD patients82–86 (not meeting our inclusion criteria) even suggest a prognostic benefit of obesity. These studies, however, are inconclusive because they often lack appropriate adjustments for confounding (eg, confounding by age because obese persons are generally 7 years younger at time of their first MI than normal-weight individuals), but they stress the need for high-quality additional research. Finally, population-based cohort studies that study all-causes mortality in relation to the intake of fruits and vegetables,87–90 whole grains,87,91,92 legumes,93 nuts,94,95 or salt96–98 are scarce but are generally supportive of a protective effect of the recommendations.
The trials on combined dietary interventions showed impressive results, varying from 35% to 55% mortality reduction. Other intervention studies in CAD patients showed benefits of combined lifestyle and dietary changes on surrogate end points and cardiac events.99,100 The cohort study in 11 000 CAD patients by Barzi et al36 showed an almost 50% lower mortality risk for those with the highest dietary quality score. Mortality risk reductions associated with dietary quality reported from other populations were generally smaller (15% to 25%), but a significant benefit was demonstrated in many studies.101–110 Two studies in elderly people101,104 showed a 60% to 70% lower mortality associated with a higher quality score for a combination of both lifestyle and dietary habits. Although the studies on combined changes are promising, they shed no light on the dominant mechanism and on the contribution of the individual lifestyle and dietary factors. More knowledge on the benefits of the 6 individual dietary goals in particular is necessary for designing effective preventive strategies.
In conclusion, there is evidence from mortality studies in CAD patients that smoking cessation, physical activity, moderate alcohol consumption, and combined dietary changes improve prognosis. Effect size estimates for the lifestyle goals vary between 20% and 35% mortality reductions. Data on the benefits of individual dietary goals are limited. For the future, more and better-quality studies are needed to reduce the uncertainty that surrounds these effect size estimates.
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Rodrigues EJ, Eisenberg MJ, Pilote L. Effects of early and late administration of angiotensin-converting enzyme inhibitors on mortality after myocardial infarction. Am J Med. 2003; 115: 473–479.(J.A. Iestra, RD; D. Kromh)
Nutrition and Consumer Safety Division, RIVM, Bilthoven (D.K.)
Division of Nutrition, Wageningen University Research Center, Wageningen (D.K., W.A.v.S.)
Public Health Division, RIVM, Bilthoven (H.C.B.), the Netherlands.
Abstract
Background— Guidelines for lifestyle and dietary modification in patients with coronary artery disease (CAD) are mainly supported by evidence from general population studies. CAD patients, however, differ from the general population in age (older) and treatment with preventive drugs. This review seeks to provide evidence for a prognostic benefit of lifestyle and dietary recommendations from studies in CAD patients.
Methods and Results— A literature search was performed on the effect of lifestyle and dietary changes on mortality in CAD patients. Prospective cohort studies and randomized controlled trials of patients with established CAD were included if they reported all-causes mortality and had at least 6 months of follow-up. The effect estimates of smoking cessation (relative risk [RR], 0.64; 95% CI, 0.58 to 0.71), increased physical activity (RR, 0.76; 95% CI, 0.59 to 0.98), and moderate alcohol use (RR, 0.80; 95% CI, 0.78 to 0.83) were studied most extensively. For the 6 dietary goals, data were too limited to provide reliable effect size estimates. Combinations of dietary changes were associated with reduced mortality (RR, 0.56; 95% CI, 0.42 to 0.74).
Conclusions— Available studies show convincingly the health benefits of lifestyle changes in CAD patients. Effect estimates of combined dietary changes look promising. Future studies should confirm these findings and assess the contribution of the individual dietary factors.
Key Words: coronary disease ; diet ; lifestyle ; mortality ; patients
Introduction
More than 40 years ago, Ancel Keys1 was the first to explore the relationship between coronary artery disease (CAD) and environmental factors. Since then, several lifestyle and dietary factors have been found to be associated with the risk of cardiovascular morbidity and mortality.2 This knowledge has been translated into recommendations for the general population (primary prevention) and clinical guidelines for those with manifest cardiovascular diseases (secondary prevention).
Patients with CAD, ie, myocardial infarction (MI) or angina pectoris (AP), are the largest of the secondary prevention groups. This group is characterized by older age (80% are older than 50 years) and a minority of women (30%).3 Although the prognosis of CAD patients has improved considerably during the last decades,4 they still carry a high absolute risk for future CAD events (10-year absolute risk from 20% to 80%).5 International guidelines6 defined this patient group as top priority for preventive strategies.
This study seeks to summarize the evidence that the individual lifestyle and dietary goals formulated in Table 1 can improve prognosis in CAD patients. Second, we want to provide estimates of the magnitude of the effects on survival for each individual lifestyle and dietary goal based on the available studies in CAD patients.
Methods
We conducted a systematic review of the literature on benefits of the recommended lifestyle and dietary changes in CAD patients applying the following selection criteria.
Study Population
Studies had to investigate a population of at least 50% patients diagnosed with CAD. CAD patients were defined as patients with a history of MI or AP or who underwent coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA).
Determinants and Interventions
We excluded studies on nutrient supplements if the dosage of the nutrient they provide goes beyond the amount that can reasonably be achieved by changing food habits without the use of supplements. For each lifestyle and dietary recommendation (Table 1), we defined the following determinants or interventions to be accepted in our study.
Smoking Cessation
Studies reporting smoking cessation after the diagnosis of CAD were accepted.
Physical Activity
Time spent on moderate intensive activity is the best example of operationalization of the current recommendations.11 Moderately intensive activities are those with an absolute intensity of 4 to 6 METs or a relative intensity of 40% to 60% of O2max.12 We also accepted studies on total energy expenditure, habitual daily activity scores, time spent in vigorous intensive physical activity, physical fitness, or participation in structured exercise programs.
Alcohol Consumption
Alcohol consumption had to be reported in the number of units or grams of alcohol per day. Studies reporting only alcohol intake as a percentage of total energy intake were excluded.
Energy Balance
The recommendation to maintain or attain a healthy body weight refers to both the actual as well as the previous history of the balance between energy intake and energy expenditure (physical activity). Accepted were studies on body weight maintenance after the first manifestation of CAD and studies on intentional body weight reduction in overweight or obese CAD patients in relation to survival. Studies on the association between body weight status (body mass index [BMI]) at time of event and survival were excluded because BMI at time of diagnosis does not reflect lifestyle and dietary habits after the first manifestation of CAD.
Saturated Fat and Trans–Fatty Acids
We accepted all studies investigating a reduced intake of saturated fat and/or trans–fatty acids without a substantial restriction of total fat intake. Interventions on total fat intake restrictions beyond 25 energy% were excluded because of supposed detrimental effects on HDL and triglyceride levels.13 Given the mean intake of saturated fat in most Western countries at 15 energy%, we defined a reduction of 5 energy% as a relevant difference.
Regular Fish (Oil) Consumption
The recommended 2 portions (400 g) of oily fish per week are equivalent to a daily dose of 500 to 1000 mg -3 fatty acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]).14 We accepted all studies on fish consumption and on fish oil supplements to a maximum increase of 1000 mg -3 fatty acids per day. We excluded studies with higher doses because it is unlikely that these levels can be achieved by increasing fish consumption alone.
Fruits and Vegetables
We included studies that examined the effect of the daily intake of fruits and vegetables in all available forms (fresh, canned, frozen, dried, or as juice).
Whole Grains, Legumes, and Nuts
We included studies on the effect of the daily intake of whole grains, legumes, and nuts or that studied the effect of intake of fiber from these products.
Salt
We included all studies examining the effect of sodium restriction. Because the recommended maximal salt intake is 6 g/d15 (2400 mg or 100 mmol sodium) and current intake in Western societies is 9 g, a restriction was defined as a reduction of at least 30% or 50 mmol sodium.
Combined Lifestyle and Dietary Interventions or Combined Determinant Scores
We also included studies that examined a combination of 2 of the aforementioned individual factors.
Outcome Measures
We only included studies that reported an effect on all-causes mortality.
Study Design and Follow-Up Period
Studies had to have a prospective design, being either a cohort study or a randomized controlled trial, and the follow-up period had to be at least 6 months. If available, meta-analyses of prospective studies were preferred and replaced the individual studies that they described.
Search Strategy
Data for this review were identified by searches in PubMed (1966 to May 2004) with the Medical Subject Heading (MeSH) terms coronary artery disease and patients in combination with the MeSH terms or text words lifestyle, smoking, physical activity, physical fitness, exercise, alcohol drinking, body weight, weight control, diet, saturated fat, trans–fatty acids, cholesterol, fish, fruit, vegetables, whole grains, cereals, legumes, nuts, fiber, salt, sodium, mortality, survival, and death. There was a restriction on English language. Relevant articles not identified by this strategy, but referenced in the bibliographies of these selected articles, were also included.
Data Extraction and Standardization
Summary Effect Estimates
We decided that an effect estimate per lifestyle or dietary goal could only be provided if a meta-analysis was available or if at least 2 randomized controlled trials or 2 cohort studies were available meeting the following quality criteria: in case of cohort studies, the effect estimate should be based on findings that were adjusted for confounders, at least for age and gender; in case of randomized trials, information should be given that compliance with the intervention under study was checked and considered satisfactory; and the effect estimate of each study should be based on at least 20 mortality cases to guarantee that the power of the study allowed meaningful effect estimation.
Results
Goals With Sufficient Studies to Calculate a Pooled Effect Estimate
Smoking Cessation
Two meta-analyses of cohort studies were found on smoking cessation. Duration of follow-up ranged from 2 to 20 years. All included studies consistently showed a protective effect of smoking cessation. Wilson et al16 performed a meta-analyses of 12 studies in patients with MI and found a pooled RR for all-causes mortality of 0.54 (95% CI, 0.46 to 0.62) for those who had quit smoking. Critchley and Capewell17 published a meta-analysis of 20 studies in patients with previous MI or AP and reported a pooled RR of 0.64 (95% CI, 0.58 to 0.71). Half of the studies were the same as in the first analysis. On the basis of these 2 meta-analyses, we conservatively estimate the effect size of smoking cessation in CAD patients as a 35% mortality risk reduction.
Habitual Physical Activity
We found no studies on the effect of increased physical activity on mortality in CAD patients. The effect of participation in a structured exercise program after a cardiac event (MI, AP, CABG, or PTCA) on morbidity and mortality has been evaluated in several meta-analyses.18–22 Reported effect size estimates of mortality reduction varied between 20% and 25%. Here we review the analysis by Brown et al,21 which is a 2003 update from earlier meta-analyses and which studied exercise-based rehabilitation programs separately from the comprehensive rehabilitation programs that also included educational and psychosocial interventions. In this study mortality data were available of 2585 patients in 12 randomized controlled trials. The interventions varied widely from gym-based aerobic exercise twice a week for 4 weeks to interventions lasting for 30 months with inpatient stays. Mean follow-up time was 24 months (range, 6 to 60 months). The study showed a significant beneficial effect of an exercise program. The effect on all-causes mortality was estimated as 25% risk reduction (RR, 0.76; 95% CI, 0.59 to 0.98).
Moderate Alcohol Consumption
Saturated Fat Reduction
Four28–31 randomized controlled trials and 1 cohort study32 met our criteria for fat modification. They all concerned saturated fat intake reduction. No studies were detected on the relation between trans–fatty acid intake and mortality in CAD patients. The randomized controlled trials were performed between 1960 and 1988 and intended to study a reduction of 5 energy% in saturated fat intake during 2 to 5 years of follow-up. The resulting reduction in serum cholesterol was 15% in 2 studies28,29 and only 5% in the other 2,31 raising doubts on adherence to the regimen in the latter 2 studies.30 Only in the 2 studies with the largest serum cholesterol reductions was total mortality reduced (12% and 25%), but the power of the studies was too limited to show statistically significant reductions. The probability value for heterogeneity was 0.18 for the 4 studies and 0.63 when the 2 studies with unsatisfying serum cholesterol reductions were excluded. The pooled effect estimates were not statistically significant for either the 4 or the 2 studies (Table 3). The cohort study32 in 400 Finnish CAD patients was supportive of a beneficial effect of a lower saturated fat intake. For every 4 energy% reduction in saturated fat, intake RR for all-causes mortality was 0.64 (95% CI, 0.46 to 0.88). However, this study on its own is not sufficient to be conclusive. Because the pooled effects are not statistically significant, we provide no summary effect estimate for saturated fat restriction.
Regular Fish (Oil) Consumption
We found 3 randomized controlled trials31,33–35 and 2 cohort studies32,36 fulfilling our selection criteria. The trials tested either the effect of advice to increase fatty fish consumption up to 200 to 400 g/wk31,33 or the effect of a fish oil supplement containing 900 mg EPA and DHA per day.34,35 Two of them31,34,35 showed a significant mortality reduction, but the trial in AP patients33 found a nonsignificant mortality increase in the intervention group.
Remaining Goals
Combined Interventions
Discussion
Although many of the commonly provided lifestyle and dietary recommendations (Table 1) are supported with evidence from surrogate end point studies and studies in the general population, there is only limited evidence from studies in CAD patients that these recommendations indeed improve their life expectancy. The available studies show significant effects for 3 lifestyle recommendations on prognosis of CAD patients. Effects for smoking cessation, increased physical activity, and moderate alcohol consumption vary from a 20% to 35% reduction in all-causes mortality. For individual dietary goals, evidence from studies in CAD patients was not available or was too limited to provide reliable effect estimates. A few studies on combinations of dietary changes show promising results, with mortality reductions of 45%.
In this review we included both experimental and observational studies. Randomized controlled trials are generally rated as a higher level of evidence than prospective cohort studies because they exclude self-selection and confounding by indication as a source of bias. Randomized clinical trials, however, have their own drawbacks: their inclusion criteria often limit generalization to the average patient population in routine care, their costs often limit the duration of the study, in the case of lifestyle or dietary interventions double blinding is often impossible, or the intervention itself is unethical (eg, smoking or alcohol consumption). Prospective cohort studies, on the other hand, may be confounded by unknown prognostic factors associated with lifestyle or dietary habits, but they have the advantage of giving a better reflection of the "real-life" situation with long-term exposure and mostly a mixed patient population. The advantages and disadvantages of each design do not outweigh those of the other. In this review we reported effect sizes of both study designs (if available) separately and did not make an attempt to rank one above the other.
This review has several potential limitations. Most evidence was available for studies on lifestyle changes in CAD patients. Studies on dietary changes are scarce, and several are of poor methodological quality. Confounding due to clustering of lifestyle and dietary factors as well as bias because of unblinding or poor compliance with the intervention or changes in habits of the control group is more common in lifestyle and dietary studies than in drugs trials. Many of the studies included in this review were underpowered to assess effects on total mortality. This problem may be solved by pooling the results of individual studies, but, even if tests for heterogeneity are not significant, this operation may be problematic because of the heterogeneity of studies with respect to background habits, intervention characteristics, exposure (time and dose), and length of follow-up. Sometimes the point estimates are impressive, but the wide CIs indicate a high degree of uncertainty. Therefore, caution is needed in interpreting the results and particularly in translating the effect size estimates to the individual patient.
Nevertheless, most of the presented effect estimates are in accord with results from studies performed in the general population. Table 4 compares the effect estimates in CAD patients with results from cohort studies in the general population.
Smoking Cessation
Our effect estimate of 35% risk reduction is similar to findings from population-based cohort studies indicating that quitters before age 50 have a 50% lower risk of dying than continuing smokers.41,42
Physical Activity Level
An effect estimate of 25% mortality risk reduction for an increased level of physical activity was obtained from a meta-analysis on the effect of exercise-based revalidation. Although the best available, this is not a good estimate for adherence to the guideline11 to increase habitual physical activity level to a daily amount of at least 30 minutes of moderately intensive activity. Participation in a program is not necessarily related to a higher physical activity level in the long run.43,44 However, the estimated 25% mortality risk reduction compares well with estimates from other populations. A review45 of 44 population-based cohort studies reported that adherence to the guideline was associated with a 20% to 30% reduction in all-causes mortality. Further reductions were observed at higher volumes of energy expenditure. Not only high baseline levels but also increments in physical activity level later in life are shown to be associated with lower mortality.46,47
Alcohol
Although the protective effect of moderate alcohol consumption on cardiovascular risk has been sufficiently demonstrated in the general population cohorts,48 for CAD patients there was concern about the adverse effects on the cardiovascular system, such as hypertension, arrhythmias, hemorrhagic stroke, and cardiomyopathy.49 The presented studies are consistent in their finding that moderate alcohol consumption can improve the prognosis in CAD patients, even in patients with associated heart failure,23 as long as the alcohol intake is moderate (2 to 3 U/d). The estimate of 20% mortality risk reduction in CAD patients is in range with a pooled estimate of 15% mortality reduction in cohort studies in middle-aged populations.50 Of course, the benefits of moderate alcohol consumption should always be mentioned in relation to the potential risks of excessive alcohol consumption because there are still more deaths caused by alcohol than prevented.51
Saturated Fat
Reliable effect estimates could be provided for none of the individual dietary factors.
The pooled effect estimates for saturated fat reduction were not statistically significant (for the 4 studies: RR, 0.98; 95% CI, 0.81 to 1.18) but agreed with the findings of 2 meta-analyses on fat modification combining the results of both primary and secondary prevention trials: RR, 0.94 (95% CI, 0.89 to 0.99; 17 trials)52 and RR, 0.98 (95% CI, 0.86 to 1.12; 11 trials).53 In contrast to our study, these meta-analyses also included studies on total fat restriction, which might have attenuated the effect. They confirm our finding that a trend was seen toward a greater risk reduction in trials in which better adherence to the intervention is shown by a greater reduction in serum cholesterol.
Regular Fish (Oil) Consumption
There was heterogeneity between the studies, but the calculated pooled effect estimates for the trials (12% to 23% mortality risk reduction) are in agreement with an estimate of 20% all-causes mortality reduction in a meta-analysis by Bucher et al54 based on 9 trials in CAD patients on the effects of dietary fish or fish oil supplementation in doses up to 10 g of -3 fatty acids per day. The pooled effect estimate from the cohort studies in CAD patients was also 20%. Data on fish and all-causes mortality from population-based cohorts are inconsistent and vary from 0% to 30%.55–60 Null findings in some of the studies can possibly be explained by the adverse effects of the high mercury content of fish in some geographic areas56,61 or by the fact that the protective effect is specific for fatty fish and not for total fish consumption.62 The association with CAD mortality is more frequently studied than all-causes mortality, and significant risk reductions are reported.63–65
For the remaining individual goals, studies on mortality were too few to provide effect estimates. This should not be interpreted as a lack of scientific support for these recommendations. The evidence from surrogate end point or clinical end point studies is reviewed elsewhere.66–77 Studies on all-causes mortality, however, are scarce, not only in CAD patients but also in other populations. Given the alarming signals78,79 on a high prevalence (80%) of overweight and obesity in CAD patients, it is surprising that no studies were found on the effect of intentional weight loss on mortality in CAD patients. Weight loss might be one of the mechanisms through which other lifestyle or dietary changes (eg, regular exercise or increased intake of whole grains and vegetables) might exert their protective effect, but few authors report on body weight changes.40 Cohort studies in the general population have shown that mortality is 30% to 50% lower in normal-weight individuals than in their obese peers,80 although this difference decreases with age.81 The effect that can be expected from weight reduction in patients already treated with preventive drugs is unclear. Some studies in CAD patients82–86 (not meeting our inclusion criteria) even suggest a prognostic benefit of obesity. These studies, however, are inconclusive because they often lack appropriate adjustments for confounding (eg, confounding by age because obese persons are generally 7 years younger at time of their first MI than normal-weight individuals), but they stress the need for high-quality additional research. Finally, population-based cohort studies that study all-causes mortality in relation to the intake of fruits and vegetables,87–90 whole grains,87,91,92 legumes,93 nuts,94,95 or salt96–98 are scarce but are generally supportive of a protective effect of the recommendations.
The trials on combined dietary interventions showed impressive results, varying from 35% to 55% mortality reduction. Other intervention studies in CAD patients showed benefits of combined lifestyle and dietary changes on surrogate end points and cardiac events.99,100 The cohort study in 11 000 CAD patients by Barzi et al36 showed an almost 50% lower mortality risk for those with the highest dietary quality score. Mortality risk reductions associated with dietary quality reported from other populations were generally smaller (15% to 25%), but a significant benefit was demonstrated in many studies.101–110 Two studies in elderly people101,104 showed a 60% to 70% lower mortality associated with a higher quality score for a combination of both lifestyle and dietary habits. Although the studies on combined changes are promising, they shed no light on the dominant mechanism and on the contribution of the individual lifestyle and dietary factors. More knowledge on the benefits of the 6 individual dietary goals in particular is necessary for designing effective preventive strategies.
In conclusion, there is evidence from mortality studies in CAD patients that smoking cessation, physical activity, moderate alcohol consumption, and combined dietary changes improve prognosis. Effect size estimates for the lifestyle goals vary between 20% and 35% mortality reductions. Data on the benefits of individual dietary goals are limited. For the future, more and better-quality studies are needed to reduce the uncertainty that surrounds these effect size estimates.
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