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Long-term hospital-based secondary prevention of coronary artery disease: a randomized controlled trial
Anete Kaldal1, Serena Tonstad2, Jarle Jortveit3
1Department of Research, Sørlandet Hospital HF, Lundsiden, Box 416, 4604, Kristiansand S, Norway. anete.kaldal@gmail.com.
Insights
Hospital-based secondary prevention improved survival after heart events, but did not reduce mortality. Treatment targets for LDL-cholesterol and blood pressure were better achieved with hospital follow-up.
Area of Science:
- Cardiology
- Preventive Medicine
- Health Services Research
Background:
- Guidelines for secondary cardiovascular disease prevention are established but not consistently implemented.
- Deficiencies in achieving treatment targets persist, even in high-income nations.
- This study addresses the gap between recommended and actual secondary cardiovascular care.
Purpose of the Study:
- To compare long-term hospital-based secondary preventive care with primary health care follow-up.
- To evaluate the impact on new cardiovascular events and achievement of treatment targets.
- To assess the long-term effectiveness of different secondary prevention strategies.
Main Methods:
- Randomized controlled trial involving 1540 patients hospitalized for myocardial infarction or revascularization.
- Patients were randomized to either intensive hospital-based follow-up or standard primary care.
- Follow-up extended up to 10 years, with Cox regression analyses for hazard ratios.
Main Results:
- Hospital-based follow-up significantly improved composite endpoint-free survival (HR 0.80, p=0.02) by reducing repeat PCI.
- All-cause mortality was not significantly reduced (HR 0.96, p=0.86).
- Lower LDL-cholesterol and systolic blood pressure were observed in the hospital group during the first 5 years; other preventive measures showed no difference.
Conclusions:
- Long-term hospital-based secondary preventive care enhances survival free from composite endpoints but does not impact overall mortality.
- Significant risk factors for cardiovascular disease remain unaddressed by both care models.
- The benefits of hospital-based care on blood pressure and LDL-cholesterol diminished after the cessation of annual consultations.
Background And Aims:
Despite established guidelines on secondary prevention of cardiovascular disease, practical implementation of treatment targets is deficient even in high-income countries. This study compared long-term hospital-based treatment with follow-up at primary health care regarding new cardiovascular events and achievement of treatment targets.
Methods:
This randomized controlled trial at Sørlandet Hospital, Norway 2007-2021 included patients hospitalized due to myocardial infarction (n = 760) or after scheduled percutaneous coronary intervention (PCI) (n = 677) or coronary artery bypass grafting (n = 103). Patients were randomized to hospital-based secondary preventive care with consultations 2 weeks, 3 months, 6 months and 1 year after the index event and annually for up to 5 years, or follow-up at primary health care. Final data was collected after 10 years and hazard ratios were calculated using Cox regression analyses.
Results:
Composite endpoint-free survival due to a lower rate of PCI improved in patients with hospital-based follow-up (n = 788) compared to patients followed-up at primary health care (n = 752) (HR 0.80, 95% CI 0.66-0.96; p = 0.02) but all-cause mortality was not reduced (HR 0.96, 95% CI 0.59-1.56; p = 0.86). At 1 year, LDL-cholesterol (2.1 [SD 0.7] versus 2.3 [SD 0.8] mmol/l; p < 0.001) and systolic blood pressure (132 [SD 16] versus 142 [SD 20] mm/Hg; p < 0.001) were lower in the hospital-based group, and the differences remained significant during the first 5 years. Other secondary preventive measures (smoking cessation, physical activity, body weight, glucose control, drug adherence) did not differ.
Conclusions:
Long-term hospital-based secondary preventive follow-up improved composite endpoint-free survival, but not mortality. Substantial risk factors remained unaddressed. The beneficial effects on blood pressure and LDL-cholesterol disappeared after annual consultations ceased.
Trial Registration:
The study is registered in ClinicalTrials.gov (NCT00679237) May 16, 2008.
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