Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care

doi:10.1136/bmj.326.7380.84

BMJ 2003;326:84 ( 11 January )

Primary care

Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care

Peter Murchie, higher training fellow, ^a Neil C Campbell, senior lecturer, ^a Lewis D Ritchie, Mackenzie professor of general practice, ^a Julie A Simpson, medical statistician, ^a Joan Thain, cardiac rehabilitation health visitor. ^b

^a Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Aberdeen AB25 2AY, ^b Westburn Centre, Aberdeen AB25 2XG

Correspondence to: P Murchie p.murchie{at}abdn.ac.uk

Objectives: To evaluate the effects of nurse led clinicsin primary care on secondary prevention, total mortality, andcoronary event rates after fouryears.
Design: Follow up of a randomised controlled trialby postal questionnaires and review of case notes and nationaldatasets.
Setting: Stratified, random sample of 19 general practicesin north eastScotland.
Participants: 1343 patients (673 intervention and 670 control)under 80 years with a working diagnosis of coronary heart diseasebut without terminal illness or dementia and nothousebound.
Intervention: Nurse led secondary prevention clinics promotedmedical and lifestyle components of secondary prevention and offeredregular follow up for oneyear.
Main outcome measures: Components of secondary prevention (aspirin,blood pressure management, lipid management, healthy diet, exercise,non-smoking), total mortality, and coronary events (non-fatalmyocardial infarctions and coronarydeaths).
Results: Mean follow up was at 4.7 years. Significantimprovements were shown in the intervention group in all componentsof secondary prevention except smoking at one year, and thesewere sustained after four years except for exercise. The controlgroup, most of whom attended clinics after the initial year, caughtup before final follow up, and differences between groups wereno longer significant. At 4.7 years, 100 patients in the interventiongroup and 128 in the control group had died: cumulative deathrates were 14.5% and 18.9%, respectively (P=0.038). 100 coronaryevents occurred in the intervention group and 125 in the controlgroup: cumulative event rates were 14.2% and 18.2%, respectively(P=0.052). Adjusting for age, sex, general practice, and baselinesecondary prevention, proportional hazard ratios were 0.75 forall deaths (95% confidence intervals 0.58 to 0.98; P=0.036) and0.76 for coronary events (0.58 to 1.00; P=0.049)
Conclusions: Nurse led secondary prevention improved medicaland lifestyle components of secondary prevention and this seemedto lead to significantly fewer total deaths and probably fewercoronary events. Secondary prevention clinics should be startedsooner rather thanlater.

What is already known on this topic
Several effective interventions exist for the secondary prevention of coronary heart disease, but implementing them in practice has proved difficult

Secondary prevention programmes for coronary heart disease have improved short term outcomes such as processes of care and quality of life

What this study adds
Short term improvements in uptake of secondary prevention produced by nurse led clinics are maintained in the longer term

Improved medical and lifestyle components of secondary prevention produced by nurse led clinics seem to lead to fewer total deaths and coronary events

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