General Practice

Five year follow up of patients at high cardiovascular risk who took part in randomised controlled trial of health promotion

M E Cupples, senior lecturer in general practice ^a,  A McKnight, director of general practice ^b. 

^a Department of General Practice, Queen's University, Belfast BT9 7HR, ^b Northern Ireland Council for Postgraduate Medical and Dental Education, Belfast BT7 3JH

Correspondence to: M E Cupples m.cupples{at}qub.ac.uk

Health promotion programmes for patients with coronary heart disease are valuable, ^{1 2} but there is little evidence on their lasting effect.³ A randomised controlled trial in which patients who received personalised health promotion for two years showed significant benefits in lifestyle and quality of life. ^{2 4} We investigated whether the differences in lifestyle, quality of life, and risk factors persisted between the two groups five years after enrolment.

	Participants, methods, and results

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Patients aged under 75 who had had angina (all grades included) for at least six months and no other concurrent serious illness were identified by 18 general practices in Belfast. Their diagnosis was confirmed at interview, and they were randomly allocated to receive either usual NHS care and personal health promotion from a trained nurse every four months for two years or usual NHS care alone. Sealed envelopes opened at interview showed group allocations. Both groups were reviewed after two years. Full details, including sample size calculations, have been reported previously. ^{2 4}

Patients who completed the study were invited by letter to a five year follow up interview at their general practice surgery or their home. The nurse, blind to the trial group allocation, administered a questionnaire; measured height, weight, blood pressure, and breath carbon monoxide concentration; and took a blood sample for measurement of serum cholesterol concentration. Patients completed a Nottingham health profile questionnaire.

Distributions of age (mean 63 (SD 7)), sex (59% (408/688) male), and social class (I and II, 11% (72/688); III, 47% (325/688); IV and V, 42% (291/688) were similar in both groups. After five years 250 of the 342 (73%) in the intervention group (45 defaulted, 47 had died) and 237 of the 346 (68%) in the non-intervention group (44 defaulted, 65 had died) were reviewed.

There were no significant differences between the groups in respect of blood pressure, serum cholesterol concentration, body mass index, reported frequency of angina, or restriction of activities at five years (table).

Differences between the groups both in mean reported exercise frequency and change of frequency were significant at two years (P<0.001). The difference in change of frequency was significant at five years (P<0.05). The non-intervention group reported a progressive decrease in exercise frequency over five years. The intervention group's mean exercise frequency had increased at two years but decreased subsequently.

At two years the intervention group's reported diet was better than and had improved significantly compared with that of the non-intervention group, but there were no significant differences between groups at five years. Differences between groups in mean quality of life scores at various times were not significant. The intervention group's score for social isolation showed improvement at two years but not at five years.

Initially there was no significant difference between groups in the proportion of patients who took drugs (glyceryl trinitrate, nifedipine) to prevent an angina episode; a greater proportion of the intervention group did so at both two and five years (131/250 (52%) v 94/237 (40%); P<0.001) and five years (119/250 (48%) v 91/237 (38%); P<0.05). Smoking cessation (self report validated by measurement of breath carbon monoxide concentration) was not significantly different between groups at five years (7/41 (17%) in the intervention group; 13/51 (25%) in the non-intervention group).

We also analysed the data on an intention to treat basis, with baseline or adjusted values being substituted for missing data, but this did not alter the conclusions.

	Comment

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Three years after the end of a personalised health promotion programme based in primary care for patients with angina most of the benefits identified at the end of two years had worn off. At the end of five years, benefits reported in respect of exercise and taking drugs prophylactically were still evident but smaller. The results suggest that prolonged provision of health promotion for patients may be desirable and support the recommendation that secondary prevention in coronary heart disease should be a healthcare priority.⁵

	Acknowledgments

We thank all the patients and general practitioners who participated in the study, the research nurses at each stage, and Mr Mike Stevenson of the Health and Social Care Research Unit, Queen's University of Belfast, for statistical advice.

Contributors: MC and AMcK designed the study. MC was responsible for collecting the data, interpretation, and reporting. AMcK contributed to the interpretation and reporting. Both authors are guarantors.

	Footnotes

Funding: Northern Ireland Chest, Heart and Stroke Association.

Competing interests None declared.

	References

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1.	Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squait JL. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ 1998; 316: 1334-1337.
2.	Cupples ME, McKnight A. Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk. BMJ 1994; 309: 993-996[Abstract/Free Full Text].
3.	NHS Centre for Reviews and Dissemination, University of York. Cardiac rehabilitation. Effective Health Care 1998; 4: 7-9.
4.	Cupples ME, McKnight A, O'Neill C, Normand C. The effect of personal health education on the quality of life of patients with angina in general practice. Health Educ J 1996; 55: 75-83.
5.	Ebrahim S, Davey Smith G. Systematic review of randomised controlled trials of multiple risk factor interventions for preventing coronary heart disease. BMJ 1997; 314: 1666-1674[Abstract/Free Full Text].

(Accepted 20 May 1999)