Published online before print June 9, 2008, doi: 10.1161/CIRCULATIONAHA.107.748095
(Circulation. 2008;117:3109-3117.)
© 2008 American Heart Association, Inc.
Preventive Cardiology |
Efficacy of In-Hospital Multidimensional Interventions of Secondary Prevention After Acute Coronary Syndrome
A Systematic Review and Meta-Analysis
From the Departments of Community Medicine and Ambulatory Care (R.A., N.R., J.C.) and Internal Medicine (R.A., J.C.), and Alcohol Treatment Center (J.G.), University of Lausanne, Lausanne, Switzerland, and the Departments of Community Health Sciences and Medicine (W.A.G.), Center for Health and Policy Studies, University of Calgary, Calgary, Alberta, Canada.
Reprint requests to Dr William Ghali, Health Science Centre, 3330 Hospital Drive NW, Calgary, Alberta, Canada T2N 4N1. E-mail wghali{at}ucalgary.ca
Received October 23, 2007; accepted March 27, 2008.
Background— Secondary prevention programs for patients experiencing an acute coronary syndrome have been shown to be effective in the outpatient setting. The efficacy of in-hospital prevention interventions administered soon after acute cardiac events is unclear. We performed a systematic review and meta-analysis to determine whether in-hospital, patient-level interventions targeting multiple cardiovascular risk factors reduce all-cause mortality after an acute coronary syndrome.
Methods and Results— Using a prespecified search strategy, we included controlled clinical trials and before-after studies of secondary prevention interventions with at least a patient-level component (ie, education, counseling, or patient-specific order sets) initiated in hospital with outcomes of mortality, readmission, or reinfarction rates in acute coronary syndrome patients. We classified the interventions as patient-level interventions with or without associated healthcare provider–level interventions and/or system-level interventions. Twenty-six studies met our inclusion criteria. The summary estimate of 14 studies revealed a relative risk of all-cause mortality of 0.79 (95% CI, 0.69 to 0.92; n=37'585) at 1 year. However, the apparent benefit depended on study design and level of intervention. The before-after studies suggested reduced mortality (relative risk [RR], 0.77; 95% CI, 0.66 to 0.90; n=3680 deaths), whereas the RR was 0.96 (95% CI, 0.64 to 1.44; n=99 deaths) among the controlled clinical trials. Only interventions including a provider- or system-level intervention suggested reduced mortality compared with patient-level–only interventions.
Conclusions— The evidence for in-hospital, patient-level interventions for secondary prevention is promising but not definitive because only before-after studies suggest a significant reduction in mortality. Future research should formally test which components of interventions provide the greatest benefit.