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A greater role for lifestyle change in the secondary prevention of acute coronary events

ESC Press Statement

Adherence to lifestyle advice about diet, exercise and smoking cessation following acute coronary syndrome (ACS) has a substantial effect on lowering the risk of further events, according to a study of more than 18,000 patients reported in the 16th February issue of the journal Circulation.

For example, the six-month risk of a subsequent heart attack in those who stopped smoking was around one half that of those who continued to smoke (a relative risk of 0.57); diet and exercise were associated with a similarly reduced risk. However, patients who reported persistent smoking and non-adherence to diet and exercise had an almost four-fold increased risk of further ACS (myocardial infarction/stroke/death) compared with never-smokers who did modify diet and exercise.

According to an accompanying editorial, this marked improvement in cardiovascular morbidity and mortality seen with lifestyle modification in the ACS population is "a novel and compelling finding". The editorial adds that such results "should raise a new level of focus on the timely initiation of behavioral modification after MI, similar to what is currently done with acute pharmacological intervention". It was striking in the study that at 30 days following ACS, 96.1% of subjects had been prescribed antiplatelet drugs and 78.9% statins - while around one-third of smokers were still smoking, and adherence to neither diet nor exercise recommendations was reported by 28.5%.

Speaking on behalf of the European Society of Cardiology (ESC), Professor Guy De Backer from the Department of Public Health at Ghent University, Ghent, Belgium, said the study confirmed the "crucial importance" of lifestyle not only in the primary prevention of cardiovascular disease, but now in secondary prevention, even within a few months of an acute coronary event.

However, Professor De Backer cautioned that, according to this study, the prescription of drugs for secondary prevention seems an easier option than modifying lifestyle. "These results indicate that we must give more attention to lifestyle modification," he said, "but this and other studies show that it is not easily achieved, even after a heart attack." In the latest EUROASPIRE study of the ESC, for example, 17% of coronary patients still smoked cigarettes, and 35% were obese.(2)

Professor De Backer proposed that lifestyle change will be best achieved in an integrated multidisciplinary programme, which is positively offered to patients. In the EUROASPIRE study one in five obese patients said they had never been told they were overweight, one half had not followed dietary advice to lose weight, and almost two-thirds had not increased their physical activity.

"The potential of lifestyle modification is very important," said Professor de Backer, "and I think we all need a more positive attitude to lifestyle changes. But it's not just a matter for the cardiologists but for a whole multidisciplinary rehabilitation team."

He added that the findings of the Circulation study are in line with the recommendations of the ESC's latest guidelines on cardiovascular prevention.(3)


1. Chow CK, Jolly S, Rao-Melacini P. et al. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation 2010; 121: 750-758.
2. Kotseva K, Wood D, De Backer G, et al. EUROASPIRE III: A survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from twenty-two European countries. Eur J Cardiovasc Prev Rehabil 2009; 16: 121-137.
3. Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: fourth joint task force of the European Society of cardiology and other societies. Eur J Cardiovasc Prev Rehabil 2007; 14 (Suppl 2): S1-S113.
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Notes to editor

The European Society of Cardiology (ESC) represents more than 62,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.