Advertisement

Effect of Sustaining Lifestyle Modifications (Nonsmoking, Weight Reduction, Physical Activity, and Mediterranean Diet) After Healing of Myocardial Infarction, Percutaneous Intervention, or Coronary Bypass (from the REasons for Geographic and Racial Differences in Stroke Study)

      Guidelines recommend lifestyle modification for patients with coronary heart disease (CHD). Few data demonstrate which lifestyle modifications, if sustained, reduce recurrent CHD and mortality risk in cardiac patients after the postacute rehabilitation phase. We determined the association between ideal lifestyle factors and recurrent CHD and all-cause mortality in REasons for Geographic and Racial Differences in Stroke study participants with CHD (n = 4,174). Ideal lifestyle factors (physical activity ≥4 times/week, nonsmoking, highest quartile of Mediterranean diet score, and waist circumference <88 cm for women and <102 cm for men) were assessed through questionnaires and an in-home study visit. There were 447 recurrent CHD events and 745 deaths over a median 4.3 and 4.5 years, respectively. After multivariable adjustment, physical activity ≥4 versus no times/week and non-smoking versus current smoking were associated with reduced hazard ratios (HRs; 95% confidence interval [CI]) for recurrent CHD (HR 0.69, 95% CI 0.54 to 0.89 and HR 0.50, 95% CI 0.39 to 0.64, respectively) and death (HR 0.71, 95% CI 0.59 to 0.86 and HR 0.53, 95% CI 0.44 to 0.65, respectively). The multivariable-adjusted HRs (and 95% CIs) for recurrent CHD and death comparing the highest versus lowest quartile of Mediterranean diet adherence were 0.77 (95% CI 0.55 to 1.06) and 0.84 (95% CI 0.67 to 1.07), respectively. Neither outcome was associated with waist circumference. Comparing participants with 1, 2, and 3 versus 0 ideal lifestyle factors (non-smoking, physical activity ≥4 times/week, and highest quartile of Mediterranean diet score), the HRs (and 95% CIs) were 0.60 (95% CI 0.44 to 0.81), 0.49 (95% CI 0.36 to 0.67), and 0.38 (95% CI 0.21 to 0.67), respectively, for recurrent CHD and 0.65 (95% CI 0.51 to 0.83), 0.57 (95% CI 0.43 to 0.74), and 0.41 (95% CI 0.26 to 0.64), respectively, for death. In conclusion, maintaining smoking cessation, physical activity, and Mediterranean diet adherence is important for secondary CHD prevention.
      Although lifestyle modification has clear benefits and is recommended for secondary prevention of coronary heart disease (CHD),
      • Graham I.
      • Atar D.
      • Borch-Johnsen K.
      • Boysen G.
      • Burell G.
      • Cifkova R.
      • Dallongeville J.
      • De Backer G.
      • Ebrahim S.
      • Gjelsvik B.
      • Herrmann-Lingen C.
      • Hoes A.
      • Humphries S.
      • Knapton M.
      • Perk J.
      • Priori S.G.
      • Pyorala K.
      • Reiner Z.
      • Ruilope L.
      • Sans-Menendez S.
      • Op Reimer W.S.
      • Weissberg P.
      • Wood D.
      • Yarnell J.
      • Zamorano J.L.
      • Walma E.
      • Fitzgerald T.
      • Cooney M.T.
      • Dudina A.
      • Vahanian A.
      • Camm J.
      • De Caterina R.
      • Dean V.
      • Dickstein K.
      • Funck-Brentano C.
      • Filippatos G.
      • Hellemans I.
      • Kristensen S.D.
      • McGregor K.
      • Sechtem U.
      • Silber S.
      • Tendera M.
      • Widimsky P.
      • Zamorano J.L.
      • Altiner A.
      • Bonora E.
      • Durrington P.N.
      • Fagard R.
      • Giampaoli S.
      • Hemingway H.
      • Hakansson J.
      • Kjeldsen S.E.
      • Larsen M.L.
      • Mancia G.
      • Manolis A.J.
      • Orth-Gomer K.
      • Pedersen T.
      • Rayner M.
      • Ryden L.
      • Sammut M.
      • Schneiderman N.
      • Stalenhoef A.F.
      • Tokgozoglu L.
      • Wiklund O.
      • Zampelas A.
      European Society of C, European Association for Cardiovascular P, Rehabilitation, Council on Cardiovascular N, European Association for Study of D, International Diabetes Federation E, European Stroke I, International Society of Behavioural M, European Society of H, European Society of General Practice/Family M, European Heart N
      European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).
      • Smith Jr., S.C.
      • Benjamin E.J.
      • Bonow R.O.
      • Braun L.T.
      • Creager M.A.
      • Franklin B.A.
      • Gibbons R.J.
      • Grundy S.M.
      • Hiratzka L.F.
      • Jones D.W.
      • Lloyd-Jones D.M.
      • Minissian M.
      • Mosca L.
      • Peterson E.D.
      • Sacco R.L.
      • Spertus J.
      • Stein J.H.
      • Taubert K.A.
      World Heart F, the Preventive Cardiovascular Nurses A
      AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
      • Leon A.S.
      • Franklin B.A.
      • Costa F.
      • Balady G.J.
      • Berra K.A.
      • Stewart K.J.
      • Thompson P.D.
      • Williams M.A.
      • Lauer M.S.
      American Heart A, Council on Clinical C, Council on Nutrition PA, Metabolism, American association of C, Pulmonary R
      Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
      <20% of cardiac patients complete cardiac rehabilitation programs.
      • Arena R.
      • Williams M.
      • Forman D.E.
      • Cahalin L.P.
      • Coke L.
      • Myers J.
      • Hamm L.
      • Kris-Etherton P.
      • Humphrey R.
      • Bittner V.
      • Lavie C.J.
      American Heart Association Exercise CR, Prevention Committee of the Council on Clinical Cardiology CoE, Prevention, Council on Nutrition PA, Metabolism
      Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings: a science advisory from the American Heart Association.
      • Suaya J.A.
      • Shepard D.S.
      • Normand S.L.
      • Ades P.A.
      • Prottas J.
      • Stason W.B.
      Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery.
      Few data demonstrate which secondary prevention lifestyle modifications, if sustained after the postacute CHD event period, reduce the risk for recurrent CHD or all-cause mortality.
      • Graham I.
      • Atar D.
      • Borch-Johnsen K.
      • Boysen G.
      • Burell G.
      • Cifkova R.
      • Dallongeville J.
      • De Backer G.
      • Ebrahim S.
      • Gjelsvik B.
      • Herrmann-Lingen C.
      • Hoes A.
      • Humphries S.
      • Knapton M.
      • Perk J.
      • Priori S.G.
      • Pyorala K.
      • Reiner Z.
      • Ruilope L.
      • Sans-Menendez S.
      • Op Reimer W.S.
      • Weissberg P.
      • Wood D.
      • Yarnell J.
      • Zamorano J.L.
      • Walma E.
      • Fitzgerald T.
      • Cooney M.T.
      • Dudina A.
      • Vahanian A.
      • Camm J.
      • De Caterina R.
      • Dean V.
      • Dickstein K.
      • Funck-Brentano C.
      • Filippatos G.
      • Hellemans I.
      • Kristensen S.D.
      • McGregor K.
      • Sechtem U.
      • Silber S.
      • Tendera M.
      • Widimsky P.
      • Zamorano J.L.
      • Altiner A.
      • Bonora E.
      • Durrington P.N.
      • Fagard R.
      • Giampaoli S.
      • Hemingway H.
      • Hakansson J.
      • Kjeldsen S.E.
      • Larsen M.L.
      • Mancia G.
      • Manolis A.J.
      • Orth-Gomer K.
      • Pedersen T.
      • Rayner M.
      • Ryden L.
      • Sammut M.
      • Schneiderman N.
      • Stalenhoef A.F.
      • Tokgozoglu L.
      • Wiklund O.
      • Zampelas A.
      European Society of C, European Association for Cardiovascular P, Rehabilitation, Council on Cardiovascular N, European Association for Study of D, International Diabetes Federation E, European Stroke I, International Society of Behavioural M, European Society of H, European Society of General Practice/Family M, European Heart N
      European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).
      • Smith Jr., S.C.
      • Benjamin E.J.
      • Bonow R.O.
      • Braun L.T.
      • Creager M.A.
      • Franklin B.A.
      • Gibbons R.J.
      • Grundy S.M.
      • Hiratzka L.F.
      • Jones D.W.
      • Lloyd-Jones D.M.
      • Minissian M.
      • Mosca L.
      • Peterson E.D.
      • Sacco R.L.
      • Spertus J.
      • Stein J.H.
      • Taubert K.A.
      World Heart F, the Preventive Cardiovascular Nurses A
      AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
      • Leon A.S.
      • Franklin B.A.
      • Costa F.
      • Balady G.J.
      • Berra K.A.
      • Stewart K.J.
      • Thompson P.D.
      • Williams M.A.
      • Lauer M.S.
      American Heart A, Council on Clinical C, Council on Nutrition PA, Metabolism, American association of C, Pulmonary R
      Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
      Additionally, the long-term CHD risk reduction benefits of multiple lifestyle factors have not been extensively studied. Therefore, we determined the association of (1) ideal levels of individual lifestyle factors that are the focus of cardiac rehabilitation programs, including waist circumference, physical activity, adherence to a Mediterranean diet, and smoking status, and (2) multiple ideal lifestyle factors with recurrent CHD and all-cause mortality. Determining these associations with recurrent CHD events and all-cause mortality can justify maintaining lifestyle modifications for secondary prevention and reinforce current guidelines. To do so, we analyzed a large population-based cohort of adults in the United States with existent CHD enrolled in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study.

      Methods

      The REGARDS study has been described previously.
      • Howard V.J.
      • Cushman M.
      • Pulley L.
      • Gomez C.R.
      • Go R.C.
      • Prineas R.J.
      • Graham A.
      • Moy C.S.
      • Howard G.
      The reasons for geographic and racial differences in stroke study: objectives and design.
      In brief, 30,239 adults aged ≥45 years from all 48 continental states of the United States and the District of Columbia were enrolled from January 2003 to October 2007. By design, the REGARDS study oversampled blacks and residents of Southeastern United States (North Carolina, South Carolina, Georgia, Alabama, Mississippi, Tennessee, Arkansas, and Louisiana). The current analysis was restricted to REGARDS participants reporting a history of CHD (defined in the following) at baseline and having recurrent CHD follow-up data (n = 4,174). Each participating center's Institutional Review Board governing human subject research approved the REGARDS study protocol. All participants provided informed consent.
      Baseline data were collected through a telephone interview, self-administered questionnaires, and an in-home examination. During computer-assisted telephone interviews administered by trained staff, participants' age, race, gender, smoking status, education, annual household income, physical activity, self-rated health, regular aspirin use, and self-report of previous diagnosed co-morbid conditions (e.g., diabetes, myocardial infarction, coronary revascularization procedures) were collected. Because awareness of a CHD event could prompt behavior changes, history of CHD was defined as self-reported myocardial infarction, angioplasty or stenting of a coronary artery, or coronary bypass surgery. During the in-home examination, technicians measured waist circumference and blood pressure (BP) and collected blood and spot urine samples (described previously).
      • Howard V.J.
      • Cushman M.
      • Pulley L.
      • Gomez C.R.
      • Go R.C.
      • Prineas R.J.
      • Graham A.
      • Moy C.S.
      • Howard G.
      The reasons for geographic and racial differences in stroke study: objectives and design.
      Prescription and over-the-counter pill bottles were reviewed for medications taken during the 2 weeks before the in-home study visit. The use of clopidogrel, β blockers, statins, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers were considered in this analysis. After the in-home examination, participants completed and mailed a self-administered Block 98 Food-Frequency Questionnaire to the coordinating center.
      Low-density lipoprotein cholesterol was calculated using the Friedewald equation. Diabetes was defined by self-report with concurrent use of insulin or oral hypoglycemic medications or fasting serum glucose ≥126 mg/dl or nonfasting serum glucose ≥200 mg/dl. High-sensitivity C-reactive protein was measured by particle-enhanced immunonephelometry. Estimated glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation.
      • Levey A.S.
      • Stevens L.A.
      • Schmid C.H.
      • Zhang Y.L.
      • Castro 3rd, A.F.
      • Feldman H.I.
      • Kusek J.W.
      • Eggers P.
      • Van Lente F.
      • Greene T.
      • Coresh J.
      • Ckd E.P.I.
      A new equation to estimate glomerular filtration rate.
      Reduced estimated glomerular filtration rate was defined as levels <60 ml/min/1.73 m2. Albuminuria was defined as urinary albumin/urinary creatinine ratio ≥30 mg/g.
      Four lifestyle factors were evaluated: abdominal obesity, physical activity, adhering to a Mediterranean-style diet, and cigarette smoking. Compared with body mass index, waist circumference has been shown to have a stronger association with cardiovascular (CV) events
      • Czernichow S.
      • Kengne A.P.
      • Stamatakis E.
      • Hamer M.
      • Batty G.D.
      Body mass index, waist circumference and waist-hip ratio: which is the better discriminator of cardiovascular disease mortality risk?: evidence from an individual-participant meta-analysis of 82 864 participants from nine cohort studies.
      and, thus, was chosen as a measure of adiposity in the current analysis. Abdominal obesity was defined as a waist circumference of >102 cm and >88 cm for men and women, respectively. Physical activity was assessed with the question “How many times per week do you engage in intense physical activity, enough to work up a sweat?” Response options were “none,” “1 to 3,” or “≥4” times per week. The Food-Frequency Questionnaire was processed with NutritionQuest software to estimate the average dietary nutrient intake for 1 year before participants' in-home visit. A Mediterranean diet score was created with 14 all-inclusive food groups and nutrients (e.g., potatoes, vegetables, legumes, fruits and nuts, dairy products, cereals, meats, fish, eggs, monounsaturated lipids, polyunsaturated lipids, saturated lipids and margarines, sugar and sweets, nonalcoholic beverages), using a monounsaturated/saturated fats ratio similar to methods described by Trichopoulou et al.
      • Trichopoulou A.
      • Costacou T.
      • Bamia C.
      • Trichopoulos D.
      Adherence to a Mediterranean diet and survival in a Greek population.
      Participants were grouped into quartiles based on the study population's distribution of Mediterranean diet scores (cut points: ≤3, 4 to <5, 5, and ≥5 [higher quartiles: better adherence]). Current smoking was defined as responding “yes” to both questions: “Have you smoked at least 100 cigarettes in your lifetime?” and “Do you smoke cigarettes now, even occasionally?” Ideal lifestyle factors were (1) not having abdominal obesity, (2) physical activity ≥4 times/week, (3) Mediterranean diet score in the highest quartile, and (4) being a nonsmoker.
      Two outcomes were studied: recurrent CHD or all-cause mortality. After the baseline visit, living participants or their proxies were contacted biannually by way of telephone to assess potential recurrent CHD events and vital status. When a CHD-related hospitalization or a death was reported, medical records were retrieved and trained clinicians adjudicated events following published guidelines.
      • Luepker R.V.
      • Apple F.S.
      • Christenson R.H.
      • Crow R.S.
      • Fortmann S.P.
      • Goff D.
      • Goldberg R.J.
      • Hand M.M.
      • Jaffe A.S.
      • Julian D.G.
      • Levy D.
      • Manolio T.
      • Mendis S.
      • Mensah G.
      • Pajak A.
      • Prineas R.J.
      • Reddy K.S.
      • Roger V.L.
      • Rosamond W.D.
      • Shahar E.
      • Sharrett A.R.
      • Sorlie P.
      • Tunstall-Pedoe H.
      Epidemiology AHACo, Prevention, Committee AHAS, World Heart Federation Council on E, Prevention, European Society of Cardiology Working Group on E, Prevention, Centers for Disease C, Prevention, National Heart L, Blood I
      Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; the European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; and the National Heart, Lung, and Blood Institute.
      • Safford M.M.
      • Brown T.M.
      • Muntner P.M.
      • Durant R.W.
      • Glasser S.
      • Halanych J.H.
      • Shikany J.M.
      • Prineas R.J.
      • Samdarshi T.
      • Bittner V.A.
      • Lewis C.E.
      • Gamboa C.
      • Cushman M.
      • Howard V.
      • Howard G.
      • Investigators R.
      Association of race and sex with risk of incident acute coronary heart disease events.
      • Prineas R.J.
      • Crow R.S.
      • Zhang Z.-M.
      The Minnesota Code Manual of Electrocardiographic Findings (including measurement and comparison with the Novacode): Standards and Procedures for ECG Measurement in Epidemiologic and Clinical Trials.
      Online sources (e.g., Social Security Death Index), the National Death Index, and reports from next of kin were used to detect participant deaths. Circumstances of the death were obtained by interviewing proxies or next of kin, from death certificates, autopsy reports, and medical records. Definite or probable CHD events (nonfatal myocardial infarction or acute CHD death) and all-cause mortality through December 31, 2009 were analyzed.
      Participant characteristics were calculated by number of ideal lifestyle factors (0, 1, 2, or ≥3). Crude rates for recurrent CHD were calculated for levels of each lifestyle factor. Cox proportional hazard models with progressive adjustment were used to calculate the hazard ratios (HRs) for recurrent CHD associated with each lifestyle factor. An initial model (model 1) included adjustment for age, gender, race, and geographic region of residence. A second model (model 2) included additional adjustment for low-density lipoprotein cholesterol, BP, education, annual household income, self-rated health, diabetes, albuminuria, estimated glomerular filtration rate, C-reactive protein, and use of aspirin, clopidogrel, β blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and statins. Next, the cumulative incidence of recurrent CHD was calculated by number of ideal lifestyle factors (physical activity ≥4 times/week, highest quartile of Mediterranean diet adherence, and nonsmoking). As waist circumference was not associated with recurrent CHD or all-cause mortality, it was excluded from the analysis of number of ideal lifestyle factors. Cumulative incidence curves were plotted by number of ideal lifestyle factors. HRs for recurrent CHD associated with the number of ideal lifestyle factors were calculated with similar adjustment as described previously. Identical analyses were repeated for all-cause mortality. Missing data were imputed with 10 data sets using chained equations.
      • White I.R.
      • Royston P.
      • Wood A.M.
      Multiple imputation using chained equations: issues and guidance for practice.
      The number (%) of imputed lifestyle factors were waist circumference: 28 (0.7%), physical activity: 62 (1.5%), smoking: 12 (0.3%), and Mediterranean diet score: 1,355 (32.5%). Analyses were conducted using Stata/IC 12.1 (Stata Corporation, College Station, Texas).

      Results

      The mean age and the proportion of participants taking aspirin and statins were higher in those with more ideal lifestyle factors (Table 1). Women and blacks were less likely to have more ideal lifestyle factors. The percentage of participants with less than a high school education, an annual household income <$20,000, albuminuria, and diabetes was lower with more ideal lifestyle factors. The mean systolic and diastolic BP, waist circumference, low-density lipoprotein cholesterol, and C-reactive protein were lower as the number of ideal lifestyle factors increased. Other participant characteristics were similar across the number of ideal lifestyle factors.
      Table 1Baseline characteristics of the REasons for Geographic and Racial Differences in Stroke (REGARDS) study population with coronary heart disease by number of ideal lifestyle factors
      Participant characteristicNumber of Ideal Lifestyle Factors
      Ideal lifestyle factors were defined as not having abdominal obesity, physical activity ≥4 times per week, Mediterranean diet score in the highest quartile, and being a non-smoker.
      0

      (n = 240)
      1

      (n = 1,383)
      2

      (n = 1,452)
      3 – 4

      (n = 1,100)
      Percentage of sample5.7%33.1%34.8%26.4%
      Age (years)64.8 (0.5)67.2 (0.3)69.7 (0.3)70.4 (0.3)
      Female57.1%47.2%32.5%21.6%
      Black40.9%39.8%33.9%25.9%
      Less than a high school education25.1%20.0%17.0%12.5%
      Household Income <$20,00037.3%28.8%20.2%12.7%
      Geographic Region
       Stroke belt36.4%35.3%34.1%33.5%
       Stroke buckle18.9%21.5%22.2%20.4%
       Other region44.7%43.2%43.7%46.1%
      Diabetes mellitus46.9%45.4%33.2%23.9%
      Systolic blood pressure (mm Hg)130.9 (1.2)131.6 (0.5)129.5 (0.5)128.0 (0.6)
      Diastolic blood pressure (mm Hg)75.8 (0.6)76.1 (0.3)75.0 (0.3)74.0 (0.3)
      Low estimated GFR (<60 ml/min/1.73 m2)22.1%24.4%25.1%17.1%
      High albumin to creatinine ratio (≥30 mg/g)32.2%28.7%23.9%17.4%
      Aspirin Use74.6%74.4%75.0%82.6%
      Clopidogrel Use20.0%19.0%19.5%17.2%
      Statin Use58.2%62.3%65.7%68.6%
      Beta blocker use55.3%53.9%53.1%51.9%
      ACE inhibitor use44.4%39.9%40.1%36.8%
      Angiotensin receptor blocker use15.2%22.2%18.3%15.8%
      Abdominal obesity
      Abdominal obesity = waist circumference for men: >102 cm and women: >88 cm.
      100.0%86.8%44.1%12.2%
      Serum LDL-cholesterol (mg/dL)103.5 (2.6)100.6 (1.0)98.7 (1.0)95.1 (1.1)
      C-reactive protein mg/L4.8 (4.7 – 4.9)3.3 (3.2 – 3.3)2.4 (2.4 – 2.4)1.6 (1.6 – 1.6)
      Number in the table numbers is percentage or mean ± standard error except C-reactive protein which is geometric mean (95% confidence interval).
      GFR = estimated glomerular filtration rate.
      Abdominal obesity = waist circumference for men: >102 cm and women: >88 cm.
      Ideal lifestyle factors were defined as not having abdominal obesity, physical activity ≥4 times per week, Mediterranean diet score in the highest quartile, and being a non-smoker.
      The prevalence of ideal waist circumference, physical activity ≥4 times/week, high Mediterranean diet adherence, and nonsmoking was 46.9%, 30.1%, 25.4%, and 84.6%, respectively. There were 447 recurrent CHD events over a median follow-up of 4.3 years (maximum 6.9). Incidence of recurrent CHD was lower in subjects with higher levels of physical activity, higher Mediterranean diet adherence, and nonsmokers (Table 2). Recurrent CHD rates were not substantially different for subjects with and without abdominal obesity. The HRs for recurrent CHD were lower for subjects participating in physical activity 1 to 3 or ≥4 times/week versus no physical activity, subjects more adherent to a Mediterranean diet, and nonsmokers versus current smokers after adjustment for age, race, gender, and region of residence. Although participating in physical activity 1 to 3 or ≥4 times/week and not smoking remained associated with a lower HR for recurrent CHD after multivariable adjustment, the HR comparing the highest with the lowest quartile of Mediterranean diet score was no longer statistically significant.
      Table 2Crude incidence rates and hazard ratios for recurrent coronary heart disease associated with individual lifestyle factors
      Individual lifestyle factorsEvents/persons at riskIncidence Rate (95% CI)Hazard Ratio (95% CI)
      Crude (per 1,000 person-years)Model 1Model 2
      Abdominal obesity
      Abdominal obesity = waist circumference >102 cm for men, >88 cm for women.
       Yes241/2,21527.2 (23.7 – 30.6)1 (reference)1 (reference)
       No206/1,95925.7 (22.2 – 29.2)0.88 (0.73 – 1.07)1.07 (0.87 – 1.31)
      p-value--0.2070.503
      Physical Activity
       None225/1,61136.7 (31.8 – 41.5)1 (reference)1 (reference)
       1 – 3 times/week119/1,30821.6 (17.7 – 25.6)0.59 (0.47 – 0.75)0.72 (0.57 – 0.90)
       4+ times/week104/1,25519.7 (15.9 – 23.5)0.53 (0.42 – 0.68)0.69 (0.54 – 0.89)
      p-trend--<0.0010.002
      Mediterranean diet score
      The cut-points for the lowest to highest quartile of the Mediterranean diet scores were ≤3, >3 to 4, >4 to 5, and >5.
       Quartile 1 (lowest - worse score)175/1,38532.2 (26.8 – 37.6)1 (reference)1 (reference)
       Quartile 291/88425.5 (19.2 – 37.8)0.79 (0.60 – 1.03)0.85 (0.65 – 1.12)
       Quartile 385/84524.1 (18.1 – 30.2)0.73 (0.53 – 1.03)0.76 (0.54 – 1.07)
       Quartile 4 (highest - better score)96/1,06021.9 (16.9 – 26.9)0.66 (0.48 – 0.90)0.77 (0.55 – 1.06)
      p-trend--0.0110.084
      Current Smoker
       Yes102/64243.9 (35.4 – 52.4)1 (reference)1 (reference)
       No345/3,53223.7 (21.2 – 26.2)0.47 (0.37 – 0.56)0.50 (0.39 – 0.64)
      p-value--<0.001<0.001
      Model 1 includes age, race, sex, and region of residence, education and income.
      Model 2 includes variables in Model 1 plus LDL cholesterol, systolic and diastolic blood pressure, self-rated health, diabetes, albuminuria, estimated glomerular filtration rate, C-reactive protein, aspirin use, clopidogrel use, beta blocker use, angiotensin converting enzyme inhibitor use, angiotensin receptor blocker use, and statin use.
      Abdominal obesity = waist circumference >102 cm for men, >88 cm for women.
      The cut-points for the lowest to highest quartile of the Mediterranean diet scores were ≤3, >3 to 4, >4 to 5, and >5.
      Over a median follow-up of 4.5 years (maximum 6.9), 745 deaths occurred. More physical activity, higher Mediterranean diet adherence, and not smoking were associated with lower crude rates and age-, race-, gender-, and region of residence–adjusted HRs for mortality (Table 3). More physical activity and not smoking remained associated with lower HRs for death after full multivariable adjustment. The highest Mediterranean diet quartile was no longer significantly associated with mortality after multivariable adjustment. Abdominal obesity was not associated with mortality before or after multivariable adjustment.
      Table 3Crude incidence rates and hazard ratios for all-cause mortality associated with individual lifestyle factors
      Individual lifestyle factorsEvents/persons at riskIncidence Rate (95% CI)Hazard Ratio (95% CI)
      Crude (per 1,000 person-years)Model 1Model 2
      Abdominal obesity
      Abdominal obesity = waist circumference >102 cm for men, >88 cm for women.
       Yes382/2,21541.8 (37.6 – 46.0)1 (reference)1 (reference)
       No363/1,95943.7 (39.2 – 48.2)0.93 (0.80 – 1.08)1.15 (0.98 – 1.35)
      p-value--0.3200.090
      Physical Activity
       None409/1,61364.0 (57.8 – 70.2)1 (reference)1 (reference)
       1 – 3 times/week166/1,30829.2 (24.7 – 33.7)0.48 (0.40 – 0.58)0.61 (0.50 – 0.73)
       4+ times/week171/1,25431.7 (26.9 – 36.5)0.50 (0.42 – 0.61)0.71 (0.59 – 0.86)
      p-trend--<0.001<0.001
      Mediterranean diet score
      The cut-points for the lowest to highest quartile of the Mediterranean diet scores were ≤3, >3 to 4, >4 to 5, and >5.
       Quartile 1 (lowest - worse score)274/1,38548.3 (42.3 – 54.3)1 (reference)1 (reference)
       Quartile 2165/88445.6 (37.8 – 53.4)0.92 (0.75 – 1.14)1.02 (0.82 – 1.27)
       Quartile 3145/84540.0 (32.0 – 48.0)0.78 (0.61 – 1.00)0.83 (0.63 – 1.08)
       Quartile 4 (highest - better score)161/1,06035.6 (29.4 – 41.7)0.68 (0.55 – 0.86)0.84 (0.66 – 1.07)
      p-trend--<0.0010.061
      Current Smoker
       Yes156/64263.4 (53.4 – 73.3)1 (reference)1 (reference)
       No589/3,53239.3 (36.1 – 42.5)0.46 (0.38 – 0.55)0.53 (0.44 – 0.65)
      p-value--<0.001<0.001
      Model 1 includes age, race, sex, and region of residence, education and income.
      Model 2 includes variables in Model 1 plus LDL cholesterol, systolic and diastolic blood pressure, self-rated health, diabetes, albuminuria, estimated glomerular filtration rate, C-reactive protein, aspirin use, clopidogrel use, beta blocker use, angiotensin converting enzyme inhibitor use, angiotensin receptor blocker use, and statin use.
      Abdominal obesity = waist circumference >102 cm for men, >88 cm for women.
      The cut-points for the lowest to highest quartile of the Mediterranean diet scores were ≤3, >3 to 4, >4 to 5, and >5.
      The prevalence of 0, 1, 2, or 3 ideal lifestyle factors (i.e., physical activity ≥4 times/week, Mediterranean diet in the highest quartile, non-smoking) was 10.1%, 48.2%, 33.2%, and 8.5%, respectively. The cumulative incidence for recurrent CHD and mortality were each lower with progressively more ideal lifestyle factors (Figures 1 and 2). These associations remained present after multivariable adjustment (Tables 4 and 5).
      Figure thumbnail gr1
      Figure 1Crude cumulative incidence for recurrent CHD associated with number of ideal lifestyle factors. Ideal lifestyle factors were defined as not having abdominal obesity, physical activity ≥4 times/week, Mediterranean diet score in the highest quartile, and being a nonsmoker.
      Figure thumbnail gr2
      Figure 2Crude cumulative incidence for all-cause mortality associated with number of ideal lifestyle factors. Ideal lifestyle factors were defined as not having abdominal obesity, physical activity ≥4 times/week, Mediterranean diet score in the highest quartile, and being a nonsmoker.
      Table 4Crude incidence rates and hazard ratios for recurrent coronary heart disease associated with number of ideal lifestyle factors
      Number of ideal lifestyle factors
      Ideal lifestyle factors were defined as not having abdominal obesity, physical activity ≥4 times per week, Mediterranean diet score in the highest quartile, and being a non-smoker.
      Events/persons at riskIncidence Rate (95% CI)Hazard Ratio (95% CI)
      Crude (per 1,000 person-years)Model 1Model 2
      071/42246.2 (35.1 – 57.2)1 (reference)1 (reference)
      1230/2,01128.8 (24.8 – 32.7)0.56 (0.42 – 0.75)0.60 (0.44 – 0.81)
      2124/1,38621.2 (17.3 – 25.0)0.40 (0.30 – 0.55)0.49 (0.36 – 0.67)
      323/35515.0 (7.7 – 22.2)0.28 (0.16 – 0.49)0.38 (0.21 – 0.67)
      p-trend--<0.001<0.001
      Model 1 includes age, race, sex, and region of residence, education and income.
      Model 2 includes variables in Model 1 plus LDL cholesterol, systolic and diastolic blood pressure, waist circumference, self-rated health, diabetes, albuminuria, estimated glomerular filtration rate, C-reactive protein, aspirin use, clopidogrel use, beta blocker use, angiotensin converting enzyme inhibitor use, angiotensin receptor blocker use, and statin use.
      Ideal lifestyle factors were defined as not having abdominal obesity, physical activity ≥4 times per week, Mediterranean diet score in the highest quartile, and being a non-smoker.
      Table 5Crude incidence rates and hazard ratios for all-cause mortality associated with number of ideal lifestyle factors
      Number of ideal lifestyle factors
      Ideal lifestyle factors were defined as not having abdominal obesity, physical activity ≥4 times per week, Mediterranean diet score in the highest quartile, and being a non-smoker.
      Events/persons at riskIncidence Rate (95% CI)Hazard Ratio (95% CI)
      Crude (per 1,000 person-years)Model 1Model 2
      0106/42264.8 (52.0 – 77.6)1 (reference)1 (reference)
      1392/2,01147.4 (42.2 – 52.6)0.58 (0.46 – 0.73)0.65 (0.51 – 0.83)
      2213/1,38635.5 (29.9 – 41.1)0.42 (0.32 – 0.54)0.57 (0.43 – 0.74)
      335/35522.3 (14.1 – 30.6)0.26 (0.17 – 0.41)0.41 (0.26 – 0.64)
      p-trend--<0.001<0.001
      Model 1 includes age, race, sex, and region of residence, education and income.
      Model 2 includes variables in Model 1 plus LDL cholesterol, systolic and diastolic blood pressure, waist circumference, self-rated health, diabetes, albuminuria, estimated glomerular filtration rate, C-reactive protein, aspirin use, clopidogrel use, beta blocker use, angiotensin converting enzyme inhibitor use, angiotensin receptor blocker use, and statin use.
      Ideal lifestyle factors were defined as not having abdominal obesity, physical activity ≥4 times per week, Mediterranean diet score in the highest quartile, and being a non-smoker.

      Discussion

      In the current analysis of a nationwide sample of patients with prevalent CHD, not smoking, more physical activity, and adherence to a Mediterranean diet were each associated with a lower recurrent CHD and all-cause mortality risk. However, only 40% of participants had ideal levels for 2 or 3 of these lifestyle factors. While the associations between adherence to a Mediterranean diet and recurrent CHD and all-cause mortality were attenuated after multivariable adjustment, not smoking and participating in physical activity remained protective. Additionally, there was a strong and graded association for lower recurrent CHD and mortality with more ideal lifestyle factors. Subjects with 3 ideal lifestyle factors had a 62% and 59% lower risk for recurrent CHD and mortality, respectively.
      Smoking is a leading preventable cause of premature death and disability.
      • Palmer R.C.
      • McKinney S.
      Health care provider tobacco cessation counseling among current African American tobacco users.
      The 45% to 55% lower risk for recurrent CHD events and all-cause mortality in the present study is similar to 2 other cohort studies of patients with a history of CHD.
      • Rea T.D.
      • Heckbert S.R.
      • Kaplan R.C.
      • Smith N.L.
      • Lemaitre R.N.
      • Psaty B.M.
      Smoking status and risk for recurrent coronary events after myocardial infarction.
      • Critchley J.A.
      • Capewell S.
      Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review.
      Considering that 15% of this sample of adults of United States was smoking despite having a history of CHD, smoking cessation should continue to be a high priority to lower recurrent CHD and mortality risk in patients with CHD.
      A 2005 meta-analysis demonstrated a 24% and 28% reduction in recurrent CHD and all-cause mortality, respectively, comparing subjects randomized to a physical activity rehabilitation program versus usual care.
      • Graham I.
      • Atar D.
      • Borch-Johnsen K.
      • Boysen G.
      • Burell G.
      • Cifkova R.
      • Dallongeville J.
      • De Backer G.
      • Ebrahim S.
      • Gjelsvik B.
      • Herrmann-Lingen C.
      • Hoes A.
      • Humphries S.
      • Knapton M.
      • Perk J.
      • Priori S.G.
      • Pyorala K.
      • Reiner Z.
      • Ruilope L.
      • Sans-Menendez S.
      • Op Reimer W.S.
      • Weissberg P.
      • Wood D.
      • Yarnell J.
      • Zamorano J.L.
      • Walma E.
      • Fitzgerald T.
      • Cooney M.T.
      • Dudina A.
      • Vahanian A.
      • Camm J.
      • De Caterina R.
      • Dean V.
      • Dickstein K.
      • Funck-Brentano C.
      • Filippatos G.
      • Hellemans I.
      • Kristensen S.D.
      • McGregor K.
      • Sechtem U.
      • Silber S.
      • Tendera M.
      • Widimsky P.
      • Zamorano J.L.
      • Altiner A.
      • Bonora E.
      • Durrington P.N.
      • Fagard R.
      • Giampaoli S.
      • Hemingway H.
      • Hakansson J.
      • Kjeldsen S.E.
      • Larsen M.L.
      • Mancia G.
      • Manolis A.J.
      • Orth-Gomer K.
      • Pedersen T.
      • Rayner M.
      • Ryden L.
      • Sammut M.
      • Schneiderman N.
      • Stalenhoef A.F.
      • Tokgozoglu L.
      • Wiklund O.
      • Zampelas A.
      European Society of C, European Association for Cardiovascular P, Rehabilitation, Council on Cardiovascular N, European Association for Study of D, International Diabetes Federation E, European Stroke I, International Society of Behavioural M, European Society of H, European Society of General Practice/Family M, European Heart N
      European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).
      • Balady G.J.
      • Ades P.A.
      • Comoss P.
      • Limacher M.
      • Pina I.L.
      • Southard D.
      • Williams M.A.
      • Bazzarre T.
      Core components of cardiac rehabilitation/secondary prevention programs: a statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group.
      The present study was unable to determine whether the participants completed a cardiac rehabilitation program. However, our study does extend previous research from the postacute to the long-term outpatient setting and suggests that maintaining physical activity after completing cardiac rehabilitation, regardless of the frequency, may be important for reducing recurrent CHD and all-cause mortality risk.
      • Suaya J.A.
      • Shepard D.S.
      • Normand S.L.
      • Ades P.A.
      • Prottas J.
      • Stason W.B.
      Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery.
      • Cottin Y.
      • Cambou J.P.
      • Casillas J.M.
      • Ferrieres J.
      • Cantet C.
      • Danchin N.
      Specific profile and referral bias of rehabilitated patients after an acute coronary syndrome.
      • Lavie C.J.
      • Thomas R.J.
      • Squires R.W.
      • Allison T.G.
      • Milani R.V.
      Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease.
      Despite a limited number of intervention and observational studies, the American Heart Association and European dietary guidelines for secondary prevention recommend a healthy dietary pattern that can be largely achieved by adhering to a Mediterranean diet consisting primarily of fruits, vegetables, fish, fiber, and low amounts of saturated fats.
      • Smith Jr., S.C.
      • Benjamin E.J.
      • Bonow R.O.
      • Braun L.T.
      • Creager M.A.
      • Franklin B.A.
      • Gibbons R.J.
      • Grundy S.M.
      • Hiratzka L.F.
      • Jones D.W.
      • Lloyd-Jones D.M.
      • Minissian M.
      • Mosca L.
      • Peterson E.D.
      • Sacco R.L.
      • Spertus J.
      • Stein J.H.
      • Taubert K.A.
      World Heart F, the Preventive Cardiovascular Nurses A
      AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • Benjamin E.J.
      • Berry J.D.
      • Borden W.B.
      • Bravata D.M.
      • Dai S.
      • Ford E.S.
      • Fox C.S.
      • Franco S.
      • Fullerton H.J.
      • Gillespie C.
      • Hailpern S.M.
      • Heit J.A.
      • Howard V.J.
      • Huffman M.D.
      • Kissela B.M.
      • Kittner S.J.
      • Lackland D.T.
      • Lichtman J.H.
      • Lisabeth L.D.
      • Magid D.
      • Marcus G.M.
      • Marelli A.
      • Matchar D.B.
      • McGuire D.K.
      • Mohler E.R.
      • Moy C.S.
      • Mussolino M.E.
      • Nichol G.
      • Paynter N.P.
      • Schreiner P.J.
      • Sorlie P.D.
      • Stein J.
      • Turan T.N.
      • Virani S.S.
      • Wong N.D.
      • Woo D.
      • Turner M.B.
      on behalf of the American Heart Association Statistics C, Stroke Statistics S
      Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
      • Perk J.
      • De Backer G.
      • Gohlke H.
      • Graham I.
      • Reiner Z.
      • Verschuren M.
      • Albus C.
      • Benlian P.
      • Boysen G.
      • Cifkova R.
      • Deaton C.
      • Ebrahim S.
      • Fisher M.
      • Germano G.
      • Hobbs R.
      • Hoes A.
      • Karadeniz S.
      • Mezzani A.
      • Prescott E.
      • Ryden L.
      • Scherer M.
      • Syvanne M.
      • Scholte op Reimer W.J.
      • Vrints C.
      • Wood D.
      • Zamorano J.L.
      • Zannad F.
      European Association for Cardiovascular P, Rehabilitation, Guidelines ESCCfP
      European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts).
      • Sofi F.
      • Abbate R.
      • Gensini G.F.
      • Casini A.
      Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis.
      • Serra-Majem L.
      • Roman B.
      • Estruch R.
      Scientific evidence of interventions using the Mediterranean diet: a systematic review.
      Recently, the Prevencion con Dieta Mediterranea (PREDIMED) trial reported adherence to a Mediterranean diet in subjects without history of CHD to be associated with a 29% and 11% lower risk for CV disease and all-cause mortality, respectively, over 4.8 years of follow-up.
      • Estruch R.
      • Ros E.
      • Salas-Salvado J.
      • Covas M.I.
      • Corella D.
      • Aros F.
      • Gomez-Gracia E.
      • Ruiz-Gutierrez V.
      • Fiol M.
      • Lapetra J.
      • Lamuela-Raventos R.M.
      • Serra-Majem L.
      • Pinto X.
      • Basora J.
      • Munoz M.A.
      • Sorli J.V.
      • Martinez J.A.
      • Martinez-Gonzalez M.A.
      • Investigators P.S.
      Primary prevention of cardiovascular disease with a Mediterranean diet.
      In the present study, higher Mediterranean diet scores had a strong protective benefit against recurrent CHD and mortality after adjustment for age, race, gender, and region of residence. Although this association was not statistically significant after full multivariable adjustment, many of the variables included in the final model may be on the causal pathway between diet and outcomes. With that consideration, the present study suggests that more closely following a Mediterranean diet may be beneficial for patients with CHD.
      Abdominal obesity is related to several CV risk factors (e.g., hypertension, diabetes).
      • Klein S.
      • Burke L.E.
      • Bray G.A.
      • Blair S.
      • Allison D.B.
      • Pi-Sunyer X.
      • Hong Y.
      • Eckel R.H.
      American Heart Association Council on Nutrition PA, Metabolism
      Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
      The 2011 American Heart Association/American College of Cardiology Foundation secondary prevention guidelines recommend an initial 5% to 10% body weight reduction to reduce obesity-associated CV risk factors (e.g., BP) and, in the long-term, achieving a body mass index of 18.5 to 24.9 kg/m2 and waist circumference ≤88 and ≤102 cm for women and men, respectively.
      • Smith Jr., S.C.
      • Benjamin E.J.
      • Bonow R.O.
      • Braun L.T.
      • Creager M.A.
      • Franklin B.A.
      • Gibbons R.J.
      • Grundy S.M.
      • Hiratzka L.F.
      • Jones D.W.
      • Lloyd-Jones D.M.
      • Minissian M.
      • Mosca L.
      • Peterson E.D.
      • Sacco R.L.
      • Spertus J.
      • Stein J.H.
      • Taubert K.A.
      World Heart F, the Preventive Cardiovascular Nurses A
      AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
      In the present study, there was no association between waist circumference and recurrent CHD or mortality. Studying obesity-related outcomes in the population with CHD using an observational study design is challenging. An obesity paradox, wherein obesity is protective against recurrent CHD and death in patients with CHD, has been reported in several studies.
      • Bashey S.
      • Muntner P.
      • Kini A.S.
      • Esquitin R.
      • Razzouk L.
      • Mathewkutty S.
      • Wildman R.P.
      • Carson A.P.
      • Kim M.C.
      • Moreno P.R.
      • Sharma S.K.
      • Farkouh M.E.
      Clustering of metabolic abnormalities among obese patients and mortality after percutaneous coronary intervention.
      • Villareal D.T.
      • Apovian C.M.
      • Kushner R.F.
      • Klein S.
      American Society for N, Naaso TOS
      Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society.
      Randomized controlled trials are needed to determine whether intentional weight reduction and maintenance are important for secondary prevention of CHD and all-cause mortality. Importantly, a long-term trial of an intensive lifestyle intervention designed to achieve long-term weight loss in subjects with type 2 diabetes was recently discontinued because of futility despite improvements in individual CV risk factors.
      In the context of primary prevention, maintaining more ideal lifestyle factors has been associated with reduced CHD and all-cause mortality risk.
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • Benjamin E.J.
      • Berry J.D.
      • Borden W.B.
      • Bravata D.M.
      • Dai S.
      • Ford E.S.
      • Fox C.S.
      • Franco S.
      • Fullerton H.J.
      • Gillespie C.
      • Hailpern S.M.
      • Heit J.A.
      • Howard V.J.
      • Huffman M.D.
      • Kissela B.M.
      • Kittner S.J.
      • Lackland D.T.
      • Lichtman J.H.
      • Lisabeth L.D.
      • Magid D.
      • Marcus G.M.
      • Marelli A.
      • Matchar D.B.
      • McGuire D.K.
      • Mohler E.R.
      • Moy C.S.
      • Mussolino M.E.
      • Nichol G.
      • Paynter N.P.
      • Schreiner P.J.
      • Sorlie P.D.
      • Stein J.
      • Turan T.N.
      • Virani S.S.
      • Wong N.D.
      • Woo D.
      • Turner M.B.
      on behalf of the American Heart Association Statistics C, Stroke Statistics S
      Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • Hong Y.
      • Zhang Z.
      • Loustalot F.
      • Gillespie C.
      • Merritt R.
      • Hu F.B.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      Although the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation recommend a multifaceted, comprehensive cardiac rehabilitation program for recovering cardiac patients, there are few data demonstrating a benefit from maintaining ideal levels of individual or multiple lifestyle factors in patients living with CHD after the postacute rehabilitation phase.
      • Balady G.J.
      • Ades P.A.
      • Comoss P.
      • Limacher M.
      • Pina I.L.
      • Southard D.
      • Williams M.A.
      • Bazzarre T.
      Core components of cardiac rehabilitation/secondary prevention programs: a statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group.
      The present study fills this evidence gap by demonstrating a strong association with reduced risk for recurrent CHD and all-cause mortality associated with having ideal levels of lifestyle factors. The effect size for recurrent CHD and all-cause mortality risk reduction with multiple ideal lifestyle factor levels is similar to that of statins and antihypertensive medication.
      • Mihaylova B.
      • Emberson J.
      • Blackwell L.
      • Keech A.
      • Simes J.
      • Barnes E.H.
      • Voysey M.
      • Gray A.
      • Collins R.
      • Baigent C.
      Cholesterol Treatment Trialists C
      The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials.
      Although most participants with CHD in the present study were taking statins and antihypertensive medication, ideal lifestyle factors maintained a strong protective association with reduced recurrent CHD and mortality. These data support the use of lifestyle modification as part of optimal medical management for patients with CHD.
      The results from the present study should be interpreted in the context of potential limitations. CHD at baseline was self-reported and we were unable to confirm these reports. Additionally, given the design of REGARDS, we were unable to monitor participants for outcomes starting on the date of their incident CHD event. Physical activity and Mediterranean diet adherence were self-reported and assessed at only 1 time point. There may be residual confounding as more complete ascertainment of socioeconomic status was not available. Despite these limitations, the present study has a number of strengths. These include the collection of information on multiple lifestyle factors using a standardized method, adjudication of recurrent CHD events, and the inclusion of a large nationwide population-based sample of black adults and white adults.

      Acknowledgment

      Mr. Booth and Drs. Muntner, Safford, and Farkouh were responsible for study conception; Drs. Safford and Brown for data collection; Mr. Booth and Drs. Muntner and Levitan for data analysis; Mr. Booth for manuscript writing; and Mr. Booth and Drs. Muntner, Safford, Levitan, Brown, and Farkouh for critical manuscript review.

      Disclosures

      Drs. Levitan, Brown, and Muntner receive research support through grant R01 HL080477 from the National Institutes of Health (NIH) and Amgen Inc. ; Dr. Farkouh receives research support from Amgen Inc.; Dr. Safford receives research support through grants R01 HL080477 and K24 HL111154 from NIH and Amgen Inc. Mr. Booth has no conflict of interest to disclose. Mr. Booth and Dr. Muntner had full access to all the data and take responsibility for the integrity of the data and accuracy of the data analysis.

      References

        • Graham I.
        • Atar D.
        • Borch-Johnsen K.
        • Boysen G.
        • Burell G.
        • Cifkova R.
        • Dallongeville J.
        • De Backer G.
        • Ebrahim S.
        • Gjelsvik B.
        • Herrmann-Lingen C.
        • Hoes A.
        • Humphries S.
        • Knapton M.
        • Perk J.
        • Priori S.G.
        • Pyorala K.
        • Reiner Z.
        • Ruilope L.
        • Sans-Menendez S.
        • Op Reimer W.S.
        • Weissberg P.
        • Wood D.
        • Yarnell J.
        • Zamorano J.L.
        • Walma E.
        • Fitzgerald T.
        • Cooney M.T.
        • Dudina A.
        • Vahanian A.
        • Camm J.
        • De Caterina R.
        • Dean V.
        • Dickstein K.
        • Funck-Brentano C.
        • Filippatos G.
        • Hellemans I.
        • Kristensen S.D.
        • McGregor K.
        • Sechtem U.
        • Silber S.
        • Tendera M.
        • Widimsky P.
        • Zamorano J.L.
        • Altiner A.
        • Bonora E.
        • Durrington P.N.
        • Fagard R.
        • Giampaoli S.
        • Hemingway H.
        • Hakansson J.
        • Kjeldsen S.E.
        • Larsen M.L.
        • Mancia G.
        • Manolis A.J.
        • Orth-Gomer K.
        • Pedersen T.
        • Rayner M.
        • Ryden L.
        • Sammut M.
        • Schneiderman N.
        • Stalenhoef A.F.
        • Tokgozoglu L.
        • Wiklund O.
        • Zampelas A.
        • European Society of C, European Association for Cardiovascular P, Rehabilitation, Council on Cardiovascular N, European Association for Study of D, International Diabetes Federation E, European Stroke I, International Society of Behavioural M, European Society of H, European Society of General Practice/Family M, European Heart N
        European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).
        Eur J Cardiovasc Prev Rehabil. 2007; 14: E1-E40
        • Smith Jr., S.C.
        • Benjamin E.J.
        • Bonow R.O.
        • Braun L.T.
        • Creager M.A.
        • Franklin B.A.
        • Gibbons R.J.
        • Grundy S.M.
        • Hiratzka L.F.
        • Jones D.W.
        • Lloyd-Jones D.M.
        • Minissian M.
        • Mosca L.
        • Peterson E.D.
        • Sacco R.L.
        • Spertus J.
        • Stein J.H.
        • Taubert K.A.
        • World Heart F, the Preventive Cardiovascular Nurses A
        AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
        Circulation. 2011; 124: 2458-2473
        • Leon A.S.
        • Franklin B.A.
        • Costa F.
        • Balady G.J.
        • Berra K.A.
        • Stewart K.J.
        • Thompson P.D.
        • Williams M.A.
        • Lauer M.S.
        • American Heart A, Council on Clinical C, Council on Nutrition PA, Metabolism, American association of C, Pulmonary R
        Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
        Circulation. 2005; 111: 369-376
        • Arena R.
        • Williams M.
        • Forman D.E.
        • Cahalin L.P.
        • Coke L.
        • Myers J.
        • Hamm L.
        • Kris-Etherton P.
        • Humphrey R.
        • Bittner V.
        • Lavie C.J.
        • American Heart Association Exercise CR, Prevention Committee of the Council on Clinical Cardiology CoE, Prevention, Council on Nutrition PA, Metabolism
        Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings: a science advisory from the American Heart Association.
        Circulation. 2012; 125: 1321-1329
        • Suaya J.A.
        • Shepard D.S.
        • Normand S.L.
        • Ades P.A.
        • Prottas J.
        • Stason W.B.
        Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery.
        Circulation. 2007; 116: 1653-1662
        • Howard V.J.
        • Cushman M.
        • Pulley L.
        • Gomez C.R.
        • Go R.C.
        • Prineas R.J.
        • Graham A.
        • Moy C.S.
        • Howard G.
        The reasons for geographic and racial differences in stroke study: objectives and design.
        Neuroepidemiology. 2005; 25: 135-143
        • Levey A.S.
        • Stevens L.A.
        • Schmid C.H.
        • Zhang Y.L.
        • Castro 3rd, A.F.
        • Feldman H.I.
        • Kusek J.W.
        • Eggers P.
        • Van Lente F.
        • Greene T.
        • Coresh J.
        • Ckd E.P.I.
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2009; 150: 604-612
        • Czernichow S.
        • Kengne A.P.
        • Stamatakis E.
        • Hamer M.
        • Batty G.D.
        Body mass index, waist circumference and waist-hip ratio: which is the better discriminator of cardiovascular disease mortality risk?: evidence from an individual-participant meta-analysis of 82 864 participants from nine cohort studies.
        Obes Rev. 2011; 12: 680-687
        • Trichopoulou A.
        • Costacou T.
        • Bamia C.
        • Trichopoulos D.
        Adherence to a Mediterranean diet and survival in a Greek population.
        N Engl J Med. 2003; 348: 2599-2608
        • Luepker R.V.
        • Apple F.S.
        • Christenson R.H.
        • Crow R.S.
        • Fortmann S.P.
        • Goff D.
        • Goldberg R.J.
        • Hand M.M.
        • Jaffe A.S.
        • Julian D.G.
        • Levy D.
        • Manolio T.
        • Mendis S.
        • Mensah G.
        • Pajak A.
        • Prineas R.J.
        • Reddy K.S.
        • Roger V.L.
        • Rosamond W.D.
        • Shahar E.
        • Sharrett A.R.
        • Sorlie P.
        • Tunstall-Pedoe H.
        • Epidemiology AHACo, Prevention, Committee AHAS, World Heart Federation Council on E, Prevention, European Society of Cardiology Working Group on E, Prevention, Centers for Disease C, Prevention, National Heart L, Blood I
        Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; the European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; and the National Heart, Lung, and Blood Institute.
        Circulation. 2003; 108: 2543-2549
        • Safford M.M.
        • Brown T.M.
        • Muntner P.M.
        • Durant R.W.
        • Glasser S.
        • Halanych J.H.
        • Shikany J.M.
        • Prineas R.J.
        • Samdarshi T.
        • Bittner V.A.
        • Lewis C.E.
        • Gamboa C.
        • Cushman M.
        • Howard V.
        • Howard G.
        • Investigators R.
        Association of race and sex with risk of incident acute coronary heart disease events.
        JAMA. 2012; 308: 1768-1774
        • Prineas R.J.
        • Crow R.S.
        • Zhang Z.-M.
        The Minnesota Code Manual of Electrocardiographic Findings (including measurement and comparison with the Novacode): Standards and Procedures for ECG Measurement in Epidemiologic and Clinical Trials.
        Springer, London; New York2010 (1 online resource (xiii, 328 p.))
        • White I.R.
        • Royston P.
        • Wood A.M.
        Multiple imputation using chained equations: issues and guidance for practice.
        Stat Med. 2011; 30: 377-399
        • Palmer R.C.
        • McKinney S.
        Health care provider tobacco cessation counseling among current African American tobacco users.
        J Natl Med Assoc. 2011; 103: 660-667
        • Rea T.D.
        • Heckbert S.R.
        • Kaplan R.C.
        • Smith N.L.
        • Lemaitre R.N.
        • Psaty B.M.
        Smoking status and risk for recurrent coronary events after myocardial infarction.
        Ann Intern Med. 2002; 137: 494-500
        • Critchley J.A.
        • Capewell S.
        Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review.
        JAMA. 2003; 290: 86-97
        • Balady G.J.
        • Ades P.A.
        • Comoss P.
        • Limacher M.
        • Pina I.L.
        • Southard D.
        • Williams M.A.
        • Bazzarre T.
        Core components of cardiac rehabilitation/secondary prevention programs: a statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group.
        Circulation. 2000; 102: 1069-1073
        • Cottin Y.
        • Cambou J.P.
        • Casillas J.M.
        • Ferrieres J.
        • Cantet C.
        • Danchin N.
        Specific profile and referral bias of rehabilitated patients after an acute coronary syndrome.
        J Cardiopulm Rehabil. 2004; 24: 38-44
        • Lavie C.J.
        • Thomas R.J.
        • Squires R.W.
        • Allison T.G.
        • Milani R.V.
        Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease.
        Mayo Clin Proc. 2009; 84: 373-383
        • Go A.S.
        • Mozaffarian D.
        • Roger V.L.
        • Benjamin E.J.
        • Berry J.D.
        • Borden W.B.
        • Bravata D.M.
        • Dai S.
        • Ford E.S.
        • Fox C.S.
        • Franco S.
        • Fullerton H.J.
        • Gillespie C.
        • Hailpern S.M.
        • Heit J.A.
        • Howard V.J.
        • Huffman M.D.
        • Kissela B.M.
        • Kittner S.J.
        • Lackland D.T.
        • Lichtman J.H.
        • Lisabeth L.D.
        • Magid D.
        • Marcus G.M.
        • Marelli A.
        • Matchar D.B.
        • McGuire D.K.
        • Mohler E.R.
        • Moy C.S.
        • Mussolino M.E.
        • Nichol G.
        • Paynter N.P.
        • Schreiner P.J.
        • Sorlie P.D.
        • Stein J.
        • Turan T.N.
        • Virani S.S.
        • Wong N.D.
        • Woo D.
        • Turner M.B.
        • on behalf of the American Heart Association Statistics C, Stroke Statistics S
        Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
        Circulation. 2013; 127: e6-e245
        • Perk J.
        • De Backer G.
        • Gohlke H.
        • Graham I.
        • Reiner Z.
        • Verschuren M.
        • Albus C.
        • Benlian P.
        • Boysen G.
        • Cifkova R.
        • Deaton C.
        • Ebrahim S.
        • Fisher M.
        • Germano G.
        • Hobbs R.
        • Hoes A.
        • Karadeniz S.
        • Mezzani A.
        • Prescott E.
        • Ryden L.
        • Scherer M.
        • Syvanne M.
        • Scholte op Reimer W.J.
        • Vrints C.
        • Wood D.
        • Zamorano J.L.
        • Zannad F.
        • European Association for Cardiovascular P, Rehabilitation, Guidelines ESCCfP
        European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts).
        Eur Heart J. 2012; 33: 1635-1701
        • Sofi F.
        • Abbate R.
        • Gensini G.F.
        • Casini A.
        Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis.
        Am J Clin Nutr. 2010; 92: 1189-1196
        • Serra-Majem L.
        • Roman B.
        • Estruch R.
        Scientific evidence of interventions using the Mediterranean diet: a systematic review.
        Nutr Rev. 2006; 64: S27-S47
        • Estruch R.
        • Ros E.
        • Salas-Salvado J.
        • Covas M.I.
        • Corella D.
        • Aros F.
        • Gomez-Gracia E.
        • Ruiz-Gutierrez V.
        • Fiol M.
        • Lapetra J.
        • Lamuela-Raventos R.M.
        • Serra-Majem L.
        • Pinto X.
        • Basora J.
        • Munoz M.A.
        • Sorli J.V.
        • Martinez J.A.
        • Martinez-Gonzalez M.A.
        • Investigators P.S.
        Primary prevention of cardiovascular disease with a Mediterranean diet.
        N Engl J Med. 2013; 368: 1279-1290
        • Klein S.
        • Burke L.E.
        • Bray G.A.
        • Blair S.
        • Allison D.B.
        • Pi-Sunyer X.
        • Hong Y.
        • Eckel R.H.
        • American Heart Association Council on Nutrition PA, Metabolism
        Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
        Circulation. 2004; 110: 2952-2967
        • Bashey S.
        • Muntner P.
        • Kini A.S.
        • Esquitin R.
        • Razzouk L.
        • Mathewkutty S.
        • Wildman R.P.
        • Carson A.P.
        • Kim M.C.
        • Moreno P.R.
        • Sharma S.K.
        • Farkouh M.E.
        Clustering of metabolic abnormalities among obese patients and mortality after percutaneous coronary intervention.
        Am J Cardiol. 2011; 107: 1415-1420
        • Villareal D.T.
        • Apovian C.M.
        • Kushner R.F.
        • Klein S.
        • American Society for N, Naaso TOS
        Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society.
        Am J Clin Nutr. 2005; 82: 923-934
      1. Weight loss does not lower heart disease risk from type 2 diabetes. U.S. Department of Health and Human Services National Institutes of Health (NIH) News: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 2012
        • Yang Q.
        • Cogswell M.E.
        • Flanders W.D.
        • Hong Y.
        • Zhang Z.
        • Loustalot F.
        • Gillespie C.
        • Merritt R.
        • Hu F.B.
        Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
        JAMA. 2012; 307: 1273-1283
        • Mihaylova B.
        • Emberson J.
        • Blackwell L.
        • Keech A.
        • Simes J.
        • Barnes E.H.
        • Voysey M.
        • Gray A.
        • Collins R.
        • Baigent C.
        • Cholesterol Treatment Trialists C
        The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials.
        Lancet. 2012; 380: 581-590