Epidemiology and Prevention

Association of Diet, Exercise, and Smoking Modification

With Risk of Early Cardiovascular Events After Acute
Coronary Syndromes
Clara K. Chow, MBBS, FRACP, PhD; Sanjit Jolly, MD, MSc, FRCPC;
Purnima Rao-Melacini, MSc; Keith A.A. Fox, BSc (Hons), MB, ChB, FRCP, FESC, FMedSci;
Sonia S. Anand, MD, PhD, FRCPc; Salim Yusuf, DPhil, FRCPC, FRSC

BackgroundAlthough preventive drug therapy is a priority after acute coronary syndrome, less is known about adherence
to behavioral recommendations. The aim of this study was to examine the influence of adherence to behavioral
recommendations in the short term on risk of cardiovascular events.
Methods and ResultsThe study population included 18 809 patients from 41 countries enrolled in the Organization to
Assess Strategies in Acute Ischemic Syndromes (OASIS) 5 randomized clinical trial. At the 30-day follow-up, patients
reported adherence to diet, physical activity, and smoking cessation. Cardiovascular events (myocardial infarction,
stroke, cardiovascular death) and all-cause mortality were documented to 6 months. About one third of smokers
persisted in smoking. Adherence to neither diet nor exercise recommendations was reported by 28.5%, adherence to
either diet or exercise by 41.6%, and adherence to both by 29.9%. In contrast, 96.1% of subjects reported antiplatelet
use, 78.9% reported statin use, and 72.4% reported angiotensin-converting enzyme/angiotensin receptor blocker use.
Quitting smoking was associated with a decreased risk of myocardial infarction compared with persistent smoking (odds
ratio, 0.57; 95% confidence interval, 0.36 to 0.89). Diet and exercise adherence was associated with a decreased risk of
myocardial infarction compared with nonadherence (odds ratio, 0.52; 95% confidence interval, 0.4 to 0.69). Patients
who reported persistent smoking and nonadherence to diet and exercise had a 3.8-fold (95% confidence interval, 2.5 to
5.9) increased risk of myocardial infarction/stroke/death compared with never smokers who modified diet and exercise.
ConclusionsAdherence to behavioral advice (diet, exercise, and smoking cessation) after acute coronary syndrome was
associated with a substantially lower risk of recurrent cardiovascular events. These findings suggest that behavioral
modification should be given priority similar to other preventive medications immediately after acute coronary
syndrome.
Clinical Trial Registration InformationURL: http://clinicaltrials.gov/ct2/show/NCT00139815. Unique identifier:
NCT00139815. (Circulation. 2010;121:750-758.)
Key Words: acute coronary syndrome cardiovascular diseases diet exercise prevention smoking

associated with an 30% lower crude risk rate of death and

S moking, poor diet, and lack of exercise are important risk
factors for coronary heart disease.1 Population studies
attribute a substantial proportion of the decline in cardiovas-
cular diseases seen in some high-income countries (HICs) in
recent decades to falling rates of smoking secondary to
aggressive policy interventions and improved diets as a
consequence of specific food policies, improved trade, and
increased availability of fruit and vegetables.2 6 Smoking
cessation is effective in the secondary prevention of coronary
heart disease. A recent systematic review found that smoking
cessation in persons with known coronary heart disease was
myocardial infarction (MI) during the subsequent 3 to 7
years.7 However, many of these studies enrolled persons with
established coronary heart disease (not presenting with acute
events), had limited information on confounding factors (such
as risk factors or secondary preventive treatments), and did
not examine whether benefits occurred early after an acute
event. Some small studies have indicated that benefits may
occur as early as 1 year after acute coronary syndrome (ACS)
presentation, but they have not been large enough to evaluate
whether such benefits persist after controlling for risk factors

Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.
Received July 6, 2009; accepted November 3, 2009.
From the Population Health Research Institute (C.K.C., S.J., P.R.-M., S.S.A., S.Y.) and Departments of Medicine (C.K.C., S.S.A., S.Y.) and
Epidemiology (S.S.A.), McMaster University, and Hamilton Health Sciences (C.K.C., S.J., P.R.-M., S.S.A., S.Y.), Hamilton, Ontario, Canada; The
George Institute for International Health, University of Sydney, Sydney, New South Wales, Australia (C.K.C.); and Centre for Cardiovascular Science,
University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
Correspondence to Dr Clara K. Chow, Hamilton General Hospital, 237 Barton St E, Hamilton, Ontario, L8L 2X2, Canada. E-mail
cchow@george.org.au or clara.chow@phri.ca
2010 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.109.891523

750
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 Chow et al Behavioral Modification Effects After ACS 751

or the use of proven pharmacological or interventional Table 1. Adherence to Secondary Preventive Medications at
therapies.8,9 Certain dietary recommendations (eg, Mediterra- 30-Day and 6-Month Follow-Up
nean diet) and exercise have also been shown to be effective At Discharge, At 30 Days, At 6 Months,
in the secondary prevention of coronary heart disease.10,11 Medication n (%) n (%) n (%)
Cardiac rehabilitation programs that target health behaviors Antiplatelet 18 145 (96.5) 18 069 (96.1) 17 106 (94.7)
and adherence to drugs have also been associated with better
Statin 14 820 (78.8) 14 792 (78.0) 13 389 (90.5)
outcomes.12 Some of these benefits may occur early, but this
ACE/ARB 13 705 (72.9) 13 643 (72.5) 12 251 (89.8)
is unclear.13
-blocker 15 506 (82.4) 9100 (48.4) 7110 (78.1)
Editorial see p 733 Percentage adherence compared with previous visit.
Clinical Perspective on p 758
The main aim of these analyses was to examine the tion. For patients with prior MI, PCI, or CABG, a modified MI
influence of adherence to behavioral recommendations on definition was used as detailed previously.15
risk for short-term (6 months after the index event) cardio-
vascular outcomes and whether there is incremental benefit in
Analysis
Patients included in this analysis were those who survived 30 days
modifying multiple lifestyle behaviors after controlling for and reported information on lifestyle behaviors at the 30-day
the use of pharmacological secondary prevention measures. follow-up visit. Smoking status was classified according to self-
report into 4 categories: never smokers, former smokers (ex-smokers
Methods who quit before entry into the OASIS 5 study), recent quitters (those
The Organization to Assess Strategies in Acute Ischemic Syndromes that reported not smoking at the 30-day follow-up visit but who were
(OASIS) 5 was a randomized, double-blind, double-dummy trial in current smokers at study entry), or persistent smokers (those who
which fondaparinux was compared with enoxaparin in patients with were smokers at study entry and reported smoking at the
unstable angina or MI without ST-segment elevation.14 In total, 30-day follow-up).
20 078 patients from 576 centers in 41 countries were recruited Diet/exercise program adherers were classified into 3 categories:
between April 9, 2003 and May 30, 2005; 11 558 came from HICs no diet/exercise (those who responded no to regular exercise and
diet questions at the 30-day follow-up, either diet or exercise (those
and 8520 came from low- and middle-income countries (LMICs)
who responded yes to exercise or diet questions), or both diet and
(http://web-worldbank.org). Patients were eligible if they met at least
exercise (those who responded yes to all exercise and diet
2 of the 3 criteria: age of at least 60 years, an elevated level of
questions). Unadjusted subject characteristics are reported by these
troponin or creatine kinase-MB isoenzyme, or ECG changes indic-
groups.
ative of ischemia. Patients with contraindications to low-molecular-
The associations between smoking status and outcomes and
weight heparin, recent hemorrhagic stroke, indications for anticoag-
diet/exercise and outcomes were examined in separate age- and
ulation other than an ACS, or a serum creatinine level of at least 3
sex-adjusted logistic regression models and in multivariable logistic
mg/dL (265 mol/L) were excluded. Further details are reported
regression models. For multivariable analysis, a forward variable
elsewhere.15
selection procedure was used. The final model included factors that
At baseline, data on demographics, risk factors, and comorbidities
increased the area under the curve of the model and decreased the
were collected. At follow-up visits at 30, 90, and 180 days, the
Akaike information criteria of the model or were known strong
following simple questions on behavioral modification were in- predictors of outcomes. The final model included baseline risk
cluded: Smoking was assessed with the question, Is the patient factors of age, sex, region of origin, history of hypertension, history
currently smoking? Answer options were yes and no. Cur- of diabetes, body mass index, creatinine, and history of prior MI;
rently smoking was defined as smoking at least 1 cigarette (or cigar
or pipe) per day within the last month. Those who used only chewing
tobacco were recorded as never smokers. Exercise was assessed with
the question, Is the patient exercising regularly (30 minutes 3
times a week)? Answer options were yes and no. Exercise was
noted to include walking uninterrupted or as part of an exercise
program. Details on type of exercise or exercise intensity were not
recorded. Diet was assessed with the question, Has patient received
counseling for dietary modification? Answer options were yes
and no. If the response was affirmative, then the follow-up
question was, Is the patient compliant? Answer options were yes
and no. Diet counseling was described as formal counseling
individually, in a group with a dietitian or professional nutrition-
ist, or at a secondary rehabilitation clinic. Details on the nature of
the dietary advice or intensity of the program attended were
not recorded.
Use of drugs and treatments of percutaneous coronary intervention
(PCI) or coronary artery bypass grafting (CABG) were recorded at
baseline, discharge, and 30, 90, and 180 days. Patients were followed
up for 180 days, and the outcomes of MI, death, and stroke were
systematically recorded. All of the events were adjudicated by a
central committee according to standardized operational definitions.
In brief, stroke was defined as the presence of a new focal
neurological deficit thought to be vascular in origin with signs or
symptoms lasting 24 hours. MI was defined as either pathological
findings or a typical rise in enzymes with at least 1 of the following: Figure 1. Quitting or persisting in smoking at the 30-day and
ischemic symptoms, new Q waves, ECG changes indicative of 6-month follow-up. At 6 months, there were 458 deaths and 87
ischemia (ST elevation or depression), or coronary artery interven- missing.

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752 Circulation February 16, 2010

Figure 2. Adherence to exercise and

diet at the 30-day and 6-month follow-
up. At 6 months, there were 458 deaths,
92 missing from exercise adherence, and
86 missing from diet adherence.

PCI/CABG interventions before 30 days; and reported use of Table 2. Key Characteristics by Economic Regions
secondary preventive medications at 30 days, including -blockers, Characteristics HICs LMICs P
statins, antiplatelets, and angiotensin-converting enzyme/angiotensin
receptor blocker (ACE/ARB) use. Total cholesterol, low-density Baseline
lipoprotein cholesterol, high-density lipoprotein cholesterol, and Age, y 67 (11.2) 66.5 (10.3) 0.0027
triglycerides were not included in final models because they were Women, n (%) 3608 (33.3) 3574 (44.8) 0.0001
available in only about half of the subjects. Occupation also was not
included because the majority of participants (77%) were retired and Unemployed, n (%) 513 (4.7) 658 (8.2) 0.0001
prior occupation information for this group was not collected. BMI, kg/m2 27.5 (4.6) 27.2 (4.4) 0.0001
In sensitivity analyses, adjustment for total cholesterol, low- Total cholesterol, mmol/L 5.2 (1.4) 5.5 (1.8) 0.0001
density lipoprotein cholesterol, high-density lipoprotein cholesterol,
Creatinine, mmol 93.1 (27.1) 94 (30.9) 0.0318
triglycerides, unemployment, occupation, history of cancer, heart
failure, and peak creatine kinase resulted in minor changes to the Diabetes, n (%) 2666 (24.6) 1975 (24.8) 0.8114
adjusted odds ratio (OR) for each outcome. Among these parameters, Hypertension, n (%) 6592 (60.9) 5997 (75.2) 0.0001
the greatest increase in area under the curve for the total model
Family history of CAD, n (%) 2572 (23.7) 1241 (15.6) 0.0001
occurred with addition of low-density lipoprotein cholesterol. For
example, the area under the curve of the final model predicting MI Former smoking, n (%) 3916 (36.1) 2103 (26.4) 0.0001
including all risk factors increased by 3% from 0.726 to 0.748 with Current smoking, n (%) 2648 (24.4) 1606 (20.1) 0.0001
the addition of low-density lipoprotein cholesterol. All of the Never smoking, n (%) 4267 (39.4) 4267 (53.5) 0.0001
analyses were performed with the statistical software Stata/SE 10
(StataCorp LP, College Station, Tex) and repeated with SAS version Previous MI, n (%) 2627 (24.2) 2140 (26.8) 0.0001
9.1 for Unix (SAS Institute Inc, Cary, NC). In-hospital stay
Hospital stay, d 8.9 (5.8) 11.3 (6.4) 0.0001
Results Heart failure, n (%) 1137 (10.5) 1689 (21.2) 0.0001
Patient Characteristics, Medications, and Lifestyles Peak total CK 253.9 (355.3) 253.8 (365) 0.9865
Of the 20 078 persons enrolled in the OASIS study, 18 809 PCI in first 30 d, n (%) 5094 (47) 1954 (24.5) 0.0001
persons were alive and reported on behaviors at the 30-day CABG in first 30 d, n (%) 1343 (12.4) 527 (6.6) 0.0001
follow-up visit. The average age of this group was 66.8 years Post-MI treatments, n (%)
(range, 21.4 to 97.8 years); 38.2% were women; 54.6% had Antiplatelet 10371 (95.7) 7698 (96.5) 0.0066
MI without ST elevation and 45.4% had unstable angina at -blocker 4342 (40.1) 4758 (59.7) 0.0001
study entry; and 37.5% had PCI and 9.9% had CABG before
ACE/ARB 7409 (68.4) 6234 (78.2) 0.0001
discharge or within 30 days of the event. Adherence to
Statin 8697 (80.3) 6095 (76.4) 0.0001
secondary preventive drugs at the 30-day and 6-month
Any BP lowering 10 035 (92.6) 7574 (95) 0.0001
follow-up was generally better (Table 1) than adherence to
behavioral modification (Figure 1&2). Post-MI behaviors, n (%)
Diet modification 5553 (51.3) 5499 (68.9) 0.0001
Variations by Region and Country Regular exercise 4987 (46) 3038 (38.1) 0.0001
Economic Classification Smoking cessation (% of 1679 (63.4) 1123 (69.9) 0.0069
In HICs and LMICs and across all regions, the use of current smokers)
antiplatelet medication was similarly high (Tables 2 and 3). BMI indicates body mass index; CAD, coronary artery disease; CK, creatine kinase;
However, variations existed for other medication use. Use and BP, blood pressure. Values are mean (SD) or frequency (%) as appropriate.

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 Chow et al Behavioral Modification Effects After ACS 753

Table 3. Key Characteristics by Region

North Latin Western Eastern South East
Characteristics America America Europe Europe Australia Africa Asia India P
Baseline
Age, y 66.5 (11.7) 66.1 (10.9) 67.3 (11.3) 67.1 (10.1) 67.2 (11.3) 60.5 (11.8) 65.5 (10) 62.9 (9.9) 0.0001
Women, n (%) 706 (33.7) 731 (41.2) 2099 (32.2) 2928 (46.1) 144 (29.1) 64 (34.2) 325 (36.7) 185 (38.1) 0.0001
Unemployed, n (%) 179 (8.5) 87 (4.9) 242 (3.7) 560 (8.8) 37 (7.5) 22 (11.8) 37 (4.2) 7 (1.4) 0.0001
BMI, kg/m 2
28.5 (5.7) 27.2 (4.5) 27.2 (4.2) 27.8 (4.3) 28.1 (5.1) 27.6 (4.7) 24.6 (3.6) 24.4 (3.7) 0.0001
Total cholesterol, 4.8 (1.3) 5.1 (2.1) 5.2 (1.5) 5.6 (1.5) 4.9 (1.2) 5.6 (1.9) 5.1 (2) 4.8 (1) 0.0001
mmol/L
Creatinine, mmol 95.9 (28.5) 97.9 (36.2) 91.5 (26.8) 92.4 (25.6) 92.6 (27) 99.2 (35.2) 94.4 (35.5) 105.2 (42.1) 0.0001
Diabetes, n (%) 592 (28.2) 457 (25.8) 1478 (22.6) 1480 (23.3) 103 (20.9) 52 (27.8) 286 (32.3) 193 (39.7) 0.0001
Hypertension, n (%) 1403 (66.9) 1311 (73.9) 3703 (56.7) 4869 (76.6) 285 (57.7) 118 (63.1) 611 (69) 289 (59.5) 0.0001
Family history of CAD, 763 (36.4) 396 (22.3) 1450 (22.2) 868 (13.7) 164 (33.2) 73 (39) 51 (5.8) 48 (9.9) 0.0001
n (%)
Former smoking, n (%) 841 (40.1) 645 (36.4) 2331 (35.7) 1641 (25.8) 236 (47.8) 67 (35.8) 198 (22.4) 60 (12.3) 0.0001
Current smoking, n (%) 541 (25.8) 390 (22) 1581 (24.2) 1269 (20) 107 (21.7) 66 (35.3) 237 (26.8) 63 (13) 0.0001
Never smoking, n (%) 715 (34.1) 739 (41.7) 2614 (40) 3448 (54.2) 151 (30.6) 54 (28.9) 450 (50.8) 363 (74.7) 0.0001
Previous MI, n (%) 556 (26.5) 411 (23.2) 1518 (23.3) 1891 (29.7) 142 (28.7) 54 (28.9) 113 (12.8) 82 (16.9) 0.0001
Previous stroke, n (%) 131 (6.2) 75 (4.2) 352 (5.4) 425 (6.7) 26 (5.3) 8 (4.3) 94 (10.6) 15 (3.1) 0.0001
Previous cancer, n (%) 260 (12.4) 57 (3.2) 418 (6.4) 259 (4.1) 67 (13.6) 8 (4.3) 16 (1.8) 0 (0) 0.0001
In-hospital stay
Hospital stay, d 8.4 (6.2) 9.3 (6.4) 9 (5.7) 11.8 (6.1) 7.9 (5.6) 6.6 (4.4) 11 (7.4) 7.2 (3.9) 0.0001
Heart failure, n (%) 262 (12.5) 204 (11.5) 608 (9.3) 1410 (22.2) 63 (12.8) 43 (23) 163 (18.4) 73 (15) 0.0001
Total CK 248.7 (351.8) 249.2 (362.5) 244.8 (345.8) 251.7 (359.5) 274.1 (320.8) 350.1 (412.1) 301.9 (445.5) 311.1 (389.1) 0.0001
PCI in first 30 d, n (%) 1021 (48.7) 560 (31.6) 3085 (47.3) 1748 (27.5) 147 (29.8) 31 (16.6) 412 (46.6) 44 (9.1) 0.0001
CABG in first 30 d, 337 (16.1) 196 (11) 693 (10.6) 427 (6.7) 70 (14.2) 18 (9.6) 79 (8.9) 50 (10.3) 0.0001
n (%)
Post-MI treatments, n (%)
Antiplatelet 2020 (96.3) 1703 (96) 6244 (95.6) 6114 (96.2) 483 (97.8) 183 (97.9) 844 (95.4) 478 (98.4) 0.0185
-blocker 901 (43) 646 (36.4) 2536 (38.8) 3651 (57.4) 230 (46.6) 128 (68.4) 642 (72.5) 366 (75.3) 0.0001
ACE/ARB 1522 (72.6) 1174 (66.2) 4292 (65.7) 5175 (81.4) 364 (73.7) 143 (76.5) 628 (71) 345 (71) 0.0001
Statin 1716 (81.8) 1305 (73.6) 5287 (81) 4899 (77.1) 444 (89.9) 103 (55.1) 609 (68.8) 429 (88.3) 0.0001
Any BP lowering 1939 (92.5) 1588 (89.5) 6053 (92.7) 6125 (96.3) 440 (89.1) 178 (95.2) 821 (92.8) 465 (95.7) 0.0001
Post-MI behaviors, n (%)
Diet 990 (47.2) 1478 (83.3) 3358 (51.4) 4083 (64.2) 278 (56.3) 73 (39) 364 (41.1) 428 (88.1) 0.0001
Exercise 913 (43.5) 660 (37.2) 3175 (48.6) 2367 (37.2) 300 (60.7) 48 (25.7) 322 (36.4) 240 (49.4) 0.0001
Smoking cessation 292 (54.0) 318 (81.5) 1014 (38.8) 856 (67.5) 63 (58.9) 26 (39.4) 176 (74.3) 57 (90.5) 0.0001
(% of current smokers)
Abbreviations as in Table 1. Values are mean (%) when appropriate.

of statins was higher in HICs than in LMICs. South Africa
reported the lowest rates of statin use at 55.1%. ACE/
ARBs, -blockers, and any blood pressurelowering ther-
apy (-blockers, calcium channel blockers, diuretics) use
was slightly higher in LMICs compared with HICs. Both
PCI and CABG were more frequent in HICs, particularly
North America.
Adherence to diet advice was reported more frequently by
individuals in LMICs versus HICs, but regular exercise was
higher in HICs versus LMICs. Participants from India had the
highest rate of dietary adherence (88.1%); participants from
South Africa had the lowest rate (39.0%). The highest rate of
exercise was in Australia (60.7%), and lowest was in South
Africa (25.7%). The highest rates of smoking cessation were
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in Latin America (81.5%) and India (90.5%), whereas the
lowest was in Western Europe (38.8%).
General Characteristics of Behavior Modifiers
Versus Nonmodifiers
Smoking Categories
Nonsmokers and former smokers were older at presenta-
tion compared with quitters and persistent smokers. Per-
sistent smokers and recent quitters were generally similar;
however, quitters reported higher rates of dietary adher-
ence (60.8% versus 47.2%) and exercise (49.9% versus
42.2%) (Table 4).
754 Circulation February 16, 2010

Table 4. Characteristics of ACS Patients by Smoking Status

Never Former Recent Persistent
Characteristic Smokers Smokers Quitters Smokers P
n 8534 (45.4) 5944 (31.6) 2802 (14.9) 1522 (8.1)
Baseline
Women, n (%) 5095 (59.7) 1132 (19) 598 (21.3) 353 (23.2) 0.0001
Unemployed, n (%) 396 (4.6) 339 (5.7) 218 (7.8) 217 (14.3) 0.0001
Age, y 70 (9.6) 67.9 (9.8) 59.2 (10.5) 58.3 (10.8) 0.0001
BMI, kg/m2 27.4 (4.5) 27.7 (4.4) 27 (4.4) 26.9 (4.8) 0.0001
Diabetes, n (%) 2395 (28.1) 1576 (26.5) 419 (15) 249 (16.4) 0.0001
Hypertension, n (%) 6396 (74.9) 3992 (67.2) 1406 (50.2) 790 (51.9) 0.0001
Family history of CAD, n (%) 1416 (16.6) 1312 (22.1) 645 (23) 438 (28.8) 0.0001
Previous MI, n (%) 2005 (23.5) 1985 (33.4) 412 (14.7) 361 (23.7) 0.0001
Previous stroke, n (%) 535 (6.3) 406 (6.8) 116 (4.1) 68 (4.5) 0.0001
Previous cancer, n (%) 474 (5.6) 453 (7.6) 91 (3.2) 67 (4.4) 0.0001
Creatinine, mmol/L 92.5 (28.3) 98.3 (30.9) 88.9 (24.9) 88.7 (27) 0.0001
Total cholesterol, mmol/L 5.3 (1.4) 5.1 (1.6) 5.5 (2) 5.4 (1.4) 0.0001
LDL cholesterol, mmol/L 3.3 (1.1) 3.1 (1.2) 3.5 (1.1) 3.3 (1.1) 0.0001
HDL cholesterol, mmol/L 1.3 (0.4) 1.2 (0.5) 1.2 (0.5) 1.2 (0.4) 0.0001
Triglycerides, mmol/L 1.8 (1.2) 1.9 (1.5) 2 (1.8) 2.1 (1.6) 0.0001
In hospital
Hospital stay, mean, d 10.4 (6.2) 9.8 (6.5) 9.6 (5.9) 8.2 (4.8) 0.0001
Heart failure at admission, n (%) 1495 (17.5) 840 (14.1) 308 (11) 183 (12) 0.0001
Total CK 229.4 (317.6) 239 (322.8) 328.8 (448.6) 307.2 (481.2) 0.0001
PCI in first 30 d, n (%) 2618 (30.7) 2421 (40.7) 1326 (47.3) 681 (44.7) 0.0001
CABG in first 30 d, n (%) 740 (8.7) 709 (11.9) 374 (13.3) 45 (3) 0.0001
Secondary prevention, 30 d, n (%)
Aspirin 7850 (92) 5511 (92.7) 2672 (95.4) 1433 (94.2) 0.0001
Antiplatelet 8146 (95.5) 5714 (96.1) 2733 (97.5) 1470 (96.6) 0.0001
-blocker 4509 (52.8) 2791 (47) 1145 (40.9) 654 (43) 0.0001
ACE/ARB 6382 (74.8) 4351 (73.2) 1885 (67.3) 1020 (67) 0.0001
Any BP lowering 8062 (94.5) 5573 (93.8) 2576 (91.9) 1392 (91.5) 0.0001
Statin 6445 (75.5) 4827 (81.2) 2335 (83.3) 1182 (77.7) 0.0001
Dietary compliance 5177 (60.7) 3448 (58) 1705 (60.8) 719 (47.2) 0.0001
Regular exercise 3280 (38.4) 2703 (45.5) 1399 (49.9) 642 (42.2) 0.0001
PCI 30 d to 6 mo 421 (4.9) 380 (6.5) 198 (7.1) 71 (4.7) 0.0001
CABG 30 d to 6 mo 279 (3.3) 236 (4.0) 133 (4.8) 34 (2.2) 0.0001
Abbreviations as in Table 1.

Diet and Exercise Categories
Adherers to both diet and exercise were younger than
nonadherers. Length of hospital stay was similar across
categories, but prevalence of heart failure was lower in
adherers. Rates of never smoking were similar across groups,
but recent quitting was more common in adherers to diet and
exercise. Use of aspirin, -blockers, and ACE/ARB was
similar across groups, but statin use was higher in adherers
despite lipid levels being similar. There was a significant
trend to increased weight loss in the first 30 days in adherers
to diet/exercise compared with other groups (Table 5).
Relationship Between Behavioral Change and
Cardiovascular Outcomes
Among the study population that survived to 30 days after
ACS presentation, 455 (2.4%) had a subsequent MI, 120
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(0.6%) had a subsequent stroke, and 481 (2.6%) died by the
end of the 6-month follow-up period.
Event Rates in Relationship to Smoking Behavior
Compared with persistent smokers, quitters had an OR (from
fully adjusted models) of 0.57 (95% confidence interval [CI],
0.36 to 0.89; P0.0145) for MI and an OR of 0.74 (95% CI,
0.53 to 1.02; P0.0698) for MI/stroke/death (Table 6).
Diet and Physical Activity Behaviors
Compared with nonadherers to either diet or exercise, people
who were adherent to either diet or exercise had an OR for
MI, stroke, or death (from fully adjusted models) of 0.85
(95% CI, 0.73 to 0.99; P0.03), and people who were
adherent to both diet and exercise had an OR of 0.46 (95% CI,
0.38 to 0.57; P0.0001) (Table 7). ORs calculated from fully
 Chow et al Behavioral Modification Effects After ACS 755

Table 5. Characteristics of ACS Patients According to Health Behaviors

Characteristics No Diet/Exercise Modification Either Diet or Exercise Modification Both Diet and Exercise Modification P
n 5356 (28.5) 7829 (41.6) 5624 (29.9)
Baseline
Women, n (%) 2323 (43.4) 3131 (40.0) 1728 (30.7) 0.0001
Unemployed, n (%) 400 (7.5) 433 (5.5) 338 (6.0) 0.0001
Age, y 68.7 (10.8) 67.2 (10.6) 64.3 (10.8) 0.0001
BMI, kg/m2 27.3 (4.6) 27.4 (4.5) 27.5 (4.4) 0.0149
Diabetes, n (%) 1396 (26.1) 1975 (25.2) 1270 (22.6) 0.0001
Hypertension, n (%) 3679 (68.7) 5315 (67.9) 3595 (63.9) 0.0001
Family history of CAD, n (%) 1046 (19.5) 1641 (21.0) 1126 (20.0) 0.1141
Previous MI, n (%) 1480 (27.6) 2041 (26.1) 1246 (22.2) 0.0001
Previous stroke, n (%) 371 (6.9) 482 (6.2) 273 (4.9) 0.0001
Previous cancer, n (%) 374 (7.0) 450 (5.7) 261 (4.6) 0.0001
Total cholesterol, mmol/L 5.2 (1.5) 5.3 (1.6) 5.3 (1.7) 0.0003
LDL cholesterol, mmol/L 3.2 (1.1) 3.3 (1.2) 3.3 (1.1) 0.0001
HDL cholesterol, mmol/L 1.2 (0.4) 1.2 (0.5) 1.2 (0.5) 0.0772
Triglycerides, mmol/L 1.8 (1.3) 1.9 (1.6) 1.9 (1.4) 0.1545
Creatinine, mmol/L 94.6 (30.4) 93.8 (29.6) 92 (25.9) 0.0001
Never smoker, n (%) 2533 (47.3) 3545 (45.3) 2456 (43.7) 0.0007
Former smoker, n (%) 1627 (30.4) 2574 (32.9) 1818 (32.3) 0.0085
Current smoker, n (%) 1195 (22.3) 1709 (21.8) 1350 (24) 0.0098
In hospital
Hospital stay, mean, d 10.2 (6.7) 10 (6.3) 9.5 (5.4) 0.0001
Total CK 230.7 (324.3) 257.2 (363.6) 271.4 (383.6) 0.0001
Heart failure at admission, n (%) 896 (16.7) 1219 (15.6) 711 (12.6) 0.0001
PCI in first 30 d, n (%) 1847 (34.4) 2841 (36.3) 2360 (42.0) 0.0001
CABG in first 30 d, n (%) 510 (9.5) 800 (10.2) 560 (10.0) 0.4222
Secondary prevention, 30 d, n (%)
Aspirin 4910 (91.7) 7251 (92.6) 5311 (94.4) 0.0001
Antiplatelet 5085 (94.9) 7506 (95.9) 5478 (97.4) 0.0001
-blocker 2635 (49.2) 3921 (50.1) 2544 (45.2) 0.0001
ACE/ARB 3917 (73.1) 5717 (73.0) 4009 (71.2) 0.0425
Any BP lowering 5042 (94.1) 7316 (93.4) 5251 (93.4) 0.1836
Statin 3981 (74.3) 6166 (78.8) 4645 (82.6) 0.0001
Recently quit (% overall) 676 (12.6) 1148 (14.7) 978 (17.4) 0.0001
Weight loss between baseline and 0.503 (2.66) 0.789 (2.83) 0.888 (3.13) 0.001
30 d, mean (SD), kg*
PCI 30 d to 6 mo 278 (5.5) 435 (5.9) 353 (5.5) 0.7348
CABG 30 d to 6 mo 140 (2.8) 288 (3.9) 240 (3.9) 0.0016
Abbreviations as in Table 1.
*Weight data at baseline and 30 days were available for 4211 in the no modification group, 6654 in the either modification group, and 5039 in the both modifications group.

adjusted models were not materially different from those Discussion

calculated by age- and sex-adjusted models. Analyses were
repeated with a hierarchical model to control for country
within region and center within country, and results were
similar to those reported here.
Effects of Multiple Lifestyle Changes
For each category of smoker, change in diet and exercise had
additive effects in decreasing risk of cardiovascular events.
Persistent smokers who did not modify diet or exercise had
the highest risk of a repeat cardiovascular event (fully
adjusted OR, 3.77; 95% CI, 2.40 to 5.91; Figure 3).
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This study found that adherence to recommendations regard-
ing smoking, diet, and exercise at 30 days after ACS is
associated with a substantially lower rate of short-term major
cardiovascular outcomes and all-cause mortality. Compared
with persistent smokers, recent quitters had a lower risk of MI
and a marginally lower risk of the composite outcome.
Adherers to diet and exercise had a 50% lower risk for all
major events in 6 months compared with nonadherers. The
risk associated with diet alone or exercise alone was similar
for MI and stroke, but for death, exercise may be more
756 Circulation February 16, 2010

Table 6. Relationship Between Diet/Exercise Modification and Repeat Cardiovascular Events in Patients With ACS
Risk of MI Risk of Stroke Risk of Death Risk of Death/MI/Stroke

Category OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P

No diet/exercise Reference Reference Reference Reference
Diet only 0.93 (0.741.16) 0.5137 0.84 (0.541.31) 0.4357 0.91 (0.731.13) 0.3986 0.91 (0.771.07) 0.2605
Exercise only 0.78 (0.561.1) 0.1547 0.94 (0.521.68) 0.8256 0.61 (0.420.88) 0.0091 0.69 (0.540.89) 0.0037
Both diet and exercise 0.52 (0.400.69) 0.0001 0.46 (0.260.82) 0.0079 0.45 (0.330.60) 0.0001 0.46 (0.380.57) 0.0001
Models were adjusted for age; sex; region; history of hypertension, diabetes, and prior MI; body mass index; creatinine; PCI/CABG before 30 days; and use of
-blockers, statins, antiplatelets, and ACE/ARB drugs at 30 days.

important. Persistent smokers who did not diet or exercise
had an 4-fold risk of cardiovascular events compared with
never smokers who dieted and exercised. Excess risk for all
of the categories was apparent after accounting for multiple
confounders, including drug treatments, PCI, and CABG,
suggesting that the benefits of adherence to lifestyle modifi-
cation are additional to the benefits conferred by drugs and
interventions.
Our study suggests that these benefits accrue early (by 6
months). Smoking cessation may lead to early benefit through
reversal of platelet activation, coronary artery spasm, and
ventricular arrhythmias.16 Diet and exercise may have early
benefits through risk factor control,12,17 improved plaque
stabilization in response to less oxidative stress damage, and
fewer arrhythmias resulting from membrane stabilization.18,19
An important potential explanation for the benefits seen in
adherers is that adherence per se is a marker of adherence to
other beneficial treatments and healthy behaviors in unmea-
sured ways. That is, the effects seen with lifestyle behaviors
here are not a true effect of diet and exercise per se but are
related to characteristics of adherers. This study did not
demonstrate substantial differences in characteristics or drug
treatments in adherers to diet/exercise or smoking cessation
compared with nonadherers. We also examined whether those
who do not change behavior are more or less compliant with
medications and did not identify a relationship (analyses not
shown). Supportive of the above notion is that good lifestyle
behaviors appear to cluster (eg, persons who quit smoking
had higher rates of adherence to diet and exercise). Random-
ized studies have found that those with improved adherence
to either study drug or placebo are relatively protected
compared with nonadherers and postulate that this may be
due to other unmeasured health attitudinal characteristics.20
Although it is not clear what the cause of the decreased risk
is in adherers to lifestyle recommendations, this study adds to
the body of evidence that behavior modification is associated
with substantial benefits. This study highlights the early
benefits of lifestyle modification and the incremental benefits
of multiple behavior changes and underscores the relatively
poor adherence to lifestyle recommendations (compared with
preventive drug therapy) in a well-treated clinical trial
population.
The strengths of this study are its large size and its
inclusion of patients with ACS from a wide range of centers
in multiple countries. The study had detailed records of the
use of secondary preventive medications at follow-up visits,
enabling us to assess the effect of this important potential
confounder. An additional strength is the rigorous, systematic
reporting of events and highly complete follow-up resulting
from the study being principally a large clinical trial.
Potential limitations of this study are that information on
secondary preventive lifestyle behaviors was collected with
simple self-report questions. The definitions of quitting and
persistent smoking relied on self-report and were not vali-
dated by cotinine measurements. Similarly, we did not collect
details on actual diet or exercise and hence cannot quantify
them or describe which elements of diet or exercise programs
are associated with the lower risk.
We acknowledge that unmeasured baseline characteristics
may have had an impact on subsequent events (eg, socioeco-
nomic status, physical disability). Reporting of compliance
may vary substantially according to geographic region or
cultural traditions. There could be a potential for misclassi-
fication because adherers/nonadherers were categorized at the
30-day follow-up; however, such misclassifications would
tend to minimize real differences between groups, so our data
may be an underestimate of the true benefits of behavioral
change after ACS.
This study found that individuals who change their behav-
ior (quit smoking and modify diet and exercise) after ACS are

Table 7. Relationship Between Smoking and Repeat Cardiovascular Events in Patients With ACS
Risk of MI Risk of Stroke Risk of Death Risk of Death/MI/Stroke

Category OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P

Persistent smoker Reference Reference Reference Reference
Quitter 0.57 (0.360.89) 0.0145 0.40 (0.141.17) 0.0930 0.93 (0.591.46) 0.7594 0.74 (0.531.02) 0.0698
Ex-smoker 0.68 (0.480.98) 0.3990 0.79 (0.361.74) 0.5547 0.65 (0.440.97) 0.0360 0.68 (0.510.90) 0.0067
Never smoker 0.49 (0.340.71) 0.0002 0.83 (0.381.82) 0.6397 0.59 (0.400.89) 0.0108 0.59 (0.440.78) 0.0002
Models were adjusted for age; sex; region; history of hypertension, diabetes, and prior MI; body mass index; creatinine; PCI/CABG before 30 days; and use of
-blockers, statins, antiplatelets, and ACE/ARB drugs at 30 days.

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 Chow et al Behavioral Modification Effects After ACS 757

No. of Odds Ratio for MI or Stroke or Death

Characteristic Patients (95% CI) P Value

Never smoker, diet & exercise 2442 Reference category -

Never smoker, either diet/exercise 3515 1.96(1.45-2.65) <0.0001

Never smoker, No diet/exercise 2519 2.42(1.78-3.29) <0.0001

Former smoker, diet & exercise 1793 1.25(0.85-1.85) 0.2586

Former smoker, either diet/exercise 2529 2.46(1.80-3.37) <0.0001 Figure 3. Risk of repeat cardiovascular events
(MI/stroke/death) with progressive behavioral
Former smoker, No diet/exercise 1590 2.36(1.68-3.30) <0.0001
change. Models were adjusted for age; sex;
region; history of hypertension, diabetes, prior
Quit smoking, diet & exercise 972 1 62(0 96-2
1.62(0.96 2.75)
75) 0.0732
0 0732 MI, body mass index, creatinine, v n30days.
Quit smoking, either diet/exercise 1143 2.03(1.32-3.13) 0.0014 The reference category is never smoker and
Quit smoking, No diet/exercise 679 3.22(2.07-5.03) <0.0001 diet and exercise.

Persistent smoker, diet & exercise 379 1.95(1.00-3.82) 0.0502

Persistent smoker, either diet/exercise 590 2.97(1.83-4.82) <0.0001
Persistent smoker, No diet/exercise 536 3.77(2.40-5.91) <0.0001

0.5 1.0 2.0 3.5 6.0

at substantially lower risk of repeat cardiovascular events.
These benefits are seen early (6 months), and the benefits
from each behavior modification are additive. These results
indicate that adherence to behavioral recommendations in the
immediate postevent care of patients with ACS should be
given as high a priority by physicians and caregivers as other
secondary preventive medications and invasive strategies and
justify a significant investment in establishing programs that
systematically enhance early lifestyle modification and sec-
ondary prevention.
Acknowledgment
We thank Rizwan Afzal, senior statistician, for advice.
Sources of Funding
Dr Chow is supported by a Cottrell Fellowship from the Royal
Australasian College of Physicians and Public Health (Sidney Sax)
Overseas Fellowship cofunded by the National Health and Medical
Research Council and National Heart Foundation of Australia. Dr
Yusuf holds an endowed research chair of the Heart and Stroke
Foundation of Ontario. Dr Anand holds the May Cohen Eli Lilly
Chair in Womens Health Research and Michael G. DeGroote Heart
and Stroke Foundation Chair in Population Health. The OASIS study
was funded by Sanofi-Aventis, Organon, and GlaxoSmithKline. The
funding sources had no involvement in the analyses presented here.
Disclosures
None.
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CLINICAL PERSPECTIVE
Although preventive drug therapy is a priority after myocardial infarction (MI), less is known about adherence to
behavioral recommendations. The aim of this study was to examine the influence of adherence to behavioral
recommendations on the risk for repeat MI. The study population included 18 809 patients from 41 countries enrolled in
the Organization to Assess Strategies in Acute Ischemic Syndromes (OASIS) 5 randomized clinical trial. One month after
presenting with MI, 28.5% reported nonadherence to diet and exercise recommendations, and about one third of smokers
persisted in smoking. In models adjusted for known risk factors and medical treatments, quitting smoking was associated
with about half the risk of repeat MI compared with persistent smoking (odds ratio, 0.57; 95% confidence interval, 0.36
to 0.89), and diet and exercise adherence was associated with about half the risk of repeat MI compared with nonadherence
(odds ratio, 0.52; 95% confidence interval, 0.4 to 0.69). Persistent smoking and nonadherence to diet and exercise were
associated with a 3.8-fold (95% confidence interval, 2.5 to 5.9) increased risk of cardiovascular events (MI, stroke, and
death) compared with risks in never smokers who modified diet and exercise. These analyses highlight the relatively poor
adherence to behavioral advice (diet, exercise, and smoking cessation) after MI and suggest that behavioral modification
should be given priority similar to other preventive medications immediately after MI because they are associated with
substantial benefits in the prevention of repeat events.

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 Association of Diet, Exercise, and Smoking Modification With Risk of Early
Cardiovascular Events After Acute Coronary Syndromes
Clara K. Chow, Sanjit Jolly, Purnima Rao-Melacini, Keith A.A. Fox, Sonia S. Anand and Salim
Yusuf

Circulation. 2010;121:750-758; originally published online February 1, 2010;

doi: 10.1161/CIRCULATIONAHA.109.891523
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Copyright 2010 American Heart Association, Inc. All rights reserved.
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