Frequency and Impact of Lifestyle Modification in Patients With Coronary Artery Disease: The Japanese Coronary Artery Disease (JCAD) Study

Study Questions:

Are lifestyle modifications widely used in clinical practice, and do such modifications reduce all-cause mortality in nonresearch patient populations?


The Japanese Coronary Artery Disease (JCAD) study enrolled patients with coronary artery disease (CAD), defined as ≥75% stenosis in ≥1 of three major coronary arteries. All patients were enrolled in the cohort between April 2000 and March 2001 from 202 hospitals throughout Japan. Patients with missing data on exercise or diet were excluded from the study. Lifestyle interventions were defined based on Japanese national guidelines for diet and physical activity, and dependent on each attending physician’s discretion. Patients were followed every 6 months for 3 years post-enrollment. The primary outcome of interest was all-cause mortality. Secondary outcomes included recurrent cardiovascular events, cerebral events, and vascular events. Recurrent cardiac events were defined as fatal and nonfatal myocardial infarctions, unstable angina, or heart failure requiring medical therapy, percutaneous coronary intervention, or coronary artery bypass graft surgery, resuscitated cardiac arrest, or cardiopulmonary event on arrival. Cerebral events were defined as cerebral hemorrhage, cerebral infarction, or transient ischemic attack. Aortic dissection and rupture of aortic aneurysm were classified as vascular events.


A total of 13,812 patients are included in the JCAD cohort, of which 11,893 were included in the present study. During follow-up, 4,237 patients (35.6%) received exercise intervention and 8,642 patients (72.7%) received dietary intervention. Unadjusted all-cause mortality was lower among patients who had received lifestyle interventions (exercise or diet) compared to those who did not receive such interventions (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.56-0.84 for exercise, and HR, 0.75; 95% CI, 0.62-0.91 for diet). After adjustment for multiple potential confounders including age, sex, cardiovascular risk factors, and medications, these associations remained significant (HR, 0.73; 95% CI, 0.55-0.96 for exercise, and HR, 0.74; 95% CI, 0.58-0.95 for diet). A similar benefit was observed for cardiac mortality (HR, 0.56; 95% CI, 0.34-0.91 for exercise, and HR, 0.64; 95% CI, 0.42-0.97 for diet), but not for cerebral or vascular mortality.


The investigators concluded that both diet and exercise interventions among patients with CAD reduce all-cause mortality, even after adjustment for multiple factors.


This well-done study demonstrates the secondary prevention benefits of lifestyle modification. However, as the authors note, large numbers of cardiac patients do not receive such interventions. Efforts to increase the receipt of lifestyle modification should be a high priority among providers.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine

Keywords: Japan, Coronary Artery Disease, Life Style, Myocardial Infarction, Ischemic Attack, Transient, Coronary Disease, Constriction, Pathologic, Percutaneous Coronary Intervention, Cerebral Infarction, Heart Failure, Confidence Intervals, Coronary Artery Bypass, Cerebral Hemorrhage

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