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. 2015 Dec 22;2015(12):CD009386.
doi: 10.1002/14651858.CD009386.pub2.

Internet-based interventions for the secondary prevention of coronary heart disease

Reena Devi  1 , Sally J Singh, John Powell, Emily A Fulton, Ewemade Igbinedion, Karen Rees
Affiliations

Internet-based interventions for the secondary prevention of coronary heart disease

Reena Devi et al. Cochrane Database Syst Rev. .

Abstract

Background: The Internet could provide a means of delivering secondary prevention programmes to people with coronary heart disease (CHD).

Objectives: To determine the effectiveness of Internet-based interventions targeting lifestyle changes and medicines management for the secondary prevention of CHD.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, in December 2014. We also searched six other databases in October 2014, and three trials registers in January 2015 together with reference checking and handsearching to identify additional studies.

Selection criteria: Randomised controlled trials (RCTs) evaluating Internet-delivered secondary prevention interventions aimed at people with CHD.

Data collection and analysis: Two review authors independently assessed risk of bias and extracted data according to the Cochrane Handbook for Systematic Reviews of Interventions. We assessed evidence quality using the GRADE approach and presented this in a 'Summary of findings' table.

Main results: Eighteen trials met our inclusion criteria. Eleven studies are complete (1392 participants), and seven are ongoing. Of the completed studies, seven interventions are broad, targeting the lifestyle management of CHD, and four focused on physical activity promotion. The comparison group in trials was usual care (n = 6), minimal intervention (n = 3), or traditional cardiac rehabilitation (n = 2).We found no effects of Internet-based interventions for all-cause mortality (odds ratio (OR) 0.27, 95% confidence interval (CI) 0.04 to 1.63; participants = 895; studies = 6; low-quality evidence). There was only one case of cardiovascular mortality in a control group (participants = 895; studies = 6). No incidences of non-fatal re-infarction were reported across any of the studies. We found no effects for revascularisation (OR 0.69, 95% CI 0.37 to 1.27; participants = 895; studies = 6; low-quality evidence).We found no effects for total cholesterol (mean difference (MD) 0.00, 95% CI -0.27 to 0.28; participants = 439; studies = 4; low-quality evidence), high-density lipoprotein (HDL) cholesterol (MD 0.01, 95% CI -0.06 to 0.07; participants = 437; studies = 4; low-quality evidence), or triglycerides (MD 0.01, 95% CI -0.17 to 0.19; participants = 439; studies = 4; low-quality evidence). We did not pool the data for low-density lipoprotein (LDL) cholesterol due to considerable heterogeneity. Two out of six trials measuring LDL cholesterol detected favourable intervention effects, and four trials reported no effects. Seven studies measured systolic and diastolic blood pressure; we did not pool the data due to substantial heterogeneity. For systolic blood pressure, two studies showed a reduction with the intervention, but the remaining studies showed no effect. For diastolic blood pressure, two studies showed a reduction with the intervention, one study showed an increase with the intervention, and the remaining four studies showed no effect.Five trials measured health-related quality of life (HRQOL). We could draw no conclusions from one study due to incomplete reporting; one trial reported no effect; two studies reported a short- and medium-term effect respectively; and one study reported both short- and medium-term effects.Five trials assessed dietary outcomes: two reported favourable effects, and three reported no effects. Eight studies assessed physical activity: five of these trials reported no physical activity effects, and three reported effectiveness. Trials are yet to measure the impact of these interventions on compliance with medication.Two studies measured healthcare utilisation: one reported no effects, and the other reported increased usage of healthcare services compared to a control group in the intervention group at nine months' follow-up. Two trials collected cost data: both reported that Internet-delivered interventions are likely to be cost-effective.In terms of the risk of bias, the majority of studies reported appropriate randomisation and appropriate concealment of randomisation processes. A lack of blinding resulted in a risk of performance bias in seven studies, and a risk of detection bias in five trials. Two trials were at risk of attrition bias, and five were at risk for reporting bias.

Authors' conclusions: In general, evidence was of low quality due to lack of blinding, loss to follow-up, and uncertainty around the effect size. Few studies measured clinical events, and of those that did, a very small number of events were reported, and therefore no firm conclusions can be made. Similarly, there was no clear evidence of effect for cardiovascular risk factors, although again the number of studies reporting these was small. There was some evidence for beneficial effects on HRQOL, dietary outcomes, and physical activity, although firm conclusions cannot yet be made. The effects on healthcare utilisation and cost-effectiveness are also inconclusive, and trials are yet to measure the impact of Internet interventions on compliance with medication. The comparison groups differed across trials, and there were insufficient studies with usable data for subgroup analyses. We intend to study the intensity of comparison groups in future updates of this review when more evidence is available. The completion of the ongoing trials will add to the evidence base.

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Conflict of interest statement

RD: RD is also an author of one of the included trials (Devi 2014).

SS: SS is also an author of one of the included trials (Devi 2014).

JP: JP is also an author of one of the included trials (Devi 2014).

EF: None declared.

EI: None declared.

KR: None declared.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Cardio events, outcome: 1.1 Revascularisation.
5
5
Forest plot of comparison: 2 Total cholesterol, outcome: 2.1 Total Cholesterol.
6
6
Forest plot of comparison: 3 HDL cholesterol, outcome: 3.1 HDL Cholesterol.
7
7
Forest plot of comparison: 4 LDL cholesterol, outcome: 4.1 LDL Cholesterol.
8
8
Forest plot of comparison: 5 Triglycerides, outcome: 5.1 Triglycerides.
9
9
Forest plot of comparison: 6 Systolic blood pressure, outcome: 6.1 Systolic Blood Pressure.
10
10
Forest plot of comparison: 7 Diastolic blood pressure, outcome: 7.1 Diastolic Blood Pressure.
1.1
1.1. Analysis
Comparison 1 Clinical outcomes, Outcome 1 Total Mortality.
1.2
1.2. Analysis
Comparison 1 Clinical outcomes, Outcome 2 Revascularisation.
2.1
2.1. Analysis
Comparison 2 Total cholesterol, Outcome 1 Total Cholesterol.
3.1
3.1. Analysis
Comparison 3 HDL cholesterol, Outcome 1 HDL Cholesterol.
4.1
4.1. Analysis
Comparison 4 LDL cholesterol, Outcome 1 LDL Cholesterol.
5.1
5.1. Analysis
Comparison 5 Triglycerides, Outcome 1 Triglycerides.
6.1
6.1. Analysis
Comparison 6 Systolic blood pressure, Outcome 1 Systolic Blood Pressure.
7.1
7.1. Analysis
Comparison 7 Diastolic blood pressure, Outcome 1 Diastolic Blood Pressure.
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References

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References to ongoing studies

Dale 2014 {published data only}
    1. Dale L, Whittaker R, Jiang Y, Stewart R, Rolleston A, Maddison R. Improving coronary heart disease self‐management using mobile technologies (Text4Heart): a randomised controlled trial protocol. Trials 2014;15:71. - PMC - PubMed
ISRCTN29243064 {unpublished data only}
    1. ISRCTN29243064. Effectiveness of a comprehensive telerehabilitation program for the heart. http://www.controlled‐trials.com/ISRCTN29243064 (accessed January 2015).
NCT02228603 {unpublished data only}
    1. NCT02228603. How to enhance physical activity after cardiac rehabilitation? A randomised controlled study comparing two follow‐up training exercise programs. https://clinicaltrials.gov/show/NCT02228603 (accessed January 2015).
NCT02350192 {unpublished data only}
    1. NCT02350192. Effectiveness of an e‐health educational intervention for cardiovascular disease adults in improving total exercise and outcomes. https://clinicaltrials.gov/ct2/show/NCT02350192 (accessed January 2015).
Redfern 2014 {published data only}
    1. Redfern J, Usherwood T, Harris MF, Rodgers A, Hayman N, Panaretto K, et al. A randomised controlled trial of a consumer‐focused e‐health strategy for cardiovascular risk management in primary care: the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) study protocol. BMJ Open 2014; Vol. 4, issue 2. [DOI: 10.1136/bmjopen-2013-004523] - DOI - PMC - PubMed
Reinwand 2013 {published data only}
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Shah 2011 {published data only}
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