title: Global secondary prevention strategies to limit event recurrence after myocardial infarction: results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network.
abstract: BACKGROUND
  Secondary prevention is not adequately implemented after myocardial infarction (MI). We assessed the effect on quality of care and prognosis of a long-term, relatively intensive rehabilitation strategy after MI.
  
  
  METHODS
  We conducted a multicenter, randomized controlled trial in patients following standard post-MI cardiac rehabilitation, comparing a long-term, reinforced, multifactorial educational and behavioral intervention with usual care. A total of 3241 patients with recent MI were randomized to a 3-year multifactorial continued educational and behavioral program (intervention group; n = 1620) or usual care (control group; n = 1621). The combination of cardiovascular (CV) mortality, nonfatal MI, nonfatal stroke, and hospitalization for angina pectoris, heart failure, or urgent revascularization procedure was the primary end point. Other end points were major CV events, major cardiac and cerebrovascular events, lifestyle habits, and drug prescriptions.
  
  
  RESULTS
  End point events occurred in 556 patients (17.2%). Compared with usual care, the intensive intervention did not decrease the primary end point significantly (16.1% vs 18.2%; hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.74-1.04). However, the intensive intervention decreased several secondary end points: CV mortality plus nonfatal MI and stroke (3.2% vs 4.8%; HR, 0.67; 95% CI, 0.47-0.95), cardiac death plus nonfatal myocardial infarction (2.5% vs 4.0%; HR, 0.64; 95% CI, 0.43-0.94), and nonfatal MI (1.4% vs 2.7%; HR, 0.52; 95% CI, 0.31-0.86). A marked improvement in lifestyle habits (ie, exercise, diet, psychosocial stress, less deterioration of body weight control) and in prescription of drugs for secondary prevention was seen in the intervention group.
  
  
  CONCLUSIONS
  The GOSPEL Study is the first trial to our knowledge to demonstrate that a multifactorial, continued reinforced intervention up to 3 years after rehabilitation following MI is effective in decreasing the risk of several important CV outcomes, particularly nonfatal MI, although the overall effect is small.
  
  
  BACKGROUND
  ClinicalTrials.gov Identifier: NCT00421876.
authors.affiliation: Fondazione Salvatore Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico, Veruno, Italy. pantaleo.giannuzzi@fsm.it
authors.forename: Pantaleo
authors.initials: P
authors.lastname: Giannuzzi
authors.forename: Pier Luigi
authors.initials: PL
authors.lastname: Temporelli
authors.forename: Roberto
authors.initials: R
authors.lastname: Marchioli
authors.forename: Aldo Pietro
authors.initials: AP
authors.lastname: Maggioni
authors.forename: Gianluigi
authors.initials: G
authors.lastname: Balestroni
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Ceci
authors.forename: Carmine
authors.initials: C
authors.lastname: Chieffo
authors.forename: Marinella
authors.initials: M
authors.lastname: Gattone
authors.forename: Raffaele
authors.initials: R
authors.lastname: Griffo
authors.forename: Carlo
authors.initials: C
authors.lastname: Schweiger
authors.forename: Luigi
authors.initials: L
authors.lastname: Tavazzi
authors.forename: Stefano
authors.initials: S
authors.lastname: Urbinati
authors.forename: Franco
authors.initials: F
authors.lastname: Valagussa
authors.forename: Diego
authors.initials: D
authors.lastname: Vanuzzo
mesh_terms: D000787:Angina Pectoris / Q000209:etiology; D005260:Female; D006333:Heart Failure / Q000209:etiology; D006801:Humans; D008019:Life Style; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000517:prevention & control* / Q000534:rehabilitation; D009204:Myocardial Revascularization; D055502:Secondary Prevention; D013315:Stress, Psychological / Q000209:etiology; D020521:Stroke / Q000209:etiology