Background
Coronary heart disease (CHD) remains the leading cause of mortality worldwide, representing a significant public health challenge. Physical activity is well established as a protective factor that reduces the risk of recurrent cardiac events and improves overall cardiovascular health. Conversely, increasing evidence has identified sedentary behavior—characterized by prolonged sitting or low energy expenditure activities—as an independent risk factor for cardiovascular morbidity and mortality. Despite the importance of these behavioral factors, adherence to physical activity guidelines among patients with CHD is often suboptimal, and sedentary time is frequently excessive. Thus, identifying effective, non-pharmacological interventions to increase physical activity and reduce sedentary behavior is crucial for secondary prevention in this population.
Study Design and Methods
This systematic review and meta-analysis by Miu et al. rigorously examined randomized controlled trials (RCTs) assessing non-pharmacological interventions targeting physical activity and/or sedentary behavior in patients diagnosed with coronary heart disease. The investigators executed a comprehensive search across eight major English and Chinese databases from inception through July 2025, including a total of 5608 patients derived from 25 studies reported in 28 articles. Interventions were categorized into two main types: those using behavioral change techniques alone and those combining motivational strategies with behavioral change techniques. The Cochrane risk-of-bias tool (version 2) was employed to ensure methodological quality. Meta-analyses were conducted using Review Manager 5.4 when sufficient homogeneity was present, and narrative synthesis was utilized otherwise.
Key Findings
Meta-analytic results indicated that both intervention types significantly increased total physical activity time. Specifically, interventions combining motivational strategies and behavioral change techniques demonstrated a standardized mean difference (SMD) of 0.34 (95% confidence interval [CI]: 0.24 to 0.45, p < 0.001, I2 = 9%), and interventions using only behavioral change techniques showed a slightly lower but still significant SMD of 0.30 (95% CI: 0.12 to 0.47, p < 0.001, I2 = 0%). Both intervention categories also yielded statistically significant improvements in moderate-to-vigorous physical activity (MVPA) time, with an SMD of 0.23 (95% CI: 0.12 to 0.35, p < 0.001, I2 = 0%). However, meta-analyses of sedentary behavior outcomes across ten studies did not demonstrate significant reductions following any intervention, highlighting a potential gap in current intervention strategies.
The evidence suggests that motivational enhancements—such as counseling, goal-setting, and feedback—may bolster the already beneficial effect of behavioral change techniques, including self-monitoring, action planning, and environmental restructuring, underpinning increased physical activity engagement. The low to moderate heterogeneity supports the robustness of these findings across diverse clinical settings and populations.
Due to insufficient data and heterogeneity among studies focusing specifically on sedentary behavior, the lack of significant improvements calls for the development of tailored intervention components explicitly designed to target sedentary time reduction in CHD populations.
Expert Commentary
These findings align with current clinical guidelines that advocate for incorporating behavioral counseling alongside structured exercise programs in secondary prevention for CHD. The additive benefit of combining motivational strategies with behavioral techniques presents a compelling case for multifaceted intervention designs that address not only knowledge and skills but also motivation and self-efficacy.
Limitations include variability in intervention delivery modes, intensity, and duration across studies, which may affect generalizability. Additionally, the failure to influence sedentary behavior indicates a need for distinct and possibly technology-driven interventions, such as prompting devices or workplace modifications to reduce uninterrupted sitting time.
Emerging mechanistic insights suggest that physical activity induces favorable cardiovascular remodeling and improves autonomic regulation, whereas sedentary behavior may induce deleterious metabolic and inflammatory changes independent of physical activity. Hence, clinical practice must prioritize interventions that simultaneously increase physical activity and interrupt sedentary periods to maximize cardiovascular protection.
Conclusion
This systematic review underscores that non-pharmacological interventions incorporating both motivational strategies and behavioral change techniques effectively increase physical activity among patients with coronary heart disease, predominantly in terms of total and moderate-to-vigorous physical activity. However, the current interventions appear insufficient to reduce sedentary behavior significantly. Future research should focus on developing and rigorously testing novel, targeted interventions that address sedentary time reduction while sustaining physical activity improvements. Translating these findings into clinical practice could enhance secondary prevention efforts, ultimately lowering recurrent cardiac events and improving quality of life in CHD patients.
Funding and Registration
This systematic review is registered with PROSPERO under the registration number CRD42024500076. Details regarding funding were not specified in the primary report.
References
Miu EYN, Lam SKK, Xu M, Cheng HY. Effects of non-pharmacological interventions on physical activity and sedentary behaviour among patients with coronary heart disease: A systematic review and meta-analysis. Int J Nurs Stud. 2025 Nov;171:105180. doi: 10.1016/j.ijnurstu.2025.105180. Epub 2025 Aug 5. PMID: 40818250.
Additional relevant literature:
1. Anderson L, Oldridge N, Thompson DR et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016;2016(1):CD001800. doi:10.1002/14651858.CD001800.pub3.
2. Diaz KM, Howard VJ, Hutto B et al. Patterns of Sedentary Behavior and Mortality in US Middle-Aged and Older Adults: A National Cohort Study. Ann Intern Med. 2017;167(7):465-475. doi:10.7326/M17-0212.
3. Ekelund U, Tarp J, Steene-Johannessen J et al. Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis. BMJ. 2019;366:l4570. doi:10.1136/bmj.l4570.
