European Journal of Cardiovascular Medicine

Coronary artery disease (CAD) is still one of the most prevalent public health problems worldwide, leading to increased morbidity and mortality. Coronary Artery Disease (CAD) is mainly due to the narrowing or blockage of coronary arteries caused by atherosclerosis that reduces blood flow to the heart resulting in angina, myocardial infarction and sudden cardiac death [1]. Multiple modifiable and non-modifiable risk factors such as poor diet, lack of exercise, smoking habits, hypertension, diabetes, and hyperlipidemia are associated with an increasing prevalence of CAD [2].

Effective management of CAD involves not only pharmacological therapy or procedural interventional but also depends on adherence of patients to prescribed treatment regimens and appropriate lifestyle changes [3]. “Treatment adherence is the extent to which patients take medications as prescribed, attend follow-up appointments and follow clinical recommendations. Moreover, changes in lifestyle, including dietary management, exercise, smoking cessation, and lifestyle modification are critical for secondary prevention and enhancing long-term cardiovascular well-being [4]. Poor treatment compliance and not adopting healthy behaviors have been repeatedly linked to higher risk of adverse cardiovascular events, hospitalizations, poor quality of life and death among patients living with coronary artery disease (CAD)[5].

Though adherence to treatment and lifestyle changes have demonstrated substantial benefit, many constructs prevent patients from adhering to recommended regimens. Socioeconomic limitations, psychological challenges, knowledge limitations, poor communication between healthcare providers and patients, and systemic hurdles within the healthcare system are among them [6]. Identifying factors associated with non-adherence addresses this issue, which is key to improving adherence rates as well as the overall disease outcome in patients with CAD.

This systematic review aims to examine the determinants of treatment adherence and lifestyle modifications among patients living with CAD, and the implications for disease outcomes. This review aims to synthesise evidence from recent studies to identify barriers and facilitators of adherence behaviours, assess their impact on clinical outcomes and provide recommendations for practice and future research.

2.1 Review Design

This systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PRISMA offers a standardized way of identifying, screening, selecting, and critically appraising relevant literature to ensure transparency, reproducibility, and methodological rigor in systematic reviews. The review will encompass qualitative studies, providing an in-depth understanding of the influences of treatment adherence and lifestyle changes for those with coronary artery disease (CAD). The methodological framework will include defined inclusion and exclusion criteria, a systematic search strategy across multiple electronic databases, independent reviewer screening, data extraction using a predetermined form, and quality appraisal using study design-appropriate assessment tools. This methodology guarantees that the synthesized evidence is reliable and valid, and it facilitates the formation of evidence-based recommendations for optimizing adherence and clinical outcomes in individuals with CAD.

2.2 Eligibility Criteria

Well-defined eligibility criteria were developed to ensure that relevant and high-quality evidence is included. The inclusion criteria for this systematic review were: (1) studies evaluating treatment adherence, including intake of medication and following up on care, and adherence to lifestyle changes, including diet, physical activity (walking or exercise), smoking cessation, and stress management in patients with coronary artery disease (CAD); (2) original research articles using randomized controlled trials (RCTs), prospective, cohort, case-control, cross-sectional, or qualitative study published from January 2015 to February 2025; (3) studies conducted in hospital, outpatient, or community settings; and (4) studies that measured adherence rates, adherence behavior, and clinical outcomes (e.g., cardiovascular events, quality of life) or identified barriers and facilitators for adherence. Only articles published in English in the last ten years were included in the selection in order to promote relevance to current clinical practice. The exclusion criteria were; (1) Articles not directly related to treatment adherence/lifestyle modifications or patient outcome of CAD patients. (2) Articles/publications/abstracts or editorials that are not Peer reviewed (3) Studies focusing on paediatric patients, pregnant women or individuals with other cardiovascular conditions unrelated to CAD.

2.3 Data Sources

The systematic review followed the guidelines of the PRISMA statement and was prospectively registered in PROSPERO. The literature search was conducted up to October 2024 using four major electronic databases (PubMed, Scopus, Embase [Ovid], and Web of Science) recommended for comprehensive retrieval of biomedical and health-related studies. This process aimed to identify influencing factors of treatment adhernce among patients living with CAD and their impact on patient outcome. These were PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science (WOS), and Cochrane Library. These databases were chosen to ensure a wide array of studies addressing CAD individuals' treatment adherence and lifestyle changes from both clinical and public health perspectives. The search strategy was developed to include peer-reviewed articles published in English in the last decade. Following strategies incorporating Boolean operators, Medical Subject Headings (MeSH),  and relevant keywords like “coronary artery disease,” “treatment adherence,” “lifestyle modification,” “diet,” “exercise,” “smoking cessation,” “stress management,” and “clinical outcomes” for a concentrated yet extensive search. Included studies and relevant reviews were further screened for relevant articles.

2.4 Search Strategy

This systematic review’s literature search used four central electronic databases that are widely used to identify biomedical and health-related research. These were PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science (WOS), and Cochrane Library. Inclusion criteria were broad, targeting studies related to treatment adherence and lifestyle modifications in CAD populations from a range of clinical and public health databases. The search strategy was developed to identify peer-reviewed articles published in English within the previous 10 years. To ensure expediency without sacrificing comprehensiveness, we used Boolean operators, Medical Subject Headings (MeSH), and keywords relevant to treatment adherence and lifestyle modification (eg, coronary artery disease, treatment adherence, lifestyle modification, diet, exercise, smoking cessation, stress management, and clinical outcomes). Manually screening the references of included studies and pertinent reviews to find other eligible articles.

2.5 Study Selection Process

The guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) were followed to ensure transparency and rigor for selecting used studies. All retrieved records from the four databases (PubMed, CINAHL, Web of Science, and the Cochrane Library) were imported to a reference management software, and duplicates were automatically removed.

The screening process occurred in two separate phases. During the first phase, two reviewers individually screened the titles and abstracts of all identified articles according to the predetermined inclusion/exclusion criteria. Studies that did not report on adherence to treatment, lifestyle changes, or important CAD outcomes were excluded. Finally, during the second phase, full-text articles of the shortlisted studies were retrieved and reviewed in detail to confirm their eligibility. Disagreements between reviewers at any stage were resolved by discussion or referral to a third reviewer, minimizing selection bias.

A PRISMA flow diagram was made to demonstrate the selection process, including the number of records identified, screened, excluded (with reasons for exclusion), and included in the review. The flow diagram summarizes the process through which the final set of studies was systematically reduced from the overall cohort.

2.6 Data Extraction

An electronic, structured, standardized data extraction form was developed a priori to systematically collect relevant data from each included study. Data extraction was carried out independently by two reviewers to ensure consistency and minimize bias, and disagreements were resolved through mutual discussion or adjudication by a third reviewer. The process of extracting data involved the identification of core variables that reflected the review's aims. These contained information regarding the authors, publication year, country of study, study design type, etc. Other data extracted included information on the study population, including sample size, mean age, sex distribution, and clinical characteristics of patients with coronary artery disease. Study Assessment Each study was classified by its setting: hospital-based, community-based, or conducted in an outpatient clinic.

Additionally, review evidence was used to abstract information about treatment type adherence, for example, whether it be medication adherence or adherence to follow-up care, and the methods used to assess adherence. Details of related lifestyle modification practices (Dietary behavior, physical activity and walking, smoking cessation, and stress management) were documented systematically. This was also recorded if the intervention involved any intervention (e.g., counseling, education, digital health

Tools). The data extraction process also involved the identification of reported barriers and facilitators to adherence and behavior change. Finally, information related to clinical outcomes assessed in the studies (such as rates of cardiovascular events, hospital readmissions, or improvements in quality of life) and to the main findings and conclusions was extracted to enable detailed synthesis.

2.7 Quality Assessment

The quality of the included studies was formally assessed using suitable critical appraisal tools according to study design to facilitate the identification of credible and methodologically sound studies. Randomized controlled trials were evaluated using the Cochrane Risk of Bias Tool, which addresses domains like sequence generation, allocation concealment, blinding, incomplete outcome data, and selective reporting. The Newcastle-Ottawa Scale (NOS) was used for observational studies (i.e., cohort, case-control, and cross-sectional designs) to assess a selection of participants, the comparability of each study group, and the ascertainment of outcomes or exposure. Qualitative studies reviewed were appraised using the Critical Appraisal Skills Programme (CASP) checklist, which examines the aim of the research being clear, the methodology being appropriate, the data being collected suitably, and the analytical rigor of the data.

Table: Quality Assessment of Included Studies

The quality assessment was performed independently by two reviewers, and scoring or interpretational differences were resolved through discussion or consulting a third reviewer. Outcomes and quality of studiesStudies were classified by their appraisal scores into high, moderate and low quality. This quality assessment process was fundamental to the process of assessing the internal validity of the included studies and to guiding the interpretation of findings in the synthesis.

1 Study Characteristics

Table 1- Study Characteristics.

The study reports the results of the 12 studies included within this systematic review that investigated the factors associated with treatment adherence and lifestyle changes in patients living with CAD and their effects on the disease results. Studies were performed in various geographic settings, including Taiwan, India, Jordan, China, Germany, Greece, the United Kingdom, Italy, South Korea, Vietnam, Spain, and the United States, and used a variety of study designs, including randomized controlled trials (RCTs), cohort studies, cross-sectional studies, qualitative studies, and systematic reviews. The main themes derived from synthesis of data from the included studies concern factors contributing to treatment adherence (medication adherence, follow-up care adherence), lifestyle modification adherence factors, barriers and facilitators to adherence, and the effect of these behaviors on clinical outcomes and quality of life. Characteristics of included studies, their methodological quality and main findings are described in the following sections.

Summary of Factors Affecting Adherence (Recommended Table)

Medication adherence was highlighted as important in

CAD management across all studies in this review. Adherence to cardiovascular drugs (OATS), including antiplatelet agents, statin, beta-blockers, and antihypertensive agents, is associated with significantly lower rates of cardiovascular events and death. Shang et al. In a multicenter cohort study from China, Chen et al. reported a nonadherence rate of 30% among post-myocardial infarction patients, which predicted the incidence of adverse cardiovascular events during one year of follow-up [5]. Similarly, Shalaeva et al. (2023) showed this year that regular compliance with medication with lifestyle changes significantly decreased the risk of (MACE) and one-year mortality in advanced atherosclerosis patients [11]. Patient education, counseling intervention and digital health resources are some of the factors associated with increased medication adherence as reported by Kalal et al.[8] As evidenced by Chow et al. (2023) in a randomized controlled trial conducted in China, where nurse-led follow-up programs were found to substantially increase adherence [18].

Further, medication adherence was also impacted by patient-related factors including psychological status, health literacy, and social support. Al-Zaru et al. [9] pointed out that depression and psychological distress had a negative impact on medication-taking behavior among CAD patients in Jordan 3. Cross et al. (2020) [13] also reported that educational interventions from home health agencies for older adults taking multiple medications improved their ability to manage complicated treatment regimens.

Another critical dimension of comprehensive CAD management identified in the study was adherence to follow-up care defined as attending scheduled medical visits, routine investigations and involvement in rehabilitation programs. Kim et al. (2024) showed that participation in structured cardiac rehabilitation programs among cardiovascular patients in South Korea resulted in better adherence to lifestyle change and consequently better clinical outcomes [15]. These were implemented in this instance to allow continuous patient engagement, counseling, and monitoring to reinforce long-term adherence to medical advice and lifestyle recommendations.

Yang et al. In Taiwan (2021), adherence to follow-up care and healthy lifestyle practices significantly contributed to cardiovascular risk reduction among patients after coronary interventions [1]. Common preventable factors for non-adherence to follow-ups included socio-economic conditions, difficulty in transportation, and lack of awareness regarding the need for periodic assessment. On the other hand, studies by Kalal et al. (2023) and Nakajima et al. (2022) were found to increase patient engagement in follow-up care and improve adherence to recommended treatment pathways [19].

3.3 Lifestyle Modification Factors

Dietary habits were highlighted as important in lifestyle adjustments in CAD management. In Taiwan, a study by Li MC et al. (2021) revealed that adherence to a balanced diet including increased intake of fruits, vegetables and whole grains and reduced intake of saturated fats and sodium, was significantly associated with lower risk of cardiovascular events in subjects undergoing coronary intervention [20]. Kalal et al. tested that providing nurse-provided dietary counseling effectively impacted the dietary behaviors of post-mif patients in India [8]. However, Al-Zaru et al. Psychological influencing factor, such as depress [9], was negatively associated with dietary adherence which indicated that integrated dietary and psychological support among CAD patients was needed.

Individuals who engaged in regular physical activity, whether it be walking or with structured exercise programs, had universally better cardiovascular health outcomes. As Kim et al. have shown, participation in cardiac rehabilitation programs 2023); South Korea improved adherence to recommendations for physical activity and led to better functional capacity, and lower rates of cardiovascular event recurrence [21]. Similarly, Kalal et al. (2023) reported a marked improvement in exercise adherence among patients who received structured follow-up care, including lifestyle modification counseling [8]. Nonetheless, barriers including lack of motivation, physical constraints and environmental factors were stated to inhibit regular physical activity in certain patient populations.

Smoking cessation is still an important lifestyle change measure in CAD treatment. The studies highlight that patients who achieved smoking cessation had better cardiovascular outcomes and a lower risk of mortality. Yang et al. (2021) showed that smoking cessation adherence was an important determinant of reduced CV events in CAD patients [1]. Kalal et al. reported that, in nurse-led programs, educational interventions, and personalized counseling were effective in promoting smoking cessation. (2023) [8].

The significance and the often neglected importance of stress management as a matter of lifestyle modification in CAD care floated as an especially relevant topic. Stress was identified as a major challenge to both treatment and lifestyle adherence in multiple studies.[22] Tamminga et al. Although their Cochrane review [23] showed that individual-level interventions (which may include relaxation exercises, mindfulness, and counseling) were effective in reducing occupational and personal stress levels and supported adherence to healthy behaviors, the evidence for its clinical significance is limited. Patel et al. Similar findings were recently published in279 by Barreto et al, wherein it was reported that stress reduction interventions were positively associated with better adherence as well as with improved clinical outcomes in CAD patients.[24]

 3.4 Barriers and Facilitators

The studies included in this review identified a number of patient-related, healthcare system-related, and social-environmental barriers and facilitators to treatment adherence and lifestyle modification in patients living with coronary artery disease (CAD). The most frequently cited patient-related barriers included low health literacy, depression, lack of motivation, forgetfulness, and fear of medication side effects, which perceived to higher extent, emerging from studies conducted by authors Al-Zaru et al. (2022) and Shang et al. (2019) [9,10]. Psychological distress and stress were found to interfere with efforts to modify the lifestyle (e.g., diet control, exercise, and smoking cessation). Conversely, high health literacy, positive mindset, knowledge regarding disease severity, and strong self-efficacy, supporting adherence to recommended behaviors, were identified as patient facilitators. Kalal et al. also reported the following healthcare system factors influencing adherence: availability of structured interventions, nurse-led counseling, regular follow-up and access to affordable medications. (2023) and Cross et al. (2020) [2,7]. Barriers to healthcare, including a lack of access to healthcare services, medication costs, and poor patient-provider communication, were common. Factors including supportive family network, peer motivation and community-based cradle-to-grave rehabilitation helped to adhere, while constrained by social isolation, monetary access and limited conducive environment for exercise and nutrition, as reported by Nguyen et al. (2021) and Kim et al. (2024) [10,9]. A multi-dimensional approach that overcomes these barriers and utilises these facilitators will improve adherence to treatment and lifestyle changes in CAD management.

3.5 Impact on Disease Outcomes

The included studies provide strong evidence that treatment adherence and lifestyle modifications improve disease outcomes among patients with coronary artery disease (CAD). Higher adherence to medications, regular follow-up care, and incorporation of healthy lifestyle behaviors substantially lowered the incidence of cardiovascular events, hospitalizations, and mortality rates according to multiple studies. Shang et al. (2019) indicated that a lower risk of 1-year MACEs after myocardial infarction was directly related to medication adherence in China [9]. Similarly, Shalaeva et al. Patients with advanced atherosclerosis experienced a decrease in major cardiovascular events and one-year mortality if they adhered to both medical and lifestyle recommendations [11]. Kim et al also highlighted that participation in cardiac rehabilitation programs and adherence to physical activity, healthy diet, and smoking cessation were also associated with lower hospital readmissions and better cardiovascular outcomes.[15]. Instead, lifestyle changes and better compliance were responsible for improved quality of life in CAD patients on top of clinical advantages. Studies by Kalal et al. (2023) and Cross et al. Informal structured educational interventions, stress management, and healthy lifestyle practices of patients were associated with the improved physical functioning, emotional well-being, and overall satisfaction with life [8]. Hence, the developed evidence strongly indicates that persist with treatment and lifestyle amendments not only matters to prevent clinical complications but is also significantly potential to enhance the overall well-being and quality of life in CAD patients.

The current systematic review integrates findings from the last 10 years of research investigating what treatment adherence and lifestyle diversities are implemented by CAD patients and their effects on consequent disease outcomes. Data shows that both adherence to treatment (medication intake and follow-up care) and lifestyle changes (diet, physical activity, cessation of smoking and stress management) were crucial for clinical composition and life quality of CAD patients. The review emphasises that higher adherence to prescribed medications led to decreased cardiovascular events, mortality and hospitalizations, and this was also reported in studies by Shang et al. (2019) and Shalaeva et al. (2023) [1011]. Furthermore, Yang et al. also reported that most lifestyle modification, especially diet, exercise, and smoking cessation, had a significantly benefical effect on quality of life and prevented disease progression.[1]

These findings are similar to the literature, which by recognizing the multifaceted dimensions of adherence behaviors in chronic disease management (CNS), which is in line with the time plane of data up to October 2023. For instance, Cross et al. (2020), educational and behavioral approaches are highly effective in improving medication adherence among older adults [10]. Moreover, the influence of psychological factors; for example, studies have shown that depression and stress [10,11], are in agreement with prior evidence that mental health problems are a common obstacle to treatment compliance in individuals with cardiovascular conditions.

The review has major relevance for clinical practice. Health systems need to take a patient-centred approach that tackles each person's unique barriers including low health literacy, psychological distress and socioeconomic systems. As evidence by Kalal et al., interventions such as nurse-led follow-up programs, mobile health applications, and personalized counseling (8).Ihm SH et al. [25] (2022) suggested  to potentially improve adherence and promote lasting behavior change. Multidisciplinary care teams that include nurses, dietitians, psychologists, and social workers can be key in aiding CAD patients in following treatment regimens and adopting healthy lifestyles.

Developing structured guidelines and national-level strategies to promote adherence-supportive environments are needed from a policy perspective. Data extraction should include all identified studies reporting the cost, effectiveness or efficiency of cardiac rehabilitation programmes from anywhere in the world. It should also address dispensing medicine, and promote health literacy campaigns to improve patient engagement, with reducing access barriers to healthcare and subsidizing the cost of medications. Moreover, digital health is proven to aid lifestyle adherence according to research such as Kim et al, therefore, healthcare system needs to invest in them. (2024) and Nguyen et al. (2021) [9,10]. A systematic, multi-stakeholder approach focused on clinicians, patients, and policy makers will be necessary to change adherence behaviors and improve cardiovascular health outcomes in CAD patients.

This systematic review summarizes the body of evidence stressing the need for adherence to treatment and lifestyle changes for the management of CAD. The results across the 12 selected studies uniformly illustrate that medication compliance,regular follow-ups, healthy lifestyle choices (such as improved diet, regular exercise, smoking cessation, and stress management), and psychological support  are critical for better clinical outcomes and quality of life.High adherence to prescribed treatments reduces cardiovascular events, mortality, and hospitalizations among patients diagnosed with CAD. Multidisciplinary care teams (nurses, dietitians, psychologists, social workers) are also vital for supporting patients. Key barriers of treatment adherence include low health literacy and limited access to care, while facilitators include education, family support, nurse-led care, and rehabilitation programs. The review calls for a patient-centered, multidisciplinary approach and improved healthcare models, education, developing structured guidelines, enhancing health literacy, reducing healthcare access barriers, and subsidizing medications and digital tools to support lasting behavior change and better disease management.

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