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Cardiac rehabilitation after myocardial infarction: An invaluable intervention that is little used in Portugal
Reabilitação cardíaca após enfarte do miocárdio: uma intervenção fundamental, pouco praticada em Portugal
Miguel Mendes
Serviço de Cardiologia do Centro Hospitalar de Lisboa Ocidental -, Hospital de Santa Cruz, Carnaxide, Oeiras, Portugal
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"paginaFinal" => "203" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Miguel Mendes" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Miguel" "apellidos" => "Mendes" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia do Centro Hospitalar de Lisboa Ocidental -, Hospital de Santa Cruz, Carnaxide, Oeiras, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reabilitação cardíaca após enfarte do miocárdio: uma intervenção fundamental, pouco praticada em Portugal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The article by Magalhães et al. published in this issue of the <span class="elsevierStyleItalic">Journal</span> assesses the benefits of a cardiac rehabilitation program (CRP) lasting an average of eight weeks on control of cardiovascular risk factors in patients with coronary artery disease, 65% of whom had suffered an acute coronary syndrome (ACS).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The current European Society of Cardiology guidelines for the management of ACS<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> give cardiac rehabilitation a class I recommendation (level of evidence B) and consider it a mandatory performance measure; they also recommend the adoption of a healthy lifestyle and a specific pharmacological regimen based on dual antiplatelet therapy, beta-blockers, angiotensin-converting enzyme inhibitors (or angiotensin II receptor antagonists) and statins.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Changing behaviors, especially in the long term, is not easy to achieve in the context of usual patient care, which is characterized by brief consultations, with no support from audiovisual material or other professionals such as psychologists, nutritionists and exercise physiologists, or advice on smoking cessation. The traditional approach does not allow for patient education or clarification of any questions the patients or their relatives may have, nor does it provide the necessary support for behavior modification, which includes compliance with a permanent therapeutic regimen, smoking cessation if applicable, diet modification, regular exercise and adoption of a less stressful lifestyle.</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is essential to provide information on the measures to be taken, discuss foreseeable problems and establish support mechanisms if patients and their relatives are to comply with these recommendations in the long term.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Such changes are difficult to achieve because they entail abandoning habits that have been entrenched for decades, often in families of low socioeconomic status and often in asymptomatic patients who do not feel or understand the need to change.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Studies by Iestra et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and Chow et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> in <span class="elsevierStyleItalic">Circulation</span> demonstrated significant reductions in mortality as a result of controlling traditional cardiovascular risk factors, which the INTERHEART study<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> had previously shown to be responsible for 90% of cases of ACS and which are implicated in subsequent coronary events.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Various studies and meta-analyses<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> have shown that CRPs reduce overall and cardiovascular mortality by 25–30%, particularly programs with a strong exercise component. Such programs, which for many are merely exercise programs adapted to cardiac patients, are in fact much more; they are holistic secondary prevention programs that include exercise, education of patients and their relatives, promotion of behavioral changes, adoption of a healthy lifestyle, early return to everyday activities and compliance with the pharmacological therapy recommended in international guidelines.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A study by Darwood et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> revealed that simply advising patients to stop smoking is not sufficient and that only institutional smoking cessation programs or a CRP will achieve this. Lavie and Milani<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> demonstrated that CRPs also alleviate the psychological effects of ACS (hostility, anxiety or depression) in patients of all age groups, although the benefits are greater in younger patients, in whom such effects are more significant.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The article by Magalhães et al. is based on the results of close cooperation between physiatrists and cardiologists at Hospital de Santo António, Porto, who set up a CRP several years ago that is known for its quality and the number of patients treated. It shows that participation in the program produces a significant reduction in risk factor profiles at all assessments during follow-up (three, six and 12 months after enrollment on the program), with excellent results in BP lowering, smoking cessation, diabetes control and levels of physical activity. The results were less favorable in terms of obesity, which is in agreement with the literature,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and lipid profile, for which the currently available therapeutic arsenal, allied to a degree of diet modification, could produce better results.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the GOSPEL study,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> published by Giannuzzi et al. in 2008, 3241 patients were randomized to one of two groups: 1620 participated in a month-long residential CRP and 1621 received usual care; the groups were compared in terms of control of traditional risk factors, adoption of a healthy lifestyle, cardiovascular events and overall and cardiovascular mortality. As in the study by Magalhães et al., the patients in the CRP group presented a healthier lifestyle over a three-year follow-up, as shown by higher levels of physical activity, lower levels of psychological stress and healthier diet. With regard to risk factors, the CRP group showed better lipid profile and blood pressure levels and a higher rate of smoking cessation. In contrast to Magalhães et al., the GOSPEL study reported a sustained reduction in body mass index but found no statistically significant difference between the two groups in serum levels of HbA1c, whereas the Portuguese study obtained positive results for this parameter.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The GOSPEL investigators, with a larger population and longer follow-up, obtained positive outcomes for the study's two composite endpoints: cardiovascular mortality, nonfatal infarction and nonfatal stroke; and cardiac death and nonfatal infarction.</p><p id="par0060" class="elsevierStylePara elsevierViewall">It would be useful if CRP centers in Portugal, under the auspices of the Portuguese Society of Cardiology's Study Group on Exercise Physiology and Cardiac Rehabilitation, were to perform a national multicenter survey in order to determine whether cardiac rehabilitation as secondary prevention after ACS gives better results in terms of mortality, quality of life and cost-effectiveness compared to the usual care provided in public hospitals.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In Portugal, the rate of enrollment of eligible candidates in CRPs is less than 4%,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> compared to over 30% in most European countries.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The situation in Portugal falls short of the ideal due to regional differences in the availability of CRP centers, with a significant deficit in inland areas compared to the littoral and in the south compared to the north; furthermore, patients have limited access due to the cost of programs in private non-hospital centers and the lack of funding agreements with the national health service, which is responsible for the health care of around 80% of the population.</p><p id="par0070" class="elsevierStylePara elsevierViewall">At a time when the national health service is assessing the types of care it should provide to the population, and in the light of the evidence and the European Society of Cardiology's guidelines, it is clearly justified and appropriate to strengthen the areas of prevention and rehabilitation which have been shown to be effective in reducing mortality and health costs in developed countries.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mendes, M. Reabilitação cardíaca após enfarte do miocárdio: uma intervenção fundamental, pouco praticada em Portugal. Rev Port Cardiol. 2013. <span class="elsevierStyleInterRef" id="intr0005" href="http://dx.doi.org/10.1016/j.repc.2013.01.002">http://dx.doi.org/10.1016/j.repc.2013.01.002</span>.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 5 | 11 |
| 2024 October | 40 | 29 | 69 |
| 2024 September | 57 | 24 | 81 |
| 2024 August | 44 | 26 | 70 |
| 2024 July | 30 | 30 | 60 |
| 2024 June | 26 | 14 | 40 |
| 2024 May | 31 | 23 | 54 |
| 2024 April | 31 | 27 | 58 |
| 2024 March | 32 | 15 | 47 |
| 2024 February | 17 | 21 | 38 |
| 2024 January | 22 | 19 | 41 |
| 2023 December | 24 | 26 | 50 |
| 2023 November | 26 | 18 | 44 |
| 2023 October | 26 | 19 | 45 |
| 2023 September | 18 | 20 | 38 |
| 2023 August | 28 | 17 | 45 |
| 2023 July | 16 | 9 | 25 |
| 2023 June | 20 | 14 | 34 |
| 2023 May | 31 | 24 | 55 |
| 2023 April | 10 | 7 | 17 |
| 2023 March | 22 | 24 | 46 |
| 2023 February | 17 | 21 | 38 |
| 2023 January | 28 | 15 | 43 |
| 2022 December | 30 | 23 | 53 |
| 2022 November | 35 | 25 | 60 |
| 2022 October | 36 | 14 | 50 |
| 2022 September | 37 | 38 | 75 |
| 2022 August | 44 | 30 | 74 |
| 2022 July | 41 | 40 | 81 |
| 2022 June | 34 | 30 | 64 |
| 2022 May | 22 | 32 | 54 |
| 2022 April | 40 | 22 | 62 |
| 2022 March | 20 | 30 | 50 |
| 2022 February | 17 | 16 | 33 |
| 2022 January | 23 | 21 | 44 |
| 2021 December | 56 | 37 | 93 |
| 2021 November | 42 | 34 | 76 |
| 2021 October | 49 | 34 | 83 |
| 2021 September | 24 | 34 | 58 |
| 2021 August | 38 | 31 | 69 |
| 2021 July | 24 | 32 | 56 |
| 2021 June | 36 | 14 | 50 |
| 2021 May | 64 | 34 | 98 |
| 2021 April | 61 | 14 | 75 |
| 2021 March | 29 | 22 | 51 |
| 2021 February | 43 | 8 | 51 |
| 2021 January | 32 | 16 | 48 |
| 2020 December | 46 | 5 | 51 |
| 2020 November | 24 | 13 | 37 |
| 2020 October | 16 | 6 | 22 |
| 2020 September | 60 | 3 | 63 |
| 2020 August | 22 | 7 | 29 |
| 2020 July | 44 | 8 | 52 |
| 2020 June | 33 | 3 | 36 |
| 2020 May | 25 | 5 | 30 |
| 2020 April | 34 | 20 | 54 |
| 2020 March | 31 | 5 | 36 |
| 2020 February | 28 | 31 | 59 |
| 2020 January | 18 | 3 | 21 |
| 2019 December | 16 | 4 | 20 |
| 2019 November | 16 | 4 | 20 |
| 2019 October | 28 | 3 | 31 |
| 2019 September | 11 | 8 | 19 |
| 2019 August | 25 | 7 | 32 |
| 2019 July | 31 | 10 | 41 |
| 2019 June | 17 | 6 | 23 |
| 2019 May | 38 | 2 | 40 |
| 2019 April | 21 | 12 | 33 |
| 2019 March | 70 | 7 | 77 |
| 2019 February | 50 | 7 | 57 |
| 2019 January | 16 | 7 | 23 |
| 2018 December | 45 | 7 | 52 |
| 2018 November | 94 | 3 | 97 |
| 2018 October | 207 | 26 | 233 |
| 2018 September | 78 | 17 | 95 |
| 2018 August | 21 | 7 | 28 |
| 2018 July | 26 | 1 | 27 |
| 2018 June | 40 | 7 | 47 |
| 2018 May | 42 | 6 | 48 |
| 2018 April | 50 | 3 | 53 |
| 2018 March | 85 | 2 | 87 |
| 2018 February | 51 | 6 | 57 |
| 2018 January | 61 | 6 | 67 |
| 2017 December | 95 | 5 | 100 |
| 2017 November | 43 | 9 | 52 |
| 2017 October | 34 | 6 | 40 |
| 2017 September | 29 | 13 | 42 |
| 2017 August | 34 | 12 | 46 |
| 2017 July | 29 | 5 | 34 |
| 2017 June | 35 | 7 | 42 |
| 2017 May | 32 | 6 | 38 |
| 2017 April | 35 | 2 | 37 |
| 2017 March | 43 | 35 | 78 |
| 2017 February | 40 | 4 | 44 |
| 2017 January | 19 | 3 | 22 |
| 2016 December | 18 | 14 | 32 |
| 2016 November | 22 | 8 | 30 |
| 2016 October | 19 | 16 | 35 |
| 2016 September | 12 | 5 | 17 |
| 2016 August | 3 | 1 | 4 |
| 2016 July | 11 | 10 | 21 |
| 2016 June | 10 | 4 | 14 |
| 2016 May | 13 | 3 | 16 |
| 2016 April | 34 | 1 | 35 |
| 2016 March | 53 | 16 | 69 |
| 2016 February | 58 | 20 | 78 |
| 2016 January | 37 | 8 | 45 |
| 2015 December | 48 | 6 | 54 |
| 2015 November | 43 | 14 | 57 |
| 2015 October | 50 | 10 | 60 |
| 2015 September | 36 | 15 | 51 |
| 2015 August | 38 | 17 | 55 |
| 2015 July | 45 | 9 | 54 |
| 2015 June | 33 | 4 | 37 |
| 2015 May | 28 | 10 | 38 |
| 2015 April | 42 | 16 | 58 |
| 2015 March | 35 | 4 | 39 |
| 2015 February | 31 | 5 | 36 |
| 2015 January | 37 | 8 | 45 |
| 2014 December | 45 | 10 | 55 |
| 2014 November | 37 | 9 | 46 |
| 2014 October | 46 | 10 | 56 |
| 2014 September | 38 | 12 | 50 |
| 2014 August | 42 | 5 | 47 |
| 2014 July | 40 | 11 | 51 |
| 2014 June | 36 | 9 | 45 |
| 2014 May | 35 | 5 | 40 |
| 2014 April | 53 | 6 | 59 |
| 2014 March | 60 | 17 | 77 |
| 2014 February | 57 | 9 | 66 |
| 2014 January | 61 | 12 | 73 |
| 2013 December | 54 | 7 | 61 |
| 2013 November | 53 | 17 | 70 |
| 2013 October | 52 | 12 | 64 |
| 2013 September | 64 | 20 | 84 |
| 2013 August | 68 | 20 | 88 |
| 2013 July | 78 | 31 | 109 |
| 2013 June | 44 | 19 | 63 |
| 2013 May | 62 | 17 | 79 |
| 2013 April | 13 | 3 | 16 |
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