Editorial comment
In-hospital psychological intervention in cardiac rehabilitation following acute coronary syndrome: Brief is better than nothing
Intervenção psicológica intrahospitalar na reabilitação cardíaca após a síndrome coronária aguda: breve é melhor do que nada!
Ana Abreu
Departamento de Cardiologia, Faculdade de Medicina da Universidade de Lisboa, Serviço de Cardiolologia, CHULN, Hospital de Santa Maria, Lisboa, Portugal
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ACEIs: angiotensin-converting enzyme inhibitors; ARBs: angiotensin receptor blockers; BBs: beta-blockers; ECG: electrocardiogram; HF: heart failure; HR: heart rate; IV: invasive ventilation; LV: left ventricular; LVEF: left ventricular ejection fraction; PPCM: peripartum cardiomyopathy; RR: respiratory rate; SBP: systolic blood pressure; SpO<span class="elsevierStyleInf">2</span>: peripheral oxygen saturation; SvcO<span class="elsevierStyleInf">2</span>: central venous oxygen saturation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Tatiana Guimarães, Andreia Magalhães, Arminda Veiga, Manuela Fiuza, Walkíria Ávila, Fausto J. 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"idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511730447X?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204919301527?idApp=UINPBA00004E" "url" => "/21742049/0000003800000005/v2_201911300820/S2174204919301527/v2_201911300820/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "In-hospital psychological intervention in cardiac rehabilitation following acute coronary syndrome: Brief is better than nothing" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "369" "paginaFinal" => "372" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Ana Abreu" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Ana" "apellidos" => "Abreu" "email" => array:1 [ 0 => "ananabreu@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Cardiologia, Faculdade de Medicina da Universidade de Lisboa, Serviço de Cardiolologia, CHULN, Hospital de Santa Maria, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Intervenção psicológica intrahospitalar na reabilitação cardíaca após a síndrome coronária aguda: breve é melhor do que nada!" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Education in health for patients and healthcare providers, including multidisciplinary programs and e-health, is currently a hot topic.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The idea that educational interventions are beneficial for patients with coronary artery disease is supported by a Cochrane systematic review.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> Nevertheless, further research is needed to determine the best and most cost-effective format for delivery of educational programs.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The article by Fernandes et al. in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> examines the specific topic of education and psychological intervention for cardiovascular (CV) patients after acute coronary syndrome (ACS) and their perception of disease and treatment, as well as health habits, to improve adherence to lifestyle changes and risk factor control. This subject, which is important due to the pressing need to decrease CV risk after ACS, has been previously studied in the field of cardiac secondary prevention and rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">On the basis of solid evidence, the guidelines recommend comprehensive post-discharge ACS care that covers management of biomedical and lifestyle risk factors, pharmacotherapy, assessment of psychological factors, and assistance in initiating and maintaining behavioural change.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4–6</span></a> Educational interventions for CAD patients should be considered an essential part of cardiac rehabilitation (CR).<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3–7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Health education interventions are comprehensive programs that healthcare providers deliver to patients to help improving clinical outcomes by increasing adherence to and maintenance of healthy behaviours.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> These programs need to take patients’ characteristics into account, and health psychologists are essential for this aspect of the intervention.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As pointed out by Fernandes et al.,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> current thinking is that education and promotion of knowledge during the hospitalization period about the disease, risk factors and treatment improve the rehabilitation process following ACS. As well as patients’ view of their own illness affecting physical and psychological aspects of disease, as the authors show,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> other important socioeconomic aspects are also involved, like return to work.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The in-hospital post-ACS phase is a unique opportunity to identify risk factors, plan lifestyle changes, and to ensure that the patient is referred to the most suitable center for phase II of the CR program.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> Hospitalization itself provides access to individuals not registered with a general or specialist doctor, who otherwise would not undergo any intervention.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> There is evidence that patients may be more motivated to engage with lifestyle and behavioural changes while still in hospital.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Experiencing a major life event, such as going into hospital, has been identified as a catalyst for initiation of healthy behaviours and thus an ideal opportunity for intervention.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> The effect of an in-hospital intervention may depend on the individual patient's characteristics, including age, literacy, motivation for change, level of depression and anxiety, and family support. However, such an intervention may be less effective in some patients in the very early stages of hospitalization for ACS, due to the shock resulting from the acute stress of admission. Post-traumatic stress disorder, which occurs in 15-25% of myocardial infarction patients, can cause emotional apathy, lack of interest and memory loss, leading to communication difficulties and amnesia.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The best time to intervene during hospital stay is immediately before discharge. Patients are stabilized and reassured, knowing they will leave the hospital soon. Nurses can play an important role in this process, communicating the essential information provided by doctors. Psychologists can begin a brief intervention on disease perception and tailored behavioural modification, as demonstrated in Fernandes et al.’s paper,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> which can be continued and extended in outpatient CR.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3–6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients’ health knowledge needs to be put into practice in daily life. It is unclear which is the best approach to lifestyle and behaviour change at an individual level. Interventions designed to change behaviour may fail to achieve the desired results,<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">14,15</span></a> and there is little evidence on the impact of health promotion interventions among specific patient groups.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> Many current interventions target only one risk behaviour, failing to meet the needs of patients with multiple vulnerabilities, such as low levels of health literacy, reduced psychological capability and entrenched cultural and social barriers to health.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> Individualized counseling is the basis for motivation and commitment. Recommendations include assisting individuals to understand the relationship between their behaviour and their health, and helping them to assess the barriers to behaviour change. Decision-making should be shared between caregiver and patient.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4,17,18</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Previous to the article by Fernandes et al.,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> an interesting in-hospital psychological intervention study<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> set out to address barriers to lifestyle behaviour change, assess the feasibility and acceptability to patients of delivering an intervention in an acute setting, and analyze preliminary changes to lifestyle behaviours and measures of self-reported health, well-being, and perceived control after four weeks. It highlighted the need to personalize interventions to the individual's needs and circumstances, help people to develop skills to regulate their behaviour, and provide social support for behaviour change plans. The investigators, who used the framework of the ‘Behaviour Change Wheel’<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> for the intervention, showed that it was feasible to design and deliver an evidence-informed psychological intervention in a hospital setting.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> Preliminary health gains were shown by self-reported achievement of goals. Addressing lifestyle risk behaviours such as smoking and poor diet is the single most important way to improve health and reduce premature deaths.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> The intervention reached deprived groups who had multiple factors impeding lifestyle behaviour change<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> and enabled the development of resilience and coping skills in these deprived groups that would be transferable to other life situations, including management of long-term conditions.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">An important limitation of in-hospital psychological intervention is that although hospitals are in theory a good place to deliver health promotion interventions, these tend not to be prioritized due to competing staff priorities and lack of time and training.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> For this reason, in-hospital interventions need to be short, direct and concise. There are few examples of similar psychological interventions aimed at addressing multiple lifestyle risk behaviours in hospital patient-based interventions.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Several comments can be made regarding the present study.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> One concerns the randomization process: although the differences were not significant, the intervention group included younger and more educated patients. Both intervention and control groups were around 30% female, as usually occurs in trials. Instead of weekly randomization, it would have been more appropriate to perform a stratified randomization, including age, gender and educational level as parameters for stratification, to avoid bias.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The model of intervention used was generic and not specific for gender or age. As admitted by the authors, the fact that men and women present different psychosocial profiles regarding response and adaptation to ACS requires different interventions, as reported in the literature,<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> and underlines the importance of gender-specific intervention protocols in CR. Several programs have been proposed that are adapted to age and gender, in order to optimize the results, including adherence. The impact of these two variables and educational level should be further investigated in future studies and taken into account when planning intervention programs.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Certain aspects of the study need to be clarified. Were all patients asymptomatic and stable at the time of intervention within 2-3 days of ACS? How many were in fact anxious or depressed? The guidelines on CV prevention state that treatment of psychosocial risk factors can counteract psychosocial stress, depression and anxiety, thus facilitating behaviour change and improving quality of life and prognosis. Assessment of such risk factors is essential before any psychological or educational intervention. In a previous paper<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> from the same research group as the present paper, anxiety and depression after ACS were significantly reduced and illness cognition improved significantly after a brief psychological intervention, and these changes were maintained or enhanced at one- and two-month follow-up.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally, although it is well known that education to improve knowledge of disease, health promotion, risk factor control and lifestyle changes is essential for CV patients, some issues deserve special consideration.</p><p id="par0080" class="elsevierStylePara elsevierViewall">What are the real importance and clinical implications of Fernandes et al.’s study?</p><p id="par0085" class="elsevierStylePara elsevierViewall">(1) The paper calls attention to the need to conduct a larger trial examining in-hospital education, in which patients should be randomized by gender, age and educational level, in order to test different forms of communicating information and effective ways of educating patients to obtain the best outcomes. There is a gap in the evidence, and we still need to determine which interventions are most effective in specific groups, such as young/old, male/female, high/low socioeconomic status, and high/low educational level. Interactions between caregiver and patient should always follow the principles of patient-centered communication.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17,26,27</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">(2) There is evidence that more extensive and/or longer interventions lead to better long-term results in terms of behavioural change and prognosis,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> so education should continue through phase II (outpatient) CR, which we know is frequently not attended. Results from EUROASPIRE IV<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> and V<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> show that patients hospitalized for CAD only attend CR programs in one half and one third of cases, respectively. An in-hospital intervention enables patients who will not attend a phase II CR program to receive an educational intervention which may increase phase II CR referral and uptake.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> Lifestyle changes may begin earlier.</p><p id="par0095" class="elsevierStylePara elsevierViewall">(3) Considering the importance of phase I CR and an initial psychological intervention, psychologists and nurses need to be specifically involved in this task, which should be included within the scope of the multidisciplinary CR team. At the least, a brief psychological intervention, which had a beneficial effect in this study, can be administered, and at the same time psychologists should identify depression, anxiety and other psychological problems associated with CAD and refer these patients for psychiatric intervention.</p><p id="par0100" class="elsevierStylePara elsevierViewall">(4) To widen the scope of this psychological and educational intervention, e-health education can be developed, which is likely to reach more patients, particularly younger and better-educated groups. Tele-education could continue the initial brief in-hospital intervention, enhancing its results and prolonging their effects over time.</p><p id="par0105" class="elsevierStylePara elsevierViewall">To conclude, I would say that a brief in-hospital psychological intervention in the context of CR following ACS must be better than no intervention at all.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The author has 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 "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient education in the management of coronary heart disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.P.R. 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| 2021 May | 30 | 41 | 71 |
| 2021 April | 104 | 34 | 138 |
| 2021 March | 46 | 28 | 74 |
| 2021 February | 32 | 16 | 48 |
| 2021 January | 56 | 16 | 72 |
| 2020 December | 32 | 9 | 41 |
| 2020 November | 32 | 20 | 52 |
| 2020 October | 20 | 9 | 29 |
| 2020 September | 21 | 12 | 33 |
| 2020 August | 22 | 11 | 33 |
| 2020 July | 20 | 12 | 32 |
| 2020 June | 20 | 21 | 41 |
| 2020 May | 37 | 8 | 45 |
| 2020 April | 23 | 9 | 32 |
| 2020 March | 28 | 15 | 43 |
| 2020 February | 60 | 23 | 83 |
| 2020 January | 26 | 10 | 36 |
| 2019 December | 30 | 6 | 36 |
| 2019 November | 24 | 11 | 35 |
| 2019 October | 37 | 21 | 58 |
| 2019 September | 21 | 30 | 51 |
| 2019 August | 31 | 11 | 42 |
| 2019 July | 23 | 24 | 47 |
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