Cardiovascular disease (CVD), particularly acute coronary syndrome (ACS), is an important cause of mortality in developed countries and is responsible for a large number of hospital admissions, as well as for significant personal and financial costs.1 Cardiac rehabilitation (CR) programs reduce cardiovascular mortality, all-cause mortality and non-fatal ACS and facilitate physical and psychological recovery following acute events.2–5 Furthermore, CR significantly reduces the associated burden on healthcare by maximizing physical, psychological and social functioning and promoting behaviors that reduce or prevent the recurrence of acute events.5,6 Despite the plentiful evidence supporting the effectiveness of CR, studies show that there is low adherence to these programs,7–9 with participation rates varying from 21 to 75%.6,10,11 Two surveys in European countries concluded that less than half of eligible patients participate in CR programs in most countries.10,11

The negative impact of ACS on patients’ psychological functioning has been linked to a lower adherence to therapy and consequently to greater cardiac vulnerability, constituting a higher risk for the recurrence of an acute event.12,13 Multidisciplinary programs that include a psychological component appear to be highly effective and have shown significant benefits in post-ACS morbidity and mortality.14–16 Various clinical trials assessing the effectiveness of such programs have supported the provision of biopsychosocial care in hospital-based cardiac rehabilitation.17,18

In Portugal, research in this area is still scarce and clinical trials on psychological intervention in CR are practically non-existent. This study aims to assess the effectiveness of a brief multidisciplinary psycho-educational intervention in hospitalized ACS patients targeting various psychosocial and behavioral outcomes.

Tables 2 and 3 present the sociodemographic and clinical characteristics of the sample. The groups were equivalent in most sociodemographic variables and all clinical variables, with only a marginally significant difference found for age, the CG being slightly older (66.1±12.6 vs. 61.8±12.1 years).

The EG and CG differed at pre-test in most of the psychosocial outcomes (Table 4), although these pre-test differences were controlled for in testing the hypotheses. The CG had lower levels of anxiety (9.34±4.03 vs. 12.45±3.73) and depression (9.61±4.49 vs. 12.80±4.05). Regarding illness cognitions at pre-test, the EG had more negative perceptions of their illness for the personal control, identity, comprehensibility and emotions sub-scales of the BIPQ.

This study aimed to test the efficacy of a brief in-hospital psychosocial intervention directed at improving emotional and cognitive outcomes for patients with ACS. The results demonstrate significant benefits for the EG in terms of less anxiety and depression and more positive illness representations after the intervention, in comparison to the CG, who received standard medical care. These results are even more significant given the fact that the EG had a less favorable psychosocial profile at pre-test than the CG. These results were independent of patients’ age and baseline scores on the psychosocial variables studied. The advantages of the intervention for the EG were particularly noticeable at two months post-discharge, suggesting that the effects of the intervention lasted into the rehabilitation period, counteracting the psychosocial deterioration that was observed in the CG.

The positive impact of this intervention in terms of depressive symptoms is important bearing in mind the predictive effect of depression on cardiovascular mortality after ACS.21,22 The intervention program sought to prevent the increase in both anxiety and depression associated with post-ACS rehabilitation, not only by promoting education about ACS and its treatment but also by increasing psychosocial skills (adaptive cognitive and cognitive-behavioral coping strategies) used to reduce the negative psychological impact of the acute event. Implementation of behavioral and cognitive coping strategies to deal with emotional difficulties associated with a cardiac event is an active component of many multimodal psychological intervention programs, and is believed to be a factor directly related to reducing the recurrence of ACS.23,24

Our results also support the effectiveness of the intervention program in changing disease cognitions. Patients in the EG had more positive illness representations after the intervention, and had perception of greater personal control and a greater understanding of the meaning of their disease. Indeed, one of the main aspects of the intervention program was education regarding disease cognitions, providing information that could correct beliefs and help patients become more active participants in the process of illness and treatment. The positive results in terms of increased understanding of the disease are in agreement with those obtained in other studies, which report a positive effect of a brief hospital intervention at this level.16 From the standpoint of decreased cardiac vulnerability, the significant increase in understanding of the disease is also important, since there are indications of an association between good understanding of the disease and increase in therapeutic adherence.9 Increased perception of personal control also has important clinical implications, as several studies have shown that a strong sense of control in coronary patients is an important predictor of improved emotional state25 and quality of life in the context of CR after ACS.26

Research into the factors predicting a lack of adherence to CR has pointed to the importance of psychosocial aspects, such as patients’ illness cognitions and emotional state.27 De Vos et al.6 investigated patient compliance with CR and reasons for refusing or abandoning programs, finding that the main reasons for not completing CR programs were other physical problems, patients’ belief that they could handle their own problems, and the cost of rehabilitation. The literature suggests that patients’ emotional state (e.g. anxiety and depression) and illness representations need to be assessed early on as a way of optimizing adherence to and benefits of CRP, promoting better psychosocial adaptation in the post-ACS period.5,28–30. Patients’ beliefs about their illness and treatment have been found to predict clinical and psychological outcomes post-discharge.14 There is evidence that the perception that one can have some control over the course of illness, as well as belief in treatment success, are determining factors in recovery.31

This study presents evidence that a brief psychosocial intervention undertaken during hospitalization presents considerable benefits in improving psychological morbidity and adaptation to post-ACS rehabilitation. The intervention administered is of low financial cost, carries low patient and professional burden (less than three hours in total duration), and can be easily implemented in routine healthcare. This type of intervention can be particularly useful in countries such as Portugal that have fewer medical and economic resources.

The most favorable time for psychological intervention, in terms of effectiveness, is at hospitalization, when patients are most accessible to this type of intervention and to lifestyle changes. This has been confirmed by international studies and trials evaluating the efficacy of psychological intervention in post-ACS rehabilitation16,31 and also by our previous study that evaluated the effectiveness of a psychological intervention program in phase II of cardiac rehabilitation.20,32 The fact that patients are close in time to the acute coronary event, are in a supportive environment, and are physically present and have time available for participation in the intervention, creates a window of opportunity that our intervention appears to have optimized. A psychological approach during hospitalization is essential to identify and assess the representations of disease and the patient's emotional state, which significantly influence the quality of the post-ACS rehabilitation process.

The current study has some limitations. We did not assess whether the positive gains in psychosocial adjustment in the EG translated into better cardiac function and physical health than in the CG. However, it is generally accepted that psychosocial maladjustment (particularly anxiety and depression or depressive symptoms) are independent factors of worse prognosis in post-ACS patients,33–37 involving neuroendocrine and inflammatory mechanisms as well as behavioral factors.38 Furthermore, a longer follow-up would establish whether these positive effects in adjustment persist over a longer period of time. It is important to replicate this intervention study in other hospital-based coronary care units and to include longer follow-up periods and a more diverse array of outcomes, both clinical (e.g. recurrence of ACS) and behavioral (e.g. lifestyle changes).

Despite these limitation, our results highlight the positive impact of a brief psychological intervention in phase I of a CR program, targeting recognized psychological risk factors for ACS rehabilitation and ultimately for cardiac prognosis.

The authors have no conflicts of interest to declare.