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plan lifestyle changes&#44; and to ensure that the patient is referred to the most suitable center for phase II of the CR program&#46;<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&#44; who otherwise would not undergo any intervention&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Experiencing a major life event&#44; such as going into hospital&#44; has been identified as a catalyst for initiation of healthy behaviours and thus an ideal opportunity for intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> The effect of an in-hospital intervention may depend on the individual patient&#39;s characteristics&#44; including age&#44; literacy&#44; motivation for change&#44; level of depression and anxiety&#44; and family support&#46; However&#44; such an intervention may be less effective in some patients in the very early stages of hospitalization for ACS&#44; due to the shock resulting from the acute stress of admission&#46; Post-traumatic stress disorder&#44; which occurs in 15-25&#37; of myocardial infarction patients&#44; can cause emotional apathy&#44; lack of interest and memory loss&#44; leading to communication difficulties and amnesia&#46;<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&#46; Patients are stabilized and reassured&#44; knowing they will leave the hospital soon&#46; Nurses can play an important role in this process&#44; communicating the essential information provided by doctors&#46; Psychologists can begin a brief intervention on disease perception and tailored behavioural modification&#44; as demonstrated in Fernandes et al&#46;&#8217;s paper&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> which can be continued and extended in outpatient CR&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients&#8217; health knowledge needs to be put into practice in daily life&#46; It is unclear which is the best approach to lifestyle and behaviour change at an individual level&#46; Interventions designed to change behaviour may fail to achieve the desired results&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">14&#44;15</span></a> and there is little evidence on the impact of health promotion interventions among specific patient groups&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> Many current interventions target only one risk behaviour&#44; failing to meet the needs of patients with multiple vulnerabilities&#44; such as low levels of health literacy&#44; reduced psychological capability and entrenched cultural and social barriers to health&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> Individualized counseling is the basis for motivation and commitment&#46; Recommendations include assisting individuals to understand the relationship between their behaviour and their health&#44; and helping them to assess the barriers to behaviour change&#46; Decision-making should be shared between caregiver and patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;17&#44;18</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Previous to the article by Fernandes et al&#46;&#44;<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&#44; assess the feasibility and acceptability to patients of delivering an intervention in an acute setting&#44; and analyze preliminary changes to lifestyle behaviours and measures of self-reported health&#44; well-being&#44; and perceived control after four weeks&#46; It highlighted the need to personalize interventions to the individual&#39;s needs and circumstances&#44; help people to develop skills to regulate their behaviour&#44; and provide social support for behaviour change plans&#46; The investigators&#44; who used the framework of the &#8216;Behaviour Change Wheel&#8217;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> for the intervention&#44; showed that it was feasible to design and deliver an evidence-informed psychological intervention in a hospital setting&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> Preliminary health gains were shown by self-reported achievement of goals&#46; Addressing lifestyle risk behaviours such as smoking and poor diet is the single most important way to improve health and reduce premature deaths&#46;<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&#44; including management of long-term conditions&#46;<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&#44; these tend not to be prioritized due to competing staff priorities and lack of time and training&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> For this reason&#44; in-hospital interventions need to be short&#44; direct and concise&#46; There are few examples of similar psychological interventions aimed at addressing multiple lifestyle risk behaviours in hospital patient-based interventions&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Several comments can be made regarding the present study&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> One concerns the randomization process&#58; although the differences were not significant&#44; the intervention group included younger and more educated patients&#46; Both intervention and control groups were around 30&#37; female&#44; as usually occurs in trials&#46; Instead of weekly randomization&#44; it would have been more appropriate to perform a stratified randomization&#44; including age&#44; gender and educational level as parameters for stratification&#44; to avoid bias&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The model of intervention used was generic and not specific for gender or age&#46; As admitted by the authors&#44; the fact that men and women present different psychosocial profiles regarding response and adaptation to ACS requires different interventions&#44; as reported in the literature&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> and underlines the importance of gender-specific intervention protocols in CR&#46; Several programs have been proposed that are adapted to age and gender&#44; in order to optimize the results&#44; including adherence&#46; The impact of these two variables and educational level should be further investigated in future studies and taken into account when planning intervention programs&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Certain aspects of the study need to be clarified&#46; Were all patients asymptomatic and stable at the time of intervention within 2-3 days of ACS&#63; How many were in fact anxious or depressed&#63; The guidelines on CV prevention state that treatment of psychosocial risk factors can counteract psychosocial stress&#44; depression and anxiety&#44; thus facilitating behaviour change and improving quality of life and prognosis&#46; Assessment of such risk factors is essential before any psychological or educational intervention&#46; In a previous paper<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> from the same research group as the present paper&#44; anxiety and depression after ACS were significantly reduced and illness cognition improved significantly after a brief psychological intervention&#44; and these changes were maintained or enhanced at one- and two-month follow-up&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally&#44; although it is well known that education to improve knowledge of disease&#44; health promotion&#44; risk factor control and lifestyle changes is essential for CV patients&#44; some issues deserve special consideration&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">What are the real importance and clinical implications of Fernandes et al&#46;&#8217;s study&#63;</p><p id="par0085" class="elsevierStylePara elsevierViewall">&#40;1&#41; The paper calls attention to the need to conduct a larger trial examining in-hospital education&#44; in which patients should be randomized by gender&#44; age and educational level&#44; in order to test different forms of communicating information and effective ways of educating patients to obtain the best outcomes&#46; There is a gap in the evidence&#44; and we still need to determine which interventions are most effective in speci&#64257;c groups&#44; such as young&#47;old&#44; male&#47;female&#44; high&#47;low socioeconomic status&#44; and high&#47;low educational level&#46; Interactions between caregiver and patient should always follow the principles of patient-centered communication&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17&#44;26&#44;27</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">&#40;2&#41; There is evidence that more extensive and&#47;or longer interventions lead to better long-term results in terms of behavioural change and prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> so education should continue through phase II &#40;outpatient&#41; CR&#44; which we know is frequently not attended&#46; 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&#44; respectively&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> Lifestyle changes may begin earlier&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">&#40;3&#41; Considering the importance of phase I CR and an initial psychological intervention&#44; psychologists and nurses need to be specifically involved in this task&#44; which should be included within the scope of the multidisciplinary CR team&#46; At the least&#44; a brief psychological intervention&#44; which had a beneficial effect in this study&#44; can be administered&#44; and at the same time psychologists should identify depression&#44; anxiety and other psychological problems associated with CAD and refer these patients for psychiatric intervention&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">&#40;4&#41; To widen the scope of this psychological and educational intervention&#44; e-health education can be developed&#44; which is likely to reach more patients&#44; particularly younger and better-educated groups&#46; Tele-education could continue the initial brief in-hospital intervention&#44; enhancing its results and prolonging their effects over time&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">To conclude&#44; 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&#46;</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&#46;</p></span></span>"
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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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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Education in health for patients and healthcare providers&#44; including multidisciplinary programs and e-health&#44; is currently a hot topic&#46;</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&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> Nevertheless&#44; further research is needed to determine the best and most cost-effective format for delivery of educational programs&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The article by Fernandes et al&#46; 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 &#40;CV&#41; patients after acute coronary syndrome &#40;ACS&#41; and their perception of disease and treatment&#44; as well as health habits&#44; to improve adherence to lifestyle changes and risk factor control&#46; This subject&#44; which is important due to the pressing need to decrease CV risk after ACS&#44; has been previously studied in the field of cardiac secondary prevention and rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">On the basis of solid evidence&#44; the guidelines recommend comprehensive post-discharge ACS care that covers management of biomedical and lifestyle risk factors&#44; pharmacotherapy&#44; assessment of psychological factors&#44; and assistance in initiating and maintaining behavioural change&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#8211;6</span></a> Educational interventions for CAD patients should be considered an essential part of cardiac rehabilitation &#40;CR&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#8211;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&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> These programs need to take patients&#8217; characteristics into account&#44; and health psychologists are essential for this aspect of the intervention&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As pointed out by Fernandes et al&#46;&#44;<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&#44; risk factors and treatment improve the rehabilitation process following ACS&#46; As well as patients&#8217; view of their own illness affecting physical and psychological aspects of disease&#44; as the authors show&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> other important socioeconomic aspects are also involved&#44; like return to work&#46;<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&#44; plan lifestyle changes&#44; and to ensure that the patient is referred to the most suitable center for phase II of the CR program&#46;<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&#44; who otherwise would not undergo any intervention&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Experiencing a major life event&#44; such as going into hospital&#44; has been identified as a catalyst for initiation of healthy behaviours and thus an ideal opportunity for intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> The effect of an in-hospital intervention may depend on the individual patient&#39;s characteristics&#44; including age&#44; literacy&#44; motivation for change&#44; level of depression and anxiety&#44; and family support&#46; However&#44; such an intervention may be less effective in some patients in the very early stages of hospitalization for ACS&#44; due to the shock resulting from the acute stress of admission&#46; Post-traumatic stress disorder&#44; which occurs in 15-25&#37; of myocardial infarction patients&#44; can cause emotional apathy&#44; lack of interest and memory loss&#44; leading to communication difficulties and amnesia&#46;<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&#46; Patients are stabilized and reassured&#44; knowing they will leave the hospital soon&#46; Nurses can play an important role in this process&#44; communicating the essential information provided by doctors&#46; Psychologists can begin a brief intervention on disease perception and tailored behavioural modification&#44; as demonstrated in Fernandes et al&#46;&#8217;s paper&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> which can be continued and extended in outpatient CR&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients&#8217; health knowledge needs to be put into practice in daily life&#46; It is unclear which is the best approach to lifestyle and behaviour change at an individual level&#46; Interventions designed to change behaviour may fail to achieve the desired results&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">14&#44;15</span></a> and there is little evidence on the impact of health promotion interventions among specific patient groups&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> Many current interventions target only one risk behaviour&#44; failing to meet the needs of patients with multiple vulnerabilities&#44; such as low levels of health literacy&#44; reduced psychological capability and entrenched cultural and social barriers to health&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> Individualized counseling is the basis for motivation and commitment&#46; Recommendations include assisting individuals to understand the relationship between their behaviour and their health&#44; and helping them to assess the barriers to behaviour change&#46; Decision-making should be shared between caregiver and patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;17&#44;18</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Previous to the article by Fernandes et al&#46;&#44;<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&#44; assess the feasibility and acceptability to patients of delivering an intervention in an acute setting&#44; and analyze preliminary changes to lifestyle behaviours and measures of self-reported health&#44; well-being&#44; and perceived control after four weeks&#46; It highlighted the need to personalize interventions to the individual&#39;s needs and circumstances&#44; help people to develop skills to regulate their behaviour&#44; and provide social support for behaviour change plans&#46; The investigators&#44; who used the framework of the &#8216;Behaviour Change Wheel&#8217;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> for the intervention&#44; showed that it was feasible to design and deliver an evidence-informed psychological intervention in a hospital setting&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> Preliminary health gains were shown by self-reported achievement of goals&#46; Addressing lifestyle risk behaviours such as smoking and poor diet is the single most important way to improve health and reduce premature deaths&#46;<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&#44; including management of long-term conditions&#46;<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&#44; these tend not to be prioritized due to competing staff priorities and lack of time and training&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> For this reason&#44; in-hospital interventions need to be short&#44; direct and concise&#46; There are few examples of similar psychological interventions aimed at addressing multiple lifestyle risk behaviours in hospital patient-based interventions&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Several comments can be made regarding the present study&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> One concerns the randomization process&#58; although the differences were not significant&#44; the intervention group included younger and more educated patients&#46; Both intervention and control groups were around 30&#37; female&#44; as usually occurs in trials&#46; Instead of weekly randomization&#44; it would have been more appropriate to perform a stratified randomization&#44; including age&#44; gender and educational level as parameters for stratification&#44; to avoid bias&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The model of intervention used was generic and not specific for gender or age&#46; As admitted by the authors&#44; the fact that men and women present different psychosocial profiles regarding response and adaptation to ACS requires different interventions&#44; as reported in the literature&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> and underlines the importance of gender-specific intervention protocols in CR&#46; Several programs have been proposed that are adapted to age and gender&#44; in order to optimize the results&#44; including adherence&#46; The impact of these two variables and educational level should be further investigated in future studies and taken into account when planning intervention programs&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Certain aspects of the study need to be clarified&#46; Were all patients asymptomatic and stable at the time of intervention within 2-3 days of ACS&#63; How many were in fact anxious or depressed&#63; The guidelines on CV prevention state that treatment of psychosocial risk factors can counteract psychosocial stress&#44; depression and anxiety&#44; thus facilitating behaviour change and improving quality of life and prognosis&#46; Assessment of such risk factors is essential before any psychological or educational intervention&#46; In a previous paper<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> from the same research group as the present paper&#44; anxiety and depression after ACS were significantly reduced and illness cognition improved significantly after a brief psychological intervention&#44; and these changes were maintained or enhanced at one- and two-month follow-up&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally&#44; although it is well known that education to improve knowledge of disease&#44; health promotion&#44; risk factor control and lifestyle changes is essential for CV patients&#44; some issues deserve special consideration&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">What are the real importance and clinical implications of Fernandes et al&#46;&#8217;s study&#63;</p><p id="par0085" class="elsevierStylePara elsevierViewall">&#40;1&#41; The paper calls attention to the need to conduct a larger trial examining in-hospital education&#44; in which patients should be randomized by gender&#44; age and educational level&#44; in order to test different forms of communicating information and effective ways of educating patients to obtain the best outcomes&#46; There is a gap in the evidence&#44; and we still need to determine which interventions are most effective in speci&#64257;c groups&#44; such as young&#47;old&#44; male&#47;female&#44; high&#47;low socioeconomic status&#44; and high&#47;low educational level&#46; Interactions between caregiver and patient should always follow the principles of patient-centered communication&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17&#44;26&#44;27</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">&#40;2&#41; There is evidence that more extensive and&#47;or longer interventions lead to better long-term results in terms of behavioural change and prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> so education should continue through phase II &#40;outpatient&#41; CR&#44; which we know is frequently not attended&#46; 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&#44; respectively&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> Lifestyle changes may begin earlier&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">&#40;3&#41; Considering the importance of phase I CR and an initial psychological intervention&#44; psychologists and nurses need to be specifically involved in this task&#44; which should be included within the scope of the multidisciplinary CR team&#46; At the least&#44; a brief psychological intervention&#44; which had a beneficial effect in this study&#44; can be administered&#44; and at the same time psychologists should identify depression&#44; anxiety and other psychological problems associated with CAD and refer these patients for psychiatric intervention&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">&#40;4&#41; To widen the scope of this psychological and educational intervention&#44; e-health education can be developed&#44; which is likely to reach more patients&#44; particularly younger and better-educated groups&#46; Tele-education could continue the initial brief in-hospital intervention&#44; enhancing its results and prolonging their effects over time&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">To conclude&#44; 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&#46;</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&#46;</p></span></span>"
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ISSN: 08702551
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