As realization grows of the influence of psychological and behavioral factors on recovery from acute coronary syndrome (ACS), most current cardiac rehabilitation programs emphasize education about the disease and treatment as a way to improve treatment adherence and psychosocial adjustment.1–6

For recovery from ACS, psychoeducational interventions focus on education about disease and health while supporting the adoption of lifestyles appropriate to the needs of cardiac rehabilitation, optimization of risk factor control, and maintenance of protective factors.5,7-9 This approach emphasizes not only the active role that patients can play in their own recovery, but also the importance of a scientific approach to planning interventions designed to promote behavior changes that take into consideration an educational component throughout the rehabilitation process after ACS.2,10-12 Thus, key behavior changes include those affecting motivation, knowledge, the psychological and physical ability to perform the behavior, and the opportunity to perform it. Intervention strategies involving motivation should ensure that individuals have access to easily understandable information.13–17

It is well documented that education and promotion of knowledge about disease, risk factors and treatment during hospital stay have positive effects on the rehabilitation process after ACS and decrease cardiac vulnerability. Eshah et al.18 evaluated the effectiveness of a program of education, counseling and behavioral skills on knowledge, attitudes and beliefs about ACS and adoption of healthy lifestyles. The intervention group showed significantly better cardiac-related knowledge, and better scores for attitudes, health responsibility, nutritional behaviors, interpersonal relationships and adoption of healthy lifestyles. In the HUNT-2 study, the prevalence of low educational level was higher among those who developed acute myocardial infarction during the follow-up period.19 A study by Caspar-Bauguil et al.20 confirmed the positive impact of counseling and education about diet and lifestyle, conducted after ACS, on long-term outcome (one-year follow-up).

In summary, the results from clinical studies in this field are unanimous in emphasizing the importance of psychoeducation about the disease in cardiac rehabilitation after ACS, as well as identifying the period of hospital stay as a key time for effective preventive psychological intervention.2,5,21-24 The above findings highlight the importance of promoting planned interventions at the time of admission which provide education on cardiovascular risk factors, treatment and cardiac rehabilitation. The effectiveness of health education in cardiac rehabilitation can be enhanced if information is provided in the context of a planned and theoretically grounded intervention.2,5,11-17

Tables 1 and 2 present the sociodemographic and clinical characteristics of the study 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 disease knowledge (Table 3), with higher levels in the CG (5.66±3.40 vs. 4.78±4.02) (F=5.030; p=0.027), although this difference was controlled for in hypothesis testing. The groups were similar regarding health habits (Table 3), with a mean of 3.63 for risk behavior in the EG and 3.7 in the CG (F=1.17, p=0.281).

Our results demonstrate the short- and medium-term effectiveness of the intervention program developed and assessed in this study, indicating a positive effect on important aspects of rehabilitation after ACS, such as increase in knowledge about the disease and treatment, and improvement in health habits. These results are clinically significant and have important implications for the literature on the planning and assessment of the effectiveness of psychological interventions in cardiac rehabilitation. As stated above, education and the promotion of knowledge regarding the disease, risk factors, and treatment are pivotal to the quality of the process of cardiac rehabilitation.5,8,17 In our study, the provision of information about the disease, conducted in the context of the intervention program, was associated with improvements in health habits and lifestyles. Similarly to other studies in this area,2,19,24 our results illustrate the usefulness of a scientific approach in planning interventions that promote behavior change and the importance of the educational component throughout the rehabilitation process after ACS.

The level of knowledge regarding the disease and treatment increased significantly in the EG from pre- to post-test, but not in the CG, in whom there was no significant change. This result is particularly striking because the EG had a lower level of knowledge about the disease and treatment (e.g. knowledge about the symptoms and consequences of the disease) at pre-test than the CG. This significant increase in the level of knowledge in the EG thus confirms the importance of education about the disease, treatment and rehabilitation in terms of the effectiveness of psychological intervention in this area.

As predicted, there was an increase in health-promoting behaviors and a decrease in risk behaviors from pre- to post-test in the EG. These positive changes were not found in the CG. Regarding health habits, statistically significant differences were recorded between the two groups from pre- to post-test, with improvements for the EG: over time (between hospital admission and two months after discharge), the EG significantly decreased risk behaviors, such as consumption of fats and salt, and increased positive habits such as regular exercise and blood pressure monitoring. The intervention thus had a positive effect on three important areas of cardiac rehabilitation: nutrition (decreased consumption of fats and salt), physical activity (significant increase in regular exercise) and adherence to preventive therapeutic measures (increased frequency of blood pressure measurement). The detrimental effects of high cholesterol and salt intake and hypertension on the severity of coronary atherosclerosis are well known.27,28 At the same time, exercise is essential for cardiovascular health and physical rehabilitation after ACS, which is why it is a key target of current cardiac rehabilitation programs.15,21,28

In our study, there was a slight difference in age at pre-test, with the EG being slightly younger than the CG (p=0.56), which may have impacted our results. Younger age is considered to be one of the strongest predictors of drop-out from cardiac rehabilitation programs,12,29 and models which combine education and intervention are needed to promote motivation and adherence in these patients. Longer psychological intervention programs after hospital discharge, which combine education on the disease and cognitive-behavioral intervention, might be a good alternative, as suggested in a previous study by our group.30 In the present study, the randomization process did not include age or gender, and we chose a generic model of intervention (not specific for gender or age). The fact that men and women present different psychosocial profiles regarding response and adaptation to ACS, and therefore require different interventions, has been reported in the literature,26 and highlights the importance of gender-specific intervention protocols in cardiac rehabilitation regarding emotional and behavioral aspects. There has also been reference to the impact of age in post-ACS rehabilitation, with older women having a worse psychosocial profile. Therefore, taking into consideration the importance of variables such as age and gender in psychosocial outcomes, the impact of age should be further investigated in future studies and taken into account when planning intervention programs.

It is important to put these gains into context with those that were observed in emotional state and disease cognition in our earlier study,22 particularly the significant decrease in anxiety levels and depression that the EG revealed from hospital admission to the post-intervention time point, as well as the acquisition of more adaptive disease cognition. These gains were not seen in the CG, which highlights the effectiveness of the psychological intervention program tested. In light of this, the biopsychosocial intervention we performed appears to have had a synergistic effect involving several psychosocial dimensions associated with rehabilitation, which supports the use of multifaceted approaches in this type of intervention.

In recent years we have investigated the effectiveness of various modalities of psychological intervention in cardiac rehabilitation.30–32 In our experience, the hospitalization period provides a unique opportunity for effective intervention regarding both psychosocial prevention and education.33 Other authors have reported that brief educational interventions during the hospitalization period are effective in improving adherence to healthy behaviors15 and improving disease perceptions.34,35 The fact that patients are close to the acute event, are in a controlled environment where the intervention is available, and have the free time to participate, provides a window of opportunity for intervention. In our study, as well as positive results in disease perceptions, the EG showed increased knowledge about disease and treatment, less anxiety and depression over time, and positive changes in health habits and lifestyle at two months after the intervention. The post-discharge session may have had an important role in relapse prevention and competence reinforcement.

In conclusion, the intervention we used appears to have promoted a profile of adjustment over time, helping patients in the EG to deal more appropriately with the implications of the rehabilitation process. By contrast, patients in the CG experienced a significant decrease in their level of knowledge and cardiovascular health-promoting behaviors over time. In addition, the results of our study support the idea that the hospitalization period provides a unique opportunity for preventive psychosocial intervention and that psychological factors at this stage can play a key role in the rehabilitation process. The study's results are particularly interesting considering that the intervention administered was brief (of less than three hours duration) with a low associated cost. The follow-up plan for the present study includes a medium- and long-term follow-up (up to one year) to investigate whether the positive results are consistent and sustained in the long term. However, in our opinion, the results obtained so far clearly indicate the benefits of integrating a psychological intervention in phase I of hospital cardiac rehabilitation programs.

All procedures in this study were in accordance with the standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

The authors have no conflicts of interest to declare.