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Keywords:

  • acute myocardial infarction;
  • counselling;
  • education;
  • functional capacity;
  • six-minute walk test

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions and Recommendations
  8. Acknowledgements
  9. References

The present study aims to determine the effects of individual education and counselling given to first-time myocardial infarction patients, including its effect on compliance with treatment. The sample comprised 90 patients, 45 in the intervention and 45 in the control group, selected by sequential sampling from first-time myocardial infarction patients. Data were collected between April and November 2008 by means of patient information form, International Physical Activity Questionnaire, 6 min walk test, Modified Borg Scale, Morisky Medication Adherence Scale and Canadian Cardiovascular Society Angina Grade Classification. In the intervention group more improvement was observed in comparison with the control group in terms of frequency of physical activity, body mass index and waist circumference. It was observed that the intervention group's metabolic equivalent of task values and 6 min walk test distance increased more in comparison with the control group 3 months after baseline, and there was a statistically significant difference. The results indicated that individual education and counselling provided to patients having experienced acute myocardial infarction increased functional capacity by providing patients with advice on how to lose weight and by improving compliance with treatment through physical activity behaviours (frequency and duration).


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions and Recommendations
  8. Acknowledgements
  9. References

Today, health education, which is a significant component of illness management, is the most effective method used for enabling individuals with medical problems to return to their normal activities and for improving life quality, increasing functional capacity and decreasing disability.[1] Providing education and counselling in order to decrease psychological and physiological problems and increase physical activity capacity and life quality alongside medical treatment is the most important thing to do after myocardial infarction (MI).[2, 3]

Implementation of a well-planned and timely education and counselling programme suitable for the acute myocardial infarction (AMI) patient's needs before discharge[4, 5] is significant for increasing the effectiveness of education as well as decreasing the length of stay in hospital and reducing the risk of rehospitalization due to recurring ischemia.[6-8] In order to increase compliance, patient education planned on the basis of the individual's needs, self-monitoring, follow-up by phone and provision of social support are significant.[9]

Therefore, the present study aims to determine the effects of individual education and counselling given to first-time AMI patients, including its effect on compliance with treatment.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions and Recommendations
  8. Acknowledgements
  9. References

Sample and selection

The research was conducted between April and November 2008 in the cardiology inpatient units of two hospitals.

We hypothesized that implementation of the individual education and counselling programme for MI patients would (i) increase patients’ physical activity capacity [6 min walk test (6MWT) and metabolic equivalents of task (MET) scores]; (ii) decrease cardiovascular risk factors by reducing body mass index and waist circumference and discouraging an inactive lifestyle; and (iii) improve medication adherence.

The sample consisted of patients who received treatment in the programme between the fifth and seventh days post-MI, were 70 years old at most, and did not have chest pain or heavy morbidity at a level that might prevent participation in the study. On the other hand, patients were excluded from the study if they had had an AMI previously, had participated in cardiac education and consultancy programmes before, had chest pain and dyspnoea, or required bypass after the intervention.[10-15]

The sample size was calculated as 90 patients on the basis of the number of patients who were hospitalized because of MI in these units in the past year (n = 450) (data at 95% confidence interval and analysis at 80% power). During the study period, the patients who met the inclusion criteria were enrolled in the study until the targeted sample size was reached. The patients were grouped into two by means of sequential sampling, so that 45 patients formed the intervention group and 45 patients formed the control group. Patients meeting the inclusion criteria were informed about the study and those who agreed to participate were included in the study until the target sample size was reached (Fig. 1).

figure

Figure 1. Study design.

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Measurement

The 7-day short form of the International Physical Activity Questionnaire (IPAQ) was used in order to evaluate MI patients’ physical activity level capacities within the last 7 days prior to discharge and 3 months post-discharge.[16, 17] Patients’ physical activity level was classified in one of three categories (low, medium and high) based on total weekly MET scores as appropriate according to the IPAQ guidelines for data processing and analysis.[16] Those who did not carry out the physical activities assessed by the IPAQ were evaluated as inactive.[16, 17]

The 6MWT and Modified Borg Scale were used in order to evaluate patients’ physical activity capacities.[10, 11, 13, 18, 19] Submaximal exercise tests can be applied safely on the fourth to seventh day post-MI.[20] Enright and Sherrill[21] determined the reference value for the 6MWT as 350 m.[18, 21] The test lasted 6 min, with the patients walking according to the American Thoracic Society (ATS) protocol published in 2002.[14] Prior to the test, patients were informed about the application of the test and the walking area. At the end of the 6 min, the total distance walked by the patients was measured.[10-14] The patients’ level of tiredness and tidal volume were monitored via the Modified Borg Scale in line with ATS protocol, and the pulse, oxygen saturation values and blood pressures were monitored by means of a pulse oximeter. The ATS test protocol recommends ending the test if there is any abnormality in oxygen saturation, blood pressure or pulse. The criteria for early ending were not detected in any of the patients.[10-12, 18]

The Morisky Medication Adherence Scale was used for measuring patients’ compliance with drug treatment. The scale was devised by Morisky et al.[22] The scale scores vary between 1 and 13 points. Those individuals who had scores of 1–7 were defined as compliant with treatment, whereas those who had 8 and over were classified as non-compliant with treatment.[22-24] For this reason, the patients’ baseline evaluations were done on the basis of the 90 patients as total. As for the third-month evaluations, they were done on the basis of 45 patients for each group.

The Canadian Cardiovascular Society Angina Grade Classification (CCSC)[25-27] was used in both the first session and in the session that took place 3 months later in order to classify participants’ angina level. In the present study, the revised version, in which a Class 0 is added to the original classification ranging between Classes 1 and 4, was adopted.[28] Class 0 equates to the absence of pain, whereas Classes 1 to 4 indicate increasingly greater angina volume. The CCSC was adopted for the present study because it determines the level of angina, which is a significant criterion for whether the patient can perform the walking test. In this study, patients whose angina level was Class 4 were not administered the walking test.

Patients’ height, weight and waist circumference were measured.

Education and counselling programme

An individual education and counselling programme was developed for the study on the basis of researchers’ clinical experiences and the relevant literature.[29-33] Visual materials were prepared to be used in education: a Desktop education and counselling guide for post-myocardial infarction patients, as well as brochures on returning to healthy life following MI (nine brochures). The content of the education programme was planned according to patients’ needs. Individualized education plans included information on MI, medication, stress management, the effects of smoking and alcohol consumption, blood pressure control/hypertension management, the importance of physical activity, weight control, healthy eating and the importance of diabetes control. The content of each subject was devised considering each patient individually. Education sessions, which lasted approximately 1 h, were delivered. Furthermore, a home education kit comprising nine brochures on returning to healthy life following MI was prepared for the intervention and control group participants and distributed to all patients.

Study process

Two interviews were conducted with the patients in the intervention (n = 45) and control (n = 45) groups in the clinic prior to discharge and 3 months after discharge. All of the patients in the intervention group were individually trained between the fifth and seventh days before discharge for an hour in accordance with the content of the Desktop education and counselling guide for post-myocardial infarction patients. In the fourth and eighth weeks following discharge, telephone counselling was conducted with the patients in this group twice. In these phone interviews, information on measures for decreasing cardiovascular risks (physical activity, quitting smoking and preventing passive smoking, decreasing and controlling blood pressure, compliance with drug treatment) was given and patients’ questions were answered. All of the patients in both groups completed the study, and all answered questionnaires and took the 6MWT 3 months post-discharge. Patients in the control group were not provided with telephone counselling and education. Figure 1 shows the study design. Patients in both groups received treatment according to hospital treatment protocol without any change for this study.

Ethical considerations

Ethical consent was obtained from the institutions involved. Patients invited to participate in the research were informed of the study aims and expectations in accordance with the Helsinki Declaration. Those whose oral consent for participation was obtained were included in the study. In addition, in order to use the questionnaires, the consent of their developers/authors was obtained. Similarly, the consent of each patient's specialist physician was obtained before administration of the 6MWT.

Statistical analysis

In data assessment, the spss program was used. Data related to cases’ descriptive features and to measurements are shown as frequency, percentage and mean ± SD. The χ2 test was employed in the comparison of the two groups’ sociodemographic features. For statistical analysis, the paired Student's t-test was used for comparing baseline and third-month results in intervention and control groups, The Mann-Whitney U-test was used in order to compare mean differences before and after education. The results were evaluated at 95% confidence and 0.05 significance level.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions and Recommendations
  8. Acknowledgements
  9. References

Of the participants, 77.8% (n = 70) were male. The majority were aged 45–54 (46.7%), 55–64 (16.7%) or 65–70 (28.9%). No significant difference was found between the intervention and control groups in terms of sex, age, occupation or educational level (P > 0.05) (Table 1).

Table 1. Sociodemographic features (n = 45 per group)
 InterventionControlTotalχ2P
n%n%n%
Gender        
 Female920.01124.42022.20.250.61
 Male3680.03475.67077.8
Age        
 30–4436.748.977.80.740.86
 45–542351.11942.24246.7
 55–64715.6817.81516.7
 65–701226.71431.12628.9
Employment status        
 Worker613.324.488.95.350.25
 Officer48.9817.81213.3
 Retired1840.01431.13235.6
 Housewife613.31124.41718.9
 Unemployed1124.41022.22123.3
Education        
 Illiterate12.2613.377.85.590.13
 Primary school2248.91431.13640.0
 Secondary/high school1737.82044.43721.1
 University511.1511.11011.1

Medications used by study participants before and after AMI are shown in Table 2.

Table 2. Medication use before and after acute myocardial infarction
MedicationOn medications before AMI*On medication after AMIzP
n%n%
  1. * P < 0.05.  Wilcoxon signed-ranks test. ACE, angiotensin-converting enzyme; AMI, acute myocardial infarction.

Aspirin2831.18998.9−7.810.000*
Plavix8897.8−9.380.000*
ACE inhibitors3033.34853.3−4.020.000*
Beta blockers55.68695.6−9.000.000*
Calcium channel blockers22.2−1.410.15
Diuretics88.9−2.820.005*
Statins1820.08897.8−8.360.000*
Oral antidiabetics1516.71516.70.001.000
Proton pump inhibitors88.91820.0−2.670.008*
Insulin33.355.61.410.15

The average duration of phone counselling was 7.44 ± 2.52 min on the first call and 5.33 ± 1.26 min on the second call. On the first phone call, patients frequently asked questions about healthy eating and weight control (64.4%, n = 20), physical activity recommendations (35.6%, n = 16), smoking cessation and passive smoking (33.3%, n = 15), lowering blood pressure and keeping it under control (33.3%, n = 15), blood glucose control (20%, n = 9) and medication (20%, n = 9). On the second phone counselling session, patients frequently asked about healthy eating and weight control (20%, n = 9), physical activity recommendations (20%, n = 9), smoking cessation and passive smoking (17.8%, n = 8) and medication (13.3%, n = 6).

The findings related to effect of education on capacity for physical activity, CCSC score and adherence are shown in Table 3. There was no difference between the baseline results of intervention and control groups for any of the parameters (MET: t(88) = −0.612, P = 0.542; Morisky: t(60) = 0.585, P = 0.561; CCSC: t(88) = 0.769, P = 0.444; frequency of physical activity (times/week): t(88) = 1.587, P = 0.116; physical activity time (hours spent in each activity): t(88) = 0.569, P = 0.571). Frequency of physical activity improved 3 months later in both intervention and control groups (P < 0.001, P = 0.001). There was no significant improvement in the intervention group in comparison with the control group (mean differences P = 0.09). Considering physical activity time, over the 3-month period, both groups improved at similar levels and there was not much difference between the intervention and control groups (mean differences P = 0.99) (Table 3). It was found that the MET values for the intervention group (4734.4 ± 6526.4) and the control group (3263.1 ± 4205.1) were similar at baseline and three months later (mean differences P = 0.06) (Table 3). By the third month, the walking distance of the intervention group at the third month was greater than that of the control group (302.6 ± 73.3 m) and had increased (357.0 ± 66.2 m) in comparison with the pre-education period (276.4 ± 60.0 m). There was improvement in the control group's walking distance over the 3 months; however, this improvement was less than that of the intervention group (mean differences P = 0.000) (Table 3).

Table 3. The effect of education on capacity for physical activity, CCSC class and adherence (n = 45 per group)
 InterventionControlMean differences (P)
BaselineThird monthPBaselineThird monthP
  1. Data are given as mean ± standard deviation.  Comparison of the mean differences in the intervention and control group (the group which did not receive training); hypothesis: difference in the intervention group will be higher than that in the control group.  Paired–samples t-test. § Mann–Whitney U-test.  Wilcoxon signed-rank tests. 6MWT, six-minute walking test; CCSC, Canada Cardiovascular Society Angina Grade Classification; MET, metabolic equivalents of task (walking + moderate-intensity activity + vigorous activity); MMAS, Morisky Medication Adherence Scale.

Frequency of physical activity (times/week)0.5 ± 0.81.2 ± 0.70.0000.3 ± 0.60.8 ± 0.70.0010.09
Physical activity time (hours spent in each activity)0.5 ± 0.70.6 ± 0.50.060.4 ± 0.60.7 ± 0.50.130.99
MET4833.1 ± 9102.84734.4 ± 6526.40.0536330.1 ± 13640.73263.1 ± 4205.10.830.065§
6MWT distance (m)276.4 ± 60.0357.0 ± 66.20.000256.4 ± 76.5302.6 ± 73.30.0000.000§
MMAS score5.2 ± 2.01.4 ± 1.70.0004.9 ± 2.13.6 ± 2.10.0030.000§
CCSC class2.2 ± 0.40.2 ± 0.40.0002.1 ± 0.30.3 ± 0.40.0000.15§

There were improvements in both groups’ compliance with drug treatment 3 months after baseline. However, the improvement was greater in the intervention group. It was determined that both groups’ mean differences were significant, with the intervention group scoring higher (mean differences P = 0.000) (Table 3). It was determined that in both groups, patients’ mean CCSC class before education was Class 2 or 3, and after education the mean CCSC class regressed to Class 0 (intervention: 0.2 ± 0.4, control: 0.3 ± 0.4). There was no significant improvement in the intervention group in comparison with the control group (mean differences P = 0.15) (Table 3).

It was determined that the decrease in patients’ waist circumference (women: 91.2 ± 10.0; men: 94.8 ± 6.0) was greater in the intervention group in comparison with the control group (women: 91.2 ± 8.6; men: 93.5 ± 7.6), and there was a significant difference between the two groups (mean differences P = 0.000). The intervention group patients improved from highly risky to normal waist circumference. In addition, patients’ body mass index (BMI) values decreased significantly in both groups, although this decrease was significantly higher in the intervention group as compared with the control group (mean differences P = 0.009) (Table 4).

Table 4. The effect of education on waist circumference and body mass index (n = 45 per group)
MeasurementInterventionControlMean differences (P)§
BaselineThird monthPBaselineThird monthP
  1. Data are given as mean ± standard deviation.  Comparison of the mean differences in the intervention and control group (the group which did not receive training); hypothesis: difference in the intervention group will be higher than that in the control group.  Paired–samples t-test. § Mann–Whitney U-test.  Waist circumference classification: risky, 94–102 cm (men), 80–88 cm (women); very risky, > 102 cm (men), > 88 cm (women). †† BMI classification: normal, 18.5–24.9 kg/m2; overweight, 25–29.9 kg/m2, obese, 30–40 kg/m2; morbidly obese, 40 kg/m2 and over (according to Turkish Society of Cardiology and World Health Organization). BMI, body mass index.

Waist circumference (cm)       
 Male98.3 ± 8.394.8 ± 6.00.00095.0 ± 8.793.5 ± 7.60.0030.000§
 Female95.0 ± 12.991.2 ± 10.00.00092.0 ± 10.691.0 ± 8.60.003
 All patients97.7 ± 9.394.0 ± 7.00.00094.3 ± 9.292.9 ± 7.90.003
BMI (kg/m2)††28.4 ± 3.727.5 ± 3.00.00028.0 ± 3.327.5 ± 2.80.0000.009§

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions and Recommendations
  8. Acknowledgements
  9. References

Similarly to many previous studies,[34-38] the majority of the patients in both groups consisted of men (77.8%) (Table 1). In Turkey, women get coronary artery disorder (CAD) less frequently than men (the prevalence in 2000 was only 21%).[32] According to the 2000–2010 data of the Turkish Adult Heart Disease Risk Factors Study, the prevalence of CAD in men is still higher than in women.[33] In line with the literature,[34, 36, 37, 39] the majority of the patients in the present study were in the age groups 45–54 (47.7%) and 65–70 (28.9%) (Table 1).

In Akdur et al.'s[40] study, at the end of the evaluation it was found that most of the pre-AMI patients did not carry out any physical activity, whereas after the education, 50.3% of the AMI patients started walking regularly. In the 2010 report of the World Health Organization, it was emphasized that doing physical activity for at least 30 min each day will help prevent MI.[41] As heavy weight increases MI risk, the importance of regular physical activity and healthy diet should be highlighted in order to maintain ideal body weight.[41] Karim and Gormley[42] stated that rehabilitation programme patients exercised more frequently and longer and had more knowledge about the benefits of exercise. In the present study, it was determined that by the third month after the first evaluation, the duration and frequency of physical activity significantly increased in both intervention and control groups, whereas there was no significant difference between mean differences of control and intervention groups. This might be due to the short duration of follow-up (Table 3).

It was also seen that the intervention patients experienced more improvement in terms of moving from highly risky waist circumference (men: > 102 cm; women: > 88 cm) to risky (male: < 94 cm; women: < 80 cm) and normal (men: < 94 cm; women: < 80 cm) waist circumference measurements in comparison with the control group (mean differences P = 0.000). In addition, it was found that transition from overweight to normal weight could not be maintained over the 3-month period in either group, yet improvement was observed (Table 4). This expected result is in line with the literature; as patients’ physical activity levels increase (Table 3), there is improvement in waist circumference and BMI as well (Table 4).

Jackevicius et al.[43] state that drug counselling has a positive effect, increasing compliance and decreasing mortality. The presence of higher treatment compliance in the intervention group patients (1.4 ± 1.7) in comparison with the control group (3.6 ± 2.1) can be accounted for by the intervention patients’ increased physical activity capacity (Table 3). In a study, patients (n = 392) were given general information on coronary artery disease risk factors and the significance of lifestyle change, and at the end of the 6-month follow-up, 50% of the patients displayed positive reactions to medical treatment.[7] In the present study it was determined that intervention group patients had higher compliance with treatment following the education and counselling (Table 3). Many studies[36-38, 42, 44-46] have demonstrated that education and counselling are necessary in order to maintain and continue patients’ lifestyle changes.

In a similar study, intervention patients’ sixth- and 12th-month functional limitations were found to be much fewer than those of the standard care group (P < 0.01).[47] As for the present study, at the 3-month evaluation, intervention and control groups’ functional limitations were evaluated as CCSC Class 0 at a similar rate. This can be accounted for by the lack of chest pain, due to the positive effects of drug therapy both in the acute phase and over the 3 months post-AMI and the illness improvement process. For both groups in the primary and secondary evaluations, it was determined that patients had no functional limitations that would prevent their taking a walking test (Table 3).

According to a World Health Organization report, 60–85% of adults in the world are not active enough.[48] The American College of Sports Medicine and the American Heart Association recommend intensive activity of at least 20 min 3–5 days each week or medium-level physical activity for at least 30 min each day in order for physical activity to be beneficial.[49-52] In the present study it was observed that MET values of the intervention group patients were much higher than those of the control group, and patients started doing physical activity regularly (Table 3). In the 3–6 month period following MI, patients’ functional capacities and life quality were negatively affected. For this reason, this result shows that education has a positive effect on functional capacities; patients realize the importance of being physically active for increasing functional capacity and that education is effective. In the present study, patients were re-evaluated 3 months after AMI. As stated in the literature,[7] in the 3-month period following AMI, patients’ life quality might decrease, which makes one question whether patients’ functional capacities might be lower in comparison with the pre-illness phase. Therefore, it is thought that the lower MET values after the education might have to do with the illness and treatment process (Table 3).

Change in functional capacity is the key to evaluating a patient's performance.[10, 13, 15, 18, 53] Nogueira et al.[18] also state that the 6MWT can be administered in safety, even in the first week of MI, to stable MI patients without any complications. The AHA recommends that a maximum-effort exercise test be avoided for two weeks after AMI and that submaximal exercise tests be carried out before discharge.[18, 20] In the present study all participants completed the test. As in similar studies,[18, 53] no complications (dyspnoea, pain) were experienced before, during or after the test.

In this study, similarly to Nogueira et al.,[18] at the third-month evaluation after education, the intervention group patients’ walking distances were found to be higher than the reference value (350 m).[21] However, the control group's walking distances were found to be lower than the threshold value (Table 3). In this respect, in order to maintain functional status and improve life quality, necessary interventions should be developed in order to prevent sedentary lifestyle and keep the patient physically active.

Conclusions and Recommendations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions and Recommendations
  8. Acknowledgements
  9. References

Patients admitted to the hospital during the study period showed a remarkably imbalanced ratio between men and women, although the men-to-women ratio among patients who were not involved in the study was balanced. Taken together with previous studies showing that CAD is more frequent in men than in women[18, 53], there is a need to explore this issue in future studies.

The individualized education increased functional capacity by providing patients with advice on how to lose weight and by improving compliance with treatment through physical activity behaviours (frequency and duration). Individualized education and counselling programmes are tools that might be effective for improving patients’ functional states and quality of life and should be administered to AMI patients before discharge. The education programme and materials developed for this study can be used in cardiology services and clinics in the education of AMI patients.

It has been determined that the present study is the second study to examine AMI patients’ functional capacity and administer the 6WMT.[18] Therefore, the obtained data can guide exercise studies in AMI and provide important information as to patients’ functional capacity, response to treatment and prognosis, in addition to guiding future studies.

Limitations

Because of time limitations, the patients could be monitored for only 3 months. In Turkey there have been few studies evaluating AMI patients’ functional status by means of 6MWT and measuring life quality and improvement in functional state after education and counselling. For this reason, future studies should adopt a similar view and monitor MI patients for a longer period (6 months or 1 year). This study examined only a small number of patients, and the subject matter definitely needs more examination and a larger study.

Strengths

The strengths of this study were as follows:

  1. Two groups (intervention and control) were examined.
  2. There was no drop-out.
  3. In the clinics and services where this research was conducted, the support of the health team members facilitated reaching patients and long-term monitoring.
  4. In the 3-month period post-discharge, patients were provided with the opportunity to contact the trainer for counselling.
  5. The audiovisual materials helped make patients and family more willing to participate in the study.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions and Recommendations
  8. Acknowledgements
  9. References

We would like to thank the patients who contributed to the present study with their participation.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions and Recommendations
  8. Acknowledgements
  9. References
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