Long-term effects of nurse-led individualized education on middle-aged patients with acute coronary synrome: a quasi-experimental study

Acute myocardial infarction (AMI) and unstable angina exist on a spectrum of clinical diseases collectively identified as acute coronary syndrome (ACS). The mortality rate for patients with ACS has decreased because of thrombolytic agents and advances in treatments such as surgical reperfusion [1]. In addition, the long-term prognosis has been shown to be excellent in hospital survivors, and the 1-year survival rate is 89.5% [2]. However, 18.4% of patients are at risk of subsequent major adverse cardiac events.

According to the Statistics Office of Korea [3], heart disease was the second leading cause of death in the country in 2015, with 55.6 deaths per 100,000 population, and ischemic heart disease accounted for 55.2% of cardiovascular deaths. The 1-year mortality rate for patients with AMI who had received acute treatment was shown to be 8.3%, and patients with recurrent AMI exhibited an increased risk of death relative to that of those with new-onset AMI [4].

To prevent the occurrence of major adverse cardiac events (MACE), particularly re-stenosis, subsequent interventions should focus on behavioral modification and the reduction of risk factors for cardiovascular disease. Interventions should also strive to secure optimum health-related quality of life (HRQoL) by helping patients to recover their physical, social, and mental function following ACS [5]. Previous studies have shown that patients who adhered to self-care regimens during the acute and recovery stages of ACS reduced their risk of CVD by modifying unhealthy habits and behavior [6]. A previous study involving patients with ACS showed that self-efficacy exerted a direct effect on self-care compliance [7]. Therefore, education programs that focus on the prevention of a second acute coronary event and improvement of lifestyle habits should emphasize the improvement of self-efficacy to comply with self-care regimens and promote healthy behavior.

In Korea, adult patients with ACS aged 65 years or younger tend to exhibit a significantly higher number of lifestyle-related cardiovascular risk factors, including smoking, binge drinking, stress, unhealthy diet, and hyperlipidemia, relative to those observed in older patients [8]. In addition, middle-aged individuals in the most productive age bracket are focused on their careers and become vulnerable to stress and chronic health problems. Nonetheless, the vast majority of people in this age group have been shown to exhibit poor awareness of the seriousness of CVD [8]. A meta-analysis of 18 studies showed that the presence of even a single risk factor in individuals in their 40s or 50s dramatically increased their lifetime risk of CVD, relative to that observed in individuals with no risk factors [9]. According to the Korea Acute Myocardial Infarction Registry Study, 62.4% of 39,978 patients with ACS who were treated between 2005 and 2013 were men, and 46% were current smokers. Smoking has also been shown to be the most frequent cause of AMI in people younger than 65 years of age [10]. Moreover, another study reported that smokers with AMI who received percutaneous coronary intervention (PCI) were younger relative to nonsmokers, whose mean age was 58 years, and the 1-year mortality rate for the smoking group was significantly higher relative to that observed for the nonsmoking group [11]. Therefore, the importance of reducing lifestyle risk factors to prevent secondary attacks should be emphasized for middle-aged patients with new-onset ACS.

As mentioned, ACS is an acute disease that requires consistent education and management to prevent recurrent events and complications. Therefore, patient education should focus on an active patient role in disease management via self-care compliance. We believe that nurses play a key role in providing education regarding certain issues, such as risk factors and signs of MACE, for patients and their caregivers. Furthermore, nurses are well placed to communicate the need to maintain self-care to the clinical team. Practical and effective nursing interventions should be tailored to individuals’ educational needs and aim to reduce cardiovascular risk factors [12]. Yıldız et al. [13] found that strong individualized education provided prior to discharge following cardiac intervention improve quality of life (QoL) and relieved anxiety related to postdischarge self-care practices. Therefore, nurse-led, individualized education could be the most effective strategy for ACS patients with respect to promoting lifestyle modification.

To examine the above-mentioned issues, we provided middle-aged patients with new-onset ACS with nurse-led, individualized education prior to discharge, with the aim of preventing a secondary attack. Specifically, we sought to test the following hypotheses:

In the current study, nurse-led, individualized education was provided for middle-aged patients who had experienced new-onset ACS, prior to discharge. Two follow-up calls were made during the 1-year period following discharge. The results showed that self-efficacy did not differ significantly between the 2 groups during the follow-up period. This finding supports those reported by Taft et al. [21], which showed that cardiac self-efficacy following individualized education did not differ significantly between control and intervention groups. However, some previous studies have reported different results. For example, in one study, self-efficacy exerted the strongest effect on self-care compliance in patients with acute myocardial infarction [22]. These contradictory findings highlight the necessity for future research. In the current study, self-efficacy scores in the intervention and control groups had increased during the first 3 months following discharge and decreased 12 months subsequent to discharge. Although patients reported that they had strong purpose and the will to live because they had acquired information via individualized education following acute treatment, they became less motivated to maintain their health after experiencing little improvement.

The intervention group showed significantly greater differences in self-care compliance at 3- and 12-month follow up relative to that observed in the control group. This finding supports those of a previous study conducted by Uysal and Ozcan [23], which involved a group of AMI patients, of whom 75% and 71% were men and younger than 65 years of age, respectively. In the study, the patients were provided with approximately 1 h of individualized education via a brochure that provided information regarding disease, stress management, lifestyle modification, and diabetes control. As a result, the increase in physical activity and decrease in waist circumference in the intervention group were greater relative to those observed in the control group. Moreover, the findings of the current study are consistent with those of Mok et al.’s study [24], which showed that AMI patients who had received nurse-led, individualized education and counseling and telephone follow up adopted healthier diet habits, such as low-fat and -salt diets, and exhibited greater improvements in high-density lipoprotein cholesterol levels 3 months later. In addition, a systematic review and meta-analysis conducted by Fredericks and Yau [25] showed that individualized education regarding coronary artery disease was effective at improving compliance with a self-care program consisting of a diet regimen, medicine, an exercise regimen, risk factor modification, self-assessment, and reductions in hospital readmissions. Therefore, the results of the current study emphasize the ongoing need for the provision of nurse-led, individualized education prior to discharge, to prevent a secondary attack through lifestyle modification, particularly for middle-aged patients with ACS.

To determine the effects of individualized education on HRQoL, we obtained PCS and MCS scores. The results showed that PCS scores tended to increase with time in both groups and did not differ significantly between the 2 groups. A previous study conducted by Wong and Chair [26] showed that QoL tended to improve until 1 month subsequent to the PCI. It also showed that PCS and MCS scores began to decrease 3 months subsequent to the PCI, which emphasized the need for supportive, long-term nursing interventions to maintain improvements in QoL. In the current study, mental HRQoL (represented by MCS scores) increased in both groups until 3 months subsequent to the intervention, following which a gradual decrease in MCS scores was noted in control group. However, the intervention group showed a consistent increase in scores until 12 months later, indicating significant differences between the 2 groups and in the intervention group over time. These findings could be attributed to the long-term telephone counseling and individualized education provided in the study. However, in a study involving 288 patients with AMI who received individualized education via telephone 3 and 6 months subsequent to discharge and completed the SF-36, physical HRQoL differed significantly between the control and intervention groups. However, mental HRQoL did not differ significantly between the 2 groups [27]. In the current study, nurse-led, individualized education did not impact on significant difference between the 2 groups. One possible reason for this finding is that physical health was maintained because of the natural physical recovery process over time.

The main limitation of the study was that the participants were recruited from a single academic medical center; therefore, the findings were not generalizable to all patients with ACS in Korea. Furthermore, data were collected using self-report questionnaires and did not consider physiological parameters or clinical outcomes. Future collaborative studies examining this population should include changes in physiological indicators and MACE, such as readmission or mortality, over a longer period.

The current study provided a basis for useful nursing strategies via which nurse-led, individualized education is provided for middle-aged patients with new-onset ACS, prior to discharge. Counseling provided via follow-up calls also appeared to improve the mental HRQoL by enhancing self-care compliance. Therefore, structured, individualized education should be provided to middle-aged patients with ACS by cardiovascular nurses, as part of routine predischarge education, to prevent secondary adverse events. Further studies are required to examine objective clinical outcomes, based on advanced methodology, and explore the barriers against lifestyle modification in qualitative studies involving long-term follow-up.