AHA 2008: Look at recovery following an acute coronary syndrome as a continuum

Recovery following an acute coronary syndrome is a phase in a larger cardiovascular disease continuum, and prevention of downstream complications needs to begin immediately following the event, says Shirley M. Moore, PhD, RN.

Early reperfusion after the cardiac event to reduce ischemia is actually the start of the recovery, according to Dr. Moore. Health behavior change strategies are the next step, but unfortunately the methods used are often outdated. “Knowledge is not enough to change behavior,” she says. “We need to use contemporary approaches.”

Joint goal setting is one underused strategy. “The literature is clearly showing that if we negotiate the goals with patients, even medications, that in the long run we’ll have better compliance with the full regimen,” says Dr. Moore, professor and associate dean for research, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland.

Sustained follow-up after discharge is also important. “We have to learn that one-time contact with patients at discharge…is not making much of a difference at all,” she says.

Social/environmental engineering involves family participation in tweaking the daily routine to promote healthier living.

Assessing and treating depression is essential after a cardiac event because the incidence of depression in patients with coronary heart disease is approximately double that in the population at large, she says. The PHQ-9, the nine-item depression scale of the Patient Health Questionnaire, has been shown to be a powerful tool for assisting primary care clinicians in diagnosing depression as well as selecting and monitoring treatment. A score of 20 or greater is an indication for referral for aggressive treatment of depression, she says.

Fifty percent of patients with acute coronary syndromes use post-acute care services, such as skilled nursing facilities or intermediate rehabilitation services. Among patients with myocardial infarction, 30% go to skilled nursing homes. Those most likely to use post-acute care are older patients, women, those with long hospital lengths of stay, and those with multiple comorbidities. “What that means is that we have a handoff to nurses in the next setting…and they are not teaching cardiac protocols and lifestyle change,” Dr. Moore says. Therefore, successful strategies for health behavior change with discharge to home may not work for patients discharged to rehabilitation facilities.

Telehealth is gaining popularity in recovery intervention for its monitoring capabilities, allowing for sustained follow-up and counseling, advice and education, and better patient self-management.