Acute myocardial infarction (AMI) is a serious and common illness that affects the cardiovascular system. Its sudden onset, high fatality rate, and recurrence rate significantly impact patients’ safety and quality of life. Owing to considerable improvement in living standards, AMI has become a major cause of death and disability, seriously increasing the burden on society. The cardiac rehabilitation program, which involves a multidisciplinary approach to assist patients with daily life guidance, diet guidance, exercise guidance, disease knowledge guidance, medication guidance, psychological guidance, risk factor control guidance, and other comprehensive guidance, has been proven to play a decisive role in the recovery of patients’ cardiac function and the improvement of their quality of life. In addition, these programs help reduce treatment costs and prevent the reoccurrence of disease as well as adverse effects in cardiac patients. However, the introduction and execution of these initiatives are currently in their early stages, characterized by a gradual pace and encountering numerous challenges. Specifically, in the context of AMI, there have been documented instances of reduced engagement, adherence, and compliance with rehabilitation programs, even within industrialized nations. Diverse treatment phases and models have been designed to enhance patient care, patient participation, compliance, and effectiveness of rehabilitation programs. Participation in post-myocardial infarction management CR programs has been reported under par levels which is posing a great threat and burden on society. Various theories and models of behavioral change are proposed to improve patient participation and compliance in cardiac rehabilitation. These theories and models have been utilized in the past to improve patient health and can also improve patients’ perception, and behavior toward active participation in cardiac rehabilitation programs.
Acute myocardial infarction (AMI) is the obstruction of the blood flow in the left main coronary artery, the right main artery, or its branch vessels, resulting in a sudden decrease in blood flow or even an interruption of blood flow.
AMI is a serious, intense, and progressive cardiac disease that often leads to the appearance of anxiety and depression among patients. A high prevalence of psychological issues has also been reported in previous studies, which frequently results in the reoccurrence of cardiac issues, decreased quality of life, and no interest in physical activities and work life. Cardiac rehabilitation (CR) significantly reduces psychological problems such as anxiety and depression in patients with AMI. Poor quality of life in terms of physical and mental health is often observed in AMI patients with cooccurrence of psychological problems. CR programs not only reduce the prevalence of anxiety and depression but also improve the quality of life.
This narrative review summarizes the concept of cardiac rehabilitation, and its significance and highlights various theories and models of behavior change to increase compliance in disease management in the context of acute myocardial infarction. The database search engines (PubMed and Google Scholar were searched for relevant terms such as behavioral theory, behavioral model, cardiac rehabilitation, cardiac rehabilitation programs, and acute myocardial infarction). Initially, the titles and abstracts of all articles were screened, and suitable articles were then selected based on their relevance to the topic. A total of 345 research articles were screened using the online databases. Subsequently, only those studies were finally included in the review that discussed the impact of theories and models on enhancing patients’ disease conditions through behavior modification.
The World Health Organization (WHO) defines cardiac rehabilitation as “the sum of all activities that have a beneficial effect on the disease itself and the patient’s physical, psychological and social functioning, leading to an improved quality of life and a more normal return to social life.” Historically, cardiac rehabilitation programs primarily centered around exercise-based training. However, contemporary CR programs have expanded their scope to encompass health promotion behaviors aimed at managing weight, diet, cholesterol levels, diabetes, blood pressure, and other critical factors contributing to patients’ overall physical and mental well-being. The clinical guidelines and cardiac association recommendations worldwide strongly recommend initiating and implementing CR programs for AMI and heart failure patients.
Cardiac rehabilitation is a preventive treatment program aimed at preventing vascular disease recurrence. The main goal of the program is to provide a tailored approach that is specifically designed to address the unique needs of each patient. Using this approach, the program can effectively identify the risk factors associated with cardiovascular disease and implement preventive measures to help reduce the likelihood of developing the disease. It uses a comprehensive model of five core interventions to provide personalized care for patients with cardiovascular disease in the acute, recovery, and maintenance phases and throughout life, which includes pharmacological intervention, exercise intervention, nutritional intervention, psychological intervention (including sleep management) and smoking and alcohol cessation (
| Phase I | It is an acute phase of hospitalization during which cardiac inpatients receive education and interventions from healthcare professionals, including cardiologists and nurses, who closely supervise them 24/7. This phase is of short duration and only lasts a few days until the patient is stable and no longer immobile. |
| Phase II | The second phase of rehabilitation lasts from 2 weeks to 12 months post-patient discharge. It is a period of intensive surveillance in which structured exercise routines, educational and psychological interventions, and lifestyle changes such as diet management, sleep management, stress and anxiety management, smoking cessation, and alcohol cessation are provided. |
| Phase III | The third phase is a long-lasting superficial supervision rehabilitation period which starts right after the second phase either at home or in the community-based CR centers. The digital-based technologies such as telehealth, digital apps, internet-based training, and education, etc. are mostly utilized in this phase. |
| Hospital-based initial rehabilitation (Phase I) | The hospital-based initial rehabilitation is the treatment model in which the patients are assessed during their hospital stay and are monitored and guided about the benefits of CR. The early rehabilitation program provides many clinical benefits to the patients, including but not limited to reduced mortality, a decrease in risk factors such as blood pressure and heart rate, etc., and enhanced ventricular functions. The treatment model is best suited for patients with multimorbidity and those requiring intensive care, but it can be expensive for patients paying their treatment costs. |
| Hospital-based secondary rehabilitation (Phase II) | Secondary hospital-based rehabilitation is designed for outpatients after 2-6 weeks of completion of their necessary treatment and discharge from the hospital. The patients frequently visit the hospital for follow-up guidance and disease management. However, these are time-consuming, inconvenient, and expensive, especially for old people and patients dwelling at far distances from hospitals. |
| Home-based rehabilitation (Phase III) | The home-based CR treatment model has added clinical advantages and is not time and space dependent. Few home-based telerehabilitation programs have successfully improved patients’ cardiac health, cognitive abilities, and mental health by using various technology-driven tools such as remote sensors and virtual exercise machines, etc. for monitoring and management of cardiac patients. |
| Hybrid community-based rehabilitation (Phase III) | Another treatment model is an individualized community-based service which is more economical and transport-convenient than a hospital-based model. |
Cardiac rehabilitation has been found to be effective in controlling cardiac symptoms, stabilizing or reversing the atherosclerotic process, reducing the physical and psychological effects of heart disease, and lowering the risk of sudden death. Research indicates that CR improves cardiovascular outcomes and overall health, reducing the incidence of recurrent myocardial infarction.
Studies conducted in Latin America have shown that cardiac rehabilitation is a cost-effective intervention and significantly reduces the high expenses associated with passive treatments.
Anxiety and depression are frequently observed psychological symptoms in patients suffering from AMI. Cardiac rehabilitation programs have been shown to significantly reduce social and psychological symptoms like anxiety, depression, and general disinterest in daily routines.
| Type of Significance | Examples |
|---|---|
| Clinical significance | Control cardiac symptoms, stabilize or reverse atherosclerosis, lower risk of sudden death, lower risk of reoccurrence of myocardial infarction, enhance medication adherence, increase exercise stamina, reduce cardiovascular risk factors such as smoking, blood pressure, lipid profile, diabetes, etc. Some studies indicated the positive influence of CR on AMI patients. |
| Economic significance | CR programs are cost-effective, reduce the high costs of passive treatment and save long-term costs by preventing disease reoccurrence. A systematic review conducted to evaluate the cost-effectiveness of rehabilitation programs proved the economic significance of cardiac rehabilitation interventions compared to usual medical care. The exercise-based intervention proved to be much more economical compared to telehealth and other CR interventions. |
| Social significance | Improved quality of life, and reduced psychological effects of cardiac disease such as anxiety and depression experienced during and after treatment. A Cochrane review indicated significant improvements in quality-adjusted life years of AMI patients undergoing exercise-based randomized trials. |
Participation in post-myocardial infarction management CR programs has been reported under par levels (28.0%) in the United Kingdom (UK) compared to other cardiovascular diseases, especially old age people, women, and patients with comorbid conditions. The UK Cardiac Rehabilitation Audit Report of 2019 found that 50% of patients had comorbidities, which strongly impacted compliance and participation in CR programs.
The Transtheoretical Model proposes that behavioral change is not an instant event but rather a gradual process. It emphasizes the importance of an individual’s decision-making ability and suggests that varying strategies should be used to help individuals develop and sustain healthy habits throughout their lives. The TTM model was utilized to evaluate the willingness of cardiac patients to modify their health behaviors concerning exercise routine, eating habits, and mental relaxation. It was found that a considerable number of patients were not willing to change their behaviors. However, those with a higher risk of cardiovascular illness were observed to be more willing to change.
The utilization of TTM for behavior change in women with osteoporosis has yielded promising results. Specifically, the implementation of this model has led to statistically significant improvements in self-efficacy, nutrition, walking distance, and overall process of change. These findings are particularly noteworthy given the challenges associated with promoting behavior change in individuals with osteoporosis. The TTM model is a valuable tool for healthcare providers seeking to improve outcomes in this population and warrants further investigation.
The IMB model is an intervention model that focuses on providing information, motivation, and behavioral skills to encourage certain behaviors. This model is scientifically rigorous and has found extensive application in the medical domain. The IMB model has been utilized in patient education for various medical conditions and has demonstrated significant benefits in enhancing patients’ lifestyles, quality of life, and treatment adherence.
Researchers conducted a study to evaluate the effectiveness of a mobile application in the exercise-based cardiac rehabilitation of patients with coronary artery disease. The study found that patients who received information based on the IMB model endorsed by the application showed significant improvement in exercise tolerance and adherence to the rehabilitation program, resulting in superior outcomes. This study highlights the enormous potential of mobile technologies in the field of cardiac rehabilitation.
The theory of self-determination is based on people’s psychological growth and development of motivation. Of the several motivation theories, SDT is widely used in the field of cardiac rehabilitation and believes that the satisfaction of basic psychological needs and independent motivation is related to enthusiasm for performance.
The studies conducted in the United States of America (USA) examined the effect of SDT-based interventions on exercise behavior in patients with CR. Patients who had higher levels of psychological need satisfaction and self-determined motivation demonstrated a greater propensity for autonomous exercise.
The PRECEDE-PROCEED model has been well-validated for its effectiveness in reducing depression and improving the quality of life. Healthcare professionals can evaluate health factors more comprehensively by using this model, leading to a more effective implementation of intervention strategies. An intervention study was conducted among patients who underwent CABG surgery, with the aim of improving their sleep quality based on the constructs of the PRECEDE-PROCEED model. The study successfully demonstrated a significant improvement in the quality of sleep among the patients.
The Family-Centered Empowerment Model improves the quality of life of chronic illness patients by engaging and empowering family members/caregivers and providing them with the necessary knowledge and skills to manage their patients effectively. It is a highly effective model that enhances the quality of life for patients and their families. Additionally, it serves as a useful intervention model for healthcare providers, enabling them to cater to the healthcare needs of their patients in a better manner.
A clinical study confirmed that the model effectively improved the mental health of patients suffering from myocardial infarction. The study assessed psychological factors such as anxiety levels, perceived stress, and quality of life, both physically and mentally, using the model-based approach. The intervention group resulted in significant improvements in anxiety and stress symptoms, as well as overall health levels.
The Omaha System presents health problems to patients and develops care plans based on their condition, making clinical practice more standardized and quantitative. The system has been shown to improve the quality of care in both children and adults with cardiovascular problems.
| Author (Year) | Country | Model/Theory Used | Disease | Study Outcome |
|---|---|---|---|---|
| N.F. Eshah (2019) |
Jordan | Trans Theoretical Model | Ischemic Heart Disease | Patients with a higher risk of cardiovascular illness were willing to change their behavior. |
| Jeihooni et al. (2018) |
Iran | Trans Theoretical Model | Osteoporosis | Improvements in self-efficacy, nutrition, walking distance, and overall process of change. |
| Chen et al. (2018) |
China | Trans Theoretical Model | COPD | Improved pulmonary functions, improved compliance, and better quality of life. |
| Wen et al. (2019) |
China | Trans Theoretical Model | Ostomy | Improvements in self-management of disease and process of change. |
| Shi et al (2022) |
China | IMB Model | Cardiac patients who received PCI | Improvement in exercise tolerance and medication adherence. |
| Zahmatkeshan et al. (2021) |
Iran | IMB Model | Cardiovascular patients | Increase in medication and treatment adherence. |
| Zarani et al. (2010) |
Iran | IMB Model | CABG | Improvement in psychological factors improved medication adherence in the intervention group. |
| Li et al. (2022) |
China | IMB Model | CHD | Improved cardiopulmonary function, increased physical fitness, and self-efficacy among patients. |
| Kim et al. (2023) |
South Korea | IMB Model | Metabolic syndrome | The IMB model components were considered crucial for developing interventions to influence health behaviors in effective disease management. |
| Russel et al (2009) |
USA | Self-determination theory | Cardiovascular disease | An increase in self-determined motivation in the intervention group resulted in improved participation in exercise routines. |
| Russel et al (2010) |
USA | Self-determination theory | Cardiovascular disease | Increased attendance in CR and improvements in exercise frequency and duration were observed after the model-based intervention. |
| Rahman et al. (2015) |
UK | Self-determination theory | Cardiovascular disease | The model-based intervention significantly improved psychological well-being which ultimately improved health behaviors among patients. |
| Saebu et al. (2013) |
Norway | Self-determination theory | Physical disability | The model-based intervention significantly increased patients’’ self-efficacy and motivation for physical activity. |
| Ranjbaran et al. (2015) |
Iran | The PRECEDE-PROCEED model | Sleep quality in CABG patients | Significant improvements were observed in the quality of sleep after the intervention. |
| Vanzella et al. (2022) |
Canada | The PRECEDE-PROCEED model | Cardiovascular disease | Endorsement of the implementation of model-based interventions that aim to improve patients’ knowledge and behavior towards physical exercise. |
| Wang et al. (2017) |
China | The PRECEDE-PROCEED model | Chronic heart failure | The model-based intervention effectively relieved depressive symptoms and improved the quality of life in the intervention group. |
| Raei et al. (2022) |
Iran | Family-Centered Empowerment Model | Myocardial infarction | Decreased stress and anxiety levels in the intervention group. |
| Vahedian-Azimi et al. (2016) |
Iran | Family-Centered Empowerment Model | Myocardial infarction | Improved physical and mental health. |
| Yin et al. (2022) |
China | Omaha System Theory | CHD | Increased medication adherence and reduced adverse effects in the intervention group. |
| Fang et al. (2022) |
China | Omaha System Theory | Stroke | Improvements in performing daily activities and a reduction in the number of falls. |
COPD = Chronic obstructive pulmonary disease, PCI = Percutaneous coronary intervention, CABG = Coronary artery bypass graft, CHD = Coronary heart disease, IMB Model = Information motivation behavior skill model
There is a growing concern regarding the low adoption and inadequate compliance with cardiac rehabilitation programs globally. This issue has been a persistent challenge for healthcare providers and policymakers alike, as it has significant implications for the long-term health outcomes of patients with cardiovascular diseases. The success of rehabilitation programs, particularly in countries where the recovery rate of cardiac diseases, especially AMI, is lower than in developed countries, depends on the comprehensive understanding and professional knowledge of healthcare providers, as well as the positive behavior and motivation of patients. Therefore, it is imperative for the healthcare community to improve cardiac rehabilitation guidance for patients by offering comprehensive, scientific, model-based effective approaches, leading to greater heart recovery and associated benefits. The implementation of theory and model-based interventions has the potential to provide patients with increased adaptability, enhanced motivation, and improved adherence to rehabilitation. In the future, the integration of theories, and models with developing technologies, new devices, and information technologies may facilitate patients’ engagement in cardiac rehabilitation by addressing various challenges and barriers.
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This work did not receive any funding from any organization.
The author declare to have no conflict of interest regarding this work.
Usman Rashid Malik – Conceptualization, Writing – original draft, review and editing
Usman Rashid Malik
Commissioned and externally peer-reviewed
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