Original articlesPractical support predicts medication adherence and attendance at cardiac rehabilitation following acute coronary syndrome
Introduction
Social support has a marked impact on the progression of coronary heart disease (CHD) and recovery following ACS [1]. For example, Williams et al. [2] reported that the 5-year death rate of patients undergoing coronary angiography was three times greater in unmarried individuals who lacked a close confidant compared with those who were either married or had a confidant. The odds of death in the first 6 months following myocardial infarction (MI) were 2.9 in a cohort of older patients in New Haven who lacked emotional support compared with those with two or more sources of support, independently of clinical and sociodemographic factors [3]. More recently, an analysis of the Enhancing Recovery in Coronary Heart Disease dataset indicated that perceived social support was associated with improved clinical outcomes over 4.5 years following MI independently of other risk factors, but only in patients without elevated depression scores [4]. Favorable effects of social support have been obtained in other studies of cardiac patients [5], [6], [7]. Direct associations between low social support and activation of inflammatory and neurohumoral pathways may be responsible [8], although social supports may also encourage adherence to medication and maintenance of prudent lifestyle changes [1], [9], [10].
Social support has several different functions, providing information and advice, confiding relationships, and practical help [11]. These functions do not necessarily coincide; a warm relationship may supply emotional support without being helpful in practical terms, and the information and advice provided by emotional confidants may not be accurate. The contribution of these different elements in CHD is not clear but is relevant to patient management and psychosocial interventions. It is possible that different types of social support may have differential effects on the behavioral and biological mechanisms that link social support with CHD morbidity and mortality. For example, practical support may have a greater impact than emotional support on the behavioral pathways influencing disease outcomes.
In a recent meta-analysis of research that has investigated the relationship between different types of social support and medication adherence across a range of conditions, practical support was found to have the strongest relationship with medication adherence [12]. Across the 122 studies included in this analysis, the odds of adherence (compared with nonadherence) were 3.6 times higher among those who receive practical support than among those who do not, whereas the odds of adherence (compared with nonadherence) were less than two times higher among those who receive emotional support than among those who do not. This suggests that practical support has particular relevance to secondary prevention behavior. It is possible that these differential effects may also be observed in other behaviors that are critical for secondary prevention following an ACS, such as cardiac rehabilitation.
In this study, we investigated the influence of practical and emotional support on two key recovery behaviors, medication adherence, and cardiac rehabilitation attendance in patients following ACS. We hypothesized that having more sources of practical support would be particularly important in predicting these recovery behaviors independently of demographic and clinical factors. Depressed mood may also influence these behaviors [13], [14] so was taken into account in the analysis.
Section snippets
Participants
The participants in this study were 262 patients admitted to one of four hospitals in the London area as part of a study of behavioral and emotional triggers of ACS [15]. Inclusion criteria were a diagnosis of ACS based on the presence of chest pain plus verification by diagnostic electrocardiographic (ECG) changes (new ST elevation >0.2 mV in two contiguous leads in leads V1, V2 or V3 and >0.1 mV in 2 contiguous other leads, ST depression >0.1 mV in two contiguous leads in the absence of any
Results
The sample consisted of 202 men and 60 women aged from 32–87 years (mean, 60.7). The majority of patients (67.6%) were married, and 40.1% were smokers. One hundred eighty-three (69.8%) presented with a STEMI and 79 (30.2%) with an NSTEMI or UA. Scores on the GRACE index averaged 95.7 (S.D., 27.3).
The number of patients who stated that they had no sources of practical support was 78 (29.8%); 42 (16.0%) had one practical support, and 142 (54.2%) had two or more sources of support. Forty eight
Discussion
This study investigated whether practical and emotional social support assessed at the time of hospitalization for ACS predict behaviors relevant to clinical outcomes at 12 months post-ACS. The study was not powered to investigate clinical cardiac end points. We found that practical but not emotional support predicted both mediation adherence and rehabilitation attendance independently of age, gender, marital status, and clinical risk. The effects were substantial, with a more than twofold
Acknowledgments
This research was supported by the British Heart Foundation and the Medical Research Council.
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