Editorial

Behavioral Cardiology: Cardiology’s New Frontier of Action

Cardiovascular diseases are the leading cause of morbidity professionals interact with their patients. Patient education
and mortality around the world, and particularly in Brazil, and simplification of dosage must be part of the strategy to
despite advances in their diagnosis and treatment1. It is improve patients' adherence. In addition, the background of
speculated that these adverse events are due in part to the this study ultimately refers to behavior. In recent years, the
lack of patients’ adherence to medical (pharmacological and term "behavioral cardiology" has been used to define a new
non-pharmacological) recommendations2,3. In this regard, the frontier of action in cardiology and currently encompasses
evaluation of adherence and, eventually, the identification of the relationship between mental and cardiovascular health,
the causes of failure in adherence are recommended to be the influence of psychosocial factors on the incidence of
part of the cardiovascular anamnesis4. In the study published cardiovascular diseases, and finally, behavioral aspects of
by Oliveira-Filho et al5 in the Arquivos Brasileiros de Cardiologia the patients that determine higher or lower adherence to
entitled "Improving Post‑Discharge Medication Adherence medical recommendations9,10. Several behavioral theories
in Patients with CVD: A Pilot Randomized Trial", the topic complement each other and seek to explore the different
of adherence is approached in a randomized clinical study domains that govern the behavior of a patient before a risk
conducted by the authors. In this study, 61 patients diagnosed factor or a disease. Similarly, there are several examples
with cardiovascular disease were, upon discharge from the in the literature demonstrating that health interventions,
hospital, randomized to receive an intervention focused on at an individual or population level, have a higher chance
education and information, including dosage simplification, of success when based on a combination of behavioral
and based on a 4-item adherence scale versus standard theories, with emphasis on the health belief model, the
treatment. The authors compared adherence outcomes at 1 and stages of change, social cognitive theory, self-efficacy and
12 months of follow up, as well as clinical outcomes (hospital positive reinforcement11. In all these theories, the issues of
readmission and death) in the follow-up period. The adherence information and patient education are central.
rate was assessed with the 8-item therapeutic adherence scale Specifically, according to the health belief model12, the key
by Morisky6,7. At 1-month follow-up, the adherence rate was domains that govern behavior are the perceived susceptibility
significantly higher in the intervention group (83.3% versus to a certain risk or disease, the perceived severity of the
48.4%). During long-term follow-up, the adherence rate disease, and the benefits of and barriers to a specific behavioral
declined to a statistically non-significant difference between change. According to this theory, the first step for a patient
groups, but remained around 61% in the intervention group. to adhere to recommendations (whether practicing physical
As for readmissions and deaths, there was no significant activity or taking a medication to prevent a cardiovascular
difference between groups, although the study was not designed outcome) is to notice him/herself at risk of developing the
primarily to analyze these outcomes. However, we emphasize disease. The literature indicates that in this first step patients
that taking into consideration the adherent patients regardless already underestimate their risk13.
of allocation group, the rate of clinical outcomes was lower In addition, the benefits of cardiovascular prevention occur
when compared with non-adherent patients. In a recent study, in the long term, whereas the barriers to lifestyle changes are
Castellano et al8 evaluated the polypill versus standard treatment in the present. Physicians and health professionals should
in patients after acute myocardial infarction and observed an seek to calibrate the risk perception of the patient; in this
improvement in adherence rate, but not in cardiovascular regard, education and health information are fundamental.
outcomes. Dosage simplification, which was common to both The patient who knows his/her disease and receives
studies, appears to be effective and may be a trend. accurate information for handling the therapy tends to have
Methodologically well-planned and executed, the greater adherence to treatment, as shown in the study by
study by Oliveira-Filho et al5 provides lessons applicable Oliveira-Filho et al5. In addition, offering information to
to clinical practice and to the way physicians and health the patient improves engagement. The behavioral theories
have proposed that patient and family involvement in the
treatment plan is crucial to overcome barriers and achieve
the best benefits.
Keywords
It is worth noting, however, that not all patients are ready
Cardiovascular Diseases / trends; Indicators of Morbidity
to take responsibility for their treatment. The theory of stages
and Mortality; Medication Adherence; Treatment Outcome.
of change14 defines different stages of aptitude to change.
Mailing Address: Marcelo Katz • Patients may be in the pre-contemplative phase, i.e., not ready
Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, Bloco A1, 4o andar,
Coordenação do Programa de Cardiologia, São Paulo, SP – Brazil for change, and in some cases, even in denial of the disease
E-mail: mkatz@einstein.br or the inherent risks. In the contemplative phase, patients
understand the risks and accept the need for change; in the
DOI: 10.5935/abc.20150002 preparation phase, they plan effectively the action of change,

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 Katz e Wajngarten
Behavioral Cardiology

Editorial

discussing "how to execute the change"; in the action phase, as essentials when planning the change. A good example is
they effectively initiate the changes; and in the maintenance the issue of obesity. Discussing diet in this context involves the
phase, healthy attitudes become a sustainable habit. The role evaluation of the family, what the patient eats at work, what
of the physician and other health professionals is fundamental types of food, and at what cost it is offered in the community
to the advancement of the stages. in which he/she lives.
One thing useful in effecting change is to work with the We should stress that when it comes to behavior and
patients' self-efficacy, which is self-confidence about the ability adherence, more than a hundred factors have been
to change. To set treatment goals with positive reinforcement identified as potential predictors of adherence, therefore one
after fulfillment of the goals works in most cases. As an cannot expect a "one size fits all intervention"3. It is indeed
example, to establish a target of twice a week for physical fundamental to develop alternative methods to implement
activity for a sedentary patient who does not practice physical interventions that are effective and accessible. Additionally,
activity. Even though this is not ideal, it is achievable. When the it is necessary to apply technological resources as tools in the
patient achieves this goal it improves his/her self-confidence, engagement and participation of the patients. Finally, in our
and the positive reinforcement from the health professional understanding, the financing and dissemination of studies on
improves his/her self-esteem. The next step is to define as a adherence must be a priority.
target thrice-a-week activity, and so on. Therefore, in the field of behavioral theories applied to
It is worth mentioning the importance of assessing the interventions in health, the study of Oliveira-Filho et al.5 brings
environment in which the patient is inserted when there a great contribution to current knowledge. We believe that
is intention to promote a positive behavioral change. It is this article will be of great usefulness to the readers of the
necessary to understand family, work and community cores Arquivos Brasileiros de Cardiologia.

References
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