Non-Pharmacological Management

Counselling and Education

Educational needs

A number of studies have highlighted the importance of counselling and education in ensuring the future well-being of patients with acute myocardial infarction (AMI), both peri- and post-discharge.

Patients’ educational needs were highlighted in a study by Dracup and colleagues,¹ who investigated patients’ knowledge of heart disease and their perception of risk of future AMI. All patients had either a history of acute AMI or of invasive treatment for ischaemic heart disease.

The authors found that many patients, particularly men, had significant gaps in their knowledge of the symptoms of AMI. A high proportion thought that their risk of a future AMI was the same as or less than in their contemporaries. Patients who had had bypass surgery were especially likely to think this.¹

Men, elderly individuals, those with lower levels of education, and those who have not attended a cardiac rehabilitation programme may need more education and counselling to help them recognise the symptoms of AMI and respond appropriately.¹ European guidelines recommend that patients’ partners and families should be informed about the symptoms of MI and how to respond to it.²

Counselling, adherence and outcomes

There is evidence that, following an MI, counselling and education initiatives can improve the likelihood of adherence with prescribed medication,3-5 and that improved adherence is associated with better clinical outcomes.^4,5

Educational mailings have been shown to improve adherence to beta-blockers in the post-MI setting; for every 16 patients receiving the intervention, 1 additional patient would become adherent. However, this study did not measure clinical outcomes.³

Spertus and co-workers studied patients who were prescribed a thienopyridine following the placement of a drug-eluting stent.⁴ Patients who had stopped taking their antiplatelet agent at 30 days were less likely to have been given discharge instructions about their medications than those who continued treatment beyond this time-point (88% vs 95%; p = 0.05). Furthermore, 1-year mortality among those who had stopped treatment at 30 days was significantly higher than in those who continued therapy (7.5% vs 0.7%; p < 0.0001); rehospitalisation was also higher in discontinuers, but not significantly so (23% vs 14%; p = 0.008).

Jackevicius and associates investigated rates of primary non-adherence (i.e. not filling the first prescription) among >4000 Canadian patients discharged from hospital following MI.⁵ They found that medication counselling upon discharge was associated with an increased likelihood of filling all discharge prescriptions, compared with filling none. One-year mortality was significantly higher among the two groups of patients who filled either some or none of their discharge prescriptions, compared with those who filled all of their discharge prescriptions.⁵ Patients who received discharge medication counselling, as documented in their charts, had a significantly lower risk of mortality.

Taken together, these studies suggest that pre-discharge and ongoing patient counselling and education can translate into improvements in adherence with therapy, which is likely to lead to better outcomes.

Counselling may include:

• signs and symptoms of recurrent infarction, and the need to contact emergency medical services without delay; 
• simple explanations of the drugs prescribed upon discharge, and reinforcement of the need for adherence; 
• signs and symptoms of heart failure;
• self-monitoring requirements (e.g. measurement of bodyweight for patients with heart failure).