Behavioral Cardiology: Cardiology’s New Frontier of Action

Cardiovascular diseases are the leading cause of morbidity and mortality around the world, and particularly in Brazil, despite advances in their diagnosis and treatment. It is speculated that these adverse events are due in part to the lack of patients’ adherence to medical (pharmacological and non-pharmacological) recommendations^,. In this regard, the evaluation of adherence and, eventually, the identification of the causes of failure in adherence are recommended to be part of the cardiovascular anamnesis. In the study published by Oliveira-Filho et al in the Arquivos Brasileiros de Cardiologia entitled “Improving Post‑Discharge Medication Adherence in Patients with CVD: A Pilot Randomized Trial”, the topic of adherence is approached in a randomized clinical study conducted by the authors. In this study, 61 patients diagnosed with cardiovascular disease were, upon discharge from the hospital, randomized to receive an intervention focused on education and information, including dosage simplification, and based on a 4-item adherence scale versus standard treatment. The authors compared adherence outcomes at 1 and 12 months of follow up, as well as clinical outcomes (hospital readmission and death) in the follow-up period. The adherence rate was assessed with the 8-item therapeutic adherence scale by Morisky^,. At 1-month follow-up, the adherence rate was significantly higher in the intervention group (83.3% versus 48.4%). During long-term follow-up, the adherence rate declined to a statistically non-significant difference between groups, but remained around 61% in the intervention group. As for readmissions and deaths, there was no significant difference between groups, although the study was not designed primarily to analyze these outcomes. However, we emphasize that taking into consideration the adherent patients regardless of allocation group, the rate of clinical outcomes was lower when compared with non-adherent patients. In a recent study, Castellano et al evaluated the polypill versus standard treatment in patients after acute myocardial infarction and observed an improvement in adherence rate, but not in cardiovascular outcomes. Dosage simplification, which was common to both studies, appears to be effective and may be a trend.

Methodologically well-planned and executed, the study by Oliveira-Filho et al provides lessons applicable to clinical practice and to the way physicians and health professionals interact with their patients. Patient education and simplification of dosage must be part of the strategy to improve patients’ adherence. In addition, the background of this study ultimately refers to behavior. In recent years, the term “behavioral cardiology” has been used to define a new frontier of action in cardiology and currently encompasses the relationship between mental and cardiovascular health, the influence of psychosocial factors on the incidence of cardiovascular diseases, and finally, behavioral aspects of the patients that determine higher or lower adherence to medical recommendations^,. Several behavioral theories complement each other and seek to explore the different domains that govern the behavior of a patient before a risk factor or a disease. Similarly, there are several examples in the literature demonstrating that health interventions, at an individual or population level, have a higher chance of success when based on a combination of behavioral theories, with emphasis on the health belief model, the stages of change, social cognitive theory, self-efficacy and positive reinforcement. In all these theories, the issues of information and patient education are central.

[…]