Introduction
Cardiovascular disease (CVD) is a leading cause of death worldwide, accounting for 30% of global deaths.1 Over the next few decades, CVD will continue as the leading cause of mortality worldwide.2 ,3 Furthermore, the burden of CVD is growing disproportionately in low and middle income countries (LMICs), where 80% of CVD deaths occur.4 Myocardial infarction (MI) is a leading cause of CVD-associated morbidity and mortality.5–7 Recurrent MI within 5 years is common, affecting 15–22% of patients' aged 45–64 years and 22% of patients aged >65 years.6 In addition to the physical toll, an MI may cause or exacerbate significant mental health comorbid conditions.
The health-related quality of life (HRQoL) is increasingly being used as an outcome measure of coronary heart disease.8–10 As the population ages and survival of ischaemic coronary events continues to improve, assessment of HRQoL is necessary as an important and useful outcome measure complementing the traditional ‘hard outcomes’ such as mortality and recurrent MI for evaluating impact of disease and benefits of medical interventions.8 Post-MI increases in patient stress may translate into worse HRQoL.6 ,11–13 Evidence suggests that a decline in health status is associated with worse prognosis, disease progression and healthcare outcomes in patients with cardiac disease.12 ,14–16
Cardiac rehabilitation (CR) is an outpatient model of chronic disease management for secondary CVD prevention. It is a class I indication for patients with coronary heart disease.17 In a meta-analysis, the use of CR post-MI has been shown to improve function and exercise capacity, decrease morbidity and mortality, and also improves quality of life, perceived stress and anxiety.1 ,18 Hence, CR serves as a key tool in addressing the global burden of CVD.1 Despite recommendations, CR remains underutilised with low participation and adherence rates in both high income and LMICs.1 The reasons for CR underuse include geographic access, cost, organisational and patient factors, and patient education and understanding of the nature of CR and the associated benefits.19–21 Participation in home-based or hybrid CR programmes is associated with cost-effective and equivalent benefits to supervised programmes.22–24 With advances in technology, hybrid home-based programmes have been developed that incorporate email, secure websites and videoconferencing between patients and providers. Recently, the utility of smartphone applications has also been investigated.21
The Family-Centered Empowerment Model (FCEM) was designed and first reported by Dr Fatemah Ahlani at Tarbiat Modarres University.25 It's aim was to improve the care and outcomes of patients with chronic diseases and has previously been evaluated and validated in a number of chronic disease states.7 ,26–32 The primary aim of the model is to empower the patient/family unit to promote health quality. The model has four stages: (1) determining perceived threat (group discussion method); (2) self-efficacy (problem-solving method); (3) improving self-esteem (educational participation method) and (4) process and outcome evaluations. We investigated the impact that an FCEM-focused hybrid CR programme employing in-hospital and outpatient components, direct education, video teleconferencing and smartphone technology had on patient anxiety and perceived stress, and overall quality of life has measured by HRQoL among patients hospitalised with acute MI (AMI) in a coronary care unit (CCU).