id 7952

ORIGINAL RESEARCH

 

Discovery of cardiovascular disease: associating causes and experiencing the context of a referral hospital

 

Maria Aparecida BaggioI; Alacoque Lorenzini ErdmannII; Giovana Dorneles Callegaro HigashiIII; Cintia KoerichIV; Gabriela Marcelino de Melo LanzoniV

I Ph.D. in Nursing. Professor, Collegiate of Nursing, State University of Western Paraná. Brazil. E-mail: mariabaggio@yahoo.com.br
II Nurse. Ph.D. in Philosophy of Nursing. Professor, Federal University of Santa Catarina. Brazil. E-mail: alacoque@newsite.com.br
III Ph.D. in Nursing. Postdoctoral student, Graduate Program in Nursing, Federal University of Santa Catarina. Brazil. E-mail: gio.enfermagem@gmail.com
IV Master in Nursing. Ph.D. student, Graduate Program in Nursing, Federal University of Santa Catarina. Brazil. E-mail: cintia.koerich@gmail.com.br
V Ph.D. in Nursing. Professor of the Department of Nursing of the Federal University of Santa Catarina. Brazil. E-mail: gabriela.lanzoni@ufsc.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.7952

 

 


ABSTRACT

Objective: to understand how patients experience the discovery of cardiovascular disease and how the process occurs, from diagnosis to these patients' cardiac rehabilitation in a cardiology referral hospital. Method: in this qualitative, descriptive study, using Grounded Theory, 29 subjects (patients, relatives and health personnel) underwent semi-structured interviews between October 2010 and May 2012. The study was approved by the research ethics committee (No. 001/2010). Results: the referral institution displays weaknesses in its structure and in the sphere of the health personnel's actions, but has a cardiac rehabilitation program, which offers multi-professional care, physical fitness equipment, favors social interaction and promotes patients' mental health. Conclusion: in addition to investing in physical infrastructure and human resources, training for health personnel to care for surgical cardiac patients is key to meeting service users' demands.

Keywords: Nursing; cardiovascular disease; myocardial revascularization; cardiology service hospital.


 

 

INTRODUCTION

The increase in the life expectancy of the population indicates an increase in the number of individuals over 70 years old. The life expectancy of the Brazilian people in 2011 was 74.1 years old, and in 2012 it was 74.6 years old. As for gender, the expectation of men increased from 70.6 years old in 2011 to 71 years old in 2012; and women from 77.7 to 78.3 years old. It is estimated that the elderly reach 26.8% of the population in 20601.

Cardiovascular diseases belong to the main causes of morbidity and disability in Brazil and the world among the diseases of population aging, particularly coronary artery disease2.

Cardiovascular disease is associated with several risk factors, especially those related to inadequate lifestyle habits, such as sedentary lifestyle, consumption of fatty foods, obesity, alcoholism, and smoking3. Disease prevention is based on adopting a healthy lifestyle. However, in the absence of prevention, the disease stays and treatment and rehabilitation resources need to be used.

The patient´s knowledge about the experiences and meanings that permeate the process of sickness and cardiovascular treatment favors the intervention of nursing and health professionals. Therefore, the question is: How do patients experience the discovery of cardiovascular disease? What factors do they attribute to the disease? How do they describe the onset of symptoms? How does the context of the hospital interfere in the process of treatment and surgical rehabilitation? Thus, the objective of the study was to understand how patients experience the discovery of cardiovascular disease and how the process occurs from the diagnosis of the disease to the cardiac rehabilitation in a hospital institution, being a reference in cardiology.

 

LITERATURE REVIEW

Cardiovascular diseases represented the third cause of hospitalizations for the Unified Health System (SUS) in 2007with 1,156,136 hospitalizations, with heart failure as the main cause4. Expenses related to the SUS highly complex cardiovascular care increased from approximately R$ 395 million in 2000 to approximately R$ 736 million in 2005, an increase of 86.2%5. Cardiovascular diseases were the main cause of death in Brazil in 2010, accounting for 31.2% of deaths, followed by cancer (16.7%), chronic respiratory diseases (6.0%), chronic non-communicable diseases and Diabetes (5.3%)6.

The mortality of patients undergoing myocardial revascularization surgery may reach 10%. Considering only elective surgeries, the death rate drops to 6.3%. In emergency surgeries, the rate increases to 7%. The risk of death is higher for patients aged 60 years old or over, especially for females7. For patients aged 70 and 80, the risk of death is 8.3%, whose percentage of mortality does not show a difference between this ages8.

The conditions increasing the risk of death in patients undergoing myocardial revascularization are extracorporeal circulation time, longer mechanical ventilation time, the length of stay in intensive care, bleeding reoperation, prolonged inotropic support and use of blood products8.

Considering these data, nursing and health professionals should act from disease prevention, treatment, and rehabilitation, guiding self-care measures and clarifying doubts to individuals, reducing (re) hospitalization, morbidity and mortality, and high health costs9.

 

METHODOLOGY

This study is qualitative, descriptive in nature. A review of the data of a broad study was performed entitled Signifying the surgical experience and the living process of the patient undergoing myocardial revascularization surgery . The methodological reference used was Data Based Theory (TFD) 10. The study scenario was a public health institution, a reference in cardiac surgery, located in the Southern Region of Brazil.

The data collection was performed through the individual and semi-structured interview from October 2010 to May 2012, and it had four sample groups. The inclusion criterion for the constitution of the first sample group was that the individual was over 18 years old and have undergone myocardial revascularization surgery in the period from 2005 to 2010.

The first sample group consisted of eight revascularized patients. The patients´ interview started with the question: Tell me about your experience of discovering heart disease and performing myocardial revascularization surgery. The other questions were addressed by the researchers, based on the answers given. The individuals´ speeches were recorded by digital voice recorder. From the analyzed material, a great interface emerged with the institution, mainly with the services that offered the internal routines.

For the second sample group, six health professionals (two physicians, two nurses, one physical educator, one nursing technician) were interviewed who had direct contact with the re-vascularized patient. The second sample group pointed to the need to include family members in a new group. Then, the third sample group had three relatives and two revascularized patients. Finally, the fourth group with 10 revascularized patients was formed to consolidate and improve the categories in their properties and dimensions.

The method used foresees this movement of coming and going in the search for the understanding/confirmation of the meanings revealed by the participants10. The theoretical saturation of the data was reached with 29 participants.

The development of the project was approved by the Research Ethics Committee of the institution where the study was developed under Nº 001/2010. The ethical principles were respected at all stages of the research, as provided in Resolution Nº 466/2012 of the National Health Council11. The participants authorized their voluntary participation by signing the Free and Informed Consent Term. The participants were identified by the initials: patients (Pa), professionals (Pr), Family (Fa), followed by cardinal numbers to identify, respectively, the order of the interview and the sample group to ensure anonymity

The data collection and analysis process was guided by theoretical sampling, as recommended by TFD, whose data collected, when analyzed, led to the next data collection and comparative analysis, successively. The codes were grouped and the categories and subcategories defined and developed in their properties and dimensions, followed by the open, axial and selective coding process10. From the analysis emerged three categories that supported the phenomenon in question: Discovering the cardiovascular disease; Knowing the institution of reference and Understanding the rehabilitation program.

 

RESULTS

The emerging categories of the study are presented below according to the statements obtained.

Discovering the Cardiovascular Disease

In this category, participants reported life habits before the illness. In general, they had an active, sometimes stressful life due to overwork. They made meals commonly rich in animal and saturated fats, accompanied by alcohol consumption, as the speeches illustrate:

[...] I ate a [...] griddle, crackling. That is right [referring to the crackling] I ate straight. I ate mortadella [...] which has plenty of lard; And pork [...] I liked to have a beer [...]. (Fa1.3)

[...] I took the cart and delivered. I sat at 3 o'clock in the morning and 4 o'clock in the morning I left the company and delivered. It arrived the other day at dawn [...]. (Pa3.3)

Knowledge of atherosclerotic cardiovascular disease triggered feelings of sadness in patients. These associate the appearance of the disease with the habits of life and the hereditary factors, placing them as the main responsible for the occurrence of the disease. Here are the testimonials:

[...] at first, it was sad, but despite that I was already aware because it is already genetic [referring to hereditary factors]. Of the family, 80% died of infarction [...]. (Pa1.1)

My sisters have high blood pressure; my brother had a stroke [...] my sister is operated [cardiac revascularization]. (Pa7.1)

For some patients, the symptoms of the disease suddenly appeared. For others, they were expressed gradually, postponing the search for medical care. However, symptomatic patients sought medical help, but the initial diagnosis was not assertive. The symptoms that motivated the search for the health service were mainly: pain in the left arm, in the thoracic region, in the epigastric region and/or exertion fatigue. The narratives reveal:

[...] I was with a 90% obstruction, but I did not feel anything... I was treated at the UH [University Hospital], and the doctor said that I had nothing, it was all in my head. (Pa4.4)

[...] she felt pain, tightness in her heart, pain in her arms ... she went to the doctors; They said it was muscle pain [...] (Fa8.3)

I started with chest pain, I went to the hospital, I got Buscopam and a stomach medicine. They thought it was from the stomach [...]. (Pa2.3)

The participants reported basically the same symptoms when they had a myocardial infarction. Sometimes, these symptoms were confused with those of other pathologies, postponing the diagnosis and treatment of the patient in an acute condition of heart failure.

Before surgical intervention, for myocardial revascularization, some patients underwent diagnostic angiography followed by angioplasty, with stent implantation. Others had an indication of revascularization as a priority intervention due to the degree of obstruction, confirmed by angiographic diagnosis. For these patients, the surgical option meant the only possibility of survival according to the reports:

[...] I wanted to be operated. Otherwise, I would not be able to take much time. The doctor said that if I were not operated, I would not be able to last five months. (Pa1.1)

They did not ask me anything; they just said it was the only way out. I had 1% chance to survive. (Pa3.1)

During hospitalization, the patients and their families received guidance from the health team regarding the surgical process, as well as the inherent risks according to the following statements:

We always call a family member together to clarify the risk [...] 2% to 4% of mortality in surgery and some risks related to intercurrences [...]. (Pr4.2)

There was one [resident] who was two months away from becoming a doctor and explained everything to me. (Pa3.4)

Although participants received the information that re-vascular heart surgery would be the only option to avoid new events of infarction and even death, when preoperative guidance and clarification about the surgical process by nursing and health professionals are performed, they favored acceptance of treatment and made the experience positive.

Knowing the reference institution

This category shows the structure of the institution, according to the testimony:

[...] the Cardiology Institute does cardiac transplantation, does large surgery, very complex surgery [...] this is very important for the hospital, trusting it, makes it reference. (Pr1.2)

However, this institution recognized as a regional reference in cardiology has weaknesses, which are pointed out by the study subjects:

The physical structure is inadequate, the number of beds is too small for the demand of patients [...] sometimes anesthesiologist is missing [...] the patient stays 30, 40, 60, 90 days awaiting [surgery]. (Pr6.2)

[...] that lot of hospitalized patients, many with urinary tract infection, so long in here. Others are weakened when they go to surgery because they have already lost weight [...] with low hematocrit for food, which is bad. (Pr3.2)

Another issue related to the institution concerns the care routines of professionals in an intensive environment, which should provide the recovery of the patient in the postoperative period of cardiac surgery. However, there are situations that make sleep and rest difficult during this period:

[...] you are in pain, you are concentrating to relax, to sleep suddenly... come one and turn on all the lights, no matter what time it is. (Pa5.1)

The previous testimony warns about the need for the health team to seek strategies that minimize the discomfort provoked, in the sense of favoring a less traumatic experience to the patient.

Understanding the Cardiac Rehabilitation Program

This category points to the cardiac rehabilitation program of the reference institution as an important tool for recovery and maintenance of revascularized patients´ health. This program, created in 1997, gradually acquires structural improvements and gains more followers:

It began to create strength, to create the body of the program and we gained a bigger space... increased the number of equipment, the structures, began to have many patients joining the program [...]. (Pr1.2)

Besides offering professional accompaniment and equipment for physical conditioning, the cardiac rehabilitation program encourages the participation of family members in the process and enables the socialization of the experienced by the patients, favoring their adherence, as can be seen:

Sometimes here in rehabilitation [...] I find a lot of cool people, here we talk [...]. Sometimes there are people here who have had surgery for 20 years, so I am happy [...]. (Pa9.3)

The program consists of four phases. The first phase occurs in hospital admission, when the program is disclosed to the patient with the necessary explanations, being emphasized the importance of their participation after discharge. The second phase starts after discharge, lasting two or three months, in which the patients are followed up by a physical educator during the practice of treadmill exercise and exercise bicycle. The third, lasting from four to six months, differs from the second phase due to the lesser need for supervision in the effort activities. The fourth phase - maintenance of physical conditioning - has an indefinite duration. Here there is the professional´s report:

Today we see the literature highlighting three phases, but we, by the structure that the hospital offers through the support of the population, we end up doing the four phases, because it becomes more viable [...]. (Pr1.2)

The patient´s participation in the program, in all phases of rehabilitation, ensures easy access to medical appointments and examinations, as well as facilitates the interaction and exchange of life experiences, important for their social reintegration and psychic health.

 

DISCUSSION

The statements of this study are related to the development of cardiovascular disease in lifestyle and hereditary factors. Inadequate diet, sedentary lifestyle, obesity, smoking, alcohol consumption, family history and the presence of dyslipidemia are risk factors that significantly increase the morbidity and mortality rate due to cardiovascular disease12.

However, morbidity and mortality indicators cannot be modified exclusively by the application of high complexity technology in referral services. Changes in people´s unhealthy lifestyle are fundamental5, and they can be encouraged by health practices and public policies, through investments in interventions and actions related to behavioral factors13.

Health professionals have an important role in guiding and raising patients´ revascularization on issues related to diet, exercise and lifestyle to assist them in the changes needed for a healthier lifestyle. Therefore, the practice of physical exercises should be motivated and frequently followed, considering that they encourage the individual to follow the recommended care with their health14. In this context, the importance of the cardiac rehabilitation program appears as a stimulus for the social interaction and maintenance of the physical condition of the re-vascularized patient.

The difficulty of the healthcare professional in recognizing the signs and symptoms of cardiovascular disease increases the uncertainty regarding the early diagnosis, with consequent impairment in the treatment of the patient, which should be immediate15. Considering that most of the deaths due to acute myocardial infarction occur in the first hours of disease (40% to 65% in the first hour and approximately 80% in the first 24 hours), early identification and diagnosis of the cardiovascular disease is essential, since the increased severity of the disease results in worse outcomes16. To that end, the promotion of health education to the population to guide the identification and management of signs and symptoms17, as well as the diagnostic training of health professionals can be an efficient strategy.

When patients and their families receive information about the need for a surgical procedure, they are usually affected by feelings of sadness, disbelief and stress. At that time, the health team can contribute favorably, offering a sensitive and humanized care, combined with technical skills and scientific knowledge to improve the health outcomes and quality of life of these patients18.

Despite being a reference in cardiology in the State of Santa Catarina, the studied institution has similar weaknesses as those reported in other studies, which refer to the institutional infrastructure and the long waiting time of the patients to perform surgeries, also identified in studies conducted in the South and Central-West regions of Brazil19-20.

The postponement of surgeries and the consequently extended stay due to lack of bed for the postoperative recovery of the patients, which in the case of myocardial revascularization surgery occurs in an intensive care setting, are also evidenced in other studies20.

The expectation and waiting for a condition for surgery can make the experience exhaustive and stressful for the patient and their family members. The excess of noise inherent to the intensive care unit in immediate postoperative recovery and failure to meet the sleep and rest needs, fundamental for patient recovery, and the experience of the surgical process may become negative21. Also, pain sensations are common to the patient in the postoperative period of cardiac surgery, whose external stressor stimuli may potentiate the pain symptomatology, reflecting the vital parameters, impairing the evolution of the re-vascularized patient22.

The cardiac rehabilitation program of the institution studied provides a structure to meet the real needs and potentials of the revascularized patients, according to recommendations23 and international guidelines24 to minimize the risk of new cardiac events through behavioral and environmental changes, and healthy life to avoid recurrence of the disease23. In Brazil and abroad, rehabilitation programs are developed in three or more phases, which can start even during hospitalization. These phases include anamnesis and physical examination of the patients, education regarding cardiovascular risk factors, sessions of therapeutic exercise, attendance by a multi-professional team, guidance on the adequate use of medications and the accomplishment and maintenance of physical activity and physical exercise on the other days of the week25.

The cardiac rehabilitation program must be performed by a multi-professional team from the preoperative period to promote the return of the re-vascularized patient to his usual social and work activities. The guidelines and educational practices initiated during this period favor the patient's surgery, allowing a reduction in the rates of postoperative complications and length of hospital stay. Therefore, they speed up the recovery, enabling the patient to return to his/her usual routine more quickly26-27.

In this study, the patient´s permanence in the cardiac rehabilitation program is attributed to facilitating access to drug therapy and the performance of exams and consultations, as well as opportunities for interaction, coexistence, and socialization in a group. The social interaction that the cardiac rehabilitation service provides to its adherents contributes considerably to the reduction of anxiety and depression rates, which frequently affect the revascularized cardiac patient, helping to develop a satisfactory level of physical and social activity and psychological balance after the event of disease and cardiac surgery28,29.

The continuity of the actions developed in the cardiac rehabilitation program can be developed in basic care, through the nurse´s role, increasing in recent years. This professional, with knowledge of the causal factors of coronary disease, can act with the patients in the prevention and reduction of the incidence of the disease and the improvement of the quality of life through educational strategies in cardiac rehabilitation, applied in the family health strategy30.

 

CONCLUSION

The study reached the proposed goal of understanding how cardiac revascularized patients experience the discovery of the cardiovascular disease, from the diagnosis of the disease to cardiac rehabilitation.

It was identified that life habits and genetic factors were the main responsible for the manifestation of atherosclerotic heart disease in the study patients, whose re-vascularized heart surgery meant the possibility of survival.

The promotion of health education to the population about signs and symptoms of atherosclerotic heart disease and the diagnostic training to health professionals can facilitate early care and treatment. The health professionals have an important role not only to dignify and treat but also to guide the patient about the surgical process, a condition that facilitates their understanding and acceptance of surgery.

The reference hospital institution shows structural fragilities and within the scope of the actions of the professionals in the intensive care environment. Too much waiting time for the surgery and the prolonged hospitalization period of the patients make the surgical process a negative experience.

The rehabilitation program is potential for patient recovery. In addition to offering professional accompaniment and equipment for the physical conditioning of the patient in rehabilitation, the health team can contribute with health orientations that encourage the individual to rethink and to acquire new practices in their daily life for a healthy life.

The study shows the limitations related to the method and process of data collection that was based on interview and did not include observation of the participants that could have benefited the characterization process of the institution. It is suggested that other contexts and individuals be investigated to confirm the results of this study and/or to add new knowledge.

 

REFERENCES

1.Instituto Brasileiro de Geografia e Estatística [site de Internet]. Expectativa de vida. [cited 2016 Sep 12] Available from: http://teen.ibge.gov.br/noticias-teen/7827-expectativa-de-vida

2.Ramos GC. Aspectos relevantes da doença arterial coronariana em candidatos à cirurgia não cardíaca. Rev Bras Anestesiol. 2010; 60(6): 662-5.

3.Gama GGG, Mussi FC, Mendes AS, Guimarães AC. (Des)controle de parâmetros clínicos e antropométricos em indivíduos com doença arterial coronária. Rev esc enferm USP. 2011; 45(3): 624-31.

4. Bocchi EA, Marcondes-Braga FG, Ayub-Ferreira SM, Rohde LE, Oliveira WA, Almeida DR, et al. Sociedade Brasileira de Cardiologia. III Diretriz Brasileira de Insuficiência Cardíaca Crônica. Arq Bras Cardiol. 2009; 93(1 supl.1): 1-71.

5. Migowski ARN, Chaves RBM, Coeli CM, Ribeiro ALP, Tura BR, Kuschnir MCC, et al. Precisión de la relación probabilística en la evaluación de la alta complejidad en cardiología. Rev Saude Publica. 2011; 45(2): 269-75.

6. Ministério da Saúde(Br). Secretaria de Vigilância em SaúdeMortalidade por doenças crônicas no Brasil: situação em 2010 e tendências de 1991 a 2010. [website]. Secretaria de Vigilância em Saúde/MS. Saúde Brasil 2011: uma análise da situação de saúde e a vigilância da saúde da mulher. [cited 2016 Sep 08] Available from: http://portalsaude.saude.gov.br/portalsaude/arquivos/pdf/2013/Fev/21/saudebrasil2011_parte1_cap4.pdf

7.Cadore MP, Guaragna JCVC, Anacker JFA, Albuquerque LC, Bodanese LC, Piccoli JCE, et al. Proposição de um escore de risco cirúrgico em pacientes submetidos à cirurgia de revascularização miocárdica. Rev Bras Cir Cardiovasc. 2010; 25(4): 447-56.

8. Anderson AJPG, Barros Neto FXR, Costa MAC, Dantas LD, Hueb AC, Prata MF. Preditores de mortalidade em pacientes acima de 70 anos na revascularização miocárdica ou troca valvar com circulação extracorpórea. Rev Bras Cir Cardiovasc. 2011; 26.1: 69-75.

9.Lemos KF, Davis R, Moraes MA, Azzolin K. Prevalência de fatores de risco para Síndrome Coronariana aguda em pacientes atendidos em uma emergência. Rev Gaúcha Enferm. 2010; 31(1): 129-35.

10. Strauss A, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. 2ª ed. Porto Alegre (RS): Artmed; 2008.

11.Ministério da Saúde (Br). Conselho Nacional de Saúde. Resolução no. 466/2012: diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. Brasília (DF): Ministério da Saúde; 2012.

12. Stipp MAC. A gerência do cuidado na enfermagem cardiovascular. Esc Anna Nery. 2012; 16(1): 7-9.

13.Santos I, Soares CS, Berardinelli LMM. Promovendo o autocuidado de clientes com obesidade e coronariopatia: aplicação do diagrama de pender. Rev enferm UERJ. 2013; 21(3): 301-6.

14.Vila VSC, Rossi LA, Costa MCS. Experiência da doença cardíaca entre adultos submetidos à revascularização do miocárdio. Rev Saude Publica. 2008; 42(4): 750-6.

15.Gouveia VA, Victor EG, Lima SG. Pre-hospital attitudes adopted by patients faced with the symptoms of acute myocardial infarction. Rev Latino-Am Enfermagem. 2011; 19(5): 1080-7.

16.Banner D. Becoming a coronary artery bypass graft surgery patient: a grounded theory study of women's experiences. J Clin Nurs. 2010; 19(21-22): 3123-33.

17.Gonçalves FG, Albuquerque DC. Educação em saúde de pacientes portadores de insuficiência cardíaca. Rev enferm UERJ. 2014; 22(3): 422-8.

18.Piegas LS, Feitosa G, Mattos LA, Nicolau JC, Rossi Neto JM, Timerman A, et al. Sociedade Brasileira de Cardiologia. Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto agudo do Miocárdio com Supradesnível do Segmento ST. Arq Bras Cardiol. 2009; 93(6 supl.2):e179-e264.

19.Sisson MC, Oliveira MC, Conill EM, Pires D, Boing AF, Fertonani HP. Users' satisfaction with the use of public and private health services within therapeutic Itineraries in southern Brazil. Interface. 2011; 15(36): 123-36.

20.Chaves Sá SP, Gomes do Carmo T, Secchin Canale L. Avaliando o indicador de desempenho suspensão cirúrgica, como fator de qualidade na assistência ao paciente cirúrgico. Enferm glob. 2011; 10(23): 200-9.

21.Baggio MA, Pomatti DM, Bettinelli, LA, Erdmann AL. Privacidade em unidades de terapia intensiva: direitos do paciente e implicações para a enfermagem. Rev Bras Enferm. 2011; 64(1): 25-30.

22.Miranda AFA, Silva LF, Caetano JA, Sousa AC, Almeida PC. Avaliação da intensidade de dor e sinais vitais no pós-operatório de cirurgia cardíaca. Rev esc enferm USP. 2011; 45(2): 327-33.

23.National Heart Foundation of Australia & Australian Cardiac Rehabilitation Association [site de Internet]. Recommended Framework for Cardiac Rehabilitation 4. [cited 2016 Sep 11] Available from: http://www.heartfoundation.org.au/SiteCollectionDocuments/Recommended-framework.pdf

24.European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). [site de Internet]. European Society of Cardiology. [cited 2016 Aug 10] Available from: http://eurheartj.oxfordjournals.org/content/early/2012/05/02/eurheartj.ehs092.full.pdf+html

25.Magalhães S, Viamonte S, Ribeiro MM, Barreira A, Fernandes P, Torres S, et al. Efeitos a longo prazo de um programa de reabilitação cardíaca no controlo dos fatores de risco cardiovasculares. Rev Port Cardiol. 2013; 32(3): 191-9.

26.Nery RM, Barbisan JN. Efeito da atividade física de lazer no prognóstico da cirurgia de revascularização do miocárdio. Rev Bras Cir Cardiovasc. 2010; 25(1): 73-8.

27.Miranda RCV, Padulla SAT, Bortolatto CR. Fisioterapia respiratória e sua aplicabilidade no período pré-operatório de cirurgia cardíaca. Rev Bras Cir Cardiovasc. 2011; 26(4): 647-52.

28.Blumenthal JA. New frontiers in cardiovascular behavioral medicine: Comparative effectiveness of exercise and medication in treating depression. Cleve Clin J Med. 2011; 78(Suppl 1): S35-43.

29.Sardinha A, Araújo CGS; Silva ACO, Nardi AE. Prevalência de transtornos psiquiátricos e ansiedade relacionada à saúde em coronariopatas participantes de um programa de exercício supervisionado. Rev psiquiatr clín. 2011; 38(2): 61-5.

30.Fassarella CS, Pinto VAE, Alves AS. O enfermeiro como educador na reabilitação cardíaca dentro da Estratégia Saúde da Família: revisão de literatura. Rede de Cuidados em Saúde. 2013; 7(1):1-8.