Document Type : Original Article(s)


1 Assistant Professor, Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

2 Professor, Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

3 Research Assistant, Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

4 Resident, Department of Cardiovascular Medicine, University of California San Diego, San Diego, CA

5 Professor, Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

6 Professor, Department of Psychosomatic Medicine and Psychotherapy, University of Freiburg, Freiburg, Germany


BACKGROUND: Growth of cardiovascular disease (CVD), variation in provision of medical services, rising costs, and increasing information availability through the media are making patients more actively involved in decision-making process of their treatment. The aim of this study was to better understand the components of patient competence in the context of coronary artery disease (CAD) and to further evaluate their relations with medical, demographic, and psychosocial characteristics.METHODS: In this cross-sectional study, 148 patients with at least one year diagnosis of acute coronary syndrome (ACS) were enrolled in the study from April to June 2014. Data on demographic characteristics, depression, anxiety, quality of life (QOL), social support, and drug adherence were collected from participants. Pearson correlation, one way analysis of variance (ANOVA), and multiple linear regression tests were performed for analyzing data.RESULTS: The mean age of patients was 53.63 ± 5.15. Of the participants, 58 (39.5%) and 61 cases (41.5%) were found to be depressed and anxious, respectively. Higher levels of self-regulation correlated with higher education years and social support, and also with lower depression and anxiety (P < 0.050). Stress management and confronting the threat were linked to education years, depression, anxiety, QOL, and social support (P < 0.050).CONCLUSION: The patients with CAD, in order to be involved in the proper treatment process and manage their emotions during this process, need to have the required competencies. Patient competence as a whole and its components have been related to medical, demographic, and psychosocial characteristics.


  1. World Health Organization. 2008-2013 Action plan for the global strategy for the prevention and control of noncommunicable diseases. Geneva, Switzerland: WHO; 2009.
  2. Belanger E, Rodriguez C, Groleau D. Shared decision-making in palliative care: A systematic mixed studies review using narrative synthesis. Palliat Med 2011; 25(3): 242-61.
  3. Street RL Jr, Voigt B. Patient participation in deciding breast cancer treatment and subsequent quality of life. Med Decis Making 1997; 17(3): 298-306.
  4. Kranich C. Patients' competences. What do patients need to know and be able to do?. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2004; 47(10): 950-6.
  5. World Health Organization. Integrated chronic disease prevention and control [Online]. [cited 2018]; Available from: URL:
  7. Burton D, Blundell N, Jones M, Fraser A, Elwyn G. Shared decision-making in cardiology: Do patients want it and do doctors provide it? Patient Educ Couns 2010; 80(2): 173-9.
  8. Henwood S, Wilson MA, Edwards I. The role of competence and capacity in relation to consent for treatment in adult patients. Br Dent J 2006; 200(1): 18-21.
  9. Roohafza H, Sadeghi M, Khani A, Afshar H, Amirpour A, Sarrafzadegan N, et al. Development and validation of cardiac patient competence questionnaire, Iranian version. ARYA Atheroscler 2015; 11(4): 220-7.
  10. Leo RJ. Competency and the capacity to make treatment decisions: A primer for primary care physicians. Prim Care Companion J Clin Psychiatry 1999; 1(5): 131-41.
  11. White DB, Curtis JR, Lo B, Luce JM. Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers. Crit Care Med 2006; 34(8): 2053-9.
  12. Sheridan SL, Viera AJ, Krantz MJ, Ice CL, Steinman LE, Peters KE, et al. The effect of giving global coronary risk information to adults: A systematic review. Arch Intern Med 2010; 170(3): 230-9.
  13. Tunzi M. Can the patient decide? Evaluating patient capacity in practice. Am Fam Physician 2001; 64(2): 299-306.
  14. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002; 288(19): 2469-75.
  15. Berg JW, Appelbaum PS, Grisso T. Constructing competence: Formulating standards of legal competence to make medical decisions. Rutgers Law Rev 1996; 48(2): 345-71.
  16. Krumholz HM, Peterson ED, Ayanian JZ, Chin MH, DeBusk RF, Goldman L, et al. Report of the national heart, lung, and blood institute working group on outcomes research in cardiovascular disease. Circulation 2005; 111(23): 3158-66.
  17. Pedersen SS, Herrmann-Lingen C, de Jonge P, Scherer M. Type D personality is a predictor of poor emotional quality of life in primary care heart failure patients independent of depressive symptoms and New York Heart Association functional class. J Behav Med 2010; 33(1): 72-80.
  18. Barber JP, Liese BS, Abrams MJ. Development of the cognitive therapy adherence and competence scale. Psychother Res 2003; 13(2): 205-21.
  19. Luepker RV, Apple FS, Christenson RH, Crow RS, Fortmann SP, Goff D, et al. Case definitions for acute coronary heart disease in epidemiology and clinical research studies: A statement from the AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; the European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; and the National Heart, Lung, and Blood Institute. Circulation 2003; 108(20): 2543-9.
  20. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007; 50(7): e1-e157.
  21. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130(25): 2354-94.
  22. Montazeri A, Vahdaninia M, Ebrahimi M, Jarvandi S. The Hospital Anxiety and Depression Scale (HADS): Translation and validation study of the Iranian version. Health Qual Life Outcomes 2003; 1: 14.
  23. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67(6): 361-70.
  24. EuroQol--a new facility for the measurement of health-related quality of life. Health Policy 1990; 16(3): 199-208.
  25. Saffari M, Pakpour AH, Naderi MK, Koenig HG, Baldacchino DR, Piper CN. Spiritual coping, religiosity and quality of life: A study on Muslim patients undergoing haemodialysis. Nephrology (Carlton) 2013; 18(4): 269-75.
  26. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assess 1988; 52(1): 30-41.
  27. Bagherian-Sararoudi R, Hajian A, Ehsan HB, Sarafraz MR, Zimet GD. Psychometric properties of the Persian version of the multidimensional scale of perceived social support in Iran. Int J Prev Med 2013; 4(11): 1277-81.
  28. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986; 24(1): 67-74.
  29. Tengland PA. Empowerment: A conceptual discussion. Health Care Anal 2008; 16(2): 77-96.
  30. Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet 2004; 364(9444): 1523-37.
  31. Farin E, Schmidt E, Gramm L. Patient communication competence: Development of a German questionnaire and correlates of competent patient behavior. Patient Educ Couns 2014; 94(3): 342-50.
  32. Paulus MP, Yu AJ. Emotion and decision-making: Affect-driven belief systems in anxiety and depression. Trends Cogn Sci 2012; 16(9): 476-83.
  33. Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: How education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health 1992; 82(6): 816-20.
  34. Matthews KA, Gallo LC. Psychological perspectives on pathways linking socioeconomic status and physical health. Annu Rev Psychol 2011; 62: 501-30.
  35. Stewart MJ, Hirth AM, Klassen G, Makrides L, Wolf H. Stress, coping, and social support as psychosocial factors in readmissions for ischaemic heart disease. Int J Nurs Stud 1997; 34(2): 151-63.
  36. Roohafza H, Talaei M, Pourmoghaddas Z, Rajabi F, Sadeghi M. Association of social support and coping strategies with acute coronary syndrome: A case-control study. J Cardiol 2012; 59(2): 154-9.
  37. Cene CW, Haymore LB, Lin FC, Laux J, Jones CD, Wu JR, et al. Family member accompaniment to routine medical visits is associated with better self-care in heart failure patients. Chronic Illn 2015; 11(1): 21-32.
  38. Putman-Casdorph H, McCrone S. Chronic obstructive pulmonary disease, anxiety, and depression: State of the science. Heart Lung 2009; 38(1): 34-47.
  39. Yohannes AM, Willgoss TG, Baldwin RC, Connolly MJ. Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: Prevalence, relevance, clinical implications and management principles. Int J Geriatr Psychiatry 2010; 25(12): 1209-21.
  40. Egede LE. Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability. Gen Hosp Psychiatry 2007; 29(5): 409-16.
  41. Hartley CA, Phelps EA. Anxiety and decision-making. Biol Psychiatry 2012; 72(2): 113-8.
  42. Ockene IS, Miller NH. Cigarette smoking, cardiovascular disease, and stroke: A statement for healthcare professionals from the American Heart Association. American Heart Association Task Force on Risk Reduction. Circulation 1997; 96(9): 3243-7.
  43. Al-Naggar RA, Al-Dubai SA, Al-Naggar TH, Chen R, Al-Jashamy K. Prevalence and of smoking and associated factors among Malaysian University students. Asian Pac J Cancer Prev 2011; 12(3): 619-24.
  44. Yalcin BM, Unal M, Pirdal H, Karahan TF. Effects of an anger management and stress control program on smoking cessation: A randomized controlled trial. J Am Board Fam Med 2014; 27(5): 645-60.
  45. Horwitz RI, Horwitz SM. Adherence to treatment and health outcomes. Arch Intern Med 1993; 153(16): 1863-8.
  46. Hagihara A, Murakami M, Chishaki A, Nabeshima F, Nobutomo K. Rate of health insurance reimbursement and adherence to anti-hypertensive treatment among Japanese patients. Health Policy 2001; 58(3): 231-42.