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Heart failure (HF) after acute myocardial infarction (AMI) seriously affects the prognosis and quality of life of patients, and the timeliness of nursing intervention is crucial. As a theoretical framework for nursing intervention, timing theory emphasizes timeliness and accuracy, and can comprehensively improve the overall prognosis of patients.
Objective
To explore the impact of nursing measures based on timing theory on clinical outcomes of patients with heart failure after acute myocardial infarction.
Methods
Patients with heart failure after acute myocardial infarction admitted to the People’s Hospital of Henan Province from January 2023 to June 2024 were selected as the research objects. A total of 90 patients were included and randomly divided into the experimental group and the control group, with 45 patients in each group. The experimental group received systematic nursing intervention based on opportunity theory, and the control group received routine nursing care. Cardiac function indicators (LVEF, LVEDV, LVESV, NT-proBNP) of patients in the two groups were evaluated before and after the intervention, Immediately before treatment (T0), Patients ‘exercise endurance (6MWT), anxiety and depression (GAD-7, PHQ-9) and quality of life (MLHFQ) were evaluated 1 month (T1), 3 months (T3) and 6 months (T6) after treatment. Patients in both groups were followed up regularly for 6 months.
Results
After intervention, the cardiac function indicators (LVEF, LVEDV, LVESV, NT-proBNP) of the two groups were significantly improved, and the experimental group was better than the control group (p < 0.05). After the intervention, the exercise endurance 6MWT, anxiety and depression (GAD-7, PHQ-9) and quality of life (MLHFQ) scores of patients in both groups were significantly improved, and the scores in the experimental group at the same day (T0), 1 month (T1), 3 months (T3) and 6 months (T6) after treatment were significantly better than those in the control group (p < 0.05), and both showed a trend of continuous improvement.
Conclusion
Timing theory has important application value in the continuous care of patients with heart failure after acute myocardial infarction. Scientific and precise timing of nursing intervention can significantly improve patients ‘cardiac function, exercise endurance, emotional state and quality of life.
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Introduction
Acute myocardial infarction (AMI) is one of the most common and life-threatening cardiovascular diseases, and its morbidity and mortality remain high globally.The latest statistics from the World Health Organization (WHO) show that about 17 million people die from cardiovascular disease every year around the world, of which AMI is the core cause of death, accounting for more than 30% [1]; my country’s 2023 Cardiovascular Disease Annual Report shows that the number of hospitalized patients with AMI has reached 1.222 million, and the inpatient mortality rate is 4.0% [2]. However, heart failure (HF) after AMI is still one of the fatal complications, and its impact on patients ‘long-term quality of life and prognosis cannot be ignored [3, 4]. Studies have found that about 20% to 30% of patients with acute myocardial infarction develop heart failure some time after the onset of the disease, especially patients with widespread myocardial necrosis [5]. Heart failure not only significantly increases patient mortality and readmission rates, but also has long-term impacts on patients ‘daily life and social functions [6, 7]. A large number of studies have confirmed [8, 9] that scientific and precise nursing intervention can effectively improve the long-term prognosis and quality of life of patients with AMI and HF.Therefore, carrying out scientific and precise nursing intervention for patients with heart failure after AMI is of great significance to improving the long-term prognosis and quality of life of patients.
In recent years, timing theory, as a theoretical framework that emphasizes the timeliness and timing of nursing intervention, has attracted widespread attention from scholars in cardiovascular disease care.This theory was first systematically applied to the field of cardiovascular care by Lyu et al. [10]. Its core logic is to implement adaptive intervention at critical time points based on changes in physiology-psychological-social needs of disease progression, which has been proven to significantly improve the effectiveness of intervention. Targeting. For patients with heart failure after AMI, the timing of nursing intervention is particularly critical. The development of HF after AMI has clear time-dependent characteristics: 24–36 hours after the onset is the acute injury period, which is the golden window for suppressing the extension of infarction area [11]; 3 months is the critical period for myocardial remodeling, which directly affects the recovery of cardiac function [12]; 6–12 months after discharge is the rehabilitation consolidation period, and continuous intervention is needed to maintain the rehabilitation effect [13]. Therefore, the timeliness and accuracy of nursing intervention have a crucial impact on patient clinical outcomes. Early cardiac function monitoring, fluid management, anticoagulation and other measures in the acute phase can significantly reduce the incidence of acute heart failure and the aggravation of complications [14]. Implementing appropriate exercise interventions targeting exercise endurance, diet management, and psychological support focusing on alleviating anxiety and depression (and improving emotional health) during the rehabilitation period can help restore cardiac function and reduce the deterioration of heart failure [15]. Therefore, matching nursing interventions with the patient’s disease development and precise treatment at appropriate time points may have a positive impact on the clinical outcomes of AMI patients [16, 17]. However, most of the existing research focuses on nursing intervention in the acute phase, and systematic research on the timing of nursing intervention is still insufficient.
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Based on this, This study focused on patients with heart failure after AMI, By setting four time points: the day after treatment, 1 month after treatment, 3 months after treatment, and 6 months after treatment, the effects of continuous nursing intervention based on timing theory on patients ‘cardiac function, Sports endurance, Anxiety, depression and quality of life. The research results will provide a basis for nurses to formulate personalized nursing plans, Promote the precise and personalized development of cardiovascular disease nursing intervention and improve the overall quality of nursing care, with a view to making positive contributions to patient rehabilitation and social health.
Materials and methods
Research object
This study adopted a prospective cohort design and selected patients with heart failure after acute myocardial infarction (AMI) admitted to the Cardiac Intensive Care Unit (CCU) of Henan Province People’s Hospital from January 2023 to June 2024. The inclusion and exclusion criteria were determined based on objective electronic medical record data (disease diagnosis, comorbidities, etc.) combined with specialized clinical assessments (cardiac function, cognitive status, etc.), with verification by two independent researchers. The case screening process involved 156 hospitalized patients, with 66 excluded (12 with NYHA class IV heart failure, 18 with severe comorbidities, 3 in pregnancy/lactation, 15 with cognitive/psychiatric disorders, and 18 with other severe cardiac conditions), ultimately enrolling 90 cases that were randomly assigned to either the experimental group or control group (45 cases each). Inclusion criteria: Age 18 years and above, male or female; diagnosis of acute myocardial infarction (AMI) and heart failure occurring within 24 hours of admission; degree of heart failure must comply with NYHA Functional Classification Class II to III; Voluntary participation in this study and sign informed consent. Exclusion criteria: Patients with severe heart failure classified as NYHA Class IV; patients complicated with severe liver failure, end-stage renal disease, malignant tumors, or other serious systemic diseases; pregnant or breastfeeding women; patients with cognitive impairment or severe mental illness; patients complicated with aortic dissection, significant valvular heart disease, or other serious cardiac conditions. This study has been approved by the Medical Ethics Committee of Henan Province People’s Hospital.
In this study, the quality of life score of patients with heart failure after acute myocardial infarction was used as the main evaluation indicator to compare the two sample means. The sample size calculation formula is as follows:
Let σ be the estimated standard deviation for both populations, and δ be the difference between the two means. With α set at 0.05 (two-tailed), β at 0.10, and power (1-β) at 0.90. Based on preliminary experimental results, the quality of life scores showed σ = 2.413 and δ = 1.8 for the two patient groups. Substituting these values into the sample size formula yielded N = 38 per group. Accounting for a 15% potential attrition rate, a total of 90 patients were enrolled in the study. Randomization process: The statistician used IBMSPSS25.0 to generate random numbers from 1 to 90, which divided the experimental group into odd numbers and the control group into odd numbers; the allocation was concealed using a sealed envelope method, and the package was opened after baseline evaluation. Nursing staff, patients and assessors were blinded to group the situation to prevent bias.
Research methods
Basic care (both groups received)
Basic care content: ① Vital signs monitoring: Measure body temperature, heart rate, blood pressure, etc. regularly every day, and report abnormalities in a timely manner; ② Drug management: dispense medicines according to doctor’s advice, supervise medication taking, and record compliance; ③ Body fluid and electrolyte management: measure body weight every day, record receipts and outs, check electrolytes regularly, and maintain blood potassium at 3.5–5.5 mmol/L; ④ Basic life care: Assist in turning over, knocking back, etc. to prevent complications; ④ Routine health education: issue manuals and explain them once a week (30 minutes); ④ Discharge guidance: Provide a written summary to clarify the follow-up visit, medication and emergency treatment methods; ③ Routine follow-up: Telephone or outpatient follow-up visits 1, 3, and 6 months after discharge to inquire about symptoms and medication.
Control group nursing
The control group added routine heart failure management to basic care: Nursing staff regularly monitor the patient’s vital signs, weight and edema to ensure that drugs are taken on time, and perform electrolyte tests to keep blood potassium within the normal range. For patients with anxiety or depression, caregivers provide psychological counseling and encourage patients to express emotions and pay attention to psychological needs. In rehabilitation care, nurses assist patients with basic bedside physical activities, such as knee flexion and extension and sit-up training, to promote the recovery of limb function. In terms of health education, nurses provide routine nursing knowledge after myocardial infarction, focusing on diet management, drug use and life precautions. At discharge from the hospital, nursing staff provides the patient with medication instructions and life guidance, and arranges follow-up visits. During follow-up, the nursing staff evaluated the patient’s cardiac function changes and symptoms, and adjusted the drug treatment plan in a timely manner.
Nursing in the experimental group (continuous nursing based on timing theory)
Based on the timing theoretical framework of Lyu et al. [10], the implementation process: ① Baseline evaluation: the responsible nurse evaluates the patient’s disease stage, cardiac function, psychological state, living environment, etc.;② Plan formulation: According to the acute period (1–7 days after admission), rehabilitation period (8–21 days after admission), and after discharge, an individualized intervention plan is formulated;③ Dynamic adjustment: weekly re-evaluation and adjustment of the intervention plan as needed. Specific intervention content:
(1)
Acute Phase Care: Psychological Support, Basic Nursing, and Health Education Psychological Support: Nursing staff observe patients’ anxiety and depressive mood within 24 hours of admission and provide targeted psychological counseling. For anxious patients, relaxation techniques (such as deep breathing and meditation) are used to guide them, while non-verbal expressions are monitored to adjust the approach accordingly. Face-to-face communication with patients is conducted daily to encourage expression of emotions and concerns. Open-ended questions are employed to understand their psychological needs, and gentle encouragement is provided to enhance confidence in recovery. Basic Nursing: Nursing staff monitor vital signs every two hours, ensure accurate connection of equipment, and record data, notifying the physician in case of abnormalities. Body weight is measured daily. If weight gain exceeds 1 kilogram, the physician is consulted to adjust diuretics; Edema was assessed using the “2+4” method [18]. This method presses the tibial area for 2 seconds and observes the duration of depression (≤4 seconds is mild edema, and > 4 seconds is moderate to severe edema). If edema is found, it will be reported to the doctor in a timely manner. Confirm patient information before dispensing, supervise medication and monitor fluid balance, and record urine volume. Electrolyte testing is performed every week, and if abnormal blood potassium is found, drugs are adjusted promptly and potassium salt is supplemented. Health education: Nursing staff provide graphic and graphic health education materials every day, and explain the key points of myocardial infarction care and diet adjustments through interviews, and ask interactive questions to ensure patient understanding. After each education, ask patients for their understanding and answer questions. Nursing staff demonstrated how to use sphygmomanometers, scales and other equipment, guided patients to operate independently and review the results.
(2)
Nursing during the rehabilitation period: functional recovery and prevention of complications. Functional recovery: When the patient resumes activities, the nursing staff first performs bedside physical activities, such as knee flexion and extension, ankle rotation, and helps the patient sit up from the bed, supports his back and shoulders, and prevents falls. Gradually increase the intensity of activity according to the patient’s degree of heart failure, guide the patient to stand and promote blood circulation through walking. When the patient’s cardiac function recovers, the nursing staff helps the patient gradually increase the walking time and distance, monitor heart rate and blood oxygen saturation, and ensure that the activity intensity is appropriate. When rehabilitation is progressing well, the nursing staff and the patient jointly set walking goals and help the patient achieve them gradually through daily monitoring. Nutritional intervention: Nursing staff explain the principles of low-sodium diets to patients, guide the selection of low-salt foods and check the salt content in meals, and ensure that the canteen prepares meals according to low-sodium standards. After discharge, a low-salt diet is provided. For a high-protein diet, caregivers assist dietitians in formulating plans that focus on protein sources, recommend low-fat fish, chicken breast and beans, and adjust meal lists to suit patient preferences. After each meal, ask the patient about his appetite, ensure adequate protein intake, and adjust the diet plan as needed. Complications monitoring and intervention: Nursing staff checked the patient’s weight and lower limb edema at fixed times every day, pressed the legs to observe the rebound speed of edema, recorded the results and reported to the doctor. In terms of lung infection prevention, nursing staff encourage patients to carry out hourly deep breathing and cough training to help discharge phlegm. For patients who cannot expectorate, regular expectoration care, such as back percussion, chest vibration and aerosol inhalation, should be given to ensure smooth lungs.
(3)
Post-discharge care: Continuous care and follow-up. Discharge guidance: Before discharge, nursing staff will provide personalized health education based on the patient’s condition, using illustrations, written materials and video resources to explain diet management (such as low-sodium and high-protein food choices), exercise guidance (recommended according to cardiac function grading), symptom monitoring (such as weight, edema, dyspnea monitoring) and drug management (drug name, dose, medication duration and side effects). After each education, the nursing staff will ask the patient and family members about their understanding and confirm the effect of the education through questions. When discharged from the hospital, nursing staff will sort out the drugs, indicate the name, dose and duration of administration, and provide education on how to use the drugs, doses and side effects. Within one week after discharge from hospital, nursing staff urged patients to take their medicine on time via phone or text message, and returned regularly to ensure that patients followed their doctor’s advice. Regular follow-up: The nursing staff arranges the first follow-up at the time of discharge to ensure that it takes place within 1 week, and arranges follow-up visits based on the patient’s condition. At each follow-up visit, the nurse used NYHA Functional Classification to assess the degree of heart failure and assessed mental health. The nurse will also inquire about changes in symptoms, feedback to the attending doctor, coordinate with the adjustment of the treatment plan, and conduct examinations and short-term monitoring if necessary.
(4)
Critical opportunity intervention: Nursing staff dynamically adjust the nursing plan according to changes in patient’s cardiac function and mental state. When cardiac function improves, the intensity of activity will be gradually increased and family exercise will be guided; when mental health improves, the frequency of psychological counseling will be reduced and more health management guidance will be provided. According to follow-up assessments, if edema or abnormal blood pressure occurs, the nursing staff will assist in adjusting the drug regimen and follow up on side effects of the drug. At each follow-up visit, the nurse will assess cardiac function and quality of life, record the assessment results, and adjust nursing measures in a timely manner based on changes. Patients in both groups were followed up regularly for 6 months.
Nurse responsibilities
Nursing responsibilities: ① Health education: Provide daily individualized guidance during hospitalization, conduct multimodal health education before discharge, and reinforce key points during follow-up; ② Monitoring: Measure vital signs every 2 hours and assess edema daily during hospitalization, evaluate cardiac function and symptoms during follow-up; ③ Coordination and communication: Promptly report abnormal findings to cardiologists, request psychiatric consultation when GAD-7≥10 or PHQ-9≥15; ④ Questionnaire administration: Distribute and collect GAD-7, PHQ-9, and MLHFQ scales at T0, T1, T3, and T6 time points; ⑤ 6MWT implementation: Conducted by two nurses following standardized procedures; ⑥ Rehabilitation guidance: Provide exercise rehabilitation instructions during hospitalization and follow-up; ⑦ Daily nursing coordination: Organize and coordinate all nursing interventions.
Outcome measures
Cardiac function
Cardiac function was assessed using the New York Heart Association (NYHA) Cardiac Functional Classification System [19]. The attending doctor evaluated it at baseline and at 1, 3, and 6 months after intervention, and combined with daily activities, symptoms and physical examination to determine the classification; The physical classification is: level I is not restricted in activities, and the patient can carry out daily activities without obvious palpitations or shortness of breath; level II is mildly restricted in activities, and palpitations or shortness of breath may occur in daily activities, but there are no symptoms at rest; level III is significantly restricted in activities, and palpitations or shortness of breath occur during light activities, and there are few symptoms at rest; level IV is also symptoms at rest, and any physical activity will cause discomfort.
Changes in left ventricular ejection fraction (LVEF), left ventricular end systolic volume (LVESV) and left ventricular end diastolic volume (LVEDV) were measured by echocardiography before and after intervention. All measurements were made using a single Philips EPIQ 7C ultrasound system (Philips Medical Company of the Netherlands), equipped with a 3.5 MHz phased array probe, and performed blindly by a certified doctor. Measurements were made at baseline and 6 months after intervention, and each indicator was taken 3 times to take the average; LVEF is a key indicator for assessing left ventricular systolic function. Normal values are usually between 50 and 70%, and values below 50% indicate systolic dysfunction. LVEDV reflects the left ventricular volume at the end of diastolic phase and is related to cardiac load and degree of expansion. Increase usually indicates cardiac expansion and may be a sign of heart failure. LVESV reflects the left ventricular end-systolic volume. A larger it indicates a decrease in blood output per contraction, indicating a decrease in systolic function.
Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is an important marker for assessing patients ‘cardiac load and cardiac function, and its level usually increases with the weakening of cardiac function. 5 mL of venous blood was collected immediately before the start of treatment (T0), placed in an EDTA anticoagulant tube, centrifuged at 3000 revolutions per minute for 10 minutes, and the supernatant was collected and tested using a Cobase601 electrochemiluminescent immunoassay system (Roche Diagnostics, Germany). The detection range was 5- 35,000 pg/mL. For asymptomatic healthy adults, NT-proBNP concentrations are usually less than 125 pg/mL. In patients with heart failure, NT-proBNP levels are significantly elevated. According to the concentration of NT-proBNP, the reference standards are < 125 pg/mL(healthy people), 125-1000 pg/mL(mild heart failure), 1000–5000 pg/mL(moderate heart failure), and > 5000 pg/mL(severe heart failure).
Exercise endurance
The 6-minute walk test (6MWT) [20] was employed to assess patients’ exercise tolerance. The procedure was conducted on a 30-meter flat corridor with markings every 5 meters. Patients rested for 10 minutes before the test while vital signs were measured, and test instructions were provided. Standardized encouragement was given every minute. The test was paused if fatigue, chest pain, or other concerning symptoms occurred and was immediately terminated with appropriate medical intervention in case of severe adverse events. Reference standards followed Ferreira et al. [20]: < 150 meters indicated severe heart failure, 150–425 meters moderate heart failure, and > 425 meters mild heart failure. The total 6-minute walk distance (6MWD) in meters was recorded and classified according to these criteria.
Psychological mood
Mental status was assessed using the General Anxiety Disorder Scale (GAD-7) [21] and the Patient Health Questionnaire (PHQ-9) [22]. The Chinese versions of GAD-7 and PHQ-9 verified by Zeng et al. [23] and Wang et al. [24] were used, both of which have been widely used in patients with heart disease. In this study, the Cronbach’sα coefficients for GAD-7 and PHQ-9 were 0.82 and 0.85, respectively, indicating good internal consistency.
GAD-7 contains 7 items, involving anxiety, worry, tension, uncontrollable anxiety and somatic symptoms. It uses a 4-level score (0 = no at all, 1 = a few days, 2 = more than half of the days, 3 = almost every day). The total score is 0–21. The grading standard is: 0–4 points without anxiety, 5–9 points mild anxiety, 10–14 points moderate anxiety, and 15–21 points severe anxiety.
PHQ-9 contains 9 items, covering symptoms such as depressive mood, loss of interest, sleep disorders, changes in appetite, fatigue, uselessness, and difficulty in attention. It is scored on a 4-level basis (0 = no at all, 1 = a few days, 2 = more than half of the days, 3 = almost every day), with a total score of 0–27 points. The grading standards are: 0–4 points without depression, 5–9 points with mild depression, 10–14 points with moderate depression, 15–19 points with moderate depression, and ≥20 points with severe depression.
Quality of life
Patients ‘quality of life was assessed using the Minnesota Quality of Life Score (HFMLQ) scale [25]. The Chinese version of MLHFQ verified by Li et al. was used, and the reliability and validity of this version has been verified in China heart failure patients; in this study, its Cronbach’sα coefficient was 0.88, indicating good internal consistency. The MLHFQ contains 21 items covering physical function, emotional health, social activities and perception of self-health. It is scored on a 5-level basis (0 = no impact, 1 = slight impact, 2 = moderate impact, 3 = significant impact, 4 = extremely significant impact), with a total score of 0–105 points. The grading criteria are: 0 point no impairment, 1–30 points mild impairment, 31–60 points moderate impairment, 61–90 points severe impairment, and 91–105 points extremely severe impairment.
Statistical methods
Data were analyzed statistically using IBM SPSS25.0 software. Continuous variables that conform to a normal distribution are expressed as mean ± standard deviation (mean±SD), and the differences between the two groups are compared using independent sample t-tests. For non-normally distributed continuous variables, the median and quartile (Median[IQR]) were expressed, and the Mann-Whitney U test was used for inter-group comparisons. Categorical variables are expressed as frequencies and percentages, and comparisons between groups were performed using the χ2 test or Fisher’s exact test. In order to evaluate the interaction effect between groups × time and compare the temporal trend of outcome indicators between the two groups, continuous variables with normal distribution were analyzed using repeated measures analysis of variance (ANOVA), and variables with potentially missing data or unsatisfactory distribution were analyzed using linear mixed effects model (LMM). p < 0.05 indicates that the difference is statistically significant.
Results
There were no statistically significant differences between the two groups in baseline characteristics such as age, gender, BMI, smoking history, number of chronic diseases, cardiac function classification, number of stents installed, myocardial infarction site, and myocardial infarction type (p > 0.05), which was comparable (Table 1).
Table 1
Comparison of baseline characteristics between the two patient groups
Variable
Experimental Group(n = 45)
Control Group(n = 45)
c2/t
P-value
Age
59.89±5.78
61.52±5.58
1.361
0.177
Gender
0.200
0.655
Male
31 (68.89)
29 (64.44)
Female
14 (31.11)
16 (35.56)
BMI
27.61±3.25
26.58±3.78
1.386
0.169
Smoking History
21 (46.67)
24 (53.33)
0.400
0.527
Chronic Disease History
1.419
0.701
0
7 (15.56)
8(17.78)
1
20 (44.44)
23 (51.11)
2
15 (33.33)
10 (22.22)
≥3
3 (6.67)
4 (8.89)
NYHA Class
0.421
0.517
Class II
29 (64.44)
26 (57.78)
Class III
16 (35.56)
19 (42.22)
Number of Stents Implanted
0.965
0.810
0
5 (11.11)
4 (8.89)
1
17 (37.78)
21 (46.67)
2
21 (46.67)
19 (42.22)
3
2 (4.44)
1 (2.22)
˃3
0 (0.00)
0 (0.00)
Myocardial Infarction Location
1.197
0.754
Anterior Wall
25 (55.56)
21 (46.67)
Inferior Wall
11 (24.44)
15 (33.33)
Posterior Wall
6 (13.33)
5 (11.11)
Other
3 (6.67)
4 (8.89)
Type of Myocardial Infarction
0.711
0.399
STEMI
25 (55.56)
21 (46.67)
NSTEMI
20 (44.44)
24 (53.33)
Hospital Stay
14.23±2.56
13.89±2.31
0.682
0.497
Note: All data are presented as n (%) or mean ± SD
The results of cardiac function indicators showed that the left cardiac function indicators in the experimental group improved significantly after the intervention. Specifically, after intervention, LVEF in the experimental group (39.48±4.25%) was significantly higher than that in the control group (36.48±3.34%)(p < 0.001), while LVEDV and LVESV were significantly lower than that in the control group (p < 0.001). In addition, the NT-proBNP level in the experimental group was significantly lower than that in the control group (p < 0.001), indicating that cardiac functional pressure was significantly relieved. In contrast, there were no significant differences in the indicators (LVEF, LVEDV, LVESV, NT-proBNP) between the two groups before intervention (p > 0.05)(Table 2). The results of the 6-minute walk test (6MWT) showed that the exercise endurance of patients in both groups improved over time, but the improvement in the experimental group was significantly better than that in the control group. Specifically, at T0 (stable hospitalization period), there was no significant difference in 6MWT scores between the two groups (p > 0.05). At 1 month, 3 months and 6 months after treatment, the 6MWT scores of the experimental group were significantly better than those of the control group (p < 0.001). Repeated measures analysis of variance showed that 6MWT had significant main effects of time, main effects between groups, and interaction effects between groups × time (p < 0.001). (Table 3). Figure 1 more intuitively shows the comparison of cardiac function indicators (LVEF, LVEDV, LVESV, NT-proBNP) and exercise tolerance (6MWT) between the experimental group and the control group before and after intervention.
Table 2
Comparison of cardiac function between the two patient groups
Indicator
Group
Pre-intervention
Post-intervention
t-value
P-value
LVEF(%)
Experimental Group(n = 45)
30.73±2.76
39.48±4.25
1.783
0.078
Control Group(n = 45)
32.05±4.13
36.48±3.34
3.723
< 0.001**
LVEDV(mL)
Experimental Group(n = 45)
124.83±10.78
87.10±10.82
1.348
0.181
Control Group(n = 45)
121.11±15.05
101.07±15.05
5.056
< 0.001**
LVESV(mL)
Experimental Group(n = 45)
74.83±10.78
40.86±7.07
1.439
0.154
Control Group(n = 45)
71.25±12.74
51.52±10.58
5.62
< 0.001**
NT-proBNP(ng/L)
Experimental Group(n = 45)
3442.21±440.18
1260.67±132.95
0.201
0.841
Control Group(n = 45)
3423.31±451.83
1489.15±52.68
10.718
< 0.001**
Table 3
Comparison of six-minute walk test results between the two patient groups
Group
6MWT
T0
T1
T3
T6
FGroup
FTime
FGroup × Time
Experimental Group(n = 45)
180.31±31.62
221.25±55.15
350.61±60.25
405.85±70.15
89.642
586.319
42.875
Control Group(n = 45)
185.37±33.50
251.26±50.16
280.26±55.12
320.15±60.18
t-value
0.737
3.688
5.779
6.220
P-value
0.463
< 0.001**
< 0.001**
< 0.001**
< 0.001**
< 0.001**
< 0.001**
Note: T0, T1, T3, T6 represent the day of treatment completion, 1 month, 3 months, and 6 months after treatment, respectively. * indicates p < 0.05; ** indicates p < 0.01. 6MWT, six-minute walk test
Fig. 1
Comparison of cardiac function indicators (LVEF, LVEDV, LVESV, NT-proBNP) and exercise tolerance (6MWT) between the experimental group and the control group before and after intervention. (A) left ventricular ejection fraction (LVEF); (B) left ventricular end diastolic volume (LVEDV); (C) left ventricular end systolic volume (LVESV); (D) N-terminal pro-brain natriuretic peptide (NT-proBNP); (E)6-minute walk test (6MWT). * p < 0.05,**p < 0.01
The results of anxiety status (GAD-7 score) showed that there was no significant difference in the GAD-7 score between the two groups at the same day (T0) after treatment (p > 0.05). At 1 month (T1), 3 months (T3) and 6 months (T6) after treatment, the scores in the experimental group were significantly lower than those in the control group (p < 0.001), and showed a trend of continuous improvement. Repeated measures analysis of variance showed that GAD-7 scores had significant main effects on time, main effects between groups, and interaction effects between groups × time (p < 0.001) (Table 4). The results of depressive status (PHQ-9 score) showed that at the day after treatment (T0), there was no significant difference in the PHQ-9 score between the two groups (p > 0.05). The PHQ-9 scores in the experimental group after treatment (T1, T3, and T6) were significantly lower than those in the control group, and the depressive symptoms in the experimental group continued to improve with the extension of treatment time. Repeated measures analysis of variance showed that PHQ-9 score had significant main effects on time, main effects between groups, and interaction effects between groups × time (p < 0.05) (Table 5). The results of quality of life (MLHFQ score) showed that there was no significant difference in quality of life scores between the two groups on the day after treatment (T0)(p > 0.05). At 1 month (T1), 3 months (T3) and 6 months (T6) after treatment, the scores of the experimental group were significantly lower than those of the control group (p < 0.05), and the quality of life of the experimental group continued to improve with the extension of treatment. Repeated measures analysis of variance showed that HFMLQ scores had significant main effects on time, main effects between groups, and interaction effects between groups × time (p < 0.001) (Table 6). Figure 2 shows the comparison of anxiety (GAD-7), depression (PHQ-9) and quality of life (MLHFQ) scores between the experimental group and the control group at different time points (T0, T1, T3, T6), and the pairwise comparison of GAD-7 scores, PHQ-9 scores and MLHFQ scores at different time points in the experimental group.
Table 4
Comparison of anxiety status between the two patient groups
Group
GAD-7
T0
T1
T3
T6
FGroup
FTime
FGroup × Time
Experimental Group(n = 45)
10.29±2.46
6.48±1.89
4.79±1.75
3.74±1.27
32.892
892.156
18.764
Control Group(n = 45)
10.52±2.53
7.86±1.65
6.62±1.72
4.98±1.27
t-value
0.437
3.690
5.003
4.631
P-value
0.663
< 0.001**
< 0.001**
< 0.001**
< 0.001**
< 0.001**
< 0.001**
Note: T0, T1, T3, and T6 represent the day of treatment completion, 1 month post-treatment, 3 months post-treatment, and 6 months post-treatment, respectively; * indicates p < 0.05; ** indicates p < 0.01
Table 5
Comparison of depression status between the two groups of patients
Group
PHQ-9
T0
T1
T3
T6
FGroup
FTime
FGroup × Time
Experimental Group(n = 45)
11.12±1.38
4.12±1.23
3.76±1.08
3.09±1.18
5.168
617.275
3.840
Control Group(n = 45)
11.02±1.47
5.36±1.62
4.54±1.32
3.75±1.41
t-value
0.333
4.089
3.068
2.408
P-value
0.740
< 0.001**
0.003**
0.018*
0.025
< 0.001**
0.010
Note: T0, T1, T3, and T6 represent the day of treatment completion, 1 month post-treatment, 3 months post-treatment, and 6 months post-treatment, respectively; * indicates p < 0.05; ** indicates p < 0.01
Table 6
Comparison of quality of life between the two groups of patients
Group
MLHFQ
T0
T1
T3
T6
FGroup
FTime
FGroup × Time
Experimental Group(n = 45)
71.31±5.41
66.81±4.97
62.75±3.32
51.05±4.61
194.324
428.915
56.328
Control Group(n = 45)
72.32±7.18
69.26±4.85
65.35±2.78
64.25±4.37
t-value
0.754
2.367
4.028
13.940
P-value
0.453
0.020*
< 0.001**
< 0.001**
< 0.001**
< 0.001**
< 0.001**
Note: T0, T1, T3, and T6 represent the day of treatment completion, 1 month post-treatment, 3 months post-treatment, and 6 months post-treatment, respectively; * indicates p < 0.05; ** indicates p < 0.01
Fig. 2
(A, C, E) Comparison of the scores of anxiety (GAD-7), depression (PHQ-9) and quality of life (MLHFQ) between the experimental group and the control group at different time points (T0, T1, T3, T6); (B, D, F) Comparison of the scores of GAD-7, PHQ-9 and MLHFQ at different time points in the experimental group. * p < 0.05,**p < 0.01
AMI is an acute, high-risk cardiovascular event. Its pathological process is mainly caused by acute coronary artery occlusion causing myocardial ischemic necrosis [26]. Although with the advancement of medical technology, especially the widespread application of percutaneous coronary intervention and thrombolytic therapy, mortality in the acute phase has been greatly reduced, HF after AMI is still one of the key factors leading to long-term poor prognosis of patients [27]. The mechanism of HF after AMI is complex, involving multiple factors such as ventricular remodeling after myocardial necrosis, decompensation of cardiac function, and systemic inflammation [28, 29]. This complexity makes the management of HF after AMI not only require rapid intervention during the acute period, but also requires continuous and precise nursing management during the rehabilitation period to improve patient prognosis and improve quality of life. This study is based on timing theory, focusing on the timeliness and accuracy of nursing intervention, To systematically assess the impact of continuous nursing intervention based on timing theory on HF patients after AMI. The core results showed that after 6 months intervention, the improvement of cardiac function indexes (LVEF, LVEDV, LVESV, NT-proBNP), exercise endurance (6MWT), psychological status (GAD-7, PHQ-9 scores) and quality of life (MLHFQ scores) in the experimental group was significantly better than that in the control group (all p < 0.05). These improvements persisted at multiple time points (T1–T6), confirming the superiority of timing theory-guided care in optimizing clinical outcomes for this patient group.
The results of this study showed that the cardiac function indicators (LVEF, LVEDV, LVESV, NT-proBNP) of patients in both groups were significantly improved after intervention, and the experimental group was better than the control group (p < 0.05). This may be related to the more precise and comprehensive continuous nursing intervention based on the timing theory. Xu et al. [30] found that clinical psychological intervention based on timing theory can significantly reduce the levels of inflammatory factors such as high-sensitivity C-reactive protein (hs-CRP) and tumor necrosis factor-α(TNF-α) in patients with AMI, and significantly improve their quality of life. Qin et al. [31] research showed that after AMI patients receive percutaneous coronary intervention, nursing intervention based on timing theory can significantly improve the patient’s daily life management, disease knowledge management and drug compliance. After acute myocardial infarction, ventricular remodeling is one of the key mechanisms for the deterioration of cardiac function [28]. Acute nursing provides psychological support, basic nursing and health education, It laid a preliminary foundation for improving subsequent patient outcomes. Psychological support measures effectively relieve patients ‘anxiety and depression, improve over-activation of the hypothalamic-pituitary-adrenal axis (HPA axis), reduce the secretion level of stress hormones such as cortisol, thereby reducing the metabolic burden on the heart [32]. At the same time, nursing staff accurately monitor vital signs and fluid balance, timely adjust diuretics and electrolyte supplementation, optimize cardiac preload and afterload, significantly reduce ventricular wall stress, Reduce the risk of adverse ventricular remodeling and improve LVEDV and LVESV in patients with AMI [33]. Health education provides long-term support for the protection of cardiac function by strengthening patients ‘awareness of diseases and improving their self-management capabilities. Nursing staff demonstrated and guided patients to independently operate equipment such as sphygmomanometers and scales, allowing patients to monitor changes in physical signs in a timely manner outside the hospital and take corresponding measures to further reduce their risk of re-hospitalization. It should be noted that in the results of the 6-minute walk test, the increase in walking distance in T1(1 month after treatment) in the control group was greater than that in the experimental group. This phenomenon is not a special abnormality, but a periodic performance caused by short-term assault activities in patients under the lack of strict exercise intensity control in routine care; Based on the timing theory, the experimental group paid more attention to the protection of cardiac function in the early stages after AMI, and was more cautious in exercise intervention. Although the short-term increase was low, the long-term improvement was more sustained and significant. This characteristic was fully consistent with the core rule of “safety first and improvement later” after AMI rehabilitation. Nursing intervention aimed at functional recovery during the rehabilitation period seems to have played a role in improving cardiac function. Personalized exercise plans with gradually increasing intensity may promote vasodilatation and capillary formation in skeletal muscles, helping to improve peripheral circulation and muscle mitochondrial function. These mechanisms not only significantly improve patients ‘exercise endurance, but also reduce their myocardial oxygen demand, optimize cardiac output, and ultimately promote a significant increase in patients’ LVEF [34]. In terms of prevention of complications, nursing staff may help reduce the risk of heart failure recurrence and other complications in the experimental group by closely monitoring patients ‘weight and edema, guiding low-salt diet, and preventing lung infections. Nutritional interventions such as a salt, protein diet appear to optimize the patient’s metabolic environment, Improve electrolyte balance, blood sugar and lipid metabolism. By reducing chronic inflammatory reactions and oxidative stress, NT-proBNP levels in patients with AMI were significantly reduced and their cardiac metabolic burden was comprehensively improved [35]. In post-discharge nursing care, continuous nursing and regular follow-up continue the intervention effect by dynamically adjusting nursing measures. Nursing staff intervene at critical moments to adjust the activity intensity and frequency of psychological counseling according to changes in cardiac function and mental state to ensure the continued appropriateness of nursing intervention [36]. Timely adjustment and drug optimization for edema or abnormal blood pressure not only consolidates the intervention effect, but also prevents potential deterioration of cardiac function. The improvement in mental health may be the result of a synergistic effect of multiple interventions. Psychological support indirectly promotes the recovery of cardiac function and the improvement of exercise ability by alleviating patients ‘psychological stress, enhancing their confidence in recovery, and improving sympathetic-vagal balance. In addition, the improvement in mental health also significantly reduces patients ‘daily activities and impaired social function, further improving their quality of life [37, 38]. The significant improvement in quality of life may be closely related to the synergistic effect of comprehensive nursing measures in the experimental group at each stage. Interventions such as cardiac function protection, exercise ability improvement, emotional state improvement, nutritional support and social function recovery fully meet patients ‘physiological, psychological and social needs. Comprehensively improve patients ‘quality of life by reducing symptom burden, enhancing self-management capabilities and improving social adaptability [39, 40]. Therefore, continuous nursing intervention based on timing theory has shown significant advantages in improving patients ‘cardiac function, exercise ability, mental state and quality of life by integrating precise nursing measures in multiple stages of acute, rehabilitation and post-discharge.
Although this study has achieved important results, there are still shortcomings: this study is a single-center, small sample study, which may limit the broad applicability of the results; the follow-up time is short, focusing only on the 6-month outcome, and the impact of nursing intervention on the long-term prognosis of patients is not discussed; in addition, the individual effects of specific nursing interventions have not been analyzed by item, making it difficult to clarify the relative contributions of different interventions. At the same time, this study may be influenced by the Hawthorne effect: both groups of patients may deliberately perform better in the 6MWT because they are aware of being observed and provide more positive responses in self-reported questionnaires (GAD-7, PHQ-9, MLHFQ), which may lead to bias in outcome measurements. Future research should expand the sample size and verify the long-term effects of nursing intervention guided by timing theory based on multi-center studies. At the same time, it is necessary to further explore the independent role and synergistic mechanism of different nursing measures in improving cardiac function, exercise endurance, emotional state and quality of life. Combining modern technologies such as remote monitoring and artificial intelligence-assisted personalized nursing solutions can further improve the accuracy and effectiveness of nursing interventions and provide patients with more comprehensive, dynamic and long-term health management support.
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Conclusion
Based on the timing theory, this study systematically evaluated the impact of nursing intervention on cardiac function, exercise endurance, emotional status and quality of life in patients with heart failure (HF) after acute myocardial infarction (AMI). Research results show that nursing intervention can significantly optimize patients ‘cardiac function indicators, improve exercise endurance, relieve anxiety and depression, and improve quality of life. The improvement in the experimental group was significantly better than that in the control group, and showed a trend of continuous change. Nursing intervention based on timing theory adopts precise and individualized management strategies. This study observed that it may inhibit ventricular remodeling, regulate cardiac load, and reduce inflammatory response during the acute period, and may optimize metabolic function and improve cardiopulmonary adaptability during the rehabilitation period. In addition, psychological intervention appears to relieve patients ‘emotional burden and promote multi-dimensional recovery in this study cohort. These results highlight the importance of timely nursing intervention and provide a scientific basis for optimizing nursing strategies for patients with AMI related HF.
Declarations
Ethical Statement
This study “Construction and Application Research of Hand Hygiene Intervention Plan for ICU Conscious Patients Based on the Theory of Planned Behavior” has been approved by the Medical Ethics Committee of Henan Provincial People’s Hospital (Approval No.: (2022) Lunshen No. (123), Validity Period: September 26, 2022 - September 26, 2023).Relevant materials (including Research Plan V2.0, Informed Consent Form V1.1, etc.) have been reviewed and revised as per the Committee’s suggestions to meet ethical standards. The research will abide by ethical principles (e.g., Declaration of Helsinki, national regulations), fully inform subjects, protect their rights, and submit the annual progress report before September 26, 2023.
Competing interests
The authors declare no competing interests.
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