Changes in physical activity among coronary and hypertensive patients: A longitudinal study using the Health Action Process Approach

Motivational and emotional correlates of physical activity and sedentary behavior after cardiac rehabilitation: an observational study

BACKGROUND

The present study assessed physical activity (PA) and sedentary behavior (SB) levels and their motivational and emotional health-related correlates, in outpatients following a cardiovascular rehabilitation (CR) program, and compared these variables with those of a healthy control group.

METHODS

The study included 119 participants: 68 CR outpatients (Mage 57.76 ± 10.76; 86.76% males) and 51 control participants matched on age (Mage 57.35 ± 6.33 years; 45.10% males). PA and SB were assessed using accelerometers during the first week post-discharge for outpatients and during a typical week for controls. Motivational (i.e., perceived capabilities, affective and instrumental attitudes, intention, approach-avoidance tendencies) and emotional health-related variables (i.e., anxiety, depressive symptoms, fatigue, pain intensity) were measured using validated scales. PA and SB data from 17 outpatients and 42 controls were valid for analysis, resulting in a final sample of 59 participants.

RESULTS

CR outpatients engaged an average of 60.21 (± 34.79) min of moderate-to-vigorous PA (MVPA), and 548.69 (± 58.64) min of SB per day, with 18 more minutes of MVPA per day than controls (p = .038). Univariate and multivariate regressions indicated that positive affective attitudes were associated with higher MVPA (b = 10.32, R2 = 0.07, p = .029), and that males spent more time in SB than females (b = 40.54, R2 = 0.09, p = .045). Univariate and multivariate logistic regressions showed that meeting the World Health Organization's weekly guidelines for MVPA was associated with higher perceived capabilities toward PA and more positive affective attitudes (OR = 1.17, p = .030; OR = 1.26, p < .001, respectively). Interaction tests showed no significant differences in these results between outpatients and controls.

CONCLUSION

The study highlights an association between higher perceived capabilities and positive affective attitudes toward PA with higher PA levels after outpatient CR. While these findings suggest that enhancing these motivational variables may be beneficial for increasing PA levels after CR, longitudinal and experimental studies are needed to further establish their role.

Determinants of physical activity in newly diagnosed obstructive sleep apnea patients: testing the health action process approach

This study aims to identify the determinants associated with physical activity (PA) behavior in newly diagnosed obstructive sleep apnea (OSA) patients by applying the Health Action Process Approach (HAPA) with a longitudinal design. Anthropometric and clinical (OSA severity, subjective somnolence, use of continuous positive airway pressure (CPAP)) variables, the determinants of physical activity specified in the HAPA (motivational self-efficacy, outcome expectancies, risk perception, intention, maintenance self-efficacy, action planning, coping planning, social support), as well as physical activity behavior were assessed using a longitudinal (T1 and T2) design in a sample of 57 OSA patients in routine care. Applying regression analyses, regarding the motivation phase, the amount of explained variance in intention was 77% and 39% of the variance in physical activity. In the motivational phase, motivational self-efficacy, risk perception and outcome expectancies were associated with intention. In the volitional phase, physical activity at T1 and social support (family) were related with physical activity at T2. In conclusion, the assumptions of HAPA were partially found in the context of newly diagnosed OSA patients. This study provided additional evidence regarding the role of motivational self-efficacy, outcome expectancies and risk perception during motivational phase, and highlighted the important role of social support from the family in the PA in this population.

Effectiveness of a tailored communication intervention to improve physical activity in hypertensive patients: a twelve-month randomized controlled trial

BACKGROUND

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality globally. Arterial hypertension is one of the main cardiovascular risk factors. Despite this, individuals with hypertension often fail to follow medical advice to counteract cardiovascular risks. A physically active lifestyle is one of the most challenging behaviors to adopt. This study aimed to preliminarily investigate the effectiveness of a tailored print message intervention to increase physical activity in patients with arterial hypertension.

METHODS

A sample of 188 patients with hypertension (mean age = 63 years; SD = 10.9; 50% men) participated in a theory-based tailored health communication intervention. Participants were randomly assigned to three parallel groups: (1) the tailored group, which received tailored health brochures; (2) the non-tailored group, which received non-tailored health brochures; or (3) the usual care group, which received no informative print materials. The longitudinal physical activity trajectories (baseline, 6- and 12-month follow-ups) were examined using repeated measures ANOVA and growth curve models.

RESULTS

At the baseline, 38.8% of patients achieved the target physical activity. This percentage rose to 43.0% at 6-month follow-up and 46.0% at 12-month follow-up. The descriptive statistics divided in function of the experimental group suggested differences in the longitudinal trend of the mean physical activity depending on the experimental group. However, statistical significance using repeated measures ANOVA did not support this observation. The analysis of the growth curves suggested that the tailored group showed a progressive increase in physical activity over twelve months (the model that best described the longitudinal trajectory was a linear growth model). The non-tailored group showed an increase in physical activity six months after the beginning of the intervention, followed by a decrease (free time score model). The usual care group did not change over time (no-growth model).

CONCLUSIONS

Findings suggest the effectiveness of the tailored intervention proposed. However, further investigations and empirical confirmations are required.

TRIAL REGISTRATION

ISRCTN13415993 ( https://doi.org/10.1186/ISRCTN13415993 ). Registration date: 08/04/2019.

Development and feasibility of a theory-guided and evidence-based physical activity intervention in pregnant women with high risk for gestational diabetes mellitus: a pilot clinical trial

BACKGROUND

Physical activity has been utilized as an effective strategy to prevent gestational diabetes mellitus (GDM). However, most pregnant women with high risk for GDM did not achieve the recommended physical activity level. Furthermore, relevant physical activity protocols have varied without theory-guided and evidence-based tailored to pregnant women with high risk for GDM. This study aimed to develop and pilot test a theory-guided and evidence-based physical activity intervention protocol for pregnant women with high risk for GDM.

METHODS

The study design was guided by the Medical Research Council Framework for Developing and Evaluating Complex Intervention (the MRC framework). The preliminary protocol for physical activity intervention was developed based on self-efficacy theory, research evidence identified from systematic reviews and clinic trials, stakeholder engagement, context, and economic considerations. The preliminary intervention protocol was validated through a content validity study by an expert panel of 10 experts. A single-blinded randomized controlled trial (RCT) was designed to test the feasibility and acceptability of the intervention.

RESULTS

The validity of the preliminary intervention protocol was excellent as consensus was achieved. The final 13 sessions of self-efficacy enhancing physical activity intervention protocol were developed, including knowledge education, exercise clinic visits and video, and group discussions with face-to-face and online blended sessions. In the feasibility study, 34 pregnant women with high risk for GDM were randomized for the intervention (n = 17) or the control group (n = 17). The recruitment and retention rates were 82.9% and 58.9%, respectively. Women in the intervention group had a lower incidence of GDM (26.7% vs. 36.5%) than the control group (P >0.05). All participants were satisfied with the intervention and agreed that the intervention was helpful.

CONCLUSIONS

The developed self-efficacy-enhancing physical activity intervention is a feasible and acceptable intervention for enhancing physical activity among pregnant women with high risk for GDM and is ready to be tested in a more extensive RCT study.

TRIAL REGISTRATION

The study was registered on 4 February 2022 (ChiCTR2200056355) by the Chinese Clini Trial Registry (CHiCTR).

Self-care in coronary heart disease patient and caregiver dyads (HEARTS-IN-DYADS)-Protocol of a multicenter longitudinal study

Self-care performed by patients and the caregiver contribution to this self-care are essential for improving cardiovascular outcomes; however, so far, no studies have sufficiently investigated this field in Italy. This paper describes a research protocol of a multi-center longitudinal study designed to investigate the self-care of patients affected by coronary heart disease (CHD), the caregiver's contribution to this self-care, the predictors of patient and caregiver self-care, the mediating role of self-efficacy, and the self-care outcomes. Data collection will be performed across seven Italian inpatient settings at baseline and 3 and 6 months from enrollment. Multilevel modeling and actor partner interdependence models will be implemented on a sample of 330 patient-caregiver dyads to adjust for the interdependence of measurements. The study received approval from an ethics committee in Italy and was financed in January 2021 by a grant from the Solidal Foundation in Alessandria. This research will advance the knowledge about the self-care process in CHD. The results will guide research and clinical practice by identifying variables sensitive to educational interventions.

How to optimize the adherence to a guideline-directed medical therapy in the secondary prevention of cardiovascular diseases: a clinical consensus statement from the European Association of Preventive Cardiology

A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.

Linking Exercise Intention to Exercise Action: The Moderating Role of Self-Efficacy

As physical exercise benefits both physical and psychological health of college students, it is important to promote the habit of physical exercise among them. This study adopted the Health Action Process Approach (HAPA) model to understand the exercise intention–action link and determine the moderating role of self-efficacy. We recruited 242 students from a university in China and asked them to complete a six-wave survey. The survey results indicated that exercise intention was positively related to both coping planning and action planning, which pave the way to performing the action of exercise. However, such mediation effects varied under conditions of self-efficacy. Participants with high self-efficacy exhibited stronger relationships between intention and planning, and between planning and action. The study results suggest that planning has a time-lagged mediation effect in the relationship between intention and action. Additionally, the findings shed light on the moderating role of self-efficacy, which can be useful in developing health-promotion strategies for college students.

Development and Validation of a Scale to Measure Self-efficacy and Self-management in People With Coronary Heart Disease

BACKGROUND

Self-management is important in reducing coronary risk factors and in preventing recurrent cardiac events. An enabling factor that promotes self-management among patients with coronary heart disease (CHD) is self-efficacy. However, there is no standardized measure that captures self-efficacy and self-management concurrently in this population.

AIM

The authors of this study report on the development and validation of a brief scale to measure self-efficacy and self-management in patients with CHD.

METHODS

Scale development and testing comprised (1) item generation, (2) content validity, and (3) pilot testing. The Heart Health Self-Efficacy and Self-Management (HH-SESM) scale includes 2 constructs: self-efficacy and self-management, measured concurrently. Components of the HH-SESM scale consisted of items related to behavioral and coronary risk factor modification. Survey data from 143 participants were used in exploratory factor analyses to test the factorial validity and internal consistency of the scale.

RESULTS

Twelve items with the same response format were included in the exploratory factor analysis. The factor analysis revealed a single-factor solution accounting for 36.7% and 36.5% of the variance in scores of the self-efficacy and self-management scales, respectively. The correlation ( r = 0.72, P < .001) between the self-efficacy and self-management constructs indicates moderate convergent validity. Cronbach α of self-efficacy (0.83) and self-management (0.81) constructs showed good internal consistency.

CONCLUSION

The HH-SESM is a brief, easy-to-administer, and reliable measure of self-efficacy and self-management in patients with CHD.

Sense of Coherence Predicts Physical Activity Maintenance and Health-Related Quality of Life: A 3-Year Longitudinal Study on Cardiovascular Patients

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. A physically active lifestyle can improve the health-related quality of life (HRQoL) of people with CVD. Nevertheless, adherence to a physically active lifestyle is poor. This study examined the longitudinal (pre-event, 6-, 12-, 24-, and 36-month follow-ups) physical activity profiles in 275 patients (mean age = 57.1 years; SD = 7.87; 84% men) after the first acute coronary event. Moreover, it investigated the associations among physical activity, sense of coherence (SOC), and HRQoL. Physical activity profiles were identified through latent class growth analysis, and linear regressions were then performed to explore the association between physical activity, SOC, and HRQoL. After the cardiovascular event, 62% of patients reached adequate physical activity levels and maintained them over time (virtuous profile). The remaining 38% could not implement (23%) or maintain (15%) a healthy behavior. A strong SOC at baseline (standardized β = 0.19, p = 0.002) predicted the probability of belonging to the virtuous profile. Moreover, a strong SOC at baseline (standardized β = 0.27, p < 0.001), together with the probability of belonging to the virtuous profile (standardized β = 0.16, p = 0.031), predicted a better HRQoL at the final follow-up. Findings showed a strong relationship between SOC, the ability to adopt a physically active lifestyle stably over time, and HRQoL in patients with CVD. They suggest the importance of tailoring physical activity interventions by promoting resilience resources such as SOC to improve patients’ quality of life after an acute coronary event.

Investigating men's motivations to engage in genetic screening for BRCA1 and BRCA2 mutations

BRCA1 and BRCA2 mutations are associated with an increased risk of developing numerous cancers, including breast, ovarian, pancreatic, melanoma and prostate cancer. Men face BRCA-related cancer risks as women do. However, there is considerably less research on the psychological determinants of men engaging in BRCA1/2-related cancer prevention compared to women. The present research aimed to study the determinants of men’s motivations to engage in genetic screening for BRCA1 and BRCA2 through the lens of the Health Action Process Approach. One hundred and twenty-five men (mean age = 58.53 y/o, SD = 10.37) completed an online survey. The intention to undergo genetic screening for BRCA1/2 mutations in men was significantly and positively associated with self-efficacy and risk perception. Moreover, having offspring positively affected intention as well. The relationships between intention (and planning) and positive outcome expectancies, age, and family history of breast-related cancer were not statistically significant. Most information on BRCA1 and BRCA2 mutations is tailored to women due to the availability of effective surgical risk reduction procedures for women’s breast and ovarian cancer. Future research should focus on the best methods of communicating informed decision-making for men facing the risk of such mutations.

Effect of an educational program on physical activity in individuals undergoing their first percutaneous coronary intervention: A randomized clinical trial

BACKGROUND

Educational programs designed for specific populations to improve regular physical activity need to be tested.

OBJECTIVES

To evaluate the effectiveness of an educational program, when compared to usual care, on improving physical activity 5 to 7 months after hospital discharge in adult patients undergoing their first percutaneous coronary intervention.

METHODS

Randomized controlled trial with two groups: usual care (n = 56) and educational program (n = 53) interventions. Data on sociodemographic and clinical characteristics were collected and the Baecke-Habitual Physical Activity Questionnaire, Self-efficacy Scale for Physical Activity, and Hospital Anxiety and Depression Scale were administered at baseline and follow-up. Participants in the educational program received an intervention based on Social Cognitive Theory, focused on physical activity, followed by three telephone calls. The usual care group received the hospital routine information. Unadjusted and adjusted differences between the two groups in mean score changes (with 95% confidence intervals [CI]) were calculated for all outcomes.

RESULTS

At follow-up, the educational program group showed higher mean ± standard deviation scores than the usual care group for practice of physical activity (7.94 ± 1.84 vs. 6.90 ± 1.89) and for self-efficacy (3.98 ± 3.75 vs. 2.52 ± 3.12). Adjusting for baseline outcome, the difference in mean change between groups was 0.89 (95% CI: 0.32, 1.46) for physical activity and 2.30 (95% CI: 1.12, 3.49) for self-efficacy. There were no statistical differences between groups in symptoms of anxiety and depression.

CONCLUSION

The educational program may be an effective intervention in increasing habitual physical activity and self-efficacy for physical activity in individuals with coronary artery disease.

Fear of Movement and Physical Self-Efficacy Partially Mediate the Association Between Fatigue and Physical Activity Among Kidney Transplant Recipients

Fatigue is one of the most distressing symptoms in renal transplant patients, causing functional impairment and worsening their quality of life. However, the mechanism by which fatigue affects physical activity is unclear. A cross-sectional study using a convenient sampling approach was utilized to investigate 665 kidney transplant recipients recruited from the transplantation centers of six general hospitals from July and September 2019. Structural equation modeling was used to examine the interaction among fatigue, fear of movement, physical self-efficacy, and physical activity. Our study found fatigue was directly negatively associated with physical activity and had an indirect impact on physical activity through the mediating effects of physical self-efficacy and fear of movement. These variables accounted for 44.4% of the variation in physical activity. Our findings alert healthcare providers for the importance of fatigue management for physical activity and focused attention on fear of movement and physical self-efficacy in renal transplant recipients.

Predicting psychological factors affecting regular physical activity in hypertensive patients: Application of health action process approach model

Aim

The aim of this study was to determine the factors affecting the behaviour of regular physical activity in patients with hypertension using the health action process approach (HAPA) model.

Design

This cross-sectional study was conducted on 176 hypertension patients, in Astaneh-e-Ashrafiyeh, Guilan, Iran, 2018-2019.

Methods

Data collection tools included demographic characteristics, medical history, the short form of International Physical Activity Questionnaire (IPAQ) and scales related to the HAPA model. The data were analysed using chi-square, independent t test, one-way ANOVA, Pearson's correlation coefficient and path analysis on AMOS, version 23.0.

Results

Action self-efficacy (β = 0.59), outcome expectancy (β = 0.20) and risk perception (β = 0.18) had a statistically significant effect on intention. Moreover, the path coefficient between intention (β = 0.35) and coping self-efficacy (β = 0.29) with physical activity was statistically significant. The results revealed that HAPA constructs were able to describe 45% of the variance in intention and 31% of the variance in physical activity behaviour.

Conclusion

The HAPA model is a useful framework for describing the factors affecting physical activity in hypertension patients.

'Nobody will put baby in the corner!': A qualitative evaluation of a physical activity intervention to improve mental health

Physical activity is beneficial for mental health, but people with mental health issues are less likely to be physically active than the general population. Socially prescribed programmes of activity are rarely adhered to, with high levels of drop out, and the proportion of people who continue after programmes have finished is even smaller. Lasting change therefore needs a fundamental change in behaviour, so an intervention grounded in behaviour change theory may be more likely to succeed. The aim of this original study was to understand the facilitators and barriers to participation and adherence to a supportive, personalised, physical activity programme for patients with mental health conditions. The intervention entailed a 16-week programme of activity, tailored to individual capability, supported by a dedicated 'behaviour change' practitioner trained in motivational interviewing. Fourteen people who had completed the intervention were interviewed in three focus groups in 2018. Data were transcribed verbatim then analysed for barriers and facilitators using Framework Analysis and the Theoretical Domains Framework. Twenty-five overarching themes were identified, which mapped onto 11 domains from the framework. Ten themes were barriers and 15 facilitators. Barriers included stigma, negative self-beliefs and difficulty trusting others. The facilitators reframed these negative attributes. For example, participants described feeling confident as a function of achieving personalised goals and learning something new. The intervention changed the way participants thought and acted. This original intervention has succeeded where many have failed, as it changed the way these participants with mental health conditions thought about physical activity. By reframing it as personally achievable and physically beneficial, participants' attitudes and behaviour changed as well, making it more likely they would sustain physical activity in future. These unique findings are likely to translate internationally due to the simplicity of the intervention, and the potential to improve lives of the most vulnerable.

The effect of regulatory focus and time preference on the dual process of physical activity: A cross-sectional study among nurses

AIMS

To examine the dual process of physical activity adoption among nurses and its relationships with two personal orientations-regulatory focus-the tendency to focus on promotion (vs. prevention) goals and time preference as measured by delay discounting: the tendency to overvalue immediate rewards over long-term ones.

BACKGROUND

The dual process theory suggests that both conscious and non-conscious processes influence the adoption of physical activity. However, the role of regulatory focus and time preference in this process was not yet examined.

DESIGN

A cross-sectional online survey among 143 nurses during August-November 2017.

METHODS

Validated measures were used to estimate physical activity habit strength (a non-conscious process) and intention, planning and behaviour control (conscious processes), physical activity level, regulatory focus and time preference. Multivariable ordered logit and logistic models were specified to examine determinants of both processes.

RESULTS

Promotion focus was positively associated with having a strong habit of physical activity among nurses with moderate-to-low activity levels, but it was negatively associated with habit for active nurses. As for time preference, higher delay discounting was negatively associated with nurses' conscious intention to adopt physical activity and with their action planning.

CONCLUSION

Promotion focus and time preference are associated with both conscious and non-conscious processes of physical activity adoption among nurses and should be considered in future health promotion interventions targeted to this population.

IMPACT

Promotion focus and time preference have a significant role in this dual process. Enhancing physical activity of health providers by adjusting the intervention to personal orientations may improve public health.

Improving Physical Activity mHealth Interventions: Development of a Computational Model of Self-Efficacy Theory to Define Adaptive Goals for Exercise Promotion

The practice of regular physical exercise is a protective factor against noncommunicable diseases and premature mortality. In spite of that, large part of the population does not meet physical activity guidelines and many individuals live a sedentary life. Recent technological progresses and the widespread adoption of mobile technology, such as smartphone and wearables, have opened the way to the development of digital behaviour change interventions targeting physical activity promotion. Such interventions would greatly benefit from the inclusion of computational models framed on behaviour change theories and model-based reasoning. However, research on these topics is still at its infancy. The current paper presents a smartphone application and wearable device system called Muoviti! that targets physical activity promotion among adults not meeting the recommended physical activity guidelines. Specifically, we propose a computational model of behaviour change, grounded on the social cognitive theory of self-efficacy. The purpose of the computational model is to dynamically integrate information referring to individuals’ self-efficacy beliefs and physical activity behaviour in order to define exercising goals that adapt to individuals’ changes over time. The paper presents (i) the theoretical constructs that informed the development of the computational model, (ii) an overview of Muoviti! describing the system dynamics, the graphical user interface, the adopted measures and the intervention design, and (iii) the computational model based on Dynamic Decision Network. We conclude by presenting early results from an experimental study.

The Mediating Role of Perceived Social Support Between Physical Activity Habit Strength and Depressive Symptoms in People Seeking to Decrease Their Cardiovascular Risk: Cross-Sectional Study

BACKGROUND

Regular physical activity treatment has been advocated for the prevention and rehabilitation of patients at risk of cardiovascular diseases and depressive symptoms. How physical activity is related to depressive symptoms is widely discussed.

OBJECTIVE

The aim of this internet-based study was to investigate the role of perceived social support in the relationship between physical activity habit strength and depressive symptoms.

METHODS

In total, 790 participants (mean 50.9 years, SD 12.2, range 20-84 years) who were interested in reducing their cardiovascular risk were recruited in Germany and the Netherlands. Data collection was conducted via an internet-based questionnaire addressing physical activity habit strength, depressive symptoms, and perceived social support. Cross-sectional data analysis was done with SPSS version 24 using the Macro PROCESS version 2 16.3 by Hayes with bootstrapping (10,000 samples), providing 95% CIs.

RESULTS

Physical activity habit strength was negatively related to depressive symptoms (r=-.13, P=.006), but this interrelation disappeared when controlling for perceived social support (beta=-.14, SE 0.09, P=.11). However, there was an indirect relationship between physical activity habit strength and depressive symptoms, which was mediated via perceived social support (beta=-.13; SE 0.04, 95% CI -0.21 to 0.06). The negative relationship between physical activity habit strength and depressive symptoms was fully mediated by perceived social support.

CONCLUSIONS

We suggest that physical activity treatment in people interested in reducing their cardiovascular risk should also embed social support to target depressive symptoms. Internet-based interventions and electronic health may provide a good option for doing so.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01909349; https://clinicaltrials.gov/ct2/show/NCT01909349 (Archived by WebCite at http://www.webcitation.org/73Y9RfdiY).

Clustering of Lifestyle Risk Factors in Acute Coronary Syndrome: Prevalence and Change after the First Event

BACKGROUND

Healthy lifestyles are modifiable risk factors for acute coronary syndrome (ACS) onset and recurrence. While unhealthy lifestyles tend to cluster together within the general healthy population, little is known about the prevalence and clustering of these behaviours in people with ACS before and after the first acute event. The aim of this study was to identify lifestyle profiles of patients with ACS and to explore their change after their first coronary event.

METHODS

Three hundred and fifty-six patients completed self-report measures of healthy habits at the beginning of cardiac rehabilitation and 6 months later. By adopting a person-oriented approach, we analysed lifestyle clustering and its change over time. Differences in depression, anxiety, and negative illness perception among lifestyle profiles were assessed.

RESULTS

We identified seven profiles, ranging from more maladaptive to healthier clusters. Findings showed a strong interrelation among unhealthy habits in patients. We highlighted a moderate individual and group stability of cluster membership over time. Moreover, unhealthier lifestyle profiles were associated with higher levels of depression, anxiety, and negative illness perception.

CONCLUSION

These results may have implications for the development and implementation of multimodal interventions addressing wider-ranging improvement in lifestyles by targeting multiple unhealthy behaviours in patients with ACS.