Front. Cardiovasc. Med. Frontiers in Cardiovascular Medicine Front. Cardiovasc. Med. 2297-055X Frontiers Media S.A. 10.3389/fcvm.2024.1388164 Cardiovascular Medicine Original Research Knowledge and attitude toward postoperative antithrombotic management and prevention in patients with coronary revascularization: a cross-sectional study LiuChunlu 1 † ZhangHaijun 1 † YangLiming 2 ChenLihua 1 ZuChanghao 1 WangFangfang 1 DaiYunjia 1 ZhaoHaiyan 1 * Department of Cardiology, Kailuan General Hospital, Tangshan, China Department of Cardiology, Tangshan Gongren Hospital, Tangshan, China

Edited by: Lorenzo Menicanti, IRCCS San Donato Polyclinic, Italy

Reviewed by: Rosario Caruso, University of Milan, Italy

Giacomo Bortolussi, IRCCS San Donato Polyclinic, Italy

 Correspondence: Haiyan Zhao hanyan7922@163.com

These authors have contributed equally to this work

 17052024 2024 111388164 29022024 08052024 © 2024 Liu, Zhang, Yang, Chen, Zu, Wang, Dai and Zhao. 2024Liu, Zhang, Yang, Chen, Zu, Wang, Dai and Zhao

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

 Background

This study aimed to explore the knowledge and attitude (KA) toward postoperative antithrombotic management and prevention among coronary artery disease (CAD) patients who underwent coronary revascularization.

 Methods

This cross-sectional study enrolled CAD outpatients and inpatients between May and December 2023 at Kailuan Medical Group at Tangshan. Basic demographic characteristics and KA scores were collected through a self-made questionnaire.

 Results

This study included 523 valid questionnaires. The mean knowledge and attitude scores were 13.20 ± 6.20 (range: 0–26) and 43.68 ± 6.01 (range: 21–50), respectively, indicating poor knowledge and favorable attitude. Multivariable logistic regression analysis showed that junior high school education (OR = 2.160, P = 0.035), high school or technical school education (OR = 2.356, P = 0.039), and monthly average income >5,000 RMB (OR = 3.407, P = 0.002) were independently associated with knowledge. Knowledge (OR = 1.095, P = 0.002), BMI ≥ 24.0 kg/m2 (OR = 0.372, P = 0.011), junior high school (OR = 3.699, P = 0.002), high school or technical school (OR = 2.903, P = 0.028), high associate degree or above education (OR = 6.068, P = 0.014), monthly average income 3,000–5,000 RMB (OR = 0.296, P = 0.005), monthly average income > 5,000 RMB (OR = 0.225, P = 0.021), with hypertension (OR = 0.333, P = 0.003), blood tests every 2–3 weeks (OR = 10.811, P = 0.011), blood tests every month (OR = 4.221, P = 0.024), and blood tests every 2–3 months (OR = 3.342, P = 0.033) were independently associated with attitude.

 Conclusion

CAD patients who underwent coronary revascularization had poor knowledge but favorable attitudes toward postoperative antithrombotic management and prevention. The study underscores the need for targeted education, especially for individuals with lower education and income levels, ultimately improving patient compliance and cardiovascular outcomes.

 myocardial infarction knowledge attitude antiplatelet drugs cross-sectional study section-at-acceptanceCoronary Artery Disease Background

Acute coronary syndromes (ACS) includes a spectrum of conditions associated with acute myocardial ischemia and/or necrosis, usually secondary to a reduction in coronary blood flow, including unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI) (1). The most common cause of ACS is plaque rupture in the setting of underlying coronary artery disease (CAD) (2). The common risk factors for CAD include tobacco abuse, dyslipidemia, hypertension, diabetes mellitus, and a family history of CAD (3). Revascularization of CAD can be performed electively or urgently when stenosis is significant (>50% stenosis) (4–7), and the most common type of surgery includes percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). CABG is a cardiac surgery in which a blood vessel segment, an artery or vein, is grafted from the aorta to bypass a blockage in a coronary artery, creating a new conduit to enhance blood flow to the heart (8), while PCI involves balloon dilation and stent implantation (9), and they both improve patients' survival outcome (10).

Antiplatelet therapy is recommended after CABG or PCI and is an important factor in improving patients' outcomes. Indeed, antiplatelet therapy decreases the risk of vein graft failure and major adverse cardiovascular events (MACE) (11) but at the expense of an increased bleeding risk (12). The antiplatelet therapies are mainly oral drugs that are taken at home without supervision. Hence, compliance with treatment is an important factor affecting the prognosis of coronary revascularization. Compliance with guideline-directed medical therapy following CABG or PCI was reported to be 67% at 1 year and 53% at 5 years (13). It is worth emphasizing that patient adherence to treatment is crucial and depends on the individual's understanding of medication purposes, recognizing warning signs, being aware of potential side effects, and having a positive attitude toward the treatment (14, 15). Postoperative antithrombotic therapy plays a crucial role in preventing thrombotic events and ensuring successful outcomes in patients undergoing coronary revascularization. Patient knowledge and attitude toward antithrombotic management are essential factors influencing treatment adherence and effectiveness. However, existing literature lacks a comprehensive understanding of the specific gaps in patient knowledge and attitude regarding postoperative antithrombotic therapy, particularly in the context of coronary revascularization.

Hence, evaluating the knowledge and attitude (KA) of antiplatelet therapy after coronary revascularization could provide important data about the gaps, misconceptions, and misunderstandings that could constitute barriers to optimal treatments (16, 17). Although several studies reported viewpoints of healthcare providers on antiplatelet therapy (18, 19), there were no related studies discussing KA toward postoperative antithrombotic management and prevention in patients with coronary revascularization. Assessing knowledge and attitude (KA) could allow the design of educational and motivational interventions to improve the practice of patients with CAD toward antiplatelet drugs, possibly improving patient outcomes. Therefore, this study aimed to investigate the KA toward postoperative antiplatelet management and prevention among CAD patients after coronary revascularization.

 Methods Study design and participants

This cross-sectional study enrolled CAD outpatients and inpatients between May and December 2023 at Kailuan Medical Group in Tangshan, Hebei Province, China. The inclusion criteria were: (1) clinically diagnosed with CAD or underwent PCI or CABG due to CAD, and (2) were well-informed about the study and voluntarily participated in this study. The exclusion criteria were: (1) consciousness, mental, or cognitive impairments, (2) malignant tumors, (3) severe systemic infectious diseases, or (4) immune system disorders. The research protocol was approved by the ethics committee of Kailuan General Hospital. Informed consents were obtained from the participants before they completed the survey. This study is reported according to the CROSS statement (20).

 Questionnaire

The questionnaire design was based on the 2021 ACC/AHA/SCAI Guidelines for Coronary Revascularization (11) and the relevant literature (1, 10, 12, 13, 21). After the initial design, feedback from three experts, including two specialists in cardiovascular medicine and one in epidemiology, was sought and used to refine the questionnaire. Forty individuals were enrolled for a pretest to assess the reliability and validity of the questionnaire. The pretest reliability analysis showed that the Cronbach's α coefficients for knowledge, attitude, and overall were 0.892, 0.621, and 0.865, respectively, indicating good internal consistency. The overall data analysis showed that the Cronbach's α coefficients for knowledge, attitude, and overall were 0.838, 0.953, and 0.886, indicating good internal consistency. The Kaiser-Meyer-Olkin (KMO) measure was 0.924, suggesting good validity.

The final questionnaire was in Chinese and encompassed three parts: basic demographic characteristics, knowledge dimension, and attitude dimension. The basic demographic characteristics section comprised 14 questions on demographic and socioeconomic characteristics. The knowledge dimension consisted of 14 questions, with responses categorized into “Aware”, “Moderately aware”, and “Unaware”, scored 2, 1, and 0 points, respectively. The total score range was from 0 to 26 points. The 14th question investigated the sources of knowledge about antithrombotic management, without assigning scores. The attitude dimension comprised 10 questions and employed a 5-point Likert scale. For positively framed questions, responses ranged from “Strongly agree” to “Strongly disagree” scored from 5 to 1. Conversely, negatively framed questions are scored in reverse. The attitude score range was 10–50 points. Knowledge was deemed sufficient, and attitude was considered positive if the score exceeded 75% of the total score in the attitude dimension (22).

 Questionnaire distribution and quality control

The survey questionnaires were distributed to the study participants through two channels: WeChat groups and face-to-face interactions in clinical examination rooms. The WeChat groups were created by the clinic to advertise medical information and news to patients. The study was simply advertised, and those interested in participating could participate. The patients have also proposed the study during routine medical examinations. Trained research team members checked all questionnaires for validity. Incomplete questionnaires, the questionnaires that took <30 s or >480 s to complete, had obvious logical errors [e.g., impossible age or body mass index (BMI, kg/m2)] or were completed using all the same options (e.g., all first choices) and were considered invalid.

 Sample size calculation

The sample size was calculated using the formula for cross-sectional studies: α=0.05, n=[Z(1−α/2)/δ]2×p×(1−p) whereZ_(1−α/2)=1.96 whenα=0.05, the assumed degree of variability of p = 0.5 maximizes the required sample size, and δ is an admissible error (which was 5% here). The theoretical sample size was 480, which included an extra 20% to allow for subjects to be lost during the study.

 Statistical analysis

Data analysis was performed using SPSS 22.0 (IBM, Armonk, NY, USA). They were tested for normal distribution using the Kolmogorov-Smirnov test. Continuous data with a normal distribution were described as means ± standard deviation (SD) and analyzed using Student's t-test; otherwise, they were presented as medians (interquartile range, IQR) and analyzed using the Wilcoxon rank-sum test. Univariable and multivariable logistic regression analyses were used to analyze the covariates independently associated with knowledge and attitude. Variables with P < 0.05 in the univariable analyses were included in the multivariable analyses (enter method). A two-sided P-value < 0.05 was considered statistically significant.

 Results Basic characteristics of the participants

Eleven questionnaires with an impossible BMI, one questionnaire from a participant reportedly under the age of 18, and two questionnaires with all responses in the knowledge and attitude dimension marked as “A” were excluded. Hence, 523 valid questionnaires were included in the analysis (validity rate of 97.39%). Most participants were >70 years old (30.02%), overweight (61.95%), male (68.07%), were urban residence (55.83%), with junior high school education (43.21%), earning monthly average income of 3,000–5,000 RMB (52.77%), not smoking (58.89%), not drinking (64.05%), not consuming coffee or tea (86.81%), with hypertension (69.98%), without diabetes (60.23%), without hyperlipidemia (78.01%), without a history of coronary heart disease (79.92%), >5 years since ACS (34.80%), underwent PCI (95.79%), taking antithrombotic medication (84.51%), and undergoing blood tests every 2–3 months (58.70%) (Table 1).

Basic characteristics, knowledge and attitude scores.

Variable n (%) Knowledge Attitude
  Mean ± SD P Mean ± SD p
Total 523 13.20 ± 6.20 43.68 ± 6.01
Age (years) 0.566 0.973
 <60 147 (28.11) 13.59 ± 6.24 43.59 ± 5.97
 60–65 104 (19.89) 13.61 ± 6.51 43.70 ± 5.91
 66–70 115 (21.99) 12.74 ± 6.04 43.56 ± 5.96
 >70 157 (30.02) 12.89 ± 6.09 43.86 ± 6.20
Body mass index (kg/m2) 0.401 0.021
 <24.0 199 (38.05) 12.90 ± 5.93 44.46 ± 5.34
 ≥24.0 324 (61.95) 13.37 ± 6.36 43.21 ± 6.35
Gender 0.679 0.448
 Male 356 (68.07) 13.12 ± 6.21 43.55 ± 6.11
 Female 167 (31.93) 13.36 ± 6.19 43.98 ± 5.81
Residence 0.293 0.023
 Urban 292 (55.83) 13.45 ± 6.40 43.15 ± 6.13
 Rural 231 (44.17) 12.87 ± 5.93 44.35 ± 5.81
Education <0.001 0.149
 Primary school or below 126 (24.09) 11.35 ± 5.68 42.61 ± 6.59
 Junior high School 226 (43.21) 13.27 ± 6.20 44.04 ± 5.71
 High school/technical school 115 (21.99) 13.98 ± 6.10 43.95 ± 5.97
 Associate degree and above 56 (10.71) 15.45 ± 6.53 44.13 ± 5.80
Monthly average income (RMB) <0.001 0.467
 <3,000 175 (33.46) 11.83 ± 5.82 44.04 ± 5.51
 3,000–5,000 276 (52.77) 12.82 ± 5.90 43.63 ± 6.44
 >5,000 72 (13.77) 17.94 ± 6.06 43.01 ± 5.46
Smoking 0.898 0.963
 Yes 215 (41.11) 13.15 ± 6.14 43.67 ± 6.29
 No 308 (58.89) 13.22 ± 6.25 43.69 ± 5.82
Drinking 0.400 0.713
 Yes 188 (35.95) 13.50 ± 6.40 43.81 ± 6.27
 No 335 (64.05) 13.02 ± 6.08 43.61 ± 5.87
Regular consumption of coffee or tea 0.042 <0.001
 Yes 69 (13.19) 14.61 ± 6.54 40.68 ± 5.47
 No 454 (86.81) 12.98 ± 6.12 44.14 ± 5.97
Hypertension 0.410 0.213
 Yes 366 (69.98) 13.34 ± 6.12 43.90 ± 6.22
 No 157 (30.02) 12.85 ± 6.38 43.18 ± 5.49
Diabetes 0.164 0.663
 Yes 208 (39.77) 12.73 ± 5.86 43.54 ± 6.41
 No 315 (60.23) 13.50 ± 6.41 43.78 ± 5.74
Hyperlipidemia 0.021 <0.001
 Yes 115 (21.99) 12.02 ± 6.27 39.30 ± 5.36
 No 408 (78.01) 13.53 ± 6.15 44.92 ± 5.60
Family history of coronary heart disease 0.167 <0.001
 Yes 105 (20.08) 13.94 ± 6.58 40.31 ± 6.05
 No 418 (79.92) 13.01 ± 6.09 44.53 ± 5.70
Duration of coronary heart disease affliction 0.148 0.839
 <1 year 177 (33.84) 12.46 ± 6.54 43.89 ± 6.16
 1–5 years 164 (31.36) 13.63 ± 6.31 43.51 ± 6.01
 >5 years 182 (34.80) 13.52 ± 5.71 43.65 ± 5.89
Type of coronary artery revascularization procedure 0.964 0.147
 Percutaneous coronary intervention (PCI) 501 (95.79) 13.20 ± 6.14 43.76 ± 5.94
 Coronary artery bypass grafting (CABG) 22 (4.21) 13.14 ± 7.50 41.86 ± 7.45
Currently taking antithrombotic medications <0.001 0.002
 Yes 442 (84.51) 13.66 ± 6.15 44.03 ± 6.17
 No 81 (15.49) 10.64 ± 5.89 41.80 ± 4.64
Frequency of routine blood tests while taking antithrombotic medication 0.083 0.002
 Weekly 26 (4.97) 15.23 ± 6.45 40.92 ± 6.69
 Every 2–3 weeks 47 (8.99) 14.13 ± 5.40 44.87 ± 5.48
 Monthly 143 (27.34) 13.62 ± 6.79 44.84 ± 6.10
 Every 2–3 months 307 (58.70) 12.68 ± 5.96 43.20 ± 5.87
Knowledge dimension

The mean knowledge score was 13.20 ± 6.20 (range: 0–26), indicating poor knowledge. Higher knowledge scores were observed with higher education (P < 0.001), higher income (P < 0.001), consumption of coffee or tea (P = 0.042), those without hyperlipidemia (P = 0.021), and currently taking antithrombotic medication (P < 0.001) (Table 1). The items with the poorest knowledge scores were K9 [25.43%; “Novel oral anticoagulants (NOACs), mainly including apixaban, rivaroxaban, and dabigatran”] and K8 (31.40%; “Warfarin is the most commonly used anticoagulant therapy drug”). Hospital lectures and education were the primary sources of knowledge (47.42%) (Table 2).

Knowledge dimension.

Knowledge, n (%) Aware Moderately aware Unaware
K1. Coronary artery disease is a type of heart artery disease, and coronary heart disease is the most common type 244 (46.65) 159 (30.40) 120 (22.94)
K2. Modifiable risk factors for cardiovascular disease include blood pressure, cholesterol, smoking, obesity, etc. 297 (56.79) 161 (30.78) 65 (12.43)
K3. Coronary artery revascularization procedures include percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) 209 (39.96) 150 (28.68) 164 (31.36)
K4. Major complications after coronary artery revascularization surgery include in-stent thrombosis, low blood pressure, and arrhythmia 168 (32.12) 122 (23.33) 233 (44.55)
K5. Antithrombotic treatment is divided into antiplatelet therapy and anticoagulant therapy 112 (21.41) 100 (19.12) 311 (59.46)
K6. Antithrombotic treatment after coronary artery surgery should be maintained for life 262 (50.10) 218 (41.68) 43 (8.22)
K7. Aspirin is the most commonly used antiplatelet therapy drug 273 (52.20) 226 (43.21) 24 (4.59)
K8. Warfarin is the most commonly used anticoagulant therapy drug 80 (15.30) 79 (15.11) 364 (69.60)
K9. Novel oral anticoagulants (NOACs), mainly including apixaban, rivaroxaban, and dabigatran 65 (12.43) 68 (13.00) 390 (74.57)
K10. Routine blood tests, fecal occult blood, and coagulation function should be regularly checked during antithrombotic treatment 220 (42.07) 217 (41.49) 86 (16.44)
K11. The main complication of antithrombotic treatment is bleeding. 228 (43.59) 238 (45.51) 57 (10.90)
K12. Antithrombotic treatment should be used cautiously in case of severe liver and kidney dysfunction, poor coagulation function, etc. 127 (24.28) 85 (16.25) 311 (59.46)
K13. Percutaneous coronary intervention (PCI) is one of the thrombolytic treatment methods 197 (37.67) 114 (21.80) 212 (40.54)
Medical-related books and materials Hospital lectures and education New media Multi-media Relatives and friends
K14. Where do you generally acquire knowledge about antithrombotic management? 48 (9.18) 248 (47.42) 91 (17.40) 38 (7.27) 98 (18.74)
Attitude dimension

The mean attitude score was 43.68 ± 6.01 (range: 21–50), indicating a favorable attitude. Higher attitude scores were observed with a smaller BMI (P = 0.021), rural residence (P = 0.023), no consumption of coffee or tea (P < 0.001), those without hyperlipidemia (P = 0.021), those with a family history of CAD (P < 0.001), currently taking antithrombotic medication (P = 0.002), and undergoing blood tests every 2–4 weeks (P = 0.002) (Table 1). Table 3 presents the distribution of the attitude of each item.

Attitude dimension.

Attitude, n (%) Strongly agree Agree Neutral Disagree Strongly disagree
A1. I worry about the occurrence of thrombosis after surgery 250 (47.80) 212 (40.54) 44 (8.41) 16 (3.06) 1 (0.19)
A2. I worry that thrombosis after surgery will threaten my life 260 (49.71) 215 (41.11) 31 (5.93) 17 (3.25) 0
A3. I believe that antithrombotic treatment is necessary after surgery 241 (46.08) 228 (43.59) 49 (9.37) 5 (0.96) 0
A4. I believe that implementing effective preventive measures will improve postoperative quality of life 253 (48.37) 233 (44.55) 30 (5.74) 6 (1.15) 1 (0.19)
A5. I worry that there will be complications with antithrombotic treatment after surgery 247 (47.23) 219 (41.87) 39 (7.45) 17 (3.25) 1 (0.19)
A6. I believe that regardless of preoperative or postoperative, quitting smoking is necessary to reduce the risk of thrombosis 270 (51.63) 219 (41.87) 26 (4.97) 8 (1.53) 0
A7. I believe that in addition to antithrombotic drug treatment, it is necessary to coordinate with glycemic, lipid-lowering, and antihypertensive treatments according to the condition 257 (49.14) 234 (44.74) 26 (4.97) 6 (1.15) 0
A8. I believe that long-term antithrombotic treatment increases my financial burden 227 (43.40) 196 (37.48) 73 (13.96) 27 (5.16) 0
A9. I believe that when facing long-term antithrombotic treatment, family support is very important 261 (49.90) 224 (42.83) 26 (4.97) 10 (1.91) 2 (0.38)
A10. I believe that hospitals can regularly hold lectures on antithrombotic treatment 281 (53.73) 210 (40.15) 27 (5.16) 5 (0.96) 0
Multivariable logistic regression analysis

Multivariable logistic regression analysis found that junior high school (OR = 2.160, 95% CI: 1.058–4.411, P = 0.035), high school or technical school (OR = 2.356, 95% CI: 1.045–5.312, P = 0.039), and monthly average income >5,000 RMB (OR = 3.407, 95% CI: 1.619–7.166, P = 0.002) were independently associated with knowledge (Table 4). The knowledge (OR = 1.095, 95% CI: 1.032–1.160, P = 0.002), BMI ≥ 24.0 kg/m2 (OR = 0.372, 95% CI: 0.175–0.794, P = 0.011), junior high school (OR = 3.699, 95% CI: 1.615–8.473, P = 0.002), high school or technical school (OR = 2.903, 95% CI: 1.124–7.500, P = 0.028), high associate degree or above (OR = 6.068, 95% CI: 1.449–25.408, P = 0.014), monthly average income 3,000–5,000 RMB (OR = 0.296, 95% CI: 0.126–0.692, P = 0.005), monthly average income >5,000 RMB (OR = 0.225, 95% CI: 0.063–0.799, P = 0.021), with hypertension (OR = 0.333, 95% CI: 0.160–0.693, P = 0.003), blood tests every 2–3 weeks (OR = 10.811, 95% CI: 1.732–67.487, P = 0.011), blood tests every month (OR = 4.221, 95% CI: 1.213–14.691, P = 0.024), and blood tests every 2–3 months (OR = 3.342, 95% CI: 1.105–10.109, P = 0.033) were independently associated with attitude (Table 5).

Univariable and multivariable logistic regression analysis of knowledge.

  Univariable analysis Multivariable analysis
OR (95%CI) P OR (95%CI) P
Age (years)
 <60 Ref.
 60–65 1.046 (0.564–1.942) 0.886
 66–70 0.772 (0.409–1.456) 0.424
 >70 0.960 (0.547–1.682) 0.885
Body mass index (kg/m2)
 <24.0 Ref.
 ≥24.0 1.158 (0.708–1.818) 0.523
Gender
 Male Ref.
 Female 0.864 (0.539–1.385) 0.543
Residence
 Urban Ref.
 Rural 0.738 (0.474–1.150) 0.180
Education
 Primary school or below Ref. Ref.
 Junior high School 2.362 (1.198–4.655) 0.013 2.160 (1.058–4.411) 0.035
 High school/technical school 3.057 (1.471–6.354) 0.003 2.356 (1.045–5.312) 0.039
 Associate degree and above 4.141 (1.817–9.436) 0.001 2.215 (0.863–5.688) 0.098
Monthly average income (RMB)
 <3,000 Ref. Ref.
 3,000–5,000 1.391 (0.813–2.382) 0.229 1.085 (0.603–1.929) 0.785
 >5,000 4.997 (2.634–9.479) < 0.001 3.407 (1.619–7.166) 0.002
Smoking
 Yes 0.954 (0.614–1.483) 0.835
 No Ref.
Drinking
 Yes 1.253 (0.804–1.952) 0.319
 No Ref.
Regular consumption of coffee or tea
 Yes 2.015 (1.144–3.549) 0.015 1.318 (0.697–2.492) 0.396
 No Ref. Ref.
Hypertension
 Yes 1.292 (0.770–2.167) 0.333
 No Ref.
Diabetes
 Yes 1.168 (0.721–1.890) 0.528
 No Ref.
Hyperlipidemia
 Yes 0.602 (0.378–0.957) 0.032 0.653 (0.399–1.067) 0.089
 No Ref. Ref.
Family history of coronary heart disease
 Yes 0.902 (0.530–1.535) 0.704
 No Ref.
Duration of coronary heart disease affliction
 <1 year Ref.
 1–5 years 1.274 (0.748–2.170) 0.372
 >5 years 1.041 (0.610–1.776) 0.883
Type of coronary artery revascularization procedure
 Percutaneous coronary intervention (PCI) Ref.
 Coronary artery bypass grafting (CABG) 1.225 (0.441–3.402) 0.697
Currently taking antithrombotic medications
 Yes 1.650 (0.839–3.244) 0.147
 No Ref.
Frequency of routine blood tests while taking antithrombotic medication
 Weekly Ref. Ref.
 Every 2–3 weeks 0.387 (0.128–1.175) 0.094 0.465 (0.141–1.529) 0.135
 Monthly 0.589 (0.241–1.442) 0.247 0.683 (0.257–1.815) 0.445
 Every 2–3 months 0.376 (0.159–0.891) 0.026 0.404 (0.157–1.041) 0.061

Univariable and multivariable logistic regression analysis of attitude.

  Univariable analysis Multivariable analysis
OR (95%CI) P OR (95%CI) P
Knowledge score 1.081 (1.026–1.140) 0.004 1.095 (1.032–1.160) 0.002
Age (years)
 <60 Ref.
 60–65 1.148 (0.499–2.642) 0.745
 66–70 1.439 (0.611–3.385) 0.405
 >70 1.076 (0.517–2.239) 0.844
Body mass index (kg/m2)
 <24.0 Ref. Ref.
 ≥24.0 0.415 (0.208–0.830) 0.013 0.372 (0.175–0.794) 0.011
Gender
 Male Ref.
 Female 1.140 (0.606–2.146) 0.685
Residence
 Urban Ref.
 Rural 1.659 (0.902–3.052) 0.104
Education
 Primary school or below Ref. Ref.
 Junior high school 2.049 (1.015–4.136) 0.045 3.699 (1.615–8.473) 0.002
 High school/technical school 1.431 (0.657–3.117) 0.367 2.903 (1.124–7.500) 0.028
 Associate degree and above 2.167 (0.698–6.726) 0.181 6.068 (1.449–25.408) 0.014
Monthly average income (RMB)
 <3,000 Ref. Ref.
 3,000–5,000 0.431 (0.207–0.897) 0.024 0.296 (0.126–0.692) 0.005
 >5,000 0.563 (0.205–1.541) 0.263 0.225 (0.063–0.799) 0.021
Smoking
 Yes 1.313 (0.719–2.400) 0.375
 No Ref.
Drinking
 Yes 1.136 (0.616–2.095) 0.682
 No Ref.
Regular consumption of coffee or tea
 Yes 0.509 (0.248–1.048) 0.067
 No Ref.
Hypertension
 Yes 0.309 (0.169–0.567) <0.001 0.333 (0.160–0.693) 0.003
 No Ref. Ref.
Diabetes
 Yes 0.871 (0.456–1.660) 0.674
 No Ref.
Hyperlipidemia
 Yes 0.857 (0.478–1.537) 0.605
 No Ref.
Family history of coronary heart disease
 Yes 0.355 (0.195–0.648) 0.001 0.669 (0.325–1.377) 0.275
 No Ref. Ref.
Duration of coronary heart disease affliction
 <1 year Ref.
 1–5 years 0.983 (0.479–2.016) 0.962
 >5 years 0.968 (0.482–1.945) 0.927
Type of coronary artery revascularization procedure
 Percutaneous coronary intervention (PCI) Ref. Ref.
 Coronary artery bypass grafting (CABG) 0.344 (0.121–0.975) 0.045 0.408 (0.119–1.399) 0.154
Currently taking antithrombotic medications
 Yes 0.706 (0.291–1.713) 0.441
 No Ref.
Frequency of routine blood tests while taking antithrombotic medication
 Weekly Ref. Ref.
 Every 2–3 weeks 8.289 (1.575–43.616) 0.013 10.811 (1.732–67.487) 0.011
 Monthly 5.485 (1.829–16.452) 0.002 4.221 (1.213–14.691) 0.024
 Every 2–3 months 3.059 (1.196–7.822) 0.020 3.342 (1.105–10.109) 0.033
Discussion

This study found that patients with CAD who underwent coronary revascularization have poor knowledge but favorable attitudes toward postoperative antithrombotic management and prevention. The questionnaire covered several aspects of antithrombotic management, but the patterns of poor knowledge were different among the participants. In addition, categories of patients were identified as associated with poorer knowledge, underscoring the importance of tailored patient education programs aimed at improving knowledge levels, particularly among individuals with lower education and income.

In this study, most patients with CAD were above 60 years old, which is consistent with the epidemiology of ACS (1, 2, 10, 23). The participants in the present study were older than in two previous KAP studies in patients with CAD (24, 25), suggesting a small likelihood of selection bias in the present study. The smoking rate in this study was lower than that in the other two previous studies (24, 26). Two previous studies reported that 97% (24) and 71% (25) of the participants could name the symptoms of CAD. Akshay et al. (24) reported that 50% of participants knew what CAD is, and 66.1% knew that the patients should follow a specific diet. Mohammad et al. (27) reported that about 50% of their participants could correctly answer general CAD questions. Similar results were observed in the present study. The questionnaire covered knowledge areas like the nature of CAD, the risk factors for CAD, the management of CAD, complications after CAD surgery, antithrombotic types, the length of antithrombotic therapy, the antithrombotic drugs available, examinations to perform during antithrombotic treatment, and the complications of antithrombotic treatment. Still, the patterns of incorrect responses were different among participants. A future study should examine whether the questionnaire developed here could be used to identify the KA areas to be improved and provide tailored educational and motivational interventions to the patients.

In the present study, higher education and higher income were both associated with higher knowledge scores. It is well known that a more favorable socioeconomic status is associated with better health literacy (28). Similar results were also observed previously (24, 29). Higher BMI was associated with lower attitudes, possibly because they tended to have poorer lifestyle habits and low willingness to change them. Higher education was also associated with a more favorable attitude. Surprisingly, higher income was associated with a less favorable attitude. It could be because patients with lower incomes are more willing to cultivate a good attitude toward therapy to avoid MACE, complications, and additional medical expenses. Less frequent blood examinations were also associated with a more favorable attitude, possibly because of saved time and money. Hence, these results suggest that although all patients would benefit from educational interventions, those with a lower socioeconomic status could profit even more.

This study also found that knowledge was independently associated with attitude, indicating that improving knowledge through education should also improve the attitude. This study showed that all patients would benefit from education, but those with low education and low income, i.e., those with lower socioeconomic status, would benefit the most. Still, available data in the literature suggested that healthcare providers have moderate knowledge of antiplatelet therapy (18, 19). Considering that healthcare providers are a primary source of reliable health information, as in the present study, their knowledge of antiplatelet therapy should be improved.

However, this study still had several limitations. The study was performed at a single center, resulting in a relatively small sample size. In addition, the participants were all from the same geographical area, limiting the generalizability of the results to other areas. The questionnaire was designed by the investigators according to the literature and local practice, policies, and reality. Hence, the questionnaire has limited exportability, and the results could lack generalizability. The items about the clinical characteristics of the participants were self-reported, and the results could be biased. In the present study, the practice was not evaluated because compliance, as the main practice indicator, could not be determined reliably. Finally, all KAP studies are at risk of the social desirability bias (30, 31), but considering that knowledge was poor, that bias has a low likelihood.

In conclusion, this study underscored the importance of tailored patient education programs aimed at improving knowledge levels, particularly among individuals with lower education and income. Addressing these gaps in understanding may enhance overall patient compliance and contribute to better cardiovascular outcomes following coronary revascularization. Future interventions should consider these factors to optimize postoperative antithrombotic management and prevention strategies among CAD patients.

 Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

 Ethics statement

The studies involving humans were approved by Kailuan General Hospital (No. 2020031). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

 Author contributions

CL: Conceptualization, Data curation, Investigation, Writing – original draft, Writing – review & editing. HZ: Formal Analysis, Investigation, Writing – original draft. LY: Data curation, Investigation, Writing – original draft. LC: Data curation, Investigation, Writing – original draft. CZ: Data curation, Investigation, Writing – original draft. FW: Data curation, Investigation, Writing – original draft. YD: Data curation, Investigation, Writing – original draft. HZ: Conceptualization, Data curation, Writing – original draft, Writing – review & editing.

 Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

 Acknowledgments

We thank the other staff of the Department of Cardiology, Kailuan General Hospital, for their support in data collection.

 Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

 Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

 Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fcvm.2024.1388164/full#supplementary-material

 References AmsterdamEAWengerNKBrindisRGCaseyDEJrGaniatsTGHolmesDRJr 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. (2014) 130(25):e344–426. 10.1161/CIR.000000000000013425249585 IbanezBJamesSAgewallSAntunesMJBucciarelli-DucciCBuenoH 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. (2018) 39(2):119–77. 10.1093/eurheartj/ehx39328886621 M. Authors/Task Force, PiepoliMFHoesAWAgewallSAlbusCBrotonsC. 2016 European guidelines on cardiovascular disease prevention in clinical practice: the sixth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts): developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur J Prev Cardiol. (2016) 23(11):NP1–96. 10.1177/204748731665370927353126 LevineGNBatesERBlankenshipJCBaileySRBittlJACercekB 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines and the society for cardiovascular angiography and interventions. Circulation. (2011) 124(23):e574–651. 10.1161/CIR.0b013e31823ba62222064601 HillisLDSmithPKAndersonJLBittlJABridgesCRByrneJG 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. (2011) 124(23):e652–735. 10.1161/CIR.0b013e31823c074e22064599 PatelMRDehmerGJHirshfeldJWSmithPKSpertusJA, American College of Cardiology Foundation Appropriateness Criteria Task, et al. 2009 appropriateness criteria for coronary revascularization: a report by the American College of Cardiology Foundation appropriateness criteria task force, society for cardiovascular angiography and interventions, society of thoracic surgeons, American association for thoracic surgery, American heart association, and the American society of nuclear cardiology endorsed by the American society of echocardiography, the heart failure society of America, and the society of cardiovascular computed tomography. J Am Coll Cardiol. (2009) 53(6):530–53. 10.1016/j.jacc.2008.10.00519195618 FihnSDBlankenshipJCAlexanderKPBittlJAByrneJGFletcherBJ 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines, and the American association for thoracic surgery, preventive cardiovascular nurses association, society for cardiovascular angiography and interventions, and society of thoracic surgeons. Circulation. (2014) 130(19):1749–67. 10.1161/CIR.000000000000009525070666 DiodatoMChedrawyEG. Coronary artery bypass graft surgery: the past, present, and future of myocardial revascularisation. Surg Res Pract. (2014) 2014:726158. 10.1155/2014/72615825374960 AhmadMMehtaPReddivariAKRMungeeS. Percutaneous coronary intervention. In: StatPearls. Treasure Island, FL: Ineligible Companies (2023). Disclosure: Parth Mehta declares no relevant financial relationships with ineligible companies. Disclosure: Anil Kumar Reddy Reddivari declares no relevant financial relationships with ineligible companies. Disclosure: Sudhir Mungee declares no relevant financial relationships with ineligible companies. PMID: 27478119 BraunwaldE. Unstable angina and non-ST elevation myocardial infarction. Am J Respir Crit Care Med. (2012) 185(9):924–32. 10.1164/rccm.201109-1745CI22205565 M. Writing Committee, LawtonJSTamis-HollandJEBangaloreSBatesERBeckieTM 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. J Am Coll Cardiol. (2022) 79(2):e21–129. 10.1016/j.jacc.2021.09.00634895950 SandnerSRedforsBGaudinoM. Antiplatelet therapy around CABG: the latest evidence. Curr Opin Cardiol. (2023) 38(6):484–9. 10.1097/HCO.000000000000107837751394 Pinho-GomesACAzevedoLAhnJMParkSJHamzaTHFarkouhME Compliance with guideline-directed medical therapy in contemporary coronary revascularization trials. J Am Coll Cardiol. (2018) 71(6), 591–602. 10.1016/j.jacc.2017.11.06829420954 JimmyBJoseJ. Patient medication adherence: measures in daily practice. Oman Med J. (2011) 26(3):155–9. 10.5001/omj.2011.3822043406 MartinLRWilliamsSLHaskardKBDimatteoMR. The challenge of patient adherence. Ther Clin Risk Manag. (2005) 1(3):189–99.18360559 AndradeCMenonVAmeenSKumar PraharajS. Designing and conducting knowledge, attitude, and practice surveys in psychiatry: practical guidance. Indian J Psychol Med. (2020) 42(5):478–81. 10.1177/025371762094611133414597 World Health Organization. Advocacy, Communication and Social Mobilization for TB Control: a Guide to Developing Knowledge, Attitude and Practice Surveys. (2008). Available online at: http://whqlibdoc.who.int/publications/2008/9789241596176_eng.pdf (accessed November 22, 2022). RaiRMohanBBabbarVDangN. Practices and perceptions of doctors for patients on anti-platelets during dental surgery: a national survey. J Maxillofac Oral Surg. (2014) 13(3):249–52. 10.1007/s12663-013-0523-625018596 Al-MohaissenMAAl-MehisenRLeeTAl-MadiEM. Managing cardiac patients: dentists’ knowledge, perceptions, and practices. Int Dent J. (2022) 72(3):296–307. 10.1016/j.identj.2021.04.00634256924 SharmaAMinh DucNTLuu Lam ThangTNamNHNgSJAbbasKS A consensus-based checklist for reporting of survey studies (CROSS). J Gen Intern Med. (2021) 36(10):3179–87. 10.1007/s11606-021-06737-133886027 FoxKAMehtaSRPetersRZhaoFLakkisNGershBJ Clopidogrel in unstable angina to prevent recurrent ischemic events: benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the clopidogrel in unstable angina to prevent recurrent ischemic events (CURE) trial. Circulation. (2004) 110(10):1202–8. 10.1161/01.CIR.0000140675.85342.1B15313956 ObaghaECAjayiIAbdullahiGAUmeokonkwoCD. Clients’ satisfaction with preventive services for malaria during pregnancy in Anambra state, Nigeria. BMC Public Health. (2020) 20(1):1660. 10.1186/s12889-020-09767-233148250 O’GaraPTKushnerFGAscheimDDCaseyDEJrChungMKde LemosJA 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. (2013) 127(4):e362–425. 10.1161/CIR.0b013e3182742cf6 AkshayTVShruthilayaCKRafiyathVVRajeshKSSubrahmanyamKKumartRR. Knowledge, attitude and practice of ischemic heart disease patients towards their medication. H Pharma Res Intl. (2021) 33(58A):256–62. 10.9734/jpri/2021/v33i58A34114 MirzaASAslamSPerrinKCurtisTStenbackJGipsonJ Knowledge, attitudes and practices among patients with coronary artery disease in Dhaka, Bangladesh. Intl J Communit Med Publ Aff. (2016) 3(10):2740–8. 10.18203/2394-6040.ijcmph20163355 YahyaRMuhamadRYusoffHM. Association between knowledge, attitude and practice on cardiovascular disease among women in Kelantan, Malaysia. IJCRIMPH. (2012) 4:82–98. MohammadNBRahmanNAAHaqueM. Knowledge, attitude, and practice regarding the risk of cardiovascular diseases in patients attending outpatient clinic in Kuantan, Malaysia. J Pharm Bioallied Sci. (2018) 10(1):7–14. 10.4103/jpbs.JPBS_227_1729657502 SvendsenMTBakCKSorensenKPelikanJRiddersholmSJSkalsRK Associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among Danish adults. BMC Public Health. (2020) 20(1):565. 10.1186/s12889-020-08498-832345275 HertzJTSakitaFMManavalanPMmbagaBTThielmanNMStatonCA. Knowledge, attitudes, and preventative practices regarding ischemic heart disease among emergency department patients in northern Tanzania. Public Health. (2019) 175:60–7. 10.1016/j.puhe.2019.06.01731401252 BergenNLabonteR. “Everything is perfect, and we have no problems”: detecting and limiting social desirability bias in qualitative research. Qual Health Res. (2020) 30(5):783–92. 10.1177/104973231988935431830860 LatkinCAEdwardsCDavey-RothwellMATobinKE. The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland. Addict Behav. (2017) 73:133–6. 10.1016/j.addbeh.2017.05.00528511097