In brief
A cross-sectional survey of 236 Saudi post-PCI patients found smoking, physical inactivity, and low antiplatelet adherence were all common and co-occurred, but no firm lifestyle-adherence link was confirmed except a tentative, hypothesis-generating signal for arthritis.
What this article is about
Quick Answer
A cross-sectional survey of 236 Saudi post-PCI patients found smoking, physical inactivity, and low antiplatelet adherence were all common and co-occurred, but no firm lifestyle-adherence link was confirmed except a tentative, hypothesis-generating signal for arthritis.
Student takeaways
Key Takeaways
- Among 236 Saudi adults who had a PCI within the prior 12 months, the sample was predominantly male (73.7%) and older, with 83.9% aged over 50.
- Smoking prevalence was 23.3% (55 of 236 participants), and physical inactivity was highly prevalent, with 57.2% (135 participants) reporting they never engaged in regular exercise.
- Antiplatelet medication adherence was suboptimal: 55.4% (129 participants) were classified as having low adherence on the self-reported Morisky Medication Adherence Scale-8 (MMAS-8).
- In multivariable analysis, arthritis was the only statistically significant predictor of adherence (AOR 2.81, 95% CI 1.01 to 7.84, p = 0.048), but the authors noted this does not survive Bonferroni correction and is hypothesis-generating.
- Smoking (AOR 0.52) and physical inactivity (AOR 0.45) showed inverse but statistically non-significant trends with adherence, so no firm lifestyle-adherence link was confirmed.
Student summary
Why This Research Matters
This cross-sectional survey looked at how lifestyle behaviours and medication-taking come together in patients recovering from percutaneous coronary intervention (PCI), a procedure that opens blocked heart arteries with a stent or balloon. The researchers studied 236 Saudi adults who had undergone PCI within the previous 12 months at two tertiary cardiac centres in Riyadh, Saudi Arabia. Their goal was to describe smoking and physical-activity patterns, measure how well patients kept taking their antiplatelet medication, and explore whether lifestyle factors were linked to adherence. Antiplatelet medications, such as aspirin and similar drugs, are a cornerstone of secondary prevention after PCI because they help keep the treated artery from re-clotting; stopping them early can raise the risk of serious events. Because this was a survey done at one point in time, it can describe what patients reported and look for associations, but it cannot prove that one thing causes another.
The sample was mostly male (73.7%) and older, with 83.9% aged over 50. The findings paint a concerning picture of health behaviours in this group. About one in four participants (23.3%, or 55 of 236) reported smoking, and physical inactivity was very common: 57.2% (135 participants) said they never engaged in regular exercise such as walking, swimming, or other structured activity. Medication adherence, measured with the self-reported Morisky Medication Adherence Scale-8 (MMAS-8), was also suboptimal, with 55.4% (129 participants) classified as having low adherence. In other words, unhealthy lifestyle behaviours and poor medication-taking were each common, and they tended to co-occur in the same patients.
The researchers then used statistical models to see whether lifestyle factors predicted adherence. In the multivariable analysis, which adjusted for conditions including hypertension, diabetes, arthritis, and heart disease, arthritis was the only statistically significant predictor of adherence (adjusted odds ratio 2.81, 95% confidence interval 1.01 to 7.84, p = 0.048). Importantly, the authors themselves cautioned that this result does not survive Bonferroni correction for multiple comparisons and should be read as hypothesis-generating, not as a confirmed effect. Smoking (adjusted odds ratio 0.52) and physical inactivity (adjusted odds ratio 0.45) showed inverse trends with adherence, but neither reached statistical significance. So the honest bottom line is that the study documented how widespread these problems are, but it did not confirm a firm statistical link between lifestyle habits and adherence, except for the tentative arthritis signal.
Why does this matter to nursing? The authors frame their results as a rationale for developing integrated nursing interventions that address smoking, physical inactivity, and medication non-adherence at the same time, rather than treating them as separate problems. Nurses are often the professionals who counsel cardiac patients about lifestyle, teach them why antiplatelet therapy must not be stopped without medical advice, and follow up after discharge. This paper reminds students that secondary prevention is holistic: a patient who quits smoking but stops their medication, or who takes pills faithfully but never exercises, is only partly protected. It also highlights the value of routinely screening for adherence using tools like the MMAS-8 and asking about exercise and smoking in a respectful, non-judgmental way.
A few cautions are worth keeping in mind. This study describes patients in a specific setting (two Riyadh centres) and culture, so the exact numbers may not transfer to other populations. Self-reported adherence and self-reported activity can be affected by memory and social desirability, meaning real behaviour could be even less favourable. Most importantly, students should not read the arthritis finding as clinical guidance; the authors clearly labelled it hypothesis-generating. Nurses should never adjust or stop a patient's antiplatelet medication based on lifestyle factors alone, and any concerns about adherence, side effects, or bleeding should be discussed with the prescribing team. The real takeaway is the need for well-designed, adequately powered future trials of nurse-led programs that tackle multiple risk factors together, and the everyday nursing skill of appraising evidence critically, noticing when a finding is preliminary rather than definitive.
Source abstract
Study Overview
Lifestyle behaviours and medication adherence are interrelated components of cardiovascular secondary prevention, yet their co-occurrence in Middle Eastern post-percutaneous coronary intervention (PCI) populations remains poorly characterised. This study described smoking status and physical activity patterns, assessed antiplatelet medication adherence, and explored associations between lifestyle factors and adherence among Saudi patients following PCI.A cross-sectional survey was conducted among 236 Saudi adults who had undergone PCI within the preceding 12 months at two tertiary cardiac centres in Riyadh, Saudi Arabia. Data were collected on smoking status, cigarette consumption, self-reported physical activity frequency (defined as the frequency of engagement in regular exercise such as walking, swimming, or other structured physical activity), and self-reported medication adherence measured via the Morisky Medication Adherence Scale-8 (MMAS-8). Descriptive statistics characterised lifestyle and adherence patterns. Bivariate analyses (chi-square tests) and multivariate binary logistic regression were used to explore associations between lifestyle factors and adherence, adjusting for comorbidities including hypertension, diabetes mellitus, arthritis, and heart disease.Participants were predominantly male (73.7%) and older adults (83.9% aged >50 years). Smoking prevalence was 23.3% (= 55 of 236 participants), and physical inactivity was highly prevalent, with 57.2% of the sample (= 135) reporting never engaging in regular exercise. Adherence was suboptimal, with 55.4% of participants (= 129) classified as having low adherence (self-reported, measured via the MMAS-8). In multivariate analysis, arthritis was the only statistically significant predictor of adherence (adjusted odds ratio [AOR] = 2.81, 95% confidence interval [CI]: 1.01-7.84,= 0.048; note, however, that this finding does not survive Bonferroni correction for multiple comparisons and should be interpreted as hypothesis-generating). Smoking (AOR = 0.52, 95% CI: 0.19-1.45,= 0.213) and physical inactivity (AOR = 0.45, 95% CI: 0.09-2.25,= 0.332) showed inverse but statistically non-significant trends with adherence.Unhealthy lifestyle behaviours and low medication adherence were each highly prevalent and co-occurred in this post-PCI population, though associations between lifestyle factors and adherence were not statistically confirmed except for arthritis. These descriptive findings are hypothesis-generating and provide a rationale for future adequately powered prospective studies and trials evaluating integrated nursing interventions that simultaneously address smoking, physical inactivity, and medication non-adherence in Saudi cardiac care settings.
Evidence appraisal
Main Findings
- Among 236 Saudi adults who had a PCI within the prior 12 months, the sample was predominantly male (73.7%) and older, with 83.9% aged over 50.
- Smoking prevalence was 23.3% (55 of 236 participants), and physical inactivity was highly prevalent, with 57.2% (135 participants) reporting they never engaged in regular exercise.
- Antiplatelet medication adherence was suboptimal: 55.4% (129 participants) were classified as having low adherence on the self-reported Morisky Medication Adherence Scale-8 (MMAS-8).
- In multivariable analysis, arthritis was the only statistically significant predictor of adherence (AOR 2.81, 95% CI 1.01 to 7.84, p = 0.048), but the authors noted this does not survive Bonferroni correction and is hypothesis-generating.
- Smoking (AOR 0.52) and physical inactivity (AOR 0.45) showed inverse but statistically non-significant trends with adherence, so no firm lifestyle-adherence link was confirmed.
Practice transfer
Clinical Relevance
- Nurses can screen post-PCI patients for both lifestyle risk factors and medication adherence, since this study shows the two problems often co-occur in the same person.
- Validated self-report tools such as the MMAS-8 can help open a non-judgmental conversation about missed doses, but self-report may understate true non-adherence and should be paired with clinical follow-up.
- Patient teaching should stress that antiplatelet therapy after PCI is protective and should not be stopped without medical advice; adherence concerns should be routed to the prescribing team, not managed by adjusting doses independently.
- Because smoking and physical inactivity were each common, secondary-prevention counselling that addresses multiple behaviours together may be more useful than tackling one factor in isolation.
- The findings support advocating for adequately powered, nurse-led integrated intervention programs rather than acting on the study's preliminary, unconfirmed statistical associations.
Faculty notes
Educational Relevance
Use this cross-sectional survey (n = 236 post-PCI adults in Riyadh) to teach measured interpretation of descriptive, hypothesis-generating research. It is an excellent case for distinguishing prevalence description from causal inference: the study documents high co-occurrence of smoking (23.3%), physical inactivity (57.2%), and low antiplatelet adherence (55.4% by MMAS-8), yet finds no confirmed lifestyle-adherence association. The single significant predictor (arthritis, AOR 2.81, p = 0.048) is explicitly flagged by the authors as failing Bonferroni correction, giving a ready-made teaching moment on multiple-comparison correction, confidence intervals that hug 1.0, and the danger of over-reading a marginal p-value. Ask students to critique self-report measurement bias, the single-time-point design, and generalizability limits from a two-centre male-predominant sample. Connect the discussion to holistic cardiovascular secondary prevention and the nurse's role in adherence counselling, motivational interviewing, and smoking-cessation and activity support. The paper also models scientific humility: the authors position their work as a rationale for adequately powered prospective trials of integrated nurse-led interventions, which is a useful frame for discussing why negative or inconclusive findings still advance a field and how research questions mature from descriptive to interventional.
Critical appraisal
Limitations
- The cross-sectional, single-time-point design can describe patterns and associations but cannot establish that lifestyle factors cause changes in adherence.
- Smoking, physical activity, and adherence were all self-reported, so recall and social-desirability bias may make the true behaviours look more favourable than they are.
- The only significant predictor (arthritis) did not survive correction for multiple comparisons and was explicitly labelled hypothesis-generating, so it should not guide practice.
Classroom use
Discussion Questions
- Why is antiplatelet medication adherence especially important in the first year after a PCI, and what could happen if a patient stops early?
- This study found that unhealthy lifestyle behaviours and low adherence co-occurred. How might these problems reinforce one another in a real patient's life?
- The authors labelled the arthritis finding as hypothesis-generating. What does that phrase mean, and why did they add it?
- How does the Bonferroni correction change the way you should interpret a p-value of 0.048 when many comparisons were made?
- What are the strengths and weaknesses of using a self-report scale like the MMAS-8 to measure adherence?
- How might the sample being 73.7% male and mostly over 50 affect whether these results apply to other patients?
- What non-judgmental questions could a nurse ask to explore why a cardiac patient is missing doses?
- The study was done at two centres in Riyadh. How could culture, health system, and setting influence lifestyle and adherence patterns?
- Why might the authors argue for an integrated intervention that targets smoking, activity, and adherence together rather than separately?
- If you were designing a stronger follow-up study, what design features would you add to move from description toward evidence of cause and effect?
Knowledge check
Quiz
1. What study design did this research use?
- Randomized controlled trial
- Cross-sectional survey
- Systematic review
- Longitudinal cohort followed for five years
Rationale: The authors describe a cross-sectional survey of 236 patients at one point in time, which can show associations but not cause and effect.
2. How many participants were included in the study?
- 55
- 129
- 236
- 914
Rationale: The survey enrolled 236 Saudi adults who had undergone PCI within the preceding 12 months.
3. What proportion of participants were classified as having low medication adherence on the MMAS-8?
- 23.3%
- 55.4%
- 73.7%
- 83.9%
Rationale: 55.4% (129 of 236 participants) were classified as having low adherence on the self-reported MMAS-8.
4. Which factor was the only statistically significant predictor of adherence in the multivariable analysis?
- Smoking
- Physical inactivity
- Arthritis
- Diabetes mellitus
Rationale: Arthritis was the only significant predictor (AOR 2.81, p = 0.048), though the authors noted it did not survive Bonferroni correction.
5. How did the authors describe the arthritis finding?
- A confirmed causal effect
- Hypothesis-generating
- The main outcome of the trial
- Clinically actionable guidance
Rationale: The authors explicitly cautioned that the arthritis association was hypothesis-generating because it did not survive correction for multiple comparisons.
6. What percentage of participants reported that they never engaged in regular exercise?
- 23.3%
- 32%
- 57.2%
- 73.7%
Rationale: Physical inactivity was highly prevalent, with 57.2% (135 participants) reporting they never engaged in regular exercise.
7. What tool was used to measure medication adherence?
- Morisky Medication Adherence Scale-8 (MMAS-8)
- Beck Depression Inventory
- Columbia Suicide Severity Rating Scale
- QSEN competency checklist
Rationale: Adherence was measured by self-report using the MMAS-8.
8. What is a PCI (percutaneous coronary intervention)?
- A procedure to open blocked heart arteries
- A type of antiplatelet medication
- A psychiatric screening interview
- A physical activity questionnaire
Rationale: PCI is a procedure that reopens narrowed or blocked coronary arteries, after which antiplatelet therapy is a key part of secondary prevention.
9. Which statement best reflects the study's main conclusion?
- Smoking clearly causes poor adherence
- Unhealthy lifestyle and low adherence were common and co-occurred, but a firm link was not confirmed
- Most patients had excellent adherence and healthy habits
- Physical inactivity strongly protected against non-adherence
Rationale: The study documented high prevalence and co-occurrence, but associations between lifestyle factors and adherence were not statistically confirmed except for the tentative arthritis signal.
10. Why should nurses not adjust a patient's antiplatelet regimen based on this study's lifestyle findings?
- Antiplatelet drugs are harmless so adjustment is unnecessary
- The associations were preliminary and unconfirmed, and dosing decisions belong to the prescribing team
- The study proved lifestyle has no effect on adherence
- Nurses are never involved in adherence counselling
Rationale: The findings were hypothesis-generating, and any adherence or medication concern should be discussed with the prescriber rather than acted on by changing therapy.
Study cards
Flashcards
What does PCI stand for?
Percutaneous coronary intervention, a procedure that opens blocked or narrowed heart arteries.
How many patients were in this study?
236 Saudi adults who had a PCI within the preceding 12 months.
Where was the study conducted?
At two tertiary cardiac centres in Riyadh, Saudi Arabia.
What study design was used?
A cross-sectional survey.
What tool measured adherence?
The self-reported Morisky Medication Adherence Scale-8 (MMAS-8).
What was the smoking prevalence?
23.3% (55 of 236 participants).
What proportion never exercised regularly?
57.2% (135 participants).
What proportion had low medication adherence?
55.4% (129 participants).
What was the sex distribution?
Predominantly male, 73.7%.
What age group dominated the sample?
Older adults; 83.9% were over 50 years old.
Which factor was the only significant predictor of adherence?
Arthritis (AOR 2.81, 95% CI 1.01 to 7.84, p = 0.048).
Why should the arthritis finding be interpreted cautiously?
It did not survive Bonferroni correction for multiple comparisons and was labelled hypothesis-generating.
Were smoking and inactivity significant predictors of adherence?
No; both showed inverse trends but were not statistically significant.
Why is antiplatelet therapy important after PCI?
It helps prevent the treated artery from re-clotting, a key part of secondary prevention.
Can this study prove cause and effect?
No; its cross-sectional design can only describe patterns and associations.
What is a main limitation of the adherence and activity data?
They were self-reported and can be affected by recall and social-desirability bias.
What is the nursing take-home message?
Secondary prevention is holistic; nurses should address adherence, smoking, and activity together.
Why did the authors call for future studies?
To conduct adequately powered prospective trials of integrated nurse-led interventions.
What conditions were adjusted for in the model?
Hypertension, diabetes mellitus, arthritis, and heart disease.
What is the overall clinical population studied?
Cardiac patients in secondary prevention after PCI, not a psychiatric population.
Search-ready answers
Frequently asked questions
What was this study trying to find out?
It described smoking and physical-activity patterns, measured antiplatelet medication adherence, and explored whether lifestyle factors were linked to adherence in Saudi patients after PCI.
Did the study prove that smoking or inactivity causes poor adherence?
No. Both showed inverse trends, but neither was statistically significant, and the cross-sectional design cannot establish cause and effect.
What was the one significant predictor found?
Arthritis was the only significant predictor of adherence, but the authors stressed it was hypothesis-generating and did not survive correction for multiple comparisons.
How was adherence measured?
Through patient self-report using the Morisky Medication Adherence Scale-8 (MMAS-8).
Is this a psychiatric study?
No. It focuses on cardiovascular secondary prevention after PCI, though its lessons about medication adherence apply broadly to nursing, including psychiatric care.
Why does adherence matter after PCI?
Antiplatelet medications help keep the treated artery open, so stopping them early can raise the risk of serious cardiac events.
How many patients had unhealthy behaviours or low adherence?
About a quarter smoked, over half never exercised, and over half had low adherence, and these problems often occurred together.
Can these numbers be applied to all cardiac patients?
Not directly. The sample came from two Riyadh centres and was mostly older men, so the exact figures may not transfer elsewhere.
What should a nurse do if a cardiac patient reports missing doses?
Explore the reasons non-judgmentally, reinforce the importance of the medication, and involve the prescribing team; nurses should not adjust the regimen on their own.
What is the main takeaway for nursing students?
Secondary prevention is holistic, screening for adherence and lifestyle is valuable, and preliminary findings should be appraised critically rather than treated as proven.