Cardiovascular Disease

Cardiovascular diseases (CVD), which include stroke, hypertension (HTN), arrhythmias, coronary heart disease (CHD), and heart failure (HF) are major contributors to mortality and morbidity. Although the most prevalent form of CVD is HTN, the majority of CVD deaths are attributed to CHD. The prevalence and incidence of CHD increase dramatically with age and CHD is the leading cause of death in the elderly, with 84% of all CHD deaths in those 65 years of age or older (American Heart association [AHA],2001).



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Angina, sudden death and myocardial infarction (MI) are the major manifestations of CHD. Twenty-five percent of men and 38% of women will die within 1 year of their MI (AHA). Although HF may result from valvular dysfunction and other conditions, the majority of cases of HF are attributable to CHD with approximately 22% of men and46% of women disabled by heart failure post MI (AHA). Despite the importance of CHD, prevention and management of CHD are only beginning to be studied in the elderly population. The Second World Assembly on Aging in 2002 addressed the international issue of supporting patients in both primary and secondary prevention of CHD and HF that are so prevalent in the geriatric population. 
Although control of hypertension and dyslipidemia have been shown to reduce CVD mortality and morbidity in both middle-aged and elderly individuals, the efficacy of other measures such as lowering homocysteine and fibrinogen levels, quitting smoking, exercising or weight reduction are not yet established in the elderly. Nevertheless, such measures appear to be warranted (Kannel, 1997; Glad-dish & Rajkumar, 2001). Much of our current knowledge, however, is still based on studies conducted with non-elderly individuals. CHD and subsequent MI are potentially preventable conditions. The recent publication of the standards of care for both dyslipidemia (Adult Treatment Panel III [ATP III] Guidelines, 2001) and hypertension (Chobanian et al., 2003) do not make guidelines specific to different adult age groups. Older and younger adults are classified by their risk factors, with increasing age yielding a higher risk score in the Framingham Risk Profile. Research aimed at prevention must address the importance of established risk factors in the elderly, as well as identifying new risk factors specific to the elderly population. Age-related differences exist between younger and elderly individuals regarding cardiac risk factors, and the role of conventional cardiac risk factors remains controversial. In addition, diabetes mellitus is a prevalent problem, and is considered a CHD equivalent (ATP III). Diabetes is also associated with an increased risk of recurrent MI, HF, and death following MI. Knowledge of diabetes management in relation to the of development of CHD and MI, as well as to longterm outcomes, however, is limited. Secondly, although information regarding patient management of cardiac risk factors is limited, recent trials of lipid lowering agents have demonstrated a beneficial effect on morbidity and mortality (Mostaghel & Waters, 2003). Large multicenter hypertension trial shave also begun to demonstrate the efficacy of aggressive hypertension treatment in reducing risk of CHD (Puddey, 2000). Identification and evaluation of the efficacy of other preventive interventions, therefore, need to be documented, as well as individual characteristics that contribute to better risk factor control. Nursing also has an important role in studying methods and adequacy of dissemination of guidelines for primary prevention of CHD established by the AHA, not only to the public, but to health care providers (Williams et al., 2002). Levels of physical activity and control of lipids, HTN, obesity, and smoking need to be determined, along with side effects of these interventions. Management of diet and exercise may pose special challenges; medications to treat hypertension and lipid abnormalities may not be well-tolerated and the potential for side effects and drug interactions is increased in the setting of polypharmacy. Finally, consideration of psychosocial factors is warranted. Psychosocial influences, which may contribute to control cardiac risk factors, and quality of life, which may be affected by control of cardiac risk factors, however, have not been widely studied in the elderly population. Advanced age is known to be associated with an increased risk of in-hospital death following MI, and a beginning understanding of prognostic factors for short-term mortality is available (Normand et al., 1997; Chyun et al., 2002). 
Efficacy of monitoring for complications, and methods to prepare individuals and their caregivers for discharge, within a shortened hospital stay, however, need to be studied. Awareness of prognostic factors can assist in identifying patients at risk of shortterm mortality so that interventional nursing care can be targeted, delivered to, and assessed in high-risk individuals. Many individuals who are eligible for aspirin or beta blocker therapy following MI do not receive these medications upon discharge. Discrepancies between other medications known to have a survival benefit—ACE inhibitors, lipid lowering agents—may also exist and need to be documented, along with reasons for any discrepancy. Although coronary revascularization procedures—angioplasty or bypass surgery—are being used more frequently, nursing research is also needed to document post-discharge complications and long-term management of underlying CHD. Hospitalization for acute MI or revascularization may provide the only opportunity to maximize CHD management, as well as link the individual to a cardiac rehabilitation program following discharge. Older age has consistently been associated with poorer long-term outcomes—death, re-current MI, and CHF—following MI. Although acute MI-related prognostic factors are beginning to be identified (Chyun et al., 2002), information on post-discharge factors that may have contributed to these outcomes, as well as to use of health care services, has not been documented. It is unknown how patients manage their cardiac condition, control specific cardiac risk factors, or if they participate in cardiac rehabilitation. Nor is it known what factors contribute to or prevent successful CHD management in the elderly. 
Angina and psychosocial factors may contribute to long-term management of CHD and adverse outcomes, yet only limited information is available on these possible influences (Stuart-Shor et al., 2003). These data are crucial prior to much-needed interventional studies aimed at decreasing the substantial mortality and morbidity associated with CHD and MI. Potential psychosocial factors that may contribute to poorer long-term outcomes, therefore, need to be identified. Educational strategies directed specifically to the needs of the elderly and their caregivers also need to be identified and tested. In addition, factors, such as the impact of functional status, which has been linked to mortality require further study in the elderly population with CHD. Functional status has been shown to be an important prognostic factor after MI, even after adjustment for other prognostic factors, yet it has not been widely studied, despite higher levels of functional disability in the elderly. Functional loss appears to be proceeded by a decline in physical performance, and early functional limitations or mild impairments that are not evident clinically have been shown to predict subsequent functional dependence (Gill, Williams, Mendes de Leon, & Tinettit, 1997). Subjects at risk of functional decline may be identified early, prior to loss of function, so that interventions may be targeted. Although physical performance and functional status may influence participation in a cardiac rehabilitation program, both can be greatly improved through exercise rehabilitation. Therefore, low levels at outset should not prohibit participation. Cardiac rehabilitation, including exercise rehabilitation, has been shown to improve exercise tolerance and assist in control of cardiac risk factors; however, few studies are available that address these issues in the elderly (Lavie & Milani, 1995; Pasquali, Alexander, & Peterson, 2001). 
Although physical activity is central to management of CHD, and it is recommended that men and women should be strongly encouraged to participate in exercise-based cardiac rehabilitation and that special efforts be made to overcome obstacles to entry and participation, the elderly, particularly elderly women, are referred to and enroll less frequently than younger individuals (Lavie & Milani, 1995). Despite improvements in functional status, anxiety, depression, mobility, health care resource consumption, and mortality with exercise, the majority of older adults report having no regular exercise and most report not having walked a mile in the past year. The reasons that individuals do not enroll in cardiac rehabilitation have not been well defined, but probably result from a combination of physical, psychosocial, and economic factors. Barriers to participation, therefore, need to be explored and strategies for improving access and maintaining participation tested.
Prevalence of HF in the elderly MI population increases with increasing age, and following MI, older age has been shown to be related to the development of HF despite normal systolic function. Normal age-related changes in the elderly also appear to affect diastolic, rather than systolic function. HF is associated with decreased quality of life and a decrease in functional capacity. While multidisciplinary teams, focusing on coordination of inpatient, outpatient and home care have demonstrated positive outcomes in terms of functional capacity, length of stay, readmission rates, self-care knowledge, patient satisfaction, and quality of life (Rich etal., 1995; Venner &Solitro-Seelbinder, 1996; Naylor et al., 1994; Stanley & Prasun, 2002;Grady et al., 2000), and prognostic factors for readmission have been identified, HF re-mains the leading cause of hospitalization in the elderly. 
Additional interventional studies are needed on management of common problems in this population—monitoring for deterioration in clinical status, medication, dietary and fluid adjustment, social support, and noncompliance—as well as in innovative strategies, such as use of structured exercise programs, in HF management. In addition, with the recent publication of new guidelines for HF, a new staging system expands the continuum of care to encompass prevention and includes screening and treatment targets for people at high risk for developing heart failure (Hunt et al., 2001). As HF will continue to be an important problem in the elderly population, nursing research should focus on evaluating nursing interventions that reduce hospital admission and improve quality of life.



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