Coronary heart disease.doc

Coronary Heart Disease

Running head: OLDER ADULT AND CORONARY HEART DISEASE

The Older Adult and Coronary Heart Disease

Jillian Burke

Saint Francis Xavier University

1


Abstract

Coronary heart disease, also known as coronary artery disease, is the most prevalent type of

cardiovascular disease. Coronary heart disease is an umbrella term that encloses angina pectoris

and acute coronary syndrome. Acute coronary syndrome includes unstable angina and acute

myocardial infarction. The main cause of the formation of coronary heart disease is

atherosclerosis, which is the formation of lipids and fibrous tissue that in result creates a block in

the vessel wall and therefore decreases the blood flow to the heart. Coronary heart disease is the

number one killer for both men and women. Just as coronary heart disease fully impacts the

individual person, it impacts healthcare with increasing amounts of money spent on patients with

the disease. Some signs and symptoms of this disease include; pain, weakness or numbness, and

anxiety. Although pain is felt in both younger and older adults, it is perceived uniquely in older

adults with coronary heart disease. Smoking is the number one risk factor for coronary heart

disease and in repeated studies, older adults who smoked were found to have increased rates of

cardiovascular mortality than older adults who did not participate in smoking. Coronary heart

disease like any other disease has an unlimited continuous impact on the person’s overall

independence and quality of life. Diabetes mellitus is commonly connected to cardiovascular

disease and it is found that people with diabetes that die, usually end up dyeing due to a

cardiovascular condition, such as coronary heart disease. There are many aspects of an older

adult’s life that can influence their ability to improve their lifestyle. These include; mobility,

socioeconomic status, availability to transportation, access to good nutrition, and family suppot.

2



The most widespread type of cardiovascular disease is coronary heart disease. Coronary

heart disease is a term that is used to describe insufficient blood supply to the heart or

myocardium. It consists of angina pectoris and acute coronary syndrome. Acute coronary

syndrome includes unstable angina and acute myocardial infarction. The goal for the care of a

person with coronary heart disease is to decrease the myocardial oxygen demand and increase

the myocardial oxygen supply, or both.

The main cause of the formation of coronary heart disease is atherosclerosis. The

coronary arteries anatomic structure makes them predominantly vulnerable to atheroma

development. The two points that are most susceptible to atheroma development are the branch

points and bifurcations. Atherosclerosis is an abnormal accumulation of lipid and fibrous tissue

with a fibrous cap in the vessel wall which creates blockages that result in reduced blood flow to

the heart. The lesion that is created and therefore causes decreased blood flow to the heart is

called an atheroma. Atheroma is also known as plaque and is referred to as plaque by many

people. If the fibrous cap is ruptured and it hemorrhages into the plaque it creates a thrombus

which results in blood flow obstruction. The obstruction of blood flow from a thrombus

potentially results in a myocardial infarction. Therefore coronary heart disease is a risk factor for

myocardial infarction. Atherosclerosis is a disease that is progressive and that can be shortened

and even reversed in some instances. There are causes of coronary heart disease are; vasospasm

of the coronary arteries, myocardial trauma from internal or external forces, congenital

abnormalities, decreased oxygen supply, increased demand for oxygen, and structural disease.

(Day, Paul, Williams, Smeltzer, & Bare, 2007, p.717-718)

3


There are risk factors for every illness and disease which increase a person’s probability

of developing that particular disease or illness. Coronary heart disease has nonmodifiable and

modifiable risk factors associated with it. The nonmodifiable risk factors are risk factors that

people can not change no matter how healthy they live. The modifiable risk factors are areas that

the person can help to control and maintain in their life. The nonmodifiable risk factors for

coronary heart disease are; family history of coronary heart disease, increasing age, male, and

African American. The modifiable risk factors include; high blood cholesterol, smoking and

tobacco use, hypertension, diabetes mellitus, lack of estrogen in women, physical inactivity, and

obesity. (Day, Paul, Williams, Smeltzer, & Bare, 2007,p.719)

In the study by Vuori, 2007, it was established that people who are physically inactive

have a 30-50% increased risk of developing coronary heart disease compared with people who

are at least moderately active. As mentioned in this article study, the American Heart Association

recommends that older people participate in moderately intensive activities such as aerobics for

30 minutes at a time.

Patient’s with coronary heart disease exhibit signs and symptoms that allow for the

patient and health care workers to diagnosis and treat the coronary heart disease. Some signs and

symptoms include; pain, weakness or numbness, and anxiety. The pain is typically described as

heavy, pressuring, burning, choking, crushing, or a strangling sensation. Although signs and

symptoms do occur with coronary heart disease, symptoms do not occur in patients until the

vessel is 75% occluded. These signs and symptoms mentioned are generally referred to for

younger adults and not the older adult population.

Older adults often do not exhibit the same typical pain for coronary heart disease as

younger adults would exhibit. This is due to the decreased response of neurotransmitters in the

4


older adult. The most common symptom that older adults convey when they have coronary heart

disease is dyspnea. Older adults are also different than younger adults in that older adults usually

have symmetrical pain in both arms rather than only in the left arm as younger adults have. The

older adult may exhibit coronary heart disease without any symptoms, known as silent CAD.

This can cause difficulty in recognizing and diagnosing the disease. The change in symptoms of

coronary heart disease should be educated to the older adult population especially those with

known cardiovascular problems or with high cardiovascular risk factors. Older adults should be

encouraged to recognize their pain and symptoms so that they can take their prescribed

medications and not allow the pain or symptoms to progress. Diagnostic tests that are used to

commonly diagnose coronary heart disease, such as noninvasive stress testing, in younger adults,

potentially may not be practical due to other conditions in the older adult. These other conditions

could contribute to the patient not being able to exercise. These conditions consist of peripheral

vascular disease, foot problems, arthritis, physical disability, and degenerative disk disease.

(Day, Paul, Williams, Smeltzer, & Bare, 2007, p.24)

Normal aging changes that occur as a result of getting older make it difficult to detect

symptoms of disease such as coronary heart disease. These normal aging changes contribute to

the disease process and therefore make older adults exhibit their symptoms different from adults

that are younger with coronary heart disease. Within the heart, there are particular changes that

occur as adults become older. These changes include the thickening and stiffening of the heart

valves and the decreasing elasticity of the heart muscle and arteries. These normal aging changes

allow the majority of older adults to continue living a life, but the heart is unable to react as

efficiently to stress compared to when the heart was younger. Due to these changes within the

5


heart, older adults can show signs of fatigue with increasing activity and increasing fatigue when

stress rises.

High blood cholesterol levels are associated with coronary heart disease. There are four

element of fat metabolism; total cholesterol, low density lipoproteins, high density lipoproteins,

and triglycerides. These four elements are primary factors that affect the development of heart

disease. Low density lipoproteins apply a harmful effect onto the arterial wall which accelerates

atherosclerosis. High levels of triglycerides, serum cholesterol, and low density lipoproteins can

be controlled usually by diet, exercise, weight reduction or weight maintenance, and

medications. Medications may be needed in some cases to control patient’s cholesterol levels.

These medications are lipid lowering medications which can reduce coronary heart disease

mortality in patients. Medications to decrease cholesterol levels include; 3-Hydroxy-3-

methylglutaryl coenzyme A, Nicotinic acids, Fibric acid or fibrates, and Bile acid sequestrants or

resins. 3-Hydroxy-3-methylglutaryl coenzyme incorporate medications such as lovastatin,

pravastatin, Fluvastatin, Atorvastatin, and simvastatin. Nicotinic acids incorporate Niacin and

immediate, extended, and sustained nicotinic acids. Fibric acids include Fenofibrate and

Clofibrate. Bile Acid Sequestrants include Cholestryramine, Colesevelam, and Colestipol HCL.

(Day, Paul, Williams, Smeltzer, & Bare, 2007, p.719-720)

Changing lifestyles is a complex process. Patients with coronary heart disease have to

adapt to a new lifestyle in either one or several areas of their lives. Creating new lifestyle habits

needs to result from behavior changes. These behavior changes tend to result from a threat of the

behavior, such as developing coronary heart disease and the belief that the change will result in a

outcome that is valued or positive. The ability to change behaviors is individual and usually past

experience of changed behaviors help to predict whether or not the person potentially going to be

6


able to positively change their behaviors. Patients with coronary heart disease who join a cardiac

rehabilitation program may find this beneficial in assisting them to change behaviors. For

example, physical exercise is done in the presence of professionals and this encourages the

patients to being the behavioral change.

(Karner, Tingstrom, Abrandt-Dahlgren, & Bergdahl, 2005)

Older adults that are diagnosed with coronary heart disease may exhibit difficulty in

adapting to a healthier lifestyle due to a decrease in mobility or loss of mobility. These patients

therefore may not be able to participate in exercise compared to older adults that do not have a

decrease in mobility. This decline in mobility may result from another disease. Some causes of

decreased mobility are; Multiple Sclerosis, paraplegic, weakness and fatigue as a result of a

health condition. There is usually always some increase in activity that a patient can do. For

example, if a patient with coronary heart disease is in a wheelchair they could do upper body

exercises.

Diseases that affect the cognitive functioning of some older adults, such as Alzheimer’s

or dementia, may contribute to these patients not fully being able to incorporate particular

changes in their lifestyle if they develop coronary heart disease. These patients who have later

stages of the dementia or Alzheimer’s disease may also not be able to communicate symptoms of

the disease due to lack of ability to fully communicate. The possible decrease in communication

and understanding of the disease can contribute to tough diagnosis and treatment of coronary

heart disease. After learning about coronary heart disease and also about dementia, I can imagine

how difficult it is to incorporate a healthy lifestyle into the patients with both coronary heart

disease and dementia, as these patients may not remember the conversation 5 minutes later. From

experience with my grandmother, I know how difficult it is to educate her on new ideas or her

7


health concerns as she is unable to recall the conversation altogether or she is only able to recall

certain areas of the conversation.

Coronary heart disease is a key cause of death and illness in the elderly population.

Exercise can improve functional capacity and prolong an active lifestyle in the elderly

population. Regular exercise therefore decreases the disability of the older adult. It expected that

patients with cardiovascular disease are going to increase in the years to come. Increasing the

number of patients with cardiovascular disease is going to also increase the amount of money of

the healthcare system needing to be spent on these patients. Patients with coronary heart disease

have restrictions in their every day lives with their physical bodies, their psychological and social

functioning. These restrictions potentially can lead to a decrease in their activities of daily living

and a decrease in independence. Other factors, such as, depression, negatively affect the recovery

stage of cardiac rehabilitation patients. (Sandstrom & Stahle, 2005)

Older adults who smoked were found to have increased rates of cardiovascular mortality

than older adults who did not participate in smoking actions. Today, humans are living longer

lives and therefore coronary heart disease is becoming a greater than before root of illness and

death in the older adult population. When treating coronary heart disease there are primary and

secondary preventions used. These preventions include; ACE inhibitors, statins, treatment of

hypertension, use of antithrombotic agents, are B-adrenoceptor antagonists. Statins lower the

LDL cholesterol and reduce the level of isoprenoids. Isoprenoids are molecules that assist in the

metabolism of proteins. Statins also reduce platelet reactivity and decrease inflammation.

(Andrawes, Bussy, & Belmin, 2005)

As mentioned previously, cigarette smoking is a risk factor for coronary heart disease.

Smoking can contribute to coronary heart disease in three different ways. First of all, people who

8


smoke have decreases oxygen and therefore, a heart with decreased oxygen can decrease the

heart’s pumping ability. Second, nicotinic acid in tobacco raises the heart rate and blood

pressure. Finally, tobacco increases platelet adhesion and causes a detrimental vascular response,

which leads to a higher probability of thrombus formation. Cigarette smoking cessation is greatly

encouraged throughout people with increased risks of coronary heart disease. Smoking cessation

results in a 30-50% risk reduction of heart disease in the first year after smoking cessation

begins. (Day, Paul, Williams, Smeltzer, & Bare, 2007, p.721)

Cigarette smoking as a risk factor for coronary heart disease is reinforced by Andrawes,

Bussy, & Belmin (2005), who found that older adults who smoked were found to have increased

rates of cardiovascular mortality.

ACE inhibitors prevent coronary events in individuals who are considered high risk

individuals. Older adult women that use hormonal therapy were found in several studies to have

a decreased occurrence of coronary heart disease. This finding was later disregarded after

looking at women’s socioeconomic statuses. It was concluded that hormone replacement therapy

did not benefit women and coronary heart disease. Additionally there were findings of increasing

occurrence of ischemic events. Hormone therapy is no longer used as a preventive measure for

older women in preventing cardiovascular events. (Andrawes, Bussy, & Belmin, 2005)

There have been many studies conducted that found there was a relationship between

coronary heart disease and socioeconomic status in the middle age person. This particular study

conducted by Sundquist, Jahansson, Qvist, & Sundquist, (2005), was aimed to study the

relationship between coronary heart disease and socioeconomic status in the older adult.

Smoking, Obesity, high cholesterol levels, hypertension, and physical inactivity were identified

as main risk factors. It was found in this study that low socioeconomic status is linked to

9


coronary heart disease. Healthy behaviors such as smoking cessation and physical activity should

be introduced and encouraged in older adults among all socioeconomic statuses. Since coronary

heart disease is linked to socioeconomic status in both middle and older adults, it is important to

assess the life path and history of the patient when caring for older adults.

(Sundquist, Jahansson, Qvist, & Sundquist, 2005)

Women can experience atypical symptoms or nonspecific symptoms in their chest pain.

These labels can lead to a missed diagnosis or coronary heart disease. Women that had a

diagnosis of nonspecific chest pain were found to have more of the risk factors of coronary heart

disease. Women that experienced nonspecific chest pain and resulted in coronary heart disease

were found more in women over the age of 65. Although this particular study found that women

who were diagnosed with nonspecific chest pain potentially are at an increased risk of coronary

heart disease, there still needs to be other studies conducted to support this and further research

the relationship between nonspecific chest pain and an increased risk of coronary heart disease.

(Robinson, et al., 2006)

Coronary heart disease is the number one killer among women. Women are not referred

to specialists for heart symptoms as often as men are. There is a myth around the public that

heart disease is a man’s disease. This causes women to delay seeking medical attention and

therefore believing that there is a heart problem. Today, the public is becoming more aware that

heart disease is both a male and female disease, but in previous years it was not known. This is

relevant to older adults in that in their previous years they were lead to believe that the disease

was a man’s disease and therefore may still believe this. This could result in older women not

reaching out for healthcare when they have early signs and symptoms of coronary heart disease

10


Coronary heart disease like any other disease has an unlimited continuous impact on the person’s

overall independence and quality of life. Each person will cope with the disease individually,

with some people coping adequately and others needing constant medical care. This disease

impacts the patient’s physical, emotional, and psychological aspects of their lives. Coronary

heart disease causes the patient to reintroduce their lifestyle such as diet. Patient’s that are

diagnosed with coronary heart disease commonly need to change their diet, exercise, and

possibly other factors in their lives. An example of a diet change for coronary heart patients

would be to limit their salt intake. A reduction in sodium has been shown to help improve

hypertension and therefore would benefit a person with a heart condition such as coronary heart

diseae. (Day, Paul, Williams, Smeltzer, & Bare, 2007, p. 199)

Normal aging changes impact older adult’s lives completely and when a disease is

involved on top of the aging changes, it becomes increasingly more stressful and may allow for a

decreased ability of coping. Older adults greatly rely on their personal spiritual or religious

beliefs to help them throughout their aging and disease processes. There are several diet

suggestions that should be followed by the older adult when dealing with normal aging changes

and most importantly when there is a disease involved. The food that a person eats greatly

impacts their health and therefore impacts there bodies ability to help combat a disease such as

coronary heart disease. Older adults fat consumption should remain between 20-25% of the total

amount of calories in an older adult’s diet. Carbohydrates should be about 55-60% of the older

adult’s caloric intake. The amount of protein that an older adult consumes should remain the

same as a younger adult. Particular food that should be encouraged in the older adult population

to assist with normal aging changes include; fruit, brown rice, whole grains, and potatoes. These

11


foods are full of minerals, vitamins, and fibre that help the body deal with normal aging changes

and allow the body to be healthy to deal with disease such as coronary heart disease.

(Day, Paul, Williams, Smeltzer, & Bare, 2007, p. 199)

Just as coronary heart disease fully impacts the individual person, it impacts healthcare

costs. Cardiovascular disease is the most costly disease in Canada. Health Canada reiterates the

fact that this impact of the costs of cardiovascular puts a burden on the Canadian healthcare

system.

Diabetes mellitus is commonly connected to cardiovascular disease. Diabetic patients that

die usually die as a result of cardiovascular disease. Therefore, diabetic patients are seen as

having the same risk of developing a cardiac event as patients with coronary heart disease. Both

diabetic and coronary heart disease patients are at increased risk of a cardiac event with a ten

year span. (Day, Paul, Williams, Smeltzer, & Bare, 2007, p. 722-723)

Nursing care for the older patient with coronary heart disease is very important. When

assessing older adults it is important to remember that older adults over all well-being relies on

physical, mental, social, and environmental factors. Nurses are responsible to help in the care of

patients with coronary heart diseases that have pain and signs and symptoms of the disease.

Nurses collaborate with the patient to help treat the pain, reduce anxiety level, education of the

disease and the process of the disease, and education on early detection of coronary heart

disease. Nurses are responsible to help patients learn the importance of using their nitroglycerin

and the when they should use it, if they have angina pectoris. Nurses assist the patient’s in

modifying their lifestyles to accommodate to their pain, anxiety, and signs and symptoms such as

dyspnea. Nurses assess the patient’s lifestyle and discover if their pain or dyspnea appears with

activity and if so, how much activity it takes to initiate the pain or dyspnea is further assessed.

12


Once the nurse and patient determine the amount of activity it takes to initiate the pain or

dyspnea, they alter the patient’s activities and incorporate rest periods as often as needed to

decrease or elevate the pain and dyspnea. Nurses need to be extremely sensitive to the patient’s

overall health and coping. Other disease process or illnesses affect greatly the person’s response

to treatment, their coping, and their overall health with coronary heart disease. The older patient

with coronary heart disease requires exceptional attention and specific attention to their signs and

symptoms as they appear different or in decrease than younger people with coronary heart

disease. (Day, Paul, Williams, Smeltzer, & Bare, 2007, p. 105, 727-728)

It is essential that patient’s experiences are reviewed and understood in order to improve

coronary heart disease prevention and education in the future. Healthcare professionals perceive

that coronary heart disease is a male disease although recently females with coronary heart

disease have increased interest. Increasing information about the gendered character of coronary

heart disease helps nurses to stop stereotypical beliefs of coronary heart disease being a male

disease. (Emslie, 2005)

In conclusion, it is unique to treat to an older adult with coronary heart disease as older

adults’ exhibit different signs and symptoms with coronary heart disease than do younger adults.

There is no single solution to coping with coronary heart disease, as every individual has

different coping styles and deals with the disease differently. Lifestyle factors greatly impact the

risks of developing coronary heart disease and the progression of the disease.

13


References

Andrawes, W. F., Bussy, C., & Belmin, J. (2005). Prevention of Cardiovascular Events in

Elderly people. Adis Date Information, 22 (10), 859-876.

Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Medical- Surgical

Nursing: Lippincott Williams & Wilkins.

Emslie, C. (2005). Women, men and coronary heart disease: a review of the qualitative literature.

Journal of Advanced Nursing, 51(4), 382-395.

Karner, A., Tingstrom, P., Abrandt-Dahlgren, M., & Bergdahl, B. (2005). Issues and Innovations

in Nursing Practice. Incentives for lifestyle changes in the patients with coronary heart

disease. Journal of Advanced Nursing, 51(3), 261-275.

Nicklas, B. J., Cesari, M., Penninx, B. W., Kritchevsky, S. B., Ding, J., Newman, A., et al.

(2006). Abdominal Obesity Is an Independent Risk Factor for Chronic Heart Failure in

Older People. Journal Compilation, 54(3), 413-420.

Robinson, J. G., Wallace, R., Limacher, M., Sato, M., Cochrane, B., Wassertheil- Smoller, S.,

etal. (2006). Elderly Women Diagnosed with Nonspecific Chest Pain May be an

Increased Cardiovascular Risk. Journal of Women’s Health. 15(10), 1151-1160.

Sandstrom, L., and Stahle, A. (2005). Rehabilitation of elderly with coronary heart disease-

Improvement in quality of life at a low cost. Advances in Physiotherapy, 7, 60-66.

Sundquist, K., Johansson, S. E., Qvist, J., & Sundquist, J. (2005). Does Occupational social class

predict coronary heart disease after retirement? A 12-year follow up study in Sweden.

Scadinavian Journal of Public Health, 33, 447-454.

14

Documents

Coronary heart disease.doc