coronary heart disease.doc
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Coronary Heart Disease
Running head: OLDER ADULT AND CORONARY HEART DISEASE
The Older Adult and Coronary Heart Disease
Jillian Burke
Saint Francis Xavier University
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Coronary Heart Disease
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.
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Coronary Heart Disease
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)
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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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.
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