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The results of this study suggest that future risk of cardiovascular disease may be reduced by minimizing sugar intake. These findings are based on observational studies, and further experimental studies are warranted to confirm the finding of a potential beneficial effect of chocolate consumption. Depression has been strongly implicated in predicting CAD.
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Shah et al found that in adults younger than 40 years, depression and history of attempted suicide are significant independent predictors of premature cardiovascular disease and ischemic heart disease mortality in both males and females. C-reactive protein CRP is a protein in the blood that demonstrates the presence of inflammation, which is the body's response to injury or infection; CRP levels rise if inflammation is present. The inflammation process appears to contribute to the growth of arterial plaque, and in fact, inflammation characterizes all phases of atherothrombosis and is actively involved in plaque formation and rupture.
According to some research results, high blood levels of CRP may be associated with an increased risk of developing coronary artery disease CAD and having a heart attack. C-reactive protein measurement is not recommended for cardiovascular risk assessment in asymptomatic high-risk adults, low-risk men 50 years or younger, or low-risk women 60 years or younger.
An elevated lipoprotein a [Lp a ] level is an independent risk factor of premature CAD [ 48 ] and is particularly a significant risk factor for premature atherothrombosis and cardiovascular events. Measurement of Lp a is more useful for young individuals with a personal or family history of premature vascular disease and repeat coronary interventions.
Lp a may be used to identify people at increased cardiovascular risk, but as of yet, there have been no studies on Lp a lowering because of the lack of available agents that are effective in reducing this value. Therefore, low-density lipoprotein LDL lowering is probably the best strategy in people with elevated Lp a levels. Homocysteine is a natural by-product of the dietary breakdown of protein methionine. In the general population, mild to moderate elevations are due to insufficient dietary intake of folic acid.
Homocysteine levels may identify people at increased risk of heart disease, but again, due to the lack of agents that effectively alter the homocysteine levels, studies have not shown any benefit from lowering the homocysteine level. An imbalance of the clot dissolving enzymes eg, tissue plasminogen activator [tPA] and their respective inhibitors plasminogen activator inhibitor-1 [PAI-1] may predispose individuals to myocardial infarctions.
Thus, core lipid composition and lipoprotein particle size and concentration may provide a better measure of cardiovascular risk prediction. Levels of fibrinogen , an acute-phase reactant, increase during an inflammatory response. This soluble protein is involved in platelet aggregation and blood viscosity, and it mediates the final step in clot formation. Significant associations were found between fibrinogen level and risk of cardiovascular events in the Gothenburg, Northwick Park, and Framingham heart studies. Medical conditions such as end-stage renal disease ESRD , [ 55 ] chronic inflammatory diseases affecting connective tissues eg, lupus, rheumatoid arthritis , [ 3 , 4 ] human immunodeficiency virus HIV infection acquired immunodeficiency syndrome [AIDS], highly active antiretroviral therapy [HAART] , [ 5 ] and other markers of inflammation have all been widely reported to contribute to the development of CAD.
ESRD is associated with anemia, hyperhomocysteinemia, increased calcium phosphate product, calcium deposits, hypoalbuminemia, increased troponin, increased markers of inflammation, increased oxidant stress, and decreased nitric oxide activity factors, all of which may contribute to increased CAD risk. Low serum testosterone levels have a significant negative impact on patients with CAD.
More studies are needed to assess better treatment. This additional risk may be independent of conventional cardiovascular risk factors. One study suggests women aged 50 years or younger who undergo a hysterectomy are at an increased risk for cardiovascular disease later in life. Too little sleep is also associated with an increased risk of stroke.
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The association between sleep and cardiac events is consistent across different populations. A population-based study by Laugsand et al found that insomnia is associated with a moderately increased risk of acute myocardial infarction. Oberg et al suggest an association between birth weight and risk of cardiovascular disease within disease-discordant dizygotic twins but not monozygotic twins.
The Copenhagen City Heart Study found that xanthelasmata raised yellow patches around the eyelids but not arcus corneae white or grey rings around the cornea constitutes an independent risk factor for cardiovascular disease. Presence of xanthelasmata indicated increased risk for myocardial infarction, ischemic heart disease, and severe atherosclerosis. Vitamin D and parathyroid hormone PTH were measured, and the outcomes included myocardial infarction, heart failure, cardiovascular death, and all-cause mortality.
Further randomized controlled trials are required. Studies indicate that using electron-beam computed tomography EBCT scanning to identify coronary calcification can reveal at-risk individuals and perhaps allow for medical monitoring. The risk benefit of using CT angiography in an asymptomatic patient for the identification of atherosclerotic plaques is still a subject of much debate.
The negative predictive value of CT angiography, however, is very high. CAD identified by CT angiography has significant prognostic implications. Polak et al suggest the maximum intima-media thickness of the internal carotid artery along with the presence of plaque significantly but modestly improves the classification of risk of cardiovascular disease in the Framingham Offspring Study cohort. One study suggested regression or slow progression of carotid IMT due to cardiovascular drug therapies does not reduce cardiovascular events.
The guideline also states that in asymptomatic intermediate-risk adults, measurement of ankle-brachial index is reasonable for cardiovascular risk assessment. Other potential risk factors for developing CAD have yet to be defined. However, as data are deciphered from the human genome project, the list of genetic contributors to CAD should greatly increase. For patients without diabetes and known CAD, a noninvasive, whole-blood test based on gene expression and demographic characteristics may be beneficial in assessment of obstructive CAD.
In a year comparison of 10 biomarkers for predicting death and major cardiovascular events in approximately individuals, the most informative biomarkers for predicting death were blood levels of B-type natriuretic peptide BNP , CRP, homocysteine, renin, and the urinary albumin-to-creatinine ratio. Cystatin C Cys-C has been proposed as an indicator of renal dysfunction that is associated with cardiovascular events and it has shown to be a good predictor of long-term mortality in patients with normal renal function.
Individuals with elevated multimarker scores had a 4-fold higher risk of death and an almost 2-fold higher risk of major cardiovascular events relative to those with low multimarker scores. Measurement of HDL cholesterol should be used as part of the initial cardiovascular risk assessment but should not be used as a predictive tool of residual vascular risk in patients who are treated with potent high-dose statin therapy to lower LDL cholesterol.
Changes and recommendations include the following. Stroke is added to the list of coronary events traditionally covered by risk prediction equations. The guidelines focus primarily on the year risk of atherosclerosis-related events; they focus secondarily on the assessment of lifetime risk for adults aged 59 or younger without high shorter-term risk.
The strongest predictors of year risk are identified as age, sex, race, total cholesterol, high-density lipoprotein cholesterol HDL-C , blood pressure, blood-pressure treatment status, diabetes, and current smoking status. If risk prediction needs to be further sharpened after risk prediction equations have been performed, the guidelines indicate that coronary-artery calcium scores, family history, high-sensitivity C-reactive protein, and the ankle-brachial index can be used.
The guidelines recommend that statin therapy be considered in individuals whose year atherosclerotic cardiovascular disease event risk is 7. For patients years of age who do not have existing clinical ASCVD, the guidelines recommend assessing clinical risk factors every years. Development of a new diabetes risk prediction tool for incident coronary heart disease events: C-reactive protein elevation and disease activity in patients with coronary artery disease. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: Increased coronary-artery atherosclerosis in rheumatoid arthritis: Myocardial disease in human immunodeficiency virus HIV infection: Long-term prognostic value of coronary calcification detected by electron-beam computed tomography in patients undergoing coronary angiography.
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Heart Disease and Stroke Statistics -- Update. Diabetes and Cardiovascular disease: Risk stratification for primary prevention of coronary artery disease: Mack M, Gopal A. Epidemiology, traditional and novel risk factors in coronary artery disease. Significance of a positive family history for coronary heart disease in patients with a zero coronary artery calcium score from the Multi-Ethnic Study of Atherosclerosis.
Ethnic differences in cardiovascular risks and mortality in atherothrombotic disease: Associations between lipoprotein a levels and cardiovascular outcomes in black and white subjects: Isolated low levels of high-density lipoprotein cholesterol are associated with an increased risk of coronary heart disease: Multiple biomarkers for the prediction of first major cardiovascular events and death. N Engl J Med. Serum gamma-glutamyltransferase levels predict the progression of coronary artery calcification in adults with type 2 diabetes mellitus.
Regional left ventricular myocardial dysfunction as a predictor of incident cardiovascular events MESA multi-ethnic study of atherosclerosis. J Am Coll Cardiol. Risk factor and prediction modeling for sudden cardiac death in women with coronary artery disease. Combined lifestyle factors and cardiovascular disease mortality in Chinese men and women: Intensive lipid lowering with atorvastatin in patients with stable coronary disease.
Impact of high-normal blood pressure on the risk of cardiovascular disease. Impact of blood pressure and blood pressure change during middle age on the remaining lifetime risk for cardiovascular disease: Meta-analysis comparing mediterranean to low-fat diets for modification of cardiovascular risk factors. Effect of dietary protein supplementation on blood pressure: Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. Smoking status and risk for recurrent coronary events after myocardial infarction.
Huxley RR, Woodward M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: Whole-grain, cereal fiber, bran, and germ intake and the risks of all-cause and cardiovascular disease-specific mortality among women with type 2 diabetes mellitus. Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: Cardiovascular risk prediction in diabetic men and women using hemoglobin A1c vs diabetes as a high-risk equivalent. Abdominal adiposity and coronary heart disease in women.
Coronary artery calcification in obese youth: Impact of body weight and extreme obesity on the presentation, treatment, and in-hospital outcomes of 50, patients with ST-Segment elevation myocardial infarction results from the NCDR National Cardiovascular Data Registry. Normal-weight central obesity and mortality risk in older adults with coronary artery disease. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: Walking compared with vigorous exercise for the prevention of cardiovascular events in women.
Adherence to a low-risk, healthy lifestyle and risk of sudden cardiac death among women. Association of fitness in young adulthood with survival and cardiovascular risk: Screen-based entertainment time, all-cause mortality, and cardiovascular events: Population-based study with ongoing mortality and hospital events follow-up. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. Diagnosis and management of the metabolic syndrome: Consumption of added sugars and indicators of cardiovascular disease risk among US adolescents.
Chocolate consumption and cardiometabolic disorders: Depression as a predictor for coronary heart disease. Am J Prev Med. Mental stress induces transient endothelial dysfunction in humans. Stress and the metabolic syndrome: Depression and history of attempted suicide as risk factors for heart disease mortality in young individuals. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein.
Elevated lipoprotein a , hypertension and renal insufficiency as predictors of coronary artery disease in patients with genetically confirmed heterozygous familial hypercholesterolemia. Measurement issues related to lipoprotein heterogeneity.
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Low-density lipoproteins containing apolipoprotein C-III and the risk of coronary heart disease. What to teach to patients with heart failure and why: The most important objective of heart failure HF treatment is to reach and preserve patients' clinical stability. Several studies have shown that programs aimed at systematic education, developed by multidisciplinary teams, are positive strategies to work with these patients.
Nurses active in HF clinics play a fundamental role in the educational process and continuity of patient care. The objectives of these processes are to teach, reinforce, improve and constantly evaluate patients' self-care abilities, which include weight monitoring, sodium and fluid restrictions, physical activities, regular medication use, monitoring signs and symptoms of disease worsening and early search for medical care.
Therefore, education to understand HF and the development of self-care abilities are considered key points to improve adherence, avoid decompensation crises and, consequently, to maintain patients clinically stable. This article presents a careful review of the aspects involved in the patient education process by nurses in the context of HF clinics.
Heart failure HF is a syndrome which imposes marked functional limitation, impairing importantly in patients' quality of life. In spite of several important advances in HF therapy, derived from better physiopathological understanding, hospital admissions rate continued to increase in the last decade 1. Among the most important causes of hospital admissions, decompensation episodes are dominant, caused mostly by poor adherence to treatment, both pharmacologic and non-pharmacologic Within this unfavorable scenario, one the objectives of HF management is to reach and maintain clinical stability of patients, which is based on a fairly complex therapeutic regimen.
In this review article, we discuss in details why and ways to approach patients and their families regarding educational aspects in HF to better cope with the burden of the disease. It is important to emphasise that HF is a chronic and progressive syndrome, in which adjustments and modifications in lifestyle are very important. Many patients consider themselves healthy and show little adherence to orientations given by the medical team until they present the first HF decompensation episode. The initial approach with a HF patient should not include all of the aspects regarding the complexity of HF treatment.
It is conventionally assumed that when patients learn about their disease they understand it better and, in consequence, are more adherent. At times, however, there remains lack of understanding between what is taught about self-care and what is absorbed or retained by the patients; even when there is supposedly a better knowledge of the disease, which not necessarily means better adherence 5. The orientations must, therefore, be given repeatedly and positively reinforced. Nurses, physicians, nutritionists as well as other members of the multidisciplinary team play important roles on the education of HF patients.
There are several tools to provide better understanding of HF aspects to patient. It is possible to design specific strategies to obtain better outcomes regarding patient education in HF 1,3, Risk factors predictive of hospitalization and readmission due to HF include poor knowledge and adherence to the recommendations for self-care, involving restriction of fluid intake, restriction of sodium intake in the diet, daily weight monitoring, physical activity and the regular use of medications 1,3. Within this context, a study with ambulatory patients in a HF clinic, detecting failures in relation to what was taught to the patients and what they really understood and apply in their daily life.
The poor adherence was also related to little knowledge of the disease and self-care principles, to living alone and to the fact that patients had not had previous hospitalization due to decompensated HF 5. The orientation of the HF patient about the home control of the daily weight has an important role on the identification of hypervolemia signs 8. Patients must be instructed to check their weight in the morning after urinating and before breakfast, wearing light clothes and using the same scale.
An increase of 1. A recent multicentric randomized study with patients class III or IV of the New York Health Association investigated whether a technologic system for daily monitoring of weight and symptoms could reduce hospitalizations primary outcome , mortality or to improve life quality secondary outcomes. Although no differences in rehospitalization rates were detected, the study showed a significant decrease in mortality in 6 months in the intervention group 8.
Available data, however, indicate that it is difficult for patients to correlate a sudden increase in weight with HF worsening According to national and international guidelines , patients are advised to monitor weight daily and, in the event of a sudden weight increase, to contact the medical team or adjust the diuretic dose. The adjustment of the diuretic dose for HF patients by nurses through structured protocols has been recommended in the literature. It is important to point out that the flexibility of the use of these medications depends on the self-care ability of the patient, as well as on the organization of the medical service, since there is need of constant monitoring and follow-up.
Within this context, nursing intervention must focus on the education of patients and their families for the early recognition of these signs and symptoms, avoiding decompensation episodes. Drugs employed in the treatment of most HF patients are based on guidelines recommendations from American Heart Association and Brazilian Society of Cardiology, using combination of five main drug types: The amount of medication employed, the maintenance of the therapeutic regimen, and the number of daily doses are factors of great influence on adherence to treatment.
The larger the amount of drugs, number of doses and changes in the therapeutic regimen, the greater are the probabilities that the patient will stop using them, with a consequent increase in the decompensation risk 3. The systematic education of the patient has thus been shown as the key component in the search for a better adhesion to HF treatment 1,3,5. The medication regimen must be reviewed with the patient and presented to him in a schematic way, with emphasis on the medication names, indications, doses, schedules and possible side effects 3.
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A simple strategy, which has been employed for several years by our group, involves the drawing of a table with the name and time of medications, which is placed in a site easily seen by the patient and relatives. The patients must be advised to always take their medication, even when they feel well, since that is a consequence of an efficient treatment.
The nurse's role is to instruct the patient to bring the table or the prescriptions to every appointment in the HF clinic or when readmission is necessary, since it makes easier to identify possible omissions, dose increase or confusion. The increasing knowledge on the physiopathology of the disease, and the evident benefits of physical activity observed in clinical studies, established an important therapeutic role for physical exercise on the stable chronic cardiac dysfunction.
HF results in fatigue symptoms and progressive dyspnea at stress or rest which is frequently the main reason for seeking urgent medical help. In , a first randomized study with 99 HF stable patients distributed in intervention with exercise and control without exercise groups, assessed if moderate long-term exercise would increase functional ability and life quality.
Both parameters showed significant improvement in trained patients after 14 months follow-up. The sustained effect of functional improvement seems to be associated to a low rehospitalization rate due to HF and a lower death rate Presently, physical activity for patients with left ventricular dysfunction with previous or current symptoms stage C receives guidelines recommendation grade IIa and evidence level A The orientation should be individualized according to the HF grade and patient age A home-based walking program is the best option to avoid the negative physiological and psychological consequences of inactivity.
The walked distance should be gradually increased, if possible 3, This orientation is one of the non-pharmacological important, and frequently neglected, measures for HF treatment and should always be included in nursing consultations. Rest - Physical activity was considered, until the 's, relatively or absolutely contra-indicated for individuals with increased cardiac area, decreased left ventricular systolic function and HF Stable patients were advised to avoid physical activity in order to preserve cardiac function.
This finding may be an evidence that the old concept is still valid for many patients. Rest was considered beneficial for increasing renal blood flow and improving urinary debt Prolonged rest or inactivity, however, may cause atrophy of the skeletal musculature, exacerbation of HF symptoms, thromboembolism and decreased exercise tolerance 14, Rest is presently indicated only in episodes of acute decompensation, and even then according to each patient's limitation The guidelines for the diagnostics and treatment of HF recommend working activities which do not demand great efforts, and the definitive retirement is restricted to severe HF cases Exercise intolerance, dependent on the disease severity, may be one of the limiting factors for daily life activities.
The patient is advised to identify the presence or absence of fatigue and shortness of breath when doing daily chores and, from then on, to monitor the improvement or aggravation of the symptoms. Many of the patients report carrying out daily chores slowly and without much effort Stable patients are encouraged to keep sexual activity, with the necessary adjustments to avoid excess effort and the appearance of symptoms The subject should be approached by the multidisciplinary team in a natural and informative way during the first consultation and whenever the patient presents questions or difficulties.
Psychological symptoms derived from the HF, physical limitation, side effects of drugs diuretic and betablockers , presence of diabetes mellitus, and hypertension are some of the factors which can be involved with erectile dysfunction. Class I and II patients can make safe use of sildenafil, but must be informed that, when using nitrates, sildenafil can be used only 24 h after its interruption Sodium restriction - A recent study 18 with a years follow-up showed the correlation between a diet with no sodium restriction and the incidence of HF.