Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Heart Disease

Heart disease affects the lives of millions of people every year so it is important to understand the characteristics and risk factors associated with this condition.  Risk factors for heart disease fall under two categories: modifiable risks and nonmodifiable risks.  Modifiable risks include things that we can control such as obesity, smoking and high fat intake whereas nonmodifiable risks include things that we cannot control such as gender, heredity and age.  But first, we must understand what heart disease is and how it affects our bodies.  Research suggests that heart disease is a result of damage to the lining and inner layers of the heart arteries.  Plaque begins to build up where there are damaged arteries (What Causes Heart Disease, 2014).  Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay. Factors that can contribute to this damage include smoking, blood vessel inflammation, elevated amounts of sugar in the blood due to insulin resistance or diabetes, high blood pressure and high amounts of fats and cholesterol in the blood.
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A1. Pathophysiology
Heart disease is a clinical manifestation when the heart can not provide a sufficient amount of blood flow to maintain the metabolic requirements for systemic venous return.  Heart failure is the result of several mechanisms such as pump function disorder, neurohormonal activation disorder and salt-water retention disorder (Palazzuoli, 2010).  It develops when there is an abnormality in cardiac function causing blood to not pump at a healthy rate.  Several factors can contribute to the damage including smoking, high blood pressure, inflammation of the blood vessels, and increased amounts of cholesterol in the blood. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

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The average human heart beats almost four million times per year, pumping enough blood to fill an oil tanker during a lifetime.  Composed of striated cardiac muscles, the heart is supplied oxygen and nutrients from the coronary arteries.  Over time, some people experience damage to the cardiac muscles which can lead to a weakening of the heart’s ability to pump blood.  If blood is inadequately being pumped, fluid can build up in the lungs, liver and other vital organs.
There are several conditions that can lead to heart disease including anemia, diabetes, obesity, cardiomyopathy, obstructive sleep apnea and cardiac muscle disease.  Diseases related to the heart valves can also cause heart failure.  Damaged or leaking valves cause the heart to pump harder pump back-flowing blood. Some of the main pathologies of heart disease include over loading of the ventricle with blood during diastole, lowered cardiac output causing an increase in the heart rate, stroke volume decreasing as the ventricle rises at the end of systole, reduced cardiac reserve and hypertrophy (Mandal, 2009) Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.
A2. Standard of Practice for Heart Disease
The national standard of practice is driven by the Clinical Practice Guidelines published by the National Guideline Clearinghouse (NGC).  The NGC provides a guideline of recommendations on current evidence based practice to help healthcare workers provide safe and efficient care to patients with heart disease.  These evidence based guidelines have the potential to maximize the outcome of a patient (Petruccelli, n.d.).  In 1933 Sir Thomas Lewis wrote in his textbook on heart disease that “The very essence of cardiovascular medicine is the recognition of early heart failure” (Lewis, 1937).
According to the American College of Cardiology a thorough history and physical should be performed in patients that present with heart disease to identify any cardiac or non-cardiac disorders and/or behaviors that may cause the acceleration of the disease.  Volume status and vital signs as well as patient weight, jugular venous pressure and the presence of orthopnea or peripheral edema should be assessed as they may be signs/symptoms of fluid retention.  Risk scores are obtained upon assessment to estimate the risk of mortality in patients with heart disease Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.
For patients presenting with signs/symptoms of heart failure, initial laboratory evaluations include complete blood count, troponin, serum creatinine, urinalysis, serum electrolytes, bun, glucose, fasting lipid profile, liver function tests and thyroid-stimulating hormone.
Because heart disease has a high mortality rate, results in decreased quality of life, increased hospitalizations and an extensive therapeutic routine, new research and evidence based data is constantly being done to improve outcomes of the proposed therapies.  Because this is a chronic condition, the effect of therapies may not be noticeable right away.  The prognosis varies from patient to patient when taking into account co-morbidities, life style and genetic factors.  As a result, not all treatments will work for all patients, making it difficult to generalize one specific treatment regimen as the “go-to” for heart disease. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.  The assessment of specific outcomes of therapy are complicated by the potential differential impact of the many co-therapies (Albert, Boehmer, Ezekowitz, Givertz, Klapholz, Linderfeld,…Walsh, 2010).
The complexity and high prevalence of heart disease in today’s society, has resulted in numerous treatment options and practice guidelines.  Different practice guidelines have been created by various organizations.  The American Heart Association [AHA] along with The American College of Cardiology Foundation [ACCF] have developed one set of practice guidelines and have been producing practice guidelines jointly in the area of cardiovascular disease since 1980.  These guidelines are not only comprehensive but they also address all aspects of prevention, evaluation, therapy (both pharmacological and device) as well as disease management for patient’s diagnosed with heart disease.  These guidelines play a major role in clinical management of the disease process. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

A2a. Pharmacological Treatments

Cardiac Glycosides
Can be used for any severity of heart disease
Slows the ventricular rate

Aldosterone receptor antagonists
Recommended for advanced heart disease
Improves survival and morbidity
Recommended in addition to Ace-inhibitors and beta-blockers

Diuretics (loop diuretics, thiazides and metolazone)
 
Decreases fluid overload
Results in rapid improvement of dyspnea and increased exercise tolerance
Should be taken with ACE-inhibitors and beta-blockers
Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Beta-adrenoceptor antagonists (Beta-blockers)
Used as treatment for a severities of heart disease
Reduces hospitalizations, improves function and can slow down progression of the disease
Slow the heart rate, allowing the left ventricle to fill more completely

Angiotensin-converting enzyme inhibitors (ACE-inhibitors)
Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay
1st Line of defense
Helps improve control of heart disease
Reduces need for hospitalization, improving patient quality of life
Assists with electrolyte and water balance by increasing the release of water and salt to urine, lowering blood pressure
Vasodilation improves hemodynamics in heart disease and reduces blood pressure

Angiotensin II receptor blockers
Assists blood vessels to relax and dilate
Helps release water and salt to the urine, lowering blood pressure
Decreases pressure on the left ventricle of the hear must pump against

Anti-thrombotic agents
 
Heart disease is often accompanied by a hypercoagulable state
Reduces the incidence of coronary ischemic events
Inhibits vasodilation

**Drugs to use with caution for patients with heart failure:  lithium, tricyclic anti-depressants, corticosteroids, calcium antagonists, NSAIDs and Class I anti-arrhythmic agents

(Cleland, 2005)

 
The pharmacological treatment for heart disease will vary based on the severity of the disease, the patient’s co-morbidities and the patient’s classification.  The AHA and ACCF classify patients into four classes ranging from A to D, with the stages of heart disease distinguishing risk factors and abnormalities of the cardiac structure as being associated with heart disease.  The pharmacological interventions take into account both. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.
As mentioned previously, the practice guidelines for heart disease as set forth by the AHA and ACCF work hand in hand with the standardized pharmacological treatment throughout the United States.  Virginia, and more specifically my community, utilize these practice guidelines in the treatment of heart disease.  Angiotensin-converting enzyme (ACE) inhibitors should be used in the treatment of heart failure related to systolic dysfunction.  ACE inhibitors cause relaxation of the blood vessels and decrease blood volume.  This leads to lower blood pressure and decreased oxygen demand on the heart.  Some examples of ACE inhibitors include Lisinopril, Captopril, Trandolapril and Enalapril which have all been proven in clinical trials to be effective in reducing morbidity and overall mortality rates in patient with heart disease (Flather & Kober, 2000).  Unless otherwise contraindicated, ACE inhibitors should be considered a priority intervention.
Also for patients with heart disease related to systolic dysfunction, beta blockers are recommended, unless a patient is dyspneic at rest with hemodynamic instability, signs or symptoms of congestion or those with a previous intolerance to beta blockers (Bleske, Chavey,…Van Harrison, 2008).  Beta blockers block the action of adrenaline and noradrenaline.  Coreg, Metoprolol, Propranolol and Atenolol have been proven in clinical trials to decrease overall mortality.  When a patient takes beta blockers, the heart beats more slowly and with less force.  This reduces blood pressure and helps blood vessels to expand, improving blood flow. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay
Aldosterone antagonists are receptor antagonists located at the mineralocorticoid receptor.  They are recommended for patients with heart disease.  Aldosterone receptor antagonists block the effects of hormones produced naturally in the adrenal glands that can cause heart disease to worsen.  They affect the balance of water and salts going into the urine.  They also help lower blood pressure and protect the heart by reducing congestion.  Spironolactone is a nonselective aldosterone antagonist and eplerenone is selective to the aldosterone receptor.  These are the only two aldosterone antagonists commercially available in the United States.  Aldosterone antagonism is recommended for patients with heart disease who also have dyspnea rest as well as for patients post myocardial infarction who have developed systolic dysfunction.
Angiotensin II receptor blockers (ARBs) block the actions of angiotensin II, which is produced in the kidneys.  It prevents angiotensin II from binding with angiotensin II receptors in the blood vessels, causing them to dilate and reduce blood pressure.  ARBs are often used to treat patients with heart disease that cannot tolerate ACE inhibitors, but they can also be added in addition to ACE inhibitors.  Losartan and Valsartan are commonly used ARBs, typically found in the hospital setting.
Diuretics assist the body to get rid of excess fluid by encouraging the kidneys to make more urine.  They are commonly used for patients with heart disease to manage fluid volume overload, which can be acute or chronic.  Diuretics cause the kidneys to put more sodium in the urine.  As the sodium is excreted from the blood, it takes water with it to the kidneys.  They cause wasting of potassium and magnesium.  Getting rid of the excess fluid lessens the load on the heart because there is less fluid to pump around the body, easing congestion on the lungs.
In my community, use of these drugs are standard practice.  There are best practice guidelines which outline the use of each drug, potential side effects and things that patients should look out for to tell their physician.  A nationally tracked indicator of heart disease management includes asking relevant questions to patients upon discharge related to their heart disease medications, specifically about the use of a beta blocker, ACE inhibitor or ARBs.  Pharmacists within the hospital setting are trained to reconcile medication upon admission and discharge to ensure patients are prescribed the correct medication to optimize their treatment regimen.  Patients are given access to My Chart, which allows them to access their medications post hospitalization at any time in case their community pharmacist has any questions.
Providers within the community have access to electronic health records which allow them to see previously prescribed medications, discontinued medications and the physicians reasoning for adding/deleting a particular medication as well as any adverse reactions noted.
Within the hospital, case managers work directly with patients to provide community resources so they are able to get their medications more easily and affordably once discharged.  Physicians will typically write a 30-day prescription for most medications to give a patient ample time to see their primary care physician or community resource. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay
Extensive efforts to ensure patients have the education and resources needed to remain compliant once discharged to the community, have decreased overall re-hospitalization rates.  It is also important to focus on prevention and education.  My hospital hosts health fairs, blood pressure screenings and community education classes to make people aware of the modifiable risk factors associated with heart disease to try to decrease the risk of heart disease before it gets to the point of having someone hospitalized for heart disease.
A2b. Clinical Guidelines
Quality measures include:

Patients must be given ACE inhibitor angiotensin II receptor blocker. If not, there must be clear documentation of intolerance to both.
Patients must be given adult smoking cessation advice or counseling
Patients given discharge instructions must include:

Activity
Weight Monitoring
Diet
List of discharge medications and dosages
Follow up care
What to do if symptoms worsen

Diagnosis

A diagnosis of heart disease takes into account the whole picture of physical findings, symptoms and tests.  Based on these results, the physician will order a chest x-ray, echocardiogram and electrocardiography to analyze heart shape/size and function as well as evaluating the lungs for fluid build-up.  Certain specifics a physician will test for: Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Blood Tests- kidney and thyroid function, cholesterol levels and the presence of anemia
BNP-level of BNP increases as heart disease worsens
Chest x-ray-shows size of the heart and whether there is fluid build-up
Echocardiogram-provides pictures of the heart’s valves and chambers so the physician can study the action of the heart
Doppler Ultrasound-evaluates blood flow across the heart valves
Ejection Fracture-<55% Stress test- the heart is stressed by walking on a treadmill. This will help identify clogged arteries   Patient Education Understanding Heart Disease Causes of Heart Disease Common Questions Nutritional Planning Adapting Your Lifestyle Plan periods of rest Be sure to get plenty of rest, ensuring that you keep your feet up to minimize swelling in the legs Conserve your energy Cutting down on some of your daily activities or using less energy during tasks will help you have more energy to do more tasks throughout your day Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay Manage a healthy weight Monitor fluctuations in your weight…fast weight gain can mean fluid retention Reading food labels Avoid to much fluid intake Limiting sodium intake Increasing intake of high potassium foods Dried fruits Fresh vegetables Fresh fruits Fish Fresh meat Stop smoking Smoking causes your heart to work harder to supply the body with enough oxygen Be aware of triggers to smoking Being around smokers Alcohol Emotional stress Maintain up-to-date immunizations Respiratory problems can worsen heart disease, vaccinations can provide immunity against flu and pneumonia Monitor your blood pressure and heart rate Gives you confidence in the treatment you are doing Helps give information to the physician about trends Manage your medicines Take your medication as prescribed to get the best possible outcome Take your medications with you when you go to the doctor A2c. Standard Practice of Disease Management Initiatives in Virginia to prevent and combat heart disease include promoting the use of guidelines for primary and secondary prevention as well as increasing quality care in federally funded healthcare centers.  On the national level, in 1999 the National Coalition for Women with Heart Disease, a patient centered organization, was founded creating a wide support network, educational seminars and advocating for legislation.  In 2002, The Heart Truth campaign was created to raise awareness about heart disease, risk factors and preventative action. The standard of practice of care for the management of heart disease is consistent in Virginia as it is across the nation.  Patients with heart disease may experience signs and symptoms of a heart attack such as angina, vomiting, and extreme fatigue, difficulties breathing and swelling in the feet, ankles, legs and abdomen.  Treatment is based on exhibited symptoms and can be pharmacological and nonpharmacological including lifestyle modifications. No single test can diagnose heart disease.  If heart disease is suspected, the national standard is for a physician to order an electrocardiogram to detect and record the hearts electrical activity.  The test will show how fast the heart is beating and if the beat is regular or irregular.  Another standard of care is performing a stress test to make the heart work harder and beat faster through exercise while testing is completed on the heart.  A stress test can show possible signs and symptoms of heart disease such as abnormal changes in the heart rate, blood pressure, shortness of breath and abnormalities in the hearts rhythm. A chest x-ray is typically ordered to give the physician a picture of the organs and structures within the chest and can reveal signs of heart disease.  Blood tests check the levels of cholesterol, sugars, fats and proteins in the blood.  Abnormal levels can indicate heart disease. If other tests suggest heart failure, the physician would order a coronary angiography using a special dye and x-ray to look inside of the arteries (What Causes Heart Disease, 2014). The State of Virginia can help educate the public about the importance of disease prevention through regular check ups.  They can also assist by providing healthcare workers updates on guidelines and best practices for treating patients at risk and affected by heart disease.  Virginia has also established policies for raising awareness for recognizes the signs and symptoms of heart disease and heart attack and helping hospitals implement system changes to adhere to national guidelines and recommendations for victims of heart disease (Moon, 2008). A3. Characteristics of Heart Disease Heart disease affects approximately 5.1 million people (Heart, 2015).   Common symptoms of heart disease include shortness of breath, weight gain, swelling in the feet, ankles, stomach or legs, fatigue and weakness.  Early diagnosis and treatment can greatly increase the quality and length of life for people affected by heart disease.  Treatment typically includes medications, diet modifications, increased physical activity and smoking cessation. There are four stages of heart disease to describe the evolution of the disease. Stage A refers to people who are at high risk for developing heart failure based on one or more risk factors Stage B refers to patients that show no symptoms of heart failure Stage C refers to patients who have in the past, or currently, show symptoms of heart failure with underlying structural heart disease Stage D refers to patients with end-stage heart disease requiring specialized treatments (Diseases, 1964) When thinking about the characteristics of heart disease, genetics should always be a factor.  Individuals that have a parent that suffered a heart attack are at an increased risk for heart disease.  Although we cannot control our gender, heredity or age, there are several risk factors that can be reduced and/or eliminated to lessen the risk of heart disease. Modifiable risk factors include smoking cessation, maintaining a healthy diet and proper weight control.  As little as 20% of a person’s body weight increases the cholesterol levels in the body (Mandal, 2009). Access to Care-Approximately 7.3 million Americans with heart disease are currently uninsured (Federal Access to Care Issues, 2013).  This makes them less likely to receive appropriate care which results in worsening medical outcomes, including increased mortality rates.  Current advocacy priorities initiated federally include implementing health reform, opposing policies that cut benefits or increase costs under Medicare and Medicaid, supporting funding for community access, expanding access to AEDs and CPR training for high school students, lay rescuers and professional responders, increased public knowledge of lifesaving approaches and increased funding for the National Emergency Medical Services Information System and other EMS programs (Ayanian, 2001). Treatment Options- The goal of treatment is typically the same for men and women with a goal of relieving symptoms, reducing risk factors to slow or stop the buildup of plaque, lowering the potential for blood clot formation, widening plaque clogged arteries and preventing complications related to heart disease.  Treatments include: Lifestyle Changes such as smoking cessation, diet modification, increased physical activity, maintaining a healthy weight, reducing stress and depression.  Medications can help reduce the hearts workload and relieve symptoms, lower cholesterol levels, blood pressure and prevent blood clots and prevent the possibility of a heart or sudden death.  A patient may need surgery to treat heart disease such as angioplasty, CABG, percutaneous coronary intervention and coronary artery bypass grafting.  Cardiac rehab is also part of the national standard of care.  It includes exercise training to teach safe exercising, muscle strengthening and improve stamina as well as education, counseling and training to help the patient understand their condition and identify ways to lower risk for future medical issues related to the heart. Life Expectancy and Outcomes-Since 2004, the death rate related to heart disease has fallen.  In 2013 there were 211 deaths per 100,000 people in Virginia and 223 in the nation.  This gave Virginia the 25th lowest rate in the country (Measuring Cardiovascular Disease, 2015).  Across the state (Virginia) deaths related to heart disease have continued to fall.  According to US government statistics, there are almost 300,000 deaths each year (Moon, 2008).  Of the total heart disease related deaths each year, 8.6 million are women and is the largest single cause of deaths in women worldwide (Fact Sheets, n.d.).  Heart disease is listed as the underlying cause of death for 31% of all deaths in the United States-that’s almost 2200 deaths per day. A3a. Disparities Health disparities continue to exist for low income populations and minorities.  There is evidence that these groups have earlier onset of heart disease and earlier death associated with the advanced disease related to biological, psychosocial, environmental and behavioral issues.  Programs have been implemented by public health groups nationwide to modify known risk factors, focusing on tobacco cessation, increased physical activity, healthier diets and preventative screening.  There has been minimal progress noted in the heart disease health disparities among low income and minority populations.  People living in low income communities have less access to affordable and nutritious food, parks for physical activity and limited access to health screenings.  Fresh and organic produce tend to more expensive than canned or frozen food.  Disparities are seen with patients that carry Medicare as well as non-Medicare patients. Disparities are also noted on an international level based on a patients’ insurance or noninsured status.  Patients that do not carry insurance and are unable to pay privately, are typically discharged home with minimal prescriptions and no access to home health leaving family members to take care of them. According to the World Health Organization, about 16 million people across the world die of heart disease each year (The World Health Report, 2003).  Due to a lack of resources and education, developing countries are twice as likely to see patient deaths related to heart disease.  Heart disease has no socioeconomic, gender or geographic boundaries. According to The World Health Report, heart disease is the leading cause of death in the European Union, accounts for over 245, 000 deaths in the UK and an estimated 8 million people in Canada have some form of heart disease.  In these countries, the prevalence of hypertension is very high with citizens not being treated.  In low-income countries, there is usually one person that is the primary money maker for the family.  Due to limited financial resources, many are not able to seek the treatment that they need or take the time away from work to seek treatment.  Low-income communities have unequal distribution of goods and little to no access to healthcare services, healthy foods or safe, green outdoor areas for activity.  There is easy access to alcohol, tobacco and unhealthy foods such as fast food. Among African Americans 10.3% suffer from heart disease, 4.9% of Hispanics suffer from heart disease, 3.3% of Asians suffer from heart disease and 5.6% of Caucasians suffer from heart disease (Thom, 2006).  It is estimated that by 2030, over 44% of the United States population will have some form of heart disease.  The American Heart Association’s 2020 Impact Goals include improving the cardiovascular health of Americans by as much as 20% while reducing the mortality rate related to heart disease by 20%. Analysis of data sets reported by the Center for Disease Control showed that adults older than 18 years old, disparities were noted for all risk factors examined.  Mexican American men had the highest prevalence of obesity while African American women without a high school education had a high prevalence of obesity.  Regardless of age or sex, African Americans had the highest prevalence of hypertension while Caucasian and Mexican American men had the highest prevalence of hypercholesterolemia along with Caucasian women (Thom, 2006).  Smokers with family incomes lower than the poverty level is twice as likely than adults in the highest family income group. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay A4a. Factors Contributing to Managing Heart Disease Medication compliance is a huge factor in management of heart disease.  Cost is one of the most common reasons people have for not taking their medications.  For patients having financial issues, the physician may be able to prescribe another medication that is more cost effective.  There are also public and private programs that offer discounted or free medications such as manufacturers’ aid or patient assistance programs.  Income and age will often determine eligibility.  It is estimated that three out of four Americans so not take their medications as directed (Medication Adherence, n.d.).  Poor medication adherence takes the lives of 125,000 Americans annually. Some medication assistance programs that can assist a patient better manage heart disease are: RX Outreach- a charitable nonprofit patient assistance program that provides access to affordable generic and brand name medications FamilyWiz Community Service Partnership-distributes free prescription savings cards and a price look up tool NeedyMeds-a national non-profit resource that helps people locate assistance programs to help them afford medications and healthcare costs Due to the high cost of medications, some patients do not purchase them.  A patient with heart disease can experience many complications if they do not follow their medication regimen as prescribed.  Research has proven that a variety of medications are needed for the best outcomes in the treatment of heart disease.  Each medication treats a different symptom or contributing factor to promote the overall treatment.  Each individual medication cannot do their job correctly if not taken correctly.  In a nutshell, proper use of prescribed medications for the treatment of heart disease has been proven to save lives, prolong life and improve overall heart function. Medication noncompliance can lead to an unmanaged disease process as evidence by the mechanism of action of the medications.  For example, diuretics are prescribed to heart disease patients to help the body to rid itself of excess fluids and sodium via urination.  If a patient is not taking their medications as prescribed, there can be an increased workload of the heart as well as increased buildup of fluid in the lungs, ankles and legs making the condition much worse. Lack of insurance coverage can also affect a patient’s ability to manage their heart disease.  Plans such as Medicare Part B covers for preventative screening every 5 years.  There are no costs for the tests and everyone who has Medicare Part B is covered.  Medicare also covers one visit per year as a preventative service.  For patients that are experiencing heart failure, Medicare offers comprehensive cardiac rehabilitation that includes exercise, education and counseling (Your Medicare Coverage, n.d.).  This program is provided in a hospital outpatient setting or in a doctor’s office. A patient that has private insurance typically will have a rehabilitation plan included as part of their coverage.  For instance, with Anthem, a patient can receive up to sixty visits in a calendar year for