Running head: HEART DISEASE 1

Interventional Effectiveness and Management of Heart Disease

Jacob Kimble, Kristy Eckman, Paige Meadows, Manuel Mavroudis, Reanna Bell

Youngstown State University

NURS 3749: Nursing Research

Ms. Randi Heasley

05 April 2021
HEART DISEASE 2

Abstract

Cardiovascular disease is the leading cause of death globally. Throughout this paper, we

have looked at several research studies to try and determine how taking action and following a

health regimen has affected the quality of life for these patients. Our research found alarming

data about heart disease patient's ability to maintain their medication regimen and change their

lifestyle after being discharged from the hospital. By doing so, we were able to determine that

changes in diet, exercise, and following the appropriate rehabilitation or physician orders greatly

affected the mortality rates. To further our understanding, our study looked into referral steps

hospitals take to ensure patients seek treatment after hospitalization and achieve high adherence

to health promotion.
HEART DISEASE 3

Literature Review

Introduction

Cardiovascular disease is a prominent issue worldwide. Many people develop disorders

of the heart, however, the question is: Can anything be done to reduce this risk? Most risk factors

are modifiable meaning they can be prevented or treated before progressing to heart disease.

Some of these risk factors include a sedentary lifestyle, obesity, smoking, and hypertension

among many more. Throughout this paper, we will be discussing the effects dietary intake,

exercise, treatment effectiveness, and cardiac rehab have on the prevalence, management, and

mortality rates of cardiac disease.

Dietary Intake

Cardiovascular disease is highly affected by what you consume. In this part of our

research, I will be discussing the effects dietary intake has on cardiovascular disease. It may be

assumed that a general diet is appropriate in intervening with this type of disease process but

what really matters is the contents of each food item, such as lipids or fats, vitamins, electrolytes,

omega-3’s, and supplements. As previously mentioned, heart disease is highly affected by and

can be the result of obesity and/or high cholesterol consumption.

A diet that has been found to highly decrease the mortality rate in these patients is called

the Mediterranean diet. So, what exactly is the Mediterranean diet? This type of diet is

characterized by decreasing the number of lipids, dairy, red meat, and cholesterol consumption

while emphasizing an increased intake of vegetables, poultry, protein, and whole grains. Overall,

this diet impacts heart health and is a key player in health promotion and prevention.
HEART DISEASE 4

According to the Hale Project published in 2004, a drop in mortality rate related to

cardiovascular disease was associated with following the Mediterranean diet and other health

promotion measures such as cessation of smoking and lifestyle changes. After conducting a

study on 2,339 individuals, only 371 resulted in death from cardiovascular disease. Participants

that had low adherence resulted in about 60% of the mortalities. “Among individuals aged 70-90

years, adherence to a Mediterranean diet and healthful lifestyle is associated with a more than

50% lower rate of all-cause and cause-specific mortality” (Knoops et al., 2004. p. 1433). With

these results provided, the Mediterranean diet undoubtedly has a positive impact on mortality

rates and complications related to cardiovascular disease.

The Moli-Sani Study published by the International Journal of Cardiology (2019)

examines the specific effects and results of the Mediterranean Diet individually and with the

combination of statins. Stains are used in cardiovascular patients to lower the total cholesterol,

which I previously mentioned is a contributing factor to the disease. After narrowing down 1,320

candidates to reliable participants, this study took 1,180 subjects and looked at how each factor

plays a role in the mortality rate of these patients. Not only did this study show a decrease in

mortality, but it compares the adherence levels of the diet to show how effective it can be with

higher compliance.

According to this study, participants with high adherence to the diet resulted in a 32%

lower risk of all-cause mortality, whereas those with moderate adherence resulted in a lower rate

of only 30% (Bonaccio et al., 2019, p. 250-251). When combining statins into the diet, it showed

very similar results to high adherence. When used separately, it was not shown to be a

contributing factor to lowering cardiovascular mortality rates. Another result of this data was the

overall effects diet and statins had on the inflammatory process. “Our results showed that the
HEART DISEASE 5

best combination of the Mediterranean Diet and statins is associated with reduced low-grade

inflammation with a magnitude greater than expected” (Bonaccio et al., 2019, p. 252). With the

pathophysiology of heart disease, increased inflammation is correlated to mortality, by

decreasing it, it can overall decrease the risk of death.

After reviewing these two research articles, I can conclude that diet does play an

important role in decreasing the mortality rates and overall health of these patients. Specifically,

the Mediterranean Diet has been shown to decrease these rates by almost a third of what it was

before. Cardiovascular patients are heavily affected by what they consume; by incorporating this

diet among the other basics such as physical exercise and lifestyle changes into their care plan,

we can promote health and optimal life expectancy.

Exercise

Having a cardiovascular disorder can have an impact on a patient’s lifestyle. Some people

may think that if a patient has a cardiovascular disorder then they should not be exerting extra

energy to try exercising, while others believe that exercise helps keep the heart in good

condition. In this section, we will discuss the impact exercise can have on the well-being of a

patient diagnosed with cardiovascular disease by exploring the different types of exercise that

patients can practice, and the amount of exercise that can be beneficial for the patient.

According to O’Donovan et al., (2018) the participants were grouped into the different

categories of inactive “participants not undertaking any PA of moderate or vigorous intensity”,

insufficient activity “undertaking some moderate-vigorous PA but not meeting the current PA

guidelines”, sufficient activity “those meeting and exceeding the guidelines 150 min/week

moderate or 75 min/week vigorous PA”, and high activity “those exceeding 300 min/week
HEART DISEASE 6

moderate-vigorous PA” O’Donovan et al., (2018, pg 484). This study goes on to show that when

participants with cardiovascular disorders exercise, it reduced the risk of all cardiovascular

disorders that were studied. The study showed that exercise in general decreased the risk of

cardiovascular disease. However, the concern is whether the intensity of the physical activity

performed altered the patient outcome or not.

In the O’Donovan et al., (2018) study, it was found that if a participant performed any

amount of exercise, even if it did not meet the guidelines, there was still a reduction in deaths

caused by cardiovascular disorders. This goes to show that if a patient exercises, it is helpful for

their health, especially if they have a cardiovascular condition. This study also found that for

participants with the condition of hemorrhage stroke, exercise helped their condition by reducing

the risk of a stroke when it was performed at a moderate level, however, if the patient performed

high activity, it could put the patient at an increased risk of having a stroke. Higher levels of

exercise also did not help participants with the condition of coronary heart disease, in these

participants, there was “a plateau in risk reduction at higher levels of PA” O’Donovan et al.,

(2018, pg 485). These outcomes show that exercise is good for patients experiencing

cardiovascular disorders, but sometimes higher levels of exercise were not as beneficial.It was

noted that some of the discrepancies with high levels of activity could be due to reporting bias on

how vigorous of activity the participant reported they were participating in. In this study,

exercise helped patients with cardiovascular disease, but it was also found that aerobic exercise

increased protection more than strength training did. This allows us to see that different types of

exercise and different amounts of exercise can influence the protection value exercise has on

patients with cardiovascular disease.

HEART DISEASE 7

In the study performed by Amiri et al., (2020), exercise was split into the different

categories of light, moderate, and vigorous activity, and they were determined by the

participant’s leisure time and their physical and occupational activity. The results showed there

was a gender difference on how exercise helped with their cardiovascular disorders. In this study,

middle-aged men achieved a better outcome than elderly men or women in either grouping. They

believe this is due to the amount of exercise participated in. In this study, middle-aged men

participated more in the advanced levels of exercise. Since participants who exercised in that

level had a 20% lower risk of cardiovascular disease, this study shows that vigorous activity

decreases the risk of cardiovascular disorders Amiri et al., (2020).

For the elderly men and for middle-aged and elderly women in the Amiri et al. (2020)

study, exercise was still beneficial. It was found during this study that participants who exercised

from the start and for participants who started exercising partway through the study all had a

lower prevalence of cardiovascular disease than the participants who did not exercise at all. Even

though the amount of exercise required, and the intensity needed to lower cardiovascular disease

prevalence is still debated and needing research, the results that the study agrees upon is that any

type and amount of exercise is better for patients with cardiovascular disease than if they do not

participate in any exercise at all. Overall, in patients with cardiovascular disorders, exercise can

lower their risk factors of increased cardiovascular issues, and lower the risk of dying from their

cardiovascular disorder.

Treatment Effectiveness

A seemingly prevalent problem with heart disease is the effectiveness of the treatment;

Keeping in mind that for treatment to be effective there needs to be patient adherence. This ties

into the patient’s ability to change their lifestyle. To begin, a study was done using the
HEART DISEASE 8

Medication Event Monitoring System that would identify the effectiveness of a patient's

adherence to their medication after hospitalization for Heart Failure. In fact, Jia-Rong Wu and

Debra K. Moser(2018) stated, “...that patients with better medication adherence had fewer HF

symptoms and that medication adherence mediated the relationship between HF symptoms and

cardiac event-free survival.” This showed that medication is dependent on the patient’s ability to

follow as prescribed. Patient adherence was just a small slice of the pie that caused

complications after hospital stays.

Overall, 90 out of the 219 patients were categorized as non-adherent to prescribed HF

medications (41%). A total of 46% of patients with HF symptoms were non-adherent to

medication compared with 32% of patients without HF symptoms. In the unadjusted

logistic regression model, patients with HF symptoms were 1.8 times more likely to be

non-adherent compared with those without HF symptoms (odds ratio [OR] = 1.8, 95%

CI: 1.00–3.23, p = .05). (Moser, Wu, 2018)

The results found in this study arise from the follow-up appointments made to ensure that

the heart failure patients will abide by the orders given to them. As a part of prevention, a study

was done to view how patients are referred for follow-up appointments to track their adherence.

Adjusted analyses in this study found a significance in the way patients are referred reflects the

enrollment in follow-up appointments after being discharged for cardiac disease. The study

found the greatest chance of rehabilitation uses a combination of referrals, liaison with

automatic, 85.8% referral, 73.5% enrollment. (Grace, Russel, Reid 2011) Furthermore, a study

done by Ehimwenma J. Ogbemudia and John Asekhame found that patient rehospitalization is

preventable in many of the heart failure patients observed. In their study, the researchers stated,

“Multiple rehospitalization for heart failure is a challenge for the elderly, but 55.5% of these
HEART DISEASE 9

readmissions are preventable. Poor drug compliance and pulmonary infections were the most

common preventable participants.” (Ogbemudia, Asekhame 2016) Findings emerge that

increasingly question how preventable rehospitalization is for cardiac patients. The next study

would find that after the patients are discharged rehospitalization goes as follows: original cohort

(n=7,562), second hospitalization (n=5,680), third hospitalization (n=4,253), fourth

hospitalization (n=3,147), and fifth hospitalization (n=2,356). After hospitalization, these rates of

rehospitalizations are alarming because heart disease is the leading cause of death in the United

States. The results found in the studies viewed show that rehospitalization is preventable with the

patient's ability to follow their prescribed regimen and lifestyle changes. (Braga, Tu, Austin,

Sutradhar, Ross, Lee 2018)

Cardiac Rehabilitation

Cardiac rehabilitation does not change an individual’s past, however, it can definitely

change a person’s future. In this section of the research, I will be discussing the overall health

benefits for the elderly population with acute compensation heart failure and also individuals

with acute coronary syndrome who participate in a cardiac rehabilitation program. Cardiac rehab

is a medically supervised program designed to improve your cardiovascular health if you have

experienced a heart attack, heart failure, angioplasty, or heart surgery.

Heart failure is not uncommon especially with the older population, Acute

decompensated heart failure (ADHF) is a leading cause of hospitalization in older individuals in

the United States. Severely reduced physical function and frailty are major determinants of

adverse outcomes in older patients with hospitalized ADHF. Older patients with chronic HF have

severe impairments in physical function due to the combined effects of aging, cardiovascular
HEART DISEASE 10

dysfunction, and impaired skeletal muscle function. When these patients are hospitalized they are

put on bed rest which further exacerbates the problem by dysfunction and acute muscle loss

(Zadeh, Dorri, Shafiee 2015). Cardiac rehabilitation is an extremely helpful program for

post-operative care and improves the quality of life for these individuals. Cardiac rehabilitation is

a simple monitoring program for the safe return to physical activities to a multidisciplinary

program including improving medical treatment, nutritional counseling, smoking cessation, risk

stratification, stress management, hypertension management, and the control of diabetes or

dyslipidemia. Each of these outcomes help improve the overall quality of life and help reduce

further complications from occurring.

In a particular case study, the primary outcome is to assess the efficacy of cardiac

rehabilitation intervention on physical function measured by the change in total SPPB (Short

Physical Performance Battery) score from baseline to 3 months. The data is obtained by

independent, trained assessors who are anonymous to participants. The SPPB measures physical

function using 3 components: usual gait speed over 4 meters, time to complete 5 chair rises, and

standing balance with a progressively narrow base of support. Each component is scored on a

0–4 scale and summed for an overall score range of 0–12. From this program, they have

conducted that the rehospitalization rate within 6 months for these people has decreased by

29.3% (Zadeh, Dorri, Shafiee 2015). In conclusion, cardiac rehabilitation reduces

rehospitalizations for people with heart and decreases the mortality rate of older people with

heart failure.

The next topic is the effect of cardiac rehabilitation on quality of life in patients with

acute coronary syndrome. Acute coronary syndrome is a condition brought on by a sudden

reduction or blockage of blood flow to the heart. This particular study was created on 50 patients
HEART DISEASE 11

with acute coronary syndrome admitted to the coronary care units of Shohada Hospital in Isfahan

in 2013-2014. The participants were randomly assigned to two groups called phase one and

phase two. Phase one was the group that would use the cardiac equipment and phase two

consisted of calling people and referring them to the hospital for care. The results of the study

have shown that the scores in all domains of quality life significantly increased in phase 1

whereas in phase 2, the scores in all domains of qualified life were not significant before and

after their intervention. Acute coronary syndrome is a life-threatening disease and should be

managed as soon as possible. About 1 million people per year in the United States suffer from

this disease and it is projected that 23.6 million people will die from acute coronary artery

disease by 2030 ( Reeves, Whellen, Duncan, 2017). The results of this specific study showed that

cardiac rehabilitation programs could lead to improving the quality of life in patients with acute

coronary syndrome. We need to encourage people to participate in these programs if they have

these specific health problems because the millions of fatalities can be reduced tremendously by

2030 if they partake in these programs to improve their overall quality of life

Comparing Results

There are many ways to treat heart disease, but what happens when you do not take those

preventive or quality-improving measures? Some people may not change their lifestyle simply

because they do not properly know how to. Han (2019) states, “Adequate awareness of

cardiovascular disease may help in its prevention and control.” The ignorance of a heart-healthy

lifestyle can be significantly attributed to lack of knowledge. In the study conducted by Han, the

stroke and heart attack warning signs that were least identified were poor vision and referred

shoulder pain, men having a lower knowledge score than women. It was found that a knowledge

deficit about cardiovascular disease was associated with older age, male, lower education level,
HEART DISEASE 12

lack of regular exercise, unmarried, unemployed, poor economic status, poor health behaviors,

poor diet, stress, and hypertension or dyslipidemia (Han, 2019). These behaviors increase the

risk of hypertension, diabetes, coronary artery disease, hyperlipidemia, atherosclerosis, heart

failure, stroke, heart attack, and many other complications, including death. Most people also do

not understand that the heart and lungs follow one another. Untreated or ignored heart disease

can cause fluid buildup in the lungs, shortness of breath, decrease oxygen situations, and activity

intolerance. Someone with heart disease and an unchanged lifestyle may find themselves not able

to tolerate the activity that they are used to.

Han (2019) found that 19% of the population had a poor understanding of the signs and

symptoms of a stroke or heart attack. Those with predisposing conditions such as hypertension or

hyperlipidemia mostly did not know the warning signs. The most commonly identified signs and

symptoms were chest pain and shortness of breath. The least identified symptom was referred

shoulder pain. In order to increase the population’s understanding of cardiovascular disease and

the deadly complications that can result from it, such as heart attack or stroke, community

resources and outreach must be increased. Community outreach also must be available to those

with fewer resources than others to improve the incidence of cardiovascular disease today.

Those who do not manage their cardiovascular disease also may not know about other

lifestyle interventions. The core components to managing cardiovascular disease include patient

assessment, nutrition counseling, weight management, blood pressure management, lipid

management, diabetes management, tobacco cessation, psychosocial management, physical

activity counseling, and exercise training (Aggarwal, 2021). Leaving out a single factor of these

core components significantly increases the risk for heart disease or life-threatening outcomes. In

addition, certain individuals may not take their medications, which can cause a snowball effect of
HEART DISEASE 13

complications to the body. Medications for heart disease may include aspirin, beta-blockers,

statins, calcium channel blockers, ACE inhibitors, cholesterol-lowering agents, diuretics, and

anticoagulants. Forgetting these medications can increase the risk of further complications, even

death. Those with comorbidities, such as diabetes, are at an even higher risk.

Eating a heart-healthy diet and exercising can seem expensive and unattainable to people.

Gyms can be expensive, but walking around the house, stairs, or around the block daily can

significantly decrease the risk of heart disease. Along with exercise, diet is an important factor as

mentioned earlier. It can be just replacing saturated fats with polyunsaturated fats to decrease

LDLs. Decreasing salt intake, a Mediterranean diet, the DASH diet, or the whole-foods

plant-based diet are proven to be heart-healthy(Aggarwal, 2021). Adequate access to

nutritionists, counseling or even how to read a nutrition label could ultimately have a major

impact on heart disease and deadly complications. Consuming an excessive amount of fats

ultimately settles in the vascular system, decreasing blood flow, decreasing oxygen, and causing

complications. There are many risk factors, signs and symptoms, and methods of treatment for

cardiovascular disease and its complications. It is up to the patient to take charge of their health,

and up to the community to offer resources and increase patient education to those who may not

have quick and easy access to information.

HEART DISEASE 14

References

Aggarwal, M., Ornish, D., Josephson, R., Brown, T. M., Ostfeld, R. J., Gordon, N., Madan, S.,

Allen, K., Khetan, A., Mahmoud, A., Freeman, A. M., & Aspry, K. (2021). Closing Gaps

in Lifestyle Adherence for Secondary Prevention of Coronary Heart Disease. The

American Journal of Cardiology, 145, 1–11.

https://doi-org.eps.cc.ysu.edu/10.1016/j.amjcard.2021.01.005

Amiri, P., Azizi, F., Jalali-Farahani, S., Khalili, D., Masihay-Akbar, H., Naesri, P. (2020).

Long-term incidence of cardiovascular outcomes in the middle-aged and elderly with

different patterns of physical activity: Tehran lipid and glucose study. BMC Public

Health, 20 (1), https://doi.org/10.1186/s12889-020-09747-6

Bonaccio, M., Di Castelnuovo, A., Costanzo, S., Persichillo, M., De Curtis, A., Cerletti, C.,

Donati, M. B., de Gaetano, G., & Iacoviello, L. (2019). Interaction between

Mediterranean diet and statins on mortality risk in patients with cardiovascular disease:

Findings from the Moli-sani Study. International Journal of Cardiology, 276, 248–254.

Retrieved from https://doi-org.eps.cc.ysu.edu/10.1016/j.ijcard.2018.11.117

Han, C. H., Kim, H., Lee, S., & Chung, J. H. (2019). Knowledge and Poor Understanding

Factors of Stroke and Heart Attack Symptoms. International Journal of Environmental

Research and Public Health, 16(19).

https://doi-org.eps.cc.ysu.edu/10.3390/ijerph16193665

Juarez R Braga, Jack V Tu, Peter C Austin, Rinku Sutradhar, Heather J Ross, Douglas S Lee,

Recurrent events analysis for examination of hospitalizations in heart failure: insights

from the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) trial, European
HEART DISEASE 15

Heart Journal - Quality of Care and Clinical Outcomes, Volume 4, Issue 1, January

2018, Pages 18–26, https://doi.org/10.1093/ehjqcco/qcx015

Khalife-Zadeh, A., Dorri, S., & Shafiee, S. (2015). The effect of cardiac rehabilitation on quality

of life in patients with acute coronary syndrome. Retrieved April 01, 2021, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598906/#:~:text=%5B13%5D%20Thes

e%20studies%20revealed%20that,smoking%2C%20and%20level%20of%20stress

Knoops, K. de Groot, L. Kromhout, D. Perrin, A. Moreiras-Varela, O. Menotti, A. van Staveren,

W. (2004). Mediterranean Diet, Lifestyle Factors, and 10-Year Mortality in Elderly

European Men and Women. Findings from the Hale Project. 292(12):1433-1439.

Retrieved from https://jamanetwork.com/journals/jama/fullarticle/199485

O’Donovan, G., Hamer, M., Stamatkis, E. (2018, November 11). Association between physical

activity and sub-types of cardiovascular disease death causes in a general population

cohort. European Journal of Epidemiology, 34,483-487.

https://doi.org/10.1007/s10654-018-0460-2

Ogbemudia, E. J., & Asekhame, J. (2016). Rehospitalization for heart failure in the elderly. Saudi

medical journal, 37(10), 1144. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5075381/

Reeves, G., Whellan, D., Duncan, P., O'Connor, C., Pastva, A., Eggebeen, J., . . . REHAB-HF

Trial Investigators. (2017, March). Rehabilitation therapy in OLDER acute heart Failure

Patients (REHAB-HF) TRIAL: Design and rationale. Retrieved March 10, 2021, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5341700

Wu, J. R., & Moser, D. K. (2018). Medication adherence mediates the relationship between heart

failure symptoms and cardiac event-free survival in patients with heart failure. The

Journal of cardiovascular nursing,

HEART DISEASE 16

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5714687/