593032
research-article2015
WHSXXX10.1177/2165079915593032Workplace Health & SafetyWorkplace Health & Safety
Workplace Health & Safety
Professional Pr actice
Cardiovascular Update
Risk, Guidelines, and Recommendations
Tamera Pearson, PhD, FNP-BC, ACNP-BC1
Abstract: This article provides an update of the
current status of cardiovascular disease (CVD) in the
United States, including a brief review of the underlying
pathophysiology and epidemiology. This article presents
a discussion of the latest American Heart Association
guidelines that introduce the concept of promoting
ideal cardiovascular health, defined by seven identified
metrics. Specific CVD risk factors and utilization of the
10-year CVD event prediction calculator are discussed.
In addition, current management recommendations of
health-related conditions that increase risk for CVD, such
as hypertension and hypercholesterolemia, are provided.
Finally, a discussion of detailed evidence-based lifestyle
recommendations to promote cardiovascular health and
reduce CVD risks concludes the update.
Keywords: chronic illnesses, disease prevention, health
promotion, primary care, application of evidence
C
ardiovascular disease (CVD) is the number one cause of
death in the United States and globally, affecting both
men and women. The World Health Organization
(WHO) estimates that CVD claimed 17 million lives worldwide
in 2012, and this number is predicted to double in the next 15
years (WHO, 2015). One of three deaths in the United States is
attributable to CVD (Mozaffarian et al., 2015a). To begin
addressing this universal problem, the WHO created an Atlas of
Heart Disease and Stroke aimed at reducing CVD risks by
educating policy makers, organizations, and health professionals
who can affect population health (WHO, 2015). In an effort to
reduce morbidity and mortality related to CVD, the American
Heart Association (AHA) developed an online resource center to
promote workplace health (AHA, 2015). Although there are
many types of heart and artery diseases (including valvular
heart disease, heart failure, arrhythmias, peripheral arterial
disease, and aneurysms), the emphasis of the WHO and AHA
health promotion efforts and the focus of this update article are
atherosclerotic heart disease and stroke.
DOI: 10.1177/2165079915593032. From 1Western Carolina University. Address correspondence to: Tamera Pearson, PhD, FNP-BC, ACNP-BC, Associate Professor, School of Nursing, Western Carolina
University, 28 Schenck Parkway, Ashville, NC 28803, USA; email: tlpearson@wcu.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2015 The Author(s)
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September 2015
Pathophysiology and Epidemiology
Atherosclerosis
Atherosclerosis is a complex disease that limits perfusion
throughout the body and can significantly affect vital organs.
Inflammation is the underlying trigger that initiates the
atherosclerotic process, perpetuates plaque development, and
stimulates continued accumulation of plaque components that
can eventually form a thrombus (Brashers, 2015). The outcome
of untreated atherosclerosis is decreased blood flow in the
micro and macro vascular systems. Atherosclerosis in the heart
or brain significantly increases the risk of myocardial infarction
or stroke.
Heart Disease
One of the interesting findings in heart statistics is that over
the past decade, the death rate from heart disease fell by 39% in
the United States (Mozaffarian et al., 2015b). During the same
time period, procedures and surgeries for heart disease
increased by 28% due to the development of new treatments
that have improved outcomes (Mozaffarian et al., 2015b).
Despite this small bit of good news, the pervasiveness of
atherosclerotic heart disease continues to be of great concern
and remains the leading cause of death among both men and
women, accounting for one of seven deaths in the United States
(Mozaffarian et al., 2015b). More women than men die from
heart disease today, and the number of deaths in women aged
35 to 44 years has increased over the past 5 years (Gulati, Shaw,
& Bairey Merz, 2012; Mosca et al., 2011; Roger et al., 2011).
Stroke
Deaths from strokes declined by 21% between 2001 and
2011; new medications and procedures might have also
improved this trend (Mozaffarian et al., 2015a, 2015b). Yet,
stroke is the fourth leading cause of death and is currently the
number one cause of disability in the United States (Mozaffarian
et al., 2015b). African Americans are twice as likely to suffer a
stroke compared with their White counterparts (Lehmkuhl et al.,
vol. 63  ■  no. 9
2012; Malarkey, Jarjoura, & Klatt, 2013; Mozaffarian et al.,
2015b).
Clearly, the most current heart disease and stroke statistics
paint a picture of the far-reaching impact of CVD in the United
States. Both men and women from all ethnic groups are at risk
for developing atherosclerosis and suffering a subsequent CVD
event. In an effort to use the current data on the risks for heart
disease and stroke, several professional organizations
collaborated over the last year to initiate a new approach to
addressing the issue of CVD through education and prevention.
New Approach to CVD and Cardiovascular
Health
Rather than simply focusing on the perpetual problem of
CVD, the new approach emphasizes promoting “Ideal
Cardiovascular Health” (Eckel et al., 2014). CVD may affect
individuals’ abilities to enjoy a productive job or fulfilling
hobbies and can elicit worry or cause a burden for family
members who have to undertake additional duties. Individuals,
families, and businesses may feel an economic strain related to
CVD. Consequently, the new guidelines endeavor to refocus
from the aftermath of CVD to prevention of CVD through health
promotion. The AHA, along with the American College of
Cardiology (ACC) and the National Heart Blood and Lung
Institute, developed evidence-based lifestyle management
guidelines to prevent CVD and promote cardiovascular health
(Eckel et al., 2014). “Current evidence supports a range of
complementary strategies to improve cardiovascular health”
(Mozaffarian et al., 2015a, p. 435).
Ideal Cardiovascular Health
The new AHA guidelines promote the concept of ideal
cardiovascular health, characterized by specific behaviors and
physiological measurements determined by a scientific review
of the published literature (Eckel et al., 2014; Goff et al., 2014;
Mozaffarian et al., 2015a). The seven delineated health metrics
for ideal cardiovascular health are not smoking, engaging in
sufficient physical activity, eating a healthy diet, and maintaining
a normal body weight, optimal total cholesterol level, normal
blood pressure, and normal fasting blood glucose in the
absence of drug treatment (Table 1; Mozaffarian et al., 2015a).
The aim of this new focus is to generate ideas and implement
strategies and incentives across health care systems, in
communities, schools, businesses, and at home that can
contribute to the promotion of cardiovascular health
(Mozaffarian et al., 2015a).
CVD Risk Factors
According to the statistical update by the AHA, American’s
overall cardiovascular health status is poor (Mozaffarian et al.,
2015b). Identifying CVD risks is an imperative first step toward
improving cardiovascular health because the information from
risk assessments can guide the development of a risk reduction
plan. Evidence supports evaluation of the following CVD risks
Workplace Health & Safety
Table 1.  Delineated Health Metrics for Ideal Cardiovascular
Health
Not smoking
Engaging in sufficient physical activity
Eating a healthy diet
Maintaining a normal body weight
And in the absence of drug treatment
Having an optimal total cholesterol level
Having a normal blood pressure
Having a normal fasting blood glucose
Source. Mozaffarian et al. (2015a).
that are in opposition to ideal health metrics: smoking, lack of
physical activity, unhealthy diet, overweight or obesity,
hyperlipidemia, hypertension, diabetes mellitus, and family
history of CVD (Goff et al., 2014; Mozaffarian et al., 2015a).
Experts note that when designing risk reduction plans,
consideration of additional unique CVD risk factors such as
C-reactive protein, coronary calcium score, and ankle brachial
index may be beneficial (Goff et al., 2014).
Clearly, assessment and treatment of CVD risks are vital
because atherosclerosis develops over decades. Reducing the
cumulative exposure to the effects of any modifiable CVD risks
is crucial. Understanding the current status of population CVD
risks can provide a foundation for risk appraisal and is the
purpose of the 2015 Heart Disease and Stroke Statistics Update,
which compiled the following data (Mozaffarian et al., 2015a).
•• Approximately 30% of deaths in the United States from
heart disease are attributable to smoking and exposure to
secondhand smoke. Currently, 20% of men and 16% of
women in the United States smoke cigarettes. The
economic burden associated with the health care costs
and lost productivity from the effects of smoking is
greater than US$289 billion.
•• Only half of adults meet the recommended aerobic
physical activity guidelines; one of three does not
participate in any physical activity.
•• Less than 1% of Americans more than 21 years old meet
the AHA definition of a healthy diet, and 69% of adults
are overweight or obese.
•• Forty-three percent of Americans have a total cholesterol
level over 200 mg/dL, and one of three has an elevated
low-density lipoprotein (LDL) level.
•• 80 million Americans have hypertension, and only 54% of
these individuals have their blood pressure adequately
controlled through treatment.
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•• Type 2 diabetes mellitus affects 1 of 10 adults in the
United States, and this prevalence is expected to increase.
•• A positive family history of CVD in a first-degree relative
increases the likelihood of having heart disease or a
stroke by 45% to 50%. Clustering of both environmental
lifestyle factors and genetic influences contribute to CVD
family history.
•• C-reactive protein levels, coronary calcium score, and
ankle brachial index have all been shown to be
associated with increased incidence of CVD events and
may inform CVD risk reduction treatment decisions.
CVD Risk Assessment Calculator
The latest AHA guidelines recommend assessing traditional
CVD risk factors every 4 to 6 years in 20- to 49-year-old adults
who have no known CVD (Goff et al., 2014). In adults aged 40 to
79 years without known CVD, the assessment should also include
an estimation of 10-year risk of first atherosclerotic cardiovascular
event, defined as a myocardial infarction or stroke, using an
evidence-based prediction calculator every 4 to 6 years (Goff
et al., 2014). The CVD risk calculator application is available on
the web and for handheld devices at the following sites:
•• http://my.americanheart.org/cvriskcalculator
•• http://www.cardiosource.org/en/Science-And-Quality/
Practice-Guidelines-and-Quality-Standards/2013-
Prevention-Guideline-Tools.aspx
Specific information that must be entered into the risk
calculation includes gender, age, total cholesterol, high-density
lipoprotein, and systolic blood pressure, whether taking
medication for hypertension, a diabetes diagnosis, and personal
smoking history (Goff et al., 2014). The calculator then produces
a risk percentage as a prediction suffering an atherosclerotic
cardiovascular event within the next 10 years. CVD treatment
decisions can then be based on this risk percentage.
Promotion of Cardiovascular Health
As previously noted, the assessment and treatment of identified
CVD risks are imperative to promote ideal cardiovascular health.
Occupational health nurses can focus on some of these CVD risk
factors while working with their clients by measuring blood
pressure, cholesterol, and blood sugar, as well as providing
instruction about lifestyle choices. Being aware of the most recently
published guidelines for each of these CVD risk factors can
provide a foundation for nurses to advocate for wellness programs
and provide personal health education in the workplace. Current
evidence-based diagnosis and management recommendations for
hypertension, hypercholesterolemia, diabetes, and related CVD
lifestyle choices are noted below.
Blood Pressure
During 2014, updated hypertension management guidelines
were released that defined new target blood pressure levels for
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September 2015
adults based on age and health-related conditions. Individuals
under age 60 years, as well as those with diabetes or chronic
kidney disease, should aim for a blood pressure of 140/90 or
lower (Page, 2014). The target level for those 60 to 79 years of
age without defined health-related conditions is now 150/90
(Page, 2014). Many people in the United States have
undiagnosed or undertreated hypertension that contributes to
increasing CVD risk over time (Wall, Hannan, & Wright, 2014).
Cholesterol
In 2013, new cholesterol guidelines to reduce atherosclerotic
cardiovascular risk in adults were published based on fasting
LDL level, presence of disease, and use of the 10-year CVD risk
calculator described earlier in this article (Stone et al., 2014).
The evidence-based recommendations indicated that statin
therapy is likely to benefit four defined groups: those with
existent clinical CVD, with an LDL equal to or greater than
190mg/dL, with a 10-year estimated CVD risk of 7.5% or greater,
and over age 50 years with a diagnosis of diabetes (Stone et al.,
2014). Statin medication to lower cholesterol should be
considered for primary prevention of CVD and to reduce the
risk of a CVD event in adults who fall into any of these
categories.
Blood Glucose
Maintenance of a normal fasting blood sugar between 100
and 126 is also recommended as a metric of cardiovascular
health. The most recent diabetes guidelines include information
about pre-diabetes and obesity treatment recommendations
(American Diabetes Association, 2014; Garber et al., 2013).
Diabetes management details are beyond the scope of this
article, but the lifestyle discussion below is applicable to
preventing and controlling diabetes.
Lifestyle
Primary CVD prevention and risk reduction through a
healthy lifestyle are the basis of the updated AHA and ACC
guideline on lifestyle management and support the concept of
ideal cardiovascular health (Eckel et al., 2014). General
nutritional recommendations are to eat a diet that emphasizes
fruits, vegetables, whole grains, low-fat dairy products, poultry,
fish, legumes, and non-tropical oils and nuts, while limiting red
meat, sweets, and sugar-sweetened beverages (Eckel et al.,
2014). Specific dietary advice is provided to address CVD risks
based on evidence in the literature. Examples include reducing
saturated fat intake to 5% to 6%, limiting calories from trans-fat
to aid in lowering LDL cholesterol, and decreasing sodium
intake to between 1500mg and 2000mg a day to lower blood
pressure (Eckel et al., 2014). In addition to healthy eating, all
individuals should engage in aerobic physical activity for a
minimum of three to four times a week for 40 minutes to
promote ideal cardiovascular health.
Finally, stress reduction activities are another important
aspect of a healthy lifestyle that nurses can encourage. Research
vol. 63  ■  no. 9
shows that negative psychological stress produces a variety of
physiologic changes that lead to inflammation, the underlying
trigger for atherosclerosis, and other chronic diseases (Forshee,
Clayton, & McCance, 2010; Ippoliti, Canitano, & Businaro, 2013;
Iwata, Ota, & Duman, 2013). Many therapies and activities have
been shown to reduce stress, including exercise, yoga, music
therapy, progressive relaxation, and mindfulness (Khoury et al.,
2013). One study found that participation in 6 to 8 weeks of
mindfulness practice at work resulted in significantly less
perceived stress, less reported work burnout, and improved
sleep and general health (Malarkey et al., 2013). Thus,
occupational health nurses may be in an ideal setting to
promote stress reduction and improve cardiovascular health.
Conclusion
Current evidence indicates that CVD remains the leading
cause of death for both men and women. “Ideal cardiovascular
health” is a new approach focusing on specific
recommendations. The process of health promotion starts with
the assessment and identification of CVD risk factors using
evidence-based recommendations aimed at reducing risk and
improving cardiovascular health. Occupational health nurses
can use this information to communicate with organizations that
promote wellness programs aimed at improving cardiovascular
health for all.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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completed multiple research studies focused on cardiovascular
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