Coronary Artery Disease Risk Management

Online Course #933 V.2- 4 Contact Hours
Author: Carolyn Hunter, RN, MA
Editor: Shelda L. Shank, RN, BSN, PHN
©2010 National Center of Continuing Education, Inc.

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Instructional Objectives:

1. Recall the pathophysiology of coronary artery disease.
2. Identify the major and secondary risk factors associated with coronary artery disease.
3. State the pathophysiological changes related to modifiable risk factors.
4. Identify effective strategies for patient education.
5. List characteristics of the adult and elderly learner.
6. Identify principles of teaching/learning that guide the education of the client.
7. Outline motivational strategies that will assist the client to meet the goals set.
8. Name the components of an effective program for prevention of coronary artery disease.
9. Identify at least one strategy that will assist the client in managing each modifiable risk.

Introduction

Coronary Artery Disease (CAD) affects eleven million Americans. Annually, this results in 550,000 deaths. Nurses can play a role in prevention of this disease by being knowledgeable of the risk factors associated with the disease. This course will acquaint the nurse with the risk factors, particularly the modifiable ones, so that the nurse may be a teacher-motivator for the client. Specific tools for assessment and strategies for success will be emphasized.
The American Heart Association plays a major role in research and education for this disease. A consensus panel from the AHA has strongly urged that a multidisciplinary approach - including physician, nurse and dietitian - manage the risk therapy program. The panel has found compelling scientific evidence demonstrating that risk factor interventions will extend life, improve quality of life, decrease the need for surgical procedures, and reduce the incidence of myocardial infarction.
Current research includes many strategies for preventing coronary heart disease. Ongoing research includes the effect of community-based health education programs, positive motivational strategies, effects of lowering cholesterol and triglycerides, gender differences and nutritional studies. The nurse should keep abreast of the latest research findings.

Pathophysiology Review of Atherosclerosis and Coronary Artery Disease

Coronary artery disease (CAD) is characterized by a variety of physiological conditions. The primary result of CAD is obstruction to the blood flowing through the arteries that supply nourishment to the heart muscle. These conditions include atherosclerosis, arteriosclerosis, arteritis, coronary artery spasms, coronary thrombosis, coronary embolus and infectious diseases. Hypertension plays a major role in causing the disease, with atherosclerosis and hypertension being the most prevalent syndromes leading to CAD.
Atherosclerosis, a common arterial disorder characterized by yellowish plaques of cholesterol, lipids and cellular debris in the inner layers of the walls of arteries, results from alteration in the dynamic nature of the vasculature. You will recall that the artery is composed of three layers: the intima, the media, and the adventitia. The first evidence of atherosclerosis is fatty streaks along the intima and media. Research has demonstrated that the lipoproteins (the vehicles which carry cholesterol and triglycerides) move into the smooth muscle of the artery.
The streaks may be seen in children by the age of 15. As aging occurs these streaks change to plaques. Low density lipoprotein (LDL) and other substances such as prostaglandins and hormones serve as cofactors for the growth and progression of the plaque. Even though this process is slow, it starts early, pointing out the importance of early risk reduction strategies beginning in childhood.
Hypertension adversely affects all aspects of cardiovascular function. A continuous increase in perfusion pressure results in hypertrophy of the smooth muscle. This results in alterations in size, shape, and cytoplasm of the endothelium, intima, and smooth muscle cells. This influences plaque evolution. These two risk factors, atherosclerosis and hypertension, continue the damaging process to the coronary artery.
Are there gender differences regarding CAD? It is not widely recognized that the most common cause of death in women, as well as men, is coronary artery disease. In the United States half of the deaths are attributed to women. The only difference between the sexes is that women have clinical symptoms about ten years later than men. Because of this, CAD in women has been considered an elderly woman's problem. However, this is an erroneous assumption: l00,000 of the annual 250,000 deaths from CAD in women occur before the age of 65.

Risk Factors

The etiology of coronary artery disease is multifactorial. Even though some risks are considered major risks, it is the combination of risks that increases the likelihood of developing clinical symptoms of the condition. Three risks are considered major. These are hypertension, elevated serum cholesterol, and cigarette smoking. Some factors cannot be changed or modified, such as age, gender, ethnicity, and heredity. This discussion will focus on the factors that can be modified, particularly the major risk factors. See Table 1 for factors that contribute to CAD.

MAJOR RISK FACTORS

• Elevated blood pressure - can be modified
• Cigarette smoking - can be modified
• Elevated serum cholesterol - can be modified

SECONDARY RISK FACTORS

• Heredity/Family history - non-modifiable
• Age - non-modifiable
• Sex - non-modifiable
• Race - non-modifiable
• Diabetes mellitus - can be modified
• Obesity - can be modified
• Diet high in saturated fat - can be modified
• Elevated serum triglycerides - can be modified
• Lack of exercise - can be modified
• Stress - can be modified
• Oral contraceptives - can be modified

TERMS

• Low Density Lipoprotein - LDL increases the risk
• High Density Lipoprotein - HDL decreases the risk
• Coronary Artery Disease - CAD
• Triglycerides
• Apolipoprotein-B
• Total Cholesterol
• Atherosclerosis
• Saturated
• Polyunsaturated
• Monounsaturated
• Hydrogenated

The knowledge that the nurse has regarding the pathophysiology of each risk factor will provide guidance when working with the client regarding the elimination or reduction of risk factors. Even though some of the risk factors are not modifiable, they may not be as critical with early intervention. Since most of the factors can be eliminated or modified, the client has incentive to correct the problem. It is this incentive that the nurse can use for motivation as they work together to achieve the goal of prevention of coronary artery disease.

Risk Factors (Modifiable)

Hypertension
Hypertension, often called the silent disease, is one of the major contributors to coronary artery disease. In adults, the definition of hypertension is when the systolic pressure is 140mm Hg or above and the diastolic pressure is 90 mm Hg or above. You will recall that the systolic pressure is the pressure against the walls of the arteries during the contraction of the heart and diastolic is the pressure when the heart is at rest. The diastolic pressure is the most important one to have reduced: the pressure is elevated against the wall of the artery constantly, causing damage and injury to the lining of the artery, and allowing lipids to move into the lining. It also causes substances to move through the lining more easily due to the direct pressure. These structural changes increase the wall to lumen ratio of the arteries and have the enhancing effect of the sympathetic nervous system. Over time, this stress on the wall of the arteries contributes to fatigue and rupture of the arterial walls and plaques deposited on arterial walls.
There is evidence that the alterations discussed can be reversed as a result of antihypertensive therapies. Current treatments include angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists. Research is focused on calcium medication to determine the most effective treatment. The nurse will need to be aware of the pharmaceuticals available for the client. Improved nutrition and exercise are important therapeutic regimes to be utilized with the pharmaceutical treatment.

Cigarette Smoking
Although the pathophysiology linking smoking and CAD is not as specific as with hypertension, it is clear that smokers have decreased coronary reserve. It is known that nicotine precipitates vasospasm, and vasospasm leads to ischemia. Platelet aggregation and thrombosis are increased in smokers, leading to a decreased diameter of the arterial lumen and causing more damage. The High Density Lipoproteins (HDLs) are also lowered by smoking.
The famous Framingham study clearly showed this as a major risk factor. One study showed that smoking cessation lowered the risk of CAD by 50%. The good news is that after a year of smoking cessation, the risk of CAD declines to the nonsmoker level. This is powerful information to share with clients.

Elevated Serum Cholesterol
In order for fat, as a source of energy, to be utilized by the membranes of the body, the body has developed several different types of particles to transport fats and lipids in the blood stream. These particles are made up of proteins, phospholipids, and free cholesterol. Plasma levels of total cholesterol (all particles), low-density lipoprotein cholesterol (LDL) and triglycerides all have positive correlation with increased risk for CAD. The reverse is true of high-density lipoproteins (HDL). HDL serves to assist with removing cholesterol from the blood, while the LDL serves to keep the cholesterol in the blood vessel wall in the form of plaque.
Again, the Framingham study, conducted over a 30 year period, has demonstrated a direct relationship between total cholesterol and coronary disease mortality for persons under 50. The elevated levels of total cholesterol and LDL cholesterol have been shown to be directly associated with an increased incidence of cardiovascular morbidity and mortality. High levels of HDL (sometimes known as the "good cholesterol") have also decreased the incidence. Both drug and nutrition therapies have been indicated to reduce death and disability in middle-aged men. Studies done to date have not demonstrated as clearly the effect of reduction of cholesterol in women.
Until recently most cardiovascular studies were done on men, but currently the number of studies are increasing on women.
A recent Gallup survey revealed that four of five women, and one of three physicians, did not know that heart disease is the number one killer of women. Even more amazing, most of the 505 women surveyed felt confident that their primary care physician could accurately diagnose heart disease - but a staggering 89% of the 300 physicians surveyed felt that they needed more education about women and heart disease.
In response to this startling lack of knowledge, the American Heart Association and the American Medical Women's Association launched a campaign called The Difference in a Woman's Heart. Dedicated to increasing public awareness of heart disease in women, the program's goals include:

• Facilitating early and accurate diagnosis
• Heightening awareness of heart disease in women through ongoing physician and patient education
• Increasing efforts aimed at preventing heart disease in women.

The nurse should keep abreast of new studies to improve patient teaching. Even though the studies are not as specific for women, diets high in fat contribute to obesity, thus creating another risk factor. Certainly reducing fat, specifically animal fat, will assist with reduction of both total cholesterol and obesity. (See Table 2 for blood cholesterol levels.)

Recommendations of the Adult Treatment Panel of the
National Cholesterol Education Program for Classification of Patients

>240 mg/dL (>6.21 mmol/L)
High Blood Cholesterol

>160 mg/dL (>4.13 mmol/L)
High Risk LDL-Cholesterol

Source: NCEP ATP

Diabetes Mellitus
Atherosclerosis is correlated with the glucose intolerance associated with diabetes. This occurs partly because of alterations in carbohydrate and fat metabolism. This may result in direct damage to vessel basement membrane with the elevated blood glucose. The incidence of atherosclerosis is higher among those with diabetes mellitus than the general population. Individuals with diabetes mellitus are also more likely to have other risk factors such as obesity, hypertension and elevated serum lipids. These risk factors appear to act in synchrony to increase plaque formation.

Obesity
Obesity is defined as an excessive accumulation of fat on the body. When one is 20% - 30% over average for height, weight, and body structure, this creates a problem with respiration and circulation. Abdominally distributed obesity seems to be especially highly correlated with atherosclerosis. Closely associated with obesity are hypertension, hypercholesterolemia, elevated triglycerides, increased blood glucose levels, reduced carbohydrate tolerance, sedentary lifestyle, and reduced HDL levels.
As you can see, reducing weight may bring other modifiable factors under control as well. The added strain on the work of the heart requires increased circulation to the coronary arteries. As a result, the heart receives two insults from obesity: increased work and blocked arteries.

Diet High in Saturated Fat
Another factor related to cholesterol and obesity is a diet high in saturated fat. Saturated fat is dietary fat derived primarily from animals. It is present in meats, dairy products, coconut oil, palm oil, chocolate, nondairy whipped toppings and coffee creamer. Saturated fat contributes significantly to increasing the LDL levels of the blood cholesterol.

Elevated Serum Triglycerides
Even though elevated levels of triglycerides in the blood are not an independent risk factor in CAD, there is an indirect association of triglycerides with atherosclerosis. It is thought that a diet high in saturated fats, sugar, and alcohol contributes to elevated triglycerides. Again, obesity is an interacting modifiable factor. Triglycerides are divided into two categories: Type IV and Type V. Type IV triglycerides are manufactured by the body; Type V are triglycerides consumed in the diet, and include those manufactured by the body by conversion of fat.

Lack of Exercise
Effects of immobility are well known to the nurse caring for the sick person. The circulatory, respiratory, endocrine, and gastrointestinal systems are especially affected. If these same consequences are transferred to a person already having risk factors for CAD, the problems are enhanced greatly. Obese, smoking, and inactive persons are at greatest risk. Physical inactivity may decrease HDL levels, collateral circulation, and vessel size. It will also increase total cholesterol levels, glucose intolerance, body weight, and blood pressure. Even a small gradual increase of exercise will benefit the biological systems greatly by reversing these changes.

Oral Contraceptives
In some women, oral contraceptives will increase blood pressure and thrombus formation. These factors need to be considered when determining the use of these drugs, especially for women who have a history of thrombophlebitis. Women who smoke are at higher risk when taking oral contraceptives. The doses of estrogen have been reduced in the current formulations of these products; therefore, the risk might have been reduced slightly. However, there are no recent prospective studies to determine the current risks.

Stress
Stress and personality factors, such as "Type A" behavior, have received considerable public and professional attention for the past twenty years. Even though early studies showed a higher incidence of death due to myocardial infarction in "Type A individuals," more recent studies showed a lower rate than in those not considered to be "Type A." Type "A" behavior is characterized by aggressiveness, ambitiousness, hostility, competitiveness, and a sense of urgency. Because the characteristics are multiple, it is often difficult to measure these objectively. Anger and hostility may play a greater role for clients at risk for CAD. Stress results in the release of endogenous catecholamines that contribute to the workload of the heart and the entire cardiovascular system. The rushed, stressed person may also not be inclined to exercise and eat well. Many stressed people tend to smoke and are hypertensive. For more information on this subject, order course #478 "Anger Kills."

Strategies for Effective Patient Education

The goal of health promotion is to encourage individuals to take responsibility to improve their health. A high level of wellness can be achieved by all ages, the chronically ill, and the disabled, as well as everyone else. The nurse needs to keep this in mind as she develops the most effective strategy for her area-based client population.
The public is increasingly more aware of health promotion as seen in the media, schools and community programs. This should have a positive effect on individuals taking charge of their own health. Unfortunately, even with all the information, this is not true for many. The nurse is continually challenged by persons difficult to motivate to achieve goals mutually set. The client, too, is challenged by the different, and sometimes conflicting, information from the media. The news will often include a report of a study just completed that refutes information reported earlier. Studies on the effect of cholesterol and sodium in the diet are often conflicting. Sometimes these reports are from a small study and have not been reviewed by other experts or the American Heart Association. The damage may already be done as the client believes the news report. The nurse will need to keep aware of the new reports and help the client with sorting through this information as it affects him. The AHA consensus panel of experts is a good source of information for the nurse.
Although client education is the best place to start, simply providing information is not the only solution. The education you provide must also include strategies for motivation and materials the client may use at home. Today, nurses have access to video materials, excellent written materials, and information about community-based programs. With these resources, the nurse may plan accordingly.
Utilizing the nursing process, the framework will include: assessment of need for education; assessment of readiness; planning and developing an individualized program; implementation of the program; and documentation and evaluation of the patient education. Probably the assessment of readiness is the most difficult for the nurse. All the great programs in the world will not be effective if the patient is not ready to learn. The assessment includes:
(1) awareness of risk factors and/or diagnosis
(2) previous knowledge and experience
(3) intellectual level
(4) motivational level
(5) physical condition
(6) psychological state
(7) perceived need to learn.
All factors take time to assess. Therefore, a one time interview and plan probably will not be effective. The time the nurse spends with the patient over the long term will greatly influence the success of the educational plan.

The Adult and Elderly Learner
Working with the adult learner is usually characterized by focusing on developing the individual's own goals. Adults want to know why they need to learn something new and often will enjoy the learning sessions. However, they come to the situation with a great deal of life experience, set habits of tastes, some amount of pride, many preoccupations (i.e., work, family, worries), and a desire to learn things they can use now. Adults have the ability to change, but sometimes find it difficult. The nurse who is sensitive to these characteristics will be the most effective.
Generally, adults learn better in small groups or a workshop environment. The nurse who sees herself as a facilitator, and utilizes the participant as a co-teacher and co-learner, will be the most effective. As the nurse asks the client for suggestions and effective strategies used by the client to make lifestyle changes, the adult will become a more eager participant. Effective strategies for specific risk factors will be discussed later in this study.
Working with the elderly client may present other challenges. However, it is important to take into account the changes of aging that will affect the learning of your client. Some of the physiological changes will impact the ability to participate in classes. Older clients will fatigue more easily than younger ones. Providing frequent breaks will help compensate for this. Because of the decrease of lean muscle mass, and increase in subcutaneous fat with aging, sitting in uncomfortable chairs will become painful. Your older clients will be more comfortable in padded chairs with armrests.
If you are working with the older client on an exercise program, you need to take into consideration the changes in cardiovascular and respiratory changes of aging. Slowing heart rate, decreased stroke volume and decline in cardiac output are normal changes of aging. Decreased function also occurs in the respiratory system. Vital capacity is lost, and lung tissue loses its elasticity. These changes affect the client's energy level, strength, and speed. As a result, endurance will be affected. Although many older adults have remarkable endurance, this needs to be taken into consideration. If the client is too fatigued after these exercise sessions, motivation may be lost and the client discouraged about continuing the program. Other considerations regarding the elderly are sensory changes. Vision changes include loss of the lens' ability to accommodate as it becomes less elastic, larger, and more dense. Loss of visual acuity is common. Glare is a serious problem, and loss of peripheral vision may affect many. It is important then to use teaching materials that have large print and good color contrasts. Check the lighting in your classroom to minimize glare. A sheer curtain over the outside windows may help reduce glare, and incandescent lighting is better than fluorescent lighting. The loss of peripheral vision may impact your client's ability to interact with others in the group, as they may not be aware of the persons sitting next to them.
Hearing loss is very common. High pitched sounds go first, but with aging, the sounds in the middle and lower ranges are lost as well. Word sounds are distorted, especially if there is background noise. Clients with presbycusis will need more time to process the information. It is important for the nurse to speak slowly and distinctly and face the client directly. Speaking with a lower pitch will also help your client.
It is important to take a holistic approach to assessing changes associated with the aging of your client. In addition to assessing the physiological changes previously discussed, psychological, sociological and cultural dimensions must be assessed. Research is conflicting on the cognitive changes of aging, but some elderly do have problems with short-term memory. With this problem comes fear and anxiety that they are "losing their minds." The resulting anxiety may impact their ability to learn more than the actual lost of memory. The important concept is the attitude of both the client and the nurse. It is easy to get discouraged. However, if the appropriate pace and teaching strategy are used, this problem is not insurmountable. Using written materials, lists, and calendars for appointments are all good ways to assist the client. The important variable is interest. Most of us remember what is important to us. Meaningless trivia is soon forgotten. The good news is that more complex intellectual abilities increase with age, and this should be emphasized.
Cultural aspects will impact strategies used by the nurse. It is important to assess these differences. The nurse needs to be sensitive to these differences when assessing nutritional needs, exercise and other aspects of lifestyles. Attempting to change activities in ways contrary to tradition will probably be unsuccessful and can influence other aspects of the plan. Working with, and not to, the client is the key word.

Principles of Teaching/Learning
The principle, "learning takes place when behavior is changed" may help guide you when planning, implementing and evaluating your teaching plan. However, it is important to understand the learning process. It is multifaceted and sometimes complicated.
Learning can be categorized into three broad types: cognitive, affective, and psychomotor. The cognitive part is the body of knowledge that the learner is grasping. The affective is the emotional response to the learning situation. The psychomotor includes the skills or actions the person takes with new knowledge. Therefore, it is important that the nurse plan and evaluate all aspects of the teaching session to be clear that the person has internalized the information, has accepted it, and has followed it with a change.
The categories of learning must be used as the nurse and the client establish short- and long-term goals. The goals are used by the nurse to evaluate the effectiveness of the plan. If the goals address only the cognitive aspects of learning, the effect on attitudes and action will not be known.
As you work with the client, you should see evidence that the client is problem solving by using critical thinking regarding improvement of their health. The nurse who models the strategies she is teaching will be the most effective. As the client sees you using creative and critical thinking skills, he will gain the ability to use them, too. Social learning theory is a model of behavioral change most commonly cited as an effective strategy for CAD clients. It utilizes behavioral, cognitive, and environmental factors in the plan.
Social learning theory emphasizes the importance of self-efficacy as the focus of behavior change. Self-efficacy is a "person's assessment of his or her ability to organize and execute a course of action to attain a designated type of performance." This relates to the person's confidence that they will succeed.
Self-efficacy is influenced by four factors:
(1) information and persuasion
(2) observation of others
(3) successful performance of the behavior
(4) physiological feedback
Information and persuasion from the health care professional that the person respects will have the strongest influence. The professional will need to help the person focus on the most important aspects of the learning that needs to take place. The expectations of the health care professional will strongly influence the behavior of the client.
The observation of others with similar risks can have a strong social effect on the client. Cardiac rehabilitation classes have already served as a support group for persons participating in the classes. Those who have been in the program and have benefited by the results will encourage the newcomer. The new person in the cardiac risk classes will look to the others who have succeeded as role models.
Unfortunately, many look to past failures at losing weight or quitting smoking as an obstacle for future success. The nurse will need to focus on different ways that the client can succeed with the new behavior. Ask the client to review what they did previously that was unsuccessful, and help him develop a different plan.
There is nothing like objective, concrete laboratory work to encourage a patient. As the person sees changes in cholesterol level, lower blood pressure, or better treadmill exercise test results, the motivation to continue the program will be enhanced.
The components of successful programs noted in clinical research and the experience of those engaging in these programs are:

• positive, accurate expectations about results
• precisely defined behavior change
• realistic goals
• contracting
• prevention of lapse and relapse
• modeling
• prompting
• feedback
• problem solving
• rewards
• social support

Each of these components will be discussed later in this study with strategies for risk management.

Motivation for Lifestyle Changes
Hans Selye, known as the father of stress, once stated that if you can laugh fifteen times a day it will relieve stress. Having a positive outlook and a good sense of humor will help the nurse and the client achieve the goals set for reducing the risk of heart disease. Achieving the motivation and maintaining it to make significant life-style changes are probably the hardest tasks that individuals have.
It is known that a habit begins with small thread but forms a cable impossible to break. A person will not work on breaking that cable unless they can see the benefits. Therefore, the first step is personal motivation. The clients should be encouraged to view themselves and the necessary changes in a positive light.
The nurse needs to develop a plan, following her assessment of the client, that is individualized and hopefully effective for that person. First, the nurse needs to seek to understand what the patient wants. This can be done by using open-ended questions. Ask the patient to describe the goals or anticipated outcomes of the lifestyle changes. After these goals are elicited, the nurse will need to show personal interest in the client and continue to offer encouragement. Even during times of failure, the nurse can be a great support in helping the person to put the failure behind them and move forward.
Another positive approach to motivation is the warmth and good feelings that the client gets from the nurse. If the client views the nurse as a problem-solver and a resource, these feelings will continue.
Finally, the nurse will need to get a commitment from the client to pursue the goals set. You may need to ask the client, "Why not?" - just to get them thinking about this commitment. As the old habits are replaced by the new healthy habits, the person will begin to feel better and move toward the goals.
Ultimately, motivation lies solely with the client. The nurse plays a strong role in encouragement, but the motivation must come from within. Some strategies to share with the client include: meditation, vivid guided imagery, positive self-talk, and a sense of humor.
Daily meditation, or reflection, gives the individual a chance to get hold of his thoughts. Meditation can take the form of just sitting comfortably in a quiet place, away from distractions for at least 10 minutes. It is a time to clear the mind and try to dispel any worrisome thoughts. The person will need to remind himself to remove these stressful thoughts using statements such as, "I'll worry about that later." - and channel these thoughts into a problem solving method. Some find that reading Scripture or meditation materials can help with the reflective process. Since many of your clients are probably stressed, they may find meditation difficult. Encourage them to give it at least a three-week trial.
Vivid guided imagery is another technique that may help the person with motivation. This involves the person visualizing himself as he will be later, after successfully meeting his goals. Sometimes, the imagery needs to be very vivid such as the person imagining the grease dripping from the fried chicken he had planned to eat.
Another strategy is positive self-talk. Encourage the person to use language. "I am healthy, I enjoy my life, I want to feel good" are examples of ways for the person to speak to himself.
Again, a sense of humor will be the strongest asset you and your client will have. Norman Cousins demonstrated well the power of laughter in restoring one's health.

Effective Programs to Promote Wellness
The most effective health promotion programs include both educational and personal counseling. These programs provide individual and group support for the client at risk of CAD. The participants work with a variety of health professionals in a team approach to gain control of the health problems that lead to atherosclerosis. This team consists of the physician, nurse, dietitian, psychologist, and exercise specialist. A nurse practitioner who specializes in cholesterol management is often utilized. A structured program is usually necessary to accomplish these changes.
An example of one such program is HeartAction, sponsored by the Heart Institute of Spokane, Washington. This program begins with an individual session with a nurse to measure and discuss each risk for heart disease. A personal action plan is then designed to change those risk factors. Laboratory tests and medical histories are included. During the fourteen weeks of support the following occur:

• Communication between the program nurses and primary physician to determine the right approach for each person's needs
• Personal coaching by a nurse over the period of the program to create a high likelihood of reaching personal goals
• Heart healthy nutrition classes by a registered dietitian
• Help with smoking cessation through a personal plan or referral to a special class
• Stress management classes to support a healthy new lifestyle
• Exercise program provided by a cardiac rehabilitation program, or a home exercise prescription, and
• Physician-guided management of related conditions such as diabetes, high blood pressure and cholesterol disorders.

The clients are referred to the program by their primary health care provider who remains in control of all aspects of the patient's care. Eligibility is determined by the risk factors the patient exhibits. The guidelines for referral include:
(1) person with total cholesterol > 240, or
(2) HDL < 35, or
(3) total cholesterol 200-239 with two or more risk factors,
(4) have lipoprotein analysis and
(5) further evaluation.
The program serves patients with, and without, coronary artery disease. Persons without a diagnosis of CAD should have two or more risk factors and LDL < 130.
After a person has completed the yearlong program, he is referred to other community resources to assist with maintaining the lifestyle changes. The lipid disorder management continues after the fourteen-week course is completed. Please see Table 3 for the HeartAction flow chart to summarize this program.

Table 3 Heart Action Flow Chart

Managing Risks: Strategies for Success

The success of an effective risk management program begins with a careful assessment of the client. An overall risk assessment is done, which includes modifiable and non-modifiable risks. Then, a program of action is planned with the client's needs in mind, focusing on modifiable risks. The nurse will be able to access available assessment tools. An example of a tool that the client can complete is included in Table 4.
Once the assessment is completed, a multidisciplinary approach is used. The nurse as a case manager, or patient educator, usually is the coordinator for this approach.
Modifiable risks will be discussed, including a strategy for each. Some strategies may be used for all risks, but this study will be divided by risks to enhance the most effective for that risk. Since most of your clients will have more than one risk factor, a combination of strategies will be used.

Calculating Heart Disease Risk

Weight

Smoking

Hypertension
Education for this person will include important ways to control blood pressure. The client will need to have blood pressure checked often, and be encouraged to keep the records to create the self-efficacy needed to gain results. The client may have a friend, or family member, or someone at the local grocery store or community center, take their blood pressure. This way, the client is accountable to the plan. The client should, however, have a consistent plan and have the blood pressure taken at the same place, same time of day and in a reclining position.
Additional education will include dietary changes. Although 40% of the population are not affected by sodium, 60% are. Therefore, it is beneficial for the client to reduce their intake to 2500 milligrams per day. This can be accomplished by teaching them to read nutritional labels on packaged food and by decreasing the amount of salt added to the diet. Omitting highly salty foods, and refraining from adding more salt after the food is prepared, will help. Note the amounts of sodium in Table 5.
Canned tuna fish illustrates a significant observation from that table. If the tuna is packed in oil it has 1280 milligrams per serving, compared to 69 milligrams in water packed tuna. It is noted that meat high in fat is often high in sodium.
For the client on antihypertensive medication, the nurse will teach about the drug, especially side effects, toxic effects, and how to observe and report any untoward reactions. When most clients don't "feel" any different with hypertension, they are prone to skip dosages or stop taking the medication without notifying their health care provider. The nurse needs to stress the importance of taking the drug as prescribed, and report any undesirable side effects or untoward effects before stopping or altering the dosage. An effective strategy regarding medication is to have the client keep a chart of all medications taken. This chart includes:

• a list of the drugs (including non-prescription drugs
• the reason for taking the drug
• dosage and timing of the drug
• special instructions (i.e. "take with food or milk")
• side effects
• treating side effects (i.e. call Dr. if blood pressure is below l00 systolic and 60 diastolic).

The client should be encouraged to take this list of medications to the physician(s), or nurse practitioner(s), who are prescribing the medications. In addition, the nurse case manager or educator should review the list to be sure the patient understands the monitoring of the medication. An example of a chart is included the American Heart Association booklet, "An Active Partnership for the Health of Your Heart." Community-based programs for education often use these booklets, and each client will have his own copy as a workbook. An effective component of a successful program to reduce blood pressure will be prompted. The prompts used are to remind the person to check nutrition labels, have blood pressure taken at regular intervals, and using the medication chart, will help the person be successful. Many place their calendar or notes on their refrigerator. If the nurse is the one monitoring the blood pressure, a phone call to the client may be the prompt.

Smoking
Addiction to cigarettes is both physical and psychological. The breaking of this dependency requires extensive work for the individual. A referral to a smoking cessation class may be the nurse's best option for the client. In this class the person will have positive, reinforced action steps to curb the addiction.
However, not all choose this form of help. If one chooses to break the habit, there are steps the nurse may share. The education part includes: the physical urge to smoke; feelings of being deprived; and the brain's programming to think "cigarette" at certain times of the day.
Physical symptoms may include light-headedness, sleepiness or headaches for a few weeks. The physical urges will begin to be farther and farther apart. The client may be encouraged to time the urge to smoke and will note that at first, they last about a minute, then get shorter.
Initially, the client may feel deprived because he used the cigarette as a time for relaxation or reward. Encourage the client to take positive action with exercise or relaxation techniques. Unfortunately, many substitute high calorie food as a reward. Encourage the use of low calorie snacks or gum. The client is urged not to grow too hungry. Three small meals with three snacks planned throughout the day may help. This way the person is eating something every three hours.
The programmed smoking habit is difficult to break. One hint by former smokers is to plan activities at those particular times when one used to smoke. Since exercise is a requirement of a successful smoking cessation program, taking a walk during a coffee break may accomplish two goals. Encourage the client to remember that he is in control, and that he can change his habits. Others close to the client can help by not smoking, and by making the home or workplace a non-smoking environment.
If the person is using the nicotine patch or gum, the nurse will need to educate the person about the use and abuse of this drug. Unfortunately many smokers become dependent on the patch or gum. Caution the client to use the medication only when he has quit smoking completely, and to never mix it with cigarettes.
The use of contracts may be an effective strategy to prevent relapse. The contract needs to have the following components:
(1) a realistic and specific goal, (i.e. "I promise that I will remain a nonsmoker for the next year")
(2) a plan if there is a relapse
(3) signatures of the client and a witness.
The contract helps the client become accountable and will reinforce the goal.
Together with contracting, the strategy of relapse prevention may help. Many abstinent clients who relapse justify continued smoking by telling themselves that since they already failed in the attempt to quit, they might as well keep on smoking. A relapse prevention program involves preparing the client to cope with the lapse from a good habit to a bad habit.
During relapse prevention training, the person is taught to identify the situations or feelings that lead to the lapse and learn and practice skills to cope with the situations. Relapse prevention programs may need to be conducted by professionals trained in this special technique.

Elevated Serum Cholesterol
The major education done for this risk factor is a change in diet. If a person with elevated serum cholesterol needs to reduce body weight, a planned nutritional program, directed by a dietitian, may be needed. However, the nurse may also help with this plan.
Your teaching regarding the source of cholesterol in the diet is essential. Approximately 60 to 70% of cholesterol is produced by the liver and intestines, and the remainder is eaten. The client should be encouraged to eat less than 200 milligrams of cholesterol a day. Since cholesterol comes from saturated fat, the person should be encouraged to read nutrition labels on prepared foods. Nutrition labels include both saturated and unsaturated fat. The client should be encouraged to have less than 25% of the fat calories come from saturated fat. Note: Use Tables 5 and 6 as teaching tools.

Since not all food, such as meat, has a nutrition label the following tips may help:
(1) Eat only lean beef, fish and poultry, not to exceed six ounces per day. (Three ounces of meat is about the size of a deck of cards).
(2) All obvious fat should be trimmed, and all skin of poultry removed before cooking.
(3) Steam, boil, broil or bake.
(4) Limit egg yolks to three per week, including use in cooking.
(5) Avoid organ meats such as liver, heart, kidney, or brains.
(6) Use skim milk products including ice milk and fat-free yogurt.
(7) Use cholesterol-free oils such as canola, olive, or corn.
(8) Choose margarine that has twice as much polyunsaturated fat as saturated fat.
Encourage the client and family members to use cookbooks that include variations for reducing fat in the recipes. If your client does not do the shopping and/or cooking, be sure that the person who does is in the teaching sessions. Successful programs include family members, or significant others in the classes.
Eating out may present a problem for your client. Fortunately, many restaurants offer "heart healthy" menus. Tips include asking for salad dressing "on the side" to control the amount, or using a low calorie dressing. Many find they can eat bread without butter or margarine. Once a person has become accustomed to low-fat cooking, high-fat foods may not taste as good as he remembers.
Feedback may be an effective strategy for reducing cholesterol in the diet. Lab results of lower cholesterol levels will be a great reward for the client. Another component is positive, accurate expectations about results. As you set goals together for dietary changes, plan to check blood cholesterol in three months so the client will see the benefits of lifestyle changes in a concrete way.

Use the Food Guide Pyramid to help you eat better every day...the Dietary Guidelines Way. Start with plenty of Breads, Cereals, Rice, and Pasta; Vegetables; and Fruits. Add two to three servings from the Milk group and two to three servings from the Meat group. Each of these food groups provides some, but not all, of the nutrients you need. Foods in one group can't replace those in another. No one food group is more important than another is - for good health you need them all. Go easy on fats, oils, and sweets, the foods in the small tip of the pyramid.

How Many Servings Do You Need?

The Food Guide Pyramid shows a range of servings for each food group. The number of servings that are right for you depends on how many calories you need. Calories are a way to measure food energy. The energy your body needs depends on your age, sex and size. It also depends on how active you are. In general, daily intake should be:

• 1,600 calories for most women and older adults;
• 2,200 calories for kids, teen girls, active women and most men; and
• 2,800 calories for teen boys and active men.

Those with lower calorie needs should select the lower number of servings from each food group. Their diet should include 2 servings of meat for a total of 5 ounces. Those with average calorie needs should select the middle number of servings from each food group. They should include 2 servings of meat for a total of 6 ounces. Those with higher calorie needs should select the higher number of servings from each food group. Their diet should include 3 servings of meat for a total of 7 ounces. Also, pregnant or breastfeeding women, teens, or young adults up to age 24 should select 3 servings of milk.
The amount of food that counts as one serving is listed. If you eat a larger portion, it is more than one serving. For example, a slice of bread is one serving, so a sandwich for lunch would equal two servings.
For mixed foods, estimate the food group servings of the main ingredients. For example, a large piece of sausage pizza would count in the bread group (crust), the milk group (cheese), the meat group (sausage) and the vegetable group (tomato sauce). Likewise, a helping of beef stew would count in the meat group and the vegetable group.
Adapted from the Food Guide Pyramid, Home and Garden Bulletin Number 252. U.S. Department of Agriculture, Human Nutrition Information Services.

What Counts As A Serving?

Diabetes Mellitus
If your client has diabetes mellitus, a careful assessment will need to be done to determine whether they have accepted the condition, and are working with a health care professional for management. Unfortunately, many diabetics increase their risk for CAD because they have not been able to comply with the regimen of exercise, nutrition, and medication. In addition, many non-insulin dependent diabetics are overweight, adding another risk to the list. The nurse will be a source of education and motivation for the client. Information that the client must have includes:

• knowledge about the disease
• dietary management
• medication administration
• prevention of complications
• methods for monitoring blood sugar and exercise maintenance

This may be overwhelming at first. Many communities now have "diabetic schools" that include education for longer periods. If your community has one, this would be a good referral. A new diabetic will need to deal with this prior to managing other risks. Fortunately, effective diabetic control usually means good cardiovascular risk control.
Social support is often an effective strategy to use. Family and friends may be especially supportive if they, too, are educated about effective diabetic management. The client may also use the "buddy system" with another diabetic to help with compliance. The nurse may need to caution the support people not to be negative, but encouraging.

Obesity
The same knowledge that the person has gained on dietary changes for reducing cholesterol will be utilized with a weight reduction program. The principle of reducing fat intake will lead to significant reduction of weight in most obese clients. However, it will be important to reduce both fat and sugar to accomplish the goal.
Unfortunately, many prepared products that advertise low or no fat have increased sugar in the product. The client will need to have this knowledge when choosing a diet plan. Most obese clients do better in a supportive environment and often do well in groups that help them plan, cook, and shop for food. Your client will need to be evaluated for calories needed to sustain a one to two-pound weight loss each week. The individual will need to be cautioned about fad or crash diets that cause fast weight loss, as usually the weight returns easily.
An effective way to plan the diet to lose weight is to determine the number of calories needed to sustain a weight loss. Then, use the food pyramid as a guide, and a food exchange list to plan each day so that a goal can be reached. See Table 6 for the food pyramid. The person should choose the lower number of servings on the pyramid to achieve weight loss. The food exchange list will determine the size of portions the person should eat. How does a person know how many calories to eat to safely reduce the weight? The American Heart Association has developed a formula to help determine the ideal weight for that person. From this you can calculate your daily fat gram allowance that will help you with the weight loss. The formula can be found in Table 7. As most plan this type of diet, it becomes evident that the bulk of calories and fat comes from meat. A lifestyle change that needs to occur is thinking of meat as a condiment rather than the main part of the meal. This is a significant change. Eating only six ounces of meat a day will be much less than previously eaten. The increase for most people will be eating three fruits and vegetables each day. The increase of grains found in bread, cereal, and pasta, for example, will compensate for the person's perceived loss of meat.
Although the nutrition labels help with choosing the right food, the client may need a nutritionist to help with selecting and planning meals that suit individual and cultural needs. The nutritionist may suggest eating three small meals and three snacks a day to prevent the hunger that is sometimes associated with lowering calories. The client will be encouraged to eat approximately every three hours.
Strategies that help with weight loss include social support, rewards, and defining realistic goals. The support received from others who are trying to lose weight is effective. Overeaters Anonymous and Take Off Pounds Sensibly (TOPS) have been noted for helping to reach and maintain goals. Many overweight people use food as a reward or comfort. The nurse might suggest a new outfit as a reward and encourage the person to follow through with this reward. Initially, the client needs to set realistic goals. The goal needs to be attainable and not something that they "wish" for themselves. People who believe they need to look like the models in magazines are setting themselves up for failure. The nurse or nutritionist is important in setting a goal of sensible weight for the person's height and age. After the client has maintained that goal for a while they can always reset it.

Formula for Calculation of
Fat in Diet

Diet High in Saturated Fat
Even though the person may not be overweight, the diet may still be too high in saturated fat. Knowledge regarding the use of polyunsaturated fat can be the most effective. The recommended ratio of polyunsaturated to saturated fat is 2: l. The use of saturated fat has probably occurred because the person depends upon beef as his primary source of protein. By changing to lean beef, poultry, and fish the person may be able to attain this goal.
Tips that will help the person who has difficulty giving up foods high in saturated fat include:
(1) Trim off visible fat; broil or barbecue, and skip the gravy;
(2) Make stews or soups that contain meat, chill overnight, and lift off the fat before you reheat and serve;
(3) Use Teflon pans and/or nonstick spray;
(4) Don't force yourself to eat all the meat in a restaurant; take some home for the next day.
The individual may know that meat is high in saturated fat, but may not know that dairy products, coconut and coconut oil, palm oil, chocolate, nondairy whipped toppings, and coffee creamer are also high in saturated fat. Again, remind the client to read nutrition labels (Table 5) and if the ingredients contain lard or animal fat, these are high in saturated fat. This is one risk factor that can be greatly modified by education and reinforcement. It will be important to give written material to the client so that he will not be confused on reading labels. The information in Table 5 may be useful for your client.

Elevated Serum Triglycerides
The person with elevated triglycerides usually has a diet high in saturated fats, alcohol, and foods rich in sugar. Therefore, the previous discussion should also apply to this risk. If one will reduce sugar and concentrated sweets, the triglyceride level should drop. Encourage the client to read nutrition labels (Table 5) and note the total carbohydrate section. The sugars should be less than 50% of the total carbohydrate in the serving portion. The example in Table 6 is an excellent one because the sugar is less than 25% of the total carbohydrate. Breakfast cereal is a good example to compare, because many contain more than 50% of the total carbohydrate. The principle is that complex carbohydrates are better than simple sugars, as it takes more energy to burn the complex carbohydrates. Also, caution the client to read the serving size on the nutrition label. Many believe that the facts belong to the whole container.
The use of alcohol should be minimal. If triglyceride level is very high it should be avoided completely. Since sugar and alcohol may be difficult to give up, the client will need social support and encouragement in this area. The good news is, if the obese client is successful with weight loss, the triglyceride level should drop, too.

Lack of Exercise
The change from sedentary to an active lifestyle has positive effects on many people. Not only do they feel better, but it also helps with the other risk factors. Diabetics who exercise have better control of their condition. The person who is trying to lose weight, or stop smoking, will find that increased exercise helps. In addition, exercise offers a social outlet with others, which will reinforce improved behavior. Before starting an exercise program the individual should be evaluated for cardiac function. This is often done by a treadmill stress test. This will guide the health care professional with a prescription for exercise. If the person is obese and sedentary, a professional who specializes in cardiac exercise can recommend the appropriate exercise plan.
If the person can participate in a class with others with the same goal, he will often be more successful. Or, the exercise counselor can help the person develop his own plan at home. Most exercise programs encourage a warm-up time with stretching of muscles. This is followed by about 20 to 30 minutes of aerobic exercise, which involves motion and the use of large muscles. Aerobic exercise is recommended three to four times a week. For a sedentary person, walking is usually the first point of exercise. As the person improves, the pace is picked up and time extended. The sedentary person is cautioned to challenge himself, but not to the point of exhaustion. Other aerobic exercise includes jogging, swimming, exercise bicycle, treadmill, and cross country skiing. Obviously, the client is encouraged to build up to more strenuous activities. Pushing oneself, and being too competitive, defeats the purpose of exercise and may be unsafe for the individual. The exercise must be enjoyable for the person to continue.
Isometric exercises are also encouraged. These exercises include the use of weights and resistance. This should be prescribed by the fitness counselor to ensure the increase in activity or light weights is correct. For example, when lifting a weight, one should exhale to prevent the Valsalva maneuver, causing increased strain on the circulatory system.
Contracting may an effective way to accomplish the goal of improved exercise. The person will agree to set a specific goal and commit to the program with others. The contract may state exactly what he will do each week (i.e. "I will walk 20-30 minutes 5 days a week"). In addition, the contract will state that he will record the exercise in a log. The contract should include what the person will do if they do not exercise. The exercise plan may be reinforced by lab reports of lowered cholesterol and higher HDL's.
It is important that accurate expectations be communicated to the client. Clients abandon programs if their expectations exceed the perceived benefit. Some clients expect sudden and major changes from the beginning of an exercise program. It may be beneficial for the client to observe others who have been in the exercise regime for several years and discuss their experiences. Seeing others model the behavior may help the client and alleviate concerns about how to go about a change.

Stress
As the client begins the program, he will be asked to evaluate the stress in his life. Since this is subjective the client is the best one to identify his own level of stress. He may be encouraged to take a self-inventory test that identifies stress-related behaviors. At the conclusion of the program, he should again review to determine his progress. The nurse plays a role in helping the client determine the stressors and plan goals accordingly. Some of the education that the nurse can offer includes teaching relaxation techniques; educating about the negative effects of anger and hostility; helping the client with problem solving skills; and helping the client refocus to change from old habits to new heart healthy habits.
The most effective strategy is helping the client with problem solving. It will help the client overcome barriers and difficulties with behavioral change. When nurses have been educated to use the nursing process they are skilled in the steps of problem solving. As the nurse helps the client identify the problems in concrete terms, explore possible solutions, and then identify a plan to implement these solutions, the client then takes control of the situation. Next, the nurse helps the client evaluate the plan as he implements it. Anger and hostility are life long habits and may be difficult for the client to break. The nurse should positively reinforce even small changes.

Alternative Treatments

Vitamin B3 (nicotinic acid or niacin): Nutrition-oriented doctors have found the medical applications of Vitamin B3 to be both dramatic and diverse. In relation to CAD, three to six grams a day of niacin can lower serum cholesterol and triglyceride levels. In addition, niacin therapy often increases HDL-cholesterol (the "good" kind). Despite the obvious benefits, niacin is not prescribed too often by doctors. It is not always necessary to use such large doses to achieve the desired effect. In a study of 72 patients with heart disease, niacin in amounts less than 1,000 mg/day increased HDL levels, while doses averaging 1,300 mg/day decreased serum cholesterol by 11%. These lower doses are less likely to cause side effects, such as skin flush, than the higher quantities that are prescribed.
Another report suggests that even smaller daily amounts of niacin (100 mg) can lower cholesterol if the trace mineral chromium (200 mg) is taken at the same time.
Chitosan (pronounced "kite-o-san"): According to W. Edward Hanks, M.D., graduate of UC Irvine Medical School, board-certified in internal medicine and cardiology, Chitosan is a new, absolutely unique product that works like a magnet, literally pulling fat and cholesterol from the digestive tract and carrying it away before it can be metabolized by the body. It is an all-natural fiber taken from the exoskeleton of shellfish. The basic concept behind Chitosan is this: if you can tie dietary fat to fiber, it will go along for the ride with the fiber, passing through the body rather than being absorbed. Unlike resins, gums, and fibers that passively prevent fat absorption, Chitosan actively attracts and attaches anywhere from 3-12 grams of fat per gram of fiber. It has proven effective in lowering levels of harmful LDL cholesterol while boosting levels of beneficial HDL cholesterol. According to the American Heart Association, "Prevention of fat is the best way to reduce disability and death from cardiovascular diseases and strokes. Excess weight, dietary sugars and cholesterol are the three biggest contributors to heart disease."
CoQ10 (coenzyme Q10): Basic nutrient, powerful healer. One of the great tragedies of modern medicine is that doctors continue to ignore CoQ10, a nutrient that, if used properly, would relieve the suffering of millions of Americans (especially heart patients). CoQ10 is a vitamin-like compound that occurs naturally in our bodies. We obtain some from food, but most is manufactured within the body from raw materials. It is an essential component of one of the most fundamental biochemical processes in living beings: the converting of fuel into energy. CoQ10 performs this function by catalyzing the production of ATP, storing energy for later use. Increasing amounts of supplemental CoQ10 promote healing in tissues that use a lot of energy: specifically the heart muscle, and cells of the immune system. Studies in Japan show dramatic value to heart patients; other studies have shown that it effectively lowers high blood pressure.
Flaxseed: Hippocrates extols the medicinal virtues of flaxseed in his writings, and Mahatma Gandhi asserted that "wherever flaxseed becomes a regular food item, there will be better health." Few herbs have been held in such high esteem by so many cultures through so many eras. The popularity of flax and why its fame prevails is confirmed by contemporary research.
Essential Fatty Acids (EFAs) are the primary nutritional constituents of flaxseed. The two key EFAs are linoleic acid, also known as LA or Omega 6, and linolenic acid, a.k.a. LNA or Omega 3. These two fatty acids are essential, meaning we need them but are unable to manufacture them; therefore, they must be supplied by the diet. A fundamental aspect of EFA activity is its ability to metabolize fats. This is due, at least in part, to EFA's oxygen-attracting properties. By bringing more oxygen into the body, metabolic processes increase in speed and function. This, in turn, results in an increase of the fat burning and fat utilization processes. Increasing body levels of the "good" fats results in a natural decline in the body levels of "bad" fats, including artery-clogging LDL cholesterol.

Summary

Nurses play a big part in managing the risks for coronary artery disease. As the nurse identifies the risk factors with clients she becomes a pivotal person in the success of planned intervention. By using the skills identified in this study of goal setting, contracting, relapse prevention, modeling, prompting, feedback and problem solving, the nurse will help the individual with lifestyle changes that promote healthier living. The scientific information the nurse may share with the client will reinforce the importance of changing the behaviors that often lead to coronary artery disease.

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