Cardiovascular Disease as a Global Burden

Discuss about the Cardiac Nursing for Premature Cardiovascular Disease.

Cardiovascular disease is a great burden worldwide and it is now recognized as the leading cause of death in the world. According to a review on cardiac disease burden worldwide, it has been found that 32% of global death in the world has been caused due to cardiovascular disease. The number of lives lost due to heart disease is increasing more rapidly in low and middle income countries and there is a need to control regional variations in the diagnosis of heart problems and the mortality associated with it. In response to high health care cost and disease burden of cardiovascular disease, policy related changes is needed to address contextual factors associated with risk of the disease. The global commitment is to reduce the rate of premature cardiovascular disease by 25% by 2025. In response to this commitment, role of cardiac rehabilitation is now realized to restore health of affected people (Roth et al., 2015). The essay discusses the importance of cardiac rehabilitation for people with cardiac health needs and explains the role of nurse in cardiac rehabilitation of patients with cardiovascular disease.

Cardiac rehabilitation is now a part of contemporary heart disease care and treatment because it can treat wide spectrum of cardiac disease. It is defines as the combination of interventions implemented to provide the best physical, psychological and social conditions to patients with chronic cardiovascular disease and reduce the progression of disease and optimal functioning of patients in the community. Wide range of strategies are employed during the cardiac rehabilitation process which includes exercise, behavioral changes, education of healthy behavior, psychological supports and other strategies (Anderson et al., 2016). The main benefit of cardiac rehabilitation is that it has a major impact on heart failure etiology. A study investigating the benefits of cardiac rehabilitation based on heart failure etiology gave the indication that cardiac rehabilitation approaches like physical exercise has positive impact on muscle fibre. The two years outpatient follow-up study also mentioned about the efficacy of cardiac rehabilitation on stabilizing various clinical and laboratory parameter in heart patients. Patient education helped them to stabilize their heart rate and maintain their weight too. The study proved the benefits of clinical rehabilitation in heart failure patients and suggested exercise training in all heart failure patients despite difference in heart failure etiology  (Koukoui et al., 2015).

Understanding Cardiac Rehabilitation for Heart Failure

Though exercise-based cardiac rehabilitation has been recommended by many studies, most heart failure patients do not receive it. This might be due to the variation in the cost of cardiac rehabilitation service. However, cardiac rehabilitation with emphasis on exercise is considered important for patient because it has been found to reduce the mortality rate by 20-30% compared to those who do not receive exercise interventions (Lewinter et al., 2015). Another study showed the direct benefits of exercise training on coagulation and clotting factors and development of inflammatory markers. Consistent results for reduction in cardiovascular mortality with exercise activity has been found in many studies and across people with many types of cardiovascular heart disease (Anderson et al., 2016).

Another study evaluated the effectiveness of exercise-based rehabilitation in terms of mortality, hospital admission rates and health related quality of life.  The study finding showed that exercise rehabilitation does not reduce the risk of all cause mortality, however it leads to reduction in hospital admissions rates and improvement in health related quality of life. In addition, positive results from exercise training is consistent in participants irrespective of their age, gender and severity (Taylor et al., 2014). Hence, considering the impact of clinical outcome of patients, it is very important to provide such interventions to heart failure patients. It is regarded as a cost effective and comprehensive approach to reducing risk factors and improving physiological, functional, psychological and nutritional status of patients.

Despite numerous benefits of outpatient cardiac rehabilitation (CR), very few referrals are given to patient for participation in such activities. One research suggested addressing the barrier to participation in CR by educating the patients and health care system about the benefits of CR and identifying the reason for lack of referral. To identify lack of referral to CR, it is also necessary to analyze level of health investments and health system barriers such as poor infrastructure and poor perception about the value of CR. In addition, to increase the participation of people in outpatient CR, it would necessary to raise understanding about the process and designing the CR programs in such a way that majority of patients can accept such form of care. Increased coverage and implementation of innovative strategies to cover more number of patients in such programs is also crucial to the achievement of the global commitment for reduction in cardiovascular mortality rate. Several digitals tools has the advantage in raising awareness and improving coverage of such program. For example, telemedicine, internet based programs and mobile applications are useful tools to raise awareness about importance for CR in restoring optimal functioning in cardiac failure patients (Arena et al., 2012). This approach will help to address alarmingly low rate of participation in CR programs.

Benefits of Exercise-based Cardiac Rehabilitation

The above discussion proves that there are many evidence based article to prove the efficacy of CR on improving health of patients with cardiovascular disease. It is multidisciplinary approach to care where a team of nurse specialist, occupational therapist, dietitian, phsyiotherapist and other support staffs helps patients to change behavior and self-manage the disease by means of diverse CR activities. The cardiac rehabilitation nurse mainly assist and guides patients to adapt to healthy path and lower the risk of heart disease. They facilitate patients to bring lifestyle changes. Such nurse also requires communication skills to persuade patients to adapt new health behavior and experience the benefits of positive life styles changes.  Improving the nursing education regarding CR program is also critical to maximize beneficial effects on patient’s quality of life, body weight, exercise capacity, lipid profile, blood pressure, mortality rate and myocardial infarction (Edmunds, 2012).

The first important role of nurse during cardiac rehabilitation is to educate patients and counsel them regarding strategies to combat cardiovascular disease and get actively involved in medical treatment. The hospitalization period is considered the most important point of initiation of cardiac rehabilitation and interventions given by nurse is most likely to increase the participation rate in CR programmes. A research study proved the critical role of nurse in improving participation in CR programme. A community based intervention of home visit and telephone calls from nurses were implemented and the data regarding the participation rate in CR was calculated. The outcome of the study showed significant improvements in cardiac rehabilitation programmes. The increase was seen after 1 years and hospitalization rate in treatment group also improved considerably (Doll et al., 2015). Hence, this study further confirms that nurse play a role in educating patents and promoting active participation in cardiac rehabilitation programmes.

Nurse also educate patients after open heart surgery and such activities of nurse reduces physical and emotional difficulties in patients. This does not means that nurse educate patents in preoperative stage, they also implement preoperative education and counseling on post operative complication. The nursing activity regarding education patients before and after surgery also reduced stress in patients. One study selected study and control group.  and the study group patients received structural eduactoon and counseling course by nurse prior to surgery. The main outcome of this research was that nurse initiated counseling sessions reduces the rate of preoperative complications in patients and they also showed reduced level of anxiety post the operation (Zhang et al., 2012).

Barriers to Participation in Cardiac Rehabilitation

Home based care is also a part of the cardiac rehabilitation programs. Home based care is considered necessary to address high rehospitalization rates and premature death in people with chronic health disease. Past studies have shown that exercise based CR do not reduce all cause of mortality, however nurse led home based intervention has been found to bring improvements in all cause of health outcomes. This is because home based interventions are more responsive to clinical and psychological health needs of cardiovascular patient. One research study evaluated the benefits of nurse led home based intervention (HBI) on outcome of patients. The common elements of this intervention was home visit of registered cardiac nurse specialist after 7 to 14 days of hospitalization, follow up with multidisciplinary team, focus on addressing residual risk in case of unplanned hospitalization and recommendation of long-term management of risk in patients. The statistical analysis of research data revealed prolonged event-free survival and increase in number of days spent outside hospital in patients receiving HBI (Stewart et al., 2016). However, difference were found in effect of HBI on all cause mortality because of age factors and concurrent diagnosis. Hence, changes in screening and referral protocols are likely to improve nurse role in HBI in real world setting.

Many heart failure patients also have end of life care needs and palliative care are likely to improve health of such patients. Research has shown there is lack of communication between health care staffs and heart failure (HF) patients regarding prognosis. Many do not wish to engage in such conversation because they feel that patients might not entered the terminal phase. However, heart failure nurses hold a key responsibility in coordinating care of HF patient and discuss about palliative care service with HF patients. One study evaluated nurse’s perspective regarding discussion on prognosis and end of life care with patients. The main purpose of the survey was to find out patient’s concern regarding discussing about prognosis and end-of life care and find out barriers and facilitators to discussing palliative care with patients. The outcome of the study gave idea about attitude, confidence and comfort of nurse in interaction with patients. Most nurses had the opinion that they are supposed to discuss prognosis. 97% of nurse were confident in discussing prognosis, however some nurses were uncomfortable that such discussion might increase the stress level of patient (Hjelmfors et al., 2014). Hence, the main conclusion from the study was that nurse found clinician to responsible for discussing palliative care with HF patients. Though open communication is necessary to make informed decisions, however it has been found nurse believed the main role of HF clinic is to provide medical treatment and not educate patients. Hence, more encouragement activity is needed to make nurse understand their communication responsibility in delivery basis palliative care.

The Role of Nurses in Cardiac Rehabilitation

As mentioned previously, cardiac rehabilitation is delivered by multidisciplinary team in which specialist heart failure nurse also plays an important role. One research evaluated the perception and experience of multidisciplinary and specialist HF nurse in management of heart failure patients. This research work was important because of little knowledge regarding specialist nurse role in working with multidisciplinary team. Nurse involvement is necessary and their role begins at the initial diagnosis of heart failure. The study participants gave the insight that education can be best delivered during interaction between nurse and pateinst during home visit. The chances of assimilation of information in patients is also high in such case because patients are more relaxed in home environment. However, nurses also reported that difference patients have different capability to receive information. For instance, some patients may have language difficulty or some may have cognitive disability. In such situation, nurse need to balance educational needs in patients and provide personalized information. HF nurse also emphasized the need for liaison with practitioners and clinicians (Glogowska et al., 2015). Hence, the study gives the implication that specialist HF nurse plays an important role in bridging the gap between primary and secondary care and managing heart failure patient.

The essay summarized the importance of cardiac rehabilitation on improving symptoms and quality of life of heart failure patients. Many types of cardiac rehabilitation programs such as home based care, exercise based CR, educating patients and self-management training has been found to improve clinical outcome of patients. The review of research literature particularly highlights the role of nurse in CR and how they intervene to educate patients, support them during CR and provide psychological support to patients. However, studies have also pointed out to certain barrier experience by nurse in implementing CR and in such case, addressing and mitigating this barrier is considered important for reducing the morbidity and mortality associated with heart disease.

Reference

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Arena, R., Williams, M., Forman, D. E., Cahalin, L. P., Coke, L., Myers, J., … & Lavie, C. J. (2012). Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings. Circulation, 125(10), 1321-1329.

Doll, J. A., Hellkamp, A., Ho, P. M., Kontos, M. C., Whooley, M. A., Peterson, E. D., & Wang, T. Y. (2015). Participation in cardiac rehabilitation programs among older patients after acute myocardial infarction. JAMA internal medicine, 175(10), 1700-1702.

Edmunds, L. (2012). Improving wellbeing with cardiac rehabilitation. Nursing times, 108(40), 17-19.

Glogowska, M., Simmonds, R., McLachlan, S., Cramer, H., Sanders, T., Johnson, R., … & Purdy, S. (2015). Managing patients with heart failure: a qualitative study of multidisciplinary teams with specialist heart failure nurses. The Annals of Family Medicine, 13(5), 466-471.

Hjelmfors, L., Strömberg, A., Friedrichsen, M., Mårtensson, J., & Jaarsma, T. (2014). Communicating prognosis and end-of-life care to heart failure patients: A survey of heart failure nurses’ perspectives. European journal of cardiovascular nursing, 13(2), 152-161.

Koukoui, F., Desmoulin, F., Lairy, G., Bleinc, D., Boursiquot, L., Galinier, M., … & Rouet, P. (2015). Benefits of cardiac rehabilitation in heart failure patients according to etiology: INCARD French study. Medicine, 94(7).

Lewinter, C., Doherty, P., Gale, C. P., Crouch, S., Stirk, L., Lewin, R. J., … & Bland, J. M. (2015). Exercise-based cardiac rehabilitation in patients with heart failure: a meta-analysis of randomised controlled trials between 1999 and 2013. European journal of preventive cardiology, 22(12), 1504-1512.

Roth, G. A., Huffman, M. D., Moran, A. E., Feigin, V., Mensah, G. A., Naghavi, M., & Murray, C. J. (2015). Global and regional patterns in cardiovascular mortality from 1990 to 2013. Circulation, 132(17), 1667-1678.

Stewart, S., Wiley, J., Ball, J., Chan, Y. K., Ahamed, Y., Thompson, D. R., & Carrington, M. J. (2016). Impact of nurse-led, multidisciplinary home-based intervention on event-free survival across the spectrum of chronic heart disease: composite analysis of health outcomes in 1226 patients from 3 randomized trials. Circulation, CIRCULATIONAHA-116.

Taylor, R. S., Sagar, V. A., Davies, E. J., Briscoe, S., Coats, A. J., Dalal, H., … & Singh, S. (2014). Exercise?based rehabilitation for heart failure. The Cochrane Library.

Zhang, C. Y., Jiang, Y., Yin, Q. Y., Chen, F. J., Ma, L. L., & Wang, L. X. (2012). Impact of nurse-initiated preoperative education on postoperative anxiety symptoms and complications after coronary artery bypass grafting. Journal of Cardiovascular Nursing, 27(1), 84-88.