C H A P T E R 20

Cardiovascular Function

LEARNING OBJECTIVES to other body systems for removal. Because the cardiovascu-
lar system has a tremendous adaptive capacity, healthy older
After reading this chapter, you will be able to: adults will not experience any significant change in cardio-
1. Describe age-related changes that affect vascular performance because of age-related changes alone. In
cardiovas-cular function. the presence of risk factors, however, the cardiovascular
system is less efficient in performing life-sustaining activi-ties,
2. Identify risk factors for cardiovascular disease
and serious negative functional consequences can occur.
and orthostatic and postprandial hypotension.
3. Describe the functional consequences of age-
related changes and risk factors related to AGE-RELATED CHANGES THAT AFFECT
cardio-vascular function. CARDIOVASCULAR FUNCTION
4. Assess cardiovascular function and risks for cardio-
As with many aspects of physiologic function, it is difficult to
vascular disease with emphasis on those that can be
determine whether cardiovascular changes are attributable to
addressed through health promotion interventions.
normal aging or other factors. Knowledge about distinct age-
5. Teach older adults and their caregivers about inter- or disease-related changes in cardiovascular function is
ventions to reduce the risk for cardiovascular disease. confounded by the fact that, until recently, there was no tech-
nology to detect asymptomatic pathologic cardiovascular
processes, such as the occlusion of a major coronary artery.
Thus, some conclusions from earlier studies may have attrib-
K E Y P O I N T S uted pathologic changes to normal aging. Studies using newer
diagnostic techniques found that 36% and 39% of men and
abdominal obesity metabolic syndrome women, respectively, have subclinical coronary heart disease
adaptive response obesity and only 12.6% of people aged 85 years or older have neither
atherosclerosis orthostatic hypotension clinical nor subclinical disease (Cademartiri, LaGrutta, de
Feyter, & Kresstin, 2008). Currently, many studies of age-
atypical presentation physical inactivity
related changes are longitudinal and include subjects who have
baroreflex mechanisms plaque been carefully screened for asymptomatic cardiovascu-lar
cardiovascular disease postprandial disease.
DASH dietary pattern hypotension In addition, because sociocultural factors affect cardiovas-
home blood pressure pseudohypertension cular function, it is difficult to draw conclusions about lifestyle
monitoring stepped-care approach factors that affect entire societies. Systolic blood pressure, for
example, increases gradually in adults who live in Western
hypertension systolic hypertension
societies but not in those from less industrialized societies.
lipid disorders white coat
Therefore, changes that have been attributed to in-creased age
Mediterranean dietary hypertension may, in fact, be related to lifestyle, sociocultural factors, or
pattern pathologic conditions. Cross-cultural studies are now being
used to identify the effects of lifestyle and other sociocultural
factors that affect cardiovascular function. A major focus of
T he cardiovascular system helps maintain homeostasis by bringing research is on identifying those risk factors that are most
amenable to interventions so that evidence-based interventions
oxygen and nutrients to organs and tissues and by transporting
carbon dioxide and other waste products can be recommended.

408
 Cardiovascular Function CHAPTER20 409

Promoting Cardiovascular Wellness in Older Adults

Nursing Assessment
• Usual heart rate, sounds, rhythm
• Blood pressure, including
hypotension
• Risks for cardiovascular disease
• Signs and symptoms of
cardiovascular disease
• Knowledge about cardiovascular
disease

Age-Related Changes Risk Factors

• Myocardial degenerative • Hypertension, hyperlipidemia
changes Negative Functional • Inactivity
• Arterial stiffening Consequences • Obesity
• ↑ peripheral resistance • ↓ adaptive response • Dietary habits
• Altered baroreflex mechanisms to exercise • Tobacco smoking
• ↑ susceptibility to • Stress, depression
hypertension, • ↓ social supports
hypotension
• ↑ susceptibility to
arrhythmias
• ↓ cerebral blood
flow

Nursing Interventions
• Teaching about diet, exercise, optimal weight
• If applicable, teaching about smoking
cessation
• Teaching about hypertension and dyslipidemia
• Teaching about signs and symptoms of
heart disease

Wellness Outcomes
• Improved cardiovascular function
• Prevention of cardiovascular disease
• Normal blood pressure and serum lipids
• Improved longevity and quality of life

Myocardium and Neuroconduction Mechanisms
Age-related changes of the myocardium include amyloid de-
posits, lipofuscin accumulation, basophilic degeneration, my-
ocardial atrophy or hypertrophy, valvular thickening and
stiffening, and increased amounts of connective tissue. The
left ventricular wall becomes slightly enlarged in healthy older
adults, but any significant myocardial atrophy that oc-curs is
due to pathologic processes. In addition, the left atrium
enlarges, even in healthy older adults. Other age-related
changes include thickening of the atrial endocardium, thick-
ening of the atrioventricular valves, and calcification of at
least part of the mitral annulus of the aortic valve. These
changes interfere with the ability of the heart to contract com-
pletely. With less effective contractility, more time is required
to complete the cycle of diastolic filling and systolic empty-
ing. In addition, the myocardium becomes increasingly
410 PA R T 4Promoting Wellness in Physical Function
irritable and less responsive to the impulses from the
sympa-thetic nervous system.
Age-related changes in cardiac physiology are minimal,
and the changes that do occur affect cardiac performance
only under conditions of physiologic stress. Even under
stressful conditions, the heart in healthy older adults is able
to adapt, but the adaptive mechanisms may differ from
those of younger adults or be slightly less efficient. The
age-related changes that cause functional consequences
primarily involve the electrophysiology of the heart (i.e.,
the neuroconduction system). Age-related changes in the
neuroconduction system include a decrease in the number
of pacemaker cells; in-creased irregularity in the shape of
pacemaker cells; and in-creased deposits of fat, collagen,
and elastic fibers around the sinoatrial node.
Vasculature
Age-related changes affect two of the three vascular layers,
and functional consequences vary, depending on which
layer is affected. For example, changes in the tunica intima,
the in-nermost layer, have the most serious functional
consequences in the development of atherosclerosis,
whereas changes in the tunica media, the middle layer, are
associated with hypertension. The outermost layer (the
tunica externa) does not seem to be affected by age-related
changes. This layer, composed of loosely meshed adipose
and connective tissue, supports nerve fibers and the vasa
vasorum, the blood supply for the tunica media.
The tunica intima consists of a single layer of endothelial
cells on a thin layer of connective tissue. It controls the entry
of lipids and other substances from the blood into the artery
wall. Intact endothelial cells allow blood to flow freely with-
out clotting; however, when the endothelial cells are damaged,
they function in the clotting process. With increasing age, the
tunica intima thickens because of fibrosis, cellular prolifera-
tion, and lipid and calcium accumulation. In addition, the en-
dothelial cells become irregular in size and shape. These
changes cause the arteries to dilate and elongate. As a result,
the arterial walls are more vulnerable to atherosclerosis
(discussed in the section on risk factors).
The tunica media is composed of single or multiple
layers of smooth muscle cells surrounded by elastin and
col-lagen. The smooth muscle cells are involved in the
tissue-forming functions of producing collagen,
proteoglycans, and elastic fibers. Because it provides
structural support, this layer controls arterial expansion and
contraction. Age-related changes that affect the tunica
media include an in-crease in collagen and a thinning and
calcification of elastin fibers, resulting in stiffened blood
vessels. These changes are particularly pronounced in the
aorta, where the diameter of the lumen increases to
compensate for the age-related ar-terial stiffening.
Although these changes are viewed as age related,
longitudinal and cross-cultural studies are raising questions
about the impact of lifestyle variables on arterial stiffness.
Age-related changes in the tunica media cause increased
peripheral resistance, impaired baroreceptor function, and di-
minished ability to increase blood flow to vital organs. Al-
though these changes do not cause serious consequences in
healthy older adults, they increase the resistance to blood flow
from the heart so that the left ventricle is forced to work
harder. Moreover, the baroreceptors in the large arteries be-
come less effective in controlling blood pressure, especially
during postural changes. Overall, the increased vascular stiff-
ness causes a slight increase in the systolic blood pressure.
Veins undergo changes similar to those affecting the ar-
teries, but to a lesser degree. Veins become thicker, more
di-lated, and less elastic with increasing age. Valves of the
large leg veins become less efficient in returning blood to
the heart. Peripheral circulation is further influenced by an
age-related reduction in muscle mass and a concurrent
reduction in the demand for oxygen.
Baroreflex Mechanisms
Baroreflex mechanisms are physiologic processes that reg-
ulate blood pressure by increasing or decreasing the heart rate
and peripheral vascular resistance to compensate for transient
decreases or increases in arterial pressure. Age-related changes
that alter baroreflex mechanisms include arterial stiffening and
reduced cardiovascular responsiveness to adrenergic
stimulation. These changes cause a blunting of the
compensatory response to both hypertensive and hypotensive
stimuli in older adults, so the heart rate does not increase or
decrease as efficiently as in younger adults.
RISK FACTORS THAT AFFECT
CARDIOVASCULAR FUNCTION
Many factors affect cardiovascular function by increasing the
risk for heart disease, which has been the leading cause of
death in the United States for almost a century. Heart disease,
or cardiovascular disease, refers to all pathologic processes
that affect the heart and circulatory system including specific
disease entities, such as coronary heart disease (also called
coronary artery disease), arrhythmias, atherosclerosis, heart
failure, myocardial infarction, peripheral vascular disease, ve-
nous thromboembolism, stroke, and transient ischemic at-
tacks. Although stroke (also called cerebrovascular disease)
and transient ischemic attacks are considered cardiovascular
conditions because of their underlying pathology, they are
considered neurologic conditions in clinical practice because
of their effects. (Refer to Chapter 27 for discussion of heart
failure; this chapter focuses on conditions that can be ad-
dressed through health promotion interventions to reduce all
types of cardiovascular disease.)
Researchers, health planners, and health care providers are
concerned about risks for cardiovascular disease not only be-
cause of its significant prevalence and mortality rate but also
because it poses a heavy economic burden. Most importantly
from a wellness perspective, there is mounting evidence that
most cardiovascular disease is preventable through modifi-
cation of risk factors (Foody, 2008). Thus, this is a major
focus of health promotion efforts, including patient
education and motivation for behavior change.
Studies have identified the following risk factors as the
most important contributing factors to cardiovascular disease:
stress, weight, lipids, diabetes, blood pressure, physical in-
activity, smoking cessation, inadequate intake of fruit and
vegetable, and excessive alcohol consumption (D’Agostino et
al., 2008; Dennison & Hughes, 2009; Schenk-Gustofsson,
2009). These conditions can be addressed through medical
management and health promotion interventions, as dis-cussed
in this chapter and in Chapters 21 (smoking cessation) and 27
(diabetes). Some risk factors, such as age, race, gen-der, and
heredity, cannot be modified, but it is important to consider
their influence on a person’s overall risk profile. In recent
years, there is increasing recognition that race and gen-der can
affect both the risk for developing cardiovascular dis-ease and
the chance of having adverse outcomes. For example, there is
strong evidence of health disparities asso-ciated with increased
prevalence and poorer management of heart disease and
related risk factors in women and African Americans (e.g.,
Spertus, Jones, Massoudi, Rumsfeld, & Krumholz, 2009;
Taylor et al., 2009; Weiss, 2009). Although age, gender, and
race cannot be changed, it is important to recognize variations
in manifestation and management of car-diovascular disease
that occur in specific groups. Socioeco-nomic and
psychosocial factors also affect the risk profile for heart
disease and these factors are pertinent to a holistic ap-proach
to care of older adults.
DIVERSITY NOTE
At age 40, lifetime risk for cardiovascular disease in men is
67% and for women it is 50%. By the age of 85 years, the risk
is equal in men and women.
DIVERSITY NOTE
The average age of a person having a first major cardiovascular
event is 65.8 years in men and 70.4 years in women (Berra, 2008).
Atherosclerosis
Atherosclerosis is a disorder of the medium and small arteries
in which patchy deposits of lipids and atherosclerotic plaques
reduce or obstruct blood flow. It is implicated in 75% of all
cardiovascular deaths in the United States (Lewis, 2009).
Because atherosclerosis is the underlying pathologic process
associated with most cardiovascular disease, the term ather-
osclerotic cardiovascular disease is sometimes used (see dis-
cussion on pathologic conditions for details). Several theories
about the pathophysiology of atherosclerosis have been pro-
posed since the mid-1970s, and our understanding of athero-
sclerosis has increased significantly in recent years due to the
Cardiovascular Function CHAPTER20 411
use of more sophisticated imaging techniques. It is now un-
derstood that atherosclerosis is a pathologic condition that
begins during childhood with asymptomatic but identifiable
changes and progresses through adulthood to the point that
it is found in 80% to 90% of adults aged 30 years and older
(Lewis, 2009).
Atherosclerosis involves a continuum of changes in the
ar-terial wall that develop in the following sequence (Insull,
2009):
1. Early fatty streak development during childhood and
ado-lescence: low-density lipoprotein (LDL) cholesterol
par-ticles accumulate in the arterial intima and initiate
an inflammatory response.
2. Early fibroatheroma phase during teens and 20s: (a)
macrophage “foam cells” and other inflammatory cells
ac-cumulate, (b) some protective responses are initiated
but necrotic debris causes further inflammation, (c)
extracel-lular lipids accumulate and form lipid-rich
necrotic cores that occupy 30% to 50% of the arterial
wall volume, (d) a fibrous cap, called a plaque, forms
over the necrotic core under the endothelium.
3. Advancing atheroma at 55 years and older: (a) fibrous cap
in a few sites becomes thin and weakened; (b) the thin-
capped fibroatheroma is susceptible to rupturing and caus-
ing a life-threatening thrombosis; (c) if fibroatheroma does
not rupture, it may enlarge and further reduce the ar-terial
lumen; (d) as long as the plaque does not occupy more than
40% of the lumen, the arterial walls can expand to
compensate, but if the plaque occupies more arterial space,
symptoms result; (e) diseased artery may leak within the
arterial wall and provoke further fibrous tissue.
In summary, atherosclerotic changes begin in childhood
and can progress to plaque formation. Plaque lesions, which
can rupture, remain stable, or continue to grow, are the un-
derlying cause of most cardiovascular disease. Studies have
found that multiple asymptomatic cycles of plaque erosion and
healing occur in 60% of sudden cardiac deaths before the fatal
event (Insull, 2009). Thus, it is important to identify and
address risk factors before patients experience symptoms. All
the risk factors associated with cardiovascular disease, as
described in this section, are risks for the development and
progression of atherosclerosis.
Physical Inactivity
Physical inactivity (also called physical deconditioning in ref-
erence to cardiovascular function) is a factor that not only in-
creases the risk for cardiovascular disease for all people but
also diminishes cardiovascular function in healthy older
adults. Thus, even in the absence of pathologic processes,
inadequate patterns of physical activity will interfere with the
ability of older adults to adapt to age-related cardiovascular
changes. According to evidence-based guidelines, the level of
physical inactivity that increases the risk for cardiovascular
disease is fewer than 30 minutes of moderate physical activity
at least 5 days weekly or 20 minutes of vigorous physical
412 PA R T 4Promoting Wellness in Physical Function
activity at least 3 days weekly. National data indicate that 6% and
24% of younger and older adults, respectively, do not achieve
adequate levels of physical activity and, therefore, have 1.5 to 2.4
times the relative risk for coronary heart diseases (Lloyd-Jones,
2009). Conditions that often occur in older adults and contribute
to physical deconditioning include acute illness, a sedentary
lifestyle, mobility limitations, any chronic condi-tion that
interferes with physical activity, and psychosocial in-fluences,
such as depression or lack of motivation.
DIVERSITY NOTE
Physical inactivity is higher in women than in men and in African American
and Hispanic adults than in white adults (Lloyd-Jones et al., 2009).
Tobacco Smoking
Tobacco smoking is a major avoidable cause of cardiovascular
disease, and there is indisputable evidence that all forms of to-
bacco use (smoking and smokeless or exposure to secondhand
smoke) increase the risk for cardiovascular disease and mor-
tality. Research data indicate that cardiovascular disease be-
comes symptomatic 10 years earlier, and death occurs 13 years
earlier in current smokers than in nonsmokers (Surinach et al.,
2009). In addition, national data indicate that 35% of smoking-
related deaths are due to cardiovascular disease (Lloyd-Jones
et al., 2009). Effects of smoking on the cardiovascular system
include acceleration of atherosclerotic processes, increased
systolic blood pressure, elevated LDL cholesterol level, and
decreased high-density lipoprotein (HDL) cholesterol level.
Even short exposures to secondhand smoke increase the risk of
a heart attack because of immediate adverse effects on the
heart, blood, and vascular systems. In addition, nonsmokers
who are exposed to secondhand smoke at home or work have
25% to 30% greater risk of developing heart disease (Lloyd-
Jones et al., 2009). It should be emphasized that these cardio-
vascular effects are in addition to the effects of nicotine on
respiratory function (see Chapter 21) and other aspects of
health (e.g., increased risk for development of many cancers).
Dietary Habits
Randomized controlled trials confirm that dietary habits
can increase many risk factors for cardiovascular disease,
includ-ing weight, blood pressure, glucose levels, and
lipoprotein and triglyceride levels. A review of studies
summarized the following findings related to dietary habits
and cardiovascular health (Lloyd-Jones et al., 2009):
● Total fat intake was less important than type of fat con-
sumed; replacing saturated fat with polyunsaturated fat
reduced cardiovascular risk by 24%.
● Each 2% of calories from trans fats were associated with
a 23% higher risk of coronary heart disease.
● Intake of 2.5 servings daily of whole grains was
associated with a 21% lower risk of cardiovascular
disease when compared with 0.2 servings daily.
● When compared with little or no consumption of fish or
fish oil, consumption of one to two servings per week of
oily fish was associated with a 36% lower risk of cardio-
vascular mortality.
● Each additional daily serving of fruits or vegetables was
associated with a 4% lower risk of coronary heart
disease and 5% lower risk of stroke.
● Low-sodium interventions were associated with a 25%
lower risk of cardiovascular disease after 10 to 15 years
of follow-up.
In addition to studies of specific types of foods, many
studies looked at the protective effects of dietary patterns,
which are discussed in the section on nursing interventions.
Obesity
Obesity, which is defined by body mass index (BMI) $30
kg/m2, is associated with increased risk for many patho-logic
conditions including stroke, diabetes, lipid disorders,
atherosclerosis, hypertension, and coronary heart disease. In
recent years, increasing attention is being paid to abdominal
obesity (also called abdominal adiposity) as an independent
risk factor for cardiovascular disease. Abdominal obesity, de-
fined as a waist circumference more than 102 and 88 cm or
waist-to-hip ratio of 0.95 and 0.88 for men and women, re-
spectively, can occur even in people with normal BMI. Sig-
nificant evidence indicates that abdominal adipose tissue is
biologically and metabolically different from subcutaneous fat
and, in fact, may have a greater impact on cardiovascular
disease than overall obesity (Carr & Tannock, 2009). Analysis
of data from the Nurses’ Health Study found that higher waist
circumference was a strong risk factor for mortality from car-
diovascular disease even among normal-weight women
(Zhang, Rexrode, Van Dam, Li, & Hu, 2008).
DIVERSITY NOTE
Prevalence of obesity among noninstitutionalized adults
between the ages of 64 and 75 years is 36% for women and
24% for men (Lloyd-Jones et al., 2009).
Hypertension
Prevalence for hypertension in American adults aged 65 years
and older is 70.8%, with a prevalence of 63.0% and 76.6% for
men and women, respectively (McDonald, Hartz, Unger,
& Lustik, 2009). Hypertension is defined as blood pressure of
140/90 mm Hg or higher, or a blood pressure that requires
treatment with an antihypertensive medication. Hypertension
is a disease of the cardiovascular system, and in older adults, it
is also an independent risk factor for additional cardiovas-
cular diseases, including coronary artery disease, ischemic
stroke, peripheral arterial disease, and congestive heart failure
(Aronow, 2008). Since the early 2000s, studies found that
blood pressure even at the high end of normal (i.e., 130 to
139/85 to 89 mg Hg) is a risk factor for stroke, myocardial
infarction, sudden cardiac death, coronary heart disease,
heart failure, renal disease, and all-cause mortality (e.g.,
Kokubo et al., 2008). Thus, hypertension is both a disease
of the car-diovascular system and a risk factor for
additional cardiovas-cular disease.
Until recently, health care practitioners viewed systolic
blood pressure as less important than diastolic blood pressure
as a criterion for treatment of hypertension. Recent clinical
trials, however, support the evidence-based recommendation
to treat systolic hypertension (also called isolated systolic
hypertension) because the risk of cardiovascular disease in-
creases proportionately as systolic pressure increases from 115
mm Hg (Rashidi & Wright, 2009; Williams, Lundholm,
& Sever, 2008). This is especially pertinent to older adults
because systolic hypertension is the most common type of
hypertension in the elderly and is strongly associated with
organ damage, and increased risk of cardiovascular disease
and mortality (Duprez, 2008).
Risk factors for the development of hypertension include
age, ethnicity, genetic factors, overweight, physical inactivity,
sleep apnea, psychosocial stressors, and lower education and
socioeconomic status. In addition, dietary patterns that in-
crease the risk for hypertension include higher intake of fats
and sodium, lower potassium intake, and excessive alcohol
consumption (Lloyd-Jones et al., 2009). When dietary pat-
terns of different cultural groups are compared, there is a
strong relationship between average daily sodium consump-
tion and prevalence of hypertension (Flegel & Magner, 2009).
The Joint National Committee (JNC) on Detection, Eval-
uation, and Treatment of High Blood Pressure has published
seven reports, with the eighth one planned for publication in
late 2011. Because each of these reports revised the classifi-
cation of hypertension, a blood pressure measurement that was
considered normal in 1980 was deemed pathologic in the
2000s. Another consideration is that at one time, the upper
normal range for systolic blood pressure was “100 plus your
age,” so an 84-year-old person could have a systolic blood
pressure of 184 and not be diagnosed as having hypertension.
This perspective gradually changed and the same standards for
determining hypertension apply to adults of all ages. The JNC
recommends a classification of hypertension by stages to
emphasize the risk of any degree of high blood pressure as a
factor in cardiovascular disease (JNC, 2003). To clarify var-
ious terms, Table 20-1 defines some of the criteria used re-
garding blood pressure in older adults.
DIVERSITY NOTE
Significant health disparities are apparent in the control of
hyperten-sion, with blacks having a 27% lower chance of
adequate control (Lloyd-Jones et al., 2009).
Lipid Disorders
Lipid disorders (also called dyslipidemias or hyperlipidemias)
is a broad term that encompasses all abnormalities of lipopro-
Cardiovascular Function C H A P T E R 2 0 413
T A B L E 2 0 - 1 Criteria for Normal Blood Pressure and
Stages of Hypertension
Systolic Diastolic
Adult Blood Pressure (mm Hg) (mm Hg)
Normal ,120 And ,80
Prehypertension 120–139 Or 80–89
Hypertension, stage I 140–159 Or 90–99
Hypertension, stage II $160 Or $100
Source: JNC. (2003). The seventh report of the Joint National Committee
on Preven-tion, Detection, Evaluation, and Treatment of High Blood
Pressure. Journal of the American Medical Association, 289, 2560–2577.
tein metabolism, including low levels of HDLs (often referred
to as “good cholesterol”) and elevated levels of total choles-
terol, triglycerides, or LDL (often referred to as “bad cho -
lesterol”). Public awareness of the importance of testing for
lipid disorders has increased since the early 1980s, when cho-
lesterol and saturated fat became household words. By the
1990s, numerous studies began confirming a positive asso-
ciation between lipoprotein levels and coronary heart disease,
and there was widespread support for cholesterol screening for
all adults. During the early 2000s, the National Choles-terol
Education Program issued and widely disseminated an updated
evidence-based set of guidelines on cholesterol man-agement,
called the Adult Treatment Panel (ATP) III. These guidelines
were updated in 2004 and the updates continue as part of the
National Heart, Lung, and Blood Institute plan to develop
integrated cardiovascular risk reduction criteria. The ATP III
and other evidence-based guidelines emphasize the value of
screening for and treating lipid disorders in adults.
Although there is much scientific support for addressing
lipid disorders as a risk for cardiovascular disease, questions
have been raised about the value of cholesterol screening and
treatment for older adults, particularly for those older than 75
years and those who have no cardiovascular disease. Ac-
cording to current evidence-based guidelines, screening for
lipid disorders is appropriate for older people who had never
been evaluated, but repeated screening is less important for
older adults who have normal levels because lipid levels are
not likely to change after age 65 (U.S. Preventive Services
Task Force, 2008). Current data also indicate that older adults
would benefit significantly from lipid-lowering therapy
(Ducharme & Radhamma, 2008). Moreover, because older
adults have a greater risk for developing coronary heart dis-
ease, they are likely to gain more than younger adults from
treatment of lipid disorders (U.S. Preventive Services Task
Force, 2008). See the Evidence-Based Practice Box 20-1 that
summarizes pertinent information about preventing cardio-
vascular disease.
DIVERSITY NOTE
African Americans and Mexican Americans are less likely than
whites to be screened for dyslipidemia (Lloyd-Jones et al., 2009).
414 PA R T 4Promoting Wellness in Physical Function
Evidence-Based Practice 20-1
Evidence-Based Practice Related to
Prevention of Cardiovascular Disease
Statement of the Problem
● Significant advances have been made in preventing and treating
cardio-vascular disease through medical interventions. However,
diet and lifestyle therapies—which are commonly neglected—
remain the foun-dation of clinical intervention for prevention.
Recommendations for Nursing Assessment
● Assess health-related behaviors pertinent to cardiovascular health:
dietary patterns, weight, level of physical activity, and smoking.
Recommendations for Nursing Care
● Calculate BMI and discuss with patients.
● Advocate a healthy dietary pattern consistent with American
Heart Association recommendations.
● Encourage regular physical activity.
● Discourage smoking among nonsmokers and encourage
smoking cessation among patients who do smoke.
Teaching Points for Older Adults and Caregivers
● Consume an overall healthful diet: variety of fruits, vegetables, and grains,
especially whole grains; choose fat-free and low-fat dairy products,
Metabolic Syndrome
Metabolic syndrome (also called insulin resistance syn-
drome) refers to a group of clinically identifiable condi-
tions, which include lipid disorders, hypertension, and
insulin resistance, that increase the risk for developing car-
diovascular disease or type 2 diabetes. Each condition is an
independent risk for disease, but when they occur together,
they disproportionately increase the probability of compli-
cation, morbidity, and mortality related to cardiovascular
disease or type 2 diabetes (Mazzo, 2008). Criteria for meta-
bolic syndrome have been established by the ATP III
guide-lines and have also been defined by the International
Diabetes Foundation and the World Health Organization.
Based on ATP III guidelines, the American Heart Associa-
tion states that metabolic syndrome is diagnosed when
three or more of the following risk factors are present
(Lloyd-Jones et al., 2009):
● Central obesity, defined as waist circumference equal to
or greater than 40 inches (102 cm) in men or 35 inches
(88 cm) in women
● Blood pressure equal to or higher than 130/85 mm Hg
● HDL cholesterol lower than 40 mg/dL in men or equal
to or lower than 50 mg/dL in women, or drug treatment
for a lipid disorder
● Triglycerides equal to or greater than 150 mg/dL, or
specific treatment for hypertriglyceridemia
● Fasting blood glucose level equal to or greater than 100
mg/dL, or drug treatment for increased glucose.
legumes, poultry, and lean meats; eat fish, preferably oily fish,
at least twice weekly; limit intake of saturated and trans fats and
cholesterol; limit intake of foods and beverages that have added
sugar; select nutrient-dense foods.
● Aim for a healthy BMI of 18.5 to 24.9 kg/m 2.
● Aim for optimal lipid profile: LDL levels ,100 mg/dL, HDL .50
mg/dL in women and .40 in men, and triglycerides ,150 mg/dL.
● Aim for normal blood pressure: systolic blood pressure ,120 mm
Hg and diastolic blood pressure ,80 mm Hg.
● Adopt dietary modifications that lower blood pressure: reduced
salt in-take, increased potassium intake, caloric deficit to induce
weight loss, moderation of alcohol intake for those who drink.
● Aim for fasting blood glucose level #100 mg/dL.
● Be physically active: accumulate $30 minutes of physical activity
most days of the week and at least 60 minutes most days of the
week for peo-ple attempting to lose weight or maintain weight loss.
● Avoid use of and exposure to tobacco products.
SOURCES: Diet and lifestyle recommendations revision 2006. A scientific state-
ment from the American Health Association Nutrition Committee. Lichtenstein
AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, . . .
Wylie-Rosett J. (2006). Diet and lifestyle recommendations revision
2006: a sci-entific statement from the American Heart Association
Nutrition Committee. Circulation 114(1):82–96.
DIVERSITY NOTE
Two studies found that men and whites are more likely to
develop metabolic syndrome compared with women and
blacks (Lloyd-Jones et al., 2009).
Psychosocial Factors
Psychosocial factors that are associated with increased risk for
developing cardiovascular disease include stress, anxiety,
depression, social isolation, poor social supports, and person-
ality characteristics, such as higher anger and hostility in-
dices. One focus of current studies is on the relationship
between prolonged stress (also called chronic stress) and risk
for developing chronic cardiovascular conditions, such as ath-
erosclerosis, hypertension, and lipid disorders. Studies have
found the following associations between stress and cardio-
vascular disease (Larzelere & Jones, 2008; Lee et al., 2010):
● Psychosocial stress was comparable to smoking and hy-
pertension as risk factors for myocardial infarction.
● Chronically stressful situations have been linked to in-
creased risk of coronary artery disease and adverse
cardiac events.
● Acute stress has been associated with increased risk for
acute cardiovascular events.
● Anger, anxiety, and occupational stress have been found
to increase the risk for acute coronary events.
● High levels of emotional distress in patients with conges-
tive heart failure are associated with poorer outcomes.
Studies also indicate that yoga, meditation, and other stress-
reduction methods are effective for reducing blood pressure
and preventing cardiovascular disease (Sidani & Figueredo,
2009; Sidani & Ziegler, (2008).
Depression has not been identified as a primary risk factor
for cardiovascular disease, but it is a risk factor for recurrent
coronary events and cardiovascular-related mortality in peo-
ple who have had a myocardial infarction. Studies also have
found that depression accelerates cardiovascular disease in
women with diabetes (Evangelista & McLaughlin, 2009).
Thus, it is an important consideration with regard to second-
ary prevention interventions. A recent review of studies that
were used for developing evidence-based practice found that
prevalence of depression during initial hospitalization for my-
ocardial infarction ranged from 7% to 41% (depending on
assessment method), with an average of 20%. This same re-
search review found that up to 60% of patients reported de-
pression 1 month or longer postmyocardial infarction (Green,
Dickenson, Nease, & Campos-Outcalt, 2009). Nurses caring
for older adults even months after a myocardial infarction need
to be aware of this close link so that they can include this
dimension in a holistic approach to care.
DIVERSITY NOTE
One study found that African Americans with coronary heart
disease were less likely to be treated with antidepressant
medications com-pared with whites despite having similar levels
of depression (Waldman et al., 2009).
Heredity and Socioeconomic Factors
Heredity plays a significant role in the risk for developing
cardiovascular disease. Large population-based studies
show a strong link between reported history of premature
parental coronary heart disease and cardiovascular disease,
including atherosclerosis and myocardial infarction, in
offspring (Lloyd-Jones et al., 2009). Although inherited
conditions cannot be changed, people who are aware of
having these risk factors may be more motivated to address
modifiable risks.
The relationship between socioeconomic status and car-
diovascular disease has been a focus of research for several
decades. A Centers for Disease Control and Prevention (CDC)
survey of adults found that people with less than a high school
level of education were twice as likely as college graduates to
have multiple-risk factors for cardiovascular dis-ease (Lloyd-
Jones et al., 2009). Although income and educa-tion are not
easily modified, it is important to recognize that these
conditions influence not only the risk for cardiovascular
disease but also the use of preventive and interventional
measures. From a holistic perspective, nurses need to con-
sider these factors when planning health education interven-
tions to address individualized needs of older adults.
Cardiovascular Function CHAPTER20 415
Risk for Cardiovascular Disease
in Women and Minority Groups
Because cardiovascular disease had long been viewed as a
disease of middle-aged men, early research focused
primarily, or exclusively, on men. This perspective began
changing dur-ing the 1990s when studies showed that
although the preva-lence of cardiovascular disease is lower
in younger women than younger men, it increases
dramatically after the age of 50 years in women. The
following statistics from national databases are indicators
of the extent of cardiovascular morbidity and mortality
among women in the United States (McSweeney, Cleves,
Zhao, Lefler, & Yang, 2010; Weiss, 2009):
● Heart disease and stroke together account for 41.3% of
all deaths in women; this is equivalent to a woman dying
from cardiovascular disease every minute of every day.
● Cardiovascular disease affects 36.6% of women, with
the age-related prevalence increasing from 36.2% for
those between the ages of 45 and 54 years to 68.5% for
those aged 65 years and older.
● Although many women perceive breast cancer as their
greatest threat, cardiovascular disease kills 12 times as
many women each year as breast cancer.
● Annual rates of the first major cardiovascular event is sim-
ilar for men and women, but occurs about 10 years later for
women; by the age of 75 years, the lifetime risk for
cardiovascular disease is the same in men and women.
● 38% of women versus 25% of men die within 1 year
after a first heart attack.
● Women are more likely to have more subtle
manifestations of coronary artery disease (e.g., a
myocardial infarction), so they are less likely to pursue
appropriate evaluation or to be diagnosed accurately.
● Women with cardiovascular disease are less likely than
men to be treated according to evidence-based
guidelines, and their survival rates are worse.
Along with the growing recognition of unique aspects of
cardiovascular disease in women, there has been increasing
focus on the disproportionate burden of cardiovascular-related
death and disability among minority populations. Na-tional
data show that African Americans have a higher risk of heart
disease and more severe hypertension than whites do.
American Indians, Mexican Americans, Native Hawaiians,
and some Asian Americans are other groups in which the rate
of cardiovascular disease is higher than in whites.
In addition to having more risk factors, African Americans
have the highest age-adjusted death rate for cardiovascular dis-
ease, and they are more likely than other groups to have risk
factors, such as diabetes, obesity, hypertension, and lipid dis-
orders. One study of factors associated with differences in out-
comes of black and white patients after a heart attack attributed
the disparity in outcomes to black patients having worse risk
factors, including diabetes, high cholesterol levels, high blood
pressure, and lower socioeconomic status (Spertus et al., 2009).
416 PA R T 4Promoting Wellness in Physical Function
Another study concluded that there is a clear need for
improved methods of identifying and effectively treating
dyslipidemia in African Americans (Taylor et al., 2009).
Studies are also focusing on variations of cardiovascular
risk factors and interventions in Asian/Pacific Islander
Amer-icans. One study found that there may be differences
in both therapeutic response and adverse effects of
antihypertensive medications between Asian/Pacific
Islander Americans and whites (Watson, 2009).
FUNCTIONAL CONSEQUENCES
AFFECTING CARDIOVASCULAR
WELLNESS
Healthy older adults experience no significant cardiovascular
effects when they are resting, but, when they engage in exer-
cise, their cardiovascular function is less efficient. However,
older adults who have risk factors for cardiovascular disease
are likely to experience negative functional consequences as-
sociated with pathologic processes. This section reviews the
functional consequences in older adults who have no risk fac-
tors, and the sections on nursing assessment and interventions
focus on risk factors that can be addressed to prevent patho-
logic processes that commonly affect cardiovascular function.
Effects on Cardiac Function
Cardiac output, the amount of blood pumped by the heart
per minute, is an important measure of cardiac performance
be-cause it represents the heart’s ability to meet the oxygen
re-quirements of the body. Although reduced cardiac output
is common in older adults, it is associated primarily with
patho-logic, rather than age-related, conditions. With the
exception of a slight decrease in cardiac output at rest in
older women, healthy older adults do not experience any
decline in cardiac output.
Effects on Pulse and Blood Pressure
Normal pulse rate for healthy older adults is slightly lower
than that for younger adults, but older adults are likely to have
harmless ventricular and supraventricular arrhythmias because
of age-related changes that affect cardiac conduction mecha-
nisms. Atrial fibrillation—a more serious arrhythmia—
commonly occurs in older adults, but this is associated with
pathologic conditions (e.g., hypertension, coronary artery dis-
ease) rather than with age-related changes. In most popula-
tions across the world, there is an age-related linear increase in
systolic blood pressure from age 30 to 40 years, and this
change is steeper for women than for men. There also is a
progressive decrease in diastolic pressure beginning around
age 50 years (Williams et al., 2008).
Effects on the Response to Exercise
A negative functional consequence that affects cardiovascular
performance in healthy older adults is a blunted adaptive
response to physical exercise. Physiologic stress, such as that
associated with exercise, increases the demands on the car-
diovascular system by four to five times the basal level. The
adaptive response involves many aspects of physiologic func-
tion, including the respiratory, cardiovascular, musculoskele-
tal, and autonomic nervous systems. The maximum heart rate
achieved during exercise is markedly decreased, and the peak
exercise capacity and oxygen consumption decline in older
adults. Physical deconditioning and other risk factors account
for some of this decline. Similarly, studies confirm that max-
imum oxygen uptake during exercise decreases with aging but
is affected to a greater extent by risk factors, such as pro-
longed bedrest (McGavock et al., 2009).
Effects on Circulation
Functional consequences also can affect circulation to the
brain and the lower extremities. For example, age-related
changes in cardiovascular and baroreflex mechanisms can re-
duce cerebral blood flow to some extent in healthy older adults
and to a greater extent in older adults who have diabetes, hy-
pertension, lipid disorders, and heart disease. In addition, in-
creased tortuosity and dilation of the veins, along with
decreased efficiency of the valves, lead to impaired venous
return from the lower extremities. Consequently, older adults
are prone to developing stasis edema of the feet and ankles,
and they are more likely to develop venous stasis ulcers.
M r. C. is a 64-year-old African American who fre-
quently comes to your Senior Wellness Clinic to have you
check his blood pressure. He has been taking hy-
drochlorothiazide, 25 mg, and verapamil, 120 mg, every
morning, and his blood pressures range between 126/80
and 130/84 mm Hg. Mr. C. sees his primary care provider
once a year and obtains additional health care through
community resources, such as health fairs. Mr. C.’s 86-year-
old mother recently died of a cerebrovascular accident, and
his father died in his early 50s of a heart attack. Mr. C. has
had hypertension since he was 24, and both of his
daughters have high blood pressure as well. Neither Mr. C.
nor anyone in the household smokes tobacco. He gets very
little exercise and weighs 210 pounds, about 30 pounds
more than his ideal weight. He reports that he “gets winded
easily” when walking up or down a flight of steps or when he
has to walk “a long distance” (which he defines as the
distance across the parking lot to the senior center). He
attributes this to “getting old.”
T H I N K I N G P O I N T S
● What age-related changes in cardiovascular function is
Mr. C. likely to be experiencing?
 ● What risk factors are likely to be contributing to Mr. Cardiovascular Function CHAPTER20 417
C.’s experience of “getting winded?”
● What risk factors does Mr. C. have for cardiovascular
disease? Box 20-1 Risk Factors for Hypotension
● What further information would you want to obtain
Risks for Orthostatic Hypotension
for assessing his risk for cardiovascular disease?
Pathologic Processes
● Hypertension, including isolated systolic hypertension
● Parkinson’s disease
● Cerebrovascular disorders
● Diabetes
PATHOLOGIC CONDITIONS AFFECTING ● Anemia
CARDIOVASCULAR WELLNESS: ORTHOSTATIC ● Autonomic dysfunction
AND POSTPRANDIAL HYPOTENSION ● Arrhythmias
● Volume depletion (e.g., dehydration)
Orthostatic and postprandial hypotension are conditions that ● Electrolyte imbalances (e.g., hyponatremia, hypokalemia)
frequently affect cardiovascular function in older adults due to
Medications
a combination of age-related changes (e.g., decreased ● Antihypertensives
baroreflex sensitivity) and risk factors. These cardiovascular ● Anticholinergics
conditions are not serious in and of themselves, but they are ● Phenothiazines
addressed in this chapter because they can lead to serious ● Antidepressants
consequences. Moreover, they are often overlooked and it ● Anti-Parkinson agents
● Vasodilators
clearly is within the realm of nursing to identify hypotension ● Diuretics
in older adults (see section on Nursing Assessment). ● Alcohol
Orthostatic hypotension (also called postural hypoten-
sion) is defined as a reduction in systolic blood pressure and Risks for Postprandial
diastolic blood pressure of at least 20 or 10 mm Hg, respec- Hypotension Pathologic Processes
● Systolic hypertension
tively, within 1 to 4 minutes of standing after being recumbent
● Diabetes mellitus
for at least 5 minutes. Studies have found that 20% of ● Parkinson’s disease
community-dwelling older adults and 30% to 50% of those in ● Multisystem atrophy
nursing homes have orthostatic hypotension (Mussi et al.,
2009). Although orthostatic hypotension can occur in healthy Medications
● Diuretics
older adults, it is more likely to occur in those who have risk
● Antihypertensive medications ingested before meals
factors, such as the pathologic conditions and adverse med-
ication effects listed in Box 20-1. In addition, the risk can be
increased by the total number of medications in regular use
2008). Physiologic changes that can cause postprandial hy-
and by a combination of conditions, such as Parkinson’s dis-
potension include impaired baroreflex mechanisms, quicker
ease and anti-Parkinson medications (Hiitola, 2009).
rate of gastric emptying, the release of vasoactive gastroin-
One study found that age, pre-hypertension, hypertension,
testinal hormones, and impaired autonomic regulation of
and diabetes mellitus were important determinants of ortho-
gastrointestinal perfusion. Carbohydrates, and glucose in par-
static hypotension in a population of community-dwelling
ticular, may contribute to the development of postprandial hy-
adults (Wu, Yang, Lu, Wu, & Chang, 2008). Orthostatic hy-
potension. Older adults who have falls, syncope, weakness, or
potension can be asymptomatic or it can be accompanied by
dizziness should be evaluated for postprandial hypotension
symptoms such as fatigue, lightheadedness, blurred vision, or
because it can lead to stroke and coronary heart disease if it is
cognitive difficulties. Although it might seem to be a rel-
not recognized and treated (Jian & Zhou, 2008).
atively harmless condition, it can affect the safety and quality
of life and lead to serious negative functional consequences.
Studies have found that it may cause up to 30% of all synco-
NURSING ASSESSMENT OF
pal events and is associated with increased overall mortality
and increased risk of falls and cardiovascular diseases (Farrell, CARDIOVASCULAR FUNCTION
2009; van Hensbroek et al., 2009; Verwoert et al., 2008). From a wellness perspective, nursing assessment of cardio-
Moreover, hypotension is one of the few treatable neu-rologic vascular function focuses on identifying risks for cardiovas-
conditions that is a risk for falls (Arbogast, Al-shekhlee, cular disease and the older adult’s knowledge about his or her
Hussain, McNeeley, & Chelimsky, 2009). risk profile because many risks can be addressed through
Postprandial hypotension, defined as a systolic blood pres- health education interventions. Moreover, when older adults
sure reduction of 20 mm Hg or more within 2 hours of eating a would benefit from improving their health-related behaviors
meal, occurs in 34% to 65% of older adults (Jian & Zhou, (e.g., diet, exercise), nurses need to assess their readiness for
changing behaviors, as discussed in Chapter 5. Assessment of
physical aspects of cardiovascular function (e.g., heart rate,
blood pressure) is similar in older and younger adults, but
418 PA R T 4Promoting Wellness in Physical Function
nurses also need to assess for hypotension. In addition,
nurs-ing assessment needs to consider that older adults may
have atypical manifestations of cardiovascular disease (e.g.,
a heart attack).
Wellness Opportunity
Nurses address body–mind–spirit interconnectedness by identifying stress-
related factors that increase the risk for cardiovascular disease and
encouraging the use of stress management methods, such as meditation.
Assessing Baseline Cardiovascular Function
Physical assessment indicators of cardiovascular function
(e.g., peripheral pulses and heart rhythm and sounds) are
the same for all healthy adults. Nurses must keep in mind,
how-ever, that older adults are more likely to have chronic
condi-tions that affect cardiovascular function. The
following findings are common in older adults, but in the
absence of symptoms or other abnormal findings, they
usually are not indicative of any serious pathologic process:
● Auscultation of a fourth heart sound
● Auscultation of short systolic ejection murmurs
● Difficulty percussing heart borders
● Diminished or distant-sounding heart sounds
● Electrocardiographic changes such as arrhythmias, left
axis deviation, bundle branch blocks, ST-T wave
changes, and prolongation of the P-R interval.
If a murmur, arrhythmia, or any other unusual finding is
detected, it is important to determine whether it reflects a new
development, a preexisting but previously unidentified con-
dition, or a preexisting condition that has already been eval-
uated. The nurse asks questions to determine the person’s
awareness of such abnormal findings. Any of the following
terms might be used by older adults to describe arrhythmias:
fluttering, palpitations, skipped beats, extra beats, or flip-flops.
It is advisable to ask the older person about a history of
arrhythmias before auscultation, because asking immedi-ately
after auscultation could cause undue concern.
Arrhythmias may be caused by cardiac diseases, electrolyte
imbalances, physiologic disturbances, or adverse medication
effects; alternatively, they may be harmless manifestations of
age-related changes. Likewise, murmurs may be caused by
age- or disease-related conditions. Therefore, when murmurs
or arrhythmias are detected, their significance is assessed in
relation to the person’s history as well as in relation to the po-
tential underlying causes. It is also important to find out the
date of the person’s last electrocardiogram because this may
provide baseline information regarding the duration of asymp-
tomatic or unrecognized changes.
Assessing Blood Pressure
Although only a few nurses have primary responsibility for
medical management of blood pressure, all nurses are respon-
sible for accurate assessment of blood pressure and for deci-
sions regarding the implications of these findings. Thus, all
nurses need to be familiar with the most current guidelines for
detection of hypertension so that health promotion efforts can
be directed toward interventions. Despite mounting med-ical
evidence that the identification and management of hy-
pertension has important health benefits, fewer than 40% of
people with hypertension achieve good control in community
settings (Banegas et al., 2008). Nurses are in a key position to
detect hypertension, provide health education, and refer older
adults for further medical evaluation and treatment.
Accurately assessing blood pressure in older adults may be
more difficult than in younger adults for several reasons. First,
blood pressure in older adults is more variable and has an
increased tendency to fluctuate in response to postural changes
and other factors. In addition, older adults commonly have
pseudohypertension, which is the phenomenon of ele-vated
systolic blood pressure readings that result from the in-ability
of the external cuff to compress the arteries in older people
with arteriosclerosis. This phenomenon explains the finding of
extremely elevated systolic blood pressure readings in people
without any evidence of end-organ damage and with normal
diastolic blood pressure readings. Another as-sessment
consideration is the common occurrence of white coat
hypertension (also called isolated office hypertension), which
is the phenomenon of blood pressure readings being high
during office visits to a primary care practitioner but normal
when self-assessed at home.
In recent years, home blood pressure monitoring, which
is the practice of self-measurement of blood pressure, has been
endorsed by national and international guidelines in-cluding
those posted by the American Heart Association and the
Preventive Cardiovascular Nurses Association (Pickering et
al., 2008). Self-monitoring provides a more accurate as-
sessment base of information, which is particularly important
for older adults because they are more susceptible to white
coat hypertension and their systolic readings are more vari-
able. Moreover, self-measurement of blood pressure can also
be used to detect orthostatic or postprandial hypotension if
readings are taken in both sitting and standing positions. In
addition, studies suggest that home blood pressure monitor-ing
can lead to better control of hypertension if health care
professionals use the information and take appropriate action
(Mallick, Kanthety, & Rahman, 2009).
Assessment of blood pressure in older adults is aimed at
detecting not only hypertension but also orthostatic and
post-prandial hypotension. Box 20-2 summarizes
guidelines for accurate assessment of blood pressure in
older adults, includ-ing the technique for assessing for
orthostatic and postpran-dial hypotension.
Identifying Risks for Cardiovascular Disease
The assessment of risks for cardiovascular disease, with em-
phasis on identifying modifiable risk factors, provides a basis
for health promotion interventions. Hypertension, lipid dis-
orders, and smoking cessation (discussed in Chapter 21) are
 Box 20-2 Guidelines for Assessing Blood Pressure
For Accurate Blood Pressure Measurement in Older
Adults
● Recognize that blood pressure readings are likely to vary, particularly in
response to external factors (e.g., meals or postural changes).
● Blood pressure measurements are likely to have diurnal
variations, with lowest levels during the night and highest
levels after rising in the morning.
● The person should wait 1 hour after eating to have his or
her blood pressure checked, except when checking for
postprandial hypotension.
● The person should not have ingested caffeine or smoked
a ciga-rette within 30 minutes before having his or her
blood pressure checked.
● The person should be seated and resting for 5 minutes
before having his or her blood pressure checked.
For Assessment of Orthostatic Hypotension
● Maintain the person’s arm in the same position (either parallel or
perpendicular to the torso) during supine and standing positions.
● Obtain initial blood pressure reading after the person has
been in a sitting or lying position for at least 5 minutes.
● Obtain second blood pressure reading after the person
has been standing for 1 to 3 minutes.
For Assessment of Postprandial Hypotension
● Obtain initial blood pressure reading before a meal.
● Obtain second and third reading at 15-minute intervals
after the meal is completed.
Method of Assessing Blood Pressure
● The person should be seated with arm bared and feet flat
on the floor.
● Support the person’s arm as near to the heart level as possible.
● Ask the person to refrain from talking while you check his
or her blood pressure.
● Use a sphygmomanometer that has been checked for accuracy.
● Use an appropriate-sized cuff (i.e., the length of the cuff bladder
should be at least 80% of the circumference of the arm, and the
width should be 20% wider than the diameter of the arm).
important remediable conditions for older adults who have
these risks. In addition, obesity, physical inactivity, and
cer-tain dietary habits are risk factors that can be addressed
through improved health-related behaviors. Figure 20-1 is
an example of one of the many easy-to-use assessment
tools that are available to identify risk factors. Nurses can
use Box 20-3 as a guide for nursing assessment of risks.
Wellness Opportunity
Nurses promote personal responsibility and self-awareness by
teaching older adults to use self-assessment tools (e.g., Figure
20-1) to identify their risks for heart disease.
Assessing Signs and Symptoms of Heart Disease
Assessment of older adults for heart disease is complicated by
the fact that the symptoms often differ from the expected
manifestations. Congestive heart failure, for example, often
Cardiovascular Function CHAPTER20 419
● Record the cuff size that is used. (Cuffs that are too small
will yield falsely high readings, whereas cuffs that are too
large will yield falsely low readings.)
● Fit the deflated cuff firmly around the upper arm, with the center of
the cuff bladder over the brachial artery and the bottom of the cuff
about 1 to 11⁄2 inches above the bend of the arm.
● Inflate the cuff to 20 or 30 mm Hg above the palpated
systolic blood pressure.
● Deflate the cuff at a rate of 2 to 3 mm Hg per second.
● Measure systolic blood pressure at the first sound and
diastolic blood pressure at the onset of silence.
● If auscultatory gaps are heard, estimate the systolic blood
pressure by applying the cuff, palpating the radial pulse,
and inflating the cuff until the pulse is no longer felt.
● Record the magnitude and range of the gap (e.g., 184/82
mm Hg, auscultatory gap 176–148).
● If a very low diastolic blood pressure is heard, record the
onset of Korotkoff phases IV and V (e.g., 138/72/10 mm Hg).
Also, be sure not to press too hard on the stethoscope.
● Measure blood pressure in both arms the first time it is
assessed; then measure it in the arm with the higher
reading on subse-quent determinations.
● If sounds are difficult to auscultate, support the person’s arm above
his or her head for 30 seconds. Then inflate the cuff, have the
person lower the arm, and measure the blood pressure.
● If it is necessary to recheck the blood pressure in the same
arm, deflate the cuff fully before reinflating it and wait at
least 2 min-utes before taking another measurement.
Normal Findings
● Normal blood pressure is less than 120 mm Hg systolic blood
pressure, and less than 80 mm Hg diastolic blood pressure.
● The normal difference between lying/sitting and
standing systolic blood pressure is 20 mm Hg or less
after standing for 1 minute.
● The normal difference between lying/sitting and
standing diastolic blood pressure is 10 mm Hg or
less after standing for 1 minute.
begins very subtly, and the early manifestations may be men-
tal changes secondary to the physiologic stress. Thus, older
adults are likely to be in more advanced stages of heart failure
before an accurate diagnosis is made. Likewise, older people
with angina and acute myocardial infarctions are likely to have
subtle and unusual manifestations, called atypical pres-
entation, rather than the classic symptom of chest pain. Be-
tween one-fourth and two-thirds of all myocardial infarctions
are not clinically recognized as such, with women and older
adults having a higher rate of atypical presentation. Studies
also indicate that women and older adults are more likely to
seek help for atypical symptoms during the months before they
experience an acute coronary event (Graham, Westerhout,
Kaul, Norris, & Armstrong, 2008). Atypical signs and symp-
toms include fatigue; nausea; anxiety; headache; cough; visual
disturbance; shortness of breath; and pain in the jaw, neck, or
throat.
An important nursing assessment consideration is that older
adults as well as health care professionals are likely to attribute
420PA R T 4 Promoting Wellness in Physical Function

FIGURE 20-1 Example of an easy-to-use assessment tool for identifying risk factors for cardiovascular
disease. An interactive tool for assessing risk factors is available at http://www.nhlbi.nih.gov. (From U.S.
Department of Health and Human Services, Public Health Service, National Institutes of Health, National
Heart, Lung, and Blood Institute. [May 2001]. What is your risk of developing heart disease or having a heart
attack? NIH publication no. 01–3290. Rockville, MD: Author.) (continued)
 Cardiovascular Function CHAPTER20 421

FIGURE 20-1 (continued)

422 PA R T 4Promoting Wellness in Physical Function
Box 20-3 Guidelines for Assessing Risks
for Cardiovascular Disease in Older Adults
Questions to Identify Risk Factors
for Cardiovascular Disease
● Do you have, or have you ever had, any heart or
circulation problems (e.g., stroke, angina, heart attack,
blood clots, or pe-ripheral vascular disease)? If yes, ask
the usual questions about type of therapy, and so on.
● When was the last time you had an electrocardiogram?
● What is your normal blood pressure? Have you ever
been told that you have high blood pressure, or
borderline high blood pressure?
● Do you take, or have you ever taken, medications for heart
prob-lems or blood pressure? If yes, ask the usual questions
about type, dose, duration of therapy, and the like.
● Do you smoke, or have you ever smoked? If yes, ask
additional questions, such as those appropriate for
assessing respiratory func-tion, Chapter 21.
● Do you know what your cholesterol levels are? When
was the last time you had your cholesterol checked?
● Do you have diabetes? When was the last time you had your
blood sugar (glucose) level checked and what was the result?
● What is your usual pattern of exercise?
Additional Considerations Regarding Risk Factors
● Calculate BMI and compare the person’s ideal weight
to his or her present weight.
● Determine usual dietary habits, paying particular attention to
the person’s intake of sodium, fiber, and types of fat. (This infor-
mation is usually obtained during the nutritional assessment.)
atypical symptoms to other conditions, such as arthritis or indi-
gestion, or even to “normal aging.” Therefore, nurses need to keep
in mind that complaints about fatigue; digestion; respira-tion; or
pain in the arms, shoulders, or upper trunk can be indi-cators of
cardiac disease. Assessment is further complicated by the fact that
older adults often have more than one underlying condition that
could be responsible for these symptoms. It is not unusual, for
example, for an older person to have an esophageal reflux
disorder as well as a history of ischemic heart disease. Nurses also
need to consider that older adults who have mobility impairments
or other functional limitations may not be active enough to
experience exertion-related symptoms. Therefore, in addition to
focusing the assessment on the usual manifestations of
cardiovascular function, the nurse must incorporate informa-tion
about other systems and overall functioning. In addition, a
baseline electrocardiogram is helpful in establishing the possi-
bility of silent or atypical myocardial ischemia.
Assessing Knowledge About Heart Disease
In addition to assessing signs and symptoms, nurses need to as-
sess the older adult’s knowledge about manifestations of heart
disease. This is particularly important because immediate med-
ical attention is a major factor in determining outcomes of heart
attacks, and all people need to be aware of the warning signs so
that they can initiate appropriate help-seeking actions. Thus,
nurses should ask at least one question to determine the older
adult’s knowledge about the signs and symptoms of a heart at-
tack. Nurses also can include a question about what the person
would do and whom they would call if they thought they were
experiencing a heart attack. Box 20-4 summarizes the guide-
lines for assessing cardiovascular function and detecting car-
diovascular disease in older adults, emphasizes the assessment
components that are unique to older adults, and refers to addi-
tional assessment components that apply to adults in general.
DIVERSITY NOTE
Knowledge of heart attack and stroke symptoms is lacking
among adults in the United States and is lowest among older
adults, racial minorities, and other groups who are at highest
risk for cardiovascular disease (Bell et al., 2009).
NURSING DIAGNOSIS
If the nursing assessment identifies risks for cardiovascular
disease, a nursing diagnosis of Ineffective Health Mainte-
nance may be applicable. This diagnosis is defined as
Box 20-4 Guidelines for Assessing
Cardiovascular Function in Older Adults
Questions to Assess for Cardiovascular Disease
● Do you ever have chest pain or tightness in your chest?
If yes, ask the usual questions to explore the type, onset,
duration, and other characteristics.
● Do you ever have difficulty breathing? If yes, ask the usual
ques-tions regarding onset and other characteristics.
● Do you ever feel lightheaded or dizzy? If yes, ask about
specific circumstances, medical evaluation, and methods
of dealing with symptoms and ensuring safety.
● Do you ever feel like your heart is racing, is irregular, or has extra or
skipped beats? If yes, ask about any prior medical evaluation.
● Have you ever been told that you had a heart murmur? If
yes, ask about any prior medical evaluation.
Information Obtained During Other Portions
of an Assessment that May Be Useful in
Assessing Cardiovascular Function
● Do you tire easily or feel that you need more rest
than is ordinarily required?
● Do you have any problems with indigestion?
● Do your feet or ankles ever get swollen?
● Do you wake up at night because of difficulty breathing or be-
cause of any other discomfort? Have you made any adjustments
in your sleeping habits because of difficulty breathing (e.g., do
you use more than one pillow or sleep in a chair)?
● Do you have any pain in your upper back or shoulders?
Interview Questions to Assess for Postural Hypotension
● Do you ever feel lightheaded or dizzy, especially when you
get up in the morning or after you’ve been lying down?
● If yes: Is this feeling accompanied by any additional
symptoms, such as sweating, nausea, or confusion?
● If yes: Do any of the risks listed in Box 20-1 apply to
you? If yes, ask about any prior medical evaluation.
“inability to identify, manage, and/or seek out help to main-
tain health” (NANDA International, 2009). Related factors
common in older adults include lack of physical activity and
insufficient knowledge about preventive measures. For older
adults with impaired cardiovascular function, applicable nurs-
ing diagnoses may include Activity Intolerance, Decreased
Cardiac Output, and Ineffective Tissue Perfusion (Cardiopul-
monary). The nursing diagnosis of Risk for Injury may be ap-
propriate for older adults with orthostatic or postprandial
hypotension, particularly in the presence of additional risk
factors for falls and fractures (e.g., osteoporosis, neurologic
disorders, and medication side effects).
Wellness Opportunity
Nurses can use the wellness nursing diagnoses, Readiness for
Enhanced Nutrition or Readiness for Enhanced Knowledge, for older
adults who are interested in developing heart-healthy dietary habits or
learning about health-promoting behaviors to prevent heart disease.
PLANNING FOR WELLNESS OUTCOMES
When older adults have risks for cardiovascular disease,
nurses can apply any of the following Nursing Outcomes
Classification (NOC) terminologies to identify wellness out-
comes in their care plans: Health Orientation, Health-Promot-
ing Behavior, Knowledge: Diet, Knowledge: Health Behavior,
Risk Control: Cardiovascular Health, Risk Control: Tobacco
Use, and Weight Control. Wellness outcomes for older adults
with cardiovascular disease include Cardiac Dis-ease Self-
Management, Circulation Status, Health Seeking Behavior,
Knowledge: Cardiac Disease Management, Tissue Perfusion:
Cardiac, and Tissue Perfusion: Peripheral. Addi-tional
outcomes include maintaining blood pressure within the
normal range and preventing negative consequences of ortho-
static or postprandial hypotension (e.g., falls and fractures).
Wellness Opportunity
Nurses address body–mind–spirit interconnectedness by
including stress level as an outcome directed toward
reducing the risk for cardiovascular disease.
NURSING INTERVENTIONS TO PROMOTE
HEALTHY CARDIOVASCULAR FUNCTION
From a wellness perspective, nursing interventions to pro-
mote healthy cardiovascular function focus on primary and
secondary prevention of cardiovascular disease. These inter-
ventions address specific risk factors, such as smoking, hy-
pertension, obesity, and lipid disorders as well as preventive
measures, such as optimal levels of physical activity, heart-
healthy dietary patterns, and stress-reduction actions. Al-
though pharmacologic and medical interventions are often
Cardiovascular Function CHAPTER20 423
used to reduce risk factors, teaching about health promotion
actions is a nursing intervention that is appropriate in
almost all situations. In addition to addressing risks for
cardiovascu-lar disease, nurses can address orthostatic or
postprandial hy-potension and the related functional
consequences, such as falls and fractures.
Nurses can use the following Nursing Interventions Clas-
sification (NIC) terminologies in care plans to promote car-
diovascular wellness: Cardiac Care, Coping Enhancement,
Counseling, Exercise Promotion, Health Education, Medita-
tion Facilitation, Nutritional Counseling, Self-Responsibility
Enhancement, Simple Guided Imagery, Simple Relaxation
Therapy, and Teaching: Individual.
Addressing Risks Through Nutrition
and Lifestyle Interventions
Nutrition interventions can be used to address risk factors
in all adults and are particularly important for prevention or
management of obesity, hypertension, and lipid disorders.
Re-search reviews related to dietary influences on
cardiovascular disease support the following evidence-
based recommenda-tions (Katcher, Lanford, & Kris-
Etherton, 2009; Van Horn et al., 2008):
● 25% to 35% of energy needs should come from dietary fat,
with less than 7% coming from saturated fats and trans fats
combined, and with less than 200 mg/day of cholesterol
● Although 25 g/day of soy protein is a good substitute for
animal protein to decrease saturated fat intake, it does
not reduce LDL cholesterol to any significant degree
● Diets should include mushrooms, olive oil, cruciferous
vegetable, whole-grain breads, and foods that are high in
vitamin B complex
● 2 to 3 g/day of plant sterols and stanols (found in yogurt,
margarines, and some cereals) can decrease total choles-
terol and LDL cholesterol by as much as 15%; however,
sterols/stanols can reduce absorption of carotenoids and
fat-soluble vitamins
● Alcoholic beverages in the amount of one drink daily for
women and two drinks for men may be beneficial for
pre-venting cardiovascular disease; however, people
who do not consume alcohol should not start drinking
and it is clearly contraindicated in some conditions (e.g.,
car-diomyopathy, hypertension, arrhythmias, and risk
for alcoholism)
● Current evidence does not support the use of antioxidant
supplements, but diets should include fruits and vegetables
that are rich in nutrients, including antioxidants.
Many studies have looked at the effects of a Mediter-
ranean dietary pattern, which is characterized by higher in-
takes of fish, poultry, nuts, fruits, legumes, vegetables, and
lower intake of red and processed meats. Overall, the
Mediterranean dietary pattern results in lower intake of satu-
rated and trans fats and higher intake of monounsaturated and
polyunsaturated fats. In addition, complex carbohydrates are
the main type of carbohydrates. Research studies have found
424 PA R T 4Promoting Wellness in Physical Function information when they teach about the many positive func-
tional consequences of regular physical exercise.
that this dietary pattern has significant benefits both for pri- Smoking is a major risk factor for cardiovascular disease,
mary prevention of coronary heart disease in the general and quitting smoking is beneficial for people at any age. A
pop-ulation and for secondary prevention for people who longitudinal study found that smoking cessation was the most
already have pathologic changes (Lloyd-Jones et al., 2009; important independent predictor of mortality in patients who
Sparling & Anderson, 2009). had coronary artery bypass graft surgery, with those patients
The DASH dietary pattern, which refers to the Dietary who quit smoking gaining 3 years in life expectancy com-
Approaches to Stop Hypertension, is an evidence-based eat- pared with those who continued to smoke (van Domburg,
ing plan that is promoted by many organizations including Reimer, Hoeks, Kappetein, & Rogers, 2008). Benefits of
the National Institutes of Health and the American Heart smoking cessation as a secondary prevention intervention
As-sociation. This dietary pattern is characterized by high begin immediately and are as effective in older adults as they
intake of fruits, vegetables, and plant proteins from grains, are in younger people. An important nursing responsibility is
nuts, and legumes; moderate intake of low- or nonfat dairy to provide health education regarding smoking cessation, as
foods; and low intake of sodium and animal protein and is discussed in Chapter 21.
widely rec-ognized as a primary and secondary preventive
intervention for hypertension. Studies have identified the Secondary Prevention
following ben-eficial effects of DASH-type diets: lowered
When nurses care for older adults who have cardiovascular dis-
blood pressure, decreased LDL and triglyceride levels,
ease, referrals for secondary prevention programs, such as car-
lower risk of coronary heart disease and stroke, and lower
diac rehabilitation, are an important part of care (Figure 20-2).
all-cause mortality in peo-ple with hypertension (Fung et
Despite evidence-based guidelines recommending cardiac re-
al., 2008; Lloyd-Jones et al., 2009; Parikh, Lipsitz, &
habilitation programs, referral rates are low and one study found
Natarajan, 2009). A longitudinal study of women who
that only 14% of Medicare patients with acute myocar-dial
developed heart failure found that women who followed the
infarctions had enrolled (Mazzini, Stevens, Whalen, Ozonoff, &
DASH diet had a 37% lower rate after adjusting for other
Balady, 2008). Although referrals need to be ini-tiated by primary
risk factors (Levitan, Wolk, & Mittleman, 2009).
Another focus of nutrition-related research is on the poten-tial care practitioners, nurses have an important responsibility to
benefits of commonly consumed foods and beverages, such as encourage participation when referrals are
chocolate and tea, that are rich in polyphenols. There is in-
creasing evidence that cocoa and chocolate may improve car-
diovascular function and exert antioxidant, anti-inflammatory,
antiplatelet, and antihypertensive effects (Frishman, Beravol,
& Carosella, 2009). Epidemiologic studies indicate that cocoa
and other polyphenols can reduce the risk of cardiovascular
disease, but long-term clinical trials are needed before
evidence-based recommendations can be determined (Corti,
2009; Grassi, 2009). Similarly, although epidemiologic stud-
ies have found an association between green tea intake and
reduced risk for cardiovascular disease, clinical trials are not
sufficient to support an evidence-based recommendation
(Ferguson, 2009; Schneider & Segre, 2009). One study found
that highly fermented black tea may be equally potent as green
tea in promoting beneficial cardiovascular effects (Lorenz et
al., 2009).
Additional lifestyle interventions that are effective for pre-
venting cardiovascular disease include remaining physically
active, managing stress, refraining from smoking, and main-
taining ideal body weight. Research reviews identify strong
evidence supporting the importance of physical exercise as an
intervention for preventing cardiovascular disease and im-
proving life expectancy (Katcher et al., 2009). Specific pos-
itive effects on cardiovascular function identified in studies
include weight loss; reduced blood pressure; improved overall
cardiac function; lower rates of cardiovascular disease; im-
proved lipid, glucose, and triglyceride levels; and decreased FIGURE 20-2 Exercise is an important preventive intervention.
risk of developing diabetes and cardiovascular disease (Nesto, (Courtesy of Monte Unetic.)
2008). Positive effects of exercise on other aspects of health
are noted throughout this text, and nurses can incorporate this
made. Nurses also can suggest that patients ask their
primary care practitioners about a referral for preventive
services such as stress management, cardiac rehabilitation,
smoking cessa-tion, or exercise counseling.
DIVERSITY NOTE
Asians, Hispanics, and Native Americans are less likely than
white older adults to receive post–acute cardiac rehabilitation
services (Dolansky et al., 2010).
Wellness Opportunity
Nurses communicate positive attitudes about aging by talking
with older adults about personal responsibility for addressing
risks for car-diovascular disease and communicating that it’s
never too late to incor-porate healthy behaviors into daily life.
Addressing Risks Through
Pharmacologic Interventions
Before and during the 1990s, hormonal replacement therapy
was recommended for menopausal women as an intervention
for preventing cardiovascular disease. This recommendation
was based on epidemiologic studies, but it was reversed in
2002 when longitudinal and large-scale investigations con-
cluded that risks outweighed the benefits as a preventive
intervention. The use of low-dose aspirin is another pharma-
cologic intervention that has been investigated for the preven-
tion of cardiovascular disease, with emphasis on determining
whether the potential benefits outweigh the increased risks for
gastrointestinal bleeding and hemorrhagic stroke. In the early
2000s, studies concluded that the balance of benefit and harm
is most favorable in people with a high risk for, or a history of,
cardiovascular disease. In 2009, the U.S. Preventive Task
Force (USPTF, 2009) published updated evidence-based
guidelines with the following recommendations:
● Men aged 45 to 79 years and women aged 55 to 79
years: encourage aspirin use when potential
cardiovascular ben-efit outweighs potential harm of
gastrointestinal hemor-rhage or ischemic strokes
● Men and women aged 80 years and older: no recommen-
dation due to insufficient evidence
Box 20-5 summarizes health education interventions
regard-ing risk for cardiovascular disease in older adults.
Preventing and Managing Hypertension
Although relatively few nurses prescribe medications for hy-
pertension, all nurses need to understand current guidelines
and recommendations for management of hypertension be-
cause they are responsible for making appropriate decisions
related to blood pressure. Nursing interventions for people
with hypertension also include evaluating a patient’s response
to prescribed medications and teaching about interventions for
hypertension. In addition, nurses can promote wellness
Cardiovascular Function CHAPTER20 425
Box 20-5 Health Promotion Activities to
Reduce the Risks for Cardiovascular Disease
Detection of Risks
● Have blood pressure checked annually.
● If the total serum cholesterol level is less than 200 mg/dL,
have it rechecked every 5 years. If the total serum
cholesterol level is between 200 and 239 mg/dL, follow
dietary measures to re-duce it and have it rechecked
annually. If the total serum cho-lesterol level is 240 mg/dL
or more, obtain a further medical evaluation.
Reduction of Risks
● Give high priority to smoking cessation, if you smoke.
● Avoid passive smoking (i.e., inhaling smoke from other
people’s cigarettes).
● Maintain weight at a level less than 110% of ideal weight.
● Exercise daily, and engage in aerobic exercise (i.e.,
exercise that increases the pulse rate) several times
weekly for 30 to 45 min-utes each time.
● Avoid foods that are high in sodium, and follow dietary
meas-ures to reduce serum cholesterol levels.
● Discuss with your primary care provider the use of low-dose as-
pirin therapy as a preventive measure, particularly if there is any
history of coronary artery disease or cerebrovascular events.
by teaching about self-care measures for preventing and treat-
ing hypertension. This is particularly important because
lifestyle modifications—including diet, weight loss, physical
activity, and moderation of alcohol—are an integral compo-
nent of effective hypertension management (Padiyar, 2009).
The stepped-care approach to management of hyperten-
sion was introduced in the first JNC report, published in the
1970s, and it has been consistently recommended in subse-
quent reports. This approach recommends that lifestyle mod-
ifications be tried initially, followed by pharmacologic
interventions to achieve ideal blood pressure. Lifestyle inter-
ventions that have the most significant impact on hyperten-
sion are substantial weight loss and a dietary pattern that
includes low-sodium and high-potassium foods (Sica, 2008).
Dietary guidelines for the United States recommend that daily
sodium intake be no more than 2300 mg/day for children aged
2 years and older and that it be no more than 1500 mg/ day for
those in specific groups, including all blacks, people with
hypertension, and all middle-aged and older adults. This
recommendation for lower sodium intake applies to 69.2% of
U.S. adults; however, national surveys estimate that the
average intake of sodium among children aged 2 years and
older is more than 3400 mg/day (CDC, 2009). Thus, nurses
have important responsibilities with regard to teaching older
adults and their caregivers about sodium intake.
Many medications are used for treating hypertension, and
selection of the best medication is based on variables such as
therapeutic effectiveness and the presence of concomitant
conditions. The classes of medications that are used most
commonly to manage hypertension are diuretics, beta-
blockers, angiotensin-converting enzyme (ACE) inhibitors,
426 PA R T 4Promoting Wellness in Physical Function
Box 20-6 Guidelines for Nursing Management of Hypertension
Health Promotion Interventions
The following lifestyle modifications are recommended
for all people with hypertension:
● Avoidance of tobacco
● Weight reduction when appropriate (i.e., when the person
weighs more than 110% of his or her ideal weight)
● 30 to 45 minutes of exercise, such as brisk walking, at
least five times weekly
● Limitation of alcohol intake to one drink per day (e.g., 2 ounces of
100-proof whiskey, 8 ounces of wine, or 24 ounces of beer).
The following nutritional interventions are recommended
for all people with hypertension:
● Sodium intake limited to 1.5 g daily
● Avoidance of processed foods
● Daily intake of 7 to 8 servings of grains and grain
products and 8 to 10 servings of fruits and vegetables
and calcium channel blockers. Studies have found that all
of these classes of antihypertensives are equally effective,
but individual patient responses may vary depending on
factors such as age and ethnicity. For example, one large
study found that a calcium channel blocker was more
effective in blacks, an ACE inhibitor was best for young
white men, and a beta-blocker worked best in older white
men (Sica, 2008). Another research review concluded that
the additive effect of antihy-pertensives from two different
classes is approximately five times more effective in
lowering blood pressure than increas-ing the dose of one
drug (Wald, Law, Morris, Bestwick, & Wald, 2009).
In recent years, there is increasing emphasis on selecting a
drug that not only treats hypertension but also prevents major
cardiovascular events and mortality. A review of studies con-
cluded that the type of drug used was less important than the
degree to which blood pressure is controlled with regard to
reducing the risk of major cardiovascular events (Sica, 2008).
Selection of antihypertensives also is based on consideration
of potential adverse effects, which is particularly important for
older adults (Corrigan & Pallaki, 2009). For example, there is
increasing concern about adverse metabolic effects associated
with diuretics and beta-blockers in some people (Johnson et
al., 2009). One advantage of combining drugs from two
classes is that hypertension can be controlled effec-tively and
with fewer adverse effects with lower doses of each drug
(Wald et al., 2009). Box 20-6 summarizes guidelines for
interventions for hypertension and includes health education
information about nutrition and lifestyle interventions. Re-
sources for health education and evidence-based practice for
hypertension are listed at the end of this chapter. Figure 20-3
illustrates examples of some of the culturally specific health
education materials that are available at the National Institutes
of Health.
Considerations Regarding the Treatment of Hypertension
● Risks from and definitions of hypertension apply to all
age cate-gories (refer to Table 20-1 for criteria).
● A person’s blood pressure should be measured at least
three times before making any decisions about treatment.
● Home blood pressure monitoring is recommended for
initial and on-going assessment.
● The safety of antihypertensive agents is improved by carefully se-
lecting the medication, starting with low doses, and changing the
medication regimen gradually, in small increments, if necessary.
● The goals of hypertensive treatment are to control blood
pressure by the least intrusive means and to prevent
cardiovascular mor-bidity and mortality.
● Treatment is directed toward achieving and maintaining a
systolic blood pressure of ,130/80 mm Hg if this can be
achieved with-out compromising cardiovascular function.
● For older adults with isolated systolic hypertension or
systolic blood pressure levels of 140 to 160 mm Hg,
lifestyle modifications should be the first treatment step.
DIVERSITY NOTE
Asian/Pacific Islander Americans are more likely than whites to experi-
ence coughing as an adverse effect of ACE inhibitors (Watson, 2009).
Wellness Opportunity
Nurses promote personal responsibility for managing hypertension
by talking with older adults about self-monitoring of blood pressure.
M r. C. is now 70 years old and his blood pressure
fluctuates between 130/88 and 146/94 mm Hg. He con-
tinues to take hydrochlorothiazide, 25 mg, and verapamil,
120 mg, every morning. Mr. C. and his wife live with their
daughter and her teenage children. Mr. and Mrs. C. usually
do the family grocery shopping, and his wife and daughter
prepare the family meals. A diet history reveals that the
family usually eats fried fish or chicken about four times a
week and pig’s feet or ham hocks for the other main meals.
Common side dishes are corn, okra, grits, cornbread, sweet
potatoes, black-eyed peas, and fried greens. For cooking,
the family uses lard, salt pork, or bacon drippings. Their
usual beverage is decaffeinated coffee with sugar and
cream. The family generally has cereal and toast for break-
fast, but they have bacon and eggs on Saturdays and
Sundays. Mr. and Mrs. C. eat their noon meal at the
 Cardiovascular Function CHAPTER20 427

senior center 5 days a week. Mr. C.’s weight is still

T H I N K I N G P O I N T S

about 30 pounds more than his ideal weight. For the
past several years, he has participated in the exercise
program at the senior center, but gets little additional
exercise and con-tinues to complain of “getting
winded” when he walks across the parking lot.
● What additional information would you obtain for
fur-ther assessment of Mr. C.’s cardiovascular status?
● What nutritional and lifestyle interventions would
you discuss with Mr. C. regarding his hypertension?
● What teaching materials would you use for health ed-
ucation with Mr. C.?

A B

C D
FIGURE 20-3 Examples of culturally specific health education materials that are available from
the National Institutes of Health.
428 PA R T 4Promoting Wellness in Physical Function
Preventing and Managing Lipid Disorders
Although nurses usually do not prescribe medications for treat-
ment of lipid disorders, they are responsible for teaching about
preventing and managing lipid disorders. Thus, nurses need to be
familiar with lipid disorders treatment guidelines, such as the ATP
70 mg/dL (Sachdeva et al., 2009). For links to the most up-to-
date guidelines visit at http://thePoint.LWW.com/
Miller6e. The updated ATP recommendations (Grundy et al.,
2004) lists the following conditions as risk factors:
● Cardiovascular disease (e.g., angina, angioplasty, bypass
surgery)
● Cerebrovascular conditions (e.g., ischemic stroke, transient

III. This revised report focuses on people aged 50 years and older
and encourages health care providers to con-sider a number of risk
factors for people of any age when eval-uating the need for
interventions. Thus, goals for lipid profiles vary depending on the
number of risk factors. For example, the LDL goal for healthy
people with no risk factors is less than 160 mg/dL, but the LDL
goal for someone with multiple risks is less than 100 mg/dL.
Recent evidence indicates that the ther-apeutic goal for LDL in
high-risk patients should be less than
ischemic attacks, symptomatic carotid artery stenosis)
● Peripheral vascular conditions
● Diabetes mellitus.
As with treatment of hypertension, nutrition and lifestyle
interventions are the first-line approaches, and medications
(e.g., statins) are prescribed if goals are not achieved with non-
pharmacologic interventions. Essential nutrition and lifestyle

Box 20-7 Nutritional Interventions for People With High Cholesterol

Dietary Measures to Promote a Healthy Lipid Profile

● Include foods that are high in fiber content in your daily diet (e.g., whole grains).
● Include soy proteins in your daily diet (e.g., tofu, soy milk).
● Eat a minimum of two servings of fatty fish weekly.
● Limit total fat intake to less than 30% of your total daily calorie intake.
● Limit total daily cholesterol intake to 200 mg.
● Use nonfat or low-fat dairy desserts.
● Consumption of butter or margarine should be limited, but margarines that contain
stanols are beneficial (e.g., Becanol).
● Use egg whites, omega-3 eggs, or egg substitutes.
● Limit consumption of lean meats to five or fewer 3- to 5-ounce servings per week.
Trim fat off meats and the skin off poultry.
● Avoid eating processed meats (e.g., bacon, bologna, sausage, hot dogs).
● Avoid gravies, fried foods, and organ meats.

Guide to Types of Fats

Effect on Lipid
Type of Fat Sources Examples Profile
Saturated fatty acids Animal fats and Meat, poultry, butter, Negative: increases
some vegetable and lauric and LDL and total
oils (usually solid at palm oils cholesterol
room tempera-
tures)
Trans fatty acids Vegetable oils that Dairy products, Negative: increases
are processed into baked goods, snack LDL cholesterol
margarine or short- foods and lowers HDL
ening cholesterol
Monounsaturated fatty acids Vegetable oils (usu- Olive, peanut, and Positive: decreases
ally liquid at room canola oils LDL
temperatures)
Polyunsaturated fatty acids Seafood Corn, sunflower, saf- Positive: decreases
and veg- flower, canola, and LDL
etable oils (soft or linoleic oils
liquid at room tem-
peratures)
Omega-3 fatty acids Fatty fish Tuna, salmon, Positive: decreases
herring, mackerel LDL cholesterol
and triglycerides

LDL, low-density lipoprotein; HDL, high-density lipoprotein.


Box 20-8 Education Regarding Orthostatic and Postprandial Hypotension
Preventing and Managing Orthostatic
and Postprandial Hypotension
● Maintain adequate fluid intake (i.e., eight glasses of
noncaf-feinated beverages daily).
● Eat five or six smaller meals daily, rather than large meals.
● Avoid excessive alcohol consumption.
● Avoid sitting or standing still for prolonged periods,
especially after meals.
Health Promotion Measures Specific to
Orthostatic Hypotension
● Change your position slowly, especially when moving
from a sit-ting or lying position to a standing position.
● Before standing up, sit at the side of the bed for several
minutes after rising from a lying position.
● Maintain good physical fitness, especially good muscle tone, and
engage in regular, but not excessive, exercise. (Swimming is an
excellent form of exercise because the hydrostatic pressure pre-
vents blood from pooling in the legs.)
● Wear a waist-high elastic support garment or thigh-high
elastic stockings during the day, and put them on before
getting out of bed in the morning.
● Sleep with the head of the bed elevated on blocks.
● During the day, rest in a recliner chair with your legs elevated.
● Take measures to prevent constipation and avoid straining
during bowel movements.
interventions for lipid disorders include dietary modifications,
maintenance of ideal body weight, and incorporation of reg-
ular exercise in one’s daily routine. Nutrition interventions
focus on dietary fat intake, with emphasis on limiting foods
containing saturated fats and trans fatty acids and increasing
foods that are high in polyunsaturated and monounsaturated
fats. Box 20-7 summarizes health education interventions for
prevention and management of lipid disorders in older adults.
Preventing and Managing Orthostatic
or Postprandial Hypotension
Interventions aimed at preventing orthostatic and postpran-dial
hypotension can be initiated as health measures for older
adults who have any of the risk factors listed in Box 20-1. For
older adults with symptomatic orthostatic hypotension, inter-
ventions to alleviate the problem are important for maintain-
ing quality of life and preventing serious consequences. In
addition, nurses address safety issues by implementing inter-
ventions that are directed toward preventing falls and frac-
tures, as discussed in Chapter 22.
For older adults with postprandial hypotension, interven-
tions can be implemented around mealtimes. In institutional or
home care settings, registered dietitians may be helpful in de-
veloping a plan for addressing postprandial hypotension, but in
any setting, nurses assume responsibility for health educa-tion
about interventions. In older adults with postprandial
hypotension, low-carbohydrate meals may be effective in
Cardiovascular Function CHAPTER20 429
● Avoid medications that increase the risk for orthostatic
hypotension, particularly if additional risk factors are
present (refer to Box 20-1).
● Avoid sources of intense heat (e.g., direct sun, electric
blankets, and hot baths and showers) because these
cause peripheral vasodilation.
● If taking nitroglycerin, do not take it while standing.
Health Promotion Measures Specific
to Postprandial Hypotension
● Minimize the risk for postprandial hypotension by taking
antihy-pertensive medications (if prescribed) 1 hour after
meals rather than before meals.
● Eat small, low-carbohydrate meals.
● Avoid alcohol consumption.
● Avoid strenuous exercise, especially for 2 hours after meals.
Safety Precautions if Hypotension Cannot Be Prevented
● Reduce the potential for falls and other negative functional
conse-quences of postprandial hypotension by remaining
seated (or by lying down) after meals.
● Call for assistance if help is needed with walking.
● Adapt the environment to minimize the risk and
consequences of falling (e.g., ensure good lighting, install
grab bars, keep pathways clear).
addressing postprandial hypotension. Also, agents that slow down
the rate of gastric emptying, such as xylose and the nat-ural food
supplement guar gum, may alleviate postprandial hy-potension.
One study found that the hypoglycemic agent acarbose is effective
and safe for treating postprandial hypoten-sion (Jian & Zhou,
2008). Additional interventions are sum-marized in Box 20-8,
which can be used as a tool for educating older adults about
orthostatic and postprandial hypotension.
EVALUATING EFFECTIVENESS
OF NURSING INTERVENTIONS
One measure of the effectiveness of health promotion inter-
ventions is the extent to which the older adult verbalizes cor-
rect information about the risks. Also, the older adult may
verbalize intent to change or eliminate the lifestyle factors that
increase the risk of impaired cardiovascular function. For ex-
ample, the older adult may agree to join an exercise program
and follow dietary measures to reduce serum cholesterol lev-
els. Effectiveness of interventions can also be measured by
determining the actual reduction in risk factors. For example,
the person’s serum cholesterol level may decrease from 238 to
198 mg/dL after 6 months of regular exercise and dietary
modifications. For older adults with impaired cardiovascular
function, nurses evaluate the extent to which the signs and
symptoms are alleviated and the extent to which older adults
verbalize correct information about managing their condition.
430 PA R T 4Promoting Wellness in Physical Function

M r. C. is now 74 years old and continues to come to the Senior Wellness Clinic for
monthly blood pressure checks. He reports that his doctor recently started him on a
medication for high cholesterol and told him to “watch my diet,” but gave no further
information or educational mate-rials about what to do about his cholesterol.

N U R S I N G A S S E S S M E N T

Mr. C. has no knowledge about dietary sources of choles- he does not know which foods are good or bad. He tries to
terol, and is unaware that his diet, which he terms “soul buy foods that say “no cholesterol” on the label, but says
food,” is high in cholesterol. Although he says that he has that the labels are too confusing about the different kinds of
heard a lot about “good and bad cholesterol” in the news, fats.

N U R S I N G D I A G N O S I S

Your nursing diagnosis is Altered Health Maintenance related
to lack of regular exercise, dietary habits that contribute to
hyperlipidemia, and insufficient information about lifestyle
factors that increase the risk of cardiovascular disease. Evi-
dence of these risk factors comes from Mr. C.’s inactivity,
eating patterns, history of hypertension, and family history
of cardiovascular disease. Also, Mr. C. has verbalized
insuf-ficient information about the relationship between
exercise and cardiovascular function and about dietary
measures to control cholesterol.

N U R S I N G C A R E P L A N F O RM R . C .

Expected Outcome Nursing Interventions Nursing Evaluation

Mr. C.’s knowledge of risk
factors for cardiovascular
impairment will increase.
Mr. C.’s knowledge of the
relationship
between diet and
serum cholesterol
levels will increase.
• Discuss the risk factors for impaired • Mr. C. will be able to
cardiovascular function, using Figure 20-1 and describe his risk factors for
information from Box 20-3. cardiovascular disease.
• Emphasize the risk factors that can be • Mr. C. will identify those risk
addressed through lifestyle modifications factors that he can address
(e.g., exercise, weight loss, and dietary through lifestyle changes.
measures to control cholesterol levels).
• Use teaching materials obtained from the American • Mr. C. will accurately describe
Heart Association to illustrate the relationship the relationship between food
between diet and serum cholesterol levels. Provide intake and cholesterol levels.
a copy of these pamphlets for Mr. C. to take home.
• Suggest that Mr. C. discusses the information in • Mr. C. will identify family eating
the pamphlets with his wife and daughter. habits that contribute to his
elevated serum cholesterol level.
• Ask Mr. C. to bring his wife to the nursing clinic
next month so that you can talk with both of them
about dietary measures to control cholesterol.

Mr. C. will modify one
dietary habit that
contributes to his high
cholesterol level.
• Work with Mr. C. to make a list of the foods
associated with high cholesterol levels (e.g.,
fried foods, ham hocks, lard, bacon, and eggs).
• Give Mr. C. a copy of Box 20-7 and use it to
discuss dietary measures to reduce cholesterol.
• Ask Mr. C. to select one change in dietary habits that
will have a positive effect on his cholesterol level (e.g.,
switching from lard to vegetable oil for frying foods).
• Mr. C. will state that he is willing to
change one eating habit that con-
tributes to his high cholesterol level.
• Next month, Mr. C. will report
that he has changed one
eating pattern that contributes
to high cholesterol levels.
 Cardiovascular Function CHAPTER20 431

Expected Outcome Nursing Interventions Nursing Evaluation

Mr. C. will increase his
knowledge about the
relationship between
exercise and
cardiovascular function.
Mr. C. will begin
exercising on a regular
basis.
Mr. C. will eliminate
lifestyle factors that
increase the risk for
cardiovascular disease.
• Use pamphlets from the American Heart Association • Mr. C. will describe the
to teach about the effects of aerobic exercise on beneficial effects of regular
cardiovascular function. aerobic exercise.
• Review information about the relationship between
exercise and weight.
• Discuss ways in which Mr. C. can incorporate regular • Mr. C. will verbalize a commit-
exercise into his daily activities. ment to perform 30 minutes of
exercise 3 days a week.
• Invite Mr. C. and his wife to participate in the
daily Eldercise program that is offered following
the noon meal at the senior center.
• Ask Mr. C. to invite his wife to your monthly • Mr. C.’s total cholesterol
appointments so that she can also receive level will be #200 mg/dL at
important health education. the end of 6 months.
• Identify a plan that will enable Mr. and Mrs. C. • Mr. C.’s serum cholesterol level
to gradually incorporate additional dietary will remain below 200 mg/dL.
measures aimed at reducing cholesterol into
the family meal plans. • Mr. C. will report that he
engages in 30 minutes of
exercise 5 times weekly.
• Identify a plan that will enable Mr. and Mrs. C. • Mr. C. will report that he follows
to include 30 minutes of exercise 5 times the dietary measures presented in
a week. Box 20-7.

• Discuss weight reduction with Mr. C. and emphasize • Mr. C.’s weight will be reduced
that dietary modifications and regular exercise are to between 180 and 198 pounds,
interventions that should facilitate weight loss. and he will maintain that weight.

T H I N K I N G P O I N T S

● What factors affect Mr. C.’s ability to manage his cardio- ● Explore some of the health education listed at the end of
vascular condition and address his risk factors, and how this chapter to find teaching tools that would be
would you address these factors in your interventions? appropri-ate for Mr. C.

Chapter Highlights • Heredity and socioeconomic factors

• Special considerations for women and minority groups
Age-Related Changes That Affect
Cardiovascular Function Functional Consequences Affecting
• Degenerative changes of myocardium Cardiovascular Wellness
• Arterial stiffening • Effects on cardiac function
• Thicker, less elastic, more dilated veins • Effects on pulse and blood pressure
• Increased peripheral resistance • Effects on response to exercise
• Altered baroreflex mechanisms • Effects on circulation
Pathologic Condition Affecting Cardiovascular
Risk Factors That Affect Cardiovascular Function
Function • Orthostatic and Postprandial Hypotension
• Atherosclerosis
• Physical inactivity Nursing Assessment of Cardiovascular Function (Figure
• Tobacco smoking 20-1; Table 20-1; Boxes 20-2 through 20-4)
• Dietary habits • Baseline cardiovascular function (heart rate, sounds,
• Obesity, especially abdominal obesity and rhythm)
• Hypertension • Blood pressure, including hypertension and orthostatic or
• Lipid disorders postprandial hypotension
• Metabolic syndrome • Risks for cardiovascular disease, with emphasis on modi-
• Psychosocial factors fiable conditions
432 PA R T 4Promoting Wellness in Physical Function
• Signs and symptoms of heart disease
• Knowledge about heart disease
Nursing Diagnosis
• Ineffective Health Maintenance
• Decreased Cardiac Output
• Ineffective Tissue Perfusion (Cardiopulmonary)
Planning for Wellness Outcomes
• Health-Promoting Behaviors
• Risk Control: Cardiovascular Health
• Risk Control: Tobacco Use
• Cardiac Disease Self-Management
Nursing Interventions to Promote Healthy
Cardiovascular Function (Boxes 20-5
through 20-8; Evidence-Based Practice)
• Teaching about nutrition and lifestyle interventions
(exer-cise, heart-healthy diet, optimal body weight,
cessation of smoking if applicable)
• Evidence-based practice related to promoting cardiovas-
cular health
• Referrals for secondary prevention programs for
older adults who have cardiovascular disease
• Pharmacologic interventions for prevention of
cardiovascular disease
• Lifestyle and pharmacologic interventions
for hypertension
• Medication, nutrition, and lifestyle interventions for lipid
disorders
• Prevention and management of orthostatic and
postpran-dial hypotension
Evaluating Effectiveness of Nursing Interventions
• Verbalization of correct information about risks
• Reported participation in health promotion interventions
(e.g., heart-healthy diet, regular exercise, weight reduc-
tion, and smoking cessation when applicable)
• Indicators of cardiovascular function within normal
range (e.g., blood pressure, serum lipids)
• If applicable, alleviation of signs and symptoms of
cardiovascular disease
Critical Thinking Exercises
1. Discuss how each of the following factors influences
car-diovascular function, including orthostatic
hypotension: lifestyle, medications, age-related changes,
and pathologic conditions.
2. Demonstrate how you would teach a home health aide to
assess blood pressure and orthostatic hypotension correctly.
3. Describe the questions and considerations that you
would include in an assessment of cardiovascular
function in an older adult who has no complaints of
heart problems, but who has a history of falling twice in
the past month and who has not been evaluated by a
primary care provider in the past year.
4. You are asked to give a health education talk entitled
“Keeping Your Heart Healthy” at a senior center. What
in-formation would you include in the presentation?
What local resources (i.e., specific contact information
for agen-cies or organizations in your area) would you
suggest your audience contact for further information?
What audiovi-sual aids would you use? How would you
involve the par-ticipants in the discussion?
5. You are working in an assisted-living facility in which
sev-eral of the residents have orthostatic hypotension.
What would you include in your health education
regarding management of orthostatic hypotension?
Resources
For links to these resources and additional helpful Internet
resources related to this chapter, visit at http://thePoint.
lww.com/Miller6e.
Clinical Tools
American Heart Association
• Interactive self-assessment tools related to blood
pressure and cardiovascular risks
• Interactive quizzes to test heart-health knowledge on topics
such as fats, cholesterol, physical activity, and high
blood pressure
Hartford Institute for Geriatric Nursing
• Try This: Best Practices in Nursing Care to Older
Adults Issue SP3 (2010), Cardiac Risk Assessment of
the Older Cardiovascular Patient; The Framingham
Global Risk Assessment Tools
Issue SP4 (2010), Vascular Risk Assessment of the Older
Cardiovascular Patient: The Make-Brachial Index
(ABI) National Heart Lung and Blood Institute
• Health-risk calculators related to blood pressure and
heart conditions
Evidence-Based Practice
Mosca, L., Banks, C. L., Benjamin, E. J., Berra, K., Bushnell,
C., Dolor, R. J., et al. (2007). Evidence-based guidelines for
car-diovascular disease prevention in women: 2007 update.
Circulation, 115, 1481–1501. National
Heart Lung and Blood Institute
• Cardiovascular Risk Reduction Guidelines in Adults: Cho-
lesterol Guideline Update (ATP IV), Hypertension Guideline
Update (JNC 8), Obesity Guideline Update (Obesity 2),
Integrated Cardiovascular Risk Reduction Guideline.
National Guideline Clearinghouse
• Diet and lifestyle recommendations for cardiovascular
health
• Exercise promotion: walking in elders
• Nutrition practice guideline for hypertension
• Lipid disorders
• Hypertension
Health Education
American Heart Association
• Heart-health information in Spanish, Vietnamese, Simplified
Chinese, and Traditional Chinese
American Stroke Association
Centers for Disease Control and Prevention
• WISEWOMAN program to prevent disease among
women most in need
 • Office of Minority Health: information on cardiovascular
disease in racial and ethnic minority
populations DASH diet
Heart and Stroke Foundation of Canada
National Heart, Lung, and Blood Institute
• Publications about heart health for selected audiences, includ-
ing African Americans, Asian Americans/Pacific Islanders,
Latinos, Native Americans/Alaska Natives, and Women
• Online toolkit with resources to address heart disease in
women
• Latino Cardiovascular Health Resources: Salud para
su Corazon (For the health of your heart)
National Stroke Association
REFERENCES
Lichtenstein, A. H., Appel, L. J., Brands, M., Carnethon, M., Daniels, S.,
Franch, H. A., . . . Wylie-Rosett, J. (2006). Diet and lifestyle recom-
mendations revision 2006: A scientific statement from the American
Heart Association Nutrition Committee. Circulation, 114(1), 82–96.
Arbogast, S. D., Alshekhlee, A., Hussain, Z., McNeeley, K., & Chelimsky, T.
C. (2009). Hypotension unawareness in profound orthostatic hy-potension.
The American Journal of Medicine, 122, 574–580.
Aronow, W. S. (2008). Hypertension and the older diabetic. Clinics
in Geriatric Medicine, 24, 489–501.
Banegas, J. R., Segura, J., de la Sierra, A., Gorostidi, M., Rodriguez-
Artalejo, F., Sobrinho, J., . . . Spanish Society of Hypertension
ABPM Registry Investigators. (2008). Gender differences in office
and ambulatory control of hypertension. The American Journal of
Medicine, 121, 1078–1084.
Bell, M., Lommel, T., Fischer, J. G., Lee, J. S., Reddy, S., & Johnson, M.
A. (2009). Improved recognition of heart attack and stroke symptoms
after a community-based intervention for older adults, Georgia, 2006–
2007. Preventing Chronic Disease, 6(2), 1–11.
Berra, K. (2008). Lipid-lowering therapy today. Journal of
Cardiovascular Nursing, 23(5), 414–421.
Cademartiri, F., LaGrutta, L. L., de Feyter, P. J., & Kresstin, G. P. (2008).
Physiopathology of the aging heart. Radiology Clinics of North
America, 46, 653–662.
Carr, M C., & Tannock, L. L. (2009). Body-fat distribution and
mortality risk: Thinking small. Circulation, 117, 1627.
Centers for Disease Control and Prevention. (2009). Application of lower
sodium intake recommendations to adults: United States, 1999–2006.
MMWR: Morbidity and Mortality Weekly Report, 58(11), 281–283.
Corrigan, M. V., & Pallaki, M. (2009). General principles of hypertension
management in the elderly. Clinics in Geriatric Medicine, 25, 207–212.
Corti, R. (2009). Cocoa and cardiovascular health. Circulation,
119, 1433–1441.
D’Agostino, R. B., Ramachandran, S. V., Pencina, M. J., Wolf, P. A.,
Cobain, M., Massaro, J. M., & Kannel, W. B. (2008). General cardio-
vascular risk profile for use in primary care. Circulation, 117, 743–
753.
Dennison, C. R., & Hughes, S. (2009). Should we screen for risk factors
or disease? A current debate in the prevention of cardiovascular
events. Journal of Cardiovascular Nursing, 24, 18–20.
Dolansky, M. A., Xu, F., Zullo, M., Shishehbor, M., Moore, S. M., & Rimm,
A. A. (2010). Post-acute care services received by older adults following a
cardiac event. Journal of Cardiovascular Nursing, 25, 342–349.
Ducharme, N., & Radhamma, R. (2008). Hyperlipidemia in the elderly.
Clinics in Geriatric Medicine, 24, 471–487.
Duprez, D. A. (2008). Systolic hypertension in the elderly: Addressing
an unmet need. The American Journal of Medicine, 121, 179–184.
Evangelista, O., & McLaughlin, M. A. (2009). Review of cardiovascular risk
factors in women. Gender Medicine, 6, 17S–36S.
Farrell, T. W. (2009). Orthostatic hypotension. Ferri’s clinical
advisor, 2009. Philadelphia: Mosby Elsevier.
Cardiovascular Function CHAPTER20 433
Ferguson, L. R. (2009). Nutrigenomics approaches to functional foods.
Journal of the American Dietetic Association, 109, 452–458.
Figueredo, V. M. (2009). The time has come for physicians to take
notice: The impact of psychosocial stressors on the heart. The
American Jour-nal of Medicine, 122, 704–712.
Flegel, K., & Magner, P. (2009). Get excess salt out of our diet.
Canadian Medical Association Journal, 181, 263.
Foody, J. M. (2008). Prevention as the intervention. Cardiology
Clinics, 26, xiii–xv.
Frishman, W. H., Beravol, P., & Carosella, C. (2009). Alternative and
complementary medicine for preventing and treating
cardiovascular disease. Disease of the Month, 55, 121–192.
Fung, T. T., Chiuve, S. E., McCullough, M. L., Rexrode, K. M., Logros-
cino, G., & Hu, F. B. (2008). Adherence to a DASH-style diet and
risk of coronary heart disease and stroke in women. Archives of
Internal Medicine, 168, 713–720.
Graham, M. M., Westerhout, C. M., Kaul, P., Norris, C. M., &
Armstrong, P. W. (2008). Sex differences in patients seeking medical
attention for prodromal symptoms before an acute coronary event.
American Heart Journal, 156(6), 1210–1216.e1.
Grassi, D. (2009). Flavonids, vascular function, and cardiovascular
protec-tion. (2009). Current Pharmacy Des, 15(10), 1072–1084.
Green, L. A., Dickenson, W. P., Nease, D. E., & Campos-Outcalt, D. (2009).
AAFP guideline for the detection and management of post-myocardial
infarction depression. Annals of Family Medicine, 7, 71–79.
Grundy, S. M., Cleeman, J. I., Merz, N. B., Brewer, H. B. Jr., Clark,
L.T., Hunninghake, D. B., . . . Stone, N. J. (2004). Implications of
recent clinical trials for the National Cholesterol Education Program
Adult Treatment Panel III Guidelines. Circulation, 110, 227–239.
Hiitola, P. (2009). Postural changes in blood pressure and the prevalence
of orthostatic hypotension among home-dwelling elderly aged 75 years
or older. Journal of Human Hypertension, 23, 33–39.
Insull, W. (2009). The pathology of atherosclerosis: Plaque
development and plaque responses to medical treatment. The
American Journal of Medicine, 122, S3–S14.
Jian, Z., & Zhou, B. (2008). Efficacy and safety of acarbose in the treat-
ment of elderly patients with postural hypotension. Chinese Medical
Journal, 121, 2054–2059.
Johnson, J. A., Boerwinkle, E., Zinch, I., Chapman, A. B., Bailey, K.,
Cooper-DeHoff, R. M., . . . Turner, S. T. (2009). Pharmacogenomics
of antihypertensive drugs: Rationale and design of the
Pharmacogenomic Evaluation of Antihypertensive Responses (PEAR)
study. American Heart Journal, 157, 442–449.
Joint National Committee on Prevention, Detection, Evaluation, and
Treat-ment of High Blood Pressure (JNC). (2003). The Seventh Report
of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. Journal of the American
Medical Association, 289, 2560–2577.
Katcher, H. I., Lanford, J. L. G., & Kris-Etherton, P. M. (2009). Lifestyle
approaches and dietary strategies to lower LDL-cholesterol and
triglycerides and raise HDL-cholesterol. Endocrinology and Metabolic
Clinics of North America, 38, 45–78.
Kokubo, Y., Kamide, K., Okamura, T., Watanabe, M., Higashiyama, A.,
Kawanishi, K., & Kawano, Y. (2008). Impact of high-normal blood
pressure on the risk of cardiovascular disease in a Japanese urban
co-hort. Hypertension, 52, 652–659.
Larzelere, M. M., & Jones, G. N. (2008). Stress and health. Primary
Care Clinical Office Practice, 35, 839–856.
Lee, K. S., Song, E. K., Lennie, T. A., Frazier, S. K., Chung, M. L.,
Heo, S., . . . Moser, D. K. (2010). Symptom clusters in men and
women with heart failure and their impact on cardiac event-free
survival. Journal of Cardiovascular Nursing, 25, 263–272.
Levitan, E. B., Wolk, A., & Mittleman, M. A. (2009). Consistency with
the DASH diet and incidence of heart failure. Archives of Internal
Medicine, 169, 851–857.
Lewis, S. J. (2009). Prevention and treatment of atherosclerosis: A practi-
tioner’s guide for 2008. The American Journal of Medicine, 122, S38–S50.
434 PA R T 4Promoting Wellness in Physical Function
Lloyd-Jones, D., Adams, R., Carnethon, M., DeSimone, G., Ferguson,
B., Flegal, K., . . . American Heart Association Statistics Committee
and Stroke Statistics Subcommittee. (2009). Heart disease and stroke
sta-tistics–2009 update. Circulation, 119, e1–e161.
Lorenz, M., Urban, J., Engelhardt, U., Baumann, G., Stangl, K., & Stangl,
V. (2009). Green and black tea are equally potent stimuli of NO
produc-tion and vasodilation: New insights into tea ingredients
involved. Basic Research in Cardiology, 101(1), 100–110.
Mallick, S., Kanthety, R., & Rahman, M. (2009). Home blood
pressure monitoring in clinical practice: A review. The American
Journal of Medicine, 122, 803–810.
Mazzini, M. J., Stevens, G. R., Whalen, D., Ozonoff, A., & Balady, G.
J. (2008). Effect of an American Heart Association Get with the
Guide-lines program-based clinical pathway on referral and
enrollment into cardiac rehabilitation after acute myocardial
infarction. American Journal of Cardiology, 101, 1084–1087.
Mazzo, A. D. (2008). Insulin resistance syndrome and glucose dysregula-tion
in the elderly. Clinics in Geriatric Medicine, 24, 437–454.
McDonald, M., Hartz, R. P., Unger, A. N., & Lustik, M. B. (2009).
Preva-lence, awareness, and management of hypertension,
dyslipidemia, and diabetes among United States adults aged 65 and
older. Journal of Gerontology: Medical Sciences, 64A, 256–263.
McGavock, J. M., Hastings, J. L., Snell, P. G., McGuire, D. K., Pacini, E.
L., Levine, B. D., & Mitchell, J. H. (2009). A forty-year follow-up of
the Dallas bed rest and training study: the effect of age on
cardiovascular response to exercise in men. Journal of Gerontology:
Medical Sciences, 64A, 293–299.
McSweeney, J. C., Cleves, M. A., Zhao, W., Lefler, L. L., & Yang, S.
(2010). Cluster analysis of women’s prodromal and acute myocardial
infarction symptoms by race and other characteristics. Journal of
Car-diovascular Nursing, 25, 311–322.
Mussi, C., Ungar, A., Salvioli, G., Menozzi, C. Bartoletti, A., Giada, F. . . .
For the Evaluation of Guidelines in Syncope Study 2 Group. (2009).
Orthostatic hypotension as cause of syncope in patients older than 65
years admitted to emergency departments for transient loss of con-
sciousness. Journal of Gerontology: Medical Sciences, 64A, 801–806.
NANDA International. (2009). Nursing diagnoses: Definitions and classi-
fication 2009–2011. Oxford, UK: Wiley-Blackwell.
Nesto, R. W. (2008). Comprehensive clinical assessment of modifiable
cardiometabolic risk factors. Clinical Cornerstone, 9, S9–S19.
Padiyar, A. (2009). Nonpharmacologic management of hypertension in
the elderly. Clinics in Geriatric Medicine, 25, 213–219.
Parikh, A., Lipsitz, S. R., & Natarajan, S. (2009). Association between a
DASH-like diet and mortality in adults with hypertension: Findings
from a population-based follow-up study. American Journal of
Hyper-tension, 22, 409–416.
Pickering, T. G., Miller, N. H., Ogedegbe, G., Krakoff, L. R., Artinian,
N. T., & Goff, D. (2008). Call to action on use and reimbursement
for home blood pressure monitoring. Journal of Cardiovascular
Nursing, 23, 299–323.
Rashidi, A., & Wright, J. T. (2009). Drug treatment of hypertension in
older hypertensives. Clinics in Geriatric Medicine, 25, 235–244.
Sachdeva, A., Cannon, C. P., Deedwania, P. C., Labresh, K. A., Smith, S.
C., Dai, D., . . . Fonarow, G. C. (2009). Lipid levels in patients
hospital-ized with coronary artery disease: An analysis of 136,905
hospitaliza-tion in Get With The Guidelines. American Heart Journal,
157, 111–117.e2.
Schenk-Gustafsson, K. (2009). Risk factors for cardiovascular disease
in women. Maturitas, 63, 186–190.
Schneider, C., & Segre, T. (2009). Green tea: Potential health benefits.
American Family Physician, 79, 591–594.
Sica, D. A. (2008). Management of hypertension in the outpatient setting.
Primary Care: Clinics in Office Practice, 35, 451–473.
Sidani, M., & Ziegler, C. (2008). Preventing heart disease: Who needs to
be concerned and what to do. Primary Care: Clinics in Office
Practice, 35, 589–607.
Sparling, M. C., & Anderson, J. J. B. (2009). The Mediterranean Diet
and cardiovascular disease. Nutrition Today, 44(3), 124–133.
Spertus, J. A., Jones, P. G., Massoudi, F. A., Rumsfeld, J. S., & Krumholz, H.
M. (2009). Factors associated with racial differences in myocardial
infarction outcomes. Annals of Internal Medicine, 150, 314–324.
Surinach, J. M., Alvarez, L. R., Coll, R., Carmona, J. A., Sanclemente, C.,
Aguilar, E., . . . FRENA, Investigators. (2009). Differences in cardio-
vascular mortality in smokers, past-smokers, and non-smokers: Find-
ings from the FRENA registry. European Journal of Internal
Medicine, 20, 522–526.
Taylor, H. A., Akylbekova, E. L., Garrison, R. J., Sarpong, D., Joe, J.,
Walker, E., . . . Steffes, M. W. (2009). Dyslipidemia and the treatment
of lipid disorders in African Americans. The American Journal of
Med-icine, 122, 454–463.
U.S. Preventive Services Task Force. (2008). Screening for lipid
disorders in adults: Recommendation Statement. Retrieved from
http://ahrq.gov/clinic/uspstf08/lipid/lipidrs.htm.
U.S. Preventive Services Task Force. (2009). Aspirin for the
prevention of cardiovascular disease: U.S. Preventive Services
Task Force Recommendation Statement. Annals of Internal
Medicine, 150, 396–404.
Van Domburg, R. T., Reimer, W. S., Hoeks, S. E., Kappetein, A. P., &
Rogers, A. J. (2008). Three life-years gained from smoking
cessation after coronary bypass surgery: A 30 year follow-up study.
American Heart Journal, 156, 473–476.
Van Hensbroek, P. B., Van Dijk, N., Van Breda, G. F., Scheffer, A. C.,
Van der Cammen, T. J., Lips, P., . . . Combined Amsterdam and
Rotterdam Evaluation of FALLs (CAREFALL) study group (2009).
The CAREFALL triage instrument identifying risk factors for recur-
rent falls in elderly patients. The American Journal of Emergency
Medicine, 27, 23–36.
Van Horn, L., McCoin, M., Kris-Etherton, P. M., Burke, F., Carson, J. A.
S., Champagne, C. M., . . . Sikand, G. (2008). The evidence for dietary
prevention and treatment of cardiovascular disease. Journal of the
American Dietetic Association, 108, 287–331.
Verwoert, G., Mattace-Rasso F., Hofman, A., Heeringa, J., Stricker, B.
H. C., Breteler, M. M. B., & Witteman, J. C. M. (2008). Orthostatic
hy-potension and risk of cardiovascular disease in elderly people:
The Rotterdam study. Journal of the American Geriatrics Society,
56, 1816–1820.
Wald, D. S., Law, M., Morris, J. K., Bestwick, J. P., & Wald, N. J.
(2009). Combination therapy versus monotherapy in reducing blood
pressure: Meta-analysis on 11,000 participants from 42 trials. The
American Journal of Medicine, 122, 290–300.
Waldman, S. V., Blumenthal, J. A., Babyak, M. A., Sherwood, A., Sketch,
M., Davidson, J., & Watkins, L. L. (2009). American Heart Journal,
157, 77–83.
Watson, J. E. (2009). Hypertension in Asian/Pacific Island Americans.
Journal of Clinical Hypertension, 11(3), 148–152.
Weiss, A. M. (2009). Cardiovascular disease in women. Primary
Care Clinics: Office Practice, 36, 73–102.
Williams, B., Lindholm, L. H., & Sever, P. (2008). Systolic pressure is
all that matters. The Lancet, 371, 2219–2221.
Wu, J. S., Yang, Y. C., Lu, F. H., Wu, C. H., & Chang, C. J. (2008).
Population-based study on the prevention and correlates of orthostatic
hypotension/hypertension and orthostatic dizziness. Hypertension
Research, 31, 897–904.
Zhang, C., Rexrode, K. M., Van Dam, R. M., Li, T. Y., & Hu, F. B.
(2008). Abdominal obesity and risk of all-cause, cardiovascular, and
cancer mortality. Circulation, 117, 1658–1667.