Coronary heart disease
Coronary artery disease (CAD) is a heart disease in which blood flow is obstructed through the coronary arteries that usually supply the heart with oxygen-rich blood. It is a condition in which plague (made up of fat, cholesterol, calcium, and other substances found in the blood) builds up in the coronary arteries; this condition is referred to as atherosclerosis or “hardening of the arteries.”
Atherosclerosis is gradual; most often takes decades before the affected person is in danger of cardiovascular problems. If CAD is untreated it often continues to worsen. Many CAD patients have symptoms like chest pain (angina) and fatigue, which occur when the heart does not receive sufficient oxygen. However, as many as 50 percent of patients do not have symptoms until a heart attack occurs.
Millions of people in the United States have CAD. However, strategies to aid in reducing risk factors for CAD, or slow its progression has already started which include: learning your family medical history, eating a heart-healthy diet, exercising regularly among others.
1. Analysis of the coronary artery disease
Atherosclerosis or hardening of the arteries
Atherosclerosis or plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes blood clots more likely to form in your arteries. Blood clots can partially or totally block blood flow.
Figure A: shows a normal artery with normal blood flow.
Figure B: shows an artery with plaque buildup (Atherosclerosis). (Parmacek, 2001).
When coronary arteries are narrowed or blocked, oxygen-rich blood cannot reach the heart muscle. This can result into angina or a heart attack. Angina is chest pain or discomfort that occurs when insufficient oxygen-rich blood is flowing to an area of your heart muscle. Angina may feel like pressure in ones chest. Also, the pain may occur in ones shoulders, arms, neck, jaw, or back. On the other hand, heart attack happens when blood flow to a given area of ones heart muscle is totally blocked. Hence, preventing oxygen-rich blood from reaching that area of heart muscle and causes it to die which can lead to serious problems and even death if not treated quickly. CAD with time weakens the heart muscle and lead to heart failure (where heart cannot pump enough blood throughout your body) and arrhythmias (problems with the speed or rhythm of ones heartbeat).
The other names of CAD include: Atherosclerosis, coronary heart disease, hardening of the arteries, heart disease, ischemic heart disease, or narrowing of the arteries. (Parmacek, 2001).
Does it affect many people?
Millions of people, approximately7 million Americans suffer from CAD.
Is it serious?
CAD is the most popular type of heart disease. It is the leading cause of death among men and women in the United States; more than 500,000 Americans die of CAD-related heart attacks each year. (Bruce, 2000).
Which age group does it affect?
Some Atherosclerosis or hardening of the arteries occurs as a person grows older. However, the most affected people are those over 45 years for men and over 55 years for women. Men are at a higher risk of CAD than are women. A woman’s risk increases after menopause.
What services are employed to detect and treat the disease?
Doctors often diagnose CAD based primarily on the patient’s:
– medical and family histories
– risk factors
– the results of a physical exam and diagnostic tests and procedures
Diagnostic Tests and Procedures for CAD
If a doctor thinks a patient has CAD, he or she will have to do one or tests since no single test can diagnose CAD. This is to aid in identifying blockages in the arteries. These tests include:
· Physical examination by the doctor. This entails a complete medical history and coronary risk profile.
· Electrocardiogram (EKG): Is a simple test that detects and records the heart’s electrical activity as a graph, or series of wave lines, on a moving strip of paper or video monitor. The highly sensitive electrocardiograph machine help in detecting heart irregularities, disease and damage by measuring the heart’s rhythms and electrical signals. It can also show signs of a previous or current heart attack.
· Stress Testing: Involve exercising to make the heart work hard and beat fast during which heart tests are performed. If one cannot exercise, he/she is given medicine to speed up the heart rate. The reaction of the heart under exertion can be measured and evaluated. This allows the doctor to evaluate the performance of the heart under strenuous conditions. Some of these stress tests use a radioactive dye, sound waves, positron emission tomography or cardiac magnetic resonance imaging to take pictures of ones heart when it’s working hard and when it’s at rest. The imaging stress tests can show how well blood is flowing in the different parts of ones heart. Also, they can show how well ones heart pumps blood when it beats.
· Echocardiography: It uses sound waves to visualize the structure and function of the heart. It creates a moving picture of the heart; the size, shape and how well the heart chambers and valves are working. It can also show areas of poor blood flow to the heart, areas of heart muscle that are not contracting normally, and previous injury to the heart muscle caused by poor blood flow. (CardioSmart, 2002).
· Blood Tests: Here the risk factors for CAD are measured such as levels of cholesterol, homocysteine, C-reactive protein and blood clotting factors. Abnormal levels often may show that you have risk factors for CAD.
· Chest X Ray: This takes a picture of the organs and structures in the chest, which include the heart, lungs, and blood vessels. It can show signs of heart failure, as well as lung disorders and other causes or symptoms that are not due to CAD.
· Electron-Beam Computed Tomography: This test is done to find and measure calcium deposits in and around the coronary arteries. The more calcium detected, the more likely one has CAD. (CardioSmart, 2002).
· Coronary Angiography and Cardiac Catheterization: This test may be requested by the doctor if other tests or factors show that one is likely to have CAD. It uses dye and special x rays to reveal the insides of ones coronary arteries. (Bruce, 2000).
Treatments for CAD
These vary depending on the severity of the disease, the location of any blockages in the blood vessels, the presence of any risk factors and the overall health of the patient.
Types of treatment include lifestyle changes, medication, and interventional and surgical techniques. The objectives of treatments are as follows:
– to relieve symptoms
– to reduce risk factors in an effort to slow, stop, or reverse the Atherosclerosis
– to lower the risk of blood clots forming, which can result into a heart attack
– to widen or bypass clogged arteries
– to prevent complications of CAD. (Parmacek, 2001).
Lifestyle Changes: This can usually help to prevent or treat CAD. These changes may be the only treatment needed for some people. They include:
· Following a heart healthy eating plan so as to prevent or reduce high blood pressure and high blood cholesterol and also to maintain a healthy weight. Part of a healthy eating plan includes foods high in soluble fiber which help block the digestive track from absorbing cholesterol. These foods include whole grain cereals like oatmeal and oat bran; fruits like apples, bananas, oranges, pears, and prunes; legumes like kidney beans, lentils, chick peas, black-eyed peas, and lima beans. Certainly, a diet high in fruits and vegetables can increase essential cholesterol- lowering compounds in ones diet.
· Increasing physical activity. First one need to check with the doctor to know how much and what kinds of activity are safe for him/her. Regular physical activity can actually lower many CAD risk factors including cholesterol, high blood pressure, and excess weight. It can also lower ones risk for diabetes and raise his/her levels of HDL cholesterol- the “good” cholesterol that helps prevent CAD. Average intensity activities include brisk walking, dancing, bowling, bicycling, gardening, and housecleaning.
· Losing weight, if one is overweight or obese. Maintaining a healthy weight can also decrease risk factors for CAD.
· Quitting smoking, if one smokes. Also, avoid exposure to secondhand smoke. Smoking can certainly damage and tighten blood vessels and raise ones risk for CAD.
· Learning to cope with and reduce stress. According to research, the most commonly reported cause of a heart attack is an emotionally upsetting event—especially one involving anger. Some of the ways people cope with stress for instance drinking, smoking, or overeating, are not heart healthy. (Parmacek, 2001).
Medications: may be needed to treat CAD if lifestyle changes are not enough. Medicines can decrease the workload on ones heart and relieve CAD symptoms, decrease ones chance of having a heart attack or dying suddenly, lower ones cholesterol and blood pressure, prevent blood clots, prevent or delay the need for a special procedure
Medicines which are used to treat CAD include anticoagulants, aspirin, beta blockers, calcium channel blockers, nitroglycerin, among others. They are divided into categories which include:
· Beta blockers: These are medications that reduce the workload of the heart through blocking certain chemicals from binding to beta receptors in the heart.
· Nitrates: Are medications that majorly cause blood vessels to relax and dilate, allowing more oxygen-rich blood to reach the heart.
· Calcium channel blockers/calcium antagonists: Are medications that fundamentally increase blood flow through the heart and may also reduce the workload of the heart through blocking calcium ions from signaling the blood vessels to constrict or tighten.
· Antiplatelets for example, aspirin: Are medications that reduce the formation of blood clots by reducing the ability of platelets- clotting component of the blood, to bind together and form a blood clot.
· Statins: Is a type of cholesterol-reducing drug which lowers the levels of fats (lipids) in the blood, which include cholesterol and triglycerides. They work through blocking the production of specific enzymes used by the body to make cholesterol. They are effective in lowering blood fat levels in patients with high cholesterol hence of great importance in the prevention of coronary, cerebrovascular and peripheral vascular disease. (CardioSmart, 2002).
What are some of the health care research questions asked in relation to it?
Many patients may want to ask their doctor the following questions regarding coronary artery disease:
· I’m concerned about my cardiac health because of a family history, but I do not have other risk factors. How often should I get my blood checked?
· Will I need to take medicine for life if I begin on medication to control CAD?
· Is there anything I should have done differently or could be doing differently, to interfere with the disease?
· Is it possible to reverse coronary artery disease?
· What symptoms should trigger me to visit your office?
· What kind of exercise do you recommend for me?
· What kind of dietary choices should I make in order to reduce my risk of heart attack?
· What is the best source for dietary information?
· How will you decide if I need to undergo a procedure such as bypass surgery?
· Are my children at increased risk because of the CAD I have? (CardioSmart, 2002).
The other questions which can be asked by health care research include:
· What is coronary artery disease?
· How is CAD diagnosed and treated?
· What types of heart disease are treated with surgery?
· How do physicians determine whether surgery is required?
· What types of health care providers are involved in cardiac surgery?
· How long does it take to recover from heart surgery?
· Should people with coronary artery disease take an aspirin a day? Can aspirin really prevent heart attacks?
· Can coronary artery disease be reversed? Can the arteries actually clear up?
· What kinds of fats should I avoid? (Parmacek, 2001).
2. Research and discussion on the utilization of the resources and access to care for CAD.
Coronary heart disease still remains the leading cause of death in America. Even though CAD and stroke involve very expensive therapies and extensive hospital utilization, the actual cost of preventive measures is also quite expensive. A number of factors determine the cost-effectiveness of statin therapy for the primary and secondary prevention of CAD. A risk-based strategy for the selection of patients appears to give cost-effective utilization of this powerful treatment strategy. Necessary patient selection should be accompanied by rapid measures to improve utilization and compliance by improving physician and patient education.
Fundamental science advances, technologic developments and economic drivers entails the basic external dynamics which affects the practice of cardiovascular medicine and surgery over the last decades. The major expression of these developments was actually to contain costs and also to reorganize the process of cardiovascular care. In this current century, concerns involving the appropriateness of care, how best to minimize variability in health care results and how to evaluate quality of care are essential issues to be addressed. (Betancourt, Hepke & Hickman, 2003, p. 145).
A major significant development for cardiac care has been the increasing isolation of invasive cardiology from other specialties who are involved in treating CAD. The isolation is actually organizational, clinical and spatial (for instance, the stop of daily, multi-specialty clinical conferences on CAD patients to greatly discuss treatment alternatives; the increase in referral for specific angioplasty after coronary angiography among others.). Furthermore, the isolation of cardiology might be the most vital organizational development in cardiovascular care because of its effect on clinical pathways for CAD patients on which these patients are referred for cardiac surgery.
Utilization of Diagnostic and Therapeutic Procedures
According to one of the most recent national statistics from the American Heart Association, coronary artery bypass graft (CABG) surgery, and percutaneous transluminal coronary angioplasty (PTCA) have all increased substantially over a two-decade period. Actually CABG increased 432 percent from 1979 to 1997. Cardiac catheterizations also increased 299 percent from 1979 to 1997 and finally PTCA increased 188 percent from 1987-1997. (Betancourt, Hepke & Hickman, 2003).
Organizational approaches to utilize resources and to follow clinical pathways focus on ensuring the fundamental infrastructure for high-quality clinical programs: a strong clinical and administrative leadership; sufficient resources to assure the financial worth of the large, complex organizations for these clinical programs; and meeting the increasing need for information management for clinical practice. The strategies include organizing groups within hospitals around multi-disciplinary clinical paths (e.g. acute chest pain, stroke, and transplant) and regionalizing care in major centers of excellence which can either be physical or virtual centers. The invention of new methods for diagnosing AMI together with better pharmacologic therapies (e.g. anticoagulants), make it more possible to rule out AMI in the emergency room hence avoiding admissions for many patients.
What are cultural and social factors that influence the care for CAD?
Medicine constantly faces various critical and conflicting challenges. The great and always changing cultural diversity of our population needs doctors to develop new skills in communication and negotiation with their patients. However, managed care constraints, litigation, and also growing regulatory pressures have greatly compromised communication and trust between physicians and patients. Hence, this together with the surge in technologic development, has led the medical system further toward a disease-based approach to health care where individuals are seen as ‘cases’ and look down upon the socio-cultural and humanistic aspects of patient care. Therefore, this has resulted into a diminishing faith especially in the medical establishment and also the rise of alternative medical philosophies and practices. It is certain that a medical system that enables doctors to refocus on the patient-centered, personal, and unique experience of ‘illness’ is actually an imperative for our time. (Witt, Brawer& Plumb, 2007)
Most recent studies that have been focused on the access to cardiac services which include coronary artery bypass surgery (CABG), have actually revealed that blacks, the poor, Latinos and the uninsured pass through fewer like procedures compared to white and insured patients. Due to the limitations of these studies and the great nature and expense of CABG, this study was undertaken to determine results in the not insured and insured populations for this procedure. The hypothesis examined here was that demographics instead of access to care and economics influence results in CABG.
What access measures are used in the available literature for CAD (e.g. screening, diagnostics and surgical procedures, vaccinations, treatment options?
One of the access measures available includes ambulances which have both ECG and monitoring equipment as emergency departments. But emergency departments have more medications (e.g. intravenous nitrates, beta-blockers, anticoagulants) that can put a stop to a threatened heart attack, and they can also transport the patient to the catheterization laboratory for actual diagnosis and treatment. Usually experienced cardiac catheterization laboratories are mostly prepared to repair coronary arteries within an hour any time of day or night on an emergency basis. (Zeitel, Goodwin & Kimberley, 1991).
Is access to care as measured by these indicators equitable?
Prevention is an essential role for all health care providers. Health care providers can aid individuals to stay healthy by preventing disease and also they can prevent complications of disease existing through aiding patients live with their illnesses. In order to accomplish this role, however, providers certainly need data on the significance of their services and the chance to compare these data over time or across communities.
Although these indicators often use hospital in-patient data, their aim is an out-patient health care. The quality of in-patient care is most unlikely to be a vital determinant of admission rates for ambulatory care sensitive situations except for the patients readmitted soon after discharge from hospital. Prevention Quality Indicators (PQIs) are used to assess the quality of the health care system wholly specifically the quality of ambulatory care so as to prevent medical complications. Hence, these measures can be of the greatest value if calculated at the population level and if used by public health groups and other organizations that are concerned with the health of populations. (Chad, Elliott, Andrea & Lee, 2007).
How are health outcomes influenced by access?
The differences in use and access to medical care and procedures have become the major focus of increasing concern from the public and governmental agencies. According to reports, lack of health insurance is related with limited access to medical care, and also that medical care is delayed or left in these patients when serious symptoms/signs occur. Thus lack of medical insurance coverage seems to be related with a lower access to recommended preventive services, increased intense of illness on admission, an increase in potentially avoidable hospital admissions, and less access to invasive procedures and technologically advanced treatment. (Chad, Elliott, Andrea & Lee, 2007).
An increase in adverse medical outcomes in the modern population has been related to lack of health coverage. Studies have revealed a measurable decline in health status of patients who have lost health insurance because of health status or employment transition. For instance, in the Rand Health Insurance Experiment, the financial payments in the form of co-payments served as major barriers to access and led into clinically important adverse outcomes.
Many studies have just focused on the poor, believing that low income is related with poor health, limited education and limited access to healthcare. There is no attempt that has been made to separate the poor from those not insured in these studies. (Surg, 2001).
3. Analysis of quality and care of CAD.
Coronary artery bypass graft (CABG) surgery is one of the most frequently carried out surgical procedures in the United States. Several community hospitals have initiated cardiac surgery programs since this surgery is both profitable and prestigious. Recently, specialty cardiac hospitals have emerged hence adding to the number of new cardiac surgery programs. However, the new programs might result in causing a fall in the volume of CABG operations done at other hospitals within that region.
What indicators are used to measure care quality for CAD?
According to studies, hospitals with lower volume have higher operative mortality. Also, states which have no rules governing the introduction of cardiac surgery programs have lower hospital volumes, and hence higher operative mortality.
Is care for CAD adequate in U.S.?
The care for CAD is improving but is not yet completely adequate. Almost each year approximately one million Americans with CAD undergo a cardiac procedure to improve blood flow to the heart. CABG surgery is over half of these procedures. Thus, many complications and death are declining since surgeons and hospitals given feedback concerning their patients’ health results have consequently undertaken particular quality improvement activities.
How is CAD influenced by managed care?
Medication characteristics among different people, beyond cost alone influence decisions to underuse treatment in response to financial pressures. Also, According to Reuters Health research reporters, increasing calcium formation in the coronary arteries is actually the best predictor of a CAD existence in patients with type 1 diabetes. Also, new findings suggest that control of body mass index can aid slow calcium formation and retard the progression of atherosclerosis; this is in addition to controlling cholesterol levels, albumin excretion rate, and the other known risk factors for heart disease
One example of a quality improvement program for CAD.
Get with the Guidelines (GWTG) is the most powerful hospital-based quality improvement program which enables healthcare provider teams to constantly treat heart and stroke patients according to the current guidelines. It touches the lives of many patients hospitalized for heart disease and stroke, in a nationwide strive to reduce risk from these diseases.
4. Discuss ways in which health care reform could potentially impact care for CAD.
Fundamental transformation in CAD burden has resulted from past social progress and ongoing medical innovation, due to changes in two major areas. First, the affluent Western societies formed a lifestyle which is certainly unhealthy. It is actually to blame for the leading causes of death nowadays which include coronary heart diseases, stroke, several different cancers, sexually transmitted diseases (STI), asthma, diabetes and finally fatalities of poly-pharmacy. Second, globalization coupled with mass tourism and mass immigration has initiated or brought back great number of infectious and tropical diseases to the Western societies. Therefore, there is dire need to achieve sustainable ways of behavior or lifestyle changes.
There are several instances of how patient care has improved since GWTG-CAD started. According to a given data at the end of 2006, it shows that more than 94 percent of these patients are currently being counseled on smoking cessation, compared with only 58.7 percent when the program commenced. Again, there is great improvement in the percentage of patients now receiving treatment to improve their cholesterol, as well as those receiving beta blockers and other medications to improve their health results.
According to research, these interventions work actually save lives. Reasonably, every patient should obtain every treatment that is right for them all the time. Hence, health-care providers need to continue to work with hospitals to ensure that necessary treatments are being given 100 percent of the time. (Hansen Fred, 2007, p.180).
Does CAD require screening, monitoring, surgery, hospitalizations?
Yes, it requires the above. Screening strategies have been proposed and evaluated; even though CAD accounts for much of the mortality associated with surgery, regular coronary arteriography and prophylactic myocardial revascularization is not of any practical value. Patients who have no clinical evidence of CAD may proceed to surgery without much investigation. However, patients with a history of CAD that is certainly stable and not seriously limiting should be monitored keenly in the preoperative period. Also, those with seriously symptomatic CAD should be assessed by a cardiologist. Note that peripheral vascular surgery is not an obvious indication for cardiac screening or prophylactic myocardial revascularization.
How does managed care compare with other types of plans in providing care for CAD?
The self monitoring of health conditions and initiation of personal risk management are great challenges, but certainly well worth it. If two-thirds of the population instead of just one third is able to maintain a normal body weight, then the CAD burden for the health service could be nearly halved. Opposite to the common belief, free access/reach to the health service with no payment does not serve the patient since it is an invitation to forget ones health and also results to a general waste of resources. (Bruce, 2000, p. 457).
Are there any relevant trend?
Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality—with low-volume hospitals having the highest mortality. Medicare data (1992–2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume—a side effect that might increase mortality.
5. Are there data on the care provided for CAD in different health plans in the US?
There are actually data abstracted from the medical records which include age, gender, ethnicity, insurance status, ejection fraction, complications, and survival. These data collectively gives suggestion that patients with stable CAD, preserved systolic function, and averagely preserved exercise capacity deserve a test of intensive medical therapy before referral for angioplasty. (Hansen Fred, 2007, p. 201).
Addressing an issue I consider important.
Financially challenged population seems to present for treatment earlier in life with CAD compared with the financially stable. Risk factors between these two groups are similar, except for tobacco use which seems to be a great problem in the poor population. The disease severity in both populations seemed to be the same, however, the non insured patients had equal early survival with better late survival. Also, access to care in both the groups was equivalent. Mostly, in the public hospital setting for CAD state, the financially challenged are given access to the modern treatment technology with quality outcomes.
Coronary artery disease (CAD) still is and will continue to be the most important healthcare challenge of the 21st century despite great advances in medical and surgical approaches to treat it. Even though plans and efforts are being made to support and encourage more women in therapeutic tests, there is need for educational process specifically medical school, to broadly address sex specific pathophysiology and treatment instead of just depending on subspecialty training for improving healthcare delivery in women.
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