Page 780 - Cardiac Nursing

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756 PA R T V / Health Promotion and Disease Prevention
follows: American Indian/Alaskan Native, 32.4%; black or Hypertension carries particular importance as a cardiovascular risk
African American, 23.0%; non-Hispanic white, 21.9%; Hispanic, factor for several reasons: it is highly prevalent, it is relatively sim-
15.2%; and Asian 10.4%. 19 Since 1965, rates of smoking in ple to identify, it is a major risk for devastating cardiovascular out-
4
adults 18 years of age and older have declined by 50%. Data comes, and control of hypertension is known to decrease its risk. 35
from the Youth Risk Behavior Survey show that 23% of high Prevalence of hypertension increases with age among white, black,
school students were current smokers in 2005 (23% of female stu- and Mexican-American subjects (Fig. 32-4). The prevalence of hy-
dents and 22.9% of male students). 20 Cigarette use in this age pertension is highest among black persons at all ages. Results
group was stable or increased during the 1990s and then de- from a cross-sectional analysis of data from the National Health
creased significantly from the late 1990 to 2003, however, preva- and Nutrition Examination Survey (NHANES) 1999 to 2002
lence was unchanged during 2003 to 2005. and NHANES III 1988 to 1994 showed that the prevalence of
hypertension increased from 35.8% to 41.1% among black per-
Smoking and CHD sons, with hypertension particularly high among black women
(44%). 36 The prevalence of hypertension also increased among
Cigarette smoking is perhaps the most preventable known cause white persons from 24.3% to 28.1%. Hypertension is associated
of CHD today, leading to more deaths from CHD than from ei- with three- to four-fold increases in the risk of CHD, stroke,
21
ther lung cancer or chronic obstructive pulmonary disease. The and MI, 22,24,26 and it increases the risk of peripheral vascular
CHD risk increases with number of cigarettes smoked, longer du- disease, renal failure, and congestive heart failure in men and
ration of smoking, and younger age at initiation of smoking. 22,23 women across the life span. 24,37 The normalization of blood
The CHD risk of male cigarette smokers is two (aged 60 years pressure dramatically decreases the risk of stroke, renal failure,
and older) to three (aged 30 to 59 years) times that of nonsmok- cardiac failure, and coronary events. 38–40 Even in the elderly,
ers, 24 whereas women who are current smokers have up to four control of hypertension confers major benefits against stroke,
times the risk of first MI of those who have never smoked. 25–27 coronary events, and all cardiovascular events. 39,41 Hypertension
This elevation in the risk of MI and CHD death is sustained from and the nurse’s role in its management are discussed in detail in
youth into advanced age for men and women. 23,28 Smoking low- Chapter 35.
tar ( 17.6 mg), low-nicotine ( 1.2 mg), or filter cigarettes does
not lower the risk of MI compared with high-tar, high-nicotine,
or nonfiltered cigarettes 29,8
Smoking cessation confers benefit regardless of sex, age, or SERUM LIPIDS AND
presence of CHD. Men and women of all ages with documented LIPOPROTEINS
CHD who quit smoking have half the risk of mortality compared
with those who continue to smoke. 30–32 This finding was con- Elevated serum total cholesterol and LDL cholesterol are asso-
firmed in a systematic review of 20 prospective cohort studies of ciated with an increased risk of CHD in men and women of all
patients with CHD that reported all-cause mortality and had at ages. 42–44 The prevalence of hypercholesterolemia is higher in
33
least 2 years of follow-up. The results demonstrated that smok- U.S. women than in men, and higher in white and black than
ing cessation was associated with reduction in risk for all-cause in Mexican-American subjects (National Center, 1997) (Table
mortality in patients with CHD; risk reduction was consistent re- 32-2). CHD rates are lower for women than men at any given
gardless of other factors including age and gender. There are many level of serum cholesterol. 42 Decreasing trends in total and
successful approaches to smoking cessation, and these interven- LDL choletesterol levels have been noted over time; the per-
tions are less costly than many other preventive interventions. 34 centage of adults with a total cholesterol level of at least 240
Smoking cessation should be encouraged regardless of age, sex, or mg/dL during 1988 to 1994 decreased from 20% to 17% dur-
the presence of established disease. ing 1999 to 2002. 45 The increase in the proportion of adults
using lipid-lowering medication has likely contributed to the
Environmental Tobacco Smoke decreases that have been observed.
Serum HDL cholesterol has a protective effect against CHD. A
It is estimated that 53,000 deaths annually are attributable to en- 1-mg/dL increment in HDL is associated with a 2% (men) to 3%
vironmental tobacco smoke (ETS), making it the third leading (women) decrement in total CHD risk, and a 3.7% (men) to 4.7%
preventable cause of death in the Unites States. 21 Ten times as (women) decrement in CHD mortality. At any given level of LDL,
46
many of these deaths are caused by CHD as by lung cancer. Ex- higher levels of HDL confer protection against CHD. A level less
35
posure of nonsmokers to ETS from a spouse who smokes in- than 40 mg/dL for adults is considered low HDL and increases risk
creases the risk of CHD death by 30% in men and women. This for CHD. In 2005, for adults in the United States 20 years and
risk increases with the amount smoked by the spouse. 21 ETS older, the prevalence of HDL less than 40 mg/dL was 44.6 million. 4
causes arterial endothelial damage, may initiate or accelerate the Attention has been focused on subfractions of HDL and
development of atherosclerosis, and increases platelet aggregation, LDL, the apolipoproteins (apoAI, apoAII, apoB), and lipopro-
which may result in coronary thrombosis. 21 Thus, the effects of tein(a) (Lp(a)). In a study of the predictors of premature CHD at
ETS are similar to those of smoking cigarettes. 47
coronary arteriography, Kwiterovich and associates found that
apoB was more strongly associated with an increase in CHD risk
in women than in men, whereas ApoAI was more strongly asso-
HYPERTENSION ciated with a decrease in CHD risk in men than in women. In-
creasing levels of Lp(a) are also associated with an increase in
Hypertension is defined as a systolic blood pressure of 140 mm CHD risk. 48–51 In the Framingham Heart Study, the relative risk
Hg or more or diastolic blood pressure of 90 mm Hg or more. for CHD associated with elevated Lp(a) was 1.6 in women 49 and