Cardiovascular disease: What women don’t know can kill them

Your hospital can raise risk awareness; avoid big expenses

Make sure your cardiac services line managers take steps to tailor their approaches to women. Raising the cardiovascular consciousness of your hospital’s entire female population — not just those past menopause — could save lives, in addition to making your facility’s capitated contracts more profitable. If your hospital is not keeping up with recent findings on the impact of cardiovascular disease (CVD) on women, and acting on them, it may be missing a prime opportunity to reduce cardiac care costs. (See related story on lipid-lowering in women, p. 58.)

Begin with education, but be aware that the best educational attempts will fall on deaf ears if women remain convinced that CVD is a man’s disease and that their risk begins only after menopause. (See related story on the "COP" technique, p. 59.)

Women account for almost half of heart attack deaths, yet they are unlikely to believe they’re at risk for CVD. (See charts on pp. 55-56.) Even after that hurdle is vaulted, they are often treated differently from men because hospitals use treatment models based on men.

Dennis Schwesinger, cardiovascular service line administrator at The Health Alliance of Greater Cincinnati, joined forces a few months ago with Marcia Swehla, service line administrator for women’s health for the alliance, and developed a cardiac risk assessment tool designed to be mailed to the alliance’s entire female population. What the heart quiz hopes to accomplish is to raise awareness of CVD as a potential threat to women of all ages — and to avoid their having to be hospitalized for expensive procedures.

Heart quiz covers family history and lifestyle

The Alliance Women’s Heart Quiz includes 20 questions asking about the recipients’ physical characteristics, medical history, family history, and lifestyle. Included are questions dealing with ability to handle stress, typical fiber and fat intake, and exercise habits. The oversize, four-color mailer is designed to be easily folded and returned postage-free to the hospital.

"Like many others, hospitals in the alliance have retrospective programs in place to educate women about cardiovascular risk," Schwesinger explains. At cardiology discharge, for example, patients routinely receive counseling from dietitians and case managers about cardiac rehabilitation and recommended lifestyle modification. "But lately," says Schwesinger, "we’ve been trying to be more prospective, as opposed to retrospective, regarding women and cardiovascular disease. We’re trying to identify risk in a timely manner, modify that risk, and intervene early enough to avoid further damage."

The Health Alliance of Greater Cincinnati provides heart care for much of the region’s population. Four hospitals comprise the alliance: The Christ Hospital, University Hospital, The St. Luke Hospitals, and The Jewish Hospitals.

More bang for the buck

The Alliance Women’s Heart Quiz is a major campaign that casts a wide net. At a cost of $30,000 for printing alone, the facility is circulating the risk-assessment questionnaire to nearly 400,000 women.

The majority was included with a hospital newsletter that regularly is mailed to 250,000 women. Others are being distributed at special hospital programs for women. Radio and TV ads bring in requests for the questionnaire, and some were sent to regional physicians who care for women — OB/GYNs and primary care physicians — with requests that they distribute the pieces to their patients.

By June the results should be in. "We expect a return of about 30,000 reports," says Swehla. "Once they’re in, we will transfer the information onto a scan sheet, and the results will be tabulated by Lifestyle Management Resources in Plymouth, MA. The women who returned their questionnaire will receive an evaluation of their heart health."

A woman who scores at low risk will be sent a letter congratulating her and offering tips on how to stay healthy. "Most women who respond will already be under the care of a primary care physician," says Schwesinger. "We’ll just urge them to go for regular checkups. If a woman doesn’t have a doctor, we’ll refer her to one."

If a woman scores at moderate risk, her letter will say she needs follow-up and will include information on how to locate a doctor in the area if she needs one. Included will be a brochure about heart disease risk.

"The woman at high risk," says Schwesinger, "will receive a phone call from an Alliance community cardiac coordinator who will facilitate the woman’s getting the help she needs." The nurse will conduct a more thorough and detailed risk assessment of the woman over the phone, or the woman may get an appointment to come in for her assessment. Questions on the second-stage assessment will deal with how often the woman has a physical examination, her level of alcohol consumption, and other detailed information. At that point, the cardiac coordinator will have a realistic idea of the woman’s risk and will arrange for early intervention when appropriate. The next step is an appointment with a cardiologist who is aware of the results of her assessment.

"That women’s risk assessment tool puts Cincinnati in the forefront in terms of women and heart disease," says Kathleen C. Ashton, RN, PhD, assistant professor of nursing at Rutgers, the State University of New Jersey, in Camden. "There are many risk assessment instruments out there, but most do not focus on women. Because heart disease is thought of as a man’s disease, even hospitals with wellness programs and women’s health program rarely include the issue. Topics like birth control, menopause, hormone replacement therapy, and breast cancer take center stage. Women are typically thought of as breasts and uteri." (See related story on the dearth of guidelines on CVD and women, p. 58.)

Nurses positioned to help

"The Alliance’s mailer was money well-spent," says Renee Obial, RN, MSN, cardiovascular and thoracic clinical nurse specialist at The Jewish Hospitals in Cincinnati. "The project will ultimately result in reduced care cost overall through early interventions. I’d like to see every woman I know fill it out and return it. Women’s lack of cardiovascular awareness is a big problem."

Obial says that nurses in the cardiac cath lab or those doing stress testing in radiology are best positioned to educate patients. She says, "When I’m consulted as to whether a patient — man or woman — is a surgical candidate, I make sure to draw the family, including children, into the counseling. I ask men and women, young and old, about lifestyle, including exercise habits and diet."

Women being treated for CVD are more amenable to advice about secondary preventive measures than are those unaware or unconvinced of their risk. Prompt intervention at early signs of angina, for example, can alter the course of disease and prevent progression to myocardial infarction.

Women CVD patients usually older

Since women typically contract CVD later in life than men because of estrogen’s protective effect, their rehabilitation needs differ from those of men. (See related story on estrogen and CVD, p. 60.) Women tend to be more resistant to exercise prescriptions than men and may have to be convinced of the importance of a healthy lifestyle. They also may have to be convinced that physical activity is necessary. They need encouragement, and they need to be assured of the regimen’s safety.

Women’s recovery from cardiac events progresses differently from that of men. The prognosis for women is equal to or worse than for men following heart attack, coronary artery bypass grafting, or angioplasty. (See related stories on the prevalence of CVD in women and how CVD symptoms, including chest pain, differ in men and women, pp. 57, 58.)

While they tend to return to their jobs later, they typically resume household chores too soon because "somebody has to do it." Nurses can help patients adjust to necessary changes in their lives following cardiac events by encouraging them to set realistic goals and to accept outside help.

Upon discharge, take time to carefully answer patients’ questions about medication and lifestyle modification. Promote learning by not rushing and by repeating recommendations. Help patients realize that going to their OB/GYNs each year is not sufficient screening for cardiovascular disease.

Be a role model

Be a role model for these patients. Get them to stop smoking by setting appointments with groups proven to be effective. Enlist a dietitian to come and talk about altering eating habits. Role playing can be effective when a patient seems hesitant about being assertive in getting what she needs from, for example, a waitress. Give examples from personal or other patients’ experiences. Recommend local overeaters’ support groups that address patients’ needs.

The American Heart Association is an excellent source for educational materials about CVD and women’s special needs. Obtain information appropriate to your patient’s age, disease level, and reading ability. Involve her spouse, other family, or a trusted friend in discharge training so they can help the patient to modify her lifestyle and take medication properly.