Learning Objectives1. Understand basic distinctions betwee.docx

Learning Objectives
1. Understand basic distinctions between heart defects, heart
disease, and stroke
2. Describe how cardiovascular disorders affect different
individual, familial, and social domains
3. Identify the prevalence of cardiovascular disorders within
specific populations
4. Compare and contrast prevention and treatment methods for
different cardiovascular disorders
5. Describe societal elements that influence diagnosis and care
of cardiovascular disorders
Cardiovascular Disorders:
Congenital Heart Defects,
Heart Disease, and Stroke
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CHAPTER 6Section 6.1 Introduction to Cardiovascular
Disorders
6.1 Introduction to Cardiovascular Disorders
The literature about cardiovascular disorders can be confusing.
It abounds with abbrevia-tions and different names for the same
disorder or procedure. Let’s begin by saying that the
cardiovascular system comprises the heart (cardio) plus the
blood vessels, or circulatory
(vascular) system. The most common cardiovascular disorder is
high blood pressure, or hyperten-
sion, which is covered in Chapter 5.
It is estimated that 83.6 million adults in the United States (or
more than one in every three) had
a cardiovascular disorder in 2010 (Go et al., 2013). Table 6.1
shows how many people were diag-
nosed with different cardiovascular disorders in the United
States in 2010, or the prevalence of
various cardiovascular disorders.
Table 6.1: Prevalence of cardiovascular disorders in the United
States, 2010
Condition Prevalence (in millions)
Hypertension 77.9
Angina (chest pain) 7.8

Myocardial infarction (heart attack) 7.6
Stroke (all types) 6.8
Heart failure 6.1
Congenital cardiovascular defects 0.65 to 1.3
Prevalence of cardiovascular disorders in the United States:
hypertension = systolic pressure of 140 mmHg or over, or
diastolic pressure of 90 mmHg or over.
Note that individuals may have more than one disorder, so
adding up the prevalence of each disorder does not give a
total of unique individuals.
Source: Go, A.S., Mozaffarian, D., Roger, V.L., Benjamin, E.J.,
Berry, J.D., & Borden, W.B. Heart disease and stroke
statistics—2013
update: a report from the American Heart Association.
Circulation, 127(1), p. 109. Copyright © American Heart
Association. Used by
permission
As the report from the American Heart Association, “Heart
Disease and Stroke Statistics—2013
Update,” makes clear in 200-plus pages, there are many
different cardiovascular disorders (Go et
al., 2013). We will examine three cardiovascular disorders—
briefly touching on congenital heart
defects and focusing mainly on heart disease and stroke.
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Disorders
History of the Heart
Both the ancient Egyptians and Greeks believed the
heart was the center of human life, both physically
and spiritually. Later, the Romans understood the
central role of the heart in sustaining life. It was in
the second century CE that Roman physician Clau-
dius Galen made several important observations
about the heart based on experiments in monkeys.
Galen’s work, including observations on blood circu-
lation, valves, veins, and arteries, became the basis
for understanding heart function for the next mil-
lennium and more. However, his theory about the
four humors in the body needing to be in balance
was later disproven.
Leonardo da Vinci (1452–1519) accurately described
and sketched the four chambers of the heart, the
coronary vascular system, and the heart valves.

He also described arteriosclerosis in great detail
and asked
why the vessels in the old acquire great
length and those which used to be straight
become bent and the coat thickens so much as to close up and
stop the move-
ment of the blood, and from this arises the death of the old.
(Keele, 1951, p. 212)
He also noted an atrial septal defect, which he found in the
course of his dissections. However, he
accepted Galen’s view of heart function (Keele, 1951).
Leonardo da Vinci/©Bettmann/Corbis
Leonardo da Vinci was able to accurately
describe and sketch the heart.
Case Study: An Example of Cardiovascular Disorders
Ken had been diagnosed with hypertension and was treated for
it for many years. One day, when he
was 49 years old, Ken experienced sudden severe chest pain and
was taken to the hospital, where he
was admitted. A blocked artery in his heart was opened, and a
tiny mesh tube (or stent) was inserted
into it to keep it open. He was released from the hospital a few
days later, feeling much better than
before his hospitalization.
Five years later, when Ken was 54, he was working in his
construction company office as usual one
morning. His coworkers could hear him talking on the phone
when suddenly the talking stopped and
they heard a loud thump. They rushed in and found him
unconscious on the floor. Luckily Ken’s cowork-

ers were knowledgeable and alert; one knew cardiopulmonary
resuscitation (CPR), and the other one
called 911. Ken didn’t seem to be responding to the CPR, but
just a few minutes after the phone call,
they could hear the ambulance siren and the emergency medical
technicians arrive. They administered
care and took Ken to the emergency room of the local hospital,
where physicians tried to revive him,
but efforts were unsuccessful and he was pronounced dead. As
the physician explained to Ken’s wife,
Judith, an electrical problem in his heart caused it to suddenly
stop pumping blood. This is known as
cardiac arrest, or sudden cardiac arrest.
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Disorders
In 1628, William Harvey first described blood circulation,
correctly surmising that the heart
pumps blood throughout the body. In the next century, blood
pressure was first measured by
Stephen Hales in 1733, and inventions of the stethoscope (in
1816 by Rene Laennec) and the
electrocardiogram (in 1903 by Willem Einthoven) made
possible great strides in our understand-
ing of the heart. Einthoven received the 1924 Nobel Prize in
medicine for his invention.
The first major surgery on the great vessels near the heart was
performed by Robert Gross in
1938 in an attempt to repair a pulmonary artery defect. This
much-heralded operation opened

the modern era of cardiac surgical intervention. World War II
probably did much to further the
cause of cardiac surgery, which was performed in the field
under less than ideal conditions. The
first successful attempt to repair the hearts of “blue babies”
(babies born with tetralogy of Fallot,
a heart defect that causes poor oxygenation of the blood and a
resulting bluish tint, or cyanosis,
in the skin) was made by the team of Alfred Blalock, Helen
Taussig, and Vivien Thomas at Johns
Hopkins Hospital in 1944.
Before modern times, most people lived active lives and tended
to be lean. However, after the
Industrial Revolution in the 19th century, death from
cardiovascular disorders began to increase.
Toward the middle of the century, concern about the rising
epidemic raised interest in studying
what might be contributing to cardiovascular disorders,
including heart disease and stroke.
Congenital Heart Defects
Congenital heart defects (also known as congenital
cardiovascular defects) are structural prob-
lems in the heart or major blood vessels that form during fetal
development and are present at
birth. Most occur very early in development, during
the first few weeks of pregnancy, before the mother
even knows that she is pregnant. In most cases, the
causes of congenital heart defects are unknown. We
do know that maternal obesity, diabetes, and smok-
ing are risk factors, so it is best for women who are
planning to become pregnant to lose weight if nec-
essary, manage their diabetes, and stop smoking.

Some congenital heart defects are minor and disap-
pear as the child grows; some are more serious and
may result in death before birth or require surgery
before birth or soon after birth for survival. More
than one fourth of infants who have died of a birth
defect have had a heart defect (Go et al., 2013).
Some congenital heart defects are not diagnosed
until adolescence or adulthood. In this section, we
briefly cover a few of the more common congenital
heart defects.
Major cardiovascular defects may be identified at
birth because the infant appears blue or has low
iStock/Thinkstock
The human heart.
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Disorders
blood pressure. Others are identified within the first few months
of life because of breathing diffi-
culties, feeding problems, or lack of normal weight gain. Most
major defects require intervention;
some operations can be done without opening the chest, and
others require open-heart surgery.
Most children with major defects have to be seen periodically
by a pediatric cardiologist. After
surgery, some children lead normal lives, whereas others have
limitations to their physical activity.
Table 6.2 shows the prevalence of some of the more common

major congenital heart defects. To
fully understand the biology of congenital heart defects, review
how a normal heart works. Visit
the American Heart Association at
http://www.heart.org/HEARTORG/ to review the basics about
healthy heart functions.
Table 6.2: Prevalence of select congenital heart defects per
10,000 births
Defect No./10,000 births
Atrioventricular septal defect 4.7
Tetralogy of Fallot 4.0
Transposition of the great arteries 3.0
Hypoplastic left heart syndrome 2.3
Truncus arteriosus 0.7
Source: Go, A.S., Mozaffarian, D., Roger, V.L., Benjamin, E.J.,
Berry, J.D., & Borden, W.B. Heart disease and stroke
statistics—2013
update: a report from the American Heart Association.
Circulation, 127(1), p. 153. Copyright © American Heart
Association. Used by
permission.
Ventricular Septal Defect
Ventricular septal defect (VSD) is the most common congenital
heart defect. It is an opening or
hole in the wall (or septum; the plural is septa) between the two
lower heart chambers (or ven-
tricles). The opening allows extra blood to be pumped to the

lung arteries and creates extra work
for both the lung and the heart. A small VSD does not need
intervention, but a larger one causes
problems and has to be closed through open-heart surgery,
usually while the child is quite young
(American Heart Association [AHA], 2009b).
Atrial Septal Defect
Atrial septal defect (ASD) is an opening or hole in the wall
between the two upper heart cham-
bers (or atria; the singular is atrium). However, all children are
born with this hole, which allows
blood to bypass the lungs while the child is in the womb (in
utero) and receiving oxygenated blood
from the mother through the placenta. Normally, the ASD closes
within a few months after birth,
but sometimes it does not. A small ASD is probably not a
problem, but a large ASD needs to be
mechanically closed (AHA, 2009a).
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http://www.heart.org/HEARTORG/
Disorders
Case Study: Marfan Syndrome
Ben was adopted when he was 1 day old. Diane and David had
talked to his birth mother at length,
although they hadn’t actually met her before Ben was born.
Diane remembers thinking that Ben’s
birth mother had unusually long slender fingers. When Ben was
4 months old, his pediatrician told
Diane that she thought he had some features of Marfan

syndrome, a rare genetic disorder caused by
a defect in the gene for a connective tissue protein that affects
many parts of the body, including the
aorta and heart valves. People with Marfan syndrome are often
unusually tall and slender. The pedi-
atrician made arrangements for Ben to be seen by a genetic
counselor, who became their base for all
ensuing medical procedures.
Ben was 5 months old when he was examined by a Marfan
specialist who confirmed the characteristic
physical traits and tested his blood. He was indeed positive for
Marfan, so they arranged for Ben to be
seen by an ophthalmologist, a cardiologist, an orthopedic
surgeon, and a pulmonologist. Ben is at the
more severe end of the syndrome, and will probably need
cardiac surgery within the next two years.
He has worn glasses since he was 2 years old and has been
getting physical and occupational therapy
every week, first at home and later at the school he attends for
special needs children.
Other Congenital Heart Defects
Atrioventricular septal defect (also known as atrioventricular
canal or endocardial cushion defect)
is a large hole in the wall (septum) at the center of the heart
separating the two upper cham-
bers (atria) and the two lower chambers (ventricles). Defects in
the valves that normally regulate
movement of blood from upper to lower chambers are usually
present as well.
Tetralogy of Fallot has four components. The major ones are a
ventricular septal defect and an
obstruction between the right ventricle and the lungs (stenosis—
narrowing or constriction—of

the pulmonary valve). In addition, the aorta is misplaced over
the septal defect, and the right ven-
tricle muscle is abnormally thick.
Transposition of the great arteries reverses the aorta and
pulmonary artery so that the aorta
receives oxygen-poor blood and the lungs receive oxygen-rich
blood. It must be repaired for the
child to survive.
In hypoplastic left-heart syn-
drome, the whole left side of
the heart—including the aorta,
aortic valve, left ventricle, and
mitral valve—is underdeveloped.
This defect is fatal unless treated
within the first month of life.
Truncus arteriosus is the fusion
of two large arteries carrying
blood away from the heart in
addition to a ventricular sep-
tal defect. Surgery is needed to
repair this defect. iStock/Thinkstock
Some children with cardiovascular defects can participate in
normal activities after repair.
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Disorders
Heart Disease

Heart disease begins with the narrowing of arteries that supply
blood, oxygen, and nutrients to
the heart muscle (the coronary arteries). Narrowing results from
a deposit of fats and other sub-
stances to form a thick film on the interior of the artery walls, a
buildup known as plaque. The
process of plaque formation is known as atherosclerosis, or
colloquially known as “hardening of
the arteries” because the arteries become stiff as plaque builds
on their inner surface. As plaque
builds up, the arteries become narrower and blood flow can
slow or stop, reducing the amount of
oxygen that reaches the heart muscle. As mentioned earlier,
narrowing of the arteries is known
as stenosis, and the reduction of blood flow, and therefore a
reduction of oxygen and nutrients, is
known as ischemia.
Coronary arteries, which branch off from the aorta near the left
ventricle, supply the heart with all
the blood, oxygen, and nutrients it needs in order to pump
continuously and keep blood flowing
throughout the body. Heart disease is often termed coronary
heart disease or coronary artery
disease. The coronary arteries supply the blood and oxygen to
the heart that allow this specialized
muscle to continue to work day in and day out. Reduced blood
flow through the coronary arter-
ies may create chest pain from reduced oxygen and buildup of
waste material. This pain, known
as angina, or angina pectoris, is a symptom of heart disease.
Angina is more likely to occur with
increased activity, heavy meals, stress, or emotional upset. It
usually goes away with rest or treat-
ment with nitroglycerine, a medicine that relaxes blood vessels
(a vasodilator) and allows blood

flow to increase.
Cardiologists distinguish between stable angina and unstable
angina. Stable angina happens pre-
dictably with exertion, emotional upset, exposure to cold, or
overeating and resolves with rest or
taking nitroglycerine. Unstable angina is not predictable, may
happen at rest or with light activ-
ity, does not resolve with rest or nitroglycerine, and is a
warning sign of a possible heart attack.
Stable angina can go unchanged for years, but unstable angina
can happen without warning,
even to those who have not experienced stable angina. Unstable
angina needs to be evaluated
immediately.
In addition to angina, other common symptoms of heart disease
include shortness of breath and
fatigue. Even if there is no obvious pain, reduced blood flow to
the heart muscle means that some
of the heart cells die and the heart becomes weaker, which may
lead to inadequacy in pumping
enough blood to meet the body’s needs (termed heart failure) or
problems in the rate or rhythm
of the heartbeat (arrhythmias).
If a blood vessel to the heart becomes mostly or totally blocked,
a heart attack (also known as
myocardial infarction) may result. If blood flow is not restored
very quickly, a section of the heart
muscle starts to die. Depending on which coronary artery is
blocked and how much of the heart
muscle becomes ischemic, a heart attack may cause permanent
disability or death. The faster
blood flow can be restored, the better the outcome will be.

Warning signs of a heart attack include the following:
• chest discomfort that lasts for several minutes or that recurs—
may feel like uncom-
fortable pressure, fullness, squeezing, or pain;
• discomfort in other areas of the upper body, including arms,
back, neck, jaw,
or stomach;
• shortness of breath with or without chest discomfort;
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Disorders
• sweating, nausea or vomiting, or lightheadedness; and
• in women, more likely, shortness of breath, nausea or
vomiting, and back or jaw pain
as presenting symptoms (AHA, 2013b)
Anyone experiencing any of these symptoms or witnessing them
in someone else should call 911
or the local emergency response number within 5 minutes.
Web Field Trip
Women often fail to recognize heart attack symptoms or
attribute them to other causes, such as the flu
or acid reflux. A video from the AHA’s Go Red for Women/
public awareness campaign exaggerates
this tendency but underlines the importance of responding to
warning signs promptly: http://www

.youtube.com/watch?v=t7wmPWTnDbE.
Critical Thinking Questions
1. What do you think interferes with women’s ability to
recognize their condition?
2. What are the typical images most often associated with
having a heart attack?
In addition to distinguishing between the different forms of
angina, cardiologists distinguish
between less severe and more severe heart attacks: non-ST-
elevation myocardial infarction
(NSTEMI) and ST-elevation myocardial infarction (STEMI),
respectively. The different names
reflect whether the ST segment of an electrocardiogram (ECG
or sometimes EKG) tracing shows
a change from normal baseline heart electrical activity. The
diagnosis of NSTEMI or STEMI affects
treatment: In NSTEMI, damage is caused by partial blockage
(occlusion) of a coronary artery with-
out extensive damage to the heart muscle. In STEMI, by
contrast, more complete occlusion of a
major coronary artery results in damage that extends throughout
the depth of the heart muscle.
Unstable angina, NSTEMI, and STEMI are often grouped
together under the umbrella term acute
coronary syndrome (ACS), as all are medical emergencies and
require immediate (acute) evalua-
tion and treatment. However, treatment depends on which form
of ACS the patient is experienc-
ing. In 2010, approximately 625,000 people were discharged
from the hospital with a diagnosis
of ACS. Of these, an estimated 363,000 were males and 262,000
were females (Go et al., 2013).

Stroke
Interruption (or severe reduction) of normal blood flow to part
of the brain is known as a stroke.
Another name for stoke is cerebrovascular disease (cerebro
refers to the brain). Stroke is often
termed a “brain attack,” because what happens in the brain
during a stroke is similar to what
happens in the heart during a heart attack: Reduced arterial
blood flow deprives the affected part
of the brain of oxygen and nutrients, and within minutes, some
brain cells begin to die. Stroke is
the fourth leading cause of death in the United States and the
leading cause of serious long-term
disability (National Institute of Neurological Disorders and
Stroke [NINDS], n.d.-a). Key risk factors
for stroke include hypertension, smoking, atrial fibrillation (a
type of arrhythmia), and physical
inactivity (American Stroke Association, 2013).
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http://www.youtube.com/watch?v=t7wmPWTnDbE
http://www.youtube.com/watch?v=t7wmPWTnDbE
Disorders
Everyone should be familiar with the signs of a stroke:
• sudden numbness or weakness of the face, arm, or leg,
especially on one side of the
body;
• sudden confusion or trouble speaking or understanding speech;

• sudden trouble seeing in one or both eyes;
• sudden trouble walking, dizziness, or loss of balance or
coordination; and
• sudden severe headache with no known cause (NINDS, n.d.-b)
If someone experiences any of these symptoms or sees them in
someone else, that person should
not hesitate to call 911, noting the time that symptoms first
appeared. Stroke is always an emer-
gency. The good news is that today, stroke is treatable, and the
faster medical attention is received,
the better the chance of avoiding long-term brain damage and
disability.
There are two major types of stroke: ischemic, which is caused
by a blocked artery, and hemor-
rhagic, which is caused by a leaking or burst blood vessel. Most
strokes (approximately 80%) are
ischemic. They can be triggered when a plug forms in one of the
arteries that supply blood to the
brain. In someone with atherosclerosis, the plug often consists
of plaque or a blood clot that forms
around a ruptured plaque, called thrombotic ischemic stroke.
Another form of ischemic stroke
occurs when a blood clot or other debris formed in a distant part
of the body is carried to the brain
and blocks one of the narrower brain arteries, called embolic
ischemic stroke.
Hemorrhagic stroke occurs when a blood vessel in the brain
leaks or bursts; bleeding occurs into
or around the brain, which stops or decreases blood flow to
other areas of the brain. Hemorrhagic
stroke often occurs in people with hypertension, but it also can
result from vascular defects in the
brain. Normally, brain cells are not in direct contact with blood;

nutrients and oxygen pass across
the smallest blood vessels, the capillaries, to the brain cells or
neurons, and waste material passes
from the neurons into the capillaries. The presence of blood
around neurons is toxic and inter-
rupts their normal function.
Sometimes people have one or more symptoms of a stroke that
appear to clear up within minutes
or up to an hour without leaving any noticeable disability.
Known as a transient ischemic attack
(TIA), also called a mini-stroke, it is caused by a temporary
decrease in the brain’s blood supply.
Because there is no way of knowing whether the signs of a
stroke indicate a full stroke or a TIA,
all stroke symptoms should be treated as an emergency. In
addition, people who have had a TIA
are at increased risk for having a more serious stroke. Indeed,
having any type of stroke puts a
person at risk for having another one: About one quarter of
those who have had a stroke will have
another one within 5 years (NINDS, 2013e). Most recurrent
strokes happen within two years of
the first one, and the risk of stroke decreases with time.
However, if it does strike, recurrent stroke
increases the risk for disability and death.
After a person survives a stroke, the next question concerns
disability: how bad and for how long.
The degree of disability depends on both the location of the
stroke within the brain (the critical
functions controlled by that part of the brain) and the size of the
area affected. A stroke on the left
side of the brain affects functioning on the right side of the
body, and vice versa.

The most common disabilities from stroke include:
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Disorders
• complete paralysis on one side of the body (hemiplegia) or
weakness in the muscles
on one side of the body (hemiparesis); paralysis or weakness
confined to one area,
such as an arm, leg, or side of the face;
• cognitive deficits, including memory loss and problems with
higher levels of thinking
such as planning and making judgments, also known as
executive function;
• speech and language problems, which may include both the
inability to form words
because the muscles of the mouth aren’t working properly
(dysarthria) and the inabil-
ity to understand and form language (aphasia);
• emotional difficulties, including problems with depression or
the ability to control
feelings;
• problems in activities of daily living such as walking,
dressing, eating, and personal
hygiene; and
• pain, numbness, or other sensations in parts of the body
affected by stroke.

After being released from the hospital, most people who have
had a stroke go into intensive reha-
bilitation before going home. Rehabilitation is discussed in the
section on treatment.
Common Misperceptions About Heart Disease and Stroke
A number of misconceptions and misperceptions persist about
heart disease and stroke that may
contribute to inaction or inappropriate action.
People Are Reluctant to Call 911
People tend to wait much too long, often more than two hours,
before getting help. They may
think they are experiencing a false alarm, or they may be afraid
to admit that they or their loved
one is having a heart attack or stroke. Although it is easy to
understand why this happens, it is
dangerous to wait.
A related misperception is to think it’s better to drive or have
someone else drive to the
emergency room rather than calling 911 when emergency
services are available in the region.
Emergency medical personnel can begin lifesaving measures
well before a person reaches
the emergency room, which may save a life or lessen the
severity of a resulting disability.
Cardiac Arrest Is the Same as a Heart Attack
Cardiac arrest is caused by a malfunction in the heart’s
electrical system that stops the heart
from beating; it often results in death within a few minutes
unless immediate treatment is avail-
able (see about treatment, below). In contrast, a heart attack is a
blockage in blood flow to the

heart muscle; the heart keeps beating, so the attack does not
usually result in immediate death.
Confusion arises because sometimes a heart attack can trigger
cardiac arrest, but there are other
triggers as well.
Heartbeat Is a Reliable Indicator of Heart Health
Resting heart rate in adults is generally between 50 and 90 beats
per minute. Some people think
that an occasional fast (tachycardia) or erratic heartbeat
(arrhythmia) is an indicator of a heart
attack, which is almost never the case unless there is
accompanying chest pain, shortness of
breath, or another symptom of heart attack. However, it is a
good idea to have an erratic heartbeat
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CHAPTER 6Section 6.2 Using Bronfenbrenner’s Model to
Better Understand Cardiovascular Disorders
Case Study: Identifying Factors That Contribute to
Cardiovascular
Disorders
The monumental Framingham Heart Study began in 1948 with
funding from the U.S. National Heart
Institute (now the National Heart, Lung, and Blood Institute
[NHLBI). Its objective was to identify fac-
tors that contribute to the development of cardiovascular
disorders by closely following a large group
of people for a long time (a longitudinal study).
The 5,209 original participants from the town of Framingham,
Massachusetts, enrolled in the study

with no symptoms of cardiovascular disorders and no previous
heart attacks. Using thorough physical
exams and interviews about lifestyle habits conducted every two
years with participants, investigators
were able to identify risk factors for cardiovascular disorders.
The study was later broadened to include
spouses and children of the original participants, as well as a
group of people with a more diverse
background than the original one. Eventually, grandchildren of
the original group and children of the
diverse group were also included.
The study identified high blood pressure, high cholesterol,
smoking, obesity, diabetes, and physical
inactivity as major risk factors for cardiovascular disorders. In
addition, the study has contributed to
our understanding of a number of other factors, such as how
other blood lipids, age, sex, and psycho-
social factors contribute to the development of these pervasive
disorders. Unfortunately, the budget
for this long-running trial was cut drastically in 2013, which
translates into layoffs and therefore fewer
examinations and laboratory activities for this well-studied
group. Visit the Framingham Heart Study
website (http://www.framinghamheartstudy.org/) to learn more
about the ongoing study, calculate
your risk for cardiovascular disorders, and see highlights of the
research milestones.
checked out by a health care provider, because such arrhythmias
may contribute to a person’s risk
for stroke. A number of factors can increase heart rate,
including stress, smoking, too much caf-
feine, dehydration, and fever. Although not a reason for acute
concern, frequent fast heart rate
should be checked by a health care provider.

Some people think that a slower than normal resting heart rate
(bradycardia) is a cause for con-
cern. The truth is that a slow resting heart rate in a younger
person is generally a sign that the
heart is strong. However, a slowed heart rate in an elderly
person, particularly if accompanied by
fatigue, dizziness, or fainting, should be checked out.
6.2 Using Bronfenbrenner’s Model to Better Understand
Cardiovascular Disorders
Bronfenbrenner’s bioecological model of human development
views the individual within the center of several concentric
circles of the larger world: the family and others with whom the
individual has intimate interactions (micro perspective); the
immediate community,
including school or work (meso perspective); and the larger
society and culture, including eth-
nicity, nationality, and socioeconomic status (SES; macro
perspective). The model postulates the
interaction as a two-way phenomenon: The individual both
affects and is affected by each sphere
of influence. For further discussion, please review Chapter 1.
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http://www.framinghamheartstudy.org/
Micro Perspectives
Cardiovascular events such as angina, heart attack, and stroke
are generally observed in people

who have accumulated risk factors for these events, including
smoking, hypertension, and obesity.
However, data have shown that, in many cases, the trigger is an
acute episode of psychological or
emotional stress.
George Engel (1977; 1978; 1980), who generated the early
literature on the biopsychosocial
approach to medicine, hypothesized that neural mechanisms
were responsible for triggering sud-
den cardiac arrest. (For further discussion of Engel’s ideas, see
the discussion on the biopsycho-
social model in Chapter 2.) Some of these mechanisms result
from early family experience. For
instance, Thomas (1976) found that early family attitudes were
correlated with premature hyper-
tension, cardiovascular disease, and death much later in life.
Although much of the work linking psychosocial stress with
cardiovascular events was done sev-
eral decades ago, recent research has uncovered details about
the biological mechanisms that
may be involved. For instance, a tendency toward angry
rumination is correlated with stress-
provoked release of endothelin-1 in patients with heart disease.
Endothelin-1 is produced by
the cells lining blood vessels and can trigger plaque rupture,
leading to cardiovascular events
(Fernandez et al., 2010). Another mechanism thought to be at
play in cardiovascular events is
stress-induced increase in coagulation (clot formation), which
has been found to increase with age
(Wirtz et al., 2008). Investigators have also found that people
who have already had a heart attack
may be particularly sensitive to stress-induced increases in
sympathetic nervous activity, which, in

turn, can provoke arrhythmias that can induce sudden cardiac
arrest (Magri et al., 2012).
Case Study: One Family’s Experience With Cardiovascular
Disorders
Julie was 41 and was at home preparing to take her sons to
school one morning. She reached down to
pick up something that she had dropped and fell over. Not
understanding why she couldn’t get up, she
screamed, and her 12-year old son, Daniel, came in and asked
why her mouth looked funny. She told
him that she thought she was having a stroke and to call a
neighbor, but he insisted on calling 911. The
paramedics came and took her to the hospital. She kept talking
in the ambulance—it was her way to
retain some control in a situation that was, in reality, totally out
of her control. Julie reached the hospi-
tal in plenty of time to be given the appropriate drug to treat her
ischemic stroke.
Julie was under tremendous psychological stress in the days
before her stroke. While recovering from a
knee operation, her husband had been diagnosed with a lung
problem that looked like cancer. It turned
out not to be cancer, but he came close to dying during the
surgery to remove the growth and was in the
intensive care unit for 10 days. The day of the stroke, Julie was
headed to work to tell her good friend
and colleague who had recently lost her mother that she had
been laid off from their failing company.
Like many women in stressful situations, Julie was ignoring her
own physical care. Because of the psy-
chosocial stress, she had recently taken up smoking, which she
hadn’t done since college. Her weight
was too high, she was unaware that she had developed

hypertension, and she was taking birth control
pills. All these risk factors were heightened because Julie is
Black—in the United States, Blacks have
a higher risk for stroke than any other racial or ethnic group.
This mix of heightened risk factors plus
extreme psychological stress, which probably decreased her
normal ability to cope, made Julie a prime
target for the stroke she experienced.
Although Julie recovered well from her stroke, her illness
temporarily put even more stress on her two
young sons, who were terrified that both their parents might die.
atL80953_06_c06.indd 178 12/5/13 1:38 PM
Case Study: A Community Coordinates to Support a Local
Family
Judith’s children were both in high school when her husband
Ken (whose story starts the chapter) died
suddenly from cardiac arrest. Judith hates going to the high
school where her children were students.
She remembers going in to tell them their dad had died and
thinking, “This is the last moment when
they think their lives are normal. I don’t want it to end!”
A friend drove them to the hospital and on the way she said to
her children, “This is the way he would
have wanted to go.” When they arrived at the hospital, the nurse
had Judith go in to see Ken alone first.
It was then that the staff explained to her what had happened.
They had stopped trying to revive him

when it was clear his brain was no longer functioning.
They lived in a small town, but Judith attributes the immediate
response to the family’s loss to the
community of high school parents (meso sphere) where
everyone learned of Ken’s death through the
children. “We didn’t have to make a meal for ourselves for
several months, and I would arrive home to
find that the lawn had magically been cut. In a horrible
situation, I felt lucky.”
Meso Perspectives
Work, school, worship, and community circles of influence
interact reciprocally with the individ-
ual and family spheres of influence. The level of interaction
experienced by the individual and
family most likely affects whether and how much the next,
meso, sphere supports the individual
and the family.
Researchers have found that smaller social networks are an
independent predictor of cardiovas-
cular mortality and risk for stroke (Rutledge et al., 2008). In a
recent review of prospective studies,
those who experienced social isolation showed a 1.5-fold
increased risk of heart disease and a
1.3-fold risk of workplace stress (Steptoe & Kivimaki, 2013).
So it would appear that sparse
interaction between the micro and meso spheres has an adverse
effect on the individual (or
family’s) health.
The norms of an individual’s social network can have a large
effect on health behavior. Christakis
and Fowler (2007) originally observed that social networks had
a large effect on obesity; using

the extensive database of the Framingham Heart Study, they
found that weight gain appeared to
spread across social networks. Their publication the following
year found a similar situation for
smoking cessation; to wit, if a person’s spouse quit smoking,
there was a 67% lower likelihood that
the smoking spouse would continue smoking. Similar effects
were seen among siblings, friends,
and coworkers from small firms, though not among immediate
neighbors (Christakis & Fowler,
2008). So it is the “social neighborhood” and not the physical
neighborhood that is important.
With time, smokers were more likely to be found on the
periphery of social networks, that is, less
engaged. Recently, these investigators found that aspirin use to
avoid cardiovascular events was
more likely to be adopted if someone in the individual’s
network either was taking aspirin or had
had a recent cardiovascular event (Strully et al., 2012).
Macro Perspectives
Although the physical effects of cardiovascular disorders are
seen mostly within the individual and
immediate family spheres, the physical and larger social
environment (macro perspective) can
either promote or create barriers to health-promoting activities
(Stineman & Streim, 2010).
atL80953_06_c06.indd 179 12/5/13 1:38 PM
It can be difficult to tease out the components of cultural

differences that influence health behav-
iors. For instance, although Blacks are disproportionally
affected by high blood pressure and
resulting stroke, they participate in physical activity that might
counteract this risk at lower rates
than Whites. In an attempt to tease out some of the contributing
factors, Black participants in a
community-based trial were interviewed before and after the
trial. Peer social support for physical
activity and neighborhood walkability were both significantly
related to average daily moderate to
vigorous physical activity (Coulon, Wilson, & Egan, 2013).
Much of the research correlating SES with heart disease has
been done with single-time assess-
ment of neighborhood or individual SES. However, the risk for
heart disease is known to accumu-
late over time. To address this effect, investigators in a multi-
ethnic study correlated SES over the
entire life span with subclinical atherosclerosis. They found that
both childhood and adult SES
were independently and significantly correlated with
atherosclerosis in men, but an additional
factor, neighborhood SES, was a significant factor in women
(Lemelin et al., 2009).
Although randomized controlled trials, the gold-standard of
clinical research in cardiovascular dis-
orders, have often ignored women (Dolor et al., 2012), several
epidemiological investigations have
recently focused on correlating women’s SES or cultural factors
with cardiovascular disorders.
For example, researchers hypothesized that cardiovascular
inflammation is a key contributor to
atherosclerosis and cardiovascular events among seemingly
healthy women (and men). So Clark

et al. (2012) tested the hypothesis that three biomarkers of
cardiovascular inflammation would
vary with state-level (macro) and individual (micro) SES in
women. They found that one measure,
high-sensitivity C-reactive protein, varied by state-level SES,
but the other two were influenced
only by individual income. The investigators urged additional
study to identify what higher income
states are doing differently than lower income states that
influences cardiovascular inflammation
in women.
In the federally funded Women’s Ischemia Syndrome Evaluation
(WISE), low income (less than
$20,000 a year) proved to be the most significant factor
predicting increased risk for cardiovascu-
lar death or heart attack. Those women with the lowest income
were more likely to be uninsured
or enrolled in public health insurance and had the highest five-
year hospitalization and drug costs.
The investigators emphasized that their findings “support a
profound intertwining between pov-
erty and poor health” and the need for “policies that track unmet
healthcare needs of and wors-
ening clinical status for low-income women” (Shaw et al., 2008,
p. 1082).
Although the U.S. health care system generally does a good job
at instituting evidence-based
treatment for cardiovascular disorders, such as treatment for
NSTEMI and STEMI (Somma et al.,
2012), it does a poor job at promoting positive changes in
cardiovascular health behaviors and
risk factors—in other words, prevention. In the 2013 Heart
Disease and Stroke Statistics, the AHA
listed a number of ways that health care systems might redress

this imbalance. The following were
among their recommendations:
• electronic systems for scheduling and tracking initial and
follow-up visits for behavior
change and medication use, as well as a means for providing
participants with feed-
back on their progress (i.e., two-way interaction between the
individual and
the system);
• integrated systems to provide all the members of a health care
team (physicians,
nurse practitioners, dietitians, physical activity specialists, and
social workers) with
information to coordinate care; and
atL80953_06_c06.indd 180 12/5/13 1:38 PM
CHAPTER 6Section 6.3 Cardiovascular Disorders Through the
Life Span
• reimbursement guidelines that reward efforts to change health
behaviors and risk
factors (Go et al., 2013).
The same publication also recommended evidence-based
approaches the larger society might use
to promote cardiovascular health behaviors and reduce risk
factors:
• subsidies to lower prices of more healthful foods and
beverages along with taxes on
less healthful ones;

• nationally organized school interventions to promote improved
diet and physical
activity;
• comprehensive workplace wellness programs with nutrition,
physical activity, and
smoking cessation components;
• restrictions on television advertisement for less healthful
foods and beverages aimed
at children; and
• media campaigns to reduce smoking, especially as part of
multicomponent population-
level efforts (Go et al., 2013).
It is expected that the Patient Protection and Affordable Care
Act (ACA) of 2010 will promote some
of these changes, which may be instituted first in the Medicaid
program (AHA, 2013a). In addition
to policy approaches, macro systems affect people with chronic
diseases in another significant
way—how well research and public health strategies are funded.
For example, although cardio-
vascular disorders are the major categorical cause of death in
the United States, heart disease
received only 5% ($1.3 billion) and stroke only 1% ($310
million) of total research funded by the
National Institutes of Health (NIH) in 2012 (NIH, 2013a;
2013b). Total NIH research funding, the
major national source, was $24.5 billion.
In comparison with the NIH, the U.S. Centers for Disease
Control and Prevention (CDC), the
major funding source for prevention studies and programs in the

United States, received only
$55.3 million in 2011 for its Division of Heart Disease and
Stroke Prevention (CDC, 2013a),
despite the fact that nearly 200,000 deaths each year from heart
disease and stroke are deemed
preventable (CDC, 2013r).
6.3 Cardiovascular Disorders Through the Life Span
Cardiovascular disorders are the primary cause of death in the
United States. For exam-ple, in 2009, the number of deaths
resulting from major cardiovascular disorders in 2009 increased
linearly with age—from 1,000 among the age group 15–24
years, to 83,000
among 55- to 64-year-olds, to 306,000 in the age group 85 years
and older (Kochanek, Xu, Murphy,
Minino, & Kung, 2011). As Figure 6.1 shows, the percentage of
deaths in a given age group due to
cardiovascular disease increases linearly as well, starting with
the age group 15–24 years, reaching
43% of causes of death among those aged 85 years and older.
atL80953_06_c06.indd 181 12/5/13 1:38 PM
Life Span
Figure 6.1: Percentage of all deaths due to cardiovascular
disorders
in the United States by age, 2008
Cardiovascular disorders are the primary cause of death in the
United States.

Source: National Heart Lung and Blood Institute. (2012b).
Morbidity & Mortality: 2012 chart book on cardiovascular,
lung, and blood diseases (Chart 3-9).
Retrieved from
http://www.nhlbi.nih.gov/resources/docs/2012_ChartBook_508.
pdf
Although more than half of deaths from congenital defects
occur in infants (aged less than
1 year), people with cardiovascular defects who survive
childhood are still vulnerable to the results
of these defects as adults. A small number of deaths from
congenital defects occur at every age
through 85 years and older (Kochanek et al., 2011), although no
separate data are available for
congenital heart defects by age after the first year.
Congenital Heart Defects Through the Life Span
We do not understand enough about the origin of congenital
heart defects to know why they
happen, but we do know that they tend to be set in motion very
early in the developmental pro-
cess, before the mother even knows that she is pregnant. Most
congenital heart defects become
apparent immediately after birth or during the first few months
of life, as the infant has difficulty
breathing, feeding, or gaining weight as expected. However,
some defects may be detected by
ultrasound during pregnancy. When severe defects are found
early in pregnancy, the family can
be counseled and educated about the defect to help decide
whether to continue or terminate
the pregnancy. If carried to term, the family has to decide on
interventional management before
birth (by operating on the fetus in utero) or after birth, or
choose nonintervention with palliative

care (focus on comfort rather than cure). Hypoplastic left-heart
syndrome is this kind of severe
defect. In a large series of cases in which hypoplastic left-heart
syndrome was detected during
pregnancy, approximately 11% of families chose to terminate
the pregnancy and 7% chose post-
natal palliative care (Rychik, 2013).
<1 1–4
0
10
20
30
40
45
5
15
25
35
D
e
a
th
s

(
p
e
rc
e
n
t)
Age group (years)
5–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 ≥85
atL80953_06_c06.indd 182 12/5/13 1:38 PM
http://www.nhlbi.nih.gov/resources/docs/2012_ChartBook_508.
pdf
Life Span
Among Canadian children who had severe heart defects with
surgical repair completed by 6 weeks
of age between July 2000 and June 2005, health-related quality
of life, as measured by the Pedi-
atric Quality of Life Inventory, was significantly below the
norm at 4 years of age (Garcia Guerra
et al., 2013). Several investigators have emphasized the
importance of assessing quality of life of
children with congenital heart defects as part of normal
pediatric cardiology practice (Uzark et al.,
2013; Wray, Brown, Marino, & Franklin, 2011).
Some children and adolescents who have congenital heart

defects have restrictions on their phys-
ical activity, whether they have had corrective surgery or not.
Dulfer, Helbing, Duppen, and Utens
(2013) reviewed how such restrictions affect psychosocial
functioning and found no consistent
relationship between exercise capacity or physical activity and
psychosocial quality of life. How-
ever, they did find that self-reported symptoms of depression
affected both physical and psycho-
social quality of life and strongly recommended screening for
depression in this population.
Because of advances made in treating congenital heart disease
during the last few decades, there
are now more people aged 20 years and older with congenital
heart disease than those younger
than 20. Although the population of adolescents and adults with
congenital heart disease is grow-
ing, our knowledge of the epidemiology, longitudinal data, and
wants and needs of this population
is not keeping pace. There are not nearly enough care facilities
in the United States or Canada to
serve this population, nor is there any formal mechanism for
transferring adolescents from pedi-
atric to adult health care (Moodie, 2011).
The problem was acknowledged by the CDC through a meeting
on congenital heart defects that
focused on four key areas: epidemiology, health services, long-
term morbidity and mortality, and
long-term psychosocial and neurodevelopmental outcomes.
Participants included physicians,
surgeons, epidemiologists, public health officials, advocates,
and people with congenital heart
disease. Results of the meeting were published as a special
report in August 2013. One import-

ant point the meeting raised is that there “are no population-
based data on the prevalence [of
congenital heart defects] beyond early childhood in the United
States” (Oster et al., 2013, p. 3).
Birth control has to be carefully considered by women with
congenital heart defects, as some
forms may pose health risks. Barrier methods are the safest;
birth control pills that have estrogen
can cause blood clots. Also, whether to become pregnant should
be reviewed with health care
providers, as children of both men and women with
cardiovascular defects may inherit the defect.
Pregnancy also poses special risks for women with congenital
heart defects.
Heart Disease and Stroke
Although the prevalence of heart disease increases dramatically
with age, it does affect younger
people as well, as can be seen in Figure 6.2. Note that the
prevalence of heart disease in the group
aged 18–44 years decreased dramatically (25%) between 2006
and 2010, from 6.7% to 6.0% (CDC
2011g).
atL80953_06_c06.indd 183 12/5/13 1:38 PM
Life Span
Figure 6.2: Percent prevalence of heart disease in the United
States, 2006–2010
Though heart disease is more prevalent for adults 65 years or

older, it is also affects younger people.
Source: Centers for Disease Control and Prevention. (2011a).
Prevalence of coronary heart disease—United States, 2006–
2010. Morbidity and Mortality
Weekly Report, 60(40), 1377–1381.
Stroke is uncommon in the young, but it does happen. In
contrast to what is found in adults,
hemorrhagic stroke is more common in children than ischemic
stroke. Risk factors for stroke in
children include infection, brain injury, and certain genetic
diseases such as Marfan syndrome and
sickle-cell disease. Symptoms of stroke in children may include
seizures, fever, or convulsions in
addition to those commonly seen in adults. Children usually do
better than adults with recovery
and rehabilitation, as their brains are adaptable, but those who
have accompanying seizures do
not do as well (NINDS, 2013e).
Stroke prevalence increases dramatically with age (see Figure
6.3). Note that during the period
1999–2008, the prevalence of stroke was higher in women at all
ages except for the age group
65–74 years. Women face a particular risk for stroke during
pregnancy, childbirth, and meno-
pause, which is likely attributable to hormonal changes.
Although the absolute risk of stroke in
women of childbearing years is low, it goes up relatively with
pregnancy. In fact, the primary cause
of maternal death during pregnancy is hemorrhagic stroke
(National Institute of Neurological Dis-
orders and Stroke, 2013).
20102006 2007 2008

Year
2009
0
5
15
10
20
25
H
e
a
rt
d
is
e
a
s
e
(
p
e
rc

e
n
t)
18–44
Age group (years)
45–64
≥65
atL80953_06_c06.indd 184 12/5/13 1:38 PM
Life Span
Web Field Trip
Learn more about what can be done to avoid preventable deaths
from a CDC fact sheet, “Prevent-
able Deaths From Heart Disease & Stroke,” that provides
information about relationships between
age, race or ethnicity, sex, geographic location, and rates for
preventable deaths (http://www.cdc.gov
/vitalsigns/HeartDisease-Stroke/index.html).
Critical Thinking Questions
1. Which ethnic or racial groups are at highest risk? What
regions of the United States have the
greatest number of preventable deaths?
2. What are some of the CDC’s recommendations for combating

this problem on the micro, meso,
and macro levels?
Figure 6.3: Prevalence of stroke by age and sex in the United
States, 1999–2008
Stroke prevalence increases with age for both males and
females.
Source: National Heart Lung and Blood Institute. (2012b).
Morbidity & Mortality: 2012 chart book on cardiovascular,
lung, and blood diseases (Chart 3-51).
Retrieved from
www.nhlbi.nih.gov/resources/docs/2012_ChartBook_508.pdf
The CDC launched an effort in September 2013 to combat what
it terms “preventable deaths”
from heart disease and stroke—deaths that could have been
avoided by changes in health hab-
its, such as quitting smoking; increasing physical activity;
lowering salt in the diet; and managing
high blood pressure, high cholesterol, and diabetes. In addition
to changes in personal habits,
communities can make a difference by providing safe places to
exercise and smoke-free areas.
Close to 60% of preventable heart disease and stroke deaths are
seen in people younger than 65
(CDC, 2013q).
≥7535–44 44–54 55–64
Age group (years)
65–74
0

4
8
2
6
14
12
10
S
tr
o
k
e
(
p
e
rc
e
n
t)
Female
Male
atL80953_06_c06.indd 185 12/5/13 1:38 PM

http://www.cdc.gov/vitalsigns/HeartDisease-Stroke/index.html
http://www.cdc.gov/vitalsigns/HeartDisease-Stroke/index.html
www.nhlbi.nih.gov/resources/docs/2012_ChartBook_508.pdf
CHAPTER 6Section 6.4 Treatment Approaches and Prevention
6.4 Treatment Approaches and Prevention
The disease processes that lead to cardiovascular disorders—
particularly heart disease and stroke—can start early in life and
are affected by lifestyle behaviors. Thus, modifying behav-ior
while people are young potentially has the greatest impact.
Prevention
In 2010, the AHA set goals for promoting cardiovascular health
and reducing disease burden.
Focusing on health promotion is an important conceptual change
from the previous focus on
disease. The AHA set out seven criteria for ideal cardiovascular
health that includes four ideal
health behaviors (nonsmoking, body mass index [BMI] , 25
kg/m2, physical activity at goal
levels, and diet consistent with current guidelines) and three
ideal health factors (untreated
total cholesterol , 200 mg/dL, untreated blood pressure , 120/80
mmHg, and fasting blood
glucose , 100 mg/dL; Lloyd-Jones et al., 2010). Overweight and
obesity are determined by BMI,
which is calculated using weight in kilograms divided by
surface area in square meters (kg/m2):
Normal BMI is 18.5–24.9; overweight is 25.0–29.9; and obese
is 30.0–39.9.
Since the AHA criteria were defined, several research groups
have used them to examine car-

diovascular health in the United States and have found that it is
far from ideal. For example, in
a community-based sample of 12,744 people in the
Atherosclerosis Risk in Communities Study
who were initially free of cardiovascular disorders in the late
1980s, only 0.1% met all seven
criteria for ideal cardiovascular health. Even so, over the next
20 years, those with the best
cardiovascular health had the fewest cardiovascular events,
including stroke, heart attack, and
heart failure (Folsom et al., 2011). Yang et al. (2012) found
similar correlations in 44,959 people
from the National Health and Nutrition Examination Survey:
Only 1.2% of the population met all
seven criteria in 2005–2010, but those who met the most criteria
had the lowest risk for total
and cardiovascular mortality.
Treatment of Congenital Heart Defects
For minor congenital defects, a child may just need to be
checked by a pediatric cardiologist peri-
odically to monitor his or her progress. For more major defects,
repairs are made either by cardiac
catheterization or through open-heart surgery. Defects that are
not amenable to these proce-
dures may require a heart transplant.
Interventional cardiac catheterization permits some repairs to be
done without opening the chest;
thus, it is less invasive and allows for faster healing than open-
heart surgery. A thin plastic tube
or catheter is threaded from the neck or groin into the heart.
Through the catheter, the surgeon
can close a septal defect or an abnormal blood vessel or widen a
narrowed vessel or a stiff valve.

Open-heart surgery may be needed to correct some major
defects such as transposition of the
great arteries or hypoplastic left-heart syndrome. Sometimes the
repair is done in stages—an
immediate minor repair might be done to allow the child to gain
sufficient strength to withstand
major surgery.
A heart transplant (removal of the diseased heart and
replacement with one taken from a donor)
is performed only when repair is not possible. The donor heart
must be matched by blood type
and body size. The recipient takes medication throughout life to
prevent immune rejection of the
new heart and is regularly monitored for side effects from those
immunosuppressive medications.
atL80953_06_c06.indd 186 12/5/13 1:38 PM
Some children with congenital heart defects are able to
participate in normal activities after repair,
but some have their activities limited. This is an individual
decision made between parents and
the pediatric cardiologist based on the characteristics of the
defect, the success of the repair, and
the child’s endurance.
Because of advances in treating infants and children, more
people with congenital heart defects are
living into adulthood. However, even if their defects were
repaired in childhood, adults with con-
genital heart defects need to have regular checkups with adult

congenital heart defect specialists.
Adults with congenital heart defects have higher rates of
hospitalization and emergency room
visits, and may face shorter a shorter life span than people
without cardiovascular defects. Several
recent publications have urged health care providers to discuss
advance care planning and end-of-
life issues in adults with congenital heart defects (Kovacs,
Landzberg, & Goodlin, 2013; Tobler et
al., 2012). (See Chapter 3 for more information on these topics.)
Treatment and Prevention of Heart Disease
Heart disease covers a wide range of severity—from stable
angina through ACS and cardiac arrest.
Three general approaches are taken to heart disease treatment:
lifestyle changes to reduce the
risk of more severe heart disease (primary prevention) or
recurrent episodes of the same dis-
ease (secondary prevention), medication, and surgery. Since the
1940s, there have been great
advances in cardiac surgery, such as open-heart surgery,
implantable medical devices to help a
compromised heart function, coronary artery bypass surgery,
heart transplant, and a permanent
artificial heart (The Franklin Institute, n.d.). In addition,
cardiac rehabilitation (rehab) is usually an
important part of the treatment plan.
Stable Angina
The goals of treating stable angina are (a) to reduce pain,
discomfort, and the frequency of symp-
toms; and (b) to prevent or lower the risk of a heart attack and
death by treating the underlying
heart condition.

Lifestyle changes to reduce the risk for heart disease (see
earlier) are an important first step. Peo-
ple can also learn their physical endurance limits and sit down
or take breaks as they approach
them. Gradually increasing physical activity can also raise
endurance. Knowing what triggers bouts
of angina can help manage it. For example, if heavy meals
trigger angina, then avoiding them
makes sense. Or if emotional upset is a frequent trigger, then
avoiding upsetting situations or
learning how to handle them helps.
In addition to lifestyle changes, some form of nitrate medication
is often prescribed. The most
frequently used nitrate is nitroglycerine, which is placed under
the tongue or between the cheek
and gum to immediately relieve painful angina episodes. Other
medications that may be pre-
scribed include:
• beta blockers,
• calcium-channel blockers,
• angiotensin-converting enzyme (ACE) inhibitors,
• oral antiplatelet medications, and
• anticoagulants (NHLBI, 2011).
atL80953_06_c06.indd 187 12/5/13 1:38 PM
If these drugs do not offer sufficient relief, then cardiac rehab
may be prescribed. An alternative
noninvasive approach to treating resistant or refractory angina
is enhanced external counterpulsa-

tion therapy. With the patient lying on a table, three inflatable
cuffs are placed on each leg (calves,
lower thighs, and upper thighs or buttocks) and electrodes are
placed on the chest. The electrodes
are connected to an electrocardiograph that controls the cuffs,
which are gently inflated to coin-
cide with diastole (heart muscle relaxation) and deflated during
systole (heart muscle contrac-
tion). Treatments are given for 1 hour, 5 days a week, for 7
weeks. The therapy increases blood
flow to the coronary arteries and may encourage the growth of
extra collateral, small coronary
arteries that function as natural bypass vessels (Manchanda &
Soran, 2007).
Acute Coronary Syndromes
Initial therapy for ACS focuses on stabilizing the person,
relieving ischemia-related pain, and pro-
viding medication to reduce heart muscle damage and prevent
further ischemia. Because it is not
possible to distinguish among unstable angina, NSTEMI, and
STEMI before arriving at the hospital,
all three disorders receive the same initial treatment:
• Nitroglycerine and aspirin are given if not received
previously.
• Other drugs may be given.
• Blood is drawn to assess biomarkers for heart muscle damage
(which may be
repeated periodically).
• An ECG is done to evaluate heart rhythm and check for
STEMI.
• A risk assessment is done to assess the likelihood of
additional cardiac complications.

Results from these procedures determines initial management
strategy. This initial strategy com-
prises either medication alone or cardiac catheterization and
angiography, in which dye is intro-
duced into the coronary arteries through a catheter in order to
view coronary circulation on an
x-ray and locate coronary artery blockage. Medication alone is
more likely to be used for people
who have unstable angina or NSTEMI and who are assessed to
be at low risk for additional cardiac
complications.
If an angiograph is done, the results determine the next step:
either medical therapy alone, a
procedure called percutaneous coronary intervention (PCI; also
called angioplasty or balloon
angioplasty), or coronary artery bypass graft (CABG) surgery.
In PCI, a balloon is introduced into
the partially blocked coronary artery via the end of a catheter
and inflated to flatten the blocking
plaque, thus allowing blood to flow more freely. A stent may be
inserted during the procedure to
make sure that the artery stays open. (Although an intervention,
PCI is not generally considered
surgery.)
In contrast, CABG is major open-heart surgery. An artery or
vein from another part of the body is
put in place (grafted) to allow blood to flow around (bypass) a
blocked coronary artery. Multiple
coronary arteries may be bypassed during one surgery. CABG is
more likely to be done for people
with more complex disease, those for whom PCI cannot be
done, or those who have diabetes. It is
not clear why, but for people with diabetes and heart disease,
CABG is more effective than PCI for

preventing additional cardiac complications (Zhang, Yang, Hu,
Lei, & Wang, 2012).
When someone who with ACS leaves the hospital, he or she is
prescribed a number of different
medications that help prevent another episode of ACS or other
cardiac complications. These prob-
ably include:
atL80953_06_c06.indd 188 12/5/13 1:38 PM
• aspirin;
• another anticlotting medication such as clopidogrel, prasugrel,
or ticagrelor;
• a beta blocker;
• cholesterol-lowering therapy; and
• an ACE inhibitor or angiotensin receptor blocker if the heart
is weak.
Cardiac Arrest
Cardiac arrest occurs when the heart’s electrical system
malfunctions and the heart stops pump-
ing blood properly. Although cardiac arrest may be triggered by
a heart attack, the immediate
cause is usually an arrhythmia, often ventricular fibrillation,
which is a disorganized beating of the
ventricles that prevents them from pumping blood. Unless life-
support steps are taken within min-
utes, a person undergoing ventricular fibrillation will die. It is
estimated that between 2005 and
2010, 92% of roughly 300,000 people who experienced sudden
cardiac arrest outside the hospital

did not survive (McNally et al., 2011).
However, in spite of these grim statistics, prompt action on the
part of bystanders and emergency
medical services, acting on the “chain of survival,” can
substantially increase the patient’s chances.
Actions needed include:
• rapid activation of emergency medical services by calling 911;
• rapid initiation of CPR;
• prompt use of an automated external defibrillator;
• rapid delivery of advanced life support by emergency medical
service personnel; and
• early hospital care (McNally et al., 2011).
Upon reaching the hospital, therapeutic hypo-
thermia may be used to cool the patient, which
decreases the brain’s need for blood and thus pro-
tects the brain from damage. A recent study of peo-
ple who survived cardiac arrest and were treated
with therapeutic hypothermia found that 79% (30
of the 38) of patients who were still working at the
time of their cardiac arrest were able to return to
work. In other words, their cognitive function was
not affected, whereas without hypothermia, those
who survive cardiac arrest almost always exhibit
neurological damage (Fugate et al., 2013).
Someone surviving cardiac arrest may have an
implantable cardiac defibrillator (ICD) surgically
placed in the chest to prevent future arrhythmias.
An ICD detects heart rhythm abnormalities and
restores them with an electrical shock. Although
costly, ICDs have been shown to reduce subsequent
mortality (Epstein et al., 2008). To date, no anti-
arrhythmic drug therapy has been shown to be as

effective (Malhotra & Das, 2011). Other implantable
devices include a left ventricular assist device, which
iStock/Thinkstock
Use of an automated external defibrillator
is part of the “chain of survival” that can
increase the chance of survival of a patient
suffering cardiac arrest.
atL80953_06_c06.indd 189 12/5/13 1:38 PM
helps maintain the heart’s pumping ability, and a pacemaker,
which regulates the heart rhythm in
those whose heartbeat is too fast, too slow, or irregular (AHA,
2012a).
Cardiac Rehabilitation
The aims of cardiac rehab are to improve health and well-being
and prevent recurrent events in
people with stable angina or ACS. Cardiac rehab is usually
provided by a team that may include
doctors, nurses, exercise therapists, physical and occupational
therapists, and mental health spe-
cialists. Programs are tailored to each individual and usually
involve a multifaceted approach:
• exercise training to help participants learn to exercise safely,
strengthen their muscles,
and improve stamina; and
• Education and counseling to learn to manage heart disease by:

○ quitting smoking;
○ managing hypertension and diabetes;
○ controlling cholesterol and triglycerides;
○ eating a “heart healthy” diet;
○ exercising regularly;
○ taking prescribed medications as directed; and
○ reducing stress and depression, which often result from
cardiac procedures.
Participating in cardiac rehab helps people resume their normal
activities sooner and more safely.
Stroke
Highly effective ways of treating stroke are available, but they
must be administered at a hospital
within three to four hours of the time stroke symptoms appear.
So, as emphasized, stroke (or sus-
pected or possible stroke) should always be considered an
emergency.
Acute Treatment
When someone who is having a stroke or a TIA arrives at a
hospital, he or she undergoes a neu-
rologic examination. The patient (or the person accompanying)
is usually asked what happened
and when symptoms began. Blood tests, an ECG, and a
computed tomography (commonly called
a CT or CAT) scan is usually done to determine whether the
stroke is ischemic or hemorrhagic.
Another imaging approach that might be used is magnetic
resonance imaging (commonly known
as an MRI).
For ischemic stroke, the standard treatment involves dissolving
the clot and improving blood flow
by administering an enzyme, tissue plasminogen activator

(tPA), intravenously through the arm.
However, tPA must be administered within 3 hours (or in
certain people, up to 4.5 hours) after the
start of stroke symptoms to improve the chance of recovery. If
it is not possible to determine when
symptoms started, the person is not eligible to receive tPA.
Because tPA dissolves clots, it is not effective for hemorrhagic
stroke, in which the primary objec-
tive is to stop the bleeding. In some cases, it is possible to use
an endovascular approach—
introducing a catheter to the site of the rupture and repairing the
blood vessel break through
the catheter. In other cases, it may be necessary to stop the
bleeding surgically, which is much
more invasive.
atL80953_06_c06.indd 190 12/5/13 1:38 PM
Case Study: An Example of One Patient’s Treatments Poststroke
When Julie left the hospital three or four days after being
admitted for ischemic stroke, she was placed
on lipid-lowering and antihypertensive medications; she also
was advised to find a an alternative to
birth control pills and to lose weight. At rehab, she did some
physical therapy (walking up and down
stairs), but most of the time was spent on speech and language
therapy. Her therapist had her reading
silently and then out loud.
Follow-up: Julie’s hypertension is gone and she is no longer on
antihypertensive medication. She

stopped smoking and went off birth control pills, although she
still struggles with weight. She has a
steady job as a manager of a surgical practice at a local
hospital, and she found that job before her
short-term disability ran out. However, Julie doesn’t want her
current employer to know about her
stroke. She feels that there would be some stigma in that
knowledge and she might face discrimination
because of it.
Rehabilitation
The aims of stroke rehab are to regain as much function as
possible as well as to prevent recur-
rent strokes, which affect about 25% of people within five years
of a first event (NINDS, 2013e).
The brain has an enormous capacity to form new pathways to
compensate for functions lost by
neuronal death (this quality is known as brain plasticity). So
intensive stroke rehab encourages
the brain’s own recovery process. In addition to doctors and
nurses, the stroke rehab team usually
includes physical and occupational therapists, speech–language
pathologists, nutritionists, and
psychologists or counselors. The program is tailored to the
individual’s needs. Most progress in
regaining function with rehab will probably be made in the first
few weeks and months immedi-
ately following a stroke. However, progress can continue at a
slower pace for years if the person
continues working toward goals. Table 6.3 lists some of the
functions of individuals on the stroke
rehab team.
Table 6.3: Members of the stroke rehabilitation team and their
functions

Member Areas Addressed
Physical therapist Restoring movement, balance, and
coordination
Occupational therapist Relearning activities of daily living:
eating,
hygiene, dressing, and so on
Speech–language pathologist Relearning language skills,
speaking clearly,
swallowing problems
Psychologist or counselor Dealing with emotions, particularly
depression
Social worker or case manager Aiding the patient and caregiver
to arrange for
help and equipment
A paper presented at the 2013 International Stroke Association
meeting found that depression
is very common following a stroke, and suicidal thoughts are
found in up to 7.8% of stroke survi-
vors—more than among people surviving a heart attack or
cancer. Variables that were important
predictors of recent suicidal thoughts included depression score,
age, BMI, education level, SES,
sex, and marital status (Towfighi, Markovic, & Ovbiagele,
2013). Apart from the depression that
follows the onset of a chronic illness, a biological event that
increases the risk for depression likely
happens in the brain of people who experience stroke.
atL80953_06_c06.indd 191 12/5/13 1:38 PM

CHAPTER 6Section 6.5 Social Issues in Cardiovascular
Disorders
Preventing Recurrence
After being released from the hospital, people who have had a
stroke are probably prescribed
medication to help prevent future strokes. Some types of
medication that may be prescribed
include:
• aspirin or other anticoagulants (medications that prevent blood
clots),
• antihypertensive medication,
• cholesterol-lowering medication, or
• medication to prevent atrial fibrillation.
A low-fat, low-sodium diet that emphasizes fruits and
vegetables is also recommended. Women at
high risk for a stroke, including those who have had a previous
stroke or TIA, should not take birth
control pills or other sources of estrogen.
In addition, if plaque buildup or blockage of the carotid arteries
(the main arteries through
the neck supplying blood to the brain) was noted during stroke
evaluation, a procedure may
be recommended. There are two basic approaches: carotid
endarterectomy, which surgically
removes the plaque, and carotid angioplasty. Carotid
angioplasty, like cardiac angioplasty, uses a
balloon-tipped catheter to flatten the plaque and widen the
artery; it also may use a stent to hold
the artery open.

Two large randomized trials compared the outcomes of carotid
endarterectomy with angioplasty
in people with carotid stenosis who were at risk for stroke. End-
point evaluations were done by
people blinded to which treatment the participant had
undergone. The end point for both trials
was a composite of stroke, heart attack, and death. Both trials
found that the two treatments pro-
duced the same result: no difference in the composite end point,
although both found a higher
risk of stroke with angioplasty and a higher risk of heart attack
with endarterectomy (Brott et al.,
2010; Mantese et al., 2010).
6.5 Social Issues in Cardiovascular Disorders
By 2030, the AHA projects that nearly 41% of the United States
population will have some form of cardiovascular disorder (Go
et al., 2013). Because of the enormous impact that car-
diovascular disorders have on our society, there are myriad
ways in which we can view how
society shapes the person’s experience in dealing with these
disorders, from disparities in rates
of cardiovascular disorders and access to quality care, to costs
of care, and policy affecting care.
Disparities
When it comes to cardiovascular disorders, major disparities are
seen in rates of disease, death
from disease, and access to quality care. Categories of disparity
include geography, racial or ethnic
background, sex, and SES.
One of the most prominent disparities in cardiovascular
disorders is the so-called “stroke belt,”
which should be called the “cardiovascular disorders belt.” This

is the area encompassing much of
the southeastern United States that was first identified by
scientists and epidemiologists several
decades ago. Within the affected area, all aspects of
cardiovascular disorders—from prevalence
atL80953_06_c06.indd 192 12/5/13 1:38 PM
Disorders
of individual disorders to overall and preventable deaths—are
more frequent than in most of the
rest of the country. The risk of preventable death from heart
disease and stroke varies by county,
even within the same state (CDC, 2013r). Figure 6.4 depicts
data for each of the separate states.
Figure 6.4: Number of preventable deaths per 100,000 in the
United States,
2008–2010
Southern states, such as Mississippi and Arkansas, have higher
rates of preventable deaths.
Source: Centers for Disease Control and Prevention (2013i).
Interactive atlas of heart disease and stroke tables. Division for
heart disease and stroke
prevention: Interactive atlas. Data retrieved from
http://nccd.cdc.gov/DHDSPAtlas/reports.aspx
For many years, epidemiologists hypothesized that the higher
rates of cardiovascular disorders
seen in the stroke belt were caused by higher population

percentages of Blacks (who seem to
have a higher risk for stroke than Whites) and the lower income
of people in that area, which is
also associated with higher risk. However, recent data have
contradicted this idea. For example,
the REasons for Geographic and Racial Differences in Stroke
(REGARDS, n.d.) research project is a
collaborative effort between several universities and the NINDS
to explore risk factors for stroke
in people 45 years and older. Investigators in the REGARDS
study have linked more than 60% of
the racial difference in stroke risk to consuming an unhealthy
“southern” diet that contains added
fats, fried food, organ meats, and high-fat dairy products.
Conversely, these investigators found
that consuming a plant-based diet decreased the risk for stroke
by up to 20% (Judd et al., 2013).
In addition, various genetic differences between Whites and
Blacks probably account for some of
the disparity in risk for cardiovascular disorders. Another
REGARDS study found that high urine
albumin levels predicted new heart attacks in Blacks but not in
Whites. Recurrent heart attacks
were not affected, which suggests that after an initial heart
attack, both groups received effective
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atL80953_06_c06.indd 193 12/5/13 1:38 PM
http://nccd.cdc.gov/DHDSPAtlas/reports.aspx
Disorders
secondary prevention therapies such as aspirin, lipid-lowering
medications, and smoking-cessation
counseling (Gutierrez et al., 2013). Note that a large sample of
literature indicates that more
genetic variation occurs within racial categories than between
categories. In conclusion, there is
no question that racial disparities in death from stroke exist,
with Black males topping the list at
over 60 deaths per 100,000, compared with just over 40 among
men of all races and ethnicities
(NHLBI, 2012b).
One factor that may at least partially account for this disparity
is the availability of Joint Commis-
sion–certified primary stroke centers for treating people
undergoing stroke. The Joint Commis-
sion’s Primary Stroke Center Certification Program began in
December 2003. The program has used
standards developed by the American Heart
Association/American Stroke Association (AHA/ASA)
in certifying more than 1,000 primary stroke centers in the
United States and Puerto Rico, all of
which use best practices in stroke management in the acute care
setting. Another REGARDS study
explored the evaluation of Blacks and Whites for suspected
stroke events. The study found that of
1,000 suspected strokes, only 204 had been evaluated in a
primary stroke center. The major deter-

mining factor appeared to be geography; there were no
differences by race, income, or education
level (Mullen et al., 2013). (For an interactive map of Joint
Commission–certified stroke centers,
go to http://www.strokecenter.org/trials/centers/ and zoom in on
the various regions. (For an
explanation of the accreditation process, see the Joint
Commission’s fact sheet on certification, at
http://www.jointcommission.org/assets/1/6/Facts_about_Primar
y_Stroke_Center_Certification
.pdf.) However, another study found apparent racial disparities
in administering tests at a north-
eastern emergency department’s chest pain unit: People of
African descent had significantly
decreased odds of receiving stress testing at this center (Napoli,
Choo, Dai, & Desroches, 2013).
As discussed earlier, women are not as aware as they might be
of the risks of cardiovascular disor-
ders. To counter this trend, the AHA has been educating women
with the objective of increasing
awareness of the risks, knowledge of symptoms, and preventive
behaviors. This effort has been
rather successful: Between 1997 and 2012, awareness that
cardiovascular disorders are the lead-
ing cause of death in women nearly doubled in White women
(30% to 56%). However, awareness
among Black and Hispanic was only 30% in 2012, suggesting
that continued effort is needed to
reach this group (Mosca, Hammond, Mochari-Greenberger,
Towfighi, & Albert, 2013).
Although cardiac rehab improves function and reduces
morbidity and mortality in both men and
women, only 55% of women were referred to receive it.
Disparities were even greater for older

women (Daniels, Arena, Lavie, & Forman, 2012). Another
group that misses out on cardiac rehab
is Medicare beneficiaries: Only 13.9% were enrolled after a
heart attack, and only 31% after CABG
surgery (Suaya et al., 2007).
Costs
Cardiovascular disorders are the most costly of any major
diagnostic group. For 2009, direct costs
(inpatient hospital, emergency room, outpatient visits,
prescribed medication, and home health
care) were estimated to be $192.1 billion, and total indirect
costs (lost productivity and mortality)
were estimated to be $120.5 billion for a total of $312.6 billion.
This is substantially higher than
the total estimated costs of cancer and benign neoplasm, which
were estimated at $228 billion in
2008 (Go et al., 2013).
atL80953_06_c06.indd 194 12/5/13 1:38 PM
http://www.strokecenter.org/trials/centers/
y_Stroke_Center_Certification.pdf
y_Stroke_Center_Certification.pdf
Disorders
Although current data are inadequate, congenital heart defects
also can be very costly to care for.
In 2003, the most expensive neonatal hospital charges per
patient were for hypoplastic left-heart
syndrome ($199,597), truncus arteriosus ($192,781), coarctation

of the aorta, and transposition
of the great arteries (more than $150,000 each; Go et al., 2013,
p. e155). Of course, those figures
do not include subsequent hospitalizations and specialty follow-
up care, which can cost much
more than a family can cope with. And, as little as is known
about costs of congenital heart defect
care in infants and children, even less is known about the costs
of care in adults, as Oster et al.
(2013) emphasized.
The estimated total direct and indirect cost for heart disease in
the United States for 2009 was
$195.2 billion. A significant percentage of people cannot afford
poststroke medication (which cost
approximately $725 a month in 2004), and that percentage rose
from 8.1% in 1997 to 12.7% in
2004, when it represented almost 76,000 U.S. stroke survivors
(Levine et al., 2007, p. 1559). These
economic burdens are expected to double between 2013 and
2030. In comparison, the estimated
direct and indirect cost of stroke in the United States for 2009
was $38.6 billion (Go et al., 2013,
p. e145).
Because risk for stroke doubles with each decade after age 55,
and the U.S. population is aging
on average, total direct and indirect costs for stroke are
expected to rise 129% between 2012 and
2030 (Ovbiagele et al., 2013). Given that stroke is at least in
part preventable, greater emphasis on
effective prevention, acute care, and rehab will have a
tremendous societal impact.
Public Policy
According to a baseline report from the CDC, the U.S. health

care system does really well at diag-
nosing and treating disease but does not provide adequate basic
preventive services. The report
found that
tens of millions of people in the United States have not been
benefiting from key
preventive clinical services, and that there are large disparities
by demographics,
geography, and health care coverage and access. (Frieden, 2012,
p. 1)
“Improved clinical management of the ABCs—aspirin, blood
pressure control, cholesterol man-
agement, and smoking cessation—can significantly reduce the
risk for cardiovascular disease, our
nation’s leading killer,” the director of the CDC proclaimed in
the foreword (Frieden, 2012, p. 2). It
is expected that the ACA will provide increased access to
preventive services, which are mandated
to be covered by insurance, and this report will provide the
baseline against which progress will
be measured over the next few years.
Already in the last few years, a collaborative effort between the
CDC and state, municipal, and
private organizations (particularly the AHA) has been exploring
ways to promote prevention. The
AHA produced a policy statement in 2011 emphasizing the
importance of prevention for car-
diovascular disorders. It particularly emphasized primordial and
primary prevention. Primordial
prevention is defined as averting the “development of risk
factors before they happen,” and
atL80953_06_c06.indd 195 12/5/13 1:38 PM

Disorders
primary prevention is defined as using interventions designed to
modify “risk factors once they
are present with the goal of preventing an initial CVD event”
(AHA, 2011). In contrast, secondary
prevention is defined as preventing the recurrence of an initial
cardiovascular event. In all these
efforts, the overall goal of prevention is to “increase the number
of years that people can enjoy
quality of life and compress the time that people experience
disease and disability” (AHA, 2011).
Examples of primordial prevention approaches include:
• community- and school-based programs to increase physical
activity, improve nutri-
tion, and prevent tobacco use;
• smoke-free laws in public buildings;
• laws requiring calorie counts on restaurant menus; and
• targeted type 2 diabetes screening programs (AHA, 2011).
Examples of primary prevention approaches include:
• obesity management programs;
• excise taxes on tobacco;
• tobacco cessation programs, including comprehensive
coverage within Medicaid; and
• building bike and pedestrian trails (this falls under both
primordial and primary pre-

vention; AHA, 2011).
One example of programs that have grown out of these policy
efforts is Million Hearts (http://
millionhearts.hhs.gov/index.html). Started in 2011, the program
is a collaborative effort among
communities, federal agencies, nonprofit organizations, and the
private sector to reach the goal
of preventing one million heart attacks and strokes by 2017 by
focusing on the ABCs (CDC, 2011f).
Another program run by the CDC’s Division for Heart Disease
and Stroke Prevention is WISE-
WOMAN/ (Well-Integrated Screening and Evaluation of Women
Across the Nation; http://www
.cdc.gov/wisewoman/), which provides low-income,
underinsured and uninsured women aged
40–64 years with screening for cardiovascular disorders,
including heart disease and stroke.
In addition to screening, this program provides disease
counseling, education, referral, and
follow-up. There are presently 21 local and tribal programs in
20 states.
The CDC is supporting innovative research to promote smoking
cessation. Secondhand smoke is
an important risk factor for heart disease and stroke, yet many
people employed in restaurants
and bars are consistently exposed to secondhand smoke at work
(for an in-depth discussion
of smoking, see Chapter 8: “Substance Use”). Restaurant and
bar owners have been fighting
against stringent smoke-free laws for years, because they are
afraid that they will lose business
if such laws are passed. However, a study supported by the CDC
looked at the effects of smoke-

free laws and found no adverse effects on business in
restaurants and bars (Loomis, Shafer, &
van Hasselt, 2013).
The September 2013 issue of Vitalsigns/, a CDC publication,
examined preventable deaths from
heart disease and stroke. In addition to emphasizing who is at
highest risk and how risks can be
managed, the publication suggested several policy changes:
atL80953_06_c06.indd 196 12/5/13 1:38 PM
http://millionhearts.hhs.gov/index.html
http://millionhearts.hhs.gov/index.html
http://www.cdc.gov/wisewoman/
http://www.cdc.gov/wisewoman/
Chapter Summary CHAPTER 6
• Insurers, health care systems, and health care providers can:
○ use electronic records to identify people who can benefit
from interventions and
follow their progress;
○ offer low or no copays on blood pressure and cholesterol
medication; and
○ refer people to community resources, such as smoking
cessation and blood pres-
sure self-management programs.
• Health departments and community organizations can:
○ work with health care systems to monitor quality indicators
and carry out such
innovations as team-based care;

○ promote smoking cessation, tobacco-free areas, and access to
healthy food; and
○ partner with local hospitals to make sure community health
needs are addressed
(CDC, 2013r).
Chapter Summary
Cardiovascular disorders form the most important disorder
group in the United States, both in
terms of number of people with these chronic disorders and
costs to society for treatment and
lost productivity. More than one in every three adults in the
United States had a cardiovascular
disorder in 2010. Highlights of the major cardiovascular
disorders discussed:
• Congenital heart defects are structural problems of the heart or
major blood vessels
caused by developmental problems.
• Heart disease starts with narrowing of the coronary arteries
from plaque buildup on
the inner walls (or atherosclerosis), which can slow or stop the
normal blood flow and
thereby block oxygen from reaching the heart muscle.
• Heart attack is caused by a sharp decrease in blood and
oxygen reaching coronary arteries.
• Cardiac arrest is caused by disorganization in the electrical
system that keeps the
heart beating.
• Stroke is the interruption or severe reduction of normal blood

flow to part of the brain.
It can be caused by either an obstruction in blood vessels
supplying the brain or bleeding
from the brain’s blood vessels.
The U.S. health care system does well at diagnosing and
treating cardiovascular disorders but not
as well at promoting activities to prevent them, particularly
among those of lower SES. The sad
fact is that many cardiovascular disorders are preventable
through seven key health-promoting
activities; these include four ideal health behaviors and three
ideal health factors. However, only
a small percentage of the U.S. population meets all seven goals.
People who meet more of the
seven criteria for cardiovascular health have lower rates of
cardiovascular events such as stroke,
heart attack, and heart failure.
Funding for research and prevention of cardiovascular disease is
not commensurate with the
enormity of the problem. Cardiovascular disorders are the most
costly of any major diagnostic
group and are expected to rise as the population ages. Although
the prevalence of cardiovascular
disorders increases dramatically with age, both heart attacks and
strokes occur in younger people.
The ACA mandates increased access to cardiovascular
preventive services.
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Key Terms CHAPTER 6

Key Terms
activities of daily living Self-care activities, for
example, feeding, dressing, grooming, mobil-
ity, bathing, work, and homemaking. These
abilities are impaired in individuals who have
lowered functioning due to illness or disability.
acute coronary syndrome A collective name
for unstable angina, NSTEMI, and STEMI; all
are medical emergencies that require immedi-
ate evaluation.
angina or angina pectoris Pain usually result-
ing from decreased blood flow to parts of the
heart; often a symptom of heart disease.
angiography Use of a special dye introduced
by cardiac catheterization that allows x-ray
examination of blood flow through the coro-
nary arteries.
angioplasty See percutaneous coronary
intervention.
aphasia Inability to understand language and
form words.
atherosclerosis The process of plaque buildup
on inner arterial walls.
body mass index A measure of body leanness,
overweight, or obesity; weight in kilograms
divided by surface area in square meters;
usually obtained from a table rather than

calculated.
cardiac arrest A medical emergency in which
the heart suddenly stops beating, usually
without warning; caused by something going
wrong with the electrical system that normally
keeps the heart beating rhythmically; different
from a heart attack. Also known as sudden
cardiac arrest.
cardiac catheterization Use of a small plastic
tube threaded through a blood vessel in the
neck or groin to the heart; allows for minor
heart repairs without opening the chest cavity.
cardiovascular system The heart, blood ves-
sels, and circulatory system.
carotid arteries Main vessels through the
neck that supply blood to the brain.
coronary arteries Vessels supplying the heart
with blood, oxygen, and nutrients.
coronary artery bypass graft Surgical use of a
blood vessel from another part of the body to
go around (bypass) a blocked coronary artery;
abbreviated as CABG.
dysarthria Problems forming words because
the mouth muscles are not working properly.
electrocardiogram The printout of an electro-
cardiograph; recording of the electrical activity
associated with heart muscle function. Abbre-
viated as ECG (or EKG).

endarterectomy Surgical removal of plaque
from an artery.
endovascular Repairing a blood vessel from
the inside through the use of a catheter.
hemiparesis Weakness in the muscles on one
side of the body.
hemiplegia Complete paralysis on one side of
the body.
implantable cardiac defibrillator Also called
implantable cardioverter defibrillator or ICD;
device that detects heart arrhythmias and
shocks the heart back into normal rhythm.
ischemia Reduction in blood flow through
arteries that results in decreased oxygen and
fewer nutrients reaching cells.
myocardial infarction Another name for heart
attack.
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Critical Thinking and Discussion Questions CHAPTER 6
Critical Thinking and Discussion Questions
1. What is the downside of calling 911 if heart attack, cardiac
arrest, or stroke is suspected?
What is the upside?

2. Why is it important to note the time that stroke symptoms
were first observed?
3. What determines the type and extent of disability following a
stroke?
4. Distinguish between heart attack and cardiac arrest.
5. Define primordial, primary, and secondary prevention and
give an example of each.
6. How might policies ensuring the availability of
cardiovascular medications at low or no
cost prove to be cost effective?
nitroglycerine Drug that relaxes blood vessels
and increases blood flow; most often used to
treat angina.
non–ST-elevation myocardial infarction A
less serious heart attack, without rise in the ST
segment of an electrocardiogram tracing.
onset First appearance, or beginning.
palliative care Treatment to ease the severity
of symptoms but without curing the underly-
ing disease or condition.
percutaneous coronary intervention Heart
catheterization with flattening of plaque along
the inner wall of an artery through use of a
balloon; a stent may be placed to keep the ves-
sel open. Also known as angioplasty or balloon
angioplasty.
plaque In cardiology, deposit of fatty material
on interior of artery walls.

prevalence The number of cases of a disease
that are present in a specific population at a
given time.
primary prevention Modifying or removing
risk factors before they cause problems.
primordial prevention Thwarting the develop-
ment of risk factors before they happen.
secondary prevention Avoiding recurrence of
a problem once it has happened.
stable angina Predictable chest pain that hap-
pens with heavy activity, emotional upset, and
so on, and usually resolves with rest or taking
nitroglycerine.
ST-elevation myocardial infarction A more
serious heart attack than the NSTEMI type,
with extensive damage to heart muscle and
rise in the ST segment of an electrocardiogram.
stenosis Narrowing or constriction, for exam-
ple, of a blood vessel.
stent Small metal mesh tube that may be
coated with drugs or used “bare”; in cardio-
vascular procedures, used to keep a previously
blocked blood vessel open.
transient ischemic attack (TIA) Stroke symp-
toms that clear up within minutes or up to an
hour.

unstable angina Chest pain that is not predict-
able, may start or get worse with rest or light
activity, does not resolve with rest or nitroglyc-
erine, and is a warning sign of a possible heart
attack. It should be evaluated immediately.
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