Caring for Older Patients with Chronic Cardiac Disease: An Increasing Challenge for Cardiac Nurses in the 21st Century

As we move further into the 21st Century it is clear that the nature and overall burden imposed by coronary heart disease (CHD) on the health care systems of developed countries is rapidly changing. For example, in the 1970's the major focus of treatment was directed towards reducing premature deaths due to acute myocardial infarction (AMI) in predominantly middle-aged men [1]. The MONICA data set has shown that our efforts to alter the risk factor profile of whole populations through reduced smoking rates and improved control of blood pressure and cholesterol levels, in addition to the introduction of more effective treatment of AMI (thrombolysis being the most profound of these) has resulted in an overall decline in age-adjusted mortality rates attributable to CHD [2]. Although we have recently shown that lower socio-economic groups have not received the full benefit of these treatment strategies [3], and there remains a focus on effective and rapid treatment of acute coronary events, it is clear that we are now dealing with the consequences of an older patient population categorised by an increasing prevalence of chronic cardiac disease [4]. This short paper outlines the reasons why this change has likely occurred, the epidemiology of key chronic cardiac disease states and the opportunity for cardiac nurses to adapt to this changing burden and establish a greater, more valued role in the health care system. In many developed countries the combination of declining birth rates and the progressing ageing of the ‘baby boomers’ who represent a surge in birth rates following the Second World War has resulted in a rapid increase in the proportion of elderly in the population [5]. It is these subjects who have the highest incidence of pre-existing CHD and hypertension [6]. A major contributor to this phenomenon is improved survival rates in those patients who develop CHD and who would have previously died prematurely [2]. This represents a major paradox in the fight against CHD — the greater the success we have in treating CHD in younger individuals the greater burden we create for the health care system through the creation of potentially older individuals with chronic cardiac disease states that are associated with high levels of health care utilisation and limited treatment options. In the absence of a ‘vaccine’ for CHD, therefore, it is reasonable to assume that the number of older individual patients with residual problems from ‘early’, but non-fatal, CHD events and more prolonged exposure to chronic hypertension and other risk factors will fuel an even greater burden in the future [1]. The epidemiologic trends described above are best illustrated by the striking rise in the incidence and prevalence of CHF and atrial fibrillation (AF) — two chronic cardiac disease states that are closely associated with increasing age and exposure to acute coronary events and/or chronic hypertension. For example, we have recently shown that survival after AMI in Scotland has increased markedly over the period 1986–1996, at least in part because of better medical treatment [7]. As AMI is a powerful risk factor for the development of CHF (and its most important precursor) [8] it should be of little surprise that the rate of heart failure admissions also increased dramatically during this period [9]. As hospital use represents the major component of expenditure relating to CHF, it should also be of no surprise that the cost of CHF in the UK has more than doubled during the 1990's accounting for more that 4% of health care expenditure in the year 2000 [10]. Fig. 1 shows that if the sex and age-specific trends observed during this period remain constant over the next 20 years, the number of heart failure-related events will continue to increase dramatically — especially in older individuals. It is important to note that even if population admission rates fall, the absolute number of heart failure admissions will still rise due to larger numbers of older individuals in the Scottish population overall. These data are typical of other developed countries [4]. Projected burden of all heart failure-related admissions in Scotland for the period 2000–2020 based on current epidemiologic trends The dramatic rise in the burden imposed by CHF is not a lone phenomenon. We have recently shown that admission rates in AF have also increased dramatically during the period 1986–1996. Over this period, AF-related admissions almost tripled in both men and women and, like CHF, the most striking increases occurred in older individuals [11]. As AF is frequently associated with other debilitating conditions such as stroke, and indeed CHF, and requires complex long-term treatment [12], it is also of little surprise that its cost to the health care system in the UK has also risen dramatically over the past decade [13]. Although these data are specific to the UK, these phenomena have been reported in other developed countries [4,14] and represent a key indication that the nature and burden of CHD is changing and requires a concerted response and restructuring of health care systems to cope with the burden imposed by these disease states on both physical and financial resources. Overall, older patients with CHD are likely to have multiple disease states that require complex treatment (e.g. the patient with CHF who has renal failure that precludes the use of angiotensin converting enzyme inhibitors and complicates fluid management). Such patients obviously require expert and individualised care. For the health care system the optimal outcome in this context, is cheap and effective management that limits costly components of health care expenditure (most notably hospital admissions). There is little doubt that the ideal management protocol would involve close supervision by cardiologists, however, the number of available cardiologists and the cost of specialist attention precludes such an arrangement. Likewise, there is a plethora of evidence to suggest that the current health care system, in its present form, is unable to cope with the sustained pressure of primary CHD-related events and the consequence of residual problems in surviving patients. Despite a number of obstacles, there is also increasing evidence that cardiac nurses who are able to provide relatively cheap but effective specialist care can take a greater role in managing older patients with chronic cardiac disease states [15]. As such, a number of nurse-led programmes have been developed in response to the increasing need to address the burden described in this paper. The current role of nurse-led services and the related issues that need to be addressed to ensure that such services are indeed established in the areas where they are most needed and to their full potential impact will be described in the next issue of this journal [15]. It would be a serious misjudgement on the part of the nursing profession if we forget that primary and secondary prevention strategies represent the best way to limit the burden of chronic cardiac disease states — particularly if they are able to produce full, rather than partial, control of modifiable risk factors such as hypertension, smoking and hypercholesterolaemia. We are currently experiencing an epidemic of our own creation — older patients with chronic cardiac disease states with impaired quality of life and limited treatment options having exhausted an armoury of interventions that are essentially ‘palliative’ rather than ‘curative’. Based on current trends and without a dramatic development in the prevention and treatment of CHD, the number of such patients will continue to increase in the medium to longer-term. These patients are imposing an increasing burden on the health care system. The challenge for cardiac nurses is clear — providing individualised and effective care that recognises and addresses the many factors that can contribute to better health outcomes even if not prolonged life.