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Young Adults’ Perception of Cardiovascular Disease Risk
The Journal for Nurse Practitioners xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Brief Report
Young Adults’ Perception of Cardiovascular Disease Risk Jacqueline O'Toole, MSc, NP, Irene Gibson, MA, RGN, Gerard T. Flaherty, MD a b s t r a c t Keywords: cardiovascular disease cardiovascular risk young adults
Early detection of cardiovascular disease (CVD) risk factors in young adults and identification of risk may reduce future CVD burden. The emergency department provides a setting for identifying young adults with CVD risk when they present with chest pain. However, before offering CVD risk advice, it is imperative to understand knowledge and perception of CVD risk factors in young adults because knowledge is crucial to risk modification. This descriptive, cross-sectional pilot study provides useful insights into the lifestyle habits and CVD risks in this cohort. The findings of this pilot study may be helpful to nurse practitioners worldwide. © 2019 Elsevier Inc. All rights reserved.
Globally, chest pain is a frequent presenting symptom to emergency departments (EDs), accounting for 5% to 10% of ED visits each year, and provides an ideal opportunity to assess cardiovascular disease (CVD) risk.1 Up until recently, systematic cardiovascular risk assessment in men (< 40 years) and women (< 50 years) with no known CVD risk factors (CVDRFs) is not recommended; however, when an individual presents to an ED with chest pain, underlying CVD must be considered and consequently CVDRFs and CVD risk assessed.2,3 CVD is a slow progressing disease with subclinical signs of CVD measurable years before disease manifests.4 Globally, CVD is recognized as the single most common cause of death, with CVD prevention nationally and internationally high on the political agenda.5,6 CVD prevention is targeted at eliminating or reducing the impact of CVDs and their associated disabilities and is defined as a coordinated set of actions, at the population level or targeted at an individual.2 Although European guidelines are insufficient to address screening and treatment of CVDRFs in young adults, more recent American guidelines suggest it is reasonable to assess adults 20 to 39 years old for CVD.3,7,8 A prerequisite for making sound decisions about one’s CVD health is adequate knowledge of CVD risk factors.9 However, knowledge alone is not sufficient to promote behavior change, and a lack of knowledge can impede appropriate behavioral change.10 A common approach to poor lifestyle choices is to wait until CVD develops to prescribe lifestyle change or medication management rather than prevent or delay the onset of CVD.11 It is reasonable to consider global recommendations in that premature mortality from CVD can be partly countered by efficient action dealing with key behavioral CVDRFs.12 Through modest CVDRF reduction, mortality rates from CVD could be halved.12 Literature examining the knowledge and perception of CVDRFs in young adults is limited and focuses on college students or those with a high level of education
https://doi.org/10.1016/j.nurpra.2019.06.010 1555-4155/© 2019 Elsevier Inc. All rights reserved.
in the United States.13-15 Therefore, further European research is required in a more varied, less academic socioeconomic cohort. A pilot study was undertaken to examine CVD risk and knowledge and perceptions of CVDRFs in a cohort of young adults who presented to an Irish ED with chest pain. Methods Twenty-six individuals were recruited by a nurse practitioner (NP) over a 3-month period in an adult ED where chest pain accounts for 9% of the total attendances. Convenience sampling was used to recruit participants. Once an acute coronary syndrome was ruled out, young adults between 20 and 45 years old were referred to the NP ED chest pain clinic within 72 hours of their discharge. On arrival to the clinic, the NP undertook an assessment and fasting bloodwork. This cross-sectional pilot study collected quantitative and qualitative data that assessed baseline demographics and ascertained knowledge and perception of CVD risk using validated questionnaires.16 Self-perceived CVDRFs and self-perceived 10-year risk of heart attack or stroke was ascertained using investigatordeveloped questions as part of the questionnaire. Actual CVD risk was calculated using the European low-risk Systematic COronary Risk Evaluation (SCORE) and relative risk charts for those < 40 years of age.17 Relative risk SCORE charts provide an estimate of risk in a younger person < 40 years old with a combination of CVD risks in contrast to a person of the same age and sex who has ideal risk factor levels.18 The primary outcome variables assessed in this study were 1) knowledge, 2) perception, 3) self-perception, and 4) actual cardiovascular risk and risk factors in young adults. Secondary outcome measures included biometric measurements of systolic blood pressure (SBP,) venous fasting blood profiles for glucose and lipids, and body mass index category. SBP was
2
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measured in both arms after the participant had been resting for 5 minutes and the greater of the 2 results was recorded for analysis.2 Venous fasting blood profiles for glucose and lipids were taken and analyzed in the organization’s central laboratory after participants had been fasting for 12 hours. Recommended targets include SBP < 140, total cholesterol < 5 mmol/L, low-density lipoprotein < 3 mmol/L, high-density lipoprotein > 1 mmol/L, and blood glucose < 6.0 mmol/L (Table 1).2 Data were analyzed using descriptive and inferential statistics using a prepared statistical package (SPSS Version 22; IBM Corp, Armonk, NY). Spearman correlations were used to explore the strength of the relationship between the knowledge and perception of CVD risk. Qualitative data were interpreted using thematic analysis on the self-perceived estimation of CVDRFs and 10-year risk. Full ethical approval was granted for this study from the research ethics committee within the lead author’s organization (#20170228).
Table 2 Presence of Cardiovascular Risk Factors (N ¼ 26) Cardiovascular Risk Factors Nonmodifiable Race (white) Sex (male) Family history of heart disease or stroke in a first-degree relative Modifiable Overweighta Increased systolic blood pressureb Smokers Elevated fasting blood glucosec Sedentary behaviord Increased total cholesterol levele a b c d e
N
(%)
23 17 13
89 65.4 50
18 8 6 0 18 11
69.2 30.8 22.1 0 69.2 42.3
Overweight, body mass index > 24.9 kg/m2. Increased systolic blood pressure > 140. Fasting blood sugar > 6.0. Sedentary behavior < 30 minutes of moderate physical activity at least 5 days/wk. Total cholesterol levels > 5.0 mmol/L.
Results The final sample for this pilot study was composed of 26 young adults. The mean age of the study participants was 39.96 (± 5.7) years. Of participants, 65% were aged 40 years, and the remaining 35% were aged 39 years. The majority of the sample was male (65%). Ethnicity was reported as white (89%). More than half of participants (54%) attended third-level education, and the majority were employed (85%). Private health insurance was indicated in 31%. Table 1 indicates the modifiable CVDRFs of the participants and European clinical targets. Of the modifiable CVDRFs (Table 2), current smokers accounted for 22%. Although 73% reported that they felt they did not exercise enough, analysis indicates 31% were achieving recommended daily targets for exercise of 30 minutes of moderate aerobic activity 5 days per week and 69% were not. When asked if they thought they were overweight, 73% reported that they were overweight. However, the actual weight recorded indicated that 69% were overweight and had a body mass index > 24.9 kg/m2. The most frequently encountered CVDRFs were sedentary lifestyle (69%) and overweight (69%) followed by a family history of CVD (50%) and high total cholesterol in 42% of participants. Fasting blood sugar levels were within normal ranges for all participants (< 5.0 mmol/ L). Increased SBP (> 140 mm Hg) was detected in 31% of participants. The number of CVDRFs identified per participant is detailed in Table 3. Based on clinical data, more than half of the participants (54%) had 2 CVDRFs identified. Figure indicates self-perceived versus actual calculated CVDRFs and suggests self-perceived CVDRFs were lower than the actual calculated CVDRFs, with the exception of weight. The relationship between knowledge (The Heart Disease Fact Questionnaire) and perceived severity and susceptibility of CVD risk (The Health Beliefs Related to Cardiovascular Disease Questionnaire) was investigated using the Spearman correlation coefficient.16 There was a modest, positive correlation between the 2
variables (r ¼ 0.459, n ¼ 24, P < .05), with high levels of knowledge associated with high levels of perceived severity. The European low-risk SCORE was used to predict the 10-year risk of a fatal CVD event in those 40 years old (65.3%), and relative risk was determined for those 39 years old (34.7%). More than half (72%) of the participants believed they had a moderate (1%-5%) to very high (> 10%) risk of a fatal CVD event within 10 years. All participants were calculated to be at low absolute (< 1%) risk. Those < 40 years old were automatically low (< 1%) risk because of age, despite identified CVD risks, and showed a low relative risk (mean ¼ 1.5, standard deviation ¼ .75). According to SCORE, 69% of participants overestimated their 10-year risk of a fatal CVD event, and only 31% correctly identified their risk. Qualitative thematic analysis showed that family history and being overweight were the most common contributors to their perceived risk estimation.
Discussion Despite advancing knowledge and preventive strategies, CVDRFs are evident and remain a concern in this cohort. Despite all participants in this pilot study being identified as low risk of having a fatal cardiovascular event within 10 years because of age, more than half of the young adults had 2 or more CVDRFs identified. This is of concern, bearing in mind that the severity of atherosclerosis in young adults increases with the number of CVDRFs.18 The most frequently occurring modifiable CVDRFs in this pilot study were being sedentary (69%) and overweight (69%). Similar findings are reported in that a frequently occurring CVDRF in young adults is being overweight.13 Historically, obesity is associated with higher levels of blood pressure and adverse lipid profiles.19 Compared with individuals with a healthy body weight, overweight young adults with a body mass index greater than 25 kg/m2 have
Table 1 Modifiable Cardiovascular Disease Risk Factors of Study Participants Variable
Mean
Standard Deviation
Recommended Clinical Targets
Systolic blood pressure (mm Hg) Total fasting cholesterol (mmol/L) Low-density lipoprotein (mmol/L) High-density lipoprotein (mmol/L)
128 4.9 2.89 1.37
11.05 .721 .661 .341
< < < > >
a b c
140a 5.0 mmol/La 3.0 mmol/Lb 1.0 in malesc 1.2 in femalesc
Recommended clinical targets for those > 40 years of age with identified cardiovascular disease risk factors. Low-density lipoprotein: very high-risk target level < 1.8, high risk target level < 2.6, and low to moderate risk target level < 3 (all patients considered low risk in the table). High-density lipoprotein: there is no specific target but > 1.0 mmol/L in men and > 1.2 in women indicate lower risk.7
J. O'Toole et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
3
Perceived versus Actual CVD Risks Factors 20 18
Number of participants
16 14 12 10 8 6 4 2 0 Smoking
High Overweight Adequate Cholesterol exercise
Blood pressure
Diabetes
Family history
Crdiovascular Disease Risk Factors Figure. Self-perception of CVDRFs versus actual CVDRFs identified.
1.5 to 2 times greater risk of developing coronary heart disease.11 This study shows a high prevalence of self-reported sedentary behavior. Only 31% of participants were achieving the recommended 30 minutes per day of moderate aerobic physical activity.2 Despite smoking as an identified CVDRF, only 22% of participants are current smokers. A large number (42%) of participants had high serum cholesterol levels identified, and 24% of those were < 40 years old. Overall, this study found no statistical association between age and total cholesterol levels. However, high serum cholesterol is known to have a continuous graded relationship to long-term risk of CVD death for younger men with elevated serum cholesterol levels and longer estimated life expectancy for younger men with favorable serum cholesterol levels.20 Low levels of high-density lipoprotein were recorded in 39% of study participants. Guidelines suggest lifestyle intervention to increase high-density lipoprotein levels, including increasing habitual physical activity, reducing excessive body weight, and dietary interventions.2 A high resting SBP accounted for 31% of participants in this study. The most common reason for the absence of cardiovascular health in young adults in the US is high blood pressure.10 One in 10 young adults is unaware of having high blood pressure; therefore, it is left untreated.13 Tran and Zimmerman13 report that participants with a high knowledge of CVDRFs perceived themselves to be of low to moderate risk of CVD. The study indicates that participants similarly displayed a high level of knowledge of CVDRFs; however, in contrast, perceived themselves to be at a moderate to very high risk of death from a cardiovascular event within a 10year time frame.13 This might possibly be explained in that participants had presented to the ED with chest pain and were suspected to have had a cardiac event. Younger persons will
always be at low absolute risk even when risk factor levels are unfavorable; no combination of risk factors will place a person in the high-risk category (> 5% 10-year risk of fatal CVD).21 Interestingly, overestimation of risk may contribute to increased stress, overmedication, and medical seeking behaviors, which can affect an individual’s quality of life rather than his or her absolute risk for CVD. 22 Therefore, the use of risk estimation scores should be communicated with young adults to generate an understanding of risk and subsequently offer lifestyle advice in order to modify their risk. In young adults, the use of SCORE and relative risk charts allows clinicians to communicate that although participants are at low absolute risk, their risk is still “x” times higher than it could be if they had ideal risk factor levels.18 High knowledge levels were positively associated with perceived severity of CVD; this may be because of the fact that a large percentage of participants had a family history of CVD and may have witnessed the consequences of an event, which generated a greater awareness of CVDRFs.
Implications for Practice Within the ED setting, nursing has a pivotal role to play in ascertaining actual versus perceived CVD risk using risk assessment tools and in determining effective preventive strategies. Future research is warranted to evaluate predictors of lack of behavior change despite knowledge of CVDRFs to help empower individuals to reduce their future risk of CVD events. Many risk assessment tools beyond SCORE exist and should be considered in future research.
Limitations of Study Table 3 The Number of Cardiovascular Disease Risk Factors (CVDRFs) Identified in Study Participants (N ¼ 26) Number of CVDRF
1 CVDRF
2 CVDRF
3 CVDRF
4 CVDRF
5 CVDRF
n
%
n
%
n
%
n
%
n
%
2
7.7
14
53.8
3
11.5
5
19.2
2
7.7
Generalizability is limited because of the small number of participants, convenience sampling, and a cross-sectional design. Recruitment was undertaken in an ED after patients had presented with chest pain; therefore, patients may have perceived themselves to be at CVD risk. Furthermore, participants may not have understood the terms cardiovascular disease or risk despite a high level of education. A segment of data collection included self-reported data
4
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on specific behaviors; self-reported data may underestimate the proportion of individuals considered at risk. References 1. Bidmead T, Goodacre S, Maheswaran R, O’Cathain A. Factors influencing unspecified chest pain admission rates in England. Emerg Med J. 2015;32:439-443. 2. Piepoli M, D’Agostino R, Larson M, Massaro J, Vasan R. European Guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J. 2016;37: 2315-2381. 3. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;11:596-646. 4. Juonala M, Viikari J, Ronnemaa T, et al. Associations of dyslipademias from childhood to adulthood with carotid intima-media thickness, elasticity and brachial flow-mediated dilatation in adulthood. The Cardiovascular Risk in the Young Finns Study. Arterioscler Thromb Vasc Biol. 2008;28:1012-1101. 5. Healthy Ireland 2015. Healthy Ireland Survey 2015, Summary findings. Dublin Government Publications. http://health.gov.ie/wp- content/uploads/2015/10/ Healthy-Ireland-Survey-2015-Summary-of-Findings.pdf. Accessed January 1, 2016. 6. Office of Disease Prevention and Health Promotion-Healthy People 2020. https://www.healthypeople.gov/. Accessed February 1, 2017. 7. Tran DT, Zimmerman LM. Cardiovascular risk factors in young adults: a literature review. J Cardiovasc Nurs. 2014;30(4):298-310. https://doi.org/10.1097/ JCN.0000000000000150. 8. Mozaffarian G, Roger D, Benjamin E, et al. Heart disease and stroke statistics– 2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6-e245. https://doi.org/10.1161/CIR.0b013e318282ab8f. 9. Homko C, Zamora L, Santamore W, Kashem A, et al. Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease. J Cardiovasc Nurs. 2008;23(4):332-337. 10. Lynch EB, Liu K, Kiefe CI, Greenland P. Cardiovascular disease risk factor knowledge in young adults and 10-year change in risk factors: the Coronary Artery Risk Development in Young Adults (CARDIA) study. Am J Epidemiol. 2006;164(12):1171-1179. https://doi.org/10.1093/aje/kwj334. 11. Loria CM, Liu K, Lewis CE, et al. Early adult risk factor levels and subsequent coronary artery calcification: the CARDIA study. J Am Coll Cardiol. 2007;49(20): 2013-2020. https://doi.org/10.1016/j.jacc.2007.03.009. 12. World Health Organisation. Global Status Report on Non Communicable Diseases. 2010. http://www.who.int/nmh/publications/ncd_report_full_en.pdf. Accessed November 1, 2016.
13. Tran D, Zimmerman L. Cardiovascular risk factors among college students: knowledge, perception and risk assessment. J Am Coll Health. 2017;65(3): 158-167. 14. Gharaibeh M, Alzoubi K, Khabour O, et al. Assessment of cardiovascular risk factors among university students: the gender factor. Cardiol Res. 2012;3(4): 172-179. 15. Abshire D, Lennie T, Moser D, Mudd-Martin P. Perceptions related to cardiovascular disease risk in Caucasian college males. Am J Mens Health. 2015;10(6): NP136-NP144. 16. Tran D, Zimmerman L. Validation of the knowledge and perception of cardiovascular risk factors questionnaires for college students. J Nurs Meas. 2016;24(2):202-213. 17. European Society of Cardiology. European guidelines on CVD prevention in clinical practice SCORE e European Risk Charts. 2012. https://www.escardio. org/static_file/Escardio/Subspecialty/EACPR/Documents/scor e-charts.pdf. Accessed September 1, 2016. 18. Cooney M, Dudina A, Graham I. Value and limitations of existing scores for the assessment of cardiovascular risk: a review for clinicians. J Am Coll Cardiol. 2009;54(14):1209-1227. 19. Paul TK, Srinivasan SR, Wei C, et al. Cardiovascular risk profile of asymptomatic healthy young adults with increased femoral artery intima-media thickness: The Bogalusa Heart Study. Am J Med Sci. 2005;330(3):105-110. 20. Thompson DR, Obarzanek E, Franko DL, et al. Childhood overweight and cardiovascular disease risk factors: The National Heart and Lung and Blood Institute Growth and Health Study. J Pediatr. 2007;150: 18-25. 21. Stamler J, Daviglus M, Garside D, Dyer A, Greenland P, Neaton J. Relationship of baseline serum cholesterol levels in 3 large cohorts of younger men to long term coronary, cardiovascular, and all-cause mortality and to longevity. JAMA. 2000;284(3):311-318. 22. Desgraz B, Collet TH, Rodondi N, Cornuz J, Clair C. Comparison of self-perceived cardiovascular disease risk among smokers with Framingham and PROCAM scores: a cross-sectional analysis of baseline data from a randomised controlled trial. BMJ Open. 2017;7:e012063. https://doi.org/10.1136/bmjopen2016-012063.
Jacqueline O'Toole, MSc, NP, is a nurse fellow of the European Society of Cardiology and an advanced nurse practitioner in cardiology at Naas General Hospital in Naas, County Kildare, Ireland, and can be contacted at [email protected]. Irene Gibson, MA, RGN, is the director of programs at the School of Medicine, National University of Ireland in Galway, Ireland. Gerard T. Flaherty, MD, is a professor at the School of Medicine, National University of Ireland. All are associated with the National Institute for Prevention and Cardiovascular Health, Galway, Ireland. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Brief Report
Young Adults’ Perception of Cardiovascular Disease Risk Jacqueline O'Toole, MSc, NP, Irene Gibson, MA, RGN, Gerard T. Flaherty, MD a b s t r a c t Keywords: cardiovascular disease cardiovascular risk young adults
Early detection of cardiovascular disease (CVD) risk factors in young adults and identification of risk may reduce future CVD burden. The emergency department provides a setting for identifying young adults with CVD risk when they present with chest pain. However, before offering CVD risk advice, it is imperative to understand knowledge and perception of CVD risk factors in young adults because knowledge is crucial to risk modification. This descriptive, cross-sectional pilot study provides useful insights into the lifestyle habits and CVD risks in this cohort. The findings of this pilot study may be helpful to nurse practitioners worldwide. © 2019 Elsevier Inc. All rights reserved.
Globally, chest pain is a frequent presenting symptom to emergency departments (EDs), accounting for 5% to 10% of ED visits each year, and provides an ideal opportunity to assess cardiovascular disease (CVD) risk.1 Up until recently, systematic cardiovascular risk assessment in men (< 40 years) and women (< 50 years) with no known CVD risk factors (CVDRFs) is not recommended; however, when an individual presents to an ED with chest pain, underlying CVD must be considered and consequently CVDRFs and CVD risk assessed.2,3 CVD is a slow progressing disease with subclinical signs of CVD measurable years before disease manifests.4 Globally, CVD is recognized as the single most common cause of death, with CVD prevention nationally and internationally high on the political agenda.5,6 CVD prevention is targeted at eliminating or reducing the impact of CVDs and their associated disabilities and is defined as a coordinated set of actions, at the population level or targeted at an individual.2 Although European guidelines are insufficient to address screening and treatment of CVDRFs in young adults, more recent American guidelines suggest it is reasonable to assess adults 20 to 39 years old for CVD.3,7,8 A prerequisite for making sound decisions about one’s CVD health is adequate knowledge of CVD risk factors.9 However, knowledge alone is not sufficient to promote behavior change, and a lack of knowledge can impede appropriate behavioral change.10 A common approach to poor lifestyle choices is to wait until CVD develops to prescribe lifestyle change or medication management rather than prevent or delay the onset of CVD.11 It is reasonable to consider global recommendations in that premature mortality from CVD can be partly countered by efficient action dealing with key behavioral CVDRFs.12 Through modest CVDRF reduction, mortality rates from CVD could be halved.12 Literature examining the knowledge and perception of CVDRFs in young adults is limited and focuses on college students or those with a high level of education
https://doi.org/10.1016/j.nurpra.2019.06.010 1555-4155/© 2019 Elsevier Inc. All rights reserved.
in the United States.13-15 Therefore, further European research is required in a more varied, less academic socioeconomic cohort. A pilot study was undertaken to examine CVD risk and knowledge and perceptions of CVDRFs in a cohort of young adults who presented to an Irish ED with chest pain. Methods Twenty-six individuals were recruited by a nurse practitioner (NP) over a 3-month period in an adult ED where chest pain accounts for 9% of the total attendances. Convenience sampling was used to recruit participants. Once an acute coronary syndrome was ruled out, young adults between 20 and 45 years old were referred to the NP ED chest pain clinic within 72 hours of their discharge. On arrival to the clinic, the NP undertook an assessment and fasting bloodwork. This cross-sectional pilot study collected quantitative and qualitative data that assessed baseline demographics and ascertained knowledge and perception of CVD risk using validated questionnaires.16 Self-perceived CVDRFs and self-perceived 10-year risk of heart attack or stroke was ascertained using investigatordeveloped questions as part of the questionnaire. Actual CVD risk was calculated using the European low-risk Systematic COronary Risk Evaluation (SCORE) and relative risk charts for those < 40 years of age.17 Relative risk SCORE charts provide an estimate of risk in a younger person < 40 years old with a combination of CVD risks in contrast to a person of the same age and sex who has ideal risk factor levels.18 The primary outcome variables assessed in this study were 1) knowledge, 2) perception, 3) self-perception, and 4) actual cardiovascular risk and risk factors in young adults. Secondary outcome measures included biometric measurements of systolic blood pressure (SBP,) venous fasting blood profiles for glucose and lipids, and body mass index category. SBP was
2
J. O'Toole et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
measured in both arms after the participant had been resting for 5 minutes and the greater of the 2 results was recorded for analysis.2 Venous fasting blood profiles for glucose and lipids were taken and analyzed in the organization’s central laboratory after participants had been fasting for 12 hours. Recommended targets include SBP < 140, total cholesterol < 5 mmol/L, low-density lipoprotein < 3 mmol/L, high-density lipoprotein > 1 mmol/L, and blood glucose < 6.0 mmol/L (Table 1).2 Data were analyzed using descriptive and inferential statistics using a prepared statistical package (SPSS Version 22; IBM Corp, Armonk, NY). Spearman correlations were used to explore the strength of the relationship between the knowledge and perception of CVD risk. Qualitative data were interpreted using thematic analysis on the self-perceived estimation of CVDRFs and 10-year risk. Full ethical approval was granted for this study from the research ethics committee within the lead author’s organization (#20170228).
Table 2 Presence of Cardiovascular Risk Factors (N ¼ 26) Cardiovascular Risk Factors Nonmodifiable Race (white) Sex (male) Family history of heart disease or stroke in a first-degree relative Modifiable Overweighta Increased systolic blood pressureb Smokers Elevated fasting blood glucosec Sedentary behaviord Increased total cholesterol levele a b c d e
N
(%)
23 17 13
89 65.4 50
18 8 6 0 18 11
69.2 30.8 22.1 0 69.2 42.3
Overweight, body mass index > 24.9 kg/m2. Increased systolic blood pressure > 140. Fasting blood sugar > 6.0. Sedentary behavior < 30 minutes of moderate physical activity at least 5 days/wk. Total cholesterol levels > 5.0 mmol/L.
Results The final sample for this pilot study was composed of 26 young adults. The mean age of the study participants was 39.96 (± 5.7) years. Of participants, 65% were aged 40 years, and the remaining 35% were aged 39 years. The majority of the sample was male (65%). Ethnicity was reported as white (89%). More than half of participants (54%) attended third-level education, and the majority were employed (85%). Private health insurance was indicated in 31%. Table 1 indicates the modifiable CVDRFs of the participants and European clinical targets. Of the modifiable CVDRFs (Table 2), current smokers accounted for 22%. Although 73% reported that they felt they did not exercise enough, analysis indicates 31% were achieving recommended daily targets for exercise of 30 minutes of moderate aerobic activity 5 days per week and 69% were not. When asked if they thought they were overweight, 73% reported that they were overweight. However, the actual weight recorded indicated that 69% were overweight and had a body mass index > 24.9 kg/m2. The most frequently encountered CVDRFs were sedentary lifestyle (69%) and overweight (69%) followed by a family history of CVD (50%) and high total cholesterol in 42% of participants. Fasting blood sugar levels were within normal ranges for all participants (< 5.0 mmol/ L). Increased SBP (> 140 mm Hg) was detected in 31% of participants. The number of CVDRFs identified per participant is detailed in Table 3. Based on clinical data, more than half of the participants (54%) had 2 CVDRFs identified. Figure indicates self-perceived versus actual calculated CVDRFs and suggests self-perceived CVDRFs were lower than the actual calculated CVDRFs, with the exception of weight. The relationship between knowledge (The Heart Disease Fact Questionnaire) and perceived severity and susceptibility of CVD risk (The Health Beliefs Related to Cardiovascular Disease Questionnaire) was investigated using the Spearman correlation coefficient.16 There was a modest, positive correlation between the 2
variables (r ¼ 0.459, n ¼ 24, P < .05), with high levels of knowledge associated with high levels of perceived severity. The European low-risk SCORE was used to predict the 10-year risk of a fatal CVD event in those 40 years old (65.3%), and relative risk was determined for those 39 years old (34.7%). More than half (72%) of the participants believed they had a moderate (1%-5%) to very high (> 10%) risk of a fatal CVD event within 10 years. All participants were calculated to be at low absolute (< 1%) risk. Those < 40 years old were automatically low (< 1%) risk because of age, despite identified CVD risks, and showed a low relative risk (mean ¼ 1.5, standard deviation ¼ .75). According to SCORE, 69% of participants overestimated their 10-year risk of a fatal CVD event, and only 31% correctly identified their risk. Qualitative thematic analysis showed that family history and being overweight were the most common contributors to their perceived risk estimation.
Discussion Despite advancing knowledge and preventive strategies, CVDRFs are evident and remain a concern in this cohort. Despite all participants in this pilot study being identified as low risk of having a fatal cardiovascular event within 10 years because of age, more than half of the young adults had 2 or more CVDRFs identified. This is of concern, bearing in mind that the severity of atherosclerosis in young adults increases with the number of CVDRFs.18 The most frequently occurring modifiable CVDRFs in this pilot study were being sedentary (69%) and overweight (69%). Similar findings are reported in that a frequently occurring CVDRF in young adults is being overweight.13 Historically, obesity is associated with higher levels of blood pressure and adverse lipid profiles.19 Compared with individuals with a healthy body weight, overweight young adults with a body mass index greater than 25 kg/m2 have
Table 1 Modifiable Cardiovascular Disease Risk Factors of Study Participants Variable
Mean
Standard Deviation
Recommended Clinical Targets
Systolic blood pressure (mm Hg) Total fasting cholesterol (mmol/L) Low-density lipoprotein (mmol/L) High-density lipoprotein (mmol/L)
128 4.9 2.89 1.37
11.05 .721 .661 .341
< < < > >
a b c
140a 5.0 mmol/La 3.0 mmol/Lb 1.0 in malesc 1.2 in femalesc
Recommended clinical targets for those > 40 years of age with identified cardiovascular disease risk factors. Low-density lipoprotein: very high-risk target level < 1.8, high risk target level < 2.6, and low to moderate risk target level < 3 (all patients considered low risk in the table). High-density lipoprotein: there is no specific target but > 1.0 mmol/L in men and > 1.2 in women indicate lower risk.7
J. O'Toole et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
3
Perceived versus Actual CVD Risks Factors 20 18
Number of participants
16 14 12 10 8 6 4 2 0 Smoking
High Overweight Adequate Cholesterol exercise
Blood pressure
Diabetes
Family history
Crdiovascular Disease Risk Factors Figure. Self-perception of CVDRFs versus actual CVDRFs identified.
1.5 to 2 times greater risk of developing coronary heart disease.11 This study shows a high prevalence of self-reported sedentary behavior. Only 31% of participants were achieving the recommended 30 minutes per day of moderate aerobic physical activity.2 Despite smoking as an identified CVDRF, only 22% of participants are current smokers. A large number (42%) of participants had high serum cholesterol levels identified, and 24% of those were < 40 years old. Overall, this study found no statistical association between age and total cholesterol levels. However, high serum cholesterol is known to have a continuous graded relationship to long-term risk of CVD death for younger men with elevated serum cholesterol levels and longer estimated life expectancy for younger men with favorable serum cholesterol levels.20 Low levels of high-density lipoprotein were recorded in 39% of study participants. Guidelines suggest lifestyle intervention to increase high-density lipoprotein levels, including increasing habitual physical activity, reducing excessive body weight, and dietary interventions.2 A high resting SBP accounted for 31% of participants in this study. The most common reason for the absence of cardiovascular health in young adults in the US is high blood pressure.10 One in 10 young adults is unaware of having high blood pressure; therefore, it is left untreated.13 Tran and Zimmerman13 report that participants with a high knowledge of CVDRFs perceived themselves to be of low to moderate risk of CVD. The study indicates that participants similarly displayed a high level of knowledge of CVDRFs; however, in contrast, perceived themselves to be at a moderate to very high risk of death from a cardiovascular event within a 10year time frame.13 This might possibly be explained in that participants had presented to the ED with chest pain and were suspected to have had a cardiac event. Younger persons will
always be at low absolute risk even when risk factor levels are unfavorable; no combination of risk factors will place a person in the high-risk category (> 5% 10-year risk of fatal CVD).21 Interestingly, overestimation of risk may contribute to increased stress, overmedication, and medical seeking behaviors, which can affect an individual’s quality of life rather than his or her absolute risk for CVD. 22 Therefore, the use of risk estimation scores should be communicated with young adults to generate an understanding of risk and subsequently offer lifestyle advice in order to modify their risk. In young adults, the use of SCORE and relative risk charts allows clinicians to communicate that although participants are at low absolute risk, their risk is still “x” times higher than it could be if they had ideal risk factor levels.18 High knowledge levels were positively associated with perceived severity of CVD; this may be because of the fact that a large percentage of participants had a family history of CVD and may have witnessed the consequences of an event, which generated a greater awareness of CVDRFs.
Implications for Practice Within the ED setting, nursing has a pivotal role to play in ascertaining actual versus perceived CVD risk using risk assessment tools and in determining effective preventive strategies. Future research is warranted to evaluate predictors of lack of behavior change despite knowledge of CVDRFs to help empower individuals to reduce their future risk of CVD events. Many risk assessment tools beyond SCORE exist and should be considered in future research.
Limitations of Study Table 3 The Number of Cardiovascular Disease Risk Factors (CVDRFs) Identified in Study Participants (N ¼ 26) Number of CVDRF
1 CVDRF
2 CVDRF
3 CVDRF
4 CVDRF
5 CVDRF
n
%
n
%
n
%
n
%
n
%
2
7.7
14
53.8
3
11.5
5
19.2
2
7.7
Generalizability is limited because of the small number of participants, convenience sampling, and a cross-sectional design. Recruitment was undertaken in an ED after patients had presented with chest pain; therefore, patients may have perceived themselves to be at CVD risk. Furthermore, participants may not have understood the terms cardiovascular disease or risk despite a high level of education. A segment of data collection included self-reported data
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on specific behaviors; self-reported data may underestimate the proportion of individuals considered at risk. References 1. Bidmead T, Goodacre S, Maheswaran R, O’Cathain A. Factors influencing unspecified chest pain admission rates in England. Emerg Med J. 2015;32:439-443. 2. Piepoli M, D’Agostino R, Larson M, Massaro J, Vasan R. European Guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J. 2016;37: 2315-2381. 3. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;11:596-646. 4. Juonala M, Viikari J, Ronnemaa T, et al. Associations of dyslipademias from childhood to adulthood with carotid intima-media thickness, elasticity and brachial flow-mediated dilatation in adulthood. The Cardiovascular Risk in the Young Finns Study. Arterioscler Thromb Vasc Biol. 2008;28:1012-1101. 5. Healthy Ireland 2015. Healthy Ireland Survey 2015, Summary findings. Dublin Government Publications. http://health.gov.ie/wp- content/uploads/2015/10/ Healthy-Ireland-Survey-2015-Summary-of-Findings.pdf. Accessed January 1, 2016. 6. Office of Disease Prevention and Health Promotion-Healthy People 2020. https://www.healthypeople.gov/. Accessed February 1, 2017. 7. Tran DT, Zimmerman LM. Cardiovascular risk factors in young adults: a literature review. J Cardiovasc Nurs. 2014;30(4):298-310. https://doi.org/10.1097/ JCN.0000000000000150. 8. Mozaffarian G, Roger D, Benjamin E, et al. Heart disease and stroke statistics– 2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6-e245. https://doi.org/10.1161/CIR.0b013e318282ab8f. 9. Homko C, Zamora L, Santamore W, Kashem A, et al. Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease. J Cardiovasc Nurs. 2008;23(4):332-337. 10. Lynch EB, Liu K, Kiefe CI, Greenland P. Cardiovascular disease risk factor knowledge in young adults and 10-year change in risk factors: the Coronary Artery Risk Development in Young Adults (CARDIA) study. Am J Epidemiol. 2006;164(12):1171-1179. https://doi.org/10.1093/aje/kwj334. 11. Loria CM, Liu K, Lewis CE, et al. Early adult risk factor levels and subsequent coronary artery calcification: the CARDIA study. J Am Coll Cardiol. 2007;49(20): 2013-2020. https://doi.org/10.1016/j.jacc.2007.03.009. 12. World Health Organisation. Global Status Report on Non Communicable Diseases. 2010. http://www.who.int/nmh/publications/ncd_report_full_en.pdf. Accessed November 1, 2016.
13. Tran D, Zimmerman L. Cardiovascular risk factors among college students: knowledge, perception and risk assessment. J Am Coll Health. 2017;65(3): 158-167. 14. Gharaibeh M, Alzoubi K, Khabour O, et al. Assessment of cardiovascular risk factors among university students: the gender factor. Cardiol Res. 2012;3(4): 172-179. 15. Abshire D, Lennie T, Moser D, Mudd-Martin P. Perceptions related to cardiovascular disease risk in Caucasian college males. Am J Mens Health. 2015;10(6): NP136-NP144. 16. Tran D, Zimmerman L. Validation of the knowledge and perception of cardiovascular risk factors questionnaires for college students. J Nurs Meas. 2016;24(2):202-213. 17. European Society of Cardiology. European guidelines on CVD prevention in clinical practice SCORE e European Risk Charts. 2012. https://www.escardio. org/static_file/Escardio/Subspecialty/EACPR/Documents/scor e-charts.pdf. Accessed September 1, 2016. 18. Cooney M, Dudina A, Graham I. Value and limitations of existing scores for the assessment of cardiovascular risk: a review for clinicians. J Am Coll Cardiol. 2009;54(14):1209-1227. 19. Paul TK, Srinivasan SR, Wei C, et al. Cardiovascular risk profile of asymptomatic healthy young adults with increased femoral artery intima-media thickness: The Bogalusa Heart Study. Am J Med Sci. 2005;330(3):105-110. 20. Thompson DR, Obarzanek E, Franko DL, et al. Childhood overweight and cardiovascular disease risk factors: The National Heart and Lung and Blood Institute Growth and Health Study. J Pediatr. 2007;150: 18-25. 21. Stamler J, Daviglus M, Garside D, Dyer A, Greenland P, Neaton J. Relationship of baseline serum cholesterol levels in 3 large cohorts of younger men to long term coronary, cardiovascular, and all-cause mortality and to longevity. JAMA. 2000;284(3):311-318. 22. Desgraz B, Collet TH, Rodondi N, Cornuz J, Clair C. Comparison of self-perceived cardiovascular disease risk among smokers with Framingham and PROCAM scores: a cross-sectional analysis of baseline data from a randomised controlled trial. BMJ Open. 2017;7:e012063. https://doi.org/10.1136/bmjopen2016-012063.
Jacqueline O'Toole, MSc, NP, is a nurse fellow of the European Society of Cardiology and an advanced nurse practitioner in cardiology at Naas General Hospital in Naas, County Kildare, Ireland, and can be contacted at [email protected]. Irene Gibson, MA, RGN, is the director of programs at the School of Medicine, National University of Ireland in Galway, Ireland. Gerard T. Flaherty, MD, is a professor at the School of Medicine, National University of Ireland. All are associated with the National Institute for Prevention and Cardiovascular Health, Galway, Ireland. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.