End Your Heart Disease Now
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See reference for aspirin use at uspreventiveservicestaskforce.
Calculating the risk of heart attacks
If your blood pressure is higher, talk to your healthcare provider about ways to lower it including lifestyle and diet modifications. Medications may be prescribed for higher blood pressures. Here's information on how to take your blood pressure the right way. If your levels are high, ask how you can lower them. Diets that include omega 3 fatty acids may help. In some cases, medications such as statins may be important to your care. The link between preeclampsia and heart disease is not yet well known among the general population.
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Heart Disease Prevention | MedlinePlus
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Stay at a healthy weight Body mass index BMI is your body weight relative to your height. If you smoke, stop! Know your family health history If you have a family history of high blood pressure or heart disease, you are more likely to get it later in life.
Talk with your doctor about aspirin Taking low-dose aspirin may reduce your risk of heart attack and stroke depending on your age and other risk factors. Featured Video. View all Videos. Preeclampsia Awareness Survey Models exist which predict mortality specific to patients with HF. Comorbidity, defined as the concomitant course of 2 or more medical diseases in the same patient, is practically the norm in the elderly population. Population studies have shown that both the prevalence of comorbidity and the number of simultaneous diseases in a single patient increase with age.
Elderly patients with HF often have other diseases or disabilities, which makes this disease behave very differently compared to younger patients, thus contributing to worse progress.
More than half the elderly patients hospitalized for HF are readmitted within 6 months following hospital discharge, and most of these readmissions are due to non-cardiac causes. The prognosis of elderly patients also depends on their frailty and functional state, which are aspects that are not included in most prognostic indexes. The concept of fragility refers to the reduced ability to overcome times of stress that places the individual at risk.
Frailty is progressive, tends to be associated with chronic disease, worsens with advancing age and often culminates in dependency on other people. The presence of 3 or more of these signs or symptoms of frailty has been associated with a worse clinical course, with greater rates of dependency, hospitalization and death. When this situation progresses and frailty becomes severe, it would be correct to prioritize alleviating symptoms and improve the quality of life.. The patient's functional state, defined as the group of activities and functions needed to maintain autonomy in everyday physical, mental, and social functions, is of crucial importance to changes in the health parameters in the elderly person.
Measurements of functional state have demonstrated their great value as predictors of hospital evolution. Even more, they carry greater weight in predicting hospital stay, institutionalization or death than the diagnosis, diagnosis-associated groups or other standard indexes for measuring disease. In fact, physical functionality is the single most important factor in predicting hospital mortality in the elderly person 26 and it surpasses other indexes of disease severity.. Thus, it is important to thoroughly evaluate the degree of independence of the elderly person before the acute situation leading to admission begins, as well as the main cause of the limitation.
A study conducted by Inouye et al 27 identified 3 functional variables independently associated with day and 2-year mortality in the elderly hospitalized due to medical disease: dependency in the instrumental activities of daily life, cognitive dysfunction, and symptoms of depression.
A simple predictive model based on these 3 variables can predict which elderly patients with medical disease are at high, intermediate or low risk of mortality in the 2 following years. Furthermore, the inclusion of these functional measurements in other prognostic indexes based on the disease improves the predictive capacity of mortality after 2 years in elderly patients.
Measures of functional state, such as the Barthel basal index applied prior to hospitalization due to decompensated HF, have shown to be predictors of mortality in elderly patients hospitalized for HF. The therapeutic decisions taken to prevent sudden death in elderly patients with heart disease should be based not only on the results of clinical trials, but also on the risk of the intervention itself, comorbidity, life expectancy and, of course, the patient's preferences. The options for preventing sudden death are antiarrhythmic drugs, ablation, and implantable cardioverter-defibrillators ICD.
Amiodarone is the only antiarrhythmic which has shown not to increase mortality in patients with heart disease, but neither does it improve survival. On the other hand, a recently published study, in which most patients were older than 70 years, demonstrated that catheter ablation in patients who had received a defibrillator reduced the frequency of arrhythmic episodes. In any case, and for the time being, the only option which has been demonstrated as reducing sudden death in patients is the ICD.
However, the elderly have barely been represented in the clinical trials that have evaluated these devices. It should be mentioned that, in most of the studies, the rate of complications during ICD implantation in elderly patients was similar to the rest of the population, 33 and therefore age itself should not be a limitation for intervention.. In view of the fact that the benefits of ICD become evident 1 year from implantation, 8 their use does not appear to be indicated in patients with a life expectancy less than this period.
One registry found that life expectancy among octogenarian patients receiving an ICD is less than that of patients aged between 60 and 70 years; however, the average life expectancy was over 4 years, which means that other aspects that reduce survival apart from age should be identified.
We should recall that these devices can prevent arrhythmic death, but not death due to pump failure, and thus their implantation in patients with advanced heart disease with a life expectancy 35 Taken together, we can say that indications for ICD implantation are similar to those of younger patients, but comorbidities should be taken into account, as well as how far the heart disease has advanced, and the decision of the patient.
Beyond the measures taken to prevent sudden death lies the attitude toward therapy that should be adopted when dealing with the elderly person with advanced heart disease presenting cardiac arrest. One of the most difficult decisions to take when caring for the elderly with advanced heart disease involves terminality and the do-not-resuscitate order. This order, that taken strictly means not implementing cardiopulmonary resuscitation maneuvers, is often associated with a reduction in other treatment and care. After adjusting for the severity of the disease, prognostic factors and age, the patients with these orders are 30 times more likely to die than those without them, which may indicate a reduction in the quality of care.
In fact, in a ward of patients with HF, physicians have a mistaken view regarding the desire of the patient to receive cardiopulmonary resuscitation or not. This decision should be made after thorough assessment of the prognostic and quality of life indexes.. Another controversial aspect, and one that is scarcely addressed in the terminal patient, is the decision to deactivate an implanted ICD.
Symptoms not always obvious
A study based on interviews with the relatives of dead patients who received an ICD showed that deactivation was only proposed to 27 patients, of whom 21 accepted it. The most recent American guidelines 36 on the use of devices to control arrhythmias recommend that the terminal patient and the family members should be informed about the outcome of ICD deactivation, and that this decision and a brief summary of the conversation should be noted in the medical record, and finally, that the ICD deactivation order should be accompanied by the do-not-resuscitate order.
In case of disagreement among the medical team, the hospital ethical committee should be consulted for their assessment and advice.. Experience shows that patients who know their diagnosis and its prognosis and participate in decision-making have better symptomatic control. However, we should not overestimate the autonomy of the patient, since the decision-making capacity of the elderly person with terminal heart disease may be affected by situations inherent to their disease denial, depression, despair, fear.
In order to accept the decision made by the elderly person with advanced heart disease, the physician should evaluate their competence, reviewing the mental abilities needed to make decisions. Some studies have shown that there is little agreement between the wishes of the patient and those expressed by the family member in charge of decision-making or by the physician. However, most patients prefer that, in the event of conflict, the opinion of the family member or that of their physician should be followed and not their own previously expressed wishes.
In a recently published review, Chochinov 40 showed that the patient's perception of dignity, particularly among those with terminal disease, depends to a great extent on their physician and proposes several approaches to care aimed at conserving dignity, summarized as the ABCD Table Palliative care refers to those activities aimed at improving the quality of life of the patients and their families facing the problem of a potentially fatal disease, through the prevention and relief of suffering by means of early identification, evaluation and treatment of pain as well as other problems, including physical, psychological, and spiritual.
Care should not end when the patient dies, since it includes assisting with the grieving process among the family. Grieving is the set of mental representations and behaviors related to emotional bereavement and is an adaptation process that helps to reestablish the personal and family equilibrium shattered by the death of a loved one. The normal or uncomplicated grieving process does not usually exceed 2 years, but may become pathological when the mental adaptation process fails. It is important to emphasize that various predisposing and avoidable factors lead to pathological grieving and these include poor physician-family communication, being unprepared, failure to satisfy the family, poor symptom control and the lack of involvement of the health personnel during all stages, especially the last one.
Early intervention in the patient's family would be of great help in identifying risk factors, guiding action and offering advice to them in a more focused manner. Figure 2.
Caring for someone with heart failure towards the end of life
The aim of treatment in relation to the duration of fatal disease progression. The figure shows that there is no incompatibility between curative and palliative medicine; both approaches should be combined in the elderly patient with terminal heart disease from the beginning. Modified from Gibbs et al. Palliative care should not be withheld until the last moments of life.
The death throes form the final phase of the disease in which the patient is very close to the death days or hours. It is imperative that in this phase the therapeutic aims should be redefined and, due to increasing distress, intervention should be centered on the family and the patient. The aim in this period is to keep the patient as comfortable as possible.