This paper presents a case study analysis of cardiovascular disease, one of the leading causes of death in the United States. It examines the physical and psychological demands the condition places on patients and their families, explores evidence-based and patient-centered care models, and identifies the interdisciplinary team personnel required for optimal management. The paper also discusses environmental, cultural, and psychological barriers to self-care, along with strategies to overcome them. A care plan synthesis addresses modifiable cardiovascular risk factors, healthy behaviors, rehabilitation, and prevention recommendations. Throughout, the paper emphasizes that effective cardiovascular management requires coordinated, multidisciplinary care tailored to the individual patient's values, circumstances, and psychological needs.
One of the leading causes of death in the United States is cardiac arrest. It accounts for almost 50% of all fatalities each year and affects nearly 14 million individuals in America. This number includes those with angina pectoris (chest pain) and individuals with congestive heart failure, resulting in inadequate blood circulation to the tissues. Nearly 1.5 million individuals in America suffer heart attacks annually, and about a third of them die. In addition, every year more than 700,000 patients with cardiovascular disease undergo either surgery or balloon angioplasty (American Association of Cardiovascular, 2013). Treatment for individuals with cardiovascular disease is multi-dimensional and includes quitting smoking, cholesterol reduction, exercise training, and blood pressure control.
Best-practice management of cardiovascular disease involves multidisciplinary care. There is strong evidence that, among those hospitalized with the disease, patients who receive collaborative care achieve better health outcomes than those who do not. The multidisciplinary care described in this paper is designed primarily for patients with symptoms of cardiovascular disease who have a history of hospitalization and a high risk for further exacerbations and adverse clinical outcomes. Patients with cardiovascular disease require comprehensive care, including pharmacological therapy, non-pharmacological interventions, education, support for self-care, and management of related conditions.
Models of multidisciplinary cardiovascular care applied in Australia and elsewhere informed this paper. While no single specified model of best-practice multidisciplinary care exists for cardiovascular patients, current evidence supports broad principles that include coordination of care and patient involvement in self-care. A variety of recommended components can be identified from the most successful organized cardiovascular interventions. Preliminary evidence suggests that programs applying a range of evidence-based treatments are associated with reduced rates of adverse cardiovascular events compared to lower-intensity programs (Jowett & Thompson, 2007).
Some physical conditions associated with cardiovascular disease are underreported. Severe side effects can lead to serious consequences and even death. Relatively minimal attention has been given to constipation, even though diet and lifestyle factors contribute to its occurrence in cardiac patients. Anxiety and depression are commonly experienced by cardiac patients and are associated with reduced quality of life and increased mortality. However, the evidence for the effectiveness of medical and psychological therapies for depression in this population has been mixed. Preliminary evidence indicates that providing a range of psychological therapies may be an effective way of meeting cardiac patients' psychological needs (Watson & Preedy, 2013). Specific psychological therapies include psycho-educational classes addressing behavioral risks and modification, brief individual treatment for patients with mild, moderate, and severe mental health concerns, group sessions, and individual treatment using cognitive-behavioral therapy for anxiety, depression, and the modification of negative life events.
Cardiac rehabilitation is a multidisciplinary activity designed to accomplish psychological, physical, and emotional recovery, enabling patients to achieve and maintain improved health. Cardiac rehabilitation attendance is lower among patients with depression, and dropout rates are higher in this group. Psychosocial therapies have been developed within cardiac rehabilitation programs and are endorsed by the Coronary Heart Disease foundation. Despite this, only a minority of depressed patients receive treatment for their depression. A strong evidence base exists for the effectiveness of psychological therapies in addressing depression and anxiety in the general population. Several studies have analyzed the efficacy of psychosocial therapies in patients with cardiac disease, with mixed results. A Cochrane review in 2012 determined that, while psychological therapies showed no evidence of effect on total or cardiac mortality, they did show some small reduction in depression and anxiety among cardiovascular patients (Holloway, 2014).
Evidence-based medicine (EBM) refers to the integration of the best available evidence from systematic analysis with physician expertise to treat patients; researchers contend that both are essential. Without the incorporation of evidence-based care, clinical practice can become outdated. On the other hand, without clinical expertise, physicians might be led by empirical evidence even when it is not suitable for or applicable to an individual patient. The EBM perspective, however, is largely confined to a biomedical approach that does not clearly incorporate the patient's viewpoint. When a physician does not actively engage the patient, EBM can effectively reduce treatment decisions to just the "evidence" (Lock, Keane & Perry, 2010). To prevent a reductionist approach to medical practice, clinical expertise and the careful inclusion of patient preferences and values are needed to temper how evidence is applied to the individual. Moreover, in some clinical situations, evidence may be sparse or unavailable, making the individual's perspective critical in order to avoid paternalism.
Patient-centered care, by contrast, invites the patient to be an active participant in his or her own care. It focuses on the patient's experience with illness, and physicians practicing patient-centered care consider the biopsychosocial factors of the disease while making treatment choices in collaboration with the patient, taking into account individual values and preferences. Studies suggest that patient-centered care increases treatment adherence and leads to improved outcomes. However, some argue that patient-centered care lacks a strong evidence base and is a "fuzzy concept." At its most extreme, physicians might be viewed merely as "advisors" or technical service providers. The primary goal, however, is to improve the health and health outcomes of the patient, with one of the central aims being the facilitation of shared decision-making.
At either extreme, it is important to recognize that the physician and the cardiac patient may approach the medical encounter with different priorities. The physician typically aims to identify and treat the illness based on the patient's signs and objective data obtained from physical examinations, laboratory assessments, or health history. Conversely, the patient may seek care only when symptoms disrupt work or social interaction, or when others notice a problem. These information-seeking behaviors are often motivated by a desire to understand and "make sense" of the condition. Researchers have described these self-explanations, or the beliefs a patient holds about his or her condition, as the Patient Explanatory Model of Illness (Miller & Taylor, 2005). Explanatory models can considerably affect the clinical encounter as well as an individual's overall health behaviors. For example, if a patient attributes symptoms to "getting out of shape" rather than cardiac disease, he or she may delay seeking care or withhold relevant information from the physician. These explanatory models are rooted in lived sociocultural experiences, shaped by family and friends.
"Care team roles, monitoring, and congestion management"
"Cultural, environmental, and psychological barriers to self-care"
"Risk factor modification, healthy behaviors, and rehabilitation programs"
Self-care is a complicated and multi-faceted phenomenon that requires comprehensive consideration of patients' psychological status, personality characteristics, physical capabilities, family support, living conditions, comorbidities (especially cognitive function), and capacity for learning. Inadequate knowledge about cardiovascular disease, symptom recognition, and self-care practices, combined with despondency and psychological difficulties, limits patients' capacity for effective self-care. A supportive environment, adequate motivation, and well-structured care programs employing effective educational methods that build self-care skills should be recommended to healthcare providers and family members alike.
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