Patient engagement and heart disease

Heart disease claims 2,000 lives per day in the United States. It is the leading cause of death for both men and women -- accounting for 1 of 4 deaths.  Over 75% of seniors have heart disease. Coronary heart disease alone costs the United States $109 billion annually. Half of all adults have at least one of three key risk factors for heart disease: smoking, high blood pressure, and high LDL cholesterol.

What is heart disease?

The term heart disease contains several conditions, but often refers to coronary heart disease. According the the Mayo Clinic, coronary artery disease develops when your coronary arteries — the major blood vessels that supply your heart with blood, oxygen and nutrients — become damaged or diseased. Plaque, cholesterol-containing deposits on your arteries, is usually to blame for coronary artery disease.

When plaque builds up, it narrows your coronary arteries, causing your heart to receive less blood. Eventually, the decreased blood flow may cause chest pain, shortness of breath, or other symptoms. When your heart is completely blocked from blood flow, you have a heart attack.  Perhaps one of the most frightening things about heart disease is that plaque can build silently over decades without making itself known through physical symptoms. 

DIAGNOSIS

According to the Mayo Clinic, heart disease can be diagnosed with one or more of the following tests: 

Cholesterol test. A cholesterol test, also known as a lipid panel, measures the amount of cholesterol and triglycerides in your blood. Cholesterol is usually broken down into HDL and LDL. HDL (high-density lipoproteins) transports cholesterol from the body's tissues to the liver where it gets excreted through bile. HDL is commonly known as "good" cholesterol as it takes cholesterol away. LDL (low-density lipoproteins) runs the process in reverse. LDL takes newly-made cholesterol from the liver to the body's tissues where it is used in for cell functioning. LDL is commonly known as "bad" cholesterol since an excess of LDL can lead to plaque formation. Triglycerides, like LDL, is another form of fat that travels to body's tissues through the blood stream. 

Electrocardiogram (ECG). An electrocardiogram records electrical signals as they travel through your heart. The activity is detected through electrodes attached to the body. An ECG is used to measure heartbeat rate and regularity as well as the size and position of the heart's chambers. An ECG can often reveal evidence of previous heart damage (including a heart attack) or can determine if a heart attack is in progress.

Echocardiogram. An echocardiogram is often referred to as an "echo". Much like a sonogram that produces a picture of a baby within its mother's womb, an echocardiogram uses sound waves to produce images of your heart. During an echocardiogram, your doctor can determine whether all parts of the heart wall are contributing normally to your heart's pumping activity. Parts that move weakly may have been damaged during a heart attack or be receiving too little oxygen. This may indicate coronary artery disease or various other conditions.

Stress test. If your signs and symptoms occur most often during exercise, your doctor may ask you to walk on a treadmill or ride a stationary bike during an ECG. This is known as an exercise stress test. In some cases, medication to stimulate your heart may be used instead of exercise. Some stress tests are done using an echocardiogram. For example, your doctor may do an ultrasound before and after you exercise on a treadmill or bike. Or your doctor may use medication to stimulate your heart during an echocardiogram. Another stress test, known as a nuclear stress test, helps measure blood flow to your heart muscle at rest and during stress. It's similar to a routine exercise stress test but with images in addition to an ECG. Trace amounts of radioactive material — such as thallium or a compound known as sestamibi (Cardiolite) — are injected into your bloodstream. Special cameras can detect areas in your heart that receive less blood flow.

Cardiac catheterization or angiogram. To view blood flow through your heart, your doctor may inject a special dye into your arteries (intravenously). This is known as an angiogram. The dye is injected into the arteries of the heart through a long, thin, flexible tube (catheter) that is threaded through an artery, usually in the leg, to the arteries in the heart. This procedure is called cardiac catheterization. The dye outlines narrow spots and blockages on the X-ray images. If you have a blockage that requires treatment, a balloon can be pushed through the catheter and inflated to improve the blood flow in your coronary arteries. A mesh tube (stent) may then be used to keep the dilated artery open.

CT scan. Computerized tomography (CT) technologies, such as electron beam computerized tomography (EBCT) or a CT coronary angiogram, can help your doctor visualize your arteries. EBCT, also called an ultrafast CT scan, can detect calcium within fatty deposits that narrow coronary arteries. If a substantial amount of calcium is discovered, coronary artery disease may be likely. A CT coronary angiogram, in which you receive a contrast dye injected intravenously during a CT scan, also can generate images of your heart arteries.


Magnetic resonance angiography (MRA). This procedure uses MRI technology, often combined with an injected contrast dye, to check for areas of narrowing or blockages — although the details may not be as clear as those provided by coronary catheterization.

 

RISK FACTORS

According to the Mayo Clinic, risk factors for coronary artery disease include:

  • Age. Simply getting older increases your risk of damaged and narrowed arteries.
  • Sex. Men are generally at greater risk of coronary artery disease. However, the risk for women increases after menopause.
  • Family history. A family history of heart disease is associated with a higher risk of coronary artery disease, especially if a close relative developed heart disease at an early age. Your risk is highest if your father or a brother was diagnosed with heart disease before age 55, or your mother or a sister developed it before age 65.
  • Smoking. Nicotine constricts your blood vessels, and carbon monoxide can damage their inner lining, making them more susceptible to atherosclerosis. The incidence of heart attack in women who smoke at least 20 cigarettes a day is six times that of women who've never smoked. For men who smoke, the incidence is triple that of nonsmokers.
  • High blood pressure. Uncontrolled high blood pressure can result in hardening and thickening of your arteries, narrowing the channel through which blood can flow.
  • High blood cholesterol levels. High levels of cholesterol in your blood can increase the risk of formation of plaques and atherosclerosis. High cholesterol can be caused by a high level of low-density lipoprotein (LDL), known as the "bad" cholesterol. A low level of high-density lipoprotein (HDL), known as the "good" cholesterol, also can promote atherosclerosis.
  • Diabetes. Diabetes is associated with an increased risk of coronary artery disease. Both conditions share similar risk factors, such as obesity and high blood pressure.
  • Obesity. Excess weight typically worsens other risk factors.
  • Physical inactivity. Lack of exercise also is associated with coronary artery disease and some of its risk factors.
  • High stress. Unrelieved stress in your life may damage your arteries as well as worsen other risk factors for coronary artery disease.

Risk factors often occur in clusters and may build on one another, such as obesity leading to diabetes and high blood pressure. When grouped together, certain risk factors put you at an ever greater risk of coronary artery disease. For example, metabolic syndrome — a cluster of conditions that includes elevated blood pressure, high triglycerides, elevated insulin levels and excess body fat around the waist — increases the risk of coronary artery disease.

Sometimes coronary artery disease develops without any classic risk factors. Researchers are studying other possible factors, including:

  • Sleep apnea. This disorder causes you to repeatedly stop and start breathing while you're sleeping. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system, possibly leading to coronary artery disease.
  • C-reactive protein. C-reactive protein (CRP) is a normal protein that appears in higher amounts when there's swelling somewhere in your body. High CRP levels may be a risk factor for heart disease. It's thought that as coronary arteries narrow, you'll have more CRP in your blood.
  • Homocysteine. Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue. But high levels of homocysteine may increase your risk of coronary artery disease.
  • Fibrinogen. Fibrinogen is a protein in your blood that plays a central role in blood clotting. But too much may increase clumping of platelets, the type of blood cell largely responsible for clotting. That can cause a clot to form in an artery, leading to a heart attack or stroke. Fibrinogen may also be an indicator of the inflammation that accompanies atherosclerosis.
  • Lipoprotein (a). This substance forms when a low-density lipoprotein (LDL) particle attaches to a specific protein. Lipoprotein (a) may disrupt your body's ability to dissolve blood clots. High levels of lipoprotein (a) may be associated with an increased risk of cardiovascular disease, including coronary artery disease and heart attack.

 

MEDICATIONS

According to the Mayo Clinic, various drugs can be used to treat coronary artery disease, including:

  • Cholesterol-modifying medications. By decreasing the amount of cholesterol in the blood, especially low-density lipoprotein (LDL, or the "bad") cholesterol, these drugs decrease the primary material that deposits on the coronary arteries. Boosting your high-density lipoprotein (HDL, or the "good") cholesterol may help, too. Your doctor can choose from a range of medications, including statins, niacin, fibrates and bile acid sequestrants.
  • Aspirin. Your doctor may recommend taking a daily aspirin or other blood thinner. This can reduce the tendency of your blood to clot, which may help prevent obstruction of your coronary arteries. If you've had a heart attack, aspirin can help prevent future attacks. There are some cases where aspirin isn't appropriate, such as if you have a bleeding disorder or you're already taking another blood thinner, so ask your doctor before starting to take aspirin.
  • Beta blockers. These drugs slow your heart rate and decrease your blood pressure, which decreases your heart's demand for oxygen. If you've had a heart attack, beta blockers reduce the risk of future attacks.
  • Nitroglycerin. Nitroglycerin tablets, sprays and patches can control chest pain by opening up your coronary arteries and reducing your heart's demand for blood.
  • Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). These similar drugs decrease blood pressure and may help prevent progression of coronary artery disease. If you've had a heart attack, ACE inhibitors reduce the risk of future attacks.
  • Calcium channel blockers. These medications relax the muscles that surround your coronary arteries and cause the vessels to open, increasing blood flow to your heart. They also control high blood pressure.

Procedures to restore and improve blood flow

Sometimes more aggressive treatment is needed. According to the Mayo Clinic, here are a few options:

  • Angioplasty and stent placement (percutaneous coronary revascularization). In this procedure, your doctor inserts a long, thin tube (catheter) into the narrowed part of your artery. A wire with a deflated balloon is passed through the catheter to the narrowed area. The balloon is then inflated, compressing the deposits against your artery walls. A stent is often left in the artery to help keep the artery open. Some stents slowly release medication to help keep the artery open.
  • Coronary artery bypass surgery. A surgeon creates a graft to bypass blocked coronary arteries using a vessel from another part of your body. This allows blood to flow around the blocked or narrowed coronary artery. Because this requires open-heart surgery, it's most often reserved for cases of multiple narrowed coronary arteries.

 

LIFESTYLE CHANGES

As with all of the chronic diseases in this series, the following behavior changes can reduce risk:

Eat healthy foods. Try the Dietary Approaches to Stop Hypertension (DASH) diet, which emphasizes fruits, vegetables, whole grains and low-fat dairy foods. Get plenty of potassium, which can help prevent and control high blood pressure. Eat less saturated fat and total fat.

Maintain a healthy weight. If you're overweight, losing even 5 pounds (2.3 kilograms) can lower your blood pressure.

Increase physical activity. Regular physical activity can help lower your blood pressure, strengthen your heart, and keep your weight under control. Strive for at least 30 minutes of physical activity a day.

Limit alcohol. Even if you're healthy, alcohol can raise your blood pressure and your triglyceride levels. If you choose to drink alcohol, do so in moderation — up to one drink a day for women and everyone older than age 65, and two drinks a day for men.

Don't smoke. Tobacco injures blood vessel walls and speeds up the process of hardening of the arteries. 

Manage stress. While the research is not clear on how exactly stress effects heart disease, most doctors recommend reducing stress in order to reduce heart disease risk

Monitor your blood pressure at home. Home blood pressure monitoring can help you keep closer tabs on your blood pressure, show if medication is working, and even alert you and your doctor to potential complications. 

 

How mobile can Help with Health Literacy

The first step in patient engagement is patient education. With all of the medical misinformation available online, patients should have a trusted resource at their fingertips. Below is an sample of the Mayo Clinic's health library optimized for a smart phone:

      

 

How mobile Can Help with Health Management

Patient engagement goes beyond education. Education should lead to active health management. Until the last few years, personal health management meant endless manual journaling -- a process that few maintained. The good news is that mHealth offers a solution that is at once less labor intensive and more effective than manual tracking.

 

Bottom Line

Given its prevalence, virtually all adults should be vigilant about reducing heart disease. Coronary artery disease, which is the most common type of heart disease, kills more than 385,000 people annually and costs more than $100 billion. If sustained, simple lifestyle changes can go a long way towards lowering heart disease risk. With mHealth, these lifestyle changes don't have to mean endless manual journaling and data capturing.

Interested in mHealth for your health system? See:

mHealth and the Closing Window for Patient Engagement

mHealth ROI Part 1: Readmissions

mHealth ROI Part 2: HCAHPS / Value-Based Purchasing

mHealth ROI Part 3: Patient Loyalty