The Heartache of Cardiovascular Comorbidities
Despite advances in the detection and treatment of cardiovascular disorders, about one in four deaths in America are caused by heart disease, annually. [1] But heart disease is only one of many chronic medical conditions adults experience. The Centers for Disease Control reports that nearly half of all American adults live with at least one chronic medical condition, and about 25 percent of adults are diagnosed with two or more chronic conditions. [2] The American Heart Association cites heart disease as the cause of death in “at least 68 percent of people age 65 or older,” and there is an established link between cardiovascular disease and diabetes that suggests heart health has implications beyond the circulatory system. [3] Diabetes, meanwhile, perpetuates the cascade of illness, as the disease affects not only blood glucose levels but also kidney and heart function.
More than the Sum of Their Parts
These statistics raise important implications for Family Nurse Practitioners (FNPs) and other primary care providers as an example of how chronic conditions can have unexpected, far-reaching consequences on the body’s systems that induce comorbidities. When working with the patients who have multiple chronic conditions, Nurse Practitioners (NPs) should take an approach that encompasses not only the disease state, but also the extended health implications of the condition, such as the patient’s ability to manage care at a level that will achieve desired outcomes.
Diabetes is a condition that illustrates why viewing a patient holistically can promote better health for the individual. While a relationship between type 2 diabetes and higher rates of cardiovascular disease is well-established, [4] many practitioners continue to approach diabetes strictly as a condition of blood sugar regulation or obesity. [5] However, the effects of diabetes on the heart are not limited to blood sugar and weight gain. If clinicians view diabetic heart disease through the narrow lens of glucose, they miss seeing a large part of the picture.
Beyond Blood Sugar: How Diabetes Affects the Heart
Researchers are beginning to unravel the precise mechanisms involved in how diabetes alters heart function, and several of the most damaging effects are not caused by blood glucose levels alone. Diabetes contributes to cardiomyopathy, which is a disease that affects the heart muscle. Refer to the interactive feature below to see how.
How Nurse Practitioners Can Identify and Treat Diabetic Heart Disease
Applying a philosophy of treating the whole patient and not just the disease, Nurse Practitioners have the opportunity to collaborate with patients to identify, treat, and prevent diabetic cardiomyopathy. Specifically, NPs can:
- Look beyond blood sugar. While regulating a patient’s blood sugar levels is a primary objective in treating diabetes, a healthy A1C level should represent but one rung of the overall treatment ladder. Regulating blood glucose can reduce microvascular damage like retinopathy, a disease of the retina which impairs vision, but it has less of an effect on macrovascular damage, like heart ischemia. [6] Refrain from assuming that well-controlled sugar levels protect a patient from developing cardiomyopathy. In addition to glucose management, blood pressure regulation also needs to be considered when treating diabetic patients, as this demographic’s blood pressure goal is lower than that of the general population. According to Georgetown University’s School of Nursing & Health Studies assistant professor Melissa H. Frisvold, Ph.D., CNM, APRN, using statins to decrease cholesterol (and therefore high blood pressure) is more effective than prescribing insulin alone.
- Intervene early. At the first sign of a cardiac symptom in a patient previously diagnosed with diabetes, Nurse Practitioners may consider ordering additional tests or intervening with an appropriate therapy rather than the “watchful waiting” method.
- Educate the patient population. Patients newly diagnosed with diabetes may not understand their cardiovascular risk. NPs can raise awareness among populations of diagnosed and suspected diabetes patients through educational campaigns in provider offices and the community at large. This is when NPs should not only educate patients about the risks related to diabetes exacerbation, says Frisvold, but also inform them about health choices to prevent cardiovascular disease, such as appropriate exercise, nutrition, and smoking cessation.
- Consider social determinants of health. Environmental, social, and behavioral factors of a patient’s situation can greatly influence a Nurse Practitioner’s treatment plans. For example, patients with low literacy levels may not adhere to a medication regimen simply because they cannot interpret the dosing on the label. Patients without reliable transportation can face obstacles that prevent them from making it to their provider’s appointment. Diabetics who live in an urban food desert will find it challenging to achieve optimal dietary goals. By identifying and addressing social determinants of health, Nurse Practitioners simultaneously influence well-being in their patients who are experiencing multiple comorbidities.
Conclusion
As the incidence of comorbidities increases, more primary care patients can be considered complex patients. Reducing the risk of fatal coronary events in diabetic patients requires understanding how diabetes affects the heart and vascular system.
To expand on the limited view of the condition, NPs may consider the possible non-sugar related effects a metabolic disorder can have on other systems, including the kidneys and, especially, the heart. With their advanced degrees and experience applying a holistic perspective, Nurse Practitioners are ideally positioned to drive positive health outcomes in these challenging populations.
SOURCES
[1] “Heart Disease Facts,” Centers for Disease Control (2015), accessed April 6, 2017
[2] “Chronic Disease Overview,” Centers for Disease Control (2016), accessed March 28, 2017
[3] “Cardiovascular Disease and Diabetes,” American Heart Association (2016), accessed March 28, 2017
[4] Iciar Martín-Timón, Cristina Sevillano-Collantes,Amparo Segura-Galindo, and Francisco Javier del Cañizo-Gómez, “Type 2 Diabetes and Cardiovascular Disease: Have All Risk Factors the Same Strength?,” World Journal of Diabetes 5, no. 4 (2014), accessed July 5, 2017
[5] Aastha Chawla, Rajeev Chawla, and Shalini Jaggi, “Microvascular and macrovascular complications in diabetes mellitus: Distinct or continuum?,” Indian Journal of Endocrinology and Metabolism 20, no. 4 (2016), accessed August 4, 2017
[6] W. Todd Cade, “Diabetes-Related Microvascular and Macrovascular Diseases in the Physical Therapy Setting,” Physical Therapy 88, no. 11 (2008), accessed March 29, 2017