Atherosclerosis and Hyperlipidemia, Essay Example

Healthcare Disparity

Healthcare practice is full of disparities. One such instance of disparity is seen in the analysis, research and treatment of those effected by atherosclerosis and hyperlipidemia.Atherosclerosis presents as an early degenerative plaque formation in the arteries that subsequently causes coronary problems, strokes, and further complications. Atherosclerosis manifests in patients when they’re young and progresses as plaque matures in the arteries through high cholesterol, lipid and cell inflammation. The problem with mature plaque is that is has a mobility that younger plaque doesn’t have and thus, mature plaque “has the potential to produce a flow-limiting, thrombotically active matrix with infiltration of inflammatory cells. As a result, the patient is at considerable risk for acute ischemic events”(Fazel & Johnson, n.d. para. 5).Studies show that younger women are more prone to get atherosclerotic disease than men of the same age.[1]This percentage of women increases after menopause. These women are treated with atheroprotective action of endogenous estrogen.Studies have shown that hormone replacement therapy (HRT) has been used, however, the efficacy of HRT in empirical data through blind tests/trials has shown that HRT has not in fact been beneficial in any way to women. Thissuggests a disparity between proponents for HRT to treat atherosclerotic disease, and research studies that disprove its efficacy. It must also be examined, however, that estrogen isn’t ineffective for treatment but that HRT could be beneficial under the right advancement, test subjects, regiment treatment and “selective estrogen receptor modulators” (Akishita, 2004, p. 175). This paper will expound on the healthcare discrepancy in the treatment of atherosclerotic disease and the uneven dispersing of the disease in women over men, and the increase of the disease in women after menopause.

Population

Atherosclerotic disease, which is a coronary heart disease, persists in the population of young women as opposed to men of similar age as the chart shows(Stone, 2013, p. 520). The disease has proven itself progressive as after menopause, women are even more likely to acquire the disease. During this age, the disease, along with hyperlipidemia in women, also increases in levels after a woman hits menopause. These statistics speak to an overwhelming phenomenon that has been explained by modern medicine through the use of “atheroprotective actions of endogenous estrogen and its defect in postmenopausal women” (Akishita, 2004, p. 175).Doctors profess to the benefits of hormone therapy to curtail the effects of the disease in women.HRT helps in the reduction of this cardiovascular disease especially in concerns with postmenopausal women (Akishita, 2004, p. 175). The chart below offers more vivid details about the population disparity among men in women in concerns with Atherosclerotic disease (Akishita, 2004, p. 175).

The chart clearly delineates the prevalence of the disease as it’s split between men and women (leaning toward women) and then again how it progresses as a woman is pre and post menopausal.The chart can be broken into further details by offering that women at 50 years have a lower risk of acquiring the disease as opposed to men of the same age. Contrasting to this point is that the risk increases with age for women. Although there’s a high stake on the empirical data pointing to the gender difference disparity in the ages, there is also the strange difference between women in pre- and post-menopausal stages of their lives: postmenopausal women have a higher risk for cardiovascular disease than in age-matched premenopausal women suggesting that menopause itself is a risk factor” (Akishita, 2004, p. 176).

Health problem

Atherosclerotic disease in women has many attributable factors. These vary (and one never omits another) in postmenopausal women. One risk in the increase in atherosclerotic disease in women during menopause is atherogenic (e.g. “hyperlipidemia, hypertension, obesity, and insulin resistance” (Akishita, 2004, p. 176).Other risks involved in this disease include “vasoprotectiveactions of estrogen such as the stimulation of nitric oxide productionand inhibition of vascular smooth muscle cell proliferation(Akishita, 2004, p. 176).Stone (2013) cites other risks including  “dyslipidemia, hypertension, diabetes mellitus, smoking, chronic kidney disease (CKD), a family history of premature CAD, a history of CAD, noncardiogenic cerebral infarction, PAD, age and sex. In this article, we describe the comprehensive management of CVD” (p. 517).

Atherosclerotic disease occurs 2-3 times more in women than in men in Akishita’s study.Akishita also points to the plasma averages for total cholesterol in women (aged 50-59) being somewhere around 230 mg/dl (Akishita, 2004, p. 176).Within this age range of menopausal women, there was a triglyceride increase that lead to increased LDL cholesterol levels. This is important because Estrogen stimulates the activity of hepatic LDL receptor and increases the uptake of LDL cholesterol by the liver, resulting in the reduction of plasma LDL cholesterol levels. Also, through inactivation of hepatic triglyceride lipase, estrogen inhibits the conversion of IDL into LDL and hepatic uptake of HDL, resulting in plasma LDL cholesterol reduction and plasma HDL cholesterol elevation. Augmentation of hepatic and intestinal apo A-I synthesis by estrogen further contributes to the increase in HDL cholesterol production. The lowering effect of estrogen on plasma Lp(a) levels is important because statins do not have similar effects. Additionally, estrogen is known to inhibit the oxidation of LDL cholesterol (Akishita, 2004, p. 176).

With this data, Akishita points out that samples of women that took HRT to lower risk of atherosclerosis and hyperlipidemia had less an occurrence with the disease than those who did not (Akishita, 2004, p. 176).

Other than HRT and other treatments, Stone (2013) suggests a few other courses of action for treating the disease:

At present, the degree of atherosclerosis is primarily evaluated using imaging techniques. Invasive techniques include angiography (to assess the severity of stenosis) as well as angioscopy and intravascular ultrasonography (to qualitatively assess the vessel walls). Noninvasive techniques include transcutaneous ultrasonography of the arteries, such as the carotid artery, to qualitatively and quantitatively evaluate the degree of atherosclerosis. Carotid artery ultrasonography is often used in general practice because the extent of carotid sclerosis has been shown to be correlated with the risk of cerebrovascular disease (521).

There are also other tests that can be administered to find out whether or not a woman has coronary disease and this include a stress test (in which the patient is strapped to a bike, treadmill, etc.,) and moniters are hooked up to read the patient’s heartrate which informs the primary care physician about blood pressure. An electrocardiogram (ECG may also be used to decipher whether or not someone is at risk for coronary disease as it will record any abnormalities in the heart’s rhythm or scar tissue issues in the heart as well as areas in the heart that are suffering from any decrease in blood flow. Imaging techniques such as the once mentioned above can aid in deciphering where exactly (to a millimeter of an inch) blood flow is being restricted in the heart due to coronary issues. A more beneficial way to see blood flow problems associated with coronary disease is to have the patient go through an angiography (in which a dark ink is injected into the patient in order to more thoroughly see how the arteries are clogged, or whether or not the arteries are performing up to par with what their function is “The management of carotid artery stenosis has also continued to evolve from an aggressive, early surgical approach with the advent of the carotid endarterectomy to the initiation of progressive medical management options and the development of advanced percutaneous intervention. Carotid endarterectomy continues to be the clear treatment of choice in symptomatic patients with >70% carotid stenosis. However, strict risk factor modification, including improved antihypertensive therapy, lipid management, smoking cessation, and antiplatelet therapy, have led to less-compelling indications for immediate surgery in asymptomatic populations” (Fazel & Johnson, n.d. para. 3).[2]An angiography is used to determine areas of damage as well as where lipids have built up in the arteries. This may be important as it may lead to discovering areas in which blood flow is restricted and may prevent problems in other areas of the body such as the legs, brain, kidneys.

Health promotion strategies

Using estrogen to replace lost hormones for women is not a new concept, and has been used for curtailing the progress of atherosclerotic disease progressively.In fact, in 1998 a study was done in which postmenopausal women who were positive for coronary heart disease were put on “a large-scale randomized placebo-controlled secondary prevention trial” (Akishita, 2004, p. 177): this strategy failed (after four years, and maintaining a dosage of HRT, estrogen failed to exude supportive enough data to promote the use of HRT in the treatment of this disease).As Akishita’s table realizes the breakdown in postmenopausal women and their potential risks/disease.

In fact, in 2002, another trial proved that not only did HRT prove non-beneficial, but the treatment lead to coronary risks or even stroke to the women.Akishita states that the concern now becomes

…the thrombogenic effect of estrogen through the coagulation/fibrinolysis system would overcome the anti-atherogenic effect such as the improvement of lipid metabolism and endothelial function. Based on the opinion that progestin that is used to prevent myometrial cancer might be harmful, or the dose of regular HRT could be too much, the development of new regimens have been in progress. For the prevention of atherosclerosis, the development of selective estrogen receptor modulators (SERM) is ongoing and anticipated (Akishita, 2004, p. 177).

The delineation of strategy for attacking coronary disease includes low-density lipoprotein, high-density lipoprotein, and monitoring triglycerides. The therapeutic principle includes prevention through medication but only after significant changes to lifestyle have been made by the patient, and furthermore, drug therapy should coincide with any lifestyle changes (again, this must be monitored in order to be productive as a tool in managing this disease, and prevention).

If the nurse practitioner and the primary care physician agree on a course of action for the woman, and that course of action includes drug therapy then certain factors must be considered. The factors that must be considered are specific drugs and modifications of drugs depending on if the patient is low or high risk for coronary disease. Specific drugs that have proven beneficial to this disease (and if HRT is not the course of preferred action) especially for patients with hyper-LDL include, “cholesterolemia, statins are the first drug of choice. Resin, probucol and/or ezetimibe are used in combination with statins or selected when statins cannot be administered. The combination of statins and EPA is useful for treating high-risk patients with hyper-LDL cholesterolemia. For treating hypertriglyc- eridemia accompanied by hypo-HDL cholesterolemia, drugs such as fibrates and nicotinic acid derivatives should be considered” (Stone, 2013, p. 521). It is clear from Stone’s assessment that the difference between high and low risk for coronary disease makes a great difference in drug therapy.

Proposed changes for the nurse practitioner

While previous studies spoke for and supported the efficacy of HRT in the treatment of atherosclerotic disease in postmenopausal women the results have been desultory. Studies have also shown, however, that HRT is not completely unbeneficial to the stricken. This improvement is seen in the use of “plasma lipids” (Akishita, 2004, p. 177) through more studied experiments (e.g. selective subjects for placebo and other effects) as well as changes in the HRT dosage (such as prescribing half as much) (Akishita, 2004, p. 176).

In table 2, Akishita points out certain guidelines for treatment of atherosclerosis and hyperlipidemia such as HRT treatments (or continuation of treatments) for postmenopausal women[3]. The benefits of HRT for these women must exceed the risks involved in taking hormones. If a patient shows signs of “climacteric disorder or osteoporosis” (Akishita, 2004, p. 176) and are therefore at high risk for coronary disease as well as other diseases such as diabetes mellitus, then risk factors must be ruled out as leading to one or the other through care and treatment (often with medication). If a flagging in health occurs in an at-risk women for atherosclerosis then treatment must resume with her primary interventions as the risk involved with one are greater (death)

(Akishita, 2004, p. 177).

Lipids aren’t the only biomarkers the disease is going against, researchers also point to apo measurements, lipoprotein, and prothrombotic (Frohlich & Al-Sarraf, 2013, para. 2). The lipid profile suggests by these researchers points to proper management when it comes to curtailing coronary disease. Preventative measure that nurse practitioners can promote with their patience include “therapeutic lifestyle changes and medications” (Frohlich & Al-Sarraf, 2013, para. 3).These changes are commonly referred to by their conglomerate name: lifestyle interventions. Such measures by nurses are part of the cornerstone that makes them better nurses. Some of these lifestyle changes are: quitting smoking, maintaining a healthy and fit body weight, exercising on a regular basis, watching diet[4] intake of saturated fats/sugars/starch, and finally decreasing stress levels (Frohlich & Al-Sarraf, 2013, para. 2). In the realm of change in medications (although not a lot can be done about medicines that are life-altering and salubrious for a person’s health, some medication can be somewhat beneficial) “lipid-lowering, anti-hypertensive, and anti-coagulant can be effectively used”?(Frohlich & Al-Sarraf, 2013, para. 3). Such small changes allow the CAD to boast of a 50 percent decrease in women with this disease (over a 20 year time span); so much so that “in Canada, cardiovascular disease is no longer the leading cause of death”?(Frohlich & Al-Sarraf, 2013, para. 3).

Guidelines to treat this coronary disease, in regards to the nurse practitioner, include a review of the efficacy of the medicine being used and security that it’s up-to-date and of the highest quality. This is important for the nurse practitioner so that they’re aware of their client’s individual needs in regards to the medication and the best dosages to take as it’s contingent upon individual analysis for efficacy.Also, “The statin RCTs provide the most extensive evidence for the greatest magnitude of ASCVD event reduction, with the best margin of safety” (Stone, 2013, p. 53).

More specifically, this coronary disease may be easier detected using the multidetector CT (MDCT) that has been used to better find artery lesions in patients. Thorough knowledge of the patient and the efficacy of it (in a percentage world) to patient well-being is important to implement for the nurse practitioner.Also the use of ultrasonography (as well as MDCT) have proven to be far less invasive of a procedure as well as much easier to perform for the nurses.Researchers point toward a future in which guidelines for treatment can be utilized prior to fear of onset of severe symptoms.

Conclusion

The use of invasive strategies in dealing with atherosclerosis and hyperlipidemia  as well as noninvasive strategies result in similar effects: unclogging patient’s arteries from lipids so that risk of coronary disease lessens. Drug therapy, lifestyle changes, and hormone implementation are all ways in which medical science has combated this rise in women acquiring this disease. The arbitrary nature of the disease, in attacking women more than men of the same age group, than of women who are post-menopausal, is captious. In order to properly assess a patient, it’s necessary to look at their life and to decide what contingent factors need to be addressed in order for that patient to maintain the status quo in regards to health. This may be done through various means such as daily monitoring of food intake, as well as exercise during the course of the day, as well as the more research baseddilemma’s of the trial and errors of medication. The risk factors of coronary disease include being a female after the age of 50 as well as post-menopausal, high blood pressure, sleep apnea, depression, diabetes, obesity, and family history. This paper has shown the different and myriad ways in which coronary disease may be prevented, treated and the impetus to the disparity in the healthcare system as to it’s origins and treatments and has come to the conclusion that women are more at risk of coronary disease in their later years than men. As such, a woman needs to be more conscientious about what she puts in her body and other healthy habits to begin including in her life.

Problem

Atherosclerosis and hyperlipidemia are the hardening of the arteries because of too much lipids. This in turn may lead to serious heart conditions such as disease and heart attacks.These conditions while present in men are more prevalent in women, and even more so in post-menopausal women.

Cause

Atherosclerotic disease is caused in part by high cholesterol and stress: atheroprotective actions of endogenous estrogen defect results in arthrosclerosis. As cholesterol levels rise in the blood, so to does lipids (commensurately): to the point where arteries begin to be blocked by this obstruction (lipids).Thus, the higher a person’s cholesterol the more at risk they are of getting atherosclerosis.This range shifts depending on whether or not good or bad cholesterol is being discussed.

Prevention/Treatment Plan

One of the main treatments for atherosclerotic is estrogen (hormone therapy) in the form of estriol. Estriol should be prescribed to a patient as follows: 2-8 mg day. In order to prevent atherosclerosis the patient must consider lifestyle changes such as watching diet, exercising, stopping smoking, etc. so that when they reach menopause, they have less of a chance of getting this coronary disease. The treatment plan once the disease is acquired consists of exercise, medications, weight loss, and especially diet changes in order to ensure low blood sugar levels as well as weight loss (which helps tremendously in many ways, not just atherosclerosis.

Medications

Cholesterol control medicines may be prescribed for the patient depending on any previous ailments/diseases (to ensure drug interference isn’t a factor). Medications for coronary disease also have a way of interfering with a person’s liver so ensuring that no other detrimental effects occur while taking medication for coronary disease is essential.

References

Akishita, M. (2004). Atherosclerosis and hyperlipidemia.Japan Medical Association Journal 47(4). 175-178.

Fazel, P., & Johnson, K. (n.d.). Current role of medical treatment invasive management in carotid atherolerotic disease. Baylor Healthcare Systems. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2277346/

Frohlich, J., & Al-Sarraf, A. (2013). Cardiovascular risk and atherosclerosis prevention.Cardiovascular Pathology 22(1). 16-18.

Stone, N. et al. (2013). ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerosis cardiovascular risk in adults.Circulation. Retrieved from http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.short?rss=1&ssource=mfr

Weitz, J. et al. (1996). Diagnosis and treatment of chronic arterial insufficiency of the lower extremities : a critical review. American Heart Association. Retrieved from http://www.besancon-cardio.org/recommandations/insuf-chr.htm

[1]Weitz et al. (1996) point out, “Epidemiological studies indicate that up to 5% of men and 2.5% of women 60 years of age or older have symptoms of intermittent claudication. The prevalence is at least threefold higher when sensitive noninvasive tests are used to make the diagnosis of arterial insufficiency in asymptomatic and symptomatic individuals.The symptoms of chronic arterial insufficiency of the lower extremities progress rather slowly over time. Thus, after 5 to 10 years, more than 70% of patients report either no change or improvement in their symptoms, while 20% to 30% have progressive symptoms and require intervention, and less than 10% need amputation. Despite the relatively benign prognosis for the affected limb, however, symptoms of intermittent claudication should be viewed as a sign of systemic atherosclerosis. This explains why, compared with age-matched controls, patients with intermittent claudication have a threefold increase in cardiovascular mortality” (para. 2).

[2] The purpose of these therapies is to prevent progression of vascular closing or occlusion.

[3] A practitioner’s goal in patient therapy is to “prevent cardiovascular complications” such as strokes or even death, from occurring. As such the best form of treatment is argued to be aspirin (Weitz et al., 1996, para. 3).

[4] In order for diet to be a proper preventative measure the patient must eat low-fat as well as low-cholesterol diet. Other items that are necessary to incorporate in the diet include use of monosaturated oils when cooking (e.g. coconut, olive, red palm oil) which help to lower LDL. Also, low-fat dairy products should be consumed instead of ones high in fat. When eating at a restaurant the patient should eat baked, broiled or grilled meat (cooking that expels unnecessary fats). Consuming more fish, omega-3, nuts, fruits, vegetables, and whole grains also help to improve diet and cholesterol. Processed foods should be avoided (such as cheeses). Alcohol should be avoided as well as soda pop, sports drinks and juices.