The Nurses Role in Tackling Coronary Heart Disease - Essay Example

?THE NURSE’S ROLE IN MANAGING CORONARY HEART DISEASE The Nurses’ Role in Tackling Coronary Heart Disease Introduction Coronary heart diseases are currently one of the major sources of mortality and morbidity in the adult population. Coronary heart diseases (CHD) cause other symptoms and health issues on adults, and death is often the end consequence for patients suffering from the disease. With the current issues on nutrition and reduced levels of activity among youth and adult population, the prevalence of this disease has significantly increased. The management of this disease is largely based on the actions of the patient and the interventions of the medical health professionals. Nurses are at the very frontline of managing this disease. They are in the best position as health professionals in the management of CHD. This paper shall critically assess and evaluate the nursing management of cholesterol levels in the holistic care and management of CHD. It shall examine relevant literature and critically discuss the existing and desirable standards of care. This study is being undertaken in order to establish a clear and comprehensive understanding of CHD based on nursing management. Discussion There are about 17 million who die from cardiovascular diseases on a yearly basis (WHO, 2011). Most of these deaths are attributed to coronary heart disease and cerebrovascular diseases. Physical inactivity, unhealthy eating habits, and smoking are just some of the causes of these diseases. In 2009, about 5000 died from coronary heart disease in Wales with about 118,000 people having had a heart attack at some point and about 120,000 more suffering from angina. This disease also cost the NHS about 3.2 billion pounds with about 9 billion pounds cost to the entire UK economy (BHF, 2011, p. 2). The trends in the incidence of CHD are largely based on social patterns with mortality rates higher for the deprived areas, as compared to the least deprived areas. The rates of CHD in Wales are slightly higher as compared to the rest of England with male incidence rates higher than 10% as compared to the rest of England. Behaviours commonly attributed as causes for CHD include smoking, unhealthy eating, physical inactivity, and heavy intake of alcohol (BHF, 2011, p. 2). Obesity, increased cholesterol, high blood pressure and diabetes are considered risk factors for the development of coronary heart disease. Coronary heart disease, also known as coronary artery disease is said to affect about 14 million men and women in the US (Singh, 2010). It develops when fatty materials, calcium, and scar tissue accumulates in the arteries supplying the heart with blood. These arteries are arteries crucial to the efficient functioning of the heart with such heart muscles being supplied with oxygen and nutrients to enable heart functions (Singh, 2010). This plaque narrows the arteries and as a result, the heart does not get an adequate supply of oxygen-filled blood. With narrowed blood vessels, the blood flow to the heart becomes slower and causes chest pain or angina (Singh, 2010). With continued plaque formation, complete blockage of arteries may result, causing a heart attack (myocardial infarction) or disturbance in heart rhythms leading to sudden cardiac arrest. From years of its earliest development, the inner linings of the coronary arteries are very smooth and this allows the smooth and easy passage of blood through the different systems of the body. As a person gets older, the cholesterol and calcium content in the arterial walls accumulate, making them thicker (Singh, 2010). The plaque formation on the arterial walls is primarily caused by unhealthy diets, including one which is high in fats and cholesterol. Smoking and limited activity or exercise can increase the plaque formation. This process is known as atherosclerosis or the hardening of the arteries (Singh, 2010). This plaque forms like a firm shell, but has a soft inner core where cholesterol is stored. When blood hits such plaque with each flow and pump, such plaque may open and expose its cholesterol layer. This cholesterol layer actually promotes blood clotting (Singh, 2010). These clots may sometimes reduce the flow of blood and cause angina; they may also block the flow of blood altogether. The medical management of this disease includes a wide-range of interventions. It primarily includes the implementation of lifestyle changes which may start off with the imposition of a healthy diet, one which is low on fat and cholesterol. A therapeutic lifestyle changes (TLC) is one of the measures recommended by the National Heart Lung and Blood Institute. This therapy includes changes in the diet, physical activity, and weight management (NHLBI, n.d). Through this therapy, less than 7% of the person’s calories would come from saturated fat. The Dietary Approaches to Stop Hypertension (DASH) is also recommended in the management of high blood pressure. It focuses on fruits and vegetables and whole grains. Increasing physical activity can also help manage CHD. Other measures like quitting smoking, managing weight, and managing stress are also therapeutic means to manage CHD. Medicines are also recommended for CHD. Various medications perform different functions including: reduction of heart’s workload; decrease of risk of heart attack; decrease cholesterol levels; prevent blood clots; prevent or delay surgery (NHLBI, n.d). These medicines are known as anticoagulants, blood thinners, ACE inhibitors, calcium channel blockers, and nitroglycerin. Procedures which are meant to manage the disease include angioplasty and CABG. Angioplasty is a nonsurgical intervention which opens narrowed coronary arteries. CABG or coronary artery bypass grafting is when arteries from other parts of the body are utilized to bypass the blocked artery to improve blood flow, ease angina, and prevent a heart attack (NHLBI, n.d). These are general interventions for CHD which largely apply to the medical profession. These interventions mention cholesterol levels and the management of such levels in order to reduce narrowing of blood vessels. The nurse is an important member of the healthcare team who plays a crucial role in managing a patient’s cholesterol levels. Various studies discussing such management shall be critically assessed below. The role of the nurse in the management of CHD is mostly on health education. Nursing education in relation to cholesterol management refers largely to advising and teaching the patient about proper diet. This diet must be one which is low in fat and cholesterol. In order to implement this type of diet, behavioural modifications have to be implemented into the patient’s life. In a study by Ammerman, et.al., (2002), the authors sought to evaluate the efficacy of behavioural dietary interventions in ensuring dietary changes related to chronic disease reduction. It also sought to establish the efficacy of specific interventions in various population subgroups. The authors established that implementing a reduced intake of total and saturated fat and an increased diet of fruit and vegetables was able to successfully reduce saturated fat and total fat in patients. These interventions proved to produce positive results with dietary changes in behaviour generally yielding healthy populations. In effect, the authors concluded that most interventions presented positive reviews in the use of diet behaviour modification in relation to the prevention and management of chronic diseases, including heart disease. This study helps establish a wide review of perspectives from various studies on the benefits of behaviour modification in the management of cholesterol and of coronary heart disease. It does not however offer more specific perspectives on coronary heart disease in relation to the management of cholesterol. Further review is needed in order to establish clear support and results. Allen, et.al., (2002, p. 678) sought to evaluate the efficacy of implementing a nurse case management program in lowering blood lipids among patients with CHD. It covered about 228 consecutive eligible adults diagnosed with hypercholesterolemia and CHD recruited for this study after revascularization. This study randomized patients to receive either lipid management, alongside individualized lifestyle modification and pharmacologic intervention or usual care enhanced with feedback on lipids to their primary provider (Allen, et.al., 2002, p. 678). The study revealed that more patients in the intervention group than in the control group received low-density lipoprotein cholesterol (LDL-C) levels. Improvements in lipids and lipoproteins were seen alongside improvements in diet and exercise patterns in the intervention group. The authors concluded that the control of hypercholesterolemia among patients who have gone through coronary revascularization can be better managed through the application of a nursing case-management system. In effect, the authors set forth that nurse case management programs would be able to establish opportunities which would improve the appropriate application of better treatment paradigms (Allen, et.al., 2002, p. 678). This study is reliable because it applies valid and reliable methods of research through its random processes and clear statistical tools. It draws it results from the results established by the tables and statistical applications. No fallacies are seen from this study. It portrays results which also match the currently existing studies and literature on the subject matter. In a study by Campbell, et.al., (1998, p. 447) the authors set out to evaluate whether nurse-run clinics in general practice can improve secondary prevention among patients with CHD. This study covered about 1100 patients under 80 years of age diagnosed with CHD, but without terminal illness or dementia. The nurse-run clinics set forth medical and lifestyle aspects of secondary prevention with regular follow-ups. It was set to consider aspirin use, blood pressure management, dietary fat, and smoking status. In the course of the study, the authors established that significant improvements were apparent after aspirin management, lipid management, physical activity, and diet (Campbell, et.al., 1998, p. 447). The authors concluded that the nurse-run clinics were practical means of implementing general practice; and they effectively improved secondary prevention in CHD. Through these clinics, patients were able to gain an effective component of secondary prevention with future cardiovascular risks and mortality reduced to a significant degree (Campbell, et.al., 1998, p. 447). This study presents clear results supported by reliable data. It points out the important role of nurses in the management of lipids and in reducing cholesterol levels of patients. With this study, more emphasis is placed on the nurses’ role in reducing and managing a patient’s cholesterol. Moore, et.al., (1999, p. 197) discussed that the current trend in prioritizing in the NHS brings much attention to the debate on efficient and effective management of conditions in relation to modern lifestyle. In this debate, nutrition is considered a main issue; this is very much in line with the international consensus on the accepted diet for the prevention of coronary heart disease and cancer (Moore, et.al., 1999, p. 197). Since the late 1990s, the government has emphasized that primary care is the best setting in which nutrition education to the general public can be initiated. Low fat diets are one of the main interventions in the reduction of cholesterol levels (NHS, 1998, p. 6). The efficacy of low fat diets is very much based on how restrictive they are and their degree of adherence. In instances when patients’ diets are managed by others, including physicians and nurses, or by staff in metabolic wards, changes in the diet may be seen and may lead to promising results (Scottish Inter Collegiate Guidelines Network, 1996). However, assessment of the general population has manifested only limited changes in cholesterol levels (LeTouze and Calman, 1996, p. 3). Such studies point out that cholesterol reduction which may be seen from lipid lowering diets may be minimal and the impact on clinical outcomes may prove disappointing (Cade and O’Connell, 1991, p. 147). The impact of dietary interventions used alone manifested a greater decrease in blood cholesterol as compared to other dietary trials, most likely because participants were more inclined to follow strict diets or they stayed in institutions which controlled their diet to a greater extent (Ienatsch, 1999, p. 13). Despite such promising results however, lipid-lowering diets have not been wholly effective in decreasing cholesterol levels. Authors claim that this may be due to the fact that complex carbohydrates are substituted for total fat and in the process reducing HDL as well as LDL cholesterol (Levine, 1993, p. 115). In effect, even if total cholesterol level is reduced, the LDL/HDL ratio is not affected and in effect, the CHD risk is not affected. These studies then point out the importance of focusing on the decrease of LDL levels, and on increasing HDL levels; such an intervention would remove the bad cholesterol and leave the good cholesterol in the body. Some studies also recommend the use of garlic, oats, and soy protein in lowering cholesterol. In various studies, garlic was shown to exert a cholesterol lowering effect in the diet (Kushner, 1995, p. 546). Other reviews also demonstrated that oats or psyllium-rich cereals decreased cholesterol levels (Hiddink and Hautvast, 1995, p. 842). Other studies pointed out that soy protein substituted for meat protein manifested decrease in cholesterol (McPherson, 1995, p. 27). With the proper management of such a diet in coordination with the nurse, a decrease in the patient’s cholesterol levels may be consistently expected and seen. In relation to drugs, statins have been and still are the recommended drug of choice in lowering cholesterol levels. These statins have been known to reduce cholesterol levels by more than 20%. In effect, they have been known to reduce cholesterol levels and reduce the risk of CHD mortality by about 25% (Johnston, 1995, p. 36). In relation to the nurse, her role is to assist in the administration of said medications, to instruct the patient of the action of the drug, as well as the expected side-effects and possible adverse effects of the drug. Betteridge, et.al., (1993, p. 359) discusses the management of hyperlipidaemia based on the guidelines as set by the British Hyperlipidaemia Association. The authors discussed that there is much evidence pointing to the fact that the identification and treatment of dyslipidaemia will likely decrease the risk of developing premature CHD (before the age of 65). Diagnosing the cause of increased plasma lipid levels will assist in ensuring that appropriate decisions will be made in relation to management and treatment. The essence of treatment is nutritional counselling and much focus to the major risk factors of CHD, most especially smoking and high blood pressure (Betteridge, et.al., 1993, p. 359). For some patients with severe hyperlipidaemia, drug therapy may be needed. The fitting drugs have to be based on a specific lipid abnormality before it can be treated. In general however, patients having clinical vascular diseases have to be treated aggressively as compared to those needed primary prevention. This study pointed out that more studies have to be undertaken in order to establish individual risks and to ensure proper therapy. Genetic factors, changes in the lipoproteins and other coagulation and thrombolytic factors are important in individual risk assessment (Betteridge, et.al., 1993, p. 359). This study establishes the importance of adequate assessment techniques in the management of lipid or cholesterol levels in at-risk patients. This study also emphasized on nutritional counselling which was also pointed out by earlier studies as an important part of cholesterol management. Authors Scholte op Reimer, and colleagues (2002, p. 87) sought to establish whether guidelines on patient education in risk factor management are continued in clinical practice; it also sought to evaluate the contribution of nursing in risk factor management as seen by patients with CHD. This study covered three Dutch hospitals with consecutive patients for acute myocardial infarction. This study revealed that for some of the following individuals: smokers, overweight patients, patients with hypertension, high cholesterol, and those with sedentary lifestyles, information on the dangers of CHD and the risks of the disease on them were shared by the physician and nurses. Some of them were informed by their nurses and some by their physicians (Scholte op Reimer, et.al., 2002, p. 87). In effect, this study established that many CHD patients with CHD were not properly informed by their nurses and their physicians about the risk factors related to their disease. They do not remember having received information from their physicians and nurses about the management of the risk factors of CHD. This study clearly indicates some gaps in the management of CHD and the health education process. As perceived by patients, they viewed the contribution of nurses as compared to the physicians in the management of CHD is minimal (Scholte op Reimer, et.al., 2002, p. 87). In effect, if the management of risks is seen as a main function of nurses, the current nursing activities in this regard must be considered within an improved organization standard. This study presents a challenge to the nursing practice, especially in terms of health education in the face-to-face setting with the patient. There is a need for the nurse to display more contributory actions in the management of CHD and in imparting information to the patient at risk for developing CHD and those who are already suffering from the disease. McHugh, et.al., (2001, p. 317) also discussed the efficacy of a nurse-led shared care programme with the end goal of improving coronary heart disease factor levels and general health status and also to minimize depression among patients about to undergo CABG. This study covered about 98 consecutive patients who were on the waiting list for elective CABG at the Glasgow Royal Infirmary University NHS Trust. Patients were either assigned to the usual case or the nurse led intervention programme (McHugh, et.al., 2001, p. 317). For the shared care programme, health education and motivational interviews were carried out with the patient on a monthly basis. The programme was implemented in the patients’ homes by the community-based cardiac liaison nurse and b the general practice nurse (McHugh, et.al., 2001, p. 317). The patients were assessed based on their smoking status, obesity, physical activity, anxiety, depression, plasma cholesterol, and alcohol intake. After going through the intervention process, the authors were able to establish that in the nurse-led programme, as compared to those receiving usual patient care were more inclined to stop smoking and to lose weight. Their BP also decreased to a greater degree as compared to those in the control group (McHugh, et.al., 2001, p. 317). In effect, this study established that a nurse-led intervention was more effective in improving care for CHD patients. This study was able to accurately and clear establish important results in relation to the management of cholesterol and CHD. A nurse initiated and managed process showed much promise in addressing important risks and issues in management of CHD. Woollard, et.al. (2003, p. 131) sought to evaluate the thesis that practice-based health-promotion programmes by nurse-counsellors would be able to reduce cardiovascular risk factors, especially among patients with an increased risk for CHD. This study covered 591 eligible patients from Australia who agreed to be randomized to one of three groups. In the low intervention group, monthly contacts for a year following by one face-to-face counselling session was implemented; in the high intervention, individual face-to-face counselling was implemented for over a year, monthly for up to 1 hour; and the controls group received usual care only. Based on the results, no significant results in the three groups were seen (Woollard, et.al., 2003, p. 131). Cholesterol levels were not significantly different for the three groups. These results indicate that the presence of nurse-counsellors do not necessarily improve cholesterol levels and decrease CHD risks; the important consideration is still on physician-based interventions (Woollard, et.al., 2003, p. 131). These results seem to contradict the earlier studies which indicate support for nurse-led interventions. Further studies in this direction need to be undertaken in order to establish more definitive results. In the study by Vale, et.al., (2002, p. 245) the authors discussed about coaching patients with coronary heart disease in order to achieve target cholesterol levels. This study sought to test coaching as a technique in assisting patients in gaining their target cholesterol levels. This study assigned randomly chosen patients to receive either coaching intervention or usual medical care. Outcome measures included testing for fasting serum total cholesterol, serum triglyceride and calculated low-density lipoprotein cholesterol levels measured at 6 months after randomization. The study revealed that after 6 months, the serum triglyceride and LDL-C levels of patients were much lower in the coaching intervention groups than in the usual care group (Vale, et.al., 2002, p. 245). In effect, the authors set forth that coaching is an effective intervention in the management of cholesterol levels as it helps guide the patients in their diet and nutrition, ensuring that they would be able to secure better health outcomes in the prevention and management of CHD. Aish and Eisenberg (1996, p. 259) sought to evaluate the impact of nursing care according to Orem’s nursing theory on nutritional self-care of myocardial infarction patients. This efficacy was assessed as a condition which would motivate changes in a patient’s behavior. About 104 respondents were randomly chosen to participate and were assigned to treatment and control groups. Nursing interventions were applied during the first 6 weeks of hospital discharge and proved to be effective in providing support for healthy and low-fat eating behaviour. The authors concluded that nursing care was able to influence the patient’s self care and impacted on patient’s healthy eating (Aish and Eisenberg, 1996, p. 259). The Orem model, in effect, proved to be helpful in providing guidelines in the planning of effective care. This study provides important details on the application of nursing interventions via healthy habits and nutrition in the management of patient cholesterol. The results of this study very much support the existing literature and studies known about cholesterol in the management of CHD. In the paper by Roderick, et.al., (1997, p. 7), the authors set out compare the efficacy of a structured dietary advice by practice nurses with the standard health education in changing a patient’s serum cholesterol, weight, and diet. This was carried out as a randomized controlled trial covering eight general practices in England and Wales assigned within matched geographical pairs to dietary advice or usual care. For the dietary advice group, the patients were given dietary advice from specially trained nurses, with the advice being based on negotiated change standards and strengthened at follow-up (Roderick, et.al., 1997, p. 7). In the usual care group, the subjects were given standard health education tools only. About 956 respondents were included in the study. The serum cholesterol in the dietary advice group was significantly lower as compared to the usual practices group. There was also a decrease in weight in the dietary advice group as compared to the usual practice group; total and saturated fat levels in the saturated group was also lower in the dietary advice group (Roderick, et.al., 1997, p. 7). The authors concluded that applying standard health education alone had no significant effect on reduction of coronary heart disease risks – in this case, in lowering serum cholesterol levels. Instead, applying a dietary advice intervention with the assistance of nurses can decrease weight, serum cholesterol levels, and overall risk of coronary heart disease among patients at risk and those already diagnosed with CHD (Roderick, et.al., 1997, p. 7). This study was able to establish the importance of health education and dietary advice in lowering cholesterol levels and how nurses can assist in the process. The research presents important details on the role of nurses in decreasing weight and in playing an active role in the management of serum cholesterol levels in patients at risk for CHD. Conclusion This study portrays the different means by which cholesterol can be decreased and how such decrease can assist in eliminating the risk of coronary heart disease. Coronary heart disease is one of the major causes of mortality in the global and in the national population. Its major caused include low levels of physical activity, high cholesterol levels, smoking, unhealthy diets, and excessive alcohol intake. Nurses can assist in decreasing such risk by assisting in the decrease of cholesterol levels. Such cholesterol levels can be decreased through the implementation of adjustments in diet via low fat and low cholesterol foods; the implementation of exercise and increased physical activity; the elimination of smoking; and through the use of statins. The role of the nurse is to assist and to educate the at-risk patients in these interventions, helping ensure that the patient would understand and would apply the changes in his life with the hope of reducing cholesterol levels and reducing his risk for coronary heart disease. Works Cited Aish, A. & Isenberg, M. (1996), Effects of Orem-based nursing intervention on nutritional self-care of myocardial infarction patients, hr. J. Nurs. Stud., volume 33(3), pp. 259-270. Allen, J., Blumenthal, R., Margolis, S., Young, D., Miller, E., & Kelly, K. (2002), Nurse case management of hypercholesterolemia in patients with coronary heart disease: Results of a randomized clinical trial, American Heart Journal, volume 144(4), pp. 678-686 Ammerman, A., Lindquist, C., Lohr, K., & Hersey, J. (2002), The Efficacy of Behavioral Interventions to Modify Dietary Fat and Fruit and Vegetable Intake: A Review of the Evidence, Preventive Medicine, volume 35(1), pp. 25-41 Betteridge, D., Dodson, P., Durrington, P., Hughes, E., Laker, M., Nicholls, D., Rees, J., Seymour, J., Thompson, G., & Winder, A. (1993), Management of hyperlipidaemia: guidelines of the British Hyperlipidaemia Association, Postgrad Med J, volume 69: pp. 359-369 British Heart Foundation, (2011), Coronary heart disease statistics in Wales, February 2011, London: Greater London House Cade J., & O'Connell S. (1991), Management of weight problems and obesity: knowledge, attitudes and current practice of general practitioners, Br J Gen Pract, volume 41: pp. 147–150. Campbell, N., Ritchie, L., Thain, J., Deans, H., Rawles, J., Squair, J., (1998), Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care, Heart, volume 80: pp. 447–452 Hiddink G., & Hautvast J. (1995), Nutrition guidance by primary care physicians: perceived barriers and low involvement, Eur J Clin Nutr, volume 49: pp. 842–851. Ienatsch, G. (1999), Knowledge, attitudes, treatment practices, and health behaviors of nurses regarding blood cholesterol, J Continuing Educ Nurs, volume 30: pp. 13–19. Johnston A. (1995), Health related-behaviour change, in Sharp I (ed.), Coronary Heart Disease Prevention in Primary Care: The Way Forward, Report of an expert meeting, National Heart Forum, London: HMSO, pp. 36–47. Kushner R. (1995), Barriers to providing nutrition counselling by physicians: a survey of primary care practitioners, Prev Med, volume 24: pp. 546–552. LeTouze S, Calman M. (1996), The banding scheme for health promotion in general practice. Health Trends, volume 28: p. 3. Levine B. (1993), A national survey of attitudes and practices of primary-care physicians relating to nutrition: strategies for enhancing the use of nutrition in medical practice, Am J Clin Nutr, volume 57: pp. 115–119. McHugh, F., Lindsay, G., Hanlon, P., Hutton, M., Brown, C., Morrison, D., & Wheatle, J. (2001), Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: a randomised controlled trial, Heart, volume 86: pp. 317–323 McPherson K. (1995), A population approach to interventions in primary care: assessing the evidence, in Sharp I. (ed.), Coronary Heart Disease Prevention in Primary Care: The Way Forward, Report of an expert meeting, National Heart Forum. London: HMSO, pp. 27–36 Moore, H., Adamson, A., Gill, T., & Waine, C. (1999), Nutrition and the health care agenda: a primary care perspective, Family Practice, volume 17 (2): pp. 197-202. National Heart Lung and Blood Institute, (n.d), How Is Coronary Heart Disease Treated?, viewed 11 June 2011 from http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_Treatments.html National Health Services (1998), Effective Health Care, viewed 11 June 2011 from http://www.york.ac.uk/inst/crd/EHC/ehc41.pdf Roderick, P., Ruddock, V., Hunt, P., Miller, G. (1997), A randomized trial to evaluate the effectiveness of dietary advice by practice nurses in lowering diet-related coronary heart disease risk, British Journal of General Practice, volume 47, pp. 7-11. Singh, V. (2010), Coronary Heart Disease, eMedicine Health, viewed 11 June 2011 from http://www.emedicinehealth.com/coronary_heart_disease/article_em.htm Scholte de Reimer, W., Jansen, C., de Swart, E., Boersma, E., Simoons, M., & Deckers, J. (2002), Contribution of nursing to risk factor management as perceived by patients with established coronary heart disease, European Journal of Cardiovascular Nursingv, volume 1, pp. 87–94 Scottish Inter Collegiate Guidelines Network (1996), Obesity in Scotland. Integrating Prevention with Weight Management. SIGN (pub) No. 8. Edinburgh Valea, M., Jelinka, M., Best, J., Santamaria, J. (2002), Coaching patients with coronary heart disease to achieve the target cholesterol: A method to bridge the gap between evidence-based medicine and the “real world”—randomized controlled trial, Journal of Clinical Epidemiology, volume 55, pp. 245–252 Woollarda, J., Burkea, V., Beilina, L., Verheijdenb, M., & Bulsarab, M., (2003), Effects of a General Practice-Based Intervention on Diet, Body Mass Index and Blood Lipids in Patients at Cardiovascular Risk, European Journal of Cardiovascular Prevention & Rehabilitation, volume 10(1), pp. 31-40 World Health Organization (2011), The Atlas of Heart Disease and Stroke, viewed 11 June 2011 from http://www.who.int/cardiovascular_diseases/resources/atlas/en/ Read More