Chapter Two Conceptual framework 2.1 Introduction
Transcript of Chapter Two Conceptual framework 2.1 Introduction
Chapter Two Conceptual framework
2.1 Introduction
In this chapter key concepts, as identified in Chapter One, namely the patient
(who suffers from CAD and underwent CABG surgery, PTCA or insertion of a
coronary stent), lifestyle adaptations, CAD and risk factors for CAD are
discussed.
2.2 The patient The patient in this study suffers from CAD. CAD is an insidious, progressive
disease that results in coronary arterial narrowing or complete occlusion. There
are numerous causes of CAD but atherosclerosis is the most prevalent.
Fatty streaks occur within the arteries during childhood, but symptoms, such as
angina, only occur when the atherosclerotic plaque occludes 75% of the vessel
lumen, usually in late middle age. Epidemiologic data collected during the past 50
years have demonstrated an association between the presence of specific risk
factors and the development of CAD. One of the most important epidemiologic
studies is the Framingham Heart Study, which began in 1948 and continues
today with third and fourth generations of participants. Blood cholesterol,
smoking, activity levels, blood pressure and electrocardiographic results are
checked on a regular basis for participants in this study. As a result, specific risk
factors and lifestyle habits have been identified as being associated with an
increased probability for the development of atherosclerosis. These are referred
to as CAD risk factors (Urden, Stacey & Lough, 2002:395; Clochesy et
al.,1996:336-337). Risk factors for CAD are discussed in 2.3.
A patient, suffering from CAD, who underwent CABG surgery, PTCA or insertion
of a coronary stent, is regarded as a holistic being and not just the physical but
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also spiritual concept is taken in consideration. The patient functions in an
integrated, interactive manner with the environment, and the environment in turn
influence the way patients regard their illness, and the meaning to their lives of
having these procedures done. Human health behaviour is influenced by the
internal and external environment. To ensure commitment and maintenance in
the type of lifestyle adaptations and health behaviour essential for cardiac
rehabilitation this holistic nature of the patient, integrated in the external and
internal world, should be kept in mind. The process of rehabilitation and lifestyle
adaptations is such an extensive step that it involves all dimensions of the patient
as a holistic being. An important part of the external environment is the family. It
is therefore crucial to involve them in the rehabilitation process to improve the
patient’s willingness to adapt their lifestyle and maintenance of this lifestyle
(Rand Afrikaans University, 2002:2-8).
The patient’s body includes several anatomic structures and physiological
processes. In this case the body suffers from CAD and is thus not a normal
healthy body. In order to ensure a long and healthy life the patient should
maintain a healthy lifestyle to ensure optimum health. Patients’ motivation to
maintain a healthy lifestyle is influenced by their instinct to survive. If patients feel
or understand that to behave in certain ways can or will be potentially dangerous
to their bodies they might not act in such a manner. They might rather behave in
a way that will be beneficial to their health and will ensure a long and healthy life.
Patients with CAD should for instance stop smoking, eat a healthy diet, exercise
and take their medication as prescribed, among other things (Bridgeman,
1988:95-129; Friedman, 1990:57-90).
Human behaviour is complex and difficult to predict. Decisions are frequently a
response to chance events and apparently random thought processes. The
Health Belief Model (Kozier, Erb, Blais & Wilkinson,1995:27). is one of the
numerous models of behavioural decision-making developed to try and provide a
basic understanding of at least some of the processes underlying human
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behaviour. This model suggests that the likelihood of individuals engaging in a
particular type of health-related behaviour is a function of their perceptions of the
relationship between that behaviour and an illness, their perceived susceptibility
to that illness, its seriousness and the particular costs and benefits involved in
engaging in any type of behaviour. The costs may be social, financial and/or
physical. Factors influencing adherence to anti-hypertension medication, for
example, may include the perceived health benefits (often not immediately
obvious), the hassle of remembering to take medication and concerns about
side-effects and consequences of long-term use of medication. A final influence
on behaving in a specific manner is the presence of cues to action. These may
take the form of a reminder to engage in some form of action, including such
things as health checks, reminders from doctors on routine visits, and so on
(Kozier et al. 1995:250-251).
The psyche which refers to all experiences and also behaviour in the individual,
includes intellectual, emotional and will processes. Intellect refers to the capacity
and quality of psychological processes of association, analysis, judgement and
comprehension to which an individual is capable. Emotion refers to the
instrument of the patient’s dislikes and preferences. Will is the instrument of the
individual’s decision-making and is indicative of the individual’s capacity to make
choices. It expresses the “want to” or “not want to” and is a decision made
without external pressure. To undergo the necessary lifestyle adaptations,
patients with CAD, who underwent CABG surgery, PTCA or insertion of a
coronary stent, have to understand and comprehend the changes that are to be
made and need to have the will, intellect and emotional readiness to continue
with these changes for the rest of their lives (Rand Afrikaans University, 2002:2-
5).
According to Friedman (1991:21-29) personality, which is part of a person’s
psyche, is influenced by the effects of stress on the body in view of the fact that
the body is from childhood to adulthood exposed to different physical reactions
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on stress. Stress is influenced by the individual’s perception and interpretation of
a situation, how harmful it is and his ability/willingness to handle the situation.
Stress has different physiological reactions on the body, such as tiredness,
hypertension and suppression of the immune system. It also causes some
people to smoke more, use more alcohol, exercise less, eat unhealthily etc. Most
of the above-mentioned reactions will have a negative effect on someone who
was just diagnosed with CAD and underwent CABG surgery, PTCA or insertion
of a coronary stent. It is therefore important to understand how stress influences
the body and know how to cope with it in a more productive way (Argyle,
1992:231-236; Kagan in Levi, 1981:8-11; Sutherland & Cooper, 1990:1-224).
Douglas (1992:54-64) emphasizes the inclusion of stress management and
behaviour modifications for type A personalities. The type of lifestyle that these
individuals live, make them more susceptible to CAD. Krantz and Blumenthal
(1987:8) state type A individuals as hard-driving, competitive, aggressive and
impatient. In retrospective and prospective studies type A behaviour patterns are
associated with over twice the rate of new coronary events, compared to the type
B behaviour patterns. If a person is genetically inclined to be more aggressive
and has a dominant temperament his energy should rather be redirected so that
these characteristics influence his illness in a positive rather than negative way.
He can for example learn how to use his anger to motivate him to exercise
(Friedman, 1990:38-58; Friedman, 1991:22).
People are brought up with certain values and important influence of these
values on their attitude has over the years been accepted by different
researchers (Botha, 1972:15-23; Hattingh, 1991:93-95; Kirchenbaum, 1977:8-9;
Smith, 1977:240-243; Straughan, 1993:49). Values contribute strongly to the
internal environment of a patient. According to Smith (1977:241) values are
determinants of virtually all kinds of behaviour that could be called social
behaviour. Values will influence the way patients adapt their lifestyle. Hattingh
(1991:39) describes values as the preference attitude, moral convictions,
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principles and standards of a group or individual. The values that a patient have
and the principles and standards that are regarded important in the group that
they find themselves in will have a great influence on how they perceive CAD and
undergoing CABG surgery, PTCA or insertion of a coronary stent, and how they
will adapt their lifestyle to it. It will determine whether they feel it is important to
change their lifestyle or not.
Taking responsibility for, and adopting the right attitude towards illness and the
adaptations that have to be undertaken in his life, is essential for the patient with
CAD who underwent CABG surgery, PTCA or insertion of a coronary stent.
Patients who do not take responsibility for their condition and who do not adhere
to the necessary changes put their own health at risk, and are in danger of going
through the whole ordeal again. Douglas (1992:75) states that it might seem
reasonable to presume that if people actively seek help from a physician, they
will follow the instructions or advice given to them. However, this would be a rash
presumption and one that is not supported by the available evidence. The
commonly reported statistic is that around fifty percent of individuals drop out of
such programmes, or do not fulfil anything close to their requirements (Douglas
1992:75).
It seems to be in our nature as human beings to want to break the rules. It is
jokingly said that the first recorded incidence of non-compliance occurred when
Eve defied God’s prescription in the Garden of Eden and ate an apple from the
forbidden tree.
The external environment points at situations outside the individual which have
an influence on his life. This influences the way patients behave, respond and
maintain their lifestyle. All meaningful stimuli or objects, in the individual’s
external environment, are referred to as the physical environment. Stimuli refer to
any aspect which leads to direct or indirect adaptation in behaviour. Object is any
part of the environment of which the individual is aware and to which he reacts
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with a certain attitude. Aspects of the physical environment which have an effect
on health behaviour include location, climate, geography and income. How
convenient or inconvenient it is for patients to comply with adaptations, for
example exercise, in terms of climate, geography and location will influence their
adaptability and compliance towards these changes. It may not be worthwhile for
a farmer to travel 200 km to be able to participate in exercises in a gym, but to
walk 20 minutes on his farmland can be much more convenient. Aspects such as
these should be kept in mind when discussing lifestyle adaptations with a patient
(Rand Afrikaans University, 2002:2).
The most important part of the external environment is the social aspect. This
refers to all persons or meaningful others (family, next of kin, partners) in the
individual’s external environment. Because patients are social beings it is
impossible for them to function in isolation. Therefore the whole family, as part of
the external environment, should be involved in the rehabilitation program. The
social support of family, friends, colleagues and partners can make an individual
feel accepted and may encourage behaviour that improves his health. It may also
improve compliance. If patients’ families “join in” the new healthy lifestyle they will
encourage the patients in their effort to adapt their lifestyle. As Wright and
Leahey (2000:13) explains: “Nursing has a commitment and obligation to involve
families in healthcare” Cohen, Mock and Rinqvist (1981:233) support this by
stating that some determinants of successful long-term outcome, as reflected by
return to functional levels and lifestyle seen prior to infarction, include the family
structure and personal relationships, attitudes of personal physicians and
employers, and social support within the community. (Argyle, 1992:237-240;
Friedman, 1990:97-115; Friedman, 1991:25-27).
The spiritual environment, which is also part of the external environment,
includes meaningful spiritual elements or events in the individual’s external
environment including values, convictions, norms, ethical principles, meaning of
life as well as relationships with others (Rand Afrikaans University, 2002:2).
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“What people believe about health matters has an important effect on what they
do about their health; namely their health behaviour” (Argyle, 1992:243) If people
are misinformed they might interpret symptoms incorrectly or believe that illness
is some kind of punishment. Several philosophers claim that contemplation about
the seriousness of disease, with the belief that the possibility exists to contract
the disease, as well as the fact that some types of health behaviour will be
successful in preventing the disease will motivate people to adopt a certain type
of health behaviour. Some people see illness as a challenge and this motivates
them even more to reveal a certain type of health behaviour (Bandura,
1977:1977; Janz & Becker, 1984:1-47; Fishbein & Ajzen, 1975:223).
It is for this reason important that patients’ background, values and beliefs should
be kept in mind when approaching them to adapt their lifestyle. This will ensure
better compliance and understanding of what is expected of them. Patients who
are at risk to develop CAD are discussed next.
2.3 Risk factors for coronary artery disease It is encouraging to know that public awareness of risk factors contributing to the
development of CAD is increasing. However, as people are living longer than
before and cardiovascular disease is most prevalent in elderly persons, CAD
continues to be a worldwide public health problem (Urden et al. 2002:395).
Factors that increase the risk of developing CAD include age, gender, genetic
factors (family history), hyperlipidaemia, diet high in saturated
fat/cholesterol/calories, obesity, impaired glucose tolerance, physical inactivity,
homocystein, cigarette smoking, oral contraceptives and hypertension (Urden et
al. 2002:395-397; Lindsay & Gaw, 2004:33; Connaughton, 2001:87).
Urden et al. (2002:395-397) further divide risk factors into modifiable and non-
modifiable factors. Risk factors for CAD are discussed under these headings next
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2.3.1 Non-modifiable risk factors Non-modifiable risk factors include factors that cannot be changed such as age,
gender and family history.
2.3.1.1 Age
CAD increases with age in both men and women. This is due to the fact that the
arteries also become older and more rigid, making them more susceptible for
atherosclerosis and increasing the risk of CAD. It is rare in the first two decades
of life, becoming more prevalent after the age of 30 (Lindsay & Gaw, 2004:33;
Urden et al. 2002: 395).
2.3.1.2 Gender CAD symptoms occur approximately 10 years later in women than in men.
Before the age of 60 years CAD is much more marked in males than females.
Beyond 60 years of age, CAD in females increases at an accelerated rate and
after the seventh decade the rate approaches that in males. Epidemiological
studies reveal that women are relatively protected against CAD while pre-
menopausal and that this protection is less evident in the postmenopausal years
(Urden et al. 2002:395; Lindsay & Gaw, 2004:33-34).
2.3.1.3 Family history A significant family history of CAD is considered to be present if the disease is
diagnosed in first-degree relatives before the age of 60 years. The clustering of
factors such as hypertension, diabetes and obesity is also common. This fact
suggests a genetic predisposition to the development of CAD (Urden et al.
2002:395-396; Lindsay & Gaw, 2004:34).
2.3.2 Modifiable risk factors Modifiable risk factors are factors that can be changed by means of adopting a
healthier lifestyle.
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2.3.2.1 Elevated serum lipids Hyperlipidaemia or hypercholesterolaemia (raised levels of blood lipids) is a
leading factor responsible for severe atherosclerosis, which in its part leads to
CAD. This can be caused by both genetic and environmental factors and, most
importantly, through interactions between genetic make-up and lifestyle factors
such as diet.
Cholesterol is subdivided into the following specific proteins:
1. High-density lipoprotein cholesterol (HDL-C) which is associated with
‘good’ cholesterol
2. Low-density lipoprotein cholesterol (LDL-C) which is associated with
‘bad’ cholesterol
3. Very-low density lipoprotein cholesterol (VLDL-C) which is associated
with ‘very bad ‘ cholesterol
(Urden et al. 2002:398; Premitt & Kramer, 2005:113)
High levels of LDL cholesterol have been associated with atherosclerosis and
CAD. In contrast, high levels of HDL cholesterol have been shown to reduce
some of the harmful effects of LDL and VLDL cholesterol.
HDL cholesterol moves easily through the blood and is actually beneficial to the
body. It is stable and does not adhere to artery walls. It helps to prevent heart
disease by carrying cholesterol away from the arteries back to the liver, where
the process of its removal from the body begins. LDL and VLDL cholesterol
contains more fat and less protein than HDL. LDL and VLDL cholesterol is
‘unstable’ and tends to disintegrate. Rather then being removed from the body by
the liver, it adheres to and can damage the cells lining the inside of artery walls,
causing atherosclerosis and CAD (Premitt and Kramer. 2005).
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Table 2.1 Levels for HDL and LDL cholesterol considered as normal by doctors and hospitals in Gauteng
Pathologist Ampath Lancet
Cholesterol 3.0 - 5.2 mmol/L 3.21 – 5.2 mmol/L
HDL cholesterol 0.9 – 1.6 mmol/L > 1.0 mmol/L
LDL Cholesterol 2.0 – 3.4 mmol/L < 3.4 mmol/L
(Lancet & Ampath Pathologists, 2005)
2.3.2.2 High fat diet There are three major types of fat – saturated, polyunsaturated and mono-
unsaturated that can be taken in through diet:
• Saturated fats are mainly found in foods of animal origin e.g. red meat,
poultry (skin), eggs, full cream milk and full cream dairy products, take-
away foods and processed meats. Vegetable sources of saturated fat are
palm and coconut oils and fats, often used in commercial snacks and
baked goods.
• Polyunsaturated fats are found in vegetable oils such as sunflower oil,
fish and polyunsaturated margarines.
• Mono-unsaturated fats are found mainly in plant foods e.g. olive oil,
canola oil, nuts and avocado. It is also found in mono-unsaturated
margarines.
Polyunsaturated fats and mono-unsaturated fats are less likely to promote
heart disease and should therefore be used in preference to saturated fats. They
all, however, have the same energy content. It is emphasised that a patient
should know to cut out the “bad” fats (saturated fats) or at least cut down to
smaller amounts. They are encouraged to rather use “good” fats
(polyunsaturated and mono-unsaturated fats). Fats are however very
important to the body and should not be cut out of the diet completely.
(Niewenhuyzen & Muller, 2005:1).
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Diets that are high in saturated fats and oils greatly increase the risk of the
following:
• Atherosclerosis, as early as childhood
• Hypertension
• Obesity (defined as a body mass index of higher than 30), which can
place tremendous strain and additional workload on the heart. (The
formula to calculate BMI to discussed under 2.3.2.3. Obesity.)
(Sacher 2005)
2.3.2.3 Obesity Obesity is a condition in which a person has a body mass index of 30 or higher. It
is the second largest leading cause of preventable death, contributing to serious
health problems such as cancer, heart disease (CAD) and stroke. About 40% of
South Africans are obese. Obesity is often associated with sedentary lifestyle. It
also increases susceptibility to the development of other risk factors, such as
hypertension, diabetes type two and hyperlipidaemia. Research has shown that
the distribution pattern of fat on the body is now considered an indicator of CAD
risk factors. The more weight carried in the abdominal area, producing a large
waist, the greater the risk of developing CAD. Excess abdominal adiposity
indicates additional fat around the abdominal organs, including the heart, as
compared to individuals who have a smaller waist and larger hips (Urden et al.
2002:397; Roitman, La Fonteine & Drimmer, 1998:118; Lindsay & Gaw,
2004:35).
There are two basic ways in which obesity increases the risk of heart disease.
Firstly, it can indirectly contribute to heart disease by causing changes in the
body that increase the risk of heart disease. These changes include the following:
• Hypercholesterolemia
• Elevated triglycerides
• Lowered levels of LDL cholesterol
• Hypertension
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• Increased risk of type two diabetes
The second way is by causing unhealthy changes in the heart itself. As the heart
struggles to compensate for extra body mass through which it must circulate
blood, the left ventricle can become hypertrophic. This can eventually lead to
heart failure.
Body mass index is a tool by which one uses weight and height to determine if
one is underweight, overweight or obese.
BMI is calculated as follows:
[ weight (kilograms)] / [height (metres)2].
Table 2.2 Body mass index
Body mass index
Classification Risk of developing CAD, type two diabetes and hypertension
< 18.5 Underweight Low
18.5 – 24.9 Normal Low
25.0 – 29.9 Overweight Increased
30.0 – 34.9 Obese High
35.0 – 39.9 Very obese Very high
> 40 Extremely
obese
Extremely high
(D’Agostino 2005).
2.3.2.4 Diabetes mellitus Diabetes mellitus is a major public health problem reaching epidemic proportions.
Type two diabetes mellitus increases the risk of all manifestations of vascular
disease, including CAD. CAD accounts for the majority of type two diabetes
mellitus-related morbidity and mortality. As much as 75% of deaths in people with
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type two diabetes mellitus will be from cardiovascular disease (Urden et al.
2002:851-853; Clochesy et al. 1996:1101; Lindsay & Gaw, 2004:313-314).
Insulin resistance is now known to be the major culprit in the conglomeration of
cardiovascular risk factors collectively termed the ‘metabolic syndrome’. It
includes hyperinsulinaemia, insulin resistance, obesity, hypertension,
hyperglyceridaemia and reduced HDL cholesterol concentration. In addition to
the above-mentioned risk factors, other thrombotic risk factors correlating with
insulin resistance include elevated levels of plasminogen activator inhibitor I (PAI-
I), factor VII and fibrinogen. Hyperinsulinaemia and insulin resistance thus help
promote the development of atheromatous plaque. In association with a
prothrombin antifibrinolytic state it promotes cardiovascular disease (Clochesy et
al. 1996:1141; Urden et al. 2002:852; Lindsay & Gaw, 2004:313-314;
www.Health24.co.za, 2005).
2.3.2.5 Physical inactivity Research shows that people who get regular exercise are less likely to have
heart attacks or die from heart disease. Exercise has dramatic benefits for the
heart and blood vessels, which include the following:
• Decreases oxygen demand on the heart
• Strengthens the myocardium
• Reduces levels of triglycerides, LDL cholesterol and homocystein
• Increases HDL cholesterol
• Lowers blood pressure
• Stimulates the process of angiogenesis, by which the body creates
collateral veins to bypass clogged or diseased blood vessels
• Helps to keep blood vessels clear of clots and build-up of plaque
• Prevents obesity
• Prevents the process of atherosclerosis. (Research done among identical
female twins provided results that proved a direct link between
accumulation of fat in the abdominal region and arterial stiffness. The
conclusion was drawn that even women with a genetic predisposition to
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arterial stiffness can reduce this risk, if they engage in regular physical
activity.)
• Decreases the risk of type two diabetes mellitus
(www.Health24.co.za, 2005; Urden et al. 2002:397; Lindsay & Gaw, 2004:34-
35).
2.3.2.6 Homocystein Homocystein is an amino acid produced as a normal by-product in the
breakdown of methionine. Methionine is an essential amino acid acquired mostly
from eating red meat. Moderate levels of homocystein are helpful for growth and
maintenance of healthy tissue. However, excessive homocystein levels have
been shown to correlate closely with various types of vascular damage and heart
disease. With a proper nutritional balance (more fruit, vegetables and poultry and
less red meat), homocystein is either converted back into methionine (an
essential amino-acid) or into simple amino-acids (cystein and cystathionine)
which are easily flushed from the body via urine. This conversion of homocystein
cannot occur unless the body has enough of three B-Vitamins: vitamin B6,
vitamin B12 and folic acid. Research seems clear that high levels of
homocystein can be prevented or treated by increasing the intake of Vitamin B
(www.Health24.co.za).
Many studies have found a link between high homocystein levels and heart
disease. Research on this topic began in 1968, when Kilmer McCully of Harvard
Medical School investigated the early deaths of children with a rare genetic
disorder, homocystinuria, involving high levels of homocystein. He was surprised
to discover that these children had severe atherosclerosis and often died from
heart attacks or strokes, which is extremely rare among children. Thereafter
numerous studies have been done and have found links between high
homocystein levels and atherosclerosis. (www.Health24.co.za).
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Table 2.3 Levels of homocystein considered normal by doctors and hospitals in Gauteng
Pathologists Ampath Lancet
Homocystein levels
5.0 – 15.0
umol/L
4.5 – 12.4 umol/L
(Lancet & Ampath Pathologists, 2005)
2.3.2.7 Smoking Smoking is the chief avoidable cause of premature death and ill health in the
world. The main diseases caused by smoking are CAD and lung cancer. The
greater the number of cigarettes smoked per day, the greater the risk of CAD.
Cigarette smoking alters serum lipid levels unfavourably, decreasing HDL
cholesterol levels and increasing LDL cholesterol levels. Smoking rapidly
increases the heart rate and constricts blood vessels, while simultaneously
reducing the blood’s capacity to carry oxygen. Smoking is associated with both
aspects of atherosclerosis. It promotes the development of artherosclerotic
lesions, thus creating sites susceptible to blockage, and promotes the occurrence
of triggering events, such as adhesion of platelets to these lesions, which lead to
blockage (Lindsay & Gaw, 2004:135; Urden et al. 2002:397). A multinational
study done in New York on 5000 patients indicated that smokers who have had a
heart attack at a relatively young age run the same risk of having a stroke,
another heart attack or dying as do their older counterparts who do not smoke
(Douglas, 2004:4).
2.3.2.8 Oral contraceptives The risk of CAD in women is increased by oral contraceptives. These drugs alter
blood coagulation, platelet function and fibrinolytic activity. It may adversely affect
the integrity of vascular endothelium, resulting in atherosclerosis and CAD. The
risk is further increased by cigarette smoking or the presence of other risk
factors. Women already at risk of developing CAD are encouraged to use other
forms of contraception (Urden et al. 2002:397).
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Oral contraceptives containing estrogens are the most common cause of
hypertension in women. Though initially mild, hypertension usually increases with
oral contraceptive use over time. Concomitant use of cigarettes and alcohol
increases the risk of cardiovascular morbidity in women (Clochesy et al.
1996:525).
2.3.2.9 Hypertension
Hypertension is the elevation of systolic or diastolic blood pressure in the
vascular system. The higher the pressure, the higher the risk of damage to the
arteries, which lead to atherosclerosis and a greater risk of CAD. In
epidemiological studies, there is a close relationship between blood pressure
(systolic and diastolic) and the risk of stroke, CAD and other cardiovascular
events. Hypertension has many predisposing factors that overlap with CAD risk
factors including older age, high dietary sodium intake, obesity, sedentary
lifestyle, excessive alcohol consumption etc. (Urden et al. 2002:397; Lindsay &
Gaw, 2004:77; Clochesy et al. 1996:367).
Table 2.4 Blood pressure classification
Category Systolic (mmHg)
Diastolic (mmHg)
Normal BP
Normal < 130 < 85
High-Normal 130 – 139 85 – 89
Hypertension
Stage 1 140 – 149 90 – 99
Stage 2 160 – 179 100 – 109
Stage 3 >180 > 110
(Urden et al. 2002:433)
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2.3.2.10 Stress and anger Type A behaviour patterns, including time-urgency, hostility, anger and anxiety
have also been associated with the development of CAD. The type of lifestyle
that these individuals live make them more susceptible to CAD. Krantz &
Blumenthal (1987:8) defines type A individuals as hard-driving, competitive,
aggressive and impatient. In retrospective and prospective studies type A
behaviour patterns are associated with over twice the rate of new coronary
events, compared to type B behaviour patterns. Anger causes tachycardia,
hypertension and narrowing of the arteries. This results in blood being more
viscous and increases the risk of blood clots (Urden et al. 2002:397;
www.health24.co.za, 2005).
How stress and behaviour influence the development of CAD is not understood
well. The possible mechanisms by which stress exerts its negative effects on the
risk of CAD have been cited as an increase in blood pressure and heart rate,
increased plasma cholesterol levels and adverse effects on coagulation and
fibrinolysis (Lindsay & Gaw, 2004:35-36; Urden et al. 2002:397).
2.3.2.11 Alcohol A strong inverse relationship exists between the moderate consumption of
alcohol (30g alcohol/day: 1-2 drinks for women, 2-3 drinks for men) and the
incidence of CAD . This apparent protective effect of alcoholic beverages on CAD
has been ascribed to properties of alcohol itself and not other components of
specific drinks. As much as 50% of this benefit is thought to be due to the
capacity of alcohol to increase HDL and reduce thrombotic tendency, effects
which may be mediated through an increase in the ratio of oestrogen to
testosterone. In addition, red wine contains natural antioxidant compounds
(polyphenols) that may also contribute to cardio protection. In sharp contrast to
these favourable effects of alcohol, it is well known that intake above a moderate
level is associated with an increased level of CAD, a variety of cancers and other
socially deleterious effects (Lindsay & Gaw, 2004:163-164).
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Various studies have shown that moderate intake of alcohol (one drink per day)
significantly improves the elasticity of arteries, which is an important indicator of
cardiovascular health. This positive effect seems to be true of not only red wine,
but even beer and hard liquor. In contrast, studies have proved that heavy
drinking is detrimental to cardiovascular health (www.Heartcentreonline.com,
2005).
Patients who are at risk of CAD should undergo lifestyle adaptations (defined in
1.5.2). The focus of the study is on the adaptations that these patients undergo
and the rehabilitative road they walk in adapting their lifestyle and maintaining
this new lifestyle. The researcher is aware that lifestyle adaptation is part of the
cardiac rehabilitation process that the patient with CAD should undergo after
having CABG surgery, PTCA or insertion of a coronary stent. The cardiac
rehabilitation process is therefore discussed next.
2.4 Cardiac rehabilitation Berra et al. (1991:41) describe cardiac rehabilitation as the process by which a
person with cardiovascular disease, including but not limited to patients with
coronary heart disease, is restored to or maintained at his or her optimal
physiological, social, vocational and emotional status. The World Health
Organization defines cardiac rehabilitation as follows: “The sum of activities
required to ensure the best possible physical, mental and social conditions so
that the cardiac patient may resume as normal a place as possible in the life of
the community” (www.medicinet.com, 2005).
Guidelines compiled by the Agency for Health Care Policy and Research
(AHCPR) in the United States of America describe cardiac rehabilitation as a
comprehensive long-term program which includes medical evaluation, prescribed
exercise, risk monitoring, education and counselling (www.medicinet.com, 2005).
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It is a continuous process that includes patient education, psychosocial
counselling, risk factor modification, an exercise program and re-education.
Cardiac rehabilitation is subdivided into four phases (discussed in 2.4.1). These
four phases make provision for the patients’ specific needs in the different stages
of illness and the recovery period. Patients will move from one stage to the next
according to their individual needs and disease (Coats, Mc Gee, Stokes and
Thompson, 1995:12-13; Hatchett & Thompson, 2002:840; Hoeman, 2002:730;
Woods, Sivarajan Froelicher & (Underhill) Motzer, 2000:840).
The aims of cardiac rehabilitation are to return patients to optimum health within
the confines of their disease, to highlight individual risk factors and encourage
patients to make long-term adaptations where indicated. It also provides the
opportunity to educate relatives. Educating relatives does not only serve as
opportunity to teach them but also enables them to better understand what the
patient is going through and to support them better. The importance of the family
as part of the patient’s external environment is once more emphasized. Family
and friends should be encouraged to participate in the education process.
Cardiac rehabilitation also provides an environment where patients and family
acknowledge their role in accepting responsibility for their health and emphasizes
the necessity of dealing with a progressive disease (Hatchett & Thompson,
2002:840; Lindsay & Gaw, 2004:274).
Cardiac rehabilitation strives for the achievement and maintenance of optimal
cardiac condition and includes the control of cardiac risk factors. A better
conditioned cardiovascular system improves the quality of life and may decrease
morbidity in the patient with cardiac disease (Hojnacki as quoted by King,
1975:231).
Cardiac rehabilitation can be divided into four different phases, which are
discussed next.
31
2.4.1 Phases of cardiac rehabilitation Phase one occurs during inpatient stay or after a stepwise change in the patient’s
condition, e.g. acute myocardial infarction, admission for revascularization,
admission with unstable angina, CABG surgery, PTCA or insertion of a coronary
stent (Hoeman, 2002:730; Lindsay & Gaw, 2004:274). This phase usually
includes light supervised exercise such as walking the halls and stair climbing.
Most rehabilitation teams are multidisciplinary and advice and education may be
given by the most relevant health-care professional. Issues such as risk factors,
diet, medication, sexual activity, exercise, returning to work and normal life at
home are addressed. This phase usually lasts from five days to two weeks.
During this time a patient is normally hospitalized in a cardiac intensive care unit.
Hatchett & Thomson (2002:231) emphasizes that the opportunity should be used
during this phase to discuss the symptoms and prognosis of CAD. In this way a
positive approach towards recovery, early mobilization and discharge can be
established (http://www.sts.org/doc/3563 ,2004; Coats et al. 1995:13; Hoeman
2002:730).
Risk factors are also assessed during this phase. Risk factors are divided into
modifiable and non-modifiable risk factors, (as discussed earlier in 2.3) It is an
integral part of the rehabilitation process and is carried out throughout the four
phases of rehabilitation. Advice at this stage should be tailored to patients’ needs
and willingness to make adaptations to their life. Discussions should be initiated
about preventive strategies and necessary lifestyle adaptations. Information
should be collected about risk factors such as family history of CAD, personal
history of CAD, smoking history, dietary habits and blood lipid profile, body mass
index, blood pressure and history of hypertension, diabetes, physical activity
levels and functional capacity, stress, anxiety, socio-economic status, vocational
status and leisure activities (Lindsay & Gaw, 2004: 275-276; Van Zyl, 2003: 21).
32
Patients should be reassured about their medical status, financial issues and the
influence on their professional life. Sometimes these aspects are at the forefront
of patients’ minds and the quicker they are reassured that the event need not
have a negative effect on their life, the better. All misconceptions the patient may
possibly have about CAD must be dealt with in a realistic way, because it may
influence his potential for recovery after having CABG surgery, PTCA or insertion
of a coronary stent. Here the support of family and colleagues is once again very
important. The patient shouldn’t unnecessarily be stressed by financial worries or
work-related issues (Coats et al. 1995:14; Woods et al. 2000:853; Lindsay &
Gaw, 2004:275).
According to Coats et al. (1995: 17-18) it is important to plan patients’ discharge
properly. The patient should be urged from the beginning to think about small
lifestyle adaptations (discussed in 2.4) Issues such as returning to work, driving a
car, sexual relations and drug therapy should be addressed. Confusion about
these issues or unanswered questions can result in unnecessary stress.
Phase two begins right after discharge from hospital. It usually lasts from two to
twelve weeks, depending on the patient’s progress. Patients often feel anxious
and isolated during this stage. As cardiac mortality rate is very high during this
time, due to the fact that patients are participating in physical activity for the first
time again after the event and also because the patients are home and alone
again for the first time, it is very important that patients should know and
understand which signs and symptoms are dangerous and which are not.
Extensive education should be given to the patient with regards to starting
exercise and initiating activities. Patients are usually very motivated during this
time and the opportunity should be used to the fullest by all rehabilitation
personnel (Coats et al. 1995: 20; Hoeman, 2002:737; Lindsay & Gaw, 2004:278-
279).
33
According to the American Society of Thoracic Surgeons (STS) the goals of
phase two are to:
• Improve functional capacity and endurance
• Provide education of lifestyle adaptations
• Reduce fear and anxiety about increased activity or exercise
• Assist in making optimal social and psychological adjustments
The importance of education in the following areas are also emphasized:
• Medication review
• Lifestyle adaptations and goal setting
• Nutrition counselling
• Stress management
• Safe performance of activities including sexual activity, vocational and
recreational pursuits
(http://www.sts.org/doc/3563, 2005).
Woods (2000:841) adds that education and counselling should be aimed to uplift
patients’ psychological status and prevent depression and anxiety which is
prevalent in this phase.
Phase three takes the form of a structured exercise and health education
program that lasts from four to twelve weeks, starting about two to four weeks
after discharge. The exercise and activities are more intense and are structured
to suit patients’ individual needs and fitness levels (Coats et al. 1995:25-26;
Hatchett & Thompson, 2002:32).
The American STS sets out the following goals for phase three:
• Provide an ongoing exercise program
• Offer support necessary to make and maintain lifestyle adaptations
• Achieve the desired goal, such as, independent lifestyle or return to work
• Prevent progression of heart disease
(http://www.sts.org/doc/3563, 2005).
34
During this phase patients generally return to work and support is aimed at
assisting them in this step. Where returning to previous employment is not
possible appropriate suggestions may be made (Coats et al. 1995:26). Lindsay &
Gaw (2004:279-281) also emphasize that this is the time when patients’
motivation starts to drop due to the fact that they are now on their own and less
supervision is present. It is important to encourage patients to become
independent as soon as possible and to strengthen their confidence to make
adaptations on their own. It is during this phase that the patient’s values should
be strengthened and emphasized. As mentioned before by Smith (1977:241)
values are determinants of virtually all kinds of behaviour that could be called
social behaviour. Values will influence the way patients adapt their lifestyle.
Hattingh (1991:39) also emphasises that values influence the preference attitude,
moral convictions, principles and standards of a group or individual.
Phase four is a wellness program, consisting of two stages. Coats et al.
(1995:27-28) explain it as follows: Firstly the maintaining of long-term, individual
goals and secondly the professional monitoring of patients’ clinical status and
general progress (doctors’ follow-up visits). Issues that are monitored include
medication, risk factors, lifestyle adaptations, weight control, psychosocial status
and vocational support. During phase four patients are handed over from
rehabilitation staff to primary health care staff. Relevant patient records,
especially on progress and medication, are given to the patient’s general
practitioner who will continue the treatment (Coats et al. 1995:28-29; Lindsay &
Gaw, 2004:28).
It is again important to strengthen and emphasise the patients’ values during this
phase, in order to ensure that they adapt their lifestyle and are motivated to
continue this new life. Throughout the phases of cardiac rehabilitation the patient
is motivated to adapt his lifestyle. Like cardiac rehabilitation this is a continuous
process. The lifestyle adaptations patients with CAD, who underwent CABG
surgery, PTCA or insertion of a stent are discussed next.
35
2.5 Lifestyle adaptations
In the lifestyle heart trial conducted by Ornish (1998:387), the objective was to
determine if lifestyle adaptations in diet, exercise, smoking and stress could
affect coronary atherosclerosis. Patients with angiographically documented CAD
were assigned to an experimental group or to a usual care control group. The
experimental group patients were prescribed a regimen that included a low-fat
vegetarian diet, smoking cessation, stress management training, moderate
aerobic exercise and group support. After only one year, patients in the
experimental group showed significant overall regression of coronary
atherosclerosis. After five years, these findings were confirmed with reduced
severity of coronary artery stenoses and reduced numbers of myocardial
infarctions, cardiac related hospital admissions and cardiovascular related deaths
in the experimental group (Ornish et al. 2005:387).
Connaughton (2001: 87) also emphasizes that patients with CAD should address
lifestyle adaptations such as stopping smoking, dietary modifications, following a
structured exercise program and management of stress and alcohol
consumption. The different lifestyle adaptations will be discussed next.
2.5.1 Eating a healthy diet and maintaining a healthy weight Hyperlipidaemia, obesity, diabetes, and hypertension are recognized as major
risk factors for CAD (as described in 2.4.2). Dietary modifications have an
important role to play in the management of these risk factors. It is not
uncommon for individuals to present with one or more of these conditions
(www.medicinet.com, 2005; Lindsay & Gaw, 2004:159).
Every individual has certain food preferences and it is not easy to set out rules of
what to eat and what to avoid. Aspects such as allergies and religious restrictions
should also be taken into consideration. Dietary modifications should therefore be
planned on an individual basis and will vary from person to person.
36
However to achieve and maintain a heart-healthy eating pattern, the following
guidelines are recommended:
Eat a variety of fruit and vegetables. Choose five or more servings of
whole fruits and vegetables - especially dark green, orange or yellow -
each day.
Eat a variety of grain products, especially whole grains, choosing six or
more servings per day.
Include low-fat or fat-free dairy products, fish (at least two servings per
week), legumes (beans), poultry (skin removed) and lean meats.
Limit cholesterol-raising fats such as saturated fats. Limit full-fat dairy
products, high-fat meats, fried foods, products made with partially
hydrogenated vegetable oils, tropical oils (e.g. palm kernel oil, coconut oil)
and egg yolks. Instead choose fats and oils with two grams or less
saturated fat per tablespoon, low-fat or non-fat dairy products, and lean
meats. In addition, limit dietary cholesterol to less than 300 mg per day.
Balance the total number of calories (energy) you eat with the total energy
used each day to maintain a healthy body weight.
Maintain a level of physical activity that keeps you fit and matches your
energy (calorie) intake to maintain a healthy body weight. Participate in at
least 30 minutes of physical activity on most days. For weight loss,
maintain an activity level that exceeds the amount of calories that you eat
every day.
Limit intake of foods that are high in calorie content and low in nutrition,
including foods with a high sugar content such as soft drinks or candy.
Consume less than 2400 mg (approximately one teaspoon) of sodium per
day. People with hypertension should strive for an even lower intake.
Avoid salty foods and avoid adding salt to food during and after cooking.
Check food labels for salt content of packaged foods.
Limit alcohol intake to no more than one alcoholic drink per day for women
and no more than two drinks per day for men.
(www.medicinet.com, 2005)
37
These guidelines encourage eating a wide variety of foods high in complex
carbohydrates from whole grains, fibre, vitamins and minerals. This diet is also
low in fat, cholesterol and salt. Eating excessive amounts of foods (especially
foods high in saturated fat, sugar and salt) should be avoided. Every meal or
dinner party may not meet all these guidelines. Instead of concentrating on each
meal, these guidelines should be applied to achieve an overall heart-healthy
eating pattern (www.medicinet.com, 2005).
Compliance appears to be improved if factors such as dietary advice are aimed
at the whole family so that the patient’s adapted diet style is readily incorporated
into the family’s eating pattern. Individualizing the diet to the patients’ specific
needs and preferences also has a positive effect on compliance
(www.medicinet.com, 2005; Urden et al. 2002:396, Lindsay & Gaw, 2004:172).
2.5.2 Stop smoking CAD is one of the main diseases caused by smoking. However, the benefits of
quitting are experienced within the first day.
As soon as a smoker stops smoking the body starts to eliminate tobacco
constituents. Within eight hours nicotine levels will be reduced by half and within
24-48 hours of stopping, the smoker’s carbon monoxide level will be comparable
with that of a non-smoker. The oxygen level gradually returns to normal and the
heart beat slows. The lungs start to clear the tar, the cilia recover and the ex-
smoker feels less wheezy and breathless. Within a week the senses of smell and
taste improve, teeth are whiter and breath fresher (Urden et al. 2002:397,
Lindsay & Gaw, 2004:134).
The long-term benefits to cardiovascular risk are considerable and these benefits
occur at all age groups and all stages of cardiovascular disease. The excess risk
of CAD from smoking reduces by half within 1 year of stopping smoking. After 15
years, the risk reverts to about the same level as that of someone who has never
38
smoked. As would be expected, the level to which the risk drops varies between
individuals and depends on how long the patient smoked, how heavily they
smoked and other risk factors present. For an individual who already has heart
disease or who has had a heart attack, giving up smoking reduces the risk of
premature death of another heart attack by up to 50% or more (Lindsay & Gaw,
2004:134-135).
In order to successfully stop smoking one should understand smoking, determine
why someone started in the first place and why they continue or decide to stop.
Some of the factors why people start smoking are peer pressure or curiosity. Due
to reasons such as dependence patients on nicotine cannot or do not want to
give it up. Nicotine is very addictive and a smoker gets used to a certain level of
nicotine in their blood. They then have to smoke to maintain the nicotine levels in
their blood. Many smokers enjoy the taste and ritual handling of their cigarettes.
They may reward themselves with a cigarette after completing a difficult task.
Cigarettes also have a social function and can act as ice breakers, be used as
time fillers and to deal with boredom (www.heartcenteronline.com).
Smokers learn to use cigarettes as a means of relieving stress and believe that
cigarettes “calm the nerves”. In fact nicotine is a powerful stimulant and what
actually happens is that withdrawal symptoms emerge when a smoker has not
smoked for a while. The next cigarette alleviates these symptoms and the
smoker feels better and relaxed. Some smokers smoke to aid their concentration
but again, this is more a result of habit and association. The smoker deliberately
chooses to use a cigarette to help him concentrate (and to ward off withdrawal
restlessness) and therefore feels more concentrated – a self-fulfilling prophecy.
Smokers are very good at denial or adopting a fatalistic approach to the
consequences of smoking. They tell themselves: “I’m going to die any way” or
“My uncle is 92 and he still smokes 40 a day”. Research proved that out of 1000
young male smokers, one will be murdered, six will be killed on the roads and
250 will be killed by tobacco. Forty percent of smokers do not collect their
39
pension as they die before retirement, compared with only 15% of non-smokers
(www.medicinet.com, 2005 ; Lindsay & Gaw , 2004:156).
Another powerful obstacle is fear of gaining weight, particularly in young women
who are under constant social pressure to be thin. Even though cigarettes
contribute to elevated metabolism that promotes weight loss, people tend to gain
weight after stopping mostly due to the habit of smoking being replaced by eating
(Urden et al. 2002:397, Lindsay & Gaw, 2004:134).
.
The three main components of smoking are pharmacological addiction, habit and
psychological dependence. All three need to be addressed in an attempt to stop.
Health professionals have a high credibility with smokers and can be effective in
helping them to stop for good. Most patient contacts can provide an opportunity
to intervene on smoking. The most effective intervention strategy for health
professionals is minimal intervention, backed up with referral to specialist
services. Minimal intervention aims to equip patients with the knowledge and
motivation they need to adopt different behaviour, one stage at a time.
Motivational interviewing techniques should be used in discussing smoking with
patients, involving open questions and active listening, with the patient doing the
decision-making. Advice and information offered should be relevant to what the
patient says. The whole practice can be involved in creating the climate for
cessation. Non-smoking should be promoted as the norm throughout the practice
(www.medicinet.com, 2005 ; Lindsay & Gaw , 2004:156).
2.5.3 Exercise Physical activity has a key part to play in improving health and well-being. One of
its benefits is that it helps prevent CAD (Lindsay & Gaw 2004 :189). It has been
calculated by the British Heart Foundation that 37% of deaths due to CAD under
the age of 75 are attributable to physical inactivity. Exercise is an everyday part
of life for many people. Previously people with heart disease were advised to
“take it easy” and certainly never to take part of any form of exercise. Now,
however, not only is exercise recommended as a way to prevent heart disease,
40
but it is used as part of the rehabilitation process in those who suffer from CAD
after having CABG surgery, PTCA or insertion of a coronary stent (British Heart
Foundation, 2002:www.health24.com:2005).
The idea behind exercise to either prevent, or treat heart disease is that a regular
training program will improve general cardiovascular fitness. In simple terms, this
will improve your ability not only to exercise, but to carry out normal everyday
activities (www.health24.com:2005).
Exercise does not only have physical but also emotional benefits. Exercise is an
excellent component of stress management. Taking a walk after dinner can be as
helpful to the mind as the digestive system. Walking as a family can improve
communication and teach healthy habits that will last a lifetime. Exercise is also
well known for its ability to reduce depression. It can increase the confidence and
independence of a patient suffering from CAD, especially after a frightening
episode such as a myocardial infarction or coronary artery bypass surgery.
Exercise is a good tool for feeling both physically and emotionally stronger after
going through a period of fear and vulnerability.
Connaughton (2001:86) identified various non-pharmacological interventions
proven to reduce the risk of recurrent cardiac events. For example, the negative
effects of alcohol consumption and smoking are eliminated or reduced, this risk
reduces accordingly. Dietary modifications regarding cholesterol reduction and
control, weight reduction and regular physical activity and exercise all reduce the
risk of cardiac events recurring ( www.heartcenteronline.com ).
Exercise prescriptions should be individualised. It is important that the exercise
fits in with the patient’s lifestyle and daily activities so that they don’t experience
exercise as a burden and compliance to the program is poor. Parameters such
as type, intensity, duration, and frequency should be specified and realistic
exercise gaols should be set. It is also important that the patient enjoys the
41
exercise to ensure better compliance (Lindsay & Gaw, 2004:313-314; Clochesy
et al. 1996:367).
2.5.4 Behavioural adaptation
CAD is dependent, to a large extent, on our behaviour and our psychological
circumstances. Cigarette smoking, dietary behaviour, exercise levels and the
prevalence and impact of psychological stress are considered key behavioural
risks.
Although patients may ultimately wish to optimise their health, whether or not
they engage in health-promoting behaviours are governed more by short-term
costs and benefits than by long-term possible health outcomes. Patients may
consider adopting a low-fat diet to reduce their risk of CAD, but be beset by more
immediate problems. Their families may not wish to adapt their diet, they may
have to learn new cooking methods, eat less favoured foods, perhaps even
increase the cost of their shopping. These short-term costs may override the
benefit of potential long-term health gains and prevent adoption of appropriate
behavioural change (Lindsay & Gaw, 2004: 217-234).
At any one time patients may be more or less motivated to adapt their behaviour.
A key aspect of counselling is to identify what stage of adaptation the individual is
at and to tailor any intervention accordingly (Lindsay & Gaw, 2004: 217-234).
Taking responsibility and the right attitude towards illness and the lifestyle
adaptations to be undertaken is essential for the health of the patient with CAD
who underwent CABG surgery, PTCA or insertion of a coronary stent. Patients
who do not take responsibility for their condition and who do not adopt the
needed changes put their own health at risk, and are in danger of going through
the whole ordeal again. It should be stressed that the patient is suffering from
CAD and if he does not adapt his lifestyle cardiac events will recur. Statistics
have shown that second time CABG surgery, PTCA and coronary stents are less
42
successful and the mortality rates are higher (According to Statistics South
Africa). Patients with coronary artery reduction are forced, due to physiological
changes, to make lifestyle adaptations (Gotto as quoted by Palm, 1990:1).
It is also important that patients comply with medicine regimes and follow-up
visits to their doctor. A recent study has shown that in patients who suffer from
CAD, who underwent CABG surgery, PTCA or insertion of a coronary stent, and
who also have elevated cholesterol levels, the use of cholesterol-lowering
medication can lower cholesterol levels and prolong vein graft function. Patients
are also advised about the importance of lifestyle adaptation to lower their
chance of developing further atherosclerosis in their coronary arteries. These
include stopping smoking, exercise, reducing weight and dietary fat, as well as
controlling blood pressure and diabetes (http://www.medicinenet.com, 2004).
The discussion in 2.5 makes it clear that it is important to identify and address
risk factors present in the lifestyle of patients with CAD who underwent CABG
surgery PTCA or insertion of a coronary stent. These patients should be informed
on how they can adapt their lifestyle and motivated to maintain this new lifestyle.
2.6 Conclusion In this chapter (chapter two) various aspects of the conceptual framework were
discussed. It was shown that when lifestyle adaptations are considered for
patients with CAD who underwent CABG surgery, PTCA or insertion of a
coronary stent, all aspects of their environment should be taken note of. Various
risk factors for CAD and the different phases of cardiac rehabilitation were looked
into, as part of the lifestyle adaptations needed to be done. These factors were all
taken into account when the questionnaires for the study were compiled (see
table 2.5 and 2.6).
43
Table 2.5 Relevant topics covered in questionnaire one (Annexure one)
Topic Question number
Age 2.3.1.1 5
Gender 2.3.1.2 4
Obesity 2.3.2.3 10 + 11
Physical activity 2.3.2.5 + 2.5.1 + 2.5.3 19 + 20
Diet 2.3.2.1 + 2.3.2.2 + 2.3.2.6 + 2.5.1 23 – 27
Smoking 2.3.2.7+ 2.5.2 28 – 30
Stress and anger 2.3.2.10 13 + 33 – 34
Alcohol 2.3.2.11 21 + 22
Behavioural adaptation 2.5.4 14 – 18 + 37
Family and social support 2.2 5 + 35 + 36
History of previous cardiac event 8
Medication 2.2. 31
Table 2.6 Relevant topics covered in questionnaire two (Annexure two)
Topic Question number
Obesity 2.3.2.3. + 2.5.1 1
Physical activity 2.3.2.5 + 2.5.1 + 2.5.3 7 + 8
Diet 2.3.2.1 + 2.3.2.2 + 2.3.2.6 + 2.5.1 11 – 14
Smoking 2.3.2.7 + 2.5.2 15 - 18
Stress and anger 2.3.2.10 20
Alcohol 2.3.2.11 9 + 10
Behavioural adaptation 2.5.4 2 – 6 + 23 + 24
Family and social support 2.2 21 - 22
Medication 2.2 19
44