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The Current Level Of Nursing Knowledge Regarding The The Current Level Of Nursing Knowledge Regarding The

Management Of Cardiovascular Disease In Postmenopausal Management Of Cardiovascular Disease In Postmenopausal

Women Women

Lynda Smith Hardin Mississippi University for Women

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THE CURRENT LEVEL OF NURSING KNOWLEDGE REGARDING

THE MANAGEMENT OF CARDIOVASCULAR DISEASE

IN POSTMENOPAUSAL WOMEN

being

An Evidence Based Practice Project Presented to

the Graduate Faculty o f Mississippi University

for Women in Partial Fulfillment of the Requirements

for the Degree of Master o f Science in Nursing

by

Lynda Smith Hardin

BSN, University o f Southern Mississippi

D ate_________________ Approved___J iGraduate Studies Director

Approved ____________Graduate Program Director

ProQuest Number: 27919768

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Graduate Committee Approval

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hereby approves her project as meeting partial

fulfillment o f the requirements for the Degree of

Master o f Science in Nursing

Date I 3 * j PQ___________ Approved______ _______________ ______Supervising Professor/Committee Chair

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Copyright © 2006 Lynda Smith HardinAll rights reserved. No part o f this work may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the author’s prior written permission.

Ill

DEDICATION

I wish to dedicate this research project to my wonderful family. Only with their

continuous love, support, and encouragement could I have possibly completed this

overwhelming task. To my husband, David, thank you for your understanding during

these past twelve months and for operating on auto pilot vrithout complaint as I focused

completely on graduate school demands while neglecting family responsibilities. You

nudged me to make this commitment even though I was hesitant to do so. You’ve done

whatever it took to keep the pressure on me to a minimum during this pursuit o f my

degree. To Jessica, my precious daughter, thank you for your support as the two o f us

have struggled through graduate school together. Despite the fact that you were two

thousand miles away in California, you were always only a phone call away. I could

always count on you to listen when I needed to vent or something had me stressed out.

Your unique personality kept me on my toes, never knowing what you’d come up with

next. I love you, my free spirit, my “Princess Grace.” To my son, Barrett, my kindred

spirit, thank you for tolerating Mom as a roommate every Sunday night so that I didn’t

have such a long day on Mondays. I hope both o f you children know just how very

special you are to me. To my parents, thank you for your tolerance and understanding as I

have remained MIA throughout the past year from most all o f the family functions. I

appreciate your support during this time that has been dedicated to the advancement of

my career.

Most importantly, I dedicate this research to my Lord and Savior Jesus Christ for

the patience and perseverance He has provided to sustain me during this endeavor.

Without Him, this would not have been possible.

IV

THE CURRENT LEVEL OF NURSING KNOWLEDGE REGARDING

THE MANAGEMENT OF CARDIOVASCULAR DISEASE

IN POSTMENOPAUSAL WOMEN

Lynda Smith Hardin, MSN(c), RN

Mississippi University for Women, 2006

Supervising Professor: Mr. Robert Swanson

Abstract

Cardiovascular disease (CYD) is the single leading cause o f death and a

significant cause of morbidity o f American women. Despite years of research and

compelling data indicating that CYD is largely preventable, alarming trends in the

prevalence and management o f risk factors in women continue to occur. In 2005, the

estimated direct and indirect cost o f CYD was $393.5 billion (American Heart

Association [AHA], 2005). Despite the fact that CYD kills more women per year than the

next six causes of death combined; only 13% of women consider CYD to be their

greatest health risk (AHA, 2005). Educating the healthcare provider, as well as the

patient, is key to women adopting the necessary lifestyle modifications. According to

Mosca et al. (1999), a 1995 Gallup Survey demonstrated that four of five women and

32% o f their primary care physicians did not know that CYD was the leading killer o f

American women.

The purpose of this Evidence Based Practice (EBP) project was to develop an

Advanced Practice Nurse (APN) knowledgebase regarding cardiovascular disease in

postmenopausal women. A Boolean computer search of healthcare literature utilizing

CINAHL, MEDLINE, and the COCHRANE Library was conducted for this review. The

research questions asked were as follows:

1. What is the level of nursing knowledge regarding CVD in postmenopausal women?

2. What are the Evidence-Based Practice guidelines for the cardiovascular healthcare of

postmenopausal women?

3. According to the literature, what is the role o f the Nurse Practitioner (NP) in the

management o f CVD in postmenopausal women?

Nola J. Pender’s Health Promotion Model served as the theoretical foundation for

this clinical project and guided the systematic review through data collection of the

healthcare literature. A knowledgebase of findings was developed according to the

template developed by Davidson (2003). EBP guidelines regarding the cardiovascular

healthcare o f postmenopausal women were presented. Implications and recommendations

for nursing theory, nursing research, advanced nursing practice, nurse practitioner

education, and health policy are encouraged from the ideas explored.

VI

ACKNOWLEDGEMENTS

I would like to thank Mr. Robert Swanson, my research advisor, for his guidance

and assistance in the completion of this project. I also wish to thank Dr. Janice Unruh

Davidson for introducing me to the research process and instilling in me a passion for

research to be done as it should be.

I also wish to thank Dr. Sandra Kirkland for her support throughout the graduate

program. She was always available when I had questions or needed someone to vent to.

She was an inspiration for me, a role model, and a mentor. Thank you all for the time you

invested in our class.

VII

TABLE OF CONTENTS

COPYRIGHT PAGE............................................................................................... iii

DEDICATION PAGE.............................................................................................. iv

ABSTRACT............................................................................................................... v

ACKNOWLEDGEMENTS.......................... vii

TABLE OF CONTENTS....................................................................................... vii

LIST OF TABLES...................................... xi

CHAPTER I - Dimensions o f the Problem............................................................ 1

Problem Statement.........................................................................................1

Statement of Purpose....................................................................................2

Significance of the Study....................................................... 2

Theoretical Foundation.................................................................................4

Definitions o f Terms..................................................................................... 5

Cardiovascular Disease................................................................... 6

Theoretical........................................................................... 6

Operational.......................................................................... 6

Postmenopausal women................................... 6

Theoretical.................................................................... . , . .6

Operational.........................................................................6

Nurse Practitioner...........................................................................6

Theoretical..........................................................................6

Operational..........................................................................6

Research Questions......................................................................................7

V lll

Delimitations.................................................................................................. 7

Limitations......................................................................................................7

Summary......................................................................................................... 8

CHAPTER II - Review o f Literature.......................................................................9

An Overview o f the Healthcare Literature Related to Cardiovascular

Disease in the Postmenopausal Woman...................................... 9

Summary....................................................................................................... 17

CHAPTER III — Design and Methodology.......................................................... 19

Approach...................................................................................................... 19

Literature Selection Procedure............. 19

Literature Analysis Procedure.................................................................. 20

Summary.......................................... 21

CHAPTER rV — Knowledgebase Findings and Practice-Based Application..22

Research Question One...............................................................................22

Research Question Two.............................................................................. 22

Research Question Three............................................................................ 23

Summary........................................................................................................25

CHAPTER V — Evidence-Based Conclusions, Implications and

Recommendations. .....................................................................................26

Summary of the Investigation................................................................... 26

Interpretations of Findings with Conclusions......................................... 26

Research Question One................................................................ 27

Research Question Two............................................................... 27

IX

Research Question Three ................................................ ..27

Limitations...................................................................................................28

Implications and Recommendations..................................... 28

Nursing Theory.................... 28

Nursing Research i........................................................ 29

Advanced Nursing Practice................... 29

Nurse Practitioner Education........................................................29

Health Policy.......................... 30

Summary............................................ 30

REFERENCES............................................................ 32

APPENDICES ............................................................................................. 35

LIST OF TABLES

Table Page

1. Summary o f Literature Searches...................................................................................... 3

2. Pender’s Theoretical Assertions....................................................................................... 5

3. Evidence-Based Recommendations-Lifestyle Factors.................................. 23

4. Evidence-Based Recommendations-Risk Factors....................................................... 24

XI

CHAPTER I

Dimensions of the Problem

Coronary vascular disease (CVD) is the single leading cause of death and a

significant cause of morbidity of American women. Despite years o f research and

compelling data indicating that CVD is largely preventable, alarming trends in the

prevalence and management of risk factors in women continue to occur. These risk

factors are well documented and their management and treatment are relatively cost-

effective (Mosca, et al.). In 2005 the estimated direct and indirect cost o f CVD is $393.5

billion (American Heart Association [AHA], 2005).

AHA reports that despite the fact that CVD kills more women per year than the

next six causes o f death combined; only 13% of women consider CVD to be their

greatest health risk A 1995 Gallup Survey demonstrated that four o f five women and 32%

of primary care physicians did not know that CVD was the leading cause of death for

women (Mosca, et al.). Educating the healthcare provider as well as the patient is key to

women adhering to health promoting activities. Research done in England by Campbell

et al., (1998) revealed that patients showed more compliance with their disease

management regimen when there was a united focus o f both patient and healthcare

provider.

Problem Statement

AHA reports that the number one fear o f death in women continues to be from

cancer. The reality is that in 2002, the death rates were 25.6 for breast cancer and 41.6 for

lung cancer. These statistics are compared to 273.4 for women who died from CVD that

same year. One in 30 female deaths was from breast cancer, while one in 2.5 was from

CVD (AHA, 2005).

Cardiovascular disease is the most common cause of death o f both men and

women and is recognized as having distinct gender-specific features. Many o f these

features are credited for the discrepancies in evaluation and treatment o f CVD in women.

On average, coronary artery disease presents 10 years later in women than in men. The

median age for myocardial infarctions (MI) is approximately 20 years older in women

than in their male counterparts (Tecce, Dasgupta & Doherty, 2003). The reason for this

delay is not completely understood, but it appears to be due to a cardioprotective benefit

o f endogenous hormones prior to menopause. The incidence o f CVD in young women

remains low, but following menopause, women catch up to men quickly, and within a

decade after menopause, the prevalence of coronary disease is nearly equal. The U.S.

Census estimates that there will be 40 million Americans age 65 and older in 2010 (AHA,

2005). With longer life-expectancies, women routinely live one-third o f their lives after

menopause therefore making CVD a significant issue for women.

Statement o f Purpose

The purpose of this project was to review and explore literature related to the

current level o f nursing knowledge in the occurrence and management of CVD in the

postmenopausal woman (PMW) and to further determine applicable evidence-based

practice guidelines as a focus for future research.

Significance o f the Study

The current level of healthcare knowledge regarding CVD and postmenopausal

women is increasing now that CVD is recognized as the single leading cause of death in

women over age 50 in the U.S. Research results vary significantly regarding gender

differences and the cardioprotective effects o f hormone replacement therapy (HRT)

among other issues. Until these studies are published, our focus as healthcare providers

should be on the treatment o f risk factors previously proven to favorably impact

cardiovascular morbidity and mortality. A computer search o f CINAHL, MEDLINE, and

COCHRANE revealed the following results:

Table 1Summary of Literature Searches_______________________________________________ _Search Terms Number o f Citations Database

CVD, PMW, Nurse Practitioner (NP) 0 CINAHL1 MEDLINE0 COCHRANE

CVD and PMW 217 CINAHL35 MEDLINE2 COCHRANE

CVD and NP 13 CINAHL34 MEDLINE9 COCHRANE

PMW and NP 1 CINAHL7 MEDLINE2 COCHRANE

CVD and Pender 9 CINAHL0 MEDLINE

58 COCHRANE

PMW and Pender I CINAHL0 MEDLINE

27 COCHRANE

NP and Pender 2 CINAHL0 MEDLINE10 COCHRANE

Note. CINAHL = Cumulative Index to Nursing and Allied Health Literature, MEDLINE = Medical Literature Online, COCHRANE = Cochrane Library (Cochrane Database o f Systematic Review, Cochrane Database o f Abstracts o f Reviews o f Evidence, and Cochrane Clinical Trials Register)

The clinical significance of this study is to utilize the results to provide cost-

effective and high quality care to postmenopausal Avomen in the treatment and prevention

o f CVD. A woman’s cardiovascular risk sky rockets once she has passed menopause.

This causes women to move from low risk to extremely high risk for cardiovascular

events in just over a decade.

Theoretical Foundation

Nola J. Pender’s Health Promotion Model (HPM) provided the theoretical

foundation for this study. Pender’s theory identifies the variables that lead to adherence

or rejection of health promoting activities. Her theory contributes a nursing solution to

health policy and healthcare reform by providing a means for understanding how

consumers can be motivated to attain personal health. The model is an attempt to depict

the multifaceted nature o f persons interacting with the environment as they pursue health.

The HPM has a competence or approach-oriented focus. Health promotion is motivated

by the desire to increase well being and actualize human potential.

The HPM has been formulated through induction by use o f existing research to

form a pattern o f knowledge about health behavior. The HPM is a conceptual model that

was formulated with the goal o f integrating what is known about health-promoting

behavior to generate questions for further testing. This model provides a framework for

seeing how the results o f previous research fit together more clearly and how concepts

can be manipulated for further study. Pender’s major assumptions reflect the behavioral

science perspective and emphasize the active role o f the patient for managing health

behaviors by modifying the environmental context. Pender’s theoretical assertions

derived from the model are listed in the table below:

Table 2Pender’s Theoretical Assertions“ 1. Prior behavior and inherited and acquired characteristics influence beliefs, affect, and

enactment o f health-promoting behavior.2. Persons commit to engaging in behaviors from which they anticipate deriving

personally valued benefits.3. Perceived barriers can constrain commitment to action, mediator o f behavior, and

actual behavior.4. Perceived competence or self-efficacy to execute a given behavior increases the

likelihood o f commitment to action and actual performance o f behavior.5. Greater perceived self-efficacy results in fewer perceived barriers to specific health

behavior.6. Positive affect toward a behavior results in greater perceived self-efficacy, which can,

m turn, result in increased positive affect.7. When positive emotions or affect are associated with a behavior, the probability o f

com m itm ent and action are increased.8. Persons are more likely to commit to and engage in health-promoting behaviors when

significant others model the behavior, expect the behavior to occur, and provide assistance and support to enable the behavior.

9. Families, peers, and healthcare providers are important sources o f interpersonal influence that can increase or decrease commitment to and engagement in health- promoting behavior.

10. Situational influences in the external environment can increase or decrease commitment to or participation in health-promoting behavior.

11. The greater the commitment to a specific plan o f action, the more likely health- promoting behaviors are to be maintained over time.

12. Commitment to a plan o f action is less likely to result in the desired behavior when competing demands over which persons have little control require immediate attention.

13. Commitment to a plan o f action is less Ukely to result in the desired behavior when other actions are more attractive and thus preferred over the target behavior.

14. Persons can modify cognitions, affect, and the interpersonal and physical environments to create incentives for health actions.”

Toomey & Alligood, 2002 (pp. 630-631)

Definition o f Terms

For the purpose of this study the following terms were defined:

Cardiovascular Disease

Theoretical All diseases affecting the heart and blood vessels. This includes

arteriosclerosis, coronary artery disease, heart valve disease, arrhythmias, heart failure,

hypertension, orthostatic hypotension, shock, endocarditis, diseases o f the aorta and its

branches, disorders o f the peripheral vascular system, and congenital heart disease.

Operational. Diseases of the heart and/or blood vessels including acute events

such as myocardial infarctions and strokes as woil as chronic conditions like

hypertension.

Postmenopausal women

Theoretical. Any woman who has been without menses for at least 12

consecutive months.

Operational Any woman whose ovaries no longer produce estrogen either

naturally or due to surgical removal.

Nurse Practitioner

Theoretical A registered nurse with additional education and experience, a

masters degree, and is licensed to practice as an advanced practice nurse who assesses,

diagnoses, treats, and manages both acute and chronic routine illnesses.

Operational. An advanced practice nurse, licensed and working as a healthcare

provider.

Research Questions

For the purposes of this study the following research questions were generated:

1. What is the level o f nursing knowledge regarding cardiovascular disease in

postmenopausal women?

2. What are the evidence-based practice guidelines for cardiovascular healthcare of

postmenopausal women?

3. According to the literature, what is the role o f the nurse practitioner in the management

o f cardiovascular disease in postmenopausal women?

Delimitations

Literature for the purposes of this integrative literature review will be delimited to

the following:

1. Literature which pertains to cardiovascular disease and postmenopausal women.

2. Literature that is available in the English language.

3. Literature that is available through CINAHL, MEDLINE, or the COCHRANE Library,

or those referenced by articles from these sources and retrieved via other databases

accessible through the Fant Library at the Mississippi University for Women.

Limitations

For the purpose of this investigation, the following limitations were identified:

1. Despite the vast amount of information found on cardiovascular disease and

postmenopausal women, very little research addresses the contribution of the nurse

practitioner.

2. The sample size o f selected references.

3. The information obtained cannot be generalized beyond the scope of the research

reviewed.

8

Summary

Cardiovascular disease in postmenopausal women is clearly a significant issue

both due to the mortality and morbidity o f the disease, as well as to the prevalence in the

U.S. Vast differences exist in the occurrence, presentation, diagnosis and treatment o f

CVD in women and in men. Until menopause, women have a very low risk o f developing

CVD. Within a decade o f reaching menopause, women have matched and surpassed the

risks of their male counterpart.

The money spent annually on treatment o f CVD could instead be used for

prevention of the devastating CVD events. The obvious focus must be on the modifiable

risk factors for the prevention and treatment o f CVD. Pender’s Health Promotion Model

emphasizes the importance of individual assessment o f the factors believed to influence

health behavior changes and therefore serves as this study’s theoretical foundation.

CHAPTER II

Review o f Literature

For the purposes of this investigation, data-based manuscripts were reviewed and

critiqued using a knowledgebase template for cardiovascular disease in postmenopausal

women (see Appendix A). Literature reviewed regarding cardiovascular disease in

postmenopausal women totaled 13 manuscripts, which represented reviews of another

611 references. In this chapter, an overview o f each study variable is presented as it has

emerged from the developing knowledgebase.

An Overview o f the Healthcare Literature

Related to Cardiovascular Disease in Postmenopausal Women

According to the American Heart Association (Brown et al., 2005), a

retrospective analysis o f 8,928 subjects revealed significant data related to cardiovascular

disease, postmenopausal women and the use o f aspirin. The researchers found that

women taking aspirin had a significantly lower risk o f cardiovascular death as well as

death from all causes, compared to women who did not take aspirin. Eighty-one mg

aspirin was equally as effective as 325 mg in this population. The strength o f this data-

based research by Brown et al. was the large sample size, while the weakness was that no

cause-and-effect could be demonstrated since this was not a randomized trial. The

conclusion could not be made that aspirin actually caused the reduction in the

cardiovascular events. This study does, however, provide the foundation for further

research on the benefits o f aspirin therapy in postmenopausal women.

In a systematic literature review by Anderson and Kessenich (2001), indexed in

CINAHL, various concepts were reviewed. In this data-based article the authors reviewed

10

the concepts o f cardiovascular disease, women, gender differences, risk factors, signs and

symptoms, and clinical management. The research included 42 references. Women were

found to differ from men in occurrence, presentation, diagnosis, treatment, and outcomes

o f cardiovascular disease. Education o f both women and their healthcare providers is

essential in improving patient outcomes. The strength o f the review is the large number

o f references reviewed. A weakness was identified in the design of the study in that the

methodologies o f cited references varied widely. This literature selection methodology

allows for possibly skewed data. The study does, however, provide the opportunity for

further research on cardiovascular disease in postmenopausal women

According to a manuscript by Campbell et al. (1998), indexed in MEDLINE, the

concepts o f cardiovascular disease, secondary prevention, nurse led clinics and primary

care were explored. This data-based article reports a randomized clinical trial that

involved 1,173 subjects. Twenty-one references were cited in this research. The large

sample size was a strength of the study, while the fact that only a minority of the subjects

were female represents a concerning weakness. The relevancy o f the results for

postmenopausal women is questionable since so few were involved in the study. The

possibility of self-report bias is an additional weakness. The key finding of this study

revealed that nurse led clinics in primary care can improve both medical and lifestyle

components o f secondary prevention effectively. Further research involving

postmenopausal women is indicated.

In a data-based study by Cassidy (2005), indexed in MEDLINE, a number of

concepts were explored. This systematic literature review examined menopause, nutrition

and diet, and women’s health. The 38 references that were cited included very few

11

American women. The excellent teaching information included for postmenopausal

women with cardiovascular disease was a major strength of the study. The studies

indicated that many of the diseases associated with aging could actually be prevented or

minimized by modest changes in dietary intake and physical activity. These results are

encouraging and provide a foundation for further research involving American women to

verify findings in that population.

According to a systematic literature review o f randomized double-blind trials by

Farquhar, Maijoribanks, Lethaby, Lamberts, and Suckling (2005), indexed in the

Cochrane Library, a number o f articles were reviewed. The authors explored

perimenopausal women, postmenopausal women, and hormone replacement therapy in

this data-based study. An overwhelming strength o f the study is that 35,089 subjects were

involved. The weakness lies in the merged data from the 66 references utilized and the

fact that this literature selection methodology could account for skewed findings. The key

findings include that combined hormone replacement therapy significantly increased the

risk of deep vein thrombosis, stroke, breast cancer, and gallbladder disease. Estrogen only

therapy also significantly increased the risk o f stroke and gallbladder disease. Hormone

replacement therapy should not be used for the routine management o f chronic disease.

The only statistically significant benefits of hormone replacement therapy were decreased

incidence of fractures and colon cancer with long-term use. Relief o f vasomotor

symptoms is currently the only reason to prescribe hormone replacement. The risk and

benefits must be weighed carefully by the healthcare provider and discussed with the

patient. More research is definitely needed on the safety o f hormone replacement therapy.

12

In a data-based manuscript by Jackson, Aarabi, and Wallis (2005), indexed in the

Cochrane Library, a number of studies were reviewed. The authors explored the concepts

o f cardiovascular disease, aspirin, adverse effects, and benefits. This meta-analysis of

blinded studies, open studies with blinded end-point assessment, randomized control

trials, and cluster randomized trials reviewed 26 articles. The strength of this study is the

large sample size. Unfortunately, the weakness is reflected in the lack of heterogeneity of

trials therefore causing a threat o f skewed data. The findings reflect a clear reduction in

mortality and non-fatal cardiovascular disease events among those with prior myocardial

infarction (MI), stroke, bypass surgery, angioplasty, peripheral vascular disease, or

angina with aspirin use. The Food and Drug Administration (FDA) also extended the use

o f aspirin for use with acute evolving Mis and to wider categories o f secondary

prevention of cardiovascular events. Primary cardiovascular events were reduced by

aspirin use, also. Aspirin has serious possible side effects o f gastrointestinal bleeding and

hemorrhagic strokes. The opportunity for further research qualifying both the precise

benefits and risks o f aspirin therapy in primary prevention is clear.

According to a data-based study by Moustapha and Robinson (1999), indexed in

CINAHL, another independent risk factor for atherosclerosis in the elderly has been

identified. This meta-analysis reviewed 30 references regarding the concepts of

homocysteine, cardiovascular risk factors, older populations, and menopause. The

strength o f this research is the identification o f a high plasma level o f total homocysteine

concentration as an independent risk factor for atherosclerosis. The lack of heterogeneity

of studies was identified as a weakness of the research. The key findings include the

complexity o f this elevated homocysteine level are likely related to suboptimal vitamin

13

status and kidney dysfunction. Pending results from further studies, only high risk

patients should be screened for this potential marker. Treatment includes dietary changes,

or if unsuccessful, then supplementation with folic acid and vitamin B12. The threat o f

this study is the lack o f clinical trials to identify the mechanism, if any, by which

increased homocysteine may cause vascular damage. This provides an excellent

foundation for further research on the usefulness o f this newly identified inflammatory

marker.

In an observational analysis by Parsons et al. (2004), indexed in MEDLINE,

several concepts were explored. The authors o f this data-based article cited 36 references

and reviewed the concepts of postmenopausal women, acute coronary syndromes, and

hormone replacement therapy. The large number o f postmenopausal women (n = 4,029)

studied was identified as a strength o f this study. A significant weakness, however, is that

the observational analysis was conducted in a database collected for other purposes,

therefore preventing the proof o f a causal relationship between hormone replacement

therapy and outcomes. The key findings revealed that overall hormone use was low

among women with acute cardiac syndrome and varied according to race, region, and

demographics. No significant association of hormone use with intermediate clinical

outcomes among postmenopausal women who had recently suffered an acute coronary

event was identified.

The results extend the randomized clinical trials into the acute setting and support

the absence o f an indication for hormone use for secondary prevention o f atherosclerotic

disease. The threat o f this study is found in the unmeasured confounding variables,

including data collection methods that do not address comparisons between different

14

agents, doses, routes, or length of administration o f hormones. The opportunity exists for

future research on hormone replacement therapy in postmenopausal women.

According to Ridker, Hennekens, Buring, and Rifai (2000), in their data-based

study indexed in MEDLINE, C-reactive protein was explored as a measure o f cardiac

risk. In this prospective, nested case-control study o f 28,263 subjects, the additional

concepts reviewed were lipid levels, women, and cardiovascular disease. Thirty-two

references were cited. The large number of subjects was identified as a strength of the

study. A weakness identified was the fact that only healthy postmenopausal women were

studied for only a short period o f time. This threatens the results due to the possibility

that findings may vary with longer time intervals. C-reactive protein (CRP) proved to be

the strongest and most significant predictor o f the risk o f fiiture cardiovascular (CV)

events. Half o f the women studied who had cardiovascular events did not have overt

hyperlipidemia. CRP should be added to standard lipid screening to improve methods for

identifying persons at high risk for future CV events and thus become candidates for

primary prevention interventions such as the use o f statins.

Schedlbauer, Schroeder, Peters and Fahey (2004), in a data-based inquiry cited in

the Cochrane Library, examined the concepts of lipid lowering drugs, cardiovascular

disease, and patient adherence. These randomized controlled trials included 5,942

subjects and 128 references were reviewed by the authors. The large number o f subjects

was identified as a definite strength of the study. The short follow-up of only 2 - 2 4

months and the lack of a valid method for measuring adherence were identified

weaknesses. The majority o f studies did not increase adherence significantly by

informing, reminding, and motivating patients. Particular types o f interventions did not

15

seem to be more effective than others. It is emphasized that adherence rates were

extremely variable, which makes comparison between trials difficult. Despite efforts to

increase the use o f lipid lowering medication and despite the fact that poor adherence to

medication is common, randomized controlled trials in this area are limited in both

number and quality. At this stage, no adherence-enhancing intervention can be

recommended in clinical practice. The opportunity for further research to address

adherence with a more patient-centered approach is needed. This would alleviate the

threat o f the possibly skewed or unreliable data due to the substantial heterogeneity

between these trials.

In a systematic literature review by Tecce, Dasgupta, and Doherty (2003),

indexed in the Cochrane Library, several concepts were analyzed. The concepts o f this

data-based study included heart disease, older women, gender differences, diagnosis,

treatment and risk factors. Forty-four references were cited by the authors. The strength

of this study is the identification o f gender differences in the diagnosis and treatment of

cardiovascular disease. The merged subject data is an identified weakness. The literature

selection methodology could account for skewed data therefore presenting a threat to the

findings. Key findings include that women and men are equally susceptible to

cardiovascular disease and its associated mortality and morbidity, yet women may not be

offered invasive strategies as fi-equently as their male counterparts. The presentation of

cardiovascular disease differs in men and women, therefore clinicians must be aware of

these differences in order to achieve early diagnosis. Risk factor modification is

imperative. Therapy must be individualized. This study provides a foundation for further

research regarding gender differences in cardiovascular disease.

16

According to Vega (2001), indexed in both MEDLINE and CINAHL, the

concepts of hormone replacement therapy, menopause, postmenopausal women,

cardiovascular prevention and coronary heart disease were reviewed. The author o f this

data-based study reviewed 72 references that included 513 subjects in this systematic

literature review. A strength o f the study was the large number of observational studies.

The weakness identified was that the study was limited to only one specific treatment

regimen for secondary prevention. The threat o f this research is that the results o f the

observations and the randomized controlled trials do not match, and too much emphasis

is being placed on the observations. Further research using randomized clinical trials is

imperative to alleviate these discrepancies.

Observational studies associating estrogen therapy vdth or without an

added progestin have consistently and strongly suggested an impressive risk reduction o f

cardiovascular disease among postmenopausal women. The cardioprotective effects o f

estrogen are explained by several plausible mechanisms. These claims are still considered

inconclusive because of lack of data from large clinical trials to support them. The only

RCT done showed HRTs had no overall cardiovascular benefit. For now the wisest

course is to recommend the alternative interventions that have been proven by clinical

trials supporting their effectiveness in reducing adverse cardiac events.

In a retrospective meta-analysis by Whitney et al. (2004), indexed in CINAHL,

several concepts were examined. These concepts involved cardiovascular disease,

osteoporosis, statins, physical activity, and postmenopausal women. The extensive

reference list that included 176 articles is identified as a major strength o f the study. The

heterogeneity o f trials represents a weakness. This literature selection methodology could

17

account for skewed findings that threaten the study. The researcher found that although

mounting evidence supports a link between bone and CV health, it is unclear which of

these conditions initiates the disease process and how each condition affects the other. It

also remains to be determined if exercise provides a synergistic effect with statins (or

other medication) and additional health benefits. Further research will contribute to the

limited body of knowledge and may have implications for future therapeutic targets,

screening, prevention and cost-effective treatment of atherosclerosis, heart disease, and

osteoporosis.

Summary

A review o f the literature reveals that cardiovascular disease in postmenopausal

women is clearly a significant issue both due to the mortality and morbidity o f the

disease, as well as to the prevalence in the U.S. The money spent annually on treatment

o f CVD could instead be used for prevention of the devastating CVD events. Gender

differences are well documented, and although gender is non-modifiable, education for

both women and their healthcare providers regarding the discrepancies is imperative.

HRT is recommended only for the treatment o f hot flashes, insomnia and other symptoms

of menopause, not for CVD protection. Despite the potential cardioprotective and

osteoporosis effects of HRT, there is also evidence of detrimental effects o f this therapy

in CVD. The risks and benefits o f HRT should be discussed with the patient prior to

initiation for any purpose. Family history of early MI is a significant risk factor that also

is non-modifiable.

The obvious focus must be on the modifiable risk factors for the prevention and

treatment of CVD. Hyperlipidemia and hypertension may be controlled by a combination

18

o f appropriate diet, exercise, smoking cessation and medication. Diabetes and obesity are

both treated with the combination o f diet, exercise and medication. Alcohol intake should

be limited to one or less drinks per day. Exercise should be a minimum of 30 minutes o f

brisk walking per day. Eighty-one mg o f aspirin per day should be taken unless

contraindicated. These recommendations along with the appropriate medications needed

for each specific category of CVD will promote the optimum level o f health for

postmenopausal women with CVD.

CHAPTER III

Design and Methodology

This study explores the literature regarding cardiovascular disease in

postmenopausal women, the evidence-based practice guidelines, and the nurse

practitioners role in the disease management. This chapter will present the specific

parameters proposed for this research investigation. It will establish the approach,

literature selection procedure, and literature analysis procedure.

Approach

An integrated literature review, which is a review o f research that combines

comprehensive information on a topic, weighs pieces o f evidence, and integrates

information to draw conclusions about the state o f knowledge, will be used for this

project. This investigation is an evidence-based practice systematic review. While an

integrative literature review summarizes research on a topic o f interest, by placing the

research problem in context and identifying gaps and weaknesses in prior studies to

justify the new investigation (Polit & Peck, 2004), evidence-based practice seeks to

integrate best research evidence with clinical expertise and patient values (Straus,

Richardson, Glasziou, & Haynes, 2005). A summary of the current literature regarding

cardiovascular disease in postmenopausal women is provided.

Literature Selection Procedure

CINAHL, MEDLINE, and the COCHRANE Library were searched for literature

regarding cardiovascular disease and postmenopausal women. Relevant literature was

printed and reviewed for potential contributions to this investigation. The reference lists

from these articles were manually searched and selected additional resources were

19

20

retrieved from other reputable scholarly sources in the healthcare field. Article selection

was based on inclusion of at least one o f the relevant concepts, whether as the focus of

the article or as part o f a broader topic. Other informative articles were also included to

further explore the knowledgebase.

The systematic review began with literature from CINAHL to identify relevant

nursing literature on cardiovascular disease in postmenopausal women. Next, both

MEDLINE and the COCHRANE Library were searched for further relevant literature.

All articles were retrieved through the Mississippi University for Women Fant Library

via internet databases. The review incorporated data beyond nursing literature to expand

the knowledgebase for a thorough review, thus providing a multi-disciplinary approach.

Literature Analysis Procedure

For the purposes of this study, the articles were selected then studied manually for

their significant contribution to the investigation. They were separated into categories

according to the particular aspect o f the research they addressed. The relevant issues

include CVD statistics, gender differences, hormone replacement therapy, lipids,

hypertension, diet, exercise, obesity, diabetes, smoking, osteoporosis and aspirin use. A

knowledgebase of literature critiques developed by Dr. Janice Unruh Davidson (2003)

was utilized to organize the literature by source and date, variables o f interest, literature

type and research tools, research design and sample size, theoretical foundation,

references, and key findings (see Appendix A). Data was then analyzed for relevancy o f

findings and summarized utilizing the template format to assist in application of findings

to the clinical problem. These findings represent the current state o f knowledge available

21

that is discussed in Chapter Four according to the research questions regarding

cardiovascular disease in postmenopausal women and its management.

Summary

This chapter presented the data-based research approach. Techniques for literature

selection and literature analysis have been described. This investigation will allow

healthcare providers to identify areas related to further research in understanding and

managing cardiovascular disease in postmenopausal women.

CHAPTER IV

Knowledgebase Findings and Practice-Based Application

The purpose of this chapter is to present the findings of the knowledgebase that

was derived from this evidence-based systematic literature review regarding

cardiovascular disease in postmenopausal women. Pertinent findings o f this study are

provided with practice-based applications from current clinical practice guidelines.

A systematic literature search o f CINAHL, MEDLINE, and the COCHRANE

Library was conducted by this author in order to obtain the knowledgebase findings. A

total o f 13 citations were reviewed with an additional 611 references represented.

Findings from the literature reviewed are addressed in this section in terms of each

research question generated for the scope o f this study.

Research Question One

Research question one asks: “What is the level o f nursing knowledge regarding

cardiovascular disease in postmenopausal women?” Based on the articles reviewed and

found relevant to the above question, the level o f nursing knowledge regarding

cardiovascular disease in postmenopausal women is quite broad. There is a massive

number of studies related to the occurrence, presentation, diagnosis, treatment and

outcomes o f women with cardiovascular disease. More research is needed, however,

regarding such concepts as the usefulness o f c-reactive protein and homocysteine levels

as increased risk factors.

Research Question Two

Research question two asks: “What are the evidence-based practice guidelines for

cardiovascular healthcare of postmenopausal women?” Each o f the articles reviewed

22

23

provided recommendations including management o f hypertension, lipid levels, exercise,

hormone replacement, smoking cessation, and diet. These recommendations are listed in

Table 3 below.

Table 3Evidence-Based Recommendations-Lifestyle Factors_______________________ _Lifestyle Factors Goals Recommendations

Smoking Complete cessation Avoid passive smoke

Encourage cessation each visit Reinforce nonsmoking status Provide counseling and

pharmacotherapy

Physical activity At least 30min. daily o f moderate exercise

Incorporate physical activity into daily activities

Cardiac rehab program for women with recent CV events

Nutrition AHA Step I Diet if healthy AHA Step n Diet in women

with CVD Limit sodium chloride Increase fiber Consume 5 servings o f

fruits/vegetables

Low saturated fat and high in fiber Drink skim milk Diets rich in antioxidants Limit alcohol to one glass/day

Weight Achieve/maintain desirable weight

Target BMI 18.5-24.9 Target waist < 35 inches

Gradual and sustained weight loss Dietary consult i f needed

Psychosocial factors Decrease stress Improved quality o f life Maintain social support

Positive coping mechanisms Adequate rest Treat depression/anxiety Prevent social isolation

Mosca et al. (1999)

24

Table 4Evidence-Based Recommendations-Risk Factors

R isk factors Goals Recom m endations

Blood pressure Below 140/90 Promote above lifestyle behaviors Pharmacotherapy for BP > 160/100,

& 140/90 after 3 months o f lifestyle changes

Lipids Women s CVD:L D L < 130

Women c CVDL D L < 100

H D L > 45T G < 150

Above lifestyle changes Pharmacotherapy to maintain

LDL, HDL, & TG

Diabetes FBS 80-120 HS BS 100-140 A 1 C < 7 LDL < 100 T G < 150 Control BP

ADA dietLow calorie diet pm weight loss Regular physical activity Pharmacotherapy as indicated for BS

HRT Only if benefits outweigh risks

Short-term for menopause symptoms pm

Individualize decision after risks & benefits discussed

Progestin and estrogen combination if uterus is intact

Anticoagulants Prevention of clots Use ASA 81mg if not contraindicated

B-blockers Reduce reinfarction rate sudden death, & mortality p MI

Start within hours o f evolving M l if not contraindicated and continue indefinitely

ACE inhibitors Reduce morbidity &mortality p MI & c LV dysfunction

Start early unless hypotensive or contraindicated

Continue indefinitely for LVdysfunction, may stop in 6 weeks otherwise

Mosca et al. (1999)

25

Research Question Three

Research question three asks: “According to the literature, what is the role of the

nurse practitioner in the management o f CVD in postmenopausal women?” None o f the

articles reviewed addressed the role o f the nurse practitioner in the management o f CVD

in postmenopausal women. The inclusive term, “healthcare provider” was used in

addition to physician or “primary care provider”.

Summary

This chapter presents the findings o f a knowledgebase that was derived from an

evidence-based literature review regarding cardiovascular disease in postmenopausal

women. Pertinent findings were examined according to each of the three research

questions addressed in Chapter I.

CHAPTER V

Evidence-Based Conclusions, Implications and Recommendations

The purpose o f this study was to investigate the current level o f nursing

knowledge regarding cardiovascular disease in postmenopausal women. This chapter

provides a summary of this investigation, including interpretations of the findings and the

conclusions drawn from these results, as well as the limitations o f the study, and

recommendations for future nursing research.

Summary o f the Investigation

The purpose o f this investigation was to examine the current level o f nursing

knowledge regarding cardiovascular disease in postmenopausal women utilizing Nola J.

Pender’s Health Promotion Model. This model (Appendix B) served as the logical

theoretical approach for this research due to the importance o f health promotion in the

management o f CVD in postmenopausal women. The course o f this investigation was

guided by three research questions. An extensive search o f CINAHL, MEDLINE, and the

COCHRANE Library followed by the review o f 13 relevant articles provided the

information summarized in chapter two. There was limited research regarding the role of

the nurse practitioner in the management o f CVD in postmenopausal women except

under the general term o f primary care provider. Implications for nursing theory, nursing

research, advanced nursing practice, nurse practitioner education and health policy are

identified.

Interpretation o f Findings with Conclusions

According to the literature analysis, a great deal o f research is available regarding

the occurrence, presentation, diagnosis, treatment, and outcomes of CVD in

26

27

postmenopausal women. More study is needed, however, regarding additional

inflammatory markers such as c-reactive protein and homocysteine levels and their

significance as risk factors. This author has attempted in this investigation to consolidate

the current information available regarding CVD in postmenopausal women.

Research Question One

Research question one asks: “What is the level of nursing knowledge regarding

CVD in postmenopausal women?” A vast amount of knowledge exists regarding the

occurrence, presentation, diagnosis, treatment, and outcomes of CVD in postmenopausal

women, however further research is needed regarding the significance of additional

cardiac markers and the effectiveness o f newly developed pharmacotherapeutics.

Research Question Two

Research question two asks: “What are the evidence-based practice guidelines for

cardiovascular healthcare o f postmenopausal women?” The literature reveals specific

evidence-based guidelines as presented in tables 3 and 4. Most of these guidelines

involve lifestyle factors such as smoking cessation, physical activity, nutrition, weight

management, and psychosocial factors. The additional risk factors addressed are blood

pressure control, lipid and diabetes management, anticoagulation, and

pharmacotherapeutics.

Research Question Three

Research question three asks: “According to the literature, what is the role of the

nurse practitioner in the management o f CVD in post menopausal women?” In the

literature reviewed, the nurse practitioner role was not singled out specifically. The role

o f the primary care provider o f which the nurse practitioner is included, however, was

28

discussed at great lengths. The contribution o f the primary care provider in the

management o f CVD in postmenopausal women is indisputable. Each healthcare

encounter must include an assessment o f lifestyle factors that enhance the cardiovascular

health o f the postmenopausal woman. The unique risk factors and presentation o f the

disease in this population must be recognized by the nurse practitioner as well as taught

to the patients and caregivers to enable early recognition o f symptoms. Pender’s Health

Promotion Model aptly depicts the active role the nurse practitioner can have regarding

the teaching and encouragement o f lifestyle changes.

Limitations

As discussed previously, one limitation identified in this study was the lack of

published literature specifically related to the role o f the nurse practitioner in the

management o f CVD in postmenopausal women. Only one of the articles reviewed

specifically addressed this issue. An additional limitation was the potential for biased

data due to the literature selection methodology utilized in this systematic review o f

applicable research.

Implications and Recommendations

This investigation o f healthcare literature regarding CVD in postmenopausal

women provided implications and recommendations focused on nursing theory, nursing

research, advanced nursing practice, nurse practitioner education, and health policy. Each

of the areas are presented in this section.

Nursing Theory

The theoretical foundation for this study was Nola J. Pender’s Health Promotion

Model. This model clearly depicts the influence that the nurse practitioner can have

29

regarding the adherence to the lifestyle modifications necessary for the cardiovascular

health maintenance of postmenopausal women. This theory helps to guide further

research into areas o f patient-provider relationships and the validation of evidence-based

practice.

Nursing Research

Nursing research relates to a systematic method designed to develop knowledge

about ideas o f interest to the nursing profession. A great deal of research exists describing

certain concepts o f CVD in postmenopausal women. Research regarding the specific

contribution of the nurse practitioner in this population with CVD is limited. This

research serves to empower practice and enhance the status of nursing as a profession by

expanding nursing’s scientific knowledgebase.

Advanced Nursing Practice

An advanced practice nurse (APN) is a registered nurse who through advanced

training is qualified to assume some of the duties and responsibilities formerly only

assumed by physicians. As a primary care provider, it is imperative for the APN to be

knowledgeable o f the available research that exists regarding CVD in postmenopausal

women. This knowledgebase will allow the foundation for the evidence-based practice

guidelines to be incorporated by the APN. Prompt recognition of the unique

characteristics o f CVD in this population as well as the management strategies are

invaluable weapons in the APN’s arsenal.

Nurse Practitioner Education

This knowledgebase o f information regarding CVD in postmenopausal women

must be incorporated into the education of all nurse practitioners. The knowledge is

30

necessary for the transition o f the experienced nurse into the role o f a primary care

provider. The findings of nursing research are useless if the process does not include the

dissemination o f the information to those whom it will benefit in practice.

Health Policy

A shift in health policy from treatment to wellness promotion has presented an

open door for the nurse practitioner as a primary care provider. The majority o f

physicians have traditionally chosen disease specialties rather than the wellness

promotion of primary care as their focus. This opportunity challenges nurse practitioners

to stay abreast o f the latest research and trends in health policy.

Summary

This chapter presented the evidence-based conclusions, implications, and

recommendations that were derived from this systematic literature review. Implications

and recommendations for nursing theory, nursing research, advanced nursing practice,

nurse practitioner education, and health policy were provided as they emerged from the

concepts explored. The limitations identified as well as the interpretation of the findings

were discussed.

The purpose o f this Evidence-Base Practice (EBP) project was to develop an

advanced practice nurse knowledgebase regarding cardiovascular disease in

postmenopausal women. The research questions asked were as follow:

1. What is the level o f nursing knowledge regarding CVD in postmenopausal women?

2. What are the evidence-based practice guidelines for cardiovascular healthcare o f

postmenopausal women?

31

3. According to the literature, what is the role o f the nurse practitioner in the management

o f CVD in postmenopausal women?

A Boolean computer search of nursing and medical literature utilizing CINAHL,

MEDLINE, and the COCHRANE Library was conducted for this review. Pender’s

Health Promotion Model served as the theoretical foundation for this clinical project and

guided the systematic review through data collection of the healthcare literature. A

knowledgebase was then developed utilizing the template developed by Davidson which

captured the source and database, variables o f interest, literature type and research tools,

research design and sample size, theoretical foundation, number of references, strengths,

weaknesses, opportunities, threats and key findings of each of the articles reviewed.

Evidence-based practice recommendations were presented and further nursing research

was advised.

The overwhelming prominence o f cardiovascular disease in postmenopausal

women presents a challenge to each nurse practitioner to stay current on research findings

on the concept so that the best possible care can be provided to each patient. How could

one teach what they do not know?

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Medicine. 34(12), 779-807.

APPENDIX A

Cardiovascular Disease in Postmenopausal Women

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APPENDIX B

Nola J. Pender’s Health Promotion Model

INDIVIDUAL CHARACTERISTICS AND EXPERIENCES

BEHAVIOR-SPECIFIC COGNITIONS AND AFFECT

BEHAVIORALOUTCOME

Peroeived benefits o f action

behavior

Personalfectors:

biological,psychological,sociocultural

Perceived barrieîs to action

Perceived self- efficacy

Activity-relatedaffect

Interpersonalinfluences

(fenaily, pœi^, providers)

norms, support, models

Immediate competing demands (low control) and preferences ( h i ^

control)

Commitment 1 Health-to a plan o f -W promoting

action 1 behavior

Situational influences:

options, demand characteristics,

aesthetics

Nola J. Pender’s Health Promotion Model. Tomey and Alligood (2002).