Heart disease, cardiac rehabilitation and elderly females: are we getting it right?

Heart disease is a leading cause of premature death in the UK (Lockyer and Bury 2002, Peterson and Rayner 2002). Every year 150 000 people in the UK suffer a myocardial infarction. (British Heart Foundation 1999). Heart disease causes reductions in the quality of life and costs the NHS millions.

Heart disease is the number one killer of women in the industrialised world. Over 60,000 women die of heart disease in the United Kingdom each year (Collins 1996).
Myocardial Infarction (MI) is the primary cause of death for women who are more than 40 years of age. Meta-analysis of research studies suggests that women's risk of dying during the first 2 weeks after a heart attack is double that of men (Stone 1995, Schenck-Gustafsson 1996). Further, no aspect of women's lives escape the impact of heart disease (Rhodes and Bowles 2002).

The Department of Health (DoH) has identified health gains and service targets to achieve increases in the quality of life of all those persons suffering from cardiovascular disease. Overall health gains aim to reduce premature deaths from cardiovascular disease by 33% by 2002, compared with 1988. Further, the DoH maintain that post MI rehabilitation programmes should take place at an early stage and be continuous as research has shown that post MI rehabilitation can reduce the number of post MI deaths, reduce post MI morbid events and result in an increase in quality of life for the post MI patient (Jones and West 1996, Tod et al 2002).

However, a major problem identified within Cardiac Rehabilitation (CR) research studies is that of patient non-adherence, particularly among the elderly female population (Moore 1996, DoH 2000). Although a number of studies have suggested possible reasons for this, it is difficult to draw conclusions given that evidence gained from research into this area is based almost exclusively on male patients under the age of 70 (Hamilton and Seidman 1996, Thow et al 2000). Further, different studies measure and define adherence in different ways, making comparisons difficult.

To achieve its outcomes and to fulfill national service framework guidelines, the DoH aims to stimulate research into the most effective methods of rehabilitation for post MI patients. However, efforts to achieve these aspirations are hampered by the problem of patient non-adherence, particularly among the elderly female population.

As already mentioned, the majority of research studies into heart disease and/or cardiac rehabilitation programmes focus upon men (Martensson et al 1998, Rhodes and Bowles 2002). Indeed, it is still widely believed that heart disease is only a problem encountered by men (King et al 2002). Research shows that women, themselves, underestimate their risk of heart disease. Other studies demonstrate that medical and nursing staff also underestimate the occurrence and significance of heart disease in women (Ebbesen 1999). Lockyer and Bury (2002) suggest that there is a more general assumption: that heart disease is a disease of a male dominated society. These false beliefs, it has been suggested, may account for why women are less likely to be diagnosed with a cardiac problem and why they are less likely to receive cardiac treatment and care.
Despite these assumptions, however, there is research which has examined heart disease in women. It shows that women do suffer from heart disease (Wenger 1994) and that they can benefit, just as much as men, from cardiac treatment, care and rehabilitation (Plach 2002). The myth, however, that heart disease is predominately a male phenomena, may account for why women receive less cardiac rehabilitation than men do. Despite cardiac rehabilitation now being embedded in UK government policy, women are still under-represented in all aspects surrounding cardiac rehabilitation (Thow et al 2000). Women are poorly represented in cardiac rehabilitation research.

Women and Cardiac Rehabilitation

Cardiac rehabilitation is a multidisciplinary intervention, designed to improved post MI quality of life and reduce post MI morbidity and mortality. Its aim, to improve the quality of life for post MI sufferers, applies equally to women as it does to men.
Despite this, women are still not gaining the post MI care and attention that they deserve. Although great strives have been made in raising awareness that heart disease kills thousands of women every year, women are more likely not to be enrolled upon a rehabilitation programme and those that are, are more likely to drop out of such programmes.

More research needs to be conducted into how women suffer, recover from and endure heart disease. Once this has been done, appropriate, gender specific cardiac rehabilitation programmes can be developed which will improve the quality of life for all female sufferers of myocardial disease and/or infarction.

References

British Heart Foundation (1999) Coronary heart disease statistics The British Heart Foundation, London , UK.

Collins P. (1996) Heart disease and women. European Heart Journal Vol. 17, Supplement D.

Department for Health (2000) National Service Framework for Coronary Heart Disease. Department of Health, London, UK.

Ebbesen L S. (1999) Women in Cardiac Rehabilitation: our stories. University of Toronto Ed.D Pg 192.

Hamilton G A., Seidman R N. (1996) A comparison of the recovery period for men and women after acute myocardial infarction. Heart and Lung Vol. 22, (4).

King K B., Quinn J R., Delehanty J M., Rizzo S., Eldredge D H., Caufield L., Ling F S. (2002) Perception of risk for coronary heart disease in women undergoing coronary angiography. Heart and Lung Vol. 31, (4).

Lockyer L., Bury M. (2002) The construction of a modern epidemic: the implications for women of the gendering of coronary heart disease. Journal of Advanced Nursing Vol. 39, (5).

Martensson J., Karlsson J E., Fridlund B (1998) Women patients with congestive heart failure: how they conceive their life situation. Journal of Advanced Nursing Vol. 28, Pg. 1216-1224.

Moore S M. (1996) Women's and men's preferences for cardiac rehabilitation program features. Journal of Cardiopulmonary Rehabilitation Vol. 16, (3).

Peterson S., Rayner M. (2002) Coronary heart disease statistics 2002 edition British Heart Foundation Health Promotion Research Group, Department of Public Health, Oxford, UK.

Plach S K. (2002) Women and cardiac rehabilitation after heart surgery: patterns of referral and adherence. Rehabilitation Nursing Vol. 27, (3).

Rhodes D L., Bowles C L. (2002) Heart failure and its impact on older women's lives. Journal of Advanced Nursing Vol. 39, (5).

Stone K S. (1995) Cardiovascular disease and women's health. Heart and Lung Vol. 24, (6).

Schenck-Gustafsson K. (1996) Risk factors for cardiovascular disease in women: assessment and management. European Heart Journal Vol. 17, Supplement D.

Thow M., Isoud P., White M., Robertson I., Keith E., Armstrong G. (2000) Uptake and adherence of women post myocardial infarction to phase III cardiac rehabilitation: are things changing? Coronary Health Care Vol. 4, (4).

Tod A M., Lacey E A., McNeill F. (2002) I'm still waiting…..barriers to accessing cardiac rehabilitation services. Journal of Advanced Nursing Vol. 40, (4).

Wenger N K. (1994) Modern coronary rehabilitation. Postgraduate Medicine Vol. 94, (2).

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