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SNPG917 Evidence Into Practice

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SNPG917 Evidence Into Practice

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Course Code: SNPG917
University: University Of Wollongong

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Country: Australia

What are the risk-factors that increase the risk of cardiovascular disease in older people?

Significance of the study
According to the Australian Government Department of Health (2016), cardiovascular disease is the leading cause of death and disease burden in Australia. The total number of people who are living with cardiovascular disease (CVD) is increasing gradually. According to the reports during the tenure of 2014 to 2015, 4.2 million Australian adults are reported to be suffering from CVD. Of them 1.2 million people are detected with complex CVD condition like stroke and heart disease and 2.6 million adult Australian are reported of having hypertension and 430,000 have indicated of having heart attack at certain point of time (Australian Government Department of Health, 2016). The research conducted by Halter et al. (2014), stated that prevalence of CVD increases with age driven in certain parts through an absolute rise in the incidence of CVD among adults who are over 65-year of age. However, the exact mechanisms and the associated risk factor underlying the age-associated increase in risk of CVD among older adults remain poorly understood. Proper analysis of the risk factor behind the CVD development among the older adults will help frame proper interventions before hand and thereby helping to promote health related quality of life of the those individuals (Halter et al., 2014; Afilalo et al., 2014).
Key terms
Cardiovascular disease: This is the type of heart disease which leads to malfunction of the heart due to the damage of the arteries
Hypertension: It is the long-term condition where the blood pressure of the arteries is persistently elevated
Obesity: Again of uncontrollable body fat is defined as obesity
Type 2 Diabetes mellitus: Lifestyle disease common among older adults which is insulin resistance and is characterized by high level of blood glucose
Question for literature review
What are the risk-factors that increase the risk of cardiovascular disease in older people?
Search strategy
The online search of the literary articles through electronic database was done in Medline, CINHAL and Scopus. These databases were selected because these are available from the University of Wollongong Library. Based in the scope of the research question, the election of the keywords was done in order to increase the number of hits of relevant search (Parahoo, 2014). The main keywords which were use for the search of the scholarly articles online are highlighted below:


Keyword 1

Boolean Operator

Keyword 2

Boolean Operator

Keyword 3


Cardiovascular disease


Older adults


Risk Factor

Boolean Operator







Heart disease





Table: Combination of Keywords Used
Source: Created by author
The Boolean search operators (AND/OR) were use in order to combine the keywords and to perform various permutation and combination with keywords. According to Chaudhuri et al. (2014), use of Boolean operators help to refine the search results. The main inclusion criteria which were selected for the search include papers which are published on or after 2014 and communicated in English. The filter of 2014 to 2018 was chosen in order to focus on the latest progress in the research in CVD. The main exclusion criterion was the papers which were published before 2014. Other exclusion criteria include studies conducted over young adults or adolescence.

The total number of articles selected after the use of keywords


Number of redundant articles


Number of articles omitted after title scrutiny


Number of articles omitted after abstract scrutiny


Number of articles omitted after fill-text analysis


Final article selected


Table: Search statistics
Source: Created by author
Summary of evidence (600)
The analysis of the articles which were retrieved through electronic database highlighted three potential factors which increases the risk of developing cardiovascular disease among the older adults and this include (a) Type 2 Diabetes, (b) High blood pressure or hypertension and (c) Obesity
Type 2 Diabetes Mellitus (T2DM)
According to Aune, Norat, Leitzmann, Tonstad and Vatten (2015), CVD is a common co-morbidity among the older adults with T2DM. In this domain, Einarson, Acs, Ludwig and Panton (2018) conducted a systematic review over the literature which are published in-between 2007 to 2017 over the topics like stroke, myocardial infarction, angina pectoris, ischemic heart disease, coronary heart disease and heart failure. The analysis of the 57 selected articles highlighted that prolong past history of T2DM increase the risk of developing CVD among the older adults. The coronary artery disease and the stroke are highlighted as the major contributor towards high risk of mortality. Shah et al. (2015) conducted cohort study in order to elucidate the effect of the risk factor, T2DM over the progress of CVD. Their aim was to study the association between T2DM and incident of CVD. Their cohort included 1921260 individuals. The analysis of the results highlighted that peripheral arterial disease and heart failure are most common and initial manifestation of CVD diseases among T2DM population. The relative risk of mortality increases with age. The association between T2DM and CVD was shown inversely through the observational population study conducted by Hayward et al. (2015). Their 10 years of follow-up study elucidated that patients with T2DM who are randomly assigned to intensive glycemic control for 5.6 years had fewer reported cases of CVD in comparison to the control group who received no specific treatments for glycemic control.
High Blood Pressure
Hypertension or high blood pressure is also regarded as a potential risk factor behind the development of CVD among the older adults. Wu et al. (2015) conducted a large cohort study over 77,389 community dwelling older adults who are age more than 65-years in order to study the effect of high blood pressure behind the development of CVD during the tenure of 2006 to 2010. The analysis of the hazard ratio among the three different hypertension group revealed that high systolic blood pressure is associated with higher mortality rate and increase in the vulnerability of developing CVD. The significance of the data was highlighted with the statistical analysis with confidence interval of 95%. Yong, Lin and Tan (2017) conducted a study over the older adults of China in order to study the primary prevention method of CVD. The main primary prevention model targeted by the study includes hypertension, in the form of high blood pressure management, anti-hypertension medication and dyslipidemia or the management of hypercholesterolemia. The analysis of the results highlighted that the effective management of the high blood pressure helps in reducing the mortality and the morbidity rate associated with CVD. These results showed that high level of blood pressure or hypertension is a potential risk factor behind the development of CVD among the older adults. Miller, Navar, Roubin and Oparil (2016) conducted a similar study like Yong, Lin and Tan (2017) over the older adults in order to analyze the primary prevention mode of CVD and cardiac arrest. The analysis of the results highlighted that the early detection and the treatment of the hypertension or high blood pressure helps to decrease the severity of the disease and the vulnerability of encountering cardiac accident or strokes. This analysis further highlighted that the group of population who have prolong history of unmanaged high blood pressure are more vulnerable towards developing CVD.
Dhana et al. (2016) conducted a population based observational study over the older adults in order to study in order to elucidate the impact of obesity and over-weight over the life expectancy of the older adults and the risk of developing CVD. They developed multistate tables in order to calculate the prevalence, incidence rate and the hazard ratio. The analysis of this data for a 12 year of follow-up highlighted that obesity has no direct relation with the life-expectancy of the older adults but increases the risk of developing CVD. Amarya, Singh and Sabharwal (2014) conducted a systematic review and meta-analysis in order to study the health consequences of obesity among the older adults. The qualitative analysis of the data collected from the literary articles highlighted that the population of the older adults who are obese are more predispose towards the development of type 2 diabetes mellitus and hypertension, which in turn increases the risk of developing CVD leading to stroke.
Critical review of literature
Generally methodology selected for the selected study was fair. While majority of the study were cohort or population based observational study, few are systematic review and meta-analysis. The selection of the online literary articles failed to highlight any randomised control trial which coincided with the scope of the research. According to Deaton and Cartwright (2018) the analysis of the randomised control trial is a rigorous way of determining the cause-effect relation between the overall treatment and the outcome of the study. Sherman et al. (2014) are of the opinion that the double or the single blinded randomised control trials are powerful experimental design that helps to provide medical information, which are unbiased. So lack of incorporation of the randomised control trial can be highlighted as a drawback of this review. Incorporation of the secondary research is another drawback of the study as Moher et al. (2015) are of the opinion that systematic reviews, which are not based on the randomised control trial has so specific design of selection and thus the outcome of the data are at times biased. Apart from this the review was succinct and compact. The study conducted by Mandviwala, Khalid and Deswal (2016) also highlighted that obesity is an important marker against the development of cardiovascular disease. Obesity invites in several metabolic syndrome like T2DM and hypertension which are further characterised as independent risk factor behind the development of T2DM. Mandviwala, Khalid and Deswal (2016) further highlighted in their review that proper calculation of the obesity paradox helps in proper assessment of CVD.
Strength and limitation
The review of the literature was based on analysis of the factors contributing towards the development of the cardiovascular disease among the older adults. The selected studies for the review of literature were mainly based on large sample size and focus was analysis of the selected risk factors towards the contribution of the disease development. However, there are few limitations of the study; one selected group of study was focused over the China population. According to Lewis (2015) results obtained through a study which are directed towards any particular population might not be applicable over the global scale and this might be highlighted as a limitation.
Relevance and impact of findings and identified gaps
The main relevance of the findings is, the study successful highlighted the three potential factors which are the main contributors towards the development of the CVD among the older adults. This analysis of the risk factor is helpful towards the effective prevention of such chronic diseases from the grass-root level. The detection of the risk factor during the early stage helps to prevent the disease development and thereby helping to improve the better-quality of life. Proper elucidation of the risk factors helps the healthcare professionals to devise the intervention plan accordingly. However, the review of literature failed to highlight the lifestyle factors which are responsible to the development of the CVD due to lack of time and word count. According to Colpani et al. (2018) lifestyle factors like smoking, drinking, unhealthy diet and lack of proper physical exercise increases the risk of developing CVD irrespective of the age bracket. The analysis of these unhealthy lifestyle factors help in framing proper intervention for the disease.
Thus from the above discussion it can be concluded that CVD is an important reason underlying the high risk of mortality and morbidity among the older adults of Australia. The development of the CVD hampers the quality of life and well-being of the older adults. The analysis of the literatures which are published online highlighted that three main factors underlying the disease development is previous disposition of type 2 diabetes mellitus, high blood pressure or hypertension and obesity. The main implication of the research is analysis of the risk factors of CVD helps in the framing of the proper interventions for the effective treatment of the disease. However, the review of literature failed to incorporate the randomised control trails in the analysis and also failed to encompass the unhealthy lifestyle habits which contribute towards the disease development. 
Afilalo, J., Alexander, K. P., Mack, M. J., Maurer, M. S., Green, P., Allen, L. A., … & Forman, D. E. (2014). Frailty assessment in the cardiovascular care of older adults. Journal of the American College of Cardiology, 63(8), 747-762. DOI: 10.1016/j.jacc.2013.09.070
Amarya, S., Singh, K., & Sabharwal, M. (2014). Health consequences of obesity in the elderly. Journal of Clinical Gerontology and Geriatrics, 5(3), 63-67. https://doi.org/10.1016/j.jcgg.2014.01.004
Aune, D., Norat, T., Leitzmann, M., Tonstad, S., & Vatten, L. J. (2015). Physical activity and the risk of type 2 diabetes: a systematic review and dose–response meta-analysis. https://doi.org/10.1007/s10654-015-0056-z
Australian Government Department of Health.  (2016). Cardiovascular disease. Access date: 27th October. Retrieved from: https://www.health.gov.au/internet/main/publishing.nsf/content/chronic-cardio
Chaudhuri, S., Clochard, M., & Solar-Lezama, A. (2014, January). Bridging boolean and quantitative synthesis using smoothed proof search. In ACM SIGPLAN Notices (Vol. 49, No. 1, pp. 207-220). ACM. doi>10.1145/2535838.2535859
Colpani, V., Baena, C. P., Jaspers, L., van Dijk, G. M., Farajzadegan, Z., Dhana, K., … & Chowdhury, R. (2018). Lifestyle factors, cardiovascular disease and all-cause mortality in middle-aged and elderly women: a systematic review and meta-analysis. doi: 10.1007/s10654-018-0374-z
Deaton, A., & Cartwright, N. (2018). Understanding and misunderstanding randomized controlled trials. Social Science & Medicine, 210, 2-21. https://doi.org/10.1016/j.socscimed.2017.12.005
Dhana, K., Berghout, M. A., Peeters, A., Ikram, M. A., Tiemeier, H., Hofman, A., … & Franco, O. H. (2016). Obesity in older adults and life expectancy with and without cardiovascular disease. International journal of obesity, 40(10), 1535. doi: 10.1038/ijo.2016.94
Einarson, T. R., Acs, A., Ludwig, C., & Panton, U. H. (2018). Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007–2017. Cardiovascular diabetology, 17(1), 83. https://doi.org/10.1186/s12933-018-0728-6
Halter, J. B., Musi, N., Horne, F. M., Crandall, J. P., Goldberg, A., Harkless, L., … & Schmader, K. E. (2014). Diabetes and cardiovascular disease in older adults: current status and future directions. Diabetes, 63(8), 2578-2589. https://doi.org/10.2337/db14-0020
Hayward, R. A., Reaven, P. D., Wiitala, W. L., Bahn, G. D., Reda, D. J., Ge, L., … & Emanuele, N. V. (2015). Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. New England Journal of Medicine, 372(23), 2197-2206. DOI: 10.1056/NEJMoa1414266
Lewis, S. (2015). Qualitative inquiry and research design: Choosing among five approaches. Health promotion practice, 16(4), 473-475.
Mandviwala, T., Khalid, U., & Deswal, A. (2016). Obesity and cardiovascular disease: a risk factor or a risk marker?. Current atherosclerosis reports, 18(5), 21. https://doi.org/10.1007/s11883-016-0575-4
Miller, A. P., Navar, A. M., Roubin, G. S., & Oparil, S. (2016). Cardiovascular care for older adults: hypertension and stroke in the older adult. Journal of geriatric cardiology: JGC, 13(5), 373. doi:  [10.11909/j.issn.1671-5411.2016.05.001]
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., … & Stewart, L. A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), 1. https://doi.org/10.1186/2046-4053-4-1
Parahoo, K. (2014). Nursing research: principles, process and issues. Macmillan International Higher Education.
Shah, A. D., Langenberg, C., Rapsomaniki, E., Denaxas, S., Pujades-Rodriguez, M., Gale, C. P., … & Hemingway, H. (2015). Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1· 9 million people. The lancet Diabetes & endocrinology, 3(2), 105-113. https://doi.org/10.1016/S2213-8587(14)70219-0
Sherman, R. E., Anderson, S. A., Dal Pan, G. J., Gray, G. W., Gross, T., Hunter, N. L., … & Shuren, J. (2016). Real-world evidence—what is it and what can it tell us. N Engl J Med, 375(23), 2293-2297. Retrieved from: https://buster.zibmt.uni-ulm.de/dpv/dateien/DPV-Wiss-Real-World%20Evidence%20-%20What%20Is%20It%20and%20What%20Can%20It%20Tell%20Us.pdf
Wu, C. Y., Hu, H. Y., Chou, Y. J., Huang, N., Chou, Y. C., & Li, C. P. (2015). High blood pressure and all-cause and cardiovascular disease mortalities in community-dwelling older adults. Medicine, 94(47). doi:  [10.1097/MD.0000000000002160]
Yong, J., Lin, D., & Tan, X. R. (2017). Primary prevention of cardiovascular disease in older adults in China. World journal of clinical cases, 5(9), 349. doi:  [10.12998/wjcc.v5.i9.349]

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