By Alex Colombos, CRC, MA, MPS, MA Ed
Certified Rehabilitation Counselor
New Mexico High lands University/Rehabilitation Association Service Researcher in Rehabilitation Counseling & Disability Studies (2010-2013)
Certified Rehabilitation Counselor
New Mexico High lands University/Rehabilitation Association Service Researcher in Rehabilitation Counseling & Disability Studies (2010-2013)
A. Case Study
John is a 45 year old accountant who has always reported a lot of stress and chest pain, especially when the income tax deadline approaches every April. John is also a heavy smoker and a personality type-A person. A few months ago, he reported to the E.R. (emergency room) with acute chest pain, shortness of breath, fatigue, chest pressure and looking pale. He was rushed to the Coronary Care Unit. His treadmill test, his electrocardiogram (ECG) and his coronary arteriogram turned to be abnormal, with the coronary arteriogram revealing a 90% occlusion of the left main coronary artery. As a result, he had an emergency bypass surgery. Rigidity and occlusion of the artery due to a plaque of lipids and fat were the cause of John’s Arteriosclerotic heart disease or arteriosclerosis, which is also called atherosclerosis, especially when there is plaque of lipids and fats (Falvo, 2009). John has reduced his exercise program and the hours of work from 60 per week to 50, but still his schedule is very heavy and overloaded and thus, stressful and anxiety provoking. However, he is still 250 pounds. His stress makes him eat a lot and as he avoid walking and exercise things get worse. He is also a heavy smoker who smokes an average of 40 cigarettes per day. His also on medication and has reduced smoking to 20 cigarettes per day, but still has moments of high blood pressure and chest pain and chest pressure, as he often gets anxious about his future and the future of his three children and his wife, who doesn’t work as she has to take care of their three children, since her and her husband’s parents have died and they have nobody to take care of the children and their two children whose increasing needs require more money and as a result more hours of work.
B. Diagnosis
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| Lung X-ray |
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| ultrasound arteriography with doppler effect |
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| regular arteriography |
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| Echocardiogram |
The traditional diagnostic methods for arteriosclerosis are both invasive and noninvasive. Invasive tests include arteriography or arteriogram, where a needle is inserted in the arteries and x-rays are taken (Strandness, 2010). Noninvasive tests are chest X-ray or Chest Roentigenography, where an amount of radiation is emitted and the electrocardiogram (ECG), which is “a graphic representation of the electrical currents within the heart” (Falvo, 2009, p.398), the echocardiogram where electrical signals of the heart are converted into ultrasound images and it is used to test the heart and all are performed by a radiologist or a radiological technologist while the Holter Monitor is a type of electrocardiogram which uses a monitor to graphically represent the electrical impulses as a continuous process unlike the traditional one of the one-time reading at a laboratory setting and can be performed by a cardiologist or a technician. The monitor can be portable and the patient may be hooked up to it holding it and checking his/her heart (Falvo, 2009). Ultrasonic arteriography uses Doppler effect that is generating “flow images” converted from electrical signals of the heart (Strandness, 2010). Also, the cardiac stress test is a graphic representation of the heart’s activity during an exercise, such as walking on a running carpet and can be performed by a cardiologist or a technician (Falvo, 2009).
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| stress test |
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| Holter Monitor |
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| ECG |
C. Etiology
Arteriosclerosis is the loss of flexibility of the arteries. It could be any arteries, from the coronary heart arteries, as in John’s case, to those of the peripheral circulatory system and the cerebral and carotid arteries (Falvo, 2009). Arteriosclerosis is interchangeably replaced and identified with atherosclerosis, but there is a slight difference. Atherosclerosis is a type of arteriosclerosis (Mayo Clinic, 2010). In fact, it’s a step ahead: the artery, instead of being simply occluded and narrowed, which is called stenosis, as in the case of arteriosclerosis, in atherosclerosis, it also has an atheroma or plaque of fat and lipids being formed, as already briefly mentioned in the case study (Epstein, 1999).
When the atherosclerosis is severe to the point the plaque totally blocks the artery so it becomes totally occluded, then myocardial infarction may occur (Falvo, 2009). This plaque is caused by hyperlipidemia or high concentration of lipids or fats due to high levels of cholesterol, a condition called hypercholesteremia. Cholesterol is naturally produced by the body. The good cholesterol or HDL (High-Density Lipoprotein) helps transporting LDL (Low-Density Lipoprotein) or bad cholesterol to the liver in order to be metabolized and excreted (Epstein, 1999). There is also the cholesterol taken by foods high in lipids, especially modified lipids and lipoproteins (Falvo, 2009). Arteriosclerosis and especially its subtype of atherosclerosis, is a type of inflammatory disease and not just a typical cardiovascular disease. Inflammation may also be tightly associated with atherogenesis or the generation/production of atheroma (plaque). That is due to the fact that chronic arteriosclerotic lesions trigger a series of cellular and molecular responses that, in aggregate, follow the same mechanism as in the inflammatory diseases. That has a major impact on arteries, muscles, and vital organs and its chronicity (prolonging/excessive duration of illness) manifest a severe chronic illness (Epstein, 1999). Atherosclerosis is usually considered a heart problem, but it often affects other areas of the body (Mayo Clinic, 2010). Although, atherosclerosis may lead to a diverse array of medical problems and conditions, it is both curable and preventable (Mayo Clinic, 2010).
Too much fat builds up on the arterial walls causing a thrombus, a plaque acting as a blood clot that impedes the blood circulation, as it narrows the artery and makes it more rigid and inflexible for the blood to flow. When the thrombus dislodges from the artery walls and travels in the bloodstream, it becomes an embolus in the form of an air bubble, a fat globule or other foreign matter (Falvo, 2009). When the passage is too small for the embolus to pass, the embolus gets stuck and totally interrupts the blood circulation in the specific organ or body part causing embolismus (Falvo, 2009). When that happens in the coronary arteries of the heart, as in John’s case, it causes myocardial infraction, known as heart attack (Falvo, 2009). Restricted blood flow may affects the kidneys causing renal failure or it may cause angina pectoris or chest pain which may exacerbate to heart attack when the blood flow in the coronary arteries is restricted. Smoking, as happened with John, can also cause and exacerbate arteriosclerosis as tar and nicotine build up in the artery and make it inflexible and narrow thus blocking blood flow (Falvo, 2009).
D. Biopsychosocial Aspects
a) Biological Aspect
People with arteriosclerosis may suffer intense chest pain and chest pressure, lose their breath, get tired easily, may feel unfit and reduce exercise and hours of work and may avoid walking as they want to avoid heart attack. They may become pale as the blood flow is disrupted and reduced especially in the upper part of the body which due to gravity may get less blood. However, avoiding walking or light exercise may contribute to obesity and other factors that negatively affect cardiovascular problems, including arteriosclerosis (Falvo, 2009). Studies showed that people with atherosclerosis that are careful with their diet and especially those who are vegetarian have a much better prognosis (Guyton, nd). Moderate walking and light exercise help a lot in the improvement of cardiovascular health. Some symptoms people with arteriosclerosis may experience, include feeling either dizzy or light-handed, pain and tingling of left arm and their hands may feel numb. Atherosclerosis as an inflammatory disease causes a lot of inflammation and pain in the arteries and the muscles (Epstein, 1999). These are symptoms of getting heart attack. People with arteriosclerosis, like John, need to quit smoking, not just reduce it, but sometimes it is very difficult to stop it cold turkey and they may need to enter a smoking cessation program that can help them reduce their cravings (Falvo, 2009).
b) Psychological Aspect
In a fast-paced urban society, arteriosclerosis a common word, usually, is associated with stress and anxiety. Arteriosclerosis may cause symptoms and problems of many severe cardiovascular diseases and it may also cause problems and even failure of other organs and systems of the body, so it is not an accident it is so frequent and it is behind many different types of medical problems (Epstein, 1999). As a result, having this disease may cause fear to the person who has it and sometimes even denial (Falvo, 2009). However, as it is mostly a word associated with etiology (causes), cholesterol and common and frequently occurring symptoms that may often be ignored and trivialized, as most middle and old adults have issues with cholesterol, people may go to the other extreme and hope that their arteriosclerosis may stay at the common levels and do not go further causing chronic vascular and arterial problems or causing serious problems in the carotid, eyes, the brain, the heart, or other vital organs. For this reason, people with arteriosclerosis often overreact to their illness and they may avoid activities, getting into fights or arguments, or expressing emotions as they may want to avoid heart attack (Falvo, 2009).
c) Social Aspect
1. Interpersonal Relationships
Having a cardiovascular and inflammatory condition such as arteriosclerosis which can sometimes be unexpected on what it may cause and as its symptoms may be similar to prodromal (premonitory/leading to disease/early occurring/preliminary stage) symptoms of heart attack (Epstein, 1999), that may come with stigma. People observing one having such symptoms may be afraid and overreact, be overprotective, especially in the family or the community (Falvo, 2009). Fear of losing a loved one from future heart attack or other cardiovascular condition caused by chronic arteriosclerosis may raise issues of who will support the family, especially if the main bread winner is the person with arteriosclerosis (Falvo, 2009). Lack of understanding may bring anger and resentment in the family and community. Absence of social support may make it even harder to cope (Falvo, 2009).
Couples may avoid sex as one of them may fear of hypertension and even heart attack caused by intensive sexual activities and expression of intense intimate feelings. However, avoiding sex is not really a solution and therefore, individuals should discuss their concerns with their physicians and try to find the right one that makes them feel comfortable discussing such issues. Also, physicians should know how to motivate their patients to discuss such issues, as they may be afraid of labeling and being ridiculed and that’s because circulatory problems and low blood flow may cause loose or none erections (Falvo, 2009).
Social isolation, depression and introverted behavior may appear and interfere with everyday interpersonal relationships (Falvo, 2009). Changes in diet, activities and other aspects of lifestyle may become obvious in everyday socializing (e.g. family reunion/holiday dinner, meetings, business lunch/dinner, gym, field trips/excursions, hanging out, etc.). Also, people with arteriosclerosis and other cardiovascular diseases may often not overtly exhibit symptoms, so that their environment may continue expecting them to act as they used to and that may be detrimental in some instances, as the person may not tell their family, loved ones, community or work environment about their medical condition (Falvo, 2009).
2. Independent Living
Lifestyle changes with arteriosclerosis. Diet has to change and weight needs to be controlled and therefore a clinical nutritionist/dietician should be consulted (Guyton, nd). Strenuous activities and intensive exercise have to be reduced, but appropriate exercise and moderate walking need to be continued for prevention with a help of a physical therapist or exercise physiologist/licensed physical education teacher, as some gyms may provide them. Also, tobacco and alcohol use may need to be reduced and smoking cessation and alcohol use psychoeducational and prevention programs may help (Falvo, 2009). Driving alone or doing a strenuous manual work may be negatively contributing to one’s condition, but the individual may need to feel independent and “ normal”, so may continue engaging in the same lifestyle. Physicians need to pinpoint such challenges from the intake and offer good communication and advice to their patients, which, unfortunately, not always happen or rather many doctors fail to do so (Falvo 2009).
3. Vocational Pursuits
The often asymptomatic course of arteriosclerosis or the mild overt and, sometimes not even overt, display of its symptoms may often be ignored and trivialized when catching up with work demands. Workers may be afraid to talk about arteriosclerosis as it is more like a set of symptoms and cause of a diverse and often unexpected array of problems and they don’t want to over-explain or overpathologize their condition. And that is because many employers, once they find out that their employee has a cardiovascular condition, even of a mild type, they may overreact, take it as a formidable barrier to work, because of the profound symbolism and importance of heart and the pervasiveness of the circulatory system and its ominous conditions. As a result, they may rethink of hiring a person with such a condition or they may not promote the individuals with this condition or may not give them responsible and powerful positions that may come with challenges and stress (Falvo, 2009). However, if there is a progressive exacerbation of the symptoms clearly associated with the condition, employees should tell their bosses, but some coaching by their physician or a help-line or a serious medical website would be helpful. Work activities such as standing, stooping, pushing, and lifting may cause hypertension and anomalies in the circulation and thus could lead to immediate and often unexpected cardiovascular episodes (Falvo, 2009). Especially those who work in stress-provoking jobs, such as accounting, as in John’s case, who work for many hours and do sedentary work, may need some special and appropriate exercise (e.g. cardio). People who had bypass surgery, as John, or other heart surgeries, may need to be extra careful with their work lifestyle, especially those with pacemaker, which may interfere with electronic devices in the workplace and elsewhere (Falvo, 2009).
4. Recreation/Leisure
Most recreational activities and even sports can be continued, but extremely rigorous activities should limited or avoided (Falvo, 2009). Other healthy recreational activities may be a good substitute (Falvo, 2009). Also, entertainment that may be associated with bad habits such as overeating, alcohol use, and smoking should be avoided (Guyton, nd). Recreational activities may help the heart stabilize its circulation and cope with inflammatory issues caused arteriosclerosis (Epstein, 1999) as well as prevent social isolation and depression (Falvo, 2009).
E. Treatment/Intervention/ Suggestions
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| carotid endartectomy |
Anti-cholesterol medications for reducing LDL may be prescribed, such as Lipitor, Crestor, and Vytorine (Guyton, nd). For those with carotid arteriosclerosis, carotid entartectomy, where an incision in carotid is made in order to place a stent into the carotid keeping the artery walls stretched to prevent obstruction, occlusion or stenosis (Falvo, 2009). Bypass surgery or CABG (coronary artery bypass graft), as in John’s typical atherosclerosis case, uses a graft in order to replace a removed segment of the artery or even create a new “shortcut” artery to enable blood flow. In cases, where the artery is just narrowed artery, percutaneous coronary intervention (PCI) is used, where a stent widens the narrowed coronary artery (Falvo, 2009). Sodium intake should be restricted as causing water retaining which increase heat’s workload. Low-fat and low-cholesterol diet and elimination of tobacco use are very important for prevention of myocardial infarction, stroke, and kidney failure (Falvo, 2009 – Guyton, nd)). Individuals with arteriosclerosis, and especially those with atherosclerosis, need to systematically seek medical evaluation, prescribed exercise, and in some cases, education and counseling, especially when lack of education or independent living are the case, or when psychological, psychosocial, psychosexual, interpersonal, and vocational issues emerge (Falvo, 2009).
References
Epstein, F. H. (1999). Atherosclerosis: an inflammatory disease. The New England Journal of Medicine 340 (2), 1-12.
Falvo. D.R. (2009). Medical and Psychosocial Aspects of Chronic Illness and Disability. Sudbury, NJ: Jones and Barlett Publishers.
Guyton, J.R. (nd). Atherosclerosis: A story of cells, cholesterol, and clots.
Mayo Clinic (2010). Arteriosclerosis Vs. Atherosclerosis. University of California at San Diego.
Strandness, E. D. (2011). Noninvasive Evaluation of Arteriosclerosis : comparison of methods. Arteriosclerosis, Thrombosis, and Vascular Biology, 3:103-116.
