Summary
This study explored the views of a diverse group of 39 older people about CVD and its risk prediction. Most participants had CVD or CVD risk factors, and many were taking CVD preventive medications. Findings suggest that older people held poor understanding of the term ‘cardiovascular disease’ and its risk assessment/prediction, but knew what having a ‘heart attack’ or ‘stroke’ meant, and were aware of lifestyle risk factors for CVD. Most participants reported wanting to know their CVD risk and how to reduce it, but two would rather leave such predictions to their God. Importantly, participants distinguished between CVD outcomes, fearing a stroke due to perceived disability and effect on independence and quality of life, but being less concerned about a heart attack, which was perceived to be treatable and cause less disability or swifter death.
Strengths and limitations
To the authors’ knowledge, this study is the first to investigate elders’ preferences regarding CVD risk prediction. A strength of the study is the inclusion of an ethnically diverse group of older people of Māori, Pacific, South Asian, and European ethnic groups, from different geographical sites in New Zealand including city, rural, and urban. The research team included ethnic-specific researchers to contextualise findings and sense-check data within specific ethnic groups.
Embedded within the methodologies were key processes to ensure the trustworthiness of the findings. These included collaboration with ethnic-specific researchers to ensure credibility, dependability, and contextualisation of data, and reflexivity of each researcher when engaged with coding reiterations, so that the stories of the participants, and not the researchers, came through. Qualitative data may not be completely transferable, but, given the convergence of views, the findings are likely to be reflected in similar population groups.
Important limitations are that participants were a small sample of self-selected volunteers living at home or with extended family, or in retirement complexes. Therefore, they may not be representative of all older people, in particular of those in aged residential care. Furthermore, this was a small study that did not aim for data saturation, as a diverse range of rich data was expected owing to the heterogeneity of the participants. However, for the question on the views of older people on CVD risk prediction, data saturation was reached with only three opinions; the majority wanting to know their risk so they could lessen it, that stroke risk was more important than coronary, and the belief that the only person who should deliver such news was their God.
Comparison with existing literature
It is not surprising that participants did not understand the term ‘cardiovascular disease’ because it is a medical term for various diagnoses (for example, coronary heart disease [CHD], stroke, peripheral vascular disease, and heart failure) owing to arterial atherosclerosis. While CVD medical management seeks to mitigate the pathophysiological impact of arterial atherosclerosis, the benefit and harms of treatment are usually conveyed to patients by clinicians according to risk factor (for example, reduce BP or cholesterol) or common CVD outcomes (for example, reduce risk of a heart attack or stroke).18
However, it is perhaps surprising that participants were unaware that CVD risk could be predicted and managed, given that many were on CVD preventive medications. This may be in part because, in New Zealand, the Ministry of Health has promoted CVD risk assessment as having a ‘heart and diabetes check’ and these checks are recommended for people aged <75 years.10,18 With the exception of two participants, there was substantial interest in the fact that the risk of CVD outcomes could be predicted, as well as a desire to be offered and know their own prognosis, and to discuss and understand it.
This study’s findings are consistent with other studies in that the majority of participants are reported to be interested in their prognosis or individualised survival statistics.11–16,19 For example, in a study of 40 older Americans (African American, Chinese American, European American, Latinos, and other) 75% indicated they would want to discuss prognosis with their doctor to prepare logistically/financially, emotionally, or spiritually, as well as to involve family and friends, make health-related decisions, and make the most of the time they have left.11 However, as in the present study, some did not. Indeed, one in four participants said they would prefer not to discuss prognosis as they thought the information was not useful, was too emotionally distressing, or that doctors cannot estimate prognosis (only God can).11 Furthermore, similar to the present study, a sense of helplessness stemming from a family history (for example, ‘my mother had a stroke and therefore so will I’) was also expressed. In a study of older Chinese females on health and cancer screening,25 the authors report themes of genetic predisposition (for example, inheritance from their ancestors) and a sense of fatalism towards illness (what will happen will happen).
Earlier CVD risk equations have been developed for separate categories of CVD outcomes. For example, in 1991 Anderson et al published separate equations for myocardial infarction, CHD, death from CHD, stroke, CVD, and death from CVD.26 However, more recent equations that include older patients have comprised only one composite outcome.5–8 The present findings suggest that, for older people, it is important for CVD risk prediction tools to not only identify the magnitude of CVD risk, but also to separate outcomes such as non-fatal stroke, non-fatal CHD, fatal CVD, and all-cause mortality. These separate prognostic outcomes are important for discussions and decision making regarding the potential benefits and harms of treatment, especially when the potential harms (adverse effects) may be experienced immediately, while the potential benefits may only be reaped after many years. The present study is also consistent with national guidance10 and findings made by Jansen et al,27 which suggest participants want to know their prognosis and be involved in clinical discussions and decisions.28
Implications for research and practice
All but two participants wanted to know their CVD risk and how to manage it, and welcomed individualised clinician advice. However, because they distinguish between CVD outcomes such as stroke and myocardial infarction, CVD risk prediction algorithms should be developed to provide separate prognostic indicators for the separate CVD outcomes, taking into consideration both the magnitude of CVD risk and the type of CVD outcome. Importantly, participants in this study valued interaction with their GP and trusted them to make the best decision for them as an individual. A recent systematic review of 47 clinical practice guidelines on CVD prevention found that, although older people are mentioned in most guidelines, the information provided to guide treatment for older people is vague and limited.28 Clearer guidance is needed for tailoring management to each older person’s context and facilitating greater involvement in shared decision making that considers patient preferences and goals.18
