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From the article provided What do you view as two (2) of the biggest barriers in preventing cardiovascular death? How can they be overcome?Journal of Cardiovascular Nursing
Vol. 34, No. 5, pp. 357–360 x Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Progress in Prevention
Empowering Nurses to Lead Efforts to Reduce
Cardiovascular Disease and Stroke Risk
Tools for Global Impact
Yvonne Commodore-Mensah, PhD, MHS, RN, FAHA, FPCNA;
Ruth-Alma Turkson-Ocran, PhD, MPH, MSN, RN, FNP-BC;
Cheryl R. Dennison Himmelfarb, PhD, RN, ANP, FAHA, FPCNA, FAAN
ardiovascular disease (CVD) is
the leading cause of morbidity
and mortality in the United States
and globally.1,2 The Global Burden
of Disease Study has demonstrated
that progress in reducing mortality
from noncommunicable diseases such
as CVD stalled or reversed between
1990 and 2017.2 Although medications to lower blood pressure and
cholesterol are the most cost-effective
interventions to reduce the burden
of CVD, mortality from CVD has
increased globally since 2007.3 Lifestyle modification, however modest,
can substantially minimize the risk
for CVD and stroke.4 However,
adopting and maintaining heartYvonne Commodore-Mensah, PhD, MHS,
Assistant Professor, Johns Hopkins School of
Nursing, Baltimore, Maryland.
Ruth-Alma Turkson-Ocran, PhD, MPH,
PhD Candidate, Johns Hopkins School of
Nursing Baltimore, Maryland.
Cheryl R. Dennison Himmelfarb, PhD, RN,
Sarah E. Allison Endowed Professor, Johns
Hopkins School of Nursing, Baltimore,
The authors have no funding or conflicts of
interest to disclose.
Yvonne Commodore-Mensah, PhD, MHS,
RN, FAHA, FPCNA Johns Hopkins School of
Nursing, 525 N Wolfe St, Rm 419, Baltimore,
MD 21205 (Ycommod1@jhu.edu).
DOI: 10.1097/JCN.0000000000000606
healthy behaviors such as physical
activity and a healthy dietary pattern are challenging for many individuals all over the world. Factors
contributing to stalled efforts in reducing the burden of CVD and stroke
are complex; they include systemlevel, provider-level, and patient-level
Tackling this global health problem requires a team-based approach.
Healthcare professionals representing
different disciplines have critical roles
to play in managing risk factors for
CVD and stroke. Nurses are well positioned to take on the role of team
leaders in managing CVD and stroke
risk and have proven their ability to
reduce CVD and stroke risk through
nurse-led and team-based models
for CVD prevention.5–7 Nurses represent the largest segment of the
healthcare workforce and play a
crucial role in promoting health and
well-being. There are approximately
29 million nurses and midwives
globally, with almost 4 million nurses
in the United States.8 Nurses adhere
to treatment guidelines and protocols,
reduce hospitalization, improve quality of life, and provide cost-effective
services to diverse populations. The
role of nurses in reducing CVD risk
factors such as hypertension has expanded in the past 5 decades, complementing that of the physician and
other members of the interdisciplinary
healthcare team.9 Although the scope
of practice of nurses varies in the
United States and globally, they are
skilled health professionals who provide care that is holistic and considers the multiple determinants of
health, including social determinants.
Nurses are well trusted to provide
care across the lifespan and work
with diverse communities all over
the world.
Mobilizing, investing in, and
equipping nurses with appropriate
training, resources, and implementation tools are essential strategies
in the global agenda to curb the rising burden of CVD and stroke. In
addition to involving nurses in highlevel policy-making, practice, and
research, there is an urgent need to
empower nurses with the proven
strategies, tools, and resources to lead
healthcare teams to prevent, detect,
and manage risk for CVD and stroke.
Outlined below and in the Table are
resources and tools to build capacity
among nurses to manage CVD and
stroke risk locally and globally.
1. World Health Organization (WHO)
HEARTS technical package for
cardiovascular disease management in primary care10:
The HEARTS technical package
is a resource that provides a strategic
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
358 The Journal of Cardiovascular Nursing x September/October 2019
TABLE Tools to Build Capacity Among Nurses for Global
Management of Cardiovascular Disease and Stroke Risk
World Health Organization (WHO) HEARTS technical package for cardiovascular disease management in primary care10
• Health-lifestyle counseling
∘ Key principles of motivational interviewing and relevant techniques
∘ The 5As (Ask, Advise, Assess, Assist, and Arrange) brief interventions to promote healthy lifestyle (ie, increased physical activity,
healthy diet, tobacco cessation, screen for harmful use of alcohol)
• Evidence-based treatment protocols
▪ Hypertension detection and treatment
▪ Diabetes detection and treatment
▪ Example of essential cardiovascular disease (CVD) medications
• Access to essential medicines and technology
▪ Essential medicines list
▪ Essential list of 6 technologies for CVD screening and monitoring (stethoscope, measuring tape, weighing scale, equipment and
supplies for measuring urine albumin and ketones, blood pressure measurement device, equipment and supplies for measuring blood
glucose and cholesterol)
• Risk-based charts (available soon)
• Team-based care
∘ Steps to implementing team-based care
▪ Engage the team
▪ Determine the team composition
▪ Design workflows to reflect the new model of care
▪ Increase communication among the team, practice, and patients
▪ Use a gradual approach to implement the model
▪ Optimize the care model
∘ Distribution of staff responsibility for hypertension management
∘ Task reassignment for clinic and staff management
∘ Workflow for blood pressure
• Systems for monitoring
∘ Standardized indicators for monitoring HEARTS implementation
∘ Data collection tools (WHO STEPwise approach to Surveillance [STEPS])
∘ CVD patient treatment card
World Health Organization Package of Essential Noncommunicable (WHO PEN) disease interventions for primary healthcare in
low-resource settings
• Protocols for
∘ Prevention of heart attacks, strokes, and kidney disease through integrated management of diabetes and hypertension
∘ Health education and counseling on healthy behaviors
∘ Self-care among patients with cardiovascular disease, diabetes, or respiratory disease
• Sample clinical record for monitoring WHO PEN interventions
• CVD risk prediction charts
• Lists of essential medicines and technologies for primary care and low resource areas
World Heart Federation (WHF)
• Fact Sheets on CVD and risk factors
• Roadmaps
• Infographics on CVD
• CVD advocacy toolkits
• Videos and webinars
• Presentations on CVD, risk factors, and CVD management
Preventive Cardiovascular Nurses Association (PCNA)

Clinical Resources

• Patient education tools
∘ Angina, antiplatelet therapy, atrial fibrillation, hypertension, cholesterol, diabetes, familial hypercholesterolemia, heart failure, heart
healthy toolkit, lipoprotein(a), triglycerides, venous thromboembolism and blood clots
• Provider tools
∘ Atrial fibrillation and stroke infographic, atrial fibrillation disease awareness presentation slides, angina miscommunication graphic,
customizable clinical forms, peripheral arterial disease video series, access to innovative medicines, healthcare provider tip sheet,
access to innovative medicines patient tip sheet, stroke prevention guide, heart health toolbox professional resources
approach to improving cardiovascular
health globally. It consists of 6 modules in multiple languages, including
English, French, Spanish, and Russian.
The step-by-step modules provide a
framework and implementation guide
for managing CVD and stroke risk
and require tailoring to each country’s
unique context. The 5-step approach
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Nurses to Leading Efforts to Reduce CVD and Stroke Risk 359
for implementing HEARTS includes
(1) engage stakeholders, (2) select
demonstration site, (3) plan implementation, (4) implement and monitor, and (5) evaluate and scale up.
Target users for the modules include
national, subnational, and primary
care provider teams.
2. WHO Package of Essential Noncommunicable (PEN) disease interventions for primary healthcare
in low-resource settings11:
The WHO PEN is a resource that
provides a collection of prioritized
interventions and tools that guide
the delivery of quality, cost-effective
care for noncommunicable diseases
in different settings, including lowresource areas. The WHO PEN
facilitates early detection and management of CVD and to prevent
the development of adverse events
or life-threatening complications. The
WHO PEN is available in English
for use by healthcare professionals
and other members of the primary
care team. The WHO PEN includes
protocols to aid with detection, diagnoses, and management of CVD,
myocardial infarction and stroke
risk prediction tools, and guidelines
on basic requirements for essential
medicines and technologies as well
as instruments to assess the impact
of the resource. Flow charts are used
in the clinical protocols to present
evidence-based interventions and a
CVD prediction tool to help healthcare professionals identify and classify persons who are at high risk for
adverse CVD events. This integrated
multifactorial risk approach is costeffective and improves outcomes.11
3. World Heart Federation (WHF)12:
The The World Heart Federation
is a global collaboration representing
several entities, including national and
intercontinental cardiology scientific
societies and foundations; scientific,
medical, and professional communities; as well as patients and charitable organizations. It is the only CVD
nongovernmental organization in official relations with the WHO, and a
member of the Non-Communicable
Disease Alliance. It also leads global
advocacy efforts for action to prevent, control, and reduce the global
burden of CVD. Resources from this
organization are available in English.
4. Preventive Cardiovascular Nurses
Association (PCNA)13:
The PCNA is a nursing organization that is dedicated to managing
CVD and has a mission to promote
nurses as leaders in CVD prevention
and management across the lifespan.
The PCNA serves as a leading voice
for CVD prevention and management and supports nurses through
professional and patient education,
leadership, and advocacy on issues
pertaining to CVD. The Global Cardiovascular Nursing Leadership
Forum,14 an initiative created by
PCNA, seeks to engage, mobilize,
and empower an international community of nurse leaders to promote
the prevention of CVD and stroke
worldwide through research, education, policy, and advocacy.15
There is a pressing need to provide nurses globally with resources
and tools to educate patients and
populations regarding risk factors
for CVD and stroke to prevent premature death and the costly complications of these conditions. In
both resource-constrained and abundant settings, nurses can lead healthcare teams to improve access to
cost-effective interventions to reduce
CVD and stroke risk. Nurses must
be deliberately engaged in policymaking regarding prevention efforts
and in the global health agenda to
reduce morbidity and mortality. Ensuring that nurses’ scope of practice
reflects the full extent of their training
and licensure will improve the ability
of healthcare systems to offer the necessary preventive measures to reduce
burden and to manage the volume
and acuity of patients living with
CVD and stroke. However, in many
settings, this effort will require rigorous training of nurses and redesigning
healthcare systems to empower nurses
to practice at levels beyond their current scope of practice.
The NursingNow! Campaign,16
a collaboration between the WHO
and International Council of Nursing, is a 3-year effort (2018–2020)
that seeks to improve global health
by raising the status of nurses worldwide. The 5 core areas of (1) ensuring that nurses and midwives have
a more prominent voice in health
policy-making, (2) encouraging greater
investment in the nursing workforce,
(3) recruiting more nurses into leadership positions, (4) conducting research that helps determine where
nurses can have the greatest impact,
and (5) sharing of best nursing practices are all directly relevant to the
fight against CVD and stroke. The
WHO has also designated 2020 as
the “Year of the Nurse and Midwife” to honor the 200th birth anniversary of Florence Nightingale.17
This commemoration presents governments with a unique opportunity
to reimagine nursing in the 21st
century and empower them to lead
global efforts to avert deaths and
disability due to CVD and stroke.
1. Benjamin EJ, Muntner P, Alonso A,
et al. Heart disease and stroke
statistics— 2019 update: a report from
the American Heart Association. Circulation. 2019;139(10):e56–e528. doi:
10.1161/CIR.0000000000000659 [doi].
2. Global Burden of Cardiovascular
Diseases Collaboration, Roth GA,
Johnson CO, et al. The burden of cardiovascular diseases among US states,
1990–2016. JAMA Cardiol. 2018;
3(5):375–389. doi: 10.1001/jamacardio.
2018.0385 [doi].
3. GBD 2017 Causes of Death Collaborators. Global, regional, and national
age-sex-specific mortality for 282 causes
of death in 195 countries and territories,
1980–2017: a systematic analysis for the
global burden of disease study 2017.
Lancet. 2018;392(10159):1736–1788.
doi: S0140-6736(18)32203-7 [pii].
4. Artinian NT, Fletcher GF, Mozaffarian
D, et al. Interventions to promote physical activity and dietary lifestyle changes
for cardiovascular risk factor reduction in adults: a scientific statement
from the American Heart Association.
Circulation. 2010;122(4):406–441. doi:
5. Berra K, Miller NH, Jennings C. Nursebased models for cardiovascular disease prevention: from research to
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
360 The Journal of Cardiovascular Nursing x September/October 2019
clinical practice. J Cardiovasc Nurs.
2011;26(4 Suppl):S46–S55. doi:10.1097/
6. Berra K, Fletcher B, Hayman LL,
Miller NH. Global cardiovascular disease and stroke prevention: a call to
action for nursing. J Cardiovasc Nurs.
2019;34(3):197–198. doi:10.1097/JCN.
7. Brush JE Jr., Handberg EM, Biga C,
et al. 2015 ACC health policy statement
on cardiovascular team-based care and
the role of advanced practice providers.
J Am Coll Cardiol. 2015;65(19):
2118–2136. doi:10.1016/j.jacc.2015.03.
8. Haddad LM, Toney-Butler TJ. Nursing shortage. In: StatPearls. Treasure
Island, FL: StatPearls Publishing LLC;
2019. NBK493175 [bookaccession] https://
Accessed July 27, 2019.
9. Himmelfarb CR, Commodore-Mensah
Y, Hill MN. Expanding the role of
nurses to improve hypertension care
and control globally. Ann Glob Health.
2016;82(2):243–253. doi:10.1016/j.
10. World Health Organization (WHO).
HEARTS technical package. https://
hearts/en/. Accessed May 31, 2019.
11. World Health Organization (WHO).
Tools for implementing WHO PEN
(package of essential noncommunicable
disease interventions). https://www.
en/. Accessed May 31, 2019.
12. World Heart Federation. Resources.
org/resources. Accessed May 31, 2019.
13. Preventive Cardiovascular Nurses
Association. https://pcna.net/. Accessed
May 31, 2019.
14. Global Cardiovascular Nursing Leadership Forum. https://gcnlf.pcna.net/.
Accessed May 31, 2019.
15. Hayman LL, Berra K, Fletcher BJ,
Houston Miller N. The role of nurses
in promoting cardiovascular health
worldwide: the global cardiovascular
nursing leadership forum. J Am Coll
Cardiol. 2015;66(7):864–866. doi:10.
16. World Health Organization (WHO).
Nursing Now campaign. https://
now_campaign/en/. Updated 2018.
Accessed May 31, 2019.
17. World Health Organization (WHO).
Executive board designates 2020 as
the “Year of the nurse and midwife”.
2020year-of-nurses/en/. Updated 2019.
Accessed May 31, 2019.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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