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i

The ESC Textbook of

Cardiovascular Nursing
ii

ESC SERIES PUBLICATIONS PAGE

The ESC Textbook of Cardiovascular Medicine (Third Edition)

Edited by A. John Camm, Thomas F. Lüscher, Gerald Maurer, and Patrick W. Serruys

The ESC Textbook of Intensive and Acute Cardiovascular Care (Third Edition)
Edited by Marco Tubaro, Pascal Vranckx, Eric Bonnefoy-​Cudraz, Susanna Price, and
Christiaan Vrints

The ESC Textbook of Cardiovascular Imaging (Third Edition)

Edited by José Luis Zamorano, Jeroen J. Bax, Juhani Knuuti, Patrizio Lancellotti, Fausto J. Pinto,
Bogdan A. Popescu, and Udo Sechtem

The ESC Textbook of Preventive Cardiology

Edited by Stephan Gielen, Guy De Backer, Massimo Piepoli, and David Wood

The EHRA Book of Pacemaker, ICD, and CRT Troubleshooting: Case-​Based Learning with
Multiple Choice Questions
Edited by Haran Burri, Carsten Israel, and Jean-​Claude Deharo

The EACVI Echo Handbook

Edited by Patrizio Lancellotti and Bernard Cosyns

The ESC Handbook of Preventive Cardiology: Putting Prevention into Practice

Edited by Catriona Jennings, Ian Graham, and Stephan Gielen

The EACVI Textbook of Echocardiography (Second Edition)

Edited by Patrizio Lancellotti, José Luis Zamorano, Gilbert Habib, and Luigi Badano

The EHRA Book of Interventional Electrophysiology: Case-​Based Learning with Multiple Choice
Questions
Edited by Hein Heidbuchel, Mattias Duytschaever, and Haran Burri

The ESC Textbook of Vascular Biology

Edited by Robert Krams and Magnus Bäck

The ESC Textbook of Cardiovascular Development

Edited by José Maria Pérez-​Pomares and Robert Kelly

The EACVI Textbook of Cardiovascular Magnetic Resonance

Edited by Massimo Lombardi, Sven Plein, Steffen Petersen, Chiara Bucciarelli-​Ducci, Emanuela
Valsangiacomo Buechel, Cristina Basso, and Victor Ferrari

The ESC Textbook of Sports Cardiology

Edited by Antonio Pelliccia, Hein Heidbuchel, Domenico Corrado, Mats Borjesson, and
Sanjay Sharma

The ESC Handbook of Cardiac Rehabilitation: A Practical Clinical Guide

Edited by Ana Abreu, Jean-​Paul Schmid, and Massimo Piepoli
iii

The ESC Textbook

of Cardiovascular
Nursing
EDITED BY

Catriona Jennings
Honorary Professor and Director of Nursing and Interdisciplinary Relations,
National Institute for Prevention and Cardiovascular Health,
National University of Ireland, Galway, Republic of Ireland

Felicity Astin
Professor of Nursing, School of Human and Health Sciences, University of Huddersfield and
Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK

Donna Fitzsimons
Professor of Nursing, Head of School of Nursing & Midwifery
Queen’s University Belfast, Belfast, UK

Ekaterini Lambrinou
Professor in Medical Nursing and Specialties and Gerontology Department of Nursing, School
of Health Sciences, Cyprus University of Technology, Limassol, Cyprus

Lis Neubeck
Professor of Cardiovascular Nursing, School of Health and Social Care,
Edinburgh Napier University, Edinburgh, UK

David R. Thompson
Professor of Nursing, School of Nursing and Midwifery,
Queen’s University Belfast, Belfast, UK

1
iv

1
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© European Society of Cardiology 2022
The moral rights of the authors have been asserted
Impression: 1
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British Library Cataloguing in Publication Data
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ISBN 978–​0–​19–​884931–​5
DOI: 10.1093/​med/​9780198849315.001.0001
Printed in Great Britain by
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v

Foreword

The ESC Textbook of Cardiovascular Nursing is an im- part of the nurse’s role is as an educator, but few have had
portant resource for cardiovascular nurses at all stages the opportunity to access training in this field. The chapter
of their career. It is the work of leading experts in car- entitled ‘Patient education and communication’ ad-
diovascular care and is divided into three sections. The dresses this gap. The chapters that follow consider some
first section, ‘The centrality of nursing within cardiovas- of the challenges that nurses face as well as a snapshot of
cular care’, comprises three chapters: ‘The epidemiology what the future may hold for the professions: ‘Addressing
of cardiovascular disease’, ‘Delivering high-​quality car- the current challenges for the delivery of holistic care’ and
diovascular care’, and ‘Key considerations for continuing ‘Looking forward: the future of cardiovascular care’.
professional development and specialization’. This section The authors’ commitment to evidence-​informed prac-
describes the public health needs of the population with tice makes this textbook of great value to all nurses who
cardiovascular problems and how best to prepare nurses care for cardiac patients. Most of the authors are them-
to meet the challenges of delivering evidence-​ based selves researchers and they cite the latest evidence as well
cardiovascular care. as current clinical practice guidelines and advocate for a
The second section, ‘Holistic nursing care: assess- ‘patient-​centred care approach’ for all cardiac patients
ment, intervention, and evaluation’, comprises nine chap- and their families.
ters. The first chapter is called ‘Anatomy and physiology The ESC Textbook of Cardiovascular Nursing is practical
of the healthy heart’ and provides an overview of how for both graduate and postgraduate nursing programmes
the healthy heart functions. This is followed by ‘Nursing that provide courses on cardiovascular care. It should be
assessment and care planning in the context of cardio- essential reading for nurses who work in inpatient and/​
vascular care’. Together, these two chapters provide an or outpatient cardiovascular settings. Its value extends to
important foundation on which to develop the condition-​ hospital wards and nursing units, including intensive care
specific content that follows about the management and units as well as the community setting.
care of patients presenting with common cardiovascular Catriona Jennings, editor-​ in-​
chief, is Honorary
conditions. These chapters are entitled ‘Care of the pa- Professor at the National University of Ireland, Galway,
tient with coronary heart disease’, ‘Care of the patient with and an internationally recognized clinician, educator, and
cardiac arrhythmias’, ‘Care of the patient with valvular scientist with many years of experience in the prevention
heart disease’, ‘Care of the patient with inherited cardiac of cardiovascular disease. Among her accomplishments
conditions and congenital heart diseases’, and ‘Care of are the EUROACTION trials and the EUROASPIRE surveys
the patient with heart failure’. Many cardiovascular condi- that promote interdisciplinary models of preventive care.
tions are long term and so the patient plays an important She is also one of the founders of the Masters of Science,
role in managing their heart health. The next chapter, Postgraduate Diploma in Preventive Cardiology and the
‘Cardiovascular prevention and rehabilitation’, provides clinical Preventive Cardiology programme, both devel-
a comprehensive overview which offers both online and oped at Imperial College London. Professor Jennings’s
hard copy resources and references, which could well serve extensive background in nursing practice and research is
as a standalone guide to cardiovascular risk reduction amply evident throughout this excellent textbook.
and health promotion. ‘Pharmacology for cardiovascular Felicity Astin, co-​editor, is a clinical academic nurse
nurses’ is an exceptionally well-​organized and well-​written and Professor of Nursing at the University of Huddersfield
chapter and provides readers with a logical, easy-​to-​follow and holds a joint appointment with Calderdale and
approach to understand cardiac medications. Huddersfield NHS Foundation Trust. She led the devel-
The textbook concludes with a section entitled ‘Pro­ opment and publication of the original Core Curriculum
fessional considerations for nurses working in cardiovas- for the Continuing Professional Development of Nurses in
cular care’ which includes three chapters. An important Europe, supported by the expertise of the Association of
vi

vi Foreword

Cardiovascular Nursing and Allied Professions (ACNAP) identification and management of atrial fibrillation, and
Education Committee. The Core Curriculum has been technologies to improve access to healthcare. Professor
translated into several languages and provided the im- Neubeck has been awarded several grants for her re-
petus for this textbook. Professor Astin’s applied research search, for which she has been widely acknowledged and
focuses upon person-​centred care in cardiology practice honoured. She is the current President of the ESC ACNAP.
to examine patients’ experiences of the care they receive David R. Thompson, co-​ editor, is Professor of
and use the findings to drive improvement in healthcare Nursing at Queen’s University Belfast. He is Honorary
provision. Professor in the Department of Psychiatry, University of
Donna Fitzsimons, co-​editor, is Professor of Nursing and Melbourne, Australia; Adjunct Professor in the School of
is currently Head of the School of Nursing and Midwifery Public Health, Monash University, Melbourne, Australia;
and a member of the Senate at Queen’s University Belfast. Honorary Professor in the School of Nursing and
She holds several significant leadership roles at the Midwifery, University of Queensland, Brisbane, Australia;
European Society of Cardiology (ESC), was the first nurse and Distinguished Professor in the School of Nursing at
elected to the ESC Board (2014–​2020), and contributed to Anhui Medical University, Hefei, China. In addition, he is a
the Clinical Practice Guidelines in the same period. She founding editor of the European Journal of Cardiovascular
pioneered the launch of the ESC Patient Forum between Nursing. Professor Thompson’s research focuses on
2018 and 2020 and is committed to the involvement of understanding the experiences, concerns, and needs of
patients, carers, and the wider interdisciplinary team as patients, their partners, and family. His prolific publica-
a means to enhance patient experience and outcomes. tions on cardiac care, specifically cardiac rehabilitation
Professor Fitzsimons’s research is widely cited and has and psychosocial responses to illness, have guided the
guided patient care and professional development for sev- care of cardiac patients for several decades.
eral decades. This distinguished group of scientists, educators, and
Ekaterini Lambrinou, co-​editor, is Associate Professor clinicians have produced a fresh, state-​of-​the-​art textbook.
and first elected academic staff in the Department of As a fellow of the ESC and the American Heart Association,
Nursing at the Cyprus University of Technology, Limassol, I have worked with these esteemed colleagues for more
Cyprus. Her research and cardiovascular nursing mainly than three decades. Their textbook is a boon to all those
focus on the care of patients with heart failure. She has in the nursing profession who care for patients with heart
actively contributed to ESC Guidelines and position state- disease. I recommend it without reservation.
ments. She is a regular contributor to the activities of
Erika Sivarajan Froelicher, MA, MPH, PhD, FAAN
ACNAP and the Heart Failure Association of the ESC.
Emeritus Professor
Lis Neubeck, co-​editor, is Professor of Cardiovascular
Department of Physiological Nursing,
Health in the School of Health and Social Care at
School of Nursing, and
Edinburgh Napier University. She is Honorary Professor of
Department of Epidemiology and Statistics,
Sydney Nursing School, Charles Perkins Centre, University
School of Medicine
of Sydney in Australia where she lived before her appoint-
University of California San Francisco
ment in Edinburgh. Her research focuses on innovative so-
San Francisco, CA, USA
lutions to secondary prevention of cardiovascular disease,
vii

Letter to nurses from the

ESC Patient Forum

‘It is more important to know what sort of person personal encounter can turn a potentially frightening ex-
has a disease than to know what sort of disease a perience into a compassionate interaction.
person has.’ We are thankful for the much-​needed human touch, the
William Osler reassurance, and the humanity nurses provide while we
are surrounded by beeping and flashing monitors or anx-
Dear Nurses, iously awaiting a medical procedure.
While the aphorism by William Osler may still have some We hope that you will inquire about our hopes and ex-
resonance, this textbook demonstrates that in the twenty-​ pectations and explain what we should expect in the fol-
first century it is possible to know both the person and the lowing days and weeks and how our lives will change.
disease, and through positive therapeutic relationships We count on you, with care and understanding, to help
that respect the patient perspective to better achieve the us to believe we can confidently take on the challenges
outcomes that matter to patients. ahead, that everything is going to be all right, that we will
This textbook combines the objective clinical details be all right.
with the recognition of the importance of patient partici- We need our nurses to always be alert and develop spe-
pation in care and understanding the emotional impact cial little antennas that help you notice even our smallest
of cardiovascular disease on patients. Knowledge and handicaps, our pain, our fears because in respect of your
understanding save lives and make a real difference to the unenviable workload and the stressful environment we
quality of life of those whom you care for. might not dare to say something.
Recognizing that we, your patients, are persons and Nurses, we count on your scientific knowledge incorp-
what defines us is so much more than our illness, is fun- orated in this book, and we rely on you to help us—​with
damental for our care. We wish to be listened to, treated kindness, compassion, and empathy.
as individuals with feelings, and given the opportunity to You are our hand-​holders and comforters, reassurance
have a voice in the decisions about our treatment and care. providers, listeners, and translators and our appreciation
Being a patient is also being weak and vulnerable. You and thanks for your dedication, support, and efforts is
go with us through some of the darkest hours and most endless.
intimate moments in our lives. In this situation, a positive Your ESC Patient Forum
vii
ix

Preface

We are proud to present this textbook on cardiovas- pharmacology are also included. The textbook concludes
cular care to you on behalf of the European Society of with a chapter which looks into the future challenges and
Cardiology (ESC) Association of Cardiovascular Nursing opportunities for nurses and the evolution of nursing in
and Allied Professionals (ACNAP). The team of editors cardiovascular care.
and authors of this textbook are experienced practitioners This textbook is designed for registered nurses working
who wish to dedicate this textbook to all those individual in a cardiology setting, to be used alongside a variety of
patients and families who we have cared for throughout teaching and learning approaches, including problem and
our own careers and who have helped to teach us what we team-​based learning using clinical cases to facilitate how
know today. We realize that the care of patients with car- to apply theory in practice, and guided reflective prac-
diovascular disease is becoming increasingly specialized tice to encourage learners to develop new knowledge and
and that there is a need for resources to better educate ways to practise that arise from thinking about their own
and support staff new to the area. This textbook is just or other observed practice. Cross-​referencing is used to
one of those resources developed by ACNAP. We hope it encourage learners to make links and to explore all parts
inspires you to ask questions, search for answers, and be- of the textbook that are relevant to their learning. The
come the best cardiovascular nurse you can be. There is textbook is not aimed at advanced nurse practitioners
now a strong body of evidence confirming that educating who would expect more advanced educational content;
the nursing workforce internationally increases patient nevertheless, they may find it to be a useful educational
safety and saves lives. As a cardiovascular nurse, we tool. It is just one innovative element within the suite of
understand that you will be committed to that objective, ACNAP resources developed over recent years that are
and we further hope that the learning within this textbook available at https://​www.escardio.org/​Sub-​specialty-​
will help you to work more closely with us to help fulfil the communities/​Association-​of-​Cardiovascular-​Nursing-​&-​
ESC mission, which is to reduce the burden of cardiovas- Allied-​Professions. We encourage you to join the ACNAP
cular disease across the world. international community of nurses, where you can be part
This textbook builds on our Core Curriculum for the of a vibrant community of nurses of all kinds who are dedi-
Continuing Professional Development of Nurses Working cated to driving up the quality of cardiovascular care, and
in Cardiovascular Care and provides in-​depth learning for you can benefit from connecting with them and becoming
nurses specializing in caring for patients with coronary an active part of this community.
heart disease, cardiac arrhythmias, valvular heart disease, Since the creation of coronary care units in the 1960s,
inherited cardiac conditions and congenital heart dis- the evolution of cardiac surgery, and the development
eases, and heart failure. The pathology of these conditions of interventional cardiology, which includes close moni-
is described as well as the normal anatomy and physi- toring and management of patients by nurses supported
ology of the heart. While tailoring nursing assessment and by modern technology, our profession has had an in-
interventions to the care of patients with heart disease, creasingly important role in cardiovascular care requiring
it emphasizes high-​quality holistic care taking account extended skills, specialization, and autonomy. These
of the needs of patients with complex comorbidities, as clinical nurse specialist roles have contributed to the de-
well as their families. The imperative of prevention and re- livery of holistic and person-​centred cardiovascular care.
habilitation in terms of both primary and secondary pre- Importantly, nurses, whose fundamental premise is the
vention is confirmed as well as educational, behavioural, delivery of holistic care, are in a prime position to con-
and therapeutic interventions. The epidemiology of car- tribute to reducing health inequalities, improving health
diovascular disease is covered including disease burden literacy, and playing an important role in preventing dis-
and inequalities across European regions. Chapters de- ease. However, the expectation of what nurses can and
voted to patient education and communication and to should do in the context of cardiovascular care varies
x

x Preface

significantly across Europe and indeed globally. This vari- the education and preparation of nurses for specialization.
ation is a function of several factors including the culture The ACNAP strategic plan builds on its commitment to
of healthcare and the standing of nurses within it; the edu- further nursing science in Europe, but also looks beyond
cation and preparation of nurses for both general and spe- this goal to address both education and clinical practice
cialist care; the healthcare system of each country; and the issues. Education is supported through the annual scien-
availability of physicians and specially trained nurses and tific EuroHeartCare Congress which reaches out to nurses
the nature of interdisciplinary working. and allied professionals across Europe and other coun-
In 1980, Professor Paul Hugenholtz, first Fellow, Founder, tries worldwide, and also with the ACNAP Core Curriculum
and early President of the ESC, acknowledged the import- which was launched in 2015. Curricula for nursing edu-
ance of building on the potential of nurses and actively cation vary enormously across European countries, but
encouraged this professional group to get involved in the these curricula define the essential content for cardiovas-
ESC. Attie Immink, a nurse from the Netherlands, took cular nursing. In addition, issues around health policy,
the initiative by bringing nursing sessions into the ESC regulation, and assessment of competencies mean that
Congress and finally establishing the ESC Working Group nurses are prevented from practising to the full extent of
on Cardiovascular Nursing in 1991.This small group of their education and training. In some countries, nursing
specialist nurses, mainly from Northern Europe, had ambi- lacks the formal and recognized medical specialty training
tious goals to put nursing research on the European map. that physicians undergo where roles are clearly defined. If
The group held their first scientific conference in the spring nurses are to meaningfully contribute to meeting the ESC
of 2000 in Glasgow, UK, and established the European mission of reducing the burden of cardiovascular diseases
Journal of Cardiovascular Nursing in 2002, which has sub- in Europe and, further, to reducing premature mortality
sequently grown to become a leading nursing journal glo- from non-​communicable diseases to levels recommended
bally. In 2006, the Working Group was transformed into by the World Health Organization, these training issues
the ESC Council on Cardiovascular Nursing and Allied must be addressed.
Professions, and in 2018, the Council became the seventh The ACNAP Core Curriculum, which exists alongside
Association of the ESC—​the ACNAP. the ESC Core Curriculum for the Cardiologist, serves as
ACNAP has conducted two surveys of nursing educa- a template for structure, content, and educational phil-
tion principally among its membership and attendees osophy in national academic institutions, especially
at EuroHeartCare conferences, the first between 2009 in those countries where this is missing. Like the cardi-
and 2011 and the second in 2018. Both have identified ology core curriculum, it also requires the development
a huge variation in the availability and content of spe- of specialist curricula within the field of cardiovascular
cialist cardiovascular education and training for nurses medicine. ACNAP, in collaboration with the Heart Failure
across Europe. In the most recent survey1 of 876 European Association and the European Association of Percutaneous
nurses, while most reported being educated to bachelor Cardiovascular Interventions, has already published
level, a significant minority of 46% had reached masters nursing curricula. In addition, ACNAP has worked with the
or doctorate level, possibly reflecting the study population Preventive Cardiovascular Nurses Association to develop a
of conference attendees and those holding membership Certificate Programme in Cardiovascular Preventive Care.
with a professional association. Despite this, many re- Given the large global burden of cardiovascular dis-
ported feeling unable to fulfil their clinical roles to optimal eases, and ageing populations with comorbidities and
levels. These perceptions were particularly evident in rela- complex care needs, nurses, who represent the largest
tion to acute care and cardiovascular risk factor manage- healthcare workforce worldwide, are well placed to advo-
ment with respondents expressing a need for education cate for and deliver evidence-​based care and to make an
and training opportunities either as face-​to-​face courses important contribution to the delivery of high-​quality car-
or via blended or e-​learning modes. This textbook is just diovascular care across the different healthcare economies
one part of that armoury that we hope will help you join in Europe and beyond. In order to fulfil the real potential of
with us in the fight against heart disease. our international workforce, we need to ensure that nurses
An important priority for improving the quality of care entering into specialization, following their basic nursing
for patients with cardiovascular disease, which is the lar- education, receive appropriate training for specialization
gest cause of premature mortality worldwide, is to build on which is of an equal standard across Europe. Despite all
the potential of the nursing workforce. In order for nurses the considerable progress in cardiovascular care over re-
to fulfil this potential, there is a need for standardization in cent decades, there is still much to be done and we hope
xi

Preface xi

that this textbook supplies you with the knowledge and in- Reference
spiration to help you play your part in beating the world’s 1. Fitzsimons D, Carson M, Hansen T, Neubeck L, Tanas
biggest killer. M, Hill L. The varied role, scope of practice and
A word of sincere thanks and acknowledgement is due to education of cardiovascular nurses in ESC-affiliated
the authors—​expert clinicians, researchers, and educational- countries: An ACNAP survey. Eur J Cardiovasc Nurs.
ists from all over the world and, in some cases, who represent 2021;20(6):572–9.
nursing leadership groups which are partners of ACNAP inter- Catriona Jennings
nationally. In working with these bodies, ACNAP has been Felicity Astin
able to contribute to international leadership initiatives to Donna Fitzsimons
promote cardiovascular nursing education and research and Ekaterini Lambrinou
improve clinical practice. Our hope is that all these partners Lis Neubeck
will find our ACNAP textbook useful in supporting the educa- David R. Thompson
tion and preparation of nurse specialists internationally.
xii
xii

Contents

Symbols and abbreviations xv

Contributors xvii

Section 1 The centrality of nursing within cardiovascular care

Chapter 1 The epidemiology of cardiovascular disease 3

Guy De Backer, Ian Graham, María Teresa Lira, Laura L. Hayman,
and Izabella Uchmanowicz
Chapter 2 Delivering high-​quality cardiovascular care 29
Lis Neubeck, María Teresa Lira, Ercole Vellone, Donna Fitzsimons,
Lisa Dullaghan, and Julie Sanders
Chapter 3 Key considerations for continuing professional development
and specialization 55
Lis Neubeck, Jennifer Jones, Izabella Uchmanowicz, Sue Koob,
Catriona Jennings, María Teresa Lira, Shirley Ingram, and
Donna Fitzsimons

Section 2 Holistic nursing care: assessment, intervention, and evaluation

Chapter 4 Anatomy and physiology of the healthy heart 81

Geraldine Lee, Gabrielle McKee, Andreas Protopapas, and Ian D. Jones
Chapter 5 Nursing assessment and care planning in the context of
cardiovascular care 111
Ekaterini Lambrinou, Diane L. Carroll, Howard T. Blanchard,
Eleni Kletsiou, Felicity Astin, Alison Woolley, Jo Tillman, Ricardo Leal, and
Rosie Cervera-​Jackson
Chapter 6 Care of the patient with coronary artery disease 145
Valentino Oriolo, Margaret Cupples, Neil Angus, Susan Connolly, and
Felicity Astin
Chapter 7 Care of the patient with cardiac arrhythmias 179
Geraldine Lee, Nina Fålun, Neil Angus, Jeroen Hendriks, Tone M. Norekvål,
Selina Kikkenborg Berg, and Donna Fitzsimons
Chapter 8 Care of the patient with valvular heart disease 215
Tone M. Norekvål, Britt Borregaard, Tina B. Hansen, Trine B. Rasmussen,
and Sandra B. Lauck
Chapter 9 Care of the patient with inherited cardiac conditions and
congenital heart diseases 241
Jodie Ingles, Tootie Bueser, Pascal McKeown, Philip Moons,
and Donna Fitzsimons
xiv

xiv Contents

Chapter 10 Care of the patient with heart failure 283

Tiny Jaarsma, Anna Stromberg, Ekaterini Lambrinou,
Andreas Protopapas, Loreena Hill, Ana Ljubas, and
David R. Thompson
Chapter 11 Cardiovascular prevention and rehabilitation 303
Catriona Jennings, Kathy Berra, Laura L. Hayman, Irene Gibson,
Jennifer Jones, Alison Atrey, David R. Thompson, Chantal F. Ski,
Mary Kerins, Tara Conboy, Lis Neubeck, Robyn Gallagher, and Sue Koob
Chapter 12 Pharmacology for cardiovascular nurses 369
Jan Keenan, Rani Khatib, Gabrielle McKee, Todd Ruppar, and
Franki Wilson

Section 3 Professional considerations for nurses working in cardiovascular care

Chapter 13 Patient education and communication 399

Felicity Astin, Emma Harris, Lis Neubeck, Robyn Gallagher,
and Jennifer Jones
Chapter 14 Addressing the current challenges for the delivery of holistic care 419
David R. Thompson, Martha Kyriakou, Izabella Uchmanowicz,
Jan Keenan, Rani Khatib, Loreena Hill, Lis Neubeck,
Ekaterini Lambrinou, and Abigail Barrowcliff
Chapter 15 Looking forward: the future of cardiovascular care 443
David R. Thompson, Lis Neubeck, and Robyn Gallagher

Index 453
xv

Symbols and abbreviations

AAS acute aortic syndrome ECG electrocardiography/​electrocardiogram

ABG arterial blood gas ECMO extracorporeal membrane oxygenation
ABPM ambulatory blood pressure monitoring EDS Ehlers–​Danlos syndrome
ACE angiotensin-​converting enzyme EDV end-​diastolic volume
ACNAP Association of Cardiovascular Nursing and Allied ESC European Society of Cardiology
Professions EU European Union
ACS acute coronary syndrome(s) FS frailty syndrome
ADP adenosine diphosphate FTAAD familial thoracic aortic aneurysm and dissection
ADR adverse drug reaction GBD Global Burden of Disease
AF atrial fibrillation GCNLF Global Cardiovascular Nursing Leadership
AHA American Heart Association Forum
AI artificial intelligence GTN glyceryl trinitrate
AMI acute myocardial infarction HbA1c glycated haemoglobin
ANP advanced nurse practitioner HBPM home blood pressure monitoring
APN advanced practice nurse HCM hypertrophic cardiomyopathy
ARB angiotensin II receptor blocker HDL-​C high-​density lipoprotein cholesterol
AV atrioventricular HDL-​C high-​density lipoprotein
AVSD atrioventricular septal defect HFmrEF heart failure with a mid-​range ejection fraction
BACPR British Association for Cardiovascular Prevention HFpEF heart failure with a preserved ejection fraction
and Rehabilitation HFrEF heart failure with a reduced ejection fraction
BMI body mass index HSBC Health Behaviour in School-​age Children
BNP B-​type natriuretic peptide hs-​TnT high-​sensitivity troponin T
bpm beats per minute ICC inherited cardiac condition
CABG coronary artery bypass graft ICCU intensive cardiac care unit
CAD coronary artery disease ICD implantable cardioverter defibrillator
CCS chronic coronary syndrome(s) ICN International Council of Nurses
CCTGA congenitally corrected transposition of the great ICVH ideal cardiovascular health
arteries IHI Institute for Healthcare Improvement
CHD congenital heart disease INR international normalized ratio
CI confidence interval IVR idioventricular rhythm
CNS clinical nurse specialist LDL low-​density lipoprotein
COVID-​19 coronavirus disease 2019 LDL-​C low-​density lipoprotein cholesterol
CPVT catecholaminergic polymorphic ventricular LMWH low-​molecular-​weight heparin
tachycardia LQTS long QT syndrome
CRT cardiac resynchronization therapy LV left ventricle/​ventricular
CRT-​D cardiac resynchronization therapy device LVEF left ventricular ejection fraction
CS cardiogenic shock LVNC left ventricular non-​compaction
cTn cardiac troponin LVOTO left ventricular outflow tract obstruction
CVD cardiovascular disease MAP mean arterial pressure
CVH cardiovascular health MCS mechanical circulatory support
CVPR cardiovascular prevention and rehabilitation MEA mean electrical axis
DALY disability-​adjusted life year MFRR multifactor risk reduction
DBP diastolic blood pressure MI myocardial infarction
DCM dilated cardiomyopathy MINOCA myocardial infarction with non-​obstructive
DOAC direct oral anticoagulant coronary arteries
xvi

xvi Symbols and abbreviations

MONICA Multinational MONItoring of Trends and S3 third heart sound

Determinants of CArdiovascular Disease S4 fourth heart sound
NACP National Cardiac Audit Programme SA sinoatrial
NICE National Institute for Health and Care Excellence SBP systolic blood pressure
NOAC non-​vitamin K antagonist oral anticoagulant SCAI Society for Cardiovascular Angiography and
NRT nicotine replacement therapy Interventions
NSTE non-​ST-​segment elevation SCD sudden cardiac death
NSTEMI non-​ST-​segment elevation myocardial infarction SCORE Systematic Coronary Risk Evaluation
NYHA New York Heart Association SMART Specific, Measurable, Achievable,
OARS Open-​ended questions, Affirmation, Reflective Realistic, Timely
listening, Summarizing STEMI ST-​segment elevation myocardial infarction
OGTT oral glucose tolerance test SVT supraventricular tachycardia
PCI percutaneous coronary intervention TAVI transcatheter aortic valve implantation
PCSK9 proprotein convertase subtilisin/​kexin type 9 TCS temporary circulatory support
PDA patent ductus arteriosus TGA transposition of the great arteries
PDSA Plan–​Do–​Study–​Act TOF tetralogy of Fallot
PPCI primary percutaneous coronary intervention TWI T-​wave inversion
PPCM peripartum cardiomyopathy UFH unfractionated heparin
PREM patient-​reported experience measure UK United Kingdom
PRO patient-​related outcome URL upper reference limit
PROM patient-​reported outcome measure US United States
QI quality improvement VAD ventricular assist device
RAAS renin–​angiotensin–​aldosterone system VA-​ECMO venoarterial extracorporeal membrane
RCM restrictive cardiomyopathy oxygenation
RCT randomized controlled trial VKA vitamin K antagonist
RV right ventricle/​ventricular VSD ventricular septal defect
S1 first heart sound VT ventricular tachycardia
S2 second heart sound WHO World Health Organization
xvi

Contributors

Neil Angus, RN, MN BN (Hons), Rosie Cervera-​Jackson, RN, MA (Oxon), MSt, DipHe
PG Cert (Professional & Higher Education) FHEA Practice Educator Royal Brompton Hospital
Senior Lecturer London, UK
University of the Highlands and Islands, Inverness, UK
Tara Conboy, RGN, BSc, MScN, MScPC, FIPC
Felicity Astin, RN, BSc (Hons), PG Cert (Education), Occupational Health Advisor
MSc, PhD, FHEA Medmark Occupational Health, Dublin, Ireland
Professor of Nursing
Susan Connolly, MB BCh BAO, PhD, FRCP Edin
University of Huddersfield and Calderdale and
Consultant Cardiologist
Huddersfield NHS Foundation Trust
Western Health and Social Care Trust, Enniskillen, UK
Huddersfield, UK
Margaret Cupples, MD, FRCGP
Alison Atrey, BSc, PG Dip, Ad PG Dip, SRD, PhD
Emeritus Professor
Honorary Clinical Fellow
Queen’s University Belfast, Belfast, UK
National University of Ireland
Ireland, Galway Guy De Backer, MD, PhD
Emeritus Professor
Abigail Barrowcliff MPharm IPP PG(Dip) Pharm
Ghent University, Ghent, Belgium
Advanced Clinical Pharmacist - Cardiovascular Services
Leeds Teaching Hospitals NHS Trust Lisa Dullaghan, MSc, RN
Leeds, UK Interim Assistant Director Nursing—​Safe &
Effective Care
Kathy Berra, MSN, NP, BC, MSN, NP-BC, FAANP, FPCNA,
South Eastern Health & Social Care Trust, Belfast, UK
FAHA, FAAN
Co-Director, The LifeCare Company Nina Fålun, RN, ICN, MSc
Stanford Prevention Research Center (Ret) Clinical Nurse Specialist
Stanford University School of Medicine (Ret) Haukeland University Hospital
Stanford, CA, US Bergen, Norway
Senior lecturer
Howard T. Blanchard, DNP, MEd, RN, ACNS-​BC, CEN
Western Norway University of Applied Sciences
Clinical Nurse Specialist
Bergen, Norway
Massachusetts General Hospital, Boston, MA, US
Donna Fitzsimons, BSc, PhD
Britt Borregaard, RN, MPQM, PhD
Professor and Head of School of Nursing & Midwifery,
Associate Professor
Queen’s University Belfast, Northern Ireland
Odense University Hospital, Odense, Denmark
Robyn Gallagher, RN, BA, MN, PhD
Tootie Bueser, RN, MSc, PhD
Professor of Nursing
Director for Nursing & Midwifery, South East Genomic
The University of Sydney, Sydney, Australia
Medicine Alliance
Guy’s & St Thomas’ Hospital NHS Foundation Trust Irene Gibson, RGN, MA, PG Dip, FNIPC
London, UK Director of Programmes and Innovation at the National
Institute for Cardiovascular Health (NIPC)
Diane L. Carroll, PhD, RN, FAAN, FAHA, FESC
Galway, Ireland
Nurse Researcher, Munn Center
Nursing Research Ian Graham, MB, BCh, BA, BAO, FRCPI, FESC, FTCD
Massachusetts General Hospital, Boston, MA, USA Professor of Cardiovascular Medicine
Trinity College Dublin, Dublin, Ireland
xvi

xviii Contributors

Tina B. Hansen, PhD Jennifer Jones, PhD, MSc, PGCertEd, MCSP, HPC, FIPC
Associate Professor Associate Professor
Zealand University Hospital, Denmark National University of Ireland, Galway and Director of
Training and Education
Emma Harris, BSc, PhD
National Institute for Prevention and Cardiovascular
Research Fellow in Patient Education and
Health
Communication
Galway, Ireland
University of Huddersfield, Huddersfield, UK
Jan Keenan, RN, DipN (London), PGDip Ed, MSc
Laura L. Hayman, PhD, MSN, FAAN, FAHA, FPCNA
Non-Medical Prescribing Lead, Oxford university
Professor of Nursing
Hospitals, and Visiting Fellow, Oxford Brookes University
UMass Boston and UMass Medical School,
Boston, MA, US Mary Kerins, RGN, SCM, Cert CCU, Dip Cardiac
Rehabilitation, MSc
Jeroen Hendriks, RN, MSc, PhD
Manager of Cardiac Rehabilitation Services
Professor of Cardiovascular Nursing
St James’s Hospital, Dublin, Ireland
Flinders University and Royal Adelaide Hospital,
Adelaide, Australia Rani Khatib, DPharm (PhD), FRPharmS
Consultant Cardiology Pharmacist and Honorary Senior
Loreena Hill, BSc, MSc, PhD
Lecturer
Lecturer (Teaching & Research)
Leeds Teaching Hospitals NHS Trust and University of
Queen’s University Belfast, Belfast, UK
Leeds, Leeds, UK
Jodie Ingles, GradDipGenCouns, PhD, MPH
Selina Kikkenborg Berg, RN. Ph.d. FESC. FAHA
Head, Clinical Genomics Laboratory and Cardiac Genetic
Professor of Cardiology
Counsellor
The Heart Center
Centre for Population Genomics, Garvan Institute
Copenhagen University Hospital Rigshospitalet,
of Medical Research, and UNSW Sydney, Sydney,
Denmark
Australia
Centenary Institute, The University of Sydney, Sydney, Eleni Kletsiou, RN, MSc, PhD
Australia University General Hospital Attikon, Athens, Greece
Department of Cardiology, Royal Prince Alfred Hospital,
Sue Koob, MPA
Sydney, Australia
CEO
Shirley Ingram, RGN, MSc Preventive Cardiovascular Nurses Association,
Advanced Nurse Practitioner Madison, WI, US
Registered Nurse Prescriber
Martha Kyriakou, RN, BSc, MSc, PhD
Department of Cardiology
Nurse
Tallaght University Hospital
Nicosia General Hospital, Nicosia; and Cyprus University
Dublin, Ireland
of Technology, Limassol, Cyprus
Tiny Jaarsma, RN, PhD
Ekaterini Lambrinou, RN, BSc, MSc, PhD, FESC, FHFA
Professor
Professor in Medical Nursing & Specialties and
Linköping University, Linköping, Sweden
Gerontology Nursing
Catriona Jennings, BA (Hons), PhD, PG Cert ULT, FESC, Director, MSc in Advanced Acute and Intensive
FPCNA, FIPC Cardiology Care
Honorary Professor of Nursing and Interdisciplinary Department of Nursing, School of Health Sciences,
Relations Cyprus University of Technology
National University of Ireland—​Galway, Galway, Ireland
Sandra B. Lauck, PhD
Ian D. Jones, RN, PhD, PGCLT Clinical Associate Professor and Clinician Scientist
Professor of Cardiovascular Nursing University of British Columbia, Vancouver, BC, CA
Liverpool John Moores University, Liverpool, UK
xix

Contributors xix

Ricardo Leal, BSc, MSc Trine B. Rasmussen, PhD

Charge Nurse, Associate Professor/​Senior Researcher
Royal Brompton Hospital - Adult Intensive Care, University of Copenhagen/​Herlev and Gentofte University
London, UK Hospital, Copenhagen, Denmark

Geraldine Lee, BSc, PhD Todd Ruppar, RN, PhD, FAHA, FAAN
Reader in Advanced Clinical Practice John L. and Helen Kellogg Professor of Nursing
Kings College London, London, UK Rush University, Chicago, IL, US

María Teresa Lira, MScN, CV Specialist, FPCNA Julie Sanders, RN, BSc (Hon), MSc, PhD, FESC
Executive Coordinator of Research Unit Director Clinical Research
Hospital Clínico Fuerza Aérea de Chile Santiago, Chile St Bartholomew’s Hospital
Barts Health NHS Trust and Honorary Clinical Professor
Ana Ljubas, Msc, FESC
of Cardiovascular Nursing, The Wiliam Harvey Research
Assistant Director for Nursing, Head Nurse
Institute, Queen Mary University of London
University Hospital Centre Zagreb, Zagreb, Croatia
London, UK
Gabrielle McKee, BA (Mod), PhD
Chantal F. Ski, PhD
Associate Professor
Professor and Director of the Integrated Care Academy
Trinity College Dublin, Dublin, Ireland
University of Suffolk, Ipswich, UK
Pascal McKeown, MD, FRCP, FESC
Anna Stromberg, PhD
Head of School and Dean of Education
Professor
School of Medicine, Dentistry & Biomedical Sciences
Linköping University; and Linköping University Hospital,
Queen’s University Belfast, Whitla Medical Building
Linköping, SE
Lisburn Road, Belfast
David R. Thompson, RN, BSc, MA, PhD, MBA, FRCN,
Philip Moons, PhD, RN, FESC, FAHA, FAAN
FAAN, FESC, MAE
Professor of Healthcare and Nursing Science
Professor of Nursing
KU Leuven, Leuven, Belgium; University of Gothenburg,
Queen’s University Belfast, Belfast, UK
Gothenburg, Sweden; and University of Cape Town,
Cape Town, South Africa Jo Tillman, RGN, BSc, MSc
Senior Nurse/​Matron
Lis Neubeck, BA (Hons), PhD, FESC
Royal Brompton Hospital, Guys and St Thomas’ NHS
Professor of Cardiovascular Nursing
Foundation Trust, London, UK
Edinburgh Napier University, Edinburgh, UK
Izabella Uchmanowicz, RN, PhD, FESC, FHFA
Tone M. Norekvål, RN, MSc, PhD, FESC, FAHA
Professor
Professor of Nursing
Wroclaw Medical University, Wroclaw, Poland
Haukeland University Hospital, Bergen; and University
of Bergen; and Western Norway University of Applied Ercole Vellone, PhD, RN, FESC, FAAN
Sciences, Bergen, Norway Associate Professor of Nursing
University of Rome Tor Vergata, Rome, Italy
Valentino Oriolo, MSc, FESC
Cardiac ACP Franki Wilson, MPharm, PGDip
Department of Emergency UHBW Associate Senior Advanced Clinical Pharmacist
Lecturer CVS Pharmacology Leeds Teaching Hospitals, Leeds, UK
UWE Education Chair, EAPCI
Alison Woolley, RN, ANP, MSc
Education Committee, ACNAP
Lead Nurse for Pre-​Operative Cardiac Surgery
Supervision and Assessment Lead, AIM, HEE
St George’s University Hospital NHS Foundation Trust,
Andreas Protopapas, RN, BSc, MMedSc, PhD London, UK
Lecturer in Nursing
European University Cyprus, Nicosia, Cyprus
xx
1

Section 1: The centrality

of nursing
within
cardiovascular
care
2
3

1 The epidemiology of
cardiovascular disease
GUY DE BACKER, IAN GRAHAM, MARÍA TERESA LIRA, LAURA L. HAYMAN,
AND IZABELLA UCHMANOWICZ

CHAPTER CONTENTS

Introduction 4 Introduction 11
The burden of cardiovascular disease across Europe 4 Cardiovascular disease risk estimation: overview
Historical background 4 and use in clinical practice 12
Cardiovascular disease mortality 5 Cardiovascular risk estimation in special
Premature cardiovascular disease mortality 7 populations 16
Morbidity 8 The future in cardiovascular disease estimation 20
Economic burden of cardiovascular disease 10 The role of the nurse 20
Summary 11 Explanation of the cardiovascular disease epidemic and
Cardiovascular risk across the lifespan 11 consequences for the future 20

KEY MESSAGES is 30% higher in men than in women, in particular for

acute myocardial infarction admissions.
● Global risk calculation has been considered the
● Cardiovascular disease (CVD) remains a major cause best tool for comprehensive cardiovascular primary
of total mortality in Europe, accounting for 45% of all prevention, to deal with the risk of developing
deaths in Europe as a whole and 37% of total mortality atherosclerotic CVD.
in the European Union. ● To prevent death and morbidity from CVD, the
● Results from the European Society of Cardiology Atlas guidelines highlight the importance of identifying
of Cardiology demonstrate important inequalities, asymptomatic patients who would be candidates for
with CVD deaths accounting for more than 50% of all more intensive, evidence-​based medical interventions
deaths in some countries compared with less than 30% that reduce CVD risk.
in others. ● In recent years, challenges in cardiovascular risk
● Disability-​adjusted life years may be among the most estimation efforts have included how to estimate it in
appropriate quantitative indicators of how effective different vulnerable groups more accurately, such as
preventive and therapeutic strategies are in reducing children and adolescents, young adults, older adults,
the CVD burden. and immigrants, and how other factors, such as social
● Another indicator of the burden of CVD morbidity is the status or literacy, may influence expected outcomes.
hospitalization rate for cardiovascular conditions which
4

4 Section 1 The centrality of nursing within cardiovascular care

● The nurse or nurse specialist is uniquely well placed to The burden of cardiovascular
play a pivotal role in risk estimation and management
through her or his knowledge of the science of risk disease across Europe
estimation, its practical application, and her or his role The purpose of this section is to describe the health
as counsellor and advisor through the nurse’s unique burden caused by CVD to society in Europe using dif-
relationship with patients, families, and communities ferent data sources. Reports from authorities dealing
for holistic assessment and shared decision-​making. with the burden of CVD are available particularly from
● Regardless of the strategy, prevention of CVD should the European Society of Cardiology (ESC),1 the European
be coordinated and implemented at many levels, from Heart Network,2 the World Health Organization (WHO),3
international roadmaps and guidelines to national and and the Global Burden of Disease (GBD) study group.4
regional policies and standard operating procedures of Comparisons of these results are not always possible
individual healthcare centres and other business entities. because the data are not harmonized from the outset;
● Prevention of CVD should take a multidisciplinary, results are also presented for sets of different countries,
multifactorial, and societal approach including for example, all or some of the 53 member states of the
strategies to improve health literacy, empowerment, WHO’s European Region, of the 28 European Union (EU)
self-​care management, and environmental adaptations. member states, and of the 56 ESC member countries.
Mortality statistics are mainly based on official data with
limitations regarding the quality of the data, including
Introduction cause of death certification. Results on morbidity from the
GBD study have been estimated by modelling surveillance
In this chapter, we will cover the available epidemiological data and results from surveys and from hospital records,
data for cardiovascular disease (CVD). The chapter starts all of which also have limitations in terms of validity and
with a description of the health burden caused by CVD precision. Clearly, standardization across Europe of defin-
in Europe using different data sources. A brief historical itions, data collection methods, and validation procedures
background is given of CVD followed by a description of is required, with an emphasis on real data to reduce the
the burden of CVD mortality and morbidity. The preva- need for estimates and modelling.
lence of CVD, which refers to the number of people who
are currently living with CVD in the population, and eco-
nomic burden of CVD are also discussed. Next, risk factors
Historical background
for CVD are described focusing on atherosclerosis and The epidemic of CVD is a dramatic story in its own right.
certain genetic conditions (e.g. familial hypercholester- It started with alarming rises in CVD mortality rates in
olaemia). CVD risk estimation is highlighted along with Western countries after the Second World War, resulting
an overview of clinical practices. The preventive role of in a warning by the Executive Board of the WHO in 1969:
nurses is intimately linked to estimating the patient’s risk ‘Mankind’s greatest epidemic: coronary heart disease has
for CVD and working with the health team and the patient reached enormous proportions striking more and more
in their shared decision-​making. Additionally, there is a at younger subjects. It will result in coming years in the
detailed description of several risk estimation equations greatest epidemic mankind has faced unless we are able
and the important role of risk modifiers and biomarkers. to reverse the trend by concentrated research into its
Challenges in cardiovascular risk estimation efforts have cause and prevention.’ In the absence of precise and valid
included not only how to address it in different regions or statistics it was difficult to understand the epidemic. This
countries, but also how to estimate it in different vulner- was the background of the world’s largest epidemiological
able groups more accurately, such as children and ado- study ever conducted of heart disease, stroke, risk fac-
lescents, young adults, older adults, and immigrants, and tors, and population trends: the Multinational MONItoring
how other factors, such as social status or literacy, may of Trends and Determinants of CArdiovascular Disease
influence expected outcomes. Finally, there is a section on (MONICA) Project5. During the 1980s and 1990s, the
an explanation of the CVD epidemic and consequences attack rates of acute myocardial infarction (AMI) were
for the future. Prevention of CVD should take a multidis- registered in communities across four continents during
ciplinary, multifactorial, and societal approach including a 10-​year period using a standardized protocol. In people
strategies to improve health literacy, empowerment, self-​ aged 35–​64 years, large differences in attack rates of AMI
care management, and environmental adaptations. were observed as well as large differences in changes
5

Chapter 1 The epidemiology of cardiovascular disease 5

Men Women
FIN-NKA UNK-GLA
FIN-KUO UNK-BEL
UNK-GLA AUS-NEW
UNK-BEL FIN-NKA
FIN-TUL USA-STA
CAN-HAL DEN-GLO
SWE-NSW
POL-WAR
ICE-ICE
FIN-KUO
DEN-GLO
CAN-HAL
AUS-NEW
POL-WAR SWE-NS
CZE-CZE NEZ-AUC
USA-STA RUS-NOI
RUS-MOC ICE-ICE
NEZ-AUC POL-TAR
LTU-KAU FIN-TUL
RUS-MOI RUS-NOC
BEL-CHA RUS-MOC
RUS-NOC BEL-CHA
AUS-PER RUS-MOI
POL-TAR YUG-NOS
YUG-NOS AUS-PER
SWE-GOT SWE-GOT
RUS-NOI CZE-CZE
GER-BRE BEL-GHE
BEL-GHE
GER-BRE
GER-EGE
FRA-STR
FRA-STR
GER-EGE
SWI-TIC
GER-AUG LTU-KAU
FRA-LIL FRA-LIL
ITA-BRI GER-AUG
ITA-FRI ITA-FRI
SWI-VAF ITA-BRI
FRA-TOU FRA-TOU
SPA-CAT CHN-BEI
CHN-BEI SPA-CAT
0 200 400 600 800 1000 0 100 200 300 400 500

Average annual event rate per 100,000 Average annual event rate per 100,000

Fig. 1.1 Average annual age-​standardized event rates of AMI per 100,000, for men and women aged 35–​64 years, based
on observations during the first 3 years of registration in the mid-​1980s (see reference5 for the precise years and the
identification of the communities).
Source data from Tunstall-​Pedoe H. MONICA. Monograph and multimedia sourcebook: world’s largest study of heart disease, stroke,
risk factors, and population trends 1979–​2002. Geneva: World Health Organization; 2003.

of these attack rates over time; this is illustrated in changes in coronary care and secondary prevention were
➤ Fig. 1.1 and ➤ Fig. 1.2. strongly linked with declining coronary endpoints.7
These results and others clearly illustrate the dynamics
of the epidemic of CVD in the last decades of the twen-
Cardiovascular disease mortality
tieth century, confirming the trends seen in official mor-
tality statistics and illustrating large differences between CVD is still a major cause of total mortality in Europe, ac-
communities and over time. The results also showed that counting for 45% of all deaths in Europe as a whole (40%
temporal changes in attack rates of AMI varied by region in men and 49% in women) and 37% of total mortality in
within countries, for instance, in Belgium, where a sig- the EU (34% in men and 40% in women).2 Results from
nificant difference in attack rate of AMI and in temporal the ESC Atlas of Cardiology demonstrate important in-
change was observed between the populations of Ghent equalities, with CVD deaths accounting for more than 50%
and Charleroi, two cities 100 km apart in which the same of all deaths in some countries compared with less than
healthcare system is operational (see ➤ Fig. 1.1 and 30% in others.1 Although the annual number of deaths
➤ Fig. 1.2 comparing BEL-​GHE with BEL-​CHA). The overall from CVD has declined in some high-​ income Western
conclusion of the MONICA Project was that changes in European countries between 1990 and 2013, globally in
cardiovascular risk factors explain partly the variation Europe more and more people are dying from CVD. This is
in population trends in coronary heart disease6 and that mainly due to the demographic growth and the ageing of
6

6 Section 1 The centrality of nursing within cardiovascular care

Men Women
FIN-NKA RUS-MOC
FIN-KUO FRA-STR
ICE-ICE AUS-NEW
SWE-NS FIN-NKA
AUS-NE FIN-TUL
NEZ-AUC FIN-KUO
CAN-HAL ICE-ICE
UNK-BEL
SWE-GOT
GER-AUR
ITA-BRI
USA-STA
FIN-TUL NEZ-AUC
DEN-GLO BEL-GHE
SWE-GO DEN-GLO
FRA-STR USA-STA
SWI-VAF UNK-BEL
BEL-GHE SWE-NS
AUS-PER AUS-PER
RUS-MOI FRA-TOU
GER-BRE RUS-MOI
SWI-TIC FRA-LIL
ITA-BRI ITA-FRI
FRA-TOU CHN-BEI
GER-AUU GER-AUU
UNK-GLA GER-BRE
FRA-LIL POL-TAR
RUS-MO UNK-GLA
ITA-FRI CAN-HAL
RUS-NO POL-WAR
GER-EGE
BEL-CHA
CZE-CZE
RUS-NOC
BEL-CHA
YUG-NOS RUS-NOI
POL-WA GER-EGE
POL-TAR SPA-CAT
LTU-KAU CZE-CZE
SPA-CAT LTU-KAU
CHN-BEI YUG-NOS
RUS-NOI GER-AUR
–15 –10 –5 0 5 10 –15 –10 –5 0 5 10
Annual trend percent Annual trend percent

Fig. 1.2 Average annual change from the mid-​1980s to the mid-​1990s in age-​standardized attack rates of AMI in per cent,
for men and women aged 35–​64 years at baseline. The horizontal bars represent the annual trend in per cent and the 95%
confidence intervals. Declining trends are shown to the left of the zero line, increasing trends to the right (see reference (5)
for the precise years and the identification of the communities).
Source data from Tunstall-​Pedoe H. MONICA. Monograph and multimedia sourcebook: world’s largest study of heart disease, stroke,
risk factors, and population trends 1979–​2002. Geneva: World Health Organization; 2003.

populations—​more women than men ultimately die from In 2014, age-​ standardized mortality rates from cor-
CVD, particularly from stroke, and this also has to do with onary heart disease across ESC member countries were
their longer life expectancy. These results should warn us 214 and 384 per 100,000 in women and men, respectively.
that the burden of CVD will remain a major challenge as The variation between countries is huge with rates greater
the European population grows and ages. than 500 and greater than 800 per 100,000 in women
The rise in the absolute number of people dying from and men, respectively, in Belarus, Kyrgyzstan, Republic
CVD is in sharp contrast with the significant decline that of Moldova, the Russian Federation, and Ukraine com-
has been observed in age-​adjusted CVD mortality rates pared with less than 60 and less than 120 per 100,000 in
in many European countries. This steep decline in age-​ women and men, respectively, in France, Luxembourg, the
adjusted CVD mortality rates had already started from Netherlands, Portugal, and Spain.1 Age-​standardized mor-
the early 1970s onwards in some high-​income countries tality rates for stroke are less different between the sexes
in Europe; a similar but delayed pattern is now observed but large differences are also present between countries.
from the beginning of this century in other mainly Central Temporal changes between 1985 and 2014 in 38 ESC
and Eastern European countries. However, recent stat- member countries reveal a decline in the age-​standardized
istics suggest that the decline in CVD mortality among mortality rate for CVD from 374 to 209 deaths per
adults in some countries in past decades is now plat- 100,000 in women and from 586 to 339 per 100,000 in
eauing, especially in young adults.8–​11 men. This decline was observed in both high-​income and
7

Chapter 1 The epidemiology of cardiovascular disease 7

300

250

200
Death/100,000

150

100

50

0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Bulgaria France Hungary Kazakhstan
Russian Federation United Kingdom

Fig. 1.3 Time trends in coronary heart disease mortality, men under 65 years.

middle-​income countries but large differences existed at and cholesterol (mainly reflecting diet), and under half to
the national level.1 treatments; in ➤ Fig. 1.5, the percentages of the decrease
In summary, CVD and coronary heart disease mortality in deaths from coronary heart disease attributed to treat-
peaked in Western Europe in the 1960s. From then on, ments and to risk factor changes are presented based on
the gradient changed from South–​North to West–​East, studies using the IMPACT model and others.13
with Eastern Europe peaking in the 1980s and 1990s. In
➤ Fig. 1.3 and ➤ Fig. 1.4, time trends in coronary heart dis-
Premature cardiovascular disease
ease mortality are presented for men and women, respect-
ively, aged less than 65 years from 1980 to 2010 in a few mortality
selected countries. It should be appreciated that showing Although around two-​thirds of all CVD deaths in Europe
coronary heart disease mortality in people younger than occur in people aged over 75, approximately 1.3 million
65 years may be misleading because an apparent decline people die annually of CVD before that age, which can
may reflect a transfer of events to older ages, and the total be considered as premature mortality. This is a serious
burden of CVD may still increase. Furthermore, as outlined burden to society not only at the level of the individual
later, a reducing CVD case fatality rate may conceal the patient but also from a socioeconomic perspective. It is
true disease burden, as more people live with CVD as a also assumed that a large proportion of these premature
chronic disease. CVD deaths can be prevented by lifestyle adaptations and
The causes of declines in coronary heart disease mor- an optimal control of CVD risk factors.
tality have been explored by Simon Capewell through a In Europe, these premature CVD deaths are responsible
technique known as IMPACT modelling.12 In general, over for 35% of all deaths before the age of 75 years; in some
half of the observed declines relate to changes in major high-​income countries, cancer has now taken over the
risk factors, notably smoking, elevated blood pressure lead as a cause of premature mortality. In contrast to CVD
8

8 Section 1 The centrality of nursing within cardiovascular care

80

70

60

50
Death/100,000

40

30

20

10

0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Bulgaria France Hungary Kazakhstan
Russian Federation United Kingdom

Fig. 1.4 Time trends in coronary heart disease mortality, women under 65 years.

mortality at all ages, less women than men died prema- 5.8 million in women. One-​half of all new cases was due
turely from CVD in the ESC member countries.1 to ischaemic heart disease, slightly more in men than
in women; stroke accounted for 14% of all new cases,
somewhat more in women than in men. In the EU, the
Morbidity
annual incidence of CVD in 2015 was estimated at 6 mil-
Given the significant decline of the case fatality due to lion new cases.
CVD, the most recent CVD mortality statistics no longer Results from the ESC Atlas of Cardiology2 reveal that
reflect the real burden of disease in absolute number. CVD in ESC member countries increased from 1990 to
Statistics on the morbidity of CVD are, however, less avail- 2015 in high-​and middle-​income countries, respectively,
able or less comparable between countries because of by 11% and 22% in women and by 17% and 26% in men.
differences in defining and ascertaining morbidity. Some
results are presented here on the incidence and the preva- Prevalence
lence of CVD, on disability-​adjusted life years (DALYs) lost
The prevalence of CVD refers to the number of people
due to CVD, and on hospitalizations for CVD.
who are currently living with CVD in the population.
Based on GBD data, it was estimated that, in 2015, 85
Incidence
million people out of the 831 million inhabitants in the
The incidence of CVD gives the number of new cases 53 countries of the WHO’s European region lived with
that occur within a given time period, such as 1 year. CVD; of these 85 million, almost 49 million lived in the
Estimates from the GBD database show that in 2015 EU.14 According to GBD data, there were approximately
the annual incidence of CVD was more than 11 million 83.5 million people living with CVD in the ESC member
new cases in Europe as a whole,2 5.4 million in men and countries in 2015.1
9

Chapter 1 The epidemiology of cardiovascular disease 9

United States, 1968–76 40 54 6

New Zealand, 1974–81 40 60

The Netherlands, 1978–85 46 44 10

United States, 1980–90 43 50 7

IMPACT Scotland, 1975–94 35 55 10

IMPACT New Zealand, 1982–93 35 60 5

IMPACT England and Wales,

38 52 10
1981–2000

IMPACT United States, 1980–2000

47 44 9
(our study)

Finland, 1972–92 24 76

IMPACT Finland, 1982–97 23 53 24

0 50 100
Decrease in Deaths (%)

Treatments Risk factors Unexplained

Fig. 1.5 Illustration of IMPACT modelling estimates of the proportionate causes of declines in coronary heart disease
mortality. Percentages of the decrease in deaths from coronary heart disease attributed to treatments and risk factor
changes. See original study for references.12

Age-​standardized prevalence rates of CVD were higher large differences between countries such as −16.6% in
in men compared to women and were higher in Central men in Germany compared to +4% in men in Belarus.2
and Eastern Europe compared with Northern, Western,
and Southern Europe.
Disability-​adjusted life years lost due to CVD
Over the past 25 years, the absolute number of patients
with CVD increased in Europe by 34% in men and by 29% DALYs may be among the most appropriate quantitative
in women; in the EU, the respective rise was 32% in men indicators of how effective preventive and therapeutic
and 26% in women. strategies are in reducing the CVD burden. A DALY can be
The age-​ standardized prevalence rates decreased thought of as one lost year of ‘healthy’ life. DALYs lost due
slightly over the same time period in Europe: with a relative to CVD encompass both premature CVD deaths and phys-
reduction of 9% in men and 5% in women with, however, ical and psychosocial disabilities caused by living with
10

10 Section 1 The centrality of nursing within cardiovascular care

CVD. The sum of DALYs lost due to CVD can be thought Table 1.1 Estimated DALYs lost due to CVD per 1000
of as an indicator of the gap between the actual health population in some European countries, 2012
status of a population and the optimal health situation
where all people live to an advanced age in good health, Country All, Men, Women,
free of CVD. n/​1000 n/​1000 n/​1000
According to GBD data,4 in 2015, DALYs lost due to CVD
France 40 44 36
in women and men across ESC member states accounted
for a total of 8 million and 36 million years lost, respect- Switzerland 41 44 37
ively, which corresponded to 22% and 24% of all DALYs
lost. In Europe as a whole, it was estimated that 64 mil- UK 46 53 39
lion DALYs were lost due to CVD, representing 23% of all Sweden 55 60 50
DALYs; in the EU, that figure was 26 million, representing
19% of all DALYs.2 Belgium 51 56 46
The rates of DALYs from CVD are generally higher in
Italy 54 57 51
Central and Eastern Europe than in Northern, Southern,
and Western Europe.2 To illustrate the variation between Finland 63 76 51
countries, results of crude rates of WHO estimates for the
Germany 67 72 62
number of DALYs lost due to CVD per 1000 population in
a few European countries are presented in ➤ Table 1.1.15 Czech Republic 85 94 76
In both sexes, the numbers differ between countries by a
factor of four to five. Poland 90 106 74
Between 1990 and 2015, a reduction in mean age- Croatia 95 102 87
standardized rates of DALYs from CVD per 100,000 lost
to CVD was observed across ESC member states in Romania 125 139 111
both women (from 5759 to 3451) and men (from 9764 to
Latvia 153 177 134
6326). There was also in 2015 a clear difference in age-
standardized rates of DALYs from ischaemic heart dis- Bulgaria 167 187 149
ease per 100,000 lost to ischaemic heart disease between
Russian 181 217 150
high-​income ESC member countries (1004 and 2407 in
Federation
women and men, respectively) compared with middle-​
income ESC member countries (2715 and 5977 in women Ukraine 194 214 177
and men, respectively). Broadly speaking, there is a West–​
East gradient, as with CVD mortality. Source data from World Health Organization. Health Statistics
and Information Systems. http://​www.who.int/​healthinfo/​global_​
burden_​disease.
Hospitalizations
Another indicator of the burden of CVD morbidity is
the hospitalization rate for cardiovascular conditions. Economic burden of cardiovascular
The WHO European Hospital Mortality database for 31 disease
European countries provides admission rates for CVD per
The burden of CVD can also be expressed in economic
1000 population.16
terms. The estimated cost to the EU economy is €210
The admission rate was 30% higher in men than in
billion per year; around 53% (€111 billion) is due to
women, in particular for AMI admissions. Between coun-
healthcare costs, 26% (€54 billion) to productivity losses,
tries, significant differences in admission rates existed
and 21% (€45 billion) to the informal care of people
but no geographical pattern appeared; these differences
with CVD2 (http://​www.ehnheart.org/​cvd-​statistics/​cvd-​
may reflect both differences in the severity of CVD burden
statistics-​2017.html). Approximately 28% of the overall
and in the access to healthcare systems. As an illustra-
costs of CVD is related to coronary heart disease and
tion, results of hospitalization admission rates are given
20% to stroke. The costs of CVD are responsible for 8%
in ➤ Table 1.2 for CVD, AMI, and heart failure for the years
of the total healthcare expenditure in Europe, varying
2011 or 2012 in some European countries.
11

Chapter 1 The epidemiology of cardiovascular disease 11

Table 1.2 Hospital inpatient admission rates per 1000 ● The CVD burden remains a major challenge when
population for CVD, AMI, and heart failure, 2011–​2012, by absolute numbers are considered: the annual incidence
country is estimated at 11 million new cases of CVD in Europe
and 6 million new cases in the EU. In 2015, more than
Country CVD, AMI, Heart 85 million people were living with CVD in Europe.
n/​1000 n/​1000 failure, ● Although mean age-standardized rates of DALYs from
n/​1000
CVD have been reduced across ESC member states,
Ireland 14.0 1.9 1.4 CVD was responsible for 8 and 36 million years lost in
women and men, respectively, in 2015, accounting for
Spain 14.5 1.6 2.2
22% and 24% of all DALYs lost.
UK 14.7 1.8 1.3 ● Regarding costs to the EU economy, it is estimated that
CVD costs approximately €210 billion per year.
The Netherlands 19.5 2.4 1.8

Switzerland 21.5 3.2 2.0

France 23.9 1.6 3.3 Cardiovascular risk across

Czech Republic 30.7 2.6 3.9
the lifespan
Hungary 35.5 2.4 3.7
Introduction
Austria 40.0 2.5 2.9
From an early era, mankind has been searching for
Germany 40.3 3.8 4.6 ways of predicting the future. In the health arena, the
focus has been on identifying risk factors for the devel-
Lithuania 45.4 4.1 4.6 opment of future avoidable health-​threatening events.
A risk factor is something that is likely to increase
Source data from World Health Organization. Health Statistics the chances that a particular event will occur,17 thus
and Information Systems. http://​www.who.int/​healthinfo/​global_​
increasing the likelihood of developing a disease. This
burden_​disease.
term was coined in 1961 by Dr Thomas R. Dawber of
the Framingham Heart Study which led to the identifi-
from 3% to 19% between countries. In 2015, the costs cation of the major CVD risk factors, most of which are
per capita were €218,000 in Europe as a whole varying modifiable, suggesting the possibility of intervention
from €48,000 to €365,000 between countries.2 for prevention.18
The atherosclerosis associated with CVD starts in early
childhood and develops slowly, but at a variable rate, over
Summary
many years. While age is sometimes considered as a risk
factor, it is really just a measure of exposure time. Starting
● Statistics from different databases show that CVD with a variable genetic predisposition, the rate of progres-
remains a major cause of death, accounting for 45% sion is then modified by the intensity of lifestyle, environ-
of all deaths in Europe and 37% of total mortality in mental, and biochemical risk factors. This forms the basis
the EU. of preventive strategies.
● There still exist important inequalities in CVD mortality While certain genetic conditions such as familial hyper-
with deaths from AMI and stroke being on average cholesterolaemia may be associated with aggressive
higher in Central and Eastern Europe compared to CVD, in most people, the rate of increase in low-​density
Northern, Southern, and Western European countries. lipoprotein cholesterol and blood pressure may be deter-
● Age-​adjusted CVD mortality rates started to decline mined by multiple mutations or polymorphisms which,
in the 1970s in some high-​income countries in Europe individually, have a small effect. These may have a very
and have also been falling since the beginning of this modest effect on 5-​year risk but, because they operate
century in middle-​ income European countries. This from birth, their effect on true lifetime risk may have been
decline is, however, plateauing in young adults in some underappreciated. This has been supported by Mendelian
countries of the world. randomization studies19 which provide evidence that
12

12 Section 1 The centrality of nursing within cardiovascular care

low-​density lipoprotein cholesterol and raised blood pres- over-​or undertreatment in individuals with low or high
sure are (1) truly causal and (2) that their rate of rise is risk respectively.26–​29
genetically determined, although of course modified by Relative risk compares the possibility of suffering a
conventional risk factors over the years. As will be noted cardiovascular event in a person with risk factors com-
in the later section on the future of risk estimation, this pared to one without.30 At individual level, risk models
raises the possibility of identifying young people and help to educate and motivate people to introduce lifestyle
families in whom lifestyle measures to reduce risk are par- changes and to improve their treatment adherence to
ticularly important. achieve risk reduction,23,28,31 including those whose short-​
term risk is low or moderate, mainly due to their young
age.32,33 Nurses can help people understand the effect of
Cardiovascular disease risk estimation:
a particular risk behaviour by reviewing the relative risk of
overview and use in clinical practice that factor; that is, how its modification can impact the fu-
ture risk of suffering a cardiovascular event. For example,
The role of risk estimation a woman aged 65 years with normal total cholesterol and
The integrated approach to estimating the cardiovascular systolic blood pressure but who smokes, can reduce her
risk of an individual is based on the concept that classic chance of a fatal cardiovascular event by 40–​50% in the
risk factors (age, sex, abnormal lipids, smoking, hyperten- next 10 years if she stops smoking. There are several ex-
sion, diabetes) have a combined effect on cardiovascular amples of nurse-​ delivered cardiovascular risk manage-
risk which may be stronger than the isolated effect of each ment, tailored to risk estimation and raising awareness
one of them. The INTERHEART study20 found that in dif- strategies, as nurses are increasingly undertaking this
ferent regions of the world these factors (including also task worldwide.30,31,34,35
abdominal obesity, psychosocial factors, consumption of
fruits, vegetables, alcohol, and regular physical activity) Risk estimation equations
accounted for 90.4% of the population-​attributable risk
for myocardial infarction, and the risk increased expo- One of the first risk estimation tools was the Framingham
nentially when they clustered. However, the incidence equation36 that includes risk factors, previously identi-
of coronary heart disease, atherosclerotic CVD, and the fied as objectively, strongly, and independently related
burden of risk of each risk factor (attributable risk) differ to coronary heart disease, using logistic and parametric
significantly among populations.21,22 The preventive role regression models. These risk factors were measured
of nurses is intimately linked to knowing the attribut- at a baseline examination of a healthy cohort who were
able risk of these factors, estimating the patient’s risk of followed up for 10 years or more, with ascertainment of
developing CVD or dying from it (using an appropriate cardiovascular events. From these data, a baseline risk
tool), and working with the health team and the patient was derived and then beta-​coefficients (in effect multi-
in their shared decision-​making on how to adopt meas- pliers) calculated using Cox or Weibull methods to esti-
ures to mitigate the effect of modifiable cardiovascular mate the effects of rising levels of individual risk factors.
risk factors.23–​25 This model is the baseline for the majority of the risk
Absolute, total, or global cardiovascular risk is de- stratification instruments developed worldwide, such
fined as the probability of developing coronary disease as the European risk charts37, the Systematic COronary
or other CVD in a determined period of time, generally Risk Evaluation (SCORE) project (38) the revised WHO
5–​10 years. Based on the weight of each risk factor in a CVD risk charts39, the American College of Cardiology/
given population, the sum of all these in an arithmetic American Heart Association 2013 pooled cohort risk equa-
equation aims to estimate an individual’s risk of suf- tions40 and, more recently, the SCORE2 and SCORE2-OP
fering a cardiovascular event as low, intermediate, or risk charts.41,42
high.26 Correct risk stratification is crucial for adequate It is nowadays usual to model stroke and coronary heart
risk management to improve outcomes. It supports disease risks separately because the proportions may vary
guideline recommendations about treatment prior- (proportionately more strokes in low-​risk countries) and
ities, initiation or adjustment of medication, lifestyle regional differences in risk are also shown between the
modification, and resource allocation and aims to avoid sexes. The effect of age should be allowed to vary; absolute
13

Chapter 1 The epidemiology of cardiovascular disease 13

risk increases with age but relative risk reduces and the was derived but this may be more a test of the mathem-
use of a constant beta-​coefficient may overestimate risk atics than of the actual performance. An external valid-
in older people. ation is clearly preferable, in which the model is tested
Over the past three decades, many risk algorithms against a well-​defined different cohort.
have been developed or adapted, after realizing that the Although the importance of validation of risk in-
initial instruments may under-​or overestimate risk when struments is strongly advised, it is frequently not per-
applied to a different population.43–45 In 2008, Beswick formed. Collins et al. conducted a systematic review of
et al. identified more than a hundred prognostic models articles, which describes the evaluation of 120 prediction
for cardiovascular primary prevention.46 Therefore, in models.51 They evidenced poorly reported key details
order to use risk equations, they need to be properly such as calibration, inappropriate designs, and lack of
adapted, according to specific epidemiological data, acknowledgement of missing data—​all crucial perform-
and their predictive value must be validated accordingly. ance measures of prediction models. Explicit guidelines
External validation is an essential step in the develop- for the validation of these instruments have not yet been
ment of risk prediction models. This process evaluates developed, and it is apparent that no tool is perfect.
and demonstrates the applicability and transportability Nevertheless, understanding the multivariate proper-
of this model from the original cohort from whom it was ties of these stratification models and appreciating their
constructed (derivation cohort) so they could be reli- inherent limitations could improve a more accurate rec-
ably used in a different cohort.47 Validation requires a ognition of patients, especially on both sides of the spec-
cohort with enough statistical power and evaluates two trum: high and low risk.52–​54
main attributes of the equation: calibration, the ability to Even though CVD risk estimation is recommended
predict the risk of suffering an event by comparing the due to the conviction that it can play an important role
observed versus predicted events, and discrimination, in therapeutic decisions of individuals and populations
the ability to identify individuals according to their risk when used properly, recent studies have found that
(high–​intermediate–​low) of developing an event in a cer- in Europe risk assessment is not always performed to
tain period of time. According to findings, recalibration guide clinical practice.55 Risk equations have little value
methods are defined and reclassification of individuals if they are not used by clinicians on a daily basis.56 Lack
may be performed.48–50 of time, disdain of prediction rules, and multiplicity of
➤ Table 1.3 summarizes the key points of the validation risk models with unclear knowledge of the best choice
process. In internal validation, the model is tested against are some of the reasons to not routinely apply risk pre-
a random subsample of the cohort from which the model diction tools.26

Table 1.3 Definitions of CVD risk score terminology

Discrimination The ability to identify who will and who will not develop CVD
Components of discrimination
1. Sensitivity: percentage of individuals who developed CVD and were identified correctly
2. Specificity: percentage who did not develop CVD and were identified correctly
3. Area under the curve (AUC): a way of expressing the maximum achievable sensitivity and
specificity
4. Positive predictive value: percentage above a certain score (cut-​point) who actually
develop CVD
5. Negative predictive value: percentage below a certain score (cut-​point) who remain
disease free

Calibration Goodness of fit; the extent to which predicted and actual cases coincide

Net Reclassification The percentage of individuals who move to a higher or lower risk category when a new risk
Index factor is added to the equation
14

14 Section 1 The centrality of nursing within cardiovascular care

The 2021 European guidelines on CVD prevention the clinicians ‘to choose the right tool for the right pa-
in clinical practice address some of these points.28 The tient’, highlighting aspects to consider for different
guidelines review the advantages and limitations of risk populations (i.e. younger or older adults, ethnic minor-
charts, compare usefulness of lifetime versus 10-​year car- ities, immigrants, and geographic regions), taking into
diovascular risk estimation tools, and thoroughly analyse account several considerations for selecting prediction
the role of other factors not included in the standard tools tools. It also recommends the use of prediction algo-
(modifiers and biomarkers). rithms for different patient categories, at the U-​Prevent
Certain people are at high or very high risk and do website (https://​u-​prevent.com/​). It should be noted that
not require a risk scoring system but rather immediate some of the algorithms on this website require further
attention to all risk factors. These include people with validation studies.
known CVD, most diabetics, and patients with mod-
erate to severe chronic kidney disease. Risk scoring The role of risk modifiers and biomarkers in
systems such as SCORE2 and SCORE2-OP are for use
CVD risk estimation
specifically in people who are apparently healthy, that
is, in a primary prevention setting. ➤ Table 1.4 sum- Despite the broad spectrum of available instruments
marizes the current European recommendations on risk and the recommendation for more specific use, it is
assessment.28 widely acknowledged that risk algorithms have their
A recent report (2019) from the European Association own limitations.26,29 Most of the score models are based
of Preventive Cardiology in collaboration with the Acute on observations from many years ago, and epidemio-
Cardiovascular Care Association and the Association of logical data have been shown to be very dynamic with
Cardiovascular Nursing and Allied Professions about risk rising or falling incidences of CVD compared with base-
prediction tools in CVD prevention has been released.26 line data.29 Moreover, cardiovascular risk factor pro-
It presents a summary of available tools, aiming to aid files also vary, leading to changes in their attributable

Table 1.4  Recommendations for CVD risk assessment

Recommendations Classa Levelb

Systematic global CVD risk assessment is recommended in individuals with any I C

major vascular risk factor (i.e. family history of premature CVD, FH, CVD risk
factors such as smoking, arterial hypertension, DM, raised lipid level, obesity, or
comorbidities increasing CVD risk).

Systematic or opportunistic CV risk assessment in the general population in men IIb C

>40 years of age and in women >50 years of age or postmenopausal with no known
ASCVD risk factors may be considered.

In those individuals who have undergone CVD risk assessment in the context of IIb C
opportunistic screening, a repetition of screening after 5 years (or sooner if risk was
close to treatment thresholds) may be considered.

Opportunistic screening of BP in adults at risk for the development of hypertension, IIa B

such as those who are overweight or with a known family history of hypertension,
should be considered

Systematic CVD risk assessment in men <40 years of age and women <50 years of III C
age with no known CV risk factors is not recommended.

ASCVD = atherosclerotic cardiovascular disease; BP = blood pressure; CV = cardiovascular;

CVD = cardiovascular disease; DM = diabetes mellitus; FH = familial hypercholesterolaemia.
a
Class of recommendation.
b
Level of evidence.
15

Chapter 1 The epidemiology of cardiovascular disease 15

risk, affecting their weight in risk equations.57,58 Such intermediate risk, even at extreme ages (≤45 years, ≥75
secular changes can be dealt with by recalibration years).28,29,60
using updated mortality and risk factor information. Regardless of the risk group classification, and the
Recalibration is also possible for non-​fatal events but is use of modifiers to refine risk stratification, nurses must
methodologically much more challenging. HeartScore, be aware of the importance of taking a detailed personal
the electronic version of SCORE, contains recalibrated and family history.64 Moreover, medical history is the first
charts for many European countries (https:// www. factor to determine the most suitable risk assessment
heartscore.org/​). tool.26 Monitoring and appropriately treating severe iso-
In the continuous search to refine the predictive ability lated risk factors as dyslipidaemia, diabetes, or hyperten-
of risk stratification instruments, several studies have sion and encouraging lifestyle changes in the presence of
been conducted59 to include in these tools other fac- inactivity, smoking, obesity, or unhealthy eating habits
tors that have demonstrated a strong and independent such as salt and saturated fat intake, must be the core
association with the chance of developing CVD, such of nurse-​led management. Also, routine reassessment of
as elevated high-​sensitivity C-​reactive protein (hsCRP), cardiovascular risk factors, and cardiovascular risk stratifi-
low ankle–​ brachial index, elevated apolipoprotein B, cation, will ensure optimal risk factor management across
and family history of premature atherosclerotic CVD.60 the lifespan.65
However, their addition to the models have not resulted In summary, global risk calculation has been con-
in improvement in their discrimination, probably because sidered, for almost two decades, the best tool for com-
they have been measured with methods that are useful prehensive cardiovascular primary prevention, aiding in
but not sufficient (area under the ROC curve, c-​statistic) the establishment of health priorities, to deal with the
or the lack of understanding, for example, of the complex risk of developing atherosclerotic CVD.27,37,43 Recent re-
genetic basis of CVD.56,59–​62 ports and guidelines from several interdisciplinary task
Several investigators have been testing new methods forces, including nursing,26,27 continue to identify as a
that may reclassify risk when adding other risk markers crucial component of effective action the identifica-
to a prediction model, such as the net reclassification tion of individuals at high risk of suffering a cardiovas-
index developed by Pencina et al.,63 but their utility is cular event. To prevent death and morbidity from CVD,
still to be demonstrated.58,59,62 In practice, adding more the guidelines highlight the importance of identifying
factors to a risk equation may only make it more complex asymptomatic patients who would be candidates for
(limiting also its use in countries with limited resources). more intensive, evidence-​based medical interventions
Instead, they propose to take them into account as that reduce CVD risk. This remains a major public health
complementary information to assist clinical judge- challenge as a significant number of events occur in
ment, especially in those individuals at intermediate the apparently healthy population, and young individ-
risk or near a threshold of risk stratification between two uals with severe isolated risk factors are usually clas-
categories.29,56,60,62 sified as being at intermediate risk using standard risk
Cardiovascular risk modifiers, including biomarkers, equations.29
are comorbid conditions or markers not routinely Nurses must be aware of epidemiological consider-
screened but with the potential of providing additional ations, including the burden of risk factors and the par-
prognostic guidance.29,60 The most recommended add- ticular incidence of CVD in their target population, as well
itional factors that improve or modify risk estimation, as select the appropriate risk estimation tool, reviewing
and whose assessment is feasible in daily practice, are their validation process to judge and estimate how useful
physical activity, socioeconomic status, social isolation a certain model is for their own clinical practice and con-
or lack of social support, family history of premature CVD, sidering additional valuable data enabling individual
body mass index and central obesity, coronary artery cal- tailored risk management.
cium score, other lipids as triglycerides or apolipoprotein Finally, it is important to highlight that not only pri-
B, ankle–​brachial blood pressure index, and carotid ultra- mary prevention of CVD requires risk estimation to
sonography.28,29,60 In comparative studies of markers guide evidence-​based management. Patients with other
of subclinical atherosclerosis, the coronary artery cal- cardiovascular-​specific pathologies or risk factors, not al-
cium score has shown the best reclassification ability in ways included in the estimation equations, may benefit
16

16 Section 1 The centrality of nursing within cardiovascular care

from the use of specific risk tools. For example, for patients and management of established risk factors for CVD with
with diabetes, there is the ADVANCE risk en­gine66 or the emphasis on promoting cardiovascular health in child-
DIAL model67; for patients with a vascular disease history, hood and adolescence and reducing risk for incident CVD
the SMART (which is in the process of recalibration)68 in adulthood.79
and SMART-REACH models69 are avail­ able; for pa- Evidence supporting the importance of prevention and
tients with coronary artery disease the EUROASPIRE management of established risk factors for CVD beginning
risk model estimates 2-year risk of recurrent CVD70 and early in life emanates from basic, clinical, and population-​
for patients with heart failure, the MAGGIC risk calcu- based studies. Autopsy studies have demonstrated that
lator71 or the Seattle heart failure model72 are pro­posed. atherosclerotic processes begin in childhood and are as-
The U-​Prevent website, recommended by current guide- sociated with the presence of potentially modifiable and
lines,26 includes these and other algorithms for different non-​modifiable risk factors including smoking, obesity,
patient categories. dyslipidaemia, and elevated blood pressure.80,81 Tracking
of these risk factors from childhood to adulthood has been
observed in studies conducted in the US and globally.82-84
Cardiovascular risk estimation in Data from several studies including the Cardiovascular
special populations Risk in Young Finns Study link the presence of cardio-
vascular risk factors in adolescence with indicators of
Introduction subclinical atherosclerosis in adulthood (e.g. carotid ar-
tery intima–​media thickness).85 In contrast, longitudinal
In recent years, challenges in cardiovascular risk estima- studies have demonstrated that preservation of low levels
tion efforts have included not only how to address it in of cardiovascular risk is associated with less subclinical
different regions or countries, but also how to estimate atherosclerosis in adulthood.86–​87 Finally, the prevalence
it in different vulnerable groups more accurately, such as of potentially modifiable risk factors in childhood and
children and adolescents, young adults, older adults, and adolescence, as documented in population-​based studies
immigrants, and how other factors, such as social status conducted globally, underscore the importance of preven-
or literacy, may influence expected outcomes. tion beginning early in the life course.88,89 Risk factors of
Also, some comorbidities are relevant for CVD manage- particular concern are the prevalence and trends of over-
ment, either because they share risk factors or because weight and obesity, a recognized risk factor for type 2 dia-
some processes or treatments inherent to the pathology betes mellitus and CVD.
increase the cardiovascular risk. Some examples are The WHO collaborative, cross-​sectional Health Behaviour
chronic kidney disease,73 inflammatory arthritis,35 cancer in School-​age Children (HBSC) survey has provided data
treatments,28,74 especially breast cancer patients who re- (estimates) of health behaviours and well-​being as well as
ceive highly cardiotoxic treatments leading to heart failure socioenvironmental factors in children and adolescents in
incidence rates of up to 30%75 and an increased CVD mor- Europe since 1983.90 Based on self-​reported height and
tality risk exceeding their breast cancer mortality risk,76 weight, recent HBSC data, consistent with reports from
and HIV patients with increased survival, due to more the GBD study, indicate that the prevalence of overweight
effective and widespread treatment,77 in whom a recent and obesity among 11-​, 13-​, and 15-​year-​olds is high but
meta-​analysis found a twofold higher AMI risk association varies between countries and the sexes.91,92 In all three age
with chronic HIV infection.78 groups, the reported prevalence was higher in Southern
Europe than in Northern Europe. In the GBD study, 24%
Cardiovascular risk in children and and 23% of boys and girls, respectively, were either over-
adolescents weight or obese in developed/​ high-​income countries.92
Valid and reliable instruments for prediction of adult-​onset The prevalence of overweight and obesity in children and
CVD based on estimation of risk in childhood and ado- adolescents in developing/​low-​and middle-​income coun-
lescence do not exist. During the past 40 years, however, tries also increased substantially from approximately 8%
substantial research attention has focused on factors that in 1980 to 13% in 2013 for boys and girls.92 Since obesity
contribute to the development and progression of athero- clusters with other established risk factors for CVD in child-
sclerotic and hypertensive processes in early life. Results hood and adolescence, healthcare providers are advised to
of this research have informed guidelines for assessment assess and monitor blood pressure, lipid profile, and insulin
17

Chapter 1 The epidemiology of cardiovascular disease 17

resistance in children and adolescents who present with documented and attributed to differences in contextual
obesity.79 characteristics: children and adolescents from less af-
Central to preventing overweight and obesity and pro- fluent families were generally more likely to self-​report
moting cardiovascular health across the life course are a ‘poorer’ diet as well as other health behaviours than
lifestyle behaviours, particularly patterns of physical their more affluent counterparts.91 Specifically, breakfast
activity and dietary intake. Methodological limitations and fruit consumption as well as daily evening meals
notwithstanding, data from the WHO and findings from were more common in children and adolescents from
epidemiological studies conducted in Europe provide higher-​ affluence families. Daily soft drink consump-
insight and have been used to guide and inform re- tion, primarily sugar-​sweetened beverages, was associ-
commendations for clinical and public health practice, ated with lower affluence in most countries and regions
multilevel policies, as well as future research.93,94 A re- but was more common among higher-​affluence groups
cent report from the 2013/​2014 HBSC study focused on in Albania, Armenia, Estonia, the Republic of Moldova,
29 European countries emphasizes the importance of and Romania. A well-​established major contributor to
factors that operate beyond the individual level in acqui- overweight and obesity, the reported average daily con-
sition and maintenance of physically active lifestyles.95 sumption across all HBSC countries and regions for 13-​
While WHO and other evidence-​based guidelines recom- year-​old boys and girls was 21% and 16%, respectively.
mend at least 60 minutes/​day of moderate-​to vigorous-​ Consistent with global data, healthy eating behaviours
intensity physical activity for children and adolescents became less common during the school-​ age/​
adoles-
aged 5–​ 17 years, global data support the findings of cent transition (11–​15 years of age). Of note, and well
Weinberg and colleagues and point to the importance documented globally, time spent being physically active
of social and environmental determinants of health be- declined during the school-​ age/​adolescent transition
haviours and health.95 In this recent report from HBSC, particularly among girls. While 30% of 11-​year-​old boys
substantial variation in activity was observed within met the requirement of 60 minutes/​day of moderate-​to
countries including within Europe. For example, 40% of vigorous-​ intensity physical activity, this decreased to
11-​year-​olds in Finland met WHO guidelines while only 21% at age 15. A similar trend was observed for girls:
13% of their counterparts in Italy met the recommenda- 21% of 11-​year-​old girls met this daily requirement for
tions for 60 minutes/​ day of moderate-​to vigorous-​ physical activity while only 11% of 15-​year-​olds met the
intensity physical activity. Relatedly, 76% of Danish requirement.91
15-​year-​olds but only 30% of their Albanian counter- Adding to the importance of adolescence as a critical
parts participated in vigorous physical activity outside time for cardiovascular health promotion and preventive
the school environment for two or more hours per week.95 interventions are data on tobacco use, the leading cause
Taken together and consistent with studies conducted in of preventable death globally. While estimates for early ini-
the US,96 the findings from this study point to the import- tiation and weekly smoking have declined since the 2009/​
ance of macro-​level factors that operate beyond the level 2010 HBSC survey, both remain high in some countries
of the individual as key determinants of health behav- and regions.91 The ‘average’ reported estimates across
iours and health. While additional research is needed to countries of 15-​year-​olds who smoke at least once per
explicate the pathways and mechanisms through which week was 12% and 11% for boys and girls, respectively. In
these macro-​level factors interact with individual char- contrast, in Croatia, 25% and 21% of 15-​year-​old boys and
acteristics to influence health behaviours and health girls, respectively, reported smoking at least once a week.
in children and adolescents, healthcare providers, child Of note, and consistent with US data, the prevalence of
health advocates, and other stakeholders are advised to weekly smoking increased significantly with age (from 11
consider these factors in assessing and managing health to 15 years of age) in most of the WHO European Region
behaviours and in developing and implementing pre- and was also associated with other adverse health behav-
ventive interventions for children and adolescents. iours including high levels of alcohol consumption and
Establishing and maintaining healthy patterns of unhealthy eating habits.91
dietary intake across the life course are also influenced While the HBSC survey provides self-​ report esti-
by macro-​level factors, referred to as contexts (e.g. fam- mates of health behaviours, patterns and trends over
ilies, schools, communities) in socioecological models time as well as between and within-​country differences
of health and development.97 In the 2016 HBSC compre- in social determinants of health are important consid-
hensive report, inequalities in eating behaviours were erations. Investing in Children: The European Child and
18

18 Section 1 The centrality of nursing within cardiovascular care

Adolescent Health Strategy 2015–​2020 reminds us of challenge to the health of current and future gener-
these important sociodemographic differences in deter- ations of Europeans is the prevalence and projected
minants of health and encourages monitoring and sur- trends of overweight/​obesity. A major risk factor for CVD
veillance of health behaviours and indicators of health in adults, obesity tracks from adolescence to adulthood
over time and with efforts focused on obtaining high-​ with approximately 80% of obese adolescents retaining
quality data.98 this chronic condition into adulthood. Patterns of phys-
The guiding principles of this document for European ical activity and dietary intake are key components of
countries that are developing and/​ or revising child maintaining energy balance and preventing overweight
and adolescent health strategies are particularly note- early in life and across the life course. Clearly, avail-
worthy and include adopting a life-​course and evidence-​ able data support the urgent need for implementa-
informed approach, promoting strong partnerships and tion of evidence-​ based, multidisciplinary, multisectoral
intersectoral collaboration, and adopting a rights-​based preventive interventions, as suggested in Investing in
approach.98 Children.98 This document emphasizes investing in both
Since CVD is the major cause of morbidity and individual as well as population-based approaches to
premature mortality in most of the European coun- prevent and manage overweight/obesity. Investing fo-
tries, a life-​course approach to individual/​clinical and cused on individuals as well as population-​based/​public
population-​ based primary prevention is particularly health approaches to prevent and manage overweight/​
noteworthy. This guiding principle is based on the recog- obesity. Nurses and nurse practitioners working within
nition that adult health and disease are rooted in health multidisciplinary teams are well prepared and positioned
and experiences in previous stages of the life course and in healthcare and community settings to assess and
it systematically reflects economic, social, environmental, manage overweight/​obesity as part of an integrated pro-
biomedical, behavioural, and other relevant factors that file approach to cardiovascular health promotion and risk
influence health. Targeted efforts to disrupt negative reduction for children and adolescents.79 As the largest
intergenerational cycles that are created by or contribute healthcare discipline globally and advocates for the health
to health inequities are also emphasized.98 Investing in of the public, nurses and organized nursing societies must
Children outlines efforts designed to enhance the life- participate in targeted country-​and region-​specific activ-
style behaviours central to cardiovascular health across ities designed to allocate resources and increase capacity
the life course with particular emphasis on policies that for life-​course ideal cardiovascular health for all peoples
support primordial prevention, preventing the devel- of the world.
opment of established risk factors by developing and
maintaining healthy lifestyle behaviours.99 Successful Risk estimation in young adults
adoption and implementation of such policies requires
(<50 years)
continuing emphasis on evidence-​based multisectoral
approaches. For example, the WHO European physical Absolute risk may not be accurate for younger populations
activity strategy for 2016–​2025 contains priority policies as age is a relevant predictor of 10-​year risk. Individuals
including (but not limited to) adopting national guide- under the age of 50 years will always tend to be classified
lines tailored to the promotion of physical activity among with low absolute risk even in the presence of a very un-
adolescents, improving urban planning and transport favourable risk factor profile or severely intense isolated
infrastructure to promote active transport, creating en- factors, with a higher risk of early CVD onset and high risk
vironments to support physical activity for children and across their remaining lifespan.26,28,56,101 Some suggested
adolescents (free outdoor sport, safe walking and cycling strategies to address this are the use of relative risk charts
routes), ensuring school curricula include a strong phys- or ‘risk age’, lifetime risk calculators, or CVD-​ free life
ical education component, and ensuring adolescents years.26,28,56,102
with lower affluence or disabilities have easy access to For example, a 40-​year-​old man who smokes, has a total
physical activity opportunities.100 cholesterol level of 300 mg/​dL (8 mmol/​L), and a systolic
Taken together, the prevalence and trends in CVD-​ blood pressure of 160 mmHg has a 3% absolute risk of
related lifestyle behaviours in children and adolescents presenting with a fatal cardiovascular event in the next
in Europe demonstrate some progress towards achieving 10 years. Compared with a 40-​year-​old man who does not
established goals (e.g. reducing tobacco use). A major smoke, has a normal total cholesterol level, and normal
19

Chapter 1 The epidemiology of cardiovascular disease 19

systolic blood pressure (whose estimate risk is 0%), his risk, or other similar approaches, is recommended. The
relative risk is three times higher than this second indi- information obtained regarding a predicted risk must
vidual, of the same sex and age. translate into meaningful actions and sharing it with the
Also, the 40-​year-​old man with a 3% risk has the same patient raises awareness, increases self-​motivation, and
risk as a 60-​year-​old man who does not smoke, has a enables shared decision-​ making when setting realistic
normal total cholesterol level, and normal systolic blood goals.26
pressure (3%). This comparison has been referred to as
‘vascular age’.101 In this example, the 40-​year-​old man
with the described burden of risk has the same probability Risk estimation in older people
of dying of a cardiovascular event as the healthy 60-​year-​ Age is a measure of exposure time rather than being a
old man. Communicating lifestyle changes and the im- risk factor as such, and older people with even modest
portance of adherence to treatment can reduce his relative risk factor levels may be at high risk with the possibility
risk; if he fails to modify his burden of risk factors, he may of overmedication. Several specific considerations apply
lose 20 years of CVD-​free life. to CVD risk estimation in older people. These have been
Lifetime risk calculators aim to estimate the risk of addressed in the 2021 ESC Guidelines on CVD preven-
an individual developing CVD at some point in their tion in clinical practice28 and the SCORE2-OP algorithm
lifetime.54,103 These estimations provide a more com- was specifically developed to estimate 10-year fatal and
prehensive assessment of the overall burden, because non-fatal CVD events adjusted for competing risk in ap-
they also take into account competing risks (i.e. death parently healthy people aged >=70 yrs42.
from cancer).102 Increases in life expectancy have also
been taken into account for the need of longer-​term risk Risk estimation in ethnic minorities and
prediction tools (i.e. 30-​year risk).104 However, these immigrants
models also have some limitations. The main concerns
are that their analyses have been restricted to risk fac- Migration between countries is increasingly growing, es-
tors measured at a single age (not considering dynamic pecially in Europe, Asia, and North America.108 According
changes of risk factor levels or treatment) and mainly in to the European Commission, 22.3 million non-​EU citizens
predominant populations.102 In addition, the lack of cut-​ were living in the EU on 1 January 2018, representing 4.4%
off points to define risk levels and guidelines for man- of the EU population; the main regions of origin are India,
agement using these scales have been pointed out.101 China, North Africa, and Pakistan.109
There are some modifiers of cardiovascular risk that Ethnic differences in the prevalence of cardiovascular
are more prevalent in younger populations that need risk factors are well documented in the literature: gen-
to be taken into account, such as substance abuse. etic background, lifestyle, environmental factors, cultural
Reports from the US national health survey two dec- and religious habits, awareness, and the way people per-
ades ago evidenced that regular cocaine use was associ- ceive and cope with illness and disease influence cardio-
ated with an increased likelihood of non-​fatal myocardial vascular health.26,108,110 Therefore, the profile of burden
infarction in people aged 18–​ 45 years; 25% of these of risk differs among immigrant populations.111 For ex-
events were attributable to frequent use.105 Cocaine pro- ample, South Asians have a higher prevalence of dia-
duces acute effects such as electrocardiographic ab- betes and hypertension whereas white populations have
normalities, acute hypertension, arrhythmia, stroke, a higher prevalence of smoking and obesity. On the other
and AMI, due to coronary artery spasm resulting from hand, Chinese and South Americans have a lower overall
adrenergic system stimulation, and long-​ term use in- CVD risk.28,108,112
duces cardiomyopathy, endothelial injury, and vascular However, evidence suggests that CVD risk profiles
fibrosis.106,107 change after a residence time, with ethnic-​specific tem-
In summary, risk estimation in younger adults needs poral trends declination in cardiovascular health over
more research56 and nursing plays an important role in time, or with significative differences when compared
gathering evidence. Medical and family history (i.e. fa- with second-​generation (born in host country) individ-
milial hypercholesterolaemia), lifestyle, behaviours, and uals.28,108,110,112 This has been explained by the phenom-
modifiers must be thoroughly analysed. Estimation of enon of acculturation, that is, a process of ‘adaptation and
the impact of risk factors, through relative risk, lifetime exchange of behavior patterns to the principal culture in
Another random document with
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 Pinching.
Pinching is the operation of moving a gun, or mortar, by small
heaves of the handspike, without allowing it to turn on its axis. It is
moved little by little, and never raised in its progress, but rubs
against the skid on which it rests.

Cross-lifting.
To cross-lift a gun, or carriage, is to move it in a direction nearly
perpendicular to its axis. Heavy guns, mounted, or dismounted,
require a long lever, and a fulcrum, for cross-lifting. Guns of medium
weight may be cross-lifted by means of handspikes.

Article 2.

FULCRUMS, AND PROPS.

Any piece of strong timber of suitable dimensions may serve for a
fulcrum, or a prop. It is called a fulcrum when used to support a
lever, and a prop when used as a temporary support for anything
else.

Fulcrums.
The distance of the fulcrum from the weight which is to be raised
should be such that, when the lever rests upon the top of it, the point
may be put under the weight, and the lever form such an angle with
the horizon that, when it is heaved down, and the small end nearly
touches the ground, the weight may be raised to the required height.
Except with very heavy bodies, care must be taken, in placing a
fulcrum, that it is inclined in a small degree towards the body, so that
when the lever acts it may bring the fulcrum into a vertical position.

Props.
There cannot be a better prop than a quoin, when it is long
enough, or a piece of wood of that shape, of proportionate size.
 If the wheels of a carriage are to be taken off, and the carriage
propped, the trail should be first secured from slipping.
The props are placed under each cheek, or under the shoulder of
the axletree, with a slight inclination towards the carriage.
When one wheel only is to be taken off, and the other scotched,
the props may be placed vertically; but practice alone will point out
the proper position of props in all situations.
The point of the lever must not be withdrawn, until it is evident that
the prop is well placed.

Article 3.

LIFTING JACK.
The lifting jack forms part of the equipment of every battery, and
battering train. It may be applied to many of the purposes for which a
long lever is used; but it is commonly employed to raise the wheels
of carriages from the ground when they are to be greased, or
exchanged, and to extricate them from ruts and holes.
The wheel opposite to that which is to be raised must be scotched.
On soft ground a piece of board must be placed under the foot of
the jack, to prevent its sinking.
There are three kinds of lifting jacks in the service—
1st. The common lifting jack is used for field carriages only. The
arm, which may be adjusted, within certain limits, to any required
height, is a lever of the first kind, and is applied accordingly. The
body of the jack is the support on which it works.
2nd. The tooth and pinion jack is of greater power than the
common jack, and is used for heavy carriages. It is applied vertically
under the carriage, which is raised by turning the winch of the jack.
3rd. The screw jack is an elevating screw of large dimensions, and
is of greater power than either of the other two. Like the tooth and
pinion jack, it is applied vertically under the body, which is raised, like
the breech of a gun, by turning up the screw. The foot of it is
furnished with three spikes, to prevent its slipping when the screw is
turned.
If a wheel is to be extricated from a rut, into which it has sunk so
far that the lifting jack cannot be applied in the ordinary manner, the
jack is placed as close to the wheel as possible, on the outside of it.
A piece of rope, passed under the nave, is made fast to the extremity
of the arm, if the common jack is used, or to the fork, if either of the
other kinds be employed. The jack is then worked as usual, and
stones or other hard substances are thrown under the wheel, to
prevent its sinking, as often as it may be necessary to take fresh
purchases.
The tooth and pinion and screw jacks may be employed to move
bodies horizontally a few inches, provided a good abutment or
support can be found for the foot of the stock. By the application of
two jacks, in opposite directions, bodies may be brought together to
be spliced, riveted, &c.

Article 4.

RO L L ER S.
Rollers are solid cylinders of wood, used in mounting guns upon
their carriages, in shifting them from carriage to carriage, and in
moving them through passages too narrow to admit of the use of the
ordinary means of transport. Their dimensions vary, according to the
nature of the service for which they are intended.
They can be used with advantage, only on a perfectly level plane
surface.
When a cylindrical body is moved on rollers, they must be
perfectly horizontal, or it will roll off them; and even when the rollers
are horizontal, steadying handspikes should, if possible, be applied,
to guard still further against such an accident.
 The rollers must be placed at right angles to the direction in which
they are intended to move, projecting equally on each side of the
axis of the gun, or other body, which they support.
A gun laid upon rollers may be moved, either by hauling upon it
with ropes, or by means of levers. In the last case, two holes
crossing each other at right angles, are pierced near each end of the
several rollers, and in them are inserted the points of iron levers, by
means of which the rollers are turned in the required direction.
In order that rollers may be used with the greatest effect, and that
there may be as little necessity as possible for shifting them during
the course of an operation, it must be borne in mind,—
1st. That a roller moves in a direction perpendicular to its own
axis.
2nd. That it moves over half the space only which is traversed by
the body it supports.

Article 5.

CRAB CAPSTAN.
A crab capstan consists of a barrel, (in shape, a frustum of a
cone,) and of a framework of wood and iron by which the barrel is
supported in a vertical position with its largest diameter next the
ground. It is furnished with two levers, called capstan bars, which are
passed through mortices in the upper part of the barrel, and by
means of which the barrel may be turned about on its axis. By
means of the crab capstan, a few men, acting at the levers, can
move weights which would be far beyond their strength, if applied in
the ordinary manner; and it may, therefore, be used with advantage
in many situations, in which it may be either difficult to command
labour, or desirable to economise it.
One end of a rope is made fast to the weight which is to be
moved, and is called the standing end. The other, called the running
end, is passed two or three times round the lower part of the barrel,
the loose or running end being kept above the turns, and stretched
taught by the man who passed it round. As the barrel is turned, the
standing end of the rope winds round it, forces the turns up the
barrel, and clears itself. As fast as the running end comes off the
barrel, it is coiled by a man appointed to that duty.
The capstan, when used, is secured by ropes to pickets, driven on
the opposite side of it to that on which the strain acts upon it. Three
men at each end of both bars—i. e., twelve men in all—is the
greatest number that can be employed at the capstan with
advantage; and two men are required for the running end of the fall,
as previously described. The levers are twelve feet in length, and the
power of twelve men, acting upon them, is about equivalent to that of
132 men acting at the end of a taught rope.
If a crab capstan cannot be procured, the windlass of a gyn may
be used as a substitute, the cheeks being laid on the ground and
secured with pickets; or a temporary capstan may be rigged, by
lashing four handspikes to the spokes and felloe of a limber wheel,
which is turned upon the pintail of the dismounted limber.

Article 12.

SL ING CART.
The sling cart weighs about 15 cwt., and is employed for moving
heavy ordnance. It is capable of carrying 65 cwt.
One non-commissioned officer and six men are required,
numbered as usual; but it can be worked by one non-commissioned
officer and four men.
Articles required:—
One sling of six-inch white rope, two fathoms long, with an eye-
splice at each end.
One sling tye, of one-inch tarred rope, two feet long.
One prypole.
 One prypole rope, 2½-inch, three fathoms long.
Two levers, six feet nine inches long.
Two lever ropes, of two-inch tarred rope, each two fathoms.
Two pawls.
Two common handspikes.
Two pieces of short skidding, about 4½ feet long, and five or six
inches square.
The detachment is drawn up in rear of and facing the cart, the
command is given, “Form the order of exercise—to the right face—
quick march.” The detachment wheels to the left, and the ranks open
out. Nos. 2 and 3 halt one pace in rear of and covering the wheels.
The whole one pace from each other, and covering.

Disposition, and duties of the Men.

No. 1 attends to the pawl, and commands.

Left side. Right side.
3 has charge of the left lever, 2 has charge of the right lever,
and skids the gun when and skids the gun when
necessary. necessary.
5 has charge of a handspike, 4 has charge of a handspike,
assists 3 at the lever, and assists 2 at the lever, and
skidding, and raises the skidding, and raises the
weight when it is to be weight when it is to be
lashed. lashed.
7 assists 3 at the lever, slings, 6 assists 2 at the lever, slings,
and unslings the gun, and and unslings the gun, and
lashes it to the prypole. lashes it to the prypole.

Form the order of march. Quick march. If the gun be not on

skids, a piece of skidding is placed under it, a little in front of the
trunnions, to make room for the sling to be passed under the piece.
Before the piece is slung, the trunnions are brought vertical, or
nearly so, either by the ordinary method of slewing, or by means of
the sling cart, as follows:—
Back the cart over the gun. Scotch the wheels. Form the
order of exercise. Quick march. Unlash the prypole, levers,
and handspikes. Fix the sling to the right of the windlass.
Overhaul the sling. Prepare to raise the right trunnion.
Heave in the slack. Take up levers. Right lever take
purchase. Heave. Left lever take purchase. Right lever
fetch. Left lever heave. Right lever take purchase. Left
lever fetch. Halt. Out levers. Sling the gun. Heave in the
slack. Man the levers. Heave. Left lever hold on. Right lever
fetch. Alternately to the lever numbers—Hold on, and fetch, until
the gun is close to the axletree, Halt. Prepare to raise the
breech. Raise the breech. (If necessary, Take a fresh purchase.
Heave.) Halt, lash the breech. Lash levers, and handspikes.

Unslinging the Gun.

Unlash levers, and handspikes. Unlash the prypole. Man
the levers. Ease off. Left lever hold on. Right lever fetch.
Right lever hold on. Left lever fetch. Out levers.

Slinging a Howitzer.
A howitzer is slung, and unslung according to the foregoing
details.

Slinging a Mortar.
A mortar is slung with the muzzle towards the rear. For a 13-inch
mortar, the wheels of the sling waggon ought to be used for the sling
cart, and a double-barrelled windlass, if procurable.

Unslinging a Mortar.
See “Unslinging a Gun.”

Slinging a Mortar bed.

 The windlass for raising Mortar beds is of a different construction
from that of guns, being square in the middle, and cylindrical at each
end. The bed is slung with the front part towards the rear of the cart.
Sling the bed. Lash the bed.

Unslinging a Mortar bed.

Unslinging a mortar bed is just the reverse of slinging, each
number undoing what he had previously done.

Article 13.

S L ING WAG G O N.
The sling waggon weighs about 29 cwt., and is employed for
moving heavy ordnance, and their standing carriages. It requires a
detachment of 1 non-commissioned officer and 8 men; but 1 non-
commissioned officer and 6 men can sling any weight below a 24-
pounder.
The following articles are required:—
One sling of five-inch white rope, 2½ fathoms long, and having an
eye-splice at each end.
One sling tye of one-inch tarred rope, two feet long.
One breech rope, or carriage sling, of 2½-inch tarred rope, 6
fathoms long.
Two levers, six feet nine inches long.
Two lever ropes, of two-inch tarred rope, 2½ fathoms each.
Two pawls.
Four common handspikes.
Two pieces of skidding, about four feet long, and six or seven
inches square.
One pair of strong dragropes.
 The detachment is numbered in the usual manner, and takes post
for exercise, as at the sling cart.

Disposition, and duties of the men.

No. 1 attends to the pawls, and commands.

Left side. Right side.
3 has charge of the left lever, 2 has charge of the right lever,
and skidding, scotches the and skidding, scotches the
wheels in rear, assists in wheels in rear, assists in
unlimbering, and limbering unlimbering, and limbering
up. up.
5 has charge of a handspike, 4 has charge of a handspike,
assists 3 at the lever, assists 2 at the lever,
scotches the wheels in front, scotches the wheels in front,
fixes the carriage sling, and fixes the carriage sling, and
assists in unlimbering, and assists in unlimbering, and
limbering up. limbering up.
7 assists 3 at the lever, slings, 6 assists 2 at the lever, slings,
and unslings the gun, lashes and unslings the gun, lashes
the breech, handspikes, and the breech, handspikes, and
levers, and assists in levers, and assists in
unlimbering, and limbering unlimbering, and limbering
up. up.
9 assists in unlimbering, and 8 assists in unlimbering, and
limbering up, keys, and limbering up, keys, and
unkeys the limber chain, and unkeys the draught chain,
fixes the breech rope. and fixes the breech rope.

Bringing the stores.—If the stores are not with the waggon, Nos. 2
and 3 bring a lever each, and 4 and 5 two handspikes each; 6 the
gun sling, and 7 the carriage sling or breech rope; 8 and 9 the skids
and drag ropes.
The gun is supposed to be lying on skids, and its carriage on one
side, with its breast nearly in line with the breech.
 Form the order of march. Quick march. Back the waggon
over the gun. Prepare to unlimber. Unlimber. Out levers.
Prepare to turn the gun carriage over. Turn the gun
carriage over—Heave. Take off the trucks. Prepare to lift
the carriage to the cross-bar. Lift the carriage to the
cross-bar. Fix the carriage sling. Take up levers. Right lever
take a purchase—Heave. Out levers—off sling. Prepare to
limber up. Limber up. Prepare to back the waggon. Back the
waggon. Scotch the hind wheels. Put on the trucks. Form
the order of exercise. Quick march. Prepare to raise the
trunnion on the right. Heave in the slack. Take up levers.
Right lever take a purchase—Heave. Left lever take a
purchase. Right lever fetch. Left lever heave. Out levers.
Sling the gun. Man the levers. Left lever hold on—Right
lever fetch. Prepare to raise the breech. Raise the breech.
Frap and make fast. Place stool bed, and quoin. Lash up
levers, and handspikes.

Dismounting the Gun, and Carriage.

Place skids, unlash, and scotch the wheels. Unlash the
breech. Form the order of exercise. Quick march. Levers
take a purchase to lower the gun. Bear down. Ease off.
Right lever hold on. Left lever fetch. Left lever hold on.
Right lever fetch. Ease off.

Slinging Howitzers.
A howitzer is slung in the same manner as a gun.

Slinging Mortars.
A 13-inch mortar and its bed require each a waggon for itself; but
a 10 or 8-inch mortar can be conveyed on its bed, by one waggon.
Limber up. Unscotch the wheels. Run the waggon back.
Prepare to lash up the muzzle. Heave. Run the waggon
forward.
 Article 15.

TRIANGLE GYNS.
There are two patterns of triangle gyn, the small and the large.
The small gyn has legs sixteen feet long, weighs about 8½ cwt.,
including the tackle, and is capable of raising with safety 65 cwt. It is
principally used for mounting guns and howitzers on their carriages,
and for dismounting them; and for placing ordnance of every
description on platform waggons.
The large gyn has legs twenty feet long, weighs about 11½ cwt.,
including the tackle, and is also capable of raising with safety 65 cwt.
It is principally used for mounting guns upon traversing platforms,
and for dismounting them.
The rear of the gyn is the part where the windlass is fixed. The
front of the gyn is the prypole.

Strength of Gyn Detachments.

One non-commissioned officer and ten men are allowed to raise
and work the gyn, numbered as for gun drill.
The same number is sufficient to carry the small gyn. The large
one should be drawn to the place where it is to be used in a hand
cart.
At exercise the even numbers are on the right, and the odd
numbers on the left.
The following is the list of stores required for the service of gyns:—

One fall, of 3½-inch white rope, seventy-two feet long, for the
small gyn.
One fall, of 3½ inch white rope, ninety-six feet
}
long.
One staple, fixed in the top of the prypole. } For
One four-inch block for whip. } the large
 One whip fall, of 1½-inch rope, thirty feet long. } gyn.
Four lashing ropes, each nine feet long. }

Two levers and lever ropes. }

One triple block. }
One double block. }
One sling, of six-inch white rope, of a length to suit
}
the
dimension of the gun or other object which is to be
}
slung.
One single lashing rope, 2½-inch, for slinging
}
mortars.
One piece of spun yarn, three-stranded, 1½
}
fathom long,
for seizing the clinch of the fall. }
One ditto, one fathom long, for stoppering the fall. } With
One fid, (for which a couple of handspikes may be } both
substituted,) for slinging the gun; or,— } patterns.
One short piece of skidding, for the same
}
purpose,
for slinging mortars and howitzers. }
One hammer. }
Three trucks, or small pieces of board, four inches
}
thick,
with a hole in the centre of each, to receive the
}
spikes of
the feet of the gyn on soft ground. Handspikes laid
}
upon the
ground, and on each side of the several spikes, will
}
answer
this purpose. }
 One pair of dragropes. }

Disposition, and duties of the Men.

No. 1 commands.
Left side. Right side.
3 carries the foot of the left 2 carries the foot of the right
cheek, has charge of the left cheek, has charge of the
lever, keys and unkeys the right lever, keys and unkeys
left capsquare, runs the the right capsquare, runs the
carriage up, or back. carriage up or back.
5 carries the top of the left
4 carries the top of the right
cheek, assists 3 at the lever,
cheek, assists 2 at the lever,
runs the carriage up, or
runs the carriage up or back.
back.
7 carries the levers and 6 carries the windlass, passes
handspikes, assists 6 to the fall round it, holds on the
pass the fall round the fall and makes it fast, eases
windlass, holds on next to off the fall, and lowers the
him. gun.
9 carries the top of the prypole
8 carries the foot of the prypole
with sling, fid, trucks, &c.,
with sling, fid, trucks, &c.,
holds on the fall behind 7,
holds on the fall behind 6. xx
and coils it up.
11 assists in carrying the blocks, 10 assists in carrying the blocks
and fall, reeves, and and fall, reeves, and
unreeves the triple block, unreeves the double block,
assists in slinging the gun, assists in slinging the gun,
and steadies it on his own and steadies it on his own
side. side.

Put the gyn together, and reeve the tackle. Place the
windlass.

To raise, and place a Gyn.

 Prepare to raise the gyn. At a small gyn the tackle is hooked
before the gyn is raised; at a large gyn it is not hooked until after the
operation has been performed. At the Small gyn, Hook the tackle.
Raise the gyn. Halt. Prepare to place the gyn, either pattern.
Lift the cheeks in, out, to the right, or to the left. At the
Large gyn, Prepare to hook the tackle. Hoist the tackle.
To raise a Gun, or other object, and to mount and dismount a Gun or
Howitzer on, and from a standing carriage; or to shift it from one
carriage to another.
Post yourselves. Pass the fall round the windlass. Put on
the sling, and hook the block. Fix the sling, to a gun, or
howitzer without dolphins. Or, Fix the lashing, to a mortar, or other
piece of ordnance with dolphins. Fix the sling, to a mortar bed.
Shift the fall to the right of the windlass. Haul taught.
Everything being prepared for raising the piece, &c., which has been
slung, Work the levers. Heave. Fetch. Heave, Fetch, alternately
until the piece, &c., is high enough. High enough. Make fast the
fall. If a gun, or howitzer is to be dismounted, the carriage is run
from under by Nos. 2, 3, 4, 5, and the piece is lowered to the ground
—Prepare to lower the piece. Lower. The piece is unslung, and
the sling removed by the same numbers that slung it. Before striking
the large gyn, the tackle must be unhooked; an operation exactly the
reverse of hooking. Prepare to strike the gyn. Strike the gyn.
Take the gyn to pieces.

To mount a Gun, and Carriage, upon a platform waggon, by means

of a triangle gyn.
The gyn is placed over the gun in the usual manner, and the
platform waggon is brought to the side of the gyn, with its rear
towards the muzzle of the gun. The gun is then raised, by means of
the gyn; and, when high enough, and the fall made fast, the carriage
is run back by Nos. 2, 3, 4, 5. Prepare to back the waggon. Back
the waggon. Lower the gun. The sling is then removed, and the
waggon is run forward. The gun carriage is next brought under the
gyn, and turned bottom upwards—Lift. Fix the carriage sling.
The carriage is now raised by means of the gyn, and is lowered upon
the piece. Lash the carriage.

Article 16.

GIBRALTAR GYN.
The Gibraltar gyn is principally used for mounting, and
dismounting guns, and howitzers on, and from standing carriages. It
weighs 10¾ cwt., and can support three tons with safety.
The following stores are required for the service of the gyn:—
One fall, of 3½-inch white rope, eight fathoms long.
Two lashings for slinging the gun, of 2½-inch tarred rope, each
twenty feet long.
One stopper, about 5½ feet long, of 2½-inch tarred rope, more
than one half plaited as a gasket.
One iron triple block, with brass sheaves, to which is attached a
bar of iron 2½ feet long, for suspending the gun, its ends turned up
to prevent the slings slipping off.
Four common handspikes. Two dragropes.
One non-commissioned officer and six men are allowed for
working the gyn, numbered as usual.
The gyn is moved by means of dragropes hooked to the staples of
the front, or rear axletrees by Nos. 6 and 7. It can be drawn over
hard level ground by the working detachment of six men. On ground
of an unfavourable nature, a greater number than this is necessary.
The rear of the gyn is the part where the windlass is fixed.
The detachment being formed a few paces in rear of the gyn, No.
1 gives the word, “Take post for exercise—To the right face—
Quick march.” The detachment wheels to the left, and the ranks
open out. Nos. 2 and 3 halt one pace in rear of their respective
axletree arms. The whole one pace from each other, and covering.
 Disposition, and Duties of the Detachment.

No. 1 commands.
Left side. Right side.
3 runs the carriage up, or back, 2 runs the carriage up, or back,
heaves round the windlass, heaves round the windlass,
assists 7 to sling the gun. assists 6 to sling the gun.
5 runs the carriage up, or back, 4 runs the carriage up, or back,
assists to hold on the fall, holds on the fall, makes it
stoppers, and unstoppers it. fast, and lowers the gun.
7 reeves the tackle, slings, and 6 reeves the tackle, slings, and
unslings the gun at the unslings the gun near the
chase, and steadies it. xx first reinforce, steadies the
gun, and overhauls the
tackle.

Prepare to place the gyn. Place the gyn by hand, (or by

crosslifting). Reeve the tackle. Prepare to sling the piece.
Sling the piece. Haul in the slack. Heave round the windlass.
Halt. Stopper the fall. Shift the fall. Halt. The carriage having
been run under the piece, or away from it, as may be required, the
piece is lowered, and cast loose, each number reversing the
operations which he performed in lashing; and raising it.
 PA R T V I I I .
GUNNERY.

By the Parabolic Theory, the greatest range is when the angle of

elevation is 45°, or half a right angle; and the ranges are equal at
angles, equally above, and below 45°. In projectiles, moving with
velocities not exceeding 300 or 400 feet per second of time, the
Parabolic theory will resolve cases tolerably near the truth; but in
cases of great projectile velocities, that theory is quite inadequate,
without the aid of data, drawn from good experiments; for so great is
the effect of the resistance of the air to projectiles of considerable
velocity, that some of those, which in the air range only two or three
miles, would, in vacuo, range between twenty and thirty miles. The
effects of this resistance are also various, according to the velocity,
the diameter, and the weight of the shot.
By experiments it will be found that the greatest range (instead of
being constantly that at an elevation of 45°, as in the Parabolic
theory), will be at all intermediate degrees between 45° and 30° (with
ordinary charges about 42°), being more, or less, both according to
the velocity, and the weight of the projectile; the smaller velocities,
and larger shells ranging farthest when projected almost at an
elevation of 45°; while the greatest velocities, especially with the
smaller shells, range farthest with an elevation of about 30°.
However, as sufficient experiments have not yet been made to
establish true rules for practical gunnery, independent of the
Parabolic theory, we must at present content ourselves with the data
of some one certain experimental range, and time of flight at a given
angle of elevation, and then, by help of these, and the Parabolic
theory, we can determine the like circumstances for other elevations
that are not greatly different from the former, assisted by the
following rules:—
 PRACTICAL RULES IN GUNNERY.

1.—To find the Velocity of any shot, or shell.

It has been found by experiments, that with shot of mean windage,
and powder of mean strength, a charge of one-third of the weight of
the ball gives an initial velocity of about 1600 feet per second:
therefore, to find the velocity given by any other charge, divide three
times the weight of the charge by the weight of the ball, and multiply
the square root of the quotient by 1600, the product will be the
velocity in feet, or the space the shot passes over in the first second.
[28]

2. The first graze, with given elevation, and charge, being known,
to determine the charge for any other first graze, and elevation.
Multiply the known charge, and elevation into the proposed first
graze, also the proposed elevation into the known first graze, and
divide the first product by the last, for the charge required in ounces.
3. Given the range for one charge, to find the range for another
charge, or the charge for another range.
The ranges have the same proportion as the charges; that is, as
one range is to its charge, so is any other range to its charge, the
elevation of the piece being the same in both cases.

Table of Velocities, &c., of shells.

Nature of shells, in inches 13 10 8 5½ 4⅖

Their weight (loaded) in pounds 200 92 46 16 8
Charge of powder (land service) do. 5 3 2 1 ½
The velocities 436 500 629 693 693

From Experiments on the velocities of shot, the following results

have been obtained:—
1. The time of a ball’s flight is nearly as the range, the gun, and
elevation being the same.
 2. The velocities decrease as the distances increase (arising from
the resistance of the air, which opposes the progress of the shot,) in
a proportion somewhat higher than the squares of the velocities
throughout, and subject only to a small variation.
3. Very little advantage is gained, in point of range, by increasing
the charge more than is necessary to attain the object, the velocities
given by large charges being very soon reduced to those by
moderate charges; those, for instance, given by half the shot’s
weight are reduced to an equality with those by one-third, after
passing through a space of only 200 feet. (Vide 8.)
4. Very little benefit is derived from increasing the length of guns,
the velocity given by long guns of 22 calibres being reduced to an
equality with that of short guns of 15½ calibres with similar charges,
after passing through the following spaces—viz.:—

With ½ the shot’s weight, about 285

” ⅓ do. do. 200
” ¼ do. do. 150
” ⅙ do. do. 115
5. The resistance of the air against balls of different diameters with
equal velocities, is very nearly in the proportion of the squares of
their diameters, or as their surfaces.
6. A very great increase of velocity may be acquired by a decrease
of windage, from ⅓ to ¼ being lost by the windage of ½0 the
diameter of the bore.
7. By firing the charge in different parts (separately, or
simultaneously), by compressing the charge, by the use of wads, by
varying the weight of the gun to lessen the recoil, or even by
stopping the recoil entirely, no sensible change is produced in the
velocity of the ball.
8. The velocity increases with the charge, to a certain point,
peculiar to each gun; but, by further increasing the charge, the
velocity gradually diminishes; yet the recoil is always increased by
an increase of charge. (Vide 3.)
9. The velocities of balls fired with equal charges increase to a
certain point, when the gun is longer, in a proportion which is nearly
the middle ratio between the square and cube roots of the length of
the bore.
10. When shot of different weights are fired with the same charges
of powder, the velocities communicated to them are nearly in the
inverse ratio of the square roots of their weights. Therefore, shot
which are of different weights, and impelled by the firing of different
charges of powder, acquire velocities which are directly as the
square roots of the charges of powder, and inversely as the square
roots of the weights of the shot. By making use of shot of a heavier
metal than iron (lead for instance) the momentum of the shot
discharged with the same charge of powder would be increased in
the ratio of the square root of the shot’s weight, which would both
augment the force of the blow with which it would strike, and also the
extent of the range.
Compound-shot, or shells filled with lead, fired with charges
increased ⅛th, will increase the power of range considerably.
11. With common shells at 45° elevation, the time of flight is nearly
equal to the square root of the range in feet, divided by 4; or, more
nearly, equal to the square root of the quotient of the range in feet,
divided by 16-1/12.
12. The range at 45° elevation is nearly equal to the square of the
time of flight in seconds, multiplied by 16-1/12 feet. The range at 15°
will be about half that at 45°.
13. Upon inclined planes, at any elevation, there are always two
elevations with which any range may be obtained.
The elevation which gives the greatest range, on a given ascent, is
equal to half the sum of 90° added to the ascent.
The elevations which give equal ranges on a given ascent, are the
complements of each other added to the ascent.