The Journal for Nurse Practitioners 15 (2019) e197ee200

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The Journal for Nurse Practitioners

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Brief Report

Young Adults’ Perception of Cardiovascular Disease Risk

Jacqueline O'Toole, MSc, NP, Irene Gibson, MA, RGN, Gerard T. Flaherty, MD

a b s t r a c t
Keywords: Early detection of cardiovascular disease (CVD) risk factors in young adults and identification of risk may
cardiovascular disease reduce future CVD burden. The emergency department provides a setting for identifying young adults with
cardiovascular risk
CVD risk when they present with chest pain. However, before offering CVD risk advice, it is imperative to
young adults
understand knowledge and perception of CVD risk factors in young adults because knowledge is crucial to
risk modification. This descriptive, cross-sectional pilot study provides useful insights into the lifestyle habits
and CVD risks in this cohort. The findings of this pilot study may be helpful to nurse practitioners worldwide.
© 2019 Elsevier Inc. All rights reserved.

Globally, chest pain is a frequent presenting symptom to
emergency departments (EDs), accounting for 5% to 10% of ED visits
each year, and provides an ideal opportunity to assess cardiovas-
cular disease (CVD) risk.1 Up until recently, systematic cardiovas-
cular risk assessment in men (< 40 years) and women (< 50 years)
with no known CVD risk factors (CVDRFs) is not recommended;
however, when an individual presents to an ED with chest pain,
underlying CVD must be considered and consequently CVDRFs and
CVD risk assessed.2,3 CVD is a slow progressing disease with sub-
clinical signs of CVD measurable years before disease manifests.4
Globally, CVD is recognized as the single most common cause of
death, with CVD prevention nationally and internationally high on
the political agenda.5,6 CVD prevention is targeted at eliminating or
reducing the impact of CVDs and their associated disabilities and is
defined as a coordinated set of actions, at the population level or
targeted at an individual.2 Although European guidelines are
insufficient to address screening and treatment of CVDRFs in young
adults, more recent American guidelines suggest it is reasonable to
assess adults 20 to 39 years old for CVD.3,7,8
A prerequisite for making sound decisions about one’s CVD
health is adequate knowledge of CVD risk factors.9 However,
knowledge alone is not sufficient to promote behavior change, and
a lack of knowledge can impede appropriate behavioral change.10 A
common approach to poor lifestyle choices is to wait until CVD
develops to prescribe lifestyle change or medication management
rather than prevent or delay the onset of CVD.11 It is reasonable to
consider global recommendations in that premature mortality from
CVD can be partly countered by efficient action dealing with key
behavioral CVDRFs.12 Through modest CVDRF reduction, mortality
rates from CVD could be halved.12 Literature examining the
knowledge and perception of CVDRFs in young adults is limited and
focuses on college students or those with a high level of education
in the United States.13-15 Therefore, further European research is
required in a more varied, less academic socioeconomic cohort. A
pilot study was undertaken to examine CVD risk and knowledge
and perceptions of CVDRFs in a cohort of young adults who pre-
sented to an Irish ED with chest pain.
Methods
Twenty-six individuals were recruited by a nurse practitioner
(NP) over a 3-month period in an adult ED where chest pain ac-
counts for 9% of the total attendances. Convenience sampling was
used to recruit participants. Once an acute coronary syndrome was
ruled out, young adults between 20 and 45 years old were referred
to the NP ED chest pain clinic within 72 hours of their discharge. On
arrival to the clinic, the NP undertook an assessment and fasting
bloodwork. This cross-sectional pilot study collected quantitative
and qualitative data that assessed baseline demographics and
ascertained knowledge and perception of CVD risk using validated
questionnaires.16 Self-perceived CVDRFs and self-perceived 10-year
risk of heart attack or stroke was ascertained using investigator-
developed questions as part of the questionnaire. Actual CVD risk
was calculated using the European low-risk Systematic COronary
Risk Evaluation (SCORE) and relative risk charts for those < 40 years
of age.17 Relative risk SCORE charts provide an estimate of risk in a
younger person < 40 years old with a combination of CVD risks in
contrast to a person of the same age and sex who has ideal risk
factor levels.18 The primary outcome variables assessed in this
study were 1) knowledge, 2) perception, 3) self-perception, and 4)
actual cardiovascular risk and risk factors in young adults. Sec-
ondary outcome measures included biometric measurements of
systolic blood pressure (SBP,) venous fasting blood profiles for
glucose and lipids, and body mass index category. SBP was

https://doi.org/10.1016/j.nurpra.2019.06.010
1555-4155/© 2019 Elsevier Inc. All rights reserved.
e198 J. O'Toole et al. / The Journal for Nurse Practitioners 15 (2019) e197ee200

measured in both arms after the participant had been resting for 5 Table 2
minutes and the greater of the 2 results was recorded for analysis.2 Presence of Cardiovascular Risk Factors (N ¼ 26)

Venous fasting blood profiles for glucose and lipids were taken and Cardiovascular Risk Factors N (%)
analyzed in the organization’s central laboratory after participants Nonmodifiable
had been fasting for 12 hours. Recommended targets include SBP < Race (white) 23 89
140, total cholesterol < 5 mmol/L, low-density lipoprotein < 3 Sex (male) 17 65.4
mmol/L, high-density lipoprotein > 1 mmol/L, and blood glucose < Family history of heart disease or stroke 13 50
in a first-degree relative
6.0 mmol/L (Table 1).2 Data were analyzed using descriptive and
Modifiable
inferential statistics using a prepared statistical package (SPSS Overweighta 18 69.2
Version 22; IBM Corp, Armonk, NY). Spearman correlations were Increased systolic blood pressureb 8 30.8
used to explore the strength of the relationship between the Smokers 6 22.1
Elevated fasting blood glucosec 0 0
knowledge and perception of CVD risk. Qualitative data were
Sedentary behaviord 18 69.2
interpreted using thematic analysis on the self-perceived estima- Increased total cholesterol levele 11 42.3
tion of CVDRFs and 10-year risk. Full ethical approval was granted a
Overweight, body mass index > 24.9 kg/m2.
for this study from the research ethics committee within the lead b
Increased systolic blood pressure > 140.
author’s organization (#20170228). c
Fasting blood sugar > 6.0.
d
Sedentary behavior < 30 minutes of moderate physical activity at least 5 days/wk.
e
Total cholesterol levels > 5.0 mmol/L.

Results
The final sample for this pilot study was composed of 26 young
adults. The mean age of the study participants was 39.96 (± 5.7)
years. Of participants, 65% were aged
40 years, and the remaining
35% were aged  39 years. The majority of the sample was male
(65%). Ethnicity was reported as white (89%). More than half of
participants (54%) attended third-level education, and the majority
were employed (85%). Private health insurance was indicated in
31%. Table 1 indicates the modifiable CVDRFs of the participants
and European clinical targets.
Of the modifiable CVDRFs (Table 2), current smokers accounted
for 22%. Although 73% reported that they felt they did not exercise
enough, analysis indicates 31% were achieving recommended daily
targets for exercise of 30 minutes of moderate aerobic activity 5
days per week and 69% were not. When asked if they thought they
were overweight, 73% reported that they were overweight. How-
ever, the actual weight recorded indicated that 69% were over-
weight and had a body mass index > 24.9 kg/m2. The most
frequently encountered CVDRFs were sedentary lifestyle (69%) and
overweight (69%) followed by a family history of CVD (50%) and
high total cholesterol in 42% of participants. Fasting blood sugar
levels were within normal ranges for all participants (< 5.0 mmol/
L). Increased SBP (> 140 mm Hg) was detected in 31% of partici-
pants. The number of CVDRFs identified per participant is detailed
in Table 3. Based on clinical data, more than half of the participants
(54%) had 2 CVDRFs identified. Figure indicates self-perceived
versus actual calculated CVDRFs and suggests self-perceived
CVDRFs were lower than the actual calculated CVDRFs, with the
exception of weight.
The relationship between knowledge (The Heart Disease Fact
Questionnaire) and perceived severity and susceptibility of CVD
risk (The Health Beliefs Related to Cardiovascular Disease Ques-
tionnaire) was investigated using the Spearman correlation coef-
ficient.16 There was a modest, positive correlation between the 2
variables (r ¼ 0.459, n ¼ 24, P < .05), with high levels of knowledge
associated with high levels of perceived severity.
The European low-risk SCORE was used to predict the 10-year
risk of a fatal CVD event in those
40 years old (65.3%), and rela-
tive risk was determined for those  39 years old (34.7%). More
than half (72%) of the participants believed they had a moderate
(1%-5%) to very high (> 10%) risk of a fatal CVD event within 10
years. All participants were calculated to be at low absolute (< 1%)
risk. Those < 40 years old were automatically low (< 1%) risk
because of age, despite identified CVD risks, and showed a low
relative risk (mean ¼ 1.5, standard deviation ¼ .75). According to
SCORE, 69% of participants overestimated their 10-year risk of a
fatal CVD event, and only 31% correctly identified their risk. Qual-
itative thematic analysis showed that family history and being
overweight were the most common contributors to their perceived
risk estimation.
Discussion
Despite advancing knowledge and preventive strategies,
CVDRFs are evident and remain a concern in this cohort. Despite all
participants in this pilot study being identified as low risk of having
a fatal cardiovascular event within 10 years because of age, more
than half of the young adults had 2 or more CVDRFs identified. This
is of concern, bearing in mind that the severity of atherosclerosis in
young adults increases with the number of CVDRFs.18
The most frequently occurring modifiable CVDRFs in this pilot
study were being sedentary (69%) and overweight (69%). Similar
findings are reported in that a frequently occurring CVDRF in young
adults is being overweight.13 Historically, obesity is associated with
higher levels of blood pressure and adverse lipid profiles.19
Compared with individuals with a healthy body weight, overweight
young adults with a body mass index greater than 25 kg/m2 have

Table 1
Modifiable Cardiovascular Disease Risk Factors of Study Participants

Variable Mean Standard Deviation Recommended Clinical Targets

Systolic blood pressure (mm Hg) 128 11.05 < 140a

Total fasting cholesterol (mmol/L) 4.9 .721 < 5.0 mmol/La
Low-density lipoprotein (mmol/L) 2.89 .661 < 3.0 mmol/Lb
High-density lipoprotein (mmol/L) 1.37 .341 > 1.0 in malesc
> 1.2 in femalesc
a
Recommended clinical targets for those > 40 years of age with identified cardiovascular disease risk factors.
b
Low-density lipoprotein: very high-risk target level < 1.8, high risk target level < 2.6, and low to moderate risk target level < 3 (all patients considered low risk in the table).
c
High-density lipoprotein: there is no specific target but > 1.0 mmol/L in men and > 1.2 in women indicate lower risk.7
 J. O'Toole et al. / The Journal for Nurse Practitioners 15 (2019) e197ee200
20
18
16
14
Number of participants
12
10
8
6
4
2
0
Smoking
Cholesterol
Figure. Self-perception of CVDRFs versus actual CVDRFs identified.
1.5 to 2 times greater risk of developing coronary heart disease.11
This study shows a high prevalence of self-reported sedentary
behavior. Only 31% of participants were achieving the recom-
mended 30 minutes per day of moderate aerobic physical activity.2
Despite smoking as an identified CVDRF, only 22% of participants
are current smokers.
A large number (42%) of participants had high serum cholesterol
levels identified, and 24% of those were < 40 years old. Overall, this
study found no statistical association between age and total
cholesterol levels. However, high serum cholesterol is known to
have a continuous graded relationship to long-term risk of CVD
death for younger men with elevated serum cholesterol levels and
longer estimated life expectancy for younger men with favorable
serum cholesterol levels.20 Low levels of high-density lipoprotein
were recorded in 39% of study participants. Guidelines suggest
lifestyle intervention to increase high-density lipoprotein levels,
including increasing habitual physical activity, reducing excessive
body weight, and dietary interventions.2
A high resting SBP accounted for 31% of participants in this
study. The most common reason for the absence of cardiovascular
health in young adults in the US is high blood pressure.10 One in 10
young adults is unaware of having high blood pressure; therefore, it
is left untreated.13
Tran and Zimmerman13 report that participants with a high
knowledge of CVDRFs perceived themselves to be of low to
moderate risk of CVD. The study indicates that participants
similarly displayed a high level of knowledge of CVDRFs; how-
ever, in contrast, perceived themselves to be at a moderate to
very high risk of death from a cardiovascular event within a 10-
year time frame.13 This might possibly be explained in that
participants had presented to the ED with chest pain and were
suspected to have had a cardiac event. Younger persons will
Table 3
The Number of Cardiovascular Disease Risk Factors (CVDRFs) Identified in Study
Participants (N ¼ 26)
Number 1 CVDRF 2 CVDRF 3 CVDRF
of CVDRF
n % n % n %
2 7.7 14 53.8 3 11.5
e199
Perceived versus Actual CVD Risks Factors
High Overweight Adequate Blood Diabetes Family
exercise pressure history
Crdiovascular Disease Risk Factors
always be at low absolute risk even when risk factor levels are
unfavorable; no combination of risk factors will place a person in
the high-risk category (> 5% 10-year risk of fatal CVD).21 Inter-
estingly, overestimation of risk may contribute to increased
stress, overmedication, and medical seeking behaviors, which
can affect an individual’s quality of life rather than his or her
absolute risk for CVD. 22 Therefore, the use of risk estimation
scores should be communicated with young adults to generate
an understanding of risk and subsequently offer lifestyle advice
in order to modify their risk. In young adults, the use of SCORE
and relative risk charts allows clinicians to communicate that
although participants are at low absolute risk, their risk is still
“x” times higher than it could be if they had ideal risk factor
levels.18
High knowledge levels were positively associated with
perceived severity of CVD; this may be because of the fact that a
large percentage of participants had a family history of CVD and
may have witnessed the consequences of an event, which gener-
ated a greater awareness of CVDRFs.
Implications for Practice
Within the ED setting, nursing has a pivotal role to play in
ascertaining actual versus perceived CVD risk using risk assessment
tools and in determining effective preventive strategies. Future
research is warranted to evaluate predictors of lack of behavior
change despite knowledge of CVDRFs to help empower individuals
to reduce their future risk of CVD events. Many risk assessment
tools beyond SCORE exist and should be considered in future
research.
Limitations of Study
Generalizability is limited because of the small number of par-
ticipants, convenience sampling, and a cross-sectional design.
Recruitment was undertaken in an ED after patients had presented
4 CVDRF 5 CVDRF with chest pain; therefore, patients may have perceived themselves
to be at CVD risk. Furthermore, participants may not have under-
n % n %
stood the terms cardiovascular disease or risk despite a high level of
5 19.2 2 7.7
education. A segment of data collection included self-reported data
e200 J. O'Toole et al. / The Journal for Nurse Practitioners 15 (2019) e197ee200
on specific behaviors; self-reported data may underestimate the
proportion of individuals considered at risk.
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Jacqueline O'Toole, MSc, NP, is a nurse fellow of the European Society of Cardiology and
an advanced nurse practitioner in cardiology at Naas General Hospital in Naas, County
Kildare, Ireland, and can be contacted at jacqueline.otoole@hse.ie. Irene Gibson, MA,
RGN, is the director of programs at the School of Medicine, National University of
Ireland in Galway, Ireland. Gerard T. Flaherty, MD, is a professor at the School of
Medicine, National University of Ireland. All are associated with the National Institute
for Prevention and Cardiovascular Health, Galway, Ireland.
In compliance with national ethical guidelines, the authors report no relationships
with business or industry that would pose a conflict of interest.