Cardiac Review, An Issue of Critical Care Nursing Clinics , livre ebook

Cardiovascular Review , Vol. 23, No. 4, December 2011
ISSN: 0899-5885
doi: 10.1016/S0899-5885(11)00064-5

Contributors
Critical Care Nursing Clinics of North America
Cardiovascular Review
GUEST EDITOR: Bobbi Leeper, MN, RN, CNS, CCRN, FAHA
Cardiovascular Services, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA
CONSULTING EDITOR: Janet Foster, PhD, RN, CNS
ISSN  0899-5885
Volume 23 • Number 4 • December 2011

Cardiovascular Review , Vol. 23, No. 4, December 2011
ISSN: 0899-5885
doi: 10.1016/S0899-5885(11)00065-7

Contents

Contributors
Forthcoming Issues
Preface
Acute Coronary Syndrome
Acute Coronary Syndrome: New and Evolving Therapies
Coronary Artery Bypass Surgery
A Journey Through Heart Valve Surgery
Cardiogenic Shock
Pulmonary Issues in Acute and Critical Care: Pulmonary Embolism and Ventilator-induced Lung Injury
Electrolyte Disorders in the Cardiac Patient
Pulmonary Arterial Hypertension
Comprehensive Care of Adults with Acute Ischemic Stroke
Diabetes and Cardiovascular Disease
Index
Cardiovascular Review , Vol. 23, No. 4, December 2011
ISSN: 0899-5885
doi: 10.1016/S0899-5885(11)00066-9

Forthcoming Issues
Cardiovascular Review , Vol. 23, No. 4, December 2011
ISSN: 0899-5885
doi: 10.1016/j.ccell.2011.10.002

Preface

Barbara “Bobbi” Leeper, MN, RN-BC, CNS M-S, CCRN Bobbi.Leeper@baylorhealth.edu ,
Cardiovascular Services, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA


Barbara “Bobbi” Leeper, MN, RN-BC, CNS M-S, CCRN Guest Editor
This issue of Critical Care Nursing Clinics provides a comprehensive review and update of some of the significant cardiovascular disease patient issues we are dealing with today. We know that cardiovascular disease is a major health problem not only for the United States but globally, representing a significant financial burden. The content in this issue addresses clinical practice related to the patient with cardiovascular disease. The issue begins with a review of acute coronary syndromes and a brief review of the atherosclerotic process followed by important aspects for the management of angina, non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction. The next article brings us forward with new and evolving therapies for acute coronary syndromes. For those patients who require a surgical intervention, there is an overview of coronary artery bypass surgery, which is helpful for those who do not routinely care for these patients. Heart valve surgery is discussed beginning with where we are today and transitioning to invasive transcatheter aortic valve replacement, which is likely to become standard practice as technology evolves.
General topics that are always a challenge when caring for the patient with cardiovascular disease are cardiogenic shock, pulmonary issues focusing on pulmonary embolism and ventilator-induced lung injury, electrolyte disorders, and glucose control. The latest information about caring for a patient with pulmonary hypertension is provided as well as information about comprehensive care of adults with ischemic stroke. Many facilities are seeking certification for stroke. This article provides key information related to that process.
It is hoped that the readers of this issue will find content within that will help them in some aspect of their practice, whether they are pursuing certification, looking for articles to help with orienting new staff to a cardiac ICU, or searching for evidenced-based practices. There's something in this issue for almost every nurse caring for a patient with cardiovascular disease.
Cardiovascular Review , Vol. 23, No. 4, December 2011
ISSN: 0899-5885
doi: 10.1016/j.ccell.2011.10.001

Acute Coronary Syndrome

Barbara Leeper, MN, RN-BC, CNS M-S, CCRN a , * Bobbi.Leeper@baylorhealth.edu , Alaina M. Cyr, BSN, RN, CAPA, NE-BC b , c , Christa Lambert, BSN, RN, CEN b , Kimberlee Martin, RN b
a Cardiovascular Services, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA
b The Heart Hospital Baylor Plano, 1100 Allied Drive, Plano, TX 75093, USA
c College of Nursing, The University of Texas at Arlington, 411 South Nedderman Drive, Arlington, TX 76019, USA
* Corresponding author

Keywords
• Acute coronary syndrome • Coronary • ST-segment elevation myocardial infarction • Angina • Heart • Cardiac
At present, cardiovascular disease affects 82.6 million Americans, with more than 8 million Americans experiencing a myocardial infarction (MI) annually. More than 800,000 will succumb to the effects of cardiovascular disease. 1 Although the death rate attributable to cardiovascular disease has declined, it is still the primary cause of death in the United States, accounting for approximately 34% of all deaths. 1 According to the American Heart Association, an American dies from cardiovascular disease every 39 seconds. 1 A recent policy statement from the American Heart Association predicted 40.5% of the population in the United States will have some form of cardiovascular disease, including hypertension, coronary heart disease, heart failure, or stroke. 2 Mortality from cardiovascular disease is estimated to reach 23.4 million by the year 2030. Annually in the United States, an estimated $165.4 billion in direct and indirect costs of cardiovascular disease are realized, with projections of $818 billion in 2030. 2 Hospital emergency departments are inundated on a daily basis with patients presenting with a variety of symptoms. Patients presenting with cardiac symptoms are in need of rapid assessment, diagnosis, and treatment. The following content describes the spectrum of acute coronary syndrome (ACS), management of ACS, and secondary prevention strategies.

Overview of Atherosclerosis
Acute coronary syndrome (ACS) represents a spectrum of the atherosclerotic process including unstable angina, non-ST-segment elevation MI (NSTEMI), and ST-segment elevation MI (STEMI). It is associated with increased risk of acute myocardial infarction (AMI) and cardiac death. 3 These life-threatening disorders are a major cause of emergency care and hospitalization in the United States.
Although other conditions may lead to the development of angina, the most common cause is atherosclerosis. Atherosclerosis is a disease of the medium and large arteries. The earliest manifestation of atherosclerosis begins in childhood and is characterized by the presence of fatty streaks in the walls of the arteries. The atherosclerotic process begins with injury to the endothelial cells lining the artery. Inflammation ensues, with the accumulation of lipids, cholesterol, calcium, and cellular debris within the intima of the vessel wall. Over time, this process leads to the buildup of these materials protruding into the lumen of the coronary artery, forming an advanced lesion called “fibrous plaque” that usually appears in early adulthood and progresses with age. 4 Unless the plaque ruptures, the patient can remain asymptomatic for a long time. If the plaque ruptures, the platelets become activated and aggregate at the site of the rupture. The intrinsic clotting cascade is activated, resulting in the formation of a thrombus at the site that may cause either fixed occlusion of the vessel or intermittent occlusion. Over time, the thrombus is resorbed and the plaque continues to enlarge. This process may be repeated several times until there is significant obstruction of the coronary artery leading to the onset of symptoms.
The plaque may be described as stable or unstable. The stable plaque does not rupture but continues to increase in size, eventually reducing blood flow and leading to the development of angina. The unstable plaque is also referred to as a vulnerable plaque that is prone to rupture. Triggers for plaque rupture have been found to have a circadian rhythm, occurring more often in the morning. Plaque rupture is also associated with seasonal variation, specifically in the winter, and is often associated with emotional stress or exertion.

Signs and Symptoms
The patient begins experiencing symptoms when the coronary artery becomes so narrowed that blood supply is insufficient to meet the metabolic demands of the cardiac muscle cells, causing ischemia of the myocytes. The symptoms often begin with exertion, which can be in the form of emotional or physical stress. The typical signs and symptoms may include discomfort in the jaw, neck, one or both arms, chest tightness or heaviness, and complaints of shortness of breath. It is important for the clinician to differentiate the signs and symptoms associated with angina from those associated with AMI. Refer to Box 1 for additional signs and symptoms associated with angina and AMI. A patient experiencing angina will usually have resolution of the discomfort with termination of exertion or after administration of nitroglycerin. The patient experiencing an AMI will have discomfort or pain lasting longer than 20 minutes that usually is not relieved by nitroglycerin. Other signs may include diaphoresis, nausea and vomiting, tachycardia, and shortness of breath. Patients may also report a feeling of impending doom or general feeling of not being well. 3 Women in the throes of experiencing an MI may not have complaints of chest discomfort. Instead, they are likely to have more subtle symptoms such as fatigue and indigestion. The symptom of dyspnea should not be overlooked. Studies have shown self-reported dyspnea in patients undergoing stress perfusion testing was an independent predictor of cardiac and total mortality. The risk of sudden cardiac death was increased fourfold even when patients had no prior history of coronary artery disease. 5

Box 1 Signs and symptoms associated with angina and AMI
Anginal Equivalent:
Resolve with rest OR nitroglycerin
Pain or discomfort
Jaw
Neck
Ear
Arm
Epig