The Tell-Tale Heart Attack
Monday January 13, 2003
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- Edgar Allan Poe
IN THE DEAD OF NIGHT, Ed can hear his heart beating. There are no other sounds, just the beating of his heart. Though he knows he is not alone, he has never felt lonelier. It is so quiet here in the middle of the night, not like he expected. He is overwhelmed with fear, and exhaustion, and yet he cannot sleep. It has been a long day, and when someone asks, he says he is fine. But alone now, in the middle of the night, listening to his heartbeat, he is afraid.
Ed Williams,* a 75-year-old man, has always enjoyed good health. He is active and athletic, never making excuses for his age and always advocating the benefits of an active life. But early this morning as Ed was out walking through his neighborhood, the chest pain returned, the same chest pain that had been nagging him for the past three or four weeks. It wasn't even a pain, just a little discomfort, and it always went away after a few minutes. But today it was different. No matter what he did, it just wouldn't go away. He cut his walk short, went home, and waited. He worried, he lay down, he sat up, he got into his car.
Ed felt foolish as he walked into the ED. "I'm sure it's nothing," he says, trying to smile at the triage nurse, "but I've been having this pain in my chest." That was this morning - the time that he can't stop thinking about now.
"When patients come into our ED with chest pain," says Christine Rice, RN, BSN, nursing care coordinator in the ED at St. Francis Hospital in Roslyn, NY, "we automatically make them a level I emergent case." And chest pain includes shoulder or jaw pain, epigastric pain, anything that may indicate a myocardial infarction. In an ED that evaluated 400 chest pain patients a month, nothing is left to chance.
"There is no such thing as soft chest pain here," adds Nancy Kostel-Donlon, RN,C, MSN, CCRN, CPAN, clinical nurse specialist in critical care. "We take every situation seriously." As for Ed, an ECG is done within 10 minutes of his arrival, and before he has time to catch his breath, Ed is informed that he is having a heart attack.
Join the Crowd
It is understandable that Ed feels vulnerable and alone, but he is in very good company. Each year in the US about 800,000 people suffer an acute myocardial infarction and more than 200,000 of them die. One hundred thousand of these people die within one hour of the onset of symptoms, before they ever reach the hospital ED.1
Ed is not even alone in his delay to seek help or in his mode of transportation. According to the American College of Cardiology, most patients do not seek medical help for two hours or more after symptom onset, even though every minute of delay reduces the effect of treatment.
Statistics also show that only half of the people having a heart attack call 911 for an ambulance; the other half, like Ed, drive themselves or have someone drive them. This error in judgment can also delay the effectiveness of treatment. According to a report in Circulation, patients transported by
ambulance have a 24% higher chance of receiving fibrinolytic therapy or angioplasty. Ambulance-transported patients also received fibrinolytics 12 minutes sooner, and angioplasty 31 minutes sooner than self-transported patients.2
Knowing they have already lost precious time, the ED team is determined not to lose another minute. "We get a full history, draw blood for creatine kinase-MB (CK-MB) and cardiac troponin (cTnI, cTnT), start IVs, medicate with nitroglycerin (Tridil), heparin, tirofiban (Aggrastat), morphine, and metoprolol (Lopressor) if ordered," explains Christine Weber, RN, BSN, senior clinical nurse, ED. "We premedicate for contrast dye allergies if necessary, and prepare the patient for the cath lab," she adds.
PTCA vs. Thrombolytics
For Class I treatment of acute MI, the American College of Cardiology/American Heart Association (ACC/AHA) recommendation calls for an acute MI protocol that provides a clinical examination and 12-lead ECG within 10 minutes, and a "door-to-needle" time that is less than 30 minutes for thrombolytic therapy. But Ed will be traveling a different route today.
Some studies have found that the incidence of death, nonfatal reinfarction, and nonfatal stroke was lower in patients who received primary percutaneous transluminal coronary angioplasty (PTCA) compared to those who received fibrinolytic therapy. Angioplasty is the Class I ACC/AHA recommendation as an alternative to thrombolytic therapy for patients -
· who have acute MI and ST-segment elevation
· who have new or presumed new left bundle branch block (LBBB)
· who can undergo angioplasty of the infarct-related artery within 12 hours of onset of symptoms or greater than 12 hours if ischemic symptoms persist1
The accompanying caveat states that the use of angioplasty over fibrinolytic therapy should be based on institutional experience, availability, and timeliness, after weighing the risks associated with angioplasty.
In studying the research findings of PTCA vs. thrombolytics, the ACC/AHA found that the positive research results were attributed to several factors including the extensive experience of the interventionalists and the capability to perform PTCA within 60 to 90 minutes of arrival at the hospital. The guidelines point out that the number of hospitals that are prepared to perform emergency PTCA is limited, and that though the transfer of a patient with an MI to a facility that can perform PTCA is possible, the delay in treatment time may outweigh any added benefit.1
Timing Is Everything
Ed has never seen people move so quickly. Everyone has a task to complete and every action is coordinated. He can tell they have done this many times before. Time and experience are not a concern for the staff at the St. Francis Hospital, The Heart Center, where 15,143 patients were treated in the cardiac catheterization lab and 2,476 open heart surgeries were performed in 2001.
"Standard protocol is 90 minutes from the ED door to the first balloon inflation," says Dana Shapiro, RN, AAS, senior clinical nurse in the cardiac cath lab at St. Francis, "and we're usually faster than that." As one nurse is getting patient information, the scrub tech is prepping the patient. "We may be getting a balloon pump ready if the patient is very hypotensive, having intractable pain, and unable to tolerate the nitroglycerin," Shapiro says. "We medicate, and educate while we are getting the patient ready; no time is lost," she adds. Access for angioplasty is usually a 6 French sheath through the right femoral artery, and the patient is given conscious sedation and analgesia. "With an acute situation," Shapiro emphasizes, "everyone works as fast as they can. There is a lot of team support."
The patient's ECG and hemodynamics are monitored throughout the procedure. "In the initial phase, oftentimes they will go right to the culprit lesion that they assume is causing the infarct pattern," Shapiro says. "Once stents are placed and we've done what needs to be done, the interventionalist also takes a look at the other coronary arteries as well as the ventricular function, especially if there's a chance that the patient will have to go to surgery."
Because the patients are awake during the procedure, they can communicate with the staff. About 70% of stented patients receive a glycoprotein IIb/IIIa inhibitor such as Aggrastat or Integrelin that prevent accumulation of platelets at the occluded site. "In an acute infarct you do everything you can to reduce the thrombus blocking the artery," Shapiro adds. New skin closure devices such as collagen plugs and nondissolvable sutures are now often used to close the femoral access sites.
Restenosis
A recurring theme in coronary vascular disease is restenosis, the response of human arteries to acute injury. Clinical understanding about restenosis has changed over time, but physicians now know that it is a process of multiple components in which intimal hyperplasia and vascular remodeling play a major role. Stents, which in essence create a scaffold inside the artery, have been able to limit the vascular remodeling, but cannot prevent intimal hyperplasia.
New technology that holds out great promise for preventing this cellular reaction will be in the form of drug-eluting stents. These stents are coated with drugs that help halt smooth muscle cell development without affecting the function of endothelial cells. The research so far has shown lower rates of stenosis. These growth-inhibiting medications used thus far in the research are not familiar names in the cardiology field. Rapamycin is an immune-suppressing drug, and paclitaxel is most familiar in oncology. "This is going to be huge when it comes out," says Dorothy Veron, RN, MSN, RCIS, administrative director for the cardiac cath lab at St. Francis. "This will impact the direction of healthcare, not only decreasing the number of patients who go for open heart surgery, but also decreasing the number of patients who might need to come back for stent restenosis." The stents are expected to become available in spring of 2003.
Critical Care vs Telemetry
There have been many decisive moments throughout Ed's day. The most significant decision was made when Ed decided to seek help. If he had waited longer, his outcome would not have been the same. "A delay in seeking help," says Linda Scharp, RN, BSN, CCRN, senior clinical nurse in the cardiothoracic ICU, "can result in a massive MI. I am caring for a man now who is in cardiogenic shock. He is on a balloon pump, multiple drugs to maintain his pressure, oxygen, and a Swann catheter so we can monitor his cardiac output." At this juncture in his care, the nurses focus on preventing any extension of his MI. He is at risk for bleeding, aneurysm, stress ulcers, deep venous thrombosis, and kidney failure. In addition to the physical risks, the nurses must provide reassurance and support after this life-threatening event. "It is a delicate balancing act," says Scharp.
But Ed has been lucky. Despite his initial reluctance, Ed sought help in time and was able to have his blocked artery opened before there was any further damage to his heart. He is transferred to a stepdown unit where he will have a careful assessment of his post-PTCA condition. "We will assess his peripheral pulses, blood pressure, and telemetry heart monitor reading," says Julie Bohuslaw, RN, BSN, clinical nurse, telemetry/stepdown. "We will assess the femoral artery access site for hematoma or bleeding, and do neuro checks. We'll start patient teaching as soon as we receive him from the cath lab." Ed is scared right now, but his prognosis is good. He will hear those words again and again, until he starts to believe them.
"Because of our cardiac focus, the staff is fluent in the management of chest pain, from the ED to discharge. There is no such thing as soft chest pain in our Heart Center," Donlon says. "We orient our staff with a cardiac focus." Ed will be happy to know that.
Carol Dunbar, APRN, BC, is a contributing editor for Nursing Spectrum.
*Name has been changed.
*Feature photos by Mark Paris
References
1. ACC/AHA Guidelines for the management of patients with AMI. Available at wwwacc.org/clinicalguidelines/nov96/1999. Accessed December 15, 2002.
2. Half of heart attack patients delay treatment, Circulation: Journal of the AHA, Journal Report November 25, 2002. Available at www.americanheart.org. Accessed December 15, 2002.
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