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CARDIAC CONDITIONS, INTERVENTIONS & REHABILITATION Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. Abstract Just as a serious limb injury requires rehabilitation to return to optimal performance, the heart also requires serious rehab in order to function at its best after a trauma. When a cardiac event occurs, the patient may suffer emotional difficulties and challenges to accept and overcome events that caused the condition. Cardiac rehabilitation is a whole-body approach to restore health that incorporates a multidimensional methodology to address body, mind, and spirit. Exercise, counseling, and physical therapy combine with medical management to ensure that as much normal function as possible is restored, and that every patient is able to adapt to lifestyle changes that reduce the risk of a repeat occurrence. The cardiac rehabilitation team and program goals for various cardiac diagnoses and interventions are discussed to support further studies and to increase knowledge in everyday practice. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Continuing Nursing Education Course Planners William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster, Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Assisting patients to lower their risk of heart disease following a new cardiac diagnosis often involves specialized health professionals to encourage and educate them on best practice exercise programs and healthy lifestyle choices. Nurses are key partners within the health team to support the patient with heart disease in their progress to heal and to lead a healthy life. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Course Purpose To provide nursing professionals with knowledge of a holistic approach for cardiac rehabilitation to support the patient with heart disease to recover and heal. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Activity Review Information Reviewed by Susan DePasquale, MSN, FPMHNP-BC Release Date: 3/1/2016 Termination Date: 3/17/2018 Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. Which of the following is a modifiable risk factor for atherosclerosis: a. Diabetes mellitus b. Age c. Family history of premature coronary heart disease d. Male-pattern baldness 2. True or False: Angina is the term used to describe the pain and discomfort that occurs when the heart is deprived of blood. a. True. b. False. 3. Patients with typical myocardial infarction may have the following prodromal symptoms in the days preceding the event: a. fatigue. b. intense and unremitting for 30-60 minutes. c. a feeling of indigestion or of fullness and gas. d. All of the above. 4. There is evidence to show that comprehensive cardiac rehabilitation programs, including exercise training, can do the following: a. Reduce smoking b. Alter lipid profiles c. Reduce blood pressure d. All of the above. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction There are a number of conditions that require cardiac rehabilitation. However, each patient must be assessed regardless of the condition to ensure that he or she is a candidate for the program. If the patient presents with a cardiac condition, and is determined to be a candidate, cardiac rehabilitation will be initiated. Cardiac Conditions And Rehabilitation The conditions that require cardiac rehabilitation and program selection are unique to the patient’s health history, health resources and individual choices. Specific cardiac conditions in patients who would benefit from enrollment in a cardiac rehabilitation program are highlighted in this course. Its necessary for trained health professionals to ensure that the patient with a cardiac condition, and undergoing specific treatments and procedures, as well as their family are educated on options for recovery and healing. Myocardial Infarction (Heart Attack) Myocardial infarction, commonly known as a heart attack, “is the irreversible necrosis of heart muscle secondary to prolonged ischemia. This usually results from an imbalance in oxygen supply and demand, which is most often caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium.”15 Myocardial infarctions occur when blood flow to a section of the heart is blocked. This blockage prevents the heart from receiving the oxygen that is required to function properly. Without sufficient oxygen, the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 section of the heart will die. Myocardial infarctions are the leading killer of men and women in the United States. However, with proper treatment and long-term management, these effects can be minimized. Cardiac rehabilitation is especially useful in treating patients who have experienced myocardial infarctions.16 The following is a basic description of what occurs during a heart attack:17 Heart attacks most often occur as a result of coronary heart disease (CHD), also called coronary artery disease. CHD is a condition in which a waxy substance called plaque builds up inside the coronary arteries. The buildup of plaque occurs over many years. Eventually, an area of plaque can rupture (break open) inside of an artery. This causes a blood clot to form on the plaque's surface. If the clot becomes large enough, it can mostly or completely block blood flow through a coronary artery. If the blockage isn't treated quickly, the portion of heart muscle fed by the artery begins to die. Healthy heart tissue is replaced with scar tissue. This heart damage may not be obvious, or it may cause severe or long-lasting problems. A less common cause of heart attack is a severe spasm (tightening) of a coronary artery. The spasm cuts off blood flow through the artery. Spasms can occur in coronary arteries that aren't hardened due to plaque buildup (“atherosclerosis”). nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 Heart attacks can be associated with or lead to severe health problems, such as heart failure and life-threatening arrhythmias. Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. Arrhythmias are irregular heartbeats. Ventricular fibrillation is a life-threatening arrhythmia that can cause death if not treated right away. Etiology The primary cause of myocardial infarctions is atherosclerosis. Approximately 90% of myocardial infarctions result from an acute thrombus that obstructs an atherosclerotic coronary artery. Plaque rupture and erosion are considered to be the major triggers for coronary thrombosis. Following plaque erosion or rupture, platelet activation and aggregation, coagulation pathway activation, and endothelial vasoconstriction occur, leading to coronary thrombosis and occlusion.18 Non-modifiable risk factors for atherosclerosis include the following: Age Sex Family history of premature coronary heart disease Male-pattern baldness Modifiable risk factors for atherosclerosis include the following:19 Smoking or other tobacco use Diabetes mellitus Hypertension nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 Hypercholesterolemia and hypertriglyceridemia, including inherited lipoprotein disorders Dyslipidemia Obesity Sedentary lifestyle and/or lack of exercise Psychosocial stress Poor oral hygiene Type A personality Elevated homocysteine levels and the presence of peripheral vascular disease are also risk factors for atherosclerosis. Causes of myocardial infarction other than atherosclerosis Non-atherosclerotic causes of myocardial infarction include the following conditions:20 Coronary occlusion secondary to vasculitis Ventricular hypertrophy (i.e., left ventricular hypertrophy, idiopathic hypertrophic subaortic stenosis [IHSS], underlying valve disease) Coronary artery emboli, secondary to cholesterol, air, or the products of sepsis Congenital coronary anomalies Coronary trauma Primary coronary vasospasm (variant angina) Drug use (i.e., cocaine, amphetamines, ephedrine) Arteritis Coronary anomalies, including aneurysms of coronary arteries Factors that increase oxygen requirement, such as heavy exertion, fever, or hyperthyroidism nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 Factors that decrease oxygen delivery, such as hypoxemia of severe anemia Aortic dissection, with retrograde involvement of the coronary arteries Infected cardiac valve through a patent foramen ovale (PFO) Significant gastrointestinal bleed In addition, myocardial infarction can result from hypoxia due to carbon monoxide poisoning or acute pulmonary disorders. Infarcts due to pulmonary disease usually occur when demand on the myocardium dramatically increases relative to the available blood supply. Myocardial infarction induced by chest trauma has also been reported, usually following severe chest trauma such as motor vehicle accidents and sports injuries. Coronary Artery Spasm - A less common cause of heart attack is a severe spasm (tightening) of a coronary artery. The spasm cuts off blood flow through the artery. Spasms can occur in coronary arteries that aren't affected by atherosclerosis. What causes a coronary artery to spasm isn't always clear. A spasm may be related to: Taking certain drugs, such as cocaine Emotional stress or pain Exposure to extreme cold Cigarette smoking Signs and Symptoms Patients with typical myocardial infarction may have the following prodromal symptoms in the days preceding the event (although typical nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 ST elevation myocardial infarction (STEMI) may occur suddenly, without warning): Fatigue Chest discomfort Malaise Typical chest pain in acute myocardial infarction has the following characteristics:15 Intense and unremitting for 30-60 minutes Retrosternal and often radiates up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm Usually described as a substernal pressure sensation that also may be characterized as squeezing, aching, burning, or even sharp In some patients, the symptom is epigastric, with a feeling of indigestion or of fullness and gas The patient’s vital signs may demonstrate the following in myocardial infarction:17 The patient’s heart rate is often increased secondary to sympathoadrenal discharge The pulse may be irregular because of ventricular ectopy, an accelerated idioventricular rhythm, ventricular tachycardia, atrial fibrillation or flutter, or other supraventricular arrhythmias; bradyarrhythmias may be present In general, the patient's blood pressure is initially elevated because of peripheral arterial vasoconstriction resulting from an adrenergic response to pain and ventricular dysfunction nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 However, with right ventricular myocardial infarction or severe left ventricular dysfunction, hypotension is seen The respiratory rate may be increased in response to pulmonary congestion or anxiety Coughing, wheezing, and the production of frothy sputum may occur Fever is usually present within 24-48 hours, with the temperature curve generally parallel to the time course of elevations of creatine kinase (CK) levels in the blood. Body temperature may occasionally exceed 102°F Pathophysiology The spectrum of myocardial injury depends not only on the intensity of impaired myocardial perfusion but also on the duration and the level of metabolic demand at the time of the event. “The damage in the myocardium is essentially the result of a tissue response that includes apoptosis (cell death) and inflammatory changes. Therefore, the hearts of patients who suddenly die from an acute coronary event may show little or no evidence of damage response to the myocardium at autopsy. The typical myocardial infarction initially manifests as coagulation necrosis that is ultimately followed by myocardial fibrosis. Contraction-band necrosis is also seen in many patients with ischemia. This is followed by reperfusion, or it is accompanied by massive adrenergic stimulation, often with concomitant myocytolysis.”14 The following table provides an overview of the different outcomes that can occur in the setting of a myocardial infarction.20 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 Arrhythmogenesis In addition to the direct effects of ischemia and tissue hypoxia, decreased removal of noxious metabolites, including potassium, calcium, amphophilic lipids, and oxygen-centered free radicals, also impair ventricular performance. These abnormalities promote potentially lethal arrhythmias. Pericarditis Epicardial inflammation may initiate pericarditis, which is seen in more than 20% of patients presenting with Q-wave infarctions. Reduced systolic Lack of adequate oxygen and insufficient metabolite function delivery to the myocardium diminish the force of muscular contraction and decrease systolic wall motion in the affected territory. Abnormal regional Even brief deprivation of oxygen and the requisite wall motion metabolites to the myocardium diminishes diastolic relaxation and causes abnormal regional systolic contractile function, wall thickening, and abnormal wall motion. If the area affected is extensive, diminished stroke volume and cardiac output may result. Hypokinesis and In general, regions of hypokinesis and akinesis of the akinesis ventricular myocardium reflect the location and extent of myocardial injury. Myocardial In general, expansion of infarcted myocardium and infarction resultant ventricular dilatation (i.e., ventricular remodeling) expansion ensues within a few hours after the onset of a myocardial infarction. An expanding myocardial infarction leads to thinning of the infarct zone and realignment of layers of tissue in and adjacent to it, causing ventricular dilatation. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 Myocardial Myocardial rupture was seen in as many as 10% of fatal rupture myocardial infarctions before the era of thrombolytics, but it is now encountered much less often. When rupture occurs, it may be associated with large infarctions; indications include cardiogenic shock or hemodynamically significant arrhythmia. Patients may have a history of hypertension with ventricular hypertrophy. Ventricular A ventricular aneurysm is an outward bulging of a aneurysm noncontracting segment. In the early days of cardiac imaging, ventricular aneurysms were seen in as many as 20% of patients with Q-wave myocardial infarction, but now it is seen in less than 8%. Cardiogenic shock In patients with extensive myocardial injury, coronary blood flow diminishes as cardiac output declines and heart rate accelerates. Because coronary artery disease is usually generalized or diffuse, ischemia that occurs at a distance from the infracted segment may result in a vicious cycle in which a stuttering and expanding myocardial infarction ultimately leads to profound LV failure, hypotension, and cardiogenic shock. Effect on diastolic Immediately after the onset of myocardial infarction, the function ability of ischemic myocardium to relax declines. Relaxation is an active process that uses ATP. Impaired relaxation increases LV end-diastolic volume (LVEDV) and LV enddiastolic pressure (LVEDP). The increased LVEDP results in ventricular dilation, increased pulmonary venous pressure, decreased pulmonary compliance, and interstitial and (ultimately) alveolar pulmonary edema. These effects lead to increased hypoxemia, which may worsen ischemic injury to the myocardium. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 Prognosis Approximately thirty percent of patients who experience a myocardial infarction die within twenty-four hours of onset. Those that survive the initial event experience significant morbidity. An additional 5-10% of survivors die within the first year after their myocardial infarction. Approximately half of all patients with a myocardial infarction are rehospitalized within 1 year of their index event.20 Better prognosis is associated with the following factors: Successful early reperfusion (STEMI goals: patient arrival to fibrinolysis infusion within 30 minutes or patient arrival to percutaneous coronary intervention within 90 minutes) Preserved left ventricular function Short-term and long-term treatment with beta-blockers, aspirin, and ACE inhibitors Poorer prognosis is associated with the following factors:22 Increasing age Diabetes Previous vascular disease (i.e., cerebrovascular disease or peripheral vascular disease) Elevated Thrombolysis in Myocardial Infarction (TIMI) risk score for unstable angina/NSTEMI (7 factors: Age ≥65 year, ≥3 risk factors for cardiac disease, previous coronary disease, ST segment deviation ≥0.5 mm, ≥2 episodes of angina in last 24 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 hours, aspirin use within prior week, and elevated cardiac enzyme levels) Delayed or unsuccessful reperfusion Poorly preserved left ventricular function (the strongest predictor of outcome) Evidence of congestive heart failure (Killip classification ≥II) or frank pulmonary edema (Killip classification ≥III) Elevated B-type natriuretic peptide (BNP) levels Elevated high sensitive C-reactive protein (hs-CRP), a nonspecific inflammatory marker Secretory-associated phospholipase A2 activity is related to atherosclerosis and predicts all-cause mortality in elderly patients; it also predicts mortality or MI in post-MI patients. The presence of ST deviation in ECG lead aVR indicates an increased mortality risk. Data from the APEX-AMI (Pexelizumab in Conjunction With Angioplasty in Acute Myocardial Infarction) trial were examined to determine the incidence and prognostic value of aVR ST deviation in STEMI patients undergoing primary percutaneous coronary intervention within 6 hours of symptom onset; the investigators determined that aVR ST deviation was associated with a 50% relative increase in the risk of death within 90 days in patients with noninferior MI, while aVR ST nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 elevation in patients with inferior MI was associated with a nearly 6-fold increase in such risk. Blood glucose - elevated blood glucose level on admission is associated with increased short-term mortality in nondiabetic patients presenting with a first acute myocardial infarction. Psychological depression - The combination of acute myocardial infarction and psychological depression appears to worsen the patient's prognosis. Acute myocardial infarction may precipitate reactive depression whether or not beta-adrenergic blocking agents or other CNS-active agents are administered. Myocardial hibernation and stunning - After the occurrence of 1 or more ischemic insults, impaired wall motion is often transient (myocardial stunning) or prolonged (myocardial hibernation). These phenomena occur because of the loss of essential metabolites such as adenosine, which is needed for adenosine triphosphate (ATP)–dependent contraction. Hibernation, a persisting wall-motion abnormality that is curable with revascularization, must be differentiated from permanent, irreversible damage or completed infarct. Scar tissue and prognosis - Scars involving less than one third of the thickness of the wall, as shown on contrast-enhanced MRI, likely correspond to a recovery of myocardial function, whereas with scars measuring more than one third the thickness of the wall, the potential for recovery with therapy is limited (except in cases involving research cell therapies or surgical scar revision). nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 Other findings associated with recovery are activity on 2[Fluorine 18]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) scanning and a monophasic or biphasic contractile response to dobutamine infusion, caused by the induction of ischemia. Heart Condition Heart condition is a general term used to categorize a variety of disorders that may occur within the cardiovascular system. Coronary Artery Disease Coronary artery disease (CAD) is a condition that is characterized by the occurrence of atherosclerosis in the epicardial arteries. In this condition, the plaque narrows the coronary artery lumen, thereby impairing blood flow to the antegrade myocardial. Some patients may exhibit symptoms of blood flow reduction, while others will be asymptomatic. The reduction of coronary artery flow may occur during instances of rest of exertion. There is no consistent presentation with CAD. In many instances, the reduction in blood flow will culminate in a myocardial infarction, but not in all instances. This will ultimately depend on the severity of the obstruction and the rate or progression.23 According to the American Heart Association: “Patients with CAD can present with stable angina pectoris, unstable angina pectoris, or an MI. They may seek medical attention with their first symptomatic episode of chest discomfort. Many of these patients suffer from unrecognized CAD and may experience an acute plaque rupture or acute nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 myocardial infarction as their first coronary artery diagnostic presentation. Electrical instability can ensue, including potentially lethal cardiac dysrhythmias. Identifying high-risk persons before their first myocardial event is a multifaceted process that involves both patient and physician education efforts. Screening for coronary artery disease is not sufficient. Risk factor modification, from an early age, initiates primary prevention efforts, forestalling the development of symptomatic CAD. Severe CAD can be detected before a patient develops symptoms, especially in a high-risk patient subpopulation where pre-test probability of flow limiting coronary artery disease is higher than average. CAD is the most common type of heart disease and in 2008, 405,309 individuals died in the U.S. from this specific etiology. Every year, approximately 785,000 Americans suffer a first heart attack and another 470,000 will suffer an additional myocardial infarction (MI). In 2010, CAD alone was projected to cost the U.S. $108.9 billion including the cost of health care services, medications, and lost productivity.”24 Coronary artery disease typically begins during adolescence and progresses throughout the patient’s life. The rate of progression is very slow, and most patients will be unaware of their medical status. Although CAD typically progresses slowly, there are a number of risk factors that can accelerate or modify the progression of the condition. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 The most common risk factors include:25 Family history of premature CAD Cigarette smoking Diabetes mellitus Hypertension Hyperlipidemia Sedentary lifestyle Diagnosis The diagnostic process for coronary artery disease includes a thorough assessment and physical examination. Since the illness typically begins in adolescence, the physician will need to conduct a thorough medical history for the patient. In addition to the detailed medical history and physical examination, the physician may also require an electrocardiogram, laboratory blood tests, stress testing, and a cardiac catheterization.26 These additional assessments are often required when the initial examination produces results that indicate CAD. The following table provides a detailed overview of the various components of the patient assessment.27 History The history should include any current symptoms and a complete inventory of comorbid conditions. An inventory of cardiac risk factors, and a complete family history are essential components. The history should also include information about the character and location of discomfort, radiation of discomfort, associated symptoms, and precipitating, exacerbating, or alleviating factors. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 The importance of the family history should not be underestimated. A detailed assessment, particularly of first-degree relatives for the presence of CAD and age of diagnosis is imperative when evaluating a patient’s risk factor profile. Physical Examination The results of the physical examination of a patient with stable or unstable angina may be entirely normal. The presence of multiple risk factors or atherosclerosis in the carotid or peripheral arteries increases the likelihood that a chest pain syndrome is related to myocardial ischemia. Evaluation should include measurements of blood pressure and the brachial index. Examination of the carotid arteries should include auscultation for bruits. Examination of the chest wall, neck, and shoulders for deformities and tenderness may be helpful in diagnosing musculoskeletal chest discomfort. Cardiac auscultation may detect murmurs caused by aortic stenosis or hypertrophic cardiomyopathy, either of which can cause angina in the absence of epicardial CAD. Assessment of the abdominal aorta for an aneurysm or bruits and palpation of lower extremity pulses is necessary to evaluate for peripheral vascular disease. Careful palpation of all peripheral pulses and assessment of symmetry versus diminution are also valuable noninvasive approaches for assessing the integrity of the arterial circulation. Finally, examination for xanthelasmas, tendon xanthomas, retinal arterial abnormalities, and peripheral neuropathy can be helpful. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 Electrocardiography A resting 12-lead electrocardiogram should be obtained on all patients with suspected CAD. Electrocardiographic results are normal in approximately 50% of patients with chronic stable angina, and they can remain normal during an episode of chest discomfort. Importantly, a normal electrocardiogram does not exclude coronary artery disease. When abnormal, especially when Q waves are present in a regional myocardial territory of diagnostic duration can signify the presence of a past MI with high accuracy. Chest Radiography The usefulness of a routine chest radiograph in a patient with chest discomfort has not been established. Calcification of the aortic knob is a common finding in older patients and is a nonspecific indicator of flowlimiting obstructive coronary disease. Coronary calcification may also be present. A widened mediastinum may signify an aortic aneurysm and represent the first clue of unstable aortic disease as the cause of chest discomfort. Cardiac Computed A noninvasive imaging assessment of coronary Tomography atherosclerosis is now possible in the form of cardiac Angiography computed tomography angiography. When negative, this test possesses a high negative predictive value. The positive predictive value is also high, but exact stenosis quantification can be complicated. Associated calcification can cause a blooming artifact, resulting in an overestimation of stenosis severity. Additionally, previous coronary artery intervention in the form of coronary artery stent placement can create a blooming shadowing artifact rendering stenosis severity assessment within the stent challenging. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 Echocardiography Echocardiography is recommended for patients with stable angina and physical findings suggesting concomitant valvular heart disease. It is invaluable for assessing the patient with suspected hypertrophic cardiomyopathy. It is also recommended for the assessment of global and regional left ventricular systolic function in patients who have been diagnosed with congestive heart failure, complex ventricular arrhythmias, or a history of MI. The echocardiogram is in many ways an ideal test when assessing a patient with known CAD. It is painless, carries no known risk, and the results are available within approximately 30 minutes. An experienced echocardiographer can identify 1 or more MIs, localize the infarct to a coronary artery distribution, and assess for associated ischemic structural complications such as a left ventricular aneurysm, left ventricular pseudoaneurysm, and ventricular thrombus. Laboratory Studies Routine laboratory measurements recommended, as a part of the initial evaluation of patients with CAD, should include determination of fasting glucose and fasting lipid levels (total cholesterol, high-density lipoprotein [HDL] cholesterol, triglycerides, and calculated low-density lipoprotein [LDL] levels). Other markers such as lipoprotein(a) (Lp[a]) and highsensitivity C-reactive protein may be useful in assessing cardiac risk. High-sensitivity C-reactive protein is gaining greater prominence in assessing the inflammatory level of vascular disease and predicting future risk of vascular events, such as MIs and cerebrovascular accidents. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 This was most recently highlighted in the Jupiter Trial where patients with a LDL cholesterol level <130 mg/dL and a high-sensitivity C-reactive protein >2.0 mg/L were randomized to rosuvastatin 20 mg/d or placebo. Those with a high-sensitivity C-reactive protein >2.0 were shown to derive benefit from rosuvastatin based on a statistically significant reduction in myocardial event rates, cardiovascular mortality, and rates of death from any cause compared to those patients who were administered placebo. When working with patients who are diagnosed with coronary artery disease, there are a number of key points to remember:28 The diagnostic and treatment options for CAD are changing rapidly. New pharmaceuticals are being developed and introduced into the treatment armamentarium, particularly novel anti-platelet agents. Biologic markers are now used to track coronary artery disease activity at the vascular level, guiding medication selection and dose titration. Procedures are less invasive and offer percutaneous treatment options, such as drug-eluting stents, that were previously unavailable. Despite these advances, CAD and its deleterious manifestations represent the primary cause of mortality in the U.S. This is largely caused by poor dietary choices, sedentary lifestyles, suboptimal control of serum triglyceride, cholesterol, and glucose nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 levels, inadequate prescription medication administration and delayed dose titration, and ongoing tobacco use. Efforts at primary and secondary prevention of obstructive CAD among the general public are still lacking. Public awareness campaigns are a partial success. It is imperative for the physician to allocate time to address the importance of lifestyle modification efforts. The genetic basis of CAD is being unraveled at an accelerated pace. The future genetic assessment of a person’s lifetime risk for developing atherosclerotic vascular disease, formerly an idea is now emerging as a reality. These findings can guide lifestyle modification prescription and the choice and dosage of specific pharmaceuticals. A preemptive approach is the best way to tackle the immensity of CAD. Medications, stenting, and bypass surgery are only curative approaches. In addition to these methods, the patient must meet the health care team at least halfway to achieve a successful health outcome. Angina Angina is the term used to describe the pain and discomfort that occurs when the heart is deprived of blood. Many patients describe the feeling as a pressure or squeezing sensation in the chest. Some patients will also experience discomfort in the shoulders, arm, neck, jaw, or back. In some patients, the feeling will present as indigestion.29 Angina is not a stand-alone heart condition. Instead, it is a symptom of another heart problem. It is especially common in nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 instances of coronary heart disease. There are a number of different types of angina, all producing a specific set of conditions.30 The following section outlines the most common types of angina. Stable Angina Angina pectoris is said to be stable when its pattern of frequency, intensity, ease of provocation, or duration does not change over a period of several weeks. Identification of activities that provoke angina and the amount of sublingual nitroglycerin required to relieve symptoms are helpful indicators of stability versus progression. A decrease in exercise tolerance or an increase in the need for nitroglycerin suggests that the angina is progressing in severity or transitioning to an accelerating pattern. Symptoms of stable angina involves pain or discomfort that:31 Occurs when the heart must work harder, usually during physical exertion Doesn't come as a surprise, and episodes of pain tend to be alike Usually lasts a short time (5 minutes or less) Is relieved by rest or medicine May feel like gas or indigestion May feel like chest pain that spreads to the arms, back, or other areas Possible triggers of stable angina include: Emotional stress – learn stress management Exposure to very hot or cold temperatures – learn how cold and hot weather affect the heart. Heavy meals nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 Smoking – learn more about quitting smoking Accelerating Angina Angina pectoris is said to be accelerating when there is a change in the pattern of stable angina. This may include a greater ease of provocation, more prolonged episodes, and episodes of greater severity, requiring a longer recovery period or more frequent use of sublingual nitroglycerin. This suggests a transition and most likely reflects a change in coronary artery blood flow and perfusion of the myocardium. This frequently portends unstable angina or an acute coronary syndrome, such as an acute MI; should a patient transition from a stable to an accelerating pattern of angina then acute medical attention is warranted.32 Unstable Angina Unstable angina pectoris occurs when the pattern of chest discomfort changes abruptly. Signs of unstable angina are: symptoms at rest, a marked increase in the frequency of attacks, discomfort that occurs with minimal activity, and new-onset angina of incapacitating severity. Unstable angina usually is related to the rupture of an atherosclerotic plaque and the abrupt narrowing or occlusion of a coronary artery, representing a medical emergency with an incipient acute coronary syndrome and an MI to follow. Immediate medical attention is mandatory. Unstable angina or sometimes referred to as acute coronary syndrome causes unexpected chest pain, and usually occurs while resting. The most common cause is reduced blood flow to the heart muscle because the coronary arteries are narrowed by fatty buildups nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 (atherosclerosis) which can rupture causing injury to the coronary blood vessel resulting in blood clotting which blocks the flow of blood to the heart muscle. Unstable angina should be treated as an emergency. If the patient has new, worsening or persistent chest discomfort, he or she must receive care immediately. Symptoms of unstable angina involves pain or discomfort that:33 Often occurs while the person may be resting, sleeping, or with little physical exertion Comes as a surprise May last longer than stable angina Rest or medicine usually do not help relieve it May get worse over time Can lead to a heart attack Variant Angina Unlike typical angina – which is often triggered by exertion or emotional stress - variant angina almost always occurs when a person is at rest, usually between midnight and early morning. These attacks can be very painful. Causes of Variant (Prinzmetal) Angina: The pain from variant angina is caused by a spasm in the coronary arteries (which supply blood to the heart muscle). The coronary arteries can spasm as a result of: Exposure to cold weather Stress Medicines that tighten or narrow blood vessels Smoking Cocaine use nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 Symptoms of variant (Prinzmetal) angina include pain or discomfort that:34 Usually occurs while resting and during the night or early morning hours Are usually severe Can be relieved by taking medication Microvascular Angina This type of angina may be a symptom of coronary microvascular disease (MVD). Coronary MVD is heart disease that affects the heart’s smallest coronary artery blood vessels. Causes of microvascular angina involve spasms within the walls of these very small arterial blood vessels causes reduced blood flow to the heart muscle leading to a type of chest pain referred to as microvascular angina. The symptoms of microvascular angina involves angina that occurs in coronary MVD, which may differ from the typical angina that occurs in heart disease in that the chest pain usually lasts longer than 10 minutes, and it can last longer than 30 minutes. The pain or discomfort:35 May be more severe and last longer than other types of angina pain; May occur with shortness of breath, sleep problems, fatigue, and lack of energy; Often is first noticed during routine daily activities and times of mental stress. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 Heart Failure Heart failure occurs when the heart is unable to pump blood at a rate that is not adequate enough to maintain the requirements of tissue metabolization, or at a rate that requires an elevated diastolic filling pressure. According to the American Heart Association: “heart failure affects nearly 5.7 million Americans of all ages and is responsible for more hospitalizations than all forms of cancer combined. It is the number 1 cause of hospitalization for Medicare patients. With improved survival of patients with acute myocardial infarction and with a population that continues to age, heart failure will continue to increase in prominence as a major health problem in the United States.”36 Heart failure statistics for the United States are as follows: Heart failure is the fastest-growing clinical cardiac disease entity in the United States, affecting 2% of the population Heart failure accounts for 34% of cardiovascular-related deaths Approximately 670,000 new cases of heart failure are diagnosed each year About 277,000 deaths are caused by heart failure each year Heart failure is the most frequent cause of hospitalization in patients older than 65 years, with an annual incidence of 10 per 1,000 Rehospitalization rates during the 6 months following discharge are as much as 50% Nearly 2% of all hospital admissions in the United States are for decompensated heart failure, and the average duration of hospitalization is about 6 days nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 In 2010, the estimated total cost of heart failure in the United States was $39.2 billion, representing 1-2% of all health care expenditures The incidence and prevalence of heart failure are higher in blacks, Hispanics, Native Americans, and recent immigrants from developing nations, Russia, and the former Soviet republics. The higher prevalence of heart failure in blacks, Hispanics, and Native Americans is directly related to the higher incidence and prevalence of hypertension and diabetes. This problem is particularly exacerbated by a lack of access to health care and by substandard preventive health care available to the most indigent of individuals in these and other groups; in addition, many persons in these groups do not have adequate health insurance. The higher incidence and prevalence of heart failure in recent immigrants from developing nations are largely due to a lack of prior preventive health care, a lack of treatment, or substandard treatment for common conditions, such as hypertension, diabetes, rheumatic fever, and ischemic heart disease. Men and women have the same incidence and the same prevalence of heart failure. However, there are still many differences between men and women with heart failure, such as the following: o Women tend to develop heart failure later in life than men o Women are more likely than men to have preserved systolic function o Women develop depression more commonly than men nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 o Women have signs and symptoms of heart failure similar to those of men, but they are more pronounced in women o Women survive longer with heart failure than men The prevalence of heart failure increases with age. The prevalence is 1-2% of the population younger than 55 years and increases to a rate of 10% for persons older than 75 years.37 Causes The causes of heart failure can be broken into four main categories:38 1) Underlying causes: Underlying causes of heart failure include structural abnormalities (congenital or acquired) that affect the peripheral and coronary arterial circulation, pericardium, myocardium, or cardiac valves, thus leading to increased hemodynamic burden or myocardial or coronary insufficiency. Underlying causes of systolic heart failure include the following: Coronary artery disease Diabetes mellitus Hypertension Valvular heart disease (stenosis or regurgitant lesions) Arrhythmia (supraventricular or ventricular) Infections and inflammation (myocarditis) Peripartum cardiomyopathy Congenital heart disease Drugs (either recreational, such as alcohol and cocaine, or therapeutic drugs with cardiac side effects, such as doxorubicin) nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 Idiopathic cardiomyopathy Rare conditions (endocrine abnormalities, rheumatologic disease, neuromuscular conditions) Underlying causes of diastolic heart failure include the following: Coronary artery disease Diabetes mellitus Hypertension Valvular heart disease (aortic stenosis) Hypertrophic cardiomyopathy Restrictive cardiomyopathy (amyloidosis, sarcoidosis) Constrictive pericarditis Underlying causes of acute heart failure include the following: Acute valvular (mitral or aortic) regurgitation Myocardial infarction Myocarditis Arrhythmia Drugs (i.e., cocaine, calcium channel blockers, or betablocker overdose) Sepsis Underlying causes of high-output heart failure include the following: Anemia Systemic arteriovenous fistulas Hyperthyroidism Beriberi heart disease Paget disease of bone nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 Albright syndrome (fibrous dysplasia) Multiple myeloma Pregnancy Glomerulonephritis Polycythemia vera Carcinoid syndrome Underlying causes of right heart failure include the following: Left ventricular failure Coronary artery disease (ischemia) Pulmonary hypertension Pulmonary valve stenosis Pulmonary embolism Chronic pulmonary disease Neuromuscular disease 2) Fundamental causes Fundamental causes include the biochemical and physiologic mechanisms, through which either an increased hemodynamic burden or a reduction in oxygen delivery to the myocardium results in impairment of myocardial contraction.39 3) Precipitating causes Overt heart failure may be precipitated by progression of the underlying heart disease (i.e., further narrowing of a stenotic aortic valve or mitral valve) or various conditions (fever, anemia, infection) or medications (chemotherapy, NSAIDs) that alter the homeostasis of heart failure patients.36 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 4) Genetics of cardiomyopathy Dilated, arrhythmic right ventricular and restrictive cardiomyopathies are known genetic causes of heart failure.40 Prognosis In general, the mortality following hospitalization for patients with heart failure is 10.4% at 30 days, 22% at 1 year, and 42.3% at 5 years, despite marked improvement in medical and device therapy. Each rehospitalization increases mortality by about 20-22%. Mortality is greater than 50% for patients with NYHA class IV, ACC/AHA stage D heart failure. Heart failure associated with acute MI has an inpatient mortality of 20-40%; mortality approaches 80% in patients who are also hypotensive (i.e., cardiogenic shock).41 Pathophysiology Heart failure can occur from a variety of conditions and will present differently depending on the cause and severity of the condition. In addition, the condition will have a different impact on the patient depending on the causes and severity. The following table provides a comprehensive overview of the different effects of heart failure.42 Systolic In systolic dysfunction (also called heart failure (HF) with dysfunction reduced ejection fraction (EF)), the ventricle contracts poorly and empties inadequately, leading initially to increased diastolic volume and pressure and decreased EF. Many defects in energy utilization, energy supply, electrophysiologic functions, and contractile element interaction occur, with abnormalities in intracellular Ca modulation and cAMP production. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 Predominant systolic dysfunction is common in HF due to MI, myocarditis, and dilated cardiomyopathy. Systolic dysfunction may affect primarily the left ventricle (LV) or the right ventricle (RV); LV failure often leads to RV failure. Diastolic In diastolic dysfunction, also called HF with preserved EF, dysfunction ventricular filling is impaired, resulting in reduced ventricular end-diastolic volume, increased end-diastolic pressure, or both. Contractility and hence EF remain normal; EF may even increase as the poorly filled LV empties more completely to maintain cardiac output (CO). Markedly reduced LV filling can cause low CO and systemic symptoms. Elevated left atrial pressures can cause pulmonary hypertension and pulmonary congestion. Diastolic dysfunction usually results from impaired ventricular relaxation (an active process), increased ventricular stiffness, valvular disease, or constrictive pericarditis. Acute myocardial ischemia is also a cause of diastolic dysfunction. Resistance to filling increases with age, probably reflecting myocyte loss and increased interstitial collagen deposition; thus, diastolic dysfunction is particularly common among the elderly. Diastolic dysfunction predominates in hypertrophic cardiomyopathy, disorders with ventricular hypertrophy (i.e., hypertension, significant aortic stenosis), and amyloid infiltration of the myocardium. LV filling and function may also be impaired if marked increases in RV pressure shift the interventricular septum to the left. Diastolic dysfunction has increasingly been recognized as a cause of HF. Estimates vary, but about 50% of patients with HF have diastolic dysfunction and a normal EF; the prevalence increases with age and with diabetes. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 LV failure In failure due to LV dysfunction, CO decreases and pulmonary venous pressure increases. When pulmonary capillary pressure exceeds the oncotic pressure of plasma proteins (about 24 mm Hg), fluid extravasates from the capillaries into the interstitial space and alveoli, reducing pulmonary compliance and increasing the work of breathing. Lymphatic drainage increases but cannot compensate for the increase in pulmonary fluid. Marked fluid accumulation in alveoli (pulmonary edema) significantly alters ventilation/perfusion (V/Q) relationships: Deoxygenated pulmonary arterial blood passes through poorly ventilated alveoli, decreasing systemic arterial oxygenation (Pao2) and causing dyspnea. However, dyspnea may occur before V/Q abnormalities, probably because of elevated pulmonary venous pressure and increased work of breathing; the precise mechanism is unclear. In severe or chronic LV failure, pleural effusions characteristically develop in the right hemithorax and later bilaterally, further aggravating dyspnea. Minute ventilation increases; thus, Paco2 decreases and blood pH increases (respiratory alkalosis). Marked interstitial edema of the small airways may interfere with ventilation, elevating Paco2 — a sign of impending respiratory failure. RV failure In failure due to RV dysfunction, systemic venous pressure increases, causing fluid extravasation and consequent edema, primarily in dependent tissues (feet and ankles of ambulatory patients) and abdominal viscera. The liver is most severely affected, but the stomach and intestine also become congested; fluid accumulation in the peritoneal cavity (ascites) can occur. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 RV failure commonly causes moderate hepatic dysfunction, with usually modest increases in conjugated and unconjugated bilirubin, PT, and hepatic enzymes (i.e., alkaline phosphatase, AST, ALT, gamma-glutamyl transpeptidase [GGT]). The impaired liver breaks down less aldosterone, further contributing to fluid accumulation. Chronic venous congestion in the viscera can cause anorexia, malabsorption of nutrients and drugs, protein-losing enteropathy (characterized by diarrhea and marked hypoalbuminemia), chronic GI blood loss, and rarely ischemic bowel infarction. Cardiac If ventricular function is impaired, a higher preload is response required to maintain CO. As a result, the ventricles are remodeled over time: the LV becomes less ovoid and more spherical, dilates, and hypertrophies; the RV dilates and may hypertrophy. Initially compensatory, these changes eventually increase diastolic stiffness and wall tension (i.e., diastolic dysfunction develops), compromising cardiac performance, especially during physical stress. Increased wall stress raises O2 demand and accelerates apoptosis (programmed cell death) of myocardial cells. Dilation of the ventricles can also cause mitral or tricuspid valve regurgitation with further increases in end-diastolic volumes. Hemodynamic With reduced CO, O2 delivery to the tissues is maintained by responses increasing O2 extraction and sometimes shifting the oxyhemoglobin dissociation curve to the right to favor O2 release. Reduced CO with lower systemic BP activates arterial baroreflexes, increasing sympathetic tone and decreasing parasympathetic tone. As a result, heart rate and myocardial contractility increase, arterioles in selected vascular beds constrict, venoconstriction occurs, and Na and water are retained. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 These changes compensate for reduced ventricular performance and help maintain hemodynamic homeostasis in the early stages of HF. However, these compensatory changes increase cardiac work, preload, and afterload; reduce coronary and renal perfusion; cause fluid accumulation resulting in congestion; increase K excretion; and may cause myocyte necrosis and arrhythmias. Renal As cardiac function deteriorates, renal blood flow and GFR responses decrease, and blood flow within the kidneys is redistributed. The filtration fraction and filtered Na decrease, but tubular resorption increases, leading to Na and water retention. Blood flow is further redistributed away from the kidneys during exercise, but renal blood flow improves during rest, possibly contributing to nocturia. Decreased perfusion of the kidneys (and possibly decreased arterial systolic stretch secondary to declining ventricular function) activates the renin-angiotensin-aldosterone system, increasing Na and water retention and renal and peripheral vascular tone. These effects are amplified by the intense sympathetic activation accompanying HF. The renin-angiotensin-aldosterone-vasopressin (antidiuretic hormone [ADH]) system causes a cascade of potentially deleterious long-term effects. Angiotensin II worsens HF by causing vasoconstriction, including efferent renal vasoconstriction, and by increasing aldosterone production, which not only enhances Na reabsorption in the distal nephron but also causes myocardial and vascular collagen deposition and fibrosis. Angiotensin II increases norepinephrine release, stimulates release of vasopressin, and triggers apoptosis. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38 Angiotensin II may be involved in vascular and myocardial hypertrophy, thus contributing to the remodeling of the heart and peripheral vasculature, potentially worsening HF. Aldosterone can be synthesized in the heart and vasculature independently of angiotensin II (perhaps mediated by corticotropin, nitric oxide, free radicals, and other stimuli) and may have deleterious effects in these organs. HF that causes progressive renal dysfunction (including that renal dysfunction caused by drugs used to treat HF) contributes to worsening HF and has been termed the cardiorenal syndrome. Neurohumoral In conditions of stress, neurohumoral responses help increase responses heart function and maintain BP and organ perfusion, but chronic activation of these responses is detrimental to the normal balance between myocardial-stimulating and vasoconstricting hormones and between myocardial-relaxing and vasodilating hormones. The heart contains many neurohumoral receptors (α1, β1, β2, β3, angiotensin II type 1 [AT1] and type 2 [AT2], muscarinic, endothelin, serotonin, adenosine, cytokine, natriuretic peptides); the roles of all of these receptors are not yet fully defined. In patients with HF, β1 receptors (which constitute 70% of cardiac β receptors) are downregulated, probably in response to intense sympathetic activation. The result of downregulation is impaired myocyte contractility and increased heart rate. Plasma norepinephrine levels are increased, largely reflecting sympathetic nerve stimulation, as plasma epinephrine levels are not increased. Detrimental effects include vasoconstriction with increased preload and afterload, direct myocardial damage including apoptosis, reduced renal blood flow, and activation of other neurohumoral systems, including the renin-angiotensinaldosterone-vasopressin system. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 Vasopressin is released in response to a fall in BP via various neurohormonal stimuli. Increased vasopressin decreases renal excretion of free water; possibly contributing to hyponatremia in HF. Vasopressin levels in patients with HF and normal BP vary. Atrial natriuretic peptide is released in response to increased atrial volume and pressure; brain (B-type) natriuretic peptide (BNP) is released from the ventricle in response to ventricular stretching. These peptides enhance renal excretion of Na, but in patients with HF, the effect is blunted by decreased renal perfusion pressure, receptor downregulation, and perhaps enhanced enzymatic degradation. Because endothelial dysfunction occurs in HF, fewer endogenous vasodilators (i.e., nitric oxide, prostaglandins) are produced, and more endogenous vasoconstrictors (i.e., endothelin) are produced, thus increasing afterload. The failing heart and other organs produce tumor necrosis factor (TNF)-α. This cytokine increases catabolism and is possibly responsible for cardiac cachexia (loss of lean tissue ≥ 10%), which may accompany severely symptomatic HF, and for other detrimental changes. The failing heart also undergoes metabolic changes with increased free fatty acid utilization and decreased glucose utilization; these changes may become therapeutic targets. Changes with Age-related changes in the heart and cardiovascular system aging lower the threshold for expression of HF. Interstitial collagen within the myocardium increases, the myocardium stiffens, and myocardial relaxation is prolonged. These changes lead to a significant reduction in diastolic LV function, even in healthy elderly people. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 Modest decline in systolic function also occurs with aging. An age-related decrease in myocardial and vascular responsiveness to β-adrenergic stimulation further impairs the ability of the cardiovascular system to respond to increased work demands. As a result of these changes, peak exercise capacity decreases significantly (about 8%/decade after age 30), and CO at peak exercise decreases more modestly. This decline can be slowed by regular physical exercise. Thus, elderly patients are more prone than are younger ones to develop HF symptoms in response to the stress of systemic disorders or relatively modest cardiovascular insults. Stressors include infections (particularly pneumonia), hyperthyroidism, anemia, hypertension, myocardial ischemia, hypoxia, hyperthermia, renal failure, perioperative IV fluid loads, nonadherence to drug regimens or to low-salt diets, and use of certain drugs (including NSAIDs, β-blockers, and certain Ca channel blockers). Signs and Symptoms Signs and symptoms of heart failure include the following:43 Exertional dyspnea and/or dyspnea at rest Orthopnea Acute pulmonary edema Chest pain/pressure and palpitations Tachycardia Fatigue and weakness Nocturia and oliguria nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41 Anorexia, weight loss, nausea Exophthalmos and/or visible pulsation of eyes Distention of neck veins Weak, rapid, and thready pulse Rales, wheezing S3 gallop and/or pulsus alternans Increased intensity of P2 heart sound Hepatojugular reflux Ascites, hepatomegaly, and/or anasarca Central or peripheral cyanosis, pallor Diagnosis Heart failure is diagnosed using a set of criteria and a classification and staging process. There are a number of classification systems that can be used to diagnose heart failure. The most widely used systems include those outlined below. Framingham: The Framingham criteria for the diagnosis of heart failure consist of the concurrent presence of either 2 major criteria or 1 major and 2 minor criteria. Major criteria include the following:44 Paroxysmal nocturnal dyspnea Weight loss of 4.5 kg in 5 days in response to treatment Neck vein distention Rales Acute pulmonary edema Hepatojugular reflux S3 gallop Central venous pressure greater than 16 cm water nursece4less.com nursece4less.com nursece4less.com nursece4less.com 42 Circulation time of 25 seconds Radiographic cardiomegaly Pulmonary edema, visceral congestion, or cardiomegaly at autopsy Minor criteria are as follows: Nocturnal cough Dyspnea on ordinary exertion A decrease in vital capacity by one third the maximal value recorded Pleural effusion Tachycardia (rate of 120 bpm) Bilateral ankle edema The New York Heart Association (NYHA): The New York Heart Association (NYHA) classification system categorizes heart failure on a scale of I to IV are listed below.45 Class I: No limitation of physical activity Class II: Slight limitation of physical activity Class III: Marked limitation of physical activity Class IV: Symptoms occur even at rest; discomfort with any physical activity The American College of Cardiology/American Heart Association (ACC/AHA): The American College of Cardiology/American Heart Association (ACC/AHA) staging system is defined by the following 4 stages.46 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 43 Stage A: High risk of heart failure but no structural heart disease or symptoms of heart failure Stage B: Structural heart disease but no symptoms of heart failure Stage C: Structural heart disease and symptoms of heart failure Stage D: Refractory heart failure requiring specialized interventions Testing Diagnostic Testing The following tests may be used as part of the initial evaluation for suspected heart failure:47 Complete blood count (CBC) Urinalysis Electrolyte levels Renal and liver function studies Fasting blood glucose levels Lipid profile Thyroid stimulating hormone (TSH) levels B-type natriuretic peptide levels N-terminal pro-B-type natriuretic peptide Electrocardiography Chest radiography 2-dimensional (2-D) echocardiography Nuclear imaging Maximal exercise testing Pulse oximetry or arterial blood gas nursece4less.com nursece4less.com nursece4less.com nursece4less.com 44 Heart Procedure or Surgery Many patients who undergo heart procedures or surgery will benefit from cardiac rehabilitation. In these instances, a rehabilitation program will help the patient return to normal cardiac performance levels. There are a number of cardiac procedures that can benefit from post-procedure cardiac rehabilitation. Coronary Artery Bypass Graft Coronary artery bypass grafts are the most common cardiac surgeries performed in the United States. The procedure is used to treat patients who have significant narrowings and blockages of their coronary arteries. It is most used to treat patients with coronary artery disease. The buildup of fatty material in the arterial walls causes significant narrowing which reduces blood flow. The procedure creates new, unblocked routes around the blocked (narrowed) arteries. Once the new routes are created, adequate blood flow will return to the heart, thereby delivering the appropriate amounts of oxygen and nutrients to the heart.48 One way to treat the blocked or narrowed arteries is to: “bypass the blocked portion of the coronary artery with another piece of blood vessel. Blood vessels, or grafts, used for the bypass procedure may be pieces of a vein taken from the legs or an artery in the chest. At times, an artery from the wrist may also be used. One end of the graft is attached above the blockage and the other end is attached below the blockage. Thus, the blood is rerouted around, or bypasses, the blockage through the new graft to reach the heart muscle. This bypass of nursece4less.com nursece4less.com nursece4less.com nursece4less.com 45 the blocked coronary artery can be done by performing coronary artery bypass surgery.”49 The standard procedure for performing a bypass involves opening the chest fully and stopping the heart. This requires an intensive procedure in a standard hospital operating room. “In order to open the chest, the breastbone (sternum) is cut in half and spread apart. Once the heart is exposed, tubes are inserted into the heart so that the blood can be pumped through the body during the surgery by a cardiopulmonary bypass machine (heart-lung machine). The bypass machine is necessary to pump blood while the heart is stopped and kept still in order for the surgeon to perform the bypass operation.”23 The following is a fact sheet that provides a thorough overview of the standard bypass procedure, which the cardiac rehab team nurse may share with patients and their families.48 When atherosclerosis develops in the coronary arteries, flow of blood through these vessels is blocked, and the blood supply to heart muscle is jeopardized. If the blockages are significant enough, the end result will be a heart attack or sudden death. CABG is an operation that is designed to re-route the blood around these blockages to prevent a heart attack or sudden death. Conventionally an artery from behind the breastbone, and veins from the legs are used to "bypass" the blood around the coronary artery blockages. The operation takes 2-3 hours to perform, and begins after general anesthesia is induced. Patients are completely asleep during the entire course of the operation. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 46 The saphenous vein is removed through incisions in the legs. The length of the incision is dependent upon the amount of vein required to complete the necessary number of "bypasses" (i.e., 5 bypasses will require more vein than 2 bypasses). There are many "redundant" veins in the leg ... once some vein is removed, the other veins in the leg take over for the missing vein. Once the vein has been removed from the leg, it has the appearance of a long tube or "conduit". The vein will be divided into separate shorter segments, each of which will be used for individual bypasses. As vein is removed from the leg by a physician assistant, the surgeon simultaneously opens the chest by dividing the breast bone or sternum, affording excellent exposure of the heart. An artery behind the sternum, the left internal mammary artery (LIMA) is taken down and one end prepared for bypass grafting. Tubes or cannulae are inserted into the heart and major blood vessels surrounding the heart in preparation for cardiopulmonary bypass with the heart-lung machine. At this point, the patient is placed on the heart-lung machine. Blood is redirected from the heart into the heart-lung machine. This permits the surgeon to safely operate on the heart without blood pumping through it. The heart is then stopped, and the heart-lung machine continues to pump freshly oxygenated blood to the rest of the body, in effect, taking over the roles of the heart and lungs. The diseased coronary arteries are now identified and opened beyond the level of the blockages. The open ends of the saphenous veins and LIMA are now sewn to the openings in the coronary arteries using very fine non-absorbable suture material; these are called the "distal" anastamoses. Surgeons wear special magnifying lenses in order to see the delicate suture and small vessels. Because the "inflow" through the LIMA is left intact, as soon as the LIMA anastamosis is completed, blood flow is established to that region of the heart. A vein graft however, is harvested as a "free graft" and has no "inflow"; therefore, after the "distal" vein graft anastamosis is constructed, the other end of the vein graft is sewn to the aorta (the main artery leaving the heart) in order to establish "inflow". These are called the "proximal" anastamoses. After this stage, blood flow has now been established beyond all the blocked arteries, and the heart has effectively been "bypassed" nursece4less.com nursece4less.com nursece4less.com nursece4less.com 47 The heart-lung machine is then gradually weaned off, and the patient's heart and lungs resume their normal functions. The cannulae are removed from in and around the heart, and the sternum and incisions are closed. Drainage catheters are placed around the heart ... these are usually removed after 24 hours. Temporary pacing wires to regulate the patient's heart rate are sewn to the surface of the heart ... these are removed before the patient goes home. Following the operation, patients are transported to the Cardiac Post-Anesthesia Care Unit, a specialized unit caring exclusively for open-heart surgery patients. Patients generally awaken from anesthesia 4-6 hr after the operation. The following morning all drainage catheters and monitoring lines are usually removed, and patients are transferred to a standard hospital room in the cardiac recovery wing of the hospital. Patients undergoing a CABG operation are usually hospitalized for 4-5 days following the surgery. Patients will receive the following detailed instructions prior to the procedure(s): You will be asked to empty your bladder prior to the procedure. An intravenous (IV) line will be started in your arm or hand. Additional catheters will be inserted in your neck and wrist to monitor the status of your heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin. You will be positioned on the operating table, lying on your back. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated, a breathing tube will be inserted into your throat and into your trachea (breathing tube) to provide oxygen to your lungs, and you will be connected to a ventilator, which will breathe for you during the surgery. A catheter will be inserted into your bladder to drain urine. The skin over the surgical site will be cleansed with an antiseptic solution. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 48 Once all the tubes and monitors are in place, incisions may be made in one or both of your legs or one of your wrists to obtain a section of vein to be used for grafts. The doctor will make an incision (cut) down the center of the chest from just below the Adam's apple to just above the navel. The sternum (breastbone) will be divided in half with a special operating instrument. The doctor will separate the two halves of the breastbone and spread them apart to expose the heart. Coronary artery bypass graft surgery--on-pump procedure: In order to sew the grafts onto the very small coronary arteries, the heart must be stopped to allow the doctor to perform the very delicate procedure. Tubes will be inserted into the heart so that the blood can be pumped through your body by a cardiopulmonary bypass machine. Once the blood has been diverted into the bypass machine for pumping, the heart will be stopped by injecting it with a cold solution. When the heart has been stopped, the doctor will perform the bypass graft procedure by sewing one end of a section of vein over a tiny opening made in the aorta, and the other end over a tiny opening made in the coronary artery just below the blockage. If the internal mammary artery inside your chest is being used as a bypass graft, the lower end of the artery will be cut from inside the chest and sewn over an opening made in the coronary artery below the blockage. You may have more than one bypass graft performed, depending on how many blockages you have and where they are located. After all the grafts have been completed, the doctor will examine them to make sure they are working. Once the bypass grafts have been completed, the blood circulating through the bypass machine will be allowed back into your heart and the tubes to the machine will be removed. Your heart will be restarted. Temporary wires for pacing may be inserted into the heart. These wires can be attached to a pacemaker and your heart can be paced, if needed, during the initial recovery period. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 49 Coronary artery bypass surgery--off-pump procedure: Once the chest has been opened, the area around the artery to be bypassed will be stabilized with a special type of instrument. The rest of the heart will continue to function and pump blood through the body. The cardiopulmonary bypass machine and the perfusionist who runs it may be kept on stand-by should the procedure need to be completed on bypass. The doctor will perform the bypass graft procedure by sewing one end of a section of vein over a tiny opening made in the aorta, and the other end over a tiny opening made in the coronary artery or internal mammary artery just below the blockage. You may have more than one bypass graft performed, depending on how many blockages you have and where they are located. Before the chest is closed, the doctor will examine the grafts to make sure they are working. Possible risks associated with coronary artery bypass graft surgery include, but are not limited to, the following:50 Bleeding during or after the surgery Blood clots that can cause heart attack, stroke, or lung problems Infection at the incision site Pneumonia Breathing problems Cardiac dysrhythmias/arrhythmias (abnormal heart rhythms) Indications Class I indications for CABG from the American College of Cardiology (ACC) and the American Heart Association (AHA) are as follows:46 Left main coronary artery stenosis >50% nursece4less.com nursece4less.com nursece4less.com nursece4less.com 50 Stenosis of proximal LAD and proximal circumflex >70% 3-vessel disease in asymptomatic patients or those with mild or stable angina 3-vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV) function or 2-vessel disease and a large area of viable myocardium in high-risk area in patients with stable angina >70% proximal LAD stenosis with either ejection fraction < 50% or demonstrable ischemia on noninvasive testing Other indications for CABG include the following:51 Disabling angina (Class I) Ongoing ischemia in the setting of a non–ST segment elevation MI that is unresponsive to medical therapy (Class I) Poor left ventricular function but with viable, nonfunctioning myocardium above the anatomic defect that can be revascularized CABG may be performed as an emergency procedure in the context of an ST-segment elevation MI (STEMI) in cases where it has not been possible to perform percutaneous coronary intervention (PCI) or where PCI has failed and there is persistent pain and ischemia threatening a significant area of myocardium despite medical therapy. Contraindications CABG is not considered appropriate in asymptomatic patients who are at a low risk of MI or death. Patients who will experience little benefit from coronary revascularization are also excluded. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 51 Although advanced age is not a contraindication, CABG is less commonly performed in the elderly. Because elderly patients have a shorter life expectancy, CABG may not necessarily prolong survival. These patients are also more likely to experience perioperative complications after CABG.52 Many patients still undergo traditional bypass procedures. However, in some instances, less invasive procedures may be used. "Off-pump" procedures, in which the heart does not have to be stopped, were developed in the 1990's. Other minimally-invasive procedures, such as key-hole surgery (performed through very small incisions) and robotic procedures (performed with the aid of a moving mechanical device), increasingly are being used.53 The following table provides information on the different types of bypass procedures:51, 54-60 Off-Pump Coronary artery bypass grafting (CABG) has conventionally been Coronary an operation that requires the use of the heart lung machine. For Artery selected patients, surgeons have designed an innovative way to Bypass bypass blocked arteries on the heart without the use of the heart- Grafting lung machine ... this operation is called "off-pump coronary artery bypass grafting" or "OPCAB". Although indications for performing this procedure are more limited, and long-term results compared with conventional CABG are unknown, there are some patients who may benefit from this procedure. The principals of OPCAB are in some ways similar to that of CABG, namely, that an artery from behind the breast bone and/or veins from the legs are used to "bypass" blood around coronary artery blockages. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 52 OPCAB is different from CABG in that the heart-lung machine is not used. This means that the special catheters and "cannulae" that are placed in and around the heart for a conventional CABG operation are not used. The heart continues to pump blood to the rest of the body, and surgeons must operate on a "beating heart". An advantage of OPCAB over conventional CABG is that it may eliminate some of the risks associated with using the heart-lung machine. In most patients these risks are very, very small ... but in some older patients with significant atherosclerotic disease of their aorta, poor kidney function, or significant lung disease ... these risks may be more considerable, and OPCAB might be a reasonable and safer approach than conventional CABG. There are many more variables that determine whether or not a patient would be an acceptable candidate for OPCAB ... these issues are best discussed with your surgeon. A disadvantage of OPCAB is that because the heart is not stopped, surgeons must perform delicate suturing on a "beating heart". Consequently, stabilizing devices have been developed to help limit the motion of the heart as surgeons operate. The operation itself is similar to the CABG operation described above. General anesthesia is induced, and the patient is asleep for the entire course of the operation. The surgeon opens the chest by dividing the breastbone or sternum. An artery behind the sternum, the left internal mammary artery (LIMA), is taken down and one end prepared for bypass grafting. If more than one coronary artery will be bypassed, saphenous vein from the leg is removed and prepared for the additional bypasses. A stabilizing device is now placed on the surface of the heart, limiting the motion of the beating heart. The coronary arteries are opened beyond the sites of the blockage, and the open ends of the LIMA and vein grafts are sewn to the openings in the coronary arteries. These are called the "distal" anastamoses. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 53 Because the "inflow" through the LIMA is left intact, as soon as the LIMA anastamosis is completed, blood flow is established to that region of the heart. A vein graft however, is harvested as a "free graft" and has no "inflow" ... therefore, after the "distal" vein graft anastamosis is constructed, the other end of the vein graft is sewn to the aorta (the main artery leaving the heart) in order to establish "inflow". These are called the "proximal" anastamoses. At this point in the operation, blood flow has now been established beyond all the blocked arteries, and the heart has effectively been "bypassed". Drainage catheters are placed around the heart ... these are usually removed after 24hr. Temporary pacing wires to regulate the patient's heart rate, are sewn to the surface of the heart ... these are removed before the patient goes home. The sternum and incisions are closed, and the patient is transported to the Cardiac Post-Anesthesia Care Unit, a specialized unit caring exclusively for open-heart surgery patients. Patients generally awaken from anesthesia 4-6 hr after the operation. The following morning all drainage catheters and monitoring lines are usually removed, and patients are transferred to a standard hospital room in the cardiac recovery wing of the hospital. Patients undergoing an OPCAB are usually hospitalized for 3-4 days following surgery. To see what to expect during the recovery of this operation, please refer to our education section. Robotic- The daVinci surgical robotic system is used to perform minimally assisted invasive heart surgery. Surgeons are pioneering new robotic Coronary surgical approaches. Coronary Artery Bypass Grafting, or CABG, is Artery a surgical procedure to bypass the clogged coronary blood vessel, Bypass and restore blood flow to the heart. The surgeon uses a section of Grafting a healthy artery from the patient's left chest, known as the left internal mammary artery (LIMA), to "bypass" the diseased section of the patient's own coronary artery. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 54 Traditional bypass surgery requires the chest to be cut open, the patient's breastbone to be split, and the function of the heart to be taken over by a heart-lung bypass machine. Skilled surgeons are able to use the daVinci robot to carefully prepare the LIMA for use as a single bypass to the heart without the use of the heart-lung machine and with no incisions over the breastbone. With only small incisions over the patient's left chest, smaller surgical instruments, and greater precision in robotic surgery, patients experience less pain and have more rapid recovery times. Robotic-assisted coronary artery bypass grafting is a minimally invasive procedure. The surgeon makes several small incisions between the ribs, and then inserts a small camera and small robotic arms through the incisions. During the procedure, the surgeon sits at a console and controls the robotic instruments. The camera that was inserted provides images of the heart at a high magnification. Using robotic-assisted coronary artery bypass grafting, patients can typically undergo a single bypass using the LIMA to the main artery of the heart, known as the left anterior descending artery, or LAD. If the patient has disease in more than one vessel in the heart, this procedure can at times be combined with coronary stents in the other vessels, performed by cardiologists, to achieve repairs or bypasses to each of the diseased vessels. In this way, for selected patients, surgeons have designed an innovative way to bypass the main blocked LAD artery with minimally invasive robotic surgery, combined with stents to other vessels. Although indications for performing this procedure are more limited, and long-term results compared with conventional CABG are unknown, there are some patients who may benefit from this procedure. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 55 Minimally Coronary Artery Bypass Grafting, or CABG, is a surgical procedure Invasive to bypass the clogged coronary blood vessel, and restore blood Coronary flow to the heart. The surgeon uses a section of a healthy artery Artery from the patient's left chest, known as the left internal mammary Bypass artery (LIMA), to "bypass" the diseased section of the patient's Grafting own coronary artery. Traditional bypass surgery required the chest to be cut open, the patient's breastbone to be split, and the function of the heart to be taken over by a heart-lung bypass machine. A minimally invasive CABG is an "off-pump" procedure. Only a single 3-inch incision is typically used over the patient's left chest between the ribs and no incisions over the breastbone. The beating heart is held in place with "stabilizers", which are instruments that immobilize the area of the heart where the bypass is being done. With only a single, small incision over the patient's left chest, patients experience less pain and have more rapid recovery times. Skilled surgeons are able to use a minimally invasive incision to carefully prepare the LIMA for use as a single bypass to the heart without the use of the heart-lung machine and with no incisions over the breastbone. With a minimally invasive coronary artery bypass procedure, the surgeon can typically perform a single bypass using the LIMA to the main artery of the heart, known as the left anterior descending artery, or LAD. If the patient has disease in more than one vessel in the heart, this procedure can at times be combined with coronary stents in the other vessels, performed by cardiologists, to achieve repairs or bypasses to each of the diseased vessels. In this way, for selected patients, surgeons have designed an innovative way to bypass the main blocked LAD artery with minimally coronary artery bypass grafting, combined with stents to other vessels. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 56 Although indications for performing this procedure are more limited, and long-term results compared with conventional CABG are unknown, there are some patients who may benefit from this procedure. Endoscopic Standard incisions for harvesting saphenous vein for bypass Vein operations historically have been long incisions that run the length Harvesting of a patient’s leg. Alternatively several smaller “skip” incisions can be made to provide a more cosmetic and less painful result. Surgeons now utilize a new technology called Endoscopic Vein Harvesting that permits them to harvest a complete leg’s length of vein through a 1 or 2 small (1 cm) incisions. The incision can be made anywhere along the leg, and vein is removed using specially designed telescoping surgical and video equipment. In addition to reducing the size of the surgical scar, Endoscopic Vein Harvesting significantly reduces leg discomfort in the postoperative period, and is associated with fewer complications such as infection and hematoma formation. Percutaneous Coronary Intervention Percutaneous coronary intervention (PCI) is a non-surgical procedure that is performed on patients who have narrowed arteries. The procedure opens the narrowed arteries so that blood can flow more easily to the heart.61 With this procedure, a catheter is inserted through the skin in the groin or the arm. The catheter is inserted directly into an artery. Once the catheter is secure in the artery, several devices can be used to help expand the artery. The most common devices include a balloon, stent, or an artherectomy device. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 57 The catheter and its devices are threaded through the inside of the artery back into an area of coronary artery narrowing or blockage.62 This procedure can be used on patients who are actively experiencing a myocardial infarction. In these instances, the percutaneous coronary intervention will be used as a method of intervening and stopping the infarction by opening the blocked artery. This will reinstate blood flow to the heart, thereby stopping the acute infarction. “Although treatment of acute heart attack is a very important use of percutaneous coronary intervention, it has several other uses. Percutaneous coronary intervention can be used to relieve or reduce angina, prevent heart attacks, alleviate congestive heart failure, and allows some patients to avoid surgical treatment (coronary artery bypass graft or CABG) that involves extensive surgery and often long rehabilitation time.”63 Indications and Contraindications Clinical indications for Percutaneous Coronary Intervention include the following: Acute ST-elevation myocardial infarction (STEMI) Non–ST-elevation acute coronary syndrome (NSTE-ACS) Unstable angina Stable angina Anginal equivalent (i.e., dyspnea, arrhythmia, or dizziness or syncope) High risk stress test findings In an asymptomatic or mildly symptomatic patient, objective evidence of a moderate to large area of viable myocardium or moderate to severe ischemia on noninvasive testing is an nursece4less.com nursece4less.com nursece4less.com nursece4less.com 58 indication for PCI. Angiographic indications include hemodynamically significant lesions in vessels serving viable myocardium (vessel diameter >1.5 mm).64 Clinical contraindications for Percutaneous Coronary Intervention include the following:65 Intolerance of long-term antiplatelet therapy or the presence of any significant comorbid conditions that severely limit the lifespan of the patient (this is a relative contraindication). A Heart Team approach (involving interventional cardiologists and cardiac surgeons) should be used in patients with diabetes and multivessel coronary artery disease and in patients with severe left main disease and a high Syntax score. Relative angiographic contraindications include the following:66 Arteries < 1.5 mm in diameter Diffusely diseased saphenous vein grafts Other coronary anatomy not amenable to PCI In patients with stable angina, medical therapy is recommended as first-line therapy unless one or more of the following indications for cardiac catheterization and PCI or coronary artery bypass grafting (CABG) are present:67 Severe symptoms A change in symptom severity Failed medical therapy High-risk coronary anatomy Worsening left ventricular (LV) dysfunction nursece4less.com nursece4less.com nursece4less.com nursece4less.com 59 For patients with STEMI, immediate coronary angiography with PCI is recommended (primary PCI). For patients with NSTE-ACS, the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines on the management of NSTE-ACS (updated in 2014) recommend an early invasive strategy in most cases, with timing as follows:68 Immediate (within 2 hours) - Patients with refractory or recurrent angina with initial treatment, signs/symptoms of heart failure, new/worsening mitral regurgitation, hemodynamic instability, sustained ventricular tachycardia, or ventricular fibrillation Early (within 24 hours) - None of the immediate characteristics but new ST-segment depression, a GRACE risk score >140, or temporal change in troponin Delayed invasive (within 25-72 hours) - None of the immediate or early characteristics but renal insufficiency (glomerular filtration rate [GFR] < 60 mL/min/1.73 m2), left ventricular ejection fraction (LVEF) < 40%, early postinfarct angina, history of PCI within the preceding 6 months, prior CABG, GRACE risk score of 109-140, or TIMI score of 2 or higher Ischemia-guided approach is recommended for patients with a low-risk score (TIMI 0 or 1, GRACE < 1). Equipment for a PCI Procedure Balloon catheters for PCI have the following features:64 A steerable guide wire precedes the balloon into the artery and permits navigation through the coronary tree nursece4less.com nursece4less.com nursece4less.com nursece4less.com 60 Inflation of the balloon compresses and axially redistributes atheromatous plaque and stretches the vessel wall The balloon catheter also serves as an adjunctive device for many other interventional therapies Atherectomy devices have the following features:69 These devices are designed to physically remove coronary atheroma, calcium, and excess cellular material Rotational or orbital atherectomy, which relies on plaque abrasion and pulverization, is used mostly for fibrotic or heavily calcified lesions that can be wired but not crossed or dilated by a balloon catheter Atherectomy devices may be used to facilitate stent delivery in complex lesions Directional coronary atherectomy (DCA) has been used to debulk coronary plaques Laser atherectomy is not widely used at present Atherectomy is typically followed by balloon dilation and stenting. Intracoronary stents have the following features:67 Stents differ with respect to composition (i.e., cobalt chromium or platinum chromium), architectural design, delivery system and the drug delivered Drug-eluting stents (DESs) have demonstrated significant reductions in restenosis and target-lesion revascularization rates, with further reduction with the second-generation DESs (compared with first-generation DESs or bare-metal stents) nursece4less.com nursece4less.com nursece4less.com nursece4less.com 61 In the United States, the commercially available DESs are second-generation models that elute everolimus and zotarolimus The stents with bioabsorbable polymer, polymer-free systems or fully bioresorbable scaffolds are still investigational and not available for commercial use in the United States Stents are conventionally placed after balloon predilation, but in selected coronary lesions, direct stenting may lead to better outcomes Other devices used for PCI include the following:69 Thrombus aspiration is reasonable in selected patients undergoing primary PCI; however, one trial showed no reduction in the rate of death from any cause or the composite of death from any cause, rehospitalization for myocardial infarction, or stent thrombosis Distal embolic protection during saphenous vein graft intervention can be considered when technically feasible Technique: Intravascular ultrasonography (IVUS) and optical coherence tomography (OCT) are used in PCI for the following purposes:64 Provision of information about atherosclerotic plaque composition and burden, the vessel wall, vessel size, degree of calcium, and degree of luminal narrowing Assessment of indeterminate lesions Evaluation of adequate stent deployment nursece4less.com nursece4less.com nursece4less.com nursece4less.com 62 Intracoronary Doppler pressure wires are used in PCI as follows:70 Characterization of coronary lesion physiology and estimation of lesion severity Comparison of pressure distal to a lesion with aortic pressure enables determination of fractional flow reserve (FFR); FFR < 0.80 during maximal hyperemia (induced via administration of adenosine) is consistent with a hemodynamically significant lesion Antithrombotic therapy includes the following:71 Aspirin 162-325 mg is given to all patients on the day of PCI Unfractionated heparin, low-molecular-weight heparin (LMWHs) or bivalirudin is used at the time of balloon angioplasty or PCI; fondaparinux can be used but needs another agent along with it to prevent catheter thrombosis and therefore is less commonly preferred Antiplatelet therapy:72 Patients receiving stents are treated with a combination of aspirin and a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor). The minimum duration of P2Y12 receptor inhibitor therapy, according to the current ACCF/AHA guidelines, is as follows: Bare-metal stents - Minimum of 4 weeks DESs - Minimum of 12 months Use of proton pump inhibitors (PPIs) is appropriate in patients with multiple risk factors for gastrointestinal bleeding who require antiplatelet therapy. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 63 Glycoprotein inhibitor therapy:73 Abciximab, tirofiban, and eptifibatide have all been shown to reduce ischemic complications in patients undergoing balloon angioplasty and coronary stenting; however, evidence supporting their use was established largely before the use of oral P2Y12 inhibitors Several studies have failed to show the benefit of “upstream” administration of GPIIb/IIIa inhibitors in the era of dual antiplatelet therapy (DAPT); because GPIIb/IIIa inhibitors increase the risk of bleeding, their routine use is no longer recommended GPIIb/IIIa inhibitors can be used as an adjunctive therapy at the time of PCI, on an individual basis, for large thrombus burden or inadequate P2Y12 receptor antagonist loading. Coronary Angioplasty Percutaneous coronary intervention (PCI) is performed to open blocked coronary arteries caused by coronary artery disease (CAD) and to restore arterial blood flow to the heart tissue without open-heart surgery. Using a guidewire, a special catheter (long hollow tube) is inserted into the coronary artery and past the blockage in the blockage. The catheter contains a tiny balloon. When the catheter is in place, the balloon is inflated. The inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow.74 The following procedural steps are involved during the PCI. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 64 The use of fluoroscopy (a special type of X-ray, similar to an Xray "movie") assists the doctor in the location of blockages in the coronary arteries as the contrast dye moves through the arteries. A technique called intravascular ultrasound (IVUS), a technique that uses a computer and a transducer that sends out sound waves to create images of the blood vessels, may be used during PCI. The use of IVUS provides direct visualization and measurement of the inside of the blood vessels and may assist the doctor in selecting the appropriate size of balloons and/or stents, to ensure that a stent, if used, is properly opened, or to evaluate the use of other angioplasty instruments. A technique called fractional flow reserve (FFR) assessment is often used during a catheterization to assist in determining the significance of a moderate coronary narrowing. The technique involves placing a pressure-transducing wire across the narrowing, and after a brief infusion of medication, measuring the pressure change in the coronary artery. This may assist the physician in deciding whether PCI or stenting is appropriate. The physician may determine that another type of procedure is necessary. This may include the use of atherectomy (removal of plaque) at the site of the narrowing of the artery. In atherectomy, there may be tiny blades on a balloon or a rotating tip at the end of the catheter. When the catheter reaches the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 65 narrowed spot in the artery, the plaque is broken up or cut away to open the artery. Coronary Stenting Coronary stents are now almost universally used in PCI procedures, often following balloon angioplasty, which opens the narrowed artery and facilitates stent placement. A stent is a tiny, expandable metal coil that is inserted into the newly-opened area of the artery to help keep the artery from narrowing or closing again.67 The following are procedural steps used during stent placement. Once the stent has been placed, tissue will begin to form over it within a few days after the procedure. The stent will be completely covered by tissue within a month or so. It is necessary to take medications, such as aspirin, clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta), which decrease the "stickiness" of platelets (special blood cells that clump together to stop bleeding), in order to prevent blood clots from forming inside the stent. The physician will provide specific instructions regarding which medications need to be taken and for how long. Newer stents (drug-eluting stents, or DES) are coated with medication to prevent the formation of scar tissue inside the stent. These drug-eluting stents release medication within the blood vessel itself. This medication inhibits the overgrowth of tissue that can occur within the stent. The effect of this medication is to deter the narrowing of the newly stented blood vessel. Because stents can become blocked, it is important for nursece4less.com nursece4less.com nursece4less.com nursece4less.com 66 the patient to talk with their physician about what is needed if the patient experiences chest pain after a stent placement. If scar tissue does form inside the stent, a repeat procedure may be performed, either with balloon angioplasty or with a second stent, or occasionally with local radiation therapy (called brachytherapy) may be used to clear the scarred area and open up the vessel. Stents are most useful for:75 Short lesions in large native coronary arteries not previously treated with PTCA Focal lesions in saphenous vein grafts Treatment of abrupt closure during PTCA Other Procedures Other related procedures that may be used to assess the heart include:76 Resting or exercise electrocardiogram (ECG or EKG) Holter monitor Signal-averaged ECG Cardiac catheterization chest X-ray Computed tomography (CT scan) of the chest Echocardiography Electrophysiological studies magnetic resonance imaging (MRI) of the heart Myocardial perfusion scans Radionuclide angiography nursece4less.com nursece4less.com nursece4less.com nursece4less.com 67 Cardiac CT scan. Rotational atherectomy - This is sometimes used to aid stent placement when the plaque is hardened and calcified. Valve Replacement Heart valve replacement (or repair) is used to treat valvular heart disease. It is especially common in patients with valvular stenosis and valvular insufficiency.77 Heart valve repair or replacement surgery is a treatment option for valvular heart disease. When heart valves become damaged or diseased, they may not function properly. Conditions which may cause heart valve dysfunction are valvular stenosis and valvular insufficiency (regurgitation).78 When one (or more) valve(s) becomes stenotic, it becomes more difficult for the heart to pump blood through the valve. Valvular stenosis “may be the result of infection or aging, and the effects on the patient will vary. In some instances, such as when one or more valves become insufficient (leaky), blood leaks backwards. Based on the symptoms and overall condition of the heart, the physician may determine that the diseased valve(s) needs to be surgically repaired or replaced.”79 The following describes the traditional procedure for repairing or replacing a valve: “Traditionally, repair or replacement of heart valves has involved open-heart surgery, which means that the chest is opened in the operating room and the heart stopped for a time so that the surgeon may repair or replace the valve(s). In order to open the chest, the breastbone, or sternum, is cut in half and spread apart. Once the heart is exposed, large nursece4less.com nursece4less.com nursece4less.com nursece4less.com 68 tubes are inserted into the heart so that the blood can be pumped through the body during the surgery by a cardiopulmonary bypass machine (heart-lung machine). The bypass machine is necessary to pump blood because the heart is stopped and kept still while the surgeon performs the valve repair or replacement procedure.”80 The detailed process is described below.81 An intravenous (IV) line will be started in the arm or hand. Additional catheters will be inserted in the neck and wrist to monitor the status of the heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin. The patient will be positioned on the operating table, lying on his or her back. The anesthesiologist will continuously monitor heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once the patient is sedated, a breathing tube will be inserted through the throat into the lungs. The patient will be connected to a ventilator. A catheter will be inserted into the bladder to drain urine. The skin over the surgical site will be cleansed with an antiseptic solution. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 69 The physician will make an incision (cut) down the center of the chest from just below the Adam's apple to just above the navel. The sternum (breastbone) will be divided in half and spread them apart to expose the heart. In order to perform the valve repair or replacement, the heart must be stopped to allow the doctor to perform the very delicate procedure. Tubes will be inserted into the heart so that the blood can be pumped through the body by a cardiopulmonary bypass machine. Once the blood has been completely diverted into the bypass machine for pumping, injecting the heart with a cold solution will stop it from beating. When the heart has stopped, the doctor will perform the procedure by removing the diseased valve and putting in the artificial valve, in the case of a valve replacement. For a valve repair, the procedure performed will depend on the type of valve problem that exists, for example, separation of fused valve leaflets, repair of torn leaflets, and/or the reshaping of valve parts to ensure better function. Once the procedure has been completed, the blood circulating through the bypass machine will be allowed to reenter the heart, and the heart will be shocked with small paddles to restart its electrical activity. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 70 Once the heart is beating again, the physician will observe the heart to assess the function of the heart and the valves. Temporary wires for pacing may be inserted into the heart. These wires can be attached to a pacemaker and the heart can be paced, if needed, during the initial recovery period. The sternum will be rejoined and sewn together with small wires. The skin over the sternum will be sewn back together. The incision will be closed with sutures or surgical staples. Tubes will be inserted into the chest to drain blood and other fluids from around the heart. These tubes will be connected to a suction device to drain fluids away from the heart. A tube will be inserted through the mouth or nose into the stomach to drain stomach fluids. In recent years, more advanced techniques have been developed, which require smaller incisions and less recovery time. One such procedure is the transcatheter aortic valve replacement (TAVR).82 The TAVR is a new alternative for some cases of aortic valve stenosis. A cardiac surgeon and an interventional cardiologist typically do this hybrid procedure. The diseased valve may be repaired using a ring to support a person's own valve, or the entire valve may be removed and replaced by an artificial valve. Artificial valves may be mechanical (made of metal or plastic) or tissue (made from animal valves or human valves taken from cadavers). nursece4less.com nursece4less.com nursece4less.com nursece4less.com 71 Cardiac Pacemakers Artificial cardiac pacemakers are electronic devices that stimulate the heart with electrical impulses to maintain or restore a normal rhythm in people with slow heart rhythms. There are many situations in which an artificial pacemaker may be recommended. Most commonly, a pacemaker is used to treat arrhythmias.83 A pacemaker can relieve some arrhythmia symptoms, such as fatigue and fainting. A pacemaker also can help a person who has abnormal heart rhythms resume a more active lifestyle. Faulty electrical signaling in the heart causes arrhythmias. Pacemakers use low-energy electrical pulses to overcome this faulty electrical signaling. Pacemakers can:84 Speed up a slow heart rhythm. Help control an abnormal or fast heart rhythm. Make sure the ventricles contract normally if the atria are quivering instead of beating with a normal rhythm (a condition called atrial fibrillation). Coordinate electrical signaling between the upper and lower chambers of the heart. Coordinate electrical signaling between the ventricles. Pacemakers that do this are called cardiac resynchronization therapy (CRT) devices. CRT devices are used to treat heart failure. Prevent dangerous arrhythmias caused by a disorder called long QT syndrome. Pacemakers also can monitor and record the heart's electrical activity and heart rhythm. Newer pacemakers can monitor blood nursece4less.com nursece4less.com nursece4less.com nursece4less.com 72 temperature, breathing rate, and other factors. They also can adjust the heart rate to changes in activity. The decision to use such a device, as well as which specific type, will depend upon multiple factors, including:85 The exact nature and underlying cause of the arrhythmia Whether the condition is temporary or permanent The presence or absence of symptoms as described above The potential risk of complications from a pacemaker An artificial pacemaker provides an electrical impulse (or "discharge") that can stimulate the heart, thus restoring or maintaining a regular heartbeat. Although various types of artificial pacemaker devices are available, they generally include the following components:86 A thin metal box or case called a pulse generator, which contains the power source producing the electrical impulses of the pacemaker. In addition, the pulse generator contains a small computer processor that can be programmed to set the rate of the pacemaker, the pattern of pacing, the energy output, and various other parameters. The pulse generator for most modern permanent pacemakers weighs one to two ounces. Flexible insulated wires or leads carry electrical impulses from the generator to the heart muscle and relay information concerning the heart's natural activities back to the pacemaker. There may be several such wires, or leads, placed within the heart, most commonly in the right atrium and right ventricle. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 73 One or more electrodes at the tips of the leads transmit electrical impulses to the heart muscle when needed and also sense the heart's own electrical activity. Arrhythmias Pacemakers are used to treat arrhythmias, which are complications with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm. “The heart's conduction system must function normally for the heart to beat properly and to pump blood effectively to meet the body's needs. Problems with the flow of electrical impulses in the heart are called arrhythmias, which is a general term meaning that there is an abnormality in the pattern of electrical conduction or electrical rhythm.”87 The decision to treat an arrhythmia with a pacemaker (or any other treatment) depends in part upon whether the person has symptoms or not as well as the severity of the symptoms. There are two primary types of arrhythmias, bradyarrythmias and tachyarrythmias, which are discussed below. Bradyarrhythmias: Bradyarrhythmias are heart rhythm abnormalities that cause an abnormally slow heartbeat. Most bradyarrhythmias are due to one of two kinds of problems: sinus bradycardia or heart block. Sinus bradycardia occurs when the heartbeat is too slow because the heart's "natural pacemaker" is operating too slowly. Although some people (for example, competitive athletes) may have a slow heartbeat as a nursece4less.com nursece4less.com nursece4less.com nursece4less.com 74 result of good health, in others sinus bradycardia is an abnormal condition that requires treatment. Heart block is a term for a delay or interruption in the heart's conduction system, causing the electrical impulses to travel too slowly or to be stopped. There are several kinds of heart block, classified according to location (where in the conduction system the block occurs) and degree (whether the block is mild, causing delayed conduction, or severe, causing conduction to stop). In first-degree atrioventricular (AV) block, all electrical impulses reach the ventricles from the atria, but are abnormally slowed as they pass through the AV node. In second-degree AV block, some atrial impulses fail to reach the ventricles ("dropped beats"), resulting in a slow or an irregular heart rate. In third-degree AV block, the most serious form, no atrial impulses are conducted to the ventricles. This condition is sometimes called complete heart block. For the heart to continue to beat, a separate electrical impulse (called an escape rhythm) may be generated in the ventricles. Without an escape rhythm, the ventricles (the chambers that pump blood throughout the body) stop beating. In right bundle branch block (RBBB), the right bundle branch does not conduct impulses; the electrical impulses reach the right ventricle only by traveling through the heart muscle from the left ventricle. As a result, activation of the right ventricle is delayed. In left bundle branch block (LBBB), the left bundle branch does not conduct impulses; electrical impulses reach the left ventricle only by traveling through the heart muscle from the right ventricle. As a result, activation of the left ventricle is delayed.87-90 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 75 Tachyarrhythmias: Tachyarrhythmias are heart rhythm abnormalities that cause an abnormally fast heartbeat. Two tachyarrhythmias that are sometimes treated with a pacemaker are atrial fibrillation and ventricular tachycardia. Atrial fibrillation (AF) is a tachyarrhythmia originating in the atria. Electrical impulses appear at random in the atria and spread through the atrial muscle in an irregular, uncoordinated way. The atria "quiver" rather than contract normally. As a result, blood is not pumped effectively or regularly into the ventricles. Impulses to the ventricles may be conducted very rapidly, resulting in a rapid and irregular heart rate. Ventricular tachycardia (VT) is a tachyarrhythmia originating in the ventricles. A repetitive electrical impulse appears somewhere in the ventricles and spreads through the ventricular muscle. Usually, VT produces some effective ventricular contractions, but at a rapid rate. With very rapid VT, blood may not be pumped effectively, and cardiac arrest may result. Therefore, VT is a potentially dangerous tachyarrhythmia.91-94 Arrhythmia Symptoms The symptoms of arrhythmias vary, depending upon the specific arrhythmia and other factors, especially if there is underlying heart disease. While some people may have no symptoms, others may have various symptoms and signs. Symptoms may include:88 Fainting episodes (syncope) Dizziness or lightheadedness (presyncope) nursece4less.com nursece4less.com nursece4less.com nursece4less.com 76 Palpitations (a sensation of the heart pounding) Confusion Extreme fatigue Shortness of breath Impaired ability of the heart to pump enough blood to meet the body's needs (heart failure) Diagnostic Tests: The following tests will be used to determine the type of arrhythmia:95 EKG (Electrocardiogram) Holter and Event Monitors Echocardiography Electrophysiology Study Stress Test Underlying Causes: A variety of conditions can lead to the development of cardiac arrhythmias. Some of the more common causes are included below.96 Coronary artery disease, where there is a malfunction or damage of the heart due to narrowing or blockage of arteries supplying blood to heart muscle Damage from a heart attack and the development of scar tissue in the muscle of the heart Certain structural heart malformations present at birth (congenital heart defects) Inherited genetic abnormalities that are not necessarily associated with a structural problem of the heart, but may result in an arrhythmia (such as the long QT syndrome) nursece4less.com nursece4less.com nursece4less.com nursece4less.com 77 Abnormalities in the control and regulation of the heartbeat by the nervous system, leading to fainting (called neurocardiogenic syncope) Diseases of heart muscle tissue, called cardiomyopathies Therapy with certain medications that may alter the heart's normal rhythm Normal aging of heart muscle Types of Pacemakers A variety of types of pacemakers have been developed to restore or sustain a regular heartbeat in different ways.97 Demand pacemakers monitor the heart's natural electrical activity and discharge only when the heart's own rate is too slow or the heart misses a beat. Fixed-rate pacemakers (which are rarely used today) discharge impulses at a single, steady rate, regardless of the heart's own electrical activity. Rate-responsive pacemakers are designed to raise or lower the heart rate to help meet the body's needs during physical activity or rest. These devices also work on "demand." Temporary pacemakers — Temporary pacemakers are intended for short-term use during hospitalization. They are used because the arrhythmia is expected to be temporary and eventually resolve, or because the person requires temporary treatment until a permanent pacemaker can be placed. The pulse generator of a temporary pacemaker is located outside the body, and may be taped to the skin or attached to a belt or to the patient's bed. Patients with temporary pacemakers are hospitalized and continuously monitored. Members of the healthcare team will nursece4less.com nursece4less.com nursece4less.com nursece4less.com 78 perform regular examinations to monitor for any possible complications. Permanent pacemakers — Permanent pacemakers are pacemakers that are intended for long-term use. Pacemakers may be single, dual, or triple chambered:98 Single-chamber pacemakers have one lead to carry impulses to and from either the right atrium or right ventricle. A dual-chamber pacemaker usually has two leads, one to the right atrium and one to the right ventricle, which can allow a heart rhythm that more naturally resembles the normal activities of the heart. Triple-chambered pacemakers typically have one lead in the right atrium, one to stimulate the right ventricle, and one to stimulate the left ventricle. These devices are inserted in patients who have weakened heart muscle (which results in heart failure). These pacemakers "resynchronize" the ventricles and may improve the efficiency of the contraction of the heart, improving its blood flow. Indications for Permanent Pacemakers The following is an explanation of the specific guidelines used when determining if a permanent pacemaker is appropriate: “Specific guidelines have been established concerning the conditions when a permanent pacemaker is (1) definitely beneficial, useful, and effective, (2) may be indicated, or (3) is not useful or effective and, in some cases, may be harmful. Patients should speak with their healthcare provider concerning these guidelines and how they apply to their nursece4less.com nursece4less.com nursece4less.com nursece4less.com 79 specific case. As a general rule, permanent pacing is recommended for certain conditions that are chronic or recurrent and not due to a transient cause. Permanent pacing may be considered necessary or appropriate for certain people with symptomatic bradyarrhythmia or, less commonly, to help prevent or terminate tachyarrhythmia.”83 Absolute indications for pacemaker placement include the following:99 Sick sinus syndrome Symptomatic sinus bradycardia Tachycardia-bradycardia syndrome Atrial fibrillation with sinus node dysfunction Complete atrioventricular block (third-degree block) Chronotropic incompetence (inability to increase the heart rate to match a level of exercise) Prolonged QT syndrome Cardiac resynchronization therapy with biventricular pacing Relative indications include the following:100 Cardiomyopathy (hypertrophic or dilated) Severe refractory neurocardiogenic syncope Temporary emergency pacing is indicated for therapy of significant and hemodynamically unstable bradydysrhythmias and for prevention of bradycardia-dependent malignant dysrhythmias. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 80 Implantation Procedure/Guidelines:101 The pacemaker is most commonly implanted into soft tissue beneath the skin in an area below the clavicle, which is known as prepectoral implantation; this is located under the skin and fat tissue but above the pectoral or breast muscle. The pacemaker leads are typically inserted into a major vein (transvenously) and advanced until the electrodes are secured within the proper region(s) of heart muscle. The other ends of the leads are attached to the pulse generator. Less commonly, the pulse generator is placed under the skin of the upper abdomen. Generally the pacemaker is implanted in a sterile laboratory or operating room by a specialist (cardiologist, surgeon, or cardiac electrophysiologist) with experience in this procedure. Local anesthesia is used to make the procedure as pain-free as possible. In some cases, sedation or even general anesthesia may be used. The position of the pacemaker leads is usually checked using X-ray imaging (called fluoroscopy). The length of the procedure depends upon the type of device being placed. Recovery from the procedure is rapid, but there may be some restrictions on arm movement and activities for the first few weeks. Lead dislodgement is more common in the first few weeks after implantation. The hospital stay is usually brief, and in some cases the procedure can be done as a day surgery. Uncommon but possible risks associated with permanent nursece4less.com nursece4less.com nursece4less.com nursece4less.com 81 pacemaker implantation include collapsed lung (pneumothorax), infection, and bleeding. Once implanted, pacemakers can be programmed to change the baseline heart rate, the upper heart rate at which the pacemaker will pace, and heart rate changes that should occur with exercise. Although pacemakers are most commonly used for arrhythmia, a physician may also recommend a pacemaker in instances of:102 Atrial fibrillation – a common heart rhythm disorder in which the upper chambers of the heart beat rapidly and chaotically. Sometimes people with atrial fibrillation can also have slow rhythms. Medicines used to control atrial fibrillation may result in slow rhythms, which are treated by pacemakers. Heart failure – a condition in which the heartbeat is not sufficient to supply a normal volume of blood and oxygen to the brain and other parts of the body. A special pacemaker can be carefully programmed to increase the force of muscle contractions in the heart. This is called “biventricular pacing” or “resynchronization” therapy. Syncope – a condition best known as the common faint, is usually not serious. Some patients faint when their heart rhythm becomes very slow. For a small percentage of people who experience severe and frequent fainting spells, a pacemaker may prevent the heart rate from slowing to the point of fainting. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 82 Aging or heart disease damages the sinus node's ability to set the correct pace for the heartbeat. Such damage can cause slower than normal heartbeats or long pauses between heartbeats. The damage also can cause the heart to switch between slow and fast rhythms. This condition is called sick sinus syndrome. The patient has had an atrial fibrillation. A pacemaker can help regulate the heartbeat after the procedure. The patient is required to take certain heart medicines, such as beta-blockers, which can slow the heartbeat too much. The patient faints or has other symptoms of a slow heartbeat. The patient has heart muscle problems that cause electrical signals to travel too slowly through the heart muscle. The pacemaker may provide cardiac resynchronization therapy (CRT) for this problem. CRT devices coordinate electrical signaling between the heart's lower chambers. The patient has long QT syndrome, which puts him or her at risk for dangerous arrhythmias. Physicians also may recommend pacemakers for people who have certain types of congenital heart disease or for people who have had heart transplants. Children, teens, and adults can use pacemakers. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 83 Types of Pacemaker Programming The two main types of programming for pacemakers are:103 Demand Pacing A demand pacemaker monitors a person’s heart rhythm. It only sends electrical pulses to the heart if the heart is beating too slow or if it misses a beat. Rate-responsive A rate-responsive pacemaker will speed up or slow down the heart rate depending on how active the patient may be. To do this, the device monitors the sinus node rate, breathing, blood temperature, and other factors to determine a person’s activity level. Procedure: Placing a pacemaker requires minor surgery. The surgery usually is done in a hospital or special heart treatment laboratory.99 Before the surgery, an intravenous (IV) line will be inserted into one of the veins. The patient will receive medicine through the IV line to help him or her relax. The surgeon will numb the area where he or she will put the pacemaker so the patient doesn’t feel any pain. The surgeon may also give antibiotics to prevent infection. A needle will be inserted into a large vein, usually near the shoulder opposite the dominant hand. The needle will be used to thread the pacemaker wires into the vein and to correctly place them in the heart. An x-ray will track the wires as they pass through the vein and into the heart will so that they can be placed properly. Once the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 84 wires are in place, the doctor will make a small cut into the skin of the chest or abdomen. The pacemaker's small metal box will be inserted through the cut, placed just under the skin, and connected it to the wires leading to the heart. The box contains the pacemaker's battery and generator. Three basic types exist to serve different purposes, which are described below.101 Single-Chamber Pacemakers In a single-chamber pacemaker, only one wire (pacing lead) is placed into a chamber of the heart. Sometimes it is the upper chamber, or atrium. Other times it is the lower chamber, or ventricle. Dual-Chamber Pacemakers In dual chamber pacemakers, wires are placed in two chambers of the heart. One lead paces the atrium and one paces the ventricle. This approach more closely matches the natural pacing of the heart. This type of pacemaker can coordinate function between the atria and ventricles. Rate-Responsive Pacemakers These have sensors that automatically adjust to changes in a person's physical activity. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 85 Other devices Some devices, such as implantable cardioverter defibrillators (ICDs), designed primarily for other purposes, can function as pacemakers in certain situations. Guidelines for Pacemaker Use Patients with pacemakers are advised to avoid electromagnetic interference. Although contemporary pacemakers are less susceptible to interference than older models, electromagnetic energy can interfere in some cases. Thus, experts advise that individuals with pacemakers be aware of the following:85 Household appliances Pacemaker manufacturers do not recommend any special precautions when using normally functioning common household appliances such as microwave ovens, televisions, radios, toasters, and electric blankets. Cellular phones Due to the growing use of hand-held cellular phones, patients must be aware of their potential adverse effects. As examples, evidence suggests that cellular phones do not cause interference with permanent pacemakers. While some older generation pacemakers and implantable cardioverter-defibrillators (ICDs) did occasionally experience interference from cellular telephones, clinical experience suggests that there is no significant interference between pacemakers or ICDs and modern wireless communication devices or portable media players. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 86 Anti-theft systems Electromagnetic anti-theft security systems are often found in or near the workplace, at airports, in stores, at courthouses, or in other high-security areas. Although interference with a pacemaker is possible, it is unlikely that any clinically significant interference would occur with the transient exposure associated with walking through such a field. Based upon several studies and observations, experts advise that patients with pacemakers should: o Be aware of the location of anti-theft systems and move through them at a normal pace o Avoid sitting or standing close to an anti-theft system Metal detectors at airports Similar to antitheft systems, metal detectors at airports can potentially interfere with pacemakers, although this is unlikely. Such exposure has been shown to cause interference in some cases and may be related to the duration of exposure and/or distance between the security system and the pacemaker. Metal detectors will likely be triggered by the presence of a pacemaker and therefore at places such as airports, it will be important for individuals with pacemakers to carry an identification card for their pacemaker, and airport personnel will likely prefer to do a manual search. External electrical equipment External electrical fields do not seem to cause a problem for most people with a pacemaker. However, in workplaces that nursece4less.com nursece4less.com nursece4less.com nursece4less.com 87 contain welding equipment or strong motor-generator systems, because interference can inhibit pacing, it is recommended that a person with an implanted cardiac device remain at least two feet from external electrical equipment, verify that the equipment is properly grounded, and leave the immediate locale if lightheadedness or other symptoms develop. Diagnostic or therapeutic procedures Certain types of surgery and procedures may interfere with pacemakers. Most importantly, the use of electrocautery can inhibit pacemaker function. It is not uncommon therefore that a pulse generator may require specific reprogramming before the procedure and programming back to its baseline condition after the procedure. In some instances, a magnet is all that is required on the device to make sure that there is no problem with the device during the procedure. Such procedures include: o Magnetic resonance imaging (MRI), which uses a strong magnetic field that is pulsed on and off at a rapid rate. For most patients with a pacemaker, this procedure is contraindicated. o Transcutaneous electrical nerve/muscle stimulators (TENS), which is a method of pain control. o Diathermy, which heats body tissues with high-frequency electromagnetic radiation or microwaves. o Extracorporeal shock wave lithotripsy, the use of sound waves to break up gallstones and kidney stones. o Therapeutic radiation for cancer or tumors, which can cause permanent pacemaker damage. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 88 o Any surgery in which electrocautery is being used. The risks are greatest when the electrocautery is being performed close to the pulse generator. Pacemaker complications include the following:104 Pneumothorax Pericarditis Infection Skin erosion- Erosion of the pacer through the skin, while rare, requires device replacement and systemic antibiotics. Hematomas may be treated with direct pressure and observation, rarely requiring surgical drainage. Hematoma Lead dislodgment - Lead dislodgment generally occurs within 2 days of device implantation pacer and may be seen on chest radiography. Alternatively, fluctuating impedance may be a subtle clue, as the patient may have normal impedance when the lead is in contact with the endocardium, but infinite (or very high) impedance when the lead is dislodged. Venous thrombosis Free-floating ventricular leads may trigger malignant arrhythmias. Device-associated venous thrombosis is rare but generally presents as unilateral arm edema. Treatment includes extremity elevation and anticoagulation. Major pacemaker malfunctions include the following:83 Failure to output Failure to capture Failure to sense nursece4less.com nursece4less.com nursece4less.com nursece4less.com 89 Pacemaker-mediated tachycardia Runaway pacemaker Pacemaker syndrome Twiddler's syndrome Cardiac monitor pseudomalfunction Pacemaker pseudomalfunction Implantable Cardioverter Defibrillator An implantable cardioverter-defibrillator (ICD) is a device that is used to treat a cardiac tachydysrhythmia. It is a type of permanent pacemaker that is used to provide electrical stimuli, which causes cardiac contraction when intrinsic myocardial electrical activity is inappropriately slow or absent.105 Indications for Use Indications for implantable cardioverter-defibrillator (ICD) implant can be divided into two broad categories:106 Secondary prophylaxis against sudden cardiac death: Multiple studies have shown the ICD to be superior to antiarrhythmic drug therapy in patients with a history of lifethreatening VT and VF. Therefore, the indications for secondary prophylaxis are well supported by clinical evidence gained from randomized clinical trials. An ICD is recommended as initial therapy in survivors of cardiac arrest due to VF or hemodynamically unstable VT. Published guidelines exclude cases in which there are “completely reversible causes.” The exclusion for completely nursece4less.com nursece4less.com nursece4less.com nursece4less.com 90 reversible causes is somewhat controversial. As an example, an acute MI predisposes to polymorphic VT, and the culprit lesion may be reversed with intracoronary stenting. However, we know that any patient who presents with an MI is at increased risk of recurrent MI, which may again precipitate an unstable ventricular arrhythmia. One school of thought suggests that such patients should undergo ICD implant, even though the cause of cardiac arrest is completely reversible, because the risk of recurrence is increased. In another example, consider cardiac arrest secondary to transient prolongation of the QT interval, perhaps secondary to drug therapy. QT interval prolongation increases the risk of torsades de pointes, a potentially life-threatening arrhythmia. Withdrawal of the offending agent may normalize the QT interval, thereby reversing the cause of cardiac arrest. However, such a patient remains at risk of recurrent QT prolongation and subsequent cardiac arrest, perhaps from an electrolyte disturbance or as a result of ingestion of a different QTprolonging agent. Primary prophylaxis: Indications for primary prophylaxis account for most of ICD implants, even though the evidence for such implants is often less well established. Indications for an ICD implant as primary prophylaxis against sudden cardiac death are listed below. The nursece4less.com nursece4less.com nursece4less.com nursece4less.com 91 indications are listed as Class I or Class IIa, as classified by the ACC/AHA 2008 guidelines. Class I means that the treatment is useful, that its benefit greatly outweighs the risk, and that it should be administered. Class IIa means that the benefit outweighs the risk and it is reasonable to administer the treatment. Class IIb means that the benefit probably outweighs the risk and that the treatment may be considered. Class III means that the risk outweighs the benefit, and the treatment should not be performed. Only Class I and Class IIa indications are included in the table. For a complete list, the reader is referred to the American College of Cardiology (ACC)/American Heart Association (AHA) 2008 guidelines. The greatest predictors of risk for sudden cardiac death include left ventricular systolic function and heart failure symptoms. The vast majority of investigational studies have quantified left ventricular systolic function using the measure of left ventricular ejection fraction (LVEF). The most widely used form of heart failure symptom classification is the New York Heart Association (NYHA) functional class classification system, which classifies mild to no symptoms as Class I, and the most severe symptoms as Class IV.107 Indications for ICD placement Currently, indications for primary prophylaxis account for most of ICD implants, even though the evidence for such implants is often less well established. Class I indications (i.e., the benefit greatly outweighs the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 92 risk, and the treatment should be administered) are listed below and outlined in the following table:108,109 Structural heart disease, sustained VT Syncope of undetermined origin, inducible VT or VF at electrophysiologic study (EPS) Left ventricular ejection fraction (LVEF) < 35% due to prior MI, at least 40 days post-MI, NYHA class II or III LVEF ≤35%, NYHA class II or III LVEF ≤30% due to prior MI, at least 40 days post-MI LVEF < 40% due to prior MI, inducible VT or VF at EPS Class IIa indications (i.e., the benefit outweighs the risk and it is reasonable to administer the treatment) are as follows: Unexplained syncope, significant LV dysfunction, nonischemic cardiomyopathy Sustained VT, normal or near-normal ventricular function Hypertrophic cardiomyopathy with 1 or more major risk factors Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more risk factors for sudden cardiac death (SCD) Long QT syndrome, syncope or VT while receiving beta-blockers Nonhospitalized patients awaiting heart transplant Brugada syndrome, syncope or VT Catecholaminergic polymorphic VT, syncope or VT while receiving beta-blockers Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease nursece4less.com nursece4less.com nursece4less.com nursece4less.com 93 Indication Classification Supporting Studies Structural heart disease, sustained VT Class I AVID, CASH, CIDS Syncope of undetermined origin, Class I CIDS Class I SCD-HeFT LVEF ≤35%, NYHA Class II or III Class I SCD-HeFT LVEF ≤30% due to prior MI, at least Class I MADIT II Class I MADIT, MUSTT Class IIa Expert opinion Class IIa Expert opinion Class IIa Expert opinion Class IIa Expert opinion Class IIa Zareba et al, Viskin et inducible VT or VF at EPS LVEF < 35% due to prior MI, at least 40 days post-MI, NYHA Class II or III 40 days post-MI LVEF < 40% due to prior MI, inducible VT or VF at EPS Unexplained syncope, significant LV dysfunction, nonischemic CM Sustained VT, normal or near-normal ventricular function Hypertrophic CM with 1 or more major risk factors Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more risk factors for sudden cardiac death (SCD) Long QT syndrome, syncope or VT while receiving beta blockers al., Goel et al., Monnig et al., Goldenberg et al., Hobbs et al. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 94 Nonhospitalized patients awaiting Class IIa Expert opinion Brugada syndrome, syncope Class IIa Expert opinion Brugada syndrome, VT Class IIa Expert opinion Catecholaminergic polymorphic VT, Class IIa Expert opinion Class IIa Expert opinion heart transplant syncope or VT while receiving beta blockers Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease ICD Complications and Malfunctions: Several complications of implantable cardioverter-defibrillators (ICD) implant have been described, some of which are currently tracked in a national database of ICD implants. Acute surgical complications include the following: Pain Bleeding Pneumothorax Hemothorax Cardiac perforation with or without pericardial effusion and tamponade (sometimes requiring urgent drainage) Pulseless electrical activity following intraoperative defibrillation threshold testing111 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 95 An analysis of more than 350,000 ICD implantations included in the National Cardiovascular Data Registry – ICD Registry revealed 3.1% of patients experienced in-hospital adverse events, 1.2% experienced major adverse events, and 0.4% died. Adverse events were lower (1.9%) with single-chamber ICD implants than with dual-chamber ICD implants (2.9%) or with biventricular ICD implants (4.1%). Specific adverse event rates included lead dislodgement (1%), hematoma (0.9%), pneumothorax (0.4%), and cardiac arrest (0.3%).112 Physician level of training and level of specialty certification have been shown to affect the risk of adverse events associated with ICD implant. An ICD Registry analysis found that physicians who implant more ICDs have lower rates of procedural complications and in hospital mortality. Implant volume may partially explain the difference in adverse events among physicians with different specialty certifications. However, no inverse relationship was found between procedure volume and adverse event rate observed within the board certified category.105 Subacute and chronic complications Subacute ICD complications include the following: Pain Infection Pocket hematoma Wound dehiscence Lead dislodgment Deep venous thrombosis Upper extremity edema Degradation of lead function nursece4less.com nursece4less.com nursece4less.com nursece4less.com 96 Chronic complications include the following:113 Device-related pain Lead fracture Inappropriate shocks Erosion of device through skin Immunologic rejection – Rare Other complications include the following: Infection - ICD infection rates are higher in patients undergoing generator replacement compared with de novo implant. A prospective study revealed an infection rate of 1.3% in patients undergoing device replacement. In this study, postoperative hematoma significantly increased the risk of infection (22.7% vs. 0.98%).108 Inappropriate shocks - One of the risks of ICD implant is that of inappropriate ICD shocks. An inappropriate ICD shock is one that is not precipitated by accurate detection of a malignant ventricular arrhythmia, VT, or VF. Typically, inappropriate ICD shocks result when atrial arrhythmias, such as atrial fibrillation, atrial tachycardia, or atrial flutter, accelerate the ventricular rate beyond the set limit for delivery of ICD shock therapy. However, inappropriate shocks may also result from sinus tachycardia, supraventricular tachycardia (SVT), illicit drug use (as with cocaine and methamphetamine), and ventricular oversensing. Ventricular oversensing may occur due to T-wave oversensing, electromagnetic interference (EMI), a loose setscrew in the ICD header, or ICD lead fracture. Analysis of the MADIT II trial data revealed that 11.5% of the ICD patients received inappropriate nursece4less.com nursece4less.com nursece4less.com nursece4less.com 97 ICD shocks and that 31.2% of all ICD shocks were deemed inappropriate. Inappropriate ICD shocks were attributed to atrial fibrillation (44%), supraventricular tachycardia (36%), and abnormal sensing (20%). Patients with inappropriate shocks had greater all-cause mortality. Drug therapy with hydroxymethylglutarylcoenzyme A reductase inhibitors, or so-called statins, has been shown to reduce, by more than half, the frequency of inappropriate ICD shocks secondary to occurrence of atrial fibrillation and atrial flutter. There is some indirect evidence that the incidence of inappropriate shocks may be lower in patients with dual-chamber devices compared with patients who receive single-chamber devices.114 Failure to shock and ineffective cardioversion - Failure to deliver a shock may be caused by failure to sense, lead fracture, EMI, and inadvertent ICD deactivation. Management includes external defibrillation or cardioversion and antidysrhythmic medications. Ineffective cardioversion may result from inadequate energy output, rise in defibrillation threshold (possibly due to an antiarrhythmic medication, such as amiodarone, flecainide, or phenytoin), myocardial infarction at the lead site, lead fracture, insulation breakage, scarring at the lead implantation site, and lead dislodgment. Many ICDs deliver a programmed set of therapies per dysrhythmic episode. The number of therapies per episode is programming specific. If a delivered therapy does not terminate nursece4less.com nursece4less.com nursece4less.com nursece4less.com 98 the arrhythmia, the device proceeds to the next programmed therapy. For example, a total of 6 attempts at defibrillation are attempted per episode of ventricular fibrillation. The device attempts defibrillation and then reevaluates the cardiac rhythm. If the arrhythmia persists, it delivers therapy number 2 and so on until all 6 attempts have been delivered. Once this occurs, the device does not deliver therapy until a new episode is declared. Initial therapy for ventricular tachycardia (VT) may be antitachycardia pacing (also known as overdrive pacing) rather than cardioversion. ICDs do not prevent all sudden deaths, and acknowledging that cardiac arrest is not necessarily an ICD malfunction is important. The device may have properly delivered the required shocks for the triggering rhythm but still have been ineffective in resolving it.106 Sprint Fidelis lead fracture - In July 2007, a higher than expected rate of Sprint Fidelis model 6949 ICD lead fractures were reported. Six patients presented with lead failure 4-23 months after implant. A subsequent database search for similar reports revealed that 33% of affected patients had inappropriate ICD shocks. Analysis of affected leads revealed 33% with high lead impedance and a 35% rate of pace-sense and high-voltage conductor fracture.110 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 99 Implantation risk evaluation The acute risk of ICD implantation is small but is increased by multiple factors. The following are risk factors established by an ICD registry risk score model:108 Age greater than 70 years - 1 point Female - 2 points NYHA class III - 1 point NYHA class IV - 3 points Atrial fibrillation - 1 point Prior valve surgery - 3 points Chronic lung disease - 2 points Blood urea nitrogen (BUN) > 30 mg/dL - 2 points Reimplantation for reasons other than battery change - 6 points Dual chamber ICD type - 2 points Biventricular ICD type - 4 points Nonelective ICD implant -3 points The risk of any inhospital complication increases from 0.6% among patients with a score of less than 5 to 8.4% among the patients with greater than 19 risk points. Goals Of Cardiac Rehabilitation There are a number of different goals associated with cardiac rehabilitation. The specific goals will depend on the cardiac condition, the status of the patient, and the lifestyle goals of the patient (i.e., return to work). The rehabilitation team will work with each patient to determine his or her goals and develop a concrete set of attainable goals. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 100 General Goals or Indications The following bullets provide information regarding the main uses and indications for cardiac rehabilitation. Cardiac rehabilitation is now a Class I Indication in clinical guidelines for:7 Myocardial infarction (MI) Percutaneous Coronary Intervention (PCI) Coronary artery bypass grafting (CABG) Angina Heart failure Valvular heart disease Peripheral arterial disease (PAD) The Performance Measures Set 1 (referral to CR from both an inpatient and outpatient setting) has been endorsed by the National Quality Forum (NQF). The demonstrated evidence-based benefits of Cardiac Rehabilitation include the following:10 20-30% reduction in all-cause mortality rates Decreases mortality at up to 5 years post participation Reduced symptoms (angina, dyspnea, fatigue) Reduction in nonfatal recurrent myocardial infarction over median follow-up of 12 months Improves adherence with preventive medications Increased exercise performance Improved lipid panel (total cholesterol, HDL [good cholesterol], LDL [bad cholesterol], and triglycerides) Increased knowledge about cardiac disease and its management Enhanced ability to perform activities of daily living Improved health-related quality of life nursece4less.com nursece4less.com nursece4less.com nursece4less.com 101 Improved psychosocial symptoms (reversal of anxiety and depression, increased self-efficacy) Reduced hospitalizations and use of medical resources Return to work or leisure activities Increase Physical Fitness An increase in physical fitness can benefit most individuals with cardiovascular disease, including those who have been diagnosed with heart failure. The specific exercise regimen will vary depending on the needs and abilities of the individual, but all regimens will provide additional benefits during the recovery or maintenance stage. One of the primary benefits that occurs during an increase in physical fitness is that the patient will experience an increased ability to use oxygen to derive energy for work.115 Exercise training increases maximum ventilatory oxygen uptake by increasing both maximum cardiac output (the volume of blood ejected by the heart per minute, which determines the amount of blood delivered to the exercising muscles) and the ability of muscles to extract and use oxygen from blood. Beneficial changes in hemodynamic, hormonal, metabolic, neurological, and respiratory function also occur with increased exercise capacity. These changes can also benefit persons with impaired left ventricular function, in whom most adaptations to exercise training appear to be peripheral and may occur with low-intensity exercise.116 An increase in physical fitness also produces decreased myocardial oxygen demands for the same level of external work performed. This is demonstrated by a decrease in the product of heart rate × systolic nursece4less.com nursece4less.com nursece4less.com nursece4less.com 102 arterial blood pressure (an index of myocardial oxygen demand). These changes are also beneficial in persons with coronary artery disease, who after exercise training may attain a higher level of physical work before reaching the level of myocardial oxygen requirement that results in myocardial ischemia.117 Another benefit that occurs when patients increase their physical fitness through regular exercise training is a favorable alteration in lipid and carbohydrate metabolism. The exercise-induced increase in high-density lipoproteins is strongly associated with changes in body weight, and greater increases in high-density lipoproteins have been found in women who exercise at higher levels of recreational running.118 Increased physical fitness in overweight women and men enhances the beneficial effect of a low-saturated fat and lowcholesterol diet on blood lipoprotein levels. Increased endurance training in those who can tolerate it, will have a positive effect on adipose tissue distribution. This effect on adipose tissue distribution is likely to be important in reducing cardiovascular risk. Exercise training and an increase in general physical fitness is also shown to have a significant impact on insulin sensitivity.12 In addition, intense endurance training has been shown to initiate a highly significant salutary effect on fibrinogen levels of healthy older men. Recent studies have shown that physical activity plays an important role in the prevention and treatment of osteoporosis and certain neoplastic diseases, especially colon cancer. The following is a list of important points to consider regarding physical fitness programs:119 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 103 Developing and maintaining aerobic endurance, joint flexibility, and muscle strength is important in a comprehensive exercise program, especially as people age. Elderly women and men show comparable improvement in exercise training, and adherence to training in the elderly is high. Resistance training exercise alone has only a modest effect on risk factors compared with aerobic endurance training, but it does aid carbohydrate metabolism through the development or maintenance of muscle mass and effects on basal metabolism. Furthermore, resistance training is currently recommended by most health promotion organizations for its effects on maintenance of strength, muscle mass, bone mineral density, functional capacity, and prevention and/or rehabilitation of musculoskeletal problems (i.e., low back pain). In the elderly, resistance training is both safe and beneficial in improving flexibility and quality of life. Persons with cardiovascular disease are usually asked to refrain from heavy lifting and forceful isometric exercises, but moderate-intensity dynamic strength training is safe and beneficial in persons at low risk. Many activities of daily living require more arm work than leg work. Therefore, persons with coronary artery disease are advised to use their arms as well as their legs in exercise training. The arms respond like the legs to exercise training both nursece4less.com nursece4less.com nursece4less.com nursece4less.com 104 quantitatively and qualitatively, although ventilatory oxygen uptake is less with arm ergometry. Although peak heart rates are similar with arm and leg exercise, heart rate and blood pressure response during arm exercise is higher than leg exercise at any submaximal work rate. Therefore, target heart rates are designated 10 beats per minute lower for arm training than for leg training. Dynamic arm ergometry is usually well tolerated by persons with coronary artery disease; however, there may be an increase in blood pressure that may be of concern in certain persons. Maximum ventilatory oxygen uptake drops 5% to 15% per decade between the ages of 20 and 80, and a lifetime of dynamic exercise maintains an individual's ventilatory oxygen uptake at a level higher than that expected for any given age. The rate of decline in oxygen uptake is directly related to maintenance of physical activity level, emphasizing the importance of physical activity. Middle-aged men and women who work in physically demanding jobs or perform moderate to strenuous recreational activities have fewer manifestations of coronary artery disease than their less active peers. Meta-analysis studies of clinical trials reveal that medically prescribed and supervised exercise can reduce mortality rates of persons with coronary artery disease. In addition to the physical benefits of exercise, both short-term exercise and long-term aerobic exercise training are associated nursece4less.com nursece4less.com nursece4less.com nursece4less.com 105 with improvements in various indexes of psychological functioning. Cross-sectional studies reveal that, compared with sedentary individuals, active persons are more likely to be better adjusted, to perform better on tests of cognitive functioning, to exhibit reduced cardiovascular responses to stress, and to report fewer symptoms of anxiety and depression. Exercise training reduces depression in healthy older men and in persons with cardiac disease or major depression. Exercise also improves self-confidence and self-esteem, attenuates cardiovascular and neurohumoral responses to mental stress, and reduces some type A behaviors. Although exercise training generally has not been found to improve cognitive performance, short bouts of exercise may have short-term facilitative effects. It is estimated that only 50% of all persons who initiate an exercise program will continue the habit for more than 6 months. The issue of nonadherence is particularly important because exercise is only beneficial if it is maintained for extended periods of time. Thus, it is important to develop strategies to improve exercise initiation and adherence, especially for persons who are among the least active—some African-American women, the less educated, the obese, and the elderly. Persons of all ages should include physical activity in a comprehensive program of health promotion and disease nursece4less.com nursece4less.com nursece4less.com nursece4less.com 106 prevention and should increase their habitual physical activity to a level appropriate to their capacities, needs, and interest. Activities such as walking, hiking, stair-climbing, aerobic exercise, calisthenics, resistance training, jogging, running, bicycling, rowing, swimming, and sports such as tennis, racquetball, soccer, basketball, and “touch” football are especially beneficial when performed regularly. Brisk walking is also an excellent choice. The training effect of such activities is most apparent at exercise intensities exceeding 40% to 50% of exercise capacity. (Exercise capacity is defined as the point of maximum ventilatory oxygen uptake or the highest work intensity that can be achieved). Evidence supports that even low- to moderate-intensity activities performed daily can have some long-term health benefits and lower the risk of cardiovascular disease. Low-intensity activities generally range from 40% to 60% of maximum capacity. The 40% to 60% of maximum capacity range is similar for young, middle-aged, and elderly persons. Such activities include walking for pleasure, gardening, yard work, housework, dancing, and prescribed home exercise. For health promotion, dynamic exercise of the large muscles for extended periods of time (30 to 60 minutes, three to six times weekly) is recommended. This may include short periods of moderate intensity (60% to 75% of maximal capacity) activity (approximately 5 to 10 minutes) that total 30 minutes on most nursece4less.com nursece4less.com nursece4less.com nursece4less.com 107 days. Resistance training using eight to 10 different exercise sets with 10 to 15 repetitions each (arms, shoulders, chest, trunk, back, hips, and legs) performed at a moderate to high intensity (for example, 10 to 15 pounds of free weight) for a minimum of 2 days per week is recommended. Physical activity may have risks as well as benefits, although risks are relatively infrequent. Estimates of sudden cardiac death rates per 100 000 hours of exercise range from 0 to 2 per 100 000 in general populations and from 0.13 per 100 000 to 0.61 per 100 000 in cardiac rehabilitation programs. Studies have also demonstrated the cardiovascular safety of maximum strength testing and training in healthy adults and low-risk cardiac patients. Falls and joint injuries are additional risks associated with physical activity (especially in older women), but most of these injuries do not require medical treatment. The incidence of such complications is less in those participating in low-impact activities such as walking. Improve Physical and Mental Health There is evidence to show that comprehensive cardiac rehabilitation programs, including exercise training, can reduce smoking, alter lipid profiles, reduce blood pressure, favorably alter body weight and increase physical activity. Improvements in psychosocial outcomes have also been shown. The following table provides an overview on the goals and benefits in each of these areas:5.14.116.121-129 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 108 Smoking Strong advice from physicians to stop smoking, especially in hospital, has been shown to be important. In one uncontrolled study, such physician recommendations, coupled with follow-up advice from nurses, were associated with a one-year self-reported quit rate of 62%. In another study of patients who had undergone coronary bypass surgery, reduced smoking rates were found at one year in the group randomly allocated to a program of exercise training and education, coupled with physician advice to stop smoking, compared with the control group. Spousal support has been shown to facilitate smoking cessation in cardiac patients. In a randomized controlled study of inpatient group education followed by weekly telephone calls for six weeks after discharge from hospital, results showed a significantly greater decrease in smoking and unhealthy eating habits, and a significantly greater increase in physical activity, among patients whose partners also participated in the program. While there were no overall differences at 12 months between the intervention and control groups, a greater rate of smoking cessation was found in the intervention group among patients whose partners had participated. In general, evidence suggests that interventions to reduce smoking are more likely to be effective if they are initiated in hospital when patients are more highly motivated rather than after discharge from hospital. Further, a meta-analysis of controlled trials of cardiac patient education concluded that while interventions, on average, showed no significant impact on smoking behavior, behaviorally oriented interventions generally produced better outcomes. Behavioral strategies, such as regular reinforcement of advice to stop smoking and continuing support, appear necessary. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 109 The positive studies described above indicate that follow-up telephone contact by nurses is a convenient, inexpensive and effective method of reinforcing physician advice to stop smoking. Lapses tend to occur when interventions cease. Instructing patients in relapse prevention methods before they lapse is therefore of critical importance. Lipids Patients who participated in an educational program by mail and telephone reported a significant decrease in dietary fat intake after six months compared with a control group receiving usual care, but no significant differences were found between groups in cholesterol levels. Beneficial effects upon lipid levels have been reported from interventions combining education and behavioral strategies with the use of lipid lowering drugs. A large study of a home-based multifactorial intervention combining education, counseling and lipid lowering medication achieved a significant mean reduction in total cholesterol and dietary fat intake in the treatment group after four years, compared with the control group. Another multifactorial intervention, which included lipid-lowering medication, also reported a significant reduction in serum cholesterol levels in the intervention group compared with the control group. A recent randomized controlled trial studied the effects of diet alone, a combination of diet and exercise, exercise alone and usual care in men and postmenopausal women with low levels of HDL cholesterol and raised LDL cholesterol. This study showed that the Step 2 diet of the US National Cholesterol Education Program was ineffective in lowering LDL cholesterol unless it was coupled with exercise training. Similarly, a nonrandomized controlled study reported significant improvements in lipid levels from a combination of education, counseling and exercise compared with exercise alone. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 110 Blood The effectiveness of antihypertensive drugs in lowering blood pressure pressure is well established. Further, beneficial effects upon blood pressure in cardiac patients have been reported from two multifactorial interventions including exercise training. One randomized controlled trial of a multifactorial intervention including lifestyle advice, which was reinforced during the four year follow-up, produced significant benefits in reduction of blood pressure in cardiac patients in the intervention group compared with the control group. A significant reduction in blood pressure was also reported in a multifactorial intervention involving exercise, education and support. However, in another randomized controlled trial of exercise training and education, there was no impact upon blood pressure levels. A further multifactorial intervention of stress management, exercise, intensive dietary restriction and support produced no significant impact on blood pressure levels, with both the intervention and control groups showing a decrease in blood pressure at one year. Education and behavioral interventions for weight reduction, physical activity and moderation of dietary sodium and alcohol consumption are recommended as definitive or adjunctive therapy for hypertension. They are important components of a multifactorial approach to reduce hypertension in cardiac patients. Body weight Dietary education, counseling and behavioral interventions designed to reduce body weight can help patients lose weight and should be provided as part of comprehensive cardiac rehabilitation. Education as a sole intervention is unlikely to achieve and maintain weight loss. Several studies have reported a reduction in body weight as a result of comprehensive cardiac rehabilitation programs which include exercise, education, counseling and behavioral interventions. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 111 A randomized controlled trial conducted over four years demonstrated a statistically significant body weight reduction of 4 % in the intervention group compared with the control group. Patients in the intervention group received individual advice regarding lifestyle modification, which incorporated goal setting, a monitored home exercise program, follow-up by mail, telephone contact and regular visits to the clinic for follow-up. Considerable weight loss occurred amongst the dedicated subjects enrolled in a study of a one-year intervention including a low fat vegetarian diet, group discussion for social support, stress management and exercise. Significantly greater weight loss was also reported in the treatment group in two further studies, and in another study, a reduction in body fat was achieved in subjects receiving the intervention. In all three studies, however, the mean weight loss was less than 3 kg. A significant reduction in body mass index, percentage of body fat and other measures was reported in one study and in another, in percentage of body fat in women. Other studies involving exercise reported no changes in body weight. A randomized controlled study comparing exercise training alone, exercise training plus group education and counseling, and a control group found no significant differences between groups in weight loss after three and six months. Positive results were reported from three studies, which did not involve exercise. Another randomized controlled trial reported a significant reduction in mean body weight at one to 10 year follow-up in patients in the intervention group receiving nutritional counseling compared with the control group. In that study, the intervention was intensive for the first three months, followed by a continued intervention for three years. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 112 Psychosocial Education, counseling and behavioral interventions, either alone well-being or as part of multifactorial interventions, improve psychological wellbeing and improve quality of life. They should therefore be integral parts of comprehensive cardiac rehabilitation programs. Psychological disability has long been recognized as a greater barrier to recovery than physical impairment. Thus, an important aim of cardiac rehabilitation programs should be to improve the psychological wellbeing of patients. The psychological benefits of exercise training are widely acknowledged. An important issue is whether specific education, counseling or behavioral interventions enhance psychological wellbeing, additional to those benefits achieved through exercise training. Stress The aims of stress management programs are to assist the patient to identify stressors, to recognize characteristic emotional and physical responses to stress, to decrease levels of general arousal and to develop effective coping strategies. Through the use of various techniques including relaxation therapy, meditation, cognitive therapy, anxiety management and biofeedback, the patient is taught how to reduce stressful reactions by altering stress-inducing perceptions of situations. By acquiring more effective coping skills, maladaptive responses to stress may be reduced. Several studies have reported benefits from relaxation therapy. In one study, patients who received cognitive training early after myocardial infarction had greater confidence in their ability to control their stress than those who received relaxation therapy. In another, relaxation training was found to enhance the psychological effects of exercise training. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 113 In a study involving monthly monitoring of stress levels of patients and home nursing visits for those with high stress scores, a significant reduction in stress scores was found as well as a significantly reduced rate of long-term recurrence of acute myocardial infarction and a marginal impact on cardiac mortality during the first year after infarction. Little impact was observed on those with low levels of stress in hospital. The authors concluded that patients who can benefit from such an intervention may be identified in hospital. Summary Patients with a cardiac condition must be assessed to ensure that he or she is a candidate for a cardiac rehabilitation program. There are a number of conditions require cardiac rehabilitation, and, likewise, a number of different goals associated with cardiac rehabilitation. The specific goals depend upon the cardiac condition, the status of and the lifestyle goals of the patient. The cardiac rehabilitation team is trained to work with each patient to determine his or her goals and to develop a concrete set of individual attainable goals. The primary goal of cardiac rehabilitation programs is to reduce cardiac symptoms in patients. However, the specific goals will differ depending on the type and severity of cardiac condition. In some instances, the goal will be to eliminate the cardiac condition. In other instances, the goal will be to maintain a level of health that prevents further damage from the cardiac condition.116 Prior to initiating a cardiac rehabilitation program, the medical provider will need to work with the patient to determine the specific treatment goals. Throughout nursece4less.com nursece4less.com nursece4less.com nursece4less.com 114 the course of treatment, the patient is assessed and monitored to ensure goals are being met.120 This course addressed the cardiac conditions that would benefit from patient participation in a cardiac rehabilitation program. The history and role of cardiac rehabilitation is a lengthy topic recommended for further reading by the interested learner. There are a number of different goals associated with cardiac rehabilitation. The specific goals will depend on the cardiac condition, the status of the patient, and the lifestyle goals of the patient (i.e., return to work). The rehabilitation team will work with each patient to determine his or her goals and develop a concrete set of attainable goals. Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 115 1. While men and women have the same incidence and the same prevalence of heart failure, which of the following states a difference noted between men and women with heart failure: a. Women tend to develop heart failure earlier in life than men do. b. Men are more likely than women to have preserved systolic function. c. Women develop depression more commonly than men do. d. Women have signs and symptoms of heart failure similar to those of men, but they are less pronounced in women. 2. Cardiac rehabilitation is useful in treating heart patients so long as the program is instituted before the patient has experienced his or her first heart attack. a. True. b. False. 3. Which of the following is a modifiable risk factor for atherosclerosis: a. Diabetes mellitus b. Age c. Family history of premature coronary heart disease d. Male-pattern baldness nursece4less.com nursece4less.com nursece4less.com nursece4less.com 116 4. There are a number of different goals associated with cardiac rehabilitation. Which statement best describes the specific program for a patient? a. the patient’s cardiac condition is not a factor because cardiac rehabilitation is useful for patients with varied cardiac conditions. b. the lifestyle goals of the patient is not relevant because the focus should be on cardiac rehabilitation. c. The rehabilitation team will work with each patient to determine his or her goals and develop a concrete set of attainable goals. d. None of the above. 5. Patients with pacemakers are advised to avoid electromagnetic interference. Which of the following devices does the evidence suggest may interfere with permanent pacemakers? a. Properly operating household appliances such as microwave ovens, televisions, radios, toasters, and electric blankets. b. Cellular phones. c. Electromagnetic anti-theft security systems. d. Diagnostic or therapeutic procedures used in certain types of surgery and procedures. 6. True or False: Angina is the term used to describe the pain and discomfort that occurs when the heart is deprived of blood. a. True. b. False. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 117 7. Patients with typical myocardial infarction may have the following prodromal symptoms in the days preceding the event: a. Fatigue. b. Intense and unremitting for 30-60 minutes. c. A feeling of indigestion or of fullness and gas. d. All of the above. 8. The following is/are true when a patient increases his or her physical fitness program: a. Most individuals with cardiovascular disease will benefit from increased physical fitness so long as they have NOT been diagnosed with heart failure. b. One of the primary benefits that occurs during an increase in physical fitness is that the patient will experience an increased ability to use oxygen to derive energy for work. c. Exercise training decreases maximum ventilatory oxygen because the muscles extract and use oxygen from blood. d. Physical fitness program do not benefit persons with impaired left ventricular function. 9. There is evidence to show that comprehensive cardiac rehabilitation programs, including exercise training, can do the following: a. Reduce smoking b. Alter lipid profiles c. Reduce blood pressure d. All of the above. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 118 10. Intracoronary stents have the following features: a. The commercially available second-generation DESs that elute everolimus and zotarolimus are not approved for use in the United States. b. Bare-metal stents are used exclusively to target lesion revascularization. c. Drug-eluting stents (DESs) have demonstrated significant reductions in restenosis. d. Stents with bioabsorbable polymer, polymer-free systems or fully bioresorbable scaffolds are approved and available for commercial use in the United States. 11. Non-modifiable risk factors for atherosclerosis include the following: a. A person’s age and gender b. Family history of premature coronary heart disease c. Male-pattern baldness d. *All of the above. 12. Immediately after the onset of myocardial infarction, the ability of ischemic myocardium to relax declines. Impaired relaxation ___________ LV end-diastolic volume (LVEDV) and LV end-diastolic pressure (LVEDP). a. decreases b. *increases c. does not interfere with d. may both increase or decrease nursece4less.com nursece4less.com nursece4less.com nursece4less.com 119 13. Studies have shown that _________________ helps to reduce stress levels in patients after myocardial infarction. a. massage therapy b. *cognitive behavioral therapy c. group therapy d. desensitization therapy 14. Aging or heart disease damages the ______________ ability to set the correct pace for the heartbeat. a. *sinus node’s b. atrial node’s c. ventricle’s d. heart’s atrioventricular 15. Beneficial effects upon lipid levels have been reported from interventions combining __________________________ with the use of lipid lowering drugs. a. low fat diet alone b. exercise alone c. *education and behavioral strategies d. cognitive behavioral therapy 16. The greatest predictors of risk for sudden cardiac death include ________________and heart failure symptoms. a. *left ventricular systolic function b. right ventricular systolic and diastolic function c. right ventricular filling pressure d. answers b and c above nursece4less.com nursece4less.com nursece4less.com nursece4less.com 120 17. Rate-responsive pacemakers have sensors that automatically adjust to changes in a person's __________. a. cardiac output b. *physical activity c. atrial rhythm d. none of the above 18. Persons with cardiovascular disease may safely perform a. heavy-lifting and forceful isometric exercises, under guidance b. *moderate-intensity dynamic strength training, for person’s at low risk c. stretching and pilates exercises after completing cardiac rehab d. hot yoga exercises, for no more than 30 minutes 19. A dual-chamber pacemaker usually has two leads, one to the ______________ and one to the ________________. a. *right atrium and right ventricle b. right atrium and left atrium c. left atrium and left ventricle d. both ventricles 20. The following tests may be used to determine type of an arrhythmia, EXCEPT: a. EKG (Electrocardiogram) b. Echocardiography c. *Transesophageal electrocardiogram bubble study d. Stress Test nursece4less.com nursece4less.com nursece4less.com nursece4less.com 121 21. Patients needing a temporary pacemaker would be a. *hospitalized. b. not requiring hospitalization. c. sent home with a 24-hour ambulatory EKG. d. not expected to need a permanent pacemaker. 22. _____________________________ is gaining greater prominence in assessing the inflammatory level of vascular disease and predicting future risk of vascular events, such as MIs and cerebrovascular accidents. a. High-sensitivity CPK b. *High-sensitivity C-reactive protein c. High-sensitivity CK d. High-sensitivity LDL and LDH 23. Abciximab, tirofiban, and eptifibatide are examples of a. *Glycoprotein inhibitor therapy b. Antianginals c. Antibiotics that specifically treat pericarditis d. Anticoagulant therapy 24. Medications shown to reduce ischemic complications in patients undergoing balloon angioplasty and coronary stenting belong to the following medication category: a. Antianginals b. Anticoagulants c. *Glycoprotein inhibitor therapy d. Antibiotic medication 25. True or False. Multiple studies have shown the ICD to be superior to antiarrhythmic drug therapy in patients with a history of life-threatening VT and VF. a. *True. b. False. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 122 26. While going through airports, individuals with pacemakers should a. not be concerned of metal detectors being triggered b. *carry their pacemaker ID card c. not expect airport personnel to request a manual search. d. Both and c above. 27. Diastolic dysfunction predominates in conditions of a. hypertrophic cardiomyopathy. b. disorders with ventricular hypertrophy. c. amyloid infiltration of the myocardium. d. *All of the above. 28. For health promotion, dynamic exercise of the large muscles for extended periods of time is recommended, such as a. a full hour seven days a week. b. an hour every other day. c. *30 to 60 minutes, three to six times weekly. d. 15 to 20 minutes, every day of the week. 29. True or False. Increased physical fitness in overweight women and men enhances the beneficial effect of a lowsaturated fat and low-cholesterol diet on blood lipoprotein levels. a. *True. b. False. 30. Epicardial inflammation may initiate pericarditis, which is seen in more than 20% of patients presenting with _________________. a. *Q-wave infarctions. b. ST depression. c. prolonged QT interval. d. sudden death. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 123 31. Major pacemaker malfunctions include the following: a. Failure to output. b. Failure to capture. c. Failure to sense. d. *All of the above. 32. The failing heart and other organs produce a. *tumor necrosis factor. b. tumor cells. c. cytokines. d. None of the above. 33. Each rehospitalization for heart failure increases mortality by about _________ percent. a. 45 – 47 b. 33 – 35 c. *20 – 22 d. 15 - 17 34. The rate of decline in oxygen uptake is directly related to a. geographic region. b. *maintenance of physical activity level. c. genetic factors. d. Answers a and b above. 35. The TAVR is a new alternative for some cases of a. coronary blockage. b. pulmonary stenosis. c. *aortic valve stenosis. d. mitral valve prolapse. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 124 36. Artificial heart valves may be a. mechanical metal. b. mechanical plastic. c. tissue made from animal valves or human valves taken from cadavers. d. *All of the above. 37. The demonstrated evidence-based benefits of Cardiac Rehabilitation include all EXCEPT: a. Reduced symptoms (angina, dyspnea, fatigue). b. Increased exercise performance. c. *Ability to no longer need to take heart medication and to perform high intensity exercise and competitive sports. d. Enhanced ability to perform activities of daily living. Correct Answers: 1. c 6. a 11. d 16. a 21. a 26. b 31. d 2. b 7. d 12. b 17. b 22. b 27. d 32. a 3. a 8. b 13. b 18. b 23. a 28. c 33. c 4. c 9. d 14. a 19. a 24. c 29. a 34. b 5. d 10. c 15. c 20. c 25. a 30. a 35. c nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36. d 37. c 125 Reference Section The reference section of in-text citations include published works intended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text. The following citations pertain to the course series on cardiac rehabilitation, which include: CARDIAC CONDITIONS, INTERVENTIONS & REHABILITATION and THE CARDIAC REHAB TEAM: A HOLISTIC APPROACH TO RECOVERY AND HEALING. 1. Scarborough P, Bhatnagar P, Wickramasinghe K, Smolina K, Mitchell C. Coronary heart disease statistics 2010 edition. Br Hear Found. 2010;21. 2. Maganti K, Rigolin VH, Sarano ME, Bonow RO. Valvular Heart Disease: Diagnosis and Management. Mayo Clinic Proceedings. 2010. p. 483– 500. 3. Leon AS, Franklin B a, Costa F, Balady GJ, Berra K a, Stewart KJ, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease. Circulation. 2005;111:369–76. 4. Wenger NK. Current Status of Cardiac Rehabilitation. Journal of the American College of Cardiology. 2008. p. 1619–31. 5. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils o. Circulation. 2007 May 22;115(20):2675–82. 6. Donker FJ. Cardiac rehabilitation. Clinical Psychology Review. 2000. p. 923–43. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 126 7. Fernandez RS, Davidson P, Griffiths R, Salamonson Y. Improving cardiac rehabilitation services - Challenges for cardiac rehabilitation coordinators. Eur J Cardiovasc Nurs. 2011;10:37–43. 8. Wofford JD, Wofford E, Beissel GF, Brumfield J. Cardiac rehabilitation. N Engl J Med. 2002;2:379–80. 9. Reeves GR, Whellan DJ. Recent advances in cardiac rehabilitation. Curr Opin Cardiol. 2010;25:589–96. 10. Lavie CJ, Milani R V. Benefits of cardiac rehabilitation and exercise training. Chest. 2000;117:5–7. 11. Lavie CJ, Berra K, Arena R. 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Pathophysiology of coronary artery disease. Circulation. 2005;111:3481–8. 27. Pflieger M, Winslow BT, Mills K, Dauber IM. Medical management of stable coronary artery disease. Am Fam Physician. 2011;83:819–26. 28. Hall SL, Lorenc T. Secondary prevention of coronary artery disease. Am Fam Physician. 2010;81:289–96. 29. Infarction SM. Unstable Angina and NSTEMI. Cardiovasc Med. 2004;1– 13. 30. Kelemen MD. Angina pectoris: Evaluation in the office. Medical Clinics of North America. 2006. p. 391–416. 31. Petticrew M, Turner-Boutle M, Sheldon T a. Management of stable angina. Postgrad Med J. 1997;79:332–6. 32. Conti CR. Grading chronic angina pectoris (myocardial ischemia). Clinical Cardiology. 2010. p. 124–5. 33. Trinca M, Dionísio P, Araújo F V., Soares R, Vasconcelos J, Caeiro A, et al. Unstable angina: individualized stratification and prognosis. Rev Port Cardiol. 2000;19:567–78. 34. Lanza GA, Sestito A, Sgueglia GA, Infusino F, Manolfi M, Crea F, et al. 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