United Kingdom (UK) has a high rate of Coronary Heart Disease (CHD) (National Service Frame, (NSF)2000) among developed countries, with CHD being the most common cause of death in England and Wales and one of the highest in the world (NICE 2003). British Heart Foundation (BHF) statistics shows that in 2007, cardiovascular disease (heart disease and stroke) amounts to the main cause of premature death in people less than 75yrs in the UK. BHF also states that over 2 million people suffer from some form of CHD and approximately 91,000 deaths in the UK is caused by CHD; with 19% of deaths being men and 13% being women (BHF 2010).
CHD also has a socioeconomic effect on the country, it has estimated to cost the UK in direct healthcare £1.8 billion in 2001 (Shearer et al 2004) while building a cost of approximately £5.8 billion in 2007 resulting from lost of work days because of death, illnesses and care for people with heart disease (BHF 2007). BHF also states that CHD in general can cost the UK economy approximately £9 billion per year in its treatment and management. Acute myocardial infarction (MI) is one of the causes of mortality in CHD. Acute MI, according to Leya et al (1995), is caused by an abrupt thrombotic coronary artery occlusion, resulting from ruptured atheromatous plaques releasing blood clots into the coronary vascular system (NSF2000). Early intervention or revascularisation either by percutaneous coronary intervention (PCI) or coronary artery by-pass graft (CABG) can reduce the risk of morbidity and or mortality in patients (NSF2000).
With the help of a case study I will aim to explore the pathway followed in the treatment of an acute MI event, focusing on the proposed management together with the psychological responses of the patient and relatives. Keeping in accordance with the Nursing and Midwife Council (NMC 2008) Code of conduct, the patient name would be changed to maintain their privacy and confidentiality.
Mr Peter Paul is a 52yr old fire officer married to a 46yr old teacher. Apart from his hypertension, which is well controlled, he considered himself physically healthy, eating appropriately and attended gym 3-4 times per week in order to maintain his physical prerequisite for his job. At one gym session he felt some chest pain with some shortness of breath and was advised by his brother, who is also a doctor, to attend the hospital for investigation. Has wife was contacted and met him at the hospital. Earlier electrocardiogram (ECG) done, showed no changes however Mr Paul was kept in for further investigation and to await blood test result. In the mean time Mr Paul was considered to have Acute Coronary Syndrome (ACS) and was administered the appropriate treatment. Even though ST-elevation or depression may not be evident on an ECG, the patient may be at a higher risk for acute MI and even death (Forselv and Vik-mo 2007).
As Mr Paul awaited his test result, he went into cardiac arrest in the presence of his wife and brother. The arrest team attend and he was resuscitated, his ECG now had large ST-elevations in leads V1 and aVR, and taken to the Catheterisation lab (Cath Lab) for further investigations. Coronary angiogram showed severe left anterior descending (LAD) and right coronary (RCA) stenosis corresponding to ECG changes (Andreas et al 2003). Percutaneous coronary angioplasty (PCI) was immediately undertaken to revascularised the area by inserting three drug eluting stents, restoring blood flow, relieving symptoms and alleviating the risk of death (NSF 2000).
CHD is a term given to conditions related to the inadequate flow of blood to the cardiac muscles, resulting from a gradual build up of atheroma (fatty deposits) in the coronary arteries (Conway and Fuet 2007) known as atherosclerosis. Atherosclerosis is the process whereby fat is deposited in the intima layer of arteries and builds up over time, impeding the flow of blood (Mitra et al 2004). When atherosclerosis occurs in the coronary arteries, the interruption in blood flow can cause an imbalance to the ratio of oxygen supply and demand to cardiac muscle, resulting in necrosis/ischemia and cell death (infarction) (Conway and Fuet 2007). Once the process of ischemia or infarction occurs, it may be manifested as radiating chest pain or chest discomfort, shortness of breath, nausea, palpitations and in some case collapse (Newson 2010 and BHF Angina) which is referred to as angina symptoms (BHF Angina). Angina symptoms can normally follow periods of physical exertion or emotional stress (De Backer et al 2003) among other things and may quickly be relieve with rest. Atherosclerosis forms plaque, which is described as a large localised area of fatty/lipid deposit encased in a thin, soft outer fibrous layer which can easily be damaged or suddenly rupture (Mitra et al 2004, Kucia and Horowitz (2010). Kucia and Horowitz (pp 163, 2010) also describe these plaques as “unstable or vulnerable plaques” which can easily rupture causing an acute MI or death. Acute MI occurs when the atheromas plaque ruptures causing haemorrhage within the artery, initiating the body’s natural clotting cascade in response. The resulting thrombus formation within the artery’s lumen soon occludes the blood flow (Leahy 2006). According to Thim et al (2008) the rupture of these atheromas plaque is the leading cause, approximately 75%, of acute MI and death.
Mr Paul had suffered from an acute MI as evident by ST-segment changes on his ECG. According to Thim et al (2008) the rise of the ST-segment would signify a complete occlusion of the coronary artery affected by the thrombus formation and would also indicate the ischaemic or infracted areas of the myocardium that is supplied by said artery, evident on a 12-lead ECG. The main aim at this point was focused on immediate revascularisation of the region to reduce or avoid further ischaemia or infarction of cardiac muscle. Zeitz and Quinn ( pp 194, 2010) suggested that the timeline of ischaemia to myocardial cell death begins within 15 minutes of the artery being occluded and by 3 hours 50% of the muscle supplied by the artery would die. Mr Paul was taken to the Catheterisation Lab to undergo primary Percutaneous Coronary Intervention (PCI) opposed to thrombolysis to re-perfuse the area.
Various studies and analysis over the years have compared both the mechanical and pharmacological options of reperfusion therapy for patients. In all studies, PCI has conclusively proven to be the treatment of choice. Comparative study done by Anderson et al (2003) documented PCI to be the ‘superior’ choice for reperfusion in ST elevation MI (STEMI) as opposed to thrombolysis. In early years thrombolysis had been the treatment of choice with great beneficial outcomes in reducing mortality; compared to doing nothing; (Ratcliffe and Pepper 2008) once administered in a timely manner (Zeitz & Quinn pp.198 2010, Ratcliffe & Pepper 2008). However thrombolytic therapy had its disadvantages. Randomised trial done by Grines et al (1993) and supported by Keeley (2003) and many others indicated that thrombolytic therapy had an increase complication of bleeding and due to the lack of ability to look into the arteries, it was difficult to assess whether the drug had its full effect in dissolving the clot. If the clot was not fully dissolved there was high risk of early restenosis or reinfarction. Ratcliffe and Pepper (2008) had identified that the increase in haemorrhaging was due to the non-selective nature of the thrombolytic drug on the body and not only on the culprit artery, due to this it was avoid in high risk groups like the elderly. Multiple studies had proven PCI to show a substantial reduction in bleeding complications, mortality rate and reinfarction compared to thrombolysis. This is due to the mechanical process of identifying the culprit lesion and directly administering a balloon and stent to successfully achieve full reperfursion (Ratcliffe and Pepper 2008). Assebury et al (2007), Keeley (2003), and Zijlstra (1999) have all examined the adverse effect of PCI on patient from 6 months onward and concluded that PCI had a significantly lower rate in mortality, infraction, haemorrhage complication or restenosis, giving it greater success both in the short term and long term over thromboysis (Ratcliffe and Pepper 2008). Thrombolysis even though not as prevalent, continues though to have its values in the treatment of acute MI. As indicated by Ratcliffe and Pepper (2008) and evident in the PRAGUE study (1999), thrombolysis remains of great importance in area where patients does not have readily available access to facilities providing PCI services or the patients themselves is not medically fit for transfer to a PCI facilities. Zeitz and Quinn (pp.198-199, 2010) has indicated that thrombolysis, if used would only be successful when administered within the first 3 hours of the onset of the event, but most effective within the first hour of symptoms. Due to PCI’s effectiveness the European Society of Cardiology (ESC) (Silber et al 2010) has recommended it as the primary choice of treatment for a patient with STEMI or cardiogenic shock in any facility providing a PCI service.
A coronary angiogram was done prior to the PCI procedure to evaluate the anatomy of the coronary artery and identify the culprit lesion (Day et al pp.181 2010, BHF Angina) causing the problem. It was identified that Mr Paul had two vessels coronary artery disease; he had a 75% long stenosis of the right coronary artery (RCA) and a 90% stenosis of the left anterior descending (LAD). The team decided to proceed to primary PCI angioplasty as recommended by the ESC for patients presenting with STEMI. ESC defined primary PCI as a means of revascularising the culprit lesion within 12 hours of the onset of the individual’s symptoms without prior use of a thrombolytic therapy. The main aim of primary PCI was to re-instate blood flow to the affected myocardium before permanent damage sets in and therefore all efforts should be made to avoid any delays to the procedure (Berger et al 1999, Harjai et al 2006). According to multiple randomised trials and the recommendations by ESC, supported by the NICE (2003) guidelines, it was agreed that patients presenting with; multiple diseased vessels, vessels of small calibre, long length lesions, diabetics and vein grafts among others; should have Drug-Eluting stents (DES) inserted during PCI procedure as opposed to Bare metal stents, in order to reduce the risk of early in stent restenosis. This restenosis is mainly caused by the body’s natural healing process which involves cell proliferation in damage areas causing the artery’s lumen to narrow once more (NICE 2003 and ESC 2010). DES are coated with drugs such as; corticosteroids to reduce inflammation, immunosuppressant also to reduce inflammation or paclitaxel to inhibit cell division; which are slowly released over a period of 1-2 years into the damaged artery walls (ESC 2010). Mr Paul had three DES, 2 to the RCA and 1 to the LAD, successfully inserted and return to the recovery area to start his rehabilitation process.
Mr Paul was rushed to the Catheterisation Lab with very little time for him or his wife to understand and accept what was taking place. Mr Paul was in shock following his resuscitation efforts and his wife very anxious and frightened after witnessing his cardiac arrest and resuscitation procedure, and then a quick decision was taken for primary PCI. Following a successful PCI, Mr Paul and his family started their rehabilitation process which included coping with the effects and changes that CHD may have on his everyday life. Brink et al (2008) cited Lazarus and Folkman’s (1984) definition of coping as “conscious cognitive and behavioural efforts of the individual to mange perceived discrepancies between situational demands and the capacity available to meet the demands”, which would include a change in thought processes or behaviour, in an effort to successfully deal with the situation. It was suggested by Brink et al (2008) that patients faced with CHD may either accept their disease and work positively to overcome it or they may simply, avoid the situation as a coping mechanism which may later result in depression. Mr Paul, very anxious from preceding events was eager and opened to information trying to make sense of the events, especially as he considered himself a healthy man. Skaggs et al (2007) described this behaviour as a method of self re-evaluation created by the sudden life changing event of the CHD, it forces Mr Paul to re think his life’s goals and purpose and how it will impact on his commitments, values and general sense of order. Both he and his wife questioned how this illness would affect him, his present lifestyle including his job, as the illness can lead to decrease physical and social activities or even have psychological effects (Skaggs et al (2007). His wife was very anxious to know what to expect for the future and how to deal with it in an attempt to support he husband through his recovery. Mahrer-Imhof et al (2006) had reported that partner are just as much affected by the acute events which may bring with it periods of depression, high levels of stress and anxiety. It was also stated that these partners may either adopt a negative coping strategy of an overprotective nature or provide positive support which will encourage the patient in their self care management. Support between couples during the illness has proven to have an important positive influence on recovery and can assist in defining coping strategies for future changes in relation to a now chronic cardiac disease (Mahrer-Imhof et al 2006 and Kristofferzon et al 2003).
The Paul’s found strength in each other however needed more guidance for their future. We as nurses had the duty of supporting the family through this stressful period. Davidson and Webster (2010) summarises that nurses need to be more empathetic to the needs of the patient and relatives, and not regard the event as just another procedure. They continued to say that this acute event can prove to be very devastating and if not adjusted to quickly and efficiently it can result in psychological, social or physical problems. Nurses need to encourage or facilitate self-management without appearing as though they are dictating to the patient; they work together with the patient and relatives as a partnership providing required knowledge and skills for the future (Davidson and Webster 2010). Although we would have liked to provide as much information possible so that the Paul’s could have made informed decisions about their future, great care was needed not to overload them with information. It was identified by Carroll (2005) that proving large amounts of information within a short period can result in the individual, feeling confused and overwhelmed especially if the information was given by a variety of people within the medical team. She also suggested that these individuals may not be as attentive or cognitively receptive at this early stage of their illness, therefore whatever information was given should be precise, clear and consistent by all staff involved. This was done with an aim of alleviating their anxiety for the immediate period but ensuring them that all required information and skills would be given over time prior to discharge. Mr Paul was taken to the Coronary Care unit to continue his recovery which would have included referral and assessment by the Rehabilitation nurse who would develop a care package relating to his identified needs.
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