Symptoms associated with coronary heart disease include chest pain, dyspnoea, palpitations and collapse (Delahaye, 1999).
VOL: 99, ISSUE: 27, PAGE NO: 46
Ian Jones, BSc, DPSN, PGCLT, RGN, is lecturer in cardiac nursing, School of Nursing, University of Salford, Manchester
Irene Goode, RGN, is senior sister, cardiology ward, Blackpool Victoria Hospital
Percutaneous transluminal coronary angioplasty (PTCA) has been found effective for relieving some of these symptoms (RITA-2 trial participants, 1997). The National Service Framework for Coronary Heart Disease (Department of Health, 2000) identified a need to double the number of these procedures carried out per year by 2010 to provide a service comparable with the rest of western Europe.
Patients with angina who continue to experience chest pains despite receiving drug therapy should have a coronary angiogram to assess the severity of the disease and the need for further intervention. During an angiogram, a cardiac catheter is introduced via an arterial sheath (a small tube inserted into the artery to provide arterial access). The cardiac catheter enters a main artery and is advanced towards the coronary arteries under X-ray guidance.
Once the cardiac catheter is in place, a radio opaque dye is injected into each of the coronary arteries and its flow rate is monitored. The severity of disease will dictate further treatment such as drug therapy, PTCA and coronary artery bypass grafting. The femoral artery is the most common site for coronary angiogram. The radial artery and occasionally the brachial artery can be used if femoral pulses are weak.
PTCA and coronary stent implantation
PTCA can be carried out either electively in a patient with stable angina, or as an emergency in high-risk patients with unstable angina. It can also be used in patients following an acute myocardial infarction to aid reperfusion of the myocardium instead of thrombolysis (dissolution of a blood clot by an enzyme such as streptokinase), or if thrombolysis has failed.
PTCA is the most popular treatment for patients who have one or two diseased coronary arteries (VanRiper and VanRiper, 1997). However, the rapid development of technology in this field has enabled cardiologists to use this procedure for some patients who have multivessel coronary artery disease.
A balloon-tipped cardiac catheter is introduced into the affected coronary artery (following an angiogram). The balloon is then inflated several times at the point of the narrowing of the coronary artery. This inflation compresses the atheromatous plaque, which causes the narrowing, so improving coronary blood flow.
To ensure the continued viability of the artery, a coronary stent (a cylindrical tube) may then be inserted at the plaque site. The stent is placed in the artery over the PTCA balloon and is then permanently embedded in the artery after the atheromatous plaque has been compressed (VanRiper and VanRiper, 1997). The catheter is then removed from the coronary artery, and subsequently from the body, via the arterial sheath.
Despite improvements in technique and the types of balloons used in PTCA, restenosis continued to be a problem (VanRiper and VanRiper, 1997). However, Fischman et al (1994) had found that this risk is reduced following the insertion of a coronary stent. Risks associated with PTCA range from vascular trauma to death, and these risks are increased in patients with unstable angina (Swanton, 1998).
Nursing care after PTCA and stent insertion
PTCA is a very complex procedure. Immediately after it, the patient is at risk of arrhythmia and myocardial infarction. The patient may be required to stay in bed for several hours and is completely dependent on nurses. The patient’s family may also require psychological support during this difficult period.
When the patient returns to the ward or department following the procedure, cardiac monitoring should be commenced to detect any arrhythmias, and the patient should be observed for signs of chest pain. A 12-lead electrocardiogram should be recorded to identify any changes which could indicate the presence of ischaemia or stent occlusion.
Observations of blood pressure (BP), heart rate, respirations and temperature should be recorded at a frequency recommended by local policy and according to the patient’s condition. Initially this usually involves the measurement of BP, pulse and respirations every 30 minutes, and temperature every four hours.
The limb that has been used for the procedure needs to be closely monitored for signs of poor arterial circulation. Colour and warmth of the limb should be checked. Pulses, distal to the puncture site, should be monitored at regular intervals to ensure adequate blood flow. For example, foot pulses should be checked if a femoral approach is used. The nurse will also need to observe the puncture site itself for signs of haematoma (Grossman and Baim, 2000) or bleeding.
Patients may experience pain from the puncture site and discomfort from their prolonged period of immobility, so analgesia may be required.
Radial artery approach
Nursing care following the PCTA and stent insertion can differ depending on the artery used for the procedure. If a radial artery is used, the arterial sheaths are removed in the cardiology laboratory and a specially designed radial compression system is applied. This remains in place for four hours. After this time, if there is no evidence of haemorrhage, a pressure bandage may be applied for 24 hours.
One advantage of using the radial artery is that the patient can be nursed in a semi-recumbent position immediately after the procedure and may get out of bed after four hours, so minimising the risks involved with remaining in bed. Also, patients who have an elective procedure can be managed as day cases.
Femoral artery approach
The femoral artery is a much deeper artery and haemostasis is more difficult to achieve. If a femoral artery has been used, the patient will still have a femoral artery sheath, and may also have a venous sheath in place when returning to the ward. These sheaths cannot be removed until the anticoagulant effects of heparin given during the procedure have dissipated. This may take up to six hours (Lilley and Aucker, 2001) and clotting times will need to be monitored throughout this time. The patient will need to remain in bed, lying flat, during this period.
During PTCA, the patient will have received an intravenous bolus dose of a glycoprotein IIb/IIIa (GPIIb /IIIa) inhibitor followed by a maintenance infusion over 12 hours to reduce the risk of intracoronary thrombus formation. (When the radial approach is used, the GPIIb /IIIa inhibitor is usually only prescribed to patients with unstable angina).
GPIIb/IIIa inhibitors work by inhibiting platelet activity at the injured atheromatous plaque by blocking the GPIIb/IIIa receptors at the platelet surface membrane.
These drugs are very aggressive antithrombotic agents that can cause severe bleeding. All potential bleeding sites will need to be closely monitored, and the infusion itself will need to be managed correctly.
Once the activated clotting time is within an acceptable range, the arterial sheath may be removed by a doctor or nurse who has received specific training in this procedure. When the arterial sheath is removed from the artery, direct pressure is applied until haemostasis is achieved. Pressure can be applied manually or by the application of a compression device designed for this purpose, for example, a Femstop. After removal of the sheath, the nurse must carry out regular observations of blood pressure, pulse, temperature and circulation to the affected limb.
The patient should lie flat for two hours following sheath removal (though this time limit may vary according to local policy and consultant preference) as movement could dislodge any newly formed clots and cause bleeding (Botti et al, 2001).
The removal of the sheath and subsequent pressure on the patient’s groin can activate the parasympathetic nervous system, resulting in a drop in the patient’s heart rate and blood pressure. Therefore, 500mcg of atropine sulphate is needed if these symptoms occur.
The patient may be discharged home the day after the procedure if he or she has had an uneventful recovery and has a platelet count of between 150x109/litre and 170x109/litre.
Discharge and ongoing care following PTCA - The patient and his or her family should receive written advice on what to do following a PTCA and they should also be provided with the telephone number of the cardiology ward so that they have a point of contact.
Nurses should ensure the patient understands the risks associated with coronary heart disease (British Cardiac Society et al, 1998) and strategies to reduce them. The patient should also know about any prescribed medicines.
The patient requires a combination of 300mg of aspirin and 75mg of clopidogrel for 28 days, which has an antithrombotic effect. This is in addition to any other cardiac drugs that he or she may be prescribed. After 28 days, clopidogrel can be discontinued and the aspirin dose reduced to 75mg daily. The patient will then be followed up in the outpatients department.
All patients should be offered some form of cardiac rehabilitation following PTCA and any other percutaneous coronary intervention (DoH, 2000). However, there are very few studies that have investigated the rehabilitation needs of these patients, so it is difficult to say whether the positive results obtained with patients following a myocardial infarction can be generalised to include patients who have had a PCI.
Percutaneous coronary interventions are a reasonably safe and effective treatment for patients experiencing the symptoms of coronary heart disease. It is more affordable, requires fewer resources and is less traumatic than coronary artery surgery.
Technological advances and the increased efficacy of drug therapy have meant the outcomes for patients have improved. Also, for some elective patients at low risk, this type of procedure is now available as a day case.
The use of PCI will increase, leading to a dramatic rise in pressure on regional services. This may be tempered by the use of more day-case facilities. However, it could also mean this procedure could soon be carried out for patients at low risk in designated general hospitals, so ensuring that regional services are developed to cater for the needs of the patients at a higher risk.
The British Association for Nursing in Cardiac Care (BANCC) provides a forum for communication, professional development and national representation for all nurses in Britain who are involved in the care of cardiac patients. For more information, e-mail: email@example.com, tel: 020 7383 3887, fax: 020 7383 5961, or write to: BANCC, c/o British Cardiac Society, 9 Fitzroy Square, London, W1T 5HW