Page 546 - Cardiac Nursing

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522 PA R T I V / Pathophysiology and Management of Heart Disease
4
for patients with no immediate access to a catheter-based proce- PCI (Class I, level of evidence: B). If the patient presenting with
dure or a catheterization laboratory. UA/NSTEMI has a subsequent troponin that is positive for MI,
the patient should be considered for an invasive strategy of revas-
Coronary Angiography for STEMI cularization (Class I, level of evidence: A). If an invasive strategy is
2
According to the ACC/AHA STEMI guidelines, diagnostic coro- undertaken in the patient presenting with UA/NSTEMI, PCI is
nary angiography should be performed: recommended for one to two vessel CAD with or without signifi-
cant proximal left anterior descending disease but with a large area
1. In candidates for primary or rescue PCI. (Class I, level of evi-
of viable myocardium (Class I, level of evidence: B). PCI is rec-
dence: A)
ommended in this patient population with multivessel CAD if
2. In patients with cardiogenic shock who are candidates for
suitable coronary anatomy is present with normal LV function and
revascularization. (Class I, level of evidence: A) 4
the absence of diabetes mellitus. (Class I, level of evidence: A).
3. In candidates for surgical repair of ventricular septal rupture or
severe mitral regurgitation. (Class I, level of evidence: B)
4. In patients with persistent hemodynamic and/or electrical in- Early, Late, and Long-Term Care of
stability. (Class I, level of evidence: C) Patients With ACS
Early Hospital Care
Primary PCIs for STEMI
2
The ACC/AHA STEMI guidelines recommend that, if immedi- Patients with definite or probable UA/NSTEMI who are hemody-
namically stable should be admitted to the inpatient unit for bed
ately available, primary PCI should be performed in patients with
rest with ongoing monitoring of cardiac rhythm and careful obser-
STEMI (including true posterior MI) or MI with new or pre-
vation for recurrent ischemic symptoms. Supplemental oxygen
sumably new LBBB who can undergo PCI of the infarct artery
should be administered to all patients (UA/NSTEMI and STEMI)
within 12 hours of symptom onset, if performed in a timely fash-
with arterial oxygen desaturation less than 90% (Class IIa, level of
ion (balloon inflation within 90 minutes of presentation) by per- 2,4
evidence: C). High-risk UA/NSTEMI patients with ongoing
sons skilled in the procedure. The procedure should be supported
chest discomfort, those with hemodynamic instability, and STEMI
by experienced personnel in an appropriate laboratory environ-
patients who are unstable after initial reperfusion should be admit-
ment. (Class I, level of evidence: A) 4
2
Specific considerations for primary PCI are : ted to a cardiac care unit (CCU) for 24 hours of observation.
After admission, optimal management for the UA/NSTEMI pa-
1. Primary PCI should be performed as quickly as possible with tient has dual goals: relieve ischemia and prevent serious adverse out-
the goal of a medical contact-to-balloon or door-to-balloon in- comes. These goals are accomplished through antiischemic drug
terval of within 90 minutes. (Class I, level of evidence: B) therapy, anticoagulation, and ongoing risk stratification to determine
2. If symptom duration is within 3 hours and the expected door- the appropriate use of invasive reperfusion strategies. Assessment of
to-balloon time minus the expected time is within 1 hour, pri- LV function by echocardiogram is recommended for immediate and
mary PCI is generally preferred. (Class I, level of evidence: B). ongoing patient management. If a patient with UA/NSTEMI has re-
However, if symptom onset is greater than 1 hour, fibrinolytic current symptoms or there is ongoing evidence of ischemia after ini-
therapy (fibrin-specific agents) is generally preferred. (Class I, tiation of medical therapy, coronary angiography is indicated. 4
level of evidence: B)
3. If symptom duration is greater than 3 hours, primary PCI is Late Hospital Care
generally preferred and should be performed with a medical In preparation for discharge from the hospital, it is important to
contact-to-balloon or door-to-balloon interval as short as possi- use two patient-centered goals to guide management: (1) Prepare
ble and a goal within 90 minutes. (Class I, level of evidence: B) the patient and his/her family as much as possible to resume their
4. Primary PCI should be performed for patients younger than normal activities of daily living; and (2) utilize this acute event as
75 years with ST elevation or LBBB who develop shock within an opportunity to reevaluate the patient and family lifestyle, and
36 hours of MI and are suitable for revascularization that can if warranted, institute aggressive risk factor modification. There is
be performed within 18 hours of shock unless further support little time to educate patients as to lifestyle changes necessary for
is futile because of patient’s wishes or contraindications/unsuit- risk factor modification during acute hospitalization. Patients who
ability for further invasive care. (Class I, level of evidence: A) have undergone successful PCI are typically discharged the fol-
5. Primary PCI should be performed in patients with severe con- lowing day. Uncomplicated CABG length of stay is typically 4 to
gestive heart failure (CHF) and/or pulmonary edema (Killip 7 days. Patients who have undergone noninvasive testing usually
class 3) and onset of symptoms within 12 hours. The medical are discharged in 1 to 2 days. 4
contact-to-balloon or door-to-balloon time should be as short A further barrier to education is that frequently patients are un-
as possible. (Class I, level of evidence: B) der emotional stress due to the crisis, which hinders their absorption
of information necessary for change. However, it is important to use
Reperfusion Strategies for this time when the event is fresh in the patient’s and family’s minds
UA/NSTEMI to introduce the concept of risk factor modification. Written mate-
rials given to the patient during the acute phase are helpful and can
In the patient with UA/NSTEMI, the decision for initial conser- be reviewed on an outpatient basis during subsequent clinic visits. 4
vative versus initial invasive strategies is evaluated. An early inva- At discharge, detailed written and verbal instruction for the post-
sive strategy with diagnostic angiography and intent to perform ACS patient should include education on medications, diet, exercise,
4
revascularization is indicated in patients with UA/NSTEMI if the and smoking cessation if appropriate. Pharmacotherapies started in
anginal symptoms are refractory and/or hemodynamic or electrical the inpatient setting, such as oral antiischemic, antiplatelet, and an-
instability are present unless there are known contraindications to tihypertensive medications are continued after discharge. Referral to