Page 547 - Cardiac Nursing

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C HAPTER 22 / Acute Coronary Syndromes 523
cardiac rehabilitation (if ordered by the provider) and scheduling of life-threatening arrhythmias, driving should not resume for 2 to
a timely outpatient appointment should be done prior to discharge 3weeks after discharge from the hospital or after an outpatient
from the hospital. Scheduling of a timely outpatient appointment visit with a cardiologist or cardiology nurse practitioner.
should occur before discharge as well. Minimizing the risk of recur-
rent cardiovascular events requires ongoing patient compliance with
prescribed therapies and recommended lifestyle modification. PHARMACOLOGICAL
Patient-specific risk for postdischarge mortality after ACS can be MANAGEMENT OF ACS
predicted on the basis of clinical information and the ECG. The
Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Sup-
pression Using Integrilin Therapy (PURSUIT), TIMI, and Global Optimal medical management includes a regimen that provides res-
Registry of Acute Coronary Events (GRACE) risk models are help- olution of ischemia, relief from discomfort, and prevention of adverse
ful in completing this risk assessment and have been validated for pa- outcomes. Medical management for ACS includes antiischemic
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tients experiencing UA/NSTEMI. 4,67–71 agents, analgesia, ACEI, antiplatelet, and anticoagulants therapies.
Long-Term Medical Therapy Antiischemic Therapies
A team of health care providers in the outpatient setting should work Nitrates
with patients and their families to aggressively manage CAD risk fac-
tors. Section V, Health Promotion and Disease Prevention, details Actions/Indications. NTG promotes vasodilatation of vas-
CAD risk factor modification strategies. Cardiac rehabilitation per- cular smooth muscle in the peripheral and coronary arteries. Re-
sonnel are particularly instrumental in patient education due to fre- duction in ischemia and angina results from decrease in systemic
quent patient contact. This recommendation is inclusive of patients vascular resistance (afterload) and decrease in myocardial oxygen
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who have undergone primary revascularization. Patient education demand. NTG promotes dilatation of coronary arteries and col-
should be focused on detailed information regarding specific targets lateral blood flow to improve coronary blood flow into ischemic
for LDL-C and high density lipoprotein cholesterol (HDL-C), 4,5 regions of the myocardium. NTG also causes dilatation to a lesser
blood pressure (BP), 73 diabetes mellitus, diet and weight manage- extent of veins and capillaries which decreases venous return and
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ment, physical activity, and tobacco cessation. Once informed, reduces preload. 4,81 NTG is indicated for ischemic discomfort of
patients are in a better position to take responsibility for the man- acute and chronic stable angina.
agement of their coronary risk factors.
All patients with elevated systolic or diastolic BPs should be ed- Contraindications/Adverse Reactions. NTG is con-
ucated and attempt to achieve BPs less than 140 mm Hg systolic traindicated in patients who take phosphodiestererase inhibitors
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and 80 mm Hg diastolic. Patients with diabetes, chronic renal for erectile dysfunction (sildenafil citrate within previous 24 hours
failure, and/or LV dysfunction should achieve a lower range. 3,73 or tadalafil within 48 hours) because of increased and prolonged
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Every means available should be utilized in assisting patients to NTG-mediated vasodilatation with these medications.
be successful at smoking cessation. Tobacco cessation programs, Nitrates can cause a sudden decrease in BP and should be
health provider counseling, and the use of pharmacologic agents avoided in patients with an initial BP less than 90 mm Hg, or
are recommended to maximize the potential for success. 74,75 30 mm Hg or more below their baseline, and/or with marked
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In patients with diabetes and ACS, normoglycemia (a blood bradycardia or tachycardia. Headache is a common side effect
glucose level in the range of 80 to 110 mg/dL) is the glycemic of nitrate therapy.
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goal. For diabetics with ACS, lipid-lowering agents are important Administration. Sublingual NTG 0.4 mg tablets should be
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to achieve target LDL-C levels of 70 mg/dL or less. Patients who used every 5 minutes until symptoms are relieved or three doses are
are overweight should be instructed in diets for weight loss and taken. Patients who continue to have angina not relieved by sublin-
the important role exercise plays in maintaining ideal body mass gual NTG while in the hospital can be started on an IV infusion.
index. Exercise also plays a pivotal role in decreasing insulin re- IV NTG is indicated for ongoing ischemic discomfort, control of
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sistance and improving overall well-being. 77,78 hypertension, or management of pulmonary edema. Topical or
Daily walking can be encouraged immediately for all patients. oral nitrates can be used as an alternative for patients with stable
Patients with residual ischemia should be cautioned to rest angina symptoms and used to transition from an NTG infusion.
should any symptoms occur and to notify their health care Nursing Implications. Use of all forms of NTG in ACS re-
provider of symptom recurrence. Cardiac rehabilitation programs quires monitoring of hemodynamic status and response to ther-
have demonstrated effectiveness in improving exercise tolerance apy. Tolerance to the therapeutic effects of nitrates is dose- and
without increasing cardiovascular complications. The exercise duration dependent. After 24 hours of continuous therapy with
program and the support to adhere to prescribed management all NTG medications, titration should be attempted with a regi-
regimes improves both blood lipid and blood glucose levels. 79 men that includes a nitrate-free interval. Abrupt cessation of IV
Comprehensive cardiac rehabilitation involves individualized risk NTG has caused recurrent ischemia. Therefore, a decreasing titra-
factor assessment, education, and modification, in addition to tion of dose is recommended. 4
prescribed monitored exercise. Cardiac rehabilitation programs
can contribute to return to work. 80 -Adrenergic Blockers
In patients who are stable at discharge from the hospital with-
out complications, sexual activity with the usual partner can be re- Action/Indications. -Blockers act by competitively block-
sumed within 7 to 10 days. If otherwise in compliance with state ing the effects of catecholamines on cell membrane -receptors. 1 -
laws, the patient can begin driving a car one week after discharge Adrenergic receptors located in the myocardium inhibit cate-
from the hospital. In patients with complicated MI or evidence of cholamine activity at receptor sites and reduce myocardial