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550 PA R T I V / Pathophysiology and Management of Heart Disease
VSD (ventricular septal defect) closure have been used for a brief Anxiety Related to Uncertainty
time as humanitarian device exemptions in high-risk patients with About PCI and Its Outcomes
presumed paradoxical embolism. 82 Patients are currently treated
with PFO devices through enrollment into clinical trials. At the time of admission, anxiety may occur related to unfamiliar
Paradoxical embolism is often invoked as a cause of stroke environment, unfamiliar treatment modality, and uncertainty of
when no other cause can be easily identified. Between 30% and outcome. Chest pain/discomfort related to myocardial ischemia if
40% of strokes in young patients (less than 55 years) have no the patient is in the acute phase of MI or unstable angina may
identifiable cause. The association between a PFO and stroke is contribute to increased anxiety causing increased pulse rate, respi-
stronger in younger patients. A review of observational studies ratory rate, and blood pressure. Patients may exhibit inability to
suggested a rate of recurrent events in patients undergoing percu- focus attention or signs of anxiety such as facial grimaces, hand
taneous closure of a PFO to be 0% to 4.9% compared with 3.8% clutched to chest, anger, and moaning.
to 12% in medically treated patients. Major complications occur
in 1.5% of patients undergoing percutaneous PFO closure. 82 Goals
Currently there is insufficient evidence to recommend closure To reduce anxiety and to provide the patient and family with suf-
of PFO in patients with a first stroke and PFO. 82,83 A tran- ficient information to allow appropriate decision making.
scatheter PFO closure may be considered in patients with recur-
rent cryptogenic stroke despite optimal medical therapy (Class IIb Interventions
recommendation:). 83 Provide concise explanations of all procedures and a calm, organ-
An incidental finding in some patients with migraine with aura ized delivery of care to alleviate anxiety. Perform history and phys-
was the presence of a PFO. A recent trial confirmed the high ical assessment of the patient under consideration for PCI. Obtain
prevalence of right-to-left shunt in patients with migraine with baseline ECG and laboratory data. Implement conventional meas-
aura, and supports further need for investigation. Larger trials are ures to relieve ischemic chest pain. Utilize skilled assessment to dis-
currently underway in the USA and Europe. 84 tinguish pain from anxiety (many indices of anxiety are also cues
to pain; anxiety also increases myocardial oxygen demand and may
contribute to ischemic pain). Assess patient/family level of under-
FUTURE DIRECTIONS FOR PCI standing about PCI and postprocedure care. (Risks, potential
complications, and alternative therapies are part of informed con-
Interventional cardiology has expanded to provide an array of sent and should be addressed by the cardiologist.) Provide patients
treatment options for CAD. DESs have significantly decreased with alternative means of coping with stress and anxiety, such as
restenosis and repeat revascularization but with the small but dev- music therapy, meditation, and relaxation techniques.
astating risk of very late stent thrombosis. New antiproliferative
drug coatings (zotarolimus and everolimus) for stents are coming Outcome Criteria
to market with promising results. 85,86 Outcomes include reduction of inappropriately elevated heart
Bioabsorbable stents and nonpolymer technology (polymers in rate, respiratory rate, and blood pressure; reduction in magnitude
some patients cause a hypersensitivity reaction) with potential to and numbers of verbal and nonverbal indices of anxiousness; pa-
reduce stent thrombosis are currently in clinical trials. The bioab- tient/family self-reports of questions answered; patient/family en-
sorbable stent is designed to mechanically reduce the coronary le- gages in decision making.
sion and provide support to the vessel until the vessel wall heals
and endothelialization is complete. Unlike the metallic stents, a Risk of Altered Myocardial Tissue
bioabsorbable stent is designed to be slowly metabolized by the Perfusion Causing Chest Pain/
body and completely absorbed over time. A preliminary clinical Discomfort Related to Myocardial
trial with bioabsorbable stents has shown clinical safety in patients Ischemia
with CAD. This platform of stents, if successful, has potential for
reducing stent thrombosis. 87 The risk of recurrent chest pain/discomfort is related to ongoing is-
Longitudinal databases need to be created to follow patient out- chemia and decreased myocardial tissue perfusion secondary to
comes more consistently and identify the risks and benefits of the abrupt closure, vascular spasm, loss of coronary artery side branch,
interventional procedures. A comprehensive database combined distal microembolization, or slow flow secondary to thrombus bur-
with continued research with interventional devices will help de- den in ACS. The patient may return to the floor with complaints
termine future recommendations. The percutaneous treatment of of continuing or recurring chest pain/discomfort, and may still
congenital abnormalities with noninvasive techniques will con- have residual chest pain related to MI, or procedural event.
tinue to evolve as outcome data become available. The cost for new
technology and research will continue to be a challenge. Goals
To prevent, detect, and treat chest pain/discomfort and inade-
quate myocardial tissue perfusion.
NURSING MANAGEMENT OF
PATIENTS UNDERGOING PCI Interventions
Obtain baseline vital signs, ECG, and place patient on teleme-
Nursing management focuses on identification and preparation of try monitor with lead that reflects the lesion treated. Compare
eligible patients before treatment and on prevention, detection, current ECG and ECG taken prior to procedure. Administer
and treatment of potential complications after interventional car- nitroglycerin as ordered. If patient had an MI or vascular
diology measures. spasm, or has a potential for distal microembolization, continue