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652 PA R T I V / Pathophysiology and Management of Heart Disease
and secondary prevention of SCD. The greatest benefits are seen ger of recurrent VF. The patient will need aggressive correction
2
in those patients with multivessel disease and decreased left ven- for acute ischemia, and possibly hemodynamic support. The
7
tricular function. Surgery is indicated for those patients with patient will require continuous ECG monitoring until an ICD
conventional criteria (i.e., uncontrolled angina, or left main or is placed. An intravenous line is left in place for immediate ve-
multiple-vessel CHD) or with specific criteria for antiarrhythmic nous access. Time of hospital discharge is related to the cause of
surgery (i.e., discrete ventricular aneurysms or inducible, poten- the cardiac arrest, the type of diagnostic studies required, and
tially lethal, arrhythmias not controlled by medication). 7 the eventual therapies selected by the patient and family. If the
Because of the complexity of SCD mechanisms, treatment is patient will be receiving an ICD, the implications of an ICD
geared at delaying further progression of CHD in those patients must be discussed thoroughly, and further educational needs
with known cardiac disease. Long-term treatments include pre- should be evaluated.
venting thrombus formation and plaque rupture, preventing ar-
rhythmias, stabilizing autonomic balance, improving pump func- Emotional Support
tion, and correcting ischemia. 63 Emotional support given to patients and their families affects
their quality of life. Patients and their families experience fear of
Antiarrhythmic Therapy. The uses of antiarrhythmic drugs recurrent cardiac arrest. Fear is exacerbated further at the time of
are valuable in the immediate period after resuscitation. Intra- transfer out of the cardiac care unit to a telemetry unit, and fur-
venous amiodarone and -blockers are the most effective antiar- ther still at the time of discharge from the hospital. Fear of trans-
rhythmics in the early postarrest phase. However, unlike - ferring out of the ICU is known as “transfer anxiety,” and can
65
blockers and ACE inhibitors, certain antiarrhythmics, particularly lead to physical complaints and symptoms of anxiey. The effect
class I drugs, have been associated with increased mortality rates that SCD survival has on quality of life and anxiety is not well
7
despite suppressing ventricular ectopy. Increased mortality was defined. Some studies report an increase in stress, anxiety, fear,
seen in the Cardiac Arrhythmia Suppression Trial (CAST) study and memory difficulties associated with cardiac arrest. 66,67 An-
with the use of encainide and flecainide in the patient after acute other study found that emotional distress is similar between car-
MI. CAST II showed increased mortality rates in this same group diac patients, whether patients have had a cardiac arrest or not. 68
60
with the use of moricizine. In contrast, several trials have shown Another study has shown a decrease in anxiety after 6 months to
a beneficial effect on mortality with the use of amiodarone, a class 1-year postarrest. 69 However, a consistent theme is that interven-
III drug, in patients after MI. Properties of amiodarone that may tions aimed at educating the patient and family about their dis-
help reduce mortality after MI are coronary vasodilatation and ease process and ICD decrease anxiety. Cardiac nurses play a ma-
heart rate reduction, which serve to reduce ischemia. 32,51 jor therapeutic role in the management of SCA survivors and
their families.
Implantable Cardioverter Defibrillator. ICD therapy has
emerged as the therapy of choice for secondary prevention of Patient and Family Education
SCD in patients with pre-existing heart disease. Three large mul- Information regarding the impact of specific education interven-
ticenter trials compared ICD therapy versus antiarrhythmic drug tions for SCA survivors is limited, and is mostly focused on the
therapy in survivors of SCA and demonstrated ICD therapy was patient with an ICD. Cardiac arrest survivors have decreased abil-
superior to best antiarrhythmic drug therapy (Display 27-7). Re- ity to concentrate when compared to noncardiac arrest patients
cent years have produced dramatic technological improvements in with heart disease. 68 Hypoxia during cardiac arrest leads to both
ICDs. Devices are smaller, implantation has been greatly simpli- diffuse brain injury and to injury of focal memory regions of the
fied, and therapy options are greater, which help to reduce the brain. Studies have documented persistent memory impairment
number of unnecessary shocks. Treatment of life-threatening ven- in the VF survivor. 70,71 Knowing that memory is compromised,
tricular arrhythmias will most likely remain the domain of the patient education may be difficult and family members will need
ICD in the future. Antiarrhythmic drugs and catheter ablation to be involved early in the process to help with ongoing patient
will continue to complement the ICD, decreasing the frequency education and recovery. When Dougherty et al. 72 interviewed
of ICD discharges and, hopefully, improving quality of life. (See partners of SCA survivors who received an ICD during the first
Chapter 28 for additional ICD information.) year of recovery, the partners conveyed eight major concerns: (1)
physical care, (2) emotional care, (3) memory, (4), ICD, (5)
Nursing Management money, (6) uncertain future, (7) health care providers, and (8)
of SCD Survivors family. Nurses providing care to SCA survivors and their families
should keep these concerns in mind when providing education
Survivors of cardiac arrest and their families have physiological, and support.
psychological, and educational needs that differ from those of the All of this information is overwhelming and almost impos-
patient with acute myocardial ischemia and infarction. However, sible for patients and their families to remember without
if the underlying cause of SCA includes ischemia, management of teaching aids such as booklets, charts, videotapes, and pictures.
the patient with ischemia and infarction should be included in Family members may also feel particularly overwhelmed by the
nursing care. thought of recurring episodes. Support groups have been
shown to provide a means for seeking educational information,
Physiological Nursing Management and developing camaraderie with others to assist in coping
After cardiac arrest, patients are admitted to the cardiac care with anxieties. 73,74 Nurses often coordinate ICD support
unit. A complete evaluation for heart disease is obtained on all groups, providing an essential role in the education and sup-
patients, and is used as the basis of treatment goals. Occasion- port of patients and their families as they ask questions and
ally, patients present with an “arrhythmia storm” and are in dan- discuss issues.