Treatments

Ongoing technological advances in the treatment of cardiovascular disorders help patients live longer with a better quality of life than ever before. These treatments include drug therapy, surgery, balloon catheter treatments, and emergency treatment for heart rhythm disturbances.

Cardiovascular disorders: Drug therapy

Drugs are critical to the treatment of many cardiovascular disorders. Drugs that may be used to treat cardiovascular disorders include:

  • adrenergics
  • antianginals
  • antiarrhythmics
  • antihypertensives
  • antilipemics
  • antiplatelet agents
  • diuretics
  • inotropic agents
  • thrombolytics.

Cardiovascular disorders: Surgery

Despite the drama of successful single- and multiple-organ transplants, improved immunosuppressants, and advanced ventricular assist devices (VADs), far more patients undergo conventional surgeries such as coronary artery bypass grafting (CABG). However, for this and other cardiovascular surgeries, the patient initially recovers in the cardiac intensive care unit (ICU). The role of the medical-surgical nurse is to promote recovery and help smooth the transition from hospital to home using appropriate patient-teaching techniques.

Cardiovascular disorders: CABG

CABG circumvents an occluded coronary artery with an autogenous graft (usually a segment of the saphenous vein or internal mammary artery), thereby restoring blood flow to the myocardium. CABG techniques vary according to the patient’s condition and the number of arteries needing bypass. The most common procedure, aortocoronary bypass, involves suturing one end of the autogenous graft to the ascending aorta and the other end to a coronary artery distal to the occlusion. (See Bypassing coronary occlusions.)

 

Cardiovascular disorders

 

CABG caveat

Focus Topic: Cardiovascular disorders

More than 400,000 Americans (most of them male) undergo CABG each year, making it one of the most common cardiac surgeries. Prime candidates include patients with severe angina from atherosclerosis and others with CAD who have a high risk of MI. Successful CABG can relieve anginal pain, improve cardiac function and, possibly, enhance the patient’s quality of life.

Even so, although the surgery relieves pain in about 90% of patients, its long-term effectiveness is unclear. Such problems as graft closure and development of atherosclerosis in other coronary arteries may make repeat surgery or other interventions necessary. (See EECP: Treatment for severe angina.) Also, because CABG doesn’t resolve the underlying disease associated with arterial blockage, CABG may not reduce the risk of MI recurrence.

 

Cardiovascular disorders

 

Patient preparation

Take the following steps to help prepare the patient for surgery and support him after surgery:

  • Reinforce the surgeon’s explanation of the surgery for the patient. Also, explain the complex equipment and procedures used in the ICU or postanesthesia care unit (PACU).
  • Restrict food and fluids after midnight and provide a sedative, if ordered.
  • On the morning of surgery, also provide a sedative, as ordered, to help the patient relax.
  • Teach the patient to cough and deep breathe with an incentive spirometer.
  • Explain the use of pain medications and nonpharmacologic pain control methods that will be used after surgery.

Monitoring and aftercare

The patient requiring CABG will be monitored in the cardiac ICU after surgery. He’ll be transferred to the medical- surgical unit for further postoperative care when his condition is stable. After transfer to the medical-surgical unit:

  • Provide analgesia or encourage the use of patient-controlled analgesia (PCA), if appropriate.
  • Monitor for postoperative complications, such as stroke, pulmonary embolism, pneumonia, and impaired renal perfusion.
  • Gradually allow the patient to increase activities, as ordered.
  • Monitor incision sites for signs of infection or drainage.
  • Provide support to the patient and his family to help them cope with recovery and lifestyle changes.
  • Encourage the patient to do his coughing and deep-breathing exercises.
  • Apply compression devices to the patient’s lower extremities to help prevent the formation of deep vein thrombosis.

Home care instructions

Instruct the patient to:

  • watch for and immediately notify the practitioner of any signs or symptoms of infection (redness, swelling, or drainage from the leg or chest incisions; fever; or sore throat) or possible arterial reocclusion (angina, dizziness, dyspnea, rapid or irregular pulse, or prolonged recovery time from exercise)
  • call the practitioner in the case of weight gain greater than 3 lb (1.4 kg) in 1 week
  • follow his prescribed diet, especially sodium and cholesterol restrictions
  • maintain a balance between activity and rest by trying to sleep at least 8 hours each night, scheduling a short rest period each afternoon, and resting frequently when engaging in tiring physical activity
  • follow his exercise program or cardiac rehabilitation if prescribed
  • follow lifestyle modifications (no smoking, improved diet, and regular exercise) to reduce atherosclerotic progression
  • contact a local chapter of the Mended Hearts Club and the AHA for information and support
  • make sure he understands the dose, frequency of administration, and possible adverse effects of prescribed medications
  • avoid lifting objects that weigh more than 10 lb (4.5 kg) for the next 4 to 6 weeks
  • perform coughing and deep-breathing exercises, splint the incision with a pillow to reduce pain while doing these exercises, and use an incentive spirometer to prevent pulmonary complications.

Cardiovascular disorders: MIDCAB

Until recently, cardiac surgery required stopping the heart and using cardiopulmonary bypass to oxygenate and circulate blood. Now, for certain patients, minimally invasive direct coronary artery bypass (MIDCAB) can be performed on a pumping heart through a small thoracotomy incision. The patient may receive only right lung ventilation along with drugs such as beta- adrenergic blockers to slow the heart rate and reduce heart movement during surgery.

It accentuates the positive

Focus Topic: Cardiovascular disorders

Advantages of MIDCAB include shorter hospital stays, use of shorter-acting anesthetic agents, fewer postoperative complications, earlier extubation, reduced cost, smaller incisions, and earlier return to work. Patients eligible for MIDCAB include those with proximal left anterior descending lesions and some lesions of the right coronary and circumflex arteries.

Patient preparation

Before the procedure, take these steps:

  • Review the procedure with the patient, and answer his questions. Tell him that he’ll be extubated in the operating room or within 2 to 4 hours after surgery.
  • Teach the patient to cough and breathe deeply through use of an incentive spirometer.
  • Explain the use of pain medications after surgery as well as nonpharmacologic methods to control pain.
  • Let the patient know that he should be able to walk with assistance the first postoperative day and be discharged within 48 hours.

Monitoring and aftercare

The patient undergoing MIDCAB may be monitored in a cardiac ICU or step-down unit after surgery. He’ll be transferred to the medical-surgical unit for further postoperative care when his condition is stable. After transfer to the medical-surgical unit:

  • Provide analgesia or encourage the use of PCA if appropriate.
  • Monitor for postoperative complications, such as stroke, pulmonary embolism, pneumonia, and impaired renal perfusion.
  • Gradually allow the patient to increase activities as ordered.
  • Monitor the incision site for signs of infection or drainage. Depending on the procedure, the patient will have one to three small chest incisions.
  • Provide support to the patient and his family to help them cope with recovery and lifestyle changes.

Home care instructions

Before discharge, instruct the patient to:

  • continue with the progressive exercise started in the hospital
  • perform coughing and deep-breathing exercises, splint the incision with a pillow to reduce pain while doing these exercises, and use the incentive spirometer to reduce pulmonary complications
  • avoid lifting objects that weigh more than 10 lb (4.5 kg) for the next 4 to 6 weeks
  • wait 2 to 4 weeks before resuming sexual activity
  • check the incision site daily and immediately notify the practitioner of any signs or symptoms of infection (redness, foul- smelling drainage, or swelling) or possible graft occlusion (slow, rapid, or irregular pulse; angina; dizziness; or dyspnea)
  • perform any necessary incisional care
  • follow lifestyle modifications
  • take medications, as prescribed, and report adverse effects to the practitioner
  • consider participation in a cardiac rehabilitation program.

Cardiovascular disorders: Port access cardiac surgery

Port access cardiac surgery is another minimally invasive surgical technique. In this procedure, the surgeon performs coronary bypass grafting through small incisions with the aid of videoscopes. This procedure requires a shorter hospital stay, promoting faster recovery. Also, because the heart can be turned, port access allows the surgeon to perform more bypass grafting.

 

Picture using ports

Focus Topic: Cardiovascular disorders

This procedure uses a small anterior thoracotomy and several small “port” chest incisions. The surgeon inserts a thorascope through the ports to view the heart. As with traditional cardiac surgery, the surgeon creates a cardiopulmonary bypass. However, the procedure uses the femoral artery and vein cannulation, reducing the risk of atrial fibrillation associated with atrial cannulation. Also, rather than cross-clamping the aorta — increasing the risk of atherosclerotic emboli — port access surgery internally occludes the aorta with an inflated endo aortic balloon, which prevents air and thrombotic emboli during bypass.

Patient preparation

Before the procedure, take these steps:

  • Teach the patient to perform coughing and deep-breathing exercises and how to use an incentive spirometer.
  • Tell the patient that he’ll be assisted to a sitting position and allowed to ambulate as early as the first postoperative evening.

Monitoring and aftercare

The patient undergoing port access cardiac surgery will require nursing care similar to MIDCAB. After transfer to the medical-surgical unit, follow these steps:

  • Provide analgesia or encourage the use of PCA, if appropriate.
  • Monitor for postoperative complications, such as stroke, femoral artery dissection, and femoral artery or vein occlusion.
  • Gradually allow the patient to increase activities, as ordered.
  • Monitor the incision site for signs of infection, drainage, or bleeding.
  • Provide support to the patient and his family to help them cope with recovery and lifestyle changes.

Home care instructions

Before discharge, instruct the patient to:

  • continue with the progressive exercise started in the hospital
  • perform coughing and deep-breathing exercises, splint the incision with a pillow to reduce pain while doing these exercises, and use the incentive spirometer to reduce pulmonary complications
  • avoid lifting objects that weigh more than 10 lb (4.5 kg) for the next 4 to 6 weeks
  • wait 2 to 4 weeks before resuming sexual activity
  • check the incision site daily and immediately notify the practitioner of any signs and symptoms of infection (redness, foul-smelling drainage, or swelling) or possible graft occlusion (slow, rapid, or irregular pulse; angina; dizziness; or dyspnea)
  • check for bleeding or hematoma at the femoral insertion sites
  • follow lifestyle modifications
  •  take medications as prescribed and report adverse reactions to the practitioner
  • comply with the laboratory schedule for monitoring International Normalized Ratio (INR) if the patient is receiving warfarin (Coumadin)
  • consider participation in a cardiac rehabilitation program.

Vascular repair

Vascular repair may be used to treat:

  • vessels damaged by arteriosclerotic or thromboembolic disorders (such as aortic aneurysm or arterial occlusive disease), trauma, infections, or congenital defects
  • vascular obstructions that severely compromise circulation
  • vascular disease that doesn’t respond to drug therapy or nonsurgical treatments such as balloon catheterization
  • life-threatening dissecting or ruptured aortic aneurysms
  • limb-threatening acute arterial occlusion.

Vascular repair includes aneurysm resection, endovascular repair, grafting, embolectomy, vena caval filtering, endarterectomy, and vein stripping. The specific surgery used depends on the type, location, and extent of vascular occlusion or damage. (See Understanding types of vascular repair.)

In all vascular surgeries, there’s a potential for vessel trauma, emboli, hemorrhage, infection, and other complications. Grafting carries added risks because the graft may occlude, narrow, dilate, or rupture.

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Understanding types of vascular repair

Focus Topic: Cardiovascular disorders

Cardiovascular disorders

 

Patient preparation

Vascular surgery may be performed as an emergency procedure or a scheduled event. Take the following steps before surgery:

  • Reinforce all explanations about surgery and recovery.
  • Perform and document a vascular assessment, focusing on the area that requires treatment.
  • If the patient is awaiting surgery for aortic aneurysm repair, be on guard for signs and symptoms of acute dissection or rupture. Note especially sudden severe pain in the chest, abdomen, or lower back; severe weakness; diaphoresis; tachycardia; or a precipitous drop in blood pressure or loss of pulses in the lower extremities. If any of these conditions occur, call the surgeon immediately; he may need to perform life-saving emergency surgery.

Monitoring and aftercare

After surgery, the patient will be cared for in the ICU. He’ll be transferred to the medical-surgical unit for further postoperative care when his condition is stable. After transfer to the medical-surgical unit, take these steps:

  • Frequently assess peripheral pulses, using Doppler ultrasonography if palpation proves difficult.
  • Assess extremities bilaterally for muscle strength and movement, color, temperature, and capillary refill time.
  • Provide analgesia, or encourage the use of PCA, if appropriate.
  • Gradually allow the patient to increase activities as ordered.
  • Monitor the incision site for signs of infection or drainage.
  • Monitor for complications, such as infection, bleeding, and vessel occlusion.
  • Provide support to the patient and his family to help them cope with recovery and lifestyle changes.
  • Maintain venous compression devices to the patient’s lower extremities as appropriate to help prevent deep vein thrombosis.

Home care instructions

Instruct the patient to:

  • check his pulse (or have a family member do it) in the affected extremity before rising from bed each morning and to notify the practitioner if he can’t palpate his pulse or he develops coldness, pallor, numbness, tingling, pain, or swelling in the extremities
  • continue with the progressive exercise started in the hospital
  • perform coughing and deep-breathing exercises, splint the incision with a pillow to reduce pain while doing these exercises, and use the incentive spirometer to reduce pulmonary complications
  • avoid lifting objects that weigh more than 10 lb (4.5 kg) for the next 4 to 6 weeks
  • check the incision site daily and immediately notify the practitioner of any signs and symptoms of infection
  • take medications as prescribed and report adverse reactions to the practitioner
  • comply with the laboratory schedule for monitoring INR if the patient is receiving warfarin.

Cardiovascular disorders: Valve surgery

To prevent heart failure, a patient with valvular stenosis or insufficiency accompanied by severe, unmanageable symptoms may require valvuloplasty (valvular repair), commissurotomy (separation of the adherent, thickened leaflets of the mitral valve), or valve replacement (with a mechanical or prosthetic valve).

Because of the high pressure generated by the left ventricle during contraction, stenosis and insufficiency most commonly affect the mitral and aortic valves. Other indications for valve surgery depend on the patient’s symptoms and on the affected valve:

  • For aortic insufficiency, the patient may need valve replacement after signs and symptoms (palpitations, dizziness, dyspnea on exertion, angina, and murmurs) have developed or the chest X-ray and ECG reveal left ventricular hypertrophy.
  • For aortic stenosis, valve replacement or balloon valvuloplasty is recommended if cardiac catheterization reveals significant stenosis.
  • For mitral stenosis, valvuloplasty or commissurotomy is indicated if the patient develops fatigue, dyspnea, hemoptysis, arrhythmias, pulmonary hypertension, or right ventricular hypertrophy.
  • For mitral insufficiency, the patient may undergo valvuloplasty or valve replacement when signs and symptoms (dyspnea, fatigue, and palpitations) interfere with the patient’s activities or in acute insufficiency (as in papillary muscle rupture).

It gets complicated

Focus Topic: Cardiovascular disorders

Although valve surgery carries a low risk of mortality, it can cause serious complications. Hemorrhage, for instance, may result from unligated vessels, anticoagulant therapy, or coagulopathy resulting from cardiopulmonary bypass during surgery. Stroke may result from thrombus formation caused by turbulent blood flow through the prosthetic valve or from poor cerebral perfusion during cardiopulmonary bypass. In valve replacement, bacterial endocarditis can develop within days of implantation or months later. Valve dysfunction or failure may occur as the prosthetic device wears out.

Patient preparation

Before surgery, perform these steps:

  • As necessary, reinforce and supplement the surgeon’s explanation of the procedure.
  • Tell the patient that he’ll awaken from surgery in an ICU or PACU. Explain that he’ll be connected to a cardiac monitor and have I.V. lines, an arterial line and, possibly, a pulmonary artery or left atrial catheter in place.
  • Let him know that he’ll breathe through an endotracheal tube connected to a mechanical ventilator and that he’ll have a chest tube in place.

Monitoring and aftercare

The patient undergoing valve surgery will be cared for in the cardiac ICU after surgery. He’ll be transferred to the medical-surgical unit when his condition is stable. After transfer to the medical-surgical unit, take these steps:

  • Provide analgesia, or encourage the use of PCA, if appropriate.
  • Monitor for postoperative complications, such as stroke, pulmonary embolism, pneumonia, impaired renal perfusion, endocarditis, and hemolytic anemia.
  • Gradually allow the patient to increase activities as ordered.
  • Monitor the incision site for signs of infection or drainage.
  • Provide support to the patient and his family to help them cope with recovery and lifestyle changes.

Home care instructions

Instruct the patient to:

  • immediately report chest pain or fever, or redness, swelling, or drainage at the incision site
  • immediately notify the practitoner if signs or symptoms of heart failure (weight gain, dyspnea, or edema) develop
  • notify the practitioner if signs or symptoms of post-pericardiotomy syndrome (fever, muscle and joint pain, weakness, or chest discomfort) develop
  • follow the prescribed medication regimen and report adverse reactions
  • follow his prescribed diet, especially sodium and fat restrictions
  • maintain a balance between activity and rest
  • follow exercise or rehabilitation program if prescribed
  • inform his dentist and other doctors of his prosthetic valve before undergoing surgery or dental work; he may be ordered to take prophylactic antibiotics before such procedures.

Cardiovascular disorders: Implantable cardioverter-defibrillator

The implantable cardioverter-defibrillator (ICD) has a programmable pulse generator and lead system that monitors the heart’s activity, detects ventricular bradyarrhythmias and tachyarrhythmias, and responds with appropriate therapies. Its range of therapies includes antitachycardia and bradycardia pacing, cardioversion, and defibrillation. Some defibrillators also have the ability to pace the atrium and the ventricle, pace both ventricles, or provide therapy for atrial fibrillation.

ICDs are indicated for patients who have experienced sudden cardiac death syndrome or syncope secondary to a ventricular arrhythmia. Those at high risk for ventricular fibrillation or tachycardia—such as those with dilated or hypertropic cardiomyopathy or those with prolonged QT syndrome—may also receive ICDs. The device can be programmed to defibrillate and pace according to the patient’s condition. (See Inserting an ICD.)

 

Cardiovascular disorders

 

Patient preparation

Before the procedure, take the following steps:

  • Reinforce the cardiologist’s instructions to the patient and his family, answering any questions they may have.
  • Emphasize the need for the device to the patient, and explain the potential complications and ICD terminology.
  • Restrict food and fluid for 12 hours before the procedure.
  • Provide a sedative on the morning of the procedure as ordered to help the patient relax.

Monitoring and aftercare

The patient undergoing ICD implantation will be monitored on a telemetry or medical-surgical unit. After the procedure, take these steps:

  • Monitor for arrhythmias and proper device functioning.
  • Gradually allow the patient to increase activities as ordered.
  • Monitor the incision site for signs of infection or drainage.
  • Provide support to the patient and his family to help them cope with recovery and lifestyle changes.
  • Encourage family members to learn cardiopulmonary resuscitation (CPR).

Home care instructions

Before discharge, instruct the patient to:

  • avoid placing excessive pressure over the insertion site or moving or jerking the area until the postoperative visit
  • check the incision site daily and immediately notify the practitioner of any signs and symptoms of infection
  • wear a medical identification band and carry information about his ICD at all times
  • take medications as prescribed and report adverse reactions to the practitioner
  • keep a log recording discharges and any symptoms.

 

Cardiovascular disorders

 

Cardiovascular disorders: VAD

A temporary life-sustaining treatment for a failing heart, the VAD diverts systemic blood flow from a diseased ventricle into a pump, which then sends the blood into the aorta. Used most commonly to assist the left ventricle, this device may also assist the right ventricle or both. (See VAD: Help for the failing heart.)

Candidates for a VAD include patients with:

  • massive MI
  • irreversible cardiomyopathy
  • acute myocarditis
  • inability to wean from cardiopulmonary bypass
  • valvular disease
  • bacterial endocarditis
  • rejection of a heart transplant.

The device may also benefit patients awaiting a heart transplant, enabling them to live for months or years at home with a portable left VAD until a donor heart is located.

The downside

Focus Topic: Cardiovascular disorders

Unfortunately, the VAD carries a high risk of complications. For example, the device damages blood cells, creating the risk of thrombus formation and subsequent pulmonary embolism or stroke. As a result, if ventricular function hasn’t improved in 96 hours, the doctor may consider a heart transplant.

Patient preparation

Before the procedure, take the following steps:

  • Explain to the patient that you must restrict his food and fluid intake before surgery.
  • Tell him that his cardiac function will be continuously monitored using an ECG, a pulmonary artery catheter, and an arterial line.

Monitoring and aftercare

The patient having a VAD implanted will be monitored in the cardiac ICU. He’ll be transferred to the medical-surgical unit when his condition is stable. After transfer to the medical-surgical unit, take these steps:

  • Provide analgesia, or encourage the use of PCA, if appropriate.
  • Monitor for postoperative complications, such as stroke, pulmonary embolism, pneumonia, and impaired renal perfusion.
  • Gradually allow the patient to increase activities as ordered.
  • Monitor the incision site for signs of infection or drainage.
  • Provide support to the patient and his family to help them cope with recovery and lifestyle changes.

Home care instructions

Before discharge, instruct the patient to:

  • immediately report redness, swelling, or drainage at the incision site; chest pain; or fever
  • immediately notify the practitioner if signs or symptoms of heart failure (weight gain, dyspnea, or edema) develop
  • follow the prescribed medication regimen and report adverse reactions
  • follow his prescribed diet, especially sodium and fat restrictions
  • maintain a balance between activity and rest
  • follow exercise or rehabilitation program if prescribed
  • comply with the laboratory schedule for monitoring INR if the patient is receiving warfarin.
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