Care of Patient in Acute and High Dependency Care - Coursework Example

Care of Patient in Acute and High Dependency Care I. Introduction Health care delivery system endeavors to provide two essential rights: the right to access to care and the right to quality in services delivered. Despite the fact that the current care delivery system is not perfect, these rights should never seriously slow down health care professionals and staffs in their continuous pursuit of providing best possible care to their elderly patients especially in cases of Acute Myocardial Infarction (MI) wherein most patients are older adults so vulnerable requiring the maximum care and management. This article sets out the appropriate and suggested care for patients under acute, high dependency or critical care placement. Specifically, the patient that will be studied has had a Myocardial Infarction. Initially, the profile of the patient has been made available for the purpose of developing a care plan. II. Patient's Altered Physiology Theories attempting to explain the physiologic changes that occur during the aging process include genetic theories, cellular theories, and organ system theories. Other physiologic concepts of aging that are proposed are nutrient deprivation, lipofuscin, wear and tear theory, and cross-linking theory. Psychologic theories abound and include disengagement theory, activity theory, life course theory, and continuity theory. None of the said theories or constructs can claim sufficient evidence to account for aging effects that are experienced by older people. The majority of theorists and practitioners agree that with advanced age come factors such as increased vulnerability, increased susceptibility to disease, decrease in vitality, and slowed response to and recovery from stress. The structural changes described translate into specific cardiovascular problems, such as hypertension, decreased cardiac output, CHF, valvular dysfunction, and cardiac arrhythmias or conduction disturbances. Other changes in cardiovascular physiology compound these problems. Already mentioned is the decreased arterial oxygen tension, which can aggravate any vascular problem and make elderly patients with circulatory compromise (coronary artery or peripheral artery insufficiency) have more severe symptoms than they would, based on their anatomic vascular disease alone. The elderly also have an increased resting heart rate, perhaps related in part to an increased level of catecholamines. Nonetheless, when increased heart rate or contractility is needed, in the case of physiologic stress, there is a decrease in responsiveness to beta-adrenergic stimulation. Thus maximum heart rate and ability to increase the ejection fraction are less. The elderly are also much more sensitive to small changes in plasma volume. The natural changes of aging in the kidneys, coupled with changes in the function of the renin-angiotensin axis, actually make the elderly person more susceptible to dehydration. There is a decreased thirst drive. Vasopressin secretion is decreased in response to decreased plasma volume. There is also decreased renin production, therefore decreased angiotensin, and, ultimately, decreased aldosterone production. In addition, when plasma volume is decreased, the elderly person may be more symptomatic because compensatory mechanisms such as the baroreceptor reflex are also less responsive. Thus the elderly person with small decreases in plasma volume might be light-headed, dizzy, or even syncopal. One study found a substantial drop in arterial blood pressure in elderly patients after a meal. There have been significant increases in this group in postprandial symptoms, including syncope, angina, and myocardial infarction (MI). The mechanism of postprandial hypotension is thought to be the diversion of blood flow to the gut, resulting in a relatively reduced intravascular volume elsewhere in the vascular tree. Other relatively mild hemodynamic changes occur with defecation, urination, and postural change. The incidence of symptomatology associated with such mild hemodynamic changes is negligible in the young but significant in the elderly. There is a significant increase in the frequency of falls in the elderly, and although falls are often multifactorial, no doubt a number are related to events such as those described, which can cause small but eventful hemodynamic changes in the elderly. Add to that diuretic therapy for hypertension or CHF, and the elderly person is at even more risk. As an illustration of the impact of aging changes in the elderly heart and vascular system, imagine the elderly person facing a physiologic stress such as surgery, acute illness, or perhaps pneumonia. In either instance the elderly heart now needs to increase its cardiac output to generate a greater circulatory flow to vital organs. First, the left ventricular early (passive) diastolic filling is less because of a stiffened, less compliant ventricle. Less volume is delivered to the aorta in systole. Therefore an increase in systolic contraction may be required. The left ventricle is slightly thickened, but unless there has been an MI or there is ischemia, contractile strength should be preserved. Yet the maximum increase possible in ejection fraction is lower in the elderly. Increased heart rate can compensate for decreased filling volume, but the maximum heart rate attainable is lower in the elderly. In addition, because of aging changes in the arterial tree, the peripheral resistance is higher. There is increased after-load for the systolic contraction to overcome. The blood volume that is delivered to the peripheral circulation is therefore less, despite the increased demand. Add to that any decrease in plasma volume, and the situation is compounded. Beta-adrenergic stimulation is present, but the aging heart responds less to this stimulus. If aging coronary arteries are also affected by atherosclerotic changes, there may be ischemia and increased risk for MI. All of this, plus decreased arterial oxygen tension and decreased efficiency of oxygen extraction, can make an elderly cardiovascular system unable to deliver increased cardiac output on demand. Age-related changes in the cardiovascular system are a combination of changes natural to aging, cardiovascular disease present and co-morbid conditions that affect the cardiovascular system. Taken as a whole, the natural history of heart disease is that it increases with aging. The manifestations of heart disease, the treatments, and the outcomes may all differ in the elderly person, compared with the younger person. Yet elderly people can improve their cardiovascular function with exercise. With regular cardiovascular exercise such as a gradual program of brisk walking for 30 minutes at least three times a week, exercise tolerance improves through increased arterial oxygen tension but chiefly through increased efficiency of oxygen uptake and extraction (air to blood to tissue). As a result, resting heart rate and blood pressure fall. Body fat percentage can be decreased, and muscle strength and joint flexibility can be increased, resulting in better mobility, balance, and gait. For that reason the aging cardiovascular system, like the aging musculoskeletal system, can still be conditioned. III. Patient Profile Mr. Smith is 70 years old that has had myocardial infarction requiring appropriate and definite nursing care and management in view of the fact that he is considered to be in a state of high dependence. IV. Background Eight of every 10 people worldwide aging 65 or older have at least one chronic medical problem, nevertheless 60% of those over 65 are without any functional or physical limitations from their conditions. On the other hand, when there is illness or disability in the elderly population, cardiovascular disease is still the most frequent cause. Congestive heart failure is the most common medical problem necessitating hospitalization in the elderly. More than half of the patients hospitalized annually for acute myocardial infarctions are more than 65 years old. Finally, coronary artery disease causes 70% to 80% of the deaths in the over-65 age group (Duncan and Vittone, 1996). Therefore proper diagnosis and treatment of cardiovascular diseases can help to both maintain the health of the large number of functionally independent elderly and reduce morbidity and mortality in the elderly in acute and chronic care settings. Changes in the cardiovascular system occur with aging. Some of these changes can be considered natural in an aging organism. Others occur with the onset of a disease process in the cardiovascular system itself. Still other changes are the result of coexisting medical conditions. There are anatomic changes in the blood vessels, the heart itself, the heart valves, and the conducting systems, as well as physiologic or functional changes. V. CARE PLAN A. Care Intervention An important aspect with any risk factor modification program is that a given patient may have multiple risk factors that may lead to cumulative risks for stroke that require multi-targeted interventions (Sacco, 1998). An emerging issue in stroke prevention and stroke treatment is that therapies shown to be effective in clinical trials are not being used or are being used sub-optimally (Matchar, 1998). Hypertensive individuals like Mr. Smith need to reduce blood pressure to under 140 mm Hg systolic and under 90 mm Hg diastolic. Wolf (1998) generally recommended weight reduction in obese patients and a program of moderate physical activity. The use of the HMG-CoA-reductase inhibitors or statin medications for the reduction of total cholesterol and low-density lipoprotein (LDL)-cholesterol concentrations has been shown to have some benefit for reduction of stroke. In addition to reducing LDL-cholesterol, HMG-CoA-reductase inhibitors prevent precipitation of vascular events by stabilizing atherosclerotic plaque and exerting beneficial effects of clotting (Wolf, 1998). The benefit of anti-platelet therapy with aspirin in preventing vascular outcomes is well established. It reduces relative risk for stroke, myocardial infarction, and vascular death by about 25% compared with placebo (Easton, 1998). While debate continues regarding the best dosing for prophylaxis, it is generally adequate to start with a small dose ("baby aspirin," 81 mg). The dose may be increased (325 mg or 650 mg per day) in patients with high risk or who have experienced minor cerebrovascular episodes while on lower doses. Another agent that inhibits platelet aggregation is ticlopidine, which is useful for patients with TIA in whom aspirin therapy has not successfully eliminated occurrence of symptoms or who are not able to take aspirin. Patients who have had an embolic stroke or are at very high risk may require anticoagulation with warfarin (Coumadin). Patients with atrial fibrillation who are at high risk for stroke should receive warfarin (Feinberg, 1998). Warfarin therapy is monitored by means of the International Normalization Ratio (INR), which is now reported with the prothrombin time. Used for many years in other countries, the INR has recently been adopted in the United States to monitor anticoagulation therapy with warfarin because of less variability in results. The usual target range for the INR is 2 to 3, although this may vary for the individual patient and is usually monitored monthly once the correct dose is determined. Some elderly patients with atrial fibrillation may not be considered good candidates for anticoagulation. These may include patients who have a tendency to fall, patients who may not be able to manage medication regimens reliably (and have no assistance), or those who refuse or are unable to have blood drawn frequently. For these patients the priority is adequate control of the heart rate. This may be accomplished with diltiazem or digoxin, which a cardiologist or other physician may administer intravenously with cardiac monitoring until initial control is achieved. Another option includes cardio-version with medication maintenance. These patients may also benefit from aspirin therapy at the 325-mg daily dose (Wolf, 1998). Patients with carotid stenosis of 70 % to 99% should be evaluated by a vascular surgeon for possible endarterectomy. Several studies have evaluated this intervention and found benefits in certain populations, although Wolf (1998) the potential risks of the procedure must be weighed carefully. Although many surgeons may delay surgery until stenosis is 90% to 99%, it is beneficial to obtain the input of the vascular surgeon in the management of the patient whenever significant stenosis is present. It has been established that successful outcomes for this procedure depend on low rates of stroke and death within 30 days of the surgery for the hospital and the surgeon performing the procedure (Bratzler, 1998). Apart from the U.K., smoking causes 417,000 deaths each year in the U.S.A. (American Heart Association, 1998). The risk for stroke decreases among those who quit smoking and approaches that of nonsmokers in about 5 years (Sacco, 1998). Practitioners need to be familiar with various smoking cessation programs and tools to be prepared to help the patient with this difficult task. There are two addictions associated with smoking: the response behavior and the nicotine. A patient who has smoked less than half a pack a day (10 cigarettes) may not require much more than moral support and assistance in substituting a different, healthier habit when the smoking "trigger" occurs. These triggers often include first thing on arising in the morning, commuting in the car, and after a meal. Substituting other behaviors such as going for a walk, brushing the teeth, or chewing gum may help to "break the habit" for lighter smokers. Heavier smokers will probably require a tapered nicotine replacement in addition to behavioral modifications. There are several nicotine replacement systems currently on the market. These include gum and titrated patches. When considering a nicotine replacement patch, one must consider the number of cigarettes smoked in an average day. The patient who smokes irregularly, or less than half a pack per day, may actually be increasing the nicotine dose by using a patch and may benefit from one of the other replacements. A recent tool in smoking cessation is Zyban (Glaxo Wellcome), a short-term, low-dose buproprion course that helps to alleviate the craving for tobacco. 1. Patient Education It is critical to educate patients regarding the devastating effects of stroke and especially their individual risk factors. At each visit the patient should be asked about smoking cessation, exercise, and attention to other modifiable risk factors, as appropriate. Patients and caregivers must also be educated regarding the signs of a TIA or stroke, and the importance of immediate care must be emphasized. Summary Prevention of stroke is a very important task for those caring for persons of all ages especially the case of Mr. Smith, because so many high-risk behaviors begin early in life. On the other hand, because strokes tend to occur in the elderly population, this seems to be the time most providers and patients focus on the issue. Fortunately, interventions aimed at reducing risk are still effective and beneficial. Additionally, many interventions such as smoking cessation, exercise, and aspirin therapy are neither difficult nor expensive. However, the practitioner must identify patients with risk factors so that appropriate education and intervention can begin before the first stroke causes disability and possibly death. B. Care Management and Therapy for Acute Myocardial Infarction The elderly patient who is actually having an acute MI, like the elderly patient with angina, may present atypically. Most have some chest discomfort, but there is again likely to be dyspnea more than pain or pressure. Elderly patients, like Mr. Smith, are less likely to become diaphoretic. Instead, the presenting symptoms of acute MI in the elderly may be acute confusion, syncope, and stroke, if not sudden death. Interestingly, in the elderly, the common early complication of acute MI is stroke, and a common complication of acute stroke is acute MI (Duncan and Vittone, 1996). There is greater in-hospital and long-term mortality from acute MI in the elderly than in the younger age group. The mortality in those over age 70 is four times greater than the average. The increase in CHF of Mr. Smith is due to increased incidence of prior infarction, cardiomyopathy, hypertensive cardiac hypertrophy, and increased frequency of multivessel CAD, meaning more and larger areas of heart muscle already compromised by ischemia. Incidence of papillary muscle rupture is also increased, causing acute mitral valve dysfunction and secondary CHF, and the incidence of myocardial wall rupture is also increased. The incidence of postinfarction pericarditis is not increased in the elderly patient. There is also no increased frequency of ventricular tachycardia (V-Tach) (Duncan and Vittone, 1996). C. Emergency Treatment of Acute Myocardial Infarction Initial therapy of the patient should include an immediate aspirin 160 to 325 mg, administration of sublingual nitrates (NTG SL 1/150 every 5 minutes x three), and immediate transfer to an emergency room or acute care setting (this medicine is available in the U.K. and the U.S.). If available, administration of oxygen (carefully noting any history of chronic obstructive pulmonary disease [COPD]), pain relief with morphine as required, and use of nitrates unless the systolic BP is below 90 or the heart rate is below 50 or higher than 100 are indicated. Should Mr. Smith will be in an acute setting; intravenous (IV) heparin is started, as well as thrombolytic therapy if the history and ECG meet the criteria. Currently thrombolytic therapy, using streptokinase, urokinase, or tissue plasminogen activator, is reserved for those with symptoms compatible with acute MI and ST segment elevation more than 1 mm or LBBB on ECG (Ryan et al., 1996). This same regimen, except, of course, for thrombolytics, should be generally used for the patient presenting with anginal symptoms for whom acute MI is possible and must be ruled out. Oxygenation should be monitored by pulse oximetry and subsequent arterial blood gas measurements if there is significant history of lung disease. If pain is not relieved, narcotics should be administered, starting with 2 to 5 mg of IV morphine if not otherwise contraindicated (e.g., by allergy). If pain persists, the patient is a candidate for IV nitroglycerin drip, for which the starting dose is usually 5 g per minute, titrated upward to a maximum of 75 to 100 g per minute, as required to control pain. The patient presenting with symptoms compatible with angina, in whom suspicion of acute MI is high, should also be heparinized, hospitalized on a telemetry unit, and evaluated by a cardiologist (Fauci et al., 1994). Thrombolytic Therapy (Agents) The critical goal of the management in the acute period of the disease is to retrieve as much myocardium as possible and refurbish contractile function of heart chambers. This is accomplished largely with thrombolytic drugs, such as streptokinase, urokinase, alteplase (recombinant tissue plasminogen activator, rtPA) or reteplase. Streptokinase is a sterile, purified protein extract produced by group C beta-hemolytic streptococci binding in a noncovalent fashion to plasminogen, forming an activator complex which then converts circulating plasminogen to plasmin. When given intravenously, streptokinase reduces total peripheral vascular resistance and systematic blood pressure. It may not be the fibrinolytic agent of choice in patients with preexisting hypotension or shock. Allergic reactions such as fever and shivering as well as anaphylactic shock are seen very rarely in patients. Urokinase, on one hand, is a nonselective activator of plasminogen that is produced by the kidney and excreted in the urine. The intravenous use of urokinase for acute MI gains its large international experience in a country in Europe that has not been studied in the U.S. Urokinase deserves mention since it is the only thrombolytic agent that has been studied in pregnancy with its doses causing no harm to the fetus. Alteplase is a purified glycoprotein of 527 amino acids made using complementary DNA from a human melanoma cell line. It has the property of fibrin-enhanced conversion of plasminogen to plasmin. Since it has short half-life and fibrin selectively, concomitant therapy with heparin is considered mandatory. Occurring naturally in humans, alteplase does not trigger allergic reactions. Reteplase is a nonglycosylated modified form of tPA (tissue plasminogen activator) produced through the use of recombinant DNA technology. It must be given concomitantly with aspirin and intravenous heparin. It is a known abortifacient in rabbits when given at three times the human dose. After the acute perimyocardial infarction period, long-term management should include aspirin therapy, beta-blocker therapy with or without other anti-anginals (nitrates and calcium channel blockers), and ACE inhibitors. Non-medical management of cardiac risk factors is equally important. Treatment goals should include maintenance of ideal weight, control of hyperlipidemia, and, if necessary and appropriate, estrogen replacement therapy. Diet should be the American Heart Association step 2 diet for most. It contains less than 7% saturated fat and 200 mg per day of cholesterol minimally. Target for total low-dose lipoproteins should be below 130. Smoking cessation is essential to success. Patients who are functionally able should be in a formal rehabilitation program, which should include working up to a goal of 20 minutes of exercise at least three times per week. Such programs have shown positive benefit in the elderly but have been underused (Duncan and Vittone, 1996; Ryan, et al., 1996). D. Care Management Precautions Though flecainide and encainide are more recent and more potent antiarrhythmic agents worldwide and in the U.K., they have also been shown to increase mortality in patients with ventricular arrhythmias after acute myocardial infarction, with age being an independent risk factor (Akiyama et al., 1992). Procainamide has been shown to decrease short-term survival after cardiac arrest and resuscitation outside the hospital (Hallstrom et al., 1991). The side effects include nausea, vomiting, diarrhea, light-headedness, hypotension, edema, dizziness, and depression (Physicians Desk Reference, 1999). Procainamide can also cause a lupus syndrome. Because of the limited benefit-risk ratio for these drugs, they should be prescribed only under the close supervision and monitoring of a cardiologist. Nitroglycerin preparations (nitrates), both orally and applied to the skin for treatment of ischemic heart disease and angina, may predispose the elderly patient to the development of light-headedness, postural hypotension, syncope, and falls, especially when used in an increasing dosage. Other common side effects include headache, faint or rapid heartbeat, nausea, and vomiting. Rare side effects include blurred vision, dry mouth, and skin rash occurring at the site of administration for topical preparations. Seizures may also occur in very high doses (Ishikawa et al., 1997). Patients who use the patch preparations should remove the patch for 4 to 6 hours per day to prevent the development of tolerance from the drug. Aspirin in a dose of 81 mg has been shown to be significantly more effective than placebo in reducing the incidence of cerebral infarction, fatal myocardial infarction, and subsequent risk of stroke, subsequent transient ischemic attack, and death in elderly patients with a history of previous transient ischemic attack. However, there was an associated, insignificant increase in hemorrhagic stroke (The SALT Collaborative Group, 1991). It has been shown to significantly reduce the risk of severe angina, myocardial infarction, and death at 6 and 12 months in elderly patients (age below 70) with non-Q-wave myocardial infarction or unstable angina (Wallentin, 1991). It also has been shown to be effective in significantly reducing cardiovascular and all-cause mortality, according to a survey of 2418 women with coronary artery disease at 3 years' follow-up. This risk reduction occurred in women over age 60, as well as those with hypertension, diabetes, and previous myocardial infarction (Harpaz et al., 1996). Because of its relative safety, a baby aspirin should be a part of every older patient's medication regimen unless contraindicated by active gastrointestinal bleeding, a history of bleeding diathesis, other blood disorder, or a history of allergy to aspirin. A dose of 75 mg is as effective as 325 mg, with significantly less chance of gastrointestinal bleeding. This dose may safely be used as prophylaxis in asymptomatic patients with a history of peptic ulcer disease as well. It has been shown to be equally as effective as warfarin in patients younger than 75 years of age with a history of nonrheumatic atrial fibrillation in preventing stroke. Exceptions include patients with risk factors such as a history of hypertension, previous thromboembolism, or heart failure (Stroke Prevention in Atrial Fibrillation Investigators, 1994). The 325-mg dose is also indicated in patients for prevention of a recurrent thrombotic stroke instead of the 75-mg prophylactic dose. Aspirin has also been shown in a case-control study to reduce the risk of colon cancer (Thun, Namboordiri, and Heath, 1991). Patterned after the philosophy of the standard treatment of early myocardial infarction, thrombolytic agents (streptokinase and recombinant tissue plasminogen activator) have also been used in the last several years in various clinical trials in an attempt to prove their efficacy for early treatment of ischemic cerebrovascular accident. For the reason that the conflicting data on outcomes such as short-term complications (bleeding and death) and short- and long-term neurologic outcomes, their use is not recommended at this time (Miyawaki, 1997). Patient's Pain in Myocardial Infarction (Chest Pain) In the acute myocardial infarction is commonly characterized by varying degrees of chest pain along with discomfort, sweating, weakness, nausea, vomiting, and arrhythmia. It may sometimes cause a loss of consciousness and to some extent, sudden death. Of all the stated indications, chest pain is the most common symptom of acute myocardial infarction which is often described as a sensation of tightness, pressure, or squeezing. Being in an acute myocardial infarction, pain radiates most frequently to the left arm where the human heart is tilted. It may also radiate to the jaw, neck, the other arm, and back. Consequently, the patient may complain because of dyspnea (shortness of breath) following the chest pain felt by the patient. More often, women experience a lot different symptoms compared to men. In women, the most common indication of myocardial infarction include dyspnea, weakness, and fatigue. Usually, fatigue, sleep disturbances, and dyspnea have been reported as commonly occurring prodromal symptoms manifesting in as long as one month prior the actual clinically manifested ischemic event. Chest pain in women may be less predictive of coronary ischemia than in men. However, according to a certain study, one third of all myocardial infarctions are without chest pain or other indications. Commonly, it is referred to as "silent" myocardial infarction happening frequently to elderly patients including patients diagnosed with diabetes mellitus. In such a case, Mr. Smith belongs to this age group partition with less probability of chest pain. Comfort seems to be an intrinsic balance of the physiologic, emotional, social, and spiritual essence of the individual and can be perceived as an integral component of wellness. By definition comfort is "a state of ease and satisfaction of the bodily wants and freedom from pain and anxiety." The absence of physical pain is not always sufficient to provide comfort. Mr. Smith, along with the aged, may have their biologic or bodily needs satisfied but be emotionally distressed. Conversely, physical needs may be the priority and no comfort is possible until need fulfillment is accomplished. Nurses use the word comfort to describe goals and outcomes to nursing measures, but the meaning remains vague and essentially abstract to the person who is the recipient of the nursing intervention. Hamilton (1989) studied the meaning and attributes of comfort from the point of view of the chronically ill elderly hospitalized in a geriatric setting. The questions explored were the elderly's definition of comfort, contributors to and distractors from comfort, and how to increase elders' comfort. The findings identified several themes: disease process (pain, bowel function, and disability); self-esteem (feelings, adjustment, independence, usefulness, faith in God); positioning (if elders could carry out activites in bed, chair, or wheelchair); approach and attitude of staff (relationships, encounters); and hospital life (surroundings and environment-feeling at home, well fed, pleasant surroundings). Hamilton (1989) explains comfort as multidimensional "and meaning many things to different people." This description parallels McCaffery's definition of pain, which states: "Pain is whatever the person experiencing pain says it is" (McCaffery and Beebe, 1989). From these interpretations of pain and comfort the question can be raised as to whether there is a way to identify comfort discomfort zones outside acute or chronic pain in a manner similar to the pain assessment measures presently used. This is definitely a fruitful area for research. The prevalence of pain in the elderly who live in the community (especially those with myocardial infarction) is known to be twice that of the young and is considered to be extremely high in the long-term care setting. Ferrell (1991) suggests that the incidence of pain in the community is 25% to 50% and as much as 85% in long-term care due to the presence of conditions that cause chronic pain such as arthritis, gout, and peripheral vascular disease. In the aged, fear and anxiety generate negative effects that emanate from thoughts that pain will result in crippling, forced dependency or that it will be of such intensity that the ability to cope will be inadequate. Pain weakens and interrupts the individual's ideas of relations to self, to others, to the environment, and in time and space. The aged are at high risk for pain-inducing situations (Ebersole & Hess 1998). Conclusion: Future Enhancement of Nursing Care Acute pain as a result of myocardial infarction precipitates restlessness, grumbling, and audible moans, groans, and crying, to mention a few manifestations. The individual in chronic/cardiac or acute pain decreases movement; movements are quiet, controlled, and deliberate. Vital signs may be unstable, or there may be an increase in pulse rate and an elevation in blood pressure; however, if pain persists for some time, vital signs stabilize and are not a reliable indicator of pain. Ask questions and discuss the situation you observe. Assessment of pain in the elderly is important for several reasons: pain is the most common symptom of disease; an accurate assessment will lead to an accurate diagnostic; assessment facilitates evaluation of the effects of therapy; assessment can help differentiate acute, endangering pain from long-standing chronic pain; and successful pain management begins with an accurate assessment. The most important recent change must be percutaneous transluminal coronary angioplasty (PTCA). PTCA, first reported in 1978, has been undertaken in a relatively small way in the United Kingdom since 1980. No formal trials of angioplasty versus vein grafting or medical treatment have been reported. Despite this, the application of the technique has grown steadily from the dilatation of a single stenosed vessel to multiple vessels, from one proximal lesion to more than one, from patients with stable angina to those with unstable angina and from concentric to eccentric vascular lesions. PTCA is increasingly used after acute myocardial infarction treated successfully by thrombolytic therapy. Complications are not unknown with mortality at approximately 1 percent, iatrogenic myocardial infarction 5 percent, new angina 7 percent, and acute need for vein graft surgery 5-7 percent. Late restenosis may occur in as often as 33 percent of cases and in one recent series overall rates of failure were as high as 27 percent. In this context, much depends on the skill and experience of the physician performing the procedure. The management of acute myocardial infarction offers the most alternatives available to the physician. Approaches vary from care at home without hospital admission to the general public in techniques of cardiopulmonary resuscitation (CPR) and the provision of superbly efficient paramedic emergency services. Within hospital coronary units there is a bewildering array of possible options in drug therapy with recent emphasis on thrombolysis followed urgently by angiography and, when feasible, angioplasty. (5,098 words) APPENDIX Aldosterone Steroid: a steroid hormone, secreted by the adrenal cortex, that controls mineral and water balance. Angiotensin Hormone that raises blood pressure: a hormone that causes blood pressure to rise, formed in the blood by a series of processes that can be influenced by drugs. Anticoagulation Stoppage of blood clotting: prevention of blood clots from forming. Atrial Fibrillation Rapid irregular heartbeat of the upper part of the heart: rapid chaotic beating of the muscle in the atria of the heart and may stop pumping blood. Baroreceptors Pressure-sensitive nerve ending: a nerve ending that is sensitive to blood pressure changes. Beta-Adrenergic Producing epinephrine: producing or activated by epinephrine or a similar substance. Bradyarrhythmia Slowness and irregular heartbeat: slowness and irregularity in the rhythm of the heartbeat. Bupropion Medication that is used as antidepressant: an oral antidepressant medication used also in assisting patients to stop tobacco smoking. It works to inhibit neuronal uptake of dopamine in the central nervous system. Cardiomyopathy Heart disease: a disease of the heart muscle, usually chronic and with an unknown or obscure cause. Carotid Stenosis Constriction or narrowing of a duct, passage, or opening in the large artery on each side of the neck that supplies blood. Catecholamines Type of organic compound: a compound that acts as a neurotransmitter or hormone. Cerebrovascular Of brain's blood vessels: relating to or involving the blood vessels that supply the brain. Diaphoretic Sweat-inducing: describes agents that induce sweating, or their effect. Digoxin Heart stimulating drug: a glycoside extracted from foxglove leaves. Heart stimulant. Dyspnea Difficulty in breathing: difficulty in breathing, often caused by heart or lung disease. Endarterectomy Surgical removal of obstruction in artery: the surgical removal of material that is wholly or partially obstructing blood flow in an artery. Hyperlipemia Excessive fats in blood: an excessive level of fats or lipids in the blood. Hypertrophy Enlargement by cell growth: a growth in size of an organ through an increase in the size, rather than the number, of its cells. Ischemia Lack of blood: an inadequate supply of blood to a part of the body, caused by partial or total blockage of an artery. Lipofuscin Pigment that increases with age: a golden-brown pigment deposited in muscle and nerve cells at a rate that increases progressively with age. Pericarditis Inflammation of pericardium: inflammation of the pericardium. Plasmin Fibrin-dissolving plasma protein: a plasma enzyme that helps break down fibrin. Plasminogen Precursor of plasmin: the inactive precursor of plasmin. Postprandial After meal: occurring after a meal, especially an evening meal. Prophylaxis Treatment to prevent disease: a treatment that prevents disease or stops it from spreading. Prothrombin Plasma protein: a plasma protein that is converted to thrombin during blood clotting. Renin Enzyme released by kidneys: an enzyme released by the kidneys that breaks down proteins and helps regulate blood pressure. Streptokinase Enzyme produced by bacterium: an enzyme produced by streptococci. Used in dissolving blood clots. Symptomatology Study of symptoms: the study of the relationships between symptoms and diseases. Set of symptoms: the set of symptoms that are associated with a disease or that affect a patient. Syncope Fainting episode: the action of fainting, or a fainting fit. TIA Transient Ischemic Attack Thrombolysis Breaking down of blood clot: the breaking down of a blood clot by infusion of an enzyme into the blood. Urokinase Enzyme in blood and urine: an enzyme, produced by the kidneys, that catalyzes the conversion of plasminogen to plasmin. Used medicinally, to dissolve blood clots. Vasopressin Hormone that raises blood pressure: a hormone produced by the pituitary gland that causes narrowing of the arteries and raises blood pressure. 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