Secondary Prevention of ACS - Case Study Example

Running ACS: Secondary Prevention ACS: Secondary Prevention Introduction This paper deals with applying the guidelines of the British Heart Foundation and SIGN 93 to practice in the cardiac unit of a regional hospital. It will cover counseling during the patient’s stay in hospital after acute treatment for M. I. in order to ensure that secondary ACS events are prevented. It will address practical considerations in a busy nursing practice in an acute-care M.I. ward, and answer the question “What is possible to do within the relatively short time periods that these patients are in our care?” The process of treating patients post-M.I. has improved in the past 10 years. Based on solid clinical evidence and new drugs and devices, the rate of secondary M.I.’s and morbidity can be reduced substantially with proper post-M.I. medical intervention (Hinstridge 1991). Newer findings demonstrate that aggressive post-M.I. treatment can have a significant impact on morbidity and mortality, as well as improving a patient’s quality of life years. Compliance remains a major issue, both in terms of taking medications and ceasing behaviours which can contribute to secondary ACS. The special concentration of this paper will be on patients while in the cardiac unit and in the following critical weeks. This paper also deals with the role of the ACS nurse in the regional cardiac care setting. Despite the overwhelming evidence that following new, more aggressive proceedures can save lives, there is still some resistance from staff to make the changes necessary to assure that the new guidelines are followed. Role of ACS Nurse in Patient Care Recent data gathered by the British Heart Foundation has established the importance of following new, more-aggressive guidelines in the treatment of post-ACS patients in order to assure a reduced risk of secondary events. The NHS is committed to instituting new interventional techniques (both drug and angioplasty routines), and has begun a policy of installing ACS-specialised nurses in each regional heart center. The reaction of staff to this new specialty is mixed at best (Dunckley 2006). Effective implementation of new ACS procedures starts with EMT response to calls, Emergency Room staff response to patients with M. I. symptoms, and Cardiac Unit response with rapid drug and angioplasty treatment. Such changes require significant staffing and schedule modification, which can be met with resistance, despite the clear evidence that the procedures can save lives. Practical considerations also intercede, as nurses must interpret the new BHF guidelines and ensure that they are followed as a part of nuring operating procedures. Treatment of Post-ACS Survivors The acute-care ACS nurse needs to both understand and play an active role in explaining to the patient the role of the medications he/she is taking in order to prevent secondary ACS events. One drug regimen which is quite helpful to the patient’s prognosis is the administration of dual antiplatelet therapy. Two recent studies, the CHARISMA and CAPRIE studies, demonstrated that clopidogrel is not always indicated for patients post-M.I. A subsequent analysis of the CHARISMA patient set for those patients who had experienced documented cardiovascular, cerebrovascular, or peripheral arterial disease benefited from dual antiplatelet therapy (clopidogrel plus aspirin) (Hughes 2007). The CAPRIE data suggests that clopidogrel alone is better than aspirin therapy alone, which suggests that single-drug therapy with clopidogrel makes sense for patients with an allergy or intolerance to aspirin. Contraindications to dual antiplatelet therapy include those patients with a previous history or a danger of hemorrhagic stroke, those who are about to undergo further surgery, or those who have danger of other kinds of bleeding (Hughes 2007) (Cannon 2006). It is important to counsel the patient to continue antiplatelet therapy once leaving the cardiac clinic. The primary reason is that patients’ risk of a subsequent M. I. increases by a factor of 7 if they have received a drug-eluting stent and stop therapy prematurely. Although there are ample numbers of single-drug therapy trials for post-ACS patients, there are fewer studies which examine the clinical effects of a combination of drugs (with the notable exception of aspirin) (Mukherjee 2003). Aspirin alone can reduce post-M.I. re-infarction rate by 25 to 30 percent. An additional risk accrues to those patients who begin statin therapies and then stop them. The risk is that patients’ rate of plaque formation may increase with cessation of the therapy. It is the responsibility of the acute-care ACS-responsible nurse to explain both the workings of statins, and why it is important to stay on medications without interruption. A good deal of ongoing treatment depends on the state of the patient, which can range from stage 4 congestive heart failure (CHF) to a vulnerable-plaque “silent” heart attack. Additional factors for ongoing treatment include: (1) the amount of heart muscle damaged in the M.I., (2) the subsequent therapies used, (3) the clinical state of the patient, including co-morbidities, and (4) the state of compliance of the patient. This section will deal with each of these patient subsets in turn. Patient Compliance Patients who have experienced ACS or are suffering from CHF are incented to comply with their therapy recommendations. The unfortunate side-effects of beta-blockers, diuretics and statins can make it difficult for the patients to comply. Regardless of the therapies chosen, compliance is important. Following are some of the key areas of compliance, and how they relate to acute-care nursing and consultation with the post-ACS patient and his/her family: 1. As shown before, stopping Plavix or statin therapy increases the risk of a subsequent M.I. The acute care nurse can explain to the patient and his/her family how Plavix works, and how stopping Plavix affects the patients’ prognosis. The patient must also inform his or her physician whenever new medical procedures are being contemplated that Plavix therapy must be continued. Failure to proceed with Plavix can increase the chances of a secondary ACS event up to seven times (if the patient has received a DES). 2. Patients who are in the later stages of CHF need to continue to take their diuretics if they are to reduce the number of visits to the hospital cardiac unit. Patients are non-compliant many times because diuretics (especially taken before going to bed) require the patient to get up often during the night. In fact, many CHF episodes of cardiac insufficiency happen at night, partly related to the build-up of fluids. Again, the acute-care coronary nurse needs to work especially closely with the ACS patient’s spouse in order to insure compliance. 3. Diabetics who do not adequately measure their glucose levels or do not adequately dose their insulin are at significant risk for subsequent vascular disease and an additional series of ACS events. It may behoove the acute-care nurse to (a) establish glucose and glycosolated hemoglobin levels several times during the patient’s sojourn in the acute-care unit, and (b) to ensure proper re-education about the proper measurement and administration of insulin, and reinforcement of eating proper foods in order to prevent glucose and insulin spikes (particularly in the case of insulin resistance and Type-II diabetes). Clinical evidence is incontrovertible: patients who maintain their therapy post-ACS are likely to reduce their chances of additional ACS events by up to 77%. The overwhelming issue in preventing secondary ACS is therefore insuring on-going patient compliance (Sud 2005). Counseling the Patient Prior to Discharge The few months following the patient’s encounter with ACS are critical to his or her chances of undergoing another myocardial infarction. While many of the drug regimens have been discussed above, it is my responsibility and that of others in the cardiac unit to counsel patients while they are in the facility. In particular, it is important for us to counsel the patients on changing life habits that are the greatest contributors to secondary ACS episodes. In addition to the pharmaceutical regimens, we work with patients on the following issues: 1. Recommend smoking cessation programs which have been shown to work in the past. 2. Recommend diet programs sponsored by our clinic, including on-going measurement. 3. Work with family members (generally the spouses) to help set up and monitor an exercise program. The drawbacks for the nursing staff of these recommendations are that patients prove extremely resistant to change in these habits and addictions. Rather than being discouraged by the low compliance rate, the nurse supervisor should encourage staff to celebrate improvement ‘at the margins,’ that is, a smoking cessation or exercise program that is successful for 10 to 20 percent of their charges, rather than 100% (which is unobtainable and can therefore be demotivating). This follow-on evidence is relevant to nursing care in the cardiac unit, because the ACS nurse has the opportunity to educate patients and begin the process of follow-up which stays with the patient after he or she returns home. During the time that the patient is in the cardiac ward, the nurse can work with the ACS sufferer and his or her spouse and family in order to put together a program to minimize the chances of a subsequent ACS event. The strategies chosen for the patient include the following: 1. Make the patient aware of the program by the British Heart Foundation for improving heart health (SIGN 2007). This is a comprehensive book written for the layperson which details all the elements needed in order to improve overall conditioning. 2. According to the SIGN guidelines, counsel the patient on changing life habits which can improve his/her prognosis. Smoking Cessation The role of the nurse is to suggest stopping smoking to the patient, and help the patient and his/her family to understand how the prognosis can be improved. Although it is difficult to convince patients to stop, there is clinical evidence that the advice of a nurse practitioner can double the chances that a patient will stop smoking: Research indicates that success rates for unaided smoking cessation doubles from 5% to 10% of attempts when instigated by simple advice to quit from the clinician (Fiore et al., 1996). Advising smoking cessation promotes self-efficacy by implying the NP believes the smoker can be successful. The NP reinforces the message that smoking is unhealthy, not the norm, and is an issue of concern by providing a smoke-free office (Neeley 2000). The BHF recommends referral to stop-smoking groups, replacement therapy and has a stop-smoking hotline, all of which the nurse can recommend to the patient (BHF 2007). Obesity and Diabetes Counseling Over 1/3 of British citizens are overweight. Many post-ACS patients are obese or morbidly-obese. There is a high correlation of “Factor X,” or disease syndromes which lead to higher percentage incidence of ACS and secondary ACS amongst patients who exhibit high weight and Type-II diabetes. Although pharmaceutical products are helpful, the nurse needs to help the patient with counseling to help reduce the underlying causes of insulin resistance and obesity. In the short term, the nurse should consult the patient’s glucose tolerance testing results, assess Body Mass Index (BMI) and understand how much exercise the patient is doing. In order to treat short-term symptoms of insulin resistance, the nurse may work with the patient on a regimen of glucophage. More importantly, exercise of as little as 72 minutes of moderately-paced walking can make a significant difference in insulin resistance and cardiac health, even in the absence of weight loss (Fox, et al. 2007). The nurse can counsel the patient on the importance of starting a moderate exercise regimen with low-impact programs which are attainable for the patient. Cholesterol Control Statins have been established by the BHF to be a significant contributor to lower the risk of subsequent ACS events. The primary efficacy of statins is to reduce overall cholesterol, but there are anti-inflammatory effects which reduce overall risks of strokes and M. I (Nissen 2004). The nurse’s role is to consult with the patient on the efficacy of statins, and to ensure that the patient is given an adequate dose, that the side-effects are manageable, and that the patient understands the need to stay on his/her statin regimen for a long period of time. Maintain Alertness to Symptoms The nurse plays a key role in instructing the patient on being alert to symptoms of subsequent ACS. Patients and their spouses and families can improve an ACS-sufferer’s chances of survival if they are able to contact the proper authorities and get the patient to the hospital quickly after the onset of symptoms. In many nurses’ clinical experience, the spouse plays a key role in monitoring the health of the patient at home. In many cases, the spouse should be educated on the symptoms of further M.I. or stroke events, and encouraged to get the patient to the hospital post-haste in the event of such symptoms. Establish an On-Going Monitoring Function Patients will need on-going monitoring to ensure that their weight-loss, smoking cessation and basic measures of heart health are monitored by their primary care physician after discharge. The role of the ACS nurse is to counsel the patient, and to share the program and obtain agreement from the patient’s primary care physician. To the degree that the designated ACS nurse can affect community medicine, he or she can put programmes in place that encourage follow-up at home and within support group settings to encourage progress. Conclusion New therapeutic options have brought significant improvements in patient prognoses post-ACS event. Although clinical evidence is strong for single-use of some pharmaceutical therapies, additional work needs to be performed in order to assess long-term results. The BHF guidelines for the treatment of post-ACS patients are not yet fully implemented across the network of hospitals. The attempt to create an ACS nursing function has been met with some resistance from staff in many NHS heart centers. The life-saving benefits of aggressive intervention have been demonstrated by BHF-sponsored and other clinical studies, with an estimate that up to half of deaths post-ACS can be prevented if these procedures are followed. The role of the ACS nurse is to therefore work with the rest of the staff to ensure that guidelines are followed, patients are carefully followed-up and treatment regimens put in place to assure that the danger of patients encountering a second ACS event is reduced. References Anand, S. S. et al. «The Warfarin Antiplatelet Vascular Evaluation Trial Investigators. Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. .» NEJM, 2007: 217-227. BHF. How to Stop. 2007. http://www.bhf.org.uk/smoking/how_step1.asp (accès le July 21, 2007). Brookes, Linda. Late-Breaking Clinical Trials: RITA 3, PRAGUE-2, GIPS, . 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