Oxford Handbook of Cardiac Nursing [3rd Edition] 0198832443, 9780198832447, 9780192568588, 0192568582, 9780192568571, 0192568574

Table of contents :
Half-Title......Page 2
Series......Page 3
Title......Page 4
Copyright......Page 5
Foreword......Page 6
Preface......Page 8
Acknowledgements......Page 10
Contents......Page 12
Contributors to third edition......Page 14
Contributors to previous editions......Page 16
Symbols and abbreviations......Page 18
Covid-19......Page 22
1 Introduction: prevention of cardiovascular disease......Page 24
2 Cardiac assessment......Page 52
3 Cardiac investigations......Page 102
4 Valvular disease......Page 114
5 Infective endocarditis......Page 138
6 Coronary heart disease: stable angina......Page 152
7 Acute coronary syndromes......Page 164
8 Interventional cardiology for coronary heart disease......Page 182
9 Cardiac surgery......Page 206
10 Chronic heart failure......Page 240
11 Bradycardias and blocks......Page 264
12 Tachycardias......Page 294
13 Electrophysiology......Page 318
14 Congenital heart disease and inherited
cardiac conditions......Page 332
15 Cardiomyopathy......Page 356
16 Other cardiac problems......Page 376
17 Cardiac rehabilitation......Page 394
18 Cardiovascular emergencies......Page 408
19 Cardiovascular drugs......Page 446
Appendix 1: Further suggested resources......Page 472
Appendix 2: Heart diagrams......Page 474
Index......Page 476

Citation preview

OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of Cardiac Nursing

Published and forthcoming Oxford Handbooks in Nursing Oxford Handbook of Adult Nursing Oxford Handbook of Cancer Nursing Oxford Handbook of Cardiac Nursing, 2e Oxford Handbook of Children’s and Young People’s Nursing, 2e Oxford Handbook of Clinical Skills for Children’s and Young People’s Nursing Oxford Handbook of Clinical Skills in Adult Nursing Oxford Handbook of Critical Care Nursing Oxford Handbook of Dental Nursing Oxford Handbook of Diabetes Nursing Oxford Handbook of Emergency Nursing Oxford Handbook of Gastrointestinal Nursing Oxford Handbook of Learning and Intellectual Disability Nursing Oxford Handbook of Mental Health Nursing

Oxford Handbook of Midwifery, 2e Oxford Handbook of Musculoskeletal Nursing Oxford Handbook of Neuroscience Nursing Oxford Handbook of Nursing Older People Oxford Handbook of Orthopaedic and Trauma Nursing Oxford Handbook of Perioperative Practice Oxford Handbook of Prescribing for Nurses and Allied Health Professionals Oxford Handbook of Primary Care and Community Nursing, 2e Oxford Handbook of Renal Nursing Oxford Handbook of Respiratory Nursing Oxford Handbook of Women’s Health Nursing

OXFORD HANDBOOK OF 

Cardiac Nursing THIRD EDITION

edited by Kate Olson Visiting Lecturer Nursing Division City University of London UK and Health Professional Milton Keynes Community Cardiac Group Milton Keynes UK

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1 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2021 The moral rights of the author have been asserted First Edition published in 2007 Second Edition published in 2014 Third Edition published in 2021 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2020944517 ISBN 978–​0–​19–​883244–​7 Printed and bound in China by C&C Offset Printing Co., Ltd. Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-​to-​date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-​pregnant adult who is not breast-​feeding Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

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Foreword It cannot be ignored that these are challenging times in our profession and specialty. Cardiovascular disease remains one of the global top five causes of early death and is attributable for over a quarter of all UK deaths. With approximately 7.4 million people currently living with cardiovascular disease in the UK, a figure that is likely to increase due to an ageing and growing population, health service demand is high. However, alongside this increasing demand, we live in a time of punishing health service challenges including staff shortages, and the as yet uncertain implications of Brexit. Currently, it is predicted that the NHS could be short of between 250 000 and 350 000 healthcare staff in the next 10yrs. Despite this, the publication of The National Health Service (NHS) Long Term Plan in January 2019 outlined ambitious improvements for our patients, including providing world-​class care for major health problems, over this same 10yr time-​frame. Incorporating values-​based healthcare, making better use of data and technology, and ‘doing things differently’ by providing person-​centred care, care networks, and integrated care systems are all proposed mechanisms for delivering these changes. However, with challenge and change comes opportunity and I  believe this is a great time to be a cardiac clinical nurse. We are already part of a dynamic and continuously evolving specialty with exposure and opportunity to be at the forefront of caring for patients using the newest technology, drugs, and care processes to strive for excellence in patient outcomes and experience. This is expertly highlighted in this third edition by the considerable number of new sections (e.g. CT coronary angiogram (Chapter  3), valve-​in-​valve insertion, sutureless aortic valve replacement (Chapter 4), postoperative AF (Chapter 9), electroanatomical 3D mapping (Chapter  13), familial hypercholesteraemia, genetics and genomics, and sudden cardiac death (Chapter 14), and the extensive update throughout incorporating guidelines published since 2014. Equally, I am delighted that this edition also highlights the specialist nurse role with a new section on nurse-​led valve clinics (Chapter  4) and that the role of the heart failure nurse section has increased (Chapter 10), which really depicts progression and advancing nursing roles. It would be remiss of me, given my research background, not to mention the research need for cardiac nurses to be contributing to, and leading research to further progress the evidence on which to base clinical practice. With the current increased national emphasis on clinical academic careers in nursing and the use of research in practice, there really is a wealth of opportunity for cardiac nurses to shape and deliver world-​class, high-​quality cardiovascular care. Professor Julie Sanders Director Clinical Research, St Bartholomew’s Hospital, Barts Health NHS Trust and Clinical Professor of Cardiovascular Nursing, Queen Mary University of London

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Preface The world of cardiac care continues to develop and since the publication of the second edition of the Oxford Handbook of Cardiac Nursing there have been a number of changes in the field. It is important to reflect these changes and so each chapter has been completely revised and updated. A  number of evidence-​based guidelines have been published or updated since the previous edition and relevant ones have been included at the end of each chapter. Stroke has been included for the first time in the chapter on cardiovascular emergencies. This is a potential complication of conditions such as atrial fibrillation and so it was felt that the emergency treatment of this would be a useful addition. Genetics and genomics is a growing field within healthcare and is very important to the understanding of some inherited cardiac conditions. Therefore, a section on this has been included for the first time. As ever feedback from readers helps to shape the changes made to this new edition and feedback from readers for improvements for further editions would be welcome. Kate Olson October 2019

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Acknowledgements A number of people have contributed to the development of this new edition. I would particularly like to thank Tracey Bowden, Rachel Grant, and Lynda Filer, who have updated chapters for all three editions of the book, and Alex Chamberlain and Imelda Sotto, who kindly agreed to update chapters for this particular edition, as well as Professor Julie Sanders, who wrote the foreword. I would also like to thank Anne McLeod and Maria Bliss, who gave me advice, and the reviewers, who gave me useful and constructive feedback. I will be forever grateful to Steve and Evie Olson, who gave me unending support, patience, and understanding during the writing of this edition. Kate Olson October 2019

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Contents Contributors to third edition  xiii Contributors to previous editions  xv Symbols and abbreviations  xvii Covid-19  xxi 1 Introduction: prevention of cardiovascular disease 2 Cardiac assessment 3 Cardiac investigations 4 Valvular disease 5 Infective endocarditis 6 Coronary heart disease: stable angina 7 Acute coronary syndromes 8 Interventional cardiology for coronary heart disease 9 Cardiac surgery 10 Chronic heart failure 11 Bradycardias and blocks 12 Tachycardias 13 Electrophysiology 14 Congenital heart disease and inherited cardiac conditions 15 Cardiomyopathy 16 Other cardiac problems 17 Cardiac rehabilitation 18 Cardiovascular emergencies 19 Cardiovascular drugs

1 29 79 91 115 129 141 159 183 217 241 271 295 309 333 353 371 385 423

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Contents

Appendix 1: Further suggested resources  449 Appendix 2: Heart diagrams  451 Index  453

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Contributors to third edition Tracey Bowden Chapters 3, 7, and 8 Barts Charity Clinical Doctoral Research Fellow Centre for Health Services Research School of Health Sciences City University of London London, UK and Senior Lecturer in Cardiac Care, Nursing Division School of Health Sciences City University of London London, UK

Lynda Filer Chapter 19 Lecturer, Nursing Division School of Health Sciences City University of London London, UK

Alex Cambridge Chapter 13 Deputy Principal Cardiac Physiologist Barts Heart Centre Barts Health Trust St Bartholomew’s Hospital London, UK

Imelda Sotto Chapter 10 Senior Clinical Nurse Specialist Heart Failure Service Barts Health Trust St Bartholomew’s Hospital London, UK

Rachel Grant Chapter 11 Lecturer in Critical Care Nursing, Nursing Division School of Health Sciences City University of London London, UK

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Contributors to previous editions Shaun Bowden Chapter 13 1e UK Account Manager Hansen Medical Tracey Bowden Chapters 3, 7, and 8 2e Senior Lecturer in Cardiac Care School of Health Sciences City University London, UK Jane Butler Chapters 10 and 15 2e Consultant Nurse Barts Health NHS Trust London Chest Hospital London, UK Lynda Filer Chapter 19 1e and 2e Lecturer in Applied Biological Sciences School of Health Sciences City University London, UK Tracey Gibson Chapter 8 1e Lecturer in Adult Nursing St Bartholomew School of Nursing and Midwifery City University London, UK

Rachel Grant Chapters 2 and 11 1e and 2e Lecturer in Critical Care Nursing School of Health Sciences City University London, UK Sarah E Green Chapters 7 and 15 1e Ward Sister Coronary Care Unit United Bristol Healthcare NHS Trust Bristol, UK Shawn Holden Chapter 13 2e Chief Cardiac Physiologist St Bartholomew’s Hospital London, UK SA Mohiddin Chapter 15 2e Consultant Cardiologist and Honorary Senior Lecturer Barts and the London NHS Trust London, UK Karen Rawlings-Anderson Joint Editor 1e Senior Lecturer, Division of Nursing School of Health Sciences City, University of London London, UK

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Symbols and abbreviations 1° primary 2° secondary 2 important % cross reference x controversial topic H warning > greater than < less than ♂ male ♀ female ∴ therefore ~ approximately M website i increased/​increasing d decreased/​decreasing 2D two-​dimensional 3D three-​dimensional ABG arterial blood gases ABPM ambulatory blood pressure monitoring AC atrial conduction ACC American College of Cardiology ACE angiotensin-​converting  enzyme ACHD adult congenital heart disease ACS acute coronary syndromes ACT activated clotting time ADH antidiuretic hormone ADP adenosine diphosphate A&E Accident and Emergency Department AECG ambulatory electrocardiography monitoring AED automated external defibrillator AF atrial fibrillation AH atrium to His AHA American Heart Association ALS advanced life support AP action potential APPT activated partial thromboplastin time AR aortic regurgitation ARB angiotensin receptor blockers

ARVC

arrhythmogenic right ventricular cardiomyopathy AS aortic stenosis ASAP as soon as possible ASD atrial septal defect ASH asymmetrical septal hypertrophy AV atrioventricular AVNRT atrioventricular node re-​entry tachycardia AVRT atrioventricular re-​entry tachycardia AVPU alert/v​ oice/p​ ain/u​ nresponsive AVR aortic valve replacement BBB bundle branch block BPM beats per minute BCL basic cycle length BCNIE blood culture-​negative infective endocarditis BE base excess BIMA bilateral internal mammary artery BiPAP bilevel positive airway pressure BiVAD biventricular assist device BLS basic life support BMI body mass index BMS bare metal stents BNP B-​type natriuretic peptide BP blood pressure BRS bioresorbable scaffolds BVP biventricular pacing CABG coronary artery bypass graft/​s CAD coronary artery disease CBT cognitive behaviour therapy CCF congestive cardiac failure CCU Coronary Care Unit CDRIE cardiac device-​related infective endocarditis CFAE complex fractionated atrial electrograms CHB complete heart block CHD coronary heart disease CHF chronic heart failure CK creatine kinase CKD chronic kidney disease

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Symbols and abbreviations CK-​MB

creatine kinase muscle and brain CMR cardiac magnetic resonance CO cardiac output CO2 carbon dioxide COA coarctation of the aorta COPD chronic obstructive pulmonary disease CPAP continuous positive airway pressure CPB cardiopulmonary bypass CPR cardiopulmonary resuscitation CPRP cardiovascular prevention and rehabilitation programmes CPVT catecholaminergic polymorphic ventricular tachycardia CR cardiac rehabilitation CRT capillary refill time or cardiac resynchronization therapy CRU Cardiac Recovery Unit CS coronary sinus CSM carotid sinus massage CT computed tomography CVA cerebrovascular accident CVD cardiovascular disease CVP central venous pressure CVS cardiovascular system CWS colour, warmth, sensation CXR chest  X-​ray DCM dilated cardiomyopathy DC direct current DCT distal convoluted tubule DEB drug-​eluting balloons DES drug-​eluting  stents DKA diabetic ketoacidosis DN district nurse DVLA Driver and Vehicle Licensing Authority DVT deep vein thrombosis ECG electrocardiogram Echo echocardiograph ECMO extra corporeal membrane oxygenation EF ejection fraction EGM electrogram EHRA European Heart Rhythm Association EP electrophysiology EPS electrophysiological study

ESC

European Society of Cardiology ESR erythrocyte sedimentation rate ETT exercise tolerance test FAST facial weakness, arm weakness, speech problems FBC full blood count F-​FDG fluorodeoxyglucose FH familial hypercholesterolaemia GFR glomerular filtration rate GI gastrointestinal GP general practitioner GTN glyceryl trinitrate GUCH grown-​up congenital heart [disease] H2O water Hb haemoglobin HCM hypertrophic cardiomyopathy HCO3 bicarbonate HDL high-​density lipoprotein HDU high dependency unit HFPEF heart failure with preserved ejection fraction HFREF heart failure with reduced ejection fraction Hg mercury HIV human immunodeficiency virus HMG-​CoA 3-​hydroxy-​3-​methyglutaryl-​ coenzyme A HR heart rate HRA high right atrium HRS Heart Rhythm Society HV His to ventricle interval IABP intra-​aortic balloon pump IACT intra-​atrial conduction time ICC inherited cardiac condition ICD implantable cardioverter-​defibrillator ICP intra cranial pressure IE infective endocarditis IM intramuscular IMA internal mammary artery INR international normalized ratio ITU intensive therapy unit IV intravenous IVF idiopathic ventricular fibrillation JVP jugular venous pressure K+ potassium

Symbols and abbreviations LA LAD LAH LBBB LDL LFT LGV LMS LMWH LQTS LV LVAD LVEDD

left atrium/​atrial left anterior descending left atrial hypertrophy left bundle branch block low-​density lipoprotein liver function test large goods vehicle left main stem low-​molecular-​weight heparin long QT syndrome left ventricle/​ventricular left ventricular assist device left ventricular end diastolic diameter LVEDP left ventricular end diastolic pressure LVEF left ventricular ejection fraction LVF left ventricular failure LVH left ventricular hypertrophy LVOT left ventricular outflow tract LVOTO left ventricular outflow tract obstruction LVSD left ventricular systolic dysfunction MAP mean arterial pressure M,C&S microscopy, sensitivity, and culture MI myocardial infarction MIDCAB minimally invasive direct coronary artery bypass MPS myocardial perfusion scintigraphy MR mitral regurgitation MRA mineralocorticoid antagonist MRI magnetic resonance imaging MRSA methicillin-​resistant Staphylococcus aureus MS mitral stenosis MSCT multi-​slice computed tomography MUGA multiple gated acquisition MV mitral valve MVP mitral valve prolapse MVR mitral valve replacement Na+ sodium NAC N-​acetylcysteine NaCl sodium chloride NACR National Audit for Cardiac Rehabilitation NBM nil by mouth

NG nasogastric NHS National Health Service NICE National Institute for Health and Care Excellence NIV noninvasive ventilation NMS neurally mediated syncope NOAC nonvitamin K antagonist oral anticoagulant NRT nicotine replacement therapy NSAID nonsteroidal anti-​inflammatory  drug NSF National Service Framework NSTEMI non-​ST segment elevation myocardial infarction NVE native valve endocarditis NYHA New York Heart Association O2 oxygen OH orthostatic hypotension PA pulmonary artery PAH pulmonary arterial hypertension PAP pulmonary artery pressure PAWP pulmonary artery wedge pressure PCA patient controlled analgesia PCCD progressive cardiac conduction defect PCI percutaneous coronary intervention PCT proximal convoluted tubule PCV packed cell volume PDA patent ductus arteriosus PE pulmonary embolism PEA pulseless electrical activity PEEP positive end expiratory pressure PES programmed electrical stimulation PET positron emission tomography PFO patent foramen ovale PND paroxysmal nocturnal dyspnoea POBA plain old balloon angioplasty PoTs postural orthostatic tachycardia syndrome PPCI primary percutaneous coronary intervention PPCM pregnancy-​related cardiomyopathy PPI proton pump inhibitor PPM permanent pacemaker

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Symbols and abbreviations PS PSV PTCA

pulmonary stenosis passenger service vehicle percutaneous transluminal coronary angioplasty PTT partial thromboplastin time PVC premature ventricular contraction PVD peripheral vascular disease PVE prosthetic valve endocarditis PVR pulmonary vascular resistance RA right atrium/​atrial RAAS renin–​angiotensin–​ aldosterone system RAH right atrial hypertrophy RBBB right bundle branch block RCM restrictive cardiomyopathy RFA radiofrequency ablation RR respiratory rate RSVP reason, story, vital signs, plan RV right ventricle/​ventricular RVA right ventricular apex RVAD right ventricular assist device RVF right ventricular failure RVH right ventricular hypertrophy RVOT right ventricular outflow tract RVOTO right ventricular outflow tract obstruction SA sino-​atrial SaO2 oxygen saturation SAECG signal average ECG SBAR situation, background, assessment, recommendation SC subcutaneous SCD sudden cardiac death SGA supraglottic airway S-​ICD subcutaneous implantable defibrillator SIGN Scottish Intercollegiate Guidelines Network SIMV spontaneous intermittent mandatory ventilation S/​L sub-​lingual SLE systemic lupus erythematosus SNP serum natriuretic peptides SOB shortness of breath SOBOE shortness of breath on exertion SPECT single photon emission computerized tomography SpO2 peripheral oxygen saturation

STEMI

ST-​segment elevation myocardial infarction STS Society of Thoracic Surgeons SUAVR sutureless aortic valve replacement SV stroke volume SVi stroke volume index SVE supraventricular ectopic SVT supraventricular tachycardia TAVI transcatheter aortic valve implantation TAVR transcatheter aortic valve implantation TFT thyroid function test TGA transposition of the great arteries TIA transient ischaemic attack TLOC transient loss of consciousness TOE transoesophageal echocardiograph TOF tetralogy of Fallot TPR temperature, pulse, and respiration TR tricuspid regurgitation TS tricuspid stenosis TTE transthoracic echocardiograph U&E urea & electrolytes UA unstable angina UFH unfractionated heparin UTI urinary tract infection VA venoarterial VAD venticular assist device VE ventricular ectopic VF ventricular fibrillation VHD valvular heart disease VIP Visual Infusion Phlebitis ViV valve in valve VSD ventricular septal defect VT ventricular tachycardia VTE venous thromboembolism VV venovenous WACA wide area circumferential ablation WBC white blood cell WPW Wolff–​Parkinson–​White yrs years

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Covid-19 Since this book was updated the world has been in the grip of the Covid-19 pandemic. This has had far far-reaching consequences, the extent of which may not be fully known for some time yet. We know that those people with pre-existing heart and circulatory conditions are at increased risk of becoming seriously unwell with Covid-19, particularly if they are over the age of 70. Although staying at home will have helped prevent those at increased risk contracting the virus, the potential consequences of this for some such as social isolation and decreased mobility will have other detrimental physical and mental health effects. Services such as cardiac rehabilitation have been paused and innovative new formats such as live video exercise classes have been introduced. Unfortunately, it was reported by the British Heart Foundation1 in April 2020 that the numbers reporting with a suspected heart attack in England had halved from an average of 300/day at the start of March to 150/day at the end. This equates to approximately 5000 people. It was felt that a combination of fear of contracting the virus when attending hospital and not wanting to over burden the NHS were the reasons why many did not seek help with symptoms. There was also a drop in the number of primary PCIs of 38% in March this year compared to the same period last year.2 Diagnostic investigations such as Echocardiograms saw a drop in numbers by two thirds for April/May 2020 as services were paused for all but the most urgent.3 In June 2020 it was reported that approximately 28,000 in-patient cardiac procedures in England had been deferred creating a backlog as services were resumed.4 A similar pattern has been shown across Europe and the USA. Although research grants are likely to be cut this year, important research is being undertaken into effects of Covid-19 on the circulatory system, in particular the endothelium.5 Stem cell technology used to explore treatments for heart failure is being used to understand the effects of Covid-19 on the heart.6

1 British Heart Foundation (2020) Lives at risk due to 50% drop in heart attack A&E attendances.. www.bhf.org.uk, (accessed 27/7/2020). 2 British Heart Foundation (2020) Lives at risk due to 50% drop in heart attack A&E attendances. www.bhf.org.uk, (accessed 27/7/2020). 3 British Heart Foundation (2020) Around 190,000 fewer vital heart ultrasounds in England during lockdown. www.bhf.org.uk, (accessed 27/7/2020). 4 British Heart Foundation (2020) Heart and circulatory patients among millions on treatment waiting lists. www.bhf.org.uk (accessed 27/7/2020). 5 Varga Z, Flammer AJ, Steiger P, Haberecker M et al (2020) Endothelial cell infection and endotheliitis in Covid-19.The Lancet. 395 (10234), 1417–1418 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30937-5/fulltext (accessed 27/7/2020). 6 British Heart Foundation (2020) ‘Heart-in-a-dish’ to study the effects of Coronavirus. www.bhf. org.uk (accessed 27/7/2020).

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Covid-19 Many healthcare staff working in cardiac services had a period of redeployment and retraining to work in areas for those suffering from Covid-19. There is no doubt that the burden on the NHS and staff has been enormous and may continue for some time to come. Support for those working in the NHS has been apparent and to date the NHS Charities Together Covid-19 urgent appeal has raised over £130 million pounds some of which has already been used to fund the immediate and practical needs of NHS staff, volunteers, and patients.7 The extent of the sequelae of the Covid-19 pandemic are difficult to foresee in terms of cardiovascular disease and its management; however, it has demonstrated the resilience of the workforce and spawned some innovative approaches to cardiovascular care not utilizsed previously. The impact of these has yet to be evaluated. Kate Olson 27 July 2020

7 NHS Charities Together (2020) £65 million in Covid-19 Appeal grants allocated to NHS charities. www.nhscharitiestogether.co.uk (accessed 27/7/2020).

Chapter 

Introduction: prevention of cardiovascular disease What does the book cover?  2 Mortality and morbidity  3 Policy context  4 Cardiac developments and trends  6 Prevention of cardiovascular disease  10 Risk factors for cardiovascular disease  12 Nonmodifiable risk factors  14 Modifiable risk factors: 1  16 Modifiable risk factors: 2  18 Dietary factors  20 Diabetes  22 Behaviour change  24 Concordance  26 Related guidance  28

1

2

Chapter    Introduction: prevention

of CVD

What does the book cover? This book is intended as a quick reference for nurses working in areas where they care for patients with cardiac problems. It does not cover every aspect of cardiac disease in great depth but provides the essential information required to care for patients presenting with cardiac problems. Although cardiovascular disease (CVD) affects the entire cardiovascular system, the scope of this book does not enable discussion of peripheral vascular disease (PVD). However, a new section on stroke has been added for this edition (% Stroke, Chapter  18, p.420). This book covers all the forms of heart disease that nurses working in the cardiac field might encounter (e.g. valvular disease, infective diseases, congenital and inherited diseases of the heart, common arrhythmias, and cardiac emergencies), but the primary focus is on coronary heart disease (CHD), which remains one of the largest single killers in the UK. Related topics are cross-​referenced within the book where relevant. The book covers a wide range of issues pertinent to nursing patients with cardiac problems irrespective of the clinical arena in which they are managed. The initial chapters of the book cover the assessment of the patient and outline the investigations that the patient might have. Interventions that the patient might require and pharmacological management are also included. The book gives relevant information to nurses working in a variety of specialties in the UK. Patients with cardiac problems are not always managed in a specialist unit; indeed, many of those with cardiac disease present with their first symptoms to a general practitioner (GP) or practice nurse, or their symptoms are picked up when they are treated for another unrelated problem. Around 80% of patients with CVD have at least one other condition.1 Whether you work in primary care, a general ward, or within a specialist cardiac service, this book will help you find out about the essential elements of cardiac problems that you might not be familiar with. For more in-​depth information on specific topics, there are various texts and journals readily available on the market. Each chapter has a list of appropriate guidelines at the end of the chapter, and suggested further reading and resources can also be found at the end of the book in Appendix 1. This introductory chapter briefly outlines the context within which cardiac care exists. It identifies the extent of the burden of cardiac disease and the background of policy drivers that have influenced recent developments in cardiac care. A discussion of the risk factors for CVD and health promotion is also included.

1 British Heart Foundation (2019) UK Factsheet. BHF, London.

Mortality and morbidity

Mortality and morbidity CVD is one of the main causes of death in the UK, accounting for >168 000 deaths in 2017. Of all deaths from CVD, 737% are from CHD, 9% are from vascular dementia, and >21% are from stroke. Currently 7.4 million people in the UK are living with heart or circulatory disease. There are 1.3 million people with atrial fibrillation (AF), with a further estimated 300 000 undiagnosed. Since the 1960s the death rate from CVD in the UK has been falling; however, more than 45 000 people 10% over 10yrs), it is now recommended that all people aged 40–​74yrs have a risk factor assessment. This should include questions about smoking history, family history of CVD, and measurement of BP; blood tests for glucose levels and total cholesterol, high-​(HDL) and low-​density lipoprotein (LDL); weight and waist circumference; in addition to an assessment of lifestyle factors, such as physical activity levels. Many risk factor scoring tools can then be used to predict an individual’s risk of developing CVD. When calculating this risk, consider a prior history of diabetes, medication, organ damage, CVD, and ethnicity. Tools that may be used include JBS3,20 SCORE,21 ASSIGN,22 or QRisk3.23 It is important to remember that, while a young person with several risk factors may have a fairly low absolute risk of developing CVD, their relative risk compared with someone of the same age without those risk factors will be high. A number of tools will also have algorithms for treatment management. Audit risk factors regularly.

2 0 21 22 23

https://​www.jbs3risk.co.uk/​pages/​risk_​calculator.htm www.heartscore.org www.assign-​score.com www.qrisk.org

13

14

Chapter    Introduction: prevention

of CVD

Nonmodifiable risk factors Age The development of atherosclerosis takes place over a number of years and, ∴, the risk of developing CHD i with age, particularly over the age of 65yrs. Individuals might have also developed other comorbidities, such as diabetes and hypertension, which are both independent risk factors for CVD.

Ethnicity i levels of CVD are seen in the South East Asian population (71.4 times higher than predicted for the rest of the population). This is often associated with higher levels of diabetes, FH, and i waist circumference. Although individuals from Africa and the Caribbean have a lower level of CHD, they have higher levels of hypertension and stroke.

Gender ♂ have higher rates of CHD because of the protective effects of oestrogen in ♀ before the menopause. Over the age of 75yrs the rates are equal. ♀ often present later and frequently have atypical symptoms; coronary arteries are smaller in ♀ and they are more likely to suffer with Syndrome X (% Syndrome X, Chapter 6, p.133). They also seem to have more severe complications following MI and surgery.

Family history A family history of CHD is considered a risk factor. The risk is i depending on the following factors: • CHD in a close family member—​e.g. sibling or parent • Number of relatives with CHD • The age at which CHD first presented—​the younger the presentation, the greater the risk. In some cases, there could be a history of FH. If this is the case, it is important that all family members are regularly screened. Family history also has an important role in cardiac diseases that have genetic links, such as cardiomyopathy.

Severe mental illness People with severe and prolonged mental illness are at risk of dying on average 15–​20yrs earlier than other people. Two thirds are from avoidable physical illnesses such as CVD.24

24 NHS (2016) Five-​Year Forward View for Mental Health for the NHS in England. NHS, London.

Nonmodifiable risk factors

15

16

Chapter    Introduction: prevention

of CVD

Modifiable risk factors:  Smoking Smoking causes a number of diseases, including many cancers. The risks associated with CVD are attributable to the chemicals within cigarettes. Some of these have an effect on the endothelium and i the likelihood of atherosclerosis developing. Carbon monoxide binds more readily with haemoglobin than oxygen (O2) and, ∴, d the amount of O2 available to the myocardium. Nicotine leads to the release of adrenaline, which causes vasoconstriction and, ∴, i the workload of the heart. It also leads to hypertension and i platelet aggregation. The impact of smoking is greater on those with hypertension or diabetes.

Smoking cessation When assessing smoking history, it is important to consider both the number of cigarettes smoked per day and the number of years the individual has smoked. This is also important in those who might have stopped smoking for a few years but who previously smoked for many years. Previous attempts at quitting and the methods used should also be assessed. Strategies for smoking cessation include advice, nicotine replacement therapy (NRT), and medication. Although individually each of these is proven to be successful, the strategy used should consider the individual’s dependence on smoking and their motivation to quit. If they have a high motivation and low dependence, advice might be enough. If, however, they have a high dependence, they will probably require NRT. Referral to trained smoking cessation advisers should be offered. Smokers are four times more likely to give up with stop smoking services. The National Centre for Smoking Cessation Training offers training for health professionals and is a resource for evidence-​based interventions.25

Advice Even brief advice (5min) can be successful, so it is important that healthcare professionals discuss smoking where possible. Health professionals are advised to use the three As26: Ask and record smoking status; Advise patients of health benefits of stopping; Act on patient’s response. Questions should focus on the individual’s smoking habit, their dependence on smoking, their willingness to give up smoking, and their understanding of the effects smoking has on their health. Motivational interviewing (% Motivational interviewing, p.25) has proven to be beneficial in assisting with smoking cessation. Other patients may find Internet-​ based interventions useful, such as M www.smokefree.nhs.uk, which has a number of tools to help people assess addiction and look at the method best suited to them to help them stop smoking. Telephone quitlines and text message services have also proved to be beneficial.

2 5 https://​www.ncsct.co.uk/​ 26 National Institute for Health and Care Excellence (2018) Stop Smoking Interventions and Services. NG92. NICE, London.

Modifiable risk factors: 

E-​cigarettes Although the evidence of long-​term effects is still developing, e-​cigarettes are felt to be less harmful than tobacco and can be helpful. It is important to advise patients that they are not proven to be risk free.

NRT NRT can take the form of gum, sublingual tablets, inhalators, nasal spray, and patches. The product used will depend on the patient’s preference and advice of the clinician, as some products may be contraindicated. NRT is beneficial for patients who have a high level of dependence on smoking.

Medication Bupropion can decrease the desire to smoke and the withdrawal symptoms. It should be taken 1–​2wks prior to quitting smoking. There are a number of contraindications, such as pregnancy, breastfeeding, and a history of bipolar disorder. It should not be prescribed to under 18s. Side effects include seizure (rare), dry mouth, rash, and insomnia. Varenicline has been specifically developed to help with smoking cessation. It also reduces the desire to smoke and d withdrawal symptoms. It also has a number of contraindications, such as pregnancy and breastfeeding, and should be used with caution in those with psychiatric illness as it may i suicidal thoughts. It should not be prescribed to under 18s.

Relapse Although some patients can be successful in quitting at their first attempt, for others smoking cessation can take longer. If the patient does relapse, the nurse should help them to understand the reasons for this and encourage them to have another attempt at giving up smoking.

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Chapter    Introduction: prevention

of CVD

Modifiable risk factors: 2 Hypertension High BP (systolic BP >140mmHg and diastolic BP >90mmHg) leads to i cardiac workload and i the risk of stroke, organ damage (e.g. renal impairment), and PVD. It is the leading risk factor for heart and circulatory disease in the UK. It is estimated that 6–​8 million people have undiagnosed or uncontrolled i BP.27 It can be caused by smoking, high sodium intake, and, to a certain extent, i levels of stress over a period of time. However, in some cases there is no identifiable cause. This is known as ‘essential hypertension’. NICE guidance on ° hypertension28 recommends that if a recorded BP is 140/​90mmHg the patient should be offered ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis. Home monitoring (HBPM) can be used as an alternative. Dietary modification, stopping smoking, d alcohol intake, and i levels of physical activity all help to lower BP levels. Recommendations29 for offering antihypertensive medication are as follows: • Stage 1 hypertension—​average BP >140/​90 –​159/​99mmHg, and ABPM daytime average or HBPM 135/​85 –​149/​94mmHg, aged 4wks) and either an ejection fraction (EF) of 38°C, large pericardial effusion). • Pain management is the central therapeutic tool. Aspirin and nonsteroidal anti-​inflammatory drugs (NSAIDs) are usually prescribed with colchicine as an adjunct to this. • Antitubercular medication is required for tuberculous pericarditis and the appropriate antibacterial agents are required if a causative organism is isolated. • Antibiotics such as benzylpenicillin, flucloxacillin, or gentamicin are commonly prescribed if bacterial infection is suspected. • Low-​dose corticosteroids may be used if there are contraindications to aspirin, NSAIDs, and colchicine.

Nursing considerations The main principles of nursing care are as follows: • Administer anti-​inflammatory drugs and evaluate their effectiveness. • Manage symptoms, such as pyrexia and pain. • Monitor cardiovascular status. • Support the patient’s psychological needs. Pericarditis can commonly result from an underlying condition and the patient is likely to be anxious. The following should be considered for patients with a diagnosis of acute pericarditis depending on the severity of symptoms: • Record temperature at least every 4h—​i frequency if patient feels feverish or if temperature i. • Monitor blood pressure (BP) and pulse to assess cardiovascular status at least every 4h—​i frequency if symptoms deteriorate. • Monitor respiratory rate and SpO2 at least every 4h—​administer supplemental O2, as prescribed. • Daily 2-​lead ECG. • Because the patient is relatively immobile during the acute phase, it is wise to measure and fit antiembolism stockings. • Risk assessment for pressure ulcers is also indicated if the patient is immobile and feverish—​implement preventive measures, depending on risk assessment score. • Exercise should be restricted until the patient has recovered.

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Pericardial effusion This is the accumulation of fluid in the space between the layers of the pericardium. The fluid can have the following origin: • Exudate of serous fluid or pus • Transudate from heart failure • Blood from trauma or malignant disease. If the fluid builds up gradually, symptoms might be minimal because pericardial stretching can occur, and cardiac function might not be compromised. European Society of Cardiology (ESC) guidelines2 classify the size as: mild 20mm as assessed by Echo. Rapid accumulation of fluid can lead to cardiac tamponade (% Cardiac tamponade, p.405) if the underlying cause is not identified and treated.

Signs and symptoms • The patient may be asymptomatic, and the effusion discovered as part of examination for something else • Pericardial-​type pain might be present • Dyspnoea • Fever • Cough • Weakness and lethargy • Symptoms associated with an underlying condition—​e.g. ascites and peripheral oedema in heart failure • If there is compression of other structures this may lead to symptoms such as nausea, dysphagia, hoarseness, hiccups.

Investigations • 2-​lead ECG—​shows d voltage and tachycardia. Electrical alternans might be seen, whereby the complexes vary in amplitude from cycle to cycle. This reflects changes in the heart’s position within the effusion and is highly suggestive of pericardial effusion. • CXR—​an enlarged cardiac silhouette is visible if >250mL of fluid has accumulated. An enlarged heart without evidence of pulmonary venous congestion makes the diagnosis of pericardial effusion probable. • An echocardiogram can show excess fluid and the size of the effusion can be estimated. Serial Echos are helpful to observe progress of the effusion. • CT. • CMR.

Clinical management • The effect on haemodynamics needs to be assessed. • If the effusion is associated with pericarditis, that needs to be treated. 2 Adler Y, Charron P, Imazio M, Badano L, Baron-​Esquivias G (205) 205 ESC Guidelines for the diagnosis and management of pericardial diseases. The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). European Heart Journal 36, 292–​64.

Pericardial effusion

• No specific treatment is required for the effusion, but the underlying condition must be diagnosed and treated. • Pericardiocentesis (‘pericardial tap’) might be required if the cause is not known because this can help to establish the nature of the effusion. Any fluid drawn should be sent for testing to rule out tuberculosis.

Nursing considerations The main principles of nursing care are as follows: • Manage symptoms of the underlying condition. • Monitor cardiovascular status because cardiac tamponade is a possible sequela of pericardial effusion. • Support the patient’s psychological needs. The following are considered for all patients who are diagnosed with pericardial effusion, but additional interventions relating to the underlying cause of the effusion might be required: • Record temperature at least every 4h—​i frequency if the patient feels feverish or if the temperature i. • Monitor BP and pulse to assess cardiovascular status at least every 4h—​ i frequency if symptoms deteriorate. • Monitor respiratory rate and SpO2 at least every 4h—​administer supplemental O2, as prescribed. • Daily 2-​lead ECG. • Monitor fluid status—​either using a fluid-​balance chart or by measuring the patient’s weight daily. • Observe neck veins for signs of i jugular venous pressure (JVP) (% General assessment of the patient, p.32).

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Constrictive pericarditis This is usually caused by tuberculosis, mediastinal irradiation, previous surgery, viral, idiopathic, connective tissue disorder, or trauma. The pericardium becomes fibrosed and scarred, losing its elasticity. The heart becomes compressed, restricting diastolic filling. The presentation of constrictive pericarditis is similar to that of right ventricular failure (RVF).

Signs and symptoms • d cardiac output (CO) and compensatory tachycardia • Low pulse volume • Engorged neck veins • Abdominal swelling • Fatigue • Hepatomegaly and ascites • Peripheral oedema • Pleuritic pain • Dyspnoea.

Investigations • 2-​lead ECG—​abnormal, but usually nonspecific, changes (e.g. low-​ voltage QRS). AF might be present. • CXR—​calcification might be seen. The heart is usually small or normal in size. • Echocardiogram—​pericardial thickening may be evident. • CT or a CMR scan—​can show pericardial thickening and reduces the need for a biopsy to differentiate between restrictive cardiomyopathy and constrictive pericarditis (% Imaging studies: nuclear and cardiac magnetic resonance, p.86; Imaging studies: computed tomography calcium scoring, p.88). • Cardiac catheterization—​abnormalities in diastolic chamber pressures are seen. • Blood tests—​usually show abnormal liver function test (LFT) and i WBC count.

Clinical management • Prevention is the best form of management. However, if severe pericardial constriction is evident, surgical pericardiectomy is required.

Nursing considerations These relate mainly to the symptoms of right-​sided failure that the patient presents with. The main principles of nursing care are as follows: • Manage the symptoms of the condition. • Monitor cardiovascular status. • Support the patient’s psychological needs, especially in relation to preparation for surgery.

Constrictive pericarditis

The following are considered for all patients who are diagnosed with constrictive pericarditis, but additional interventions related to the underlying cause of the pericarditis (e.g. antitubercular therapy) and preparation for surgery are required (% Preoperative assessment, p.186): • Monitor BP and pulse to assess cardiovascular status at least every 4h—​ i frequency if symptoms deteriorate. • Monitor fluid status—​either using a fluid-​balance chart or by measuring the patient’s weight daily. • Observe neck veins for signs of i JVP (% General assessment of the patient, p.32). • Risk assessment for pressure ulcers is also indicated if the patient is immobile—​implement preventive measures, depending on risk assessment score. • Antiembolism stockings are contraindicated if peripheral oedema is present.

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Myocarditis Myocarditis is inflammation of the myocardium. It may be associated with pericarditis—​myopericarditis. It causes a wide range of symptoms, from minor influenza-​like symptoms to severe heart failure and sudden death. The causes of myocarditis are numerous (Box 6.) and treatment greatly depends on the symptoms and aetiology. Often the cause is unknown and is attributed to a virus. There is a generalized inflammatory response, which can cause myocyte necrosis, and it is this part of the disease process that usually gives rise to clinical signs and symptoms. It is thought to have three phases: • Phase —​viral stage • Phase 2—​autoimmune phase • Phase 3—​dilated cardiomyopathy (DCM).

Signs and symptoms Variable and often nonspecific because of the aetiology, but patients seek medical help when the following occur: • Chest pain • Dyspnoea • Palpitations • Syncope • Fatigue • Fever. The most dramatic presentation will be acute DCM (% Dilated cardiomyopathy, p.342).

Investigations • 2-​lead ECG—​can reveal minor or major abnormalities. • CXR—​can show nonspecific abnormalities related to heart failure or cardiac enlargement. • Echocardiogram—​can identify cardiac dysfunction. • Blood tests—​i levels of cardiac markers are present because of myocyte damage. C-​reactive protein (CRP) and B-​type natriuretic peptide (BNP) are likely to be elevated. Viral titres can help to identify the causative organism. Box 6.  Causes of myocarditis • Viral (e.g. Enterovirus, Parvovirus, Rickettsia, Coxsackie B, mumps, hepatitis C, and HIV) • Fungal (e.g. candidiasis and aspergillosis) • Bacterial (e.g. diphtheria, legionella, and salmonella) • Protozoal (e.g. Trypanosoma) • Drug-​induced (e.g. cocaine, arsenic, inotropes, and reactions to drugs such as sulfonamides) • Sarcoidosis • Others (e.g. radiation, peripartum, and autoimmunity).

Myocarditis

• CMR imaging—​helpful as a diagnostic tool for identifying myocarditis (% Imaging studies: nuclear and cardiac magnetic resonance, p.86; Imaging studies: computed tomography calcium scoring, p.88). • Biopsy—​endomyocardial biopsy can help in the diagnosis, but it is costly and invasive.

Clinical management • Restrict physical activity. • Eradicate infective organism. • Symptom management for arrhythmias and heart failure. • In patients with severe haemodynamic compromise, an intra-​aortic balloon pump (IABP), left ventricular assist device (LVAD), or extra-​ corporeal membrane oxygenation (ECMO) might be required (% Intra-​ aortic balloon pumps (IABPs), p.410; Ventricular assist devices, p.414; Extra-​corporeal membrane oxygenation, p.415.).

Nursing considerations These relate mainly to the symptoms that the patient presents with. The main principles of nursing care are as follows: • Manage the symptoms of the condition. • Monitor cardiovascular status. • Support the patient’s psychological needs. The following are considered for all patients who are diagnosed with myocarditis, but additional interventions related to the underlying cause (e.g. antibacterial therapy) are required. • Initially continuous cardiac monitoring is advised to assess for signs of arrhythmias and ST changes. • Monitor BP and pulse to assess cardiovascular status at least every 4h—​ i frequency if symptoms deteriorate. • Record temperature at least every 4h. • Monitor fluid status—​either using a fluid-​balance chart or by measuring the patient’s weight daily to detect developing heart failure or evaluate treatment of heart failure. • Observe neck veins for signs of i JVP. • Risk assessment for pressure ulcers is also indicated because the patient is immobile—​implement preventive measures, depending on risk assessment score. • Antiembolism stockings are contraindicated if peripheral oedema is present.

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cardiac problems

Athlete’s heart The term ‘athlete’s heart’ refers to normal physiological changes that occur as a result of prolonged cardiovascular exercise, which can simulate heart disease. The changes can include the following: • i left ventricular volume • d resting heart rate (HR) • Slowing of atrioventricular (AV) nodal conduction, with first-​degree AV nodal block seen on an ECG • Left ventricular hypertrophy (LVH) indicated on ECG • Incomplete right bundle branch block (RBBB) on ECG. If the athlete stops training, the heart returns to its previous condition. If changes as just outlined are noted, further investigations are warranted to rule out pathophysiological reasons for the changes. Echocardiography is used to distinguish between athlete’s heart and hypertrophic cardiomyopathy (HCM). Because the person with athlete’s heart does not have any symptoms, the signs are usually picked up when they are being treated for some unrelated medical or surgical condition. In these instances, the main nursing considerations are related to supporting the patient through any investigations and ensuring that they understand the reasons for these. 2 Emphasize that the changes noted are physiological responses to prolonged exercise rather than pathophysiological changes that require treatment. Investigations are required to rule out any pathophysiological cause.

Preparticipation screening in young athletes In some countries and some parts of the UK, preparticipation screening in young athletes is conducted to rule out conditions such as HCM, congenital defects, and arrhythmias that may lead to sudden cardiac death (SCD). While ECG changes may be due to athlete’s heart, other areas such as episodes of syncope, chest pain, family history of cardiac disease, palpitations, i BP, and excessive dyspnoea not related to exercise should all be investigated further.

Cardiac cancers

Cardiac cancers Cancer of the heart is extremely rare. However, nurses working in cardiac areas could care for patients with the following:

Myxoma This is usually benign. Usually occurs in the left atrium (LA) and is a tumour attached to the septum by a pedicle. Thus, its position can vary with posture and so associated symptoms might be transient. Symptoms are usually related to obstruction of the mitral valve (MV) and resemble those of mitral stenosis (MS) (% Mitral valve stenosis, p.102). Diagnosis is made from an echocardiogram and surgical intervention is required.

Carcinoid syndrome Malignant carcinoid tumours, with liver metastases, can be associated with stenosis and regurgitation of the pulmonary and tricuspid valves. The mechanism of the valve lesion is not fully understood, but it is thought to be related to secretion of kinins by the tumour. However, symptoms of right-​ sided heart failure can be present, and these are treated using conventional therapy (% Clinical management, p.226).

Carcinoma-​related pericardial effusions Pericardial effusion can result from fluid infiltration from adjacent lung or breast tumours in patients with advanced-​stage disease. Treatment is palliative and related to symptom management.

Angiosarcoma This is a rare soft tissue sarcoma. It may be linked to past radiotherapy; however, as it is very rare the cause is often unknown. The patient may not have any symptoms until the cancer has spread to other parts of the body. Symptoms may include shortness of breath (SOB), chest pain, and signs of pleural effusion. The patient may require surgery, radiotherapy, and chemotherapy.

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Heart disease in pregnancy Heart disease is the leading cause of maternal death in the UK. Some of the reasons for this include coronary artery disease (CAD), i maternal age, obesity, and Type 2 diabetes. More women with congenital heart disease are also surviving to adulthood and, although pregnancy can be tolerated well with many congenital heart defects, there are some that pose higher risks to both the mother and the fetus. Normal haemodynamic changes during pregnancy include the following: • i CO (due to an i stroke volume (SV) and HR) • d systemic vascular resistance (SVR) • i ventricular chamber mass • Pro-​arrhythmic state due to i catecholamines and hormonal changes • i Hypercoagulability. The most dramatic haemodynamic changes occur during labour, delivery, and the early postpartum period. The ESC has produced guidelines on the management of cardiovascular disease (CVD) in pregnancy. Some of the essential messages are as follows3:

General • Counselling of women with known or suspected CVD should start before pregnancy and include genetic counselling. • Echo should be performed on pregnant patients with new or unexplained cardiovascular signs and symptoms. • ECG, Echo, exercise test, CT, or magnetic resonance imaging (MRI) may be used to estimate risk pre-​pregnancy. • High-​risk women should be managed in specialist centres. • Suspected fetal congenital malformations in affected families should have an Echo. • Diagnostic tests involving radiation should be avoided (Echo, exercise test, or MRI (without contrast) preferred). • Cardiac catheter and surgery avoided in pregnancy where possible. • Vaginal delivery preferred. • Induction at 40wks.

Congenital heart disease • Risk of pregnancy depends on disease, ventricular and valve function, and cyanosis. • Individualized plan of follow-​up should be devised. • Pregnancy is not recommended in pulmonary i BP, congenitally corrected transposition of the great arteries (TGA), New York Heart Association (NYHA) class III/​IV, ejection fraction (EF) 45mm.

Valve disease • Moderate and severe MS should be treated pre-​pregnancy as poorly tolerated. • Pregnancy is not recommended in severe aortic stenosis (AS). • Regurgitant lesions better tolerated than stenotic. • For those with mechanical valves, oral anticoagulant with low-​dose vitamin K antagonist are safest. This would normally be changed to either low-​molecular-​weight heparin (LMWH) or unfractionated heparin (UFH) at 36wks.

Coronary artery disease • Primary percutaneous coronary intervention (PPCI) is the treatment of choice in acute coronary syndromes (ACS)/​ST-​segment elevation myocardial infarction (STEMI). • Pregnancy is usually okay in known CHD if there is no residual ischaemia or clinical signs of left ventricular (LV) dysfunction.

Cardiomyopathy • Pregnancy is usually tolerated well in HCM. • There is a risk of deterioration in DCM. • Peripartum cardiomyopathy is usually suspected if there is LV systolic dysfunction without identifiable cause in the last month of pregnancy or first months postpartum.

Arrhythmias • May become more frequent during pregnancy or may manifest for the first time. • β-​blockers may be used for AF. • If the mother is haemodynamically unstable with an arrhythmia, cardioversion should be considered. • Implantable cardioverter defibrillator (ICD) should be considered pre-​ pregnancy if there is a high risk of SCD. • Atrioventricular node re-​entry tachycardia (AVNRT) or atrioventricular re-​entry tachycardia (AVRT)—​vagal manoeuvres or adenosine should be considered.

Hypertension • Drug treatment of severe i BP is beneficial. • Target BP when treating hypertension in pregnancy is 35/​85mmHg.4 • Labetalol, nifedipine, or methyldopa are the recommended drugs of choice in the long-​term management of i BP in pregnancy. 4 National Institute for Health and Care Excellence (209) Hypertension in Pregnancy: Diagnosis and Management. NG33. NICE, London.

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• Angiotensin-​converting enzyme (ACE) inhibitors, angiotensin II antagonists, and direct renin inhibitors are contraindicated in pregnancy. • If there are any symptoms of pre-​eclampsia (e.g. severe headache, blurred vision) medical advice should be sought as soon as possible. • If there is a high risk of pre-​eclampsia, the patient may need to take aspirin from 2wks until birth of the baby.

Related guidance

Related guidance Adler Y, Charron P, Imazio M, Badano L, Baron-​Esquivias G (205) 205 ESC Guidelines for the diagnosis and management of pericardial diseases. The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). European Heart Journal 36, 292–​64. National Institute for Health and Care Excellence (209) Hypertension in Pregnancy:  Diagnosis and Management. NG33. NICE, London. Regitz-​Zagrosek V, Roos-​Hesselink JW, Bauersachs J, et al. (208) 208 ESC guidelines on the management of cardiovascular diseases during pregnancy. European Heart Journal 39(34), 365–​24.

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Chapter 7

Cardiac rehabilitation Introduction  372 Cardiovascular prevention and rehabilitation  374 Delivery of cardiac rehabilitation  378 Management of lifestyle and risk factors  380 Physical activity  382 Psychosocial assessment  384 Related guidance  384

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Introduction The risk factors for cardiovascular disease (CVD) and their suggested management are discussed in Chapter  (% Nonmodifiable risk factors, p.14; Modifiable risk factors:  , p.16) along with the role of health promotion (% Behaviour change, p.24). This chapter looks at the role of cardiac rehabilitation for those at risk of cardiac disease or who have sustained a cardiac event. Cardiac rehabilitation has been a priority area for a long time from the National Service Framework for Coronary Heart Disease; NHS Improvement Heart and now features in the NHS Long Term Plan. The introduction of certification for cardiovascular prevention and rehabilitation programmes (CPRP) has meant that their quality can be measured. The introduction of more technology-​based interventions has opened up the opportunity for more people to participate, particularly for individuals that could not, or did not, want to attend a traditional CPRP. The National Audit for Cardiac Rehabilitation (NACR)2 audit figures for 208 suggest more people are taking up cardiac rehabilitation.

 National Health Service (209) The NHS Long Term Plan. NHS England, London. 2 National Audit of Cardiac Rehabilitation (208) Quality and Outcomes Report 208. BHF, York.

Introduction

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Cardiovascular prevention and rehabilitation All patients who have had a cardiac event should be offered cardiac rehabilitation. Those at high risk of CVD can also benefit from CPRP. This can start before admission, for those patients that are being admitted for cardiac surgery or an intervention, at a pre-​admission clinic, or while the patient is on the waiting list. However, it usually commences during the in-​patient stay. Figure 7. illustrates a pathway for cardiac rehabilitation.3 While most Trusts might employ cardiac rehabilitation nurses and/​or teams, it is the responsibility of all nurses to participate in the rehabilitation process when the opportunity presents itself.

Standards and core components of cardiac rehabilitation The British Association for Cardiovascular Prevention and Rehabilitation has produced standards and core components for disease prevention and rehabilitation (Box 7.).4 The core components are: • Health behaviour change and education • Lifestyle risk factor management—​physical activity and exercise; healthy eating and body composition; tobacco cessation and relapse prevention • Psychosocial health • Medical risk management • Long-​term management • Audit and evaluation. Patients should be identified and referred to the cardiac rehabilitation team as soon as possible. Regardless of whether the patient is willing or able to participate in a formal exercise programme they will still need information and reassurance about their condition. It is important to remember that immediately after a cardiac event the patient might not be in a position to take in too much information, so all verbal information should be supported by appropriate written literature. The family should be included where possible. Referral to other services (e.g. dietician, smoking cessation adviser, psychologist) might be required following assessment of cardiac rehabilitation needs.

3 Department of Health (200) Service Specification for Cardiac Rehabilitation Services. Department of Health, London. 4 British Association for Cardiovascular Prevention and Rehabilitation (207) The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 207 (3rd edition). British Cardiovascular Society, London.

Reproduced under the Open Government Licence from Department of Health (200) Service Specification for Cardiac Rehabilitation Services. Department of Health, London.

Fig. 7.  Pathway for cardiac rehabilitation.

Cardiovascular prevention and rehabilitation

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Box 7.  Standards for cardiac rehabilitation . The delivery of six core components by a qualified and multidisciplinary team, led by a clinical coordinator. 2. Prompt identification, referral, and recruitment of eligible patient populations. 3. Early initial assessment of individual patient needs, which informs the agreed personalized goals that are reviewed regularly. 4. Early provision of a structured cardiovascular prevention and rehabilitation programme (CPRP), with a defined pathway of care, which meets the individual’s goals and is aligned with patient preference and choice. 5. Upon programme completion, a final assessment of individual patient needs and demonstration of sustainable health outcomes. 6. Registration and submission of data to the National Audit for Cardiac Rehabilitation (NACR) and participation in the National Certification Programme (NCP-​CR). Reproduced from British Association for Cardiovascular Prevention and Rehabilitation Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 207 (3rd edn).

Cardiovascular prevention and rehabilitation

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Delivery of cardiac rehabilitation An individual patient assessment and goal setting takes place either in hospital or post-​discharge. At this point suitability to exercise as well as the most appropriate mode of CPRP can be decided. It is recommended that patients should be engaged in relevant aspects of cardiac rehabilitation within 2wks of diagnosis (stable angina or heart failure) or discharge from hospital. During this period patients are likely to be receptive to advice regarding lifestyle changes. Depression, anxiety, and social isolation can also be issues, which cardiac rehabilitation can help to address. Rehabilitation should be evidence based and designed to meet the needs of the individual patient. Regardless of the mode of delivery, the individual should have access to the multidisciplinary team and should be support during the process. It may include the following aspects: • Telephone support, in the form of follow-​up calls or helpline services • Home visits by a specialist cardiac nurse • Drop-​in or organized out-​patient clinics • Web-​based programmes • Literature • Community-​based or hospital-​based exercise programmes • Home-​based programmes such as the Heart Manual5 or the REACH-​HF (Rehabilitation EnAblement in CHronic Heart Failure) programme6 for heart failure patients are available with monitoring and support from cardiac rehabilitation staff • Some programmes may be run by community centres, charities, private organizations, and sport centres, particularly for long-​term exercise maintenance. High priority for CPRP is given to those with acute coronary syndromes (ACS), coronary revascularization or heart failure. However, where possible, programmes should be available for all types of cardiac conditions and those following device insertion or cardiac resynchronization therapy. Evidence suggests that the more encouragement patients are given to attend an exercise programme, the more likely they are to participate. Even if patients are not able to exercise, it is important that they are given appropriate advice regarding their individual risk factors. This advice needs to be practical, realistic, and achievable. There are various resources available to help health professionals develop and deliver cardiac rehabilitation (see % Related guidance, p.384). Re-​assessment of the patient should take place at the end of a structured exercise programme followed by a long-​term management plan.

5 NHS Lothian (209) The Heart Manual:  Post Myocardial Infarction Edition. http://​www. theheartmanual.com (accessed  September 209). 6 National Institute for Health Research (209) Rehabilitation EnAblement in CHronic Heart Failure (REACH-​ H F).  https:// ​ clahrcprojects.co.uk/​ resources/​ p rojects/​ rehabilitation-​ e nablement-​ chronic-​heart-​failure-​reach-​hf-​intervention (accessed  September 209).

Delivery of cardiac rehabilitation

Long-​term follow-​up Some patients may carry on to attend a community-​based cardiac rehabilitation programme. There are also a number of patient-​led support groups that can be beneficial. Long-​term follow-​up may include auditing of risk factors, such as smoking cessation rates, in addition to morbidity and mortality figures. This auditing may be carried out by the patient’s GP practice.

Auditing of cardiac rehabilitation Each cardiac rehabilitation programme is expected to audit and evaluate their service. This should include clinical outcomes as well as patient experience and satisfaction. In the UK this information is collected by the NACR and an annual report is produced. Certification has recently been introduced to give programmes an opportunity to ensure they are meeting the standards and core components of the British Association for Cardiovascular Prevention and Rehabilitation (BACPR).

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Management of lifestyle and risk factors The goals of lifestyle management are as follows: • Improve quality of life. • Help to control symptoms, such as shortness of breath (SOB), lethargy, and chest pain. • Reduce the risk of a further cardiac event or death. • i the lifespan of coronary artery bypass graft/​percutaneous coronary intervention (CABG/​PCI). To achieve these goals, many patients might need help with changing behavioural risk factors (% Behaviour change, p.24). It is important that patients are motivated to change behaviour that has a negative effect on their health and that they set realistic goals to achieve this. If the patient has a number of risk factors, such as the need to stop smoking and lose weight, advice regarding priorities might be required. Nurses can help patients to set goals/​objectives for behavioural change. However, it is vital that these are the patient’s goals and not those of the healthcare professional. The role of the nurse is to assess levels of knowledge, and provide the patient with relevant information using different and appropriate methods and encouragement to achieve their goals. It is important that the goals set are realistic, achievable, and measurable. For example, if weight loss is the target, the patient needs to decide how much weight they want to lose and the period of time in which they will achieve the weight loss. They also need to think about how they will achieve this (e.g. by committing to an exercise programme, joining a slimming club, etc.). The nurse can help with setting goals and providing advice on sensible weight loss. To i motivation, it is important that the patient includes a system of rewards for achieving their goals. Support of family and friends is beneficial. The aim should be for lifestyle changes to become permanent and the emphasis should be on finding practical and enjoyable solutions so that the patient does not feel deprived. Often, small changes in behaviour will result in a positive effect on a person’s health. Although the patient might only be focusing on one area, such as weight loss, this can also lead to an improvement in physical fitness, d blood pressure (BP), and d blood cholesterol levels. Misconceptions around CPRP and illness perception should also be addressed. Topics for the educational component of CPRP can include7: • Pathophysiology and symptoms • Interventions such as CABG • Lifestyle factors including physical activity, healthy eating, weight management, smoking cessation • Management of i BP, lipids, and glucose • Cardioprotective medication • Psychosocial and emotional self-​management 7 British Association for Cardiovascular Prevention and Rehabilitation (207) The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 207 (3rd edn). British Cardiovascular Society, London.

Management of lifestyle and risk factors

• Cardiopulmonary resuscitation • Resuming and maintaining sexual relations and issues around sexual dysfunction • Occupational/​vocational factors • Activities of daily living. Advice on reducing risk factors for CVD can be found in Chapter .

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Physical activity Physical activity can help to d BP, i high-​density lipoprotein (HDL) cholesterol, d a person’s risk of a stroke, help prevent or control diabetes, aid weight loss, and improve the chances of survival following a heart attack. It also has a positive effect on depression, anxiety, and improves well-​being. It is therefore an important part of rehabilitation and 2° prevention. Physical activity should be part of daily activities and, while some individuals may find it beneficial to join a gym or a formal exercise class, this is not necessary or appropriate for all. Following a cardiac event, individuals should seek medical advice prior to undertaking any strenuous exercise. Physical activity levels will depend on the symptoms the patient is experiencing and any other comorbidities, such as arthritis or respiratory conditions, that may limit activity. However, individual programmes can be tailored to suit the patient’s needs. There are a number of assessments that can be used a guide to the level of exercise that is safe for an individual to do such as an exercise tolerance test (ETT), 6 Minute Walk Test, or Chester Step Test. Walking is an activity that most patients will be able to do and, if done regularly, will help improve fitness levels. Other aerobic activities include cycling, swimming, and dancing. General advice for those who are i their physical activity includes the following: • Activities should include a warm-​up and cool-​down period. • As well as a warm-​up and cool-​down, CPRP usually offer an aerobic component (using gym machines or other exercises) and muscular strength and endurance (MSE). MSE helps improve balance and reduces falls risk in later life. • Those patients who experience angina should carry glycerol trinitrate (GTN) spray or tablets with them (in some cases it may be advisable for individuals to take GTN prior to any exercise). • Activity should be stopped if the individual experiences chest pain, dizziness, acute SOB, or palpitations. However, where possible, the individual should keep their feet moving so that they do not stop exercise abruptly. • Activity levels should be i gradually. The time spent doing the activity, the intensity, and the distance (or duration) can be i if the individual has not experienced any problems with the activity. • Those with angina should not exercise in very cold weather or immediately after a heavy meal. • It is better for the individual to try and do small amounts frequently. The aim is to build up to 50min of moderately intense aerobic activity, such as brisk walking or cycling, in a week. • The ‘talk test’ can be used as a way for individuals to check if they are exercising at the right intensity. The aim is that the individual should still be able to talk but will feel warm and be breathing heavily. If they cannot talk while exercising, they are working too hard and should slow down. CPRP may use more formal methods of assessing exercise intensity including heart rates and perceived exertion.

Physical activity

Sex Patients might be anxious about resuming sexual activity following a cardiac event. However, it is suggested that if an individual can climb a flight of stairs they should be able to participate in sexual activity. Some medications (e.g. β-​blockers) can affect sexual performance (% β-​blockers, p.430). Patients should discuss their concerns with their GP or cardiologist.

Return to work Returning to work following a cardiac event may be influenced by the following factors: • Age • Other comorbidities • Economic status • Attitude of patient and family • Type of work (e.g. heavy manual labour would not be advisable post-​ myocardial infarction (MI) or post-​cardiac surgery) • Attitude of physician • Attitude of employer • Recurrence of symptoms.

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Psychosocial assessment Patients may experience depression, anxiety, and social isolation after a cardiac event. Although this is quite normal, and is usually temporary, in some patients it can be more severe and can have a negative effect on their recovery. A basic psychosocial assessment should be performed on all patients while they are in hospital. This may include anxiety, depression, illness perception, social support, stress, sexual well-​being, and quality of life. If necessary, the patient should be referred to a psychologist or other appropriate practitioner. There are a variety of tools (often questionnaires) that can be used to explore the patient’s psychological and emotional needs and quality of life. Cognitive behavioural therapy can be useful for those with anxiety or depression. CPRP should offer relaxation and also include stress management. An assessment of psychosocial health should be done at the end of the programme too.

Related guidance Anderson L, Thompson D, Oldridge N, Zwisler A-​D, et al. (206) Exercise based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews. https://​doi.org/​ 0.002/​465858.CD00800.pub3 British Association for Cardiovascular Prevention and Rehabilitation (207) The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 207 (3rd edn). British Cardiovascular Society, London. British Heart Foundation (208) Cardiac Rehabilitation: The Big Picture. BHF, London. National Audit of Cardiac Rehabilitation (208) Quality and Outcomes Report 208. BHF, York. National Health Service (209) The NHS Long Term Plan. NHS England. National Institute for Health and Care Excellence (203) Cardiac Rehabilitation Services (Commissioning Guide). Myocardial Infarction: Cardiac Rehabilitation and Prevention of Further Cardiovascular Disease. CG72. NICE, London. Piepoli MF, Hoes AW, Agewall S, Albus C, et  al. (206) European Guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. European Heart Journal 37, 235–​8. Public Health England (209) Health Matters: Preventing Cardiovascular Disease. DH, London. Scottish Intercollegiate Guidelines Network (207) Cardiac Rehabilitation SIGN 50. Health Improvement Scotland, Edinburgh.

Chapter 8

Cardiovascular emergencies Introduction  386 Assessment of the deteriorating patient  388 Basic life support  392 Resuscitation  394 Advanced life support  396 Defibrillation  398 Pulmonary embolism (PE)  400 Tension pneumothorax  404 Cardiac tamponade  405 Pulmonary oedema  406 Cardiogenic shock  408 Intra-​aortic balloon pumps  410 Ventricular assist devices (VAD)  414 Extra-​corporeal membrane oxygenation  415 Acute aortic syndromes  416 Stroke  420 Related guidance  422

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Introduction Cardiovascular emergencies are either sudden events or are preceded by a noticeable deterioration in the patient’s condition. Although critically ill patients are usually cared for in a level 2 or 3 specialist unit (e.g. Cardiac Care Unit (CCU), high dependency unit (HDU), intensive therapy unit (ITU)) it is becoming more common for these patients to be found on general wards. Many hospitals will have outreach teams to facilitate the appropriate care of these patients and provide support for the staff looking after them. Appropriate assessment, prompt treatment, documentation, and communication are vital in the management of those with cardiovascular emergencies. The importance of ‘Human Factors’ has been discussed in recent years, in particular the importance of teamwork and minimizing errors in patient care. This chapter discusses the assessment of the deteriorating patient, resuscitation, and the causes and treatment of some cardiovascular emergencies including stroke.

 NHS England (203) Human Factors in Healthcare. NHS, London.

Introduction

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Assessment of the deteriorating patient Many in-​hospital cardiac arrests could potentially be prevented if it is noted that a patient’s condition is deteriorating and that appropriate interventions are then put in place. Changes in observations, in particular respiratory rate, can be an early indication of deterioration; however, this is not always recorded accurately or frequently. Use an ABCDE approach to assess the patient: • Airway • Breathing • Circulation • Disability • Exposure. Many trusts use a track and trigger system to highlight patients who are at risk of deterioration and who may need assessment or intervention by a critical care outreach team. An example of this is the National Early Warning Score 2, which is the system recommended for use in hospitals in England.2

Airway An assessment of the airway includes detection of signs of partial or full airway obstruction. This may include the following: • No sound—​this could indicate full obstruction • Snoring • Gurgling • Choking • Gasping • Stridor • Obvious visual obstruction • Oedema • Swelling • Bleeding • If the patient can talk to you, they have a patent airway. Simple airway manoeuvres, such as head tilt/​chin lift, may open the airway and relieve the obstruction. If a neck injury is suspected, use a jaw thrust to prevent damage to the cervical spine. Suction might be required for fluids, such as blood, vomit, or excess saliva. Only remove dentures if they are loose or ill-​fitting and likely to cause an obstruction. An airway adjunct, such as a nasal or oropharyngeal airway, can also be used to support the airway. Do not use nasal airways if a skull fracture is suspected (e.g. bruising around ears and eyes or cerebrospinal fluid leaking from the nose or ears). Only use oropharyngeal airways if the person is deeply unconscious.

2 Royal College of Physicians (207) National Early Warning Score (NEWS) 2:  Standardising the Assessment of Acute-​Illness Severity in the NHS. Updated report of a working party. RCP, London.

Assessment of the deteriorating patient

Breathing A full description of respiratory assessment is found in % Respiratory assessment (p.66). In a deteriorating patient, assess the following: • Rate, rhythm, pattern, and depth of respirations (2 breaths/​min may indicate a problem) • Use of accessory muscles to help breathing • Inability to speak in full sentences • Breath sounds—​listen for gurgling, wheezes, and crackles • Equal air entry—​causes of unequal air entry include pneumothorax, consolidation, and basal collapse • Chest symmetry • Position of the trachea • Evidence of peripheral or central cyanosis • Complaints of shortness of breath (SOB) or difficulty breathing • Evidence of a cough with production of sputum—​check colour, consistency, odour, and quantity • O2 saturation levels • Arterial blood gases (if necessary). If there are signs of respiratory distress, the patient should be sat upright. If O2 is required in an emergency situation, it should be given (5L/​min) through a mask with a reservoir bag attached to maintain SpO2 94–​98% or 88–​92% (for those at risk of hypercapnic respiratory failure, e.g. chronic obstructive pulmonary disease (COPD)).3

Circulation In addition to cardiovascular observations, the assessment of circulation includes looking for any obvious signs of bleeding. The following should be included: • Heart rate (HR), rhythm, and volume. • Blood pressure (BP). • 2-​lead electrocardiogram (ECG). • Observation of neck veins to see if they are full or collapsed and central venous pressure (CVP), if available. • Urine output (should be >0.5mL/​kg of body weight/​h) and fluid balance. • Evidence of bruising, swelling, redness, bleeding, or pain. • Observation of wound sites, if present. • Capillary refill—​assess by applying pressure to the fingertip held at heart level, for 5s. When the pressure is released, the skin should resume normal colour within 2s. • Colour and temperature of the skin. • Palpate central and peripheral pulses (unable to palpate peripheral pulses if systolic BP 90mmHg and signs of impaired organ perfusion, e.g. altered mental state; cool, clammy skin; oliguria. Causes of cardiogenic shock include the following: • Acute MI (most common cause) • PE • Aortic/​mitral stenosis • Prosthetic valve failure • Acute myocarditis • Drug toxicity • Ventricular septal defect (VSD) • Cardiac tamponade • Rupture of valve cusps • Ruptured LV aneurysm • Aortic dissection.

Signs and symptoms CO d initially, which leads to a d in urine output and an i in pulse. This triggers mechanisms, such as vasoconstriction, which lead to a din peripheral perfusion and metabolic acidosis. Tachycardia, d BP, JVD, cool and clammy peripheries, increased serum lactate levels, altered mental state, oliguria, and peripheral oedema may all be present. The patient may also have signs of respiratory distress including i RR, SOB, use of accessory muscles, and d SpO2.

Management Management includes identifying and treating the cause, e.g. percutaneous coronary intervention (PCI) for STEMI if suitable. Revascularization with coronary artery bypass graft (CABG) may be required. Invasive monitoring, such as pulmonary artery (PA), pulmonary artery wedge pressure (PAWP), and arterial monitoring, is usually required to aid treatment. The patient should be catheterized to monitor urine output closely (aim for 0.5mL/​kg of body weight/​h). Fluids might need to be given if hypovolaemia is present, or if the patient has drug-​induced hypotension or no evident cause for cardiogenic shock. Opiates, such as IV diamorphine, can help to relieve  Ibanez B, James S, Agewall S, et al. (208) 207 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-​segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-​segment elevation of the European Society of Cardiology (ESC). European Heart Journal 39(2), 9–​77.

Cardiogenic shock

preload, in addition to pain. Monitor ABG and O2 saturation levels and give O2 therapy accordingly. Medical management might include inotropes and IV vasopressors. In some cases, mechanical support such as an intra-​ aortic balloon pump (IABP) (% Intra-​aortic balloon pumps (IABPs), p.410), left ventricular assist device (LVAD) (% Ventricular assist devices (VAD), p.414), or extra-​corporeal membrane oxygenation (ECMO) (p.415) may be required. The goal of treatment is to preserve left ventricular function and prevent the onset of irreversible multi-​organ dysfunction. Support for the patient and family is vital; the prognosis is often poor.

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Intra-​aortic balloon pumps Description The IABP is a counterpulsation device placed in the aorta, just below the aortic arch (See Fig.  8.7), which deflates and inflates in a controlled manner. The balloon holds 730–​40mL of gas, which is usually helium. The patient’s ECG or cardiac cycle triggers inflation and deflation. The balloon can be set to inflate every one, two, three, or four contractions. The IABP has two ° benefits for the heart, as follows: • The balloon deflates just before systole and, ∴, d the workload of the heart by d the afterload. • The balloon inflates in diastole, which i blood flow to the coronary arteries and brain. 2° benefits include improvements in CO, ejection fraction, and systemic perfusion, and a d in HR, PAWP, and systemic vascular resistance.

Indications The IABP should only be placed in those patients where it is felt there will be an improvement in their condition: • Cardiogenic shock caused by mechanical complication such as VSD • Acute mitral regurgitation (MR) • Septic shock • Unstable angina • Post cardiac surgery if it has been difficult to take a patient off bypass • Pre cardiac surgery in unstable patients • A bridge to cardiac transplantation • A support during coronary angiogram/​angioplasty/​valvuloplasty for unstable patients. (a) Cardiac diastole

(b) Cardiac systole

Balloon inflated to increase coronary perfusion during diastole

Balloon deflated to allow systemic perfusion during systole

Coronary perfusion Fig. 8.7  Intra-​aortic balloon pump position. Reproduced with permission from Ramrakha P and Moore K (eds) (2004) Oxford Handbook of Acute Medicine (2nd edn). Oxford University Press, Oxford.

Intra-aortic balloon pumps

Contraindications • Aortic insufficiency • Abdominal and aortic aneurysm • Contraindications to anticoagulation • Uncontrolled tachyarrhythmias • Severe aortoiliac disease • Aortic dissection • Prosthetic graft in thoracic aorta • Irreversible brain damage • Severe peripheral vascular disease.

Complications of IABP therapy Complications can occur during IABP insertion and after the IABP is in situ. It is the nurse’s responsibly to monitor the patient for any signs of complications. Complications can be physical and psychological.

Complications during insertion • Haemorrhage • Puncture/​dissection of aorta • Rupture of the balloon, causing a gas embolism • Failure to advance the catheter far enough because of atherosclerotic disease.

Complications during use • Limb ischaemia • Depression and anxiety • Back pain • Haemorrhage • Aortic dissection • Infection • Timing problems, leading to inappropriate inflation/​deflation; this could then lead to an i in cardiac workload • Sepsis • Thrombocytopenia • Thromboembolism • Renal failure.

Nursing care The nurse must observe the patient for any signs of the listed complications, in addition to understanding how the machine works. The longer the IABP remains in place, the greater the risk of complications such as sepsis or anxiety and depression. The patient must stay flat (can sit to no more than 45°) with the affected limb straight, which can lead to back pain, in addition to complications from immobility. Other nursing care includes the following: • Monitor cardiovascular observations such as HR, BP, RR, mean arterial pressure (MAP). • Observe limb for any signs of ischaemia—​compare each foot for colour, warmth, sensation, and pedal pulses. • Check BP in both arms and also radial pulses—​report any differences. • Observe the femoral insertion site for signs of infection, haemorrhage, or haematoma formation.

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• Monitor urine output (0.5mL/​kg of body weight/​h) to ensure that the kidneys are being perfused. • Check the trigger and IABP frequency is as prescribed. • Check the balloon-​assisted trace on the machine (Fig. 8.8) and monitor inflation timings. • Provide psychological support for both patient and family. • Monitor the patient for chest pain. • Care of pressure areas. • Observe for neurological complications such as cerebrovascular accident (CVA). • Administer anticoagulants, as prescribed. The patient must be on heparin. • Report any abnormalities of IABP functioning to the perfusionist and doctor. The IABP might be removed if there are signs of infection or malfunction. As the patient’s condition improves, the timing cycle is d. It is usually appropriate to remove the IABP when the inflation ratio is :4. The heparin infusion should be stopped first and the activated clotting time (ACT) should fall to