Mr. E, 60, arrives in the ED complaining of increasing chest pain over the past few days. On arrival, his BP is 158/92 mm Hg, with a heart rate of 92 beats/minute and a respiratory rate of 20 breaths/minute. Mr. E has a history of poorly controlled hypertension; he's overweight and doesn't exercise regularly. He states that in addition to the chest pain he has experienced some nausea, increased sweating, and difficulty breathing with exertion. His 12-lead ECG shows T wave inversion in leads II, III, and aVF. Lab testing in the ED reveals normal levels of creatinine kinase (CK), CK-MB, and troponin. He's placed on oxygen, given I.V. pain medication, and is monitored for changes.
Based on these findings and his history, Mr. E is quickly taken to the interventional cardiology lab and prepared for a coronary angiogram. You're able to provide information and education about the procedure before he goes to the lab.
Mr. E asks you what to expect when he goes to the lab and why the procedure is being done. You explain to him that a coronary angiogram examines the arteries that supply blood to the heart. When those arteries become narrowed or clogged, it can lead to chest pain; if severe, it can lead to heart muscle damage.
Mr. E can expect that a spot on his groin or arm will be numbed and a small tube or catheter will be inserted into an artery. This thin tube is then threaded along the artery until it gets to one of the coronary arteries. Dye is injected into the arterial system so the cardiologist can see if there are any blockages. Mr E. may experience some flushing or a warm feeling while the dye is being injected, but he should let the team know immediately if he experiences any chest pain.
After you answer all of Mr. E's questions, it's time to prepare him for the procedure. His orders indicate that an angioplasty will be performed if necessary. The standard preparation for your patient undergoing angiography and possible angioplasty includes:
* checking lab results, including complete blood cell count, electrolytes, blood urea nitrogen, creatinine, and prothrombin time/partial thromboplastin time
* making sure he isn't on or has stopped any anticoagulants
* asking him if he has been N.P.O. for the last 6 hours
* asking him about allergies, especially to iodine, shellfish, contrast dye, or latex
* keeping him and his family informed.
In addition, your patient should be wearing a gown without metal snaps because these interfere with the X-ray films. Patients at risk for allergic reaction are given a dose of diphenhydramine just before being moved to the cardiology lab to prevent itching during the procedure.
Risks and benefits
As with any invasive procedure, there are risks and benefits. The risks are more common in patients older than age 75 and include bleeding from the catheter insertion site, allergic reaction to the dye, dysrhythmia during the procedure, kidney damage from the dye, catheter fracture, and stroke or acute myocardial infarction. Higher rates of complications also occur in female patients, those with renal disease or diabetes, and those with extensive coronary artery disease. Of concern for every patient is the risk of restenosis, or closure of the coronary artery due to endothelial overgrowth or clotting at the site of the stent placed during angioplasty.
The obvious benefit of angioplasty and stenting is avoidance of coronary artery bypass graft surgery. After the coronary artery is open, chest pain is improved and the risk of an acute coronary event is reduced.
The angiogram reveals that Mr. E has a narrowing of the right coronary artery, and the decision is made to perform angioplasty. The interventional cardiologist has a choice of several different methods to open the coronary artery.
Percutaneous transluminal coronary angioplasty (PTCA), also known as balloon angioplasty, uses a small balloon-tipped catheter that's inserted into the narrowed part of the artery. When the balloon expands, the plaque material that was occluding the coronary artery is compressed into the arterial wall to allow increased blood flow (see Picturing PTCA).
Stenting uses a small metal mesh tube that opens and supports the coronary artery. The procedure utilizes a balloon-tipped catheter that has a stent placed over the balloon. The balloon is inflated against the wall of the artery. When deflated, the stent remains in place, forming a scaffold and holding open the artery (see Picturing an intravascular stent). In some cases, a drug-eluting stent may be used. These stents contain medication that's slowly released to help prevent clotting at the stent site and restenosis of the artery.
Rotoblation uses a specially pointed tip that's able to rotate at a high rate of speed. This rotation cuts the plaque from the arterial wall into microscopic pieces that are then flushed out of the body by the liver and spleen. The use of this procedure has been reduced due to research and improvements in other methods.
Keeping it open
Mr. E returns from the cardiology lab after successful angioplasty with stent placement. After measuring his vital signs, you ensure that he stays in a comfortable flat position. Postangioplasty patients generally stay perfectly flat for about 2 hours. The head of the bed can then be elevated about 30 degrees for the next 4 hours. Because patients must be relatively flat and still during this time, they'll either use a fracture bedpan or have a urinary catheter. The sheath is generally left in place and connected to a pressure bag. A 5-pound sandbag should be kept near the bed to apply direct pressure to the site should any bleeding occur. Some interventional cardiologists use a collagen plug at the arterial puncture site to reduce the risk of hemorrhage rather than leaving the sheath in place.
Mr. E is allowed clear liquids until the groin sheath is removed, and he's allowed out of bed with assistance about 6 hours after sheath removal. When his vital signs and ECG remain stable and there's no bleeding from the catheter site, he's discharged home in the care of his wife.
You review discharge instructions with Mr. E and his wife, informing them to watch for any bleeding or swelling from the groin site or increasing pain in the groin or leg. The cardiologist has placed Mr. E on clopidogrel, 75 mg by mouth every day. He may have to take this antiplatelet drug for up to 1 year after the angioplasty, and he shouldn't stop taking it unless advised by the cardiologist. Possible adverse reactions include increased bleeding, neutropenia, liver failure, rash, nausea, diarrhea, body aches, or fatigue. He should report any adverse reactions to his cardiologist immediately.
You advise Mr. E not to take any other antiplatelet medications, with the exception of low-dose aspirin as prescribed, or nonsteroidal anti-inflammatory drugs while taking clopidogrel. Instruct him to take it easy for the next few days, especially when walking up stairs.
Mr. E will be followed regularly by his cardiologist, with periodic ECG and stress testing. He should avoid elective surgery while taking clopidogrel, and because he had a stent placed, he shouldn't have a magnetic resonance imaging scan done for the next 4 weeks. Mr. and Mrs. E are instructed about a heart healthy diet. With the help of the cardiac rehabilitation team at the hospital, Mr. E will develop an exercise routine. You advise him to make sure he takes his antihypertensive medication as prescribed and to monitor his BP regularly. Instruct him to call 911 and go directly to the ED for any chest pain, arm pain, fatigue, or other signs of coronary artery blockage.
Learn more about it
Abrams A, Pennington S, Lammon C. Clinical Drug Therapy: Rationales for Nursing Practice. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
Cardiovascular Care Made Incredibly Visual! Philadelphia, PA: Lippincott Williams & Wilkins; 2008:202–203.
Smeltzer S, Bare B, Hinkle J, Cheever K. Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Lippincott Williams & Wil-kins; 2009.