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Chapter 30 Coordinating Care for Patients With Cardiac Disorders
Plaque
Balloon inflated
Stent in place to hold artery open
The decision between PCI and CABG is made by the healthcare team and patient based on degree of disease, surgical risk, hemodynamic stability, symptom severity, and the patient’s goals. Other, less common, invasive treatment strategies, such as atherectomy and transmyocardial laser revascularization (TMLR), may be performed in patients meeting limited criteria. During an atherectomy, plaque within the coronary artery is shaved and removed through a specialized catheter during cardiac catheterization. In TMLR, the patient’s heart is surgically exposed, and a laser is used to create 20 to 40 tiny channels from the outside of the left ventricle to the chamber within. The outside openings are closed by clots, but the channels stay open on the inside. The procedure is also thought to stimulate angiogenesis, the formation of new blood vessels from preexisting vessels. Lifestyle Management Diet and physical activity play an important role in the treatment of CAD and its risk factors of hypertension, hyperlipidemia, diabetes, and obesity (see Genetic Con- nections: Genome Studies Lead to New Risk Reduction Strategies). Maintaining a healthy body weight or a body- mass index (BMI) of less than 30 kg/m 2 is critical in the management of CAD. A diet that is low in saturated fat and sodium as well as high in fruits, whole grains, and vegetables and considers personal and cultural prefer- ences should be discussed. Engaging in regular moderate- intensity physical activity at least 30 minutes a day, 5 days a week is recommended. Stopping tobacco use and avoiding exposure to smoking should be encouraged. Screening and treatment for depression can reduce ischemic events and improve quality of life in patients with CAD. Refraining from excessive alcohol use may reduce CAD risk. Patients with ACS, especially after PCI or CABG, should be referred and encouraged to participate in a comprehensive cardiac rehabilitation program. Cardiac rehabilitation is a supervised program of education, counseling, and super- vised physical activity. Ideally, cardiac rehab begins before discharge and continues in the outpatient setting. Partici- pation improves morbidity and mortality, reduces angina episodes, and decreases rehospitalizations. Unfortunately, only a small percent of eligible patients participate.
FIGURE 30.3 Stent placement within the artery. Step 1: A catheter with a small balloon on its tip is advanced to the area with atherosclerotic plaque. Step 2: The balloon is inflated and deflated to open the lumen of the artery. Step 3: The stent is advanced to hold the artery open and maintain adequate blood flow.
gas exchange and perfusion while the heart is stopped to provide a still, bloodless field for surgery. Then arteries or veins being used as bypasses are surgically attached to the diseased coronary artery, creating an alternate path for blood to flow around the blockage. Common vessels used are the internal thoracic (mammary), radial artery, and saphenous vein. Bypasses made from arteries have greater longevity, but more bypasses can be made with saphenous veins, which require an additional incision in the leg. Multiple blockages may be bypassed in the same surgery. For example, a patient with four large coronary artery blockages would undergo a quadruple bypass. Minimally invasive coronary surgery CABG (MICS CABG) may be an alternative to CABG. MICS CABG involves a left chest incision and multiple smaller inci- sions that act as ports for instruments. A CBP is used, and multiple vessels can be bypassed. Minimally invasive direct coronary artery bypass (MIDCAB) is an option for some patients, in which incisions similar to those in MICS CABG are made. A pressor device placed through the chest incision immobilizes a part of the heart while the internal thoracic artery is used to bypass a single blockage. A similar procedure through a sternotomy incision allows for addi- tional vessels to be bypassed. Because both procedures do not require a CPB, they are called off-pump or “beating heart surgery.” Potential advantages of all these procedures include faster recovery times and fewer complications. Patients who undergo CABG are sent to a critical care unit for intensive monitoring and care. Multiple hemo- dynamic monitoring catheters, chest tubes, an endotra- cheal tube, mechanical ventilation, a nasogastric tube, an indwelling bladder catheter, and a temporary pacemaker wire may all be needed postoperatively. Nursing care of the patient undergoing CABG is described in Chapter 32.
Genetic Connections
Genome Studies Lead to New Risk Reduction Strategies A family history of heart disease is often due to genetics. Scientists have discovered genetic variants that affect cho- lesterol levels, lipid metabolism, blood vessel formation, and inflammation. Some variants are reliable predictors of coronary artery disease. New treatments to lower blood lipid levels are being developed based on this genetic infor- mation, which will allow for individualization of treatment.
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