Nursing the Cardiac Patient E-Book

Melanie Humphreys

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Essential Clinical Skills for Nurses
• Sprache: Englisch

Seitenzahl: 427

Veröffentlichungsjahr: 2011

Beschreibung

Nursing the Cardiac Patient is a practical guide that addresses the management of cardiac patients across the spectrum of health care settings. It assists nurses in developing a complete understanding of the current evidence-based practice and principles underlying the care and management of the cardiac patient. It combines theoretical and practical components of cardiac care in an accessible and user-friendly format, with case studies and practical examples throughout.

Leseprobe

Table of Contents

Cover

Title page

Copyright page

Contributor Biographies

Preface

Acknowledgements

Chapter 1 Acute Coronary Syndrome in Perspective

Introduction

The challenge of saving lives

The scope of this book

Chapter 2 Reducing the Risk: Primary Care Initiatives

Introduction

Primary care initiatives in perspective

Identification of those “at risk”

Rapid access chest pain clinics

Sudden cardiac death

Early recognition and access to emergency services

Early CPR

Early defibrillation

First responders

Summary

Chapter 3 Assessment of the Cardiovascular System

Introduction

Cardiovascular assessment in perspective

Chest pain assessment

Electrocardiography

Laboratory tests

Diagnostic procedures

Summary

Chapter 4 Diagnosing Acute Coronary Syndrome

Introduction

Acute coronary syndromes in perspective

Interpreting the 12-lead ECG

Biochemical markers

Risk stratification

Imaging techniques

Summary

Chapter 5 Unstable Angina

Introduction

Unstable angina in perspective

Treatment strategies

Summary

Chapter 6 Non-ST Segment Elevation Myocardial Infarction

Introduction

Non-ST segment elevation myocardial infarction in perspective

Causes

Diagnosis

Treatment of NSTEMI

Summary

Chapter 7 ST Segment Elevation Myocardial Infarction

Introduction

ST segment elevation myocardial infarction in perspective

Care priorities

Treatment priorities

Complications of STEMI

Territories of STEMI: special considerations

Special patient groups

Continuing care

Rehabilitation and secondary prevention

Summary

Chapter 8 Therapeutic Intervention in Acute Coronary Syndromes

Introduction

Pathophysiology of ACS

Early identification of ACS

Early therapeutic intervention

Therapeutic intervention for STE-ACS and NSTE-ACS

Primary percutaneous coronary intervention

Facilitated percutaneous coronary intervention

Summary

Chapter 9 Cardiothoracic Care

Introduction

Preparation for surgery

The operation

Postoperative care

Cardiac care after the first 24 hours

Fast tracking

Discharge

Summary

Chapter 10 Arrhythmias and their Management

Introduction

Electrophysiology of the heart

The conduction system

Manifestations of arrhythmias

Arrhythmias

Arrhythmia treatment

Peri-arrest arrhythmias

Cardiac arrest rhythms

Summary

Chapter 11 Emergency Cardiac Care

Introduction

Cardiac emergencies in perspective

Early warning scoring systems

Assessing the emergency cardiac patient

Acute heart failure

Pericarditis

Cardiac tamponade

Electrolyte disorders

Summary

Chapter 12 Long-Term Cardiac Conditions

Introduction

Heart failure

Refractory angina

Atrial fibrillation

Summary

Chapter 13 Cardiac Rehabilitation

Introduction

Cardiac rehabilitation in perspective

Provision of cardiac rehabilitation

Summary

Chapter 14 Secondary Prevention Within the Community

Introduction

Ongoing risk factor modification

Psychological wellbeing

Psychosocial wellbeing

Cardioprotective medication

Summary

Chapter 15 Ethical Issues in Cardiac Care

Introduction

Ethical theory and principles in perspective

Ethical decision-making frameworks

Informed consent

DNAR

The ethics of withdrawal of active treatment

Patients’ rights and responsibilities

Summary

Appendix A: Patient Transfer to Theatre/Specialist Centre

Introduction

Transfer in perspective

Preparation of the patient for intrahospital or interhospital transfer

Summary

Appendix B: Cardiac Rehabilitation Circuit Class

Class management

Staffing ratios

Other considerations

Appendix C: Cardiac Pacemakers

Indications and usage

Pacemaker function

NASPE/BPEG code

Index

This edition first published 2011

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Library of Congress Cataloging-in-Publication Data

Nursing the cardiac patient / edited by Melanie Humphreys.

p. ; cm. – (Essential clinical skills for nurses)

 Includes bibliographical references and index.

 ISBN-13: 978-1-4051-8430-4 (pbk. : alk. paper)

 ISBN-10: 1-4051-8430-2 (pbk. : alk. paper) 1. Heart–Diseases–Nursing– Great Britian. 2. Heart–Diseases–Patients–Nursing–Great Britian. I. Humphreys, Melanie. II. Series: Essential clinical skills for nurses.

 [DNLM: 1. Cardiovascular Diseases–nursing–Great Britain. 2. Nursing Care–methods–Great Britain. WY 152.5]

 RC674.N89 2011

 616.1'20231–dc23

2011015207

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781444346121; ePub 9781444346138; Mobi 9781444346145

Contributor Biographies

Editor

Melanie HumphreysDirector of Postgraduate and Post-qualifying Studies, Senior Lecturer in NursingMSc Research Methodology, MA Medical Ethics and Law, BSc (Hons) Educational Studies (Nursing), RNT, RGN, ONC, ENB 124, ENB 998Melanie is currently Director of Postgraduate Studies and Post-qualifying Studies, at the School of Nursing and Midwifery at Keele University. She has many years’ experience in nursing and teaching within cardiac care and emergency care. She currently undertakes a role as educational consultant to the Resuscitation Council (UK) on their generic instructor courses (GIC) delivered across the UK, and is an advanced life support (ALS) instructor.

Consultant Editor

Dr Dominic CoxConsultant Interventional CardiologistMBChB, BSc (Hons) Physiol, MRCPDominic has worked as a consultant interventional cardiologist at Northampton General Hospital since 2004. His specialist interests are in coronary intervention, general cardiology and bradycardia pacing. He initially studied human physiology and worked on diving and survival physiology at the National Hyperbaric centre. He then trained in medicine in Aberdeen and undertook specialist training in cardiology in the north east of England. He undertakes the role of medical director and instructor on both ALS and GIC courses.

Contributors

Lisa CooperAdvanced Nurse Practitioner – Sister, Emergency DepartmentMSc Advanced Clinical Nursing Practice, BN Hons, ALS(I)Lisa has worked in A&E for 20 years, the past 10 years as a sister at Walsall Manor Hospital. She is an Advanced Nurse Practitioner and an ALS instructor. She has worked with the British Paralympic swimming team and attended both the Sydney and Athens Paralympic games as part of the team, and has also attended many European Championships. She currently works part time in clinical informatics as a business change facilitator, while maintaining her role in A&E.

Brenda CottamAssistant Director of Education, BASICS Education ScotlandRGN, ENB 182, DPSN, DipIMC (RCSEd), PGCert Med EdBrenda is currently working as the Assistant Director of Education with BASICS Education Scotland and is a founder nurse member of the Faculty of Pre-Hospital Care. BASICS Education Scotland provides education and training for healthcare professionals involved in pre-hospital immediate medical care across Scotland, mostly GPs and nurses working in remote, rural and island practice areas. Brenda has a background in anaesthesia and cardiac critical care nursing in both the UK and USA, and held a resuscitation officer position in Tayside for eight years. Prior to her appointment to BASICS Education Scotland over a year ago, she worked for the British Heart Foundation for eight years as Community Resuscitation Co-ordinator for Scotland, developing public and schools programmes for cardiopulmonary resuscitation (CPR) training, and advising and assessing public access defibrillation grants.

Debbie DanitschConsultant Nurse – Cardiothoracic NursingDHSc, MSc, BEd (Hons), DipN (Lond), PGDEA, RNT, RGNDebbie has spent most of her nursing career caring for acutely/critically ill adults. She secured a consultant nurse role in cardiothoracics in 2002, at the time the first and only role nationally of its kind. She successfully finished her doctoral studies in 2009. She has vast experience working on cardiac advanced life support courses, developing protocols that have since been used by the European Resuscitation Council.

Sarah DickieNurse Consultant – Emergency NursingMBA, PGC Teaching & Learning in Higher Education, PGCE Health Research, BSc (Hons) Nursing, RGN, ENB199Sarah is a nurse consultant working in unscheduled care pan-Ayrshire for NHS Ayrshire & Arran, a joint appointment with the University of the West of Scotland. The major focus for her clinical expertise is in emergency care. She has previously worked as a research nurse on a critical care transfer project in Yorkshire and is an instructor on the Safe Transfer and Retrieval course (STaR).

Anne DormerBHF Lead Nurse Heart FailureMSc, BSc (Hons), RNAnne has worked to lead and deliver services for heart failure patients since 2001. Education is an important part of her role and she spent several years organising the North West Heart Failure Forum before handing over the facilitation of this group to the Greater Manchester and Cheshire Cardiac Network in 2010. The forum delivers study days and networking opportunities for heart failure nurses and healthcare professionals with an interest in heart failure in the north west of England.

Fiona FoxallLecturer in NursingMA Medical Ethics, (BSc) Hons Nursing Studies, DPSN, PGCE(FAHE), ENB100, RNFiona Foxall qualified as a Registered General Nurse in 1984 and worked as a senior intensive care sister until 1990, when she moved into nurse education. She has always maintained clinical currency and competence by continuing to practise, teaching critical care nurses and undertaking continuing professional development within the intensive care setting. She was employed as the head of continuing development in the School of Health at the University of Wolverhampton but now lives and works in Australia.

Tim GroveExercise Specialist (Cardiac Rehabilitation Services)MScTim has been an exercise specialist in cardiac rehabilitation for nearly 10 years and he currently co-ordinates the exercise component of Heatherwood and Wexham Park hospitals phase III cardiac rehabilitation programme. He graduated in 2007 with a master’s degree in cardiovascular rehabilitation from the University of Chester and he lectures and assesses on the British Association for Cardiac Rehabilitation’s Phase IV Exercise Instructor course. Tim has also published in peer-reviewed journals, fitness magazines and presented poster presentations at the European Society of Cardiology’s world congress and at the British Association for Cardiac Rehabilitation’s conference.

Ian JonesSenior Lecturer in Cardiac NursingRN, PhDIan qualified as a nurse in 1990 and has spent the past two decades working in cardiac care. He is a former president of the British Association for Nursing in Cardiovascular Care and has published widely in the field. He is currently employed as a senior lecturer in cardiac nursing and nurse researcher at the University of Salford in Greater Manchester.

Jan KeenanConsultant Nurse – Cardiac MedicineRGN, Nurse Prescriber, RNT, MSc Health Studies, PGD Higher Professional EducationJan has been the consultant nurse in cardiac medicine at the Oxford Radcliffe Hospitals NHS Trust since 2001. She holds an Honorary Teaching Fellowship at the School of Health and Social Care, Oxford Brookes University. She is currently President and Honorary Secretary of the British Association of Nurses in Cardiovascular Care and a council member of the British Cardiovascular Society. Jan holds a highly clinically focused role and works across the team to achieve demonstrable improvements across the patient pathway in the cardiac directorate at the ORH, as well as influencing the wider organisational and national agenda for nursing and cardiac care.

John McGowanSenior Resuscitation OfficerRGN, RMN, MSc, BSc (Hons), BA, DIMC, RCSEdJohn has been the resuscitation officer at the Southern General Hospital Glasgow since 1993. His special interests include acute cardiovascular care, resuscitation in childhood, environmental medicine and pre-hospital care.

Claire RushtonLecturer in NursingMA, BA (Hons), PGCHE, Dip Critical Care Nursing, DipN, RN (Adult)Claire is a lecturer in the School of Nursing and Midwifery at Keele University. She contributes to teaching in foundation and adult branch pre-registration nursing courses at diploma and degree level. She also contributes to the Learning Beyond Registration teaching portfolio and takes the lead for the module on legal and ethical issues in healthcare. Her clinical background is in cardiology nursing. Her interests include end-of-life care and she has completed a MA in medical ethics and law through which she explored the potential impact of the Mental Capacity Act (2005) on women’s end-of-life decision making. Claire is also interested in heart failure and co-morbidity, and particularly the impact of co-morbidity on changing prognosis in heart failure. She is a peer reviewer for the British Journal of Cardiac Nursing.

Pauline WalshHead of School, Nursing and Midwifery, Keele UniversityMA Medical Ethics & Law, DPSN, ENB100, RGN, ONC.Pauline started her nursing career in Gloucestershire, qualifying in 1984, and worked clinically in trauma orthopaedics, surgery and intensive care nursing. Her academic interests revolve around healthcare ethics and professional practice, and she gained a master’s degree in medical ethics in 1991 with a specific focus on life and death decision making. Since September 2010 she has been head of school in nursing and midwifery at Keele University.

Celia WarlowSenior Resuscitation OfficerMA (Ed Man), BSc, Cert Ed, RGNCelia is resuscitation services manager at Northampton General Hospital NHS Trust. She has worked in the field of resuscitation practice for 21 years, and is passionate about her role and improving all aspects of this field of science. Celia led a small team to develop an MSc in resuscitation practice at Brighton University in 2005, where she holds honorary lecturer status. She has also been an educational advisor to the Resuscitation Council (UK) since 1998.

Jackie YounkerSenior Lecturer in NursingBSN, MSN, PG CertEdJackie is currently a senior lecturer at the University of the West of England, Bristol. She has a background in cardiac and critical care nursing. She teaches clinical assessment skills and her areas of interest are advanced practice nursing, critical care and resuscitation.

Preface

The treatment of cardiac conditions has changed, and continues to change dramatically. The pace of change also appears to be accelerating. Cardiac conditions are common and life threatening, but thankfully there has never been a time where we have been able to do so much to lengthen and improve the lives of our patients. Specialist cardiac nurses form an elite cadre in healthcare and, as such, face many exciting challenges. Cardiac care probably involves more equipment and technology than any other field of medicine. Along with technology there are more drug treatments and an increasing role for nurses in prescribing and monitoring therapies. These times are without doubt the most exciting period in medical history in which to look after patients with cardiac disorders.

This book is designed to help the modern nurse tackle these challenges and to give new and experienced nurses an understanding of the key areas of cardiac disease. This knowledge can then be used to help patients with the understanding that this is a changing field: that what we have done in the past will give us experience and understanding, but that cardiac care is leading a healthcare revolution.

One of the key rewards of dealing with patients who are critically ill with cardiac conditions is that there are often dramatic improvements with modern treatments. The old-style Coronary Care Unit (CCU) of the 1970s and 1980s has changed beyond recognition, with most of the drama of the acute myocardial infarction (MI) being dealt with by primary percutaneous coronary intervention (PCI) in the cathlab. In that setting CCU can become a place where there are greater extremes of health. Some patients will feel completely well following their brief MI, which has been completely treated, immediately. The nurse looking after such patients may find the challenge will lie in getting cardiac rehabilitation messages on board in patients who can be so well and whose suffering was only relatively brief. The other end of the scale is that patients with major cardiac events are surviving for longer through the initial phase of illness and are having much more done for them acutely. Thus sicker, frailer and older patients may survive what were thought to be untreatable conditions. Their needs may be far more complex, both from a cardiological and nursing viewpoint.

Thus there are nursing care challenges because we are able to help people recover more quickly from very serious conditions and also because survival is better and patients are routinely offered more complex treatment. Undoubtedly society’s expectations of what can and should be delivered are also changing. Nursing has a key role in the interaction with the patient and family, which will have its own challenges.

Cardiac nurses are involved in the initial assessment and treatment of acute coronary syndromes (ACS) through to delivering definitive therapy, as well as aftercare and cardiac rehabilitation. Newer roles are now routine, such as helping to assess and monitor those patients whose ACS has been managed without intervention, and providing follow-up and secure hospital discharge. Nurse-led revascularisation clinics routinely provide follow-up for patients post PCI and coronary artery bypass graft (CABG). For those patients with significant risk of long-term serious ventricular arrhythmia, the nurse specialist can help guide them through the complexities of life-saving device therapy with implantable cardioverter defibrillators (ICD) and cardiac re-synchronisation therapy (CRT) implantation.

One of the greatest challenges is to provide a workforce with the necessary skills to deliver the care needed to meet these changing needs. The fundamentals and “anatomy” of the disease process are well understood. This book is a tool to cover the groundwork and encourage lifelong learning to meet the needs of such an exciting medical field. The professional rewards for being part of the cardiac healthcare team are being seen now.

Eighty to ninety percent of cardiology care in the UK is now delivered in the non-elective, urgent or emergency setting. This means that when patients attend with their first cardiac event they are being given “complete” treatment. Thus an ACS will often be the index event in a patient’s complete inpatient revascularisation, arrhythmia management, etc. Therefore there is a need for nurses to understand all aspects of cardiac care when dealing with ACS patients as the patient’s stay may encompass many cardiac treatments.

Dominic Cox

Consultant Editor

Acknowledgements

I would like to extend my sincere thanks to all of the contributing authors for their valuable contributions to this book; between them they have a wealth of clinical experience and expertise within the many and varied fields of cardiac care. I am particularly grateful to Rebecca McBride, who acted as a critical reader at many stages of the compilation process and offered much in the way of constructive feedback. I extend my thanks to the consultant editor, Dominic Cox, a great mentor and friend, for reviewing the clinical accuracy of the text and making helpful and valuable suggestions to improve it.

I would also like to thank the many undergraduate and postgraduate students I have worked with, in clinical practice and in the classroom, who have inspired me to find different ways of learning and teaching this amazingly dynamic and challenging subject area.

Melanie Humphreys

Chapter 1

Acute Coronary Syndrome in Perspective

Melanie Humphreys

Introduction

Significant change in how and where cardiac care is delivered has occurred since the National Service Framework (NSF) for Coronary Heart Disease (CHD) was first published in 2000. The pace of change has been rapid in terms of both clinical advances and different service models for delivery of care. Cardiac nurses now move seamlessly across organisational boundaries, moving from a patient’s home, to the GP practice and acute trust setting (DH, 2005a).

Front-line clinicians and other practitioners continue to champion the development of cardiac services, bringing innovation and excellence to service development and delivery as practices and technologies evolve and advance.

Much of the content of the NSF for CHD is as relevant now as it was in 2000, and will probably still be relevant in 2020. As progress continues and the achievements that have already been realised are built upon, it is important that nurses continue to develop their own underpinning knowledge and enthusiasm to continue to grow within cardiac nursing. Patient expectation and need, technology and working practices in cardiology are continually advancing, and many nurses are in a position to contribute to the discussions about quality of care through the National Quality Board, which oversees the setting of priorities for the service in the future. Lord Darzi’s report High Quality Care For All provided reaffirmation of the importance of putting quality at the centre of what all healthcare professionals do and the need to look across the whole patient pathway (DH, 2008a).

The Challenge of Saving Lives

Cardiovascular disease is the UK’s biggest cause of premature death and CHD accounts for more than 110,000 deaths in England each year. In March 2000, when the NSF for CHD was published, the chapters focused on CHD patient pathways; since then three important documents have been published. In March 2005, a final chapter was added on arrhythmia and sudden cardiac death. This focused on the care of patients living with dysrhythmias and families in which a sudden cardiac death had occurred (DH, 2005b). In May 2006, national commissioning guidance was published on the care of adolescents and adults with congenital heart disease (DH, 2006), and in 2008 a report on the National Infarct Angioplasty Project was published (DH, 2008b). This document sets out the new national strategy to treat heart attacks using primary angioplasty, which represents a major breakthrough in terms of reducing mortality, speed of rehabilitation and readmission rates. Many specialist cardiac nurses contributed to these important pieces of work, and many will continue to make positive contributions in the forthcoming years (DH, 2009a).

In The Coronary Heart Disease National Service Framework, progress report for 2008 (DH, 2009a), the initial aims are discussed. These were to reduce mortality from heart disease and stroke and related circulatory diseases in people under 75 by at least 40% by 2010; this was set out in the public health White Paper Saving Lives: Our Healthier Nation in 1999. It was based on the trend data available at the time, including international comparisons, and was seen as a significant challenge. However, since then, steady progress has been made and the target has been met, five years ahead of schedule. This was considered to be a major achievement, attributable to the shared efforts of those working in many parts of the healthcare system. The report identified a number of specific achievements, including the following.

People suffering a heart attack are receiving either:thrombolysis, more quickly than before; orprimary angioplasty services.Waiting times for cardiac surgery have dropped dramatically since the publication of the NSF for CHD and outcomes have improved. In April 2002, there were 7,558 people waiting for a coronary artery bypass graft and 4,364 of them had been waiting three months or more; by December 2008 this had fallen to 1,670 people waiting and only six people had been waiting longer than three months (DH, 2009a).In primary care, secondary prevention has improved and is attributable to the additional incentive of the Quality and Outcomes Framework, a performance management system for GPs that is supervised by primary care trusts (PCTs) (DH, 2009b).The prescription rate for cholesterol-reducing statins has more than doubled over the past three years, cutting mortality from CHD and the number of heart attacks each year.Smoking cessation has also made a major contribution. Smoking prevalence among adults dropped from 28% in 1998 to 21% in 2007 (DH, 2009a).

Despite these examples of very positive trends within the realms of “saving lives”, cardiovascular diseases (CVD) continue to exert a huge burden on individuals and society, with CHD remaining the single most common cause of death in the UK and other developed countries (British Heart Foundation, 2008), accounting for 198,000 deaths each year. One in three deaths (35%) is from CVD.The main forms of CVD are CHD and stroke. About half (48%) of all deaths from CVD are from CHD.

Coronary heart disease is the most common cause of death in the UK. Around one in five deaths in men and one in seven in women are from the disease (BHF, 2008). CHD causes around 94,000 deaths in the UK each year. Other forms of heart disease cause more than 31,000 deaths in the UK each year, so in total there were just under 126,000 deaths from heart disease in the UK in 2006.

Cardiovascular disease is one of the main causes of premature death in the UK (death before the age of 75). Thirty percent of premature deaths in men and 22% of premature deaths in women were from CVD in 2006 (BHF, 2008). CVD was responsible for more than 53,000 premature deaths in the UK in 2006.

Cardiovascular disease deaths as a whole have steadily declined since the 1970s, with a reported 27% reduction in mortality from heart disease, stroke and related diseases in people aged less than 75 years of age since 1996 (DH, 2005c).

Interestingly, UK morbidity data suggest that CHD prevalence is, in fact, increasing, and this seems to be particularly marked in people aged 75 years or more. A recent analysis by Majeed and Aylin (2005) suggests that by 2031:

the number of cases of CHD will rise by 44% (to 3,190,000) and hospital admissions related to CHD will increase by 32% to 265,000the number of people with heart failure will rise by 54% (to 1,303,000) and hospital admissions will increase by 55% to 124,000the number of people with atrial fibrillation will rise by 46% (to 1,093,000) and hospital admissions will increase by 39% to 85,000.

While great progress has been made in moving cardiovascular care from tertiary prevention to secondary prevention, health plans must continue to drive CHD care further along the continuum towards primary prevention of CVD. CVD risk factors should be managed not only after a coronary event has occurred, but also before the onset of such an event. Ideally, healthy lifestyles should be promoted with all patients so that risk factors for CVD never develop. In this way, the future may well see CVD care moving from the inpatient setting to the outpatient setting.

The Scope of this Book

The acute coronary syndromes (ACS) represent the unstable phase of CHD and encompass a range of conditions that result in myocardial ischaemia or infarction. Despite advances in the knowledge of disease processes and improved pharmacological and interventional therapies, ACS continues to have significance for practitioners working across the spectrum of primary, secondary and tertiary care arenas (DH, 2009a).

Virtually every pathological process affecting the heart can lead to a critical cardiac event, and commonly sudden death within the community and within the hospital setting, therefore a good understanding of cardiac events and their immediate management is essential in optimising patient health and reducing mortality and morbidity. Through a structured approach of assessment, initiating investigations, treatment and delivering appropriate care, within the community and hospital setting, potentially life-threatening cardiac events can be identified. This will enable medical attention to be delivered in these situations, and ensure the most appropriate evidence-based care and treatment strategies are adopted (Humphreys, 2009).

Through a structured and focused approach this text offers a practical guide to nursing the cardiac patient; it addresses the management of cardiac patients within both community and hospital settings. It has relevance to nurses working across the nursing milieu, and will help to develop a comprehensive understanding of the contemporary evidence-based practice and principles underlying the care and management of the cardiac patient (Figure 1.1).

Figure 1.1 The cardiovascular disease continuum.

As cardiac events have huge significance for all practitioners, this book will prove to be a practical resource for many nurses working within both general and specialist emergency/cardiac hospital settings. It will also have relevance for primary care workers wishing to develop their knowledge within all aspects of cardiac care, and as such will appeal to paramedics and other healthcare professionals working within general practice.

References

British Heart Foundation (BHF) (2008) Coronary heart disease statistics database. www.heartstats.org

Department of Health (2009a) The Coronary Heart Disease National Service Framework: Building on Excellence, Maintaining Progress; progress report for 2008. London, Department of Health.

Department of Health (2009b) Developing the Quality and Outcomes Framework: Proposals for a New, Independent Process: Consultation Response and Analysis. London, Department of Health.

Department of Health (2008a) High Quality Care For All: NHS Next Stage Review final report. London, Department of Health.

Department of Health (2008b) National Infarct Angioplasty Project (NIAP) interim report. London, Department of Health.

Department of Health (2006) A Commissioning Guide for Services for Young People and Grown Ups with Congenital Heart Disease (GUCH). London, The Stationery Office.

Department of Health (2005a) Creating a Patient-led NHS: Delivering the NHS Improvement Plan. London, Department of Health.

Department of Health (2005b) Arrhythmias and sudden cardiac death. National Service Framework for Coronary Heart Disease. London, The Stationery Office.

Department of Health (2005c) Leading the Way: The Coronary Heart Disease National Service Framework; progress report. London, The Stationery Office.

Department of Health (2000) National Service Framework for Coronary Heart Disease. London, The Stationery Office.

Department of Health (1999) Saving Lives: Our Healthier Nation. London, The Stationery Office.

Humphreys M (2009) Cardiac emergencies. In: Jevon P, Humphreys M and Ewens B Nursing Medical Emergency Patients. Oxford, Blackwell Publishing.

Majeed A and Aylin P (2005) Dr Foster’s case notes. The ageing population of the United Kingdom and cardiovascular disease. British Medical Journal 331: 1362.

Chapter 2

Reducing the Risk: Primary Care Initiatives

Melanie Humphreys and Brenda Cottam

Introduction

Before the publication of the National Service Framework (NSF) for Coronary Heart Disease (CHD) (DH 2000a), the state of cardiovascular prevention and care in England was considered by many to be below the standard of other comparable Western countries. The UK as a whole had higher mortality and morbidity from coronary heart disease (CHD). Mortality was falling at a slower rate than elsewhere and there was clear evidence from published national and international studies that access to specialist care, including coronary revascularisation, was lower than in other countries (Quinn, 2007).

Coronary heart disease, stroke and related conditions remain a major cause of early death; however, mortality rates are reportedly falling due to improved treatment of cardiovascular events and improved management of primary preventative strategies, such as smoking cessation. In the UK, primary prevention treatment has produced three times the impact on mortality that secondary prevention management has (Kelly and Capewell, 2004). The prescription rate for cholesterol-reducing statins more than doubled from 2006 to 2009, cutting mortality from CHD and the number of heart attacks each year. Smoking cessation has also made a major contribution. Smoking prevalence among adults dropped from 28% in 1998 to 21% in 2007 (DH, 2009a). Secondary prevention has improved further within primary care, attributable to the additional incentive of the Quality and Outcomes Framework (DH, 2009b). The aim of this chapter is to understand the approach to primary care strategies aimed at reducing the risk of acute cardiac events.

Learning outcomes

At the end of this chapter the reader will be able to:

describe, using evidence-based sources, an overview of the referral and assessment process used within primary carecritically discuss the importance of current rapid diagnostic clinics and investigationsoutline the significance of sudden cardiac deathcritically discuss the significance of community schemes and their impact within primary care.

Primary Care Initiatives in Perspective

Saving Lives: Our Healthier Nation, published as a White Paper in July 1999 (DH, 1999), set a target to reduce the death rate from CHD and stroke and related diseases in people below the age of 75 by at least 40% by 2010. Following the launch of the NSF on 6 March 2000, CHD was firmly established as a priority area across government. The paper identified primary prevention as a crucial means of reducing prevalence of CHD. Standard four of the NSF for CHD states that “general practitioners and primary health care team should identify all people at significant risk of cardiovascular disease but who have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks” (p.4). Milestone three of Chapter 2 suggests that “every practice should have a protocol describing the systematic assessment, treatment and follow-up of people…whose risk of CHD events is >30% over ten years” (p.16), setting the way for a clear strategic direction for the management of CHD. The publication of the 10-year NHS plan (DH, 2000b) four months later reconfirmed key “immediate priority” milestones for delivery of the NSF, including the establishment of Rapid Access Chest Pain Clinics (RACPCs), increased revascularisation capacity and faster treatment, including, where necessary, pre-hospital thrombolysis delivered by paramedics. Smoking cessation was given high priority as a “key plank” of the wider public health programme; by 2004 at least a quarter of a million people had been helped to quit smoking for at least four weeks. A school fruit programme was instituted to ensure that around nine million children aged four to six years received at least one piece of fresh fruit every school day (Boyle, 2004).

The Health and Social Care Standards and Planning Framework 2005/6–2006/7 states that “in primary care, practice based registers [should be up-dated] so that patients with CHD and diabetes continue to receive appropriate advice and treatment in line with NSF standards and, by March 2006, ensure practice-based registers and systematic treatment regimes, including appropriate advice on diet, physical activity and smoking, also cover the majority of patients at high risk of CHD, particularly those with hypertension, diabetes and a BMI greater than 30” (DH, 2004). The Public Health White Paper Choosing Health: Making Healthy Choices sets outs the government’s agenda to provide more opportunities, support and information for people who want to adopt a healthier lifestyle, which will contribute towards combating the modifiable risk factors that cause CHD (DH, 2005c).

Among the host of reforms since 1997, one of the most significant underpinning the NSF was arguably the renegotiation of the general medical services contract for general practitioners (GPs), which from April 2004 introduced a system of financial reward for performance on key areas including CHD in primary care (Quinn, 2007). A key component of the Quality and Outcomes Framework (QoF) was for improvements in patient care across four domains: clinical, organisational, “additional services” and patient experience. CVD, with diabetes and hypertension, forms a major component of the “points” attracting financial reward in the clinical domain. Use of disease registers in primary care, alongside improvements in clinical coding and protocols, also attract points under the organisational and patient experience domains (Capps, 2004). The QoF data have also been useful in providing epidemiological insights into the relationship between CHD prevalence, quality of care and socioeconomic deprivation (Strong et al., 2006).

Identification of those “at Risk”

The Framingham risk scoring system is widely used and available via many general practice computer systems to score each patient’s relevant risk factors; these are then calculated to determine 10-year (short-term) risk for developing CHD (Grundy et al., 2001). Framingham risks include:

agesexHDL cholesteroltotal cholesterolsystolic blood pressuresmoking statusdiabetic statusfamily history of ischaemic heart disease (IHD).electrocardiogram (ECG) evidence of left ventricular hypertrophy (optional).

However, not all practices use the Framingham software. The INTERHEART study lists nine categories that account for more than 90% of the associated risks of initial myocardial infarction (Yusuf et al., 2004). Consistent results were found across 52 countries worldwide. They suggest that most premature myocardial infarction can be prevented if treatment is offered to the younger cohort of patients.

They conclude that worldwide, the two most important risk factors, which contribute to two-thirds of risk, are:

smokingabnormal ratio of blood lipids.

Other important risk factors in men and women are:

diabeteshypertensionabdominal obesitypsychosocial factors, i.e. stresslack of daily consumption of fruits and vegetableslack of daily exercise.

Modest alcohol consumption (three to four drinks weekly) has been determined to be a preventative measure (these factors are explored further in Chapters 14 and 15).

Collins and Altman (2009) have assessed the performance of the QRISK cardiovascular risk prediction algorithm in a primary care setting in the UK, and have compared QRISK with equivalent Framingham algorithms. The QRISK algorithm is based on the largest risk prediction study ever undertaken and highlights a potential use of large-scale electronic health record systems. A team has linked electronic health records from several million people to produce a cardiovascular risk prediction algorithm that is claimed to be more accurate and better validated than previous ones. Although prediction algorithms are available for many conditions, most are based on small numbers, are poorly validated, infrequently updated and not generalisable. Moreover, most prediction algorithms are weak predictors and are not used regularly. QRISK is just the first of many continuously updatable prediction algorithms that will become available worldwide as electronic health record systems replace current paper-based systems. The planned UK General Practitioner Extraction Service, for example, should soon be capturing data relevant to risk prediction from most of the population (GPES, 2009). The sharing of such algorithms is considered to be the best way to facilitate their effective implementation (Jackson et al., 2009).

The NSF for CHD advises that patients who have a 10-year risk greater than 30% be added to the at-risk register and offered the same lifestyle advice and treatment as those patients already suffering with CHD, especially with a body mass index (BMI) >30. However, BMI as an indicator of risk has been challenged, with greater focus being placed on high-risk abdominally obese patients rather than BMI (Despres et al., 2001; Grundy et al., 2001), this was also identified in the INTERHEART study (Yusuf et al., 2004). Despres et al. (2001) state that the simple measurement of the waist circumference can indicate accumulation of abdominal fat; adding fasting triglyceride concentrations to the waist measurement would improve the practitioner’s ability to identify abdominally obese men likely to have the features of the insulin resistance syndrome. This study focused on men, and there is little evidence to support this theory for women. This is an area where more research is needed.

Viscerally obese men are characterised by an atherogenic plasma lipoprotein profile.

A triad of non-traditional markers for CHD found in viscerally obese middle-aged men (hyperinsulinaemia, raised apolipoprotein B concentration, and small LDL particles) increases the risk of CHD 20-fold.Even in the absence of hypercholesterolaemia, hyperglycaemia or hypertension, obese patients could be at high risk of CHD if they have this “hypertriglyceridaemic waist” phenotype.

The INTERHEART study claims that the effect of the nine risk factors are consistent in men and women, across different geographic regions and by ethnic group, making the study applicable worldwide. Among the implications of this study the concept of a uniform preventative strategy for heart attack across the world appears very attractive and of great potential impact. The ways in which the heart attacks that follow from the nine risk factors reflect the interplay of environmental and constitutional (genetic) influences remain to be further explored.

Rapid Access Chest Pain Clinics

Chest pain is a major burden on patients and the NHS, resulting in an estimated 634,000 primary care consultations (Stewart et al., 2003). They make up a large proportion of emergency department (ED) attendances and acute medical admissions (Goodacre et al., 2005), and many of these patients do indeed have an acute coronary syndrome (ACS). Stable angina pectoris is a common condition in the UK, with an estimated 96,000 new cases each year, and 955,000 people currently living with the condition (BHF, 2009). The incidence rises with age and is higher in men.

The NSF set out plans to establish rapid access chest pain clinics (RACPCs) throughout England in order that new patients with new onset chest pain, referred by their GP, could undergo timely specialist assessment (DH, 2000a). Referral to an RACPC is facilitated by protocols agreed at the primary/secondary care interface supported by the local cardiac network. Standardised pro formas are widely used to ensure appropriate use of the RACPC for its intended purpose (the RACPC is not appropriate for patients with suspected ACS or those with known CHD already under the care of the cardiology department) and to minimise delay (Quinn, 2007). The RACPC specialist nurse undertakes baseline history and clinical examination. A normal ECG does not rule out CHD but provides a baseline and helps to exclude factors such as bundle branch block, which would hamper analysis of an exercise test. If the clinical picture suggests new onset stable angina, an exercise tolerance test is usually performed. Additional tests considered would include:

stress echocardiographymyocardial perfusion imagingmagnetic resonance imaging (MRI)cardiac computer tomography (CT)calcium scoring.

Studies have suggested that the RACPC has provided an efficient and effective substitution for the traditional cardiology outpatient clinic model (Smallwood, 2009; Taylor et al., 2008; Sekhri et al., 2006). The establishment of RACPCs in England demanded many new skills from nurses working in cardiac care to ensure that competent cardiac assessment and management is facilitated. The focus of these clinics remains to provide a high level of care and assessment to patients admitted with chest pain or a cardiac arrhythmia. Practitioners working in RACPCs have developed their roles and often offer chest pain assessment services throughout acute and emergency care areas (Smallwood, 2009). Such advanced roles are established to augment, rather than replace, the doctor’s role (DH, 2005a). Many working in chest pain assessment teams were involved in meeting the thrombolysis targets through nurse-initiated thrombolysis; the emphasis has now focused on timely referral for primary angioplasty (DH, 2009).

Other roles and skills these practitioners may develop and offer include:

24-hour cardiac assessmentstratification of patients according to riskinitiating treatment strategies for ACSprescribinginterpretation of heart and lung soundsadvanced interpretation of ECGsadvanced life support skillsteachingoffering advice and support to junior doctors and nursesdiagnosis and treatment of arrhythmiasmanaging nurse-led clinicsliaising with senior medics to request and interpret relevant tests, i.e. exercise tests, angiogramsfollow-up clinics for patients post revascularisation and for medically managed patients with ACS.

The Healthcare Commission undertook a formal evaluation of NSF implementation in 2005 (Healthcare Commission, 2005), reporting evidence of significant progress towards many of the national standards, particularly in relation to heart attack treatment, faster diagnosis of angina and reducing waits for revascularisation, underpinned by increased investment and targeted modernisation initiatives. The commission report also recognised the significant advances made in development of primary care CHD registers, but highlighted the need for further work to improve preventive work on a population basis and to provide better care for patients with heart failure or requiring cardiac rehabilitation (these will be explored within Chapters 13, 14 and 15).

The delivery of community-based services continues to be developed; the White Paper Our Health, Our Care, Our Say: A New Direction For Community Services (Secretary of State for Health, 2006) sets out a vision for health and social care delivered outside hospitals, identifying five areas for change.

Improved access and more funding following the patient, ensuring personalised care, and expansion of walk-in (health) centres in the community.The shifting of care away from hospitals closer to people’s homes, and investment in community hospitals and facilities.Improving working and information sharing between health and social care, and better co-ordination between the NHS and local councils.Budgets to increase choice by direct payment or care budget for people to pay for their own home help or care. PCTs required to act on findings of patient surveys.More action on prevention through introduction of the NHS “life check” at key points in an individual’s life, and linking the London 2012 Olympics to a “Fitter Britain” campaign (Secretary of State for Health, 2006).

The implications of these reforms for services for patients with chest pain are unclear, but it is possible that chest pain assessment clinics and similar services could be situated in diagnostic centres run by GPs (DH, 2009; DH, 2008; DH, 2005b).

Sudden Cardiac Death

Sudden cardiac death is still the most important cause of premature death in the industrialised world, accounting for 700,000 deaths per year in Europe (Handley et al., 2005; Priori et al., 2004); with CHD remaining the UK’s biggest killer. In the European guidelines for resuscitation published in 2005, Handley et al. state that some 40% of victims suffering sudden cardiac arrest are known to be in ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), and postulate that this figure is likely to be much higher, but this remains unknown as it is not monitored in the first few minutes after cardiac arrest.

Early Recognition and Access to Emergency Services

Mueller et al. (2006) contest that “sudden” cardiac death is not always just that. Indeed, signs and symptoms are evident for some time before cardiac arrest occurs, thus meaning this could be a very preventable cause of death if public education about recognising warning signs truly reached its target. They also contend that although early cardiopulmonary resuscitation (CPR) and early defibrillation undeniably saves lives, where this is targeted (e.g. public places) could be misdirected, as most deaths occur in the home or a residential area, where bystander CPR and access to defibrillation is least likely. Advertising campaigns supporting the recognition of the symptoms of ACS have been targeted to raise public awareness and the emphasis on the need to make early 999 calls.

Early CPR

Eisenburger and Safar (1999) report the value of early CPR, which has been well established. They remind us that the impact of bystander CPR (BCPR) is well documented, showing that the increase in survival from cardiac arrest can be doubled in areas where extensive public CPR programmes operate.

Community CPR and first aid training is now commonly accessible in most areas throughout the UK via:

first aid training agenciesvoluntary aid societiespublic access by voluntary groupsworkplaces, through first aid at work.

In the UK, statutory NHS ambulance services aim to reach 75% of cardiac arrest and chest pain (and other immediately life-threatening) emergency calls within a nationally set target time of eight minutes (measured under “call connect”). However, within three to four minutes post-arrest, cerebral damage becomes a significant factor (Eisenburger and Safar, 1999). Therefore survival from cardiac arrest depends on:

early recognition and call to emergency servicesearly CPR to reverse the effects of hypoxiaearly defibrillation to correct VF or VT, both associated with sudden cardiac arrest.

This is now well established in the discipline of resuscitation, and the Chain of Survival first conceptualised by Cummins et al. in 1991 (in Handley et al., 2005) is now the mantra of modern-day resuscitation (Figure 2.1).

Figure 2.1 The Chain of Survival.

Reproduced with permission from Laerdal Medical Ltd.

This means that bystander and community-based CPR plays a significant role in return of spontaneous circulation (ROSC) after cardiac arrest. However, audits of out of hospital cardiac arrest still show the frequency of BCPR remains poor, with less than one-third of cardiac arrest victims benefiting from BCPR before emergency services arrive (Eisenburger and Safar, 1999). The importance of BCPR is evidenced in one UK study by Dowie et al. (2003). Their work with the London Ambulance Service showed that BCPR increased the chance of survival by 10% over a monitored period of time. However, this study demonstrated a high percentage of BCPR (44%) in progress when the ambulance arrived.

Early Defibrillation

In the past few decades, the advent of automated external defibrillators (AEDs) in public places has meant that early access to defibrillation has become much more common. Advances in manufacturing and technology mean these simple and accurate AEDs can be used safely in workplaces, public places and even in the home (Jorgensen et al., 2003). Evidence is undisputed regarding the significance of early defibrillation. When the International Liaison Committee on Resuscitation (ILCOR) published its guidelines for CPR and emergency cardiac care in 2000, it stated:

With reported survival rates of up to 49%, PAD (public access defibrillation) has the potential to be the single greatest advance in the treatment of prehospital sudden cardiac death since the invention of CPR.

Yet appropriate placement of AEDs is still contested. Handley et al. (2005) reflect the most common opinion that defibrillators should be sited in places where large numbers of the public gather or pass though (railway stations, airports, shopping centres etc) and where cardiac arrests occur once every two years or more. Similarly, remote areas where ambulance response times are likely to be extended also influence where AEDs and community based programmes should be sited. This is supported by most national defibrillation programme planners and ILCOR (2000) suggest that PAD programmes prove to be cost effective when measured against years of added life. However, Handley et al (2005) remind us that up to 80% of cardiac arrests occur in residential or private settings. This then needs to be addressed through emergency dispatch systems to enable rapid responses with a defibrillator to residential settings as well as public places. Community first responders must therefore arrive on scene within five minutes – before emergency medical services – to be a truly effective resource, although their target response time is eight minutes.

The European Resuscitation Council and the European Society of Cardiology recognised the significance of community-based defibrillation and in 2004 produced policy statements making recommendations surrounding the use of AEDs in Europe. These included guidance for:

legislationtraining and updating lay and co-respondersaccess to and via emergency service call systemsaudit of AED useneeds analysescost benefits to public health.

First Responders

The UK has seen rapid development of first and community first responder schemes in the last decade. Community first responders are:

…volunteers who respond to emergency calls within their local community. They are generally lay people who have received basic medical training from their ambulance service. They respond, when available, to immediately life-threatening calls, usually in a rural area or one that is difficult for ambulances to reach within the current time target of eight minutes. They are not a substitute for professional paramedics and technicians, but they augment the ambulance service’s response.

(Healthcare Commission, 2007)

First responders come from a variety of backgrounds – from co-responders in other emergency services (police, fire, coastguard), staff in public places providing a localised emergency response (e.g. shopping centres, railway stations and airports), first aid organisation partners or volunteers from military backgrounds, to the general public keen to support emergency response systems in their local communities. They are not employees of ambulance services, but when called out by the ambulance services act as agents for them as part of the emergency response (Healthcare Commission 2007). Many nurses and healthcare practitioners are taking up this voluntary role.

First responder groups are set up in areas of identified need – now mostly influenced and defined by local ambulance service audit data in order to be sure of a co-ordinated response backed up by technicians/paramedics. The Healthcare Commission (2007) indicated that ambulance services see benefits in community first responder schemes, which have already had a positive impact on response times.

Colquhoun et al.