Therapies After Cardiac Stent Placement Research Paper

The intervention of prevention strategies for various health disorders has achieved progress. But there are still some unaddressed issues as far as the cardiac problems are concerned.

One of the important issues may be safety regarding a particular therapy. So, the present description focuses on an area where various cardiac problems are managed by anticoagulant and antiplatelet therapy after cardiac stent placement.

Cardiac problems associated with the interruption of blood supply have prompted various health care professionals to work on agents that combat such defects. Cardiac ischemia is a similar disorder that results due to the obstruction or lack of blood supply to the heart muscle (www.americanheart.org). Also known as coronary artery disease and coronary heart disease, it could contribute to a heart attack without any signs, and approximately 3 to 4 million Americans were anticipated to have such ischemic episodes (www.americanheart.org).

Advancements in medical science have led to the development and incorporation of stents into routine clinical practice. However, their utility has initiated safety concerns. It was reported that stents may contribute to adverse effects like thrombosis in patients receiving the percutaneous coronary intervention (Lucking & Newby, 2007). Hence, this problem has drawn the attention of health care providers to work on antithrombotic and anticoagulant therapies to achieve a balance between reducing ischaemic events and minimizing bleeding complications in patients (Lucking & Newby, 2007).

Newsome et al. (2008) have described that for patients with either bare metal or drug-eluting stents, perioperative stent thrombosis may become a life-threatening complication. Further, they have also revealed that noncardiac surgery would enhance the risk of stent thrombosis, myocardial infarction, and death, particularly when patients undergo surgery early after stent implantation.

Therefore, the cardiac stents have appeared to aggravate the problem rather than providing a remedy. There is a need to overcome the concerns prevailing in society about the clinical application of coronary artery stents. Therefore, the main objective of this description is to search for reliable treatment options with the hope of modifying the existing practices aimed at correcting heart problems.

Earlier workers have described that a combination approach that involves antiplatelet and anticoagulant therapy would lessen the prevalence of cardiac events and hemorrhagic and vascular complications (Schomig et al., 1996). This was revealed when a comparative study was made on a large number of subjects given with ticlopidine plus aspirin that constituted antiplatelet regimen and intravenous heparin, phenprocoumon, and aspirin for anticoagulant regimen (Schomig et al., 1996). This has indicated the efficacy of the combinational approach.

The platelet activation by thromboxane and adenosine diphosphate (ADP), aggregation by glycoprotein IIb/IIIa (GPIIb/IIIa) receptors were reported to be inhibited by c7E3 (abciximab), and monoclonal antibodies directed against GPIIb/IIIa. This has subsided in both acute and subacute complications. Similarly, ADP-mediated platelet activation was also reported to be blocked by thienopyridines, which could be found to be synergistic to aspirin in their effects on the complications of coronary intervention (King, 2000). It was further revealed that Ticlopidine and a novel drug, clopidogrel, in conjunction with aspirin, have implications for preventing subacute thrombosis after stent implantation (King, 2000).

Hence, pharmacological agents need to be developed that could hinder the key mechanisms associated with the pathogenic platelet activity. Such intervention may restore the function of platelets and improve the condition of patients receiving cardiac stents. For this purpose, a long follow-up may also be required to monitor the post-therapeutic episodes.

Levine et al. (2003) described that patients with contrast dye allergies intended to be cured by PCI need to be recognized and pretreated with steroids and an H1-blocker. There is also a need for the intervention of Hydration before and after the procedure to minimize the risks for contrast nephropathy. Similarly, patients suffering from groin, abdominal, or back pain, and those with a decrease in hematocrit or unexplained hypotension, should be diagnosed with the relevant complaints carefully (Levine et al., 2003). It should be only after these preliminary tests patients treated with coronary stents should receive aspirin plus clopidogrel (Levine et al., 2003). This may indicate that the PCI procedure needs to be implemented after a thorough evaluation of other known clinical symptoms.

Further, anti-platelet and anti-thrombotic agents were reported to lessen the problem of peri-procedural myonecrosis, stent thrombosis, and other complications. Some of the anticoagulant agents such as unfractionated heparin (UFH), the low-molecular-weight heparins (LMWH), and direct thrombin inhibitors, and antiplatelet agents aspirin, thienopyridines, and glycoprotein IIb/IIIa antagonists would provide optimal adjunctive antithrombotic therapy for percutaneous coronary interventions (Kadakia & Ferguson, 2005). There is a need to implement a method of procedural anticoagulation in low risk, not-low risk, and high-risk PCI, as it could furnish information on the appropriate dosage effects (Kadakia & Ferguson, 2005).

This could indicate that the PCI-mediated adverse effects may be better managed by selecting and categorizing the patients into groups where the effects of therapies may be studied.

This could have a tremendous impact on the clinical condition of patients because the severity of the clinical manifestations may be understood in the initial stages and an appropriate therapeutic regimen would be instituted. This would mean that depending on the magnitude of risk, there could be an opportunity to decide whether to choose a single or combination therapy. However, further confirmations may be largely required to carry out this procedure.

There is a need to implement specific changes in the cardiac care practice and evaluate them. This would more probably rely on the nurse care strategies. As PCI would contribute to the increased risk of hemorrhage, to ensure the safety of drugs such as aspirin, clopidogrel, and warfarin a thorough investigation may be required as described earlier (DeEugenio et al., 2007). Warfarin was believed to be an independent predictor of major bleeding after PCI in patients receiving dual antiplatelet therapy (DeEugenio et al., 2007). A good sample size of patients who would be undergoing PCI may be mandatory to evaluate the efficacy of pharmacological agents. The patients should be administered warfarin in addition to aspirin, and clopidogrel. This study may appear central for nurse care. This is because earlier there were controversies regarding the use of the above-mentioned drugs. It was described that patients who have received these agents after PCI was found with a bleeding event and few of them also required a blood transfusion (Oxford et al., 2005). Hence, the bleeding problems may like to be originated from the use of aspirin, thienopyridine, and warfarin early after PCI with stent placement. Therefore, nurse professionals should be aware of all clinical complications associated with anticoagulant and antiplatelet therapy. To avoid further consequences of blood loss, procedures to secure patients’ blood need to be implemented like keeping commercially available blood in advance or selecting an appropriate donor.

Further, there is also a need to evaluate patients who use bivalirudin. It was reported that patients using the combination of heparin and bivalirudin were 3 times more likely to have vascular complications(Dumont, 2007). This may suggest that patients after PCI should discontinue the use of bivalirudin as an adjunct to heparin.

However, antiplatelet therapy was considered as the reliable treatment method for patients undergoing PCI and patients who have acute coronary syndromes. More probably clopidogrel in combination with aspirin could effectively inhibit cardiovascular events (Angiolillo, Guzman & Bass, 2008).

Despite some pitfalls of developing atherothrombotic events, clopidogrel may be beneficial to patients (Angiolillo, Guzman & Bass, 2008). Hence, nurses should critically evaluate the risk-benefit ratio for a valuable practice intended for cardiac patients. Finally, the nurse should adopt the practice of providing facilitated PCI that aims at pretreating patients with any pharmacological agent allowing the achievement of some recanalization and possibly myocardial reperfusion, which might later translate into an improved clinical outcome. (Zimarino et al., 2008). Facilitated PCI should be made by administering glycoprotein IIb-IIIa inhibitors for patients at high risk of cardiovascular events and at low risk of bleeding more than a 60-minute delay to primary PCI could be anticipated to yield significant results (Zimarino et al., 2008).In conclusion, the problem of PCI-induced adverse effects in patients could be overcome by the combination approaches rather than single or independent therapies. This has become evident from the earlier studies that concentrated on therapeutic aspects that began with ticlopidine plus aspirin, and heparin, phenprocoumon, and aspirin (Schomig et al., 1996). Similarly, the incorporation of novel drug clopidogrel in the therapeutic regimen has further increased the efficacy of the combination approach. Patients with other complaints such as allergies groin, abdominal, or back pain, etc would require a pre-diagnosis before they are recommended for PCI (Levine et al., 2003). The categorization of patients into low risk, not-low risk, and high-risk PCI may enable the care providers to study the actual problem and pinpoint the errors (Kadakia & Ferguson, 2005). The utility of warfarin as an independent predictor of major bleeding has some limitations. Hence its use needs to be carefully evaluated when recommended in combination with aspirin and clopidogrel. The elimination of bivalirudin as an adjunct to heparin could minimize vascular complications. The implementation of procedural anticoagulation and facilitated PCI may play a beneficial role in the management of cardiac events. Hence, these evidence-based strategies may help nurse care to overcome the problems concerned with PCI.

References

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