Caring for women undergoing cardiac ablation

Radiofrequency cardiac ablation (RFCA) has become the treatment of choice for many cardiac arrhythmias that have not responded to medication. Complications of cardiac ablation include bleeding, thrombosis, pericardial tamponade, and stroke. Many complications are procedure specific, and several complications can be avoided with appropriate nursing care. Quality patient outcomes begin with competent nursing care. Therefore it is vital for a patient undergoing a percutaneous cardiac ablation procedure to receive supportive care and pre- and post-interventional patient education. This article discusses the nursing care of women undergoing RFCA.     

Autonomy and reason: treatment choice in breast cancer

The practice of offering choice to those women with breast cancer for whom either breast conserving surgery or mastectomy would be equally beneficial has come to be seen as an important aspect of medical care. As well as improving satisfaction with treatment, this is seen as satisfying the ethical principle of respect for autonomy. A number of studies, however, show that women are not always comfortable with such choice, preferring to leave treatment decisions to their surgeons. A question then arises as to the extent that these women can be seen as autonomous or as exercising autonomy. This paper argues, however, that the understanding of autonomy which is applied in current approaches to breast cancer care does not adequately support the exercise of autonomy, and that the clinical context of care means that women are not able to engage in the kind of reasoning that might promote the exercise of autonomy. Where respect for autonomy is limited to informed consent and choice, there is a danger that women's interests are overlooked in those aspects of their care where choice is not appropriate, with very real, long‐term consequences for some women. Promoting the exercise of autonomy, it is argued, needs to go beyond the conception of autonomy as rational individuals making their own decisions, and clinicians need to work with an understanding of autonomy as relational in order to better involve women in their care.     

Influences on women's participation in cardiac rehabilitation.

The purpose of this study was to compare the cardiac rehabilitation referral and enrollment rates of men and women eligible for cardiac rehabilitation. A review of 202 hospital charts found that men and women were equally likely to be referred for cardiac rehabilitation, but women were significantly less likely to enroll (p < 0.05). Ten women who did not enroll and 20 women who did enroll were interviewed to determine factors that influenced their participation in the program. Major motives for enrolling included a desire to improve one's health and the strength of the physician's recommendation. Barriers to enrollment included concern for family members, transportation problems, physical limitations, and expense. Surprisingly, all of the women who did not enroll showed an interest when contacted after they were discharged from the hospital. Based on the findings of this study, it was recommended that cardiac rehabilitation staff telephone women after they are discharged to answer questions, clarify misconceptions, and encourage enrollment in a cardiac rehabilitation program.     

Vaginal birth after caesarean section (VBAC): exploring women's perceptions

Aims and objectives. This study was designed to complement local audit data by examining the lived experience of women who elected to attempt a vaginal birth following a previous caesarean delivery. The study sought to determine whether or not women were able to exercise informed choice and to explore how they made decisions about the method of delivery and how they interpreted their experiences following the birth. Background. The rising operative birth rate in the UK concerns both obstetricians and midwives. Although the popular press has characterized birth by caesarean section as the socialites’ choice, in reality, maternal choice is only one factor in determining the method of birth. However, in considering the next delivery following a caesarean section, maternal choice may be a significant indicator. While accepted current UK practice favours vaginal birth after caesarean (VBAC) in line with the research evidence indicating reduced maternal morbidity, lower costs and satisfactory neonatal outcomes, Lavender et al. point out that partnership in choice has emerged as a key factor in the decision‐making process over the past few decades. Chaung and Jenders explored the issue of choice in an earlier study and concluded that the best method of subsequent delivery, following a caesarean birth, is dependent on a woman's preference. Design and methodology. Using a phenomenological approach enabled a holistic exploration of women's lived experiences of vaginal birth after the caesarean section. Results. This was a qualitative study and, as such, the findings are not transferable to women in general. However, the results confirmed the importance of informed choice and raised some interesting issues meriting the further exploration. Conclusions. Informed choice is the key to effective women‐centred care. Women must have access to non‐biased evidence‐based information in order to engage in a collaborative partnership of equals with midwives and obstetricians. Relevance to clinical practice. This study is relevant to clinical practice as it highlights the importance of informed choice and reminds practitioners that, for women, psycho‐social implications may supersede their physical concerns about birth.     

Transcutaneous cardiac pacing

Transvenous cardiac pacing is currently the pacing procedure of choice in patients with severe, life-threatening bradyarrhythmias that do not respond to pharmacotherapy. However, pacing catheters can be difficult to insert and frequently fail to capture in severely hypotensive patients. Therefore, there has been a recent resurgence of interest in external pacing methods. Newer transcutaneous cardiac pacing units are easy to apply and especially suited for unconscious patients with severe, life-threatening bradyarrhythmias. There is no operator danger and, if need be, cardiopulmonary resuscitation can continue while the electrodes are in place and the unit is operating. Human and animal studies to date have shown that there are no significant short-term clinical hazards or pathologic abnormalities when using this technique.     

Impaired cardiac adjustment to pregnancy in type I diabetes

To assess the adaptation of the heart of diabetic subjects in the natural volume overload state of pregnancy, echocardiography was performed during each trimester and postpartum in 17 women with insulin-dependent diabetes mellitus (IDDM) and in 11 healthy women. The mean duration of diabetes was 14 yr and signs of microvascular complications were detected in 6 patients. The diabetic women had slightly smaller left ventricles than the control women already in the basal state (postpartum), and the pregnancy-induced increase in left ventricular size and stroke volume was less in the diabetic than in the control women. The heart rate rise also tended to be less in the diabetic women, resulting in a markedly smaller increase in cardiac output in this group (1.3 vs. 3.4 L/min, P less than .01). Left ventricular systolic function, wall thicknesses, or left atrial size did not differ between the groups at any point in the study. Minor collections of pericardial fluid were observed in 14 (76%) diabetic women and in 5 (45%) control women during the second and/or third trimester, but only 2 diabetic women had classic pericardial effusions. In conclusion, the normal hemodynamic adjustments to pregnancy seem to be impaired in women with IDDM. Preclinical diabetic cardiomyopathy and autonomic neuropathy may be involved in the observed alterations.     

Battering and breastfeeding in a WIC population.

The study reported in this paper was based on the hypothesis that women who are victims of domestic violence may be less likely to select breastfeeding than women who are not abused. Informed consent was obtained from 212 women at 2 Women, Infants and Children (WIC) Nutritional Supplemental Program clinics in the Midwestern United States. The Abuse Assessment Screen was administered by interview and women were also questioned about intended feeding choice and whether they had breastfed any previous children. No association was found between present or previous abuse and infant-feeding choice. Nevertheless, the findings of this study can be considered important, for two reasons: (1) this was an initial inquiry examining the relationship between having been abused and ability to choose the feeding method of a newborn; and (2) women in the sample who reported present or current abuse were able to breastfeed their infants in the same proportion as those who did not report abuse, which suggests that a woman's concern for her child overcomes her possible fears of control by the batterer.     

Modern nondepolarizing myorelaxants in cardiac surgery

The electromyographic and hemodynamic profile and side effects of the new nondepolarizing myorelaxants Mivacurium chloride (Mivacron), Cisathracurium besilate (Nimbex), Rocuronium bromide (Esmerone) were studied in 117 adult patients. All the test myorelaxants as bolus or infusion in a dose of 3.ED95 were found to be effective in creating adequate conditions for tracheal intubation and neuromuscular block (NMB) maintenance during operations on the coronary arteries and cardiac vales under extracorporeal circulation. In terms of the onset rate of NMB, Esmerone is the drug of choice for tracheal intubation. Esmerone and Nimbex in a dose of 3.ED95 did not produce a noticeable hemodynamic effect. The former was found to have a slight vagolytic effect. When rapidly injected as bolus, Mivacron caused a significant decrease in blood pressure and heart rate by 10-12%. Based on a comprehensive study, the authors have scientifically substantiated principles in the choice of nondepolarizing myorelaxants in cardiac surgical patients in relation to the baseline hemodynamic values, the stage of an operation, and the duration of artificial pulmonary ventilation.     

Women and cardiac rehabilitation: referral and compliance patterns

Heart disease is the primary killer among American women. Differences in referral for cardiac rehabilitation, as well as compliance rates, have been reported between male and female cardiac patients. This study explored the use of Phase I and Phase II cardiac rehabilitation programs by male and female patients. In particular, the study aimed to investigate the relationship between eligibility and subsequent referral to Phase II cardiac rehabilitation in both men and women, as well as their compliance rates in completing Phase II. In addition, for those patients who never started a Phase II program, their reasons for nonparticipation were explored. Structured patient interviews and chart audits were used to explore cardiac rehabilitation eligibility criteria, referral and completion rates. The sample consisted of 87 patients (46 women and 41 men) who were admitted with a medical diagnosis of angina, myocardial infarction, coronary artery bypass grafting, or valve replacement surgery. Men had higher eligibility rates for Phase I, whereas women had higher eligibility rates for Phase II; more men received a referral for Phase II from their physician than women did. Men had a higher completion rate with Phase II compared with women. For those patients who chose not to start a Phase II program, the most common reasons cited included transportation problems, insurance issues, and having exercise equipment at home. Although women are being referred for cardiac rehabilitation, fewer complete the programs. Continued education is essential to teach women the importance of cardiac rehabilitation to overall recovery and adaptation to an acute cardiac event. In addition, cardiac rehabilitation programs must be structured to meet the unique needs of women and thereby remove obstacles that have prevented higher participation rates by women in the past.     

Primary cardiac sarcomas

Antiplatelet therapy is a cornerstone of secondary prevention in patients with prior stroke or transient ischemic attack. Recent clinical trials and subanalyses of previous trials have influenced the selection of antiplatelet agents. Clinical decisions regarding the use of antiplatelet therapies have also been affected by recent advancements in our understanding of drug action, metabolism and drug–drug interactions. Aspirin has an established role in secondary prevention of stroke, although some patients are unable to tolerate it and others are resistant to its antiplatelet effects. Platelet function tests are available, but their routine use is not yet established. Clopidogrel and the combination of aspirin with extended-release dipyridamole both have established roles in secondary stroke prevention, but the optimal choice of agent is not always clear. Clinical trials of head-to-head comparisons will be discussed, as well as trials of combination therapies. In addition, several issues have surfaced recently impinging on the use of clopidogrel, especially relating to variable metabolism of the drug to its active metabolite and to interactions with proton pump inhibitors. The clinical implications of these issues will be discussed with respect to the secondary prevention of stroke.     

Blunt cardiac trauma

The incidence of cardiac injury after blunt chest trauma is difficult to determine and ranges from 8% to 76%. Moreover, the clinical presentation varies tremendously without a real gold standard to exclude or document cardiac involvement. Electrocardiogram as a single test is not sensitive or specific for diagnosing cardiac contusion. Furthermore, creatine kinase MB is non-reliable in the setting of severe trauma involving the liver, intestines or diaphragm. Although troponins T and I are highly specific for cardiac injury, their sensitivity in the setting of trauma is poor. The echocardiogram is very useful in the evaluation of trauma patients with suspected cardiac involvement. However, poor windows in the setting of chest and lung injuries and in intubated patients might be a major problem limiting the accuracy of transthoracic echocardiogram. On the other hand, transesophageal echocardiogram seems to be more sensitive and specific in trauma patients and should be the test of choice in patients with high clinical suspicion for blunt cardiac trauma.     

Preferences for cardiac tests and procedures may partially explain sex but not race disparities

Objective

There are known race and sex differences in emergent cardiac care. Many feel these differences reflect a bias from the physician. We hypothesized these differences may be the result of patient preferences.

Methods

Emergency department (ED) patients 40 years and older with a chief complaint of chest pain were surveyed from July 11 through December 9, 2005, at 2 academic EDs. This prospective survey study included demographics and prior cardiac test experience. Preferences for hypothetical cardiac tests and procedures were compared between race and sex using χ² or Fisher exact tests.

Results

Two hundred sixteen patients were enrolled. The mean age was 55 ± 12 years (43% men and 51% black). Blacks compared with whites preferred the electrocardiogram (ECG) to the technetium-99m sestamibi (MIBI) stress test. Blacks also preferred a percutaneous coronary intervention (PCI) compared with whites who were more likely to forego PCI. These racial differences disappeared when a physician recommended a procedure. There were no race preferences between PCI vs coronary artery bypass graft, whether or not a doctor recommended the procedure. For sex, there were no preferences between ECG vs MIBI stress test or cardiac catheterization, whether or not a doctor recommended the test or procedure. With regard to a choice between PCI and coronary artery bypass graft, women were more likely to decline the procedure than men. Even with a physician-recommended procedure, women were more likely to refuse than men, whereas men were more likely to accept it.

Conclusions

Blacks were more likely to prefer the less invasive stress test and wanted PCIs more, but these racial differences disappeared when a physician-recommended test was offered. Women were more likely to refuse the most invasive cardiac procedure compared with men. The sex-related preferences might partially explain why women receive fewer invasive cardiac procedures than men. However, race-related cardiac preferences suggest that other factors beyond patient preference account for fewer PCIs in black patients.     

Why do women underestimate the risk of cardiac disease? A literature review

BACKGROUND: Despite the quantity of information available to women about risk factors for cardiovascular disease (CVD), many women do not perceive this risk. AIM: This paper seeks to identify factors in the published literature that influence women's risk perception of heart disease, and how these perceptions influence health outcomes. METHOD: A literature search from 1985 to 2006 using the CINAHL, Medline, Embase and PsycINFO electronic databases was undertaken. The keywords used were 'perceived risk', 'cardiac risk factors', 'cardiovascular disease', 'risk misconception', and 'heart disease', combined with 'women' and/or 'gender'. Additional data was obtained by manual searches of bibliographies of articles identified in the electronic searches, and Internet searches. FINDINGS: Until the late 1980s, CVD was perceived as a disease which primarily affected men, as few large clinical trials recruited women. This resulted in a lack of data documenting the relationship between known risk factors and gender. Until recently, health professionals have not focused on disseminating gender-specific information about CVD risks to women, causing women to underestimate their risk of developing CVD even when risk factors are clearly evident. Furthermore, women are less likely than men to recognise the signs and symptoms of CVD, delay in seeking treatment, and fail to adopt healthy lifestyles, all of which increase the incidence of mortality and morbidity in a disease that is largely preventable. CONCLUSION: This review highlights the need for health professionals to 'bridge the gap' between perceived and actual risk of CVD in women, and to develop educational programs that specifically target women.     

Patient choice of breast cancer treatment: impact on health state preferences

BACKGROUND: Multiple treatment options exist for many medical conditions. The extent to which physicians should involve the patient in the choice the treatment to be delivered is not well understood. OBJECTIVE: To test the impact of breast cancer treatment choice on patients' health state preferences. DESIGN AND SETTING: A cohort from 29 hospitals (primarily referral centers) in Massachusetts, Texas, Washington DC, and New York. Subjects were surveyed at 5 months, 1 year, and 2 years following surgery and asked whether they had a choice in the type of treatment received. SUBJECTS: Women age 67 or older treated in 1996 to 1997 for localized breast cancer (n = 683). MEASURES: Patient preferences for current health state, assessed with patient valuations using the visual analogue scale (VAS) from the EuroQol instrument and with general public valuations using the Health Utilities Index (HUI), and 1-year medical costs. RESULTS: For the adjusted analysis at 5 months, the adjusted mean VAS score was 78.7 for women who reported a choice and 75.3 for women who reported no choice, a difference of 3.4 (P = 0.03). The difference in the HUI score was 3.6 (P= 0.10) and the difference in the 1-year medical costs was -4363 dollars (P = 0.01). There were no statistically significant differences at the 1-year and 2-year interviews. CONCLUSIONS: A woman's perception of choice of surgical treatment for breast cancer is associated with a short-term benefit on her preference of health state, suggesting choice helps with recovery, but does not provide long-term benefits.     

Impaired cardiac autonomic function in women with prior gestational diabetes mellitus

BACKGROUND: Cardiac autonomic neuropathy is a common dysfunction in manifest diabetes mellitus and is associated with duration of diabetes and/or an inadequate glycaemic control. Heart rate variability (HRV) reflects autonomic heart function. The aim of the present study was to investigate whether in women with prior gestational diabetes (GD; pre-type 2 diabetes) alterations of cardiac autonomic function can be observed after delivery in relation to insulin sensitivity and glycaemic control. MATERIALS AND METHODS: Forty-eight healthy women with prior GD were consecutively admitted to the study. HRV was analysed by both time, as well as frequency, domain methods using 24-h Holter monitoring. In addition, 20 women with normal glucose tolerance during and after pregnancy were investigated as control subjects. All women underwent a frequently sampled intravenous glucose tolerance test (FSIGT) for measurement of insulin sensitivity. RESULTS: Time domain analysis (standard deviation of normal RR intervals; SDNN) showed a reduced HRV in 25 out of the 48 (52%) women with prior GD. Frequency domain analysis revealed that in these 25 subjects both low and high frequency components of power spectral density (reflecting mainly sympathetic respectively parasympathetic activity) were reduced, indicating that sympathetic as well as parasympathetic functional impairment may be assumed. However, a relative predominance of the sympathetic over parasympathetic cardiac function was observed. The impairment of cardiac autonomic function (reduced SDNN) was correlated with HbA1c values and the 2-h blood glucose concentration (oral glucose tolerance test) but not with insulin sensitivity. CONCLUSION: The present results demonstrate that in 52% of the women examined who had prior GD, an impairment of cardiac sympathetic as well as parasympathetic function was present, which related to glycaemic control, but not to insulin sensitivity. This infers that functional autonomic changes could be an early prognostic indicator in pre-type 2 diabetes.     

Personal perceptions and women's participation in cardiac rehabilitation.

The purpose of this study was to determine whether there were differences in personal perceptions between women who participated in cardiac rehabilitation (CR) and women who did not. This cross-sectional study used a convenience sample of 370 female patients who had been treated and discharged between April 1, 1995, and September 30, 1995. Three standardized scales, a self-report instrument, and medical records reviews were used to collect data at five hospitals and four CR centers in three midsized northeastern Ohio cities. Differences in personal perception and demographic variables between participants and nonparticipants were examined. Education, history of coronary heart disease (CHD), and specific cardiac diagnoses showed statistically significant differences between the groups. Logistic regression tested the model for participation. No variable or group of variables was found to predict CR participation in this sample of women. All cardiac patients need information about CR. Patients with less education, a history of CHD, and a diagnosis of stable angina need special instructions and closer follow-up.     

Automated cardiac output measurements by ultrasound are inaccurate at high cardiac outputs.

OBJECTIVE: The sonographic technique of automated cardiac output measurement (ACM) is a promising new method to measure cardiac output and could be of use in a high-risk obstetric unit in the treatment of pre-eclamptic patients. The aim was to determine the accuracy of the ACM method. DESIGN: Comparative study of the sonographic technique of ACM versus cardiac output measured by thermodilution (TD). METHODS: The study included 39 intensive care patients, 21 men, 13 non-pregnant women and five severely pre-eclamptic pregnant patients, with a wide range of cardiac outputs, in whom TD catheters had been inserted for clinical reasons. Two separate experienced observers, blinded to the results obtained with the other method, performed four successive measurements in each patient with either the ACM or TD technique. The averaged cardiac output value per patient and method was used for comparison. RESULTS: Cardiac output was successfully measured with ACM and TD in 85 and 100% of patients, respectively. Mean cardiac output measured by ACM (6.77 +/- 1.90 L/min) was significantly lower than that measured by TD (9.12 +/- 3.06 L/min). Although cardiac output values obtained with ACM were significantly correlated with those measured by TD, the ACM values were consistently lower than TD values in the higher cardiac output range; the relationship was represented by ACM = 0.35 TD + 3.55 L/min (r = 0.57, P < 0.001). The (ACM - TD) difference increased significantly with cardiac output, through a difference in stroke volume, not in heart rate. CONCLUSION: The ACM is not an accurate tool to measure cardiac output in patients with a high cardiac output, including treated pre-eclamptic women.