Reducing time in bed after percutaneous transluminal coronary angioplasty (TIBS III).

BACKGROUND: This study is the third in a series of investigations on the requisite length of time that patients should be restricted to bed after coronary arteriography or percutaneous transluminal coronary angioplasty using a femoral artery approach. METHODS: A prospective, experimental-control group design with randomization was used initially to compare the incidence of bleeding between patients who remained in bed for 4 hours and patients who remained in bed for 6 hours after sheath removal following percutaneous transluminal coronary angioplasty. RESULTS: Rapid changes in the healthcare environment led to nurses collecting complete data sets for the experimental group only. The experimental group (n = 51) was 73% male and 27% female; mean age was 57 years (SD = 11.4 years). Mean time in bed was 4.1 hours (SD = 0.27 hours). Most patients (98%) did not bleed from the femoral artery access site after remaining in bed for 4 hours following sheath removal. Ninety-two percent of patients required analgesics while in bed. Mean length of stay after the angioplasty was 1.4 days (SD = 0.79 days). Bleeding occurred in one subject and was related to multiple invasive procedures and an activated clotting time of greater than 200 seconds. CONCLUSIONS: Requisite time in bed after percutaneous transluminal coronary angioplasty has been reduced to 4 hours at the University of Virginia Medical Center, the same time required for patients undergoing cardiac catheterization. Discomfort after the procedure remains to be addressed.     

Surgical procedures after percutaneous transluminal coronary angioplasty

Since Gruentzig's introduction of percutaneous transluminal coronary angioplasty in 1974, there has been increasing clinical use of this technic. At St. Thomas Hospital in Nashville, 50 patients were selected for coronary angioplasty through December 1981. Twenty of the 50 have ultimately had coronary artery bypass surgery. Excellent dilatation of the selected coronary artery was accomplished in 19 patients. Fair dilatation was achieved six times, and four of these patients have had elective coronary artery bypass surgery. In 18 patients the vessels could not be dilated, and 12 of this group had coronary artery bypass, three on an urgent basis. In the remaining seven patients, the affected coronary stenosis was converted to 100% occlusion during the angioplasty, resulting in four emergency operations and one death. It appears that percutaneous transluminal coronary angioplasty is not as easy to master as had been anticipated, and that the results are just good enough in our hands to justify perseverence.     

Patient care after percutaneous transluminal coronary angioplasty

Review several studies that investigate head elevation, early walking, and patient comfort after percutaneous transluminal coronary angioplasty (PTCA).     

经皮冠状动脉成形术并发症及其护理

经皮冠状动脉成形术（percutaneous transluminal coronary angioplasty,PTCA）具有创伤小、安全、成功率高、患者易接受等优点,在临床上得到越来越广泛的应用,成为治疗冠心病的主要方法之一.随着技术水平的提高和设备条件的改善,PTCA的手术安全性已大为提高,但术后的并发症却显得愈加突出.因此,术前预防与术后护理对减少PTCA术后并发症显得愈加重要.     

经皮腔内冠状动脉成形并支架置入后血管再狭窄的预防及治疗

经皮腔内冠状动脉成形加支架置入自1977年应用于临床近来得到了迅速发展,目前广泛应用于治疗急性心肌梗死,但是金属支架可导致血栓形成。近年来携带并释放抑制平滑肌细胞增生药物的洗脱支架已应用于临床,可抑制新生内膜增长,降低再狭窄率。药物洗脱支架置入后延迟晚发血栓形成是近年来引起关注的关键问题,所以支架置入后要给予强有力的抗凝治疗。氯吡格雷与噻氯匹定都是有效的抗血小板药物,与噻氯匹定相比,氯吡格雷不良反应小,安全系数更大,起效也更快。联合应用氯吡格雷加阿司匹林预防及治疗经皮腔内冠状动脉成形术加支架置入后再狭窄是安全有效的。随着导管的改进及相关新技术和新疗法的应用,经皮腔内冠状动脉成形术加支架置入的安全性将进一步提高,从而降低再狭窄率。     

Lifestyle pattern change in males following percutaneous transluminal coronary angioplasty/intracoronary stenting

Utilizing a naturalistic inquiry approach, a semi-structured interview schedule and non-probability purposive sampling, this study provided detail on the rationale and influences behind the decisions of four males participants to change or not change their lifestyle patterns 3 months after a percutaneous transluminal coronary angioplasty/intracoronary stent procedure. One of the participants made a noticeable lifestyle pattern change in this period. The remaining participants failed to exhibit any discernible lifestyle pattern change or had continued with their previous behaviours. Results suggest a new 'positive' psychological health perspective, family considerations, return-to-work issues and a reluctance to participate in cardiac rehabilitation as the major factors influencing lifestyle pattern change. Because nurses spend the greatest amount of time with percutaneous transluminal coronary angioplasty/intracoronary stent patients during hospitalization, they have the best opportunity to provide up-to-date and relevant information to patients that will enable them to then make decisions concerning cardiac healthy lifestyle changes.     

Severe insulin allergy after percutaneous transluminal coronary angioplasty

Background: Insulin therapy is essential for type 1 and inadequately controlled type 2 diabetic patients. Insulin allergies have become less common since the introduction of highly purified human recombinant insulin. There are rare reports of severe insulin allergic reactions after percutaneous transluminal coronary angioplasty (PTCA) in patients with type 2 diabetes who had no previous allergic reactions. To better understand the causes and presentation of this rare acute reaction, we present the following observed case.Case summary: A 63-year-old Chinese man (height, 172 cm; weight, 68.5 kg) with a 17-year history of type 2 diabetes and hypertension was first admitted to the West China Hospital, Sichuan University, Sichuan, People's Republic of China, for uncontrolled type 2 diabetes. He used regular human insulin, neutral protamine Hagedorn insulin, or premixed insulin without any allergic reactions. Four months later, PTCA was performed because of an acute myocardial infarction. The patient was administered 50 mg of protamine after active abdominal bleeding due to a right external iliac artery rupture. Three months later, recurrent raised, pruritic erythema occurred at the insulin injection site immediately after injection. Four weeks later, he experienced an attack of generalized urticaria at multiple previous injection sites (abdomen, upper arms, thighs) after injecting premixed insulin. It was accompanied by dizziness and palpitations. During the following 3 months, the symptoms recurred 3 times; one time, the patient reported losing consciousness for 2 to 3 minutes. The results of a skin prick test found that he was allergic to human recombinant insulin and insulin lispro. The allergy was resolved by changing his treatment regimen from insulin to oral hypoglycemic agents. A Naranjo score of 10 suggested a definite relationship (score ≥9) between the adverse drug reaction and the insulin administration.Conclusions: We present a definite case of allergy associated with insulin and insulin lispro administration. The patient had not experienced anaphylactic reactions prior to PTCA and protamine administration.     

Intracoronary thrombolysis and percutaneous transluminal coronary angioplasty. Nursing implications

The advances made in the treatment of coronary artery disease and myocardial infarction are generally viewed with excitement by the health care team. As a result, it is often easy to forget that these same measures may be very frightening to patients and their families. It is the nurse's responsibility to ensure that adequate information is provided about streptokinase therapy and PTCA, not only in terms of their purposes, but also in terms of activities and sensations the patient will experience. The sympathetic stress response demonstrated by frightened patients has a significant effect on cardiovascular function. This effect in patients with an acute myocardial infarction or significant coronary artery disease can, in turn, adversely affect the outcome of therapeutic interventions. Streptokinase therapy and PTCA are still relatively new procedures. Over the next ten years they may be used both more extensively and under more acute circumstances. For the patient, however, they will remain new and frightening. Appropriate nursing interventions, particularly those related to decreasing this fright, can decrease anxiety and minimize the risks related to the sympathetic stress response, promoting patient well-being.     

经皮冠状动脉腔内成形术中反复血流阻断对心肌缺血预适应的影响

目的：评价经皮冠状动脉腔内成形术（ＰＴＣＡ）中短时、反复的血流阻断再灌注是否具有抗急性缺血预适应现象及缺血相关性心律失常的作用。方法：连续观察１３８例住院接受ＰＴＣＡ术的冠状动脉粥样硬化性心脏病患者术前及术中的心电图、心率和血压等指标变化。结果：①３３例（２３．９％）患者术中出现室性早搏（ＶＥ）３８例次，其中３０例于首次球囊扩张时发生了ＶＥ，９例记录到ＶＥ二联律或成对ＶＥ；８例于再次球囊扩张时出现ＶＥ；其中５例２次扩张时均出现ＶＥ。第１次球囊扩张时的ＶＥ检出率（２１．７％）显著高于第２次（５．８％，Ｐ＜０．０１）。②首次球囊扩张时７３例（５２．９％）出现ＳＴＴ改变，再次球囊扩张时３１例（２２．５％）有ＳＴＴ改变（Ｐ＜０．０１）；③出现ＶＥ的３８例次患者的冠脉狭窄程度（７４．０％±１１．０％）轻于无ＶＥ出现者（８５．０％±１２．０％，Ｐ＜０．０５）。结论：短时反复的冠脉闭塞再灌注过程可减轻缺血心肌细胞的电不稳定性；同时于首次球囊扩张后血流再灌注的心肌对急性缺血可产生较强的适应现象。     

Fatty acid exercise scintigraphy after percutaneous transluminal coronary angioplasty

Summary . We performed a sequential fatty acid exercise-rest scintigraphy in 18 patients with an initially successful percutaneous transluminal coronary angioplasty (PTCA) to study the concordance of trends in symptoms, exercise tolerance and myocardial metabolism. Eleven patients stopped the exercise because of angina pectoris in the preoperative test; 2 days after PTCA this number decreased to two, but again increased to eight 3 months later. Exercise time (9–7 ± 0–6 min, mean ± SEM) and maximum exercise heart rate (128 ± 4 beats min^-1) were at least as good immediately after the operation as originally (8–8 ± 0–6 min and 121 ± 4 beats min^-1, respectively). After 3 months both parameters were significantly (P<0–05) better (10–3 ± 0–6 min and 136 ± 4 beats min^-1, respectively) than originally. Some relative improvement in washout was noticed in 61% 2 days and in 56% of cases 3 months after PTCA. Fatty acid exercise uptake was more homogeneous in 72% of cases immediately after angioplasty and in 44% 3 months later. The trend in fatty acid uptake, exercise characteristics, and also in symptoms was most favourable among the eight patients with a dilatated left anterior descending coronary artery. Although the gamma camera technique possibly underestimated the effects of angioplasty, the impaired fatty acid metabolism could be linked with persistent symptoms after the operation. We conclude that most patients can safely participate in a symptom-limited (maximal) ergometry test already 2 days after PTCA, and that postoperatively myocardial perfusion and metabolism improve rapidly. However, this advantage is eventually lost to some degree, even if exercise tolerance continues to improve.     

Role of cardiac troponin testing in percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) is a common invasive procedure for myocardial revascularization. This article reviews the role of monitoring cardiac troponins in identifying procedural myocardial damage as a result of PTCA, its associations with balloon inflation time, stenting, side-branch occlusion and the prognostic implications of elevated levels of cardiac troponins. A review of several studies demonstrates that cardiac troponins are more sensitive than creatine kinase MB, CK-MB (mass) in detecting minor myocardial damage during PTCA. Increases in post-procedural cardiac troponin T and cardiac troponin I are associated with a greater degree of morbidity and mortality. Increases are more common and more pronounced following a longer duration of balloon inflation time, stenting and side-branch occlusion. Elevated cardiac troponins pre-procedure are a poor prognostic indicator.     

Effects of percutaneous transluminal coronary angioplasty on coronary adenosine concentrations in humans

BACKGROUND: Even minimal amounts of adenosine is released during myocardial ischemia. Its role in coronary blood flow has been extensively studied, but little is known about its behaviour during percutaneous transluminal angioplasty (PTCA) in man. MATERIAL AND METHODS: Using in situ samples the aim of this study was to evaluate adenosine plasma concentration before and after PTCA. Ten patients (8 men and 2 women, mean age 65 +/- 9 years) with a single stenosis of the left anterior descending coronary artery (LAD) of at least 70% and 10 healthy volunteers (4 men and 6 women, mean age 55 +/- 9 years) were included in the study. RESULTS AND DISCUSSION: We found that there is a close relationship between the degree of the stenosis and the adenosine concentrations in the great cardiac vein and in the LAD, and that after PTCA there is a drop in adenosine concentration downstream from the stenosis. This study confirms the crucial role of adenosine in coronary blood flow control.