OPTIMAL CARE POST

INTERVENTION
CORONARY
ANGIOPLASTY
 LEARNING OBJECTIVES

 IDENTIFY HOW TO PREVENT, DETECT AND TREAT:

 THROMBOSIS
 RESTENOSIS
 DISEASE PROGRESSION

 Understand the post Angioplasty coroner nursing care

 Understand the complications that may occur and how to treat them
 OPTIMAL CARE AFTER PCI
PREVENTION, DETECTION AND TREATMENT OF SHORT- AND LONG-TERM COMPLICATIONS ARE VITAL
TO OPTIMIZING PATIENTS' OUTCOMES POST PCI.

Goal of post-PCI care is to prevent, detect and treat:

 Thrombosis
 Restenosis
 Disease progression
STENT THROMBOSIS: DEFINITION
STENT THROMBOSIS IS A RARE BUT POTENTIALLY LIFE-THREATENING ADVERSE EVENT AFTER PCI. ST
EVENTS ARE CLASSIFIED AS DEFINITE, PROBABLE OR POSSIBLE.

Three categories of evidence (ARC):

Definite/Confirmed Acute Coronary Syndrome AND

• Angiographic confirmation of thrombus or occlusion
OR
• Pathologic confirmation of acute thrombosis

Probable Unexplained death within 30 days

Target vessel MI without angiographic confirmation of

thrombosis or other identified culprit lesion

Possible UNEXPLAINED DEATH AFTER 30 DAYS

 STENT THROMBOSIS: PREVENTION'
ANTIPLATELET AGENTS ARE THE CORNERSTONE OF POST-PCI THERAPY.
ESC RECOMMENDS A MINIMUM 1-MONTH DAPT FOR BMS & 6 MONTHS FOR DES, WITH A MINIMUM 12-
MONTH DURATION IN STEMI.

 Dual antiplatelet treatment (DAPT)

 ASA 75-325 mg daily with either:
 Clopidogrel 75 mg daily
 Prasugrel 10 mg daily
 Ticagrelor 90 mg BID

 Minimum duration of DAPT:

 1 month after BMS implantation
 6 months after DES implantation
 1 year in all patients after ACS, irrespective of revascularization strategy
 STENT THROMBOSIS: PREVENTION
POST-PCI PATIENTS ARE REQUIRED TO REMAIN ON ANTIPLATELET THERAPY INDEFINITELY. WHEN CONSIDERING
ANTIPLATELET THERAPY INTERRUPTION, THE RISK OF THROMBOSIS AND BLEEDING SHOULD BE CAREFULLY
WEIGHED.

 Secondary prevention demands lifelong anti-platelet therapy with 75-325 mg ASA

daily

 In patients with compelling indication for vitamin K antagonist treatment (AF with
CHADS2 score ≥ 2, mechanical valve), triple therapy should be prescribed for the
shortest necessary duration with frequent INR measurement (target 2-2.5) and
BMS should be considered

 If surgery is needed and cannot be postponed beyond the recommended period of

DAPT, ASA should be considered during the perioperative period

 In surgical procedures with low to moderate bleeding risk, surgeons should be

encouraged to operate on DAPT
 RESTENOSIS: CLINICAL PRESENTATION
RESTENOSIS IS AN ACCELERATED PROLIFERATIVE HEALING RESPONSE TRIGGERED BY VESSEL WALL
INJURY AND TYPICALLY PRESENTS AS ANGINA OR AMI WITHIN 8 MONTHS POST-PCI .

 Within 1 to 8 months after PCI patient presents with:

 Exertional angina: 25-85%
 Unstable angina: 11-41%
 Acute MI: 1-6%

 No systemic pharmacological treatment is recommended to prevent restenosis

RESTENOSIS: FUNCTIONAL TESTING
FUNCTIONAL TESTING OPTIONS FOR IDENTIFICATION OF RESTENOSIS POST-PCI INCLUDES STRESS/EXERCISE
TESTING (ECG) AND IMAGING (ECHO OR NUCLEAR), HOWEVER WITHIN 2 YEARS OF PCI ROUTINE TESTING IS NOT
RECOMMENDED.

Routine screening after PCI has shown poor sensitivity and specificity

Exercise testing after discharge is helpful for activity counseling and/or exercise training as part of
cardiac rehabilitation
DISEASE PROGRESSION: RISK FACTORS
THE MAJORITY OF RISK FACTORS FOR CVD ARE MODIFIABLE AND MOST CAN BE ADDRESSED WITH
LIFESTYLE CHANGES TO HELP PREVENT CARDIAC EVENTS.
POST PCI LIFESTYLE AND RISK FACTOR MANAGEMENT
ESC MAKES SPECIFIC RECOMMENDATION FOR LIFESTYLE AND RISK FACTOR MODIFICATIONS POST
PCI.
 DISEASE PROGRESSION: ACE INHIBITORS

 Use of ACE inhibitors should be considered in all patients with atherosclerosis in the absence of contraindications
 But, given their relatively modest effect, their long-term use cannot be considered mandatory in post-STEMI patients who
are normotensive, without heart failure, or have neither LV systolic dysfunction nor diabetes
DISEASE PROGRESSION: BETA BLOCKERS
ALTHOUGH BETA-BLOCKERS ARE INDICATED POST ML, ACS OR LV DYSFUNCTION, THERE IS SOME
UNCERTAINTY REGARDING THEIR EFFICACY ON TOP OF CURRENT TREATMENT STRATEGIES.
 DISEASE PROGRESSION: BETA BLOCKERS
BETA-BLOCKERS HAVE NOT SHOWN A BENEFIT IN STABLE OUTPATIENTS WITH AND WITHOUT CAD.

This observational study of patients with either CAD risk factors only, known prior Ml, or known CAD without Ml, showed the
use of beta-blockers was not associated with a lower risk of composite cardio-vascular events.
 ASSESMENT

History
 Identify if the patient has an existing cardiac condition
 Age of the patient
 Identify normal cardiac rhythm for the patient by referring to the pre procedure ECG ‘s
 Identify whether the patient had a interventional cardiac catheter
 Identify acces site (position and whether arterial or venous)
 Check if the patient has been on anticoagulantion
 Identify if the patient had any complications during theatre
 Enquire about the findings of the catheter procedure
 Ascertain what medications have been administered or ordered
NURSING CARE PLAN

Obtaining vital signs Prevention or

Education of the and blood test detection of vascular
patient in the results accesscomplications
lab

Anxiety
Hydration & diuresis Pain management
management
Education of the Patient in the CathLab

The Any chest pain or discomfort they may be feeling

patient Pain or bleeding at the access site
should Shortness of breath
report Doubts
to
his/her
nurse
POST PROCEDURE VITAL SIGNS & BLOOD TESTS

Post-PCI ECG monitoring is done to detect ST

abnormalities and arrhythmias

Blood pressure and O2 saturation levels are

observed

ACT should be <160 seconds before sheath Removal

Blood glucose should be monitored

Hematology and electrolytes should be repeated

ancompared with previous values
PREVENTING VASCULAR ACCESS SITE
COMPLICATIONS
Femoral approach
Radial approach

The amount of time the patient Keep the affected hand, wrist,
should remain at complete bed and arm still for 2-4 hours and,
rest without bending the knee is again, follow local practice
dependent on the local practice
and whether a percutaneous
closure device was used
 PREVENTING VASCULAR ACCESS SITE
COMPLICATIONS
Record French size and location of punctures

Check access site periodically to detect signs of complications, such as

bleeding, hematoma or swelling
Groin and circulation observations include pedal pulses, color, warmth, movement and sensation of
the affected leg and foot

Be aware and check for retroperitoneal bleed

Patient stability, heart rate, Pain at the site, back, or Diagnosis: abdominal CT Scan
rectum
Blood pressure
HYDRATION & DIURESIS

Patients may have oral fluids and normal medication, but should
not eat until after the sheath is removed

Urinary retention may occur while the sheath is in place

• Monitor urine output and signs of bladder distention or Discomfort
• A urinary catheter may need to be inserted

Oral hydration may be helpful in preventing contrast induced

nephropathy
PAIN MANAGEMENT

It is important Patients should Monitor the

to keep the not be suffering
patient from pain post patient’s pain
comfortable PCI level

If the patient has

been prescribed
medication,
administer it as
instructed
ANXIETY MANAGEMENT

Potential causes of patient’s anxiety

• Pain
• Future CABG
• Lack of information/education
• Worried about their family

Try to uncover and address the patient’s needs, thereby

reducing anxiety
 POST PCI INSTRUCTIONS FOR THE PATIENT
POST- PCI CARE MUST INCLUDE SPECIFIC INSTRUCTIONS TO THE PATIENT, PARTICULARLY REGARDING THEIR DAPT.

 Stress the importance of antiplatelet treatment —no change should be made without cardiologist's authorization
 Patient should advise all treating practitioners of DAPT regime (i.e. dental procedures, etc.)

 Plan follow-up visits

 Help patient understand instructions and possible complications of post-PCI medical treatment

 Provide recommendations for risk reduction, including:

 Smoking
 Lipid management
 Blood pressure control
 Weight
 Diabetes

 Make sure the patient identifies an emergency contact

 POST PCI: INSTRUCTIONS FOR THE REFERRING PHYSICIAN
POST- PCI CARE MUST ALSO INCLUDE SPECIFIC INSTRUCTIONS TO THE REFERRING PHYSICIANS,
INCLUDING PROCEDURE DETAILS AND DAPT PLAN.

 Provide procedure details: vessel treated, result, type of stent(s) implanted, etc.

 Report complications or incidents during the procedure

 Report use of a closure device

 Detail the antiplatelet treatment plan

 Identify the person to contact if symptoms occur or if a change in antiplatelet treatment is planned
 SUMMARY

 Prevention, Detection and Treatment of complications are vital for our patients post PCI.

 Medications post PCI should be only be discontinued with physician consent i.e. DAPT

 The majority of risk factors for CVD are modifiable, and most can be addressed by lifestyle changes to help prevent a first or
recurrent cardiac event.