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ADVANCES IN CARDIOVASCULAR CARE: 50 YEARS OF PROGRESS

ADVANCES IN CARDIOVASCULAR CARE: 50 YEARS OF PROGRESS. Beverly Lowentritt RN,MSN,CS,FNP. Joe’s Story 1957. 46 yr old short-haul truck driver Faithful 25 yr employee, husband, father of 4 Smokes 2 packs a day (unfiltered Camels) Ht/Wt: 5’11”/ 230 pounds

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ADVANCES IN CARDIOVASCULAR CARE: 50 YEARS OF PROGRESS

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  1. ADVANCES IN CARDIOVASCULAR CARE:50 YEARS OF PROGRESS Beverly Lowentritt RN,MSN,CS,FNP

  2. Joe’s Story1957 • 46 yr old short-haul truck driver • Faithful 25 yr employee, husband, father of 4 • Smokes 2 packs a day (unfiltered Camels) • Ht/Wt: 5’11”/ 230 pounds • Diet: bologna and cheese sandwich, Hostess cupcake, whole milk • Exercise: heavy, physical labor • Stress: sole breadwinner, extremes in temp, no air conditioning in truck or company • No physician • Family history – father died in his 40’s

  3. Risk Factors for Acute Coronary Syndrome (ACS) Modifiable: • Sedentary lifestyle • Cigarette smoking • Obesity • High-fat diet • Hypertension Non-modifiable: • Male gender • Family history • Diabetes • Menopause

  4. Joe’s Last Day on the Job • 3-day history of weak, dizzy, nausea, indigestion – unrelieved by Alka Seltzer • Temp outside: 105 “in the shade” • Tells no one!! • Noted by another employee to be visibly SOB, sitting down frequently • “Falls out” – no CPR, dies of “heart attack” OR

  5. Joe’s Last Day on the Job • Sitting down and asks for a doctor • Ambulance – station wagon and untrained driver – transported to a hospital room • Physician orders: CBC, oxygen, tepid fluids, no coffee or stimulants, soft bland diet, quiet room, bedrest for 2 weeks • Discharged to return home to sedentary lifestyle -NEVER TO WORK AGAIN!!! • ROI??? – 25 yrs for company, productive life cut short for Joe

  6. Joey’s Story2007 • 46 yr old short-haul truck driver – 12 hr rotating shifts in large, noisy industrial environment • 6-month employee, husband, father of 4 • Smokes 2 packs a day (filtered) • Ht/Wt: 5’11”/ 230 pounds • Diet: Big Mac, fries, large Coke, apple pie • Exercise: work • Stress: divorced, financial overstretch • No physician • Family history – grandfather (Joe) died age 46

  7. Joey’s First Day of the Rest of His Life • Chronic complainer but today weak, diaphoretic, rubbing chest, SOB • “Falls out” – nurse/employees initiate CPR, **AED applied • Ambulance arrives (paramedics) – 12-lead EKG transmitted, lab drawn, IV, **ASA, “packaged” for transport • **E.D. - “Door to balloon” time < 90 minutes • **Cath Lab – **catheter, balloon, stent • **CV surgery - **IABP

  8. Joey’s First Day of the Rest of His Life • **CCU – arterial lines, monitors, 1:1 care, defibrillator and Crash Cart • Step-down unit after 2 days • CHF – STAT Team called – “tuned up” – remains on Step Down Unit • Early, aggressive mobility • Discharged < 1 week • **Cardiac rehab • Progressive recovery at home • RETURN TO WORK in 6-8 weeks!! • ROI - $$$thousands at work, immeasurable at home

  9. AMERICAN HEART ASSOCIATION • 400,000 to 460,000 die of heart disease each year • 1261 lives yesterday • 13% of these deaths are in the workplace

  10. Prevalence of cardiovascular diseases in adults age 20 and older by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, stroke and hypertension.

  11. Annual rate of first heart attacks by age, sex and race (ARIC: 1987-2000). Source: NHLBI’s ARIC surveillance study, 1987-2000.

  12. Estimated direct and indirect costs of major cardiovascular diseases and stroke(United States: 2007). Source: NHLBI.

  13. RISK ASSESSMENT FOR CARDIOVASCULAR DISEASE EARLY INTERVENTION IS KEY TO SUCCESS KNOW AND TREAT RISK FACTORS BY AGE 20!!!

  14. RISK FACTORS FOR CV DISEASE Major That Cannot Be Changed: • Increasing age - >83% who die are 65 or older • Gender – male • Heredity – IT’S HARD TO OUTRUN YOUR GENES!!!

  15. RISK FACTORS FOR CV DISEASE Major That Can Be Modified: • Tobacco • Elevated cholesterol • High blood pressure • Physical inactivity • Obesity • Diabetes

  16. Trends in the age-adjusted prevalence of health conditions, U.S. adults ages 20-74 (NHANES:1971-74 to 1999-2000). Source: Briefel and Johnson. Annu Rev Nutr. 2004;24:401-431. Printed with permission from the Annual Review of Nutrition.

  17. CONTRIBUTING FACTORS • Stress • Alcohol • ??????

  18. TOP 10 ADVANCES IN CV CARE IN PAST 50 YEARS 1) Cardiac catheterization • Accurate diagnosis of coronary disease • Produced first clear images of abnormal blood vessels, cardiac chambers, and valves • Paved way for successful cardiac surgery and interventional radiology

  19. TOP 10 ADVANCES IN CV CARE IN PAST 50 YEARS 2) CV Interventional Therapy • Balloon angioplasty, stent placement (drug-eluting vs. bare metal), ASD repair • Excellent results overall!! • Risk of M.I., stroke, death

  20. DRUG-ELUTING STENT

  21. TOP 10 ADVANCES IN CV CARE IN PAST 50 YEARS 3) Cardiovascular surgery • Cardiopulmonary bypass machine • Cardiac “window” • Rapid, safe interventions commonplace in many hospitals • Some are not candidates

  22. TOP 10 ADVANCES IN CV CARE IN PAST 50 YEARS • Lifesaving techniques • AEDs, antiarrhythmic drugs, implantable defibrillators, ablation • Reduced incidence of sudden cardiac death • Drugs have fatal S.E.s, no evidence of prolonged life

  23. TOP 10 ADVANCES IN CV CARE IN PAST 50 YEARS 5) Intensive Care • Major reduction in inpatient mortality through monitoring, central venous and right heart monitoring, drug delivery and highly skilled care • Patients still die despite all

  24. RAPID RESPONSE TEAMRRMC MODEL Situation Triggers Assessment/Treatment (STAT) Team • Critical Care Charge Nurse (or designee) Coordinator • Supervisor • Respiratory Therapist • Unit Charge Nurse • Patient’s Nurse

  25. STAT TEAM Criteria: • Acute change in vital signs (defined) • Acute decline in O2 saturation • Altered mental status • S&S of stroke • Repeated seizures • CONCERNED staff

  26. TOP 10 ADVANCES IN CV CARE IN PAST 50 YEARS 6) Noninvasive CV diagnosis • Reduces hazard of invasive procedures (Holter monitor, CTA, cardiac MRI, Echo, stress test) • Improved accuracy of diagnosis • Subjective (false positives and negatives) – SHOULD NOT REPLACE GOOD OL’ H&P and critical thinking

  27. TOP 10 ADVANCES IN CV CARE FOR PAST 50 YEARS 7) Molecular review of CV system normal and abnormal evaluation to the molecular level (thrombosis, heart failure, acute coronary syndrome)

  28. Pathogenesis of ACS Fibrous Plaque Complicated Lesion/Rupture Intracoronary Thrombus Atheroma Reduced Blood Flow Myocardial Ischemia Myocardial Necrosis TnI, TnT, CK-MB, Myoglobin Unstable Angina Myocardial Infarction Asymptomatic

  29. Risk Factors for Acute Coronary Syndrome (ACS) Modifiable: • Sedentary lifestyle • Cigarette smoking • Obesity • High-fat diet • Hypertension Non-modifiable: • Male gender • Family history • Diabetes • Menopause

  30. TOP 10 ADVANCES IN CV CARE IN PAST 50 YEARS • Management of AMI: • ASA, B-blocker, ACE or ARB if LVSD, time to percutaneous coronary intervention (PCI) <90 min., antiplatelet therapy • Reduction in mortality from 30% to 5-10% today • Cardiogenic shock remains a dreaded complication and often results in death

  31. TOP 10 ADVANCES IN CV CARE IN PAST 50 YEARS • Treatment of Heart Failure • ACE, ARB • Intraaortic balloon pump (IABP) • Heart transplantation • “Feel better” • Little impact on overall mortality

  32. TOP 10 ADVANCES IN CV CARE IN PAST 50 YEARS 10) Cardiovascular preventive medicine • Framingham Heart Study – landmark study • Steady decline in M.I. and stroke mortality and sudden death, exercise, cardiac rehab and smoking cessation programs • More work to do!! < 50% pts with HTN adequately treated and worse for lipid disorders!!!!

  33. Obesity Trends* Among U.S. AdultsBRFSS,1990, 1995, 2005 (*BMI 30, or about 30 lbs overweight for 5’4” person) 1995 1990 2005 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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