Gene therapy for the treatment of cardiovascular disease.

Although still experimental at the present time, gene therapy for the treatment of cardiovascular disease is on the horizon. Numerous clinical trials in patients with flow-limiting coronary artery disease are in progress. In order to keep up with advances in gene therapy, critical care nurses must develop a background in this discipline. This challenge rests in the hands of nursing educators to incorporate a sufficient amount of genetic content into the curriculum. Genetics in the curriculum is essential because it is the central science of health care. Genetic discoveries are changing our understanding of the mechanisms of disease and the diagnosis, treatment, and prevention of cardiovascular disease in particular. Gene therapy is likely to influence our daily nursing practice, and nurses must have an adequate knowledge of genetics to provide accurate information to patients and families so that they can make informed decisions about their health care.

Outcomes management for interventional cardiology.

In the evolution of quality assessment activities in interventional cardiology, outcomes management has become the benchmark for demonstrating optimal care. The high volume of interventional cardiology procedures performed each year mandates that efficient, high-quality and cost-effective patient care be delivered to all patients with cardiovascular disease. Although the interventional cardiology procedures represent only a snap shot of the patient's management of coronary artery disease, a long-term plan for positive outcomes is required. A multidisciplinary approach to outcomes management facilitates institutions to be competitive in today's health care market.

Martha N. Hill: transformational leader.

Martha N. Hill, PhD, RN, FAAN, is a world-renowned researcher, educator, and nursing leader. Her election as president of the American Heart Association, effective June 1997, places her in one of the highest regarded positions in the field of cardiology. Despite her success on a national and international level, Dr. Hill has managed to continue to mentor and conduct clinical research with her nursing colleagues and students at The Johns Hopkins University in Baltimore, Maryland.

Acute effects of conjugated estrogens on coronary blood flow response to acetylcholine in men.

Estrogen therapy is associated with a 50% reduction in the clinical manifestations of coronary artery disease in postmenopausal women. Attenuation of coronary vasomotor dysfunction may contribute to estrogen's cardioprotective effects. We hypothesized that conjugated estrogens, which contain several vasoactive estrogenic compounds, may favorably influence the vasomotor response to acetylcholine in men. Twenty men, 56 +/- 5 years of age, referred for clinically indicated coronary angiography, participated in this study. Acetylcholine-induced changes in coronary flow were measured by quantitative coronary angiography and intracoronary Doppler ultrasonography before and 15 minutes after intravenous administration of conjugated estrogens (0.625 mg) in 12 men and placebo in 8 men. Initial acetylcholine infusion resulted in no significant increase in coronary blood flow. However, 15 minutes after estrogen administration repeat acetylcholine infusion caused a mean 32% increase in coronary blood flow from 41 +/- 5 to 54 +/- 8 ml/min (p = 0.02). Acetylcholine-induced change in flow after estrogen was significantly different from that before estrogen (p = 0.03). Placebo administration did not affect acetylcholine-induced changes in coronary flow. Thus, intravenous conjugated estrogens favorably modulate acetylcholine-induced changes in coronary hemodynamics in men. This suggests that novel nonfeminizing estrogenic compounds may have anti-ischemic effects in men.

Clinical evaluation of a microsample coagulation analyzer, and comparison with existing techniques.

A new microsample coagulation analyzer (Hemochron Jr.) has recently been developed which performs a modified activated clotting time (ACT+) and an aPTT by using different reagents. The Hemochron Jr. measures the clotting time of a 5-microliter whole-blood sample by an optical detector and extrapolates the results to the activated clotting time (ACT+) or the plasma-activated partial thromboplastin time by using a validated regression analysis. We compared 124 simultaneous ACT+ and Hemochron ACTs, and 53 paired Hemochron Jr. aPTTs and hospital laboratory aPTTs, in 44 patients during coronary intervention. The Hemochron Jr. aPTT closely correlated with the lab aPTT (r = .79, P < .0001), and the test results were available much more rapidly than the lab aPTT (3.5 +/- 1.1 vs. 56.3 +/- 25.5 min, P = 0.0029). A comparison of duplicate ACT+ measurements did not identify a significant difference in the means (292 +/- 115 sec vs. 293 +/- 112 sec, P = 0.72). The ACT+ closely correlated with the Hemochron ACTs (r = .85, P < .0001). At baseline, the mean ACT+ (175 +/- 43 sec) exceeded the Hemochron ACT (144 +/- 36 sec) by 22% (P < .001). After heparin administration, the mean ACT+ (378 +/- 74 sec) exceeded the Hemochron ACT (332 +/- 65) by 12% (P < .001). The Hemochron Jr. provides a fast and reproducible methodology for measuring ACT and aPTT, using a small blood volume. Further studies are required to determine the optimal anticoagulation range when using the Hemochron Jr. during or after interventional procedures.

Primary angioplasty in the acute myocardial infarction setting.

Management of patients experiencing an acute myocardial infarction has evolved dramatically during the past 2 decades. The role and timing of percutaneous transluminal coronary angioplasty in patients experiencing a myocardial infarction has remained controversial and under investigation. In recent studies, it was revealed that direct use of percutaneous transluminal coronary angioplasty in the presence of an acute myocardial infarction appears to be a safe, effective, and economical method of reperfusion.

HIV infection, exercise, and immune function.

Decreased physical endurance is viewed by both HIV-infected people and their primary nurses as a major healthcare problem. There is a widespread belief among HIV-infected people that the way to improve their endurance is through exercise. Yet healthcare providers are divided about the role of exercise. This paper presents an overview of decreased endurance as a major problem in this population, with a review of the literature on exercise in healthy and chronically-ill populations, including those with HIV infection, and its effect on immune function.

Preprocedural anticoagulation does not reduce angioplasty heparin requirements.

To determine whether continuous preprocedural heparin influences the need for anticoagulation during percutaneous transluminal coronary angioplasty (PTCA), we compared heparin requirements in patients therapeutically anticoagulated after continuous heparinization for > or = 12 hours with patients not pretreated with heparin (controls). A Hemochron device was used to monitor the activated clotting time (ACT) values during the procedure. An ACT > or = 300 seconds was used as a measure of optimal anticoagulation. Patients pretreated with heparin had significantly higher preprocedural ACT measurements (163 +/- 31.5 vs 126 +/- 13 seconds, p < 0.001) and partial thromboplastin time (PTT) measurements (46 +/- 15 vs 25 +/- 3 seconds, p < 0.001) than controls. While the amount of heparin needed to achieve an initial ACT > 300 seconds was slightly greater in control patients (10,682 +/- 1,852 vs 9,269 +/- 2,993 units, p < 0.001), the total heparin required to maintain an ACT > 300 seconds throughout the procedure was similar between the two groups (11,551 +/- 3,181 units vs 12,136 +/- 2,575 units, p = NS). Thus preprocedural anticoagulation does not significantly reduce total heparin requirements, and these patients should receive the same initial heparin regimen as patients not pretreated with intravenous heparin.

Myocardial reperfusion injury: the critical challenge.

Oxygen-free radical production and reperfusion injury are complex mechanisms. New and improved methods for maximizing the benefits of reperfusion while minimizing reperfusion injury are on the horizon in the 1990s. Critical care nurses play a crucial role in the assessment, planning, and intervention of patients experiencing the deleterious effects of free radicals and reperfusion injury. Thus, a sound knowledge base in the pathophysiology of reperfusion injury, the detrimental effects of free radicals, and the potential benefits of free-radical scavengers is essential.

Reperfusion and reperfusion injury in acute myocardial infarction.

Recognition of the clinical markers of reperfusion and comprehension of the effects of reperfusion injury in acute myocardial infarction provide a unique challenge for today's critical care nurse. In this article we will explore the processes of reperfusion injury. A review of relevant literature and presentation of a clinical case study and care plan will enable the critical care nurse to construct a larger knowledge base and assist in the nursing management of patients with acute myocardial infarction. Evaluation and treatment of reperfusion and reperfusion injury remains under investigation, but through the skills of assessment, planning, and intervention the critical care nurse can coordinate prompt and appropriate care to the patient with an acute myocardial infarction.