Direct oral anticoagulant drugs for the management of venous thromboembolism.

ABSTRACT: Direct oral anticoagulants (DOACs) are effective for both prevention and treatment of venous thromboembolism (VTE) and have favorable safety in comparison with warfarin. Although drug-drug interactions with DOACs are not as frequent as with warfarin, certain drugs can interfere with DOAC metabolism, affect DOAC efficacy, and potentially cause adverse reactions when used in combination with DOACs. The NP must determine which agent is most beneficial for the individual patient with VTE based on a number of factors. A knowledge of periprocedural management of DOACs will assist the NP in providing a smooth transition for patients undergoing minor and major procedures and surgeries.

Factors affecting STEMI performance in six hospitals within one healthcare system.

BACKGROUND: How quickly percutaneous coronary intervention is performed in patients with ST-elevation myocardial infarction (STEMI) is a quality measure, reported as door-to-balloon (D2B) time. OBJECTIVES: To explore factors affecting STEMI performance in six hospitals in one healthcare system. METHODS: This was a retrospective chart review of clinical features and D2B times. Predictors for D2B times were identified using multivariate linear regression. RESULTS: The median D2B time for all six hospitals was 63 minutes and all hospitals surpassed the minimal recommended percentage of patients achieving D2B time ≤90 minutes (87.8%vs75%,p<0.001). Patient confounders adversely affect D2B times (+21.5 minutes, p<0.001). Field ECG/activation with emergency department (ED) transport (-22.0 minutes) or direct cardiac catheterization laboratory (CCL) transport (-27.3 minutes) was superior to ED ECG/activation (p<0.001). CONCLUSION: Field ECG/STEMI activation significantly shortened D2B time. To improve D2B time, hospital and Emergency Medical Service collaboration should be advocated to increase field activation and direct patient transportation to CCL.

Diagnosis of venous thromboembolism using clinical pretest probability rules, D-dimer assays, and imaging techniques.

ABSTRACT: Venous thromboembolism is a significant clinical entity that includes two associated medical disorders: deep vein thrombosis and pulmonary embolism. The goal of this article is to describe the optimal approach to evaluating venous thromboembolism including pretest probability clinical decision rules and appropriate testing to ensure an accurate diagnosis.

Predictors and outcomes of postoperative respiratory failure after cardiac surgery.

BACKGROUND: Postoperative respiratory failure after cardiac surgery (CS-PRF) is a devastating complication and its incidence and predictors vary depending on how it is defined and the patient population. AIMS: This study was conducted to determine the incidence, predictors and outcomes of CS-PRF defined as prolonged mechanical ventilation >48 hours and reintubation. METHODS: This is a retrospective chart review of 1257 patients who underwent cardiac surgery between June 2011 and December 2018. The research questions were addressed through bivariate inferential, descriptive and binary logistic regression. RESULTS: The overall incidence of CS-PRF was 15.9% and significant regression predictors included diabetes mellitus (OR = 1.77, P = .001), preoperative renal replacement therapy (OR = 2.07, P = .033), need for intraoperative transfusion (OR = 2.35, P = .000), combined coronary bypass/valvular surgery (OR = 2.61, P = .001) and intra-aortic balloon pump (OR = 3.60, P = .000). CS-PRF patients had increased postoperative blood transfusions (69.5% vs 27.9%, P = .000), reoperation for bleeding (9.0 vs 0.4%, P = .000), pleural effusion (13.5% vs 4.1%, P = .000), pneumonia (33.5% vs 1.6%, P = .000), acute kidney injury (70.9% vs 39.9%, P = .000), atrial fibrillation (42.5% vs 26.3%, P = .000), coma/encephalopathy (21.5% vs 3.3%, P = .000) and cerebrovascular accident (6.0% vs 1.3%, P = .000). They also had longer intensive care (262.1 vs 97.4 hours, P = .000) and hospital lengths of stay (17 vs 8 days, P = .000), and increased in-hospital mortality (17.5% vs 0.4%, P = .000). Survivors of CS-PRF were less likely to be discharged home (38.0% vs 84.4%, P = .000). CONCLUSIONS: Knowledge of predictors for CS-PRF may help identify patients who are at risk for this complication and who may benefit from preventive measures to promote early extubation and to avert reintubation.

Predictors and Outcomes of Acute Kidney Injury after Cardiac Surgery.

A retrospective study was performed to evaluate predictors and outcomes of acute kidney injury (AKI) post-cardiac surgery based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The incidence of AKI post-cardiac surgery was 30.3% for AKI Stage 1, 7.1% for AKI Stage 2, and 7.9% for AKI Stage 3. Smoking history, postoperative acute respiratory failure, and postoperative blood transfusion were predictors of all AKI stages. Hypertension, cardiopulmonary bypass, and postoperative coma/encephalopathy were predictors of higher AKI stages. AKI post-cardiac surgery was significantly associated with poor postoperative outcomes, including prolonged intensive care unit and hospital lengths of stay, lower likelihood to be discharged home, and increased postoperative mortality. AKI is a common complication after cardiac surgery, and knowledge of predictors of post-cardiac surgery AKI helps identify patients at risk.

Cardiac risk assessment: decreasing postoperative complications.

Preoperative cardiac assessment helps identify patients undergoing noncardiac surgery who are at risk for significant postoperative cardiac complications and those who may benefit from additional preoperative evaluation and perioperative care. Advanced practice nurses can identify surgery- and patient-related risks by conducting a thorough health history and physical examination. Multiple risk indices and evidence-based guidelines are available to inform health care providers regarding patient evaluation and strategies to reduce postoperative cardiac risk. In general, preoperative tests are recommended only if the findings will influence medical therapy or perioperative monitoring or will require postponement of surgery until a cardiac condition can be corrected or stabilized. Medication management is a crucial component of the preoperative assessment; providers may need to initiate the use of beta-blockers and make decisions regarding continuing or withholding antiplatelet and anticoagulant therapy. Preoperative cardiac risk stratification, medication reconciliation, and device management are essential for providing safe care for patients.

Advanced practice nursing: shaping health through policy.

PURPOSE: To highlight the importance of advanced practice nurses (APNs) becoming politically engaged as key to promoting the healthcare interests of patients, communities and the profession and to offer specific strategies on how to become politically competent. DATA SOURCES: Robert Wood Johnson Foundation, CINAHL, PubMed. CONCLUSIONS: APNs must come to see political engagement as a professional obligation and health policy as something that they can shape rather than something that happens to them. IMPLICATIONS FOR PRACTICE: The overall goal of healthcare reform is the provision of quality, safe and cost-effective healthcare for all Americans. APNs are graduate prepared clinicians that focus on health and illness management and are strategically positioned to lead the way in shaping and implementing health policy priorities.

The impact of an electronic medical record surveillance program on outcomes for patients with sepsis.

OBJECTIVES: To evaluate the effects of this EMR surveillance on sepsis, severe sepsis or septic shock outcomes in patients admitted to a medical telemetry unit, including length of hospital stay, patient discharge and mortality. METHODS: A retrospective review of pre- and post-implementation of a pilot electronic medical record (EMR) sepsis surveillance. RESULTS: Implementing EMR sepsis surveillance significantly improved home discharge (49.0% versus 25.3%, p < .05) and reduced hospital mortality (1.0% versus 9.3%, p < .05). Although there was no difference in the length of hospital stay for the whole group, patients in the surveillance group who triggered an alert on the EMR surveillance had a decreased length of hospital stay compared to those without an alert (7.2 ± 4.2 versus 11.6 ± 9.4 days, p < .05). CONCLUSION: These results offer promising evidence that the use of an EMR sepsis surveillance alert could decrease the ravishing effects of sepsis, severe sepsis and septic shock by early identification and treatment.

Moyamoya disease: a case of vanishing cerebral vessels.

PURPOSE: To provide an overview of moyamoya disease (MMD) including pathophysiology, epidemiology, clinical presentation, diagnosis, treatment, and prognosis. DATA SOURCES: Selected clinical and epidemiological studies, review articles, and diagnostic guidelines for MMD. CONCLUSIONS: MMD is a rare cerebrovascular disease characterized by progressive stenosis of the distal internal carotid arteries and their major branches. The dilated and fragile basal collateral circulations display a "puff of smoke" appearance and thus are called moyamoya vessels. Other unique features of MMD include 2:1 female preponderance and its peak incidence in two age groups: early childhood and adults in their mid-40s. The pathophysiology of MMD is unclear and possible causes include genetic linkage, angiogenesis, autoimmune disease, cranial radiation, and infection of the head and neck. Most patients are symptomatic and may present with ischemic or hemorrhagic strokes, seizure, or headache. The diagnosis depends on clinical presentation and radiographic imaging, and disease progression may be halted with direct or indirect cerebral revascularization. IMPLICATIONS FOR PRACTICE: It is important to make a correct diagnosis and provide appropriate treatment to reduce the morbidity and mortality associated with MMD. A prompt referral for possible surgical revascularization offers the best chance to reduce additional cerebral injuries and improve clinical outcomes.

Postoperative pulmonary complications: reducing risks for noncardiac surgery.

Postoperative pulmonary complications (PPCs) are a major contributor to the overall risk of noncardiac surgery that may lead to serious postoperative morbidity and long-term mortality. Nurse practitioners should be familiar with risk indices for PPCs, clinical guidelines, and risk reduction strategies to prevent PPCs and improve PPC outcomes.

ICD deactivation: review of literature and clinical recommendations.

Implanted cardioverter defibrillators (ICDs) are an essential part of the management for patients at risk for life threatening arrhythmias. Despite new technologies, all patients ultimately will reach the end of their lives, either because of underlying cardiac disease or another terminal illness. Having an ICD at the end of life may deny a patient the chance of sudden cardiac death and result in a slower terminal disease and pain and anxiety due to shocks from their device. The purpose of this article is to present a focused literature review on the barriers surrounding deactivation of ICDs and to summarize the recommendations of the Heart Rhythm Society Consensus Statement on the management of ICDs in patients nearing end of life or requesting withdrawal of therapy.

Effect of bronchodilator treatment on the incidence of postoperative atrial fibrillation after cardiac surgery.

OBJECTIVE: We sought to examine the effects of bronchodilator treatment on the incidence of postoperative atrial fibrillation (POAF) after cardiac surgery. METHODS: A cross-sectional design using a retrospective chart review was performed in patients who underwent cardiac surgery. Those who had previous atrial fibrillation or preoperative bronchodilator treatment were excluded from the final sample (n = 506). The Statistical Package for the Social Sciences (SPSS, Inc., Chicago, IL) was used for statistical analyses. RESULTS: The incidence of POAF in this study was 27.9%, and was associated with age (P < .01) and type of cardiac surgery (P < .05), indicating that increasing age, and combined cardiac surgery were more likely to precipitate POAF. Bronchodilator treatment did not increase POAF. However, combined therapy significantly (P < .01) precipitated more POAF (48.7%) than did albuterol (21.4%) or levalbuterol (18.5%). CONCLUSIONS: Postoperative atrial fibrillation continues to be a common complication after cardiac surgery. Bronchodilator treatment with either albuterol or levalbuterol did not precipitate POAF, unless both agents were given to the same patients postoperatively.

Diagnosis and management of primary aldosteronism.

Primary aldosteronism (PAL) is characterized by excessive production of aldosterone, which leads to hypernatremia, hypertension (HTN), hypokalemia, and alkalosis. Three crucial diagnostic steps include case detection, case confirmation, and subtype classification. Marked improvement or cure of HTN is achieved with appropriate treatment.

Methadone-induced torsades de pointes: a twist of fate.

A case of methadone-induced torsades de pointes is presented to demonstrate clinical features that predispose patients to this serious cardiac arrhythmia. A patient who was receiving methadone maintenance treatment for heroin addiction presented to the hospital with dizziness and near-syncope. He was taking a relatively high dose of methadone but was not taking any concomitant cytochrome P450 inhibitor or QT-prolonging drugs. He had prolonged corrected QT interval, hypokalemia, and hypomagnesemia on admission and was later found to have severe left ventricular dysfunction. On admission to a telemetry unit, the patient experienced chest discomfort and palpitations with corresponding torsades de pointes that was terminated with correction of hypokalemia and hypomagnesemia. The corrected QT interval became shorter but remained profoundly prolonged until methadone was substituted with buprenorphine.

Postural orthostatic tachycardia syndrome: diagnosis and treatment.

BACKGROUND: Postural orthostatic tachycardia syndrome (POTS) is an autonomic disorder characterized by an exaggerated increase in heart rate that occurs during standing, without orthostatic hypotension. Women are most frequently affected, and may present with palpitations, chest discomfort, shortness of breath, weakness, exercise intolerance, lightheadedness, presyncope, and syncope. METHODS: We present three cases of POTS in otherwise healthy women, and discuss the clinical management of different types of this orthostatic intolerance. RESULTS AND CONCLUSION: The diagnosis was established with a tilt-table test in 1 patient who became symptom-free with ß-blockade and nonpharmacologic treatment, including fluid therapy, liberal sodium intake, support hose, and a reconditioning exercise program. The other 2 were diagnosed through a standing test, serum norepinephrine levels, and red-cell volumes. One patient had neuropathic POTS and partially responded to b-blockade and nonpharmacotherapy. The other patient had hyperadrenergic POTS and responded well to nonpharmacotherapy, a dualacting b-blocker, and a vasoconstrictor agent. Postural orthostatic tachycardia syndrome is not an uncommon clinical entity and making a correct diagnosis is crucial in providing appropriate treatment to restore patients' functional capability and quality of life.

Health promotion behaviors in women with chest pain.

OBJECTIVE: We sought to determine health promotion behavior (HPB) in women with chest pain (CP), and to explore the best predictors of HPB. METHODS: The sample included 39 women without previous coronary heart disease (CHD), between ages 30 and 65 years, who were admitted with low-risk or intermediate-risk CP. The Health Promotion Lifestyle Profile II, the CHD Knowledge Tool for Women, and the Benefits and Barriers Scales were used to measure HPB, CHD knowledge, benefits, and barriers to risk modification for the study. RESULTS: Women had low HPB scores (X¯ = 127.3 ± 23.5). The best predictors for HPB (adjusted R(2) = .44) included educational level (ß = .34, P = .010), hyperlipidemia (ß = -.25, P = .05), benefits (ß = .33, P = .017), and barriers to risk modification (ß = -.41, P = .004). CONCLUSIONS: Women do not practice HPB regularly. Women with less education, hyperlipidemia, lower perceived benefits, or higher perceived barriers to risk modification are less likely to practice HPB. Barriers exert the strongest influence on HPB.

Clinical presentation and treatment of atrial fibrillation in Wolff-Parkinson-White syndrome.

A case of Wolff-Parkinson-White syndrome with atrial fibrillation (AF) is reported in a patient who presented with syncope, tachycardia, and hypotension. The electrocardiogram (ECG) showed a fast irregular rhythm with wide polymorphic QRS tachycardia without the QRS twisting around the isoelectric baseline, diagnostic of AF and Wolff-Parkinson-White syndrome. The patient did not respond to intravenous amiodarone. Elective cardioversion restored sinus rhythm, and the ECG showed a wide QRS complex, short PR interval, and delta wave, indicating the presence of an accessory pathway and pre-excitation. AF was easily induced during the electrophysiologic study, requiring electrical cardioversion for severe hypotension. Successful radiofrequency ablation of the accessory pathway completely prevented further inducible AF. The patient no longer had any evidence of pre-excitation on ECG and remained symptom-free with no medications for 11 months.