There are few clinical content areas in health care with more robust empirically based evidence than cardiovascular disease. Hundreds of randomized controlled trials (RCTs) have been conducted over many decades, leading to a very rich set of evidence-based guidelines and practice recommendations (cf. Antman et al. 2004; Krumholz et al. 2006; Schocken et al. 2008 among many others). This rich evidence base has led to a number of quality improvement efforts over many years in hospitals, outpatient centers, and other sites where care is delivered.

Despite this rich base of evidence generally available in cardiology, the majority of these guidelines focus on physician care. Most guidelines address use of devices and procedures, as well as medical management of patients experiencing both acute cardiovascular events and the effects of long-term, chronic disease. Few of these guidelines address non-physician care, although in some instances, recommendations are made for health care professionals other than physicians. This chapter will focus on the evidence for interventions that do not require physician action, although most of the clinical care provided to patients with cardiovascular disease includes multidisciplinary team care, and physicians are usually integral members of the health care team. Specific actions, such as ordering tests and procedures, prescribing medications, and ordering and/or delivering invasive procedures or placing devices into a patient’s body, generally require at least physician oversight, and these will not be the major focus of this chapter, even though some of these actions can be performed by non-physician providers, such as advanced practice nurses and, in some jurisdictions, pharmacists. Other actions, including education, coaching, lifestyle modification approaches, monitoring and managing chronic disease (except for medication management), and working with patients in their homes and communities, are more often in the domain of nurses and other health care professionals, and I will focus on these activities.

In this chapter, I first provide an overview of cardiology and care for patients with cardiovascular disease, followed by a section describing specific care interventions that have substantial nursing input supported by research evidence. The focus here is to describe evidence-based practice (EBP) in nursing care for patients with cardiovascular disease. In the final section, I summarize the current impact of nursing-focused interventions for patients with cardiovascular disease.

It is useful to review the profound changes in cardiovascular care driven by the emerging evidence base in cardiology. As recently as 40 years ago, there were few interventions available for people who experienced myocardial infarction (MI—death of heart muscle due to coronary artery disease, colloquially called a heart attack) (Malach & Imperato 2006). Patients either survived an MI, or died, and a high proportion died. Those who survived often experienced serious loss of heart muscle, which often led to serious compromise and the development of chronic heart failure. The only curative intervention available for coronary artery disease was coronary artery bypass grafting (CABG), in which a section of vein from the leg is grafted onto one or more coronary arteries to reopen the arteries. This was high-risk, expensive surgery, requiring that the chest wall be surgically opened to provide direct access to the coronary arteries. Only a limited number of hospitals had the capacity to perform it. This led to problems of access due to expense and geography. For many people with coronary artery disease, inability to pay or lack of physical access led to loss of heart muscle, loss of quality of life, and, in many cases, to early death.

In the intervening four decades, new approaches have revolutionized care for people with coronary artery disease, especially those with symptoms suggestive of coronary artery blockage. The most important were the advent of thrombolysis (Armstrong 2001), as well as percutaneous coronary intervention (PCI)—the use of minimally invasive methods to introduce balloons and stents (small metal strips that hold the artery open) through the vasculature into the coronary anatomy (Jamshidi et al. 2008; Melikian & Wijns 2008; Ryan et al. 2007); significant improvements in coronary artery bypass graft surgery, including improvements in anesthesia; the advent of drugs to lower blood cholesterol levels, particularly a class of drugs called statins, which not only lower blood cholesterol but also inhibit inflammation in the arteries (Schwartz 2007); and increasing evidence to show which drugs are most beneficial for patients with cardiovascular disease (Anderson et al. 2007; Bonow et al. 2008; Califf et al. 2007; Krumholz et al. 2008; Peterson et al. 2008). In the newest wave of evidence are findings that show that most patients with stable coronary artery disease can be managed medically, without invasive procedures of any kind (Boden & Gupta 2008; Boden et al. 2008; Eid & Boden 2008). However, there is also evidence that shows that a large proportion of patients who would benefit from medical management are not receiving optimal medical care, nor are they receiving invasive procedures. The picture is emerging of gaps related to gender, age, income, and possibly race and ethnicity, in providing evidence-based, individually optimized care (Austin et al. 2008; Ho et al. 2007; Jackevicius et al. 2008; Peterson et al. 2006; Pilote et al. 2007; Spertus & Furman 2007; Tricoci et al. 2007).

Most of these innovations were focused on care of patients with acute coronary syndromes (unstable angina or chest pain and MI), but they had ripple effects on care for other cardiovascular conditions. Important advances in care of heart failure and cardiac arrhythmias include implantable cardioverter defibrillators (Jung et al. 2008), and the use of new biomarkers for diagnosis and staging of heart failure (Andrade & Sharar 2008; McDonald et al. 2008). Biomarkers have also changed the approach to detecting and treating acute coronary syndromes and other cardiovascular disease (Abi-Saleh et al. 2008; Parikh & De Lemos 2006). Finally, yet more change is likely in the near future, as stem cell and genetic therapies offer new opportunities for diagnosis and treatment of cardiovascular disease (Anwaruddin et al. 2007; Eriksson et al. 2006; Hare & Chaparro 2008; Rahman & Maclellan 2006; Rizik et al. 2006). These changes were not only in procedures, devices, and drugs but they also motivated significant innovation in the systems of providing care to patients with cardiovascular disease.

The vast majority of procedures used to care for patients with acute coronary syndromes (over 90% in most developed countries) are now PCIs, rather than CABG. Rather than being performed in operating suites, PCI is performed in what are known as cardiac catheterization laboratories, or cardiac cath labs. Training for PCI is not a surgical specialty, but a sub-specialization within cardiology, which in turn is a sub-specialty of internal medicine or pediatrics. Although nurses and other professionals, including technicians, are trained to provide care within cardiac cath labs, care is quite different from surgery requiring general anesthesia; most cardiac catheterization and PCI procedures are done under conscious sedation. As a result, many procedures can be done on an ambulatory or outpatient basis, compared with the admissions required for CABG surgery. This innovation alone has revolutionized the care provided. Many hospitals have cardiac cath labs even though they do not have surgical suites. In general, if a hospital cannot provide CABG surgery as an emergency option, cardiac catheterization is limited to imaging, without providing reperfusion intervention such as PCI.

The movement to ambulatory care for patients who previously would have required surgery has led to other innovations in service delivery, including a renewed emphasis on secondary prevention, or attempting to ensure that someone who has suffered a previous episode of acute coronary syndrome does not experience another one. Secondary prevention is typically managed through primary care services in most countries, although it may be offered in the context of cardiac rehabilitation in others (Clark et al. 2005). Typically, cardiac rehabilitation focuses on lifestyle modification, as well as prescribing drugs that have been shown to decrease the risk of recurrent coronary and related events (MI, stroke, and death). Secondary prevention offered through primary care often focuses principally on drug prescribing and control of risk factors, including hypertension, diabetes, and renal disease. In primary care, this kind of secondary prevention is often described as chronic disease management or care, to emphasize the reality that the medications and/or lifestyle modification are required for the rest of the person’s life, not just to assist during an acute episode (Balady et al. 2007; Thomas et al. 2007).

Nurses often provide frontline care in both cardiac rehabilitation and chronic disease management. In many places, nurses are the primary providers of secondary prevention or chronic disease management services; in others, they work collaboratively within a team of providers, who may include cardiologists, primary care physicians, dieticians, exercise physiologists, physical and occupational therapists, and other disciplines (Coons & Fera 2007). Nurses provide care in all settings, from emergency departments where initial emergent or urgent care is provided, to operative suites or cardiac cath labs, to coronary care or other inpatient acute care units, to outpatient ambulatory care either in primary care or rehabilitation. The rest of this chapter will focus on the evidence for the care that nurses provide for patients with cardiovascular disease.

A wide variety of outcomes have been used to measure how well care is delivered (often called process outcomes), the extent to which care is related to desired outcomes (preference outcomes, including quality of life), and “hard” outcomes (Bonow et al. 2008; Mehta et al. 2007). The latter are usually a mixture of death, recurrent MI or unstable angina requiring hospitalization, or related events such as stroke. Among process outcomes, a number of outcomes have been proposed, and many are included in clinical practice guidelines as indicators of quality of care. These include measures such as:

• Administration of aspirin within 24 hours of onset of chest pain symptoms;
  
• Ensuring that all patients with documented MI are prescribed aspirin, beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACE-I), unless contraindicated, on hospital discharge (Ko et al. 2008).

More recently, health-related quality of life outcomes, related to patient preferences, have gained acceptance in cardiovascular care to assess the degree to which services and care provision affects how well people feel (Beinart et al. 2003; Rumsfeld et al. 2001, 2003). Health-related quality of life measures both perceived health status— how people feel—and preferences, which may include preferences about treatments, as well as preferences about the health state the person is in. Both disease-specific and generic health-related quality of life measures are used to measure outcomes of care (Spertus 2008; Spertus et al. 2008; Weintraub et al. 2008). Specific links to depression and other mental health issues have been noted for some time (Maddox et al. 2008; Plomondon et al. 2008; Sullivan et al. 2007).

All of these measures can be used to evaluate outcomes for providers other than physicians. For example, in a paper published several years ago, the relationship between nurse staffing on inpatient care units and in-hospital mortality for patients who had experienced an MI was examined, and an association between increased nurse staffing and lower rates of in-hospital death was found (Person et al. 2004). A number of nurse-specific interventions have been shown to improve quality indicators, or process outcomes, and nursing interventions have been shown to improve patient perception of quality of care.

The next section describes specific interventions in which nurses play a leading role in caring for patients with cardiovascular disease. Within each intervention type, I discuss specific cardiovascular health problems, and how the intervention applies to that health problem.

Care pathways or maps

Care pathways or care maps (also called critical or clinical pathways) are primarily used in inpatient care settings. They have been used extensively in care of patients with cardiovascular health problems, most often with patients suffering from chronic heart disease and acute coronary syndromes, although they have also been used in other cardiac conditions, such as syncope (Herzog et al. 2006). While this type of intervention has been around a long time, care pathways or maps are still being actively developed and implemented in inpatient care settings (Cannon 2008; Gardetto et al. 2008; Lombardo et al. 2008; de Luca et al. 2008; McDermott et al. 2008).

In general, care pathways are multidisciplinary guides that use evidence to develop protocols and specific steps for caring for patients from first contact with the hospital—often in the emergency department—through to hospital discharge. The most comprehensive approaches include specific protocols and instructions for discharge planning, and specify how and when patients should receive follow-up care. The types of care covered include medications to be used during hospitalization, and what should be prescribed at discharge, specific nursing interventions to assure that patients are progressing along a trajectory that will allow them to be discharged from the hospital and regain self-care function, and discharge instructions designed to minimize risk of rapid rehospitalization. Results from care pathways and maps are mixed, but when well designed and well implemented, they can result in considerable improvement (Gardetto et al. 2008).

The interdisciplinary aspect of care pathways or maps is essential. Full implementation requires the full collaboration of multiple disciplines (Peterson et al. 2008; Leggat 2007). Physicians are responsible for ensuring accurate diagnosis, staging, and prognosis, as well as for ordering appropriate tests and prescribing medications. Nurses are responsible for monitoring during the inpatient stay, ensuring that patients and families receive adequate and appropriate education to minimize risks, and managing discharge planning. This should include referrals to appropriate community agencies, as well as education about lifestyle and medication adherence.

A recent example of clinical path implementation describes how implementing a clinical path to manage acute decompensated heart failure during inpatient admission in a single academic health center resulted in more complete discharge instruction, and decreased readmissions to the hospital within 7 and 90 days after discharge (Lombardo et al. 2008). This is a fairly commonly reported result of implementing a clinical pathway. Most are locally derived and highly tailored to the specific hospital setting. The level of specificity often makes it difficult to move a developed clinical path from one hospital to another, as resources or even terms used to describe different roles may differ significantly from setting to setting.

In an attempt to deal with this problem, and to develop pathways that might transfer from one setting to another, there have been efforts to develop more generic toolkits to inform cardiac care that can be adapted from one hospital to another (Cannon et al. 2002; Mehta et al. 2002; Morrow & Cannon 2005). Some of these have focused on acute coronary syndromes, while others have focused on heart failure. Overall, these two cardiovascular health problems have been the greatest focus in clinical pathway development.

Early clinical pathways were not always as clear as they may have needed to be in delineating roles for each of the health care disciplines involved in providing care. Generally, if the pathway is not developed by an interdisciplinary team, it is difficult to ensure that appropriate roles and responsibilities are delineated. Even when roles and responsibilities are appropriate, there may be gaps in carrying out the actions required. One example, which crosses many different approaches to implementing EBP, is that nurses do not always have appropriate skills and knowledge to make community-based referrals (Edwards et al. 2007). In all likelihood, the members of the health care team with the best skills to manage referrals are social workers, but it is sometimes the case that their skills focus on referrals for social services rather than for health services. It is essential to give attention to issues such as referrals, and who among the team has the skills to manage them appropriately and efficiently. It may be necessary to expand the team as necessary competencies are mapped out through the care pathway development process.

In summary, clinical pathways are often good approaches to implementing clinical practice guidelines and EBP. The kinds of outcomes that have been studied include repeat hospitalization and mortality, but do not as yet include quality of life assessment. In order for clinical pathways to be effective, they must usually be tailored to local resources, and attention must be paid to specifying required roles and who will fulfill them. However, there is little evidence in the published, peer-reviewed literature about the sustainability of the results from implementing clinical pathways.

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