NURSING 7121 Heart Failure Management

In this assignment, the case study of Mr. Ben is discussed and he was admitted to the emergency ward with a history of chest pain of two hours. He also complained that, his pain was radiating towards the left arm along with this, nausea, breath shortness and diaphoresis were there. From the case study it is seen that, he is a regular smoker and consumer of beers.

1. From the assessment of Ben Long, he was diagnosed with anterolateral myocardial ischemia ( MI) and he had a high blood pressure and heart rate. Anterolateral MI are occurred due to blockage of proximal anterior descending coronary artery (LAD) along with right coronary artery or left circumflex artery. As Ben is diagnosed with STEMI, it is said that, STEMI is the result of proximal and complete blockage in coronary artery. STEMI refers to elevation of ST segments in the 12-lead ECG (Rajiah et al. 2013).

During the anterolateral MI the conduction system of the heart is highly altered. In case of anterolateral myocardial infarction transient bundle branch block may occur and sometimes it is associated with the structural damage of the myocardial cells. Along with this, hemorrhage is in the conduction system is quite common in myocardial infarction. In the fibers of the left branch, myocytolysis is observed and it is the sign of reversible or irreversible cell damage. In this case A-V blockage is seen and it causes permanent alteration in the myocardial conduction system. In case of Ben Long may possible that he may have A-V blockage as he has no evident Q wave in his ECG and it is sign of defective conduction system due A-V blockage (Elizari,  Baranchuk and Chiale  2013).

Mr. Ben Long may suffer from the potential complications such as fibrillation, heart block, ventricular tachycardia and also he have the risk of stroke. Along with this, risk of having cardiogenic shock is also there as heart is unable to pump enough amount of blood during this condition (Kutty, Jones and Moorjani  2013).

2. After diagnosing Mr. Ben Long, doctors have ordered to follow some steps such as continuation of oxygen, intravenous morphine, fibrinolytic therapy, heparin, aspirin and clopidogrel.  Generally, during anterolateral MI it is recommended that, aspirin should be given at a very low dose that is 75mg along with clopidogrel 375mg dose (Ray 2014). Aspirin in low dose helps to irreversibly block the formation of thromboxane A2 in the platelets and as a result it inhibits the platelet aggregation. Due to this, antiplatelet property aspirin is used to treat incidence of myocardial infarction. Myocardial infarction is caused mainly due to blockage of blood vessels and low amount of aspirin helps in reducing the blockage.  Clopidogrel is also used to induce platelet aggregation by preventing them to stick with each other and thus helps to prevent unnecessary clots. Clopidogrel selectively inhibits the adhesion of ADP to its receptor on the platelet named P2Y 12 receptor and activate the ADP-mediated GP IIb/ IIIa complex. This irreversible action is responsible for the platelet aggregation (Ray 2014).

Morphine used in myocardial ischemia patients works by two ways. Firstly, it helps in reducing the chest pain along with rendering anxiolysis. Secondly, Morphine vasodilates the blood vessels so that, blood pressure and heart rate can be reduced and demand of myocardial oxygen is lowered (Kubica et al. 2015). The dose of heparin in case of acute MI is recommended as 4000 unit (bolus), followed by infusion of heparin (not more than 1000U/hr) (Aleksey et al. 2013). Heparin helps in preventing unnecessary blood clot formation. In addition, fibrinolytic therapy is also recommended for Mr. Ben Long. Fibrinolytic therapy is used to treat MI and when there is a clot inside the blood vessels, it is used to dissolve the clots that act as barrier to the blood flow.  This fibrinolytic therapy is capable of reestablishing the antegrade blood flow in most of MI patients. In case of Mr.Ben Long, it is seen that, he has high blood pressure that is 140/90, heart rate that is 90 beats/min. In this condition morphine will be very much effective as it can reduce the heart rate and blood pressure and along with also reduce the pain by enhancing the blood flow to the myocardial tissues. Aspirin and clopidogrel can also be used as it act as an antiplatelet aggregator. The oxygen therapy will be effective as it will enhance the oxygen supply to the myocardial tissues. Heparin must be used as it will help in anticoagulation when simultaneous fibrinolytic therapy is delivered. To give proper care to Mr. Long it is recommended for the nurses to observe closely as patient is in severe chest pain and he is diagnosed with myocardial infarction. The drugs he is prescribed should be given intravenously as he may have problem in swallowing. During the time of STEMI patients’ drug administration the nurse should follow the drug dose as per the instruction.  As the patient has risk of stroke, the nurse should follow the doctor’s instructions properly and if there is any complications the nurse should immediately report to the doctor (O’gara et al. 2013).

3. Mode of actions of drug administration:

The case study represents chest pain of a truck driver Ben, who was experiencing sudden chest and associated with short breathiness, nausea, and diaphoresis.

Aspirin and clopidogrel :

Mode of action and rationale:

The lower amount of aspirin showed antithrombotic actions by preventing arterial thrombosis. A study by Ibanez et al. (2017), suggested that aspirin the gold standard antiplatelet which functions through irreversible inhibition of cyclooxygenase (cox) activity. In order to function properly, initial stretching of cardiac muscles prior to contraction is crucial. In intact heart, the closest approximation of preload is ventricular end diastolic volume. Patient with acute myocardial infarctions the initial muscle lengthen ( preload ) influences the heart to eject blood during systole ( afterload) (Bonaca et al. 2015). As observed in this case study, the patient was experiencing crushing pain, which radiated in his left arm associated with shortness of breath. In myocardial infarction, myocardial oxygen supply hinders due to the formation of blood in the coronary artery. Consequently, due to the lack of oxygen supply in the myocardial muscles may result in heart failure (Eikelboom et al.2017). Therefore, 75 mg of aspirin was given to the patient with a combination of clopidogrel in order to prevent the blood clot and reduce the preload , afterload. Clopidogrel functions by blocking platelets from the sticking together and preventing from producing clots (Hiatt et al. 2017). Since he was experiencing massive chest pain low dose of aspirin with a combination of clopidogrel was administrated.

 Intravenous morphine:

Opioid drugs, typified by morphine, have the potential to produce analgesia, mood changing, and physical dependence. Motov et al. (2015), suggested that  It acts in both central and peripheral nervous system by binding and activating the opiate receptor, each of which involves in different brain functions. Consequently, it controls the anxiety level of the patient, reduces the subsequent heart rate increase followed by a reduction of pain (Ankumah et al. 2017). As observed in this case study, the patient was experiencing ever chest pain, which transmitted to the left arm of the patient, and despite fibrinolytic therapy, and he developed signs of left ventricular dysfunction. Therefore, morphine was administrated intravenously to reduce the anxiety level of the patient by working on the centre nervous system. It helped to reduce the heart rate of the patient, which might proceed towards heart failure (Motov et al. 2015). Furthermore, it helped in managing the severe pain he was experiencing for two hours (Hiatt et al. 2017). However, morphine also has other side effects such as trouble in breathing, feeling light-headed and nausea (Ankumah et al. 2017).

Heparin:

Shahzad et al. (2014), suggested that heparin is an injectable anticoagulant that used for preventing the blood clot in the vessels. According to Han et al. (2015), stated that heparin is highly sulfated glycosaminoglycan and highly negative charged biological molecule. It acts a blood thinner that prevents the formation of the clot. Heparin binds to the enzyme inhibitor antithrombin iii (AT) causing a conformational change that results in the activation through an increase in the flexibility of the reactive side loop (Shahzad et al. 2014). The activated antithrombin iii then effectively inactivates thrombin, factor Xa and other proteases. Therefore, blood clot formation stops within the vessels. As observed in the case study, it was the patient was experiencing ever chest pain, which transfered to the left arm of the patient, and despite fibrinolytic therapy, and he developed signs of left ventricular dysfunction. Therefore, heparin was administrated to the patient for reducing the blood clots of blood vessels of the patient, which reduced the myocardial oxygen (Han et al. 2015). Consequently, it will increase the blood supply in heart and reduce the probability of heart failure inpatient.

References:

Aleksey, N., Timur, N., Nodir, J., Mahsud, H. and Saodat, A., 2013. Low Efficiency of the Standard Dosing of Unfractionated Heparin in Patients NSTEMI Elderly Female and Moderate Chronic Kidney Disease Hospitalized Within 12 Hours. Journal of the American College of Cardiology, 62(18 Supplement 2), p.C206.

Ankumah, N.A.E., Tsao, M., Hutchinson, M., Pedroza, C., Mehta, J., Sibai, B.M., Chauhan, S.P., Blackwell, S.C. and Refuerzo, J.S., 2017. Intravenous acetaminophen versus morphine for analgesia in labor: a randomized trial. American journal of perinatology, 34(01), pp.38-43.

Bonaca, M.P., Bhatt, D.L., Cohen, M., Steg, P.G., Storey, R.F., Jensen, E.C., Magnani, G., Bansilal, S., Fish, M.P., Im, K. and Bengtsson, O., 2015. Long-term use of ticagrelor in patients with prior myocardial infarction. New England Journal of Medicine, 372(19), pp.1791-1800.

Eikelboom, J.W., Connolly, S.J., Bosch, J., Dagenais, G.R., Hart, R.G., Shestakovska, O., Diaz, R., Alings, M., Lonn, E.M., Anand, S.S. and Widimsky, P., 2017. Rivaroxaban with or without aspirin in stable cardiovascular disease. New England Journal of Medicine, 377(14), pp.1319-1330.

Elizari, M.V., Baranchuk, A. and Chiale, P.A., 2013. Masquerading bundle branch block: a variety of right bundle branch block with left anterior fascicular block. Expert review of cardiovascular therapy, 11(1), pp.69-75.

Han, Y., Guo, J., Zheng, Y., Zang, H., Su, X., Wang, Y., Chen, S., Jiang, T., Yang, P., Chen, J. and Jiang, D., 2015. Bivalirudin vs heparin with or without tirofiban during primary percutaneous coronary intervention in acute myocardial infarction: the BRIGHT randomized clinical trial. Jama, 313(13), pp.1336-1346.

Hiatt, W.R., Fowkes, F.G.R., Heizer, G., Berger, J.S., Baumgartner, I., Held, P., Katona, B.G., Mahaffey, K.W., Norgren, L., Jones, W.S. and Blomster, J., 2017. Ticagrelor versus clopidogrel in symptomatic peripheral artery disease. New England Journal of Medicine, 376(1), pp.32-40.

Ibanez, B., James, S., Agewall, S., Antunes, M.J., Bucciarelli-Ducci, C., Bueno, H., Caforio, A.L., Crea, F., Goudevenos, J.A., Halvorsen, S. and Hindricks, G., 2017. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). European heart journal, 39(2), pp.119-177.

Kubica, J., Adamski, P., Ostrowska, M., Sikora, J., Kubica, J.M., Sroka, W.D., Stankowska, K., Buszko, K., Navarese, E.P., Jilma, B. and Siller-Matula, J.M., 2015. Morphine delays and attenuates ticagrelor exposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial. European heart journal, 37(3), pp.245-252.

Kutty, R.S., Jones, N. and Moorjani, N., 2013. Mechanical complications of acute myocardial infarction. Cardiology clinics, 31(4), pp.519-531.

Motov, S., Rockoff, B., Cohen, V., Pushkar, I., Likourezos, A., McKay, C., Soleyman-Zomalan, E., Homel, P., Terentiev, V. and Fromm, C., 2015. Intravenous subdissociative-dose ketamine versus morphine for analgesia in the emergency department: a randomized controlled trial. Annals of emergency medicine, 66(3), pp.222-229.

O’gara, P.T., Kushner, F.G., Ascheim, D.D., Casey, D.E., Chung, M.K., De Lemos, J.A., Ettinger, S.M., Fang, J.C., Fesmire, F.M., Franklin, B.A. and Granger, C.B., 2013. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61(4), pp.485-510.

Rajiah, P., Desai, M.Y., Kwon, D. and Flamm, S.D., 2013. MR imaging of myocardial infarction. Radiographics, 33(5), pp.1383-1412.

Ray, S., 2014. Clopidogrel resistance: the way forward. indian heart journal, 66(5), pp.530-534.

Shahzad, A., Kemp, I., Mars, C., Wilson, K., Roome, C., Cooper, R., Andron, M., Appleby, C., Fisher, M., Khand, A. and Kunadian, B., 2014. Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial. The Lancet, 384(9957), pp.1849-1858.