Be prepared to change stroke and cardiac care

New treatments, medications predicted

You can expect new treatments and interventions for cardiac and stroke patients to keep coming at a breakneck pace, according to Marli Bennewitz, RN, BSN, chest pain center coordinator at St. Jude Medical Center in Fullerton, CA. "More Americans die from heart attack and stroke than all cancers combined, and the advances in this field are fast-paced and ever changing," she says.

The challenges you face as a result of these changes will be multifaceted, says Debra Graf, RN, BSN, CEN, an emergency department (ED) educator at Community Medical Center in Toms River, NJ. "In addition to keeping abreast of new drugs and therapies that are continually emerging, the ED nurse is instrumental in identifying eligible patients and facilitating their entry into the appropriate care pathway," she says.

Here are changes that will affect the way you care for patients:

• New medications will be used.

New single bolus fibrinolytic agents, glycoprotein IIb/IIIa inhibitors, and low molecular weight heparins are being developed, says Graf. Existing agents are being studied in various combinations to lower mortality and morbidity associated with myocardial ischemia and infarction, she adds. For example, Bennewitz points to current studies using glycoprotein IIb/IIIa inhibitors in combination with low molecular weight heparin for acute myocardial infarction.

• There will be more aggressive pre-hospital care.

Bennewitz expects to see dramatic changes in the way cardiac patients are cared for before they arrive at the ED. "I foresee a broader use of pre-hospital electrocardiograms, and along with this, a more aggressive use of cardiac medications in the field," she says. This is a very positive change, Bennewitz says. "In an era where we have surgeons using robots to perform surgery, it is only realistic that we begin the aggressive care of our acute coronary syndrome patients in the pre-hospital arena," she says.

• There will be changes in reperfusion strategies.

Reperfusion strategies for use in myocardial infarction and stroke will continue to be refined over the next few years, Graf says. Although existing reperfusion therapies have been shown to be beneficial, they are underutilized in eligible patients with cardiac or cerebral ischemia, she argues. "More and more EDs will be establishing dedicated areas or established protocols to care for these patients in a more efficient manner," she says.

• Cardiac medications will be used for stroke patients.

Cardiac medications such as abciximab and retaplase are in clinical trials for treatment of stroke, says Graf. She adds that a defibrinogenating enzyme derived from snake venom is another type of agent being evaluated to restore perfusion in stroke. Research also is under way in the use of neuroprotective agents to be used with thrombolysis to synergistically improve outcomes, Graf reports. Drugs such as zonampanel and repinotan possibly will inhibit the ischemic cascade, she says, and glycerol and nitrone may be shown to reduce reperfusion injury.

• Treatment windows may be extended.

Emerging therapies may extend the traditional treatment window of three to 24 hours for a stroke patient to be eligible for thrombolytics, says Graf. This change will have important implications for triage nurses, she emphasizes. Although public education has raised community awareness of heart attack symptoms and the importance of early access to care, the same is not true for stroke, Graf adds. "We as ED nurses have a tremendous opportunity to impact this, through education of every patient who passes through our department," she advises.