During the month of February, we celebrate many great traditions – Black History Month, Valentine’s Day, and the birth of our forefathers to name a few. February is also American Heart Month, which was first declared by President Lyndon B. Johnson in 1964.¹ Since that time, February has been dedicated to promoting cardiovascular health by many organizations, such as the American Heart Association¹. Heart disease is the leading cause of mortality in both men and women in America.²  It is a disease that can largely be prevented through lifestyle modification¹. Due to advances in medical therapies and better heart disease education, the number of deaths associated with cardiovascular disease has seen a steady decline over the last three decades¹. 

This month brings back many memories for me.  My first job out of college in the mid-90’s was in the Intensive Care Unit (ICU) at a large medical center in mid-town Manhattan. This was a unique ICU setting where the staff rotated through the medical, coronary, surgical, and cardiovascular (post-operative) ICUs every few months.  It was during these first years that I gained an appreciation for cardiovascular disease and how it could be medically and surgically managed. In the medical ICU and coronary care unit (CCU), I cared for patients who were transferred from the Emergency Room with acute coronary syndrome (ACS) and were awaiting cardiac catheterization for diagnosis and possible angioplasty. The presentation of each patient varied widely. A stable ACS patient with mild symptoms, such as indigestion, could deteriorate rapidly into acute distress and severe chest pain and possibly full code. Stabilizing these patients with aspirin, oxygen supplementation, and sublingual nitroglycerin were critical and electrocardiogram (ECG) monitoring was of the utmost importance. I don’t think any nurse forgets witnessing ST-segment elevation for the first time. 

In the surgical and cardiovascular ICU, patients returned from the operating room with a tangle of wires, arterial lines, central lines, pulmonary artery catheters, as well as chest tubes, drains and complex surgical wounds.  Monitoring vital signs, titrating IV drips, managing oxygenation and potential bleeding were all part of the post-surgical course. Open-heart surgery patients had to be assessed frequently for elevated jugular venous pressure and pulsus paradoxus (a systemic drop in blood pressure during inspiration³), both impending signs of cardiac tamponade, an accumulation of fluid in the pericardial space. It didn’t occur too often, but when it did, it resulted in emergency subxiphoid percutaneous drainage – one of the more stressful moments for a new nursing graduate.

After a few years in New York I felt called back to Philadelphia. While attending graduate school, I worked nights in the Cardio-Thoracic Intensive Care Unit (CT-SICU) of a large teaching hospital, caring for patients following open heart surgery. I thought I had seen it all in New York and quickly realized that I had just scratched the surface when it came to caring for cardiac patients. Academic institutions often receive patients with very high acuity due to their ability to offer some of the most advanced treatment options such as intra-aortic balloon pumps (IABP), left ventricular and bi-ventricular assist devices (LVAD and BiVAD), extra-corporeal membrane oxygenation (ECMO), ventilators, and continuous hemofiltration and dialysis. There were moments when I felt more like a mechanic than a nurse working on multiple machines surrounding a fragile life at its center. 

Patients typically experience short stays and quick turn-overs in surgical ICUs, however, we had our fair share of patients who spent many weeks and months on our unit. Mr. B.* was one of those patients. Mr. B. was transferred from a local community hospital to our institution with severe heart failure. Mr. B., whose medical therapies had reached a maximum threshold, had been hospitalized multiple times with acute exacerbations of heart failure over the prior year. Each hospitalization worsened requiring increased doses of intravenous (IV) dobutamine and milrinone to improve his heart pumping capacity. Upon arrival Mr. B., who was categorized with Class 4 heart failure (severe), was evaluated by the team for heart transplant. At 64, he was above the upper limit for age exclusion, however he had no signs of lung, liver or kidney disease.  He was placed on the transplant list immediately and due to his critical condition the decision was made to place a left ventricular assist device (LVAD) to support his heart. Mr. B.’s post-operative course was riddled with complications. He experienced difficulty weaning from the ventilator and subsequently developed pneumonia. Anticoagulation was carefully titrated to prevent clotting in the LVAD, however this led to bleeding in the gastrointestinal tract. His blood glucose levels rose acutely requiring an IV insulin drip. He battled these challenges and once stabilized, Mr. B. was able to ambulate with his new device and begin rehabilitation in preparation for his transplant. He was extremely positive, cracking jokes with the nurses and always smiling. I could tell he was truly grateful for each day he was alive. Today, LVAD patients may be discharged home and are able to live comfortably with the device, some as a bridge to transplant and some as destination therapy if transplant is not an option. Mr. B. was with us for several weeks due to his complications, but was eventually discharged home.

One cold November morning, Mr. B. and his family were notified that there was a donor heart available and that he was a match. He was admitted back to our unit that afternoon and later that evening he received the gift of a new heart and a second chance at life. The surgery went extremely well. Mr. B. spent four days of recovery in the CT-SICU where we monitored him closely for rejection. He was then transferred to the general surgical ward for cardiac rehabilitation and was discharged from the hospital on post-op day 15.

The most gratifying part of being an ICU nurse is seeing your patients recover. Mr. B. returned often to say hello and thank you, which always warmed our hearts. He is one of many cardiac patients I will never forget. While Mr. B.’s story ends well, many more patients with cardiac disease are not as lucky. We as healthcare providers should continue to emphasize the importance of heart health education and lifestyle modification to prevent the progression of cardiac disease. Happy American Heart Month to all!
 

References

1. American Heart Association (2016) American Heart Month. Retrieved from http://newsroom.heart.org/events/american-heart-month-events-and-info-3136417

2. Center for Disease Control and Prevention (2016) Heart Disease Facts. Retrieved from http://www.cdc.gov/heartdisease/facts.htm

3. UpToDate (2016) Pulsus Paradoxus in Pericardial Disease. Retrieved from http://www.uptodate.com/contents/pulsus-paradoxus-in-pericardial-disease

 
*Note: Any identifying characteristics are coincidental.