The American Heart Association/American College of Cardiology in 2014 published a focused update of the 2007 and 2012 guidelines for non–ST-segment elevation acute coronary syndrome (NSTE-ACS). The management of ST-segment elevation myocardial infarction (STEMI) is described in a separate guideline published in 2013. The focused updates to the guidelines contain updated recommendations for dual antiplatelet therapy, including use of the P2Y12 inhibitor ticagrelor, which was recently approved by the Food and Drug Administration. Nurses caring for patients with acute coronary syndrome must have a good understanding of the current treatment guidelines for such patients, to help ensure delivery of evidence-based care. This review article uses a case study–based approach to describe how the new guidelines affect clinical decision making when choosing appropriate antiplatelet therapy for patients with NSTE-ACS or STEMI, depending on the patient’s clinical history and presenting characteristics.
Nesiritide appears to be an efficacious treatment for acute pulmonary edema, resistant to standard-of-care therapies, in the presence of normal left-ventricular function.
Sudden cardiac death is an elusive process that claims a significant number of lives annually in the United States. It is often associated with increased mortality within the first year after myocardial infarction, with the highest frequency occurring among patients with left ventricular dysfunction. Therefore, increasing survival rates in patients with a history of both disorders is an important goal of therapy. Recent trials suggested that an implantable cardioverter-defibrillator (ICD) in these patients may be superior to medical intervention in reducing the high mortality rate. Four major trials measured the benefits of an ICD for patients at risk for life-threatening ventricular arrhythmias. We assessed whether patients in these trials received adequate drug therapy as directed by American College of Cardiology-American Heart Association guidelines. One aim was to determine if medicated patients who served as controls in the trials were fairly represented. Furthermore, the need for improved overall guideline adherence was apparent.
Purpose
To critically evaluate current literature, review pharmacology, and discuss clinical role of ivabradine for patients with heart failure (HF) with reduced ejection fraction.
Data sources
A PubMed search was conducted using the search terms ivabradine and HF. All human studies analyzing the use of ivabradine in patients with HF with reduced ejection fraction and prescribing information were evaluated.
Conclusions
Greater benefit was seen in the prespecified subgroup with heart rate (HR) > 70 beats per minute (bpm) in the BEAUTIFUL study. Therefore, SHIFT examined the effect of ivabradine on patients with higher resting HR, lower ejection fraction, who had been hospitalized for HF within the previous year. A significant difference was found in the composite primary endpoint of cardiovascular death and hospitalizations for worsening HF in patients with HF and left ventricular systolic dysfunction, driven primarily by reduction in hospitalizations for worsening HF. The most common adverse effect was bradycardia.
Implications for practice
Ivabradine is a safe and effective medication for HR reduction to reduce hospitalizations in patients with stable, symptomatic HF (ejection fraction < 35%), in sinus rhythm, and HR > 70 bpm.
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