Retinal embolic events: frequency and impact following transcatheter aortic valve implantation (TAVI) for aortic stenosis.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) is an established treatment for patients with severe symptomatic aortic stenosis. It has a cerebrovascular accident rate of about 5% but the effect on retinal embolic events has not been previously reported. This study investigated the occurrence of retinal emboli following TAVI. METHODS AND ANALYSIS: In this prospective observational study, 20 patients underwent full ophthalmic examination to assess retinal embolic events prior to TAVI and at 48 hours and 1 month post-TAVI. RESULTS: At 48 hours post-TAVI, one patient had a new cotton wool spot in the right eye. At 1 month, another two patients had new retinal emboli events in at least one eye and a fourth patient developed retinal splinter haemorrhages in the right eye. CONCLUSION: Retinal embolic events and new retinal abnormalities following TAVI occurred in 15% and 20% of our cohort, respectively, without any associated retinal damage or significant visual problems. Retinal evaluation may be a useful surrogate test for cerebral embolisation in future studies assessing the utility of new valve prostheses and embolic protection devices.

Vascular endothelial growth factor and hypoxia-inducible factor-1α gene polymorphisms and coronary collateral formation in patients with coronary chronic total occlusions.

INTRODUCTION: We evaluated the association between two single nucleotide polymorphisms of the vascular endothelial growth factor gene and one of the hypoxia-inducible factor-1α gene and the degree of coronary collateral formation in patients with a coronary chronic total occlusion. METHODS: Totally, 98 patients with symptomatic coronary artery disease and a chronic total occlusion observed during coronary angiography were recruited. Genotyping of two vascular endothelial growth factor promoter single nucleotide polymorphisms (-152G>A and -165C>T) and the C1772T single nucleotide polymorphism of hypoxia-inducible factor-1α were performed using polymerase chain reaction and restriction fragment length polymorphism analysis. The presence and extent of collateral vessel filling was scored by blinded observers using the Rentrop grade. RESULTS: We found no association between the vascular endothelial growth factor -152G>A, -165C>T and hypoxia-inducible factor-1α -1772C>T with the presence and filling of coronary collateral vessels. A history of percutaneous coronary intervention and transient ischaemic attack/cerebrovascular accident were associated with the presence of enhanced collateral vessel formation following binary logistic regression analysis. CONCLUSION: The study findings suggest that coronary collateral formation is not associated with the tested polymorphic variants of vascular endothelial growth factor and hypoxia-inducible factor-1α in patients with symptomatic coronary artery disease and the presence of a chronic total occlusion.

Near patient anti-platelet response testing over time and gene analysis in patients admitted with acute coronary syndromes.

We sought to assess the relationships between platelet reactivity at different time points, CYP2C19*2 and ABCB1 status and clinical outcomes in patients with acute coronary syndromes (ACS). Anti-platelet response to clopidogrel was studied prospectively using the VerifyNow (VN) P2Y12 assay at the time of angiography and at 30 days post procedure in 151 patients admitted with ACS who underwent percutaneous coronary intervention (PCI). Troponin T levels were measured at angiography and 16-24 hour following PCI. DNA was extracted and the presence of CYP2C19*2 allele and ABCB1 polymorphisms were determined. Adverse cardiovascular and cerebral events (ACCE) were assessed at 12 months. High VN P2Y12 response at angiography was associated with a greater peri-procedural rise in troponin T, but not ACCE. However, VN P2Y12 response measured at 30 days was associated with ACCE (p = 0.017). CYP2C19*2 status was associated with higher VN P2Y12 response at angiography (p < 0.0001) and 30 days (p = 0.006) but not ACCE. Near-patient testing for clopidogrel response was associated with subsequent ACCE when performed 30 days following PCI, but not at angiography.

Nurses' perceptions and experiences of initiating thrombolysis: a qualitative study.

Nurse-initiated thrombolysis has become established in some trusts for patients presenting to the accident and emergency department or coronary care unit with an acute myocardial infarction. A limited approach to the exploration of this multidimensional expansion in nursing practice is noted in the literature. The aims of this study were to explore the experiential dimensions of nurses who have initiated thrombolysis, if nurses perceive themselves prepared for the role, and whether they consider role expansion a positive or negative experience. A qualitative approach was used. The sample included 12 nurses organizationally sanctioned to autonomously administer a thrombolytic agent, who completed a self-administered, predominantly open-ended questionnaire. Data were analysed using the method described by Giorgi (1997). Two major themes emerged: 'perceived pressure to deliver best practice' and 'developing patient care within a holistic framework', these themes are discussed and underpinned with supporting narratives. Nurses initiating thrombolysis have a desire to engage with delivery of a treatment proven to have a positive impact on individual patient outcomes; they express an overwhelming desire 'to do good' for their patient. Despite struggling with the possibility of adverse patient outcomes, all the nurses felt that their experiences overall were positive and all supported this with examples of practice.

Nurse-led elective cardioversion: an evidence-based practice review.

By posing a clinical practice question, this article aims to document and explore the published evidence base supporting nurse-led cardioversion. A literature review was undertaken to determine the best evidence for practice. Five articles and two conference abstracts describing practice were found to be pertinent to the question. Description of the methodology used was a weakness of all the articles studied, with only one article purported to be framed as a research study. The remainder describe a planned change in nursing practice to encompass the delivery of a service previously, organizationally viewed as, physician led. Evaluations of practice were descriptive and supported by audit data in most articles, however, appropriate evidential comparisons were not offered. These articles were critically appraised in relation to safety and efficacy. Whilst the evidence may be seen to be limited and weak, it does add credence to the notion that a nurse with a suitable experiential background and knowledge base can make a significant contribution to the care of this group of patients. It is clearly evident that further developments in practice should be framed within a research context to support and strengthen the evidence base. Four prominent themes emerged from the review, 'change milieu', 'reshaping boundaries', 'nurse-led', 'efficacy of practice', which are modelled into a conceptual framework. Nursing roles are expanding within the cardiological setting, affording practitioners unprecedented practice opportunities within a supportive organizational framework, however, these roles must be subject to appropriate evaluation in order to continue informing a robust evidence base.

An exploration of the ethical dimensions pertinent to gaining consent for thrombolysis.

--This paper explores some of the pertinent ethical principles involved in gaining consent in thrombolysis, relevant to both nurses and paramedics. --It describes ethical concerns regarding this practice. --Two key themes that have been explored are around the issue of autonomy and paternalism. --With nurse-initiated thrombolysis gaining momentum, an awareness of key ethical dimensions is fundamental.

Nurse-initiated thrombolysis: a systematic review of the literature.

This article aims to review, in a systematic manner, the current published evidence base for nurse-initiated thrombolysis. Reasons for this evolution in nursing practice are outlined. Themes emerging from the review are identified. Methodological issues are discussed. This article outlines a conceptual framework for practice evolution. Further research is needed to improve the strength of the evidence base by studies with improved design.

The introduction of nurse-initiated thrombolysis in coronary care.

Nurse-initiated thrombolysis has emerged as an organizational strategy to improve the delivery of thrombolytic agents to patients suspected of having an acute myocardial infarction. This article will outline the evolution of nurse-initiated thrombolysis on the coronary care unit in the authors' trust and present data on the critical decision-making skills of those nurses who have expanded their practice. Patients who were assessed, and whose thrombolysis was initiated by a nurse designated to deliver this treatment, had "door-to-needle" times consistent with the current targets of the National Service Framework for Coronary Heart Disease (Department of Health (DoH), 2000). A cardiologist acting as a "gold standard" reviewed the assessments of the first 50 patients seen by nurses able to deliver thrombolysis, finding each treatment decision appropriate. This gives support to the notion that appropriately trained and experienced nurses can assess and make treatment decisions in this acute care situation.