The central role of the nurse in process improvement relating to pharmacologic stress testing
Nancy P Coats et al. J Cardiovasc Nurs. 2012 Jul-Aug.
Abstract
Pharmacologic stress myocardial perfusion imaging is a noninvasive method for evaluating coronary artery disease in patients unable to exercise sufficiently to achieve a heart rate high enough to facilitate satisfactory imaging. The nuclear cardiology nurse is an invaluable member of the laboratory team that performs these tests. In this specialist role, the nurse must have a thorough knowledge of the different pharmacologic stress agents (dipyridamole, adenosine, regadenoson, and dobutamine) that can be used. This should comprise an understanding of their mechanisms of action, contraindications, drug-drug interactions, adverse effects, and administration protocols. By drawing on this knowledge, the nurse is able to verify that the right agent has been selected for each patient based on his/her medical history. The nurse also can help patients follow pretest instructions (such as withholding caffeine and certain medications) by explaining that the measures are necessary for a safe and successful procedure and that violation may result in test cancellation or postponement. On the day of the stress test, the nurse has an important role in safeguarding the patient as well as providing support and reassurance throughout the different stages of the examination. Responsibilities include explaining the entire procedure to the patients, notably, what they will be asked to do, the effect of the stress agent, the timing of each step, the adverse effects that they may experience, how any adverse events will be managed, and the importance of remaining still during imaging. This central role of the nuclear cardiology nurse in overseeing the practical aspects of the pharmacologic stress test has important implications in terms of optimizing the productivity and efficiency of their noninvasive cardiology laboratory and nuclear medicine department.
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aSymphony Health Solutions, NonRetailSource, January 2021, based on Astellas market definition of pharmacologic stress agents, as used in single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI).
INDICATION AND IMPORTANT SAFETY INFORMATION
Indication
Lexiscan® (regadenoson) injection is a pharmacologic stress agent indicated for radionuclide myocardial perfusion imaging (MPI) in patients unable to undergo adequate exercise stress.
IMPORTANT SAFETY INFORMATION
Contraindications
Do not administer Lexiscan to patients with second- or third-degree AV block or sinus node dysfunction unless these patients have a functioning artificial pacemaker.
Warnings and Precautions
Myocardial Ischemia
Fatal and nonfatal myocardial infarction, ventricular arrhythmias, and cardiac arrest have occurred following Lexiscan
injection. Avoid use in patients with symptoms or signs of acute myocardial ischemia, for example unstable angina or cardiovascular instability; these patients may be at greater risk of serious cardiovascular reactions to Lexiscan. Cardiac resuscitation equipment and trained staff should be available before administering Lexiscan. Adhere to the recommended duration of injection. As noted in an animal study, longer injection times may increase the duration and magnitude of increase in coronary
blood flow. If serious reactions to Lexiscan occur, consider the use of aminophylline, an adenosine antagonist, to shorten the duration of increased coronary blood flow induced by Lexiscan.
Sinoatrial and Atrioventricular Nodal Block
Adenosine receptor agonists, including Lexiscan, can depress the SA and AV nodes and may cause first-, second-, or third-degree AV block, or sinus bradycardia requiring intervention. In postmarketing experience, heart block (including
third degree), and asystole within minutes of Lexiscan administration have occurred.
Atrial Fibrillation/Atrial Flutter
New-onset or recurrent atrial fibrillation with rapid ventricular response and atrial flutter have been reported following Lexiscan injection.
Hypersensitivity, Including Anaphylaxis
Anaphylaxis, angioedema, cardiac or respiratory arrest, respiratory distress, decreased oxygen saturation, hypotension, throat tightness,
urticaria and rashes have occurred. In clinical trials, hypersensitivity reactions were reported in fewer than 1 percent of patients.
Hypotension
Adenosine receptor agonists, including Lexiscan, induce arterial vasodilation and hypotension. The risk of serious hypotension may be higher in patients with autonomic dysfunction, hypovolemia, left main coronary artery stenosis, stenotic valvular heart disease, pericarditis or pericardial effusions, or stenotic carotid
artery disease with cerebrovascular insufficiency. In postmarketing experience, transient ischemic attacks, seizures and syncope have been observed.
Hypertension
Adenosine receptor agonists, including Lexiscan, may result in clinically significant increases in blood pressure in some patients. In postmarketing experience, cases of potentially clinically significant hypertension have been reported, particularly in patients with underlying hypertension and when low-level
exercise was included in the MPI.
Bronchoconstriction
Adenosine receptor agonists, including Lexiscan, may cause dyspnea, bronchoconstriction and respiratory compromise. Appropriate bronchodilator therapy and resuscitative measures should be available prior to and following Lexiscan administration.
Seizure
Lexiscan may lower the seizure threshold; obtain a seizure history. New-onset or recurrence of convulsive seizures has occurred following
Lexiscan injection. Some seizures are prolonged and require emergent anticonvulsive management. Aminophylline may increase the risk of seizures associated with Lexiscan injection. Methylxanthine use is not recommended in patients who experience a seizure in association with Lexiscan administration.
Cerebrovascular Accident (Stroke)
Hemorrhagic and ischemic cerebrovascular accidents have occurred. Hemodynamic effects of Lexiscan including hypotension or hypertension may
be associated with these adverse reactions.
Adverse Reactions
In clinical trials, the most common adverse reactions (≥5%) to Lexiscan were dyspnea, headache, flushing, chest discomfort, angina pectoris or ST-segment depression, dizziness, chest pain, nausea, abdominal discomfort, dysgeusia, and feeling hot. Most adverse reactions began soon after dosing, and generally resolved within approximately 15 minutes, except for headache, which resolved in most patients within 30 minutes. Aminophylline was used as a reversal agent in 3% of patients.
In postmarketing experience, the following additional adverse reactions have occurred: supraventricular tachyarrhythmias, acute coronary syndrome (ACS), tremor, QTc prolongation, abdominal pain in association with nausea, vomiting, or myalgias, diarrhea, fecal incontinence, wheezing and musculoskeletal pain.