Straight From the Heart
Nurse researchers have their finger on the pulse of the latest developments in cardiac care

By Heather Stringer
February 14, 2002

Barbara Drew, Ph.D., RN, FAAN, thought her 37-year-old patient was recovering well after bypass leg graft surgery.

Then, without warning, the man went into shock and died. Drew, then a clinical coronary care nurse, was perplexed and frustrated. The autopsy revealed that he had died of a heart attack.

For Drew, the incident only heightened her frustration with cardiac monitors at the time. The monitor failed to show that parts of the man's heart were dying from oxygen deprivation. She and the medical staff couldn't respond until it was too late.

Drew is one of many nurses who were drawn into cardiac research by their frustrations with equipment and practices that failed to save as many patients as possible from serious heart complications. These nurse researchers are battling a disease that kills one out of every 2.5 Americans, according to the American Heart Association.

Although cardiovascular disease is the nation's No.1 killer, the public more often fears conditions such as cancer and AIDS, said Nancy Houston Miller, RN, a member of the national board of directors of the American Heart Association.

The organization sponsors American Heart Month every February, and one important message people need to hear is that heart disease is more preventable than many forms of cancer, Houston Miller said.

Now a professor and vice chair of academic programs in the department of physiological nursing at the UCSF School of Nursing, Drew focuses her research on improving the way doctors and nurses monitor patients who come to the hospital with a heart attack.

Today's heart monitors, or electrocardiograms, which provide continuous readings, are limited to data from one to two leads. The leads are able to monitor only a small portion of a patient's heart for inadequate blood supply, but this part of the heart may be functioning fine while another section is struggling.

New model
Drew's research project, funded by the National Institutes of Health, aims to invent a monitor that tracks a larger portion of a patient's heart. She's working on a new model that provides data as if a patient had 192 leads. In fact, the patient would have only 10 leads, but the machine would use a small number of electrodes to estimate the status of other parts of the heart.

If hospitals someday can use more sensitive monitors, nurses will enjoy a greater sense of control, she said.

"From a nursing standpoint, it's a practical solution," Drew said. "The machine won't interfere with the patient's movement, and we will feel better about sending patients home instead of worrying that they will have a big heart attack."

New monitors ideally would prevent inappropriate admissions, which are expensive for hospitals, Drew said. She also hopes her device will help clinicians divide people into high-risk vs. low-risk groups for heart disease.

Barbara Medoff-Cooper, Ph.D., RN, also has dedicated herself to heart research, but her study zeroes in on much smaller, younger hearts: those of infants. Infants who have undergone major heart surgery often struggle with feeding, and Medoff-Cooper is eager to learn why these babies have trouble nursing.

Disturbed feeding behaviors can increase a baby's risk of neuralgic damage, which can result in a lower-than-average IQ later in life, said Medoff-Cooper, director for the Center for Nursing Research at University of Pennsylvania.

Her research is directed at helping infants get the nutrition they need to avoid developmental delays later in life.

So far, she's conducted a pilot study that documented the feeding behaviors of babies who were full-term and had feeding problems after heart surgery. Healthy babies develop a rhythm of feeding with sucking and pausing. But the babies in her study weren't able to suck for a long period of time, Medoff-Cooper said.

"It may be that the feeding is a lot of work, and feeding may be too difficult after surgery," she said.

In the next phase of the study, researchers will experiment with things such as changing nipple flow rates to determine whether this helps the babies eat more. If the study obtains funding, the team will examine 120 infants who have undergone serious cardiac surgery in their first month of life.

Lifestyle changes
Barbara Riegel, DNSc, RN, is taking a different tack in the effort to improve cardiac care. She's trying to understand how to help heart failure patients care for themselves-and therefore avoid repeat visits to the hospital.

Riegel, a professor at the San Diego State University School of Nursing, said patients typically struggle to change their lifestyles because they don't grasp the direct correlation between their lifestyle choices and their heart's health.

"The reason why it's so challenging is because the things we tell people to do seem stupid to them," Riegel said. "We may tell them to weigh themselves every day, but they don't understand why it's important."

A sudden increase in weight can be a signal that someone ate too much salt, and the patient's body is heavier as a result of the extra water he or she drank after a salty meal.

The extra fluid in the body can make this person's heart work harder to pump. Some of these patients may feel fluid buildup in their lungs, which can give them a sense of drowning when they lie down at night to sleep, Riegel said.

Riegel is working to design programs in which heart failure patients can learn physiologic subtleties, such as the relationship between a salty Chinese meal and the "drowning" sensation.

One of the patterns she's discovered is that patients are more successful with self-care if a nurse follows up with a weekly phone call for the first six months to check in on how they are doing. Patients can ask questions and receive personalized answers.

"The patients really love the nurses calling them because they feel like somebody really cares and will help them integrate these things into their lives," Riegel said.

She's also found that female patients often don't understand that heart disease is the leading cause of death for women, not just men. Women also dismiss the importance of lifestyle changes to help their hearts because heart disease typically affects women later in life than other diseases such as breast cancer, Riegel said.

Early prevention
Patricia Liehr, Ph.D., RN, also believes that one of the best weapons to battle the heart disease epidemic is to intervene with lifestyle changes, but she's eager to see those changes start earlier in patients' lives.
Now, doctors usually wait until patients have a heart attack until they advise them to change their diet and exercise habits, said Liehr, an associate professor at the University of Texas-Houston Health Science Center School of Nursing.

Liehr is involved in a project that works with patients when they first develop Stage 1 hypertension. Like Riegel, she's found that patients are more likely to implement lifestyle changes when the treatment is personalized.

Patients had the best results when they received what she calls story-centered care. This included four meetings with patients in which she talked to them about situations in their families and jobs that could prevent them from taking care of themselves.

For example, if a patient had a stressful job situation that included frequent confrontations, they would discuss options such as quitting their job. If that were not feasible, Liehr would help the patient learn to understand the way his or her body physically manifests signals of increased blood pressure, such as head pressure or tingling in the ears. She would teach the patient that this is a sign that he or she needs to find an excuse to leave the confrontation, such as going to the bathroom to calm down.

"Many people need to understand their bodies better, and I teach them to connect with themselves," Liehr said. "I try to show them that they are allowed to make choices."

Liehr said that nurses likely will have a key role in working with Stage 1 hypertension patients if early intervention becomes common practice in hospitals.

Even as these nurse researchers pursue better prevention techniques, they admit that they face a formidable foe. Heart failure is the leading cause of hospitalization in the United States and the numbers are only increasing, Houston Miller said.

The American Heart Association's goal is to reduce cardiovascular disease, stroke and those at risk by 25 percent by 2010.

"My hope is that eventually we'd be able to abolish cardiovascular disease like other diseases, and I think we're hopefully headed in that direction," she said. "The more research that can be done in the area of prevention, the greater the likelihood that we will succeed."