Mr. Richards,* age 77 with a history of acute MI, hypertension, hypercholesterolemia, and stroke, has just undergone a diagnostic cardiac catheterization. After removal of the catheter sheath from his right femoral artery and achievement of hemostasis, he develops a facial droop, garbled speech, and right-sided weakness. The nurse immediately calls the rapid response team and activates the stroke beeper to notify the neurologist.

Mr. Richards’ vital signs are BP — 170/90; T — 97.8; P — 92; R — 16. A STAT CT scan of the head shows no evidence of an intracranial hemorrhage (ICH). Lab values are Hgb 12.2 and Hct 35.7, platelet count 221,000, PT 14.8, INR 1.2, PTT 27, and glucose 121. His National Institute of Health Stroke Scale score is 9. After an evaluation, the neurologist diagnoses Mr. Richards with an acute left-hemispheric infarct — embolic, a stroke. Mr. Richards receives 0.45% normal saline solution at 80 mL/hr and is transferred to the ICU.

Would Mr. Richards be a candidate for IV rtPA (Activase) for the stroke he experienced after cardiac catheterization?

More than 2 million cardiac catheterizations take place in the United States each year, and they remain the standard in the diagnosis of coronary artery disease.¹ A cardiac catheterization helps determine the presence and extent of coronary artery disease and evaluate left-ventricular function and valvular or myocardial disorders.²

Left-heart catheterization, the most common type of cardiac catheterization and the one associated with stroke, involves the puncture of an artery (usually the femoral, but possibly the radial or brachial). A sheath is introduced into the artery, and a catheter is advanced through the sheath up the aorta to the opening of a coronary artery. Injection of each coronary artery with contrast dye permits the cardiologist to visualize the artery and determine the presence and severity of disease. In addition, left ventriculography may be performed, during which the coronary catheter is advanced through the aortic valve, and contrast dye is injected into the ventricle to evaluate the motion of the myocardium, aortic and mitral valve function, and the left-ventricular ejection fraction (EF), the percent of blood ejected from the ventricle with each heartbeat.²

The most frequent complications of cardiac catheterization are vascular: bleeding, hematoma, pseudoaneurysm, and arteriovenous fistula at the access site. Major complications, which are infrequent, include retroperitoneal bleeding, acute renal failure, acute MI, and acute ischemic stroke.¹ The incidence rate for ischemic stroke after cardiac catheterization¹ is 0.07%, and 0.3% to 0.4% after percutaneous coronary intervention (PCI), such as angioplasty.3 But although stroke is rare, its effects can be devastating. The clinical outcome of untreated stroke has been poor, and definitive treatment strategies should be implemented.³

rtPA is now recommended to treat acute ischemic stroke postcardiac catheterization.³ Since nurses on most hospital units care for postcardiac catheterization patients, they need to be aware of this new recommendation, as well as the current evidence-based care of the ischemic stroke patient, including the risk for hematoma or bleeding at the catheterization site or into the retroperitoneum.

Stroke is a significant cause of morbidity and mortality in the United States. An estimated 700,000 Americans will have a stroke this year. Stroke is the third leading cause of death in the United States and a leading cause of severe, long-term disability.⁴ In 2007, direct and indirect costs of stroke were estimated at $62.7 billion.⁵

Most strokes (87%) are classified as ischemic, with the remainder being hemorrhagic.5 Ischemic stroke can be further defined as thrombotic or embolic.⁴ A thrombotic stroke occurs when a thrombus or clot forms in a cerebral artery. An embolic stroke occurs when a thrombus travels to the cerebral circulation from another part of the body, such as the heart or carotid artery.

Most ischemic strokes complicating cardiac catheterization are suspected to be embolic. Ischemic strokes are more common in patients with severe aortic atherosclerosis. During catheterization, wires and catheters may dislodge atheromatous plaque.³ In addition, thrombi may form on the tip of the coronary catheter.³ A depressed EF has been shown to increase stroke risk, possibly because of the dislodgment of an apical thrombus during left ventriculography.³ Interventions to reduce the risk of ischemic stroke include using atraumatic catheters (smaller catheters designed to decrease the risk of vascular embolization) and avoiding left ventriculography if possible.³

Female gender, left-ventricular hypertrophy, hypertension, diabetes mellitus, renal insufficiency, and a history of previous stroke have been shown to increase stroke risk related to cardiac catheterization.³ Other risk factors for stroke in general include dyslipidemia, smoking, and atrial fibrillation, a dysrhythmia in which the atria no longer contract effectively. Blood pools in the atria, which can lead to thrombus formation, usually in the left atrium or left atrial appendage. The thrombus can dislodge and travel to the cerebral circulation.

Ischemic stroke may occur during or immediately after catheterization; however, symptoms may be delayed for several hours. Signs and symptoms of ischemic stroke include difficulty speaking, drooping of the mouth/face on one side, arm/leg weakness or paralysis on one side, and visual disturbances.

To rtPA or not to rtPA?

The goals of treatment in acute ischemic stroke are to restore perfusion to the brain; preserve ischemic, but viable cerebral tissue (the penumbra); and reduce the severity of neurological deficits. Ischemic stroke is always a medical emergency, but with the low incidence of stroke complicating cardiac catheterization, no treatment recommendations for this kind of stroke have existed until recently.3 Case reports and small clinical trials have been the source of information on fibrinolysis (the use of rtPA to dissolve a fibrin clot).³

Several studies have focused on the use of intra-arterial (IA) rtPA after PCI.³ If the femoral artery sheath is still in place after cardiac catheterization, IA rtPA and catheter-based interventions (angioplasty and stenting and clot extraction) can be initiated.³ The IA route may provide optimal reperfusion and an improved outcome.³ However, this strategy is appropriate only when experienced personnel and the needed equipment are available.³

Due to the scarcity of trials of IV rtPA for ischemic stroke postcardiac catheterization, clinical outcomes have to be extrapolated from other clinical trials of IV rtPA for ischemic stroke in general.³ The neurologist and cardiologist should evaluate the patient for administration of rtPA. A well-defined protocol should be developed for ischemic stroke complicating cardiac catheterization or coronary angiography. (See the algorithm “Management protocol for stroke complicating cardiac catheterization” in the Journal of Invasive Cardiology, at www.invasivecardiology.com/JIC/HTML/photos/photo16819.htm)

Patients who exhibit stroke symptoms during or after cardiac catheterization must meet the same criteria for rtPA as any other patient who experiences an ischemic stroke. Unfortunately, only 5% of all ischemic stroke patients admitted to hospitals are eligible for rtPA.⁶ (Most patients delay seeking treatment and fall out of the three-hour time window for administration of rtPA.⁷) Treatment with rtPA it is infrequent and high-risk, and nurses must remain current on the latest recommended treatment regimens to maintain their competency. Most of these recommendations are based on clinical trials from the National Institute of Neurological Disorders and Stroke.

Since candidates for rtPA must receive treatment within three hours of the onset of stroke symptoms, documentation of the time of onset is crucial. With new onset symptoms of ischemic stroke in a hospitalized patient, the nurse should immediately activate the rapid response team (RRT) or stroke team. The initial evaluation includes the ABCs (airway, breathing, and circulation) followed by a neurological assessment. The use of a stroke rating scale, such as the National Institute of Health Stroke Scale is recommended.⁷ The scale tests 15 items of neurological functioning, including level of consciousness (three items), best gaze, visual fields, facial palsy, motor function (four items), limb ataxia, sensory function, language, articulation, and inattention. Each response is scored, for a total score of 0 to 42 (with “0” = normal and “42” = severe stroke). These scores help quantify the degree of neurological deficit, identify the possible area of vessel occlusion, provide an early prognosis, and identify the patient’s eligibility for interventions and the potential for complications.⁷

CT scan — STAT

A STAT CT scan of the head is ordered to rule out an ICH. The CT scan should be completed within 25 minutes and read within an additional 20 minutes (a total time of 45 minutes).⁷ Along with a CT scan, studies should include a 12-lead ECG, oxygen saturation, serum glucose, electrolytes, BUN, creatinine, CBC with platelet count, PT, INR, and PTT.⁷ These tests can help identify conditions that may cause or mimic stroke as well as determine interventions.

As mentioned, patients are candidates for rtPA if their stroke symptoms started no more than three hours earlier. Other indications for rtPA include symptoms that cause measurable neurological deficits and do not suggest a subarachnoid hemorrhage.⁷ Door-to-drug time for rtPA (the time from which the patient arrives at the ED until he or she receives rtPA) should be no more than 60 minutes.⁷

Contraindications for rtPA include head trauma, prior stroke or MI within the previous three months, GI or urinary tract hemorrhage within the previous 21 days, major surgery within the previous 14 days, a history of previous ICH, platelet count less than 100,000 mm³, blood glucose under 50 mg/dL, anticoagulant therapy, INR greater than 1.7, and residual neurological impairments after a seizure.⁷ The RRT helps monitor and stabilize the patient and transfer him or her to the ICU. A new concept in healthcare institutions, the RRT is an interdisciplinary team that may include a physician (such as a hospitalist or intensivist), critical care nurse, and respiratory therapist. The name of the team and its members may vary among institutions, but its purpose remains the same: to provide early identification, assessment, and treatment of patients who exhibit signs of deterioration — before the situation progresses to a cardiac or respiratory arrest.

One of The Joint Commission’s 2008 National Patient Safety Goals is to improve recognition and response to changes in a patient’s condition.⁸ The Joint Commission now requires that organizations have a method in place for healthcare staff to directly request additional assistance from a specially trained person if a patient’s condition appears to be worsening.⁸ The Joint Commission expects full implementation of this requirement by January 2009.⁸ Any institution accredited by The Joint Commission must meet this standard, with, for example, formation of an RRT.

The one and only

rtPA is the only drug approved by the FDA to treat ischemic stroke. It degrades the fibrin thrombus and restores perfusion to the penumbra. The nurse should assess and document the patient’s baseline blood pressure, temperature, heart rate, respiratory rate, and neurological assessment before the patient receives rtPA. The patient is weighed since the dosage of rtPA is weight-based. The recommended dose of IV rtPA is 0.9 mg/kg (maximum dose 90 mg). Ten percent of the dose is administered as an IV bolus over one minute with the remaining dosage administered by infusion over 60 minutes.⁷ The nurse should perform neurological assessments at least every 15 minutes during the infusion and every 30 minutes thereafter for six hours, then every hour until 24 hours following treatment.⁷ The major adverse event associated with rtPA is bleeding, especially ICH. If the patient develops a severe headache, acute hypertension, or nausea or vomiting, the nurse should discontinue the infusion and a STAT CT scan of the head should be performed as per hospital protocol.⁷ The patient should not receive anticoagulants or antiplatelet agents the first 24 hours after rtPA administration.⁷ A follow-up CT scan should be done at 24 hours prior to starting antiplatelet agents or anticoagulants.⁷ The nurse should monitor the hemoglobin and hematocrit for signs and symptoms of bleeding (including bleeding or hematoma at the catheterization access site).

BP management is vital before the administration of rtPA. The BP should be less than 185/110.⁷ Theoretical reasons for lowering the BP include reducing cerebral edema, decreasing the risk of hemorrhagic transformation of a cerebral infarction, reducing further vascular injury, and delaying early, recurrent stroke.⁷ Conversely, aggressive lowering of the BP may lead to neurological deterioration by reducing perfusion to ischemic areas.⁷

Decreasing the BP

In most patients, a reduction in BP occurs within the first hours after stroke without medical management. Management of the BP should be with one of the following: IV labetalol (Normodyne, Trandate); nitroglycerin (Nitropaste); or nicardipine (Cardene) infusion.⁷

Labetalol, a beta-blocker, exhibits adrenergic blocking activity within vascular smooth muscle, producing vasodilatation and a decrease in the BP. It slows the rate of sinoatrial node discharge and conduction through the atrioventricular node, decreasing the heart rate. It should be administered 10 or 20 mg IV over one to two minutes; it may be repeated one time. Onset of action is five minutes, peaking in 15 minutes, with a duration of two to four hours.⁷ Adverse effects may include hypotension and bradycardia.

Nitroglycerin, a nitrate, produces vasodilatation and lowers the BP. It should be administered as a topical application of 1 to 2 inches.⁷ Onset of action is 30 to 60 minutes with duration of two to 12 hours. Adverse effects may include hypotension and headache. If a patient receiving nitroglycerin develops a headache, careful assessment is required to rule out an ICH.

Nicardipine, a calcium channel blocker, inhibits calcium influx across the cell membrane, producing vasodilation and a decrease in the BP. It should be administered as a continuous infusion at 5 mg/hr, titrated up by 2.5 mg/hr at intervals of five to 15 minutes. The maximum dose is 15 mg/hr; when the desired BP attained, reduce to 3 mg/hr.⁷ Adverse effects may include hypotension and bradycardia. Due to the potential adverse effects of each of these drugs, the nurse should closely monitor both the BP and HR.

Once the BP is below 185/110, rtPA may be administered. If the BP remains over 185/110, do not administer rtPA. The BP should be maintained at less than 185/110 for 24 hours post-rtPA.⁷ The nurse should monitor the BP every 15 minutes during the rtPA infusion, then for another two hours, then every 30 minutes for six hours, and then every hour for 16 hours.⁷

The glucose factor

An elevated serum glucose increases morbidity and mortality associated with acute ischemic stroke.⁷ The detrimental effects of hyperglycemia include an increase in tissue acidosis secondary to anaerobic glycolysis (breakdown of glucose), lactic acidosis, and the production of free radicals, which cause cell injury.⁷ Hyperglycemia may lead to the development of cerebral edema and may be associated with an increased risk for cerebral hemorrhage.⁷ In one study, persistent hyperglycemia (glucose greater than 200 mg/dL) during the first 24 hours poststroke was an independent predictor of poor neurological outcomes.⁷ Several studies have looked at the use of insulin protocols in managing critically ill patients with a range of illnesses. In general, the desired level of serum glucose is in the range of 80 mg/dL to 140 mg/dL. A serum glucose greater than 140 mg/dL should be treated with insulin.⁷ The approach would be similar to that used with other critically ill patients with hyperglycemia. The nurse must monitor glucose levels frequently and adjust the insulin as per hospital protocol.⁷ IV fluids with 0.9% normal saline solution should be infused to maintain hydration.⁷

An elevated temperature in acute ischemic stroke is associated with an increased risk of morbidity and mortality, possibly secondary to an increased metabolic demand, and a release of neurotransmitters (chemicals that can regulate the body temperature).⁷ Lowering an elevated temperature may improve the prognosis of patients with stroke. Measures include antipyretics and cooling devices. A temperature greater than 99 F (37.2 C) should be treated with acetaminophen (Tylenol).⁷

In addition to emergency management of acute ischemic stroke during the first 24 hours, treatment modalities can include dysphagia screening (swallowing should be assessed before the patient receives liquid, food, or medication); deep vein thrombosis prophylaxis; lipid management; rehabilitation (speech, physical, occupational therapy); smoking cessation; and medications on discharge as indicated (antithrombotic, antihypertensive, and antilipidemic medications and an anticoagulant for atrial fibrillation).

Nurses may be the first clinicians to identify the signs and symptoms of ischemic stroke. Prompt activation of the RRT will allow early evaluation and possible treatment with rtPA. Following evidence-based guidelines reduces morbidity and mortality associated with ischemic stroke. Nurses must be knowledgeable about current treatment modalities so they can provide quality care and ensure a positive neurological outcome.

What happened to Mr. Richards?

An MRA of the head shows a segmental occlusion of the basilar artery. In the ICU, Mr. Richards receives a 7 mg IV bolus of rtPA over one minute, and 65 mg is infused over one hour. He develops bleeding at the catheterization site one hour post-rtPA. Manual compression is applied for 30 minutes with no further bleeding. The next day, all neurological deficits resolve completely. Mr. Richards goes home on aspirin/dipyridamole (Aggrenox), metoprolol (Lopressor), and rosuvastatin (Crestor).

*Patient’s name has been changed.

EDITOR’S NOTE: For more information about recognizing, evaluating, and treating ischemic stroke, see the Nursing Spectrum Continuing Education modules “Brain Attack, Part I — Diagnostic Studies” and “Brain Attack, Part II — Administering a Thrombolytic Agent” .