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Working on the “beating heart” with a conscious patient or performing exams and interventions without opening the thorax are possible thanks to technical developments in cardiology. While the work in the cardiac catheter laboratory of the Klinikum Ernst von Bergmann (EvB) in Potsdam has become professional routine, stress still exists: for patients, the treating physicians, and employees alike – stress that can impact the quality of medical care as well as patients’ condition and rehabilitation. A joint project of the EvB and researchers at the University of Potsdam will help to calm this “heart palpitation”.
An ambulance – lights flashing – races through Potsdam with a patient suffering from an acute myocardial infarction. She is immediately admitted to the cardiac catheter lab (CCL) at the Clinical Center. An analysis of her heart shows a life-threatening vascular constriction. The vessel must be widened immediately with a ballon catheter and a stent, if necessary. Moments later, the artery is again sufficiently supplied with blood. The quick, resolute, and professional actions of the doctors and medical staff at the CCL saved the patient's life. Only 21 minutes passed from admission to the end of the treatment, but each passing minute was nerve-racking. Emergency cases allow for no margin of error; delays can have fatal consequences. “In a heart attack, every second counts in minimizing the damage,” says Dr. Klaus Bonaventura, Medical Director of the Cardiology and Angiology Clinic. “Such situations are psychologically extremely stressful – not only for the patients but for everyone involved in the treatment. This is especially true for the few cases in which we lose a patient.”
Not all cases treated at the CCL are so dramatic, of course. Diseases of the coronary arteries, myocardium, the cardiac valves, or blood vessels throughout the body regularly arrive “on the (examination) table”. The spectrum of cardiology has grown enormously over the years, Bonaventura explains, along with treatment options. “I started as a cardiologist in 1993. Nothing is as it once was. What was forbidden is now recommended.” This applies to research methods as well as to medication and interventions.
“In most cases, patients arrive (or are referred to us by practitioners) complaining of chest discomfort, dyspnea, tightness, or pressure in the chest,” Bonaventura explains. Immediately after they are admitted, an ECG, an ultrasound, and stress tests are done to determine whether the coronary arteries should be examined more closely – possibly even treated – with the help of a cardiac catheter. “Cardiovascular diseases are by far the most common cause of death,” says the cardiologist. “Thanks to technical developments, we are now able to help many patients in the CCL, and the intervention has become almost routine – with enormous diagnostic and therapeutic potential.”
A cardiac catheter examination is an X-ray examination in the broadest sense: A contrast medium is injected, and the attending physician then inserts a catheter through an artery in the hand or leg and guides it to the heart. X-rays make visible both the vessels (and potentially dangerous constrictions) as well as the examination instrument, so that it can be guided with millimeter precision. The catheter is usually only 1.5-1.8 millimeters thick but is able to take on the necessary instruments such as a stent or a balloon should treatment become necessary. While balloon catheters can be “inflated” in heavily clogged blood vessels to, for example, loosen cholesterol deposits, stents are used to permanently expand constricted sections and keep them open. “We now have a wide range of instruments at our disposal,” says Bonaventura, “balloon catheters, which can break even stubborn incrustations at high pressures of 8-10 or even 18 bar thanks to the specific material properties, or stents coated with various drugs that allow for long-term drug treatment.”
What is remarkable is that patients are conscious throughout the procedure. There is no anesthesia; only the spot where the catheter is inserted is anesthetized. “It is important for us to involve the patients in the process,” Bonaventura explains. “The attending physicians introduce themselves, explain each step of the examination, and immediately evaluate the results, also to determine any further procedures.”
The examination, possible treatment, and potential risks (despite the routine nature of the procedures) are explained at least 24 hours before the intervention. This is prescribed by law. This may be the first time the person has had to deal with their illness, even if they have had problems for years, Bonaventura says. Most patients do not want to know about the rare-but-possible complications. “This is where the mental cinema starts: While it is ‘everyday business’ and a routine examination for us, patients naturally see the risks – however small they may be – in connection with themselves. It is important for us, however, that they make informed decisions.”
Because the CCL team is well aware of the psychological stress that patients feel after learning about the examination, it is always trying to improve how patients are informed, for example through the project “Palpitation”, for which Bonaventura has teamed up with the health associate Prof. Dr. Pia-Maria Wippert from the University of Potsdam. “It is now known that life-threatening situations – including cardiac interventions – create stress, which negatively impacts the healing and regeneration processes,” says Wippert. “The more stress, the more likely complications are,” Bonaventura adds. “Both the need for painkillers and the average duration of the hospital stay increase.” Improving how patients are informed before a cardiac catheter examination so that their fears are quelled could reduce stress.
“Palpitation” also focuses on the mental stress of the treating physicians and medical staff at the CCL, Wippert points out. “The work is very demanding: The CCL teams have to work very precisely within a very short time – under very stressful conditions, for example in life-threatening situations for patients.” The project is meant to help them as well, Bonaventura adds. Stress can affect the quality of medical care. We want to identify counteractive measures by analyzing the working environment and processes.”
The researchers of the University of Potsdam are first trying to determine which specific factors induce stress in patients and attending physicians. For this, guided interviews are conducted with volunteers from both groups that will be analyzed and then form the basis for an information and intervention program. A pre-intervention educational film will be created for patients. After watching it, they can ask specific, individual questions so that they are optimally prepared for the procedure. “For the physicians and employees, we want to develop guidelines – a number of concrete tools – to help them deal with stress,” Wippert explains. “They should learn to not take it home with them, to relax and unwind.”
The researchers plan to validate the complex interventions in a third step. Chemically analyzed hair samples will determine the chronic stress level of the physicians before, during, and after taking part in the program. “This should tell us whether stress can be permanently reduced,” says Wippert.
The goals are ambitious. “In the field of cardiology, there are many technical innovations, but we want to improve the overall conditions,” says Bonaventura, adding, “There are about 600 facilities in Germany performing about 750,000 cardiac catheter examinations each year. Our results could help many others.”
Stress Management in the Cardiac Catheter Lab: The Study “Palpitation”
Participants: Prof. Pia-Maria Wippert (University of Potsdam); Dr. Klaus Bonaventura (Cardiology and Angiology Clinic, Klinikum Ernst von Bergmann Potsdam)
Prof. Pia-Maria Wippert has been Professor of Sports and Health Sociology at the University of Potsdam since 2010. She specializes in risk stratification of stress associated diseases and intervention development.
Department Sport- und Gesundheitswissenschaften
Am Neuen Palais 10, 14469 Potsdam
Priv.-Doz. Dr. med. Klaus Bonaventura studied Human Medicine at Saarland University in Homburg/Saar. He is the medical director and head of the Cardiology and Angiology Clinic of the Klinikum Ernst von Bergmann.
Klinikum Ernst von Bergmann
Text: Matthias Zimmermann
Translation: Susanne Voigt
Published online by: Agnetha Lang
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Read this and other articles on research at the University of Potsdam in our research magazine Portal Wissen. http://www.uni-potsdam.de/en/explore-the-up/news-and-announcements/university-magazines/archive-portal-wissen.html