Effect of high-quality nursing interventions on the quality of life and cardiac index in acute coronary syndrome patients treated with drug-eluting stents: a randomized trial study

Cardiovascular diseases are among the most common causes of death, worldwide. Complications and deaths of these diseases are increasing, because of increasing of urban life, industrial lifestyles, insufficient physical activity or immobility, and socio-economic conditions. According to annual statistics, cardiovascular diseases affect deaths of more than 45%(3.9 million) in Europe, approximately 30% in United States, and almost 38% in Iran, that contain approximately 10% of women and 33% of men younger than 60 years [1].

Acute coronary syndrome (ACS) is a spectrum of cardiovascular diseases caused by oxygen deprivation due to a reduced blood supply to the myocardium. ACS patients are at risk of developing myocardial damage and heart failure, owing to the ischemic disorder of the coronary arteries and some vessels involvement [2].

Percutaneous Coronary Intervention(PCI), include percutaneous transluminal coronary angioplasty and intracoronary stenting, is an invasive intervention methods for the treatment of ACS [3]. It’s developments in patients comfortable, device technology, stenting techniques and medical treatment, have made it as an effective and safe alternative to coronary artery bypass graft (CABG), so that according to some.

studies, there are no significant difference between and PCI in the incidence of complications such as; stroke, myocardial infarction, deterioration of the patient’s health condition or even death in patients after re-establishment of blood flow [4]. Drug-eluting stents have a polymer coating that is impregnated with medicine. After application, the drug is slowly released and inhibits cell proliferation [5].

Nursing care of ACS patients is controversial and complicated, especially after angiography and stenting. Complications prevention, comprehensive support, increase motivation and education are essential tools to help these patients overcome critical conditions during new diagnoses and obtain suitable living as possible [6].

Suitable patients for coronary stents have more sensitive conditions after angiography such as, use of various drugs and their side effects, possible side effects like stent re-occlusion, stress and anxiety. They need more serious prevention of the recurrence of heart complications [5] and face challenges such as limited mobility, nutritional problems, impaired self-care, lifestyle changes and other issues. Nursing care affects all aspects of the life of patients suffering from ACS after angiography [7]. So it is necessary to provide more accurate and appropriate nursing care for them [5] that affects all aspects of their life after angiography [7]. Nursing interventions are more important for patients after angioplasty by stents or balloons. These patients may be exposed to more serious treatments like CABG, if not taking appropriate care after angiography [8].

High-Quality Nursing Interventions (HQNIs) is a new nursing approach. In this nursing approach, the patient is at the centre of attention, assessments and caring provided, and the nurse is the main source and focal point of communication and providing services to the patient on behalf of the medical team. The nurses integrate primary and continuous care to improve the quality of providing care continuously according to the treatment process and the patient’s needs and conditions [9]. Nurses should consider all of the patients’ needs, as much as possible, by being constantly available to the patient, improving their understanding and knowledge, as well as their mental states, and increase their satisfaction by emphasizing improvements in physical health and social performance [10]. Therefore, the patient considered as a whole and quality and comprehensive nursing care provided with an emphasis on the patient’s needs.

Because no study has been conducted to evaluate the effects of HQNIs on the quality of life (QOL) and cardiac index (CI) of patients undergoing stenting, the purpose of this study was to assess the effects of HQNIs on the QOL and CI of patients suffering from coronary artery involvement treated with drug-eluting stents via angiography.

In the present study, 70 patients after angiography and stenting divided into two groups, each group including 10 men and 25 women. No statistically difference detected between the mean age of intervention (60.05 ± 10.61) and control (61.22 ± 10.27) groups (p = 0.64), marital status (p = 0.62) and education level (p = 0.07).

Among all patients, 58% (41) had a family history, 44% (31) had hypertension, 31% [22] smoked, 24% [17] had high blood sugar, and 11% [8] had hyperlipidaemia.

The major places of involvement were the left anterior descending artery (LAD) 41% (58 people), right coronary artery (RCA) 23% (32 people), left circumflex artery (LCX) 13% (18 people) and lateral oblique artery (OM) 17% (10 people).

With respect to the laboratory findings of a normal frequency of haemoglobin, haematocrit, fasting blood sugar, triglyceride, cholesterol, high-concentration lipoprotein, low-concentration lipoprotein, creatinine, and relative blood prothrombin time, there was a statistically significant difference between the control and intervention groups.

The two dependent variables of QOL and CI did not have a normal distribution, based on Kolmogorov Smirnov test (p < 003).

Table 1 shows comparison mean of QOL scores between the two groups before and two months after the intervention.

Table 1 shows a statistically significant difference between the mean of QOL, before and two months after the intervention, in both groups (p = .000). According to the above table, although the mean of QOL score before the intervention (119 ± 13) was higher in the control group relative to the intervention group (115 ± 11), it increased after the intervention in the intervention group (136 ± 10) relative to the intervention group (118 ± 8.06).

Table 2 shows comparison the mean of CI scores in the two groups before and after the intervention.

Table 2 shows a statistically significant difference in the mean of CI, before (5.99 ± 2.54) and two months after the intervention (4.55 ± 2.54) in the intervention group(p = .004). However, in the control group (before and two months after, respectively: 5.02 ± 1.7, 5.19 ± 1.89), this difference was not statistically significant.

The results of this study indicated that implementing HQNIs has improved the QOL and CI of patients suffering from ACS undergoing stenting.

In terms of QOL, in Lee et al. (2020) study, HQNIs reduced patients’ negative feelings, reduced adverse reactions, and improved their QOL and sleep quality [18]. In Dink et al. (2022) study, HQNIs reduced the psychological pressure of the first chemotherapy treatment for patients who had malignant tumours and relieved patients’ anxiety and fear, which ultimately improved the effectiveness of chemotherapy [13]. Sun et al. (2023) study, HQNIs improved the QOL of patients with malignancies, also reduced anxiety, depression, pain, and fatigue [19].

Additionally, the findings of studies conducted by Chen et al. (2021) and Hu et al. (2022) have indicated that HQNIs improve the QOL of patients suffering from cancer after surgery [9, 20].

Nursing models, which are comprehensive and holistic and lead to the examination of patients’ needs in all aspects of life and the continuation of the necessary planning and goal setting on the basis of needs, ultimately improve the QOL of patients [21], since improving QOL requires changing lifestyles in terms of wrong and inappropriate habits and behaviours, especially in fields such as smoking, addiction and physical activity, inappropriate nutritional habits and stressful events, as well as paying attention to all people’s needs [22]. Nursing techniques and interventions, if they reduce stress, strengthen and increase patients’ awareness of their condition and understanding of their disease and acceptance of existing conditions, change their behaviour and ultimately improve their quality of life [23]. Various studies have indicated that HQNIs improve the knowledge and understanding of patients; reduce the complications of diseases or procedures [10]; reduce patients’ negative feelings, tension, stress and disorders [18]; increase patients’ tolerance of mental pressure; and provide the basis for improving QOL by affecting the physical activity, nutrition and health of patients and providing spiritual support to them [13]. In this nursing approach, special attention is given to the prediction of possible complications and the development or exacerbation of mental-psychological disorders as well as physical problems and planning to address them in time, in case of occurrence. In addition, strengthening the immune system with the help of a high-protein and vitamin-rich diet and proper and adequate exercise is a priority for patient care, all of which can have a positive effect on the QOL of those receiving medical and nursing services [19]. Additionally, among the other characteristics of HQNIs, it can take into account and support the patient’s family in nursing care, which can have a significant impact [20].

Another finding of this study was that providing HQNIs had a positive effect on patients’ CI. In this regard, the findings of the study of Toya et al. (2023) on the effect of nursing interventions on creating positive motivation in patients with heart function, self-management and QOL among elderly patients suffering from coronary artery disease demonstrated that while increasing patients’ tolerance, nursing interventions improved the heart function of elderly patients and increased patients’ satisfaction, in addition to increasing their knowledge at the time of discharge [24].

A study conducted by Xie et al. indicated that HQNIs improved the cardiac function of diabetic patients suffering from coronary artery disease [10]. The study of Wang et al. (2022) was also conducted with the aim of scrutinizing the effects of nursing interventions focused on targeted rehabilitation on restoring heart function and negative emotions in patients with acute myocardial infarction. These findings indicate that nursing interventions focused on reducing or preventing problems caused by disability while improving heart function and reducing the risk factors and the incidence of complications, improve mental health and QOL in patients with acute myocardial infarction in the hospital [25].

In Lin et al. (2021) study, the implementation of primary nursing in patients undergoing emergency PCI improved the heart function of patients [26].

Although heart function is influenced by various factors, such as preload and afterload space, the degree of damage to the heart muscle, the function of the heart conduction system, drugs, and the health of other organs, such as the kidney [27], appropriate nursing care, such as high-quality nursing care, can also improve lifestyles, increase awareness of risk factors and ways to prevent damage and subsequent complications, reduce stress [28], create positive motivation in patients, facilitate access to medical teams, communicate feelings more effectively with patients and family members, improve the participation and commitment of patients and families in the treatment and recovery process, and provide the basis for improving the heart function of patients [24, 25].

HQNIs can improve the prognosis of the disease, reduce or prevent adverse effects and improve the physical and mental health of the patient [10]. However, the susceptibility of heart function to many factors has led to the finding that, in some studies, nursing care has not necessarily been associated with improvements in heart function. For example, in the study conducted by Moun et al., a phone-based self-management program led by nurses in self-care behaviour failed to improve one of the biological indicators of heart function (left ventricular ejection fraction, left ventricular diastolic pressure) [29].

Based on the results of this study, integration of primary and continuous nursing approach such as HQNI can improve the QOL and heart function of patients with ACS, after angiography and drug stent placement. It can be concluded that the use of HQNI can be effectively integrated into routine cardiac care protocols to improve various dimensions of patient’s emotional, physical, mental, and social aspects, from hospital admission to continues home care, until needed. Achieving this goal requires that, nurses placed at the center of patient care, through proper planning and allocation of necessary facilities, to improve professional nursing care. Our findings may provide some evidence to support the effects of comprehensive nursing approach on the QOL and cardiac function. However, more studies are needed to expand the existing knowledge about the impact of employing HQNI on the QOL and cardiac function of patients and improve professional nursing performance in all situations, especially in critical care units.

One of the strengths of this study was that the implementation of HQNIs resulted in an improvement in the quality of life in various dimensions among ACS patients after drug-eluting stent. Therefore, this approach can be recommended as a nursing care approach, especially in critical care units, for improving the QOL and CI of operating these patients. One limitation of this study was that the participants were limited to ACS patients after drug-eluting stent, so the results cannot be generalized to other patients in different hospital settings. Another limitation of the study was the short intervention and follow-up periods. It is suggested that longer, longitudinal studies should be conducted on this topic. Furthermore, it is recommended that this intervention should be used for all patients’ groups in various hospital settings.

HQNIs is a viable nursing intervention to enhance the QOL and CI of ACS patients after treated with drug-eluting stent. To enhance evidence-based practice, further studies on this subject are recommended. Moreover, the impact of HQNIs on other outcomes in ACS, such as the levels of stress and anxiety, sleep quality, physical activity, and self-efficacy, is suggested for investigation in future studies.