Article Type: Original Article

Title:  Patients’ Knowledge Regarding Cardiac Catheterization at Cardiac Specialty Hospital in Slemani City Iraq: A Descriptive Study

 Year: 2021; Volume: 1; Issue: 1; Page No: 26 – 32

Authors:  Bayan Omar1, Nian Hamaamin Ahmed2, Dlawer Dhufr Farhad3  

Affiliations: 1Specialist Nurse, Cardiac Specialty Hospital, Slemani City, Iraq. 2Manager–Cum–Specialist nurse, Cardiac Specialty Hospital, Slemani City, Iraq.  3Cardiologist, Cardiac Specialty Hospital, Slemani City, Iraq.

Paper Summary:  
Submitted : 20-March-2021
Revised      : 19-April-2021
Accepted   : 10-May-2021
Published : 10-June-2021

Abstract

Background:  Cardiac catheterization (CC) is the inserting of a thin, hollow catheter into a chamber or vessel; it is done for diagnostic and intervention purposes.  Death charge from coronary heart disease have decreased in recent decennium, however coronary heart disease is still a major cause of morbidity and mortality worldwide especially in developed country.  Coronary heart disease refers to different condition of failing circulation of the heart and includes myocardial infarction (MI).  In this study, we assessed the patients’ knowledge regarding CC.

Materials and Methods:  A descriptive study was conducted with a purposive sample of 250 patients were selected and included from Cardiac Specialty Hospital in Slemani City, Iraq.  This study was carried out in between November 2017 and October 2018.  A self-conductive questionnaire was used for data collection.

Results: Totally 250 patients were included in this study.  Among 250 patients, 176 (70.4%) were males and 74 (29.6%) females. The validity of questionnaire was estimated through a panel of experts related to the field of the study, and its reliability was determined through a pilot study which was carried out on 105 patients who were selected purposively from the patient were admitted those who were undergone the procedure at Cardiac Specialty Hospital in Slemani city.  Most 70.4% of the participants were male and majority 212 (84.8%) were Kurdish and more than a quarter of the patient’s age was in group 60 years and above.  Among 250 patients, 202 (80.8%) were married and 117 (46.8 %) of study participants were illiterate, 171 (68.4%) of them were unemployed, and 148 (59.2%) were lived in urban area.

Conclusion: Our present study showed that the majority of participants had low level of knowledge regarding CC as well as level of knowledge from post-CC was higher than pre-CC procedure, knowledge regarding CC as well as level of knowledge in post-CC.

Key Words: patients’ Knowledge, cardiac catheterization, pre and post cardiac catheterization, Slemani City, Iraq

Corresponding Author: 
Mrs. Bayan Omar,
Specialist Nurse, Cardiac Specialty Hospital,
Slemani, Iraq.
Email ID: omerbayan82@gmail.com

Introduction:

“Cardiac catheterization (CC) is the inserting of a thin, hollow catheter into a chamber or vessel; it is done for diagnostic and intervention purposes”. [1] Death charge from coronary heart disease have decreased in recent decennium, however coronary heart disease is still a major cause of morbidity and mortality worldwide especially in developed country. Coronary heart disease refers to different condition of failing circulation of the heart and includes myocardial infarction (MI), which is the one coronary heart disease that causes most deaths. [2] Functions of the circulatory system and the heart are adversely affected by cardiovascular diseases such as coronary thrombosis artery disease, cerebrovascular disease and peripheral vascular disease but coronary artery disease is a multifactorial disease in the heart and Its occurrence depends on the bed cover of risk element, therefore, the more frequent risk factors for atherosclerosis has a largest morbidity and mortality that occur by this disease. [3]

Percutaneous coronary intervention (PCI) is the gold methods for treating coronary artery disease and it is recommended to treat ST-segment elevation myocardial infarction (STEMI) and unstable or chronic stable angina. [4] Percutaneous coronary intervention is a non-surgical intervention and referred to coronary angioplasty that done for manage the narrowing of the coronary artery branches of the heart resulting from accumulation of cholesterol plaques, this procedure must be done by cardiac specialist. [5] This process be done in emergent, lanned or rescue condition for revascularization strategy for coronary artery disease. [6] Opening the blocked artery of the heart lead to improving blood flow for the heart tissue and absence of chest pain, reoccurring myocardial infarction also sudden death may be prevented. [7]  Coronary angioplasty is relatively considered as a low-risk procedure and has a rapid recovery, also it is useful to improve prognosis, relieve symptoms, decrease ischemic events, and improve functional capacity in the heart. [8] An expert nursing care delivered within an interdisciplinary team must be present in the cardiac catheterization unit during performing percutaneous coronary intervention. [9] Monitoring vital signs, the sheath entrance site, peripheral pulses, capillary refill and chest pain must be measured by the nurses because they have an important role in this procedure. [10] All these observations are done while maintaining a patient’s sufficient periods of rest, providing required perfusions of drugs, and monitoring the patient for their amounts of fluid intake and output. [11]

Hemodynamic instability in response to invasive procedures is a consequence of patients’ experience of anxiety and stress without any previous knowledge about it. The patients report feelings of discomfort and intolerance due to prolonged bed rest in a fixed position after the procedure. [12] Nurses play a critical and important role in promotion of the patient’s information before and after the procedure. [13] Psychological problems may decreased by Patient’s knowledge about the procedure. [14] Giving verbal information for the patients by nurses and physicians is considered as common routine useful way for educating the client’s pre coronary angioplasty in many hospitals and this meaningfully leads to decrease the nursing work load, and also elevate the patients and nurses’ gratification, rest and forgiveness that related to the procedure. [15] However occurrence some complication by coronary angioplasty such as seudoaneurysm, hematoma, bleeding and arterial occlusion, that as recorded not reach to more than 14% but in general it is a safe procedure. [16]  Many studies recorded that age, gender and body weight are considered as a common predisposing factor for vascular complications. [17] Furthermore, types of medications that administered during the coronary angioplasty and chronic disease elevate the risk of vascular complications. [18] Some patient during coronary angioplasty has a chance of a disaster situation because experience life-threatening complications however most of them are discharged successfully without any complications within a day.  Managing complication need trained nurses to use critical assessment skills, and detect any vascular problem and apply suitable interventions. [19] In our study the main objectives were to describe socio-demographic characteristics of the study sample; to find out level of patients’ knowledge regarding cardiac catheterization procedure; to find out the association between level of knowledge and some socio-demographic characteristics such as age groups, gender, nationality, income, level of education, residential area and occupation status of the study sample and to find out differences between patient’s level of knowledge in pre and post cardiac catheterization procedure.

 

Materials and Methods:

This descriptive cross sectional-based study was carried out at Cardiac specialty Hospital in Slemani City for the period of about eight months from November 14th, 2017 to October 20th, 2018. The main sample of this study involved 250 patients which admitted there. A self-conductive questionnaire was used for data collection was used to record information about the patients such as: socio demographic data, which includes (patient’s age groups, gender, marital status, nationality,  monthly income, level of educational, residential area). And some question regarding cardiac catheterization (box-1).  Permission was taken from the Slemani Directorate of Health to carry out this study at the Slemani Cardiac Specialty Hospital in Slemani city. A 21 points scale was used to assess the knowledge of patients about the 21 questions or recommendations that the patient must know before undergoing the procedure. One score was given for each correct answer, so the total was 21 scores. It was divided into three equal parts. Accordingly, those who scored 1–7 were considered as having low level of knowledge, those who scored 8-14 were considered as having medium level of knowledge, and those scored 15–21 were considered as having high level of knowledge. Data were enter in Microsoft excel 2010 [Microsoft Ltd., USA] and were analyzed by using Statistical Package for Social Sciences (SPSS, version 22.0, IBM, USA). Chi-Square test was used to find association between proportions. Fisher’s exact test was used when the expected count of more than 20% of the cells of the table was less than 5. A p-value <0.05 was considered as statistically significant.

 

Results:

 Two hundred fifty patients scheduled for cardiac catheterization had been included in our present study. Their mean age (Mean + SD) was 59.54±10.56 years, ranging from 30 to 90 years. The median was 60 years.  It is evident that more than two thirds of patients aged 50-69 years, 15.6% aged less than 50 years, and 15.2% aged 70 years or older than 70. More than two thirds (70.4%) were males, and the male: female ratio was 2.4: 1.  Table1 shows also that the majority of the patients (84.8%) were Kurdish, and 80.8% were married. Regarding the income, 63.6% believe that their income was not sufficient for their daily needs, and around half (46.8%) of the patients were illiterate.  It is evident in the same table that 68.4% were unemployed (or housewives), and only 16.8% were employed. Finally, the table shows that 59.2% were living in urban areas. More than half (52%) of the studied sample had low level of knowledge, 47.2% had medium level of knowledge, and only two patients (0.8%) had high level of knowledge as shown in Figure1. Results showed that the mean knowledge score was 7.2, ranging from 1 to 16. The median knowledge was found as 7. 

Nearly most of 99.6% the patients believe that the information regarding cardiac catheterization are necessary for them, but on the contrary, the proportions of patients who had knowledge about this information was low. More than 67.6% of the patients had knowledge about the pain during the procedure, 58.4% of the patients knew that they would be awake during the procedure, and 57.2% had information about the area of insertion of the cardiac catheter. Less than 50% of the patients had information about the other items presented in Table2.   It is evident  in the table that small proportion of the patients had information ‘when to eat and drink after the procedure’, ‘when to take a shower’, ‘the period

of rest after the procedure’, ‘when to resume heavy physical activities including sexual intercourse’ in addition to the other information mentioned in the table.

In Table3, two patients with high knowledge score were combined with those of medium knowledge for the sake of the statistical

Table 1. Socio-demographic characteristics of the patients (N = 250) 

Socio-demographic characteristics Number of Patients

(n)

Percentage
Age Groups (in years)
< 50 39 15.6
50-59 82 32.8
60-69 91 36.4
≥ 70 38 15.2
Gender
Male 176 70.4
Female 74 29.6
Nationality
Kurdish 212 84.8
Arabic 36 14.4
Others 2 0.8
Marital status
Single 5 2.0
Married 202 80.8
Divorced 3 1.2
Widowed 40 16.0
Monthly Income
Sufficient 16 6.4
Barely sufficient 75 30.0
Insufficient 159 63.6
Educational status
Illiterate 117 46.8
Primary 56 22.4
Secondary 49 19.6
Diploma 17 6.8
Degree and above 11 4.4
Occupation Status
Employed 42 16.8
Unemployed 171 68.4
Retired 37 14.8
Residence Areas
Urban 148 59.2
Semi Urban 69 27.6
Rural 33 13.2

Figure: 1 Distribution of the patients’ levels of knowledge 

analysis.  Lower the age, less proportions of medium knowledge, but the differences were not significant with p-value=0.144 (p>0.05). It is evident in the table that 49.4% of males had medium knowledge compared with 44.6% of females had no significant with p=0.485 (>0.05). Regarding nationality, the highest proportion of medium knowledge was among the Arabs (63.9%) but the differences were not significant with p=0.066 (>0.05). No significant association was detected between marital status and knowledge with p=0.272 (>0.05). The highest proportion of knowledge was among those with barely sufficient income (60%), and the lowest (42.1%) was among those with insufficient income with p=0.038 (<0.05). Significant with p=0.009 association was detected between knowledge and educational level, but the distribution was not consistent where the highest proportions of medium knowledge was among graduates of primary and secondary schools (62.5%, and 59.2% respectively), while it was 54.5% among MSc holders.  No significant association was detected between occupation and the level of knowledge with p-value=0.613.  Regarding residency, 54.1% of those living in urban areas had medium knowledge, compared with 44.9% and 27.3% among those living in suburban and rural areas respectively and the test showed significant with p-value=0.017 (<0.05).

More than half (60.5%) of the studied sample had low level of knowledge, (39.5%) had medium level of knowledge, but only two patients had high level of  knowledge (1.6), (54.6%) of them had a medium level and (43.7%) had a low level of knowledge.  Results showed that the post cardiac catheterization knowledge was more than pre cardiac catheterization as shown in Figure–2.

 Discussion:

 Regarding socio-demographic characteristics of the study sample; table one showed that most of the participants’ age ranged between sixty years and above; most of them were male, majority of them were married and nearly a quarter of the patients had insufficient income and unemployed. More than half of them were illiterate and lived in urban area. The result regarding age, gender, marital status is agreed with the study done in Australia 2009 which mentioned that the number of female patients with coronary heart disease is generally much lower than male. [20]  Regarding level of knowledge figure one in our results indicated that more than half of the participants had a low level of knowledge, nearly half of them had a moderate level but Alarmingly indicated that only two patients has a high level of knowledge, The results are in agreement with the study done in Pakistan which showed that majority of the patients who were booked for cardiac catheterization were unable to properly describe the procedure. These high points that the cardiac patients are not well alert with coronary heart disease. Also finding of the study demonstrate that more than half of the participants had no any information about these questions which asked about; information regarding cardiac catheterization, taking medications such as Aspirin, Plavix before the procedure, cardiac catheterization therapeutic procedure for opening the narrowing of coronary artery, about time that should take rest after the procedure and time of avoiding oral intake after the procedure, but Worryingly the results indicated that the majority of the patients had no any information about these questions; indication of existing some investigations such as: blood urea, serum creatinine, time of taking a shower after the procedure, avoid doing heavy activities after the procedure especially sexual intercourse, complications of cardiac catheterization, such as bruising, bleeding, and allergic reactions to the dye or medications, theaim and amount of drinking clear fluid preferably water after the process.

Table 2. Distribution of patients’ knowledge about the regulations and guidelines (N = 250)

Knowledge Questions I don’t know Uncertain I know
n (%) n (%) n (%)
Do you have any information about cardiac catheterization? 148 (59.2) 85 (34.0) 17 (6.8)
Do you know checking vital signs is necessary before the

procedure?

98 (39.2) 54 (21.6) 98 (39.2)
Do you know the ECG need before the procedure? 93 (37.2) 47 (18.8) 110 (44.0)
Do you know about continuation or stoppage of your medications before the procedure? 110 (44.0) 54 (21.6) 86 (34.4)
Do you have information about taking medications such as Aspirin, Plavix before the procedure? 167 (66.8) 25 (10.0) 58 (23.2)
Do you understand that Cardiac catheterization is a diagnostic procedure for coronary artery occlusion? 124 (49.6) 10 (4.0) 116 (46.4)
Do you know that cardiac catheterization is a therapeutic procedure for opening the narrowing of coronary artery? 139 (55.6) 10 (4.0) 101 (40.4)
Do you know that you will be awake during the procedure? 71 (28.4) 33 (13.2) 146 (58.4)
Do you know you should do these investigations such as:      (blood urea, serum creatinine, Hepatitis and HIV before procedure and there aims? 223 (89.2) 21 (8.4) 6 (2.4)
Do you have information about existing pain during cardiac

catheterization?

70 (28.0) 11 (4.4) 169 (67.6)
Do you know when you can take a shower after the procedure? 218 (87.2) 12 (4.8) 20 (8.0)
Do you know for how long you should take rest after the procedure? 135 (54.0) 44 (17.6) 71 (28.4)
Do you know for how long you should avoid oral intake after the procedure? 155 (62.0) 60 (24.0) 35 (14.0)
Do you know for how long you should avoid doing heavy activities after the procedure especially sexual intercourse? 202 (80.8) 30 (12.0) 18 (7.2)
Do you know any complications of cardiac catheterization, such as bruising, bleeding, heart attack and allergic reactions to the dye or medication? 207 (82.8) 38 (15.2) 5 (2.0)
Do you know the procedure avoided if you have severe uncontrolled hypertension? 94 (37.6) 54 (21.6) 102 (40.8)
Do you believe that the information regarding cardiac

catheterization are necessary for you?

0 (0) 1 (0.4) 249 (99.6)
Do you know the aim and amount of clear fluid preferably water

after cardiac catheterization?

234 (93.6) 10 (4.0) 6 (2.4)
Do you know the cardiologist administer mild sedative medication before the procedure? 95 (38.0) 49 (19.6) 106 (42.4)
Do you know the area for performing a cardiac catheterization

insertion in the human body?

28 (11.2) 79 (31.6) 143 (57.2)

Table: 3 Association between severity and demographic variables

Variables High Medium and Low Total p-value
n

130

%

52.0

n

120

%

48.0

N

250

%

100

Age Groups (in Years)
< 50 17 43.6 22 56.4 39 100.0 0.144
50 – 59 41 50.0 41 50.0 82 100.0
60 – 69 46 50.5 45 49.5 91 100.0
≥ 70 26 68.4 12 31.6 38 100.0
Gender
Male 89 50.6 87 49.4 176 100.0 0.485
Female 41 55.4 33 44.6 74 100.0
Nationality
Kurdish 116 54.7 96 45.3 212 100.0 0.066
Arabic 13 36.1 23 63.9 36 100.0
Others 1 50.0 1 50.0 2 100.0
Marital status
Single 3 60.0 2 40.0 5 100.0 0.272
Married 100 49.5 102 50.5 202 100.0
Divorced 1 33.3 2 67.7 3 100.0
Widowed 26 65.0 14 35.0 40 100.0
Income
Sufficient 8 50.0 8 50.0 16 100.0 0.038
Barley sufficient 30 40.0 45 60.0 75 100.0
Insufficient 92 57.9 67 42.1 159 100.0
Educational Status
Illiterate 74 63.2 43 36.8 117 100.0 0.009
Primary 21 37.5 35 62.5 56 100.0
Secondary 20 40.8 29 59.2 49 100.0
Diploma 10 58.8 7 41.2 17 100.0
B.Sc. &more 5 45.5 6 54.5 11 100.0
Occupation Status
Employed 21 50.0 21 50.0 42 100.0 0.613
Unemployed 87 50.9 84 49.1 171 100.0
Retired 22 59.5 15 40.5 37 100.0
Residence Areas
Urban 68 45.9 80 54.1 148 100.0 0.017
Sub-urban 38 55.1 31 44.9 69 100.0
Rural 24 72.7 9 27.3 33 100.0

                           Bolded p-value < 0.05 Significant

This result related to many reasons; first of all we have to say that the cardiac specialty hospital in Slemani prepared most of these information by handout for every patients but as a result showed  than two thirds of patients were old age and nearly half of them were illiterate.

Figure: 2 Differences of pre and post cardiac catheterization procedure with patients’ level of knowledge

So they cannot read the instructions and  their relative did not read for them,  or some patient obtain information from  physician but forget it furthermore we have a many patients which planned cardiac catheterization and angioplasty and our nurses has no enough time for explain pre and post procedure for the patients however explaining and understanding patients regarding the procedure is considered as the heart of the science of nursing and it is a comprehensive ideal of caring [21].  Table-3 showed that the lower the age, the less the proportions of medium knowledge, but the differences were not significant (p= 0.144) the reason of this result related to performing this procedure previously.

There are very highly significant association with p–value=0.009 (p<0.001) between knowledge and educational level, but the spreading was not regular where the highest proportions of medium knowledge was among graduates of primary and secondary schools while more than of half of them was among MSc holders. No significant association was discovered between occupation and the level of knowledge with p–value=0.613 (p>0.05). Concerning residency, more than half of those living in urban areas had medium knowledge, matched with nearly half and nearly a quarter among those living in suburban and rural areas respectively p=0.017 (<0.05). The consciousness regarding post angioplasty complications and factors that raises chance of restenosis will increase clients’ obedience to drugs and will also decrease morbidity and mortality rates among coronary heart disease patients [22].

There are only two patients had a high level of knowledge, more than half of them had a medium level and nearly half of them had a low level of knowledge in post-CC procedure but in pre -CC procedure more than half of the participants had low level of knowledge, less than half had medium level of knowledge. Results showed that the post cardiac catheterization knowledge was more than pre cardiac catheterization. This result related to understanding the procedure after doing it and they sow and heard many thing during the procedure.

Conclusion:

Our study finding results showed that more than half of the participants had a low level of knowledge but surprisingly indicated that only two patients has a high level of knowledge regarding pre and post cardiac catheterization.  Most of participants were believed that the information regarding cardiac catheterization is necessary for them.  Nevertheless, this outcomes could be of great help to higher specialists as we have recognized subset of population that specially needs to be directed through alertness programs as well as suggest that urgent and Targeted awareness programs must be introduced, so a special person must be selected to explain full cardiac catheterization procedure for every patient who planned this process.  Also more than half of them had information about the area for performing a cardiac catheterization insertion in the human body. The study demonstrated that the lower the age, the less the proportions of medium knowledge, but there is no differences between them.

Implications for practice:

  1. Every physician must be explain the patients regarding pre and post CC in his clinic before the
  2. Nurses should be given more opportunities to participate symposia regarding coronary heart disease to increase ability of advice and giving instruction for patients regarding CC process, and put a special person for that
  3. This field needs to much more scientific research to provide adequate knowledge for patients during preparation of patients regarding cardiac

Authors’ Contributions: BO, NHA: Study conception and design; BO: Data collection; BO and NHA: data analysis, draft manuscript preparation.  BO, NHA and DDF authors reviewed the results and approved the final version of the manuscript.

Here, BO – Bayan Omar; NHA – Nian Hamaamin Ahmed; and DDF – Dlawer Dhufr Farhad

Source of funding:  We didn’t get any kind of funding from any other financial institutions or organizations.  

Conflict of interest:  The authors declare no conflict of interest.

References:

  1. Cardiac Available on: heartattack/diagnosing-a-heart-attack/cardiac-catheterization [Last Accessed on: 20th November 2019]
  2. Larsson, A. Common risk factors associated with acute myocardial infarction: Population-based studies with a focus on gender differences. Department of Clinical Sciences, Lund University 2011; ISBN: 978-91-86871-53-6
  3. Girotto E, Andrade SM, Cabrera MAS, Ridão Prevalência de fatores de risco para doenças cardiovasculares em hipertensos cadastrados em unidade de saúde da família. Acta Scient Health Sci 2009;31(1):77-82. DOI: 10.4025/actascihealthsci.v3li1.4492
  4. Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ and King SB: ACC/ AHA/SCAI, Guideline update for percutaneous coronary intervention-summary article: a report of the American College of Cardiology/American Heart Association Task Force of Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 2006;113(1):156-175 PMID: 16391169
  5. Oberhauser JP, Hossainy S, Rapoza Design Principles and Performance of Bioresorbable Polymeric Vascular Scaffolds. Euro Intervention 2009;5SupplF:F15-22. PMID: 22100671
  6. Rolley JX, Salamonson Y, Wensley C, Dennison CR, Davidson Nursing clinical practice guidelines to improve care for people undergoing percutaneous coronary interventions. Aust Crit Care 2011;24(1):18-38. PMID: 20833062
  7. Alhalaiqa F, Abu-Shbeeb I, Batiha AM, Masa’Deh R, Amarneh The Relation of Demographic Characteristics with Fatigue Levels among Coronary Heart Disease Patients: A Jordanian Study.  Adv Studies in Biology 2015;7:301-322. DOI: 10.12988/adb.2015.5418
  8. Fraker TD Jr, Fihn SD, 2002 Chronic Stable Angina Writing Committee, American College of Cardiology, American Heart Association, Gibbons RJ, et 2007 Chronic Unstable Angina Working Committee. Chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic unstable angina: A report of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines Working Group to develop the focused update of the 2002 guidelines for the management of patients with chronic stable angina. J Am Coll Cardiol 2007;50(23):2264-2274. PMID: 18061078
  9. Rezaei-Adaryani M, Ahmadi F, Asghari-Jafarabadi The effect of changing position and early ambulation after cardiac catheterization on patients’ outcomes: A single-blind randomized controlled trial. Int J Nurs Stud 2009;46(8):1047-1053. PMID: 19296949
  10. Saifan A, Bashayreh I, Batiha AM, AbuRuz Patient- and Family Caregiver-Related Barriers to Effective Cancer Pain Control. Pain Manag Nurs 2015;16(3):400-410. PMID: 26025799
  11. Hirsch AT, Duval Effective Vascular Therapeutics for Critical Limb Ischemia: A Role for registry-based clinical investigation. Circulation: Cardiovascular Interventions 2013;6(1):8-11. DOI: 10.1161/CIRCINTERVENTIONS.113.000127
  12. Ruffinengo C, Versino E, Renga Effectiveness of an informative video on reducing anxiety levels in patients undergoing elective coronarography: an RCT. Eur J Cardiovasc Nurs 2009;8(1):57-61 PMID: 18502689
  13. Jamshidi N, Abbaszadeh A, Kalyani Effects of video information on anxiety, stress and depression of patients undergoing coronary angiography. Pak J Med Sci 2009;25(6):901-905. Available on: https://pjms.com.pk/issues/octdec209/article/article5.html
  14. Chair SY, LI KM, Wong Factors that affect back pain among Hong Kong Chinese patients after cardiac catheterization. Eur J Cardiovasc Nurs 2004;3(4):279-285 PMID: 15572016
  15. Steffenino G, Viada E, Marengo B, Canale R, Nursing and the Medical Staff of the Cardiac Catheterization Effectiveness of video-based patient information before percutaneous cardiac interventions. J Cardiovasc Med (Hagerstown) 2007;8(5):348-353. PMID: 17443101
  1. Chhatriwalla AK, Amin AP, Kennedy KF, House JA, Cohen DJ, Rao National Cardiovascular Data Registry. Association between bleeding events and in-hospital mortality after percutaneous coronary intervention. JAMA 2013;309(10):1022-1029. DOI: 10.1001/jama.2013.1556
  2. Burzotta F, Mariani L, Trani C, Coluccia V, Brancati MF, Porto I, et al. Management and Timing of Access-Site Vascular Complications Occurring after Trans-Radial Percutaneous Coronary Circ Cardiovasc Interv 2015;8:e002863  DOI: 10.1161/CIRCINTERVENTIONS.115.002863
  3. Burzotta, F, De Vita M, Lefevre T, Tommasino A, Louvard Y, Trani, Radial Approach for Percutaneous Coronary Interventions on Chronic Total Occlusions: Technical Issues and Data Review. Catheter Cardiovasc Interv 2014;83(1):47-57 PMID: 23832527
  4. Batiha AM, Obead KA, Alhalaiqa FN, Kawafha MM, El-Razek, AA, Albashtawy M, et al. Quality of Life and Fatigue among Jordanian Cancer Iran J Public Health 2015;44(12):1704-1705 PMID: 26811823
  5. Corones K, Coyer FM, Theobald Exploring the information needs of patients who have undergone PCI. British Journal of Cardiac Nursing 2009;4(3):123-130. Available at: https://eprints.qut.edu.au/20857/1/c20857.pdf
  6. Zamanzadeh V, Jasemi M, Valizadeh L, Keogh B, Taleghani Effective factors in providing holistic care: A qualitative study. Indian J Palliative Care 2015;21(2):214-224 DOI: 10.4103/0973-1075.156506
  7. Belardinelli R, Paolini I, CianciG, Piva R, Georgiou D, Purcaro Exercise training intervention after coronary angioplasty: the ETICA trial. J Am Coll Cardiol 2001;37(7):1891-1900 PMID: 1140112

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