Module 4 Cardiovascular Disorders

Left Ventricular Failure

Most common type of heart failure; failure of the left side leads to pulmonary congestion and pressure, causing dyspnea, orthopnea, and paroxysmal nocturnal dyspnea

Right Ventricular Failure

Type of heart failure often caused by left ventricular failure; leads to venous congestion of body organs, peripheral edema, ascites, JVD, and hepatomegaly

HFrEF (Systolic Failure)

Heart failure characterized by a problem with contraction and ejection; results in decreased ventricular output, low ejection fraction, and thin/weak heart muscle; associated with S3 gallop

HFpEF (Diastolic Failure)

Heart failure characterized by a problem with relaxing and filling; stiff/thick heart muscle resists filling; normal ejection fraction; associated with S4 gallop

Systolic Heart Failure Pathophysiology

Low output triggers baroreceptors to stimulate SNS → increased HR and contractility → natriuretic peptides released → increased workload → decreased contractility → ventricular dilation

Diastolic Heart Failure Pathophysiology

Cardiac cells die during systolic HF → muscle becomes fibrotic → stiff ventricle resists filling → less blood in ventricles → decreased CO → increased cardiac workload

Congestive Heart Failure

Pulmonary congestion from diastolic failure; increased pulmonary venous pressure forces fluid into alveoli causing pulmonary edema; signs include dyspnea, crackles, low O2 sat, and S3 heart sound

Risk Factors for Heart Failure

Older age, cigarette smoking, obesity, poorly managed diabetes, metabolic syndrome, and chronic kidney disease

HF Clinical Manifestations: Congestion

Dyspnea/orthopnea/PND, cough, crackles not clearing with cough, rapid weight gain, dependent edema, abdominal bloating, ascites, JVD, sleep disturbances, fatigue

HF Clinical Manifestations: Low Cardiac Output

Decreased exercise tolerance, muscle wasting, weakness, anorexia/nausea, lightheadedness, confusion/AMS, tachycardia at rest, oliguria, cool/vasoconstricted extremities, pallor/cyanosis

HF Diagnosis

History and physical, echocardiogram (EF and ventricle sizes), chest x-ray, EKG, labs (cardiac enzymes and BNP), stress test, cardiac catheterization

HF Management

Identify and eliminate risk factors, patient education on medications (digoxin, diuretics, ACEI, beta blockers, vasodilators), cardiac rehabilitation, low-sodium/low-fat/low-cholesterol diet, daily weight monitoring

HF Goals of Therapy

Improve cardiac function, reduce symptoms, improve functional status, stabilize condition, lower hospitalization risk, delay HF progression, extend life expectancy, promote cardiac-healthy lifestyle

HF Gerontologic Considerations

May present atypically (fatigue, weakness, somnolence); decreased renal function; resistant to diuretics; more sensitive to volume changes; older men need surveillance for bladder distention with diuretic use

Hypertension Definition

Chronic condition of elevated blood pressure within arteries; normal BP is ~120/80 mmHg; can lead to heart disease, kidney damage, and stroke; classified as primary, secondary, or malignant

Hypertension Stages

Healthy:

Primary Hypertension

No single cause; accounts for 90-95% of cases; risk factors include aging, family history, African American race, sedentary lifestyle, smoking, alcohol, and hyperlipidemia

Secondary Hypertension

Result of another condition; accounts for 5-10% of cases; precipitating conditions include cardiovascular disorders, renal disease, endocrine diseases, pregnancy, and medications

White Coat Hypertension

High office BP with normal home or ambulatory BP readings

Masked Hypertension

Normal office BP with high home or ambulatory BP readings

Hypertension End-Organ Damage

Cerebrovascular (encephalopathy, stroke, dementia, retinopathy), vasculopathy (atherosclerosis, aortic aneurysm), heart disease (LVH, CAD, MI, HF, A-fib), nephropathy (proteinuria, renal failure)

Non-Pharmacological HTN Interventions

Weight reduction, dietary sodium restriction (2g/day), reduce alcohol and caffeine, exercise, smoking cessation, stress reduction, regular BP monitoring

Hypertensive Urgency

BP >180/120 mmHg with no evidence of immediate or progressive end-organ damage; treated pharmacologically; goal to normalize BP within 24-48 hours

Hypokalemia

Low blood potassium caused by loop/thiazide diuretics, vomiting/diarrhea, or poor dietary intake; symptoms include muscle weakness, cramps, fatigue, constipation, arrhythmias; complications include respiratory failure and cardiac arrest

Hyperkalemia

High blood potassium caused by kidney dysfunction, excessive intake, or potassium-sparing diuretics/ACE inhibitors; symptoms include muscle weakness, fatigue, nausea, arrhythmias; complications include cardiac arrest and muscle paralysis

HTN Older Adult Considerations

Isolated systolic hypertension due to loss of vessel elasticity; difficult to treat; polypharmacy challenges; increased risk of orthostatic hypotension; include family/caregivers in education

Coronary Atherosclerosis

Accumulation of fatty plaque on artery walls; blocks and narrows coronary vessels; ischemia occurs when left main artery is reduced by 50% or any vessel by 75%; goal is to alter disease progression

Coronary Artery Disease (CAD)

Narrowing/obstruction of one or more coronary arteries from atherosclerosis; causes decreased myocardial perfusion; leads to hypertension, angina, dysrhythmias, MI, HF, and death; collateral circulation develops

CAD Modifiable Risk Factors

BMI >30, diabetes mellitus, hypertension, alcohol use, high LDL/low HDL, tobacco use

CAD Non-Modifiable Risk Factors

Age 65+, genetic predisposition/family history

CAD Diagnostic Testing

ECG (ST depression = ischemia; ST elevation = infarction), lipid profile (LDL vs HDL), stress test, cardiac catheterization

CAD Prevention and Treatment

Tobacco cessation, manage HTN, low-calorie/sodium/cholesterol/fat diet with increased fiber, control diabetes, reduce stress, reduce alcohol, pharmacological management

Angina Pectoris

Chest pain from myocardial ischemia due to imbalance between oxygen demand and supply; caused by atherosclerosis or arterial spasm; types include stable, unstable, and variant (Prinzmetal)

Stable Angina

Caused by myocardial atherosclerosis; exertional pain lasting 5-10 min; aggravated by exercise, cold, or stress; follows a predictable pattern; relieved by rest; treated with nitrates, beta blockers, CCBs, aspirin

Unstable Angina

Caused by ruptured/thickened plaque with thrombus; increasing intensity/frequency/duration; occurs at rest or minimal activity; lasts >15 min; unresponsive to NTG; treated with O2, nitrates, beta blockers, clopidogrel, aspirin, statins, tPA

Variant (Prinzmetal) Angina

Caused by coronary vasospasm; strongly associated with cocaine and smoking; occurs at rest; transient ST elevation during pain; may have AV block or ventricular arrhythmias; treated with smoking cessation and CCBs

Angina Acute Interventions

Pain assessment, IV access, oxygen, vital signs, continuous ECG monitoring (within 10 min), nitroglycerin, bed rest in semi-Fowler's position, anxiety reduction

Peripheral Arterial Disease (PAD)

Decreased blood flow toward tissue; creates ischemia below occlusion; signs include diminished/absent pulses, stabbing pain, intermittent claudication, hair loss, dry/scaly skin, cold/gray-blue skin, elevational pallor

Venous Insufficiency

Prolonged venous hypertension stretches veins and damages valves; decreased blood flow toward heart; signs include edema, brown ankle discoloration, stasis ulcers, cellulitis; pulses are present

Ankle-Brachial Index (ABI)

Ratio of ankle to brachial blood pressure; ≥1.0 = normal; 0.9-0.99 = borderline PAD; 0.7-0.89 = mild PAD; 0.5-0.69 = moderate PAD;

PAD Nursing Interventions

Do not elevate above heart; walk to claudication then rest; avoid leg crossing, cold exposure, caffeine, tobacco; never apply direct heat to limbs; daily foot hygiene and skin inspection

PAD Treatment

Antiplatelet therapy (ASA, clopidogrel), Cilostazol (phosphodiesterase III inhibitor), high-dose statins; endovascular (angioplasty ± stent, atherectomy); surgical (bypass grafts)

Venous Insufficiency Nursing Interventions

Compression stockings (may be lifelong), avoid prolonged sitting/standing and leg crossing, avoid constrictive clothing, elevate legs above heart 10-20 min every few hours, use SCDs

Arterial Ulcer Characteristics

Punched-out, deep wound; round shape; thin, shiny, dry skin; located on toes/feet; associated with PAD

Venous Ulcer Characteristics

Leg swelling; dark red/purple/brown hardened skin; torn skin near ankle; scaling and redness near wound; usually wet; associated with venous insufficiency

Raynaud's Phenomenon

Vasospasm of arterioles causing constriction of cutaneous vessels; risk factors include female gender, tobacco use, cold temperature, and stress; affects fingers, toes, ears, cheeks; signs include blanching, cyanosis, numbness, and redness on relief

Raynaud's Nursing Interventions

Monitor pulses and skin integrity, administer vasodilators/CCBs, avoid triggers, encourage warm clothing/gloves/socks, use warm (not hot) water during attacks, advise smoking cessation, prevent hand/finger injuries

Lymphedema

Primary or secondary increased lymph due to lymphatic vessel obstruction; worse in dependent position; treated with compression stockings, manual lymphatic drainage, physiotherapy, and skin care

Ulcer Treatment: Compression Therapy

Used when ABI >0.80 is confirmed; compression up to 40 mmHg can be applied; contraindicated in arterial insufficiency

Ulcer Treatment: Debridement

Removes wound exudate and nonviable tissue; disrupts biofilm to allow antimicrobial penetration; contraindicated in gangrene, arterial insufficiency, and amputation cases

Gerontologic Vascular Considerations

Aging causes blood vessel wall changes; vessels stiffen leading to increased peripheral resistance, impaired blood flow, and increased left ventricular workload