Heart Failure, DVT, PE, and ACS: Diagnostic Tests and Management

Diagnostic tests for heart failure

BNP, echocardiogram, chest X-ray, ECG, cardiac enzymes, hemodynamic monitoring.

Echocardiogram in heart failure

It measures the ejection fraction and identifies structural or functional heart abnormalities.

Elevated BNP

BNP (B-type natriuretic peptide) increases when the heart is under stress from volume or pressure overload — indicating heart failure.

Significance of ejection fraction (EF)

EF measures how much blood the left ventricle pumps out with each beat; low EF (<40%) indicates systolic dysfunction.

Normal ejection fraction range

55-70%

Major risk factors for heart failure

Hypertension, CAD, MI, diabetes, obesity, smoking, valvular disease, and advanced age.

Systolic heart failure

The heart cannot contract effectively → decreased EF and cardiac output.

Diastolic heart failure

The heart cannot relax or fill properly → normal EF but reduced filling and cardiac output.

Causes of left-sided heart failure

Hypertension, CAD, MI, valvular disease (mitral/aortic).

Clinical manifestations of left-sided HF

Dyspnea, orthopnea, crackles, pulmonary congestion, cough, frothy sputum, fatigue.

Causes of right-sided heart failure

Left-sided HF, pulmonary hypertension, COPD, or cor pulmonale.

Clinical manifestations of right-sided HF

Peripheral edema, ascites, jugular vein distention (JVD), hepatomegaly, weight gain.

Cor pulmonale

Right-sided HF caused by chronic lung disease or pulmonary hypertension.

NYHA functional classifications for HF

Class I: No limitation of physical activity; Class II: Slight limitation with ordinary activity; Class III: Marked limitation with minimal activity; Class IV: Symptoms at rest.

Signs of fluid volume overload (congestive HF)

Edema, crackles, weight gain, JVD, ascites, dyspnea, decreased urine output.

Medications commonly used for HF

ACE inhibitors, ARBs, beta-blockers, diuretics, digoxin, vasodilators, nitrates.

Patient education for HF management

Monitor daily weight (report gain of >2-3 lb in a day or 5 lb in a week); Limit sodium & fluid intake; Take medications as prescribed; Report worsening symptoms (dyspnea, swelling, fatigue); Balance rest and activity.

Lifestyle modifications to prevent HF progression

Quit smoking, control BP and diabetes, maintain healthy weight, reduce alcohol, exercise as tolerated.

Use of diuretics in HF

To decrease fluid volume and reduce pulmonary/peripheral congestion.

Nursing interventions for HF patients

Daily weights, monitor I&O, assess lung sounds, elevate HOB, restrict fluids/sodium, and educate on medication adherence.

Risk factors for developing a DVT

Prolonged immobility, surgery (especially orthopedic), obesity, pregnancy, oral contraceptives, smoking, cancer, trauma, heart failure, and varicose veins.

Virchow's Triad

The three factors that lead to thrombosis: 1. Venous stasis 2. Endothelial injury 3. Hypercoagulability

Clinical manifestations of DVT

Unilateral leg swelling, warmth, redness, tenderness, pain, and positive Homan's sign (not routinely used).

Complications of an untreated DVT

Pulmonary embolism, chronic venous insufficiency, and post-thrombotic syndrome.

Clinical manifestations of a pulmonary embolism (PE)

Sudden dyspnea, chest pain, tachypnea, tachycardia, anxiety, hemoptysis, and hypoxia.

Laboratory tests to diagnose DVT

D-dimer (elevated in presence of clot), CBC, coagulation studies (PT/INR, aPTT).

Diagnostic tests to confirm DVT

Venous Doppler ultrasound and venography.

Diagnostic tests to confirm PE

CT pulmonary angiography (gold standard), V/Q scan, chest X-ray, ECG, and ABGs.

Purpose of anticoagulant therapy in DVT/PE

To prevent clot extension and formation of new clots — does *not* dissolve existing clots.

Common anticoagulant medications used

Heparin, enoxaparin (Lovenox), and warfarin (Coumadin); sometimes direct oral anticoagulants like apixaban or rivaroxaban.

Heparin's therapeutic goals and monitoring parameters

Monitor *aPTT* (therapeutic range 1.5-2.5× normal); monitor for bleeding and platelet count (risk for HIT).

Warfarin's therapeutic monitoring test

PT/INR; therapeutic INR usually *2-3*.

Antidotes for common anticoagulants

Heparin → *Protamine sulfate; Warfarin → Vitamin K; DOACs (like apixaban) → Andexanet alfa*.

Adverse effects of anticoagulant therapy

Bleeding, bruising, hematuria, melena, nosebleeds, and thrombocytopenia (especially with heparin).

Patient education for anticoagulant therapy

Avoid NSAIDs and aspirin unless prescribed; Use a soft toothbrush and electric razor; Report bleeding/bruising immediately; Keep consistent vitamin K intake (if on warfarin); Regular INR checks.

Risk of a pulmonary embolism (PE)

It can block pulmonary circulation, leading to impaired gas exchange, right heart strain, hypoxia, and sudden death.

How a PE occurs

A thrombus from a DVT (usually in the leg) breaks off and travels to the pulmonary artery, obstructing blood flow to the lungs.

Nursing interventions for a patient with DVT

Elevate the affected leg; Apply compression stockings (if ordered); Encourage ambulation and hydration; Do not massage the leg; Monitor for PE symptoms.

Preventive measures to reduce DVT risk in hospitalized patients

Early ambulation, leg exercises, compression devices, and prophylactic anticoagulants (like heparin or enoxaparin).

ABG findings typically seen in PE

Respiratory alkalosis (low PaCO₂) due to hyperventilation, followed by hypoxemia.

Acute Coronary Syndrome (ACS)

A group of conditions caused by sudden, reduced blood flow to the heart due to plaque rupture and thrombus formation.

Types of ACS

Unstable Angina (UA), Non-ST-Elevated Myocardial Infarction (NSTEMI), ST-Elevated Myocardial Infarction (STEMI)

Pathophysiology of ACS

Plaque in a coronary artery ruptures → platelets adhere → thrombus forms → reduced or blocked blood flow → myocardial ischemia or infarction.

Major Risk Factors for ACS

Hypertension, hyperlipidemia, smoking, diabetes, obesity, sedentary lifestyle, family history, stress, male gender, and advanced age.

Clinical Manifestations of ACS

Chest pain/pressure (may radiate to arm, jaw, or back), diaphoresis, nausea, dyspnea, anxiety, fatigue, and palpitations.

Presentation of Unstable Angina

Chest pain that occurs at rest or with minimal exertion, is unpredictable, and not relieved by rest or nitroglycerin.

Causes of Unstable Angina

Partial occlusion of a coronary artery by a thrombus — ischemia without myocardial necrosis.

NSTEMI

A non-ST-elevated myocardial infarction caused by partial occlusion of a coronary artery leading to myocardial injury.

NSTEMI vs Unstable Angina

Both may have similar symptoms, but NSTEMI shows elevated cardiac biomarkers (troponin, CK-MB) indicating myocardial damage.

ECG Changes in NSTEMI

ST-segment depression or T-wave inversion (no ST elevation).

STEMI

A complete occlusion of a coronary artery causing full-thickness myocardial infarction with ST elevation on ECG.

ECG Changes in STEMI

ST-segment elevation in two or more contiguous leads; possible development of pathologic Q waves later.

Diagnostic Tests for ACS

12-lead ECG (to classify ACS type), Cardiac biomarkers (troponin I/T, CK-MB), Echocardiogram (wall motion abnormalities), Coronary angiography (to locate blockage).

Cardiac Marker Specific for Myocardial Infarction

Troponin I/T — rises within 3-6 hours, peaks at 12-24 hours, remains elevated 7-10 days.

Initial Treatment for Suspected ACS

MONA-B: Morphine (for pain), Oxygen (if hypoxic), Nitroglycerin (vasodilator), Aspirin (antiplatelet), Beta-blocker (reduce workload).

Additional Treatment Options for ACS

Anticoagulants (heparin, enoxaparin), Antiplatelets (clopidogrel, ticagrelor), Thrombolytics (for STEMI if PCI unavailable), Percutaneous Coronary Intervention (PCI), CABG (if multiple vessel disease).

Indication for Thrombolytic Therapy

For STEMI when PCI cannot be performed within 90 minutes of arrival.

Contraindications to Thrombolytic Therapy

Recent surgery, active bleeding, hemorrhagic stroke, or uncontrolled hypertension.

Patient Education Post-ACS

Take all prescribed medications (antiplatelets, beta-blockers, statins, ACE inhibitors), Avoid smoking and alcohol, Eat a low-fat, low-sodium diet, Gradually increase activity as tolerated, Attend cardiac rehabilitation, Recognize and report recurrence of chest pain.

Goals of ACS Management

Restore coronary blood flow, Reduce myocardial oxygen demand, Prevent further clot formation, Minimize myocardial damage, Prevent complications like HF or dysrhythmias.

Complications After Myocardial Infarction

Heart failure, cardiogenic shock, dysrhythmias, pericarditis, ventricular aneurysm, and reinfarction.

Difference Between Stable and Unstable Angina

Stable: Predictable, occurs with exertion, relieved by rest/nitro. Unstable: Unpredictable, occurs at rest, not relieved by rest/nitro — medical emergency.

Quit smoking

A lifestyle change recommended for patients with ACS.

Eat a heart-healthy diet

A diet low in fat and sodium, and high in fiber, recommended for ACS patients.

Maintain a healthy weight

A lifestyle change that involves keeping body weight within a healthy range for ACS patients.

Exercise regularly

Engaging in physical activity as prescribed by the provider or cardiac rehab team for ACS patients.

Manage stress

Using relaxation or mindfulness techniques to cope with stress for ACS patients.

Gradually increase activity

A guideline for ACS patients to increase physical activity under supervision, particularly during cardiac rehab.

Avoid heavy lifting or strenuous exercise

A guideline for ACS patients to refrain from such activities until cleared by a healthcare provider.

Rest when tired

A guideline for ACS patients to balance rest with activity.

Goals of patient education for ACS

To prevent another cardiac event, improve medication adherence, promote healthy lifestyle choices, encourage early recognition of symptoms and appropriate response, and support emotional recovery and confidence in self-care.

cardiovascular system

To deliver oxygen and nutrients to tissues and remove waste products via blood circulation.

four chambers

Right atrium, right ventricle, left atrium, left ventricle.

deoxygenated blood

The right side of the heart pumps deoxygenated blood to the lungs (right atrium → right ventricle → pulmonary artery).

oxygenated blood

The left side of the heart pumps oxygenated blood to the body (left atrium → left ventricle → aorta → systemic circulation).

four heart valves

Tricuspid valve - between right atrium & ventricle, Pulmonic valve - between right ventricle & pulmonary artery, Mitral (bicuspid) valve - between left atrium & ventricle, Aortic valve - between left ventricle & aorta.

function of heart valves

To ensure one-way blood flow through the heart and prevent backflow.

lub-dub heart sounds

"Lub" (S1): Closure of mitral and tricuspid valves. "Dub" (S2): Closure of aortic and pulmonic valves.

three layers of an artery or vein

1. Tunica intima (inner endothelial layer), 2. Tunica media (smooth muscle layer), 3. Tunica externa (adventitia) (outer connective tissue).

importance of the endothelial layer

Regulates vasodilation/vasoconstriction (via nitric oxide release), prevents clot formation by producing anticoagulant substances, controls permeability and inflammation, damage to this layer contributes to atherosclerosis (plaque buildup).

arteries vs veins

Arteries have thicker tunica media (more smooth muscle and elastic tissue). Veins have valves to prevent backflow and thinner walls (lower pressure system).

blood movement through veins

Skeletal muscle contraction, venous valves, and changes in thoracic pressure during breathing.

arteries supplying blood to the heart muscle

Coronary arteries supply blood to the heart muscle.

right and left coronary arteries

Branches of the aorta.

left coronary artery (LCA)

Branches into Left anterior descending (LAD) which supplies anterior wall and septum, and Circumflex artery which supplies left atrium and lateral wall of left ventricle.

right coronary artery (RCA)

Supplies right atrium, right ventricle, inferior wall of left ventricle, and SA/AV nodes.

ischemia

Condition where blood flow to the myocardium is reduced.

myocardial infarction

Also known as a heart attack.

blood pressure (BP)

The force of blood pushing against artery walls as the heart contracts and relaxes.

systolic pressure

Pressure during heart contraction.

diastolic pressure

Pressure during heart relaxation.

normal blood pressure values

Less than 120/80 mmHg.

American Heart Association (AHA) stages of hypertension

Normal: <120 / <80 mmHg, Elevated: 120-129 / <80 mmHg, Stage 1 HTN: 130-139 / 80-89 mmHg, Stage 2 HTN: ≥140 / ≥90 mmHg, Hypertensive crisis: ≥180 / ≥120 mmHg.

hypertension

Called the 'silent killer' because it often has no symptoms but causes long-term damage to the heart, kidneys, brain, and eyes.

uncontrolled hypertension complications

Stroke, myocardial infarction, heart failure, kidney disease, and retinopathy.

non-pharmacologic treatments for hypertension

Low-sodium, DASH diet; Weight loss; Exercise (30 min most days); Limit alcohol, quit smoking; Manage stress.

common antihypertensive medications

Diuretics (e.g., hydrochlorothiazide), ACE inhibitors (e.g., lisinopril), ARBs (e.g., losartan), Beta-blockers (e.g., metoprolol), Calcium channel blockers (e.g., amlodipine).

patient education for hypertension management

Check BP regularly; Adhere to prescribed meds; Avoid high-sodium and processed foods; Don't stop meds suddenly (rebound hypertension risk); Report dizziness or persistent cough (ACE inhibitors).

cholesterol (lipid panel)

Measures the amount of fat in the blood to assess the risk for atherosclerosis and coronary artery disease (CAD).

total cholesterol

Less than 200 mg/dL