Adult II Module 8 Cardiovascular Part II - Chest Pain, Coronary Artery Disease, Carotid Artery Disease, Heart Failure

U.S Heart Disease Statistics

Heart Disease (HD) is the leading cause of death in the U.S.

• Projection for 2035: 45.1% U.S. population will have some form of HD

Estimated direct & indirect cost:

• Direct costs $318 billion to $749 billion

• Indirect costs $237 to $368 billion

   

Physiological Changes in the Heart w/Aging

Structural & physiological changes include...

• Decreased capacity to endure stress

• Limited functional reserve

• Maximum HR decreases

• Fat deposits in the sinoatrial (SA) node

• Pacemaker cells decrease as we age

• Baroreceptors are less sensitive (aorta & carotid sinus) leading to a blunted response with BP changes

• Maximum HR decreases approx. 30% between ages 20 & 80

• Cardiac dilation & increased stroke volume compensate somewhat for the diminished HR during exercise

Key Symptoms for CV Assessment

• Dizziness

• Syncope

• Palpitations

• Dyspnea/Dyspnea on Exertion

• Angina

• Chest Pain

• Edema

• Claudication

• Baseline ADLs and IADLs

• Onset, location, duration, characteristics, aggravating & relieving factors, timing (s/s @ rest or w/ activity)

• Chest pain may present as heartburn or indigestion, jaw pain

• SOB is a common symptom of an acute coronary event

Atypical Presentation of MI includes vague symptoms...

• Nausea & vomiting

• Decreased ADL status/fatigue w/o chest pain (women & diabetes)

Chest Pain

• Provoked by physical exertion

• Provoked by eating a heavy meal

Pain may radiate:

• Jaw

• Left arm

• Both arms

• Left side of neck

• Back pain

Other symptoms:

• Diaphoresis

• Elderly, Females, & Diabetics often may have an atypical presentation: SOB, DOE, weakness, N&V, fatigue, syncope

Acute Coronary Syndrome (ACS)

Plaque rupture or erosion with thromboses (true medical emergency)

1. ST Elevation Myocardial Infarction (STEMI)

• Q wave M

• Transmural MI (full thickness injury)

2. Non-ST Elevation MI (NSTEMI)

• non Q wave MI

• Subendocardial MI (partial thickness injury)

  3. Unstable Angina

ACS Symptomatology

• Gradual onset of intense chest pain

• Steady chest pain

• Substernal discomfort

• Squeezing, Crushing, Tightness, Band-like

• Pain or discomfort at rest

• Angina relieved by Nitroglycerin or Rest

• Pain can radiate to the jaw, arm, back

• May be provoked by physical activity emotional upset, or heavy meal

Acute Coronary Syndrome (ACS): Physical Exam

• Diaphoresis

• Palpitations

• SOB

• Watch for atypical presentations such as indigestion, nausea/vomiting, new onset fatigue

STEMI EKG Criteria

New ST elevation @ J point in 2 contiguous leads of ≥ 1 mm (0.1 mV) In any of the leads other than leads V2-V3

Leads V2-V3

• ≥2mm (0.2 mV) in men ≥40 years

• ≥2.5mm (0.25 mV) in men <40 years

• ≥1.5mm (0.15 mV) in women regardless of age

Presence of reciprocal ST depressions confirms STEMI

NSTEMI EKG Criteria

• New ST segment depressions 0.5 mm or greater in 2 contiguous leads

• T wave inversions 1 mm or greater in 2 contiguous leads

STEMI Examples

EKG Examples

Lateral wall NSTEMI vs inferior wall STEMI

Anterior Wall MI/Anterior STEMI

• Most common

• Most serious type

• ST segment elevation in V2-V4

• QRS looks like a tombstone

• Q waves

Outpatient Treatment-Activate EMS & ASA

• Cardiac catheterization w/intervention (angioplasty & stenting)

• Bare Metal Stent (1-3 months of dual antiplatelet therapy); Drug eluting Stent (DES)--1 year dual antiplatelet therapy (Plavix plus ASA; Brilinta plus ASA)--ASA indefinitely

• Coronary Artery Bypass Graft (veins or arterial grafts)

• Vein grafts do not last as long as Arterial grafts

• Some coronary arteries are not amenable to revascularization

• Medical Management: Beta blockers (BB), Statin, Antiplatelet therapy, Long acting Nitrates, NTG (SL q. 5 min. x 3 doses), Calcium Channel Blockers (CCB); diabetes, lipid, & HTN control; LV dysfunction: Diuretics, Entresto, ACEi or ARB if does not tolerate ACEi

The Widowmaker Heart Attack

Fixing the Widowmaker

PCI vs. CABG

Coronary Artery Disease: Patient Education/Health Promotion

• Discuss disease process and consequences

• Educate about CAD and heart attack warning signs

• Understand importance of calling 911 or an ambulance if symptoms occur

  • Chest pressure/discomfort, pain radiating to the arm/neck/jaw, diaphoresis, N/V, SOB, dizziness, rapid/irregular pulse, LOC

• Review instructions for taking aspirin and NTG

• Ongoing follow-up, medication adherence, lifestyle modification

Carotid Disease

• Stenosis is the narrowing of the arteries

  • Atherosclerotic disease

  • Extra-cranial arteries

  • Highest prevalence in older adults, HTN, heart disease

Asymptomatic

• No symptoms

• Nonspecific symptoms

Symptomatic

• Focal neurologic signs: contralateral weakness of the face, arm, leg or both. Contralateral paresthesia of the face, arm, leg or both

• If the right cerebral hemisphere is involved patient may have signs of neglect, visual or sensory extinction

• If the left cerebral hemisphere is involved can see aphasia, anomia, agraphesthesia

• TIA

• Ischemic stroke

• May be a range of other subtle BUT enduring signs

Carotid Disease: Physical Exam and Diagnostics

• Assess for signs of stroke

• Assess the carotids for bruit

• Duplex ultrasound is the first-line diagnostic tool

• Alternate diagnostic testing may include CT angiography (CTA), magnetic resonance angiography (MRA) if US cannot be done or inconclusive or if the severity of the stenosis and the presence of intrathoracic or intracranial vascular lesions need to be identified

• CBC, CMP, Lipid panel, Coags, cardiac enzymes/markers

Carotid Disease: Medical Management

• Statin: to get LDL < 100

• Control BP

• Antiplatelets (for symptomatic carotid stenosis): ASA and Plavix (Clopidogrel)

Carotid Disease: Surgical Therapy

Carotid Endarterectomy (CEA)

• American Heart Association collaborative guidelines recommend CEA within 6 months for patients with symptomatic carotid stenosis. Criteria for CEA include:

(1) average to low surgical risk

(2) reduction of the diameter of the lumen of the ipsilateral ICA by more than 70% as measured by noninvasive imaging, or more than 50% as measured by catheter angiography

(3) an anticipated rate of perioperative stroke or mortality of less than 6%

Carotid Disease: Interventional Therapy

Carotid angioplasty and stenting

• Involves retrograde arterial catheterization, traditionally through a femoral approach

• A series of stents and catheters are deployed. Angioplasty is performed to ensure safe passage of the stent using a balloon

• The collaborative AHA guidelines recommend CAS only for symptomatic patients who meet the following criteria

(1) average or low risk of complications associated with

     endovascular intervention

(2) narrowing of the arterial lumen of more than 70% as shown by noninvasive imaging, or more than 50% as demonstrated by catheter angiography

(3) risk of periprocedural stroke or death below 6%

Carotid Disease: Patient Education/Health Promotion

• Discuss the pathogenesis and consequences

• Risk factor reduction

• Ongoing follow-up

• Medication adherence

• Lifestyle modification

• Smoking cessation

U.S. Heart Failure Statistics (CDC)

• About 6.7 million adults in the United States have heart failure

• In 2022, heart failure was mentioned on 457,212 death certificates (13.9% of all causes of death)

• Heart failure costs the nation an estimated $30.7 billion in 2012. This total includes the cost of health care services, medicines to treat heart failure, and missed days of work

Heart Failure

Caused by myocardial structural or functional damage resulting in the heart’s inability to eject enough blood to maintain tissue perfusion

Preload and afterload

2 Types of Heart Failure

Heart Failure with preserved left ventricular ejection fraction> 40%

(formerly called diastolic heart failure)

• Due to stiff ventricles

Heart Failure with reduced left ventricular ejection fraction <40%

(formerly called systolic heart failure)

• Due to a decreased ability of the left ventricular to eject blood

Heart Failure Contributing Factors

• CAD & HTN

• MI, CAD

• Valvular heart disease

• Dysrhythmias (A. Fib loss of ⅓ cardiac output)

• Diabetes

• COPD

• Obstructive Sleep Apnea

• Fluid volume overload

• Hypo/Hyperthyroidism

HF Signs & Symptoms: Left

Left Ventricular Failure

• Dyspnea on exertion (DOE)

• Orthopnea

• Paroxysmal nocturnal dyspnea(PND)

• Dry cough

• Peripheral edema

• Decreased breath sounds

• May hear crackles or rales on exam

• Fatigue

HF Signs & Symptoms: Right

Right Ventricular Failure

• Ascites, hepatosplenomegaly

• Weight gain

• N/V

• Tachycardia

• Lower extremity edema

• JVD, rales, decreased oxygenation

• Fatigue

Heart Failure Diagnostic Testing

• EKG

• Echocardiography

• Weight checks

• Chest X-Ray

• Labs: Brain Natriuretic Peptide (BNP), CBC, CMP, TSH, cardiac enzymes

Heart Failure Treatment

HF treatment is targeted at symptom management & the treatment of causative disease processes

• If decompensated or signs of hemodynamic instability, send to ED

• Ace inhibitors for systolic HF, Angiotenstion receptor-neprilysin inhibitor (ARNI)- Sacubitril/Valsartan (Entresto)

• Beta Blockers (Metoprolol, Carvedilol, & Bisoprolol); Digoxin

• Diuretics to reduce volume overload(loop diuretics more effective); Spironolactone (potassium sparing diuretic)

• Reduced NA intake

• Daily weights (wt. gain 2-4 lbs/1 week)

• Flu & pneumonia vaccinations

• Mild aerobic exercise increases functional capacity; discourage alcohol & tobacco use

• Comanagment with cardiology or heart clinic

Entrestro (Valsartan/Sacubutril) (ARB/Neprilysin Inhibitor [ARNI])

ARNI therapy is the preferred vasodilating agent in patients with HFrEF

Barriers to starting Entresto:

• Clinical decompensation or deterioration

• Systolic BP < 100 mmHg

• Serum potassium > 5 mmol/L

• eGFR < 30 mL/min/1.73m2

• History of angioedema

Heart Failure Stages

Heart Failure Classification