Lec. 2 Chronic Cardiovascular Dz

Blood Pressure/CO

• blood pressure = CO x SVR

• Cardiac output = HRxSV

stroke volume

volume of blood punmped by left ventricle per beat

HTN causes

• RAAS - expansion of extracellular fluid and inc. SVR

• inc. SNS activity

• dec. vasodilation of arterioles r/t vascular dysfxn of endothelium

• immune sys rxn cuasing inflammation and dysfxn

HTN - can cause

end organ damage

• HF, retinopathy, MI, TIA left ventricle hypertrophy, CVA, CKD, cardiomyopathy, aoritic disection, PAD

HTN - inc risk due too

• Age, CKD, DM, overweight, sleep apnea, alcohol, fam. hx, hyperlip, sedentary lifestyle, smoking, stress, old age, PAD

HTN - s/sx

• HA, dizzy, chest pain, nose bleed, fatigue, urinary output changes, blurred vision, numbness

HTN - elevated

SBP 120-129

DBP <80

HTN - Stage 1

SBP 130-139

DBP 80-89

and elevated BP on 2 seperate occasions

HTN - stage 2

SBP >140

DBP >90

HTN - Emergent hypertensive crisis

SBP >180

DBP >120

no signs of damage

HTN - URgent hypertensive crisis

SBP >180

DBP >120

• end organ damage, worsening organ damage, rebound HTN

HTN - labs

• CBC - underlying conditions

• Chem panel - electrolytes, liver enzymes (TSH, BUN, CR, UA, GFR)

• EKG

• Echo - valvular dz

• Chest Xray - enlarged heart

  • CT scan

Hypertensive Crisis - Urgent HTN what to do

• lower BP no more than 20% in first hour

• bring down to 160/100 in next 2-6hrs

• get it to normal BP in 24-48hrs

• monitor bp from then on

Acute on chronic HTN - Emergent HTN

d/t new or continued end organ damage or abrupt stop of BP meds

• treatment - find damaged oragand and lower BP

• aortic disecction - reduce SBP to 140 in 1hr w/ nifedipine, lobetalol, esmolol, nitro

HTN meds - First line

• thiazides

• ACE inhibitors - prils

• ARBs - artans

• CCBs - pines

HTN meds - second line

• loop diuretics

• K sparring diuretics

• MRAs - mineral receptor antagonists - aldosterone antagonists (sprinolactone)

• Beta blockers, renin inhibitors, alpha 1 blockers

• alpha 2 agonists -

• direct vasodilators

HTN - nuring interventions

• Dietitian - DASH diet

• edu. s/sx

• dec. Na (<2g/day)

• inc. K ( >500mg/day)

• encourage physical activty

• edu. alcohol, smoking danger

• teach about correct way take blood pressure

Heart Failure - what is it

• myocardial dz that impairs contraction of the heart (sytolic), and filling of heart (diastolic) causing pulmonary or systematic congestion

  • #1 rsn for hospitalization of ppl >65

  • chronic and progressive

HFpEF

• heart failure w/ preserved Ejection fraction - 50% or greater

• diastolic dysfxn

• ventricles cant relax d/t stiffness so unable to fill properly but still ejecting proper amount inc. pressure

HFmEF

• HF w/ mildly reduced ejection Fraction

• EF 41%-49%

HRrEF

• Heart failure with reduced ejection fraction - <40%

• systolic dysfxn

• L ventricle has improper contraction, cannot pump enough blood out

Systolic Dysfxn (HFrEF) - patho

1. dec, blood ejected from ventricle

2. compensate w/ epi/norepi release - inc. HR/contractility

3. dec. kidney perfusion cause Renin release

4. angio 1 converts to angio 2 inc. BP and SVR

5. angio 2 converts to Aldosterone (inc. Na and fluid retention)

6. inc. blood vol. = inc. preload, afterload and stress on heart

7. ANP and BNP release d/t stress on heart (overstretched myocardium)

8. inc. vasodilation and diuresis cause dec. contractility

9. inc. end diastolic vol of left ventricle

10. ventricular hypertrophy (cell remodeling) occurs

11. cause fibrotic heart muscles to cause diastolic dysfxn

Left sided HF - symptoms

• pulmonary congestion, dyspnea, cough, crackles, dec. O2 lvls, s3 heart sounds, orthopnea, fatigue

right sided HF - symptoms

• edema, hepatomegaly, ascites, JVD, weight gain, fatigue, SOB

Left and RIght sidede HF - risk factors

if pt has/does

• obesity, smoking, alcohol, DM, CAD, Cardiomyopathy, valve disorders, CKD w/ overload, afib

• #1 cause HTN

Heart Failure - gerentological considerations

• Inc. BP

• Inc. ventricular wall thickness

• inc. myocardial fibrosis

• inc. heart valve calcification

• CKD that can be diuretic resitant

• urinary retention in males

Heart Failure - Labs

• BNP, troponin, lipid panel

• CBC - underlying conditions

• Chem panel - electrolytes, liver enzymes (TSH, BUN, CR, UA, GFR)

• EKG

• Echo - valvular dz

• Chest Xray - enlarged heart

• CT scan

heart failure - Medicaitons

• SGLT2 inhibitors - dec. preload, afterload and progression

• MRAs - diuretic

• ARNIS - renin angio blockers

• Beta Blockers

• Beta adrenergic blockers

Heart failure - acute on chronic manifestations - Flash pulmonary edema

inc. dyspnea, pink frothy sputum, cyanosis, shock, possible intubation

exacerbation has rapid symptom progression

• causes: Afib, MI, Pneumonia, HTN crisis, poor diet, noncompliant

Heart failure - acute on chronic manifestations - embolism

• s/sx: JVD, dec. Heart sounds, dec. BP, tachycardia

  • untreated leads to cardiac tamponade (dec. BP w/ inhalation)

• Treatment: pericardiocentesis

Advnaced Heart failure - interventions

• internal cardiac defibrillator - for inc. arrythmias

• IV drips - milrinone, dobutamine, dopamine

• biventricular pacemaker - synchronizes contraction of ventricles

• Ventricular assist device - while waiting for heart translpant

Heart failure - interventions

same as HTN except:

• teach pt when to seek treatment

• teach daily weights

• monitor intake, output, O2 furestriciton

• watch for signs of worsening

• teach about med compliance

• dietician to teach low Na, low fat

• dec. anxiety, inc. activity

Afib - patho

structural or electrophysical abnormalities alter atrial tissue causing rapid disorganized twitching of atrial musculature

• causes many atrial contractions before going into ventricle

• accessory electrical conduction pathways

• impulses may be initiated by pulmonary veins

• atrial rate = 300-600, ventricular rate = 120-200

• dec. cardiac output by 25-30%, dec. ventricular filling

Afib - risk factors

• HF, alcohol, age, MI, HTN, cardiac surgery, DM, family history, OSA, obesity, smoking, valve dz

AFIB - risks if sustained

• thrombi, ischemia of left atrium, mitral valve dysfxn, mitral regurgitation, conduction delays in ventricle, ventricular cardiomyopathy

AFIB - long term risks

MI, CVA, HF

AFIB - symptoms

• HR >150

  • dizzy, chst pain, palpitations, fatigue, SOB, syncope

Afib - treatment

depends on rate and patients symptoms

stable patient w/ Afib > 48hrs

• anticoagulation before restoring rhythym and PO meds - dofetilide preferred

Afib - intervention if unstable afib and no anticoagulants

• TEE - look for clots, keep npo 4hrs

• cardioversion

• 4 weeks of anticoagulants

• cath ablation, EPS studies - if recurring

• maze procedure

• watchmen device - device placed in left atrial appendage sealing it off to prevent clots

Afib - most commone site of thrombus

left atrial appendage

Afib - patient education

• s/sx of afib

• how to check pulse

• anticoagulant therapy

• med adherence

• s/s of MI or stroke