Clin App 2- exam 2

Coronary Artery Disease effects

Perfusion

Coronary Artery Disease Perfusion results in

O2 demand higher than supply

CAD defined

blood vessel disorder, generalized as atherosclerosis

atherosclerosis

hardening of the arteries

atheroma

fatty deposits in the coronary arteries (CAD)

CAD patho 

• caused by atherscleosis mostly

• characterized by lipid deposits within intima of artery

• endothelial injury and inflammation

Stages of Atherosclerosis

• chronic endothelial injury

• fatty streak 

• fibrious plaque 

• complicated lesion

C reactive Protein

• marker of inflammation

• increased in CAD patients

• chronic exposure to CRP associated with unstable plaques and oxidation of LDL cholestrol

Collateral Circulation

• arterial anastomoses within coronary circulation 

non modifiable risk factors for CAD

• age

• gender 

• ethnicity

• family history

• genetic predisposition 

Modifiable risk factors

• elevated serum lipids

  • cholestrol, triglycerdes, HDL, LDL

• Hypertension

• tobacco use

• physical inactivity

• diabetes

• Obesity 

• substance use

• homocystine

Nursing care of CAD

• identify high risk people and manage modifiable risk factors

• lifestyle changes with realistic goals 

• physical fitness 

• nutritional therapy

Lipid lowering drug therapy- CAD

fibric acid derivatives - lopid

bile acid sequestrates - welchol

eztemibe- zetia

Fibric Acid Derivatives ( Lopid )

• decrease triglycerides and increase HDLS

• gi side effects 

Bile Acid Sequestrates (welchol )

• increase conversion of cholestrol to bile acids

• gi side effects- bind with other drugs 

Ezetimibe ( Zetia)

Decrease absorption of dietary and biliary cholesterol

Antiplatelet therapy for CAD

ASA- reduce risk of blood clots

Clopidogrel- reduce risk of blood clots

gerontologic considerations for CAD

• more older adults have CAD

• treat hypertension and lipids

• smoking cessation 

Guidelines for Geratric with CAD

• longer warmup

• longer periods of low level activity

• longer rest periods

• avoid extreme temperatures

• 30 minutes a day

Chronic Stable Angina

a progressive disease where O2 demand is greater than supply leading to myocardial ischemia

occurs when arteries are blocked 70% or more 

patho of CAD Angina

• lack of oxygen and glucose leads to anaerobic metabolism

• lactic acid- irrirates nerve fibers- leading to pain in cardiac nerves

• refered pain from transmission to the upper thoracic posterior nerve roots 

Anaerobic metabolism

creates energy by burning carbs in absence of oxygen. occurs when lungs cant put enough oxygen in bloodstream to keep up with demands of muscles for energy 

Clinical Manifestations of CAD angina Pain

• pressure/ ache

• squeezing, heavy, choking, or suffocating sensation

• rarely sharp

• indigestion or burning

Clinical manifestations of Chronic stable Angina

• 5-15 minute duration

• ST segment depression / T wave inversion 

• subsides when precipitating factor resolved 

• Predictable and controlled with meds 

silent Ischemia

• occurs in absence of any subjective symptoms

• assocatied with diabetic neuropathy

• confirmed by ECG changes 

nocturnal angina

• occurs at night 

angina Decubitus

• chest pain when lying down 

• relived by sitting or standing 

Prinzmetals variant angina

• occurs at rest in response to a spasm of a major coronary artery

• seen in patients with history of migranes or raynauds 

spasms cause

increased levels of certain substances, narrowed blood vessels from medications, or exposure to cold weather 

Prinzmetals variant angina treatment

• moderate exercise

• SL NTG 

• CCB

• stop coke use 

Microvascular Angina

• chest pain occurs in absence of significant coronary atherosclerosis or coronary spasms

• Myocardial ischemia associated with abnormalities of the coronary microcirculation 

  • coronary Microvascular Disease affects small distal coronary arteries 

Chronic Stable Angina care

• goal is to lower O2 demand and/ or higher O2 supply 

• short acting nitrates 

Short Acting Nitrates education

• dilate peripheral and coronary blood vessels 

• if no relief in 5 mins call EMS

• repeat every 5 min max 3 dose 

• can use prophylactically

Chronic stable Angina meds

• aspirin

• SL NTG 

  • causes headache and orthostatic hypotension 

long acting nitrates

Chronic stable angina meds ( cont)

ACE inhibitors- lisinopril

Beta blockers- Metopolol 

CCBS- Amlodipine

Sodium Current Inhibitor- Ranolazine 

Chronic Stable Angina Diagnostic Studies

• chest X ray

• labs 

• 12 lead ECG 

• calcium score screening heart scan 

• echocardiogram 

• exercise stress test

• pharmacologic nuclear imaging 

Blood pressure

pressure exerted by blood on arterial walls

Systolic BP

• peak pressure against arteries during ventricular contraction

• normal is less than 120 mm hg

Diastolic BP

residual pressure in arteries during ventricular relaxation

normal = less than 80 mm Hg 

Systemic Vascular Resistance SVR

force opposing movement of blood

bp =

CO x SVR 

Orthostatic Hypotension BP  Measurement 

• BP and HR after laying for 5 minutes

• measure BP and HR at 1 minute and 3 minutes of position change 

abnormal orthostatic hypotension measurement

• SBP decreased 20 mm Hg or more

• DBP decreased 10 mm Hg or more

• HR increased 20 bpm or more 

• Reportedly lightheaded or dizzy 

Pulse Pressure

difference between SBP and DBP 

1/3 of SBP 

MAP - Mean Arterial Pressure

• average pressure within arterial system that is felt by organs in body 

• greater than 60 mm hg needed to perfuse vital organs 

Metabolic Syndrome

• increase risk of heart disease, stroke, diabetes

• increased BP 

• high blood sugar

• Excess body fat around waist

• abnormal cholestrol or triglycerides 

• apple or pear shape 

hypertension complications

• CAD 

  • atherosclerosis

• HF

• Peripheral vascular disease

  • atherosclerosis leads to PVD

• Kidney

  • nephrosclerosis leads to CKD 

• eyes

  • retinal damage

hypertensive emergency

• over hours or days

• bp over 180/110 with target organ disease

hypertensive urgency

occurs over days to weeks

bp over 180/110 with no evidence of target organ disease

Clinical Manifestations and Complications of Hypertensive crisis

• stroke

• retinopathy

• hypertensive encephalopathy

• renal insufficency

• cardiac decomposition 

• aortic dissection

Hospitalization plan for HTN emergency

• IV drug therapy to titrate to MAP

• monitor cardiac and renal 

• neurological checks 

• education

Questions to ask for HPI of HTN emergency

neurologic symptoms

• Headache

• n/v

• visual disturbances 

dyspnea, orthopnea, cough, fatigue,

meds and social history

sudden onset of severe headache suggests

subarachnoid hemorrhage

rapid onset of radiating pain in chest or back may suggest

aortic dissection

dyspnea, orthopnea, cough, fatigue can suggest

cardiac decompensation ( pulmonary edema)

cardiac assessment for HTN emergency

• assess for murmurs and gallops 

• assess for HF signs

• chest pain

lung assessment for hypertensive emergency 

assess for evidence of pulmonary edema

• wheezes

• crackles, rales

• cough

• dyspnea

abdominal assessment for HTN emergency

bruits

abdominal aortic aneurysm 

auscultate for murmur  - aortic dissection

bruits suggests

renal artery stenosis

neuro assessment for HTN emergency

A and O x4

BEFAST- stroke 

unequal pulses suggest

aortic dissection

imaging and diagnostics for HTN emergency

• chest x ray

• chest ct or mri 

• tee 

When would the Chest x ray be used 

signs of left ventricular failure 

when would chest ct or mri be indicated 

• patients with unequal pulses or widened mediastinum on Chest x ray

• looking for dissecting aortic aneurysm 

When would a TEE be indicated

patients presenting with pulmonary edema

Peripheral artery disease

thickened artery walls leading to degeneration of arteries, oxygen going to tissue

PAD risks

• smoking

• family history of premature MI or strokes

• over 50

• overweight

• inactive

• Dm

• HTN

• high cholesterol

PAD mainfestations

• intermittent claudication 

• paresthesia

• butt pain 

• pallor

• skin temp changes

• sores 

PAD causes

reduced blood flow to limbs and pain at rest

PAD reduced blood flow to limb signs

• thin, shiny, taut skin

• loss of hair on LL 

• dimished pedal pulses

• pallor with elevation

• feel better putting legs down fter they were elevated 

PAD pain at rest signs 

occurs in the foot or toes

aggravated by limb elevation 

occurs from insufficent blood flow

occurs more at night

often relieved by gravity 

PAD complications

atrophy of skin and underlying muscles

delayed healing

wound infection

tissue necrosis

arterial ulcers 

diagnosing PAD

• ankle Brachial Index

• ultrasound doppler test

• angiogram 

treatment of PAD

• bp control - reduce sodium 

• tobacco cessation 

• lower HgbA1C

• diet and statins

• ace inhibitors

Invasive interventions for PAD

• angioplasty and stents

• atherectomy 

Surgical interventions for PAD

peripheral artery bypass

PVD

inadequate return of venous blood from legs to heart

PVD symptoms

• tired and heavy and achy leg cramps

• pain worsens with standing 

• pain improves with leg elevation and activity

• brown leathery skin

• flaking and itching

• skin is hard and thick 

• stasis ulcers

PVD education

• exercise improves oxygen extraction in leg

• walking is the best choice of exercise

• lower bmi

• decrease waist circumfrince

• diet healthy

• stop smoking

• dont sit or stand too long

• compression socks

PVD foot care education

• daily feet inspection

• comfortable shoes 

• show how to check skin temp, cap refill and palpate the pulses 

PVD Cause 

damage to valves letting blood lead backwards

• due to age, extended sitting, standing, reduced movement 

Diagnosis of PVD

vascular ultrasound

Cardiomyopathies

disease of heart muscle, not letting heart pump blood correctly, can cause someone to have HF

types of cardiomyopathies

• hypertrophic

• dilated 

• Restrictive 

cardiomyopathy diagnosed through 

TEE

Dilated Cardiomyopathy

• pumping dysfunction- mostly left ventricle chamber enlargment

• age 30-60 , most common in black male

Ischemic dilated cardiomyopathy

• CAD

• MI 

non ischemic dilated cardiomyopathy

• genetic disorder- autosomal dominant - duchenne muscular dystrophy 

• structural heart 

• alcohol 

• drugs

• endocrine

• immune issues 

Evaluation of Dilated cardiomyopathy

echocardiogram

ecg

stress test

labs 

cardiac biopsy

troponin and BNP

Treatment of Dilated Cardiomyopathy

• ace or arbs

• nitrates- preload

• diuretics- preload

• beta blockers

• treat underlying issue 

• implantable cardioverter defibrillator

• LVAD - no pulse or cardiac transplant 

Hypertrophic Cardiomyopathy

• commonly inherited and caused by mutations in genes

• complications like syncope, HF, death 

clinical manifestations of hypertrophic cardiomyopathy 

Family history 

asymptomatic

• if any symptoms- chest pain, dyspnea, syncope, palpatiations

sx - systolic murmur

testing for hypertrophic myopathy

• ekg

• tee

• cardiac mri 

• genetic testing

• troponin and BNP 

treatment of hypertrophic myopathy

• improve ventricle filling

• no hard sports

• beta blockers, ccb if intolerant to BB 

• cardizem for those who cant tolerate CCB

• implantable cardioverter device

• permanent pacemaker

• septal ablation

• heart transplant 

Restrictive cardiomyopathy

heart muscle characterized by impaired ventricular filling with typically persevered systolic function and normal increased ventricular wall thickness

evaluation of restrictive cardiomyopathy

• s/s of adv HF

• look for History of radiation tx, chemo 

• echo

• cardiac cath

• cardiac biopsy 

• genetic testing 

Management of restrictive cardiomyopathy

• improve diastolic filling

• diuretics or aldosterone antagonisys

• permanent pacer for AV blocks

• Amyloidosis 

• cardiac transplant

• implantable cardioverter- defibrillator 

Takotsubo - broken heart syndrome

• secondary to extreme stress and mimics heart attack 

• acts like acute coronary syndrome

• left ventricular balloning

• EF reduced, but can recover 

symptoms of broken heart syndrome

acute chest pain with ST elevations

testing for broken heart syndrome

• ekg 

• cardiac markers- troponin and bnp

• coronary angiography

• echocardiogram