Cardiology: NURS 3102

Acute Coronary Syndrome (ACS)

A group of heart problems that happen when the blood flow to the heart gets blocked, It includes conditions like a heart attack (myocardial infarction) or unstable angina (chest pain). It's a serious emergency and can damage the heart muscle.

Heart Failure (HF)

Heart failure means the heart is not pumping as well as it should. It can happen when the heart is too weak or stiff. This leads to symptoms like shortness of breath, fatigue and fluid buildup in the body.

Dysrhythmias

These are problems with the heart's rhythm. Instead of beating normally, the heart may beat to fast, slow, or irregular

Atrial fibrillation

An irregular and often rapid heartbeat that starts in the upper chambers (atria) of the heart. It can cause heart palpitations, shortness of breath, and increase the risk of stroke

Sinus bradycardia

Is a slow heart, with a heart rate below 60 beats per minute, Can cause fatigue and dizziness

Sinus tachycardia

A fast heart rate (above 100 beats per minute). It can happen during exercise, stress, or fever. However, if it occurs at rest, it could be a sign of a more significant issue.

Heart block

A condition where the electrical signals in the heart are delayed or blocked. It causes the heart to beat too slowly, which can cause dizziness or fainting.

Ventricular tachycardia

It is a fast, abnormal heartbeat that starts in the lower chamber (ventricles) of the heart. It can be life-threatening and can cause fainting, chest pain, or cardiac arrest.

Ventricular fibrillation

A very rapid, chaotic heartbeat that makes the ventricles quiver instead of pumping blood. It is a medical emergency and can lead to cardiac arrest if not treated immediately.

Coronary Arteries

The coronary arteries deliver oxygen-rich blood from the aorta tot he heart muscle, allowing it to pump blood throughout the body.

Coronary Sinus

The heart's largest vein, which collects most of the deoxygenated blood from the heart muscle and empties into the right atrium

describe the flow of blood through the heart

-Blood enters the right atrium via the superior and inferior venae cavae, the systemic system (deoxygenated)

-Heart contracts (systole), pushing blood into the right ventricle through the tricuspid valve

-Ventricles fill with blood, contract (systole), pushing blood past the pulmonic valve into the pulmonary arteries

-Goes to the lungs to receive oxygen and returns to the heart via pulmonary veins into the left atrium

-Atrium contracts (systole), pushing blood past the mitral valve to the left ventricle.

-Ventricle contracts (systole), pushing blood through the aortic valve to the aorta.

-The aorta then distributes the oxygenated blood to the body.

Diastole

relaxation, (repolarization) where all 4 chambers of the heart relax, allowing the ventricles to fill in preparation for contraction (depolarization)

Systole

Refers to the event in the heart during contraction of the atria and ventricles.

What is the order of electrical impulses in the heart

1. Sinoatrial node

2. Atrialventricular node

3. Bundle of his

4. Right and left bundle branches

5. Pukinje fibers

Sinoatrial node

(60-100bpm) right atrium "pacemaker" (atrial contraction)

Atrialventricular node

between atriums (40-60bpm) "gatekeeper"

Delays electrical impulses, allowing the ventricles to fill and the atria to contract

Purkinje Fibers

Terminal point in the conduction system

List the layers of the heart wall

endocardium, myocardium, epicardium, pericardium

Endocardium

The inner layer composed of endothelial tissue and lines the inside of the heart and valves

Myocardium

middle layer of the heart made of muscle fibers and is responsible for the pumping action

Epicardium

Outer layer of the heart

Pericardium

A fibrous sac that encases the heart. It is made of two layers:

Visceral pericardium: attaches to the epicardium

Parietal pericardium: attaches to the great vessels, diaphragm, sternum, and vertebral column; supports the heart in the mediastinum (attaches heart to internal structures)

Cardiac output

Refers to the amount of blood pumped by each ventricle over a given period. Normal CO in a resting adult is 5L/min

CO= Stroke volume x heart rate (how fast and how much blood is going out)

Stroke volume

The amount of blood ejected from the heart in one contraction.

Adverage= 70ml

What three things are stroke volume affected by

1. Preload

2. Afterload

3. Cotractility

Preload

degree of stretch in ventricular cardiac muscle fibers at the end of diastole as the volume of blood returning to the heart increases, muscle fibers stretch increases (increasing preload) causing a stronger contraction and a greater stroke volume

Afterload

Resistance to ejection of blood from the ventricles inversely related to stroke volume-> increased afterload=decreased stroke volume

cantractility

Force generated by the contracting myocardium

What are modifiable risks for coronary artery disease

Hyperlipidemia

Cigarette smoking

Hypertension

Diabetes

Metabolic syndrome

Obesity

Physical Inactivity

What are non-modifiable risks for coronary artery disease

Family history

Increasing age

Gender (male)

Race (greater risk for African Americans)

What diet alteration do we teach patients to prevent cardiac events and manage complications

Controlling cholesterol abnormalities (excess LDL, bad fats)

Dietary: DASH, portfolio diet,

Vegetarian diets can help reduce blood lipids, blood glucose, and other related health issues.

Soluble dietary fibre: reduces cholesterol by enhancing excretion

Control servings: amount of total fat, saturated fats, cholesterol and fiber

What physical activity do we teach patients to prevent cardiac events and manage complications

1. Regular to moderate physical activity increases HDL levels and reduces triglycerides

2. 150 Minutes of moderate to vigorous aerobic activity per week in bouts of 10 minutes or more

3. Set realistic goals, engaging in activities that interest them

4. Exercise in the morning ot indoors

5. Walk in large stores during bad weather

What kinds of medication do patients typically have to prevent cardiac events and manage complications

-Lipid lowering, nicotinic acids, fibric acids or fibrates, bile acid sequestrants or resins, ezetimibe and or monoclonal antibody

-HMG-COa reductase inhibitors: statins that reduce LDL

Why is cessation of tobacco by the patient taught to prevent/ manage complications of cardiac events

Inhalation of smoke increases blood carbon monoxide levels and hemoglobin. The O2-carrying component of blood combines more readily with CO2 than with O2.

what nursing assessments should be considered when caring for a aptient with altered cardiac function

1. 12-lead ECG

2. blood laboratory values: cardiac biomarker analysis, BNP, C-reactive protein

3. cardiac stress testing

4. echocardiography

5. cardiac catheterization

6. coronary artery angiography

Cardiac biomarker analysis

(creatinine kinase, CK isoenzymes and proteins such as myoglobin, troponin T, troponin)

Cholesterol levels

HDL, LDL and triglycerides- mormal range of 100-200mg/dl

C-reactive protein (CRP)

A protein produced in the liver in response to systemic inflammation (inflammation is thought to play a roll in the development and progression of atherosclerosis)

Cardiac stress testing

A healthy coronary artery will dilate up to four times its usual diameter in response to increased metabolic demands for oxygen and nutrients. With a coronary artery suffering from atherosclerosis, it will dilate less, compromising blood flow and ischemia.

When is a stress test contraindicated

Severe aortic stenosis, acute myocarditis or pericarditis, severe hypertension, suspected left main coronary artery disease, heart failure, and unstable angina

Echocardiography

Is a noninvasive ultrasound test that is used to measure ejection fraction and examine the size, shape, and motion of cardiac structures

Cardiac catheterization

Invasive procedure used to diagnose structural and functional disease of the heart and great vessels

Stable Angina

severe narrowing of the oxygen tubes (coronary artery). Less oxygen to the heart muscles. Stable angina is caused by physical activity and is relieved by rest.

Acute coronary syndrome (unstable angina or MI)

is an emergency situation characterized by acute onset of myocardial ischemia that results in myocardial death. Includes unstable angina, NSTEMI, and Stemi. It is a sudden, reduced blood flow to the heart.

Unstable angina

there is a reduced blood flow in a coronary artery which may be due to rupture of plaque

myocardial infarction (MI)

Plaque rupture and subsequent thrombus formation result in complete occlusion of the artery, leading to injury and necrosis of the myocardium supplied by that artery. Imbalance between oxygen supply and demand. The area of infarction develops over minutes to hours (death of cells).

Total blockage (ischemia)

=tissue damage (lack of oxygen)= the release of cardiac enzymes

Troponin

proteins foun in both skeletal and cardiac muscle fibers that regulate muscle contraction. #1 indicator for an MI (3-4 hours after)

Myoglobin

Any damage to muscle tissue including myocardial necrosis

Creatine kinase

When muscle cells are damage, these are released into the blood stream 3-4 hours later. High levels can be indicative of a heart attack.

ANP

Atrial Natriuretic Peptides (released by kidneys)

Increases due to the increased stretching of the atrial wall due to increased atrial blood volume.

BNP (Brain or B-type Natriuretic peptides)

It is released due to increased pressure in the heart, which causes the blood vessels in the body to dilate and decrease the pressure in the heart. It is good to detect congestive heart failure, as the blood backs up into the heart, increasing pressure and thus increasing these levels to signify it.

angina syndrome symptoms

Chest pain during exercise that is relieved by rest

Angina Nursing Care

Rest and nitroglycerin

angina diagnostics

ROMI panel

Electrocardiogram

Echocardiogram

angina medical treatment

Nitroglycerin (usually pill)

acute coronary syndrome symptoms

-Chest pain, discomfort that occurs suddenly and continues despite medication is the presenting symptom in most patients with an MI

-Chest discomfort, SOB, indigestion, nausea, anxiety

-Cool, pale, moist skin

acute coronary syndrome nursing care

1. Pain management, rest and medication

-Immediately provide aspirin, nitroglycerin, and morphine and oxyge if hypoxic.

-*A beta blocker can be used in cases of dysrhythmia, as they slow heart rate and reduce oxygen consumption

2. Diet, addressing underlying causes

Acute coronary syndrome diagnostics

ROMI panel

Electrocardiogram

Echocardiogram

ROMI panel

Cardiac enzymes taken after a heart attack, myocardial infarction (MI)

Electrocardiogram

Obtained within 10 minutes from the time the patient reports pain or arrives in the ED. T wave inversion, ST segment elevation, and development of an abnormal Q wave

Echocardiogram

Ultrasound of the heart. evaluates ventricular function

STEMI (ST elevation MI)

TIP: HOLD YOUR BREATH

Chest pain

Oxygen SPO2 lower

Lethargy

Anxiety

Palpitations, racing heart "gallops in the chest"

Shortness of breath

Elevated ventricular rate or heart rate

Dizziness or syncope, fainting

meds for STEMI (ST elevation MI)

MED

M- Morphine (vaso dilate, pain management, increase CO)

O-Oxygen

N-Nitro

A-ASA "anti platelet congregator (325mg)

order: NOAM

what is the possible nursing intervention for individuals with a STEMI (ST elevation MI)

Pci: cath lab

Cabage: coronary artery bypass graph

Stent (keep vessel open)

signs and symptoms of a NSTEMI (Non ST elevatio MI)

TIP: HOLD YOUR BREATH

Chest pain

Oxygen SPO2 lower

Lethargy

Anxiety

Palpitations, racing heart "gallops in the chest"

Shortness of breath

Elevated ventricular rate or heart rate

Dizziness or syncope, fainting

meds for a NSTEMI (Non ST elevatio MI)

M- Morphine (vaso dilate, pain management, increase CO)

O-Oxygen

N-Nitro

A-ASA "anti platelet congregator (325mg)

Highest population at risk for a atypical MI symptoms

Older individuals may not experience pain the same way

People with diabetes, as neuropathy may alter pain perception

Can experience acute coronary syndrome differently; may feel unwell, fatigued, malaise, nausea, anxiety, weakness, palpitations, and less specific symptoms, making it more complex to recognize and diagnose

During an MI, what happens to respiration

SOB, dyspnea, tachypnea, crackles and pulmonary edema

what 6 classes of medications are commonly prescibed to those with an MI?

Nitrates

Beta blockers

Anticoagulatns

Morphine Sulphate

ACE Inhibitor

Thrombolytics

Nitrates mechanism of action

nitroglycerin

-A vasodilator to increase oxygen to the left ventricle.

-Reduces preload, reducing CO and myocardial oxygen demand

What nursing implications do you need to be aware of for nitroglycerins

-3 doses, 5 minutes apart

-Sublingual, under the tongue

-No viagra (afil X)

-Take while sitting

-HA and hypotension is normal

Beta blockers mechanism of action

Metroprolol

-Provides rest to the heart, by slowing the heart rate and bp.

-Stimulates beta 1.

What nursing implications do you need to be aware of with beta blockers

-Monitor for SOB, respiratory distress, HR, and blood glucose for those with diabetes

-Use cautiously with people with asthma, COPD, or impaired renal function

Anticoagulants' mechanism of action

(Heparin, warfain, ASA)

to inhibit specific clotting factors to prevent formation or enlargement of clots.

Heparin (clot-stabilizing)

Prevents CLOT growth

What nursing implications do you need to be aware of with anticoagilants

-Watch PTT (Heparin)

-Watch for bleeding

-Check INR for warfarin

Morphine sulphate mechanism of action

-Decreases the workload of the heart. Reduces pain and anxiety and dilates the vessels. Relaxes the heart so it can pump more effectively

-Increases CO

what nursing considerations are there with morphine sulphate

-Any pain after morphine is bad. More pain = more damage (tissue death)

-Not recommended for acute or severe bronchial asthma and paralytic ileus

-Increases intracranial pressure

-WATCH for respiratory depression

ACE inhibitor mechanism of action

Enalapril, Ramapril

Prevent the formation of angiotension, causing the bp to drop as the kidneys excrete sodium and fluids.

Nursing considerations for ACE inhibitors

-Check the patient for hyponatrium, hypovelemia, hypotension and hyperkalemia before administration

-Contraindicated in pregnancy

-Monitor fluids, BP, BUN, serum creatinine and potassium

thrombolytics mechanism of action

TPA, Streptokinase

-Clot buster. Leads to lysis of thrombus in coronary arteries, improving ventricle function, reducing the risk of HF and death. Restores blood flow

nursing considerations for thrombolytics

-Risk for bleeding---> No injection

-Monitor for dysrhythmias

Ejection fraction

-The percentage of blood leaving the heart each time it contracts (in 1 pump). Calculated using the amount of blood left during ejection, vs how much blood was present in the ventricles before leaving to oxygenate the body.

what diagnostics are used for heart failure

-Echocardiogram (55-70% is normal! BUT 40% or LESS is BAD!) 40% or less indicates heart failure

-Lab: lytes, BUN, creatinine, thyroid-stimulating hormone, CBC, BNP, liver function test, urine analysis

HIGH BNP= signs of high cardiac filling pressure

-Cardiac stress testing or cardiac catheterization may be performed to determine whether CAD and cardiac ischemia are causing HF

Right-sided heart failure (diastolic)

When the right ventricle fails, congestion in the peripheral tissues and viscera is present. Heart cant eject blood and cannot accomodat all the blood that normall returns from venous circulation

Risk factors for right-sided heart failure

-hypertension

-coronary artery disease

-diabetes

-smoking

-obesity

Advanced age

clinical manifestation of right-sided heart failure

-pulmonary congestion or a disturbance in the respiratory control mechanism

-fatigue

-increased peripheral venous pressure

-enlarged liver/spleen

-distended jugular veins

-anorexia and complaints of GI distress, weight gain and dependent edema

-hepatomegaly (tenderness RUQ) causes ascites

left-sided heart failure (systolic)

-occurs when the left ventricle can't effectively pump blood out of the ventricle into the aorta and systemic circulation

Risk factors for left-sided heart failure

-hypertension

-coronary artery disease

-valvular disease

-diabetes

-arrhythmias, obesity, kidney disease

-drugs and alcohol

(systemic, things that prevent proper return of deoxygenated blood to the body. Its pooling)

Clinical manifestation of left-sided heart failure

-Paroxysmal nocturnal dyspnea

-elevated pulmonary capillary wedge pressure

-pulmonary congestion

-tachypnea

-confusion, orthopnea, tachycardia, exertional dyspnea, fatigue, cyanosis

-oliguria: blood flow to the kidney decreases, causing decreased perfusion and reduced urine output

self care strategies for managing heart failure

Nutrition management: restriction of sodium to reduce fluid retention

Fluid Restriction: Record weight daily, reposition for edema or SOB, minimize ETOH and smoking

Exercise/activity: prescribed individually, adherence increases functional capacity and improves dyspnea.

-Should be able to talk during exercise, should stop if SOB, pain or dizziness occur and should warm up and work out in appropriate temperatures.

-Find ways to minimize exhaustion and include rest periods in your day

Stage A heart failure

patients who are at high risk for developing heart failure but have no structural abnormalities

Stage B heart failure

patients who have structural heart disease but demonstrate no symptoms of heart failure

Stage C heart failure

Patients with past or current symptoms of heart failure who have underlying structural heart disease

stage D heart failure

-Patient with refractory end-stage HF requiring special interventions.

-Continues to have symptoms despite maximal medical therapy

-recurring hospitalization

stage A heart failure treatment

treat HTN, DM, DLD - reduce risk

consider ACE/ARB

risk factor reduction

education

Stage B treatment

-Stage A recommendations

-ACE inhibitors and ARB for low ejection fraction or history of MI

-BB

-Statin

Stage C heart failure treatment

-Same as A and B

-Diuretics

-Sodium and fluid restrictions

-Implantable defibrillator

-Cardiac resynchronization therapy

Stage D treatment

-A, B and C treatment

-End of life care

-Inotropes

-Cardiac transplant

-Mechanical support