Cardiac

Preload

Is the amount of blood returning to the right side of the heart and the muscle stretch that the volume causes.

ANP is released when we have this stretch

Afterload

Is the pressure in the aorta and peripheral arteries that the left ventricle has to pump against to get the blood out.

• This pressure is referred to as resistance

Stroke volume

Is the amount of blood pumped out of the ventricles with each beat

Cardiac Output

Heart Rate x Stroke Volume

Factors that affect Cardiac Output

• Heart rate and certain arrhythmias

• Blood volume

  • Less volume = Decreased

  • More volume = Increased

• Decreased contractility

  • MI, Medications, Cardiac muscle disease

Medications that effect Preload

• Diuretics (Furosemide)

• Nitrates (Nitroglycerin)

Medications that effect Afterload

• ACE Inhibitors (Enalapril, Fosinopril, Captopril)

• ARBS (Losartan, Irbesartan)

• Hydralazine

• Nitrates

Medications that improve Contractility

• Inotropes (Dopamine, Dobutamine, Milrinone)

• Digoxin

Medications that effect Rate Control

• Beta Blockers (Propranolol, Metoprolol Atenolol, Carvedilol)

• Calcium Channel Blocker (Diltiazem, Verpamil, Amlodipine)

• Digoxin

Medications that effect Rhythm Control

• Antiarrhythmics (Amiodarone)

Pathophysiology of Decreased CO

If your CO is decreases you will not perfuse properly

Decreased CO symptoms

• LOC decreases

• Chest pain

• Lungs will sound wet

• Shortness of breath

• Cold and Clammy skin

• Urinary output decreases

• Weak peripheral pulses

3 Arrhythmias that are always a big deal

• Pulseless V-Tach

• V-Fib

• Asystole

• No CO, need CPR!

Coronary Artery Disease (CAD)

Is a broad term that includes Chronic Stable Angina and Acute Coronary Syndrome

Chronic Stable Angina pathophysiology

• Intermittent decreased blood flow to the myocardium leads to ischemia. This can lead to temporary pain/pressure in chest

• Low O2 due to exertion usually causes the pain

• Rest and Nitroglycerin SL relives the pain

Chronic Stable Angina treatment

• Medications

  • Nitroglycerin

  • Beta Blockers

  • Calcium Channel Blockers

  • Acetylsalicylic acid (Aspirin)

• Client education

• Cardiac catheterization

Nitroglycerin

• Causes venous and arterial dilation

• This dilation will decrease preload and afterload

• Also causes dilation of the coronary arteries which will increase blood flow to the heart muscle

• Take 1 every 5 mins x 3 doses

• Not okay to swallow

• Keep in dark, glass bottle

• May fizz or burn, if doesnt check exp date, replace every 6 months

• The pt WILL get a headache

• BP will drop

• Decreases workload of the heart

Beta Blockers

• Decreases BP, HR, Myocardial contractility, Workload of the heart, CO

• Propranolol, Metoprolol, Atenolol, Carvedilol

• Block the beta cells, which are the receptor sites for epi & norepi

Calcium Channel Blockers

• Causes vasodilation of the arterial system

• Decreases BP

• Decreases afterload and Increases Oxygen to the heart muscle

• Also dilates coronary arteries

• Nifedipine, Verapamil, Amlodipine, Diltiazem

Acetylsalicylic acid (Aspirin)

• Keeps platelets from sticking together

Client Education for Chronic Stable Angina

• Rest frequently

• Avoid overeating, Low fat High fiber diet is best

• Avoid excess caffeine or any drugs that increase HR

• Wait 2 hours after eating to exercise

• Dress warmly in cold weather

• Take nitroglycerin prophylactically

• Smoking cessation

• Lose weight, Decrease calories

• Avoid isometric exercise

• Reduce stress

Cardiac Catherization pre-procedure for Chronic Stable Angina

• Ask if they are allergic to Iodine or Shellfish

• Check Kidney function because the dye is excreted through urine

• Palpitations are normal

Cardiac Catherization post-procedure for Chronic Stable Angina

• Monitor vital signs

• Watch puncture sites for bleeding and hematoma formation

• Assess extremity distal to puncture site (5-Ps)

  • Pulselessnes

  • Pallor

  • Pain

  • Paresthesia

  • Paralysis

• Bed rest, Flat, Extremity straight for 4 hrs+

• Major complication post cath is Hemorrhage/Bleeding

• Report pain ASAP

• Hold metformin for 48 hrs post procedure

Acute Coronary Syndrome (MI, Unstable Angina) Pathophysiology

• Decreased blood flow to myocardium leads to Ischemia & Necrosis

• Pt does not have to do anything for this pain to come

• Rest and/or Nitro will not relieve this pain

Acute Coronary Syndrome (MI, Unstable Angina) Symptoms

• Pain (Chest discomfort, Crushing, Pressure radiating to the neck/jaw/arm/shoulder)

• Dizziness

• Sweating

• Nausea

• Vomiting

• Cold/Clammy

• BP drops

• CO decreases

• ECG changes

• Women usually present with GI symptoms, Unusual fatigue, Inability to catch their breath

• Elderly often report SOB

• Elderly, Pts w/ Diabetes, Women likely to deny symptoms because symptoms are vague and less typical

Acute Coronary Syndrome (MI, Unstable Angina) Diagnostic

• CPK-MB

• Troponin

• Myoglobin

CPK-MB

• Increases with damage to cardiac cells

• Elevates within 6 hrs and peaks in 12-24 hrs; returns to normal with 24-36 hrs

• Cardiac specific iso enzyme

Troponin

• Cardiac biomarker with high specificity to myocardial damage

• Elevates within 3-4 hrs, peaks at 10-24 hrs, and remains elevated for up to 3 weeks

Myoglobin

• Not specific enough to Dx a ACS but if Negative can rule out

• Increases within 2 hrs and peaks in 3-15 hrs

Major Arrhythmias Acute Coronary Syndrome (MI, Unstable Angina)

• Priority treatment for V-Fib = Defib

• If defibrillation doesn’t work the first med we give is Epinephrine

• Amioadarone and Lidocaine are anti-arrhythmic drugs commonly used when V-Fib and Pulseless VT are resistant to Epinephrine (Vasopressor) and Shock (Defib)

• Lidocaine toxicity = Neuro changes

Acute Coronary Syndrome (MI, Unstable Angina) Treatment

1. Oxygen

2. Aspirin (To prevent platelet aggregation)

3. Nitroglycerin

4. Morphine

• Head up position to decrease workload on the heart and increase CO

• Fibrinolytic therapy

• Percutaneous Coronary Interventions (PCI)

• Coronary Artery Bypass Graft (CABG)

• Cardiac Rehabilitation

Fibrinolytic therapy

Dissolve the clot that is blocking blood flow to the heart > Decreases the size of the infarction

• Major complication is Bleeding

Common Medications Requiring Bleeding Precautions

• Abciximab

• Acetaminophen

• Acetylsaicylic Acid

• Apixaban

• Clopidogrel

• Dabigatran

• Enoxaparin Sodium

• Eptifibatide

• Heparin Rivaroxaban

• Warafrin

Percutaneous Coronary Interventions (PCI)

• Includes all interventions such as Percutaneous Trasluminal Coronary Angioplasty (PTCA) and Stents

• Major compilation of an angioplasty is a MI

• Client may bleed from heart catheter site or they could reocclude

• If any problem occurs go to surgery

• Chest pain after surgery: Call PHP most likely reoccluding

Coronary Artery Bypass Graft (CABG)

• Open heart surgery

• Can be scheduled or emergency procedure

• Uses with multiple vessel disease or left main coronary artery occlusion

• The left main coronary artery supplies the entire left ventricle, so an occlusion can lead to sudden death

Cardiac Rehabilitation

• Smoking cessation

• Stepped care plan (increase activity gradually)

• Diet changes : Low Fat, Salt, Cholesterol

• No isometric exercises due to increasing workload of heart

• No valsalva

• No straining

• Sex can be resumed 1 week to 10 days

• Walking is the best exercise

• Teach symptoms of HF:

  • Weight gain

  • Ankle edema

  • SOB

  • Confusion

Heart Failure Causes

• Coronary Artery Disease (CAD)

• Cardiomyopathy

• Valvular Heart Disease

• Endocarditis

• Acute MI

• Hypertension

Left Sided Heart Failure

The blood is not moving forward into the aorta and out to the body. If it does not move forward, then it will go backwards into the lungs

Left Sided Heart Failure Symptoms

• Pulmonary congestion

• Dyspnea

• Cough

• Blood tinged frothy sputum

• Restlessness

• S3

• Orthopnea (SOB when laying flat)

• Nocturnal dyspnea

Right Sided Heart Failure

The blood is not moving forward into the lungs. If it does not move forward then it goes bacward into the venous system

Right Sided Heart Failure Symptoms

• Distended neck

• Edema

• Enlarged organs

• Weight gain

• Ascites

Systolic Heart Failure

Heart can’t contract and eject

Diastolic Heart Failure

Ventricles can’t relax and fill

Heart Failure Diagnosis

• B-Type Natriuretic Peptide (BNP)

• CXR - enlarged heart, pulmonary edema

• Echocardiogram

• NY Heart Association Functional Classification of Persons with HF - Classes 1-4 (4=worst)

B-Type Natriuretic Peptide (BNP)

• Secreted by ventricular tissues in the heart when ventricular volumes and pressures in the heart are increased

• Can be positive for HF when CXR does not indicate a problem

• Sensitive indicator

Heart Failure Treatments

• Medications

  • ACE Inhibitors

  • ARBs

  • Beta Blockers

  • Digoxin

  • Diuretics

  • IV inotropes & Vasodilators for severe HF or decompensating HF

• Low Sodium Diet

• Elevate HOB

• Weigh daily and report a gain of 2-3 lbs per day (1-2 kg)

• Report symptoms of recurring failure

• Pacemaker

Pacemaker

• Are used to increase HR

• Worry if the rate drops below the set rate

• Your natural pacemaker is your SA node

Post procedure Care for Pacemakers

• Monitor the incision

• Electrode displacement is the most common complication

• Immobilize the arm

• Assisted passive ROM to prevent frozen shoulder

• Keep the pt from raising the arm higher than shoulder height

Pacemaker Symptoms of Malfunction

• Loss of capture - no contraction following the stimulus

• Failure to sense - fires at inappropriate times

• Watch for any signs of decreased CO or Rate

Pacemaker Client Education

• Check pulse daily

• ID card or bracelet

• Avoid electromagnetic fields

• Avoid MRIs

Who is at risk for Pulmonary Edema

• Any person receiving IV fluids really fast

• The very young and the very old

• Any person who has a history of heart or kidney disease

Pulmonary Edema Pathophysiology

• Fluid is backing up into the lungs and the heart is unable to move the volume forward

• Usually occurs at night when the client goes to bed

Pulmonary Edema Symptoms

• Sudden onset of Breathless

• Restless/Anxious

• Severe hypoxia

• Productive cough (Pink frothy sputum)

Pulmonary Edema Treatment

• Oxygen

• Medications

  • Diuretics (Furosemide, Bumetanide)

  • Nitroglycerin

  • Morphine

  • Nesiritide

• Positioning - Upright, Legs down

• Prevention - Check lung sounds, Avoid FVE

Furosemide for PE

• Causes diuresis and vasodilation which traps more blood out in the arms and legs and reduces preload

• 40 mg IV push slowly over 1-2 mins to prevent hypotension and ototoxicity

Bumetanide for PE

• Can be given IV push or as a continuous IV fusion to provide rapid fluid removal

• 1-2 mg IV push given over 1-2 mins

Nitroglycerin for PE

• Vasodilation which decreases afterload

• Decreased afterload means increased CO because the heart is pumping against less pressure, and more blood can be moved forward

Morphine for PE

2 mg IV push for vasodilation to decrease preload and afterload

Nesiritide for PE

• IV infusion, short term therapy, not to be given more than 48 hrs

• Vasodilates veins and arteries and has a diuretic effect

Cardiac Tamponade Pathophysiology

• Blood, fluid or exudates have leaked into the pericardial sac resulting in compression of the heart

• This can happen if the client has had a Motor vehicle collision, Right ventricular biopsy, MI, Pericarditis, Hemorrhage post CABG

Cardiac Tamponade Symptoms

• Decreased CO

• Muffled/Distant Heart sounds

• Neck veins distended

• Clear lung sounds

• Shock

• Narrowed pulse pressure

• Hallmark signs

  • Both

  • Increased CVP

  • Decreased BP

Cardiac Tamponade Treatment

• Pericardiocentesis to remove fluid around heart

• Surgery

Arterial Disorders Pathophysiology

• More symptomatic in lower extremities

• Arterial blood isn’t getting to the tissue

• It is a medical emergency if you have an acute arterial occlusion

• If you have atherosclerosis in one place, you have it everywhere

• Arteries carry oxygenated blood

Arterial Disorders Symptoms

• Decreased peripheral pulses or no palpable pulse

• Coldness/Numbness of the extremity

• Atrophy (decreased muscle tone)

• Pain at rest means severe obstruction

• Bruit (turbulent blood flow)

• Skin/Nail changes (Brittle/Thick)

• Ulcerations

• Hallmark sign = Intermittent claudication (pain)

Arterial Disorders Treatment

• Angioplasty (unblocking a blood vessel)

• Endarterectomy (removal of inner artery)

• Dangle artery problems

Venous Disorders

• Inflammation and Chromic ulcers occur

• Could develop a DVT

• Veins carry deoxygenated blood away

• Elevate vein problems

Chronic Arterial Insufficiency

• Pain - Intermittent claudication (progresses to pain at rest)

• Pulses - Decreased or may be absent

• Color - Pale when elevated, Red with lowering of leg

• Temp - Cool

• Edema - Absent or Mild

• Skin changes - Thin, Shiny, Loss of hair over foot

• Ulceration - If present will involve toes or feet

• Gangrene - May develop

• Compression - Not used

Chronic Venous Insufficiency

• Pain - None to aching pain

• Pulses - Normal

• Color - Normal

• Temp - Normal

• Edema - Present

• Skin changes - Brown around ankles, Thick skin, Scarring

• Ulceration - If present will be on side ankle

• Gangrene - Does not develop

• Compression - Used