CAD/CHD, Valve, MI, Infective Endocarditis, Pericarditis

What is Coronary Heart Disease (CHD)?

CHD is insufficient delivery of oxygen to the heart muscle due to narrowing or blockage of the coronary arteries, most commonly from atherosclerosis which can l/t MI

What Causes CHD? – Atherosclerosis

• Endothelial injury → inflammation

• Lipid-laden macrophages form foam cells

• Fatty streaks develop

• Fibrous plaque forms and may calcify

• Plaque protrudes into lumen → ↓ blood flow → angina/MI

Non-Modifiable Risk Factors (Cannot Change) of CHD

• Increased age

• Family history

• Male gender

• Female post-menopause

Modifiable Risk Factors (Can Change) of CHD

• Dyslipidemia (↑ LDL, ↓ HDL, ↑ triglycerides)

• Hypertension

• Cigarette smoking

• Diabetes mellitus

• Obesity

• Sedentary lifestyle

Why Smoking Is So Dangerous?

• ↑ HR & BP

• ↑ LDL & triglycerides

• ↓ HDL

• ↑ platelet aggregation

• ↑ endothelial dysfunction

• ↓ oxygen carrying capacity

• ↑ inflammatory proteins

• Accelerates atherosclerosis

Diet for CHD

What Increases Risk

• High saturated fats

• High LDL foods

• High triglyceride intake

• Excess sodium

• Obesity-promoting diet

Heart-Healthy Diet Recommendations

From DASH diet & cardiovascular management slides

Hypertension%2C+PVD%2C+arterial…

:

• 🥦 4–5 servings vegetables daily

• 🍎 4–5 servings fruits daily

• 🌾 7–8 servings whole grains

• 🥛 Low-fat/nonfat dairy

• 🐟 Lean protein (fish, poultry)

• 🥜 Nuts, seeds, beans

• 🍭 Limit sweets

• 🧂 Reduce sodium

---

❤ How Diet Protects the Heart

• ↓ LDL cholesterol

• ↑ HDL cholesterol

• ↓ BP

• ↓ inflammation

• ↓ workload on heart

Remember from your HF slides:
High sodium → fluid retention → ↑ preload → ↑ cardiac workload.

What is Myocardial Ischemia?

Temporary reduction in blood flow → not enough oxygen to the heart muscle.

Myocardial cells become ischemic within 10 seconds of a coronary occlusion. 

Reversible if blood flow returns in time
No permanent cell death
Troponin usually normal

What is Stable Angina and Prinzmetal/variant angina?

Stable angina and Variant (Prinzmetal) angina are manifestations of myocardial ischemia.

Stable Angina

What it means:

• Predictable chest pain

• Occurs when oxygen demand increases

Triggered by:

• Exercise

• Stress

• Cold weather

• Heavy meals

Why?

The coronary arteries are narrowed by plaque (atherosclerosis).
When the heart works harder → it needs more oxygen → narrowed artery cannot supply enough → pain.

Key characteristics:

• Predictable

• Relieved by rest

• Relieved by nitroglycerin

• Lasts < 15 minutes

Prinzmetal Angina

Also called:

Variant or vasospastic angina

What happens?

• Coronary artery spasms

• Temporary severe narrowing

• Occurs at rest

• Unpredictable

Important:

• NOT caused by exercise

• Often occurs at night or early morning

• Can cause serious arrhythmias

From your slide:

Rarely associated with MI, but can lead to VF

VF = Ventricular Fibrillation → life-threatening.

Key Differences between Myocardial Infarction and Ventricular Fibrlilation

Feature	MI	VF
Problem Type	Blood flow blockage	Electrical chaos
Cause	Coronary artery clot	Electrical instability
Pulse	Usually present (early)	No pulse
Conscious?	Usually awake (initially)	Unconscious
Troponin	Elevated	Not primary issue
Treatment	MONA, PCI, thrombolytics	CPR + Defibrillation

What is MI? what is happening?

MI = prolonged ischemia → irreversible cell death

• Oxygen supply stops

• Anaerobic metabolism begins

• Lactic acid builds up

• ↓ ATP

• Cells become acidotic

• Troponin released

• Cell death → possible heart failure

Two types of MI

ST-Elevation Myocardial Infarction (STEMI)

What it means:

“ST-Elevation” on ECG.

What is happening?

• Complete coronary artery occlusion

• Full-thickness damage (transmural infarction)

• Large area of myocardium affected

ECG:

⬆ ST segment elevation

Troponin:

⬆ Elevated

Treatment:

Immediate reperfusion required

• PCI (angioplasty) is preferred

• Thrombolytics if PCI unavailable

Non-ST-Elevation Myocardial Infarction (NSTEMI)

What it means:

No ST elevation on ECG.

What is happening?

• Partial coronary artery occlusion

• Partial-thickness damage (subendocardial infarction)

• Smaller area of myocardium affected

ECG:

• ST depression or T-wave inversion

• No ST elevation

Troponin:

⬆ Elevated

Treatment:

• Antiplatelets

• Anticoagulants

• Possible PCI

• Not usually immediate thrombolytics

Early sign of MI

• Diaphoresis

• Nausea & vomiting

• Chest pain radiating to neck/shoulder

• Hypertension

• Tachycardia (starts off tachy!)

Late sign of MI

• ↓ BP (due to ↓ cardiac output)

• Bradycardia (can occur later)

• Crackles

• JVD

• S3 or S4

• Fever (inflammatory response from cell death)

• Skin: ashen, clammy, cool

NCLEX clue:
Early = SNS stimulation
Late = Pump failure

What is Stable Angina in more detailed?

Temporary myocardial ischemia - angina is the symptoms
NO permanent cell death
NO troponin elevation

• Heaviness or tightness

• Comes on gradually

• Predictable (stable angina)

• Goes away with rest

• Goes away with SL nitroglycerin

• May radiate to arm, jaw, scapula

• Associated nausea or dyspnea

Angina is NOT:

• Sharp, fleeting pain

• Random stabbing pain

Angina Management

Nitroglycerin

How it works:

• Dilates blood vessels

• ↓ preload

• ↓ afterload

• Improves coronary blood flow

teaching about nitroglycerin

• Sit down before taking - d/t otho. hypo.

• 1 tablet, then call EMS (home setting)

Assess vitals
Apply oxygen (if needed)

Put patient on cardiac monitor
Give SL nitroglycerin
Reassess pain and BP
May repeat every 5 minutes × 3 if BP stable

You do NOT call EMS — because you are already in an acute care setting.

• Store in dark bottle

• Headache is common (treat with acetaminophen)

• Remove transdermal patch after 10–12 hrs and have free time. Rotates sites

Nurses:  Wear gloves when administering, do not apply where defibrillator pads might go—can cause burning if needed

Pt has chest pain with transdermal patch recently applied –contact HCP—do not give another patch

• DO NOT take with sildenafil (Erectile dysfunction drug) (severe hypotension risk)→ s/s priapism

Chest Pain Differences from MI and Angina

Occurs in BOTH:

• Radiating chest pain

• Epigastric distress

MI ONLY:

• Pain not relieved by NTG

• Fear/impending doom

• Pain relieved by opioids

• Persistent >20 min

• Biomarker elevation

ANGINA ONLY:

• Pain relieved by NTG

Main Diagnostic measure for MI

Troponin (>0.05=MI)

Others: Increased Myoglobin, Lactate dehydrogenase, Creatin Kinase (CK)

What about if troponin comes negative? How to further assess the narrowing?

Angina vs MI — KEY DIFFERENCES

Feature	Angina	MI
Cause	Temporary ischemia	Prolonged ischemia → cell death
Pain Duration	<15 minutes	>20 minutes
Relief	Rest & nitroglycerin	Not relieved by NTG
Troponin	Normal	Elevated
ECG	May be normal	ST changes (STEMI/NSTEMI)
Tissue Damage	No	Yes
Fever	No	Yes (late sign)
Opioids needed?	No	Yes (often morphine)

What is Acute Coronary Syndrome (ACS)

Unstable Angina + Myocardial Infarction = ACS

ACS occurs when:

• Atherosclerotic plaque ruptures

• Acute thrombus forms

• Coronary blood flow is reduced or blocked

• Myocardial ischemia occurs

• May progress to infarction (irreversible damage)

It is a medical emergency.

Emergency Management of ACS

MONA-B:

• Morphine

• Oxygen

• Nitroglycerin

• Aspirin

• Beta blocker

What is Sudden Cardiac Arrest?

Unexpected death within 1 hour of symptom onset.

It is usually caused by a lethal dysrhythmia, most commonly:

Ventricular Fibrillation

How Sudden Cardiac Arrest connect to MI?

A myocardial infarction can:

• Damage tissue

• Create electrical instability

• Trigger VT → VF

• Cause sudden cardiac arrest

Thrombolytic drugs: Indication, contraindications, s/e, antidote?

Suffix: ase

Examples: Streptokinase, Alteplase,

Indication: dissolve (lysis) unwanted blood clots; Used for strokes, heart attack, pulmonary embolism, DVT

Contraindications:

Recent surgery, active bleeding, uncontrolled ypertension, current anticoagulant use, NSAIDS

AE: Bleeding

Antidote: Aminocaproic Acid

What is Mitral valve stenosis?

• The mitral valve opening is narrowed

• Blood cannot pass easily into the LV

• Blood backs up into the LA

Common caused of Mitral valve stenosis?

After untreated strep throat:

Rheumatic Fever → s/ s Joint Inflammation, Sydenham chorea, Truncal Rash ← Primarily in Children

What Happens to Blood Flow during Mitral valve stenosis?

1⃣ LA pressure increases
2⃣ LA enlarges
3⃣ Blood backs up into lungs
4⃣ Pulmonary congestion occurs

What is Mitral Valve Regurgitation?

“Permits backflow of blood from the left ventricle to the left atrium during ventricular systole.”

The valve does NOT close completely

• Blood leaks backward into the left atrium

That backward flow causes the murmur.

What is Mitral Valve Prolapse?

What Happens in Mitral Valve Prolapse?

Normally:

• During systole (ventricular contraction)

• The mitral valve closes tightly

• Blood moves forward into the aorta

In MVP:

The valve cusps bulge (billow) upward into the left atrium during systole

Because they do not close tightly:

• Blood may leak backward into the LA

• This can cause mitral regurgitation

What is Aortic stenosis

• The aortic valve opening is narrowed

• Blood has difficulty leaving the LV

• The LV must work much harder to pump blood out

Why Does It Happen?

Age-related calcification

Congenital bicuspid aortic valve

Accumulates Over Decades

This is a slow, progressive disease.

What Happens to the Heart?

LV pressure increases
LV muscle thickens (left ventricular hypertrophy)
Eventually → ↓ cardiac output

This is a pressure overload problem.

SAD

• Syncope (especially with exertion)

• Angina

• Dyspnea (heart failure)

What is Aortic Regurgitation?

“The leaflets cannot close properly during diastole.”

Normally:

• During diastole, the aortic valve closes

• Prevents blood from flowing back into the left ventricle (LV)

In aortic regurgitation:

• The valve does NOT close completely

• Blood leaks backward from the aorta → left ventricle

This is called regurgitation (insufficiency).

What Is Infective Endocarditis?

An infection of the inner lining of the heart (endocardium), usually affecting the heart valves.

Most commonly caused by:
Bacteria

How Do Bacteria Get There that causes Infective  Endocarditis (Valves)?

Bacteria enter the bloodstream (bacteremia) through:

• IV drug use (injection of drugs)

• Trauma

• Dental procedures

• Genitourinary procedures

• Indwelling urinary catheters

• GI instrumentation

• Spread from respiratory infections

What Happens in the Heart that causes Infective  Endocarditis (Valves)?

Bacteria attach to damaged endothelium (usually a valve)
2⃣ They multiply
3⃣ They form vegetations

Blood-borne microorganisms adhere and proliferate, infiltrate thrombi, and accelerate the clotting cascade

That means:

• Infection + clot formation happen together.

Manifestations of Infective Endocarditis, complication

Fever

New or changed cardiac murmur

Petechial lesions of the skin, conjunctiva, and oral mucosa

weight loss

back pain

night sweats

Manifestations secondary to embolism in any organ

Why Is Aortic Valve Endocarditis So Dangerous?

Heart failure in up to 80% with aortic valve endocarditis
Manifestations secondary to embolism in any organ

Spleen, kidney, peripheral blood vessels

What Is Myocarditis?

inflammation of the heart muscle (myocardium).

This can reduce contractility → ↓ cardiac output.

what causes Myocarditis?

Immune –mediated disease (IBD, SLE)

Physical agents (ETOH)

Bacteria, Viruses, Fungal and Parasitic (see Box 18.3)

(i.e., HIV, Influenza, Strept, Candida)

what is Pericardial Effusion? s/s

“Fluid Around the Heart”

The heart sits inside a sac called the pericardium.

Normally:

• There is a small amount of lubricating fluid (15–50 mL).

In pericardial effusion:

• Excess fluid accumulates in the pericardial space.

S/S of right heart failure

an abnormal accumulation of fluid in the pericardial cavity.

what is Cardiac Tamponade

when Pericardial Effusion become severe → Fluid in the pericardium builds up and results in compression of the heart.

Onset may be rapid or more gradual.

Sign and Symptoms of Cardiac Tamponade

cardiogenic shock; shortness of breath, weakness, lightheadedness, and cough

muffled

What Is Acute Pericarditis?

inflammation of the pericardium, the sac surrounding the heart.

When inflamed:

• The pericardial layers rub against each other

• Causes sharp chest pain

• May produce a friction rub

What causes Acute Pericarditis?

Idiopathic

Viral Cause (influenza, hepatitis, measles, mumps, varicella)

HIV* most common complication of HIV is Pericarditis

MI, Trauma, surgery, uremia, TB

Connective tissue diseases

Radiation therapy

Clinical Manifestations Acute Pericarditis?

Pain worsen when supine → Position in upright position and sl leaning forward as this decrased pain by using gravity to take pressure off heart muscle

Inflammation

Fever

Pericardial Damage

Leukocytosis

Malaise

Tachycardia

What is Chronic Pericarditis?

After repeated or severe pericarditis:

• The inflamed pericardium heals with fibrosis and scarring

• The sac becomes thick, rigid, and non-elastic

• It may even calcify

Instead of being soft and flexible, it becomes like a tight shell around the heart.

Symptoms of Chronic Pericarditis

• Activity intolerance

• Weakness

• Fatigue

• Systemic venous congestion

Goal: improve cardiac contractility.