Module 2: Cardiovascular disease

Coronary Artery Disease

• most prevalent type of cardiovascular disease in adult.

• Is the term given to heart problems caused by narrow heart (coronary) arteries that supply blood to the heart muscles.

Ischemic Heart Disease

• is a condition in which there is an inadequate supply of blood and oxygen to a portion of the myocardium

• Imbalance between myocardial oxygen supply and demand.

• Caused mainly by Atherosclerosis of Coronary Artery

• It includes – Angina: Stable & Unstable – Myocardial infarction – Heart failure & Arrhythmia

Pathophysiology

• Reduced blood flow in a coronary artery (rupture of an atherosclerotic plaque).

• A clot begins to form on top of the coronary lesion, but the artery is not completely occluded

• Flow cannot be increased resulting to ischemia resulting to chest pain

Precipitating factors

• Overexertion

• Exposure to cold

• Overeating

• Emotional stress

Risk Factors

• DM

• Atherosclerosis (hardening of the blood vessels due to plaque formation)

• Hypertension

• Hormonal imbalances

Medication

• Nitrates (Nitroglycerine) : Short- and long-term reduction of myocardial oxygen consumption through selective vasodilation

• Beta-adrenergic blocking agents (Metoprolol) : Reduction of myocardial

  oxygen consumption by blocking beta-adrenergic stimulation of the heart

• Calcium Ion Antagonists (Amlodipine) : Negative inotropic effects; indicated in patients not responsive to beta-blockers; used as primary treatment for vasospasm

• Antiplatelet (Aspirin) : Prevention of platelet aggregation

• Anticoagulants (Heparin) : Prevention of thrombus formation

Nursing Management

• assist w/ ambulation

• pain elevation

• diet, exercise, CABG

Angina

is chest pain or discomfort caused when your heart muscle doesn't get enough oxygen-rich blood. It may feel like pressure or squeezing in your chest. The discomfort also can occur in your shoulders, arms, neck, jaw, or back.

Stable Angina

• type of angina episodic clinical syndrome where there is no change in severity of attacks.

Unstable Angina

• type of angina Deterioration (24 hrs.) in previous stable angina with symptoms frequently occurring at rest, i.e., acute coronary syndrome.

Intractable or Refractory Angina

• type of angina severe incapacitating chest pain

Silent Ischemia

• Type of angina Objective evidence of Ischemia (such as electrocardiographic changes with the stress test), but patient reports no pain

Variant Angina (Prinzmetal)

• type of angina Pain at rest with reversible ST-Segment elevation; thought to be caused by coronary artery vasospasm

Myocardial Infarction

• Commonly known as a heart attack, occurs when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle.

Pathophysiology

• Coronary occlusion due to thrombosis, embolism, or hemorrhage adjacent to atherosclerotic plaque. Insufficient blood flow from cardiac, hypertrophy, hemorrhage, shock, or severe dehydration.

Risk Factors

• Age, Gender

• Lifestyle: Stress, Habits

• Diet

• Chronic illness: DM, HPN

Assessment

• Type: Sudden, severe, crushing, heavy, tightness

• Location: Substernal, radiates to one or both arms, jaw, neck

• Duration: >30 mins

• Relief: Oxygen, narcotics Not relieved by rest and nitroglycerin

• Subjective data: Shortness of breath, apprehension, fear of impending death, nausea

• Objective data: Symptoms of shock, cyanosis, diaphoresis, restless

Diagnostic test

• ECG

• chest x-ray

• chest CT

• coronary CT angiography

• cardiac MRI,

• coronary angiography

• echocardiogram

Nursing Management

• MONA (Morphine, Oxygen, Nitrates, Acetylsalicylic acid)

• CVP: normal= 5-15cm H20

• Lab data: Na+135-145; K 3.5-5.0 mEq/L

• Stool Softener, avoid Valsalva, mouth breathing

Coronary artery bypass graft (CABG)

performed with the patient under general anesthesia (saphenous vein, left internal

mammary artery) is grafted distal to the coronary artery lesion, bypassing the obstruction

Percutaneous Transluminal Coronary Angioplasty (PTCA)

one at cardiac lab. Insertion of catheter at the femoral artery, sometimes at the radial vein going to the aorta, and into the coronary arteries.

Sample procedure

• Balloon-tipped catheter is passed into the affected coronary artery and

  placed across the area of the atheroma (plaque).

• Balloon is then rapidly inflated and deflated with controlled pressure.

• A stent is placed to maintain patency of the artery, and the balloon is

  removed

Coronary Artery Stent

metal mesh that provides structural support to a vessel at risk of acute closure (partially/complete) after PTCA.

Heart Failure

• is often referred as congestive Heart failure is often referred as congestive heart failure (CHF). Occurs when heart is unable to pump sufficiently to maintained blood flow to meets the body needs

• can be systolic dysfunctions or diastolic dysfunctions

Classification

• Left sided

• Right Sided

• High Output

• Low Output

Etiology

• The incidence of heart failure increases with advancing age and coronary artery disease

• Diabetes

• Cigarette Smoking

• Obesity

• Elevated Total Cholesterol

• Abnormally High or Low Hematocrit Level

• Proteinuria

Medical Management

• control HPN and atrial fibrillation

• optimize pharmacologic regimens

• reduce heart workload by reducing preload and afterload

• promote lifestyle conducive to cardiac health

Pharmacological Management

• Digoxin

• Betablockers

• Inotropes

• Angiotensin II receptor blockers (ARBs : Tan)

• Ace Inhibitors (-pril)

• Diuretics

Surgical Management

• heart transplantation

Left sided Heart Failure

• left ventricle cardiac output is less then volume received from pulmonary circulation; blood accumulates in the left ventricle, left atrium.

• Pulmonary congestion forcing fluid from pulmonary capillaries into pulmonary tissue and alveoli causing pulmonary interstitial edema and impaired gas exchange.

Right Sided heart failure

• right ventricle cardiac output is less then volume received from the peripheral venous circulation, blood accumulates in RA, RV and peripheral venous system.

• Increased venous pressure led to JVD and increased capillary hydrostatic pressure throughout the venous system.

High Output Heart failure

• occurs in response to condition that causes the heart to work harder to supply blood; the increase oxygen demand can only meet only with an increase in cardiac output.

Low Output Heart Failure

• occurs in response to high BP of hypovolemia which results in impaired peripheral circulation and vasoconstrictions.

Orthotopic heart transplantation

is a well-established and commonly utilized procedure for end-stage heart failure patients. Heterotopic heart transplantation (HHT) is a surgical procedure that allows the graft to be connected to the native heart in a parallel fashion.

Heterotopic heart transplantation

is a surgical procedure that allows the graft to be connected to the native heart in a parallel fashion. The main advantage of HHT is to assist the patient's native heart and to maintain circulation in the cases of severe acute rejection.

Total Artificial Heart

Much research has been conducted trying to develop a mechanical device that can permanently replace the heart and has no external tubes or cables. Several successful cases have been reported. However, research is continuing.

Ventricular Assist Device (VAD)

• It is an Electromechanical device for assisting cardiac circulation, which is used either to partially or to completely replace the function of a failing heart.

• The function is different from that of artificial cardiac pacemakers; some are for short-term use, typically for patients recovering from myocardial infarction (heart attack) and for patients recoveringfrom cardiac surgery.

Hypertension

• another name for high blood pressure. It can lead to severe health complications and increase the risk of heart disease, stroke, and sometimes death. Blood pressure is the force that a person's blood exerts against the walls of their blood vessels.

Oral Drugs

• ACE inhibitors : Catopril

• Betablockers: Labetalol

• Clonidine guanabenz, prazosin, and minoxidil

• Loop diuretic: is generally prescribed in addition to be antihypertensive agents.

Hypertensive Crises

• is a severe increase in blood pressure that can lead to a stroke. Extremely high blood pressure — a top number (systolic pressure) of 180 millimeters of mercury (mm Hg) or higher or a bottom number (diastolic pressure) of 120 mm Hg or higher — can damage blood vessels.

Manifestation

• ARF, identified by a sudden absence of urine output Catecholamine excess.

• Cardiovascular compromise, identified by the chest pain of an acute coronary syndrome or aortic dissection.

Pharmacologic Management

• Angiotensin-converting enzyme (ACE) inhibitors

• Angiotensin receptor blockers (ARBs)

• Diuretics

• Beta-blockers

• Calcium channel blockers

Nursing Management

• Monitor BP

• administer antiHPN drugs

• 2 large-bore IVs

• O2

• limit fluid intake

• assess ECG

Hypertensive urgency

• defined as an elevation of SBP (>220mmHg) and/or DBP (>125mmHg)

  without evidence of acute end-organ damage.

• defined as a sudden increase in systolic and/or diastolic BP associated with end- organ damage of the CNS, the heart, or the kidneys.

• Not necessitate admission to ICU

• BP is lowered gradually over a period of 24 to 48 h

• Usually treated with rapid-acting oral antihypertensive agents

Antihypertensive Emergency

• A hypertensive emergency is an acute, marked elevation in blood pressure that is associated with signs of target-organ damage. These can include pulmonary edema, cardiac ischemia, neurologic deficits, acute renal failure, aortic dissection, and eclampsia.

Cardiomyopathy

• cardiac muscles ate too thin, hard, or thick leading to weaker output

• Disease of the heart muscle which inhibits heart pumping, making less oxygen to the body

Causes

• Genetics

  • due to deposits of particles making myocardium hard

    • Amyloidosis = protein deposits

    • sarcoidosis = inflammatory cell deposits

    • Hemochromatosis = iron deposits

• Damage to the heart

  • due to radiations

Characteristics

• Dilated - Distended heart muscle

• Restrictive - rock hard heart muscle

• Hypertrophic - huge trophy-like heart muscle

Category

• Primary - develop all by itself

• Secondary - cause of HTN or valve disease

Medication

• ACE inhibitors (-pril) (calm down and slow HR)

• Beta blocker(-olol) (slow HR)

• Calcium Channel Blocker (-pine, -zem)

• Digoxin (Cardiac Glycoside) (deeper contraction)

• Diuretics (Dehydrate body to decreased pressure)

Surgery

• Left ventricular Assist Device

• Heart Transplant

Dilated Cardiomyopathy

• chambers of the heart are distended and loosening up the valve causing no effective systole

• causing systole failure

• less cardiac output, less oxygen out of the body

Process

• Body thinks that we have low BP and increased SNS and increased heart rate and RAAS

Symptoms

• Syncope and altered LOC (Restlessness and agitation)

• SOB and fatigue

• Angina and ECG (Heart block)

• Left Heart failure (Lung filled w fluid = Crackles and Pulmonary Edema)

• Right Heart failure (Body fluid = edema, ascites, and JVD)

• Regurgitation (Tricuspid and Bicuspid valves)

• Narrow pulse pressure

• S3 Murmur

Diagnostic test

• Chest X-ray

• Angiography

• Echocardiogram

• Elevated BNP (breaking and stretching of ventricles) (>100 not good)

Treatment

• Diet (low in sodium and fat)

• Rest periods

• Exercise

• Stop smoking and alcohol

• stress reduction

Restrictive Cardiomyopathy

• rock hard heart or heart muscle thickens

Pathophysiology

• heart muscles thickens and does not allow ventricle stretch and refill, refill problems.

• less blood in, less cardiac output, less oxygen out to the body

• making heart more stiff

Symptoms

• Restlessness and Agitation

• angina and dysrhythmias

• HF

  • LHF = Crackles and pulmonary edema

  • RHF = edema, ascites, JVD

Diagnostics

• CXR - normal not enlarge

• Echocardiography - normal

• MRI - rule out pericarditis

Goal

• increase cardiac output and oxygen to the body

• mostly repaired when lessening radiation exposure

Hypertrophic Cardiomyopathy

• Most deadly

• heart becomes thick and hard, limits the heart from filling

• septal starts to grow blocking the exchange of blood

Causes

• Genetics

Symptoms

• mostly asymptomatic, but later on when exposed to strenuous activity shows symptoms

• SOB and Fatigue

• Altered level of consciousness

• S3 murmur

Diagnostic test

• Heart murmur

• CXR (Normal)

• Echo (Septal wall thickened)

Surgery

• myomectomy

Medication

• Beta blockers (Block beats)

• Calcium Channel Blockers (Calm heart)

Infective Endocarditis

• inflammation of the endocardium layer of the heart

• bacteria and viruses gets in the bloodstream through invasive procedure (e.g. invasive procedure)

• pathogen attaches to the valved involved and WBC cannot reach the valve since they do not have blood stream

Causes

• Invasive procedure

• implants

• central lines

• IV drug use

• rheumatic heart disease

Complications

• narrow valve

• heart failure

• embolism

Types

• Acute IE: affects patients with healthy heart valve, sudden and very severe

• Subacute IE: affects patients with preexisting condition. subtle signs and symptoms.

Symptoms

PATHOGENS

• Petechiae

• Anorexia

• Tired and weak

• High Fever and Heart Failure

• Oster’s Nodes : Tender red lesions on hands and feet

• finGernails clubbing

• Embolic events: erythematous, non tender lesions on palm and foot

• Night sweats and New cardiac murmur

• Splenomegaly

• Roth Spots: burst blood vessels in retinas

Diagnostics

• Transesophageal echocardiogram

Medication

• Vancomycin

• Rocephin

Fibrinolytic therapy

• an important clinical intervention for patients experiencing acute ST segment elevation MI (STEMI)

• is predicted on the theory that the significant event in the acute coronary syndrome is rupture of an atherosclerotic plaque with thrombus formation

Selection criteria

• No more than 12 H from the onset of chest pain and preferably within 30 min of diagnosis of ST segment elevation myocardial infarction

• ST segment elevation on electrocardiogram or new-onset left bundle branch block

• Ischemic chest pain unresponsive to sublingual nitroglycerin

• no conditions causing predisposition to hemorrhage

Agents

• Streptokinase: derived from beta-hemolytic streptococci, combined with plasminogen, enzyme responsible for clot dissolution.

• Tissue Plasminogen Activator: is a naturally occurring enzyme that is clot specific and has a very short half-life

• Recombinant Plasminogen Activator: variant of tPA

• Tenecteplase: genetically engineered variant of alteplase with slower plasma clearance and better fibrin specificity

Percutaneous coronary interventions

• has become the gold standard in the treatment of acute coronary disease and to reverse ongoing and infarctions