Cardiovascular Disorders- Level 2

Cardiovascular System

Lecture Objectives: Cardiovascular Disease

• Etiology and Pathophysiology

• Risk Factors

• Clinical Manifestations

• Diagnostic Tests

• Complications

• Treatments

• Nursing Interventions

Cardiovascular Disease

• CAD (Coronary Artery Disease)

  • Asymptomatic

  • Chronic Stable Angina

• ACS (Acute Coronary Syndrome) - More serious manifestations of CAD

  • Unstable Angina

  • MI (Myocardial Infarction)

    • NSTEMI (Non-ST Elevation MI)

    • STEMI (ST Elevation MI)
      Cardiac circulation involves the right coronary artery, left anterior descending coronary artery, left main, and left circumflex.

Definition of CAD (Coronary Artery Disease)

• Atherosclerosis of the coronary arteries

• Slow, gradual narrowing of the coronary arteries that supply blood and oxygen to the heart muscle.

Atherosclerosis

A. Chronic Endothelial Injury
* Hypertension
* Tobacco use
* Hyperlipidemia
* Hyperhomocysteinemia
* Diabetes
* Infections
* Toxins

B. Fatty Streak
* Lipids accumulate and migrate into smooth muscle cells

C. Fibrous Plaque
* Collagen covers the fatty streak
* Vessel lumen is narrowed
* Blood flow is reduced
* Fissures can develop

D. Complicated Lesion
* Plaque rupture
* Thrombus formation
* Further narrowing or total occlusion of vessel. Can occur in any artery in the body!

Collateral Circulation

• Collateral vessels grow around ischemic areas.

• Triggered by ischemia

Risk Factors of CAD

• Modifiable:

• Dyslipidemia: Elevated LDL cholesterol, low HDL cholesterol, high triglycerides.

  Hypertension.

  Smoking

  Diabetes Mellitus

  Obesity

  Sedentary Lifestyle

  Poor Diet

• Non-Modifiable:

• Age: Increased risk with age (men >45 years, women >55 years).

  Gender: Men are at a higher risk before menopause; postmenopausal women have an increased risk.

  Genetics: Family history of CAD or premature cardiovascular disease (CVD).

  Ethnicity: Higher incidence in African Americans and South Asians.

• Risk Factor Management

Assesment & Diagnostics:

A. Electrocardiogram (ECG/EKG)

- ST-segment depression or T-wave inversion → Suggests myocardial ischemia.

- Pathologic Q waves → Suggests previous MI.

- ST-segment elevation → Indicates acute MI.

B. Stress Testing (Exercise or Pharmacologic Stress Test)

Purpose

C. Echocardiogram

Purpose

D. Nuclear Imaging (Myocardial Perfusion Scan)

E. Coronary Calcium Scoring (CT Scan)

Coronary Angiography (Cardiac Catheterization) – Gold Standard

• Findings: >50% stenosis in a major artery confirms CAD.

S/s:

• Stable Angina: Chest pain or discomfort precipitated by exertion or stress, relieved by rest or nitroglycerin.

  Unstable Angina: More severe chest pain, may occur at rest, and is not relieved by nitroglycerin.

  Shortness of Breath (Dyspnea)

  Fatigue and Weakness

  Palpitations

  Dizziness or Syncope (Fainting)

  Nausea/Vomiting (especially in women and diabetic patients)

Complications:

Acute Coronary Syndrome (ACS) Unstable angina, Non-ST Elevation Myocardial Infarction (NSTEMI), or ST-Elevation Myocardial Infarction (STEMI).

Heart Failure

Cardiac Arrhythmias Risk of atrial fibrillation (AFib), ventricular tachycardia, and ventricular fibrillation.

Sudden Cardiac Death Can occur due to severe ventricular arrhythmias or acute coronary occlusion.

Medications:

Antiplatelet Therapy:

- Aspirin (81-325 mg daily)

- Clopidogrel (Plavix)

Lipid-Lowering Agents:

- Statins (e.g., Atorvastatin, Rosuvastatin)

- Ezetimibe or PCSK9 inhibitors

Beta-Blockers:

- Metoprolol, Atenolol

ACE Inhibitors/ARBs:

- Lisinopril, Losartan

Nitrates:

- Nitroglycerin sublingual (PRN for angina)

Calcium Channel Blockers:

- Amlodipine, Diltiazem

Diuretics and Antihypertensives

Interventions:

• Administer Medications as Prescribed:

  • Provide Oxygen Therapy:

  • Encourage Lifestyle Changes:

  .

  • Educate on Nitroglycerin Use:

  - Teach patients to take 1 tablet every 5 minutes up to 3 doses for chest pain.

  • Monitor for ACS Symptoms

  • Psychosocial Support:

  • Discharge Planning & Follow-Up:

  - Ensure patients attend cardiac rehabilitation and routine cardiology visits.

Health Promotion/Patient Teaching

• Identify at-risk patients for CAD.

• Risk screening.

• Management of high-risk patients.

• Reducing risk factors (What will you teach as a nurse for the modifiable risk factor prevention?).

• Modify eating habits for healthy ones

• Dont smoke

• Exercise

• Manage stress

• Monitor BP regularly

  • What medications or lifestyle changes need to be included in the prevention of CAD?

Management of CAD

• Lifestyle changes

• Nutritional therapy

• Drug therapy

  • Lipid-lowering drugs for hyperlipidemia

  • Antiplatelets

• Gerontologic considerations

Angina

• "Pain in the chest"

• Myocardial ischemia

• Supply and demand

Assessment of Angina

• Health history

• Pain

  • PQRST (Precipitating event, Quality, Radiation, Severity, Time of onset)

• Vital signs

• Auscultate

• Assess peripheral circulation

Possible Locations of Chest Pain

• Upper chest

• Substernal radiating to neck and jaw

• Substernal radiating down left arm

• Epigastric

• Epigastric radiating to neck, jaw, and arms

• Neck and jaw

• Left shoulder

• Intrascapular and down both arms

Factors Influencing Cardiac O_2 Needs

• Decreased O_2 Supply

  • Cardiac

    • Coronary artery atherosclerosis

    • Coronary artery spasm/thrombus

    • Dysrhythmias

    • Heart failure

    • Valve disorders

• Increased O_2 Demand or Consumption

  • Left Ventricular hypertrophy

  • Tachycardia

  • Aortic stenosis

  • Dysrhythmias

  • Cardiomyopathy

Factors Influencing Cardiac O_2 Needs

• Decreased O_2 Supply

  • Noncardiac

    • Anemia

    • Asthma, COPD

    • Hypovolemia

    • Hypoxemia,

    • Pneumonia

• Increased O_2 Demand or Consumption

  • Anxiety

  • Hypertension

  • Hyperthermia

  • Hyperthyroidism

  • Physical exertion

  • Substance (stimulant) abuse (cocaine, amphetamines)

Major Types of Angina

• Silent Ischemia

• Microvascular Angina

• Prinzmetal's Angina

  • Vascular artery spasm

• Chronic Stable

• Unstable (Falls under ACS)

Angina Types Explained

• Silent Ischemia - No subjective symptoms

• Microvascular Angina - Absence of coronary atherosclerosis or spasm

• Prinzmetal Angina (Variant Angina)

  • Spasm of a coronary artery

  • Occurs often at rest

  • Triggered by: Smoking and increased levels of some substances

  • Rare

  • Treatment: Nitro, Calcium channel blockers

Chronic Stable Angina

• Episodic pain lasting a few minutes

• Similar pattern of onset, duration, intensity

• Provoked by exertion (stress, exercise, physical activity)

• Relieved by rest or nitro

Diagnostic Studies for CAD/Chronic Stable Angina

• EKG

• Chest X-Ray

• Stress Test

  • Exercise

  • Nuclear

  • Echo

• Electron Beam Computed Tomography (EBCT)

• Cardiac Catheterization

• Labs

Chronic Stable Angina Treatment

• Antiplatelet/Anticoagulants

• Antianginal

• ACE Inhibitor/Angiotensin Receptor Blocker

• Beta Blocker

• BP Control

• Cigarette Smoking Cessation

• Cholesterol Management

• Calcium Channel Blockers

• Cardiac Rehab

• Diet

• DM Management

• Depression Screening

• Education

• Exercise

• Tx

ACS (Acute Coronary Syndrome)

• Includes:

  • Unstable Angina

  • MI (Myocardial Infarction)

    • Non-ST Elevation MI (NSTEMI)

    • ST Elevation MI (STEMI)

Unstable Angina

• New onset angina

• Unpredictable angina of increasing frequency, duration, or severity

• Pain at rest or with minimal exertion (ex.: sleeping)

• Easily provoked

Care of the Patient with Angina

• Balance oxygen supply and demand

  • MONA

    • Morphine

    • Oxygen

    • Nitroglycerin

    • Aspirin (Plavix)

  • MONA GREET ALL PATIENTS WITH CHEST PAIN

Clinical Manifestations of MI

• Pain

• Sympathetic Nervous System Stimulation

• Cardiovascular Manifestations

• N/V

• Fever Possible
  *What is the priority for the MI? How will this be treated?

Degree of Infarction

• After an MI, the heart muscle has three zones of damage:

  • Ischemic zone

  • Area of injury

  • Area of necrosis

• Necrotic tissue dies from lack of blood flow. Injured cells may recover and ischemic cells can be saved if the area is reperfused promptly.

Complications of MI

• Dysrhythmias

• Heart Failure

• Cardiogenic Shock

• Papillary Muscle Dysfunction

• Left Ventricular Aneurysm

• Ventricular Septal Wall & Left Ventricular Free Wall Rupture

• Pericarditis

• Dressler Syndrome

Diagnostic Studies for UA/MI

• EKG

• Stress Testing

• Serum Cardiac Biomarkers

• Coronary Angiography

Serum Cardiac Markers (UA/MI)

• Released into the blood from necrotic heart muscle after MI

  • CK rise after 6 hours after MI

  • CKMB specific to myocardial cells

  • Troponin has greater specificity/affinity of MI and increase 4-6 hours after onset of MI

  • Myoglobin

Stress Testing

• Exercise Stress Test

  • Treadmill

• Stress Test with those unable to exercise

  • IV Medications

• Pre-Procedure

  • What do we do?

Electrical System and EKG

• P wave: Atrial Depolarization

• QRS complex: Ventricular Depolarization

• T wave: Ventricular Repolarization

\text{Isoelectric segment}

• Delay at AV Node: Atrial Conduction

EKG: It’s All About the ST

• P wave, QRS complex, and T wave represent atrial depolarization, ventricular depolarization and ventricular repolarization respectively.

Ischemia, Injury, Infarction (EKG Changes) slide 34

• Ischemia: ST segment depression, T wave inversion

• Injury: ST segment elevation

• Infarction: Pathologic Q wave, ST segment elevation, T wave inversion

Which Leads Look Where?

• Inferior Wall: II, III, aVF (RCA)

• Lateral Wall: I, aVL, V5, V6 (Circ)

• Anterior Wall: V3-V4 (LAD)

• Septum: V1, V2 (LAD)

• Anterior wall and septum often infarct together because both supplied by LAD, so anteroseptal MI shows in V1-V4

Overview of Terms

• Heart Catheterization (Heart Cath)

• Coronary Angiography

• PCI (Percutaneous Coronary Intervention)

Treatment Options Overview

• Time is Muscle!

  • Angioplasty

  • Stents

  • Fibrinolytic Therapy

  • CABG (Coronary Artery Bypass Graft)

PCI (Percutaneous Coronary Intervention)

• Off to Cath Lab!

• Evaluate the coronary arteries

• Goal: Open affected artery within 90 minutes of ED arrival

• Common procedure

• First-line treatment for PT’s with MI!

Balloon Angioplasty

• Guiding catheter is inserted into the aorta.

• Balloon catheter is positioned at vessel narrowing and inflated.

Application of Coronary Stent

• A stent is expanded within the artery to support the vessel walls.

Cardiac Stents

• Stents are used to maintain the patency of coronary arteries after angioplasty.

Occlusion of RCA

• Images showing occlusion and subsequent repair of the right coronary artery (RCA).

Post PCI Nursing Care

• Monitor site, peripheral pulses, cap refill

• Post-procedure orders

• Continuous EKG monitoring & VS

• Pain control

• Meds

• Diet

• Patient teaching!!!!

Thrombolytic Therapy

• Treatment when PCI not available

• Criteria:

  • Chest pain less than 12 hrs

  • EKG shows STEMI

  • No bleeding contraindications

• Fibrinolytic Therapy

  • Retavase (RPA), Alteplase (TPA), Tenecteplase (TNKase)

CABG Indications

• Failed medical management or PCI

• Left main CAD

• 3 vessel disease

• Not a candidate for PCI

• Sternotomy

• Graph veins (saphenous site)

• Post-op risk: Bleeding, MI, CVA, Infection

Post-Op Nursing Indications CABG

• ICU 24-36 hrs

• Drug therapy

• Hemodynamic status

• Monitor for bleeding (chest tube is placed in mediastinal area)

• Dysrhythmias are common

• Neurovascular checks

• Wound care (sternotomy site and graph site)

• Early mobilization/cough deep breathing

Sudden Cardiac Death

• Sudden disruption in cardiac function with abrupt loss of CO and cerebral blood flow

• 400,000 deaths/year in the US

• Predictors:

  • Left ventricular dysfunction (EF < 30%)

  • Ventricular dysrhythmias post MI

• Treatments: EP studies, AICD, Amiodarone, Heart Transplant

Nitroglycerin

• Route:

  • Short Acting

    • Sublingual, Spray

    • IV

  • Long Acting

    • PO, Paste, Transdermal

• Give 1 dose Q 5 min X3 (no relief call 911)

• Drug interactions

• Contraindications

• Side effect: HA, Tingling, Flushing, Dizziness, Hypotension

• Teaching: What will you need to teach about Nitro?

Chronic Stable Angina & ACS: Drug Therapy

• Antiplatelet Agents

  • ASA, Plavix (Clopidogrel); Effient(Prasugrel); Brilinta (Triagrelor), Glycoprotein IIa/IIIa inhibitors

• Lipid Lowering Agents

  • Statin Drugs

  • Niacin

  • Fibric Acid Derivatives

  • Omega 3- Fatty Acids

• Opioid Analgesics

  • Morphine Sulfate (Morphine)

Chronic Stable Angina & ACS: Drug Therapy (Continued)

• Nitrates

  • Sublingual, Spray, IV Drips, Ointment, Transdermal, PO

• Beta-Adrenergic Blockers

• Calcium Channel Blockers

• Angiotensin-Converting Enzymes (ACE) Inhibitors

• Angiotensin II Receptor Blockers (ARBs)

• Sodium Current Inhibitors

Chronic Stable Angina & ACS: Drug Therapy (Continued)

• Anticoagulant Agents

  • Unfractionated Heparin (Heparin)

  • Low-Molecular Weight Heparin (Lovenox)

  • Vitamin K Antagonist (Coumadin)

  • Direct Thrombin Inhibitors (Angiomax)

Chronic Stable Angina & ACS: Drug Therapy (Continued)

• Thrombolytic Agents

  • Reteplace (Retavase), Alteplase (Activase), Tenecteplase (TNKase)

• Antidysrhythmic Drugs

• Stool Softeners

Cardiac Rehab - "Mended Hearts"

• Long Term

• Exercise

• Risk Factor Modification

• Patient Education

• Sexual Counseling

Nursing Implementation

• Health Promotion

• Nutritional Therapy

• Drug Therapy

• Physical Activity

• Home Blood Pressure Monitoring/HR

• Patient Compliance

Goals of Nursing Care

• Relieve Chest Pain

• Manage Blood Pressure

• Assist the Client in Reducing Cardiac Workload

• Promote Oxygenation

• Psychosocial Support

Health Promotion

• Reduce Risk Factors

• Instruction on Use of Medications

• Reduce Anxiety

• Provide Adequate Knowledge of Treatment and Problem

Nursing Diagnosis

AFIB

• Normal electrical pathways vs. Abnormal electrical pathways

• Normal sinus rhythm originates from the sinus (SA) node and travels to the Atrioventricular (AV) node.

• Atrial fibrillation involves abnormal electrical pathways.

Atrial Fibrillation

• Heart Rate: A: 350-650 bpm, V: Slow to rapid

• Rhythm: Irregular

• P Wave: Fibrillatory (fine to course)

• PR interval: N/A

• QRS: <.12