Cardiac and Vascular Diseases

Exemplar Diseases

• Primary (essential) hypertension has no clear underlying cause
• Secondary hypertension is caused by another health condition
• Urgency vs. emergency hypertension crisis are different situations requiring tailored responses
• CAD stands for coronary artery disease which is caused by atherosclerosis
• There are two types of CAD stable and unstable angina
• ACS stands for acute coronary syndrome which includes STEMI and N-STEMI
• Cardiac catheterization can treat many heart conditions from CAD, and ACS and be critical in emergencies
• MI means myocardial infarction, commonly known as a heart attack
• Peripheral venous disease (PVD) affects the veins
• Peripheral artery disease (PAD) affects the arteries
• Normal EKG waves need to be interpreted to understand any irregular heart activity or conditions
• RAAS relates to hypertension, and is triggered by low blood pressure

Terms to Know

• Cardiac output (CO) is the amount of blood pumped in the circulatory system in 1 minute, measured in liters per minute (L/min)
• CO is calculated as: Stroke Volume (SV) x Heart Rate (HR)
• A normal cardiac output (CO) is 4-8 L/min
• Stroke volume is the volume of blood pumped out of the left ventricle per beat, measured in milliliters per beat (mL/beat)
• Systemic vascular resistance (SVR) refers to the force opposing blood movement, being the degree of constriction
• SVR is used in assessing blood flow, blood pressure and cardiac function
• High blood pressure (180/110) indicates vasoconstriction, leading to increased SVR and BP
• Low blood pressure (89/50) indicates vasodilation, leading to decreased SVR and BP
• Mean arterial pressure (MAP) is the average pressure in arteries during one cardiac cycle
• MAP is a better indicator of perfusion to vital organs than systolic blood pressure (SBP)
• MAP is calculated using the formula: (Systolic Blood Pressure (SBP) + 2(Diastolic Blood Pressure (DBP)))/3
• A normal MAP is between 60-100 mmHg
• MAP greater than 100 mmHg signifies too much pressure in the arteries indicating the heart is working too hard
• MAP less than 60 mmHg indicates not enough perfusion occurring resulting in low blood flow
• Ejection fraction (EF) is the percentage of blood leaving the heart with each contraction
• EF is a key indicator for measuring heart contractility
• A normal ejection fraction is between 55%-75%
• If the left ventricular ejection fraction (LVEF) is 60% then this falls within a normal range (WNL)
• Pulse pressure, calculated as SBP - DBP, should normally be 40 mmHg
• Pulse pressure Example: 120/80 = 40 mmHg which is normal (WNL)
• Pulse pressure example: 160/90 = 70 mmHg which is high because it is greater than 40 mmHg indicating hypertension

Diagnostics

• Echocardiograms uses ultrasound to measure EF and LVEF
• Echocardiograms are difficult to read in obese patients and sometimes need contrast to improve results
• EKGs and ECGs measure the electrical conductivity of the pumping heart
• A P-wave measures atrial depolarization
• A problem conducting electrical signals can be observed if there are issues with the P-wave
• A PR interval indicates a problem in conduction usually in the AV node, bundle of His, or bundle branches
• The PR segment shows a delay at the AV node
• The QRS complex shows ventricular depolarization
• A pathological Q wave in the QRS complex, indicates a past MI
• The QRS interval measures how long it takes for ventricular depolarization
• conduction problems may be indicated by bundle branch issues
• ST segment elevation or depression is caused by injury, ischemia or infarction
• T wave measures ventricular repolarization
• electrolyte imbalances, ischemia, or infarction can cause tall peaked, inverted T waves
• QT interval measures ventricular depolarization and repolarization
• Women tend to have slightly longer QT intervals than men
• Electrolyte imbalances, drugs or HR changes can cause more repolarization than depolarization problems
• The isoelectric line indicates no electrical activity is occurring
• Atrial fibrillation can be improved by bearing down resulting in decreased heart rate

Common Causes of Dysrhythmias

• Dysrhythmias can be caused by accessory pathways, cardiomyopathy, conduction defects, heart failure, myocardial infarction or valve disease
• Dysrhythmias can be caused by electrolyte or acid-base imbalances
• Alcohol, caffeine and tobacco can induce dysrhythmias
• Herbal supplements, drug effects, emotional distress, or drowning can induce dysrhythmias
• Electric shock, sepsis, hypoxia or toxins can induce dysrhythmias

Diagnostics Summary

• Blood tests for dysrhythmias include troponin (MI), CK-MB, LDL + HDL (CAD), BNP (HF) levels
• Diagnostic tests include ECG/EKG, EF measurement, CXR, CT, and MRI
• Cardiac catheterization or angiography is another diagnostic test
• Exercise stress tests can determine if any obstructions cause chest pain during exertion

RAAS

• RAAS regulates blood pressure and fluid balance which are related to hypertension
• Reactions to low BP triggers RAAS causing increased BP through vasoconstriction from angiotensin II and increased fluid retention caused by aldosterone
• Overactive RAAS results in chronic HTN that can be treated by anti-HTN meds like ACE inhibitors or ARBs
• Renin is the enzyme released when there is dysfunction of RAAS which starts the entire process
• Angiotensin II constricts blood vessels, increases BP, and increases aldosterone
• Uncontrolled hypertension indicates fluid overload leading to weight questions
• Hemorrhaging indicates fluid deficit
• Fluid deficit is indicated by fevers and conditions like Crohn's due to vomiting, diarrhea and diaphoresis

Hypertension

• Primary hypertension accounts for 90-95% of cases with no clear underlying cause
• Secondary hypertension accounts for 5-10% of cases and is caused by another health condition
• Risk factors for primary hypertension includes age (50+), alcohol use, diabetes mellitus and ethnicity
• Family history, sodium intake, gender, hyperlipidemia and obesity are risk factors for primary hypertension
• Sedentary lifestyle, socioeconomic status, psychological stress are risk factors for primary hypertension
• Non-modifiable risk factors include genetics, ethnicity, age and gender
• Risk factors for secondary hypertension include cirrhosis, and coarctation (narrowing) of the aorta
• Drug relates medications, endocrine disorders, and neurological problems a risk factor for secondary hypertension
• Pregnancy induced tumors and sleep apnea are all risk factors for secondary hypertension
• Glomerulonephritis and renal disease are risk factors for hypertension
• The main cause of hypertension is increased systemic vascular resistance (SVR) and constriction
• The number one cause of strokes is noncompliance with hypertension medications

Diagnosing Hypertension

• Repeated blood pressure measurements are the main test used for diagnosis
• EKG/ECG, echocardiogram, CXR, blood tests, urinalysis and retinal exams are tests to diagnose hypertension
• Hypertension is known as the "silent killer” because it is often asymptomatic until target organ damage occurs
• Symptoms include fatigue, dizziness, palpitations, angina, and dyspnea
• Hypertension crisis is characterized by a sudden systolic blood pressure (SBP) greater than 180 and/or diastolic blood pressure (DBP) greater than 120
• Severe headaches, nosebleeds and dyspnea are all signs of a hypertensive crisis

Treatment

• DASH diet includes low salt/sugar/fat, sodium and cholesterol
• The DASH diet limits salty foods and recommends salt intake be limited to 2300 mg/day
• The DASH diet also focuses on fruits, vegetables, nuts, beans, lean meats, whole grains and high fiber
• Exercise and weight loss help decrease workload leading to decreased atherosclerosis buildup
• Diuretics remove excess fluid, sodium, and water retention which decreases edema and BP
• Examples of diuretics include Furosemide, Bumatenide, and Hydrochlorothiazide,
• Limiting alcohol consumption to no more than 2 drinks per day helps manage hypertension
• Monitor BP regularly, especially before taking medication and watch orthostatic hypotension
• Monitor BP regularly and taking before medications and hold if SBP is less than 100 to avoid hypotension
• HTN meds should never be stopped abruptly to avoid rebound HTN
• Alpha-adrenergic agonists like Clonidine can cause withdrawal, rebound HTN, tachycardia, headache, and tremors
• Alpha-adrenergic blockers like Doxazosin and Prazosin, lower urine outflow resistance in BPH
• B-Adrenergic blockers lower heart rate and reduce palpitations making them an important treatment option
• Heart rate and blood pressure should be monitored regularly due to risk for hypotension and bradycardia
• Diabetes patients should use caution due to may depress tachycardia associated with hypoglycemia and adversely affect glucose metabolism
• Non-cardioselective B-Blockers should be used with caution in asthma patients
• Mixed alpha and beta blockers like Carvedilol and Labetalol are IV available for HTN crises
• When using mixed alpha and beta blockers, patients should be supine during IV administration
• Assess upright position tolerance before allowing upright activities
• ACE inhibitors cause vasolidation while preventing changes in muscle
• NSAIDs, ASA and ibuprofen should not be taken with ACE inhibitors
• Calcium channel blockers come with heart failure concerns and grapefruit juice interactions
• Intravenous Nicardipine is available for hypertensive crisis and peripheral IV sites should be changed every 12 hours
• Nitroglycerin is IV available for hypertensive crises especially with myocardial ischemia
• IV Sodium Nitroprusside is indicated for hypertensive emergency
• Hydrochlorothiazide can lead to orthostatic hypotension, hypokalemia and alkalosis
• NSAIDS shouldn’t be taken with Hydrochlorothiazide

Complications of Hypertension

• Target organ damage includes hypertensive heart disease, left ventricular hypertrophy, and heart failure (CAD, LVH, HF)
• Target organ damage includes cerebrovascular disease (TIA, stroke - cannot move limbs)
• Target organ damage includes peripheral vascular disease in peripheral vessels, kidney damage and retinopathy

Hypertensive Emergency vs Urgency

• Hypertensive emergency occurs within hours to days with SBP > 220/140
• Hypertensive urgency occurs within days to weeks with SBP> 180/120
• Hypertensive emergency YES target organ damage including encephalopathy
• Encephalopathy and cerebral edema from hypertensive emergency leads to symptoms like severe headache, confusion, coma, N/V or seizures
• Hypertensive urgency means NO target organ damage has occurred
• Emergency treatment means decrease BP via IV sodium nitroprusside
• Urgency situations can be treated with PO anti-HTN meds: captopril , Labetalol, Amlodipine
• Severe hypokalemia requires IV K+ first to avoid arrhythmias

CAD

• Coronary artery disease (CAD) is atherosclerosis (hardening) of coronary arteries
• The process of CAD is where fatty streaks turn into plaques and lesions
• There are two forms of CAD chronic (stable angina) and acute (ACS, unstable angina, STEMI, N-STEMI)
• Diagnosis includes assessment cholesterol, triglycerides levels, and c-reactive protein (CRP)
• EKG/ECG, echocardiogram, stress test, cardiac cath, blood test are all diagnostic tests
• HTN, high LDL, low LDL, DM, and obesity are modifiable risk factors of CAD
• Diet, sedentary lifestyle, stress and HTN are modifiable risk factor
• Non-modifiable risk factors are age, gender, family Hx, ethnicity
• Symptoms include fatigue, dizziness, dyspnea, angina, ischemia, and pain or discomfort
• Low fat, low cholesterol diets are treatments which include both monounsaturated and polyunsaturated fats
• Manageable risks need health promotion to reduce risk factors
• Antiplatelets and anticoagulants both increase bleeding risk
• Beta blockers decrease workload for blood pressure
• Calcium channel blockers relax vessels
• Nitroglycerin vasodilator relaxes and opens up arteries for better blood flow
• Monitor LFTs for liver failure and hepatotoxicity Increase effects of warfarin can occur
• Statins decrease cholesterol levels
• Niacin can be taken with food and can be taken with ASA or ibuprofen before to reduce flushing
• Omega-3 acid ethyl esters should be taken with food with those who have increase bleeding risk
• Complications can include angina, MI, HF, stroke and PAD/PVD related issues

Treatment of Angina

• Stable (chronic) angina is more common and predictable, stopping within a few minutes of nitroglycerin or rest
• Unstable (acute) angina is more serious and unpredictable potentially continuing despite resting or nitroglycerin
• ECGs are used to rule out acute MI both with stable and unstable angina
• Tx for both stable and unstable is MONA: morphine, O2, nitroglycerin, ASA
• STEMI is a complete occlusion with extensive damage characterized by ST elevation
• NSTEMI has partial occlusion and less extensive damage on the subendocardial myocardium
• MONA, anticoagulants, antiplatelets, ACE inhibitors, ARBS, beta-blockers, statins
• Adjunct for STEMI is to administer MONA and anticoagulants

Cardiac Catheterization

• Attach to HR monitor first b/c of dysrhythmias

• Cardiac Catheterization (or Coronary Angiography): catheter inserted through artery to Dx or Tx conditions (angioplasty or PCI – BF)

• Allergies: Iodine, shellfish, latex, contrast dye Gadolinium as a substitute dye for contrast (allergy) Hold metformin and anticoagulants (warfarin) Insertion sites: Femoral, radial, brachial arteries

• Priority nursing assessment: VS Peripheral circulation (pulse, color, temp., sensation) NV assessment, pulse ox, ❤️​ and breath sounds, cardiac biomarkers & Cr

• Teaching: NO caffeine/ exercise before, NPO 6H before Supine 2H after Increase fluid intake à flush contrast (bad for kidneys) Flushed/fluttering feeling of contrast Explain use of local anesthesia

• Complications: Bleeding à assess and address with a pressure/gauze dressing Bruising (hematoma) Blood clot Infection Irregular HR

• Serious Complications: MI Stroke Kidney damage from dye Perforation Ischemia Blockage of artery Complete cessation (blockage) of blood flow to a protion of the myocardium, which can lead to sudden death Sustained ischemia → 20 min. of ischemia before cell death 80-90% cases → thrombus or blood clot

• DIAGNOSIS Troponin = MI EKG/ECG Cardiac marker = CK-MB Angiography

• SS Palpitations Impending sense of doom Anxiety Dizziness/Fatigue Angina → jaw, neck, shoulder pain HTN + angina = maybe acute MI – assess/intervene first

20 minutes = charateristic of acute MI Obtain a 12 LEAD ECG for chest pain, records electrical activity from 12 different angles to identify signs of acute MI Dyspnea Tachycardia or Bradycardia Irregular Rythm and Irregular HR Decreased O2 Sats Pallor Weakness

Peripheral Vascular Disease

• Peripheral Vascular Diseases consists of Peripheral Venous Disease and Peripheral Artery Disease
• Peripheral Artery Disease affects blood flow, perfusion and oxygen delivery needing careful assessment
• PAD patients likely have CAD
• Lifestyle changes: Elevate + compress, no prolonged sitting or standing, maintain weight

Peripheral Venous vs Peripheral Artery Disease

• Risk factors for PVD: Age, Smoking, DM, HTN and Obesity
• Skin will feel warm with PVD whereas Skin will feel cold with PAD
• Pain will be Heavy, dull, throbbing, or aching with PVD whereas pain will be worse at night
• Pulse will be present/normal pulse with PVD whereas pulse will be weak/absent distal in legs/feet
• Cap refill with PVD will be < 3 sec whereas it wil be > 3 seconds with PAD
• There wil be NO edema present with PAD
• PVD has venous ulcers (open sores, usually around the ankles) whereas
• PAD you see Wounds/sores on end of toes/ top of feet/ lateral ankle don’t heal ulcers
• Lifestyle changes: ELEVATE, warm compress, keep legs and feet warm, NO moist heating pad, prolonged sitting or standing

Kahoot Review

• Mean Arterial Pressure (MAP) is the average pressure within the arterial system felt by the body's organs during one cardiac cycle.
• Systemic Vascular Resistance (SVR) is the force that opposes the movement of blood within blood vessels or the degree of constriction.
• Stroke Volume (SV) is the volume of blood pumped from the left ventricle per beat into the aorta.
• Patients taking calcium channel blockers (diltiazem or verapamil) should avoid grapefruit juice.
• The most effective drug to treat hypertensive emergency is IV sodium nitroprusside.
• A hypertensive emergency is the type of hypertensive crisis that causes target organ damage.
• MONA is the core measure (standard protocol) used to treat an MI (Myocardial Infarction).
• Ejection Fraction (EF) measures the percentage of blood leaving your heart each time it contracts.
• The normal ejection fraction level is 55% or higher.
• Troponin I lab level is the gold standard used to diagnose a MI.
• Stable Angina, Beta Blocker Complication: If a cardiac monitor shows a HR of 45 bpm, monitor HR & BP regularly because it could cause bradycardia/
• Atherosclerosis is the Major cause of CAD.
• A BP of 136/89 = Stage 1
• In a non-compliant patient with HTN whose BP is now 180/90, excess Angiotensin II hormone increased, contributing to increased BP