Cardiac Assessment and Diagnostic Studies

Cardiac Assessment

• Women might show distinct heart problem symptoms like atypical chest pain, nausea, or fatigue, differing from men's typical chest discomfort.
• Elderly patients can have subtle heart problem symptoms, making early diagnosis challenging.
• Diabetic individuals of all genders have a greater risk of cardiovascular issues and need careful monitoring of blood pressure and cholesterol.

Diagnostic Studies for Cardiovascular Assessment

• Cardiac biomarkers help determine when cardiac injury occurs.
  • CK rises with any muscle damage.
  • CK-MB rises with skeletal or heart muscle injury and indicates cardiac MI.
  • Troponin is the most specific, identifying cardiac muscle damage, injury, or ischemia, suggesting MI.
  • Myoglobin identifies heart attack and muscle damage present in heart and skeletal muscles.

Lipid Profile and Recommended Levels

• LDL ("bad") cholesterol transports cholesterol to cells, causing deposits on vessel walls, raising the risk of CAD and MI.
  • Recommended levels:
    • Less than 160 for those with 0-1 CAD risk factors.
    • Less than 130 for those with 2+ CAD risk factors.
    • Less than 100 for known CAD or high-risk individuals.
• HDL ("good") cholesterol carries cholesterol away for excretion, decreasing CAD risk.
  • Normal range is 35-85. Recommended levels should be greater than 40 in CAD or DM patients.
• Total cholesterol is associated with atherosclerosis, which raises the risk of cardiovascular disease.
  • Recommended level is less than 200.
• BNP indicates how hard the heart works to pump blood.
  • High BNP suggests heart failure (HF)
  • It assists in diagnosing or monitoring HF treatment effectiveness.

Diagnostic Procedures: Electrocardiography/Holter Monitoring

• ECG (electrocardiogram) monitors the heart's electrical activity and conduction, showing rhythm.
  • Pre-procedure interventions include skin preparation, electrode application, HOB elevation, supine position, and ensuring the patient remains still to prevent artifacts.
  • Post-procedure intervention: removing electrodes.
  • ECG shows the heart in 12 views, detecting dysrhythmias, conduction problems, enlargement, electrolyte imbalances, drug toxicity, myocardial ischemia, or injury via ST segment analysis.
• Holter monitor is a portable device worn by outpatients, typically for 24 hours to record heart rhythm at home.
  • Patients log symptoms like palpitations or chest pain to correlate with monitor findings.

Exercise Stress Testing

• Exercise stress testing determines how the heart responds to stress; vasodilator arteries meet increased activity needs.
  • Aids in CAD diagnosis, pain cause identification, heart function assessment, and effectiveness of medications for heart problems or rhythm disturbances.
  • Exercise stress tests use a treadmill or bicycle with monitored activity to determine a "target HR." EKG and vital signs are correlated with symptoms.
  • Pre-procedure instructions include comfy clothes, tennis shoes, IV access, baseline VS rhythm assessments, and baseline 12-lead EKG.
  • 24 hours before: no caffeine, cardiac meds, or beta-blockers.
  • 3 hours before: no smoking.
  • Pharmaceutical options are available for those who cannot exercise.

Echo and Transesophageal Echocardiogram (TEE)

• Echo cardiography involves non-invasive ultrasounds that show the size, shape, and function of the heart. It aids in identifying vavular disease or effusions.
  • Place the patient in left side-lying position and explain painless procedure. The patient may feel warm jelly compress. Can be discharged immediately after procedure.
• Transesophageal Echocardiogram TEE uses a transducer in the esophagus, transmitting ultrasounds for high-quality images
  • Pre-procedure includes being NPO for 8-12 hours, and IV access.
  • After the procedure, patients should not eat/drink until the gag reflex returns, must monitor for bleeding and infection.

Cardiac Catheterization/Angiography

• Cardiac catheterization is an invasive diagnostic procedure with catheters inserted into vessels for hemodynamics (pressures) and angiograms (dye injected, x-ray pictures).

Angiography

• Angiography (contrast) visualizes major vessels and heart chambers.

Hemodynamics

• Can measure pressures in chambers like the LV, Ao, RV and PA.
• Types include left heart cath (via artery) and right heart cath (via vein).
• Pre-procedure interventions include assessing for allergies, renal function.
• Assess baseline vitals, labs, and EKG. Patient is NPO for 6 ours for the procedure with sedation given (fentanyl, midazolam.)
• Post procedure interventions include assessing vital signs and neurovascular status
• Check distal to the insertion site for bleeding hold pressure and hematoma and assess insertion site
• Have the patient lay flat in bed rest for 2 hours increase hydration to flush out the contrast.

Electrophysiology Study

• Tests electrical conduction to diagnose dysrhythmias and determine rhythm treatments.
• Attempts to induce dysrhythmias. Access is usually venous. An invasive procedure.
• Pre-procedure interventions include NPO for 6-8 hours before, conscious sedation.
• Have legs straight for femoral access. Neurovascular status should be normal and patient should stop antidysrhythmics before the procedure
• Post-procedures monitoring includes bedrest (neurovascular checks and VS monitoring), watching for dysrhythmias and friction rubs
• Risk for pneumothorax

Common Cardiac Medications

Diuretics (Furosemide/Lasix and Spironolactone/Aldactone)​

• Eliminate fluid (can be K sparing or non-K sparing)
• Treat- HF, Pulm edema, sometimes HTN

Adrenergic Inhibitors-β Blockers (Atenolol/Tenormin, Metoprolol/Lopressor, Propranolol/Inderal)​

• Produces beta adrenergic blockade in myocardium and electrical conduction system. decreases hr, contractility &conduction rate.
• Used to treat- angina, dysrhythmias, HTN, MI, HF

Vasodilators (Hydralazine /Apresonline, Nitroglycerin /Tridil, Sodium nitroprissode /Nipride)

• Dilate or prevent constriction of the blood vessels, which allow greater blood flow to various organs in the body
• Used to treat: Angina and low BP.

ACE Inhibitors (Captopril /Capoten, Enalapril /Vasotec, Lisinopril /Zestril)

• Blocks production of angiotension II, vasodilitation excretion of sodium and water by effecting kidneys prevents changes that can occur in the heart and vessels by angiotensin II & aldosterone
• Used to treat- HF, HTN, MI (decreases mortality and risk of HF), some prevention of CVD

Calcium Channel Blockers (Amlodipine/Norvasc, Diltiazem/Cardizem, Nifedipine/Procardia, Verapamil SR/Calan SR)

• Blocks CC in blood vessels with leads to vasodilatation of peripheral and central arteries increasing supply and decreasing demand BP and SVR, resulting in decreased contractility, hr, and conduction.
• Used to treat- angina, HTN, some are antiarhythmics (Cardizem- treats atrial fibrillation)

Anticoagulants (Heparin, Lovenox, Coumadin, Arixtra):

• Prevent blood from clotting excessively.
• Used to treat blood clots (AFIB, DVT, PE, heart attacks, unstable angina)

Cardiac glycoside (Digoxin /Lanoxin)

• Decreases heart rate, therefore increases force of contraction (improves efficiency by increasing SV & CO).
• Used to treat- HF, dysrhythmias

Statins (Simvastatin /Zocor, Atorvastatin /Lipitor, Rosuvastatin/Crestor)

• Decreases LDL and increases HDL
• Used to treat- hypercholesterolemia, prevents CAD, MI, stroke

Nicotinic Acid (Niacin /Niaspan)

• Reduces serum concentrations of total cholesterol, low-density lipoprotein (LDL) cholesterol, very low density lipoprotein (VLDL) cholesterol, and triglycerides, and increases concentrations of high-density lipoprotein (HDL) cholesterol.
• Used to treat: high blood cholesterol levels.

Lab Tests for Anticoagulants

• Heparin requires monitoring of PTT and platelets.
  • Protamine sulfate is the antidote.
  • Education: monitor for bleeding signs.
  • Route: IV infusion.
  • Do not give if there is a low platelet count.
• Coumadin (Warfarin) requires monitoring of PT (0-1.1) and INR (2-3).
  • Vitamin K is the antidote.
  • Assess for bleeding. Avoid leafy greens.
  • Route: tablet by mouth.
• Lovenox requires PTT monitoring.
  • Education: not for actively bleeding/low platelet count patients.

Educating Patients on Anticoagulant Therapy

• Watch for S/S of bleeding, soft bristle toothbrush, electric razor, do not give if platelets are low, assess for bleeding and bruising and avoid leafy greens. Heparin and warfarin can be given together. Lovenox and warfarin can be given together.

Digoxin Toxicity

• Early S/S: visual changes or GI disturbances
• Late S/S: EKG changes, bradycardia
• Reversal: Stop digoxin treatment, treat dysrhythmias, Digibind
• Low potassium significantly increases digoxin toxicity risk

Thrombolytic Therapy for Acute MI

• Need to be aware of contraindications and nursing considerations.
• Contraindications: recent head injury, recent surgery or trauma, prior head bleeds, uncontrolled HTN, known vascular malformations.
• Stop if active bleeding, bleeding disorders, pregnancy, hemorrhagic stroke, increased RF bleeding
• Nursing Considerations: Need consent because of drug risks, and need two IV accesses to monitor bleeding and blood draws

Coronary Artery Disease (CAD) Risk Factors

Modifiable

• Hyperlipidemia
• Tobacco use causes vessel wall narrowing
• HTN-endothelial injury, myocardial hypertrophy

Non-Modifiable

• Family history of coronary artery disease
• Age
• Gender- lower risk for women until menopause then equal risk

Angina vs. MI (ACS)

Angina:

• S/S: pain varies in intensity Heavy Feels of impending death Numbness and tingling.
• Diagnostic findings: EKG, ST depression
• Medical management: Rest, decrease workload
• Pharm treatments: May be treated like an MI until ruled out NTG (nitroglycerin) is primary treatment

MI (ACS)

• S/S: Injury- pain occurs suddenly and doesn't resolve >15 min. May radiate to arm, neck, jaw, and shoulder.
• Diagnostic findings: EKG STEMI, T-wave inversion or NON-STEMI
• Pharm treatment: MONA (Morphine, Oxygen, Nitrates(NTG) and ASA

ACS Outcomes and Interventions

• Expected outcomes: pain relief, stable vital signs, improved blood flow to the heart,prevention of further myocardial damage, and management of risk factors.
• Interventions: focus on immediate pain management with medications, cardiac catheterization, and long-term medications like beta-blockers, statins, and ACE inhibitors.

Cardiac Rehab

• Improves QOL and outcomes.
• Helps with risk reduction with education and support groups.
• Initiated in the hospital, early discharge, and long-term self-guided care

Nursing Interventions After PCI Procedure

• Monitoring vital signs and pressure and educating patient on activity restrictions and medication adherence.
• Patient is positioned lying flat with the affected limb kept straight and elevated to promote hemostasis.

CAD Discharge Education:

• Diet: Low sodium, low fat, activity restrictions for 6-8 weeks. Medication compliance lifestyle modifications: Exercise and no smoking

Structural, Infectious, and Inflammatory Cardiac Disorders

Pericarditis

• S/S: chest pain, worsens when laying down or with inspiration, feels better when sits forward.
• Diagnostic Findings: changes on echo, TEE, EKG
• Interventions: pain management, treat inflammation, watch for tamponade, sit them up and lean them forward helps decrease pain

Pericardial Effusion

• S&S: chest pain, Shortness or breath, fatigue, palpitations, coughing
• Etiology: volume compensation, infection, trauma, cancer, autoimmune disorders, post-surgical complications.
• Diagnostics: ECG, CXR, Echo, Cardiac MRI or CT scan
• Interventions: pericardiocentesis

Cardiac Tamponade

• Hallmark: pulsus paradoxus- change in BP that occurs during inspiration
• Treatments: pericardiocentesis, pericardial window

Valvular Diseases

Mitral Regurgitation

• Usually asymptomatic. May see dyspnea, fatigue, weakness, cough
• Findings: systolic murmur, may have irregular pulse & diagnostic testing with Tee

Mitral Stenosis

• Dyspnea on exertion, hemoptysis-bloody cough, cough, orthopnea, palpitations, nocturnal, respiratory & fatigue S/s

Aortic Regurgitation

• Usually asymptomatic, may have forceful heartbeat
• Findings: Diastolic murmur, pressure, ECG.
• NURSING CARE is all Non-invasive includes treating symptoms, resting, digoxin, diuretics, oxygen Nitrates (vasodilators) but also b-blockers

Aortic Stenosis

• Syncope, angina, and fatigue
• Manifestation: Loud, harsh, systolic ejection murmur that may radiate to carotid arteries.
• Diagnostic: ECHO cardiogram

Mitral Valve Prolapse

• Palpitations, Chest pain, Shortness of breath Fatigue
• Diagnostics include Echo or EKG

Cardiomyopathies

1. Dilated- ventricle becomes dilated & enlarged and 70% die within 5 years of the symptoms
2. Hypertrophic- wall becomes thickened and cannot fully relax
3. Restrictive- stiff ventricles that do not contract consistently

Nursing Interventions:

1. Decreased Cardiac output (sleeps sitting up)
2. Ineffective Tissue Perfusion (help keep warm)
3. Activity Intolerance (alternate activity with rest periods

True or False endocarditis the common is caused by endocarditis with Rheumatic fever. The answer is True

Congestive Heart Failure:

• Left Sided- think lungs Manifestations of pulmonary crackles along weight gain.
• Right Sided- think systemic Symptoms of JVD. Patient does have both symptoms

Congestive Heart FailureManifestations

• Dyspena along with rapid or irregular heart palpations
• Nursing Interventions (Diet daily weight with limited activities)

Peripheral Vascular Disease

Arterial : Legs Down and reduced blood blow Venous - Legs up blood pooling

6 P's pain, pulselessness, pale, parastrastia, paralysis, poculathermy (cold)