Cardiac Disease Symptoms

Outlier Symptoms for Diseases

• CAD can manifest as palpitations, numbness, indigestion, and unstable angina
• Angina symptoms include chest pressure, but typically no nausea/vomiting, shortness of breath, anxiety, or diaphoresis
• Acute Coronary Syndrome presents with nausea, vomiting, sudden chest pain, and anxiety
• Myocardial Infarction (MI) symptoms: pain accompanied by cool, clammy skin, paleness, diaphoresis, and a sense of impending doom
• Mitral Valve Prolapse is indicated by fatigue, dizziness, syncope, and irregular heartbeat
• Mitral Regurgitation involves coughing and crackles, which indicate pulmonary congestion
• Mitral Stenosis causes shortness of breath (SOB) to the degree that activities of daily living (ADL) are impaired
• Aortic Regurgitation leads to a palpable temporal pulse and atrial pulsation
• Aortic Stenosis may increase blood pressure
• Cardiomyopathy generally indicates an enlarged and weakened heart
• Dilated Cardiomyopathy results in SOB at rest, rapid irregular heartbeat, and low blood pressure
• Restrictive Cardiomyopathy is characterized by dyspnea and chest pain
• Hypertrophic Cardiomyopathy causes a murmur upon auscultation and fainting
• Arrhythmogenic Cardiomyopathy presents with arrhythmia on EKG and signs of heart failure (HF)
• Rheumatic Heart Endocarditis leads to an enlarged heart
• Pericarditis results in sharp chest pain that worsens with breath, pleural friction rub, and fever
• Left-sided Heart Failure (HF) includes coughing and wet lung sounds/crackles
• Right-sided Heart Failure (HF) involves edema and Jugular Vein Distension (JVD)
• Pulmonary Edema includes blood-tinged sputum
• Arterial Disease presents with pale, diminished pulses
• Peripheral Arterial Disease includes intermittent claudication, and pain is caused by elevation
• Aneurysms include sudden severe abdominal or back pain, clammy skin, and increased heart rate
• Deep Vein Thrombosis (DVT) is characterized by edema, warmth, and tenderness
• Chronic Venous Insufficiency results in hemosiderin stains
• Aneurysm causes clammy skin, sweating, increased heart rate, sudden severe abdominal or back pain

Cardiac Conduction

• Blood flows through the heart in this order: right atrium → tricuspid valve → right ventricle → pulmonary valve → pulmonary arteries → pulmonary veins → left atrium → mitral valve → left ventricle → aortic valve → aorta
• Electrical impulses travel through the heart via: SA node → AV node → bundle of His → Purkinje fibers
• The SA node acts as the heart's pacemaker and causes atrial contraction with a rate of 60-100 bpm
• The AV node acts as a backup pacemaker with a rate of 40-60 bpm
• If both the SA and AV nodes fail, the Purkinje fibers activate at a rate of 20-40 bpm which is insufficient to maintain blood pressure

Cardiac Assessment Auscultation

• Normal heart sounds are S1 and S2
• S1 is the sound of the tricuspid and mitral valves closing
• S2 is the sound of the aortic and pulmonic valves closing
• The tricuspid valve can be best auscultated at the lower left sternal border in the fourth intercostal space
• The mitral valve is best auscultated at the fifth intercostal space along the midclavicular line
• S3 and S4 heart sounds are abnormal
• The S3 heart sound indicates heart failure and fluid overload and sounds like a gallop
• The S4 heart sound indicates resistance to filling/stiffness seen in stenosis, cardiomyopathy, and Left Ventricular Hypertrophy (LVH)
• S3 is best heard at the apex of the heart
• S4 is best heard at the lower left sternal border

Diagnostic Tests and Levels

• For every cardiac patient, obtain blood work, EKG, and Past Medical History (PMHx), especially focusing on precipitating events
• An EKG is essential for any patient presenting with chest pain
• An EKG reveals the rhythm, ischemia, injury, or infarct
• T waves will invert first with ischemia
• ST-segment elevation indicates an injury pattern
• A 12-lead EKG should be a priority for patients with chest pain
• Cardiac catheterization studies heart circulation via a catheter and can open blockages with Percutaneous Coronary Intervention (PCI)
• Echocardiograms visualize heart valves and blood flow
• A transesophageal echocardiogram requires sedation to visualize the back of the heart
• EPS studies monitor electrical activity in the heart
• Holter monitors trace heart rate over a few days, correlating with a symptom journal

Blood Work

• Creatinine Kinase indicates heart tissue injury
• CKMB increases with myocardial injury, peaking in 24 hours, drawing in 8-hour increments to look for changes over 24 hours
• Troponin: the main indicator of cardiac damage, rises 4-8 hours after injury, peaks at 12-16 hours, and normalizes after 5-9 days (normal value is 0-0.5mg/ml)
• BNP - A neurohormone that regulates fluid volume. Increased BNP indicates HF when it is 100+
• C-Reactive Protein serves as an inflammatory marker that, when elevated, indicates pericarditis or rheumatic heart disease, with levels greater than 3mg/L increasing the risk for Cardiovascular Disease (CVD)
• Homocysteine correlates with CAD; less than 12 is ideal and can be lowered with B12 and folic acid

Cholesterol Values

• HDL should be 40 or higher
• LDL should be ideally less than 100, but can range from 100-160
• Total Cholesterol (TC) should be less than 200
• Triglycerides should be essentially less than 150
• Increased cholesterol increases the risk of CAD and stroke

Medications

• Always use MONA for MI/ACS
• Administer Morphine for decreased chest pain and anxiety
• Administer Oxygen to increase O2 to the myocardium as a first priority intervention
• Nitroglycerin vasodilates. Administer three tablets every 5 minutes and call 911 before the third tablet, monitor for headaches
• Aspirin prevents blood clots

Medications for Heart Failure

• Diuretics (e.g., Lasix)
• ACE Inhibitors (e.g., lisinopril, enalapril). They stop vasoconstriction
• ARBs (e.g., sartans). They block constriction
• Nitroglycerin, hydralazine, Dilatrate vasodilate blood vessels and decreases workload
• Beta Blockers (e.g., Metoprolol, atenolol, labetalol) decrease HR and BP by blocking the SNS
• Digoxin/positive inotropes increase contractility
• Milrinone or Dobutamine

Medications for HTN

• Calcium channel blockers (e.g., verapamil, cardiazem).
• Beta Blockers
• Vasodilators

Medications by Condition

• Mitral Regurgitation: ACE Inhibitors, ARBS, Beta Blockers
• Mitral Prolapse: Beta blockers prevent tachycardia
• Peripheral Artery Disease (PAD): pentoxifylline and cilostazol increase the viability of blood cells
• DVT: heparin, enoxaparin, warfarin
• Pulmonary Edema: diuretics, vasodilators, IV digoxin to control blood pressure

Medication Actions

• ACE Inhibitors (e.g., lisinopril, enalapril, captopril): decrease preload and afterload, decrease HR and BP

Medication Side Effects and Nursing Considerations

• ACE inhibitors stop vasoconstriction through renin to promote relaxation and improve heart capacity, but include side effects like dry cough and angioedema and may elevate digoxin levels
• Nursing action for ACE inhibitors: potassium-sparing considerations

HMGCO Reductase Inhibitors (Statins)

• Atorvastatin, Rosuvastatin block the enzyme that creates LDL, lowering LDL and total cholesterol while increasing HDL
• Nursing action: common side effects

Angiotensin Receptor Blockers

• Losartan (Cozaar), Valsartan (Diovan) relax blood vessels to reduce BP, reduce preload and afterload, block vasoconstriction, and reduce strain on the heart
• Side Effect: hyperkalemia
• Nursing Considerations: similar to ACE inhibitors but with fewer side effects

Beta Blockers

• Metoprolol, Atenolol, Labetalol, propranolol, the first-line medication decreases myocardial oxygen consumption and workload, decreasing heart rate and blood pressure by blocking the SNS. They also decrease afterload, renin, and smooth muscle constriction
• Side Effects: syncope, dizziness, light-headedness
• Nursing Considerations: Help prevent tachycardia, improve symptoms, and monitor HR; do not discontinue suddenly

Vasodilators

• Vasodilators are more common for acute BP that needs to be lowered
• Vasodilators include Apresoline and Nitroglycerin
• Nitroglycerin decreases myocardial oxygen consumption by vasodilation
• Side Effects: potential rebound low BP (hypotension), headache, nausea, and vomiting
• Nursing Considerations: take one tablet for chest pain and wait 5 minutes; if pain persists, take a second tablet and wait 5 minutes; if pain continues, call 911 and take the third dose; the maximum dose is three tablets; routes of administration include sublingual or IV for acute chest pain and patch for maintenance/prevention which delivers a set amount per hour for 18 hours
• Hydralazine, Isosorbide Dinitrate (Dilatrate) relax and widen blood vessels to decrease heart workload
• Nursing Considerations: impact heart function, reduce fluid congestion

Emergency Medications

• Emergency Vasodilators include nitroprusside, Nitroglycerin, and fenodopam
• Urgency Medications to lower Blood Pressure include Labetalol

Anticoagulants

• Aspirin and Enoxaparin (Lovenox)

Coumadin (Warfarin)

• Prevents blood clots in the long term
• Side Effect: bleeding
• Nursing Considerations: Monitor INR (should be around 2), avoid food with Vitamin K, used for valve replacements, or for patients going home anti-coagulated

Diuretics

• Furosemide (Lasix) increases fluid excretion by inhibiting sodium and water reabsorption, reducing preload, Systemic Vascular Resistance (SVR), and afterload
• Side Effect: can cause low potassium
• Aldactone (spironolactone) increases potassium retention and excretes more sodium and water.
• Side Effect: hyperkalemia
• Nursing Considerations: Do not give with other potassium-sparing medications and monitor for hypotension and fall risk
• Thiazides include medications such as Hydrodiuril

Ionotropic Medications

• Digoxin improves the force of myocardial contraction (contractility), strengthening the heartbeat
• Side Effects: lower heart rate, toxicity (nausea and vomiting, yellow halo) leading to blurry vision, yellow halo, nausea/vomiting, and dizziness
• Nursing Considerations: hold if HR is lower than 60 bpm, monitor if also on Calcium Channel Blockers (CCB) or ACE inhibitors as they can increase digoxin levels, and monitor potassium levels (low potassium increases the risk of toxicity)
• Milrinone and Dobutamine increase the strength of heart contractions to improve heart function
• Nursing Considerations: positive inotropes used in Heart Failure do not directly affect BP

Calcium Channel Blockers

• Amlodipine (Norvasc), Diltiazem (Cardizem), Adalat, Verapamil vasodilate and decrease HR, BP, and the strength of contraction, decreasing cardiac workload, HR, and afterload
• Side Effects: lower leg edema, hypotension, digoxin toxicity
• Nursing Considerations: need calcium for muscle contraction; less calcium results in less contraction and lower HR. Projects myocardial volume so don't overstretch muscle.

Antiplatelets

• Enoaparin and Aspirin prevent platelet aggregation
• Thienopyridines such as clopidogrel block platelet aggregation

Heparin

• Prevents the formation of new clots
• Nursing Considerations: Monitor Partial Thromboplastin Time (PTT)

Bile Acid Sequestrants

• Cholestyramine (Questran) lowers total cholesterol, HDL, and LDL by decreasing fat absorption
• Side Effects: GI issues, can bind to other medications and decrease effectiveness

Cholesterol Absorption Inhibitor

• Ezetimibe (Zetia) lowers LDL and Triglycerides by blocking a liver enzyme that makes cholesterol for intestinal absorption
• Nursing Considerations: use if patients can't tolerate statins
• Side Effect: severe facial flushing due to vasodilation

Nicotinic Acids

• Niacin (Niaspan) reduces total cholesterol, LDL, and triglycerides, and increases HDL
• Side Effects: facial flushing, headache, and itching chills

Fibric Acids

• Fenofibrate (Tricor) synthesizes triglycerides

Alpha Adrenergic Medications

• Doxazosin, Prazosin, Terazosin vasodilate and act on smooth muscle

Hypertension

• Requires elevated diastolic and systolic levels, not due to pain or trauma
• Primary HTN is the patient's main problem and includes:
• White coat HTN due to anxiety
• Isolated HTN where only systolic is high (diastolic is fine)
• Malignant HTN is a severe increase in BP that comes on quickly due to a trauma or damage of an organ
• Signs/symptoms: headaches, blurred vision, and is a 911 emergency

Stages of Hypertension

• Normal: less than 120/80 mmHg
• Prehypertension: 120-139/80-89 mmHg
• Stage 1: 140-159/90-99 mmHg
• Stage 2: equal to or greater than 160/100 mmHg
• Emergency: malignant or stage 2 and requires nitroprusside and fenodopam
• Urgency: stage 1 and requires labetalol or ACE inhibitors

Hypertension cont.

• Crisis is anything over 180/20 mmHg
• Nursing Considerations: Emergency care can cause organ damage. Administer nitroglycerin
• Damage includes blindness, kidney failure, stroke, myocardial infarction, and pulmonary edema

Treatment for Hypertension

• Requires calcium channel blockers, beta blockers, and vasodilators
• Non-medication options include diet and exercise or the DASH diet

Complications of Uncontrolled Hypertension

• Uncontrolled hypertension will cause Heart Failure (HF) due to the thickening of the heart muscle

Heart Failure

• The decreased ability to pump enough to meet the body's oxygen demands
• It is not curable but treatable and occurs when the bottom of the heart is overstretched
• Systolic (Right-Sided) HF which involves a pumping problem, overstretch with fluid, the right ventricle does not pump, and the fluid backs up to the periphery/body
• Results from weakened heart muscles which decrease the ability to pump
• Signs/Symptoms: Jugular Vein Distention (JVD), weight gain, fluid overload of the peripheral edema
• Causes: damage from MI, cardiomyopathy, Left-Sided angina, and valve dysfunction
• Diastolic (Left-Sided HF) involves a Left Ventricle that is too stiff to fill
• It is related to the stiffness of the ventricle that decreases the ability to pump Signs/Symptoms: pulmonary congestion & crackles, S3 heart sound, shortness of breath, low oxygen, alveoli filled with fluid, cough, and dyspnea
• Can be caused by uncontrolled HTN, hypertrophy, LV overload, stenotic valves, or untreated infection
• Treatment: Requires a heart transplant

Diagnosing Heart Failure

• Chest X-Ray (CXR)
• Brain Natriuretic Peptide (BNP; above 100 indicates Heart Failure)
• Echocardiogram
• Liver Function Test (LFT) for the right side of the heart

Treatment

• Diuretics (Lasix) to unload fluid to decrease congestion to relieve symptoms
• ACE Inhibitors, such as lisinopril and enalapril slow the progression by decreasing preload and overall workload and stopping vasoconstriction. Work well with myocardial infarction and hypertension
• ARBS decrease preload and afterload and block constriction; monitor for high potassium
• Vasodilators, such as nitroglycerin, hydralazine, and Dilatrate dilate blood vessels and decrease workload
• Beta Blockers, such as metoprolol, decrease HR and BP to decrease workload; block SNS
• Digoxin/positive inotropes increase myocardial force and contractility
• If medication fails, consider a Left Ventricular Assist Device (LVAD) and transplant

Non-Medication Methods

• Lifestyle changes
• Increasing exercise with weight loss
• Fluid restriction
• DASH diet
  • Low sodium
  • Protein (lean meat, fish, or chicken without skin)
  • No fat
  • Limit dairy
  • High vegetables
  • Limit alcohol
  • Limit triglycerides

Acute Coronary Syndrome and Angina

• HF TX is "UNLOAD FAST"
• Upright
• Nitrates
• Lasix
• Oxygen
• Ace inhib
• Digoxin
• Fluid (dec
• Afterload (dec)
• Sodium (dec)
• Test (dig ABG and K)
• Acute Coronary Syndrome pt presents with acute chest pain
• Sudden onset, chest pain unless diabetic, shortness of breath, diaphoresis, nausea/vomiting, anxious, and pale
• Diagnose immediately with a 12 lead EKG. Draw troponin
• 12 lead ST elevations= Acute MI (above P wave) means 90m to save heart
• 12 lead ST depression= most MI, injury already occurs (ischemia)
• Treatment is RA MONA B (not in order)
  • R: reperfuse -> from ED go to cath law to get heart O2, have 60 min
  • ED to cath in less than 60 min
  • Intervention in 30 min -> have 90 total before heart dies
  • If can't get to cath lab put pt on fibrinolytics to break up clot.
  • A: Aspirin -> 4 baby aspirin 81mg each
  • M: Morphine -> dec cardiac workload of chest pain/anxiety
  • O: Oxygen -> dec cardiac workload, improve O2 to the heart muscle
  • N: Nitroglycerine
  • 1 sublingual tab, wait 5min. Follow with another tab. Wait 5 min -> call 911 -> take tab 3
  • In hospital -> given IV
  • A: Ace inhibitors -> lisinopril to dec vasoconstriction
  • B: Beta blocker (w/in 24hrs)
• Number one intervention is oxygen to dec myocardial need and pain

Angina vs. Myocardial Infarction

• Angina causes temporary lack of blood flow to the coronary arteries.
• Definition: chest pain lasting less than 15 min, REVERSIBLE cell injury.
• Symptoms: Chest pain, heartburn, palpitations, SOB indigestion, radiate to arm/shoulder, tightness/pressure in chest, heaviness, radiate to neck/jaw/back
• Cruising Pian means turned into MI
• Does NOT cause nausea/vomiting or seating
• Is almost predictable chest pain, the main cause is the atherosclerotic plaque d/t CAD and not enough blood flow to the heart, still from plaque in vessels even if stable.
• Can have cardiac symptoms or no chest pain and treat symptom not diagnosis
• Give O2 then nitro then morphine then the Betal blocker (MONA) Types:
• Stable: pain w/ activity reives w/ rest or medication to open the coronary arteries → Stable angina turning into Acute Coronary Syndrome
• Unstable: pain worsens, does not resolve w. rest/meds
• Intractable: pain increases drastically
• Silent: asymptomatic (accept for EKG changes)
• Dx: EKG or troponin
• TX: Medication (MONA)
• FIRST TX is always oxygen to reduce pain and increase oxygen to pt with Firts symptoms
• Primary Tx is Nitroglycerin → dilates coronary arteries to improve blood flow and dec O2 consumption
• Nitroglycerin can be short or long-acting → Active chest pain is treated first with sublingual, while maintenance/prev is treated with a patch to deliver 18hr release amount medicine (observe for SE: hypotension h/a) Beta Blockers: decrease O2 deman, decrease what causes pain, HR and BP

Medications and Conditions

• CCB: to decrease HR, BP, and cardiac workload

• Antiplatlet: (asprin, enoxaphrin) prevent plt aggravation and clots

• Thienopyrides (plavix): block plt aggregation

• Heparin: prevent new clot from forming

Myocardial Infarction

• Sustained ischemia with cell death lasts more 30min

signs/symptoms: cool clammy pale n/v, sudden doom, diaphoretic

Angina vs MI

• Angina is an ischemia injury that can be REVERSED
  • Precipitated by exertion or stress
  • Relieved by rest or meds
• Early intervention can prevent the MI:
• Give MONA and go to cath lab within 60-90 min
• MI (when you dont catch, stop, rhe pain, then tissue dies) → scar tissue to uscle Still go to cath lab to prevent bigger or second heart attack

Cardiac Catherization

• Procedure to open up blockages

• Insert via groin or radial artery

   Pt EDU: will be awake with mild sedation (so we know if having CP) If find balckage PCTA to place stent IV dye warm
  

Post Procedure:

• Assess Vitals (especial site) Assess chest pain, also asses groin to confirm should not hurt If site bleeding hold pressure and call for help Pt on bed rest to keep limb straight

Mitral Valve Regurgitation

• Blood flows back from LV → LA during systole
• Rick: backflow into pulminary system -> RV

Aortic Regurgitation

• Blood flows back into LV from aorta during diastole LV dilates during diastole to accommodate larger B'v causing Left s-ide heart failure

Mitral Stenosis

• Narrowing of stiffnessD/T Calcium deposit (blood wont flow from LA -> LV.
• RF: Age in infection Symptoms:Main: point cannot do ADL
• DX: Echocardiogram
• TX: Ballon to open valve or replacent, valvuloplasty replace mechinical on anticoag for life

Mitral Valve Prolapse

• 2 flaps valve back int atria during systole and blood backs up Irregular HB, tachydaria More common in women, blood collects leading to risk of clots + HF. Dx: echocardiogram Rx: Beta blockers to prevent tachcardia Valve Replacement: replaces regurgitation, valves, prolapes or infection and Warafrin LT if replacement a mechanical valve 2-3 INR

Valvuloplasty

• Opening valve for Stenosis: is only 28-48hrs
• Damahed valve is open via balloon cath = if unsucessful, begin antibotics to prevent minimal infection during dental work

Cardiomyopathy

Weakened heart muscle which makes harder to pump blood leading to HF Weakness → dec BF → SNS an RAAS activation→ fluid retention → inc cardiac workload → HF Treatment for all Types: Low Na diet to lower BP, Implanted defibrillator, anticoagulant, transplant,

Types Dialated:

• Dialates: dialated w/o enelagred muscles (STRETCHED)
• Cause: Virus, low immune system genetic Symptoms:SOB + not rest →raid irreg, dizzy / low BP, why Dangerous blood in can form stay ventricles (contracting + clots

Restrictive

• Rigid Ventricle walls Heart cannot contract bt beats, dangerous heart filler Symptoms SOEBP, Hypertrop Muscle becomes abnormally thick has less time for smaller volumes (septumes enlarges for larger) Symptoms: murmurs ausculation

Arterial and Venous Diseases: Atherosclerosis vs. Arteriosclerosis

• Arteriosclerosis is the hardening and narrowing of the small arteries, while Atherosclerosis refers to the buildup of plaques that narrow larger arteries

Peripheral Arterial Disease

• PAD is the dec in arterial flow to extremities, when blood circulation can not get to toes caused by increase fats (atherosclerosis)

PAD Signs and Symptoms

• Intermittent Caudcation caused by pain with elevation in legs Symptoms: dec pulse or hair , feet be cold/neortic ( could lead to gangree) from circulation RF: hyperplidmia (decrease Circulation) Ultrasound to blockage NC: Dangling Pentoxiflyine + synthetic by pass (antiplalet stickers) , stockinys

Venous

blood returns to heart : PE: clots -> dVT deep veins endothelial -> Damage BVS causes Blood to veins + coaguale: caused bed, immobile , obesity + post Op. Extremity, warmth/ tendress Ultrasound + emulation (Pressure + compression + elevats) + ROM + immobality Heprain Lovenox Sub Q

DVT is the decrease blood pressure cause

• Damage weakens acusse legs in obstruation +blood

• Venous: hemosidin increase Warm = elevats

Pulmonary Edema

• Is Excess fluid + can cause and death + cause hear death SOB. frothy Cxr: increase Diurets, vasodilators + HF to HF (sit leg +dangling to)

Rhematic Endocardits

: Bema: L will HF Enlarged infection: (percarditis

Patho: excessive causes stiff is appropriatly fill

Pericaditis: infection lower decrease CO Sharps

• CXR +WCB + increased increased Tx: goes own : worsened window