Cardiac Health: Risk Factors

Cardiac Study Notes

Modifiable Risk Factors

• High blood pressure can be managed through diet, exercise, and medications.
• High cholesterol can be managed by lowering LDL and increasing HDL through diet, exercise, and medication.
• Quitting smoking helps reduce heart disease risk.
• Controlling blood sugar levels through diet, exercise, and medications is key for diabetes management.
• An unhealthy diet high in saturated fats, trans fats, cholesterol, and sodium should be avoided to maintain heart health.
• Regular exercise can help control weight, lower blood pressure, and improve cholesterol levels.
• Maintaining a healthy weight through diet and exercise is important for overall health.
• Limiting alcohol intake can help prevent high blood pressure.
• Managing stress through relaxation and exercise can improve heart health.

Unmodifiable Risk Factors

• The risk of heart disease increases with age.
• Men generally have a higher risk of heart disease at a younger age than women, but women's risk increases after menopause.
• A family history of heart disease increases your risk, especially if closely related.
• African Americans, Hispanics, and South Asians are at a higher risk for heart disease.

Diuretics

• Examples include Furosemide (Lasix), Hydrochlorothiazide (HCTZ), and Spironolactone (Aldactone).
• Diuretics work by removing excess fluid from the body through increased urination, which reduces blood volume and lowers blood pressure.
• Potential side effects include hypokalemia, dehydration, dizziness, and orthostatic hypotension.
• Take diuretics in the morning to prevent nocturia, and consume potassium-rich foods if taking non-potassium-sparing diuretics.
• When taking diuretics rise slowly when standing to avoid dizziness.

Beta Blockers

• Metoprolol (Lopressor), Carvedilol (Coreg), and Atenolol (Tenormin) are examples.
• These medications block beta-adrenergic receptors, reducing heart rate and myocardial oxygen demand.
• Side effects can include bradycardia, low blood pressure, shortness of breath, fatigue, dizziness, depression, cold extremities, and allergic reactions.
• Abruptly stopping beta blockers may cause rebound hypertension or tachycardia.
• When taking beta blockers monitor heart rate and notify the healthcare provider if it drops below 60 bpm; patients should also be cautious when combining with other medications that lower heart rate and to avoid alcohol.

ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors)

• Examples are Lisinopril (Prinivil), Enalapril (Vasotec), and Captopril (Capoten).
• They prevent the conversion of angiotensin I to angiotensin II, causing vasodilation and reduced blood pressure.
• Side effects include orthostatic hypotension, dry cough, hyperkalemia, dizziness, and a rare but serious swelling known as angioedema.
• Patients should be aware to monitor for and report a persistent dry cough or any swelling in the face or throat (angioedema).
• When taking ACE inhibitors avoid potassium-rich foods or supplements and regularly check blood pressure, reporting any significant changes.

ARBs (Angiotensin II Receptor Blockers)

• Losartan (Cozaar), Valsartan (Diovan), and Irbesartan (Avapro) are examples.
• ARBs function by blocking angiotensin II receptors, preventing vasoconstriction and lowering blood pressure.
• Potential side effects include hyperkalemia, dizziness, and fatigue.
• Avoid potassium supplements and potassium-rich foods and monitor for dizziness or lightheadedness, especially when standing up.

Calcium Channel Blockers (CCBs)

• Dihydropyridines (Amlodipine (Norvasc), Nifedipine (Procardia)) and Non-Dihydropyridines (Verapamil (Calan, Verelan), Diltiazem (Cardizem)) are available.
• They block calcium from entering heart and blood vessel cells, leading to vasodilation and reduced heart rate (non-dihydropyridines).
• Common side effects of Dihydropyridines include peripheral edema, headache, and flushing.
• Non-Dihydropyridines side effects include bradycardia, constipation (especially with Verapamil), and dizziness.
• Avoid grapefruit juice consumption, report swelling in feet/legs (peripheral edema) or changes in heart rate, and increase dietary fiber intake to prevent constipation.

Statins

• Examples include Atorvastatin (Lipitor), Simvastatin (Zocor), and Rosuvastatin (Crestor).
• Statins inhibit cholesterol synthesis in the liver, reducing LDL cholesterol levels and cardiovascular risk.
• Potential side effects include muscle pain or weakness, liver dysfunction, and gastrointestinal upset.
• Report any signs of muscle pain or weakness as it may indicate rhabdomyolysis, take the medication in the evening for maximum efficacy, and avoid grapefruit juice to reduce the risk of side effects.

Nitrates

• Examples include Nitroglycerin (Nitrostat) and Isosorbide Mononitrate (Imdur).
• They dilate blood vessels, reducing preload and myocardial oxygen demand, relieving angina.
• Headache, dizziness, hypotension, and reflex tachycardia are potential side effects.
• Store nitroglycerin in a cool, dark place in its original container, sit or lie down when taking to avoid dizziness or fainting, and for chest pain, take one dose every 5 minutes (up to 3 doses) and seek emergency care if pain persists after the third dose.

Anticoagulants

• Warfarin (Coumadin), Heparin, and Apixaban (Eliquis) are examples.
• Anticoagulants prevent clot formation by interfering with the body's clotting process.
• Side effects include bleeding (e.g., bruising, black stools) and GI upset.
• Monitor for signs of bleeding and immediately notify a healthcare provider.
• If on Warfarin, maintain consistent Vitamin K intake.

High Blood Pressure

• Determined by two or more readings of consistently high blood pressure on separate occasions.
• Systolic blood pressure measures the pressure in arteries when your heart beats.
• Diastolic blood pressure is the pressure in your heart when it relaxes.
• Stage 1 hypertension is defined as >130-139/>80-89.
• Stage 2 hypertension is defined as >140/>90.
• It is considered the "silent killer" as most patients will not even know their blood pressure is high.
  • If blood pressure is significantly high though, patients may experience headaches, shortness of breath, nosebleeds, chest pain, jaw pain, or shoulder/back pain.
• Additional tests may need to be ordered to determine the cause of high blood pressure with the implementation of lifestyle modifications.
• Patients should monitor their blood pressure at home for trending purposes.
• To measuring blood pressure accurately, use the correct cuff size, position the arm correctly, relax and avoid certain activities
  • Correct cuff side, with the bladder width at least 40% of the arm circumference and bladder length covers at least 80% of the arm circumference.
  • Adopt the proper positioning by sitting upright, feet flat, and arm below the heart level.
  • Relax for a few minutes before measuring blood pressure and avoid smoking, drinking caffeine, or exercising for at least 30 minutes before.

Electrocardiogram (EKG/ECG)

• EKGs measure the electrical activity of the heart. Aids in diagnosing heart conditions, such as arrhythmias, heart attacks (STEMI, MI).
• EKGs monitor heart health over time, useful if the patient has a known condition.
• EKGs assist in evaluating symptoms such as chest pain, shortness of breath, dizziness, or palpitations.
• EKGs help assessing heart function by evaluating how well treatments, medications and pacemakers are working.

Echocardiogram

• "Echo" uses ultrasound waves to create a detailed image of your heart.
• It helps assess the structure and function of the heart, including the chambers, and blood flows.
• It is non-invasive, painless, and helps diagnose heart conditions, heart disease progression, and evaluate treatment effectiveness.

Ejection Fraction (EF)

• The ejection fraction (EF) is a percentage of how much blood the left ventricle pumps out with each contraction and is important for assessing heart function.
• The left ventricle pumps blood into the aorta, which distributes blood to the rest of the body.
• A good EF range is about 55% to 70%.
• A percentage of lower than 50% indicates that the heart is not pumping effectively, which can lead to heart failure.

Common Signs of Low Ejection fraction

• Shortness of breath, especially while active or laying down.
• Fatigue or weakness, even when not doing much.
• Swelling (edema) in feet, ankles, legs, or stomach.
• Rapid or irregular heartbeat, leading to palpitations or a racing heart.
• Exercise intolerance.
• Chest pain (angina) due to the heart working harder and not getting enough oxygen.
• Mental confusion.
• Loss of appetite/nausea.

Treatment of Hypertensive Patients

• The goal is to lower blood pressure to a safe level, not to cure it.
• Untreated high blood pressure can lead to stroke, heart attack, and kidney disease.
• Lifestyle modifications, medication adherence and proper follow ups can lower blood pressure along with DASH diet etc

Lifestyle Modifications for Managing Hypertension

• Involve exercise (lowers sodium intake), medication adherence (take medications), and monitor and follow up (take blood pressures at home)
• Lifestyle modifications can be supported by setting reminders, understanding medications and its risks if discontinued
• A patient can simply routine with the help of their PCP so they dont show up for ED visits

Dash Diet

• A diet to reduce hypertension
• This includes Fruits/veggies, whole grains, low-fat dairy and lean protein (fish, poultry, beans) and nuts, seeds, beans
• Limit amount of sodium – 2,300 mg per day or 1,500 mg per day if you have high blood pressure, and also limit saturated fats and trans fats
• Instead of butter/lard choose olive oil, avocados and nut betters. Avoid fatty meats and full-dairy products.
• Increase Potassium, Calcium, and Magnesium, and do it in moderation: 1 drink per day for women and 2 for men
• Avoid sugars and refined carbs and assist your patient with suggestions that are healthy.

Low Potassium (HypoKAlemia) Signs

• Muscle weakness and cramps, fatigue, constipation, abnormal heart rhythms and tingling and numbness
• Patients with nausea and vomiting and frequent urination and thirst tend to have low potassium
• Monitor their potassium level in Thiazide diuretics patients or Loop Diuretics and if level is low, suggest a potassium supplement to doctor.

Convincing Patients to Quit Smoking

• Have the patient consider what or who they would quit for, e.g., seeing grandkids graduate high school.
• Encourage the use of nicotine patches and gum.
• Teach the patient to recognize their triggers and provide medication and counseling/support groups

Systems Effected by Smoking

• Smoking damages blood vessels, increases blood pressure, and increases the risk for heart disease and stroke.
• Increases the risk for COPD, emphysema, chronic bronchitis, and lung infection/cancer.
• Vascular: Constricts blood vessels that can reduce blood flow to various organs and tissues
• Immune system: Weakens the immune system – get sick more
• Smoking can lead to infertility, complications during pregnancy, and fetal harm.
• Damages oral health by promoting gum disease, tooth loss, and oral cancer.
• Skin and aging: Increases skin aging (wrinkles/dull skin)
• Bones: Weakens bones and increases risk for fractures
• It activates the flight of fight in and releases stress hormone
• Activates the flight of fight which releases the hormone Epinephrine - increases heart rate and blood pressure

Mean Arterial Pressure

• A better understanding of the overall blood pressure
  • <60 means the organs are not getting enough blood, leading to damage or stroke.

  • 100 means the heart is working too much, leading to heart attack or kidney issues.

• MAP formula: MAP = SBP + (DBP x 2) ÷ 3

Cardiac output

• Equation: CO = SV x HR
• Normal resting conditions are defined as Stroke volume of 70 ml/beat x heart rate 72 beats/min and outputs 5040 ml/min

Stroke Volume

• Stroke Volume Equation: EDV - ESV
• Can lead to multiple issues such as impact the ventricles if its to high above 100
  • Reduced cardiac output causes the ventricles have not enough time to fill with flood before contracting again causing heart failure
• The workload can increase leading to high blood pressure, heart attack or stroke
• The condition of having heart failure can also lead to reduced heart efficiency causes dizziness, shortness of breath, and chest pain
• Potential arrhythmias can occur, and oxygen demand can increase

Terminology

• Preload: Blood volume from a ventricle before contraction
• Afterload: The pressure the heart has to work again to eject blood during systole
• Stroke Volume: The amount of blood that is ejected by the LEFT ventricle of the heart in ONE contractions
• Coronary Artery Disease (CAD) is where the Coronary arteries become narrow and blocked, leading to plaque development (atherosclerosis)
  • Plaques harden or rupture overtime, reducing blood flow to the heart which can trigger chest pain (vagina-angina), shortness of breath and fatigue

Risk factors for CAD, diagnosis, and treatment

• Having high blood pressure, high cholesterol, smoking, diabetes, obesity, and a sedentary lifestyle
• Using Electrocardiograms (ECG/EKG), stress tests, echocardiograms, and coronary angiograph to diagnose
• Treatments are Diet, exercise, quit smoking, medications (for cholesterol, blood pressure, prevent blood clots), and sometimes surgery as well as Healthy diet, physical activity, managing stress, and avoid tobacco

Cholesterol-Lowering Medications (Statins)

• Decrease LDL and lower LDL by inhibiting cholesterol synthesis (Atorvastatin, Simvastatin, Rosuvastatin)
• Risk factors: Muscle pain, liver dysfunction, gastrointestinal upset can occur
• Patient teaching: Take at night for better efficacy, report conditions, and avoid grape juice

Blood Pressure-Lowering Medications

• Beta Blockers reduce your heart rate and myocardial oxygen demand by reducing heart rate and Side Effects: Bradycardia (Propranolol, Metoprolol, Atenolol)
• To prevent rebound hypertension or tachycardia do not stop abruptly (ACE Inhibitors - Lisinopril, Enalapril, Ramipril)

Side effects

• ACE inhibitors cause: Orthostatic Hypotension, hyperkalemia report if persists
• ARB Side effects: Avoid potassium-rich and report if dizziness persist after taking medication (Losartan, Valsartan, Irbesartan)
• Peripheral edema is a side effect for CCB - (Amlodipine, Nifedipine, Verapamil) and grapefruit juice can affect drug effectiveness

Antiplatelet and Anticoagulant Medications

• Used to prevent blood flow and are Antiplatelets: (Aspirin, Clopidogrel, Ticagrelor) and Anticoagulant: (Warfarin, Rivaroxaban)
• Side effects of bleeding can: increased, and causes upset stomachs
• If taking as prescribed, monitor blood and watch for NSAIDS

Respiratory

• Allergic Rhinitis causes runny nose, nose, etc
  • Treatment: Medications like Antihistamines
• Sinusitis (sinus infection)
  • causes Face pain, congestion, etc, Nasal corticosteroids Antibiotics (only if bacterial)
• Pharyngitis - Sore throat, difficult swallowing, swollen lymph nodes, fever
  • Treatment: rest, hydration, for Viral, antibiotics if bacterial
• Tonsillitis - Watch their airway and throat and Test
  • Treatment: rest, hydration, if bacteria FINISH MEDS

Lower Respiratory

• Is located at the Lungs, Trachea, Etc
• Pneumonia- Fever chills, treatment is Bacterial and use ABs
• COPD- Treatment is albuterol and quit smoking can occur:
• Bronchitis- Elevate the head, treatment can be rest, hydrate, and or ABs,
• TB- test and use medication
• Active or Latent
• Epistaxis- nose bleeds
• This can happen when your nose is dry, if someone is injured to seek attention
• Read Sp02

Assessments

• Sp02 are to monitor your body function
• Work of Breathing which measures how much you use to relax
• Vitals are at RR, HR, Spo2, etc, when asking questions

Values and Tests

• Incentive Spirometer- to keep sac full
• Magnesium equation
• Normal Calcium: depends on how it's done
• ABGS depends upon how well it pumps your PH
• K normal = 3.5 to 5