Cardiac: HTN, Aneurysm, Heart Failure & Valvular Disease

• Cardiac day 3 consists of:
• HTN and HTN Crisis
• Aortic Aneurysm
• Heart Failure
• Infectious Endocarditis
• Valvular Heart Disease

Blood pressure regulation

• Blood pressure is a product of cardiac output and systemic vascular resistance
• Cardiac parameters that affect blood pressure:
  • Heart rate
  • Contractility
  • Conductivity
• Sympathetic nervous system parameters that affect blood pressure:
• α₁- and a2-Adrenergic receptors (vasoconstriction)
• ẞ2-Adrenergic receptors (vasodilation)
• Renal fluid volume control parameters that affect blood pressure:
• Renin-angiotensin-aldosterone system
• Natriuretic peptides
• Neurohormonal parameters that affect blood pressure:
  • Angiotensin
  • Norepinephrine
• Local regulation parameters that affect blood pressure:
  • Vasodilators (Prostaglandins Nitric oxide)
  • Vasoconstrictors (Endothelin)

IDD and Cardiovascular Disease

• Cardiovascular disease is prevalent among people with intellectual and developmental disabilities (IDD).
• Especially those with Down, 22q11 deletion, Fragile-X, and Prader-Willi syndromes
• Risk factors for cardiac disorders are increased with:
• Physical inactivity
• Smoking
• Obesity
• Prolonged use of certain psychotropic medication
• Screen for cardiovascular risk factors earlier and more regularly than in the general population and promote prevention in IDD patients
• A nurse should assess:
• Blood pressure screenings
• Pulse oximetry screenings
• Oxygen saturation levels
• Feeding difficulties
• All information based on 2018 Canadian Consensus Guidelines

HTN & Organ Injury

• Eyes can experience arteriovenous nicking, narrowing of retinal arterioles, hemorrhages, exudates, and papilledema due to hypertension
• Kidneys can experience microalbuminuria, proteinuria, and Serum creatinine ≥1.5 mg/dl due to hypertension
• The brain can experience stroke and transient ischemic attack due to hypertension
• The heart can experience CAD, heart failure, and left ventricular hypertrophy due to hypertension
• The abdomen can experience aneurysms and aortic dissection due to hypertension
• The penis can experience erectile dysfunction due to hypertension
• Peripheral vasculature can experience intermittent claudication and faint or absent peripheral pulses due to hypertension
• Systolic blood pressure (SBP) and diastolic blood pressure (DBP) values for hypertension:
• Normal: SBP <120 and DBP Hypertension,
• Elevated: SBP 120-129 and DBP <80
• Stage 1: SBP 130-139 or DBP 80-89
• Stage 2: SBP ≥140 or DBP ≥90

Age-Related Changes

• As patients age incidence of HTN increases, but it becomes more challenging to control due to age related changes
• Increase in stiffness of cardiac muscle and vascular resistance
• Decrease in elasticity of arteries, adrenergic receptor sensitivity, renal function, and renin response
• Metabolism/Excretion Considerations:
• May be prolonged d/t decreased perfusion to gut.
• Greater risk for orthostatic hypotension
• Monitor kidney and liver function
• When starting meds start slow and titrate up as needed/tolerated

HTN Crisis

• Clinical presentation:
  • Severe headache
  • Nausea
  • Vomiting
  • Seizures
  • Confusion
  • Coma
• Treatment:
  • Admit to hospital
  • IV drug therapy- controlled
  • Decrease BP slowly
  • Monitor cardiac, renal & neuro frequently
• Hypertensive Emergency:
  • BP >180/120
  • Multiple organs involved
  • Present (ICP, hemorrhage, HF, MI, Renal, aortic aneurysm, retinopathy)
  • IV drug therapy and decrease BP slowly are used
• Hypertensive Urgency:
  • BP >180/120
  • Absent organ disease
  • Oral medications are used

Nursing Initial HTN Assessment

• Initial assessment on a client in hypertensive crisis includes measurement of blood pressure, heart rate, respirations, and O₂ saturation
• Blood pressure is at 210/120 mm Hg
• Heart rate is 109/min
• Respirations are 20/min
• O₂ saturation is 96%
• Level of consciousness is the priority assessment

Aortic Aneurysm

• Aorta is the largest artery in the body
• Aortic aneurysm is a permanent, localized outpouching or dilation of the vessel wall
• Incidence increases with age
• May occur in more than one location:
  • Aortic
  • Thoracic
  • Abdominal (AAA)

Aortic Aneurysm Risk Factors

• Older age
• Male gender
• Tobacco use
• High blood pressure (BP)
• Coronary artery disease
• Family history
• High cholesterol
• Lower extremity PAD
• Carotid artery disease
• Previous stroke

Aortic Aneurysm Clinical Manifestations

• Abdominal aortic aneurysms (AAA) are often asymptomatic
• Findings include:
  • Bruit, or pulsatile mass in periumbilical area left of midline on physical exam
  • When patient examined for unrelated problem
• CT scan
• Abdominal x-ray
• Angiography
• May mimic pain associated with abdominal or back disorders

Aortic Aneurysm Complications

• Rupture is a serious complication- medical emergency
• Rupture into retroperitoneal space
  • Bleeding may be tamponade by surrounding structures, thus preventing exsanguination and death
  • Severe back pain - aneurysm has ruptured
  • May/may not have back/flank ecchymosis (Grey Turner's sign)

Aortic Aneurysm Diagnostic Studies

• X-rays of the chest can demonstrate the mediastinal silhouette and any abnormal widening of the thoracic aorta
• X-rays of the abdomen may show calcification within the wall of AAA
• ECG can rule out MI
• Ultrasound is useful in screening for aneurysm & monitoring for size, can see blood going through widened blood vessel and identify blood walking out from it
• CT scan/MRI diagnose and assess location and severity, CT scan better
• Echocardiogram assesses valve and structure
• Angiography is anatomic mapping of aortic system using contrast.It is not a reliable method of determining diameter or length and Can provide accurate information about involvement of intestinal, renal, or distal vessels

Aortic Aneurysm Collaborative Care

• Early detection and prompt treatment are essential
• For <5.4 cm , risk factor modification, U/S & CT q6-12 months
• 5.5 cm is the threshold for repair
• Surgical intervention may occur earlier in patients with a genetic disorder, rapidly expanding aneurysm, symptomatic patients, and high rupture risk (Marfan's and Ehlers-Danlos syndrome – rapidly expanding and rupturing)
• Surgical therapy:
  • If ruptured, emergent surgical intervention required
  • 90% mortality with ruptured AAAs
• Preop:
  • Hydration is required
  • Stabilize electrolytes (blood sugar, potassium, magnesium levels prior to surgery), coagulation, and hematocrit

Nursing Aortic Aneurysm Management

• Intra-abdominal hypertension (IAH) with associated abdominal compartment syndrome (ACS) is possible
  • Lethal complication in an emergency repair of a ruptured AAA
  • Persistent IAH reduces blood flow to the viscera resulting multisystem organ failure
• Treatment for IAH:
  • Open surgical decompression (fasciotomy)
  • Percutaneous catheter decompression for drainage Management
• Postop:
  • ICU monitoring of hemodynamics central venous pressure (pre-load), vent, oxygen, ECG
  • Peripheral perfusion status (CMS/ Neurovascular checks)
  • Frequent pulse assessment and mark pulse locations with felt-tip pen Management
• Postop requires renal perfusion status monitoring:
  • Urinary output
  • Fluid intake
  • Daily weight
  • CVP/PA pressure
  • Blood urea nitrogen/creatinine
• Ambulatory and home care requires:
  • Encourage patient to express concerns
  • Instruct patient to gradually increase activities
  • No heavy lifting x 6 weeks
  • Teach about signs and symptoms of complications (Infection and Neurovascular changes)

Heart Failure

• Heart failure is myocardial insult due to previous MI, endocarditis, CAD, HTN, myocarditis etc
• Is when the heart muscle has problems and cannot meet needed oxygen demands
• Results in the heart longer able to meet the O2 demands of the tissues and organs. MI, intiam., hyp., coronary artery disease
• Leads to decreased cardiac output and decreased perfusion, impaired gas exchange, fluid imbalances and decreased functional ability
• Normal LVEF (left Ventricular ejection fraction) is 55-65%
• With disease it can decrease to 5-10%
• Projected 8 million adults by 2030 & costs >$30 Billion/yr

Heart Failure Right and Left Side Comparison

• Right-Sided Heart Failure Signs:
  • Right ventricular heaves
  • HR
  • Anasarca (massive generalized edema)
  • Ascites
  • Edema (e.g., pedal, scrotum)
  • Hepatomegaly
  • Enlarged liver
  • JVD
• Right-Sided Heart Failure Symptoms:
• Not feeling like wanting to eat
• Anorexia and GI bloating
• Anxiety, depression
• Fatigue
• Nausea
• RUQ pain
• Left-Sided Heart Failure Signs:
  • Fluid backs up in the lungs
  • Left ventricular heaves
  • HR
  • S₃ and S₄ heart sounds
  • ABGS: ↓ PaO₂, slight ↑ PaCO₂
  • Confusion, restlessness
  • Dry, hacking cough
  • Crackles (pulmonary edema)
  • Pleural effusion
  • PMI displaced inferiorly and left of the midclavicular line (LV hypertrophy)
  • Pulsus alternans (alternating pulses: strong, weak)
  • Shallow respirations up to 32-40/min
  • Frothy, pink-tinged sputum (advanced pulmonary edema)
• Left-Sided Heart Failure Symptoms:
  • Anxiety, depression
  • Dyspnea
  • Fatigue, weakness
  • Nocturia
  • Orthopnea
  • Paroxysmal nocturnal dyspnea

Heart Failure Diagnostics

• Chronic Heart Failure:
  • Tests measure baseline function
  • Exercise stress test, 6 min walk test, sleep studies are used
• Acute Decompensated Heart Failure:
  • Assessing how much worse than baseline
  • Hemodynamic Monitoring, LVEF, endocardial biopsy are used
• CV Assessment: what symptoms are worse than baseline
• Determine underlying cause , anything we can fix (illness, medications..)
• Biomarkers (BNP, NT-ProBNP, liver function, kidney function)
  • is released when the heart is stressed- big change= more stressed
  • Create or compare to baseline BNP increased in HF (normal <100pg/ml) heart
• Chest Xray, ECG, Echocardiogram, Nuclear imaging, cardiac cath create or compare to baseline, assess decompensation, r/o other processes
  • Structural function-blood flow and cardiac output, new infection new stress

Chronic Heart Failure Collaborative Care

• Refer to Pathopharm for Medications
  • Diuretics
  • RAA system inhibitors (ACEI)
  • Vasodilators
• Nutritional therapy entails:
  • Low sodium diet
  • DASH (dietary approaches to stop hypertension) – focus on fruits, vegetables, whole grains, and lean proteins
  • Severe: Fluid restriction, less than 2L/day
• Daily weights are required in which patients have to call provider if weight gain is >3-5 lbs/week

Transplant

• For end-stage heart failure
• Selection process identifies patients who would most benefit from a donor heart
• Survival rate of 85-90% at 1 year and 75% at 3 year
• Bridge to transplant
• VAD: Ventricular Assisted Device

Infective Endocarditis (IE)

• Infection of the inner layer of heart, including the cardiac valves
• Improved prognosis with antibiotic therapy
• 40,000-50,000 new cases diagnosed in the U.S. each year that have to use IV antibiotics

Infective Endocarditis Risk Factors

• Heart valve disease (Aortic stenosis, mitral valve disease)
• Use of prosthetic valves
• Renal dialysis
• IV Drug Abuse
• Bacteremia/sepsis
• Rheumatic heart disease
• Use of intravascular devices resulting in infections
• Procedures: oral/dental, respiratory tract incisions (adenoids/tonsil surgeries), skin/musculoskeletal surgeries

Infective Endocarditis Manifestations

• Nonspecific
• Fever
• Chills
• Weakness
• Malaise
• Fatigue
• Anorexia
• Murmur (new)
• Heart failure

Manifestations of Infective Endocarditis

• Onset of new Murmur in most patients
• Heart failure
• Splinter hemorrhages in nailbeds, petechial
• Janeway lesions on fingers/toes
• Manifestations secondary to embolism:
  • Spleen
  • Kidneys
  • Limbs
  • Brain
  • Lungs

Infective Endocarditis Diagnostic Studies

• Medical History: Any recent surgical/ invasive procedures (dental, gyn, urological) or Risk assessment (IV drug user)
• Blood cultures performed at 3 different sites over an hour (before starting antibiotics)
• CBC, WBC (high, low or normal)
• Chest Xray to rule out other infections
• ECG shows dysrhythmias and ECG abnormalities
• Echocardiogram: Look at valves for vegetation & function and Blood flow in atria and ventricle
• Duke Criteria (2 major criteria or 1 major and 3 minor or 5 minor criteria) is used for risk stratifying for infective endocarditis
  • Major: + blood cultures, evidence of endocardial involvement/echo +
  • Minor: Predisposing heart condition or IV drug use/ fever/ vascular findings/ immunologic findings (roth, oslers, nephritis)/ +blood culture that doesn't meet major criteria

Infective Endocarditis Collaborative Care

• Curative measures include:
  • Accurate identification of organism
  • IV antibiotics (long-term) (likely will need a PICC or other long term access)
  • Valve replacement if needed
• Supportive measures include:
  • Antipyretics
  • Fluids
  • Rest
  • Repeat blood cultures

Infective Endocarditis Nursing Implementation

• Requires health promotion: identify those at risk, assess hx, teach the importance of antibiotic treatment
• Drug rehabilitation
• Patient teaching
• IV Antibiotic therapy 4-6 weeks
• Need for Prophylactic antibiotic treatment for:
  • Certain dental procedures
  • Respiratory tract incisions
  • Tonsillectomy and adenoidectomy
  • Surgical procedures involving infected skin, skin structures, or musculoskeletal tissue

Valvular Heart Disease

• Types of valvular heart disease depends on:
  • Valve(s) affected
  • Type of functional alteration(s) (Stenosis or Regurgitation)

Valvular Heart Disease Characteristics

• Stenosis (constriction/narrowing)
  • Thickening of the valve
  • Valve orifice is smaller
  • Forward blood flow is impeded
  • Pressure differences reflect the degree of stenosis-valves close, blood can't get up to atrium
  • Dypsnea, tachycardia, low BP
• Regurgitation (incompetence/insufficiency)
  • Incomplete closure of valve leaflets
  • Results in backward flow of blood-valves do not fully close

Valvular Heart Disease Manifestations

• Mitral Valve stenosis

  • Dyspnea on exertion, hemoptysis
  • Fatigue
  • Atrial fibrillation on ECG, palpitations, stroke Loud, accentuated S1; low-pitched, diastolic murmur

• Mitral valve regurgitation

• Acute: Usually not tolerated well, new systolic murmur with pulmonary edema and cardiogenic shock developing rapidly

• Chronic: Weakness, fatigue, exertional dyspnea, palpitations; an S3 gallop, holosystolic murmur

• Aortic valve stenosis:

  • Angina, syncope, dyspnea on exertion, heart failure
  • Normal or soft S₁, diminished or absent S2, systolic murmur, prominent S4

• Aortic valve regurgitation

  • Acute: Abrupt onset of profound dyspnea, chest pain, left ventricular failure and cardiogenic shock
  • Chronic: Fatigue, exertional dyspnea, orthopnea, PND; water-hammer pulse; heaving precordial impulse; diminished or absent S₁, S3, or S4; soft high-pitched diastolic murmur, Austin Flint murmur

Valvular Heart Disease Diagnostics

• The following can be identified from these studies:
  • History and Physical: Heart sounds, activity intolerance, BP, HR.... CV assessment
  • Chest Xray: Heart size, altered pulmonary circulation and valve calcification
  • ECG: HR, Rhythm, Ischemia or ventricular hypertrophy
  • 3D echocardiography: Assess mitral valve and congenital heart disease
  • Transesophageal echo: Diagnosis and monitor disease progression, Blood flow in atria ventricle
  • Echocardiogram: Look at the valve function, structure and heart chamber size
  • Cardiac Cath: Detects pressure changes in heart chambers and across the valves

Valvular Heart Disease Collaborative Care

• Conservative management includes:
  • Prophylactic antibiotic therapy to prevent recurrent infections
  • Dependent on valve involved and disease severity
  • Prevent exacerbations of HF, pulmonary edema, thromboembolism, and recurrent endocarditis
• Valve Replacement can be mechanical or biological
• Mechanical has artificial materials (metal, carbon, dacron) while biological are human cadaver, bovine, porcine, and some man- made material
• Mechanical lasts longer than Biologic; biological are less durable than mechanical
• Mechanical can cause risk of thromboembolism/ need anticoagulation while biological can cause no risk/ no need for anticoagulation
• Mechanical does not need replacement while biological Depending on age, may need replacement.

Valvular Heart Disease Nursing Implementation

• Health promotion includes:
• Diagnosing and treating streptococcal infection
• Prophylactic antibiotics for patients with history
• Encourage compliance especially with anticoagulation
• Teach patient when to seek medical treatment

Target Groups for Prophylactic Antibiotics

• Those with Prophylactic heart valve or prosthetic material used to repair heart valve
• Previous history of infectious endocarditis
• Congenital heart disease (CHD)
  • Unrepaired cyanotic CHD (including palliative shunts and conduits)
  • Repaired congenital heart defect with prosthetic material or device for 6 mo after the procedure
  • Repaired CHD with residual defects at the site or adjacent to the site of prosthetic patch or prosthetic device
• Cardiac transplantation recipients who develop heart valve disease
• The following conditions or procedures, need prophylactic antibiotics: -Oral -Dental manipulation involving the gums or roots of the teeth -Dental manipulation involving puncture of the oral mucosa -Dental extractions or implants -Prophylactic teeth cleaning with expected bleeding -Respiratory tract infections: Respiratory tract incisions (e.g., biopsy) -Incision for Tonsillectomy and adenoidectomy -Gastrointestinal and genitourinary: Wound infection and Urinary tract infection