Cardiovascular Disorders and Atherosclerosis

Cardiovascular Disorders

• Cardiovascular disorders include Peripheral Arterial Disease, Coronary Artery Disease, Acute Coronary Syndrome also known as Myocardial Infarction, and Pericarditis.

Arteries

• Arteries carry oxygenated blood and nutrients to the tissues.
• Arteries have muscular walls capable of handling pressurized flow.
• Arterial flow is ensured in one direction by the force of the heart.

Atherosclerosis

• Atherosclerosis is the hardening or thickening of arteries.
• It is characterized by lipid deposits within the arterial intima.
• Atherosclerosis is a progressive disease, beginning with endothelial injury.
• Advanced Atherosclerosis leads to progressive limitation in distal perfusion.
• Atherosclerosis is the cause of Peripheral arterial disease and Coronary artery disease (also: cerebral, mesenteric, and renal artery disease!).
• Smoking, diabetes mellitus, hyperlipidemia, hypertension, and age are risk factors for atherosclerosis.
• Atherosclerosis can cause vasoconstriction, endothelial pressure and diabetes.
• Atherosclerosis can lead to CAD(coronary artery disease), PAD (peripheral artery disease), Angina, and Intermittent Claudication.

Peripheral Arterial Disease (PAD)

• PAD is the progressive narrowing of arteries (lower extremities) because of advanced atherosclerosis.
• PAD is associated with high mortality, major coronary events, and stroke.
• PAD is often undiagnosed and undertreated.
• PAD's progression is slow.
• Advanced PAD often includes many occlusions.
• Claudication (intermittent lower extremity pain) is a symptom of PAD where people don't feel pain until 60-70% of the artery is occluded.
• Symptoms of PAD occur when the artery becomes 60-75% blocked.
• Classic PAD symptom: "Intermittent Claudication”.
• Additional PAD symptoms include paresthesia (peripheral neuropathy).
• Nursing assessments for PAD: Assess hair/ toenails, temperature, pain pattern, edema, pulses, capillary refill.
• Skin changes with PAD includes elevation pallor/ dependent rubor.
• Claudication results in intermittent lower extremity pain
• Rest Pain is also a symptom.
• Left untreated PAD can lead to Acute Limb Ischemia.
• Smoking is the number one modifiable risk factor for PAD.
• Other modifiable risk factors include physical inactivity, obesity, hyperlipidemia, hypertension, elevated homocysteine, and diabetes.
• Non-modifiable risk factors include increased age(symptoms from 50-70 years), race, and genetics.

PAD - Diagnostic Tests

• Ankle Brachial Index measures the ratio of blood pressure in the ankle to the BP of the arm.
• Doppler Ultrasound measures blood flow through the vessels.
• Segmental Blood Pressures compares pressures to detect blockages.
• Angiography is invasive, using contrast dye, specific.
• MRI is non-invasive, and produces detailed images of arteries
• A reading above 1.4 on the ABI indicated calcification/vessel hardening and referral to vascular specialist is indicated.
• A reading of 1.0-1.4 on the ABI indicated the test is normal, and no action is needed.
• A reading of 0.9-1.0 on the ABI is acceptable and no action is needed
• A reading of 0.8-0.9 on the ABI indicated some arterial disease, and treatment for risk factors is indicated.
• A reading of 0.5-0.8 on the ABI indicated moderate arterial disease, and referral to a vasucalar specialist is indicated
• A reading of less than 0.5 on the ABI indicated severe arterial disease, and referral to a vascular specialist is indicated.

PAD - Complications

• Critical Limb Ischemia can be a complication of PAD:
• Critical Limb Ischemia leads to Delayed or Non-healing wounds following minor trauma.
• Primary Arterial Lesions, Gangrene, infection, and Amputation can be caused by PAD
• Patients with PAD and a 100% artery occlusion may not need revascularization because of collateral development of blood vessels.
• Angiogenesis is new blood vessel growth.

PAD- Treatment

• Pharmacological treatments include lipid lowering drugs, ACE, low dose aspirin, Plavix, Cilostazol and pentoxifylline for intermittent claudication.
• Non-pharmacological treatments include risk factor modification (tobacco cessation, dietary modifications, hypertension management and BG control), and exercise therapy.

PAD- Surgical Options

• PAD can be treated by Revascularization.
• Bypass surgery is a revascularization option. Native vein vs synthetic veins are used.
• Angioplasty (endovascular) is another revascularization option to treat PAD.
• Not every patient is a surgical candidate. Conservative management and amputation may be the only options.

PAD- Postoperative Care

• Patients must be monitored for mobility and blood flow.
• Postoperative nursing focuses includes checking CMS, temperature, and assessing the operative site.
• CMS checks should compare the contralateral limb.
• Perfusion problems before surgery are a high risk for problems after intervention.
• The operative site should be checked for bleeding, hematoma, thrombosis, and compartment syndrome.
• Patients should be out of bed doing ambulation, keeping the legs elevated when out of bed.
• Bleeding, new occlusion, and pain should be monitored.
• Reduce the chance of VTE.
• Reduce the chance of PNA.
• Incisional care is important for treatment.

PAD- Nursing Care/ Teaching

• Nursing goals for PAD are adequate tissue perfusion, Pain relief, Increased exercise tolerance, Maintain intact and healthy skin of the lower extremities, Increased knowledge of disease and treatment plan.
• Focus on Modifiable Risk Factors: Proper nutrition,medication adherence, smoking cessation, Exercise, management of diabetes, podiatry care.

Coronary Artery Disease

• Coronary Artery Disease (CAD) is a chronic and progressive disease caused by atherosclerosis.
• Plaque buildup in coronary arteries effects the perfusion on the heart muscle.

CAD- Symptoms

• CAD begins when one of the coronary arteries has 70% or greater blockage.
• CAD symptoms include exercise intolerance, dyspnea, fatigue, chest pain also known as Angina, with pain ofter being sub-sternal
• Angina is associated with ECG changes.
• Stable Angina refers to when chest will hurt during exertion like stairs, until rest.
• Unstable Angina - NSTEMI refers to partial vessel blockage with abrupt onset and unpredictability.
• Full Vessel Occlusion - STEMI is when a vessel is fully blocked.

CAD- Risk factors

• Smoking is the #1 modifiable/ Lifestyle factors to consider.
• Modifiable/ Lifestyle factors include hypertension, hyperlipidemia, diabetes (makes CAD 2-4x more likely), physical inactivity, obesity, Elevated Homocysteine, stress, and substance abuse.
• Non-modifiable risk factors include increased age, race & gender, and genetics.

CAD - Treatment

• Pharmacological treatments include medications like lipid lowering drugs and low dose aspirin or Plavix.
• Non-pharmacological treatments include like changing lifestyle, risk factor modification, tobacco cessation, dietary modifications, hypertension management, and BG control.

Prinzmetal's Angina

• Pain with Prinzmetal's Angina is caused by a coronary spasm and unrelated to Coronary Artery Disease
• Coronary spasm causes include substance exposure, and cold weather exposure.
• Pain may subside with exercise, nitro, or spontaneously.
• Treatment: calcium channel blockers, nitrates, stopping use of offending substances.

Chronic Stable Angina

• Chronic Stable Angina lasts less than 5 minutes.
• The problem with Angina is oxygen Demand is greater than oxygen Supply
• The goal is Decreasing O2 demand, or increase O2 supply
• Treatment involves Pain relief, Immediate and appropriate treatment, Preservation of heart muscle, Effective coping, Participation in cardiac rehab with physical therapists.
• For nursing care, ask the patient to describe pain & rate it and have them take nitro(should relieve it).
• Nursing care includes assess VS, EKG, heart sounds, and nonverbal pain cues.
• Support and reassure the patient.

Diagnostics for Angina

• Diagnostics include 12-lead ECG Labs, Chest Xray, Echocardiogram, Exercise stress test, Pharmacological stress test and Cardiac Catheterization with PCI.
• CKMB for labs should be done after testing.
• Cardiac Catheterization is gold standard with dye inserted to identify blockage.
• Thrombolytic medications may be given if PCI is unavailable.
• Echocardiograms are a good indication of heart structures.

Surgical Options

• Coronary Artery Bypass Graft(CABG) surgery that requires sternotomy & Cardiopulmonary Bypass can treat angina:
• CABG may use LIMA or a Leg vein as a graft
• MIDCAB (minimally invasive) can treat angina.
• CABG surgery allows the heart to get oxygen and glucose, and allows the heart to get oxygen and glucose to function

CABG- Postoperative Nursing Care/ Teaching

• First 24-48 in ICU.
• Monitoring many invasive lines: CO monitor, Arterial Line, Chest tubes, Continuous ECG, Mechanical Ventilation, Epicardial pacing wires, Foley, NGT.
• Postop Considerations: Bleeding, Dysrhythmias, Pain, Reduce chance of VTE, Reduce chance of PNA, Incisional care.

Acute Coronary Syndrome (ACS) / Myocardial Infarction (MI)

• Acute Coronary Syndrome (ACS)/ Myocardial Infarction (MI) occurs when ischemia is prolonged and not immediately reversible.
• Previously stable atherosclerotic plaque ruptures and lodges in the vessel, platelets aggregate and a thrombus forms.
• MI may have partial or full occlusion of coronary artery with irreversible tissue death occurring after 20 minutes.
• all CAD treatment discussed thus far is preventative for MI.

Unstable Angina vs Myocardial Infarction

• Unstable Angina (NSTEMI) may be able to reperfuse a heart, and patients describe pain is significantly different than "normal".
• UA is unpredictable and needs treatment emergently with ECG changes of ST depression/ T wave inversion
• Myocardial Infarction (STEMI) is a medical emergency with reperfusion needing to occur within 90 minutes to limit infarct size.
• MI is treated with PCI vs thrombolytic therapy with ECG changes of ST elevation and pathologic Q waves.

Symptoms - Acute MI

• Acute MI features profound chest pain (crushing, substernal or epigastric).
• Silent MI has possible no pain.
• Other Symptoms include Lack of oxygen causes the heart to beat faster leading to more demand!
• Tachycardia/ Hypertension and Nausea & Vomiting are symptoms.
• Symptoms of decreased cardiac output, include low UOP, and Confusion,
• Other symptoms include Left Ventricular Dysfunction & Right Ventricular Dysfunction.

Acute MI- Assessment

• First, ask about any meds today and any allergies to medications.
• Use PQRST which is Precipitating events, Quality of pain, Region/ Location, Severity, and Timing of onset
• Treat within -90 minutes to get to PCI

MI - Diagnosis

• EKG Findings should be checked and compared to new and a previous ECG.
• The pattern of ECG changes provides information on which artery is involved.
• STEMI will have ST elevation in the leads facing the infarcted wall
• NSTEMI will have ST depression and/or T-wave inversion in leads facing the infarction
• Perform serum Cardiac Biomarkers
• Drawlabs including Troponin, CK, CK-MB of the myocardial muscle.
• Cardiac Catheterization is also performed

MI - Treatment

• Perform quick diagnosis and Treatment with PCI
• Follow up a 12 Lead -> ST elevations go directly to cath lab for treatment.
• If there are Facilities without cath labs: Perform Thrombolytic therapy
• Administer Medications.
• Implement Nutrition treatment – initially NPO then heart healthy diet

MI - Nursing Care (Acute Phase)

• Focus on pain relief with quick appropriate treatment and preservation of heart muscle.
• Nursing care to anticipate inclues giving 12-lead ECG, Continuous ECG, Monitoring, Upright positioning, Oxygen, IV access, Nitro, aspirin, Morphine for pain, High dose statin, and Obtain Labs.
• IV drugs given includes IV access, Nitro,Morphine oxygen and nitrogren.
• Aspirin is given to help to prevent further clots with chest pain.

Cardiac Catheterization & PCI - Nursing Management

• Pre-Procedure- Assess for Allergie to contrast dye ,establish Baseline assessments and labs, NPO 6-12 hrs, Administer or hold specific meds (as directed, and teaching patients what to expect.
• Post Procedure monitoring includes pain comparisons, assess EKG, CMS checks, monitoring for bleeding or hematoma, changes to EKG and following Bedrest as per policy.
• Expected Outcomes include- Minimal bleeding, Stable vital signs. Cardiac rhythm stable (without irregular beats)

MI - Complications

• Healing for necrotic heart muscle lasts weeks and many complications can develop.
• Dysrhythmias,Heart failure , Cardiogenic Shock, Papillary Muscle Dysfunction/ Rupture, LV Aneurism, Ventricular Septal Wall Rupture and Pericarditis are all complications.

MI Nursing Care - Post Acute Phase

• Promote rest and comfort
• Gradually increase physical activity – "listen to your body"
• Reduce anxiety through teaching
• Get Support systems for patients' emotional, or spiritual needs to help
• Teaching- Review Risk factors, meds, and incisional care.
• Advise them to Participate in Cardiac Rehab for 6 months with exercise, diet, with psychological support:
• Advise patient to discuss when to resume sexual activity with the doctor:
• Check If they can climb 1-2 flights of stairs without the feeling short of breath.

Pericarditis

• Pericarditis is the Inflammation of the pericardium, often with fluid accumulation also know as pericardial effusion.
• Normal volume 15mL of fluid
• Pericarditis Often occurs 2-3 days following MI
• Symptoms include Sudden onset Mild to severe sharp chest pain, increased pain with inspiration, coughing, laying down, which is relieved when sitting up.
• A pericardial friction rub is a hallmark finding.
• Patients may also have a fever

Pericarditis - Complications/treatment

• Effusions can lead to tamponade that restricts the movement of the heart, decreased cardiac output, and impaired perfusion
• Diagnostics: ECHO- most helpful, visualize cardiac wall movement, with labs & EKG- nonspecific.
• Treatments: Procedural Treatment with pericardiocentesis, with Medical Treatment of: aspirin, NSAIDs, Abx if infectious
• Acute Pericarditisis due to Inflammation of the pericardia sac and contains 10-15ml of Sereous fluid
• Can be infectious or non infectious from viral fungal, MI cancer trama radiation hypersensitivity, rheumatic fever