Cardiovascular Health & Perfusion

• These notes cover perfusion and cardiovascular health, including coronary circulation, cardiac output, heart conditions, lab tests, ECGs, and interventions.

Objectives

• Students should learn to assess cardiovascular dysfunction's physiological and psychosocial aspects.
• Diagnostic cardiovascular assessments, including invasive and non-invasive tests, preparation, and follow-up care, must be understood.
• Knowledge of age-related cardiovascular changes should be synthesized to modify patient care.
• Able to plan and evaluate nursing care for cardiovascular dysfunction and describe evidence-based practices related to it.

Perfusion Unit Topics

• Coronary heart disease is a key area of study.
• Acute coronary syndrome, including myocardial infarction (MI), is critical.
• Management of dysrhythmias for MI must be understood.
• Pacemaker and implantable cardioverter-defibrillator (ICD) therapy are included.
• Acute endocarditis and cardiac valvular disorders are relevant.
• Cardiomyopathy and aortic aneurysms are important topics.
• The concept of shock states is necessary.

Anatomy Review: Coronary Circulation

• Knowledge of coronary circulation is vital for nurses working with heart disease patients.

Cardiac Conduction System and Electrocardiogram

• SA Node; it's the start of the electrical system
• AV Node; receives the signal from the SA AV node and delays it briefly
• The impulse flow travels through the Bundle of His, Left and Right Bundle fibers, and Purkinje Fibers
• ECG segments are: P, Q, R, S, and T waves
• ECG Intervals: PR interval, QRS Interval, and QT Interval

Glossary of Terms Related to Cardiac Output

• Cardiac output (CO) measures the liters of blood pumped by the ventricle per minute; normal range is 4-8 L/min.
• Cardiac index (CI) is CO divided by body surface area; normal range is 2.8-4.2 L/min/m².
• Stroke volume (SV) quantifies blood ejected with each heartbeat.
• Ejection fraction (EF) is the percentage of end diastolic volume ejected per heartbeat.
• Pulse pressure is the difference between systolic and diastolic blood pressure, ⅓ of SBP.
• Mean arterial pressure (MAP) shows the average pressure in the arterial system as felt by organs, calculated as (SBP + 2 × DBP) ÷ 3.
• Systemic vascular resistance refers to the force opposing blood flow in the systemic circulation.

Factors Affecting Cardiac Output

• Preload is the volume of blood in the ventricles at the end of diastole.
• Contractility is the heart's ability to function as a pump.
• Afterload is peripheral resistance against which the left ventricle must pump.

Cardiovascular Laboratory Tests

• Cardiac enzymes, including Troponin T and I, and CK, CK-MB, are tested.
• C-reactive protein is assessed to determine risk factor for coronary heart disease (CHD).
• Homocysteine levels are important.
• Cardiac natriuretic peptides, such as Atrial (ANP), B-type (BNP), and C-type, are measured.
• Lipid and lipoprotein profiles, including cholesterol, triglycerides, HDL, and LDL, are evaluated.

Types of Electrocardiography (ECG)

• Involves 12-lead ECG
• Continuous monitoring via hardwire and telemetry options.
• Continuous ambulatory monitoring, known as Holter monitoring is an option.
• Cardiac stress testing
  • Exercise and chemical (dobutamine) stress testing options.
  • Isotope or nuclear stress testing can also be used.

Coronary Heart (CHD)

• Atherosclerosis leads to CHD and occludes coronary arteries, causing ischemic symptoms. Such as unstable angina, MI, and sudden cardiac death.

Risk Factors for CHD

• Modifiable: includes elevated serum lipids, hypertension, tobacco use, physical inactivity, obesity, diabetes mellitus, metabolic syndrome, psychologic stress, homocysteine level, and substance use.
• Nonmodifiable: includes age, gender, ethnicity, family history, and genetic predisposition.

Hallmark Symptom of CHD

• Ischemia develops with 60% or more plaque buildup, leading to angina (chest pain), more common symptom.
• Asymptomatic individuals may have atypical symptoms, especially women, older adults, and those with heart failure (HF) or diabetes mellitus (DM).
• After angina, CHD may lead to MI, HF, or sudden cardiac death.

Nursing and Interprofessional Care: CHD

• Physical fitness: Use Frequency, Intensity, Time, and Type (FITT formula), 30 minutes most days with resistance training.
• Benefits: weight reduction and a 10% decrease in systolic BP.
• Nutrition: Decrease saturated fats and cholesterol; increase Fiber, complex CHOs, and decrease red meat, egg yolks, and whole milk.

Collaborative and Nursing Management: CHD

• Lipid-lowering medications If diet and exercise fail
  • Statins: inhibit synthesis. Lower LDL, increase HDL, and monitor for the liver damage/Myopathy.
  • Niacin: decreases LDL and triglycerides by inhibiting synthesis, increases HDL; side effects include flushing, GI side effects, and orthostatic hypotension.
  • Fibric acid derivatives (gemfibrozil) decrease triglycerides and increase HDL; can cause GI side effects.
• Lipid-lowering Medications.
  • Bile Acid Sequestrants: increase cholesterol conversion to bile acids and can bind with other drugs potentially has GI side effects
  • Ezetimibe: decreases absorption of dietary and biliary cholesterol.
• Antiplatelet therapy: aspirin (ASA) or clopidogrel.

Gerontologic Considerations: CHD

• Modify physical activity and Need physical activity guidelines
  • Include longer warm-up and rest periods, Longer periods of low-level activity, avoid temperature extremes, and 30 minutes most days minimum
• Strategies to reduce risk and treat CHD are effective
• Treat hypertension and ↑ lipids, smoking cessation should be included.
• Likely to change when hospitalized or symptomatic

Angina Pectoris

• Characterized by episodes of paroxysmal pain or pressure in the anterior chest due to insufficient coronary blood flow.
• Exertion or stress increases myocardial oxygen demand (mvO2), BVs cant supply adequate blood flow.
• Types: stable, silent, nocturnal, variant (Prinzmetal).

Clinical Manifestations of CHD: Angina

• Angina pain: Pressure/ache, Squeezing, heavy, choking, rarely sharp, indigestion
• Progressive disease
  • O2 needs > O2 available, causing myocardial ischemia
  • Occurs when arteries are 60–75% blocked
  • Hypoxic within 10 seconds
  • Myocardial cells viable for 20 minutes

Clinical Manifestations of CHD Chronic Stable Angina

• Intermittent chest pain* that occurs over a long duration with the same pattern duration intensity of symptoms.
• ST segment depression and/or T-wave.
• Usually controls with nitrates

Chronic Stable Angina (Medications)

• The goal is to decrease demand and/or increase O supply.
• Short Acting Nitrates such as
  • Dilate peripheral and coronary blood vessels.
  • Administer sublingually
  • Repeat every 5 mins, max 3 times
• Long Acting Nitrates
  • reduce incidents of angina.
  • Side effects may include Orthostatic hypotension and Headaches.

Chronic Stable Angina (Medications)

• Medications such as Angiotensin are used if the EF is 40% or less, or of with diabetic history ß-adrenergic, in those with LV dysfunction and increase with BP, Calcium Channels Sodium Current Inhibitor, and Ranolazine for antianginal drug adequacies

Chronic Stable Angina (Nursing/Collaborative Management)

• Cardiac catheterization (CC) to visualize, and repair Coronary Blockages (open blockages) via angioplasty, stents,
• Cardiac catheterization (CC)

Clinical Manifestations of ACS Unstable Angina

• New onset
• Can occur at rest
• Frequency worsens
• Unpredictable
• Medical emergency! Symptoms may be unique to women.

Focus on Nursing Care Chronic Stable Angina and ACS

• Includes objective data, dysrhythmias, assessing the pulse

Focus on Nursing Care Chronic Stable Angina

• Upright position and supplemental Oxygen with medications, auscultation

ECG Changes Associated With Acute Coronary Syndrome (ACS)

• ECG analysis provides information; the Lateral ECG leads I, AVL.
• Anteroseptal leads: V1-V4.
• Lateral leads: V5, V6. ; and Inferior leads: II, III, aVF.

ECG Changes Associated With ACS

• Ischemia: ST-segment depression and/or T-wave inversion > 1mm.
• This process is reversible is O2 is improved

Interprofessional Care Acute Coronary Syndrome

• Review ECG's to make sure serial ECGs are correctly compared.
• Administer nitro/oxygen, ASA, and morphine.
• Ongoing monitoring, Bed rest
• STEMI or NSTEMI with cardiac markers: reperfusion therapy. Emergent PCI, Thromolytic, and balloon angioplasty are used.

Interprofessional Care

• Thrombolytic, within 30 mins, for STEMI.
• Thrombolytic is monitored closely and has strict guidelines

Clinical Manifestations of ACS Myocardial Infarction

• Result from Ischemia, irreversible process, death

Clinical Manifestations of ACS: Myocardial Infarction

• immobilize. nitrates. jaw. arms
• Chest pains, and radiation.

Clinical Manifestations of ACS Myocardial Infarction

• Catecholamine causes Diaphoresis.
• The pt may have crackles.

Acute Coronary Syndrome (ACS) Diagnosis

• Diagnosed first with health history and a 12 ECG- and then cardiac enzymes

Interprofessional Care ACS: Surgical

• Coronary requires revascularizatoin due either from failed medical failures, history of diabetes or dysfunction.

Interprofessional Care Acute Coronary Syndrome

• Surgical and is done if revasculatization is done minimally

Focus on Nursing Care

• coronary interventions

CABG: Postoperative Nursing Care

• Pain/Bleeding.

Some Possible Postoperative Complications of Coronary Artery Bypass

• Decreased cardiac, kidney, neurological dysfunction and infection.

Collaborative Care Acute Coronary Syndrome

• Therapy nitroglycerin, and Anticoagulants.

Collaborative Care Acute Coronary Syndrome

• Progress from to lowcholestrall.

Focus on Nursing Care

• Cardiac diet- monitoring

Focus on Nursing Care Acute Coronary Syndrome

• Reperfusion for those with cardiac activity

Sudden Cardiac Death (SCD)

• Most commonly