Cardiovascular System: Aging & Nurse's Role

Effects of Normal Aging on the Cardiovascular System

• By age 65, physiological changes typically reduce the heart's pump efficiency
• The heart retains functionality unless impacted by underlying cardiovascular diseases

Nurse's Role in Cardiovascular Disease

• Nurses should understand the prevalence of cardiac disease, its risk factors, and progression
• Nursing interventions and patient education are key components of care

Risk Factors for Cardiovascular Disease

• The existence of multiple risk factors heightens the overall cardiovascular risk

Nonmodifiable Risk Factors

• Normal physiological changes occur with age
• A family history of cardiovascular issues before age 50 is a risk factor
• Middle-aged men are more susceptible than middle-aged women, but CVD is a more common cause of death in women
• Women develop CAD later in life due to estrogen's protective effects pre-menopause
• CAD incidence elevates in women 50 and older
• African Americans face a higher incidence of myocardial infarction (MI) and stroke, with more women affected than men
• There is also increased risk in the Hispanic population compared to non-Hispanics, with more women affected than men

Modifiable Risk Factors

• Smoking increases cardiovascular disease risk due to nicotine, tar, and carbon monoxide
• Tachycardia, hypertension, and vasoconstriction can be caused through nicotine releasing catecholamines
• Atherosclerosis and increased clot formation result from tar and carbon monoxide
• Elevated lipid concentrations in the plasma is Hyperlipidemia
• The HDL to LDL ratio best indicates cardiovascular disease development
• Higher LDL levels heighten the risk of heart disease
• Decreased HDL levels increase CAD risk. High levels are protective
• Diet, weight reduction, and physical exercise can modify this risk
• Statin drugs can also be included in treatment
• Hypertension is often a silent killer with no signs or symptoms until damage is apparent
• Heart disease, stroke, heart failure, plus cardiovascular death risk all increase with hypertension
• Diet, exercise, and pharmacological management can modify hypertension
• Cardiac disease is more prevalent with Diabetes Mellitus
• Atherosclerosis occurs from elevated blood glucose levels damaging the arterial intima
• Risk can be modified by controlling blood glucose
• Obesity increases the heart's workload and contributes to other risk factors
• A Sedentary Lifestyle correlates to a higher cardiovascular disease development risk
• Aerobic exercise enhances heart efficiency, reduces blood glucose, improves HDL to LDL ratio, and lowers weight
• The body responds to Stress by releasing catecholamines that elevate heart rate and cause vasoconstriction
  • Risk can be modified by stress reduction techniques
• Type D personality (chronic negativity, pessimism, social inhibition) increases risks as a Psychological Risk Factor

Acute Coronary Syndrome (ACS)

• ACS includes stable angina, unstable angina, and acute myocardial infarction (AMI)
• AMI constitutes myocardial necrosis caused by ischemia
• Prompt recognition and treatment for AMI improve outcomes
• Pathophysiology arises from an imbalance between myocardial oxygen supply and demand, thus decreasing coronary artery profusion
• Atherosclerosis is often the cause
• After 20 minutes of ischemia, irreversible myocardial cell damage and cellular death begin
• Early interventions, like thrombolytics, reduce myocardial damage by restoring perfusion to the ischemic zone

MI (Myocardial Infarction) Classification

• Spontaneous MI (Type I) is due to plaque rupture and artery occlusion
• MI (Type II) is secondary to ischemic imbalance

Infarct Locations

• Infarcts generally occur in the left ventricle, but can occur in the right ventricle (one-third of inferior infarcts)

Assessment

• Men may experience severe, crushing, tight, squeezing, or pressure-like chest pain
• The pain can be precordial, substernal, in the back, or radiating to the arms, neck, or jaw
• Skin may be cool, clammy, pale, diaphoretic, dusky, or ashen
• Other symptoms: dyspnea, tachypnea, feeling faint, intermittent loss of sensorium, nausea and vomiting, hypotension, dysrhythmias, anxiety, restlessness, denial, depression, and a sense of impending doom
• Chest pain may not be the most obvious symptom in women
• Additionally, they can experience dyspnea, nausea, vomiting, diaphoresis, syncope, fatigue, and palpitations
• Silent Infarction is ischemia without any presenting signs or symptoms
• This is common among individuals with diabetes due to neuropathy

Diagnosis

• Diagnosis depends on symptoms, a 12-lead ECG analysis, and assessment of cardiac enzymes
• Suggestive of AMI, ECG findings include ST-segment elevation in two or more contiguous leads, ST-segment depression, and a new-onset left bundle branch block
• Elevated Troponin I and Troponin T, as assessed through Cardiac Enzymes, confirm the diagnosis of AMI
• Cardiac catheterization is an emergency procedure

Complications

• Cardiac dysrhythmias, heart failure, thromboembolism, rupture of the heart, pericarditis, infarct extension/recurrence, and cardiogenic shock constitute Complications

Medical Management

• Goals: Reperfusion, reduce infarct size, prevent and treat complications, emotional support, and patient education
• Treatment aims to relieve pain with Morphine sulfate IV and nitrates
• To maintain O2 saturation above 90%, administer Oxygenation via nasal cannula
• To prevent platelet aggregation use Aspirin, clopidogrel, prasugrel, and heparin
• Decrease heart rate, blood pressure, and myocardial oxygen consumption by using Beta Blockers, starting within 24 hours after ACS
• Within 24 hours in STEMI patients with LVEF of 40% or less, history of hypertension, diabetes, or chronic kidney disease, ACE Inhibitors reduce ventricular remodeling
• To restore blood flow, Percutaneous Coronary Intervention (PCI) and Fibrinolytic Therapy are used -- PCI is more effective than thrombolysis, and should be performed within 120 minutes after first medical contact -- Using Fibrinolytic Therapy, dissolve the clot and increase blood flow to the myocardium, this works best if treated within 1 to 2 hours of onset

Nursing Considerations

• Hemodynamic monitoring must be done, plus monitoring for bleeding (after thrombolytics), dysrhythmias, re-occlusion/reinfarction, and hemorrhagic stroke

Patient Outcomes

• Adequate cardiac output, ability to tolerate progressive activity, verbalization of relief of pain or fear, and demonstration of positive coping mechanisms

Code Management and Resuscitation

• Patients with ACS may require life-saving resuscitation and interventions
• Codes are initiated for cardiac or respiratory arrest or life-threatening cardiac dysrhythmias
• Prompt recognition and immediate Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) use is essential for improved patient outcomes

Rapid Response Teams (RRT)

• The goal of Rapid Response Teams (RRT) is to improve recognition of, and the response to clinical deterioration in patients
• Another goal is to improve patient outcomes and decrease hospital mortality
• Deterioration in heart rate, blood pressure, respirations, pulse oximetry saturation, altered mental status, reduced urinary output, and abnormal laboratory values are all activation criteria

Role of Caregivers in Code Management

• Caregivers must promptly recognize and respond by initiating BLS and ACLS quickly
• Code teams all necessitate physicians, nurses, respiratory therapists, pharmacists, ECG technicians, and chaplains
• Teamwork is essential

Code Equipment

• Standard emergency equipment and medications come in the code cart
• Nurses must be familiar with its contents at all times
• A cardiac board provides a hard, level surface for chest compressions
• A AED monitors cardiac rhythm, plus is capable of transcutaneous pacing used by a monitor-defibrillator

Resuscitation

• Use Basic Life Support (BLS) until the code team arrives
• Focus Basic Life Support (BLS) with CPR high-quality compressions and early defibrillation -- The goal is to Restore effective circulation, oxygenation, and ventilation with the return of spontaneous circulation (ROSC)
• The use of the ABCD approach occurs during Advanced Cardiovascular Life Support (ACLS) -- Airway, Breathing, Compressions/Circulation, Differential Diagnosis -- Treat reversible causes of Hs and Ts --- Hs: Hypovolemia, hypoxia, hydrogen ion (acidosis), hypokalemia or hyperkalemia, and hypothermia are all Hs --- Ts: Tension pneumothorax, cardiac tamponade, toxins (drug overdose), and thrombosis (pulmonary and coronary) are all Ts -- Plus treatment of dysrhythmias --- Such as ventricular fibrillation, and pulseless ventricular tachycardia --- Pulseless electrical activity (PEA) and asystole --- Symptomatic Bradycardia --- And Unstable Tachycardia.

Post-Resuscitation Care

• Survival and life quality of the patient improves with Systematic post-cardiac arrest care after ROSC

Goals

• Optimize the patient's cardiopulmonary function and tissue perfusion
• Transport the patient to an appropriate critical care unit
• Identify and treat precipitating causes of arrest to prevent another arrest

Interventions

• Insertion of an advanced airway, maintaining blood pressure and oxygenation
• Controlling dysrhythmias with continuous ECG monitoring
• Advanced neurological monitoring with serial neurologic assessments
• Monitor for metabolic acidosis and correct electrolyte abnormalities
• Manage hyperglycemia.
• Provide emotional support.

Targeted Temperature Management (TTM)

• Hypothermia decreases the metabolic rate and suppresses ischemia-induced inflammatory reactions
• Cool the patient to a temperature of 32 to 36 degrees Celsius after Return of Spontaneous Circulation (ROSC)
• Methods include ice packs, cooling blankets, specialized cooling pads, ice-cold isotonic IV fluids, and endovascular devices
• Continuous monitoring of core body temperature
• Begin rewarming after 24 hours in a slow manner, and fever should be avoided after normothermia is achieved