Heart Disease in Canada

Heart Disease in Canada

• Heart disease is the second leading cause of death, accounting for 27.6% of all deaths.
• It, along with stroke are leading causes of hospitalization in Canada.
• Approximately 2.4 million Canadians over the age of 20 will experience ischemic heart disease.
• Cardiovascular disease costs are approximately $22 billion per year in Canada.
• Furthermore, it is the second leading contributor to national healthcare costs.
• Minority and low-income populations experience a disproportionate burden of death and disability from cardiovascular disease.
• Cardiovascular disease rates are greater in communities with poor access to health care due to financial, geographic, cultural, social, and educational barriers.
• About 1 in 12 Canadian adults age 20+ live with diagnosed heart disease
• Every hour 14 Canadian adults age 20+ with diagnosed heart disease die.
• Death rate is 2.9x higher for adults age 20+ with diagnosed heart disease compared to those without.
• Death rate is 4.6x higher among adults age 20+ who had a heart attack compared to those without
• Death rate is 6.3x higher among adults age 40+ with diagnosed heart failure compared to those without
• Men are twice as likely to suffer a heart attack than women.
• Men are newly diagnosed with heart disease about 10 years younger than women.
• From 2000-2001 to 2017-2018, the number of Canadian adults newly diagnosed with heart disease decreased from 217,600 to 162,730.
• Furthermore, the death rate decreased by 21%.
• Reducing the risk of heart disease involves being smoke-free, staying physically active, eating a healthy diet, maintaining a healthy weight, and limiting alcohol use.
• Early detection and management of conditions such as high blood pressure, diabetes, and high cholesterol can help reduce the risk of heart disease.

Hypertension

• About one in five adult Canadians has high blood pressure.
• Normal blood pressure: <120 mm Hg / <80 mm Hg
• Blood pressure is the force of blood pumped from the heart against the blood vessels.
• Hypertension involves persistent elevation of systolic blood pressure (SBP) ≥140 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg, or current use of antihypertensive medication(s).
• Hypertension is the most significant modifiable risk factor for cardiovascular disease and mortality in Canada.
• As blood pressure increases, so does the risk for myocardial infarction (MI), heart failure, stroke, and renal disease.
• Its prevalence increases with age and is more common in older adults.
• Hypertension is more prevalent in older women than in older men.
• Women with high blood pressure have a greater risk for cardiovascular disease.

Factors Influencing Blood Pressure

• Cardiac factors: Heart rate, contractility, and conductivity
• Blood pressure results from cardiac output multiplied by systemic vascular resistance.
• Sympathetic nervous system:
  • α1- and α2-Adrenergic receptors (vasoconstriction)
  • β2-Adrenergic receptors (vasodilation)
• Renal fluid volume control:
  • Renin-angiotensin-aldosterone system
  • Natriuretic peptides
• Neurohormonal factors:
  • Angiotensin (vasoconstrictor)
  • Norepinephrine (vasoconstrictor)
• Local regulation:
  • Prostaglandins (vasodilator)
  • Nitric oxide (vasodilator)
  • Endothelin (vasoconstrictor)

Normal Regulation of Blood Pressure

• Cardiac output (CO) is the total blood flow through the systemic or pulmonary circulation per minute.
• CO can be described as stroke volume (SV, the amount of blood pumped out of the left ventricle per beat) multiplied by the heart rate (HR) for 1 minute.
• Systemic vascular resistance (SVR) is the force opposing the movement of blood within the blood vessels.

Hypertension Subtypes

• Isolated systolic hypertension (ISH):
  • Sustained elevation of SBP ≥140 mm Hg and a DBP <90 mm Hg.
  • Common in older persons, related to loss of elasticity in large arteries.
• Primary (essential) hypertension:
  • Majority of adult patients.
• Secondary hypertension:
  • 5 to 10% in adults; >80% in children.
  • Treatment is aimed at eliminating the underlying cause, e.g., renal disease, endocrine disorders, certain medications.

Primary (Essential) Hypertension

• Caused by complex interaction between genes and environment.
• Contributing factors:
  • Increased SNS activity.
  • Increased sodium-retaining hormones and vasoconstrictors.
  • Increased sodium intake.
  • Diabetes mellitus.
  • Greater than ideal body weight.
  • Excessive alcohol intake.

Primary Hypertension Risk Factors

• Advancing age
• Heavy alcohol consumption
• Cigarette smoking
• Diabetes mellitus
• Elevated serum lipids
• High dietary sodium
• Gender
• Family history
• Obesity
• Ethnicity
• Sedentary lifestyle
• Socioeconomic status
• Psychosocial stress

Clinical Manifestations of Hypertension

• Hypertension is often a silent disease.
• It is frequently asymptomatic until it becomes severe and target-organ disease has occurred.
• Severe hypertension symptoms: fatigue, reduced activity tolerance, dizziness, palpitations, angina, and dyspnea.

Primary Hypertension Complications

• Hypertensive heart disease
• Coronary artery disease
• Left ventricular hypertrophy
• Heart failure
• Cerebrovascular disease
• Peripheral arterial disease
• Nephrosclerosis (kidneys)
• Retinal damage

Hypertension Canada Guidelines Recommend

• Adults with a confirmed diagnosis of hypertension should have a baseline assessment of:
  • Cardiovascular risk factors, including screening for diabetes, hyperlipidemia, and renal disease.
  • Baseline status of organs at risk of damage due to CAD (target organ damage).
  • Routine lab testing

Diagnostic Studies for Primary Hypertension

• Urinalysis
• Blood chemistry (potassium, sodium, blood urea, and creatinine)
• Fasting blood glucose
• Fasting total cholesterol and high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides
• Standard 12-lead electrocardiography
• Ambulatory blood pressure monitoring (24 hrs)

Interprofessional Care for Primary Hypertension

• Search for and monitor for target-organ damage.
• Lifestyle modifications:
  • Nutritional therapy
  • Weight reduction
  • Modification in alcohol consumption
  • Physical activity
  • Avoidance of tobacco products
  • Stress management
• Medication therapy
• Patient teaching and at-home monitoring

Health Behavior Management for Hypertension

• Physical exercise: 30-60 minutes of moderate-intensity dynamic exercise (e.g., walking, jogging, cycling, or swimming) 4-7 days per week.
• Weight Reduction: Maintenance of a health body weight (BMI 18.5 -24.9, and waist circumference <102 cm for men, and <88 cm for women) to prevent hypertension.
• Reduce alcohol: consumption (or abstain) to reduce blood pressure and prevent hypertension; there is no safe limit for alcohol consumption to prevent hypertension.
• Diet: Consume a diet emphasizing fruits, vegetables, low-fat dairy products, whole-grain foods rich in dietary fiber, and protein from plant sources; restrict cholesterol and saturated fats.
• Sodium intake: 2000mg (2g of salt) per day.
• Stress Management: should be considered as an intervention such as Cognitive-Behavioral interventions.
• Tobacco cessation

Medication Therapy for Primary Hypertension

• Target blood pressure of Target < 140/90 mm Hg is attained through health management behaviours and medication
• Thiazide/thiazide-like diuretics
• ACE-I
• ARB
• Long-acting CCB
• Beta-blocker (not indicated as first-line therapy for age 60 and above).
• Single pill combination (recommended SPC choices are those in which an ACE-I is combined with a CCB, an ARB with a CCB, or an ACE-I or ARB with a diuretic)
• Renin-angiotensin system (RAS) inhibitors are contraindicated in pregnancy, and caution is required in prescribing to women of childbearing potential.

Nursing Management: Primary Hypertension

• Overall goals:
  • Achieve and maintain target blood pressure
  • Understand and implement the therapeutic plan
  • Experience minimal or no unpleasant adverse effects
  • Feel confident in managing and coping with the condition
• Health promotion:
  • Lifestyle modifications and reduction of modifiable risk factors
  • Individual patient evaluation and education
  • Screening programs
• Ambulatory and home care:
  • Long-term management of hypertension, assisting with adhering to treatment plans
  • Patient and family teaching: nutritional therapy, medication therapy, physical activity, home monitoring of blood pressure, tobacco cessation, and stress management

Nursing Interventions

• Adverse effects of antihypertensive drugs can lead to nonadherence to therapy. Common adverse effects include:
  • ACE inhibitors (ex. Ramipril): Cough
  • Some diuretics (ex. Indapamide): Impotence
  • Adrenergic-inhibiting agents: Orthostatic hypotension, sexual dysfunction.
  • Vasodilators and angiotensin inhibitors: Tachycardia, orthostatic hypotension.
  • β-Adrenergic Blockers (ex. Propranolol): Bronchospasm
• Non-adherence can stem from inadequate teaching, blood pressure returning to normal range, lack of motivation, medication costs, lack of a trusting relationship with healthcare providers, etc.

Orthostatic Hypotension

• Orthostatic hypotension, a common adverse effect of several antihypertensive drugs, results from autonomic nervous system dysfunction regulating blood pressure during position changes.
• Orthostatic hypotension is defined as a drop in blood pressure (≥20 mm Hg systolic and/or ≥10 mm Hg diastolic) that occurs within 3 minutes of standing.
• Symptoms: dizziness, weakness, and faintness upon transitioning from sitting or lying down to an upright position.

Coronary Artery Disease

• Coronary artery disease blood vessel disorder affecting the heart's arteries.
• Included in the general category of atherosclerosis.
• Hypertension is a major risk factor for CAD, doubling the risk.
• Patients with coronary artery disease (CAD) can be asymptomatic or can develop chronic stable angina.
• Unstable angina (UA) and myocardial infarction (MI), more serious manifestations of CAD, are termed acute coronary syndrome (ACS).

Atherosclerosis in Coronary Artery Disease

• Characterized by a focal deposit of lipids, primarily within the walls of arteries.
• Can occur in any artery of the body
• In CAD, it occurs in the arteries around the heart.
• The endothelial lining is altered because of inflammation and injury.

Coronary Artery Disease: Etiology and Pathophysiology

• Collateral circulation develops in the coronary circulation.
• Adequate collateral circulation is more likely with slow occlusion of coronary arteries over time.
• Factors contributing to collateral circulation: inherited predisposition and chronic ischemia.
• Slow occlusion allows sufficient collateral circulation, maintaining myocardial blood and oxygen supply.
• Rapid-onset of coronary artery disease or spasm hinders collateral development, leading to severe ischemia or infarction.

Coronary Artery Disease: Risk Factors

• Nonmodifiable risk factors:
  • Age, sex, and ethnicity
  • Family history and genetics
• Modifiable risk factors:
  • Elevated serum lipid levels
  • Elevated blood pressure (BP)
  • Tobacco use
  • Physical inactivity
  • Obesity
  • Diabetes mellitus
  • Elevated fasting blood glucose level
  • Psychosocial risk factors
  • Homocysteine elevation
  • Substance use

Nursing and Interprofessional Management: Coronary Artery Disease

• Health promotion:
  • Identification of people at high risk: health history, family history, cardiovascular symptoms, lifestyle habits, psychosocial factors, and employment.
  • Management of people at high risk
  • Physical activity: improve physical fitness by following the FITT formula: frequency (how often), intensity (how hard), time (how long), and type (isotonic). Everyone should aim for at least 150 minutes of moderate to vigorous activity each week.
  • Nutritional therapy: eating a healthy balanced diet improves one's heart health, lowering cardiovascular risk

Nursing Management: Health Promotion for Coronary Artery Disease

• Recommend preventive measures for all at risk for CAD.
• Focus on controlling modifiable risk factors:
  • Ideal body weight maintenance
  • Adequate physical exercise
  • Reduction of saturated fats intake
  • Tobacco avoidance
• Nurses encourage lifestyle changes to reduce CAD risk.
• Furthermore, assist patients in clarifying personal values and recognizing susceptibility to CAD.
• Help set realistic goals and prioritize risk factors for change.
• Respect patients' decisions regarding lifestyle changes.
• Some may not change until symptoms manifest or after an MI.

Nursing and Interprofessional Management: Coronary Artery Disease (Cont.)

• Fat intake should account for 30% of calories, mainly from mono- and polyunsaturated fats.
• Collaborate with a dietician to help modify a client's diet.

Medication Therapy

• Medications that restrict lipoprotein production
• Medications that increase lipoprotein removal
• Medications that decrease cholesterol absorption
• Low dose ASA

Chronic Stable Angina

• Chronic stable angina is a progressive disease, and patients may be asymptomatic for many years, however, some develop chronic but stable chest pain syndromes.
• Angina is chest pain.
• Clinical manifestations of reversible myocardial ischemia stem from insufficient blood flow (narrowing of coronary arteries by atherosclerosis).
• It presents as intermittent chest pain occurring over a long period, with the same pattern of onset, duration, and intensity.
• Usually subsides when the precipitating factor is relieved.
• Pain typically lasts 3-5 minutes, pain at rest is unusual.

Location of Pain During Angina

• Midsternal, left shoulder and down both arms, neck, and arms
• Substernal radiating to neck and jaw or down the left arm
• Epigastric, radiating to neck, jaw, and arms
• Intrascapular

Factors Precipitating Angina

• Physical Exertion: Increased HR reduces the time the heart spends in diastole and results in an increased myocardial oxygen demand; Isometric exercise of the arms (e.g., raking, lifting heavy objects, or shovelling snow) can cause exertional angina.
• Temperature Extremes: Workload of the heart is increased; Blood vessels constrict in response to cold stimulus; Blood vessels dilate and blood pools in the skin in response to a hot stimulus.
• Strong Emotions: The sympathetic nervous system is stimulated, workload increases.
• Consumption of a Heavy Meal: During the digestive process, blood is diverted to the GI system, reducing blood flow in the coronary arteries.
• Tobacco Use: Nicotine causes vasoconstriction and an increase in HR; Tobacco diminishes available oxygen by increasing the level of carbon monoxide.
• Sexual Activity: The cardiac workload and sympathetic stimulation are increased; In a person with CAD, the extra cardiac workload may precipitate angina.
• Stimulants: HR and subsequent myocardial oxygen demand are increased.
• Circadian Rhythm Patterns: Manifestations of CAD tend to occur in the early morning after the patient awakens.

Interprofessional Management

• Reduction of risk factors (same as clients with CAD).
• Medication therapy:
  • Antiplatelet
  • Cholesterol-lowering medication
  • Nitrates
  • Other cardiac medications as needed
• Lifestyle modifications: smoking, diet, exercise, etc.
• Education
• Manage precipitating factors.

Valvular Heart Disease

• Two atrioventricular valves: Mitral, Tricuspid
• Two semilunar valves: Aortic, Pulmonic
• Valves work to keep blood moving forward (open) and prevent moving backward (close).
• Its types depend on:
  • Valve(s) affected
  • Type of functional alteration(s)

Valvular Heart Disease

• Stenosis: valve cannot fully open or is narrowed impeding forward blood flow.
• Regurgitation: valve cannot close completely = backward blood flow
• Valve disorders occur in children and adolescents primarily from congenital heart conditions.
• In adults, they result from cardiovascular disease or damage, e.g., smoking, hypertension, hyperlipidemia, diabetes, connective tissue or inflammatory disorders, endocarditis, heart attack, or radiation.

Infective Endocarditis

• An infection of the heart valves or the endocardial surface of the heart.
• The endocardium, the inner layer of the heart is contiguous with the valves, thus inflammation from IE affects the cardiac valves.

Rheumatic Fever and Heart Disease

• Rheumatic fever is an inflammatory disease that may affect connective tissues of the body, especially those of the heart, brain, joints, or skin
  • Delayed abnormal immunological response to group A streptococcal infection
  • Potentially involves all layers of the heart (endocardium, myocardium, and pericardium)
  • Prevention: teaching clients to seek treatment for streptococcal pharyngitis (strep throat)
• Rheumatic heart disease is a chronic condition from rheumatic fever, characterized by scarring and deformity of the heart valve

Mitral Valve Stenosis

• Narrowing of the mitral valve impedes blood flow between the left atrium and left ventricle: too much blood in the left atrium.
• Increased left atrial pressure and volume cause dilation of the left atrium and blood back up into pulmonary circulation, which causes hypertrophy of the pulmonary vessels.
• Most adult cases result from rheumatic heart disease (causes scarring).

Mitral Valve Stenosis: Clinical Manifestations

• Common:
  • Exertional dyspnea/difficulty breathing
  • Palpitations from atrial fibrillation
  • Fatigue
  • Murmur
• Less common:
  • Hemoptysis (from pulmonary congestion)
  • Chest pain (from decreased CO)
  • Seizures or a stroke (emboli from blood stasis in the left atrium)

Mitral Valve Regurgitation

• The mitral valve doesn't fully close = blood flows back into the left atrium = increased workload on the left atrium and left ventricle to maintain CO.
• Chronic: atrial enlargement, ventricular dilation, and eventual ventricular hypertrophy.
• It can lead to left-sided heart failure.
• In acute situations, increased pressure, thus volume backs up into the pulmonary system (left atrium and ventricle don't have time to compensate.)
• The majority result from is:
  • Myocardial infarction (MI)
  • Chronic rheumatic heart disease
  • Mitral valve prolapse
  • Ischemic papillary muscle dysfunction
  • Infective endocarditis

Mitral Valve Regurgitation: Clinical Manifestations

• Acute: thready peripheral pulses and cool, clammy extremities
• Chronic: asymptomatic for years until the development of some degree of left ventricular failure
• Murmur
• Initial symptoms of left ventricular failure:
  • Weakness
  • Fatigue
  • Palpitations
  • Dyspnea that gradually progresses to orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema

Mitral Valve Prolapse (MVP)

• "Floppy” Mitral valve
• It is an abnormality that allows the leaflets to prolapse back into the left atrium during systole.
• Unknown cause, one of the most common valvular conditions.
• Usually benign
• Serious complications can occur:
  • Mitral valve regurgitation
  • Infective endocarditis
  • Sudden cardiac death
  • Cerebral ischemia

Mitral Valve Prolapse: Clinical Manifestations

• Most patients are asymptomatic for life.
• Murmur
• Dysrhythmias (e.g., premature ventricular contractions, paroxysmal supraventricular tachycardia, ventricular tachycardia)
  • Palpitations
  • Light-headedness
  • Dizziness
• May or may not present with angina (chest pain)
  • Episodes tend to occur in clusters, especially during stress.
  • Pain may be accompanied by dyspnea, palpitations, and syncope.
  • Pain does not respond to antianginal treatment (Nitrates).

Aortic Valve Stenosis

• Narrowing of the aortic valve obstructs the flow from the left ventricle to the aorta during systole.
• Decreased CO = ventricular hypertrophy, pulmonary hypertension, decreased tissue perfusion, and heart failure.
• Usually discovered in childhood, adolescence, or young adulthood
• Those noted later usually have aortic stenosis from rheumatic fever/calcification of a normal valve

Aortic Valve Stenosis: Clinical Manifestations

• "SAD" mnemonic: (advanced state)
  • Angina - but cannot use Nitrates
  • Syncope
  • Exertional dyspnea
• This classic triad reflects left ventricular failure.
• Murmur
• Poor prognosis when symptoms and valve obstruction are not relieved.

Aortic Valve Regurgitation

• When the aortic valve doesn't fully close, blood flows backwards during diastole and raises the blood flow in the left ventricle (volume overload).
• It is a medical emergency
• Chronic Regurgitation stems from rheumatic heart disease, congenital bicuspid aortic valve, syphilis and chronic rheumatic heart conditions
• The left ventricle compensates through dilation and hypertrophy
• However, this means, eventually, cardiac contractility will decline and Pulmonary hypertension and right ventricular failure will develop
• Acute aortic regurgitation results from infective endocarditis, trauma, and aortic dissection

Aortic Valve Regurgitation: Clinical Manifestations

• Chronic aortic regurgitation
  • Remains asymptomatic for years
  • Then the patient will present with exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and abnormal heart sounds

Diagnostic Studies for Valvular Heart Disease

• Patient's history/physical exam
• Echocardiography and Doppler imaging
• Chest radiograph
• ECG
• Cardiac catheterization

Interprofessional Care for Valvular Heart Disease

• Treatment depends on the valve involved and the severity of the disease.
• Non-surgical:
  • Prevention of rheumatic fever and infective endocarditis
  • Prophylactic antibiotic therapy
  • Preventing exacerbations of HF, acute pulmonary edema, thromboembolism, and recurrent endocarditis
  • Medications to treat/control Vasodilators, Inotropes, Diuretics, B-Blockers, anticoagulants, antidysrhythmics
  • Sodium restriction
• Surgical therapy: valve repair/valve replacement

Nursing Care Planning

• The goals are that the patient
  • will have normal cardiac function
  • experience improved activity tolerance
  • experience an understanding of the disease process and adhere to health maintenance measures

Nursing Implementation Health Promotion:

• Prevention of rheumatic valvular disease is accomplished by:
  • Diagnosing and treating streptococcal infection
  • Providing prophylactic antibiotics for patients with a history rheumatic fever and IE
  • Prophylactic treatment is especially recommended for patients who are at risk before they undergo certain dental or surgical procedures
• A crucial precaution is to follow a drug treatment program if there is a history of IV drug use

Nursing Implementation

• Follow acute intervention, ambulatory & home care
• Ensure that the the patient adheres to care/medication recommendations
• Assess heart/breath sounds often to monitor medication effectiveness by assessing if medication is successful via auscultation
• Design activity to the patient's limitations. Avoid strenuous activity.
• Conserving energy, setting priorities, taking planned rest periods
• Discourage smoking.
• Education: medications/ when to seek medical treatment
• Follow up care
• Medical alert bracelet