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• This lecture covers cardiovascular alterations, including hypertensive crisis, angina, myocardial infarction (MI), cardiomyopathy, and interventional studies, with focus on arterial and venous aspects

Normal Heart Structure

• The heart resides in the mediastinal space and is covered by the pericardium
• It is composed of three layers, including the epicardium, myocardium, and endocardium
• The right side of the heart operates under low pressure, while the left side functions under high pressure
• Cardiac valves regulate blood flow

Autonomic Control of Heart

• The sympathetic nervous system influences the heart through norepinephrine
• The parasympathetic nervous system affects the heart through acetylcholine
• Chemoreceptors and baroreceptors also influence heart function

Cardiac Function

• Key aspects of cardiac function involve coronary circulation, the conduction system, hemodynamics, and heart sounds
• Heart sounds include S1, S2, S3, and S4
• Heart murmurs are caused by turbulent blood flow through the valves

Characteristics of a Heart Murmur

• Heart murmur is caused by turbulent blood flow
• The sound may be described as rumbling, blowing, harsh, or musical
• Assessment involves identifying location, sound, loudness, intensity, and other audible heart sounds

Coronary Artery Disease (CAD)

• CAD is marked by the progressive narrowing of coronary arteries due to atherosclerosis
• Coronary heart disease and atherosclerotic heart disease are associated

Pathophysiology of CAD

• Epithelial cell injury in the tunica intima occurs
• This triggers platelet aggregation, monocyte migration, and lipoprotein entry into the intima
• Fatty streaks develop as monocytes turn into macrophages, forming lipid-rich "foam cells"
• Atheromas form

CAD Progression (Part 2)

• Damage to the tunica intima leads to the release of platelet-derived growth factor
• Results in proliferation of smooth muscle cells
• A fibrous cap forms
• The fibrous cap consists of connective tissue and LDL
• Frequently, the fibrous cap ruptures, causing a thrombus and initiating the clotting cascade

CAD Progression (Part 3)

• Adhesion occurs when platelets bind to receptors
• Activation happens when platelets change shape and activate receptors
• Release of Thromboxane A2 and serotonin occurs
• Glycoprotein IIb/IIIa receptors are activated
• Aggregation occurs when platelets clump together
• Drugs such as aspirin and glycoprotein IIb/IIIa inhibitors can be used to halt the process

Risk Factors for CAD

• Non-modifiable risk factors include age, with risk increasing for men over 45 and women over 55, and family history
• Modifiable risk factors include smoking, inactivity, being overweight, cholesterol levels (especially high LDL and low HDL), diabetes, and hypertension

Assessing Patient History

• It is important to gather information on risk factors, prior hospitalizations, shortness of breath, chest pain, and medications
• Specifically assess the use of erectile dysfunction medications if nitroglycerin is being considered
• A psychosocial history, including stressors, should be recorded

Diagnostic Studies for CAD

• Diagnostic studies include a 12-lead electrocardiogram (ECG) and Holter monitor
• An exercise tolerance test (stress test) can assess the heart
• The demand on the heart is increased during the test
• Stress induced with drugs like adenosine is used if the patient cannot tolerate exercise
• Monitor vital signs and ECG during stress test
• Further testing may include pharmacological stress testing, nuclear stress testing, and a chest X-ray

Additional Diagnostic Studies

• Echocardiography, which involves ultrasound, is used to visualize cardiac structures
• Transesophageal echocardiography is another method
• A multigated blood pool study (MUGA scan) is a further option

Advanced Diagnostic Studies

• Positron emission tomography (PET scan)
• Cardiac magnetic resonance imaging

Cardiac Catheterization and Arteriography

• Includes an electrophysiology study and use of a catheter typically in the right or left side of the heart
• Measures heart pressures, which is similar to a pulmonary artery catheter
• Measures cardiac output
• Arteriography visualizes blood vessels

Post-Catheterization Care

• Bed rest with the head of the bed no higher than 30 degrees
• Monitor bleeding, noting that newer collagen agents may be used for hemostasis
• Monitor pulses
• Antiplatelet drugs are often prescribed after procedures like PCI
• Discharge may occur in 6 to 8 hours, depending on diagnosis and procedures

Important Laboratory Tests

• A complete blood count (CBC) is essential for monitoring hemoglobin and hematocrit levels
• Sodium, potassium, calcium, and magnesium levels should be examined

Cardiac Enzymes

• Troponin I and T can be detected as early as 1 hour after injury
• Normal Troponin I levels are less than 0.5 mcg/L
• Normal Troponin T levels are less than 0.1 mcg/L

Cholesterol

• HDL is considered good cholesterol
• LDL is considered bad cholesterol

Desirable LDL Target Levels

• For those with no CHD and less than two risk factors, the LDL target is 160 mg/dL
• For those with no CHD but with two or more risk factors, the LDL target is 130 mg/dL
• For CAD patients, the LDL target is under 100 mg/dL

CAD Treatment

• Lifestyle changes include a low-cholesterol, low-salt diet, aerobic exercise, and weight loss
• Smoking cessation is crucial
• Management of hypertension and diabetes if these conditions are present
• Medications, particularly lipid-lowering agents, can be used, with a need to assess the advantages and disadvantages of each type

Medications for Hyperlipidemia (Part 1)

• HMG-CoA reductase inhibitors, e.g. statins, slow cholesterol production
• Bile acid resins, such as cholestyramine and colestipol, bind and are excreted via the bowel
• Ezetimibe (Zetia) blocks the absorption of cholesterol in the digestive tract

Medications for Hyperlipidemia (Part 2 of 3)

• Nicotinic acid inhibits LDL synthesis and increases HDL
• It has many side effects
• Fibric acid derivatives, such as gemfibrozil, increase Very Low Density Lipoprotein (VLDL) clearance

Medications for Hyperlipidemia (Part 3)

• Patients on lipid-lowering medications should be carefully monitored
• Combination therapy may be needed to achieve target goals

Medications Affecting Platelets

• Aspirin (ASA) inhibits thromboxane A2
• Other medications include dipyridamole, ticlopidine, and clopidogrel

Types of Angina

• Stable (chronic, exertional) angina occurs with effort; it is considered classic angina
• ECG shows T-wave inversion
• Responds to rest and nitroglycerin
• Unstable (crescendo) angina occurs more often and is more severe, with less relief
• An ECG may show ST elevation
• Treated with rest, nitroglycerin, drugs affecting platelets, and potentially revascularization
• Variant or Prinzmetal's angina involves vasospasms
• Causes ST elevation during pain episodes
• Treated with calcium channel blockers

Angina

• Angina is myocardial ischemia
• Oxygen demand is higher than supply

Angina/Chest Pain: Signs and Symptoms

• Chest pain is a classic symptom of angina
• The pain is often midsternal
• May radiate to arms, jaw, or back
• ECG changes may occur in the ST segment/T wave

Case Study: Mr. T

• Mr. T. showed chest pain the past 2 years
• He has angina
• Takes 0.3 mg of SL nitroglycerin (NTG) for it
• His chest pain is usually exertion related
• Lately, he has had to take the NTG more often
• He has a cardiologist appointment next week

Case Study: Questions

• Possible questions regarding presented case study include:
• Why is Mr. T experiencing more pain
• What could be done at this point to prevent an MI

Nursing Diagnoses related to Angina

• Acute chest pain related to myocardial ischemia
• Knowledge Deficit related to unfamiliarity with disease
• Activity intolerance related to ischemic changes

Nursing Management for Angina

• Maintain cardiac output and assist with ADLs
• Focus on pain relief
• Promote self-care and risk factor modification
• Administer medications and oxygen
• Provide postprocedure observation and care following cardiac catheterization, angioplasty, or bypass surgery

Patient Care Outcomes

• Relief of chest discomfort should be achieved
• Patient should appear relaxed and comfortable
• Patient should understand angina pectoris and its management
• Patient should be able to describe cardiac risk factors and strategies to reduce them
• Activities should be performed within the limits of the disease, without chest pain or discomfort and with no ECG changes reflecting ischemia

Nursing Management of Angina

• Nursing management of the patient with angina is aimed toward assessing and documenting episodes of chest pain
• Nursing interventions should focus on early identification of myocardial ischemia, control of chest pain, recognition of complications, and maintenance of a calm environment
• Must document the pain, heart rate, blood pressure, respirations, temperature, skin color, pulses, urine output, and overall tissue perfusion

Acute Coronary Syndrome (ACS)

• ACS involves ischemia with myocardial cell death
• Characterized by an imbalance of oxygen supply and demand
• Includes stable angina, unstable angina, or acute myocardial infarction
• Causes include atherosclerosis, emboli, blunt trauma, and spasm

Acute Myocardial Infarction (AMI)

• Types of AMI includes non-ST segment elevation (NSTEMI) and ST segment elevation (STEMI)
• Note that collateral circulation can occur

Assessment Findings with AMI

• Midsternal chest pain, which is often severe, crushing, squeezing, and may radiate; unrelieved with nitrates
• Pale and diaphoretic appearance
• Dyspnea, tachypnea, and/or hypotension
• Syncope
• Feelings of impending doom
• Nausea and vomiting
• Dysrhythmias

Diagnosis of AMI includes

• Signs and symptoms, including atypical symptoms in women
• A 12-lead ECG showing ST elevation followed by Q wave, which signifies Q-wave myocardial infarction, or ST depression, which signifies non-Q-wave myocardial infarction
• Elevated serum troponin I and T

Case Study: AMI Scenario

• Paramedics treat Mr. T. with oxygen, IV access, and a baby aspirin to chew
• Mr. T. is transported to the hospital
• Upon arrival his heart rate is 110 beats/min; he is diaphoretic
• Tachycardia is dangerous

Case Study Question About ECG Changes

• The question to answer is:
  • A 12-lead ECG is done in the field
  • What changes would you expect if Mr. T. is having an MI

Case Study: Question (2 of 2)

• Paramedics note ST-segment elevation in Leads II, III, and aVF
• The questions to answer is:
  • What therapies will be administered in the field?
  • In what area of the heart do changes in these leads indicate damage?

Diagnosis based on ECG Findings

• Presence of Q waves on the ECG is most conclusive of infarction

Nursing Diagnoses

• Acute chest pain
• Poor tissue perfusion

Nursing Goals: AMI

• Maintain cardiac output
• Treat pain
• Assess for complications
• Increase activity tolerance
• Relieve anxiety
• Provide ongoing and discharge teaching

Medical Management: AMI

• Pain relief with morphine and nitroglycerin
• Oxygen
• Prevention of platelet aggregation
• Percutaneous Coronary Intervention (PCI)
• Fibrinolytic therapy
• Medications for treatment include nitrates, beta blockers, and angiotensin-converting enzyme inhibitors
• Autologous bone marrow stem cell treatment to the damaged myocardium

Complications of AMI

• Dysrhythmias
• Sudden death
• Heart failure
• Cardiogenic shock
• Ventricular aneurysm or rupture
• Papillary muscle dysfunction
• Pericarditis
• Infarct extension

Prioritizing Care After Morphine Administration

• The next action is to assess the patient for pain relief and signs of any adverse effects of the medication
• Focus should be on assessing patient’s pain relief and to be on the lookout for any adverse side effects, such as hypotension and problems with breathing

Primary Angioplasty

• Transport to catheterization lab is needed for emergent percutaneous intervention or stenting, if available
• Results are often better outcomes than thrombolytics

Thrombolytic Therapy

• Time is muscle; 6-hour window matters
• Thrombolytic agents include tissue plasminogen activator (t-PA), streptokinase, and reteplase
• Heparin and glycoprotein IIb/IIIa inhibitors

Case Study: Thrombolytic Therapy

• Mr. T. triaged to the ED with inferior wall MI, Hospital in rural area with severe weather
• PCI is 2 hours away by ground transport, So thrombolytics are to be administered
• Mr. T. was started on reteplase within 1 hour

Case Study: Question (1 of 3)

• Questions to answer include:
  • Why was Mr. T. treated with thrombolytics rather than transported for a PCI?

Case Study: Question (2 of 3)

• Question to answer includes:
  • Because Mr. T. is having an inferior wall MI, what complications should be anticipated while getting him ready for the thrombolytic therapy?

Case Study: Question (3 of 3)

• Questions to answer include:
  • What nursing care was done prior to starting reteplase?
  • What is involved in the nursing care with a patient being given reteplase?
  • What complications should be assessed during and after administration of the medication?

Interventional Cardiology

• Interventional cardiology is an important field
• Includes percutaneous transluminal coronary angioplasty (PTCA) and intracoronary stenting with drug-eluting stents

PTCA: Percutaneous Transluminal Coronary Angioplasty

• Increases blood flow to the myocardium
• Criteria for PTCA are uncompromised collateral flow, Lesions are noncalcified, must not be a bifurcation of vessels
• A balloon catheter is inflated

Coronary Stents

• Put tubes alongisde angioplasty to keep vessel open
• Prevents restenosis from angioplasty
• PTCA, anticoagulation therapy

Case Study/Questions

• One day after the thrombolytic therapy, Mr. T.'s cardiac rhythm suddenly dropped to 40 beats/min, and he became very dizzy and breathless
• What should the nurse do?
• What drugs could be used?

Case Study/Questions

• Mr. T. is discharged from the hospital 2 days after the MI
• What kind of discharge instructions are needed?
• What kinds of medications should be ordered?
• What psychosocial support should be provided to Mrs. T. and Rutchie?

Surgical Revascularization Techniques

• Various surgical options are available including coronary artery bypass graft (CABG) surgery
• Options also include minimally invasive direct coronary artery bypass (MIDCAB) surgery and transmyocardial revascularization (TMR)

Coronary Artery Bypass Graft (CABG) Surgery

• The CABG is a technique that provides conduits/vessels for blood flow
• Involves the saphenous vein, internal mammary artery, and radial artery
• Arteries demonstrate longer blood flow

Indications for CABG

• Surgical intervention may be needed such as unstable angina, AMI
• Required in the failure of percutaneous interventions

Risks Associated with CABG

• Mortality increases are associated with:
  • Left ventricle dysfunction
  • Emergency surgery
  • High Age
  • Female sex
  • Number of diseased vessels
  • Decreased ejection fraction with congestive heart failure

Standard CABG Procedure

• A median sternotomy or sternum split, excision of pericardium
• Performed with a cardiopulmonary bypass
• Myocardial preservation is achieved through cardioplegia
• There are grafts used
• Requires weaning from bypass
• Patient might defibrillate if needed
• Involves mediastinal and chest tubes
• Uses epicardial pacing wires
• Has wire sternum

Goals of CABG Surgery

• Boost the blood flow to the myocardium
• Relieve symptoms
• Prolong survival
• Improve quality of life

Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Surgery

• The patient must be on port-access coronary artery bypass as well as cardiopulmonary bypass
• Minimally invasive direct coronary artery bypass surgery requires no cardiopulmonary bypass
• Heart is still beating
• Only 1 or 2 bypasses

General Postoperative Cardiac Surgery Complications

• Low cardiac output
• Renal impairment
• Gastrointestinal dysfunction
• Impaired peripheral circulation
• Mediastinal bleeding is possible
• Very serious complications such as atrial dysrhythmias, hypovolemia

Postoperative Complications Specific to CABG

• Dysrhythmias
• Impaired contractility; low cardiac output
• Intraoperative myocardial infarction
• Pericardial tamponade
• Respiratory insufficiency
• Pain
• Emboli/Stroke
• AMI
• Shock
• Death

Case Study Complications

• After revascularization, the patient had chest pain that prompted them to visit the cardiologist. Now has T-wave changes on anterior leads
• The patient required catheterization
• There was blockage on the left main coronary artery
• Now requires a CABG

Case Study Questions

• Why is a CABG scheduled and not PCI?
• What are the psychosocial implications of having surgery at a tertiary care center?

Why is LIMA used?

• CABG is now required and has undergone the procedure
• Uses LIMA vessel
• What are the postoperative priorities?

Transmyocardial Revascularization (TMR)

• Uses Laser channels into ventricle to reach perfusion
• Does increase perfusion but only occurs over time
• Poor candidates for CABG
• Mixed results from clinical trials

Enhanced External Counterpulsation (EECP)

• Serves as angina treatment when a patient is not a candidate for bypass surgery or PCI
• Cuffs apply pressure to legs to increase arterial blood pressure
• No sure data that EECP reduces ischemia
• Alleviates angina and improves quality of life

Arrhythmias

• Arrhythmias may be treated with:
  • Radiofrequency catheter ablation
  • Permanent pacemakers
  • Implantable cardioverter-defibrillator

Radiofrequency Catheter Ablation

• Treats Supraventricular tachycardia
• Interrupts electrical conduction or activity
• Uses Radiofrequency
• Undergoes Electrophysiology for best treatment paths

Characteristics of Temporary and Permanent Pacemakers

The are multiprogramable regarding:

• Rate
• Voltage
• Sensitivity
• Stimulus duration
• Refractory period

Can pace atria, ventricles, or dual chamber Inserted transvenously

Implantable Cardioverter-Defibrillator (ICD)

• Used to treat survivors of sudden cardiac arrest
• Some have built-in pacemakers
• Delivers high-energy shock
• Requires Patient education
• Requires understanding of all Emergency procedures

Heart Failure

• A condition in which the heart is unable to generate adequate flow to meet the body's metabolic demands
• Can be systolic, with impaired contractility, or diastolic, with impaired filling

Etiology of Heart Failure

• AMI
• Hypertension
• Idiopathic
• Cardiomyopathy
• Valvular disease

Pathophysiology of Left Heart Failure (1 of 3)

• Decreased pump action which will lead to not reaching metabolic demands
• Backup of blood flow from the left ventricle
• Fluid buildup in the lungs
• If unmanaged, the backflow will continue and lead to right heart failure

Pathophysiology of Heart Failure (2 of 3)

• Compensatory mechanisms occur, these include renin-angiotensin-aldosterone system and the sympathetic nervous system
• If the prior heart stages fail, right heart failure will cause systemic symptoms

Pathophysiology of Heart Failure (3 of 3)

• Brain natriuretic peptide (BNP) is known to regulate fluid and electrolyte balance
• Cardiac hormone is secreted by ventricular myocytes in response to wall stretch
• Normal 100 pg/mL
• Higher levels indicate a plasma which means a bad function and severity of heart failure
• In decompensated heart failure, BNP has no rise
• Good marker for differentiating between pulmonary and cardiac causes of dyspnea

Assessment of Heart Failure

• Left-sided failure signs and symptoms
• Right-sided failure signs and symptoms
• Examination of neck veins
• Presence or absence of edema
• Perfusion status
• Lung sounds
• Chest x-ray and Hemodynamic monitoring (pulmonary artery catheter) are recommended

Diagnostics Testing: Heart failure

• Echocardiogram to study the heart condition
• Arterial blood gases and Serum electrolytes
• BUN/Creatinine
• Complete blood count
• B-type natriuretic peptide (BNP)
• Hepatic function
• ECG

Heart Failure Medical Treatment (1 of 3)

• Improve pump function via
• Diuretics
• ACE inhibitors
• Angiotensin receptor blockers
• Beta blockers such as carvedilol [Coreg]
• Digoxin

Heart Failure Medical Treatment (2 of 3)

• For acute situations, intravenous Nesiritide citrate (Natrecor) can be used, to reduce workload
• Intraaortic balloon pump
• Mechanical circulatory support devices (MCSDs)
• Biventricular pacing
• The patient also needs nursing intervention, rest, and activity as tolerated including cardiac rehabilitation

Heart Failure Medical Treatment (3 of 3)

• You should seek to Optimize the flow of gas, by taking:
• Airway assessment for proper breathing
• Semi-Fowler positioning
• Supplemental oxygen
• Continuous positive airway pressure (CPAP)
• Diuresis
• Control sodium and fluid retention
• Daily weights
• VTE prophylaxis

Case Study/Questions on Heart Failure

• The patient had a CABG and was difficult to wean from the machine
• An intraaortic balloon pump was a better decision
• Why was the IABP inserted?
• What are some related nursing intervention?

Case Study: Heart Failure Discharge

• The patient required the IABP for 1 day
• His postoperative course was uneventful, and it was removed
• 6 days after, he was free to go
• The patient requires understanding of their disease

Symptoms of Heart Failure Complications

• Pulmonary Edema
• Dyspnea
• Cyanosis
• Gurgles
• Pink, frothy sputum
• Hypoxemia
• Cardiogenic shock

Common Inflammatory Heart Diseases

• Pericarditis-inflammation of the pericardium
• Endocarditis-inflammation of the endocardium

Pericarditis

• Etiology includes that following a myocardial infarction
• Uremia
• Cancers
• Can lead to infusion, tamponade, and scarring

Hallmarks of Pericarditis

• Includes friction rub, pulsus paradoxus and initial ST elevation

Assessment and Management of Pericarditis

• Nursing Assessment is the first priority here
• Relieve Pain
• Procedures:
  • pericardiocentesis
  • pericardial window

Endocarditis (1 of 3)

• Condition where endocardium is continuous with valves
• Causes Vegetation
• Embolization
• Valvular dysfunction

Symptoms and Assessment Finding of Endocarditis (2 of 3)

• The clinical presentation -High fever and shaking chills -Night sweats, cough, weight loss -General malaise, weakness, fatigue, headache, musculoskeletal complaints -New murmurs and other heart sounds -Symptoms of HF -May have Skin abnormalities
  • Janeway lesions
  • Osler nodes

Endocarditis (3 of 3)

• Need to Diagnose through, echocardiogram, transesophageal echocardiography
• Should treat with antibiotics and rest
• Prevention: antibiotic prescription before treatments
• May be necessary to treat this condition before a dentist appointment
• Also important to see if any history of:
  • Heart valve
  • History of endocarditis
  • Microvascular pressure with regurgitation

Vascular Alterations (1 of 3)

• Aortic aneurysms which include
• Dilation or thinning of wall
• Thoracic aortic
• Thoracoabdominal aortic
• Abdominal aortic
• Should be treated based on size and symptoms
• These vascular condition can be deemed to be:
  • False versus true

Vascular Alterations (2 of 3)

• Can also involve aortic dissection, which can mean that intima tear of the vessel
• Sudden
• Sharp
• Be wary of their Shifting pain
• Suspect Marfan syndrome

Vascular Alterations (3 of 3)

• To treat these vascular alteration there is:
  • Surgical Treatment
    • Open approach
    • Endovascular approach