Understanding Atherosclerosis

• Atherosclerosis involves plaque formation in arteries, leading to coronary artery disease and inflammation.

Signs of Atherosclerosis

• Fatty streaks
• Jagged edges visible on MRI or CT scans with contrast
• Reduced blood flow due to narrowing arteries
• Plaque develops a calcium fibrous cap
• Plaque rupture or tears can cause blood clots that lodge in cardiac arteries

Consequences of Atherosclerosis

• Arterial stenosis or total occlusion can occur, reducing blood flow
• Ischemia develops in tissues distal to the blockage

Risk Factors and Testing

• Hyperlipidemia can start in childhood
• Testing includes cholesterol, LDL, LP(a), Apolipoprotein B & A, triglycerides, and C-reactive protein (CRP)
• Causes are hereditary, gender, age, and ethnicity

Interventions and Medications

• Interventions include DASH diet, lipid-lowering agents, no smoking, and exercise
• Statins are used to lower lipid levels
• Liver function studies and rhabdomyolysis should be monitored when taking statins
• Statins should be taken in the evening
• Report muscle pain to the health care provider
• Fibrates (clofibrate, fenofibrate) are used to lower lipid levels and should be taken 30 minutes before meals
• These can increase the effects of anticoagulants and hypoglycemics
• Aspirin 30 minutes before Niacin can reduce flushing

Coronary Artery Disease (CAD)

• Obstruction of blood flow leads to angina, MI, or sudden death
• Prevention: stop smoking, low-cholesterol diet, lipid-lowering agents, normal blood pressure and sugars, and low-dose aspirin

Angina Pectoris

• Chest pain due to ischemia from reduced coronary artery blood flow
• Narrowed vessels constrict causing reduce blood and oxygen to the heart muscle and ischemia
• Causes of angina: CAD, vasospasm, valvular heart disease, hypertension, heart failure

Symptoms of Angina

• Discomfort, fullness, burning, heaviness, pressure, or squeezing, often radiating to the left side
• Feeling of doom
• Referred pain can occur in shoulders, neck, back, or arms without chest pain
• Women may have chest pain, jaw pain, heartburn, fatigue, SOB, or nausea
• Patients may appear pale, diaphoretic, and dyspneic

Angina Treatments

• Administer one nitroglycerin tablet, repeat every 5 minutes up to 3 doses
• Call 911 after 3 doses
• Medications: antiplatelets, beta blockers, calcium channel blockers, nitrates
• Nursing diagnoses: acute pain, deficient knowledge

Nursing Interventions for Angina

• Monitor vitals, administer O2
• Assess pain level
• Administer fast-acting nitroglycerin
• Notify HCP if pain is unrelieved after 3 doses
• Stay with patient
• Provide pt education and encouragement

Types of Angina

• Stable: Predictable, occurs with exertion, relieved by rest or nitroglycerin
• Unstable: Unpredictable, occurs at rest, can lead to MI
• Vasospastic/Variant: Due to coronary spasm, cyclical, often at night, prolonged pain
• Microvascular: Spasms in tiny arteries, more common in women, severe pain

Fast Acting Nitroglycerin

• Carry at all times
• Keep tablets sealed in dark container, replace every 6 months
• Use before activity that can cause angina
• Tingling should be felt under the tongue
• Do not shake NTG aerosol
• Can cause lightheadedness, sit/lie down
• Can cause headache for 1-2 weeks
• Aspirin may relieve headache
• Can change blood pressure

Nitroglycerin Administration

• Wear gloves
• Remove patch before MRI or defibrillation
• Rotate patch
• Apply to clean, dry, hairless area
• Provide nitrate-free period

Important Nitrate Interactions

• Do not take with erectile dysfunction medications due to severe drop in BP

Acute Coronary Syndrome (ACS)

• Sudden reduction in blood flow leading to myocardial ischemia
• Includes unstable angina, NSTEMI, STEMI
• STEMI: Complete blockage, full-thickness damage, ST elevation, high troponin
• Non-STEMI: Partial blockage, no ST elevation, elevated troponin
• Silent Ischemia: No classic symptoms, common in older adults, women, HTN, diabetes

Sudden Cardiac Death

• Lethal ventricular arrhythmias or asystole
• Requires immediate CPR

Myocardial Infarction (MI)

• Death to heart muscle
• Signs and symptoms: Classic crushing pain, SOB, dizziness, nausea, diaphoresis
• Atypical symptoms: absent chest pain, fatigue, cramping, anxiety, feeling of doom
• Women's symptoms: SOB, fatigue, epigastric/abdominal pain, chest discomfort, discomfort between shoulder blades, N/V
• Heart failure symptoms: S3/S4 heart sounds, wheezing, crackles
• Prodromal symptoms: Unusual fatigue, sleep disturbances, dyspnea

MI Treatment

• Invasive procedures: balloon angioplasty, coronary artery stents
• Thrombolytics: time sensitive (within 1-6 hours of symptom onset, 30 minutes of arrival in ED)
• Post MI: Bed rest, low sodium, no caffeine

Post-MI Medications

• Plavix, low dose aspirin, beta blocker, ACE inhibitors, statin, heparin

Timely MI Treatment

• Call 911; do not drive self
• Goal: restore blood flow within 90 minutes of arrival
• Thrombolytics: Tenecteplase
• INR, PTT, platelets, and fibrinogen checks
• Avoid venipunctures for 24 hours after admin

Post-Op Nursing Care

• Monitor vitals, arrhythmias, provide incisional care, monitor for depression, assist with pain relief
• Monitor peripheral pulses, cap refill, color, temperature, BP, ECG, urine output
• Maintain a quiet environment and rest in semi-Fowler's position
• Dangle feet at bedside for 15 minutes, use commode, out of bed to chair for 30-60 minutes, partial bath, ROM
• Obtain baseline vitals and stop activity and report abnormal responses

Peripheral Vascular Disease

• Arterial blood clot can become embolus
• Common in legs and arms
• S/S: abrupt onset, chronic arterial insufficiency, gangrene may develop rapidly
• Anticoagulants, thrombolytics, thrombectomy, embolectomy

Peripheral Arterial Disease

• Disorder of arterial circulation with chronic narrowing
• Reduces blood supply, ischemia develops
• Atherosclerosis is the leading cause
• Functional: vasospasm noted in Raynaud's

PAD symptoms

• Shiny, hairless legs, thick toenails, dry flaky skin, muscle cramps, intermittent claudication
• Reddish when dependent, pale when elevated, cool to touch, diminished/absent pulses

Interventions for PAD

• Low fat/cholesterol diet
• Do not elevate legs, avoid bending knees, prolonged sitting, or crossing legs
• Surgery: Aortofemoral bypass

Buerger Disease

• Avoid smoking or risk losing hands/feet

Aneurysms

• Bulging of weakened artery wall
• Abdominal aortic aneurysm most common
• Risk factors: smoking, trauma, atherosclerosis, HTN, congenital abnormalities
• Dissecting: tear in artery wall, cavity fills with blood and may rupture
• Signs and Symptoms: Flank pain, back pain, abd fullness, N/V, pulsating abd mass, low BP, high HR
• Rupture symptoms: severe pain, shock
• Interventions: control BP, bypass graft, avoid lifting, exercise, reduce stress

Peripheral Tissue Perfusion

• Legs could be discolored, mottled, and cool to touch

Nursing Interventions Aneurysm

• Monitor circulation/sensation every 1-4 hours
• Measure abd girth every shift to detect bleeding
• Monitor CBC to detect bleeding
• Teach signs and symptoms of infection

Varicose Veins

• Tortuous dilated veins, hereditary
• Primary: problem with vessel wall
• Secondary: blood stasis in deep venous system (DVT)
• Contributing factors: prolonged standing, pregnancy, obesity
• Signs and Symptoms: spider veins, dull pain, cramping, edema, heavy feeling, ulcers
• Interventions: control weight, move around, elevate legs, exercise, compression stockings, vein stripping

Venous Insufficiency

• Pooling of blood in lower extremities
• Valves can rupture, leaking red blood cells into tissues
• Leg/foot may have: edema, brownish coloration, hard skin
• Goal: decrease edema/heal ulcers, compression wraps, elevate legs, avoid prolonged standing/sitting, walk, skin grafts

Nursing Interventions Venous Insufficiency

• Wound care, elevating legs, protect legs from injury, avoid heating devices, apply compression from foot upward, do not cross legs/ wear tight clothing

Vascular Bypass and Graft

• Bypass: Graft anastomosed to the artery below and above
• Graft repair: Diseased area replaced with graft

Endarterectomy

• Arteriosclerotic plaques are dissected
• Carotid artery common
• Risk of plaque breaking off causing TIA/stroke after surgery

Angioplasty

• Open plaque blocker arteries using balloon/laser

Complications of Vascular Surgery

• Bleeding/hemorrhage: apply pressure and notify HCP
• Drainage: can cause swelling/hematoma formation
• Fluid volume deficit/shock
• Re-occlusion: surgical emergency
• Loss of pedal pulse: notify HCP
• Blood flow needs to be reestablished within 4-6 hours to prevent risk of amputation
• Neuro dysfunction: monitor for stroke

Post OP Interventions

• Airway, vitals, neuro checks, neurovascular checks, monitor lytes, fluid status, hourly I+O, furosemide
• Avoid constricting measures on extremities, assist with ambulation
• Monitor for increased abdominal girth can indicate bleeding

Lymphangitis

• Inflammation/infection related to strep or staph infections, occurs in arms/legs, may cause sepsis
• Pain, red streak, chills, fever
• Antibiotics, heat, elevation, pneumatic pressure devices, monitor for edema/skin breakdown

EKG Interpretation

• 1 small box: 0.04 seconds
• PR interval: 0.12-0.2 seconds
• R wave to count the heart rate; multiply by 10
• ST segment: elevated, STEMI, complete blockage

Six Steps Process EKG

• Regularity of rhythm, heart rate, P wave, PR interval, QRS interval, QT interval

Sinus Bradycardia

• Med: Adenosine IV (6mg,12mg,12mg, expect asystole)

Atrial Flutter

• Flutter waves labeled between QRS complexes
• Ventricular rhythm and QRS evenly spaced out
• No P waves; flutter wave/sawtooth, pooling of blood in the atria
• Treatment: anticoagulation before cardioversion, ablation

Atrial Fibrillation

• Irregularly irregular, atrial rate not measurable, no P waves
• Treatment: if unstable synchronized cardioversion, anticoagulants

Ventricular Tachycardia

• Ventricular problem, QRS wide
• pulse: synchronized cardioversion
• no pulse: defibrillate/CPR

Ventricular Fibrillation

• Irregular, lethal arrythmia, quivering
• Treatment: Check responsiveness/pulselessness, CPR, defibrillation, epinephrine

Cardiac Pacemakers

• Generates electrical pulse, stimulates heart to beat
• Atrial pacemaker: spike before P wave
• Ventricular pacemaker: spike before Q
• Know the settings, know when to see a spike
• Monitor ekg, symptoms, apical pulse

Defibrillation

• Electrical shock to reset lethal ventricular arrythmias
• Paddles pressed firmly against chest
• Second intercostal space: right of sternum
• Anterior axillary line: fifth intercostal space
• Pulseless VT, V-FIB

Synchronized Cardioversion

• VT with pulse, A fib, A flutter

Heart Failure

• Progressive inability of heart to pump enough blood
• Left ventricle weakens first, failure of one lead to failure of other
• CAD is the most common cause
• Test: serum b-type natriuretic peptide: BNP

Left-Sided Heart Failure

• HTN major cause, blood backs up from left ventricle into lungs
• SOB, crackles, pink frothy sputum

Right-Sided Heart Failure

• Caused by LHF
• Cor Pulmonale: right ventricle hypertrophies and fails due to increased pulmonary pressure
• Peripheral edema, dependent edema

Acute Heart Failure (Pulmonary Edema)

• Severe fluid congestion in the alveoli
• Signs and Symptoms: Pink, frothy sputum, rapid respirations with accessory muscles, severe dyspnea, orthopnea, crackles, wheezes, anxiety, clammy cold skin
• Interventions: Semi fowlers/ fowlers, O2, mechanical ventilation, diuretics, vasodilators, reduce workload of left ventricle

Chronic Heart Failure

• Progressive
• Signs and Symptoms: Fatigue, pink frothy sputum, Cheyne stokes, crackles, wheezes, HR up, chest pain, dry cough, edema, cyanosis, alt mental status, malnutrition, dyspnea, orthopnea, weight gain, clammy skin, paroxysmal nocturnal dyspnea
• Goal: relieve pain, improve heart pumping ability, decrease demand for O2
• Interventions: Deep breathing, supplemental O2, decrease heart workload, maintain water/sodium balance, warfarin/furosemide, monitor sodium/potassium, low sodium diet, weight management, activity, monitor I/O, jugular vein distention, monitor lung crackles, bedrest HOB up
• Report weight gain 2-3 lbs over 1-2 days

Cardiac Resynchronization

• Shock them on the R wave; restores normal timing of ventricular contraction

Cardiac Transplantation

• End stage HF; Age: usually no one older than 65
• Immunosuppressive therapy, lifelong anti-rejection meds
• Complications: organ rejection, infection, malignancies, anti-rejection
• Monitor lung sounds for crackles