ischemia definition
insufficient oxygen supply to meet requirements of myocadium
infarction definition
Necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue
Atherosclerosis
depositing of cholesterol and other lipids within the intimal lining of the coronary artery
Major cause of CAD is...
Atherosclerosis
Collateral circulation
circulation by secondary channels after obstruction of the principal channel supplying the heart
Nonmodifiable risk factors for CAD
age
gender
ethnicity
family history
genetic predisposition
Modifiable risk factors for CAD
elevated serum lipids
Hypertension
tobacco use/2nd hand smoke
Physical inactivity
obesity
diabetes
metabolic syndrome
psychological states
substance abuse
Management of CAD
controlling modifiable risk factors
weight, diet, smoking
Encouraging lifestyle changes
-education
-clarify personal values
-set realistic goals
Nutritional therapy associated with managing CAD
Decrease:
saturated fats and cholesterol
red meat, egg yolks, whole milk
Increase:
complex carbs and fiber
Omega-3 fatty acids
Medications for CAD
statins-inhibit cholesterol synthesis, decreasing LDL and increasing HDL
Niacin- lowers LDL and increases HDL
Antiplatelet therapy
-ASA
-Clopidogrel (plavix)
Chronic stable angina
Occurs with exercise and an increase in O2 demands, it is predictable and controlled (nitro)
Characteristics of chronic stable angina
transient pain lasting 5-15 minutes
most often due to exertion
relief with rest or nitro
mid-sternal, radiation
tightness or pressure
ST segment depression during pain (will go away once pain is relieved)
Diagnosing chronic stable angina
12 lead ECG
chest xray
labs
calcium-score screening heart scan
echo
exercise stress test
pharm-nuclear imaging
acute interventions for chronic stable angina
Semi-fowler's position
supplemental oxygen
12-lead ECG
nitrate followed by an opioid analgesic
auscultate heart and breath sounds
meds for chronic stable angina
Antipletelet aggregation -Aspirin
Nitrates
Betablockers
Ace inhibitors
Calcium Channel Blockers
Surgical management for chronic stable angina
Percutaneous coronary intervention (PCI)
Balloon angioplasty
Stents
Unstable Angina
easily provoked, more frequent, less predictable, and can happen at rest.
acute coronary syndrome
Partial occlusion :Unstable angina or NSTEMI
total occlusion:STEMI
Difference between a STEMI and NSTEMI
A STEMI is more serious with ST elevation (more damage)
NSTEMI- less serious, meaning not fully occluded
What is a priority action when a patient presents with Chest pain?
12 lead- ECG
How long does it take for myocardial cell death to occur?
20 minutes
Pain seen with Myocardial infarction
Severe, immobilizing pain that is not relieved with rest, change in position, or nitrate admin.
Heaviness, pressure, tightness, burning, constriction or crushing feeling
substernal, retrosternal, epigastric; pain may radiate to neck, jaw or arms
Symptoms of Myocardial infarction
Pain
initial increase in HR and BP, then BP decreases
crackles (r/t HF)
JVD (r/t HF)
abnormal heart sounds
N/V
Fever (r/t systemic inflammatory process caused by myocardial cell death)
Possible symptoms of myocardial infarction in women
Nausea, breathlessness, Flu like symptoms, unexplained fatigue, weakness or dizziness. fear of impending doom.
Complications of MI
Dysrhythmias
HF
Cardiogenic shock
One way you can distinguish MI from unstable angina?
The pain from an MI will be much worse and not be relieved with nitro.
Initial interventions with MI
12-lead ECG
Semi-fowler's position
oxygen
IV access
Nitroglycerin and aspirin
morphine
Labs that you would expect to be ordered with MIs
troponin
cardiac enzymes
CBC
CKMB
myoglobin
MONAB (MI)
Morphine
Oxygen
Nitro
Aspirin
Betablocker
normal troponin ranges
troponin T <.10
troponin I <0.03
What lab value indicates myocardial injury?
Any elevation in troponin levels
normal myoglobin levels
<90 mcg/L
normal creatinine kinase ranges
females: 30-135 units/L
males: 55-170 unites/L
which cardiac biomarker is the most helpful in determining if a MI occurred?
troponin levels
Acute intervention for ACS (UA or MI)
continuous monitoring
-ECG
-ST segments
-Heart and Breath sounds
-VS, pulse ox, I&O
rest and comfort
anxiety reduction
emotional and behavioral reaction
Door to Balloon time
90 minutes
Preferred treatment for confirmed MI
Emergent PCI
-balloon angioplasty and drug-eluting stents
What therapy is done if PCI isn't available?
Thrombolytic therapy
Thrombolytic therapy definition
stops infarction by dissolving the thrombus (given IV), ideally done within the first hour, must be done within 6 hours of onset of symptoms.
Who cannot receive thrombolytic therapy?
Patients with:
uncontrolled hypertension
recent surgery (of any kind)
recent trauma
any bleeding problems.
Candidates for Coronary surgical revascularization
-Failed medical treatment
-presence of L main coronary artery or 3 vessel disease
-Not a candidate for PCI
-Failed PCI with ongoing chest pain
-Hx of diabetes mellitus
-when long term benefits of CABG are superior to those of PCI
Post op care with CABG
Assess for bleeding
monitor hemodynamic status
assess fluid status
replace electrolytes PRN
restore temperature
monitor for atrial fibrillation
surgical site care
pain management
DVT prevention
Pulmonary hygiene
Monitor for cognitive dysfunction
Why it Atrial fibrillation common after a CABG?
inflammation from the procedure
How long after MI does it take for scar tissue to replace necrotic tissue?
6 weeks
Ventricular remodeling
Normal myocardium will hypertrophy and dilate in an attempt to compensate for the infarcted muscle. initially good, but then creates an increase in O2 demands and can lead to HF
When can sexual activity resume after an MI?
typically 7-10 days or when patient can successfully climb two sets of stairs
True or False. a patient who has suffered and MI should take prophylactic nitrates before engaging in sexual activity.
True
These types of medications are contraindicated with Nitrates (requires patient education)
Erectile dysfunction medications
Sudden cardiac death
unexpected death from cardiac causes. most commonly caused by ventricular dysrhythmias
Endocarditis definition
inflammation of the endocardium resulting from a microbial infection. Bacteria enters the blood stream-> colonizes on valve leaflets-> Valves deformed, scarred stenosis and regurgitation.
Risk factors/Causes of endocarditis
IV drug use
poor dental hygiene
systemic infections
structural defects
prosthetic valve replacement (contaminated valve or perioperative bacteremia)
Signs and Symptoms of Endocarditis
Flu like symptoms (chills, fever, joint pain, cough, SOB)
Murmur
Microemboli
-petechiae
-Splinter hemorrhages
-Osler's nodes
-janeway lesions
-Roth's spots
Complications of Endocarditis
High mortality (without treatment)
Embolization of vegetation fragments
Heart Failure
Valvular problems
Hypertrophy
Diagnosis of Endocarditis
Recurrent fever
Murmur
S/S HF
S/S embolization
Positive blood cultures (X2)
Echocardiogram (TEE) to see vegetation
Treatment of Endocarditis
IV antibiotic therapy
-generally 4-6 weeks
Surgical
-repair/replace valve
-remove large vegetations
-remove valve that is continued source of infection and responsive to antibiotic Tx
Patient education for endocarditis
-stop doing drugs
-PICC line care
-Medication teaching
-S/S HF
-S/S recurrent endocarditis
-tell them to notify Health care provider of valve --replacement, disease or murmur prior to invasive procedure
-good oral hygiene-regular dental care
-importance o
Pericarditis definition
inflammation and increase in the fluid in the pericardium (normally about 30 mL)
Causes of pericarditis
Infection
-viral, bacterial, fungi, parasites
non-infection
-Post MI
-Post heart surgery
-renal failure
-trauma
-autoimmune, connective disease
Signs and symptoms of Pericarditis
muffled heart sounds
fever
tachycardia
DOE
pericardial friction rub
chest pain
-abrupt onset, grating, sharp, steady or intermittent. may radiate, increases with deep breathing, coughing or change in position
Diagnosing pericarditis
Elevated WBC
Slight increase in cardiac enzymes (not as high as with MI)
ECG will show ST segment elevation in most leads
Echo: looks for effusion, restriction
Complications of pericarditis
Pericardial effusion
Cardiac tamponade
Treatment for pericarditis
Medications
-antibiotics
-aspirin, tylenol (decrease fever)
-NSAIDS (decrease inflammation)
-possible corticosteroids (decrease inflammation)
Procedures
-pericardiocentesis (emergent, cardiac tamponade)
Nursing care with pericarditis
-meds
-positioning ( pain may be relieved by sitting up and leaning forward)
-respiratory assessment
-coughing/deep breathing/IS
-Oxygen
-vitals
- have the patient rest
Signs and symptoms of cardiac tamponade
JVD
muffled heart sounds
tachypnea
decreased blood pressure
decreased HR
dyspnea
fatigue
Causes of cardiomyopathy (general)
Primary
-idiopathic
Secondary
-ischemia
-infectious disease
-toxins
-metabolic disorders
-connective tissue disorders
-nutritional deficiencies
Dilated cardiomyopathy definition
Fibers degenerate, become necrotic and are replaced by fibrotic tissue. Chambers then dilate and contraction is impaired leading to decreased CO
--> less blood can be pumped by the left ventricle which is enlarged and weakened.
Causes of dilated cardiomyopathy
most often idiopathic
other causes r/t infection, chemo, alcohol abuse and HTN
Signs and symptoms of dilated cardiomyopathy
develop slowly over time
-SOB
-decreased activity tolerance
-fatigue
-dysrhythmias
-thrombi in LV
Treatment for dilated cardiomyopathy
Manage HF symptoms
ICD
biventricular pacer
Heart transplant
ICD. what does it stand for, and what is its purpose?
Implanted Cardioverter defibrillator
shocks your heart if it detects a lethal rhythm
Hypertrophic cardiomyopathy
unequal hypertrophy of Left ventricle and septum, causing hypercontractility especially upper septum. Slower to relax, leads to decrease in filling, and a decrease in CO.
Hypertrophy can lead to obstruction of outflow tract.
Causes of hypertrophic cardiomyopathy
Genetic in >50% fo cases
-defect in cardiac muscle development
Chronic HTN
-heart tries to manage HTN by getting larger (hypertrophy)
Signs and Symptoms of hypertrophic cardiomyopathy
often develop with exertion
Dyspnea, angina, syncope, ventricular dysrhythmias, fatigue, dizziness, palpitations, murmur
CAN be asymptomatic. (most common cause of sudden cardiac death in young people)
Diagnosing hypertrophic cardiomyopathy
Echocardiogram
Cardiac cath
Treatment for hypertrophic cardiomyopathy
Prevent/treat HR
RESTRICT activity
ICD
BiV pacing
antidysrhythmics
Removal of section of hypertrophied septum
Alcohol ablation
restrictive cardiomyopathy
ventricular walls become rigid and stiff due to endocardial scarring. Filling is impaired decreasing Cardiac Output. EF and contractility is normal
Diagnosing restrictive cardiomyopathy
echocardiogram
Signs and Symptoms or restrictive cardiomyopathy
Signs and symptoms of HF
-dyspnea, exercise intolerance, palpitations, fatigue
Treatment for Restrictive Cardiomyopathy
Poor prognosis- 1/2 will die within 2 years
Treat HF symptoms
exercise restriction
avoid dehydration
possible transplant
Nursing care for patients with Cardiomyopathy
(similar to HF)
Educate/Modify
-diet
-exercise
-medications
(diuretics, betablockers)
-disease information
-symptoms to report
What valves are most commonly affected with valvular diseases?
the aortic or mitral valve
Causes of Valvular heart disease
Acquired
-Rheumatic heart disease (caused by untreated rheumatic fever)
-Acute bacterial endocarditis
-MI
Congenital
-often no manifestations until adulthood)
What occurs with valve stenosis
Valves stiffen and fuse together and cannot fully open or close. Can be caused by scarring or calcium deposits.
-> leads to decrease in stroke volume and cardiac output, and increase in afterload and some regurgitation
What occurs with valve regurgitation?
Valves do not close completely causing backward blood flow.
Signs and Symptoms of valvular disease
Murmur
in acute event- s/s of HF may develop
Diagnosing valvular disorders
Echocardiogram
Exercise tolerance test or stress echo
CXRay
ECG
Heart Catheterization
MRI
TEE
Treatment of Valve disorders
Medications
-Diuretics
-Betablockers
-Digoxin
-Calcium Channel Blockers
Prophylactic antibiotics for any invasive procedures
Valvuloplasty, annuloplasty, surgical replacement
Nursing care with valve disorders
Identify/ report new murmurs
Treatment same as HF if symptoms