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Chapter 13: Cardiovascular Alterations

Terms in this set (42)

CAD:
a. It is the narrowing or obstruction of 1 or more coronary arteries as a result of atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries.

Pathophysiology:
a. The disease can cause decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply, leading to hypertension, angina, dysrhythmias, MI, heart failure, and death.
b. Collateral circulation, which is more than 1 artery supplying a muscle with blood, is normally present in the coronary arteries, especially in older persons.
c. The development of collateral circulation takes time and develops when chronic ischemia occurs to meet metabolic demands; therefore, occlusion of a coronary artery in a younger individual is more likely to be lethal than one in an older individual.
d. The symptoms occur when the coronary artery is occluded, it causes ischemia.

Risk factors:
a. Non-modifiable factors
-Age: Men older than 45 and women older than 55.
-Family history.

b. Modifiable factors:
-Smoking
-Inactivity
-Overweight
-Cholesterol (High LDL, Low levels of HDL)
-Diabetes
-Hypertension

History:
a. It is necessary to know the history of the patient's use of phosphodiesterase type 5 inhibitors that can be taken for erectile dysfunction, such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra). (e.g., These medications can potentiate hypotensive effects of nitrates such as NTG, therefore it should be contraindicated.


Assessment:
a. Possibly normal findings during asymptomatic periods.
b. Chest pain.
c. Palpitations.
d. Dyspnea
e. Syncope
f. Cough or hemoptysis
g. Excessive fatigue

Diagnostic Studies:
a. 12-lead ECG:
-This noninvasive test, also known as the ECG.
-It is used to identify the rhythm disturbances; pericarditis, pulmonary diseases, left ventricular hypertrophy; and myocardial ischemia, injury, and infarction.

b. Chest radiography:
-It is performed in the anteroposterior view.
-It detects cardiomegaly, cardiac positioning, degree of fluid infiltrating the pulmonary space or pericardial space.

c. Holter Monitor:
-They are used to detect the suspected dysrhythmias.
-The Holter monitor is a small portable recorder connected to the patient by three to five electrodes.
-The recorder is worn 24 to 48 hours.

d. Exercise Tolerance Test:
-It is a noninvasive test, also known as a stress test, the patient is connected to an ECG machine while exercising.
-The stress test is used to document exercise-induced ischemia and can identify those individuals who are prone to cardiac ischemia during activity, even though their resting ECGs are normal.

e. Pharmacological stress test:
-This test is done in conjunction with radionuclide scintigraphy or echocardiography.
-Medications such as regadenoson, dipyridamole, or adenosine are used to cause vasodilation of normal coronary arteries.

f. Nuclear stress testing:
-This test can be done with exercise to increase the sensitivity of the test.
-It is used for patients who have an ECG that precludes an accurate interpretation of ST-segment changes, and it is also used in conjunction with medications for patients who cannot walk on a treadmill.

g. Echocardiography:
-This is a non-invasive imaging procedure that uses ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers.

h. Transesophageal echocardiography (TEE):
-This test provides ultrasonic imaging of the heart as viewed from behind the heart.
-In TEE, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus.
-This technique provides a clear picture of the heart because the esophagus lies against the back of the heart and is parallel to the aorta.

i. Multi-gated blood acquisition study (MUGA):
-It is used to assess the left ventricular function.
-An isotope is injected, and images of the heart are taken during systole and diastole to assess the LVEF of the heart.

j. Cardiac magnetic resonance imaging (MRI):
-Is known as a noninvasive test used to evaluate tissues, structures, and blood flow.
-The technique uses magnetic resonance to create images of hydrogen ions as they are emitted, picked up, and fed into a computer.
-The computer reconstructs the image, which can be used to differentiate between healthy and ischemic tissue.
-MRI is used to diagnose or evaluate CAD, aortic aneurysm, congenital heart disease, left ventricular function, cardiac tumors, thrombus, valvular disease, and pericardial disorders.

k. Cardiac computed tomography:
-It is a non-invasive way to image the heart three-dimensionally.
-It is used to evaluate for CAD, valvular disease, pericardial disease, and aneurysms and to map the pulmonary veins before ablation.

l. Positron emission tomography (PET):
-It is a scan that is a noninvasive way to study cardiac tissue perfusion.
-Radioactive isotopes are injected IV to enable the imaging.

m. Cardiac Catheterization:
-It is an invasive procedure that can be divided into two stages (right-sided and left-sided catheterization).
-It is used to measure pressures in the chambers of the heart, cardiac output, and blood gas content; to confirm and evaluate the severity of lesions within the coronary arteries; and to assess left ventricular function.

Post-catheterization Care:
-Best rest a minimum of 4 hours; head of bed no higher than 30 degrees.
-Monitor bleeding; newer collagen agents for hemostasis may be used.
-Monitor pulses
-Anti-platelet drugs after the procedure (usually after interventions such as PCI).
-May be discharged in 6 to 8 hours after completion of test; it depends on the diagnosis and procedures done.

n. Electrophysiology:
-It is a invasive procedure that usually involves the introduction of an electrode catheter percutaneously from a peripheral vein or artery into the cardiac chamber or sinuses and the performance of programmed electrical stimulations of the heart.
-Electrophysiology aid in recording intra-cardiac ECG's, diagnostic cardiac conduction defects, evaluating effectiveness of anti-arrhythmia's medications, and determining the proper choice of a pacemaker.
Diet: low cholesterol, low salt.
Exercise: Aerobic
Weight loss
Smoking cessation
Management of hypertension and diabetes, if present.

Medications:
Lipid-lowering agents include statins, bile acid resins, ezetimibe, nicotinic acid, and a newer class of medications called pro-protein convertase subtillisin/kexin type 9 (PCSK9) inhibitors.

a. Statins lower LDL by the slowing the production of cholesterol and increasing the liver's ability to remove LDL from the body and are well tolerated by most individuals.
b. Some commonly prescribed medications include lovastatin, atorvastatin, pravastatin, simvastatin, and rosuvastatin. (i.e., It is recommended that most statins be given as a single dose in the evening because more cholesterol is at night).

Ezetimibe:
a. It works in the digestive tract by blocking the absorption of cholesterol from food.
b. It is often used in conjunction with other cholesterol-reducing medications.
c. It can cause liver disease, therefore liver function tests must be monitored.
d. The medication is contraindicated in patients with severe hepatic disease, when added to statins it decreases cardio problems.

Nicotinic acid, or niacin:
a. It reduces total cholesterol, LDL, and triglycerides levels, and it increases HDL.
b. The medication is available over the counter; its use in lowering cholesterol must be done under a provider.
c. It is a long acting, once-daily dose by prescription.
d. Side effects: metallic taste in mouth, flushing, and increased feelings of warmth.
e. Major side effects: Hepatic dysfunction, gout, and hyperglycemia.
f. It must be given separately from other medications due to it affecting the absorption of other meds.
g. Administer niacin at night/w food or taking 325 mg of non-enteric aspirin 30 minutes before the niacin dose can reduce some of the side effects.

Fibric acid derivatives:
a. If triglyceride levels are elevated, patients may be prescribed agents that lower triglyceride levels such as Gemfibrozil increases HDL.
b. Patients should be monitored carefully.
a. HF is known as impaired cardiac function of one or both ventricles.
b. Patients can either have preserved ejection fraction (HFpEF) or have a reduced ejection fraction.
c. Patients with HFpEF have an LVEF of 50% or greater, and those with HFrEF have an LVEF of less than 40%.
d. Those with LVEF values are between 40% to 50% are borderline.

Left-sided HF:
a. The left ventricle cannot pump efficiently.
b. The ineffective pumping action causes a decrease in cardiac output, leading to poor perfusion.
c. The volume of blood remaining in the left ventricle increases after each beat.
d. As the volume increases, it backs up into the left atrium and pulmonary veins and into the lungs causing congestion.


Right-sided HF:
a. It is usually a consequence of left-sided HF, it can be a primary cause of HF after a right ventricular MI, or it may occur secondary to pulmonary pathology.

Brain natriuretic peptide:
a. Cardiac hormone:
-It is secreted by ventricular myocytes in response to wall stretch.
-Normal 100 pg/ml.
b. Plasma concentrations reflect severity of HF.
-It is decompensated HF, BNP rises.
-As HF is treated, BNP is lower.
c. It is a good marker for differentiating between pulmonary and cardiac causes of dyspnea.


Assessment of HF:
Right sided-HF:
"SWELLING"
S: Swelling of legs, hands, and liver.
W: Weight gain
E: Edema (pitting)
L: Large neck veins (Jugular vein distention)
L: Lethargic
I: Irregular HF (a-fib)
N: Nocturia (lying down allows fluid to go to kidneys)
G: Girth (abdomen, increase in size... breathing issues, anorexia, and nausea).

Left-sided HF:
D: Dyspnea
R: Rales (crackles)
O: Orthopnea (sit up to breathe especially at night)
W: Weakness
I: Increased HR (trying to get blood to organs)
N: Nagging cough (frothy/blood tinged sputum)
G: Gaining weight (2-3 Ib in a day or 5 Ibs. in a week)
1. Complete history (physical exam)
a. Intravascular volume, with examination of neck veins and presence of hepatojugular reflux.
b. Presence or absence of edema
c. Perfusion status, which includes BP, quality of peripheral pulses, capillary refill, and temperature of extremities.
d. Lung sounds, which may not be helpful.

2. Chest radiographic exam: It views heart size and configuration and to check the lung fields to determine whether they are clear or opaque. (i.e., fluid filled).

3. Hemodynamic monitoring: Invasive monitoring may be done to assess mixed venous oxygen saturation, stoke index, cardiac index, and pulmonary artery pressures, especially in those who do not response to conventional therapy.
4. Non-invasive imaging of cardiac structures: The single most useful test in evaluating patients with HF is the echocardiogram, which can evaluate ventricular enlargement, wall motion abnormalities, and valvular structures.
5. Serum electrolytes: low sodium is a sign of advanced or end-stage disease; low K+ is associated with duiresis, high potassium is seen in renal impairment; BUN and creatinine levels are elevated in low perfusion states, renal impairment, or with overduiresis.
6. BNP
Brain natriuretic peptide:
a. Cardiac hormone:
-It is secreted by ventricular myocytes in response to wall stretch.
-Normal less than 100 pg/ml.
b. Plasma concentrations reflect severity of HF.
-It is decompensated HF, BNP rises.
-As HF is treated, BNP is lower.
c. It is a good marker for differentiating between pulmonary and cardiac causes of dyspnea.
7. Liver function test
8. ECG/EKG
Assess for worsening symptoms:
a.Right-sided (peripheral swelling) vs. Left sided (Pulm. issues)
Pt's responsiveness to medications: HR (digoxin), BP (ACE/ARB), volume status (diuretics/foley and daily weights).
-Labs: K+, BUN, creatinine, digoxin levels, BNP, and troponin.
-Cardiac and fluid restriction diet.
-Edema decreases, keep legs elevated.
-High fowler's to help with breathing.
-Safety: Orthostatic hypotension and swelling of feet (falls).

Teaching:
a. Low sodium diet: 2-3 grams/per day.
b. Fluid restriction: 2L per day.
c. Vaccination: flu and pneumonia.
d. Aerobic exercise as tolerated.
e. Daily weights : 2 to 3 Ibs. per day or 5 Ibs. per week. (Early sign of CHF) notify the provider.
f. Compliance with meds.
g. Smoking cessation and limit ethanol.
h. Early S+S HF: SOB, orthopnea, and weight gain.

Medications:
"Always Administer Drugs Before A Ventricle Dies"
a. Ace Inhibitors: ACE:
-1st line treatment prescribed with beta blockers
-End in "pril" Lisinopril
-Side effects: Increase in K+ and dry nagging cough.
-Block the conversion of Angiotensin I and II (vasodilation, decrease BP, and kidney excrete Na+, which can lead to a decrease in aldosterone (It keeps K+ and excrete Na+)

ARBs:
a. It used in the place of ACE inhibitors
b. It ends in Sartan (Losartan)
c. Side effects: Hyperkalemia, no nagging cough.
d. It blocks angiotensin II receptors: vasodilation
e. Some effects as ACE inhibitors: Angiotensin II decreases aldosterone.

Diuretics:
a. It used in combination with ACE/ARBs to decrease water and Na+ retention (decrease in edema) and helps the heart easier (patient urinates ALOT!)
b. Loop Lasix decreases potassium
c. Potassium-sparing aldosterone (increase potassium)


Beta-Blockers:
a. It blocks Norepinephrine effects on the heart muscle.
-Its negative inotropic effect= It decreases myocardial contraction (slow HR) and decreases cardiac workload.
-It ends in "lol": metoprolol, carvediol, bisoprol.
-Side effects: Bradycardia, mask hypoglycemia in diabetics, Not for COPD or asthmatic patients.
-Avoid Grapefruit juice due to the lack of absorption.

Anti-coagulants:
a. It is not used in every pt. with HF.
b. HF pt's a-fib, or a history of blood or an Ejection fraction of less 35% ("systolic dysfunction).

Vasodilators:
Arterial dilator (Hydralazine) is sometimes prescribed with a nitrate like Isordil (venous dilator).
-It is used sometimes if a patient can't take ACE or ARB.
-Vasodilation of arteries or veins to decrease the blood and fluid.
-Side effects: Hypotension leads to orthostatic.

Digoxin;
a. Positive inotropic: It increases the hearts ability to contract stronger.
b. Negative chronotropic: It causes the heat to beat slower.
c. It allows the heart to rest and pump more blood.
d. It is not the 1st line treatment.
e. It is used in Left ventricular systolic dysfunction.
f. Toxicity an issue: It increases chances, if a patient hypokalemic (less than 3.5)
g. Digoxin range is 0.5 to 2 ng/ml.
-Check for apical pulse less than 60 bpm
h. Toxic signs: N/V, vision changes: yellowish-green halos
(Digibind: antidote).

*IMPORTANT: Nesiritide citrate (Natrecor) intravenous for acute decompensation of HF.
Aortic Aneurysms:
a. It is an abnormal dilation of the arterial wall caused by localized weakness and stretching in the medial layer or wall of the aorta.
b. The aneurysm, it can be located anywhere along the abdominal aorta.
c. The goal of treatment is to limit the progression of the disease by modifying risk factors, controlling the BP to prevent strain on aneurysm, recognizing symptoms early, and preventing rupture.

Types of aortic aneurysm:
True aneurysms:
a. Fusiform: It is a diffuse dilation that involves the entire circumference of the arterial segment.
b. Saccular: It is distinct localized out-pouching of the artery wall.
c. Dissecting: It is created when blood separates the layers of the artery wall, forming a cavity between them.

False aneurysms:
a. Pseudo-aneurysm: It is known to occur when the clot and connective tissue that are outside the arterial wall as a result of vessel injury or trauma to all 3 layers of the arterial wall.

Assessment:
Thoracic:
a. Pain extending to neck, shoulders, lower back, or abdomen.
b. Syncope
c. Dyspnea
d. Increased pulse
e. Cyanosis
f. Hoarseness, difficulty swallowing due to pressure from the aneurysm.

Abdominal aneurysm:
a. It is a prominent, pulsating mass in the abdomen, at or above the umbilicus.
b. Systolic bruit over the aorta.
c. Tenderness on deep palpation.
d. Abdominal or lower back pain.

Rupturing aneurysm:
a. Severe abdominal or back pain.
b. Lumbar pain radiating to the flank and groin.
c. Hypotension
d. Increased pulse rate
e. Signs of shock
f. Hematoma on flank area.

Interventions:
a. Monitor V/S
b. Obtain information regarding back or abdominal pain.
c. Questioning the client regarding sensation of pulsation in the abdomen.
d. Check peripheral circulation, including pulses, temperature, and color.
e. Observe for signs of rupture.
f. Note any tenderness over the abdomen.
g. Monitor for abdominal distention.