Cardiovascular Pt 1

Cardiac output equation and normal amount
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Cardiac output equation and normal amount
-CO= SV x HR
-4-8 L/min
Cardiac index equation and normal amount
- CL=CO/Body surface area
-2.8-4.2 L per minute per meter squared
factors affecting CO
-HR
-Preload
-Contractility
-Afterload
Preload
•Volume of blood stretching the ventricles at the end of diastole
•Increased with HTN, aortic valve disease, and hypervolemia
•Decreased with rapid HR or hypovolemia
Contractility
increased by epinephrine and norepinephrine
Afterload
•Peripheral resistance against which the left ventricle must pump
•Depends on size of the ventricle, wall tension, and arterial BP
Preload increased in
hypervolemia, regurgitation of cardiac valves, heart failure
afterload increased in
hypertension, vasoconstriction
-Increasedd Afterload= increased cardiac workload
Angina Pectoris (chest pain)
-insufficient supply of oxygen and energy-rish nutrients to meet the hearts demands
-result of reduction in the oxygen supply-to-demand ratio
Antianginal therapy goal
Increase blood flow to the ischemic myocardium, decrease myocardial oxygen demand, or both
Antianginal therapy types-nitrates -beat blockers -calcium channel blockersNitrates Medications-Nitroglycerin -Isosorbide Dinitrate -MononitrateNitrates MOA•dilate all blood vessels -> relax smooth muscle cells that are part of all structure of veins and arteries -> redistribution of blood and oxygen to ischemic myocardial tissue and reduction of anginal symptomsNitrates Adverse Effects-Headache -Reflex tachycardiaNitrates Interactions•alcohol, beta blockers, calcium channel blockers, phenothiazines, and erectile dysfunction drugs!!!!! (sildenafil=Kill, tadalafil, and vardenafil)Beta Blockers Types-Metoprolol -Atenolol -PropranololBeta blockers MOA•block beta receptors -> rate at which the SA node fires decreases -> Also, slows conduction through the AV node and reduce myocardial contractility -> this slows the heart rate reducing myocardial oxygen demand (reduces workload of the heart)Beta blockers: Black box warningDo not stop abruptly - must be tapered offBeta Blockers: Adverse Effects-Decreased HR -Can mask signs of Hypoglycemia!!! -fatigue -depression -wheezing -dyspneaCalcium Channel Blockers Types-Amlodipine -Verapamil -Diltiaze, -Nifedipinecoronary artery disease (CAD)-Blood vessel disorder -AtherosclerosisAtherosclerosis-hardening of the arteries -can occur in any artery of the body -Major cause of CAD -Develops over many years -endothelial injury and inflammation play a large role in developmentCAD is also referred to asArteriosclerotic heart disease (ASHD) Cardiovascular heart disease (CVHD) Ischemic heart disease (HD) Coronary heart disease (CHD)Stages of arthersclerosis-fatty streak -fibrous plaque -Complicated lesionAtherosclerosis caused by-HTN -tobacco use -hyperlipidemia -diabetesArthersclerosis want to try to lower...LDLsCollateral Circulation-some arterial anastomoses(connections) exist within coronary circulation -2 factors contribute to the growth and extent of collateral circulation -Inherited predisposition to develop new blood vessels -Presence of chronic ischemiaRisk factors for CAD: Nonmodifiable-increasing age -Gender (highest among middle-aged men) men over 45 and women over 55 -Ethnicity: more common in white than black men -Genetic predispositionCAD Risk factors: Major-Total cholesterol: > or equal to 200 mg/dL -Triglycerides: > or equal to 150 -LDL: > 130 mg/dL -HDL: <40 mg/dL Men and <50 mg/dL Women -BP: > 120/80 mm Hg** -Diabetes* -Tobacco Use -Physical Inactivity -ObesityCAD risk factors: Contributing-Psychosocial risk factors(depression, hositlity) -High homocysteine levels -Substance abuseWant to monitor what and treat what for CADBP!!Chronic stable Angina-chest pain that occurs intermittently over a long period of time -similar pattern of onset, duration, and intensity of symptoms -pain lasts for a few minutes -Subsides when precipitating factor is resolvedChronic stable Angina Drug therapy•Short Acting Nitrates •Long Acting Nitrates •Angiotensin- Converting Enzyme (ACE) inhibitors •Angiotensin Receptor Blockers (ARBs) •B-Adrenergic Blockers •Calcium Channel Blockers •Lipid Lowering Agentsshort acting nitrates-sublingual nitroglycerin -Relieves pain in about 5 minutes -Lasts for 30-40 minCan repeat short acting nitrates every..5 minutes for a max of 3 doses -need more than 3 doses= go to hospital/call the ambulanceshort acting nitrates S/E-headache ( can give tylenol for headache!!!) -dizziness -flushing -orthostatic hypotension -tolerance can occurShort acting nitrates moadilates the blood vessels and CA-> relaxation of smooth muscle cells-> restore blood flow and O2 to the cellsLong acting nitrates: Isosorbide Dinitrate Use and S/E-Reduces frequency of angina attacks -S/E: Headache, orthostatic hypotension, toleranceLong acting nitrates: Names-Isosorbide Dinitrate -Nitroglycerin ointmentNitroglycerin ointment prevents...prevents angina for 3-6 hoursLisinopril: CLass and use-ACE inhibitor -Pt's w/chronic stable anginba with an EF of 40% or less, diabetes, HTN, or CKD should take an ACELosartan Class and results in-ARBS -Results in vasodilation and reduced blood volumeIf pt cannot tolerate ______ step down to an ____-ACE -ARBBeta adrenergic blockers ex-atenolol -propranolol -metoprololBeta-adrenergic blockers moadecrease myocardial contractility, HR, SVR, and BP -this will reduce the myocardial O2 demand and relieve angina symptomsBeta-adrenergic blockers contraindications-systolic HF -serious conduction disturbances (bradycardia)Beta adrenergic blockers s/edecrease in HR, CO, cardiac contractilityCalcium channel blockers ex-amlodipine -verapamil -diltiazem -nifedipineCalcium channel blocker main effects•Systemic vasodilation with decreased SVR •Decreased myocardial contractility •Coronary vasodilation •Decreased HRCalcium channel blocker contraindications•Acute MI •Second- or third- degree AV heart block •Hypotension****Calcium channel blocker S/E•Hypotension •Palpitations •Tachycardia or bradycardiaDo not take ____ or _____ with calcium channel blockers-Grapefruit -grapefruit juiceacute coronary syndrome 2 types-Unstable Angina; Non-ST-segment elevation MI -St-segment elevation MIPartially Blocked-NSTEMI and Unstable anginaTotally OccludedSTEMIUnstable Angina-chest pain that is new on onset, occurs at rest, or occurs with increasing frequency, duration, or less effort -lasts 10 or more minutes -will see ischemic changes in EKGTrue or Flase: You want to got to the ER immediately if suffering from unstable anginaTrueMyocardial Infarction (MI)-abrupt stoppage of blood flow through the coronary artery with a thrombus -irreversible cell death -serum cardiac biomarkers released into the blood -Troponin*****MI: STEMI-Occlusive thrombus -ST-elevation -PCI or thrombolytic therapyMI: NSTEMI-NOnocclusive thrombus -DOES NOT CAUSE ST-ELEVATION -May see ST depression and/or T wave inversion -Catheterization -Thrombolytic therapy not indicated (d/t not being fully occluded)Want to go to ER immediately for what?STEMIMI clinical manifestations-Pain: not relieved by rest, position change, nitrate; Severe! -Sympathetic Nervous System Simulation: Diaphoresis, increased HR and BP, vasoconstriction of peripheral blood vessels -Cardiovascular manifestations: drop in BP d/t decreased CO -N/v -FeverMI BP initially starts____ and then ____-high -drops -can lead to decreased blood flow to organsMI complicationsDysrhythmias -ischemica can cause dysrhythmias -Most common compliction post MI -Ventricular tachycardia and v-fib occur within 4 hours after onset of painacute coronary syndrome diagnostic studies-ECG -Serum cardiac biomakers -Cardiac cathECG: STEMIST elevationECG: NSTEM/UAST depression and/or T wave inversionYou can only tell the difference with bloodwork for what 2 things-NSTEMI -UASerum cardiac biomakers: Troponin-Serum levels increase 4-6 hrs after MI onset -Peak at 10-24 hours -Return to baseline over 10-14 daysSerum cardiac biomakers: CK-MB-levels rise about 6 hours after MI -Peak at 18 hours -Return to normal within 24-36 hoursSerum cardiac biomakers: Myoglobin-peak in 3-15 hoursFor ______ Troponin is elevated but Troponin is not elevated for _______-NSTEMI -UAcardiac catheterization Stemi vs NSTEMI/UA-STEMI: pts must undergo within 90 minutes after presentation -NSTEMI/UA : within 12-72 hours after presentationPercutaneous coronary intervention (PCI)•Catheter with deflated balloon in inserted into the blocked artery •The balloon is inflated •Compresses plaque against the artery wall •Results in vessel dilation and larger vessel diameter •Stent may be placedAcute coronary syndrome Drug therapy-Antiplatelet therapy (aspirin) -IV Nitroglycerin -Morphine -B-adrenergic blockers -ACE inhibitors -Angiotensin Receptor blockers -Antidysrhythmic drugs -Lipid lowering drugs -Stool softenersIV nitroglycerin (Goal of therapy, decreases, increases, closely monitor.onset of action)-Goal of therapy: reduce angina pain and improve coronary blood flow -Decreases preload and afterload -Increases myocardial O2 -Closely monitor BP -Immediate onset of actionMorphine (Type, Decreases, monitor for)-Vasodilator -Decreases cardiac workload, BP, HR -Monitor for Bradycardia and hypotensionLow Molecular Weight Heparin (LMWH): Name, given to, prevents-Enoxaparin -Given to UA/NSTEMI pt's -Prevents conversion of fibrinogen to fibrin-> prevent microemboli from formingLMWH Nursing Implementation-monitor vital signs and pulse ox -continuous ECG monitoring -Serial cardiac biomarkers -Maintain bedrest for first 12-24 hoursA nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? a. angina can be relieved with rest and nitrogylcerin b. the pain of an MI resolves in less than 15 minutes c. the type of activity that causes an MI can be identified d. angina can occur for longer than 30 minutesA. Angina can be relieved with rest and nitroglycerinA patient is admitted to the ICU with a diagnosis of NSTEMI. Which drug(s) would the nurse expect the patient to receive? (select all that apply) a. oral statin therapy b. antiplatelet therapy c. thrombolytic therapy d. prophylactic antibiotics e. intravenous nitrogylcerinA. Oral Statin therapy B. Antiplatelet therapy E. Intravenous nitroglycerinA 68-year- old male patient has been taking the nitrate isosorbide dinitrate for 2 years for angina. He recently has been experiencing erectile dysfunction and wants a prescription for sildenafil. Which response would the nurse most likely hear from the prescriber? a. "He will have to be switched to isosorbide mononitrate of he wants to take sildenafil." b. "Taking sildenafil with the nitrate may result in severe hypotension, so a contraindication exists." c. "I'll write a prescription, but if he uses it he needs to stop taking the isosorbide for one dose." d. "These drugs are compatible with each other, and so I'll write a prescription."B. "Taking sildenafil with the nitrate may result in severe hypotension, so a contraindication exists."