Advancing Heart Disease:

1
Advancing Heart Disease

• Living within the realm of CORONARY ARTERY
  DISEASE

2
Become heart smart...

• Whats happening within the myo- cardium
  muscle fibers that produces a pumping action so
  unique? electrical chemical nerve
  impulses electrolytes daily stresses

Places in our heart!
3
Coronary disease Which of these do you think is
true?

• A. Has its share of patient denial.
• B. Develops over years of poor habits.
  C. Has multiple factors that can
  accelerate the process.
  D. Can be triggered by
  emotional upset. E. All
  of the above.

4
What factors might contribute to the development
of any disease process?
5
Attributable factors representing known causes

• Immune systems competency
• Travel across borders
• Medication interactions
• Presence of illness or infection including
  systemic problems such as gouty or rheumatoid
  arthritis

• Genetics (Heredity) and Culture
• Malnutrition
• Lifestyles
• Environment

6
The cardiologists point of view -save that
achy-breaky heart

• Its mostly about diagnosing the problem,
  resting the heart, and controlling the
  rate/rhythm/BP with medications and use of
  procedures.

7
It takes a lot of fine tuning to keep the heart
in working order!
8
The Oxford University Study from England

• Participants were 69,017 women, age 38 to 63
  years, from the U.S. Nurses Health Study.
• Excluded were women with a history of MI,
  unstable angina, coronary artery bypass surgery,
  hyperlipidemia, diabetes, and stroke.

9

• Questionnaires assessed lifestyle and medical
  history (updated every two years)
• Dietary intake and patterns were identified with
  factor analysis and divided into quintiles.
• The women were followed for 12 years. A total of
  821 cases of CAD was confirmed.

10
The two test groups were labeled

• The Prudent Groups eating patterns were
  characterized by
• Higher intakes of fresh fruits, vegetables, whole
  grains, legumes, poultry, and fish.
• Less likely to smoke, used vitamin supplements,
  and consume more folate, fiber, and protein than
  the other group.
• A risk factor reduction of 24 for coronary
  artery disease was determined.

11
The Western group the results are in!

• Characterized by eating patterns that include
  higher intakes of red and processed meats,
  refined grains, chips, desserts, and sweets.
• The increased risk for coronary artery disease
  was measured at 46.

12
Taking Care of the Client with Coronary Artery
Disease
13
Cardiac nursing is a lot about

• Limiting activity until a possible M.I. is ruled
  out
• Administering a variety of medications that
  control rate/rhythm/BP
• Pain Management

I heard it was siesta time
14
What part of the hearts electrical conduction
system regulates the RATE ?
15
Order of the electrical impulses

• Sino-atrial (SA node) Atrial-ventricular
  (AV node)
  Bundle of His
• R L Bundle Branches Purkinje
  Fibers

16
Cardiac Medications Why they are so
important...

• Main Goal To enhance a diseased hearts valve
  wall motion, strengthen the myocardium, and
  regulate the conduction system.
• RESULTING OUTCOME To decrease the overall
  workload on the heart.

17
Actions of cardiac medications

• Controlling the volume of blood entering into and
  leaving the chambers
• Improving muscle contractility and oxygen flow
• Regulating the rate and rhythm

A cycle that works!
18
Amounts of blood/fluid - (Altering the
Preload volume)

• Origin Volume entering from the inferior and
  superior vena cava.
• Measurement Central Venous Pressure (CVP) 10
  to 18 mm Hg., around 14 is normal. An invasive
  line, called a Swan-Ganz, measures CVP pressure.

19
Time to Preload -

• Medication Choices DIURETICS - Loop (Lasix,
  Bumex) Moderate-acting (HydroDIURIL, HCTZ,
  Diazide)
• VASODILATORS - Nitroglycerine (NTG), Isordil,
  Cardizem, Lopressor, Vasotec

20
Vasodilators Importance

• 1. They open the arterial walls
  channel to reduce the pressure (resistance)
  against it.
• 2. They allow an increase of blood flow
  carrying the oxygen saturation.

21
So how does this affect the blood pressure?
22
Improving the Afterload Volume to the
Systemic Circulation...

• Decreases the blood pressure
• Increases the circulating systemic volume
• Aortic pressure builds approx. 10 times gt from
  initial blood entering R. atrium
• Examples Anti-arrhythmic medications work by
  altering the calcium, potassium, or sodium ions
  entering into the myocardial fibers.

23
Fluffy is in heart failure, fluid surrounding his
sick heart...

• Which classification of meds would help his heart
  improve the quickest? A. Vasodilator
  B. Narcotic C. Anti- arrhythmic D.
  Diuretic

Im such a FUR BALL!
24
Strengthening Myocardial Contractility

• Improves ventricular emptying by making the
  hearts myocardium stronger. Note After a
  heart attack, frequent ventricular
  irritability/perfusion problems exist.
  
  
• Medication Cardiac Glycosides slows
  strengthens, - Digoxin (Lanoxin). Dosing
  includes 0.125 and 0.25 mgs tablets.

25
Tachycardia gt than 100 b.p.m...Controlling
the Rate!

• To Fast Ventricles dont completely fill. Rates
  continuing over 130 bpm. will quickly become a
  problem for a diminished cardiac output.

26
Bradycardia marine turtles to the rescue...

• To Slow Decreases cardiac output tremendously
  and causes a reduction of oxygen and tissue
  perfusion.

THE FEW! THE PROUD! THE SLOW!
27
What medications return the rate to WNL ?

• Sustained Tachycardia
• Calcium-channel blockers, beta-blockers
• Symptomatic Bradycardia
• Atropine

I just want this thing to work sensibly!
28
The Hearts Pacemaker

• Sino-atrial node (SA) controls rate. Without
  this electrical influence, the ventricles would
  pace at around 40 beats per minute. The atria at
  60 beats per minute. Idio-ventricular pacing
• The heart could no longer be an effective pump!

29
CARDIAC OUTPUT FORMULA

• Circulating Volume 5 to 5.5 Liters/minute
• Cardiac Output Stroke Volume x Rate
  5 L appro. 70 mls x 72-80 bpm
• A diseased heart muscle would try to compensate
  by increasing the beats per minute! Remember,
  the ventricles are worn out!

30
Compute the cardiac output in liters for

• Average heart rate 88 Stroke
  volume 65 mls per ventricle beat
  Turtle speed 0.01 miles per hour

Why did my heart rate speed up?
31
Toxic blood levels...

• How does Digoxin toxicity, such as a 2.4 level,
  affect the cardiac output?
• Normal range 1.0 - 2.0 mg./dl.

Thats A Hard One! Gee, is that to high?
32
Severe Bradycardia Could Affect The Already
Diseased Heart

• Dig Toxicity is very common in the elderly
  population. As the blood level rises, it affects
  the action of the S.A. node by slowing the pacing
  (symptomatic bradycardia). Other symptoms
  include

• Loss of appetite
• Nausea/Vomiting
• Blurred or yellow vision
• Syncope

33
How does enlarging the coronary arteries
(vasodilating)

• improve the the hearts functioning? A.
  The atrial-ventricular valves open
  and close more readily. B. More oxygen
  flows via the blood
  stream. C. The S.A. node performs more
  competently. D. Increases the muscle
  contractility.

34
Which two meds represent examples of
vasodilators?

• A. Dyazide/Lasix B. Lanoxin/Atropine
  C. Isordil/Nitro- glycerine
• D. Zocor/Lortab

35
Identify five risk factors contributing to
cardiovascular disease

• Does this mean I have to give up my ugly,
  bad habits?. A quote from the Lifestyles of
  the Rich Famous

36
The Moral of this Story - Eat
More Veggies!

• Family history
• Age - Gender - Race
• Smoking
• Hyperlipidemia
• Hypertension
• Diabetes - Obesity
• Sedentary life-style
• Daily stresses

37
Hyperlipidemia

• Medications such as Mevacor, Lipitor, Lopid, and
  Zocor help to lower serum cholesterol.
• Monitoring liver function is extremely important.

38
Unstable Angina (Chest Pain)

• What can be some of the MAJOR differences between
  cardiac related chest pain and having a real
  heart attack?

39
Unstable anginas differences...

• A reduced amount of oxygen to the myocardium
  causing substernal pain with or without radiation
  to the arms, jaw, or shoulder.

40
Clinically, the patient can be

• Very pale
• Apprehensive
• Diaphoretic
• Achy or intense chest pain develops
  Key Point
• Minor changes in vital signs or current rhythm
  (E.C.G.)

41
How important are N.T.G. tablets?

• PRN orders Give one tablet, s.l., every 3 to 5
  minutes. May repeat once or twice if chest pain
  is unresolved. Follow up in the ER if pain is
  not relieved after three tablets.
  Nursing Considerations Obtain a baseline BP
  pulse first and document the same before
  administering each consecutive s.l. tablet. May
  cause severe hypotension.

42
M.I. - Is My Heart Broken?
Can it be patched?
43
Your patient puts his light on

• Im having this burning, tight pressure in my
  chest. Help me, Im scared. Its
  apparent that your patient is in ACUTE DISTRESS.
  What should be your first and second
  response/action on behalf of your patient ?

44
Cardiogenic Shock. A whole lot more than a lack
of oxygen!

• Ashen, gray color
• Cool clammy (diaphoretic)
• Nausea Vomiting
• Extreme apprehensive
• Severe chest pain increasing in severity
  described as vice-like or elephant standing on
  chest
• Major changes in vital signs and rhythm

45
Important Interventions

• Oxygen supplements ( heals the un-damaged
  areas of the myocardium)
• Monitor dysrhthmias (altered impulses through
  the SA node affecting rate/rhythm)
• Maximum rest for 4 to 6 weeks

• Pain management concerns
• Monitor ongoing ECG, cardiac enzyme profiles, and
  other labs
• Tissue perfusion (adequate coronary
  artery blood flow surrounding the myocardium)

46
There are several types of heart attacks some
more serious

• Mildest form Inferior Wall
• Most severe Anterior Septal

47
Major NO NOs after M.I.

• Avoid showers, whirlpools, and saunas until
  further instructed by your physician.
• No lifting or activities that involve the
  shoulder/chest muscle groups.
• Avoid constipation, straining, or other
  activities where you take a deep breath and hold
  it.

48
Mrs. Inezs Heart Attack

• Mrs. Inez, age 61, is hospitalized due to a
  recent inferior wall myocardial infarction. She
  has a previous history of unstable angina and
  will soon be going to the cardiac cath lab to
  help diagnose the reason for her M.I.
• What are three complications following an M.I.
  that might occur in the first 72 hours?

49
Post - MI Complications

• Congestive Heart Failure - CHF
• Rhythm disturbances -
  ventricles become irritable beat prematurely
• Pulmonary Edema

50
Cath Lab confirms.

• Mrs. Inezs heart attack was caused by the most
  common reason - a blockage, known as an
  occlusion. 90 of her left, descending coronary
  artery was blocked distally by plaque.
• Was this the reason for her chest pain?

51
Coronary Artery Disease

• Atherosclerosis - A common arterial disorder
  characterized by yellowish plaques of
  cholesterol, lipids, and cellular debris in the
  inner layers of walls of the medium and large
  arteries.
• This occurs over a period of years, usually 10 to
  20.

52
MI s Occulsive Pathophysiology

• Atherosclerosis -(occlusion of vessels)
• Embolism
• Vaso-spasm of the coronary arteries

Mr. Type A Personality...
53
Qualities of a Type-A Personality Do you know
someone like this?

• Highly competitive
• Ambitious
• Aggressive
• Often impatient
• Feels guilty for relaxing
• Thinks quickly and selectively
• Sense of urgency when it comes to time

Taking care of business!
54
Other complications that can stop the heart dead
in its track

• Ventricular aneurysm
• Pump mechanism failure
• Fluid overload complications

• Blood Viscosity - resistance to an
  anti-coagulant
• Electrical Conduction Failure - Sick Sinus
  Syndrome
• Severe Cardiomyopathy

55
Life has its gambles...

• Do you know why someone in their 60s, 70s, etc.
  will usually survive a heart attack more
  successfully then a person in their 30s 40s?

Its not a lucky roll of the dice!
56
Its known as collateral circulation!

• New tributaries of vessels develop as the main
  coronary arteries narrow by plaque. And, this
  takes many years to establish.

57
During one evening while on the telephone...

• Mrs. Inezs conversation with her husband induced
  stress. She begins to complain of chest pain.
  Which action should the nurse perform FIRST?
• A. Call her cardiologist.
• B. Give her a NTG. tab.
• C. Ambulate her down the hall.
• D. Take her blood pressure.

58
Which of these medications help relieve

• Mrs. Inezs angina pain by working directly to
  dilate the coronary arteries?
• A. Morphine Sulfate
• B. Na Bicarbonate
• C. Isordil Nitrate
• D. Mevacor

59
Pump Failure - CHF

• Cardiac Insufficiency When the heart is no
  longer able to pump enough blood to meet the
  demands of the body tissues.
• A precursor to cardiogenic shock.

Home is where the heart lies...

My Heart Will Go On
60
Left Ventricular Failure

• Origin On a chest x-ray, the film will outline
  the left ventricle being enlarged (hypertrophy).
  The heart is com-pensated by having the walls
  grow thicker! Until it no longer helps.
• In advanced states, pleural effusion or pulmonary
  edema may develop.

61
The Patients Subjective Statements _at_ CHF

• Increased shortness of breath on exertion
• Fatigue
• Anxiety
• Weight gain

• Swelling of feet and ankles
• Decreased urinary output
• Generalized weakness
• Irritating cough esp. while lying down

62
Its not just about breathing difficulties...

• Dyspnea
• Orthropnea
• 3-4 pitting edema
• Abdominal distention
• Moist crackles - rales
• Oliguria
• Activity intolerance

63
As the crisis develops further into Right-sided
Heart Failure

• What would happen to the central venous pressure
  measurements? A. It would
  remain the same. B. It would increase
  substantially. C. It would decrease
  minimally.

64
Which classifications of medication would work
for CHF?
65
Advanced Symptoms Pulmonary Edema (quick onset)

• Major elevation of BP
• Severe dyspnea
• Diaphoresis
• Chest pain
• Copious amounts of pink-tinged sputum
• Cyanosis
• Literally, drowning in their own secretions.

66
PE An acute emergency!

• Oxygen for the severe hypoxia/cyanosis
• Elevate H.O.B. in high-fowlers
• Morphine Sulfate or Demerol, I.V.P. for pain
• Lasix 180 - 360 mg., I.V.P. to relieve fluid
  overload
• Procardia 20 mg., S.L. to reduce
  BP Vasoconstriction occurs, the patient
  complains of being hot - put a fan on them.

67
Rheumatic Heart Disease

• Ellyn, age twenty, has a history of rheumatic
  heart disease since the age of four. She is
  currently being seen for c/os feeling run down,
  aches in the hip and knee joints, and general
  malaise. Her physician believes that she has
  infectious mononucleosis. Lets look at
  some considerations and factors involved with
  RHD.

68
A Rheumatic Hearts.. ..Complications

• What organism is usually responsible for causing
  RHD? And, why is it usually a childhood
  disease?
• This blood-borne infection can attack the heart
  valves joints kidney
  nephrons .causing sepsis.

69
Ellyns physician puts her routinely on a dose of
penicillin.

• Why? A. It helps with the
  fatigue shes experiencing. B.
  The action fights off the liver
  inflammation. C. Her immune system is
  competent. D. The drug is preventing a
  reoccurring lapse of RHD.

70
Open-Heart Surgery

• Mr. Anthony, age 53, had triple by-pass graft
  surgery two days ago. He is being transferred to
  the step-down unit. His rhythm has continued to
  be in atrial fibrillation with a controlled rate
  between 80 to 105 bpm. Although this dysrrythmia
  is not unusual after a C.A.B.G., or is it a life
  or death situation, it does put him at risk for?

71
Rhythm disturbances (Atrial Fibrillation) that
could lead to a pulmonary embolism or stroke