CARDIOVASCULAR DISORDER OUTLINE • Heart rate
• Rhythm
Heart Facts
• One in six men and one in seven women aged 45-64 has
some form of heart disease or stroke; the ratio climbs to
one in three at age 65 and over.
• Twice as many people, both men and women, die of
cardiovascular disease as die of cancer.
• An estimated 3,150,000 Americans have angina pectoris
• Rheumatic heart disease afflicts 1,340,000 Americans.
(Data from the American Heart Association's 1994
Statistical Supplement, "Heart and Stroke Facts")
Atherosclerosis and Arteriosclerosis
• Common disorder of the arteries.
o Fat, cholesterol, and other substances collect in the
walls of arteries.
o Larger accumulations are called atheromas or
plaques.
• Fatty tissue erodes wall of the artery, diminishes the
elasticity and interferes with blood flow.
• Arteriosclerosis (commonly called hardening of the
arteries) frequently accompanies atherosclerosis and is
not clearly separated from it.
o Arteriosclerosis involves deposits along the arteries,
which often contain calcium.
Arteriosclerosis and Ateriosclerotic Heart Disease
(ASHD)
• Primarily affects middle age and older
• Major cause of death in men age 35-44 years old
• Major cause of death in women after menopause
• Prevention begins at birth
• 3 Main Risk Factors
o Smoking, High B/P and High Cholesterol
• Intermittent claudication (pain in calf or leg brought on by
exercise and relieved by rest) is most common early sign
of arteriosclerosis
Risk Factors for ASHD
• Non-Modifiable
o Age
o Gender
o Race
o Family history
o other illness (diabetic)
• Minor Factors
o Personality type
o Sedentary living
o Stress
o Oral Contraceptive Use
• Modifiable
o Smoking
o High calorie, fat, cholesterol, sugar and sodium diet
o High serum lipids
o Hypertension
o Obesity
o Lifestyle
Cardiovascular Assessment - Inspection
• Skin Color (pallor, cyanosis)
• Neck vein distention - reflects right atrial pressure
• Respiratory (dyspnea, Orthopnea)
• Location of PMI - if too low indicates enlarged heart
• Presence of edema - fluid volume overload
o Be sure to check sacrum for those on bedrest
• Nail clubbing - sign of chronic hypoxia
• Capillary filling - measure of peripheral circulation
• Lack of hair on legs/feet
• Venous stasis or Arterial Ulcers
• Vericose Veins
Palpation
• PMI (Located at 5th intercostal space, Left MCL)
• Thrills (palpable murmur) thrusts/heaves
• Peripheral pulses - Check all bilateral and compare
• Temperature - check bilateral
• Capillary refill - measure of peripheral circulation
Auscultation
• Heart Sounds S1 (lub) and S2 (dub)
• S1 is first heart sound from closure of Mitral and Tricuspid
• S2 is second sound from closure of aortic and pulmonic
• Don’t worry about correctly labeling sounds as S3 or S4
for now
• Murmurs are swishing sounds in-between heart sounds
(Lub-swish-Dub)
• Pericardial friction rub - rough, grating sound from
inflamed pericardial sac
• Bruit - murmur heard outside of the heart. May be heard
in carotid, jugular, temporal, abdominal, aortic, renal and
femoral arteries
• Take B/P in both arms, lying, sitting and standing
Pulse Assessment
• Note whether the pulse is regular or irregular:
o Regular - evenly spaced, may vary slightly with
respiration
o Regularly Irregular - regular pattern overall with
"skipped" beats
o Irregularly Irregular - chaotic, no real pattern, very
difficult to measure rate accurately
o A pulse greater than 100 beats/minute is tachycardia.
Pulse less than 60 beats/minute is bradycardia.
o Tachycardia and bradycardia are not necessarily
abnormal. Athletes tend to be bradycardic at rest
o Tachycardia is a normal response to stress or exercise.
B/P Assessment
• Position and support the arm slightly flexed at the elbow
• Center the bladder of the cuff over the brachial artery 2
cm above the anticubital fold
• Inflate the cuff until the radial pulse disappears. Inflate
the cuff to 30 mmHg above the estimated systolic
pressure, release slowly.
• Systolic Pressure - When you start to hear beats
• Diastolic pressure when the sounds muffle and disappear.
• Don’t use too small a cuff. The pressure will be 10, 20,
even 50 mmHg too high!
• Maximum Cuff Pressure - When the baseline is known or
hypertension is not suspected, it is acceptable in adults to
inflate to 200 mmHg
• Be aware that there could be an ausculatory gap (a silent
interval between the true systolic and diastolic
pressures).
Blood Pressure Classification in Adults
Hypertension
• Consistent elevation of diastolic B/P above 90
• Affects over 58 million people
o Incidence increases with age
o Almost twice as prevalent in Blacks
o More severe in Blacks
• Two Main types - Primary (Essential) hypertension and
Secondary Hypertension
o Primary accounts for 90% of all Hypertension
o Secondary is from a known cause such as
glomerulonephritis, Cushing’s or renal stenosis
Isolated Systolic Hypertension
• Frequently seen in older adults
• Systolic over 90, with normal diastolic
• While commonly ignored, this condition should be
treated.
• Studies show that lowering the systolic number cuts down
on strokes and heart attacks in people age 60 and over.
Primary Hypertension
• Possible contributing mechanisms:
o heredity
o vascular hypertrophy
o defects in ion handling
o hyperinsulinemia
o renin/angiotensin
Malignant Hypertension
• Severe, rapidly progressive rise in B/P that damages
small arterioles of major organ systems
• Inflammation of the arterioles of the eye is classic finding
• Primarily found in black men under 40
• Unless aggressively treated, is rapidly fatal
Complications of Hypertension
• Atherosclerosis
o Athlerosclerotic vascular occlusion
a) coronary artery disease
b) occlusive cerebrovascular
c) peripheral arterial insufficiency
• aortic dissection
• nephrosclerosis
• hypertensive heart disease with cardiac hypertrophy and
congestive heart failure
• cerebral hemorrhage
Antihypertensive Medications
• Diuretics
o Thiazide/Thiazide-like diuretics; Loop Diuretics;
Potassium Sparing Diuretics
• Adrenergic Inhibitors
o Beta-Blockers; Centrally Acting and Peripherally
acting Alpha Blockers; Combined Alpha-Beta Blockers
• Vasodilators
• ACE Inhibitors
• Calcium Antagonists
Diuretic Treatment
• Potassium Wasting Diuretics
o Thiazide Diuretics - Chlorothiazide (Diuril) and
Hydrochlorothiazide (Hyrodiuril)
o Loop Diuretics: furosemide (Lasix); Bumetanide
(Bumex)
• Monitor Daily weight and I&O - Pt should lose weight if
diuretic is effective
• Most common side effect of diuretics is electrolyte
imbalance. Others - Postural hypotension, GI symptoms,
Sexual dysfunction
• Potassium Sparing Diuretics - Inhibit aldosterone, cause
Na+ to be excreted in exchange for K+
o Spironolactone (Aldactone) - causes gynecomastia
Beta Blockers
• Atenolol (Tenormin); Metoprolol (Lopressor); Propranolol
(Inderal); Nadolol (Corgard)
• Should not be used in patient's with asthma, COPD, CHF
and heart block
• Side Effects - Bronchospasm, Bradycardia, fatigue, sexual
dysfunction, Peripheral vascular insufficiency
Alpha-1 Blockers
• Prazosin (Minipress); Terazosin (Hytrin)
• Reduce peripheral resistance by dilating arterioles and
venules
• Side effects- syncope, orthostatic hypotension, weakness;
palpitations
• Need to avoid standing for long periods of time
• Need to rise slowly to avoid orthostatic hypotension
Centrally Acting Alpha Blockers
• Clonidine (Catapres); Methyldopa (Aldomet)
• Activate central receptors that suppress vasomotor and
cardiac centers. Leads to decrease in peripheral
resistance
• Side Effects - Drowsiness, fatigue, sexual dysfunction,
Orthostatic Hypotension
Vasodilators
• Hydralazine (Apressoline)
• Dilate peripheral blood vessels by directly relaxing
vascular smooth muscle
• Usually used in combination with other meds, because
they lead to sodium and fluid retention and cause reflex
cardiac stimulation
• Side effects - Headache, dizziness, tachycardia, fatigue,
edema
Calcium Antagonists
• Amlodipine besylate (Norvasc); Diltiazem (Cardizem);
Verapamil (Calan, Isoptin) Nifedipine (Procardia)
• Inhibit influx of calcium into muscle cells which acts to
reduce arterial spasms and promote vasodilatation
• Side Effects - dizziness, fatigue, nausea, headache,
edema
Renin-Angiotensin - Aldosterone System
• Renin actives Angiotensinogen which becomes
Angiotensin I and II (with the help of ACE (angiotensin
converting enzyme). Angiotensin II causes
vasoconstriction of blood vessels and stimulates
aldosterone
• Aldosterone leads to increased fluid and sodium retention
• All act to Increase Blood pressure
Angiotensinogen Converting Enzyme (ACE) Inhibitors
• Commonly known as ACE inhibitors
o Captopril (Capoten); Enalapril (Vasotec); Lisinopril
(Zestril)
• Used for: Chronic hypertension, congestive heart failure.
• Side Effects: Cough, diarrhea, headache, loss of taste,
nausea, unusual tiredness.
• Report symptoms of
o dizziness; fainting; skin rash; chest pain.
Prevention of ASHD
• DON’T SMOKE
• Exercise and weight control
o Lowers total cholesterol, LDL's (bad cholesterol) and
the Triglycerides and may raise the good cholesterol
(HDL).
o Eat a low-fat diet and become a semi-vegetarian, eat
red meat/cheese less often
o Eat fish (not shell-fish, not fried) once a week
• Increase your intake of soluble fiber
o Oats, beans, barley, apples, carrots, citrus fruits,
sweet potatoes
• One glass of wine a day - but skip this if you are at risk
for alcohol abuse or cancer
Cholesterol Lowering Medications
• First cholesterol lower meds were bile sequestration
medications - Cholestyramine (Questran) - had lots of
side effects
• Newer and more popular meds fall into two basic
categories:
o Fibrates (including gemfibrozil [Lopid] and clofibrate)
o Statins (such as lovastatin and provastatin).
Bile Sequestrant Drugs
• Cause excretion of bile acids, which makes the liver
manufacturer more bile acids using up more cholesterol.
• Cholestyramine (Questran) and colestipol (Colestid)
o Side effects - abdominal pain, N/V and bloating.
• Naicin (nicotinic acid) limits conversion of lipids to LDL in
the liver and causes increased production of bile acids
o Must be taken in large dosages
o Common Side Effects -hot flashes and itchy, dry skin.
o Severe Side effects - Chemical hepatitis", tendency
toward diabetes, gout with arthritis and kidney
damage.
Fibrates (Fibric Acid Derivatives)
• Gemfibrozil (Lopid) - works by defeating the liver's ability
to make very low density lipoproteins, precursors to LDL,
Also raises good (HDL) cholesterol.
o Abdominal pain, diarrhea, nausea, and vomiting may
occur.
• Clofibrate (Atromid), has higher toxicity which limits its
use.
o Nausea, Flu-like symptoms, Agranulocytosis
Statins (reductase inhibitors)
• Lovastatin (Mevacor), Simvastatin (Zocor), Pravastatin
(Pravachol), Fluvastatin (Lescol)
o Interfere with the liver's ability to make cholesterol.
o Cause abnormal liver function in about two percent
of the patients. Small incidence of muscle
inflammation
o Fewer reports of side effects with Pravastatin
o Take with meals and avoid alcohol
Circulatory Problems
• Chronic circulatory problems lead to the following
changes
o Dry skin
o Dry brittle hair
o Loss of body hair
o Thick brittle nails (particularly toe nails)
o Increased capillary fill times (over 2 seconds)
 o Capillary filling is a indicator of peripheral circulatory
status
Peripheral Vascular Disease (PVD)
• characterized by lack of blood flow and oxygen to tissues
• Usually occurs as a result of accumulated fatty deposits
• Most prevalent in geriatric clients, however, prevention of
PVD needs to start at birth
• Smoking makes PVD worse, by constricting the blood
vessels and increasing the force of flow (increased B/P)
• Can be divided into Arterial and Venous PVD
Assessment of PVD
• Check peripheral pulses - know names and location of
femoral, brachial, radial, popliteal, posterior tibial and
dorsalis pedis
• Check below the site of suspected occlusion
• If can’t palpate a pulse, use a doppler
• Check capillary filling
• Check warmth and color by comparing extremities to
each other
• Arterial PVD Venous PVD -
Arterial vs Venous PVD
• Arterial
• Cool
• pale extremity
• decreased pulses
• sharp pains
• pain increases with activity or elevation
• Dry ulcer formation with necrotic tissue
• Venous
• Warm
• Flushed
• Edematous
• Aching pain
• pain increases when legs dependent
• Weeping venous ulcers
Arterial PVD
• Obstruction or constriction of arterial flow, usually in the
leg
• Intermittent claudication is an early sign of arterial PVD
(pain in calf or leg brought on by exercise and relieved by
rest)
• Later signs are loss of hair on leg and dorsum of foot,
muscle atrophy and arterial ulcers
Thromboangitis Obliterans (Buerger’s Disease)
• Obstructive inflammatory process of the peripheral
arteries
o Mostly male smokers 20-40 years old
o More often in Semitic and Oriental
o Causes Intermittent claudication, numbness and
tingling, thrombophlebitis
o May require amputation of affected digits
Raynaud’s Phenomenon
• Episodes of arterial spasm - usually in hands
• primarily in women 20-40
• Cold, numbness, paleness, and pain in one or more
fingers or toes
• Bilateral effects both hands and/or feet
• Smoking and Cold makes it worse
• Intense redness and throbbing after spasm
• Tx with calcium antagonists, may require amputation
Arterial Embolism
• Blood clots (usual from heart) tend to lodge in bifurcation
of an artery, blocking blood flow
• Symptoms depend on size and location
o Abrupt onset of pain, burning, loss of distal pulses,
cold pale extremity
• Tx with bedrest, and anticoagulants or fibrinolytics
o Surgery - embolectomy or endarterectomy within 6-
10 hours
Intermittent Claudication
• Due to narrowing or blockage of the arteries
(Atherosclerosis or arteriosclerosis Obliterans - peripheral
vascular disease).
• Frequently one of the first signs of cardiovascular disease
• Pain in legs that occurs with exercise. Pain is relieved by
rest.
• May occur in both legs and often continues to worsen
over time.
• Some people complain only of weakness in the legs when
walking or a feeling of "tiredness" in the buttocks.
• Impotence is an occasional complaint in men.
• Pain at rest is uncommon.
Arterial PVD
• Extremity has decreased oxygenation, may be pale, cool
or cyanotic
• Sharp pain, may increase with activity
• Arterial insufficiency ulcers are usually dry, pale, and may
have necrotic tissue
• To treat, need to increase blood flow to extremity
o place foot lower than heart
o Avoid tight bandages and stockings
o Need meticulous foot care to avoid ulcers
Gangrene Secondary to Arterial Occlusive Disease
Medications for Arterial PVD
• Need to dilate peripheral arteries
• Pentoxifylline (Trental) is drug of choice for PVD
• Take Trental with meals
• People who are sensitive to caffeine or theophyllin can’t
take Trental
• Side effects Dizziness, nervousness, agitation
Surgical Treatment of Arterial Peripheral Disease -
Bypass Graft
• Frequently used to treat blockages of larger artery
• Most common - Femoral-Popliteal Bypass Graft
• Post op - Keep leg fairly straight, don’t elevate, monitor
for bleeding, check peripheral pulses and skin
temperature, bedrest, calf-pumps to prevent clot
formation
Venous PVD
• In venous PVD, extremity has too much blood (can’t get
back to the heart)
• Extremity is warm, flushed, edematous
• Aching pain, gets worse with standing
• Need to facilitate blood return
o Elevate legs
o Use teds or ace wraps
• Venous stasis ulcers tend to be pink or red and produce
lots of drainage
Vericose Veins
• Venous defect allows pooling, particularly in peripheral
veins with little support
• Tend to run in families
• Peripheral veins can be removed (stripped)
• Post op, elevate legs when sitting. Avoid long periods of
standing. Keep elastic bandages tight and wrinkle free,
monitor for bleeding, check pedal pulses and edema
Deep Vein Thrombophlebitis (DVT)
• Slowed blood flow allows a clot to form.
• May have altered clotting mechanisms
• Patients on bedrest have higher risk of DVT
• People who wear tight knee socks or have pillows under
knee (compresses popliteal) have increased risk of DVT
• To prevent DVT while on bedrest - do calf pumps
(dorsiflex and extend feet frequently)
• S/S of DVT - warm, red, edematous leg
• May have positive Homan’s sign
• DVT can be silent, may be life threatening, and can lead
to embolism
Treatment of DVT
• Bedrest may be needed during acute phase
• Avoid standing still and sitting
• Check pulse distal to site of thrombosis
• Assess edema, measure calf circumference
• Don’t massage leg
• Elevate leg on pillows, use warm moist heat
• Ted hose or other compression
• Watch for signs of pulmonary embolism
• NSAIDs for pain and inflammation
Anticoagulant Therapy
• Heparin
o Give heparin with smallest needle possible in SUB-Q
tissue of abdomen. Don’t aspirate, don’t massage.
Avoid 1 inch area around umbilicus
 o Monitor PTT time
o With all anticoagulants, hematest stools for blood
• For long term treatment - Warfarin (Coumadin) orally
o Monitor PT time (coumadin interferes with
Prothrombin formation) Watch for bruising
Surgical Treatment of DVT
• Large clots can be surgically removed
• For patient with high risk of repeated DVT, a Greenfield
vena cava filter can be used
• Filter catches clots before they can migrate to the lungs,
heart or brain
• Used in conjuction with heparin or coumadin therapy
Duplex Ultrasound/Ultrasonography
• Examines the blood flow in the major arteries and veins in
the arms and legs with the use of ultrasound and
ultrasonography, which provides a visual image.
• Done in the ultrasound or radiology department.
• Veins: A water-soluble gel is placed on the transducer and
placed over vein
• Arteries: Blood pressure cuffs will be put around the
thigh, calf, and ankle to examine the legs.
Ateriogram/Venogram
• Injection of radiopaque dye into the femoral artery or vein
to determine where and how severe obstructions are
• Determine if patient has previous allergies, particularly to
procedure dyes, iodine, shellfish or strawberries
• After procedure, keep leg straight, apply pressure
dressing to site. Watch site for bleeding. Monitor pulses
distal to site.
Coronary Artery Disease (CAD)
• Coronary arteries narrowed or completely blocked by
fatty plaques (atherosclerosis).
• inadequate blood supply to the heart muscle supplied by
that artery.
• Often results in death of the involved area
• of heart muscle. This is called a myocardial infarction
("MI") or heart attack.
Myocardial Ischemia
• Myocardial Ischemia - less severe reduction in blood
supply where the heart muscle receives just enough
blood to stay alive.
• Either ischemia (poor blood supply) or infarction (virtually
no blood supply) can cause cardiac symptoms such as
chest pain or shortness of breath.
• Angina is the name given to chest, neck, jaw, back,
shoulder or arm pain caused by heart muscle that is
ischemic (not receiving enough blood supply).
Angina Pectoris
• Sharp, diffuse chest pain in response to insufficient
oxygen to cardiac muscle
• Brought on by exertion, cold, stress, over-eating
• Usually relieved by rest
• Caused by insufficient blood flow through the coronary
arteries, which leads to decreased oxygenation of cardiac
tissue
• Deoxygenation of tissue leads to build up of lactic acid,
and if continued, leads to ischemia
• Goal is to control Angina so patient can do ADL’s without
chest pain
Diagnostic Tests
• 12 Lead EKG or ECG
o records electrical conduction of heart
o Gives information about excitation of the
myocardium
o Useful for detecting arrhymias
o Can detect evidence of MI
o Telemetry - Three lead EKG used to monitor cardiac
patients in bed
• Holter monitor
o Similar to telemetry, but records results for 24 hours.
Can be used on outpatient basis, to detect
arrthymia's which occur as a result of something the
person does at home
Stress Test
• A number of stress tests are used, but the most common
is the exercise stress test
• Provides evaluation of how the heart functions during
exercise/stress
• Patient with suspected exercised induced arrhythmia or
chest pain is attached to a telemetry unit
• Patient is placed on a treadmill and walks uphill until
chest pain/arrhythmia's are reproduced or maximal
desired cardiac output is reached (calculated for each
person)
• Monitored by EKG the entire time
• Heart rate and B/P go up and lead to increased cardiac
output without pain in healthy individual
Lab values
• Triglycerides - overall fat content of serum
• Cholesterol - overall cholesterol level - Goal is to keep it
at or below 200
o HDL High density lipoproteins - “good” cholesterol,
may act to protect blood vessels from damage
o LDL Low density lipoprotein “bad” cholesterol, acts
as a “glue” to clog vessels
Nitroglycerin - Drug of Choice for Angina
• Relaxes the smooth muscle tissue of the vascular system
• Acts to dilate coronary arteries
• Increases blood flow to cardiac tissue
• Increases oxygenation of cardiac muscle
• Common Side Effects
o headache, hypotension, dizziness
Application of Nitroglycerin
• Sublingual - for acute chest pain. May take one tab under
tongue every 5 minutes until pain is relieved (up to 3
tabs). If not relieved, call MD
• Patches (Nitropatch/Nitrodur) - Remove old patch, apply
new one to any clean, intact, non-hairy part of the body
• Paste - apply the correct amount of paste to the
manufactures paper, then apply paper “patch” to
patient’s skin as above
Other Meds to treat Angina
• Calcium Channel Blockers
o Nifedipine (Procardia) - dilates both coronary arteries and
peripheral arterioles (decreases B/P)
o Can be swallowed whole, or puncture capsule with a
needle and give contents sub-lingual
o Take Calcium Channel Blockers on empty stomach
• Beta Blockers
o Atenolol (Tenormin) and Nadolol (Corgard) Acts to
suppress renin-angiotensin-aldosterone system
o Take Beta-blockers with food
• Dipyridamole (Persantine) - selectively dilates coronary
arteries (does not affect B/P)
Echocardiogram
• Echocardiogram
o Ultrasound of heart
o can view structures and movement
o Similar to fetal ultrasounds, painless, need to use
transducer gel
o No real patient prep needed
Transesophageal Echocardiography
• Uses probe to pass ultrasound transducer into the
esophagus
• more detail is possible
• Keep pt NPO 4 hours before. Topical spray or gargle to
depress gag reflex. Conscious sedation may be used.
• Keep pt NPO afterwards till gag reflex returns
Coronary Angiograms /Veinograms
• Coronary Angiography
o injection of radiopaque dye into the right and left
coronary arteries
o Helps to confirm the presence and /or degree of
coronary artery stenosis, and to determine the
amount of collateral circulation available
• Ventriculography
o injection of dye into left ventricle to visualize
ventricular wall, mitral valve and ventricular septum
function
Cardiac Catheterization
• Insertion of catheter directly into the right and/or left
ventricle to get info about ventricular function
• Gives most valuable and detailed information about
structure and function of heart
o Patency of coronary arteries
o Condition of myocardium
o Status of collateral circulation
• Relatively high risk compared to other cardiac tests
Patient Preparation
• Explain expected sensations - flushing, nausea, warmth
when dye injected
• May have chest pain or dyspnea when catheter is in heart
• Risks are hemorrhage, MI, CVA, dysrhythmia and even
death (most risk is from cardiac cath)
• Pt is NPO 4 hours before, procedure lasts 1-3 hours, lying
on x-ray table in cold room
• Post Cath, Pressure dressing to site, monitor for bleeding,
Check peripheral pulses below site
PTCA Percutaneous Transluminal Coronary Angioplasty
• In PTCA, a catheter carrying a small balloon is inserted
into coronary heart arteries through the patient's skin.
• The balloon is then repeatedly inflated and deflated to
compress the blockage that obstructs blood flow to the
heart.
Post-Procedure Care
• Always assess for adequate peripheral circulation below
the site of arterial access
• Assess site for bleeding, a pressure dressing will be in
place for at least 8 hours.
• Keep affected extremity straight and still
• Elevate HOB no more than 90 degrees
• Push fluids to get rid of dye (nephrotoxic)
• Assess heart rate and B/P
• Monitor I&O for 24 hours
Myocardial Infarction (MI)
• Usually caused by the sudden occlusion of a coronary
artery.
• The plaque in the artery takes years or decades to form,
but the final event of formation of a blood clot (or
thrombus) happens in a few minutes or hours.
• In general MIs occur at any time, although they are a bit
more common in the morning
Symptoms of MI
• Classical symptoms of a heart attack include heavy or
crushing chest pain, shortness of breath (dyspnea) and
sweating (diaphoresis).
• Less common are nausea, profound fatigue and a feeling
of impending doom.
• If you become short of breath and break out in a cold
sweat while sitting in a cool room you should be more
concerned than if these symptoms happen while walking
up a steep hill in July.
• Many heart attacks come without classical symptoms or
even without any symptoms at all (silent MI).
• Ischemic myocardium is electrically unstable
o arrhythmia's including lethal ventricular ventricular
fibrillation and ventricular tachycardia.
o Infarcts which interfere with the cardiac conduction
system may lead to heart block or conduction
defects.
• Dead or scarred myocardium is unable to contract.
• Damage may be reversible if thrombolytic therapy is in
time.
• Leads to congestive heart failure in about 40-50% of
patients with acute MI.
• In extreme cases, patients may present with cardiogenic
shock
Cardiac Isoenzymes
• Creatinine Kinase (CK)
o Normals < 2.5U F, < 4.3U Male
o Elevations indicate possible brain, heart, or muscle
injury or necrosis
• CK-MB (0-5% of total CK)
o Elevations with myocardial injury
• Lactic Dehydrogenase (LDH)
o LDH1/LDH2 LDH 1 higher than LDH2 with myocardial
damage
o Most sensitive cardiac enzyme indicator of MI
Nuclear Imaging
• Uses radioactive tracer substances
• Thallium imaging
o Dye is injected into patient’s antecubital vein.
o Imaging done 4-10 minutes after injection
o Necrotic or ischemic tissue will appear as “cold
spots” on this scan
o Often done with the patient at rest and then during
an exercise test
Coronary Artery Bypass Graft (CABG)
• CABG to relieve blockages of the coronary arteries
• Open Chest and long incision along the inside of the lower
leg.
• The leg vein is sewn in above and below the blockage in
the coronary
• Heart-lung bypass machine is used to re-route the blood
from the heart while the surgery is being done
Indications for CABG
• Unsuccessful Angioplasty
• Blockage of the left main coronary artery
• > 50% diameter stenosis
• Concomitant valve damage and any coronary artery
disease
• Unstable Angina and/or ischemia that cannot be treated
with PTCA
• Three-vessel disease of the coronary arteries regardless
of angina or ischemia
CHF
• Right Sided Failure - Complication of COPD
o Pitting peripheral Edema
o Liver enlargement and right upper quadrant pain
o Ascities
o Distended neck veins (JVD)
• Left Sided Failure - Complication of Hypertension
o Dyspnea - early sign
o Cough
o Orthopnea
o S 3 heart sound
o Paroxysmal nocturnal dyspnea (PND)
o Fatigue
o Crackles in lungs - starts at bases and works upward
Congestive Heart Failure (CHF)
• Most common hospital discharge diagnosis in persons
over age 65.
• The National Heart, Lung and Blood Institute estimates
two million Americans are afflicted with CHF and 400,000
new cases of CHF are diagnosed every year.
CHF
• CHF usually starts with L sided failure, S/S of pulmonary
congestion and pulmonary edema
• Chronic CHF leads to ventricular dilation, hypertrophy and
tachycardia
• Heart becomes enlarged and weaker
• PMI may be located at 6th intercostal space and lateral to
the MCL
• Clubbing of fingers from chronic hypoxia
Treatment of CHF
• Need to decrease fluid volume and reduce cardiac
workload
o Bedrest or reduced activity to conserve energy
o Oxygen if hypoxia is present
o Assist to cough up secretions q 2 hours
o Elevate HOB, Do not raise feet, even if edematous
o Diuretics
o Digitalis
o Fluid restrictions
o Daily weight
o I&O
o CHF Diet
CHF Diet -Low Cholesterol, Low Sodium, Low Fat Diet, -
To Return B/P to Normal
• Avoid the following foods
• Red meats, Cheese (except cottage cheese and other low
fat), Egg yolks, Shellfish (too much cholesterol)
• Cold cuts, ham, bacon, sausage, hot-dogs, chips, (sodium
and fat)
• Most soups, sodas, and canned vegetables (sodium)
• Antacids and other meds high in sodium
Alternatives
• Use lite salt (K+Cl)
• Use salt alternatives - Mrs. Dash and others
• Bake and season meats with vinegar or lemon juice
instead of butter and salt
• Use egg beaters, low sodium soups, saltless pretzels and
low sodium crackers.
• Try a baked sweet potato with a little brown sugar
• Read all labels
Low Calorie
• Watch for “Hidden” calories in drinks (milk, juice, alcohol,
soda)
• Watch the fat, sodium content and calorie content in
frozen dinners, mixes, and canned items
• Avoid High carbohydrate foods (breads, pastas, cakes)
• Avoid most fast foods
• Read the labels. Check out nutritional content
Digoxin (Lanoxin) - Cardiac Glycoside
• Cardiac Glycosides act to stimulate myocardial
contraction
• Makes heart beat slower, more regular, and more
powerful, which leads to increased cardiac output and
increased blood flow to the kidneys
• Can be given PO or IV
• Take Apical pulse for a full minute before administration,
noting rate and rhythm.
• If rate is below 60, above 110, or If rhythm is very
irregular (compared to patient’s baseline, hold med and
call MD
• Dig has a narrow therapeutic window -Watch serum
levels (0.8-2.0 ng/ml)
• Don’t take with antacids - interfere with absorption
• Persons with hypokalemia are more likely to become
digtoxic so patient needs to eat foods high in potassium
(know what these are)
• Patients on Lasix and Dig - watch for toxicity
• Antibiotics and/or calcium channel blockers can interact
with Digoxin causing increased risk for toxicity
• Digitalization - when first starting on Dig, given higher
dose - called a loading dose or a digitizing dose
• After patient responds, dose is lowered to a Maintenance
dose
• Maintenance dose is one which allows heart to function
without toxic symptoms
Signs and Symptoms of Digitalis Toxicity (serum levels
above 2.0 ng/ml)
• Cardiovascular
o Bradycardia or Tachycardia
o Bigeminy
o Ectopic beats
o Pulse deficit
• GI Effects*
o N/V
o Anorexia
o Diarrhea
o Abdominal Pain
• Neurological Effects
o Headache
o * Blurred, double or colored vision
o Confusion, irritability, restlessness, drowsiness
o Muscle weakness and cramps
• Kidney Failure, Liver Failure, Potassium Loss or Dig
Overdose can all cause Dig Toxicity
Rotating Tourniquets
• old technique used to decrease venous return to the
heart by trapping fluid in extremities
• temporarily reduces heart workload by reducing fluid
volume heart must pump around body
• B/P cuffs are used on three extremities at a time, and are
rotated every 15 minutes in a clockwise fashion.
(Rotating tourniquet machine does this automatically)
• Make sure patient has a peripheral pulse in affected
areas