ALTERATIONS

IN
Cardiac
Performance
 Coronary artery disease
(CAD)
• is a condition in which the blood supply to the
heart muscles is completely or partially
blocked.
• Is a narrowing or obstruction of one or
more coronary arteries as a result of
atherosclerosis
Causes:
1. Decreased blood 3. Increased demand for
supply blood
– Atherosclerosis
– Vasospasm – Hyperthyroidism
– Thrombus, embolus – Hyperthermia
2. Decreased oxygen in – Stress
blood
– Anemia
– Carbon monoxide
Nonmodifiable risk factors:
a. age
b. sex
c. race
d. genetics
2. Modifiable risk factors:
• Hypertension
• Hyperlipidemia
• Diabetes Mellitus
• Smoking
– elevated levels of Homocysteine
– Stress
– Sedentary life style
– obesity
CORONARY ARTERY DISEASE
Narrowing of the artery

Decreases myocardial perfusion

Ischemia and anaerobic metabolism
Classic Sign of CAD
ANGINA PECTORIS
Transient chest pain caused
by insufficient blood flow to
the myocardium resulting in
myocardial ischemia.
ANGINA PECTORIS
•Precipitating Events
– Exertion
– Emotional stress
– Eating
– Extremes of
temperature
– Sexual activity
ANGINA PECTORIS
TYPE DESCRIPTION
predictable and consistent pain that occurs on
Stable angina
exertion and is relieved by rest
Unstable angina
symptoms occur more frequently and last longer than
(preinfarction or
stable angina
crescendo)
Intractable or
Chronic, severe incapacitating chest pain
refractory angina
Variant angina
pain at rest; thought to be caused by coronary artery
(Prinzmetal’s
vasospasm
angina)
objective evidence of ischemia (such as
Silent ischemia electrocardiographic changes with a stress test), but
patient reports no symptoms
 Signs and Symptoms
• Chest Pain relieved by rest or
with the use of nitroglycerin
• An episode usually lasts less than
20 min
• Pain may spread to the left arm,
neck, back, throat, or jaw.
• shortness of breath; diaphoresis,
light-headedness, nausea and
vomiting.
DIAGNOSTICS:
• ECG - ST depression and T wave
inversion only during acute attacks
• C reactive protein
• CORONARY ANGIOGRAPHY –
provides the most accurate
information about the patency of the
coronary arteries
 MEDICAL MANAGEMENT
• Control of risk factor
• GOAL • Oxygen therapy
– To decrease the
oxygen demand
• Pharmacologic therapy
of the Nitroglycerin
myocardium and Beta-adrenergic
to increase
blocking agent
oxygen supply
Calcium channel
blockers
Antiplatelet
MYOCARDIAL INFARCTION
 MYOCARDIAL INFARCTION
o The formation of localized necrotic areas
within the myocardium.
o Usually follows sudden coronary
occlusion and the abrupt cessation of blood
and oxygen flow to the heart muscle.
severe ischemia
(> 20 - 40 minutes)

IRREVERSIBLE cellular damage

and necrosis of the myocardium.
 CLASSIFICATION OF MYOCARDIAL
INFARCTION

Classifications:
• TRANSMURAL INFARCT
-from endocardium to
epicardium
• SUBENDOCARDIAL
INFARCT
- affects myocardium and
endocardium
• INTRAMURAL INFARCT
- patchy area of the
myocardium with longstanding
angina pectoris
 SIGNS &
yspnea SYMPTOMS

nxiety
Ausea & vomiting
Hest pain
Levation in temp.
AIN/PalLor
rrythmia
Cute pulmonary edema

iaphoresis

hock
 Diagnostic Tests

⚫ECG
ECG Changes in MI
Cardiac Enzymes
 Cardiac Enzymes

CK-MB
⚫ Cardiac specific isoenzyme
⚫ Accurate indicator of myocardial damage
⚫ Elevated 4 hrs after
⚫ NV:
⚫ M- 50-325 mu/ml
⚫ F- 50-250 mu/ml
 Cardiac Enzymes
Myoglobin
⚫ Earliest enzyme to increase
⚫ Elevated 1-3 hrs after

Troponin
⚫ Protein found in the myocardium, regulates
the myocardial contractile process
⚫ Elevated 3-4 hrs after; duration is 3 weeks
 Cardiac Enzymes

Aspartate Aminotransferase (AST)

⚫ Elevated level indicates tissue necrosis
⚫ Elavated 4-6 hrs after

Lactic Dehydrogenase (LDH)

 MEDICAL MANAGEMENT
I V access/regulation
N arcotic analgesics (morphine)
P osition in Semi fowlers
A spirin/ Anticoagulant (heparin, warfarin)
R est / relieve anxiety (diazepam)
C onverting enzyme inhibitor (ACE inhibitor – captopril)
calcium channel blocker (nifedipine, verapamil)
T hrombolytics (streptokinase, urokinase & TPA)
I V beta blocker (propranolol, metoprolol, atenolol)
O xygen
N itrates (nitroglycerin)
S tool Softeners
SURGICAL
MANAGEMENT
 1. PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY

• Mechanical dilatation of the coronary vessel

wall by compressing the atheromatous
plaque
INTRAVASCULAR
STENTING • Maintains good
luminal
geometry after
balloon
deflation &
withdrawal
• Done to prevent
restenosis after
PTCA
• Risk of
thrombus
formation
2. ATHERECTOMY
• Invasive procedure that involves the
removal of the atheroma, or plaque,
from a coronary artery

3. TRANSMYOCARDIAL LASER
REVASCULARIZATION
4. CORONARY ARTERY BYPASS
GRAFT (CABG)

• Main purpose is
myocardial
revascularization
• Commonly used
grafts:
– Saphenous vein
– Internal
mammary artery
Cardiac Rehabilitation
• A process in which a
person is restored to
health & maintains
optimal functioning.
• Goals:
– To live as full, vital &
productive life
– Remain within the
limits of the heart’s
ability to respond to
activity & stress
Teaching & Counseling
• Discontinue smoking
• Continued medical supervision
• Diet modification
• Weight reduction
• Progressive exercise
• Stress management
• Resume sexual activity – after 4-6 weeks
 TEACHING GUIDE IN RESUMPTION OF
SEXUAL ACITVITY
• CLUE: able to climb two flights of stairs without
dyspnea , chest pain and other abnormalities
• Assume less fatiguing position ( non MI partner on
top)
• If both are MI patients: side lying
• Perform activity in a cool, familiar environment, early
in the morning
• Take nitroglycerine before sexual act
• Refrain from sexual activity during a fatiguing day,
after eating a large meal
• If any abnormalities occur, stop activity
COMPLICATIONS
A rrhythmias
A neurysm
C ardiogenic shock
C ardiac tamponade
C ongestive heart failure
D ressler’s syndrome
E mbolism
 CLASSIFICATION
Killip class I
- no clinical signs of heart failure
Killip class II
- with rales or crackles in the lungs, an S3
sound, and jugular vein distention
Killip class III
- with acute pulmonary edema
Killip class IV
- cardiogenic shock or hypotension &
evidence of peripheral vasoconstriction
INFECTIOUS
DISORDERS
of the
HEART
RHEUMATIC FEVER
• Inflammatory autoimmune
disease that affects the
connective tissues of the heart,
joints, subcutaneous tissues,
blood vessels of the CNS
– Complication: RHD
• `Agent: GABHS
RISK FACTORS:
• Age: 5-15 years old
• Crowding & poor hygiene
• Poor nutrition
• History of GAS infection
• Genetics
STAGES
1. Acute stage
- History of strep infection
- Subsequent involvement of
connective tissues
• Aschoff bodies (a localized area of
tissue necrosis surrounded by immune
cells)
2. Recurrent stage
- Extension of the cardiac effects of the
disease
3. Chronic stage
- Permanent deformity of the
heart valves
mitral valve stenosis
 PATHOPHYSIOLOGY
Inflammatory changes in the
connective tissues

Valvular structure becomes red swollen; small

vegetative lesions on the valve leaflets

Fibrous scar tissue

Contraction of the Shortening of the

valve leaflets chordae tendinae

Fusion of the valve leaflets

JONES CRITERIA

1.Presence of 2 major signs

2.Presence of 1 major + 2
minor
3. Evidence of GABHS
infection.
MAJOR MANIFESTATIONS:
J oints (Polyarthritis)
- painful & migratory, affects larger joints
Carditis
- heart murmurs, cardiomegaly, CHF, pericarditis
N odes (Subcutaneous Nodules)
- hard, painless nodules in the knees, wrist &
elbows
E rythema marginatum
- maplike, macular lesions on the trunk
S ydenham/Chorea or St. Vitus dance
- CNS disorder; irregular, aimless, involuntary
movement
MINOR MANIFESTATIONS:
I ncreased WBC
T emperature elevated (Fever)
E levated ESR / C – reactive protein
R aised or prolonged PR interval
I tself (previous history of rheumatic
fever
A rthralgia
DIAGNOSTIC TEST:
• (+) throat culture
• ASO titer (>250 todd in adult; >333
todd in children
• Elevated streptococcal antibody titer
• Elevated WBC, ESR, C-reactive
protein
• 2D-echo
• Jones Criteria
MANAGEMENT:
– ↓ demand from weakened heart
• CBR
• Cluster care
• Modify lifestyle post discharge
– Prevent further cardiac damage
• Penicillin IM once a month x 3-5 yrs
• Steroids
– Safety precautions for chorea
– Joint pain management
VALVULAR
HEART
DISEASES
 Types of Valvular Disease
• Stenosis
– The valve leaflets become
thickened with scar tissue
and become stenotic.
– These valves cannot open
fully, causing obstruction
of blood flow.
• Regurgitation
– Caused by scarring and
retraction of the leaflets
– Allows blood to move back
through the valve when it
should be closed.
Stenotic
valvular defect
• difficulty in
emptying itself
through the
narrow orifice ;
therefore, it
dilates and
hypertrophies.
Regurgitant valves

permit backflow of
blood

increased work
demands
on the chamber
ejecting to maintain
adequate output
 Disorders

• Mitral Stenosis
• Mitral Regurgitation
• Aortic Regurgitation
• Aortic Stenosis
Aortic valve stenosis Mitral regurgitation

Mitral valve stenosis Aortic regurgitation

CAUSES
Congenital defects
Trauma
Ischemic heart disease

Inflammation - Rheumatic endocarditis is a

common cause
Diagnosis
Cardiac auscultation - murmur
Transesophageal Echocardiography (TEE)
create an image of the internal
structures of the heart
Cardiac catheterization
• Assessment:

– Murmurs
– Fatigue, weakness
– Dyspnea, cough, orthopnea, nocturnal dyspnea
– Palpitations, chest pain, dizziness
– Jugular vein distention
– Corrigan’s pulse,

A pulse that is forceful and then suddenly

collapses. It is usually found in patients with aortic
regurgitation,

caused by the large stroke volume and rapid run off of

blood back into the left ventricle.
Management:
– Prophylactic antibiotic therapy
– Digitalis
– Diuretics
– Antidysrhythmics
– Vasodilators
– Anticoagulant
– Low-sodium diet
•Management:
• Percutaneous balloon
valvuloplasty
• a balloon-tipped
catheter is inserted,
causing a cracking
of the calcified
commissures and
enlargement of the
valve orifice.
• Surgical
– Valvuloplasty
• Closed commissurotomy
• Open commissurotomy

is the procedure
performed to separate
the fused leaflets
commissurotomy
Annuloplasty
repair of the valve annulus; is
useful for the treatment of valvular
regurgitation.

two annuloplasty techniques

1. uses an annuloplasty ring
2. tacking the valve leaflets to the atrium with sutures to
tighten the annulus
A
Annuplasty ring
Chordoplasty
repair of the chordae tendineae
 Valve replacement
Mechanical Tissue or
prosthetics BiologicValves
• They are durable • Xenografts,
• Thromboembolism Homografts,
• Anticoagulant Autografts
therapy • Long-term
anticogulant
therapy may not
be indicated