Cardiovascular Diseases

The cardiovascular system is composed of the heart, blood, and vascular system.

The cardiovascular system distributes food, oxygen, and hormones to all living cells and carries waste products and carbon dioxide away from the cells.

Types of heart diseases

Congenital Acquired

Coronary artery disease (CAD)

Conductionproblem

Valvular heart disease

Infective heart disease

Coronary artery disease (CAD)

Coronary artery disease (CAD) also known as atherosclerotic heart disease, coronary heart disease, or ischemic heart disease (IHD), is the most common type of heart disease and cause of heart attacks.

The disease is caused by plaque building up along the inner walls of the arteries of the heart, which narrows the arteries and reduces blood flow to the heart.

Risk Factors of MI

Non-modifiable: Modifiable:

Modifiable:Hypercholestorolemia

Habitual diet

Hypertension

Smoking

Obesity

Oral contraceptives

Diabetes mellitus

life style

Psychosocial tension

Lack of exercise

Dyslipidemia Hypertension Smoking Physical inactivity0

100

200

300

400

500N

o. o

f p

ati

en

ts

Risk factors

Annual incidence of CAD in relation to number of risk factors present

HypercholesterolemiaLipoproteins

HDL (“good”) LDL (“bad”)

Protective action on heart Ill effect on heart

Assist in utilization of total cholesterol

Transport LDL to liver

Biodegraded & excreted

Accelerate the process of atherosclerosis                                       

Saturated fat

Habitual diet

High in LDL

Animal fat Increases the synthesis of Cholesterol & triglyceride

Unsaturated fat High in HDL

Hypertension

Increases the risk of heart attack, stroke, kidney failure and congestive heart failure.

Increases the heart's workload

Causing the heart to enlarge and weaken overtime

SmokingCO Hb +

COHbO2 O2 supply to heart

is limited

Increases workload of heart

Nicotine

HDL

LDL

Catacholamine

Platelet adhesion Higher chance thrombus formation

Obesity

Increases strain on heartRaises BP Raises cholesterol

Sedentary living patternFavorable effects of physical activity

HDL valuesReduction of weightIncreased functional capacity of heartDecreased myocardial O2

demandDecreased platelet adhesiveness Electrical stability of myocardium

ETIOLOGYCause of coronary artery narrowing are:

AtherosclerosisThrombosisSpasmCoronary dissectionAneurysm formation

1. The main Cause of coronary artery disease is:a. Atherosclerosisb. Thrombosisc. Spasmd. Coronary dissection

2. Saturated fat are increases risk for heart disease because its:-a) High in LDLb) High in HDLc) Have both LDH and HDLd) Non of the above

3. Non-modifiable risk factors for coronary artery disease are:-a)Dietb)Family historyc)Exercised)stress

4. modifiable risk factors for coronary artery disease are:-a)Ageb)Racec)Genderd)obesity

5. HDL (“good”) is good for the hear because:-a) Protective action on heartb) Assist in utilization of total cholesterolc) Transport LDL to liverd) All of the above

CORONARY ATHEROSCLEROSISAtherosclerosis is an

abnormal accumulation of lipid, or fatty, substances and fibrous tissue in the vessel wall. These substances create blockages or narrow the vessel in a way that reduces blood flow to the myocardium.

PathophysiologyProgression of Atherosclerosis:

1.Fatty streak:• Atherosclerosis begins as fatty

streaks, lipids are deposited in the intima of the arterial wall

• The reason why some fatty streaks continue to develop is unknown, although genetic and environmental factors are involved.

• No obstruction23

2.Fibrous plaque: Plaque and thrombus formation

• Ruptured plaque or The continued development of atherosclerosis involves an inflammatory response

• T lymphocytes and monocytes (that become macrophages) infiltrate the area to ingest the lipids

• this causes smooth muscle cells within the vessel to proliferate and form a fibrous cap over the dead fatty core. These deposits, called atheromas or plaques, protrude into the lumen of the vessel, narrowing it and obstructing blood flow

3. COMPLICATE LESION: TOTAL OCCLUSION

• The thrombus may obstruct blood flow, leading to sudden cardiac death or an acute myocardial infarction (MI), which is the death of heart tissue.

CLINICAL MANIFESTATIONS

•The most common manifestation of myocardial ischemia is acute onset of chest pain. However, an epidemiologic study showed that nearly 15% of men and women who had MIs were totally asymptomatic (Kannel, 1986).•coronary arteries, which are responsible for bringing oxygenated blood to the heart, can produce symptoms such as•Shortness of breath•Sweating, nausea•Dizziness or light-headedness•Breathlessness or palpitations•Arrhythmias

Carotid arteries supply blood to the brain and neck. Marked narrowing of the carotid arteries can present with symptoms such as a feeling of weakness, not being able to think straight, difficulty speaking, becoming dizzy and difficulty in walking or standing up straight, blurred vision, numbness of the face, severe headache and losing consciousness. Peripheral arteries, which supply blood to the legs, arms, and pelvis, also experience marked narrowing due to plaque rupture and clots. Symptoms for the marked narrowing are numbness within the arms or legs, as well as pain.

Diagnosis HISTORY TAKING AND PHYSICAL EXAMINATION BLOOD TEST:-  HOMOCYSTEINE, CRP, LIPDPROFILE,

SUGAR ECG CHEST X-RAY DOPPLER ULTRASOUND OF RIGHT INTERNAL

CAROTID  STRESS TEST ECHOCARDIOGRAM. CARDIAC CATHETERIZATION CT SCAN HEART MYOCARDIAL BIOPSY HEART MRI

Angiography – Examination of the blood vessels using x-rays following the injection of a radiopaque substance.

As these plaques grow, they tend to occlude the artery producing a “visible” area of stenosis within the arterial lumen. Therefore, they are typically detected by cardiac stress tests or an angiogram.

Cardiac stress test

Angiogram

Area of Stenosis

Treatment for Atherosclerosis

Lifestyle Changes- The changes will focus on weight management, physical activity and a healthy diet.

Medication  (anteplatelets), Other medications such as statins may be prescribed to lower cholesterol, and Angiotensin-converting enzyme (ACE) inhibitors to lower blood pressure. 

Surgery - Severe cases of atherosclerosis may be treated by surgical procedures, such as angioplasty , Stents or coronary artery bypass grafting (CABG).

First, angiography provides an angiogram which allows the area of stenosis to be located.

Angioplasty – a surgical technique for restoring normal blood flow through an artery narrowed or blocked by atherosclerosis, either by inserting a balloon into the narrowed section and inflating it or by stent

The two most common surgical procedures used today are balloon angioplasty, often accompanied by stent placement, or coronary artery bypass.

BALLOON ANGIOPLASTY CORONARY ARTERY BYPASS

• A narrow balloon is inserted in the coronary artery

• The balloon is inflated to press the plaque against the arterial wall

• A stent can be inserted to hold the vessel open

• This opens the lumen and allows better blood supply

Angioplasty with Stent

Before and after angioplasty

Coronary Artery Bypass Graft – open-heart surgery in which the rib cage is opened and a section of a blood vessel is grafted from the aorta to the coronary artery to bypass the blocked section of the coronary artery and improve the blood supply to the heart

PreventionThe best way to prevent atherosclerosis is to eliminate any risk factors you might have. The best way to do this is by living a healthy lifestyle. Diet:-Controlling cholesterol abnormalitiesExerciseSmoking:-Promoting cessation of tobacco useManaging hypertensionControlling diabetes mellitus

COMPLICATION• Coronary artery disease: Stable plaques in the heart's

arteries cause angina (chest pain on exertion). Sudden plaque rupture and clotting causes heart muscle to die. This is a heart attack, or myocardial infarction.

• Cerebrovascular disease: Ruptured plaques in the brain's arteries causes strokes with the potential for permanent brain damage. Temporary blockages in an artery can also cause transient ischemic attacks (TIAs).

• Peripheral artery disease: Narrowing in the arteries of the legs caused by plaque causes poor circulation. This causes pain on walking and poor wound healing. Severe disease may lead to amputations.

• Aneurysms

Angina pectoris

Definition:Angina: Choking or suffocation.Pectoris: Chest.

Angina pectoris, is the medical term used to describe acute chest pain or discomfort.Angina occurs when the heart’s need for oxygen increases beyond the level of oxygen available from the blood nourishing the heart.

Angina is temporary chest discomfort or pain caused by coronary artery disease. It is caused by a partial blockage in the coronary artery(s). Angina is the heart’s way of telling you that there is not enough blood and oxygen supply to the heart. The usual symptom of angina is discomfort/pain (ache, pressure, heaviness, tightness, burning feeling, numbness) in the chest or the neck, jaw, arms, or back.

• Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest. The cause is usually insufficient coronary blood flow.

• Constricting chest pain, often radiating to the left shoulder and down the left arm, caused by an insufficient supply of blood to the heart. Coronary artery disease is a common cause of angina pectoris.

Types of Angina Stable angina:

People with stable angina have episodes of chest discomfort that are usually predictable. 

It triggered by: activity eating a very large meal emotional stress exposure to extreme hot or cold weather.

Normally the chest discomfort is relieved with rest, nitroglycerin (GTN) or both. Occurs in a regular pattern, usually lasts 5 minutes or less, and is easily relieved by medications

It has a stable pattern of onset, duration and intensity of symptoms.

UnstableMay be new onset of pain with exertion or at rest, or recent acceleration in severity of painOccurs in no regular pattern, usually lasts longer (30 min-), not generally relieved with rest or medicationsSometimes grouped with myocardial infarction (MI) under the diagnosis of acute coronary syndrome (ACS)

Silent ischemia: objective evidence of ischemia (such aselectrocardiographic changes with a stress test), but patient reports no symptoms

Variant Angina (Prinzmetal’s or resting angina) :

• occur spontaneously with no relationship to activity. Occurs at rest due to spasm.

• Appears to by cyclic & often occurs at about the same time each day (usually at night). Thought to be caused by coronary artery spasm

• Electrocardiogram (ECG) changes due to coronary artery spasm

SIGNS AND SYMPTOMS Retrosternal chest discomfort (pressure, heaviness,

squeezing, burning, or choking sensation) as opposed to frank pain

Pain localized primarily in the epigastrium, back, may radiate to the neck, jaw, shoulders, and inner aspects of the upper arms, usually the left arm

Pain precipitated by exertion, eating, exposure to cold, or emotional stress, lasting for about 1-5 minutes and relieved by rest or nitroglycerin

A feeling of weakness or numbness in the arms, wrists, and hands may accompany the pain, as may shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, and nausea and vomiting.

DIAGNOSTIC EVALUATION

HISTORY TAKING AND PHYSICAL EXAMINATION BLOOD TEST:-  HOMOCYSTEINE, CRP, LIPDPROFILE,

SUGAR CHANGES IN THE CARDIAC MARKER ECG CHEST X-RAY DOPPLER ULTRASOUND OF RIGHT INTERNAL

CAROTID  STRESS TEST ECHOCARDIOGRAM. CARDIAC CATHETERIZATION CT SCAN HEART MYOCARDIAL BIOPSY HEART MRI

Medical Management The objectives of the medical management of angina

are to decrease the oxygen demand of the myocardium and to increase the oxygen supply. Medically, these objectives are met through pharmacologic therapy and control of risk factors.

Revascularization procedures to restore the blood supply to the myocardium include percutaneous coronary interventional (PCI) procedures (eg, percutaneous transluminal coronary angioplasty [PTCA], intracoronary stents, and atherectomy), CABG, and percutaneous transluminal myocardial revascularization (PTMR).

Oxygen Administration.

PHARMACOLOGIC THERAPY

1. Nitroglycerin:-It helps to increase coronary blood flow by preventing vasospasm and increasing perfusion through the collateral vessels.

2. Beta-Adrenergic Blocking Agents3. Calcium Channel Blocking Agents4. Antiplatelet and Anticoagulant Medications

• Ischemic heart disease is also known as coronary artery disease or “hardening of the arteries.” Cholesterol plaque can build up in the arteries of the heart and cause “ischemia,” which means the heart is not getting enough blood flow and oxygen. If the plaque blocks an artery, a heart attack can result.

• " Ischaemia " refers to an insufficient amount of  blood. The coronary arteries are the only source of  blood for the heart muscle. If this coronary arteries are blocked, the blood supply will reduce.

Ischemic Heart Disease

Myocardial Infarction

Definition of acute Myocardial Infarction

Myocardial O2 demand

Myocardial O2 supply

Irreversible myocardial necrosis

MI refers to a dynamic process by which one or more regions of the heart experience a severe and prolonged decrease in oxygen supply because of insufficient coronary blood flow; subsequently, necrosis or death to the myocardial tissue occurs. The onset of the MI process may be sudden or gradual, and the progression of the event to completion takes approximately 3 to 6 hours. MI is one manifestation of ACS.

MI refers to the process by which areas of myocardial cells in the heart are permanently destroyed. Like unstable angina, MI is usually caused by reduced blood flow in a coronary artery due to atherosclerosis and occlusion of an artery by an embolus or thrombus.

How does the infarcted area look?

Atherosclerosis,

1Lumen (opening)2 Plaque3 Artery wall

Risk Factors of MI

Non-modifiable: Modifiable:

Etiology of myocardial infarctionCoronary artery disorders:

Atheroscelorosis Coronary artery spasm

Coronary arteritis

Circulatory disorders:HypovolemiaHypertension

Left ventricular failure

Blood disorders:Polycythemia

Anaemia

Hypoxemia

Pathophysiology of Myocardial Infarction

Stages of atherosclerosis formation

How can MI occur??Luminal narrowing of coronary blood vessel

Reduced blood flow & O2 supply to myocardium

Leads to ischemia

If not treated leads to injury

If continues for prolonged time

Myocardial infarction

Acute inferior myocardial infarction

Acute anterior myocardial infarction

ST elevation in the anterior leads V1 - 6, I and aVL

Reciprocal ST depression in the inferior leads

Acute posterior myocardial infarction

(hyperacute) the mirror image of acute injury in leads V1 – 3(fully evolved) tall R wave, tall upright T wave in leads V1 -3 usually associated with inferior and/or lateral wall MI

Anteroseptal MI

Note QS waves in V1-2, qrS complex in V3, plus ST-T wave changes)

Anterior MI (similar changes, but usually V1 is spared; if V4-6 involved call it "anterolateral”

note Q's V2-6 plus hyperacute ST-T changes)

Clinical manifestation of MI

durationlocation

radiating

Any relieving factors????

Characteristic chest pain

ECG changes

Elevated cardiac enzymes

Diagnosis of coronary artery disease

Echocardiogram

Radionuclide imaging

Angiography

Study of cardiac enzyme …….most reliable

Graphical representation of the enzyme activity in plasma following a myocardial infarction

CARDIAC ENZYME

Normal

Ng

/dl

3hrs

Peak

Myoglobin

EARLIEST INCREASE (HR)

4-24 hr 1-3 wk Troponin T or I

1–3 hr 4–12 12 hr

CK-MB 4-8 hr12-24 3–4 days

Goals of medical management of patient with MIManagement of MI

Pain Control

Pharmacological Therapy

Thrombolytic therapy

PTCA

CABG

Administration of Thrombolytic Therapy

Indications• Chest pain for longer than 20 minutes, unrelieved by nitroglycerin• ST-segment elevation in at least two leads that face the samearea of the heart• Less than 24 hours from onset of pain

Absolute Contraindications• Active bleeding• Known bleeding disorder• History of hemorrhagic stroke• History of intracranial vessel malformation• Recent major surgery or trauma• Uncontrolled hypertension• Pregnancy

Nursing Considerations• Minimize the number of times the patient’s skin is punctured.• Avoid intramuscular injections.• Draw blood for laboratory tests when starting the IV line.• Start IV lines before thrombolytic therapy; designate one lineto use for blood draws.• Avoid continual use of noninvasive blood pressure cuff.• Monitor for acute dysrhythmias, hypotension, and allergic reaction.• Monitor for reperfusion: resolution of angina or acute ST-segment changes.

• Check for signs and symptoms of bleeding: decrease in hematocrit and hemoglobin values, decrease in blood pressure, increase in heart rate, oozing or bulging at invasive procedure sites, back pain, muscle weakness, changes in level of consciousness, complaints of headache• Treat major bleeding by discontinuing thrombolytic therapy and any anticoagulants; apply direct pressure and notify the physician immediately.• Treat minor bleeding by applying direct pressure if accessible and appropriate; continue to monitor.

Pain control

Administer morphine sulphateMode of action :

Bind the opiate receptor in CNS

Inhibit the ascending pain pathway

Other pharmacological therapy

Anticoagulant

Betablockers

Calcium channel blockers

Vasodilators

Antiplatelet

POPULATION /PROBLEM INTERVENTION RESULT CONCLUSION

LEVEL OF EVIDENCE

Low serum testosterone and myocardial infarction

A survey of serum Testosteronetlevels and a range of medical and behavioral factors was conducted on 71 males aged 46 to 89 years in an extended care medical facility.

Histories of  M.I or heavy drinking were separately

associated with diminished Testosteronelevels

No other factor was associated with Testosteron level, including

age and mobility. 

Histories of  M.I or heavy drinking  were separately associated with

diminished Testosteronetllevels (P less than.002 and P less than.006, respectively). No other factor

was associated with Testosteronetl level, including age and mobility. A Testosteronetllevel of no more than 438 ng/dl best discriminated patients

with M.I  (P less than.005, sensitivity 86.2%, and selectivity 50%). Increased incidence of M.I appeared

to be influenced by Testosteronein a threshold manner, since the incidence did not rise further with

lesserTestosterone levels once the level was below 438 ng/dl. The incidence of M.I among patients

withTestosterone levels below this threshold was unaffected by their exposure to alcohol. Among the 21

formerly heavy drinkers, many (62%) showed tTestosteronelevels less than or equal to 300 ng/dl.

Increased incidence of M.I appeared to be

influenced by Testosteronein a

threshold manner.

3

1) The nurse, discussing coronary heart disease risk factors with a group of factory employees, would include which option(s) as modifiable risk factors? Select all that apply.1. hypertension2. diabetes mellitus3. obesity4. age5. heredity

2) Which diagnostic test would the nurse anticipate as priority for a pt admitted with chest pain to determine coronary heart disease status?1. coronary angiography2. stress electrocardiography3. echocardiography4. radionuclide testing

3) Aspirin has been prescribed for a pt following a myocardial infarction. What should the nurse include in teaching about this drug?1. Check with your healthcare provider before taking any herbal remedies.2. Report any itching that develops after seven days of taking the drug.3. Take at a different time of day than warfarin (Coumadin).4. Do not skip any scheduled appointments to have blood drawn for labs.

4) The nurse is assessing a pt who is six hours postoperative from coronary artery bypass graft (CABG) surgery. The pt's heart rate is 120, bp is 90/50, urine output is decreased, chest tube output is decreased, heart sounds are muffled, & peripheral pulses are diminished. What action should be taken by the nurse first?1. Notify the physician immediately.2. Recheck vital signs in 15 minutes.3. Reposition the pt.4. Increase the intravenous fluids.

5) During an office visit, a 55-yr-old female pt asks why she has not been prescribed a daily dose of aspirin. Her 56-yr-old husband has been advised by the physician to take a daily aspirin. What can the nurse explain is the most likely reason for this?1. The benefit of aspirin in women under age 65 is not clear.2. Aspirin is not recommended for women.3. This must have been an oversight.4. She has other meds that could interfere

6) During pt teaching about cardiac risk factors, the nurse knows that which laboratory test, if abnormal, requires further instruction due to the risk for the development of coronary artery disease?1. elevated homocysteine2. elevated creatinine3. elevated high density lipoprotein (HDL)4. elevated INR

7) The nurse, caring for a pt admitted w/ chest pain, realizes that which factor places the pt at the highest risk for heart disease?1. overweight & carries the weight around the waist2. mother died at age 70 of an acute myocardial infarction3. a single mother of four young children with a low income4. has a desk job & works long hours

8) The nurse, assessing a middle-aged pt experiencing chest pain, realizes that presence of which symptoms would be most characteristic of an acute myocardial infarction?1. substernal pressure type pain, radiating down the left arm2. colic-like epigastric pain3. sharp, well-localized unilateral chest & left arm pain4. sharp, burning chest pain moving from place to place

9) The nurse, caring for a pt diagnosed with Prinzmetal's or variant angina, realizes this is a serious type of chest pain. Why is this so?1. It indicates presence of coronary artery spasm.2. It indicates there is associated renal disease.3. It indicates there is associated pulmonary disease.4. It indicates the presence of a myocardial infarction.

10) A pt enters the ER complaining of chest pain that is radiating down the left arm. The emergent treatment plan for this pt includes which nursing actions? Select all that apply.

1. morphine intravenously & oxygen2. aspirin 325 mg orally3. open heart surgery4. heparin drip at 100 units per hour5. Foley catheter insertion

11) Following a transmural myocardial infarction, which ECG change stays with the pt for life?1. Q wave deepening2. ST segment elevation3. ST segment depression4. P wave inversion

12) A pt reports chest pain, nausea, & vomiting off & on for the last 4 days, which the pt interpreted as the flu. Which lab tests will provide info about acute cardiac damage for this pt?1. Troponin I & T2. Red blood cells3. CPK-MB4. Homocysteine & platelets

13) Coronary heart disease (CHD) is a major problem in the United States. Pts with which history may require closer evaluation for CHD? Select all that apply.1. diabetes2. hyperlipidemia3. positive family history4. a premenopausal woman5. hypotension

14) A nurse is conducting teaching about risk factor management for cardiovascular disease (CVD) at a senior center. What is the most important info for the nurse to include?1. Stop smoking.2. Eat in moderation.3. Exercise when able.4. Reduce saturated fats in the diet.

15) Which is the priority nursing intervention for a pt with a junctional escape rhythm?1. Assess the pt for symptoms associated with this rhythm.2. Contact the physician immediately for emergency orders.3. Eliminate caffeine from the diet.4. Prepare for a pacemaker insertion.

16) The nurse is reviewing a new prescription for propranolol (Inderal) for a pt with coronary heart disease (CHD). The nurse would call the physician & question this prescription if the pt has which history?1. has a history of asthma & chronic obstructive pulmonary disease (COPD)2. is also taking antioxidants3. is also taking simvastatin (Zocor)4. has a history of bleeding disorders

17) Angina that is characterized as atypical, occurs unpredictably & often at night & is associated with coronary artery spasm would be labeled as which type of angina?1. Prinzmetal's (variant) angina2. stable angina3. unstable angina4. ischemic angina

18) Premature ventricular contractions (PVCs) are best characterized by which statement?1. They are insignificant in people with no history of heart disease.2. PVCs typically have no pattern.3. The frequency of PVCs is not associated with specific events.4. Their incidence & significance has no relevance to the pt having had a myocardial infarction.

19) A pt reports the following symptoms to the nurse: nausea, loss of appetite, blurred & double vision, green yellow halos, vomiting & "feeling uneasy."." What situation should the nurse suspect?1. digoxin toxicity2. lidocaine toxicity3. amiodarone toxicity4. procainamide toxicity

20) the nurse is admitting a patient who is complaining of chest pain to the emergency department (ED). Which information collected by the nurse suggests that the pain is caused by an acute myocardial infarction (AMI)?1. The pain worsens when the patient raises the arms.2. The pain increases with deep breathing.3. The pain is relieved after the patient takes nitroglycerin.4. The pain has persisted longer than 30 minutes.

Answer key:-

1) 1, 2, 3

2) 1

3) 1

4) 1

5) 1

6) 1

7) 1

8) 1

9) 1

10) 1, 2

11) 1

12) 1

13) 1, 2, 3

14) 1

15) 1

16) 1

17) 1

18) 1

19) 1

20) 4