CORONARY VASCULAR DISEASE – Ch.

34

Atherosclerosis (caused by CAD)

Endothelial injury caused by:
 Hypertension
 Tobacco use
 Hyperlipidemia
 Hemodynamic factors
 Diabetes
 Infections
 Immune reactions

Endothelial injury  atherosclerosis

Fatty streaks à Fibrous plaque à Complicated Lesion à Collateral Circulation
(see slide 3)
Complicated lesion  high risk of platelet aggregation  clot  occlusion  limiting
oxygen to that part of heart  ischemia

Risk factors
Non-modifiable
 Age, Gender, race, family hx
 Until menopause, men higher risk
 African Americans higher risk
Modifiable
 Weight/sleep apnea
 Metabolic syndrome – 3 or more
1. Insulin resistance FBS >100
2. Abdominal obesity F >35 M >40
3. Triglycerides <150 or LDL < 50
4. High blood pressure
5. Elevated cRP Normal <0.1
 Smoking, alcohol consumption etc

s/s – correlate to amount of blockage

-Decrease in blood supply to that area of heart, decreases oxygen supply
-Formation of collateral circulation – beneficial compensatory mechanism, reroutes
blood supply, therefore may be asymptomatic

Ischemia – chest pain due to lack of oxygen

 SOB
 Chest pain
 Fatigue
 Nausea/vomiting
 Diaphoresis
 Females – angina diff than men, fatigue, back pain
 Elderly may not have sx at all
 Diabetes may not have sx due to neuropathy

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Tx & prevention
 Diet: Low in fat & cholesterol
 Physical activity 30 min a day

Cholesterol
HDL >50
LDL adheres to vessel walls <100, diabetic <70
Triglycerides <150
Look at the whole as well <200

 Diet – low sat fat, cholesterol

 Exercise, medications
 Statins – lower LDL, triglycerides, minimally increase HDL
 Tx of hypertension, tx of diabetes – increased risk due to sugar elevation

Angina Pectoris
O2 demand > O2 supply → myocardial ischemia
Angina = reversible ischemia
 Occurs when arteries are blocked 75% or more
 Hypoxic within 10 seconds of occlusion
 Viable for 20 minutes

*Ischemia = imbalance between oxygen supply and demand

related to an occlusion in a vessel (most common cause: CAD)

S/s
 Chest pain
 Heavy chest “pressure”
 Diaphoresis
 High pulse rate
 Sense of impending doom
 Pain that radiates to jaw, L arm, shoulder
 Women – fatigue, nausea/vomiting, upper back pain

TYPES
 Stable – occurs with exertion (physical activity, large meal)
-Pain is relieved with rest (table 34-8, p. 741)

 Unstable – occurs at rest or is not relieved at rest

-Strong indicator that MI is soon to come

 Prinzmetal’s (Variant or Vasospastic) = spasm of artery

-No relation to physical activity
-May or may not have CAD, common with patients with Raynaud’s
-Treatment is to relieve spasm, usually with CCB

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 Silent ischemia – changes on EKG, but pt does not feel pain
-See this in pts with diabetes

Diagnosis: EKG, biomarkers, stress test

Tx
 Balance O2 supply/demand (table 34-10, p. 742)
 Want to increase supply & decrease demand
 Medications, cardiac cath (PCI), stents, CABG

Medications
Nitroglycerin:
 Decreases O2 consumption by the heart to relieve pain
 Venous dilation: blood pooling in venous system
 Sublingual up to 3 doses every 5 min
 Call 911 after 5 min (if one dose does not help)
 Side effects: headache, low BP, facial flushing
 Pt teaching: sit down in case BP drops
 Need to be on cardiac monitor, monitor BP, IV in place

Beta-blockers
 Decrease oxygen consumption by decreasing HR and force of conduction through
AV node (from atrium to ventricle)

Calcium-channel blockers
 Treatment of choice for the variant/vasospastic angina

Anticoagulants
Oxygen: goal O2 sat >95%

Surgical tx
PCI – percutaneous coronary intervention
 Balloon angioplasty
 Femoral or radial artery into heart  area of occlusion
 Balloon inflated than stent place in area to keep vessel patent
 Goal is to reduce time that oxygen is not getting to the tissue
 Unstable angina/impending MI

 Assess patient’s peripheral vascular and CV status

 Need to be sure that circulation is in tact prior to the procedure and to have a
baseline for after procedure: CSM etc.

 Increased risk of clot formation at site of stent

 Need to be on anticoagulation for up to a year: ASA and plavix

CABG – coronary artery bypass graft

 Blood vessel grafted from another site (usually leg)
 Candidates based % of blockage (70% or more), number of arteries, symptoms,
degree of heart failure

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  This is open heart procedure
 Complications can include MI, arrhythmias after reperfusion, hemorrhage, renal
dysfunction r/t decreased perfusion

Post-surgery: pt on telemetry, in cardiac unit or ICU

 Hemodynamic stability:
o Cardiac output
o Heart sounds
o Pulses
o Peripheral vascular
o Blood pressure
 Pain management, wound care, nutrition, mobility
 Renal function, fluid & electrolyte balance (K and mag)
 Notify if urine output < 30 mL/hr
 Manage risk of DVTs through compression devices, heparin, etc
 S/s of infection – generalized or at site of incision
 Ventilator associated PNA
o Keep head of bed elevated
o Frequent mouth care
o Suctioning as needed
o Listen to lung sounds (atelectasis)
o Monitor for s/s of hypoxia
 Pt in cool in OR, rewarm in ICU with warming blankets
 Pts on mechanical ventilation, NG tube, 3-4 chest tubes, triple lumen catheter,
cardiac monitor, foley, arterial line

Myocardial Infarction
 100% occlusion of an artery secondary to plaque/thrombus formation
 Partial occlusion = UA or NSTEMI, total occlusion = STEMI?
 Myocardial infarction = irreversible cell death from prolonged ischemia (when pain is
not relieved, blockage continues)
 Occurs over minutes or hours
o STEMI or NSTEMI
o Also described by area of infarction
o Could be evolving or past
o Extent of damage: partial thickness or full thickness
o Complications - #1 Dysrhythmias, HF, Shock, Pericarditis (rare)

Symptoms – chest pain at rest, diaphoresis, indigestion, radiation of pain to arm, jaw, n/v,
fatigue. May be nonspecific and different for DM, females, or elderly

Diagnosis
1. EKG - goal to have this done within 10 minutes (THIS IS DONE FIRST)
2. Cardiac monitor
3. Labs – cardiac monitors, CKMB & troponin

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Diagnostics – EKG first, Troponin level (most specific cardiac marker), may have angiography
to visualize blockage followed by PCI to restore blood flow

Goal is to decrease pain & decrease amount of tissue death (restore flow)
Medications
1. Aspirin: 4 81 mg baby aspirin, chew them
2. Oxygen > 95%
3. Nitroglycerin: 3 sublingual 5 min apart
4. Morphine: decreases pain and cardiac workload

As the RN, goal is to relieve pain – obtain EKG first, sit up, apply O2, administer Aspirin
(decrease platelet aggregation) and nitro (vasodilate, decrease pain), if pain persists, can also
give morphine which decreases cardiac workload, relieve pain and can decrease anxiety

Other:
1. PCI within 90 minutes: Pt will be on anticoagulants for at least 1
2. Thrombolytic/clot busters: within 6 hours of onset of pain, great risk of bleeding
If patient doesn’t know when pain started, not a candidate. Table 34-13 p. 751.
3. CABG – for multi-vessel occlusions

Prophylactic med tx after an MI:

1. Statins – decrease risk of further plaque aggregation
2. ACE inhibitors – decrease risk of cellular remodeling
3. Aspirin – decrease platelet aggregation
4. Beta-blockers – decreases workload and manage balance of O2 supply & demand
5. Nitroglycerin – keep on them at all times in dark bottle, replace every 6 months
6. Maybe also antidysrhythmics (eg. Calcium channel blockers)

Nursing management for ACS (pages 753-763)

Acute Coronary Syndrome (ACS) = unstable angina, STEMI, NSTEMI

Drug therapy for ACS (see cardiac med slides)

 IV nitroglycerin
 Morphine sulfate
 β-adrenergic blockers
 Angiotensin-converting enzyme inhibitors
 Antidysrhythmia drugs
 Cholesterol-lowering drugs
 Stool softeners

CAD  Stable Angina or ACS

ACS  Unstable angina or MI
MI  STEMI or NSTEMI

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STRUCTURAL & INFLAMMATORY – Ch. 37

AV valves: between atria and ventricles

S1 sound = systole, closure of these valves
Closed during systole, open during diastole
 Tricuspid - right side
 Mitral - left side (LA and LV)

Semilunar valves: between ventricles and vessel

S2 sound = diastole, closure of these valves
Closed during diastole, open during systole
 Pulmonary: RV and pulmonary artery
 Aortic: LV and aorta

Valvular disease – chronic, progressive illness

Main causes = endocarditis and rheumatic heart disease

Stenosis (constriction/narrowing)
 Valve is thicker, orifice is smaller
 Doesn’t open completely
 Limits/impedes forward flow of blood from atria to ventricle
 Or from ventricles and vessels
 Pressure differences reflect the degree of stenosis

Regurgitation (incompetence/insufficiency)
 Incomplete closure of valve leaflets
 Results in backward flow of blood back into atria etc

MITRAL/BICUSPID
Mitral valve stenosis – valve is narrow/stiff, doesn’t open completely during diastole
 Therefore amount of blood that can travel from LA to LV is reduced.
 Thus, the pressure in LA will go up because more blood than there should be
 Atrium will hypertrophy & there is an increased risk for clots (blood is pooling)
 Going to go backward to area of less pressure  LA into pulmonary veins/lungs
 Pulmonary congestion  Right sided HF, JVD, hepatomegaly, edema etc.

Major risk factor- rheumatic fever/rheumatic heart disease (RHD)

Symptoms
 Dyspnea – due to blood back up, higher pressure in lungs
 Fatigue
 Paroxysmal nocturnal dyspnea
 Afib – irregular pulse
 Orthopnea
 Diastolic murmur – hear it during S2, mitral valve is open, flowing turbulently

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 Tx: symptom management
 Antiarrhythmics (if have afib)
 Anticoagulants
 Diuretics to assist with pulmonary congestion
 Calcium channel blockers/beta-blockers
 Avoid strenuous activity
 Surgical tx – valvuloplasty (balloon inflated to open valve)
 Valve repair or valve replacement (know risks/benefits p. 824)

Mitral stenosis: blood pooling in LA, diastolic murmur, dyspnea, back up for right HF

Mitral valve regurgitation – valve doesn’t close during systole, blood flows backward into LA
 Increases cardiac workload with eventual decrease in CO.
 With decreasing CO, increased workload, patient can develop HF (look for
symptoms of this)
 Systolic murmur
Mitral regurgitation: blood flow back in LA, systolic murmur, decrease in CO, HF

AORTIC VALVE
Aortic stenosis – Rheumatic heart disase, valve degeneration or congenital.
 During systole, blood flow is decreased from LV to aorta
 Results in higher blood volume of ventricle, which then hypertrophies.
 Can then develop HF, systolic murmur.
Symptoms
 Angina
 Syncope
 Exertional dyspnea
 Systolic murmur
Aortic stenosis: blood pools in LV, systolic murmur, angina, hypertrophy, HF

Aortic regurgitation – RHD.

 Blood flows backward into LV from aorta during diastole
 Increases preload
 Can also lead to HF, diastolic murmur.
Aortic regurgitation: blood flows back in LV, diastolic murmur, HF

Aortic stenosis  systolic

Mitral regurgitation  systolic

Aortic regurgitation  diastolic

Mitral stenosis  diastolic

**As the RN, always looking for signs of HF with any valvular disorder**

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*Valve repair vs. replacement – pt education re: pros/cons, implications of both (p. 824)

Valve repair
 Surgical procedure of choice
 Lower mortality
 May not restore total valve function

Valve replacement
 Higher mortality, but may restore more function

Mechanical – artificial
 Last longer
 Risk of thromboembolism
 Anticoagulants for life
 Use if life expectancy >15 years

Biological – tissue
 Bovine, porcine, and human
 Less durable
 No anticoagulation required
 Use >70 years old child, cannot take anticoagulants

Prevention:
 Diagnosing and treating streptococcal infection
 Prophylactic antibiotics for patients with history
 Encourage compliance
 Teach patient when to seek medical treatment

Pt teaching:
 Drug actions and side effects
 Importance of prophylactic antibiotic therapy
 Information related to anticoagulation therapy
 When to seek medical care
 Medical-Alert bracelet

CARDIOMYOPATHY:
1) Dilated – most common, reduce symptoms of HF
2) Hypertrophic – genetic, can happen in active/young healthy people
a. Assess for murmurs with sports physicals
b. Change in location of PMI
c. Early cardiac death in family = red flag
3) Restrictive – least common

 Most patients with cardiomyopathy develop HF

 Will require heart transplant, but due to the shortage, many die waiting.
 Be sure family knows CPR, medical alert bracelet is worn
 Patient teaching (p. 830, table 37-17)

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ENDOCARDITIS

Endocarditis – infection of endocardium

 Frequently impacts heart valves
 Vegetations that can break off valves and cause emboli to various organs

Causes:
 Rheumatic heart disease
 IV drug abuse
 Prosthetic heart valves
 Dialysis

S&S:
 *Fever*(very common)
 Chills
 Malaise
 Peteciae
 Splinter hemorrhages (nails)
 Janeway lesions,
 Osler nodes
 *New or changing murmur

Diagnosis:
 Echocardiogram to look at valves
 Blood cultures x 2 sites
 CXR, EKG

Treatment:
 Antibiotics (prolonged course), can be outpatient if stable
 Will need PICC line

Review nursing management p. 813-814

AORTIC ANEURYSM – Ch. 38

Abdominal aorta = most common site for aneurysm (dilation or outpouch of the aorta)
Two kinds – true and false

Risk factors:
 Advanced age
 Male gender
 Smoking
 HTN
 High cholesterol
 Obestiy

S&S:
 Angina

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  Pulsating mass in abdomen
 Back/epigastric pain
 However, often asymptomatic
 Detected on physical exam, CT or abdominal X-ray for other problem

#1 complication = rupture of the aneurysm (causing hemorrhage, s&s of decreased

CO/perfusion in all organ systems).
Rupture more likely if HTN is uncontrolled
Goal – prevent rupture – early detection and tx

Diagnosis – Xrays, CT scans

Treatment
 Control BP, stop smoking, control cholesterol.
 5.5 cm is threshold for repair (>5 cm in women with AAA)
 Surgical intervention may occur earlier in
 Patients with a genetic disorder
 Rapidly expanding aneurysm
 Symptomatic patients
 High rupture risk

Review nursing management p. 844-845.

AORTIC DISSECTION
 Chronic HTN – causes increased pressure on aorta (usually ascending)
 S&S - Sharp, tearing, ripping back pain ***red flag symptoms***

 High mortality rate

 Complication of cardiac tamponade: blood leaking from aorta  pressure on heart
structures

 This pt is in the ICU – surgical emergency to repair

 As the RN, keep BP and HR low (<120, <60), cardiac monitoring, looking for
signs of decreasing perfusion to organ systems

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