Heart Facts o High serum lipids

• One in six men and one in seven women aged 45-64 has some form of o Hypertension
heart disease or stroke; the ratio climbs to one in three at age 65 and o Obesity
over. o Lifestyle
• Twice as many people, both men and women, die of cardiovascular Cardiovascular Assessment - Inspection
disease as die of cancer. • Skin Color (pallor, cyanosis)
• An estimated 3,150,000 Americans have angina pectoris • Neck vein distention - reflects right atrial pressure
• Rheumatic heart disease afflicts 1,340,000 Americans. (Data from the • Respiratory (dyspnea, Orthopnea)
American Heart Association's 1994 Statistical Supplement, "Heart and • Location of PMI - if too low indicates enlarged heart
Stroke Facts")
• Presence of edema - fluid volume overload
Atherosclerosis and Arteriosclerosis
o Be sure to check sacrum for those on bedrest
• Common disorder of the arteries.
o Fat, cholesterol, and other substances collect in the walls of • Nail clubbing - sign of chronic hypoxia
arteries. • Capillary filling - measure of peripheral circulation
o Larger accumulations are called atheromas or plaques. • Lack of hair on legs/feet
• Fatty tissue erodes wall of the artery, diminishes the elasticity and • Venous stasis or Arterial Ulcers
interferes with blood flow. • Vericose Veins
• Arteriosclerosis (commonly called hardening of the arteries) frequently Palpation
accompanies atherosclerosis and is not clearly separated from it. • PMI (Located at 5th intercostal space, Left MCL)
o Arteriosclerosis involves deposits along the arteries, which • Thrills (palpable murmur) thrusts/heaves
often contain calcium. • Peripheral pulses - Check all bilateral and compare
Arteriosclerosis and Ateriosclerotic Heart Disease (ASHD) • Temperature - check bilateral
• Primarily affects middle age and older • Capillary refill - measure of peripheral circulation
• Major cause of death in men age 35-44 years old Auscultation
• Major cause of death in women after menopause • Heart rate
• Prevention begins at birth • Rhythm
• 3 Main Risk Factors • Heart Sounds S1 (lub) and S2 (dub)
o Smoking, High B/P and High Cholesterol • S1 is first heart sound from closure of Mitral and Tricuspid
• Intermittent claudication (pain in calf or leg brought on by exercise • S2 is second sound from closure of aortic and pulmonic
and relieved by rest) is most common early sign of arteriosclerosis • Don’t worry about correctly labeling sounds as S3 or S4 for now
Risk Factors for ASHD • Murmurs are swishing sounds in-between heart sounds (Lub-
• Non-Modifiable swish-Dub)
o Age Auscultation Continued
o Gender • Pericardial friction rub - rough, grating sound from inflamed
o Race pericardial sac
o Family history • Bruit - murmur heard outside of the heart. May be heard in
o other illness (diabetic) carotid, jugular, temporal, abdominal, aortic, renal and femoral
• Minor Factors arteries
o Personality type • Take B/P in both arms, lying, sitting and standing
o Sedentary living Pulse Assessment
o Stress • Note whether the pulse is regular or irregular:
o Oral Contraceptive Use o Regular - evenly spaced, may vary slightly with respiration
o Regularly Irregular - regular pattern overall with "skipped"
• Modifiable
o Smoking beats
o Irregularly Irregular - chaotic, no real pattern, very difficult
o High calorie, fat, cholesterol, sugar and sodium diet
to measure rate accurately
 o A pulse greater than 100 beats/minute is tachycardia. Malignant Hypertension
Pulse less than 60 beats/minute is bradycardia. • Severe, rapidly progressive rise in B/P that damages small
o Tachycardia and bradycardia are not necessarily abnormal. arterioles of major organ systems
Athletes tend to be bradycardic at rest • Inflammation of the arterioles of the eye is classic finding
o Tachycardia is a normal response to stress or exercise. • Primarily found in black men under 40
B/P Assessment • Unless aggressively treated, is rapidly fatal
• Position and support the arm slightly flexed at the elbow Complications of Hypertension
• Center the bladder of the cuff over the brachial artery 2 cm above • Atherosclerosis
the anticubital fold o Athlerosclerotic vascular occlusion
• Inflate the cuff until the radial pulse disappears. Inflate the cuff to  a) coronary artery disease
30 mmHg above the estimated systolic pressure, release slowly.  b) occlusive cerebrovascular
• Systolic Pressure - When you start to hear beats  c) peripheral arterial insufficiency
• Diastolic pressure when the sounds muffle and disappear. • aortic dissection
B/P Assessment • nephrosclerosis
• Don’t use too small a cuff. The pressure will be 10, 20, even 50 • hypertensive heart disease with cardiac hypertrophy and
mmHg too high!
congestive heart failure
• Maximum Cuff Pressure - When the baseline is known or • cerebral hemorrhage
hypertension is not suspected, it is acceptable in adults to inflate Antihypertensive Medications
to 200 mmHg
• Diuretics
• Be aware that there could be an ausculatory gap (a silent interval o Thiazide/Thiazide-like diuretics; Loop Diuretics; Potassium
between the true systolic and diastolic pressures).
Sparing Diuretics
Blood Pressure Classification in Adults
Hypertension • Adrenergic Inhibitors
o Beta-Blockers; Centrally Acting and Peripherally acting
• Consistent elevation of diastolic B/P above 90
Alpha Blockers; Combined Alpha-Beta Blockers
• Affects over 58 million people
o Incidence increases with age • Vasodilators
o Almost twice as prevalent in Blacks • ACE Inhibitors
o More severe in Blacks • Calcium Antagonists
Diuretic Treatment
• Two Main types - Primary (Essential) hypertension and Secondary
Hypertension
• Potassium Wasting Diuretics
o Primary accounts for 90% of all Hypertension o Thiazide Diuretics - Chlorothiazide (Diuril) and
Hydrochlorothiazide (Hyrodiuril)
o Secondary is from a known cause such as
o Loop Diuretics: furosemide (Lasix); Bumetanide (Bumex)
glomerulonephritis, Cushing’s or renal stenosis
Isolated Systolic Hypertension • Monitor Daily weight and I&O - Pt should lose weight if diuretic is
effective
• Frequently seen in older adults
• Systolic over 90, with normal diastolic • Most common side effect of diuretics is electrolyte imbalance.
Others - Postural hypotension, GI symptoms, Sexual dysfunction
• While commonly ignored, this condition should be treated.
• Potassium Sparing Diuretics - Inhibit aldosterone, cause Na+ to be
• Studies show that lowering the systolic number cuts down on excreted in exchange for K+
strokes and heart attacks in people age 60 and over.
o Spironolactone (Aldactone) - causes gynecomastia
Primary Hypertension
Beta Blockers
• Possible contributing mechanisms:
• Atenolol (Tenormin); Metoprolol (Lopressor); Propranolol
o heredity
(Inderal); Nadolol (Corgard)
o vascular hypertrophy
• Should not be used in patient's with asthma, COPD, CHF and heart
o defects in ion handling
block
o hyperinsulinemia
o renin/angiotensin
 • 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
• See pg 920-921 for more info
PPT Slide
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 Thromboangitis Obliterans (Buerger’s Disease)
o Dry skin • Obstructive inflammatory process of the peripheral arteries
o Dry brittle hair o Mostly male smokers 20-40 years old
o Loss of body hair o More often in Semitic and Oriental
o Thick brittle nails (particularly toe nails) o Causes Intermittent claudication, numbness and tingling,
o Increased capillary fill times (over 2 seconds) thrombophlebitis
o Capillary filling is a indicator of peripheral circulatory status o May require amputation of affected digits
Raynaud’s Phenomenon
Peripheral Vascular Disease (PVD) • Episodes of arterial spasm - usually in hands
• characterized by lack of blood flow and oxygen to tissues • primarily in women 20-40
• Usually occurs as a result of accumulated fatty deposits • Cold, numbness, paleness, and pain in one or more fingers or toes
• Most prevalent in geriatric clients, however, prevention of PVD • Bilateral effects both hands and/or feet
needs to start at birth • Smoking and Cold makes it worse
• Smoking makes PVD worse, by constricting the blood vessels and • Intense redness and throbbing after spasm
increasing the force of flow (increased B/P) • Tx with calcium antagonists, may require amputation
• Can be divided into Arterial and Venous PVD Arterial Embolism
Assessment of PVD • Blood clots (usual from heart) tend to lodge in bifurcation of an
• Check peripheral pulses - know names and location of femoral, artery, blocking blood flow
brachial, radial, popliteal, posterior tibial and dorsalis pedis • Symptoms depend on size and location
• Check below the site of suspected occlusion o Abrupt onset of pain, burning, loss of distal pulses, cold
• If can’t palpate a pulse, use a doppler pale extremity
• Check capillary filling • Tx with bedrest, and anticoagulants or fibrinolytics
• Check warmth and color by comparing extremities to each other o Surgery - embolectomy or endarterectomy within 6-10
• Arterial PVD Venous PVD - hours
Arterial vs Venous PVD Intermittent Claudication
• Arterial • Due to narrowing or blockage of the arteries (Atherosclerosis or
• Cool arteriosclerosis Obliterans - peripheral vascular disease).
• pale extremity • Frequently one of the first signs of cardiovascular disease
• decreased pulses • Pain in legs that occurs with exercise. Pain is relieved by rest.
• sharp pains Intermittent Claudication
• pain increases with activity or elevation • May occur in both legs and often continues to worsen over time.
• Dry ulcer formation with necrotic tissue • Some people complain only of weakness in the legs when walking
or a feeling of "tiredness" in the buttocks.
• Venous
• Impotence is an occasional complaint in men.
• Warm
• Pain at rest is uncommon.
• Flushed
Arterial PVD
• Edematous
• Extremity has decreased oxygenation, may be pale, cool or
• Aching pain cyanotic
• pain increases when legs dependent • Sharp pain, may increase with activity
• Weeping venous ulcers • Arterial insufficiency ulcers are usually dry, pale, and may have
Arterial PVD necrotic tissue
• Obstruction or constriction of arterial flow, usually in the leg • To treat, need to increase blood flow to extremity
• Intermittent claudication is an early sign of arterial PVD (pain in o place foot lower than heart
calf or leg brought on by exercise and relieved by rest) o Avoid tight bandages and stockings
• Later signs are loss of hair on leg and dorsum of foot, muscle o Need meticulous foot care to avoid ulcers
atrophy and arterial 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
PPT Slide
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
PPT Slide
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.
Coronary Arteries
Coronary Sinus
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 • Post Cath, Pressure dressing to site, monitor for bleeding, Check
o Atenolol (Tenormin) and Nadolol (Corgard) Acts to peripheral pulses below site
suppress renin-angiotensin-aldosterone system PTCA Percutaneous Transluminal Coronary Angioplasty
o Take Beta-blockers with food • In PTCA, a catheter carrying a small balloon is inserted into
• Dipyridamole (Persantine) - selectively dilates coronary arteries coronary heart arteries through the patient's skin.
(does not affect B/P) • The balloon is then repeatedly inflated and deflated to compress
Echocardiogram the blockage that obstructs blood flow to the heart.
• Echocardiogram Coronary Arteries
o Ultrasound of heart PPT Slide
o can view structures and movement PPT Slide
o Similar to fetal ultrasounds, painless, need to use Post-Procedure Care
transducer gel • Always assess for adequate peripheral circulation below the site of
o No real patient prep needed arterial access
Transesophageal Echocardiography • Assess site for bleeding, a pressure dressing will be in place for at
least 8 hours.
• Uses probe to pass ultrasound transducer into the esophagus
• Keep affected extremity straight and still
• more detail is possible
• Elevate HOB no more than 90 degrees
• Keep pt NPO 4 hours before. Topical spray or gargle to depress
gag reflex. Conscious sedation may be used. • Push fluids to get rid of dye (nephrotoxic)
• Keep pt NPO afterwards till gag reflex returns • Assess heart rate and B/P
Coronary Angiograms /Veinograms • Monitor I&O for 24 hours
• Coronary Angiography Myocardial Infarction (MI)
o injection of radiopaque dye into the right and left coronary • Usually caused by the sudden occlusion of a coronary artery.
arteries • The plaque in the artery takes years or decades to form, but the
o Helps to confirm the presence and /or degree of coronary final event of formation of a blood clot (or thrombus) happens in a
artery stenosis, and to determine the amount of collateral few minutes or hours.
circulation available • In general MIs occur at any time, although they are a bit more
• Ventriculography common in the morning
o injection of dye into left ventricle to visualize ventricular Symptoms of MI
wall, mitral valve and ventricular septum function • Classical symptoms of a heart attack include heavy or crushing
Cardiac Catheterization chest pain, shortness of breath (dyspnea) and sweating
• Insertion of catheter directly into the right and/or left ventricle to (diaphoresis).
get info about ventricular function • Less common are nausea, profound fatigue and a feeling of
• Gives most valuable and detailed information about structure and impending doom.
function of heart • If you become short of breath and break out in a cold sweat while
o Patency of coronary arteries sitting in a cool room you should be more concerned than if these
o Condition of myocardium symptoms happen while walking up a steep hill in July.
o Status of collateral circulation • Many heart attacks come without classical symptoms or even
without any symptoms at all (silent MI).
• Relatively high risk compared to other cardiac tests MI Continued
Patient Preparation
• Ischemic myocardium is electrically unstable
• Explain expected sensations - flushing, nausea, warmth when dye o arrhythmia's including lethal ventricular ventricular
injected
fibrillation and ventricular tachycardia.
• May have chest pain or dyspnea when catheter is in heart o Infarcts which interfere with the cardiac conduction system
• Risks are hemorrhage, MI, CVA, dysrhythmia and even death may lead to heart block or conduction defects.
(most risk is from cardiac cath) MI Continued
• Pt is NPO 4 hours before, procedure lasts 1-3 hours, lying on x-ray • Dead or scarred myocardium is unable to contract.
table in cold room
 • Damage may be reversible if thrombolytic therapy is in time. o Liver enlargement and right upper quadrant pain
• Leads to congestive heart failure in about 40-50% of patients with o Ascities
acute MI. o Distended neck veins (JVD)
• In extreme cases, patients may present with cardiogenic shock • Left Sided Failure - Complication of Hypertension
Cardiac Isoenzymes o Dyspnea - early sign
• Creatinine Kinase (CK) o Cough
o Normals < 2.5U F, < 4.3U Male o Orthopnea
o Elevations indicate possible brain, heart, or muscle injury o S 3 heart sound
or necrosis o Paroxysmal nocturnal dyspnea (PND)
• CK-MB (0-5% of total CK) o Fatigue
o Elevations with myocardial injury o Crackles in lungs - starts at bases and works upward
• Lactic Dehydrogenase (LDH) Congestive Heart Failure (CHF)
o LDH1/LDH2 LDH 1 higher than LDH2 with myocardial • Most common hospital discharge diagnosis in persons over age 65.
damage • The National Heart, Lung and Blood Institute estimates two million
o Most sensitive cardiac enzyme indicator of MI 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
Nuclear Imaging congestion and pulmonary edema
• Uses radioactive tracer substances • Chronic CHF leads to ventricular dilation, hypertrophy and
• Thallium imaging tachycardia
o Dye is injected into patient’s antecubital vein. • Heart becomes enlarged and weaker
o Imaging done 4-10 minutes after injection • PMI may be located at 6th intercostal space and lateral to the MCL
o Necrotic or ischemic tissue will appear as “cold spots” on • Clubbing of fingers from chronic hypoxia
this scan Treatment of CHF
o Often done with the patient at rest and then during an • Need to decrease fluid volume and reduce cardiac workload
exercise test o Bedrest or reduced activity to conserve energy
Coronary Artery Bypass Graft (CABG) o Oxygen if hypoxia is present
• CABG to relieve blockages of the coronary arteries o Assist to cough up secretions q 2 hours
• Open Chest and long incision along the inside of the lower leg. o Elevate HOB, Do not raise feet, even if edematous
• The leg vein is sewn in above and below the blockage in the o Diuretics
coronary o Digitalis
• Heart-lung bypass machine is used to re-route the blood from the o Fluid restrictions
heart while the surgery is being done
o Daily weight
Indications for CABG
o I&O
• Unsuccessful Angioplasty
o CHF Diet
• Blockage of the left main coronary artery
CHF Diet -Low Cholesterol, Low Sodium, Low Fat Diet, - To Return B/P to
• > 50% diameter stenosis Normal
• Concomitant valve damage and any coronary artery disease • Avoid the following foods
• Unstable Angina and/or ischemia that cannot be treated with PTCA • Red meats, Cheese (except cottage cheese and other low fat), Egg
• Three-vessel disease of the coronary arteries regardless of angina yolks, Shellfish (too much cholesterol)
or ischemia • Cold cuts, ham, bacon, sausage, hot-dogs, chips, (sodium and fat)
CHF
• Most soups, sodas, and canned vegetables (sodium)
• Right Sided Failure - Complication of COPD
• Antacids and other meds high in sodium
o Pitting peripheral Edema
Alternatives
 • Use lite salt (K+Cl) o Ectopic beats
• Use salt alternatives - Mrs. Dash and others o Pulse deficit
• Bake and season meats with vinegar or lemon juice instead of • GI Effects*
butter and salt o N/V
• Use egg beaters, low sodium soups, saltless pretzels and low o Anorexia
sodium crackers. o Diarrhea
• Try a baked sweet potato with a little brown sugar o Abdominal Pain
• Read all labels • Neurological Effects
Low Calorie o Headache
• Watch for “Hidden” calories in drinks (milk, juice, alcohol, soda) o * Blurred, double or colored vision
• Watch the fat, sodium content and calorie content in frozen o Confusion, irritability, restlessness, drowsiness
dinners, mixes, and canned items o Muscle weakness and cramps
• Avoid High carbohydrate foods (breads, pastas, cakes) • Kidney Failure, Liver Failure, Potassium Loss or Dig Overdose can
• Avoid most fast foods all cause Dig Toxicity
• Read the labels. Check out nutritional content Rotating Tourniquets
Digoxin (Lanoxin) - Cardiac Glycoside • old technique used to decrease venous return to the heart by
• Cardiac Glycosides act to stimulate myocardial contraction trapping fluid in extremities
• Makes heart beat slower, more regular, and more powerful, which • temporarily reduces heart workload by reducing fluid volume heart
leads to increased cardiac output and increased blood flow to the must pump around body
kidneys • B/P cuffs are used on three extremities at a time, and are rotated
• Can be given PO or IV every 15 minutes in a clockwise fashion. (Rotating tourniquet
• Take Apical pulse for a full minute before administration, noting machine does this automatically)
rate and rhythm. • Make sure patient has a peripheral pulse in affected areas
• If rate is below 60, above 110, or If rhythm is very irregular
(compared to patient’s baseline, hold med and call MD
Digoxin Continued
• 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
Digoxin Continued
• 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