Cardiac Potpourri

Renee Smith
RN, DNP, EdD(c),MSN, CEN, PHN, ACNP, TCRN
CDU Faculty
Coronary Artery Disease (CAD)
Risk factors:
 Age & gender
 Family history
 Diabetes
 Hypertension
 Tobacco use
 Sedentary lifestyle
 Diet
 Stress management
Age & gender
 Decrease in elasticity of arteries with
age
 Estrogen in females lowers serum
chol, decrease SVR, improves
endothelium dependent vasodilation,
is cardioprotective
Family history

 Genetic research is
pending
 Nature vs Nuture?
Diabetes

 Damage to intima,
microvascular
changes, damages
 Insulin modifies
lipid metabolism-
insulin makes a
diabetic fat
Hypertension

 Decreased
elasticity of blood
vessels-stenotic
 Tearing effect on
arteries
 Increased
resistance to
ejection of
ventricular volume
Tobacco use

 Decreased high density lipoproteins

 Displacement of oxygen from hgb
 Increased catecholamine response to
nictotine, HR, B/P elevates
 Increases platelet adhesiveness
 Accelerates atheroma formation
 Coronary vasospasm**
Sedentary lifestyle

 Alters lipid
metabolism ** HDL
remains elevate
with significant
exercise every
other day****
 Alters insulin
sensitivity
Diet

 Obesity: 3x higher risk of CVL disease

 5 million peds 6-17 who are
overweight
 Obesity more prone to glucose
intolerance, hypertension, elev
triglycerides, low levels of HDL
Stress management

 Catecholamines E, NE, released

during stress response
 Increase platelet aggregation
 Vasospasm**
The Continuum
 Stable angina
ACS:
 Unstable angina
 Myocardial infarction

 Patient may move back & forth along

it
CAD manifestations: Stable
 Chest pain or anginal equivalents
(jaw, left arm pain)
 Nonverbals: clutching, rubbing,
stroking chest
 Increase or decrease in HR
 Increase in BP
 Dysrhythmias
Stable vs Unstable ACS
Stable:
 Angina follows predictable level of
exertion
ACS:
 Angina not necessarily associated
with activity
 EKG ST depression
CAD Treatment Initial
 Oxygen
 Aspirin
 Nitroglycerin (NTG)
 Morphine
MI (the big one)
 Angina not relieved by ntg or rest
 Assoc s/s: dizziness, dyspnea, n/v, feeling of
impending doom
 ALOC, if decreased CO
 Rales if left ventricular CHF
 Presence of S3 or S4 gallop
 Diminished pulses
 Pallor
 EKG: ST elevation, Q waves, T wave abnormalities
 Labs: elev CKMB, Trop I, elevated glucose,
leukocytosis, ESR
MI EKG changes & areas
 Inferior: 2,3, avf
 Lateral: I, avl
 Anteroseptal: v1-v3
 Anterolateral: v4-v6
 Posterior: tall r waves in v1-v2
 Right ventricular: v4r, v5r, v6r
12 lead EKG
Cardiac Enzyme studies
 Creatine kinase (CK)
 Creatine kinase isoenzyme MB
(CKMB)
 Troponin I
 Troponin T
 Lactate dehydrogenase (LDH)
 Myoglobin
CAD Picture-What???
Cardiac Enzyme studies
Creatine kinase (CK)
 Protein released into circulation from
injured myocardial cells
 Total CK rises in 4-6 hrs after MI
Creatine kinase isoenzyme MB
(CKMB)
 More reliable specific to heart muscle
 Rises 6-10 hrs after MI
Cardiac Enzyme studies
Troponin I
 Is better cardiac marker than CKMB for MI b/c is
equally sensitive yet more specific for myocardial
injury
Troponin T
 Is poorer marker than CKMB b/c less sensitive & less
specific for myocardial injury
 Begin to rise 3 hrs from onset of CP
 T I elevations may persist 7-10 days
 T T elevations may persist 10-14 days
 Great for late MI dx
Cardiac Enzyme studies
Lactate dehydrogenase (LDH)
 Exceeds normal range 24-48 hrs after
onset of AMI
 Peaks 3-6 days after onset of pain
 Returns to baseline 8-14 days after
MI
Cardiac Enzyme studies
Myoglobin
 Protein released into circulation from
injured myocardial cells
 Can be detected within a few hours after
onset of infarct
 Peaks 1-4 hrs is earlier than CK
 Not cardiac specific
 Evidence suggests increased risk of
mortality if present <6 hrs from symptom
onset with ST segment elevation & elevated
myoglobin level
What is hot in labs for CAD!!
CRP : C reactive protein- is marker for
inflammation, in past for inflammation r/t
infection
 May predict CVL disease
BNP: B type natriuretic peptide-
 Hormone whose release signals heart
failure, ventricles release hormone when
pressure rises, signaling CHF
 Only test FDA approved as aid in dx CHF
Treatment Modes
 PTCA Percutaneous transluminal coronary angioplasty
(PTCA) is a minimally invasive procedure to open up
blocked coronary arteries, allowing blood to circulate
unobstructed to the heart muscle. The procedure begins
with the doctor injecting some local anesthesia into the
groin
 Intravascular Stent
 Artherectomy - Breaking plaque
(Rotary cutting)
 Laser

 IABP The intra-aortic balloon pump (IABP) is a mechanical device that

increases myocardial oxygen perfusion and indirectly increases cardiac output
through afterload reduction. It consists of a cylindrical polyethylene balloon that
sits in the aorta, approximately 2 centimeters (0.79 in) from the left subclavian
artery.
 CABG- use of graft to supply o2 and blood to Coronary arteryThe use of
the radial artery ensures high patency is easier to harvest and removing it does
not alter the supply of blood to the arm. The radial artery is an effective graft that
should be used for coronary artery bypass graft surgery.
Cardiac Catherization
Indications:
 Confirm presence of suspected heart disease, incl
CHD, valvular, myocardial disease
 Dx severity of disease
 Preop assessm to dx if cardiac surgery is
indicated
 Eval ventricular fxn after surg revascularization
 Eval effect of medical tx modes
 Performance of specialized cardiac interventions
e.g. internal pacer placement
Cardiac Cath
Cardiac Cath
 Nursing Interventions
 Pre-catheterization
 Fasting 8-12 hours
 Assess allergy –Iodine containing substance
 Informed consent
 Post-catheterization
 Vital signs, Check circulation, bleeding, dressing
 Encourage oral fluid as tolerate
 Assess pain
 Patient teaching: Groin flexing, restraint
Cath Complications
 Dysrhythmias
 MI
 Perforation of heart, greater vessels
 Systemic embolization
 Arterial bleeding
Echocardiography
Conditions detected by Echo:
This test, often called an "echo," shows your heart’s
movement. During this exam, your doctor places a
wand on the surface of your chest. It sends
ultrasound waves that show pictures of your
heart's valves and chambers.
 Abnormal pericardial fluid
 Valvular disorders, prosthetic valves
 Ventricular aneurysms
 Cardiac tumors, myxomas (tumor in atria)
 Congential defects, ASD’s (atria Septic Defect),
VSD’s (Ventricular Septic Defect).
Echocardiography
Conditions detected by Echo:
 Cardiac chamber size
 Stroke volume & CO
 Myocardial abnormalities, subaortic
stenosis
 Wall motion abnormalities WMA)
A WMA present at rest and unchanged with exercise
was classified as fixed. It also represents myocardial
ischemia and artherosclosis
TEE
Transesophageal echo (TEE)
 Sonar device is attached to long narrow
tube & inserted into esophagus
 Allow visualization of heart function more
closely
 Only technique for imaging thrombus in
left atrial appendage
 Interarterial shunting, aortic atheroma,
vegetations on valves, thrombus on
prosthetic valves
Radionuclide Imaging
 Stannous Pyrophosphate “Hot spot”
scanning: radioisotope injection,
technetium99m
 Heart is visualized within 2 hours
 Can view MI, evaluate myocardial
perfusion, assess left ventricular
function
 Can be combined with a stress test
(exercise test) to improve accuracy of
information example use threadmill
Radionuclide Imaging
 Thallium Imaging: “Cold spot”
uptake of isotope is greater in healthy
myocardium vs. infarct area thus cold
spot
 Can be used with exercise testing
eval extent & severity of MI
 One scan early in MI then 3-4 hrs
later
 Can eval effectiveness of lytic tx
Radionuclide Imaging
 Dipyridamole potent coronary vasodilator use
during radionuclide imaging stress test this
helps to Blocks cellular reuptake of adenosine
increase blood adenosine level and in result,
promotes optimal coronary vasodilation
 In normal vessels 3-4x flow, in
stenotic vessels flow is less or no
increase at all if severe
Exercise Stress Test
Indications:
 Evaluate pt symptoms of CAD
 Dx pt physical work capacity & aerobic
capacity
 Dx pt functional capacity after MI, aids in
planning exercise rehab
 Eval exercise induced dysrhythmias
 Eval symptom free person> 40 years old
who’s at risk for CAD
 Eval pharm intervention for dysrythmias,
angina, ischemia
Exercise Stress Test: Pt prep
 RN review purpose & method of test
 Encourage avoid coffee, tea, ETOH on
test day
 Avoid smoking, taking nitro 2 hours
before test
 Wear comfortable loose fitting
clothing, women bras ok
 Consult the MD regarding any meds
before test
Who’s high risk for MI
 Elderly
 Diabetics
 Women
Complications of MI

 Dysrhythmias of all types #1 risk of MI 24

hrs MI accured.
 Heart failure, Acute pulmonary edema
 Pericarditis-Inflammation of pericardia sac
 Cardiogenic shock: s a condition in which
your heart suddenly can't pump enough
blood to meet your body's needs.
 Cardiac Tamponade
 Papillary muscle rupture, Mitral insufficiency
and valve regurgitation, pulmonary edema,
and cardiogenic shock
 Ventricular aneurysm, ventricular rupture,
ventricular septal defect
 Cardiac arrest : Sudden death
MI Nursing Interventions
 Management of Oxygenation
 Pain Management
 Psychological Support
 Activity & Rest
 Monitoring & managing dysrhythmias
 Preventing & monitoring bleeding
 Preventing & monitoring complications
 Management of elimination give laxative for
sure. IMP
 Cardiac Rehabilitation
 Health Teaching
Risk Factor Management
 Diet (low fat, low Na)
 Activity Keep HDL level up
 Stress Management
 Medication adherence, BP, DM, Beta
blockers, Ace Inhib, Statins, ASA
(asprine), NTG
Congestive Heart Failure
 Heart failure occurs
when the heart
muscle is unable to
pump effectively &
is divided into
systolic & diastolic
functions
 Systolic & diastolic
dysfxn
Right sided CHF
 Elevated CVP Cervical
vasc Pressure.
 JVD
 Dependent edema
 High Peripheral Venous pressure
 Abdominal distention GI distress and
anorexia
 Fatigue, weakness
 Liver and spleen enlargement
 Weight gain
 Ascites, increased abdominal girth
 Nocturia – night urination
Left sided CHF
 Dyspnea, orthopnea ( is shortness of breath (dyspnea)
that occurs when lying flat) nocturnal dyspnea (refers to
attacks of severe shortness of breath and coughing that
generally occur at night ).
 Fatigue
 Pulmonary congestion dyspnea, cough,
bibasilar crackles)
 Dry or moist cough
 S3 heart sound (gallop)
 Palpitations, tachycardia,
dysrhythmias
 Frothy sputum (blood tinged)
 Mental confusion
 Anorexia
Goals of treatment
 Reduce cardiac workload
 Increase force & efficiency of cardiac
contraction, improve cardiac filling
 Maintain normal cardiac output
 Correct underlying cause of heart
failure
 Prevent complications
CHF Complications
 Acute pulmonary edema
 Cardiogenic shock
 Systemic & pulmonary emboli
 Pericardial effusion & pericardial tamponade
 Dysrhythmias
 Fluid & lyte imbalance r/t diuretics
 Sudden death
 Liver failure
 Renal failure
 Coagulopathies
Surgeries
 PTCA Percutaneous Transluminal
Coronary Angioplasty
 pp 862, 885-888,
PTCA
PTCA Phases
Atherectomy
Coronary Artery Stent
Balloon vs. Stent
Intraortic Balloon Pump (last
resort)
IABP pp 841, 811
 Inserted percut or by cutdown into
the right or left femoral artery &
advanced into thoracic aorta
 Sutured into place after balloon tip
has been positioned distal to left
subclavian artery
 Balloon cath is attached to pump that
inflates & deflates with helium
 Ballon Pump only for patient have
cardiogetic Shock
IABP Console
Intraortic Balloon Pump
 Timing is extremely important of
inflation & deflation sequence
 Timing allows for maximal
counterpulsation effect
 EKG is used to trigger balloon
 Inflates just at beginning of
ventricular diastole immediately after
closure of aortic valve “IMPortant”
IABP Timing is Everything
Intraortic Balloon Pump
 The balloon remains inflated during
diastole then deflates immediately
before the next ventricular systole
 Just before aortic valve opens
 Used to provide temporary assistance
to patients circulation until underlying
condition can be corrected
 Not for those they may not be
weanable
Intraortic Balloon Pump
 Pts usually on from 2-3 days
 Pts have been on from several days
to several months
IABP (intra aortic Ballon Pump)
indications
 Cardiogenic shock secondary to Acute MI
 Low cardiac output states Emergency diagnostic
procedures on unstable cardiac patients
 Unstable cardiac patients before & during open heart
surgery
 Assistance in removing patients from cardiopulmonary
bypass post op
 Drug resistant, life threatening dysrhythmias
 Unstable angina
 Severe AMI
IABP care of patient
 Monitor VS & cardiac indices
 Titrate vasopressors & antidysrhythmic
agents to keep patient values within estb
parameters
 Monitor peripheral pulses & circl hourly
until balloon removed
 Position patient to keep affected leg
extended, avoid hip flexion (supine)
 Keep head of bed elevated to no more than
30 degrees to prevent balloon migration
IABP care of patient
 Tilt patient q 2 hours to prevent skin
breakdown ( side to side)
 Ensure appropriate devices on bed
 Monitor site keep dressing clean &
dry, change dressing q 24-72 hours
using sterile technique
 Provide teaching to patient & family
about purpose & fxn of IABP
 Support & reassurance pt & family
Coronary Artery Bypass Graft
 CAD most common e/t when artery
becomes obstructed grafting maybe
performed
 Graft allows blood to bypass obstr portion
improves blood flow & increased 02 to
myocardial tissue distal to lesion
 Can undergo single or multiple bypass
grafts at once
On Midterm
CABG
CABG
 MIDCAB: minimally invasive not in
midterm
 Incision at left sternal border vs. large
sternotomy
 Cardioplegia (intentional arrest not used)
 Cardiopulmonary bypass not used
 Most common donor vein long portion of
saphenous v. or cephalic v. then attached
to CA then ascending aorta
 Most common artery internal mammary
(right or left) bypass obstr lesion, proximal
portion left in place
CABG
CABG
Patency rates
 Internal mammary arteries better
than those for saphenous veins grafts
 40-50% of saphenous veins grafts
close within 2 yrs (not a good thing)
 90% of internal mammary remain
patent within 10 yrs
 Inter mammary contraindicated (not
used) in diabetes, obese, large
breasts
CABG POST GRAFTING
CABG Post op care 1:1
 HR & rhythm- antidysrhythmics, pacer
 Monitor Swan Ganz cath, arterial line
 Blood pressure- dopamine, dobutrex, epi, albumin,
NS, LR
 Maintain blood volume & chest drainage ( 4 chest
tube Lateraly )
 Normalize body temp
 Patent airway (ETT& vent)ABG, Sao2
 Prevent infection
 Monitor neuro status
 Monitor fluid balance
 Anticoagulation
 Rest & sleep, Nutrition & activity
 Risk of clott ********
CABG Prep & RN consideratons
Cardiac Tamponade
 Diminished or absent point of
maximum impulse.
 Diminished heart sounds
 Tachycardia
 Paradoxic pulse
 Narrowed PP
 Distended neck veins(increased CVP)
Medications MI
 Nitroglycerin (CA vasodilation,
venous pooling)
 Aspirin (antiplatelet)
 Beta blockers (reduces mortality,
second MI)
 Ace Inhibitors (reduces
remodeling)
 Ca Channel Blockers (vasospasm)
Beta blockers
 Beta blockers: e.g. Propanolol, Metoprolol
 Inhibit beta receptors & slow ventricular rate,
decreased myocardial demand
 Indications: dysrhythmias of abnormal automaticity,
triggered activity, or reentry
 Reduce 2nd MI, recurrent ischemia, decrease
fatality?
 Give PO or IV (slow push), monitor Pulse Rate/BP,
teach patient to not discontinue abruptly, monitor for
CHF in susceptible patients
 Watch for s/s CHF, hypotension, bradycardia,
don’t give with Ca Channel blockers ****
Ace Inhibitors
 Progressive structural changes in left
ventricular myocardium in pts with overt
heart failure
 Increase muscle mass, enlarged
chamber, in result reduced wall motion
 Hypokinetic ventricle, decreased EF
Ace I inhibit this remodeling process
 The prils captopril, enalapril, lisinopril,
ramipril Watch for hyperkalemia, cough,
rash, angioedema, hypotension
Meds for CHF

 ACE Inhibitors
 Diuretics
 Intropes: Digoxin, Dobutamine
 Beta Blockers
 Vasodilators: Nitrates, Nitroprusside
 Dopamine:
 Anticoagulants
Nursing Interventions
Assessment:
 Signs of pulmonary & systemic fluid
overload
 Sao2 >90%
 Hemodynamic changes
 Vital signs
 Lung sounds crackles, wheezes
Nursing Interventions
Assess:
 CBC, Lytes, ABG’s
 EKG
 Diagnostic testing
 Daily weights
 Mental alterations
 I&O
 Signs of drug toxicity if on cardiotonics
Nursing Interventions
Activities:
 Place in high folwers
 Administer oxygen
 BR until stable
 Dietary restrictions (fluid, sodium, fat)
 Emotional support, sex counseling Q&A
 Vaccinations pneumococcal & influenza
Cardiac Arrest critical thinking
 Defibrillation, cardiovert, pacing
 Airway/Meds
 IV, Intraosseous, ET, Lines later
 IV preferred then IO, then ET
 CPR
 Crowd control
 See NUR 46 Article
ET Meds
 Meds via ET 2-2.5x dose
 Instill with NS 5-10mls bag rapidly
 LANE or NAVEL are the meds!
 Preferred drug delivery routes IV/IO