Cardiovascular Disorders

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Cardiovascular Disorders
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Coronary Artery Disease

• Etiology
• Atherosclerosis
• Thrombosis
• Spasm
• Coronary dissection
• Aneurysm formation

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Nonmodifiable CAD Risk Factors

• Age
• Gender
• Family history
• Race

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CAD Risk Factors

• Elevated serum lipids
• Hypertension
• Cigarette smoking
• Impaired glucose tolerance
• Oral contraceptives

• Diet high in saturated fat, cholesterol and
  calories
• Obesity
• Physical inactivity
• Stress/anxiety
• CRP

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Pathophysiology of Coronary Artery Disease

• Atherosclerotic plaque narrows lumen of
  artery
• Angina discrepancy between oxygen supply and
  demand causes hypoxia
• Plaque rupture and coronary thrombosis
• Plaque regression is possible with change in risk
  factors

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Acute Coronary Syndromes

• Angina - coronary ischemia
• Stable angina- predictable fixed lesions
• Unstable angina- more intense, different from
  stable angina
• Variant angina (Prinzmetal angina) caused by
  coronary artery spasm
• Silent ischemia-ECG evidence without subjective
  symptoms

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Angina

• Location
• Duration
• Quality
• Radiation
• Precipitating factors
• Medication relief

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Medical Management for Angina

• Increase coronary artery perfusion to the
  myocardium
• nitrates
• Prevent myocardial infarction disability or
  death
• Actively intervene in acute coronary syndromes

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Nursing Management of CAD and Angina

• Assessment of chest pain
• Relief of pain
• Maintain a calm environment
• Coronary precautions
• Patient education

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Myocardial Infarction

• Irreversible necrosis due to an abrupt decrease
  or total cessation of coronary blood flow
• New coronary artery thrombosis
• Coronary artery thrombosis

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Cardiovascular Disorders

• Infarction development of pathologic Q waves
• Injury elevated ST segments
• MI Evolution occurs over 6 weeks after
  infarction

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MI

• MI Location
• Anterior wall
• Anteroseptal MI
• Anterolateral MI
• Inferior wall MI
• Right ventricular MI
• Posterior wall MI

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MI

• Diagnosis of AMI
• Clinical symptoms
• 12-lead ECG changes
• Cardiac enzyme levels

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Dysrhythmias and Acute MI

• Bradycardias
• Bundle branch block
• Varying degrees of heart block
• Atrial and ventricular dysrhythmias

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Complications of Myocardial Infarction

• Pericarditis
• Cardiac rupture
• Sudden death
• Heart failure
• Pulmonary edema
• Cardiogenic shock

• Dysrhythmias
• Ventricular aneurysm
• Ventricular septal defect
• Papillary muscle rupture

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Medical Management of AMI

• Preservation of myocardium
• IV Thrombolysis
• Emergency angioplasty/stent
• Emergency coronary artery bypass surgery for
  occlusion of left main coronary artery or rupture
  of papillary muscle

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CABG
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Medical Management of AMI

• Pain control morphine and oxygen
• Management of complications
• Pharmacologic therapy
• Anticoagulation
• Reduction of myocardial workload
• nitrates
• Analgesia

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Nursing Management

• Patient assessment
• Control of anginal pain
• Balance myocardial oxygen supply and demand and
  optimize cardiac output
• Prevent complications
• Patient education

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Sudden Cardiac Death (SCD)

• Ventricular Tachycardia or Fibrillation
• Causes of sudden cardiac death (SCD)
• Heart failure
• Hypertrophic cardiomyopathy
• Hypertrophic obstructive cardiomyopathy
• Dilated cardiomyopathy
• Coronary artery disease
• Myocardial infarction
• Severe aortic stenosis
• Wolf-Parkinson-White syndrome
• Long QT interval

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Wolf-Parkinson-White
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Precipitating Causes of Heart Failure

• Reduction or cessation of medication
• Dysrhythmias
• Systemic infection
• Pulmonary embolism
• Physical, environmental and emotional stress

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Clinical Manifestations of Left Heart Failure

• Tachypnea Fatigue
• Tachycardia Dyspnea
• Cough Orthopnea
• Bibasilar crackles Paroxysmal nocturnal dyspnea
  
• Gallop rhythms (S3/S4) Nocturia
• Increased PA pressures
• Hemoptysis
• Cyanosis
• Pulmonary edema

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Clinical Manifestations of Right Heart Failure

• Peripheral edema Weakness
• Hepatomegaly Anorexia
• Splenomegaly Indigestion
• Hepatojugular reflux Weight gain
• Ascites Mental changes
• Jugular venous distention
• Increased CVP
• Pulmonary hypertension

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Complications of Heart Failure

• Shortness of breath
• Dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Cardiac asthma
• Pulmonary edema

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Medical Management of Heart Failure

• Relief of symptoms and enhancement of cardiac
  performance
• Correct precipitating causes

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Nursing Management

• Optimize cardiopulmonary function
• Optimize cardiac output
• Pulmonary artery catheter
• Preload
• Afterload
• Contractility
• Promote rest
• Pharmacologic therapy
• Provide nutrition
• Skin integrity
• Patient education

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Endocarditis

• Predisposing factors
• Rheumatic heart disease
• Congenital heart disease
• Mitral valve prolapse
• Marfan syndrome
• Peripheral arteriovenous fistulas
• Indwelling intravenous or intraarterial catheters
• Cardiac and prosthetic valve surgery
• Prosthetic aortic grafts

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Endocarditis

• Predisposing factors
• Degenerative heart disease
• Alcoholism
• Chronic hemodialysis
• Intravenous drug abuse
• Immunosuppression
• Severe burns

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Endocarditis/Myocarditis

• Causative organisms
• Streptococci/staphylococci 75-85
• RNA viruses
• DNA viruses

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Endocarditis

• Clinical manifestations
• Fever
• Splenomegaly
• Hematuria
• Petechiae
• Cardiac murmurs
• Easy fatigability
• Splinter hemorrhages in nailbeds

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Endocarditis

• Medical management
• Nursing management
• Resolve infection
• Prevent complications
• Activity as tolerated
• Patient education

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Valvular Heart Disease

• Etiology
• Rheumatic fever
• Infective endocarditis
• Inborn defects of connective tissue
• Dysfunction or ruptures of papillary muscles
• Congenital malformations
• Aging valve tissue

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Valvular Heart Disease

• Mitral valve stenosis
• Mitral valve regurgitation
• Aortic valve stenosis
• Aortic valve regurgitation
• Tricuspid valve stenosis
• Tricuspid valve regurgitation
• Pulmonic valve disease
• Mixed valvular lesions

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Valvular Heart Disease

• Medical management
• Pharmacologic therapy to control symptoms of
  heart failure
• Surgical replacement or repair
• Nonsurgical procedures

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Valvular Heart Disease

• Nursing management
• Maintenance of adequate cardiac output
• Pulmonary artery catheter (Swan-Ganz)
• Preload
• Afterload
• Optimizing fluid balance
• Patient and family education

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Atherosclerotic Diseases of the Aorta Aneurysm
and Dissection

• Atherosclerotic changes in the thoracic and
  abdominal aorta
• Blunt trauma
• Marfan syndrome
• Pregnancy
• Injury or dissection

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Indications for Aortic Aneurysm Repair

• Aneurysm greater than 5 cm
• Aneurysm progressively increasing in size
• Impending rupture
• Symptoms resulting from cerebral or coronary
  ischemia
• Uncontrollable pain
• Aortic insufficiency

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Aortic Aneurysm/Dissection

• Medical Management
• Control of hypertension
• Control of pain if dissecting
• Surgery for ascending thoracic involvement
• Surgery for progressive dissection

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Aortic Aneurysm/Dissection

• Nursing Management
• Frequent assessments
• Hypertension management
• Pain control
• Patient education

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Peripheral Vascular Disease

• Arterial vs. Venous
• Atherosclerosis is most common cause of chronic
  arterial occlusion
• Risk factors are the same as for CAD
• Other causes diabetes, smoking, hypertension,
  hyperlipidemia and male gender

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Peripheral Vascular Disease

• Assessment and Diagnosis
• Intermittent claudication
• Rest pain
• Acute occlusion
• Atrophic tissue changes

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Peripheral Vascular Disease

• Medical Management
• Control or eliminate risk factors
• Good foot care
• Alterations in life style to promote rest and
  pain relief
• Angioplasty, stents or surgery

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Peripheral Vascular Disease

• Nursing Management
• Assess quality of peripheral pulses and tissue
  perfusion
• Protect skin integrity
• Pain control
• Patient education

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Carotid Artery Disease

• 90 caused by atherosclerosis leading to
  embolism or thrombosis
• Other causes
• Fibromuscular dysplasia
• Irradiation
• Carotid dissection
• Arteritis

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Carotid Artery Disease

• Manifestations
• Neurologic deficits
• Transient ischemic attacks
• Reversible ischemic neurologic deficits
• Completed stroke
• Medical management
• Reduce risk factors
• Surgery for gt75 stenosis

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Carotid Artery Disease

• Nursing Management
• Assessment of adequate cerebral perfusion
• Neurologic assessment
• Level of consciousness, mental alertness and
  cerebral perfusion, cranial artery function
• Patient education

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Deep Vein Thrombosis

• Symptoms
• Occlusive clot
• Inflammation
• Pain
• Tenderness and redness
• Location deep vein of the leg, pelvis, and
  rarely the arm

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Deep Vein Thrombosis

• Etiology thrombophlebitis or injury and
  inflammation of the vein
• Virchows Triad
• Stasis of blood
• Endothelial injury
• Hypercoagulability

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Deep Vein Thrombosis

• Assessment and diagnosis
• Medical management
• Nursing management
• Activity
• Prevent complications
• Monitor anticoagulant therapy
• Patient education

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Hypertensive Crisis

• Emergencies with risk of end-organ damage
• Hypertensive urgencies, which are characterized
  by a serious elevation in blood pressure but do
  not put the patient at risk for end-organ damage
• Rise in diastolic pressure gt 120-130mm Hg

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Hypertensive Crisis

• Etiology
• Known hypertension
• Acute renal failure
• Acute central nervous system events
• Drug-induced hypertension
• Ingestions of tyramine while on an MAO inhibitor
• Pregnancy-induced eclampsia
• Pheochromocytoma

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Hypertensive Crisis

• Assessment and diagnosis
• CNS compromise
• Cardiovascular compromise
• Acute renal failure
• Catecholamine excess
• Diagnostic studies
• 12-lead ECG and intraarterial line

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Hypertensive Crisis

• Medical management Emergencies
• Admission to critical care
• Parenteral antihypertensive therapy
• Labetalol (alpha/beta adrenergic blocker)
• Nitroprusside (vasodilator)
• Arterial line
• Medical management Urgencies
• Oral antihypertensives and diuretics
• Lower BP only 20 to avoid cerebral ischemia

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Hypertensive Crisis

• Nursing Management
• Control BP without causing other complications
• Monitor for changes in neurologic, cardiovascular
  and renal systems
• Monitor effects of pharmacologic agents used
• Patient education