Introduction to Cardiovascular Disorders By Dr. Hanan Said Ali

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Introduction to Cardiovascular DisordersBy Dr.
Hanan Said Ali
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Learning Objectives

• Identify Anatomy of the Heart .
• Enumerates the etiology of cardiovascular
• diseases.
• Identify Cardiac Signs and Symptoms.
• Discuses different diagnostic measures for
• cardiovascular diseases.
• List the treatment modalities for cardiovascular
• diseases.

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What are The Anatomy of the Heart ?

• The heart is a hollow, muscular organ located
  in the centre of the thorax. It composed of
  three layers .The inner layer,or endocardium ,
  the middle layer, or myocardium,the exterior
  layer of the heart is called the epicardium.
  The right heart, made up of the right atrium
  andright ventricle The left side of the heart,
  composed of the left atrium and left ventricle

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Anatomy of the Heart Cont.
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Anatomy of the Heart Cont.
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Cardiac Cycle

• It has two phases
• (A) Diastole ventricles relax fill with
• blood (This is 2/3 of the
• cardiac
  cycle.)
• (B) Systolic heart contracts pushes
• blood out of the ventricles
  to
• (i) the lungs
• (ii) systemic arteries

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Etiology

• Heredity
• Increasing age
• Gender
• Hypercholesterolemia
• Smoking
• Diabetes
• Physical inactivity
• Obesity
• Stress

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Cardiac Signs and Symptoms

• Chest pain, chest discomfort ,angina pain
• Assessing Signs and Symptoms
• Where is your pain (ask patient to point to
  location on chest)
• What does the pain feel like? (pressure,
  heaviness, burning)
• How severe is it on a scale of 0 to 10?
• What causes the pain? (exertion, stress)

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Cardiac Signs and Symptoms Cont.

• Does anything relieve it? (rest, or
  nitro-glycerine)
• Does it spread to your arms, neck, jaw,
  shoulders, or back? , How long does the pain
  last?
• Do you have any additional symptoms? (shortness
  of breath, palpitations, dizziness, sweating)

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Cardiac Signs and Symptoms Cont.

• Shortness of breath, oedema, weight gain
• Assessing Signs and Symptoms
• When did you first notice feeling short of
  breath?
• Do you have a cough? If yes, what do you cough
  up?
• What makes you short of breath? Does anything
  make your breathing better or worse?

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Cardiac Signs and Symptoms Cont.

• What activities are you no longer able to do
  because you are short of breath?
• Do you ever wake up at night feeling short of
  breath?
• Do you get up at night to urinate? Have you
  noticed an increase or decrease in the amount you
  usually urinate?

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Cardiac Signs and Symptoms Cont.

• Have you noticed any weight gain or swelling in
  your feet, ankles, legs, or abdomen (sacrum if
  bedridden)?
• How many pillows do you sleep on, and has this
  changed recently?
• Do you sleep in your bed, or do you breathe
  easier sleeping in a chair?

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Cardiac Signs and Symptoms Cont.

• Assessing Signs and Symptoms
• Palpitations
• Do you ever feel your heart racing, skipping
  beats, or
• pounding?
• Do you ever feel lightheaded or dizzy?
• Are there any other symptoms that occur at the
  same
• time?
• How much caffeine do you consume?

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Cardiac Signs and Symptoms Cont.

• Do you use tobacco (cigarettes, cigars)?
• Do you use any other stimulants?
• Have there been any changes in the amount of
  stress you experience?
• How would you describe your usual activity
  level

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Cardiac Signs and Symptoms Cont.

• Assessing Signs and Symptoms
• Fatigue
• How would you describe your usual activity
  level?
• What is your current activity level?
• What were you able to do 1 month and 6 months
  ago?
• What activities can you no longer do because of
  fatigue?

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Cardiac Signs and Symptoms Cont.

• Do you feel rested when you wake up in the
  morning?
• Can you rest during the day?
• How often do you awaken at night, and for what
  reason?

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Cardiac Signs and Symptoms Cont.

• Assessing Signs and Symptoms
• Dizziness, syncope
• Do you ever feel dizzy or lightheaded?
• Do you ever pass out or have fainting spells?
• Does this happen when you move from a lying to
  a sitting or standing position?

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Cardiac Signs and Symptoms Cont.

• Do you strain while having a bowel movement or
  when urinating?
• Have you been urinating more than usual?
• Have you decreased the amount of fluids you
  normally drink?
• Do you have headaches?

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Laboratory TestsCardiac Enzyme Analysis

• Enzymes are released from injured cells when the
  cell membranes rupture.
• Most enzymes are nonspecific in relation to the
  particular organ that has been damaged.
• Certain isoenzymes, however, come only from
  myocardial cells and are released when the cells
  are damaged by sustained hypoxia, resulting in
  infarction.

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Laboratory TestsCardiac Enzyme Analysis Cardiac
Enzyme Analysis

• Creatine kinase (CK) and its isoenzyme CK-MB
• are the most specific enzymes analyzed in acute
  MI.
• Total Creatinine Phosphokinase (CPK)30 - 200
  U/L
• CK..... 50 80 U/L CPK-MB.. 0 - 8.8 ng/m

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Cardiac Enzyme Analysis Cont.

• Troponin I
• Is new laboratory test and is a contractile
  protein found only in cardiac muscle. After
  myocardial injury, elevated serum troponin I
  levels can be detected within 3 to 4 hours they
  peak in 4 to 24 hours and remain elevated for 1
  to 3 weeks.
• Normal level ....... 0 0.4 ng/ml

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CHOLESTEROL LEVELS

• Cholesterol (normal level less than 200 mg/dL)
• Elevated cholesterol levels are known to increase
  the risk for coronary artery disease.
• Factors that contribute to variations in
  cholesterol levels include age, gender, diet,
  exercise patterns, and stress levels.

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CHOLESTEROL LEVELS Cont.

• LDLs (normal level less than 130 mg/dL)
• One harmful effect of LDL is the deposition of
  these substances in the walls of arterial
  vessels. Elevated LDL levels are associated with
  a greater incidence of coronary artery disease.
• HDLs (normal range in males 35 to 65 mg/dL,
  normal range in females 35 to 85 mg/dL) have a
  protective action.
• Triglycerides (normal range 40 to 150 mg/dL),

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SERUM ELECTROLYTE LEVELS

• the serum sodium level reflects relative fluid
  balance. Generally, hyponatremia (low sodium
  level) indicates fluid excess and hypernatremia
  (high sodium level) indicates fluid deficit.
• Serum potassiumA decrease in potassium causes
  cardiac irritability and predisposes the patient
  receiving a digitalis preparation to digitalis
  toxicity and dysrhythmias.
• The effect of an elevated serum potassium level
  is myocardial depression and ventricular
  irritability.

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BLOOD UREA NITROGEN LEVEL

• In the patient with cardiac disease, an elevated
  blood urea nitrogen level may reflect reduced
  renal perfusion (from decreased cardiac output)
  or intravascular fluid volume deficit (from
  diuretic therapy)
• SERUM GLUCOSE LEVEL
• The serum glucose level is important to monitor
  because many patients with cardiac disease also
  have diabetes mellitus.

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COAGULATION STUDIES

• The values of PTT is used to assess patients
  receiving heparin therapy. Patients receiving
  heparin have their PTT levels maintained at 1.5
  to 2.5 times their baseline values
• (reference range, 25 to 38 seconds).
• Prothrombin time (PT)
• is used to monitor patients receiving therapeutic
  anticoagulation with warfarin.
• (reference range, less than 13 seconds).

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Chest X-Ray and Fluoroscopy

• A chest x-ray usually is obtained to determine
  the size, contour, and position of the heart.
• It reveals cardiac and pericardial
  calcifications and demonstrates physiologic
  alterations in the pulmonary circulation.
• Correct placement of cardiac catheters, such as
  pacemakers and pulmonary artery catheters, is
  also confirmed by chest x-ray.

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Electrocardiography

• It is a graphic recording of the electrical
  activity
• of the heart.
• The ECG is obtained by placing disposable
  electrodes in standard positions on the skin of
  the chest wall and extremities.
• The 12-lead ECG is particularly useful in
  diagnosing dysrhythmias, conduction
  abnormalities, enlarged heart chambers,
  myocardial ischemia or infarction.

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Continuous ECG Monitoring

• Continuous ECG monitoring is standard for
  patients at high risk for dysrhythmias.
• This monitor is a small tape recorder that
  continuously (from 10 to 24 hours) documents the
  hearts electrical activity on a magnetic tape.
• The patient keeps a diary of activity, noting the
  time of any symptoms, experiences, or unusual
  activities performed.

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TRANSTELEPHONIC MONITORING

• The patient attaches a specific lead system for
  transmitting the signals and places a telephone
  mouthpiece over the transmitter box the ECG is
  recorded and evaluated at another location.
• This method is often used for diagnosing
  dysrhythmias and in follow-up evaluation of
  permanent cardiac pacemakers.

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Cardiac Stress Testing

• It include three types of test
• The exercise stress test.
• The pharmacologic stress test.
• And more recently the mental or emotional stress
  test, mental stress induced, for example, when
  the patient performs a mental arithmetic test
  evokes a myocardial ischemia response similar to
  that evoked by conventional exercise testing.

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Cardiac Stress Testing Cont.

• Exercise Stress Testing
• the patient walks on a treadmill (most common) or
  pedals a stationary bicycle.
• During the test, the following are monitored
• two or more ECG leads for heart rate, rhythm, and
  ischemic changes, BP, skin temperature, physical
  appearance, perceived exertion, and symptoms
  including chest pain, dyspnea, dizziness, leg
  cramping, or fatigue.

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Cardiac Stress Testing Cont.

• the patient is instructed to fast for 4 hours
  before the test and to avoid stimulants such as
  tobacco and caffeine.
• The physician may instruct patients not to take
  certain cardiac medications, such as beta
  blockers, before the test.
• Clothes and sneakers or rubber-soled shoes
  suitable for exercising are to be worn

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Cardiac Stress Testing Cont.

• Pharmacologic Stress Testing
• Two vasodilating agents, dipyridamole (Persantin)
  and adenosine administered intravenously are used
  to mimic the effects of exercise by maximally
  dilating the coronary
• arteries.
• Dobutamine is another medication that may be used
  for patients who cannot exercise.

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• patients are instructed not to eat or drink
  anything for at least 4 hour before the test.
• This includes chocolate, caffeine, caffeine-free
  coffee, tea.
• Patients taking aminophylline or theophylline are
  instructed to stop taking these medications for
  24 to 48 hours before the test because it block
  the effects of dipyridamole and adenosine

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Echocardiography

• Echocardiography is a non invasive ultrasound
  test used to examine the size, shape, and motion
  of cardiac structures.
• It involves the transmission of high frequency
  sound waves into the heart through the chest wall
  and the recording of the return signals.
• Other techniques, such as Doppler and color flow
  imaging echocardiography, show the direction and
  velocity of the blood flow through
• the heart.

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Echocardiography
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Transesophageal Echocardiography

• A small transducer through the mouth and into the
  esophagus.
• provides clearer images because ultrasound waves
  are passing through less tissue.
• It used in detecting and evaluating the severity
  of coronary artery disease.
• The patient must be assessed before TEE for a
  history of dysphagia or radiation therapy to the
  chest that would increase the risk for
  complications.

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Transesophageal Echocardiography

• Gel applied to the skin helps transmit the sound
  waves.
• The test takes about 30 to 45 minutes.
• In preparation for a TEE study, the following
  information is reviewed
• The patient must fast for 6 hours before the
  study.
• An intravenous line is started for
  administering dobutamine and a sedative.
• The throat is anesthetized before the probe is
  inserted.
• BP and the ECG are monitored throughout the
  study.

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Radionuclide Imaging

• Myocardial Perfusion Imaging
• Thallium 201, a radioisotope, is used to assess
  myocardial perfusion.
• A dose of thallium 201 is injected into the
  intravenous line, images are taken immediately.
• Areas that do not show thallium uptake are noted
  as defects and indicate either an area of
  infarction or stress-induced myocardial ischemia.

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Radionuclide Imaging cont.

• Technetium (Tc-99m) is a newer and better
  radioisotope used for cardiac imaging.
• The patient may be concerned about receiving a
  radioactive substance and needs to be assured
  that these tracers are safe, having radiation
  exposure similar to that of other diagnostic
  x-rays.
• No post procedure radiation precautions are
  necessary.

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Cardiac Catheterization

• Is an invasive diagnostic procedure in which
  radiopaque arterial and venous catheters are
  introduced into selected blood vessels of the
  right and left sides of the heart.
• Is used most commonly to assess coronary artery
  patency and to determine if revascularization
  procedures are necessary

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Cardiac catheterization Cont.
Coronary dilatation
Cardiac catheterization
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Cardiac Catheterization cont.

• During cardiac catheterization, the patient will
  have an intravenous line in place,
• BP and ECG tracings are continuously monitored.
• Resuscitation equipment must be readily available
  during the procedure because the introduction of
  catheters into the ventricles can induce
  potentially fatal dysrhythmias.

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Cardiac Catheterization cont.

• The patient is assessed before the procedure for
  previous reactions to contrast agents or
  allergies to shellfish.
• Diagnostic cardiac catheterizations are commonly
  performed on an outpatient basis and require 8
  hours or less of bed rest for recovery.

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Angiography

• Cardiac catheterization is usually performed with
  angiography, a technique of injecting a contrast
  agent into the vascular system to outline the
  heart and blood vessels.
• Common sites for selective angiography are the
  aorta, the coronary arteries, and the right
• and left sides of the heart.

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Angiography

• NURSING INTERVENTIONS
• Instruct the patient to fast, usually for 8 to 12
  hours, before the procedure.
• Prepare the patient for the expected duration of
  the procedure indicate that it will involve
  lying on a hard table for less than 2 hours.
• Reassure the patient that mild sedatives will be
  given intravenously to relieve anxiety.

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Cardiac Catheterization cont.

• Nursing responsibilities after cardiac
  catheterization may include the following
• Observe the catheter access site for bleeding or
  hematoma formation, and assess the peripheral
  pulses in the affected extremity. Observe for
  dysrhythmias
• Evaluate temperature and color of the affected
  extremity
• and any patient complaints of pain, numbness, or
  tingling
• sensations in the affected extremity to
  determine signs of
• arterial insufficiency.

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Hemodynamic Monitoring

• Central Venous Pressure Monitoring
• The CVP, the pressure in the vena cava or the
  right atrium, is used to assess right ventricular
  function and venous blood return to the right
  heart.
• The range for a normal CVP is 0 to 8 mm Hg
• Before insertion of a CVP catheter, the site is
  prepared by shaving
• if necessary and cleansing with an antiseptic
  solution.
• A local anesthetic may be used.

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Central Venous Pressure Monitoringcont.

• The physician threads a single-lumen or
  multilumen catheter through the external jugular,
  or femoral vein into the vena cava just above or
  within the right atrium.
• Once the CVP catheter is inserted, it is secured
  and a dry sterile dressing is applied.
• The most common complications of CVP monitoring
  are infection and air embolism.

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Treatment modalities

• Pharmacologic therapy
• Control risk factors
• Transmyocardial laser revascularization
• Coronary artery bypass grafting (CABG)
• Revascularization
• -Invasive interventional procedures Percutaneous
  Transluminal Coronary Angioplasty (PTCA)
• -Directional Coronary Atherectomy (DCA)
• -Laser ablation
• -Intracoronary stent

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• Thank You