Cardiovascular Disease

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					                                Cardiovascular Disease

1. Statistics Relevant to CV Disease
       a) 2.4 million deaths from cardiovascular causes in the US each year
       b) 60% of “total mortality”
       c) Directly or indirectly costs the US $133.2 billion
       d) Hypertension-
           Major component of CVD
                 i. Known as the “silent killer”
                ii. Most often patients are asymptomatic
              iii. 65 million people are hypertensive in the US
               iv. 34% are on medication
                v. 25% are on medication but not under control

2. CV Risk Factors
     a) Unmodifiable
     b) Modifiable
     c) Cardiovascular Risk Factors
     d) Unmodifiable
                     e) Age
                     f) Gender
                     g) Family history
                     h) Heredity
     i) Modifiable
                     j) Elevated serum lipids
                     k) Hypertension
                     l) High fat diet
                     m) Smoking
                     n) Stress
                     o) Physical inactivity
                     p) Obesity
                     q) Diabetes mellitus
                     r) Metabolic syndrome
                     s) Hyperhomocysteinemia
     t) Men > Women
     u) Age: CV seen younger, now; 60% over age 65 have CV dx
     v) Metabolic syndrome: group of risk factors w/ predominant factor being fat
         around the center (apple shape)
     w) Abdominal obesity
     x) Dyslipidemia
     y) HT
     z) Insulin resistant
     aa) pro thrombotic state (High fibrinigen )
     bb) Pro inflammatory state (elevated c-reactive protein)
     cc) Hyperhomocysteinemia: large level homocystein –increase PVD dx, more
         likely to clot, MI/CVA risk increase
         Blood Pressure Classification
BP Classification
                            Hyperlipidemia DBP mmHg
                       3. SBP mmHg
Normal                    <120 a) HDL:and   <80

Prehypertension           120–139b) LDL
                                      or    80–89
                                 c) Triglycerides
Stage 1 Hypertension     140–159    or     90–99

Stage 2 Hypertension        Hypertension >100
                       4. >160      or

                               a) Normal BP
                               b) Prehypertension
                               c) Stage 1 HTN
                               d) Stage 2 HTN


                       5. Target Organ Damage: Damage that occurs to major organs fed by circulatory system
                          from untreated/prolonged HT
                             a) Heart: LV

                       6. Lifestyle Modification


                       7. Geriatric Issues with HTN

                       8. Hypertensive Urgency
                             a) Urgent: very high BP, NO acute
                             b) Rq. Tx but NOT necessarily hospitalization


                       9. Hypertensive Emergency
                             a) Presence of acute target organ damage
                             b) Tx and hospitalization

                       10. Resistant HTN


                       11. Acute Coronary Syndrome



                       12. Angina
                              Stable               Unstable         Variant             Silent Ischemia
                                                                    (Prinzmetals)
                           Predictable             Unpredictable    Less common         Patient has no
                                                                                        symptoms but
                                                                                        objective data is
                                                                                        found on ECG
                           Lasts 3-5 minutes Pain in not            Due to a spasm      Diabetic and
                           relieved by rest or of a coronary             hypertensive
                           sublingual                                    patients
                           nitroglycerin                                 commonly have
                                                                         silent ischemia
   Commonly                Considered a           artery                 Fatigue, nausea,
   subsided with           medical                                       vomiting and
   relief of               emergency                                     diaphoresis may
   precipitating                                                         be signs of
   factor (usually                                                       ischemia
   exertion) or with
   nitrates (NTG)
   Typically does          Atherosclerotic        Often occurs at        Patient has no
   not last longer         instability            rest                   symptoms but
   than 20 minutes                                                       objective data is
   after rest &/or                                                       found on ECG
   giving NTG
   Stable                  “rule-out”             Can be                 Diabetic and
                           Myocardial             associated with        hypertensive
                           infarction             smoking, ETOH,         patients
                                                  or illegal drug use    commonly have
                                                                         silent ischemia

       a) Prinzmetal’s
       b) Silent Ischemia
       c) Always consider angina a priority
               i. must rule out cardiac contribution, even if it seems like it is d/t
                  something else
13. Nursing Interventions for Cardiac Chest Pain
       a) Assess chest pain is #1
       b) Have patient sit or lie down
       c) Administer Oxygen
       d) Obtain VS
       e) Administer prn meds for chest pain (NTG, morphine)
       f) Call doctor.
       g) Continuously assess patient’s chest pain and patient’s status
       h) Nurse should remain with patient.
       i) Administer aspirin and beta-blocker if ordered
       j) Monitor cardiac rhythm and rate
       k) Ausculatate heart and lung sounds
       l) Obtain 12-lead ECG
       m) Determine cardiac serum biomarkers (CK, CK-MB, Troponin)
       n) Diet: low salt, low fat; small, frequent meals
       o) Avoid straining (laxatives if needed)– avoid Valsalva

14. Diagnostic
       a) history and physical
       b)   chest x-ray
       c)   serum lipids
       d)   cardiac enzyme values
       e)   ECG
       f)   stress testing (treadmill, pharmacologically induced)
       g)   coronary angiography

15. Treatment (same tx as PVD, just in cardiac vessels)
       a) PTCA: Percutaneous Transluminal Coronary Angioplasty
               i. Looking at cardiac vessels and opening diameter
              ii. Except in variant angina (vasospastic)
             iii. Angioplasty: balloon catheter that squishes plaque up against
                  endothelium wall
       b) Stent: use PTCA; wire mesh to prevent re-closing
       c) Atherectomy: clean out vessel
       d) Coronary Artery Bypass Surgery

16. Pharmacologic/Lifestyle Recommendations
       a) A: Aspirin and anti-anginals
       b) B: Beta-blocker and blood pressure
       c) C: Cholesterol and cigarettes
       d) D: Diet and diabetes (sodium, fat, control DM)
       e) E: Education and exercise

17. Drug Rx for Angina
       a) Antiplatelet Therapy- ASA is the drug of choice; Plavix may be initiated but
          is expensive
       b) Nitrates- SL, topical, oral, or IV
               i. Rules SL nitro: kept in brown bottle away from extreme temp, replace
                  q 3 months
                      1. Sit and wait five minutes, then take 1st nitro
                      2. Give 3 tabs, 5 minutes apart, no relief w/ rest and nitro, call
                          911
                      3. Wear gloves when handling nitro
                      4. Topical: make sure to clean off old med
       c) Beta-adrenergic Blockers- decrease myocardial contractility, HR, SVR, and
          BP to reduce the myocardial O2 demand
       d) Calcium Channel Blockers- decrease SVR, decrease myocardial contractility,
          & cause coronary vasodilatation

18. Nursing Management
       a) Assess
              i. subjective: health hx, meds, and functional health patterns
             ii. objective: general, skin, cardiovascular, and test results
       b) Diagnoses
              i. pain, anxiety, decreased CO, activity intolerance, knowledge deficit
       c) Planning
               i. w/ activity intolerance: prioritize most important activities
              ii. periods of activity and rest
       d) Implementation
               i. acute:
                      1. O2
                      2. obtain VS
                      3. 12-lead EKG
                      4. prompt pain relief
                      5. physical assessment of the chest
                      6. position the patient for comfort
              ii. chronic:
                      1. identify precipitating factors of angina and avoid
                      2. avoid extremes in weather
                      3. caution against large heavy meals (shunts blood to GI)
                      4. regular exercise
                      5. teach pts how to use NTG (keep it w/ them all the time)
                      6. assess need for psychologic adjustment to illness
             iii. The nurse will teach:
                      1. s/s of angina
                      2. How to use NTG
                      3. When to notify the doctor and when to call 911
                      4. Avoid Valsalva
                      5. Diet- low fat, low salt
                      6. Stop smoking
                      7. Control HTN and DM
                      8. Increase physical activity (cardiac rehab when appropriate)
                      9. Medication compliance and side effects
                      10. Reduce/cope with stress

19. Congestive Heart Failure – a syndrome – not a disease
       a) syndrome, not a disease
       b) occurs due to the heart’s inability to pump an adequate amount of blood to
          meet the needs of the body’s tissues
       c) often associated with long-standing hypertension and coronary artery disease
       d) Can be r/t valvular disorder

20. Statistics
        a) 4.9 million Americans have CHF
        b) 50% 5 year mortality
        c) sudden cardiac death in patients with CHF is 6-9 times higher than the
            general pop.
                i. Afib and heart stops= sudden cardiac death
        d) most frequent cause of hospitalization for people > 65 years and older
        e) half of deaths from heart disease are due to end-stage CHF
21. Risk Factors
       a) CAD
       b) increase age
       c) hypertension (threefold risk)
       d) diabetes mellitus
       e) cigarette smoking
       f) obesity
       g) hyperlipidemia
       h) proteinuria- target organ damage

22. Chronic CHF
       a) CAD
       b) Hypertensive Heart Dis.
       c) Rheumatic Heart Dis.
       d) Congenital Heart Dis.
       e) Cor pulmonale
       f) Cardiomyopathy
       g) Anemia
       h) Bacterial endocarditis

23. Acute CHF
       a) Myocardial infarction
       b) Arrhythmias
       c) Pulmonary emboli
       d) Thyrotoxicosis
       e) Hypertensive crises
       f) Rupture of papillary muscle
       g) Ventricular septal defect

24. Left Sided Failure
       a) Left-Sided
       b) related to left ventricular dysfunction
       c) causes pulmonary congestion
       d) usually due to CAD, HTN, cardiomyopathy, or rheumatic heart disease

25. Right Sided Failure
       a) backward flow to the right atrium and venous circulation
       b) venous congestion causes sx of edema, hepatomegaly, spleenomegaly, Gi
           congestion, & JVD
       c) primary cause: left-sided failure

26. Clinical Manifestations of Acute CHF
        a) manifests itself as pulmonary edema
        b) lung alveoli become filled with fluid
        c) SX:
        d) agitated, pale, possible cyanotic
       e)   skin is clammy and cold
       f)   severe dyspnea, RR > 30
       g)   wheezing, coughing, frothy pink sputum
       h)   HR rapid and BP may be increased or decreased depending on severity


27. Clinical Manifestations of Chronic CHF
        a) Fatigue
        b) Dyspnea (orthopnea, PND) (NOT AS MUCH AS ACUTE)
        c) Tachycardia SAME
        d) Edema PERIPHERA EDEMA
        e) Nocturia
        f) Skin Changes
        g) Behavioral Changes
        h) Chest Pain
        i) Weight Changes (MOST IMPORTANT THING TO TEACH PT. IS
           DAILY WEIGHT. 2-5 LB WEIGHT GAIN, CALL MD
        j) *NYHA Classifications* (see your book for 2 classification systems) FYI

28. Complications of CHF
      a) Pleural effusion
      b) Arrhythmias- #1 COMPLICATION-poor perfusion
      c) Hepatomegaly

29. Management of Acute CHF
      a) Improve left ventricular function by:
               i. decreasing intravascular volume and decreasing venous return
                  (preload)-- diuretics, nitrates, and high Fowler’s position
              ii. decrease afterload (Nipride, Morphine)
            iii. improve gas exchange (O2)
             iv. improve cardiac function (digitalis, dobutamine, amrinone, milrinone)
              v. reduce anxiety
30. Management of Chronic CHF
      a) Treat the underlying cause
      b) Oxygen supplementation
      c) Physical and emotional rest to conserve energy and decrease the need for
          additional oxygen
      d) Mechanical options-
               i. Intra-aortic balloon pump
              ii. ventricular assist devices

31. ABCD’s of Drug Therapy
      a) A: ASA (related to CAD)
              i. ACE-I (vasodilator)
      b) B: Beta-Blockers (Coreg, Zebeta , Toprol)
              i. Beta-adrenergic agonists
      c) C: Cholesterol (related to CAD)
      d) D: Diuretics (thiazides, loops, potassium-sparing)
             i. Digitalis (monitor for toxicity)

32. Nutritional Therapy in Chronic CHF
       a) Sodium restriction- 2 grams/day, severe CHF 500-1000mg/day
       b) Fluid restrictions- varies ie. 1000mL qd
       c) Weigh daily and monitor fluid retention (same time qd)

33. Pharmacology Review
       a) Antiplatelets
       b) ACE Inhibitors
       c) ARBs
       d) Beta-Agonists
       e) Beta Blockers
       f) Cholesterol Drugs
       g) Calcium Channel Blockers
       h) Digoxin
       i) Diuretics
       j) Nitrates