chronic heart diseases

8/11/2019 Chronic Heart Diseases

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CHRONIC HEART DISEASES



Review of ANATOMY & PHYSIOLOGY



What is Cardiac Output?

What is Stroke Volume?

What is normal HR?

Why are these important?

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Factors affecting Stroke Volume

Preload: the amount of blood remaining inthe ventricles at the end of diastole or thepressure generated at the end of diastole

Contractility: is the ability of the cardiacmuscle fibers to shorten and produce amuscle contraction.

Afterload: amount of pressure the Ventriclemust overcome to eject blood volume out



Autonomic Nervous SystemBuilt in control center of the body

Regulates functions not under conscious control

Blood vessels innervated by sympathetic system

* Fight or flight

Nerve endings are adrenergic and neurotransmitteris norepinephrine

- Increases HR and BP

Parasympathetic is responsible for rest and digest

Cholinergics are the nerve endings and acetylcholine isthe neurotransmitter

- Decreases HR and BP

Parasympathetic and sympathetic innervates heart

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Examine !!!

General appearance

Mentation

Color

Neck Veins

Palpations

Turgor

Cap Refill

Pulses

Auscultation



• Atherosclerosis is the abnormal accumulation oflipid deposits and fibrous tissue within arterialwalls and lumen.

•In coronary atherosclerosis, blockages andnarrowing of the coronary vessels reduce bloodflow to the myocardium.

• Cardiovascular disease is the leading cause of

death in the United States for men and women ofall racial and ethnic groups.

• CAD, coronary artery disease, is the most

prevalent cardiovascular disease in adults.



• Symptoms are due to myocardial ischemia

• Symptoms and complications are related to the

location and degree of vessel obstruction

• Angina pectoris

• Myocardial infarction

•

Heart failure• Sudden cardiac death



• Which is considered a modifiable risk

factor for coronary artery disease?

a. Race

b. Gender

c. Family history

d. Cigarette smoking



• D

•

A modifiable risk factor for coronary arterydisease is cigarette smoking. Race,

gender, and family history are

nonmodifiable risk factors.



• The most common symptom of myocardial

ischemia is chest pain; however, some

individuals may be asymptomatic or have

atypical symptoms such as weakness, dyspnea,

and nausea.

• Atypical symptoms are more common in

women and in persons who are older, or who

have a history of heart failure or diabetes.



• A syndrome characterized by episodes or

paroxysmal pain or pressure in the anterior

chest caused by insufficient coronary blood

flow.



• Physical exertion or emotional stress increases

myocardial oxygen demand and the coronary

vessels are unable to supply sufficient bloodflow to meet the oxygen demand.

• Exposure to cold, which can cause

vasoconstriction and elevated blood pressure,

with increased oxygen demand



• Eating a heavy meal, which increases the blood flow to the mesenteric area for digestion,

thereby reducing the blood supply available to

the heart muscle; in a severely compromisedheart, shunting of blood for digestion can be

sufficient to induce anginal pain

•Stress or any emotion-provoking situation,causing the release of catecholamines, which

increases blood pressure, heart rate, and

myocardial workload.



• May be described as tightness, choking, or aheavy sensation.

• Frequently retrosternal and may radiate to neck, jaw, shoulders, back or arms (usually left).

• Anxiety frequently accompanies the pain.

• Other symptoms may occur: dyspnea/shortness of breath, dizziness, nausea, and vomiting.

•

The pain of typical angina subsides with rest or NTG.

• Unstable angina is characterized by increasedfrequency and severity and is not relieved by rest

and NTG. Requires medical intervention!



• Treatment seeks to decrease myocardial

oxygen demand and increase oxygen

supply

• Medications

• Oxygen

•

Reduce and control risk factors• Reperfusion therapy may also be

done



• Nitroglycerin

– Short-term and long-term reduction of myocardial

oxygen consumption through selective vasodilation

• Beta-adrenergic blocking agents – Reduction of myocardial oxygen consumption by

blocking beta-adrenergic stimulation of the heart

•

Calcium channel blocking agents – Negative inotropic effects; indicated in patients not

responsive to beta-blockers; used as primary treatment

for vasospasm



• Antiplatelet

– Prevention of platelet aggregation

• Anticoagulant medications

– Prevention of thrombus formation



• Is the following statement True or False?

•

Nitroglycerin tablets should never beremoved and stored in metal or plastic

pillboxes.



• True

•

Nitroglycerin tablets should never beremoved and stored in metal or plastic

pillboxes.



• Symptoms and activities, especially those that

precede and precipitate attacks• Risk factors, lifestyle, and health promotion

activities

•Patient and family knowledge

• Adherence to the plan of care



• Ineffective cardiac tissue perfusion

• Death anxiety• Deficient knowledge

• Noncompliance, ineffective management of

therapeutic regimen



• Acute pulmonary edema

• Heart failure

•

Cardiogenic shock• Dysrhythmias and cardiac arrest

• Myocardial infarction



• Goals include the immediate and appropriate

treatment of angina, prevention of angina,reduction of anxiety, awareness of the disease

process, understanding of prescribed care,

adherence to the self-care program, and

absence of complications.



• Treatment of angina pain is a priority nursingconcern.

• Patient is to stop all activity and sit or rest in bed.

•

Assess the patient while performing othernecessary interventions. Assessment includes VS,and observation for respiratory distress, andassessment of pain. In the hospital setting, theECG is assessed or obtained.

• Administer oxygen.

• Administer medications as ordered or by protocol,usually NTG.



• Use a calm manner

• Stress-reduction techniques

•

Patient teaching• Addressing patient spiritual needs may

assist in allaying anxieties

•

Address both patient and family needs

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• Lifestyle changes and reduction of risk factors

• Explore, recognize, and adapt behaviors to

avoid to reduce the incidence of episodes of

ischemia

• Teaching regarding disease process

• Medications

• Stress reduction

• When to seek emergency care



• An area of the myocardium is permanently destroyed.

Usually caused by reduced blood flow in a coronary

artery due to rupture of an atherosclerotic plaque and

subsequent occlusion of the artery by a thrombus.• In unstable angina, the plaque ruptures but the artery is

not completely occluded. Unstable angina and acute

myocardial infarction are considered the same process

but at different point on the continuum.

• The term acute coronary syndrome includes unstable

angina and myocardial infarction.



• Cardiovascular

• Chest pain or discomfort not relieved by rest or nitroglycerin

palpitations.

• Heart sounds may include S3, S4, and new onset of a murmur.

• Increased jugular venous distention may be seen if the MI has

caused heart failure.

• Blood pressure may be elevated because of sympathetic

stimulation or decreased because of decreased contractility,

impending cardiogenic shock, or medications.

• Irregular pulse may indicate atrial fibrillation.

• In addition to ST-segment and T-wave changes, ECG may

show tachycardia, bradycardia, or other dysrhythmias.



• Respiratory

• Shortness of breath, dyspnea, tachypnea, andcrackles if MI has caused pulmonary congestion.

• Pulmonary edema may be present.

• Gastrointestinal

• Nausea and vomiting.

• Genitourinary

• Decreased urinary output may indicatecardiogenic shock.



• Skin• Cool, clammy, diaphoretic, and pale appearance due

to sympathetic stimulation may indicate cardiogenicshock.

•

Neurologic• Anxiety, restlessness, and lightheadedness may

indicate increased sympathetic stimulation or adecrease in contractility and cerebral oxygenation.

• The same symptoms may also herald cardiogenic

shock.• Psychological

• Fear with feeling of impending doom, or denial thatanything is wrong.



• Laboratory tests—biomarkers

– Creatine Kinase CK-MB





– Myoglobin





– Myoglobin – Troponin T or I



• What is the purpose of an

echocardiogram?

a. Evaluate arterial function of the heart

b. Evaluate ventricular function of the heart

c. Detect hyperkinetic wall motion

d. Identify ischemia changes



• B

•

The echocardiogram is used to evaluateventricular function. It can detect

hypokinetic and akinetic wall motion and

can determine the ejection fraction.



• Use rapid transit to the hospital.

• Obtain 12-lead electrocardiogram (ECG) to be read within10 minutes.

• Obtain laboratory blood specimens of cardiac biomarkers,including troponin.

• Obtain other diagnostics to clarify the diagnosis.• Begin routine medical interventions:

– Supplemental oxygen

– Nitroglycerin

–

Morphine – Aspirin 162 to 325 mg

– Beta-blocker

– Angiotensin-converting enzyme inhibitor within 24 hours

– Anticoagulation with heparin and platelet inhibitors



• Evaluate for indications for reperfusiontherapy:

– Percutaneous coronary intervention

– Thrombolytic therapy• Continue therapy as indicated:

– Intravenous heparin, low-molecular-weightheparin, bivalirudin, or fondaparinux

– Clopidogrel (Plavix)

– Glycoprotein IIb/IIIa inhibitor

• Bed rest for a minimum of 12 to 24 hours



• A vital component of nursing care!

• Assess all symptoms carefully and compare to

previous and baseline data to detect anychanges or complications.

• Monitor ECG.



• Ineffective cardiac tissue perfusion

• Risk for fluid imbalance

•Risk for ineffective peripheral tissue perfusion

• Death anxiety

• Deficient knowledge



• Acute pulmonary edema

• Heart failure

• Cardiogenic shock

• Dysrhythmias and cardiac arrest

• Pericardial effusion and cardiac tamponade



• Goals include the relief of pain or ischemic

signs and symptoms, prevention of further

myocardial damage, absence of respiratorydysfunction, maintenance of or attainment of

adequate tissues perfusion, reduced anxiety,

adherence to the self-care program, and

absence or early recognition of complications.



• Percutaneous Transluminal Coronary Angioplasty

• A balloon-tipped catheter is used to open blockedcoronary vessels and resolve ischemia.

•Catheterbased interventions can also be used toopen blocked CABGs.

• The purpose of PTCA is to improve blood flowwithin a coronary artery by compressing and

“cracking” the atheroma.

• The procedure is attempted when theinterventional cardiologist believes that PTCA

can improve blood flow to the myocardium.



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• The surgeon performs a

median sternotomy and

connects the patient to the

cardiopulmonary bypass (CPB)

machine.

• Next, a blood vessel from

another part of the patient’s body (eg, saphenous vein, left

internal mammary artery) is

grafted distal to the coronary

artery lesion, bypassing theobstruction.

• CPB is then discontinued,

chest tubes and epicardial

pacing wires are placed,and the

incision is closed



END

chronic heart diseases

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