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M Tayyab Student of Anesthesia
kmu
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Facts:The heart is about the size of a fist and weighs less than 1 pound
The average bpm is 72The average adult heart pumps about
6000-7500 liters of blood per day through 60,000 miles of blood vessels each minute at rest.
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StructureCovered by pericardium
ParietalVisceral (epicardium)
Outer heart layer: epicardiumMiddle heart layer: myocardiumInner layer: endocardium
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Structure (continued)Four hollow chambers
Two upper, atriaTwo lower, ventricles
Divided by septum and valves
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FunctionRight atrium
receives deoxygenated blood
Right ventricle pumps blood to lungs
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Function (continued)Left atrium receives oxygenated bloodLeft ventricle pumps oxygenated blood to
bodyAV valve closure: S1 heart soundSemilunar valve closure: S2 heart soundCoronary circulation
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Aorta, arteries, arterioles, capillariesVenules, veins, superior and inferior vena
cavaThree layers
IntimaMediaAdventitia
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FunctionCirculationPeripheral vascular resistance: viscosity,
length, diameterBlood pressure control
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MechanicalConduction system
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MechanicalSA node: pacemakerCardiac output (CO)Heart rate (HR)Stroke volume (SV): the volume of blood
pumped from one ventricle of the heart with each beat
CO = HR x SV
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MechanicalCardiac reservePreloadStarling’s lawAfterloadContractility
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Electrical properties:Action potentialPolarizationDepolarizationRepolarizationRefractory period
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Filling and pumpingDiastole – ventricular fillingSystole –ventricles eject blood
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SubjectiveHealth historyChest painSOBLeg painPillows to sleepMedicationsLifestyle: diet, alcohol use, exercise,
smoking, drugs
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ObjectiveGeneral appearanceSkinWoundsPulsesJugular vein distentionEdemaBreathing
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TEE (transesophageal echocardiogram)Monitor breathing, cough, gag reflexKeep NPO until gag reflex returns
Doppler sonography: is a medical imaging technique that uses ultrasound enhanced by the Doppler effect and is often provide helpful information about the flow and movement of blood and inner areas of the body Monitor BPWash extremities to remove gel after test
completed
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X-rays/CT scan/EBCTElectron beam computed tomography (EBCT)
is used to determine coronary calcium Document client allergy to fish or shellfishPregnancy risk
Angiography/cardiac catheterizationMRI
Document presence of implanted electronic devices
Radionuclear scansIncrease fluids after the test
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Telemetry/Holter monitorTeach about purpose: is a portable device
for continuously monitoring various electrical activity of the central nervous system for at least 24 hours (often for two weeks at a tim
Dry skinRemove hairAvoid getting unit wetWhen to phone the MD
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24Dr Ibrahim Bashayreh
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Coronary Artery DiseaseHeart AnatomyAtherosclerotic Plaque/AtheromaAngina PectorisMyocardial InfarctionSudden DeathOverall Management
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CAD is the largest killer of American males and females
13 million Americans have CAD1.1 million MI’s per yearEvery 26 seconds an American will suffer from a
coronary eventEvery 60 seconds an American will die because
of a coronary event@ 42% of those having a coronary event will die
from it@350K people die per year because of a coronary
event in the Emergency Department before even being admitted to the hospital
Death Rate in 2001: 177 in 100,000
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84% of those who die from CAD are 65 or older If under the age of 65, 80% mortality rate with the first
myocardial infarction Within 1 year of initial MI:
25% of men and 38% of women will die Within 8 years of initial MI:
50% of men and women under 65 will die An average of 11.5 years of life are lost due to an MI IMPORTANT:
50% of men and 64% of women who have died suddenly via CAD DID NOT HAVE ANY PREVIOUS SYMPTOMS
Sudden Death: Those with a previous history of MI have a 5-6 times
Sudden Death rate compared to the general population
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Start with anatomy…
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" Ischaemia " refers to an insufficient amount of blood. The coronary arteries are the only source of blood for the heart muscle. If this coronary arteries are blocked, the blood supply will reduce.
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Ischemic heart disease (IHD): caused by coronary atherosclerotic plaque formation which leads to imbalance between O2 supply & demandresults in myocardial ischemia
Chest pain: cardinal symptom of myocardial ischemia caused by coronary artery disease (CAD)
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Ischemia / infarction
chest pain
Diastolic Dysfunction Systolic Dysfunction
cardiac output
catecholamines
MVO2
wall tension
LV diastolic pressurepulmonarycongestionpO2
(heart rate, BP)
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High blood cholesterolHigh blood pressureSmokingObesityLack of physical activity
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Uncontrollable
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•Sex•Hereditary•Race•Age
Controllable•High blood pressure•High blood cholesterol•Smoking•Physical activity•Obesity•Diabetes•Stress and anger
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Why would there be an insufficient blood supply to the heart?Remember that the coronary arteries are
the only source of fuel to the heartThe coronary arteries may become
partially/completely occluded:Atherosclerotic Plaques
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Focal accumulation of smooth muscle cells, foam cells, cholesterol crystals and lipid under the endothelium of the artery (within the Tunica Intima)
Given time, this plaque can protrude into the lumen of the vessel reducing blood flow
Often develops at branch points or curves within the vasculature blood is slowed and/or turbulent
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Where does the plaque begin? within the Tunica Intima, the innermost wall of the artery
What is a plaque made of? Superficial fibrous cap
made of smooth muscle cells, collagen, elastin and proteinsAlso contains
Macrophages, Foam Cells, T Cells
Foam cells are one of the first cells found at the site of the fatty streak, which is the beginning of atherosclerotic plaque formation in vessels
Necrotic Center of cholesterol crystals, lipids, Apolipoprotein B LDL
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As the atheroma within the coronary arteries enlarges, the blood flow to the heart decreases and therefore so does the O2 supply
The heart is not in danger of hypoxia until 50% of the vessel is occluded
As the heart senses a decrease in O2, there is attempted compensation:Increase Heart RateIncrease Blood Pressure Aggravation/Worsening of the atheroma
When 70% of the artery is occluded, Angina Pectoris will occur
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Classification = mainly 4 typesMyocardial infarction (MI)Sudden cardiac deathAngina pectoris Chronic IHD with heart failure
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At least 70% occlusion of coronary artery resulting in pain. What kind of pain? Chest pain Radiating pain to:
Left shoulderJawLeft or Right arm
Usually brought on by physical exertion as the heart is trying to pump blood to the muscles, it requires more blood that is not available due to the blockage of the coronary artery(ies)
Is self limiting usually stops when exertion is ceased
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Angina Pectoris can be Stable or Unstable:
Stable:The pain and pattern of events is
unchanged over a period of time (months years)
Unstable:The pain and pattern is changing, be it in
duration, intensity or frequencyA Myocardial Infarction waiting to happen
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Partial or total occlusion of one or more of the coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle
When an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels
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250,000 deaths per year.30% mortality within the first 2 hours45 Minutes of Ischemia:
Cardiac muscle death occursHow is the Diagnosis Made?
Electrocardiographic changesST elevation
Myocardial enzyme elevationCreatine kinase TroponinC Reactive Protein
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When there is an atheroma, as mentioned before there can be rupture resulting in thrombus formation because of the build up of platelets
When there is breakage of the thrombus there is emboli formation
An emboli can travel to the brain (cerebral infarct) can remain in the heart (myocardial infarct) or even travel to the extremities cutting off blood supply
As the area beneath the is disrupted atheroma hemorrhages, there can is increased risk of abscess formation and infection
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Infarction leading to inability of the heart to function properly leading to Heart Failure
Angina/PainCardiogenic shock Ventricular aneurysm and ruptureEmbolism FormationArrhythmias Myocardial Infarctions
can lead to Ventricular Fibrillation (shockable!)
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Sudden Death :250,000 deaths in the US per year are caused by
what is referred to as “sudden” cardiac death Sudden Cardiac Death is also known as a
“Massive Heart Attack” in which the heart converts from sinus rhythm to ventricular fibrillation
In V-Fib, the heart is unable to contract fully resulting in lack of blood being pumped to the vital organs
V-Fib requires shock from defibrillator “SHOCKABLE RHYTHM”
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Many people are able to manage coronary artery disease with lifestyle changes and medications.
Other people with severe coronary artery disease may need angioplasty or surgery.
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Pharmaceuticals: Beta Blockers
Act either selectively or non-selectively on Beta receptors:Beta 1 cardiac muscle increase rate and contractionBeta 2 dilates bronchial smooth muscle
Ca++ Channel BlockersActs on vasculature blocking Ca++ and causing
vasodilation Nitrates
Vasculature vasodilation Anti-Hypercholesterolemia
HMG CoA Reductase Inhibitors reduction in “manmade” cholesterol thus helping to reduce atheroma formation
Antiplatelet Medication:Clopidogrel (Plavix)Aspirin
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1) Stenting2) Angioplasty (balloon)3) Bypass surgery
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Lifestyle:DietExercise Preventive treatment• Low fat, low cholesterol diet• Cessation of smoking• Red wine (in moderation)
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1. Gather information about all facets of the client’s activities, especially those that precede and precipitate attacks of anginal pain.2. Assess the risk factors in the client’s history and modifications possible to reduce risk.3. If chest discomfort is present at the time of the interview, further collection of data is delayed until pain and dysrhythmias are resolved.4. A complete physical assessment is performed to identify the presence of chest, epigastric, jaw, back, or arm discomfort which is then rated on a subjective scale of 1 to 10 in intensity. The client is questioned regarding nausea, vomiting, diaphoresis, dizziness, weakness, palpitations, and SOB
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1. Pain related to myocardial ischemia.2. Altered tissue perfusion: related to
imbalance between myocardial oxygen supply and demand.
3. Anxiety related to fear of death and knowledge deficit
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Goals1. Prevention of pain.2. Improved tissue perfusion as evidenced by absence of chest pain and absence of dysrhythmias.3. Reduction of anxiety and increased knowledge of disease process.
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1. The nurse must teach the client the link between symptoms and activity and the need to avoid activities known to cause angina, such as sudden exertion, exposure to cold, and emotional excitement.
2. Medications used in the treatment of angina include nitrates, beta-blockers, calcium channel blockers, and platelet antiaggregants. Administer cardiac medication as prescribed and be alert for adverse side effects, particularly their effect on blood pressure. Teach the client the symptoms to be aware of and what measures to take.
3. Encourage the client to remain on bedrest in order to decrease cardiac workload and oxygen consumption.
4. Administer oxygen therapy as prescribed.
5. Evaluate vital signs hourly to determine the hemodynamic effect of the drugs and the client’s tissue perfusion.
6. Nursing care should be planned so that minimal time is spent away from the bedside due to the high level of client anxiety, as well as the unstable condition of the patient.
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7. Clients with unstable angina are at high risk for myocardial infarction (MI) and sudden death. The nurse watches for development of heart failure and dysrhythmias.
8. Relieving pain is the top priority for the client with an acute MI, and medication therapy is administered to accomplish this goal.
9. Maintain patent IV for administration of fluids and vasodilators and anticoagulant therapy (Nitroglycerin and heparin). They relieve pain and they aid in minimizing permanent injury to the myocardium.10. Prepare for possible emergency heart catheterization or CABG.
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11. Whether CABG is planned as an elective procedure or performed on an emergency basis, the nurse should try to alleviate the client’s and the family’s anxiety and assist them in understanding the need for this life-saving procedure.
12. The nurse describes the postoperative course, emphasizing the close monitoring and use of sophisticated equipment. The client is encourage to tell the nurse about any discomfort post-op.
13. Encourage the client and family members to verbalize their fears and concerns.
14. Teach the client the nature of the illness and the facts needed to reorganize living habits in order to reduce the frequency and severity of anginal attacks, delay the progress of the disease, and avoid other complications.
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1. Verbalizes relief of chest pain.2. No signs of respiratory difficulties.3. Modifies lifestyle in order to prevent
future attacks.4. Demonstrates increased knowledge of
disease process and reduction in anxiety.
5. Absence of complications.
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2/11/2009 64
،نسأل الله أن يعلمنا ما ينفعنا،وأن ينفعنا بما علمنا
وأن يزيدنا علما
وفي النهايةوفي النهاية