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 in
the ventricles at the end of diastole or the
pressure generated at the end of diastole

Contractility: is the ability of the cardiac
muscle fibers to shorten and produce a
muscle contraction.

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

Autonomic Nervous System
Built 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 neurotransmitter
is norepinephrine
- Increases HR and BP

Parasympathetic is responsible for rest and digest
Cholinergics are the nerve endings and acetylcholine is
the 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 of
lipid deposits and fibrous tissue within arterial
walls and lumen.
In coronary atherosclerosis, blockages and
narrowing of the coronary vessels reduce blood
flow to the myocardium.
Cardiovascular disease is the leading cause of
death in the United States for men and women of
all 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 artery
disease 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 blood
flow 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 compromised
heart, 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 a
heavy 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 increased
frequency 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 be
removed and stored in metal or plastic
pillboxes.
True

Nitroglycerin tablets should never be
removed 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 nursing
concern.
Patient is to stop all activity and sit or rest in bed.
Assess the patient while performing other
necessary interventions. Assessment includes VS,
and observation for respiratory distress, and
assessment of pain. In the hospital setting, the
ECG 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, and
crackles if MI has caused pulmonary congestion.
Pulmonary edema may be present.
Gastrointestinal
Nausea and vomiting.
Genitourinary
Decreased urinary output may indicate
cardiogenic shock.

Skin
Cool, clammy, diaphoretic, and pale appearance due
to sympathetic stimulation may indicate cardiogenic
shock.
Neurologic
Anxiety, restlessness, and lightheadedness may
indicate increased sympathetic stimulation or a
decrease in contractility and cerebral oxygenation.
The same symptoms may also herald cardiogenic
shock.
Psychological
Fear with feeling of impending doom, or denial that
anything is wrong.
Laboratory testsbiomarkers
Creatine Kinase CK-MB
Laboratory testsbiomarkers
Creatine Kinase CK-MB
Myoglobin
Laboratory testsbiomarkers
Creatine Kinase CK-MB
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 evaluate
ventricular 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 within
10 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 reperfusion
therapy:
Percutaneous coronary intervention
Thrombolytic therapy
Continue therapy as indicated:
Intravenous heparin, low-molecular-weight
heparin, 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 any
changes 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 respiratory
dysfunction, 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 blocked
coronary vessels and resolve ischemia.
Catheterbased interventions can also be used to
open blocked CABGs.
The purpose of PTCA is to improve blood flow
within a coronary artery by compressing and
cracking the atheroma.
The procedure is attempted when the
interventional 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 patients
body (eg, saphenous vein, left
internal mammary artery) is
grafted distal to the coronary
artery lesion, bypassing the
obstruction.
CPB is then discontinued,
chest tubes and epicardial
pacing wires are placed,and the
incision is closed

END