Cardiovascular Disease (CVD) with a focus on Secondary Prevention Flashcards
• What is secondary prevention?
• Health care designed to prevent recurrence of cardiovascular events (e.g.
heart attack or stroke) in patients with diagnosed CVD.
How is arterial blood pressure regulated?
It is regulated by the sympathetic nervous system, the renin-angiotensin-aldosterone system (RAAS) and renal function
WHat is the exclusion from the rule artery=oxygenated blood, vein= deoxygenated blood?
pulmonary artery carries deoxygenated blood the only exclusion from the rule that arteries carry oxygenated blood; pulmonary vein is an exclusion as well
• Framingham Risk Scores, not available for __ years old or older
• Framingham Risk Scores, not available for 80 years old or older
WHy do we refrain from putting elderly on restrictive diets?
restrictive diets at older ages may lead to malnutrition -> do more harm than good
Why do we say that women are a bit neglected in terms of CVD?
Decreased risk for CVD prior to menopause-> less studied than men
Don’t know the exact symptoms
is hormonal replacement therapy beneficial for prevention of CVD?
no
How does estrogen help with CVD?
Estrogen is believed to have a positive effect on the inner layer of artery wall, helping to keep blood vessels flexible.
When does menopause occur?
- Average age is 51 - 54 years old
* Induced at a younger age in women who have had a hysterectomy
What happens to lipid profiles after the menopause?
- Blood pressure tends to increase
- LDL cholesterol tends to increase
- HDL, or “good” cholesterol, declines or remains the same.
- Triglycerides tend to increase.
Adults with diabetes are __ times more likely to die from heart disease than adults without diabetes.
Adults with diabetes are two to four times more likely to die from heart disease than adults without diabetes.
Myocardial Infarction (MI) or Heart Attack- definition
when one of the coronary arteries (one of the arteries that feed the heart muscle) becomes blocked and the heart tissue dies as it is not getting enough oxygen
5 common heart attack warning signs
common heart attack warning signs:
Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw or back.
Nausea, indigestion, heartburn or abdominal pain.
Shortness of breath.
Cold sweat.
Fatigue.
Lightheadedness or sudden dizziness.
Both __ and __ can cause chest pain and frequently co-exist
Both GERD and coronary artery disease (CAD) can cause chest pain and frequently co-exist
Echo vs EKG
what can be used for either?
echocardiogram (echo) electrocardiogram (EKG)
ECG
define stable angina; EKG and troponins
STABLE ANGINA - Angina pain develops when there is increased demand in the setting of a stable atherosclerotic plaque. The vessel is unable to dilate enough to allow adequate blood flow to meet the myocardial demand.
EKG: normal; normal troponins
define unstable angina; EKg and troponins
UNSTABLE ANGINA : The plaque ruptures and a thrombus forms around the ruptured plaque, causing partial occlusion of the vessel. Angina pain occurs at rest or progresses rapidly over a short period of time.
EKG: Normal, Inverted T waves, or ST depression. Troponins: Normal
define NSTEMI; EKG and troponins
NSTEMI : During an NSTEMI, the plaque rupture and thrombus formation causes partial occlusion to the vessel that results in injury and infarct to the subendocardial myocardium.
EKG: Normal, Inverted T waves, or ST depression
Troponins: Elevated
define STEMI; EKG and troponins
A STEMI is characterized by complete occlusion of the blood vessel lumen, resulting in transmural injury and infarct to the myocardium, which is reflected by ECG changes and a rise in troponins.
EKG: hyperacuate T waves or ST elevation
Troponins: elevated
What is the superior marker for myocardial damage. Why?
troponins
The most sensitive and specific test for myocardial damage. Because it has increased specificity compared with CK-MB, troponin is a superior marker for myocardial injury.
When do troponins peak?
12h
Is CK-MB test specific? When does it peak?
Creatine Kinase
It is relatively specific when skeletal muscle damage is not present.
10-24h
Is LDH test specific? When does it peak?
Lactate dehydrogenase
LDH is not as specific as troponin.
72h
What is the treatment applied post MI if Mi was detected early on? How soon should it be detected?
Thrombolysis (to dissolve clots in coronary arteries). Usually within 3 hours of the heart attack.
What does type of treatment post MI depend on?
depend how fast medical treatment is obtained for attack and severity
Describe Cardiac catheterization
can be done after or before a heart attack
• Passing catheter via arm, groin or neck
• visualization
• Angiogram- injecting special
fluid (called dye or contrast) through the catheter into a blood vessel or a chamber of the heart.
Since the dye is visible by X-ray, an X-ray movie of the circulation can be recorded.
Describe Angioplasty or PTCA (percutaneous transluminal coronary angioplasty)
Use catheter to insert
• stent
• balloon
-> opens up the artery
CABG
multiple bipasses can be done
vessel is taken eg from a leg; attaching it to an aorta and below the site where occlusion has occurred
allow to bypass the blocked section of coronary artery
What diet should he be on, immediate post-MI?
- Npo or clear liquids without caffeine
- Progress to small soft tolerated meals (Initially want blood flow supported or maximized to heart (as opposed to GI tract))
What are the symptoms experienced after MI
MI: Pain, anxiety, fatigue, SOB
• Fear, depression
5 Ways to Lower Your Risk
of a SECOND Heart Attack
1) TAKE YOUR MEDICATIONS
2) FOLLOW-UP WITH YOUR DOCTOR. See your doctor within 6 weeks of your heart attack to help keep your recovery on track.
3) MANAGE RISK FACTORS
Common risk factors include smoking, high cholesterol, high blood pressure and diabetes.
4) PARTICIPATE IN CARDIAC REHAB
5) Get support
Medications after a heart attack could include (6)
Antiplatelet agents Statins Beta blockers, ACE inhibitors Nitrates Anticoagulants Medications to protect the stomach
Why would we use Medications to protect the stomach after MI?
Examples
stress + aspirin given post MI can resutl in ulcers
• Examples: cimetidine (Tagamet), famotidine (Pepcid) and ranitidine (Zantac), or proton pump inhibitors such as pantoprazole (Pantoloc).
Why would we use Antiplatelet agents after MI? Examples
to prevent blood clots and keep a stent open.
• Example: aspirin.
Why would we use statins after MI? Examples
Statins – to lower cholesterol levels.
Why would we Beta blockers, ACE inhibitors use after MI? Examples
to treat high blood pressure
Why would we use nitrates after MI? Examples
to expand the arteries and relieve chest pain. • nitroglycerin
Why would we use anticoagulants after MI? Examples
to reduce the blood’s ability to clot.
• Warfarin (Coumadin)
What is a stroke?
insufficient blood supply to brain and death
what are the 2 types of stroke?
hemorrhagic and ischemic
Hemorrhagic- blood vessel bursts due to high pressure, atherosclerosis or congenital malformation. Bleeding and decreased blood flow; blood build up -> increased pressure and damage to smaller vessels
ischemic stroke- occurs when an artery to the brain is blocked
What are the signs of stroke
F: Face drooping. Ask the person to smile, and see if one side is drooping. …
A: Arm weakness. Ask the person to raise both arms. …
S: Speech difficulty. People having a stroke may slur their speech or have trouble speaking at all. …
T: Time to call 911!
What is the rule of side of weakness association with side of lesion
it opposite
so if the weakness is on the right side, the lesion is on the left
Ischemic stroke vs hemorrhagic in terms of signs
Ischemic- Patients may experience a combination of symptoms that include numbness or weakness on one side of the body or face, trouble speaking and difficulty with vision or balance.
Hemorrhagic- People who experience this type of stroke, in addition to other stroke symptoms, will likely experience a sudden onset headache or head pain — a warning sign that might not occur during ischemic stroke.
Which formula is recommended for caloric calculations?
Mifflin St-Jeor
What is the recommended sodium intake after a stroke/heart attack?
2g/day
Stroke nutrition theraphy
1) eat low sodium
2) eat lots of veggies, fruits, whole grains, low fat dairy
3) eat healthy kinds of fat
4) aim for healthy weight
5) get 20-30g of fiber
Diet guidelines for high TGs
- Limit or avoid sugar, sweets, sweetened beverages
- Avoid alcohol
- Achieve healthy weight
- Follow other heart healthy guidelines
Coconut oil vs butter vs unsaturated/monounsaturated vegetable oils,
- Compared to butter, coconut oil does not ↑ TChol, LDL to same extent
- Compared to unsaturated/ monounsaturated vegetable oils, coconut oil does ↑ TChol and LDL to a greater extent
Coconut oil is high in _- chain fatty acids
Coconut oil is high in medium chain fatty acids
Final coconut oil verdict
Even though coconut oil can ↑ HDL, it still is not recommended as an alternative to non-hydrogenated vegetable oils
What is AFib?
Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications.
AFib treatment and intervention
treatment is directed toward heart rate control and/or anticoagulation based on the client’s symptom and risk factors
What is the action of anticoagulants
Interferes with clotting
Thins out the blood
Nutritional implication of taking anti-coagulants
Warfarin (Coumadin): need consistent vitamin K intake
Which food intake should especially be controlled when taking warfarin
Especially cooked greens (spinach, kale, collards, beet greens,..)
• Leafy greens (raw), asparagus, broccoli, bran, chickpeas, lentils, soybeans,
swiss chard, liver, oils, egg yolk…
Apart from foods, what else can affect clotting time and thus has to be controlled?
High vitamin A or E can also affect clotting time.
__ patients may need lower dose of warfarin (__ or __?)
Asian patients may need lower dose of warfarin (genetics or diet?)
Natural products and warfarin
Some natural products also affect clotting time and some case reports of interaction:
• High amounts onions, garlic, avocado, cranberry juice, soy milk, green tea.
• ginkgo, ginseng, coenzyme Q10, St Johns wort, fish oil supplements,
• Disability affects _% of stroke survivors
• Disability affects 75% of stroke survivors
• Physical, mental, and/or emotional changes that can occur after a stroke
- Anxiety, mood swings
- Changes in cognition, attention, memory
- 30 to 50 % suffer depression
- muscle weakness
- Paralysis
- Vision loss
- Speech loss
- Difficulty swallowing
What do the other members of the team do for patients with stroke?
- Physician for overall care and prescriptions: cigarette smoking, alcohol, exercise, medical condition…
- Physical Therapy (PT): help improve muscle strength & coordination, mobility (such as standing and walking)
- Occupational Therapy (OT): help the individual to conduct activities of daily living (ADL) like brushing teeth, combing hair, bathing, feeding, cooking, toileting, or dressing. Swallowing assessment.
- Social workers plans for discharge.
- Psychologists: post-stroke depression
- Nurses: Front line care: giving medications, skin care, feeding, hydration, positioning, and monitoring vital signs such as temperature, pulse, and blood pressure.
What is heart failure?
Heart failure is a condition in which the heart can’t pump enough blood to meet the body’s needs. In some cases, the heart can’t fill with enough blood. In other cases, the heart can’t pump blood to the rest of the body with enough force. Some people have both problems
Why does the pump become less effective?
Injury to the heart or congenital abnormality-> Compensatory actions to maintain cardiac output (norepinephrine and activation of RAAS)-> Ventricular muscles undergo hypertrophy because they are working harder
Risk factors for heart failure
• Hypertension • Ischemic heart disease (IHD) • Valvular heart disease • Diabetes mellitus • Heavy alcohol or substance use • Chemotherapy or radiation therapy • Family history of cardiomyopathy • Smoking • Hyperlipidemia
Symptoms for heart failure
• Breathlessness • Fatigue • Leg swelling • Confusion- especially in the elderly • Orthopnea • Paroxysmal nocturnal dyspnea
What can echo determine when there’s heart failure?
- Decreased left ventricular (LV) ejection fraction
- Increased LV end-systolic and end-diastolic diameter
- LVH
- Wall motion abnormalities and diastolic dysfunction
- Increased RV size and/or RV dysfunction
- Valve dysfunction
- Elevated pulmonary arterial pressures (PAP)
WHat is Left ventricular ejection fraction
Left ventricular ejection fraction (LVEF or EF)= measurement of how much blood is being pumped out of the left ventricle of the heart
What does ejection fraction comapre?
the amount of blood in the heart to the amount of blood pumped out
Cut-off for ejection fraction?
normal: 50-70% - usually normal activity
Borderline: 41-49%- symptoms mat become noticeable
Reduced: <40%- symptoms may become noticeable even during rest
What is Left-sided Heart Failure?
Left ventricle doesn’t contract with enough force, low LVEF
What leads to pulmonary congestion or edema?
Pulmonary congestion is defined as accumulation of fluid in the lungs, resulting in impaired gas exchange and arterial hypoxemia.
High pressure in pulmonary capillaries leads to pulmonary congestion or edema
what is pulmonary congestion?
Pulmonary congestion is defined as accumulation of fluid in the lungs, resulting in impaired gas exchange and arterial hypoxemia.
__ or __ sides can fail: most often __ fails first
One or both sides can fail: most often left fails first
What happens if left ventricle weakens?
Left ventricle weakens and cannot empty properly = less blood to body
What happens if right ventricle weakens?
Right ventricle weakens and cannot empty as much as normal
Left-sided congestive heart failure effects (5)
- Left ventricle weakens and cannot empty
- Decreased cardiac output to system
- Decreased renal blood flow stimulates renin-angiotensin and aldosterone secretion
- Backup of blood into pulmonary vein
- High pressure in pulmonary capillaries leads to pulmonary congestion or edema
What is the final outcome of right side heart failure
Very high venous pressure causes distended neck vein and cerebral edema
Increased venous pressure results in edema in legs, liver, and abdominal organs (ascites)
What is the sudden weight gain a sign of and why?
Sudden weight gain can be a sign that heart failure is
worsening as it’s a sign of fluid retention and heart failure
Why is there edema in HF?
Increased venous pressure results in edema of periphery in right-sided HF
High pressure in pulmonary capillaries leads to pulmonary congestion or edema in left-sided HF
What is cardiomegaly and why is it observed in HF?
Cardiomegaly (enlarged heart)
• Less effective pump, has to pump more
• Less blood flow
• Kidney tries to compensate: renin + aldosterone cause vasoconstriction and
try to increase blood volume
• Heart has to work harder, vicious circle
• With time, gets worse
What is the use of BNP in HF?
B-type natriuretic peptide
BNP can be used in the diagnosis of heart failure because it is secreted when the muscle fibers in the left ventricle are stretched.
Suspect acute heart failure- steps of proceeding
1) Initial workup (history, physical, ECG, Chest X-ray)
2) In uncertain-> test BNP
What might happen to lab values when assessing fluid balance?
• Lab values may appear diluted (Lower) ex. sodium, albumin, etc..
What might happen to skin when retaining fluid?
• Skin tends to be clammy when retaining fluid
I & O values from nurses
Intake and Output records of “sensible” losses (that we can easily measure)
• Intake: All fluids that are liquid at body temperature (milk, juice, water, tea, coffee, broth/soup, popsicle, jell-o, nutritional liquid supplements..) . IV fluids.
• Output: urine (can be collected for 24 hours), feces/stool if applicable (ex. diarrhea or watery stool), vomiting if applicable.
Three main nutritional concerns for pts with HF are:
- Sodium intake
- Fluid intake
- Overall nutritional adequacy (optimization) due to early satiety, shortness of breath (SOB): Important to prevent malnutrition, cardiac cachexia…
Fluid intake recommendations in patients after heart attacks/storkes
• Sodium:2,000mg/day • Fluid:1–2L/day
Fluid restrictions
• __ per day for mild CHF
• __ per day for more severe CHF or more severe hyponatremia (< __
mmol/l Na+ in blood test)
Fluid restrictions
• 1 to 2L per day for mild CHF
• 1 to 1.5 L per day for more severe CHF or more severe hyponatremia (< 130
mmol/l Na+ in blood test)
WHat changes should be made to the Texture and timing of foods of a patient after a heart attack/stroke?
Texture and timing of foods should be adjusted to allow adequate energy intake without discomfort
Alcohol intake in post-HF patients
imit alcohol intake to one drink per day
• In patients in whom alcohol is believed to be a causative factor in the heart
failure, abstinence from alcohol is mandatory
Note about weight and BMI assessment in post-HF patients
eight and BMI can be difficult to assess if there is fluid retention (can mask weight loss)
Note about Estimated Energy requirement in HF patients
Calculations typically for comparison purposes (to compare to intake). If edema present and low activity, then 25 kcal/kg actual weight could give a rough initial estimate. Use judgement.
Note about protein in HF patients
1.1 – 1.4 g/kg actual body weight as a target for comparison purposes. If edema is increasing weight, then use lower end of range. Use judgement
What is our goal in severe cases of HF in terms of nutrition
In more advanced heart failure, typically we want to prevent further weight loss and optimize protein and kcalorie intake since there is high risk of malnutrition and poorer prognosis with malnutrition.
What determines if HF progresses or stabilizes?
- For some patients, HF can be controlled with lifestyle changes, diet, and medication.
- For others, the condition progressively worsens.
- Infection and/or cardiac events can further weaken the heart.
What is the mortality rate associated with HF?
The mortality rate is high, with 20% of people dying within the first year of diagnosis.
What is cardiac cachexia and what is the associated prevalence?
End result of heart failure (10 – 15 % of HF patients)
Weight loss with significant loss of lean body mass including cardiac muscle
What is the heart like during cardiac cachexia?
GI?
Heart is soft and flabby
Inadequate blood supply to GI tract: anorexia, nausea, feeling of fullness, constipation, abdominal pain, malabsorption, loss of normal bowel function
Why is cardiac cachexia so dangerous?
Poor prognosis, high mortality
Stages of heart failure
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