Common Cardiovascular Disorders Flashcards
Exam 3
Normal Structure of the Heart:
Composed of three layers:
Epicardium
Myocardium
Endocardium
Normal Structure of the Heart:
Where is the heart located?
Mediastinal space
Normal Structure of the Heart:
What is the heart covered by?
Covered by pericardium
Pericardium:
Where is it located?
Pericardium surrounds the external surface of the heart and the roots of the great vessels.
Pericardium:
What are the two layers of the pericardium?
- outer tough fibrous pericardium
- inner serous layer
Pericardium:
What are the two layers of the serous pericardium?
- The parietal layer
- Inner visceral layer (epicardium)
Pericardium:
Two layers of the serous pericardium: The parietal layer
The parietal layer lines the internal surface of the fibrous membrane.
Pericardium:
Two layers of the serous pericardium: The inner visceral layer
It extends to the great vessels, where it then folds over on itself to form the inner visceral layer (epicardium)
Pericardium:
What lies between the outer and inner layers?
10 to 50 mL of clear serous fluid lies between these layers and acts as a lubricant.
Pericardium:
What does the pericardium help do?
The pericardium helps restrain the heart and isolate it from infections in the surrounding structures.
Pericardium:
What is pericarditis?
Pericarditis is inflammation of the pericardium
PericarditisAssessment:
What are signs and symptoms?
Chest pain
Pericardial friction rub
Low grade fever
Shallow breaths
ST segment elevation in all 12 leads.
PericarditisAssessment:
What are signs and symptoms: What appears in EKG?
ST segment elevation in all 12 leads
PericarditisAssessment:
What are signs and symptoms: Pericardial friction rub- when is it noted?
on auscultation (raspy, high pitched- varies with the cardiac cycle)
PericarditisAssessment:
Signs and symptoms: What is the primary symptom? How is it?
The primary symptom in acute pericarditis is chest pain.
The pain tends to be pleuritic in nature and classically is made worse by breathing deeply or lying supine.
PericarditisAssessment:
What are signs and symptoms:
How is chest pain presented?
Chest Pain usually sharp & stabbing, but can be dull ache is minority of cases
PericarditisAssessment:
What are signs and symptoms:
How else does chest pain appear?
Pain that radiates to shoulder or back
Pain aggravated by breathing deeply
Pain aggravated by lying down
Pericarditisdiagnosis:
What appears on the EKG?
Diffuse ST-segment elevation with an upward concavity and PR-segment depression.
Pericarditisdiagnosis:
Lab test include:
CBC, cardiac enzyme levels, C-reactive protein, erythrocyte sedimentation rate, rheumatoid factors, and antinuclear antibody titers.
Blood cultures
Viral studies
Pericarditisdiagnosis:
Lab test include: Why would blood cultures be indicated?
Blood cultures may be indicated f there is evidence of infection
Pericarditisdiagnosis:
Lab test include: Why would viral studies be indicated?
Viral studies may be obtained if the rest of the diagnostic workup is negative
Pericarditisdiagnosis:
What confirms a diagnosis? What is important to know about this though?
The presence of a pericardial friction rub confirms the diagnosis;
however, absence of a rub does not rule out pericarditis.
Pericarditisdiagnosis:
Where and how is it best to hear a friction rub?
It is best heard with the diaphragm of the stethoscope placed over the lower to middle left sternal border.
Complicationsof Pericarditis include:
Pericardial effusion
Cardiac tamponade
Complicationsof Pericarditis include:
Pericardial effusion: What are signs and symptoms?
Distant heart sounds
Cough, dyspnea, tachypnea
Complicationsof Pericarditis include:
Cardiac Tamponade: What are signs and symptoms?
Agitation, confusion, restlessness
Tachycardia, tachypnea
Drop in blood pressure
Distended neck veins
Complicationsof Pericarditis:
Pericardial effusion: What is it?
A pericardial effusion is when excess fluid builds up in the pericardial sac around the heart.
Complicationsof Pericarditis:
Cardiac Tamponade: What is it?
a life-threatening medical emergency that occurs when fluid builds up in the sac around the heart, compressing the heart and preventing it from pumping blood properly.
Complicationsof Pericarditis:
Cardiac Tamponade: What is a key finding of this?
Key finding in cardiac tamponade is a drop in bp
Pericarditis management:
What should be done with symptoms?
Relieve symptoms, eliminate any possible causative agents, and monitor for complications.
Pericarditis management:
What meds could be used?
NSAIDs such as aspirin or ibuprofen
Colchicine (anti-inflammatory)
Steroids
Pericarditis management:
Meds: What does colchicine do?
Colchicine has been shown to successfully reduce the recurrence of pericarditis.
Pericarditis management:
Meds: What should be avoided? What cases?
Anticoagulants must be avoided in the patient recovering from MI.
Pericarditis management:
Meds: What does steroids do?
Steroids may be indicated in resistant cases
Pericarditis management:
With treatment, when do symptoms abate?
Abates over 2 to 6 weeks
Pericarditis management:
How common is it to have recurrent episodes?
Rare to have recurrent episodes
Myocarditis: What is it?
Inflammation of the myocardium
Myocarditis:
What is secondary myocarditis?
inflammation related to specific organism
Myocarditis: What is it due to?
Due to: Acute viral or autoimmune infection, radiation, meds
Myocarditis:
Due to: Acute viral or autoimmune infection, radiation, meds; what is an example of a viral infection?
Most common: viruses (flu)
Myocarditis:
What are signs and symptoms?
S&S are benign to severe heart involvement (dysrhythmias, CHF, even sudden death among young athletes)
Myocarditis:
How long after viral infection can cardiac involvement be noted?
Cardiac involvement can be seen 7-10 days after viral infection
Delay in symptoms when viral is cause
Myocarditis
What are signs and symptoms?
fatigue,
dyspnea,
palpitations,
Pleuritic Chest pain,
friction rub,
S3,
crackles,
Myocarditis
Diagnosis: What can be done?
ECG & Lab findings
Endomyocardial Biopsy
Myocarditis
Diagnosis: What is important to know about ekg and lab findings?
ECG & Lab findings are vague
Myocarditis
Diagnosis: What is the most diagnostic measure? What is important to remember about it?
Endomyocardial Biopsy - most diagnostic but lack of positivity does not rule out myocarditis
Myocarditis
What is the goal of treatment?
Goal: Manage the symptoms of poor cardiac function
Myocarditis
What does treatment include?
Tx: Supportive (Oxygen, Rest, restricted activity).
Myocarditis may resolve without further sequelae.
Myocarditis:
What is nursing management:
Athletes with myocarditis should withdraw from competitive sports for a period of at least 6 months.
Myocarditis:
What is nursing management: Athletes with myocarditis should withdraw from competitive sports for a period of at least 6 months.
What does return to training and competition depend on?
Return to training and competition depends on:
normalization of cardiac function and absence of any significant clinical findings, such as dysrhythmias.
Endocarditis:
How is the endocardium normally?
Endocardium continuous with valves
Endocarditis: What is it?
Endocarditis is an infection of the endocardial surface of the heart, including the valves.
Endocarditis:
What are common organisms that cause it?
Common organisms:
streptococci,
enterococci,
staphylococcus aureus
Endocarditis:
Who is at risk for developing this?
Children with congenital heart disease are at risk.
Adults with mitral valve prolapse, rheumatic heart disease, illicit intravenous drugs, and patients with prosthetic valves or long-term indwelling devices
Endocarditis:
What can result from this?
Can result in proliferation of bacteria, damaging the valve structure, leading to heart failure
Assessment of Endocarditis:
When do symptoms appear?
Symptoms of endocarditis usually occur within 2 weeks of the precipitating event and are related to four underlying processes: bacteremia or fungemia, valvulitis, immunologic response, and peripheral emboli
Assessment of Endocarditis:
What are symptoms?
High fever and shaking chills
Night sweats, cough, weight loss
General malaise, weakness, fatigue, headache, musculoskeletal complaints
New murmurs
Symptoms of HF
Assessment of Endocarditis:
How is a diagnosis made?
echocardiogram,
transesophageal echocardiography,
persistent bacteremia,
visualization of vegetation,
or new or worsening murmur.
Assessment of Endocarditis:
How is blood drawn to make a diagnosis?
Blood is usually drawn for three separate sets of cultures.
Assessment of Endocarditis:
What is treatment?
Treatment: antibiotics (prolonged course), immediate surgery if CHF evolves secondary to valve dysfunction.
Cardiomyopathy: What is it?
Cardiomyopathies are diseases of the heart muscle that cause cardiac dysfunction resulting in heart failure, dysrhythmias, or sudden death.
Cardiomyopathy:
What could lead to structural changes that result in functional changes?
Current theories under investigate suggest that ischemic, immune, mechanical and neurohormonal effects on the pericardium, myocardium and endothelium lead to structural changes that result in functional changes.
Cardiomyopathy:
What do structural changes on the cellular level lead to?
Structural changes at the cellular level leads to stiffness of the ventricles and smooth muscle layers in the arteries.
Cardiomyopathy:
What does both stiffness and spherical remodeling occurring in the same heart lead to?
Both stiffness and spherical remodeling may occur in the same heart, leading to a compromised cardiac output from impaired relaxation and impaired emptying.
Cardiomyopathies:
What are the most common types?
The most common types of primary cardiomyopathies in Western countries:
dilated, ischemic, nonischemic and hypertrophic cardiomyopathies (HCMs)
Dilated cardiomyopathy:
What is it and why does it happen?
DCM is characterized by increased myocardial cavity size in the presence of normal or reduced left ventricular wall thickness and impaired systolic function.
Dilated cardiomyopathy:
What may lead to a decrease in contractility in DCM?
Ischemia
Alcohol abuse
Endocrine disorders
Pregnancy
Viral infections
Muscular dystrophy
Valvular disease
All may cause a decrease in contractility
Dilated cardiomyopathy:
What is a decrease in contractility?
Ejection fraction < 40%
Dilated cardiomyopathy:
What happens overtime? Why?
Overtime, the ventricle dilates to accommodate the increased intraventricular volumes (preload)
Dilated cardiomyopathy:
Overtime, the ventricle dilates to accommodate the increased intraventricular volumes (preload)
In the dilated heart, the increased volume leads to what?
In the dilated heart, the increased volume leads to a decreased stroke volume
Dilated cardiomyopathy:
What happens to the valves? Why?
Mitral and tricuspid insufficiency develop as the valve leaflets are stretched and separated.
Dilated cardiomyopathy:
What commonly occurs?
Dysrhythmias and conduction defects commonly occur
What is the third most common cause of heart failure?
Dilated cardiomyopathy
What is the most frequent cause of heart transplantation?
Dilated cardiomyopathy:
Dilated cardiomyopathy:
What is the specific cause most of the time?
In most cases, the specific cause is unknown
Dilated cardiomyopathy:
How are some patients- symptom-wise?
Some patients remain asymptomatic or have minimal clinical findings.
Dilated cardiomyopathy:
How do symptoms usually develop?
Symptoms develop gradually and are typically related to left ventricular heart failure
Dilated cardiomyopathy:
The presence of what is associated with a poor prognosis?
The presence of right sided heart failure is associated with poor prognosis
Dilated cardiomyopathy:
What tests are done and why?
Lab tests
Echocardiogram
Dilated cardiomyopathy:
Why are lab tests for?
Lab tests include screening for potentially reversible causes, including HIV
Dilated cardiomyopathy:
Why are echocardiograms for?
The echocardiogram differentiates the primary abnormality and determines ejection fraction.
Dilated cardiomyopathy:
What procedure is done? Why?
Cardiac catheterization to rule out coronary artery disease
Treatment of dilated cardiomyopathy
Broadly includes?
Identify and eliminate potential causes of DCM
Treatment of dilated cardiomyopathy
What kind of damage is reversible?
Myocardial damage related to ingesting alcohol is reversible if detected early and the patient abstains from further drinking.
Treatment of dilated cardiomyopathy
What kind of damage is reversible?
Control of heart failure, dysrhythmias, or intracoronary thrombus
Treatment of dilated cardiomyopathy
What kind of treatment is done for severe cases? What are severe cases?
Biventricular pacing for severe symptomatic heart failure, prolonged QRS, dilated ventricle and poor ejection fraction.
Treatment of dilated cardiomyopathy
What do implantable cardioverter defibrillators (ICDs) do?
Implantable cardioverter defibrillators (ICDs) to prevent sudden death associated with lethal dysrhythmias
Treatment of dilated cardiomyopathy
What other treatments have been shown to prolong life?
Mechanical circulatory support, heart transplantation, and some medical therapies have been shown to prolong life.
Ischemic cardiomyopathy:
What causes this?
Result of oxygen levels that are inadequate to meet the metabolic demands of the myocardial cells.
Ischemic cardiomyopathy:
Result of oxygen levels that are inadequate to meet the metabolic demands of the myocardial cells.
Why do this occur? How is it?
Caused by obstruction in the coronary arteries;
may be acute or chronic
Ischemic cardiomyopathy:
What does severe, persistent ischemia lead to?
Severe, persistent ischemia causes the muscle tissue to die (MI)
Ischemic cardiomyopathy:
What happens to dead muscle?
Dead muscle is replaced with scar tissue.
The larger the scar, the greater the dysfunction.
Ischemic cardiomyopathy:
What does decreased muscle mass lead to?
Decreased muscle mass leads to decreased energy for pumping blood and decreased cardiac output.
Ischemic cardiomyopathy:
Decreased muscle mass leads to decreased energy for pumping blood and decreased cardiac output. What does this lead to?
Cardiogenic shock results
Ischemic cardiomyopathy:
What increases? What does this result in?
Left ventricular end-diastolic pressure increases, pulmonary artery pressure increase, and pulmonary edema results.
Ischemic cardiomyopathy:
Left ventricular end-diastolic pressure increases, pulmonary artery pressure increase, and pulmonary edema results. What occurs?
End-organ damage occurs
Non ischemic cardiomyopathy:
What are causes?
Idiopathic cardiomyopathy
Myocarditis
Pregnancy, heavy alcohol use, hypertension and tachycardia
Non ischemic cardiomyopathy:
Causes: Idiopathic cardiomyopathy- What is this?
heart dilates, remodels, and becomes ineffective to pump
Non ischemic cardiomyopathy:
How may this present?
May be acute or chronic
Hypertrophic cardiomyopathy(HCM)
What is this?
Hypertrophied, nondilated left ventricle not related to any obvious cause
Hypertrophic cardiomyopathy(HCM)
It is hypertrophied, nondilated left ventricle not related to any obvious cause
What would as obvious cause be?
Hypertension or aortic stenosis
Hypertrophic cardiomyopathy(HCM)
What is a characteristic feature of this?
Diastolic dysfunction is a characteristic feature
Hypertrophic cardiomyopathy(HCM)
How is the heart in this condition?
The heart can contract but cannot relax and remains abnormally stiff in diastole.
Hypertrophic cardiomyopathy(HCM)
What else may occur?
Septal wall hypertrophy may occur, leading to a left ventricular outflow tract obstruction during systole.
Hypertrophic cardiomyopathy(HCM)
What usually occurs in asymptomatic or mildly symptomatic people? What age?
Sudden death, usually from a ventricular dysrhythmia, in asymptomatic or mildly symptomatic people of any age group
HCM Assessment and treatment
Assessment: How is it usually found?
Often found unexpectedly during investigation of heart murmurs or family screening
HCM Assessment and treatment
Assessment: What is the most common symptom?
The most common symptom is dyspnea.
HCM Assessment and treatment
Assessment: What other symptoms frequently occurs?
Presyncope and syncope also frequently occur.
HCM Assessment and treatment
Assessment: What would confirm the diagnosis of this illness?
Left ventricular hypertrophy (LVH) present on the echocardiogram confirms the diagnosis.
HCM Assessment and treatment
Assessment: Who could this be a normal finding in?
Borderline LVH may be a normal finding in competitive athletes.
HCM Assessment and treatment
Treatment includes:
Control symptoms.
Prevent complications and reduce the risk for sudden death.
Genetic screening and counseling
ICD
Percutaneous ablation with ethanol or surgery to remove a portion of the septum may be necessary.
HCM Assessment and treatment
Treatment includes: Percutaneous ablation- what does it do? What is it used with?
Percutaneous ablation with ethanol or surgery to remove a portion of the septum may be necessary.
HCM Assessment and treatment
Treatment includes: How are symptomatic patients?
Most symptomatic patients can be medically managed.
Peripheral Vascular Disease:
What is it?
A group of distinct disorders involving the arteries, veins, and lymphatic vessels of the peripheral circulation.
Peripheral Vascular Disease:
What is this considered?
Noncardiac diseases that affect the circulation as a whole
Peripheral Vascular Disease:
Noncardiac diseases that affect the circulation as a whole: What does this include?
Peripheral arterial disease (PAD)
Venous disease
Peripheral Arterial Disease:
What is this?
Processes that obstruct the blood supply of the lower or upper extremities
Peripheral Arterial Disease:
Who is it common in?
Symptomatic PAD is a disease of the elderly found more commonly in men aged 70 years and older.
Patients of any age with risk factors for atherosclerosis, such as smoking or diabetes
Peripheral Arterial Disease:
What are other risk factors of PAD?
Other risk factors: hypertension, lipid disorders, family history, postmenopausal state, and hyperhomocysteinemia
Peripheral Arterial Disease:
How does the disease develop?
The disease develops in major bifurcations and areas of acute angulations.
Peripheral Arterial Disease:
What are symptoms? What is the main symptom?
Intermittent claudication is classic symptom, and is cramping, burning or aching pain in the legs or buttocks, relieved with rest (when legs dangle, when elevated,)
Peripheral Arterial Disease:
What are other symptoms?
Other symptoms: cool to touch, hair loss on extremities, nail thickening, drying of the skin
Peripheral Arterial Disease:
What are some results to monitor?
Ankle brachial index: Ratio of ankle to brachial systolic blood pressure (normal 1.0 or greater).
Critical limb ischemia = ABI less than 0.518
Peripheral Arterial Disease:
What is management of this disease?- Broadly
Modifying or eliminating risk factors
Peripheral Arterial Disease:
What is management of this disease?
Smoking cessation, aggressive treatment of hypertension, diabetes, and lipid disorders
Antiplatelets (aspirin or clopidogrel [Plavix]) to reduce the risk for MI and stroke and cilostazol (Pletal) to increase walking distance
Peripheral balloon angioplasty
Surgical bypass in severe obstruction
Peripheral Arterial Disease:
Management of this disease: What is used in severe obstruction?
Surgical bypass in severe obstruction
Peripheral Arterial Disease:
Management of this disease: What do platelets do? What are examples of platelets?
Antiplatelets (aspirin or clopidogrel [Plavix]) to reduce the risk for MI and stroke and cilostazol (Pletal) to increase walking distance
Venous disease:
What is phlebitis?
Phlebitis: vessel wall inflammation as a result of injury related to varicose veins
Venous disease:
What can phlebitis lead to?
Can lead to VTE
It can lead to the formation of a thrombus, a solid obstruction within the vein that can break loose and form a venous thromboembolism (VTE).
Superficial thrombophlebitis- What is it?
Superficial thrombophlebitis is a condition in which an injury to the vessel wall causes inflammation and clot formation in the superficial blood vessels.
Venous disease:
What are factors that predispose someone to thrombus formation?
Factors that predispose a patient to thrombus formation are vessel wall injury, stasis of blood, and increased blood coagulability (Virchow triad).
Venous disease:
What are symptoms of DVT?
Deep venous thrombosis (DVT) is characterized by pain, swelling, tenderness, and increased temperature over the affected area
Brownish in color
Venous disease:
What is accurate diagnosis of DVT?
Accurate diagnosis usually requires diagnostic testing such as compression ultrasonography.
Venous disease:
What is treatment for VTE?
The focus of care for the patient with VTE is to relieve symptoms, increase blood flow, and prevent complications.
Venous disease
Patients with DVT are at high risk for what?
Patients with DVT are at high risk for pulmonary embolism.
Venous disease
What is included in treatment strategies? What meds?
Treatment strategies include anticoagulant therapy to prevent the formation of emboli, followed by long-term warfarin or direct oral anticoagulant (DOAC; e.g., apixaban, dabigatran, edoxaban, and rivaroxaban) use to prevent recurrence.
.
Venous disease
The type of therapy used in patients depend on what?
Specific therapy depends on the patient’s history and clinical setting.
Venous disease
What is the most common complication of therapy for venous diseases?
Bleeding is the most common complication of therapy, and major hemorrhage can be fatal.
Venous disease
What kind of orders should be anticipated for venous diseases?
Anticipate orders for VTE prophylaxis based on daily interdisciplinary patient assessment for VTE risks.
This risk assessment includes determining need for ongoing central venous catheter use, current VTE prophylaxis, bleeding risks, and treatment responsiveness.
Also, aim to reduce the amount of time the patient is immobile because of the effects of treatment (e.g., analgesia, sedation, neuromuscular blockade, mechanical ventilation).
Venous disease
Anticipate orders for VTE prophylaxis based on daily interdisciplinary patient assessment for VTE risks. What is included in risk assessment?
This risk assessment includes determining need for ongoing central venous catheter use, current VTE prophylaxis, bleeding risks, and treatment responsiveness.
Venous disease
How should mechanical prophylaxis devices fit??
Mechanical prophylaxis devices should fit properly and should only be removed for cleaning and skin inspection.
What is the longest and strongest artery in the body?
The aorta
Aortic disease:
Overtime, what can happen to the aorta?
Over time, congenital, degenerative, hemodynamic, and mechanical factors stress this elastic vessel.
The result is dilation of the aortic wall, leaving the patient at risk for aortic dissection or rupture.
Aortic disease:
Over time, congenital, degenerative, hemodynamic, and mechanical factors stress this elastic vessel. What does this lead to?
The result is dilation of the aortic wall, leaving the patient at risk for aortic dissection or rupture.
Abdominal Aortic Aneurysm (AAA): What are they more common than?
More common than thoracic aortic aneurysms
Abdominal Aortic Aneurysm (AAA):
Who does it occur more in (what population)?
More frequent in males
Abdominal Aortic Aneurysm (AAA):
What is the leading risk factor for AAAs? What are other issues leading to AAAs?
Smoking is the leading risk factor for AAAs, followed closely by age, hypertension, lipid disorders, and atherosclerosis.
genetic, and environmental influences
Abdominal Aortic Aneurysm (AAA):
What is a major risk of AAA?
The major risk from AAAs is rupture, which is associated with a high rate of mortality (up to 90%).
AAA—Assessment and Management
Assessment: How do most people with AAA present?- symptomwise?
When is it typically identified?
Most patients with AAAs are asymptomatic; they are typically identified during health screening for another problem.
AAA—Assessment and Management
Assessment: What is the most common complaint?
Abdominal or back pain is the most common complaint.
AAA—Assessment and Management
Assessment: What is assessed?
Abdomen assessed for bruits or masses and assessment of peripheral pulses
AAA—Assessment and Management
Assessment: What is associated with worsening symptoms?
Worsening of symptoms is usually related to expansion or rupture of the aneurysm.
AAA—Assessment and Management
Assessment: What is the most practical method of confirming the diagnosis?
Abdominal ultrasonography is the most practical method of confirming the diagnosis
AAA—Assessment and Management
Management
Management of AAAs includes control of hypertension and elimination of risk factors, such as smoking.
AAA—Assessment and Management
Management: How should the patient be followed?
The patient should be followed with serial noninvasive tests, such as ultrasonography.
AAA—Assessment and Management
Management: What does treatment involve?
Treatment of aneurysms involves surgical repair, which is usually indicated for AAAs larger than 5.5 cm
AAA—Assessment and Management
Management: In addition to surgery, how may AAAs be repaired?
In addition to surgery, AAAs may be repaired by a minimally invasive approach using an endovascular graft.
Thoracic Aortic Aneurysm: What is the most common cause?
Most ascending thoracic aortic aneurysms are due to conditions that cause remodeling and cystic medial degeneration.
Thoracic Aortic Aneurysm: What are they also associated with?
Ascending thoracic aortic aneurysms are also associated with connective tissue disorders, genetic disorders, bicuspid aortic valve, infections, inflammatory diseases, chronic aortic dissection, and trauma.
Thoracic Aortic Aneurysm—Assessment and Management
Assessment: How do most patients present?
Like most patients with AAAs, most patients with thoracic aortic aneurysms are asymptomatic at the time of diagnosis.
Thoracic Aortic Aneurysm—Assessment and Management
Assessment: What are symptoms related to? What do these include?
Symptoms are related to the size and location of the aneurysm; these include aortic insufficiency and signs of compression of adjacent structures
Thoracic Aortic Aneurysm—Assessment and Management
Assessment: Symptoms are related to the size and location of the aneurysm; these include aortic insufficiency and signs of compression of adjacent structures
Which can lead to?
which can lead to symptoms such as hoarseness, dysphagia, dyspnea, and heart failure
Thoracic Aortic Aneurysm—Assessment and Management
Assessment: What can be fatal?
Rupture or acute dissection of a thoracic aneurysm can be fatal.
Thoracic Aortic Aneurysm—Assessment and Management
Management: What does it include?
For most ascending thoracic aortic aneurysms, surgical repair is indicated at a diameter of 5.5 cm or more.
What is the most common and lethal condition involving the aorta?
Acute aortic dissection, which occurs when the aortic wall tears, is the most common and the most lethal condition involving the aorta.
Aortic Dissection—Assessment and Management
Who is the incidence of aortic dissection highest in?
The incidence is highest in males older than 60 years with a history of hypertension.
Aortic Dissection—Assessment and Management
What are other risk factors to developing aortic dissection?
Other risk factors include connective tissue disorders (i.e., Marfan syndrome, Turner syndrome), a preexisting aortic aneurysm, cardiac surgery (aortic valve or coronary bypass), cardiac catheterization, illicit use of stimulants (cocaine, crack, methamphetamine), preexisting vasculitis, strenuous isometric resistance exercises, and trauma.
Aortic Dissection—Assessment and Management
How do most patients present?
More than 90% of patients present with sudden, intense chest pain.
Aortic Dissection—Assessment and Management
How do most patients describe symptoms?
The pain is described as “ripping” or “tearing” and may be accompanied by syncope
Aortic Dissection—Assessment and Management
How can the diagnosis be determined in most patients?
In most patients, the diagnosis can be determined with a careful history and physical examination.
Aortic Dissection—Assessment and Management
In most patients, the diagnosis can be determined with a careful history and physical examination. What would this show?
The patient will have a murmur of aortic regurgitation or alteration of the peripheral pulses with known risk factors, such as hypertension.
Aortic Dissection—Assessment and Management
What may a chest radiograph show?
The chest radiograph may show a widened mediastinum.
Aortic Dissection—Assessment and Management
If the aortic dissection involves the coronary arteries, what may be present?
Cardiac ischemia may be present if the dissection involves the coronary arteries.
Aortic Dissection—Assessment and Management
What may be another complication of aortic root?
Cardiac tamponade may be another complication of dissection involving the aortic root.
Aortic Dissection—Assessment and Management
What may be another complication if the aortic arch vessels are involved?
Neurologic deficits may occur if the aortic arch vessels are involved.
Aortic Dissection—Assessment and Management
Dissections extending to the renal arteries result in:
Dissections extending to the renal arteries result in:
elevated serum creatinine,
decreased urine output, and severe hypertension that is difficult to manage.
Aortic Dissection—Assessment and Management
To confirm the diagnosis of acute aortic dissection, what is ordered?
To confirm the diagnosis of acute aortic dissection,
transesophageal echocardiography or
contrast medium–enhanced CT
may be ordered
Aortic Dissection—Assessment and Management
What does survival depend on?
Survival of the acute phase depends on the location of the dissection, the severity of the complications, and the rapidity with which the diagnosis is confirmed.
Aortic Dissection—Assessment and Management
What does clinical management focus on?
Clinical management focuses on controlling blood pressure and managing pain.
Aortic Dissection—Assessment and Management
What is treatment when the ascending aorta is involved in the dissection?
Surgery is the treatment of choice when the dissection involves the ascending aorta.
Hypertension
Medical Management- Diagnosis
How is HTN defined?
Hypertension is defined as a systolic blood pressure greater than 130 to 139 mm Hg in stage 1 and greater than 140 mm Hg in individuals in stage 2, and a diastolic blood pressure greater than 90 mm Hg in all age groups.
Hypertension
Treatment:
Lifestyle changes
Medications
Hypertension
Treatment: What are medications used?
Diuretics
Antihypertensives
Hypertension
Clinical Manifestations include
Headaches
Chest pain
Vision changes
Shortness of breath
Renal dysfunction
Dizziness
Fatigue
Nosebleeds
Hypertension- Complications include
Dilated cardiomyopathy
Systolic dysfunction
Renal failure
Stroke
Hypertensive crisis
Hypertensive Crisis:
Who is at risk for developing this?
Patients with high blood pressure are at risk for experiencing a hypertensive crisis.
Hypertensive Crisis:
What is it?
A hypertensive crisis or emergency is defined as an acute elevation of blood pressure (greater than 180/120 mm Hg) that is associated with acute or imminent target organ damage.
Hypertensive Crisis:
How common is it? Who does it occur in mostly?
This rare but potentially fatal condition strikes about 1% to 2% of hypertensive patients, occurring more frequently in African American males and in older adult patients.
Hypertensive Crisis-Assessment
Signs and symptoms include:
Signs of encephalopathy include headache, visual disturbances, confusion, nausea, and vomiting.
Hypertensive Crisis-Assessment
Signs and symptoms include: What happens to eyes?
Examination of the retina of the eyes may reveal cotton-wool spots and hemorrhages, indicating damage to retinal nerves and rupture of retinal blood vessels;
Hypertensive Crisis-Assessment
What else may occur? What would this indicate?
Chest pain may represent acute coronary syndrome or aortic dissection.
Hypertensive Crisis-Assessment
What happens to kidneys?
Depending on the damage to the kidneys, the patient may present with decreased urine output (oliguria) or azotemia (excess urea in the blood).
Hypertensive Crisis-Management
What is the goal of treatment?
The goal is to reduce the bp by not more than 25% within 1 hour.
Hypertensive Crisis-Management
What is treatment?
Several intravenous medications are indicated in treating hypertensive crises; the choice depends on availability and the clinical situation.
Hypertensive Crisis-Management
Several intravenous medications are indicated in treating hypertensive crises; the choice depends on availability and the clinical situation. What are examples of drugs?
The selected drug may be a vasodilator, adrenergic blocker, calcium channel blocker, or an angiotensin-converting enzyme inhibitor.
Hypertensive Crisis-Management
What is necessary to avoid lowering the blood pressure too quickly? How is this accomplished?
Constant monitoring is necessary to avoid lowering the blood pressure too quickly;
this is best accomplished with an intra-arterial catheter.
Hypertensive Crisis-Management
What should be done about the cause of HTN crisis?
Identify the cause
Hypertensive Crisis-Management
Identify the cause: What could they be?
Acute or chronic kidney disease
Exacerbation of chronic hypertension
Sudden withdrawal of antihypertensive medications
Heart Failure: What is it?
Heart failure is a clinical syndrome characterized by fatigue and dyspnea on exertion (DOE), edema, orthopnea, and paroxysmal nocturnal dyspnea.
Heart Failure: What is it used to describe?
Heart failure is the term used to describe the general clinical syndrome regardless of the kind of heart failure or the etiology that produces the symptoms.
Heart Failure: Why is this the term used?
The revised guidelines recently published by a joint American College of Cardiology (ACC) and American Heart Association (AHA) task force use the preferred term heart failure rather than congestive heart failure as not all patients present with symptoms suggestive of fluid retention.
Acute Versus Chronic Heart Failure:
What does it describe?
Describes the onset and intensity of symptoms
Acute Versus Chronic Heart Failure:
Acute HF: What is it ?
Acute: sudden onset over days or hours
Acute Versus Chronic Heart Failure:
Chronic HF: What is it ?
Chronic: develop over months to years
Acute Versus Chronic Heart Failure:
Chronic HF: How may heart failure become chronic?
If the cause of acute symptoms is not reversed, then heart failure will become chronic.
Left-Sided Heart Failure: What is it?
Failure of the left ventricle to fill or empty properly
Left-Sided Heart Failure: What does it lead to?
Leads to increase in ventricular pressures and pulmonary vascular congestion
Left-Sided Heart Failure: How can it further be classified as?
systolic and diastolic dysfunction.
Left-Sided Heart Failure:
Systolic dysfunction: How is it defined? What is it caused by?
Systolic dysfunction is defined as an ejection fraction (EF) of less than 40% and is caused by a decrease in contractility.
Left-Sided Heart Failure:
Diastolic dysfunction: What is the cause of this?
Diastolic dysfunction is caused by impaired relaxation and filling.
Left-Sided Heart Failure:
Diastolic dysfunction: How is EF?
EF may be as high as 80%.
Right-Sided Heart Failure: What is it?
Failure of the right ventricle to pump adequately
Right-Sided Heart Failure: What is the most common cause of this?
Left-sided heart failure is the most common cause.
Right-Sided Heart Failure: How else can this disease exist?
Can also exist with normal left ventricle.
Right-Sided Heart Failure: What else can cause this?
Can result from pulmonary disease (cor pulmonale) and primary pulmonary artery hypertension
Right-Sided Heart Failure: What is the most common cause of ACUTE right sided heart failure?
PE is a common cause of acute right-sided heart failure.
What is the underlying result of all types of heart failure?
insufficient CO
Factors that determine Cardiac output include:
Oxygen demand
Mechanical factors
Neurohormonal mechanisms
Factors that determine Cardiac output include:
Oxygen demand
CO increases to meet increased O2 demand
Factors that determine Cardiac output include:
Mechanical factors:
Stroke volume and heart rate
Factors that determine Cardiac output
Neurohormonal mechanisms:
Catecholamines
Renin-angiotensin- aldosterone system
Heart Failure:
Assessments include:
Vital signs
Breath sounds
Monitor rate and rhythm
Skin color, temperature, peripheral pulses
Dry, persistent cough
Activity intolerance
Laboratory data
Diagnostic studies
Heart Failure:
Assessments include: Diagnostic studies like
Electrocardiography (ECG)
Echocardiography (with and without Doppler ultrasound)
Transesophageal echocardiogram (TEE)
Heart Failure
Nursing Interventions
Rest, and activity as tolerated.
Improve pump function (contractility, heart rate and rhythm)
Patient education:
Heart Failure
Nursing Interventions: Improve pump function (contractility, heart rate and rhythm)
How?
Diuretics
ACE inhibitors
Nitrates/hydralazine
Angiotensin converting enzyme inhibitors
Beta blockers (carvedilol [Coreg])
Digoxin
Heart Failure
Nursing Interventions: Patient education
Sodium restriction,
alcohol cessation,
exercise,
medication adherence,
fluid restriction
Heart Failure Complications
Pulmonary edema
Cardiogenic shock
Pleural effusion
Arrhythmias
Thrombus formation
Hepatomegly
Renal failure
Cardiovascular Disease: What does it encompass?
Cardiovascular disease encompasses both cardiac and peripheral vascular diagnoses, including coronary artery disease (CAD).
Cardiovascular Disease: CAD exists across a spectrum of severity, which includes
CAD exists across a spectrum of severity,
which includes stable angina and three diagnoses that are categorized as acute coronary syndrome (ACS):
unstable angina (UA),
non-ST-elevation myocardial infarction (NSTEMI), and
ST-elevation myocardial infarction (STEMI).
Cardiovascular Disease:
CAD exists across a spectrum of severity, which includes stable angina and three diagnoses that are categorized as acute coronary syndrome (ACS):
unstable angina (UA),
non-ST-elevation myocardial infarction (NSTEMI)
ST-elevation myocardial infarction (STEMI).
Cardiovascular Disease: What is a major cause of CAD?
Atherosclerosis is a major cause of CAD.
Cardiovascular Disease:
Major risk factors are those that have been shown through research to significantly increase the risk of cardiovascular disease.
What are the two broad groups?
Modifiable
Nonmodifiable risk factors
Cardiovascular Disease:
Modifiable includes
Smoking
Inactivity
Overweight
Cholesterol
- High LDL
- Low levels of HDL
Diabetes
Hypertension
Cardiovascular Disease:
NonModifiable includes
Age
Greater than 65 y/o
Heredity (including race)
Higher in African Americans, Mexican Americans, Native Americans, Native Hawaiians, and some Asian Americans
Gender
Men;
after menopause, the death rate rises in women
Angina- Classification
What are the groups?
Stable angina/angina pectoris
Variant (Prinzmetal) angina
Microvascular angina
Unstable angina
Angina- Classification
Stable angina/angina pectoris:
How does it occur? How is it relieved?
Physical exertion or emotional stress; relieved by rest or nitroglycerin
Angina- Classification
Variant (Prinzmetal) angina:
How does it occur? What is it the result of? What may cause this?
At rest, between midnight and 8 a.m.;
result of coronary artery spasm;
usually have severe atherosclerosis of at least one major coronary artery
Angina- Classification
Microvascular angina
Chest pain with normal epicardial coronary arteries
Acute Coronary Syndrome (ACS): What is it?
ACS is a spectrum that includes unstable angina (UA) and acute myocardial infarction (AMI).
Acute Coronary Syndrome (ACS):
ACS is a spectrum that includes unstable angina (UA) and acute myocardial infarction (AMI).
What does AMI include?
With STEMI (ST-elevation myocardial infarction)
Without STEMI (Non-ST-elevation myocardial infarction (NSTEMI))
Acute Coronary Syndrome (ACS):
ACS is a spectrum that includes unstable angina (UA) and acute myocardial infarction (AMI).
Unstable (preinfarction) angina: What is it?
Cardiac chest pain that can present as angina at rest, new-onset angina, or worsening angina
Acute Coronary Syndrome (ACS):
ACS is a spectrum that includes unstable angina (UA) and acute myocardial infarction (AMI).
Unstable (preinfarction) angina: What does it require?
Requires immediate treatment
Acute Coronary Syndrome (ACS):
ACS is a spectrum that includes unstable angina (UA) and acute myocardial infarction (AMI).
MI: What is it?
Prolonged ischemia related to an imbalance between oxygen supply and oxygen demand
Myocardial Infarction:
What is triggered and how?
Plaque rupture triggers thrombus formation at the site of an atherosclerotic lesion
Myocardial Infarction:
What results in an MI?
Occlusion of blood flow
Myocardial Infarction:
How long until irreversible damage by MI occurs?
irreversible damage after 20 to 40 minutes
Myocardial Infarction:
How can tissue be salvaged?
Tissue can be salvaged if flow is restored within 6 hours
Myocardial Infarction:
Cellular changes depend on what?
Cellular changes depend on extension and expansion of infarct and ventricular remodeling
Assessment of MI: What is noted?
Midsternal chest pain
Pale and diaphoretic
Dyspnea, tachypnea, and/or hypotension
Syncope
Feeling of impending doom
Nausea and vomiting
Dysrhythmias
Assessment of MI:
Midsternal chest pain- how is it? How is it relieved?
Severe, crushing, and squeezing pressure
May radiate
Unrelieved with nitroglycerin
Physical examination of MI:
How may patient appear? How is skin?
May appear restless, agitated, in distress
Skin is cool and moist
Physical examination of MI:
How is breathing?
Labored breathing,
Crackles
Rhonchi
Physical examination of MI:
How is heart?
Diminished S1, S3 and S4,
Pericardial friction rub
Physical examination of MI:
What is there a lack of?
Lack of point o maximal impulse
Physical examination of MI:
What is irregular?
Irregular, faint pulse
Physical examination of MI:
What else is present?
VS
low grade fever
HTN
tachycardia,
hypotension and bradycardia
Diagnostic Tests for MI:
ECG
Diagnostic Tests for MI: ECG
What does it detect?
Detects patterns of ischemia, injury, and infarction
Diagnostic Tests for MI: ECG
What causes ECG changes?
Depolarization and repolarization of cardiac cells are altered, causing ECG
Diagnostic Tests for MI: ECG
ECG: What does ischemia looks like?
T-wave inversion,
ST depression
Diagnostic Tests for MI: ECG
ECG: What does injury look like?
ST segment elevation
Diagnostic Tests for MI: ECG
ECG: What does infarction look like?
T -wave
ST segment
Q wave changes
Diagnostic Tests for MI: ECG
ECG: What does it reveal?
Reveals anatomical region involved
Lab tests for MI:
Troponin
Other blood tests
Lab tests for MI:
What is the preferred biomarker?
Troponin
Lab tests for MI:
Troponin levels include?
Troponin I
Troponin T
Lab tests for MI:
Troponin levels: Troponin I= rises? peaks? remains elevated?
Troponin I rises in 3 to 12 hours,
Peaks at 24 hours
remains elevated for 5-10 days.
Lab tests for MI:
Other blood tests include?
Chemistry
CBC
Coagulation studies
full lipid profile
Lab tests for MI:
Other diagnostic tests include:
Exercise stress testing
CXR
PET scan
Echocardiogram
MRI
Coronary angiography
Management of MI:
When should you evaluate pt?
Evaluate within 10 minutes of arrival
Management of MI
When patient arrives what do you do?
Patient history and 12 lead ECG elevation greater than 1 mm or two or more contiguous leads = MI
MI management
When patient arrives what meds do you give?
ASA
Oxygen
Nitroglycerin
Morphine
B-blocker VS
IV access
Continuous cardiac monitoring
MI management
When patient arrives what should you check
Serum cardiac markers
CBC
Chemistry and lipid profile
CXR echo
MI management
What other interventions are done?
Percutaneous coronary intervention
Fibrinolytic therapy
Surgical intervention
MI management
Percutaneous coronary intervention:
What does it do?
Reestablishes blood flow
MI management
Percutaneous coronary intervention:
What is the procedure?
Artery is opened by balloon and stent is placed
MI management
Fibrinolytic therapy:
In STEMI, when do you give drug by?
In STEMI, door to drug within 30 minutes
MI management
Fibrinolytic therapy:
When should drug be given?
Given within 3 hours of onset of symptoms
MI management
What is the surgical intervention?
CABG
Complications of Acute MI
Include what two broad groups?
Hemodynamic complication
Mechanical complication
Complications of Acute MI
Hemodynamic complications is what?
Cardiogenic shock
Complications of Acute MI
Hemodynamic complications- Cardiogenic shock- what are symptoms?
S/S of cardiogenic shock include:
rapid, thready pulse, cool, moist skin, chest pain, dyspnea, tachypnea, inspiratory crackles, systolic bloop pressure less than 85 mmHg
Complications of Acute MI
What is the most serious complication of MI?
Cardiogenic shock
Complications of Acute MI
Mechanical complication- What is it?
Ventricular Septal Rupture
Complications of Acute MI
When is the greatest risk for ventricular septal rupture?
Ventricular Septal Rupture. The greatest risk is within the first 24 hours and up to 5 days.
Complications of Acute MI
Assessment findings for ventricular septal rupture?
Assessment finding of Ventricular Septal Rupture includes a new, loud systolic murmur.
Surgical Revascularization- When is it indicated?
Unstable angina
AMI
Failure of percutaneous interventions
Surgical Revascularization-
Includes:
Coronary artery bypass graft (CABG) surgery
Minimally invasive direct coronary artery bypass (MIDCAB) surgery
Transmyocardial revascularization (TMR)
Surgical Revascularization-
CABG: Increased mortality associated with:
Left ventricle dysfunction
Emergency surgery
Age
Sex (female)
Number of diseased vessels
Decreased ejection fraction with congestive heart failure
Surgical Revascularization-
CABG Surgery: What does it do?
Provides additional conduits for blood flow
Arteries longer patency
Surgical Revascularization-
CABG Surgery: Provides additional conduits for blood flow- Where?
Saphenous vein
Internal mammary artery
Radial artery
