CV I and II

Question 1

Cardiovascular Diseases (CVD)

Answer 1

CAD/ CHD
Acute Coronary Syndrome
Metabolic Syndrome
Valvular Heart Disease 
Heart Failure
Cardiomyopathy 
Infective Endocarditis

Question 2

Factors that lead into Cardiovascular Diseases

Answer 2

1) Smoking
2) Obesity
3) Pre-diabetes & Diabetes
4) Dyslipidemia
5) Hypertension
6) Genetics

Question 3

Women and Heart Disease

Answer 3

Higher mortality after MI
Higher false positive stress tests
Higher mortality after CABG
Women diabetics have > risk for CAD

Question 4

CAD Pathogenesis

Answer 4

CAD is a complex chronic inflammatory disease, characterized by remodeling and narrowing of the coronary arteries supplying oxygen to the heart
Two components:
Inflammation
Atherosclerosis

Question 5

Inflammation in Heart

Answer 5

C-Reactive Protein (CRP) *Jan. 2003: All patients with moderate risks for heart disease should have CRP measured
Women with elevated CRP have twice the incidence of ischemic heart disease as women with normal levels.

CRP
0-1 low, 1-2 med, 2-3 high

Question 6

Atherosclerosis:

Answer 6

Lipoprotein metabolism: transports fat into bloodstream; hastens buildup of cholesterol
Hemostasis: Fibrinogen
Endothelial dysfunction - Homocysteine: natural breakdown of methionine…leads to clots *decreased with folic acid, B6, B12

Question 7

What does cholesterol do on the heart?

Answer 7

Cholesterol within cells lead to foam cells
Foam cells are earliest sign of endothelial dysfunction: core of lipid-engorged macrophages, extracellular lipids, cellular debris, fibrin and plasma proteins covered by a fibrous cap of SM cells and dense CT
Foam cells in intima create fatty streak

Question 8

Target areas for Prevention of CAD

Answer 8

Cholesterol abnormalities
Tobacco use
HTN
DM

Question 9

Normal Blood Lipid Profile

Answer 9

Total Cholesterol (TC): 200 or less (not > 4 x HDL)
HDL Cholesterol: Men 35-70; Women 35-85
TC/HDL Ratio: 4:1 or less
Triglycerides (TFG): 150 or less
LDL Cholesterol:

Question 10

Other CAD risk factors

Answer 10

Sx of PCOS: male pattern acne, hirsutism, thinning hair, skin tags, central obesity, infertility/irregular cycles, ovarian cysts
Hyperuricemia (> 5.8 mg/dl in women; >7.4 mg/dl in men)
Acanthosis nigricans

Question 11

Metabolic Syndrome: Cluster of risk factors for CAD

Answer 11

Characterized by :
Insulin Resistance
High triglycerides, low HDL, possibly high LDL
Central obesity
Hypertension
Pro-inflammatory state 
Pro-thrombotic state

Question 12

Hallmarks of Metabolic Syndrome

Answer 12

BMI > 24.9
WHR > 0.8 in women and >0.95 in men
Waist >35” women, >40” men *12 x greater risk for diabetes
Triglyceride level > 150 mg/dl
HDL  130/85
FBG levels > 100 mg/dl or abnormal GTT

Question 13

Treatment for Metabolic Syndrome

Answer 13

Lifestyle modifications – FIRST LINE
Weight loss
Increased activity
Heart healthy dietary intake
Smoking cessation
If lifestyle changes do not achieve desired effects, medications are initiated

Question 14

Medications for Metabolic Syndrome

Answer 14

Statins
ACEIs and ARBs preserve renal function
Beta-blockers prevent endothelial damage (but increase lipid levels and insulin resistance)
Thiazides are particularly effective in African Americans and elderly; prevent osteoporosis, but they increase LDL and triglycerides and increase uric acid
Calcium Channel blockers appropriate if patients don’t tolerate beta blockers
Oral anti-diabetics (metformin most commonly used)
Low-dose ASA
Folic acid and vitamin B6
Garlic
Omega-3 fatty acids/ Fish oil supplements

Question 15

Stable angina

Answer 15

is substernal pain or discomfort that is provoked by exertion or emotional stress and is relieved by rest or nitroglycerin

Question 16

Unstable angina

Answer 16

is ischemic chest pain that occurs at rest, in a crescendo pattern, or is severe and of recent onset; falls into category of ACS

Question 17

Angina Pain Characteristics

Answer 17

Retrosternal pain
Poorly localized, may radiate
May feel a “fullness” or choking sensation
DM patients, elderly patients, and female patients may all have different sx
SOB, pallor, diaphoresis, dizziness, n/v, weakness

Question 18

Diagnosis of Angina

Answer 18

Important to r/o acute coronary syndromes whenever a person presents with chest pain

Probability of CAD is suggested by the presence of risk factors

Question 19

AHA Guidelines for treating chronic stable angina

Answer 19

A.  ASA and Anti-platelets
B.  Beta blockers and B/P 
C.  Cholesterol and cigarettes
D.  Diet and Diabetes
E.  Education and Exercise

Question 20

Management and Treatment of Angina – Non-pharmacologic: aggressive management of risk factors

Answer 20

Smoking cessation
Weight loss
Exercise

Question 21

Pharmacologic Management of CVD

Answer 21

Statins, ACE Inhibitors, Antiplatelet Therapy, Beta Blockers, Nitrates

Question 22

Statins

Answer 22

1. Statins: lower LDL-C to

Question 23

ACE Inhibitors

Answer 23

ACE Inhibitors/ARBs:  recommended for all patients with angina and DM and/or LV dysfunction. 
Adverse effects/side effects: 
Cough
Hyperkalemia
Hypotension
ARF especially if given with diuretics
Potential for anaphylaxis 
Nursing Implications
Hold for SBP

Question 24

Antiplatelet Therapy

Answer 24

Antiplatelet Therapy:
ASA 81-325 mg/day is first-line therapy
Clopidogrel (Plavix) for patients who cannot tolerate ASA
Glycoprotein (GP) IIb/IIIa inhibitor class of platelet antagonists (Integrilin, ReoPro, Aggrastat)
Nursing implications:
IV forms are used in acute MI
Monitor platelet counts
At increased risk for bleeding
Safety precautions and assessment for bleeding

Question 25

Beta Blockers

Answer 25

``` Beta Blockers and Calcium Channel Blockers: Beta Blockers are first-line therapy; calcium blockers are used when beta blockers are contraindicated or not effective; they may be used in combination Nursing implications I&Os and daily weights Assess for s/sx of HF If HR ```

Question 26

Nitrates

Answer 26

``` Prevent angina in stable angina Nitroglycerin ointment (Nitro-Bid) and extended release capsules SE & Nursing measures Treat Angina IV – ACS SL for “chest pain” SE & Nursing measures ```

Question 27

Chronotherapeutic Considerations

Answer 27

Chronotherapy: tailoring of drug delivery to the timing of circadian events (statins at HS) Controlled-release, sustained-release, extended-release

Question 28

Nursing goals for angina

Answer 28

``` Treatment when sx start Prevention Reduction of anxiety/stress Understanding of disease and tx Absence of complications Adherence to self-care plan ```

Question 29

Care and Teaching Post Cardiac Catheterization

Answer 29

Changes can occur very fast Frequent assessments (VS, ECG, pulse ox, urine output, lung sounds, peripheral vascular assessment, LOC) Bedrest with HOB 30 degrees Firm pressure / pressure dressing – prevention of bleeding Monitor for signs of hemorrhage or hypovolemia Affected extremity straight Monitor for infection during recovery period

Question 30

Exercise Testing (ETT)

Answer 30

Exercise ECG should be performed in most patients with suspected or known CAD Monitoring of heart during exercise on a treadmill or stationary bike

Question 31

Pharmaceutical Stress Tests

Answer 31

``` Lasts 1-3 hours, lots of nursing monitoring Done on those unable to exercise Reveals area of heart muscle not getting adequate perfusion To dilate vessels: Adenosine (Adenocard) Dipyridamole (Persantine) Thallium (nucleotide) Dobutamine used if the others cannot be ```

Question 32

Cardiac CT Angiography(64-slice CT)

Answer 32

Use of CT imaging to get 3D picture of heart and coronary arteries made visible by contrast dye Detects Ca++, fatty deposits and narrowed arteries Non-invasive Used for high risk, unusual Sx and inconclusive stress tests Less expensive and less recovery than cardiac catheterization

Question 33

Echocardiography

Answer 33

Echocardiography Ejection Fraction (EF) Normal - A normal heart's ejection fraction is between 55% and 70%.Example: An EF of 60 % means that 60% of the total amount of blood in the left ventricle is pushed out with each heartbeat.*You can have a normal ejection fraction reading and still have heart failure. Abnormal - 75% or greater - may indicate a heart condition like hypertrophic cardiomyopathy 36-49% = pumping ability below normal indicates damage, perhaps from a previous heart attack, but it may not indicate heart failure. 35% and below = pumping ability is low A low EF is a sign of heart failure.

Question 34

Cardiac Enzymes

Answer 34

Troponin T and I: | normal troponin T

Question 35

Invasive Cardiac Procedures

Answer 35

PCI (percutaneous coronary intervention): 1. PTCA (percutaneous transluminal coronary angioplasty) Intracoronary stent implantation (DES: Drug-eluting stents) Atherectomy: extraction 2. Brachytherapy: radiation (per catheter or implanted with stent) 3. Laser revascularization 4. EPS: radiofrequency catheter ablation for recurrent SVT 5. Transmyocardial laser revascularization: forms new vessels following laser burns 6. MAZE procedure for atrial fibrillation 7. Pulmonary Vein Isolation/Ablation CABG (coronary artery bypass grafting) **Big ones to know are PTCA, stent implantation EPS for arrhythmias You may get to see these MAZE is open heart

Question 36

Nursing Care with the Postoperative Cardiac Surgery Patient

Answer 36

``` Maintain hemodynamic stability Assist recovery from anesthesia Pain management Wound care Progressive activity Nutrition Education about medication and activity Psychosocial support ```

Question 37

Differentiation of Chest Pain

Answer 37

Angina: 5-15 minutes Usually r/t exertion, emotion, eating, cold MI: > 15 minutes Spontaneous onset Often unrelated to activity Esophageal Pain: 5-60 minutes Pain increased with lying, cold liquids Treated with antacids, PPI, H2 Agonists, NTG ``` Anxiety: 2-3 minutes no radiation may have numbness and tingling Treated with relaxation ``` Pericarditis - Sharp, severe pain - May radiate, sudden onset, intermittent, increases with DB, swallowing, coughing - Treat with analgesia, anti- inflammatory meds, upright position

Question 38

Causes of Pericarditis

Answer 38

``` Idiopathic Infectious MI Neoplasm CT disorders (lupus, RA) ```

Question 39

Acute Coronary Syndromes

Answer 39

A spectrum of clinical disorders caused by ischemic heart disease including: STEMI (ST segment elevation acute MI)* most vulnerable NSTEMI: non-ST elevation acute MI) UA: Unstable Angina Syndromes that may present when MI occurs, ranging from unstable angina to acute MI; common ER admission

Question 40

Immediate Goals with Acute MI

Answer 40

Restore Perfusion and decrease mycardial necrosis (prevention of heart failure) Reduce pain and dyspnea Prevent and Treat Complications – V fib, pulseless VT, Symptomatic bradycardiac, unstable tachycardia

Question 41

Diagnosis of ACS and MI

Answer 41

``` History of symptoms and PE Serum Biomarkers EKG Elevated ST segment (STEMI vs NSTEMI) Inverted T wave Pathologic (deep) Q wave (QwMI vs NQMI) ```

Question 42

Enzyme trends post damage

Answer 42

LOOK ON SLIDE

Question 43

Medications used with MI

Answer 43

``` MSO4 5 mg IV Oxygen 2 liters/cannula NTG (sl) X 3 Q 5 minutes ASA 1 tablet, chewed (or Plavix) Metroprolol (Lopressor) 5 mg IV Q 5” X3 Fibrinolytic agent within 30-60 minutes or PCI within 60-90 minutes IV Heparin 45 min after fibrinolytic (TPA) Anti-platelet agents (Integrilin) Magnesium Sulfate 1 mg slow IV, then 15 mg over 24h Lidocaine should be avoided ACE inhibitors 24 h after MI Statins at discharge ```

Question 44

Goals for MI

Answer 44

``` Onset of Sx: call within 5 minutes EMS: arrive within 8 minutes Pre-hospital: EKG, fibrinolytics within 30” ER: PCI within 90 minutes GOLDEN HOUR: first 60 minutes TOTAL ISCHEMIC TIME: within 120” ```

Question 45

Suspected Acute MI in the Community

Answer 45

Recognize Symptoms Activate EMS Confirm with EKG and Early Defibrillation ASA (325 mg PO) and NTG (SL) Transport to hospital for PCI (within 90 minutes) or pharmacologic (fibrinolytics) management (within 30 minutes of arrival) 1:300 transported cardiac patients go into cardiac arrest; only 23% of patients with MI use EMS

Question 46

Suspected Acute MI in Hospitalized Patients

Answer 46

Diagnosis with EKG and enzymes (see Enzymes slide) ASA (325 mg po) and NTG (usually SL) O2 via n.c. Ensure IV access Bedrest Prepare for PCI Relief of sx, especially CP & dyspnea Decrease amount of myocardial necrosis to preserve LV function and prevent HF Prevent major adverse cardiac events (MACE): death, nonfatal MI Treat acute life threatening complications: V Fib, pulseless VT, symptomatic bradycardia, unstable tachycardia

Question 47

Major Focus of Nursing Care

Answer 47

Assess heart (rhythm and for S3 or S4 gallop), lungs, and for edema/urine output (hourly) Monitor cardiac rhythm (continuous) Assess and monitor pain and response to meds Monitor labs (particularly troponin) closely Maintain BR and O2 Assess and treat anxiety Monitor environmental stimulation Implement crisis intervention & patient education Medication management: SL or IV NTG, IV morphine, ACE I to decrease BP and increase fluid/Na+ excretion, beta blockers, ASA, IV heparin (monitor aPTT), clopidogrel (Plavix ®), glycoprotein IIb/IIIa inihibitor IV (Aggrastat ®)

Question 48

Potential Problems / Nursing Action

Answer 48

``` Alt in comfort: pain Impaired gas exchange: dyspnea Anxiety/fear of death Activity intolerance Alt in elimination Decreased CO; potential arrhythmias Rest, narcotics, O2, NTG, calm & quiet Positioning; O2 Pt. ed, reassurance Space activities Stool softeners, I&O Monitor EKG, VS assess for major complications ```

Question 49

MI Patient Ed. & D/C Teaching

Answer 49

Smoking cessation: The 5 A’s: ask, advise, assess, assist, arrange follow up Ensure they go home with Beta Blocker; ACE I; ASA and Plavix; Statins; NTG NSAIDS are absolutely contraindicated Mediterranean Diet, Low Na+ diet, and weight reduction Cardiac Rehab S/Sx of stable angina versus ACS S/Sx of depression Beta-blocker related erectile dysfunction

Question 50

Major Complications of MIs

Answer 50

``` Dysrhythmias Cardiogenic shock Cardiac Tamponade Ventricular Aneurysm Left Ventricular Heart Failure Pulmonary Edema Papillary Muscle Dysfunction Cardiac Arrest ```

Question 51

Cardiogenic Shock

Answer 51

Failure of the heart to pump adequately to meet perfusion needs of the body *ineffective pumping (decrease in CO leads to hypoperfusion {shock}) >40% damage to myocardium 85% mortality Tachycardia, hypotension, decreased urine output, cold, clammy skin, mental changes, s/sx of HF, CP, tachypnea

Question 52

Cardiac Tamponade

Answer 52

``` Fluid accumulates rapidly in the pericardium  decrease in cardiac output Can be caused by myocardial rupture following an MI or during cardiac surgery Symptoms (Beck’s Triad): JVD Muffled heart sounds Hypotension / tachycardia (Decreased CO) **Pulsus Paradoxus Also: narrowed pulse pressure ( ```

Question 53

Pulsus Paradoxus

Answer 53

Drop in systolic B/P of 10 mmHg or more on inspiration (r/t decreased CO) An accentuation of the normal decrease in systolic B/P with inspiration Caused by decrease LV stroke volume

Question 54

Pulsus Paradoxus

Answer 54

Drop in systolic B/P of 10 mmHg or more on inspiration (r/t decreased CO) An accentuation of the normal decrease in systolic B/P with inspiration Caused by decrease LV stroke volume

Question 55

Assessment of Pulsus Paradoxus

Answer 55

1. Establish systolic B/P 2. Inflate cuff slowly until no sounds are heard 3. Deflate slowly till systolic sounds are first heard and note pressure 4. Deflate till systolic sounds are heard throughout respiratory cycle and note pressure 5. Note difference between 3 and 4 * Normal difference is 10: P.Paradoxus

Question 56

Nursing Care for Cardiac Tamponade

Answer 56

Continuously monitor ECG for dysrhythmia formation, which may result of myocardial ischemia secondary to epicardial coronary artery compression. Monitor the BP every 5 to 15 minutes during the acute phase. Monitor for pulsus paradoxus via arterial tracing or manually Monitor urine output hourly; a drop in urine output may indicate decreased renal perfusion as a result of decreased stroke volume secondary to cardiac compression. Contact cardiology – will need to have surgically relieved (pericardial window/pericardiocentesis) at the bedside in ICU or in the OR

Question 57

Ventricular Aneurysm

Answer 57

Infarcted myocardium is thinned and bulges out during contraction (ischemic bulge in acute stage of MI) Dx with Xray, ECHO, long-term ST elevation; angiography is definitive

Question 58

Papillary Muscle Dysfunction

Answer 58

Causes mitral valve regurgitation Systolic murmur at apex Dyspnea, pulmonary edema, decreased CO