•
Leading cause of death in U.S.
•
Narrowing coronary arteries
–
Atherosclerosis

• Obstructed coronary artery
•
Increased myocardial oxygen demand
• Lactic acid release
•
Leads to pain
• Three types
–
Stable
– Unstable
– Prinzmetal’s: is a syndrome typically consisting of angina
(cardiac chest pain) at rest that occurs in cycles. It is caused by vasospasm , a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than directly by atherosclerosis

•
Chest pain
•
Radiates
•
Onset with exercise, etc.
•
Relieved by rest, nitroglycerin (NTG)
•
SOB, pallor, fear

•
Condition that includes:
–
Unstable angina
–
Acute myocardial ischemia with or without muscle damage
•
Associated with coronary artery stenosis and atherosclerotic plaque

•
Pathophysiology
–
Occluded coronary artery stops blood flow to part of cardiac muscle
–
Cellular death
– Tissue necrosis
–
Description—heart area affected
– Classification

•
Chest pain
•
Radiates to shoulder, neck, jaw, arms
•
Lasts longer than 15–20 minutes
•
Not relieved with NTG
•
Sense of impending doom
•
SOB
•
Diaphoresis
•
Nausea and vomiting

•
Manifestations in women and elderly
–
May be atypical
–
Upper abdominal pain
–
No chest pain but other symptoms

•
Related to size and location of infarct
•
Dysrhythmias
•
Pump failure
– Cardiogenic shock
•
Pericarditis

•
Pathophysiology
–
Due to altered formation of impulses or altered conduction of the impulse through the heart
– Ectopic beats
–
Heart block
– Reentry phenomenon
–
Classified to the site of impulse formation or the site and degree of conduction block

•
PVCs
•
Ventricular tachycardia
•
Ventricular fibrillation
•
AV conduction blocks
– First degree
–
Second degree
– Third degree

• Supraventricular
• Sinus tachycardia
• Sinus bradycardia
• PAC
• Atrial flutter
• Atrial fibrillation
• Junctional
• Ventricular dysrhythmias

04/11/2009
Congestive Heart Failure
Dr Ibraheem Bashayreh, RN,PhD
15

Normal heart function
Heart failure
04/11/2009
16

Congestive Heart Failure
•
Impaired cardiac pumping such that heart is unable to pump adequate amount of blood to meet metabolic needs
• Not a disease but a “ syndrome
”
•
Associated with long-standing HTN and
CAD
17
04/11/2009

Factors Affecting Cardiac Output
Preload
Cardiac Output
CO
= Heart Rate X
Stroke Volume
SV
Afterload Contractility
SV: the volume of blood pumped from one ventricle of the heart with each beat 04/11/2009
18

Factors Affecting Cardiac Output
• Heart Rate
– In general, the higher the heart rate, the lower the cardiac
• E.g. HR x Systolic Volume (SV) = CO
» 60/min x 80 ml = 4800 ml/min (4.8 L/min)
» 70/min x 80 ml = 5600 ml/min (5.6 L/min)
– But only up to a point. With excessively high heart rates, diastolic filling time begins to fall, thus causing stroke volume and thus CO to fall
19
04/11/2009

Heart Rate
60/min
80/min
100/min
130/min
150/min
04/11/2009
Stroke Volume Cardiac Output
80 ml 4.8 L/min
80/ml
80/ml
6.4 L/min
8.0 L/min
50/ml
40/ml
6.5 L/min
6.0 L/min
20

Factors Affecting Cardiac Output
•
Preload
–
The volume of blood/amount of fiber stretch in the ventricles at the end of diastole (i.e., before the next contraction)
21
04/11/2009

Factors Affecting Cardiac Output
• Preload increases with:
•
Fluid volume increases
• Vasoconstriction (“squeezes” blood from vascular system into heart)
• Preload decreases with
• Fluid volume losses
• Vasodilation (able to “hold” more blood, therefore less returning toheart)
22
04/11/2009

Factors Affecting Cardiac Output
• Starling’s Law
– Describes the relationship between preload and cardiac output
– The greater the heart muscle fibers are stretched (b/c of increases in volume), the greater their subsequent force of contraction – but only up to a point. Beyond that point, fibers get over-stretched and the force of contraction is reduced
• Excessive preload = excessive stretch → reduced contraction → reduced SV/CO
23
04/11/2009

Factors Affecting Cardiac Output
•
Afterload
– The resistance against which the ventricle must pump. Excessive afterload = difficult to pump blood → reduced CO/SV
– Afterload increased with :
• Hypertension
• Vasoconstriction
– Afterload decreased with:
• Vasodilation
24
04/11/2009

Factors Affecting Cardiac Output
•
Contractility
– Ability of the heart muscle to contract; relates to the strength of contraction.
25
04/11/2009

Factors Affecting Cardiac Output
• Contractility decreased with:
– infarcted tissue – no contractile strength
– ischemic tissue – reduced contractile strength.
– Electrolyte/acid-base imbalance
– Negative inotropes (medications that decrease contractility, such as beta blockers).
• Contractility increased with:
– Sympathetic stimulation (effects of epinephrine)
– Positive inotropes (medications that increase contractility, such as digoxin, sympathomimmetics)
04/11/2009
26

Pathophysiology of CHF
• Pump fails → decreased stroke volume /CO.
• Compensatory mechanisms kick in to increase CO
– SNS stimulation → release of epinephrine/norepinephrine
• Increase HR
• Increase contractility
• Peripheral vasoconstriction (increases afterload)
– Myocardial hypertrophy: walls of heart thicken to provide more muscle mass → stronger contractions
27
04/11/2009

Pathophysiology of CHF
– Hormonal response: ↓’d renal perfusion interpreted by juxtaglomerular apparatus as hypovolemia. Thus:
•
Kidneys release renin, which stimulates conversion of antiotensin I → angiotensin
II, which causes:
–
Aldosterone release → Na retention and water retention (via ADH secretion)
–
Peripheral vasoconstriction
04/11/2009
28

Pathophysiology of CHF
• Compensatory mechanisms may restore
CO to near-normal.
• But, if excessive the compensatory mechanisms can worsen heart failure because . . .
04/11/2009
29

Pathophysiology of CHF
• Vasoconstriction: ↑’s the resistance against which heart has to pump (i.e., ↑’s afterload), and may therefore ↓ CO
•
Na and water retention: ↑’s fluid volume, which
↑’s preload. If too much “stretch” (d/t too much fluid) → ↓ strength of contraction and ↓’s CO
•
Excessive tachycardia → ↓’d diastolic filling time → ↓’d ventricular filling → ↓’d SV and CO
30
04/11/2009

Congestive Heart Failure
•
CAD
•
Age
•
HTN
•
Obesity
•
Cigarette smoking
•
Diabetes mellitus
•
High cholesterol
•
African descent
31

Underlying causes/risk factors
• Ischemic heart disease (CAD)
• hypertension
• myocardial infarction (MI)
• valvular heart disease
• congenital heart disease
• dilated cardiomyopathy
04/11/2009
Heart failure
32

Congestive Heart Failure
Types of Congestive Heart Failure
•
Left-sided failure
–
Most common form
–
Blood backs up through the left atrium into the pulmonary veins
•
Pulmonary congestion and edema
–
Eventually leads to biventricular failure
33
04/11/2009

Congestive Heart Failure
Types of Congestive Heart Failure
•
Left-sided failure
–
Most common cause:
•
HTN
•
Cardiomyopathy
•
Valvular disorders
•
CAD (myocardial infarction)
04/11/2009
34

Congestive Heart Failure
Types of Congestive Heart Failure
• Right-sided failure
–
Results from diseased right ventricle
– Blood backs up into right atrium and venous circulation
– Causes
•
LVF
• Cor pulmonale: failure of the right side of the heart brought on by long-term high blood pressure in the pulmonary arteries and right
04/11/2009 ventricle of the heart
• RV infarction
35

Congestive Heart Failure
Types of Congestive Heart Failure
•
Right-sided failure
–
Venous congestion
•
Peripheral edema
•
Hepatomegaly
•
Splenomegaly
•
Jugular venous distension
36
04/11/2009

Congestive Heart Failure
Types of Congestive Heart Failure
•
Right-sided failure
–
Primary cause is left-sided failure
–
Cor pulmonale
•
RV dilation and hypertrophy caused by pulmonary pathology
37
04/11/2009

Clinical Manifestations
•
Pulmonary edema (what will you hear?)
–
Agitation
–
Pale or cyanotic
–
Cold, clammy skin
–
Severe dyspnea
–
Tachypnea
–
Pink, frothy sputum
38
04/11/2009

Clinical Manifestations
•
Fatigue
•
Dyspnea
–
Paroxysmal nocturnal dyspnea (PND)
•
Tachycardia
•
Edema – (lung, liver, abdomen, legs)
•
Nocturia
39
04/11/2009

Clinical Manifestations
•
Behavioral changes
–
Restlessness, confusion,
 attention span
•
Chest pain (d/t

CO and ↑ myocardial work)
•
Weight changes (r/t fluid retention)
•
Skin changes
–
Dusky appearance
40
04/11/2009

Congestive Heart Failure
•
Based on the person’s tolerance to physical activity
–
Class 1 : No limitation of physical activity
–
Class 2 : Slight limitation
–
Class 3 : Marked limitation
–
Class 4 : Inability to carry on any physical activity without discomfort
41
04/11/2009

Congestive Heart Failure
•
Primary goal is to determine underlying cause
–
Physical exam
–
Chest x-ray
–
ECG
–
Hemodynamic assessment
04/11/2009
42

Congestive Heart Failure
•
Primary goal is to determine underlying cause
–
Echocardiogram
(Uses ultrasound to visualize myocardial structures and movement, calculate EF)
–
Cardiac catheterization
43
04/11/2009

Acute Congestive Heart Failure
Nursing and Collaborative
Management
•
Primary goal is to improve LV function by:
–
Decreasing intravascular volume
–
Decreasing venous return
–
Decreasing afterload
–
Improving gas exchange and oxygenation
–
Improving cardiac function
–
Reducing anxiety
04/11/2009
44

Acute Congestive Heart Failure
Nursing and Collaborative
Management
•
Decreasing intravascular volume
–
Improves LV function by reducing venous return
–
Loop diuretic: drug of choice
–
Reduces preload
–
High Fowler’s position
45
04/11/2009

Acute Congestive Heart Failure
Nursing and Collaborative
Management
•
Decreasing afterload
–
Drug therapy:
• vasodilation, Angiotensin-converting enzyme
( ACE) inhibitors
–
Decreases pulmonary congestion
46
04/11/2009

Acute Congestive Heart Failure
Nursing and Collaborative
Management
•
Improving cardiac function
–
Positive inotropes
•
Improving gas exchange and oxygenation
– Administer oxygen, sometimes intubate and ventilate
•
Reducing anxiety
–
Morphine
04/11/2009
47

Chronic Congestive Heart Failure
•
Treat underlying cause
•
Maximize CO
•
Alleviate symptoms
48
04/11/2009

Chronic Congestive Heart Failure
•
Oxygen treatment
•
Rest
•
Biventricular pacing
•
Cardiac transplantation
49
04/11/2009

Chronic Congestive Heart Failure
•
ACE inhibitors
•
Diuretics
•
Inotropic drugs : drugs that influence the force of contraction of cardiac muscle
•
Vasodilators
• 
-Adrenergic blockers
50
04/11/2009

Chronic Congestive Heart Failure
•
Fluid restrictions not commonly prescribed
•
Sodium restriction
–
2 g sodium diet
•
Daily weights
–
Same time each day
–
Wearing same type of clothing
51
04/11/2009

Chronic Congestive Heart Failure
Nursing Management
•
Past health history
•
Medications
•
Functional health problems
•
Cold, diaphoretic skin
52
04/11/2009

Chronic Congestive Heart Failure
Nursing Management
•
Tachypnea
•
Tachycardia
•
Crackles
•
Abdominal distension
•
Restlessness
53
04/11/2009

Chronic Congestive Heart Failure
Nursing Management
•
Activity intolerance
•
Excess fluid volume
•
Disturbed sleep pattern
•
Impaired gas exchange
•
Anxiety
54
04/11/2009

Chronic Congestive Heart Failure
Nursing Management
•
Overall goals:
– 
Peripheral edema
– 
Shortness of breath
– 
Exercise tolerance
–
Drug compliance
–
No complications
55
04/11/2009

Chronic Congestive Heart Failure
Nursing Management
•
Acute intervention
–
Establishment of quality of life goals
–
Symptom management
–
Conservation of physical/emotional energy
–
Support systems are essential
56
04/11/2009

• The force of blood against the wall of the arteries.
• Systolic- as the heart beats
• Diastolic - as the heart relaxes
• Written as systolic over diastolic.
• Normal Blood pressure is less than 130 mm
Hg systolic and less than 85 mm Hg diastolic .
04/11/2009
57

• A consistent blood pressure of 140/90 mm
Hg or higher is considered high blood pressure.
• It increases chance for heart disease, kidney disease, and for having a stroke.
• 1 out of 4 Americans have High Bp.
• Has no warning signs or symptoms.
58
04/11/2009

• Makes the Heart work too hard.
• Makes the walls of arteries hard.
• Increases risk for heart disease and stroke.
• Can cause heart failure, kidney disease, and blindness.
59
04/11/2009

• High blood pressure is the most important risk factor for stroke.
• Can cause a break in a weakened blood vessel which then bleeds in the brain.
04/11/2009
60

• High Blood Pressure is a major risk factor for heart attack.
• Is the number one risk factor for Congestive
Heart Failure.
61
04/11/2009

• Kidneys act as filters to rid the body of wastes.
• High blood pressure can narrow and thicken the blood vessels.
• Waste builds up in the blood, can result in kidney damage.
62
04/11/2009

• Can eventually cause blood vessels to break and bleed in the eye.
• Can result in blurred vision or even blindness.
63
04/11/2009

• Causes arteries to harden.
• This in turn causes the kidneys and heart to work harder.
• Contributes to a number of problems.
64
04/11/2009

• Causes vary
• Narrowing of the arteries
• Greater than normal volume of blood
• Heart beating faster or more forcefully than it should
• Another medical problem
• The exact cause is not known.
65
04/11/2009

• Anyone, but it is more common in:
• African Americans- get it earlier and more often then Caucasians.
• As we get older. 60% of Americans over
60 have hypertension.
• Overweight, family history
• High normal bp:135-139/85-89 mm Hg.
66
04/11/2009

• Dr.’s will diagnose a person with 2 or more readings of 140/90mm Hg or higher taken on more than one occasion.
• White-Coat Hypertension
• Measured using a spygmomameter.
67
04/11/2009

• Don’t drink coffee or smoke cigarettes for
30 minutes before.
• Before test sit for five minutes with back supported and feet flat on the ground. Test your arm on a table even with your heart.
• Wear short sleeves so your arm is exposed.
68
04/11/2009

• Go to the bathroom before test. A full bladder can affect bp reading.
• Get 2 readings and average the two of them.
• Ask the Dr. or nurse to tell you the result in numbers.
69
04/11/2009

• Ages 18 Years and Older)
• Blood Pressure Level (mm Hg)
• Category Systolic Diastolic
• Optimal** < 120 < 80
• Normal < 130 < 85
• High Normal 130–139 85–89
04/11/2009
70

High Blood Pressure
•
Stage 1
•
Stage 2
•
Stage 3
140–159 /90–99
160–179 /100–109
180 /110
04/11/2009
71

Adopt a healthy lifestyle by:
• Following a healthy eating pattern.
• Maintaining a healthy weight.
• Being Physically Active.
• Limiting Alcohol.
• Quitting Smoking.
04/11/2009
72

• Dietary Approaches to Stop Hypertension.
• Was an 11 week trial.
• Differences from the food pyramid:
• an increase of 1 daily serving of veggies.
• and increase of 1-2 servings of fruit.
• inclusion of 4-5 servings of nuts,seeds, and beans.
73
04/11/2009

• Buy fresh, plain frozen or canned “no added salt” veggies.
• Use fresh poultry, lean meat, and fish.
• Use herbs, spices, and salt-free seasonings at the table and while cooking.
• Choose convenience foods low in salt.
• Rinse canned foods to reduce sodium.
74
04/11/2009

• Blood pressure rises as weight rises.
• Obesity is also a risk factor for heart disease.
• Even a 10# weight loss can reduce blood pressure.
04/11/2009
75

• Helps lower blood pressure and lose/ maintain weight.
• 30 minutes of moderate level activity on most days of week. Can even break it up into 10 minute sessions.
• Use stairs instead of elevator, get off bus 2 stops early, Park your car at the far end of the lot and walk!
76
04/11/2009

Alcohol raises blood pressure and can harm liver, brain, and heart
77
04/11/2009

• Injures blood vessel walls
• Speeds up process of hardening of the arteries.
04/11/2009
78

• If Lifestyle Modification is not working, blood pressure medication may be needed, there are several types:
• Diuretics-work on the kidney to remove access water and fluid from body to lower bp.
• Beta blockers-reduce impulses to the heart and blood vessels.
79
04/11/2009

• ACE inhibitors- cause blood vessels to relax and blood to flow freely.
• Angiotensin antagonists- work the same as
ACE inhibitors.
• Calcium Channel Blockers- causes the blood vessel to relax and widen.
• Alpha Blocker- blocks an impulse to the heart causing blood to flow more freely.
80
04/11/2009

• Alpha-beta blockers- work the same as beta blockers, also slow the heart down.
• Nervous system inhibitors- slow nerve impulses to the heart.
• Vasodilators- cause blood vessel to widen, allowing blood to flow more freely.
81
04/11/2009

• Hypertension is a very controllable disease, with drastic consequences if left uncontrolled.
82
04/11/2009