Cardiovascular Disorders
Understanding Medical Surgical Nursing 4th ed.,
Ch 21, 23, 24, (p.459-483), 26
Pharmacology Clear & Simple, Ch 16.
Objectives
1. Describe diagnostic test for the cardiovascular system.
2. Compare nonmodifiable risk factors in coronary artery disease
(CAD) with factors that are modifiable in lifestyle & heath
management.
3. Compare etiology/pathophysiology, S&S, medical management, &
nursing interventions for clients with cardiovascular disorders.
4. Specify teaching for clients with cardiovascular disorders.
Normal Aging Patterns
•Δ’s in cardiac musculature lead to
reduced efficiency & strength,
resulting in ↓’ed cardiac output.
•Older Adult Considerations
•Age 65 years
•Older Adult Considerations
•Heart Failure
•Edema
•Medications
•Teaching
Aging & the Cardiovascular System
• Atherosclerosis
• Arteriosclerosis
• BP ↑’s
• Vein Valves More Incompetent
• Heart Muscle Less Efficient
• Dysrhythmias Common
Cardiovascular Disease
• Number 1 Killer
• Healthy Lifestyle
• Smoking Cessation
• Dietary Fat Reduction
• 2 Servings of Fish Weekly
• Exercise
Cardiovascular Disease (cont’d)
• Go Red for Women
• American Heart Association’s
Nationwide Movement to
Celebrate the Power Women Have
to Band Together to Wipe Out
Heart Disease
• Color Red & Red Dress Linked with
This Ability
Cardiovascular Assessment
• Health History
• Symptoms – WHAT’S UP?
• Allergies
• Past Medical Hx
• Medications
• Family Hx
• Health Promotion Methods
• Diagnostic Studies
Cardiovascular Assessment cont’d
• Physical Assessment
• VS’s (T, P, R, BP, & Pain)
• Inspection
• Oxygenation, Skin Color
• Extremities: Hair, Skin, Nails, Edema, Color
• JVD
• Capillary Refill
• Clubbing
Physical Assessment (cont’d)
• Palpation
• Point of Maximum Impulse
• Extremity Temperature
• Edema
• Homans’ Sign*
Auscultation
• Heart Sounds
Joint Commission National Client Safety Goal
• Improve Accuracy of Client
Identification
• Use at Least 2 Client Identifiers
(Neither Client's Location) Whenever
Collecting Laboratory Samples or
Administering Medications or Blood
Products
• Use 2 Identifiers to Label Sample
Collection Containers in Presence of
Client
Joint Commission National Client Safety Goal (cont’d)
• Immediately Prior to Any Invasive Procedure,
Conduct Final Verification Process to Confirm
Correct Client, Procedure, Site, & Availability of
Appropriate Documents
• Improve Effectiveness of Communication Among
Caregivers
• For Orders/Telephonic Reporting of Critical
Test Results, Verify Complete Order/Test
Result by Reading Back Complete Order/
Test Result to Person Giving it
Blood Studies
• Blood Lipids
• Triglycerides, Cholesterol,
Phospholipids
• hs-CRP
• Homocysteine
• Cardiac Biomarkers
• Creatine Kinase, Troponin,
Myoglobin
Blood Studies
• B-type natriuretic peptide (BNP)
• Protein secreted from ventricles in response
to overload, such as in heart failure
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BNP
BNP
BNP
BNP
HF.
• BNP
levels below 100 pg/mL indicate no HF.
levels of 100-300 pg/mL suggest HF present.
levels above 300 pg/mL indicate mild HF
levels above 600 pg/mL indicate moderate
levels above 900 pg/mL indicate severe HF.
Blood Studies
• Blood cultures
• Complete blood count (CBC)
– Erythrocyte sedimentation rate (ESR)
• Coagulation studies
• Electrolytes
– Magnesium, K+, Calcium, Phosphorus, Glucose
• Arterial blood gases
Diagnostic Studies
• Chest X-Ray
• CT Scan
• Magnetic Resonance Imaging
• Cardiac Calcium Scan
Diagnostic Studies
• Plethysmography
• Diagnoses Deep Vein
Thrombosis/Pulmonary
Emboli/Peripheral Vascular Disease
• Pressure Measurement
• BP Readings Along Extremity
Diagnostic Studies (cont’d)
• Arterial Stiffness Index
http://www.healthfair.com/schedule-a-screening/arterial-
stiffness-index/
• Atherosclerosis/Cardiovascular Disease
• Tilt Table Test
• Lying to Standing BP & HR
• Doppler Ultrasound
• Impaired Blood Flow Reduces Sound Waves
http://www.youtube.com/watch?v=5H5FZTAic7c
Diagnostic Studies
Electrocardiogram (ECG or EKG)
• Shows Cardiac Electrical Activity
• 12-lead ECG = 12 Different Views
• Waveforms Change Appearance in Different
Leads
• Continuous Monitoring Often in Lead II
– Waveforms Upright in Lead II
Interpretation of Cardiac Rhythms
• Six-step Process
1. Regularity of Rhythm
2. Heart Rate
3. P Wave
4. P–R Interval
5. QRS Complex
6. QT Interval
Normal Cardiac Waves Are Equal
Distances Apart
Diagnostic Studies
• Holter Monitor
• Cardiac Monitors: Continuous
assessment of cardiac electrical
activity.
• Telemetry: ambulatory pts.
Exercise StressTest
• Cardiac Stress Test
• Cardiac Response to Exercise &
↑’ed Oxygen Needs
• Peripheral Vascular Stress Test
• Vascular Response to Walking
Echocardiography
http://www.youtube.com/watch?v=482CdbvapBU
• U/S
• Records Motion
• Heart Structures
• Valves
• Heart Size, Shape, Position
Transesophageal Echocardiogram
• Probe in Esophagus
• Clearer Picture
• NPO Until Gag Reflex Returns
Radioisotope Imaging
• Radioisotopes IV, Gamma Camera Scan
• Detects Cardiac Ischemia/ Damage/
Perfusion
• Thallium Imaging
• Technetium Pyrophosphate Scan
• Technetium 99m Sestamibi
• MUGA Scan
• Positron Emission Tomography (PET)
scan
Diagnostic Studies
• Fluoroscopy: action-picture
radiograph, observation of
movement.
• Angiogram: use of fluoroscopy to
view cardiovascular system.
radiographs w/radiopaque dye 
artery.
• Aortogram: x-ray w/dye aorta
Cardiac Catherization (Angiography)
Digital subtraction angiography: visualizes heart’s
chambers, valves, great vessels & coronary arteries.
1. Pressures w/in heart
2. bld.-volm. Relationship to cardiac competence
3. Valvular defects, arterial occlusion, congenital
anomalies
• Consent needed
• Assess allergy to contrast medium, iodine, &
seafood
http://www.youtube.com/watch?v=O9-gNv_-k48
Cardiac Catherization (Angiography)
Post procedure:
– Monitor Pedal pulses
– Enc. Fluids after procedure
– Avoid movement of leg keep extended
– Maintain pressure over the femoral
access site
– Check drsing & access site for
bleeding
– HOB no more than 30°
Percutaneous Transluminal
Coronary Angioplasty (PTCA)
http://www.youtube.com/watch?v=j9498DF8TU4
Catheter containing a balloon used to dilate
occluded arteries
•Preprocedure, maintain NPO status after midnight
•Postprocedure, assess distal pulses in both
extremities; maintain bedrest with limb straight for
6 to 8 hrs; assess for bleeding, changes in VSs
Laser angioplasty
Preprocedure & postprocedure care similar to PTCA
Dysrhythmias
Rhythm Disturbances
Impulse Formation Disturbed
Disturbance in Conduction
Normal Sinus Rhythm Rules
Originates from SA node with atrial &
ventricular rates of 60 to 100
beats/min
• Rhythm: Regular
• Heart Rate: 60 to 100 bpm
• P Wave: Rounded, Before each QRS
• PR Interval: 0.12 to 0.20 Seconds
• QRS Interval: < 0.10 Seconds
Dysrhythmias
Sinus bradycardia
• Atrial & ventricular rates less than 60 beats/min
• Attempt to determine cause; if medication is
suspected cause, hold, notify health care provider
• Administer atropine sulfate as prescribed
Sinus tachycardia
Atrial & ventricular rates greater than 100
beats/min
Identify, remove cause of tachycardia
Dysrhythmias
Premature Atrial Contractions
Atrial Flutter
Atrial fibrillation
• No definitive P wave can be observed
• Administer oxygen & anticoagulants, prepare
for cardioversion as prescribed
•atrial rate 350 – 600 bpm, ventricular rate
100 –180
Premature ventricular contraction
Notify health care provider if PVCs, c/o CP,
runs of ventricular tachycardia occur
Ventricular tachycardia: rate 140 - 240
• Repetitive firing of irritable
ventricular ectopic focus at rate of
140 to 250 beats/min
• Client may be stable or unstable
• Administer lidocaine (Xylocaine) as
prescribed
Ventricular fibrillation
Chaotic rapid rhythm; ventricles
quiver
Defibrillate immediately as
prescribed; initiate cardiopulmonary
resuscitation (CPR)
Defibrillation: Asynchronized countershock; terminates
pulseless VT or VF. Delivers a direct electric shock to the
myocardium to restore NSR
Automatic External Defibrillator
http://www.youtube.com/watch?v=ZOBEidFXezA
Implantable Cardioverter fibrillator
Instruct client on:
• basic functions of ICD, complications to report immediately
•how to take pulse
•to avoid strenuous activity or contact sports
•to report any signs of infection or feelings of faintness or N/V
Asystole
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Rhythm: None
Heart Rate: None
P Waves: None
P–R Interval: None
QRS Interval: None
•Cardioversion (synchronized shock)
delivery of a synchronized electrical
shock to the myocardium to restore
normal sinus rhythm.
monitor
• Skin burns
• Respiratory problems
• Changes in ST segment
• Rhythm disturbances
• BP
Cardiac Glycosides
Increase the force of myocardial
contraction & slow the HR
Side effects, toxic effects
GI disturbances (anorexia, N/V, diarrhea)
Visual disturbances
Bradycardia
Interventions
Monitor for toxicity; digoxin level above
2 ng/mL
Monitor K+ level for hypokalemia
Monitor AP; if less than 60/min, hold
medication, notify health care provider
Classification: Cardioglycoside
Agent: Digoxin (Lanoxin)
Action: ↑ cardiac force & efficiency, slows
HR, ↑ cardiac output, ↓ cardiac workload.
Nursing Interventions: monitor AP to ensure
rate ≥ 60 (call MD if held). Monitor for
digitalis toxicity (N/V, HA, anorexia,
dysrhythmias, bradycardia, tachycardia,
fatigue, visual disturbance: blurred vision,
double vision & yellow-green vision, seeing
halos around objects & seeing flickering
lights). confusion, seizures, diarrhea
Digoxin
Nursing Interventions cont’d
• Monitor for hypokalemia, hypomagnesemia &
hypercalcemia may predispose pt to Digoxin toxicity.
• Therapeutic level: 0.5 - 2 mg/dL
• Advise pts to consume foods high in potassium &
magnesium & foods low in calcium.
• Monitor potassium levels.
• High Potassium Foods:
• bananas, potatoes, beets, parsnips, turnips, broccoli,
melons, peaches, cantaloupes, kiwi, prunes, dried apricots,
dates, figs, oranges, tomatoes & squash
Beta-adrenergic Blockers
Beta Blockers (“lols”)
– ↓ the workload of the heart & ↓ myocardial oxygen
demands
• ↓ HR & BP
• May mask symptoms of hypoglycemia in DM client
– Side effects
• Bradycardia
• Hypotension
• Bronchospasm
– Interventions
• Monitor apical pulse rate & BP
• Monitor for respiratory distress
• Instruct the DM client to monitor for signs of
hypoglycemia
Classification: B-adrenergic blockers
Agent: Propanolol (Inderal)
Metoprolol (Lopressor)
Action: ↓ myocaridal O2 demand, ↓ work load
of heart, & HR
Nursing Interventions: Monitor HR & BP,
bradycardia, hypotension, new dysrhythmias,
dizziness, HA, nausea, diarrhea, sleep
disturbances. Use caution w/clients
w/bronchospastic disease.
Beta-Adrenergic Blocker
carvedilol (Coreg)
Mechanism of action - blocks beta1,
beta2, & alpha1 receptors, which ↓’s
HR& BP, ↓’s afterload, & reduces the
workload on the heart
Ace Inhibitors “prils”
Angiotensin-converting enzyme
Prevent peripheral vasoconstriction
Used to treat HTN & HF
Side effects
Persistent dry cough
Hypotension
Tachycardia
Hyperkalemia
Hypoglycemia in diabetic client
Interventions
Avoid use with K+ supplements & potassium-sparing diuretics
Monitor VSs & for signs of hyperkalemia
Instruct DM client about the risk for hypoglycemia
Instruct client to report persistent dry cough
ACE Inhibitor
lisinopril (Prinivil)
Mechanism of action - blocks ACE enzyme,
which ↓’s BP, ↑’s cardiac output, ↓’s
preload & reduces peripheral edema; ↑’ed
excretion of Na⁺ & water leads to ↓’ed
blood volume
primary use - HF & HTN
Important adverse effects - ↑ K⁺ levels,
cough, taste disturbances, hypotension
Calcium channel blockers
http://www.youtube.com/watch?v=dE-4D1dwMZQ
– ↓ the workload of the heart & ↓ myocardial
oxygen demands
• Promote vasodilation of coronary &
peripheral vessels
• Used to treat angina, dysrhythmias, &
HTN
• Used with caution in HF, bradycardia, or
atrioventricular block
– Side effects
• Bradycardia
• Hypotension
• Reflex tachycardia
Calcium channel blockers cont’d
– Interventions
• Monitor apical HR & BP
• Monitor for signs of HF
• Instruct the client to report dizziness or
fainting
M “Meals”
U “under” 100 for systolic BP hold
C “calcium” blocker
H “HTN” treatment
Common Calcium Channel Blockers
•amiodipine (Norvasc)
•nifedipine (Procardia)
•verapamil (Isoptin, Verelan)
•diltriazem (Cardizem)
Classification: Calcium channel blockers
Agent: Verpamil (Calan, Isoptin)
Diltiazem HCL (Cardizem)
Action: produces relaxation of coronary
vascular smooth muscle, dilates coronary
arteries.
Nursing Interventions: Use caution in clients
w/CHF; Monitor AP & BP, watch for fatigue,
HA, Dizziness, peripheral edema, nausea,
tachycardia
Antidysrhythmic Medications
Suppress dysrhythmias by inhibiting abnormal
pathways of electrical conduction through
the heart
Classifications
Class I: sodium channel blockers
Class II: β-blockers
Class III: potassium channel blockers
Class IV: calcium channel blockers
Interventions for antidysrhythmics
Monitor HR, respiratory rate, & BP
Provide continuous cardiac monitoring
Administer IV antidysrhythmics
Monitor for signs of fluid retention
Monitor for effective response
Common Cardiac Dysrhythmias Medications
• Amiodarone (Cordarone, Pacerone)
• Flecainide (Tambocor)
• Lidocaine (Xylocaine)
• Procainamide (Procan, Procanbid)
• Propranolol (Inderal)
• Quinidine (many trade names)
Interventions
• Monitor for Worsening arrhythmias
• Allergic reaction
• Chest pain, dizziness, syncope, SOB, cough
• Edema of the feet or legs
• Blurred vision
Anticoagulants
Prevent extension & formation of clots by
inhibiting factors in clotting cascade &
decreasing blood coagulability
– Side effects
• Bleeding
– Heparin sodium
• Normal activated partial thromboplastin
time (aPTT) 20 to 30 seconds
• Antidote is protamine sulfate
– Enoxaparin (Lovenox)
– Warfarin sodium (Coumadin)
Normal lab values
•Bleeding time: 1 – 9 minutes
•PTT: 20 – 26 seconds
•PT: 9.05 – 11.8 seconds
•INR: 2 -3 (standard warfarin
therapy)
Warfarin (Coumadin)
Classification: Anticoagulant
Action: Used in tx of A-Fib w/embolization to
prevent complication of stroke.
Nursing Interventions: Assess for signs of
bleeding & hemorrhage: monitor prothormbin
time (PT) freq during therapy; review foods
high in vitamin K. Clients should have
consistently limited intake of these foods d/t
foods causing levels to fluctuate.
Warfarin (Coumadin)
Teach Pt.
• Wear a Medic-Alert identification
when on anticoagulation therapy.
• A steady (rather than fluctuating) amt
of green leafy vegetables should be
eaten so that INR values do not
fluctuate d/t the vitamin K found in
these foods.
• Monthly blood tests are done.
• Avoid a straight razor to avoid cuts &
bleeding.
GENERIC NAME: enoxaparin
BRAND NAME: Lovenox
MECHANISM: Enoxaparin is a low molecular weight heparin
(LMWH) that is used to prevent blood clots. It is produced
by chemically breaking heparin into smaller-sized molecules.
Unlike heparin, the effect of enoxaparin does not need to
be monitored with blood tests. Enoxaparin is used to treat
or prevent blood clots & their complications (DVT or PE).
SIDE EFFECTS: The most common is bleeding.
Clients should avoid: anti-platelet medications (ASA,
clopidogrel, warfarin, or nonsteroidal anti-inflammatory
drugs (NSAIDs) ibuprofen or naproxen.
Antidote: protamine sulfate
Antiplatelet Agents
Inhibit aggregation of platelets &
prolong bleeding time
Side effects
Bleeding
Interventions
Monitor for bleeding
Implement bleeding precautions
acetylsalicylate (ASA)
Classification: non-narcotic analgesic,
anti-inflammatory
Action: Used in tx of MI, A-Fib
w/embolization to prevent complication of
stroke.
Nursing Interventions: Assess for signs
of GI bleeding & hemorrhage: monitor for
GI distress. For S&S of MI give 325 mg
PO.
Cardiac Pacemakers
http://www.youtube.com/watch?v=Y5rvTeAYuIY
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External & Temporary
Internal & Permanent
Override Dysrhythmias
Generate an Impulse
Can Be Placed in Atria, Ventricle, or Both
Dual-chamber Pacemaker
Nursing Care for Pacemakers
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Monitor ECG
Rest Several Hours
Monitor AP, Symptoms
Incision Care
How to Take Radial
Pulse
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Symptoms to Report
Pacemaker ID Card
Things to Avoid
Trigger Metal
Detectors
• Grounded Appliances
Safe
• Periodic Pacemaker
Checks
Cardiac Arrest
Sudden cessation of cardiac output
& circulatory process.
S&S: abrupt loss of consciousness,
gasping respirations followed by
apnea, absence of pulse, absence of
BP, pupil dilation, pallor & cyanosis.
Coronary Atherosclerotic Heart Disease
Coronary artery disease (CAD):
Narrowing or obstruction of one or more
coronary arteries as result of
atherosclerosis
Atherosclerosis: common arterial
disorder characterized by yellowish
plaques of cholesterol, lipid & cellular
debris in inner layers of walls of lg. &
medium-size arteries, primary cause of
atherosclerotic heart disease (ASHD).
Arteriosclerosis
Artery/arteriole walls
• Thicken
• Harden
• Loose elasticity
Atherosclerosis
• Type of Arteriosclerosis
• Plaque Formation in Arterial Wall
• Childhood Onset
Total Cholesterol:
•Desirable less than 200 mg/dL
•Borderline 200 – 239 mg/dL
•High 240 mg/dL or greater
HDL Cholesterol (high-density lipoproteins)
•Desirable 60 mg/dL or greater
LDL Cholesterol (low-density lipoproteins)
•Desirable less than 130 mg/dL (+risk factors
•Triglycerides: less than 150 mg/dL
Antilipemic Medications
HMG-CoA reductase enzyme inhibitors “statins”
• Reduce cholesterol, triglyceride, or low-density
lipoprotein levels
• Bile sequestrants
• Side effects
• Constipation
• Interventions
• Increase fluid intake & fiber in diet
• 3-Hydroxy-3-methyl-glutaryl–coenzyme A (HMGCoA) reductase inhibitors
• Side effects
• GI disturbances, visual disturbances,
elevated serum liver enzyme levels
Antilipemic Medications cont’d
• Nursing interventions
• Monitor serum cholesterol &
triglyceride levels
• Instruct client about foods low in
fat & cholesterol
• Instruct client to follow an exercise
program
• Instruct client to report visual
problems or GI disturbances
Medications for Hyperlipidemias
Classification: Antihyperlipidemics
Agent: atorvastatin (Lipitor),
simvastatin (Zocor), lovastatin (Mevacor)
Action: Inhibits HMG-CoA reductase, the
enzyme that catalyzes the early step in
cholesterol syntheisis.
Nursing Interventions: Assess baseline labs,
cholesterol & triglyceride, & liver function.
Adm. in pm. Instruct pt. to follow prescribed
diet & periodic lab tests are needed.
ASHD/CAD
• Non-modifiable Risk Factors
• Age
• Gender
• Ethnicity
• Genetic Predisposition for Hyperlipidemia
ASHD/CAD (cont’d)
• Modifiable Risk Factors
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DM
HTN
Smoking
Obesity
Sedentary Lifestyle
↑’ed Serum Homocysteine
• ↑ C-reactive protein (CRP)
ASHD/CAD (cont’d)
• Modifiable Risk Factors (cont’d)
• ↑’ed Serum Iron Levels
• Infection
• Depression
• Hyperlipidemia
• Elevated Apolipoprotein B
• Excessive Alcohol Intake
http://www.youtube.com/watch?v=N2diPZOtty0
ASHD/CAD (cont’d)
• Diagnostic Tests for Increased CVD
• Cholesterol
• Elevated Increases Risk
• Low-density Lipoproteins (LDL)
• Increased risk
• High-density Lipoproteins (HDL)
• Protective
ASHD/CAD (cont’d)
• Diagnostic Tests (cont’d)
• Lp(a) Cholesterol
• Elevated Increases Risk
• Apolipoprotein B > Apolipoprotein A
• Increased Risk
• Triglycerides
• Increased Risk
ASHD/CAD (cont’d)
• Diagnostic Tests (cont’d)
• C-reactive Protein
• Inflammation in Coronary Artery
• Shows Increased Risk
• Elevated Leukocyte Count in Women
• Increased Risk
Atherosclerosis/CAD
Contributes to Complications:
• Angina, MI, HTN, TIA, Stroke
• Sudden Death
Prevention
• Modify Risk Factors
• Low-cholesterol Diet
• Lipid-lowering Agents
• Low Dose ASA
ASHD/CAD (cont’d)
Nursing Interventions
• Reduce activity, Exercise
• Assess VSs, Monitor ECG
• Support & reassure client
• Administer oxygen, nitrates,
Lipid-lowering Agents,
• Prepare for possible tx’s
Nursing Interventions
Instruct on Medications
• Nitrates: dilate coronary arteries;
decrease preload & afterload:
(nitroglycerin)
• Calcium channel blockers: dilate
coronary arteries & reduce vasospasm:
nifedipine (Procardia)
• Cholesterol-lowering medications:
reduce development of atherosclerotic
plaques: lovastatin (Mevacor)
• β-blockers: reduce BP in individuals
with HTN: sotalol (Betapace)
ASHD/CAD (cont’d)
Nursing Interventions
• Educate client about:
• diagnostic tests
• modifiable risk factors
• Instruct client to:
• eat low-calorie, low-sodium, lowcholesterol, low-fat diet, with
increase in dietary fiber
• importance of regular exercise
ASHD/CAD
Surgical procedures
• Percutaneous Transluminal Coronary
Angioplasty (PTCA)
• Laser angioplasty
• Atherectomy
• Vascular stent
• Transmyocardial Laser
Revascularization
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–
http://www.youtube.com/watch?v=Fq4m0ajqcd0
http://www.youtube.com/watch?v=5rQjJ5hsgKw
• Coronary artery bypass graft (CABG)
– Dx after cardiac catheterization
Angina Pectoris
• Angina chest pain or discomfort that
occurs if an area of heart muscle
doesn't get enough oxygen-rich blood.
• may feel like indigestion.
• symptom of underlying heart problem,
(CAD)
• Chest pain resulting from myocardial
ischemia
Types of Angina
Stable Angina
• Most common
• exertional; occurs with activities that
involve exertion, exercise, emotional
stress
• Arteries Cannot ↑ Blood to Heart
During ↑’ed Activity
• Usually Stops with Rest/Vasodilator
Unstable Angina
• occurs with unpredictable degree of
exertion or emotion; increases in
occurrence, duration, severity over time
• No pattern. May occur more often & be
more severe than stable angina. Can occur
with or without physical exertion, & rest
or medicine may not relieve the pain.
• Requires emergency treatment, is a sign
that an MI may happen soon.
Types of Angina (cont’d)
Variant Angina (Prinzmetal’s Angina)
• Rare. A spasm in a coronary artery causes
this type of angina. Medicine can relieve
this type of angina
• Longer Duration
• Usually Occur at Rest
• Often Same Time Each Day (btw midnight
& early morning
• Coronary Artery Spasm pain can be severe
• Serious
Angina S&S
• Mild or moderate pain; may radiate to
shoulders, arms, jaw, neck, back; usually
lasts less than 5 minutes; relieved by rest
&/or NTG; dyspnea; pallor; diaphoresis
Female Angina S&S
• Chest Pain, Jaw Pain, Heartburn
• Atypical Symptoms
• Describe Less Severe Pain
• Fatigue
• Nausea
• Breathlessness
Diagnostic Tests
• ECG
• Stress Test
• Echocardiography
• Chemical Stress Testing
• Radioisotope Imaging
• Coronary Angiography/catherization
• Blood Test (cardiac enzymes normal)
Angina Interventions
• Surgical procedures
• Same as for CAD
• Medications
• Same as for CAD
• Antiplatelet medications inhibit
platelet aggregation, reduce risk
of developing acute MI
Angina Interventions
• Nursing Interventions
• Assess pain
• Bedrest
• Administer oxygen, nitroglycerin as
prescribed
• Assess ECG strip
• Instruct client about diet, wt
management, exercise, lifestyle
changes following acute episode
2 Types of Organic Nitrate
Short-acting is taken sublingually –
nitroglycerin
Drug Profile - Organic Nitrate,
Vasodilator
Nitroglycerin (Nitrostat, Nitrobid, NitroDur), short-acting nitrate
Long-acting is taken orally or
transdermally - isosorbide dinitrate
Tolerance often develops
Reduce symptoms of HF
Medications for Angina
Classification: Antianginals
Agent: Nitroglycerin
Action: to dilate coronary arteries & increase
blood flow to damaged areas. Rapid onset of
action within 2 – 5 mins.
Nursing Interventions: Nitroglycerin SL
(doesn’t relieve MI) Nitroglycerin SL, may
repeat dose in 5min. intervals if pain doesn’t
subside, up to 3x. Oxygen & ASA unless
contraindicated.
Myocardial Infarction (MI)
• Pathophysiology
• Occurs when myocardial tissue is
abruptly, severely deprived of oxygen,
leading to necrosis and infarction;
develops over several hours
• Location of MI
• Left anterior descending artery:
anterior or septal MI
• Circumflex artery: posterior or lateral
wall MI
• Right coronary artery: inferior wall MI
Silent Ischemia
Myocardial Ischemia Without CP
Sudden Cardiac Death
Cardiac Arrest Triggered by Lethal
Ventricular Dysrhythmias or
Asystole from an Abrupt
Occlusion of a Coronary Artery
MI S&S
• Crushing, Viselike Pain
• Radiates to
Arm/Shoulder/Neck/Jaw
• SOB
• Restlessness
• Dizziness, Fainting
• Nausea
• Sweating
Women & MI
• Leading Cause of Death
• African American Women at Higher Risk
• Higher Mortality Rate, More Complications
than Men
• Prodromal Symptoms the Month Before MI
– Unusual Fatigue, Sleep Disturbances,
Dyspnea
•Delay Treatment
•Less Aggressive Treatment Given
S&S
• Atypical—Women/Older Adult
– Absence of Classic Pain
– Epigastric or Abdominal Pain
– Chest Cramping
– Fatigue
– Anxiety
– Dyspnea
– Restlessness
– Falling
Older Adults & MI
• Report Shortness of Breath,
Fatigue,
Fast/Slow Heartbeats, Chest
Discomfort
• Silent MI
• Collateral Circulation
Timely Medical Care
• “Act in Time to Heart Attack Signs”
• Call 9-1-1 (or Local Emergency #)
• www.nhlbi.nih.gov/actintime/
• National Heart Attack Alert Program
• “60 Minutes to Treatment”
• www.nhlbi.nih.gov/about/nhaap
Diagnostic Tests
• Consider Patient History
• Serial ECG
• Cardiac Troponin I or T
• Myoglobin
• CK-MB
• C-reactive Protein
• Magnesium
ECG Changes With MI
Pre-Hospital Care
• “Time is Muscle”
• Chew One Uncoated Adult ASA
• Call 911 in 5 Minutes for Unrelieved Chest
Pain
• Do Not Drive Self
Emergency Percutaneous Coronary
Intervention
• Mission: Lifeline www.americanheart.org/
• Door-to-Balloon Time: 90 Minutes
• www.d2balliance.org/
Nursing Interventions
Acute Stage
• Monitor
• Oxygen
• ASA
• Morphine
Sulfate
• Thrombolytics
• Remain w/pt
• “MOAN”
• Vasodilators
• Nitrates
• Beta Blockers
• Antidysrhythmias
• Place in semiFowler’s position
Nursing Interventions
following acute episode
• Bedrest
• Bedside Commode
• ROM exercises as prescribed;
activity progression as tolerated &
as prescribed; monitor for
complications
• Emotional Supportfor Complications
of MI
Dysrhythmias, HF, pulmonary
edema, cardiogenic shock,
thrombophlebitis, pericarditis
Nursing Interventions (cont’d)
• Intra-aortic Balloon Pump
• Glucose Control
• Daily Wt.
• No Caffeine, Clear Liquids
• Fluid Restriction
• Low-fat, Low-cholesterol, Low-Na⁺ Diet
Cardiac Rehabilitation
• Arrange for client to begin before
the time of discharge
• Optimizes Functioning
• Protocols Specify Activities
•Wt. Loss
•Smoking Cessation
• Outpatient Program After Discharge
Medication Interventions
• Vasodilators
• Nitroglycerin (NTG)
• Calcium Channel Blockers
• Diltiazem, Amlodipine, Nifedipine,
Verapamil
• Beta blockers
• Propranolol, Metoprolol, Atenolol
Medication Interventions (cont’d)
• ACEI
• Captopril, Lisinopril, Ramipril,
Enalapril
• Statins
• Atorvastatin, Fluvastatin,
Lovastatin, Pravastatin,
Simvastatin, Rosuvastin
• Antiplatelets
• Aspirin, Clopridogrel (Plavix)
Thrombolytics
Dissolve clots
Contraindications
Active bleeding, stroke or other intracranial
problems, surgical client, hepatic or renal disease,
uncontrolled HTN, recent cardiopulmonary
resuscitation, or hypersensitivity
Side effects
Bleeding
Interventions
Monitor for bleeding
Implement bleeding precautions
Antidote
Aminocaproic acid (Amicar) is antidote for
streptokinase
alteplase (Activase)
Mechanism of action - convert plasminogen to
plasmin which causes fibrin to degrade, then
preexisting clot dissolves
Primary uses - acute MI, pulmonary embolism,
acute ischemic CVA, DVT, arterial thrombosis,
coronary thrombosis, clear thrombi in
arteriovenous cannulas and blocked IV
catheters
Adverse effects - abnormal bleeding;
contraindicated in clients w/active bleeding or
recent trauma
Medication Interventions (cont’d)
• Fab Four Cardiac Drugs
• Antiplatelets
• Statins
• ACEIs
• Beta Blockers
Invasive Procedures
• PCI
• Balloon Angioplasty
• Coronary Artery Stents
• Myocardial Revascularization
• Coronary Artery Bypass Graft
• Coronary Artery Occlusions
Bypassed with Vein/Artery Grafts
• ↑’s Blood Flow/Oxygen to
Myocardium
Minimally Invasive Direct Coronary
Artery Bypass (MIDCAB)
Thoracoscope
• No Cardiopulmonary Bypass
• Small Incisions
• Two Coronary Arteries Maximum
Port-Access Coronary Artery Bypass
• Combines Peripheral Cardiopulmonary
Bypass (CPB) with Minimally Invasive
Heart Access
Nursing Interventions
• Monitor VSs
• Report Symptoms
• Incisional Care
Patient Education
• Disease Information
• Medications
• Diet
• Activity
• Rehabilitation
Valvular Heart Disease
• Stenosis
Narrowed, Valve Does Not Open
Completely
Forward Blood Flow Hindered
Decreases Cardiac Output
• Regurgitation (Insufficiency)
Valve Does Not Close Completely
Blood Flow Backs Up
Mitral Valve Prolapse (MVP)
Etiology
• Unknown
• Hereditary
• Women 20 - 55 Years of Age
S&S
• Often None
• Anxiety, Fatigue
• CP, Palpitations
• Dysrhythmias
• Dyspnea
Mitral Valve Prolapse (MVP)
Therapeutic Interventions
• None, Unless Symptoms
• Healthy Lifestyle
• Avoid Stimulants/Caffeine
• Stress Management
• Beta Blockers for Tachycardia
• Valve Surgery for Severe MVP
• monitor for fatigue, atypical chest
pain, palpitations, syncope, systolic
click
Mitral Stenosis
Etiology
• Common – Prior Rheumatic Fever
• Congenital Defects, Tumors
• Rheumatoid Arthritis
• Systemic Lupus Erythematosus
• Calcium Deposits
Signs & Symptoms
• None Early
• Murmur, A Fib, CP, Palpitations
• Exertional Dyspnea, Cough, Hemoptysis
• Fatigue
Mitral Stenosis (cont’d)
• Diagnostic Tests
• ECG: P-wave Δ’s
• CXR: Enlarged Chambers
• 2-D & Doppler Echocardiography
• Coronary Angiogram
Therapeutic Interventions
monitor for dyspnea, orthopnea, rumbling
apical diastolic murmur, pitting peripheral
edema
• Prophylactic Antibiotics per Criteria
• Anticoagulants: Atrial Fibrillation
• Percutaneous Balloon Valvuloplasty
Mitral Regurgitation (insufficiency)
• Etiology
• Rheumatic Heart Disease (Most)
• Endocarditis
• Congenital Defects
• Chordae Tendineae Dysfunction
• Mitral Valve Prolapse
• S&S
• None Early
• Murmur, Palpitations, Fatigue, A-Fib, CP
• Dyspnea, Cough, Hemoptysis
Mitral Regurgitation (cont’d)
• Diagnostic Tests
• ECG: P-Wave Δ’s
• CXR: Enlarged Chambers
• 2-D & Doppler
Echocardiography
• Coronary Angiogram
Mitral insufficiency (Regurgitation)cont’d
Therapeutic Interventions
• monitor for dyspnea, orthopnea,
dizziness, signs of right ventricular
failure, pitting peripheral edema, highpitched systolic murmur
• None, Unless Symptoms
• Prophylactic Antibiotics per Criteria
• ACE Inhibitors
• Anticoagulants: A-Fib
• Mitral Valve Repair/Replacement
http://www.youtube.com/watch?v=QVk7zmJbX1s
Valvular Heart Disease(cont’d)
• Tricuspid stenosis: monitor for effort intolerance,
fluttering sensations in neck, cyanosis, ↓ cardiac output,
peripheral edema, rumbling diastolic murmur
• Tricuspid insufficiency: monitor for signs of right
ventricular failure, ascites, pleural effusion, peripheral
edema, systolic murmur
• Pulmonary stenosis: monitor for dyspnea, syncope, signs
of right ventricular failure, ascites, systolic thrill
• Pulmonary insufficiency: monitor for signs of right
ventricular failure, ascites, systolic thrill
Aortic Stenosis
• Pathophysiology
• Aortic Valve Narrowed
• Left Ventricle Contracts More
Forcefully
• Left Ventricle Hypertrophies
• Decreased Cardiac Output
• Eventual Heart Failure
Aortic Stenosis (cont’d)
Signs & Symptoms
• None Early
• Angina
• Murmur
• Syncope
• Orthopnea
• Dyspnea on Exertion
• Fatigue
• Pulmonary Edema
Diagnostic Tests
ECG
Chest X-Ray: Enlarged Left Ventricle
2-D & Doppler Echocardiography
Serial Echocardiography
Cardiac Catheterization
Aortic Stenosis (cont’d)
• Therapeutic Interventions
• monitor for dyspnea on exertion,
angina, syncope, orthopnea, harsh
systolic murmur
• Surgery
• Aortic Valve Replacement
• Valvotomy
• Treat HF Symptoms
• Prophylactic Antibiotics per
Criteria
Aortic insufficiency (Regurgitation)
Pathophysiology
• Aortic Valve Does Not Close
• Left Ventricle’s Volume Increases
• Left Ventricle Dilates
• Left Ventricle Fails
• Decreased Cardiac Output
• Pulmonary Edema
Aortic insufficiency (Regurgitation)
• Etiology
• Rheumatic Heart Disease (Most)
• Congenital Defects
• Syphilis
• Endocarditis
• Severe HTN
• Rheumatoid Arthritis
• Aortic Dissection
Aortic insufficiency (Regurgitation) cont’d
• Signs & Symptoms
• None Early
• Exertional Dyspnea, Fatigue
• Corrigan’s Pulse: Palpated Pulse
Forceful, Quickly Collapses
• Widened Pulse Pressure
• Angina at Night
Aortic insufficiency cont’d
• Diagnostic Tests
• ECG, Chest X-Ray
• 2-D & Doppler Echocardiography
• Coronary Angiogram
Therapeutic Interventions
• Monitor for dyspnea, orthopnea, angina,
tachycardia, diastolic murmur
• Vasodilator
• Surgical Valve Replacement
• Prophylactic Antibiotic Therapy per Criteria
Valvular Heart Disease (cont’d)
• General Nursing interventions
• Administer prescribed treatment for
heart failure as prescribed
• Administer oxygen as prescribed
• Administer IV fluids as prescribed
• Administer diuretics, digoxin (Lanoxin)
as prescribed
• Provide low-sodium diet as prescribed
• Administer antibiotics as prescribed
Nursing Interventions (cont’d)
• Maintain Fluid Volume
• Daily Wt.s, Assess for Edema, I&O
• Diuretics as Ordered; Monitor K⁺
Levels
• Education
• Medications
• Anticoagulants
• Monthly INR/PT Tests
• Medic Alert Identification
• Include Caregivers for Elderly
• Revised Endocarditis Prevention –
Prophylactic Antibiotics
Evaluation
• Reports Satisfactory Pain Relief
• VS’s Normal/No HF Signs
• Reports Reduced Fatigue, Task
Completion
• Remains Free of Edema, Maintains
Wt, Clear Lung Sounds
• Verbalizes Understanding of
Teaching/with No Symptom
Recurrence
Cardiac Valvular Surgery
• Minimally Invasive Surgery
• Endoscopy
• Robotic
• Traditional
• Open Cardiac Surgery with
Cardiopulmonary Bypass
• Stenosed Valve Repair
• Balloon Valvotomy
• Commissurotomy
•
http://www.youtube.com/watch?v=VrIxRfWDOm8
• Insufficient Valve Repair
• Annuloplasty
•
http://www.youtube.com/watch?v=m0qotSyH5CE
http://www.youtube.com/watch?v=7LfWleowgUk
Heart Valve Replacement
• Mechanical
• Durable
• Creates Turbulent Blood Flow
• Lifelong Anticoagulation
• Used for Younger Adults
Heart Valve Replacement (cont’d)
• Biological
• Types
• Porcine (Pig)
• Bovine (Cow)
• Allografts (Human)
• Autograft
• Cultural Considerations
• Not as Durable as Mechanical
Valves
• No Lifelong Anticoagulation
• Used for Older Adults
Valve Replacement
Complications
• Biological Valves
• Degenerative Changes
• Calcification
• Mechanical Valves
• INR/PT Monitoring for Bleeding
Risk
• Thrombus/Embolism Formation
• Anemia
• Endocarditis
Nursing Process:
Cardiac Surgery Preparation
Assessment
• Circulatory Status
• Pain Control Needs
• Diagnostic Tests
• Typing & Cross-matching of Blood Needed
Preoperative Vascular Nursing Diagnoses
• Acute or Chronic Pain
• Anxiety
• Deficient Knowledge
Cardiac Surgery Preparation
• Teaching
• Pain Management
• Endotracheal Tube/Ventilator
• Communicating
• Chest Tubes
• Coughing/Deep Breathing
• IV Lines
• Urinary Catheter
• Preoperative Medications
• prophylactic antibiotics
• Antiseptic Scrub Showers
• NPO
Postoperative Cardiac Surgery
Nursing Care
• Pain/Provide Relief
• VSs, ECG, ABGs, I&O
• Lung Sounds
• Incision
• Promote Lung Expansion
• Cough & Deep Breathe
• Turn
• Ambulate
Postoperative Cardiac Surgery
Nursing Care (cont’d)
• Prevent Infection
• Hand Hygiene, Sterile Technique
• Cleanse Stethoscope
• Each Client, Each Handwashing
• Monitor Temperature
• Teaching
• Pain Management, Medications
• Activity
• Follow-up Monitoring/Care
Layers of the Heart
Infective Endocarditis
• Entry of Organism into Bloodstream
• Risk Factors
• Immunocompromised
• Artificial Heart Valve
• Congenital/Valvular Heart Disease
• IV Drug Use
• Gingival Disease
• Prevention
• Oral/Dental care
• Prophylactic Antibiotics per Criteria
Infective Endocarditis (cont’d)
• S&S
• Fever
• Murmur
• Splinter Hemorrhages
• Petechiae
• Janeway Lesions
• Osler’s Nodes
Osler’s Nodes
Janeway
Lesions
Petechiae
Infective Endocarditis (cont’d)
• Diagnostic Tests
• Blood Cultures
• Echocardiography
• Therapeutic Interventions
• IV Antimicrobial Drug
• Rest/Supportive Care
• Home IV Antimicrobial Therapy
• Surgical Valve
Replacement/Repair
Infective Endocarditis
Therapeutic Nursing Interventions cont’d
• Monitor VSs & Cardiac status
• Report HF/Emboli Signs
• Maintain antiembolic stockings as
prescribed
• Teach
• Good Hygiene, Oral/Dental Care
• Report Symptoms: Fever, Chills,
Sweats
Pericarditis
• Inflammation of Pericardium
• Acute
• Chronic
Etiology
• Infections, Lyme Disease
• Drug Reactions, Trauma
• Connective Tissue Disorders
• Neoplastic Disease
• Postmyocardial Infarction
• Dressler’s Syndrome
• Renal Disease or Uremia
Pericarditis (cont’d)
• S&S
• CP; Substernal, Radiates, Grating
• Increases with Deep Inspiration
• Pericardial Friction Rub
• Dyspnea
• Low-grade Fever
• Cough
• Diagnostic Tests
• ECG, Echocardiogram, CT Scan, MRI
• WBC
• Pericardial Fluid
Pericarditis Nursing Interventions
• Position in high Fowler’s position,
upright, leaning forward
• Bedrest
• Pericardiocentsis
• Monitor for signs of cardiac
tamponade & Cardiac Function
• Monitor VSs
• Provide Pain Relief
• NSAIDs, Corticosteroids
Pericarditis Nursing Management
• Treat Cause
• Antibiotics
• Hemodialysis
• Pericardial Window
• Pericardiectomy
• Education
Pericardiocentsis
http://www.youtube.com/watch?v=nRFa6OdX9xU
Cardiac Tamponade
Pericardial effusion; occurs when space between
parietal & visceral layers of pericardium fill with
fluid
Data collection
•Pulsus paradoxus; ↑ central venous pressure;
jugular vein distention with clear lungs; distant,
muffled heart sounds; ↓ cardiac output
•Interventions
•critical care unit as prescribed
•Administer IV fluids as prescribed
•Prepare client for pericardiocentesis as prescribed
•Monitor for recurrence of tamponade following
pericardiocentesis
Myocarditis
• Pathophysiology & Etiology
• Acute or chronic inflammatory disorder of
myocardium as result of pericarditis
• Rare
• Often Follows Virus
S&S
• None
• fever; pericardial friction rub; murmur
• Possible Viral Infection Signs
• Chest Pain, Tachycardia
Myocarditis (cont’d)
Therapeutic Nursing Interventions
• Reduce Heart’s Workload
• Oxygen
• Treat Cause
• Antimicrobial
• Treat Heart Failure
• administer analgesics, salicylates, NSAIDs drugs,
antibiotics, digoxin (Lanoxin) as prescribed
• VSs/Cardiac Status
• Diversional Activities
• Energy Conservation
• Education
Rheumatic Heart Disease
A result of rheumatic fever, an
inflammatory disease that
predominantly results from delayed
childhood reaction to inadequately
treated childhood pharyngeal or
URT infection (group A-B-hemolytic
streptococci).
Cardiomyopathy
• Enlargement of Heart Muscle
• Subacute or chronic disorder of heart
muscle
• Dilated cardiomyopathy: heart ejects less
than 40% of blood in left ventricle (normal is
70%); reduced cardiac output leads to HF
• Hypertrophic cardiomyopathy: characterized
by massive ventricular hypertrophy; may
cause obstruction of left ventricular outflow
• Restrictive cardiomyopathy
• Characterized by restricted filling of
ventricles
•
http://www.youtube.com/watch?v=rXyVzOmyWfo
Cardiomyopathy Secondary type
•Infective: viral, bacterial, fungal,
protozoal (myocarditis)
•Metabolic, Nutritional
•Alcohol
•Drugs (prescribed & Cocaine “crack”)
•Radiation therapy
•Systemic lupus erythematosus,
Rheumatoid arthritis
Cardiomyopathy (cont’d)
• S&S
• Symptoms of left ventricular heart
failure
• Diagnostic Tests
• Chest X-Ray (Cardiomegaly)
• Echocardiography
• ECG
• Cardiac Catheterization
Cardiomyopathy (cont’d)
• Therapeutic Interventions
• Treatment symptomatic, similar to care of
heart failure (dilated & restrictive
cardiomyopathy), similar to care of MI
(hypertrophic cardiomyopathy)
• No Cure
• Palliative Care
• Anticoagulants
• Dilated
• ACE Inhibitors, Beta Blockers, Diuretics,
Digoxin
• Biventricular Pacing
• Implantable Defibrillators
• Heart Transplant
Heart Failure (HF)
• Inability of heart to maintain
adequate circulation to meet
metabolic needs of body
Older Term: Congestive Heart Failure
(cardiac insufficiency)
http://www.youtube.com/watch?v=RHJBVTdBJvI
– Classification
• Acute, chronic
Left Ventricular Failure (HF)
Causes: MI, chronic HTN
S&S
•Dyspnea, Orthopnea, Cough
•Paroxysmal nocturnal dyspnea (PND)
•Pulmonary crackles
•Evidence of pulm vascular congestion
w/pleural effusion (CXY)
Pulmonary Edema
• Acute HF, Life-threatening
• pallor
• dyspnea, orthopnea, Severe Fluid
Congestion in Alveoli, ↑Resp with
Accessory Muscles
• large amts of blood-tinged mucus
• diaphoresis
• Crackles, Wheezes
• Anxiety, Restlessness
• a medical emergency
Pulmonary Edema Diagnosis
• X-Ray, CT, MRI
• ABGs
• Pulmonary Pressures
• BNP – B type Natriuretic Peptide
• NT – proBNP – N-terminal pro BNP
PE Therapeutic Interventions
•
•
•
•
•
•
•
•
•
Immediate Treatment
Reduce Workload of Left Ventricle
Treat Underlying Cause
Fowler’s Position
Oxygen/Mechanical Ventilation
Morphine IV
Diuretics IV
Inotropic Agents IV
Vasodilators IV
Right Ventricular Failure (HF)
Causes: Lt. HF, Chronic lung disease
S&S
•Distention jugular veins (severe)
•Anorexia, nausea, & abd distention
•Liver enlargement w/RUQ pain
•Edema (pitting) feet, ankles, sacrum
Pitting Edema
Pitting Edema Scale
SCALE
DEGREE
RESPONSE
1 + Trace
Slight
Rapid
2 + Mild
4 mm
(0 - 1/4 in)
10 – 15
seconds
3 + Moderate
6 mm
(¼ - ½ in)
1 – 2 minutes
4 + Severe
8 mm
(1/2 - 1 in)
2 – 5 minutes
Heart Failure (cont’d)
Immediate Nursing management
• Place in high Fowler’s position
• Administer oxygen as prescribed
• Suction PRN as prescribed
• Monitor VS frequently
• Maintain strict I&O
• Administer diuretics, morphine
sulfate & digitalis as prescribed
• Assess lung sounds
• Monitor Labs – K+
• Monitor Wt.
Heart Failure (cont’d)
Following acute episode
• Instruct client about:
• modifiable risk factors
• proper administration of
medication regimen
• to avoid over-the-counter
medications
• to eat a low-sodium, low-fat, lowcholesterol diet
• to balance activity levels
Heart Failure (HF)
TX: Medications to ↑ cardiac efficiency
•Angiotensin-converting enzyme inhibitors
(ACE inhibitors - ACEIs)
•Angiotensin-receptor blockers (ARBs)
•Beta-adrenergic blockers
•Digitalis
•Vasodilators
•Diuretics, Potassium Supplements
First-Choice Drugs
• ACE Inhibitors & Diuretics
• Given first
• Reduce most symptoms of mild
to moderate HF
• Fewer side effects
Diuretic
furosemide (Lasix)
Mechanism of action - prevents
reabsorption of Na⁺ by the nephron of
the kidney, which ↑’s excretion of Na⁺ &
water; ↓’s blood volume, edema, &
congestion; ↓’s BP, & ↓’s workload on
heart. Cardiac output then ↑’s
Primary use - acute HF
Important adverse effects - electrolyte
imbalances
Second-Choice Drugs
• Phosphodiesterase inhibitors,
vasodilators, & beta-adrenergic
blockers
• Used in severe HF
• First-choice drugs not effective
Phosphodiesterase Inhibitors
milrinone (Primacor)
Mechanism of action - blocks
phosphodiesterase enzyme, which ↑’s
the amt. of calcium available for
myocardial contraction, which then ↑’s
force of contraction & vasodilation
Primary use - short-term support of
advanced HF
Important adverse effects - ventricular
dysrhythmia
Vasodilators
Isosorbide (Isordil)
Mechanism of action - relaxes vascular
smooth muscle, which leads to
vasodilation, which ↓’s cardiac workload
& ↑’s cardiac output
Primary use - cannot tolerate ACE
inhibitors, angina pectoris, HTN
Important adverse effects - HA,
hypotension, reflex tachycardia
Natriuretic Peptide
nesiritide (Natrecor)
Mechanism of action - acts on kidney,
which increases excretion of Na⁺ &
water, thereby ↓ BP; also causes
vasodilation, which ↓’s preload
Primary use - severe HF
Important adverse effects - severe
hypotension
Nonpharmacological Methods for HF
•Stop using tobacco
•Limit salt (Na⁺) intake & eat foods
rich in K⁺ & magnesium
•Limit alcohol consumption
•Implement a medically supervised
exercise plan
•Learn & use effective ways to deal
w/stress
•Reduce wt. to an optimum level
•Limit caffeine consumption
Chronic Heart Failure
• Progressive
• Signs & Symptoms May Worsen Over Time
Signs & Symptoms
• Fatigue & Weakness, Cyanosis
• Exertional Dyspnea
• Orthopnea, Paroxysmal Nocturnal
Dyspnea
• Cough, Crackle & Wheezes
• Tachycardia, CP
• Cheyne-Stokes Respiration
• Edema, Anemia, Malnutrition
• Nocturia
• Altered Mental Status
Complications of Heart Failure
• Liver & Spleen Enlargement
• Pleural Effusion
• Thrombosis & Emboli
• Cardiogenic Shock
Diagnostic Tests
• Screening Tests
• BNP
• Serum BUN, Creatinine
• Liver Function Tests
• Thyroid Function Test
• Ferritin
• Chest X-Ray, Echocardiography, ECG
• Exercise Stress Testing
• Cardiac Magnetic Imaging
• Cardiac Catheterization/Angiography
• Sleep Studies
Therapeutic Intervention Goals
• Improve Heart’s Pumping Ability & ↓
Heart’s Oxygen Demands
• Identify & Correct Underlying
Cause
• ↑ Strength of Heart’s Contraction
• Maintain Optimum Water & Na⁺
Balance
• ↓ Heart’s Workload
Drug Therapy
• Oxygen Therapy
• ACE Inhibitors or ARBs
• Beta Blockers
• Diuretics
• Inotropic Agents
• Vasodilators
Therapeutic Interventions
• Activity
• Na⁺ & Wt. Control
• Pacemakers, ICD
• Cardiac Resynchronization Therapy
• Mechanical Assistive Devices
• Intra-aortic Balloon Pump
• Ventricular Assist Device
• Total Artificial Heart
• Implantable Replacement Heart
Ventricular Assist Devices &
Artifical Heart
• Support Failing Heart
• Bridge to Transplantation
• Destination Therapy
• Heart Replacement
Surgical Interventions
• CABG
• Valve Replacement
• Ventricular Reconstruction
Nursing Interventions
• Oxygen
• Rest & Activity
• Positioning
• Fluid Management
• Reduce Oxygen Consumption
• Medications/Teaching
• Low-Na⁺ Diet
• Wt. Control
• Education
• Coping
Cardiac Transplantation
• End Stage Heart Failure
• Strict Selection Criteria
Indications
•Suitable physiologic/chronologic age
•End-stage heart disease refractory to medical
therapy
•Dilated cardiomyopathy
•Inoperable CAD Compliance with medical regimens
•Demonstrated emotional stability & social support
system
•Financial resources available
Contraindications
•Systemic disease w/poor prognosis
•Active infection, Active or recent malignancy
•DM, type 1, w/end-organ damage
•Recent or unresolved pulmonary infarction
•Severe pulmonary HTN unrelieved w/meds
•Irreversible renal or hepatic dysfunction
•Active peptic ulcer disease
•Severe osteoporosis
•Severe obesity
•Hx of drug or alcohol abuse or mental illness
Criteria for a
Potential Heart Donor
• Younger than 40 years
• Weigh within 20 lbs of prospective
recipient.
• Presence of no active infections
• Presence of no significant cardiac
or malignant disease
• No HTN or DM
Cardiac Transplantation (cont’d)
• Immunosuppressive Therapy Preoperatively
• Lifelong Antirejection Therapy
• Complications
• Rejection
• Infection
• Malignancies
• Anti-rejection Medicine Side Effects
• Grapefruit juice may ↓ potency of meds
as it ↑’s body metabolism.
Cardiac Transplantation (cont’d)
Nursing Interventions
• Pre & Postop surgical care
• Monitor temporary pacemaker, labs
• Monitor NGT & CT
• Monitor O2, I/O’s, IVs, urine cath
• Assess Pain
• Assess Pt. emotional state
• Assess for complications of rejections