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Cardiovascular Disease

HTN
Hypertension remains one of the most important preventable
contributors to disease and death. Abundant evidence from
randomized controlled trials (RCTs) has shown benefit of
antihypertensive drug treatment in reducing important health
outcomes in persons with hypertension
Direct correlation with CVD
As B/P elevates so does risk of:
o MI
o Stroke
o Heart failure
o Renal disease
HTN
o >140/90
Pre-hypertension
o 120-139/80-89
Primary vs. secondary
Clinical signs of HTN
o Silent killer
o Fatigue
o Dizziness
o Palpitations
o Angina
o Dyspnea
o Headache
o Often no symptoms until damage has occurred
Complications of HTN
o Stroke
o Peripheral vascular disease
o Coronary artery disease
o Renal failure
Diagnostic Studies
o Electrolytes
o Urinalysis
o Lipid panel
o EKG
o Ambulatory/home monitoring
Lifestyle modifications
o Weight reduction
o DASH eating plan
o Reduce dietary sodium
o Increase physical activity

o Avoid tobacco
o Manage psychosocial factors
Pharmacological treatment
o Diuretics
o Angiotensin converting enzymes (ACE) inhibitors
o Angiotensin receptor blockers (ARBs)
o Beta blockers
o Calcium channel blockers
o Combination medications
o Drugs
Hydrochlorothiazide (HCTZ)
Amlodipine (Norvasc)
Metoprolol (Lopressor)
Captopril (Capoten)
Atenolol (Tenormin)
Lisinopril (Zestril)
Nifedipine (Procardia)
Losartan (Cozzar)
Furosemide (Lasix)
Valsartan (Diovan)
Hypertensive Crisis
o Extremely elevated B/P
o Urgency vs Emergency
o 180/110 ----- 220/140
o Often seen in patients with HTN who are not taking meds
as prescribed
o Illicit drugs may also cause
o Headache, nausea/vomiting, seizures, confusion and coma
o Assess for target organ damage

Hyperlipidemia (HL)
Elevated lipid levels
Total cholesterol > 200
LDL (bad cholesterol) >130
HDL (good cholesterol)
o > 40 in men
o > 50 in women
Triglycerides <150
Lifestyle changes/modifications
Medical Management
o Statins
Simvastatin (Zocor)
Pravastatin (Pravachol)

Rosuvastain (Crestor)
Atorvastatin (Lipitor)
o Niacin (Niacor)
o Bile acid sequestrants
Cholestyramine (Questran)
Colesevalam (WelChol )
o Cholesterol absorption inhibitors
Ezetimibe (Zetia)
Coronary Artery Disease CAD
Terminology
o Arteriosclerotic heart disease (ASHD)
o Cardiovascular heart disease (CVD)
o Ischemic heart disease (IHD)
o Coronary heart disease (CHD)
Atherosclerosis is major cause of CAD
Focal deposit of cholesterol and lipids inside arterial wall
Endothelial lining can be injured by:
o Smoking
o HTN
o DM
o Infection
Development of CAD
o Fatty streak
o Fibrous plaque
o Complicated lesion
Risk Factors
o Modifiable
Elevated lipids
HTN
Obesity
DM
Smoking
Physical inactivity
Metabolic syndrome
Elevated homocysteine level
Depression
Type A personality types
Substance abuse
o Non-modifiable
Age
Gender
Ethnicity

Family history
Genetic inheritance

Angina
Chest pain
Clinical symptom of reversible myocardial ischemia
Can occur when there is :
o Increased demand for O2
o Decreased supply of O2
Order
o Artery is typically occluded >75% for ischemia to occur
Decreased blood flow to myocardium
Anaerobic metabolism occurs
o Lactic acid is produced
Irritation of myocardial cells
CHEST PAIN DEVELOP
Chronic stable angina
o Occurs intermittently over a long period of time with the
same pattern of onset, duration and intensity
Silent ischemia
o Occurs in the absence of symptoms
o Often seen in diabetics
PQRST assessment of Angina
o P Precipitating factors
o Q Quality of the pain
o R Radiation of pain
o S Severity of pain
o T Timing
Prinzmetals angina
o Occurs at rest usually in response to a spasm of a major
coronary artery
Micorvascular angina
o Myocardial ischemia associated with abnormalities of the
coronary microcirculation
Angina decubitus
o Occurs only when lying down and is usually relieved by
standing
Nocturnal angina
o Occurs only at night but not always when the patient is
sleeping or lying down
Unstable Angina
o Chest pain that is new in onset, occurs at rest, or has a
worsening pattern

o Chronic stable angina can progress to unstable angina


o Can be the first symptom of CAD
o Unpredictable and is an emergency
Nitroglycerine for Angina
o Short acting nitrates (prn use)
Acute pain or to pain prevention
Sublingual tablet
Translingual spray
o Long acting nitrates (daily use)
Isorborbide dinitrate (Isordil)
Isorborbide monoitrate (Imdur)
Nitroglycerine ointment or patch
o Side effects:
Headaches, vertigo or orthostatic hypotension
Diagnostic Studies
o Detailed history and physical exam
o Chest x-ray
o EKG
o Labs
o Echocardiogram
o Cardiac catheterization
Arterial sheath is placed
Dye is injected
X-rays are taken
Blockages can be seen
Coronary revascularization
Balloon angioplasty
Stent placement

Acute Coronary Syndrome


When ischemia is prolonged and not immediately
reversible
Unstable angina
Non-ST segment elevation myocardial infarction (NSTEMI)
ST segment elevation myocardial ischemia (STEMI)
Myocardial Infraction MI
Sustained ischemia causing irreversible myocardial cell death
80-90% are due to acute thrombus formation
When thrombus develops myocardial perfusion distal to the
occlusion is halted and necrosis develops
The degree of altered function depends on the area of heart
involved and the size of the infarction

TIME IS OF THE ESSENCE IN PATIENTS WITH UNSTABLE ANGINA


AND ACUTE MI
Cardiac cells can only withstand ischemia for about 20 minutes
before cellular death occurs
Symptoms
o Chest pain
o Diaphoresis
o Pale, cool or clammy skin
o Initially increased HR and B/P
o Nausea and vomiting
o Fever
Diagnostic studies
o EKG
o Serum cardiac markers
o Coronary angiography
Complications
o Dysrhythmias
o Heart failure
o Cardiogenic shock
o Papillary muscle dysfunction
o Ventricular aneurysm
o Pericarditis
o Dressler syndrome
Collaborative Care
o Establish IV access
o Apply O2
o Nitrates and antiplatelet agents
o EKG and telemetry
o Vital signs
Goal: Reestablish Coronary Circulation
o Get patient to the cardiac cath lab
o Percutaneous coronary intervention (PCI)
First line treatment with confirmed MI
Assess blockage
Determine collateral circulation
Evaluate left ventricular function
Advantages
An alternative to surgery
Performed with local anesthesia
Patient is ambulatory within 24 hours after
procedure
Decreased length of hospital stay
Can usually return to work within one week

Nursing care post PCI


Assess affected extremity for circulation
Observe puncture site
Pressure to puncture site if necessary
Assess vital signs
Monitor for dysrhythmias
Control pain
o Stent or angioplasty
o Fibrinolytic therapy (clot busters)
Goal is to stop the infarction process by dissolving
the thrombus
Need to give ASAP after onset of symptoms
All are given IV
Need to start multiple IV lines before med is given
Increased risk for bleeding
Contraindications
Absolute Contraindications
Active internal bleeding or bleeding diathesis
(excluding menstruation)
Known history of cerebral aneurysm or
arteriovenous malformation
Known intracranial neoplasm (primary or
metastatic)
Previous cerebral hemorrhage
Recent (within past 3 mo) ischemic stroke
Significant closed-head or facial trauma
within past 3 mo
Suspected aortic dissection
Relative Contraindications and Cautions
Active peptic ulcer disease
Current use of anticoagulants
Pregnancy
Prior ischemic stroke (>3 mo ago), dementia,
or known intracranial pathologic condition not
covered in absolute contraindications
Recent (within 3 wk) surgery (including eye
laser surgery) or puncture of noncompressible
vessel
Recent (within 2-4 wk) internal bleeding
Serious systemic disease (e.g., advanced or
terminal cancer, severe liver or kidney disease)

Severe uncontrolled hypertension (BP


>180/110 mm Hg) on presentation or chronic
severe poorly controlled hypertension
Traumatic or prolonged (>10 min)
cardiopulmonary resuscitation
o Coronary surgical revascularization (CABG)
When is CABG done?
Failed medical treatment
Left main coronary artery disease
Triple vessel disease
Failed PCI
Ongoing chest pain or DM
Placement of new vessels to transport blood
Typically use internal mammary artery, radial artery,
or saphenous vein
Requires a sternotomy
Patient is on cardiopulmonary bypass
Requires 5-7 day hospitalization
Longer recovery time than PCI
Nursing care Post CABG
Assess (vitals, skin/wounds, drains, tubes
cardiac/respiratory)
Control pain
Encourage activity
Teaching
Medication adherence
Sudden Cardiac Death
o An unexpected death resulting from a variety of several
causes
o A sudden disruption of cardiac function
Abrupt loss of cardiac output and cerebral blood flow
o Causes:
Acute ventricular dysrhythmias
Structural heart disease
Conduction disturbances
o May or may not of had an MI
o Often no warring signs
o Diagnostic work-up necessary
o Prevention of recurrence
Implantable cardiac defibrillator (ICD)
o Teach warning signs
o CPR and AED are important tools for survival