Cardiac

• the amount of blood returning to the right side of heart and the muscle stretch that the volume causes
• *ANP is released when we have stretch

More volume, more stretch

• the pressure in aorta and peripheral arteries that the left ventricle has to pump against to get the blood out
• *Referred to as resistance
• *think of hurricane blowing on door

• With hypertension, theres even more resistance for the left ventricle to pump again
• High after-load decreases cardiac output and decreases forward flow
• It wears your heart out!

the amount of blood pumped out of ventricles with each beat

Heart rate x stroke volume

Cardiac output changes according to body's needs: running vs sitting

• Pulseless Vtach
• V-fib
• asystole

*There is NO cardiac output

• Most common type of cardiovascular disease
• Broad term for Chronic stable angina and acute coronary syndrome

• Intermittent decreased blood flow to heart which leads to temp pain/pressure in chest
• Pain is brought on by low O2, usually due to excursion
• Is relieved by rest and/or nitro

• Beta blockers
• Calcium channel blockers
• Acetylsalicylic acid

• Beta blockers
• Decrease workload of heart by blocking beta cells, which are receptor sites for epi/norepi
• Decreases cardiac output
• *Because it decreases cardiac output, it will also decrease HR and BP. so need to monitor

• Calcium channel blockers - prevent angina
• Will decrease BP by causing vasodilation of the arterial system
• Dilate coronary arteries
• Two benefits: They decrease afterload and increase oxygen to heart muscle

• Aspirin!
• Inhibits platelets from sticking

• Other than health habits...
• Avoid excess caffeine or drugs the increase Hr
• Wait 2 hours after eating to exercise
• Dress warmly in cold weather (ANY extreme temp change can precipitate attach)
• Avoid isometric exercise
• *All cause increased BP = makes heart work harder

Procedure used to diagnose heart disease

• Ask if they are allergic to iodine or shellfish - iodine based dye used during procedure
• ALWAYS check kidney function
• "Hot shot" - Educate dye can cause flushing and hot feeling
• Palpitations are normal

helps to protect kidneys from iodine dye

Need to check kidney function before using dye as it can cause kidney failure

• Monitor VS
• Watch puncture site for bleeding and hematoma
• Assess extremity distal to site w 5-P's
• Must lay flat for 4x6 hrs
• Report pain
• Hold Metformin if pt is taking it

• Pulselessness 
• Pallor
• Pain
• Paresthesia (pins and needles)
• Paralysis

• MI &unstable angina
• Involves decreased blood flow to myocardium that will involve both ischemia and necrosis
• Client doesn't need to be active to bring pain on
• Rest and/or nitrate will NOT relieve pain

• Pain! - Crushing pressure on chest, radiating to left arm and left jaw, or pain between shoulder blades
• **Women usually have GI s/s, epigastric complains to pain btwn shoulders, aching jaw or choking sensation
• Cold/clammy/BP drops
• Vomiting - stimulates vagal nerve, drops BP & perfusion

• STEMI: ST-segment Elevation Myocardial Infarction: indicates pt is having MI & has muscle damage going on. Goal is to get to cath lab in less than 90 mins 
• Worry about the STEMI!! Time is muscle

NSTEMI: Non-ST-Segment Elevation Myocardial Infaction: these clients are less worrisome

• SOB
• also can have behavioral changes

• CPK-MB
• Troponin
• Myoglobin

• Cardiac specific isoenzyme
• Increased if there is damage to cardiac cells
• Elevates withing 3-12 hrs after onset and peaks at 12-24 hrs

• Cardiac biomarker with high specificity to myocardial damage
• Elevates within 3-4 hours and remains elevated for up to 3 weeks
• Most sensitive and most specific

• Not really diagnostic because it's not specific
• But if negative, can rule out muscle damage

• Defibrillate
• If first shock doesn't work, give epi

• Amiodarone!
• anti-arrhythmic med

Amiodarone - first drug of choice. Hypotension is side effect! So could go from fast rate to slow

Lidacaine - decreases irritability of heart. Sign of toxicity is neuro changes.

Goal is to dissolve the clot that is blocking blood flow to heart muscle which decreases the size of the infarction.

Needs to be administered withing 6-8 hours!

NOT in central line! If bleeding does occur, can't compress neck veins. must be peripheral

thrombolytics

• PCI
• CABG

• Percutaneous Coronary Intervention
• Includes all interventions such as PTCA (angioplasty) and stents

MI is a major complication of angioplasty. Also, pt could bleed from heart cath site, or could reocclude

If there are any problems, they are headed to surgery! Any chest pain after procedure, you call the doc at once as they are probably reoccluding!

Pt's will be put on thrombolytic or anti-platelet meds! (Acetylsalicylic acid, Plavix, etc.)

• Coronary artery bypass graft (another name for Open Heart Surgery) 
• Can be scheduled or emergent procedure
• Used with multiple vessel disease or left main coronary artery occlusion
• *The left main coronary artery supplies entire left ventricle

Left main coronary artery occlusion = Think Sudden Death or Widow Maker

• Smoke cessation
• Gradual increase in activity
• Diet changes: low fat, low salt, low cholesterol
• No isometric exercises
• No straining... should be on stool softener (colace)

Sex can be resumed in pt w/o complications in 1 wk to 10 days. Best time is sex in morning

Best exercise is walking

S/S of HR: weight gain, ankle edema, SOB, confusion

Complication that can result with probs such as cardiomyopathy, valvular heart disease, endocarditis, acute MI, and hypertension. 

Leading cause is hypertension

types include left sided and right sided

Blood is not moving forward into aorta and out to body. It's backing up into lungs.

• S/S include:
• Pulmonary congestion/dyspnea/orthopnea
• Cough
• Blood tinged frothy sputum
• restlessness/tachycardia (think HYPOXIA!)
• S-3 heart sound
• Nocturnal dyspnea

Blood is not moving forward toward lungs... moving backward into venous system

• S/S include:
• distended neck veins
• Edema
• Enlarged organs
• Weight gain
• Ascites

Systolic heart failure: heart can't contract and eject

Diastolic heart failure: ventricles can't relax and fill

• BNP
• CXR
• Echocardiogram
• New York Heart Association Functional Classification of Persona's with HF

• B-type natriuretic peptide
• secreted by Ventricular tissues with ventricular volumes and pressures in heart are increased
• Sensitive indicator
• Can be positive for HF when CXR doesn't indicate prob

CXR: will show enlarged heart, pulmonary infiltrates

Echocardiogram: looks at pumping action of ejection fraction of heart

New York Heart Ass. Functional Classification of Persons with HF: Classes 1-4, 4 being the worst. shows degree of heart failure

• Meds
• Low sodium diet
• Elevate HOB
• weigh daily and report gain of 2-3
• Educate s/s of recurring failure
• Pacemaker

• ACE inhibitors
• ARBS:
• Digoxin

• Drug of choice
• they suppress the Renin Angiotensin System and prevents conversion of angiotensin I to angiotensin II

results in arterial dilation and increased stroke volume

Block angiotensin II receptors and cause decrease in arterial resistance and decreased BP

***May be used first because of the dry, nagging cough by ace inhibitors 

They both block aldosterone! 

We then lose sodium and water, but end up retaining potassium! So, risk is hyperkalemia!

• Makes the heart contract harder and slows down the heart rate thus giving ventricles time to refill.
• Must monitor for toxicity

Cardiac output will go up which will increase kidney perfusion

Often given in combo with ACE inhibitor, ARBS, beta blocker, or diuretic

Normal Dig level: 0.5 - 2

Will be given a digitalizing dose (loading dose) which means they will be given a larger dose than what the pt will be sent home with. 

• S/S of early toxicity: N/V
• S/S of late toxicity: arrhythmia and vision changes (halos)

ALWAYS check apical pulse

Any electrolyte imbalance can promote Dig Toxicity

• "Natural pacemaker is SA node, sends out impulse for heart to contract
• If heart rate drops below 60, Cardiac output can decrease.

A Pacemaker is used to increase the heart rate with symptomatic bradycardia.

Any pacemaker will have a set rate of a certain minimal HR.  A demand pacemaker kicks in only when needed. A fixed rate pacemaker fires at a fixed rate.

It's ok for rate to increase but never decrease. Always worry if the rate drops below the set rate!

Monitor the incision

Most common complication is electrode displacement

therefore, immobilize the arm (in sling) but also do passive ROM to prevent frozen shoulder.

But keep pt from raising the arm higher than shoulder height to keep from dislodging wires.

Loss of capture - no contraction happens after stimulus

Failure to sense - pacemaker fires at inappropriate times

• Can result from:
• Pacemaker not programmed correctly
• Electrodes can dislodge
• Battery may be depleted

Watch for any sign of decreased cardiac output or decreased rated

• Check pulse daily
• Have an ID card or bracelet
• Avoid electromagnetic fields (cell phones or large motors)
• Avoid MRI's
• Will set off alarms at airports
• Avoid contact sports

• Those are risk:
• any person receiving IV fluids really fast
• The very old and very young
• any person with hx of heart or renal disease

Usually occurs at night when the client goes to bed

• S/S include: 
• Sudden onset
• Breathless/restless/anxious (think hypoxia)
• Productive cough (pink, frothy sputum)

• Treatment:
• Oxygen - keep above 90%
• Medications
• Positioning - Sit up, dangle legs to displace some of the blood
• Prevention: when possible, monitor lung sounds and avoid fluid excess

Blood, fluid, or exudates have leaked into the pericardial sac resulting in compression of heart.

Hallmark sign is increasing CVP and decreasing BP

Narrowed: think cardiac tamponade

• Widened: Increased ICP
• *From base line!

Pulse pressure is difference between systolic and diastolic

• Decreased cardiac output
• CVP will increase, BP will decrease
• Heart sounds muffled or absent
• Neck veins distended

Pressure in all 4 chambers of heart at same time


Tx:  Pericardiocentesis to remove fluid/blood around heart. May require surgery

Arterial blood isn't getting to tissues! 

If you have atherosclerosis in one place, you have it everywhere! It's a medical emergency if you have an acute arterial occlusion!  Pt will report numbness & pain. No palpable pulse.  

• Hallmark sign is Intermittent claudication (cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.)
• Pain at rest means severe obstruction

Arterial disorders of lower extremities are usually treated with either angioplasty or endarterectomy (removing material causing blockage)

Elevating arteries will cause pain, to DANGLE!!

If it's a vein, then you would find relief with elevating.