Adult II: Cardiac Unit

• Hypertension (HTN)
• Coronary atherosclerosis- plaque from high cholesterol
• Acute coronary syndrome (ACS)
• Endocarditis
• Pericarditis
• Congestive heart failure (CHF)

• Endocardium-”into” inner most layer
• Myocardium- muscle layer “squeeze”
• Epicardium
• Pericardium- outer most layer “peri= outer”

Blood is always going through atria first then ventricle

• Left side to the body
• Right side to the lung

• Pulmonic
• Tricuspid- right side
• Mitral (also called bicuspid or atrioventricular)- left side
• Aortic

• 1. Blood comes to heart via the inferior & superior vena cava
• 2. Right atrium
• 3. Tricuspid valve
• 4. Right ventricle
• 5. Pulmonic valve
• 6. Pulmonary artery
• 7. Blood comes back to heart from lung via pulmonary vein
• 8. Left atrium
• 9. Mitral valve
• 10. Left ventricle
• 11. Aortic valve
• 12. Aorta (aorta will carry it to the body)

• Contraction of the heart
• Time between S1 to S2 (lub dub)

• Relaxation of the heart
• Time between S2 and repeat of S1

• Contraction of the heart
• K+ leaves and Na+ enters the cell

• Relaxation of the heart
• K+ returns to the cell and Na+ leaves

• ionic movement within the cells (myocardial cells)
• Sodium ions going out potassium ions coming in calcium making the myocardial to squeeze

• Sinoatrial node
• Primary pacemaker of the heart
• normal is a normal HR 60-100 (beats per minute)

• atrioventricular node
• Secondary pacemaker of the heart
• normal here is 40-60 BPM
• AV node will kick up if SA node doesn’t work the secondary pacemaker

• calculation of the amount of blood pumped from the left ventricle in one heartbeat.
• Normal is 50-100mLs.

amount of blood pumped from the ventricles in liters per minute (lets us know how well we’re oxygenating)

Stroke volume x heart rate

• percentage of blood pumped out of the heart with each heartbeat.
• Normal is 55-75%
• >70% is not an A+; it is a sign of cardio myopathy (enlarged heart).
• < 55% is heart failure, you can have systolic or diastolic heart failure

• Chest pain/ palpitations (nose to naval)
• Shortness of air
• Edema
• Fatigue/dizziness
• Poor circulation
• Decreased cap refill, ruddy/discolored legs, decreased, doppler, or absent pulses

• Level of activity/ inactivity
• Smoking
• Obesity
• Stress
• Hypertension (HTN)
• High cholesterol/ blood sugars

• Family history of cardiac disease
• Gender: MEN have higher risk
• Race: AFRICAN AMERICAN have higher risk
• Age: >45 y/o male, >55 y/o female

• tricuspid & mitral valves closing
• Heard best at A PEX OF THE HEART

• pulmonic and aortic valves closing
• Heard best at BASE OF THE HEART

• Caused by ventricles not emptying completely
• Heart best LYING ON LEFT SIDE & commonly caused by CHF

• Caused by ventricles resistance to filling
• Left ventricular enlargement/ low compliance
• 90% of elderly have this
• Atrial gallop so atria

• Aortic- right 2nd intercostal space
• Pulmonics- left 2nd intercostal space
• Erbs Point-left 3rd intercostal space
• Tricuspid- 4th intercostal space lower left sternal border
• Mitral- left 5th intercostal space mid clavicular line

• Provokes pain
• What makes it better/ worse?
• What was going on/ what were you doing when the pain started?
• Qualities
• Description (sharp, stabbing, dull, aching, etc.)
• Region/ Radiation (where is it at? Does it travel?)
• Severity (pain scales)
• Timing/ Duration
• When did it start?
• How long does the pain last? (intermittent, constant)

• pressure squeezing chest pain
• alleviate- rest, nitroglycerine oxygen and MONA

pain with inspiration is indicative to that disease process

morphine, oxygen, nitroglycerin, aspirin

• considerations in women
• “Nose to naval”
• Fatigue
• Weakness
• Diaphoresis
• Nausea/ vomiting
• Arm or neck pain
• Irritability/ anxiety
• Women don’t traditionally have chest pain, men do
• Gi upset and indigestion
• Patients feeling a sense of doom

• Decreased ability to palpate peripheral pulses
• Kyphoscoliosis (“grandma’s hump) may move cardiac apex downward
• Systolic BP increases with age
• Orthostatic hypotension- more common: higher risk for syncope
• Murmurs common in elderly (60%)
• Most common cardiac symptom is FATIGUE

• Quick-acting vasodilator used for chest pain
• Typically given sublingually
• Helpful when blood flow is inhibited because it forces vessel open (dilates) and thus blood flow returns a bit (the goal)
• Remember: It quickly opens vessels
• An immediate headache will follow
• HYPOtension will occur since the vessels are dilating

• Give 1 dose sublingually
• If chest pain (CP) after 5 mins, repeat a second time & CALL EMS
• If CP after another 5 mins, repeat a third dose and final time
• DO NOT take more than 3 doses (due to HYPOtension)

• Headache
• HYPOtension
• Nausea
• Dizziness
• Flushing
• Decreased LOC

• opens up like Nitro but does it slowly & produces peripheral vasodilation
• Preferred for chest pain due to vasodilation and decrease air hunger

• Respiratory depression
• Decreased LOC/confusion/lethargic
• drowsiness/ sedation
• Dizziness
• Rebound headache

• (moment in time- 12 leads: rate and rhythm)
• Electrical activity in the heart
• Not continuous

• A continuous EKG with fewer leads- not as in depth
• Inpatient or outpatient (if outpatient called a Holter monitor)

Ultrasound to evaluate valves, ejection fraction and fluid levels around the heart

Measures the heart’s ability to perform under stress

patient walking on a treadmill

simulates exercise with medication (dobutamine or adenosine)

• In-depth imaging of coronary arteries
• Coronary arteries are the vessels on the outside of the heart that feeds to the heart

• Increased with heart failure
• Normal depends on age, generally less than 100 pg/mL

• Increased with systemic inflammation, so non-specific
• Can indicate progression of atherosclerosis (plaque in arteries)
• Normal less than 3 mg/L

• high levels rise in relation to endothelial lining damage and formation of thrombus related to atherosclerosis
• High risk greater than 15 mcmol/L

• Sensitive in few hours after MI, but non-specific
• Normal in men is 50-325 ng/mL
• Normal in women is 50-250 ng/mL

• Sensitive for muscle tissue damage, but non-specific
• Normal is 5-70 ng/mL

• Cardiac sensitive, so the gold standard *
• Released in 2-4 hours and lasts up to 14 days
• Normal range less than 0.02 ng/mL however newer tests may use a different scale
• Important to trend every 2-3 hours x3 draws
• Enzyme in the cardiac cells, not typically measurable in the blood they are released during cardiac damage

Normal <200 mg/dL

Normal 100-200 mg/dL

• High density lipoprotein
• We want it to be high
• Normal in men 35-70 mg/dL
• Normal in women 35-85 mg/dL

• Low density lipoprotein
• We want it to be low
• Normal <100 mg/dL
• High risk >60 mg/dL

• “Atherosclerosis” (plaque)
• Fatty cholesterol/ plaque build up on the wall of the artery
• Plaque inhibits the blood flow through artery
• Blood/platelets clot around the plaque and this eventually leads to a blockage
• The blockage is Acute Coronary Syndrome (ACS) total blockage, EMERGENT
• Mechanism of a heart attack/myocardial infarction
• CAD is partial blockage
• Give Aspirin which is an antiplatelet - used for the prevention and treatment and is going to reduce the risk of a clot forming

• Chest pain or angina****
• Shortness of breath
• Nausea
• weakness

• Elevated LDL
• Diabetes
• HTN
• Smoking
• Elevated triglycerides
• Metabolic syndrome

• Change is modifiable causes
• Blood sugar control
• Healthy, low-fat diet
• Stop smoking
• Daily ASA

• Low cholesterol diet
• Exercise
• Change modifiable causes
• Cholesterol lowering medications, “Statins”

• Lipid lowering drugs
• HMG CoA reductase inhibitors
• Reduces “bad” (LDL & triglyceride) cholesterol in blood
• Also increases “good” (good” (HDL) cholesterol in blood
• Avoid grapefruits/grapefruit- can increase levels of drug and thus cause liver damage’
• Most common side effect: muscle soreness/leg cramps
• Still need to fix the diet (low fat) but also need to take medications!

• Transition from angina (CAD) to the total blockage (ACS)
• The plaque has now become A total obstruction
• Angina is a precursor for MI

• myocardial (heart muscle) ischemia (inadequate blood supply)
• The blood supply is now BLOCKED (ACS); difference between CAD (not totally blocked)
• MI heart is lacking oxygen from blocked artery
• Needs to be reopened mechanically ASAP
• Cardiac catheterization
• Door to balloon time of 90 minutes or less

• Nitroglycerin/ “Nitro”
• ASA
• Beta-blocker
• ACE inhibitor
• Statin

• Heart attack
• Portion of heart past the blockage no longer receiving adequate blood flow
• Time is heart
• Intervene quickly (cardiac cath) to reopen vessel (longer=more damage)

• Chest pain that is crushing or substernal
• Pain: nose to naval
• Atypical signs in women & elderly
• EKG changes (sometimes not all the time)
• Left arm pain
• Jaw pain
• Nausea
• Anxiety- impending doom
• BP changes
• Diaphoresis

• Immediate intervention (cardiac cath)
• MONA (morphine, oxygen, nitroglycerine, aspirin)

• Performed in the cath lab under light sedation
• Radial (R preferred) or femoral artery accessed to guide a catheter to the heart
• Dye is injected to evaluate Perfusion and possible blockages in coronary arteries
• Stenting/ opening of the vessel can be performed in live time

• so monitor kidney function post-procedure
• Patients receive fluids to flush dye through kidneys, so monitor for s/s fluid overload
• Purpose: diagnostic not intervention- make sure vessels are open and patent

• TR band (trans radial)
• Slowly release air from the band to relieve pressure
• No bending, pulling, pushing or using wrist
• Weight restriction 10 days post procedure on wrist: using hand to lift self off bed- educate
• Reduced hematoma formation with this type of access
• Easier to see if there’s bleeding due to smaller area

• Requires 2-6 hours of STRICT bedrest and lying totally flat after
• Monitor for hematoma formation *bleed into tissue
• Retroperitoneal bleed= behind the peritoneal
• Decreased peripheral pulses
• Purple discoloration/ bruising around site/groin/back/vulva/testes/down to the knee or further
• Hardening of the site- assess Q15 mins
• Unilateral leg swelling
• Sudden urge to have a bowel movement
• Back pain
• Impending doom

• Lovenox
• Antiplatelets (platelet aggregation inhibitor)
• plavix/ clopidogrel
• Blood thinners
• Side effects for all blood thinners/antiplatelets

• SubQ injection
• Low molecular weight heparin
• Used in prophylaxis of treatment of DVT/PE

• plavix/ clopidogrel
• brilinta/ ticagrelor
• effient/ pragugrel
• Reduce risk of death, MI, CVA, refractory ischemia, vessel blockage in CV patients
• These keep stents placed during cardiac cath patent

• Eliquis/Apixaban
• Xarelto/Rivaroxaban
• Pradaxa/Dabigatran

• Bleeding
• Bruising
• Hematoma
• Thrombocytopenia
• Anemia
• Dyspnea

• Anticoagulant/ blood thinner
• Used to prevent MI, CVA, and used to treat/further prevent DVT and PE
• Who needs warfarin vs other blood thinners?
• The “Big Daddy” of blood thinners- works better and it stronger
• Monitor levels with INR
• Therapeutic is either 2-3 or 2.5-3.5 depending on physician order
• vitamin K is the antidote

• Monitor and report s/s bleeding (urine, stool, gastric, hematoma formation, uncontrolled)
• Avoid NSAIDs in excess (multiplies risk of bleeding)
• Eat low but consistent amounts of Vit K foods: green leafy vegetables, liver, vegetable oils (counteracts warfarin)
• Avoid grapefruit juice (increases blood thinning)
• Weekly INR checks (because SLOW half-life: 5-7 days)
• Avoid excessive drinking (alcohol causes an increase in anticoagulation effect)

• -half life 60-90 minutes
• -rapidly metabolized
• Blood thinner/anticoagulant given:
• Prophylactically via Sub Q or
• For treatment of PE/DVT/ACS/suspicion of MI given via IV

• Creates a negative charge to the surface of platelets, inhibiting their clumping action
• Very fast half-life/rapidly metabolized

• aPTT levels or new “Heparin assay” every 6 hours until 2 therapeutic draws
• If pt takes Xarelto or Eliquis, cannot use heparin assay and must use aPTT
• Therapeutic range depends on physician and reason for use

Do not give to pts who are already bleeding or extremely high risk (trauma, intracranial hemorrhage, internal bleeding, bleeding disorders)

• Greater than 140/90 - 2 separate readings in 2 separate visits
• Blood is flowing through constricted blood vessels, thus increasing the pressure – the blood pressure

• Headaches
• Dizziness
• Flushing
• Blurred vision
• Nosebleeds
• Anxiety
• Occasional
• Retinal hemorrhages, exudates, cotton-wool spots on retina, papilledema (swelling on the optic nerve)

• Ethnicity- African Americans
• Diabetes
• Elevated lipids- Cholesterol (plaque)
• Impaired renal function
• Obesity- working harder to produce more blood and pump it
• Age
• family history

• Alter modifiable risk factors
• Control blood sugars
• Take medications as prescribed
• Reduce stress
• Stop smoking
• Repair unhealthy diet: heart healthy- low fat and low salt

• Unidentified cause
• Ethnicity
• Family hx
• Obesity
• Stress
• High sodium/fat intake
• Treatment: antihypertensive medications
• Primary/1st line: Diuretics (hydrochlorothiazide)

• Identifiable cause (ex: renal disease)
• Renal disease
• Narrowing of renal arteries
• Hyperaldosteronism
• Medication side effects
• Coarctation of the aorta
• Treatment: treat the underlying cause only

• Drop in BP with positive position changes
• Take BP lying first, then sitting, then standing
• Wait 2-3 minutes between each reading
• A positive/abnormal reading is when the BP drops 20 or more points systolically
• Encourage slow position changes & be mindful of fall precautions
• Causes: dehydration *, fluid loss, prolonged bedrest

• Elevated BP but not concern for organ/tissue damage
• Headache
• Nosebleeds
• Anxiety
• Cause usually medication noncompliance, also can be trauma/organ failure

• >180/120
• Organ damage may occur if BP now lowered soon
• Intracranial hemorrhage
• MI
• Aortic aneurysm dissection (life threatening)
• Assess medication compliance and barriers

• Sodium/fat restriction (quantifiable numbers)
• Sodium: less than 2000 mg/day
• Fat: usually 2-3 g less per day
• Increase exercise/activity
• Weight reduction
• Stop smoking
• Stress reduction
• meditation

• End in “pril”
• Lower total peripheral resistance
• Relieves s/s of progression of HF
• dry , constant cough/”ACE cough”
• Can cause angioedema: more prominent in AA
• Does not affect pulse

• End in “sartan”
• Lower total peripheral resistance & resistance and afterload
• Relieves s/s of progression of HF
• If ACE cough, this is what one will be switched to
• *** ACE or ARB never combined

• End in “lol”
• Blocks sympathetic nervous system
• Dilates vessels & decreases heart rate and BP
• Avoid sudden discontinuation: can cause rebound issues
• Hold HR<60bpm

• End in “pine” except ditiazem & verapamil
• Blocks calcium ions, thus vasodilation = lowering BP
• Lower systemic vascular resistance
• Give on empty stomach
• Monitor for arrhythmias, SOA, edema
• Do not discontinue abruptly

• Increases urine production
• Decreases fluid volume & ECF
• Take in the morning/during the day
• Monitor electrolytes

• inflammation of the pericardium
• Typically following respiratory infection/ virus
• May be related to MI
• Sudden onset of symptoms but not long-lasting

chest pain (sharp, stabbing, may travel), friction rub heard,SOA, pain relieved when sitting up and leaning forward

• drain/spirate pericardial fluid if exists
• Antibiotics
• Anti-inflammatory
• Pain medications
• Manage HTN
• Treat fever if develops
• **usually goes away on its own if not then it turns to cardiac tamponade

• Excessive fluid accumulation in the pericardiac sac
• Emergent! Must be drained ASAP via pericardiocentesis
• Complications from pericarditis
• Can be caused by trauma, infection, CHF, cancer
• Symptoms include hypotension, muffled heart sounds, JVD, pulse pradoxus (decrease in HR during inspiration)
• Monitor vitals and do detailed assessment for changes

• chronic condition where the heart does not pump or relax/fill as effectively as it should
• 2 types: left and right sided

• Atherosclerosis
• MI
• Cardiomyopathy
• HTN
• Valvar disorders
• DM
• Renal insufficiency resulting in fluid overload

• Class 1
• No limitation of physical activity
• Class 2
• Slight limitation of physical activity
• Class 3
• Symptoms with minimal exertion
• Class 4
• Symptoms at rest

• Definition: left ventricle can no longer pump enough blood around the body
• Pulmonary veins/capillaries get “backed up”
• Results in impaired gas exchange and pulmonary edema

Dyspnea, cough, frothy or blood/tinged sputum, crackles, cyanosis, anxiety & fatigue, dizziness, increased oxygen needs/low o2 sat

Accumulation of fluid in the alveoli & interstitial lung space from severe heart failure

• Pink (blood tinged), frothy sputum
• Hypoxia
• dyspnea/SOA
• Cyanosis
• Diaphoresis
• Arrhythmias
• Decreased BP
• Use of accessory muscles when breathing

• Diuretics
• Vasodilators
• Inotropic agents
• Antihypertensives
• Pain medication (morphine, air hunger)
• Monitor:EKG for changes (typically tachyarrhythmias), Vital signs (for elevated BP especially), Medication compliance

• heart failure right side can no longer contract effectively cardiac
• Peripheral tissue and viscera, particularly abdomen get “backed up”

• JVD
• Lower extremity pitting edema
• ascites/liver enlargement
• Fluid retention
• Weight gain
• Fatigue

• Daily weight (>2lb/day or 5lb/week is fluid backing up)
• Intake and output
• Fluid restriction (2,000mL or less per day)
• Oxygen if needed
• Heart healthy diet (low Na+ of 2,000mg or less, low fat)
• Diuretics
• Medication adherence
• Labs (BNP, electrolytes)
• EDUCATE

• The heart does not pump adequately
• Decreased amount of blood is ejected from the heart
• Blood carries oxygen, so decrease oxygen circulation including to the brain

• Decreased LOC
• Lethargic
• Nocturnal dyspnea/ cannot lay flat
• Decrease in quality of pulse and BP

• Oxygen
• Medication to aide in myocardial perfusion and contractility
• Meds: diuretic, beta-blockers, possible blood thinners and ACE inhibitor
• Diuretics
• salt/fluid restrictions

• EDUCATE! Patients cannot do what they don’t know to do
• Lifestyle changes (diet, exercise, stress modification)
• Medication adherence
• Daily weight
• Avoid NSAIDs

• Stay out of the hospital
• Prevent disease worsening
• Manage disease with physician collaboration

• Lasix/furosemide
• Aldactone/spironolactone
• ACE inhibitors
• ARBs
• Diuretics

• Loop diuretic
• Potassium-wasting diuretics
• Give slow IV- can cause Ringing in the ears “ototoxicity”

• potassium-sparing diuretics
• Watch kidney function for high K+
• Can be taken in combination with other diuretics

• Pulls fluid from Extravascular space to intravascular space so patient can “pee it off”
• Diuretics are pulling fluid off and can lead to dehydration
• Urine output is a measure of how well diuretics are working

• Epinephrine
• Digoxin (Lanoxin)

• “Epi” or “Epi-Pen”
• Sympathomimetic agent (mimics sympathetic nervous system)
• Emergency treatment for allergic reaction or anaphylaxis & used in code blue
• Works by relaxing airway muscles and tightening blood vessels
• Side effects: palpitations, sweating, nausea

• Slows and strengthens the heart
• Cardiac glycoside
• Used in mild/moderate heart failure and to control ventricular response in a-fib
• Side effects: bradycardia, dizziness, confusion, blurry vision, arrhythmias, rash

too much of the drug builds up in the body causing toxic levels

• GI upset, visual changes (yellow/green discoloration), seeing a “halo” around lgihts
• Therapeutic level: 0.8-2

• Decreased venous blood flow to lower extremities
• Veins sag, swell, push outward

• Aching or cramping pain in extremities
• Pain gets worse when standing
• LE edema
• Ankle skin pigment darkened
• Thickened/hardening of skin on LE
• Ulcers
• affects upper part of calf and high ankle

• TED hose
• Surgery: stenting or bypass
• Sclerotherapy in early stages

• Decreased arterial blood flow to lower extremities
• Arteries narrowing, hardening, pulling inward
• **secondary to another disease process

• Intermittent claudicatio
• Cramps at night in LE
• Diminished/absent pulses
• Fiery, dusky skin of leg when in dependent position
• Cool to the touch
• Typically do not have hair on their legs

*pain is worse with exercise due to not enough blood flow to support exercise = less pain at rest

• TED hose
• ASA or ASA + antiplatelet
• Surgical: stenting or bypass

• Blood clot/thrombosis in an extremity
• Affected extremity is unilaterally swollen

Immobility, surgery, trauma, family history, cancer/clotting disorder, obesity, random

• Pain in extremity affected
• Affected extremity unilaterally swollen
• Reddened and hot extremities
• Difficulty walking
• Shortness of air

• Improve perfusion
• Blood thinners
• Lovenox, xarelto, eliquis, warfarin
• Possible need for heparin gtt to bridge to warfarin

• Early ambulation after surgery
• Compression devices (SCDs)
• Ted hose ( but not when laying in bed)
• ROM exercises
• DVT prophylaxis medications