CARDIOVASCULAR DISORDER OUTLINE • Heart rate

• Rhythm
Heart Facts • Heart Sounds S1 (lub) and S2 (dub)
• One in six men and one in seven women aged 45-64 has • S1 is first heart sound from closure of Mitral and Tricuspid
some form of heart disease or stroke; the ratio climbs to • S2 is second sound from closure of aortic and pulmonic
one in three at age 65 and over. • Don’t worry about correctly labeling sounds as S3 or S4
• Twice as many people, both men and women, die of for now
cardiovascular disease as die of cancer. • Murmurs are swishing sounds in-between heart sounds
• An estimated 3,150,000 Americans have angina pectoris (Lub-swish-Dub)
• Rheumatic heart disease afflicts 1,340,000 Americans. • Pericardial friction rub - rough, grating sound from
(Data from the American Heart Association's 1994 inflamed pericardial sac
Statistical Supplement, "Heart and Stroke Facts") • Bruit - murmur heard outside of the heart. May be heard
in carotid, jugular, temporal, abdominal, aortic, renal and
Atherosclerosis and Arteriosclerosis femoral arteries
• Common disorder of the arteries. • Take B/P in both arms, lying, sitting and standing
o Fat, cholesterol, and other substances collect in the Pulse Assessment
walls of arteries. • Note whether the pulse is regular or irregular:
o Larger accumulations are called atheromas or o Regular - evenly spaced, may vary slightly with
plaques. respiration
• Fatty tissue erodes wall of the artery, diminishes the o Regularly Irregular - regular pattern overall with
elasticity and interferes with blood flow. "skipped" beats
• Arteriosclerosis (commonly called hardening of the o Irregularly Irregular - chaotic, no real pattern, very
arteries) frequently accompanies atherosclerosis and is difficult to measure rate accurately
not clearly separated from it. o A pulse greater than 100 beats/minute is tachycardia.
o Arteriosclerosis involves deposits along the arteries, Pulse less than 60 beats/minute is bradycardia.
which often contain calcium. o Tachycardia and bradycardia are not necessarily
abnormal. Athletes tend to be bradycardic at rest
Arteriosclerosis and Ateriosclerotic Heart Disease o Tachycardia is a normal response to stress or exercise.
(ASHD) B/P Assessment
• Primarily affects middle age and older • Position and support the arm slightly flexed at the elbow
• Major cause of death in men age 35-44 years old • Center the bladder of the cuff over the brachial artery 2
• Major cause of death in women after menopause cm above the anticubital fold
• Prevention begins at birth • Inflate the cuff until the radial pulse disappears. Inflate
• 3 Main Risk Factors the cuff to 30 mmHg above the estimated systolic
o Smoking, High B/P and High Cholesterol pressure, release slowly.
• Intermittent claudication (pain in calf or leg brought on by • Systolic Pressure - When you start to hear beats
exercise and relieved by rest) is most common early sign • Diastolic pressure when the sounds muffle and disappear.
of arteriosclerosis • Don’t use too small a cuff. The pressure will be 10, 20,
Risk Factors for ASHD even 50 mmHg too high!
• Non-Modifiable • Maximum Cuff Pressure - When the baseline is known or
o Age hypertension is not suspected, it is acceptable in adults to
o Gender inflate to 200 mmHg
o Race • Be aware that there could be an ausculatory gap (a silent
o Family history interval between the true systolic and diastolic
o other illness (diabetic) pressures).
• Minor Factors
o Personality type Blood Pressure Classification in Adults
o Sedentary living Hypertension
o Stress • Consistent elevation of diastolic B/P above 90
o Oral Contraceptive Use • Affects over 58 million people
• Modifiable o Incidence increases with age
o Smoking o Almost twice as prevalent in Blacks
o High calorie, fat, cholesterol, sugar and sodium diet o More severe in Blacks
o High serum lipids • Two Main types - Primary (Essential) hypertension and
o Hypertension Secondary Hypertension
o Obesity o Primary accounts for 90% of all Hypertension
o Lifestyle o Secondary is from a known cause such as
glomerulonephritis, Cushing’s or renal stenosis
Cardiovascular Assessment - Inspection Isolated Systolic Hypertension
• Skin Color (pallor, cyanosis) • Frequently seen in older adults
• Neck vein distention - reflects right atrial pressure • Systolic over 90, with normal diastolic
• Respiratory (dyspnea, Orthopnea) • While commonly ignored, this condition should be
• Location of PMI - if too low indicates enlarged heart treated.
• Presence of edema - fluid volume overload • Studies show that lowering the systolic number cuts down
o Be sure to check sacrum for those on bedrest on strokes and heart attacks in people age 60 and over.
• Nail clubbing - sign of chronic hypoxia Primary Hypertension
• Capillary filling - measure of peripheral circulation • Possible contributing mechanisms:
• Lack of hair on legs/feet o heredity
• Venous stasis or Arterial Ulcers o vascular hypertrophy
• Vericose Veins o defects in ion handling
Palpation o hyperinsulinemia
• PMI (Located at 5th intercostal space, Left MCL) o renin/angiotensin
• Thrills (palpable murmur) thrusts/heaves Malignant Hypertension
• Peripheral pulses - Check all bilateral and compare • Severe, rapidly progressive rise in B/P that damages
• Temperature - check bilateral small arterioles of major organ systems
• Capillary refill - measure of peripheral circulation • Inflammation of the arterioles of the eye is classic finding
Auscultation • Primarily found in black men under 40
• Unless aggressively treated, is rapidly fatal • Renin actives Angiotensinogen which becomes
Angiotensin I and II (with the help of ACE (angiotensin
Complications of Hypertension converting enzyme). Angiotensin II causes
• Atherosclerosis vasoconstriction of blood vessels and stimulates
o Athlerosclerotic vascular occlusion aldosterone
a) coronary artery disease • Aldosterone leads to increased fluid and sodium retention
b) occlusive cerebrovascular • All act to Increase Blood pressure
c) peripheral arterial insufficiency Angiotensinogen Converting Enzyme (ACE) Inhibitors
• aortic dissection • Commonly known as ACE inhibitors
• nephrosclerosis o Captopril (Capoten); Enalapril (Vasotec); Lisinopril
• hypertensive heart disease with cardiac hypertrophy and (Zestril)
congestive heart failure • Used for: Chronic hypertension, congestive heart failure.
• cerebral hemorrhage • Side Effects: Cough, diarrhea, headache, loss of taste,
Antihypertensive Medications nausea, unusual tiredness.
• Diuretics • Report symptoms of
o Thiazide/Thiazide-like diuretics; Loop Diuretics; o dizziness; fainting; skin rash; chest pain.
Potassium Sparing Diuretics Prevention of ASHD
• Adrenergic Inhibitors • DON’T SMOKE
o Beta-Blockers; Centrally Acting and Peripherally • Exercise and weight control
acting Alpha Blockers; Combined Alpha-Beta Blockers o Lowers total cholesterol, LDL's (bad cholesterol) and
• Vasodilators the Triglycerides and may raise the good cholesterol
• ACE Inhibitors (HDL).
• Calcium Antagonists o Eat a low-fat diet and become a semi-vegetarian, eat
Diuretic Treatment red meat/cheese less often
• Potassium Wasting Diuretics o Eat fish (not shell-fish, not fried) once a week
o Thiazide Diuretics - Chlorothiazide (Diuril) and • Increase your intake of soluble fiber
Hydrochlorothiazide (Hyrodiuril) o Oats, beans, barley, apples, carrots, citrus fruits,
o Loop Diuretics: furosemide (Lasix); Bumetanide sweet potatoes
(Bumex) • One glass of wine a day - but skip this if you are at risk
• Monitor Daily weight and I&O - Pt should lose weight if for alcohol abuse or cancer
diuretic is effective Cholesterol Lowering Medications
• Most common side effect of diuretics is electrolyte • First cholesterol lower meds were bile sequestration
imbalance. Others - Postural hypotension, GI symptoms, medications - Cholestyramine (Questran) - had lots of
Sexual dysfunction side effects
• Potassium Sparing Diuretics - Inhibit aldosterone, cause • Newer and more popular meds fall into two basic
Na+ to be excreted in exchange for K+ categories:
o Spironolactone (Aldactone) - causes gynecomastia o Fibrates (including gemfibrozil [Lopid] and clofibrate)
Beta Blockers o Statins (such as lovastatin and provastatin).
• Atenolol (Tenormin); Metoprolol (Lopressor); Propranolol Bile Sequestrant Drugs
(Inderal); Nadolol (Corgard) • Cause excretion of bile acids, which makes the liver
• Should not be used in patient's with asthma, COPD, CHF manufacturer more bile acids using up more cholesterol.
and heart block • Cholestyramine (Questran) and colestipol (Colestid)
• Side Effects - Bronchospasm, Bradycardia, fatigue, sexual o Side effects - abdominal pain, N/V and bloating.
dysfunction, Peripheral vascular insufficiency • Naicin (nicotinic acid) limits conversion of lipids to LDL in
Alpha-1 Blockers the liver and causes increased production of bile acids
• Prazosin (Minipress); Terazosin (Hytrin) o Must be taken in large dosages
• Reduce peripheral resistance by dilating arterioles and o Common Side Effects -hot flashes and itchy, dry skin.
venules o Severe Side effects - Chemical hepatitis", tendency
• Side effects- syncope, orthostatic hypotension, weakness; toward diabetes, gout with arthritis and kidney
palpitations damage.
• Need to avoid standing for long periods of time Fibrates (Fibric Acid Derivatives)
• Need to rise slowly to avoid orthostatic hypotension • Gemfibrozil (Lopid) - works by defeating the liver's ability
Centrally Acting Alpha Blockers to make very low density lipoproteins, precursors to LDL,
• Clonidine (Catapres); Methyldopa (Aldomet) Also raises good (HDL) cholesterol.
• Activate central receptors that suppress vasomotor and o Abdominal pain, diarrhea, nausea, and vomiting may
cardiac centers. Leads to decrease in peripheral occur.
resistance • Clofibrate (Atromid), has higher toxicity which limits its
• Side Effects - Drowsiness, fatigue, sexual dysfunction, use.
Orthostatic Hypotension o Nausea, Flu-like symptoms, Agranulocytosis
Vasodilators Statins (reductase inhibitors)
• Hydralazine (Apressoline) • Lovastatin (Mevacor), Simvastatin (Zocor), Pravastatin
• Dilate peripheral blood vessels by directly relaxing (Pravachol), Fluvastatin (Lescol)
vascular smooth muscle o Interfere with the liver's ability to make cholesterol.
• Usually used in combination with other meds, because o Cause abnormal liver function in about two percent
they lead to sodium and fluid retention and cause reflex of the patients. Small incidence of muscle
cardiac stimulation inflammation
• Side effects - Headache, dizziness, tachycardia, fatigue, o Fewer reports of side effects with Pravastatin
edema o Take with meals and avoid alcohol
Calcium Antagonists Circulatory Problems
• Amlodipine besylate (Norvasc); Diltiazem (Cardizem); • Chronic circulatory problems lead to the following
Verapamil (Calan, Isoptin) Nifedipine (Procardia) changes
• Inhibit influx of calcium into muscle cells which acts to o Dry skin
reduce arterial spasms and promote vasodilatation o Dry brittle hair
• Side Effects - dizziness, fatigue, nausea, headache, o Loss of body hair
edema o Thick brittle nails (particularly toe nails)
Renin-Angiotensin - Aldosterone System o Increased capillary fill times (over 2 seconds)
 o Capillary filling is a indicator of peripheral circulatory • May occur in both legs and often continues to worsen
status over time.
• Some people complain only of weakness in the legs when
Peripheral Vascular Disease (PVD) walking or a feeling of "tiredness" in the buttocks.
• characterized by lack of blood flow and oxygen to tissues • Impotence is an occasional complaint in men.
• Usually occurs as a result of accumulated fatty deposits • Pain at rest is uncommon.
• Most prevalent in geriatric clients, however, prevention of Arterial PVD
PVD needs to start at birth • Extremity has decreased oxygenation, may be pale, cool
• Smoking makes PVD worse, by constricting the blood or cyanotic
vessels and increasing the force of flow (increased B/P) • Sharp pain, may increase with activity
• Can be divided into Arterial and Venous PVD • Arterial insufficiency ulcers are usually dry, pale, and may
Assessment of PVD have necrotic tissue
• Check peripheral pulses - know names and location of • To treat, need to increase blood flow to extremity
femoral, brachial, radial, popliteal, posterior tibial and o place foot lower than heart
dorsalis pedis o Avoid tight bandages and stockings
• Check below the site of suspected occlusion o Need meticulous foot care to avoid ulcers
• If can’t palpate a pulse, use a doppler Gangrene Secondary to Arterial Occlusive Disease
• Check capillary filling Medications for Arterial PVD
• Check warmth and color by comparing extremities to • Need to dilate peripheral arteries
each other • Pentoxifylline (Trental) is drug of choice for PVD
• Arterial PVD Venous PVD - • Take Trental with meals
Arterial vs Venous PVD • People who are sensitive to caffeine or theophyllin can’t
• Arterial take Trental
• Cool • Side effects Dizziness, nervousness, agitation
• pale extremity Surgical Treatment of Arterial Peripheral Disease -
• decreased pulses Bypass Graft
• sharp pains • Frequently used to treat blockages of larger artery
• pain increases with activity or elevation • Most common - Femoral-Popliteal Bypass Graft
• Dry ulcer formation with necrotic tissue • Post op - Keep leg fairly straight, don’t elevate, monitor
• Venous for bleeding, check peripheral pulses and skin
• Warm temperature, bedrest, calf-pumps to prevent clot
• Flushed formation
• Edematous Venous PVD
• Aching pain • In venous PVD, extremity has too much blood (can’t get
• pain increases when legs dependent back to the heart)
• Weeping venous ulcers • Extremity is warm, flushed, edematous
Arterial PVD • Aching pain, gets worse with standing
• Obstruction or constriction of arterial flow, usually in the • Need to facilitate blood return
leg o Elevate legs
• Intermittent claudication is an early sign of arterial PVD o Use teds or ace wraps
(pain in calf or leg brought on by exercise and relieved by • Venous stasis ulcers tend to be pink or red and produce
rest) lots of drainage
• Later signs are loss of hair on leg and dorsum of foot, Vericose Veins
muscle atrophy and arterial ulcers • Venous defect allows pooling, particularly in peripheral
Thromboangitis Obliterans (Buerger’s Disease) veins with little support
• Obstructive inflammatory process of the peripheral • Tend to run in families
arteries • Peripheral veins can be removed (stripped)
o Mostly male smokers 20-40 years old • Post op, elevate legs when sitting. Avoid long periods of
o More often in Semitic and Oriental standing. Keep elastic bandages tight and wrinkle free,
o Causes Intermittent claudication, numbness and monitor for bleeding, check pedal pulses and edema
tingling, thrombophlebitis Deep Vein Thrombophlebitis (DVT)
o May require amputation of affected digits • Slowed blood flow allows a clot to form.
Raynaud’s Phenomenon • May have altered clotting mechanisms
• Episodes of arterial spasm - usually in hands • Patients on bedrest have higher risk of DVT
• primarily in women 20-40 • People who wear tight knee socks or have pillows under
• Cold, numbness, paleness, and pain in one or more knee (compresses popliteal) have increased risk of DVT
fingers or toes • To prevent DVT while on bedrest - do calf pumps
• Bilateral effects both hands and/or feet (dorsiflex and extend feet frequently)
• Smoking and Cold makes it worse • S/S of DVT - warm, red, edematous leg
• Intense redness and throbbing after spasm • May have positive Homan’s sign
• Tx with calcium antagonists, may require amputation • DVT can be silent, may be life threatening, and can lead
Arterial Embolism to embolism
• Blood clots (usual from heart) tend to lodge in bifurcation Treatment of DVT
of an artery, blocking blood flow • Bedrest may be needed during acute phase
• Symptoms depend on size and location • Avoid standing still and sitting
o Abrupt onset of pain, burning, loss of distal pulses, • Check pulse distal to site of thrombosis
cold pale extremity • Assess edema, measure calf circumference
• Tx with bedrest, and anticoagulants or fibrinolytics • Don’t massage leg
o Surgery - embolectomy or endarterectomy within 6- • Elevate leg on pillows, use warm moist heat
10 hours • Ted hose or other compression
Intermittent Claudication • Watch for signs of pulmonary embolism
• Due to narrowing or blockage of the arteries • NSAIDs for pain and inflammation
(Atherosclerosis or arteriosclerosis Obliterans - peripheral Anticoagulant Therapy
vascular disease). • Heparin
• Frequently one of the first signs of cardiovascular disease o Give heparin with smallest needle possible in SUB-Q
• Pain in legs that occurs with exercise. Pain is relieved by tissue of abdomen. Don’t aspirate, don’t massage.
rest. Avoid 1 inch area around umbilicus
 o Monitor PTT time • Provides evaluation of how the heart functions during
o With all anticoagulants, hematest stools for blood exercise/stress
• For long term treatment - Warfarin (Coumadin) orally • Patient with suspected exercised induced arrhythmia or
o Monitor PT time (coumadin interferes with chest pain is attached to a telemetry unit
Prothrombin formation) Watch for bruising • Patient is placed on a treadmill and walks uphill until
Surgical Treatment of DVT chest pain/arrhythmia's are reproduced or maximal
• Large clots can be surgically removed desired cardiac output is reached (calculated for each
• For patient with high risk of repeated DVT, a Greenfield person)
vena cava filter can be used • Monitored by EKG the entire time
• Filter catches clots before they can migrate to the lungs, • Heart rate and B/P go up and lead to increased cardiac
heart or brain output without pain in healthy individual
• Used in conjuction with heparin or coumadin therapy Lab values
Duplex Ultrasound/Ultrasonography • Triglycerides - overall fat content of serum
• Examines the blood flow in the major arteries and veins in • Cholesterol - overall cholesterol level - Goal is to keep it
the arms and legs with the use of ultrasound and at or below 200
ultrasonography, which provides a visual image. o HDL High density lipoproteins - “good” cholesterol,
• Done in the ultrasound or radiology department. may act to protect blood vessels from damage
• Veins: A water-soluble gel is placed on the transducer and o LDL Low density lipoprotein “bad” cholesterol, acts
placed over vein as a “glue” to clog vessels
• Arteries: Blood pressure cuffs will be put around the Nitroglycerin - Drug of Choice for Angina
thigh, calf, and ankle to examine the legs. • Relaxes the smooth muscle tissue of the vascular system
Ateriogram/Venogram • Acts to dilate coronary arteries
• Injection of radiopaque dye into the femoral artery or vein • Increases blood flow to cardiac tissue
to determine where and how severe obstructions are • Increases oxygenation of cardiac muscle
• Determine if patient has previous allergies, particularly to • Common Side Effects
procedure dyes, iodine, shellfish or strawberries o headache, hypotension, dizziness
• After procedure, keep leg straight, apply pressure Application of Nitroglycerin
dressing to site. Watch site for bleeding. Monitor pulses • Sublingual - for acute chest pain. May take one tab under
distal to site. tongue every 5 minutes until pain is relieved (up to 3
tabs). If not relieved, call MD
Coronary Artery Disease (CAD) • Patches (Nitropatch/Nitrodur) - Remove old patch, apply
• Coronary arteries narrowed or completely blocked by new one to any clean, intact, non-hairy part of the body
fatty plaques (atherosclerosis). • Paste - apply the correct amount of paste to the
• inadequate blood supply to the heart muscle supplied by manufactures paper, then apply paper “patch” to
that artery. patient’s skin as above
• Often results in death of the involved area Other Meds to treat Angina
• of heart muscle. This is called a myocardial infarction • Calcium Channel Blockers
("MI") or heart attack. o Nifedipine (Procardia) - dilates both coronary arteries and
Myocardial Ischemia peripheral arterioles (decreases B/P)
• Myocardial Ischemia - less severe reduction in blood o Can be swallowed whole, or puncture capsule with a
supply where the heart muscle receives just enough needle and give contents sub-lingual
blood to stay alive. o Take Calcium Channel Blockers on empty stomach
• Either ischemia (poor blood supply) or infarction (virtually • Beta Blockers
no blood supply) can cause cardiac symptoms such as o Atenolol (Tenormin) and Nadolol (Corgard) Acts to
chest pain or shortness of breath. suppress renin-angiotensin-aldosterone system
• Angina is the name given to chest, neck, jaw, back, o Take Beta-blockers with food
shoulder or arm pain caused by heart muscle that is • Dipyridamole (Persantine) - selectively dilates coronary
ischemic (not receiving enough blood supply). arteries (does not affect B/P)
Angina Pectoris Echocardiogram
• Sharp, diffuse chest pain in response to insufficient • Echocardiogram
oxygen to cardiac muscle o Ultrasound of heart
• Brought on by exertion, cold, stress, over-eating o can view structures and movement
• Usually relieved by rest o Similar to fetal ultrasounds, painless, need to use
• Caused by insufficient blood flow through the coronary transducer gel
arteries, which leads to decreased oxygenation of cardiac o No real patient prep needed
tissue Transesophageal Echocardiography
• Deoxygenation of tissue leads to build up of lactic acid, • Uses probe to pass ultrasound transducer into the
and if continued, leads to ischemia esophagus
• Goal is to control Angina so patient can do ADL’s without • more detail is possible
chest pain • Keep pt NPO 4 hours before. Topical spray or gargle to
Diagnostic Tests depress gag reflex. Conscious sedation may be used.
• 12 Lead EKG or ECG • Keep pt NPO afterwards till gag reflex returns
o records electrical conduction of heart Coronary Angiograms /Veinograms
o Gives information about excitation of the • Coronary Angiography
myocardium o injection of radiopaque dye into the right and left
o Useful for detecting arrhymias coronary arteries
o Can detect evidence of MI o Helps to confirm the presence and /or degree of
o Telemetry - Three lead EKG used to monitor cardiac coronary artery stenosis, and to determine the
patients in bed amount of collateral circulation available
• Holter monitor • Ventriculography
o Similar to telemetry, but records results for 24 hours. o injection of dye into left ventricle to visualize
Can be used on outpatient basis, to detect ventricular wall, mitral valve and ventricular septum
arrthymia's which occur as a result of something the function
person does at home Cardiac Catheterization
Stress Test • Insertion of catheter directly into the right and/or left
• A number of stress tests are used, but the most common ventricle to get info about ventricular function
is the exercise stress test
• Gives most valuable and detailed information about • Uses radioactive tracer substances
structure and function of heart • Thallium imaging
o Patency of coronary arteries o Dye is injected into patient’s antecubital vein.
o Condition of myocardium o Imaging done 4-10 minutes after injection
o Status of collateral circulation o Necrotic or ischemic tissue will appear as “cold
• Relatively high risk compared to other cardiac tests spots” on this scan
Patient Preparation o Often done with the patient at rest and then during
• Explain expected sensations - flushing, nausea, warmth an exercise test
when dye injected Coronary Artery Bypass Graft (CABG)
• May have chest pain or dyspnea when catheter is in heart • CABG to relieve blockages of the coronary arteries
• Risks are hemorrhage, MI, CVA, dysrhythmia and even • Open Chest and long incision along the inside of the lower
death (most risk is from cardiac cath) leg.
• Pt is NPO 4 hours before, procedure lasts 1-3 hours, lying • The leg vein is sewn in above and below the blockage in
on x-ray table in cold room the coronary
• Post Cath, Pressure dressing to site, monitor for bleeding, • Heart-lung bypass machine is used to re-route the blood
Check peripheral pulses below site from the heart while the surgery is being done
PTCA Percutaneous Transluminal Coronary Angioplasty Indications for CABG
• In PTCA, a catheter carrying a small balloon is inserted • Unsuccessful Angioplasty
into coronary heart arteries through the patient's skin. • Blockage of the left main coronary artery
• The balloon is then repeatedly inflated and deflated to • > 50% diameter stenosis
compress the blockage that obstructs blood flow to the • Concomitant valve damage and any coronary artery
heart. disease
Post-Procedure Care • Unstable Angina and/or ischemia that cannot be treated
• Always assess for adequate peripheral circulation below with PTCA
the site of arterial access • Three-vessel disease of the coronary arteries regardless
• Assess site for bleeding, a pressure dressing will be in of angina or ischemia
place for at least 8 hours. CHF
• Keep affected extremity straight and still • Right Sided Failure - Complication of COPD
• Elevate HOB no more than 90 degrees o Pitting peripheral Edema
• Push fluids to get rid of dye (nephrotoxic) o Liver enlargement and right upper quadrant pain
• Assess heart rate and B/P o Ascities
• Monitor I&O for 24 hours o Distended neck veins (JVD)
Myocardial Infarction (MI) • Left Sided Failure - Complication of Hypertension
• Usually caused by the sudden occlusion of a coronary o Dyspnea - early sign
artery. o Cough
• The plaque in the artery takes years or decades to form, o Orthopnea
but the final event of formation of a blood clot (or o S 3 heart sound
thrombus) happens in a few minutes or hours. o Paroxysmal nocturnal dyspnea (PND)
• In general MIs occur at any time, although they are a bit o Fatigue
more common in the morning o Crackles in lungs - starts at bases and works upward
Symptoms of MI Congestive Heart Failure (CHF)
• Classical symptoms of a heart attack include heavy or • Most common hospital discharge diagnosis in persons
crushing chest pain, shortness of breath (dyspnea) and over age 65.
sweating (diaphoresis). • The National Heart, Lung and Blood Institute estimates
• Less common are nausea, profound fatigue and a feeling two million Americans are afflicted with CHF and 400,000
of impending doom. new cases of CHF are diagnosed every year.
• If you become short of breath and break out in a cold CHF
sweat while sitting in a cool room you should be more • CHF usually starts with L sided failure, S/S of pulmonary
concerned than if these symptoms happen while walking congestion and pulmonary edema
up a steep hill in July. • Chronic CHF leads to ventricular dilation, hypertrophy and
• Many heart attacks come without classical symptoms or tachycardia
even without any symptoms at all (silent MI). • Heart becomes enlarged and weaker
• Ischemic myocardium is electrically unstable • PMI may be located at 6th intercostal space and lateral to
o arrhythmia's including lethal ventricular ventricular the MCL
fibrillation and ventricular tachycardia. • Clubbing of fingers from chronic hypoxia
o Infarcts which interfere with the cardiac conduction Treatment of CHF
system may lead to heart block or conduction • Need to decrease fluid volume and reduce cardiac
defects. workload
• Dead or scarred myocardium is unable to contract. o Bedrest or reduced activity to conserve energy
• Damage may be reversible if thrombolytic therapy is in o Oxygen if hypoxia is present
time. o Assist to cough up secretions q 2 hours
• Leads to congestive heart failure in about 40-50% of o Elevate HOB, Do not raise feet, even if edematous
patients with acute MI. o Diuretics
• In extreme cases, patients may present with cardiogenic o Digitalis
shock o Fluid restrictions
Cardiac Isoenzymes o Daily weight
• Creatinine Kinase (CK) o I&O
o Normals < 2.5U F, < 4.3U Male o CHF Diet
o Elevations indicate possible brain, heart, or muscle CHF Diet -Low Cholesterol, Low Sodium, Low Fat Diet, -
injury or necrosis To Return B/P to Normal
• CK-MB (0-5% of total CK) • Avoid the following foods
o Elevations with myocardial injury • Red meats, Cheese (except cottage cheese and other low
• Lactic Dehydrogenase (LDH) fat), Egg yolks, Shellfish (too much cholesterol)
o LDH1/LDH2 LDH 1 higher than LDH2 with myocardial • Cold cuts, ham, bacon, sausage, hot-dogs, chips, (sodium
damage and fat)
o Most sensitive cardiac enzyme indicator of MI • Most soups, sodas, and canned vegetables (sodium)
Nuclear Imaging • Antacids and other meds high in sodium
Alternatives
• Use lite salt (K+Cl)
• Use salt alternatives - Mrs. Dash and others
• Bake and season meats with vinegar or lemon juice
instead of butter and salt
• Use egg beaters, low sodium soups, saltless pretzels and
low sodium crackers.
• Try a baked sweet potato with a little brown sugar
• Read all labels
Low Calorie
• Watch for “Hidden” calories in drinks (milk, juice, alcohol,
soda)
• Watch the fat, sodium content and calorie content in
frozen dinners, mixes, and canned items
• Avoid High carbohydrate foods (breads, pastas, cakes)
• Avoid most fast foods
• Read the labels. Check out nutritional content
Digoxin (Lanoxin) - Cardiac Glycoside
• Cardiac Glycosides act to stimulate myocardial
contraction
• Makes heart beat slower, more regular, and more
powerful, which leads to increased cardiac output and
increased blood flow to the kidneys
• Can be given PO or IV
• Take Apical pulse for a full minute before administration,
noting rate and rhythm.
• If rate is below 60, above 110, or If rhythm is very
irregular (compared to patient’s baseline, hold med and
call MD
• Dig has a narrow therapeutic window -Watch serum
levels (0.8-2.0 ng/ml)
• Don’t take with antacids - interfere with absorption
• Persons with hypokalemia are more likely to become
digtoxic so patient needs to eat foods high in potassium
(know what these are)
• Patients on Lasix and Dig - watch for toxicity
• Antibiotics and/or calcium channel blockers can interact
with Digoxin causing increased risk for toxicity
• Digitalization - when first starting on Dig, given higher
dose - called a loading dose or a digitizing dose
• After patient responds, dose is lowered to a Maintenance
dose
• Maintenance dose is one which allows heart to function
without toxic symptoms
Signs and Symptoms of Digitalis Toxicity (serum levels
above 2.0 ng/ml)
• Cardiovascular
o Bradycardia or Tachycardia
o Bigeminy
o Ectopic beats
o Pulse deficit
• GI Effects*
o N/V
o Anorexia
o Diarrhea
o Abdominal Pain
• Neurological Effects
o Headache
o * Blurred, double or colored vision
o Confusion, irritability, restlessness, drowsiness
o Muscle weakness and cramps
• Kidney Failure, Liver Failure, Potassium Loss or Dig
Overdose can all cause Dig Toxicity
Rotating Tourniquets
• old technique used to decrease venous return to the
heart by trapping fluid in extremities
• temporarily reduces heart workload by reducing fluid
volume heart must pump around body
• B/P cuffs are used on three extremities at a time, and are
rotated every 15 minutes in a clockwise fashion.
(Rotating tourniquet machine does this automatically)
• Make sure patient has a peripheral pulse in affected
areas