Cardiovascular System ➢ CO= Stroke Vol x HR

Heart: The human heart is an organ that pumps blood ➢ CO= 70 mlsx 70 bpm
throughout the body via the circulatory system, supplying ➢ CO= 4900 mls (Apprx 5L)
oxygen and nutrients to the tissues and removing carbon 2. Stroke Volume (SV)
dioxide and other wastes. Amount of blood ejected by the left ventricle into the
Heart wall: 3 Layers of the Heart aorta per beat (apprx 70 mls)
1. Epicardium: Outer Layer
2. Myocardium: Cardiac Muscle Stroke Volume is determined by:
3. Endocardium: Endothelium 1. Preload:
Enclosed by Pericardium: 2 Layers • Degree of myocardial fiber stretch before
1. Viceral pericardium contraction
2. Parietal pericardium • Related to the volume of distending the ventricles
Chambers at the end of diastole
Valves of the Heart: 2 types • Determine by the amount of venous return
A. AV: Artrioventricular valve 2. Frank- Starling Law of the Heart:
1. Tricuspid • Conceptualizes that the greater the myocardial
2. Bicuspid(mitral) stretch, with in physiologic limits, the more forceful
B. Semilunar Valve the ventricular contraction, thereby increasing
1. Aortic stroke volume
2. Pulmonic 3. After load:
Open during ventricular systole and diastole • Afterload, also known as the systemic vascular
Chordatendinae cordis: resistance (SVR), is the amount of resistance the
1. Anchored to ventricular wall by papillary muscles heart must overcome to open the aortic valve and
2. Supports the AV valve during ventricular systole to push the blood volume out into the systemic
prevent prolapse circulation.

Autonomic Influence on Cardiac Activity

Autonomic Nervous System:
➢ Influences myocardial contractility and rate
1. Sympathetic Nervous System
2. Parasympathetic Nervous System
Coronary Arteries
Two main Coronary arteries Baroreceptors:
1. Left Coronary Artery
1. Circumflex Artery
2. Left Anterior Descending Artery
2. Right Coronary Artery
1. Right Artery
2. Right Ventricle

Carotid and aortic bodies

• Pressure sensitive structures.
In Decrease BP
➢ Reflex in SNS response
Conduction System o Increase pulse rate
o Increase contractility
o Vasoconstriction
o Increases BP
Chemoreceptors – special nerve cells or receptors that
sense changes in the chemical composition of the blood.
Medulla Oblongata
Major chemoreceptor of the heart
➢ Decrease in pH or pa02 lead to SNS response = in:
• Tachycardia
• Vasoconstriction
• And increase myocardial contractility
➢ Decrease in paC02 and increase pH lead to passive
vasodilation.
Cardiac Index
➢ an accurate indicator of tissue perfusion. Represents
Cardiac Cycle – note cardiac output in terms of liters per minute per square
Terms: meter of the body surface area, N:2.4 to 4.0L/min
1. Cardiac Output Physiologic Changes in the Heart with Aging
➢ The volume of blood ejected from the left 1. Decrease myocardial contractility. Reduce cardiac
ventricle into the aorta per minute reserve.
2. General thickening of endocardium and valves.
3. Conducting fibers are replaced by fibrous tissue. this 6. Serum Tryglycerides
reduces the effectiveness of pacemaker cells, • Fasting 10-12 hours
decreases conductivity and leads to dysrythmias • N: 140-200mg/dL
Assessment of the Client with Cardiovascular Disorder 7. Blood Cultures
Nursing History • Infectious disease of the heart (e.g. Pericarditis)
Risk Factors of CVD • Caution is taken to prevent contamination of
Non-Modifiable the specimen. To Ensure accuracy of result
• Age 8. Serum Enzyme Studies
• Heredity a. Aspartate Amino Transferase (AST)
• Gender • SGOT
• Race • Elevated=tissue necrosis
Modifiable • Most cardiac specific enzyme
• Stress • Accurate indicator of myocardial damage
• Diet • NoRa
• Exercise • M: 50-325 mu. /ml
• Smoking • F: 50-250 mu. /ml
• Alcohol b. Lactic Dehydrogenase (LDH)
• HPN • LDH isoenzymes, LDH1 is the most sensitive
• Hyperlipedimia indicator of myocardial damage
• DM 9. Hydroxybutyrate Dehyhydrogenase (HBD)
• Obesity • Elevation is always accompanied by LDH
• Personality Type or Behavioral • Detects Silent MI,remains elevated elevate
• Contraceptive Pills • NoRa: 140 – 350 u
Physical Examination 10. Troponin
Inspection • Most specific laboratory test to detect MI
• Skin Color • Troponin has three components I, C, T
• NVD 11. Urinalysis
• Respiration • CVD related to renal function
• PMI • Albuminuria
• Peripheral Edema • Myoglobinuria
Palpation 12. Blood Uric Acid (BUA)
• Peripheral Pulse • This test reflects adequacy of renal tissue
• Apical Pulse perfusion thereby glomerular filtration
Percussion metabolites
• Pulmonary Edema • NoRa: 2.5-8 mg/dl
Auscultation: Heart Sound 13. Serologic Test
• S1 (“lubb’) • VDRL helps indicates presence of syphilis, this
• S2(“dub”) disease involves development of aortic disorder
• S3 • Serum Electrolytes:
• S4 • Electrolytes affects cardiac contractility,
• Murmurs specifically Na, K Ca
• Pericardial Friction Rub • NoRA ranges are follows:
Common Manifestation of CVD 1. Na 135-145 mEq/L
1. Dyspnea: SOB 2. K 3.5-4-5 mEq/L
a. Dyspnea on Exertion 3. Ca 4.5 – 5.5 mEq/L or 8.6-10 mg/dL
b. Orthopnea 14. Electrocardiography (ECG, EKG)
c. Paroxysmal Nocturnal Dyspnea • Graphical recording of the electrical activities of
2. Chest Pain the heart.
3. Edema • Painless (no electrocution or shock)
4. Syncope • Waves, complexes and intervals.
5. Palpitations – occurs during mild exertion may • P wave depolarization of the atria.0.04 t0 0.11
indicate: heart failure, anemia, thyrotoxicosis secs
6. Fatigue • PR interval. Time of transmission from the SA
Laboratory & Diagnostic Tests rt Cardiovascular Function node to the AV node.0.12 to 20 secs.
Laboratory Tests: • ST segment. Represents the plateau phase of
1. Complete Blood Count the action potential
2. Erythrocyte Sedimentation Rate • T wave: Ventricular repolarization
Normal Range: Common ECG changes
M: 15-20 mm/hr a. Hypokalemia:
F: 20-30 mm/hr • U-wave
3. Blood Coagulation Test • Depressed ST segment
• Prothrombin Time (PT,Pro Time) • Short T wave
Normal range is 11-16 secs. b. Hyperkalemia
• Partial Thromboplastine Time (PTT) • Prolong QRS Complex
• Activated Partial Thromboplastine Time (APTT) • Elevated ST segment
4. Blood Urea Nitrogen (BUN) • Peaked T wave
• N:10-20 mg/dL c. MI
5. Blood Lipids • Elevated ST segment
• Serum Cholesterol • Interted T wave
• NPO 10-12 hours • Pathologic Q wave
• N: 150 to 200 mg/dL 15. Holter Monitoring
 • Continues (24 hours) monitoring ECG Monitoring 7. Monitor extremities for color, temperature, pulse and
• The portable monitoring system: telemetry unit sensation. Impaired circulation in the affected
Invasive hemodynamic monitoring extremities is manifested by pallor or cyanosis, cold
16. Central Venous Pressure skin, diminished pulse or pulselessness, and numbness
• Monitors the pressure within the right atrium or tingling sensation
17. Pulmonary Artery pressure (PAP) and Pulmonary Angiography/Arteriography
Capillary Wedge Pressure • Involves introduction of contrast medium into the
• Swan-Ganz catheter is inserted is inserted via vascular system to outline the heart and blood
antecubital vein into the right side of the heart vessels.
and is floated into the coronary artery. It reflects • May be done during cardiac catheterization
pressure in the left heart. LHCHF may lead to • Nursing interventions are similar to that cardiac
pulmonary Edema. catheterization
• Observe for hypotension after the procedure
Sonic Studies because the contrast medium used in angiography
1. Echocardiography may cause profound diuretic effects.
• Uses UTZ to assess cardiac structure Magnetic Resonance Imaging
• No special preparation is required • Strong magnetic field and radio waves are used to
• Painless (30-60 minutes) detect and define differences between healthy and
2. Transesophageal Echocardiography (TEE) disease.
• Allows ultrasonic imaging of the cardiac structures • MRI can actually show the heart beating and the
and great vessels via esophagus blood flowing in any direction. It can image over
3. Phonocardiography three spatial dimensions and overtime.
• Involves the use of electrically recorded amplified • It is used for examination of the aorta, detection of
cardiac out comes. tumors, cardiomyopathties and paricardiac disease.
• It is helpful in assessing the exact timing and Nursing Intervention:
characteristics of murmurs and extra heart sounds • Secure written consent. Consent is required for
diagnostic test that involve use of contrast medium
Laboratory and Diagnostic Tests rt Cardiovascular Function MRI, gandolinium is commonly used.
Stress Testing or Exercise Testing: • Inform the procedure may last 45-60 minutes. The
• ECG is monitored during exercise during exercise on client is less anxious when he knows what to expect.
a treadmill or a cycle-like device. • Assess for claustrophobia
• The purpose of stress test are as follows: • Remove metal items
• Identify ischemic heart disease • Instruct the client MRI unit makes a loud, knowing
• Evaluate patient with chest pain noise.
• Evaluate effectiveness of therapy • CAUTION: clients with pace makers, prosthetic valves
• Develop individual fitness program during are recently implanted clips or wires are not available
rehabilitation. for MRI scans.
Radiologic Tests:
Chest Roentgenograms (X-Rays)
• To determine overall size and configuration of the
heart and size of the cardiac chamber
Cardiac Fluoroscopy
• Facilitates observation of the heart from varying
views while the heart is in motion
Cardiac Catheterization
• Assess oxygen levels, pulmonary blood flow,
cardiac, output, heart structures
1. RS Heart Catheterization: insertion of catheter
via cut down into a large vein, e.g. medical
cubital or brachial vein.
2. LS Heart Catheterization: passing a catheter via
brachial and femoral artery.
Nursing Interventions
Before the Procedure
1. Provide Psychological Support, Allay Anxiety
2. Assess for allergy to iodine/ seafoods (Contrast
medium).
3. Obtain baseline VS
4. NPO b4 the procedure (N and V)
5. Have client void, Promote Comfort
6. Sedate
7. Mark distal pulse
After the procedure:
1. Bed rest until VS is stable
2. Monitor VS (peripheral pulse)
3. Monitor ECG, note for dysrhythmias
4. Apply pressure dressing and small sand bag or ice
over the puncture wound site. To prevent bleeding
5. immobilize affected extremity in extension
6. Do not elevate HOB more than 30 degrees if femoral
site was used: Acute Hip Flexion (Cir Imp)
Cardiovascular Disorders Effects
Plaques begin to Lipids are engulfed by • Direct relaxing effect on vascular smooth muscle,
form from cells cells (foam cells) &
Risk factors
which imbed into the smooth muscle cells resulting in generalized vasodilation
endothelium develop. • Decrease peripheral resistance & systolic pressure
• Decrease myocardial oxygen demand by
Oxidized LDL Coronary
Non-modifiable
attracts monocytes & Atherosclerotic decreasing heart rate, BP, myocardial
& modifiable
macrophages to site heart disease contractility, and calcium output.
Beta Adrenergic Blockers
Non-specific Lipids and 1. Propranolol (Inderal)
Decrease Coronary
injury to arterial platelets assimilate tissue perfusion
wall into area 2. Metoprolol (Lopressor)
3. Nadolol (Nadolol)
Desquamation
Increase permeability/ Coronary
4. Atenolol (Tenormin)
of endotheial 5. Pindolol (Visken)
Adhesion Molecules Ischemia
lining
6. Esmolol (Breviblock)
This leads to: Effects
✓ Decrease Myocardial Oxygenation • Decrease myocardial oxygen demand by
✓ Angina Pectoris decreasing heart rate, BP, myocardial
✓ Myocardial Infarction contractility, and calcium output.
Self-Management Education Guide: Decrease Risk for Calcium Channel Blockers
Coronary Heart Disease • Verapamil (Isoptin,Calan)
✓ Daily management of HPN • Nifedipine (Procardia, Adalat,Calcibloc)
✓ Stop smoking • Diltiazem (Cardizem)
✓ Avoid passive smokers • Amlodipine (Norvasc)
✓ If overweight? • Nicardipine (Cardene)
✓ Follow a healthy heart diet Effects
✓ Reduce Stress • Inhibit calcium ion transportation into myocardial
✓ Allow adequate time for rest and relaxation cells to depress inotropic and chronotropic
✓ These are life-long life-style changes activity, decreasing cardiac force workload
Angina Pectoris • Has a vasodilation effect
• Transient Chest pain caused by insufficient blood flow • It reduces coronary vasospasm
to the myocardium resulting in myocardial ischemia Other meds
• Results when myocardial oxygen demand exceeds Platelet Aggregation Inhibitors
myocardial oxygen supply • ASA
Pathophysiology • Diypiridamole (persantin)
Diminished • Clopidrogel (Plavix)
Reduced Coronary
DAAPHT
Tissue Perfusion
Myocardial • Ticlopidine
Oxygenation Inhibits platelet aggregation
Anticoagulants
• Heparin Sodium: inactivates thrombin and other
Chest Pain
Increase Lactic Anaerobic clotting factors inhibiting conversion of fibrogen to
Acid production Metabolism fibrin, fibrin clot formation is prevented
• Warfarin Na
• Dicumarol: inhibits hepatic synthesis of Vitamin K
DM
Manifestations Nursing Intervention for Drug Therapy
Acute Regurgitation
• Pain Nitroglycerine
Atherosclerosis
• Pallor • Assume sitting or supine position when taking the drug
P
• Diaphoresis • Take maximum dose of 3 doses at 5 minutes interval
Hypertension
• Dyspnea • Practice gradual change of position.
Thromboangiitis obliterans
• Faintness • If taken sublingual, the medication causes burning or
• Palpitations stinging sensation under the tongue: potent
• Dizziness • Sublingual route: onset of 1-2 minutes duration of
• Digestive disturbances action is 30 minutes
• Angina: PQRST pain Assessment • Offers sips of water before giving nitrates:
Types of Angina • Instruct client to avoid drinking alcohol
1. Stable Angina • Transdermal patch: 1 a day: morning, rotation at
2. Unstable Angina chest wall, remove path at night to prevent
3. Variant Angina tolerance.
4. Nocturnal Angina • Evaluate effectiveness: relief chest pain
5. Angina Decubitus • Store in cool dry place; use dark/amber colored air
6. Intractable Angina tight container. Do not refrigerate it may destroy by
7. Post Infarction Angina heat light or moisture.
Precipitating Events of Angina Pectoris • Change stock every 3 months
1. Exertion • Observe for side effects: head ache, flushed face,
2. Emotions dizziness, faintness, tachycardia. --first few doses do
3. Eating heavy meals not discontinue.
4. Environment Beta adrenergic blockers
Pharmacological Management: • Assess pulse rate before administration of the drug:
Vasodilators: • Administer food to prevent GI upset
• Nitroglycerine • Do not administer Inderal (Propranolol) to asthma.
• Amyl Nitrate • Do propranolol not administer with px with DM.
• Isosorbide • Give extra caution with client with heart failure.
 • SE: nausea, vomiting, mental depression, mild • Nitroglycerine before exercise
diarrhea fatigue and impotence. • Increase intent of exercise gradually
• Antidote for beta blocker poisoning is glucagon. 4. Activity
Calcium channel blockers: • Encouraged with in patients’ limitations
• Assess HR and BP • Promote relief of anxiety and feeling of well being
• Monitor hepatic and renal function • Facilitate reduction in present level of activity
• Administer 1 hour or 2 hours after meals. • Advise client to minimize emo out burst
• Antidote is glucagon • Encourage to maintain an optimistic outlook to
Platelet Aggregation Inhibitors help relieve the work of the heart
• Assess bleeding 5. Diet
• Avoid straining at stool • Low Na low fat low cholesterol and high fiber diet
• ASA with food • Avoid saturated fats
• ASA toxicity: • White meat without skin, fish
• ASA may cause bronchoconstriction observe for • Read labels
wheezing Myocardial Infarction
Treatment and Surgical Interventions ➢ Formation of necrotic areas within the myocardium.
• Percutaneous Trans Luminal Angioplasty ➢ Prolonged ischemia: lasting 35 to 45 mins produces an
• Mechanical Dilatation of the coronary vessel wall by irreversible cellular damage and necrosis of the
compressing the atheromatous plaque. myocardium
Pathophysiology

• Intravascular stenting
• Biologic stent is produces through coagulation of
collagen and elastin and other tissues in the vessel
wall by laser, photo coagulation or radio frequency-
induced heat

Manifestations
✓ Pain
✓ Anxiety and Apprehension
✓ Shock
✓ Fever
✓ Acute Pulmonary Edema
✓ Elevated CK-MB,
Laser therapy of the heart
✓ Elevated LDH AST
• Light Amplification by Stimulated Emission of
✓ Elevated Troponin Levels
Radiation
Collaborative Management
• It produces necrosis hemostasis coagulation and
Medications
evaporation of tissue
1. Analgesics:
Coronary Artery Bypass Graft
• Relieve Pain(priority)
• Reduces angina
• Morphine Sulfate
• Recommended for severe narrowing of one or more
• Nitroglycerine
branches of the coronary arteries exist
• Lidocaine
• Myocardial revascularization.
2. Thrombolytic therapy
• Disintegrate blood clots
• Streptokinase, urokinase, TPA
• Most crucial 3-6 hours after MI
3. Anticoagulant and anti-platelet.
4. Other meds
• BABA
• Diazepam (valium)
Treatment:
• Goal: Prevention of further tissue injury and infarct size
Nursing Intervention for Client with Angina
• Maximize perfusion and minimize tissue demands.
1. Promote comfort: relieving pain
• Cardiac monitoring-dysrhythmias
• Nitroglycerine
• PTCA
2. Promote Tissue Perfusion
• Diet: low Cholesterol and Low Na
• Avoid over fatigue
• Bedrest: 24-28 hours to decrease o2 demand
• Stop activity if chest pain is present
• Progressive ambulation unless cmplction occurred
3. Facilitate learning
Nursing Interventions
• Promote positive attitude and active participation
1. Promote oxygenation and Tissue perfusion
of the client and the family – Compliance
• Avoid fatigue ✓ ECG
• Promote activity and rest
• O2 therapy ✓ VS
• Slower activity with more rest.
• Semi-fowlers ✓ Effects of daily activities
• Plan regular activity program
• Monitor: ✓ Rate and rhythm of pulse
2. Promote rest and minimize unnecessary disturbance Collaborative Management
3. Promote comfort: Relieve pain 1. Monitor hourly output. LOC arrhythmias
• Morphine sulfate as prescribe 2. Provide psychosocial support
• Diazepam 3. Decrease pulmonary Edema
• CCU • Crackles and wheezing
• Provide psychosocial support to client and family • Note: dyspnea, cough, hemoptysis, orthopnea
4. Promote Activity • Monitor ABG and MAC
• Gradual • Administer drug therapy as ordered
• Monitor signs of dysrhythmias during activity 4. Utilize counter pulsation device
5. Promote Nutrition and Elimination • Mechanical cardiac assistance/ diastolic
• Small frequent feedings augmentation
• Low calorie, cholesterol and Na diet • Intra-aortic balloon catheter via femoral artery
• Avoid stimulants into aorta.
• Avoid very hot and cold foods Nursing Interventions
• Vagal stimulation that can lead to bradycardia 1. Perform hemodynamic monitoring: PAP, PCWP Intra-
and cardiac arrest arterial BP
• Use bedside commode 2. Oxygen therapy
• Administers stool softeners 3. Correct hypovolemia: IV fluids as ordered
6. Promoting relief of anxiety and feeling of well being Pharmacotherapy
7. Provide opportunity for client & family to explore • Vasodilators:
concerns & identify alternative methods if necessary. o Nitroglycerine, Nitroprusside, Phentolamine
8. Facilitate learning • Inotropic agents:
9. Teaching starts once free of pain & excessive anxiety. o Digitalis, Dopamine, Dobutamine
10. Promote positive attitude and active participation of • Diuretics: Furosemide
client and family. • Nabicarbonate
Teaching and Counseling 2. Thromboembolism
Self-Management and Education Guide • When platelets aggregate at area of necrosis, an
• Discontinue smoking attempt of body to repair tissue injury.
• Control HPN • Can lead to pulmonary embolism
• Low calorie, saturated fats and cholesterol and low Nursing Interventions
Na intake • Pharmocotherapy
• Progressive exercise ✓ Anticoagulants and Thrombolytics
• Take prescribe meds • Observe signs and symptoms of PE
• Sex: after 4-6 weeks from discharge. ✓ Dysnea
• Stress management techniques ✓ Chest pain
• Return to usual home activities, relationships and work ✓ Coughing
at earliest is beneficial ✓ Hemoptysis
Teaching guide on resumption of Sexual activity ✓ Rapid weak pulse
• Assume less fatigue position ✓ Pallor
• The non –Mi Partner takes the active role • Early ambulation
• Perform the activity in a cool, familiar environment 3. PERICARDITIS
• Take nitrates before • An inflammation of the pericardium which occurs
• Refrain from sexual activity during fatiguing day, after approximately 1-6 weeks after acute MI
eating a large meal, or drinking alcohol. • Antigen –antibody response
• If dyspnea, chest pain, dizziness, palpitations occur • Pericardial effusion/Cardiac tamponade
moderation should be observed, if symptoms, stop. • Constrictive pericarditis:
• Develop other means of sexual expression Manifestations:
Complication of MI ✓ Pain: anterior chest is relieved by upright and
• Dysrhythmias leaning position
• Cardiogenic Shock ✓ Pericardial friction rub: scratching, grating,
• Thromboembolism creaking sound
• Pericarditis ✓ Dyspnea
• Ruptured myocardium ✓ Fever, sweating, chills
• Ventricular aneurysm ✓ Joint pains
• CHF ✓ Arrhythmias
1. CARDIOGENIC SHOCK Nursing Interventions
• Results from profound left ventricular failure usually 1. Elevate HOB
from massive MI 2. Promote rest
• It results in low cardiac output>>>>>systemic 3. Administer prescribe pharmacotherapy:
Hypoperfusion • ASA and Corticosteroids
• High mortality rate 4. Cardiac tamponade: becks triad
• Jugular vein distention
• Muffles heart sounds
• Diminished or absent pulse
Management
• Pericardiocentesis – aspiration of blood in
pericardial sac.
4. Rupture of Myocardium
• It is common in transmural MI
o Necrosis of entire heart wall-from pericardium
to endocardium
• Causes immediate cardiac tamponade & death
5. Ventricular Aneurysm
• Involves thinning, ballooning and hypokinesis of
the left ventricular wall after a transmural MI.
• The dysfunctional area often becomes filled with
necrotic debris and clot sometimes is rimmed by
the calcium ring.
• The debris or clot may fragment and travel into
the systemic arterial circulation, thereby
immobilization.
• The aneurysm may rupture causing cardiac
tamponade and death
6. CHF/ HEART FAILURE
• “Congestive heart failure”
• “Congestive Cardiac Failure”
• “Pump Failure” – inability of heart to provide
sufficient pumping action to maintain blood flow
to meet demands of body.
2 Main Types
1. LSCHF
Symptoms
2. RSCHF
Causes: LSCHF RSCHF
Tachypnea Jugular vein distention
Cardiac
Rales/ crackles Pitting edema
a. HPN
Cyanosis Ascites
b. Arrythmias
Heart gallop Hepatomegaly
c. Valvular Heart Defects
Dyspnea on exertion Anasarca
d. Amyloidosis
Orthopnea Nocturia
e. Ischemic Heart Diseases
Paroxysmal nocturnal dyspnea Jaundice
f. Myocarditis Diagnosis
Non- Cardiac 1. No gold Standard Test
a. Alcohol 2. Framingham Criteria
b. Smoking 3. Boston Criteria
c. Obesity 4. Echocardiogram
d. Diabetes
5. CXR
e. Endocarditis 6. ECG
Pathophysiology Functional Classification (NYHA)
NO LIMITATION is experience in any activities:
Class
there are no symptoms from ordinary
I
activities

Slight MILD LIMITATION of activity; the patient

II
is comfortable at rest or with mild exertion

Marked LIMITATION of any activity: The

III
patient is comfortable only at rest

Any physical activity brings on discomfort

IV
and symptoms occur at rest
Framingham CRITERIA
• Requires simultaneous presence of 2+ of following
major criteria or 1 in conjunction with 2 of:
STAGES
1. Major
• Paroxysmal nocturnal dyspnea
• Neck vein distension
• Rales
• Cardiomegaly
• Acute pulmonary edema
• S3 gallop
• Increase intravenous pressure
• Hepatojugular reflux
• Weight loss: 4.5 Kg in 5 days
2. Minor
• Bilateral ankle edema
• Nocturnal cough
• Dyspnea on ordinary exertion
• Hepatomegaly
• Pleural effusion
• Decrease in vital capacity by 1/3 from
maximum recorded
• Tachycardia (> 120bpm)
Boston criteria
• No more than 4 points are allowed from each
category; hence the composite score (the sum of the
subtotal from each category) maximum 12
 • Definite Heart Failure: 8-12 points or irregularly, you may be given medication or
• Possible Heart Failure: 5-7 points electric shock therapy (cardioversion).
• Unlikely:4 points or less • Stomach and Blood Cleaning
Criterion Point Value • To treat toxicity, your doctor might pump your
stomach by inserting a tube down your throat. You
Category I: History might also be asked to take charcoal tablets to lower
the level of digitalis in your blood.
Rest dyspnea 4
• If your condition is extreme, your doctor may use a
Orthopnea 4 method called hemodialysis (blood filtering). This will
remove digitalis from your blood. Specific antibodies
PND 4 may also be prescribed to target and lower digitalis
levels in your body.
Dyspnea while walking on
2 Management CHF L/R
level area
1. Moderate physical activity, when symptoms are mild
Dyspnea while climbing 1 or moderate; bed rest when severe symptoms
2. Weight reduction: physical activity and diet
Category II: Physical Exam
modification
HR abnormality (1 pt if 91- 3. Monitor weight: parameter that can easily be
110bpm: 2 points if > 110 1 or 2 measure at home. Rapid increase is generally due to
bpm) fluid retention
4. Sodium restriction: precipitate or exacerbate heart
Jugular venous Elevation (2 failure
pts if > 6 cm H2O;3 pts if > 5. Fluid restriction: Px with CHF has diminished ability to
2 or 3
than 6cm H20 plus excrete free water load
hepatomegaly or edema 6. Behavior modification:
• Low Na diet
Lung Crackles (1 pt basilar 2
1 or 2 • Treatment of anemia
pts if more than basilar
7. Surgery:
Category III: Chest Radiography • Heart Transplant
8. Palliative and hospice care:
Alveolar Pulmonary Edema 4 • Make sure the patient has a medical “POWER
Interstitial Pulmonary Edema 3 OF ATTORNEY” and discussed his or her wishes
with this individual
Bilateral Pleural Effusion 3

Cardio Thoracic Ratio greater

3
than 0.50

Upper Zone Flow redistribution 2

Diagnostic tests
1. Imaging
• CXR
• ECG/EKG
• Echocardiography
2. Blood Test
• CBC
• Na and K
3. Measuring Liver function, Renal function
4. Body weight monitoring
Management Drugs: 3 D’s
1. Dilators
• ACE inhibitors
• Beta blockers
• Calcium Chanel Blockers
2. Diuretics
• Furosemide
3. Digitalis
• Digoxin
These are symptoms of digitalis toxicity:
✓ Confusion.
✓ Irregular pulse.
✓ Loss of appetite.
✓ Nausea, vomiting, diarrhea.
✓ Fast heartbeat.
✓ Vision changes (unusual), including blind spots,
blurred vision, changes in how colors look, or seeing
spots.
Management of Digitalis toxicity
• Breathing Assistance
• If you are having trouble breathing, breathing
machines may help. If your heart is beating too slowly