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Cardiac Notes

Medical Surgical Conditions and Treatment for the PTA (Southwest Tennessee
Community College)

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The Cardiovascular System - Normal Structure and Function

The Cardiac Basics
Cardiovascular System -
● Carries oxygenated blood and nutrients to the cells
● Transports CO2 and wastes from the cells
● A reservoir for blood coming from the tissues
● Review anatomy and physiology
Structure -
● Septum divides the heart vertically
● Four Chambers
○ Right and Left Atrium
○ Right and Left Ventricles
■ Thickness in chamber walls depends on the distance the blood is
transferred to.

Muscle Layers -
● Endocardium
○ Inner layer which lines the chambers
● Myocardium
○ Middle layer made of muscle
● Epicardium
○ Outer layer of visceral pericardium

Normal Blood Flow -

● Veins: carry blood back to the heart
● Arteries: take blood away from the heart

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Path of Blood Flow -

● Deoxygenated Blood
○ Superior & Inferior Vena Cava
○ Right Atrium
○ Tricuspid Valve
○ Right Ventricle
○ Pulmonary Semilunar Valve
○ Pulmonary Artery
○ Lungs
■ Oxygenation Occurs
● Oxygenated Blood
○ Pulmonary Vein
○ Left Atrium
○ Mitral Valve
○ Left Ventricle
○ Aortic Semilunar Valve
○ Aorta - Body
■ Body consumes oxygen, blood becomes deoxygenated and is carried
back
Valves -
● Purpose
○ Retain blood in one chamber until the next chamber is ready
○ Keeps blood flowing in same direction (one-way)
● Atrioventricular Valves
○ Mitral (LA/LV)
○ Tricuspid (RA/RV)
■ Valves close during Systole
■ Open during Diastole - fill up ventricles
● Semilunar Valves
○ Aortic
■ Separates LV from Aorta
○ Pulmonic

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■ Separates RV from Pulmonary Artery

● Close during Diastole - allow blood to fill up
● Open during Systole - allow blood to flow

Heart Sounds -
● S1 - first heart sound you hear
● Lub -
○ Mitral and Tricuspid Valves close
○ Ventricles contract at the same time - systole
○ Aortic and Pulmonic Valve open
● S2 - second sound you hear
● Dub -
○ Aortic and Pulmonic Valves close
○ Ventricles are filling with blood - diastole
○ Mitral and Tricuspid Valves open

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● S2 sounds are loudest at the base

● S1 sounds are loudest at the apex
Coronary Blood Flow -
● First to receive blood
● Left coronary artery
○ Supplies LA, LV, and Septum
● Right coronary artery
○ Supplies SA node, AV node, RA, RV
● Collateral circulation
○ Connections between two branches of arteries
○ Protective qualities
○ Develops collateral circulation in the presence of occlusions
○ Venous system parallels the arterial-form the coronary sinus
■ Created slowly, over time

Conduction System - pg 596

● SA Node
○ Area in heart that initiates electrical impulse
● AV Node
● Bundle of His
● Left and Right bundle branches
● Purkinje Fibers
○ When electrical impulse reaches here, heart will contract
● SA Node - 60-100 beats per minute (resting)
● AV Node - 40-60 beats per minute
● Bundle of His, Bundle Branches, Purkinje Fibers - 15-40 beats per minute

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Electrocardiogram -

● Allows us to see the conduction inside the heart

● P Wave - atria are contracting
● PR Interval - Top of P Wave to the R - Time it takes for the SA node to reach the AV node
● QRS Complex - represents ventricular contraction (systole)
● ST Interval - time it takes between reaching the T Wave - Diastole
● T Wave - indicate that diastole is occuring
Cardiac Innervation -
● Sympathetic nervous system (SNS) (Body’s Accelerator, Speeds Everything Up)
○ Increases in heart rate conduction and increase contractions
○ Epinephrine and Norepinephrine (Chemicals, Catakolemenes,
Neurotransmitters)
■ Increase the heart rate, conduction, and contractility
● Parasympathetic nervous system (PNS) (Body’s Breaks, Slows everything down)
○ Vagus nerve stimulation
■ Slow heart rate, slow conduction, and decreased strength of contractions
SNS vs PNS -

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Cardiac Cycle -
● Contraction and relaxation are one cycle - one heart beat
○ Electrical Activity
■ Electrical impulses sent through the heart
○ Mechanical Activity
■ Heat physically moves, it pumps
● Ventricles relax during diastole
○ Filling up with blood
● Ventricles contract during systole
○ Ventricles eject blood into the pulmonary artery and circulation
Cardiac Output -
● Volume of blood ejected by the heart each minute
○ Determined by stroke volume times heart rate
CO = HR x SV
● Stroke Volume is the amount of blood ejected with each contraction
● Normal Stroke volume is 60-100 mL
● Normal CO is 4-8L/min
● 50-70% is normal
Factors that Effect Stroke Volume -
● Preload
○ Amount of blood left in ventricle at end of diastole
○ Increased preload causes increased stroke volume and cardiac output
■ Caused by increased venous return and overhydration
● Contractility
○ Ability for cardiac muscle to shorten and contract
● Afterload
○ Amount of pressure that ventricles need to push against to eject blood-
determined by arterial pressure

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Myocardial Oxygen Consumption -

● 70-75% oxygen must be available to the myocardial tissue by the coronary arteries
● 35% needed by skeletal muscles at rest
● 75% needed by skeletal muscles with activity
● 2 ways to increase coronary blood flow by the coronary arteries
○ Increase the coronary blood flow by coronary artery vasodilation
○ Increase the oxygen in the blood with supplemental oxygen
Blood Pressure -
● Measurement of pressure exerted by blood against the walls of the arterial system
○ Systolic BP
■ Peak pressure exerted against the arteries when the heart contracts
○ Diastolic BP
■ Residual pressure of the arterial system during ventricular relaxation
(filing)
● BP is affected by CO & PVR
○ BP = CO x PVR
Other Terms -
● Pulse pressure: difference between SBP & DBP
● Mean arterial pressure: perfusion pressure felt by organs in the body
○ MAP = (SBP + 2DBP) / 3
○ MAP >60 is necessary to sustain vital organ function
Age Related Changes -
● Contractility
● Valves
● SA Node
● Nerve Fibers

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● Prolonged Recovery time

● Dysrhythmias
● Arterial Changes
● Venous Changes
● Pulse Pressure
● Prolonged Adaptation
● HTN - not an expected age related change (treat HTN in older adults)
Nursing Assessment of Cardiac Function -
○ Acute -
■ What is the presenting problem
■ Is there an Airway/Breathing problem that needs to be addressed
■ What are the new symptoms
○ Chronic -
● Chief complaint
○ What brought the patient in
■ Symptoms
● Ex: Fatigue, SOB - (Cardiac Problem)
● Medical history
○ Previous medical history - Assessing for Target Organ Damage
○ Rheumatic Fever
○ Strep Infection
■ Can damage heart valves
○ History of smoking
○ Diabetes Mellitus
● Family history
○ Do family members have a history of cardiac disorders
○ Hypertension
○ Coronary Artery disease
● Review of systems
○ Weight gain
○ Fatigue
○ Shortness of Breath
○ Dizzy spells
○ Edema
● Functional assessment
○ How does the issue impact their daily life
■ Impact their ADL performance
Physical Exam -
● Height & Weight
● Vital signs
○ What are we looking for?
■ Pulse
● Present?
● Rate

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● Rhythm
○ Regular or Irregular
● Quality
○ How strong are they?
■ 4 Point Scale
● 0 - Absent
● 1+ - weak
● 2+ - bounding
● 3+ - strong
■ Respirations
● Listen to lung sounds
○ Crackles, etc.
● Work
○ Difficulty?
■ When does it happen?
■ Why does it happen?
■ Blood Pressure
● Skin
○ Color
○ Hair Distribution
○ Capillary Refill
○ Palpate Temperature
● Cardiac
○ Listen to the heart sounds
■ Clear
■ Muffled / Faint
■ Extra Heart Sounds Present?
■ Murmurs
● Backflow of blood back through the valve
■ Pericardial rub
● Grating sound - rubs against inside of chest
○ 5 Locations
■ Aortic
● 2nd intercostal space, Right Sternal Border
■ Pulmonic
● 2nd intercostal space, Left Sternal Border
■ Erb’s Point
● 3rd Intercostal space, Left Sternal Border
■ Tricuspid
● 4th intercostal space, Left Sternal Border
■ Mitral
● 5th intercostal space, Midclavicular Line
● Extremities
○ Assess for edema

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■ 1+ -
■ 2+ -
■ 3+ -
■ 4+ -
5 Areas for Listening to the Heart

Lab Tests -
● ABG’s
○ pH - 7.35-7.45
■ >7.45 indicates a state of alkalosis
■ <7.35 indicates a state of acidosis
○ PaCO2 - 35-45 (regulated by lungs) - Acidic
○ HCO3 - 22-26 (regulated by kidneys) - Alkaloid
● Cardiac Enzymes - Cardiac Panel, Triple Enzymes,
○ Indicates damage to the heart and brain
○ CK: found in brain, heart, and skeletal muscles
■ Elevating when muscles or nerves are injured
■ Rise within 6 hours
■ Return to normal with 2-3 days
○ CK-MB: specific to cardiac cells
■ Specific for myocardial cells
● Rise 3-6 hours after injury
● Decrease at 12-24 hours after injury
● Return to baseline by at least 48 hours
■ Does not always indicate damage to the heart
● Angina
○ Decreased blood flow to the heart, damage/injury has not
yet occured
○ Troponin: most specific and indicates damage to cardiac muscle
■ Determines if chest pain is caused by a heart attack
■ Caused by cardiac injury

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■ If negative - not heart

■ If elevated - something wrong with the heart
■ Elevated within about 3 hours
■ Stays in the bloodstream for 10-14 days
● Cardiac Protein Markers
○ Myoglobin: found in cardiac and skeletal muscle
■ Inflammation or trauma could cause this to rise
Lab Tests -
● Complete Blood Count
○ WBC
○ RBC
○ Hgb/Hct
○ Platelets
■ Indicate the ability of the blood to clot
● Lipid Profile - measures serum lipids / serum cholesterol levels
○ Total Cholesterol
■ < 200
○ Lipoproteins
■ HDL
● Heart protective cholesterol
● Want a higher level
○ Exercise and Healthy Weight increases HDL
■ Removes from coronary arteries
■ LDL
● Bad Cholesterol
● Want a lower level in patients with CAD
○ Deposits in coronary arteries
○ Triglycerides
■ Increased with LDL
● B-type Natriuretic Peptide (BNP)
○ Cardiac hormone released in the presence of ventricular dysfunction
■ Below 100 pg/Ml indicates no heart failure
■ Due to fluid volume overload
○ BMP - Basic Metabolic Panel
■ BUN, Creatinine, etc.
● C-Reactive Protein (CRP)
○ Measures systemic inflammation
○ Can predict risk for CV disease
Diagnostic Tests and Procedures -
● CXR
● Electrocardiogram
● Echocardiogram
● MRI
● CT

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● Nuclear Cardiology
● Stress Testing
● Perfusion Studies
● Cardiac Catheterization
● Coronary Angiography
● Electrophysiology Study

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Electrocardiography
Objectives -
● Discuss the principles and uses of electrocardiography
● Explain the relationship between the electrical activity of the heart, cardiac conduction,
and normal heart sounds
● Identify the heart rate and cardiac waveforms (P, QRS, T, U) as well as PR interval
● Interpret basic cardiac dysrhythmias
○ Sinus bradycardia
○ Sinus tachycardia
○ Atrial flutter
○ Atrial fibrillation
○ Ventricular tachycardia
○ Ventricular fibrillation
○ Asystole
● Normal Sinus Rhythm
● Ventricular Fibrillation
● Atrial Fibrillation
ECG -
● ECG or EKG are graphic representations of electrical activity of the heart
○ Reveals the electrical function
○ Identify any potential rhythm issues
● ECG cannot tell mechanical function
○ How can you evaluate mechanical function of the heart?
■ PEA - Pulsal Electrical Activity -
● No pulse, but electrical activity is present
■ Epicardiogram -
● Ultrasound
○ How is the heart pumping
● 3 Lead or 5 Lead Telemetry (focusing on)
Basic Electrophysiology -
● Cardiac Cells
○ Myocardial Cells
■ Contractility
● Shorten and cause contraction
○ Pacemaker Cells
■ Automaticity
● Ability to create impulse, on its own without being stimulated from
an external source
■ Conductivity
● Ability to receive an impulse and conduct it to the next source
■ Excitability
● Conductivity from an outside source
Cardiac Action Potential -
● Action Potential

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○ 5 phase cycle
○ Changes in concentration of electrolytes -
■ Na+ and K+ are responsible for conduction
■ Ca++ and Cl- are responsible for contraction
○ Polarization
■ State of readiness
○ Depolarization
■ Contraction
○ Repolarization
■ Relaxation
○ 0 - depolarization
■ Receive pulse, contraction begins
○ 1, 2, 3 - repolarization
■ Resting phase
○ 4 - polarization
■ Cells can receive another impulse at this point

Normal Conduction -
● SA Node(right atria) > AV Node(floor of right atria) > Bundle of His(ventricular septum) >
Right & Left Bundle Branches(left and right ventricles) > Purkinje Fibers(throughout each
ventricle)
Conduction Pattern -

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Pathway of Conduction -

1. Atrial depolarization, initiated by SA Node, causes the P wave

2. With atrial depolarization complete, the impulse is delayed at the AV node
3. Ventricular depolarization begins at apex, causing the QRS complex. Atrial repolarization
occurs
4. Ventricular depolarization is complete
5. Ventricular repolarization begins at apex, causing T wave
6. Ventricular repolarization is complete
Intrinsic Rates -

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● Sinus Node
○ 60-100 beats per min
● AV Junction
○ 40-60 beats per min
● Ventricles
○ 15-40 beats per min
ECG Leads -
● Leads show negative to positive reflection
○ (-) Right Shoulder
○ (+) Left Lower Ribs
● Current going towards (+) lead shows as an upward deflection on ECG
● Current going towards (-) lead shows a downward deflection

(Three Lead - Upper right chest (white (-)), Upper left (black), Lower left
(white (+)))
● 5 Lead Telemetry Monitor
○ Right Upper - White Electrode
○ Right Lower - Green Electrode (below the rib cage)
○ Left Upper - Black Electrode
○ Left Lower - Red Electrode
○ 4th intercostal space - Brown Electrode
■ Snow over Grass
■ Smoke over Fire
■ Chocolate in the Middle
○ Connect Snaps to the Electrodes before positioning on chest
○ Alligator connectors after positioning on chest
● Choose sites not over bone
● Avoid skin folds
○ Can produce artifact
■ Irregular tracing on the monitor
● Tell patient to avoid excessive movement
● Treat patient, not monitor - anything wrong, assess patient
ECG Graphing - pg 610

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● Horizontal Axis - Time

● Vertical Axis - Voltage
● Smallest Box - 0.04 seconds
● Small Box - 0.2 seconds
● 15 small boxes - 3 seconds
ECG Waves -

ECG Tracing -
● Is rate regular
○ Is there a P wave, QRS Complex, T wave?
● PR Interval - From the SA node to the AV node
○ 0.12-0.2 seconds
○ Measure from start of P to the Q
■ First upward slope to the first downward slope (>0 - <0)
● QRS Complex

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○ 0.08-0.12 seconds
○ Measure from start of Q to end of S
● QT Interval
○ Measure from start of Q to end of T

ECG Analysis -
● Calculate Rate
○ Count # of QRS Complexes in 6 seconds x 10
○ Count # of small boxes between R waves ÷ 1500
○ Count # of large boxes between R waves ÷ 300
○ Calculate the atrial and ventricular rate
■ *Can only do this with a regular rhythm
● Determine Rhythm
○ Regular Rhythm
■ Equal distance between R waves
○ Irregular rhythms
○ P to P Interval
■ Atrial rhythm
○ R to R Interval
■ Ventricular rhythm
● The P Wave
○ Are P waves present
■ All P waves look similar
■ One P wave before each QRS complex
● Originates from the Atria
○ Same size and shape?
■ If so, coming from the SA node
○ PR Interval
■ Normal duration
■ Consistent

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○
● QRS Complex
○ Identify the QRS
■ Normal duration (0.08 - 0.12 seconds)
■ Do all QRS complexes look similar

○
● ST Interval
○ If this is elevated or depressed compared to the baseline - indicator for ischemia
● T Wave
○ T wave present
■ Are all T waves similar
■ Same deflection as QRS
○ QT Interval
■ Normal Duration
■ Consistent

○
● Ectopic Beats
○ Look for any abnormal beats for changes in the rhythm

○
○ U Wave - Indicates an Electrolyte imbalance
■ Note that it is present
Sinus Arrhythmias - (See Common Dysrhythmias Handout)
● Sinus Bradycardia

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○
○ HR : <60 bpm
○ Rhythm : Regular
○ P Wave : Present
○ PR Interval : 0.12-0.2
○ QRS Complex : 0.08-0.12
○ Cause
■ Meds (beta-blockers, digitalis)
■ Valsalva
● Need to Educate
■ Hyperkalemia
■ MI
○ Symptoms
■ Syncope
■ Weakness
■ Dizziness
■ weak/slow pulse
■ Decreased CO (↓ BP)
○ Treatment
■ Asymptomatic:
● Observation
■ Symptomatic
● Correct cause
● Atropine
○ HR <50
● Pacing
○ Externally - hook pt up pacing machine
○ Internally - pacemaker inside the body
● Sinus Tachycardia

○
○ HR : > 100-150 bpm
○ Rhythm : Regular
○ P Wave : Present
○ PR Interval : 0.12-0.2
○ QRS Complex : 0.08-0.12
○ Cause
■ Fever
■ Hypovolemia
■ Stress/Exercise

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■ AMI
■ SNS stimulation
○ Symptoms
■ Palpitations
■ Chest pain with very fast rates
■ Decreased CO (↓ BP)
■ Syncope
■ Hypotension
○ Treatment
■ Correct cause
■ Vagal Stimulation
■ Beta-blockers
● Atrial Fibrillation - Rapid & Irregular
○ Can’t see P waves due to rapid rate of the atria
○ QRS is normal
○ Atrial Rate > Ventricular Rate

○
○ Rate: Atrial > Ventricular
○ Rhythm : Irregularly Irregular
○ P Wave : Unable to determine (fibrillation wave)
○ PR Interval: Unable to determine
○ QRS Complex: 0.08-0.12
○ Cause
■ CAD
■ MI
■ HF
■ Mitral Valve
■ Stenosis
■ Hyperthyroidism
○ Symptoms
■ Irregular rapid pulse
■ Palpitations
■ Fatigue
■ SOB
■ Angina
■ Decreased CO (BP Variable)
○ Treatment
■ CCB (Diltiazem)
■ Anticoagulants

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■ Cardioversion
■ Ablation
○ Risk for clots
■ Want the pt to be on a blood thinner
● Atrial Flutter - Rapid & Regular
○ No P wave due to atrial rate (240-350)
○ Saw tooth pattern (flutter waves)
○ Normal QRS

○
○ Rate : Atrial > Ventricular
○ Rhythm : Regular or Irregular
○ P Wave : Flutter waves
○ PR interval: unable to determine
○ QRS Complex : 0.08-0.12
○ Causes
■ CAD
■ MI
■ HF
■ Mitral Valve
■ Stenosis
○ Symptoms
■ Rapid Pulse
■ Palpitations
■ Fatigue
■ SOB
■ Angina
■ Decreased CO (BP Variable)
○ Treatment
■ CCB (diltiazem)
■ Anticoagulants
■ Cardioversion
■ Ablation
● Ventricular Tachycardia - Fast & Regular
○ Rate is usually >100 bpm
○ Absent P waves
○ Wide QRS
○ Will progress to V. Fib. without treatment
○ Unpredictable - Deadly

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○
○ Rate : >100
○ Rhythm: Regular
○ P Wave: None
○ PR Interval: None
○ QRS Complex: Wide
○ Causes
■ HF
■ AMI
■ CAD
■ Hypokalemia
■ Digoxin toxicity
○ Symptoms
■ Dizziness
■ Chest pain
■ LOC with pulse or without pulse
■ Decreased CO (with pulse \/ BP, without pulse no BP)
○ Treatment
■ With Pulse
● Synchronized
● Cardioversion
● Amiodarone
■ Pulseless
● CPR
● Defibrillation
● ACLS protocol

● Ventricular Fibrillation - Rapid & Irregular - Lethal Rhythm

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○ Rates are >300 bpm

○ Extremely irregular & unorganized
○ NO cardiac output
○ CPR & Defibrillation

○
○ Rate : none
○ Rhythm : Unorganized
○ P Wave: none
○ PR interval: none
○ QRS Complex : Unorganized
○ Causes
■ CAD
■ AMI
■ Electrolyte imbalance
■ Untreated v. Tach
○ Symptoms
■ LOC with no pulse
■ No CO (No BP)
○ Treatment
■ CPR
■ Defibrillation
■ ACLS protocols
● Asystole - No pulse - No Rhythm - No Cardiac Output
○ No pulse
○ Continue CPR
○ Give ACLS drugs
○ Can NOT shock asystole

○
○ Rate : None
○ Rhythm : None
○ P Wave: None
○ PR Interval : None
○ QRS Complex: None
○ Causes
■ Acute Resp. Failure
■ Myocardial Damage
○ Symptoms

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■ LOC with no pulse

■ No CO (No BP)
○ Treatment
■ High Quality CPR

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Cardiac Disorders
Manifestations, Treatment, and Nursing Care for the Patient with Cardiac Disorders
Coronary Artery Disease - (Ischemic Heart Disease)
● Coronary Artery Disease (CAD) :
○ Large coronary arteries are blocked or partially blocked
■ Blockage in arteries
● Atherosclerosis : (Underlying)
○ Inflammation, fatty deposits, and hardening of the arteries
○ Starts with an injury to the very inner lining of that artery
○ Increase in cholesterol to that site
● Risk
○ Directly related to levels of increased cholesterol in the artery
■ Decrease LDLs
● Developmental Stages
○ Fatty streaks
○ Fibrous plaque
○ Complicated lesions

● Chronic endothelial injury

○ Hypertension
○ Tobacco use
○ Hyperlipidemia
○ Hyperhomocysteinemia
○ Diabetes
○ Infections
○ toxins
● Yellow - Fatty Streak - No symptoms with fatty streak
○ Can be reversed with diet, exercise, other therapies
● Blue - Fibrous Plaque - beginning of changes to endothelium of arterial walls

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○ LDL’s and platelet growth factors stimulate thickening of the arterial wall
● Red - Complicated Lesion (unstable plaque)- Inflammatory process results and leads to
instability of the plaque (ulceration and rupture) platelets accumulate and thrombus is
formed
○ Can lead to total occlusion

● A - Open, functioning coronary artery

● B - Partial coronary artery closure with collateral circulation being established
● C - Total coronary artery occlusion with collateral circulation bypassing the occlusion to
supply blood to the myocardium
● If there is a spasm - there is not enough time for collateral circulation
Risk Factors for CAD -
● Nonmodifiable risk factors
○ Age
○ Gender
■ ~50 - Males
■ >65 - equal risk for both males and females
○ Ethnicity
■ ~ Caucasian
○ Family history
■ Increased CPR
● Modifiable risk factors
○ Elevated serum lipids
■ Cholesterol and lipids
○ Hypertension
○ Tobacco use
■ Nicotine - releases epinephrine/norepinephrine
● Triggers SNS
■ Smoke - increases LDL cholesterol
■ Carbon Monoxide - reduces the ability to transport oxygen
○ Physical inactivity
■ Cardiovascular/Aerobic exercise for at least 30 minutes a day, most days
of the week
■ Weight lifting
● Reduce risk of clot formation

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● Incourage collateral circulation to develop

○ Obesity
■ More tissue for heart to supply blood to
■ Heart working harder
● Heart will enlarge
● Requires more oxygen
■ BMI - >30
● Need extra focus
■ Weight in abdomen (circumference)
● >40” - men - increased risk
● >35” - women - increased risk
○ Diabetes
■ Keep DM controlled
Signs and Symptoms : CAD -
● Progressive - can be happening in the body for years, unnoticed
● >50%-70% blockage results in symptoms
○ Pain is most common
■ Angina pectoris (chest pain)
● Sign of ischemia
○ Coronary artery disease has progressed
● Predictable
○ Increased with exercise
● As it progresses - Unpredictable
○ Can happen at rest
■ Stable or ACS
○ Acute Coronary Syndrome (ACS)
■ MI (Unstable/NSTEMI or STEMI)
● Chest pain
● Unstable
○ No elevation in enzymes
● NSTEMI
○ Cardiac enzymes elevated
● STEMI
○ Cardiac enzymes elevated
○ Worse, terms of severity, than both NSTEMI or Unstable
Angina
■ Sudden Cardiac Death

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Treatment & Care: CAD -

● Prevention and early treatment
● Identification of people at high risk
● Controlling modifiable risk factors
● Encourage lifestyle changes
○ Education
■ Stress Management
○ Clarify personal values
○ Set realistic goals
● Nutritional Therapy
○ Slightly elevated cholesterol level
■ Want to lower total cholesterol and LDL
● Decrease saturated fats in diet
● Increase complex carbohydrates
○ Whole grains, fruits, vegetables, fiber
○ Elevated triglycerides
■ Eliminate alcohol and sugars from diet
● Exercise
○ 30 minutes a days plus weight training 2 days a week
○ Increases HDL
● Medications
○ Statins
■ First line drug to bring down cholesterol level
○ Niacin
■ Secondary drug to bring down cholesterol
○ Antiplatelet meds
■ ASA
● Aspirin
■ Clopidogrel
● Helps prevent clot formation
Angina Pectoris -
● Progressive disease
○ Occurs when the demand for oxygen by the myocardial cells exceeds the supply
of oxygen delivered and leads to myocardial ischemia
● Angina = Reversible Ischemia
○ Occurs when coronary arteries are blocked

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○ Hypoxic within 10 seconds of occlusion

○ Viable for 20 minutes
● Stable (Chronic)
○ Occurs most often with exercise or activity and subsides with rest
○ Activity has increased oxygen demand of the heart
○ Occurs with the same pattern, same onset, same duration, and same intensity
everytime it happens
■ Crushing sensation, heavy, squeezing, indigestion
○ Usually lasts 5-15 minutes
○ Goes away when cause is removed
■ Ex: exercising patient can sit down
○ Nitro can relieve symptoms
● Unstable
○ Occurs at rest or minimal activity not relieved with nitro
○ Pain is more severe
○ Not predictable
● Variant (Prinzmetal)
○ Caused by coronary artery spasm and may not be associated with CAD
○ Unpredictable
○ Can occur at rest
○ At times can be caused by oxygen demand being increased
○ Can also be caused by other substances :
■ Smoking
■ Alcohol
■ Amphetamines
○ When spasm goes away - pain goes away
○ Calcium Channel Blockers
■ Prevent spasms from occurring
○ PQRST
Stable Angina -
● Manage Risks & Prevent Progression of Disease
○ A - Aspirin, Antianginal Agents (Nitro), ACE Inhibitors
■ Nitro - one pill every 5 minutes prn, sublingual
● After taking first pill and pain has not subsided, call 9-1-1
● Do not take with ED medications
○ Too much vasodilation can occur
○ B - Beta Blockers and Blood Pressure
○ C - Cigarette Smoking and Cholesterol
○ D - Diet and Diabetes Management
○ E - Education and Exercise
■ Meds
■ Reducing risk factors
■ Symptoms of an MI
■ When to go to hospital

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■ Need to give encouragement

■ Explain how and why

● Women are more likely to experience unexplained fatigue, syncope, nausea, right arm
pain, jaw pain, and SOB
○ Less than 30% report chest pain

Acute Myocardial Infarction -

● Pathophysiology:
○ Occlusion of artery-partial or total
○ Ischemia results
○ Prolonged ischemia >20 minutes leads irreversible cell death
■ Collateral circulation can minimize damage
■ Full thickness necrosis - 4-6 hours, up to 12 hours
● Tissue will not function correctly
○ Healing begins after approx. 24 hours - 2 weeks
■ Scar tissue will start to form
● Need to take it easy

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■ 6 weeks - scar tissue will replace necrotic tissue

○ Scar tissue formation = loss of function
○ Compensation
■ Hypertrophy - increase size
■ Ventricles - dialate
● Cardiac Remodeling
■ Heart failure can occur
Signs and Symptoms (AMI) -
● Chest pain
○ Does not go away with nitro or rest
○ Male - heaviness, pressure, crushing, feeling of indigestion (may take antacids,
but won't help)
○ Can occur when active or at rest
○ Usually lasts for >20 minutes
○ More severe than previous chest pains
● Changes in vital signs
○ Body is releasing epi/norepi
○ Blood pressure increases
○ Heart rate increases
○ CO - drops after extended period of time
■ Decreased urine output
■ Increased temperature (first 24 hours , low-grade (inflammatory))

● SOB
● Diaphoresis
● Cool, clammy skin
● Lightheaded
● Ashen - Grey skin color
● Nausea & Vomiting
● Anxiety
○ Increase cardiac workload and oxygen demand
■ Need to calm the patient down
● Sense of Doom
○ Attempt to reduce anxiety and calm patient down
● Atypical Symptoms
○ Women
○ Patients with Diabetes
○ Elderly
Medical Diagnosis (AMI) -
● ECG - needs to happen within 10 minutes of arrival
○ Ischemia - T-Wave inverted
○ Injury - ST segment elevation/depression
■ STEMI vs NSTEMI
○ Infarction-significant Q Wave

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○ Dysrhythmias
● Cardiac Enzymes
○ Troponin: rise 3 hrs after injury and peak in 12 hours
○ CK & CK-MB: rise 3-12 hours after injury and peak in 24 hours
○ Myoglobin: released 1-4 after injury, but not specific to cardiac
■ Also released after injury to skeletal muscle or with renal failure

Medical Treatment (AMI) -

● GOAL - Preserve myocardial tissue and prevent tissue death
● Medical Treatment
○ M - Morphine - 3
■ Peripheral pooling of blood
■ Decrease blood that returns to the heart
■ Decrease Preload
■ Helps diminish anxiety
■ Impact breathing - decrease tachypnea and relax bronchial smooth
muscles
● Improve gas exchange
● Decrease oxygen demand
● Decrease work load of the heart
○ O - Oxygen - 1
■ Administer O2
○ N - Nitroglycerin-Sublingual or IV - 2
■ Nitro IV - Dilate coronary arteries
● Allow for some perfusion to go through
○ A - Aspirin - 4
■ Antiplatelet

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● If they haven't taken any in the last 24 hours

○ No - administer 4 chewable 81 mg tablets
● TNK - fibermelolic
○ IV Med - breaks down the clot
○ Can’t get patient to PCI
○ High risk for bleeding
● Nursing Care
○ Vitals
■ Continuous monitoring
○ ECG monitoring
○ Bed Rest
■ Decrease work load of heart
○ Pain management
■ Morphine
○ Monitor for complications
■ Dysrhythmias
■ Heart failure
■ Cardiogenic shock
■ Thromboembolism
■ Ventricular aneurysm
AMI: Treatment -
● STEMI
○ Emergent PCI for reperfusion
■ Within 90 minutes of arrival
■ Door to balloon time
○ Fibrinolytic therapy
● NSTEMI
○ Medical management
○ PCI
● Post Procedure Care
○ Lay flat for 6 hours
■ Prevent bleeding from site
○ Monitor insertion site for bleeding
○ Monitor affected extremity for adequate perfusion
■ Five Ps and Ts
○ Frequent vitals
○ Patient education
■ Stent placement requires clopidogrel

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CABG: Nursing Care -

● Coronary Artery Bypass Graft
○ Unsuccessful attempts at stent placement
○ Extensive disease
● Post-Op Care
○ ICU for first 24-36 hours
○ Pleural/Mediastinal chest tubes
○ Continuous tele monitoring
○ Epicardial pacing wires
○ Urinary catheter

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○ Sternal Precautions

Other Treatment for AMI -

● Drug Therapy
○ Aspirin & Anti-Platelet drugs
○ Beta-blockers
○ ACE inhibitors
○ Nitroglycerin (PRN)
● Other Therapy
○ Exercise
■ Cardiac rehab
● Monitored exercise
○ Diet
■ Low sodium
■ Low fat
○ Reduce Stress
○ Smoking Cessation
■ Give information
○ Manage Chronic Conditions
■ Hypertension
■ Diabetes
Nursing Care -
● Cardiac Rehab
○ Prevent future cardiac events
○ Promote healthy behaviors
○ Supervised exercise (Telemetry)
○ Education
○ Monitor progression
● Patient Teaching for discharge p. 647
Complications (AMI) -
● Dysrhythmias - 80% of patients
● Heart failure - ventricles to empty causing increased preload - leads to pulmonary and
systemic edema
● Cardiogenic shock - frequent cause of death due to severe damage to LV

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● Thromboembolism
○ Sudden severe dyspnea
○ Chest pain
○ Can be fatal
● Ventricular Aneurysm / Rupture - weakened heart muscle

Sudden Cardiac Death (SCD) -

● Rapid loss of cardiac output
○ No blood going anywhere
● Develops an arrythmia
○ V. tach or v. fib
● Unexpected death from cardiac causes
● Abrupt disruption in cardiac function, resulting in loss of CO and cerebral blood flow
● Most commonly caused by ventricular dysrhythmias
● No warning signs or symptoms if no MI
○ No known heart history
● Prodromal symptoms if associated with MI (right before occurring (1 hour onset))
○ Chest pain, palpitations, dyspnea
○ Death usually within 1 hour of onset of acute symptoms
● 24-hour Holter monitoring
● Electrophysiologic study (EPS) - Stress test
○ Electrodes in the heart
■ Try to recreate what happened - so they can fix it
● Implantable cardioverter-defibrillator (ICD)
○ Will shock the heart back to a normal rhythm
● Antidysrhythmic drugs
○ Amiodarone
Audience Response Question -
● The most significant factor in long-term survival of a patient with sudden cardiac death is
○ Absence of underlying heart disease
○ Rapid implementation of emergency services and procedures
○ Performance of perfect technique in resuscitation procedures
○ Maintenance of 50% of normal cardiac output during resuscitation efforts

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● The nurse is caring for a patient who survived a sudden cardiac death. What should the
nurse include in the discharge instructions?
○ Because you responded well to CPR, you will not need an implanted defibrillator
○ Your family members should learn how to perform CPR and practice these
skills regularly
○ The most common way to prevent another arrest is to take your prescribed drugs
○ Since there was no evidence of a heart attack, you do not need to worry about
another episode

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Heart Failure & Other Related Cardiac Disorders

Heart Failure -
● Chronic, progressive conduction
○ Ventricular dysfunction
○ Reduced cardiac output
○ Decreased tissue perfusion
○ Volume overload
● Affects approximately 5.7 million Americans
● About ½ of those diagnosed die with 5 years
● Costs approx. $30.7 billion dollars annually
Cause & Risk -
● Usually preceded by some other cardiac conditions
○ Coronary Artery Disease (CAD)
○ Hypertension (HTN)
○ Myocardial Infarction (MI)
○ Cardiomyopathy
○ Valvular Disorders
● FAILURE
○ F - Faulty Heart Valves
■ Stenosis or Regurgitation
○ A - Arrhythmias
■ A. Fib. or Tachycardias
○ I - Infarction
○ L - Lineage
■ Congenital history
○ U - Uncontrolled Hypertension
○ R - Recreational Drug use
■ Cocaine
■ Alcohol
○ E - Evaders
■ Viruses
■ Infections
Types of Heart Failure -
● Systolic Failure
○ Most common
○ Areas of the heart (usually the left ventricle) becomes enlarged and weak and the
muscle is no longer strong enough to pump blood from the heart out to the body
○ Decrease in Ejection Fraction
■ Ejection fraction <45%
● Diastolic Failure (preserved ejection fraction)
○ Muscle becomes stiff and can no longer relax which prevents the affected
chamber from filling with blood
Pathophysiology (HF) -

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● Inability of the heart to meet the metabolic demands of the body which leads to
decreased cardiac output which results in a cycle of compensation that leads to
worsening HF
○ Usually due to weakened left ventricle
● Compensation:
○ Sympathetic nervous system activation (Epi/Norepi to increase HR, contractility,
peripheral vasoconstriction, increases hearts O2 demand, increases hearts work,
volume overload)
○ Renal compensation - (RAAS System) to increase blood volume (fluid retention)
○ B-Natriuretic Peptides released (too much fluid is going on, symptoms caused by
heart failure)
■ Promote vasodilation and cause diuresis (enlargement of vessels)
○ Cardiac muscle hypertrophy (cardiac remodeling)
■ Heart muscle will change
● Dilate
● Hypertrophy
○ Increase cardiac workload
○ Increase O2 demand

Compensation -
● Compensatory mechanisms will increase cardiac output for a time but also
○ Increases cardiac oxygen demand
○ Leads to cardiac cell death
○ Process repeats and eventually leads to a further decrease in cardiac output
○ Eventually will result in decompensated heart failure
Signs and Symptoms -
● Left Sided Failure -
○ Most common
○ Blood backs up into pulmonary circulation causing respiratory-type symptoms
○ Increased HR, extra heart sounds (S3, S4), decreased BP
○ Other symptoms related to decreased cardiac output and decreased tissue
perfusion

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● DROWNING
○ D - Dyspnea
○ R - Rails
■ Crackles
○ O - Orthopnea
■ Sleeps with two or more pillows, or sleeping in a chair
○ W - Weakness
○ N - Nocturnal Paroxysmal Dyspnea
■ Happens when pt is sleeping
■ When body is laying down and body starts to reabsorbs the liquids in the
body
■ Pt wakes up with a suffocating feeling
■ Strong desire to sit up
○ I - Increased HR
■ SNS activated
○ N - Nagging Cough
■ First symptom?
■ Dry productive cough
■ Cough medicine will not help
■ Acute decompensation - pulmonary edema
● Pink, frothy, sputum
○ G - Gaining Weight
■ Two - Three pounds in a day
■ Three - Five pounds in a week
Signs & Symptoms -
● Right Sided Failure -
○ Usually indicates more advanced disease
○ Blood backs up into venous circulation (the body), increased BP and increased
HR
○ JVD, Peripheral Edema, and Weight Gain all indicate fluid retention

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○ GI symptoms are common

● SWELLING
○ S - Swelling of the hands, feet, liver, and the spleen
○ W - Weight Gain
■ Fluid retention
■ Kidney failure
○ E - Edema
■ Pitting edema
■ Dependent extremities - pt is on bed rest (assess sacrum and scrotum)
○ L - Large Neck Vein
■ JVD
○ L - Lethargic
■ Fatigue
○ I - Irregular Heart Rate
■ A. Fib
○ N - Nocturia
○ G - Gerth
■ Increase in abdominal size - azyties
■ Can cause breathing issues
■ Fluid in abdomen
● Anorexia
● Nausea
Medical Diagnosis -
● Need complete history and physical
○ Causative factors
○ Current symptoms
● Echocardiogram (echo)
○ Measures ejection fraction
○ Measures heart size
○ Differentiates between Systolic and Diastolic Blood Pressure
● Chest X-Ray

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○ Cardiomegaly
○ Lung fields
● Labs
○ BNP
■ Positive - Higher number, Worse the disease
○ BUN/Creatinine
■ Kidney involvement - kidneys aren’t receiving blood flow they need
■ Responsible for creating erythropoietin (responsible for making RBCs)
○ Liver Enzymes
■ Elevate
○ Electrolyte levels
■ Fluid overload -
● Hyponatremia
● Changes in potassium (depends on diuretic)
○ H&H
■ Hematocrit - used to identify hydration status (lower, due to dilution)
○ RBCs
Classification of HF Severity -
● ACC/AHA Stages of Severity
○ A - High risk, no structural changes or symptoms
○ B - Structural changes, but no symptoms
○ C - Structural changes, with prior or current symptoms
○ D - Advanced structural changes and marked symptoms at rest AND required
specialized interventions
Drug Therapy -
● Diuretics
○ 1st line therapy
○ Balance volume loss with BP
○ Treats symptoms ONLY
● Drugs that Inhibit the RAAS
○ Protects renal function
○ Decreased preload
○ Prevent cardiac remodeling
■ Decreased BP
■ Helps with tissue perfusion
■ Help with cardiac remodeling
● Beta-Blockers
○ Requires CAREFUL dosage
○ Can improve EF
○ Increase exercise tolerance
○ Slow progression
○ Reduce hospitalization
○ Prolong survival
Other Medications -

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● Positive Inotropes (Cardiac Glycoside)

○ Digoxin - lanoxin -
■ Positive inotropic med - increases force of cardiac contractions
■ Decrease HR
■ Improve CO
■ Risk for Toxicity - monitor potassium levels
■ Increases forces of contraction
■ Slows conduction and HR
■ 2nd line drug
■ Narrow therapeutic range
■ Many adverse effects and drug interactions
● Vasodilators
○ Nitrates
○ Morphine
Non-Pharmacological Treatment -
● In patient
○ Lo-sodium diet
○ Fluid restriction
○ Daily weight
■ Weight themselves everyday at the same time
■ Best if before breakfast, after going to the bathroom
■ Same type of clothing
■ Same scale
● Report the 2-3 lb a day, or 3-5 lb a week to provider
○ Strict I/Os
○ Oxygen, if needed
○ Monitor response to symptoms
○ LOTS OF EDUCTION
■ Diet
■ Medications
■ Signs and Symptoms of Worsening
○ Prevent readmission
● Home Management
○ Lo-sodium diet
○ Control contributing factors
○ Fluid restriction
○ Daily weight
○ Monitor for change in symptoms (new or worsening)
○ Medication compliance
○ Progressive exercise
Other Treatment Options -
● Pacemakers/ICD
○ Control dysrhythmias
○ Prevent mortality

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● Ultrafiltration
○ Removes excess fluid from the blood
● Stage D or End-Stage Treatment
○ Ventricular Assist Devices
■ LVAD
■ Bridge to transplant or destination therapy
○ Heart Transplant
○ Total Artificial Heart
■ For bi-ventricular failure
Complications (HF) -
● Dysrhythmias
○ Ventricular Tachycardia
● Kidney Impairment
● Liver impairment
● Acute decompensated HF
○ Pulmonary edema
○ Cardiogenic shock
Nursing Care -
● Decreased Cardiac Output
○ Interventions
● Excess Fluid volume - need to be receiving diuretics, monitor urine output
○ Interventions
● Impaired Gas Exchange
○ Interventions
● Activity Intolerance
○ Interventions
Patient Education -
● Heart Failure Re-Admission is a CORE Measure
○ Not reimbursed by Medicare/Medicaid within 30 days
○ Know the signs and symptoms of worsening HF
● Teaching
○ 1. FACES -
■ F - Fatigue
■ A - Activities are limited
■ C - Chest congestion, Cough
■ E - Edema
■ S - Shorntess of Breath
○ 2. Weight
■ 2-3 lbs in a day
■ 3-5 lbs in a week
○ 3. Low-Sodium Diet
■ <2 g Na
■ Salt substitutes contain potassium
■ DASH Diet

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● Avoid canned / Processed

○ 4. Medication Education
■ What is it for?
■ How and when to take it?
■ Side Effects
■ Pill Organizer
○ 5. Conserve Energy
■ Balance activity and rest
■ Group cares together
■ Pay attention to symptoms that indicate fatigue
○ 6. Exercise Training
■ Progressive exercise
● Improve symptoms
Cardiomyopathy -
● Dilated
● Hypertrophic
● Restrictive
● Cardiac disease that affects the structure and/or function of the myocardium (heart
muscle)
● Cause and Effect of Heart Failure
○ Dilated: most common type
■ Causes: infection, cardiotoxic agents, CAD, genetics, HTN, pregnancy,
and valve disease
■ Ventricular muscle wall becomes stretched out
● Left is worse than right
○ Impairs the ability to pump blood
○ Hypertrophic
■ Causes: aortic stenosis, genetics, HTN
■ Thickening of the arterial wall
● Leads to poor filling
■ Can be genetic
■ Caused by stenosis
○ Restrictive
■ Causes: endomyocardial fibrosis, tumors, radiation
■ Most rare form
■ Walls of the ventricle become stiff
● Restricts ability to be filled with blood
■ Common with inflammatory processes

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Signs & Symptoms - (Consistent with Left Ventricular Failure)

● Dilated
○ Decreased exercise tolerance
○ Fatigue
○ Dyspnea
○ Cough
○ Abdominal bloating
○ Nausea
○ Anorexia
○ Weak pulses
○ Pallor
○ JVD
● Hypertrophic - due to thickened walls
○ Massive ventricular hypertrophy
○ Forceful left ventricular contractions
○ Impaired ventricular filling
○ Exertional dyspnea
○ Fatigue
○ Angina (chest pain)
■ Won't be related to activity
■ Can happen at rest
○ Syncope
○ Dysrhythmias
● Restrictive
○ Activity intolerance
■ SOB, Fatigue
Cardiomyopathy -
● Diagnostic Studies
○ Exclude other causes of HF
○ Echo
■ Ultrasound of the heart
● Assess ventricular walls and the valves

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○ Assess the function of the heart

○ CXR
■ Can see the heart - assessing for enlargement
○ Complete patient history
■ Signs and symptoms
■ Past medical history
● Complications
○ Dysrhythmias
○ Heart Failure
○ Sudden Cardiac Death
Nursing Care & Treatment
● Dilated
○ Control HF Symptoms & treat underlying causes
○ Does not respond well to therapy
○ Heart Transplant
○ Diuretics
○ ACE inhibitors
○ Positive inotrope
■ Help with CO
○ Progression - End Stage
■ Heart transplant
● Hypertrophic
○ Improve ventricular filling
○ Surgical reduction
■ Remove portion of thickened tissue
○ AICD placement
○ Frequent Rest
○ Beta-Blockers
○ Calcium Channel Blockers
■ Chest pain and Syncope
○ Avoid strenuous exercise
■ Thickened wall takes more O2
● Further increases O2 demand - heart wont beable to keep up
Cardiac Transplant -
● Transfer of a healthy donor heart to a patient with a diseased heart
● Treats many end-stage cardiac conditions
○ Heart Failure
○ Cardiomyopathy
○ Valvular heart disease
● Strict Criteria must be met
○ Looking for Patient
■ Life expectancy
● 1 year or less
■ Age : Less than 65 years old

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■ No occurrent active infection

■ No cancer
■ No current signs of alcohol or drug abuse
● Priority given to patients who are acutely ill
● Post-Transplant Care
○ Patient education
○ Prevent rejection (acute & chronic)
■ Prevented with a variety of immunosuppressive drugs
○ Higher risk of infection and causes
○ In ICU - Private Room
■ People should be using PPE - Prevent from infection
■ Lines/Tubes/Drains - removed ASAP (with pt tolerance)
■ Teach family about proper PPE and handwashing techniques
■ Discharge -
● Ways to avoid infections
○ Avoid crowds
○ Good handwashing
○ Signs and symptoms of relief
Pacemakers -
● Temporary Pacing
○ Acute cardiac surgery
● Transcutaneous pacing
○ For emergency situations - symptomatic bradycardia
○ Through the skin
■ Transvenous
● Through the vein
■ Epicardial
● Through the heart
○ Use of sedation (if time)
● Permanent Implanted Pacemaker
○ Atrial and/or Ventricular pacing
○ Completely implanted into the SubQ tissue
■ Send an electrical impulse if the SA node does not
● Implantable Cardioverter - Defibrillator (ICD)
○ For patient who have suffered from SCD or have spontaneous VT
○ Can also have pacing capabilities
○ Sends a shock to fix abnormal heartbeat

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Nursing Care: Patients with Pacemakers

● Monitor patient vital signs
● Pacemaker spikes should be seen
● Assess vital signs and inspect incision
● Limit movement of arm on affected side
● Assess pacemaker for misfiring
● Three major problems with pacing
○ Failure to pace
■ Electrical impulse was not fired when it was supposed to
■ No pacer spike
● Can happen because of a dislodged wire
○ Failure to capture
■ There was not a captured reading
■ Pacer spike, but no QRS
■ Settings are too low
○ Failure to sense
■ Does Not sense the pts rhythm
■ Sends an impulse when it was not needed
■ Pacer spikes too close to pts rhythm
● Teach the patient how to count their pulse
○ Full minute everyday
○ Keep a record - bring with them to their appointments
○ Instructed to notify provider if pulse is less than 60 bpm
■ Programed rate (if pulse is below)
● Monitor for signs and symptoms of infection
● Always carry and ID card with information about the pacemaker

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Cardioversion -
● Delivery of a synchronized shock to stop abnormal rhythms from either the atria or
ventricle
● Can be used as an elective or emergency procedure
● Shock synchronized with R wave
● Patient sedated
● Emergency situation (VT or VF) > Defibrillation
○ Stop with synchronized shock to unsynchronized shock
Vascular Disorders -
● Aortic & Mitral Valve Dysfunction
Valvular Disease -
● Stenosis
○ Narrowing of the valves
○ The opening of the valve is smaller and forward flow of blood is impaired
○ Causes difference in pressure on each side of the valve
○ Aortic or mitral valves affected
● Regurgitation
○ Incompetent valve doesn’t completely close
○ Allows for backward flow of blood
○ Mitral or aortic valves affected
Aortic Stenosis -
● Cause and Effect
○ Rheumatic fever in older adults & congenital in when affects children or young
adults
○ Results in obstruction of blood flow from the LV to the aorta causing hypertrophy
& decreased CO
○ Eventually leads to pulmonary HTN and HF
● Symptoms
○ Occur when valve is ⅓ normal size
○ Includes:
■ Angina
■ Syncope
■ DOE (dyspnea on exertion) - due to LV failure
○ Systolic Murmur and S4 present
○ Poor prognosis without surgical repair
Mitral Stenosis -
● Cause and Effect
○ Rheumatic Heart disease in adults
○ Blood blocks flow and creates high L atrial pressure and pulmonary HTN
● Symptoms
○ DOE (dyspnea on exertion) is primary symptom
○ Includes:
■ Angina
■ Fatigue

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■ DOE - due LV failure

○ Low pitched diastolic murmur (best heard at apex)
Aortic Regurgitation -
● Cause and Effect
○ Acute AR:
■ Trauma & infectious endocarditis
○ Chronic AR:
■ Rheumatic heart disease or other inflammatory disorders
○ Backflow of blood from aorta into the LV
○ Volume overload in the LV leads to hypertrophy & dilation & eventually RV failure
● Symptoms
○ Acute AR:
■ Sudden LV failure
■ Cardiogenic shock
○ Chronic AR:
■ Soft or absent S1 & S2 & soft, high-pitched diastolic murmur
■ Asymptomatic until significant dysfunction
Mitral Regurgiation -
● Cause and Effect
○ Chronic rheumatic heart disease
○ Mitral valve prolapse
○ Infectious endocarditis
○ Blood flow backwards from LV to the LA increasing workload of the L heart
causing LA enlargement, LV dilation & hypertrophy
○ Strep antibiotics - used to prevent heart damage
● Symptoms
○ Remain asymptomatic for years
○ Begin as weakness, fatigue, palpitations, and dyspnea
○ Advances to PND and peripheral edema
○ Loud S3 & loud murmur heard at the apex
Mitral Valve Prolapse -
● Cause and Effect
○ Usually inherited condition
○ Strong genetic link seen with patient’s who have other connective tissue
disorders, collagen problems, or Marfan’s syndrome
● Symptoms
○ Majority of cases do not cause symptoms (about 90%)
○ Murmur that is loudes during systole
○ Chest pain that occurs during emotional stress
○ May also experience dyspnea, palpitations & syncope
○ MR is rare but most serious complication

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Valvular Disease -
● Diagnostic Tests
○ History & Physical
○ CT with contrast
■ Gold standard for aortic disorders
○ CXR
■ Heart enlargement
○ Echo
■ Shows structure, function, & heart chamber size
■ Monitor progression
● Treatment
○ Prophylactic AB therapy
■ RF & IE
○ Medications to control symptoms of HF
○ Anticoagulant therapy
○ Valve repair or replacement
Valvular Replacement -
● Prosthetic Valves
○ Made of artificial material
○ More durable & last longer
○ Increased risk of clotting
○ Require long-term anticoagulant therapy
■ Warfarin
■ INR goal 2.5-3.5 (Book - 3-4.5)
● Tissue Valves
○ Made from bovine, porcin, or cadaver tissue
○ Produce more natural blood flow
○ Less durable
○ Early calcification and stiffening of leaflets
○ No anticoagulants required
Inflammatory Disorders -
● Infective Endocarditis

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● Pericarditis
Infective Endocarditis -
● Infection of endocardium (innermost layer of the heart)
○ Affect heart valves
● Less common with improved ABX therapy
● Subacute affects those with pre-existing valve disease
○ Develops over months
● Acute affects those with no diseased valves
○ Develops rapidly and is progressive
● Caused by IV drug use or infection (bacterial, viral, or fungal)
● Turbulent blood flow within the heart allows microorganisms to infect valves
● Vegetations form and stick to the surface of valves
● Can break off and enter circulation and become emboli
○ Affects 50% of those with IE and results in organ damage, limb infarction,
pulmonary emboli, or stroke
● Cardiac Risk Factors
○ Prior IE
○ Prosthetic valve
○ Acquired valve disease
○ Rheumatic heart disease
○ Congenital heart disease
○ Marfan’s syndrom
○ Cardiomyopathy
● Non-cardiac Risk Factors
○ Hospital acquired sepsis
○ IV drug use
○ Infection
■ Staphylococcus and Streptococcus
○ Invasive procedures
IE: Clinical Manifestations -
● Mostly non-specific
○ Low grade fever and chills
○ Weakness and fatigue
○ Malaise
○ Anorexia
● Subacute symptoms
○ Arthralgias, myalgias, back pain, abdominal pain, weight loss, HA, and clubbing
of fingertips
● Vascular
○ Splinter hemorrhages
○ Petechiae
○ Osler’s nodes
○ New or changed murmur
■ Affects aortic and mitral valve

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○ HF in 50-80%
IE: Treatment and Care -
● Diagnostic Methods
○ Question about recent dental or surgical procedures
○ Blood cultures x2
○ CBC with differential
○ ESR and CRP levels
○ Echo showing vegetation
● Treatment
○ Long-term IV AB
○ Valve replacement for poor response to AB
○ Symptomatic management
■ Antipyretics
■ Fluids
■ Rest
Pericarditis -
● Inflammation of the pericardial sac
● Associated with viral infections or MI
● Inflammatory response brings in neutrophils and increased blood flow leading to fibrin
deposits
● Symptoms include
○ Sever, sharp chest pain
■ Worse with inspiration
■ Relieved by sitting up & leaning forward
○ Radiates to neck, arms, or L shoulder
○ Tachypnea
○ Fever
○ Pericaridal friction rub (sounds like rubbing two balloons together)
● Complications include
○ Preicardial effusion
■ Fluid build up
■ Distant and muffled heart sounds
○ Cardiac tamponade
■ Large effusion compresses the heart and decreases CO
■ Muffled heart sounds, narrowed pulse pressure and JVD
● DX Tests
○ ECG
■ Rule out MI
○ Echo
■ Best for visualizing effusion
○ EBC, ESR, CRP
■ Measures inflammation
● Treatment
○ Underlying cause

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○ AB and NSAIDS
○ Pericardiocentesis
■ Immediately drain fluid
○ Pericardial window
■ Continuous drainage

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Congenital Heart Defects

Congenital Heart Defects -
● Fetal heart develops by 8 weeks gestation
● Causes
○ Alcohol use
○ Drug use
○ Infection
○ Advanced maternal age
● Classified as acyanotic or cyanotic
Defects in the Septum -
● Atrial-Septal Defect (ASD)
○ Pathophysiology:
■ Incomplete formation of the septal wall between the L and R atrium
○ Signs/Symptoms:
■ Murmur
■ Fluid overload
○ Treatment:
■ Spontaneously close
■ Surgery
○ Nursing Care:
● Ventricular-Septal Defect (ASD)
○ Pathophysiology:
■ Incomplete closure of the septal wall between the L and R ventricle
○ Signs/Symptoms:
■ Usually asymptomatic
■ R sided failure
■ Murmur
○ Treatment:
■ Surgery
○ Nursing Care:
Defects of the Vessels and Valves -
● Patent Ductus Arteriosus (PDA)
○ Pathophysiology:
■ Failure of duct to close after birth
○ Signs/Symptoms:
■ Murmur
■ Right failure
○ Treatment:
■ Indomethacin
■ Surgery
○ Nursing Care:
● Coarctation of the Aorta
○ Pathophysiology:
■ Narrowing of the aortic arch or descending aorta

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○ Signs/Symptoms:
■ High BP and bounding pulse in upper extremities
■ BP in lower extremities is at least 10 points lower than in the upper
extremities
○ Treatment:
■ Surgery
○ Nursing Care:
Combination Defects -
● Tetralogy of Fallot
○ Pathophysiology:
■ Combination of 4 different defects that occur together
○ Signs/Symptoms:
■ Cyanosis
■ Squatting position
○ Treatment:
■ Meds, oxygen
■ Surgery
○ Nursing Care:
Parent Education -
● Co-existing heart failure
● Age of child r/t signs and symptoms
● Focus on:
○ Oxygen nutrition
○ Promoting growth
○ Providing opportunities for normal development

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Test Breakdown -
● 100 pts
○ 13 - Coronary Artery Disease
○ 12 - MI
○ 14 - Heart Failure
○ 6 - Valves
○ 8 - Diagnostic Tests (Handout)
○ 7 - Multiple Choice (Rhythms)
○ 20 - Meds
○ 4 - Peds Questions
○ 1 - Short Answer (Three Points)
○ 5 - Math
○ 4 - Rhythm Strip (2 points each - 1 for correct rhythm & 1 for correct numbering)

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