CARDIAC

SYSTEM
Case Study
 75 y/o man admitted to your floor for CHF exacerbation
 Multiple hospitalizations over the last year related to
exacerbations (dyspnea and fluid overload).
 He doesn’t understand why he has “heart failure” when
he can’t breathe…he thinks it is a respiratory problem,
not cardiac.
 How do you explain this to him?
Anatomy Review
Heart Chambers
 Left & Right Atrium
 Left & Right Ventricle
Valves
 Atrioventricular
o Tricuspid Valve
o Mitral Valve
 Semilunar
o Pulmonic Valve
o Aortic
Review Continued
• Coronary Arteries
• Left Coronary Artery
• Right Coronary Artery
• Myocardium
Normal cardiac cycle

Click here for video

Blood flow video here

Functions of the heart

Cardiac Electrophysiology
 Electric impulses that stimulate myocardium contraction
 SA & AV Nodes
 Bundle of His
 Purkinje Fibers
 Cardiac Action Potential
Normal cardiac electrophysiology
Quiz question 1
Review of Cardiac Action Potential
Cardiac Output
 Total amount of blood ejected by a ventricle in 1 min.
 CO=HRxSV
 Average CO in a resting adult is 4-6 L/min
 CO changes depending on needs****
o Metabolic demands of tissue
o Stress
o Exercise
o Illness
Gerontologic cardiovascular changes
 Loss of cellular function in conduction system  slower
heart rate
 Size of heart increases due to hypertrophy  reduces
volume of blood that heart chambers can hold
 Decrease in strength of contractions from hypertrophy
and changes in the structure of myocardium
 ***These all negatively impact cardiac output!
 Valves stiffen  results in backflow  murmurs
Gerontologic cardiovascular changes
 Longer for the body to compensate
 Older adults become symptomatic
• Fatigue, dyspnea, palpitations
 Decrease in strength of contractions from hypertrophy
and changes in the structure of myocardium
Gender considerations

■ Women develop CAD later than men

■ Anatomical differences
■ Estrogen
– Increased HDL
– Reduction in LDL
– Dilation of blood vessels
– What happens to women around age 50 that changes all of this?
Symptoms of abnormal pathophysiology

■ The most common symptom is chest pain/discomfort

■ Other common symptoms:
– Epigastric discomfort
– Nausea / vomiting
– Diaphoresis
– Syncope
– Shortness of breath (SOB) / dyspnea
– Pain between the shoulders / jawline
– Change in mental status and unexplained falls in older adults
General cardiac diagnostics
■ Myocardial infarction (MI): 12 lead EKG, cardiac labs (troponin, CK)
■ Blood chemistries: BUN, Ca, Creat, Mag, K, Na
■ Coagulation studies: PTT, aPTT, PT, INR
■ Hematologic studies: CBC, Hgb, Hct, plts, WBC
■ Lipid profile
■ Cholesterol
■ Triglycerides
■ BNP
■ CRP
■ CXR
■ Echocardiogram
■ Cardiac catheterization
Dysrhythmias
■ A dysrhythmia is:
– Disruption in the cardiac conduction pathway or
– Disorders of the electrical impulse conduction within the heart
– Or both
■ Can cause a disturbance of:
– Rate
– Rhythm
– Or both
■ Can possibly alter blood flow and cause hemodynamic changes
■ Diagnosed by analysis of electrographic waveform
Dysrhythmias
■ Atrial
– Premature atrial contractions (PACs)
– Atrial fibrillation (AF)
– Atrial flutter

■ Ventricular
– Premature ventricular contractions (PVCs)
– Ventricular tachycardia (VT)
– Ventricular fibrillation (VF)
– Ventricular asystole
Conduction abnormalities
(heart blocks)
■ First-degree AV block
■ Second-degree AV block type I
■ Second-degree AV block type II
■ Third-degree AV block
Expected exam findings
Quiz question

The nurse is assessing a patient admitted with a heart block. When placed on a
monitor, the patient’s electrical rhythm displays as progressively longer PR
durations until there is a nonconducted P wave. Which type of heart block does the
nurse expect that this patient has?
1. First-degree
2. Second-degree type I
3. Second-degree type II
4. Third degree
Quiz answer

2. Second-degree type I

Rationale: In first-degree heart block, the PR is constant but greater than 0.20
seconds. Second-degree AV block type II has a constant PR interval and the
presence of more P waves than QRS complexes. Third-degree AV block presents
with irregular PR intervals.
Second-degree block type I
(wenkebach)

Figure 29.28
Coronary artery disease
Pathophysiology

Figure 30.2
Coronary arteries
Clinical manifestations
■ Angina pectoris
■ Symptoms caused by ischemia to the myocardial tissue
■ Symptoms & complications r/t location and degree of obstruction to vessel
■ Possible symptoms:
– Epigastric distress, pain radiating to jaw or left arm, SOB
– Atypical symptoms in women
■ Myocardial infarction
■ Heart failure
■ Sudden cardiac death
CAD risk factors

■ Modifiable risk factors cited as major:

– Cholesterol abnormalities
– Tobacco use
– HTN
– Diabetes
■ Elevated LDL: primary target for cholesterol-lowering meds
■ Metabolic syndrome
■ Hs-CRP (high sensitivity C-reactive protein)
■ See table 30.1 in text
CAD prevention

■ Control cholesterol
■ Dietary measures
■ Physical activity
■ Meds
■ Cessation of tobacco use
■ Manage HTN
■ Control diabetes
Pathophysiology
Laboratory goals

■ American College of Cardiology & AHA

– LDL < 100 mg/dL (or less than 70 for high-risk patients)
– Total cholesterol < 200 mg/dL
– HDL
• Males > 40 mg/dL
• Females > 50 mg/dL
– Triglyceride < 150 mg/dL

■ Target is LDL lowering via meds / diet / lifestyle modifications

Angina

■ Characterized by episodes or paroxysmal pain or pressure in the

anterior chest caused by insufficient coronary blood flow.
■ Physical exertion or emotional stress increases myocardial oxygen
demand, and the coronary vessels are unable to supply sufficient
blood flow to meet the oxygen demand.
■ Stable and unstable angina
Angina assessment and findings

■ Pain that may radiate to the left arm, back, neck, and jaw.
■ Chest pressure, SOB, dyspnea, fatigue, nausea, vomiting, diaphoresis,
weakness, syncope, and epigastric discomfort.
■ May be describe as tightness, choking, or a heavy sensation.
■ Anxiety is often present with the pain.
■ Stable angina: pain is often alleviated with rest and/or meds (NTG)
■ Unstable angina: increased frequency and severity, not relieved by rest or NTG.
– Requires medical intervention!
Angina pathophysiology

■ Caused by atherosclerotic disease

■ Significant obstruction of one major artery
■ When demand increases (exercise), flow needs to also increase
■ When there is a blockage, flow can’t increase and ischemia results
Gerontologic considerations

■ 33% of pts with CAD are over 75

■ Diminished pain transition that occurs with aging may affect presentation of
symptoms
■ Teach older adults to recognize their ‘chest pain-like’ symptoms (i.e., weakness)
■ Pharmacologic stress testing; cardiac catheterization
■ Meds should be used cautiously!
Acute coronary syndrome (ACS) &
Myocardial Infarction (MI)
■ Emergent situation
■ Characterized by the destruction of heart muscle from lack of oxygenated blood
supply.
– Results in myocardial death (ex: MI) if interventions do not promptly occur
– The most common cause of obstruction is atherosclerosis

■ Other terms you may see: coronary occlusion, heart attack

– MI is the preferred term
ACS & MI pathophysiology

■ Unstable angina – reduced blood flow in coronary artery (rupture of a plaque)

■ Cloth formation can develop (not completely occlude artery)
– Can result in chest pain
■ Will likely have MI if there is no intervention

■ MI – plaque rupture and thrombus formation results in complete occlusion of

artery
■ This leads to ischemia and necrosis of the myocardium supplied by that specific
artery
Pathophysiology continued
■ Other causes of MI
– Vasospasm, decreased oxygen supply (blood loss or low BP),
increased O2 demand (rapid HR or ingestion of drugs)
■ **All abnormal pathology surrounds profound imbalance between
myocardial oxygen and demand
■ Area of infarction develops over minutes to hours
■ Every 43 seconds an American will have an MI
■ Early recognition and intervention is key
Coronary artery bypass grafts

Figure 32.11
Veins commonly used for bypass
graft procedures

Greater & lesser

saphenous veins
Photo: myheart.net
Valvular disease
■ Mitral valve prolapse
■ Mitral stenosis
■ Aortic stenosis

Terms:
PATHOPHYSIOLOGY
Mitral valve
prolapse
 Mitral
stenosis
 Aortic
stenosis
Cardiomyopathy

■ A disorder in which the heart muscle becomes weak.

■ A series of progressive events that culminates in impaired sudden cardiac
output and can lead to heart failure, sudden death, or dysrhythmias.
■ Types:
– Dilated cardiomyopathy (DCM)
– Hypertrophic cardiomyopathy (HCM)
– Restrictive/constrictive cardiomyopathy (RCM)
– Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D)
– Unclassified cardiomyopathy
Question #2

What is the main electrolyte involved in cardiomyopathy?

1. Calcium
2. Phosphorus
3. Potassium
4. Sodium
Answer to question #2

4. Sodium

Rationale: Sodium is the major electrolyte involved with cardiomyopathy.

Cardiomyopathy often leads to heart failure, which develops, in part, from fluid
overload. Fluid overload is often associated with elevated sodium levels.
Congestive heart failure

■ Heart failure is a progressive disease characterized by myocardial cell

dysfunction, resulting in the inability of the heart to pump enough cardiac output
to meet the demands of the body
■ HF historically has been referred to as congestive heart failure (CHF) because
many patients experience pulmonary or peripheral congestion with edema.
■ HF is recognized as a clinical syndrome characterized by signs and symptoms
of fluid overload or inadequate tissue perfusion.
Heart failure continued

■ Heart failure indicates myocardial disease, where there is a problem with the
contraction of the heart (systolic failure) or filling of the heart (diastolic failure)
■ Some cases are reversible depending on the cause
■ Most HF is a chronic, progressive condition managed with lifestyle changes and
medications
Chronic HF

■ HF is more common in people who are 65 or older

■ Almost 7 million people have HF

■ HF is a leading cause of hospitalizations among persons 65 and older

■ HF hospitalizations have increased 26% since 2012

Pathophysiology
of HF
Clinical manifestations
Table 30.5

Right sided Left sided

Jugular vein distention (JVD) SOB, dyspnea, orthopnea
Dependent edema Crackles on auscultation
Hepatomegaly Pale color, weak pulses, cool
temperature in extremities, delayed
capillary refill
Ascites Fatigue, weakness
Weight gain Dry, nonproductive cough initially
Viscera and peripheral congestion Low O2 saturation
Oliguria
Gerontologic considerations

■ Normal age-related changes

■ Reasons for increased hospitalizations
– Can not detect symptoms as easily
– Attribute s/sx of other things (dyspnea or fatigue)
– Decreased renal function
CHF interactive learning

Video 1

CHF case study

Hypertension (HTN)

■ AKA high blood pressure

■ 47% of adults have HTN
■ The American College of Cardiology/American Heart Association (ACC/AHA)
defines hypertension as a systolic blood pressure (SBP) of 130 mm Hg or
higher and/or a diastolic blood pressure (DBP) of 80 mm Hg or higher.
Hypertension guidelines
Hypertension
“The silent killer”

■ Essential or Primary HTN:

– Accounts for 90% to 95% of patients
– Has no identifiable medical cause
■ Secondary HTN:
– Responsible for 2% to 5% of patients
– Caused by: renal parenchymal disease, sleep apnea, pregnancy related,
etc.
■ HTN control is at 16.1% with a target of 18.9% per Healthy People 2030.
■ Highest prevalence is black adults in the United States
HYPERTENSION PATHOPHYSIOLOGY
Clinical manifestations

■ Typically, none evident other than elevated BP

■ Symptoms arise after long-term increased BP has resulted in target organ
damage (TOD) and are serious
– Retinal and other eye changes
– Renal damage
– Myocardial infarction
– Cardiac hypertrophy
– Stroke
HTN risk factors
■ HTN
■ Smoking
■ Obesity
■ Physical inactivity
■ Dyslipidemia
■ Diabetes mellitus
■ Microalbuminuria or GFR <60 mL/min
■ Older age
■ Family history
HTN CASE STUDY
NCLEX
REVIEW
QUESTIONS
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