Coronary Heart Disease

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tiffanydawnn
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134856
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Coronary Heart Disease
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2012-02-28 08:07:18
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Coronary Heart Disease
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Coronary Heart Disease
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  1. heart
    • located in mediastinum of thoracic cavity between vertebral column and sternum
    • flanked by lungs
  2. pericardium
    • protects and anchors, prevents overfilling
    • fibrous: outer layer
    • parietal: middle fluid layer
    • visceral: inner layer
  3. heart wall
    • epicardium: covers entire heart and great vessels
    • myocardium: middle layer, cardiac muscles
    • endocardium: lines chambers and vessels
  4. chambers and valves
    • two upper atria
    • two lower ventricles
  5. blood flow
    SVC/IVC (DOB) > RA > tricuspid > RV > pulmonary valve > pulmonary artery > lungs (DOB<->OB) > pulmonary veins > LA > mitral > LV > aortic valve > aorta (OB)
  6. S1 sound (lubb)
    • closure of AV valves (tricuspid and mitral)
    • onset of ventricular systole
    • ventricular blood pushes up against AV valves and snaps them shut
    • also forces open SL valves
  7. S2 sound (dub)
    • closure of semilunar valves (pulmonary and aortic)
    • onset of ventricular diastole
    • blood falls down from pulm artery and aortic arch d/t gravity
  8. systemic circulation
    • left side of heart, aorta, capillaries, venous system, vena cava
    • high pressure system
    • supplies blood to body tissues
  9. pulmonary circulation
    • right side of heart, pulmonary artery, lungs, pulmonary veins
    • low pressure system
  10. coronary circulation
    L and R coronary arteries from base of aorta encircle myocardium
  11. cardiac cycle
    • contraction and relaxation of the heart (a heart beat)
    • ventricular filling -> ventricular systole (contraction) -> ventricular diastole (relaxation)
    • 70-80 times per minute
  12. stroke volume
    • amount of blood pumped in one cardiac cycle
    • 60-100mL
    • how strong the heart is contracting
  13. ejection fraction
    • SV / end diastolic volume (amount of blood in ventricle at diastole)
    • normal 50-60%
  14. cardiac output
    • amount of blood pumped in one minute
    • SV x HR
    • indicated how well heart is pumping (affects tissue perfusion)
    • normal 4-8L/min
    • represents amount of blood perfusing tissues
    • affected by HR, preload, afterload, contractility
  15. HR
    • increased by SNS
    • decreased by PNS
    • tachycardia -> increased CO
    • bradycardia -> decreased CO
    • very rapid HR decreases ventricular filling time -> CO decreased, coronary artery perfusion decreased (because CAs fill during diastole)
  16. contractility
    • strength of contraction of individual cardiac fibers
    • aka inotropy
    • poor contractility -> decreased CO
  17. preload
    • amount of myocardial stretch at end of diastole (just before contraction)
    • increased volume = increased preload = increased SV and CO
    • decreased volume = decreased preload = reduced SV and CO
  18. afterload
    • force the ventricles must overcome to eject blood
    • pressure in the arterial system ahead of the ventricles
    • right ventricle afterload - PVR (pulmonary vascular resistance)
    • left ventricle afterload - SVR (systemic vascular resistance)
    • increased BP -> increased PVR/SVR -> increased afterload
  19. conduction system
    • several masses of nerve tissue
    • controls rate, rhythm, force of HB
    • SA -> AV -> Bundle of His -> Purkinje fibers
  20. regulation of HR
    • sympathetic fibers
    • --alpha and beta receptors
    • --stimulation increases HR, conduction, force of contractions
    • parasympathetic fibers
    • --SA node, AV node, atrial tissue
    • --stimulation decreases HR, conduction, force of contractions
  21. coronary artery disease
    • impaired blood flow to the myocardium
    • usually caused by atherosclerosis
    • can lead to angina, acute coronary syndrome, MI, dysrhythmias, heart failure, and death
    • chronic ischemic heart disease - stable angina and Prinzmetal angina
    • acute coronary syndrome - unstable angina and MI
  22. myocardial ischemia
    • inadequate O2 supply to myocardium
    • caused by
    • --decreased coronary perfusion (occlusions, narrow vessels, decreased BP)
    • --increased cardiac workload (increased HR, contractility, preload, afterload, metabolism)
    • --decreased blood O2 content (impaired gas exchange, low RBC/Hgb)
    • cellular metabolism switches from aerobic to anaerobic metabolism -> lactic acid -> cell damage -> tissue death
  23. CAD patho
    • plaque accumulates in intimal and medial layers of CA
    • plaque made of lipoproteins and fibrous tissue
    • high LDLs increase risk of atherosclerosis
    • damage to arteries from hyperlipidemia, smoking, infections, toxins, HTN -> inflammation
    • lipids, collagen, debris calcify (atheromas)
    • decreased lumen size -> decreased blood flow
    • atheromas ulcerate or rupture -> thrombosis/embolus
  24. LDL
    • low density lipoproteins
    • bad cholesterol
    • carry cholesterol from liver to peripheral tissues
  25. HDL
    • high density lipoproteins
    • carry cholesterol from peripheral tissues to liver
  26. CAD risk factors
    • non modifiable: genetics, ethnicity, age, gender
    • men > 45, women > 55 (estrogen is heart-protective)
    • modifiable:
    • diet - fruits, veggies, grains, unsaturated fats are protective
    • inactivity - exercise increases O2 to heart, decreases BP
    • smoking - CO damages arterial lining, nicotine increases BP, HR, and vasoconstricts
    • obesity - increased rates of HTN, diabetes, hyperlipidemia
    • HTN - damages lining of arteries, stimulates plaque development
    • diabetes - increases lipid levels, damages lining of arteries
    • hyperlipidemia - LDL deposits cholesterol on arterial wall
    • emerging: inflammation
    • women: oral contraceptives, premature menopause, hormone replacement therapy
  27. metabolic syndrome
    • group of metabolic risk factors
    • truncal obesity
    • hyperlipidemia
    • HTN
    • elevated BGL
    • clotting
    • inflammation
    • insulin resistance
  28. CAD dx
    • lipid profile:
    • CHO < 200
    • HDL > 60
    • LDL < 130
    • triglycerides < 150
    • C-reactive protein: inflammatory mediator (> 3 = risk for CAD)
    • ankle-brachial index < 0.9 = PAD, > risk for CAD
    • exercise ECG: detect myocardial ischemia, chest pain, fatigue, dysrhythmias
    • EBCT: CT scan of heart and CA
    • myocardial perfusion imaging: eval myocardial blood flow and perfusion at rest and under stress
  29. CAD risk factor management
    • quit smoking
    • change diet: low cholesterol, healthy fats, veggies, fiber
    • exercise
    • manage HTN and DM
  30. CAD meds
    • statins
    • bile acid sequestrants
    • nicotinic acid
    • fibrates
    • low dose aspirin
    • ACE/ARBs
  31. statins
    • lower LDL by inhibiting a liver enzyme
    • monitor LFTs
    • s/e: muscle pain, tenderness, brown urine (myopathy - muscle breakdown)
  32. bile acid sequestrants
    • lower LDL by binding bile acids in intestine (prevent reabsorption)
    • s/e: GI upset
  33. nicotinic acid (niacin)
    • lowers LDL, total cholesterol, and triglyceride levels
    • s/e: flushing, increased HR
  34. fibrates
    lower serum triglyceride levels
  35. complementary therapies
    • diet and exercise
    • vitamins
    • omega 3
  36. CAD nursing dx
    • imbalanced nutrition (more) r/t obesity
    • ineffective health maintenance r/t risk factors
  37. angina pectoris
    • chest pain r/t reduced coronary blood flow which causes temporary imbalance between supply and demand
    • imbalance r/t CAD, atherosclerosis, vessel constriction, anemia, heart failure, ventricular hypertrophy, pulmonary disease
  38. exercise, hyperthyroidism, stimulant abuse, stress increase also demand
  39. angina patho
    • lack of O2 causes temporary, reversible myocardial ischemia
    • reduced O2 causes anaerobic metabolism -> lactic acid buildup -> pain
    • three types:
    • --stable
    • --unstable
    • --Prinzmetal
  40. stable angina
    • predictable r/t increased cardiac workload s/t physical exertion, stress, cold
    • relieved by rest and nitrates
  41. Prinzmetal angina
    • aka variant angina
    • chest pain at night, unrelated to activity
    • caused by vasospasm
    • tx: calcium channel blockers
  42. unstable angina
    • unpredictable
    • increasing frequency, severity, duration
    • occurs with stress or at rest
    • risk for MI
  43. angina manifestations (stable)
    • chest pain - tightness, pressure, squeezing, burning, radiates to jaw or left arm
    • --lasts < 15 minutes
    • --relieved by rest
    • indigestion, nausea, vomiting, upper back pain (women)
    • unstable: dyspnea, pallor, tachycardia, anxiety, fear
  44. angina dx
    • EKG - 1st test - cardiac conduction changes with ischemia
    • stress EKG
    • radionuclide testing - eval myocardial perfusion and L ventricular function
    • coronary angiography
    • --aka cardiac cath
    • --gold standard for coronary artery eval
    • --cath into femoral or brachial artery
    • --dye injected to visualize CA branches
  45. angina meds
    • goal: reduce O2 demand and increase O2 supply
    • nitrates
    • beta blockers
    • calcium channel blockers
    • aspirin
  46. nitrates
    • dilates veins and arteries to decrease myocardial work and O2 demand
    • vasodilation reduces preload and afterload
    • SL, IV, transdermal, PO (Indur)
    • s/e: HA, hypotension (r/t systemic dilation)
    • at home: take one, sit down, if no relief in 5 min call 911
    • at hosp: check BP, O2, give nitro, wait 5 min, repeat x 3 then get EKG and call MD
  47. beta blockers
    • stable angina
    • prevent anginal attacks by blocking epi/norepi (which stimulate heart)
    • reduce HR, myocardial contractility, BP -> reduced myocardial demand
    • contraindicated asthma/COPD - bronchospasm, bradycardia
    • use with caution in HF
  48. calcium channel blockers
    • stable angina
    • prevent attacks by reducing myocardial demand, increasing myocardial O2 supply
    • reduce BP, contractility, HR - reduce demand
    • potent coronary vasodilator - increase supply
    • use with caution in dysrhythmias, HF, hypotension
  49. aspirin
    • prophylaxis
    • reduce risk of platelet aggregation and thrombus formation
    • prevents clots -> MI
  50. angina nursing dx
    ineffective tissue perfusion, cardiac r/t impaired cardiac blood flow
  51. acute coronary syndrome
    • unstable cardiac ischemia - acute angina and acute MI
    • patho: coronary blood flow reduced but not fully occluded -> ischemia -> reduced contraction -> reduced output
    • results in injured myocardial cells
    • caused by:
    • --plaque rupture -> blood clot
    • --CA spasm
    • --progressive CA obstruction
    • --CA inflammation
    • --increased O2 demand/decreased O2 supply (blood loss, anemia)
  52. ACS manifestations
    • chest pain - substernal or epigastric that lasts longer than 10-20 minutes
    • more severe and prolonged than angina
    • dyspnea, diaphoresis, pallor, cool skin, tachycardia, hypotension (r/t decreased CO)
  53. ACS dx
    • CK/CK-MB - WNL or transient elevation
    • troponin - elevated (myocardial damage)
    • EKG - changes in cardiac conduction
  54. ACS meds
    • goal: reduce ischemia, reduce risk of clotting
    • fibrinolytics - clot busters (rarely used)
    • nitrates
    • beta blockers
    • aspirin, Plavix (antiplatelet) - bleeding/hemorrhage (bruising, petechiae, purpura, occult bleeding)
  55. revascularization
    • restore blood flow and O2 to ischemic tissue
    • nonsurgical:
    • --PTCA
    • --intracoronary stents
    • surgical:
    • CABG
  56. PTCA
    • percutaneous transluminal coronary angioplasty
    • treats stable angina unrelieved by meds, unstable angina, acute MI, LCA stenosis, CABG stenosis
    • arterial catheter guided into coronary artery
    • guide wire threaded through catheter
    • balloon threaded over guide wire and inflated for 30 sec to 2 mins
    • compresses plaque against arterial wall, reduces occlusion
  57. intracoronary stent
    • cardiac cath procedure
    • usually done with PTCA
    • metallic stent is placed over balloon and threaded over guide wire
    • after balloon inflation/removal, stent is left in artery
    • Plavix for 1 year after procedure
    • risk for clotting, bleeding
    • monitor BP, chest pain, hemorrhage
  58. CABG
    • coronary artery bypass graft
    • surgery that uses a section of a vessel to create a bypass from aorta to coronary artery
    • bypasses area of obstruction
    • open heart surgery
  59. MIDCAB
    minimally invasive coronary artery bypass
  60. TMLR
    transmyocardial laser revascularization
  61. acute myocardial infarction
    • necrosis of myocardial cells
    • loss of function -> reduced cardiac output -> cardiogenic shock
  62. MI patho
    • usually caused by unstable lesions that rupture -> thrombus formation
    • complete blockage of blood flow -> prolonged tissue ischemia -> irreversible cell damage (> 20-45 mins)
    • cellular acidosis, electrolyte imbalances, hormones -> conduction changes -> decreased contractility -> decreased SV, CO, BP, tissue perfusion
  63. MI manifestations
    • severe, crushing chest pain - sudden onset, unrelieved by rest or nitro
    • women/elderly: atypical chest pain - indigestion, heartburn, nausea, vomiting
    • SNS stimulation: anxiety, tachycardia, cool, clammy skin (vasoconstriction)
    • tachypnea
  64. MI complications
    • dysrhythmias - most frequent complication
    • pump failure - reduced cardiac contractility, ventricular wall motion, compliance -> heart failure
    • cardiogenic shock - impaired tissue perfusion r/t pump failure
    • infarct extension and expansion - continued myocardial necrosis
    • structural defects - aneurysms, valve defects
    • pericarditis - r/t inflammatory response s/t tissue death
  65. MI dx
    • serum cardiac markers - ordered on admission + 3 days
    • --CK - 4-6 hours after MI
    • --CK-MB > 5% = MI
    • --troponin
    • CBC - elevated WBC
    • ESR - inflammation
    • ABGs
    • EKG - conduction changes
    • Echo - eval cardiac wall motion and LV function (decreased contraction)
    • hemodynamic monitoring
  66. MI meds
    • NOMA
    • nitro/O2/morphine/asa
    • fibrinolytics
    • antidysrhythmics
    • beta-blockers
    • ACE inhibitors
  67. MI tx
    • bedrest 12 hours
    • gradual increase in activity
    • quiet environment
    • cardiac diet

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