Coronary Heart Disease CHD Leading cause of

Coronary Heart Disease (CHD) • Leading cause of death in U. S. • Narrowing coronary arteries – Atherosclerosis

Angina Pectoris Pathophysiology • • • Obstructed coronary artery Increased myocardial oxygen demand Lactic acid release Leads to pain Three types – Stable – Unstable – Prinzmetal’s: is a syndrome typically consisting of angina (cardiac chest pain) at rest that occurs in cycles. It is caused by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than directly by atherosclerosis

Angina Pectoris Manifestations • • • Chest pain Radiates Onset with exercise, etc. Relieved by rest, nitroglycerin (NTG) SOB, pallor, fear

Acute Coronary Syndrome • Condition that includes: – Unstable angina – Acute myocardial ischemia with or without muscle damage • Associated with coronary artery stenosis and atherosclerotic plaque

Acute Myocardial Infarction (AMI) • Pathophysiology – Occluded coronary artery stops blood flow to part of cardiac muscle – Cellular death – Tissue necrosis – Description—heart area affected – Classification

AMI Manifestations • • Chest pain Radiates to shoulder, neck, jaw, arms Lasts longer than 15– 20 minutes Not relieved with NTG Sense of impending doom SOB Diaphoresis Nausea and vomiting

AMI Manifestations (continued) • Manifestations in women and elderly – May be atypical – Upper abdominal pain – No chest pain but other symptoms

AMI Complications • Related to size and location of infarct • Dysrhythmias • Pump failure – Cardiogenic shock • Pericarditis

Cardiac Dysrhythmias • Pathophysiology – Due to altered formation of impulses or altered conduction of the impulse through the heart – Ectopic beats – Heart block – Reentry phenomenon – Classified to the site of impulse formation or the site and degree of conduction block

Types of Cardiac Dysrhythmias (continued) • • PVCs Ventricular tachycardia Ventricular fibrillation AV conduction blocks – First degree – Second degree – Third degree

Types of Cardiac Dysrhythmias • • Supraventricular Sinus tachycardia Sinus bradycardia PAC Atrial flutter Atrial fibrillation Junctional Ventricular dysrhythmias

ECG Changes in Angina Pectoris vs. Myocardial Infection

Congestive Heart Failure Dr Ibraheem Bashayreh, RN, Ph. D 04/11/2009 15

Heart failure Normal heart function 04/11/2009 16

Congestive Heart Failure Definition • Impaired cardiac pumping such that heart is unable to pump adequate amount of blood to meet metabolic needs • Not a disease but a “syndrome” • Associated with long-standing HTN and CAD 04/11/2009 17

Factors Affecting Cardiac Output Preload Cardiac Output = CO Heart Rate X Afterload Stroke Volume SV Contractility SV: the volume of blood pumped from one ventricle of the heart with each 18 beat 04/11/2009

Factors Affecting Cardiac Output • Heart Rate – In general, the higher the heart rate, the lower the cardiac • E. g. HR x Systolic Volume (SV) = CO » 60/min x 80 ml = 4800 ml/min (4. 8 L/min) » 70/min x 80 ml = 5600 ml/min (5. 6 L/min) – But only up to a point. With excessively high heart rates, diastolic filling time begins to fall, thus causing stroke volume and thus CO to fall 04/11/2009 19

Heart Rate Stroke Volume Cardiac Output 60/min 80 ml 4. 8 L/min 80/ml 6. 4 L/min 100/min 80/ml 8. 0 L/min 130/min 50/ml 6. 5 L/min 150/min 40/ml 6. 0 L/min 04/11/2009 20

Factors Affecting Cardiac Output • Preload – The volume of blood/amount of fiber stretch in the ventricles at the end of diastole (i. e. , before the next contraction) 04/11/2009 21

Factors Affecting Cardiac Output • Preload increases with: • Fluid volume increases • Vasoconstriction (“squeezes” blood from vascular system into heart) • Preload decreases with • Fluid volume losses • Vasodilation (able to “hold” more blood, therefore less returning toheart) 04/11/2009 22

Factors Affecting Cardiac Output • Starling’s Law – Describes the relationship between preload and cardiac output – The greater the heart muscle fibers are stretched (b/c of increases in volume), the greater their subsequent force of contraction – but only up to a point. Beyond that point, fibers get over-stretched and the force of contraction is reduced • Excessive preload = excessive stretch → reduced contraction → reduced SV/CO 04/11/2009 23

Factors Affecting Cardiac Output • Afterload – The resistance against which the ventricle must pump. Excessive afterload = difficult to pump blood → reduced CO/SV – Afterload increased with: • Hypertension • Vasoconstriction – Afterload decreased with: • Vasodilation 04/11/2009 24

Factors Affecting Cardiac Output • Contractility – Ability of the heart muscle to contract; relates to the strength of contraction. 04/11/2009 25

Factors Affecting Cardiac Output • Contractility decreased with: – – infarcted tissue – no contractile strength ischemic tissue – reduced contractile strength. Electrolyte/acid-base imbalance Negative inotropes (medications that decrease contractility, such as beta blockers). • Contractility increased with: – Sympathetic stimulation (effects of epinephrine) – Positive inotropes (medications that increase contractility, such as digoxin, sympathomimmetics) 04/11/2009 26

Pathophysiology of CHF • Pump fails → decreased stroke volume /CO. • Compensatory mechanisms kick in to increase CO – SNS stimulation → release of epinephrine/norepinephrine • Increase HR • Increase contractility • Peripheral vasoconstriction (increases afterload) – Myocardial hypertrophy: walls of heart thicken to provide more muscle mass → stronger contractions 04/11/2009 27

Pathophysiology of CHF – Hormonal response: ↓’d renal perfusion interpreted by juxtaglomerular apparatus as hypovolemia. Thus: • Kidneys release renin, which stimulates conversion of antiotensin I → angiotensin II, which causes: – Aldosterone release → Na retention and water retention (via ADH secretion) – Peripheral vasoconstriction 04/11/2009 28

Pathophysiology of CHF • Compensatory mechanisms may restore CO to near-normal. • But, if excessive the compensatory mechanisms can worsen heart failure because. . . 04/11/2009 29

Pathophysiology of CHF • Vasoconstriction: ↑’s the resistance against which heart has to pump (i. e. , ↑’s afterload), and may therefore ↓ CO • Na and water retention: ↑’s fluid volume, which ↑’s preload. If too much “stretch” (d/t too much fluid) → ↓ strength of contraction and ↓’s CO • Excessive tachycardia → ↓’d diastolic filling time → ↓’d ventricular filling → ↓’d SV and CO 04/11/2009 30

Congestive Heart Failure Risk Factors • CAD • Age • HTN • Obesity • Cigarette smoking • Diabetes mellitus • High cholesterol 04/11/2009 • African descent 31

Heart failure Underlying causes/risk factors • Ischemic heart disease (CAD) 70 % • hypertension • myocardial infarction (MI) • valvular heart disease • congenital heart disease • dilated cardiomyopathy 04/11/2009 32

Congestive Heart Failure Types of Congestive Heart Failure • Left-sided failure – Most common form – Blood backs up through the left atrium into the pulmonary veins • Pulmonary congestion and edema – Eventually leads to biventricular failure 04/11/2009 33

Congestive Heart Failure Types of Congestive Heart Failure • Left-sided failure – Most common cause: • HTN • Cardiomyopathy • Valvular disorders • CAD (myocardial infarction) 04/11/2009 34

Congestive Heart Failure Types of Congestive Heart Failure • Right-sided failure – Results from diseased right ventricle – Blood backs up into right atrium and venous circulation – Causes • LVF • Cor pulmonale: failure of the right side of the heart brought on by long-term high blood pressure in the pulmonary arteries and right ventricle of the heart 04/11/2009 • RV infarction 35

Congestive Heart Failure Types of Congestive Heart Failure • Right-sided failure – Venous congestion • Peripheral edema • Hepatomegaly • Splenomegaly • Jugular venous distension 04/11/2009 36

Congestive Heart Failure Types of Congestive Heart Failure • Right-sided failure – Primary cause is left-sided failure – Cor pulmonale • RV dilation and hypertrophy caused by pulmonary pathology 04/11/2009 37

Acute Congestive Heart Failure Clinical Manifestations • Pulmonary edema (what will you hear? ) – Agitation – Pale or cyanotic – Cold, clammy skin – Severe dyspnea – Tachypnea – Pink, frothy sputum 04/11/2009 38

Chronic Congestive Heart Failure Clinical Manifestations • Fatigue • Dyspnea – Paroxysmal nocturnal dyspnea (PND) • Tachycardia • Edema – (lung, liver, abdomen, legs) • Nocturia 04/11/2009 39

Chronic Congestive Heart Failure Clinical Manifestations • Behavioral changes – Restlessness, confusion, attention span • Chest pain (d/t CO and ↑ myocardial work) • Weight changes (r/t fluid retention) • Skin changes – Dusky appearance 04/11/2009 40

Congestive Heart Failure Classification • Based on the person’s tolerance to physical activity – Class 1: No limitation of physical activity – Class 2: Slight limitation – Class 3: Marked limitation – Class 4: Inability to carry on any physical activity without discomfort 04/11/2009 41

Congestive Heart Failure Diagnostic Studies • Primary goal is to determine underlying cause – Physical exam – Chest x-ray – ECG – Hemodynamic assessment 04/11/2009 42

Congestive Heart Failure Diagnostic Studies • Primary goal is to determine underlying cause – Echocardiogram (Uses ultrasound to visualize myocardial structures and movement, calculate EF) – Cardiac catheterization 04/11/2009 43

Acute Congestive Heart Failure Nursing and Collaborative Management • Primary goal is to improve LV function by: – Decreasing intravascular volume – Decreasing venous return – Decreasing afterload – Improving gas exchange and oxygenation – Improving cardiac function – Reducing anxiety 04/11/2009 44

Acute Congestive Heart Failure Nursing and Collaborative Management • Decreasing intravascular volume – Improves LV function by reducing venous return – Loop diuretic: drug of choice – Reduces preload – High Fowler’s position 04/11/2009 45

Acute Congestive Heart Failure Nursing and Collaborative Management • Decreasing afterload – Drug therapy: • vasodilation, Angiotensin-converting enzyme (ACE) inhibitors – Decreases pulmonary congestion 04/11/2009 46

Acute Congestive Heart Failure Nursing and Collaborative Management • Improving cardiac function – Positive inotropes • Improving gas exchange and oxygenation – Administer oxygen, sometimes intubate and ventilate • Reducing anxiety – Morphine 04/11/2009 47

Chronic Congestive Heart Failure Collaborative Care • Treat underlying cause • Maximize CO • Alleviate symptoms 04/11/2009 48

Chronic Congestive Heart Failure Collaborative Care • • Oxygen treatment Rest Biventricular pacing Cardiac transplantation 04/11/2009 49

Chronic Congestive Heart Failure Drug Therapy • ACE inhibitors • Diuretics • Inotropic drugs : drugs that influence the force of contraction of cardiac muscle • Vasodilators • -Adrenergic blockers 04/11/2009 50

Chronic Congestive Heart Failure Nutritional Therapy • Fluid restrictions not commonly prescribed • Sodium restriction – 2 g sodium diet • Daily weights – Same time each day – Wearing same type of clothing 04/11/2009 51

Chronic Congestive Heart Failure Nursing Management Nursing Assessment • • Past health history Medications Functional health problems Cold, diaphoretic skin 04/11/2009 52

Chronic Congestive Heart Failure Nursing Management Nursing Assessment • • • Tachypnea Tachycardia Crackles Abdominal distension Restlessness 04/11/2009 53

Chronic Congestive Heart Failure Nursing Management Nursing Diagnoses • • • Activity intolerance Excess fluid volume Disturbed sleep pattern Impaired gas exchange Anxiety 04/11/2009 54

Chronic Congestive Heart Failure Nursing Management Planning • Overall goals: – Peripheral edema – Shortness of breath – Exercise tolerance – Drug compliance – No complications 04/11/2009 55

Chronic Congestive Heart Failure Nursing Management Nursing Implementation • Acute intervention – Establishment of quality of life goals – Symptom management – Conservation of physical/emotional energy – Support systems are essential 04/11/2009 56

What is Blood Pressure? • The force of blood against the wall of the arteries. • Systolic- as the heart beats • Diastolic - as the heart relaxes • Written as systolic over diastolic. • Normal Blood pressure is less than 130 mm Hg systolic and less than 85 mm Hg diastolic. 04/11/2009 57

High Blood Pressure • A consistent blood pressure of 140/90 mm Hg or higher is considered high blood pressure. • It increases chance for heart disease, kidney disease, and for having a stroke. • 1 out of 4 Americans have High Bp. • Has no warning signs or symptoms. 04/11/2009 58

Why is High Blood Pressure Important? • • Makes the Heart work too hard. Makes the walls of arteries hard. Increases risk for heart disease and stroke. Can cause heart failure, kidney disease, and blindness. 04/11/2009 59

How Does It Effect the Body? The Brain • High blood pressure is the most important risk factor for stroke. • Can cause a break in a weakened blood vessel which then bleeds in the brain. 04/11/2009 60

The Heart • High Blood Pressure is a major risk factor for heart attack. • Is the number one risk factor for Congestive Heart Failure. 04/11/2009 61

The Kidneys • Kidneys act as filters to rid the body of wastes. • High blood pressure can narrow and thicken the blood vessels. • Waste builds up in the blood, can result in kidney damage. 04/11/2009 62

The Eyes • Can eventually cause blood vessels to break and bleed in the eye. • Can result in blurred vision or even blindness. 04/11/2009 63

The Arteries • Causes arteries to harden. • This in turn causes the kidneys and heart to work harder. • Contributes to a number of problems. 04/11/2009 64

What causes High Blood Pressure? • • Causes vary Narrowing of the arteries Greater than normal volume of blood Heart beating faster or more forcefully than it should • Another medical problem • The exact cause is not known. 04/11/2009 65

Who can develop High Blood Pressure? • Anyone, but it is more common in: • African Americans- get it earlier and more often then Caucasians. • As we get older. 60% of Americans over 60 have hypertension. • Overweight, family history • High normal bp: 135 -139/85 -89 mm Hg. 04/11/2009 66

Detection • Dr. ’s will diagnose a person with 2 or more readings of 140/90 mm Hg or higher taken on more than one occasion. • White-Coat Hypertension • Measured using a spygmomameter. 04/11/2009 67

Tips for Having your blood pressure taken. • Don’t drink coffee or smoke cigarettes for 30 minutes before. • Before test sit for five minutes with back supported and feet flat on the ground. Test your arm on a table even with your heart. • Wear short sleeves so your arm is exposed. 04/11/2009 68

Tips for having blood pressure taken. • Go to the bathroom before test. A full bladder can affect bp reading. • Get 2 readings and average the two of them. • Ask the Dr. or nurse to tell you the result in numbers. 04/11/2009 69

Categories of High Blood Pressure • • • Ages 18 Years and Older) Blood Pressure Level (mm Hg) Category Systolic Diastolic Optimal** < 120 < 80 Normal < 130 < 85 High Normal 130– 139 85– 89 04/11/2009 70

Categories of High Blood Pressure • • • 04/11/2009 Stage 1 Stage 2 Stage 3 140– 159 /90– 99 160– 179 /100– 109 180 /110 71

Preventing Hypertension Adopt a healthy lifestyle by: • • • Following a healthy eating pattern. Maintaining a healthy weight. Being Physically Active. Limiting Alcohol. Quitting Smoking. 04/11/2009 72

DASH diet • • • Dietary Approaches to Stop Hypertension. Was an 11 week trial. Differences from the food pyramid: an increase of 1 daily serving of veggies. and increase of 1 -2 servings of fruit. inclusion of 4 -5 servings of nuts, seeds, and beans. 04/11/2009 73

Tips for Reducing Sodium • Buy fresh, plain frozen or canned “no added salt” veggies. • Use fresh poultry, lean meat, and fish. • Use herbs, spices, and salt-free seasonings at the table and while cooking. • Choose convenience foods low in salt. • Rinse canned foods to reduce sodium. 04/11/2009 74

Maintain Healthy Weight • Blood pressure rises as weight rises. • Obesity is also a risk factor for heart disease. • Even a 10# weight loss can reduce blood pressure. 04/11/2009 75

Be Physically Active • Helps lower blood pressure and lose/ maintain weight. • 30 minutes of moderate level activity on most days of week. Can even break it up into 10 minute sessions. • Use stairs instead of elevator, get off bus 2 stops early, Park your car at the far end of the lot and walk! 04/11/2009 76

Limit Alcohol Intake Alcohol raises blood pressure and can harm liver, brain, and heart 04/11/2009 77

Quit Smoking • Injures blood vessel walls • Speeds up process of hardening of the arteries. 04/11/2009 78

Other Treatment • If Lifestyle Modification is not working, blood pressure medication may be needed, there are several types: • Diuretics-work on the kidney to remove access water and fluid from body to lower bp. • Beta blockers-reduce impulses to the heart and blood vessels. 04/11/2009 79

Other Treatment • ACE inhibitors- cause blood vessels to relax and blood to flow freely. • Angiotensin antagonists- work the same as ACE inhibitors. • Calcium Channel Blockers- causes the blood vessel to relax and widen. • Alpha Blocker- blocks an impulse to the heart causing blood to flow more freely. 04/11/2009 80

Other Treatment • Alpha-beta blockers- work the same as beta blockers, also slow the heart down. • Nervous system inhibitors- slow nerve impulses to the heart. • Vasodilators- cause blood vessel to widen, allowing blood to flow more freely. 04/11/2009 81

Conclusion • Hypertension is a very controllable disease, with drastic consequences if left uncontrolled. 04/11/2009 82