Cardiovascular Assessment

Heart Anatomy
Facts:

The heart is about the size of a fist and

weighs less than 1 pound The average bpm is 72

The average adult heart pumps about 6000-

7 00 liters of blood per da! through 60"000 miles of blood vessels each minute at rest#

Heart
$tructure
%overed b! pericardium &arietal 'isceral (epicardium) *uter heart la!er: epicardium +iddle heart la!er: m!ocardium ,nner la!er: endocardium

The internal anatomy of the heart.

Heart
$tructure

(continued)

Four hollow chambers Two upper" atria Two lower" ventricles -ivided b! septum and valves

Heart
Function
.ight atrium receives

deo/!genated blood .ight ventricle pumps blood to lungs

Heart
Function

(continued)

0eft atrium receives o/!genated blood 0eft ventricle pumps o/!genated blood to

bod! 1' valve closure: $1 heart sound $emilunar valve closure: $2 heart sound %oronar! circulation

The coronary arteries.

10

Peripheral Vascular System

1orta"

arteries" arterioles" capillaries 'enules" veins" superior and inferior vena cava Three la!ers
,ntima +edia 1dventitia

Structure of arteries, veins, and capillaries.

Peripheral Vascular System

Function
%irculation &eripheral vascular resistance: viscosit!"

length" diameter 2lood pressure control

Mechanical Properties of the Heart

+echanical
%onduction s!stem

Mechanical Properties of the Heart (continued)

+echanical
$1 node: pacema3er %ardiac output (%*) 4eart rate (4.) $tro3e volume ($'): the volume of blood

pumped from one ventricle of the heart with each beat %* 5 4. / $'

Mechanical Properties of the Heart (continued)

+echanical
%ardiac reserve &reload $tarling6s law 1fterload %ontractilit!

Electrical Properties of the Heart

7lectrical

properties:

1ction potential &olarization -epolarization .epolarization .efractor! period

Electrical Properties of the Heart (continued)

Filling

and pumping

-iastole 8 ventricular filling $!stole 8ventricles e9ect blood

The cardiac cycle. Ventricular filling occurs during diastole (1); lood is pumped out of the heart to the pulmonary and systemic circulation during ventricular systole (!).

Assessment
$ub9ective
4ealth histor! %hest pain $*2 0eg pain &illows to sleep +edications 0ifest!le: diet" alcohol use" e/ercise"

smo3ing" drugs

Assessment (continued)
*b9ective
:eneral appearance $3in ;ounds &ulses <ugular vein distention 7dema 2reathing

Dia nostic Tests

T77

(transesophageal echocardiogram)

+onitor breathing" cough" gag refle/ =eep >&* until gag refle/ returns

-oppler

sonograph!: is a medical imaging technique that

uses ultrasound enhanced by the Doppler effect and is often provide helpful information about the flow and movement of blood and inner areas of the body

+onitor 2& ;ash e/tremities to remove gel after test completed

Dia nostic Tests (continued)

?-ra!s@%T scan@72%T 7lectron beam computed tomograph! (72%T) is used to determine coronar! calcium -ocument client allerg! to fish or shellfish &regnanc! ris3 1ngiograph!@cardiac catheterization +., -ocument presence of implanted electronic devices .adionuclear scans ,ncrease fluids after the test

Monitors
Telemetr!@4olter

monitor

Teach about purpose: is a portable device for

continuously monitoring various electrical activity of the central nervous system for at least 24 hours (often for two wee s at a tim -r! s3in .emove hair 1void getting unit wet ;hen to phone the +-

"schemic Heart #isease

Dr "brahim #ashayreh

2!

$ontents %vervie&
%oronary

&rtery Disease 'eart &natomy &therosclerotic (laque)&theroma &ngina (ectoris *yocardial "nfarction +udden Death ,verall *anagement

2$

$oronary Artery #isease

2-

CAD! Statistics

%1- is the largest 3iller of 1merican males and females 1A million 1mericans have %11#1 million +,6s per !ear 7ver! 26 seconds an 1merican will suffer from a coronar! event 7ver! 60 seconds an 1merican will die because of a coronar! event B C2D of those having a coronar! event will die from it BA 0= people die per !ear because of a coronar! event in the 7mergenc! -epartment before even being admitted to the hospital -eath .ate in 2001:
177 in 100"000

2.

CAD! Demo raphics and Statistics

ECD of those who die from %1- are 6 or older ,f under the age of 6 " E0D mortalit! rate with the first m!ocardial infarction ;ithin 1 !ear of initial +,: 2 D of men and AED of women will die ;ithin E !ears of initial +,: 0D of men and women under 6 will die 1n average of 11# !ears of life are lost due to an +, ,+&*.T1>T: 0D of men and 6CD of women who have died suddenl! via %1- -,- >*T 41'7 1>F &.7',*G$ $F+&T*+$ $udden -eath: Those with a previous histor! of +, have a -6 times $udden -eath rate compared to the general population

2/

30

E"actly #hat is Coronary Artery Disease ($schemic Heart Disease) and ho#%#hy does it occur'
$tart

with anatom!0

31

Definition
1

,schaemia H refers to an insufficient amount of blood# The coronar! arteries are the onl! source of blood for the heart muscle# ,f this coronar! arteries are bloc3ed" the blood suppl! will reduce#

32

&ey Concepts
,schemic

heart disease (,4-): caused b! coronar! atherosclerotic plaIue formation which leads to imbalance between *2 suppl! J demand results in m!ocardial ischemia %hest pain: cardinal s!mptom of m!ocardial ischemia caused b! coronar! arter! disease (%1-)

33

33

"schemic $ycle
$schemia % infarction Diastolic Dysfunction chest pain Systolic Dysfunction

pulmonary con estion p'(

)V diastolic pressure

cardiac output

#all tension MV'(

catecholamines (heart rate, ())

34

 4igh

blood cholesterol 4igh blood pressure $mo3ing *besit! 0ac3 of ph!sical activit!

3!

*is+ ,actors
2ncontrollable
*Se" *Hereditary **ace *A e

$ontrolla le
*Hi h -lood pressure *Hi h -lood cholesterol *Smo+in *Physical activity *'-esity *Dia-etes *Stress and an er

3$

 3hy

would there be an insufficient blood supply to the heart4

5emember that the coronary arteries are the

only source of fuel to the heart 6he coronary arteries may become partially)completely occluded7

&therosclerotic (laques

3-

Atherosclerotic Pla.ue! Definition and ,ormation

Focal

accumulation of smooth muscle cells" foam cells" cholesterol cr!stals and lipid under the endothelium of the arter! (within the Tunica ,ntima) :iven time" this plaIue can protrude into the lumen of the vessel reducing blood flow *ften develops at branch points or curves within the vasculature blood is slowed and@or turbulent

3.

Atheroma+ Atherosclerotic )la,ue

;here does the plaIue beginK within the Tunica ,ntima" the innermost wall of the arter! ;hat is a plaIue made ofK $uperficial fibrous cap made of smooth muscle cells" collagen" elastin and proteins 1lso contains +acrophages" Foam %ells" T %ells

Foam cells are one of the first cells found at the site of the fatt! strea3" which is the beginning of atherosclerotic plaIue formation in vessels

>ecrotic %enter of cholesterol

cr!stals" lipids" 1polipoprotein 2 0-0

3/

40

41

42

43

Atheroma! Continued
1s

the atheroma within the coronar! arteries enlarges" the blood flow to the heart decreases and therefore so does the *2 suppl! The heart is not in danger of h!po/ia until 0D of the vessel is occluded 1s the heart senses a decrease in *2" there is attempted compensation:
,ncrease 4eart .ate ,ncrease 2lood &ressure 1ggravation@;orsening of the atheroma

;hen

70D of the arter! is occluded" 1ngina &ectoris will occur

44

,schemic 4eart -isease

%lassification 5 mainl! C t!pes +!ocardial infarction (+,) $udden cardiac death 1ngina pectoris %hronic ,4- with heart failure

4!

Angina )ectoris

1t least 70D occlusion of coronar! arter! resulting in pain# ;hat 3ind of painK %hest pain .adiating pain to: 0eft shoulder

Jaw

0eft or .ight arm Gsuall! brought on b! ph!sical e/ertion as the heart is tr!ing to pump blood to the muscles" it reIuires more blood that is not available due to the bloc3age of the coronar! arter!(ies) ,s self limiting usuall! stops when e/ertion is ceased

4$

An ina Pectoris Continued

1ngina

&ectoris can be $table or Gnstable: $table:

The pain and pattern of events is unchanged

over a period of time (months !ears)

Gnstable:
The pain and pattern is changing" be it in

duration" intensit! or freIuenc! 1 +!ocardial ,nfarction waiting to happen

4-

Myocardial $nfarction
&artial

or total occlusion of one or more of the coronar! arteries due to an atheroma" thrombus or emboli resulting in cell death (infarction) of the heart muscle ;hen an +, occurs" there is usuall! involvement of A or C occluded coronar! vessels

4.

Myocardial $nfarctions! Statistics

2

0"000 deaths per !ear# A0D mortalit! within the first 2 hours
C +inutes of ,schemia:
%ardiac muscle death occurs

4ow is the -iagnosis +adeK 7lectrocardiographic changes

$T elevation %reatine 3inase Troponin

% .eactive &rotein

+!ocardial enz!me elevation

4/

-", Atheroma
;hen

there is an atheroma" as mentioned before there can be rupture resulting in thrombus formation because of the build up of platelets ;hen there is brea3age of the thrombus there is emboli formation 1n emboli can travel to the brain (cerebral infarct) can remain in the heart (m!ocardial infarct) or even travel to the e/tremities cutting off blood suppl! 1s the area beneath the is disrupted atheroma hemorrhages" there can is increased ris3 of abscess formation and infection !0

 ,nfarction

leading to inabilit! of the heart to function properl! leading to 4eart Failure 1ngina@&ain %ardiogenic shoc3 'entricular aneur!sm and rupture 7mbolism Formation 1rrh!thmias +!ocardial ,nfarctions can lead to 'entricular Fibrillation (shoc3ableL)
!1

Complications of Myocardial $nfarctions

Sudden Death

$udden -eath : 2 0"000 deaths in the G$ per !ear are caused b! what is referred to as MsuddenN cardiac death $udden %ardiac -eath is also 3nown as a M+assive 4eart 1ttac3N in which the heart converts from sinus rh!thm to ventricular fibrillation ,n '-Fib" the heart is unable to contract full! resulting in lac3 of blood being pumped to the vital organs '-Fib reIuires shoc3 from defibrillator M$4*%=1207 .4FT4+N

!2

 +an!

people are able to manage coronar! arter! disease with lifest!le changes and medications# people with severe coronar! arter! disease ma! need angioplast! or surger!#

*ther

!3

Mana ement of $schemic Heart Disease.

&harmaceuticals: 2eta 2loc3ers 1ct either selectivel! or non-selectivel! on 2eta receptors: 2eta 1 cardiac muscle increase rate and contraction 2eta 2 dilates bronchial smooth muscle %aOO %hannel 2loc3ers 1cts on vasculature bloc3ing %aOO and causing vasodilation >itrates 'asculature vasodilation 1nti-4!percholesterolemia 4+: %o1 .eductase ,nhibitors reduction in MmanmadeN cholesterol thus helping to reduce atheroma formation 1ntiplatelet +edication: %lopidogrel (&lavi/) 1spirin !4

Sur ical Treatment

$tenting 2) 1ngioplast! (balloon) A) 2!pass surger!
1)

!!

!$

Mana ement of $schemic Heart Disease!

0ifest!le:

-iet 7/ercise &reventive treatment 8 0ow fat" low cholesterol diet 8 %essation of smo3ing 8 .ed wine (in moderation9

!-

/ursin Assessment
1:

1# :ather information about all facets of the client6s activities" especiall! those that precede and precipitate attac3s of anginal pain# 2# 1ssess the ris3 factors in the client6s histor! and modifications possible to reduce ris3# A# ,f chest discomfort is present at the time of the interview" further collection of data is dela!ed until pain and d!srh!thmias are resolved# C# 1 complete ph!sical assessment is performed to identif! the presence of chest" epigastric" 9aw" bac3" or arm discomfort which is then rated on a sub9ective scale of 1 to 10 in intensit!# The client is Iuestioned regarding nausea" vomiting" diaphoresis" dizziness" wea3ness" palpitations" and $*2
!.

/ursin Dia nosis

&ain related to m!ocardial ischemia# 2# 1ltered tissue perfusion: related to imbalance between m!ocardial o/!gen suppl! and demand# A# 1n/iet! related to fear of death and 3nowledge deficit
1#

!/

/ursin Plan and $nterventions

:oals 1# &revention of pain# 2# ,mproved tissue perfusion as evidenced b! absence of chest pain and absence of d!srh!thmias# A# .eduction of an/iet! and increased 3nowledge of disease process#

$0

/ursing "nterventions 1# The nurse must teach the client the lin3 between s!mptoms and

activit! and the need to avoid activities 3nown to cause angina" such as sudden e/ertion" e/posure to cold" and emotional e/citement#

2# +edications used in the treatment of angina include nitrates" betabloc3ers" calcium channel bloc3ers" and platelet antiaggregants# 1dminister cardiac medication as prescribed and be alert for adverse side effects" particularl! their effect on blood pressure# Teach the client the s!mptoms to be aware of and what measures to ta3e# A# 7ncourage the client to remain on bedrest in order to decrease cardiac wor3load and o/!gen consumption# C# 1dminister o/!gen therap! as prescribed# # 7valuate vital signs hourl! to determine the hemod!namic effect of the drugs and the client6s tissue perfusion# 6# >ursing care should be planned so that minimal time is spent awa! from the bedside due to the high level of client an/iet!" as well as the unstable condition of the patient#
$1

/ursin $nterventions
-# %lients with unstable angina are at high ris3 for m!ocardial infarction (+,) and sudden death# The nurse watches for development of heart failure and d!srh!thmias# E# .elieving pain is the top priorit! for the client with an acute +," and medication therap! is administered to accomplish this goal# P# +aintain patent ,' for administration of fluids and vasodilators and anticoagulant therap! (>itrogl!cerin and heparin)# The! relieve pain and the! aid in minimizing permanent in9ur! to the m!ocardium# 10# &repare for possible emergenc! heart catheterization or %12:#
$2

/ursin $nterventions
11: ;hether %12: is planned as an elective procedure or performed on an emergenc! basis" the nurse should tr! to alleviate the client6s and the famil!6s an/iet! and assist them in understanding the need for this lifesaving procedure# 12# The nurse describes the postoperative course" emphasizing the close monitoring and use of sophisticated eIuipment# The client is encourage to tell the nurse about an! discomfort post-op# 1A# 7ncourage the client and famil! members to verbalize their fears and concerns# 1C# Teach the client the nature of the illness and the facts needed to reorganize living habits in order to reduce the freIuenc! and severit! of anginal attac3s" dela! the progress of the disease" and avoid other complications
#

$3

Evaluation
1: 'erbalizes relief of chest pain# 2# >o signs of respirator! difficulties# A# +odifies lifest!le in order to prevent future attac3s# C# -emonstrates increased 3nowledge of disease process and reduction in an/iet!# # 1bsence of complications#
$4