Coronary Heart Disease (CHD)

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

http://en.wikipedia.org/wiki/Angina_pectoris

http://en.wikipedia.org/wiki/Vasospasm

http://en.wikipedia.org/wiki/Coronary_arteries

http://en.wikipedia.org/wiki/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

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Congestive Heart FailureCongestive Heart Failure

Dr Ibraheem Bashayreh, RN,PhD

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Heart failure

Normal heart function

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Congestive Heart FailureDefinition

Congestive Heart FailureDefinition

• 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

• 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

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Factors Affecting Cardiac Output

Cardiac OutputCO

Preload

Afterload Contractility

Heart RateStroke Volume

SV= X

SV: the volume of blood pumped from one ventricle of the heart with each beat

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• 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

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Heart Rate Stroke Volume Cardiac Output

60/min 80 ml 4.8 L/min

80/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

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• Preload– The volume of blood/amount of fiber stretch

in the ventricles at the end of diastole (i.e., before the next contraction)

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• 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)

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• 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

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• 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

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• Contractility – Ability of the heart muscle to contract; relates

to the strength of contraction.

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• 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)

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Pathophysiology of CHF

• Pump fails → decreased stroke volume /CO. • Compensatory mechanisms kick in to increase CO

– SNS stimulation → release of epinephrine/nor-epinephrine

• Increase HR

• Increase contractility

• Peripheral vasoconstriction (increases afterload)

– Myocardial hypertrophy: walls of heart thicken to provide more muscle mass → stronger contractions

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– 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

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• Compensatory mechanisms may restore CO to near-normal.

• But, if excessive the compensatory mechanisms can worsen heart failure because . . .

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• 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

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Congestive Heart FailureRisk Factors

Congestive Heart FailureRisk Factors

• CAD• Age• HTN• Obesity• Cigarette smoking• Diabetes mellitus• High cholesterol• African descent

• CAD• Age• HTN• Obesity• Cigarette smoking• Diabetes mellitus• High cholesterol• African descent

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Heart failure

Underlying causes/risk factors• Ischemic heart disease (CAD)

• hypertension

• myocardial infarction (MI)

• valvular heart disease

• congenital heart disease

70%

• dilated cardiomyopathy

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Congestive Heart FailureTypes 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


– Most common form

– Blood backs up through the left atrium into the pulmonary veins

• Pulmonary congestion and edema– Eventually leads to biventricular failure

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– Most common cause: • HTN

• Cardiomyopathy

• Valvular disorders

• CAD (myocardial infarction)


– Most common cause: • HTN

• Cardiomyopathy

• Valvular disorders

• CAD (myocardial infarction)

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• 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

• RV infarction

• 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

• RV infarction

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• Right-sided failure

– Venous congestion• Peripheral edema• Hepatomegaly• Splenomegaly• Jugular venous distension


– Venous congestion• Peripheral edema• Hepatomegaly• Splenomegaly• Jugular venous distension

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– Primary cause is left-sided failure

– Cor pulmonale

• RV dilation and hypertrophy caused by pulmonary pathology


– Primary cause is left-sided failure

– Cor pulmonale

• RV dilation and hypertrophy caused by pulmonary pathology

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Acute Congestive Heart FailureClinical Manifestations

Acute Congestive Heart FailureClinical Manifestations

• Pulmonary edema (what will you hear?)

– Agitation

– Pale or cyanotic

– Cold, clammy skin

– Severe dyspnea

– Tachypnea

– Pink, frothy sputum

• Pulmonary edema (what will you hear?)

– Agitation

– Pale or cyanotic

– Cold, clammy skin

– Severe dyspnea

– Tachypnea

– Pink, frothy sputum

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Chronic Congestive Heart FailureClinical Manifestations


• Fatigue

• Dyspnea

– Paroxysmal nocturnal dyspnea (PND)

• Tachycardia

• Edema – (lung, liver, abdomen, legs)

• Nocturia

• Fatigue

• Dyspnea

– Paroxysmal nocturnal dyspnea (PND)

• Tachycardia

• Edema – (lung, liver, abdomen, legs)

• Nocturia

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• Behavioral changes

– Restlessness, confusion, attention span• Chest pain (d/t CO and ↑ myocardial work)

• Weight changes (r/t fluid retention)

• Skin changes

– Dusky appearance

• Behavioral changes

– Restlessness, confusion, attention span• Chest pain (d/t CO and ↑ myocardial work)

• Weight changes (r/t fluid retention)

• Skin changes

– Dusky appearance

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Congestive Heart FailureClassification

Congestive Heart FailureClassification

• 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

• 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

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Congestive Heart FailureDiagnostic Studies


• Primary goal is to determine underlying cause

– Physical exam

– Chest x-ray

– ECG

– Hemodynamic assessment

• Primary goal is to determine underlying cause

– Physical exam

– Chest x-ray

– ECG

– Hemodynamic assessment

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• Primary goal is to determine underlying cause– Echocardiogram (Uses ultrasound to visualize

myocardial structures and movement, calculate EF)

– Cardiac catheterization

• Primary goal is to determine underlying cause– Echocardiogram (Uses ultrasound to visualize

myocardial structures and movement, calculate EF)

– Cardiac catheterization

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Acute Congestive Heart FailureNursing and Collaborative

Management


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

• 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

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Management


Management

• Decreasing intravascular volume

– Improves LV function by reducing venous return

– Loop diuretic: drug of choice

– Reduces preload

– High Fowler’s position

• Decreasing intravascular volume

– Improves LV function by reducing venous return

– Loop diuretic: drug of choice

– Reduces preload

– High Fowler’s position

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Management


Management

• Decreasing afterload

– Drug therapy: • vasodilation, Angiotensin-converting enzyme

(ACE) inhibitors

– Decreases pulmonary congestion

• Decreasing afterload

– Drug therapy: • vasodilation, Angiotensin-converting enzyme

(ACE) inhibitors

– Decreases pulmonary congestion

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Management


Management

• Improving cardiac function

– Positive inotropes

• Improving gas exchange and oxygenation– Administer oxygen, sometimes intubate and

ventilate

• Reducing anxiety

– Morphine

• Improving cardiac function

– Positive inotropes

• Improving gas exchange and oxygenation– Administer oxygen, sometimes intubate and

ventilate

• Reducing anxiety

– Morphine

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Chronic Congestive Heart FailureCollaborative Care


• Treat underlying cause

• Maximize CO

• Alleviate symptoms

• Treat underlying cause

• Maximize CO

• Alleviate symptoms

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• Oxygen treatment

• Rest

• Biventricular pacing

• Cardiac transplantation

• Oxygen treatment

• Rest

• Biventricular pacing

• Cardiac transplantation

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Chronic Congestive Heart FailureDrug Therapy

Chronic Congestive Heart FailureDrug Therapy

• ACE inhibitors

• Diuretics

• Inotropic drugs : drugs that influence the force of contraction of cardiac muscle

• Vasodilators-Adrenergic blockers

• ACE inhibitors

• Diuretics

• Inotropic drugs : drugs that influence the force of contraction of cardiac muscle

• Vasodilators-Adrenergic blockers

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Chronic Congestive Heart FailureNutritional Therapy

Chronic Congestive Heart FailureNutritional Therapy

• Fluid restrictions not commonly prescribed

• Sodium restriction

– 2 g sodium diet

• Daily weights

– Same time each day

– Wearing same type of clothing

• Fluid restrictions not commonly prescribed

• Sodium restriction

– 2 g sodium diet

• Daily weights

– Same time each day

– Wearing same type of clothing

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Chronic Congestive Heart FailureNursing ManagementNursing Assessment


• Past health history

• Medications

• Functional health problems

• Cold, diaphoretic skin

• Past health history

• Medications

• Functional health problems

• Cold, diaphoretic skin

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• Tachypnea

• Tachycardia

• Crackles

• Abdominal distension

• Restlessness

• Tachypnea

• Tachycardia

• Crackles

• Abdominal distension

• Restlessness

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Chronic Congestive Heart FailureNursing Management

Nursing Diagnoses


Nursing Diagnoses

• Activity intolerance

• Excess fluid volume

• Disturbed sleep pattern

• Impaired gas exchange

• Anxiety

• Activity intolerance

• Excess fluid volume

• Disturbed sleep pattern

• Impaired gas exchange

• Anxiety

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Planning


Planning

• Overall goals: Peripheral edema Shortness of breath Exercise tolerance

– Drug compliance

– No complications

• Overall goals: Peripheral edema Shortness of breath Exercise tolerance

– Drug compliance

– No complications

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Nursing Implementation


Nursing Implementation

• Acute intervention

– Establishment of quality of life goals

– Symptom management

– Conservation of physical/emotional energy

– Support systems are essential

• Acute intervention

– Establishment of quality of life goals

– Symptom management

– Conservation of physical/emotional energy

– Support systems are essential

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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.

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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.

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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.

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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.

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The Heart

• High Blood Pressure is a major risk factor for heart attack.

• Is the number one risk factor for Congestive Heart Failure.

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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.

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The Eyes

• Can eventually cause blood vessels to break and bleed in the eye.

• Can result in blurred vision or even blindness.

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The Arteries

• Causes arteries to harden.

• This in turn causes the kidneys and heart to work harder.

• Contributes to a number of problems.

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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.

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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.

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Detection

• Dr.’s will diagnose a person with 2 or more readings of 140/90mm Hg or higher taken on more than one occasion.

• White-Coat Hypertension

• Measured using a spygmomameter.

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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.

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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.

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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

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Categories of High Blood Pressure

High Blood Pressure

• Stage 1 140–159 /90–99

• Stage 2 160–179 /100–109

• Stage 3 180 /110

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Preventing Hypertension

Adopt a healthy lifestyle by:

• Following a healthy eating pattern.

• Maintaining a healthy weight.

• Being Physically Active.

• Limiting Alcohol.

• Quitting Smoking.

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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.

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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.

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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.

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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!

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Limit Alcohol Intake

Alcohol raises blood pressure and can harm liver, brain, and heart

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Quit Smoking

• Injures blood vessel walls

• Speeds up process of hardening of the arteries.

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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.

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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.

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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.

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Conclusion

• Hypertension is a very controllable disease, with drastic consequences if left uncontrolled.

Documents

Coronary Heart Disease (CHD)