Cardiovascular Assessment Cardiovascular Assessment

Dr. M. KalirattinameDept. of General Medicine

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Heart AnatomyHeart AnatomyFacts:

– 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-

7500 liters of blood per day through 60,000 miles of blood vessels each minute at rest.

HeartHeartStructure

– Covered by pericardium Parietal Visceral (epicardium)

– Outer heart layer: epicardium– Middle heart layer: myocardium– Inner layer: endocardium

The internal anatomy of the heart.The internal anatomy of the heart.

HeartHeartStructure (continued)

– Four hollow chambers Two upper, atria Two lower, ventricles

– Divided by septum and valves

HeartHeartFunction

– Right atrium receives deoxygenated blood

– Right ventricle pumps blood to lungs

HeartHeartFunction (continued)

– Left atrium receives oxygenated blood– Left ventricle pumps oxygenated blood to

body– AV valve closure: S1 heart sound– Semilunar valve closure: S2 heart sound– Coronary circulation

The coronary arteriesThe coronary arteries..

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Peripheral Vascular SystemPeripheral Vascular SystemAorta, arteries, arterioles, capillariesVenules, veins, superior and inferior

vena cavaThree layers

– Intima– Media– Adventitia

Structure of arteries, veins, and capillariesStructure of arteries, veins, and capillaries..

Peripheral Vascular SystemPeripheral Vascular SystemFunction

– Circulation– Peripheral vascular resistance: viscosity,

length, diameter– Blood pressure control

Mechanical Properties of Mechanical Properties of the Heartthe Heart

Mechanical– Conduction system

Mechanical Properties of Mechanical Properties of the Heart (continued)the Heart (continued)

Mechanical– SA node: pacemaker– Cardiac output (CO)– Heart rate (HR)– Stroke volume (SV): the volume of blood

pumped from one ventricle of the heart with each beat

– CO = HR x SV

Mechanical Properties of Mechanical Properties of the Heart (continued)the Heart (continued)

Mechanical– Cardiac reserve– Preload– Starling’s law– Afterload– Contractility

Electrical Properties of the Electrical Properties of the HeartHeart

Electrical properties:– Action potential– Polarization– Depolarization– Repolarization– Refractory period

Electrical Properties of the Electrical Properties of the Heart (continued)Heart (continued)

Filling and pumping– Diastole – ventricular filling– Systole –ventricles eject blood

The cardiac cycle. Ventricular filling occurs during diastole (1); blood is pumped The cardiac cycle. Ventricular filling occurs during diastole (1); blood is pumped out of the heart to the pulmonary and systemic circulation during ventricular out of the heart to the pulmonary and systemic circulation during ventricular systole (2).systole (2).

AssessmentAssessmentSubjective

– Health history– Chest pain– SOB– Leg pain– Pillows to sleep– Medications– Lifestyle: diet, alcohol use, exercise,

smoking, drugs

Assessment (continued)Assessment (continued)Objective

– General appearance– Skin– Wounds– Pulses– Jugular vein distention– Edema– Breathing

Diagnostic TestsDiagnostic Tests TEE (transesophageal echocardiogram)

– Monitor breathing, cough, gag reflex– Keep NPO until gag reflex returns

Doppler sonography: 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 – Monitor BP– Wash extremities to remove gel after test completed

Diagnostic Tests Diagnostic Tests (continued)(continued) X-rays/CT scan/EBCT

Electron beam computed tomography (EBCT) is used to determine coronary calcium – Document client allergy to fish or shellfish– Pregnancy risk

Angiography/cardiac catheterization MRI

– Document presence of implanted electronic devices Radionuclear scans

– Increase fluids after the test

MonitorsMonitorsTelemetry/Holter 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 weeks at a tim

– Dry skin– Remove hair– Avoid getting unit wet– When to phone the MD

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Ischemic Heart DiseaseIschemic Heart Disease

Dr Ibrahim Bashayreh

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Contents OverviewContents OverviewCoronary Artery DiseaseHeart AnatomyAtherosclerotic Plaque/AtheromaAngina PectorisMyocardial InfarctionSudden DeathOverall Management

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Coronary Artery DiseaseCoronary Artery Disease

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CAD: Statistics CAD: Statistics CAD is the largest killer of American males and females 13 million Americans have CAD 1.1 million MI’s per year Every 26 seconds an American will suffer from a

coronary event Every 60 seconds an American will die because of a

coronary event @ 42% of those having a coronary event will die from it @350K people die per year because of a coronary event in

the Emergency Department before even being admitted to the hospital

Death Rate in 2001:– 177 in 100,000

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CAD: Demographics and StatisticsCAD: Demographics and Statistics 84% of those who die from CAD are 65 or older If under the age of 65, 80% mortality rate with the first myocardial

infarction Within 1 year of initial MI:

– 25% of men and 38% of women will die Within 8 years of initial MI:

50% of men and women under 65 will die An average of 11.5 years of life are lost due to an MI IMPORTANT:

– 50% of men and 64% of women who have died suddenly via CAD DID NOT HAVE ANY PREVIOUS SYMPTOMS

Sudden Death:– Those with a previous history of MI have a 5-6 times Sudden Death

rate compared to the general population

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Exactly what is Coronary Artery Exactly what is Coronary Artery Disease (Ischemic Heart Disease) Disease (Ischemic Heart Disease)

and how/why does it occurand how/why does it occur??Start with anatomy…

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DefinitionDefinition" Ischaemia " refers to an insufficient

amount of  blood. The coronary arteries are the only source of  blood for the heart muscle. If this coronary arteries are blocked, the blood supply will reduce.

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Key ConceptsKey ConceptsIschemic heart disease (IHD): caused by

coronary atherosclerotic plaque formation which leads to imbalance between O2 supply & demand– results in myocardial ischemia

Chest pain: cardinal symptom of myocardial ischemia caused by coronary artery disease (CAD)

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Ischemic CycleIschemic CycleIschemia / infarction

chest pain

Diastolic Dysfunction Systolic Dysfunction

cardiac output

catecholamines

MVO2

wall tension

LV diastolic pressurepulmonarycongestionpO2

(heart rate, BP)

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High blood cholesterol High blood pressure Smoking Obesity Lack of physical activity

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Risk FactorsRisk FactorsUncontrollable

•Sex•Hereditary•Race•Age

Controllable•High blood pressure•High blood cholesterol•Smoking•Physical activity•Obesity•Diabetes•Stress and anger

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Why would there be an insufficient blood supply to the heart?– Remember that the coronary arteries are the

only source of fuel to the heart– The coronary arteries may become

partially/completely occluded: Atherosclerotic Plaques

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Atherosclerotic Plaque: Atherosclerotic Plaque: Definition and FormationDefinition and Formation

Focal accumulation of smooth muscle cells, foam cells, cholesterol crystals and lipid under the endothelium of the artery (within the Tunica Intima)

Given time, this plaque can protrude into the lumen of the vessel reducing blood flow

Often develops at branch points or curves within the vasculature blood is slowed and/or turbulent

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Atheroma/ Atherosclerotic Atheroma/ Atherosclerotic PlaquePlaque

Where does the plaque begin? within the Tunica Intima, the innermost wall of the artery

What is a plaque made of?– Superficial fibrous cap made of

smooth muscle cells, collagen, elastin and proteins

Also contains Macrophages, Foam Cells, T Cells

Foam cells are one of the first cells found at the site of the fatty streak, which is the beginning of atherosclerotic plaque formation in vessels

– Necrotic Center of cholesterol crystals, lipids, Apolipoprotein B LDL

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Atheroma: ContinuedAtheroma: Continued As the atheroma within the coronary arteries

enlarges, the blood flow to the heart decreases and therefore so does the O2 supply

The heart is not in danger of hypoxia until 50% of the vessel is occluded

As the heart senses a decrease in O2, there is attempted compensation:– Increase Heart Rate– Increase Blood Pressure – Aggravation/Worsening of the atheroma

When 70% of the artery is occluded, Angina Pectoris will occur

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Ischemic Heart DiseaseIschemic Heart DiseaseClassification = mainly 4 types

– Myocardial infarction (MI)– Sudden cardiac death– Angina pectoris – Chronic IHD with heart failure

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Angina PectorisAngina Pectoris At least 70% occlusion of coronary artery

resulting in pain. What kind of pain?– Chest pain– Radiating pain to:

Left shoulder Jaw Left or Right arm

Usually brought on by physical exertion as the heart is trying to pump blood to the muscles, it requires more blood that is not available due to the blockage of the coronary artery(ies)

Is self limiting usually stops when exertion is ceased

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Angina Pectoris ContinuedAngina Pectoris ContinuedAngina Pectoris can be Stable or Unstable:Stable:

– The pain and pattern of events is unchanged over a period of time (months years)

Unstable:– The pain and pattern is changing, be it in

duration, intensity or frequency– A Myocardial Infarction waiting to happen

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Myocardial InfarctionMyocardial Infarction Partial or total occlusion of one or more of the

coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle

When an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels

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Myocardial Infarctions: Myocardial Infarctions: StatisticsStatistics

250,000 deaths per year. 30% mortality within the first 2 hours 45 Minutes of Ischemia:

– Cardiac muscle death occurs How is the Diagnosis Made?

– Electrocardiographic changes ST elevation

– Myocardial enzyme elevation Creatine kinase Troponin C Reactive Protein

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MI, Atheroma MI, Atheroma When there is an atheroma, as mentioned before there

can be rupture resulting in thrombus formation because of the build up of platelets

When there is breakage of the thrombus there is emboli formation

An emboli can travel to the brain (cerebral infarct) can remain in the heart (myocardial infarct) or even travel to the extremities cutting off blood supply

As the area beneath the is disrupted atheroma hemorrhages, there can is increased risk of abscess formation and infection

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Complications of Complications of Myocardial InfarctionsMyocardial Infarctions

Infarction leading to inability of the heart to function properly leading to Heart Failure

Angina/PainCardiogenic shock Ventricular aneurysm and ruptureEmbolism FormationArrhythmias Myocardial Infarctions can

lead to Ventricular Fibrillation (shockable!)

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Sudden DeathSudden Death Sudden Death :

– 250,000 deaths in the US per year are caused by what is referred to as “sudden” cardiac death

– Sudden Cardiac Death is also known as a “Massive Heart Attack” in which the heart converts from sinus rhythm to ventricular fibrillation

– In V-Fib, the heart is unable to contract fully resulting in lack of blood being pumped to the vital organs

– V-Fib requires shock from defibrillator “SHOCKABLE RHYTHM”

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Many people are able to manage coronary artery disease with lifestyle changes and medications.

Other people with severe coronary artery disease may need angioplasty or surgery.

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Management of Ischemic Management of Ischemic Heart DiseaseHeart Disease::

Pharmaceuticals:– Beta Blockers

Act either selectively or non-selectively on Beta receptors:– Beta 1 cardiac muscle increase rate and contraction– Beta 2 dilates bronchial smooth muscle

– Ca++ Channel Blockers Acts on vasculature blocking Ca++ and causing vasodilation

– Nitrates Vasculature vasodilation

– Anti-Hypercholesterolemia HMG CoA Reductase Inhibitors reduction in “manmade”

cholesterol thus helping to reduce atheroma formation– Antiplatelet Medication:

Clopidogrel (Plavix) Aspirin

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Surgical TreatmentSurgical Treatment

1) Stenting2) Angioplasty (balloon)3) Bypass surgery

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Management of Ischemic Management of Ischemic Heart Disease:Heart Disease:

Lifestyle:– Diet– Exercise Preventive treatment• Low fat, low cholesterol diet• Cessation of smoking• Red wine (in moderation)

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Nursing AssessmentNursing Assessment1.

1. Gather information about all facets of the client’s activities, especially those that precede and precipitate attacks of anginal pain.2. Assess the risk factors in the client’s history and modifications possible to reduce risk.3. If chest discomfort is present at the time of the interview, further collection of data is delayed until pain and dysrhythmias are resolved.4. A complete physical assessment is performed to identify the presence of chest, epigastric, jaw, back, or arm discomfort which is then rated on a subjective scale of 1 to 10 in intensity. The client is questioned regarding nausea, vomiting, diaphoresis, dizziness, weakness, palpitations, and SOB

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Nursing Diagnosis Nursing Diagnosis

1. Pain related to myocardial ischemia.2. Altered tissue perfusion: related to

imbalance between myocardial oxygen supply and demand.

3. Anxiety related to fear of death and knowledge deficit

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Nursing Plan and InterventionsNursing Plan and Interventions Goals

1. Prevention of pain.2. Improved tissue perfusion as evidenced by absence of chest pain and absence of dysrhythmias.3. Reduction of anxiety and increased knowledge of disease process.

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Nursing Interventions Nursing Interventions 1. The nurse must teach the client the link between symptoms and

activity and the need to avoid activities known to cause angina, such as sudden exertion, exposure to cold, and emotional excitement.

2. Medications used in the treatment of angina include nitrates, beta-blockers, calcium channel blockers, and platelet antiaggregants. Administer cardiac medication as prescribed and be alert for adverse side effects, particularly their effect on blood pressure. Teach the client the symptoms to be aware of and what measures to take.

3. Encourage the client to remain on bedrest in order to decrease cardiac workload and oxygen consumption.

4. Administer oxygen therapy as prescribed.

5. Evaluate vital signs hourly to determine the hemodynamic effect of the drugs and the client’s tissue perfusion.

6. Nursing care should be planned so that minimal time is spent away from the bedside due to the high level of client anxiety, as well as the unstable condition of the patient.

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Nursing InterventionsNursing Interventions7. Clients with unstable angina are at high risk for myocardial

infarction (MI) and sudden death. The nurse watches for development of heart failure and dysrhythmias.

8. Relieving pain is the top priority for the client with an acute MI, and medication therapy is administered to accomplish this goal.

9. Maintain patent IV for administration of fluids and vasodilators and anticoagulant therapy (Nitroglycerin and heparin). They relieve pain and they aid in minimizing permanent injury to the myocardium.10. Prepare for possible emergency heart catheterization or CABG.

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Nursing InterventionsNursing Interventions11. Whether CABG is planned as an elective procedure or

performed on an emergency basis, the nurse should try to alleviate the client’s and the family’s anxiety and assist them in understanding the need for this life-saving procedure.

12. The nurse describes the postoperative course, emphasizing the close monitoring and use of sophisticated equipment. The client is encourage to tell the nurse about any discomfort post-op.

13. Encourage the client and family members to verbalize their fears and concerns.

14. Teach the client the nature of the illness and the facts needed to reorganize living habits in order to reduce the frequency and severity of anginal attacks, delay the progress of the disease, and avoid other complications.

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Evaluation Evaluation

1. Verbalizes relief of chest pain.2. No signs of respiratory difficulties.3. Modifies lifestyle in order to prevent

future attacks.4. Demonstrates increased knowledge of

disease process and reduction in anxiety.5. Absence of complications.