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TRANSCRIPT
9/7/2010
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So Your Patient Has A Cardiac History
Barbara Leeper MN, RN, CNS M‐S, CCRN, FAHA
Baylor University Medical Center
Dallas, Texas
Objectives
• Discuss the clinical implications of the following cardiovascular problems during the post‐operative periodHypertension
Coronary artery disease
Heart Failure
• Outline key aspects of the nursing plan of care for these patients during the immediate post‐operative period
Prevalence of Cardiovascular Disease
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The Numbers
• Cardiovascular disease (CVD) continues to be an epidemic in this country
• Although mortality rates have declined the burden of CVD remains high
2006: 1 of every 2.9 deaths was attributable to CVD.
Lloyd-Jones D, et al. Heart Disease and Stroke Statistics 2010 Update: A Report from the American Heart Association. Circ 2009;109.
The Numbers – Risk Factors
• 33.6% of adults ≥ 20 years of age have hypertension
74,500,000 adults
Nearly equal in both gendersNearly equal in both genders
• 35,700,000 adults ≥ 20 years of age have total serum cholesterol levels 240 mg/dL16.2% of the population
Lloyd-Jones D, et al. Heart Disease and Stroke Statistics 2010 Update: A Report from the American Heart Association. Circ 2009;109.
The Numbers – Risk Factors
• 17,200,000 have diagnosed diabetes 7.7% of the adult population
• 6,100,000 have undiagnosed gdiabetes
• Estimated 29% have pre-diabeteswith abnormal fasting glucose levels
Lloyd-Jones D, et al. Heart Disease and Stroke Statistics 2010 Update: A Report from the American Heart Association. Circ 2009;109.
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The Numbers – Risk Factors
• 2008, among Americans 18 years of age: 23.1% of men and 18.3% of women
continued to be cigarette smokers g
• In grades 9 through 12:21.3% of male students and 18.7% of
female students reported current tobacco use
Lloyd-Jones D, et al. Heart Disease and Stroke Statistics 2010 Update: A Report from the American Heart Association. Circ 2009;109.
The Numbers – Risk Factors
• The percentage of the nonsmoking population with detectable serum nicotine (indicating exposure to secondhand smoke) was 46 4% in 1999–2004smoke) was 46.4% in 1999 2004Those 4 to 11 years of age = 60.5%
Those 12 to 19 years of age = 55.4%
Lloyd-Jones D, et al. Heart Disease and Stroke Statistics 2010 Update: A Report from the American Heart Association. Circ 2009;109.
Why is this important for us to know?
Because these are the patients we care for regardless of what their primary procedure
or diagnosis may be.
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Cardiovascular Disease
Hypertension
Coronary Artery Disease
Rhythm Disturbances
Heart Failure
Hypertension ‐ Definitions
Category SBP mmHg DBP mmHg
Normal < 120 < 80
Prehypertension 120 – 139 80 – 89
Stage 1 –Hypertension
140 - 159 90 – 99
Stage 2 Hypertension
≥ 160 ≥ 100
Chobanian et al. JNC 7 Guidelines. JAMA, 2003
Hypertension
• Considered to be the most common pre‐operative morbidity and, therefore, post‐operative morbidity
• Issues• Issues
Poorly treated hypertensive patients have increased intra‐operative BP lability which can lead to post‐op complications
• Myocardial ischemia / MI
• Stroke
• Vascular issues
Duke J. Anesthesia Secrets, ed 3. St Louis: CV Mosby, 2006
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Vasodilators
• Nicardipine
Calcium channel blocker
Easy to titrate – do
• Sodium Nitroprusside
Direct vasodilator: more arterial thanEasy to titrate do
not see extreme BP fluctuations with titration
more arterial than venous
Can cause coronary steal syndrome
Indicated for hypertensive crises
Vasodilators
• Nitroglycerine:
Direct vasodilator: balanced effects on arterial and venous bed
Some cardioprotective effects
• Nifedipine (Procardia) – sublingual
FDA Block Box Warning r/t giving this for acute lowering of blood pressure
•Associated with AMI, stroke, death
Hypotension • Consider etiologies
Hypovolemia
Functional hypovolemia
Drugsugs
Medical and surgical diseases
•DKA
•Diabetes insipidus
•High output renal failure
•Bowel disease
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Coronary Artery Disease
Spectrum of CAD
Clinical Implications
• CAD is often present in younger individuals especially if diabetic
• CAD is not always associated with symptoms
f l G i i i i l ki• Careful ECG monitoring is important looking for signs of ischemia and onset of rhythm disturbances
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ST‐Segment Monitoring
ST Segment Monitoring
• Purpose:
To identify episodes of ischemia
• Many patients have silent ischemia:
Myocardial ischemia not associated with s&s
EKG ChangesST Segment
Look at ST segment 0.06‐0.08 sec. after J point
Normal ST Segment (isoelectric)
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ST‐Segment Elevation vs DepressionDepression
ST Segment Elevation
RR
TT
PP
SS
Isoelectric LineIsoelectric LineSTST
SegmentSegmentPRPR
IntervalInterval
ST Segment Depression
PP
RR
TTPP TT
QQSS
Isoelectric LineIsoelectric Line
STSTSegmentSegment
PRPRIntervalInterval
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Rhythm Strip at 0730 1/20
3 hours later
Rhythm Disturbances
Atrial Fibrillation / Flutter
Ventricular Ectopy
AV Blocks
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Ventricular Ectopy
• Identify the cause and treat
• Consider if due to:
Ischemia
Electrolyte abnormalities
AV Blocks• Commonly associated with myocardial ischemia, especially if inferior MI.
RCA provides blood supply to inferior wall of LV and to the AV node in large number of patients.
• Assess hemodynamic impact. Remember, you can not always reply of the BP. It is late indicator of hemodynamic compromise.
• Treatment: Increase the ventricular rate
Atropine
Pacemaker
Atrial Fibrillation / Flutter
• Can occur as a consequence of hypothermia
• Common with thoracic and cardiac surgical procedures
li i l i i h i di• Clinical issues assoc with impact on cardiac output:
Loss of atrial kick
Rapid ventricular response
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Atrial Fibrillation / Flutter
• Management:
Priority is to slow conduction through the AV node thereby slowing ventricular response
•Calcium channel blockers are effective•Calcium channel blockers are effective
Secondary priority it to restore sinus rhythm
•Antiarrhythmics:
– Amiodarone commonly used
– Also consider use of procainamide
Devices
Pacemakers
Implanted Defibrillators
Pacemakers
Coding System for PacemakersI Chamber Paced II. Chamber
SensedIII.Mode of Response to a Sensed Event
O = none O = none O = none
A = atriaV = ventricleD = dual
A = atriaV = ventricleD = dual
T = triggeredI = inhibitedD = dual
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Pacemakers: Nursing Implications
• Temporary or Permanent?
• What mode of pacing is being used?
I h i k d d i• Is the patient pacemaker dependent, i.e., is there an underlying rhythm?
ICDs / PCDs
• In most cases should be inactivated (turned off) prior to the patient going to surgery
• If left on….
Fentanyl reduces defibrillation thresholdsFentanyl reduces defibrillation thresholds
Pentobarbitol and enflurane increase defibrillation thresholds
• Magnets will deactivate or reprogram
• Generally, if patient develops VT or VF, stand back and allow the device to “do its thing”
Heart Failure
Spectrum of HF
Clinical Implications
Nursing Management
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Spectrum of Heart Failure
• Definition
Complex clinical syndrome
Characterized by
• Classifications
Left sided vs right sided
Backward vs forward Characterized by
• Dysfunction of RV, LV or both
• Neurohormonal changes
Backward vs forward
Acute vs chronic
Systolic vs diastolic
Compensated vs decompensated
Frank Starling Principle
• Preload = volume administration
• Stroke Volume = contractility
Neurohormonal Responses • Decreased CO leads to:
Increased sympathetic stimulation
Activation of renin‐angiotensin‐aldoesterone system
• Increased HR
•Peripheral vasoconstriction
• Increased levels of aldosterone
– Increased reabsorption of Na+ and water
• Therefore, beta blockers and ACEIs are cornerstones of therapy
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Causes of HF
• Coronary artery disease (US)
• Hypertension
• Nonischemic dilated cardiomyopathy
• Valvular heart disease
NYHA Classification
Classification Description
I Asymptomatic with normal physical activity
II Symptomatic with normal physical activity (dyspnea)
III Less than normal physical activity causes symptoms
IV Symptomatic at rest. LV EF ≤ 25%. Annual mortality rate 40%
Taking a pt with HF to surgery
• Decompensated HF are not candidates for elective procedures. However, if emergent, a PAC and arterial line may be inserted.
These are used to monitor hemodynamicThese are used to monitor hemodynamic responses to fluid therapy, anesthetic agents as well as pharmacological interventions (inotropes and vasodilators)
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Post‐op Management in HF
• Nursing plan of care should include addressing issues related to preload, afterload and contractility
Preload: volume administrationPreload: volume administration
Afterload: vasodilator therapy
Contractility: inotropic therapy
• Our responsibility is to assess the patient’s response(s) to volume and drug titration
Hemodynamic Monitoring
• Preload – Frank Starling Principle
• Afterload
Monitor with
SV LV f l d• SVR – LV afterload
•PVR – RV afterload
The higher the afterload, the harder the heart has to work
Increases myocardial oxygen demands
May result in reduced myocardial contractility
Post‐op Fluid Management In Patients With HF
• Why give volume? To optimize the preload status of the ventricle
• Traditionally monitor “filling pressures”
RAP/CVP f RV l dRAP/CVP for RV preload
PAD/PAWP for LV preload
• However, current evidence does not support the reliability of these parameters indicating the preload status of the patient, regardless of the clinical situation.
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Post‐op Fluid Management
• How to monitor preload responsiveness
Use of SVV – stroke volume variation
• If < 13% ‐ Patient is not fluid responsive
• If > 13% patient is likely to be fluid responsive• If > 13% ‐ patient is likely to be fluid responsive
• The real issue in this group of patients is to monitor the rate of infusions, particularly those who use standard orders, i.e., 1000 mL D5/RL, infuse at 125 mL/hour
Other Considerations in HF• HF patients are more sensitive to the myocardial depressant effects of many of the anesthetic agents, especially
Propofol
Barbituates
Etomidate – has fewer effects
Ketamine may increase the HR and BP due to sympathetic effects although in patients with high SNS activity already, this drug can depress myocardial contracility
Duke J. Anesthesia Secrets, ed 3, St Louis: CV Mosby, 2006
Beta Blockers
Reduction of Perioperative CardiacReduction of Perioperative Cardiac Events
Fleischmann KE, et al. 2009 ACCF/AHA focused update on perioperative beta blockade. A report of the American College of Cardiology Foundation / American Heart Association Task Force on Practice Guidelines. Circulation 2009;109.
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Beta Blockers
• Evidence for reduction of perioperative ischemia
• May reduce risk of MI and cardiovascular death in high risk patients
.
Beta Blockers:Clinical Risk Factors
• History of:
Ischemic heart disease
C t d i h t f ilCompensated or prior heart failure
Cerebrovscaular disease
Diabetes mellitus
Renal insufficiency (pre‐op se creatinine >2mg/dL)
Fleishmann KE, et al. Circ, 2009;109
Which Patients / Procedures
• Patients who are having surgery and are receiving beta blockers for angina, symptomatic arrhythmias or hypertension
• Patients undergoing vascular surgery who arePatients undergoing vascular surgery who are at high risk determined by presence of ischemia on pre‐op testing
• Several RCTs demonstrate significant reductions in peri‐operative cardiac death associated with the administration of beta blockers Fleishmann KE, et al. Circ, 2009;109
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Risks and Caveats• Low heart rates (may drop to the 40’s)
• Hypotension (BP < 90mmHg)
• Heart failure
• “Initiation well before a planned procedure with careful titration perioperatively to achieve HR control while avoiding frank bradycardia and hypotension is recommended.”
• “Routine administration of peri‐operative beta blockers in higher fixed dose regimens is not recommended.
Fleishmann KE, et al. Circ, 2009;109