Cardiovascular Review II

Ana H. Corona, MSN, FNP-C

Nursing Instructor
October 2007
MedlinePlus; Random Outlines 2007; nurseCE.com
Coronary Artery Disease (CAD)
• Coronary arteries cannot deliver adequate blood
supply to the heart muscle to meet the tissue
demand.
• Characterized by obstruction or narrowing of the
vessel lumen.
• Risk factors some cannot be changed while
other risk factors can be modified or eliminated.
• Patient education is an important aspect of the
nursing care of patients with CAD because the
educated patient can take steps to improve his
condition.
 Risk Factors
• Risk factors that cannot be changed (non-
modified):
• age, sex, race, genetic make-up, and family
history.
• The major risk factors fall into the category
of modifiable risk factors:
• Hypertension, elevated serum cholesterol
levels, and cigarette smoking.
• Additional modifiable risk factors:
• weight, activity level, and stress levels
 Arteriosclerosis
• Primary cause of CAD. Arteriosclerosis is defined
as hardening or thickening of the arteries.
• Characterized by thickening and loss of elasticity
of the arterial walls.
• Deposits of yellowish plaques (called atheromas)
are formed within the medium and large sized
arteries.
• These atheromas are made up of cholesterol,
lipoid material, and lipophages (cells that ingest or
absorb fat).
 Diagnostic Tests
• Ankle/brachial index (ABI)
• Arteriography
• Cardiac stress testing
• CT scan
• Doppler study
• Intravascular ultrasound (IVUS)
• Magnetic resonance arteriography (MRA)
 Medications/Treatment
• Low-fat diet
• Weight loss
• Exercise.
• Blood thinners
• Cholesterol lowering agents
• Angioplasty
• Stents
Coronary Heart Disease (CHD)
Coronary heart disease (CHD) is a collective
name for a number of ischemic diseases of
the myocardium.
• The major diseases of CHD are:
– angina pectoris
– cardiac dysrhythmias
– myocardial infarction
– congestive heart failure (CHF)
– sudden cardiac death.
 Diagnostic Tests
• EKG
• Exercise Stress Test
• Echocardiogram
• Nuclear scan
• Coronary angiography/arteriography
• Electron-beam computed tomography (EBCT) to
look for calcium in the lining of the arteries -- the
more calcium, the higher your chance for CHD
• Coronary CT angiography
• Magnetic resonance angiography
 Medications
• ACE inhibitors to lower blood pressure
• Blood thinners (antiplatelet drugs) to reduce your
risk of blood clots
• Beta-blockers to lower heart rate, blood
pressure, and oxygen use by the heart
• Calcium channel blockers to relax arteries,
lowering blood pressure and reducing strain on
the heart
• Diuretics to lower blood pressure
• Nitrates (such as nitroglycerin) to stop chest pain
and improve blood supply to the heart
• Statins to lower cholesterol
 Angina Pectoris
• A clinical syndrome of ischemic heart disease
• Manifested by paroxysmal chest pain.
• An early warning of CV deterioration.
• The symptoms occur as a result of myocardial
oxygen demand that exceeds the ability of the
coronary arteries to deliver oxygen.
• (The coronary arteries supply the myocardium
with the oxygenated blood it needs to work
effectively.)
• The main cause for this inability to meet oxygen
demand is the presence of atherosclerosis that
causes advanced occlusion or stenosis of one or
more of the three major branches of the coronary
artery tree.
 Angina Pectoris
• The pain of angina pectoris occurs when
the heart is stressed or worked to a point
where the oxygen demand is greater than
the amount of oxygen that can be delivered.
• This usually occurs with exertion
• Onset of pain will occur with exertion, and
relief will normally occur with rest.
• Rest will decrease the workload on the
heart, thereby decreasing the heart's
oxygen demand and relieving the pain.
 Unstable Angina Pectoris
• A term used to describe the exacerbation
of the symptoms of angina pectoris.
• Characterized by increased severity of
symptoms, increased ease in provoking
attacks of angina, and less predictability in
controlling angina attacks.
• Symptoms may be severe enough to
mimic an acute myocardial infarction.
 Diagnostic Tests
• Blood tests to check the levels of creatine
phosphokinase (CPK), myoglobin, and
troponin I and T
• Coronary angiography
• ECG
• Echocardiography
• Stress tests
 Medication/Treatment
• Blood thinners (antiplatelet drugs)
• Aspirin and clopidogrel may reduce the
chance of heart attack in certain patients.
• Heparin and nitroglycerin.
• Other treatments may include medicines
to control blood pressure, anxiety.
 Acute Myocardial Infarction (AMI)
• Results from an imbalance between oxygen
demand and oxygen supply to the myocardium.
• In 90 percent of the cases this imbalance is
preceded by atherosclerosis and decreased
blood flow in the coronary arteries.
• The inadequate blood flow results in decreased
oxygen delivery to the heart muscle, which
causes ischemia, injury, and death of a portion
of the myocardium (infarction).
 Myocardial Infarctions
• Myocardial infarctions are described as being
anterior, inferior, or posterior, depending upon
the location of the infarcted area of the heart
muscle.
• Infarcts can be further classified as being
transmural or non-transmural.
• A transmural infarct (Non Q-Wave MI) is one
that involves damage to the full thickness of the
myocardium.
• A non-transmural MI involves only a partial
thickness of the muscle.
 Signs & Symptoms AMI
• Chest Pain is the major presenting symptom.
• Pain is usually substernal and may radiate to the
neck, shoulders, arms, or epigastric area.
• Pain is described as heaviness, constriction,
burning, or similar to indigestion.
• There may be little or no pain present at all.
• May be difficult to distinguish from angina.
• Shortness of breath, diaphoresis, weakness, fatigue,
anxiety, nausea, vomiting, abnormal blood pressure,
and abnormal heart rate.
• Pain, anxiety, and arrhythmias occur in the early
stages of MI.
• Ventricular fibrillation is the greatest threat to life in
the first hours after MI.
 Diagnostic Tests
• Coronary angiography
• CT scan
• Echocardiography
• Electrocardiogram (ECG) -- once or repeated
over several hours
• MRI
• Nuclear ventriculography
• Troponin I and troponin T
• CPK and CPK-MB
• Serum myoglobin
 Management of AMI
• ECG monitoring
• Bedrest to reduce the workload of the heart
• Intravenous therapy
• Morphine to reduce pain and relieve anxiety
• Oxygen
• Nitroglycerin to relieve pain
• Thrombolytic Therapy
• Aspirin: Antiplatelet medications to help prevent
clots
• Heparin or lovenox
• vasodilators, beta blocker, calcium channel
blockers and lidocaine as antiarrhythmic
therapy.
 Nursing Care & Management
• Three major considerations: observation
and prevention of further myocardial
damage and complications, promotion of
an environment that allows for maximum
comfort and rest, and patient education to
fully prepare the patient for discharge.
Nursing Care & Management: Continue
• Observation and prevention include the
following nursing considerations:
• (a) Frequent monitoring of the vital signs
and ECG.
• (b) Observation for signs of impending heart
failure by close monitoring of intake and
output, daily weight, breathe sounds, and
serum enzymes.
• (c) Careful assessment and documentation
of each episode of chest pain to include
severity, duration, medication given, and
relief obtained.
 Nursing Care & Management: continue
• Promotion of a restful and comfortable
environment:
• (a) Provide emotional support to reduce
anxiety and stress.
• (b) Orient patient to the (CCU) routine and
environment.
• (c) Schedule patient care activities carefully to
avoid interrupting the patient's sleep.
 Patient Education
• (a) Promote compliance with prescribed
meds, diet, and other tx measures by
explaining the need for each and the possible
consequences of noncompliance.
• (b) Review all activity limitations and
restrictions.
• (c) Counsel the patient on the action that
should be taken when he is confronted with
chest pain or other symptoms.
 Heart Failure (CHF) Inadequate cardiac output,
resulting in poor perfusion of all organ systems.

• Left heart failure: The pumping action of

the left ventricle is compromised, but the
right ventricle continues to function
normally.
• There is an imbalance between the out-put
of each ventricle.
• The right heart continues to pump blood
into the lungs to be oxygenated.
 CHF: left sided heart failure
• The failing left heart is unable to return that
same volume of blood to the systemic
circulation.
• Results in accumulation of blood in the
pulmonary blood vessels.
• Increased pressure in the pulmonary
vessels causes fluid to leak into the
interstitial lung tissue, compromising gas
exchange.
• This condition is called pulmonary edema.
 Right Sided Heart Failure
• Right sided heart failure usually follows left
sided failure.
• The increased pressure in the pulmonary
vessels causes "back pressure" to the right
side of the heart.
• This interferes with venous return, and
consequently, the organs of the body
become congested.
 CHF: right sided heart failure
• This condition, known as congestive heart
failure (CHF), is manifested by neck vein
distention and body edema.
• Right sided failure may occur without left
sided failure.
• This condition, called corpulmonale, may
be caused by pulmonary hypertension
secondary to lung disease or by the
presence of pulmonary emboli.
 CHF Diagnostic Tests
• Echocardiogram • Creatinine
• Heart catheterization • Liver function tests
• Chest x-ray • Serum uric acid
• Chest CT scan • Atrial natriuretic peptide
• Cardiac MRI (ANP) and brain
• Nuclear heart scans natriuretic peptide (BNP)
(MUGA, RNV) • Urinalysis
• ECG, which may also • Urinary sodium
show arrhythmias • Creatinine clearance
• CBC • Swan-Ganz
• Blood chemistry measurements (right
• Serum sodium heart catheterization)
• BUN
 Medications/Treatment
• Low Sodium Diet
• ACE inhibitors such as captopril and enalapril -- these
medications open up blood vessels and decrease the
work load of the heart.
• Diuretics -- there are several types including thiazide, loop
diuretics, and potassium-sparing diuretics; they help rid
your body of fluid and sodium.
• Digitalis glycosides -- increase the ability of the heart
muscle to contract properly; prevent heart rhythm
disturbances
• Angiotensin receptor blockers (ARBs) such as losartan
and candesartan which, like ACE inhibitors, reduce the
workload of the heart; this class of drug is especially
important for those who cannot tolerate ACE inhibitors
• Beta-blockers -- this is particularly useful for those with a
history of coronary artery disease
 Nursing Care & Management CHF
During the acute phase, nursing considerations
include the following:
– Monitoring fluid retention by weighing the patient
daily.
– Monitoring intake and output.
– Frequent assessment of vital signs.
– Frequent monitoring of electrolytes.
– Promoting mental and physical rest to reduce the
workload of the heart.
– Administration of prescribed medications to
improve the heart's effectiveness as a pump.
– Administration of prescribed dietary restrictions
(sodium and fluids).
Nursing Care & Management CHF

Patient education should include the following

nursing considerations:
• Instruction on effective coping mechanisms
that will reduce stress in daily living.
• Compliance in taking prescribed medications.
• Compliance in following the prescribed
dietary and fluid restrictions.
• The importance of regular check-ups.
 Q1
• Cyanosis and potential cyanide poisoning
are possible with
a. nitroglycerin
b. nitroprusside (Nipride)
c. nitrofurantoin (Macrodantin)
d. nitrous oxide
 A1
• b. nitroprusside (Nipride)
 Q2
• Identify the beta blocker(s)
a. guanabenz (Wytensin)
b. prazocin (Minipres)
c. acetbutolol (Sectral)
d. enalapril (Vasotec)
 A2
• c. acetbutolol (Sectral) -- hint -- look for
the "olol" suffix!
 Q3
• Identify the ACE inhibitor(s)
a. atenolol (Tenormin)
b. captopril (Capoten)
c. propranolol (Inderal)
d. ranitidine (Zantac)
 A3
• b. captopril (Capoten) -- hint-- look for
the "pril" suffix!
 Q4
• Digoxin (Lanoxin) causes
a. negative inotropic, positive chronotropic
action
b. negative inotropic, negative chronotropic
action
c. positive inotropic, positive chronotropic
action
d. positive inotropic, negative chronotropic
action
 A4
• d. positive inotropic, negative
chronotropic action
 Q5
• Your patient is lethargic, nauseated, and has a
pulse of 52. You see that he is taking digoxin
(Lanoxin) 0.25mg daily, and also has
hydrochlorothiazide (HydroDiuril) 50mg twice
daily. He is also playing with the color knobs on
the television. You would check for a
a. drop in sodium levels
b. drop in potassium levels
c. drop in digoxin (Lanoxin) levels
d. drop in calcium levels
 A5
• b. drop in potassium levels
 Q6
• Asthmatic patients could experience
bronchoconstriction problems with which
of the following agents?
a. isoproterinol (Isuprel)
b. digoxin (Lanoxin)
c. pindolol (Visken)
d. dextromethorphan
 A6
• c. pindolol (Visken) -- a beta blocker
can cause B-2 blocking which can
result in bronchospasm
 Q7
• Hypertensive therapy available as a 7-day
patch
a. atenolol (Tenormin)
b. methyldopa (Aldomet)
c. minoxidil (Loniten)
d. clonidine (Catapres)
 A7
• d. clonidine (Catapres)
 Q8
• Regarding nitroglycerin
a. tingling on the tongue is a sign of toxicity with
the sublingual tablets
b. special tubing is always used for IV infusion
c. oral “nitrates” such as Isordil and Sorbitrate are
just as effective as topical patches
d. care should be taken to avoid absorption of the
paste or injection solution onto the skin of the
caregiver
 A8
• d. care should be taken to avoid
absorption of the paste or injection
solution onto the skin of the caregiver
 Q9
• Nonpharmacologic therapy of
hypertension includes
a. dynamic exercise at least 3 times a week
b. magnesium and calcium supplementation
c. moderation in alcohol consumption
d. weight loss
e. all of the above
f. a, c, d only
 A9
• e. all of the above
 Q10
• Angiotensin II
a. is increased in the presence of enalapril
(Vasotec)
b. causes drops in aldosterone levels
c. can result in water retention
d. increases sodium excretion
 A10
• c. can result in water retention
 Q11
• The antihypertensive agent also used for
hair regrowth is
a. nitroglycerin
b. nitroprusside (Nipride)
c. minoxidil (Loniten) -- the topical hair
regrowth product is also known as
Rogaine
d. verapamil (Calan)
 A11
• c. minoxidil (Loniten) -- the topical hair
regrowth product is also known as
Rogaine
 Q12
• High fiber diets can have what effect on
the blood levels of digoxin (Lanoxin)?
a. lower
b. raise
c. no change
 A12
• a. lower
 Q13
• Your patient has a heart rate of 79. After
being stabilized on propranolol (Inderal),
what is a likely heart rate?
a. 84
b. 65
c. propranolol (Inderal) has no effect on
heart rate
 A13
• b. 65
 Q14
• For atrial fibrillation and atrial flutter, you
turn to
a. lidocaine (Xylocaine)
b. quinidine (Qunidex)
c. amantadine (Symmetrel)
d. pilocarpine (Isopto Carpine)
 A14
• b. quinidine (Qunidex)
 Q15
• The equation MAP = CO x TPR
a. is used to determine the flow rate of TPNs
b. describes the relationship of cardiac output and
total peripheral resistance to the average blood
(or “mean arterial”) pressure
c. shows that a decrease in CO can cause an
increase in TPR
d. shows that an increase in MAP always means
an increase in CO
 A15
• b. describes the relationship of cardiac
output and total peripheral resistance
to the average blood (or “mean
arterial”) pressure
 Q16
• Antidote for warfarin overdose
a. protamine zinc insulin
b. protamine sulfate
c. vitamin K
d. warfarin
 A16
• c. vitamin K
 Q17
• Antidote for heparin overdose
a. protamine sulfate
b. vitamin K
c. vitamin E
d. cyanocobolamine
 A17
• a. protamine sulfate
 Q18
• Antiplatelet agents include all of the
following except
a. acetylsalicylic acid
b. acetaminophen
c. ticlopidine (Ticlid)
d. dipyridamole (Persantine)
 A18
• b. acetaminophen
 Q19
• Regarding cholesterol therapy, the goal is
to
a. reduce LDL and raise triglycerides
b. reduce LDL and raise HDL
c. raise LDL and raise HDL
d. raise LDL and reduce triglycerides
 A19
• b. reduce LDL and raise HDL
 Q20
• Which organ requires extra monitoring
when the patient is undergoing lipid-
lowering therapy?
a. kidney
b. brain
c. liver
d. pancreas
 A20
• c. liver
 Q21
• A classic drug interaction, greatly involving
an increased bleeding time, involves
warfarin and
a. vitamin B-6
b. acetaminophen
c. acetylsalicylic acid
d. all of the above
 A21
• c. acetylsalicylic acid
 Q22
• Which vitamin is involved in the coagulant
process?
a. vitamin C
b. vitamin B-6
c. vitamin D
e. vitamin K
 A22
• e. vitamin K
 Antihypertensive Drugs
Beta Blockers
• Atenolol (Tenormin)
• Penbutolol (Levatol)
• Metoprolol (Lopressor)
• Carteolol (Cartrol)
• Esmolol (Brevibloc)
• Betaxolol (Kerlone)
• Acebutolol (Sectral)
• Nadolol (Corgard)
• Pindolol (Visken)
• Timolol (Blocadren)
• Propranolol (Inderal)
• Labetalol
(Trandate/Normodyne)
For hypertensive emergencies
• Nitroprusside (Nipride)
Others
• Methyldopa (Aldomet)
• Clonidine (Catapres)
• Guanfacine (Tenex)
• Guanabenz (Wytensin)
• Reserpine (Serpasil)
• Guanethidine (Ismelin)
• Prazocin (Minipres)
• Hydralazine (Apresoline)
• Minoxidil (Loniten)
• Ace Inhibitors:
• Captopril (Capoten)
• Enalapril (Vasotec)
• Lisinopril (Zestril/Prinivil)
• Benazepril
 Diuretics "Water pills"
• Hydrochlorothiazide (HydroDiuril)
• Chlorothiazide (Diuril)
• Methchlothiazide (Enduron)
• Chlorthalidone (Hygroton)
• Indapamide (Lozol)
• Furosemide (Lasix)
• Bumetanide (Bumex)
• Ethacrynic acid (Edecrin)
• Spironolactone (Aldactone)
• Triamterene with hydrochlorothiazide
(Dyazide/Maxide)
 Anti-anginal drugs

• Nitroglycerin (Nitrostat)
• Amyl nitrate
• Isosorbide Dinitrate (Isordil)
• PETN (Peritrate)
• Dipyridamole (Persantine)
 Drugs for cardiac arrhythmia
• Quinidine (Quinidex) • Bretylium (Bretylol)
• Digoxin (Lanoxin) • Nifedipine (Procardia)
• Procainamide • Bepridil (Vascor)
(Procan/Pronestyl) • Isradipine (DynaCirc)
• Disopyramide (Norpace) • Nimodipine (Nimotop)
• Lidocaine (Xylocaine) • Diltiazem (Cardizem)
• Tocainide (Tonocard) • Nicardipine (Cardene)
• Mexiletine (Mexetil) • Verapamil
• Encainide (Enkaid) (Calan/Isoptin)