MEDSURGMT

Claire Maurice G.
Juanero
BSN III-C
A. Coronary Artery Disease

The coronary arteries are the blood vessels that carry blood to your heart. Coronary
artery disease is the narrowing or blockage of the coronary arteries. This condition is
usually caused by atherosclerosis. Atherosclerosis is the build-up of cholesterol and
fatty deposits (called plaques) inside the arteries. These plaques can clog the arteries or
damage the arteries, which limits or stops blood flow to the heart muscle.
If the heart does not get enough blood, it cannot get the oxygen and nutrients it needs
to work properly. This can cause chest pain (angina) or a heart attack.
Coronary artery disease develops when the major blood vessels that supply your heart
become damaged or diseased. Cholesterol-containing deposits (plaques) in your
coronary arteries and inflammation are usually to blame for coronary artery disease.
The coronary arteries supply blood, oxygen and nutrients to your heart. A buildup of
plaque can narrow these arteries, decreasing blood flow to your heart. Eventually, the
reduced blood flow may cause chest pain (angina), shortness of breath, or other
coronary artery disease signs and symptoms. A complete blockage can cause a heart
attack.
Because coronary artery disease often develops over decades, you might not notice a
problem until you have a significant blockage or a heart attack. But you can take steps
to prevent and treat coronary artery disease. A healthy lifestyle can make a big impact.
Symptoms
If your coronary arteries narrow, they can't supply enough oxygen-rich blood to your
heart — especially when it's beating hard, such as during exercise. At first, the
decreased blood flow may not cause any symptoms. As plaque continues to build up in
your coronary arteries, however, you may develop the following coronary artery disease
signs and symptoms:
 Chest pain (angina). You may feel pressure or tightness in your chest, as if
someone were standing on your chest. This pain, called angina, usually occurs
on the middle or left side of the chest. Angina is generally triggered by physical or
emotional stress. The pain usually goes away within minutes after stopping the
stressful activity. In some people, especially women, the pain may be brief or
sharp and felt in the neck, arm or back.
 Shortness of breath. If your heart can't pump enough blood to meet your body's
needs, you may develop shortness of breath or extreme fatigue with activity.
 Heart attack. A completely blocked coronary artery will cause a heart attack. The
classic signs and symptoms of a heart attack include crushing pressure in your
chest and pain in your shoulder or arm, sometimes with shortness of breath and
sweating.
Women are somewhat more likely than men are to have less typical signs and
symptoms of a heart attack, such as neck or jaw pain. And they may have other
symptoms such as shortness of breath, fatigue and nausea.
Sometimes a heart attack occurs without any apparent signs or symptoms.
Causes
Coronary artery disease is thought to begin with damage or injury to the inner layer of a
coronary artery, sometimes as early as childhood. The damage may be caused by
various factors, including:
 Smoking
 High blood pressure
 High cholesterol
 Diabetes or insulin resistance
 Not being active (sedentary lifestyle)
Once the inner wall of an artery is damaged, fatty deposits (plaque) made of cholesterol
and other cellular waste products tend to collect at the site of injury. This process is
called atherosclerosis. If the plaque surface breaks or ruptures, blood cells called
platelets clump together at the site to try to repair the artery. This clump can block the
artery, leading to a heart attack.
The doctor will ask questions about your medical history, do a physical exam and order
routine blood tests. He or she may suggest one or more diagnostic tests as well,
including:
 Electrocardiogram (ECG). An electrocardiogram records electrical signals as
they travel through your heart. An ECG can often reveal evidence of a previous
heart attack or one that's in progress.
 Echocardiogram. An echocardiogram uses sound waves to produce images of
your heart. During an echocardiogram, your doctor can determine whether all
parts of the heart wall are contributing normally to your heart's pumping activity.
Parts that move weakly may have been damaged during a heart attack or be receiving
too little oxygen. This may be a sign of coronary artery disease or other conditions.
 Exercise stress test. If your signs and symptoms occur most often during
exercise, your doctor may ask you to walk on a treadmill or ride a stationary bike
during an ECG. Sometimes, an echocardiogram is also done while you do these
exercises. This is called a stress echo. In some cases, medication to stimulate
your heart may be used instead of exercise.
 Nuclear stress test. This test is similar to an exercise stress test but adds
images to the ECG recordings. It measures blood flow to your heart muscle at
rest and during stress. A tracer is injected into your bloodstream, and special
cameras can detect areas in your heart that receive less blood flow.
 Cardiac catheterization and angiogram. During cardiac catheterization, a
doctor gently inserts a catheter into an artery or vein in your groin, neck or arm
and up to your heart. X-rays are used to guide the catheter to the correct
position. Sometimes, dye is injected through the catheter. The dye helps blood
vessels show up better on the images and outlines any blockages.
If you have a blockage that requires treatment, a balloon can be pushed through the
catheter and inflated to improve the blood flow in your coronary arteries. A mesh tube
(stent) is typically used to keep the dilated artery open.
 Cardiac CT scan. A CT scan of the heart can help your doctor see calcium
deposits in your arteries that can narrow the arteries. If a substantial amount of
calcium is discovered, coronary artery disease may be likely.
A CT coronary angiogram, in which you receive a contrast dye that is given by IV during
a CT scan, can produce detailed images of your heart arteries.
It’s important to reduce or control your risk factors and seek treatment to lower the
chance of a heart attack or stroke, if you’re diagnosed with CAD. Treatment also
depends on your current health condition, risk factors, and overall wellbeing. For
example, your doctor may prescribe medication therapy to treat high cholesterol or high
blood pressure, or you may receive medication to control blood sugar if you have
diabetes.
Lifestyle changes can also reduce your risk of heart disease and stroke. For example:
 quit smoking tobacco
 reduce or stop your consumption of alcohol
 exercise regularly
 lose weight to a healthy level
 eat a healthy diet (low in fat, low in sodium)
If your condition doesn’t improve with lifestyle changes and medication, your doctor may
recommend a procedure to increase blood flow to your heart. These procedures may
be:
 balloon angioplasty: to widen blocked arteries and smoosh down the plaque
buildup, usually performed with insertion of a stent to help keep the lumen open
after the procedure
 coronary artery bypass graft surgery: to restore blood flow to the heart in
open chest surgery
 enhanced external counterpulsation: to stimulate the formation of new small
blood vessels to naturally bypass clogged arteries in a noninvasive procedure
Nursing Intervention
1. Monitor blood pressure, apical heart rate, and respirations every 5 minutes
during an anginal attack.
2. Maintain continuous ECG monitoring or obtain a 12-lead ECG, as directed,
monitor for arrhythmias and ST elevation.
3. Place patient in comfortable position and administer oxygen, if prescribed, to
enhance myocardial oxygen supply.
4. Identify specific activities patient may engage in that are below the level at which
anginal pain occurs.
5. Reinforce the importance of notifying nursing staff whenever angina pain is
experienced.
6. Encourage supine position for dizziness caused by antianginals.
7. Be alert to adverse reaction related to abrupt discontinuation of beta-adrenergic
blocker and calcium channel blocker therapy. These drug must be tapered to
prevent a “rebound phenomenon”; tachycardia, increase in chest pain, and
hypertension.
8. Explain to the patient the importance of anxiety reduction to assist to control
angina.
9. Teach the patient relaxation techniques.
10. Review specific factors that affect CAD development and progression; highlight
those risk factors that can be modified and controlled to reduce the risk.
B. Coronary Atherosclerosis
Arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from
your heart to the rest of your body (arteries) become thick and stiff — sometimes
restricting blood flow to your organs and tissues. Healthy arteries are flexible and
elastic, but over time, the walls in your arteries can harden, a condition commonly called
hardening of the arteries.
Atherosclerosis is a specific type of arteriosclerosis, but the terms are sometimes used
interchangeably. Atherosclerosis refers to the buildup of fats, cholesterol and other
substances in and on your artery walls (plaque), which can restrict blood flow.
The plaque can burst, triggering a blood clot. Although atherosclerosis is often
considered a heart problem, it can affect arteries anywhere in your body.
Atherosclerosis may be preventable and is treatable.
Symptoms
Atherosclerosis develops gradually. Mild atherosclerosis usually doesn't have any

symptoms.
You usually won't have atherosclerosis symptoms until an artery is so narrowed or

clogged that it can't supply adequate blood to your organs and tissues. Sometimes a
blood clot completely blocks blood flow, or even breaks apart and can trigger a heart
attack or stroke.
Symptoms of moderate to severe atherosclerosis depend on which arteries are

affected. For example:
 If you have atherosclerosis in your heart arteries, you may have symptoms,

such as chest pain or pressure (angina).
 If you have atherosclerosis in the arteries leading to your brain, you may

have signs and symptoms such as sudden numbness or weakness in your arms
or legs, difficulty speaking or slurred speech, temporary loss of vision in one eye,
or drooping muscles in your face. These signal a transient ischemic attack (TIA),
which, if left untreated, may progress to a stroke.
 If you have atherosclerosis in the arteries in your arms and legs, you may
have symptoms of peripheral artery disease, such as leg pain when walking
(claudication).
 If you have atherosclerosis in the arteries leading to your kidneys, you

develop high blood pressure or kidney failure.
Causes
Atherosclerosis is a slow, progressive disease that may begin as early as childhood.

Although the exact cause is unknown, atherosclerosis may start with damage or injury
to the inner layer of an artery. The damage may be caused by:
 High triglycerides, a type of fat (lipid) in your blood
 Smoking and other sources of tobacco
 Insulin resistance, obesity or diabetes
 Inflammation from diseases, such as arthritis, lupus or infections, or inflammation

of unknown cause
Once the inner wall of an artery is damaged, blood cells and other substances often
clump at the injury site and build up in the inner lining of the artery.
Over time, fatty deposits (plaque) made of cholesterol and other cellular products also
build up at the injury site and harden, narrowing your arteries. The organs and tissues
connected to the blocked arteries then don't receive enough blood to function properly.
Eventually, pieces of the fatty deposits may break off and enter your bloodstream.
In addition, the smooth lining of the plaque may rupture, spilling cholesterol and other
substances into your bloodstream. This may cause a blood clot, which can block the
blood flow to a specific part of your body, such as occurs when blocked blood flow to
your heart causes a heart attack. A blood clot can also travel to other parts of your
body, blocking flow to another organ.
Diagnosis
During a physical exam, your doctor may find signs of narrowed, enlarged or hardened
arteries, including:
 A weak or absent pulse below the narrowed area of your artery
 Decreased blood pressure in an affected limb
 Whooshing sounds (bruits) over your arteries, heard using a stethoscope
Depending on the results of the physical exam, your doctor may suggest one or more
diagnostic tests, including:
 Blood tests. Lab tests can detect increased levels of cholesterol and blood
sugar that may increase the risk of atherosclerosis. You'll need to go without
eating or drinking anything but water for nine to 12 hours before your blood test.
Your doctor should tell you ahead of time if this test will be performed during your visit.
 Doppler ultrasound. Your doctor may use a special ultrasound device (Doppler

ultrasound) to measure your blood pressure at various points along your arm or
leg. These measurements can help your doctor gauge the degree of any
blockages, as well as the speed of blood flow in your arteries.
 Ankle-brachial index. This test can tell if you have atherosclerosis in the

arteries in your legs and feet.
Your doctor may compare the blood pressure in your ankle with the blood pressure in
your arm. This is known as the ankle-brachial index. An abnormal difference may
indicate peripheral vascular disease, which is usually caused by atherosclerosis.
heart attack. If your signs and symptoms occur most often during exercise, your
doctor may ask you to walk on a treadmill or ride a stationary bike during an
ECG.
 Stress test. A stress test, also called an exercise stress test, is used to gather
information about how well your heart works during physical activity.
Because exercise makes your heart pump harder and faster than it does during most
daily activities, an exercise stress test can reveal problems within your heart that might
not be noticeable otherwise.
An exercise stress test usually involves walking on a treadmill or riding a stationary bike
while your heart rhythm, blood pressure and breathing are monitored.
In some types of stress tests, pictures will be taken of your heart, such as during a
stress echocardiogram (ultrasound) or nuclear stress test. If you're unable to exercise,
you may receive a medication that mimics the effect of exercise on your heart.
 Cardiac catheterization and angiogram. This test can show if your coronary

arteries are narrowed or blocked.
A liquid dye is injected into the arteries of your heart through a long, thin tube (catheter)
that's fed through an artery, usually in your leg, to the arteries in your heart. As the dye
fills your arteries, the arteries become visible on X-ray, revealing areas of blockage.
 Other imaging tests. Your doctor may use ultrasound, a computerized

tomography (CT) scan or magnetic resonance angiography (MRA) to study your
arteries. These tests can often show hardening and narrowing of large arteries,
as well as aneurysms and calcium deposits in the artery walls.
Treatment
Lifestyle changes, such as eating a healthy diet and exercising, are often the most
appropriate treatment for atherosclerosis. Sometimes, medication or surgical
procedures may be recommended as well.
Medications
Various drugs can slow — or even reverse — the effects of atherosclerosis. Here are
some common choices:
 Cholesterol medications. Aggressively lowering your low-density lipoprotein

(LDL) cholesterol, the "bad" cholesterol, can slow, stop or even reverse the
buildup of fatty deposits in your arteries. Boosting your high-density lipoprotein
(HDL) cholesterol, the "good" cholesterol, may help, too.
Your doctor can choose from a range of cholesterol medications, including drugs known
as statins and fibrates. In addition to lowering cholesterol, statins have additional effects
that help stabilize the lining of your heart arteries and prevent atherosclerosis.
 Anti-platelet medications. Your doctor may prescribe anti-platelet medications,

such as aspirin, to reduce the likelihood that platelets will clump in narrowed
arteries, form a blood clot and cause further blockage.
 Beta blocker medications. These medications are commonly used for coronary

artery disease. They lower your heart rate and blood pressure, reducing the
demand on your heart and often relieve symptoms of chest pain. Beta blockers
reduce the risk of heart attacks and some heart rhythm problems.
 Angiotensin-converting enzyme (ACE) inhibitors. These medications may

help slow the progression of atherosclerosis by lowering blood pressure and
producing other beneficial effects on the heart arteries. ACE inhibitors can also
reduce the risk of recurrent heart attacks.
 Calcium channel blockers. These medications lower blood pressure and are

sometimes used to treat angina.
 Water pills (diuretics). High blood pressure is a major risk factor for

atherosclerosis. Diuretics lower blood pressure.
 Other medications. Your doctor may suggest certain medications to control

specific risk factors for atherosclerosis, such as diabetes. Sometimes specific
medications to treat symptoms of atherosclerosis, such as leg pain during
exercise, are prescribed.
Surgical procedures
Sometimes more aggressive treatment is needed to treat atherosclerosis. If you have

severe symptoms or a blockage that threatens muscle or skin tissue survival, you may
be a candidate for one of the following surgical procedures:
1. Angioplasty and stent placement. In this procedure, your doctor inserts a long,
thin tube (catheter) into the blocked or narrowed part of your artery. A second
catheter with a deflated balloon on its tip is then passed through the catheter to
the narrowed area.
The balloon is then inflated, compressing the deposits against your artery walls. A mesh
tube (stent) is usually left in the artery to help keep the artery open.
2. Endarterectomy. In some cases, fatty deposits must be surgically removed from

the walls of a narrowed artery. When the procedure is done on arteries in the
neck (the carotid arteries), it's called a carotid endarterectomy.
3. Fibrinolytic therapy. If you have an artery that's blocked by a blood clot, your
doctor may use a clot-dissolving drug to break it apart.
4. Bypass surgery. Your doctor may create a graft bypass using a vessel from
another part of your body or a tube made of synthetic fabric. This allows blood to
flow around the blocked or narrowed artery.
Nursing Interventions
The patient and family are taught about risk factors associated with atherosclerosis, and
the health care professionals help the patient modify these factors. Patients who smoke
cigarettes are encouraged to enroll in smoking cessation programs. Community-based
plans and programs to change sedentary activity patterns, reduce stress, control
obesity, and decrease saturated fat intake to control triglyceride and cholesterol levels
are explored with the patient. The nurse or other health care professional refers the
patient for medical treatment to control hypertension and diabetes mellitus and supports
the patient's efforts to cooperate with lifestyle and health care changes. Regular
exercise of a type and extent appropriate for the patient's health and adequate rest are
prescribed. The patient is informed of the need for long-term follow-up care to prevent a
variety of body system complications.
C. Acute Coronary Syndrome
Acute coronary syndrome is a term used to describe a range of conditions associated

with sudden, reduced blood flow to the heart.
One such condition is a heart attack (myocardial infarction) — when cell death results in
damaged or destroyed heart tissue. Even when acute coronary syndrome causes no
cell death, the reduced blood flow changes how your heart works and is a sign of a high
risk of heart attack.
Acute coronary syndrome often causes severe chest pain or discomfort. It is a medical
emergency that requires prompt diagnosis and care. The goals of treatment include
improving blood flow, treating complications and preventing future problems.
Symptoms
The signs and symptoms of acute coronary syndrome usually begin abruptly. They
include:
 Chest pain (angina) or discomfort, often described as aching, pressure, tightness

or burning
 Pain spreading from the chest to the shoulders, arms, upper abdomen, back,
neck or jaw
 Nausea or vomiting
 Indigestion
 Shortness of breath (dyspnea)
 Sudden, heavy sweating (diaphoresis)

 Lightheadedness, dizziness or fainting
 Unusual or unexplained fatigue
 Feeling restless or apprehensive
Chest pain or discomfort is the most common symptom. However, signs and symptoms
may vary significantly depending on your age, sex and other medical conditions. You're
more likely to have signs and symptoms without chest pain or discomfort if you're a
woman, older adult or have diabetes.
Causes
Acute coronary syndrome usually results from the buildup of fatty deposits (plaques) in
and on the walls of coronary arteries, the blood vessels delivering oxygen and nutrients
to heart muscles.
When a plaque deposit ruptures or splits, a blood clot forms. This clot blocks the flow of
blood to heart muscles.
When the supply of oxygen to cells is too low, cells of the heart muscles can die. The
death of cells — resulting in damage to muscle tissues — is a heart attack (myocardial
infarction).
Even when there is no cell death, the decrease in oxygen still results in heart muscles
that don't work the way they should. This change may be temporary or permanent.
When acute coronary syndrome doesn't result in cell death, it is called unstable angina.
Diagnosis
If you have signs or symptoms associated with acute coronary syndrome, an

emergency room doctor will likely order several tests. Some tests may be done while
your doctor is asking you questions about your symptoms or medical history. Tests
include:
 Electrocardiogram (ECG). Electrodes attached to your skin measure the

electrical activity in your heart. Abnormal or irregular impulses can mean your
heart is not working properly due to a lack of oxygen to the heart. Certain
patterns in electrical signals may show the general location of a blockage. The
test may be repeated several times.
 Blood tests. Certain enzymes may be detected in the blood if cell death has
resulted in damage to heart tissue. A positive result indicates a heart attack.
The information from these two tests — as well as your signs and symptoms — is used
to make a primary diagnosis of acute coronary syndrome. Your doctor can use the
information to determine whether your condition can be classified as a heart attack or
unstable angina.
Other tests may be done to learn more about your condition, rule out other causes of
symptoms, or to help your doctor personalize your diagnosis and treatment.
 Coronary angiogram. This procedure uses X-ray imaging to see your heart's

blood vessels. A long, tiny tube (catheter) is threaded through an artery, usually
in your arm or groin, to the arteries in your heart. A dye flows through the tube
into your arteries. A series of X-rays show how the dye moves through your
arteries, revealing any blockages or narrowing. The catheter may also be used
for treatments.
 Echocardiogram. An echocardiogram uses sound waves, directed at your heart

from a wand-like device, to produce a live image of your heart. An
echocardiogram can help determine whether the heart is pumping correctly.
 Myocardial perfusion imaging. This test shows how well blood flows through
your heart muscle. A tiny, safe amount of radioactive substance is injected into
your blood. A specialized camera takes images of the substance's path through
your heart. They show your doctor whether enough blood is flowing through heart
muscles and where blood flow is reduced.
 Computerized tomography (CT) angiogram. A CT angiogram uses a

specialized X-ray technology that can produce multiple images — cross-sectional
2-D slices — of your heart. These images can detect narrowed or blocked
coronary arteries.
 Stress test. A stress test reveals how well your heart works when you exercise.
In some cases, you may receive a medication to increase your heart rate rather
than exercising. This test is done only when there are no signs of acute coronary
syndrome or another life-threatening heart condition when you are at rest. During
the stress test, an ECG, echocardiogram or myocardial perfusion imaging may
be used to see how well your heart works.
Treatment
The immediate goals of treatment for acute coronary syndrome are:

 Relieve pain and distress
 Improve blood flow
 Restore heart function as quickly and as best as possible
Long-term treatment goals are to improve overall heart function, manage risk factors
and lower the risk of a heart attack. A combination of drugs and surgical procedures
may be used to meet these goals.
Medications
Depending on your diagnosis, medications for emergency or ongoing care (or both) may
include the following:
 Thrombolytics (clot busters) help dissolve a blood clot that's blocking an artery.
 Nitroglycerin improves blood flow by temporarily widening blood vessels.
 Antiplatelet drugs help prevent blood clots from forming and include aspirin,
clopidogrel (Plavix), prasugrel (Effient) and others.
 Beta blockers help relax your heart muscle and slow your heart rate. They
decrease the demand on your heart and lower blood pressure. Examples include
metoprolol (Lopressor, Toprol-XL) and nadolol (Corgard).
 Angiotensin-converting enzyme (ACE) inhibitors widen blood vessels and

improve blood flow, allowing the heart to work better. They include lisinopril
(Prinivil, Zestril), benazepril (Lotensin) and others.
 Angiotensin receptor blockers (ARBs) help control blood pressure and include

irbesartan (Avapro), losartan (Cozaar) and several others.
 Statins lower the amount of cholesterol moving in the blood and may stabilize
plaque deposits, making them less likely to rupture. Statins include atorvastatin
(Lipitor), simvastatin (Zocor, Flolipid) and several others.
Surgery and other procedures
Your doctor may recommend one of these procedures to restore blood flow to your
heart muscles:
 Angioplasty and stenting. In this procedure, your doctor inserts a long, tiny
tube (catheter) into the blocked or narrowed part of your artery. A wire with a
deflated balloon is passed through the catheter to the narrowed area. The
balloon is then inflated, opening the artery by compressing the plaque deposits
against your artery walls. A mesh tube (stent) is usually left in the artery to help
keep the artery open.
 Coronary bypass surgery. With this procedure, a surgeon takes a piece of

blood vessel (graft) from another part of your body and creates a new route for
blood that goes around (bypasses) a blocked coronary artery.
Acute hospital admission
Keeping clear and comprehensive notes is crucial to ensure all nurses caring for
patients with ACS know the patients’ clinical status, areas of concerns and management
plan. Nurses caring for patients who recently had coronary angiography should monitor
radial or femoral access sites and be able to recognise complications. Close
communication with cardiac catheterisation laboratory staff and the coronary care unit is
crucial. Nurses receiving these patients need clear information about the type of
procedure they had, any complications, medications and IV fluids, and whether they
have received anticoagulants or GPIs, which will put them at greater risk of bleeding
(Macdonald et al, 2016).
General priorities for patients with ACS are haemodynamic monitoring and close
observation of vital signs. A review of fluid status can provide information about renal
perfusion, as some patients may present with, or develop, heart failure. In patients with
diabetes, capillary blood glucose levels should be regularly checked; some may be put
on IV insulin if their blood glucose is >11mmol/L. Patients recently diagnosed with
diabetes should be referred to the diabetes specialist nurse.
Symptom monitoring is important to achieve pain relief with GTN or morphine. Swift
recognition of any cardiac changes on the serial ECGs is also a key aspect of nursing
care. Patients considered at high risk should be managed where continuous cardiac
monitoring is available as they are at risk of arrhythmias, which can precede a cardiac
arrest. Patients at intermediate risk may be managed in a medical assessment unit,
where they are likely to receive serial ECGs. Nurses caring for patients with ACS should
have ECG interpretation skills, as ECG changes or arrhythmias are signs of potential
deterioration.
Other elements of nursing care include ongoing management of IV cannulas, central

venous pressure lines, urinary catheters and wounds and dressings.
Patients are likely to be anxious and frightened. Nurses should be calm and reassuring,
and ensure pain and other symptoms are well controlled. They play a central role in
providing psychosocial support; when possible, they should give patients a chance to
speak about their experiences, address their concerns and relay these to the
multidisciplinary team.
Discharge and secondary prevention in MI patients
There are several things to consider when patients with a confirmed MI (either NSTEMI
or STEMI) are ready to be discharged home (Box 2). Secondary prevention should be
at the heart of nurses’ strategies. Patients need to understand their condition and be
encouraged to make any lifestyle changes needed, which will be crucial to prevent
recurrence. They will be discharged with much information, but the priority is for them to
understand:
 They have had an acute MI;
 Results of any investigations;
 How their condition will be managed.
Patients are likely to go home with several drugs and many will need to take them for
the rest of their lives. These drugs usually comprise dual antiplatelet therapy, beta-
blockers, statins and ACE inhibitors. Some patients will also need aldosterone
antagonists. Nurses must ensure patients:
 Understand the dosages and administration routes;
 Know not to discontinue treatment without medical advice.
Where possible relatives should be involved in discussions, as they can often help with
lifestyle changes. Patients should receive advice on travel and be made aware of the
rules about driving after an MI. They should also be advised to seek urgent medical
Nurses should address patients’ concerns and refer them to cardiac nurses or dietitians
for specialist advice, as well as the primary care team for ongoing secondary
prevention. They should also encourage them to attend a cardiac rehabilitation
programme; this is particularly so for hard-to-reach groups – older people, women,
some ethnic groups, people in rural areas, those of lower socioeconomic status – in
which attendance is lower than average (NICE, 2015; Dalal et al, 2015).
D. Myocardial Infarction
Acute myocardial infarction is the medical name for a heart attack. A heart attack is a
life-threatening condition that occurs when blood flow to the heart muscle is abruptly cut
off, causing tissue damage. This is usually the result of a blockage in one or more of
the coronary arteries. A blockage can develop due to a buildup of plaque, a substance
mostly made of fat, cholesterol, and cellular waste products.
Symptoms
Common heart attack signs and symptoms include:
 Pressure, tightness, pain, or a squeezing or aching sensation in your chest or

arms that may spread to your neck, jaw or back
 Nausea, indigestion, heartburn or abdominal pain
 Shortness of breath
 Cold sweat
 Fatigue
 Lightheadedness or sudden dizziness
Heart attack symptoms vary
Not all people who have heart attacks have the same symptoms or have the same
severity of symptoms. Some people have mild pain; others have more severe pain.
Some people have no symptoms. For others, the first sign may be sudden cardiac
arrest. However, the more signs and symptoms you have, the greater the chance you're
having a heart attack.
Some heart attacks strike suddenly, but many people have warning signs and
symptoms hours, days or weeks in advance. The earliest warning might be recurrent
chest pain or pressure (angina) that's triggered by activity and relieved by rest. Angina
is caused by a temporary decrease in blood flow to the heart.
Diagnosis
Ideally, your doctor should screen you during regular physical exams for risk factors that
can lead to a heart attack.
If you're in an emergency setting for symptoms of a heart attack, you'll be asked about
your symptoms and have your blood pressure, pulse and temperature checked. You'll
be connected to a heart monitor and have tests to see if you're having a heart attack.
Tests to diagnose a heart attack include:
 Electrocardiogram (ECG). This first test done to diagnose a heart attack

records electrical signals as they travel through your heart. Sticky patches
(electrodes) are attached to your chest and limbs. Signals are recorded as waves
displayed on a monitor or printed on paper. Because injured heart muscle doesn't
conduct electrical impulses normally, the ECG may show that a heart attack has
occurred or is in progress.
 Blood tests. Certain heart proteins slowly leak into your blood after heart
damage from a heart attack. Emergency room doctors will take samples of your
blood to check for these proteins, or enzymes.
Additional tests
If you've had or are having a heart attack, doctors will take immediate steps to treat your
condition. You might also have these additional tests.
 Chest X-ray. An X-ray image of your chest allows your doctor to check the size
of your heart and its blood vessels and to look for fluid in your lungs.
 Echocardiogram. Sound waves (ultrasound) create images of the moving heart.

Your doctor can use this test to see how your heart's chambers and valves are
pumping blood through your heart. An echocardiogram can help identify whether
an area of your heart has been damaged.
 Coronary catheterization (angiogram). A liquid dye is injected into the arteries

of your heart through a long, thin tube (catheter) that's fed through an artery,
usually in your leg or groin, to the arteries in your heart. The dye makes the
arteries visible on X-ray, revealing areas of blockage.
 Cardiac CT or MRI. These tests create images of your heart and chest.

Cardiac CT scans use X-rays. Cardiac MRI uses a magnetic field and radio
waves to create images of your heart. For both tests, you lie on a table that slides
inside a long tubelike machine. Each can be used to diagnose heart problems,
including the extent of damage from heart attacks.
Treatment
Heart attack treatment at a hospital
Each minute after a heart attack, more heart tissue deteriorates or dies. Restoring blood
flow quickly helps prevent heart damage.
Medications
Medications to treat a heart attack might include:
 Aspirin. The 911 operator might tell you to take aspirin, or emergency medical
personnel might give you aspirin immediately. Aspirin reduces blood clotting,
thus helping maintain blood flow through a narrowed artery.
 Thrombolytics. These drugs, also called clotbusters, help dissolve a blood clot

that's blocking blood flow to your heart. The earlier you receive a thrombolytic
drug after a heart attack, the greater the chance you'll survive and have less
heart damage.
 Antiplatelet agents. Emergency room doctors may give you other drugs known
as platelet aggregation inhibitors to help prevent new clots and keep existing
clots from getting larger.
 Other blood-thinning medications. You'll likely be given other medications,

such as heparin, to make your blood less "sticky" and less likely to form clots.
Heparin is given by IV or by an injection under your skin.
 Pain relievers. You might be given a pain reliever, such as morphine.
 Nitroglycerin. This medication, used to treat chest pain (angina), can help

improve blood flow to the heart by widening (dilating) the blood vessels.
 Beta blockers. These medications help relax your heart muscle, slow your
heartbeat and decrease blood pressure, making your heart's job easier. Beta
blockers can limit the amount of heart muscle damage and prevent future heart
attacks.
 ACE inhibitors. These drugs lower blood pressure and reduce stress on the
heart.
 Statins. These drugs help control your blood cholesterol.
Surgical and other procedures
In addition to medications, you might have one of these procedures to treat your heart
attack:
 Coronary angioplasty and stenting. In this procedure, also known as

percutaneous coronary intervention (PCI), doctors guide a long, thin tube
(catheter) through an artery in your groin or wrist to a blocked artery in your
heart. If you've had a heart attack, this procedure is often done immediately after
a cardiac catheterization, a procedure used to find blockages.
The catheter has a special balloon that, once in position, is briefly inflated to open a
blocked coronary artery. A metal mesh stent almost always is inserted into the artery to
keep it open long term, restoring blood flow to the heart. Usually, you get a stent coated
with a slow-releasing medication to help keep your artery open.
 Coronary artery bypass surgery. In some cases, doctors perform emergency

bypass surgery at the time of a heart attack. If possible, however, you might have
bypass surgery after your heart has had time — about three to seven days — to
recover from your heart attack.
Bypass surgery involves sewing veins or arteries in place beyond a blocked or

narrowed coronary artery, allowing blood flow to the heart to bypass the narrowed
section.
You'll likely remain in the hospital for several days after blood flow to your heart is
restored and your condition is stable.
Cardiac rehabilitation
Most hospitals offer programs that might start while you're in the hospital and continue
for weeks to a couple of months after you return home. Cardiac rehabilitation programs
generally focus on four main areas — medications, lifestyle changes, emotional issues
and a gradual return to your normal activities.
It's extremely important to participate in this program. People who attend cardiac rehab
after a heart attack generally live longer and are less likely to have another heart attack
or complications from the heart attack.
1. Monitor continuous ECG to watch for life threatening arrhythmias (common within
24 hours after infarctions) and evolution of the MI (changes in ST segments and
T waves). Be alert for any type of premature ventricular beats- these may herald
ventricular fibrillation or ventricular tachycardia.
2. Monitor baseline vital signs before and 10 to 15 minutes after administering

drugs. Also monitor blood pressure continuously when giving nitroglycerin I.V.
3. Handle the patient carefully while providing care, starting I.V. infusion, obtaining
baseline vital signs, and attaching electrodes for continuous ECG monitoring.
4. Reassure the patient that pain relief is a priority, and administer analgesics
promptly. Place the patient in supine position during administration to minimize
hypotension.
5. Emphasize the importance of reporting any chest pain, discomfort, or epigastric

distress without delay.
6. Explain equipment, procedures, and need for frequent assessment to the patient
and significant others to reduce anxiety associated with facility environment.
7. Promote rest with early gradual increase in mobilization to prevent

deconditioning, which occurs during bed rest.
8. Take measures to prevent bleeding if patient is thrombolitic therapy
9. Be alert to signs and symptoms of sleep deprivation such as irritability,

disorientation, hallucinations, diminished pain tolerance, and aggressiveness.
10. Tell the patient that sexual relations may be resumed on advise of health care
provider, usually after exercise tolerance is assessed.
E. Percutaneous Coronary Artery Procedures
Percutaneous Coronary Intervention (PCI, formerly known as angioplasty with stent) is

a non-surgical procedure that uses a catheter (a thin flexible tube) to place a small
structure called a stent to open up blood vessels in the heart that have been narrowed
by plaque buildup, a condition known as atherosclerosis.
Why is it done?
PCI improves blood flow, thus decreasing heart-related chest pain (angina), making you
feel better and increasing your ability to be active. PCI is usually scheduled ahead of
time.
What is done?
 A catheter is inserted into the blood vessels either in the groin or in the arm.
 Using a special type of X-ray called fluoroscopy, the catheter is threaded through
the blood vessels into the heart where the coronary artery is narrowed.
 When the tip is in place, a balloon tip covered with a stent is inflated.
 The balloon tip compresses the plaque and expands the stent.
 Once the plaque is compressed and the stent is in place, the balloon is deflated
and withdrawn.
 The stent stays in the artery, holding it open.
What can you expect?
Your doctor will explain the risks and benefits of the procedure. Before the procedure
starts, inform your doctor if you:
 Have ever had a reaction to any contrast dye, iodine, or any serious allergic
reaction (for example, from a bee sting or from eating shellfish).
 Have asthma.
 Are allergic to any medication.
 Have any bleeding problems or are taking blood-thinning medication.
 Have a history of kidney problems or diabetes.
 Have body piercings on your chest or abdomen.
 Have had any recent change in your health.
 Are, or may be, pregnant.
Before the procedure
 Shortly before your procedure, you may receive a sedative to help you relax.
 Hair in the groin area around where the catheter will be inserted may be clipped.
 An intravenous (IV) line is inserted so, if necessary, you can be given

medications quickly.
 Electrodes will be placed on your body to monitor your heart, and a small device
called a pulse oximeter may be clipped on a finger or ear to track the oxygen
level in your blood.
During the procedure
 Most PCIs are conducted with the patient sedated but not asleep.
 You will lie on your back on a procedure table.

 A local anesthetic will be injected into the skin at the site where the catheter will
be inserted.
 Once it has taken effect, the catheter will be inserted into the blood vessels.
 You may feel a brief sting or pinch as the needle goes through the skin and some
pressure within the artery as the catheter is moved. If you are uncomfortable, tell
your doctor and if necessary additional pain medication may be given.
 When the catheter reaches the heart, the contrast dye will be released so the
area where the blood vessel is narrowed can be identified.
 When the dye is released, you may feel a brief flushing sensation or feeling of
warmth. Some people experience a salty or metallic taste in the mouth, or a brief
headache. A few people may feel nauseated or even vomit, but this is rare.
These effects are harmless usually last for only a few minutes.
 When the narrowing is located, the catheter will be advanced so the special tip
can be activated.
 It is possible to experience some chest pain or discomfort at this point, but your
doctor will monitor you carefully and the discomfort should go away quickly.
 When finished, the catheter will be withdrawn and pressure put on the insertion
site to stop the bleeding.
 Once the bleeding has stopped, a tight bandage will be applied.
 You will need to remain lying flat during this time.
 If the catheter was inserted in the groin, you will have to keep your leg straight for
several hours.
 If it was inserted in the arm, your arm will be kept elevated on pillows and kept
straight with an arm board.
After the procedure
 You will probably go to a recovery room for several hours of observation.
 You will be asked to remain in bed for 2 to 6 hours, depending upon your specific
condition.
 Pain medication may be given if you experience any discomfort.

 You will be encouraged to drink water and other fluids to help flush the contrast
dye from your body.
 Most people spend the night in hospital after a PCI.
At home
When you return home, keep an eye on the insertion site. A small bruise is normal, but
contact your doctor if you experience:
 increased pain
 redness
 swelling
 bleeding or other draining from the insertion site
 fever
 chills.
F. Coronary Artery Bypass Graft
Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow to
the heart. It's used for people who have severe coronary heart disease (CHD), also
called coronary artery disease.
CHD is a condition in which a substance called plaque (plak) builds up inside the
coronary arteries. These arteries supply oxygen-rich blood to your heart. Plaque is
made up of fat, cholesterol, calcium, and other substances found in the blood.
Plaque can narrow or block the coronary arteries and reduce blood flow to the heart
muscle. If the blockage is severe, angina (an-JI-nuh or AN-juh-nuh), shortness of
breath, and, in some cases, heart attack can occur. (Angina is chest pain or discomfort.)
CABG is one treatment for CHD. During CABG, a healthy artery or vein from the body is
connected, or grafted, to the blocked coronary artery. The grafted artery or vein
bypasses (that is, goes around) the blocked portion of the coronary artery.
This creates a new passage, and oxygen-rich blood is routed around the blockage to
the heart muscle.
Types of Coronary Artery Bypass Grafting
Traditional Coronary Artery Bypass Grafting
This is the most common type of coronary artery bypass grafting (CABG). It's used
when at least one major artery needs to be bypassed.
During the surgery, the chest bone is opened to access the heart. Medicines are given
to stop the heart, and a heart-lung bypass machine is used to keep blood and oxygen
moving throughout the body during surgery. This allows the surgeon to operate on a still
heart.
After surgery, blood flow to the heart is restored. Usually, the heart starts beating again
on its own. In some cases, mild electric shocks are used to restart the heart.
Off-Pump Coronary Artery Bypass Grafting
This type of CABG is similar to traditional CABG because the chest bone is opened to
access the heart. However, the heart isn't stopped, and a heart-lung bypass machine
isn't used. Off-pump CABG is sometimes called beating heart bypass grafting.
Minimally Invasive Direct Coronary Artery Bypass Grafting
This surgery is similar to off-pump CABG. However, instead of a large incision (cut) to
open the chest bone, several small incisions are made on the left side of the chest
between the ribs.
This type of surgery mainly is used for bypassing the blood vessels in front of the heart.
It's a fairly new procedure that's done less often than the other types of CABG.
This type of CABG isn't for everybody, especially if more than one or two coronary
arteries need to be bypassed.
G. Valvular disorders
Valvular heart disease is characterized by damage to or a defect in one of the four heart
valves: the mitral, aortic, tricuspid or pulmonary.
The mitral and tricuspid valves control the flow of blood between the atria and the
ventricles (the upper and lower chambers of the heart). The pulmonary valve controls
the flow of blood from the heart to the lungs, and the aortic valve governs blood flow
between the heart and the aorta, and thereby the blood vessels to the rest of the body.
The mitral and aortic valves are the ones most frequently affected by valvular heart
disease.
Normally functioning valves ensure that blood flows with proper force in the proper
direction at the proper time. In valvular heart disease, the valves become too narrow
and hardened (stenotic) to open fully, or are unable to close completely (incompetent).
A stenotic valve forces blood to back up in the adjacent heart chamber, while an
incompetent valve allows blood to leak back into the chamber it previously exited. To
compensate for poor pumping action, the heart muscle enlarges and thickens, thereby
losing elasticity and efficiency. In addition, in some cases, blood pooling in the
chambers of the heart has a greater tendency to clot, increasing the risk of stroke or
pulmonary embolism.
The severity of valvular heart disease varies. In mild cases there may be no symptoms,
while in advanced cases, valvular heart disease may lead to congestive heart failure
and other complications. Treatment depends upon the extent of the disease.
Symptoms
Valve disease symptoms can occur suddenly, depending upon how quickly the disease
develops. If it advances slowly, then your heart may adjust and you may not notice the
onset of any symptoms easily. Additionally, the severity of the symptoms does not
necessarily correlate to the severity of the valve disease. That is, you could have no
symptoms at all, but have severe valve disease. Conversely, severe symptoms could
arise from even a small valve leak.
Many of the symptoms are similar to those associated with congestive heart failure,
such as shortness of breath and wheezing after limited physical exertion and swelling of
the feet, ankles, hands or abdomen (edema). Other symptoms include:
 Palpitations, chest pain (may be mild).
 Fatigue.
 Dizziness or fainting (with aortic stenosis).
 Fever (with bacterial endocarditis).
 Rapid weight gain.
Causes
There are many different types of valve disease; some types can be present at birth
(congenital), while others may be acquired later in life.
 Heart valve tissue may degenerate with age.
 Rheumatic fever may cause valvular heart disease.
 Bacterial endocarditis, an infection of the inner lining of the heart muscle and

heart valves (endocardium), is a cause of valvular heart disease.
 High blood pressure and atherosclerosis may damage the aortic valve.
 A heart attack may damage the muscles that control the heart valves.
 Other disorders such as carcinoid tumors, rheumatoid arthritis, systemic lupus

erythematosus, or syphilis may damage one or more heart valves.
 Methysergide, a medication used to treat migraine headaches, and some diet

drugs may promote valvular heart disease.
 Radiation therapy (used to treat cancer) may be associated with valvular heart
disease.
Diagnosis
During your examination, the doctor listens for distinctive heart sounds, known as heart
murmurs, which indicate valvular heart disease. As part of your diagnosis, you may
undergo one or more of the following tests:
 An electrocardiogram, also called an ECG or EKG, to measure the electrical

activity of the heart, regularity of heartbeats, thickening of heart muscle
(hypertrophy) and heart-muscle damage from coronary artery disease.
 Stress testing, also known as treadmill tests, to measure blood pressure, heart
rate, ECG changes and breathing rates during exercise. During this test, the
heart’s electrical activity is monitored through small metal sensors applied to your
skin while you exercise on a treadmill.
 Chest X-rays.
 Echocardiogram to evaluate heart function. During this test, sound waves

bounced off the heart are recorded and translated into images. The pictures can
reveal abnormal heart size, shape and movement. Echocardiography also can be
used to calculate the ejection fraction, or volume of blood pumped out to the
body when the heart contracts.
 Cardiac catheterization, which is the threading of a catheter into the heart

chambers to measure pressure irregularities across the valves (to detect
stenosis) or to observe backflow of an injected dye on an X-ray (to detect
incompetence).
Treatment
The following provides an overview of the treatment options for valvular heart disease:
 Don’t smoke; follow prevention tips for a heart-healthy lifestyle. Avoid

excessive alcohol consumption, excessive salt intake and diet pills—all of which
may raise blood pressure.
 Your doctor may adopt a “watch and wait” policy for mild or asymptomatic
cases.
 A course of antibiotics is prescribed prior to surgery or dental work for those

with valvular heart disease, to prevent bacterial endocarditis.
 Long-term antibiotic therapy is recommended to prevent a recurrence of

streptococcal infection in those who have had rheumatic fever.
 Antithrombotic (clot-preventing) medications such as aspirin or ticlopidine

may be prescribed for those with valvular heart disease who have experienced
unexplained transient ischemic attacks, also known as TIAs (see this disorder for
more information).
 More potent anticoagulants, such as warfarin, may be prescribed for those who

have atrial fibrillation (a common complication of mitral valve disease) or who
continue to experience TIAs despite initial treatment. Long-term administration of
anticoagulants may be necessary following valve replacement surgery, because
prosthetic valves are associated with a higher risk of blood clots.
 Balloon dilatation (a surgical technique involving insertion into a blood vessel of

a small balloon that is led via catheter to the narrowed site and then inflated) may
be done to widen a stenotic valve.
 Valve Surgery to repair or replace a damaged valve may be necessary.

Replacement valves may be artificial (prosthetic valves) or made from animal
tissue (bioprosthetic valves). The type of replacement valve selected depends on
the patient’s age, condition, and the specific valve affected.
 Assess Heart SoundsTo identify murmur:

1. Is it an S1 or S2 murmur?
2. Which valve are you listening to?
3. What should the valve be doing at that time?
The easiest way for a nurse to determine the presence of a valve disorder is to listen for
murmurs. A murmur indicates abnormal or turbulent blood flow through the valve.
 If the valve should be open, but doesn’t open fully – stenosis
 If the valve should be closed, but doesn’t close fully – regurgitation
 Assess and Monitor CV status
o Pulses
o Capillary refill
o Skin color, temperature
o Heart rate
o Blood Pressure
o Arrhythmias (ECG)
Valve disorders can compromise cardiac output. Assess cardiovascular status to

determine if there is decreased perfusion to the tissues. If BP is dropping, HR may
increase to compensate.
 Assess respiratory status
o Lung sounds
o SpO2
o Shortness of Breath
o Sputum
If blood is not going forward or backing up, it can cause pulmonary congestion leading
to pulmonary edema. This would cause decreased SpO2, crackles in the lungs, and
possibly even pink-frothy sputum
 Notify provider of new or sudden onset or murmurs, especially if accompanied by

signs of poor perfusion or pulmonary edema
Papillary muscle rupture and mitral valve prolapse may occur suddenly. They are most
often accompanied by chest pain, shortness of breath, or other signs of heart failure.
This is an emergency that requires surgical intervention immediately. Don’t hesitate to
call for help.
 Educate patient about post-op requirements after valve replacement surgery
o Prophylactic antibiotics prior to any invasive procedures
o Bleeding Precautions (anticoagulant therapy)
o Use soft bristle toothbrush
o Maintain good oral hygiene
o Avoid dental procedures for 6 months post-op
Patients who receive artificial valve replacements will require lifelong anticoagulant
therapy. They need to be taught precautions for anticoagulant therapy, including using
electric razors and soft bristle toothbrushes and how often they will require monitoring, if
at all.
Patients with artificial heart valves are at high risk of developing endocarditis. They
need to be taught about preventative measures, including receiving prophylactic
antibiotics prior to any invasive procedures.
Oral hygiene is imperative to prevention of endocarditis after valve repair. This may
seem silly but it is a HUGE deal. The evidence has shown that bacteria from the oral
cavity are highly likely to translocate (move) to the heart and become lodged in/on the
valves. This is also why patients should avoid dental procedures for 6 months after
valve surgery. It is so important that you, as the nurse, educate them on why this is so
important.
H. Mitral Regurgitation
Mitral valve regurgitation — also called mitral regurgitation, mitral insufficiency or mitral
incompetence — is a condition in which your heart's mitral valve doesn't close tightly,
allowing blood to flow backward in your heart. If the mitral valve regurgitation is
significant, blood can't move through your heart or to the rest of your body as efficiently,
making you feel tired or out of breath.
Symptoms
Some people with mitral valve disease might not experience symptoms for many years.
Signs and symptoms of mitral valve regurgitation, which depend on its severity and how
quickly the condition develops, can include:
 Abnormal heart sound (heart murmur) heard through a stethoscope
 Shortness of breath (dyspnea), especially when you have been very active or
when you lie down
 Fatigue
 Heart palpitations — sensations of a rapid, fluttering heartbeat
 Swollen feet or ankles
Mitral valve regurgitation is often mild and progresses slowly. You may have no
symptoms for many years and be unaware that you have this condition, and it might not
progress.
Your doctor might first suspect you have mitral valve regurgitation upon detecting a
heart murmur. Sometimes, however, the problem develops quickly, and you may
experience a sudden onset of severe signs and symptoms.
Causes
Chambers and valves of the heart
Your heart has four valves that keep blood flowing in the correct direction. These valves
include the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve
has flaps (leaflets or cusps) that open and close once during each heartbeat.
Sometimes, the valves don't open or close properly, disrupting the blood flow through
your heart to your body.
Mitral valve prolapse and regurgitation
In mitral valve regurgitation, the valve between the upper left heart chamber (left atrium)
and the lower left heart chamber (left ventricle) doesn't close tightly, causing blood to
leak backward into the left atrium (regurgitation).
Mitral valve regurgitation causes
Mitral valve regurgitation can be caused by problems with the mitral valve, also called
primary mitral valve regurgitation. Diseases of the left ventricle can lead to secondary or
functional mitral valve regurgitation.
Possible causes of mitral valve regurgitation include:
 Mitral valve prolapse. In this condition, the mitral valve's leaflets bulge back into
the left atrium during the heart's contraction. This common heart defect can
prevent the mitral valve from closing tightly and lead to regurgitation.
 Damaged tissue cords. Over time, the tissue cords that anchor the flaps of the
mitral valve to the heart wall may stretch or tear, especially in people with mitral
valve prolapse. A tear can cause leakage through the mitral valve suddenly and
may require repair by heart surgery. Trauma to the chest also can rupture the
cords.
 Rheumatic fever. Rheumatic fever — a complication of untreated strep throat —

can damage the mitral valve, leading to mitral valve regurgitation early or later in
life. Rheumatic fever is now rare in the United States, but it's still common in
developing countries.
 Endocarditis. The mitral valve may be damaged by an infection of the lining of

the heart (endocarditis) that can involve heart valves.
 Heart attack. A heart attack can damage the area of the heart muscle that
supports the mitral valve, affecting the function of the valve. If the damage is
extensive enough, a heart attack can cause sudden and severe mitral valve
regurgitation.
 Abnormality of the heart muscle (cardiomyopathy). Over time, certain
conditions, such as high blood pressure, can cause your heart to work harder,
gradually enlarging your heart's left ventricle. This can stretch the tissue around
your mitral valve, which can lead to leakage.
 Trauma. Experiencing trauma, such as in a car accident, can lead to mitral valve

regurgitation.
 Congenital heart defects. Some babies are born with defects in their hearts,
including damaged heart valves.
 Certain drugs. Prolonged use of certain medications can cause mitral valve

regurgitation, such as those containing ergotamine (Cafergot, Migergot) that are
used to treat migraines and other conditions.
 Radiation therapy. In rare cases, radiation therapy for cancer that is focused on
the chest area can lead to mitral valve regurgitation.
 Atrial fibrillation. Atrial fibrillation is a common heart rhythm problem that can be

a potential cause of mitral valve regurgitation.
Diagnosis
Your doctor will ask about your medical history and your family history of heart disease.
Your doctor will also perform a physical exam that includes listening to your heart with a
stethoscope. Mitral valve regurgitation usually produces a sound of blood leaking
backward through the mitral valve (heart murmur).
Your doctor will then decide which tests are needed to make a diagnosis. For testing,
you may be referred to a cardiologist.
Tests
Common tests to diagnose mitral valve regurgitation include:
 Echocardiogram. This test is commonly used to diagnose mitral valve

regurgitation. In this test, sound waves directed at your heart from a wandlike
device (transducer) held on your chest produce video images of your heart in
motion.
This test assesses the structure of your heart, the mitral valve and the blood flow
through your heart. An echocardiogram helps your doctor get a close look at the mitral
valve and how well it's working. Doctors also may use a 3-D echocardiogram.
Doctors may conduct another type of echocardiogram called a transesophageal
echocardiogram. In this test, a small transducer attached to the end of a tube is inserted
down your esophagus, which allows a closer look at the mitral valve than a regular
echocardiogram does.
 Electrocardiogram (ECG). Wires (electrodes) attached to adhesive pads on

your skin measure electrical impulses from your heart. An ECG can detect
enlarged chambers of your heart, heart disease and abnormal heart rhythms.
 Chest X-ray. This enables your doctor to determine whether the left atrium or the
left ventricle is enlarged — possible indicators of mitral valve regurgitation — and
the condition of your lungs.
 Cardiac MRI. A cardiac MRI uses magnetic fields and radio waves to create
detailed images of your heart. This test may be used to determine the severity of
your condition and assess the size and function of your lower left heart chamber
(left ventricle).
 Cardiac CT. A CT angiogram may be performed of the chest, abdomen and

pelvis to determine whether you're a candidate for robotic mitral valve repair.
 Exercise tests or stress tests. Different exercise tests help measure your

activity tolerance and monitor your heart's response to physical exertion. If you
are unable to exercise, medications to mimic the effect of exercise on your heart
may be used.
 Cardiac catheterization. This test isn't often used to diagnose mitral valve

regurgitation. This invasive technique involves threading a thin tube (catheter)
through a blood vessel in your arm or groin to an artery in your heart and
injecting dye through the catheter to make the artery visible on an X-ray. This
provides a detailed picture of your heart arteries and how your heart functions. It
can also measure the pressure inside the heart chambers.
Treatment
Mitral valve regurgitation treatment depends on how severe your condition is, if you're
experiencing signs and symptoms, and if your condition is getting worse. The goal of
treatment is to improve your heart's function while minimizing your signs and symptoms
and avoiding future complications.
A doctor trained in heart disease (cardiologist) will provide your care. If you have mitral
valve regurgitation, consider being treated at a medical center with a multidisciplinary
team of doctors and medical staff trained and experienced in evaluating and treating
heart valve disease. This team can work closely with you to determine the most
appropriate treatment for your condition.
Watchful waiting
Some people, especially those with mild regurgitation, might not need treatment.
However, the condition may require monitoring by your doctor. You may need regular
evaluations, with the frequency depending on the severity of your condition. Your doctor
may also recommend making healthy lifestyle changes.
Medications
Your doctor may prescribe medication to treat symptoms, although medication can't
treat mitral valve regurgitation.
Medications may include:
 Diuretics. These medications can relieve fluid accumulation in your lungs or

legs, which can accompany mitral valve regurgitation.
 Blood thinners. These medications can help prevent blood clots and may be
used if you have atrial fibrillation.
 High blood pressure medications. High blood pressure makes mitral valve

regurgitation worse, so if you have high blood pressure, your doctor may
prescribe medication to help lower it.
Surgery
Your mitral valve may need to be repaired or replaced. Doctors may suggest mitral
valve repair or replacement even if you aren't experiencing symptoms, as this may
prevent complications and improve outcomes. If you need surgery for another heart
condition, your doctor may repair or replace the diseased mitral valve at the same time.
Mitral valve surgery is usually performed through a cut (incision) in the chest. In some
cases, doctors may conduct minimally invasive heart surgery, which involves the use of
smaller incisions than those used in open-heart surgery.
Doctors at some medical centers may perform robot-assisted heart surgery, a type of
minimally invasive heart surgery. In this type of surgery, surgeons view the heart in a
magnified high-definition 3-D view on a video monitor and use robotic arms to duplicate
specific maneuvers used in open-heart surgeries.
Mitral valve repair

Surgeons can repair the valve by reconnecting valve flaps (leaflets), replacing the cords
that support the valve, or removing excess valve tissue so that the leaflets can close
tightly. Surgeons may often tighten or reinforce the ring around a valve (annulus) by
implanting an artificial ring (annuloplasty band).
Doctors may use long, thin tubes (catheters) to repair the mitral valve in some cases. In
one catheter procedure, doctors insert a catheter with a clip attached in an artery in the
groin and guide it to the mitral valve. Doctors use the clip to reshape the valve. People
who have severe symptoms of mitral valve regurgitation and who aren't candidates for
surgery or who have high surgical risk may be considered for this procedure.
In another procedure, doctors may repair a previously replaced mitral valve that is
leaking by inserting a device to plug the leak.
Mitral valve replacement
If your mitral valve can't be repaired, you may need mitral valve replacement. In mitral
valve replacement, your surgeon removes the damaged valve and replaces it with a
mechanical valve or a valve made from cow, pig or human heart tissue (biological tissue
valve).
Biological tissue valves degenerate over time, and often eventually need to be replaced.
People with mechanical valves need to take blood-thinning medications for life to
prevent blood clots.
Your doctor can discuss the risks and benefits of each type of heart valve with you and
discuss which valve may be appropriate for you.
Doctors continue to study catheter procedures to repair or replace mitral valves. Some
medical centers may offer mitral valve replacement during a catheter procedure as part
of a clinical trial for people with severe mitral valve disease who are aren't candidates
for surgery. A catheter procedure can also be used to insert a replacement valve in a
biological tissue replacement valve that is no longer working properly.
Nursing Interventions and Rationales

o Pulses
o Capillary refill
o Heart rate
o Blood Pressure
o Arrhythmias (ECG)

o Lung sounds
o SpO2
o Sputum


call for help.
at all.
important.
I. Mitral stenosis
Mitral valve stenosis — or mitral stenosis — is a narrowing of the heart's mitral valve.
This abnormal valve doesn't open properly, blocking blood flow into the main pumping
chamber of your heart (left ventricle). Mitral valve stenosis can make you tired and short
of breath, among other problems.
The main cause of mitral valve stenosis is an infection called rheumatic fever, which is
related to strep infections. Rheumatic fever — now rare in the United States, but still
common in developing countries — can scar the mitral valve. Left untreated, mitral
valve stenosis can lead to serious heart complications.
Symptoms
You may feel fine with mitral valve stenosis, or you may have minimal symptoms for
decades. Mitral valve stenosis usually progresses slowly over time. See your doctor if
you develop:
 Shortness of breath, especially with exertion or when you lie down
 Fatigue, especially during increased physical activity
 Swollen feet or legs
 Dizziness or fainting
 Coughing up blood
 Chest discomfort or chest pain
Mitral valve stenosis symptoms may appear or worsen anytime your heart rate
increases, such as during exercise. An episode of rapid heartbeats may accompany
these symptoms. Or they may be triggered by pregnancy or other body stress, such as
an infection.
In mitral valve stenosis, pressure that builds up in the heart is then sent back to the
lungs, resulting in fluid buildup (congestion) and shortness of breath.
Symptoms of mitral valve stenosis most often appear in between the ages of 15 and 40
in developed nations, but they can occur at any age — even during childhood.
Mitral valve stenosis may also produce signs that your doctor will find during your
examination. These may include:
 Heart murmur
 Fluid buildup in the lungs
 Irregular heart rhythms (arrhythmias)
Causes
Causes of mitral valve stenosis include:
 Rheumatic fever. A complication of strep throat, rheumatic fever can damage

the mitral valve. Rheumatic fever is the most common cause of mitral valve
stenosis. It can damage the mitral valve by causing the flaps to thicken or fuse.
Signs and symptoms of mitral valve stenosis might not show up for years.
 Calcium deposits. As you age, calcium deposits can build up around the ring
around the mitral valve (annulus), which can occasionally cause mitral valve
stenosis.
 Other causes. In rare cases, babies are born with a narrowed mitral valve
(congenital defect) that causes problems over time. Other rare causes include
radiation to the chest and some autoimmune diseases, such as lupus.
Diagnosis
Your doctor will ask about your medical history and give you a physical examination that
includes listening to your heart through a stethoscope. Mitral valve stenosis causes an
abnormal heart sound, called a heart murmur.
Your doctor also will listen to your lungs to check lung congestion — a buildup of fluid in
your lungs — that can occur with mitral valve stenosis.
Your doctor will then decide which tests are needed to make a diagnosis. For testing,
you may be referred to a cardiologist.
Diagnostic tests
Common tests to diagnose mitral valve stenosis include:
 Transthoracic echocardiogram. Sound waves directed at your heart from a

wandlike device (transducer) held on your chest produce video images of your
heart in motion. This test is used to confirm the diagnosis of mitral stenosis.
 Transesophageal echocardiogram. A small transducer attached to the end of a

tube inserted down your esophagus allows a closer look at the mitral valve than a
regular echocardiogram does.
 Electrocardiogram (ECG). Wires (electrodes) attached to pads on your skin

measure electrical impulses from your heart, providing information about your
heart rhythm. You might walk on a treadmill or pedal a stationary bike during an
ECG to see how your heart responds to exertion.
 Chest X-ray. This enables your doctor to determine whether any chamber of the
heart is enlarged and the condition of your lungs.
 Cardiac catheterization. This test isn't often used to diagnose mitral stenosis,

but it might be used when more information is needed to assess your condition. It
involves threading a thin tube (catheter) through a blood vessel in your arm or
groin to an artery in your heart and injecting dye through the catheter to make the
artery visible on an X-ray. This provides a detailed picture of your heart.
Cardiac tests such as these help your doctor distinguish mitral valve stenosis from other
heart conditions, including other mitral valve conditions. These tests also help reveal the
cause of your mitral valve stenosis and whether the valve can be repaired.
Treatment
If you have mild to moderate mitral valve stenosis with no symptoms, you might not
need immediate treatment. Instead, your doctor will monitor the valve to see if your
condition worsens.
Medications
No medications can correct a mitral valve defect. However, certain drugs can reduce
symptoms by easing your heart's workload and regulating its rhythm.
Your doctor might prescribe one or more of the following medications:
 Diuretics to reduce fluid accumulation in your lungs or elsewhere.

 Blood thinners (anticoagulants) to help prevent blood clots. A daily aspirin may
be included.
 Beta blockers or calcium channel blockers to slow your heart rate and allow
your heart to fill more effectively.
 Anti-arrhythmics to treat atrial fibrillation or other rhythm disturbances

associated with mitral valve stenosis.
 Antibiotics to prevent a recurrence of rheumatic fever if that's what caused your

mitral stenosis.
Procedures
You may need valve repair or replacement to treat mitral valve stenosis, which may
include surgical and nonsurgical options.
Percutaneous balloon mitral valvuloplasty
In this procedure, also called balloon valvotomy, a doctor inserts a soft, thin tube
(catheter) tipped with a balloon in an artery in your arm or groin and guides it to the
narrowed valve. Once in position, the balloon is inflated to widen the valve, improving
blood flow. The balloon is then deflated, and the catheter with balloon is removed.
For some people, balloon valvuloplasty can relieve the signs and symptoms of mitral
valve stenosis. However, you may need additional procedures to treat the narrowed
valve over time.
Not everyone with mitral valve stenosis is a candidate for balloon valvuloplasty. Talk to
your doctor to decide whether it's an option for you.
Mitral valve surgery
Surgical options include:
 Commissurotomy. If balloon valvuloplasty isn't an option, a cardiac surgeon

might perform open-heart surgery to remove calcium deposits and other scar
tissue to clear the valve passageway. Open commissurotomy requires that you
be put on a heart-lung bypass machine during the surgery. You may need the
procedure repeated if your mitral valve stenosis redevelops.
 Mitral valve replacement. If the mitral valve can't be repaired, surgeons may
perform mitral valve replacement. In mitral valve replacement, your surgeon
removes the damaged valve and replaces it with a mechanical valve or a valve
made from cow, pig or human heart tissue (biological tissue valve).
Biological tissue valves degenerate over time, and often eventually need to be replaced.
People with mechanical valves will need to take blood-thinning medications for life to
prevent blood clots. Your doctor will discuss with you the benefits and risks of each type
of valve and discuss which valve may be appropriate for you.
Nursing Interventions: Mitral Stenosis
1. Before giving penicillin, ask the patient if she’s ever had a hypersensitivity
reaction to the drug.
2. Assist the patient with bathing as necessary.
3. Allow the patient to express his concerns over being unable to meet her
responsibilities because of activity restrictions.
4. Place the patient in an upright position to relieve dyspnea, if needed.
5. Prepare the patient for valve replacement or percutaneous balloon valvuloplasty,

as indicated.
6. Keep the patient on a low-sodium diet.
7. Watch closely for signs of pulmonary dysfunction caused by pulmonary

hypertension, tissue ischemia caused by emboli, and adverse reactions to drug
therapy.
8. Explain all tests and treatments to the patient.
9. Advise the patient to plan for periodic rest in her daily routine to prevent undue
fatigue.
10. Teach the patient about diet restrictions.
J. Aortic Regurgitation
Aortic valve regurgitation — or aortic regurgitation — is a condition that occurs when

your heart's aortic valve doesn't close tightly. Aortic valve regurgitation allows some of
the blood that was pumped out of your heart's main pumping chamber (left ventricle) to
leak back into it.
The leakage may prevent your heart from efficiently pumping blood to the rest of your
body. As a result, you may feel fatigued and short of breath.
Aortic valve regurgitation can develop suddenly or over decades. Once aortic valve
regurgitation becomes severe, surgery is often required to repair or replace the aortic
valve.
Symptoms
Most often, aortic valve regurgitation develops gradually, and your heart compensates
for the problem. You may have no signs or symptoms for years, and you may even be
unaware that you have the condition.
However, as aortic valve regurgitation worsens, signs and symptoms may include:
 Fatigue and weakness, especially when you increase your activity level
 Shortness of breath with exercise or when you lie down
 Swollen ankles and feet
 Chest pain (angina), discomfort or tightness, often increasing during exercise
 Lightheadedness or fainting
 Irregular pulse (arrhythmia)
 Heart murmur
 Sensations of a rapid, fluttering heartbeat (palpitations)
Causes
has flaps (cusps or leaflets) that open and close once during each heartbeat.
your heart and potentially impairing the ability to pump blood to your body.
In aortic valve regurgitation, the valve between the lower left heart chamber (left
ventricle) and the main artery that leads to the body (aorta) doesn't close properly,
which causes some blood to leak backward into the left ventricle. This forces the left
ventricle to hold more blood, possibly causing it to enlarge and thicken.
At first, left ventricle enlargement helps because it maintains adequate blood flow with
more force. But eventually these changes weaken the left ventricle — and your heart
overall.
Any condition that damages a valve can cause regurgitation. Causes of aortic valve
regurgitation include:
 Congenital heart valve disease. You may have been born with an aortic valve
that has only two cusps (bicuspid valve) or fused cusps rather than the normal
three separate cusps. In some cases a valve may only have one cusp
(unicuspid) or four cusps (quadricuspid), but this is less common.
These congenital heart defects put you at risk of developing aortic valve regurgitation at
some time in your life. If you have a parent or sibling with a bicuspid valve, it increases
the risk that you may have a bicuspid valve, but it can also occur if you don't have a
family history of a bicuspid aortic valve.
 Age-related changes to the heart. Calcium deposits can build up on the aortic

valve over time, causing the aortic valve's cusps to stiffen. This can cause the
aortic valve to become narrow, and it may also not close properly.
 Endocarditis. The aortic valve may be damaged by endocarditis — an infection

inside your heart that involves heart valves.
 Rheumatic fever. Rheumatic fever — a complication of strep throat and once a

common childhood illness in the United States — can damage the aortic valve.
Rheumatic fever is still prevalent in developing countries but rare in the United
States. Some older adults in the United States were exposed to rheumatic fever
as children, although they may not have developed rheumatic heart disease.
 Other diseases. Other rare conditions can enlarge the aorta and aortic valve
and lead to regurgitation, including Marfan syndrome, a connective tissue
disease. Some autoimmune conditions, such as lupus, also can lead to aortic
valve regurgitation.
 Trauma. Damage to the aorta near the site of the aortic valve, such as damage
from injury to your chest or from a tear in the aorta, also can cause backward
flow of blood through the valve.
Diagnosis
To diagnose aortic valve regurgitation, your doctor may review your signs and
symptoms, discuss your and your family's medical history, and conduct a physical
examination. Your doctor may listen to your heart with a stethoscope to determine if you
have a heart murmur that may indicate an aortic valve condition. A doctor trained in
heart disease (cardiologist) may evaluate you.
Your doctor may order several tests to diagnose your condition, and determine the
cause and severity of your condition. Tests may include:
 Echocardiogram. Sound waves directed at your heart from a wandlike device

(transducer) held on your chest produces video images of your heart in motion.
This test can help doctors closely look at the condition of the aortic valve and the
aorta. It can help doctors determine the cause and severity of your condition, and
see if you have additional heart valve conditions. Doctors may also use a 3-D
echocardiogram.

echocardiogram to get a closer look at the aortic valve. In this test, a small transducer
attached to the end of a tube is inserted down the tube leading from your mouth to your
stomach (esophagus).
 Electrocardiogram (ECG). In this test, wires (electrodes) attached to pads on

your skin measure the electrical activity of your heart. An ECG can detect
 Chest X-ray. This enables your doctor to determine whether your heart is

enlarged — a possible indicator of aortic valve regurgitation — or whether you
have an enlarged aorta. It can also help doctors determine the condition of your
lungs.
 Exercise tests or stress tests. Exercise tests help doctors see whether you
have signs and symptoms of aortic valve disease during physical activity, and
these tests can help determine the severity of your condition. If you are unable to
exercise, medications that have similar effects as exercise on your heart may be
used.
 Cardiac MRI. Using a magnetic field and radio waves, this test produces detailed
pictures of your heart, including the aorta and aortic valve. This test may be used
to determine the severity of your condition.
 Cardiac catheterization. This test isn't often used to diagnose aortic valve

regurgitation, but it may be used if other tests aren't able to diagnose the
condition or determine its severity. Doctors may also conduct cardiac
catheterization prior to valve replacement surgery to see if there are obstructions
in the coronary arteries, so they can be fixed at the time of the valve surgery.
In cardiac catheterization, a doctor threads a thin tube (catheter) through a blood vessel
in your arm or groin to an artery in your heart and injects dye through the catheter to
make the artery visible on an X-ray. This provides your doctor with a detailed picture of
your heart arteries and how your heart functions. It can also measure the pressure
inside the heart chambers.
Treatment
Treatment of aortic valve regurgitation depends on the severity of your condition,

whether you're experiencing signs and symptoms, and if your condition is getting worse.
If your symptoms are mild or you aren't experiencing symptoms, your doctor may
monitor your condition with regular follow-up appointments. Your doctor may
recommend that you make healthy lifestyle changes and take medications to treat
symptoms or reduce the risk of complications.
You may eventually need surgery to repair or replace the diseased aortic valve. In some
cases, your doctor may recommend surgery even if you aren't experiencing symptoms.
If you're having another heart surgery, doctors may perform aortic valve surgery at the
same time. In some cases, you may need a section of the aorta (aortic root) repaired or
replaced at the same time as aortic valve surgery if the aorta is enlarged.
If you have aortic valve regurgitation, consider being evaluated and treated at a medical
center with a multidisciplinary team of cardiologists and other doctors and medical staff
trained and experienced in evaluating and treating heart valve disease. This team can
work closely with you to determine the most appropriate treatment for your condition.
Surgery to repair or replace an aortic valve is usually performed through a cut (incision)
in the chest. In some cases, doctors may perform minimally invasive heart surgery,
which involves the use of smaller incisions than those used in open-heart surgery.
Surgery options include:
Aortic valve repair
To repair an aortic valve, surgeons may conduct several different types of repair,
including separating valve flaps (cusps) that have fused, reshaping or removing excess
valve tissue so that the cusps can close tightly, or patching holes in a valve.
Doctors may use a catheter procedure to insert a plug or device to repair a leaking
replacement aortic valve.
Biological valve replacement
Mechanical valve replacement
Aortic valve replacement

Aortic valve replacement is often needed to treat aortic valve regurgitation. In aortic
valve replacement, your surgeon removes the damaged valve and replaces it with a
valve). Another type of biological tissue valve replacement that uses your own
pulmonary valve is sometimes possible.
Biological tissue valves degenerate over time and may eventually need to be replaced.
Doctors may also conduct a catheter procedure to insert a replacement valve into a
failing biological tissue valve that is no longer working properly. Other procedures using
catheters to repair or replace aortic valves to treat aortic valve regurgitation continue to
be researched.
Nursing Interventions and Rationales
o Pulses
o Capillary refill

o Heart rate
o Blood Pressure
o Arrhythmias (ECG)

o Lung sounds
o SpO2
o Sputum

call for help.

at all.
important.
K. Aortic stenosis
Aortic valve stenosis — or aortic stenosis — occurs when the heart's aortic valve
narrows. This narrowing prevents the valve from opening fully, which reduces or blocks
blood flow from your heart into the main artery to your body (aorta) and onward to the
rest of your body.
When the blood flow through the aortic valve is reduced or blocked, your heart needs to
work harder to pump blood to your body. Eventually, this extra work limits the amount of
blood it can pump, and this can cause symptoms as well as possibly weaken your heart
muscle.
Your treatment depends on the severity of your condition. You may need surgery to
repair or replace the valve. Left untreated, aortic valve stenosis can lead to serious
heart problems.
Aortic stenosis is one of the most common and serious valve disease problems. Aortic
stenosis is a narrowing of the aortic valve opening. Aortic stenosis restricts the blood
flow from the left ventricle to the aorta and may also affect the pressure in the left
atrium.
Although some people have aortic stenosis because of a congenital heart defect called
a bicuspid aortic valve, this condition more commonly develops during aging as calcium
or scarring damages the valve and restricts the amount of blood flowing through.
Symptoms
Aortic valve stenosis ranges from mild to severe. Aortic valve stenosis signs and
symptoms generally develop when narrowing of the valve is severe. Some people with
aortic valve stenosis may not experience symptoms for many years. Signs and
symptoms of aortic valve stenosis may include:
 Abnormal heart sound (heart murmur) heard through a stethoscope
 Chest pain (angina) or tightness with activity
 Feeling faint or dizzy or fainting with activity
 Shortness of breath, especially when you have been active
 Fatigue, especially during times of increased activity
 Not eating enough (mainly in children with aortic valve stenosis)
 Not gaining enough weight (mainly in children with aortic valve stenosis)
The heart-weakening effects of aortic valve stenosis may lead to heart failure. Heart
failure signs and symptoms include fatigue, shortness of breath, and swollen ankles and
feet.
Causes
has flaps (cusps or leaflets) that open and close once during each heartbeat.
your heart and potentially impairing the ability to pump blood to your body.
In aortic valve stenosis, the aortic valve between the lower left heart chamber (left
ventricle) and the main artery that delivers blood from the heart to the body (aorta) is
narrowed (stenosis).
When the aortic valve is narrowed, the left ventricle has to work harder to pump a
sufficient amount of blood into the aorta and onward to the rest of your body. This can
cause the left ventricle to thicken and enlarge. Eventually the extra work of the heart
can weaken the left ventricle and your heart overall, and it can ultimately lead to heart
failure and other problems.
Aortic valve stenosis can occur due to many causes, including:
 Congenital heart defect. The aortic valve consists of three tightly fitting,

triangular-shaped flaps of tissue called cusps. Some children are born with an
aortic valve that has only two (bicuspid) cusps instead of three. People may also
be born with one (unicuspid) or four (quadricuspid) cusps, but these are rare.
This defect may not cause any problems until adulthood, at which time the valve may
begin to narrow or leak and may need to be repaired or replaced.
Having a congenitally abnormal aortic valve requires regular evaluation by a doctor to

watch for signs of valve problems. In most cases, doctors don't know why a heart valve
fails to develop properly, so it isn't something you could have prevented.
 Calcium buildup on the valve. With age, heart valves may accumulate deposits
of calcium (aortic valve calcification). Calcium is a mineral found in your blood.
As blood repeatedly flows over the aortic valve, deposits of calcium can build up
on the valve's cusps. These calcium deposits aren't linked to taking calcium
tablets or drinking calcium-fortified drinks.
These deposits may never cause any problems. However, in some people —
particularly those with a congenitally abnormal aortic valve, such as a bicuspid aortic
valve — calcium deposits result in stiffening of the cusps of the valve. This stiffening
narrows the aortic valve and can occur at a younger age.
However, aortic valve stenosis that is related to increasing age and the buildup of
calcium deposits on the aortic valve is most common in older people. It usually doesn't
cause symptoms until ages 70 or 80.
 Rheumatic fever. A complication of strep throat infection, rheumatic fever may

result in scar tissue forming on the aortic valve. Scar tissue alone can narrow the
aortic valve and lead to aortic valve stenosis. Scar tissue can also create a rough
surface on which calcium deposits can collect, contributing to aortic valve
stenosis later in life.
Rheumatic fever may damage more than one heart valve, and in more than one way. A
damaged heart valve may not open fully or close fully — or both. While rheumatic fever
is rare in the United States, some older adults had rheumatic fever as children.
Diagnosis
To diagnose aortic valve stenosis, your doctor may review your signs and symptoms,
discuss your medical history, and conduct a physical examination. Your doctor may
listen to your heart with a stethoscope to determine if you have a heart murmur that may
indicate an aortic valve condition. A doctor trained in heart disease (cardiologist) may
evaluate you.
Your doctor may order several tests to diagnose your condition and determine the
cause and severity of your condition. Tests may include:
 Echocardiogram. This test uses sound waves to produce video images of your

heart in motion. During this test, specialists hold a wandlike device (transducer)
on your chest. Doctors may use this test to evaluate your heart chambers, the
aortic valve and the blood flow through your heart. A doctor generally uses this
test to diagnose your condition if he or she suspects you have a heart valve
condition.
This test can help doctors closely look at the condition of the aortic valve, and the cause
and severity of your condition. It can also help doctors determine if you have additional
heart valve conditions.

echocardiogram to get a closer look at the aortic valve. In this test, a small transducer
attached to the end of a tube is inserted down the tube leading from your mouth to your
stomach (esophagus).
 Electrocardiogram (ECG). In this test, wires (electrodes) attached to pads on

your skin measure the electrical activity of your heart. An ECG can detect
 Chest X-ray. A chest X-ray can help your doctor determine whether your heart is
enlarged, which can occur in aortic valve stenosis. It can also show whether you
have an enlarged blood vessel (aorta) leading from your heart or any calcium
buildup on your aortic valve. A chest X-ray can also help doctors determine the
condition of your lungs.
 Exercise tests or stress tests. Exercise tests help doctors see whether you
have signs and symptoms of aortic valve disease during physical activity, and
these tests can help determine the severity of your condition. If you are unable to
exercise, medications that have similar effects as exercise on your heart may be
used.
 Cardiac computerized tomography (CT) scan. A cardiac CT scan uses a

series of X-rays to create detailed images of your heart and heart valves. Doctors
may use this test to measure the size of your aorta and look at your aortic valve
more closely.
 Cardiac MRI. A cardiac MRI uses magnetic fields and radio waves to create
detailed images of your heart. This test may be used to determine the severity of
your condition and evaluate the size of your aorta.
 Cardiac catheterization. This test isn't often used to diagnose aortic valve

disease, but it may be used if other tests aren't able to diagnose the condition or
to determine its severity.
In this procedure, your doctor threads a thin tube (catheter) through a blood vessel in
your arm or groin and guides it to an artery in your heart.
Doctors may inject a dye through the catheter, which helps your arteries become visible
on an X-ray (coronary angiogram). This provides your doctor with a detailed picture of
your heart arteries and how your heart functions. It can also measure the pressure
inside your heart chambers.
Treatment
Treatment for aortic valve stenosis depends on the severity of your condition, whether
you're experiencing signs and symptoms, and if your condition is getting worse.
If your symptoms are mild or you aren't experiencing symptoms, your doctor may
monitor your condition with regular follow-up appointments. Your doctor may
recommend you make healthy lifestyle changes and take medications to treat
symptoms or reduce the risk of complications.
You may eventually need surgery to repair or replace the diseased aortic valve. In some
cases, your doctor may recommend surgery even if you aren't experiencing symptoms.
If you're having another heart surgery, doctors may perform aortic valve surgery at the
same time.
Surgery to repair or replace an aortic valve is usually performed through a cut (incision)
in the chest. Less invasive approaches may be available, and your doctor will evaluate
you to determine if you're a candidate for these procedures.
If you have aortic valve stenosis, consider being evaluated and treated at a medical
center with a multidisciplinary team of cardiologists and other doctors and medical staff
trained and experienced in evaluating and treating heart valve disease. This team can
work closely with you to determine the most appropriate treatment for your condition.
Surgery options include:
Aortic valve repair
Biological valve replacement
Surgeons rarely repair an aortic valve to treat aortic valve stenosis, and generally aortic
valve stenosis requires aortic valve replacement. To repair an aortic valve, surgeons
may separate valve flaps (cusps) that have fused.
Balloon valvuloplasty
Doctors may conduct a procedure using a long, thin tube (catheter) to repair a valve
with a narrowed opening (aortic valve stenosis). In this procedure, called balloon
valvuloplasty, a doctor inserts a catheter with a balloon on the tip into an artery in your
arm or groin and guides it to the aortic valve. The doctor performing the procedure then
inflates the balloon, which expands the opening of the valve. The balloon is then
deflated, and the catheter and balloon are removed.
The procedure can treat aortic valve stenosis in infants and children. However, the
valve tends to narrow again in adults who've had the procedure, so it's usually only
performed in adults who are too ill for surgery or who are waiting for a valve
replacement, as they typically need additional procedures to treat the narrowed valve
over time.
Aortic valve replacement
Mechanical valve replacement
Aortic valve replacement is often needed to treat aortic valve stenosis. In aortic valve
replacement, your surgeon removes the damaged valve and replaces it with a
valve).
Biological tissue valves degenerate over time and may eventually need to be replaced.
Transcatheter aortic valve replacement
Doctors may perform a less invasive procedure called transcatheter aortic valve
replacement (TAVR) to replace a narrowed aortic valve. TAVR may be an option for
people who are considered to be at intermediate or high risk of complications from
surgical aortic valve replacement.
In TAVR, doctors insert a catheter in your leg or chest and guide it to your heart. A
replacement valve is then inserted through the catheter and guided to your heart. A
balloon may expand the valve, or some valves can self-expand. When the valve is
implanted, doctors remove the catheter from your blood vessel.
Doctors may also conduct a catheter procedure to insert a replacement valve into a
failing biological tissue valve that is no longer working properly. Other catheter
procedures to repair or replace aortic valves continue to be researched.
Nursing Interventions: Aortic Stenosis
1. Assist the patient in bathing, if necessary.
2. Provide a bedside commode because using a commode puts less stress on the
heart than using a bedpan.
3. Offer diversional activities that are physically undemanding.
4. Alternate periods of rest to prevent extreme fatigue and dyspnea.
5. To reduce anxiety, allow the patient to express his concerns about the effects of
activity restrictions on his resposibilities and routine.
6. Keep the patient’s legs elevated while he sits in a chair to improve venous return
in the heart.
7. Place the patient in an upright position to relieve dyspnea.
8. Administer oxygen as needed to prevent tissue hypoxia.
9. Keep the patient in a low sodium diet. Consult with a dietitian to ensure that the
patient receives foods that he likes while adhering to the diet restrictions.
10. Allow the patient to express his fears and concerns about the disorder, it’s impact
on his life, and any impending surgery.
11. Monitor the patient’s vital signs, weight, and intake and output for signs of fluid
overload.
12. Evaluate patient’s activity tolerance and degree of fatigue.
13. Monitor the patient for chest pain that may indicate cardiac ischemia.
14. Regularly assess the patient’s cardiopulmonary function.
15. Observe the patient for complications and adverse reactions to drug therapy.
L. Valvuloplasty and Commissurotomy
What is valvuloplasty?
Valvuloplasty may be done to open a stiff (stenotic) heart valve. In valvuloplasty, your
doctor inserts a very small, narrow, hollow tube (catheter) into a blood vessel in the
groin and advances it through the aorta into the heart. Once the catheter reaches the
stiff valve, your doctor inflates a large balloon at the tip of the catheter until the flaps
(leaflets) of the valve are pushed opened. Once the valve has been opened, the doctor
deflates the balloon and removes the catheter.
To keep the blood flowing forward during its journey through the heart, there are valves
between each of the heart's pumping chambers:
 Tricuspid valve. Located between the right atrium and the right ventricle
 Pulmonary (or pulmonic) valve. Located between the right ventricle and the
pulmonary artery
 Mitral valve. Located between the left atrium and the left ventricle
 Aortic valve. Located between the left ventricle and the aorta
Why might I need valvuloplasty?

Valvuloplasty may be done to open a heart valve that has become stiff. But, not all
conditions in which a heart valve becomes stiff are treatable with valvuloplasty.
If the heart valves become damaged or diseased, they may not work properly.
Conditions that may cause problems with the heart valves are valvular stenosis
(stiffened valve) and valvular regurgitation (leaky valve). When one (or more) valve(s)
becomes stiff, the heart muscle must work harder to pump the blood through the valve.
Stiff valves may be caused by infection (such as rheumatic fever or staphylococcus
infections), birth defects, and aging. If one or more valves become leaky, blood leaks
backwards and less blood is pumped in the proper direction.
Heart valve disease may cause the following symptoms:
 Dizziness
 Chest pain
 Trouble breathing
 Palpitations
 Edema (swelling) of the feet, ankles, or abdomen
 Rapid weight gain due to fluid retention
There may be other reasons for your doctor to recommend a valvuloplasty.

What are the risks for valvuloplasty?
Possible risks of valvuloplasty include:
 Bleeding at the catheter insertion site
 Blood clot or damage to the blood vessel at the insertion site
 Significant blood loss that may require blood transfusion
 Infection at the catheter insertion site
 Abnormal heart rhythms
 Kidney failure
 Stroke
 New or worsening valve regurgitation (leakage)
 Rupture of the valve, requiring open-heart surgery
 Death
If you are pregnant or think you could be, tell your healthcare provider due to risk of
injury to the fetus from a valvuloplasty. Radiation exposure during pregnancy may lead
to birth defects. Also tell your provider if you are lactating, or breastfeeding.
There is a risk of allergic reaction to the dye. If you are allergic or sensitive to
medicines, contrast dyes, iodine, or latex should, tell your doctor. If you have kidney
failure or other kidney problems, tell your doctor.
Some people may find lying still on the procedure table for the length of the procedure
may cause some discomfort or pain.
There may be other risks depending on your specific medical condition. Be sure to
discuss any concerns with your doctor before the procedure.
How do I get ready for a valvuloplasty?
 Your doctor will explain the procedure to you and ask if you have any questions.
 You will be asked to sign a consent form that gives your permission to do the
test. Read the form carefully and ask questions if something is unclear.
 Tell your doctor if you have ever had a reaction to any contrast dye, or if you are
allergic to iodine.
 Tell your doctor if you are sensitive to or are allergic to any medicines, latex,
tape, or anesthetic agents (local and general).
 You will need to fast for a certain period before the procedure. Your doctor will
tell you how long to fast, usually overnight.
 If you are pregnant or think you could be, tell your doctor.
 Tell your doctor if you have any body piercings on your chest or abdomen.
 Tell your doctor of all medicines (prescription and over-the-counter) and herbal
supplements that you are taking.
 Tell your doctor if you have a history of bleeding disorders or if you are taking
any anticoagulant (blood-thinning) medicines, aspirin, or other medicines that
affect blood clotting. You may need to stop some of these medicines before the
procedure.
 Your doctor may request a blood test before the procedure to determine how
long it takes your blood to clot. Other blood tests may be done as well.
 Tell your doctor if you have a pacemaker.
 You may receive a sedative before the procedure to help you relax.
 Based on your medical condition, your doctor may request other specific
preparation.
What happens during a valvuloplasty?
A valvuloplasty may be done as part of your stay in a hospital. Procedures may vary
depending on your condition and your doctor’s practices.
Generally, a valvuloplasty follows this process:
1. Remove any jewelry or other objects that may interfere with the procedure. You
may wear your dentures or hearing aids if you use either of these.
2. Change into a hospital gown and empty your bladder before the procedure.
3. A healthcare professional will start an intravenous (IV) line in your hand or arm to
inject medicine or give IV fluids, if needed.
4. If there is excessive hair at the catheter insertion site (groin area), it may be
shaved off.
5. A healthcare professional will connect you to an electrocardiogram (ECG) to

monitor and records the electrical activity of the heart. Your vital signs (heart rate,
blood pressure, breathing rate, and oxygenation level) will be monitored during
the procedure.
6. There will be several monitor screens in the room, showing your vital signs, the
images of the catheter being moved through the body into the heart, and the
structures of the heart as your doctor injects the dye.
7. You will get a sedative medicine in your IV before the procedure to help you
relax. However, you will likely remain awake during the procedure
8. A healthcare professional will check and mark your pulses below the injection
site and compare them to pulses after the procedure.
9. A local anesthetic will be injected into the skin at the insertion site. You may feel
some stinging at the site for a few seconds after the local anesthetic is injected.
10. Once the local anesthetic has taken effect, your doctor will insert a sheath, or
introducer, into the blood vessel. This is a plastic tube through which the catheter
will be inserted into the blood vessel and advanced into the heart.
11. Your doctor will insert the valvuloplasty catheter through the sheath into the
blood vessel and to the heart.
12. Once the catheter is in place, your doctor will inject contrast dye through the
catheter into the valve to look at the area. You may feel some effects when the
contrast dye is injected into the IV line. These effects include a flushing
sensation, a salty or metallic taste in the mouth, or a brief headache. These
effects usually last for a few moments.
13. Tell the doctor if you feel any breathing difficulties, sweating, numbness, itching,
chills, nausea or vomiting, or heart palpitations.
14. The doctor will watch the contrast dye injection on a monitor. He or she may ask
you to take a deep breath and hold it for a few seconds.
15. Once the balloon is in place and has been inflated, you may notice some
dizziness or even brief chest discomfort. This should subside when the balloon is
deflated. However, if you notice any severe discomfort or pain, such as chest
pain, neck or jaw pain, back pain, arm pain, shortness of breath, or breathing
difficulty, tell your doctor.
16. Your doctor may inflate and deflate the balloon several times to open the valve.
17. Once the valve is opened sufficiently, your doctor will remove the catheter. He or
she may close the catheter insertion site with a closure device that uses collagen
to seal the opening in the artery, by the use of sutures, or by applying manual
pressure over the area to keep the blood vessel from bleeding. Your doctor will
determine which method is appropriate for your condition.
18. If your doctor uses a closure device, he or she will apply a sterile dressing to the
site. If manual pressure is used, the doctor (or an assistant) will hold pressure on
the insertion site so that a clot will form. Once the bleeding has stopped, a very
tight bandage will be placed on the site.
19. Your doctor may decide not to remove the sheath, or introducer, from the
insertion site for about 4 to 6 hours. This allows the effects of blood-thinning
medicine to wear off. You will need to lie flat during this time. If you become
uncomfortable in this position, your nurse may give you medicine to make you
more comfortable.
20. Next, you will be taken to the recovery area. NOTE: If the insertion was in the
groin, you will not be allowed to bend your leg for several hours. To help you
remember to keep your leg straight, the knee of the affected leg may be covered
with a sheet and the ends tucked under the mattress on both sides of the bed to
form a type of loose restraint.
What happens after a valvuloplasty?
In the hospital
After the procedure, you may be taken to the recovery room for observation or returned
to your hospital room. You will remain flat in bed for several hours after the procedure. A
nurse will monitor your vital signs, the insertion site, and circulation and sensation in the
affected leg or arm.
Tell your nurse right away if you feel any chest pain or tightness, or any other pain, as
well as any feelings of warmth, bleeding, or pain at the insertion site in your leg or arm.
Bed rest may vary from 2 to 6 hours depending on your specific condition. If your doctor
placed a closure device, your bed rest may be of shorter duration.
In some cases, the sheath or introducer may be left in the insertion site. If so, your
period of bed rest will be longer. After the sheath is removed, you may be given a light
meal.
You may be given medicine for pain or discomfort related to the insertion site or having
to lie flat and still for a prolonged period.
You will be encouraged to drink water and other fluids to help flush the contrast dye
from your body.
You may feel the urge to urinate often because of the effects of the contrast dye and
increased fluids. You will need to use a bedpan or urinal while on bed rest so that you
don't bend your affected leg or arm.
You may resume your usual diet after the procedure, unless your doctor decides
otherwise.
After the specified period of bed rest, you may get out of bed. The nurse will help you
the first time you get up, and may check your blood pressure while you are lying in bed,
sitting, and standing. Move slowly when getting up from the bed to avoid any dizziness
from the long period of bed rest.
You will most likely spend the night in the hospital after your procedure. Depending on
your condition and the results of your procedure, your stay may be longer. You will
receive detailed instructions for your discharge and recovery period.
At home
Once at home, watch the insertion site for bleeding, unusual pain, swelling, and
discoloration or temperature change at or near the injection site. A small bruise is
normal. If you notice a constant or large amount of blood at the site that cannot be
contained with a small dressing, call your doctor.
If your doctor used a closure device for your insertion site, you will be given specific
information about how to take care of the insertion site. There will be a small knot, or
lump, under the skin at the injection site. This is normal. The knot should gradually
disappear over a few weeks.
It will be important to keep the insertion site clean and dry. Your doctor will give you
specific bathing instructions.
Your doctor may advise you not to participate in any strenuous activities. Your doctor
will tell you when you can return to work and resume normal activities.
Tell your doctor to report any of the following:
 Fever or chills
 Increased pain, redness, swelling, or bleeding or other drainage from the

insertion site
 Coolness, numbness or tingling, or other changes in the affected extremity
 Chest pain or pressure, nausea or vomiting, profuse sweating, dizziness, or

fainting
 Decreased urination
 Swelling of the extremities or abdomen
 Weight gain of over 3 pounds in one day
Your doctor may give you other instructions after the procedure, depending on your
particular situation.
Next steps
Before you agree to the test or the procedure make sure you know:
 The name of the test or procedure
 The reason you are having the test or procedure
 What results to expect and what they mean
 The risks and benefits of the test or procedure
 What the possible side effects or complications are
 When and where you are to have the test or procedure
 Who will do the test or procedure and what that person’s qualifications are
 What would happen if you did not have the test or procedure
 Any alternative tests or procedures to think about
 When and how will you get the results
 Who to call after the test or procedure if you have questions or problems
 How much will you have to pay for the test or procedure
L. Valvuloplasty and Commissurotomy
Commissurotomy is an open-heart surgery that repairs a mitral valve that is narrowed

from mitral valve stenosis.
During this surgery, a person is put on a heart-lung bypass machine. The surgeon
removes calcium deposits and other scar tissue from the valve leaflets. The surgeon
may cut parts of the valve structure. This surgery opens the valve.
It is used for people who have severe narrowing of the valve and aren't good candidates
for balloon valvotomy.
Commissurotomy is used for people who have severe narrowing of the valve and aren't
good candidates for balloon valvotomy. A commissurotomy is most often done if the
mitral valve is very damaged or has a lot of calcium buildup.
After surgery, symptoms are relieved because the surgery opens the narrowed mitral
valve, allowing blood to flow more easily through the heart.
A commissurotomy surgery has the risks of any open-heart surgery with a heart-lung
bypass. The exact risks of surgery vary depending on the person's specific condition
and general health prior to surgery.
Risks during surgery and soon after surgery. These risks include dangerous blood
clots, bleeding, infection, stroke, and risks associated with anesthesia. About 1 out of
100 people die from this surgery.
Risks after surgery. Complications that happen after surgery include:
o Mitral valve regurgitation. The valve might be damaged so that it doesn't close
normally and allows blood to leak backward in the heart.
o Restenosis. The valve can become narrow again. You may need another repair
surgery or a valve replacement surgery.
M. Annuloplasty, Leaflet repair, chordoplasty and valve replacement
Annuloplasty
AnnuloplastyOpen pop-up dialog box
An annuloplasty is a procedure to tighten or reinforce the ring (annulus) around a valve

in the heart. It may be done during other procedures to repair a heart valve.
Why it's done

An annuloplasty is done to reshape, reinforce or tighten the ring around a heart valve.
The ring around a valve in the heart (annulus) can widen and change from its normal
shape. This may occur when the heart is enlarged or if you have a leaky valve. When
the ring is widened, the valve flaps attached to the ring may not open and close
correctly. As a result, blood can leak backward through the valve.
An annuloplasty may be recommended to fix the valve. Doctors may perform

annuloplasty alone or with other techniques to repair a heart valve.
What you can expect
Annuloplasty mitral valve repairOpen pop-up dialog box
In an annuloplasty, the doctor measures the size of the existing ring. Then the doctor
sews a band to the existing ring around the valve. The band may be rigid or flexible.
This procedure can be done during open-heart surgery or minimally invasive heart
surgery, which involves smaller incisions.
Researchers are studying less-invasive ways to perform annuloplasty and other heart
valve procedures using long, thin tubes.
Problems with the posterior leaflet are generally corrected by a small series of chords or
a small resection of the abnormal portion of the valve. Anterior leaflet dysfunction is
managed by creation of new chords or chordal transfer. Anterior leaflet repair
techniques are technically challenging, requiring a skilled and experienced surgical
team to achieve the best result. All repairs include an annuloplasty, which is a complete
or partial ring placed around the circumference (rim) of the valve.
Mitral Valve Posterior Leaflet Prolapse — Valve Repair Surgery
During mitral valve repair heart surgery, triangular resection is the technique used most
frequently for posterior leaflet prolapse.
Triangular Resection Mitral Valve Repair
Ruptured chords at free edge of posterior leaflet. Region to be resected is indicated.
Abnormal segment has been removed. Leaflet edges are sewn together.
Annuloplasty completes the repair.
Chondroplasty refers to surgery of the cartilage, the most common being corrective

surgery of the cartilage of the knee.
Surgery known as thyroid chondroplasty (or tracheal shave) is used to reduce the

visibility of the Adam's Apple in transgender women.
Aortic valve repair and aortic valve replacement are procedures that treat diseases
affecting the aortic valve, one of four valves that control blood flow through the heart.
The aortic valve helps keep blood flowing in the correct direction through the heart. It
separates the heart's main pumping chamber (left ventricle) and the main artery that
supplies oxygen-rich blood to your body (aorta).
With each contraction of the ventricle, the aortic valve opens and allows blood to flow
from the left ventricle into the aorta. When the ventricle relaxes, the aortic valve closes
to prevent blood from flowing backward into the ventricle.
When the aortic valve isn't working properly, it can interfere with blood flow and force
the heart to work harder to send blood to the rest of your body.
Aortic valve repair or aortic valve replacement can treat aortic valve disease and help
restore normal blood flow, reduce symptoms, prolong life and help preserve the function
of your heart muscle.
N. Cardiomyopathy
Cardiomyopathy (kahr-dee-o-my-OP-uh-thee) is a disease of the heart muscle that
makes it harder for your heart to pump blood to the rest of your body. Cardiomyopathy
can lead to heart failure.
The main types of cardiomyopathy include dilated, hypertrophic and restrictive

cardiomyopathy. Treatment — which might include medications, surgically implanted
devices or, in severe cases, a heart transplant — depends on which type of
cardiomyopathy you have and how serious it is.
Symptoms
There might be no signs or symptoms in the early stages of cardiomyopathy. But as the
condition advances, signs and symptoms usually appear, including:
 Breathlessness with exertion or even at rest
 Swelling of the legs, ankles and feet
 Bloating of the abdomen due to fluid buildup
 Cough while lying down
 Fatigue
 Heartbeats that feel rapid, pounding or fluttering
 Chest discomfort or pressure
 Dizziness, lightheadedness and fainting
Signs and symptoms tend to get worse unless treated. In some people, the condition
worsens quickly; in others, it might not worsen for a long time.
Causes
Often the cause of the cardiomyopathy is unknown. In some people, however, it's the
result of another condition (acquired) or passed on from a parent (inherited).
Contributing factors for acquired cardiomyopathy include:
 Long-term high blood pressure
 Heart tissue damage from a heart attack

 Chronic rapid heart rate
 Heart valve problems
 Metabolic disorders, such as obesity, thyroid disease or diabetes
 Nutritional deficiencies of essential vitamins or minerals, such as thiamin (vitamin

B-1)
 Pregnancy complications
 Drinking too much alcohol over many years
 Use of cocaine, amphetamines or anabolic steroids
 Use of some chemotherapy drugs and radiation to treat cancer
 Certain infections, especially those that inflame the heart
 Iron buildup in your heart muscle (hemochromatosis)
 A condition that causes inflammation and can cause lumps of cells to grow in the
heart and other organs (sarcoidosis)
 A disorder that causes the buildup of abnormal proteins (amyloidosis)
 Connective tissue disorders
 Infection with COVID-19

Dilated
cardiomyopathyOpen pop-up dialog box
Hypertrophic cardiomyopathyOpen pop-up dialog box
Types of cardiomyopathy include:
 Dilated cardiomyopathy. In this type of cardiomyopathy, the pumping ability of

your heart's main pumping chamber — the left ventricle — becomes enlarged
(dilated) and can't effectively pump blood out of the heart.
Although this type can affect people of all ages, it occurs most often in middle-aged
people and is more likely to affect men. The most common cause is coronary artery
disease or heart attack.
 Hypertrophic cardiomyopathy. This type involves abnormal thickening of your

heart muscle, particularly affecting the muscle of your heart's main pumping
chamber (left ventricle). The thickened heart muscle can make it harder for the
heart to work properly.
Hypertrophic cardiomyopathy can develop at any age, but the condition tends to be
more severe if it becomes apparent during childhood. Most affected people have a
family history of the disease, and some genetic mutations have been linked to
hypertrophic cardiomyopathy.
 Restrictive cardiomyopathy. In this type, the heart muscle becomes rigid and
less elastic, so it can't expand and fill with blood between heartbeats. This least
common type of cardiomyopathy can occur at any age, but it most often affects
older people.
Restrictive cardiomyopathy can occur for no known reason (idiopathic), or it can by

caused by a disease elsewhere in the body that affects the heart, such as when iron
builds up in the heart muscle (hemochromatosis).
 Arrhythmogenic right ventricular dysplasia. In this rare type of

cardiomyopathy, the muscle in the lower right heart chamber (right ventricle) is
replaced by scar tissue, which can lead to heart rhythm problems. It's often
caused by genetic mutations.
 Unclassified cardiomyopathy. Other types of cardiomyopathy fall into this

category.
Diagnosis
Your doctor will conduct a physical examination, take a personal and family medical
history, and ask when your symptoms occur — for example, whether exercise brings on
your symptoms. If your doctor thinks you have cardiomyopathy, you might need to
undergo several tests to confirm the diagnosis, including:
 Chest X-ray. An image of your heart will show whether it's enlarged.
 Echocardiogram. This uses sound waves to produce images of the heart, which

show its size and its motions as it beats. This test checks your heart valves and
helps your doctor determine the cause of your symptoms.
 Electrocardiogram (ECG). In this noninvasive test, electrode patches are

attached to your skin to measure electrical impulses from your heart. An ECG
can show disturbances in the electrical activity of your heart, which can detect
abnormal heart rhythms and areas of injury.
 Treadmill stress test. Your heart rhythm, blood pressure and breathing are
monitored while you walk on a treadmill. Your doctor might recommend this test
to evaluate symptoms, determine your exercise capacity and determine if
exercise provokes abnormal heart rhythms.
 Cardiac catheterization. A thin tube (catheter) is inserted into your groin and
threaded through your blood vessels to your heart. Doctors might extract a small
sample (biopsy) of your heart for analysis in the laboratory. Pressure within the
chambers of your heart can be measured to see how forcefully blood pumps
through your heart.
Doctors might inject a dye into your blood vessels so that they show on X-rays
(coronary angiogram). This test can be used to ensure there are no blockages in your
blood vessels.
 Cardiac MRI. This test uses magnetic fields and radio waves to create images of
your heart. Cardiac MRI might be used in addition to echocardiography,
particularly if the images from your echocardiogram aren't helpful in making a
diagnosis.
 Cardiac CT scan. You lie on a table inside a doughnut-shaped machine. An X-

ray tube inside the machine rotates around your body and collects images of
your heart and chest to assess the heart size and function and heart valves.
 Blood tests. Several blood tests might be done, including those to check your
kidney, thyroid and liver function, and to measure your iron levels.
One blood test can measure B-type natriuretic peptide (BNP), a protein produced in
your heart. Your blood level of BNP might rise when your heart is in heart failure, a
common complication of cardiomyopathy.
 Genetic testing or screening. Cardiomyopathy can be hereditary. Discuss

genetic testing with your doctor. He or she might recommend family screening or
genetic testing for your first-degree relatives — parents, siblings and children.
Treatment
The goals of cardiomyopathy treatment are to manage your signs and symptoms,
prevent your condition from worsening, and reduce your risk of complications.
Treatment varies by which type of cardiomyopathy you have.
Medications
Your doctor might prescribe medications to improve your heart's pumping ability,
improve blood flow, lower blood pressure, slow your heart rate, remove excess fluid
from your body or keep blood clots from forming.
Be sure to discuss possible side effects with your doctor before taking any of these
drugs.
Surgically implanted devices
Several types of devices can be placed in the heart to improve its function and relieve
symptoms, including:
 Implantable cardioverter-defibrillator (ICD). This device monitors your heart

rhythm and delivers electric shocks when needed to control abnormal heart
rhythms. An ICD doesn't treat cardiomyopathy, but watches for and controls
abnormal rhythms, a serious complication of the condition.
 Ventricular assist device (VAD). This helps blood circulate through your heart.
VAD usually is considered after less-invasive approaches are unsuccessful. It
can be used as a long-term treatment or as a short-term treatment while waiting
for a heart transplant.
 Pacemaker. This small device placed under the skin in the chest or abdomen
uses electrical impulses to control arrhythmias.
Nonsurgical procedures
Other procedures used to treat cardiomyopathy or arrhythmia include:
 Septal ablation. A small portion of the thickened heart muscle is destroyed by

injecting alcohol through a long, thin tube (catheter) into the artery supplying
blood to that area. This allows blood to flow through the area.
 Radiofrequency ablation. To treat abnormal heart rhythms, doctors guide long,

flexible tubes (catheters) through your blood vessels to your heart. Electrodes at
the catheter tips transmit energy to damage a small spot of abnormal heart tissue
that is causing the abnormal heart rhythm.
Surgery
Types of surgery used to treat cardiomyopathy include:
 Septal myectomy. In this open-heart surgery, your surgeon removes part of the
thickened heart muscle wall (septum) that separates the two bottom heart
chambers (ventricles). Removing part of the heart muscle improves blood flow
through the heart and reduces mitral valve regurgitation.
1. Provide oxygen at 2 to 4 L/min to maintain or improve oxygenation.
2. Minimize oxygen demand by maintaining the patient at bed rest.
3. Provide liquid diet on acute phase,
4. Administer diuretic as prescribed to reduce preload and afterload.
5. Monitor serum potassium before and after administration of loop diuretics.
6. Prophylactic heparin may be ordered to prevent thromboembolus formation

secondary to venous poisoning.
7. Institute pressure ulcer prevention strategies secondary to hypoperfusion or

vasoconstriction agents.
O. Rheumatic Endocarditis
Rheumatic heart disease is a condition in which the heart valves have been
permanently damaged by rheumatic fever. The heart valve damage may start shortly
after untreated or under-treated streptococcal infection such as strep throat or scarlet
fever. An immune response causes an inflammatory condition in the body which can
result in on-going valve damage.
What causes rheumatic heart disease?
Rheumatic heart disease is caused by rheumatic fever, an inflammatory disease that

can affect many connective tissues, especially in the heart, joints, skin, or brain. The
heart valves can be inflamed and become scarred over time. This can result in
narrowing or leaking of the heart valve making it harder for the heart to function
normally. This may take years to develop and can result in heart failure.
Rheumatic fever can occur at any age, but usually occurs in children ages 5 to 15 years
old.
What are the symptoms of rheumatic heart disease?
A recent history of strep infection or rheumatic fever is key to the diagnosis of rheumatic
heart disease. Symptoms of rheumatic fever vary and typically begin 1 to 6 weeks after
a bout of strep throat. In some cases, the infection may have been too mild to have
been recognized, or it may be gone by the time the person sees a doctor.
These are the most common symptoms of rheumatic fever:
 Fever
 Swollen, tender, red and extremely painful joints — particularly the knees and
ankles
 Nodules (lumps under the skin)
 Red, raised, lattice-like rash, usually on the chest, back, and abdomen
 Shortness of breath and chest discomfort
 Uncontrolled movements of arms, legs, or facial muscles
 Weakness
Symptoms of rheumatic heart disease depend on the degree of valve damage and may
include:
 Shortness of breath (especially with activity or when lying down)
 Chest pain
 Swelling
How is rheumatic heart disease diagnosed?
People with rheumatic heart disease will have or recently had a strep infection. A throat
culture or blood test may be used to check for strep.
They may have a murmur or rub that may be heard during a routine physical exam. The
murmur is caused by the blood leaking around the damages valve. The rub is caused
when the inflamed heart tissues move or rub against each other.
Along with a complete medical history and physical exam, tests used to diagnose
rheumatic heart disease may include:
 Echocardiogram (echo). This test uses sound waves to check the heart's

chambers and valves. The echo sound waves create a picture on a screen as an
ultrasound transducer is passed over the skin overlying the heart. Echo can show
damage to the valve flaps, backflow of blood through a leaky valve, fluid around
the heart, and heart enlargement. It’s the most useful test for diagnosing heart
valve problems.
 Electrocardiogram (ECG). This test records the strength and timing of the

electrical activity of the heart. It shows abnormal rhythms (arrhythmias or
dysrhythmias) and can sometimes detect heart muscle damage. Small sensors
are taped to your skin to pick up the electrical activity.
 Chest X-ray. An X-ray may be done to check your lungs and see if your heart is
enlarged.
 Cardiac MRI. This is an imaging test that takes detailed pictures of the heart. It
may be used to get a more precise look at the heart valves and heart muscle.
 Blood tests. Certain blood tests may be used to look for infection and
inflammation.
How is rheumatic heart disease treated?
Treatment depends in large part on how much damage has been done to the heart
valves. In severe cases, treatment may include surgery to replace or repair a badly
damaged valve.
The best treatment is to prevent rheumatic fever. Antibiotics can usually treat strep
infections and keep rheumatic fever from developing. Anti-inflammatory drugs may be
used to reduce inflammation and lower the risk of heart damage. Other medicines may
be needed to manage heart failure.
People who have had rheumatic fever are often given daily or monthly antibiotic
treatments, possibly for life, to prevent recurrent infections and lower the risk of further
heart damage. To reduce inflammation, aspirin, steroids, or non-steroidal medicines
may be given.
Nursing Management
Nursing care of a child with rheumatic fever include:
Nursing Assessment
Nursing assessment for a child with rheumatic fever are as follows:
 History. Obtain a complete up-to-date history from the child and the caregiver;
ask about a recent sore throat or upper respiratory infection; find out when the
symptoms began, the extent of the illness, and what if any treatment was
obtained.
 Physical exam. Begin with a careful review of all systems, and note the child’s
physical condition; observe for any signs that may be classified as major or minor
manifestations; in the physical exam, observe for elevated temperature and
pulse, and carefully examine for erythema marginatum, subcutaneous nodules,
swollen or painful joints, or signs of chorea.
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses are:
 Acute pain related to joint pain when extremities are touched or moved.
 Deficient diversional activity related to prescribed bed rest.
 Activity intolerance related to carditis or arthralgia.
 Risk for injury related to chorea.

 Risk for noncompliance with prophylactic drug therapy related to financial or
emotional burden of lifelong therapy.
 Deficient knowledge of caregiver related to the condition, need for long-term

therapy, and risk factors.
Nursing Care Planning and Goals
Main Article 4 Acute Rheumatic Fever Nursing Care Plans
The major nursing care planning goals for rheumatic fever are:
 Reducing pain.
 Providing diversional activities and sensory stimulation.
 Conserving energy.
 Preventing injury.
Nursing interventions for a child with rheumatic fever include:
 Provide comfort and reduce pain. Position the child to reduce joint pain; warm
baths and gentle range-of-motion exercises help to alleviate some of the joint
discomforts; use pain indicator scales with children so they are able to express
the level of their pain.
 Provide diversional activities and sensory stimulation. For those who do not

feel very ill, bed rest can cause distress or resentment; be creative in finding
diversional activities that allow bed rest but prevent restlessness and boredom,
such as a good book; quiet games can provide some entertainment, and plan all
activities with the child’s developmental stage in mind.
 Promote energy conservation. Provide rest periods between activities to help

pace the child’s energies and provide for maximum comfort; if the child has
chorea, inform visitors that the child cannot control these movements, which are
as upsetting to the child as they are to others.
 Prevent injury. Protect the child from injury by keeping the side rails up and
padding them; do not leave a child with chorea unattended in a wheelchair, and
use all appropriate safety measures.
Evaluation
Goals are met as evidenced by:
 Reducing pain.
 Providing diversional activities and sensory stimulation.
 Conserving energy.
 Preventing injury.
P. Myocarditis
Myocarditis is an inflammation of the heart muscle (myocardium). Myocarditis can affect

your heart muscle and your heart's electrical system, reducing your heart's ability to
pump and causing rapid or abnormal heart rhythms (arrhythmias).
A viral infection usually causes myocarditis, but it can result from a reaction to a drug or
be part of a more general inflammatory condition. Signs and symptoms include chest
pain, fatigue, shortness of breath, and arrhythmias.
Severe myocarditis weakens your heart so that the rest of your body doesn't get enough
blood. Clots can form in your heart, leading to a stroke or heart attack.
Treatment for myocarditis depends on the cause
Myocarditis is an inflammation of the heart muscle (myocardium). Myocarditis can affect

your heart muscle and your heart's electrical system, reducing your heart's ability to
pump and causing rapid or abnormal heart rhythms (arrhythmias).
A viral infection usually causes myocarditis, but it can result from a reaction to a drug or
be part of a more general inflammatory condition. Signs and symptoms include chest
pain, fatigue, shortness of breath, and arrhythmias.
Severe myocarditis weakens your heart so that the rest of your body doesn't get enough
blood. Clots can form in your heart, leading to a stroke or heart attack.
Treatment for myocarditis depends on the cause
Causes
Often, the cause of myocarditis isn't identified. Potential causes are many, but the
likelihood of developing myocarditis is rare. Potential causes include:
 Viruses. Many viruses are commonly associated with myocarditis, including the

viruses that cause the common cold (adenovirus); COVID-19; hepatitis B and C;
parvovirus, which causes a mild rash, usually in children (fifth disease); and
herpes simplex virus.
Gastrointestinal infections (echoviruses), mononucleosis (Epstein-Barr virus) and

German measles (rubella) also can cause myocarditis. It's also common in people with
HIV, the virus that causes AIDS.
 Bacteria. Numerous bacteria can cause myocarditis, including staphylococcus,

streptococcus, the bacterium that causes diphtheria and the tick-borne bacterium
responsible for Lyme disease.
 Parasites. Among these are such parasites as Trypanosoma cruzi and

toxoplasma, including some that are transmitted by insects and can cause a
condition called Chagas disease. This disease is much more prevalent in Central
and South America than in the United States, but it can occur in travelers and in
immigrants from that part of the world.
 Fungi. Yeast infections, such as candida; molds, such as aspergillus; and other

fungi, such as histoplasma, often found in bird droppings, can sometimes cause
myocarditis, particularly in people with weakened immune systems.
Myocarditis also sometimes occurs if you're exposed to:
 Medications or illegal drugs that might cause an allergic or toxic

reaction. These include drugs used to treat cancer; antibiotics, such as penicillin
and sulfonamide drugs; some anti-seizure medications; and some illegal
substances, such as cocaine.
 Chemicals or radiation. Exposure to certain chemicals, such as carbon

monoxide, and radiation can sometimes cause myocarditis.
 Other diseases. These include disorders such as lupus, Wegener's

granulomatosis, giant cell arteritis and Takayasu's arteritis.
Diagnosis
Early diagnosis is key to preventing long-term heart damage. After a physical

examination, your doctor might order one or more tests to confirm that you have
myocarditis and determine its severity. Tests might include:
 Electrocardiogram (ECG). This noninvasive test shows your heart's electrical
patterns and can detect abnormal rhythms.
 Chest X-ray. An X-ray image shows the size and shape of your heart, as well as
whether you have fluid in or around the heart that might indicate heart failure.
 MRI. Cardiac MRI will show your heart's size, shape and structure. This test can
show signs of inflammation of the heart muscle.
 Echocardiogram. Sound waves create moving images of the beating heart. An

echocardiogram might detect enlargement of your heart, poor pumping function,
valve problems, a clot within the heart or fluid around your heart.
 Blood tests. These measure white and red blood cell counts, as well as levels of
certain enzymes that indicate damage to your heart muscle. Blood tests can also
detect antibodies against viruses and other organisms that might indicate a
myocarditis-related infection.
 Cardiac catheterization and endomyocardial biopsy. A small tube (catheter)

is inserted into a vein in your leg or neck and threaded into your heart. In some
cases, doctors use a special instrument to remove a tiny sample of heart muscle
tissue (biopsy) for analysis in the lab to check for inflammation or infection.
Treatment
In many cases, myocarditis improves on its own or with treatment, leading to a complete
recovery. Myocarditis treatment focuses on the cause and the symptoms, such as heart
failure.
In mild cases, persons should avoid competitive sports for at least three to six months.
Rest and medication to help your body fight off the infection causing myocarditis might
be all you need. Although antiviral medications are available, they haven't proved
effective in the treatment of most cases of myocarditis.
Certain rare types of viral myocarditis, such as giant cell and eosinophilic myocarditis,
respond to corticosteroids or other medications to suppress your immune system. In
some cases caused by chronic illnesses, such as lupus, treatment is directed at the
underlying disease.
Drugs to help your heart
If myocarditis is causing heart failure or arrhythmias, your doctor might hospitalize you
and prescribe drugs or other treatments. For certain abnormal heart rhythms or severe
heart failure, you may be given medications to reduce the risk of blood clots forming in
your heart.
If your heart is weak, your doctor might prescribe medications to reduce your heart's
workload or help you eliminate excess fluid, including:
 Angiotensin-converting enzyme (ACE) inhibitors. These medications, such

as enalapril (Vasotec), captopril (Capoten), lisinopril (Zestril, Prinivil) and ramipril
(Altace), relax the blood vessels in your heart and help blood flow more easily.
 Angiotensin II receptor blockers (ARBs). These medications, such as losartan

(Cozaar) and valsartan (Diovan), relax the blood vessels in your heart and help
blood flow more easily.
 Beta blockers. Beta blockers, such as metoprolol (Lopressor, Toprol-XL),

bisoprolol and carvedilol (Coreg), work in multiple ways to treat heart failure and
help control arrhythmias.
 Diuretics. These medications, such as furosemide (Lasix), relieve sodium and

fluid retention.
Treating severe cases
In some severe cases of myocarditis, aggressive treatment might include:
 Intravenous (IV) medications. These might improve the heart-pumping function

more quickly.
 Ventricular assist devices. Ventricular assist devices (VADs) are mechanical

pumps that help pump blood from the lower chambers of your heart (the
ventricles) to the rest of your body. VADs are used in people who have
weakened hearts or heart failure. This treatment may be used to allow the heart
to recover or while waiting for other treatments, such as a heart transplant.
 Intra-aortic balloon pump. Doctors insert a thin tube (catheter) in a blood

vessel in your leg and guide it to your heart using X-ray imaging. Doctors place a
balloon attached to the end of the catheter in the main artery leading out to the
body from the heart (aorta). As the balloon inflates and deflates, it helps to
increase blood flow and decrease the workload on the heart.
 Extracorporeal membrane oxygenation (ECMO). With severe heart failure,

this device can provide oxygen to the body. When blood is removed from the
body, it passes through a special membrane in the ECMO machine that removes
carbon dioxide and adds oxygen to the blood. The newly oxygenated blood is
then returned to the body.
The ECMO machine takes over the work of the heart. This treatment may be used to
allow the heart to recover or while waiting for other treatments, such as a heart
transplant.
In the most severe cases, doctors might consider urgent heart transplantation.
Some people might have chronic and irreversible damage to the heart muscle requiring
lifelong medications, while other people need medications for just a few months and
then recover completely. Either way, your doctor is likely to recommend regular follow-
up appointments, including tests to evaluate your condition.
Nursing Intervention for Myocarditis Disease:
Diferent nursing interventions for myocarditis disease are in the following:
1. Give a comfortable position (semi-fowler position).
2. Monitor pain characteristics and administer analgesics as needed and use

salicylates around the clock.
3. Give O2 supplement and ensure saturation ˃90%.
4. Give drugs as indicated (Aspirin, Steroids).
5. Give anti pyretic drug if fever present.
6. Provide a calm and quite environment and give emotional support while patient is
confined to hospital or home with restrictive intravenous therapy.
7. Check vital sign and record it carefully.
8. Carefully monitor intake output.
9. Closely monitor sign for cardiac tamponade.
10. Ensure bed rest to reduce myocardial oxygen requirements and reduce heart
rate.
11. Ensure rest and activity according to degree of tolerance.
12. Ensure high protein, high carbohydrate, and low sodium diet to meet adequate
nutrition.
13. Explain all procedures to patient that improve patient confidence.

14. Prepare patient for surgery if needed
15. If patient received surgical treatment, provide post surgical care and instruction.
16. After surgery, monitor patient’s temperature, fever may be present for weeks.
17. Provide 4 hourly mouth cares and serve attractive meals that stimulate appetite.
18. Instruct to avoid people who have an upper respiratory tract infection.
19. Monitor for signs and symptoms of organ damage such as stroke (CVA, brain
attack), meningitis, heart failure, myocardial infarction, glomerulonephritis, and
splenomegaly.
20. Instruct patient and family about activity restrictions, medications, and signs and
symptoms of infection.
Q. Pericarditis
The Pericardium
The pericardium is a thin, two-layered, fluid-filled sac that covers the outer surface of
the heart. It provides lubrication for the heart, shields the heart from infection and
malignancy, and contains the heart in the chest wall. It also keeps the heart from over-
expanding when blood volume increases, which keeps the heart functioning efficiently.
What is pericarditis?
Pericarditis is an inflammation of the pericardium. Pericarditis is usually acute – it

develops suddenly and may last up to several months. The condition usually clears up
after 3 months, but sometimes attacks can come and go for years. When you have
pericarditis, the membrane around your heart is red and swollen, like the skin around a
cut that becomes inflamed. Sometimes there is extra fluid in the space between the
pericardial layers, which is called pericardial effusion. Pericarditis can affect anyone, but
it is most common in men aged 16 to 65.
What are the symptoms of pericarditis?
Pericarditis can cause chest pain that:
 Is sharp and stabbing (caused by the heart rubbing against the pericardium)
 May get worse when you cough, swallow, take deep breaths or lie flat
 Feels better when you sit up and lean forward
You also may feel the need to bend over or hold your chest to breathe more
comfortably.
Other symptoms include:
 Pain in your back, neck or left shoulder Trouble breathing when you lie down
 A dry cough
 Anxiety or fatigue
Pericarditis can cause swelling in your feet, legs and ankles. This swelling may be a
symptom of constrictive pericarditis. This is a serious type of pericarditis where the
pericardium gets hard and/or thick. When this happens, the heart muscle can’t expand,
and it keeps your heart from working like it should. Your heart can become compressed,
which causes blood to back up into your lungs, abdomen and legs, and cause swelling.
You can also develop an abnormal heart rhythm.
If you have symptoms of constrictive pericarditis, including shortness of breath, swelling

of the legs and feet, water retention, heart palpitations, and severe swelling of the
abdomen, call your cardiologist to schedule an evaluation.
What causes pericarditis?
There are many causes of pericarditis:
 Viral pericarditis is caused by a complication of a viral infection, most often a

gastrointestinal virus.
 Bacterial pericarditis is caused by a bacterial infection, including tuberculosis.
 Fungal pericarditis is caused by a fungal infection.
 Parasitic pericarditis is caused by an infection from a parasite.
 Some autoimmune diseases, such as lupus, rheumatoid arthritis and

scleroderma can cause pericarditis. Other causes of pericarditis include injury to
the chest, such as after a car accident (traumatic pericarditis), other health
problems such as kidney failure (uremic pericarditis), tumors, genetic diseases
such as Familial Mediterranean Fever (FMF), or rarely, medications that
suppress the immune system.
Your risk of pericarditis is higher after a heart attack, heart surgery (postpericardiotomy
syndrome), radiation therapy or a percutaneous treatment, such as cardiac
catheterization or radiofrequency ablation (RFA). In these cases, it is likely that the
inflammation of the pericardium is an error in the body’s response to the procedure or
condition. It can sometimes take several weeks for symptoms of pericarditis to develop
after bypass surgery.
Many times, the cause of pericarditis is unknown. This is called idiopathic pericarditis.
About 15-30% of patients with pericarditis have repeat episodes of pericarditis that
come and go for many years.
How is pericarditis diagnosed?
Sharp pain in the chest and back of the shoulders and difficulty breathing are 2 major
clues that you may have pericarditis rather than a heart attack. Your doctor will talk to
you about your symptoms and medical history, such as whether you have recently been
sick and review your history of heart conditions, surgery and other health problems that
could put you at a higher risk of pericarditis.
Your doctor will listen to your heart. Pericarditis can cause a rubbing or creaking sound,
caused by the rubbing of the inflamed lining of the pericardium. This is called the
“pericardial rub” and is best heard when you lean forward, hold your breath and breathe
out. Depending on how bad the inflammation is, your doctor may also hear crackles in
your lungs, which are signs of fluid in the space around the lungs or extra fluid in the
pericardium.
Cleveland Clinic imaging specialists in the Center for the Diagnosis and Treatment of
Pericardial Diseases often use a variety of ways to check for pericarditis and any
complications, such as pericardial effusion or constrictive pericarditis. You may need
one or more tests, such as:
 Chest X-ray to see the size of your heart and any fluid in your lungs.
 Electrocardiogram (ECG or EKG) to look for changes in your heart rhythm. In

about half of all patients with pericarditis, the heart rhythm goes through a
sequence of four distinct patterns. Some patients do not have any changes, and
if they do, they may be temporary.
 Echocardiogram (echo) to see how well your heart is working and check for fluid
or pericardial effusion around the heart. An echo will show the classic signs of
constrictive pericarditis, including a stiff or thick pericardium that constricts the
heart’s normal movement.
 Cardiac MRI to check for extra fluid in the pericardium, pericardial inflammation
or thickening, or compression of the heart. A contrast agent called gadolinium is
used during this highly specialized test.
 CT scan to look for calcium in the pericardium, fluid, inflammation, tumors and
disease of the areas around the heart. Iodine dye is used during the test to get
more information about the inflammation. This is an important test for patients
who may need surgery for constrictive pericarditis.
 Cardiac catheterization to get information about the filling pressures in the heart.
This is used to confirm a diagnosis of constrictive pericarditis.
 Blood tests can be used to make sure you are not having a heart attack, to see
how well your heart is working, test the fluid in the pericardium and help find the
cause of pericarditis. If you have pericarditis, it is common for your sedimentation
rate (ESR)and ultra sensitive C reactive protein levels (markers of inflammation)
to be higher than normal. You may need other tests to check for autoimmune
diseases like lupus and rheumatoid arthritis.
What treatments are available for patients with pericarditis?
Medications
Treatment for acute pericarditis may include medication for pain and inflammation, such
as ibuprofen and aspirin. Depending on the cause of your pericarditis, you may need an
antibiotic or antifungal medication.
If your symptoms are severe, last longer than 2 weeks, or clear up and then return, your
doctor may also prescribe an anti-inflammatory drug called colchicine. Colchicine can
help control the inflammation and prevent pericarditis from returning weeks or even
months later.
If you need to take large doses of ibuprofen, your doctor may prescribe medications to
ease gastrointestinal symptoms. If you take large doses of nonsteroidal anti-
inflammatory drugs (NSAIDs), you will need frequent follow-up appointments to look for
changes in your kidney and liver function.
If you have chronic or recurrent pericarditis, you may need to take NSAIDs or colchicine
for several years, even if you feel well.A diuretic (“water pill”) usually helps get rid of the
extra fluid caused by constrictive pericarditis. If you develop a heart rhythm problem,
your doctor will talk to you about treatment.
Your doctor may also talk to you about treatment with steroids or other medications,
such as azathioprine, IV human immunoglobulins, anakinra.
Other treatments
Most times, medications are the only treatment needed for patients with pericarditis.
But, if fluid builds up in the pericardium and compresses the heart, you may need a
procedure called pericardiocentesis. A long, thin tube called a catheter is used to drain
the extra fluid. The catheter and a needle are guided to the pericardium with the use of
echocardiography. If the fluid cannot be drained with the needle, a surgical procedure
called a pericardial window is performed.
If you have constrictive pericarditis, you may need to have some of your pericardium
removed. The surgery is called a pericardiectomy.
Surgery is not usually used as treatment for patients with recurrent pericarditis, but your
doctor may talk to you about it if other treatments aren’t successful.
Nursing Interventions for Pericarditis
Mild cases: just needs rest and it will go away on its own.
 Assess patient’s pain (very painful)
 Keep patient in high Fowler’s position (avoid supine) because this relieves pain
 Monitor for Cardiac Tamponade (fluid compressing the heart):
o Pulsus paradoxus (during the inspiratory phase that is a 10 or greater

mmHg drop in the systolic blood pressure)
o Jugular venous distention with clear lungs
o Heart sounds are muffled (fluid buildup on the heart
o Tachycardia
o Hypotension
Administer medications as prescribed by physician:
 Aspirin OR
 NSAIDS (nonsteroidal anti-inflammatory medications) Ibuprofen…watch for GI

bleeding..take with a full glass of water
 Colchicine: decreases the inflammation (used in gout) don’t take with grapefruit
juice because this increases toxicity (nausea vomiting, abdominal pain, (can take
it with or without food)
 Corticosteriods: used if patient not responding to other treatments…

Prednisone..decreases the inflammation
 IV antibiotics for infection
R. Heart Failure
The term “heart failure” makes it sound like the heart is no longer working at all and
there’s nothing that can be done. Actually, heart failure means that the heart isn’t
pumping as well as it should be. Congestive heart failure is a type of heart failure that
requires seeking timely medical attention, although sometimes the two terms are used
interchangeably.
Your body depends on the heart’s pumping action to deliver oxygen- and nutrient-rich
blood to the body’s cells. When the cells are nourished properly, the body can function
normally. With heart failure, the weakened heart can’t supply the cells with enough
blood. This results in fatigue and shortness of breath and some people have coughing.
Everyday activities such as walking, climbing stairs or carrying groceries can become
very difficult.
Heart failure is a serious condition, and usually there’s no cure. But many people with
heart failure lead a full, enjoyable life when the condition is managed with heart failure
medications and healthy lifestyle changes. It’s also helpful to have the support of family
and friends who understand your condition.
How the normal heart works
The normal healthy heart is a strong, muscular pump a little larger than a fist. It pumps
blood continuously through the circulatory system.
The heart has four chambers, two on the right and two on the left:
 Two upper chambers called atria (one is called an atrium)
 Two lower chambers called ventricles

The right atrium takes in oxygen-depleted blood from the rest of the body and sends it
through the right ventricle where the blood becomes oxygenated in the lungs.
Oxygen-rich blood travels from the lungs to the left atrium, then on to the left ventricle,
which pumps it to the rest of the body.
The heart pumps blood to the lungs and to all the body’s tissues through a sequence of
highly organized contractions of the four chambers. For the heart to function properly,
the four chambers must beat in an organized way.
What is heart failure?
Heart failure is a chronic, progressive condition in which the heart muscle is unable to
pump enough blood to meet the body’s needs for blood and oxygen. Basically, the heart
can’t keep up with its workload.
At first the heart tries to make up for this by:
 Enlarging. The heart stretches to contract more strongly and keep up with the
demand to pump more blood. Over time this causes the heart to become
enlarged.
 Developing more muscle mass. The increase in muscle mass occurs because

the contracting cells of the heart get bigger. This lets the heart pump more
strongly, at least initially.
 Pumping faster. This helps increase the heart’s output.
The body also tries to compensate in other ways:
 The blood vessels narrow to keep blood pressure up, trying to make up for the
heart’s loss of power.
 The body diverts blood away from less important tissues and organs (like the
kidneys), the heart and brain.
These temporary measures mask the problem of heart failure, but they don’t solve it.
Heart failure continues and worsens until these compensating processes no longer
work.
Eventually the heart and body just can’t keep up, and the person experiences the
fatigue, breathing problems or other symptoms that usually prompt a trip to the doctor.
The body’s compensation mechanisms help explain why some people may not become
aware of their condition until years after their heart begins its decline. (It's also a good
reason to have a regular checkup with your doctor.)
Heart failure can involve the heart’s left side, right side or both sides. However, it usually
affects the left side first.
Symptoms
Heart failure can be ongoing (chronic), or your condition may start suddenly (acute).
Heart failure signs and symptoms may include:
 Shortness of breath (dyspnea) when you exert yourself or when you lie down
 Fatigue and weakness
 Swelling (edema) in your legs, ankles and feet
 Rapid or irregular heartbeat

 Reduced ability to exercise
 Persistent cough or wheezing with white or pink blood-tinged phlegm
 Increased need to urinate at night
 Swelling of your abdomen (ascites)
 Very rapid weight gain from fluid retention
 Lack of appetite and nausea
 Difficulty concentrating or decreased alertness
 Sudden, severe shortness of breath and coughing up pink, foamy mucus
 Chest pain if your heart failure is caused by a heart attack
Causes
Chambers and valves of the heartOpen pop-up dialog box
Enlarged heart, in
heart failureOpen pop-up dialog box
Heart failure often develops after other conditions have damaged or weakened your
heart. However, the heart doesn't need to be weakened to cause heart failure. It can
also occur if the heart becomes too stiff.
In heart failure, the main pumping chambers of your heart (the ventricles) may become
stiff and not fill properly between beats. In some cases of heart failure, your heart
muscle may become damaged and weakened, and the ventricles stretch (dilate) to the
point that the heart can't pump blood efficiently throughout your body.
Over time, the heart can no longer keep up with the normal demands placed on it to
pump blood to the rest of your body.
An ejection fraction is an important measurement of how well your heart is pumping and
is used to help classify heart failure and guide treatment. In a healthy heart, the ejection
fraction is 50 percent or higher — meaning that more than half of the blood that fills the
ventricle is pumped out with each beat.
But heart failure can occur even with a normal ejection fraction. This happens if the
heart muscle becomes stiff from conditions such as high blood pressure.
Heart failure can involve the left side (left ventricle), right side (right ventricle) or both
sides of your heart. Generally, heart failure begins with the left side, specifically the left
ventricle — your heart's main pumping chamber.
Type of heart failure Description
Left-sided heart failure Fluid may back up in your lungs, causing

shortness of breath.
Right-sided heart failure Fluid may back up into your abdomen, legs
and feet, causing swelling.
Systolic heart failure The left ventricle can't contract vigorously,

indicating a pumping problem.
Diastolic heart failure The left ventricle can't relax or fill fully,
(also called heart failure with indicating a filling problem.
preserved ejection fraction)
Any of the following conditions can damage or weaken your heart and can cause heart
failure. Some of these can be present without your knowing it:
 Coronary artery disease and heart attack. Coronary artery disease is the most
common form of heart disease and the most common cause of heart failure. The
disease results from the buildup of fatty deposits (plaque) in your arteries, which
reduce blood flow and can lead to heart attack.
 High blood pressure (hypertension). If your blood pressure is high, your heart
has to work harder than it should to circulate blood throughout your body. Over
time, this extra exertion can make your heart muscle too stiff or too weak to
effectively pump blood.
 Faulty heart valves. The valves of your heart keep blood flowing in the proper
direction through the heart. A damaged valve — due to a heart defect, coronary
artery disease or heart infection — forces your heart to work harder, which can
weaken it over time.
 Damage to the heart muscle (cardiomyopathy). Heart muscle damage

(cardiomyopathy) can have many causes, including several diseases, infections,
alcohol abuse and the toxic effect of drugs, such as cocaine or some drugs used
for chemotherapy. Genetic factors also can play a role.
 Myocarditis. Myocarditis is an inflammation of the heart muscle. It's most

commonly caused by a virus, including COVID-19, and can lead to left-sided
heart failure.
 Heart defects you're born with (congenital heart defects). If your heart and its
chambers or valves haven't formed correctly, the healthy parts of your heart have
to work harder to pump blood through your heart, which, in turn, may lead to
heart failure.
 Abnormal heart rhythms (heart arrhythmias). Abnormal heart rhythms may

cause your heart to beat too fast, creating extra work for your heart. A slow
heartbeat also may lead to heart failure.
 Other diseases. Chronic diseases — such as diabetes, HIV, hyperthyroidism,

hypothyroidism, or a buildup of iron (hemochromatosis) or protein (amyloidosis)
— also may contribute to heart failure.
Causes of acute heart failure include viruses that attack the heart muscle, severe
infections, allergic reactions, blood clots in the lungs, the use of certain medications or
any illness that affects the whole body.
Risk factors
A single risk factor may be enough to cause heart failure, but a combination of factors
also increases your risk.
Risk factors include:
 High blood pressure. Your heart works harder than it has to if your blood
pressure is high.
 Coronary artery disease. Narrowed arteries may limit your heart's supply of

oxygen-rich blood, resulting in weakened heart muscle.
 Heart attack. A heart attack is a form of coronary disease that occurs suddenly.
Damage to your heart muscle from a heart attack may mean your heart can no
longer pump as well as it should.
 Diabetes. Having diabetes increases your risk of high blood pressure and

coronary artery disease.
 Some diabetes medications. The diabetes drugs rosiglitazone (Avandia) and

pioglitazone (Actos) have been found to increase the risk of heart failure in some
people. Don't stop taking these medications on your own, though. If you're taking
them, discuss with your doctor whether you need to make any changes.
 Certain medications. Some medications may lead to heart failure or heart

problems. Medications that may increase the risk of heart problems include
nonsteroidal anti-inflammatory drugs (NSAIDs); certain anesthesia medications;
some anti-arrhythmic medications; certain medications used to treat high blood
pressure, cancer, blood conditions, neurological conditions, psychiatric
conditions, lung conditions, urological conditions, inflammatory conditions and
infections; and other prescription and over-the-counter medications.
Don't stop taking any medications on your own. If you have questions about
medications you're taking, discuss with your doctor whether he or she recommends any
changes.
 Sleep apnea. The inability to breathe properly while you sleep at night results in
low blood oxygen levels and increased risk of abnormal heart rhythms. Both of
these problems can weaken the heart.
 Congenital heart defects. Some people who develop heart failure were born
with structural heart defects.
 Valvular heart disease. People with valvular heart disease have a higher risk of
heart failure.
 Viruses. A viral infection may have damaged your heart muscle.
 Alcohol use. Drinking too much alcohol can weaken heart muscle and lead to
heart failure.
 Tobacco use. Using tobacco can increase your risk of heart failure.
 Obesity. People who are obese have a higher risk of developing heart failure.
 Irregular heartbeats. These abnormal rhythms, especially if they are very

frequent and fast, can weaken the heart muscle and cause heart failure.
Complications
If you have heart failure, your outlook depends on the cause and the severity, your
overall health, and other factors such as your age. Complications can include:
 Kidney damage or failure. Heart failure can reduce the blood flow to your
kidneys, which can eventually cause kidney failure if left untreated. Kidney
damage from heart failure can require dialysis for treatment.
 Heart valve problems. The valves of your heart, which keep blood flowing in the
proper direction through your heart, may not function properly if your heart is
enlarged or if the pressure in your heart is very high due to heart failure.
 Heart rhythm problems. Heart rhythm problems (arrhythmias) can be a

potential complication of heart failure.
 Liver damage. Heart failure can lead to a buildup of fluid that puts too much
pressure on the liver. This fluid backup can lead to scarring, which makes it more
difficult for your liver to function properly.
Some people's symptoms and heart function will improve with proper treatment.
However, heart failure can be life-threatening. People with heart failure may have
severe symptoms, and some may require heart transplantation or support with a
ventricular assist device.
Diagnosis
To diagnose heart failure, your doctor will take a careful medical history, review your
symptoms and perform a physical examination. Your doctor will also check for the
presence of risk factors, such as high blood pressure, coronary artery disease or
diabetes.
Using a stethoscope, your doctor can listen to your lungs for signs of congestion. The
stethoscope also picks up abnormal heart sounds that may suggest heart failure. The
doctor may examine the veins in your neck and check for fluid buildup in your abdomen
and legs.
After the physical exam, your doctor may also order some of these tests:
 Blood tests. Your doctor may take a blood sample to look for signs of diseases
that can affect the heart. He or she may also check for a chemical called N-
terminal pro-B-type natriuretic peptide (NT-proBNP) if your diagnosis isn't certain
after other tests.
 Chest X-ray. X-ray images help your doctor see the condition of your lungs and
heart. Your doctor can also use an X-ray to diagnose conditions other than heart
failure that may explain your signs and symptoms.
 Electrocardiogram (ECG). This test records the electrical activity of your heart

through electrodes attached to your skin. It helps your doctor diagnose heart
rhythm problems and damage to your heart.
 Echocardiogram. An echocardiogram uses sound waves to produce a video

image of your heart. This test can help doctors see the size and shape of your
heart along with any abnormalities. An echocardiogram measures your ejection
fraction, an important measurement of how well your heart is pumping, and which
is used to help classify heart failure and guide treatment.
 Stress test. Stress tests measure the health of your heart by how it responds to
exertion. You may be asked to walk on a treadmill while attached to an ECG
machine, or you may receive a drug intravenously that stimulates your heart
similar to exercise.
Sometimes the stress test can be done while wearing a mask that measures the ability
of your heart and lungs to take in oxygen and breathe out carbon dioxide. If your doctor
also wants to see images of your heart while you're exercising, he or she may use
imaging techniques to visualize your heart during the test.
 Cardiac computerized tomography (CT) scan. In a cardiac CT scan, you lie on

a table inside a doughnut-shaped machine. An X-ray tube inside the machine
rotates around your body and collects images of your heart and chest.
 Magnetic resonance imaging (MRI). In a cardiac MRI, you lie on a table inside
a long tubelike machine that produces a magnetic field, which aligns atomic
particles in some of your cells. Radio waves are broadcast toward these aligned
particles, producing signals that create images of your heart.
 Coronary angiogram. In this test, a thin, flexible tube (catheter) is inserted into a
blood vessel at your groin or in your arm and guided through the aorta into your
coronary arteries. A dye injected through the catheter makes the arteries
supplying your heart visible on an X-ray, helping doctors spot blockages.
 Myocardial biopsy. In this test, your doctor inserts a small, flexible biopsy cord
into a vein in your neck or groin, and small pieces of the heart muscle are taken.
This test may be performed to diagnose certain types of heart muscle diseases
that cause heart failure.
Treatment
Heart failure is a chronic disease needing lifelong management. However, with

treatment, signs and symptoms of heart failure can improve, and the heart sometimes
becomes stronger. Treatment may help you live longer and reduce your chance of dying
suddenly.
Doctors sometimes can correct heart failure by treating the underlying cause. For
example, repairing a heart valve or controlling a fast heart rhythm may reverse heart
failure. But for most people, the treatment of heart failure involves a balance of the right
medications and, in some cases, use of devices that help the heart beat and contract
properly.
Medications
Doctors usually treat heart failure with a combination of medications. Depending on your
symptoms, you might take one or more medications, including:
 Angiotensin-converting enzyme (ACE) inhibitors. These drugs help people
with systolic heart failure live longer and feel better. ACE inhibitors are a type of
vasodilator, a drug that widens blood vessels to lower blood pressure, improve
blood flow and decrease the workload on the heart. Examples include enalapril
(Vasotec), lisinopril (Zestril) and captopril (Capoten).
 Angiotensin II receptor blockers. These drugs, which include losartan (Cozaar)

and valsartan (Diovan), have many of the same benefits as ACE inhibitors. They
may be an alternative for people who can't tolerate ACE inhibitors.
 Beta blockers. This class of drugs not only slows your heart rate and reduces
blood pressure but also limits or reverses some of the damage to your heart if
you have systolic heart failure. Examples include carvedilol (Coreg), metoprolol
(Lopressor) and bisoprolol (Zebeta).
These medicines reduce the risk of some abnormal heart rhythms and lessen your
chance of dying unexpectedly. Beta blockers may reduce signs and symptoms of heart
failure, improve heart function, and help you live longer.
 Diuretics. Often called water pills, diuretics make you urinate more frequently
and keep fluid from collecting in your body. Diuretics, such as furosemide (Lasix),
also decrease fluid in your lungs so you can breathe more easily.
Because diuretics make your body lose potassium and magnesium, your doctor may
also prescribe supplements of these minerals. If you're taking a diuretic, your doctor will
likely monitor levels of potassium and magnesium in your blood through regular blood
tests.
 Aldosterone antagonists. These drugs include spironolactone (Aldactone) and

eplerenone (Inspra). These are potassium-sparing diuretics, which also have
additional properties that may help people with severe systolic heart failure live
longer.
Unlike some other diuretics, spironolactone and eplerenone can raise the level of
potassium in your blood to dangerous levels, so talk to your doctor if increased
potassium is a concern, and learn if you need to modify your intake of food that's high in
potassium.
 Inotropes. These are intravenous medications used in people with severe heart

failure in the hospital to improve heart pumping function and maintain blood
pressure.
 Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength

of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin
reduces heart failure symptoms in systolic heart failure. It may be more likely to
be given to someone with a heart rhythm problem, such as atrial fibrillation.
You may need to take two or more medications to treat heart failure. Your doctor may
prescribe other heart medications as well — such as nitrates for chest pain, a statin to
lower cholesterol or blood-thinning medications to help prevent blood clots — along with
heart failure medications. Your doctor may need to adjust your doses frequently,
especially when you've just started a new medication or when your condition is
worsening.
You may be hospitalized if you have a flare-up of heart failure symptoms. While in the
hospital, you may receive additional medications to help your heart pump better and
relieve your symptoms. You may also receive supplemental oxygen through a mask or
small tubes placed in your nose. If you have severe heart failure, you may need to use
supplemental oxygen long term.
Surgery and medical devices
In some cases, doctors recommend surgery to treat the underlying problem that led to
heart failure. Some treatments being studied and used in certain people include:
 Coronary bypass surgery. If severely blocked arteries are contributing to your

heart failure, your doctor may recommend coronary artery bypass surgery. In this
procedure, blood vessels from your leg, arm or chest bypass a blocked artery in
your heart to allow blood to flow through your heart more freely.
 Heart valve repair or replacement. If a faulty heart valve causes your heart
failure, your doctor may recommend repairing or replacing the valve. The
surgeon can modify the original valve to eliminate backward blood flow.
Surgeons can also repair the valve by reconnecting valve leaflets or by removing
excess valve tissue so that the leaflets can close tightly. Sometimes repairing the
valve includes tightening or replacing the ring around the valve (annuloplasty).
Valve replacement is done when valve repair isn't possible. In valve replacement
surgery, the damaged valve is replaced by an artificial (prosthetic) valve.
Certain types of heart valve repair or replacement can now be done without open heart
surgery, using either minimally invasive surgery or cardiac catheterization techniques.
 Implantable cardioverter-defibrillators (ICDs). An ICD is a device similar to a

pacemaker. It's implanted under the skin in your chest with wires leading through
your veins and into your heart.
The ICD monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, or
if your heart stops, the ICD tries to pace your heart or shock it back into normal rhythm.
An ICD can also function as a pacemaker and speed your heart up if it is going too
slow.
 Cardiac resynchronization therapy (CRT), or biventricular pacing. A
biventricular pacemaker sends timed electrical impulses to both of the heart's
lower chambers (the left and right ventricles) so that they pump in a more
efficient, coordinated manner.
Many people with heart failure have problems with their heart's electrical system that
cause their already-weak heart muscle to beat in an uncoordinated fashion. This
inefficient muscle contraction may cause heart failure to worsen. Often a biventricular
pacemaker is combined with an ICD for people with heart failure.
 Ventricular assist devices (VADs). A VAD, also known as a mechanical

circulatory support device, is an implantable mechanical pump that helps pump
blood from the lower chambers of your heart (the ventricles) to the rest of your
body. A VAD is implanted into the abdomen or chest and attached to a
weakened heart to help it pump blood to the rest of your body.
Doctors first used heart pumps to help keep heart transplant candidates alive while they
waited for a donor heart. VADs may also be used as an alternative to transplantation.
Implanted heart pumps can enhance the quality of life of some people with severe heart
failure who aren't eligible for or able to undergo heart transplantation or are waiting for a
new heart.
 Heart transplant. Some people have such severe heart failure that surgery or
medications don't help. They may need to have their diseased heart replaced
with a healthy donor heart.
Heart transplants can improve the survival and quality of life of some people with severe
heart failure. However, candidates for transplantation often have to wait a long time
before a suitable donor heart is found. Some transplant candidates improve during this
waiting period through drug treatment or device therapy and can be removed from the
transplant waiting list.
A heart transplant isn't the right treatment for everyone. A team of doctors at a
transplant center will evaluate you to determine whether the procedure may be safe and
beneficial for you.
Palliative care and end-of-life care
Your doctor may recommend including palliative care in your treatment plan. Palliative
care is specialized medical care that focuses on easing your symptoms and improving
your quality of life. Anyone who has a serious or life-threatening illness can benefit from
palliative care, either to treat symptoms of the disease, such as pain or shortness of
breath, or to ease the side effects of treatment, such as fatigue or nausea.
It's possible that your heart failure may worsen to the point where medications are no
longer working and a heart transplant or device isn't an option. If this occurs, you may
need to enter hospice care. Hospice care provides a special course of treatment to
terminally ill people.
Hospice care allows family and friends — with the aid of nurses, social workers and
trained volunteers — to care for and comfort a loved one at home or in hospice
residences. Hospice care provides emotional, psychological, social and spiritual support
for people who are ill and those closest to them.
Although most people under hospice care remain in their own homes, the program is
available anywhere — including nursing homes and assisted living centers. For people
who stay in a hospital, specialists in end-of-life care can provide comfort,
compassionate care and dignity.
Although it can be difficult, discuss end-of-life issues with your family and medical team.
Part of this discussion will likely involve advance directives — a general term for oral
and written instructions you give concerning your medical care should you become
unable to speak for yourself.
If you have an implantable cardioverter-defibrillator (ICD), one important consideration

to discuss with your family and doctors is turning off the defibrillator so that it can't
deliver shocks to make your heart continue beating.
Nursing Management
Despite advances in the treatment of HF, morbidity and mortality remains high. Nurses
have a major impact on outcomes for patients with HF.
Nursing Assessment
The nursing assessment for the patient with HF focuses on observing for the
effectiveness of therapy and for the patient’s ability to understand and implement self-
management strategies.
Health History
 Assess the signs and symptoms such as dyspnea, shortness of breath, fatigue,
and edema.
 Assess for sleep disturbances, especially sleep suddenly interrupted by

shortness of breath.
 Explore the patient’s understanding of HF, self management strategies, and the
ability and willingness to adhere to those strategies.
Physical Examination
 Auscultate the lungs for presence of crackles and wheezes.
 Auscultate the heart for the presence of an S3 heart sound.
 Assess JVD for presence of distention.
 Evaluate the sensorium and level of consciousness.
 Assess the dependent parts of the patient’s body for perfusion and edema.
 Assess the liver for hepatojugular reflux.
 Measure the urinary output carefully to establish a baseline against which to

assess the effectiveness of diuretic therapy.
 Weigh the patient daily in the hospital or at home.
Diagnosis
Based on the assessment data, major nursing diagnoses for the patient with HF include
the following:
 Activity intolerance related to decrease CO.
 Excess fluid volume related to the HF syndrome.
 Anxiety related to breathlessness from inadequate oxygenation.
 Powerlessness related to chronic illness and hospitalizations.
 Ineffective therapeutic regimen management related to lack of knowledge.
Planning & Goals
The care plan necessary for HF focuses on:
 Promoting physical activities.
 Reducing fatigue.
 Relieving fluid overload symptoms.

 Decreasing anxiety.
 Increasing the patient’s ability to manage anxiety.
 Encouraging the patient to verbalize his or her ability to make decisions and
influence outcome.
 Teaching the patient about self-care program.
Nursing interventions for a patient with HF focuses on management of the patient’s

activities and fluid intake.
 Promoting activity tolerance. A total of 30 minutes of physical activity every

day should be encouraged, and the nurse and the physician should collaborate
to develop a schedule that promotes pacing and prioritization of activities.
 Managing fluid volume. The patient’s fluid status should be monitored closely,
auscultating the lungs, monitoring daily body weight, and assisting the patient to
adhere to a low sodium diet.
 Controlling anxiety. When the patient exhibits anxiety, the nurse should
promote physical comfort and provide psychological support, and begin teaching
ways to control anxiety and avoid anxiety-provoking situations.
 Minimizing powerlessness. Encourage the patient to verbalize their concerns

and provide the patient with decision-making opportunities.
Nursing Priorities
1. Improve myocardial contractility/systemic perfusion.
2. Reduce fluid volume overload.
3. Prevent complications.
4. Provide information about disease/prognosis, therapy needs, and prevention of

recurrences.
Evaluation
For the expected patient outcomes, the following are evaluated:
 Demonstration of tolerance for increased activity.

 Maintenance of fluid balance.
 Less anxiety.
 Decides soundly regarding care and treatment.
 Adherence to self-care regimen.
S. Arteriosclerosis and Atherosclerosis
Arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from
your heart to the rest of your body (arteries) become thick and stiff — sometimes
restricting blood flow to your organs and tissues. Healthy arteries are flexible and
elastic, but over time, the walls in your arteries can harden, a condition commonly called
hardening of the arteries.
Atherosclerosis is a specific type of arteriosclerosis, but the terms are sometimes used
interchangeably. Atherosclerosis refers to the buildup of fats, cholesterol and other
substances in and on your artery walls (plaque), which can restrict blood flow.
The plaque can burst, triggering a blood clot. Although atherosclerosis is often
considered a heart problem, it can affect arteries anywhere in your body.
Atherosclerosis may be preventable and is treatable.
Symptoms
Atherosclerosis develops gradually. Mild atherosclerosis usually doesn't have any

symptoms.
You usually won't have atherosclerosis symptoms until an artery is so narrowed or

clogged that it can't supply adequate blood to your organs and tissues. Sometimes a
blood clot completely blocks blood flow, or even breaks apart and can trigger a heart
attack or stroke.
Symptoms of moderate to severe atherosclerosis depend on which arteries are

affected. For example:
 If you have atherosclerosis in your heart arteries, you may have symptoms,

such as chest pain or pressure (angina).
 If you have atherosclerosis in the arteries leading to your brain, you may

have signs and symptoms such as sudden numbness or weakness in your arms
or legs, difficulty speaking or slurred speech, temporary loss of vision in one eye,
or drooping muscles in your face. These signal a transient ischemic attack (TIA),
which, if left untreated, may progress to a stroke.
 If you have atherosclerosis in the arteries in your arms and legs, you may
have symptoms of peripheral artery disease, such as leg pain when walking
(claudication).
 If you have atherosclerosis in the arteries leading to your kidneys, you

develop high blood pressure or kidney failure.
Causes
Development of atherosclerosisOpen pop-up dialog box
Atherosclerosis is a slow, progressive disease that may begin as early as childhood.

Although the exact cause is unknown, atherosclerosis may start with damage or injury
to the inner layer of an artery. The damage may be caused by:
 High triglycerides, a type of fat (lipid) in your blood
 Smoking and other sources of tobacco

 Insulin resistance, obesity or diabetes
 Inflammation from diseases, such as arthritis, lupus or infections, or inflammation

of unknown cause
Once the inner wall of an artery is damaged, blood cells and other substances often
clump at the injury site and build up in the inner lining of the artery.
Over time, fatty deposits (plaque) made of cholesterol and other cellular products also
build up at the injury site and harden, narrowing your arteries. The organs and tissues
connected to the blocked arteries then don't receive enough blood to function properly.
Eventually, pieces of the fatty deposits may break off and enter your bloodstream.
In addition, the smooth lining of the plaque may rupture, spilling cholesterol and other
substances into your bloodstream. This may cause a blood clot, which can block the
blood flow to a specific part of your body, such as occurs when blocked blood flow to
your heart causes a heart attack. A blood clot can also travel to other parts of your
body, blocking flow to another organ.
Risk factors
Hardening of the arteries occurs over time. Besides aging, factors that increase the risk
of atherosclerosis include:
 Diabetes
 Obesity
 Smoking and other tobacco use
 A family history of early heart disease
 Lack of exercise
 An unhealthy diet
Complications
The complications of atherosclerosis depend on which arteries are blocked. For

example:
 Coronary artery disease. When atherosclerosis narrows the arteries close to
your heart, you may develop coronary artery disease, which can cause chest
pain (angina), a heart attack or heart failure.
 Carotid artery disease. When atherosclerosis narrows the arteries close to your

brain, you may develop carotid artery disease, which can cause a transient
ischemic attack (TIA) or stroke.
 Peripheral artery disease. When atherosclerosis narrows the arteries in your

arms or legs, you may develop circulation problems in your arms and legs called
peripheral artery disease. This can make you less sensitive to heat and cold,
increasing your risk of burns or frostbite. In rare cases, poor circulation in your
arms or legs can cause tissue death (gangrene).
 Aneurysms. Atherosclerosis can also cause aneurysms, a serious complication

that can occur anywhere in your body. An aneurysm is a bulge in the wall of your
artery.
Most people with aneurysms have no symptoms. Pain and throbbing in the area of an
aneurysm may occur and is a medical emergency.
If an aneurysm bursts, you may face life-threatening internal bleeding. Although this is
usually a sudden, catastrophic event, a slow leak is possible. If a blood clot within an
aneurysm dislodges, it may block an artery at some distant point.
 Chronic kidney disease. Atherosclerosis can cause the arteries leading to your

kidneys to narrow, preventing oxygenated blood from reaching them. Over time,
this can affect your kidney function, keeping waste from exiting your body.
Prevention
The same healthy lifestyle changes recommended to treat atherosclerosis also help
prevent it. These include:
 Quitting smoking
 Eating healthy foods
 Exercising regularly
 Maintaining a healthy weight
Diagnosis
During a physical exam, your doctor may find signs of narrowed, enlarged or hardened
arteries, including:
 A weak or absent pulse below the narrowed area of your artery
 Decreased blood pressure in an affected limb
 Whooshing sounds (bruits) over your arteries, heard using a stethoscope
Depending on the results of the physical exam, your doctor may suggest one or more
diagnostic tests, including:
 Blood tests. Lab tests can detect increased levels of cholesterol and blood
sugar that may increase the risk of atherosclerosis. You'll need to go without
eating or drinking anything but water for nine to 12 hours before your blood test.
Your doctor should tell you ahead of time if this test will be performed during your visit.
 Doppler ultrasound. Your doctor may use a special ultrasound device (Doppler

ultrasound) to measure your blood pressure at various points along your arm or
leg. These measurements can help your doctor gauge the degree of any
blockages, as well as the speed of blood flow in your arteries.
 Ankle-brachial index. This test can tell if you have atherosclerosis in the

arteries in your legs and feet.
Your doctor may compare the blood pressure in your ankle with the blood pressure in
your arm. This is known as the ankle-brachial index. An abnormal difference may
indicate peripheral vascular disease, which is usually caused by atherosclerosis.

heart attack. If your signs and symptoms occur most often during exercise, your
doctor may ask you to walk on a treadmill or ride a stationary bike during an
ECG.
 Stress test. A stress test, also called an exercise stress test, is used to gather
information about how well your heart works during physical activity.
Because exercise makes your heart pump harder and faster than it does during most
daily activities, an exercise stress test can reveal problems within your heart that might
not be noticeable otherwise.
An exercise stress test usually involves walking on a treadmill or riding a stationary bike
while your heart rhythm, blood pressure and breathing are monitored.
In some types of stress tests, pictures will be taken of your heart, such as during a
stress echocardiogram (ultrasound) or nuclear stress test. If you're unable to exercise,
you may receive a medication that mimics the effect of exercise on your heart.
 Cardiac catheterization and angiogram. This test can show if your coronary

arteries are narrowed or blocked.
A liquid dye is injected into the arteries of your heart through a long, thin tube (catheter)
that's fed through an artery, usually in your leg, to the arteries in your heart. As the dye
fills your arteries, the arteries become visible on X-ray, revealing areas of blockage.
 Other imaging tests. Your doctor may use ultrasound, a computerized

tomography (CT) scan or magnetic resonance angiography (MRA) to study your
arteries. These tests can often show hardening and narrowing of large arteries,
as well as aneurysms and calcium deposits in the artery walls.
Treatment
Lifestyle changes, such as eating a healthy diet and exercising, are often the most
appropriate treatment for atherosclerosis. Sometimes, medication or surgical
procedures may be recommended as well.
Medications
Various drugs can slow — or even reverse — the effects of atherosclerosis. Here are
some common choices:
 Cholesterol medications. Aggressively lowering your low-density lipoprotein

(LDL) cholesterol, the "bad" cholesterol, can slow, stop or even reverse the
buildup of fatty deposits in your arteries. Boosting your high-density lipoprotein
(HDL) cholesterol, the "good" cholesterol, may help, too.
Your doctor can choose from a range of cholesterol medications, including drugs known
as statins and fibrates. In addition to lowering cholesterol, statins have additional effects
that help stabilize the lining of your heart arteries and prevent atherosclerosis.
 Anti-platelet medications. Your doctor may prescribe anti-platelet medications,

such as aspirin, to reduce the likelihood that platelets will clump in narrowed
arteries, form a blood clot and cause further blockage.
 Beta blocker medications. These medications are commonly used for coronary

artery disease. They lower your heart rate and blood pressure, reducing the
demand on your heart and often relieve symptoms of chest pain. Beta blockers
reduce the risk of heart attacks and some heart rhythm problems.
 Angiotensin-converting enzyme (ACE) inhibitors. These medications may
help slow the progression of atherosclerosis by lowering blood pressure and
producing other beneficial effects on the heart arteries. ACE inhibitors can also
reduce the risk of recurrent heart attacks.
 Calcium channel blockers. These medications lower blood pressure and are

sometimes used to treat angina.
 Water pills (diuretics). High blood pressure is a major risk factor for

atherosclerosis. Diuretics lower blood pressure.
 Other medications. Your doctor may suggest certain medications to control

specific risk factors for atherosclerosis, such as diabetes. Sometimes specific
medications to treat symptoms of atherosclerosis, such as leg pain during
exercise, are prescribed.
Surgical procedures
Sometimes more aggressive treatment is needed to treat atherosclerosis. If you have

severe symptoms or a blockage that threatens muscle or skin tissue survival, you may
be a candidate for one of the following surgical procedures:
 Angioplasty and stent placement. In this procedure, your doctor inserts a long,
thin tube (catheter) into the blocked or narrowed part of your artery. A second
catheter with a deflated balloon on its tip is then passed through the catheter to
the narrowed area.
The balloon is then inflated, compressing the deposits against your artery walls. A mesh
tube (stent) is usually left in the artery to help keep the artery open.
 Endarterectomy. In some cases, fatty deposits must be surgically removed from

the walls of a narrowed artery. When the procedure is done on arteries in the
neck (the carotid arteries), it's called a carotid endarterectomy.
 Fibrinolytic therapy. If you have an artery that's blocked by a blood clot, your
doctor may use a clot-dissolving drug to break it apart.
 Bypass surgery. Your doctor may create a graft bypass using a vessel from
another part of your body or a tube made of synthetic fabric. This allows blood to
flow around the blocked or narrowed artery.
The patient and family are taught about risk factors associated with atherosclerosis, and
the health care professionals help the patient modify these factors. Patients who smoke
cigarettes are encouraged to enroll in smoking cessation programs. Community-based
plans and programs to change sedentary activity patterns, reduce stress, control
obesity, and decrease saturated fat intake to control triglyceride and cholesterol levels
are explored with the patient. The nurse or other health care professional refers the
patient for medical treatment to control hypertension and diabetes mellitus and supports
the patient's efforts to cooperate with lifestyle and health care changes. Regular
exercise of a type and extent appropriate for the patient's health and adequate rest are
prescribed. The patient is informed of the need for long-term follow-up care to prevent a
variety of body system complications.
T. Peripheral Arterial Occlusive Disease
Occlusive peripheral arterial disease is blockage or narrowing of an artery in the

legs (or rarely the arms), usually due to atherosclerosis and resulting in
decreased blood flow.
 Symptoms depend on which artery is blocked and how severe the blockage is.
 To make a diagnosis, doctors measure blood flow to affected areas.
 Drugs, angioplasty, or surgery is used to relieve the blockage and reduce

symptoms.
Occlusive peripheral arterial disease is common among older people because it often
results from atherosclerosis (plaque or disease buildup in the wall of the blood vessel),
which becomes more common with aging.
Overview of Peripheral Arterial Disease

Occlusive peripheral arterial disease is also common among
 Men
 People who have ever smoked regularly
 People with diabetes, high blood pressure, abnormal cholesterol levels, or high

blood homocysteine (a component of protein) levels
 People who have a family history of atherosclerosis
 People who are obese
 People who are physically inactive
Each of these factors contributes not only to the development of occlusive peripheral
arterial disease but also to the worsening of the disease.
Occlusive peripheral arterial disease most commonly develops in the arteries of the
legs, including the two branches of the aorta (iliac arteries) and the main arteries of the
thighs (femoral arteries), of the knees (popliteal arteries), and of the calves (tibial and
peroneal arteries). Much less commonly, the disease develops in the arteries of the
shoulders or arms.
Occlusive arterial disease may also develop in the part of the aorta that passes through
the abdomen (abdominal aorta) or in its branches.
Occlusive peripheral arterial disease may result from
 Gradual narrowing of an artery
 Sudden blockage of an artery
When an artery narrows, the parts of the body it supplies may not receive enough
blood. An inadequate blood supply leads to insufficient oxygen levels in body tissues,
which is called ischemia. Ischemia may develop suddenly or gradually. When an artery
is suddenly or completely blocked, the tissue it supplies may die.
Blood Vessels
Gradual artery narrowing
Gradual narrowing of arteries is usually due to atherosclerosis, in which deposits of

cholesterol and other fatty materials (atheromas or atherosclerotic plaques) develop in
the walls of arteries. Atheromas may gradually narrow the interior (lumen) of the artery
and reduce blood flow. Calcium may accumulate in the walls of the blood vessels,
making the arteries stiff.
Less commonly, arteries are gradually narrowed by an abnormal growth of muscle in

the artery’s wall (fibromuscular dysplasia), inflammation (vasculitis), or pressure from
outside the blood vessel by a nearby expanding mass, such as a tumor or fluid-filled sac
(cyst).
Sudden blockage of an artery
Sudden, complete blockage of an artery may result when a blood clot (thrombus) forms
in an artery that is already narrowed. A sudden blockage may also result when a clot
breaks off (becoming an embolus) from a site such as the heart or aorta, travels through
the bloodstream, and lodges in an artery downstream. Some disorders increase the risk
of blood clot formation. They include atrial fibrillation, other heart disorders, and clotting
disorders. Inflammation of blood vessels (vasculitis), which may be due to an
autoimmune disorder, may also cause sudden blockage of an artery.
Sometimes an atheroma can rupture into the blood vessel and trigger the formation of a
blood clot that suddenly blocks an artery. Other times, a piece of fatty material breaks
off from an atheroma and suddenly blocks an artery. Sudden blockage may also result
from an aortic dissection, in which the inner layer of the aorta tears, allowing blood to
surge through the tear and separate the inner layer from the middle layer of the aorta.
As the dissection enlarges, it can block one or more arteries connected to the aorta.
Symptoms
Symptoms of occlusive peripheral arterial disease vary depending on

 Which artery is affected
 How completely the artery is blocked
 Whether the artery is gradually narrowed or suddenly blocked
Usually, about 70% of the artery’s interior has to be blocked before symptoms occur.
Gradual narrowing of an artery may result in less severe symptoms than sudden
blockage—even if the artery eventually becomes completely blocked. Symptoms may
be less severe because gradual narrowing allows time for nearby blood vessels to
expand or new blood vessels (called collateral vessels) to grow. Thus, the affected
tissue can still be supplied with blood. If an artery is suddenly blocked, there is no time
for collateral vessels to develop, so symptoms are usually severe.
Sudden, complete blockage of an artery in a leg or an arm may cause severe pain,
coldness, and numbness in the affected limb. The person’s leg or arm is either pale or
bluish (cyanotic). No pulse can be felt below the blockage. The sudden, drastic
decrease in blood flow to the limb is a medical emergency. The absence of blood flow
can quickly result in loss of sensation in or paralysis of a limb. If blood flow is absent for
too long, tissue may die, and the limb may need to be amputated.
Intermittent claudication, the most common symptom of peripheral arterial disease,

results from gradual narrowing of a leg artery. It is a painful, aching, cramping, or tired
feeling in the muscles of the leg—not in the joints. Intermittent claudication occurs
regularly and predictably during physical activity but is always relieved promptly by rest.
The muscles ache when a person walks, and the pain begins more quickly and is more
severe when the person walks quickly or uphill. Usually, after 1 to 5 minutes of rest
(sitting is not necessary), the person can walk the same distance already covered,
although continued walking will again provoke the pain at a comparable distance. Most
commonly, the pain occurs in the calf, but it can also occur in the thigh, hip, or buttock,
depending on the location of the blockage. Very rarely, pain occurs in the foot.
Peripheral Arterial Disease
As a leg artery is narrowed further, the distance a person can walk without pain
decreases. Eventually, as the disease becomes very severe, leg muscles may ache
even at rest, especially when the person is lying down. Such pain usually begins in the
lower leg or front of the foot, is severe and unrelenting, and worsens when the leg is
elevated. The pain often interferes with sleep. For relief, the person may hang the feet
over the side of the bed or rest sitting up with the legs hanging down.
Large blockages of the arm arteries, which are rare, may cause fatigue, cramping, or
pain felt in the arm muscles when the arm is used repeatedly.
Peripheral Arterial Disease (Skin Changes)

DR P. MARAZZI/SCIENCE PHOTO LIBRARY
When the blood supply is only mildly or moderately reduced, the leg or arm may look
almost normal. When the blood supply to a foot is severely reduced, the foot may be
cold, and doctors may need special equipment to detect pulses in the foot. The skin of
the foot or leg may be dry, scaly, shiny, or cracked. Nails may not grow normally, and
the hair on the leg may not grow. As the artery is narrowed further, a person may
develop sores that do not easily heal, typically on the toes or heel and occasionally on
the lower leg, especially after an injury. Infections occur easily and become serious
quickly. In people with severe occlusive peripheral arterial disease, wounds in the skin
may take weeks or months to heal or may not heal. Foot ulcers may develop. Leg
muscles usually shrink (atrophy). A large blockage may cause gangrene.
In some people who have had predictable, stable claudication, claudication can
suddenly worsen. For example, calf pain that occurs after walking 10 blocks may
suddenly occur after walking one block. This change may indicate that a new clot has
formed in a leg artery. Such people should seek medical care immediately.
Did You Know...
 When people suddenly develop a painful, cool, and pale arm or leg, they should
seek medical care immediately.
Diagnosis
 Physical examination and symptoms
 Measurement of blood pressure and blood flow
Physical examination
The diagnosis of occlusive peripheral arterial disease is based on the symptoms and
the results of a physical examination. Doctors examine the skin of the legs or arms,
noting the color and temperature and pressing gently to see how quickly color returns
after pressure is removed. These observations can help doctors determine whether
circulation is adequate. Procedures that directly measure blood pressure or blood flow
are also done.
Arterial Waveform
Blood pressure measurement is done using a standard blood pressure cuff and a
special electronic stethoscope. The systolic blood pressure is measured in both arms
and both legs. The pressure should be the same in the arms and legs. If blood pressure
in the ankle is lower than that in the arms by a certain amount (less than 90% of arm
pressure), blood flow to the legs is inadequate, and occlusive peripheral arterial disease
is diagnosed. If doctors suspect a blockage in an arm artery, they measure systolic
blood pressure in both arms. Pressure that is consistently higher in one arm suggests a
blockage in the arm with lower blood pressure, and occlusive peripheral arterial disease
is diagnosed.
Pulse assessment is also useful to assess blood flow. A doctor or nurse assesses
each pulse, including those at the armpits, elbows, wrists, groin, ankles, and feet, and
those behind the knees. The pulse in arteries beyond the blockage may be weak or
absent. For example, if doctors suspect a blockage in a leg artery, they check the pulse
below a certain point in the leg. For arteries in which the pulse is inaccessible, such as
the renal arteries, procedures that provide images of blood flow are done. A
stethoscope is used to listen for abnormal sounds caused by turbulent blood flow
through a narrowed artery (bruits).
Tissue oxygen measurements
Transcutaneous oxygen tension testing measures the oxygen level of the tissue
beneath the skin. Because oxygen is carried to the tissues by the blood, this test is an
indirect measure of the blood flow. This painless test is done by placing sensors on the
skin of the affected leg or arm and on the upper chest. Electrodes in the sensors heat
the area underneath the skin to temporarily widen the blood vessels so that the oxygen
level can be easily measured by the sensor.
Imaging
Doppler ultrasonography can be used to directly measure blood flow and can confirm
the diagnosis of occlusive peripheral arterial disease. This procedure can accurately
detect narrowing or blockage of blood vessels. Doppler ultrasonography to measure
blood flow also may be done during exercise stress testing, because some problems
appear only during exercise.
Usually, angiography, an invasive procedure in which a flexible plastic catheter is

inserted into one of the large arteries in the upper thigh, is done only when surgery or
angioplasty (opening up a blockage by inflating a small balloon within the artery) is
required. In such cases, its purpose is to provide doctors with clear images of the
affected arteries before surgery or angioplasty is done. Rarely, angiography is needed
to determine whether surgery or angioplasty is possible. In angiography, a radiopaque
contrast agent (dye), which can be seen on x-rays, is injected into an artery via the
flexible plastic catheter. The contrast agent shows an outline of the inside of the artery
when x-rays are done. Thus angiography can show the precise diameter of the artery
and is more accurate than Doppler ultrasonography in detecting some blockages.
More recently, most medical centers are doing angiography using a less invasive
method such as computed tomography (CT angiography) or magnetic resonance
imaging (called magnetic resonance angiography, or MRA). Rather than requiring an
insertion of a flexible catheter into a major artery, these tests use small amounts of a
contrast agent that are injected into the bloodstream by vein using a standard
intravenous catheter in the arm.
Other tests for diagnosing occlusive peripheral arterial disease
For people with atherosclerosis, doctors try to identify risk factors, often by doing blood
tests to measure levels of cholesterol, sugar (glucose), and, occasionally,
homocysteine. Blood pressure is measured on more than one occasion to determine if it
is consistently high.
Blood tests also may be done to identify other causes of narrowed or blocked arteries,
such as inflammation of blood vessels due to an autoimmune disorder. Such blood tests
include measuring the erythrocyte sedimentation rate (ESR) and level of C-reactive
protein, which is produced only when inflammation is present. For blockage of an arm
artery, doctors try to determine if the cause is atherosclerosis, thoracic outlet syndrome,
or inflammation of the artery (arteritis).
Doctors use magnetic resonance imaging (MRI) to rule out spinal stenosis (narrowing of
the spinal canal), which can also cause pain during physical activity. However, this pain,
unlike intermittent claudication, requires sitting, not just rest, for relief.
Prevention
The best way to help prevent occlusive peripheral arterial disease is to modify or
eliminate risk factors for atherosclerosis. Prevention includes the following measures:
 Quitting smoking
 Controlling diabetes
 Lowering high blood pressure and high cholesterol levels
 Losing weight
 Engaging in regular physical activity
 Sometimes drugs to prevent complications such as coronary artery disease
Good control of diabetes helps delay or prevent the development of occlusive peripheral
arterial disease and reduces the risk of other complications.
Treatment
 Control risk factors
 Exercise
 Drugs
 Angioplasty
 Surgery to relieve or bypass the blockage
 Amputation of a limb if tissue dies
The aims of treatment are the following:
 To prevent the disease from progressing
 To reduce the risk of heart attack, stroke, and death due to widespread
atherosclerosis
 To prevent amputation
 To improve the quality of life by relieving symptoms (such as intermittent
claudication)
Treatments include drugs such as those that relieve claudication and those that cause
clots to dissolve (thrombolytic, or fibrinolytic, drugs), angioplasty, surgery, and other
measures, such as exercise and foot care. Which treatments are used depends on
 Whether the blockage developed suddenly or gradually
 The severity of the symptoms
 The severity of the blockage
 The location of the blockage
 The risks related to the treatment (particularly for surgery)
 The person's overall health
Regardless of the specific treatments used, people still need to treat disorders that are
risk factors for atherosclerosis (such as high blood pressure, diabetes, smoking, and
high cholesterol) to improve their overall prognosis. Angioplasty and surgery are only
mechanical measures for correcting the immediate problem. They do not control or
reverse the process that caused the disease in the first place.
Exercise
Regular exercise can help relieve the pain in most people with intermittent claudication.
Exercise is the most effective treatment and may be appropriate for motivated people
who can follow a prescribed daily exercise program. Exactly how exercise relieves
claudication is not well understood, but exercise probably improves muscle function,
improves blood flow, or causes new (collateral) blood vessels to grow. People with
claudication should walk at least 30 minutes a day at least 3 times a week, if possible.
For most people, following this routine increases the distance they can walk
comfortably. Discomfort felt during walking is not dangerous. When discomfort is felt, a
person should stop walking until the discomfort subsides and then walk again. The total
walking time (excluding rest periods) must be at least 30 minutes to improve walking
distance.
Exercise is usually most effective when it is supervised by a trained therapist in

a rehabilitation program. Doctors recommend that people with claudication undergo
an exercise stress test before they begin a rehabilitation program to make sure that the
blood supply to heart muscle is adequate.
Foot care
Good foot care is important. It helps prevent wounds or foot ulcers from becoming
infected and painful or resulting in gangrene. Good foot care also helps prevent
amputation. Self-care measures include
 Inspecting the feet daily for cracks, sores, corns, and calluses
 Washing the feet daily in lukewarm water with mild soap, and dry them gently
and thoroughly
 Using a lubricant, such as lanolin, for dry skin
 Using unmedicated powder to keep the feet dry
 Cutting toenails straight across and not too short (a podiatrist may have to cut the
nails; the podiatrist needs to know that the person has peripheral arterial
disease)
 Having a podiatrist treat corns or calluses
 Avoiding adhesive or harsh chemicals to remove corns or calluses
 Changing socks or stockings daily and shoes often
 Wearing loose wool socks to keep the feet warm
 Not wearing tight garters or stockings with tight elastic tops
 Wearing shoes that fit well and have wide toe spaces
 Avoiding open shoes or walking barefoot
 Asking the podiatrist about a prescription for special shoes if the feet are
deformed
 Not using hot water bottles or heating pads
 Not soaking feet in hot water or chemical solutions
Foot ulcers require meticulous care. Such care is needed to treat infection, to protect
the skin from further damage, and to enable the person to continue to walk.
A foot ulcer must be kept clean. It should be washed daily with a mild soap or
antibacterial solution and covered daily with clean, dry dressings. The legs should be
kept below the level of the heart to help improve blood flow. People with diabetes must
control blood sugar levels as well as possible. As a rule, anyone with poor circulation to
the feet or with diabetes should have a doctor check a foot ulcer that is not healing after
about 7 days. Often, doctors prescribe an antibiotic ointment.
If foot ulcers are not healing, a person may need complete bed rest. If bed rest is
required, bandages with heel pads or foam-rubber booties should be worn to prevent
bedsores (pressure sores) from developing on the feet. The head of the bed should be
raised 6 to 8 inches (about 15 to 20 centimeters) and the legs kept at or below heart
level, so that gravity helps blood flow through the arteries. If the ulcer is infected,
doctors usually prescribe antibiotics to be taken by mouth, and the person may need to
be hospitalized.
Drugs
Drugs to treat diseases that cause peripheral arterial disease, such as high blood
pressure, diabetes, and high cholesterol, may be given. Other drugs may be given to
dissolve blood clots or prevent new clots from forming. The most commonly used drugs
are aspirin and clopidogrel, which decrease the risk of blood clot formation.
Aspirin or clopidogrel is usually given because these drugs help prevent clot formation
and reduce the risk of heart attack or stroke. They modify platelets so that they do not
adhere to blood vessel walls. Normally, platelets, which circulate in the blood, gather
and form a clot to stop bleeding when a blood vessel is injured.
Drugs such as pentoxifylline or cilostazol are taken by mouth to treat claudication.

These drugs may increase blood flow and thus the oxygen supply to muscles. Either
drug must be taken for 2 to 3 months to determine whether it is effective. However, the
usefulness of pentoxifylline is now in doubt, and many experts no longer recommend its
use. In contrast, cilostazol may result in a 50 to 100% increase in the distance that can
be walked without pain. Cilostazol should not be used by people with heart failure.
Studies also show that ramipril, which belongs to a class of drugs called angiotensin-
converting enzyme inhibitors that help blood vessels dilate and sometimes improve
blood flow, improves the distance the person can walk without pain.
Angioplasty
Angioplasty to widen a blood vessel is sometimes done immediately after angiography.

When a blockage occurs suddenly, angioplasty must be done as soon as possible to
prevent irreversible loss of limb function or amputation. Angioplasty may be done to
relieve symptoms and thus postpone or avoid surgery. Sometimes it is used in
combination with surgery or a procedure to remove a blood clot. Angioplasty consists of
inserting a catheter with a balloon at its tip into the narrowed part of the artery and then
inflating the balloon to clear the blockage. To keep the artery open, doctors may insert a
permanent wire mesh (a stent) into the artery. Some stents now contain drugs that are
slowly released (drug-eluting stents) and prevent regrowth of the blockage.
Angioplasty is usually done as an outpatient procedure.
Angioplasty is rarely painful but may be somewhat
uncomfortable because the person has to lie still on a
hard table. A mild sedative, but no general anesthetic, is
given.
The success of angioplasty varies, depending on the

location of the blockage and the severity of peripheral
arterial disease. Afterward, the person is given a drug
(such as aspirin or clopidogrel) to help prevent clots
from forming in the arteries of the limb and to prevent a
subsequent heart attack and stroke. Also, Doppler
ultrasonography is done regularly to monitor blood flow
through the artery and thus detect whether the artery is
narrowing again.
Angioplasty cannot be done successfully if too many

areas of an artery are narrowed, if the narrowed section
is too long, or if the artery is severely and extensively
hardened. After angioplasty, surgery may be needed if
a blood clot (thrombus) forms in the narrowed area, if a
piece of the clot (embolus) breaks off and blocks an
artery downstream, if blood seeps into the lining of the
artery causing a bulge inward that blocks blood flow (a
disorder called dissection), or if severe bleeding occurs.
Other devices—including lasers, mechanical cutters,

ultrasonic catheters, and rotational sanders—can be
used instead of a balloon catheter during angioplasty,
but none appear to be more effective.
Surgery
Surgery to remove the blockage or bypass surgery may be done if other treatments do
not relieve claudication. Surgery is usually done to avoid amputation of a leg when
blood flow is greatly reduced—that is, when claudication is incapacitating or occurs
during rest, when wounds do not heal, or when gangrene develops.
Surgery to remove blood clots (thromboendarterectomy) can be done when thrombolytic

drugs are ineffective or too dangerous. Surgery to remove atheromas (endarterectomy)
or other blockages may also be done.
Bypass Surgery in the Leg
Bypass surgery may be done to treat arteries that are narrowed or blocked. In this
procedure, blood is rerouted around the affected artery—for example, around part of the
femoral artery in the thigh or part of the popliteal artery in the knee. A graft consisting of
a tube made of a synthetic material or part of a vein from another part of the body is
joined to the blocked artery above and below the blockage.
Nursing Management
Provide proper positioning
 Place the client’s legs in a dependent position in relation to the heart to

improve peripheral blood flow
 Avoid raising the client’s feet above heart level unless specifically prescribed by
the health care providers
 Keep the client in a neutral, flat, supine position if in doubt about the nature of his
peripheral vascular problems.
Promote vasodilation.
 Provide insulating warmth with gloves, socks and other outerwear as appropriate.
 Keep room temperatures comfortably warm.
 Instruct the client to warm himself with warm drinks or baths.
 Never apply a direct heat source to the extremities. Limited blood flow combined
occur with normal circulation.
 Teach the client about the vasoconstrictive effects of nicotine and caffeine,
emotional stress, and chilling, discuss ways to avoid or minimize these risk
factors.
 Teach the client to avoid constricting clothes, such as garters, knee-high

stockings and belts.
 If overreplacement of glucocortiocoid is indicated, inform the client about the

purpose of therapy and possible adverse effects such as cushingoid appearance,
weight gain, acne, hirsutism, peptic ulcer, diabetes mellitus, osteoporosis,
infection, muscular weakness, mood swings, cataracts and hypertension.
Promote activity and mobility.

 For a client with decreased arterial function but without activity-limiting tissue
damage, encourage a program of balanced exercise and rest to promote
development of collateral circulation.
Provide care for a client undergoing angiography or percutaneous transluminal

angioplasty.
 Before the procedure, provide information related to the procedure, validate that
the informed consent has been obtained, mark peripheralpulses, obtain
diagnostic data as ordered and withhold food and fluids as prescribed.
 After the procedure, maintain bed rest as prescribed, keeping the involved
extremity extended, monitor vital signs and assess peripheral pulses and
circulation every 15 minutes for 2 hours and then every hour for 4 hours.
 Assess for bleeding, hematoma, or edema at the catheter insertion site,

encourage oral fluid and monitor urine output.
Provide care for a client receiving an autogenous saphenous vein or a synthetic bypass
graft.
 Prepare the client for surgery and mark the site of the peripheral pulses
 Monitor the client carefully after the procedure (especially for the first 24 hours)
for signs of graft occlusion as manifested by decreased arterial perfusion.
 Anticipate and take steps to prevent complications of any surgical procedure

involving general anesthesia, particularly respiratory problems and infection.
Provide care for a client who has received an axillofemoral or axillobifemoral bypass
graft or an endarterectomy (i.e. removal of atheromatous plaque).
 Avoid positioning the client on the side of the graft or incision after the procedure
 Warn the client not to wear tight clothing which can lead to graft occlusion
 Instruct the client on signs and symptoms of infection to report to the health care
provider.
Provide care for client undergoing an amputation.
Promote and teach skin and foot care.

U. Aneurysm
An aneurysm occurs when part of an artery wall weakens, allowing it to balloon out or
widen abnormally.
The causes of aneurysms are sometimes unknown. Some may be congenital, meaning
a person is born with them. Aortic disease or an injury may also cause an aneurysm.
A family history of aneurysm may increase your risk for developing an aneurysm. Other
risk factors include high blood pressure, high cholesterol and smoking.
Aneurysms can occur anywhere, but the most common are:
 Aortic aneurysm occurs in the major artery from the heart
 Cerebral aneurysm occurs in the brain
 Popliteal artery aneurysm occurs in the leg behind the knee
 Mesenteric artery aneurysm occurs in the intestine
 Splenic artery aneurysm occurs in an artery in the spleen
Symptoms
Most aneurysms are clinically silent. Symptoms do not usually occur unless an
aneurysm ruptures.
However, an unruptured aneurysm may still obstruct circulation to other tissues. They
can also form blood clots that may go on to obstruct smaller blood vessels. This is a
condition known as thromboembolism. It can lead to ischemic stroke or other serious
complications.
Aneurysms are generally symptomless, but their complications can cause severe chest
pain.
Rapidly growing abdominal aneurysms are sometimes associated with symptoms.

Some people with abdominal aneurysms report abdominal pain, lower back pain, or a
pulsating sensation in the abdomen.
Similarly, thoracic aneurysms can affect nearby nerves and other blood vessels,
potentially causing swallowing and breathing difficulties, and pain in the jaw, chest, and
upper back.
Symptoms can also relate to the cause of an aneurysm rather than the aneurysm itself.
For example, in the case of an aneurysm caused by vasculitis, or blood
vessel inflammation, a person may experience fever, malaise, or weight loss.
Complications
The first signs of a previously undetected aneurysm could be complications upon

rupture. Symptoms tend to result from a rupture rather than the aneurysm alone.
Most people living with an aneurysm do not experience any complications. However, in
addition to thromboembolism and rupture of the aorta, complications can include:
 Severe chest or back pain: Severe chest or back pain may arise following the
rupture of an aortic aneurysm in the chest.
 Angina: Certain types of aneurysm can lead to angina, another type of chest
pain. Angina can lead to myocardial ischemia and heart attack.
 A sudden extreme headache: If a brain aneurysm leads to SAH, the main

symptom is a sudden, severe headache.
Any rupture of an aneurysm may cause pain, low blood pressure, a rapid heart rate, and
lightheadedness. Most people with an aneurysm will not experience any complications.
Causes
An aneurysm can happen in any part of the body. Blood pressure can more easily
distend a weakened arterial wall.
Further research is necessary to confirm why an artery wall weakens to cause an

aneurysm. Some aneurysms, though less common, are present from birth as an arterial
defect.
Aortic dissection
Aortic dissection is one identifiable cause of an aortic aneurysm. The arterial wall has
three layers. Blood can burst through a tear in the weakened wall of the artery, splitting
these layers. It can then fill the cavity surrounding the heart.
If the tear occurs on the innermost layer of the arterial wall, blood channels into and
weakens the wall, increasing the risk of rupture.
People with aortic dissection often describe abrupt and excruciating chest pain. This
pain can travel as the dissection progresses along the aorta. It may, for example,
radiate to the back.
Dissection leads to compression. Compression prevents blood from returning to the

heart. This is also known as a pericardial tamponade.
Risk factors
There are some lifestyle choices and physical characteristics that can increase the
chance of an aneurysm.
 smoking tobacco
 hypertension, or high blood pressure
 poor diet
 inactive lifestyle
 obesity
Smoking is by far the most common risk factor, especially in cases of AAA. Tobacco

use has been shown not only to increase cardiovascular disease and the risk of an
aneurysm but also increase the risk of rupture once an aneurysm has taken effect.
Treatment
Not all cases of unruptured aneurysm need active treatment. When an aneurysm
ruptures, however, emergency surgery is needed.
Aortic aneurysm treatment options
The doctor may monitor an unruptured aortic aneurysm, if no symptoms are evident.
Medications and preventive measures may form part of conservative management, or
they may accompany active surgical treatment.
A ruptured aneurysm needs emergency surgery. Without immediate repair,

patients have a low chance of survival.
The decision to operate on an unruptured aneurysm in the aorta depends on a number

of factors related to the individual patient and features of the aneurysm.
These include:
 the age, general health, coexisting conditions and personal choice of the patient
 the size of the aneurysm relative to its location in the thorax or abdomen, and the
aneurysm’s rate of growth
 the presence of chronic abdominal pain or risk of thromboembolism, as these

may also necessitate surgery
A large or rapidly growing aortic aneurysm is more likely to need surgery. There are two
options for surgery:
 open surgery to fit a synthetic or stent graft
 endovascular stent-graft surgery.
In endovascular surgery, the surgeon accesses the blood vessels through a small
incision near the hip. Stent-graft surgery inserts an endovascular graft through this
incision using a catheter. The graft is then positioned in the aorta to seal off the
aneurysm.
In an open AAA repair, a large incision is made in the abdomen to expose the aorta. A
graft can then be applied to repair the aneurysm.
Endovascular surgery for the repair of aortic aneurysms carries the following risks:
 bleeding around the graft
 bleeding before or after the procedure
 blockage of the stent
 nerve damage, resulting in weakness, pain or numbness in the leg
 kidney failure
 reduced blood supply to the legs, kidneys or other organs
 erectile dysfunction
 unsuccessful surgery that then needs further open surgery
 slippage of the stent
Some of these complications, such as bleeding around the graft, will lead to further
surgery.
Cerebral aneurysm treatment options
A ruptured intracerebral aneurysm will usually need emergency surgery.
In the case of a brain aneurysm, the surgeon will normally operate only if there is a high
risk of rupture. The potential risk of brain damage resulting from surgical complications
is too great.
As for AAA, the likelihood of a rupture depends on the size and location of the
aneurysm.
Instead of surgery, patients receive guidance on how to monitor and manage the risk
factors for a ruptured brain aneurysm, for example, monitoring blood pressure.
If a ruptured cranial aneurysm results in a subarachnoid hemorrhage, surgery is likely.

This is considered a medical emergency.
This procedure would aim to close off the ruptured artery in the hope of preventing
another bleed.
Nursing Management
Intracranial Aneurysm
All patients should be monitored in the intensive care unit after an intracerebral
aneurysm.
Nursing Assessment
A complete neurologic assessment is performed initially and includes evaluation for the
following:
 Altered level of consciousness.
 Sluggish pupillary reaction.
 Motor and sensory dysfunction.
 Cranial nerve deficits (extraocular eye movements, facial droop, presence of

ptosis).
 Speech difficulties and visual disturbance.
 Headache and nuchal rigidity or other neurologic deficits.
Nursing Diagnosis
Based on the assessment data, the patient’s major nursing diagnoses may include the
following:
 Ineffective tissue perfusion related to bleeding or vasospasm.
 Disturbed sensory perception related to medically imposed restrictions.
 Anxiety related to illness and/or medically imposed restrictions (aneurysm

precautions).
Nursing Care Planning & Goals
The goals for the patient may include:
 Improve cerebral tissue perfusion.
 Relief of sensory and perceptual deprivation.
 Relief of anxiety.
 Absence of complications.
All patients should be monitored in the intensive care unit after an intracerebral
hemorrhage.
Improving Cerebral Tissue Perfusion
 Monitor closely for neurologic deterioration, and maintain a neurologic flow

record.
 Check blood pressure, pulse, level of consciousness, pupillary responses, and

motor function hourly; monitor respiratory status and report changes immediately.
 Implement aneurysm precautions (immediate and absolute bed rest in a quiet,

nonstressful setting; restrict visitors, except for family).
 Elevate the head of bed 15 to 30 degrees or as ordered.
 Avoid any activity that suddenly increases blood pressure or obstructs venous

return (eg, Valsalva maneuver, straining), instruct patient to exhale during
voiding or defecation to decrease strain, eliminate caffeine, administer all
personal care, and minimize external stimuli.
 Apply antiembolism stockings or sequential compression devices. Observe legs

for signs and symptoms of deep vein thrombosis tenderness, redness, swelling,
warmth, and edema.
Relieving Sensory Deprivation
 Keep sensory stimulation to a minimum.
 Explain restrictions to help reduce patient’s sense of isolation.
 Relieving Anxiety
 Inform patient of plan of care.
 Provide support and appropriate reassurance to patient and family.
Monitoring and Managing Potential Complications
 Assess for and immediately report signs of possible vasospasm, which may

occur several days after surgery or on the initiation of treatment (intensified
headaches, decreased level of responsiveness, or evidence of aphasia or partial
paralysis). Also administer calcium channel blockers or fluid volume
expanders as prescribed.
 Maintain seizure precautions. Also maintain airway and prevent injury if
a seizure occurs. Administer antiseizure medications as prescribed
(phenytoin [Dilantin] is medication of choice).
 Monitor for onset of symptoms of hydrocephalus, which may be acute (first 24

hours after hemorrhage), subacute (days later), or delayed (several weeks later).
Report symptoms immediately: acute hydrocephalus is characterized by sudden
stupor or coma; subacute or delayed is characterized by gradual onset of
drowsiness, behavioral changes, and ataxic gait.
 Monitor for and report symptoms of aneurysm rebleeding. Rebleeding occurs

most often in the first 2 weeks.
 Symptoms include sudden severe headache, nausea, vomiting, decreased level

of consciousness, and neurologic deficit.
 Administer medications as ordered.
 Hyponatremia: monitor laboratory data often because hyponatremia

(serum sodium level under 135 mEq/L) affects up to 30% of patients. Report low
levels persisting for 24 hours, as syndrome of inappropriate antidiuretic
hormone (SIADH) or cerebral salt wasting syndrome (kidneys cannot conserve
sodium) may develop.
Teaching Patients Self Care
 Provide patient and family with information to promote cooperation with the care
and required activity restrictions and prepare them for patient’s return home.
 Identify the causes of intracranial hemorrhage, its possible consequences, and

the medical or surgical treatments that are implemented. Discuss the importance
of interventions taken to prevent and detect complications (eg,
aneurysm precautions, close monitoring of patient). As indicated, facilitate
transfer to a rehabilitation unit or center.
Evaluation
Expected patient outcomes may include the following:
 Improved cerebral tissue perfusion.
 Relief of sensory and perceptual deprivation.
 Relief of anxiety.
 Absence of complications.
Alternatively, bypass surgery may be done. In bypass surgery, a graft consisting of a
tube made of a synthetic material or a part of a vein from another part of the body is
joined to the blocked artery above and below the blockage. Thus, blood is rerouted
around the blocked artery.
Another approach is to remove the narrowed or blocked section and insert a graft in its
place. Usually before surgery, doctors assess heart function and blood flow through the
heart to determine the relative safety of surgery, because many people with occlusive
peripheral arterial disease also have coronary artery disease.
Rarely, amputation of the leg is required if part of a limb has died or if there is no good
way to restore blood flow to the area. Amputation is done to remove infected tissue,
relieve unrelenting pain, or stop worsening gangrene. Surgeons remove as little of the
leg as possible. Preserving the knee is particularly important if the person plans to wear
an artificial leg. Physical rehabilitation after leg amputation is important.
Other treatments
Exposure to cold, which causes blood vessels to narrow (constrict) and further restricts
the blood reaching the tissue, should be minimized.
Avoiding drugs that cause blood vessels to constrict is also important. These drugs
include ephedrine, pseudoephedrine, and phenylephrine, which are components of
some sinus congestion and cold remedies.
The injection of stem cells into the legs of people with severe deficiencies in blood flow
is currently being studied. Stem cells may stimulate the growth of new blood vessels,
thereby reducing the need for amputation.
Nursing Intervention: Abdominal Aortic Aneurysm
1. Monitor vital signs.
2. Assess risk factors for the arterial disease process.
3. Obtain information regarding back or abdominal pain.
4. Question the client regarding the sensation of palpation in the abdomen.

5. Inspect the skin for the presence of vascular disease or breakdown.
6. Check peripheral circulation, including pulses,temperature, and color.
7. Observe for signs of rupture.
8. Note any tenderness over the abdomen.
9. Monitor for abdominal distention.
Nursing Interventions and Rationales: Aortic Aneurysm
 Full Pain Assessment (PQRST or OLDCARTS)
Need to determine how quickly the pain came on – sudden onset may indicate rupture.
Need to determine if the pain radiates – aneurysms tend to radiate to the back and
abdomen. Severe pain may indicate worsening aneurysm or even rupture.
 Full Abdominal Assessment
AAA’s can be seen and felt pulsating in the abdomen and a bruit can be heard. A
detailed abdominal assessment can help to identify a AAA.
 Inspection – visible pulsation
 Auscultation – systolic bruit
 Palpation – pulsation and tenderness
 Assess VS and hemodynamics
Since cardiac output can be compromised, it’s important to monitor hemodynamics and
vital signs to monitor for deterioration.

 Assess peripheral perfusion
Since cardiac output can be compromised, peripheral perfusion may be decreased.

Monitor for diminished pulses, cool, pale, clammy skin, and slow cap refill.
 Manage Pain
o Administer analgesics
o Position of comfort
Aortic aneurysms are often accompanied by pain that radiate to the back. It can even be
burning or tearing pain. We need to manage this with analgesics as well as encouraging
the patient to be in their position of comfort. For some, this might be side-lying, while
others may prefer to be on their backs.
 Administer antihypertensives
Controlling blood pressure is a top priority with an aortic aneurysm. The goal is to
decrease the pressure on the walls of the aorta while still maintaining a MAP sufficient
enough to perfuse the rest of the body. Usually this means a MAP > 65 mmHg.
 Monitor for evidence of rupture
Larger aortic aneurysms are at high risk for rupture. This would be evidenced by
sudden, severe pain that radiates to the back, flank, or groin, a hematoma on the flank
(retroperitoneal bleed), and signs of shock (↓ BP, ↑ HR, ↓ pulses, slow cap refill, cool,
pale, clammy skin)

 Prepare patient for emergency surgery if needed
Ruptured aneurysms need to go to the OR emergently for repair to prevent death from
hemorrhage. Other patients may need their aneurysm repaired in the OR or in the cath
lab (EVAR) to prevent complications.
V. Dissecting Aorta Arterial Embolism and Thrombosis
An aortic dissection is a serious condition in which the inner layer of the aorta, the large
blood vessel branching off the heart, tears. Blood surges through the tear, causing the
inner and middle layers of the aorta to separate (dissect). If the blood-filled channel
ruptures through the outside aortic wall, aortic dissection is often fatal.
Aortic dissection is relatively uncommon. The condition most frequently occurs in men in
their 60s and 70s. Symptoms of aortic dissection may mimic those of other diseases,
often leading to delays in diagnosis. However, when an aortic dissection is detected
early and treated promptly, the chance of survival greatly improves.
Causes
An aortic dissection occurs in a weakened area of the aortic wall. Chronic high blood
pressure may stress the aortic tissue, making it more susceptible to tearing. You can
also be born with a condition associated with a weakened and enlarged aorta, such as
Marfan syndrome, bicuspid aortic valve or other rarer conditions associated with
weakening of the walls of the blood vessels. Rarely, aortic dissections are caused by
traumatic injury to the chest area, such as during motor vehicle accidents.
Aortic dissections are divided into two groups, depending on which part of the aorta is
affected:
 Type A. This more common and dangerous type involves a tear in the part of the
aorta where it exits the heart or a tear in the upper aorta (ascending aorta), which
may extend into the abdomen.
 Type B. This involves a tear in the lower aorta only (descending aorta), which
may also extend into the abdomen.
Risk factors
Risk factors for aortic dissection include:
 Uncontrolled high blood pressure (hypertension)

 Hardening of the arteries (atherosclerosis)
 Weakened and bulging artery (pre-existing aortic aneurysm)
 An aortic valve defect (bicuspid aortic valve)
 A narrowing of the aorta at birth (aortic coarctation)
Certain genetic diseases increase the risk of having an aortic dissection, including:
 Turner's syndrome. High blood pressure, heart problems and a number of other

health conditions may result from this disorder.
 Marfan syndrome. This is a condition in which connective tissue, which supports

various structures in the body, is weak. People with this disorder often have a
family history of aneurysms of the aorta and other blood vessels or family history
of aortic dissections.
 Other connective tissue disorders. This includes Ehlers-Danlos syndrome, a

group of connective tissue disorders characterized by skin that bruises or tears
easily, loose joints and fragile blood vessels and Loeys-Dietz syndrome, with
twisted arteries, especially in the neck.
 Inflammatory or infectious conditions. These may include giant cell arteritis,

which is an inflammation of the arteries, and syphilis, a sexually transmitted
infection.
Other potential risk factors include:
 Sex. Men have about double the incidence of aortic dissection.
 Age. The incidence of aortic dissection peaks in the 60s and 80s.
 Cocaine use. This drug may be a risk factor for aortic dissection because it
temporarily raises blood pressure.
 Pregnancy. Infrequently, aortic dissections occur in otherwise healthy women

during pregnancy.
 High-intensity weightlifting. This and other strenuous resistance training may

increase the risk of aortic dissection by increasing blood pressure during the
activity.
Complications
An aortic dissection can lead to:

 Death due to severe internal bleeding
 Organ damage, such as kidney failure or life-threatening intestinal damage
 Stroke
 Aortic valve damage (aortic regurgitation) or rupture into the lining around the
heart (cardiac tamponade)
Symptoms
Aortic dissection symptoms may be similar to those of other heart problems, such as a
heart attack. Typical signs and symptoms include:
 Sudden severe chest or upper back pain, often described as a tearing, ripping or
shearing sensation, that radiates to the neck or down the back
 Sudden severe abdominal pain
 Loss of consciousness
 Shortness of breath
 Sudden difficulty speaking, loss of vision, weakness or paralysis of one side of

your body, similar to those of a stroke
 Weak pulse in one arm or thigh compared with the other
 Leg pain
 Difficulty walking
 Leg paralysis
Diagnosis
Detecting an aortic dissection can be tricky because the symptoms are similar to those
of a variety of health problems. Doctors often suspect an aortic dissection if the
following signs and symptoms are present:
 Sudden tearing or ripping chest pain

 Widening of the aorta on chest X-ray
 Blood pressure difference between right and left arms
Although these signs and symptoms suggest aortic dissection, more-sensitive imaging
techniques are needed. Frequently used imaging procedures include:
 Transesophageal echocardiogram (TEE). This test uses high-pitched sound

waves to produce an image of the heart. A TEE is a special type of
echocardiogram in which an ultrasound probe is inserted through the esophagus.
The ultrasound probe is placed close to the heart and the aorta, providing a
clearer picture of your heart than would a regular echocardiogram.
 Computerized tomography (CT) scan. CT scanning generates X-rays to

produce cross-sectional images of the body. A CT of the chest is used to
diagnose an aortic dissection, possibly with an injected contrast liquid. Contrast
makes the heart, aorta and other blood vessels more visible on the CT pictures.
 Magnetic resonance angiogram (MRA). An MRI uses a magnetic field and

pulses of radio wave energy to make pictures of the body. An MRA uses this
technique to look at blood vessels.
Treatment
An aortic dissection is a medical emergency requiring immediate treatment. Therapy

may include surgery or medications, depending on the area of the aorta involved.
Type A aortic dissection
Treatment for type A aortic dissection may include:
 Surgery. Surgeons remove as much of the dissected aorta as possible, block the

entry of blood into the aortic wall and reconstruct the aorta with a synthetic tube
called a graft. If the aortic valve leaks as a result of the damaged aorta, it may be
replaced at the same time. The new valve is placed within the graft used to
reconstruct the aorta.
 Medications. Some medications, such as beta blockers and nitroprusside

(Nitropress), reduce heart rate and lower blood pressure, which can prevent the
aortic dissection from worsening. They may be given to people with type A aortic
dissection to stabilize blood pressure before surgery.
Type B aortic dissection

Treatment of type B aortic dissection may include:
 Medications. The same medications that are used to treat type A aortic

dissection may be used without surgery to treat type B aortic dissections.
 Surgery. The procedure is similar to that used to correct a type A aortic

dissection. Sometimes stents — small wire mesh tubes that act as a sort of
scaffolding — may be placed in the aorta to repair complicated type B aortic
dissections.
After treatment, you may need to take blood pressure lowering medication for life. In
addition, you may need follow-up CTs or MRIs periodically to monitor your condition.
Patient Monitoring
1. Continuously monitor arterial BP during acute phase to evaluate the patient’s

response to therapy.
2. Monitor hourly urine output because a drop in output may indicate renal artery
dissection or a decrease in arterial blood flow.
3. Continuously monitor ECG for dysrythmia formation, ST segment or T-wave

changes, suggesting coronary sequelae or a decrease in arterial blood flow.
Patient Assessment
1. Assess neurologic status to evaluate the course of dissection. Confusion or

changes in sensation and motor strength may indicate compromised cerebral
blood flow (CBF).
2. Auscultate for changes in heart sound and signs and symptoms of heart failure,
which may indicate that the dissection involves the aortic valve.
3. Compare BP and pulses in both arms and legs to determine differences.
Diagnostic Assessment
1. Review serial BUN and creatinine levels to evaluate renal function.
2. Review cardiac enzymes because a dissection involving coronary arteries may

result in Myocardial Infarction.
3. Review the ECG for patterns of ischemia, injury, and infarction.
4. Review results of radiology test such as CT scan, MRI, and aotogram.
Patient Management
1. Administer oxygen therapy as ordered.
2. Keep the patient on bed rest to prevent further dissection
3. Nitroprusside may be ordered to lower BP.
4. A ?-adrenergic blocking agent such as atenolol, esmolol, or propranolol may be

ordered to reduce stress on the aortic wall.
5. Anticipate surgical intervention.
Arterial Dissection
Arterial dissection refers to the abnormal, and usually abrupt, formation of a tear along
the inside wall of an artery. As the tear becomes larger, it forms a small pouch which is
called a “false lumen.” The blood that accumulates inside this false lumen can generate
blood clots or otherwise block blood flow, leading to a stroke. The carotid and vertebral
arteries can be damaged by neck injuries or even forceful neck movements.
Symptoms
Arterial dissection can cause a droopy eye lid with a small pupil on the same side,
headache, neck pain, or stroke symptoms.
Diagnosis
Typically, a magnetic resonance imaging (MRI) and MR Angiogram are done to look at
the brain and the blood vessels of the head and neck and visualize a tear within the wall
of an artery. Sometimes a catheter cerebral angiogram (also called arteriogram), which
is a special test in which a neuroradiologist injects dye into the blood vessels in the
brain and obtains images of the blood vessels, or computed tomography (CT)
angiogram may be performed.
Treatment
Treatment is usually with blood thinners such as warfarin or low molecular weight
heparin for 3 to 6 months followed by aspirin therapy.
W. Venous Thromboembolism
Venous thromboembolism (VTE) refers to a blood clot that starts in a vein. It is the third
leading vascular diagnosis after heart attack and stroke. There are two types:
 Deep vein thrombosis (DVT) Deep vein thrombosis is a clot in a deep vein,

usually in the leg. DVT sometimes affects the arm or other veins.
 Pulmonary embolism (PE) A pulmonary embolism occurs when a DVT clot

breaks free from a vein wall, travels to the lungs and then blocks some or all of
the blood supply. Blood clots originating in the thigh are more likely to break off
and travel to the lungs than blood clots in the lower leg or other parts of the body.
What causes venous thromboembolism?
The most common triggers for venous thromboembolism are surgery, cancer,
immobilization and hospitalization.
Deep vein thrombosis forms in the legs when something slows or changes the flow of
blood. In women, pregnancy and the use of hormones like oral contraceptives or
estrogen for menopause symptoms can also play a role.
Certain groups are at higher risk for clotting:
 Older people
 People who are obese or overweight
 People with cancer or other conditions (including autoimmune disorders such as

lupus)
 People whose blood is thicker than normal because their bone marrow produces
too many blood cells
Genetic causes of excessive blood clotting are also important. This happens when there
are changes in the genetic code of some proteins needed for clotting, or proteins that
work to dissolve blood clots in the body.
Venous thromboembolism is most common in adults 60 and older, but it can occur at
any age. VTE is rare in children, though.
The future of venous thromboembolism

Pulmonary embolism is the most common preventable cause of death among hospital
patients in the United States, and yet venous thromboembolism in general – and
pulmonary embolism in particular – is often overlooked as a major public health
problem.
The potential public health benefit of preventing VTE is considerable. Data from
randomized trials involving general surgical patients suggest that adequate prevention
measures in high-risk patients can prevent VTE in one of 10 patients – and save the life
of about one of 200 patients.
Symptoms
DVT mainly affects the large veins in the lower leg and thigh, almost always on one side
of the body at a time. The clot can block blood flow and cause:
 Leg pain or tenderness of the thigh or calf
 Leg swelling (edema)
 Skin that feels warm to the touch
 Reddish discoloration or red streaks
PE, or pulmonary embolism, can be fatal and occurs when the DVT breaks free from a
vein wall and blocks some or all of the blood supply to the lungs, causing:
 Unexplained shortness of breath
 Rapid breathing
 Chest pain anywhere under the rib cage (may be worse with deep breathing)
 Fast heart rate
 Light headedness or passing out
How is it diagnosed?
Blood work may be done initially, including a test called D-dimer, which detects clotting
activity.
For DVT: ultrasound of the leg is most often used
For PE: Computed tomography, or CT scan, or CAT scan is most often used.

Sometimes ventilation-perfusion lung scan is used. Both tests are able to see
intravenous dyes in the arteries of the lung, looking for blockages by clots.
Treatments for DVT and PE
DVT
Medication is used to prevent and treat DVT. Compression stockings (also called
graduated compression stockings) are sometimes recommended to prevent DVT and
relieve pain and swelling. These might need to be worn for 2 years or more after having
DVT. In severe cases, the clot might need to be removed surgically.
PE
Immediate medical attention is necessary to treat PE. In cases of severe, life-

threatening PE, there are medicines called thrombolytics that can dissolve the clot.
Other medicines, called anticoagulants, may be prescribed to prevent more clots from
forming. Some people may need to be on medication long-term to prevent future blood
clots.
Nursing Management
DE
Nursing management for deep vein thrombosis entails the following:
Nursing Assessment
Assessment of a patient with deep vein thrombosis include:

 Presenting signs and symptoms. If a patient presents with signs and
symptoms of DVT, carrt out an assessment of general medical history and a
physical examination to exclude other causes.
 Well’s diagnostic algorithm. Because of the unreliability of clinical features,

Well’s diagnostic algorithm has been validated whereby patients are classified as
having a high, intermediate, or low probability of developing DVT.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:
 Ineffective tissue perfusion related to interruption of venous blood flow.
 Impaired comfort related to vascular inflammation and irritation.
 Risk for impaired physical mobility related to discomfort and safety

precautions.
 Deficient knowledge regarding pathophysiology of condition related to lack of

information and misinterpretation.
Nursing Care Planning & Goals
The major goals for the patient include:
 Demonstrate increased perfusion as individually appropriate.
 Verbalize understanding of condition, therapy, regimen, side effects of

medications, and when to contact the healthcare provider.
 Engage in behaviors or lifestyle changes to increase level of ease.
 Verbalize sense of comfort or contentment.

 Maintain position of function and skin integrity as evidenced by absence of
contractures, footdrop, decubitus, and so forth.
 Maintain or increase strength and function of affected and/or compensatory body

part.
The major nursing interventions that the nurse should observe are:
 Provide comfort. Elevation of the affected extremity, graduated compression

stockings, warm application, and ambulation are adjuncts to the therapy that can
remove or reduce discomfort.
 Compression therapy. Graduated compression stockings reduce the caliber

of the superficial veins in the leg and increase flow in the deep veins; external
compression devices and wraps are short stretch elastic wraps that are
applied from the toes to the knees in a 50% spiral overlap; intermittent
pneumatic compression devices increase blood velocity beyond that produced
by the stockings.
 Positioning and exercise. When patient is on bed rest, the feet and lower legs
should be elevated periodically above the level of the heart, and active and
passive leg exercises should be performed to increase venous flow.
Evaluation
Expected patient outcomes are:
 Demonstrated increased perfusion as individually appropriate.
 Verbalized understanding of condition, therapy, regimen, side effects of

medications, and when to contact the healthcare provider.
 Engaged in behaviors or lifestyle changes to increase level of ease.

 Verbalized sense of comfort or contentment.
 Maintained position of function and skin integrity as evidenced by absence of

contractures, footdrop, decubitus, and so forth.
 Maintained or increased strength and function of affected and/or compensatory

body part.
X. Varicose Veins
Varicose veins are enlarged, swollen, and twisting veins, often appearing blue or dark
purple.
They happen when faulty valves in the veins allow blood to flow in the wrong direction
or to pool.
Varicose veins are large, swollen veins that often appear on the legs and feet. They
happen when the valves in the veins do not work properly, so the blood does not flow
effectively.
The veins rarely need treatment for health reasons, but if swelling, aching, and painful
legs result, and if there is considerable discomfort, treatment is available.
There are various options, including some home remedies.
In severe cases, a varicose vein may rupture, or develop into varicose ulcers on the
skin. These will require treatment.
Symptoms
Varicose veins may not cause any pain. Signs you may have varicose veins include:
 Veins that are dark purple or blue in color
 Veins that appear twisted and bulging; they are often like cords on your legs
When painful signs and symptoms occur, they may include:
 An achy or heavy feeling in your legs
 Burning, throbbing, muscle cramping and swelling in your lower legs
 Worsened pain after sitting or standing for a long time
 Itching around one or more of your veins
 Skin discoloration around a varicose vein
Spider veins are similar to varicose veins, but they're smaller. Spider veins are found
closer to the skin's surface and are often red or blue.
Spider veins occur on the legs, but can also be found on the face. They vary in size and
often look like a spider's web.
Causes
Weak or damaged valves can lead to varicose veins. Arteries carry blood from your
heart to the rest of your tissues, and veins return blood from the rest of your body to
your heart, so the blood can be recirculated. To return blood to your heart, the veins in
your legs must work against gravity.
Muscle contractions in your lower legs act as pumps, and elastic vein walls help blood
return to your heart. Tiny valves in your veins open as blood flows toward your heart
then close to stop blood from flowing backward. If these valves are weak or damaged,
blood can flow backward and pool in the vein, causing the veins to stretch or twist.
Risk factors
These factors increase your risk of developing varicose veins:
 Age. The risk of varicose veins increases with age. Aging causes wear and tear
on the valves in your veins that help regulate blood flow. Eventually, that wear
causes the valves to allow some blood to flow back into your veins where it
collects instead of flowing up to your heart.
 Sex. Women are more likely to develop the condition. Hormonal changes during
pregnancy, premenstruation or menopause may be a factor because female
hormones tend to relax vein walls. Hormone treatments, such as birth control
pills, may increase your risk of varicose veins.
 Pregnancy. During pregnancy, the volume of blood in your body increases. This
change supports the growing fetus, but also can produce an unfortunate side
effect — enlarged veins in your legs. Hormonal changes during pregnancy may
also play a role.
 Family history. If other family members had varicose veins, there's a greater
chance you will too.
 Obesity. Being overweight puts added pressure on your veins.
 Standing or sitting for long periods of time. Your blood doesn't flow as well if
you're in the same position for long periods.
Complications
Complications of varicose veins, although rare, can include:
 Ulcers. Painful ulcers may form on the skin near varicose veins, particularly near
the ankles. A discolored spot on the skin usually begins before an ulcer forms.
See your doctor immediately if you suspect you've developed an ulcer.
 Blood clots. Occasionally, veins deep within the legs become enlarged. In such
cases, the affected leg may become painful and swell. Any persistent leg pain or
swelling warrants medical attention because it may indicate a blood clot — a
condition known medically as thrombophlebitis.
 Bleeding. Occasionally, veins very close to the skin may burst. This usually
causes only minor bleeding. But any bleeding requires medical attention.
Prevention
There's no way to completely prevent varicose veins. But improving your circulation and
muscle tone may reduce your risk of developing varicose veins or getting additional
ones. The same measures you can take to treat the discomfort from varicose veins at
home can help prevent varicose veins, including:
 Exercising
 Watching your weight
 Eating a high-fiber, low-salt diet
 Avoiding high heels and tight hosiery
 Elevating your legs
 Changing your sitting or standing position regularly
Diagnosis
To diagnose varicose veins, your doctor will do a physical exam, including looking at
your legs while you're standing to check for swelling. Your doctor may also ask you to
describe any pain and aching in your legs.
You also may need an ultrasound test to see if the valves in your veins are functioning
normally or if there's any evidence of a blood clot. In this noninvasive test, a technician
runs a small hand-held device (transducer), about the size of a bar of soap, against your
skin over the area of your body being examined. The transducer transmits images of the
veins in your legs to a monitor, so a technician and your doctor can see them.
Treatment
Fortunately, treatment usually doesn't mean a hospital stay or a long, uncomfortable
recovery. Thanks to less invasive procedures, varicose veins can generally be treated
on an outpatient basis.
Ask your doctor if insurance will cover any of the cost of your treatment. If done for
purely cosmetic reasons, you'll likely have to pay for the treatment of varicose veins
yourself.
Self-care
Self-care — such as exercising, losing weight, not wearing tight clothes, elevating your
legs, and avoiding long periods of standing or sitting — can ease pain and prevent
varicose veins from getting worse.
Compression stockings
Wearing compression stockings all day is often the first approach to try before moving
on to other treatments. They steadily squeeze your legs, helping veins and leg muscles
move blood more efficiently. The amount of compression varies by type and brand.
You can buy compression stockings at most pharmacies and medical supply stores.
Prescription-strength stockings also are available, and are likely covered by insurance if
your varicose veins are causing symptoms.
Additional treatments for more-severe varicose veins
If you don't respond to self-care or compression stockings, or if your condition is more
severe, your doctor may suggest one of these varicose vein treatments:
 Sclerotherapy. In this procedure, your doctor injects small- and medium-sized
varicose veins with a solution or foam that scars and closes those veins. In a few
weeks, treated varicose veins should fade.
Although the same vein may need to be injected more than once, sclerotherapy is
effective if done correctly. Sclerotherapy doesn't require anesthesia and can be done in
your doctor's office.
 Foam sclerotherapy of large veins. Injection of a large vein with a foam
solution is also a possible treatment to close a vein and seal it.
 Laser treatment. Doctors are using new technology in laser treatments to close
off smaller varicose veins and spider veins. Laser treatment works by sending
strong bursts of light onto the vein, which makes the vein slowly fade and
disappear. No incisions or needles are used.
 Catheter-assisted procedures using radiofrequency or laser energy. In one
of these treatments, your doctor inserts a thin tube (catheter) into an enlarged
vein and heats the tip of the catheter using either radiofrequency or laser energy.
As the catheter is pulled out, the heat destroys the vein by causing it to collapse
and seal shut. This procedure is the preferred treatment for larger varicose veins.
 High ligation and vein stripping. This procedure involves tying off a vein before
it joins a deep vein and removing the vein through small incisions. This is an
outpatient procedure for most people. Removing the vein won't adversely affect
circulation in your leg because veins deeper in the leg take care of the larger
volumes of blood.
 Ambulatory phlebectomy (fluh-BEK-tuh-me). Your doctor removes smaller
varicose veins through a series of tiny skin punctures. Only the parts of your leg
that are being pricked are numbed in this outpatient procedure. Scarring is
generally minimal.
 Endoscopic vein surgery. You might need this operation only in an advanced
case involving leg ulcers if other techniques fail. Your surgeon uses a thin video
camera inserted in your leg to visualize and close varicose veins and then
removes the veins through small incisions. This procedure is performed on an
outpatient basis.
Varicose veins that develop during pregnancy generally improve without medical
treatment within three to 12 months after delivery.
Nursing management
1. Advise patient to elevate the legs.
2. Caution patient to avoid prolonged standing or sitting.
3. Provide high-fiber foods to prevent constipation.
4. Teach simple exercise to promote venous return.
5. Caution patient to avoid knee-length stockings and constrictive clothing.
6. Apply anti-embolic stockings as directed.
7. Avoid massage on the affected area.

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Claire Maurice G.

A. Coronary Artery Disease

Atherosclerosis develops gradually. Mild atherosclerosis usually doesn't have any

You usually won't have atherosclerosis symptoms until an artery is so narrowed or

Symptoms of moderate to severe atherosclerosis depend on which arteries are

 If you have atherosclerosis in your heart arteries, you may have symptoms,

 If you have atherosclerosis in the arteries leading to your brain, you may

 If you have atherosclerosis in the arteries leading to your kidneys, you

Atherosclerosis is a slow, progressive disease that may begin as early as childhood.

 High blood pressure

 High triglycerides, a type of fat (lipid) in your blood

 Smoking and other sources of tobacco

 Insulin resistance, obesity or diabetes

 Inflammation from diseases, such as arthritis, lupus or infections, or inflammation

 A weak or absent pulse below the narrowed area of your artery

 Decreased blood pressure in an affected limb

 Whooshing sounds (bruits) over your arteries, heard using a stethoscope

 Doppler ultrasound. Your doctor may use a special ultrasound device (Doppler

 Ankle-brachial index. This test can tell if you have atherosclerosis in the

 Cardiac catheterization and angiogram. This test can show if your coronary

 Other imaging tests. Your doctor may use ultrasound, a computerized

 Cholesterol medications. Aggressively lowering your low-density lipoprotein

 Anti-platelet medications. Your doctor may prescribe anti-platelet medications,

 Beta blocker medications. These medications are commonly used for coronary

 Angiotensin-converting enzyme (ACE) inhibitors. These medications may

 Calcium channel blockers. These medications lower blood pressure and are

 Water pills (diuretics). High blood pressure is a major risk factor for

 Other medications. Your doctor may suggest certain medications to control

Sometimes more aggressive treatment is needed to treat atherosclerosis. If you have

2. Endarterectomy. In some cases, fatty deposits must be surgically removed from

C. Acute Coronary Syndrome

Acute coronary syndrome is a term used to describe a range of conditions associated

 Chest pain (angina) or discomfort, often described as aching, pressure, tightness

 Shortness of breath (dyspnea)

 Sudden, heavy sweating (diaphoresis)

 Unusual or unexplained fatigue

 Feeling restless or apprehensive

If you have signs or symptoms associated with acute coronary syndrome, an

 Electrocardiogram (ECG). Electrodes attached to your skin measure the

 Coronary angiogram. This procedure uses X-ray imaging to see your heart's

 Echocardiogram. An echocardiogram uses sound waves, directed at your heart

 Computerized tomography (CT) angiogram. A CT angiogram uses a

The immediate goals of treatment for acute coronary syndrome are:

 Improve blood flow

 Restore heart function as quickly and as best as possible

 Thrombolytics (clot busters) help dissolve a blood clot that's blocking an artery.

 Nitroglycerin improves blood flow by temporarily widening blood vessels.

 Angiotensin-converting enzyme (ACE) inhibitors widen blood vessels and

 Angiotensin receptor blockers (ARBs) help control blood pressure and include

Surgery and other procedures

 Coronary bypass surgery. With this procedure, a surgeon takes a piece of

Acute hospital admission

Other elements of nursing care include ongoing management of IV cannulas, central

Discharge and secondary prevention in MI patients

 They have had an acute MI;

 Results of any investigations;

 How their condition will be managed.

 Understand the dosages and administration routes;

 Know not to discontinue treatment without medical advice.

Common heart attack signs and symptoms include:

 Pressure, tightness, pain, or a squeezing or aching sensation in your chest or

 Nausea, indigestion, heartburn or abdominal pain

 Lightheadedness or sudden dizziness

Heart attack symptoms vary