CARDIOLOGY

Coronary Artery Disease (CAD) / Atherosclerosis Management of Atherosclerosis

- Number 1 Predisposing disorder of cardio system o Lifestyle Modifications
Heart – pumps blood – O2 – Necessary for cellular o Best Drug: Anti-hyperlipidemics (statin)
processes MOA: Increases HDl, Decreases LDL
WHAT: Nursing Consideration:
Athero – fat plaques at coronary artery  Give at bedtime (more cholesterol at HS)
Sclerosis – hardening & narrowing of coronary artery  WOF Muscle weakness: Early sign of
Consequence: Rhabdomyolysis – destruction of skeletal
Decrease blood flow to heart -> Decrease O2 to heart muscle -> microclots -> dislodged at nephron –
(Myocardial Ischemia) -> Anaerobic Respiration -> Glomerular (Tiny filters of nephron) -> FR will
Lactic acid (Toxic to tissue) decrease -> Increase waste and fluids – Renal
a. Injury -> Inflammation -> Pain/Dolor -> Angina failure
Pectoris -> Reversible o Beta blockers (OLOL)
b. Prolonged Injury -> Necrosis -> Myocardial MOA: block beta-adrenergic/sympathetic receptor
Infarction -> Irreversible Effect: Decrease HR/BP -> Decrease workload of
WHY: Loss of Elasticity of Blood vessel heart -> Decrease O2 demand -> Prevent
RISK FACTORS myocardial ischemia
Non-Modifiable Modifiable Side Effect: Bronchoconstriction (Contraindicated
 Elderly (Worn out blood  High Fat Diet to Asthma patients)
vessel  Sedentary Lifestyle o Calcium channel blockers (Amlodipine)
 Gender: Male (Vices) (Active: 30 mins/day)
Female (Higher Fat %)  Smoking
MOA: blocks CA entry to heart -> Decrease
 Family History Early: Vasodilation workload of heart
 Race (African American) Late: Vasoconstriction Peripheral vasodilator -> Decrease BP – Decrease
(Caucasian)  Stress workload of heart
 Obesity Nursing Consideration: WOF Orthostatic
 Hypertension hypotension -> drop in BP (10mmHg) with respect
 Diabetes to change in position -> Dizziness -> Risk for fall
Management: Change position slowly, Dangle legs
Signs and Symptoms: Asymptomatic (Silent Killer) at bedside/sit on bedside
Screening Test: Lipid Profile/Total Blood Cholesterol
- 12 hours fasting, Water allowed Graphy
- Normal: <200mg/dl What: Indirect visualization with the use of dye or
o HDL (High Density Lipoprotein): GOOD contrast/medium.
- Normal: >60mg/dl Nursing Consideration for graphy
o LDL (Low Density Lipoprotein): BAD  Seafood Allergy
- Normal: <100mg/dl  Renal clearance (BUN, Creatinine)
o Triglycerides: BAD  Side Effect (Metallic taste in mouth, Warm
- Normal: Male 40-160, Female 35-135mg/dl sensation upon injection)
Confirmatory Test: Angiography (PTCA)  WOF DM Type 2: Hold Metformin (OHA) for 48
What: Indirect visualization of coronary circulation hours before and after
Goal: locate clots and narrowing (for repair/plasty)
Where: Radial artery -> Femoral -> Brachial Acute Coronary Syndrome (ACS)
Nursing Consideration: Before What: Myocardial Ischemia
 Check Doctor’s order: Consent is secured by MD Why: Atherosclerosis (CAD)
 Establish baseline v/s & status of pulse (surgical Clinical Sign: Levine Sign (Chest clinching)
site) Assess pulse grade, color and temperature of Screening Test: ECG -> ST segment elevation
extremity -> If changes are present (Decrease blood
flow to site)  Angina Pectoris
 Dye consideration: Seafood allergy, Renal What: Chest pain
clearance, Side effects (Metallic taste, warm Why: Myocardial Ischemia -> Reversible
sensation), Hold OHA for 48 hours 3 E’s of Angina Pectoris (Predisposing Activities)
 Shave both groin -> Delegate to NA o Excessive Activity – blood directed to muscle
Nursing Consideration: After o Emotional Stress – blood directed to brain
 Check v/s and status of pulses o Excessive Eating – blood directed to GIT
 WOF: Bleeding -> If present: Apply pressure, sand Screening Test: ECG
bags, TR band Confirmatory test: Angiography
 WOF: Hematoma/Bruising: Normal - <4cm Treatment:
 Increase fluid intake o Promote rest – to prioritize blood flow to heart
 CARDIOLOGY
o Oxygen – High flow is allowed (>2L/min, CI to COPD o Stool Softeners – prevent straining Ex. Docusate
and Premature babies) Angina Pectoris Myocardial Infarction
o Best Drug: Nitroglycerin -> Vasodilator  Ischemia - reversible  Necrosis - irreversible
 Coronary Vasodilator: Increase O2 -> prevents  Stabbing and dull pain  Crushing/excruciating
Myocardial Ischemia -> prevents lactic acid pain
 Peripheral Vasodilator: Decrease BP -> Decrease  <15 minutes  >15 minutes
workload of heart -> Decrease O2 demand ->  Left- sided radiation  Left-sided radiation
Decrease Myocardial Ischemia (jaw, neck, shoulder, (jaw, neck, shoulder,
Side Effect: arm, and back) arm, and back)
Headache (Cephalgia) – Give Paracetamol  Main management:  Main management:
Dizziness & Blurry vision – Avoid driving. drinking Nitroglycerin, Oxygen, MONATAS
alcohol Rest (NOR)

Forms of Nitroglycerin Abdominal Aortic Aneurysm

 Sublingual What: Outpouching of the aorta
- Highly vascularized; most common Why: Loss of elasticity of aorta due to CAD
- Fast absorption (No 1st pass: Don’t pass liver) Risk Factors:
- Rule: Max 3 tabs, 5 mins interval o Males
- Photosensitive: Stored in Dark/Amber colored o Obese
container (Store up to maximum 6 months) o Sedentary Lifestyle
 Patch
o African American
- Transdermal; Sustained, Slow release
o Vices
- Rule: Rotate sites (Prevents overdose)
Consequence: Rupture of aneurysm Sx. Flank pain, Leg
- Ideally: Anterior chest; non-hairy
pain – Massive bleeding – Shock
 Intravenous
Diagnostic Test: Abdominal UTZ / Doppler / Duplex
- Fastest route; Fastest to cause hypotension
Clinical/Hallmark Sign:
- Required: Infusion pump for accurate
 Pulsating abdominal mask due to high pressure
administration
aorta (Do not palpate)
 Systolic bruit (Whooshing sound) Low pitch – bell
 Myocardial Infarction
 Subjective sensation of heart beating at abdomen
What: Chest pain
Management:
Why: Myocardial Necrosis -> Irreversible
o Type A (Ascending Aorta) With chest pain –
2 Types: STEMI and NSTEMI
increased risk for rupture
3 I’s of Myocardial Infarction
 Stat Surgical clipping
o Ischemia – Injury - Infarction
o Type B (Descending Aorta) Without chest pain –
Screening Test: ECG (ST-segment elevation)
Decreased risk for rupture
Confirmatory test: Cardiac enzyme
 Goal: Decrease size of aneurysm (Lifestyle
Troponin I CKMB
Most reliable and sensitive test Most specific and indicative
Modifications
for MI test for MI  Manage HTN, DM
Increases after 4-6 hours Increases after 6-12 hours of MI  UTZ every 3-6 months
Normal after 2-3 weeks (Good) Normal after 24-48 hours (Bad)  Surgical clipping once aneurysm becomes small
Normal: <35 Normal: Male: 2-6, Female: 2-5

Management: MONATAS
o Morphine (Opioid Analgesic)
- Depressant/Sedatives - Decreases BP & HR:
Decreases workload -> Decreases O2 demand -
prevents MI
- WOF Digoxin Toxicity (Respiratory Depression
– Sedation – coma
- Antidote: Narcan (Naloxone/Naltrexone)
o Oxygen
o Nitroglycerin (Vasodilator)
o Aspirin – prevents clotting (MI – weaker heart –
blood stasis – clots) WOF Bleeding
o Thrombolytics - dissolves clot (USA)
o Anti-coagulant (Heparin, Warfarin, Enoxaparin)
Cardiac Tamponade
What: Increased pressure in the heart
Why: Increased pericardial fluid (third space)
Normal Pericardial fluid: Up to 50 ml
Consequence: Decrease contractility of the heart ->
Incomplete blood emptying - blood stasis – Congestion
Compensatory Mechanism: Increased HR → increased
workload of the heart → increase oxygen demand →
myocardial ischemia → ACS → injury → heart failure
Predisposing Factor: Pericarditis due to Infection or
Trauma
Diagnostic Test: 2D echo/CXR -> Cardiomegaly
Clinical Sign: Beck’s Triad
 CARDIOLOGY
 Distended Jugular Vein (Normal JVP: 3cm above
Increased BP, HR, decreased contractility 
the sternal angle) Pulsation is normal when
patient is supine, Disappears when sits up.
High CVP – Distended, Low CVP - Dehydrated
 Muffled heart sound (Due to pressure in heart ->
problems in contraction) Management: 4D
 Hypotension but Increase CVP (Decreased o Best Drug: Digoxin (Digitalis)
contractility -> Decreased Cardiac Output -> MOA:
Congested -> Increase Pressure) Positive Inotropic – Increase contractility
Normal CVP: 2-6 mmHg (measured from RA) Negative Chronotropic – Decreased HR -> Decrease
 ↑CVP = fluid volume excess (more blood going workload of heart -> Decrease O2 demand –
to the heart) prevents myocardial ischemia
 ↓CVP = fluid volume deficit (less blood going Nursing Consideration:
back to the heart)  Check Apical HR for 1 full minute (hold <60)
Management:  WOF Hypokalemia (Increases chance of Digitalis
o Mild Symptoms: Corticosteroids (Decrease Toxicity)
inflammation -> Decrease pericardial fluid -> Management: Oral KCl (Potassium rich
decrease pressure in the heart. foods), KCL incorporation (not more than 10-
o Position: Orthopneic or Semi-fowler’s 20 meqs/hr)
o Pericardiocentesis: Direct removal of fluid at 3 rd  WOF Digitalis Toxicity (Normal: 0.8-2.0ng/ml)
space Antidote: Digibind/Digifab
 Orient: Stay still, Exhale and hold (more S/Sx of Digitalis Toxicity: VANDAB
comfortable), Pain meds given before Visual Disturbances
(anticipatory/abortive therapy) Anorexia
Nausea and Vomiting
Congestive Heart Failure Diarrhea, Diaphoresis
What: Excessive blood in coronary circulation Abdominal Distention
Why: Decreased contractility (Cardiac tamponade, Bradycardia (Negative chronotropic) (<60)
Mediastinal shifting) Fluid volume excess (Renal failure) o Diuretics: Increase Urine output – Decrease
Consequence: Congestion -> Compensate -> Increase congestion
HR -> Increase workload of heart -> Increase O2 - Given in morning (will disrupt sleep if night)
demand -> ACS -> Heart failure Types of Diuretics:
Screening Test: 2D echo/CXR -> Cardiomegaly  K-wasting (Hypokalemia)
Confirmatory Test: Beta/Brain Natriuretic Peptide o Loop Diuretics: Furosemide/Lasix
(BNP) o Thiazide: Microzide/Hydrochlorothiazide
 Specific protein released by ventricles in response  K-sparing (Hyperkalemia): Spinorolactone
to congestion o Dilators: Decreases BP
 Normal: <100 picograms/ml Ex. Beta Blockers, CA channel blocker
 Best drug for elevated BNP: Digoxin ACE (Angiotensin converting enzyme) Ex. Captopril,
Enalapril, Lisinorpil
LEFT-SIDED HEART RIGHT-SIDED HEART
 MOA: blocks conversion of Angiotensin I to
FAILURE FAILURE Angiotensin II -> prevent formation of
aldosterone (Water and Sodium Retention)
 Pulmonary - Oxygen  Systemic – Edema  Effect: Decrease Aldosterone levels -> promote
 Dyspnea (evident at  JVD, Increased CVP  Na and Sodium removal
night) Paroxysmal  Weight gain: Best  Adverse Effect: Angioedema (Swelling of face
Nocturnal Dyspnea indicator of fluid volume and neck) -> airway problem (1st priority)
 Orthopnea (measured status (Measured during  Paradoxical/Opposite Effect: Hypertension (2nd)
via pillows) N: 0-1 the day, before breakfast)
 Consistent Dry cough – Toxicity to ACE related
 Rales/crackles  Pitting, non-pitting,
(Pulmonary congestion) Ascites, Anasarca, Facial
to increased bradykinin levels at lungs (3rd)
 Pulmonary edema  edema, Cerebral edema  o Diet: Low Sodium Diet
 Frothy pink sputum   Hepatosplenomegaly –  Avoid seasoning/condiments, preservatives,
 Altered LOC Increase RBC death processed, canned, instant, boxed foods
 Cough    (Responsible for RBC  Limit Fluid intake (1-1.5L/day)
 Decreased cardiac production  Complete Bed rest without bathroom
output -> Oliguria  Splenomegaly – privileges
Graveyard of RBC
 Stool Softeners to avoid straining (stresses
heart)
CARDIOLOGY