CARDIOVASCULAR SYSTEM  RISK FACTORS FOR CORONARY ARTERY DISEASES

 Preload  Non-Modifiable
 Is the force used to stretch the muscle fibers at end  Age
diastole, the heart’s maximum fill point.  Gender
 It is when the atrium is contracting, and the ventricles  Ethnicity
are filling with blood.  Family history essential hypertension)
 Afterload  Genetic predisposition
 Is the force that the heart must pump against a high  Modifiable
pressure to push blood out of the left ventricle.  Elevated serum lipids
 Diastole (Preload)  Red meats are high in urea; therefore, this should
 Atrioventricular valves are open. be avoided.
 Systole (Afterload)  If you have plenty of urea, you are increasing
 Semilunar valves are open. the workload of your kidneys.
 The QRS or the Ventricular Depolarization happens.  Chicken, and fish are the one that should be
 The right ventricle is pushing deoxygenated blood taken.
against the pulmonic valves. At the same time, the left  Hypertension
ventricle is pushing oxygenated blood against the  Hypertension is the second reason for having
aortic valve. CAD.
HEART’S DISEASES  Therefore, advise the patient to:
 Coronary artery disease etiology and pathophysiology  Stop smoking.
 Atherosclerosis is the major cause of CAD  Stop eating high sodium.
 The blood vessels are obstructed with lipids, but  Stop drinking alcoholic drinks, caffeinated
the flow of blood is still good since it is still a drinks, and carbonated drinks.
partial obstruction.  Avoid stressors.
 It will take years for the lipids to become larger.  Hypertensive patient has a blood pressure of
 The lipids accumulate inside the artery. higher than 140/90.
 Left coronary artery is more prone because it  The Lumen in hypertensive patients becomes
is smaller than the right coronary artery. smaller.
 Lipids can also accumulate in the lower  Which causes the intimal layer of the artery to
extremities. become smaller also.
 Peripheral arterial disorders o If the intimal layer of the artery becomes
 This partial obstruction in the vessels causes less smaller, the production of Nitric Oxide
blood going to the brain which can lead to CVA. (NO) becomes less.
 Cerebrovascular accident  Nitric Oxide functions to dilate the
 Anteriorly – Carotid Artery vessels.
 Posteriorly – Vertebral Artery  The W C, R C, and platelets are attracted to the
 COLLATERAL CIRCULATION lipids which causes the lipids to become larger,
 When the lumens are constricted it causes high blood and if the lipids become larger in size it destroys
pressure; therefore, the amount of blood flow is the intimal layer causing the less production of NO
minimal.  As we age, we lose 85% of our ability to make
 This causes the arteries to make new blood nitric oxide.
vessels. o Therefore, advise patient to increase food
 Good collateral circulation is good. intake high in NO, such as: Arugula,
 Not all person has collateral circulation, so if you have Spinach, Red eets, Garlic, Cilantro-
this you are a Lucky person. Coriander, Lettuce, asil, Citrus Fruits,
 Not need for PTCA Watermelon, Grapefruit, and dark
 However, this collateral circulation can rupture, since chocolates.
it is still new. ut this becomes stronger a year after.  However, Grapefruit are
contraindicated to some drugs – it
lessen the potency of the drugs.

 The main reason why people is hypertensive is it

because of non-compliance with medications.
 Diabetes (#1 reason)
 Diabetes is the number one reason for having
CAD.
 2 TYPES OF HYPERTENSIONS
 PRIMARY OR ESSENTIAL HYPERTENSION / IDIOPATHIC
HYPERTENSION
 This type of hypertension is Genetic.
 90% of hypertensive patients have this type of
hypertension.
 Causes:
 This is due to Hyperactivity of the Sympathetic
Nervous System.
 This is also due to Hyperactivity of the Renin-
Angiotensin-Aldosterone-System
 This is also cause by Endothelial Dysfunction.
 Given scenario:
 For example, the patient’s blood pressure is
160/100, meaning to say the heart pushes against
a high pressure which causes the heart muscles to
become larger; and if the muscles become larger,
the muscles will demand more blood. However,
the coronary artery will not increase the amount
of blood, instead it will give the same exact
amount; therefore, the muscle contractility will
become less causing the blood to accumulate in
the left ventricle because of less elasticity which
can result to left ventricular hypertrophy.
 If there is left ventricular hypertrophy, the
apex will be change in position to 6th ICS LAAL
 SECONDARY HYPERTENSION
 The secondary hypertension is caused by direct result
of another problem or condition. For example:
 Pehocromocytoma
 Hyperthyroidism
 Neurologic Disorders that Increase ICP
 Stroke
 In stroke there is a clotted blood. This clotted
blood in our brain can increase the
intracranial pressure (ICP).
 Some clotted blood maybe caused by
aneurysm.
 Aneurysm can also be caused by uncontrolled
hypertension.
MEDICAL MANAGEMENT
 DIURETICS
 Diuretics should be given in the morning, and not
before bedtime.
 ecause it can disturb the sleeping pattern.
 Advise patients to increase potassium intake.
 ecause potassium goes along with the urine;
therefore, we need to advise the patient to
increase potassium intake to prevent risk for
hypokalemia.
 If the patient is taking diuretics always take the
weight.
 Take it in the morning before breakfast.
 Let the patient void first before taking the weight.
 Use the same weighing scale.
 This is to monitor whether the patient is gaining
or losing weight.
 Diuretics is the First-line therapy.
 Diuretics helps to eliminate excess salt and water.
 Example of diuretics:
 Furosemide -> lasix, Pharmix
 Hydrochlorothiazide —> betazide, diuzid (mild
diuretics)
 ACE-INHI ITORS
 Angiotensin-Converting-Enzyme Inhibitors
 It prevents the angiotensin 1 to be converted to
angiotensin 2
 The common adverse effect of this drug is Irritating
Cough.
 This is commonly given to patients who have an
enlarged heart, and for heart failure.
 ETA- LOCKERS
 It decreases heart rate (- chronotropic) and decreases
contractility (- inotropic).
 ecause it decreases the workload of the heart, it
protects the heart from ischemia and hypertrophy.
 It ends with OLOL.
 Atenolol – Cardioten
 Metoprolol – etaloc
 eta- lockers is also given to patients with Thyroid
problem.
 ecause in hyperthyroidism, the thyroid gland is
giving out an extensive amount of T3
(Triiodothyronine) and T4 (Thyroxine); these
hormones are responsible for metabolism of the
body, however, if it's giving out a huge amount
then the metabolism of the patient will be
accelerated, such as, very fast peristalsis,
increased respiratory rate and etc.
 This lessens the contractility of the heart.
 However, this is not that strong for hypertension.
 ALPHA- LOCKERS
 This causes vasodilation of the peripheral vessels;
thus, reduces blood pressure.
 For example: Doxacin
 Side effects of this drug are Dizziness, bradycardia,
hypotension, fatigue.
 Therefore, instruct the patient not to stand up
quickly in bed.
 Instruct the patient to do these steps:
 Sit in bed.
 Transfer to chair.
 Then stand up.
 AR S
 People who feel dizzy
 This is a non-irritating cough drug.
 If Ace-Inhibitors disturbs the sleeping pattern of the
patient, AR S are being administered.
 Same mechanism with Ace-Inhibitors, but here,
angiotensin II receptor is the one that is being
blocked.
 CALCIUM CHANNEL LOCKERS
 It usually ends with PINE.
 Amlodipine
 Nifedipine - Adalat
 It will block the calcium so that the heart muscles will
not contract forcefully.
 Since, the muscles contracts because of the
presence of calcium; therefore, with calcium
channel blockers it will help the heart to not
contract forcefully.
 Some calcium channel blockers are given sublingually.
 Prick it, then put it under the tongue because
there is plenty of blood vessels, and medicines are
reabsorbed quickly through blood vessels.
COMPLICATIONS OF HYPERTENSION
 Here are some complications that can be developed due
to hypertension.
 Cerebral Aneurysm
 Pre-Renal Failure
 lurred Vision
 The vessels in the eyes will dilate, causing blurred
vision.
 Left-ventricular hypertrophy.
LIFESTYLE MODIFICATION
 Losing excess weight
 20lbs you lose, you drop your systolic P —> 5-20
points.
 Exercise regularly
 risk walking for 30 mins drops your systolic P by 4-
9 points.
 It increases the good cholesterol (HDL).
 HDL —> when HDL is high; it is produced by the
liver, and this will remove the bad cholesterol
(LDL).
 It be released by the liver and it will go to the
arteries to get the LDL to bring it back to the
liver
 Statins are being given.
 Statins increases the good cholesterol.
 Exercise will increase the NO
 It prevents the platelets from aggregating
 Instruct the patient to Limit sodium intake.
 Eating more than 2,400mg a day (3/4 of tsp) of
sodium brings down your systolic pressure by 2-8
points.
ANGINA – CHEST PAIN
 Anaerobic metabolism
 Heart is still working even though there’s not enough
oxygen. Lack of oxygen causes the production of lactic
acid by the injured tissue, and that lactic acid will
irritate the nerve endings in the heart causing angina.
 The chest pain may radiate because of the presence
of nerve endings.
 PATHOPHYSIOLOGY
 Ischemia
 Less blood is going to the heart, and it is because
of atherosclerosis or partial obstruction of the
blood vessels.
 Heart is the pumping organ of the body.
 If there’s not enough blood going to the heart, the
heart will not contract 60-100 times per minute;
therefore, there will be less cardiac output,
resulting in less blood flow going to the different
organs of the body.
 Less blood going to the rain can cause
dizziness.
 Less blood going to the ody can cause
fatigue.
 4 E’s: Exertion, Exposure to Cold, Eating Heavy, and
Emotional Stress.
 Physical Exertion
 Moving a lot can increase the demand for oxygen
and nutrients because there is an increase in
metabolism of the cells in the muscles; however,
the coronary artery is obstructed; therefore, less
blood is received by the heart causing a less
cardiac output.
 Less cardiac output can cause you to not
be able to finish your task.
 Exposure to cold
 ecause when exposed to cold, the blood vessels
are constricted, which causes the heart to push
blood against a high pressure.
 The more the coronary artery will constrict, the
more you will have angina.
 Eating heavy meals
 The heart will give the stomach more blood for
digestion, causing less blood going to the brain.
 The heart has to work harder to supply stomach
with blood for food digestion; however, when the
coronary artery is partially obstructed, it is
impossible for the heart to pump enough blood
which leads to angina.
 Advised patient to eat small amount of food
because there will be less blood supply needed by
the stomach; therefore, the heart is able to supply
it because it is only in a minimal amount.
 Emotional Stress
 ecause of the release of catecholamines; less
cardiac output; less oxygenated blood going to
the heart muscles which causes the heart to
become weaker which leads to angina.
CLINICAL MANIFESTATIONS
 Patient with diabetes will not have severe pain
because in diabetes there is less insulin —> the
glucose needs insulin to enter the cell however if
there’s not enough insulin the glucose will go to the
blood; the blood will become viscous causing less
blood flow —> can lead to increased pressure; the
 nerve endings will be destroyed; if destroyed there
will be no pain. (peripheral neuropathy)
 Pain radiates
 Lightheadedness —> because less blood is going to
the brain
 Pallor – because less blood is going to the skin
 Necrosis
 Decreasing the supply in the myocardium.
 Prolonged ischemia —> can cause tissue damage —>
myocardial injury
 ecause of not adhering to the medications
 Myocardial Infarction —> the coronary artery died.
3 steps to kill the heart
 Myocardial ischemia
 Myocardial Injury
 Myocardial Infarction.
Types of Angina
1. Variant angina —> no lipids, only spasm
2. Prinzmetal angina —> occurs when patient is at rest
3. Unstable angina —> Severe pain, not relieved by rest;
coronary artery is obstructed for about 90%
4. Stable angina —> 50% of the coronary artery is
obstructed, can be relieved by rest.
5. If the obstruction is 100%, complete obstruction —>
myocardial infarction
NON-ST ELEVATION MI
 Elevation in ST – injury/infarction
 Depression in ST – ischemia
 NON-ST elevation MI
 Less damage to the myocardium
 Elevated cardiac biomarkers
 Enzymes released if the heart is injured —>
troponin I, T, creatinine kinase (CK-M )
 ST elevated; t-wave inverted – myocardial injury
 Q deep and wide, ST elevation, inverted T-Wave –
myocardial infarction
MEDICAL MANAGEMENT
 Oxygen —> because if you don’t give oxygen it will
further damage the heart
 To lesson the damage area in the heart
 To relieve patient from chest pain
 The injured tissue will not produce lactic acid
 Nitroglycerin
 Transdermal patch can be placed in different parts of
the body (less hair)
 It should be placed in the chest (anywhere in the
chest)
 Do not apply in the same area; because it can lead to
contact dermatitis
 If there is headache, transfer it away from the heart;
the same effect
 You can apply it to shoulder or to the abdomen.
 eta-Adrenergic locking Agents
 OLOL
 It will reduce the heart rate (slow down)
 Not given to patient with atrioventricular block
 AV block: there is a blockage in right and left
bundle of his; the impulse cannot be received
therefore the ventricles will not contract —>
decreased output.
 It will worsen the situation.
 Aspirin
 If the patient is taking aspirin it can cause bleeding
and GI irritation,
 H2 lockers and PPI will decrease gastric juices so that
you will not experience stomach pain, and bleeding
 Take it will full stomach —> if there’s still GI irritation
report to the doctor.
 PTCA
 If the obstruction is 70%
 There is a catheter (cardiac catheterization to know
what artery is obstructed)
 Diagnostic test
 Femoral artery
 They will inject a dye but this dye can accumulate
in the kidneys which can destroy the kidneys
 They will insert the stent, then inflate to push the fats
on the side of the lumen —> this it to improve the flow
of blood however the fats will stay there forever.
 Reason why the stent has many butas; so that the
tissue will grow to hold the stent there forever.
 The reason why doctors are giving aspirin is that
because there is a foreign body which is a stent;
this is used to prevent further clotted blood.
 Coronary ypass Surgery
 If the number of coronary arteries obstructed is more
than 4
PATIENT TEACHINGS – NO SURGERY
 Alternate activity with periods of rest
 Moderate activity level as needed
 Stop smoking
 ecause you get easily tired
 Lesson the sodium intake
 This is the number one cause of hypertension
 Avoid activity after eating
 The heart is busy giving blood to the stomach;
however, if you do any activities it will just add
workload to the heart because the muscles you used
in that activity also needs blood to work. —> heart
attack
 Restrict intake of caffeine/carbonated drinks
 This increase HR —> further decreases cardiac output
 Avoid exposure to cold
 Dress in warm clothing
 Strong emotions – better resign to the job
 Participate in regular exercise program
 Advise the patient to stop all the activities
 This will just add workload to the heart leading to
heart attack
 Immediately take nitroglycerin
POST OPERATIVE CARE
  Patient will be placed in a supine position  The blood in the upper and lower extremities goes
 Monitor closely for S/S of myocardial infarction inside the lungs; causing pulmonary congestion —>
 If uncomplicated, ED REST for 4-6 hours which causes difficulty of breathing, and it is relieved
 Do not flex the legs, if you kept on moving the leg the by standing up.
thrombus may become embolus.  Sudden awakening for 1-2 hours of sleep with
 Can elevate the head of the patient dyspnea; and when the patient stands up to get more
 Applying pressure because bleeding can be a air, and when they stand the fluids goes down because
complication after of gravity and now the patient can breathe normally.
 Place at the dressing so that patient will not bleed ORTHOPNEA
 After 6-8 hours of bedrest patient can now stand and  The patient cannot do supine position (because there
ambulate can be dyspnea)
 Semi-fowler, sitting position, dangled the legs, and  Place 2-3 pillows in the head and the shoulders to
then upright position. elevate the head part
 2nd post-op allowed to ambulate already  2 pillow orthopnea
HEALTH TEACHINGS  4 pillow orthopnea (if 4 pillow are used)
 Avoid vigorous use of abdominal muscles  ecause the patient cannot breath in a supine
 Coughing, sneezing, moving the bowels, lifting items position
 Can dislodge the thrombus HEMOPTYSIS
 Can cause bleeding  Coughing out of blood
 Proper hydration  High pressure in the pulmonary veins can rupture and
can cause hemoptysis
FATIGUE
 ecause of less blood
PALPITATIONS
 ecause the heart is contracting forcefully to give an
enough cardiac output
VALVULAR DISORDERS DRUG TREATMENT
Stenosis —> tightening of the lumen/narrowing  Anticoagulant
Regurgitation —> back flow: when the blood will be delivered  leeding
by the ventricles, it goes back. 
Insufficiency —> the valves does not close completely.  Atrial fibrillation
 Heart beats for 400-600 bpm/min
MITRAL REGURGITATION  Which can make the blood viscous resulting to
 Chordae Tendineae thrombus and that can become embolus which can
 Attached to the papillary muscles; it holds the valves travel to the brain leading to CVA
MITRAL STENOSIS  Cardioversion —> is the last resort for atrial
 If there is mitral stenosis: there will be accumulation fibrillation.
of blood in the atrium; the atrium will become  The patient is near death.
enlarged (increasing the pre-load)  eta-blockers, digoxin, calcium channel blockers.
 There will be a back flow of blood in the lungs leading COMMISSUROTOMY
to pulmonary congestion —> pressure in the lungs are  The doctors will insert their fingers or a small
high instrument to expand the mitral valve.
 The right ventricle is pushing against the high pressure VALVULOPLASTY
in the lungs (increasing the workload; which increases  It will widen the mitral valve because of the balloon
the demand for blood because it becomes enlarged; inserted in the right atrium.
however, the coronary artery will just give the same WARFARIN
amount of blood)  No contact sports
 Less blood —> less cardiac output  Easy to bleed
 Fatigue  Soft bristles toothbrush
 Dyspnea  Remove clutters
 Increasing pre-load in the left atrium  Patient may be prone to risk for fall
CLINICAL MANIFESTATIONS  Apply pressure to stop bleeding
 Dry cough and wheezing (clinical manifestations)
PROXYSMAL NOCTURAL DYSPNEA AORTIC STENOSIS
 The fluids or the blood entered already the alveoli  The aortic valves becomes narrowed
 Most common cardiac valve dysfunction
  Usually asymptomatic  This can attack both side of the heart but the left
 Heart murmur is the most common early sign side is the most common
 Most common in males  Coronary artery disease
 Left ventricle will enlarged first if there is aortic  Cardiomyopathy
stenosis.  Congenital
 Sudden cardiac death —> if not treated 
 Angina, Syncope, Exertional Dyspnea —> 3 cardinal
symptoms
 Syncope (fainting)
 Less blood going to the brain which can result to
dizziness —> fainting (syncope)
 Angina (Chest pain)
 Since less blood is received by the heart;
therefore, there will be anaerobic metabolism,
which causes the production of lactic acid. And
that lactic acid will irritate the nerve endings
causing chest pain
 Dyspnea
 Only small amount of blood is being sent to the
aorta, the blood is accumulating in the left
ventricles.

 If there is aortic stenosis, the blood will flow back

to the left atrium, then going back to the lungs the
blood in the lungs can no longer enter the left
atrium causing pulmonary congestion.

MITRAL REGURGITATION
 There is a backflow
 Once, the atrium filled the ventricles with blood, the
mitral valves do not close completely (insufficiency) —
>some blood pushes at the ascending aorta, but some
blood went back to the left atrium because of
insufficiency.
 Left atrium will become enlarged
 If it is enlarged, there can be a backflow in the
pulmonary veins causing pulmonary congestion
 Less blood ejected from the left ventricle
 Less cardiac output
 Easy fatiguability
 Dizziness
 Etiology
 Rheumatic fever
 Affects children in crowded places
 Cause streptococci
 Sore throat is the most common S/S
 The body will compensate by producing
antibodies to fight with streptococci.
 There will be a growth of antigen antibody
complexes.
 ecause of frequent exposure to the bacteria
 After 3 years, the AAC will target the heart; it
will destroy the valves.
 Rheumatic heart disease (adult)
 The trend now for children is tonsillectomy.
 To avoid the growth of AAC