Cardiovascular Alterations

Chapter 13
Cardiovascular Alterations
Copyright © 2017 Elsevier Inc. All rights reserved.

Normal Structure
 Heart
 Mediastinal space
 Covered by pericardium
 Composed of three layers
 Epicardium
 Myocardium
 Endocardium
Copyright © 2017 Elsevier Inc. All rights reserved. 2

Normal Structure (Cont.)
 Right side is low pressure

 Left side is high pressure
 Flow of blood
 Cardiac valves

Normal Structure (Con’t)
Figure 13-1. Location of the heart. A. Heart in mediastinum showing relationship to lungs and other anterior thoracic structures. B. Anterior view
of isolated heart and lungs. Portions of the parietal pleura and pericardium have been removed. C. Detail of heart resting on diaphragm with
pericardial sac opened. (From Patton KT, Thibodeau GA. Anatomy and Physiology. 8th ed. St. Louis: Mosby; 2013.)

Figure 13-2. Structures that direct blood flow through the heart.
(From McCance KL, Huether SE. Pathophysiology. The Biologic Basis for Disease in Adults and Children. 7th ed. St.
Louis: Mosby; 2014)

Figure 13-3. A. The atrioventricular (AV) valves in the open position and the semilunar (SL) valves in
the closed position. B. The AV valves in the closed position and the SL valves in the open position.
(From Patton KT, Thibodeau GA. Anatomy and Physiology. 8th ed. St. Louis: Mosby; 2013.)

Autonomic Control
 Sympathetic nervous system
 Norepinephrine
 Parasympathetic nervous system
 Acetylcholine
 Chemoreceptors
 Baroreceptors

Cardiac Function
 Coronary circulation
 Conduction system
 Hemodynamics
 Heart sounds
 S1, S2, S3, and S4
 Heart murmur
 Turbulent blood flow through valves

Cardiac Function (Cont.)
Figure 13-5. The coronary vessels. A. Arteries. B. Veins.

(From McCance KL, Huether SE. Pathophysiology. The Biologic Basis for Disease in Adults
and Children. 7th ed. St. Louis: Mosby; 2014; Modified from Patton KT, Thibodeau GA.
Anatomy and Physiology. 8th ed. St. Louis: Mosby; 2013.)
Cardiac Function (Cont.)
Figure 13-6. Chest areas from which each valve sound is best heard.
(Modified from Hall JE, Guyton AC. Guyton and Hall Textbook of Medical Physiology. 13th ed.
Philadelphia: Saunders; 2016.)
Heart Murmur
 Caused by a turbulence of blood flow through
the valves
 Rumbling, blowing, harsh, or musical in sound
 Identify location, sound, loudness, and intensity
and whether other heart sounds are heard

Coronary Artery Disease (CAD)
 Progressive narrowing of coronary arteries by
atherosclerosis
 Coronary heart disease
 Atherosclerotic heart disease

Figure 13-7. Progression of atherosclerosis. A. Damaged endothelium. B. Fatty streak. C. Fibrous plaque.
D. Complicated lesion.
(From McCance KL, Huether SE. Pathophysiology. The Biologic Basis for Disease in Adults and Children.
7th ed. St. Louis: Mosby; 2014.)
Pathophysiology of CAD
 Injury to epithelial cells in intima
 Platelet aggregation
 Migration of monocytes
 Lipoproteins enter intima
 Fatty streak
 Monocytes develop into macrophages
 Lipid-rich "foam cells” develop
 Atheroma

Figure 13-8. Low-density lipoprotein oxidation.
(From McCance KL, Huether SE. Pathophysiology. The Biologic Basis for Disease in Adults and
Children. 7th ed. St. Louis: Mosby; 2014; Modified from Crawford MH, Dim Arco JP, Paulus WJ:
3rd ed: Cardiology. London: Mosby-Wolfe; 2010.)
(Cont.)
 Damage to intima
 Liberates platelet-derived growth factor
 Proliferation of smooth muscle cells
 Fibrous cap forms
 From connective tissue and low-density lipoprotein
(LDL)
 Fibrous cap often ruptures
 Thrombus
 Clotting cascade initiated

(Cont.)
 Adhesion: platelets bind to receptors
 Activation: platelets change shape and activate
receptors
 Release: thromboxane A2 and serotonin
 Activate glycoprotein IIb/IIIa receptors
 Aggregation: platelets clump together
 Drugs administered to stop the process
 Aspirin
 Glycoprotein IIb/IIIa inhibitors

Risk Factors
Nonmodifiable factors Modifiable
 Age  Smoking
 Men > 45 years  Inactivity

 Women > 55 years  Overweight
 Family history  Cholesterol
 High LDL
 Low levels of HDL
 Diabetes
 Hypertension

History
 Risk factors
 Prior hospitalizations
 Shortness of breath, chest pain
 Medications
 Erectile dysfunction meds if considering nitroglycerin
 Psychosocial history
 Include stressors

Diagnostic Studies
 12-lead electrocardiogram (ECG)
 Holter monitor
 Exercise tolerance test (stress test)
 Exercise to increase demand on heart
 Stressed via drugs (e.g., adenosine) if patient cannot
tolerate exercise
 Monitoring vital signs, ECG
 Pharmacological stress testing
 Nuclear stress testing
 Chest x-ray
Diagnostic Studies
(Cont.)
 Echocardiography
 Ultrasound to visualize cardiac structures
 Transesophageal echocardiography
 Multigated blood pool study (MUGA scan)

Diagnostic Studies
(Cont.)
 Positron emission tomography (PET scan)
 Cardiac magnetic resonance imaging

Cardiac Catheterization and
Arteriography
 Electrophysiology study
 Catheter (right or left)
 Heart pressures (similar to PA catheter)
 Cardiac output
 Arteriography
 Visualize blood vessels

Post-catheterization Care
 Bed rest; head of bed no higher than 30 degrees
 Monitor bleeding; newer collagen agents for
hemostasis may be used
 Monitor pulses
 Antiplatelet drugs after the procedure (usually
after interventions such as PCI)
 May be discharged in 6 to 8 hours; depends on
diagnosis and procedures done in
catheterization laboratory

Post-catheterization Care (Cont.)
Figure 13-9. FemoStop in correct position. (Courtesy RADI Medical

Systems, Inc. Sweden.)
Laboratory Tests
 CBC
 Hemoglobin
 Hematocrit
 Sodium
 Potassium
 Calcium
 Magnesium

Cardiac Enzymes
 Troponin I and T
 As early as 1 hour after injury
 Normal values less than 0.5 mcg/L for Troponin I
 Normal values less than 0.1 mcg/L for Troponin T

Quick Quiz!
Which value, when elevated, places the patient at
lowest risk for CAD?
A. Triglycerides
B. Low-density lipoproteins (LDLs)
C. High-density lipoproteins (HDLs)
D. Very-low-density lipoproteins (VLDLs)

Cholesterol in CAD
 Categories
 HDL is considered good
 LDL is considered bad

LDL Target Levels (NIH)
 No CHD and fewer than two risk factors
o 160 mg/dL
 No CHD and two or more risk factors
o 130 mg/dL
 CAD
o <100 mg/dL

Treatment
 Diet: low cholesterol, low salt
 Exercise: aerobic
 Weight loss
 Smoking cessation
 Management of hypertension and diabetes if
present
 Medications: lipid-lowering agents
 Various types: weigh advantages and disadvantages
of each

Medications for Hyperlipidemia
 HMG-CoA reductase inhibitors; slow production:
most effective
 Statins
 Bile acid resins bind and are excreted via bowel.
 Cholestyramine
 Colestipol
 Ezetimibe (Zetia) blocks the absorption of
cholesterol in the digestive tract.

(Cont.)
 Nicotinic acid; inhibits LDL synthesis and
increases HDL; many side effects
 Fibric acid derivatives; increase VLDL clearance
 Gemfibrozil

(Cont.)
 Patients carefully monitored
 Combination therapy may be needed to reach
target goals

Medications Affecting Platelets
 ASA (inhibits thromboxane A2)
 Others: dipyridamole, ticlopidine, and clopidogrel

Types of Angina
 Stable (chronic, exertional) = effort, classic
 T-wave inversion on ECG
 Treatment: rest and nitroglycerin
 Unstable (crescendo) = more often and more
severe, less relief
 May see ST elevation on ECG
 Treatment: rest and nitroglycerin; drugs affecting
platelets; revascularization
 Variant = Prinzmetal’s (vasospasms)
 ST elevation during pain episodes
 Treatment: calcium channel blockers
Angina
 Myocardial ischemia: the heart’s demand for
oxygen is higher than the supply

Angina/Chest Pain
 Classic symptom
 Often midsternal
 May radiate to arms, jaw, or back
 ECG changes to the ST segment/T wave

Case Study
Mr. and Mrs. T. are naturalized Americans. They were born
and raised in Japan and moved to the United States 20
years ago. Mrs. T. is 45 and teaches kindergarten. Mr. T. is
54 and runs an import store. Their son, Rutchie, 16 years
old, was born in the United States. He is a sophomore in
high school, where he plays baseball.
Mr. T. started having some chest pains 2 years ago and
was diagnosed at the clinic with mild angina. He takes
nitroglycerin (NTG) 0.3 mg SL when he feels any
discomfort. His chest pain is usually exertion related.
Lately, he has had to take the NTG more often. He has an
appointment with the cardiologist next week.

Questions
 Why is Mr. T. experiencing more pain?
 What could be done at this point to prevent an
MI?

Nursing Diagnoses
 Acute chest pain related to myocardial ischemia
 Knowledge deficit related to unfamiliarity with
disease processes and treatment
 Activity intolerance related to ischemic changes

Nursing Management: Angina
 Maintain cardiac output
 Pain relief
 Self-care; risk-factor modification
 Medications
 Postprocedure observation and care following
cardiac catheterization, angioplasty, bypass
surgery.

Patient Care Outcomes
The patient will
 verbalize relief of chest discomfort,
 appear relaxed and comfortable,
 verbalize an understanding of angina pectoris and its
management,
 describe cardiac risk factors and strategies to reduce
them, and
 perform activities within limits of the disease,
as evidenced by absence of chest pain or discomfort and

no ECG changes reflecting ischemia.

Quick Quiz!
Nursing management of the patient with angina is
directed toward
A. immediate administration of nitrates.
B. assessment of history of previous anginal
episodes.
C. assessment and documentation of chest pain
episodes.
D. administration of prophylactic lidocaine for
ventricular ectopy.

Acute Coronary Syndrome (ACS)
 Ischemia with myocardial cell death
 Imbalance of oxygen supply and demand
 Includes stable angina, unstable angina or acute
myocardial infarction
 Causes
 Atherosclerosis
 Emboli
 Blunt trauma
 Spasm

Acute Myocardial Infarction (AMI)
 Types
 Non-ST segment elevation (NSTEMI)
 ST segment elevation (STEMI)
 Collateral circulation

Assessment of AMI
 Midsternal chest pain
 Severe, crushing, and squeezing pressure
 May radiate
 Unrelieved with nitrates
 Pale and diaphoretic
 Dyspnea, tachypnea, and/or hypotension
 Syncope
 Feeling of impending doom
 Nausea and vomiting
 Dysrhythmias

Diagnosis of AMI
 Signs and symptoms
 Often atypical symptoms in women
 12-lead:
 ST elevation followed by Q wave (Q-wave myocardial
infarction)
 ST depression (non–Q-wave myocardial infarction)
 Elevated serum troponin
 Troponin I
 Troponin T

Case Study
The paramedics put an oxygen cannula on Mr. T.
and start an IV in his left arm. They give him a
baby aspirin to chew, contact the local hospital,
and prepare Mr. T. for transport. Upon arrival in the
ED, Mr. T.’s heart rate is 110 beats/min, and he is
diaphoretic.
What is the danger of the tachycardia?

Question
A 12-lead ECG is done by the paramedic in the
field. What changes would you expect to see if Mr.
T. is having an MI?

Question (Cont.)
The paramedics note ST-segment elevation in
Leads II, III, and aVF. What therapies will be
administered in the field? In what area of the heart
do changes in these leads indicate damage?

Quick Quiz!
Which finding on the ECG is most conclusive for
infarction?
A. Q waves
B. Inverted T waves
C. Tall, peaked T waves
D. ST-segment depression

Nursing Diagnoses
 Acute Chest Pain
 Poor Tissue Perfusion

Nursing Goals: AMI
 Maintain cardiac output
 Treat pain
 Assess for complications
 Increase activity tolerance
 Relieve anxiety
 Ongoing and discharge teaching

Medical Management: AMI
 Pain relief: morphine, nitroglycerin
 Oxygen
 Prevention of platelet aggregation
 Percutaneous Coronary Intervention (PCI)
 Fibrinolytic therapy
 Medications (nitrates, beta blockers,
angiotensin-converting enzyme inhibitors
 Autologous bone marrow stem cell treatment to
the damaged myocardium.

Complications of AMI
 Dysrhythmias
 Sudden death
 Heart failure
 Cardiogenic shock
 Ventricular aneurysm or rupture
 Papillary muscle dysfunction
 Pericarditis
 Infarct extension

Quick Quiz!
After giving the first dose of morphine to relieve the
chest pain of a critical care patient, the next priority
action is to
A. change the intravenous tubing to maintain a
patent infusion line and reduce risk of infection.
B. bathe the patient while the analgesic is still in
effect.
C. assess the patient for pain relief and signs of any
adverse effects of the medication.
D. initiate administration of oxygen by nasal cannula.

Primary Angioplasty
 Get patient to catheterization lab for emergent
percutaneous intervention or stenting if facilities
are available
 Better outcomes than thrombolytics

Thrombolytic Therapy
 Time is muscle; 6-hour window
 Several thrombolytic agents available, such as:
 Tissue plasminogen activator (t-PA)
 Streptokinase
 Reteplase
 Heparin and glycoprotein IIb/IIIa inhibitors

Case Study
Mr. T. was quickly triaged in the ED with a
preliminary diagnosis of acute inferior wall MI. The
hospital is in a rural area, and the weather is
severe. Ground transport to the nearest hospital
able to do PCI is 2 hours. Therefore, a decision is
made to administer thrombolytics. Within 1 hour,
Mr. T. was started on reteplase.

Question
Why was Mr. T. treated with thrombolytics rather
than transported to the center for a PCI?

Question (Cont.)
Because Mr. T. is having an inferior wall MI, what
complications should be anticipated while getting
him ready for the thrombolytic therapy?

Questions
 What nursing care was done prior to starting
reteplase?
 What is the nursing care associated with a
patient receiving reteplase?
 What complications must be assessed during
and after administration of the medication?

Interventional Cardiology
 Variety of procedures
 Percutaneous transluminal coronary angioplasty
(PTCA)
 Intracoronary stenting
• Drug-eluting stents

PTCA
 Goal to increase blood flow to myocardium
 Criteria
 Uncompromised collateral flow
 Noncalcified lesions
 Lesions not on bifurcations of vessels
 Balloon catheter is inflated

PTCA (Cont.)
Figure 13-11 Coronary angioplasty procedure. A-D, Order

of procedure. (From Moser DK, Riegel B. Cardiac Nursing.
St. Louis: Mosby; 2008.)

Coronary Angiogram
Before and After PTCA
Figure 13-12. A. A thrombotic occlusion of the right coronary artery is noted (arrows). B.
Right coronary artery is opened and blood flow restored following angioplasty and
placement of a 4-mm stent. (From Lewis SL. Medical-Surgical Nursing: Assessment and
Management of Clinical Problems. 9th ed. St. Louis: Mosby; 2014.)

Coronary Stents
 Tubes placed in conjunction with angioplasty to
keep vessel patent
 Help prevent the restenosis associated with
angioplasty
 Similar procedure as PTCA
 Anticoagulation therapy

Intracoronary Stent
Figure 13-13. Placement of coronary artery stent. A. The stent is positioned at the site of the
lesion. B. The balloon is inflated, expanding the stent. The balloon is then deflated and removed.
C. The implanted stent is left in place.
(From Lewis SL. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 9th
ed. St. Louis: Mosby; 2014.)

Case Study
One day after the thrombolytic therapy, Mr. T.’s
cardiac rhythm suddenly dropped to 40 beats/min,
and he became very dizzy and breathless.

Questions
 What action should the nurse take?
 What drugs could be used?

Case Study/Questions
Mr. T. is discharged from the hospital 2 days after
the MI.
 What discharge instructions are needed?
 What medications will be ordered?
 What psychosocial support may need to be
provided to Mrs. T. and their son, Rutchie?

Surgical Revascularization
 Coronary artery bypass graft (CABG) surgery
 Minimally invasive direct coronary artery bypass
(MIDCAB) surgery
 Transmyocardial revascularization (TMR)

CABG Surgery
 Provides additional conduits for blood flow
 Saphenous vein
 Internal mammary artery
 Radial artery
 Arteries longer patency

CABG Surgery (Cont.)
Figure 13-14. Coronary bypass. In coronary bypass surgery, blood vessels are “harvested” or
“rerouted” from other parts of the body and used to construct detours around blocked coronary
arteries. Artificial vessels can also be used.
Indications for CABG
 Unstable angina
 AMI
 Failure of percutaneous interventions

Risks Associated with CABG
 Increased mortality associated with:
 Left ventricle dysfunction
 Emergency surgery
 Age
 Sex (female)
 Number of diseased vessels
 Decreased ejection fraction with congestive heart
failure

Traditional CABG
 Median sternotomy or sternum split
 Excision of pericardium
 Cardiopulmonary bypass
 Myocardial preservation or cardioplegia

Traditional CABG
(Cont.)
 Grafts
 Wean bypass; defibrillate if needed
 Mediastinal and chest tubes
 Epicardial pacing wires
 Wire sternum

Goals of CABG Surgery
 Increase blood flow to myocardium
 Relieve symptoms
 Prolong survival
 Improve quality of life

Minimally Invasive
Direct Coronary Artery
Bypass Surgery
 Port-access coronary artery bypass

 Cardiopulmonary bypass
 Incisions (ports)
 Minimally invasive direct coronary artery bypass
surgery
 No cardiopulmonary bypass
 Heart still beating
 One or two bypasses

Cardiac Surgery Complications
 Low cardiac output
 Renal impairment
 Gastrointestinal dysfunction
 Impaired peripheral circulation
 Mediastinal bleeding
 Infection: very serious if sternal
 Atrial dysrhythmias
 Hypovolemia

Complications of CABG
 Dysrhythmias  Respiratory
 Impaired contractility; insufficiency
low cardiac output  Pain
 Intraoperative  Emboli; stroke
myocardial infarction  AMI
 Pericardial  Shock
tamponade  Death

Case Study
One month after Mr. T.’s revascularization, he
develops chest pain and visits the cardiologist. He
is having T-wave changes in the anterior leads. He
is referred to the tertiary care center for additional
testing. He undergoes cardiac catheterization and
angiography, and a lesion of the left main coronary
artery is found. He is scheduled for a CABG.

Questions
 Why is CABG scheduled and not PCI?
 What are the psychosocial implications of having
surgery at a tertiary care center?

Case Study
Mr. T. undergoes CABG, and the left internal
mammary artery (LIMA) is implanted to the left
main coronary artery.
 Why is the LIMA used?

 What are the postoperative priorities?

Transmyocardial Revascularization
 Laser channels into ventricle
 Goal is to increase perfusion of heart muscle
 Relief of symptoms occurs over time
 Poor candidates for CABG
 Mixed results from clinical trials

Enhanced External Counterpulsation
 Enhanced external counterpulsation (EECP) is a
treatment for angina when the patient is not a
candidate for bypass surgery or PCI.
 EECP uses cuffs wrapped around the patient’s legs
to increase arterial blood pressure and retrograde
aortic blood flow during diastole. Sequential
pressure, using compressed air, is applied from the
lower legs to the upper thighs.
 There are no definite data that EECP reduces
ischemia; however, treatment reduces angina and
improves quality of life.
Dysrhythmias
 Radiofrequency catheter ablation
 Permanent pacemakers
 Implantable cardioverter-defibrillator

Radiofrequency Catheter Ablation
 Supraventricular tachycardia
 Interrupt electrical conduction or activity
 Radiofrequency used
 Electrophysiology

Temporary and Permanent
Pacemakers
 Multiprogrammable for:
 Rate
 Voltage
 Sensitivity
 Stimulus duration
 Refractory period
 Intersociety Commission for Heart Disease
(ICHD)

Permanent Pacemakers
(Cont.)
 Can pace atria, ventricles, or dual chamber
 Inserted transvenously

Implantable Cardioverter-
Defibrillator (ICD)
 Used to treat survivors of sudden cardiac arrest
 Some have built-in pacemakers
 Delivers high-energy shock
 Patient education
 Emergency procedures

Heart Failure
 Inability of the heart to generate adequate flow
and to meet the metabolic demands of the body
 Systolic (impaired contractility)
 Diastolic (impaired filling)

Etiology
 AMI
 Hypertension
 Idiopathic; cardiomyopathy
 Valvular disease

Pathophysiology
 Left heart failure
 Decreased pumping action
 Failure to meet metabolic demands
 Backup of blood from left ventricle
 Fluid buildup in lungs
 Backflow leads to right heart failure

Pathophysiology
(Cont.)
 Compensatory mechanisms
 Renin-angiotensin-aldosterone system
 Sympathetic nervous system
 Right heart failure
 Leads to systemic symptoms

Pathophysiology (Cont.)
 Brain natriuretic peptide (BNP)
 Cardiac hormone
• Secreted by ventricular myocytes in response to wall stretch
• Normal 100 pg/mL
 Plasma concentrations reflect severity of heart failure
• In decompensated heart failure, BNP rises
• As heart failure is treated, BNP will lower
 Good marker for differentiating between pulmonary
and cardiac causes of dyspnea

Assessment of Heart Failure
 Left-sided failure signs and symptoms
 Right-sided failure signs and symptoms
 Examination of neck veins
 Presence or absence of edema
 Perfusion status
 Lung sounds
 Diagnostic findings
 Chest x-ray
 Hemodynamic monitoring (pulmonary artery catheter)

Assessment
Diagnostics Testing
 Echocardiogram
 Arterial blood gases
 Serum electrolytes
 BUN/Creatinine
 Complete blood count
 B-type natriuretic peptide (BNP)
 Hepatic function
 ECG

Heart Failure
Nursing Interventions
 Improve pump function
 Diuretics
 ACE inhibitors
 Angiotensin receptor blockers
 Beta blockers (carvedilol [Coreg])
 Digoxin

Heart Failure Treatment
 Nesiritide citrate (Natrecor) intravenous for acute

decompensation of heart failure

Heart Failure Treatment
(Cont.)
 Reduce cardiac workload
 Intraaortic balloon pump
 Mechanical circulatory support devices (MCSDs)
 Biventricular pacing
 Nursing interventions, rest, and activity as tolerated.
 Cardiac rehabilitation

Heart Failure Treatment (Cont.)
 Optimization of gas exchange
 Airway assessment and degree of respiratory distress
 Semi-Fowler positioning
 Supplemental oxygen
 Continuous positive airway pressure (CPAP)
 Diuresis
 Control sodium and fluid retention
 Daily weights
 VTE prophylaxis

Case Study
Mr. T. had the CABG. It was difficult to get Mr. T.
weaned from the cardiopulmonary bypass
machine. A decision was made to insert an
intraaortic balloon pump (IABP).
 Why was the IABP inserted?

 What are some related nursing interventions?

Case Study (Cont.)
Mr. T. required the IABP for 24 hours, at which time
it was weaned and removed. The remainder of his
postoperative course was uneventful, and he was
discharged home 6 days after surgery.
 Discuss discharge teaching needs.

Heart Failure Complications
 Pulmonary edema
 Dyspnea
 Cyanosis
 Gurgles
 Pink, frothy sputum
 Hypoxemia
 Cardiogenic shock

Inflammatory Heart Disease
 Pericarditis—inflammation of the pericardium
 Endocarditis—inflammation of the endocardium

Pericarditis
 Etiology
 After a myocardial infarction
 Uremia
 Cancers
 Can lead to infusion, tamponade, and scarring

Hallmarks of Pericarditis
 Friction rub
 Pulsus paradoxus
 Initial ST elevation

Pericarditis
 Assessment
 Relieve pain
 Procedures:
 pericardiocentesis
 pericardial window

Endocarditis
 Endocardium continuous with valves
 Vegetation
 Embolization
 Valvular dysfunction

Assessment of Endocarditis
The clinical presentation
 High fever and shaking chills
 Night sweats, cough, weight loss
 General malaise, weakness, fatigue, headache,
musculoskeletal complaints
 New murmurs
 Symptoms of HF
 Skin abnormalities
 Janeway lesions
 Osler nodes
Endocarditis (Cont.)
 Diagnosis: echocardiogram, transesophageal
echocardiography
 Treatment: antibiotics, rest
 Prevention: antibiotic prescription before
treatments (e.g., dentist)
 Heart valve
 History of endocarditis
 Microvascular pressure with regurgitation

Vascular Alterations
 Aortic aneurysms
 Dilation or thinning of wall
 Thoracic aortic
 Thoracoabdominal aortic
 Abdominal aortic
 Treat based on size and symptoms
 False versus true

Anatomy of the Aorta
Figure 13-18. Anatomy of the aorta and its major branches.


Aneurysms
Figure 13-19. Types of Aneurysms. A, The fusiform circumferential and fusiform saccular aneurysms are true aneurysms,
caused by weakening of the vessel wall. False and saccular aneurysms involve a break in the vessel wall, usually caused by
trauma.
(From McCance KL, Huether SE. Pathophysiology. The Biologic Basis for Disease in Adults and Children. 7th ed. St. Louis:
Mosby; 2014)

(Cont.)
 Aortic dissection
 Tear of intimal layer of the vessel
 Sudden
 Sharp
 Shifting pain
 Marfan syndrome

(Cont.)
 Surgical Treatment
 Open approach
 Endovascular approach

Endoaneurysmal Repair
Figure 13-20 Surgical repair of an abdominal aortic aneurysm. A. The aneurysmal sac is incised. B.
The synthetic graft is inserted. C. The native aortic wall is sutured over the synthetic graft.
(From Lewis SL, et al. Medical-Surgical Nursing: Assessment and Management of Clinical Problems.
9th ed. St. Louis: Mosby; 2014.)

Cardiovascular Alterations

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Chapter 13

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 Right side is low pressure

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Figure 13-5. The coronary vessels. A. Arteries. B. Veins.

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 Men > 45 years  Inactivity

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Figure 13-9. FemoStop in correct position. (Courtesy RADI Medical

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 appear relaxed and comfortable,

 verbalize an understanding of angina pectoris and its

as evidenced by absence of chest pain or discomfort and

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What is the danger of the tachycardia?

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