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Imbalance Between Myocardial Supply and Demand

Imbalance Between Myocardial Supply and Demand. Irma B.Ancheta,PhD,RN. Learning Guide:. Pathophysiology of atherosclerosis, arteriosclerosis, Acute Coronary Syndrome Modifiable and non-modifiable risk factors for CAD (Coronary Artery Disease) Anti-platelet medications: aspirin

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Imbalance Between Myocardial Supply and Demand

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  1. Imbalance Between Myocardial Supply and Demand Irma B.Ancheta,PhD,RN.

  2. Learning Guide: • Pathophysiology of atherosclerosis, arteriosclerosis, Acute Coronary Syndrome • Modifiable and non-modifiable risk factors for CAD (Coronary Artery Disease) • Anti-platelet medications: • aspirin • Plavix (clopidogrel) • Medications for dyslipidemia: • HMG Co-reductase inhibitors • Niacin • Fibric acid derivatives • Anti-anginal medications: • Nitroglycerin preparations • Beta blockers • Calcium channel blocke

  3. Learning Guide: • Assessment of men and women presenting with s/s of angina, or ACS (Acute Coronary Syndrome) • Definitions and defining characteristics of: • Decreased cardiac output r/t ventricular damage, dysrhythmias • Acute pain r/t myocardial tissue damage from inadequate blood supply • Risk for bleeding r/t thrombolytic therapy • Risk for peripheral neurovascular dysfunction • Definition and Indicators of these NOCs: • Cardiac pump effectiveness • Tissue perfusion, peripheral • Review these NICs: • Cardiac Care • Cardiac care, acute • Circulatory precautions

  4. Learning Objectives: • Describe assessment strategies (and related nursing care) for patients with ACS: • Stress tests, echocardiography, cardiac catheterization, ECG monitoring • Plan, implement and evaluate care for patients experiencing Unstable angina, NSTEMI, MI • Plan, implement and evaluate care for patients post interventional cardiology procedures • Describe interventional (cath lab)/surgical interventions for myocardial revascularization • Describe health promotion strategies (and teaching plans) for patients at risk of CAD/ACS.

  5. Cardiac Review

  6. A&P Review Layers of the Heart Pericardium Epicardium Myocardium Endocardium

  7. A&P Review Cardiac Chambers Atria Ventricles

  8. Cardiac Valves AtrioventricularValves Tricuspid and mitral Semilunar Valves Pulmonic and aortic

  9. A&P Review Conduction System Atria Sinoatrial node Internodal pathways Intraatrial bundle AV Node to Bundle of HIS Ventricles Right and left bundle branches Purkinjie fibers

  10. Electrical Conduction System

  11. A&P Review • Coronary Blood Supply • Coronary Arteries • Left coronary artery divides into left anterior descending and left circumflex • Right coronary artery perfuses the right side of the heart and in most people the SA and AV nodes • In 70% of the population the RCA perfuses the posterior coronary artery

  12. Coronary Arteries Right coronary artery

  13. A&P Review • Venous Return from the Heart • Coronary sinus • Thebesian vessels drain directly into the chambers of the heart and produce physiologic shunt

  14. A&P Review • Systemic Circulation • Arterial system of resistance vessels • Capillary bed: tissue perfusion • Venous system of capacitance vessels

  15. A&P Review • Physiology • Properties of cardiac tissue • Excitability • Conductivity • Automaticity • Rhythmnicity • Contractility • Refractoriness

  16. A&P Review • Electrical Activity • Action potential

  17. A&P Review • Cardiac Cycle • Ventricular systole • Ventricular diastole • Cardiac Output

  18. A&P Review • Regulation of Heartbeat • Nervous control • Intrinsic regulation

  19. A&P Review • Control of Peripheral Circulation • Intrinsic Control • Extrinsic control

  20. Ejection Fraction

  21. Ejection Fraction Normal = 50% or higher Low = < 40%

  22. Ejection Fraction [1] MUGA (multiple-gated acquisition) Scan [2] echocardiogram [3] Cardiac Catheterization [4] Nuclear tests

  23. Risk Factors associated with Coronary Artery Disease

  24. Objectives: • Definition of CAD • Identifying risk factors (a) effects (b) treatments (c) management • Latest developments

  25. CAD Statistics • Affects nearly 13 million people in the USA • Causes 500,000 deaths each year

  26. Framingham Heart Study (FHS)

  27. Definition of Coronary Artery Disease • A narrowing of the inside diameter of arteries that supply the heart with blood. • The condition arises from the accumulation of plaque and greatly increases the risk of having a heart attack or myocardial infarction (Cooley, 1996).

  28. Modifiable Risk factors • Pathophysiologic factors: Hypertension Diabetes Hyperlipidemia • Life style factors Smoking Obesity Physical Inactivity Stress

  29. Nonmodifiable risk factors • AGE • GENDER • RACE/ETHNIC BACKGROUND • HEREDITY

  30. Emerging Risk Factors • Homocysteine= blocks NO production < elastic Blood vessels permit plaque formation TTT= B complex Folic acid, Niacin • LDL-C = mechanical injury • Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood) • Proinflammatory state (e.g., elevated C-reactive protein in the blood causes inhibition of NO) • Low Adiponectin levels increase CRP production

  31. Five Major Risk Factors • 1.Smoking • 2.Hypertension • 3.High cholesterol • 4.Diabetes • 5.Family History

  32. Smoking Effects of Smoking • Roughening effect of inside diameter of the arterial wall>formation of plaque,constriction of arteries>HPN • Increases heart rate and produces irregular heartbeats>clots>stroke • Decrease HDL levels and increase LDL > increase risk CAD

  33. Management of Smoking • Quit Smoking • Avoid secondary smoke

  34. Hypertension: • Or high blood pressure.. SBP >120 mm Hg ..DBP>80 mm Hg • Indicates a problem in the mechanism that regulates blood pressure in the circulatory system • “hyper” too much “tension” pressure

  35. Hypertension Effects of HPN • [Mechanical Injury] Causes thickening or hardening of the walls off the arteries>causes narrowing >decrease blood flow to coronary arteries>MI. • Thickening of left ventricle >decrease Cardiac output > causes CHF > kidney damage>Renal dialysis • In the diabetic population, HPN>retinal damage(retinopathy)>BLINDNESS

  36. New Features and Key Messages • For persons over age 50, SBP is a more important than DBP as CVD risk factor. • Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. • Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. • Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD. (JNC 7, 2003)

  37. New Features and Key Messages (Continued) • Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. • Certain high-risk conditions are compelling indications for other drug classes. • Most patients will require two or more antihypertensive drugs to achieve goal BP. • If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic. (JNC 7, 2003)

  38. Blood Pressure Classification

  39. Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50% (JNC 7, 2003)

  40. BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.

  41. Summary:

  42. Treatment Overview Goals of therapy • Lifestyle modification • Pharmacologic treatment • Algorithm for treatment of hypertension • Classification and management of BP for adults • Follow-up and monitoring (JNC 7, 2003)

  43. Management of hypertension • Exercise • Proper stress management • Quit Smoking • Healthy diet • Decrease sodium intake. • Anti- HPN Medication

  44. Lifestyle Change: What Difference Does it Make ? • Weight loss. (decreases SBP*1.6 mm Hg for each kg lost) • Dietary Approaches to Stop Hypertension: DASH diet: • (decreases systolic BP 8-14 mmHg) • Reducing salt in the diet.(decreases SBP 2-8 mmHg) • 30-45 minutes daily aerobic exercise • (decreases systolic BP 4-9 mmHg) • Limit alcohol. (decreases SBP* 2-4 mm Hg) • Avoidance of tobacco products. (*SBP = systolic blood pressure)

  45. Medications for HPN • Diuretics • Beta-Blockers • Calcium channel Blockers • ACEI • Vasodilators

  46. Diabetes • Causes vasoconstriction of coronary arteries >decrease blood flow > decrease oxygen supply >increase risk of heart attack or MI

  47. Management of Diabetes Healthy diet. Exercise Stress Management Medications Check Blood sugar regularly

  48. CHOLESTEROL • Effects of Increased • Cholesterol levels • Causes plaguing of the • coronary walls, • narrows coronary arteries, • creates blockage of coronary • arteries • less blood flow to heart cells • >MI

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