Cardiac

1. Cardiac Community College of Philadelphia Nursing 132 Spring 2007

2. Anatomy and Physiology Review • Structures • Chambers • Valves • Arteries • Physiology • Direction of flow • Preload • Afterload

3. Coronary Circulation

4. Structure • Epicardium • Myocardium • Endocardium • Chambers • Right and Left Atria • Right and left Ventricles • Valves • Atrioventricular • Tricuspid - Separates RA from RV • Mitral - Separates LA from the LV • Semilunar • Pulmonic – Separates RV from the Pulmonary Arteries • Aortic – Separates LV from the Aorta

5. Physiology • Blood flow through the heart • http://www-medlib.med.utah.edu/kw/pharm/hyper_heart1.html • Cardiac conduction Automaticity

6. Electrophysiology • Nodes • Pathway • Automaticity

7. Cardiac conduction

8. Basic EKG Interpretation • What is an EKG and what does it measure/record? • PQRST • Measuring boxes • Horizontal measure time: small box 0.04 seconds Large box 0.20 seconds • Vertical voltage: small box 1mm or 0.1 mV large box 5mm or 0.5 mV

9. P wave • Atrial depolarization • Small, smooth, rounded • No taller than 2.5 mm • No wider than 0.11 sec

10. Q wave • First downward deflection • Should be less than 0.03 seconds in duration and less than 25% of the R wave • Indicates myocardial infarction

11. QRS Complex • Represents ventricular depolarization

12. T wave • Ventricular repolarization • Usually rounded • Should be same direction as QRS • Inverted T waves can be a sign of ischemia • Peaked T waves can be a sign of hyperkalemia

13. U wave • Small rounded wave not always present, thought to be part of ventricular repolarization

14. PQRST

15. Chronic Stable Angina

16. Angina (Stable Chronic) • Most common sign of ischemic heart disease • Myocardial oxygen demand is increased by exercise, smoking, eating heavy foods, weather extremes, emotional distress, etc… • Atherosclerosis causes progressive fixed narrowing of the arterial lumen • Relieved by rest or pharmacological interventions • Goal is to prolong survival, reduce disease progression

17. Acute Coronary Syndrome (ACS) • Unstable Angina (UA) • Non-ST Elevated Myocardial Infarction (NSTEMI) • ST Elevation Myocardial Infarction (STEMI) Penumbra

18. Unstable Angina (UA) / Non-ST Elevated Myocardial Infarction (NSTEMI) • Imbalance between myocardial oxygen supply and demand • UA occurs at rest without exertion • Reduced myocardial perfusion • Release of biochemical markers vs. no release of biochemical markers

19. Evaluation and management • Stratification High risk Intermediate Low risk

20. Immediate Management • History, PE, 12 – Lead EKG, initial cardiac markers • Assign to 1 of 4 categories • Definite or Possible • Cont. EKG monitoring • Cardiac markers • In facility observation • Repeat EKG and cardiac markers 6-12 hours

21. EKG and cardiac markers normal follow up stress test as outpatient acceptable • Definite ACS admit to hospital – Chest pain unit if available • Hospital Care • Nursing Management • Minimize or eliminate ischemia • Administer meds • Educate • Discharge teaching

22. ST Elevation Myocardial Infarction (STEMI) • MI occurs as a result of thrombotic occlusion of one or more of the coronary arteries • ******* • CP is most common symptom, severe, doesn’t go away • Diagnosis • EKG • Cardiac markers • PE, History

24. Ventricular Remodeling – Changes in the size, shape, and thickness of the left ventricle involving both the infarcted and non-infarcted segments of the ventricle. • Penumbra • 1.68 million unique discharges for ACS in 2001, 30% estimate to have STEMI

25. Management • Pt contact with healthcare system • Initiation of fibrinolytic therapy – < 30 minutes • Balloon inflation for PCI - < 90 minutes

26. Choice of treatment decided by EM physician and resources of institution and surrounding institutions • Contraindications to fibrinolytics

27. 12 lead EKG completed and shown to experienced emergency physician WITHIN 10 minutes • Cardiac Markers • Troponin • CK-MB • Myoglobin • Lab results should not delay treatment

28. Cardiac Enzymes – Troponin, Myoglobin, CK-MB, Total CK

29. What should be done? • EKG • Lab work • Portable CXR • Oxygen • Nitroglycerin: 3 sublingual 0.04mg, IV if needed **** Phosphodiesterase inhibitor **** • Morphine Sulfate: 2 – 4mg IV • ASA chewed • Beta blocker if not contraindicated • ACE orally within 24 hours of STEMI for anterior infarct, pulm. congestion, LV EF < 40%

30. Patient Education Before Discharge • Lifestyle changes • Recognizing cardiac symptoms: calling 911 if symptoms not improving • Family education about AED, CPR • Lipid Management • Weight Management • Smoking cessation

31. Cont. • Antiplatelet Therapy: ASA, Plavix • ACE inhibitor if without contraindications • Beta blockers: except low risk and contraindications • Hypertension Control • Diabetes Management • No Hormone therapy

32. Cont. • Warfarin Therapy • Physical activity: should be encouraged and prescribed appropriately / Rehab • Follow up care with medical provider

33. See flow chart

34. Questions????

35. Cardiac Catheterization

36. Percutaneous Coronary Interventions (PCI) • “Cardiac Catheterization” • PTCA (Percutaneous Transluminal Coronary Angioplasty / Angiography) • PCI - Angioplasty, atherectomy, intracoronary stenting • Web site • http://www.heartsite.com/html/cath_4.html

37. Who undergoes PCI? • Stable CAD • Unstable angina • NSTEMI • STEMI

38. What is a stent?

39. http://www.cnn.com/2007/HEALTH/03/23/stents.vs.drugs.ap/index.htmlhttp://www.cnn.com/2007/HEALTH/03/23/stents.vs.drugs.ap/index.html

40. Preprocedural Management • What do you think? • Informed consent • Consent for CABG • Education • Hold Metformin (Glucophage), insulin etc… NPO status • Lab values - Which ones, and why??

41. Postprocedural Managment • What do you think? • 12-Lead EKG • Labs - Will CE be elevated? • Hydrate • Anticoagulation per institution • Sheath removal Femstop Manual pressure Vascular closure devices Angioseal

42. SANDBAG Study • Nurse to patient ratio of 1:1.5 or less maintained during sheath removal • Sheaths removed within 4-6 hours • Medicate for comfort, HOB can be 30 degrees • Allowed to ambulate 8 hours after removal • SANDBAGS ARE NOT EFFECTIVE TO MINIMIZE BLEEDING AND CAUSE DISCOMFOT *****Evidence-Based Practice*******

43. Complications of PCI • Abrupt Closure • Acute Stent Thrombosis < 1% • Vascular Spasm • NSTEMI • STEMI <1% • Coronary Vessel Perforation • Arrhythmias • Equipment Failure • Contrast-Related Complications • Cerebrovascular Complications • CABG Emergently

44. Groin Complications • Hematoma • Retroperitoneal bleeding • Arterial thrombosis • Pseudoaneurysm • Arteriovenous fistula

45. Nursing Management / Diagnosis • Anxiety • Risk of altered myocardial tissue perfusion • Risk of decreased cardiac output • Risk of altered cerebral tissue perfusion • Extracellular fluid volume deficit • Risk of extracellular fluid volume deficit: hemorrhage

46. Take Home Points ! • PTCA / PCI: What do they stand for? • Reasons for PCI: Evaluate and possibly provide an intervention • Stent, Atherectomy, Angioplasty • Groin complications !!!

47. Chronic Heart Failure

48. Heart Failure (HF) • Complex clinical syndrome • HF is not a stand alone diagnosis - it has a cause • What are the causes of HF? • What is HF?

49. HF is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood • CAD is the underlying cause of HF in two thirds of patients with LV systolic dysfunction • 2-Dimensional Echo is the single most useful diagnostic tool in the evaluation of patients with HF

50. Systolic Dysfunction • Diastolic Dysfunction