Ischemic heart disease

1. Cardiovascular AssessmentCardiovascular Assessment
Dr. M. Kalirattiname
Dept. of General Medicine
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Heart AnatomyHeart Anatomy
Facts:
– The heart is about the size of a fist and
weighs less than 1 pound
– The average bpm is 72
– The average adult heart pumps about 6000-
7500 liters of blood per day through 60,000
miles of blood vessels each minute at rest.

3. HeartHeart
Structure
– Covered by pericardium
 Parietal
 Visceral (epicardium)
– Outer heart layer: epicardium
– Middle heart layer: myocardium
– Inner layer: endocardium

4. The internal anatomy of the heart.The internal anatomy of the heart.

5. HeartHeart
Structure (continued)
– Four hollow chambers
 Two upper, atria
 Two lower, ventricles
– Divided by septum and valves

6. HeartHeart
Function
– Right atrium receives
deoxygenated blood
– Right ventricle pumps
blood to lungs

7. HeartHeart
Function (continued)
– Left atrium receives oxygenated blood
– Left ventricle pumps oxygenated blood to
body
– AV valve closure: S1 heart sound
– Semilunar valve closure: S2 heart sound
– Coronary circulation

8. The coronary arteriesThe coronary arteries..

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10. Peripheral Vascular SystemPeripheral Vascular System
Aorta, arteries, arterioles, capillaries
Venules, veins, superior and inferior
vena cava
Three layers
– Intima
– Media
– Adventitia

11. Structure of arteries, veins, and capillariesStructure of arteries, veins, and capillaries..

12. Peripheral Vascular SystemPeripheral Vascular System
Function
– Circulation
– Peripheral vascular resistance: viscosity,
length, diameter
– Blood pressure control

13. Mechanical Properties ofMechanical Properties of
the Heartthe Heart
Mechanical
– Conduction system

14. Mechanical Properties ofMechanical Properties of
the Heart (continued)the Heart (continued)
Mechanical
– SA node: pacemaker
– Cardiac output (CO)
– Heart rate (HR)
– Stroke volume (SV): the volume of blood
pumped from one ventricle of the heart with
each beat
– CO = HR x SV

15. Mechanical Properties ofMechanical Properties of
the Heart (continued)the Heart (continued)
Mechanical
– Cardiac reserve
– Preload
– Starling’s law
– Afterload
– Contractility

16. Electrical Properties of theElectrical Properties of the
HeartHeart
Electrical properties:
– Action potential
– Polarization
– Depolarization
– Repolarization
– Refractory period

17. Electrical Properties of theElectrical Properties of the
Heart (continued)Heart (continued)
Filling and pumping
– Diastole – ventricular filling
– Systole –ventricles eject blood

18. The cardiac cycle. Ventricular filling occurs during diastole (1); blood is pumpedThe cardiac cycle. Ventricular filling occurs during diastole (1); blood is pumped
out of the heart to the pulmonary and systemic circulation during ventricularout of the heart to the pulmonary and systemic circulation during ventricular
systole (2).systole (2).

19. AssessmentAssessment
Subjective
– Health history
– Chest pain
– SOB
– Leg pain
– Pillows to sleep
– Medications
– Lifestyle: diet, alcohol use, exercise,
smoking, drugs

20. Assessment (continued)Assessment (continued)
Objective
– General appearance
– Skin
– Wounds
– Pulses
– Jugular vein distention
– Edema
– Breathing

21. Diagnostic TestsDiagnostic Tests
 TEE (transesophageal echocardiogram)
– Monitor breathing, cough, gag reflex
– Keep NPO until gag reflex returns
 Doppler sonography: is a medical imaging technique that
uses ultrasound enhanced by the Doppler effect and is often provide
helpful information about the flow and movement of blood and inner
areas of the body
– Monitor BP
– Wash extremities to remove gel after test completed

22. Diagnostic TestsDiagnostic Tests
(continued)(continued) X-rays/CT scan/EBCT
 Electron beam computed tomography (EBCT) is used
to determine coronary calcium
– Document client allergy to fish or shellfish
– Pregnancy risk
 Angiography/cardiac catheterization
 MRI
– Document presence of implanted electronic devices
 Radionuclear scans
– Increase fluids after the test

23. MonitorsMonitorsTelemetry/Holter monitor
– Teach about purpose: is a portable device for
continuously monitoring various electrical
activity of the central nervous system for at
least 24 hours (often for two weeks at a tim
– Dry skin
– Remove hair
– Avoid getting unit wet
– When to phone the MD

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Ischemic Heart DiseaseIschemic Heart Disease
Dr Ibrahim Bashayreh

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Contents OverviewContents OverviewCoronary Artery Disease
Heart Anatomy
Atherosclerotic Plaque/Atheroma
Angina Pectoris
Myocardial Infarction
Sudden Death
Overall Management

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Coronary Artery DiseaseCoronary Artery Disease

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CAD: StatisticsCAD: Statistics
 CAD is the largest killer of American males and females
 13 million Americans have CAD
 1.1 million MI’s per year
 Every 26 seconds  an American will suffer from a
coronary event
 Every 60 seconds  an American will die because of a
coronary event
 @ 42% of those having a coronary event will die from it
 @350K people die per year because of a coronary event in
the Emergency Department before even being admitted to
the hospital
 Death Rate in 2001:
– 177 in 100,000

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CAD: Demographics and StatisticsCAD: Demographics and Statistics
 84% of those who die from CAD are 65 or older
 If under the age of 65, 80% mortality rate with the first
myocardial infarction
 Within 1 year of initial MI:
– 25% of men and 38% of women will die
 Within 8 years of initial MI:
 50% of men and women under 65 will die
 An average of 11.5 years of life are lost due to an MI
 IMPORTANT:
– 50% of men and 64% of women who have died suddenly via
CAD DID NOT HAVE ANY PREVIOUS SYMPTOMS
 Sudden Death:
– Those with a previous history of MI have a 5-6 times Sudden
Death rate compared to the general population

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Exactly what is Coronary ArteryExactly what is Coronary Artery
Disease (Ischemic Heart Disease)Disease (Ischemic Heart Disease)
and how/why does it occurand how/why does it occur??
Start with anatomy…

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DefinitionDefinition
" Ischaemia " refers to an insufficient
amount of blood. The coronary arteries
are the only source of blood for the heart
muscle. If this coronary arteries are
blocked, the blood supply will reduce.

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Key ConceptsKey Concepts
Ischemic heart disease (IHD): caused by
coronary atherosclerotic plaque formation
which leads to imbalance between O2 supply &
demand
– results in myocardial ischemia
Chest pain: cardinal symptom of myocardial
ischemia caused by coronary artery disease
(CAD)
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Ischemic CycleIschemic Cycle
Ischemia / infarction
chest pain
Diastolic Dysfunction Systolic Dysfunction
cardiac output
catecholamines
MVO2
wall tension
LV diastolic pressurepulmonary
congestion
pO2
(heart rate, BP)

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 High blood cholesterol
 High blood pressure
 Smoking
 Obesity
 Lack of physical activity

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Risk FactorsRisk Factors
Uncontrollable
•Sex
•Hereditary
•Race
•Age
Controllable
•High blood pressure
•High blood cholesterol
•Smoking
•Physical activity
•Obesity
•Diabetes
•Stress and anger

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Why would there be an insufficient blood
supply to the heart?
– Remember that the coronary arteries are the
only source of fuel to the heart
– The coronary arteries may become
partially/completely occluded:
 Atherosclerotic Plaques

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Atherosclerotic Plaque:Atherosclerotic Plaque:
Definition and FormationDefinition and Formation
 Focal accumulation of smooth muscle cells,
foam cells, cholesterol crystals and lipid under
the endothelium of the artery (within the
Tunica Intima)
 Given time, this plaque can protrude into the
lumen of the vessel reducing blood flow
 Often develops at branch points or curves
within the vasculature  blood is slowed
and/or turbulent

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Atheroma/ AtheroscleroticAtheroma/ Atherosclerotic
PlaquePlaque
 Where does the plaque begin? 
within the Tunica Intima, the
innermost wall of the artery
 What is a plaque made of?
– Superficial fibrous cap made of
smooth muscle cells, collagen,
elastin and proteins
 Also contains Macrophages,
Foam Cells, T Cells
 Foam cells are one of the first cells
found at the site of the fatty streak,
which is the beginning of
atherosclerotic plaque formation in
vessels
– Necrotic Center of cholesterol
crystals, lipids, Apolipoprotein B
 LDL

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Atheroma: ContinuedAtheroma: Continued
 As the atheroma within the coronary arteries
enlarges, the blood flow to the heart decreases
and therefore so does the O2 supply
 The heart is not in danger of hypoxia until 50%
of the vessel is occluded
 As the heart senses a decrease in O2, there is
attempted compensation:
– Increase Heart Rate
– Increase Blood Pressure
– Aggravation/Worsening of the atheroma
 When 70% of the artery is occluded, Angina
Pectoris will occur

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Ischemic Heart DiseaseIschemic Heart Disease
Classification = mainly 4 types
– Myocardial infarction (MI)
– Sudden cardiac death
– Angina pectoris
– Chronic IHD with heart failure

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Angina PectorisAngina Pectoris
 At least 70% occlusion of
coronary artery resulting in pain.
What kind of pain?
– Chest pain
– Radiating pain to:
 Left shoulder
 Jaw
 Left or Right arm
 Usually brought on by physical
exertion as the heart is trying to
pump blood to the muscles, it
requires more blood that is not
available due to the blockage of
the coronary artery(ies)
 Is self limiting usually stops
when exertion is ceased

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Angina Pectoris ContinuedAngina Pectoris Continued
Angina Pectoris can be Stable or
Unstable:
Stable:
– The pain and pattern of events is unchanged
over a period of time (months years)
Unstable:
– The pain and pattern is changing, be it in
duration, intensity or frequency
– A Myocardial Infarction waiting to happen

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Myocardial InfarctionMyocardial Infarction
 Partial or total occlusion of one or more of the
coronary arteries due to an atheroma,
thrombus or emboli resulting in cell death
(infarction) of the heart muscle
 When an MI occurs, there is usually
involvement of 3 or 4 occluded coronary vessels

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Myocardial Infarctions:Myocardial Infarctions:
StatisticsStatistics
 250,000 deaths per year.
 30% mortality within the first 2 hours
 45 Minutes of Ischemia:
– Cardiac muscle death occurs
 How is the Diagnosis Made?
– Electrocardiographic changes
 ST elevation
– Myocardial enzyme elevation
 Creatine kinase
 Troponin
 C Reactive Protein

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MI, AtheromaMI, Atheroma
 When there is an atheroma, as mentioned
before there can be rupture resulting in
thrombus formation because of the build up of
platelets
 When there is breakage of the thrombus there
is emboli formation
 An emboli can travel to the brain (cerebral
infarct) can remain in the heart (myocardial
infarct) or even travel to the extremities cutting
off blood supply
 As the area beneath the is disrupted atheroma
hemorrhages, there can is increased risk of
abscess formation and infection

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Complications ofComplications of
Myocardial InfarctionsMyocardial Infarctions
Infarction leading to inability of the
heart to function properly leading to
Heart Failure
Angina/Pain
Cardiogenic shock
Ventricular aneurysm and rupture
Embolism Formation
Arrhythmias  Myocardial Infarctions
can lead to Ventricular Fibrillation
(shockable!)

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Sudden DeathSudden Death
 Sudden Death :
– 250,000 deaths in the US per year are caused by
what is referred to as “sudden” cardiac death
– Sudden Cardiac Death is also known as a “Massive
Heart Attack” in which the heart converts from
sinus rhythm to ventricular fibrillation
– In V-Fib, the heart is unable to contract fully
resulting in lack of blood being pumped to the vital
organs
– V-Fib requires shock from defibrillator
“SHOCKABLE RHYTHM”

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Many people are able to manage
coronary artery disease with lifestyle
changes and medications.
Other people with severe coronary artery
disease may need angioplasty or surgery.

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Management of IschemicManagement of Ischemic
Heart DiseaseHeart Disease::
 Pharmaceuticals:
– Beta Blockers
 Act either selectively or non-selectively on Beta receptors:
– Beta 1 cardiac muscle  increase rate and contraction
– Beta 2 dilates bronchial smooth muscle
– Ca++
Channel Blockers
 Acts on vasculature blocking Ca++ and causing vasodilation
– Nitrates
 Vasculature vasodilation
– Anti-Hypercholesterolemia
 HMG CoA Reductase Inhibitors  reduction in “manmade”
cholesterol thus helping to reduce atheroma formation
– Antiplatelet Medication:
 Clopidogrel (Plavix)
 Aspirin

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Surgical TreatmentSurgical Treatment
1) Stenting
2) Angioplasty (balloon)
3) Bypass surgery

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Management of IschemicManagement of Ischemic
Heart Disease:Heart Disease:
 Lifestyle:
– Diet
– Exercise Preventive treatment
• Low fat, low cholesterol diet
• Cessation of smoking
• Red wine (in moderation)

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Nursing AssessmentNursing Assessment
1.
1. Gather information about all facets of the client’s
activities, especially those that precede and precipitate
attacks of anginal pain.
2. Assess the risk factors in the client’s history and
modifications possible to reduce risk.
3. If chest discomfort is present at the time of the
interview, further collection of data is delayed until
pain and dysrhythmias are resolved.
4. A complete physical assessment is performed to
identify the presence of chest, epigastric, jaw, back, or
arm discomfort which is then rated on a subjective
scale of 1 to 10 in intensity. The client is questioned
regarding nausea, vomiting, diaphoresis, dizziness,
weakness, palpitations, and SOB

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Nursing DiagnosisNursing Diagnosis
1. Pain related to myocardial ischemia.
2. Altered tissue perfusion: related to
imbalance between myocardial oxygen
supply and demand.
3. Anxiety related to fear of death and
knowledge deficit

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Nursing Plan and InterventionsNursing Plan and Interventions
Goals
1. Prevention of pain.
2. Improved tissue perfusion as
evidenced by absence of chest pain and
absence of dysrhythmias.
3. Reduction of anxiety and increased
knowledge of disease process.

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Nursing InterventionsNursing Interventions1. The nurse must teach the client the link between symptoms and
activity and the need to avoid activities known to cause angina,
such as sudden exertion, exposure to cold, and emotional
excitement.
2. Medications used in the treatment of angina include nitrates, beta-
blockers, calcium channel blockers, and platelet antiaggregants.
Administer cardiac medication as prescribed and be alert for
adverse side effects, particularly their effect on blood pressure.
Teach the client the symptoms to be aware of and what measures
to take.
3. Encourage the client to remain on bedrest in order to decrease
cardiac workload and oxygen consumption.
4. Administer oxygen therapy as prescribed.
5. Evaluate vital signs hourly to determine the hemodynamic effect of
the drugs and the client’s tissue perfusion.
6. Nursing care should be planned so that minimal time is spent away
from the bedside due to the high level of client anxiety, as well as
the unstable condition of the patient.

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Nursing InterventionsNursing Interventions
7. Clients with unstable angina are at high risk for
myocardial infarction (MI) and sudden death. The
nurse watches for development of heart failure and
dysrhythmias.
8. Relieving pain is the top priority for the client with an
acute MI, and medication therapy is administered to
accomplish this goal.
9. Maintain patent IV for administration of fluids and
vasodilators and anticoagulant therapy (Nitroglycerin
and heparin). They relieve pain and they aid in
minimizing permanent injury to the myocardium.
10. Prepare for possible emergency heart
catheterization or CABG.

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Nursing InterventionsNursing Interventions
11. Whether CABG is planned as an elective procedure or
performed on an emergency basis, the nurse should try
to alleviate the client’s and the family’s anxiety and
assist them in understanding the need for this life-
saving procedure.
12. The nurse describes the postoperative course,
emphasizing the close monitoring and use of
sophisticated equipment. The client is encourage to tell
the nurse about any discomfort post-op.
13. Encourage the client and family members to verbalize
their fears and concerns.
14. Teach the client the nature of the illness and the facts
needed to reorganize living habits in order to reduce
the frequency and severity of anginal attacks, delay the
progress of the disease, and avoid other complications.

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EvaluationEvaluation
1. Verbalizes relief of chest pain.
2. No signs of respiratory difficulties.
3. Modifies lifestyle in order to prevent
future attacks.
4. Demonstrates increased knowledge of
disease process and reduction in
anxiety.
5. Absence of complications.