most common heart diseases

1. M Tayyab
Student of Anesthesia
kmu
1

2. 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.
2

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

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

6. Function
Right atrium receives
deoxygenated blood
Right ventricle pumps
blood to lungs

7. 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

9. 9

10. Aorta, arteries, arterioles, capillaries
Venules, veins, superior and inferior vena cava
Three layers
Intima
Media
Adventitia

12. Function
Circulation
Peripheral vascular resistance: viscosity, length,
diameter
Blood pressure control

13. Mechanical
Conduction system

14. 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
Cardiac reserve
Preload
Starling’s law
Afterload
Contractility

16. Electrical properties:
Action potential
Polarization
Depolarization
Repolarization
Refractory period

17. Filling and pumping
Diastole – ventricular filling
Systole –ventricles eject blood

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

20. Objective
General appearance
Skin
Wounds
Pulses
Jugular vein distention
Edema
Breathing

21. 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. 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. 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

24. 24Dr Ibrahim Bashayreh

25. Coronary Artery Disease
Heart Anatomy
Atherosclerotic Plaque/Atheroma
Angina Pectoris
Myocardial Infarction
Sudden Death
Overall Management
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26. 26

27. 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
27

28.  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
28

29. 29

30. Start with anatomy…
30

31. " 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.
31

32. 32
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)
32

33. 33
Ischemia / infarction
chest pain
Diastolic Dysfunction Systolic Dysfunction
cardiac output
catecholamines
MVO2
wall tension
LV diastolic pressurepulmonary
congestion
pO2
(heart rate, BP)

34. High blood cholesterol
High blood pressure
Smoking
Obesity
Lack of physical activity
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35. Uncontrollable
35
•Sex
•Hereditary
•Race
•Age
Controllable
•High blood pressure
•High blood cholesterol
•Smoking
•Physical activity
•Obesity
•Diabetes
•Stress and anger

36. 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
36

37. 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
37

38.  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
38

39. 39

40. 40

41. 41

42. 42

43. 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
43

44. Classification = mainly 4 types
Myocardial infarction (MI)
Sudden cardiac death
Angina pectoris
Chronic IHD with heart failure
44

45.  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
45

46. 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
46

47. 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
47

48. 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
48

49. 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
49

50. 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!)
50

51. 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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52. 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.
52

53.  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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54. 1) Stenting
2) Angioplasty (balloon)
3) Bypass surgery
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55. 55

56. Lifestyle:
Diet
Exercise Preventive treatment
• Low fat, low cholesterol diet
• Cessation of smoking
• Red wine (in moderation)
56

57. 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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58. 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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59. 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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60. 1. 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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61. 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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62. 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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63. 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.
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64. 2/11/2009 64
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