CARDIOVASCULAR DISEASE

CARDIOVASCULAR DISEASE:

        Cardiovascular disease is a disease of heart which affects the function and structure of the heart and its vessels.Cardiovacular diseae is also called Heart disease. cardiovascular disease are the leading cause of death worldwide.

CARDIOVACULAR DISEASES RISK FACTORS: 

There are 3 categories of cardiovascular disease risk factors  –

1.Major  risk factors which cannot be changed are –

• HEREDITY
• MALE GENDER 
• INCREAING AGE 

2. Major risk factors that preventable , modifiable and controlable are –

• High blood pressure
• Tobacco smoke
• Obesity
• Diabetes
• Tobacco smoke

3. Other risk factors are

• Stress
• Diet and nutrition
• Alcohol

                     This topic includes :

•  Heart diseases  and cardio vascular investingation  like cardiac markers ck-mb, troponin t and troponin i 
• Holter monitoring,
• cardiac catheterization
• CABG
•  PTCA (PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY)
• CARDIAC CATHETERIZATION
• ECG

COMMON CARDIOVASCULAR  DISEASE ARE :

• Diseases like Coronary artery Disease (CAD)
• Heart failure
•  Angina pectoris 
• Myocardial infarction ( MI)
• Peripheral Artery Disease
•  Pericarditis, myocarditis , heart transplantation , vericose vein  and reynolds disease and their management 

    

DIAGNOSTIC TESTS AND PROCEDURE :-

A .   Cardiac markers   :-

1. CK-MB (Creatine kinase, myocardial muscle) :-

• An elevation  in value indicates myocardial damage
• Total CK IS 26 -174 units/L

2. TROPONIN :-

• Troponin is composed of the protein troponin c ,troponin I, cardiac troponin T.
• Troponin I specially has high affinity for Myocardial injury it Rises within 3 hours and persist up to 7 days.
• Normal value  Troponin I  = LOWER than 0.6 ng/ml
• Troponin T =lower than 0.1 ng/ml

3. Complete Blood count (CBC) :-

• RBC decreases in rheumatic heart disease and infective endocarditis and increased in inadequate oxygen supply to the myocardial cells
• An elevated level of hematocrit level can result from vascular volume depletion

Electrolytes :-

1. Potassium :-

• Hypokalemia causes increase cardiac instability ventricular dysrhythmia and risk of digoxin toxicity.
• ECG :- Ftattening or inversion of T wave
• ***Appearance of U wave (important to identify hypokalemia)
• ST depression
• HYPERKALEMIA causes asystole and ventricular dysrythemia
• ECG :- TALL PEAKED T WAVE
• WIDENED QRS COMPLEX
• Flat P wave and prolonged PR INTERVAL

2. Calcium :-

• Hypokalemia can cause ventricular dysrhythemia
• ECG :- PRONLONGED ST AND QT INTERVAL
• Hyperkalemia  ECG :- SHORTENED ST AND WIDENED T WAVE.
• HYPERKALEMIA causes AV BLOCK cardiac arrest etc

3. Magnesium :-

• Low magnesium level can cause ventricular tachycardia and fibrillation
• High magnesium level can cause muscle weakness hypertension and bradycardia

1. HOLTER MONITORING:-

• Noninvasive test the patient wears in holter monitor and ECG tracing is recorded continuously over 24 hours while patient performs is daily activity of Living
• It identifies dysrhythemia if they occur and evaluate the effectiveness of antidysrhythemic or pacemaker therapy

2  . ECHOCARDIOGRAPHY :-

• By echocardiography heart chamber size is measured ejection fraction is calculated and flow gradient across valve is determined.

3.  MYOCARDIAL  NUCLEAR PERFUSION TESTS:-

• It includes thallium imaging multigrade cardiac blood pool imaging
• It evaluates cardiac motion and Cardiac ejection fraction

4. ELECTRON BEAM COMPUTED TOMOGHRAPHYY SCAN (EBCT) :-

• Determined calcification is present or not in arteries
• Coronary artery calcium(CAC) is provided
• A score higher than 400 requires intensive preventive therapy.

5. CARDIAC CATHETERIZATION :-

• Cardiac catheterization is Invasive test involving insertion of catheter into heart and surrounding vessel
• It also provide information about structure and performance of heart chamber ,valves and coronary circulation
• Preprocedure :- aseess for any allergy to seafood iodine and radiopaque, if allergic the patient may be premeditated with antihistamine and corticosteroid to prevent a reaction
• NPO from six to eight hours
• *** Take height and weight of the patient because it is needed to determine the amount of dye to be administered.
• Take baseline vitals and Note quality of presence of peripheral pulses for postoperative comparison

• Postprocedure :- monitor vital signs and Cardiac Rhythm for at least 30 minutes for two hour initially

• ***Monitor peripheral pulses and colour on warm sensation of extremity to the insertion site at least 30 minute for two hour initially

• Keep the extremity extended for 4 to 6 hours as prescribed .keeping the leg straight to prevent arterial occulsion

1. PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY  (PTCA) :—

• Invasive procedure in which one or more artery are dilated with a balloon catheter to open the vessel lumen and improve arterial blood flow

• Mostly used in myocardial infarction

• Pre procedure asses  baseline vital and peripheral process.

• Postprocedure :- monitor vital sign closely

• ***Asses distal pulses in both extremity

• Administer anticoagulant such as an antiplatelet agent

2  .  CORONARY ARTERY STENTS :-

• Coronary artery stent is is used with ptca
• A balloon catheter bearing the stent is inserted into coronary artery and position at the site of occulsion and ballon inflation deployes stents

3. ATHERECTOMY :-

• Is used to improve blood flow to Limb in individual with peripheral arterial disease also remove plaque from coronary artery

4. PERIPHERAL ARTERIAL REVASCULARIZATION  :-

• It is performed to increase arterial blood flow to the affected limb
• It involves bypassing the arterial occlusion by using a graft material
• Preprocedure : assess baseline vital and peripheral pulses
• Post procedure :- monitor BP and notify the physician If any changes occurs
• Expected outcome are warmth, redness and edema because of increased blood flow.
• Monitor graft ocvulsion which often occurs within 24 hours
• Encourage coughing and deep breathing exercise
• *** following after arterial revascularization monitor for Severe pain increase because pain is first indicator of postoperative graft occlusion

5  .  CORONARY ARTERY BYPASS GRAFTING (CABG) :-

• The occulded coronary artery are bypassed with patient’s own venous or arterial blood vessels.
• The sephanous vein or internal mammary artery are commonly used.
• Preoperative:- Diuretic medication should be discontinued 2 to3 days before surgery.
• Digoxin 12 hours before surgery  and aspirin and anticoagulant 1 week before surgery should be discontinued.
• Postoperative :–
• Mechanical ventilation for 6 to 24 hrs
• Mediastinal and test tube drainage should not exceed 100 to 150 ml per hour if it exceeds then report to doctor.
• Used are generally restricted to 1500 to 2000 ml/hr bcz patient has edema.
• Monitor blood pressure closely because of hyportension can collapse the vein graft and hypertension can cause increase pressure promoting leakage from suture line causing bleeding.
• Monitor patient for cardiac tamponade
• Cardiac tamponade includes adult stoppage of heavy mediastinal drainage jugular vein distention and pulses paradoxes.
• Sternotomy incision  Heals in 6 to 8 weeks

6. HEART TRANSPLANTAION :–

• Heart should be transplanted within 6 hours from the removal from the donor

• Symptom includes hypotension, dysrhythmia, weakness , fatigue and dizziness

***Normal sinus rhythm :-

Determination of heart rate using ECG :-

• Heart rate can be calculated by 6 second strip
• 30 large box are considered for 6 sec.
• Now count the P wave in 6 sec strip( i. E  count in 30 boxes)
• In this  ECG  NO. Of  P wave is 8
• Now multiply no. Of P wave by 10 u will get estimate heart rate
• In this ECG P WAVE is 8 so 8*10 = 80
• SO HEART IS 80 PER MIN
• We can also count by counting QRS complex
• Simply count QRS count in 6 sec then multiply by 10
• ***when in question if they ask about ventriculare rate or fibrillation etc then always count or consider QRS COMPLEX

SINUS TACHYCARDIA :-

• In this ECG NO. OF P WAVE IS 12
• Now multiply by 10 then heart rate will be 120

Atrial FIBRILLATION :-

• In atrial fibrillation no definative P wave can be seen only fibrillatory wave before QRS is seen.
• Intervention  : administer oxygen
• Administer anticoagulant bcz of risk of emboli
• Prepare pt for cardio version

VENTRICULAR TACHYCARDIA :-

• Here ventricular rate is 160
• In ventricular tachycardia rate ranges from 140 to 250 beats/min.
• Ventricular tachycardia can lead to cardiac arrest.
• Intervention :-
• 1. Stable patient with sustained VT :-
• ADMINISTER OXYGEN
• Administer antidysrhythemic medication
• 2. Unstable patient with VT (With pulse and sign symptoms of decreased cardiac output) :-
• Administer o2 and antidysrhythemic
• Prepare for synchronized cardioversion
• Can be performed CPR by asking patient to cough hard every 1 to 3 sec.

VENTRICULAR FIBRILLATION :-

• In VF there is no cardiac output
• VF is fetal if not terminated in 3 to 5 sec
• Patient with VF lacks pulse Bp , respiration and heart sound
• Intervention : initiate CPR
• Then defrilate the pt immediately with 120 to200 joules (Biphasic defibrillator)
• Or 360 joules (monophasic)
• CPR is continued for 2 min and cardiac rhythm is reassed
• Administer oxygen and antidysrhythemic medication

Management of Dysrhythmia :-

1 . Vegal maneuvers :-

• It is used to terminate supraventricular tachydysthmia
• Simple maneuvers may include holding the breath, coughing, and cold water applied to the face.

2. Carotid sinus massage :-

• Turn  the head away from the side to be massaged.
• Physician massages over one carotid artery for few seconds to determine whether change in cardiac rhythm occurs
• Patient should be on cardiac monitor
• Keep ready defibrillator and resuscitation equipment ready.

3. Valsava Maneuver :-

• Doctor instruct the patient to bear down aur induces a gag reflex in patient to stimulate vegal response
• Monitor heart rate, rhythm and BP

4  .  Cardioversion :-

• Cardioversion is synchronised countshock to convert an undesirable Rhythm to a stable rhythm.
• In cardioversion lower amount of energy used then with the defibrillation
• The defbrillator is synchronised to the patient ‘R’ wave to avoid the discharge on T wave and to avoid VF
• It is an elective procedure
• Digoxin is withheld 48 hrs before the procedure
• Postprocedure :-  priority assessment includes ability of pt to maintain airway and breathing
• Monitor cardiac rhythm and level of conciousness

5 . DEFIBRILLATION :-

• Defibrillation is an asynchronous counter shock used to terminate pulseless ventricular tachycardia or ventricular fibrillation.
• The defibrillator is chaged to 120 to 200  Biphasic or 260 joules  Monophasic
• Before DP relating the patient should be insured that oxygen is cutoff to avoid hazard of Fire
• Placement of paddle electrodes :-
• One pedal is placed at third intercostal space to the right of sternum and other is placed at 5th intercostal space on left mid axillary line

6. Pacemaker :-

• It is used to maintain and stimulation of heart rate when the patient intrinsic pacemaker fails to provide perfusing rhythm
• When a pacing stimulus is given to heart a SPIKE (straight verticle line) is seen on Ecg
• Spike preceding P wave indicates that Atrium is paced and a spike preceding QRS indicates ventricle is paced

• Patient with permanent pacemaker instruct them to report dizziness, weakness, chest pain or shortness of breath

CORONARY ARTERY DISEASE ( CAD) :-

• Coronary artery disease is narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis
• Atherosclerosis is an accumulation of lipid containig plaque in the arteries
• Intervention :- PTCA  to compress palque against wall of arteries
• CABG to improve blood circulation
• Medication includes nitrates to dilate coronary arteries
• Calcium channel blocker like amplodipine to dilate coronary arteries and reduce vasospasm

ANGINA :-

• Angina chest pain resulting from myocardial ischemia
• Patterns of Angina :-
• 1. Stable Angina :  – also called exertional angina
• Occurs with activities of hard work or emotional stress and relieved by rest and nitroglycerine

• 2.  Unstable Angina :- Also called preinfarction angina

• Occurs with unpredictable degree of exertion  and increaese in occurrence duration

• Pain is not relieved by nitroglycerine

• 3 . Varient Angina :  Also called Prinzmetal’s angina or vasospastic angian

• May occurs at rest and result from coronary artery spasm

• 4. Preinfarction Angina :-

• It lasts longer than 15 min

• Chest pain that occurs days to week before an MI

• Intervention :- administer o2, asses vital sign
• Nitroglycerine to dilate coronary arteries
• Provide bed rest in semi fowler position

MYOCARDIAL INFARCTION (MI) :-

• Myocardial infarction occurs when myocardial tissue lack of oxygen supply
• Infarction does not occurs instantly but involves several hours
• After 48 hours then fasted area turns grey with yellow streaks developing neutrophils

• ECG SHOWS  ST segment elevation and T wave inversion and abnormal Q Wave

• Location of MI in Ecg at different leads

• Lateral MI :  lead 1st , aVL, V5 and V6

• Infrior MI : 2ND 3RD  AND aVF

• Septal MI :- V1 and V2

• Anterior MI : V3 AND V4

• Assessment :– substernal crushing pain

• Pain may rediate to jaw, back and left arm

• Pain occurs primarily in morning

• Diaphoresis, nausea and vomiting

• Feeling of fear and anxiety

• Trop t test shows positive result

• Intervention :- administer o2 and morphine or nitroglycerine as prescribed

• Ensure bed rest with semi fowler position

• Administer antidysrhythemic medication

• Administer beta blocker like lebatalol to slow the heart rateand increase myocardial perfusion

• **monitor BP closely, if systolic BP is lower than 100mmhgor 25 mmhg lower than previous reading then lower the head of bed and notify to doctor

• Complication of MI :

DRESSLER’S SYNDROME:-  A combination of pericarditis, pericardial effusion and pleural effusion which can occur several weeks to month after a MI

HEART FAILURE :-

• Heart failure is the inability of heart to maintain adequate cardiac output to meet the metabolic need of body bcz of impaired pumping ability.

• In 1st degree heart block PR interval will be long
• In 2nd degree PR will be long long and drop
• **signs of left ventricular failure are evident by pulmonary system

CARDIOGENIC SHOCK :-

• Cardiogenic shock is failure of heart to pump adequetly therby reducing cardiac output
• Assessment :- **BP lower than 90mmhg systolic
• Urine output lower than 30ml/hr
• Poor peripheral pulses, cool skin
• Tachycardia, tachypnea
• CVP will rise in cardiogenic shock
• Pulmonary congestion  and disorientation,and restlessness
• Intervention :-  administer morphine sulohate iv as prescribed to decrease pulmonary congestion
• Administer o2
• Administer diuretic and nitrates  while monitoing Bp
• Administer vasopressors and inotropes like dopamine
• Assist in insertion of pulmonary artery catheter to asses degree of heart failure.

Hemodynamic monitoring:-

Central venous pressure (CVP) :-

• The CVP is pressure within superior vena cava, it reflects the pressure under which blood is returned to superior vana cava and right atrium
• The CVP is measured with central line.
• Normal CVP IS 3 to 8 mmhg
• ****Elevated CVP indicates an increase in blood volume, excess iv fluids and kidney failure
• ***Decreased CVP indicates decrease in circulating blood volume, that may be due to hemorrhage, severe vasodilation etc.

Measuring CVP :-

• ***Patient should be supine, with head of bed elevated at 45 degree.
• The right Atrium is located at midaxillary LINE at fourth intercostal space the zero point on the transducer needs to be at the level of right Atrium.
• *** if the patient is on ventilator the reading should be taken at the point of end of respiration

PULMONARY ARTERY PRESSURE :-

• Pulmonary artery wedge pressure(PAWP) is normally ranges from 4 to 12 mmhg
• PAWP Elevated level indicates left ventricular failure hypervolemia mitral regurgitation
• Normal pulmonary artery pressure is 15 to 26 mmhg systolic /5 to 15 mmhg diastolic

**MEAN ARTERIAL PRESSURE (MAP) :-

• NormaL MAP IS 60 TO 70 mmhg

• It is acute or chronic inflammation of pericardium
• Heart failure and cardiac temponade may occur
• Assessment
• ***pain is aggravated by Breathing (perticularly inspiration) , coughing and swallowing
• Pain is worse when in supine position and relieved by leaning forward.
• Pericardial friction rub scrachy and high pitched sound
• Fiver and chills
• Increased Wbc
• ECG:- St segment elevation and arterial fibrillation is common
• Intervention :-
• High fowler position and leaning forward position
• Administer analgesic, NSAID or corticosteroid
• Monitor signs of cardiac temponade

MYOCARDITIS :-

• Inflammation of myocardium(middle layer)
• Assessment :- fever, pericardial friction rub
• Murmur sound like fluid is passing an obstruction
• Pulsus alternas ( alternating strong and weak pulses)
• Tachycardia and fatigue and dyspnea
• Intervention same as pericarditis

ENDOCARDITIS :-

• Inflammation of endocardium (inner most layer of heart)
• Occurs primarily in IV drug abuser, valve replacement patient
• Portal of entry of organism is oral cavity like dental procedures
• Assessment :- fever, anorexia, weight loss
• Cardiac murmur, heart failure
• Pitechie
• Splinter hemorrhage in nail beds
• Osler’ s node ( redish tender lesion on pads of finger, hand and toes
• Janeway lesion ( non tender hemorrhagic lesion on finger, toes, nose
• Clubbing of finger
• Janeway lesion pic

• Intervention :- provide adequate rest
• Monitor signs of splenic emboli ( sudden abdominal pain radiating to left shoulder and rebound tenderness)

CARDIAC TEMPONADE :-

• Cardiac Tempo restricts ventricular filling and cardiac output drops
• Pericardial effusion places the patient at risk of cardiac tamponade( an accumulation of fluid in pericardial cavity)
• Fluid of 20 to 50 ml in pericardiun can result in cardiac temponade.
• Assessment:- pulses paradoxus(abnormally large decrease in systolic bp and pulse wave amlitude during inspiration)
• Increased CVP ( NORMAL cvp is 3 to 8 mmhg)
• Jegular vein distension
• Narrowing pulse pressure
• Intervention:--critical care unit for hemodynamic monitoring
• Prepare for pericardiocentesis

VERICOSE VEIN :-

• Distended and protruding vein
• Assessment :- pain in legs with dull aching after standing
• Ankle edema

Trendelenburg’s  Test:-

• Keep the patient supine with legs elevated
• When the patient sits up, if vericosities are present, veins will fill from proximal end, normally veins fills from distal end.

Raynaud’s disease :-

• It is vasospasm of the arterioles and arteries of upper and lower extremities
• Attacks are intermittent and occurs with exposure to cold and stress
• Affects fingers, toes, ears and cheeks
• Intervention:- monitor pulse.
• Administer vasodilators
• Avoid smoking
• Wear warm clothing, socks etc

BUERGER’S DISEASE :-

• It is an disease of median and small arteries and veins
• The distal upper and lower Limb are mostly affected
• Assessment :- intermittent claudication(
• Ischemic pain occurs at digits at night
• Cool, numb sensation
• Intervention :- instruct patient to stop smoking
• Monitor pulses

AORTIC ANEURISM

THORACIC ANEURISM :-

• Assessment :-
• Pain extending to neck, shoulder abdomen
• Dyspnea, cynosis and tachycardia
• Hoarseness difficulty in swallowing
• ** DECRONgraft is used in abdominal thoracic aneurism surgery

EMBOLECTOMY :-

• Removal of an embolus from from an artery using a catherter

HYPERTENSIVE CRISIS :-

• It is any clinical condition requiring immediate bp reduction
• It is an medical emergency
• Assessment:-
• Bp diastoli higher than 120 mmhg
• Headache, confusion and drowsiness
• Blurres vision
• Intervention :-
• Maintain patent airway
• Administer antihypertensive medication like DAIZOXIDE,  SODIUM NITRO PRUSSIDE
• Check bp every 5 min
• Elevate head of bed at 45 degree
• Insert foleys catheter
• Monitor urine output

Also practice mcq on cardiovascular disease

Download pdf  here : Cardiac system disorders pdf