A.

Physiology of the Heart:

• Tricuspid valve - separates the right atrium from the right ventricle
⁃ Mitral valve - separates the left atrium from left ventricle.
• Pulmonic semilunar valve and Aortic semilunar valve- helps control the
flow of blood from the ventricles to the lungs and systemic function

B. The Heart's Electrical Conductivity

• Starts with the Sino-atrial (SA) node - the pace maker; the one that
initiates an impulse.
• Then the impulse travel to the AV node, then to the Bundle of His,
to the left and right branches and finally to the Purkinje fibers.
• These electrical activities stimulate the heart to contract (in the
cardiac muscle, impulses are transmitted by action potential).

C. Process of Conduction
a. phase 0 - depolarization - the SA node initiates an impulse
⁃ there will be influx of sodium into the cardiac cells
⁃ make the membrane potential more positive
• phase 1 - transient potassium channel opens creating negative
• phase 2 - calcium channels open causing influx of calcium into the
cells creating a plateau formation in' the action potential of the heart

d. phase 3 - repolarization
- potassium channels open causing efflux of potassium out of the cardiac cells
which make the membrane potential more negative again

e. phase 4 - resting phase

Depolarization - the electrical activation of the muscle cells of the heart and
stimulates cellular contraction.

Repolarization - returning
(P-Wave)
to the original state of electrolyte balance up to resting state.

✅This electrical activity stimulates the heart to contract.

• When impulse travel from SA node to AV
node, the atria depolarize and repolarize this will stimulate the atria to
contract.
• When impulse travel from AV node to Purkinje fibers, this will stimulate the
ventricles to contract.
One contraction of the atria and one contraction of the ventricle is one heartbeat
which represents one cardiac cycle.

D. Cardiac cycle
- refers to events taking place in the heart heartbeat.
• The right atrium receives venous blood systemic circulation
• Left atrium receives reoxygenated bloo the lungs.

Stroke volume (SV) - the volume of blood that is ejected during systole.
• The average stroke volume is 50 - 100 ml/beat.
Factors affecting the stroke volume
• Preload
• Afterload
• Contractility

a. Preload - this refers to the volume of blood that is already in the heart before
it contracts.
⁃ the filling volume of the ventricle at the end of diastole
 ⁃ This is all the venous return.Factors affecting preload
1. Position - standing will cause pulling of blood into the lower
extremities causing a decrease preload while supine position increases venous
return
2. Breathing - deep inspiration causes an increase in venous return
while the Valsalva maneuver decreases venous return

b. Afterload - this refers to the pressure that must be exceeded by the heart
before it contracts, such pressure is the blood pressure in the aorta.
⁃ the amount of resistance against which the left ventricle pumps
⁃ Therefore, if BP increases, the heart must exert too much pressure to
pump blood into the aorta.Factors affecting afterload
1. Hypertension
2. Atherosclerosis of the aorta

c. Contractility - defined as the strength of myocardial fiber during systole

- increase contraction also increases stroke volume and decrease contraction
decreases stroke volume
/ Frank-Starling law states
"the greater the stretch, the greater the force of next contraction."

Factors affecting Heart Rate

• Sympathetic Nervous System
• Parasympathetic Nervous System
• Thyroid hormones
• Temperature
• Exercise •
Mean Arterial Pressure (MAP) = is the average of the BP
MAP = SP + 2DP
—————
3
Blood Pressure
⁃ defined as the tension exerted by blood on the arterial walls
⁃ BP = CO x TPR or SVR
Cardiac Output (CO)
• the amount of blood ejected from the heart in 1 minute.
• CO = SV x HR

Physiologic principles of hemodynamics:

Factors that affect myocardial function
⬇️
Regulate BP
⬇️
Determine cardiac performance and cardiac output

WHAT IS HEMODYNAMIC MONITORING?

Measure of the pressures of the cardiovascular and circulatory system
Goals:
• Ensure adequate perfusion
• Detecting inadequate perfusion
• Titrating therapy to specific end point
• Qualifying the severity of the illness
• Differentiating system dysfunction

WHAT TO MONITOR?
• Direct arterial BP monitoring
• CVP (Right or Left atrial pressure) monitoring
• Indirect measurements of left ventricular pressures (eg.Pulmonary
artery catheters, Swan-Ganz catheters)
 • Pulmonary Arterial Catheter is a percutaneous, non-tunneled, multi-
lumen, flow directed, central venous catheter that is inserted through an
introducer into a large vein:V internal jugular (L) or (R)/ femoral vein
Vantecubital vein
• a tool for observing fluid balance (cardiopulmonary problems).

Sample catheter:
• A balloon-tipped Swan-Ganz catheter is commonly used.
• Standard PAC is 7.0, 7.5 or 8.0
French in circumference and 110 cm in length divided in 10 cm intervals
• PAC has 4-5 lumens:


Parameters measured:
1. Central Venous Pressure (CVP) - the blood pressure in the vena cava;
reflects the amount of blood returning to the heart and the ability of the heart to
pump the blood back into the arterial system
2. Pulmonary Artery Pressure (PAP) - reflects RV function, pulmonary
vascular resistance, and LA filling pressures (measured at the tip of the PAC with
balloon deflated)
3. Pulmonary Capillary Wedge Pressure (PCWP) - also known as the pulmonary
artery occlusion pressure (PAOP); provides an indirect estimate of left atrial
pressure

Complications:
1. Dysrhythmias
2. Thromboembolism
3. Mechanical, catheter knots
4. Pulmonary Infarction
5. Infection, Endocarditis
6. Endocardial damage, cardiac valve injury
7. Pulmonary Artery Rupture

Nursing Care
• During PAC insertion: check for the signed consent and follow aseptic
techniques
• Tubing is a source of infection (follow hospital protocol in changing
the tubing;
• usually after 3-5 days)
• Educate client regarding the procedure of catheter care
•
• Monitor the pressures regularly or as indicated
• Catheter connection attachments must be checked frequently if they are
secure (prevent air embolism)
• Take measurements with routine intervals on supine & at ≤25° HOB
elevation
• > When taking PAP = deflate the balloon
• • When taking PCWP = inflate the balloon
• > When taking CVP = supine (45° if orthopneic)
• • Transducer should be at RA level (midaxillary line at 4th ICS)

NORMAL VALUES:
Cardiac Output (CO) - 4.0 to 8.0 L/min Cardiac Index (CI) - 2.5 to 4.3 L/min/m2
Stroke Volume (SV) - 50 - 100 mL/beat
Mean arterial pressure (MAP) - 70 to 105 mmHg
Right arterial pressure (RAP) - 2 to 8 mmHg
Pulmonary artery wedge pressure (PAWP) - 8 - 12 mmHg
Systemic vascular resistance (SVR) - 800 to 1200
dynes/s/cm-5
CARDIOVASCULAR DISEASE

Cardiovascular Diseases
• The failure of the cardiovascular system's main elements to perform
properly is known as Cardiovascular Disease
• Cardiovascular system is also known as Circulatory system
• The main elements are:
• Heart
• Veins
• Arteries
• Blood capillaries



CORONARY ARTERY DISEASE (CAD)

• also known as coronaryHEART disease (CHD)
• describes heart disease caused by impaired coronary blood flow
• Common cause - is atherosclerosis

CORONARY ARTERY DISEASE (CAD)

• CAD can cause the following:
⁃ Angina.
⁃ Myocardial Infarction
⁃ Cardiac dysrhythmias
⁃ Conduction defects
⁃ Heart failure
⁃ Sudden death
• Men are more often affected than women
• Approximately 80% who die of CHD are 65+ y/o

CORONARY ARTERY DISEASE (CAD)

Physical Assessment
Jugular venous
pressure
• Inspection:
⁃ Skin color
⁃ Respiration
⁃ Peripheral edema
• Palpation:
⁃ Peripheral pulses

CORONARY ARTERY DISEASE (CAD)

• Auscultation:
⁃ Heart sounds (presence of S in adults & S4)
⁃ Murmurs - audible vibrations of the heart & great vessels produced by
turbulent blood flow
⁃ Pericardial friction rub - extra heart sound originating from the
pericardial sac.
⁃ may be a sign of inflammation, infection, or infiltration
⁃ described as a short, high-pitched scratchy sound

CORONARY ARTERY DISEASE (CAD)

Common Clinical Manifestations:
• Dyspnea on exertion - may indicate decreased cardiac reserve
• Orthopnea - a symptom of more advanced heart failure
• Paroxysmal nocturnal dyspnea - severe SOB that usually occurs 2-5hrs
after onset of sleep
• Chest Pain - may be due to decreased coronary tissue perfusion or
compression & irritation of nerve endings.
•
• Edema - increased hydrostatic pressure in venous system causes shifting
of plasma resulting to interstitial fluid accumulation
• Syncope - due to decreased cerebral perfusion
• Palpitations
• Fatigue

Diagnostics:
•Cardiac Enzymes/Cardiac Markers
1st: Myoglobin - is a small protein that stores oxygen
• in addition to troponin to help diagnose a heart attack
• Urine = 0 - 2mg/dL (Twithin 30mins - 2hrs afterthe attack or MI)
• blood = <70mg/dL

3rd: Creatinine kinase (CK) - intracellular

• enzymes found in muscles converting ATP to ADP
* CK-MB (creatine kinase-myocardial band) - specific to myocardial tissue
• (rises 4-6hrs after the attack & decreases to normal within 2-3days)
• male = 12-70 mg/dL
• female = 10-55 mg/dL

Diagnostics:
4th: LDH (Lactate dehydrogenase) - it is mainly used to check for tissue damage
• LDH1 - most sensitive indicator of myocardial damage)
• 45-90mg/dL - within 3-4 days & remains elevated for 14 days

Diagnostics:
• Treadmill Stress Test
• It is an ECG monitoring
ECG Tracing
during a series of activities of patient on a treadmill
Purposes:
• identify ischemic heart disease
• evaluate patients with chest pain
• evaluate effectiveness of therapy
• develop appropriate fitness program

✅ Treadmill Stress Test Instructions to patient:

• get adequate sleep prior to test
• avoid: caffeinated beverages, tea, alcohol, smoking, nitroglycerine on
the day before until the test day
• wear comfortable, loose-fitting clothes & rubber-soled shoes on the-
test day
• light breakfast on the day of the test
• inform physician of any unusual sensations during the test
• rest after the test

Pharmacologic Management for TST:

> IV vasodilators
• Dipyridamole - blocks cellular re-absorption of adenosine & increases
coronary blood flow 3-5x above baseline levels
• Adenosine - (endogenous vasodilator) - increase blood flow
• Dobutamine - used in patients with bronchospastic pulmonary disease
• increases myocardial O2 demand by increasing cardiac contractility, HR,
& BP

Diagnostics:
• Echocardiography - uses ultrasound to assess cardiac structure &
mobility
• Doppler U/S - to detect blood flow of artery & vein specifically of
lower extremities (No smoking 1hr before the test)
• Holter monitoring- portable 24hr ECG monitoring which attempts to
assess activities which precipitate dysrhythmias & its time of the day

✅MRI - to detect & define abnormalities in tissues (aorta, tumors, cardiomyopathy,

pericardial disease)
⁃ shows actual beating & blood flow; image over 3 spatial dimensions
⁃ Secure consent
⁃ Assess for claustrophobia
⁃ Remove metal items jewelries, eyeglasses)
⁃ Instruct client to remain still during the entire proceaure
⁃ Inform client of the duration (45-60mins)
⁃ CI: clients with pacemakers, prosthetic valves, recently implanted
clips or wires

Angina Pectoris
Angina Pectoris - the medical term for chest pain or discomfort due to coronary
heart disease.
• It occurs when the heart muscle does not get as much blood as it needs
due to the narrowed or blocked heart arteries
• Angina - to choke
• Angina is a symptom of CAD
• Symptomatic paroxysmal chest pain or pressure sensation associated with
transient ischemia



Types of Angina
A. Stable angina - the common initial manifestation of a heart disease
• Common cause: atherosclerosis
• Pain is precipitated by increased work demands of the heart (i.e.. physical
exertion, exposure to cold, & emotional stress)
• Pain location: precordial or substernal chest area

Stable Angina
* Pain characteristics:
> constricting, squeezing, or suffocating sensation
• Usually steady, increasing in intensity only at the onset & end of attack
• May radiate to left shoulder, arm, jaw, or other chest areas
• Pain Duration: < 15mins
• Relieved by rest (preferably sitting or standing with support) or by use of NTG.

Types of Angina
B. Unstable Angina - is chest pain that is sudden and often gets worse over a short
period of time.
• is a type of angina pectoris that is irregular or more easily provoked.
• It is classified as a type of acute coronary syndrome.

Types of Angina
C. Variant angina, also called Prinz metal angina
• This type of angina isn't due to coronary artery disease.
• It is caused by a spasm in the heart's arteries.

Variant/Vasospastic Angina (Prinz metal Angina)

• First described by Prinz metal & Associates in 1659
• Cause: Spasm of the Coronary artery disease (vasospasm) due to stenosis
• Symptoms: Severe chest pain is the main symptom. It is most often
occurs in cycle, typically at rest and overnight or same time each day usually at
early hours)
• The pain may be relieved by anginal medicine.

* Pain Characteristics: occurs during rest or with minimal exercise

- commonly follows a cyclic or regular pattern of occurrence (i.e... Same time each
day usually at early hours)
If client is for cardiac cath., Ergonovine (nonspecific vasoconstrictor may be
administered to evoke anginal attack & demonstrate the presence & location of spasm

Other Types of Angina

• Nocturnal Angina - frequently occurs at night (may be associated with
REM stage of sleep)
• Angina Decubitus - paroxysmal chest pain occurs when client sits or
stands up
• Post-infarction Angina - occurs after MI when residual ischemia may
cause episodes of angina

Classification of Angina
• Class I - angina occurs with strenuous, rapid, or prolonged exertion at
work or recreation
• Class II - angina occurs on walking or going up the stairs rapidly or
after meals, walking uphill, walking more than 2 blocks on the level or going more
than 1°flight of ordinary stairs at normal pace, under emotional stress, or in cold
• Class III - angina occurs on walking 1-2 blocks on normall or going 1
flight of ordinary stairs at
• Class IV - angina occurs even at rest

> Diagnostic Evaluation:

• Detailed pain history and Physical Assessment
• ECG or Holter monitoring
• TST
• Cardiac Imaging
• PET, MRI
• Echocardiography
• Cardiac Catheterization
• Coronary angiogram

> Treatment: directed towards MI prevention

• Lifestyle modification (individualized regular exercise program,
smoking cessation)
• Stress reduction
• Diet changes
• Avoidance of cold
• PTCA (Percutaneous Transluminal Coronary Angioplasty) may be indicated
if with severe artery occlusion

TREATMENT OF ANGINA PECTORIS

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
• Modification of risk factors (smoking, BP, lipids)
• Beta blockers
• Nitroglycerin
• Calcium channel blockers
• ACE Inhibitors
• Antiplatelet drugs
• Statins

> Drug Therapy

• Nitroglycerin (NTGs): vasodilators
 • max of 3doses at 5-min intervals
• With stinging sensation under the tongue - (normal)
• Advise clients to always carry 3 tablets
• Store meds in cool, dry place, air-tight amber bottle and change stocks
every 6 months
• Inform clients that headaches, dizziness, flushed face are common side
effects.
• For patches, rotate skin sites - usually on ACW

> Drug Therapy

• Nitroglycerin (NTGs) :vasodilatorsdeponits Transderm -patchv Nitrostat
- sublingualv Nitroglyn - oralv Nitro-Bid - intravenous

• B-adrenergic blockers:
✅VAtenolol (Tenormin)
✅Metoprolol (Lopressor)
✅Propranolol (Inderal)

*Propranolol - causes bronchospasm & hypoglycemia, do not administer to asthmatic &

diabetic clients

• Calcium channel blockers:

• Nifedipine (Calcibloc,Adalat
/ Diltiazem (Cardizem)
• Lipid lowering agents - statins:v Simvastatin
• Anti-coagulants:V ASA (Aspirin) v Heparin sodium v Warfarin (Coumadin)

> Nursing Management:
• Establish and maintain airway
• Anticipate the need for intubation
• Administer oxygen
• Start 2 intravenous lines
• Loosen clothes
• Monitor HR & rhythm
• Diet instructions (low salt, low fat, low
• cholesterol, high fiber);
• avoid animal fats
• Stop smoking and avoid alcohol
• Activity restrictions are placed within clients limitations.