hi there and welcome to cardiac one lecture so we'll talk a little bit about coronary um heart disease i was gonna say artery but same thing really affects about 13.2 million um isn't that crazy and about 650 000 deaths per year so this is an accumulation of an atherosclerotic plaque in the coronary arteries these plaques start developing at age about nine so diet of course is a big reflection of this problem contributes to angina acute coronary syndromes myocardial infarctions heart failure you name it it it really affects so much regarding the heart so it's the number one cause of death one of three will die of a cardiovascular disease and this is kind of an old statistic now but between 1999 and 2009 the rate of death from cardiovascular disease decreased by 32.7 so we started getting more aware of our diet and just exercise etc and it is it help it helps uh are you an older adult living in a healthy lifestyle if so you're likely to delay cardiovascular problems by at least seven to 14 years that's a lot so how much does it cost to have cardiovascular disease about 273 million per year i think we could use that money in other ways um and yes if you're thinking uh with just modifying our lifestyles could that change yes it could it just doesn't seem like it's that hard right but it is it's hard to be disciplined with diet exercise there's lots of distractions in life so here's the good news there are predictors to help decrease the risks of cardiovascular disease so meeting five of the seven of the following criteria decreases the likelihood of dying from heart disease by 88 okay ready they are don't be smoking so we we all know it's not a good it's not good for our health especially our heart to have a bmi of less than 25 so of course that's weight related um 150 minutes per week of moderate activity so 75 minutes of strenuous activity i read something recently that um if you just exercise six to seven minutes a day um really intensely that'll do it and so sometimes we'll say well i just don't really have time well most of us do have six or seven minutes but it's a matter of just doing it so healthy diet total cholesterol less than 200 a blood pressure less than 120 over 80 and a fast fasting plasma glucose of less than a hundred so those are those are the criteria so five of seven of those you'll decrease it by 88 pretty crazy so um biggest problems really um are the major controllable risk factors for both sexes um men have more coronary artery problems than women typically but it's smoking cholesterol diabetes high blood pressure and lack of exercise so non-controllable risk factors are related to age gender and family history so women have the onset of heart disease an average of 10 years later than men and their first heart attack 20 years later than men so that's kind of an interesting fact so why do women have less cardiovascular disease well estrogen protects our heart even after our ovaries die for about another 10 to 15 years so estrogen is a strong antioxidant it lowers ldl um c in particular which is kind of the you know the body it's an anti-inflammatory inflammation in our bodies has just causes so many problems so anytime we can decrease inflammation is a good thing however hormone replacement therapy is not cardio protective now we used to think it was it was one of the big reasons for women to take hormone replacement because we thought it was cardio protective but studies have kind of revealed that not to be true so prior to menopause menstrual bleeding decreases iron stores on a monthly basis women's iron stores are 50 percent less than men until menopause so iron acts as an oxidant on the ldl cholesterol so that oxidation puts ldl cholesterol into that arterial wall so once we stop menstruating iron levels creep up and the cardiovascular risk increases so isn't that interesting so actually we complain all our lives about you know having periods but it actually is is helping us in some ways so that's one of the reasons that they think women do not have as many problems this of course is not really testable information but super interesting what about family history father mother brother sister who first developed clinical coronary artery disease at an age younger than 45 to 55 for males and younger than 55 to 60 for females this could be predictive of a potential mi or stroke it's a modest predictor but still important to gather that information so it's it's pretty significant um the genetic factor so what can we do to decrease well cigarettes they're really big um if you just stop smoking right now you're going to have a 36 reduction in your cardiovascular risk that's huge um and appears at least as great as other secondary preventive therapies such as using statins um aspirin beta blockers ace inhibitors which you know of course a lot of focus has been on on those things but literally just smoking stopping smoking will decrease your risk by 36 percent that's that's a big chunk so stop smoking when right now smoking women um and we're not talking like attractive women here right women who smoke cigarettes have um their first heart attack almost 20 years earlier than women who don't smoke quit smoking now and the risk of heart disease drops rather quickly in only about two to three years reaching a baseline after 10 years if the patient cuts down but continues to smoke one to four cigarettes per day they will continue to have an elevated risk of of heart disease so cutting down really um you know it's good but it's not it's not the best ldls what about that cholesterol so we'd like to decrease the ldls to 70 or or less if you have cardiovascular disease diabetes high blood pressure or if you smoke so we'd like your triglycerides to be less than 150 that's milligrams per deciliter triglycerides typically are almost always really high in diabetics it also appears that hdls they've fallen out of favor and that's because of several evidence-based studies we used to think that if you had high hdls and a nice hdl to ldl ratio that that was you know really protective and that you were okay and this has been debunked now and so really we just look at ldls um that that's really the biggie as far as um treatment of statement statins etc so ldls they're they're the culprit and so what about the size of that molecule so interestingly enough we have different particle sizes and some ldls are worse than others so ldl particle size is really the most important so we have a pattern a which are large loose ldls in in their molecular size and then you have pattern b which are small dense molecules and they are prone to oxidation and penetrating the arterial walls forming those flatty fatty pack plaques that sometimes crack and attract platelets so which kind of molecules do you want you want a large and loose ones so those small and dense ones they can just warm their way into just about anything and then cause problems forming those those plaques so how do you find out your particle side yeah there is a test and the test is really not that expensive it's about 39 to 100 bucks it's usually not covered by insurance however which seems silly to me but you know whatever if the trigger glycerides are really high like typically diabetics then more than likely they will have the small indents so probably if you're a diabetic and you have high ldls you don't even need to take the test because they're going to be small and dense but um the drugs that specifically lower ldl cholesterol the statins are most effective when those ldls are small in den so statins really are the most effective drug then in in treating ldls so diabetes that's a that's a bad one 65 of people with diabetes die from some form of heart disease or stroke adults with diabetics are two to four times more likely to have heart disease or a stroke than adults without diabetes so women with diabetes have a greater risk of heart disease than men with diabetes not sure exactly why that is but when patients have both hypertension and diabetes we call that the deadly duo and it's a really common combination about 70 percent of the time this risk for cardiovascular disease doubles so diabetes and cardiovascular disease just not good so monitoring and keeping your blood sugars in the normal range is just really really important weight gain is that a bad idea um unfortunately yes um if a woman gains 44 pounds after high school her risk of heart disease increases by 250 does that make you want to go on a diet um obviously you uh you probably haven't gained 44 pounds since your high school um date but yeah it's it's not uh there's a lot of people who have gained that much weight um is all fat created equal no belly fat is worse so visceral fat is insulin resistant so um basically when you have a larger um abdomen you have a lot of visceral fat it's almost considered another endocrine organ a new or more tissue um so that produces adipocynes um and that um regulates so etipol kinds regulate glucose transport and boost inflammation responses so inflammatory mediators are produced by this visceral fat so you get specifically tumor necrosis factor alpha and interleukin-6 so do we need more inflammation in our bodies not a chance so interesting huh again this is not testable material but it's really interesting and i think as a nurse you know it's it's great to have this uh information so let's talk about angina so this is this is a big deal and of course this is really testable stuff this is a chest pain caused by a decreased coronary blood flow so decreased perfusion to the myocardium this causes that imbalance between myocardial blood supply and demand so basically your heart muscle is getting ischemic not good there are some real classic sites of anginal pain midsternal of course is really classic this can radiate up your neck and jaw and down typically your left arm so that's kind of your classic presentation women are rarely classic we like to have chest pain in kind of different spots this is why women typically are undiagnosed when it comes to angina but again classic would be your mid-sternal there are different types of angina stable as the first one we'll talk about and this occurs with just moderate or prolonged exertion this goes away by with rest so it's associated with an atherosclerotic plaque um so it's it's relief with rest or nitroglycerin so it's usually medically managed with agents like calcium channel blockers and beta blockers those are those are the most common nursing interventions with chest pain by far you see that this is capitalized in huge letters rest when we put our bodies to rest the oxygen supply is going to decrease so remember that angina is an oxygen problem you're just not getting that good oxygen to perfuse through the myocardium so the first thing that we should always do is have that patient sit down have that patient rest so this is a next slide really old picture it's been around for just everett's and lots of textbooks so it's it's this what's triggered by uh what triggers basically the angina so you see this kind of older guys coming out of a restaurant so he just ate a heavy meal he's stressed out he's a businessman he sees got his little you know briefcase there he's exposed to the cold and he's going up some stairs so he's physical you know exertion so um the classic things then that triggers stable angina are you know physical exertion exposure to cold uh being stressed out and eating a heavy meal unstable angina now this pain occurs increasingly so the pattern just gets worse usually occurs at rest or with or with activity and it causes limitations to any activity you are like oh i've got this pain i can't really move very well so if you have unstable angina you've got a big risk of an mi so between 10 and 30 percent will go on to progress in having an mi if you get the diagnosis of unstable angina 29 will die of an mi within five years so not not a good diagnosis there's another type of angina called variant angina or prims metal angina this is atypical because it's not due to like the the classic arterial plaque it is due to a coronary artery spasm so that makes it more unpredictable although most often it does happen at night but you don't have that atherosclerotic lesion involved so if this person had ongoing chest pain and they had a cardiac cath it would not show any occlusions remember that this one is caused by a spasm so let's talk about manifestations we've we've talked a little bit about it um chest pain typically again is substernal radiates across the sternum neck arms uh shoulder and jaw typically to that left arm pain is described as tight pressure constricting aching dull and constant this is really important i think because when we ask our patients you know are you experiencing any pain that's a really subjective thing so pain might be something that's sharp um but if it's you know like this pressure in your chest they're like no i'm not having any pain i've had this happen to me with a patient um who's like not had any pain but you know at the end of the shift like yeah i've been having this tight pressure in my chest all day like what yeah so make sure when you are assessing your patient and talking to them that you use words like please let me know if you have any tightness pressure anything constricting sometimes patients will describe it as like an elephant sitting on my chest that is something that needs to be reported to the nurse right away so as far as other associated symptoms they could get shortness of breath so dyspnea skin color of course most of you know i'm kind of big on that so pallor diaphoresis never a good thing especially at rest tachycardia anxiety and fear you can get indigestion nausea vomiting and and some upper back pain so this is why it's kind of hard when a patient comes in with chest pain to kind of fetter out other differential diagnosis so certainly i'm thinking about you know ulceration some sort of stomach problem is is definitely should be in there but of course we should always be leaning towards what is the most serious thing first so let's try diagnosing uh angina first of all history is good to obtain so you know is that chest pain at rest does it happen on exertion etc all the questions 1280 kg that's going to reveal the occurrence of the mi or angina and on the uh or angina on the location so we'll talk quite a bit in class about um 1280 kgs and kind of where to look but there's patterns of leads that represent the location on the heart so ischemic tissue does not repolarize normally and that's how we can look at an ekg and and tell so the focus is on that s t segment so with angina you're going to see st depression so another way of saying that is t wave inversion or sort of both so again this is something really important you need to know this if a person has angina that 12 lead ekg is going to have st depression t-wave inversion with an mi you're going to have elevation so that's much worse so again angina look for st depression