ANSWER
The cardiovascular system comprises the heart and its associated blood vessels. Endocarditis, rheumatic heart disease, and conduction system abnormalities are just a few of the problems that can arise in the cardiovascular system. Cardiovascular disease, also known as heart disease, encompasses four distinct conditions: coronary artery disease (CAD), also known as coronary heart disease (CHD), cerebrovascular disease (CVD), peripheral artery disease (PAD), and aortic atherosclerosis. CAD is caused by decreased myocardial perfusion, which causes angina due to ischemia and can lead to a heart attack (MI) and heart failure. It is responsible for one-third to one-half of all cardiovascular disease cases. Cerebrovascular disease is the term used to describe strokes, cerebrovascular accidents, and transient ischemic attacks (TIAs). Peripheral arterial disease (PAD) is an arterial disease that primarily affects the limbs and can cause claudication. Aortic atherosclerosis is a condition that is linked to thoracic and abdominal aneurysms. This activity examines the evaluation and treatment of cardiovascular disease, as well as the medical team’s role in these processes.
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Objectives:
Examine the origins of coronary artery disease.
Explain the pathology of atherosclerosis.
Summarize the heart disease treatment options.
Outline the evaluation and treatment of cardiovascular disease, as well as the medical team’s role in this process.
Get free multiple-choice questions on this subject.
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Introduction
The heart and blood vessels make up the cardiovascular system.
[1] The cardiovascular system can suffer from various issues, including endocarditis, rheumatic heart disease, abnormalities in the conduction system, and cardiovascular disease (CVD) or heart disease. Refer to the four entities at the heart of this article[2]:
Coronary artery disease (CAD): Also known as Coronary Heart Disease (CHD), this condition is caused by decreased myocardial perfusion, which causes angina, myocardial infarction (MI), and heart failure. It accounts for one-third to one-half of all CVD cases.
Cerebrovascular disease (CVD): This term encompasses stroke and transient ischemic attack (TIA)
PAD (peripheral artery disease): Arterial disease involving the limbs, which can cause claudication.
Aortic atherosclerosis: This condition includes thoracic and abdominal aneurysms.
Visit: Etiology
Although CVD can be caused by a variety of etiologies, such as emboli in a patient with atrial fibrillation leading to ischemic stroke or rheumatic fever leading to valvular heart disease, addressing risk factors associated with the development of atherosclerosis is critical because it is a common denominator in the pathophysiology of CVD.
The current consumerism and technology-driven culture, associated with longer work hours, longer commutes, and less leisure time for recreational activities, may explain the significant and steady increase in CVD rates over the last few decades. Physical inactivity, a high-calorie diet, saturated fats, and sugars are linked explicitly to the development of atherosclerosis and other metabolic disturbances such as metabolic syndrome, diabetes mellitus, and hypertension, all of which are common in people with CVD. [3] [2] [4] [5]
According to the INTERHEART study, which included participants from 52 countries, including high, middle, and low-income countries, nine modifiable risk factors accounted for 90% of the risk of having a first MI: smoking, dyslipidemia, hypertension, diabetes, abdominal obesity, psychosocial factors, fruit and vegetable consumption, regular alcohol consumption, and physical inactivity. It is worth noting that smoking was responsible for 36% of the population-attributable risk of MI in this study. [6]
Other extensive cohort studies, such as the Framingham Heart Study[7] and the Third National Health and Nutrition Examination Survey (NHANES III)[5], have discovered a strong relationship and predictive value of dyslipidemia, high blood pressure, smoking, and glucose intolerance. Sixty percent to ninety percent of CHD events occurred in people with at least one risk factor.
The American Heart Association has translated these findings into health promotion programs, emphasizing seven recommendations to reduce the risk of CVD: avoid smoking, be physically active, eat healthily, and maintain normal blood pressure, body weight, glucose, and cholesterol levels.
Non-modifiable factors such as family history, age, and gender, on the other hand, have different implications.
Family history is considered an independent risk factor, particularly premature atherosclerotic disease defined as CVD or death from CVD in a first-degree relative before age 55 (in males) or 65 (in females).
There is also evidence that CVD risk factors may influence gender differently.
Diabetes and smoking more than 20 cigarettes per day, for example, increased CVD risk in women compared to men.
CVD prevalence rises significantly with each decade of life. [12]
HIV (human immunodeficiency virus),[13] a history of mediastinal or chest wall radiation,[14] microalbuminuria,, and elevated inflammatory markers[16][17] have all been linked to an increased rate and incidence of CVD.
Due to significant bias and residual confounding in epidemiological studies, highlighting specific diet factors such as meat consumption, fiber, and coffee and their relationship to CVD remains controversial.
Visit: Epidemiology
Cardiovascular diseases (CVD) have been among the two leading causes of death in the United States since 1975, accounting for 633,842 deaths or one in every four deaths. Heart disease was the leading cause of death in 2015, followed by cancer (595,930 deaths).
[2] According to the World Health Organization, CVD is also the leading cause of death worldwide, accounting for 17.7 million deaths in 2015. (WHO). CVD is considered the most expensive, even ahead of Alzheimer’s and diabetes, with calculated indirect costs of $237 billion per year and a projected increase to $368 billion by 2035. [20]
Although the age-adjusted rate and acute mortality from MI have been declining over time, reflecting advances in diagnosis and treatment over the last few decades, the risk of heart disease remains high in the general population, with a calculated 50% risk by age 45.
[7]
[21] The incidence increases significantly with age, with some gender differences, as the incidence is higher in men at younger ages. [2] In the postmenopausal state, the difference in incidence gradually narrows. [2]
Pathophysiology is an excellent place to start.
Atherosclerosis is a pathogenic process in the arteries and aorta that can cause disease due to decreased or absent blood flow caused by blood vessel stenosis.
A combination of factors such as dyslipidemia, immunologic phenomena, inflammation, and endothelial dysfunction causes it. These factors are thought to cause the formation of fatty streaks, a hallmark in the development of atherosclerotic plaque[23], a progressive process that can begin as early as childhood. [24] This process involves intimal thickening, the accumulation of lipid-laden macrophages (foam cells) and extracellular matrix, and the aggregation and proliferation of smooth muscle cells, which results in the formation of the atheroma plaque. [25] As the lesions grow, apoptosis of the deep layers may occur, resulting in additional macrophage recruitment that can become calcified and transition to atherosclerotic plaques. [26]
Other mechanisms, such as arterial remodeling and intra-plaque hemorrhage, play an essential role in the delay and acceleration of atherosclerotic CVD progression but are beyond the scope of this article.
Visit the following pages: History and Physical.
Asymptomatic cardiovascular diseases (e.g., silent ischemia, angiographic evidence of coronary artery disease without symptoms, among others) to classic presentations (e.g., patients presenting with typical anginal chest pain consistent with myocardial infarction and those suffering from acute CVA presenting with focal neurological deficits of sudden onset).
Historically, coronary artery disease has been associated with angina, which is a pain in the substernal region described as crushing or pressure in nature, that may radiate to the medial aspect of the left upper extremity, the neck, or the jaw and that can be accompanied by nausea, vomiting, palpitations, diaphoresis, syncope, or even sudden death.
[30] Physicians and other health care providers should be aware of possible variations in symptom presentation for these patients and keep a high index of suspicion despite an atypical presentation, such as dizziness and nausea, as the only presenting symptoms in patients suffering from an acute MI. [31]), especially in people with a known history of CAD/MI and those with CVD risk factors. [32] [33][34][33][32] Other symptoms of ischemic etiology include exacerbation with exercise or activity and resolution with rest or nitroglycerin. [35]
Neurologic deficits are the hallmark of cerebrovascular disease, including TIA and stroke, with the key differentiating factor for patients with TIA being the resolution of symptoms within 24 hours.
[36] Although the specific symptoms vary depending on the affected area of the brain, the sudden onset of extremity weakness, dysarthria, and facial droop is among the most commonly reported symptoms that raise the possibility of a stroke diagnosis. [37] [38] Ataxia, nystagmus, and other subtle symptoms such as dizziness, headache, syncope, nausea, or vomiting are among the most commonly reported symptoms in patients with posterior circulation strokes that are difficult to correlate and necessitate a high level of suspicion in patients with risk factors. [39]
Patients with PAD may experience claudication of the limbs, defined as cramp-like muscle pain caused by increased blood flow demand during exercise and typically resolves with rest.
[40] Severe PAD may manifest as skin color changes and temperature changes. [41]
Most patients with thoracic aortic aneurysms are asymptomatic. Still, symptoms can develop as the aneurysm progresses from subtle symptoms caused by compression to surrounding tissues, such as coughing, shortness of breath, or dysphonia, to the acute presentation of sudden crushing chest or back pain due to acute rupture.
[42] The same is true for abdominal aortic aneurysms (AAA), which cause no symptoms in the early stages before presenting with acute abdominal pain or syncope due to acute rupture. [43]
A thorough physical examination is essential for diagnosing CVD. Begin with a general examination to look for signs of distress, such as angina, decompensated heart failure, or chronic skin changes from PAD. Carotid examination with the patient supine and the back at 30 degrees is required for the palpation and auscultation of carotid pulses, bruits, and the evaluation of jugular venous pulsations on the neck. Before auscultating the precordium, a precordial examination should be performed that includes inspection, palpation for chest wall tenderness, thrills, and identification of the point of maximal impulse. Auscultation of heart sounds begins in the aortic area with the identification of S1 and S2 sounds, followed by characterization of murmurs if present. You should pay attention to changes in inspirations and maneuvers to correctly characterize heart murmurs. When applicable, palpating peripheral pulses with bilateral examination and comparison is essential to the CVD examination. [44]
Visit: Evaluation
The hallmarks of CVD diagnosis are a thorough clinical history and physical exam focused on, but not limited to, the cardiovascular system. A history consistent with obesity, angina, decreased exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, syncope or presyncope, and claudication should prompt the clinician to obtain a more detailed history and physical exam, as well as, if appropriate, ancillary diagnostic tests (e.g., electrocardiogram and cardiac enzymes for patients presenting with chest pain).
Aside from a clinical suspicion-based diagnosis, most efforts should be directed toward primary prevention by focusing on people with risk factors and treating modifiable risk factors through all available means. Beginning at the age of 20, all patients should be involved in discussing CVD risk factors and lipid measurements. [9] Several calculators that use LDL-cholesterol and HDL-cholesterol levels, as well as the presence of other risk factors, calculate a 10-year or 30-year CVD score to determine whether additional therapies, such as statins and aspirin, are indicated for primary prevention, which is generally indicated if such risk is greater than 10%. [10] Using these calculators, like other risk assessment tools, has some limitations. It is recommended to exercise caution when assessing patients with diabetes and familial hypercholesterolemia, as their risk can be underestimated. Another limitation of their use is that people over 79 were typically excluded from the cohorts in which these calculators were developed. An individualized approach for these populations is recommended by discussing the risks and benefits of adjunctive therapies and considering life expectancy. Some experts advise reassessing CVD risk every 4 to 6 years.
Preventive measures such as healthy eating habits, avoiding obesity, and maintaining an active lifestyle are essential for all patients, especially those with non-modifiable risk factors such as a family history of premature CHD or menopause.
The use of inflammatory markers and other risk assessment methods, such as the coronary artery calcification score (CAC), is under investigation and has limited applications; however, these resources remain promising tools in the future of primary prevention by detecting people with subclinical atherosclerosis who are at risk for CVD.
Please visit: Treatment / Management
Depending on the clinical situation, CVD management can be pervasive (catheter-directed thrombolysis for acute ischemic stroke, angioplasty for peripheral vascular disease, coronary stenting for CHD); however, patients with known CVD should be intensely educated on the importance of secondary prevention through risk factor and lifestyle modification.
[9]
[46]
Visit Differential Diagnosis
Pericarditis (acute)
Angina pectoris (chest pain)
Atherosclerosis
Vasospasm of the coronary arteries
Cardiomyopathy with dilated cardiomyopathy
Arteritis of the giant cell
Hypertension
Hypertensive cardiomyopathy
The disease of Kawasaki
Myocarditis
Visit: Prognosis
Other sections have discussed the prognosis and burden of CVD.
Visit: Complications
The most feared complication of CVD is death. As previously stated, despite numerous discoveries in recent decades, CVD remains one of the leading causes of death worldwide due to the alarming prevalence of CVD in the population.
Other complications, such as the need for more extended hospitalizations, physical disability, and increased healthcare costs, are significant and are a focus for healthcare policymakers, as they are expected to rise further in the coming decades. [20]
Because the risk of life-threatening arrhythmias is exceptionally high in people with heart failure with reduced ejection fraction (HFreEF) of less than 35%, current guidelines recommend the implantation of an implantable cardioverter defibrillator (ICD) for those with symptoms equivalent to a New York Heart Association (NYHA) Class II-IV despite maximal tolerated medical therapy.
Strokes can cause severe disabling sequelae such as dysarthria or aphasia, dysphagia, focal or generalized muscle weakness or paresis that can be a temporary or permanent physical disability that can lead to a complete bedbound state due to hemiplegia with added complications secondary to immobility, as well as an increased risk of developing urinary tract infections and thromboembolic events.
People with PAD risk dying from any cause more than those without evidence of peripheral disease.
PAD complications include chronic wounds, physical limitations, and limb ischemia. [51]
Visit: Consultations
A multidisciplinary approach involving primary care physicians, nurses, dietitians, cardiologists, neurologists, and other specialists is likely to improve outcomes. This is beneficial in patients with heart failure,[52] coronary disease,[53] and current studies to assess the impact on other types of CVD are in the works and promise promising results.
Go to: Patient Education and Deterrence
Efforts should be directed toward primary prevention by leading a healthy lifestyle and eating an appropriate diet as early as possible to delay or avoid the onset of atherosclerosis related to the future risk of CVD. The American Heart Association developed the concept of “ideal cardiovascular health,” which is defined as the presence of[8]:
Nonsmoking, a body mass index of less than 25 kg/m2, goal-level physical activity, and adherence to a diet consistent with current guideline recommendations are ideal health behaviors.
Untreated total cholesterol less than 200 mg/dL, untreated blood pressure less than 120/80 mm Hg, and fasting blood glucose less than 100 mg/dL) to improve the health of all Americans and reduce CVD deaths by 20%.
People at higher risk for CVD, such as those with diabetes, hypertension, hyperlipidemia, smokers, and obese patients, should receive special attention. It is critical to modify risk factors by controlling their medical conditions, avoiding smoking, taking appropriate weight-loss measures, and maintaining an active lifestyle. [8] [9] [10] The use of statins and low-dose aspirin for primary and secondary prevention has been covered in other sections.
Visit: Pearls and Other Concerns
Cardiovascular disease encompasses four distinct entities: CAD, CVD, PVD, and aortic atherosclerosis.
CVD is the leading cause of death worldwide.
The hallmark of primary CVD prevention is measures aimed at preventing the progression of atherosclerosis.
In the prevention of CVD, risk factors and lifestyle changes are critical.
Visit: Improving Healthcare Team Outcomes
An interprofessional and patient-centered approach can help to improve outcomes for people with cardiovascular disease, as evidenced by patients with heart failure (HF) who had better outcomes when nurses, dietitians, pharmacists, and other health professionals collaborated (Class 1A).
Positive results were also obtained in people in an intervention group who were followed by an interprofessional team consisting of pharmacists, nurses, and a team of various physicians. Compared to the control group, this group had a 76% reduction in all-cause mortality from CAD. [53] Healthcare workers should educate the public about lifestyle changes and work to reduce modifiable risk factors for heart disease.
QUESTION
Competency
Prioritize nursing care strategies for clients with cardiovascular disorders.
Scenario
Cardiac disease a one of the leading causes of death in the United States. Since it is so prevalent, you want to ensure your co-workers are fully prepared to care for patients. You are hosting a lunch to provide a refresher on heart disease and how to care for patients. During the lunch, you will present a PowerPoint Presentation to your co-workers.
Instructions
Choose one of the cardiac diseases that we covered in the last two modules. Within your presentation include:
Provide a detailed overview of the disease process
Diagnosis
Treatment
Multidimensional care including risk reduction, health promotion, and nursing interventions specific to the disease process