HEART ANATOMY
The heart is about the size of your fist and weighs about 7-12 ounces. It pumps 10 pints of blood through 75,000 miles of blood vessels. It beats about 5,000 times an hour with a normal heart rate of 60 – 100 beats a minute. It is located under your breastbone with the smaller part angled to the left side. The heart is surrounded by a sac called the pericardium. This provides support for the heart. It has a small amount of fluid in it to lubricate the heart as it pumps. It is protected by the sternum (breastbone) and your rib cage.
The heart is made of all muscle and has 3 layers. The actual heart muscle is called myocardium. Its job is to pump the blood throughout the body. It actually is 2 pumps in 1 – one on the right side and one on the left side. Each side has a small hollow chamber on the top (atrium) and a larger one on the bottom (ventricle). Outside the heart, there are many blood vessel branches (known as coronary arteries) that help feed the heart. The heart needs electricity to make it work. There are special cells at the top right side of the heart that sends the signal to tell the heart when to beat. These are called the pacemaker. The pacemaker gets signals from the brain as to how fast to beat. The signal is then carried down through a pathway to the rest of the heart. The muscles contract and move the blood through the heart and out to the rest of the body. A normal heart beats 60 to 100 times a minute.
BLOOD CIRCULATION Blood enters via superior & inferior vena cava
Right atrium
Right ventricle via tricuspid valve
Lungs via pulmonary artery
Pulmonary circulation
Heart via
• Blood enters via superior & inferior vena cava • Right atrium • Right ventricle via tricuspid valve • Lungs via pulmonary artery (pulmonic semilunar valve) • Pulmonary circulation • Heart via pulmonary vein
Rosenald Sen
pulmonary vein She was born in Baltimore, Maryland on 1914. Her father was a construction worker and her mother is a home maker. She was the youngest among two daughters. Left atrium
• Left atrium
• Left ventricle via mitral valve
She died in June 22, 2007 Left ventricle via mitral valve
Education: She studied Diploma in Nursing in early 1930’s at the Providence Hospital School og Nursing In Washington D.C., In 1939 and 1945 Body systems via aorta she finished B.S. Nursing Education ( BSN Ed.) and MSN Ed successively in Catholic University of America, Washington D.C. In 1976, she become Honorary Doctorates: Doctors of Science from Georgetown University and Incarnate word college in San Antonio in Systemic Texas circulation in 1980. In 1988 she finished Doctor of Humane Letters from Illinois Wesleyan University in Bloomington, Illinois. 1988 She Graduated from University of Missouri in Columbia, Doctor Honoris Causae.
• Body systems via aorta (aortic semilunar valve) • Systemic circulation
RISK FACTORS OF HEART DISEASE
AGE (Non-modifiable)
HIGH BLOOD PRESSURE (Modifiable)
This is considered a risk factor because the older you get, the more time all the other risk factors have had to build up and cause damage. Of course, you cannot control the aging process, but you can get regular medical care and reduce any other risk factors you may have.
Certain factors increase the chance of having high blood pressure. The constant high pressure of the blood against the walls of the arteries can cause damage over time. The damage can give cholesterol a place to attach to the artery wall, causing the beginning of the atherosclerosis.
GENDER (Non-modifiable)
HIGH BLOOD SUGAR (Modifiable)
Men are more likely than women to have coronary artery problems, especially before the age of 45. A women’s risk of heart attack begins to increase when she reaches 55. To some extent, estrogen seems to protect women prior to menopause, but aftermenopause, things begin to even out, although risk is not equal until 75.
Diabetes damages the cardiovascular system by producing abnormalities in lipoproteins that may speed up atherosclerosis. It also affects cholesterol and triglyceride levels. While many things can be done to control diabetes, it can’t be permanently cured.
FAMILY HISTORY (Non-modifiable)
SEDENTARY LIFESTYLE (Modifiable)
There is a strong genetic link to high blood pressure and heart disease. If a family member has a history of early heart disease you are at higher risk for heart disease than someone with no family history of early heart disease. This means you should pay closer attention to controllable risk factors.
Exercise helps to reduce other risk factors, including improving cholesterol and triglycerides, lowering high blood pressure, relieving stress,and reducing weight. Inactivity can also increase the chance of clot formation, increasing the risk of stroke, as well as coronary artery blockage.
HIGH BLOOD CHOLESTEROL (Modifiable) STRESS (Modifiable) If there is too much in your blood, it can build up on the walls of your coronary arteries and cause a blockage. The best way to measure cholesterol is with a lipid profile. By knowing your cholesterol level and by making some changes in your diet, you can reduce the fat in the blood and keep that build-up from happening.
During a stressful situation, your body produces adrenalin, a hormone that is supposed to regulate certain functions like blood flow, heart rate, and breathing. One of the things it does is to make your blood stickier. This stickiness increases the possibility of a clot forming and coronary artery disease.
SMOKING (Modifiable)
OBESITY (Modifiable)
The nicotine and carbon monoxide in the smoke get into the blood and can damage the linings of the arteries, which can give cholesterol a place to start sticking. It can cause the muscles in the artery to go into spasm, which can reduce the blood flow.
Being overweight taxes the heart by forcing it to pump harder to nourish all the added tissue. It can limit your physical activity, influence the cholesterol level, raise blood pressure, and can induce diabetes. Modifying your diet to reduce fat and calories, and increasing your level of activity can help you to lose weight.
DISEASES OF THE HEART ATHEROSCLEROSIS
HYPERTENSION
Atherosclerosis is when fat and plaque attach to the lining of the arteries of the heart, legs and carotid arteries in the neck. The lining of the arteries become irritated and the body tries to heal this inflammation. This leads to the arteries becoming narrow and the blood flow slows down. This leads to the heart muscle not getting enough oxygen. When extra demand is placed on the heart, this could cause angina and/or a heart attack. It is not only due to less blood flow because of the narrowing of the artery, but the plaque can rupture and cause a clot to block the artery so that no blood flows. A piece of the plaque can also break off and block another artery.
The top number or your blood pressure is when the heart contracts and the blood is being pumped through the vessels. The bottom number is when the heart is at rest and the vessels are to be relaxed. When the vessels stay constricted or tight, it causes the heart to work harder to pump the blood through a smaller opening. A normal pressure is 120/80 at rest. High blood pressure that has not been controlled over a long time can cause damage to the heart muscle. If the muscle fibers have been stretched due to the back pressure of the blood that could not go through the vessels, they lose their ability to do this. Hypertension is often called the silent killer, because you will not always have any signs or symptoms.
ANGINA PECTORIS
CONGESTIVE HEART FAILURE
Angina is not a heart attack, but a distress signal that somewhere in the heart, the muscle is not getting enough oxygen. If it is not treated promptly, a heart attack can occur. This can happen with activity or at rest or both. It can occur during emotional stress or after a meal. If the frequency and severity of pain increases as the physical activity required to cause the pain goes down, this may indicate that there is severe coronary artery disease present. It can also occur if one of the arteries has closed, and the muscle is depending on collateral vessels that have formed from another artery to feed the area that is losing it’s supply of blood. They may not be able to supply the same amount of blood.
Heart failure occurs when the heart muscle becomes weak. This can be a temporary situation as when a heart attack occurs. Depending on how much muscle is damaged, will determine if the heart failure becomes chronic or long lasting. When the pumps can not continue to deliver the normal amount of blood to the lungs from the right side or to the body from the left side, the blood will back up to where it came from. When the right side fails, the signs are swelling in the hands, legs, feet, and abdomen. When the left side fails, the signs are shortness of breath, a dry hacking cough, and having to sleep propped up on 2 pillows or more.
MYOCARDIAL INFARCTION
DYSRHYTHMIAS
If a coronary artery should become completely blocked by atherosclerosis or spasm long enough, it will block the oxygen from getting to the heart muscle causing a heart attack. Any tissue that doesn’t receive oxygen for several minutes will die. Depending on how much of the heart muscle is damaged, will determine the amount of pumping action that is left. The pain of a heart attack can occur while one is sleeping or watching TV, as well as with activity. It can last longer than 30 minutes. Some people have experienced no pain, but have other symptoms like shortness of breath, chest tightness, indigestion, and fatigue.
Dysrhythmias are disorders of or changes from the regular rhythmic beating of the heart. They can occur in a healthy heart and be of little significance. Almost everyone has felt their heart beat very fast, felt a “fluttering” in their chest or felt a skipped beat when taking their pulse. These are very common if they happen occasionally and as we get older. Dysrhythmias may also indicate a serious problem and lead to heart disease, stroke, or sudden cardiac death. If dysrhythmias last for some time, causing the heart to pump less efficiently, they can cause the heart rate to be too slow (bradycardia) or too fast (tachycardia).
CHEST PAIN Chest pain or angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest. The cause is usually insufficient coronary blood flow resulting to transient myocardial ischemia lasting no more than 5-15 minutes. The insufficient flow results in a decreased oxygen supply to meet an increased myocardial demand for oxygen in response to physical exertion or emotional stress. In other words, the need for oxygen exceeds the supply. This can be cause by physical exertion, exposure to extreme temperature, eating a heavy meal , stress or any emotion-provoking situation. The pain typically is decribed as constricting, squeezing or suffocating. It is usually steady, increasing in intensity only at the onset and end of the attack. Pain in angina is usually located in the substernal area of the chest (under the chest bone), similar to heart attack that it may radiate to the left shoulder, jaw, arm or other areas of the chest. An important characteristic of angina is that it abates or subsides with rest or nitroglycerin.
TREATMENT OF ANGINA PECTORIS ANTIANGINAL DRUGS, NITRATES, NITROGLYCERIN (NTG) Use and Action: Relax and widen the blood vessels and lower the blood pressure. This reduces the workload of the heart, allows the heart to move blood more easily and increases the blood and oxygen supply to the heart muscle. Occasionally the doctor will order a patient to take NTG to prevent angina in situations or planned activities that are known to cause angina. In this case, it is taken a few minutes before. Slow or long acting - used to prevent the symptoms of angina by their slow release. They are taken daily at set time intervals. They cannot relieve an angina attack once it’s begun. Name: Fast Acting Nitroglycerin (NTG, Nitrostat, NitroQuick - sublingual tab or spray) Proper Use: 1. Sit down when taking, so you do not become dizzy or lightheaded. 2. Place a tab or spray under your tongue or on the inside of the cheek. It will be absorbed in 1-2 minutes. 3. Wait for 5 minutes. If still having angina, take a second tab or spray. 4. Wait for 5 minutes. If the angina still hasn’t completely gone, take a third pill or spray. 5. If you need that 3rd dose, then you should call your nearest hospital for Emergency transport. Do not drive or ride by yourself because you will be taking the hearts oxygen supply away. If the chest pain lasts longer then 15 minutes, is not relieved with rest and after 3 Nitroglycerin you may be having a heart attack. Side Effects: Headache, dizziness, ‑weakness, nausea, flushing of the face and hands, blurred vision, dry mouth, rash. Precautions: 1. Nitroglycerin is safe and not habit forming. 2. The tabs are sensitive to light, heat and moisture thus keep in a tightly closed, dark container and store in a cool, dry place. 3. Refill prescription every 6 months to a year and carry it in your possession at all times. 4. Check with your doctor before taking any over the counter meds for impotence ex: Viagra, Cialis, Levitra. 5. Notify your doctor if you have any symptoms that require NTG for relief.
HEART ATTACK
If myocardial ischemia is prolonged to over 30-45 minutes, this causes a heart attack or myocardial infarction (MI). This is the death of myocardial cells that occurs following prolonged oxygen deprivation. It is the culminating lethal response to unrelieved myocardial ischemia. Other causes of an MI include vasospasm (sudden constriction or narrowing) of a coronary artery; decreased oxygen supply (e.g., from acute blood loss, anemia, or low blood pressure); and increased demand for oxygen (e.g., from a rapid heart rate, or ingestion of cocaine). In each case, a profound imbalance exists between myocardial oxygen supply and demand.
The manifestations of MI include chest pain that occurs suddenly and continues despite rest and medication, weakness, shortness of breath, anxiety and restlessness, cool, pale, , and moist skin and a dreadful feeling of impending doom. Healing of the heart muscle begins soon after a heart attack and takes about six weeks. Just like a skin wound, the heart’s wound heals and a scar will form in the damaged area. But, the new scar tissue does not contract. So, the heart’s pumping ability is lessened after a heart attack. The amount of lost pumping ability depends on the size and location of the scar.
EMERGENCY PREPAREDNESS It is important to know what to do in case of an emergency. If you have a plan of action, you will be less likely to panic and do something risky. That plan should include what you can or cannot do for yourself, who and when to call for help. The first thing you should know is the symptoms. The second thing you need is a plan of action: • Stop what you are doing and rest • If you have nitroglycerin, know how to take it. • Sit down and place the pill under your tongue. Do not swallow it. • Wait 5 to 10 minutes. If you do not get relief of the pain, use a second pill, and wait 5 to 10 more minutes. • If you must use a third pill, call your nearest hospital for help. • If the pain is unusually severe, or if you become short of breath very suddenly, you do not have to wait to call the hospital. DO NOT DRIVE YOURSELF TO THE HOSPITAL! • When you call the hospital, give your name and address clearly, describe your symptoms, and inform them of any prior cardiac problems. (Example: “I am having crushing chest pain. I have taken three nitroglycerin and they didn’t help. I had a heart attack last year.”) • If you are alone and can do so, unlock a door so the rescuers can get in. • If possible, turn on a porch light to mark your home. • Have the outside of your home clearly marked with large, visible house numbers. • You should always have a medication list available with proper names and doses of your drugs. • Be able to give the call operator clear directions to your home. • Have your own phone number and address next to the phone in case a visitor would have to call for help. • Do not have a friend or relative drive you to the hospital unless trained help is not immediately accessible. This is for your safety and theirs. If you should have a serious problem, they might not be able to help you. Also, under stress, they might become involved in an accident that could injure them as well as you and others. • If you go on vacation, take a list of your medications and any medical records you have with you. • Wear your medical information bracelet if you have one. DO NOT PANIC!
ELECTROCARDIOGRAPHY
TEST PROCEDURES
This is also known as ECG or EKG, electrocardiography is a noninvasive test that records the electrical activity of the heart. Electrodes are placed on the arm, chest and legs. This test takes about 5 minutes and will help the doctor evaluate the following: • If a heart attack has occurred and if so, what part of the heart was damaged • If there are any irregular heart beats or rhythm • If there is decreased supply of blood and oxygen to the heart
CARDIAC ENZYMES
In determining the level of cardiac enzymes, a venipuncture must be done or you will be taken a sample of your blood, which will be tested in the laboratory. Specific enzymes to be tested are: • Creatinine phosphokinase (CPK-MB) which indicates myocardial cell death • Lactic dehydrogenase (LDH), another enzyme specific to the heart muscle • Myoglobin, a heme protein that helps to transport oxygen also found in cardiac and skeletal muscle • Troponin (Trop-I or Trop-T), a protein found in the myocardium, regulates the myocardial contractile process
PTCA (Percutaneous Transluminal Coronary Angioplasty) This procedure is nonsurgical and is performed under X-ray guidance. A catheter (a long, thin, flexible tube) is inserted through an artery (blood vessel) in the thigh up into the heart. A colorless dye is injected through the catheter, and X-ray pictures are taken of the heart and coronary arteries. The balloon is then inflated and deflated several times to squeeze the plaque deposits against the wall of the artery. After the X-rays are taken, the balloon and catheter are removed.
CARDIOVASCULAR INTERVENTIONS CABG (Coronary Artery Bypass Graft) This is a surgical procedure to treat severe coronary artery disease. Part of a vein or artery (called a graft) from another part of the body (a vein from the leg or an artery from the chest or forearm) is used to bypass a blockage in one ormore of the coronary arteries. The graft is attached above and below the blocked area so that blood flows around it and to the area of the heart below the blockage.
THROMBOLYTICS
MEDICATIONS
Names: Alteplase, Anistreplase, Drotrecogin, Alfa, Reteplase, Streptokinase, Tenecteplase, Urokinase Use and Action: Convert plasminogen to plasmin, an enzyme that degrades fibrin clots and lyses thrombi and emboli Side Effects: Severe bleeding can occur, especially in the brain (intracranial hemorrhage), which can be life-threatening. Streptokinase can cause fever, irregular heartbeats, low blood pressure, and an allergic reaction.
OPIOID ANALGESICS Names: Morphine sulfate, Meperidein hydrochloride Use and Action: Interacts with opioid receptor sites, primarily in limbic system, thalamus, and spinal cord. This interaction alters neurotransmitter release, altering perception of and tolerance for pain. It also relieves anxiety and induces sleep, further decreasing myocardial workload. Side Effects: Respiratory depression, sedation, constipation, nausea, vomiting, pruritus, diaphoresis, urinary retention.
ANTIARRHYTMICS Names: Amiodarone (Cordarone), Disopyramide (Norpace), Betapace (Sotalol) Use: Irregular heart beats originating in either the atria or ventricles. Side Effects: Bradycardia, heart block, heart failure, visual disturbances, hypothyroidism, liver & respiratory failure, photosensitivity, nausea, urinary hesitancy.
ANTICOAGULANTS Names: Warfarin (Coumadin), Clopidogrel (Plavix) Use and Action: Slows the blood’s ability to clot inside the vessels, by acting on the liver’s production of vitamin K clotting factor and blocking the function of platelets that form clots. Side Effects: Nausea, vomiting, diarrhea, headache, mouth ulcers, frequent bruising, bleeding gums or nosebleed
ANTIPLATELET DRUGS Names: Aspirin, Ecotrin (enteric coated), Ascriptin, Bayer, Bufferin, Empirin Use and Action: Aspirin is used to reduce fever, relieve mild to moderate aches and pains (ex: headaches) and reduce inflammation. In people with heart disease, it is used daily to thin the blood and make it less likely to clot and block the coronary arteries. Side Effects: Nausea, heartburn and stomach irritation, ringing in the ears, blurred vision, bruising or bleeding, rash.
ANGIOTENSIN CONVERTING ENZYME INHIBITORS Names: Captopril (Capoten), Enalapril (Vasotec) Use: High Blood Pressure, CHF-Congestive Heart Failure, heart attack, kidney disease. Action: Dilate (widens) the blood vessels and lowers blood pressure, which reduces the workload on the heart and allows it to pump blood more efficiently. Side Effects: Usually uncommon and initially present as weakness, dizziness and fatigue, decreased sex drive or impotence.
ANGIOTENSIN II RECEPTOR BLOCKERS Names: Losartan (Cozaar). Valsartan (Diovan), Micardis (Telmisartan), Irbesartan (Avapro) Use and Action: These medications may be used as a substitute for ACE Inhibitors, especially if a persistent cough is a problem. They are used for CHF-congestive heart failure to keep it from getting worse. Side Effects: Seldom occur but may include: dizziness, nausea, muscle cramps
BETA-ADRENERGIC BLOCKERS Names: Atenolol (Tenormin), Metoprolol (Lopressor, Toprol XL), Carvedilol (Coreg), Propranolol (Inderal) Use: High Blood Pressure, Angina, Heart Rhythm Disturbances, Migraines, Lowers risk of recurrent heart attacks. Action: Decreases blood pressure and heart rate by making the heart beat less forcefully Side Effects: Dizziness or lightheadedness, swelling, shortness of breathe, tiredness and weight gain
CALCIUM CHANNEL BLOCKERS Names: Amlodipine (Norvasc), Nicardipine (Cardene), Felodipine (Plendil), Nifedipine (Procardia, Adalat), Verapamil (Calan, Isoptin) Use: Angina, high blood pressure, some types of abnormal heart rhythm. Used cautiously with congestive heart failure. Action: Relaxes the heart’s smooth muscle, thus reducing the workload of the heart. Side Effects: Dizziness or lightheadedness, swelling, slow pulse, tiredness, shortness of breath, headache, flushing, constipation.
DIURETICS Names: Furosemide (Lasix), Torsemide (Demadex), Metolazone (Zaroxolyn), Spironolactone (Aldactone) Use: Hypertension, Heart Failure Action: Lowers blood pressure by reducing the amount of water in the body, reducing the amount of fluid your heart has to pump Side Effects: Leg cramps, dizziness, weakness, urinary frequency and incontinence, gout, high blood sugar, low potassium levels, heartburn, sun sensitivity.
PHASE I ACTIVITIES (IN-PATIENT) Cardiac rehabilitation is a process of continuing, comprehensive care designed to restore your heart function to optimal over-all health status and to maintain that status once achived. The level of restoration may be compared to that enjoyed before the cardiac event, or it may be to a new level compatible with your cardiac reserve. You must understand that the greater effort you give to achieve the goals result from your acceptance of behavioral modification activities which is going to be a lifelong process. Most in-patient rehabilitation programs are structured into several stages that gradually increase the intensity of exercise and range of permitted activities. During this time after undergoing uncomplicated cardiovascular intervention, your physician prescribes that you undergo Cardiac Rehabilitation. This entails that your activities of daily living (ADLs) must be done through progression.
PHASE I SAMPLE ACTIVITIES (IN-PATIENT)
B
B
B
B
Resting, eating, passive range-of-motion (ROM) (Day 1 - Day 2)
Partial arm movements (wash face, brush teeth), sit in chair for short periods, assitive/active exercises (Day 2 - Day 3)
VERY LIGHT ACTIVITY
Sitting in cahir 3x, standing, warm-up, ROM, breathing exercises, walking inside room (Day 3 - Day 4)
Increase movements, arms/shoulder, lateral bending, walking two lengths of hall/stairs, discharge instructions (Day 4 - Day 5)
LIGHT ACTIVITY
PHASE II & III ACTIVITIES (OUT-PATIENT) During these phases, you and your family must understand that from the beginning, the commitment towards rehabilitation is a lifelong process. Otherwise, the rehabilitation benefits will be lost. The program goal is for you to achieve the highest level of wellness possible. Phase II begins at the time of your discharge and extends to return to work or prior level of activities. These moments are crucial because you and your family are on your own. Phase III Maintenance Program can be carried out in a hospital or community-based program or may continue at home under the guidance of a health care team. Exercise should involve major muscles, dynamic (isotonic) rather than isometric, should progress gradually and for maximum benefit, it should be performed three to five times a week for about 30 minutes each.
B
PHASE II & III SAMPLE ACTIVITIES (OUT-PATIENT) B
B
B
Gardening (weeding), ballroom dancing (moderate), bed making, walking on level ground (4mph), sexual intercoure (done only after being able to climb two flights of stairs, approximately after 6 weeks)
LIGHT ACTIVITY
Golf, sawing wood, tennis (doubles), ping-pong, walking on level ground (5mph)
Cycling (13mph), swimming (backstroke), jogging, walking on level ground (5-6mph)
MODERATE TO HEAVY ACTIVITY
Swimmng (breaststroke), walking uphill (5mph)
VERY HEAVY ACTIVITY
BACK TO YOUR LIFE
RESPONSE TO ACTIVITIES & EXERCISE
You should be taught to monitor your own pulse and advised not to exceed the upper limit of your designated heart rate.. Any symptom such as shortness of breath can be taken as overexertion. If chest pain occurs, you will be asked to grade the intensity in a numerical scale of 1 to 10 with 10 as the worst possible pain. For patients who complain of symptoms such as dizziness, fainting, palpitations, ambulatory EKG monitoring may be prescribed. Please note that during Phase II, you may be enrolled in a hospital based Cardiac Rehabilitation program which usually lasts for about 10 to 12 weeks.
RETURN TO WORK This decision is not made until about 6 to 8 weeks after hospital discharge, of which is usually arrived at by the team, with concurrence of the cardiologist as a cardiac clearance is indicated. This is done early in the recovery process to help allay anxiety.
YOUR HEART RATE Before being discharged, you should be taught how to take your pulse and count it within a whole minute. Studies have shown that cardiovascular system conditioning intensity can be prescrbed based on heart rate response and rate of perceived exertion. Your heart rate is a good gauge for you to assess the limit of your activity and exercise. There are two ways to do this.
RESERVE METHOD This is a method of determining the HR range at which you should perform cardiovascular systme conditioning. The difference between the resting HR and the maximum heart rate (as determined by stress test) is considered chronotropic reserve. For conditioning purposes. 50% to 80% of the reserve capacity is added to the resting heart rate (RSR) to give a training heart rate (THR) range. The formula for determining a 60% instensity is as follows: (MHR - RHR) x 60% + RHR = THR Sample: MHR (from stress test) is 160 beats per minute. MHR (maximum heart rate) - RHR (resting heart rate) = HRR (heart rate reserve) 160 - 70 = 90 Now, determine 50% and 60% of the HRR & add to RHR 0.50 (50%) x 90 = 45 0.60 (60%) x 90 = 54 70 + (45 to 54) = 115 to 124 (training HR range)
PREDICTED METHOD Predicted MHR (220) - age (in years) x desired intensity = THR Sample: 50 year old at 60% to 70% intensity 220 (MHR) - 50 (age) = 170 170 x 0.60 (60%) = 102 to 170 x 0.70 (70%) = 115
NUTRITION AND YOUR HEART Two factors, which can significantly affect you heart health are high blood cholesterol and being overweight. There are some risk factors you cannot control, but the foods you eat and your weight are things you can change. Learning to eat healthier foods can be a good thing for both you and your family. Being overweight can affect your heart in several ways. First of all, for every pound of fat, you have about 200 miles of extra blood vessels. This means more work for your heart, just pushing blood through these vessels. High blood pressure is another risk factor associated with being overweight. Simply by losing weight, as little as ten pounds, you may be able to bring your blood pressure down to normal levels. Diabetes is another diet-related risk factor. Being overweight can hasten the onset of diabetes, and maintaining a normal weight can help to control the complications of diabetes. Diabetes weakens blood vessels, which can affect the heart, as well.
TLC DIET (Therapeutic Lifestyle Changes)
DASH DIET (Dietary Approches to Stop Hypertension)
The TLC diet (Therapeutic Lifestyle Chanhes) is the lifestyle component of the Third Report of the NCEP ATP III guidelines that focuses on diet, weight management, and increased physical activity. The ATP III guidelines specifically target LDL because of its strong, positive correlation with coronary heart disease risk.
The DASH diet (Dietary Approaches to Stop Hypertension) is a diet promoted by the National Heart, Lung, and Blood Institute (part of the NIH, a United States government organization) to control hypertension.
This eating plan is rich in fruits, vegetables, whole grains, and Overall, the TLC diet is low in saturated fats, dietary cholesterol, low-fat dairy foods; includes meat, fish, poultry, nuts and beans; and sodium, while emphasizing adequate levels of monounsatu- and is limited in sugar-sweetened foods and beverages, red rated and polyunsaturated fats diet for weight reduction. meat, and added fats. Dietary Recommendations for TLC Diet Component TLC Diet Total fat 25-35% of total calories Saturated fat <7% total calories Polyunsaturated fat Up to 10% of total calories Monounsaturated fat Up to 20% of total calories Trans fat Lower intake Carbohydrate 50-60% of total calories Dietary fiber 20-30 grams per day Protein 15-25% of total calories Cholesterol <200 mg/day Sodium <2,300 mg/day Dietary options Plant sterols/stanols Add up to 2 grams per day Soluble fiber Increase 5-10 grams per day Fish (fatty fish) Include in weekly eating plan
Dietary Nutrient Goals for DASH Diet Component Total fat Saturated fat Polyunsaturated fat Monounsaturated fat Trans fat Carbohydrate Dietary fiber Protein Cholesterol Sodium Potassium Calcium Mganessium Fish (fatty fish)
TLC Diet 27% of calories 6% of calories ---55% of calories 30 g 18% of calories 150 mg 2,300 mg 4,700 mg 1,250 mg 500 mg --
STRESS AND YOUR HEART Stress is the bodyâ&#x20AC;&#x2122;s physiological reaction to any stimulus that evokes a change. Stress causes blood vessels to expand, and other ones to contract. Your coronary arteries may respond to stress by going into spasm. This can decrease blood flow to the heart, and if there was already blockage in an artery because of a plaque, it could shut off the flow altogether. That increased stickiness, which would prevent you from bleeding to death, may cause your blood to clot too much. A clot could lodge in one of those arteries, and that too could block off blood flow. It appears that people who respond with anger and aggression when under stress are the ones who are more prone to heart attacks and problems. It seems that sustained levels of anger result in elevated levels of the male hormone testosterone in men, as well as epinephrine, norepinephrine, and cortisol. Chronic high levels of these hormones can cause coronary artery disease. There are many ways of coping with stress. Some people smoke, drink alcohol, take drugs (whether prescription or illicit), eat too much, gamble, or use some other form of escape. Most of these behaviors are potentially damaging to their bodies, and none of these things truly improve the situation.
Learning relaxation techniques may take some time and some practice, but may be well worth the effort. Progressive relaxation can be learned from pre-recorded tapes. It involves selectively isolating, tensing, and relaxing certain groups of muscles throughout the body. By systematically following the directions of a soothing voice, you can release a lot of muscle tension and learn how it feels to be relaxed. The idea is to learn to use the technique on your own whenever you feel tense. Imaging is another technique that can induce a relaxed state in times of stress. By closing your eyes and picturing a setting that is soothing and relaxing to you, you can block out the influences, which are causing your tension, so that you can restore a feeling of calmness. The scene might be the woods, mountains, the ocean, or even your own back yard. You can concentrate on imagining the air temperature, the smells, the sounds, and sensations that would occur in that setting. Meditation is the process of using a single word or phrase and repeating it to yourself to induce a feeling of relaxation. A word such as warm, calm, or home, with a soothing sound and a positive association for you can help you to block outside influences which are creating tension. Journaling is a method of coping, which involves writing down your feelings to inspect them and deal with them. By keeping a written account of your encounters, responses, and actions you can gain insight into what makes you feel better, what makes you worse, and things you might change to make improvements. Deep breathing is one of the easiest stress management techniques to learn and it can be done anywhere. Our bodyâ&#x20AC;&#x2122;s reaction to stress is to take shallow, quick breaths. Taking deep, slow breaths is one way to counteract the stress response and initiate the relaxation response. Sitting or lying down in a comfortable position, place your hand on your stomach just below your rib cage. Slowly breathe in through your nose. Your stomach should feel like it is rising and expanding outward. Exhale slowly through your mouth, emptying your lungs completely and letting your stomach fall. Repeat these steps until you feel relaxed. Using humor for alleviating stress has been proven to be beneficial. The old saying that laughter is the best medicine appears to be true when it comes to protecting the heart. Learn to laugh at yourself. Support systems are also very crucial in times of stress. Your source of support may come from family members, your spouse or your significant other. Sometimes, just verbalizing what you feel is already very therapeutic.
SMOKING AND YOUR HEART According to statistics, smokers are twice as likely as nonsmokers to have heart attacks, and five times more likely to die a sudden death from heart attack. If you have already had a heart attack or heart surgery, cigarette smoking poses some particular risks for you. No doubt, your doctor has recommended that you quit, but he may not have gone into detail about just how smoking may be affecting your heart. There are two major problems associated with smoking. The first problem is the nicotine. Nicotine has two effects on your heart. The first is that it speeds up your heart rate, and the second is that nicotine acts to constrict your blood vessels. Since it shrinks the vessels, it can raise your blood pressure in addition to reducing the blood flow to every part of your body. The second problem associated with smoking is carbon monoxide. The carbon monoxide gas is 200 times more attractive to your blood than the oxygen your body needs to survive. The single most important ingredient in successful quitting is determination. You have to want to quit. You have to believe that it matters and you have to do it for yourself. The most successful quitters are the ones who say, â&#x20AC;&#x153;I just decided to quit,â&#x20AC;? and then did.
SMOKING CESSATION Tapering refers to systematically reducing the number of cigarettes smoked in a day. This is done over time in an effort to decrease the discomfort of quitting suddenly. Nicotine fading is another technique that relies on systematically reducing the nicotine to reduce the addiction. Nicotine fading involves switching to brands of cigarettes that have less nicotine than your regular brand. Nicotine replacement therapy, the gum or patches, replaces cigarettes with another source of the drug. The person does not have hazards of the cigarette smoke, but eventually must deal with the nicotine addiction just the same. Smoking cessation classes use a variety of philosophies to address the behavior of smoking. By making the smoker aware of how, when and why he smokes, he can begin to learn other things to do to replace the smoking habit. Another is withdrawal-oriented therapy where members from a group assist smokers to become abstinent throughout the difficult initial period. There is also what we call cue exposure therapy where ex-smokers are exposed to urge eliciting cues gradually until such time that some of their evocative power may be lost. Hypnosis is a technique that can be helpful for some people, but it must be done by a reputable individual, either a doctor or therapist. NIcotine Replacement Therapy (NRT) is the administration of nicotine (chewing gum, transdernal patch, vaporiser or nasal spray) to decrease the withdrawal symptoms during the inital phase of smoking cessation. Treatment can be tapered off gradually within 2 to 6 months. Non-nicotine Pharmacologic Therapy is a new modality that uses a drug named Bupropion SR, an FDA approved monocyclic antidepressant. It is the generic chemical compound indicated for both depression and smoking cessation. This is taken orally, taken at least 7 to 12 weeks once a day for the first three days and twice a day onwards. Rapid smoking therapy is one of the most effective treatment procedures wherein clients are asked to inhale smoke at a much faster rate than usual, puffing and inhaling every 3 seconds for 3 cigarettes with 2-minute rest or until nausea is triggered.
SEX AND YOUR HEART Intimacy is a basic need for all people. The need to touch and be touched is a part of all of us. Sexuality, the side of our nature which seeks physical intimacy with others, is a part of who we are. Naturally, when something like a serious illness interrupts our lives, we are quick to examine our sexual side to make sure it is still there. Communication is the key to real intimacy. It is important to be able to talk openly and honestly about your feelings and your fears. After a heart attack or heart surgery, both partners are going to have a lot of concerns, especially about resuming sexual activity. They think that sex will put too much stress on a damaged heart. Fear and anxiety can prevent resuming a satisfying sex life. The partner without heart disease doesnâ&#x20AC;&#x2122;t want to cause a problem, and the patient is concerned with performance and worried about further heart problems. If you do not talk about these feelings they can hurt a relationship and interfere with sex. For most people, sexual activity can be safely resumed within a few weeks of a heart attack or surgery. Recovery will not be the same for each person. It usually takes about 6 weeks after a heart attack or surgery to get your strength back and about the same time for the breastbone to mend.
Post MI patients often have anxieties and fears of engaging in sexual activity. It is said that when a cardiac patient is admitted to the coronary care uniit (CCU), the most common questions asked are: “Will I live?” “Will I return to work?” “Will I make love again?” Guzetta explains that many patients are not aware of the normal sexual demands on the cardiovascular system. Many patients are reluctant to bring up the subject, and when nothing is said, they assume that sexual activity is not allowed. In the past, cardiac patients were not advised to resume sexual intercourse. The study of Masters & Johnsons showed tha the average cardiac patient having intercourse with the usual partner in a comfortable room had a heart rate of about 120 beats per minute only during the orgasm phase, a data comparable to climbing 1 or 2 flights of stairs. Having a graded exercise test about 6 to 8 weeks post MI or heart surgery can help the cardiac rehabilitation team determine when the patient can resume sexual activity. There are some ways to make resuming sex easier: • Be rested before sex.. In the morning or after a nap may be best but don’t change your habits if this makes you anxious. • Have sex in a usual or pleasant place where you won’t be interrupted. Be comfortable and relaxed. • Avoid rushing into sex and don’t expect too much at first. Allow it to happen naturally. • Be patient with yourself. Try to understand your emotions may change quickly. These sudden mood changes are usually temporary. • Be in a familiar position unless it is uncomfortable from an incision after heart surgery. If so, lie on your side to put less pressure on the chest wall and make breathing easier. Or better yet and just to be safe, assume the passive role. • Don’t have sex for at least an hour after a heavy meal. The heart sends extra blood to the stomach to help digest the food.
PUBLICATIONS
REFERENCES
• Corwin, Elizabeth. (2006). Handbook of Pathphysiology (3rd ed.). Lippincott Williams & Wilkins • DeLauane, Sue, et.al., (2010). Fundamentals of Nursing (4th ed.). Delmar Cengage Learning • Hanover Hospital. (2008). Cardiac Rehab Patient Educational Material. Departent of Education Services, Hanover • Ocampo-Balabagno, Araceli, et.al., (2001). N261 Cardiovascular Nursing (1st ed.). University of the Philippines Open University • Schull, Patricia. (2009). Nursing Spectrum Drug Handbook 2010 (5th ed.). McGraw-Hill Professional • Smeltzer, Suzzane, et.al., (2010). Textbook of Medical-Surgical Nursing (12th ed.). Lippincott Williams & Wilkins • Woods, Susan, et.al., (2009). Cardiac Nursing (6th ed.). Lippincott Williams & Wilkins
WORLD WIDE WEB • cdc.gov • emedicine.medscape.com • nhlbi.nih.gov • webmd.com
ESSENTIAL TEACHING MANUAL IN CARDIAC REHABILITATION RUSSEL DE LARA, R.N. This pamphlet is to accompany the 2nd Faculty Marked Assignment submitted in partial fulfillment for the requirements in the course N261 Cardiovascular Nursing (1st Semester, A.Y. 2011-2012)
ARACELI OCAMPO-BALABAGNO, R.N., M.A.N. INA RAGOTERO, R.N., M.A.N. UNIVERSITY OF THE PHILIPPINES OPEN UNIVERSITY M A NURSING PROGRAM
ALL COPYRIGHTS BELONG TO THER RESPECTIVE AUTHORS.