Med A3 Cardiovascular Tab 2

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  1. Raynauds Syndrome
    Periodic vasospastic events causing causing pallor or cyanotic color changes of the fingers.

    TX: Protect from cold and stress. Possible use of Vasodilator drugs such as CCB's
  2. Pulse Pressure
    -Difference b/w systolic and diastolic BP

    -Normal range: 30-40 mmHg

    -Widening (increased) PP: Vascular changes of ageing. IICP (Cushings Triad)

    -Narrowing PP: Decreased Stroke Volume (i.e. shock, CHF, hypovolemia), Tachycardia, aortic stenosis, pericardial effusion.
  3. 1. Estimate Cardiac Output (CO)

    2. Estimate CO w/ a Pts PP (pulse pressure) and HR?

    3. What is the avg value for CO?
    1. CO= HR x SV

    2. 2 x PP x HR = CO

    3. Avg value is 4900 ml
  4. Cardiac Stroke Volume?
    EDV -subtracted from- ESV

    End Diastolic Volume (EDV) - End Systolic Volume (ESV)

    Avg Value is: 70 ml
  5. The Cardioregulatory Neurotransmitters are?
    • Acetycholamine (Ach)
    • - Slows HR/ reduces Stroke Volume
    • - Released by Parasympathetic system

    • Norepinephrine (NE) & Epinephrine
    • - Increase HR/Stroke Volume
    • - Released by sympathetic neurons
  6. The ________ can provide "input" by allowing emotion, fear, anxiety to affect HR.
  7. The 4 anatomical landmarks for the Cardiovascular system.
    Aortic- 2nd RICS

    Pulmonary- 2nd LICS

    Tricuspid- 4th LICS

    Mitral/PMI- 5th LICS MCL

    "APT M"
  8. Claudication
    exercise induced lower extremity pain, relieved by rest
  9. Normal Heart sounds
    S1 (Lubb) : Closure of AV Valves = Systole (Diaphram)

    S2 (Dubb) : Closure of Semilunar valves = Diastole (diaphragm)
  10. Extra Heart Sounds
    S3 : Rapid Ventricular Filling (Left Ventricle failure) (Use bell) *Patho in older and Physio in younger*

    S4 : Forceful atrial ejection into a distended ventricle (L Ventricle Hypertrophy) *seen in CHF and constrictive conditions*

    Murmurs: Valvular pathology

    Rubs: Pericarditis

    *Think HTN or CHF if S3 or S4 are present*
  11. Physiologic splitting of S2
    Delayed closure of pulmonary valve ; Normal variant if noted on INSPIRATION but may be pathogenic if noted on EXPERATION.
  12. Dyslipidemia:
    LDL >160 mg/dL

    HDL <35mg/dL;

    Subtract 1 risk factor if HDL >60
  13. Artherosclerosis
    Plaque formation within the ARTERIAL linings and structures. NOT the veins. Associated w/ DYSLIPIDEMIA and LDL's
  14. Hyperlipidemia Causes:
    Primary = Genetic

    • Secondary = HYPERTHYROIDISM (1 of leading causes)
    • Diet, Obesity, Excess ETOH intake,
    • Pregnancy, Obstructive Liver disease, MEDS
  15. TLC
    "Therapeutic Lifestyle Changes":

    • -Decreased fat/cholesterol intake,
    • -Diet adjustments,
    • -Increases PT,
    • -Stop smoking, etc.
  16. The most common etiology of Ischemic heart Disease is ?
  17. Desirable Lipid Levels on a Random Screeen
    Total Cholesterol <200 mg/dL

    TG <200 mg/dL

    LDL <160 mg/dL

    HDL >35 mg/dL
  18. T or F

    ALL Cholesterol medications cause GI irritation & Niacin uniquely causes skin flush & itch. (Cholesterol Meds = Bile Acid, Sequestrants, Fibrates, Niacin, Statins)
  19. Rhabdomyolysis
    Acute, potentially fatal skeletal muscle condition characterized by SKELETAL MUSCLE DESTRUCTION (Myoglobinuria & CK elev. 10X normal)

    Complications include: Hyperkalemia, Cardiomyopathy, DIC, Hyperuricemia, Resp. &/or renal failure, metabolic acidosis (This is a concern with any “statin” drug therapy)
  20. Fixed corneal clouding from hypercholesterolemia, most likely in adolescents ?
    Arcus Juvenilis
  21. Myotoxicity S/Sx
    Gradually decreased muscle strength & localized or generalized muscle weakness *These S/Sx happen early or delayed in disease process*
  22. T or F

    Lipid levels may effect the evaluation of Glucose & Uric Acid?
  23. Critical Stenosis
    75% (or greater) of the lumen of 1 or more coronary arteries are obstructed by artherosclerotic plaque.
  24. Do you need to have cath studies to make a differential Dx of Coronary Artery Disease or Atherosclerosis?
  25. Angina Pectoris and it's 3 types?
    Intermittent Chest Pain caused by reversible ischemia.

    -Typical (STABLE) = Onset w/ the "4 E's" (eating, exercise, emotional, environmental) relieved w/ rest or NTG

    -Prinzmetal’s Variant = Occurs @ rest/sleep; relieved w/ NTG

    -Crescendo (UNSTABLE) = Occurs @ rest or w/ exertion; NO RELIEF w/NTG
  26. Xanthelasma
    A yellow, lipid rich plaque (a xanthoma) present on the eyelids. Especially near the inner canthus.

    *50% of Pts w/ Xanthelasma will have significant Hypercholesterolemia!
  27. Xanthomatous Tuberosity
    Xanthoma appearing on neck, shoulders, trunk, or extremities, consisting of small, elastic, and yellowish nodules.

    *Seen in Family History
  28. Common systolic and diastolic heart murmurs?
    SYSTOLIC: MR (Mitral Regurgitation) and AS (Aortic Stenosis)

    DIASTOLIC: MS (Mitral Stenosis) and AR (Atrial Regurgitation)
  29. Name the valves of the heart and their location?
    2 Atrioventricular valves (AV) & 2 Semilunar valves (SL)

    • Triscuspid- Right AV
    • Pulmonary- Right SL

    • Mitral/bicuspid- Left AV
    • Aortic - Left SL

    TPMA= "Toilet Paper My Ass"
  30. Myocardial Infarction (MI)
    Development of a defined area of myocardial necrosis caused by local ischemia. Leading single cause of death in industrialized nations.
  31. AMI Intial Management:
    • MONA-IV
    • Morphine – 2-4 mg IV if pain not relieved post 3 sublingual NTG tabs
    • O2 via nasal cannula 2-4 L/Min.
    • NTG (sublingual or spray) 0.4 mg q 5 min (unless syst. B/P <90)
    • ASA 325 mg. (chewed & swallowed)
    • IV
  32. Pericarditis
    Most often viral etiology = Acute syndrome caused by inflammation of the pericardium & characterized by chest pain, distinctive ECG changes & a pericardial friction rub on PE.
  33. Rheumatic Fever
    Inflammatory disease resulting from untreated GROUP B SSTREP (GABS) Pharyngitis

    Key clinical Features = S/Sx occur weeks after pharyngitis, Migratory Joint Pain (most common initial presentation), Erythema Marginatum, carditis/murmur, SQ Nodules, Chorea (involuntary, irregular movements)
  34. T or F

    Always rule out Thyroid Disease & OTC’s as secondary causes of HTN?
  35. Pericarditis Clinical Manifestations
    1) Preceding URI 2) Fever, myalgias, fatigue 3) Pericardial Friction Rub 4) ECG Changes (ST elev., PR seg depression) 5) Sudden onset chest pain: Aggravated by swallowing, decreased w/ sitting/leaning forward, Retrosternal, Pleuritic, Radiation to trapezius/neck region
  36. Rheumatic Fever TX?
    • Penicillin (PO/Parenteral)
    • Cephalosporins
    • Corticosteroids (If carditis present)
    • Salicylates (If carditis present)
    • Secondary Prophylaxis x 5 years = Pen VK daily, Benzathine Pen G IM q 4 weeks

  37. PE will present with?
    A) Beck’s Triad (Elev. JVP, systemic hypotension, muffled heart sounds)

    B) Pulsus Paradoxis (10 mm/hg drop on inspiration)

    C) Tachypnea

    D) Tachycardia
  38. Basic Pericarditis management ?
    Indocin, Ibuprofin, Naprosyn
  39. Aortic Dissection
    • Intima tear with entry of blood into the media. "Dissects" between the intima and adventia. #1 site is at the ascending aorta at the ligamentum arteriosum. Abrupt and severe. “Tearing/Ripping” Pleuritic Chest Pain usually w/ a Hx of untreated HTN, CXR shows widened mediastinum, indistinct aortic knob.
    • Nausea, Vomiting, Diaphoresis is common.
  40. #1 Risk factor for PE
    Prior DVT/PE
  41. Cardiac Tamponade
    Is a complication of Pericarditis w/ - Increase in pericardial fluid volume – Impaired ventricular filling – Decreased cardiac output. Physical Exam findings of “Becks Triad” (JVD, Muffled heart sounds, Hypotension) Pulsus Paradoxus. TX: Pericardiocentesis if severe & volume expanders w/ Vasopressors (Dopamine) if less severe.
  42. Aortic Disection TX:
    Lower Systolic BP to 100-110 mmHg, HR 60-80, Decrease LV contractility

    A) Nipride + Esmolol

    B) Labetolol

    Early CT surgery involvement
  43. Infective Endocarditis
    Is a complication of Pericarditis w/ - Increase in pericardial fluid volume – Impaired ventricular filling – Decreased cardiac output. Physical Exam findings of “Becks Triad” (JVD, Muffled heart sounds, Hypotension) Pulsus Paradoxus. TX: Pericardiocentesis if severe & volume expanders w/ Vasopressors (Dopamine) if less severe.
  44. 3 predisposing factors of Aortic Disection:
    HTN Hx

    Connective tissue disorders

  45. Infective Endocarditis Physical Exam Presents with...
    Fever, Chills, Fatigue CHF, Regurgitant Murmur, Tachycardia, and vascular and immunological phenomena.

    • Vascular: - Janeway lesions = Non-painful petechaei of the feet & hands
    • - Splinter hemorrhages = splinter like bleeds on nail beds with NO Hx of traums or FX
    • -Sub Conjunctiva Hemorrhages

    • Immunological: - Osler nodes - Pads of fingers and toes
    • - Roth spots - Eyes
  46. Rheumatic Fever
    • Inflammatory disease resulting from untreated GROUP B STREP (GABS) Pharyngitis
    • Key clinical Features = S/Sx occur weeks after pharyngitis, Migratory Joint Pain, Erythema Marginatum, SQ Nodules, Chorea (involuntary, irregular movements)

    TX:Penicillin, Cephalosporins, Corticosteroids (if carditis present) Salicylates (if carditis present) Secondary prophylaxis x 5 years - Pen VK Daily - Benzathine Pen G IM q 4 weeks

  47. Pulmonary Embolism
    • Traveling Clot. Source is 80-90% from lower extremity DVT.
    • Also from Fat emboli, septic emboli, right heart thrombosis

    Notable findings of: Pleuritc chest pain / Dyspnea / Resp rate >16

    #1 Risk Factor = PRIOR DVT/PE
  48. Thromboangiitis Obliterans (Buergers Diesese)
    Obstructive inflammatory diesese of superficialdistant arteries, usually involves digits of hands and toes. Numbness, tingling, and pain. Typical Male "Heavy Smoker". Signs of Pallor, ulcerative, gangrenous tissue change. Directly linked to NICOTINE!
  49. Virchow’s Triad:
    • 1) Venous Stasis: prolonged travel, bed rest, etc.
    • 2) Hypercoagulabillity: pregnancy, estrogen therapy, protein deficiency
    • 3) Endothelial Damage: Recent surgery, trauma
  50. Pulmonary Embolism TX:
    Consider? Monitor, O2, Pulse Ox, IV

    1) Anticoagulate first

    2) Low molecular wt Heparin
  51. Spontaneous Pneumothorax
    Thought to result from a rupture of a sub pleural Bleb. symptoms vary w/ size and rate of progression.

    S/S: Acute pleuritic Chest Pain, Dyspnea, Decreased breath sounds.

  52. Predisposing Factors of Pulmonary Embolism development
    • -Prolonged immobility
    • -Hypercoaguable state
    • -Vascular trauma
    • -Long bone fracture (Tibia, Femur) Fat emboli release
  53. Do NOT use Calcium Channel Blockers on CHF patients.
  54. Definition of Hypertension
    • Systolic (mm Hg) Diastolic (mm Hg)
    • Normal...........................................<120..............and.........<80
    • Pre-hypertension................................120-139..........or...........80-89
    • Stage 1 HTN......................................140-159..........or...........90-99
    • Stage 2 HTN....................................>160................or..........>100
    • *Note = based on 3 visits (Avg 2 or more readings a visit)
  55. Manage suspected PE with:
    O2, Anticoagulate, Low Molecular weight Heparin (lovonox sq q 12 hrs)
  56. Definition of Hypertension
    • ....................Systolic (mm Hg).......... Diastolic (mm Hg)
    • Normal................. <120......... and........ <80
    • Pre-hypertension...... 120-139..... or.......... 80-89
    • Stage 1 HTN............ 140-159..... or.......... 90-99
    • Stage 2 HTN.......... >160........... or.........>100

    • *Note = based on 3 visits (Avg 2 or more readings a visit)
  57. Describe the Renin- Angiotensin- Aldosterone System of controling BP
    • Kidneys release Renin =
    • Renin releases Angiotensin 1 =
    • Angiotensin 1 converts to Angiotensin Converting Enzyme (ACE) =
    • ACE converts to Angiotensin 2
    • Angiotensin 2 causes Vasoconstriction/Increased BP
    • Angiotensin 2 releases Aldosterone
    • aldosterone increases Sodium and water retention in the kidney's increasing the BP
  58. UNCOMPLICATED HTN Initial Drug Therapy
    Stage 1

    • - Thiazide diuretic for most.
    • - May consider ACEI/ARB, BB, CCB, Diuretics "ABCD"

    Stage 2

    • -Thiazide diuretic
    • -ACEI/ARB, BB, CCB, Diuretic's "ABCD"
  59. ACEI and ARB's
    Blocks the effects of ACE, preventing the formation of Angiotensin 2; therefore preventing a rise in blood pressure

    • DO NOT GIVE ACE Inhibitors (“Prils” i.e. Leptopril) to women who are pregnant, planning on getting pregnant or breast feeding.
    • Other ACE Inhibitor adverse effects include Dry cough, rashes, pancreatitits, protein uria, hyperkalemia
  60. Beta Blockers
    Reversibly antagonizes B- adrenergic receptors to Decrease CO, HR, Contractility, CNS Outflow, Renin release. All The "LOL's"

    • Beta Blockers (BB) = Do NOT Give to Asthma (may provoke) or 2nd/3rd degree heart block patients (may make complete block)
    • BB Adverse Effects = Bronchospasm, Bradycardia, Depression, bad dreams, fatigue, impotence, Elevated trigs, lowered HDL
  61. a1 antagonists
    Works by blocking a1 adrenergic receptors, resulting in arteriolar dilation. reduction in Total Peripheral Resistance. Prazosin, Terazosin

    Side effects: First dose syncope, Orthostatic Hypotension. Use with caution in the Elderly
  62. Calcium Channel Blockers CCB
    Inhibits Ca2+ channels in the heart, and vasculature, reducing contractions. Nifedipine, Diltiazem, Verapamil.

    Do NOT use Calcium Channel Blockers on CHF patients.

    Adverse Effects:
    Headache, Flushing, Palpitations, Ankle Edema
  63. Symptoms and Physical findings of Aortic Dissection
    • -Sudden and Severe chest, neck, or interscapular region pain.
    • -Increased BP differential/assymetric pulses
    • -Nuero Deficits
    • -Cardiac Tamponade features
    • -Hoarseness
    • -Dyspnea
    • -Dysphagia

  64. Predisposing factors for Aortic Dissection
    -HTN Hx

    -Connective Tissue Disorders

  65. Medical Management for Aortic Dissection
    Consider? 2 large bore IV's, Monitor, T&C, ECG

    • Goal:Decrease Systolic BP to 100-110 mmHg & HR of 60-80
    • Options of:Nipride + Esmolol OR Labetolol

    Early CT Surgery involvement
  66. Clinical manifestations of PE
    • -Pleuritic Chest Pain.. Sudden Onset
    • -Tachypnea.. Sudden Onset
    • -Tachycardia .. Sudden Onset
    • -Associated risk factors of "Virchows Triad"
  67. ID factors that predispose the development of Pulmonary Embolism
    • -Prolonged Immobility
    • -Hypercoaguable state
    • -Vascular trauma
    • -long bone fracture (tibia/femur) Fat emboli release.
  68. Describe Renin- Angiotensin- Aldosterone system assists in blood pressure control
    Kidneys >> Renin >> Angiotensin 1 >> Angiotensin Converting Enzyme (ACE) >>

    • ACE> Angiotensin 2 >> Vasoconstriction = INCREASED BP
    • ACE> Angiotensin 2 >> Aldosterone >> Renal Na+ and Water retention = INCREASED BP
  69. "First Line" Medications for HTN
    "ACT" First

    • 1) ACEI or ARB
    • 2) CCB
    • 3) Thiazide (Diuretic) * Has a risk of secondary diabetes development

    *BB's also have a risk of new onset diabetes development as a side effect
  70. Second Step Meds for HTN
    1) ACE + CCB or Thiazide diuretic = "ACT"

    2) ARB + CCB = "CAR-B"
  71. HTN Med Suffixes?
    • "Pril" = ACEI
    • "Artan" = ARB
    • "Alol" = BB
    • "Pine" = CCB
  72. Hypertensive Crisis
    URGENCY= 180/110 EMERGENCY= 220/140

    • Management = initial redux no greater than 20-25%. Goal is a gradual MAP redux to 110-115 in
    • 1st 30-60 min. Be careful how fast you drop it!
  73. CHF Signs for Left and Right side?
    • Right sided (Distension/Edema) Left Sided (Pulmonary)
    • Distended neck Veins (JVD) ............................ Tachycardia Murmur
    • Hepatomegaly............................................... Cool, clammy skin
    • Ascites ......................................................... Pulmonary Edema (Crackles)
    • Peripheral edema............................................ Cardiomegaly (displaced/enlarged PMI)
    • Abdominal Jugular Reflex................................. 3rd Heart Sound (S3)
    • Peripheral Edema.............................................Orthopnea
  75. JVD and JVD Pressure
    Increased JVD = Right Atrial Pressure

    Pt Head/ Neck/ Back at 30 Degree angle will present with jugular veins distended 5cm or > indicating Right side Failure.
  76. CHF Acute Management
    Acute CHF Management (LMNOP)

    • Lasix (diuretic) = decrease preload & Diuresis
    • Morphine = decrease preload & afterload
    • Nitrate (NTG) = decrease preload & afterload
    • Oxygen = increase PO2, & pulmonary vasodilatation
    • Positioning = increase lung volume, decrease work of resp. & venous return

    *Note:Also consider Pressors & Digoxin
  77. Arterial vs. Venous Peripheral Vascular Diesese (PVD)
    • Arterial.................................................. Venous..................
    • -Cool Temp- Pallor...............................*Warm *Flushed
    • -Bradycardia-Sharp pain........................*Edematous *Aching Pain
    • -Pain increase w/ exercise/elevation.......*Pain increased w/ dependency
    • -Dry ulcer development.........................*Weeping Venous Ulcers
  78. DVT Risk Factors
    • -Local Trauma
    • -Immobility (Bed rest/Travel)
    • -Meds (Nicotine, OCPS)
    • -Mechhanical (tight socks & pillow under knees)
    • -Pregnancy
    • -Obesity

  79. DVT Clinical Manifestations:
    • -Calf pain/tenderness
    • -Homan’s Sign (pain in calf w/ foot passively dorsiflexed)
    • -Erythema
    • -Warmth
    • -Unilateral leg swelling

    "CHEW- U' leg"
  80. Medical Management of DVT
    IMMEDIATE LMW-Heparin Therapy SQ q 12 hrs

    • Warfarin (Coumadin) Therapy
    • - Oral route
    • - 4 to 5 day overlap with Heparin
    • - Continued x 3 months

    Elevate legs/ Apply Heat * NO MASSAGE

Card Set:
Med A3 Cardiovascular Tab 2
2009-11-23 01:57:07
Med A3 Cardio

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