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How does the blood flow through the heart?
oxygenated blood enters left atrium through the aortic valve -> through mitral/bicuspid valve ->left ventricle -> pumps blood out the aorta -> arteries -> arterioles -> capillaries -> venules -> veins -> vena cava -> deox blood enters right atrium -> thru tricuspid valve -> right ventricle -> thru the pulmonary valve -> pulmonary artery -> lungs to be oxygenated -> pulmonary veins -> oxygenated blood reenters left atrium
Function of arterial blood flow?
take blood away from the heart to tissues
Function of venous blood flow?
collects blood from body tissues and takes it back to the R side of the heart where it is pumped to the lungs for reoxygenation
Conduction system of the heart?
SA node -> AV node -> bundle branches -> Purkinje fibers
What occurs during systole and diastole of the cardiac cycle?
during diastole the ventricles relax and the mitral and tricuspid valves open to allow blood to enter the ventricles passively from the atria; at the end of diastole the atria contract and propel remaining blood into ventricles & AV valves shut to prevent backflow into atria
during systole the ventricles contract and the pulmonary and aortic valves open to allow blood to flow out of the heart to the tissues and lungs; the AV valves are closed to prevent blood flowing back into the atria
2 valves on the left side of the body?
mitral and aortic
2 valves on right side of the heart?
tricuspid and pulmonic
What is result of clots in the venous system?
Result of clot in the artery of a leg?
will clog in foot and cause ischemia
Is artery or vein more critical if a clot occurs?
artery b/c it causes ischemia of a body part
Firing mechanism in the heart?
8 liters per minute
CO = ?
SV X HR
won't have to figure that on the test
How do you know if pt has good cardiac output?
pulse, BP, appearance, color, skin moisture,
If bad CO what is the appearance?
pale and diaphoretic, v/s, mottled (white/yellow/purple due to ischemia of tissues), grey, capillary refill, MM
amount of blood the heart must pump with each beat due to amnt of blood coming from veins
how much pressure that is required for the heart to pump blood out
Goal of TX?
HOw is this done?
increase CO without increases the workload of the heart
drugs that affect preload and afterload
amount of blood the heart pumps in a minute
What happens in preload is increased?
How can preload be decreased?
will increase CO
1. sit pt on side of the bed and let legs hang off so blood volume stays in the legs
2. give them diuretics to decrease BV
3. give them drugs that vasodilate - will decrease volume coming to heart
will keep blood volume in legs and decrease preload
vasodilators - decrease preload
Vasoconstriction effects on afterload?
increases it b/c small vessels increase pressure needed to get blood through
High blood pressure effects on heart?
causes blood vessels to be constricted that more volume comes to heart and afterload is increased - heart is overworked
Compensatory mechanisms of the body effect?
What are interventions for?
they make prob worse
interventions are all to counteract compensatory mechanisms of the body
3 goals of cardiac treatment?
increase CO, decrease preload & afterload
ability of the heart to change its force of contractions
Drug that can increase cardiac contractility?
mean arterial pressure
- (2 X diastolic) + systolic 3
must be at least 60
Why does diastolic pressure count 2 X more in MAP?
2/3 of the cardiac cycle is spent in diastole
Increased HR effect on CO?
can decrease CO
Tissue factors that contribute to local control of blood flow?
histamine, serotonin, kinins, prostaglandins, blood vessels, endothelial control of vasodilation and vasoconstriction, NO (nitrous oxide)
Histamine affect on blood flow to an area?
increases blood flow to area
Serotonin effect on blood flow to an area?
vasoconstriction = less blood flow to the area
kinins effect on blood flow to an area?
VASOCONSTRICTION = less blood flow to the area
2 prostaglandins and their effects on blood flow to an area?
Prostaglandin E - vasodilator - increases
Prostaglandin F - vasoconstrictor - decreases
Effect on blood flow to an area?
powerful vasodilator produced by the endothelial lining of arteries - increases blood flow to an area
Collateral circulation AKA?
Why would a 70 year old pt live from MI but a 40 year old die?
70 year old has had ischemia a while and collateral circulation has had time to develop
If a pt has good collateral circulation what would be the Tx?
nitroglyceran to keep collateral circulation open and decrease chest pain
Parasympathetic NS regulates HR through ____ nerve with increase vagal activity producing ______ HR.
What is a way a nurse can nonmedically raise a pt HR?
Have them "vagal down" bear down like having a bowel movement
SNS effect on the heart?
excitatory influence on heart rate and contractility
Teaching for a pt that does need their HR to go up?
vagal can cause decrease BF to the brain and MI
will give them stool softeners
2 ways that vagal can occur?
bearing down in any way
holding breath in anticipation of pain, etc
Main carrier of cholesterol?
2 types of lipids that are primarily ass. with hyperlipidemia?
Main S/S of venous problem in the legs?
Diff in Tx of arterial prob in legs?
swelling in the legs
in arterial will keep legs down to try to increase BF
hyperlipidemia, PAD, Raynaud disease, aneurysms,
2 sites of lipoprotein synthesis?
small intestine and liver
If a person has a blockage in their arteries what will it be caused by?
HDL effect on cholesterol?
lowers it by transporting it back to liver to be excreted
2 ways to increase HDL?
moderate alcohol intake and exercise
_____ decreases HDL/
genetic basis - not necessarily r/t what they eat or the size of the person
obesity and high calorie diets
Drugs for hypercholesterolemia?
statins that work on liver and have it decrease cholesterol production
Dx and screening for hypercholesterolemia?
all adults 20 yrs and older have a fasting lipoprotein profile done q 5 yrs
Total cholesterol normal?
< 200 mg/dL
HDL > 40mg/dL
turns liver off at night
Smoking effects on arteries?
can damage the lining of the arteries, atherosclerosis will occur at the site of damage and arteries become more sticky due to smoking so the debris sticks to the artery more easily
8 risk factors for CHD?
coronary heart disease
- 1. high LDL
- 2. family Hx of premature CHD in 1st degree relative
- 3. current cigarette smoking
- 4. hypertension
- 5. low HDL
- 6. DM
- 7. hypercholesterolemia
- 8. male gender until women hit menopause
Recommendations for total cholesterol in pt with no major risk factors, 2 or more risk factors, high risk factors, very high risk factors?
no risk factors - 160mg/dL or less
2 or more risk factors - <130 mg/dL
high risk factors - (with CHD) - < 100 mg /dL
very high risk factors (acute coronary syndromes) - < 70mg/dL
Relationship of high risk factors for CHD and age?
more risk factors = develop at earlier age
Why are hypertension and smoking risk factors for CHD?
they damage the arteries
Why is DM a risk factor for CHD?
sugar makes everything sticky and speeds atherosclerosis
Pt teaching for pt that has started cholesterol meds?
teach them they need to bake food and that they can't eat everything they want just because they have the med
find out who is doing the cooking and teach them
3 types of atherosclerotic lesions?
- 1. fatty streaks
- 2. fibrous atheromatous
- 3. complicated lesion
Fatty streak lesions?
present in CH but not sure they lead to atherosclerotic lesions
Fibrous atheromatous lesions?
lesion is a gray or pearly white elevated thickening of the vessel
Complicated lesions characterized by ____, _______, _______,
- 1. hemorrhage
- 2. ulceration
- 3. scar tissue deposits
Most important complication of a complicated lesion?
thrombosis caused by slow turbulent blood flow in the region of the plaque and ulceration of the plaque
Most dangerous type of atherosclerotic lesion?
complicated lesion b/c it can rupture and cause inflammatory process to occur which can lead to 100% occlusion
Tx for thrombus from complicated lesion?
anticoagulants, clot buster to disintergrate the clot and restore blood flow
Modifiable risk factors for CHD?
- 1. smoking cessation
- 2. hypertension
- 3. hyperlipidemia
- 4. type II DM
Unmodifiable risk factors for CHD?
- 1. age
- 2. gender
- 3. genetic factors
- 4. race
Homocysteine effect on atherosclerosis?
believed to increase risk for atherosclerosis by inhibiting anticoagulant cascade ass. and causing endothelial damage
Protein that indicates systemic inflammation when elevated?
May also indicate what?
CRP - C-reactive protein
What is the initiating factor in the dev of atherosclerosis?
damage to endothelial vessel layer
4 EX factos that may damage the endothelial tissue layer and initiate atherosclerosis?
- 1. smoking
- 2. immune mechanisms
- 3. mechanical stress - hypertension
- 4. unstable plaques and complicated lesions
Clinical manifestations of atherosclerosis?
depends on vessel involved and how much narrowing there is
ischemia V/S infarction - perfusion decrease v/s tissue death
atherosclerosis of the coronary artery
Who does it occur most in?
peripheral artery disease -
atherosclerosis / narrowed arteries reduce blood flow to the legs
most common in 70-80 year old men
5 high risk factors for PAD?
- 1. hypertension
- 2. DM II
- 3. hyperlipidemia
- 4. cigarettes
- 5. CHD / atherosclerosis in other areas
vasculitis of the med sized arteries of the hands and feet - become inflamed and swell - eventually block off the arteries and can cause ischemia of distal tissue
AKA Buerger disease
affects men b/t ages 25-40 who are heavy cig smokers
Primary symptom of PAD?
Why does this occur?
intermittent claudication - pain with walking
muscle is ischemic and requires more blood flow when being used - will do anaerobic respiration and cause lactic acid build up = pain in muscle
at rest the pain goes away
How to determine if a problem is arterial or venous when s/s is intermittent claudication:
arterial: S/S of decreased blood flow/ischemia thin/shiny skin, atrophy of leg muscle (chicken legs), cool extremity, popleteal and pedal pulses are weak or absent, hair loss on legs, elevation of leg causes color to blanch in leg, becomes deep red when leg is in dependent postion (dangling), brittle toenails,
What should nurse do if can't find pedal pulse?
dopplar the pulse and document it if found
Positioning of legs for arterial blockage?
Can you use heating pad for a pt with PAD?
NO- they may have nerve damage due to decreased blood flow and may not be able to feel if it gets too hot
can cause burns that will be hard to heal b/c of decreased BF
Tx for PAD?
- 1. walking (slowly) to the point of claudication usually is encouraged b/c it increases collateral circulation
- 2. avoidance of injury
- 3. no smoking
- 4. Tx hypertension
- 5. decrease lipids
- 6. DM treatment
Alcohol and bengay effect on PAD?
will cause vasodilation and increase BF and decrease pain
Thromboangitis Obliterans Tx?
Raynaud disease & phenomenon?
functional disorder caused by intense vasospasm of arteries & arterioles in the fingers and less often in the toes
Teaching pt with PAD?
- 1. walk until it hurts and then rest and tell them why (increased collateral BF)
- 2. need to avoid injury r/t decrease healing
- 3. watch diet and weight if high cholesterol
- 4. keep BG under control if DM
Cause of thromboangitis obliterans?
smoking - inflames vessels and cuts of blood flow to extremities = ischemia and amputation
usually in fingers and toes then advances proximally and will have to keep getting amputations
Who usually gets Raynaud disease?
healthy young women
Triggers of Raynaud's disease?
- 1. smoking
- 2. cold
- 3. emotional stress
Area usually affected by Raynauds disease?
- 1. protect from cold
- 2. decrease stressors/ triggers
- 3. avoid injury r/t decreased BF
- 4. no smoking
- 5. Ca channel blockers
- 6. Run hands under warm water
2 Meds that are give for Raynaud's disease?
Ca channel blockers b/c treat spastic arteries
Ca channel blockers effect on arteries?
decreases spasms of arteries - given for spastic arteries
Dx of Raynaud's disease?
Hx of vasospastic attacks
What happens when nitro and viagra are mixed?
extremely low BP
Complication with Raynaud's?
if fingers are injured (paper cut) they will not heal well r/t decreased BF
when BF is restored it hurts
weakened area of an artery causes small spherical dilation (outpouching) of the vessel at a bifurcation
Where do aneurysms usually occur?
What is a triple A?
usually in aorta
abdominal aortic aneurysm
2 ways aneurysms are usually found?
- 1. umbilical pulsation - DO NOT PRESS ON IT
- 2. Xray for other things - asymptomatic usually
Typical triple A pt?
man in their 70's b/c they have high blood pressure
Hypertension effect on aneurysms?
causes increased pressure and increased ballooning out of the aneurysms and possible rupture
Who gets most triple A's?
more in ppl over 50 and more in men
2 causes of triple A?
- 1. atherosclerosis
- 2. hypertension
Where do most triple A's occur?
elow the level of the renal artery and involve the bifurcation of the aorta and proximal end of the common iliac arteries
Blood flow in an aneurysm?
in the middle the blood is moving quickly and around the edges the blood is pooling
- after Tx procedures must watch for clots
- ---monitor I&O for renal clot
- ---monitor perfusion
Tx of aneurysms?
- 1. < 5cm will just watch it
- 2. > 5cm will go to surgery
- 3. go to surgery if it is getting larger also
- 4. interventional radiography - put in a graft to stabilize the aneurysm (Dacron graph)
Why might surgery not be done for aneruysm?
may have hypertension and atherosclerosis
will have bad outcome
Pt teaching with untreated aneurysm?
1. come in q 6 mo for ultrasound
Dx of aneurysm?
ultrasound, echo, CT, MRI
a life threatening condition where a longitudinal tear in the intimal layer of the vessel or separaion of the vessel wall occurs & involves hemorrhaging into the vessel wall and creating a blood-filled cavity -
S/S of abd aortic aneurysm?
- 1. pulsatile mass at umb
- 2. mid mild abd pain
- 3. lumbar discomfort due to enlargement pressing on a nerve - dissecting triple A will cause back pain
- 4. stasis of blood may cause thrombosis
Important consideration when a pt comes back from surgery for aneurysms?
must watch for clots
I&O if above renal artery - have a urometer in the foley bag
2 most common causes of aortic aneurysm?
- 1. atherosclerosis
- 2. degeneration of vessel media
after age 50 more in men than in women
2 causes of abd aortic aneurysms?
- 1. atherosclerosis
- 2. hypertension
Who gets dissection most?
men 40-60 yrs with Hx of hypertension or in younger ppl with conn. tissue diseases
S/S of dissection?
- 1. excruciating pain that is tearing or ripping feeling
- 2. BP usually moderately elevated
- 3. in late stages BP will drop due to blood loss
Dx of dissection?
- 1. TEE
- 2. history
- 3. phys exam
- 4. CT scans
- 5. MRI
numb throat and shine light down esophagus to view the chambers of the heart and watch pumping and valves
must be NPO before and after until gag reflex is good
mean arterial pressure - avg pressure in the arterial system during ventricular contraction and relaxation and is a good indicator of tissue perfusion
Tx for dissection?
- BP control
- monitor for S/S of hypvolemic shock
The systolic and diastolic components of blood pressure are det by the ____ ____ & the ___ ____ _____.
Formula for BP?
CO & peripheral vascular resistance
BP = CO X PVR
What determines peripheral vascular resistance?
radius of the arterioles
Patho of neural regulation of BP?
stimulation sent to cardiovascular center in the lower pons and medulla where info is integrated -> autonomic NS stimulation to maintain homeostasis
PNS - impulses to heart through vagus nerve
pressure sensitive receptors located in the walls of blood vessels and the heart
5 Factors involved in short-term regulation of BP?
- 1. ANS stimulation
- 2. barorecptors
- 3. arterial chemoreceptors
- 4. RAAS
- 5. vasopressin/ ADH
Arterial chemoreceptors function?
sense drop in O2 and cause widespred vasoconstriction -> increases BP
Where is it released from and what is its function?
ant pit - vasoconstrictor
Long term regulator of hypertension?
kidneys regulate with higher level of Na and water elimination
genetic hypertension that doesn't need Dx test to diagnose it - can Dx with family Hx and phys exam
may do Dx test if adopted and don't know family Hx
Most common type of HTN?
primary/essential - cause unknown - genetic
Racial groups with higher HTN?
AA and more severe HTN
not responsive to BP meds
Risk factors for primary HTN?
- 1 family Hx of HTN
- 2. race - AA
- 3. age
- 4. T2DM
- 5. hyperlipidemia
- 6. obesity
- 7. metabolic syndrome
What is the key to reducing probs from HTN?
early DX and intervention
Lifestyle factors for HTN?
- 1. gigh Na intake
- 2. excessive calorie intake
- 3. obesity
- 4. phys inactivity
- 5. excessive alcohol consumption
- 6. sleep apnea
high BP, obesity, high BG, & hyperlipidemia
Manifestations of primary HTN?
- 1. may be asymptomatic
- 2. symptoms that may be present are r/t long-term effects of HTN on the organ systems of the body
What may ppl be tested for if they have HTN?
Organs effected by HTN?
kidneys, heart, eyes, and blood vessels
What lab to look at to det renal insufficiency?
How does HTN affect the heart and the kidneys?
increases workload on the left ventricle and causes renal insufficiency
Dx of HTN?
need at least 2 or more BP readings to Dx
Lifestyle modifications to TX HTN?
- 1. weight reduction
- 2. regular phys activity
- 3. reduce dietary NA intake
- 4. moderation of alcohol intake
Pharmacologic Tx of HTN?
use a stepwise approach
If a pt comes in with creatinine of 1.2, high BP, atherosclerosis, and admitted with chest pain.....
What will the MD do?
How will renal insufficiency affect the Dx done?
usually will send for a heart cath
if have renal insufficiency cannot give the dye for heart cath b/c damages kidney
Major sequelae of HTN?
Nursing consideration if a pt is going to have a heart cath?
make sure to check creatinine on labs and notify MD if it is abnormal - this is a nursing responsibility
HTN caused by another disease process
3 EX of secondary HTN?
- 1. renal hypertension
- 2. disorders of adrenocorticosteroid hormones
- 3. phenochromocytoma
Can pt with renal insufficiency have heart cath?
yes, but they need meds to protect their kidneys - mucomyst - tastes horrible
secondary HTN accelerated and potentially fatal form
Why is one BP reading not enough for DX?
may have white coat syndrome
Who is most at risk for malignant HTN?
- 1. young AA men
- 2. women with HTN of pregnancy
- 3. ppl with renal and collagen diseases
- 1. first choice diuretics - hctz
- 2. add another drug
- 3. add another drug of diff category (helps better than just increasing mg)
- 4. will pick diff drugs for diff race b/c act diff
- ----Ca channel blockers work better for AA
Manifestations of malignant HTN?
- 1. sudden marked elevations in blood pressure
- 2. diastolic values >120mmHg
- 3. HA
- 4. restlessness
- 6. stupor
- 7. motor and sensory deficits
- 8. visual disturbances
- 9. convulsions
- 10. coma
Action before giving a BP?
check the BP!!!
Serious complication of malignant HTN?
hypertensive encephalopathy & BP
Tx of malignant hypertension?
give meds to lower BP - give them slowly to avoid sudden drop in BP
Why must BP meds be given slowly if a pt has extremely high BP?
will bottom out BP & can cause strokes
What occurs in orthostatic HTN?
abnormal drop in BP upon sitting up or standing that also causes increase in heart rate
S/S of orthostatic HTN?
- 1. tachycardia
- 2. dizziness
- 3. syncope - fainting
What is a common cause of orthostatic HTN?
Who is most at risk for it?
any anti-HTN drug can cause it
6 things that can cause orthostatic HTN?
- 1. reduced blood volume
- 2. drug-induced HTN
- 3. aging
- 4. bed rest and immobility
- 5. disorders of ANS function
- 6. dehydration or too much dialysis
How can the nurse test to see if pt has orthostatic HTN?
Why might this be ordered?
do orthostatic BP readings
if testing for dehydration or too much dialysis
dilated or tortuous veins of the lower extremities which can lead to venous insufficiency
8 causes of varicose veins?
- 1. impaired flow in deep venous channels
- 2. DVT
- 3. pressure on abd veins caused by obesity
- 4. tumor
- 5. pregnancy
- 6. standing position
- 7. heavy lifting
- 8. incompetent valves
Dx of varicose veins?
- 1. visualization
- 2. doppler ultrasound flow
- 3. angiograph
Who is varicose veins more common in?
- 1. over 50 years old
- 2. family Hx exp in women
- 3. nurses - standing a lot
S/S of varicose veins?
- 1. unsightly appearnace
- 2. aching in the lower extremities
- 3. edema
Way to prevent varicose veins?
Tx of varicose veins?
- 1. elastic support stockings
- 2. sclerotherapy
- 3. surgical treatment
Chronic venous insufficency?
valve leaflets damaged rendering them incapable of closure - emptying of deep veins cannot occur
S/S of chronic venous insufficency?
- 1. tissue congestion
- 2. edema
- 3. brown pigmentatin of skin
- 4. stasis dermatitis
- 5. stasis or venous ulcers
Where are venous ulcers usually located?
over the ankle and lower leg due to chronic venous HTN
S/S that occur in chronic venous insufficiency
- 1. stasis of blood - immobility
- 2. vessel wall injury - trauma and surgery
- 3. increased blood coagulabiluty - use of oral contraceptives
- 1. 50% are assymptomatic
- 2. fever
- 3. malaise
- 4 elevated WBC
- 5. elevated sedementation rate
- 6. positive Homan's sign
Venous thrombosis prevention?
- 1. early abulation
- 2. support stockings
- 3. sequential pneumatic compression device
- 4. prophylactic anticoagulation
- 5. ankle flexion & extension **
Dx of venous thrombosis?
- 1. venography
- 2. ultrasonography
- 3. D-dimer
S/S of venous insufficiency in legs?
- 1. edema severe
- 2. will have pulses
accumulation of fluid in the pericardial cavity due to injury,
Why do pt need to flex and extend ankle after surgery?
What is it imp to teach them?
why they need to do this and other things so they will comly
What does a positive D-dimer mean?
means pt is at risk for blood clots but not that they have them
If pt has a swollen extremity should they get up?
If 1 leg is swollen really badly should it have TED and compression applied?
What about other leg?
shouldn't get up
no TEDs and Kendalls on swollen leg
other leg - yes
life-threatening,slowing of the heart due to rapid compression of the heart due to the accumulation of lfuid, pus, or blood in the pericardial sac r/t trauma, cardiac surgery, cancer, or uremia
S/S of cardiac tamponade?
decreased CO and bradycardia
Dx of cardiac tamponade?
key to Dx ***pulsus paradoxus - drop in BP when pt takes a breath
What will occur if the pericardial effusion becomes excessive?
fluid will keep heart from filling during diastole
pull fluid off pleural effusion
Biggest issue with cardiac tamponade?
Why does pulsus paradoxis occur?
So much fluid in thoracic cavity, when take a breath there is too much pressure in there and BP drops
inflammation of the pericardial sac due to viral infections, after cardiac surgery, connective tissue disorders
What Dx test will show pleural effusion and cardiac tamponade?
What is a pt at risk for after cardiac surgery?
Who has more acute pericarditis?
more in men than women
Tx for acute pericarditis?
usually take ASA & naproxen/aleve and send home
depends on causative agent
S/S of acute pericarditis?
- 1. chest pain
- 2. pericardial friction rub
- 3. EKG changes
- 4. pain relieved by sitting up and leaning forward and slow shallow breaths
Dx of acute pericarditis?
- 1. clinical manifestations
- 2. chest X-ray
- 3. ECG
- 4. echo
Coronary Heart Disease?
CAD - coronary artery disease
Left main coronary artery?
left anterior descending that feeds blood to left ventricle and the circumflex branches
Right coronary artery?
feeds blood to back of heart, SA and AV nodes
#1 cause of coronary heart disease?
atherosclerosis - obesity, smoking, DM, hypertension, high cholesterol
right coronary artery
If someone comes to the ER with chest pain what will be done and why>?
12 lead ECG- to show if there are probs and where they may be located: can show if RCA or left coronary artery is blocked, etc
What will occur if RCA is blocked?
firing of SA node can be interrupted b/c ischemia to this area can kill SA node and they will have to have a pacemaker
left anterior descending coronary artery
Where do lesions in CHD usually occur?
first usually several cm of LAD & L circumflex or the entire length of RCA
plaques that contain a lot of collagen and fibrous conn tissue that makes it less likely to rubture - obstructs blood flow
angina that is precipitated by increase work demands of the heart and can be aleviated with rest
will occur with phys exertion, exposure to cold, and emot distress
3 characteristics of unstable angina?
- 1. occurs at rest and lasts more than 20 minutes
- 2. it is severe and described as frank pain of new onset
- 3. it occurs with a pattern that is more severe, prolonged, and frequent
Acute myocardial infarction?
What will pt complain of?
ischemic death of myocardial tissue
- 1. severe pain
- 2. crushing pain - sitting on chest
- 3. may radiate to L arm, neck, and jaw
- 4. NV
- 5. not relieved by rest or sublingual nitroglycerin
spasms of the coronary arteries that occur during rest
variant or vasospastic angina
Tx for prinzmetal angina?
Ca channel blockers
Medication for arterial spasms?
Ca channel blockers
can rupture and cause platelet adhesions & thrombus formation
platelet adhesions- fatty plaque covered in fibrin
What occurs after a plaque ruptures?
- inflammatory response -> block artery completely
- clot busters
Time for Tx with MI?
within 6 h
Stable angina main teaching?
if normal pain changes in any way need see/call MD - can mean blockage is worse
Who commonly presents differently with MI pain?
women & DM - NV, back pain, jaw/tooth pain
DM pt - have neuropathy
Dx of acute MI?
1. EKG changes - T-wave inversion, ST segment depression or elevation & dev of Q-wave
2. serum markers: myoglobin, creatine kinase MB (CK-MB), troponin I & triponin T
Tx for MI?
MONA - morphine, oxygen, nitro, aspirin (chewed)
also - analgesic agents, B-adrenergic blockers(block EPI & NE), nitrates
thrombolytics and revascularization need to be initiated within 60-90 min of onset of symptoms
What will be done with MI S/S?
12 lead ECG to see if any ST elevation & ROMI panel
If see ST elevation of ECG what is it
If have ST elevation of 12 lead but have labs that show MI what is it?
Interpreting ECG and ROMI panel?
if have elevated ST will also have increased triponin = STEMI
If don't have elevated ST but have increased triponin = NSTEMI
enzyme released from heart muscle when it is damaged
the the higher triponin = more damage to heart muscle
STEMI or NSTEMI worse?
QRS complex elevated so much it looks like a tomb stone with ST elevation
8 complications of MI?
- 1. sudden death
- 2. heart failure
- 3. cardiogenic shock
- 4. pericarditis
- 5. thromboemboli
- 6. rupture of the heart
- 7. ventricular aneurysms
- 8. may see increased temp due to necrotic tissue
- 9. arhythmias
What may occur several days after an MI?
pt may spike fever r/t inflammatory response to necrotic tissue - still need to contact MD
decreased circulation of blood due to heart failure
Why is triponin main protein for MI?
myoglobin & CK-MB will be released with ANY muscle damage
triponin is heart muscle specific
deterioration of the heart muscle
progressive cardiac hypertrophy and dilatin and impaired pumping ability of 1 or both ventricles due to alcohol abuse, drug abuse, or genetic - have a gigantic heart
S/S of dilated cardiomyopathy?
- 1. heart failure/CHF S/S:
- 2. EF 40% or less- ejection fraction (decreased L ventricle function)
- 3. dyspnea on exertion
- 4. paroxysmal nocturnal dyspnea - suddenly feel like can't breathe in middle of night
- 5. orthopnea (orthopnea X5 = need 5 pillow to prop up)
- 6. fatigue
- 7. ascites
- 8. peripheral edema
- 9. S3 or S4
- 10. ventricular arrhythmias
- 11. thrombus
Dx of dilated cardiomyopathies?
echo, chest Xray, TEE (transesophageal), cardiac cath
Tx of dilated cardiomyopathy?
- 1. digitalis to increase contractility
- 2. decrease workload of heart - decrease preload and afterload -> increases CO
uncommon, life-threatening infection of the endocardial surface of the heart and valves - may see vegetations on the valves
What does ejection fraction tell?
Lower than ____ = heart transplant.
how well left ventricle is working
normal is in 50's
lower than 20 = heart transplant
How to get pt EF?
will show on echo/ECG
2 factors in infective endocarditis?
1. a damaged endocardial surface & portal of entry by which the organism gains access to the circulatory system
2. presence of valvular disease, prosthetic heart valves, or congenital heart defects provides an env conductive to bacterial growth
If echo and heart cath have an EF on them which report is more accurate?
cardiac cath report
If MD wants to know what the L ventricular function is what will you tell them?
the EF of the pt
- 1. ACE inhibitors
- 2. diuretics
- 3. dangling legs
Ppl with valvular probs are at risk for what?
infective endocarditis when have teeth cleaned b/c blood from teeth will take bacteria to the heart
may give prophylactic ABX before and after dental cleaning to prevent it
What type of pt may need to have prophylactic ABX with dental cleanings?
What other times may this be necessary?
pt with valvular probs: valve replacement, congenital valve probs
surgery, urology procedures
What test shows vegetation on a valve?
S/S of infective endocarditis?
- 1. fever & S/S of infection
- 2. petechial hemorrhages causes by vegetations breaking off
Pt teaching with valve probs?
take ABX before and after dental cleaning
Dx of infective endocarditis?
blood cultrues, echo, TEE
Tx of infective endocardits?
Is Tx started before or after blood cultures are done?
blood cultures should be drawn first - make sure that this gets done - may start ABX before returned but must be drawn to get accurate data
Rheumatic heart disease?
acute, immune-mediated, multisystem inflammatory disease following a group A B-hemolytic strep throat infection - causes valvular probs
When does rheumatic heart diasease usually occur?
about 1-4 weeks after strep infection
How can rheumatic heart disease by prevented?
ABX can prevent the strep from damaging the valves of the heart
What MO causes rheumatic heart disease?
group A - Bhemolytic strep
What should be done if suspect a pt has rheumatic heart disease?
- 1. ask if they have had sore throat
- 2. draw labs- anti-streptolysin O titer
Test that will show that a pt has had a strep infection?
antistreptolysin O titer is positive
Dx of rheumatic heart disease?
- 1. echo
- 2. sed rate
- 3. C-reactive protein
- 4. TEE
- 5. antibiotics
- 6. positive strep titer)
Age most rheumatic fever occurs in?
What is most often affected by rheumatic heart disease?
mitral and aortic valves
Tx of rheumatic heart disease?
If a pt has had RHD what are they now at risk for?
infective endocarditis b/c they may have sustained valvular damage
Will a person with rheumatic heart disease have a positive throat culture for strep?
probably not- usually already gone
narrowing of the valve orifice and failure of the valve leaflets to open normally
valve is closed when it should be open
2 causes: may be born with stiff valve or can be RHD
What may cause it?
narrowing of the mitral valve that causes left atrium enlargement
can be caused by RHD
If a person has RHD when may they start to have probs?
as they age may have more valve probs and need valve replacement
Why may left atrium enlarge?
if mitral stenosis occurs can cause left atrium to have extra work getting blood through
narrowing of the aortic valve that causes it to be closed during systole when it should be open
RHD or Ca depositis that occur as age (elderly)
Who is at risk for aortic stenosis?
person who had RHD and the elderly
What occurs with aortic stenosis?
enlarged L ventricle due to increased work to get blood through aortic valve
will eventually cause L-sided heart failure -> may have to have surgery to prevent this
permits backward flow to occur when the valve should be closed
open when should be closed
What can occur with regurgitating valve?
increased workload for the heart r/t having to repump regurgitated blood
Causes of regurgitating valves?
RHD or congenital
Who does it usually occur in?
mitral valve prolapse - form of rugurgitating valve
usually occurs in young women
Cause of mitral valve regurg?
enlarged L atrium b/c blood comes back into atrium during systole and has to be pumped back into ventricle
Cause of aortic valve regurg?
L ventricular failure b/c blood goes into aortic valve and blood goes back into the L ventricle to be repumped
Who has mitral valve prolapse most?
women and genetic / in families
S/S of mitral valve prolapse?
- 1. tachycardia
- 2. palpitations especially under stress
#1 thing need to ask person with heart palpitations?
What else do you need to ask?
How may the this be treated?
ask about diet:
any caffeine/energy drinks
Ask about stress also: if under a lot of stress may need a B-blocker until stress is alleviated
What should be eliminated from diet of cardiac pt esp pt with arrhythmias/palpitations?
caffeine, alcohol, and cigarettes
cardiac output - amnt of blood the heart pumps each minute - normally 8L/min
reflects the loading condition of the heart a the end of diastole
shows venous return to the heart
represents the force that the contracting heart must generate to eject blood from the filling heart - systemic vascular resitance
mechanical performance of the heart
Increased preload affect on heart failure?
will increase work of heart even more if preload is higher
If vasoconstrict how will this affect preload?
How is this treated?
will increase preload and afterload
give ACE inhibitors
may dangle legs before meds are started
What position should pt with heart failure not be in?
laying flat - they will feel like they are drowning
What drug helps strengthen contractility of heart muscle?
will decrease heart rate
Compensatory mechanisms of heart failure?
- 1. Frank-Starling mechanism - heart muscle stretches -> remodeling -> heart failure b/c stretching causes permenant damage and muscle won't go back (loses elasticity)
- 2. sympathetic nervous system
- 3. RAAS
- 4. natriuretic peptides
4 causes of heart failure?
- 1. acute MI
- 2. hypertension
- 3. cardiomyopathy
- 4. renal failure
2 types of heart failure?
right and left sided
3 causes of L sided heart failure?
- 1. AMI - acute MI
- 2. valvular defects - mitral or aortic stenosis/regurg
- 3. hypertension - resistance in the vessels increases workload on heart -> heart failure
Dx of L sided heart failure?
- 1. S/S
- 2. history and physical
- 3. lab- BNP - brain natriuretic peptid - shows ventricular failure
- 4. EKG
- 5. chest x-ray
- 6. echo
S/S of L sided heart failure?
- 1. decreased CO
- 2. pulmonary congestion: crackles (air moving through water), will see on Xray
- 3. orthopnea
- 4. frothy pink sputum
- 5. paroxysmal nocturnal dyspnea
- 6. fatigue
- 7 dyspnea on exertion
3 causes of R sided heart failure?
- 1. L sided failure
- 2. pulmonary disease -COPD (not pulm congestion like left sided failure)
- 3. Cor pulmonale - increased R ventricle side due to chronic pulmonary hypertension
enlargement & failure of R ventricle due to pulmonary hypertension
What is the one diagnosis that can cause R sided heart failure?
COPD - blue bloater
Chest Xray with L sided heart failure?
will show pulmonary congestion
What does BNP indicate?
ventricular function - if it starts to go down means they are improving
Pulmonary congestion, crackles/rales, O2 sat low, pink/frothy sputum?
L sided heart failure
Person thinks have heart failure what will be done?
As get better what will occur?
BNP will go down
Why does L failure cause R failure?
because L causes fluid to back up to lungs then backs up to R ventricle -> increases work of R ventricle - R sided failure
If a pt has Hx of COPD and are swollen what type of heart failure prob have?
S/S of R sided heart failure?
- blood backs up everywhere in body and fluid escapes everywhere
- 1. peripheral edema (3+, 4+, extreme)
- 2. GI congestion - blood backs up in GI tract
- 3. liver congestion & hepatomegaly
- 4. ascites
- 5. splenomegaly
- 6. JV distention
Pt with peripheral edema, hepatamegaly, spleanamegaly, & ascites?
R sided heart failure
Goals of heart failure Tx
relieving symptoms and improving the quality of life with long-term goal of slowing, halting, or reversing cardiac dysfunction
Tx of heart failure?
- 1. decrease preload
- 2. decrease afterload
- 3. increase contractility
- 4. possible fluid restriction
- 5. salt restriction
- 6. weigh daily
- 7. drugs - diuretics, digoxin, ACE inhibitors, beta blockers
Acute pulmonary edema?
accumulation of fluid in lungs
S/S of acute pulmonary edema?
- 1. SOB
- 2. cyanosis
- 3. tachycardia
- 4. cool
- 5. frothy, pink sputum
- 6. crackles
- 7. pt will want to sit up, restless, anxious
4 Tx of acute pulmonary edema?
- 1. digoxin
- 2. diuretics
- 3. vasodilators
- 4. O2
- 5. may need face mask or mechanical ventilation
3 stages of shock?
- 1. nonprogressive stage in which the normal compensatory mechanisms prevent large changes in circulatory function
- 2. progressive state, in which the shock becomes progressively worse
- 3. irreversible stage in which the shock has progressed to such an extent that all forms of therapy are insufficient to save the person's life
failure of heart to pump
Beta blockers contraindicated in ______ but can be given slowly once they are improving and will help over time.
Congestive heart failure
Most common cause of cardiogenic shock?
What happens to cardiogenic shock pt BP?
Do we give them fluids?
no fluid- heart not pumping so won't do any good
Tx for cardiogenic shock?
- 1. decrease workload of heart
- 2. O2
- 3. vasodilators ?
- 4. vasoconstrictors
- 5. aortic balloon pump
What should not be done with cardiogenic shock to raise BP?
do not give fluids to raise BP
diminished blood volume
Causes of hypovolemic shock?
- 1. hemorrhage
- 2. severe burns
- 3. vomiting or diarrhea
S/S of hypovolemic shock?
- 1. thirst
- 2. tachycardia
- 3. cool and clammy skin
- 5. decreased UO
- 6. restlessness
- 7. can lead to apathy
- 8. stupor and coma
Drugs for cardiogenic shock?
1. vasoconstrictors - dopamine, levafed
Major side effect to look for with major vasoconstricting drugs?
necrotic tissue in extremites r/t decreased blood flow
Tx of hypovolemic shock?
- 1. treat cause
- 2. O2
- 3. fluids
- 4. blood
- 5. vasoconstrictors
If pt has not been typed and cross matched but needs blood what can be done?
give them O-
fluid shifts out of vessels: char. by loss of blood vessel tone, enlargement of the vascular compartment, and displacement of the vascular volume away from the heart and circulation
3 types of distributive shock?
- 1. neurogenic shock
- 2. anaphylactic shock
- 3. septic shock
5 complications of shock?
- 1. acute resp distress syndrome
- 2. acute renal failure
- 3. GI complications
- 4. DIC
- 5. multiple organ dysfunction syndrome -MODS
2 types of shocks that would give fluid to?
What type don't give fluid to?
distributive and hypovolemic