4.1 - CVP - PPT CVP DDx (Cardiovascular Section) Flashcards
Week 4, Monday
Describe the pH scale (neutral vs acidic vs alkaline)
Neutral = 7
Acidic <7
Alkaline >7
Describe the abnormal responses to exercise
Angina
Dyspnea
Pallor
Cyanosis
Dizziness, light-headedness
Ataxia
Intermittent claudication
Blunted BP response
Hypertensive BP response >200/110 mmHg
Drop in SBP >10-15 mmHg
Significant change in EKG rhythm
What is angina?
Substernal (chest) symptoms - heaviness, pressure, tightness, burning, squeezing, choking
Includes radiation to (L) neck, arms, back, or epigastrum
Describe the 3 types of angina - stable, unstable, Prinzmetal
Unstable - new, recent onset (within 6 wks); occurs at rest w/o precipitating factors; or abrupt change in patient’s pattern of symptoms
Stable - experienced at predictable myocardial workloads / demands / effort; “stable pattern”
Prinzmetal - coronary artery vasospasm
Describe the clinical implications of unstable vs stable angina
Stable - want to stay under the anginal threshold while exercising; may use ntg prn if angina is present or prophylactic medications (long-acting nitrates, beta-blockers, calcium channel blockers) to decrease likelihood of experiencing angina
Unstable - usually signifies worsening of the underlying CAD
What is nitroglycerin used for?
Describe how ntg should be used/
Taken prn during angina
Sublingual dose
Have patient lay down as expecting BP to drop
Releases NO, which is a potent vasodilator -> increased BF to heart, decreased TPR
Should act to relieve pain w/in 1-2 min
If no relief after 2 or 3 doses or within 20 min -> call 911
Describe the appropriate management for unstable vs stable angina
Stable - stay below anginal threshold during exercise
Unstable - immediate medical evaluation; i.e., call 911; goal is to prevent MI!
Describe the clinical presentation of Prinzmetal angina
NOT preceded by increased myocardial demands
More common in women <50 yrs
S/sx:
- Pain often occurs early in AM, awakening patients from sleep
- Occurs at rest
- Sx difficult to induce w/ exercise
Describe the medical management of Prinzmetal angina
Nitrates (ntg)
CCBs
What is a myocardial infarction?
Cell death of the myocardium
What physiologically causes an MI?
Lack of blood supply to myocardium –> tissue injury & infarction
Often results from plaque rupture with thrombus formation in a coronary vessel
What life-threatening condition can an MI lead to?
Cardiogenic shock
- Insufficient BP to heart & vital organs
What cardiac enzymes are present and indicative of an MI? Describe these
Creatine-kinase-myocardial band (CK-MB)
Lactic dehydrogenase (LDH)
Troponin
Myoglobin
Cell death -> elevation in enzymes (does not occur w/ just ischemia)
Diagnosis of MI:
- Serial measurement troponin, AND
- Clinical changes
Describe the clinical presentation of an MI
Chest pressure
Radiating pain to L arm, jaw, and thorax
Dizziness, light-headedness
Diaphoresis
Fatigue, weakness
Women:
Mental status changes
Dyspnea
Weakness / lethargy
GERD pain
Anxiety / depression
Sensation of inhaling “cold air”
Achiness, heaviness, weakness of BIL UEs
Symptoms relieved by antacids
When is it okay to initiate PT following an MI?
When cardiac troponin starts falling (before this, the cells are still dying)
Describe the “traditional” sternal precautions
No pushing, pulling, or lifting >5-10 lbs
No twisting of trunk
No raising elbows above shoulder level
(No horizontal abduction)
Advised to follow for 6-8 wks
Statins
Indications
Mechanism of action
Side effects
Indications: hyperlipidemia
- Decrease LDLs -> decrease risk of MI, CVA
MOA: Inhibit liver’s production of cholesterol
Potential side effects:
- Myalgia / myopathy (due to skeletal muscle breakdown)
- Rhabdomyolysis
- Liver impairment - asterixis, ascites
- Fever
- Nausea/vomiting
Teratogenic - must be avoided in pregnancy
What is pericarditis?
What can cause it?
Inflammation of the pericardium (fuild-filled sac)
Trauma, autoimmune, idiopathic
Describe the clinical presentation of pericarditis
Chest pain
Dyspnea
Pain RELIEVED by HOLDING BREATH or LEARNING FORWARD, SITTING UPRIGHT, KNEELING ON ALL FOURS
Pain AGGRAVATED by TRUNK MOVEMENT (creates friction of the pericardium)
Fever, chills, cough
LE edema
Mitral valve prolapse
What is it?
Describe the clinical presentation
Treatment
Mitral valve w/ lax supporting structure leads to abnormally excessive movement of mitral valve leaflets
- –> regurgitation of blood back into the L ventricle
60% of patients have no symptoms
IF symptomatic, common triad:
a) Profound fatigue
b) Palpitations (strong, fast, or galloping)
c) Dyspnea
Treatment: surgery
What is the end result of congestive heart failure?
Low cardiac output
Describe the clinical presentation of left vs right-sided heart failure
General symptoms of heart failure:
- Fatigue
- Edema (pulmonary or peripheral)
- Fluid weight gain (“congestion”)
- Dyspnea
Left-Sided:
- PULMONARY EDEMA
- Progressive dyspnea
- Productive cough
- Paroxysmal nocturnal dyspnea (sudden recurrent attack at night due to lying position)
- Orthopnea
- Fatigue, exercise intolerance
R-Sided:
- Jugular venous distension
- PERIPHERAL EDEMA (ascites, abdominal pain / discomfort, pleural effusion)
- Cyanosis
Define orthopnea
SOB (dyspnea) that occurs while lying supine
Describe systolic HF vs diastolic HF
Both result in decreased CO, but for different reasons!
Systolic HF
- Reduced ejection fracture
- Heart is “too weak to pump”
- Decreased contractility
Diastolic HF
- Preserved ejection fraction
- Heart is “too stiff to fill”
- Decreased chamber compliance -> decreased EDV -> decreased SV -> decreased C
What heart sounds may be indicative of chronic heart failure? Systolic HF? Diastolic HF?
Chronic heart failure = often S3
Systolic HF = S3 (due to increased atrial pressure leading to increased flow rates)
Diastolic HF = S4 (forceful atrial contraction into a stiff ventricle)
What is cor pulmonale?
Describe the physiology
Cor pulmonale - condition that causes the R-side of the heart to fail due to excessive pulmonary arteries hypertension
Pulmonary hypertension –> R ventricular hypertrophy & alveolar damage / capillary wall damage –> R-sided heart failure
How is jugular venous distension measured?
What is normal jugular venous distension?
What is it indicative of?
Measured w/ patient’s HOB elevated 45 deg (semi-fowler position)
Normal: <3-5 cm
R-sided heart failure
What is a DVT?
A blood clot that forms in the veins
Describe the clinical presentation of a DVT
Often asymptomatic
Pain in the region
Unilateral swelling, tenderness, & pain
Warmth
Discoloration / redness
Homan’s sign
What is Homan’s sign?
Special test for DVT
Reproduction of patient’s symptoms by squeezing calf
NOT specific nor sensitive
Review Wells Criteria for DVT
What score on Wells criteria indicates that a DVT is likely?
2 or more points
What is a pulmonary embolism?
Pulmonary vascular obstruction caused by a displaced thrombus
“blood clot in the pulmonary arteries”
Describe the clinical presentation of a PE
Dyspnea
Sharp, localized chest pain
Diffuse chest discomfort
Persistent cough
Hemoptysis (cough up blood)
Tachypnea
Tachycardia
Anxiety, restlessness
Abdominal aortic aneurysm
What is it?
Clinical presentation
Aneurysm (abnormal bulge) of the abdominal aorta
Clinical Presentation:
-Pulsating mass in the abdominal area
- Bruit heard over swollen area
- Abdominal / back / flank pain
- Claudication (poor circulation)
- Poor distal pulses (turbulent flow due to aneurysm)
Describe the medical management for an abdominal aortic aneurysm
If suspecting one –> refer to provider
If suspecting it has ruptured –> call 911
