Adult Cardiac Flashcards
Acute Coronary Syndromes
umbrella term :
-stable angina
-unstable angina
-non ST elevation ( NSTEMI )
-ST elevation MI ( STEMI )
stable angina
chest pain / discomfort with physical activity , ALLEVIATED with rest and medications
-nitroglycerin and rest
unstable angina
chest pain that occurs at rest , most concerning , NOT RELIEVED with rest or medications
-precursor for MI , tx as emergency
prinzmetal’s angina
caused by coronary artery spasm , normally occurs at night
-type of unstable angina
ACS dx test
- 12 lead EKG
- Cardiac Biomarkers
- Lipid profile
- Exercise Stress test
- Stress Echo
- coronary angiography
Cardiac Biomarkers (cardiac enzymes)
creatinine kinase
troponin I or T
myoglobin
levels rise after myocardial injury , measured every 6 hours after admission
lipid profile
triglycerides
total cholesterol
LDL
HDL
stress echo
those unable to use treadmill or bike , DOBUTAMINE can be used to increase HR mimicking effect of exercise
coronary angiography
GOLD STANDARD for ACS
-L sided heart cath
ACS medications
- OXYGEN
- Nitroglycerin
- Beta blockers
- CCB
- Antiplatelet drugs
- Morphine
- Antithrombin agents
- ACE inhibitors
ACS oxygen
ACUTE pain from angina is r/t decreased oxygen supply!!!
ACS nitroglycerin
causes vasodilation , given topically / sublingual / transdermal / IV
ACS beta blockers
used to tx angina , MI , dysrhythmias , HF , hypertension
-oral or IM
Beta blocker examples
Metoprolol
Labetalol
Carvedilol
ACS CCB
inhibits calcium ion flow across cellular membrane
Verapamil and Cardizem
calcium channel blockers
ACS antiplatelets
inhibits clotting or prevents platelet aggregation , used with UNSTABLE angina
Plavix and Aspirin
Antiplatelet agents
ACS antithrombins
inhibits antithrombin III , prevents fibrinogen to fibrin conversion
-IM or Sub q
Lovenox and Heparin
antithrombin agents
ACS morphine
used for pain relief and anxiety
-given IV
ACS ACE inhibitors
prevent angiotensin I to angiotensin II conversion
tx HTN and HF afteer MI
Enalapril / Captopril / Lisinopril
ACE inhibitors
myocardial infarction
leading cause of death among men and women in US
-increased risk b/t 6:00am and 12:00pm
MI modifiable risk factors
smoking
high LDLs
type II DM
obesity
HTN
MI non-modifiable risk factors
male gender
postmenopausal female
family hx
why are MI more common in the morning
blood pressure is at it’s highest and blood is most viscous
NSTEMI MI
partial occlusion of major coronary vessel
ST depression or T wave inversion without Q wave
will have elevated cardiac markers
STEMI MI
complete occlusion of major coronary vessel resulting in irreversible full thickness heart muscle damage
ST elevations
elevated cardiac markers
complete occlusion MI s/s
chest pain
shoulder / arm pain ( LEFT )
jaw / tooth pain
upper back pain
SOB
n/v
sweating
fatigue
R coronary MI s/s
JVD
hypotension
bradycardia : damaged SA node
n/v
L coronary artery MI ( WIDOW MAKER ) s/s
worst prognosis w / high risk of sudden death
dyspnea
tachycardia
hypertension
Women MI s/s
fatigue
diaphoresis
indigestion
arm / shoulder pain
nausea
vomiting
geriatric MI s/s
dyspnea
confusion
weakness
syncope
MI tests
- CK
- Troponin I and Troponin T
- Myoglobin
- Complete Metabolic profile
- CBC
- Coagulation Studies
- ABG
- EKG : GOLD STANDARD
- echo
- L sided heart cath
CK lab with MI
rise 6 hours post MI
peak at 18 hours
baseline 10-14 days after
Troponin MI test
preferred blood test to dx an MI , proteins are almost exclusively in heart
increase 6 hours post MI
peak 10-24 hours
baseline 10-14 days
EKG MI
GOLD STANDARD
-reveal ST depression or elevation
***WOMEN ARE LESS likely than men to have typical EKG change
echo MI
used to evaluate ventricular function like ejection fraction
MI L sided heart cath
GOLD STANDARD FOR FLOW DX
-inserted through radial or femoral
MI medications
- Oxygen
- MONA
- Heparin
- Beta Blockers
MONA
Morphine
Oxygen
Nitroglycerin
Aspirin
MI nitroglycerin
dilates coronary arteries
one tablet administered every 5 minutes w/ maximum of 3 doses
MI aspirin
help prevent platelets from enlarging or forming
MI morphine
control pain, relax coronary arteries, improve blood flow
MI heparin
started to prevent new clot formation
MI beta blockers
decrease heart workload
DO NOT USE WITH R CORONARY ARTERY MI w/ bradycardia
MI reperfusion therapy
- Fibrinolytic therapy
- percutaneous coronary intervention
MI Fibrinolytic Therapy
dissolve clot in coronary artery , symptoms MUST be present for less than 12 hours
NOT tx for unstable angina or NSEMI
3 IV sites
fibrinolytic therapy complications
excessive bleeding and hemorrhagic stroke
MI percutaneous coronary intervention
preferred method for opening blocked vessels causing and MI
-catheter with small balloon is inserted , inflated and deflated to open blocked artery
-stent may be placed
-radial or femoral insertion site
MI surgery
CABG
CABG
revascularization bypassing blockages
-typically uses saphenous vein or internal thoracic artery is used
CABG complications
bleeding
dysrhythmias
MI
stroke
nonunion of sternum
sternal infection
renal failure
HF
CABG : bypass complication
induction of systemic inflammatory response = shock
heparin induced thrombocytopenia
activation of platelets
complications of cross clamping aorta
post CABG care
monitor HR and BP continuously
hemodynamic monitor
cardiac monitor
s/s of infection
assess heart tones
core temperature
hourly I / O
skin color , pulses , edema
chest tube output / color / volume
hgb / hct / electrolytes / creatinine / BUN
post MI teaching
cardiac rehab
low cholesterol and sodium diet
avoid stress
report s/s of MI
angina
purpose / dose / SE of meds
nitroglycerin edu
no smoking
weight
cardiomyopathy
heart muscle becomes weak, enlarged, thickened and develop structural changes
cardiomyopathy risk factors
diabetes
hypertension
high cholesterol
high fat
obesity
family hx heart disease
sedentary lifestyle
smoking
alcohol
cocaine
viral infection
lyme disease
nutritional deficit
pregnancy
respiratory failure
ischemic cardiomyopathy
reduced ejection fraction caused by CAD such as MI or loss of myocardium
nonischemic cardiomyopathy
- dilated
- hypertonic
- restrictive
dilated cardiomyopathy
most common cause of HF , dilation of muscle in L ventricle causing enlargement and poor CO
hypertrophic cardiomyopathy
excessive myocardial hypertrophy , heart muscle thickens and enlarges , contraction is not weakened but filling is impaired
restrictive cardiomyopathy
stiff ventricular muscle resulting in impaired filling , results from another disease
cardiomyopathy angina s/s
chest pain
dizziness
indigestion
n/v
sweating
palpitations
SOB
fatigue
cardiomyopathy HF s/s
rapid / irregular HR
SOB
edema of legs , feet , abd.
pulmonary congestion
abnormal heart sounds
JVD
enlarged liver
fatigue
loss of appetite
cough
cardiomyopathy labs
- BNP
- CMP
- thyroid function
- CBC
- iron level
- CXR
- EKG
- R heart cath
- doppler echo
CMP lab
evaluates liver / renal function
Heart cath ejection fraction
55 - 65 % = normal
< 45 % = some disease
< 30 % = severe disease
cardiomyopathy medications
- ACE inhibitors
- ARBS
- Beta blocker
- Digoxin
- CCB
- diuretics
- nitrates
ACE inhibitors
reduce afterload , makes it easier for heart to eject blood
ex : lisinopril
ACE inhibitor SE
coughing
ARBS
for individuals who are unable to tolerate ACE inhibitors and SE
ex : losartan , valsartan
beta blocker
decrease workload of the heart
ex : metoprolol
beta blocker caution
use caution in asthma , kidney disease , COPD
digoxin
not primary cardiomyopathy tx , watch for toxicity
digoxin consideration
take apical pulse for one minute , HOLD MED when HR is < 60 bpm
CCB
reduce calcium entering the heart , decreasing stiffness
ex : verapamil , nifedipine
CCB effects
reduces :
chest pain
breathlessness
palpitations
nitrates
reduce cardiac preload
ex : nitroglycerin
pacemaker placement
wire placed in both R and L ventricle coordinating contractions ,
ICD
implantable cardioverter defibrillator recommended for patients with < 30% EF and high risk for lethal rhythms
cardiomyopathy surgery
- septal myectomy
- surgical ventricular remodeling
- Transmyocardial revascularization
- heart transplant
- left ventricular assist device
cardiomyopathy complications
- Heart Failure
- Dysrhythmias
complication of cardiomyopathy
heart failure
cardiomyopathy a-fib
places patient at risk of stroke , PE or MI
a-fib meds
prescribed antiplatelet agents and anticoagulants
cardiomyopathy teaching
- monitor exercise : cardiac rehab
- medication
- palliative service
- s/s of HF
- no alcohol , caffeine , stimulants
- caregiver knows CPR
- less fluid / sodium
Heart failure
inadequate pumping / filling of the heart
-classified on ejection fraction
left sided HF
dysfunction of left ventricle
right sided HF
inability of right side to pump blood to pulmonary vaculature
HF risk factors
HTN : particularly untreated
CAD
cardiomyopathy
MI hx
DM
obesity
smoking
high sodium diet
valvular dysfunction
cardiotoxic exposure
cardiotoxic exposure
heavy alcohol use
chemotherapy
illicit drugs : COCAINE
left sided HF
poor peripheral perfusion and backflow of blood causing fluid on the lungs
left sided HF s/s
SOB
orthopnea (discomfort lying flat)
fatigue
crackles
weight gain
poor color
weak pulses
what would you hear in L sided HF
S3 , S4 gallop!!!!
R sided HF
poor contraction of R ventricle leading to backflow of blood into R atrium and venous circulation
**affects organs
R sided HF s/s
JVD
generalized edema
hepatomegaly
ascites
loss of appetite , n/v
increased abdominal girth
HF labs
- H & P
- EKG
- CXR
- echo
- MUGA
- ABG
- CBC
- metabolic profile
- coronary angiography
- BNP
MUGA
used to calculate ejection fraction
-uses radioactive tracer injected into vein
BNP levels
< 100 = no HF
> 400 = HF likely
HF medications
- beta blockers
- ACE inhibitors
- ARBS
- Digoxin
- ARNIs
- diuretics
- nitrates
- inodilators
- vasodilators
ARNIs med
combines ARBS with neprilysin inhibitor
-reduces preload and afterload
ex: sacubitril / valsartan
spironolactone
decreases preload
use cautiously with renal insufficiency b/c hyperkalemia
nitrates
decrease preload and afterload
ex : nitroglycerin
inodilators
increase contractility and decrease afterload
ex : hydralazine, isosorbide dinitrate
HF actions
- O2
- elevate HOB
- give meds
- monitor vitals
- assess breath sounds
- fluid restriction
- comfort intervention
- assess skin color
- reduce anxiety
- monitor labs
HF weight change
> 2.5 lbs / day can be indicative of fluid retention
HF teaching
- medication management
- education on oxygen use
- rest and pace
- education on fall prevention
- s/s of worsening HF : FACES
- daily weight
- no smoking , alcohol use, mild exercise , decrease sodium , moderate caffeine, less fat
- reduce high sodium
- cardiac rehab
- potassium rich diet
potassium rich foods for HF
banana
orange juice
**one a day
FACES scale for worse HF
Fatigue
limitation of Activity
Cough and Congestion
Edema
SOB
HF daily weights
use the same scale every time
take weights at same time every day
** > 2.5 lbs / day OR 5 lbs / week = CALL DR
valvular heart disease
3 types :
1. stenosis
2. regurgitation
3. prolapse
valvular stenosis
stiffening and thickening of valves caused by calcium deposits , narrowing the opening and obstructing flow
valvular regurgitation
blood flows or leaks backwards because of incomplete closing of the valve
valvular prolapse
valve leaflets bulge backward and do not close , usually remains untreated unless there are symptoms
valvular heart disease risk
- infective endocarditis
- untreated strep infections
- CAD
- MI
- cardiomyopathy
- HF
- congenital defects
- older age
9.pregnancy - drug use : COCAINE
untreated strep infections….
cause havoc on the heart
valvular heart disease most common s/s
MURMUR
-systolic
-diastolic
systolic murmur
heard during LUB (s1)
pulmonic valves open
mitral / tricuspid are closed
**heard w/ aortic / pulmonary stenosis or tricuspid regurgitation
diastolic murmur
heard during DUB (s2)
mitral and tricuspid valves open
pulmonic values closed
**heard w/ aortic / pulmonary stenosis OR tricuspid regurgitation
valvular heart disease s/s
murmur
SOB , dyspnea , orthopnea
crackles
angina
syncope or dizziness
dysrhythmias ( A-FIB)
palpitations
fatigue
weight gain
edema
cool pale extremities
valvular heart disease labs
- CXR
- echo
- heart cath : stenosis
- stress test
- CT or MRI
- CBC
- EKG
valvular heart disease surgery
- ballon valvuloplasty
- commissurotomy
- TAVR and TMVR
- open heart surgery w/ valve replacement
balloon valvuloplasty
transcatheter procedure to repair stenosis valves , balloon opens valve
TAVR
prosthetic valve replacement
valvular heart disease meds
- beta blockers
- ARBS
- ACE inhibitors
- diuretics
- nitroglycerin
- warfarin
- antibiotics
valvular heart disease complications
- mitral stenosis : A-fib / emboli
- mitral regurgitation : L ventricle hypertophy / HTN
- aortic stenosis : aortic dissection
- infective endocarditis
- balloon valvuloplasty : bleeding / PE
valvular heart disease intervention
- provide O2 / elevate HOB
- give meds
- restrict sodium
- pain assessment
- breath sounds
- heart sounds
- daily weights / I and O
- peripheral vascular assessment : pulses, extremities , cap refill , edema
- cardiac monitor
- monitor INR on Warfarin
valvular heart disease education
- medication
- prophylactic abx for DENTAL PROCEDURE
- restrict sodium and caffeine
- s/s of HF
- anticoagulant precautions
- intake of leafy greens on warfarin
- daily weight at home
- no smoking
anticoagulant precautions
adherence to regimen
avoid sports w/ high injury risk
electric razor w/ shaving
soft toothbrush
limit alcohol : causes falls
carotid artery disease
vessel wall thickening , plaque formation , progressive narrowing of the carotid artery
carotid artery disease risks
smoking
hypertension
diabetes
dyslipidemia
sedentary lifestyle
obesity
ineffective stress management
people with coronary artery disease….
have an increase risk for developing carotid artery disease
carotid artery disease severity
< 50 % is mild
50 - 69 % is moderate
70 - 99% is severe
carotid artery disease s/s
asymptomatic until almost completely occluded
BRUIT is #1 s/s
sudden weakness
dizziness
difficulty talking
facial droop
sudden vision problems
sudden severe HA
carotid artery disease test
- carotid duplex ultrasonography
- computed tomography angiography : CTA
- MRA
- carotid angiography
- MRI
carotid duplex ultrasonography
uses high frequency sound waves to measure blood flow and detect blockages
CTA
uses IV contrast to highlight carotid artery
-faster results than MRA
MRA
uses IV contrast dye , uses radio waves to show blockages inside arteries
carotid angiography
invasive , uses catheter normally inserted femorally and guided up to carotids
-contrast dye injected
**test not normally used
MRI
essential for acute stroke assessment with carotid artery disease , shows acute ischemia
carotid artery meds asymptomatic
-healthy lifestyle
-limit alcohol
-control diabetes / HTN
-use meds to manage cause of atherosclerosis
carotid artery meds symptomatic
- antiplatelets = aspirin or plavix
- antihypertensives = CCB , ACE inhibitors, ARBs
- statins = atorvastatin , simvastatin , pravastatin , rosuvastatin
carotid artery BP to maintain….
< 140 / 90
carotid artery disease surgery
- carotid endarterectomy
- carotid artery stenting
CEA
surgery to remove plaque causing artery occlusion , wide fluctuations in BP are common
**must have arterial line in place
carotid artery stenting
uses guiding catheter up to carotid , balloon is inflated compressing fatty plaque allowing stent to be placed maximizing blood flow
carotid artery disease actions
- administer antihypertensives
- administer lipid lowering meds
- administer antiplatelets
- manage DM / blood glucose
post CEA or CAS
keep systolic BP within orders
hypotensive post carotid surgery
reposition pt flat
anticipate vasoactive drip or IV bolus
hypertensive post carotid surgery
HOB 30 degrees to allow drainage
post CEA
keep in neutral position
-decreases strain on site and carotid artery
post CAS
fluid intake / IV fluids
-aids in flushing out contrast
carotid artery disease assessment
- monitor virals closely
- neuro assessment : change in function can be s/s of stroke , CHECK after surgery to ensure no nerve damage
- auscultate carotids
- renal function post CAS
- respiratory rate , O2 , stridor
post carotid surgery nerve check
VII = facial nerve (smiling)
X = vagus (swallowing , gag reflex , “ah)
XI = spinal accessory (shrug shoulders)
XII = hypoglossal (tongue control)
carotid artery discharge
- DASH diet
- exercise
- no smoking
- limit alcohol
- stroke s/s
stroke s/s
headache
facial droop
slurred speech
loss of strength in one side
inability to shrug shoulders or stick out tongue
aneurysms (aortic artery disease)
localized dilation of an artery that forms when the middle layer of the artery is weakened
ascending aortic aneurysms
located in arch of aorta
descending aortic aneurysms
located above the diaphragm
abdominal aortic aneurysms (AAA)
located below the diaphragm in abdomen
-most common
true aneurysms
all 3 layers of arterial wall are weakened
false / pseudoaneurysm
not a distortion of the vessel wall but a leak from the artery and an eventual blood clot forms
aneurysm risk
- family hx
- advanced age
- male
- SMOKING
- atherosclerosis
- HTN
- high total serum cholesterol
- CAD
- genetics - marfan’s syndrome
aneurysms s/s
normally asymptomatic and found when looking for another medical condition
-complications happen with dissection or rupture
ruptured / dissection s/s
ripping feeling
chest / back / flank pain
normally spontaneous and gets worse
aneurysm tests
- CT abdomen with contrast
- abdominal US and TEE
- cardiac MRI
- EKG
CT for aneurysms
gold start test for assessing size and location
aneurysm meds
- ACE inhibitors
- ARBs
- Beta blockers
- antibiotics : macrolides , tetracyclines
- statins
aneurysm surgery
size and location determine surgery
< 5cm cannot have immediate surgery
> 5.5 or 6cm are surgically repaired
aneurysm complications
aortic dissection - sudden tear
aortic dissection s/s
sudden ripping or tearing feeling !!!!
-chest / back / shoulders / abdomen
diaphoresis
n/v
faintness
tachycardia
BP decrease
aneurysm assessments
- vitals
- neuro assessment
- pain
- peripheral pulses, skin , temp
- peripheral sensation
- gentle abd auscultation / palpation
aneurysm action
- administer antihypertensives
- administer statins
- administer antibiotcs
- administer stool softeners : NO STRAINING
- calm environment
aneurysm teaching
- s/s of dissection
- marfan’s syndrome should be encouraged to do regular screening
- strict regimen : med compliance, smoking, exercise, dx testing , regular US , avoid crossing legs
