Cardiac Flashcards
what is directly related to blood flow?
tissue perfusion
what is directly related to cardiac output?
blood flow
what influences blood flow & are components of SV?
“pump, pool & pipes”
pump (contractility)
pool (blood & fluid)
pipes (blood vessels)
what does unstable angina, NSTEMIs & STEMIs all result from?
coronary artery disease
describe the difference between unstable angina, NSTEMIs & STEMIs
unstable angina: has the most blood flow through a coronary artery but slightly blocked still
NSTEMI: heart attack; more blood flow blocked compared to unstable angina
STEMI: most severe form of a heart attack of MI; NO blood flow through a coronary artery
when do the coronary arteries fill?
during diastole
how do you determine a bundle branch block when looking at an EKG?
QRS is prolonged
what specific part of the heart could cause bradycardia if it is not receiving enough O2 & blood?
SA node (primary pacemaker of the heart)
what specific part of the heart could cause various heart blocks if not receiving enough O2 & blood?
AV node
what is angina pectoris?
chest pain or discomfort caused by decreased blood flow to the heart
describe the difference between stable & unstable chest pain
stable: chest pain usually w activity, gets better w rest, O2 demand is increased & supply is inadequate
unstable: chest pain that does not stop w rest
describe the difference between myocardial O2 supply & demand
supply: when the heart does not have adequate O2 supply
demand: when the heart is demanding too much O2
name 3 ways angina could present itself
- epigastric (heart burn)
- radiating down the arm, neck, etc. (not always in the chest)
- fatigue
which types of patients have atypical angina?
women, > age 65 & diabetic patients
what is a patient at risk for when they have a new onset of unstable angina?
MI, dysrhythmias or SCD (sudden cardiac death)
describe the difference in waves on an EKG w an NSTEMI & STEMI
NSTEMI: ST depression
STEMI: ST elevation
what is a common cardiac biomarker used to show the heart is releasing its injured proteins?
troponin
do we want to see troponin elevated or decreased?
decreased! we want to see peaks go down & continue to draw until we have the first peak & then first down trend
describe the difference between a positive cardiac biomarker & negative cardiac biomarker
+ = means troponins are high & pt has an NSTEMI
- = pt has unstable angina
what are the #1 complications with acute MIs?
dysrhymias
when should a pt be given oxygen?
when they are hypoxemic (O2 <90% or in resp distress)
how does aspirin help w an MI?
decreases mortality rate (diminishes platelet aggregation & prevents thrombus plaque from getting bigger)
why is nitroglycerin often administered in MI situations?
helps w chest pain (CP for a pt must be at 0!)
which med is administered for chest pain if pain is not relieved by nitroglycerin?
Morphine IV
describe preload
PULL
volume status (what is coming back to the heart)
describe afterload
PIPES
tells how vasoconstricted or vasodilated the patient is or the resistance the heart has to overcome
deals w ARTERIES!
describe contractility
the PUMP
how should a patient w HF be positioned & why? what should they avoid?
semir or high fowlers to decrease preload
they should avoid the valsalva manuever (bearing down to have a BM) because it stimulates the vagus nerve & can cause a decrease in HR & BP & puts them at risk for developing dysthymias
how does nitroglycerin affect the CVP, wedge pressure, PA pressures, SVR & BP?
decreases all of them! major vasodilator
when should you hold nitro?
if systolic BP is less than 90!
which meds should NOT be given w nitro & why?
Viagra or Sidenafil, will cause pt to be fatal!
how does morphine sulfate affect preload & afterload?
decreases them both (dilates both veins & arteries) decreasing O2 demand & myocardial workload
how do ACE inhibitors & ARBs effect preload & afterload?
decreases both but more affect on afterload (decreasing SVR & BP)
which two types of meds must be given within 24 hours of admission for a pt with an acute MI unless contraindicated?
ACE inhibitors & Beta blockers (reduces incident of sudden cardiac cath post MI)
how do beta blockers work on the heart?
they have - inotropic action & reduce myocardial O2 demand & contractility
when are Ca channel blockers used?
only used if pt cannot tolerate nitrates or beta blockers
what are examples of Ca channel blockers?
Diltiazem & Verapamil
how do Ca channel blockers affect afterload & work on the heart?
decrease afterload; decrease dromotropic, chronotropic & inotropic action of the heart
name the 1st line treatment drug for preload reduction
Nitroglycerin
name the 1st line tx drug for afterload reduction
ACE inhibitors / ARBs
name the 1st line tx drug that is considered a - inotrope
Beta-blockers
name the 1st line tx drug that is considered a - chronotrope
Beta-blockers
name an anti-platelet agent & how does it work?
aspirin - prevents stickiness of platelets so they don’t form clots
name an anticoagulant agent
heparin
what is the purpose of anti-thrombotic therapy?
to prevent further thrombus / clot formation
what is the purpose of fibrinolytic therapy & when are they used?
it destroys clots
fibrinolytic therapy is only used w which type of patients?
STEMIs!
which drugs are often combined w aspirin for a dual anti-platelet therapy?
P2Y12 receptor inhibitors (Clopidogrel & Ticagrelor) & llb / lla inhibitors (Eptifibatide & Tirofiban)
what is a risk factor of all anti platelet agents?
bleeding!!
which drugs are often started in cath lab & sometimes continued after an intervention?
llb / lla inhibitors (Eptifibatide & Tirofiban)
which med dose is often adjusted based on monitoring of PTT or APTT?
Heparin Sodium
how is Enoxaparin (Lovenox) different from heparin sodium?
more effective & expensive, less bleeding risk but w less control
do not have to monitor PTT & APTT because the half life is longer
what type of Heparin route is necessary to monitor the APTT every 6 hours?
only continuous infusion of heparin due to the half life
how does heparin affect PTT when it is therapeutic?
Increases PTT (takes more time to clot)
which drug is used to antagonize the effects of Heparin?
Protamine sulfate
other than bleeding what is another complication associated w heparin therapy? what drugs are used for this complication?
Heparin induced thromobocytopenia
stop all heparin completely & administer Bivarudin (Angiomax) or Argatroban (Acova)
name 2 interventional therapies for acute coronary syndromes
- PCI (percutaneous coronary intervention)
- CABG (coronary artery bypass graft)
what are some signs of reperfusion? name 4
- cessation of CP
- elevated ST segments return to baseline
- reperfusion dysrhythmias
- early & marked peaking of troponin
when are fibrinolytic therapy agents typically given for STEMIs? give some examples
given within 30 min of arrival to ED; Alteplase, Tenecteplase, Reteplase & Streptokinase
when is PCI used for STEMIs?
will only be used if a pt cannot be performed on within 90 minutes in a cath lab
what is also a big risk with fibrinolytics in addition to bleeding being a big risk?
stroke
describe a percutaneous coronary intervention (PCI)
coronary stents are placed
in general, what can cardiac catheterization do?
diagnose & provide interventions
name some complications post PCI
- coronary spasm (angina, CP)
- coronary artery dissection (tearing of the coronary artery)
- coronary thrombosis (cath can dislodge a clot)
- bleeding & hematoma formation at the insertion sites
- compromised blood flow to exremity
- retroperitoneal bleeding (abdominal / back pain)
- contrast induced renal failure
- ventricular dysthymias (reprofusion dysthymias)
- vasovagal response (bradycardia, hypotension, loss of consciousness)
what is mandatory in a post PCI assessment?
pulse & hematoma checks!
how do you handle a vasovagal response after a cath is removed from the groin area?
hold pressure from 20-30 min straight!
what is the point of a compression device? (TR band)
air is pushed into device to compress the artery & prevent bleeding (a few hours after the procedure, nurses will start to deflate air very slowly) always look for bleeding!!
which position should a patient be kept in post femoral PCI?
HOB no higher than 30 degrees; keep extremity straight
describe a coronary artery bypass graft (CABG)
rerouting piping & taking grafts to function as new coronary arteries
blood is bypassed & rerouted by suturing!
name 4 complications associated w acute MIs
- life threatening ventricular dysrhymias
- HF
- pulmonary edema
- cardiogenic shock
what do statins do to the heart?
decrease plaque formation
if a pt is unable to have a PCI within 90 minutes, which drugs must be given?
fibrinolytics
what does MONA BASH stand for & what are they used to treat?
M - morphine
O - oxygen
N - nitrates
A - aspirin
B - beta-blockers
A - ACE-inhibitors
S - statins
H - Heparin
used to treat the 3 types of ACS!
explain how to treat unstable anginas
MONA BASH & possible interventional treatment depending on how the pt presents
explain how to treat NSTEMIs
MONA BASH until pt is able to get into PCI
explain how to treat STEMIs
requires emergent treatment! pt must have PCI within 90 minutes & if unable adminiter fibrinolytics & MONA BASH until PCI
How do you treat a thrombus?
Fibrinolytics (only for STEMIs) because of bleeding risk OR with PCIs or CABG if PCI can’t work
what type of med removes a clot that is causing ischemia / infarction?
Fibrinolytic agent
which med reduces preload and afterload, dilates coronary arteries, increases myocardial O2 supply & reduces myocardial O2 demand?
Nitroglycerin
which med reduces preload & afterload by venous & arterial vasodilation decreasing myocardial O2 demand & relives pain?
Morphine
which med reduces heart rate to decrease myocardial O2 demand, infarct size & improve survival rate?
Beta-blocker
which med decreases afterload & myocardial O2 demand?
ACE inhibitor
describe heart failure
impairment in the ability of the ventricle to fill or eject blood effectively
what does ventricular remodeling cause the heart to do?
stiffen up & enlarge
name some clinical manifestations of left sided HF
- SOB
- orthopnea
- crackles
- elevated PAP (pulmonary artery pressures)
- post nocturnal dyspnea, S3, tacypnea, cough & hypothysis
name some clinical manifestations of right sided HF
- lower extremity edema
- jugular vein distention
- Hepatojugular reflex (when liver is pushed on, there is an increase in JVD)
- elevated CVP
- hepatomegaly, cytomegaly, ascites, pulmonary hypertension & weight gain
what does the BNP determine?
determines the severity of disease & prognosis (the higher it is, the worst off) it is well correlated w LV preload
describe the BNP
secreted by the ventricles in response to excessive stretching of the heart muscle cells
name some medications that manage chronic HF
ACEIs or ARBs, nitrates, Hydralazine, Beta-blockers, diuretics, digoxin, spironolactone & statins
name two nursing interventions for management of chronic HF
- cardiac resynchronization therapy (bioventricular pacing therapy)
- ICD (implantable cardioverter defibrillator) (senses when a pt is in a lethal rhythm & shocks them)
list 5 ways a patient could self manage chronic HF?
- adherence to drug regimen
- daily weights ( gaining of 3 lb. in a day or 5lb. in a week, notify MD)
- low Na diet
- exercise
- smoking & alcohol cessation
which three classes of meds are often given to patients experiencing acute HF?
- preload reduction meds
- afterload reduction meds
- inotropic support meds
which two devices can be used for patients experiencing acute HF?
- intraaortic balloon pump (inserted during emergencies; decreases afterload & enhances coronary artery blood flow)
- left ventricular assist device (continuously takes blood from the left ventricle into the aorta to help out the left ventricle; pt could have this long term & it could be a bridge to transplantation)
which two types of meds are used to reduce preload in acute HF?
- diuretics
- nitrates
which three types of meds are used to reduce afterload in acute HF?
- ACE’s & ARBs
- nitro (monitor BP every 5-15 min; cannot be used long term or will cause cyanide toxicity)
- hydralazine
which three types of meds are used for inotropic support in acute HF patients?
- Dobutamine
- Dopamine (low to mid dose)
- Milirinone (long half life)
The nurse is caring for a patient in an acute exacerbation of HF. Which of the following meds should the nurse anticipate?
A. Metoprolol
B. 0.9% normal saline bolus
C. Morphine
D. Dobutamine
D. Dobutamine (acute exacerbation of HF warrants meds that decrease preload, decrease afterload & improve inotropy. Dobutamine is a positive inotrope
describe an abdominal aortic aneurysm. name 6 risk factors
Localized dilatation of a portion of the aorta, >1.5 times its normal diameter; Usually at a weakened area of the aortic wall
risk factors:
1. age
2. HTN
3. Lipid disorders
4. Atherosclerosis
5. genetic predisposition (Marfan symdrome; tall w long limbs)
name 3 symptoms / assessment findings of a patient w a stable abdominal aortic aneurysm
- palpable, pulsatile mass in the umbilical area of the abdomen
- abdominal pain
- lower back pain
name 2 assessment findings of a patient w an acute rupture of an abdominal aortic aneurysm
- sudden onset of severe abdominal pain
- hypotension w abrupt loss of consciousness because of the severe loss of blood
how do you treat a stable abdominal aortic aneurysm?
risk factor modification & elimination
EX: if they smoke, have them stop & control their HPN
how do you treat an acute rupture of an abdominal aortic aneurysm?
surgical repair but this is less preferred because of the invasive risks
what are 7 S/Sx of an acute aortic dissection?
- sever & sudden HPN (around 200 systolic)
- sudden onset of intense & excruciating pain present in the back between the shoulder blades, chest & arms*
- ripping or tearing sensation within the chest
- radiation of pain down into the abdomen & lower back
- worse pain in the patient’s life
- syncope or LOC w onset of pain
- development of a murmur from aortic insufficiency; unequal pulses
describe an aortic dissection. which type is more serious?
weakened aortic medial layers, a false channel or lumen is created as blood is pumped through the tear, classified according to location; type A is more serious
how do you treat an aortic dissection? name 3 things
- BP reduction w IV beta blockers
- further systolic BP reduction w vasodilators like Nitro
- pain relief & sedation
how do we manage an aortic dissection post operatively?
IV nitro to prevent HPN & to keep sysstolic BP below 120!
what is PAD?
peripheral arterial disease (processes that obstruct the blood supply of the lower or upper extremities)
name some risk factors for PAD (9)
- atherosclerosis
- smoking
- diabetes
- age > 70
- male gender
- HPN
- hyperlipidemia
- family history
- history of MI, HF, TIA or stroke
what are the clinical manifestations of PAD?
classic 5 P’s:
1. pain! intermittent claudication (cramping, burning, aching in legs that is relieved w rest)
2. pulselessness
3. pallor
4. paresthesia
5. paralysis
what is the difference between early & late intermittent claudication?
early: cramping, burning, or aching pain in the legs or buttocks w activity that is relieved by rest
late: pain at rest is a warning sign of an anoxic limb & loss of blood supply
how can PAD be diagnosed at the bedside?
ankle brachial index: blood pressure cuff applied to one upper arm & above the ankle to obtain blood pressure readings
what is chronic venous insufficiency? name some s/sx
“pulling effect” blood cannot get back to the heart
S/SX:
1. brown pigmentation of the skin
2. edema
3. thick, flaky skin
4. ulcerations
which of the following medications is indicated for a patient w PAD?
A. Clopidogrel
B. Tenectecplase
C. Norepi
D. Nipride
A. Clopidogrel; patients should be on an anti-platelet med to prevent further thrombus formation in PAD
