Cardiac Flashcards
What controls the modulation of BNP?
Calcium
Peptide secreted by ventricles of the heart in response to excessive stretching of the heart muscles
Brain Natriuretic Peptide
In a heart failure patient, what would the BNP levels look like?
Elevated
System that regulates blood pressure and water balance
Renin Angiotension Aldosterone System
The volumetric fraction of blood pumped out of the ventricle with each heartbeat or cardiac cycle
Ejection Fraction
What is a normal ejection fraction?
70%
What is the danger level of ejection fraction?
<55%
The volume of blood pumped from one ventricle with each beat
Stroke volume
The stoke volume of the heart increases in response to an increase in the volume of blood filling the heart when all other factors remain constant
Starling’s Law
The intrinsic ability of the heart to squeeze; the potential of the myocyte to contract
Contractility
What is the most accurate measure of how a heart patient is doing?
Ejection fraction
Pressure needed to open the aortic valve
Impedance
Myocardial fiber stretch, determined by the amount of blood at the end of diastole and by the pulmonary system
Preload
The resistance against which the left ventricle must eject its load
Afterload
High density lipoproteins that enable the transportation of lipids such as cholesterol
HDL
Low density lipoproteins that enable the transportation of lipids such as cholesterol
LDL
Stretching the heart too much will cause it to explode
Starling’s Law
What is the good cholesterol?
HDL
What should the HDL levels be?
Greater than 40
What should the LDL levels be?
Less than 100
Occurs when the kidneys leak small amounts of albumin in the urine indicating protein breakdown and heart disease?
Microalbuminuria
Glycerol and a three fatty acid chain that help enable the bidirectional transference of adipose fat and blood glucose from the liver
Triglycerides
What should triglyceride levels be?
Lower than 150
Protein produced by the liver that rises when there is inflammation throughout the body, especially in the heart
C-Reactive protein
A non-protein amino acid which high levels of are linked to cardiovascular disease
Homocysteine
What is the left atrial valve?
Mitral
What is the normal stroke volume?
50 mL/contraction
What is the formula for cardiac output?
CO = HR x SV
What is the normal cardiac output?
4-7 L/min
What factors affect preload?
Blood volume, muscle fiber length, and tension
As preload increases, what also increases?
Oxygen demand
What is the right atrial valve?
Tricuspid
What factors affect after load?
Blood pressure and the diameter of the blood vessels
As after load increases, what decreases?
Cardiac Output
What factors influence impedance?
Blood viscosity, arterial constriction, and aortic compliance
What are the two major divisions of the circulatory system?
The systemic division and the pulmonary division
What are the semilunar valves?
Aortic and pulmonic
What does cold air do to systemic vascular resistance?
Increases it
What are the non-modifiable risk factors for cardiac disease?
Family history, diabetes mellitus, gender, and age
Which gender is at the biggest risk for cardiac disease?
Men until women reach menopause, then it equals out
Why do women with cardiac disease fair worse then men?
They have less collateral circulation
What is the dominant artery in females?
The right anterior decending
Why do older patients with coronary artery disease fair better than younger patients?
They have developed better collateral circulation
What values indicate metabolic syndrome?
Fasting glucose > 100, low HDLs, triglycerides > 150, BP >130/85, and waist circumference > 35” (F) or 40” (M)
What causes hyperurecemia and gout?
Increased uric acid produced by and excess of meats and alcohol
What diseases that occur during pregnancy increase the risk of cardiovascular disease later in life?
Preeclampsia and gestational diabetes
What does heavy alcohol intake increase the risk of?
Hypertension, arrhythmias, and heart disease
What cardiovascular problems does cocaine cause?
Spasms of the coronary arteries, atherosclerosis, and thrombosis
What cardiovascular problems do amphetamines cause?
Acute hypertension, arrhythmias, myocardial infarctions, and cardiomyopathy
What history should a patient with dyspnea be asked?
When did you first notice it, what brings it on, how is it relieved, and if they are taking any meds for it
What history should a patient with orthopnea be asked?
Number of pillows to sleep and the onset of the symptoms
What history should a patient with paroxysmal nocturnal dyspnea be asked?
Ask about sudden onset and termination
What history should a patient with a cough be asked?
When was it first noticed, is it productive, is it dry or moist, when did it first occur
What does a dry cough indicate?
Cardiac related without heart failure
What does a moist cough indicate?
Respiratory causes
What does a night cough indicate?
Cardiac related
What history should a patient with fatigue be asked?
What activities can no longer be performed, how often do you need to rest, and do you nap during the day
What history should a patient with chest discomfort be asked?
Type, location, how often, what precipitates it, and what alleviates it
What does a weight increase in a cardiac patient indicate?
Fluid increase
What is the most common symptom that brings patients with cardiac problems to the doctor?
Fatigue
What is an appropriate BMI range?
18.5 kg/m2 and 24.9 kg/m2
Why is BMI not alway accurate?
It doesn’t take the weight of muscles into account
What does a BMI of over 25 indicate?
The patient is overweight
What does a BMI of over 30 indicate?
The patient is obese
What does waist circumference indicate?
Central obesity
What should a patient’s head and neck be evaluated for?
Carotid bruits, JVD, and xanthomas
What is an early sign of CHF?
S3 heart sound
What does an S4 heart sound indicate?
Hypertension
What would a dissecting aorta present as?
Searing, unrelenting back pain
What are the mitral and aortic changes related to calcification that occur normally with age?
Murmurs, valve changes, and possibly rhythm changes
Fatty deposits around the eyes
Xanthomas
What do the decreased number of pacemaker cells that occur with advancing age cause?
Dysrhythmias and a slower heart rate
As people age, conduction time increases and what occurs?
PVCs
The increase of fat and fibrous tissue in the SA node that occurs with age results in what?
A loss of inherent rhythm
What do xanthomas indicate?
Elevated cholesterol levels
As people age, how does the left ventricle change?
Increases in size, stiffens, and undergoes fibrotic changes, undergoes hypertrophy
What do the changes that occur in the left ventricle with age result in?
Decreased ejection fraction, activity intolerance, and a decrease in diastolic filling
As people age, how do the aorta and arteries change?
They thicken and stiffen
What do the changes that occur in the aorta and arteries with age result in?
Hypertension, increased SVR, and there is a risk of target organ damage
As people age, what happens to their baroreceptors?
They become less sensitive
What does the decrease in sensitivity of the baroreceptors cause?
Orthostatic hypothension
As people age, what changes does the SA node undergo?
Increases in fat and fibrous tissue
What does the lipid panel measure?
Cholesterol, lipoproteins, and triglycerides
What causes an increase in lipid panel measurements?
Atherosclerosis
What is the emerging risk factor and indicator of metabolic syndrome?
Triglycerides
What should a patient’s total cholesterol be?
Less than 200 mg/dL
What should be Lp(a) levels be?
Less than 30 mg/dL
What is a lipoprotein-a?
A modified LDL
What c-reactive protein level is normal?
1 mg/dL
What c-reactive protein level indicates risk for heart disease?
> 3 mg/dL
Elevated c-reactive protein levels in patients over 60 indicate which type of drug therapy?
Statins
What do high levels of homocysteine cause?
Cell walls become vulnerable to plaque buildup
What are high levels of homocysteine treated with?
Dietary sources of B vitamins
What does a fasting blood glucose test for?
Metabolic syndrome and diabetes
What does creatinine test for?
Chronic renal insufficiency
What are ECGs used to evaluate?
Left ventricular hypertrophy
What does left ventricular hypertrophy indicate?
Longstanding hypertension
What does a patient undergoing an Exercise Treadmill Test have to be watched for?
Rebound effect
Why is Chantix a preferred smoking cessation treatment?
It doesn’t have nicotine in it
How to you know that you are exercising at an appropriate level?
The patient is in a target heart rate and has no chest pain
Why is the “Heart Healthy Diet” no longer recommended?
It is too high in sugar
Why are soluble fibers good for your diet?
Binds fat in the intestine and helps to lower cholesterol levels
Drugs used to lower LDL and triglyceride levels when diet isn’t enough
Statins
How much does statins lower total cholesterol levels by?
20%
Name the statins
Zocor, mevacor, lipitor, crestor, and pravachol
What is the action of statins?
They reduce cholesterol synthesis in the liver and increase clearance of LDL from the blood
What symptom indicates that statins should be stopped?
Muscle pain
In what patients are statins contraindicated?
Patients with liver disease, pregnancy, rhabdomyolysis, and cholestasis
What needs to be monitored for patients on statins?
Liver enzymes, total cholesterol levels, CPK levels, and PT
When should statins be taken?
In the evening
What needs to be avoided by a patient on statins?
Grapefruit
Ezetimibe, used in place of or with statins to inhibit absorption of cholesterol through small intestines
Zetia
Combo of ezetimibe and simvastatin
Vytorin
Lowers LDL and VLDL and increases HDL
Niacin
What side effect is associated with niacin?
Flushing
What needs to be monitored when a patient is on niacin?
Liver enzymes
Combines niacin and lovastatin
Advicor
Reduce triglycerides and decreases plaque, inflammation, and clots
Omega-3 Fatty Acids
A chronic disease of the arterial system including abnormal thickening and hardening of the vessel walls
Arteriosclerosis
What causes the stiffening of arteries in arteriosclerosis?
Smooth muscle cells and collagen fibers migrate to the tunica intima
What molecules affect arteriosclerosis?
Cholesterol, lipids, and phospholipids
What are the modifiable risk factors for arteriosclerosis?
Obesity, sedentary lifestyle, smoking and stress
What diseases exacerbate arteriosclerosis?
Hypertension or poor tissue perfusion
What is the leading cause of coronary and cerebrovascular heart disease?
Atherosclerosis
How does atherosclerosis occur?
Soft deposits of intra-arterial fat and fibrin in vessel walls harden over time
At what point will a patient realize they have atherosclerosis?
Only when a complication occurs
How does arteriosclerosis occur?
The artery gets damaged, setting off an inflammatory response and leading to cholesterol flooding the vessel, making it sticky
Why does an injured vessel get sticky?
Injured cells produce lower amounts of antithrombic and vasodilating cytokines
What are the causes of injuries to arteries that lead to arteriosclerosis?
Elevated blood sugars and hypertension
How is a foam cell formed?
LDL is engulfed by macrophages
What is the pathophysiology of arteriosclerosis?
Injury, cellular proliferation, macrophage migration, LDL oxidation, foam cell formation, foam cell accumulation leads to a fatty streak, fibrous plaque, and complicated plaque
What are the clinical manifestations of arteriosclerosis?
Inadequate tissue perfusion, TIA, superimposed thrombus formation, and tissue infarction
What are TIAs associated with?
Exertion, exercise, or stress
What is the goal for patients with arteriosclerosis?
Restore tissue perfusion
Measure of force applied to walls of the arteries as the heart pumps blood throughout the body
Blood pressure
What factors determine blood pressure?
Strength of the contraction, amount of blood pumped into the arteries, viscosity of blood and size and flexibility of arteries
Who has smaller arteries?
Women
Elevated systolic and/or diastolic blood pressure
Hypertension
If a patient has heart disease or diabetes, what is the recommended blood pressure?
<130/90
What is the recommended blood pressure for average patients?
<120/80
What does an increased blood pressure do to the workload of the heart?
Increases it
What does an increased blood pressure do to the physiology of the heart?
Causes it to enlarge and weaken
What population in the US is at higher risk for hypertension?
Male african americans and people with diabetes
What are the parameters for prehypertension?
120-139/80-89
What part of the nervous system regulates blood pressure?
Autonomic nervous system
What aspects of blood pressure are controlled by the autonomic nervous system?
Controls vessel diameter and peripheral vascular resistance
Which hormones of the autonomic nervous system regulates blood pressure?
Epinephrine and Norepinephrine
What does the sympathetic nervous system do in response to lowered blood pressure?
Increases heart rate, speed of conduction, contractility and peripheral vasoconstriction
What does the parasympathetic do in response to increased blood pressure?
Decreases heart rate, contractility and conductivity
Which hormone controls the parasympathetic nervous system’s response to increased blood pressure?
Acetylcholine
What do chemoreceptors respond to changes in?
PaO2, PaCO2, and pH
What do chemoreceptors do?
Stimulate vasomotor center in the medulla controlling vasoconstriction and vasodilation
Where are the baroreceptors located?
Carotid sinus, aorta, and left ventricular wall
What are the parameters for Stage 1 hypertension
140-159/90-99
What do baroreceptors respond to changes in?
Arterial pressure
How do the baroreceptors counteract a rise in arterial pressure?
Through the vagus nerve
What do the baroreceptors do?
They slow pulse and cause vasodilation
What causes baroreceptors to fail?
Hypertension
How does the amount of fluid in the ECF regulate blood pressure?
The increase in Na causes increased blood return to the heart, increased cardiac output, and diuresis
What changes does ADH undergo in response to blood volume?
Decreases in response to increased volume, increases in response to decreased volume
How does the R-A-A-S regulate blood pressure?
A rise in cardiac output produces diuresis, and stimulates Angiotensin 2 and aldosterone to constrict vessels and promote water retention
What are the parameters for Stage 2 hypertension?
> 160/>100
What does inappropriate secretion of renin increase?
PVR in essential hypertension
When blood pressure increases, what should renin do?
Fall
Idiopathic hypertension with no known cause
Primary or essential hypertension
How many of the cases of hypertension does primary hypertension account for?
92-95%
Hypertension caused by a systemic disease process that raises peripheral vascular resistance or cardiac output?
Secondary hypertension
Rapidly progressing elevation of blood pressure to >200/>130
Malignant hypertension
What are the symptoms of malignant hypertension?
Blurred vision, headaches, dyspnea, and uremia
Increased waste products in blood signifying a renal problem
Uremia
As we age, which is a better indicator for heart disease and stroke, systolic or diastolic blood pressure?
Systolic Blood Pressure
What is the most common form of hypertension in older adults?
Isolated systolic hypertension
What type of hypertension does white coat syndrome cause?
Isolated systolic hypertension
What diseases cause secondary hypertension?
Renal dysfunction, dysfunction of the adrenal medulla or cortex, primary aldosteronism, pheochromocytoma, Cushing’s syndrome, coarctation of the aorta, neurogenic disturbances, and medications
Why does a pheochromocytoma cause hypertension?
Excretes lots of epinephrine
What does aldosterone do to blood pressure and how?
It promotes sodium and therefore water retention, raising blood pressure
What is coarctation of the aorta?
Narrowing of the aorta
Chronic hypertensive damage to the walls of systemic blood vessels
Complicated hypertension
What accompanies complicated hypertension?
Target organ damage
What happens to the vasculature in patients with complicated hypertension?
Formation, dissection, rupture of aneurysms, occlusion, and edema
What happens to the renal system in patients with complicated hypertension?
Nephrosclerosis, renal arteriosclerosis, and renal insufficiency and failure
What is an early sign of renal damage caused by hypertension?
Protein in urine
What happens to the retinas of patients with complicated hypertension?
Impaired vision, retinal vascular stenosis, hemorrhage, and exudation
What happens to the brain of patients with complicated hypertension?
TIA, stroke, cerebral thrombosis, aneurysm, hemorrhage, and cognitive decline in the elderly
How is primary hypertension treated?
Diuretics, beta blockers, and ACE inhibitors
What do beta blockers or ACE inhibitors treat in patients with primary hypertension?
Overstimulation of sympathetic neural fibers in the heart and great vessels
What do diuretics treat in patients with primary hypertension?
Increased blood volume, water and sodium retention, and the hormonal inhibition of Na-K transport across cell walls
What diuretic should patients with primary hypertension be on?
Spironalactone
What should patients with primary hypertension try first for treatment?
Life style modification
What diagnostic workups should be done for patients with hypertension?
ECG, urinalysis, blood glucose, Hct, lipid panel, serum K, Ca, creatinine, and BUN
What would an ECG show to diagnose hypertension?
Evidence of left atrial and ventricular hypertrophy
Why is an urinalysis obtained in patients with hypertension?
To indicate whether there is renal damage from that hypertension
What diuretics can be given to patients with hypertension?
HCTZ, Lasix, Bumex, or Aldactone
What do calcium channel blockers do?
Interfere with membrane transfer of Ca leading to vasodilation
What are the calcium channel blockers?
Amlodipine and Cardizem
What do ACE inhibitors do?
Inhibit the enzyme that converts Angiotensin 1 to Angiotensin 2, preventing vasoconstriction
What are the ACE inhibitors?
Enalapril, captopril, and prinivil
What is a side effect of ACE inhibitors?
Dry, hacking cough, and fluid trapped in lower extremities
What do ARBs do?
Block Angiotensin 2 from binding to its receptor, thereby blocking vasoconstriction
What are the ARBs?
Losartan, candesartan, and telmesartan
What do the aldosterone receptor antagonists do?
Block aldosterone binding at receptor sites in the kidney, heart, blood vessels, and brain, thereby inhibiting water and sodium retention, reducing total plasma volume
What are the aldosterone receptor antagonists?
Inspra
What do beta blockers do?
Decrease contractility and heart rate, decreasing cardiac output
What are the beta blockers?
Metoprolol, atenolol, Coreg, Zebeta
What needs to be checked before administering a beta blocker?
Heart rate and blood pressure
What do central alpha agonists do?
Prevent uptake of norepinephrine, thereby decreasing vascular resistance
What are the central alpha agonists?
Clonidine
What do alpha adrenergic agonists do?
Dilate arterioles and veins, decreasing PVR
What are the alpha adrenergic agonists?
Minipress
What do renin inhibitors do?
Inhibit vasoconstriction and aldosterone production, reducing Na reabsorption and fluid retention
What are the renin inhibitors?
Aliskiren
What is the best medication for patients with heart disease?
Beta blockers
What needs to be monitored when a patient is on antihypertensives?
Vital signs, orthostatic blood pressures, and electrolytes, especially potassium
In general, when would you hold an antihypertensive medication?
Systolic < 90, diastolic <60
How long should nicotine and caffeine be withheld after administering an antihypertensive?
1 hour
What activities should be avoided for patients on antihypertensive medications?
Hot tubs, saunas, alcohol, and exercise
How often should home blood pressures be taken?
Once a week
What does a patient on antihypertensive meds need to be taught?
Lifetime therapy, orthostatics, sodium restriction, water restriction, and relaxation techniques
When does a hypertensive crisis occur?
When patient’s hypertension has been poorly controlled, undiagnosed, or if they have abruptly stopped taking their medications
What is the treatment for a hypertensive crisis?
IV antihypertensives
What are the IV antihypertensives used in a hypertensive crisis?
Nipride, Cardene, and normodyne
What types of drugs are the IV antihypertensives?
Potent beta blockers
What do IV antihypertensives need to be protected from?
Light
How often should the blood pressure of a patient in a hypertensive crisis be monitored?
Every 5 minutes
Who is most at risk for heart failure?
African Americans
Why is heart failure a major cause of death and disability after a MI?
Because the heart muscle is destroyed
General term used to describe several types of cardiac dysfunction that results in inadequate perfusion of tissues with blood borne nutrients
Heart failure
What are the types of heart failure?
Left sided, right sided, and high output heart failures
What proceeds 75% of heart failure cases?
Hypertension
What disease causes heart failure because of pulmonary and aortic stenosis?
Rheumatic heart disease
What population is most at risk for endocarditis?
Drug abusers
What is the most common dysrhythmia?
Atrial fibrillation
Which type of drug attacks the heart muscle?
Mycins
What are the causes of heart failure?
Hypertension, CAD, cardiomyopathy, alcohol and drug abuse, valve disease, congenital defects, cardiac infections, dysrhythmias, diabetes mellitus, smoking, family history, hyperthyroidism, and chemotherapy
What is the most common type of heart failure?
Left sided heart failure
What are the causes of left sided heart failure?
Hypertension, CAD, and valvular disease
What are the clinical manifestations of left sided heart failure?
Decreased CO and severe pulmonary congestion
Is systolic or diastolic heart failure more common?
Systolic
With systolic heart failure, what happens to preload, after load, ejection fraction, and tissue perfusion?
Preload increases, after load increases, ejection fraction decreases and tissue perfusion decreases
Left ventricle can’t relax enough during diastole, preventing inadequate filling
Diastolic heart failure
What happens to the ventricles during diastolic heart failure?
They stiffen
With diastolic heart failure, what happens to stroke volume, CO, and ejection fraction?
All remain normal
Decreased contractility of the heart, causing the heart to not be able to eject adequate blood
Systolic heart failure
What is the sign of systolic heart failure?
Increase pulmonary blood, so crackles in the lungs
Who is more at risk for diastolic heart failure?
Older adults and women post MIs
What is the sign of diastolic heart failure?
Crackles in the lungs
What happens to the coronary vessels of patients with diastolic heart failure?
They don’t get perfusion and adequate filling, causing a buildup of lactic acidosis
What are the symptoms of left sided heart failure?
Fatigue, weakness, activity intolerance, oliguria, confusion, restlessness, dizziness, tachycardia, palpitations, chest discomfort, arrhythmia, S3 gallop, pallor, pulmonary congestion, dyspnea, orthopnea, tachypnea, cough, and paroxysmal nocturnal dyspnea
What arrhythmias are common in patients with left sided heart failure?
Atrial fibrillation, PACs, and PVCs
What are the early signs of left sided heart failure?
Coughing at night and S3 gallop
Where would adventitious lung sounds be heard in patients with left sided heart failure?
Crackles and wheezes heard from the bases up
When would frothy pink-tinged sputum be seen in patient with left sided heart failure?
As it progresses to include pulmonary edema
Why does pulmonary pressure increase in patients with left sided heart failure?
The left ventricle fails to eject sufficient blood
What are the signs of pulmonary edema?
Crackles, dyspnea at rest, anxiousness, tachycardia, disorientation, and confusion
What are the signs of worsening pulmonary edema?
Pink, frothy sputum, cold and clammy, and cyanosis
The right ventricle is unable to empty completely, causing increased volume and pressure in the systemic veins
Right sided heart failure
What is the most common cause of right sided heart failure?
Diffuse hypoxic pulmonary disease
What are the signs of right sided heart failure?
Peripheral edema, JVD, hepatomegaly, splenomegaly, distended abdomen, increases abdominal girth, ascites, nocturnal polyuria, weight gain, anorexia, and nausea
Where would peripheral edema be seen in patients with right sided heart failure?
From the lower legs and ascending
What causes the anorexia and nausea seen in patients with right sided heart failure?
Liver engorgement
Physical changes in the heart that occur with heart failure
Remodeling
What are the causes of right sided heart failure?
LV failure, RV MI, pulmonary hypertension, and increased left ventricular filling pressure
What remodeling occurs in patients with heart failure?
Enlargement and thinning of the left ventricle, causing contractile dysfunction and mitral valve regurgitation
What happens to the use of oxygen, ejection fraction, and CO in patients with remodeling?
Increased use of oxygen, decreased ejection fraction, and reduced CO
What hormone contributes to remodeling in patients with heart failure?
Angiotensin 2
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms
Stage B
What are the compensatory mechanisms for heart failure?
Increase in catecholamines, increase in CO, tachycardia, increase in oxygen demand, increased stroke volume, increased venous return, more forceful contractions, and arterial vasoconstriction
Heart failure patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion
Class 2
What are the catecholamines?
Epinephrine and norepinepherine
Patients with current or prior symptoms of heart failure
Stage C
What does the increase in catecholamines do for patients with heart failure?
Increases heart rate and blood pressure
Heart failure patients with no limitations of activity, they suffer no symptoms from ordinary activities
Class 1
What system in activated in patients with heart failure due to reduced blood flow to kidneys with decreased CO?
R-A-A-S
What does the R-A-A-S do for patients with heart failure?
Vasoconstriction, aldosterone secretion, increase in preload and after load, and ventricular remodeling
Patients at high risk for developing heart failure
Stage A
What is the immune response to heart muscle injury?
Release of cytokine, interleukins, and endothelin
What does endothelin do for patient with heart failure?
Increases peripheral resistance and hypertension, actually worsening the heart failure
Patients with refractory end-stage heart failure
Stage D
Thickening of the heart muscle to compensate for low output
Hypertrophy of the myocardium
Heart failure patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest
Class 4
Potent vasoconstrictor that is released with stretching of myocardial fibers
Endothelin
What does myocardial hypertrophy do for patients with heart failure?
Increases the force of the contraction
Tumor necrosis factor that contributes to ventricular remodeling
Cytokine
What is a symptom of myocardial hypertrophy?
Loss of appetite
Heart failure patients with marked limitation of activity; they are comfortable only at rest
Class 3
Produced by ventricles with fluid overload from heart failure
BNP
What system does BNP counteract?
R-A-A-S
What does BNP promote?
Vasodilation and diuresis
Which sex has a higher concentration of BNP?
Women
Secreted by the posterior pituitary as a result of lower cerebral perfusion from low cardiac output
ADH
What does ADH do?
Causes vasoconstriction and fluid retention
What does ADH do for heart failure?
Worsens it
What are the diagnostic tests for heart failure?
Electrolytes, BUN, creatinine, urinalysis, microalbuminuria, Hb, Hct, BNP, ABG, SCG, echocardiogram, chest xray, and a MUGA scan
Why are Hb and Hct taken for patients with heart failure?
To see if the heart failure is a result of anemia
What type of heart failure would BNP be especially elevated in?
Diastolic failure
What are normal levels of BNP?
<100
Why is a BNP taken for patients with heart failure?
To differentiate between respiratory symptoms of cardiac versus pulmonary nature
Why is an ABG taken for patients with heart failure?
To reveal hypoxia and blood oxygenation
What does an ECG reveal for patients with heart failure?
Ischemia, injury to heart, dysrhythmias, and hypertrophy
What does an echocardiogram reveal in patients with heart failure?
Ejection fraction, hypertrophy, chamber enlargement, and valvular function
What does a MUGA scan reveal in patients with heart failure?
MUGA scans calculate LV ejection fraction and velocity
What extra test is done for patients with heart failure who are in critical care?
Pulmonary artery catheter measurements of pressure
What do pulmonary artery catheter measurements of pressure show?
Ventricle end diastolic pressures
What do chest X-rays reveal for patients with heart failure?
Show shape, size and location of the heart
What is the goal of treatment for patients with heart failure?
Reduce after load, reduce preload and improve cardiac contractility
What types of drugs reduce after load?
ACE inhibitors, ARBs, and B-type natriuretic peptides
What types of drugs reduce preload?
Sodium restriction, fluid restriction, diuretics, and venous vasodilators
Which drugs improve cardiac contractility?
Positive inotropic meds, vasodilators, and beta blockers
Which population are ARBs less effective in?
African Americans
What patients are ARBs good for?
Patients with the cough from ACE inhibitors and those at risk for hyperkalemia
What type of diet should patients with heart failure be on?
2-3 grams of sodium/day, 2 L of fluid/day
What do patients with heart failure need to monitor closely?
Weight and electrolyte levels
How long do loop diuretics take to work?
5 minutes
What is a side effect of rapid administration of Lasix?
Ototoxicity
How does aldactone spare potassium?
Inhibits reabsorption of sodium in distal tubules in exchange for potassium
What is the sign of hyperkalemia?
Peaked T waves
Drug used for patients with acute heart failure with dyspnea
Nitrates
What do nitrates do for patients with heart failure?
Reverses vasoconstriction, decreases volume of blood returning to the right ventricle, and improves left ventricular function
How do nitrates improve left ventricular function?
They increase coronary arteriole blood flow
What is the side effect of nitrates?
Head ache
Drugs given to decrease preload and after load, reduce anxiety, and slow respirations in patients with heart failure
Morphine sulfate
How are morphine sulfates given to patients with heart failure?
IV, in 1-2 mg increments
What do beta blockers do for patients with heart failure?
Improves morbidity, mortality, quality of life, and increases ejection fraction
How should beta blockers be administered?
Initial doses are low, started slowly and titrated up
What do cardiac glycosides do?
Improve cardiac contractility and decrease heart rate
Name the cardiac glycosides
Digoxin and digitalis
Why are cardiac glycosides used less often?
They increase myocardial oxygen demand
What patients are cardiac glycosides used for?
Those in either sinus rhythm or atrial fibrillation with class 3 or 4 heart failure
How is IV digoxin given?
Over at least 5 minutes
What needs to be assessed before giving IV digoxin?
Apical pulse
What teaching needs to take place for patients taking digoxin?
Don’t take with antacids, look for hypokalemia, how to take pulse and assess rhythm
Why would hypokalemia be very bad for patients on digoxin?
It increases the risk of dig toxicity
What are the signs of dig toxicity?
Bradycardia, halo vision, seeing red and yellow lights, dysrhythmias, anorexia, mental status changes, vomiting, and fatigue
What is the antidote for digoxin?
Digubine
Beta-adrenergic agonist given IV for short-term treatment of acute heart failure to improve contractility and increase cardiac output
Dobutrex
Inotropic and vasodilator, phosphodiestrerase inhibitor given IV that enhance calcium entry into heart cells and increases contractility
Milrinone (Primacor)
What is the therapeutic range of digoxin?
0.8-2.0 mg/mL
How often should a pulse ox be taken on a patient with heart failure?
Every 1-4 hours
At what level should oxygen sats be maintained in patients with heart failure?
> 90%
How often should patients with heart failure do deep breath and cough exercises?
Every 2 hours
How often should breath sounds be assessed on patients with heart failure?
Every 4 hours
In what position should patients with heart failure be in?
High Fowlers
What are the goals for patients with heart failure?
Improve tissue perfusion, improve gas exchange, and increase activity tolerance
What are the nursing implications for increasing activity tolerance in patients with heart failure?
Assess cardiovascular response to activity, assess vital signs, alternate periods of rest and activity, avoid activity immediately after meals, teach patients how to minimize oxygen consumption
What indicates activity is too much for patients with heart failure?
Any dramatic change in vital signs
What is a dramatic change in vital signs?
Change of blood pressure of 20 mmHg or more or increase in heart rate of 20 beats/minute or more
How can patients with heart failure minimize oxygen consumption?
Cluster activities to avoid using all of their oxygen reserve
What health teaching is needed for patients with heart failure?
Fluid restriction; daily weights and reporting gains of 2-3 pounds or more; sodium restriction; small, frequent meals; report edema and cough; and how to take pulse and blood pressure
Acute condition associated with severe heart failure in which the pressure in the lounge is increased from accumulation of blood
Pulmonary Edema
Why are patients with pulmonary edema placed in High Fowlers with their legs down?
To decrease venous return
How is pulmonary edema treated?
High flow oxygen through a non-rebreather at 10 L, give nitro, diuretics, and morphine
What is the side effect of HCTZ?
Decrease in male libido
What causes the dry, persistent cough associated with ACE Inhibitors?
Accumulation of kinins in the respiratory tract
What do patients taking aldosterone receptor antagonists need to be taught?
Avoid extra potassium, don’t use salt substitutes
What are the side effects of aldosterone receptor antagonists?
Gynecomastia and progesterone stimulation
What do central alpha agonists do?
Decrease systolic and diastolic blood pressure and heart rate
What are the side effects of central alpha agonists?
Postural hypotension, sedation, and impotence
What is the largest affect of alpha adrenergic agonists on?
Diastolic pressure
What diseases, besides heart disease, are alpha adrenergic agonists used for?
Raynaud’s disease and BPH
What do patients on renin inhibitors need to be monitored for?
Angioedema
How is the filling volume and pressure on the right side of the heart assessed?
Jugular venous pressure
How are pack-years determined?
Number of packs per day multiplied by the number of years the patient has smoked
S3 is what kind of gallop?
Ventricular
Which types of ulcers are more common?
Venous
Which types of ulcers are more severe?
Arterial
Atherosclerotic disease of arteries that perfuse the limbs
Peripheral vascular disease
How often does peripheral vascular disease occur in patients over 70?
12-20%
What is generally the end result of peripheral vascular disease?
Limb amputation
S4 is what kind of gallop?
Atrial
What are the symptoms of peripheral vascular disease often mistaken for?
Aging or peripheral neuropathy
Distal end of aorta and iliac arteries
Inflow
Where do patients with inflow occlusion complain of pain?
Lower back, buttocks, or thighs
Intra-inguinal artery segments, below the superficial popliteal
Outflow
Where do patients with outflow occlusion complain of pain?
Calves, ankles, and feet
Which type of occlusion causes significant damage?
Outflow
Where is tissue perfusion altered in patients with occlusions?
Below the level of occlusions
What is usually the first symptom of PAD?
Intermittent Claudication
What percentage of patients with PAD have intermittent claudication?
15-40%
Pain that occurs even while at rest; numbness and burring in the distal portion of extremities that is relieved with dependent position
Rest pain
Ulcers; blacked tissue on toes, forefoot, heel with a gangrenous odor
Gangrene/necrosis
Where do patients with PAD lose hair?
Lower calf, ankle, and foot
Pain, cramping, burning in the legs, usually at calf with ambulation or exercise that subsides at rest
Intermittent Claudication
What does the skin of patients with PAD look like?
Dry, scaly, mottled and thickened toenails
What color is the skin of patients with PAD?
Cold, gray-blue, or darkened, pallor when elevated and rub or when lowered
Painful ulcers on or between toes at pressure points with deep, pale, even edges that won’t heal or heal slowly
Arterial ulcers
What is Buerger’s test?
Capillary refill is greater than 15 seconds, indicating vascular compromise
Line of demarcation that will not spread to healthy tissue; causes affected area to wither and die
Dry gangrene
Soft tissue swelling due to infection of strep or staph, causing the tissue to die
Wet gangrene
Where are arterial (ischemic) ulcers frequently seen?
On the dorsum of the foot
What color are arterial ulcers?
Pale, gray, or yellow, possibly with eschar
What would the segmental systolic blood pressures of patients with PAD reveal?
Leg pressures are lower than in the upper extremities
Where are segmental systolic blood pressure taken?
Thigh, calf, and ankle
What would an exercise tolerance test show in patients with PAD?
After 5 minutes on the treadmill, the able pulse pressure will drop and claudication will occur
Graphs of arterial flow that detect changes in the volume of an organ, limb, or body by measuring the flow of blood through its veins and arteries
Plethysmography
How is the ankle-brachial index determined?
Divide the ankle pressure by the branchial pressure
What is a normal ankle-brachial index?
0.9-1.0
What test is used to diagnose PAD in diabetics?
Toe-brachial index
What ankle-brachial index indicates severe PAD?
0.5-0.75
What is the most frequent test done to diagnose PAD?
Dopplers
What ankle-brachial index indicates moderate PAD?
0.75-0.9
What is the nonsurgical management of PAD?
Exercise, positioning, promoting vasodilation, avoidance of cold, adequate fluids, and drug therapy
Test using two forms of ultrasound to show the structure of the blood vessels and the movement of the RBCs through the vessels
Dopplers
What ankle-brachial index indicates life-threatening PAD?
Below 0.5
What position needs to be avoided in patients with PAD?
Crossed legs
How is vasodilation promoted in patients with PAD?
Warmth and avoidance of nicotine and alcohol
What do Doppler studies reveal?
Obstruction, speed, and direction of flow in the blood vessels
What drugs are used for antiplatelet therapy?
Aspirin or Plavix
Suppresses platelet aggregation and acts as a direct arterial vasodilator
Pletal
What does pletal treat?
Claudication and improves skin temperature
In what patients is pletal contraindicated?
Patients with CHF
Dilates the arteries with a balloon catheter; may use a stent to maintain patency
Percutaneous Transluminal Angioplasty
What types of of occlusions are percutaneous transluminal angioplasty useful for?
Arterial occlusions that are accessible with the catheter and in patients who are poor surgical risks
When should patients with PAD avoid exercise?
If they have rest pain, venous ulcers, or gangrene
What is the general care for arterial revascularization?
Check pulses, check for bleeding or occlusion/collapse, don’t take blood pressures in the area, know baseline vitals and monitor them, site should be pink and warm, mark the site of the pulse and Doppler, and monitor for pain
What type of pain indicates an occlusion in patients with PAD?
Throbbing or burning
In what vessels can stents be placed in patients with PAD?
Common Iliac or external iliac arteries
What does stent duration in patients with PAD depend on?
Blood viscosity and compliance
Heat from laser vaporizes the plaque in arterial occlusions
Laser-assisted Angioplasty
What types of occlusions is laser-assisted angioplasty used for?
Small arterial ones
Metal burr abrades occlusion to fine particles
Artherectomy
What is the risk with any procedure that accesses an artery?
Bleeding and stroke
What needs to be monitored with procedures that access arteries?
Bleeding, vitals, H&H, and pulses
What are the surgical treatments for inflow occlusions in patients with PAD?
Aortoiliac, aortafemoral, and axillogemoral bypasses
What are the surgical treatments for outflow occlusions in patients with PAD?
Femoropopliteal and femorotibial bypasses
Which surgeries are generally more successful and have less instance of reocclusion?
Inflow
What remains even after outflow surgeries in patients with PAD?
Pain
What graphs can be used to treat patients with PAD?
Autogenous, saphenous vein, cephalic, basilic vein or synthetic grafts
Surgical removal of the plaque from the artery
Endartectomy
What does the success of endartectomies depend on?
Location and extent of arterial blockage
Where is the incision of endartectomies?
Inner lining of the diseased artery
When do graft occlusions occur after surgical treatment of patients with PAD?
Within the first 24 hours
How often do grafts have to be assessed post-op in patients with PAD?
Q15 minutes for 1 hour and then hourly
What do normal grafts look like post-op in patients with PAD?
Warm, red, and edema
How long do patients with PAD need to be on bed rest post-op?
24 hours
What is used for thrombolytic therapy?
t-PA, Integrilin, and Aggrastat
How often do platelets need to be monitored after platelet inhibitors are used?
3, 6, and 12 hours after surgery
What is the platelet inhibiting drug?
ReoPro
Increased tissue pressure within confined space, leading to tissue ischemia and necrosis
Compartment Syndrome
Where is the most common site for compartment syndrome?
Forearm or lower leg
What is the earliest sign of compartment syndrome?
Progressive pain distal to the injury that is not relieved by analgesics
What are the signs of compartment syndrome?
Pain with passive movement, inability to move digits, numbness, tingling, loss of function, pallor, coolness, diminished or absent peripheral pulses
What can result from untreated compartment syndrome?
Myoglobinuria and renal failure
What is the treatment for compartment syndrome?
Fasciotomy or amputation
What is the most common cause of PAD occlusions?
Embolus
What are the six p’s in assessing for PAD occlusions?
Pain, Pallor, Pulselessnes, Paresthenia, Paralysis, and Poiklothermia
What drugs are used to treat PAD occlusions?
Activase, t-PA, ReoPro, and Heparin
What is the surgical treatment for PAD occlusions?
Arteriotomy, thrombectomy or embolectomy
Inflammatory disease of the peripheral arteries resulting in the formation of nonatherosclerotic lesions
Buerger’s Disease
Where do the nonatherosclerotic lesions of Buerger’s Disease occur?
Digital, tibial, plantar, ulnar, and palmar arteries
What occludes or obliterates arteries in Buerger’s disease?
Thrombi and vasospasm
Who does Buerger’s disease occur in most?
Young men who are heavy smokers
What causes the symptoms of Buerger’s disease?
Slow, sluggish blood flow
What are the symptoms of Buerger’s disease?
Pain, tenderness, hair loss, rubor, cyanosis, cold sensation, diminished pulses, sharply defined lesions leading to gangrenous lesions
How is Buerger’s disease treated?
Quit smoking, vasodilators, and sympathectomy
Episodic vasospasm in arteries and arterioles of the upper and lower extremities
Raynaud’s disease/phenomenon
What are the primary diseases of Raynaud phenomenon?
Scleroderma, smoking, pulmonary hypertension, myxedema, or environmental factors
What are the signs of Raynaud?
Pallor, numbness, and cold sensation
What are the changes in skin color and sensation in Raynaud due to?
Ischemia
What is the drug therapy for Raynaud?
Procardia or Dibenzyline
Clot of fibrin attached to vessel wall
Thrombus
Bolus of matter that is circulating in the blood stream
Embolus
Clot of platelets and fibrin formed under high flow
Arterial thrombus
Clot of red blood cells and large amounts of fibrin formed under low flow
Venous thrombus
What can be an embolus?
Thrombus, air bubble, amniotic fluid, aggregate of fat, bacteria, cancer cells or a foreign substance
Previously circulating matter that has lodged and obstructed blood flow, causing ischemia
Lodged embolus
Where is a superficial venous thromboembolism located?
Below the knee
Where is a deep venous thromboembolism located?
Above the knee
What is the main complication of venous thromboemboli?
Pulmonary Emboli
What does a superficial VTE look like?
Red streak along the vein coarse that is warm and tender, possibly with edema
How is a superficial VTE treated?
Elevate the extremity, moist heat, and NSAIDs
When do DVTs occur?
After hip, knee or prostate surgery, with pregnancy, heart failure, immobility, or ulcerative colitis
What are the symptoms of a DVT?
Pain with walking, pain in the foot, leg edema, and pressure
What are the factors for a DVT?
Virchow’s triad - Alterations in blood flow, venous endothelial damage, and hyper coagulable state
What can cause alterations in blood flow?
Stasis, turbulence, and varicose veins
What can cause venous endothelial damage?
Hypertension or shear stress
What can cause a hyper coagulable state?
Hyperviscosity, age, smoking, obesity, pregnancy, trauma, burns, or cancer
What are the signs of a DVT?
Calf or groin tenderness or pain, sudden onset of unilateral swelling, Homans’ sign, and localized edema and warmth
Test to measure fibrin and degradation products to diagnose DVTs or PEs
D-dimer test
What are the venous flow studies?
Doppler, ultrasounds, venography, and MRI
How accurate are venous flow studies in diagnosing DVTs?
95%
How are DVTs managed?
Rest and elevation, warm, moist socks and drug therapy
What are the signs of a PE?
Dyspnea and chest pain
What is the drug therapy for DVTs?
Anticoagulants Heparin and then warfarin and thrombolytics
What does Heparin do for DVTs?
Inhibits fibrin formation
What are the types of Heparin?
Unfractioned and low molecular weight
When on heparin, what needs to be monitored?
PTT
What is the therapeutic level of heparin?
1.5-2X normal control
What is the heparin antidote?
Protamine Sulfate
When on Coumadin, what needs to be monitored?
PT and INR
What is the therapeutic PT/INR?
1.5-2X the control or 12-15 seconds
What is the antidote for Coumadin?
Vitamin K
What are the types of low molecular weight Heparin?
Lovenox or Fragmin
What is different between low molecular weight and unfractioned heparin?
Low molecular weight does not require constant coagulation monitoring
When a patient is on Coumadin, how often does their PT need checked?
Every 1-4 weeks
How long do thrombolytics take to work?
24 hours
How can DVTs be prevented?
Smoking cessation, avoid oral contraceptives, adequate hydration, increased mobility, early ambition, leg exercises, and compression stockings
Result of prolonged venous hypertension, stretching veins and damaging valves
Venous Insufficiency
What are the risk factors for venous insufficiency?
Prolonged standing, obesity, and pregnancy
What is the hallmark of venous insufficiency?
Hemosiderin deposits
Wood-like hard deposits of fibrin in dermis and fat from chronic venous disease that has the appearance of an inverted bottle
Lipodermatosclerosis
What do venous ulcers look like?
Irregular boarders and a large, shallow base with heavy drainage and only mild pain
Where do venous ulcers appear?
In the gaiter region - medial malleolus and lateral malleolus
What are the symptoms of venous ulcers?
Leg aches, heaviness, cramps, itchiness and edema
What are the goals of managing venous ulcers?
Reduce edema, promote venous return, and prevent stasis
Dressings for venous ulcers to assist in return of pooled blood to circulation
Compression dressings
Dressing for venous ulcers to control the wound environment and deliver some growth factors for healing
Active Dressings
Occlusive dressings for venous ulcers that provide moisture
Interactive dressings
What antibiotic is used to treat venous ulcers?
Silvadene
How can the edema associated with venous ulcers be managed?
Elevation of the leg above the heart, bed rest, and compression stockings
Distended, protruding veins that appear darkened and tortuous
Varicose Veins
How are varicose veins managed?
Elastic stockings, elevation, sclerotherapy, surgical removal, and radio frequency to heat the veins
Broad spectrum antibiotic that lowers bacterial load to levels acceptable for wound closure without causing pain
Silvadene
What is the most sensitive indicator of PAD?
Quality of the posterior tibial pulse
