Cardiac Flashcards
Review the normal changes of pregnancy affecting:
- Blood volume
- Blood volume
- Blood volume peaks 32 weeks
- RBCs production rise less than plasma → physiologic anemia, nadir at 32 wks
Review the normal changes of pregnancy affecting:
- Heart
- Displaced upward by diaphragm and rotated on long axis to the right
- Cardiac output - increased by 30 - 50 % by 20 wks
- first due to stroke volume → later on due to HR
- Heart rate
- Increases early 1st tri → slowly rises throughout pregnancy → resting HR may be 15-20 beats/minute above baseline by middle 3rd tri
- Mild resting tachycardia is normal
Review the normal changes of pregnancy affecting:
- Great vessels and arterial and venous vascular bed
- Systemic vascular resistance decreases (decreased afterload) → increase in CO does not completely compensate → drop in arterial blood pressure (as early as the 7th week)
Summary of physiologic changes - state whether each of the following increase or decrease:
- Stroke volume (SV)
- Heart rate (HR)
- Cardiac output (CO)
- Preload
- Systemic vascular resistance
- Afterload
- INCREASE: SV, HR, CO, preload
- DECREASE: systemic vascular resistance, afterload
What patient position allows for the best cardiac output?
- Left lateral decubitus
Supine position can lower cardiac output by ____%
25-30%
(compression of the IVC by gravid uterus)
What happens to cardiac output during labor?
- Progressively increases → more blood in circulation due to uterine contraction (autotransfusion)
- Also due to pain/anxiety
- Valsalva in 2nd stage: +50%
- Immediately PP: +80% (above baseline term pregnancy values)
Describe normal changes of pregnancy that may mimic signs of cardiac disease
- Palpitations
- Shortness of breath with exertion
- Chest pain
Indications for further cardiac diagnostic testing in pregnant patient
- History of known cardiac disease
- Symptoms in excess of those expected in a normal pregnancy
- Pathologic murmur
- Evidence of heart failure on physical examination
- Arterial oxygen desaturation in the absence of known pulmonary disease
List findings on physical assessment that are almost always indicative of heart disease
May indicate heart disease
- Cyanosis
- Clubbing of fingers
- Persistent neck vein distension
- Systolic murmur grade 3/6 or greater
- Diastolic murmur
- Cardiomegaly
- Persistent arrhythmia
- Persistent split second sound
- Criteria for pulmonary hypertension
Clinical symptoms of heart disease during pregnancy
(as opposed to normal changes that mimic heart disease)
- Progressive dyspnea or orthopnea
- Nocturnal cough
- Hemoptysis
- Syncope
- Chest pain
Describe the times of greatest risk during the perinatal cycle for a woman with heart disease
- Intercurrent events superimposed on pregnancy are usually responsible for acute decompensation.
- Antepartum period - most common of these are febrile episodes
- Labor and delivery - hemodynamic instability
- Post partum - “perfect storm” of volume loading, tachycardia, and increased afterload; each of these may contribute to destabilization
- ***Most heart failure occurs peripartum (per powerpt)
Risks to pregnancy (parent/fetus) when pregnant parent has heart disease
- Parental arrhythmias
- Heart failure
- Preterm birth
- Fetal growth restriction
- Small but significant risk of maternal and fetal mortality
Identify common, normal EKG changes that occur during pregnancy
- Mean QRS can shift leftward due to elevation of the diaphragm
- May return to the right as the fetus descends at pregnancy end
- Minor ST-segment and T-wave changes may be observed
- Less often, T-wave inversions may appear transiently in the left precordial leads.
- Seldom of sufficient magnitude to raise the question of ischemic heart disease
Describe the potential effect of heart disease on the fetus
Describe the anatomical condition known as mitral valve prolapse (MVP)
- Two flaps of mitral valve don’t close properly → bulge up into the left atrium
- Often asympomatic
- If prolapsing valve lets some blood flow back → regurgitation → if serious can lead to clots/stroke
- Regurgitant lesions usually get better with pregnancy
Outline the usual course of MVP in pregnancy and symptoms requiring consultation
- Affects up to 12% of young women.
- Most people are asymptomatic
- Small percentage with symptoms:
- Anxiety
- Palpitations
- Atypical chest pain
- Dyspnea with exertion
- Syncope
- Small percentage with symptoms:
- β-blockers → decrease sympathetic tone, relieve chest pain and palpitations, reduce the risk of life-threatening arrhythmias (tachy)
- If no abnormal connective tissue (ie Marfan or Ehlers-Danlos) or clinically significant mitral regurgitation, patients with mitral prolapse can be expected to have uncomplicated pregnancies
List the components included in the physical assessment of a patient with heart disease presenting to your office practice.
- Vital signs
- Careful evaluation for:
- Elevation of the jugular venous pulse
- Peripheral cyanosis or clubbing
- Pulmonary crackles
- Heart sounds
Palpitations evaluation
- Look for arrythmia with EKG
- If abnormal (REFER!) → echo to look for structural heart disease as underlying cause
- If normal EKG but persistent symptoms → consider cardiology consult and Holter
Chest pain differentials and evaluation
- Large differential from anxiety, GERD, musculoskeletal to a PE or MI
- Consider risk factors, symptom severity, and objective findings (VS, exam)
- Workup: EKG, troponin, CXR, VQ scan, CT for PE
Shortness of breath differentials and evaluation
- Differential: dyspnea of pregnancy, asthma, anxiety, VTE, pneumonia, CHF
- Workup again depends on whole picture and VS!
- CXR, VQ scan, EKG, CT for PE, echo
New York Heart Association
Functional Classes
- Class I - No sx with ordinary activity
- Class II - Some sx with ordinary activity/slight limitations to activity
- Class III - Sx with less than ordinary activity, increased limitation to physical activity
- Class IV - symptoms with any activity and possibly at rest
Heart conditions that are contraindications to pregnancy
- Pulmonary hypertension
- Severe systemic ventricular dysfunction
- Aortic root dilation (>4.5cm)
- Severe left-sided obstructive lesions
Peripartum Cardiomyopathy symptoms and risk factors
- Most commonly:
- Dyspnea
- Fatigue
- Peripheral edema
- Also: cough, orthopnea, hemoptysis
- Nonspecific symptoms: chest pain
- Etiology unknown
- Risk factors:
- Age >30 years
- Multiparity
- Black race
- Obesity
- Multifetal pregnancy
- Preeclampsia / eclampsia
- Cocaine abuse
- Long term oral tocolytic therapy (terbulatine)
- Surrogate pregnancy
