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Pathophysiology (NRSG 502) > Cardiac Function, Heart Failure, & Circulatory Shock (Ch. 27)-- Definition First > Flashcards

Cardiac Function, Heart Failure, & Circulatory Shock (Ch. 27)-- Definition First Flashcards

Exam 2

1
Q
  • Hypovolemic
    • Acute blood loss (15% or more)
  • Cardiogenic
    • Heart fails to pump sufficient amount of blood
  • Distributive (Normovolemic)
    • Capacity of vascular compartment expands
      • Neurogenic
      • Anaphylactic
      • Septic
A

Types of Shock

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2
Q

Left Ventricular Heart Failure

d/t– HTN (hypertrophy), Myocardial Ischemia (ventricular remodeling)

  • Diastolic failure
  • LVEF > 50% (normal)
  • ⇣ LV Compliance → Abnormal diastolic relaxation → Pulmonary edema

S/S– Dyspnea w/ exertion, Fatigue

Treatment– None

A

Heart Failure with Preserved Ejection Fraction (HFpEF)

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3
Q
  • Zone of hypoxic injury
    • May progress to necrosis or return to normal
  • Zone of reversible ischemia
    • May progress to necrosis or return to normal
  • Sudden severe chest pain
    • Can radiate to neck, jack, arm, or epigastric region
  • Sending of impending doom → death
  • SOB
  • Weakness
  • N/V
  • Diaphoresis

Monitoring–

  • EKG
    • Assess for rhythm changes
    • Continuous monitoring
  • Vitals
  • O2 levels
  • Lab work
    • Troponin I
      • Most specific
      • Elevated 2-12 hrs. after damage
      • Remains elevated 2-4 wks.
    • Creatinine Phosphokinase-MB (CPK-MB)
      • Not specific to the heart
      • Elevates w/i 4-8 hrs.
      • Peaks @ 24 hrs.
A

Myocardial Infarction Clinical Manifestations

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4
Q

Infection of the inner surface of the heart

Microbial agents w/i valves & endocardium → Vegetation & destruction of cardiac tissue

  • High mortality rate
  • Staphylococcal infections
    • Most common
  • Aortic & Mitral valves
    • Most common
  • Acute
    • Rapid onset
    • Normal heart valves
  • Sub-acute
    • Evolves slowly over months
    • Underlying valve abnormality
    • Life-threatening

d/t– Dental or surgical procedures, Illicit IV drug use, Valve or congenital abnormalities (⇡ risk)

Prevention– Prophylactic antibiotics (w/ dental or surgical procedure)

A

Infectious Endocarditis (IE)

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5
Q

Widespread Type I Hypersensitivity reaction → Vasodilation & Hypovolemia

Treatment– Epinephrine → Vasoconstriction, Bronchodilation, ⇡ CO & Contractility, ⇣ Histamine

TOP PRIORITY: Maintain airway

A

Anaphylactic Shock

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6
Q

Systemic Inflammatory Response System

Microvascular damage that causes clotting at all sites simultaneously

Inflammation → Endothelial injury → Clotting process repeats (steps 3-5) → All platelets & clotting factors used up → Uncontrolled bleeding

A

Disseminated Intravascular Coagulation (DIC)

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7
Q

Life-threatening compression of the heart d/t accumulation of fluid w/i pericardial sac

  • Inflammation & pressure
  • Fluid displaces septum
    • w/ inspiration
  • ⇡ Intracardiac pressure
  • ⇣ LV filling
  • ⇣ SV
  • ⇣ CO
  • Pulsus paradoxus
    • 10 mmHg + decrease in SBP w/ inspiration
A

Cardiac Tamponade

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8
Q

Volume ejected from ventricle w/ each beat

A

Stroke Volume (mL/beat)

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9
Q

Short-term pericardial inflammation

  • < 2 weeks
  • Infectious or non-infectious
A

Acute Pericarditis

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10
Q

Left Ventricular Heart Failure

d/t– Damage to myocardial tissue (MI, chronic HTN)

  • Systolic failure
  • LVEF < 40%
  • Dilation → ⇡ Preload → ⇣ Contractility
  • Ventricular remodeling d/t–
    • ⇡ SANS
    • ⇡ RAAS
    • ⇡ Inflammatory mediators
A

Heart Failure with Reduced Ejection Fraction (HFrEF)

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11
Q

Immune-mediated inflammatory response to group A streptococcal pharyngitis

  • Affects heart, skin, & connective tissue
  • Acute
    • Inflammation of all 3 layers & valves
      • Epicardium
      • Myocardium
      • Endocardium
    • History of streptococcal infection
      • Inflammatory lesions
  • Recurrent phase
    • Continued effects
  • Chronic phase
    • Permanent deformity of valves
    • 10+ years after initial infection
A

Rheumatic Heart Disease/Rheumatic Fever

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12
Q
  • Ascites
    • Fluid w/i abdomen
  • Lower extremity edema
  • Dyspnea w/ exertion
  • Fatigue
A

Constrictive Pericarditis Clinical Manifestations

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13
Q
  • ⇡ Preload = ⇡ SV
    • The further you stretch a rubberband, the harder it snaps back
  • Inotropy (⇡ SANS)
    • ⇡ Contractility
      • Curve shifts up & L
  • Failure
    • ⇣ Contractility
      • Curve shifts down & R
A

Frank-Starling Mechanism

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14
Q
  • Mitral valve stenosis (narrowing)
  • Rheumatic carditis
  • Polyarthritis
    • Most common
  • Skin lesions
A

Rheumatic Heart Disease Clinical Manifestations

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15
Q

Proportion of blood pumped out of ventricle with each beat

Measured w/ echocardiogram

LVEF (%) = (SV/EDV)100

LVEF= Left ventricular ejection fraction (normal 55-75%)

SV= Stroke volume

EDV= End diastolic volume

A

Ejection Fraction (EF)

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16
Q

Neurohumoral compensatory mechanism of HF

Diuresis & Natriuresis (⇡ GFR) → ⇣ Fluid volume → ⇣ Workload of the heart

Inhibit SANS, RAAS, ADH/Vasopressin, & CNS thirst/salt appetite signaling

  • Atrial natriuretic peptide (ANP)
    • Released from atrium
      • d/t atrial stretch, pressure, or fluid overload
  • B-type natriuretic peptide (BNP)
    • Released from ventricles
      • d/t increased ventricular pressure or fluid overload
      • Measured clinically
A

Natriuretic Peptides

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17
Q

Goal: Control compensatory mechanisms

  • First-line HFrEF treatment
    • Diuretics
      • ⇣ Blood volume
    • ACE-Is
      • ⇣ RAAS
    • Beta-Blockers
      • ⇣ SANS
A

Heart Failure Pharmacological Treatments

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18
Q

Imbalance → Ischemia, Angina, MI, or sudden death

  • Supply
    • Determinants:
      • Perfusion of blood to capillaries
        • O2-carrying capacity of blood
          • Hgb levels
  • Demand
    • ⇡ LV contractility → ⇡ O2 demand
      • Systole
    • ⇡ HR → ⇡ O2 demands & ⇣ Blood flow d/t ⇣ Filling time
    • ⇡ LV pressure → ⇡ O2 demand & Coronary artery pressure
      • d/t ⇡ Preload
      • Water balloon effect
A

Myocardial Oxygen Supply & Demand

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19
Q

Life-threatening complication of shock

Progressive dysfunction of two or more organ systems

d/t– Uncontrolled inflammatory response to severe injury/illness (sepsis, trauma, burns, major surgery…)

  • Manifestations
    • Dysfunction of–
      • Respiratory organs
      • Liver
      • Kidneys
      • GI organs
      • Heart failure

Interventions– Support affected organs

A

Multiple Organ Dysfunction System (MODS)

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20
Q

Coronary blood flow doesn’t meet metabolic demands of heart

1st– Stable angina

2nd– Unstable angina → ACS

Prolonged– MI (STEMI or non-STEMI)

A

Myocardial Ischemia

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21
Q

Dilated LV w/ thin walls (“floppy”) → ⇣ Contractility → ⇡ Preload → Systolic dysfunction & HF

d/t– DM, MI, Alcoholism, Hyperthyroidism

A

Dilated (Congestive) Cardiomyopathy

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22
Q
  • Acute Lung Injury (ALI)/Acute Respiratory Distress Syndrome (ARDS)
    • Sudden onset of profound dyspnea
    • Hypoxemia refractory to supplemental O2
    • Potentially fatal
  • Acute Kidney Injury (AKI)
    • ⇣ Renal perfusion
  • Disseminated Intravascular Coagulation (DIC)
  • Multiple Organ Dysfunction Syndrome (MODS)
A

Complications of Shock

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23
Q
  • Chest pain
    • ⇡ w/ breathing, coughing, swallowing, & positional changes
    • ⇣ w/ sitting upright & leaning forward
  • Pericardial friction rub
  • EKG changes
  • ⇣ CRP
    • C-reactive protein
  • ⇣ ESR
    • Erythrocyte sedimentation rate

Treatment– NSAIDs, Antimicrobials

A

Acute Pericarditis Clinical Manifestations

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24
Q

Acute loss of blood volume (600-900 mLs)

d/t– Hemorrhage, Burns (⇣ plasma), Loss of GI fluid (N/V)

  • Compensation
    • ⇡ SANS
    • ⇡ RAAS
    • ⇡ ADH/Vasopressin
  • Nursing interventions
    • STOP blood loss
    • Replace lost volume
A

Hypovolemic Shock

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25
Q

Heart fails to pump adequate amount of blood to meet O2 demands

d/t– MI w/ LV failure

  • ⇣ CO
    • Tissue hypoxia
    • Normal vascular volume
  • Compensatory mechanisms
    • WORSEN situation
    • ⇡ SANS
      • ⇡ HR
      • ⇡ Preload
    • ⇡ RAAS
      • ⇡ Blood volume
    • ⇡ ADH/Vasopressin
      • ⇡ Blood volume
A

Cardiogenic Shock

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26
Q

Dysfunction @ any valve → Heart Failure (HF)

  • Stenosis
    • Narrowing/stiffness of valve
      • Impaired valvular opening
    • ⇡ Resistance → ⇡ Myocardial work & ⇡ Heart chamber volume
  • Incompetent/Regurgitant Valve
    • “Floppy”
      • Impaired valvular closing
      • Backflow of blood
A

Valvular Heart Disease

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27
Q

⇡ Afterload → Hypertrophy of myocytes to compensate for ⇡ workload

Diastolic dysfunction → Systolic dysfunction

d/t– HTN, Aortic stenosis (Narrowing of aortic opening)

A

Hypertensive (Valvular) Hypertrophic Cardiomyopathy

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28
Q

Assessment of coronary blood flow & perfusion

  • Done under x-ray
  • Invasive, sterile procedure
    • Catheter placed in femoral or brachial artery or vein
  • Assess blood flow through the heart
  • Angioplasty
    • Inflate balloon → Improved blood flow through arteries
  • Stent
    • Metal mesh coil keeps arteries open
  • Heart tissue biopsy
  • Fractional flow reserve
    • Measurement of arterial blockage
  • Intravascular ultrasound (IVUS)
    • Blood vessel lumen measurement
A

Cardiac Catheterization

29
Q
  • Unpredictable chest pain unrelieved w/ rest & nitroglycerin
    • Occurs @ rest & w/ exertion
  • Ruptured atherosclerotic plaque
    • Reversible MI
      • Forewarning
      • Return of perfusion before significant necrosis occurs
  • Transient episodes @ site of plaque damage
    • Thrombotic vessel occlusion
    • Vasoconstriction
A

Unstable Angina

30
Q
  • Non-Invasive
    • Chest x-ray
      • Fluid congestion
        • White cotton candy-like appearance
    • Echocardiogram
      • Elevated filling pressures
  • Invasive
    • R heart or pulmonary artery catheterization
A

Objective Evidence of Cardiogenic Systemic or Pulmonary Congestion

31
Q
  • Impaired contractility
  • Deprivation of myocardial O2 & nutrients
    • Mismatch b/w supply & demand
  • Leads to CAD
A

Atherosclerosis

32
Q

Clinical syndrome d/t structural or functional cardiac abnormality; End result of many clinical disease states (no single S/S)

Corroborated by:

  • ⇡ Natriuretic peptide levels
  • and/or Objective evidence of cardiogenic pulmonary or systemic congestion

Ventricle is either too weak (dilation) or too stiff (stenosis) to pump blood

d/t– Ischemic heart disease (post-MI) and/or HTN → Hypertrophy and/or Dilation

Risk factors–

  • Age
  • Obesity
  • DM
  • Renal failure
  • Valvular heart disease
  • Cardiomyopathies
  • Congenital heart disease
  • Myocarditis
  • Excessive alcohol intake
A

Heart Failure

33
Q

Assessment of coronary blood flow & perfusion

  • Measure of electrical conduction through the heart
  • Impacted by
    • Temperature
    • Stress
  • Full
    • 12 leads
  • Monitor
    • 3-5 leads
A

Electrocardiogram

34
Q
  • Pressure/Volume
    • @ end of diastole
    • on LV wall prior to contraction
  • Determinants
    • End systolic volume
    • Venous return
  • Increases w/
    • ⇣ Contractility
    • ⇡ Plasma volume
A

Preload (End Diastolic Volume)

35
Q

Prolonged ischemia causes irreversible damage to the heart muscle (myocyte necrosis)

  • Myocyte injury → death
  • Structural & functional changes of cardiomyocytes (permanent cells)
    • Adverse myocardial remodeling
      • Fibrosis of myocardium
A

Myocardial Infarction

36
Q

Pulmonary vascular congestion & ⇣ CO

Left = Lungs

⇡ Pulmonary hydrostatic pressure → Pulmonary edema & Dyspnea

  • Exertional dyspnea
    • SOB w/ activity
  • Orthopnea
    • SOB while laying flat
  • Paroxysmal nocturnal dyspnea
    • Sudden SOB while sleeping
  • Fatigue & weakness
    • Especially w/ exertion
  • Pulmonary edema
    • Cough
    • Crackles
    • Wheezes
    • Sputum
      • Blood-tinged
      • Frothy
    • Tachypnea
  • Confusion
  • Tachycardia
  • Cyanosis
  • Restlessness
A

Left Heart Failure Clinical Manifestations

37
Q
  • Stenosis
    • Incomplete opening of MV during diastole → LA distention/dilation & Impaired LV filling → ⇡ Pressure w/i pulmonary venous system → Pulmonary edema
  • Regurgitation d/t MV prolapse
    • Incomplete closure of MV → Backflow into LA (systole) → LA distention/dilation & ⇣ LV SV → LV Hypertrophy → LV HF
A

Mitral Valve Disorders

38
Q

Known or suspected infection → Overactivation of inflammatory response

  • Systemic inflammatory response syndrome S/S
    • Fever
    • Tachycardia
    • Leukocytosis
    • Altered mental status
    • Hyperglycemia
  • SEVERE
    • Organ dysfunction
    • Tissue hypoxia
  • SHOCK
    • Hypotension
      • Even w/ fluid replacement
    • ⇡ Risk of mortality
A

Sepsis

39
Q
  • Venricular assist device
    • LVAD/bi-VAD
      • Internal device
      • Takes over work of LV
      • ⇡ Survival rates
        • Bridge gap to transplant
      • High maintainence
      • Infection & blood clot risk
  • Heart transplantation
    • Survival rate
      • 85% after one year
      • 65% after 5 years
    • Low donor availability
A

Advanced Therapy in End-Stage HF

40
Q
  • Dilated
    • Congestive
  • Hypertrophic
    • Obstructive
    • Hypertensive (Valvular)
A

Types of Cardiomyopathies

41
Q

Acute failure of circulatory system to supply peripheral tissues and organs with adequate blood supply resulting in cellular hypoxia

  • ⇣ O2 & Nutrients
  • ⇡ Waste
  • Impaired cellular metabolism
    • Aerobic → Anaerobic
  • Release of inflammatory mediators
A

Circulatory Shock

42
Q
  • Frank-Starling mechanism
  • SANS
  • RAAS
  • Natriuretic peptides
  • Myocardial hypertrophy → Remodeling
A

Compensatory Mechanisms of the Heart

43
Q
  • Pharmacologic therapy
    • ASA (chewed)
      • ⇣ Platelet aggregation
    • Morphine
      • Pain
      • Vasodilation
    • Sublingual Nitroglycerin (MONA)
      • Vasodilation
  • Supplemental O2
  • Active STEMI (EKG verfied)
    • Percutaneous coronary intervention (PCI)– w/i 60 min.
      • Cath lab
    • Coronary artery bypass graft (CABG)
    • Fibrinolysis– w/i 30 min.
      • Tissue plasminogen activator (tPA)
        • “Clot buster”
      • If no cath lab
A

MI Treatment (STEMI)

44
Q

Occlusion or stenosis of coronary arteries → Imbalance b/w coronary blood supply and myocardial O2 & nutrient demand

d/t– Atherosclerosis (most common)

A

Coronary Artery Disease (CAD)

45
Q

Amount of blood ejected in one minute (4-6 L)

CO = SV x HR

A

Cardiac Output (mL/min)

46
Q
  • Can and do coexist
  • HFpEF
    • Diastolic failure
      • Dilation → ⇣ Preload
    • Preserved ejection fraction
      • LVEF > 50%
  • HFrEF
    • Systolic failure
      • ⇣ Contractility
  • Reduced ejection fraction
    • LVEF < 40%
A

Types of Left Ventricular Heart Failure

47
Q

The extent of necrosis determines EKG tracing differences

  • STEMI
    • ST-segment elevation
      • Full necrosis of one area
        • Blocked conduction
      • “Tombstone” = MI
  • Non-STEMI
    • Non-ST segment elevation
      • ST-segment depression
        • Partial necrosis
          • ⇣ Conduction
      • OR T inversion
    • May indicate ischemia
      • Does not always = MI
A

Myocardial Infarction Types

48
Q
  • Predictable chest pain relieved w/ rest & nitroglycerin
  • Fixed atherosclerotic plaque
    • Narrow/partially occluded vessel
      • @ Rest, supply = demand
      • Exertion → chest pain
        • Vasoconstriction → Mismatch b/w supply and demand
A

Stable Angina

49
Q

Decreased SANS control of blood vessel tone

Increased PANS activity

d/t– Neurologic injury (vasomotor center defect– brain stem injury or anesthesia; sympathetic outflow defect– spinal cord injury)

  • Massive vasodilation
    • ⇣ Vascular tone
A

Neurogenic Shock

50
Q
  • Fatigue & weakness
    • ⇣ CO
  • Cognitive impairment
    • d/t ⇣ brain perfusion
      • Confusion
      • Memory loss
      • Restlessness
      • Anxiety
      • Insomnia
  • Cachexia & malnutrition
    • Ascites & tissue wasting w/ end-stage HF
      • ⇣ food intake d/t depression, illness, GI congestion
  • Sudden cardiac death
    • d/t ventricular tachycardia or fibrillation
A

Heart Failure Clinical Manifestations

51
Q
  • Force
    • LV must generate to eject blood into aorta
      • @ beginning of systole
    • “Load” against which heart must pump
  • Determinants
    • PVR
      • ⇡ BP = ⇡ CO & ⇡ PVR
  • Increased w/
    • ⇡ PVR
    • HTN
A

Afterload

52
Q

Systemic circulatory pressures & ⇣ CO; Inbility of RV to provide adequate blood flow to pulmonary circulation

d/t– L HF, Pulmonary HTN (hypoxic pulmonary disease)

Right = Rest of the body

⇡ Peripheral hydrostatic pressure → Edema & Third spacing

  • JVD
  • Edema
    • Peripheral
    • Dependent
  • Hepatosplenomegaly
  • GI distress
    • Anorexia
  • Ascites
    • Weight gain
A

Right Heart Failure Clinical Manifestations

53
Q

Measure of coronary blood flow & perfusion

  • Assessment of structure & function of the heart
    • Ultrasound
      • Valves
      • Septal movement & volume
      • Measurements
A

Echocardiogram

54
Q
  • Anaerobic metabolism
    • Lactic acid accumulation
    • ⇣ ATP → Na+/K+ ATPase pump failure
    • ⇡ Membrane permeability → Cell swells & bursts
  • Compensatory mechanisms (Short-term)
    • ⇡ SANS
      • ⇡ HR
      • Vasoconstriction
    • ⇡ Renin
      • ⇡ Angiotensin II
        • Vasoconstriction
        • ⇡ Blood volume
      • ⇡ Aldosterone
        • ⇡ Blood volume
A

Shock Response

55
Q
  • ⇡ Blood volume
  • ⇡ BP
  • ⇡ PVR
  • ⇡ Preload
  • ⇡ CO
A

RAAS

56
Q

Sudden coronary obstruction d/t thrombosis formation b/c of an unstable lesion

d/t– Unstable angina, MI (STEMI or non-STEMI)

  • Complications
    • Dysrhythmias
    • CHF
    • Sudden death
A

Acute Coronary Syndrome

57
Q

Development of a constrictive membrane around the heart

  • Scar tissue b/w visceral & parietal layers
  • Fixed CO
    • Regardless of contractility

d/t– Chronic inflammation, Cardiac surgery

Infection & Removal of pericardial sac → Remodeling

A

Constrictive Pericarditis

58
Q

Inappropriate ventricular hypertrophy or dilation

d/t– Genetics, Ischemia, MI (ventricular remodeling), Idiopathic

A

Cardiomyopathies

59
Q

Thickening of septal wall/⇣ LV chamber size → ⇣ Outflow from LV → ⇣ Compliance & ⇣ SV

⇣ Ventricular relaxation & ⇣ Compliance → Impaired diastole

  • Most common inherited heart defect
    • Autosomal dominant
    • 1:500
    • Cause of sudden cardiac death in young athletes
A

Hypertrophic (Obstructive) Cardiomyopathy

60
Q
  • Stenosis
    • ⇡ Afterload → LV Hypertrophy → HF
  • Regurgitation
    • ⇡ Preload → ⇡ Size/Dilation of LV → ⇡ SV → HF
A

Aortic Valve Disorders

61
Q

Myocardial tissue necrosis d/t impaired coronary blood flow

Coronary occlusion → Necrosis in 10 seconds w/o O2

A

Myocardial Infarction

62
Q
  • Preload
  • Afterload
  • Contractility
A

Factors Affecting Stroke Volume (SV)

63
Q
  • Dyspnea
  • Orthopnea
    • SOB when laying down
  • Paroxysmal nocturnal dyspnea
    • Wake up d/t SOB
  • ⇣ Exercise tolerance
  • Fatigue
  • Edema
  • Bendopnea
    • SOB w/ bending over
  • JVD
  • S3 (Third heart sound)
  • Cardiomegaly
  • Hepatojugular reflex
    • JVD w/ pressure on the liver
A

Heart Failure Clinical Manifestation

64
Q

Ability of myocardial tissue to contract

⇣ d/t– MI (most common), ⇣ O2 supply

A

Contractility

65
Q

Accumulation of fluid in pericardial cavity → Cardiac tamponade (compression/pressure) & Pulsus paradoxus (exaggeration drop in BP w/ inhalation)

d/t– Inflammation or infection (CA, cardiac surgery, trauma…)

Treatment– Removal of fluid, Percardiocentesis (needle aspiration)

A

Pericardial Effusion

66
Q
  • S/S of systemic infection
    • Fever
    • ⇡ WBCs
    • Chills
    • Diaphoresis
  • Heart murmur
A

Infectious Endocarditis Clinical Manifestations

67
Q

Dysfunction = Coronary Artery Disease (CAD)

  • Physical factors
    • Aortic bp
    • Systole = Contraction/Pushing
      • Coronary arteries compress
    • Diastole = Relaxation/Filling
      • Perfusion of the heart
  • Neural factors
    • SANS
      • ⇡ Flow
    • PANS
      • ⇣ Flow
    • Changes in HR, contractility, & bp
  • Myocardial metabolic factors
    • Driven by O2 demands
    • Protective factors
      • Adenosine
        • Vasodilation → ⇡ Blood flow
      • Nitric oxide
        • Vasodilation
A

Control of Coronary Blood Flow

68
Q
  • Can lead to each other
  • Left ventricular failure
    • HFpEF
    • HFrEF
  • Right ventricular failure
  • Both ventricles fail
A

Types of Heart Failure

Pathophysiology (NRSG 502) (16 decks)

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