Cardiac Pathology Flashcards
What to look and feel for before treatment
- discoloration of skin
- diaphoresis
- RR, HR, BP, Pulse ox
- JVD: distension of the jugular vein due to R sided heart failure
- Edema? bilateral pitting in extremities/face or neck may indicate heart failure
- quality and rhythm of pulses
- electrocardiogram/EKG
Auscultation
listening (usually with a stethoscope)
Listen to each valve area:
• Aortic: 2nd intercostal space, R sternal border
•Pulmonic: 2nd intercostal space, L sternal border
•Tricuspid: 4th intercostal space, L sternal border
•Mitral valve: 5th intercostal space, midclavicular line
Normal heart sounds: S1
first sound is the AV valves closing to begin systole
Normal heart sounds: S2
the 2nd sound is the closure of aortic and pulmonic valves at the end of systole
Abnormal heart sounds: murmur and pericarditis
• Murmur (systolic or diastolic): turbulent flow through a stenotic or regurgitant valve
•Pericardial friction rub: due to pericarditis (refers to inflammation of the pericardium, two thin layers of a sac-like tissue that surround the heart, hold it in place and help it work. A small amount of fluid keeps the layers separate so that there’s no friction between them)
Abnormal heart sounds: S3
Ventricular Gallop: vibration of distended ventricles during passive filling
- normal in children
- in adults may indicate heart failure
Abnormal heart sounds: S4
Atrial Gallop: vibration of distended ventricles upon atrial kick
-due to HTN, stenosis, MI
Lab values: BNP (B type natriuretic peptide)
Normal: less than 1,000 pg/ml
Abnormal: over 500 indicated heart failure, plan for low exercise tolerance, watch vitals closely, avoid compression, expect orthopnea
Lab values: CK-MB (creatine kinase myocardial band)
Normal: 0-3% is normal
Abnormal: elevates with MI, usually taken in 3 sets after MI, wait for the values to trend down before starting PT
Lab values: Troponin I
Normal: 0-0.2 mcg/mL
Abnormal: 100% cardiac specific, needs to be trending down to start PT
Lab values: Hgb
Normal: 13-18 m/dL men
12-16 m/dL women
Abnormal: determines O2 carrying capacity. With a low hgb the pt will fatigue easily . HR and RR daster, postible syncope. Limit exercise significantly for patients with CHF and hgb near of or below 8 m/dL
Lab values: hct
Normal: 37%-49% men, 36%-46% women
Abnormal: RBCs in relation to total blood volume. Not as reliable as it can differ based on hydration levels
Coagulation labs: prothrombin time PT
Normal: .8-1.2
Coagulation labs: partial thromboplastin time PTT
Normal: 21-35 seconds
Abnormal: 60-109 seconds
Related meds: heparin
Coagulation labs: INR international normalized ratio
Normal: .8-1.2
Related meds: warfarin/coumadin
Electrolytes: sodium Na
Normals: 135-145 mEq/L
Implications: hypernatremia, or hyponatremia
Potassium K
Normals: 3.5-5 mEq/L
Implications:
hyperkalemia
hypokalemia: arrhythmia, BLE muscle cramps
Calcium Ca
Normals: 9-11 mg/dL
Implications:
Hypercalcemia: erratic rhythm
Hypocalcemia: reduced contractility
BUN
normal: 10-20
Creatine
.5-1.2 mg/dL
Glucose
70-110 mg/dL
70 or lower should have a snack before exercising
Normal sinus rhythm
regularity of P, QRS, and T waves
Atrial flutter
rapid atrial rate (P wave) compared to the slower ventricular rate (ARS)
Atrial fibrillation
P waves are replaced by irregular and rapid fluctuations. There are no effective atrial contractions
•frequently occurs about 48 hours after open heart surgery
•often starts as afib with rapid ventricular rate (RVR)
which decreases the CO significantly resulting in fatigue, dyspnea, lightheadedness, syncope. Pt needs rest and meds, often IV.
• longer term risk of blood clots
Ventricular tachycardia
ventricular rate may be as high as 250 beats per minute. The rhythm is regular, but the atria are not contributing to ventricular filling and blood output is poor.
•if you see a run of 3 or more Vtach beats, stop and check if it is accurate
what to look for on EKG
- rate
- rhythm
- ST depression
- ST elevation
- abnormalities
premature ventricular contractions
• premature ventricular contractions (PVCs) only dangerous if excessive
Meds for arrhythmia
- Cardizem (calcium channel blocker)
- Tikosyn (sympathetic blocker)
- Amiodarone (alpha and beta blockers)
- pt will also likely be on blood thinners to prevent clots from forming in the atria and then causing CVA or PE
Med procedures for arrhythmia
cardioversion, ablation, pacemaker, maze procedure
Pacemaker precautions
- For 6 weeks after pacemaker is inserted or upgraded
- no pushing/pulling greater than 5 lbs with pacemaker side
- no shoulder abd/flex greater than 45°
- no shoulder extension
Acute coronary syndrome: ischemia of myocardium
•Stable angina: predictable, only occurs during exertion or emotional stress, relieved with rest, O2 and nitro
•Variant/spasm related Angina: (Prixmetal angina) related to a spasm of the coronary artery. Risk factors are smoking and atherosclerosis
•Unstable Angina: unpredictable, occurs at rest, is not relieved with rest, O2 and nitro
-emergency!
PT and Angina
- must terminate exercise. Check and document HR and BP
- Pt may need to take their nitroglycerin tablet. Anyone who has a prescription for this should bring the med to therapy sessions.
- If in a facility: Chest Pain Protocol: the MD will be called, oxygen applied, EKG and vitals obtained, Pain levels documented, Cardiac enzyme labs drawn.
- Never assume it isn’t a big deal!
Angina or heart burn (dyspepsia)
•Angina usually feels like pressure behind the sternum.
“Like an elephant sitting on my chest”
•Diffuse, may radiate to L jaw and L arm, b/w scapulae, xiphoid or R breast and axilla.
•Dizziness, lightheadedness, weakness, sweating, fatigue, weakness. (signs of low CO)
•Fear, agitation, anxiety.
MI
- A complete occlusion of a coronary artery due to atherosclerosis causing ischemia and cell death (infarction) of the myocardium.
- The specific artery and time spent ischemic determines the severity
- Can be treated by heart catheterization or Coronary Artery Bypass Graft (CABG)
heart cath
•percutaneous coronary intervention (PCI)
includes: percutaneous transluminal coronary angioplasty (PTCA), stent placement, laser angioplasty, and atherectomy
Heart cath L side
- Via femoral artery or *radial artery
- Coronary artery stenosis
- To evaluate the aorta or ventricular function or mitral or aortic valve function
- Pt is on bedrest for 6-8 hours, hip in neutral if femoral
- Check groin prior to and post PT even days later if femoral
Heart cath R side
- Via subclavian/femoral vein
- To evaluate R heart pressures/ electrical fx
- To calculate cardiac output
- Pre/post heart transplant
- Pulmonary HTN
- Pt is on bedrest 4-6 hours
- Check site same and next day
Coronary Artery Bypass Graft: CABG
- A vein (saphenous from leg) or (left) internal mammary artery (from inside of chest wall) is used to bypass the occluded portion of coronary artery.
- The chest is opened by sawing the sternum vertically. Therefore pt will have sternal precautions.
- Newer research is showing that strict sternal precautions may not be necessary unless cognitive issues, infection of wound or morbid obesity
- Minimally invasive option now available.
Sternal precautions
•For 6 weeks after open heart surgery (sternotomy) usually a valve replacement or CABG
• No pushing/pulling greater than 5 lbs
Incisional splinting with coughing
•Avoid bilat shoulder flexion or horizontal abduction, or extension
•Contemporary research may
lessen restrictions.
hypertension
- The most common cardiovascular disease in the US
- Powerful factor in cardiovascular morbidity and mortality
- Determined by an average of measurements taken on at least 2 occasions and measurements.
- May be labile (fluctuates b/w normal and HTN)
- May be elevated in medical environment and normal at home
HTN: Essential/Primary
Essential/Primary: 90-95% of patients
•Cause of the HTN is unknown
HTN: Nonessential/Secondary
Nonessential/Secondary: 5-10%
•The HTN is caused by an identifiable medical cause
•Primary renal disease
•Drug use
•Abnormality of the aorta or renal vasculature
• OSA
•Cushing’s syndrome or endocrine disorder
complications caused by HTN
- Heart failure
- Renal failure
- Dissecting aneurysms
- PVD
- Retinopathy
management of HTN
increasing physical activity: 40 min, 3-4 x per week, mod intensity
decrease in BP: 4-6 mm Hg for aerobic, 3 mmHg for resistance
DASH (dietary approaches to stop htn): fruits veggies, low fat dairy, reducing saturated and total fat
weight loss: 22 lbs= 5-20 mm Hg
Limit alcohol intake: 1 drink for women or lighter weight men, 2 drinks for men
Decrease sodium: less than 100 mEq/day 2-8 mmHg
CHF
- Decreased CO, causes back up of blood in to pulmonary circulation and systemically
- Results in exercise intolerance
- Common S & S: peripheral edema, crackles in lungs, dyspnea, sinus tachycardia, orthopnea and fatigue
meds for heart failure
Blood pressure meds:
•Beta blockers: lower afterload & HR
-Recognize these by –olol ex: propranolol
•Alpha blockers: lower afterload
-Recognize these by –azosin: prazosin
•Calcium Channel blockers: lower HR & BP
-dipine: amlodipine
• ACE inhibitors: blood vessel dilation
-pril: Lisinopril
Inotropes:
Digoxin, milrinone
Valve repair/replacement
•Aortic valve and Mitral valve the most common
•May be replaced with bovine or prosthetic valve.
If metal valve, will always need anticoagulation also will hear a metallic click when valve closes.
•Can be done via sternotomy or
•TAVR: transcatheter aortic valve repair (femoral artery)
BP guidelines
•Normal: Less than 120/80 mm Hg;
•Elevated: Systolic between 120-129 and diastolic less than 80;
Stage 1: Systolic between 130-139 or diastolic between 80-89;
Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
ST segment depression and/or Twave inversion
ischemia/decreased perfusion
ST segment elevation
cardiac acute injury
Q wave abnormality
transmural/full thickness MI
L sided heart failure- pulmonary congestion
Characterized by abnormal retention of fluid- congestion in pulmonary circulation and decreased cardiac output S/S: Dyspnea Crackles Orthopnea S3 ventricular gallop Tachycardia Paroxysmal nocturnal dyspnea
CHF R sided heart failure- systemic congestion
Abnormal systemic fluid congestion S/S: Ascites (accumulation of fluid in the peritoneal cavity, causing abdominal swelling) Jugular venous distension Pitting edema of LE’s Possible edema in sacral area
Location of the hear
Apex: 5th intersostal space at midclavicular line- tip of (L) ventricle
Base: 2nd intercostal space behind sternum- posterior aspect of heart; adjacent to vertebral bodies of T6 thru T9
CAD
- Narrowing or blockage of lumen of coronary arteries usually due to atherosclerosis.
- Symptoms usually not experienced until lumen is at least 70% blocked
- The most common clinical presentations are: ischemia, infarction, or arrhythmias
- Estimates are that 50% of patients with CAD present with sudden death
Angina
- Ischemia- the temporary deficiency of oxygenated blood flow to the tissues- a TEMPORARY CONDITION
- Myocardial ischemia results in ANGINA- whose classical presentation is substernal chest pressure accompanied by the Levine sign ( pt. with clenched fist over sternum)- in general symptoms are:
- Temporary pain
- Sudden onset
- Pain may radiate
- Usually lasts one to five minutes
- Usually relieved with rest/ nitroglycerin
4 most common types of angina pectoris;
- Nocturnal: angina will wake the person up from sleep with same characterisitics as angina from exertion. It may be related to CHF
- Prinzmetal’s: angina that occurs at rest secondary to CAD or spasm. It can be severe and not relieved by nitroglycerin
- Stable: occurs at predictable level of exertion, exercise, or stress; responds to nitroglycerin/ rest
- Unstable: can occur at rest or with exertion, has changed in intensity, frequency, and/or duration
Angina alternative presentation
Angina may also present as pain or heaviness in the shoulder, jaw, arm, elbow, or upper back between the scapula. It may radiate to the arm or up the throat, or may present as indigestion or even shortness of breath
Lab values post MI
- Elevated levels of CK-MB ( an isoenzyme released with intracellular myocardial damage,
- Proteins- Troponin I and Troponin T and Myoglobin
Sudden cardiac arrest
- a condition that occurs when the heart stops pumping blood. Usually, this is often caused by an electrical problem in the heart
- occasionally there is a mechanical problem where there may be a normal electrical signal but the heart muscle fails to pump
Heart attack
- caused by a circulation or plumbing problem of the heart, when one or more of the arteries delivering blood to the heart is blocked. O2 in the blood cannot reach the heart muscle and the heart becomes damaged.
- this damage to the heart muscle can lead to disturbances of the heart’s electrical system. A malfunction of the heart’s electrical system may cause dangerous heart rhythms that can cause a SCA.
- most but not all SCAs occur in patients with coronary heart disease. The first few hours after a heart attack the patient is at higher risk for SCA
EKG
P wave= atrial depolarization, this is the place where you will see a-fib if present.
QRS duration= ventricular depolarization, which is where ventricular tachycardia will show up
T wave= ventricular re-polarization, if inverted it indicates myocardial ischemia
CHF
•gradual increase in severity of a disease (inadequate circulation); may be failure of left or right ventricle or both
•major impact on organ systems other than the heart
•tiredness, breathlessness, development of edema
Compensatory Responses:
-ventricles enlarge and contract more efficiently
-constriction of arterioles with redistribution of blood flow
-activation of sympathetic and renin-angiotensin systems leads to retention of salt and water and changes in vascular tone
-desensitization of cardiac muscle to sympathetic stimulation
BNP
normal: 100
heart failure: 500
*in cases of renal dysfunction high BNP may not indicate heart problems
STOP exercise if…
- occurrence of CP, diaphoresis, dyspnea, excessive fatigue/weakness, cyanosis or dizziness/lightheadedness
- heart rate exceeds 30 bpm from rest or falls more than 10 bpm from rest
- SPO2 falls below 92%
- diastolic pressure increases greater than 10 mm Hg
- systolic pressure drops more than 10 mm Hg below resting
- presence of bi-basilar crachles that weren’t present prior to starting exercise
- presence of the S3 heart sound
- failure of monitoring equipment
