Cardio part 2 Flashcards
Where do acute MI’s usually begin?
Subendocardial layer, then progress outward w/ continued ischemia
Zone of ischemia
Tissue is O2 deprived but not injured
Zone of injury
Tissue is damaged, but not dead
Zone of necrosis
Death of myocardial tissue
25% of all MIs and highest mortality rate
LAD anterior wall of LV
-Increased risk of heart failure and dysrhythmias
MI with increased risk of sinus dysrhythmias
LCX posterior wall of LV
-Due to SA and AV node perfusion
17% of MIs, second highest mortality
RCA or LCX inferior wall of LV
-Mitral dysfunction of papillary muscles and chordae tendinae
STEMI
ST elevation MI
- Happening in real time, haven’t completed the infarct, still happening so you can still do something about it
- Abrupt occlusion
- More damage
NSTEMI
NonST elevation MI
- Partial or temp occlusion
- Ruptured plaque
What is a STEMI treated with?
PCI (percutaneous coronary intervention)
-Fibrinolytics (anticoagulant, clot buster)
What is a NSTEMI treated with?
Antiplatelets (aspirin, plavix)
Why does NSTEMI cause less damage than STEMI?
More ongoing process, body has time to generate collateral circulation
Leukocytosis with MI
Elevated WBC, usually 10-20,000
Cardiac enzymes with MI
CK-MB peak in 12-24 hrs, normal 48-72 hrs
Hallmark changes with AMI
- Myocardial ischemia
- Myocardial injury
- Myocardial infarction
- usually show no immediate ECG changes
Troponin 1 and T
Myocardial muscle protein, elevated 4-6 hrs after AMI, peaks 10-24 hrs, and remains for 5-7 days
Myocardial ischemia
T wave inversion, peaked T waves, ST segment depression (1 mm or one small box)
Myocardial injury
ST segment elevation in leads facing affected area show > or = 1 mm above baseline
Myocardial infarction
Q waves (pathologic) either >25% of the QRS complex height or >1mm wide
ACC goal for AMIs
Time from admit to ER to PCI should be less than 90 minutes
What is the recommended mode of treatment when PCI cannot be performed within 90 mins?
Fibrinolysis
Absolute contraindications for fibrinolysis
- Intracranial hemorrhage
- Known intracranial malignancy
- Known AV malformation
- Ischemic stroke within past 3 months
- Aortic dissection
- Active bleeding
- Closed head injury
Relative contraindications for fibrinolysis
- Uncontrolled HTN
- Active PUD (GI bleed)
- Recent surgery/trauma
- Pregnancy
- Concurrent anticoagulant use
Fibrinolytic meds
- Altepase (tPA)
- bolus then infusion - Streptokinase
- infusion
- can only be used once bc body develops antibodies, they’ll go into anaphylactic shock
- allergic reactions
Pain management with AMI
M-morphine
O-oxygen
N-nitrates
A-aspirin
What position should you put your AMI pt in?
Semi-Fowler’s
How does morphine help with AMIs?
Relaxes smooth muscles and decreases myocardial O2 demand
Causes of Infective Endocarditis
- IV drug abuse
- Prosthetic valves
- Systemic infections
- Structural cardiac defects
Vegetation w/ infective endo
- Vegetative lesions can develop due to accumulation of fibrin and platelets in abnormal area
- Bacteria collects in vegetation
- Vegetation continues to grow and can obstruct inflow/outflow
What might cause valvular insufficiency?
Infective endocarditis
Common ports of injury for Infective Endo
- Oral cavity during dental work
- Skin rashes, lesions, abcesses
- Surgery, placement of invasive lines
S/S of infective endo
- Fever/chills/night sweats
- Anorexia/weight loss
- Cardiac murmur
- Heart failure
- Systemic embolization
- Petechiae
- Splinter hemorrhage-distal 1/3 of nail bed
How to diagnose infective endo
Blood cultures and echoes
Non-surgical treatment of infective endo
- 4-6 wks of IV ABX, probably with PICC line and home health
- NOT anticoagulants
Surgical treatment of infective endo
- Removal/replacement of infected valve/shunt (you can’t steralize a fake part w/ abx so it needs to be replaced)
- Repair of chordae if needed
- Complicated post op
Where will you hear a murmur with infective endo?
Depends on which valve is affected
Causes of acute pericarditis
- Post acute MI
- Pist-pericardectomy syndrome
- Acute exacerbations of systemic connective tissue dz
Causes of chronic pericarditis
- Renal failure
- TB
- Radiation
- Trauma
Acute pericarditis s/s
- Substernal precordial pain that radiates to neck, back, shoulder
- Pain aggravated by breathing, coughing, swallowing
- Worse pain supine
- Friction rub
- Fever
- Elevated WBC
- ST segment “spiking,” may develop Afib
- Thickened pericardium compresses ventricles and restricts filling
Signs of right sided heart failure
JVD, hepatic engorgement, dependent edema, ascites
Diagnostic test for pericarditis
Echo
Interventions with pericarditis
- NSAIDS
- Corticosteroids if not bacterial in nature
- Pt positioning: upright and lean forward slightly
Treatment of pericarditis
- Bacterial: ABX
- Malignant: chemo/rad
- Uremic: dialysis for renal failure
- Surgery: pericardiectomy
Care for pt with pericarditis
- Auscultate for pericardial friction rub
- Avoid anti-coagulants
- Auscultate BP for paradoxical pulse, systolic BP will be 10+ higher on expiration
- Monitor for signs of cardiac tamponade
Excess of fluid within pericardial cavity
Cardiac Tamponade, more than 10mL
Effect of fluid accumulation with cardiac tamponade
Compression of the heart’s chambers and can cause a sudden decrease in CO, rapidly fatal if not identified and treated quickly
S/S of cardiac tamponade
- JVD
- Paradoxical pulse
- Decreased HR/BP
- Dyspnea/Fatigue
- Muffled heart sounds
Treatment of Cardiac Tamponade
- Initial fluid resuscitation
- Hemodynamic monitoring-all pressures equalize
- Pericardiocentesis
Pericardiocentesis
Drainage of fluid with surgery to open up and drain or with a needle at the bedside, go into pericardium but not through muscle
-If you stick the needle too far you can cause a tamponade
HTN
Systolic >140
Diastolic >90
What should diabetics with heart dz maintain their BP at?
Malignant HTN
> 200 systolic
130 diastolic
*They don’t always look/feel sick
Arterial baroreceptors
Located around carotid sinus, aorta, LV wall
-Responsive to changes in body fluid volume (increases venous return)
Calcium channel blockers for HTN
- Vasodilates
- Reduces HR
- Well tolerated
ACE inhibitors for HTN
- prils
- Prevents vasoconstriction
- Postural hypotension
- Cough
- Nephrotoxic
1st line treatment for HTN
Diuretics (hydrachlorathiazide)
-cheap
Example of vasodilator meds
Nitrates
ARBs
Sartans
Why do people get put on ARBs instead of ACE inhibitors
Nephrotoxicity
When to take diuretics
In the morning
Common problem with calcium channel blockers
Orthostatic hypotension
PVD inflow obstructions
Above inguinal ligament
PVD outflow obstructions
Below inguinal ligament
Stage 1 PVD
- Asymptomatic
- Pedal pulses decreased or absent
Stage 2 PVD
- Muscle pain/burning with exercise
- S/s reproducible-happens every time you do a certain thing
Stage 3 PVD
- Pain at rest
- Distal portion of extremities
- Hang their leg off the bed, sit up w/ legs off bed
- Pain relieved when in dependent position
Stage 4 PVD
- Necrosis
- Gangrene
What do you do if you can’t find a pulse with a doppler
Move up one and let someone know
Ankle-Brachial index w/ PVD
Compare BP in arm and in leg, pressures should be equal, PVD will be >0.9
Arteriogram w/ PVD
Heart cath of legs
Anti platelet med for PVD
Baby aspirin or Persantine
Surgical management for PVD
Angioplasty or bypass grafts
Where can you have an aneurysm
Any artery
Injury or trauma to vessel wall
False aneurysm
Fusiform aneurysm
Normal artery, reverse hourglass shape
Saccular aneurysm
Comes off on one side
True aneurysm
Happens naturally
Aortic dissection
Aorta has 3 layers, one layer splits apart. Blood doesn’t go to the right spot
When do you have surgery for an aneurysm
Nothing till its >5cm in diameter…then risk of rupture is greater than surgical risk
How to treat thoracic aneurysm
Not with surgery
Buerger’s Dz
Uncommon, young men who smoke
- Affects hands/feet
- Fibrosis binds arteries together resulting in impaired circulation
- Typically involves smaller arteries and arterioles
Treatment of buerger’s dz
- Stop smoking
- Avoid cold temps
- Surgical revascularization
Vasospasm of arterioles in upper or lower extremities, unilateral, >30 yrs, either gender
Raynaud’s phenomenon
Vasospasm of arterioles, bilaterally, ages 17-50, more common in women
Raynaud’s Dz
Manifestations of Raynaud’s
- Skin blanches w/ vasospasm, hyperemic (really red, flushed) when vasospasm goes away
- Int attacks
- Extremities feel cold, tingling, numb
- Ulcers may develop
Treatment of Raynaud’s
Calcium channel blockers to prevent spasm, vasodilators, avoid cold, stress
Thrombosis/thrombus
Blood clot
Phlebitis
Inflammation of the vein
Thrombophlebitis
Thrombus associated w/ inflammation
Most common site of thrombophlebitis
Deep veins of lower extremities
Virchow’s Triad
- Venous stasis
- Hypercoagulabity (caused by dehydration)
- Endothelial injury
DVT
Closely associated w/
- Hip/knee replacement sx
- Immobility
- Ulcerative colitis
- HF
- Prolonged sitting
Clinical man of DVT
Calf/groin pain, unilateral swelling
Diagnostic procedures
Venous US
Medical management of DVT
- Prevention (dorsiflex)
- Bedrest
- Extremity elevation
- Anticoagulants
- Surgery
Anticoagulant therapy for DVT
- Heparin bolus/infusion to dissolve clot
- Goal is PTT 1.5-2 x normal level
- Serial monitoring (CBC, PTT, PLT)
- Lovenox (1mg/kg) for prevention, not treatment
- Warfarin long term
Venous insufficiency
- Prolonged venous HTN
- Stretches veins/damages valves
- Venous stasis (edema, inability to remove waste products, ulcer formation)
Normal PTT
20-30
Clinical manifestations of venous insufficiency
Edema, stasis dermatitis (reddish brown discoloration extending up from ankles, chronic ulcers)
Management of venous insufficiency
Reduce edema, normal venous return, localized ulcer care
Pt education for venous insufficiency
- Avoid long standing periods
- Leg elevation
- Don’t cross legs
- Don’t wear restrictive clothing
- Ulcer care (unna bood, surgical debridement)
Left sided HF
Systolic: heart can’t contract forcefully
Diastolic: Loss of ventricular wall compliance, can’t fill
Right sided HF
RV doesn’t empty completely and “backs up” into venous system causing peripheral edema
1 cause of right sided HF
Left sided HF
High output failure
Less common, associated with sepsis
S/S left sided HF
Systemic
-Fatigue
^HR
-DOE
-Crackles, wheezes
-Cool extremities
-Weak pulses
S/S right sided HF
- JVD
- Enlarged liver/spleen
- Anorexia
- Peripheral edema
- Polyuria (night)
- Weight gain
Classification of HF ACC
A-pts w/ high risk
B-structural problems, no symptoms
C-symptoms
D-refractory HF
Classification of HF New York
1: without limiting symptoms
2: slight limitation of activity
3: marked limitation
4. inability to move w/o symptoms, symptoms at rest
Meds for HF
- ACEI or ARB
- Beta blockers controversial
- Diuretics
- Nitrates: vasodilate coronary arteries
- Inotropes (Digoxin: lowers HR and increases contractility)
Intra-aortic balloon pump for HF
- Placed percutaneously
- Increases coronary perfusion
- Decreases after load
- Increases CO
- Positioning: high enough in aorta that its above superior mesenteric, below carotid and great vessels, stick artery, they’ll be on bedrest
- Timing: inflates during diastole, deflates just before systole
Pulmonary Edema
Severe HF w/ volume overload, AMI, mitral valve disorders. Fluid leaks across capillaries into lung tissues
S/S of pulmonary edema
- Crackles
- Dyspnea at rest
- Confusion
- Anxiety
- Reduced UOP
- Cough
- Frothy, pink sputum
Treatment for pulmonary edema
Oxygen, diuresis, nitrates, inotropes
Most common cause of mitral stenosis
Rheumatic fever
Mitral stenosis
Valve doesn’t open fully, increased pressure in LA, then PA, then RV
- Pulmonary congestion
- Right sided heart failure
Mitral regurgitation/insufficiency
- Degeneration/infarct of papillary muscle
- Doesn’t close: allows for back flow of blood into LA and LV until LV begins to fail due to chronic volume overload
- RV failure results too
Aortic stenosis
- Most common valve dz
- Congential/age related
- Doesn’t open and obstructs LV outflow
- CO becomes fixed
- LV failure leads to RV failure
Aortic regurgitation/insufficiency
- Endocarditis, congenital
- Remain asymptomatic for years
- LV overload leading to LV failure, then RV failure
- Bounding pulse w/ wide pulse pressure
Systolic murmurs occur with what?
- Mitral regurgitation
- Aortic stenosis
Diastolic murmurs occur with what?
- Mitral stenosis
- Aortic regurgitation
Medical management for valvular heart dz
- Diuresis
- Atrial fib management
Surgical repair of valvular dz
Metal valves/porcine valves, annuloplasty, balloon dilation
