Cardiology Flashcards
1
Q
Pericardium
A
Sack around heart
2
Q
Epicardium
A
Thin, outmost layer of heart
3
Q
Myocardium
A
Thick, muscular layer of heart
4
Q
Endocardium
A
Thin, inside layer of heart
5
Q
AV valves are located between __ and ___.
A
Atria and Ventricles
6
Q
AV valves ___ with low ventricular pressure and ___ with high ventricular pressure.
A
Open, Close
7
Q
What are the four AV valves in order?
A
Tricuspid, Pulmonic, Mitral, Aortic
8
Q
Coronary circulation divides from the Aorta into the ___ and the ___.
A
Left Coronary Artery and Right Coronary Artery
9
Q
The Left Coronary Artery bifurcates into the __ and __.
A
Left Circumflex and Left Anterior Descending
10
Q
The Right Coronary Artery bifurcates into the __ and __.
A
Right Coronary Artery and Posterior Descending Artery
11
Q
What does the Left Circumflex supply?
A
Left Lateral wall
12
Q
What does the Left Anterior Descending supply?
A
Left Anterior wall
Left Anterior 2/3rds Septum
13
Q
What does the Right Coronary Artery and Posterior Descending Artery supply?
A
SA node AV node Right Ventricle Left Inferior Left Posterior
14
Q
What is the major intra-atrial pathway?
A
Bachmann’s Bundle
15
Q
Electrical conduction in the heart
A
SA node -> AV node -> Bundle of His -> RBB / LBB (LBB -> Anterior / Posterior Fascicle) -> Perkinje fibers
16
Q
Transmural Infarct
A
Includes full thickness of myocardium, endocardium, and epicardium.
17
Q
Non-transmural (subendocardial) Infarct
A
Damage limited to subendocardial region
18
Q
Define Unstable Angina
A
Positive cardiac markers and negative 12 lead changes
19
Q
Define NSTEMI
A
Positive cardiac markers and ST depression or T wave changes
20
Q
Define STEMI
A
Positive cardiac markers and ST elevation on 12 lead
21
Q
Septal wall infarcts
A
LAD occlusion
Associated with Anterior MI, RBBB, LAFHB
22
Q
Anterior wall infarcts
A
LAD occlusion
Associated with Septal MI
Anticipate Mitral valve regurgitation due to papillary muscle involvement (flash pulmonary edema)
23
Q
Lateral wall infarcts
A
Left Circumflex
Can be associated with Anterior or Anterioseptal wall MI
24
Q
Inferior wall infarcts
A
RCA occlusion
Associated with Posterior wall / Right ventricle
Look for AV node involvement with high occlusion (Frequent rhythm changes)
25
Posterior wall infarcts
RCA occlusion
Associated with Inferior wall / Right ventricle
Look for AV node involvement with high occlusion
26
Pathological Q waves
1/3rd of total height of R wave or 1 small box (0.04s)
27
1mm on EKG
0.04 seconds, 1 small box
28
5mm on EKG
0.2 seconds, 1 big box
29
Posterior EKG placement
V4 -> V7 (posterior axillary line, left of shoulder blade)
V5 -> V8 (mid-scapular line)
V6 -> V9 (left spinal border)
30
Pericarditis S/S
Atypical, sharp pain that changes with position change. Reproduceable with pressure, wants to lean forward, deep breathing causes pain.
31
Pericarditis 12 lead
Abnormalities in multiple, seemingly unrelated leads. Look for J point notching
32
Stable Angina
Onset with physical exertion or emotional stress. Pain lasts 1-5 minutes and is relieved by rest. Predictable.
33
Unstable Angina
Stable angina that has changed in frequency, quality, duration, or intensity. Pain lasts longer than 10 minutes despite rest and NTG.
34
Variant (Prinzmetals) Angina
Spontaneous episodes of C/P frequently noted at rest or on early rising (associated with circadian rhythm). Relieved with NTG.
35
Silent Angina
Objective evidence of ischemia in asymptomatic patients (Positive 12 lead or elevated enzymes).
36
Mixed Angina
Combination of Stable and Variant Angina.
37
Management of Acute MI: Preload reduction
Nitrates (improves coronary blood flow, decreases preload and left ventricle end diastolic pressure)
Morphine (decreases sympathetic tone, heart rate and O2 demand)
38
Normal CorPP
>50
39
Coronary Perfusion Pressure formula
CorPP = DBP - PCWP
40
Management of Acute MI: HR and O2 demand reduction
Beta blockers (decrease HR and increase diastolic filling time- use ONLY in post acute phase)
Calcium channel blockers (produce dilation of coronary arteries and collateral vessels along with decreased in contractility and conduction)
41
Management of Acute MI: Clot prevention and lysis
ASA/Glycoprotein IIb/IIIa inhibitors
Heparin/Lovenox
Fibrinolytics
42
True or False: Evidence suggests equivalent mortality of thrombolytics @ 30 minutes and angioplasty @ 90 minutes with angioplasty being safer.
True
43
Thrombolytics Indication
New onset STEMI
44
Thrombolytics Complications
Bleeding everywhere and anywhere.
| Reperfusion dysthymias common.
45
Thrombolytics Absolute Contraindications
```
Active internal bleeding
Suspected aortic dissection
Known intracranial neoplasm
Previous hemorrhagic stroke at any time
Any stroke in past year
```
46
Pacing complications: oversensing
"Detecting" T waves or artifact as R waves. Shuts off demand pacer.
47
Pacing complications: Failure to sense
Does not recognize R waves and randomly fires pacer. (most dangerous due to refractory period)
48
Pacing complications: Asynchronized pacing
Pacing spikes and R waves not aligning. Can cause R on T
49
Define Dilated Cardiomyopathy
Systolic heart failure caused by stretched heart and muscles thinned. Usually due to volume overload.
50
Treatment of Dilated Cardiomyopathy
Cardiac glycosides (Digitalis)
Diuretics (Lasix)
Inotropes (Dopamine/Dobutamine)
51
How does Digitalis work?
Poisons regular sodium pumps, Secondary pumps then push out sodium and pulls in calcium to the cell. Increased calcium = increased contractility.
52
Define Hypertrophic Cardiomyopathy
Diastolic failure caused by heart muscle becoming thick and large, decreased space for blood causing decreased preload and cardiac output.
53
Treatment of Hypertrophic Cardiomyopathy
Increase Preload, Increase ventricular filling with beta blockers or calcium channel blockers.
54
Define Restrictive Cardiomyopathy
Systolic failure caused by stiff and fibrous heart due to scar tissue.
55
Treatment of Restrictive Cardiomyopathy
Diuretics, anticoagulants, digitalis
56
Primary vs Secondary Cardiomyopathy
```
Primary = Cardiomyopathy causing other problems
Secondary = Other issues caused Cardiomyopathy
```
57
Define Stenotic Valve
Valve doesn't want to open
58
Define Regurgitant valve
Valve doesn't want to close
59
Most common cause of valve disease
Rheumatic fever / disease
60
Two most common valves to have problems
Mitral and Aortic
61
"Systolic murmur 2nd intercostal space right of sternum"
Aortic Stenosis
62
"Lub murmur dub"
Systolic murmur
63
"Lub dub murmur"
Diastolic murmur
64
Tricuspid valve location
Between Right Atrium and Right Ventricle. Listen at 4th ICS, left mid-clavicular
65
Pulmonary valve location
Between Right Ventricle and Pulmonary Artery. Listen at 2nd ICS, Left side of sternum
66
Mitral valve location
Between Left Atrium and Left Ventricle. Listen at 5th ICS Left side
67
Aortic valve location
Between Left Ventricle and Aorta. Listen at 2nd ICS Right side.
68
Valves that Open on Systole and Close on Diastole
Pulmonic and Aortic
69
Valves that Open on Diastole and Close on Systole
Tricuspid and Mitral
70
Chest X-ray shows "Widened Mediastinum with diffuse infiltrates"
Leaking Aorta!
71
Debakey classification of aortic aneurysm Type 1
Begins at aortic valve, ascends through ascending aorta, through arch and into descending aorta.
72
Worst aortic aneurysm prognosis
Type 1
73
Debakey classification of aortic aneurysm Type 2
Begins at aortic valve and goes into ascending aorta
74
Debakey classification of aortic aneurysm Type 3
Only in descending aorta
75
Best aortic aneurysm prognosis
Type 3
76
Treatment of Aortic Aneurysm
```
Lower BP (Nipride)
Lower HR (Metoprolol/Esmolol)
Pain control (Fentanyl)
```
77
Treatment of Hypertensive Crisis
```
Try to get to their normal BP over 30-60 minutes.
Nipride
Hydralazine
Labetalol
Ace inhibitors
Diuretics
```
78
Types of invasive hemodynamic monitoring
Arterial
Central venous
Pulmonary Artery
79
Always monitor ___ port for most accurate hemodynamic monitoring.
Distal
80
Fluid filled monitoring systems are pressurized to __
300 mmHg
81
Transducer placement
Even with the Phlebostatic Axis (4th ICS mid-axillary)
82
True or false: Arterial lines should not be used for fluid resuscitation or medication infusion.
Monitor and draw only!
| Do not fluid resuscitate or infuse medications
83
Arterial line uses
Provides continuous BP
| Easy access for labs and blood gas
84
Where are Arterial lines usually placed?
Radial or Femoral arteries
85
Trace a drop of blood through the heart
Vena cava -> RA -> Tricuspid -> RV -> Pulmonic -> Pulmonary Artery -> Lungs -> LA -> Mitral -> LV -> Aortic -> Aorta
86
Renin-Angiotensin-Aldosterone system
Renal system mechanism to improve hemodynamics by vasoconstricting and retaining water.
87
Lab value measuring Congestive Heart Failure
BNP
88
Chest X-ray: "Curly A/B lines, lung vasculature is super dense, enlarged heart"
Congestive Heart Failure
89
Treatment of Congestive Heart Failure
```
Correct systolic failure, Increase LV clearing
Decrease preload (NTG, Morphine, Lasix)
Decrease afterload (Nitroprusside)
Decrease rate (Carvedilol)
Increase contractility (Dobutamine)
Inhibit RAA system (Ace inhibitors)
```
90
Define Cardiogenic Shock
"Pump" failure causing hypotension
91
Treatment of Cardiogenic Shock
IABP
LVAD
Dopamine/Dobutamine
Nitroprusside
92
Where is Central Venous Pressure measured?
In the Vena Cava at entrance to Right Atrium (Preload)
93
Normal CVP?
2-6 mmHg
94
What does CVP measure?
Hydration status, RV function, preload
95
Causes of low CVP
Hypovolemia
| Vasodilation
96
Causes of high CVP
```
Hypervolemia
RV failure / infarct
Cardiac tamponade
Positive pressure ventilation
P.E.
Pulmonic stenosis
Tricuspid Stenosis
```
97
CVP waveform
"Gentle rolling waveform"
98
Normal Right Ventricle Pressures
Systolic - 15-25 mmHg
| Diastolic - 0-5 mmHg
99
RV waveform
Sharp upstroke and downstroke
| notching on ascending side = Right Atrial kick
100
Normal Pulmonary Artery Pressures
Systolic - 15-25 mmHg
| Diastolic - 8-15 mmHg
101
What does Pulmonary Artery Pressure measure?
Right heart output
Left heart output
Pulmonary compliance
102
Causes of low PAP
Dehydration
RV failure / infarct
Pulmonic stenosis
103
Causes of high PAP
```
Fluid overload
Mitral stenosis
Aortic stenosis
High PVR / SVR
Left ventricle failure
```
104
Pulmonary Artery Waveform
Sharp upstroke and downstroke with obvious dicrotic notch on descending terminal
105
Normal Pulmonary Capillary Wedge Pressure
4-12 mmHg
106
How is PCWP measured?
Inflating balloon until waveform changes. Never more than 1.5 ml of air.
107
Causes of low PCWP
Dehydration
| Vasodilation
108
Causes of High PCWP
```
LV failure
Pericarditis
Mitral valve stenosis
Aortic valve stenosis
Fluid overload
```
109
What does PCWP measure?
Pre-load to left ventricle
110
PCWP waveform
"Low amplitude rolling waveform"
| Resembles CVP with slightly higher values
111
PA Catheter Troubleshooting: Inadvertent wedge
Caused by migration or balloon inflation.
Fully deflate balloon
Withdraw catheter until PA waveform
112
PA Catheter Troubleshooting: Inadvertent RV waveform
PA tip is whipping around in ventricle
Verify balloon deflated
Withdraw until CVP waveform
113
Normal cardiac output
4-8 L/min
114
Cardiac Output formula
CO = HR x SV
115
Normal Cardiac Index
2.5-4.2 L/min
116
Cardiac Index formula
CI = CO / BSA
117
Normal Stroke Volume
60-135 ml
118
Increased preload = __ stroke volume
Increased
119
Increased afterload = __ stroke volume
Decreased
120
Increased contractility = __ stroke volume
Increased
121
Stroke volume = __ End diastolic volume
2/3rd
122
Normal Ejection Fraction
67%
123
EF >__ is "OK"
55%
124
Management to Decrease Preload (CVP / PCWP)
Vasodilators
Morphine
Diuretics
Ace inhibitors
125
Management to Increase Preload (CVP / PCWP)
Fluids
| Vasoconstrictors
126
What is Afterload?
Resistance heart must pump against to eject blood from ventricles
127
What is normal Pulmonary Vascular Resistance?
50-250 dynes
128
What does PVR measure?
Afterload of Right heart
129
What causes decreased PVR?
Dehydration
| RV failure
130
What causes increased PVR?
Pulmonary HTN
| Hypoxia
131
What is normal Systemic Vascular Resistance?
800-1200 dynes
132
What does SVR measure?
Afterload of Left heart
133
What causes decreased SVR?
Dehydration
Neurogenic / Septic / Anaphylactic shock
Vasodilators
134
What causes increased SVR?
Aortic Stenosis
HTN
Vasoconstrictors
Hypovolemic shock
135
Management to decrease afterload (SVR)?
Vasodilators
Nitroprusside
Dobutamine
Nifedipine
136
What is a metabolite concern with Nitroprusside?
Thiocyanate -> cyanide
137
Management to increase afterload (SVR)?
```
Vasopressors
Dopamine
Neosynephrine
Nor-Epi
Epi
```
138
Management to increase contractility
Sympathetic Nervous System stimulation
B1 agonist (Dobutamine, Epi)
Increase calcium
Cardiac glycosides (Digitalis)
139
Causes of decreased contractility
Electrolyte imbalance
Hypoxia
Acidosis
140
#1 cause of dampening waveform
Air in line
141
When do you re-zero invasive lines?
Take off, cruise altitude, landing
142
Invasive line monitoring priorities
PA catheters (due to wedge)
Arterial lines
CVP
143
IABP should be used in patient's with AMI complicated by _________.
Cardiogenic shock
144
IABP Indications
Support of AMI in cardiogenic shock
Circulatory support in post-CABG patients
Support in high risk Cath's
In severe ischemia as a bridge to revascularization
145
IABP placement
Enters Femoral artery into Aorta. Tip is distal of Left subclavian, 2-4 ICS
146
When does deflation occur on an IABP?
Beginning of systole, causing 0 or negative afterload
147
When does inflation occur on an IABP?
Diastole to push blood into coronary arteries
148
What zone should the IABP cath tip be in?
West Zone 3
149
Contraindications of IABP
```
Aortic insufficiency (Bad Valve)
Severe Aortic disease (AAA)
Severe peripheral vascular disease (Big cath into small vessels)
```
150
Complications of IABP
```
Ischemia of limb distal to insertion site
Aortic dissection
Occlude renal artery if too low
Occlude subclavian if too high
Gas emboli
```
151
If IABP balloon ruptures, what will you see?
Rusty colored flakes
152
IABP Early Inflation
Inflation before Aortic valve closure. Pushes blood back into left ventricle. Decreases CO and increases SVR. Harmful.
153
IABP Late Inflation
Suboptimal due to minimal displacement of blood back toward the coronary arteries.
154
IABP Early Deflation
Afterload reduction is lost, normal afterload pressures
155
IABP Late Deflation
Causes a "cork in aorta" due to balloon being inflated during systole. Increased workload of Left ventricle. Very harmful
156
True or False: Timing of IABP can be 1:1
False due to inability to evaluate efficiency. use 1:2, 1:3, 1:4. 1:8 as indicated.
157
A sharp V at dicrotic notch upon IABP inflation indicates
Good timing of inflation
158
A "Gentle U" after IABP deflation indicates
Good timing of deflation
159
A sharp V after IABP deflation indicates
Late deflation
160
An elevated dicrotic notch upon IABP inflation indicated
Early inflation
161
A delay after dicrotic notch before upstroke indicates
Late inflation
162
An elongated, non-gentle U shape upon deflation indicates
Early deflation
163
What is the primary trigger of the IABP?
ECG
164
What is the secondary trigger of the IABP?
Arterial pressure line
165
When should you switch to the secondary trigger of an IABP?
Artifact on ECG
| Cardiac Arrest
166
In event of power failure, cycle balloon manually every __
30 minutes
167
How to assure IABP tip placement
Get recent chest X-ray.
Balloon is 2cm distal to aortic arch (Left subclavian)
Commonly 2-3 ICS
Proximal end does not occlude renal arteries
168
Transport considerations of IABP
Monitor urinary output
Distal pulses to left hand
Insertion side lower extremity pulses
Rust colored flakes in tubing
169
What does NAVEL stand for?
```
From peripheral to medial:
Nerve
Artery
Vein
Empty space
Lymphatics
```
170
Normal Pulse Pressure
30-40
171
```
Right Failure
CVP
CI
SVR
PCWP
```
CVP: High
CI: Low
SVR: High
PCWP: Low
172
```
Hypovolemia shock
CVP
CI
SVR
PCWP
```
CVP: Low
CI: Low
SVR: High
PCWP: Low
173
```
Cardiogenic shock
CVP
CI
SVR
PCWP
```
CVP: High
CI: Low
SVR: High
PCWP: High
174
```
Vasogenic shock
CVP
CI
SVR
PCWP
```
CVP: Low
CI: High
SVR: Low
PCWP: Low
175
```
Distributive shock
CVP
CI
SVR
PCWP
```
CVP: High
CI : Low
SVR: High
PCWP: High
176
```
Sepsis shock
CVP
CI
SVR
PCWP
```
CVP: Low
CI: Low
SVR: Low
PCWP: Low
177
What do Alpha 1 receptors cause when stimulated?
Constriction of vessels
178
What do Beta 1 receptors do when stimulated?
Increase heart rate and contractions
179
What do Beta 2 receptors do when stimulated?
Dilation of bronchioles
| Dilation of vessels
180
Heart sounds: S1
"Lub" (Bicuspid/Tricuspid valve closure)
181
Heart Sounds: S2
"Dub" (Aortic / Pulmonic valve closure)
182
Heart sounds: S3
Abnormal "Kentucky"
| Excess filling of the ventricles most common in CHF
183
Heart Sounds: S4
Abnormal "Tennessee"
Blood being forced into stiff ventricle
Associated with Myocardial Infarction
