Cardiovascular

Question 1

Peripheral Venous Disease

Answer 1

-impairs blood flow in the veins (affects bloodflow TO the heart)

-Causes:
prolonged sitting or standing
obesity
pregnancy
thrombophlebitis

-Presentation:
brown discoloration
edema
statis ulcers (around ankles)

-Treatment:
ELEVATE legs
avoid crossing legs, constrictive clothing, tight socks
use compressive stockings

Question 2

Peripheral Arterial Disease

Answer 2

-impairs blood flow in the arteries (affects bloodflow AWAY from the heart)

-Presentation:
pain and cramping in legs when walking and resolves with rest (intermittent claudication = early stages)
calf muscle atrophy
leg skin is shiny with hair loss and thick toenails
necrotic ulcers
cool skin
numbness in toes
dependent rubor (dark red color of feet)

-Treatment:
weight loss
exercise therapy
tobacco cessation
meds: pentoxifylline and cilostazol
DANGLE LEGS (dang = A)

Question 3

Pacemaker

Answer 3

-surgically placed in the subcutaneous tissue of the chest
-do not raise arm above head until wound heals
- watch for hiccups (sign of dislodgement)
-avoid MRIs
- carry notifcation of pacemaker in wallet
- know set rate and check pulse DAILY
-loose-fitted clothing
-recognize and report signs of battery failure
-microwaves are ok
-no horseback riding until 8 weeks postop

-Types:
temporary (transvenous)
transcutaneous (skin, external for preparation of temporary)

Question 4

Myocardial Infarction

Answer 4

• myocardial tissue is destroyed due to reduced coronary blood flow and lack of oxygen (actual necrosis of heart muscle)
• causes: atherosclerotic heart disease and coronary artery embolism
• vital signs: tachycardic, hypotension, dyspnea
• labs: elevated myoglobin, elevated troponin I&T, elevated CK-MB enzymes
• ECG: elevated ST segment = necrosis STEMI get to cath lab immediately (depressed = ischemia)

Question 5

MI Lab Values

Answer 5

Myoglobin: 5 to 70 mcg/L
- Heme protein that helps transport oxygen
- Myoglobin is found in cardiac and skeletal muscle
- Myoglobin increases within 1-3 hours and peaks within 12 hours after the onset of MI symptoms
- Not very specific in indicating an acute cardiac event, but negative results may rule out an acute cardiac event

Troponin: 0 to 0.04 ng/mL
- Protein found in the myocardium
- Regulates the myocardial contractile process
- Three isomers of troponin (C,I and T)
- Troponin I and T specific to cardiac muscle
- An increase in the level of troponin can be detected within a few hours during acute MI, and remains elevated for as long as 2 weeks, so it can be used to detect recent past myocardial damage
- Elevated troponin can also indicate mechanical stress on the myocardium, such as from sepsis, heart failure, and respiratory failure

Creatine Kinase and Isoenzymes: 3 to 5% (5 to 25 IU/L)
- CK-MB (Cardiac Muscle)
- Cardiac specific isoenzyme found mainly in cardiac cells
- Increases when there has been damage to the cardiac cells
Indicator of acute MI; Level increases in a few hours and peaks within 24 hours
- CK-MM (Skeletal Muscle)
- CK-BB (Brain Tissue)

Question 6

Types of Heart Damage

Answer 6

Unstable Angina:
- Patient has clinical manifestations of coronary ischemia but ECG and biomarkers show no evidence of an MI

NSTEMI:
- Elevated biomarkers but no definite ECG evidence of AMI
- More stable, troponin is not that elevated (stable ST segment)

STEMI:
- Patient has ECG evidence of AMI (elevated ST segment)
- Elevated biomarkers (troponin)
- The one we worry about – deadly; get to cath lab STAT

Question 7

Pericarditis

Answer 7

• Inflammation of the pericardium
• commonly follows a respiratory infection

presentation:
- chest pressure
- pain worse with inspirations, coughing, and swallowing
- pericardial friction rub heard at left lower sternal border
- SOB
- relief of pain when sitting and leaning forward

Labs:
- cardaic enzymes (CK-MB) elevated
- ESR and CRP elevated
- positive strep cultures
- ECG shows elevated ST segment

Cardiac Tamponade:
- medical emergency where fluid accumulates in the pericardial sac
- dizziness, dyspnea, “tightness” in chest, pulsus paradoxus (decrease of 10mm Hg or more in systolic blood pressure during inhalation and sudden decrease in cardiac output), tachycardia, muffled heart sounds, and JVD, intracardiac and pulmonary artery pressures similar and elevated
- treatment: notify provider, administer fluids for hypotension, administer chest xray and ECG

Treatment:
- watch for signs of fever
- review ABGs, SaO2, chest-Xray, ECG
- listen for heart sounds (murmer or friction rub)
- administer oxygen
- administer antibiotics, atipyretics
- obtain throat cultures

Question 8

Heart Failure

Answer 8

Heart failure: heart doesn’t pump as well as it should due to diabetes, smoking, arrhythmias, heart attack
- elevated BNP (>100)
- increased BP
- dependent edema
- JVD or distended neck veins

Right Sided:
- JVD, elevated central venous pressure (vena cava), edema

Left sided:
- pink frothy sputum, elevated pulmonary artery wedge pressure, crackles in lungs, shortness of breath (dyspnea)
(left sided can cause right sided HF)