Cardiovascular Conditions Flashcards
The ability of the heart to pump depends on what?
- Automaticity
- Excitability
- Conductivity
- Contractility
- Rhythmicity
List the components of the Perfusion Triangle and some potential dysfunctions impacting each corner
- Heart (Pump function)
- pump dysfunction → CHF
- Blood vessles (Container function)
- Container dysfunction → HTN causes vasoconstriction and ischemia. Anaphylaxis and septic shock cause vasodilation leading to lethal hypotension
- Blood (Content function)
- Content dysfunction → any kind of sustained hemorrhaging will cause loss of blood content. Gastric or slow cerebral bleeding can cause “silent” loss of blood content
List 4 coronary reflexes that help maintain CO
- Baroreceptors → mechanoreceptors located in IC, stimualtion results in vasodilation, decreased HR, and decreased contractility
- Bainbridge reflex → located in R atrial myocardium. Inc volume of right atrium = inc pressure on atrial walls. Results in increased HR and contracility
- Chemoreceptors → in carotid and aortic bodies can increase rate and depth of ventilation in response to CO2 levels and can also have cardiac effects
- Ergoreceptors → regulate hemodynamics by activating mechanosensitive afferents that can inhibit sustained vagal effects on the heart caused by increased HR during physical loading
During the cardiac eval what type of info about cardiac dysfunction should you ask for?
- presence of chest pain
- location, quality, characteristics of pain
- Angina
- Previous MI
- Medications
- History of cardiac conditions
- Syncope, dizziness
- Cardiac risk factors
What is included in the PT cardiac physcial examination ?
- Observation
- Palpation
- Edema Pitting scale
- Telemetry:
- BP
- MAP = (HR * SV) * SVR
- HR
- RR
- Pulse ox
- Asculation
Things to keep in mind when taking BP
- Pt position is important
- use same extremity for serial recordings
- be aware if pt has restrictions on UE for taking BP
- Measure for OH as indicated
- record preexertion, paraexertion, postexertion BP for ID BP response to activity
- be aware of meds that affect BP
What do you eval during the cardiac ascultation?
- valvular function
- rate
- rhythm
- valvular compliance
- ventricular compliance
Saying to help you remember where telemetry leads go (if they ever disconnect)
White on Right
White clouds over green grass
Black smoke over red fire
Chocolate in the middle close to the heart
List some ECG interpretations
- ST depression of 1-2 mm = ischemia
- ST elevation = MI
- T wave inversion = MI
- Prominent Q wave = MI
- Wide QRS = bundle branch block
why is A-Fib a concerning ECG finding?
it can lead to blood clots, HF and other complications
how does V-tach and V-Fib differ on an ECG strip?
V-tach is just a fast rate that looks relatively uniform
V-fib is erratic and quick and not uniform (it is also more dangerous)
What are PVCs and do you have to stop therapy if a pt has one?
PVCs - premature ventricular contraction
if they are unifocal that’s relatively normal in adults >65 so therapy can continue
if they multifocal you need to stop and let the pt rest as they can lead to V-tach
Elevated BNP is usually indicative of ______
Heart Failure
what is the difference between SaO2 and PaO2?
SaO2 = saturation of peripheral oxygen
PaO2 = parital pressure of O2, measurement of oxygen in arterial blood
In general keep SaO2 92% and higher (STOP activity if 89% or lower)
List some various classes of cardiac medications
- Antiarrhythmic agents
- Anticoagulants
- Antihypertensives
- Combo drugs for HTN
- Antiplatelet agents
- Lipid-lowering agents
- Positive iontrophes (pressors)
- Thrombolytics (i.e fibrinolytics)
List some common cardiac conditions
- Ischemia
- HTN
- ACS
- CAD
- Angina
- MI
- Rhythm and Conduction Disturbance
- Heart disease (valvuar, myocardial, pericardial)
- Heart Failure
What is ACS?
Acute Coronary Syndrome → includes a constellation of disorders that result in MI
CAD → Angina → MI
List and describe various types of rhythm and conduction disturbances
- Agonal rhythm → irregular <20 bpm, near death
- A-fib → most common arrthythmia. Can lead to syncope due to no atrial kick.
- V-tach → rate > 100 bpm, usually regular rhythm, most common after acute MI
- V-fib → choatic rate and rhythm, will lead to death if untreated
- Multifocal VT (torsades de pointes) → irregular rhythm and rate >150 bpm
- AV blocks → rhythm disturbance where electrical conduction from atria to ventricles is partially/completely blocked
what are some common causes of A-fib?
- CHF
- CAD
- HTN
there are several degrees to AV blocks, what is a significant cut off point we are interested in as PTs?
Second degree Type II and up have a higher risk for hemodynamic instability → PT is contraindicated at this point due to how unstable the patient is
List and describe specific cardiac conditions impacting the valves, myocardium, and pericardium
- Valvular disease → affects one or more of the 4 valves in the heart
- stenosis
- regurgitation
- prolapse
- Myocardial heart disease (cardiomyopathies) → affect heart muscle tissue
- dilated
- restrictive
- hypertrophic
- Pericardial herat disease → affect pericardium (pericarditis)
- cardiac tamponade
differentiate between the 3 different cardiomyopathies
- Dilated → ventricle is dilated, with marked contractile dysfunction of myocardium
- Restrictive → endocardial scarring of ventricles, decreased compliance during diastole and decreased contracile force during systole
- Hypertrophic → thickened ventricular myocardium, less compliant to filling, thus decreased filling during diastole
what is cardiac tamponade?
fluid collects between pericardial sac and myocardium which prevent the ventricles from filling, which become life threatening
normally caused by blunt trauma like a MVC
Beck’s triad results
what is Beck’s Triad?
- Jugular venous distension
- hypotension and elevated systemic venous pressure
- muffled heart sounds
what is heart failure?
pump dysfunction that reduces CO
most common etiology = cardiomyopathy
Classifications:
- L-sided HF
- R-sided HF
- High-output failure
- Low-output failure
- Systolic dysfunction
- Diastolic dysfunction
list some S/S of HF
- Cold, pale, possiblly cyanotic extremities
- Weight gain
- peripheral edema
- Jugular venous distension
- Tachypnea
- Crackles (rales)
- decreased exercise tolerance
- dyspnea
- paroxysmal noctural dyspnea
- orthopnea
- cough
- fatigue
List some methods for cardiac management of cardiac disease
- Revascularization and reperfusion of myocardium
- Ablation procedures
- Cardioversion
- Life vest
- Valve replacement
- AVR
- Cardiac transplant
list some methods used to achieve cardiac revascularization and reperfusion to the myocardium
- Thrombolyic therapy
- Percutaneous revascularization
- CABG
describe thrombolytic therapy as well as some indications and contraindications
- used for acute management strategy for pts experiencing MIs
- Indications → chest pain suggesting MI, elevated ST segment, bundle branch block
- Contraindicated in pts at risk for excessive bleeding
**typically used in conjunction w/other meds
What is percutaneous revascularization?
aka PTCA (percutaneous transluminal coronary angioplasty)
- balloon-tipped catheter threated into occluded artery
- balloon inflated to make artery patent once again
- endoluminal stent may be used to maintain patency
- rehab → often OP procedure
- consider these pts high risk
what is CABG?
Coronary Artery Bypass Graft → vascular graft is used to revascularize the myocardium when a coronary artery is occluded (saphenous veins, internal mammery artery, or radial artery)
two approaches:
- Standard → medain sternotomy → sternal precautions
- minimally invase → no sternal precautions
*post-op possibilities → mediastinal chest tube, external pacemaker, intravascuar catheters
Describe sternal precautions
- Purpose → reduce risk for sternal dehiscence
- Duration → ~8 weeks
- Restrictions → no UE pushing, pulling, OH reached (>90º), no lifting object >10 lbs, no resistive exercises of UE
- essentially arms are NWB
- Risk factors for dehiscence:
- obesity (often double wired), COPD, DM, smoking, PVD, repeat thoracotomy, female, pendulous breasts
what are ablation procedures?
used to remove/isolate ectopic foci in order to reduce rhythm disturbance
(radiofrequency ablation, maze procedure)
leg used for procedure must remain straight and immobile for 3-4 hrs
What is cardioversion?
procedures used to restore normal heart rhythm in tachycardia arrhythmic conditions
Cardiac pacemaker implantation vs automatic implantable cardiac defibrillator
what is a life vest? (pertaining to cardiac management procedures)
Personal external defibrillator
worn by patients at high risk of sudden cardiac arrest
two components: garment monitor
T/F: VADs are not terminal devices
FALSE
used to be a bridge to transplantation but now can be a terminal device to support either the R/L ventricle
what things should be considered when assessing chest pain?
- Characteristics of the pain
- Time of onset
- Duration of symptoms
- Vital signs
- Overall CV status
- Cardiac risk factors
- gastric, pulmonary disease, psychological disorders
what is the difference between stable and unstable angina?
- Stable
- usually predictable, episodic
- triggered by physical and/or psychological stressors
- occurs with constant frequency over time
- relieved by rest or nitroglycerin
- Angina
- new onset
- occuring at rest or minimal exertion
- progressive in nature w/increased frequency of episodes
- refractory to previously effective med
- more likely to lead to MI
What is the Marburg Heart Scale?
predicts liklihood of dx of CAD
at 3 of the following:
- 55+ in men, 65+ in women
- Known CAD or cardiovascular disease
- Pain not reproducible by palpation
- Pain worse with exercise
- Pts assumption that pain is cardiogenic origin
My pt reports chest pain! What do I do?
- stop the activity and let the pt rest in a position of comfort
- monitor vital signs and telemetry
- use angina rating scale and Canadian CV Society classification of angina according to impact on physical activity
- Determine if pain is cardiogenic or noncardiogenic, stable or unstable
- If pt prescribe NO, give one dose
- edu pt on difference between stable and unstable chest pain
what are some goals for cardiac PT interventions?
- assess hemodynamic response during self-care and functional mobility
- max activity tolerance
- pt/caregiver edu for activity/behavior modification
List some absolute indications to withhold PT intervention from a cardiac pt
- decompensated CHF
- second-degree heart block w/PVCs
- third-degree heart block
- >10 PVCs/min at rest
- Chest pain w/new ST segment changes
- new onset A-fib w/rapid ventricular responses at rest (HR>100 bpm)
list some relative indications to withhold or modify PT interventions from a cardiac pt
- resting HR > 100 bpm
- resting HTN >160 systolic and >90 diastolic
- hypotension at rest (<80 systolic)
- ventricular ectopy at rest
- A-fib w/rapid ventricular response at rest (HR > 100 bpm)
- Psychosis/unstable psych condition
things to keep in mind about HR when monitoring activity tolerance in a cardiac pt
- 20-30 beats increase from resting HR generally safe intensity level
- pts on beta-blockers → do not exceed 20 beats above resting HR
- AICD → target HR 20-30 beats below threshold rate on defibrillator
- Post-heart transplant → cannot use HR to prescribe exercise
- HHR (HR recovery) → difference between peak HR w/exercise minus HR at 60 seconds
things to keep in mind about BP when monitoring activity tolerance in cardiac pts
- normotensive systolic BP increases 5-12 per increase in METs
- Abnormal response:
- systolic decrease of 10 below resting
- systolic response of >180
- diastolic response of >110
- Use BP to gauge activity intensity for pts on pacemakers w/o rate modulation
List out MET values
- Sitting (at desk, watching TV, reading) → 1.3
- Standing → 1.8
- Home activity (folding and putting away laundry) → 2.3
- Home activity (moderate effort of cleaning) → 3.5
- brisk walk → 4.3
- Yardwork → 5.0
- Running (4.3 min/mile) → 23.0
what is the general guideline for intensity on the BORG RPE scale?
5 or less on 10 pt scale
13 or less on 6-20 scale
Other things to look at when monitoring activity tolerance
- heart sounds → onset of murmers, S3 heart sounds (potentially cardiac decline)
- breath sounds → presence or increase in bibasilar crackles (potentially indicates CHF)
- ECG rhythm → known baseline, most observed rhythm, which lead is monitored, reason for monitoring
list some phases/components to cardiac interventions
- Warm-up phase
- performed at lower level of activity than exercise program
- Conditioning phase
- often consists of functional mobility training and aerobic based conditioning
- Cool-down phase
- may consist of stretching or deep breathing
- Pt edu
- promote self-monitoring and symptom recognition
- establish safe and sustainable exercise program
- lifestyle modification
- med management
what is cardiac rehabilitation?
a long-term program to establish safe exercises and activity parameters
has 3 phases
describe Phase I of cardiac rehabiliation
- started as soon as pt is stable
- begins in inpatient setting (acute care, TCU, subacute, SNF)
- Goal → tolerate ADLs, walking functional distances, climbing stairs (1-4 METs) w/appropriate VS and no CV symptoms
- Edu about risk factors and lifestyle modifications ESSENTIAL
describe Phase II of cardiac rehabilitation
- early outpatient rehab
- usually starts about 2 weeks after cardiac event
- continues pt edu
- progresses exercises and activities
describe Phase III of cardiac rehabiliation
- maintenance and prevention
- usually begins 2-3 months after cardiac event
List some D/C considerations
- Prognosis/medical complications
- PLOF
- Social situation
- Home set-up
- equipment
- Setting
- Acute, LTAC, Subacute/TCU, SNF, Home with home PT, Home with OP
