Cardiovascular Conditions Section 2 Flashcards
Which wave on an EKG represents depolarization of the atria and the firing of the SA node?
P wave
On an EKG, what represents depolarization of the ventricles? (AV node to ventricles)
The QRS complex
On an EKG, what may represent repolarization of the Perkinje fibers or a hypokalemia?
U wave
On an EKG, what represents repolarization of the ventricles?
T wave
What is cardiac output?
The amount of blood pumped by each ventricle in 1 minute
How do you calculate CO?
Stroke volume x HR per minute
What is the range of cardiac output for a normal adult at rest?
4-8L/min
What are the main factors influencing BP?
Cardiac Output x SVR (systemic vascular resistance) = BP
What is SVR?
Systemic Vascular Resistance; force opposing movement of blood in within vessels
What is the principal factor that determines SVR?
Radius of small arteries and arterioles
What happens when a-adrenergic receptors are stimulated by noepinephrine?
Vasoconstriction
What kind of receptors do blood vessels have?
a-adrenergic and b2-adrenergic
Where are b1-adrenergic receptors found?
In the heart
What neurotransmitter stimulates the b2-adrengergic receptors? What happens?
Epinephrine; vasodilation
Name where each adrenergic receptor is found and what happens when activated
a1:
- vascular smooth muscle; vasoconstriction
- heart; more contractility
a2:
- vascular smooth muscle; vasoconstriction
-presynaptic nerve terminals; inhibition of norepinephrine release
b1:
- Heart; Increased contractility and heart rate and conduction
- Kidney; Renin secretion
b2:
- Smooth muscle in blood vessels in heart; vasodilation
How does sodium contribute to blood pressure?
- Sodium attracts water
- Increases ECF volume
- This increases venous return to the heart and stroke volume
- Cardiac Output and Blood Pressure increase
What hormones secreted by the renal medulla have vasodilator effects?
Prostaglandins
What does Aldosterone do?
Stimulates kidneys to retain sodium and water
What is primary hypertension?
Elevated blood pressure without a known cause
What is secondary hypertension?
Elevated blood pressure with a cause that can be identified and corrected
What are 8 common causes of secondary hypertension?
1) Cirrhosis
2) Genetic defect of narrow artery
3) Drugs
4) Endocrine problems
5) Neurological problems
6) Pregnancy
7) Renal disease
8) Sleep apnea
What is the hemodynamic hallmark of hypertension?
Persistently increased systemic vascular resistance
Describe the different risk factors for hypertension?
Age
Alcohol: 2 drinks per day for males and 1 for females
Diabetes
Ethnicity: Higher in blacks
Sodium Intake
Family history
Gender: More common in men in young adulthood and middle age. More common in women after 64 years
Serum lipids: More common in pts with high cholesterol, triglycerides, and hyperlipidemia
Obesity
Sedentary Lifestyle
Socioeconomic Status: More common in poor and low educated populations
Stress
Tobacco
What does angiotensin do to the body?
Narrows blood vessels
Name the different types of antihypertensive drug classes, drugs, and nursing considerations
1) Central-Acting a-Adrenergic Agonists
a) clonidine; withdrawal syndrome if you suddenly stop taking it (hypertension, tachycardia, headache, tremors, apprehension, sweating)
b) guanfacine (same as above)
c) methyldopa May cause sedation so don’t drive and stuff
2) a1-Adrenergic Blockers
a) doxazosin; take at bedtime to reduce risk that comes with orthostatic hypotension
b) prazosin; (same as above)
c) phentolamine
3) b-Adrenergic Blockers (monitor pulse and BP regularly; use caution in patients with diabetes because it could hide tachycardia from low blood sugar; less effective in black patients)
a) all the drugs that end with -olol
4) ACE Inhibitors; Aspirin and NSAIDs may decrease effectiveness; adding a diuretic enhances effect but shouldn’t be used with potassium-sparing; can increase serum creatinine; may cause dry, hacking cough
a) benazepril
b) captopril
c) enalapril
d) fosinopril
e) lisinopril
5) Angiotensin II Receptor Blockers; may take 3-6 weeks to see full effects; should not be used with ACE inhibitors for patients with kidney disease
a) azilsartan
b) candesartan
c) irbesartan
d) losartan
e) olmesartan
f) telmisartan
g) valsartan
6) Calcium Channel Blockers; (A-B) use with caution in patients with heart failure; avoid grapefruit juice; avoid in patients with AV block & left ventricular systolic dysfunction. (C-I) more potent vasodilators; serious adverse events have occurred; IV nicardipine is effective for hypertensive emergencies
a) diltiazem
b) verapamil
c) amlodipine
d) clevidipine
e) felodipine
f) isradipine
g) nicardipine
h) nifedipine
i) nisoldipine
7) Direct Vasodilators
a) fenoldopam; IV used for hypertensive emergencies; use cautiously in patients with glaucoma; lay flat for 1 hour after admin
b) hydralazine; IV used for hypertensive emergencies; not used by itself due to side effects; Do not use in patients with CAD
c) minoxidil; reserved for use of severe hypertension combined with renal failure and resistance to other therapy
d) nitroglycerin; IV use for hypertensive emergencies with myocardial ischemia
e) sodium nitroprusside; IV use for hypertensive emergencies; Arterial BP monitoring recommended; wrap IV solutions in material to protect from light; metabolized to cyanide and then thiocyanate so you have to monitor thiocyanate levels
8) Aldosterone Receptor Blockers; monitor for hypokalemia and orthostatic hypotension; do not combine with potassium sparing and potassium supplements; use caution with ACE inhibitors;
a) Eplerenone
b) Spironolactone
9) Loop Diuretics; monitor for orthostatic hypotension; monitor for electrolyte values; less effective for hypertension
a) bumetanide
b) furosemide
c) torsemide
10) Potassium-Sparing Diuretics; monitor for orthostatic hypotension; monitor for hyperkalemia; contraindicated in patients with renal failure; use with caution in patients using ACE inhibitors or Angiotensin blockers; avoid potassium supplements
a) amiloride
b) triamterene
11) Renin Inhibitors; may cause angioedema in face, extremities, and in mouth; contraindicated in pregnant patients
a) aliskerin
12) Thiazides; monitor for orthstatic hypotension, hypokalemia; sodium restriction; NSAIDs can cause decrease effects and cause renal problems; each potassium-rich foods
a) chlorothiazide
b) chlorthalidone
c) hydrochlorothiazide
d) indapamide
e) metolazone
What is the preferred first-line therapy for patients with stage-1 hypertension?
Thiazide diuretic, a calcium channel blocker, and an ACE inhibitor
What classifies as resistant hypertension?
failure to reach BP goal in patients that are taking full doses of a 3-drug treatment that includes a diuretic
Should a patient double the dose of their anti-hypertensive medication if a dose is missed?
No
List the stages of hypertension
Normal: 120/80
Elevated: 120-129/<80
Stage 1: 130-139 / 80-89
Stage 2: 140+ / 90+
What are the 3 stages of atherosclerosis deevelopment?
1) Fatty streaks: lipid-filled smooth muscle cells found in coronary arteries
2) Fibrous plaque: plaque made up of lymphocytes, macrophages, and smooth muscle develops in inner walls of blood vessel
3) Complicated Lesion: plaque breaks up and forms a blood clot
Where do HDLs carry lipids? What is the process called?
Away from the arteries to the liver for metabolism; process is called reverse cholesterol transport which helps prevent lipid accumulation in artery walls
Why are LDLs considered the bad lipoproteins?
They are attracted to artery walls and contain more cholesterol than any of the other lipoproteins
What is Prinzmetal’s Angina?
Rare form of angina that occurs at rest without any increased physical exertion
What is refractory angina?
What is EECP and its benefits?
Enhanced External CounterPulsation; BP cuffs around the calves that inflate during diastole and deflate during systole to:
- Promote venous return
- Augment diastolic BP
- Increase coronary perfusion
- Improve LV filling
What is unstable angina?
What is ventricular remodeling?
How does ventricular fibrillation cause death?
What are the key signs of acute pericarditis?
Mild to severe chest pain that increases with inspiration, coughing, and movement of upper body. Often relieved by sitting forward
What is Dressler Syndrome?
Pericarditis and fever that develops 1-8 weeks after MI
What is the most common form of HF?
Left-sided heart failure
What are the two classifications of left-sided heart failure?
Systolic heart failure (HFrEF; reduced)
Diastolic heart failure (HFpEF; preserved)
What does LVEF stand for and what is a normal percentage?
Left ventricular ejection fraction; 55%-65%
How does HFrEF cause heart failure?
- Left ventricle does not generate enough pressure to eject blood through aorta
- Left ventricle dilates and hypertrophies
- Weakens heart which then cannot generate enough stroke volume causing cardiac output to decrease
- Blood backs up into left atrium causing fluid accumulation in the lungs
Describe HFpEF
- Ventricles are stiff and unable to relax and fill during diastole
- Decreased filling volume leads to decreased stroke volume and cardiac output
- Fluid accumulates in the body
What is the most common cause of right-sided HF?
Left-sided HF
What are the main compensatory mechanisms of HF?
1) Neurohormonal responses (renin-angiotensin -aldosterone system & sympathetic nervous system
2) Ventricular dilation
3) Ventricular hypertrophy
How does the renin-angiotensin-aldosterone system try to maintain homeostasis?
Goal is to increase preload and ventricular contractility to maintain cardiac output
- Kidneys sense falling CO
- Kidneys release renin which is converted to angiotensin I and then angiotensin II
- Angiotensin II vasoconstricts
- Stimulates water and sodium retention
- Stimulates aldosterone release which further retains sodium and water
-Sodium and water retention leads to higher blood pressure leading to increased cardiac output
Does does the sympathetic nervous system compensate for HF?
- Baroreceptors sense low arterial pressure
- Epinephrine & Norepinephrine are released which stimulate b-adrenergic receptors
- This increases HR and contractility
What is the Frank-Starling Law?
The strength of the heart’s contraction is directly proportional to its diastolic stretch
How does dilation compensate for heart failure?
The heart’s chamber become bigger. If they are bigger, they can hold more blood. When there is more blood, there will be more contraction to force the blood out. This will improve CO and maintain BP.
What is ADHF? What are the symptoms?
Acute Decompensated Heart Failure
Symptoms are similar to pulmonary congestion & edema and fluid overload
Describe the AHA stages of HF
A) High risk but no heart disease or symptoms
B) Heart disease is present but there are no signs or symptoms
C) Heart disease is present with prior or current symptoms
D) Advanced heart disease with continued HF
Describe the NYHA stages of HF
I: No limitation in physical activity
II: Slight limitation of physical activity. Comfortable at rest but ordinary activity results in symptoms
III: Marked limitation of physical activity. Comfortable at rest but less than ordinary activity causes symptoms
IV: Inability to do physical activity without discomfort. Symptoms may be present at rest
What are the symptoms of pulmonary edema?
- Dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Coughing
- Pale and/or cyanotic
- RR 30+
- Use of accessory respiratory muscles
- Pink, frothy sputum
- Wheezes and crackles
- S3 or S4 heart sounds
- Cool extremities
How are patients with ADHF categorized?
Dry-Warm
Wet-Warm
Dry-Cold
Wet-Cold
Describe what it means for a patient with ADHF to be Wet and Warm
Wet: Volume overload
Warm: Adequate perfusion
What is the most common presentation in a patient with ADHF? (Warm, Cold, Wet, Dry)
Wet and Warm
What are the signs of Right-Sided HF?
- Right ventricular heaves
- Increased heart rate
- Extreme general edema
- Ascites
- Hepatomegaly
- Jugular Vein Distention
- Murmurs
- Weight gain
What are the symptoms of Right-Sided HF?
- Anorexia
- GI Bloating
- Fatigue
- Nausea
- RUQ Pain
What are the signs of Left-Sided HF?
- Left Ventricular Heaves
- Increased HR
- S3 and S4 heart sounds
- Decreased PaO2
- Confusion, Restlessness
- Dry, Hacking cough
- Crackles
- Pleural Effusion
- Shallow respirations up to 32-40/min
- Frothy, pink-tinged sputum
What are the symptoms of Left-Sided HF?
- Anxiety, Depression
- Dyspnea
- Fatigue, weakness
- Nocturia
- Orthopnea
- Paroxysmal nocturnal dyspnea
What does PAWP stand for?
Pulmonary Artery Wedge Pressure
What value is considered a normal PAWP?
6-15 mmHg
What medication is first-line therapy for treating patients with fluid overload?
Diuretics
What is an inotropic drug?
A drug that affects the strength of the heart contraction
How do we measure the effectiveness of inotropic drugs?
Assess for:
-Improved cardiac output
- Blood pressure
- Urine output
- Reduced filling pressures
What are symptoms of Digoxin toxicity?
- Nausea, vomiting, diarrhea
- Yellow/Green visual discoloration, blurry vision, blind spots
- Bradydysrhythmias (less than 60 bpm), palpitations, dyspnea
What are major side effects of Ace Inhibitors?
- Hypotension
- Persistent dry cough
- Hyperkalemia
- Angioedema
What are major side effects of ARBs?
Similiar to Ace Inhibitors minus cough
Which 3 beta-blockers decrease mortality in patients with HFrEF?
1) Metoprolol Succinate
2) Bisoprolol
3) Carvedilol
What is a chronotropic drug?
A drug that changes the heart rate and rhythm
What is cor pulmonale?
Enlarging of the right ventricle due to lung problems
What is the difference between preload and afterload?
Preload: Stretching and filling of ventricles during diastole
Afterload: Pressure to pump against during systole
What are the main risk factors for Infective Endocarditis?
1) History of infective enfocarditis
2) IV drug use
3) Having a prosthetic valve
4) Infection from doctors putting in intravascular device
5) Renal dialysis
What are the 3 stages that infective endocarditis can develop into?
1) bacteremia
2) adhesion
3) vegetation
What are the manifestations of infective endocarditis?
1) Fever
2) Chills
3) Weakness
4) Fatigue
5) Anorexia
6) Splinter hemorrhages
7) Petechiae on conjunctivae, lips, buccal mucosa, palate, ankles, feet, and antecubital/popliteal area
8) Osler’s nodes on fingertips and toes
9) Systolic murmur
What is the Duke Criteria for the diagnosis of infective endocarditis?
0 major, 5 minor
1 major, 3 minor
2 major, 1 minor,
What are considered major criteria for the diagnosis of infective endocarditis?
1) Positive blood cultures
2) Typical microorganism for IE from 2 different blood cultures
3) Evidence of endocardial involvement
4) New valvular vegetation
What are considered minor criteria for the diagnosis of infective endocarditis?
1) Predisposing heart condition
2) IV drug use
3) Vascular phenomena
4) Immunologic phenomena
5) Microbiologic evidence
6) echocardiographic findings
What are some clinical manifestations of pericarditis?
1) Progressive, severe, sharp chest pain; often worse with deep inspiration and when lying flat; sitting up and leaning forward relieves the pain; pain may radiate to neck, arms, left shoulder, or trapezius muscle (makes it hard to know if it’s angina)
2) Dyspnea from trying to not breathe in too hard
3) Pericardial friction rub
How do you listen for a pericardial friction rub?
Lower left sternal border with the patient leaning forward. Ask the patient to hold their breath (since it is hard to tell a pericardial friction rub from a pleural friction rub)
What is pulsus paradoxus?
A large decrease in systolic BP during inspiration
Where is the most common site of PAD for patients without diabetes? Patients with diabetes?
Without: Femoral popliteal area
With: Below the knee
What is the classic symptom of PAD in the lower extremities?
Intermittent Claudication: Lactic acid buildup that causes pain during exercise, resolves within 10 minutes, and is reproducible
If someone has PAD in the iliac arteries, where would you expect pain?
Butt and thighs
What is a segmental BP done for and how is it done?
Done to diagnose PAD; a sphygmomanometer is placed at the knee, thigh, and ankle to measure a difference in BP using a Doppler
What are the 6 P’s of clinical manifestations of Acute Arterial Ischemia?
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Poikilothermia
What is poikilothermia?
When the limb adapts to the environmental temperature;
What is the first line treatment of Raynaud’s phenomenon?
Sustained-release calcium-channel blockers
