Cardiovascular System & Case Study

Question 1

Orthostatic hypotension

Answer 1

• Drop in blood pressure from sitting to standing
• Dizziness
• Increased risk for falls
• Fainting

Question 2

Cardiomegaly

Answer 2

• Enlargement of the heart
• Generally are weaker

Question 3

Sinus tachycardia with left bundle branch block

Answer 3

• Problem with the left branch of the heart that causes irregular electrical conductivity
• Fast heart rate
• Problem with conduction system
• Wide QRS intervals, dominant s wave in V1

Question 4

Most common cause for digoxin toxicity

Answer 4

• Hypokalemia - think diuretic therapy
• For older people specifically
• Lower body mass (especially muscle)
• Decreased glomerular filtration rate

Question 5

CS: CardioVascular Disease
You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M., a man who has been coming to the clinic for several years for management of coronary artery disease (CAD) and hypertension (HTN). A cardiac catheterization done a year ago showed 50% stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a chest x-ray (CXR) examination revealed cardiomegaly and a 12-lead electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block. You review J.M.’s morning blood work and initial assessment.

1.As you review these results, which ones are of possible concern, and why?

Answer 5

• Both hematocrit and hemoglobin are low; these results would indicate possible bleeding, which may lead to anemia. Anemia can lead to angina or aggravate heart failure symptoms. Low hemoglobin would also contribute to a decreased O2 saturation level because hemoglobin is responsible for carrying oxygen throughout the body.
• HR and BP are also high = complaining of increased symptoms - or there may be something else going on, on top of the cardiac problems.

Question 6

CS: CardioVascular Disease
You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M., a man who has been coming to the clinic for several years for management of coronary artery disease (CAD) and hypertension (HTN). A cardiac catheterization done a year ago showed 50% stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a chest x-ray (CXR) examination revealed cardiomegaly and a 12-lead electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block. You review J.M.’s morning blood work and initial assessment.

2. Knowing his history and seeing his condition this morning, what further questions are you going to ask J.M. and his daughter?

Answer 6

• What does your diet consist of
• What is your current weight ? have you been gaining or losing without trying
• Do you have any family history of HF
• What medications do you take
• Medication adherence / polypharmacy
• Do you drink alcohol or caffeine in excessive amounts
• Do you smoke
• What is your knowledge of HF
• Been under extra stress / is this affecting mood
• Is this affecting physical activity
• Any increase in swelling of feet/legs
• Elimination issues - fluids: how much do you drink daily? Urine output decreased? = Fluid retention
• Aeration: do you have a cough ? Is it productive ? What happens when you wake up gasping for breath ? How often does this happen ? How many pillows do you have ?
• Nutrition : has it changed lately ? What did you eat in the last 48 hours ? What are your favorite foods ?
• Communication : do you speak the same language ? Any auditory or visual problems that might affect communication ?
• Activity : what makes you tired ? Are there activities that affect your breathing ? Sleep problems ?
• Pain : are you expecting chest pain / discomfort / numbness in shoulders / arms / hands / neck / jaw ? How does it feel ? any other cardiac sensations ?
  Socialization : what support do you have at home ? Does it feel adequate ? How often do you leave the house ?

Question 7

CS Progress: J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and must lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on 2 pillows for the past 2 weeks. He has not salted his food since the provider told him not to because of his high blood pressure, but he admits having had ham and a small bag of salted peanuts 3 days ago. He states that he stopped smoking 10 years ago. He denies having palpitations but has had a constant, irritating, non-productive cough lately.

3. You think it’s likely that J.M. has heart failure (HF). From his history, what do you identify as probable causes for his HF?

Answer 7

• Unhealthy diet
• Hx of CAD, HTN - hypertension : heart is having to pump hard against the resistance in the vessels = cardiac muscle hypertrophy = cardiomegaly
• CAD : ischemic myocardium is not able to produce adequate stroke levels
• Anemia : decreases oxygen availability to all body tissues = heart responds by increasing blood flow = increasing oxygen demand of the heath = myocardial ischemia. Low Hct due to hemodilution
• Decreased Hgb, Hct - indication he might have anemia = risk factor for heart failure
• Enlarged heart
• Age

Question 8

CS Progress: J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and must lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on 2 pillows for the past 2 weeks. He has not salted his food since the provider told him not to because of his high blood pressure, but he admits having had ham and a small bag of salted peanuts 3 days ago. He states that he stopped smoking 10 years ago. He denies having palpitations but has had a constant, irritating, non-productive cough lately.

4. What is heart failure, possible risk factures and implications for health outcomes?

Answer 8

Heart failure: condition that develops when your heart doesn’t pump enough blood for your body’s needs. This can happen if your heart can’t fill up with enough blood. It can also happen when your heart is too weak to pump properly.

Possible risk factors:
- Metabolic syndrome
- Advanced age
- Tobacco use
- Vascular disease
- CAD

Implications:
- Damage liver or kidneys
- Pulmonary hypertension
- Irregular heartbeat
- Heart valve disease
- Sudden cardiac arrest

Question 9

CS Progress: J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and must lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on 2 pillows for the past 2 weeks. He has not salted his food since the provider told him not to because of his high blood pressure, but he admits having had ham and a small bag of salted peanuts 3 days ago. He states that he stopped smoking 10 years ago. He denies having palpitations but has had a constant, irritating, non-productive cough lately.

5. You are now ready to do your physical assessment. For each potential assessment finding for HF, indicate whether the finding indicates left-sided HF (L) or right-sided HF (R).
   ○ Weakness
   ○ Jugular (neck) vein distention
   ○ Dependent edema (legs and sacrum)
   ○ Hacking cough, worse at night
   ○ Enlarged liver and Spleen
   ○ Exertional dyspnea
   ○ Distended abdomen
   ○ Weight gain
   ○ S3/S4 gallop
   ○ Crackles and wheezes in lung

Answer 9

Weakness: Left
Jugular (neck) vein distention: Right
Dependent edema (legs and sacrum): Right
Hacking cough, worse at night: Left
Enlarged liver and spleen: Right
Exertional dyspnea: Left
Distended abdomen: Right
Weight gain: Right
S3/S4 gallop: Left
Crackles and wheezes in lungs: Left

Question 10

CS Progress:
Analapril (Vasotec) 10mg PO TID
Furosemide (Lasix) 20mg PO QAM
Carvedilol (Coreg) 6.25mg PO TID
Digoxin (Lanoxin) 0.5mg PO now, then 1.125mg PO Daily
Potassium Chloride (K-Dur) 10mEq tablet Once Daily
The provider confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written.

6. For each medication listed, identify its class and describe its purpose in treating HF.
   Enalapril : ACE inhibitor

Answer 10

Relaxes the blood vessels to lower blood pressure and increase the supply of blood and oxygen to the heart. Used commonly in patients with a reduced ejection fraction / to treat patients with heart failure.
ACE inhibitor to decrease blood volume and blood return to heart = decrease workload of the heart

Question 11

Analapril (Vasotec) 10mg PO TID
Furosemide (Lasix) 20mg PO QAM
Carvedilol (Coreg) 6.25mg PO TID
Digoxin (Lanoxin) 0.5mg PO now, then 1.125mg PO Daily
Potassium Chloride (K-Dur) 10mEq tablet Once Daily
The provider confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written.

6. For each medication listed, identify its class and describe its purpose in treating HF.
   Furosemide : diuretic

Answer 11

Used to help treat fluid retention / edema caused by heart failure. As well, it can help treat high blood pressure.

Loop diuretic = decrease fluid volume

Question 12

Analapril (Vasotec) 10mg PO TID
Furosemide (Lasix) 20mg PO QAM
Carvedilol (Coreg) 6.25mg PO TID
Digoxin (Lanoxin) 0.5mg PO now, then 1.125mg PO Daily
Potassium Chloride (K-Dur) 10mEq tablet Once Daily
The provider confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written.

6. For each medication listed, identify its class and describe its purpose in treating HF.
   Carvedilol : beta blocker

Answer 12

Slows down the heart rate, making it easier for your heart to pump blood around your body and prevent the heart from overworking. This can also reduce blood pressure and prevent angina through the widening of the blood vessels.

Question 13

Analapril (Vasotec) 10mg PO TID
Furosemide (Lasix) 20mg PO QAM
Carvedilol (Coreg) 6.25mg PO TID
Digoxin (Lanoxin) 0.5mg PO now, then 1.125mg PO Daily
Potassium Chloride (K-Dur) 10mEq tablet Once Daily
The provider confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written.

6. For each medication listed, identify its class and describe its purpose in treating HF.
   Digoxin : digitalis glycosides

Answer 13

Used to improve the strength and efficacy of the heart, or to control the rate and rhythm of the heartbeat. It leads to better blood circulation and reduced swelling of the hands and feet of patients with heart problems, especially HF.
Decreases myocardial contractility = enhances cardiac efficiency and output

Question 14

Analapril (Vasotec) 10mg PO TID
Furosemide (Lasix) 20mg PO QAM
Carvedilol (Coreg) 6.25mg PO TID
Digoxin (Lanoxin) 0.5mg PO now, then 1.125mg PO Daily
Potassium Chloride (K-Dur) 10mEq tablet Once Daily
The provider confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written.

6. For each medication listed, identify its class and describe its purpose in treating HF.
   Potassium chloride : electrolyte supplement

Answer 14

Used in the treatment of hypokalemia, often common in patients with HF. Ensuring our bodies have an adequate supply of potassium is essential because it helps our nerves and muscles function normally, which greatly impacts the functions of our heart.
As well, it also replaces the potassium that might be lost with the diuretic therapy

Question 15

Analapril (Vasotec) 10mg PO TID
Furosemide (Lasix) 20mg PO QAM
Carvedilol (Coreg) 6.25mg PO TID
Digoxin (Lanoxin) 0.5mg PO now, then 1.125mg PO Daily
Potassium Chloride (K-Dur) 10mEq tablet Once Daily
The provider confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written.

When you go to remove the medications from the automated dispensing machine, you see that carvedilol (Coreg CR) is stocked. Will you give it to J.M.? Explain.

Answer 15

I would not give it - I would call the pharmacy and see what is best to do.

This is because Coreg CR is an extended release Coreg. For J.M, they receive Coreg twice a day. If I gave Coreg CR BID it may be unsafe for my patient and not offer a therapeutic effect because I am giving my patient an inadequate dosage.

Question 16

Analapril (Vasotec) 10mg PO TID
Furosemide (Lasix) 20mg PO QAM
Carvedilol (Coreg) 6.25mg PO TID
Digoxin (Lanoxin) 0.5mg PO now, then 1.125mg PO Daily
Potassium Chloride (K-Dur) 10mEq tablet Once Daily
The provider confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written.

As you remove the digoxin tablet from the automated medication dispensing machine, you note that the dose on the tablet label is 250 mcg. How many tablets would you give?

Answer 16

I would administer 2 tablets
Because 250 mcg = 0.25mg and my patient needs 0.5mg of digoxin.

Question 17

Analapril (Vasotec) 10mg PO TID
Furosemide (Lasix) 20mg PO QAM
Carvedilol (Coreg) 6.25mg PO TID
Digoxin (Lanoxin) 0.5mg PO now, then 1.125mg PO Daily
Potassium Chloride (K-Dur) 10mEq tablet Once Daily
The provider confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written.

Based on the new medication orders, which blood test or tests should be monitored carefully? Explain your answer.

Answer 17

Potassium levels need to be monitored, for several reasons. The diuretic causes potassium to be excreted along with sodium and water, thus the potassium supplement is ordered. However, the ACE inhibitor causes retention of potassium and can lead to hyperkalemia.

Also affects digoxin toxicity susceptibility.

Question 18

CS Progress:
This is J.M.’s first episode of significant HF. Before he leaves the clinic, you want to teach him about life-style modifications he can make and monitoring techniques he can use to prevent or minimize future problems.

10. List 5 suggestions you might make and the rationale for each.

Answer 18

• Gradually increase and pace your activities to decrease the work requirements and oxygen demand of the heart
• Minimize stress to reduce sympathetic nervous system response to increased workload of the heart
• Avoid hot or cold environments; both increase cardiac demand
• Learn to take your pulse, call physician if pulse is less than 50 bpm, greater than 100 bpm, or very irregular
• Weigh yourself daily to monitor for fluid retention. Report a 2-5 pound weight gain over 1-4 days to your physician
• Carefully follow your salt-restricted diet to minimize fluid retention. Limit oral fluid intake to 2L daily.
• Take medications faithfully

Question 19

This is J.M.’s first episode of significant HF. Before he leaves the clinic, you want to teach him about life-style modifications he can make and monitoring techniques he can use to prevent or minimize future problems.

11. You tell J.M. that the combination of high-sodium foods he had during the past several days might have contributed to his present episode of HF. He looks surprised. J.M. says, “But I didn’t add any salt to them!” To what health care professional could J.M. be referred to help him understand how to prevent future crises? State your rationale.

Answer 19

• Refer to dietitian
• They can explain what foods are high in sodium, what foods to avoid, what foods to increase, and healthier food options.
• Just because you don’t add salt to food doesn’t mean it doesn’t already contain salt.

Question 20

This is J.M.’s first episode of significant HF. Before he leaves the clinic, you want to teach him about life-style modifications he can make and monitoring techniques he can use to prevent or minimize future problems.

12. After visiting with the cardiac dietitian, you review potential food choices with J.M. Which foods are high in sodium and must be avoided? Select all that apply.
    a. Canned soups
    b. Cheddar cheese
    c. Processed meats
    d. Whole wheat bread
    e. Fat-free fruit yogurt

Answer 20

A, B, C

Question 21

This is J.M.’s first episode of significant HF. Before he leaves the clinic, you want to teach him about life-style modifications he can make and monitoring techniques he can use to prevent or minimize future problems.

13. You also include teaching about digoxin toxicity. When teaching J.M. about the signs and symptoms of digoxin toxicity, which should be included? Select all that apply.
    a. Diarrhea
    b. Visual changes
    c. Increased urine output
    d. Loss of appetite or nausea
    e. Dizziness when standing up.

Answer 21

A, B, D