Chronic Cardiac Flashcards
1
Q
Beta-adrenergic blockers - Beta-blockers : action
A
block beta1 adrenergic receptors ( SNS ) found in cardiac muscle ; high dose - block beta2 in airways ( asthma & COPD !!! )
2
Q
BB & HF
A
reverse effects of sympathetic stimulation
3
Q
BB - SE
A
- Dizziness
2. Hypotension & bradycardia
4
Q
Angiotensin-converting enzyme (ACE) inhibitors - Key role in HF ( - pril )
A
inhibit renin-angiotensin-aldosterone mechanism - block conversion of angiotensin I to angiotensin II - prevents peripheral vasoconstriction; reduces blood volume ( inhibit aldosterone )
5
Q
Angiotensin II receptor blockers (antagonists) (ARBs)
A
Losartan (Cozaar) - no cough
6
Q
ACE inhibitors - SE
A
- Headache, dizziness
- Hypotension
- Persistent dry cough
- Hyperkalemia ( !!! K )
7
Q
Vasodilators
A
Hydralazine ( Apresoline )
8
Q
Vasodilators - action
A
act directly on arterial smooth muscles - produce peripheral vasodilation - lower BP , increase HR, increase CO
9
Q
Nitrates
A
- Isosorbide dinitrate ( Isordil )
2. Nitroglycerin ( Nitrostat )
10
Q
Nitrates - action
A
increases oxygenated blood flow to myocardium by dilating coronary and systemic blood vessels - pooling of blood in peripheral BVs - reduce preload & afterload & myocardial O2 demand
SE: Headache !
11
Q
Sympatholytics
A
- Methyldopa ( Aldomet )
2. Clonidine ( Catapres )
12
Q
Sympatholytics - action
A
stimulate alpha2 receptors in CNS to inhibit sympathetic cardio-accelerator and vasoconstrictor centers - decrease sympathetic outflow from CNS - decrease arterial pressure
13
Q
Alpha-adrenergic blocker
A
Prazosin ( Minipress )
14
Q
Alpha - adrenergic blocker - action
A
blocking the alpha1-receptors of vascular smooth muscle, thus preventing the uptake of catecholamines by the smooth muscle cells. This causes vasodilation and allows blood to flow more easily.
15
Q
Calcium-Channel blockers
A
- Nifedipine ( Procardia)
- Diltiazem ( Cardizem )
- Verapamil ( Isoptin )
- Amlodipine ( Norvasc )
16
Q
CCB - action
A
inhibit calcium ( contraction ) ion influx via slow channels into cells of myocardial and arterial smooth muscles - negative inotropic ; dilation !!!
17
Q
Cardiac glycosides
A
Digoxin ( Lanoxin )
18
Q
Cardiac glycosides
A
used primarily to treat HF ( & dysrhythmias); increase contractility - positive inotropic ; decrease conduction velocity via AV node ( negative dromotrope )
19
Q
Anticoagulants
A
- Heparin
- LMWH - Enoxaparin ( Lovenox) - SQ
- Warfarin (Coumadin )
20
Q
Warfarin ( Coumadin ) - oral - action - PT + INR
A
prevent conversion of vitamin K - decreasing its production in liver - reducing several clotting factors ; vitamin K - role in extrinsic pathway ( forms fibrin ) in clotting cascade.
21
Q
Foods high in Vitamin K
A
liver, cheese, egg yolk, leafy vegetables and oils
22
Q
Heparin - IV ( PTT)
A
role in intrinsic pathway - inhibits conversion of fibrinogen to fibrin - prevents formation of fibrin clot - inhibits thrombin ; given IV
23
Q
HF : DX
A
- Echocardiogram - determines ejection fraction
- EKG - electrical abnormalities
- CXR - size
- B-type Natriuretic Peptide ( BNP ) - elevated
24
Q
B-type Natriuretic Peptide (BNP)
A
neurohormone released by stressed ventricles ( fluid overload) - promote vasodilation and diuresis via Na loss in the renal tubules. Not strong enough !
25
Ejection fraction - to determine type of heart failure - echocardiogram - systolic vs diastolic
Volume of blood ejected with each contraction ; (EDV - ESV) / EDV ; normal 50-70 % ; systolic HF - drops below 40 %; diastolic - normal
26
HF: causes
1. Atherosclerosis - CAD - primary cause !!! - MI cause muscle necrosis and loss of contractility
2. HTN - increased afterload - increased workload of the heart
3. Valvular disease - difficult for blood to move forward
4. Severe anemia , hypoxia
5. Dysrhythmias
27
Right-sided HF causes
1. Left ventricular failure
2. Right ventricular MI
3. Pulmonary hypertension & COPD - cor pulmonale
28
HF - medications - IV drip
1. Nesiritide ( Natrecor )
2. Milrinone
3. Dobutamine - increase contractility and CO
4. Morphine
5. Nitrates
29
Phosphodiesterase 3 Inhibitor, positive inotropic + vasodilator ( decrease preload + afterload )
Milrinone
30
Natriuretic peptide; combats effects of epinephrine and norepinephrine ; vasodilator ; recombinant form of human B-type natriuretic peptide (hBNP)
Nesiritide ( Natrecor )
31
CAD - non-modifiable risk factors
1. Age - older
2. Gender - men up to age 65
3. Family hx
4. Race - Afro-Americans
32
CAD - modifiable risk factors
1. Elevated lipids
2. Hypertension
3. Smoking
4. Inactivity/ obesity
33
Lipids panel
Total < 200
1. triglyceride < 150
2. LDL < 130 ( < 100 high risk )
3. HDL > 45 ( higher better )
34
Smoking & CAD
1. Nicotine increases HR + causes vasoconstriction
| 2. Carbon monoxide circulating in the bloodstream - chemical injury to vessel wall
35
Exercise & CAD
1. AHA - 30 min/day
| 2. increase HDL + collateral circulation
36
CAD - contributing risk factors
1. Diabetes Mellitus
2. Stress - type A personality, hostility
3. High homocysteine levels - amino acid - damages lining of vessels
4. Metabolic syndrome - abdom. obesity, insulin resistance (FBS > 100 ) ; high lipids; hypertension .
37
CAD - DX
1. Exercise stress test
2. Echocardiogram
3. Transesophageal echocardiogram
4. Cardiac catheterization
38
Exercise stress test
EKG with exercise ; pt on treadmill - rate and incline gradually increased; drugs may be added to promote vasodilation and indicate compromised areas - Persantine + Dobutamine
Watch - ST elevation or depression - ischemia ; Stop - chest pain or EKG changes
39
Echocardiogram
ultrasound of heart ; assess ventricular walls, valves, cardiac output, ejection fraction of heart
40
Transesophageal Echocardiogram
Start IV
Tube passed down the throat into stomach ;
NPO prior
Check gag reflex ( tongue depressor) post test ;
41
Fluoroscopy
is an imaging technique that uses X-rays to obtain real-time moving images of the internal structures of a patient through the use of a fluoroscope.
42
Cardiac catheterization
invasive; fluoroscopy ; NPO; dye injected ( flushed, warm feeling) ; via groin or arm ( post - keep staright) ;
Shows blockages; can measure pressures and pumping ability of heart ; post - 4-6 hours in bed ; oral + IV fluids; monitor urine output (kidneys)
43
CAD - Diet recommendations
1. Fish - 2 x wk - omega-3 fatty acids
2. Salt < 2300 mg of sodium/day
3. Limit ETOH - 1 W; 2 M
4. Fiber 25 g
44
Antihyperlipidemics
1. Statins
2. Fibric acids
3. Bile acid sequestrants
4. Nicotinic acid
45
Statins ( - statin )
1. inhibit cholesterol synthesis in liver ( Monitor liver enzymes - baseline ; 6 mo later !!! ) ;
2. Reduce LDL + triglycerides
3. Increase HDL
SE - rare - muscle weakness; liver abnormalities ; take at night ( cholesterol synthesis)
46
Colestipol ( Colestid )
| Cholestyramine ( Questran )
Bile acid sequestrants
47
Bile acid sequestrants ( - choles )
Work in GI tract to bind ( !! may interfere with absorption of drugs and nutrients ) with bile acids ( excreted in stool ) - liver cells respond by sending cholesterol to maintain bile acid synthesis, lowering plasma levels of LDL cholesterol ; SE: GI symptoms - N/V
48
Clofibrate ( Atromid )
Gemfibrozil ( Lopid )
Fenofibrate ( Tricor )
Fibric acids
49
Fibric acids ( - fibr )
decreases VLDL - hepatic synthesis + secretion - which will reduce triglycerides ; increase HDL; SE - GI; may increase effects of anticoagulants + hypoglycemics
50
Niacin, Vitamin B3
Nicotinic acid
51
Nicotinic acid
water-soluble vitamin ; inhibits synthesis of LDL, VLDL; increase HDL ;
SE: - GI ; flushing ( upper torso and face)
Caution !!! liver disease and DM - liver enzymes !!!
Lower risk of MI ( pts that had MI)
52
Food sources high in niacin
dairy, meats, tuna, egg
53
Stable angina - classic
predictable - occurs with activity; consistent; relieved with rest
54
Unstable angina - preinfarction
can occur at rest; unpredictable
55
Prinzmetal's angina
occurs ta rest ; due to spasm of coronary artery and not plaque
56
Compensation - HF
1. Stimulation of the sympathetic NS
2. Vasopressin (ADH ) - post pituitary ( decreased cerebral perfusion)
3. Renin-Angiotensin System Activation - Aldosterone
57
HF - DX
1. Echocardiogram - EF
2. EKG
3. CXR - size of heart
4. BNP - elevated
58
Digoxin toxicity
level > 2 ng/ml ( 0.5-2 ) halos, nausea, anorexia; Monitor K ( provide foods if takes loop diuretic) ; apical 1 min;
59
Digoxin antidote for extreme toxicity
digoxin immune Fab - Digibind
60
Diuretics :
1. Thiazide - Hydrochlorothiazide (HCTZ)
2. Loop - Furosemide ( Lasix )
3. Potassium sparing - Spironolactone ( Aldactone)
61
CCB + HF
contraindicated with systolic HF
62
PE and HF - interventions - Prevent !!!
1. High-fowlers with legs dangling - decrease venous return
2. O2 - mask or intubated
3. Diuretics - Lasix - rapid
4. Morphine - small doses - decrease peripheral resistance, venous return, anxiety
5. Emotional support
6. Monitor - telemetry, I/O, VS
63
Stenosis
opening narrows
64
Regurgitation
valve does not completely close
65
Mitral stenosis
obstruction of blood from LA to LV - LA stretches ( hypertrophies - pulmonary conjestion - RHF
66
Mitral stenosis + regurgitation - cause
Rheumatic heart disease - rheumatic endocarditis
67
Mitral regurgitation
LA + LV dilate + hypertrophy - LHF - RHF
68
Mitral valve prolapse
functions normally - isn't closing properly ; PVCS, tachycardia; risk for endocarditis ; can progress to regurgitation; most asymptomatic
69
Aortic stenosis
difficult for LV to eject blood; sudden death; vascular collapse - angina, syncope, exertional dyspnea ! NTG is contraindicated
70
Aortic regargitation
blood flow back into LV - LV hypertrophy - decrease SV - weakness, SOB, fatigue ...
71
Valvular disorders DX
1. Echocardiogram
2. Transesophageal echo - detect stenosis or regurgitation
3. CXR - size of ventricles
72
Valvular disorders - reparative procedures - buys time
1. Balloon valvuloplasty
2. Valve commissurotomy
3. Annuloplasty
73
Balloon valvuloplasty
invasive ( cardiac cath lab ) ; catheter via groin or femoral vein - balloon inflated to enlarge mitral or atrial opening ; Monitor - bleeding, regurgitation, thrombi
74
Valve commissurotomy
open heart surgery ; only damaged area of valve removed ; thrombi ; debride calcium from leaflets
75
Annuloplasty
repair of annulus ( ring that is attached to leaflets) and leaflets - regurgitation is eliminated or greatly reduced
76
Valvular disorders - replacement procedures
1. Biological ( tissue ) valves
| 2. Mechanical valves
77
Biological ( tissue ) valves
cow or pig - Xenograft ; 6 weeks on Coumadin post op; life span for valve 7-10 years
78
Mechanical valves
Coumadin for the rest of the life; much more durable
79
Coumadin - INR - therapeutic range
2-3
80
Valvular disorders - post op teaching
1. Regular blood work to titrate Coumadin
2. Vitamin K foods teaching - keep steady
3. Report bleeding or bruising
4. Care of sternal incision
5. Avoid invasive dental procedures for 6 mo
6. Report changes in cardiac status
7. Medical alert bracelet
81
Protamine sulfate
antidote for heparin
82
INR - normal
1.3-2
83
aPTT - partial thromboplastin time, activated - heparin
30-40 sec
84
Dilated cardiomyopathy (DCM) - men + AA
chambers are larger - decreased contractile function; no increase in muscle wall size - blood remains in ventricle - causes backup
TX as for heart failure
85
Dilated cardiomyopathy causes
alcohol abuse; chemotherapy, viral infection; pregnancy; inflammation; poor nutrition
86
Hypertrophic cardiomyopathy (HCM)- genetic
heart muscle asymmetrically increases in size + mass - reduces size of ventricles - poor filling ; can block aorta - athletes who die suddenly
87
Hypertrophic cardiomyopathy TX
Beta- Adrenergic Blockers and Calcium Channel Blockers
| Contraindicated - vasodilators, diuretics, nitrates, cardiac glycosides
88
Restrictive cardiomyopathy
impaired ventricular stretching - stiff ventricles restrict filling during diastole ; No TX; SX- heart transplant; < 12 mo to live
89
DCM - SX
1. Cardiac transplant - preferred
| 2. Cardiomyoplasty - muscle wrapped around ventricles
90
HCM - SX
Ventricular septal myectomy - excision of hypertrophied tissue ; can take out mitral valve and replace it with smaller
91
Transplanted heart - is denervated
no longer connected via vagus nerve to autonomic NS; keeps consistent HR and responds slowly to exercise, stress, position changes - !!! orthostatic hypotension
92
Heart transplant - signs of rejection
SOB, fatigue, fluid gain, hypotension, decreased activity tolerance
93
Heart Transplant - immunosuppressants for life
Infection is major cause of death
94
Endocarditis - causes
1. Valvular disease
2. Prosthetic valves
3. Older pts
4. IV drug use
5. High risk invasive procedures
95
Endocarditis S/s
1. Fever with chills, night sweats, fatigue
2. Cardiac murmur
3. Anorexia and weight loss
96
Endocarditis - systemic embolization
1. Petechiae
2. Osler's nodes - PAINFUL, on pads of fingers or toes
3. Janeway's lesions - PAINLESS; red, purple, macules on fingers or toes
97
Pericarditis causes
1. Following MI - Dressler's syndrome ; or open heart surgery
2. Autoimmune cause - lupus
3. Lung cancer - result of chemo or radiation
4. Lung infection
98
Pericarditis S/s
1. Chest pain - left side neck, shoulder
2. Pain worse with deep inspiration
3. Eased when sitting and leaning forward
4. PERICARDIAL FRICTION RUB
Chronic - S/s of RHF
99
Pericarditis TX
1. NSAIDS, corticosteroids;
2. Antibiotics
3. Comfort - sitting upright, leaning forward
4. Pericardial drainage ( window)
100
Pericardila Effusion
fluid in pericardial space - constricts myocardium + impair ability to pump - can lead to cardiac tamponade
101
Cardiac Tamponade - S/s
1. Sudden onset - SOB, chest tightness, restless
2. Pulsus Paradoxus - SBP drops ( during inspiration) + DBP remains same
3. Distant heart sounds
4. Tychycardia
5. Decreased CO
6. Blood backing up - JVD
7. Circulatory collapse
102
Cardiac Tamponade - DX
EMERGENCY
1. Echocardiogram or x-ray to confirm
2. CVP, PA, PCWP all similar and elevated
103
Cardiac Tamponade - TX
Pericardiocentesis - needle inserted to drain fluid ; monitor for recurrence of tamponade following procedure
104
Myocarditis causes
may be associated with pericarditis, infection or due to metabolic or connective tissue disorder - Lupus
105
Myocarditis S/s
1. Fatigue, dyspnea, palpitations
| 2. Flu-like symptoms
106
Venous stasis ulcers - TX
1. Hydrocolloid dressings
2. Artificial skin products
3. Unna boot
107
Unna boot
for ambulatory pts; with venous stasis ulcers ; applied - affected limb from toes to knee; covered with elastic wrap ( hard like a cast); change 1/week;May be too tight ; bandage works because it is infused with a thick, creamy mixture of zinc oxide and calamine. This mixture helps to promote healing.
108
Peripheral arterial disease ( PAD) - cause,
1. atherosclerosis
| 2. blockage of the arteries that supply the lower legs + feet
109
PAD - S/s
1. Intermittent claudication - cramping pain; with activity; gone with rest; 50 % obstructed
2. Rest pain - late sign ; better when legs are down
3. Skin - rubor ( dpendent position), cyanotic, pallor, loss of hair, brittle nails, dry skin, ulcers, edema, gangrene (elderly)
110
PAD - DX
1. Arteriography - similar to cardiac cath; dye used
Noninvasive
2. segmental systolic BP - normal - BP in thigh + calf > BP in upper extremities ; arterial disease - BP in thigh and calf are lower.
3. Ankle-brachial index - ankle BP / brachial BP
4. Exercise tolerance test - asses when leg pain starts
111
PAD - non-surgical management
1. Exercise ( collateral circulation) - walk - pain - stop + rest - walk further ; contraindicated - severe pain, venous ulcers, gangrene
2. Position - keep legs below level of the heart ( swelling - elevate feet)
3. Don't cross legs, restrictive clothing; inspect feet daily
112
PAD - promote vasodilation
1. Warmth to extremity
2. No direct heat
3. Avoid cold, stress, caffeine, nicotine
113
PAD - Trental
1. Antiplatelet
2. Increase flexibility of RBC
3. Decrease blood viscosity
114
PAD - nonsurgical interventions
1. Percutaneous Transluminal Angioplasty - balloon
2. Laser assisted angioplasty
3. Atherectomy - rotary burr
Post procedure - bed rest 6-8 hrs; bleeding; distal pulses, vitals
115
PAD - surgical management and post-op care
Arterial revascularization : inflow ( larger) + outflow (smaller) - bypass graft (GABA)
1. Pain !!! throbbing - OK; ischemic ( like before) - clotted graft
2. Bed rest for 1 day - no bending ( hip or knee)
3. Vascular (neuro) checks - 1st hr - every 15 min ; then every hour !!!
116
Aneurysm - bulging out
localized dilation of a portion of an artery - abdominal aortic ( common) and thoracic aortic.
117
Aneurysm - causes
1. Arteriosclerosis - 85 %
2. Hypertension
3. Smoking
4. Hyperlipidemia
5. Genetic
6. Marfan syndrome - disorder of the connective tissue
118
Thoracic aortic aneurysm - S/s
1. SOB, hoarseness, difficulty swallowing
| 2. Rupture - sudden back or chest pain
119
Abdominal aortic aneurysm - S/s
1. Pain - abdominal, flank, back
2. Pulsation in upper abdomen - listen for bruit. Don't palpate !!!
3. Feeling of fullness after eating
4. Malaise + weight loss
120
Aneurysm - impending rupture - S/S
1. Sudden, severe back, abdominal pain
2. Pulsating abdominal mass
3. Hypovolemic shock
Sx !!! right away
121
Ruptured aneurysm - S/s
1. Hypotension
2. Diaphoresis
3. Decreased LOC
4. Oliguria
5. Loss of pulses
6. Retroperitoneal bleeding
122
Aneurysm - nonsurgical management
1. Monitor growth - CT scan every 6 mo
| 2. Maintain BP - antihypertensives
123
Aneurysm - surgical
Stent graft - to strengthen arterial wall !!! to avoid Aneurysmectomy - resection.
124
Aneurysm - post op
1. Graft occlusion - hypovolemia or renal failure
2. Rupture - hypovolemic shock
3. Paralytic ileus - abdominal distention ; N/V
4. MI
5. Spinal cord ischemia ( thoracic ) - asses sensation + motion
6. No heavy lifting or driving for 6 weeks
7. No pushing, pulling or straining
125
Aortic dissection
aorta tears and splits apart ; Due to poorly controlled hypertension ; blunt chest trauma, cocaine use.
126
Aortic dissection - S/s
1. Sudden - tearing chest pain radiating to back ( mistaken for MI )
2. Diaphoresis, pale, tachycardia
dx - ct scan ;
Complications - paraplegia ( decreased blood flow to spine ; renal failure ; CVA, MI.
127
Buerger's disease - Smoking
Inflammatory thrombotic disorder - affects small and medium arteries in distal arms and legs ; early sign - claudication in arch of foot, intermittent shock-like pain ; TX - Procardia (CCB)
128
Raynaud's disease
Vasospastic disorder - vasospasm precipitated by cold, emotional upset, caffeine, smoking ; Fingers - white then cyanotic with pain; TX: Procardia (CCB)
SX: sympathectomy ( cuts nerve fibers) ; can lose fingers
129
Venous disorders :
1. DVT
| 2. Chronic venous insufficiency ; complication - venous stasis ulcers
130
Chronic venous insufficiency - interventions
due to prolonged venous hypertension - stretches veins + damages valves - edema
1. Elevate legs 20 min 4-5 x per day ; elastic or compression stockings , sequentials
2. Buildup of waste - ulcers - Vitamin A+C and high protein to promote healing
131
Protamine sulfate
antidote for heparin
132
DVT - risk for PE ( if above knee )
due to venous stasis and endothelial damage; hypercoagulability of blood ;
133
DVT - S/s
1. Tenderness + pain - calf or groin
2. Unilateral edema
3. Warmth, redness, pain
4. Upper extremity - cyanosis
134
DVT - DX
1. Duplex - noninvasive - combines ultrasound and doppler
| 2. Venogram - invasive
135
DVT - TX
1. Anticoagulants
2. legs elevated
3. Compression hose
4. Measure calves and thighs
