Chronic Cardiac Flashcards
Beta-adrenergic blockers - Beta-blockers : action
block beta1 adrenergic receptors ( SNS ) found in cardiac muscle ; high dose - block beta2 in airways ( asthma & COPD !!! )
BB & HF
reverse effects of sympathetic stimulation
BB - SE
- Dizziness
2. Hypotension & bradycardia
Angiotensin-converting enzyme (ACE) inhibitors - Key role in HF ( - pril )
inhibit renin-angiotensin-aldosterone mechanism - block conversion of angiotensin I to angiotensin II - prevents peripheral vasoconstriction; reduces blood volume ( inhibit aldosterone )
Angiotensin II receptor blockers (antagonists) (ARBs)
Losartan (Cozaar) - no cough
ACE inhibitors - SE
- Headache, dizziness
- Hypotension
- Persistent dry cough
- Hyperkalemia ( !!! K )
Vasodilators
Hydralazine ( Apresoline )
Vasodilators - action
act directly on arterial smooth muscles - produce peripheral vasodilation - lower BP , increase HR, increase CO
Nitrates
- Isosorbide dinitrate ( Isordil )
2. Nitroglycerin ( Nitrostat )
Nitrates - action
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 !
Sympatholytics
- Methyldopa ( Aldomet )
2. Clonidine ( Catapres )
Sympatholytics - action
stimulate alpha2 receptors in CNS to inhibit sympathetic cardio-accelerator and vasoconstrictor centers - decrease sympathetic outflow from CNS - decrease arterial pressure
Alpha-adrenergic blocker
Prazosin ( Minipress )
Alpha - adrenergic blocker - action
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.
Calcium-Channel blockers
- Nifedipine ( Procardia)
- Diltiazem ( Cardizem )
- Verapamil ( Isoptin )
- Amlodipine ( Norvasc )
CCB - action
inhibit calcium ( contraction ) ion influx via slow channels into cells of myocardial and arterial smooth muscles - negative inotropic ; dilation !!!
Cardiac glycosides
Digoxin ( Lanoxin )
Cardiac glycosides
used primarily to treat HF ( & dysrhythmias); increase contractility - positive inotropic ; decrease conduction velocity via AV node ( negative dromotrope )
Anticoagulants
- Heparin
- LMWH - Enoxaparin ( Lovenox) - SQ
- Warfarin (Coumadin )
Warfarin ( Coumadin ) - oral - action - PT + INR
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.
Foods high in Vitamin K
liver, cheese, egg yolk, leafy vegetables and oils
Heparin - IV ( PTT)
role in intrinsic pathway - inhibits conversion of fibrinogen to fibrin - prevents formation of fibrin clot - inhibits thrombin ; given IV
HF : DX
- Echocardiogram - determines ejection fraction
- EKG - electrical abnormalities
- CXR - size
- B-type Natriuretic Peptide ( BNP ) - elevated
B-type Natriuretic Peptide (BNP)
neurohormone released by stressed ventricles ( fluid overload) - promote vasodilation and diuresis via Na loss in the renal tubules. Not strong enough !
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
HF: causes
- Atherosclerosis - CAD - primary cause !!! - MI cause muscle necrosis and loss of contractility
- HTN - increased afterload - increased workload of the heart
- Valvular disease - difficult for blood to move forward
- Severe anemia , hypoxia
- Dysrhythmias
Right-sided HF causes
- Left ventricular failure
- Right ventricular MI
- Pulmonary hypertension & COPD - cor pulmonale
HF - medications - IV drip
- Nesiritide ( Natrecor )
- Milrinone
- Dobutamine - increase contractility and CO
- Morphine
- Nitrates
Phosphodiesterase 3 Inhibitor, positive inotropic + vasodilator ( decrease preload + afterload )
Milrinone
Natriuretic peptide; combats effects of epinephrine and norepinephrine ; vasodilator ; recombinant form of human B-type natriuretic peptide (hBNP)
Nesiritide ( Natrecor )
CAD - non-modifiable risk factors
- Age - older
- Gender - men up to age 65
- Family hx
- Race - Afro-Americans
CAD - modifiable risk factors
- Elevated lipids
- Hypertension
- Smoking
- Inactivity/ obesity
Lipids panel
Total < 200
- triglyceride < 150
- LDL < 130 ( < 100 high risk )
- HDL > 45 ( higher better )
Smoking & CAD
- Nicotine increases HR + causes vasoconstriction
2. Carbon monoxide circulating in the bloodstream - chemical injury to vessel wall
Exercise & CAD
- AHA - 30 min/day
2. increase HDL + collateral circulation
CAD - contributing risk factors
- Diabetes Mellitus
- Stress - type A personality, hostility
- High homocysteine levels - amino acid - damages lining of vessels
- Metabolic syndrome - abdom. obesity, insulin resistance (FBS > 100 ) ; high lipids; hypertension .
CAD - DX
- Exercise stress test
- Echocardiogram
- Transesophageal echocardiogram
- Cardiac catheterization
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
Echocardiogram
ultrasound of heart ; assess ventricular walls, valves, cardiac output, ejection fraction of heart
Transesophageal Echocardiogram
Start IV
Tube passed down the throat into stomach ;
NPO prior
Check gag reflex ( tongue depressor) post test ;
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.
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)
CAD - Diet recommendations
- Fish - 2 x wk - omega-3 fatty acids
- Salt < 2300 mg of sodium/day
- Limit ETOH - 1 W; 2 M
- Fiber 25 g
Antihyperlipidemics
- Statins
- Fibric acids
- Bile acid sequestrants
- Nicotinic acid
Statins ( - statin )
- inhibit cholesterol synthesis in liver ( Monitor liver enzymes - baseline ; 6 mo later !!! ) ;
- Reduce LDL + triglycerides
- Increase HDL
SE - rare - muscle weakness; liver abnormalities ; take at night ( cholesterol synthesis)
Colestipol ( Colestid )
Cholestyramine ( Questran )
Bile acid sequestrants
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
Clofibrate ( Atromid )
Gemfibrozil ( Lopid )
Fenofibrate ( Tricor )
Fibric acids
Fibric acids ( - fibr )
decreases VLDL - hepatic synthesis + secretion - which will reduce triglycerides ; increase HDL; SE - GI; may increase effects of anticoagulants + hypoglycemics
Niacin, Vitamin B3
Nicotinic acid
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)
Food sources high in niacin
dairy, meats, tuna, egg
Stable angina - classic
predictable - occurs with activity; consistent; relieved with rest
Unstable angina - preinfarction
can occur at rest; unpredictable
Prinzmetal’s angina
occurs ta rest ; due to spasm of coronary artery and not plaque
Compensation - HF
- Stimulation of the sympathetic NS
- Vasopressin (ADH ) - post pituitary ( decreased cerebral perfusion)
- Renin-Angiotensin System Activation - Aldosterone
HF - DX
- Echocardiogram - EF
- EKG
- CXR - size of heart
- BNP - elevated
Digoxin toxicity
level > 2 ng/ml ( 0.5-2 ) halos, nausea, anorexia; Monitor K ( provide foods if takes loop diuretic) ; apical 1 min;
Digoxin antidote for extreme toxicity
digoxin immune Fab - Digibind
Diuretics :
- Thiazide - Hydrochlorothiazide (HCTZ)
- Loop - Furosemide ( Lasix )
- Potassium sparing - Spironolactone ( Aldactone)
CCB + HF
contraindicated with systolic HF
PE and HF - interventions - Prevent !!!
- High-fowlers with legs dangling - decrease venous return
- O2 - mask or intubated
- Diuretics - Lasix - rapid
- Morphine - small doses - decrease peripheral resistance, venous return, anxiety
- Emotional support
- Monitor - telemetry, I/O, VS
Stenosis
opening narrows
Regurgitation
valve does not completely close
Mitral stenosis
obstruction of blood from LA to LV - LA stretches ( hypertrophies - pulmonary conjestion - RHF
Mitral stenosis + regurgitation - cause
Rheumatic heart disease - rheumatic endocarditis
Mitral regurgitation
LA + LV dilate + hypertrophy - LHF - RHF
Mitral valve prolapse
functions normally - isn’t closing properly ; PVCS, tachycardia; risk for endocarditis ; can progress to regurgitation; most asymptomatic
Aortic stenosis
difficult for LV to eject blood; sudden death; vascular collapse - angina, syncope, exertional dyspnea ! NTG is contraindicated
Aortic regargitation
blood flow back into LV - LV hypertrophy - decrease SV - weakness, SOB, fatigue …
Valvular disorders DX
- Echocardiogram
- Transesophageal echo - detect stenosis or regurgitation
- CXR - size of ventricles
Valvular disorders - reparative procedures - buys time
- Balloon valvuloplasty
- Valve commissurotomy
- Annuloplasty
Balloon valvuloplasty
invasive ( cardiac cath lab ) ; catheter via groin or femoral vein - balloon inflated to enlarge mitral or atrial opening ; Monitor - bleeding, regurgitation, thrombi
Valve commissurotomy
open heart surgery ; only damaged area of valve removed ; thrombi ; debride calcium from leaflets
Annuloplasty
repair of annulus ( ring that is attached to leaflets) and leaflets - regurgitation is eliminated or greatly reduced
Valvular disorders - replacement procedures
- Biological ( tissue ) valves
2. Mechanical valves
Biological ( tissue ) valves
cow or pig - Xenograft ; 6 weeks on Coumadin post op; life span for valve 7-10 years
Mechanical valves
Coumadin for the rest of the life; much more durable
Coumadin - INR - therapeutic range
2-3
Valvular disorders - post op teaching
- Regular blood work to titrate Coumadin
- Vitamin K foods teaching - keep steady
- Report bleeding or bruising
- Care of sternal incision
- Avoid invasive dental procedures for 6 mo
- Report changes in cardiac status
- Medical alert bracelet
Protamine sulfate
antidote for heparin
INR - normal
1.3-2
aPTT - partial thromboplastin time, activated - heparin
30-40 sec
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
Dilated cardiomyopathy causes
alcohol abuse; chemotherapy, viral infection; pregnancy; inflammation; poor nutrition
Hypertrophic cardiomyopathy (HCM)- genetic
heart muscle asymmetrically increases in size + mass - reduces size of ventricles - poor filling ; can block aorta - athletes who die suddenly
Hypertrophic cardiomyopathy TX
Beta- Adrenergic Blockers and Calcium Channel Blockers
Contraindicated - vasodilators, diuretics, nitrates, cardiac glycosides
Restrictive cardiomyopathy
impaired ventricular stretching - stiff ventricles restrict filling during diastole ; No TX; SX- heart transplant; < 12 mo to live
DCM - SX
- Cardiac transplant - preferred
2. Cardiomyoplasty - muscle wrapped around ventricles
HCM - SX
Ventricular septal myectomy - excision of hypertrophied tissue ; can take out mitral valve and replace it with smaller
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
Heart transplant - signs of rejection
SOB, fatigue, fluid gain, hypotension, decreased activity tolerance
Heart Transplant - immunosuppressants for life
Infection is major cause of death
Endocarditis - causes
- Valvular disease
- Prosthetic valves
- Older pts
- IV drug use
- High risk invasive procedures
Endocarditis S/s
- Fever with chills, night sweats, fatigue
- Cardiac murmur
- Anorexia and weight loss
Endocarditis - systemic embolization
- Petechiae
- Osler’s nodes - PAINFUL, on pads of fingers or toes
- Janeway’s lesions - PAINLESS; red, purple, macules on fingers or toes
Pericarditis causes
- Following MI - Dressler’s syndrome ; or open heart surgery
- Autoimmune cause - lupus
- Lung cancer - result of chemo or radiation
- Lung infection
Pericarditis S/s
- Chest pain - left side neck, shoulder
- Pain worse with deep inspiration
- Eased when sitting and leaning forward
- PERICARDIAL FRICTION RUB
Chronic - S/s of RHF
Pericarditis TX
- NSAIDS, corticosteroids;
- Antibiotics
- Comfort - sitting upright, leaning forward
- Pericardial drainage ( window)
Pericardila Effusion
fluid in pericardial space - constricts myocardium + impair ability to pump - can lead to cardiac tamponade
Cardiac Tamponade - S/s
- Sudden onset - SOB, chest tightness, restless
- Pulsus Paradoxus - SBP drops ( during inspiration) + DBP remains same
- Distant heart sounds
- Tychycardia
- Decreased CO
- Blood backing up - JVD
- Circulatory collapse
Cardiac Tamponade - DX
EMERGENCY
- Echocardiogram or x-ray to confirm
- CVP, PA, PCWP all similar and elevated
Cardiac Tamponade - TX
Pericardiocentesis - needle inserted to drain fluid ; monitor for recurrence of tamponade following procedure
Myocarditis causes
may be associated with pericarditis, infection or due to metabolic or connective tissue disorder - Lupus
Myocarditis S/s
- Fatigue, dyspnea, palpitations
2. Flu-like symptoms
Venous stasis ulcers - TX
- Hydrocolloid dressings
- Artificial skin products
- Unna boot
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.
Peripheral arterial disease ( PAD) - cause,
- atherosclerosis
2. blockage of the arteries that supply the lower legs + feet
PAD - S/s
- Intermittent claudication - cramping pain; with activity; gone with rest; 50 % obstructed
- Rest pain - late sign ; better when legs are down
- Skin - rubor ( dpendent position), cyanotic, pallor, loss of hair, brittle nails, dry skin, ulcers, edema, gangrene (elderly)
PAD - DX
- Arteriography - similar to cardiac cath; dye used
Noninvasive - segmental systolic BP - normal - BP in thigh + calf > BP in upper extremities ; arterial disease - BP in thigh and calf are lower.
- Ankle-brachial index - ankle BP / brachial BP
- Exercise tolerance test - asses when leg pain starts
PAD - non-surgical management
- Exercise ( collateral circulation) - walk - pain - stop + rest - walk further ; contraindicated - severe pain, venous ulcers, gangrene
- Position - keep legs below level of the heart ( swelling - elevate feet)
- Don’t cross legs, restrictive clothing; inspect feet daily
PAD - promote vasodilation
- Warmth to extremity
- No direct heat
- Avoid cold, stress, caffeine, nicotine
PAD - Trental
- Antiplatelet
- Increase flexibility of RBC
- Decrease blood viscosity
PAD - nonsurgical interventions
- Percutaneous Transluminal Angioplasty - balloon
- Laser assisted angioplasty
- Atherectomy - rotary burr
Post procedure - bed rest 6-8 hrs; bleeding; distal pulses, vitals
PAD - surgical management and post-op care
Arterial revascularization : inflow ( larger) + outflow (smaller) - bypass graft (GABA)
- Pain !!! throbbing - OK; ischemic ( like before) - clotted graft
- Bed rest for 1 day - no bending ( hip or knee)
- Vascular (neuro) checks - 1st hr - every 15 min ; then every hour !!!
Aneurysm - bulging out
localized dilation of a portion of an artery - abdominal aortic ( common) and thoracic aortic.
Aneurysm - causes
- Arteriosclerosis - 85 %
- Hypertension
- Smoking
- Hyperlipidemia
- Genetic
- Marfan syndrome - disorder of the connective tissue
Thoracic aortic aneurysm - S/s
- SOB, hoarseness, difficulty swallowing
2. Rupture - sudden back or chest pain
Abdominal aortic aneurysm - S/s
- Pain - abdominal, flank, back
- Pulsation in upper abdomen - listen for bruit. Don’t palpate !!!
- Feeling of fullness after eating
- Malaise + weight loss
Aneurysm - impending rupture - S/S
- Sudden, severe back, abdominal pain
- Pulsating abdominal mass
- Hypovolemic shock
Sx !!! right away
Ruptured aneurysm - S/s
- Hypotension
- Diaphoresis
- Decreased LOC
- Oliguria
- Loss of pulses
- Retroperitoneal bleeding
Aneurysm - nonsurgical management
- Monitor growth - CT scan every 6 mo
2. Maintain BP - antihypertensives
Aneurysm - surgical
Stent graft - to strengthen arterial wall !!! to avoid Aneurysmectomy - resection.
Aneurysm - post op
- Graft occlusion - hypovolemia or renal failure
- Rupture - hypovolemic shock
- Paralytic ileus - abdominal distention ; N/V
- MI
- Spinal cord ischemia ( thoracic ) - asses sensation + motion
- No heavy lifting or driving for 6 weeks
- No pushing, pulling or straining
Aortic dissection
aorta tears and splits apart ; Due to poorly controlled hypertension ; blunt chest trauma, cocaine use.
Aortic dissection - S/s
- Sudden - tearing chest pain radiating to back ( mistaken for MI )
- Diaphoresis, pale, tachycardia
dx - ct scan ;
Complications - paraplegia ( decreased blood flow to spine ; renal failure ; CVA, MI.
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)
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
Venous disorders :
- DVT
2. Chronic venous insufficiency ; complication - venous stasis ulcers
Chronic venous insufficiency - interventions
due to prolonged venous hypertension - stretches veins + damages valves - edema
- Elevate legs 20 min 4-5 x per day ; elastic or compression stockings , sequentials
- Buildup of waste - ulcers - Vitamin A+C and high protein to promote healing
Protamine sulfate
antidote for heparin
DVT - risk for PE ( if above knee )
due to venous stasis and endothelial damage; hypercoagulability of blood ;
DVT - S/s
- Tenderness + pain - calf or groin
- Unilateral edema
- Warmth, redness, pain
- Upper extremity - cyanosis
DVT - DX
- Duplex - noninvasive - combines ultrasound and doppler
2. Venogram - invasive
DVT - TX
- Anticoagulants
- legs elevated
- Compression hose
- Measure calves and thighs
