CV Flashcards
QT prolongation may lead to…
torsades de pointes
causes of prolonged QT include
drugs - amiodarone, quinidine, haloperidol, procainamide
electrolyte problems - hypokalemia, hypocalcemia, hypomagnesemia
treatment for torsades VT
magnesium
what is the first letter of a pacemaker code?
chamber paced
what is the second letter of a pacemaker code?
chamber sensed
what is the third letter of a pacemaker code?
response to sensing
I = inhibits (pacer detects intrinsic cardiac activity and withholds its pacing stimuli)...demand D = inhibits and triggers (pacer detects intrinsic cardiac activity and fires a pacing stimulus in response) O = none
what does failure to pace look like?
no spikes when expected
what does failure to capture look like?
spikes without a QRS for ventricular pacing
what does failure to sense look like?
pacing in native beats
ICDs programmed to shock can…
defibrillate or synchronized cardiovert
ICDs programmed to burst pace can…
sense tachyarrhythmias, provide a series of beats faster than the tachyarrhythmia, then stop suddenly with hopefully the SA node recovering
ICDs can provide pacing for which arrhythmia?
bradyarrhythmias
S1 is caused by closure of which valves?
AV (mitral and tricuspid) valves
S1 is loudest where?
at apex of heart (midclavicular, 5th ICS)
which valves open during S1?
pulmonary and aortic valves
S2 is caused by closure of which valves?
semilunar valves (aortic and pulmonic)
S2 is loudest where?
at base of heart (right sternal border, 2nd ICS)
S2 splits when?
on inspiration; wide fixed splitting of S2 caused by RBBB
S2 is louder with what pulmonary issue?
PE
S3 is caused by…
a rapid rush of blood into a dilated ventricle
- pulmonary HTN and cor pulmonale
- mitral, aortic, or tricuspid insufficiency
S3 is associated with…
heart failure
ventricular gallop “Kentucky”
S4 is caused by…
atrial contraction of blood into a noncompliant ventricle
S4 is associated with…
myocardial ischemia, infarction, HTN, ventricular hypertrophy, aortic stenosis
atrial gallop “Tennessee”
pulse pressure is…
systolic - diastolic
normal is 40-60mmHg. i.e.,120/80
SBP is an indirect measurement of …
CO and SV
narrowing pulse pressure is…
a decrease of SBP with little change or increase in diastolic pressure
seen with severe hypovolemia or severe drop in CO
DBP is an indirect measurement of …
SVR
widening of pulse pressure is…
decrease in DBP
may indicate vasodilation, drop in SVR; seen in severe sepsis, septic shock; i.e.,100/38
coronary arteries are perfused when?
during diastole
murmurs of insufficiency (regurgitation) occur when valve is…
closed
murmurs of stenosis occur when valve is…
open
what valves are open/closed during systolic murmurs?
semilunar valves (A&P) are OPEN during systole (stenosis)
AV valves (M&T) are CLOSED during systole (insufficiency)
ventricular septal defect (which is most common with acute MI) may cause what kind of murmur?
systolic murmur
heard at sternal border, 5th ICS
what valves are open/closed during diastolic murmurs?
semilunar valves (A&P) are CLOSED during diastole (insufficiency) AV valves (M&T) are OPEN during diastole (stenosis)
papillary muscle dysfunction and rupture are heard loudest where?
at apex
varient/Prinzmetal’s angina - what is it? what causes it? when does it occur? what can precipitate it? troponin +/-? what medication can relieve chest pain?
- type of unstable angina associated with ST segment elevation
- due to coronary artery spasm with or without atherosclerotic lesions
- occurs at rest, may be cyclic
- may be precipitated by nicotine, ETOH, cocaine
- troponin (-)
NTG relieves CP, STs return to normal
where is the location of CAD if there are changes in II, III, aVF
RCA, inferior LV
where is the location of CAD if there are changes in V1, V2, V3, V4
LAD, anterior LV
where is the location of CAD if there are changes in V5, V6, I, aVL
circumflex, lateral LV
where is the location of CAD if there are changes in V5, V6
low lateral LV
where is the location of CAD if there are changes in I, aVL
high lateral LV
where is the location of CAD if there are changes in V1, V2
RCA, posterior LV
where is the location of CAD if there are changes in V3R, V4R
RCA, RV
what are some signs of reperfusion?
- CP relief due to fibrinolysis of clot
- resolution of ST segment deviations due to return of blood flow
- elevated troponin/CK-MB due to myocardial stunning when vessel opens
- repercussion arrhythmias (VT, VF, AIVR) due to stunning
what type of MI is associated with AV conduction disturbances: 2nd degree type I, 3rd degree heart block, sick sinus syndrome, and sinus bradycardia?
inferior MI
which type of MI may develop systolic murmur, mitral valve regurgitation secondary to papillary muscle rupture?
inferior MI
use beta blockers and NTG with caution in which MI?
inferior MI
S&S of RV infarct?
JVD, high CVP, hypotension, usually clear lungs, bradyarrhythmias, ECG with ST elevation in V4R
how to treat RV infarct?
fluids, positive inotropes
avoid preload reducers (nitrates, diuretics)
caution with BB due to hypotension
which type of MI will have reciprocal changes in lateral wall (I, aVL)?
inferior MI
which type of MI will have reciprocal changes (ST depression) in inferior wall (II, III, aVF)?
anterior MI
which type of MI may develop 2nd degree type II heart block or RBBB
anterior MI
which type of MI may develop systolic murmur and possible VSD?
anterior MI
Anterior/inferior MI has higher mortality?
anterior –> heart failure
bradycardia or tachycardia with inferior MI has higher mortality?
tachycardia
what are some complications of PCI?
STENT THROMBOSIS, RETROPERITONEAL BLEED, coronary artery perforation, distal coronary artery embolization, failure of stent deployment, intramural hematoma, stroke/TIA, arrhythmias, renal failure, MI, death
nitroprusside…when to use, what does it do, what to watch for when using?
used for hypertensive crisis/emergency
preload and after load reducer
watch for cyanide toxicity secondary to drug metabolite (thiocyanate); mental status change, tachycardia, sz, need for increase dose, unexplained metabolic acidosis
what are signs of systolic heart failure?
- dilated LV
- PMI shift to left
- mitral valve insufficiency
- EF <40%
- pulmonary edema due to poor ventricular emptying
- S3
- BP normal/low
- BNP elevated
what is the treatment for systolic heart failure?
- BB
- ACE inhibitors
- diuretics
- dilators
- aldosterone antagonists
- positive inotropes (increase strength of muscular contractions)
what are signs of diastolic heart failure?
- normal ventricular size
- hypertrophied ventricular walls and/or thick septum
- normal contractile function
- normal EF
- pulmonary edema due to high ventricular pressure
- S4 with HTN
- high BP
- BNP elevated
what is the treatment for diastolic heart failure?
- BB
- ACE inhibitors/ ARBs
- CCBs
- low dose diuretics
- aldosterone antagonists
what are some causes of right sided heart failure?
- acute RV infarct
- massive PE
- septal defects
- pulmonary stenosis/insufficiency
- COPD
- pulmonary HTN
- LV failure
what are some causes of left sided heart failure?
- CAD, ischemia
- MI
- cardiomyopathy
- fluid overload
- chronic, uncontrolled HTN
- aortic stenosis/insufficiency
- mitral stenosis/insufficiency
- cardiac tamponade
what are some signs of right sided heart failure?
- hepatomegaly
- splenomegaly
- dependent edema
- venous distention
- elevated CVP/JVD
- tricuspid insufficiency
- abdominal pain
what are some signs of left sided heart failure?
- orthopnea, dyspnea, tachypnea
- hypoxemia
- tachycardia
- crackles
- cough with pink, frothy sputum
- elevated PA diastolic/PAOP
- diaphoresis
- anxiety, confusion
what is the issue with dilated cardiomyopathy?
- systolic dysfunction, problem ejecting
- thinning, dilation, enlargement of LV chamber
- mitral valve regurgitation due to ventricular dilation
what symptoms can be seen with dilated cardiomyopathy?
- similar to systolic heart failure
- may need ventricular assist device (VAD), heart transplant
what is the issue with hypertrophic cardiomyopathy?
- diastolic dysfunction, problem filling
- increased thickening of the heart muscle and septum at the expense of the LV chamber
what symptoms can be seen with hypertrophic cardiomyopathy?
- symptoms similar to diastolic heart failure
- fatigue, dyspnea, chest pain, palpitations, s3, s4, pre syncope/syncope
dilated or hypertrophic cardiomyopathy is at increased risk for sudden cardiac death?
hypertrophic
S&S of cardiogenic shock in compensatory stage
- NARROW PULSE PRESSURE
- tachycardia
- tachypnea
- crackles, mild hypoxemia
- ABG with respiratory alkalosis or early metabolic acidosis
- anxiety, irritability
- neck vein distention
- S3, S4
- cool skin
- decreased UO
- lower than baseline BP
S&S of cardiogenic shock in progressive stage?
- hypotension
- worsening tachycardia, tachypnea, oliguria
- metabolic acidosis
- worsening crackles ad hypoxemia
- clammy, mottled skin
- worsening anxiety, or lethargy
cardiogenic shock treatment?
enhance effectiveness of pump:
- positive inotropes (avoid negative isotropy agents), vasodilators
decrease demand on pump:
- preload reduction
- after load reduction
- optimize oxygenation
- mechanical ventilation
- treat pain
- IABP for short-term support
- VAD may be used to longer periods of time than IABP
what is a ventricular assist device (VAD) used for?
used in the management of LV heart failure, cardiogenic shock, cardiac myopathies, and used in patients awaiting heart transplant
what are the benefits of IABP therapy?
inflation - increases coronary artery perfusion; inflates are dicrotic notch of the arterial waveform, beginning of diastole
deflation - decreases after load; deflates right before systole begins; determined by set trigger for deflation, R-wave of ECG or upstroke of the arterial pressure wave
what are some post-op CABG complications to look for?
TAMPONADE PERICARDITIS hemodynamic abnormalities arrhythmias electrolyte abnormalities bleeding pulmonary, renal, endocrine, GI pain, anxiety infection
what do you do during post op chest tube management?
- maintain patency - no dependent loops, only milk/strip if clots appear
- mediastinal tubes remove serosanguinous fluid from the operative site; pleural chest tubes remove air, blood, or serous fluid from the pleural space
- keep chest tubes lower than pt
- don’t clamp system unless changing the drainage system or there is a system disconnect
- if output >100 x 2hrs maintain hemodynamic stability, correct volume status, give blood products
what are some S&S to look for in cardiac tamponade?
- NARROWED PULSE PRESSURE
- PULSUS PARADOXUS - excessive drop in SBP during inspiration, cardiac muscle restriction due to tamponade, with inspiration, intrathoracic pressure increases, decreases venous return
- equalization of CVP, pulmonary diastolic and PAOP
- restlessness, agitation
- hypotension
- increased JVD
- muffled heart tones
- enlarged cardiac silhouette and mediastinum on CXR
which valve is at most risk for rupture due to trauma?
aortic valve because it’s most anterior in chest
what are some etiologies of pericarditis?
trauma (rare) viral after MI post-op cardiac surgery radiation idiopathic Dressler's syndrome - immune response after an MI, surgery, or traumatic injury
what are some S&S of pericarditis?
chest pain that worsens with inspiration dyspnea low grade temp increased sed rate *ST elevation in ALL leads cardiac tamponade post-MI, Dressler's syndrome
what is the treatment for pericarditis?
treat symptoms analgesics anti-inflammatory agents NSAIDs steroids abx monitor for worsening symptoms monitor for constrictive pericarditis monitor for cardiac tamponade
what are some etiologies for myocardial contusion?
trauma; worse outcome than pericarditis, broken vessels bleed into heart, cardiac dysrhythmias, death can occur within first 48 hours
what are some S&S of myocardial contusion?
signs of trauma chest pain that worsens with inspiration dyspnea low grade temp *ST elevation in area of injury
what is the treatment for myocardial contusion
monitor or arrhythmias
analgesics as needed
inferior MI is associated with what occlusion?
RCA
ST elevation is seen in which leads for inferior MI?
II, III, aVF
what blood vessel supplies the RV?
RCA (also supplies inferior wall of LV)
about 30% of inferior wall MI patients also have RV infarct
anterior MI is associated with what vessel occlusion?
LAD
ST elevation is seen in which leads for anterior MI?
V1-V4 precordial leads
myocardial ischemia or infarction can affect which valve function and lead to what?
mitral valve function and lead to acute mitral valve regurgitation
papillary muscle dysfunction is loudest where?
apex
papillary muscle rupture is loudest where?
apex
ventricular septal defect is be heard where?
sternal border, 5th ICS
class 1 heart failure is what?
extraordinary activity results in heart failure symptoms; ordinary activity doesn’t cause fatigue, dyspnea, palpitation, or anginal pain; no limitation of physical activity
class 2 heart failure is what?
ordinary activity results in heart failure symptoms; comfortable at rest; some limitation of physical activity
class 3 heart failure is what?
minimal activity results of heart failure symptoms; comfortable at rest, but less than ordinary activity causes HF symptoms; marked limitation of physical activity
class 4 heart failure is what?
resting causes HF symptoms; severe limitation of physical activity
what is the main cause of death for HF patients?
sudden arrhythmia; patients with class 2-4 HF are candidates for ICD
what will cause large, giant V-waves on the PAOP pressure tracing if the patient has a PA Cath?
mitral insufficiency
