CV module 1 Flashcards by Mikie Sarabia

Module 1: Review of Cardiovascular A & P and Pathophysiology

Anatomy and Physiology of the Heart
- The heart
o Muscular, _______(1) pump
o Sits _______(2) in chest
o Protective _______(3)
- Pair of _______(4)
- Pair of _______(5)
- 4 _______(6) valves
- _______(7) and veins
- Electrical _______(8) system

Answers:
1. hydraulic
2. left-middle
3. covering
4. atria
5. ventricles
6. unidirectional
7. Arteries
8. Conduction

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Pericardium
- Consists of two parts:
- _______(1) Portion: tough, loose-fitting, inelastic sac around the heart
- _______(2) Portion:
- Parietal layer: lining inside the _______(3) pericardium
- Visceral layer (_______(4)): adheres to the outside of the heart
- _______(5) Space: lies between the parietal and visceral layers

Answers:
1. Fibrous
2. Serous
3. fibrous
4. Epicardium
5. Pericardial

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Heart Wall
- Epicardium :
o outer layer of the heart wall; also called the _______(1)
- Myocardium:
o Thick, contractile, middle layer of specially constructed and arranged cardiac muscle cells
o If the myocardium is damaged this can cause a “myocardial _______(2)”
- Endocardium
o Lining of the interior of the myocardial wall and covers the trabeculae _______(3) (these help add force to the inward contraction of the heart wall)

Cardiac Muscle Fiber
- Principle location:
o wall of the _______(4)
- Principle function:
o _______(5) blood
- Type of control:
o _______(6)

Answers:
1. serous pericardium
2. infarction
3. carnae
4. heart
5. pumping
6. Involuntary

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Structural Features of the Cardiac Tissues
- Structural Features:
- Nucleus: Single (sometimes double); near the center of the cell
- Striations: _______(1)
- T tubules: large diameter; form _______(2) with the SR, regulate _______(a) entry into sarcoplasm
- Sarcoplasmic reticulum: less extensive than in skeletal muscle
- Cell junctions: intercalated disks (gap junctions and desmosomes)
- Contraction style: Syncytium (mass) of fibers compress the heart chambers in slow, separate contractions (does not exhibit tetanus or fatigue); exhibits _______(3)

Structural Features of the Cardiac Tissues
- Structural Features:
- Nucleus: Single (sometimes double); near the center of the cell
- Striations: _______(1)
- T tubules: large diameter; form _______(2) with the SR, regulate Ca(^{++}) entry into sarcoplasm
- Sarcoplasmic reticulum: less extensive than in skeletal muscle
- Cell junctions: intercalated disks (gap junctions and desmosomes)
- Contraction style: Syncytium (mass) of fibers compress the heart chambers in slow, separate contractions (does not exhibit tetanus or fatigue); exhibits _______(3)

Answers:
1. present
2. diads
a. Ca++
3. autorhythmicity

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Cardiac Myocyte Anatomy and Function
- Sarcolemma

_______(1) membrane of the cardiac muscle
o Bilayer lipid membrane containing ion channels (_______(2)), active and passive ion transporters (ATPase, _______(3)), receptors (beta, _______(4) cholinergic, adenosine), and transport enzymes (glucose transporter)
o _______(5) (“T”) tubules: deep invaginations, penetrate the myoplasm and facilitate rapid, synchronous transmission of cellular depolarization

Answers:
1. External
2. Na+, K+, Ca2+, Cl-
3. Na+/K+
4. muscarinic
5. Transverse

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Cardiac Myocyte
- Mitochondria: generates ATP required for contraction and relaxation
- _______(1): contractile unit of the cardiac myocyte
o Contains myofilaments in parallel-cross striated bundles of thin (actin, tropomyosin, troponin complex) and thick (myosin and proteins) fiber
o Connected in a series, have long and short axes and simultaneously shorten and thicken during contraction
o A-band contains _______(2) and thin filaments
o I-band contains _______(3) filaments only
o Z-line

Answers:
1. Sarcomere
2. thick
3. thin

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Functional Anatomy of the Heart
- Right and Left Atria
o 2 thin, overlying sheaths of muscle
o Oriented at right angles to each other
- Ventricles
o 3 interdigitating spiral muscle layers
- Deep _______(1)
- Superficial _______(2)
- Superficial _______(3)

Answers:
1. sinospiral
2. sinospiral
3. bulbospiral

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Atria (Receiving Chambers)
- Left and Right chambers separated by interatrial _______(1)
- Alternatively relax and contract to receive blood, then push it into the lower chambers
- Atria don’t need to generate great pressures to move blood small distances so the myocardial wall of each atria is _______(2)
- _______(3)

Answers:
1. septum
2. thin
3. Auricle

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Supporting Role of the Atria
- Facilitate transition between low pressure venous to high pressure arterial blood flow
o _______(1)
o _______(2)
- _______(3) chambers
- Atrial contraction
- Establishes final ventricular SV at end-diastole (normally contributes _______(4) of this volume)
- Absent or ineffective (_______(5)/Flutter)
- Increased activity or stress may decrease/limit CO (decreased ABP, fatigue, syncope, exertional dyspnea or acute heart failure)

Answers:
1. Reservoirs
2. Conduits
3. Contractile
4. 15-20%
5. Afib

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Functional Anatomy of the Heart
- Ventricular Muscle Layers
o _______(1) and _______(2) layers: perpendicular, oblique, and helical routes from the base to the apex
- Shorten the longitudinal axis of the LV
- Pulls the _______(3) of the heart toward the base
- Systolic “twisting” or “wringing” motion of the fibers
- _______(4)-myocardium: circumferential layers
o Reduce the _______(5) diameter
o Constricts the lumen, especially the LV

Answers:
1. Subendocardial
2. Subepicardial
3. apex
4. Mid
5. LV

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Ventricles (Pumping Chambers)
- Right Ventricle
o Large volumes of blood, movement at low pressure
o Free wall of the RV shortens against the IV septum and LV
o Receives venous blood from the RA via the _______(1) and _______(2)
- Low pressure _______(3) mmHg
- O2 saturation _______(4)%
o Blood flows from the RV through the pulmonary circulation (low resistance)
o Unable to generate the same magnitude of stroke work as the LV
o Accommodates volume overload more easily than LV

Left Ventricle
o _______(5) pressure system
o LV stroke volume (SV) is equal to the RV
o Pressure-volume work (stroke work) is _______(6)
o Thicker myocardium

Answers:
1. SVC
2. IVC
3. 2-10
4. 60-70
5. High
6. 4.5-7X >RV

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Valves (Unidirectional Flow Valves)
- Atrioventricular Valve:
o _______(1) Valve
o _______(2) Valve
- Semilunar Valves:
o _______(3) valve
o _______(4) Valve

Answers:
1. Tricuspid
2. Mitral
3. Pulmonary
4. Aortic

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Palpable Point of Maximal Impulse (PMI)
- Point in the chest where impulse of left ventricle is strongest
- Also called the _______(1) Impulse
- Normally palpable
o _____A.Intercostal space (ICS)
o _______(2) line
- PMI not where it _______(3) be?
o lateral or below 6th ICS can mean _______(4)
o Greater than 2cm in size: _______(5) or dilation
o Right sternal border: _______(6) or situs inversus

Anatomy of Coronary Blood Flow (CBF)
- Myocardial blood supply entirely from Right and Left Coronary Art.
- Blood flows from epicardial to endocardial vessels
- Coronary sinus and Anterior cardiac veins
Thesbian veins

Answers:
1. Apical
A. 5th
2. Midclavicular
3. should
4. ventricular enlargement
5. ventricular hypertrophy
6. dextrocardia

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Mechanics of Coronary Blood Flow (CBF)
- Blood flow to the LV
o Directly dependent on the difference between _______(1) and the _______(2) (CPP)
o Inversely related to the _______(3) to flow
- Coronary Perfusion Pressure (CPP)= _______(4)
o Difference between the _______(5) pressure and the ____ pressure
o Art. Diastolic pressure is more important than MAP in determining myocardial blood flow
- Reduced CPP
o Decreased _______(6) pressure?
o Increased_______(7) pressure?
o Increase in _______(8) (reduction in diastolic time) vs?
- During contraction, intramyocardial pressures in the LV get close to systemic arterial pressure
- When that happens, the force of LV contraction can almost totally occlude the intramyocardial portion of the coronary arteries
- _______(9) is almost completely perfused during diastole
- _______(10) is perfused during systole and diastole
- Greatest intramural pressure during systole affects the a.____ thus making it most vulnerable to ischemia during decreases in Coronary Perfusion Pressure (CPP)

Answers:
1. Aortic pressure
2. LVEDP
3. vascular resistance
4. Arterial diastolic pressure –LVEDP
5. Aortic and Ventricular
6. Aortic pressure
7. LVEDP
8. HR
9. LV
10. RV
a. endocardium

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Control of Coronary Blood Flow
- Coronary Blood flow normally _______(1) ml/min (average adult male)
- Myocardium regulates perfusion pressures between _______(2) mm Hg, beyond that blood flow becomes pressure dependent
- Changes in blood flow
o Hypoxia: causes coronary vasodilation
o Sympathetic stimulation increases myocardial blood flow from increased demand and _______(3) predominance activation (receptor?)
o _______(4) and _______(5) present in coronary arteries (receptors?)

Answers:
1. 250
2. 50-120
3. B2
4. Alpha1
5. Beta2

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Myocardial Oxygen Balance
- Myocardial oxygen balance is determined by the ratio of oxygen supply to oxygen demand.
- Myocardium extracts _______(1) the oxygen in arterial blood
- Increasing oxygen supply by increasing either arterial oxygen content or coronary blood flow leads to increase in tissue oxygen levels
- Increasing demand alone without increasing CBP (stenosis) ____2. tissue oxygen level

Factors Affecting Myocardial O2 Supply-Demand Balance
Supply
- Heart rate
- CPP
- Arterial O2 content
- Arterial O2 tension
- Hb concentration
- _____3. of Coronary Vessel

Demand
- Basal Requirements
- Heart Rate
- Wall Tension
- Preload
- Afterload
- Contractility

Answers:
1. 75-80%
2. decreases
3. Diameter

Cardiac Conduction System Components
- SA or sinoatrial node: Natural pacemaker of the heart, sends off the initial electrical impulses to the atria. Rate: _______(1)
- AV or atrioventricular node: Conducts electrical impulses conducted in the atrial along to the ventricles. Rate: _______(2)
- Bundle of His: Electrical impulses from the ventricles continue to be conducted through these firing areas. The Bundle of His divides into the right and left bundle branches several centimeters from the AV node. Rate: Does not usually function as a _______(3)
- Left andright bundle branches: The left bundle branch has two divisions and is thicker than the right bundle branch. The right and left bundle branches eventually divide into the Purkinje fibers. Rate: Does not usually function as a _______(4)
- Purkinje fibers: The Purkinje fibers have the fastest conduction rate within the entire heart muscle. They ensure that
all cells depolarize. Rate: < _______(5)

Answers:
1. 60-100
2. 40-60
3. pacemaker cell
4. pacemaker cell
5. 40

Cardiac Events: P wave

Atrial depolarization and contraction
Deflection caused by the passage of an electrical impulse from the SA node through the muscle of both atria
P wave abnormalities often reflect atrial enlargement
Normal: ______(1) sec (PRI: .12-.20 sec)

Cardiac Events: QRS complex
- Depolarization and contraction of the ______(2) (ventricular systole)
- AV node fires
- Includes depolarization of the interventricular septum
- Normal measurement: <______(3) sec

Cardiac Events: T wave
- ______(4) repolarization
- QT interval
- ST interval: following the QRS to beginning of ______(5)

Answers
1. .08-.11
2. ventricles
3. .10
4. Ventricular
5. T

Cardiac Cycle
- Atrial Systole
- Isovolumetric Ventricular contraction
- Ejection
- Isovolumetric ventricular relaxation
- Passive Ventricular relaxation

Atrial Systole
- Begins with the ______(1) wave (passage of electrical wave of depolarization)
- Followed by Atrial contraction or systole
- Contraction force of the atria creates a pressure gradient (high to low)
- Pressure gradient drives the movement of blood and also keeps the ____a. valves open
- Ventricule relaxed and filling with blood
- ______(2) valves are closed

Answers
1. P
a. AV
2. Semilunar

Isovolumetric Ventricular Contraction
- Onset of ventricular _______(1)
- Coincides with the _______(2) of the ECG and ______(a) heart sound
- Iso (equality or uniformity)- Volumetric (measurement of volume)
- Intraventricular pressure begins to increase
- Ventricular pressure > Atrial pressure

Ejection
- Semilunar valves open
- Pressure in the ventricles exceeds pressure in PA/Aorta
- Rapid ejection
- Reduced ejection
- ______(b) volume: blood that remains in the ventricles at the end of the ejection period
- In heart failure, residual may exceed that ejected during systole

Isovolumetric Ventricular Relaxation and Passive Ventricular Filling
- Isovolumetric Ventricular Relaxation
- Ventricular _______(3)
- Between closure of the Semilunar valves and opening of the AV valves
- 2nd heart sound from the SL valves snapping shut
- Both sets of valves are closed and ventricles are relaxing
Passive Ventricular Filling
- Intraventricular pressure drops and intra atrial pressure increases
- AV valves open

Answers
1. systole
2. R
a. 1st
b. Residual
3. diastole

Primary Principles of Hemodynamics
- ______(1) gradients
- P1-P2

Cardiac Cycle
- Defined by electrical and mechanical events
- Contraction of the atria contributes ______(2) of ventricular filling
- Waves of the ______(3) pressure tracing

RA Waveform (CVP) and ECG

______(4) wave – occurs with atrial contraction(absent in AFIB)

______(5) wave – occurs with closure of the tricuspid valve

______(6) wave – due to blood filling the atrium when the tricuspid valve is closed (Enlarged in tricuspid regurg)

Answers
1.Pressure
2. 20-30%
3. atrial
4. a
5. c
6. v

Right Atrial (RAP) Waveform
- Normal Value ______(1) mmHg
- Right Atrial Pressure = ______(2)
- Wave Fluctuations due to ______(3)

Right Ventricular (RV) Waveform
- Normal Value ______(4) mmHg
- Catheter in the ______(5) may cause ventricular ectopy

Pulmonary Artery (PA) Waveform
- Normal Value ______(6) mmHg
- Dicrotic notch represents ______(7) Valve closure
- PA diastolic pressure approximates PA wedge pressure which approximates ______(8) filling pressure (in absence of lung or MV disease)

Pulmonary capillary wedge pressure (PAWP)
- Normal value ______(9) mmHg
- Catheter wedges in ______(10) artery
- ______(11) = left atrial pressure = left ventricular diastolic pressure

Answers
1. 0-8
2. CVP
3. contractions
4. 15-25/0-8
5. RV
6. 15-25/8-15
7. Pulmonary
8. LV
9. 8-12
10. distal pulmonary
11. PAWP

General Principles and Definitions

Cardiac Output (CO)
- Amount of blood that flows out of the ventricle per unit time
- CO = _______(1) × _______(2)
Stroke Volume (SV)
- volume pumped per _______(3)
- SV = _______(4) - _______(5)
- Fick’s _______(6) to compute CO
_______(7) Volume (EDV): amount of blood in the heart at the end of diastole
_______(8) Volume (ESV)

Answers:
1. Stroke Volume (SV)
2. Heart Rate (HR)
3. heartbeat
4. End-Diastolic Volume (EDV)
5. End-Systolic Volume (ESV)
6. formula
7. End-Diastolic
8. End-Systolic

Factors that Affect Stroke Volume

Starling’s law of the heart:
- ability of the heart to change its force of contraction and therefore stroke volume in response to changes in venous return (HR _______(1))
Changes in ventricular preload leads to changes in _______(2)
Ventricular Preload is _______(3) at beginning of systole
EDV is directly related to the degree of _______(4) of the myocardial sarcomeres

Answers:
1. stays constant
2. SV (Stroke Volume)
3. EDV (End-Diastolic Volume)
4. stretch

Factors that Affect Stroke Volume - Contractility (Inotropic) - Ejection Fraction (EF) - Ratio of SV to the end-diastolic volume (EDV) - EF = _______(1) - Normal about _______(2) - Afterload: - Pumping work that the heart must do to push blood into the arteries - Wall motion abnormalities - Valvular dysfunction Stroke Volume A. Normal SV B. Normal EDV, ↑ Contraction(_______(3)) C. ↑EDV, normal contraction (Starling’s law of the heart) D. ↑EDV, ↑contraction(_______(4))

Answers: 1.(SV/EDV) × 100 2. 55% 3. EPI 4. EPI

Afterload equated with: - Either Arterial impedance to ejection or Ventricular wall tension during systole - Ventricular wall tension during systole: - Pressure the ventricle must overcome to reduce its cavity - The _______(1) the ventricular radius, the greater wall tension required to develop the same ventricular pressure - Increases in wall thickness _______(2) ventricular wall tension - Laplace’s Law

Answers: 1. larger 2. reduces

Laplace’s Law - Ventricular wall tension - Wall tension (T) = ______(a) - P: _______(1) pressure - R: _______(2) of the chamber - h: thickness of the chamber wall - Wall tension is the pressure the ventricle needs to overcome to_______(3) its cavity volume

Answers: a. P×R/2h 1. intracavity 2. radius 3. reduce

Afterload - Resistance the blood in the _______(1) must overcome to force the valves open and eject contents to circulation - Inversely related to _______(2) - Factors that increase afterload: - High BP/Systemic resistance - _______(3) heart condition? - MI/Cardiomyopathy - Factors that decrease afterload: - Decreased volume, end stage _______(4) - vasodilators - Afterload of the RV - Indirectly assessed as _______(5) - Normal PVR: ___a dynes - Afterload of the LV - Indirectly assessed as _______(6) - Normal SVR: ____b dynes

Answers: 1. ventricle 2. stroke volume or CO 3. Aortic stenosis 4. cirrhosis 5. Pulmonary Vascular Resistance (PVR) a. 100-200 6. Systemic Vascular Resistance (SVR) b. 800-1200

LV Afterload Usually Equated to SVR - Systemic Vascular Resistance - SVR = A.____ - Normal SVR = _______(1) - Systemic BP can be used as an approximation in the absence of: - Chronic changes in size, shape, or thickness of the ventricular wall - Absent acute changes in _______(2) RV Afterload Mainly Dependent on PVR - Peripheral Vascular Resistance (PVR) - PVR = B.____ - PCWP is usually substituted for LAP - Normal PVR = _______(3) - RV is more sensitive to changes in _______(4) because of its thin wall

Answers: A. 80 x [(MAP-CVP)/CO] 1. 800 – 1200 dyn/cm-5 2. SVR B. 80 x PAP-LAP/CO 3. 100-200 dyn/s/cm-5 4. afterload

Factors Affecting Ventricular Preload(EDV) - _______(1) return (most important to ventricular filling) - _______(2) volume - Distribution of Blood volume (alters small venous pressure gradient favoring blood return to the heart) - _______(3) (position during surgery) - Intrathoracic pressure (PPV or thoracotomy) - Pericardial pressure (Pericardial disease) - _______(4) tone - Rhythm (issues with atrial contraction) - _______(5) rate

Answers: 1. Venous 2. Blood 3. Posture 4. Venous 5. Heart

Determinants of Ventricular Filling - _______(1) is the most important factor - In the absence of significant pulmonary or RV dysfunction, venous return is the major determinant of LV _______(2) - EDV of both ventricles should be similar in a normal situation - CVP can be used as an index of RV and LV preload in normal adults - _______(3) or PCWP commonly use to estimate preload - Remember that because the two ventricles function in a series, their _______(4) are normally equal Factors that Affect Heart Rate Chronotropic Event Baroreceptors Carotid sinus reflex Aortic reflex Other reflexes that influence heart rate Anxiety, fear, and anger Grief Exercise Changes in body temperature

Answers: 1. Venous return 2. preload 3. LVEDP 4. outputs

Clinical Pearl: Rate Pressure Product (RPP) - The RPP is an indicator of the _______(1) requirements of the heart. - Intraoperative tachycardia can cause myocardial ischemia by increasing myocardial oxygen demand. - Controlling the heart rate significantly reduces the risk of perioperative myocardial events. - RPP = ______(a) (ideal is = or <_______(2))

Answers: 1. oxygen 2. 12,000 a. SBP × HR

Mitral Stenosis - Normally A.1___ cm² opening - Stenosis <_______(1) - 1.5-2 = Mild - 1.1-1.5 = Mod. - <1.0 = Severe. Anesthetic Goals: - Maintain SR and avoid ↑ _______(2). - Avoid hypo/hypervolemia PCWP Waveform: - Prominent _______(3) Pressure-Volume Loop: - ↓____ ; ↓_______(4) Avoid: - A. Induction agent? - B. What kind of anesthesia? - C. Vasopressor?

Answers: A.1. 4-6 1. 2 cm² 2. HR 3. A Waves 4.LVEDP and SV A.Ketamine B.SPA/Epidurals C.Ephedrine

Mitral Regurgitation - < 30% regurg. → No signs/symptoms - 30-60% → Mod. S/S - >60% → Severe S/S Gradual course, then rapid downhill. LA overload and _______(1) congestion. Anesthetic Goals: - Fast and Full - Maintain Preload - ↓______(a) (NTG, NTP) - ↓Volatile; ↑______(b) - avoid hypoxia, hypercapnia. - IABP; ↑contractility. PCWP Waveform: - _______(2) waves Pressure-Volume Loop: - ↑ ______ and _______(3)

Answers: 1. pulmonary a. SVR b. opioid 2. V 3. LVEDVand LVESV

Aortic Stenosis - Gradual Stenosing secondary to congenital, rheumatic, or degenerative disease - ______(a) LVH - Normally: ______(b) cm² - .7 - .9 → Mild Signs/Symptoms - .5 - .7 → Severe/Critical Symptoms: - DOE - Angina - Orthostatic Syncope. Hemodynamic Effects of Hypertrophy: - ______(c) cannot ↑ with activity - ↓ Perfusion of Coronary Arteries - ↑ O2 demand Anesthetic Goals: - Maintain HR ______(d) - Maintain contractility. - Maintain Preload (Avoid _______(1)) - ___E over agents. - Avoid hypotension PCWP: - Prominent _______(2) waves Arterial: - Absent ______(F) Notch and slower _______(3) notch.

Answers: a. Concentric b. 2.5-3.5 c. CO d. 50-70 1. NTG and NTP E. Opioids 2. V and A F. Dicrotic 3. anacrotic

Aortic Regurgitation - Just like Mitral Regurgitation, it could be acute or chronic. - Can be _______(1) for 20 yrs., but once symptomatic, 5 yrs. Progression. - As long as <40% SV; No S/S - Can lead to ______(a) LVH R/T constant LV systolic and diastolic volume overload. - _______(2) is a late and ominous sign PCWP: - Prominent _______(3) wave Arterial: - Rapid Rise - high ______(b) peak - low ______(c) pressure. Anesthesia Goals: - ↓______(d) preload or afterload? - Keep HR ___A. - Adequate Preload, but watch for CHF. - Forane + Vasodilator - SPA/Epidurals Okay. - keep _____B ↓ V/S? PV Loop: - ↑ ______(4) volumes? - Acute: LVEDP is ______(e): - Chronic: LVEDP is only slightly ↑ r/t congestion and absorption. Regurgitated Volume Depends on: - HR (______(f)→↑ Regurg due to more timeat Aortic Regurgitation - Aortic Pressure → A _______(5)) DAP = ↑ regurgitated

Answers: 1. asymptomatic a. Eccentric 2. Angina 3. V b. systolic c. diastolic d. Afterload A. normal B. DBP and HR 4. LVEDV and LVESV e. high f. slow 5. higher