CVD Diseases Flashcards

Question

Atherosclerotic Process

Answer 1

* Cholesterol and calcium is deposited beneath the endothelium in the lining of the artery to develop fatty streaks * Scar tissue formation at these sites will result in plaques * Plaques have a firm outer layer with a soft inner core of cholesterol * This deposition of cholesterol and calcium is a natural part of the aging process, however, having risk factors accelerates it.

Answer 2

1. Atherosclerotic Process 2. Luman Narrowing 3. Plaque Rupture

Answer 3

Results in decreased blood flow to the myocardium, resulting in ischemia which can cause chest pain Chronic ischemia can lead to myocardial fibrosis and can decrease ventricular wall compliance

Answer 4

When there is a plaque rupture it will expose the lipid core resulting in platelet adherence (clot development) The clot development will further narrow the lumen and can result in a complete occlusion and myocardial infarction This is the etiology of most myocardial infarctions

Answer 5

* These are “non-specific” and can appear gradually as the coronary arteries slowly narrow. * Heartburn * Palpitations * Dizziness or fainting * Nausea or vomiting * Diaphoresis * Exertional Angina * SOBOE * Jaw/back/arm pain * Especially left-sided

Answer 6

* **Non-Diagnostic** * High cholesterol levels * High levels of CRP * C-Reactive Protein which is a protein produced in the liver in response to inflammation

Answer 7

May reveal ischemia, MI or rhythm disorders

Answer 8

ECG may show exertional myocardial ischemia

Answer 9

Combines nuclear imaging of the blood flow to the myocardium at rest and under exertion

Answer 10

**Gold Standard**-The best way to diagnose CAD and evaluate the extent and locations of the blockages. This is the only test that indicates **whether treatment should include angioplasty or CABGs** Uses a catheter inserted into an artery (usually femoral) and threaded up the aorta to the openings of the coronary arteries Dye is injected at this point and fluoroscopy captures the image of the blood flow

Answer 11

* Non-Invasive * Lifestyle Changes * Medical Management * Invasive * Angioplasty * Stenting * CABG

Answer 12

The phenomenal drop in the heart disease death rate over the past 30 years has been due more to reducing risk factors than to advances in treatment.

Answer 13

* **Daily Low Dose Aspirin** * Will help to prevent clotting * Statins * Calcium Channel Blockers * Nitoglycerin * B-Blockers * ACE Inhibitors

Answer 14

Chemical which makes cholesterol Ex. Atorvastatin (Lipitor)

Answer 15

Angioplasty=Percutaneous Transluminal Coronary Angioplasty (PTCA) If necessary if it often done at the same time as an angiography A balloon tippe catheter is threaded into the affected coronary artery. When the **balloon is positioned at the blockage it will be inflated.** This will result in a widening of the artery as the plaque will be flattened against the arterial wall. Arteries treated with angioplasty alone can **still undergo restenosis** (1/3 of cases within 6 months)

Answer 16

Beta blockers, also known as beta-adrenergic blocking agents, are medications that **reduce your blood pressure.** Beta blockers work by **blocking the effects of the hormone epinephrine**, also known as adrenaline. When you take beta blockers, your **heart beats more slowly and with less force**, thereby reducing blood pressure. Beta blockers also **help blood vessels open up to improve blood flow.** Beta blockers aren't usually prescribed for blood pressure until other medications, such as **diuretics, haven't worked effectively.** Beta blockers generally **aren't used in people with asthma** because of concerns that the medication may trigger severe asthma attacks.

Answer 17

**Will end in -olol** Acebutolol (Sectral) Metoprolol (Lopressor, Toprol-XL) Nadolol (Corgard) Propranolol (Inderal LA, InnoPran XL)

Answer 18

Angiotensin converting enzyme inhibitors (ACE inhibitors) are medications that **slow (inhibit) the activity of the enzyme ACE**, which **decreases the production of angiotensin II**. As a result, **blood vessels enlarge or dilate, and blood pressure is reduced.**

Answer 19

**Ends in -pril** benazepril (Lotensin) lisinopril (Prinivil, Zestril, Qbrelis) perindopril (Aceon) ramipril (Altace)

Answer 20

the recurrence of abnormal narrowing of an artery or valve after corrective surgery.

Answer 21

* If necessary can be done at the same time as an angiography * Stents are used more often than not. * The goal is to help prevent restenosis, or at least lengthen the time before restenosis occurs * Use of drug-impregnated stents reduces risk of restenosis.

Answer 22

In an angioplasty the balloon will be expanded several times in order to force the plaque against the wall and then will be **completely removed from the body** In a stent the mesh will **remain in the body**

Answer 23

Used to treat severe CAD or CAD that has not responded to medical therapy or PTCA The blocked arteries will be bypassed through grafting a vessel above and below the blockage The vessels that are used most often for grafting are most commonly the saphenous vein, internal mammary artery or radial artery

Answer 24

Traditional Approach Off Pump or Beating Heart MICABS/MICS

Answer 25

Full sternotomy, heart is stopped and heart-lung bypass is used Pros: still heart; Cons: “pump time”

Answer 26

Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided, or "cracked".

Answer 27

Full sternotomy but heart is not stopped (no bypass machine is required)

Answer 28

MI-Minimally Invasive ## Footnote No sternotomy; access through the intercostal region Typically for front of the heart vessels; 1 or 2 vessels

Answer 29

These surgeries are generally very successful with low rates of complications.

Answer 30

Blood flow to the heart decreases or stops, damaging the heart muscle, which can help in Decreased ejection fraction Shortness of breath

Answer 31

* **Most MI’s are caused through a ruptured atherosclerotic plaque** * The risk factors for the development of CAD are also risk factors for an MI * Age * Smoking/illicit drugs * Hyperlipidemia * Diabetes mellitus * Poorly controlled HTN * Type A personality * Family history * Sedentary lifestyle

Answer 32

A decreased supply of oxygen can result from a lack of sufficient blood flow or an absence of blood flow Plaque rupture and thrombus formation Vasospasm of coronary artery Hypoxia Profound Hypotension Embolus to coronary arteries Aneurysm of coronary artery Arteritis

Answer 33

An aneurysm is a **localized, abnormal, weak spot on a blood vessel wall** that causes an outward bulging, likened to a bubble or balloon. Aneurysms are a result of a weakened blood vessel wall, and may be a result of a hereditary condition or an acquired disease.

Answer 34

* Inotropic Drugs * Increased contractility * Because the heart is working harder there is an increased demand of oxygen * Cocaine and Amphetamines * Beta and alpha receptors * Sympathetic receptors for an increased sympathetic response * Ephedrine * Stimulant * Often used as a medication for hypotension and spinal anesthesia * Exercise

Answer 35

* Regardless of etiology, whether it be a lack of blood supply, decreased blood supply, or increased O2 demand, there will be an area of myocardium that is deprived of oxygen * This lead to the development of ischemia, then an area of injury, and then finally an infarction * Ischemia will be on the outer border * During an area of injury there is the ability for the muscle to repair itself, but it will not be 100% repaired as there is a lot of extra fibrinogen, fat deposits, etc * Reperfusion injury is also an important component of the pathophysiology.

Answer 36

The area of infarction can be described as transmural or subendocardial based on the thickness of the injury Transmural-Full thickness of myocardium Subendocardial-Partial thickness of myocardium

Answer 37

* 0-30 Minutes * Reversible injury * 1-2 Hours * Onset of irreversible injury * 4-12 Hours * Beginning of necrosis * There will continue to be necrosis and development of scar tissues occurs up until 8th week post infarct * The risk for myocardial rupture is greatest at days 4-7 post infarct * As the tougher fibrotic scar tissue starts to form 7-10 days post infarct

Answer 38

Common among women, elderly and longstanding diabetics Results in higher mortality Can be mistaken with a GI problem such as reflux or heart burn

Answer 39

* Pain/Discomfort * Dyspnea * Nausea +/- vomiting * Anxiety– impending doom * Lightheadedness * Syncope * Cough * Pale * Diaphoresis * Dysrhythmias * Hypertension * 2° to anxiety or pain * Hypotension * Indicates ventricular dysfunction and failure

Answer 40

Tightness, pressure or squeezing Usually substernal and radiating down left arm Can involve the jaw, right arm, epigastrum (right above stomach) and back Often perceived as GI!

Answer 41

Myoglobin CK-MB Total CK Troponin I

Answer 42

Very sensitive and early marker of myocardial necrosis, but is not specific for MI Levels will begin to rise within 1 hour with peaks within 4-8 hoursWill return to normal by 36 hours

Answer 43

Levels will begin to rise within 4 hours and peak at 24 hours Levels will subside by 3 days Not specific to MI

Answer 44

Enzyme of cardiac damage

Answer 45

Troponin I is detectable at 3-6 hours with peaks at ~26 hours and remains elevated for up to 14 days This is a highly sensitive test The pattern and numbers are important This is a main test (#1 test choice for marker) and a marker of damaged tissue right after an MI where it will have an exponential increase (gotta check over several hours) and then decline over days

Answer 46

Only ~50% of patient will have diagnostic changes on their initial ECG

Answer 47

Depression (ischemia) Elevation (infarction) ST segment elevation is only considered pathologic if it occurs in two or more anatomically contiguous leads!

Answer 48

Peaking, flatten, or inversion T waves associated with potassium levels If the T wave is irregular it tends to not be due to an MI but rather it is often caused by hyperkalemia

Answer 49

Deepening and widening of Q Wave Loss of R wave resulting in a deep QS wave

Answer 50

The 12 lead ECG helps to locate areas of ischemia, infarct or injury When a specific coronary artery is blocked it can result in predictable changes of specific leads

Answer 51

Leads I, aVL, V5, V6

Answer 52

Leads II, III, aVF

Answer 53

* The patient’s presentation and ST elevation on 2 or more contiguous leads provides an immediate diagnosis * Without the need of cardiac enzymes * This means that the patient can be considered for re perfusion therapy * Those with STEMI should have reperfusion therapy: thrombolytics or angioplasty

Answer 54

The ECG alone will not confirm the MI and we have to rely on the serum markers (the pattern is important)

Answer 55

\*ACLS will use the acronym MONA for initial pharmacological therapy * **Morphine** * Analgesic for pain relief and vasodilator effects which results in reduced afterload and systemic pressure * **Oxygen** * Will increase oxygen content and therefore increasing oxygen supply * **Nitrates** * Vasodilator effect to decrease systemic vascular resistance and afterload * **Aspirin** * Reduces platelet aggregation by preventing them from sticking together * **Beta Blockers** * Reduce SNS stimulation (reduce HR) post MI and reduce afterload * Decrease oxygen demand and hypertension

Answer 56

* Reperfusion therapy is a medical treatment to restore blood flow, either through or around, blocked arteries, typically after a MI * The goal is to reduce mortality and limit the infarct size * Methods * Thrombolytics * Dissolve blood and platelet clots * Best is used within 60-90 minutes of onset * Should be given by EMT * Risk of bleeding must be considered, because you will have a time period when there is no clotting factors avalible * Percutaneous Coronary Interventions (PCI) * CABG

Answer 57

Inability for the heart to meet the metabolic demands of the body

Answer 58

Right sided-Cor Pulmonale left sided Both sides affected

Answer 59

* High output * Low output * Can be systolic or diastolic in origin

Answer 60

Although the initial event that leads to heart failure may be right-sided or left-sided in origin, long-term heart failure usually involves both sides! Because the circulatory system is a closed system when one side starts getting backed up it will eventually affect the other side

Answer 61

* Cor pulmonale is the **enlargement and failure of the right ventricle** in response to an increased vascular resistance from the lungs * Chronic pulmonary heart disease will usually result in right **ventricular hypertrophy** * Hypertrophy is an adaptive response to a long term increase in pressure as muscle cells will grow thicker in order to increase the contractile force and move the blood against a greater resistance

Answer 62

* There is a **failure in the left ventricle to move blood** to the body causing **poor systemic perfusion** * Decreased systemic perfusion will lead to vasoconstriction (increased SVR) * There will be a normal or increased BP that is needed to maintain cerebral and coronary perfusion * Blood will also back up into the pulmonary system causing **pulmonary congestion** and can lead to right ventricular failure as the right side of the heart will pump against the increased PVR which will lead to a decreased RV output * When the RH fails there is a decreased pulmonary congestion giving a false look of improvement

Answer 63

Increased PAWP HR Decreased CO Pulse pressure

Answer 64

Due to failure of the right ventricle to pump blood out to the lungs Results in blood backing up into the systemic circulation _Backwards Failure_ Decreased RV output leading to venous congestion _Forward Failure_ Decrease RV output -\> Decreased pulmonary perfusion -\>Decreased LV filling -\>Decreased LV output -\> systemic perfusion

Answer 65

Increased CVP

Answer 66

Uncommonform of heart failure that can occur when there is an excessive need for cardiac output due to an increase in peripheral demand The heart is “supranormal” and yet still inadequate Can occur when there is an increased blood volume (excess water and/or salt), excess fluid, chronic and severe anemia, etc.

Answer 67

Caused by a disorder that will impair the pumping ability of the heart May be systolic or diastolic in origin Many patient will have elements of both

Answer 68

Heart failure with reduced ejection fraction (HFrEF) Impaired ejection of blood from the heart during diastole

Answer 69

* Results from conditions that either * Impair contractility of the heart * Produce a volume or pressure overload on the heart * Ex. CAD, previous MI, A-Fib, Valve disease/dysfunction, alchol, infection, cardio myopathy, etc

Answer 70

Results in a decreased stroke volume and in turn a decreased ejection fraction

Answer 71

Heart failure with a preserved ejection fraction (HFpEF) Ejection fraction will remain the same at 50% or become lower Impaired relaxation of the heart during diastole Will result in a decreased stroke volume There will be an increase in muscle mass without dilating

Answer 72

Restrict diastolic filling Increase ventricular thickness Thus decrease chamber size Delay diastolic relaxation (fibrosis) Ex. Ventricular hypertrophy from long term HTN or aortic stenodid, diabtese, constrictive pericarditis

Answer 73

* Most Common * Myocardial ischemia * Myocardial infarction * Arrhythmias * The heart is not pumping in proper sequence (ex. A-fib) so blood does not pump well and will stay in the atrium * Clots can also form if the heart is pulling for some time * Heart valve lesions * Opening and closing problems * Congenital malformations * Pericarditis * Inflammation of sac around the heart * Cardiomyopathies

Answer 74

* Fluid overload * Renal failure * Sepsis * Biggest issue * Causes membrane variable of well weaken, so fluid will enter more easily * Vasodilation of blood vessel * Causing RHF (Cor Pulmonale) * \*\*Nitric Oxide * COPD * PE * Pulmonary HTN

Answer 75

* Exertional Dyspnea * Orthopnea * The heart is not pumping when the patient lying down and fluid will back up into the lugs * Peripheral Edema * Late stage * Paroxysmal Nocturnal Dyspnea (PND) * The heart is not pumping properly when sleeping or when the body is relaxing and fluid will back up into the lungs so when the patient wakes up they will have SOB and wheezes * Cough * Frothy, blood tinged sections * Fluid backs up from the vasculature bringing up RBC * Frothy because of surfactant (creates bubbles) * Cyanosis * Increase PAWP * Backed up pressure from the left ventricle due to fluid overload * Distinguishes heart failure and non-cardiac infections * ~4-12 mmHg

Answer 76

Fine/Coarse crackles due to the fluid “Cardiac” wheezes

Answer 77

* Peripheral/dependent edema * Dependant Edema=Gravity related swelling in the lower body * Fatigue * JVD * Hepatomegaly * Due to a backup of blood in the liver * Ascites * Abnormal accumulation of fluid in abdominal (peritoneal) cavity * When the right side of the heart loses its pumping power, blood will back up into the veins * Cyanosis * Increased CVP

Answer 78

This is the end result of different etiology’s This is what will trigger different compensatory mechanisms

Answer 79

Frank-Starling Mechanism Increased SNS activity Renin-Angiotensin Mechanism Myocardial Hypertrophy

Answer 80

* In a normal heart this will be the mechanism that is responsible for the heart pumping the blood it receives and matching the output of the two ventricles * Increased preload will increase stretch which increases force of contraction and ultimately increase stroke volume * During heart failure this mechanism is responsible for maintain normal CO in the face of end diastolic volumes * This is reflected by an increase in PAWP and CVP * This mechanism become ineffective when the myocardial fibers become overstretched * Thus CO can not increase with an increase in physical activity

Answer 81

* SNS will be stimulated through a decrease in SV and CO * Leads to (all of the below is an attempt to maintain perfusion to vital organs) * Systemic vasoconstriction * This may lead to increased afterload and further increase in myocardial demand * Stimulation of the heart * Increased HR * Increased contractility * Norepinephrine * Increases SVR

Answer 82

* Decreased SV and CO will result in a decrease perfusion to the kidneys * The kidneys will respond through releasing renin which will activate the renin angiotensin aldosterone system * End result * Aldosterone will cause sodium and water retention resulting in an increase in blood volume * Angiotensin II causes vasoconstriction * Because this mechanism results in an increase in blood volume there will also be an increase in end-diastolic volume * Indirectly this is activating the frank starling mechanism and increase CO

Answer 83

* A long term compensatory mechanism in response to increase work demand * The heart is working harder building muscle which will decrease the size of the ventricle * Less preload and less fluid that can be ejected * This results in an increased in the number of contractile fibers in the myocardium * While this mechanism allows for the ventricle to do more work it also results in an increase in myocardial demands and increase myocardial oxygen requirements

Answer 84

Further increase myocardial demand

Answer 85

Increase myocardial demand Shorten diastole

Answer 86

Further increase filling pressure Further contributes to fluid overload worsening clinical manifestations

Answer 87

Ineffective due to over stretched myocardial fibers

Answer 88

Increase myocardial oxygen requirements May reduce chamber size cause a diastolic failure

Answer 89

* Cardiomegaly * Left sided heart failure * Diffuse bilateral infiltrated (butterfly pattern) * Pleural effusion

Answer 90

Seen in the CXR with left sided heart failure These are 1-2 cm thin lines in the peripheral of the lungs They are peripheral to and external to the pleural surface They represent thickened subpleural interlobar septal and are unlikely seen at the lung bases Suggesting pulmonary edema

Answer 91

Useful to diagnose cause of heart failure

Answer 92

May diagnose cause (MI, arrthymia)

Answer 93

* Diuretics * Used to target hypervolemia * Inhibit sodium and water reabsorption * Will reduce intravascular volume, decrease CVP, decrease right and left heart filling pressures * Nitroglycerin * Causes systemic venodilation decreasing preload * Morphine

Answer 94

* β-Blockers * Inhibit sympathetic nervous system and block alpha 1 adrenergic vasoconstrictor activity * Slow down HR and dilate blood vessels * Nitroglycerin, Nitroprusside * ACE inhibitors

Answer 95

* Use with caution * Ex. Milrinone, Inamrinone, digoxin, Dobutamine, Dopamine, and Norepinephrine * Increase contractility and can increase oxygen as a result * Inotropic agents will help to restore organ perfusion and reduce congestion

Answer 96

Oxygen & NIPPV!!

Answer 97

Intra-aortic Balloon Pump Left Ventricular Assist Device Heart Transplant

Answer 98

* CPAP is the 1st line of therapy * BiPAP if hypercapnia or continued dyspnea * The increase FiO2 and Pmean will improve oxygenation * The increase intrathoracic pressure and increase PVR due to PPV will cause blood to back up on the right side * This will cause distension of the RV and a shift of the septum towards the left side * The effectively reduced preload on the left side of the heart and improved output (Frank-Starling Curve) * The increased intrathoracic pressure will also reduce transmural pressure resulting in a decreased afterload * Will help to open alveoli and get oxygen * This pressure will push fluid in the alveoli back to the vasculature

Answer 99

Restriction of dietary sodium Diuretics Nitroglycerin or long-acting nitrates ACE Inhibitors/β-blockers Cardiac rehabilitation

Answer 100

Ejection fraction is the best predictor of mortality! The lower the EF the worse the prognosis!

Answer 101

* Stenosis: This is a narrowing of a valve so that it does not open properly * Obstruct blood flow * Incompetence: This is a distortion of the valve so that it unable to close completely; results in regurgitant flow.

Answer 102

* Congenital defects * Trauma * Ischemic damage * Degenerative changes * DM and hypercholesteremia are risk factors * Inflammation/Infection * Rheumatic heart disease * Auto-immune diseases (Rheumatoid Arthritis) * Endocarditis 2°bacterial infection (IVDU) * Neoplasm * Connective tissue diseases Eg. Marfan Syndrome

Answer 103

1. Damage or inflammation of the heart valve leaflets 2. Healing results in increased collagen content and scaring 1. Valve leaflets heal together 1. Valve cannot open properly (Valve stenosis) 2. Valve leaflets become retracted 1. Valve cannot close properly (regurgitant valve)

Answer 104

Distension of the chamber that pumps the blood thru the diseased valve (and thus an increase in pressure) Impaired filling of the chamber that receives the blood (and thus decrease pressure)

Answer 105

There is backward flow thru the valve This causes distension of the chamber prior to the diseased valve (and thus increase pressure here!) This places increase work demands on this chamber

Answer 106

* Mild valvular disorders may not produce any signs or symptoms other than a heart murmur. * History of heart murmur (or newly developed) * Exertional dyspnea\*\* * Orthopnea and paroxysmal nocturnal dyspnea * Effort-induced fatigue * Angina 2°ischemia * Palpitations * Syncope * Signs of heart failure (S & S depend on whether L or R heart failure)

Answer 107

Valve dysfunction results in turbulent flows replacing the normal laminar flows and result in “murmurs” being heard Depending on the valve affected there may be extra heart sounds heard

Answer 108

Allows for viewing of the internal structures of the heart and blood flow patterns The transesophageal echo is particularly effective in identifying valve disorders

Answer 109

* Medical management of associated heart failure * Surgical intervention * Replace or repair valve– put in pig valve * Only done in severe cases * Ideal prosthetic valve is not yet invented * Percutaneous balloon valvuloplasty * For treatment of stenotic valves

Answer 110

A group of disorders that affect the heart muscle and diminishes cardiac performance It can develop as a primary or secondary disorder

Answer 111

Dilated Restrictive Hypertrophic Arrthymogenic right ventricular dysplasia

Answer 112

* Idiopathic * Genetic * Infectious * Viral, bacterial, protozoal * Toxic * Drugs, poisons, ETOH

Answer 113

* Other CV disorders * Ischemia \*\* * Hypertension * Valvular disorders * Metabolic disorders: * DM, hyperthyroidism… * Collagen Vascular Disease * SLE, RA

Answer 114

* Most Common * This type causes the heart to become enlarged and the myocardium to become weak, thin and floppy * Most often idiopathic in origin * The affected ventricle is unable to pump the blood it receives, thus, * If LV is affected ggLeft heart failure and its manifestations * If the RV is affected ggRight heart failure and its manifestations * Results in a systolic dysfunction

Answer 115

* Hallmark is inappropriate, disorganized proliferation of myocardial cells and is caused by a genetic disorder * Affects the left ventricle, frequently in the interventricular septal area * Results in an obstruction of outward flow * Results in both a systolic and diastolic dysfunction * Because the left ventricle is smaller * The leading cause of sudden cardiac death in pre-adolescent and adolescent children. * We don’t know about this until afterwards

Answer 116

* This type causes the walls of the ventricles to become stiff but not necessarily thickened * It impairs the filling of blood as the ventricle doesn’t relax normally * If LV is affected * Left heart failure and its manifestations * If the RV is affected * Right heart failure and its manifestations * Results in a diastolic dysfunction * This is the least common cardiomyopathy and is often due to infiltration by foreign materials

Answer 117

* Rare * Genetic * Two patterns: Autosomal Dominant and Autosomal Recessive * Can affect left or right wall * Loss of myocardium of the right ventricular free wall (free wall is the ventricle wall that is not the septum * Right Ventricular muscle is replaced by fat and fibrous tissue (scar tissue) * Scar tissue will affect the conduction of the hert * Right ventricle has poor dilating and contracting ability * Highly associated with ventricular arrhythmias

Answer 118

* Ventricular arrhythmias * Palpitations * Dizziness, lightheadedness, syncope * SOBOE * Heart Failure * Abnormal ECG * Sudden Cardiac Arrest

Answer 119

MRI CT scan

Answer 120

Antiarrhthmic drugs Catheter Ablation- Will damage the pace maker cells in order to prevent the off firing of the heart Implantable cardioverter defibrillator

Answer 121

* Class I (Na Channel Blocker) * Lidocaine, Phenytoin * Class II (B-Blocker) * Sotalol * Slows down HR and helps to decrease SVR * Class III (K Channel Blockers) * Amiodarone * The big problem is that this drug is toxic and will affect the lung (pulmonary fibrosis)

Answer 122

* An inflammation of the pericardium (sac that surrounds the heart) * Can be acute or chronic * The inflammation can lead to the accumulation of fluid in the pericardial sac * Characterized by chest pain, pericardial friction rub and serial ECG changes.

Answer 123

* Idiopathic * Infectious * Viral, bacterial, fungal, TB * Prior MI * 7-10% of MI patients develop this complication * Kidney failure * Cancer * Rheumatoid Arthritis/Scleroderma/SLE * Chest trauma * Rheumatic Fever * Inherited disorder * About 1/1000 hospitalized patients are diagnosed with this disorder. Many more are likely to have an mild form that goes undiagnosed.

Answer 124

1. Etiological Agent 2. Infiltrations of WBCs 3. Pericardial Vasculitis 1. Pericardial Effusion 1. Formation of cardiac tamponade 1. Exudative: Serous, fibrinous, hemorrhagic, purulent, or chylous 2. Fribrinous, retractions, and adhesion formation 1. Constrictive pericarditis 3. Formulation of granulomas 1. Seen with TB, RA, sarcosiodosis, fungal infections

Answer 125

* Chest pain * Cardinal Symptom * Pericardial rub * Dyspnea (2° to pain) * Dry cough * +/- Fever * Chills * Weakness * Signs of tamponade if large effusion present * Becks Triad: Distended neck veins, distant heart sounds, hypotension

Answer 126

Chest pain Dyspnea secondary to pain Dry cough Fourth possible sign: Kussmauls sign

Answer 127

Scarring of the pericardium after one or more episodes of pericarditis The pericardium becomes thickened and stiff making it hard for the percadium to expand Results in impaired filling of the heart, thus, diastolic dysfunction

Answer 128

Because this results in blood backing up into the extremities and lungs you will see S & S similar to heart failure Kussmaul’s sign is often seen! (Swelling JVD during insp).

Answer 129

* Lab Studies * Infectious Etiology * Increase WBC and blood cultrues * Cardiac Enzyme * Increased if myocardial infarction * CXR * May show pericardial effusion * Expanded look at the heart * White out * ECG * 4 classic stages for pericarditis * Echocardiography * Diagnosed type of effusion * CT Scan * Diagnosed type of effusion * Analysis of Pericardial Fluid

Answer 130

Elevation in all leads PR segment is depressed Depression between the end of the P wave and the beginning of the QRS complex

Answer 131

Pseudonormalisation with t wave flattening (transition) The PR segment will return to normal

Answer 132

Inverted T waves

Answer 133

Normalization If it gets normal because the electrical conduction is adapting

Answer 134

* Treatment depends on etiology * E.g. Antibiotics for bacterial pericarditis * E.g. Kidney failure causing uremic pericarditis is treated with dialysis * Due to the overload of volume * Viral will just have to take its course * General * Analgesics for pain management * Steroids for inflammation

Answer 135

* Percardiocentesis * Fluid is aspirated from the pericardium * Pericardial window * A small part of the sac around the heart is removal in order to remove drained excess fluid * Pericardiodesis * Percardiectomy

Answer 136

Excision of part of the pericardium Done for constrictive pericarditis or for chronic recurring pericarditis Usually only done in severe cases! 30% of patients will have a recurrent episode of pericarditis within 2 years

Answer 137

* A life-threatening condition in which elevated intra-pericardial pressures impair the filling of the heart during diastole * The increased pressure results from an accumulation of fluid in the pericardial sac * Results in decreased SV and CO * The severity of the condition depends on the amount of fluid present and the rate at which it accumulated

Answer 138

* Trauma * Ex. GSW, MVC * Cardiac Surgery * Cardiac Rupture secondary to MI * Pericarditis * All the etiology’s * Neoplasm

Answer 139

The pericardial space normally contains 20-50 mL of fluid Rapid accumulation of as little as 150 mL of extra fluid can markedly reduce CO However 1-2L of fluid accumulating slowly may not have any significant effect on CO due to the adaptive stretching of the pericardium The effusion can be serous, serosanguineous, hemorrhagic, or chylous

Answer 140

Increased Pericardial Pressure ► Decreased Diastolic Filling of the Heart ► Decreased SV and CO ►Signs and Symptons of Shock or Heart Failure

Answer 141

Streching of the Pericardium ► Signs and Symptons of Pericardial Effusion the streaching of the pericardium can lead to additional accumulation of pericardial effusion lead to the acute pathology of pleural effusion

Answer 142

* Beck Triad * Tachycardias * Decreased pulse pressure * Pulsus paradoxus * May be present with PEA * This is life threatening! Patient will present in acute shock!

Answer 143

Hypotension Increased Jugular Venous Pressure Diminished heart sounds

Answer 144

* Pericardiocentesis * ACUTE * Subxiphoid percutaneous drainage with an 18 gauge needle * Less Acute * Will use fluoroscopy/echo to aid * Treatment of underlying causes * For recurrent tamponade secondary effusions * Pericardial window * Pericardiodesis * Agents introduced into pericardial sac to sclerose the tissue * Pericardiectomy * If untreated it is rapidly and universally fatal!

Answer 145

A paradox in the hemostatic sequence and is characterized by widespread coagulation and bleeding A stimulus causes hyperstimulation of the clotting pathways This results in formation of diffuse clots in the microvasculature and depletion of the clotting factors, which can now result in generalized bleeding

Answer 146

DIC is not a primary disease it occurs as a complicationof a wide variety of conditions * **Infections**-Bacterial, Viral, Rickettsial, Parasitic * **Shock**, Septic, Hypovolemic * **Trauma**-Burns, Severe Head Injury, Snake Bites, Heatstroke * **Surgical Procedures** * **Other Disease States**-Malignancy, Liver Disease, Pancreatitis, SLE * **Obstetric Conditions**-Abruptio placenta, Retained dead fetus, Amniotic fluid embolism * **Hematologic Conditions**- Incompatible Transfusion, Massive Transfusion

Answer 147

1. Stimulus 2. Hyperactivation of Clotting Pathways 1. Consumption of Clotting Factors 1. Bleeding 2. Diffuse clotting and micro emboli 1. Organ and tissue ischemia 1. Organ Failure 2. Widespread Fibrinolysis