Exam 2 Flashcards
Left sided heart failure
S/sx? S
S3 -when in overload
↑ hr, weak pulses, cyanosis, cool extremities
Nocturnal/exertional dyspnea
Orthopnea, ↑ rr
Elevated pulmonary capillary wedge pressure
Pulmonary congestion ( cough, crackles, wheezes, blood tinged sputum)
Restless, dizzy, confusion, AMS
Right side heart failure
What is the other name? Why?
What are the s/sx?
Cor pulmonale, due to being secondary to chronic pulmonary problems
JVD (RV cannot pump more venous blood into lungs)
Loud S2 pulmonic component (lubDUB)
RV heave on palpitation
RUQ pain, Fatigue, ascites, enlarged liver/spleen, polyuria/nocturia
-Weight gain, dependent edema, anorexia, gi distress
Where is heart attack pain located?
Upper chest, substeral, epigastic, neck, jaw, both arms and intrascapular
Heart attack s/sx
Men vs women
Men: n/v, jaw/neck/back pain, chest pressure, sob
Women: n/v, jaw, neck, upper back pain, chest pain but NOT always, pain/pressure in low chest or abdomen, sob, fainting, indigestion, extreme fatigue
What lab values do we look at for MI vs Heart failure?
Troponin, myoglobin, creative kinase, potassium, mag, cholesterol
BUN/Cr/BNP = heart failure
Semi vs non nstemi
Stemi: St elevation, increased troponin = infarction and necrosis
Nonstemi: ST depression, t wave inversion = myocardial ischemia. Troponin ↑ can occur, both happening = myocardial cell death/ necrosis
Stemi pathophysiology
Rupture of fibrous atherosclerotic plaque = plt aggregation / thrombi form at site
Begins w/infarction of subendocardial layer of heart muscles which has greatest 02 demand and ↓ supply
Define
Zone of injury
Zone of ischemia
Zone of injury: Tissue injured not necrotic
Zone of ischemia: Tissue that is o2 deprived
What metabolic process occurs during mi?
K+, calcium, mag = changes in conduction and contraction
Catecholmines (epi/norepinephrine) released in response= ↑ hr, afterload and contraction
-increase 02. Requirements = ventricular rhythms
Ml risk factors?
Smoking, HTN, DM 2, obesity, alcohol, sedentary, stress, cholesterol ↑, metabolic syndrome, hyperlipemia
Race (black), age (65 yr), gender (male), family hx
What is MI?
What occurs in blood flow?
Myocardial infarction
Occlusion of blood flow = ischemia → injury → necrosis
What is Mona?,
What order do we give it in?
Morphine, oxygen, nitro, aspirin
O2 first
Nitro: 3x every 5 min
Morphine: ↓ pain, relax smooth muscle, & catecholmines
-2-4 mg IV push Q5-15 min
Asa - antiplatelet
What is a contraindication of nitro? What is a common side effect?
Viagra / pulmonary hypertension, “afil” drugs= fatal interaction;
Headache and orthostatic Hypotension
What medications do we give for mi?
What is one surgical intervention?
Vast dilator (nitro)
Analgesics ( morphine)
Beta blockers ( carvedilol, metoprolol )
Antiplatelets ( Asa, clopidogrel, varapraxor)
Thrombolytic therapy ( Alteplase)
Anticoags heparin, enoxaprin)
Glycoprotein inhibitors (eptifibatide)
Percutaneous coronary intervention (PCI)
What is the s/sx of cardiogenic shock?
, Cold, clammy skin
↓ pulses
Agitation
Pulmonary congestion
↑ RR, ↓ bp, ↑ hr, ↓ UOA
What is coronary artery disease?
What does it lead to?
What does it include?
Plaque buildsup in artery
Angina: hard for blood to go through artery
Heart attack: plaque cracks and a blood clot blocks artery
Includes: stable angina, ischemia, infarction
Define ischemia and infarction
Ischemia: Insufficient O2 for myocardium
Infarction: necrosis & cell death occurs when severe ischemia is prolonged and ↓ perfusion = irreversible damage
Types of angina?
Stable
Unstable
Variant (prinzmetals)
Describe stable angina
Occurs on exertion, exercise or emotional stress
Relieved by nitroglycerin
Last less than 15 min
Not associated w/n, epigastric pain, dyspnea, anxiety, diaphoresis
Describe unstable angina
Considered pre-infarction. Occurs w/wo exertion (even at rest)
Progressively gets worse
S/sx: diaphoresis, sob,
Describe variant (prinzmetal) angina
. Due to coronary artery spasm, occurs at rest
Describe EKG of pts w/angina
ST changes but no troponin/ ck levels
How does blood flow through heart? What is the acronym that helps?
Try
Performing
Better
Always
(Tricuspid, pulmonary, bicuspid, aortic valve)
What are the 2 subcategories of heart failure
Systolic (impaired contractility)
Diastolic (impaired filling)
What happens during L heart failure?
↓ pumping
Fails metabolic demands, blood backup from LV =Fluid in lungs =
Backflow leads to R HF
What does stroke volume depend on?
Preload
Afterload
Contractility
L sided heart failure is also known as?
What causes it?
CHF
Causes: hypertension, cad, valular disease
What are the causes of right sided heart failure?
LV failure, RV MI, pulmonary HTN, COPD.
What is hepatosplenomegaly?
Enlarged liver/spleen
R sided heart failure
What is high output failure? Causes?
Output remains normal/above
Caused by ↑ metabolic needs ( septicemia, anemia, hyperthyroidism)
What are the compensatory mechanisms of heart failure?
Sympathetic nervous system stimulation
Renin-angiotensin
Chemical response (bnp)
Myocardial hypertrophy
What drugs reduce afterload
Ace, arb, arni
Interventions that reduce preload?
Diuretics
Venous vasodilator
Drugs that enhance contractility?
Inotropic ( digoxin )
Beta blockers
Aldosterone antagonists
CCB
How to prevent/manage pulmonary edema
Assess for early s/sx ( crackles, dysphea, confusion)
High fowlers
O2, nitro, diuretics, morphine
What things are considered valvular heart disease?
stenosis
regurgitation
Mitral valve prolapse
What are the types of temporary pacemakers.
External: transcutaneous - delivered w 2 electrodes on skin
Epicardial: lead attached directly to heart during open heart surgery
Endocardial: transvenous, pacing wires threaded through large central vein (subclav, jugular, cephalic)
Modes of permanent pacemakers
Fixed rate (asynchronous) - constant firing w/o regard for hearts electrical activity
Demand (synchronous) - detects electrical activity, fires at ↓ hr
Tachyclysthythmia : over pacing
Why are pacemakers needed?
TX of symptomatic bradycardia, complete heart block, sick sinus syndrome, sinus arrest, systole, atrial tachydysrhythymias
Why are implantable cardioverter/ defibs needed?
Ventricular tachydyshrythrias, MI w/LV dysfunction
What is a cardioversion?
When do we do it?
Delivery of direct countershock to heart sychomied w/QRS complex
Atrial dysrhythmias, SVT, Vtach w/pulse
What is defibrillation?
When do we use it?
Delivery of unsynchronized, direct shock to heart. Stops all electrical activity, allowing sinoatrial node to take over and reestablish perfusing rhythm
V fib, pulse less Vtach
What antidysrhythmic medication do we give for…
- Bradycardia?
Atropine, dopamine, epinephrine
What antidysrhythmic medication do we give for…
Afib, SVT, and Vtach w/pulse
Amiodarone, adenosine, verapamil
What antidysrhythmic medication do we give for…
VTach w/o pulse or Vfib
Lidocaine, epinephrine
What is cardiomyopathy?
What are the types?
Hypertrophied ventricular septum
Dilated: decreased systolic function
Hypertrophic: asymmetrical ventricles + stiff LV =. Diastolic filling abnormalities (unable to relax/fill with blood)
Restrictive: rarest, stiff ventricles = no diastole filing (caused by build up of fatty deposits/fibrous tissue on R ventricle)
What drugs do we give for pts with cardiomyopathy?
Diuretics-vasodilators, cardiac glycoside
Avoid etoh and toxins
Surgical management of cardiomyopathy
Venticulomyoectomy
Ablation
Heart transplant
What is pericarditis?
What are the types?
Inflammation/alteration of pericardium
Acute: infection, post MI, post periocardiotomy syndrome
Chronic constrictive: inflammation causes thickening of pericardium
S/sx of pericarditis
- Substernal precordial pain (radiate to L neck, back, shoulder)
Pain worsening by breathing, coughing, swallowing
pt can NOT lay in supine position, worsens pain
Pericardial friction rub
Pericarditis can lead to what emergency?
Cardiac tampanode
What is cardiac tamponade?
What are the s/sx?
How do we treat it?
Fluid accumulates in pericardium
S/sx: JVD, paradoxical pulse ( bp ↓ on inhalation), ↑ hr, muffled heart sounds, decreased CO, circulatory collapse
Pericardiocentesis
What is rheumatic carditis?
Sensitivity after upper respiratory tract infection from group A strep.
inflammation in all layers of heart
forms Aschoff bodies
S/sx of rheumatic carditis
↑ hr, cardiomegaly, murmur, friction nb. Precordial pain, ecg changes (prolonged PR), heart failure
What hemodynamics monitoring is elevated w/ L heart failure ?
Positive airway pressure (PAP)
Pulmonary artery wedge pressure (pawp)
What do we do to ↑ gas exchange in pts?
Ventilator
Monitor rr
Auscultate breath sounds
Position in high bowlers
Maintain O2 sat of 90%
In heart failure, what SBP is too high?
<100, give nitro if above
What is ineffective endocarditis?
What causes it?
Microbial infection of endocardium. Blood flows rapidly from ↑ pressure zone to ↓ pressure zone = eroded endocardium. Plts/fibrinogen adhere to site, forming vegetation. Bacteria traps in ↓ pressure zone, vegetation grows. Valve appears stenotic = embolism
Caused by IV drug use, valve replacements w/alteration in immunity, structural defects
What are the s/sx of ineffective endocarditis?
Neurological changes,
Fever, malaise, fatigue, night sweats, (+) blood cultures
s3, s4, murmu
Petchiae, Splints hemorrhage, Osler nodes, jaineway lesions (hands, feet), Roth spots
sudden abd/flank pain = renal infection, hematites, pyuria (WBC in urine)
Signs of worsening/ recurrent heart failure?
Rapid weight ↑ (edema)
↓ in exercise tolerance
Cold symptoms (cough)
Nocturia
Dyspnea/ angina at rest
Valvular heart disease
What are the 5 groups?
Mitral stenosis: afib, systolic murmur
Mitral regurgitation: afib, palpitations, high pitched holostylic Murmur
Mitral valve prolapse: atypical chest pain, palpitations, atrial tachycardia, Vtach, systolic click
Aortic stenosis: angina, harsh systolic crescendo murmur
Aortic regurgitation: angina, sinus tach, blowing diastolic murmur
Valvular disease
Nonsurgical vs surgical management
Nonsurgical: rest, drug therapy, balloon valvuloplasty, trancather aortic value replacement
Surgical: direct commissiotomy, mitral value annuloplasty, heart valve replacement
What can a beta blocker do for mild heart fail
Improve activity tolerance and Orthopnea
To absorb aspirin faster, tell pt to…
Chew it
What is a S3 gallop?
Low frequency, in early diastole at end of rapid drastic filling = ventricular dysfunction
New York association classification
Class I: symptom onset w/ more than ordinary level of activity
Class II: symptom onset w/ordinary level of activity
Class III: symptom w/minimal activity
Class iv: symptoms at rest
Post op complications of pacemaker?
Pneumothorax (collapsed lung)
Hemotherax (collection of blood in pleural cavity)
Cardiac tamponade
What are the causes of AFIB
Intrinsic vs extrinsic
Inhinsic: Atrial dilation (valve regurge/stenosis, restrictive cardiomyopathy) and sick sinus syndrome
Extrinsic: age 80+, heart/lung disease, hyperthyroidism, sleep apnea, surgery, alcohol, HTN
What is afib?
Multiple disorganized re entry loops within atria, triggered by abnormal impulse initiation around pulmonary veins of left atrium
What are the symptoms of afib?
Palpitations, Dyspnea, fatigue, syncope (decreased diastolic filling time = decreased preload/Cardiac output)
What are signs of afib
Irregular pulse
NO S4 sound (no atrial kick)
Variable s1 loudness
Panasonic murmur (regurgitation in mitral/tricuspid valve)
Treatment of afib
Stroke reduction
Anticoagulants : aspirin and warfarin (3+ weeks before cardio version)
Treat underlying cause: HX, PE, TSH test, echocardiogram.
Ras inhibitor (HTN), statins for CAD, cpap for OSA, stop drinking
Rate control: <110 bpm
- beta blockers (class 3 AAD)
- Ca2+ channel blockers (Class 4 AAD)
- Digoxin (high toxicity)
- rhythm control
-antidysrhythmics:
•propafenone (decrease rate of conduction)
• class 3 (amioderone, sotalol) increase refractory period - Anticoagulants
Calculate Chads 2 score
What is the therapeutic range for Digoxin ?
1.5
If rate control drugs fail, what nonpharmacological Tx do we do?
AV node ablation W/pacemaker
If rhythm control drugs fail, what non pharmacological tx do we do?
Catheter ablation, surgical maze procedure
CHADS2 scoring w clot prevention med score
CHADS 2
-CHF: +1
-HTN: + 1
-Age (>70): + 1
-DM: +1
-Stroke (past) : +2
Prevent clotting based on score
-0: ASA only
-1: LT anticoagulant w/ ASA/warfarin
>2: indefinite anticoagulation
Advise pt on Responsible ER use with afib. What do we say?
Afib has no immediate threat to life, ONLY RVR. Only go to ER if symptoms get bad (pt may receive this due to meds)
Afib with RVR tx?
Cardioversion or Beta blockers
Atrial Tachycardia tx
Monitor unless or shows s/sx (dizzy, fatigue, SOB, HA, diaphoresis)
Aflutter tx?
Monitor
What is more life threatening? Atrial or ventricular dysthymia’s?
Ventricular
Vtach tx?
Check pulse, start compressions, are you okay? Shock rhythm
Vtach tx?
Check pulse, start compressions, are you okay? Shock rhythm
VFib tx?
Pt is dead dead, code, AED, shock. Epi
Torsades de pointes, what level do we check. Can we shock?
Magnesium level, bolus pt over 30 min
Nonshockable rhythm
Normal PR interval
Normal QRS interval
normal QT interval
0.12-0.20
0.04-0.12
.32-.44
Normal PR interval
Normal QRS interval
normal QT interval
0.12-0.20
0.04-0.12
.32-.44
Electrical conductivity of heart
1.Sinoatrial (60-100 BPM, P wave)
2. Atrioventricular (40-60 BPM, PR, atrial kick contraction)
3. bundle of His (R/L bundle branch system)
4. purkinje fibers (20-40 BPM)
Electrical conductivity of heart
1.Sinoatrial (60-100 BPM, P wave)
2. Atrioventricular (40-60 BPM, PR, atrial kick contraction)
3. bundle of His (R/L bundle branch system)
4. purkinje fibers (20-40 BPM)
ECG complexes
P wave represents what?
QRS represents what?
T wave represents what?
Atrial depolarization
Ventricular depolarization
Resting phase
ECG complexes
P wave represents what?
QRS represents what?
T wave represents what?
Atrial depolarization
Ventricular depolarization
Resting phase
Define automaticity
Cardiac cell generates action spontaneously without stimuli
Define excitability
polarization or generate action potential
Define conductivity
Electrical impulses in heart = beating
Define contractility
Performance of heart at pre/afterload, constant HR
How many PVCs are considered VTACH
5 to 7
What is the heart rate in Vtach?
What is Vtach?
100 to 280 BPM
Repetitive firing of irritable, ventricular ectopic focus (bundle branches)
Where does the Vfib rhythm come from?
Purkinje fiber
PEA with inconsistent waves
Treatment of second-degree heart block
Only monitor, electrodes may be causing it
What is the treatment of second-degree heart block?
Pacemaker needed
What will the blood pressure be like with a patient with a second-degree heart block?
SBP lower than 60
What is asytole?
What should we check?
Flatline non-shockable rhythm
Check second lead, could be be VFib
What is preload?
When does it increase?
Volume of blood in ventricles at end of diastole (end diastolic pressure)
↑= hypervolemia, regurgitation, heart failure
What is afterload?
When does it ↑?
↑ afterload =↑ _____
Resistance LV must overcome to circulate
↑ in HTN and vasoconstriction
↑ afterload =↑ Cardiacworkload
Epinephrine
Low doses?
High doses?
Low dose: ↑ CO, neutral SVR
High dose: ↑ SVR/CO
What 2 meds do we use for cardiogenic shock?
Dobutamine: ↑ CO, ↓SVR
Milrinone: ↑cAMP/ CO/ vasodilation, ↓ SVR/PVR
What does dopamine do?
Low dose: ↑ CO, UOP
High dose: ↑ CO/SVR/HR
What are the best 2pressers?
Levo and Vaso
Acronym for knowing what causes heart murmurs?
SPAMS
Stenotic valve
Partial obstruction
Aneurysms
Mitral/aortic regurgitation
Septal defect
