exam 2 CVD Flashcards
risk factors for heart disease
hypertension, hyperlipidemia, smoking, diabetes, obesity, poor diet, inactivity, excessive alcohol, family history of early onset of CAD or sudden death
TTE is what
noninvasive US of heart
done with probe outside anterior chest
harmless, high freq waves emitted from transducer penetrate the heart and reflect back as series of echos
TTE gives info about what
structure and fx of heart
dx pericardial effusion, valve disease, wall motion abnormalities, CM, aneurysm, congenital heat disease
color flow doppler TTE
direction of blood flow across regurgitant or stenosed valves
TEE
high freq ultrasound transducer placed in distal esophagus behind heart
TEE avoids interference from what
subcutaneous tissue, bony thorax, and lungs
TEE shows better visualization of what
MV, masses on valves, thoracic aorta, endocarditis
risk of TEE
esophageal perforation or bleeding
CI in pts with liver varices
ECG detects what
electrical activity of heart displayed in ECG tracings
ECG uses
Evaluate arrhythmias
Conduction defects (heart blocks)
Myocardial injury (ischemic events), damage, hypertrophy,
Pericardial disease (ie pericarditis)
Adverse reaction to medications (ie dig tox)
Electrolyte abnormalities (like hypo- or hyper- kalemia)
II, III, aVF
inferior leads
give info about RCA
aVL, I, V5, V6
lateral leads
LCx
V2, V3, V4
anterior leads
LAD
V1 and V2
septal
RCA, LAD, posterior wall
acute myocardial damage on ECG shown as
STE or inverted T waves
old MI on ECG
deep q waves
pericarditis on ECG
diffuse STE
how many leads show STEMI on ECG
2 leads
interfering factors of ECG
inaccurate placement of electrodes, tremors, e-lyte imbalances, meds (ie dig)
Why is an ECG ordered for a patient with CHF?
To check for dysrhythmias, and to assess for ischemia and scarring. The ECG may also point to another diagnosis like pericarditis or pericardial effusion.
List all the abnormalities that might be found on an echocardiogram study done on a patient with CHF.
left ventricular enlargement, little or no movement of some parts of the heart wall or septum, thinning of the myocardium, leaking of heart valves, low ejection fraction
What is the best echocardiogram test for an obese patient and why?
TEE because there is less tissue for the sound waves to penetrate and the images will be more complete and accurate.
Why would an ECG be ordered for a patient with suspected acute or chronic coronary artery disease?
To check for arrhythmia, acute ischemia and evidence of chronic scarring.
Does a normal ECG in the ED rule-out cardiac chest pain?
No. The ECG maybe normal in the ED when the patient has acute coronary insufficiency. The likelihood ratio for a negative test is close to 1 so the odds of having acute insufficiency are not changed much by a normal EKG.
most common CXR views
anterior chest against the digital or film cassette (the PA or posterior anterior view)
taken with the cassette close to the side of the chest (the lateral view
CXR primary uses - cardiac
to assess heart size ( suspect CHF )
to check for fluid in the lungs and pleural space (pleural effusion)
B-type natriuretic peptide(BNP, NT-Pro BNP)
Neuroendocrine peptides produced by ventricular myocardial cells in response to stretching
BNP, NT-pro BNP uses
Most useful as a test to rule out heart failure in an acutely dyspneic patient
Helpful prognosticator in patients with episode of decompensated heart failure that have known HF (compare with previous BNP to help guide prognosis)
BNP lab values
<100 pg/mL HF is unlikely
100 pg/mL - 400 pg/mL it is indeterminate, use clinical judgement
> 400 pg/ml, positive depending on age, sex and presence or absence of obesity
NT-Pro BNP (isolated peptide)
< 300 pg/mL HF unlikely
< 50 years of age; > 450 pg/mL HF likely
50-75 years; >900 pg/mL HF likely
> 75 years; >1800 pg/mL HF likely
bnp levels in women
tend to be higher when compared with men
bnp levels do what with age
rise
older ppl have higher baseline levels than younger ppl
bnp levels in obese ppl
tend to be lower
What factors influence the cut-off point for a BNP/NT-Pro BNP to help make a diagnosis of CHF?
age, sex, obesity
TLP includes what
total cholesterol high density or HDL cholesterol low density or LDL cholesterol Triglycerides (aka fat in the blood) Sometimes very low density or VLDL cholesterol is included
TLP goal in heart disease/high risk populations
raising HDL, lowering LDL
goal for LDL in ppl with minimal risk
130 mg/dL or less
goal for LDL in ppl with very high risk
70 mg/dl or less
USPSTF screening recommendations for lipid disorders
Men over 35 and women over 45
Start screening earlier if elevated risk
Repeat every 5 years if normal
age cut-off for screening is uncertain
Why would the practitioner order a lipid panel for a patient with coronary artery disease?
Because an elevated LDL and/or a low HDL are risk factors for progression of CAD. It is ordered as a baseline for treatment decisions.
stress test w/o imaging
ordered for pt with low probability of CAD
Sensitivity: 61-73% (not great), specificity: 59-81%
Exercise usually on a treadmill with the patient connected to an ECG machine for continuous monitoring.
Goal: get HR elevated
When 85% of predicted maximum heart rate is reached, the test is terminated
Determined by 220 – pts age x .85 = predicition
also terminated if ECG changes are suggestive of ischemia, ST segment variance > 1 mm = positive test.
stress test with imaging
Echo and Nuclear scans are done to increase sensitivity of stress testing (Sensitivity 81%, specificity 85-95%)
Nuclear: Myocardial Perfusion Imaging
Radiotracer injected, gamma camera used to scan before and after exercise to assess blood flow in the heart.
Looking for ST changes
Exercise causes the vasodilation
nuclear- myocardial perfusion imaging with regadenoson
Pharmacologic agent for those who cannot exercise: Regadenoson which causes vasodilation to coronary vessels.
Does not raise HR
Resting images are compared to stress images, look at blood flow in heart
Safe for ppl with impaired renal fx
Does not speed up heart, so it safe for a fib (will not cause RVR)
stress echo
Echo performed before and after exercise or infusion of dobutamine if unable to exercise
Do not use dobutamine for pt with a fib, will cause RVR
Looking for wall motion abnormalities with increase contractility
Do not want to see 1 wall that cannot keep up with the other walls w/ exercise
stress test recommendations
Performed when there is a possibility of cardiac disease but the chance of coronary artery disease is small enough that it is not necessary to take the patient directly to the cath lab.
Performed on low risk pts
duplex US
used to detect obstruction in larger arteries
carotid, femoral
recommended for symptoms of possible vascular obstruction
carotid duplex US recommendations
syncope (w/o clear etiology), TIA, frequent strokes, light headedness especially when looking up
femoral artery duplex US recommendations
claudication, non-healing foot ulcers in a patient without diabetes
holter monitor
continuous recording of a limited number of leads of the ECG
usually set for 24 hours and the patient keeps a log during that time recording chest pain or dizziness or other symptoms possibly related to the heart
TSH in cardiac disease
thyroid disease freq accompanies dysrhythmias such as tachycardia and a fib
hyperthyroidism with cardiac disease
can be correlated with tachycardia, a fib, elevated BP
hypothyroidism with cardiac disease
can be correlated with bradycardia, lipid disorders, pericardial effusions
CK-MB
enzyme produced by myocardial muscle when there is ischemia
CK-MB vs troponin, which is faster
CK-MB rises quickly and is cleared from blood faster than troponin
CK-MB can also rise with
shock, hypothermia, myocarditis, severe skeletal injury, myopathy
this limits the specificity of test
test of choice to dx or r/o myocardial ischemia
troponin
troponin is what
biochemical marker for cardiac disease
highly specific for myocardial cell injury
protein components for striated muscle
troponin levels change with time
elevate 2-3 hrs after injury
do 2-3 sets (q4-8 hrs) over 24 hrs
how long do troponins stay elevated after MI
7-10 days
also with cardiac surgery, stents
troponin limitations
falsely elevated with HD pts and in severe muscular injury
Why are troponins ordered for a patient who may have acute coronary syndrome?
Troponins are released from ischemic cardiac muscle so the concentration rises in the blood with ACS and other conditions that stress the heart such as pulmonary embolism and CHF. They are measured in some situations post coronary artery stenting or surgery to assess reperfusion.
What is the usual time-frame for the rise and fall of troponin levels after acute coronary obstruction?
Troponins are elevated as soon as three hours and remain elevated for 1 - 2 weeks after myocardial ischemia.
Under what circumstances would a Holter monitor be ordered?
Answer: Holter monitors are useful when the ECG in the office shows no dysrhythmia, but the patient has periodic chest pain, dizziness, palpitations, shortness of breath or syncope.
Why would the practitioner order an ECG for a patient with hypertension?
To check for dysrhythmia, cardiac hypertrophy, and evidence of coronary artery disease.
why would echo be useful for pt with HTN
to assess for cardiac hypertrophy
2nd right interspace
aortic area
2nd left interspace
pulmonic area
lower left sternal border
tricuspid area
apex
mitral area
blood flow through the heart
Superior and inferior vena cavas Right atrium and the right ventricle Pulmonary arteries Left atrium and left ventricle Aorta and the aortic arch
systole
ventricles contraction
The right ventricle pumps blood into the pulmonary arteries (pulmonic valve is open)
The left ventricle pumps blood into the aorta(aortic valve is open)
diastole
ventricles relax
Blood flows from the right atrium → right ventricle (tricuspid valve is open)
Blood flows from the left atrium → left ventricle (mitral valve is open)
PMI tapping per palpation
normal
PMI sustained during palpation
suggests LV hypertrophy from HTN or aortic stenosis
PMI diffuse during palpation
suggests dilated ventricle from CHF or cardiomyopathy
Harsh 2/6 medium-pitched holosystolic murmur best heard at the apex describes
mitral regurgitation
Soft, blowing 3/6 decrescendo diastolic murmur best heard at the lower left sternal border describes
aortic regurgitation
diastolic murmurs
MV stenosis , heard at apex, does not radiate, low pitch ruble with bell of stethoscope
systolic murmur
MV regurg
thrill
s3
tends to be early diastole, happens with increased ventiruclar filling
s4
right before s1, from ventricular stiffness, little laides with prolonged HTN, stiff ventricles
blood flow through cardiac valves
TPMA
Troponin T normal range
< 0.1 ng/ml
troponin I normal range
<0.03 ng/ml
