Final Exam (wk 1-4) Flashcards
Which 3 cardiac vessels make up 3-vessel disease
CAD in R coronary artery
LAD artery
L circumflex artery
What structures does the R coronary artery supply (6)
-R atrium and ventricle
-some L ventricle
-AV node
-SA node (60%)
-Bundle of his
What is the equation for cardiac output? Describe each component
CO = HR x SV
CO: amount of blood ejected from L ventricle per min
HR: beats per min
SV: amount of blood ejected from L ventricle per beat
What is preload?
Pre-stx to allow blood in
Increased preload —> increased SV
What is afterload?
Force of L ventricle to overcome aortic pressure to open aortic valve
Increased after load —> decreased SV
What is ejection fraction? What is the equation?
% of blood emptied from ventricle during systole
EF = SV/LVEDV
LEVDV: volume of blood before contraction
What are the 4 stages of the cardiac cycle?
Atrial contraction, isovolumetric contraction, ventricular ejection, isovolumetric relaxation
Describe the first stage of the cardiac cycle (atrial contraction)
-SA node sends signal to AV node, causing R atrium to contract
-pushes leftover blood (20%) into ventricle
-atrioventricular valves close
Describe the second stage of the cardiac cycle
-ventricles fill with blood, but not enough to push blood out
-electrical signal from bundle of his travels to R and L branches and purkinje fibers
-semilunar valves open
Describe the third stage of the cardiac cycle
-isovolumetric contraction helps ventricles contract and push blood through semilunar valves
-semilunar valves close and ventricles relax
Describe the fourth stage of the cardiac cycle
-semilunar valves closed but atrioventricular valves slightly open allowing ventricles to fill passively
Describe the BF to lungs
Deoxygenated blood from vena cava
R atrium
Via tricuspid valve
R ventricle
Via pulm valve
Pulm ARTERIES
Lungs
Describe BF to periphery
O2 blood from lungs
Pulm VEINS
L atrium
Via mitral valve
L ventricle
Via aortic valve
Aorta
6 layers of the heart (inner to outer)
Endocardium
Myocardium
Epicardium
Pericardial cavity
Parietal pericardium
Fibrous pericardium
How is myocardium different from skeletal muscle?
Automaticity; pacemaker cells keep the heart moving w/o conscious voluntary control
What are the 8 sections of the respiratory zone? Which are in the conducting and respiratory zone?
Conducting zone: Trachea, primary bronchus, bronchus, bronchi, bronchioles
Respiratory zone: respiratory bronchioles, alveolar ducts, alveolar sacs
What innervates the parietal pleura?
Phrenic and intercostal nerves
What muscles are involved with inspiration
SCM, scalenes, pec major, external intercostals, diaphragm
What muscles are involved with expiration
Internal intercostals, abdominals (rectus abd, external and internal oblique)
What is hemoglobin made of?
4 iron molecules (hemes)
4 protein molecules (globins)
What is pericarditis? What is the most common cause?
Inflammation of pericardium (usually serous pericardium) or pericardial fluid
Viral infection
S/S of acute pericarditis
-retrosternal chest pain (sharp/stabbing), might radiate to back and L mid trap
-intensifies w/ cough, deep breathing (pleuritic pain) or supine
-relieved w/ sitting up and leaning forward
-general malaise and fever (d/t infection)
What would you hear during auscultation in acute pericarditis pt?
Friction rub
What will reveal acute inflammation for pericarditis?
-labs: C reactive protein, troponin (will not continue to increase)
-echocardiography
What is constrictive pericarditis?
Chronic pericarditis or pericardial effusion —> results in thickening/scarring of pericardium
S/S of chronic pericarditis. Which is the most important to know?
-dyspnea and fatigue d/t reduced CO
-LE and abdominal swelling
-dizziness and syncope
-vague retrosternal chest pain
Jugular venous distention
How much fluid is in the pericardial sac?
15-50 mL
What is cardiac tamponade?
Lots of fluid in pericardial space exerts pressure on heart (medical emergency)
S/S of cardiac tamponade
-decreased BP
-hypoTN, shock
-decreased CO: dyspnea, fatigue, syncope, dizziness (cough, tachycardia, tachypnea)
What is Beck’s triad?
hypoTN, JVD, decreased heart sounds
Signs of cardiac tamponade
Tx for cardiac tamponade
-cardiac/pericardial window
-cut a hole in fibrous pericardium to allow fluid to drain and relieve pressure
Pericardiocentesis —> draw fluid out by inserting a needle/catheter
What is endocarditis? Causes?
Infection from bacteria or fungi
Dental work, GI/urinary procedures, catheters, IV, tattoos, drug abuse, rheumatic fever
S/S of endocarditis
-flu like symptoms: pain with breathing, SOB, swelling, fever
-rapid onset for acute
-possible mitral valve regurgitation on auscultation
Endocarditis tx
high dose long term IV abx
What is myocarditis?
-Inflammation of heart wall/mus
-affects pump and electrical
8 modifiable risk factors for CVD
-cholesterol
-stress
-diabetes
-diet
-HTN
-weight
-activity level
-tobacco
7 non-modifiable risk factors for CVD
-age
-fam hx
-genetics
-gender
-race
-chronic kidney disease
-low socioeconomic status
What type of event is stroke?
CV
What is white coat HTN? Who is it common among? When is it significant?
-elevated BP in office but normal at home
-common in older adults, females, non
-significant: >20/10 mmHg
What is masked HTN?
Office BP reading normal but home consistently above normal
3 symptoms of decreased CO
Dizziness, dyspnea, impaired ex tolerance
How do beta blockers impact HTN pts?
-impair thermoregulation
-blunt HR (won’t increase w/ ex)
-possible hypoglycemia
What is postural orthostatic tachycardia syndrome (POTS)?
Orthostatic intolerance disorder; rapid increase in heartbeat
-30bpm for adults
-40bpm for adolescents
-120 bmp within 10 mins of rising
S/S of POTs
Dizziness, lightheaded mess, fainting
What are 3 ways to help limit POTS?
-move LE before standing, move segmentally
-valsalva if not contraindicated
-pressure garments
Goal values for HDL levels in men and women
-men: >40mg/dL
-women: >50mg/dL
What are the 3 categories and values for LDL
-high risk: 160-189mg/dL
-borderline: 120-159mg/dL
-optimal: < 100 mg/dL
How to calculate the ration for total cholesterol? Higher/lower mean greater risk?
Total cholesterol/HDL
Higher ratio —> higher risk
What is more beneficial for CAD pts, exercise volume or intensity?
Volume
S/S of stable angina
-Levine sign
-tachycardia
-diaphoresis
-nausea
-dyspnea
Common triggers for stable angina
-high BP
-anemia (lack of O2, not enough Hgb)
-stress
-extreme cold
-heavy meals
-physical exertion
Stable angina PT implications
-30 to 60 min mod intensity (40-60% THR, 3-6 METS)
-avoid valsalva
-train major mus groups
-long warm up/cool down
S/S of MI
-chest pain >20 mins w/o relief w/ decreasing act or nitroglycerin
-dyspnea
-diaphoresis, cool, clammy skin
-n/v, weakness
-pulmonary rates/crackles (if HF present)
What are the 3 main types of cardiomyopathy. Briefly describe each
-dilated (ischemic or non-ischemic): enlarged L ventricle, systolic dysfxn
-hypertrophic: abnormal L ventricular wall thickness, diastolic dysfxn
-restrictive: abnormal L ventricular wall stiffness, diastolic dysfxn
Risk factors for dilated cardiomyopathy
Idiopathic, uncontrolled HTN, fam hx, inflam myocarditis, alcohol, metabolic, pregnancy related
Risk factors for hypertrophic cardiomyopathy
Genetic, autosomal dominant mutations
Risk factors for restrictive cardiomyopathy
Infiltrates; radiation therapy, scleroderma, fibrotic tissue (something damaged mus)
S/S of dilated cardiomyopathy
-decreased ejection fraction
-S3 heart sound and mitral valve regurgitation
-crackles/rales, dullness to percussion
-enlargement of heart in imaging (silhouette)
S/S of hypertrophic cardiomyopathy
-avg age 20
-dyspnea and angina (not d/t CAD)
-arrhythmias and syncope
-S4 sound
S/S of restrictive cardiomyopathy
-decreased CO
-fatigue and decreased ex tolerance
-systemic edema —> pulmonary congestion
-JVD, peripheral edema, hepatomegaly (lg liver)
-arrhythmias
How do you define HFrEF
reduced ejection fraction
HF w/ LVEF <40%
How do you define HFmrEF
mildly reduced EF
HF w/ LVEF 41-49%
How do you define HFpEF
HF w/ LVEF >50%
How do you define HFimpEF
HF w/ baseline LVEF of <40% a 10 point increase from baseline LVEF, and a second measurement of LVEF of >40%
9 common etiologies of HF
-HTN
-CAD/ischemia/MIA
-cardiac dysrhythmias
-cardiomyopathy
-valve abnorm
-chronic pericardial effusion
-PE
-pulm HTN
2 hallmark symptoms of L sided HF
Dyspnea and cough
4 hallmark symptoms of R sided HF
-jugular vein distention
-peripheral edema
-ascites and pleural effusion
-wt gain
3 signs of pulmonary congestion
Moist rales, wheezing, abnormal sputum
4 symptoms of L sided HF d/t diastolic dysfxn
-dyspnea
-cardiac asthma
-pulm edema
-hemoptysis (coughing up frothy stuff)
Orthopnea
Describe Class I of pt symps from NYHA
-No limitation of physical act
-no undue fatigue, palpitation, dyspnea
Describe Class II of pt symps from NYHA
Slight limitation; comfy at rest; ordinary PA causes fatigue, palpitation, dyspnea
Describe Class III of pt symps from NYHA
Marked limitation; comfy at rest; less ordinary act causes fatigue, palpitation, dyspnea
Describe Class IV pt symps from NYHA
Discomfort w/ PA; HF symps at rest
Compensated vs uncompensated HF
-pt dx w/ HF but not expressing signs of pulm/peripheral congestion vs. presence of new/worsening S/S that lead to unscheduled med care
What are 4 things to keep in mind when rehabbing HF
-interval training at low-mod intensity effective -prolonged warm up/cool down
-avoid valsalva
-LG mus groups, LE > UE for resistance
ACSM RPE for HF
6-11
CABG vs PTCA (percutaneous transluminal coronary angioplasty)
CABG: better long term outcomes, lower risk of CVA or MI, higher morbidity rate, longer recovery, more expensive
What is the most common CABG approach?
Sternotomy
Advantages of on pump (ONCAB)
-gives surgeon more time
-more complete vascularization
-better for emergent CABG
Disadvantages of on pump (ONCAB)
-“pump head”; post op cognitive decline
-S/S: delirium, cog changes, brain fog
-short lived 10-14 days
-can delay DC
Disadvantages of off pump (OFCAB)
-requires specially trained CV surgeon
-formation of clots
-arrhythmias
-kidney issues from loss of perfusion
-global hypoperfusion
-increased mortality risk
-higher risk of incomplete vascularization
Disadvantages of off pump (OFCAB)
-no need to stop the heart
-lower risk of clotting, arrhythmias, need for transfusions
-shorter hospital stays
Which harvest site is the best/“worst” for CABG?
Best: L internal thoracic (mammary) artery
Worst: saphenous vein (high re-occlusion rate)
Describe what a stenotic valve is and what it causes
-valve is stiff and won’t open d/t atherosclerotic plaque
-increases after load and work of heart
Describe what an incompetent valve is and what it causes. Which valves are the most common?
-“leaky”; allows back flow or regurgitation
-AV and mitral are most common
Risk factors associated w/ sternal wound complications (CABG PPT)
-obesity
-COPD
-internal mammary artery grafting
-DM
-increased blood loss/# transfused units
-high disability classification
-smoking
-prolonged cardiopulmonary bypass/surgical/time
-PVD
-prolonged mechanical vent
-female w/ large breasts
Between which two structures does an abdominal aortic aneurysm usually occur?
Aortic bifurcation and renal arteries
Abdominal aortic aneurysm risk factors
-SMOKING
-male > female
-atherosclerosis
-fam hx
-Caucasian
Absolute contraindications for heart transplant
-malignancy in last 5 years
-tobacco use < 6 months
-HIV
-significant COPD
-fixed pulm HTN
-hep b or c
Relative contraindications for heart transplant
-age >70
-active infection
-severe DM w/ end organ damage or poor glycemic control
-severe PVD
-BMI >35 kg/m^2
-severe HTN
-severe pulm dysfxn
What are the 3 surgical techniques for heart transplant
-heterotopic heart transplantation (piggyback)
-total transplantation
-biatrial technique
What is heterotopic heart transplantation — piggyback heart transplant
Native heart not removed, donor heart connected to native heart via R/L atria
What happens during a total heart transplantation
Complete excision of recipient atria w/ complete AV transplantation, bicaval and pulm venous anastomoses
Describe the biatrial heart transplant technique
Biatrial anastomoses where donor and recipient atrial cuffs are sewn together
Recipient’s SA node intact, donor’s is denervated
2 separate P waves on ECG
PT considerations with heart transplant pt
-infection control
-denervated heart (extended warm up/cool down)
-use RPE if HR is blunted
-SV and LVEF lower than norm
What are some rejection S/S of heart transplant? (7)
-low grade fever
-myalgia and fatigue
-hypoTN w/ activity but HTN w/ rest
-decreased ex tolerance and dyspnea
-arrhythmias
-wt gain d/t fluid retention
-decreased urine output
5 PT priorities post cardiac surgery
-pulm hygiene
-vitals
-wnd mg
-mobility
-DC planning
3 types of pacemakers
transcutaneous, transatrial, transvenous
Describe what a transcutaneous pacemaker is and use
-electrodes placed on chest wall
-short term, painful for pt
Describe what a transatrial pacemaker is
-electrodes placed on atrial
-not common
Describe what a transvenous pacemaker is
-electrodes placed on ventricle
-femoral a to vena cava through atria to ventricle
5 common indications for pacemaker
-SA node dysfxn (most common)
-2nd degree AV block w/ symp bradycardia
-3rd degree AV block w/ (symp brady, CHF, atrial fib or flutter)
-acute anterior MI
-severe bundle branch blocks
7 conditions that may warrant a pacemaker
-syncope
-dizziness
-CHF
-mental confusion
-palpatations
-dyspnea
-ex intolerance
What are the 3 modes of pacing for pacemaker? Briefly describe each
-fixed: preset rate
-demand: fires only when HR falls below preset value
-rate-responsive: fires depending on pt’s lvl of act
What is an ICD? Use?
-implantable cardioverter defibrillator
-shocks heart when life threatening arrhythmia detected
What is a CRT? Use?
-cardiac resynchronization device
-used w/ CHF, paces B ventricles at once
Pt edu for pacemakers and ICDS
avoid prolonged contact w/ electrical devices
3 post implant “protocols”
-sling on L arm x24 hrs
-avoid sh flex and ABD >90
-lift < 5lbs
What is another name for a holter monitor? Use?
-ambulatory electrocardiography device
-monitors electrical activity of hear for 24+ hrs
What is an LVAD? Use?
-L ventricular assist device
-mechanical pump that takes over damaged ventricle to restore norm BF
Describe the 2 types of LVADs
-pulsatile: older, noisy
-axial flow: continuous flow, quite, popular
2 main indications for LVAD
-bridge to transplant: heart transplant candidates waiting for heart
-destination therapy: long term, implant permanent
6 criteria for VAD implant
-at least 2 admissions to hospital
-not improving with meds
-hyponatremic
-hypovolemic
-ionotrope dependent
-EF < 35%
3 main purposes of ventricular assist devices
-restores CO and BP
-reduces L ventricle work and prevents further damage
-improves perfusion
What is the speed for heartMATE II?
8,000-10,000 rpm
What is the speed for heartMATE III?
5,200-6,400 rpm
3 descriptions for +++ pump flow
-BF moving over 10L/min
-lg pts
-could be indicative of clot forming in pump (let med team know immediatly)
3 descriptions for — pump flow
-BF moving less than 2.5L/min
-sm pts
-pt is hypovolemic and requires fluid bolus
When to stop tx and notify med team when working w/ pt on VAD?
if +++ or — is sustaining
What is an impella mechanical circulatory assist device?
-mini VAD that pumps blood from L ventricle into aorta
One type of pt an impella good for?
MI complicated by cardiogenic shock or needs circulatory support w/ CAD tx
Contraindications to PT with VAD
-VAD malfunction
-intra aortic balloon pump
-open chest
-active bleeding
-hemodynamic instability
-full ventilator support
PT after VAD placement; 6 things to do an look out for
-focus on fxn
-strict sternal precautions (no move in the tube)
-pulm care; careful w/ trendelenburg and percussion
-kyphotic posture -> decrease O2 flow
-HR may be blunted
-battery life
Exercise rx mgt for VAD placement
-RPE 11-13
-stop if symps of angina appear, dyspnea >5 on borg dyspnea scale
