Knowledge Deficits Cardio (Exam 1) Flashcards
Stroke Volume is dependant on 3 factors, what are they?
- Contractility
- Preload
- Afterload
Stroke Volume Factors
What are 3 factors that affect contractility?
- End-diastolic Volume
- Sympathetic Stimuation (Norepinephrine and Epinephrine)
- Myocardial Oxygen Supply
Stroke Volume Factors
What affects Preload?
Review
The End-Diastolic Volume
- End-Systolic Volume + Venous Return
BP reading error related to positioning Technique
How would BP be affected if there is an Unsupported Feet?
It would be elevated 5-10mmHG
BP reading error related to positioning Technique
How would BP be affected if there is an unsupported back?
It would be elevated 5-10mmHG
BP reading error related to positioning Technique
How would BP be affected if there is a Full Bladder?
It would be elevated 10-15mmHG
BP reading error related to positioning Technique
How would BP be affected if there are Crossed Legs?
It would be elevated 2-8mmHG
BP reading error related to positioning Technique
How would BP be affected if the Cuff is over clothing?
It would be elevated 10-40mmHG
BP reading error related to positioning Technique
How would BP be affected if the arm is unsupported?
It would be elevated 10mmHG
BP reading error related to positioning Technique
How would BP be affected if the patient is talking?
It would be elevated 10-15mmHG
What is considered Normal Blood Pressure?
Less than 120mmHG (systolic) and Less than 80mmHG (diastolic)
What is considered “Elevated” Blood Pressure?
120-129mmHG (Systolic) and Less than 80mmHG (Diastolic)
What is considered “High Blood Pressure (Hypertension) Stage 1”?
130-139mmHG (Systolic) OR 80-89mmHG (Diastolic)
What is considered High Blood Pressure (Hypertension) Stage 2?
140 or higher mmGH (Systolic) OR 90 or higher (Diastolic)
What is considered “Hypertensive Crisis”?
Higher than 180mmHG (Systolic) and/or Higher than 120mmHG (Diastolic)
Outpatient HTN Management Algorithm
If you just took BP on a patient and they do not have Hypertension Diagnosis, and they have ≤ 139mmHG systolic and/or
≤ 89mmHG diastolic. What should be done after recieving the results?
- Inform the patient of the reading
- Education the patient on lifestyle modification
- Document blood pressure
Outpatient HTN Management Algorithm
If you just took BP on a patient and they DO have Hypertension Diagnosis, and they have ≤ 139mmHG systolic and/or
≤ 89mmHG diastolic. What should be done after recieving the results?
- Inform the patient of the reading
- Education the patient on lifestyle modification
- Continue current medication regimen
- Document blood pressure
Outpatient HTN Management Algorithm
If you just took BP on a patient and they do not have symptoms of HTN, and they have 140-179mmHG systolic and/or 90-109mmHG diastolic. What should be done after recieving the results?
wait 5 minutes and recheck
- Inform patient of reading
- Determine medication compliance, if appropriate
- Monitor during therapy intervention
- Document blood pressure
- Recheck at next therapy visit
–If still in abnormal range, notify physician
–If in safe range, continue to monitor
Outpatient HTN Management Algorithm
If you just took BP on a patient and they DO have symptoms of HTN, and they have 140-179mmHG systolic and/or 90-109mmHG diastolic. What should be done after recieving the results?
- Inform patient of reading
- Determine medication compliance, if appropriate
- Contact physician
- Obtain medical clearance prior to initiating exercise
- Document blood pressure
Outpatient HTN Management Algorithm
If you just took BP on a patient and they do not have symptoms of HTN, and they have ≥180mmHG systolic and/or ≥110mmHG diastolic. What should be done after recieving the results?
Wait 5 minutes and re-check
- Inform patient of reading
- Determine medication compliance, if appropriate
- Contact physician
- Physician determines next steps
- Hold Exercise
- Document blood pressure
Outpatient HTN Management Algorithm
If you just took BP on a patient and they Do have symptoms of HTN, and they have ≥180mmHG systolic and/or ≥110mmHG diastolic. What should be done after recieving the results?
- Inform patient of reading
- Determine medication compliance, if appropriate
- Contact physician
- Physician determines next steps
- Send to emergency, if unable to contact physician
- Hold Exercise
- Document blood pressure
What are some Pathologic Causes of Sinus Bradycardia?
- Depressed intrinsic SA node automaticity due to ischemic heart disease or cardiomyopathy
- Heart blocks
- Metabolic dysfunction (e.g., hypothyroidism)
- TBI and increased intracranial pressures (Cushings’ reflex)
What is important to know about Mild Sinus Bradycardia?
- Its usually asymptomatic and does not require treatment. More pronounced HR decline, usually in the setting of a pathological condition, could produce a fall in cardiac output with Sx of fatigue, light-headedness, confusion, and/or syncope
What might Sinus Tachycardia lead to? What signs should we look for?
If the heart rate is too high, cardiac output may fall due to the markedly reduced ventricular filling time. In these cases, look for signs of:
-Hypotension
-Acute Altered Mental status (AMS)
-Ischemic chest discomfort due to increasing myocardial oxygen demand but reduced coronary blood flow
-Acute Heart Failure
- In these cases, a higher level of medical attention is necessary in order to determine whether the patient’s tachycardia is producing hemodynamic instability and other S/S or whether the S/S are producing tachycardia
What is Supraventricular Tachycardia (SVT)?
Rapid heart rhythm originating above the hearts ventricles, typcially involving the atria or atrioventricular node
Supraventricular Tachycardia
What is Atrial Tachycardia?
Abnormal heart rhythm that is characterized by a series of three or more consecutive ectopic beats originating in the atria
Supraventricular Tachycardia
What is Atrial Flutter?
This is characterized by a rapid, organized, and regular atrial rhythm. It has a unique re-entrant circuit, usually in the right atrium, which leads to the classic “Sawtooth” patten seen on the ECG
- Usually has a rate of 250-350bpm
- Usually has more than 1 P wave before every QRS complex
Re-entrant Circuit: Self-sustaining electrical pathway in the heart in which the impulse continues to circle through the tissue, causing repeated stimulation and a rapid heartbeat
Supraventricular Tachycardia
What is Atrial Fibrillation?
The most common type of Serious Arrhythmia. This is characterized by a very fast and disorganized atrail rhythm, resulting from multiple ectopic foci and/or multiple reentry circuits generating electrical impulses in a chaotic manner. This leads to irregular rhythm known as “irregularly irregular” pulse.
- Erratic quivering or twitching of the atrial muscle
How can Atrial Flutter occur? What type of patients can this occur in?
The structural and functional changes to the atrial myocardium following an Myocaridal Infarction or other sources of myocardial injury (e.g., surgery) can alter normal electrial conduction paths and set up a reentrant circuit.
- Atrial flutters can occur in individuals with other pre-existing heart conditions (e.g., valvular disease, pericarditis), have renal failure, hypertension, or chronic lung disease
What can Atrial Flutter and Atrial Fibrillation result in?
Although they are not, in and of themselves, considered lifethreatening, they can lead to serious and potentially life-threatening complications if not properly managed:
- Stroke risk due to blood stasis
- Induce heart failure via tachycardia-induced cardiomyopathy
What may PVCs be an indication of?
Can be an indication of an underlying cardiac disorder and take on added significance in that case. In those cases, due to increased risk of life-threatening ventricular arrhythmias, placement of an implantable cardioverter-defibrillator (ICD) is typically recommended
- PVCs are common even among healthy people and are often asymptomatic and benign.
When are PVCs considered serious?
- When they are paired together
- When they are mulifocal in orgin
- When they are more frequent than 10 per minute at rest
- When they are more present in triplets or more
How is Ventricular Fibrillation characterized by?
What can VF progress to?
- Erratic quivering of the ventricular muscle and a cessation of cardiac output
- VF can further deteriorate to asystole if not treated
What is the difference between ST-Segment Elevation and ST-Segment Depression?
ST-Segment elevation is generally considered a medical emergency requiring immediate intervention, whereas ST-Segment depression may or may not be immediately life-threatening depending on the clincial contex
- ST-Segmetn Elevation MORE STRONGLY correlates with myocardial injury that has extended through the full thickness of the myocardium (i.e., transmural - “across the wall”)
In general, Arrythmias that increase in frequency or complexity with progressive activity/exercise are associate with what?
Associated with Ischemia or with Hemodynamic instability, these are more likely to cause a poor outcome than isolated arrhythmias
In general, Frequent and Complex Ventricular Ectopy during exercise, especially in recovery is associated with what?
Associated with increased risk for Cardiac Arrest
During exercise with atrial fibrillation/flutter, the signs & symptoms that may develop will largely depend on:
Sx of both atrial flutter and atrial fibrillation will largely depend on underlying ventricular rate
What is a Hypertensive Response to exercise?
- A SBP ≥ 210 mmHG in men and ≥ 190 mmHG in women during exercise is often considered a hypertensive response
- A DBP ≥ of 110 mmHG is often considered a hypersensive response
What is a Hypotensive Response to exercise? What is this often associated with?
- A decrease of SBP by > 10 mmHG with or without a preliminary increase is considered abnormal and often associated with myocardial ischemia, left ventricular dysfunction, and an increase risk of subsequent cardiac events
This is a serious concern
Pre-Exercise Screen
What is recommended for a person that does not participate in regular exercise and does not have CV, metabolic, or renal disease AND no S/S suggestive of CV, metabolic or renal disease?
- Medical Clearance is not necessary
- Light to moderate-intensity exercise recommended
- May gradually progress to vigorous-intensity exercise follwing ACSM guidelines
Medical clearance is approval from a healthcare progessional
Pre-exercise Screen
What is recommended for a person that does not participate in regular exercise and has Known CV, Metabolic, or Renal disease and Asymptomatic?
- Medical Clearance Recommended
- Following medical clearance, light to moderate-intensity exercise recommended
- May gradually progress as tolerated following ACSM guidelines
Pre-exercise Screening
What is recommended for a person that does not participate in regular exercsie and has any S/S suggestive of CV, metabolic or Renal disease (regardless of disease status)?
- Medical Clearance Recommended
- Following medical clearance, light-moderate intensity exercise recommended
- May gradually progress as tolerated following ACSM guidelines
Pre-exercise Screen
What is recommended for a person that does participate in regular exercise and does not have CV, metabolic, or Renal disease and S/S suggestive of CV, metabolic or renal disease?
- Medical clearance is not necessary
- Continue moderate or vigorous-intensity exercise
- May gradually progress following ACSM guidelines
Pre-exercise Screen
What is recommended for a person that does participate in regular exercise and has Known CV, Metabolic, or Renal disease and Asymptomatic?
- Medical clearance for moderate-intensity exercise NOT necessary
- Medical clearance (within the past 12 months if no change in S/S) recommended before engaging in vigorous-intensity exercise
- Continue with moderate-intensity exercise
- Following medical clearance, may gradually progress as tolerated following ACSM guidelines
Pre-exercise Screen
What is recommended for a person that does participate in regular exercsie and has any S/S suggestive of CV, metabolic or Renal disease (regardless of disease status)?
- Discontinue exercise and seek medical clearance
- May return to exercise following medical clearance
- Gradually progress as tolerated following ACSM guidelines
What is a Symptom (Sx) Limited/Max Exercise Test (ET)?
Exercise terminated at maximal exertion or clinical limitation
What is Submaximal Exercise Testing (ET)?
Exercise terminated on achievement of a predetermined end point
Examples of endpoints:
- x bpm above resting, & predicted max HR (PMHR), %HRR
- Targert RPE or Dyspnea rating
- Workload (e.g. MET, Watts)
- Time (e.g., 6 MWT)
- Distance (Cooper 1.5 mile run test)
What is Low-Level ET?
A subset of submax testing that is sometimes described as being useful in acute setting (e.g., post-MI/CABG) in attempt to identify the high risk patient (e.g., before discharging from acute care)
- Steady intensity or ramping/increasing workload to about 2-6 METs
What are the Absolute Indications that the patient is unstable and Treatment should (Totally) be withheld?
- S/S of decompensated Cogestive Heart Failure
- > 10 PVCs/minute at rest
- Mutlifocal PVCs, unstable angina, and ECG changes associatd with ischemia/injury
- Dissecting aortic aneurism
- New Onset (< 24 hrs) A-fib with rapid ventricular response (RVR) > 100bpm (at rest)
- 2nd degree-heart block coupled with ventricular tachycardia
- 3rd degree heart block
- Chest pain with new ST segment changes on ECG
What are the Relative (it depends) indications that a patient is unstable and treatment should be Modified or withheld?
- Resting tachycardia (especially if new)
- Resting SBP > 160 or DBP > 90 (Escpecially if new)
- Resting SBP < 80
- Ventricular ectopy at rest
- MI or extension of infarction within previous 2 days
- Uncontrolled Metabolic Disease (e.g., DM)
- Psychosis or other unstable psychologic condition
What are different methods to predict max HR and work capacity?
- 220-age= predicted max HR (PMHR)
(This may overestimate true HRmax in young adults and underestimate true HRmax in persons older than 40) - 208-(0.7 x age)
(This more accurately identifies true HRmax among healthy adults across the life span, Still has a wide variation of 10-12bpm)
-With this, you also multiply by 85% (.85) to get the endpoint bpm
What is the method to predict max HR and work capacity specifically for individuals on Beta-Blockers?
164-(0.7 x age)
What are some reasons for Termination of Submaximal Testing?
- Pt request to stop
- A predetermined physiologic or other end-point has been reached
- Technical failure of any monitoring equipment
- Excessive dyspnea (using 0-10 Borg scale; will depend on case by case level)
- Sustained ventricular tachycardia
- Changes to cardiac rhythm as assessed by ECG, palpation or auscultion
- SpO2 drops below prescribed levels
- ST-Stegmetn depression ≥ 1 mm or reports of sx that could be angina
- Max tolerable (Grade 3) claudication pain
- Decreased in SBP > 10 mmHG or if SBP decreases from resting value obtained in same postural position prior to testing
- Consider cut off at a exaggerated BP response (SBP > 210 mmHG or Diastolic >115 mmHG; this will vary case-by-case)
What would happen if you place a healthy person into Trendelenburg position?
- Increase Pre-load via Increasing venous return
- Increases contractility by increasing End-Diastolic Volume
How does the Renin-Angiotensin-Aldosterone System system (RAAS) control blood pressure?
Increases blood volume to increase Stroke Volume
