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N351: Pathophysiology I > Module 7 > Flashcards

Module 7 Flashcards

1
Q

Lymphatic System carries things …

A

too large to cross the capillary membrane

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2
Q

Right Lymphatic Duct

A

Top right quarter of the body drains here

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3
Q

Thoracic Duct

A

where 3/4 of lymph drains into

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4
Q

What is the “pump” and “pipes/tubes” of the cardiovascular system?

A

Blood vessels are the pipes and the heart is the pump

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5
Q

What is the function of the circulatory system

A

To deliver O2, nutrients, and other substances to all body cells

Remove waste products of cellular metabolism

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6
Q

Intrinsic Regulators of the Circulatory System

A

Nervous System

Endocrine System

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7
Q

How does the circulatory system interact with the digestive system?

A

Digestive system supplies the nutrients

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8
Q

How does the circulatory system interact with the respiratory system?

A

Supply O2, Remove CO2, Maintain acid-base balance

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9
Q

How does the circulatory system interact with the renal system?

A

Waste removal from blood, fluid and electrolyte balance, and acid base balance

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10
Q

Pulmonary Circulation

A

Right heart pumping deoxygenated blood to the lungs for gas exchange

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11
Q

Systemic Circulation

A

Left heart pumping oxygenated blood to the rest of the body for delivery of O2 and nutrients and removal of wastes and CO2

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12
Q

Arteries

A

Carry blood AWAY from the heart

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13
Q

Capillaries

A

closest contact and level of EXCHANGE between the blood and interstitial space (interstitium) or the cellular environment

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14
Q

Veins

A

Carry blood TOWARD the heart

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15
Q

Lymphatics

A

carry plasma from the interstitium to the heart

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16
Q

How are vessels named (arteries, veins, etc)?

A

After their direction of flow, not whether they carry oxygenated/deoxygenated blood (since the pulmonary artery carries deoxygenated and pulmonary veins pump oxygenated blood)

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17
Q

Arteriovenous Malformation

A

condition where arteries and veins attach / get tangled up and disrupt normal blood flow (normal exchange thus cannot occur without that capillary there)

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18
Q

Where does the heart lie?

A

obliquely (at an angle) in the mediastinum (area above diaphragm and between the lungs; forces left lung to be different from right)

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19
Q

Dextrocardia

A

when someone’s heart is on the RIGHT instead of the left

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20
Q

Size and Weight of the heart?

A

Less than a pound and about the size of a fist

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21
Q

Functions of the Heart Wall and Fibrous Skeleton?

A

Enclose and support heart (allow heart to stay in place)

Divide the heart into 4 chambers

Possesses the valves and great vessels

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22
Q

Function of Valves

A

direct blood flow through opening and closing (issues may lead to backflow)

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23
Q

Function of great vessels

A

conduct blood to and from the heart cells

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24
Q

Coronary Circulation

A

Part of systemic circulation

Arteries and veins that serve the metabolic needs of the heart cells through coronary vessels that branch and penetrate the heart

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25
Q

What blood is NOT a part of coronary circulation?

A

Any blood pumped elsewhere in the body

Blood in the ventricles and inside the heart do not supply coronary circulation

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26
Q

Nodes

A

specialized heart cells that generate action potentials (sinoatrial and atrioventricular)

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27
Q

Function of Nerves and Specialized Muscle Cells in the Heart?

A

direct rhythmic contraction and relaxation and propel blood through pulmonary and systemic circuits

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28
Q

Ectopic Beat

A

a beat that lies outside the specialized heart cells and does not follow the normal electrical pathway

Basically, an extra beat before a normal beat (common and may feel like an extra beat or like your heart is skipping a beat)

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29
Q

Intercalated Discs

A

microscopic discs connecting cells of the heart to allow impulses to travel through the cells for rapid depolarization, and allow muscles to contract simultaneously in the right and left side in order to give a coordinated pump

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30
Q

Pericardium

A

Double walled membranous sac that encloses the heart (we have parietal and visceral)

(similar to the pleural lining in the lungs if you think about it)

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31
Q

Parietal Pericardium

A

OUTER layer of the sac surrounding the heart

It is a surface layer of mesothelium over a thin layer of connective tissue

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32
Q

Visceral Pericardium

A

INNER layer of the sac surrounding the heart

Folds back AND is continuous with the parietal pericardium to allow large vessels to enter/exit the heart without breaching the layers / not let any fluid leak out

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33
Q

Pericardial Cavity

A

Fluid containing space between visceral and parietal pericardium

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34
Q

Pericardial Fluid

A

secreted by the cells of the mesothelium to lubricate membranes and minimize friction as the heart beats

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35
Q

Epicardium

A

another name for the visceral pericardium - outermost heart layer

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36
Q

Pericardial Effusion

A

Fluid entering the pericardial membrane and building up - thus preventing effective heart beating

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37
Q

Functions of the Pericardium

A
  1. Prevents displacement of the heart during gravitational acceleration/deceleration
  2. Provides physical barrier against infection and inflammation from the lungs and pleural space
  3. Contains pain and mechanoreceptors that elicit reflex changes in BP and HR
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38
Q

Mechanoreceptors (in the heart)

A

stretch receptors in the atria (muscles) that can respond to overstretching (ex: with too much blood coming back in)

As a response they secrete atrionaturitic factor which directs the kidneys to get rid of sodium (which water follows) to decrease volume and ease the heart

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39
Q

Pain Receptors (in the heart)

A

React to low oxygenation in the heart - when the heart muscle is starved - which leads to anginal pain

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40
Q

Myocardium

A

Actual Cardiac Muscle

Anchored to the heart’s fibrous skeleton

Thickness varies between chambers, and is r/t the amount of resistance that area of muscle must overcome to pump blood from the different chambers

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41
Q

Thickest myocardial wall?

A

Left Ventricle - it has to go against systemic blood pressure (120/80)

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42
Q

Why is the right ventricle wall not as thick as the left?

A

It is about as thick as the right atrial wall because it only needs to push against pulmonary pressure (25/10) which is a great difference from the systemic pressure of the left

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43
Q

Endocardium

A

Internal lining composed of connective tissue and squamous cells

It is smooth so that way the blood flow is smooth through the heart (its the layer touching the blood inside)

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44
Q

What kind of circuit does the endocardium make ?

A

a continuous closed circuit

it is continuous with the endothelium that lines arteries, capillaries, and veins

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45
Q

What can a lack of a closed circuit lead to ?

A

Debris collection and clotting (atherosclerosis)

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46
Q

How do the atria differ from the ventricles?

A

they are smaller with thinner walls (R - 2 mm , L - 3-5 mm)

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47
Q

Atria

A

thinner walls of the heart

serve as storage units and conduits (passive filling) for blood

offer little resistance to flow of blood into ventricles

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48
Q

What sort of processes occur in the atria ?

A

Passive Processes - but, there is a tiny atrial contraction (kick) at the end

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49
Q

What can atrial failure lead to ?

A

Decrease in cardiac output

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50
Q

Ventricles

A

Thicker myocardial layer making up the bulk of the heart (R- 3-5 mm; L- 13-15 mm)

Propel blood through pulmonary and systemic circulation

Right and left are shaped differently

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51
Q

Mean Pulmonary Pressure

A

about 15 mmHg

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52
Q

Mean Arterial Pressure

A

about 92 mmHg

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53
Q

What is the most muscular portion of the heart?

A

Left Ventricle

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54
Q

What can ventricular failure lead to?

A

DRASTIC decrease in cardiac output

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55
Q

Right Ventricle shape

A

shaped like a crescent or triangle and acts like a bellows to propel large volumes of blood through a very small valve into the low pressure pulmonary circulation

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56
Q

Left Ventricle shape

A

Larger and Bullet shaped

pumps blood through a large valve opening into the higher pressure systemic circulation

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57
Q

Septum

A

separates the sides of the heart

also carries the bundle of HIS beyond the AV node

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58
Q

Interatrial Septum

A

Separates the right and left atrium

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59
Q

Interventricular Septum

A

Separates the right and left ventricles

It is an extension of the fibrous skeleton of the heart

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60
Q

What are heart valves?

A

Indentations of the endocardium

Separate the atria from the ventricles (AV) and the ventricles from the aortic and pulmonic arteries (Semilunar)

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61
Q

When do heart valves open and close?

A

With pressure changes within the chambers

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62
Q

Atrioventricular valves

A

AV Valves

open at the beginning of Diastole and allow blood to fill the ventricles

Close at the beginning of ventricular contraction to prevent backflow of blood into the atria

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63
Q

Semilunar Valves

A

open at the end of ventricular contraction when the pressure in the ventricles exceed the pressure in the pulmonary artery and aorta

Close at the beginning of ventricular relaxation as the pressure in the chambers drops below the pressure in the pulmonary artery and aorta to prevent backflow of blood into the ventricles

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64
Q

AV Valves open at the start of ___

A

Diastole (which is the ventricular filling)

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65
Q

AV Valves close at the beginning of ___ ___

A

ventricular contraction

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66
Q

Semilunar valves open at the end of ___ ___

A

ventricular contraction

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67
Q

Semilunar valves close at the beginning of ___ ___

A

ventricular relaxation

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68
Q

Chordae Tendinae

A

connect valve leaflets or cusps to papillary muscles (extension of the myocardium)

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69
Q

Papillary Muscles

A

Extensions of the myocardium that pull the cusps or leaflets together and downward at the beginning of ventricular contraction to prevent backward expulsion of the AV valves into the atria

They hold the leaflets closed during ventricular contraction

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70
Q

The ventricles are NEVER what ?

A

Fully emptied of blood

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71
Q

When the atrial kick occurs, pressure in the ventricles ___ and they will contract as the ____ valves close. ___ valves then open to do contraction firing of blood from the ventricles, making the pressure ____

A

rises ; AV ; Semilunar ; Drops

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72
Q

What are the two AV valves

A

Tricuspid and Mitral

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73
Q

What are the two semilunar valves

A

Pulmonic and Aortic

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74
Q

Largest diameter valve

A

Tricuspid

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75
Q

Valve resembling a cone shaped funnel

A

Mitral

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76
Q

Valves behave like..

A

one way swinging doors

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77
Q

Valves with 3 cup-shaped cusps

A

Pulmonic and Aortic

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78
Q

Pulmonic cusps are ___ than aortic

A

thinner

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79
Q

Great Vessels include …

A

Superior and Inferior Vena Cavae
Pulmonary Artery
Pulmonary Vein
Aorta

All are part of systemic circulation, but in reality pulmonary artery and vein are not since they handle blood from an to the lungs

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80
Q

Superior and Inferior Vena Cavae

A

Enter the right atrium

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81
Q

Pulmonary Artery

A

carries deoxygenated blood from the right ventricle to the lungs

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82
Q

Pulmonary Vein

A

carries oxygenated blood from the lungs to the left atrium

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83
Q

Aorta

A

delivers blood to systemic vessels which carry it to the rest of the body

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84
Q

Diastole

A

Relaxation Phase

Blood fills the ventricles as it passively flows through the atria

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85
Q

Systole

A

Contraction phase

Blood pumped out of the ventricles into circulations

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86
Q

Why is there a split in ventricle ejection between left and right?

A

Right ejection occurs slightly earlier due to pressure differences and the size of the lumen being different

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87
Q

What occurs first, atrial systole or ventricular systole?

A

Atrial Systole

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88
Q

What leads to atrial contraction/atrial kick?

A

Blood enters the atria from vena cavae and coronary sinuses to the right side –> on the left blood enters through 4 pulmonary veins (2 L and 2R) –> The atria fill up and distend –> AV valves open –> Blood passively fills the ventricles –> Atrial kick actively then pumps additional blood into the ventricle before ventricular contraction occurs

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89
Q

If there is no atrial kick, what can happen?

A

You can lose 25 mL

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90
Q

Most ventricular filling occurs during …

A

the first third of ventricular diastole (its a passive fill)

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91
Q

Phases of the Cardiac Cycle

A

4 Phases

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92
Q

Phase 1 of the Cardiac Cycle

A

“Isovolumetric Contraction”

This starting point is ventricular systole

Ventricular volume is constant and the increase in pressure due to this closes the AV valves

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93
Q

Phase 2 of the Cardiac Cycle

A

The semilunar and AV valves are initially closes as the ventricles squeeze on blood to raise pressure, which causes the semilunar valves to open as the ventricles contract and eject blood into circulation

Intraventricular volume and pressure decrease

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94
Q

Phase 3 of the Cardiac Cycle

A

Isovolumetric Relaxation

Semilunar valves close as the pressure goes down and the ventricles relax (but not all blood leaves the heart)

Pressure decreases in the ventricles, semilunar valves close, ventricles relax

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95
Q

Phase 4 of the Cardiac Cycle

A

Decrease in ventricular pressure opens the AV valves

This leads to passive ventricular filling from the atria into the ventricles followed by the kick

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96
Q

Isovolumetric Ventricular Relaxation and Filling

A

Diastole (Phase 3)

0.4 Seconds

Once ventricles relax after systole, pressure drops below that in arteries making semilunar valves close

When pressure in ventricles drops below that in atria, AV valves open and allow for ventricular filling

Toward the end of diastole, the atria contract (kick) and eject 25% more blood volume into the ventricles (0.1 s)

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97
Q

Isovolumetric Ventricular Contraction and Ejection

A

Systole (0.3 s)

Pressure in ventricles became greater than atria, so the AV valves shut and isovolumetric contraction of the ventricles occurs

As pressure increases and becomes greater than the arteries, the semilunar valves open and blood is ejected into the pulmonary and systemic circulation

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98
Q

The First Heart Sound

A

0.14 seconds

This is the S1 and when the AV valves shut at the beginning of systole due to increasing pressure in the ventricles

The actual sound is because the valve shuts which makes surrounding tissue vibrate which makes blood flow turbulent in the area causing the LUB

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99
Q

The Second Heart Sound

A

0.10 seconds

This is the S2 and when the Semilunar valves shut at the end of systole due to falling pressure in the ventricles

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100
Q

Amount of blood circulated?

A

5 Liters

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101
Q

Physiologic Split

A

The aortic valve closes before the pulmonic valve during S2 by 0.02 to 0.04 to 0.06 sec during expiration and inspiration

This is to allow the same amount of volume to be pumped through both the pulmonary artery and aorta (the aorta lumen is larger) so basically the pulmonary artery gets more time pumping

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102
Q

What are the valves doing during Systole?

A

AV valves are closed (S1)
SL valves are open

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103
Q

What are the valves doing in Diastole?

A

AV valves are open
SL valves are closed (S2)

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104
Q

S1 is heard…

A

as first heart sounds when the AV valves close

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105
Q

S2 is heard…

A

as second heart sounds when SL valves close

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106
Q

S3

A

can be heard as a third heart sound ventricular wall compliance is decreased and structures in the ventricular wall vibrate

The wall is stiff leading to extra noise on filling the atria or tensing of tensae chordae

Is not necessarily a non-normal finding

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107
Q

When is S3 a normal finding?

A

If its found in individuals younger than 30 years of age - its like how a new baseball glove has less give than a used one - it is not necessarily pathonomic

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108
Q

What conditions COULD cause S3?

A

congestive heart failure
valve regurgitation

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109
Q

S4

A

A fourth heart sound

NEVER NORMAL, ALWAYS BAD

can be heard on atrial systole if resistance to ventricular filling is present

may sound like DE LUB DUB (DE LUB DUB DUB if S3 is present)

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110
Q

What may cause S4?

A

Not so much related to heart failure

Related to:

Cardiac Hypertrophy
Disease
Injury or Ventricular Wall

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111
Q

Blood in the heart chambers …

A

does NOT supply O2 or nutrients to heart cells

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112
Q

Coronary Ostia

A

openings in the aorta that direct blood into coronary arteries

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113
Q

Coronary Sinus

A

an opening into the right atrium from the coronary veins

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114
Q

Coronary Arteries

A

Traverse the epicardium and branch several times to provide the heart with O2 and nutrients

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115
Q

Parts of the Right Coronary Artery

A

Conus
Right Marginal Branch
Posterior Descending Branch

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116
Q

Parts of the Left Coronary Artery

A

LAD
Circumflex Artery

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117
Q

Conus

A

right coronary artery

supplies blood to upper right ventricle

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118
Q

Right Marginal Branch

A

right coronary artery

traverses right ventricle to the heart apex

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119
Q

Posterior Descending Branch

A

right coronary artery

supplies smaller branches to both ventricles

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120
Q

LAD

A

Left Anterior Descending Artery (anterior interventricular artery)

Supplies blood to portions of the left and right ventricles and much of the interventricular septum

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121
Q

Widowmaker

A

An LAD blockage that can cause the ventricles to die and often kill a person

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122
Q

Circumflex Artery

A

Left Coronary Artery Branch

Supplies blood to the left atrium and lateral wall of the left ventricle

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123
Q

The right and left coronary arteries feed …

A

not just the muscles (mechanical part) of the heart, but also the electrical parts

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124
Q

Collateral Arteries

A

connections between two branches of the same coronary artery or connections of branches of the right and left coronary arteries

Form as a part of angiogenesis

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125
Q

When do collateral arteries spawn?

A

As we age and grow they are made through angiogenesis

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126
Q

What happens if atherosclerosis plaque is blocking a coronary artery?

A

collateral arteries via angiogenesis forms to allow new mediums of blood movement

they flow around blockages to still allow blood to flow

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127
Q

What heart layer has more collateral arteries?

A

epicardium has more than endocardium

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128
Q

Collateral circulation ____ the heart

A

protects

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129
Q

What can help form collateral arteries after an MI?

A

monitored exercise

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130
Q

What is the difference in mortality between MI in young and older people?

A

Younger people with MI are more likely to die because they have not yet formed the collateral arteries like an older person has

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131
Q

At what level does coronary circulation exchange occur?

A

the coronary capillaries

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132
Q

How many capillaries are there ?

A

1 PER CARDIAC MUSCLE CELL

3300 Capillaries per square millimeter

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133
Q

Why is cardiomegaly/hypertrophy so dangerous?

A

The increase of the heart muscle’s size is not accompanied by more coronary capillaries, so there is a supply and demand issue - the capillaries have to perfuse a larger area they were not designed to perfuse so O2 and nutrient exchange decreases thus causing hypoxia and angina

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134
Q

Coronary Veins

A

Most venous drainage occurs through these veins in the visceral pericardium

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135
Q

Great Cardiac Vein

A

smaller coronary veins feed into this greater vein which empties into the right atrium through the coronary sinus

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136
Q

Coronary Lymphatic Vessels

A

With cardiac contraction, lymphatic vessels drain fluid to lymph nodes in the anterior mediastinum which eventually will empty into the superior vena cava

This is important for protecting the myocardium against injury

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137
Q

Cardiac Conduction System Path

A

Electrical Impulse –> Fiber Shorten –> Muscle Contraction –> Systole

Post Action potential –> Fibers relax –> return to resting length –> Diastole

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138
Q

The heart contains specialized cells that generate …

A

its own action potentials without stimulation from the NS

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139
Q

The heart has its own ___ system

A

conduction

140
Q

Nodes

A

concentrated areas of specialized cells in the heart that generate AP

141
Q

What provides regulation for the heart’s conduction system?

A

ANS via SNS and PNS nerve fibers that effect heart rate and diameter of coronary vessels

142
Q

____ & ____ affect strength and duration of Myocardial contraction and relaxation

A

Hormones and Biochemicals

143
Q

The conduction system requires a lot of …

A

O2 and nutrients since it is always beating the heart

144
Q

Cardiac cells have what 3 things that are not true of muscle cells?

A
  1. Automaticity
  2. Excitability
  3. Conductivity
145
Q

Automaticity

A

can generate and discharge an electrical impulse

146
Q

Excitability

A

can respond to an electrical impulse

147
Q

Conductivity

A

ability to transmit an electrical impulse from one cell to the next cell

148
Q

Chronotropic

A

Heart Rate

149
Q

Inotropic

A

Heart Contraction (Strength)

150
Q

Dromotropic

A

Heart Conduction (Speed)

151
Q

What receptors in the heart interact with EP and NEP?

A

Beta 1 is the predominant kind

152
Q

Another name for EP and NEP?

A

Adrenaline/Noreadrenaline

153
Q

SNS effects on Chrono/Ino/Dromotropic

A

Increases all

154
Q

PNS effects on Chrono/Ino/Dromotropic

A

Decreases all

155
Q

What receptor and neurotransmitter is used in the PNS on the heart?

A

Muscarinic receptors and Acetylcholine (cholinergic receptors)

156
Q

What receptor and neurotransmitter is used in the SNS on the heart?

A

Beta 1 receptors and EP/NEP (Adrenergic Receptors)

157
Q

Pacemaker of the Heart

A

Sinoatrial Node (SA Node) - which has the highest activity for generating a signal through depolarization of cells

158
Q

Where is the SA node found?

A

Almost where the vena cavae come into the heart

159
Q

AP Pathway in the Heart?

A

SA Node –> AV Node –> Bundle of HIS –> Bundle Branches –> Purkinje Fibers

160
Q

What bpm can the SA node generate?

A

70-75 bpm

161
Q

What bpm can the AV node generate?

A

50 bpm (so if the SA node does not work there is a lower signal / chronotropism as a result)

162
Q

What bpm can the purkinje fibers generate?

A

15-30 bpm (which is not enough to keep you alive)

163
Q

Bundle branches from the Bundle of his go left and right allowing for what?

A

isovolumetric contractions (they also allow for the right ventricle / pulmonary valve to contract at a slightly different time than the left)

164
Q

P Wave on an EKG indicates

A

Atrial Contraction

165
Q

Where is the conduction pathway in the heart during atrial contraction?

A

from the SA node to the L/R atria to the AV node

166
Q

Where is the conduction pathway in the heart during Ventricular contraction

A

bundle of his to the R/L bundle branches to the Purkinje fibers

167
Q

QRS Wave on an EKG indicates

A

Ventricular Contraction

168
Q

T Wave on an EKG represents…

A

Repolarization

169
Q

ST Wave on an EKG represents

A

the beginning of relaxation after ventricular contraction

170
Q

Isoelectric Line

A

imaginary horizontal line under the EKG

171
Q

What does it mean if the ST wave (repolarization) drops below the isoelectric line?

A

It may be indicative of Ischemia in cardiac muscle tissue

172
Q

What does it mean if the ST wave (repolarization) does not reach the isoelectric line?

A

It could indicate infarction (tissue death)

173
Q

What can a peak T wave indicate?

A

Hyperkalemia

174
Q

Hyperkalemia

A

too much Potassium (K+) in the blood

175
Q

Depolarization

A

Activation - inside of the cell becomes less negatively charged due to a greater number of positive ions going into the cell

176
Q

Repolarization

A

Deactivation - becomes more negative again as positive ions leave

177
Q

Membrane Potential

A

Electrical (voltage) difference across the cell membrane that is related to changes in permeability of the membrane to sodium and potassium

178
Q

Threshold of Fire

A

Depolarization - point at which the cell membrane’s selective permeability to sodium and potassium is temporarily disrupted

179
Q

Hyperpolarization

A

Resting membrane potential becomes more negative than it initially was

could be due to hypokalemia (low potassium)

180
Q

The membrane pump ___ a passive process

A

is not

181
Q

What is the ratio of Na pumped out to K pumped in generating the resting membrane potential?

A

3 Na are pumped out for 2 K in for every ATP expended

182
Q

Level 4 is the resting membrane potential set by K… what is the voltage

A

-96 mV

183
Q

What sets the threshold to fire?

A

calcium

184
Q

Repolarization prevents ..

A

summation/Tetany - so many firings from occurring that the heart cannot pump

185
Q

Absolute versus Relative Refractory Periods

A

these are periods of repolarization when another firing cannot occur yet

In absolute, the firing cannot occur at all and is near the initial drop on the diagram

In relative, this is the second half of the drop that could potentially get a strong enough signal to fire again before reaching rest

186
Q

What can occur in a relative refractory period?

A

Arrhythmia

187
Q

As heart rate increases, ____ decreases

A

Diastole (little filling can occur leading to disorientation from the brain not getting enough O2)

188
Q

Increase in the heart rate leads to increased…

A

metabolic demand, O2 consumption, and glucose consumption

189
Q

Normal Heart Rate

A

60-100 bpm

190
Q

Sinus Tachycardia

A

> 100 bpm

191
Q

Sinus Bradycardia

A

< 60 bpm

192
Q

What does Sympathetic Stimulation from the ANS do to the heart?

A

Releases NEP –> increase heart rate, conduction speed through AV node, atrial and ventricular contractility, and peripheral vasoconstrition

193
Q

When does Sympathetic stimulation occur?

A

when a decrease in pressure is detected

194
Q

What does Parasympathetic Stimulation from the ANS do to the heart?

A

Releases Acetylcholine –> Decreases HR, lessens atrial and ventricular contractility and conductivity

195
Q

When does Parasympathetic stimulation cocur?

A

When an increase in pressure is detected (vasodilation occurs to counteract it)

196
Q

80% of NEP turns into…

A

EP

197
Q

The only input for PNS on the cardiac system is through …

A

the vagus nerve

198
Q

ECG/EKG

A

Electrocardiogram

Common, noninvasive diagnostic test that evaluates heart function by recording electrical activity

can show ST depression and Peak T wave abnormalities

199
Q

How to implement the ECG?

A
  1. Determine whether the client can lie still, breath normally, and refrain from talking
  2. Reassure them an electrical shock WILL NOT OCCUR
  3. Document all their meds that may influence results
200
Q

ECG P Wave represents

A

contraction of the atrial muscles / atrial depolarization

201
Q

ECG QRS complex represents

A

Contraction of the ventricles / ventricular depolarization

This is when the conduction signal is moving through here

202
Q

ECG T Wave represents

A

electrical changes during the relaxation phase of the ventricles / ventricular repolarization

203
Q

Why can’t we see Atrial repolarization on an ECG?

A

the QRS complex covers it up since it occurs at the same time

204
Q

On an EKG we cannot see …

A

the atrial “kick”

205
Q

What can ST wave elevation indicate

A

infarction of cardiac tissues

206
Q

What can ST wave depression indicate

A

hypoxia/ischemia/interrupted blood flow

207
Q

What can a Peak T Wave indicate

A

too much potassium

208
Q

Echocardiogram

A

Laboratory, noninvasive procedure using an ultrasound (most uncomfortable part is the gel)

Gel is applied to chest and a transducer is moved over the area to make an image of the internal heart structures like wall movement, valve opening and closing, and blood flow through

Can take 0.5 to 1.5 hours to do depending on type of echo needed

209
Q

What does the echocardiogram evaluate?

A

How well the heart is moving

How well the valves are working

The size of the heart and its pumping chambers

How much blood when full and what was ejected from the ventricles

210
Q

How to implement an Echocardiogram?

A

determine the client’s ability to lie still, breath normally, and refrain from talking

211
Q

Ejection Fraction

A

measure of how well the heart is performing as shown by the echocardiogram

It is found by taking the measure of volume in the ventricle when full and volume in ventricle after ejection

212
Q

Exercise EKG

A

“Stress Test”

Exercise on equipment (most commonly treadmill) until ischemic ECG changes, angina, dyspnea, or SOB - occurs due to not enough O2 getting to myocardial cells thus triggering pain receptors

Noninvasive (invasive if used with radionuclide)

Studies heart during activity and detects coronary artery diseases

consent form needed due to potential complications

213
Q

Exercise ECG should not be performed when …

A

There is:

significant aortic stenosis

Untreated HTN

CHF

unstable angina

214
Q

CHF stands for

A

Congestive Heart Failure

215
Q

Significant Aortic Stenosis

A

Cannot open the aortic valve fully, thus leading to not being able to increase blood supply well, and thus could send someone into anginal attack with ECG changes

216
Q

Unstable Angina

A

Pain in myocardial muscle tissue from unknown reasons

217
Q

Persantine

A

for patients who cannot do exercise

it causes dilation of coronary exercise to make you feel like you exercised

218
Q

What may be added during an exercise EKG?

A

Radionuclide studies (Thallium)

219
Q

Bruce Protocol

A

Increasing the incline and speed of the stress test every 3 minutes until either target heart rate is reached with no issues or some other problem occurs

A cardiologist must be present for the test

220
Q

What sort of patients get an Exercise EKG?

A

ones who are suspected of having heart disease or a blockage in order to better evaluate, so long as they have not had an MI

221
Q

What to do Preprocedure for an Exercise Test?

A

Ensure informed Consent

Ensure client has adequate rest the night before

Instruct client to eat a light meal 1 to 2 hours before

Instruct client to avoid smoking, ROH, and caffeine prior to procedure

Ask physician about taking prescribed meds on day of procedure

Instruct client to wear nonconstructive, comfortable clothing and supportive shoes

222
Q

What to do Postprocedure for an Exercise Test?

A

Instruct client to notify the physician if any chest pain, dizziness, or SOB occurs

Instruct client to avoid hot bath/shower for at least 1 to 2 hours post procedure (as it can cause vagus response)

223
Q

Holter Monitoring

A

A noninvasive test where client wears a Holter monitor and an ECG tracing is recorded continuously over a period of 24 hours or more

Not used as much now that we use event monitors which are smaller, lightweight, and disposable

Its like a continuous ekg

224
Q

What does a Holter Monitor do?

A

it takes an ECG tracing and can ID disrhythmias while evaluating the effectiveness of antidysrhythmics or pacemaker therapy

225
Q

Implementation of Holter Monitoring

A

Instruct client to resume normal daily activities and to maintain a diary documenting activities and any symptoms that develop

226
Q

Coronary Arteriography

A

An invasive cardiac catheterization that is the most precise means to document presence of CAD

It takes X-Rays of the heart and tells presence of CAD and measures LVF (Left ventricular function)

227
Q

The gold standard of cardiac tests?

A

Coronary Arteriography / Coronary Catherization

228
Q

When is a coronary arteriography indicated for patients?

A

Patients with:

Severe Angina

Recurrent Chest Pain of Uncertain Etiology

Survivors of Cardiac Arrest

Those suspected of CAD or an active MI

229
Q

What measurements of left ventricular function (LVF) does a coronary arteriography give?

A
  1. LVEDP (left ventricular end diastolic pressure)
  2. LVEDV (left ventricular end diastolic volume)
  3. Ejection Fraction (EF)
230
Q

The coronary arteriography can detect coronary artery stenosis (narrowing). What percentage of occlusion is significant?

A

greater than 70%

when it is this high there is limited flow and a heparinized stent needs to be put in place to hold the coronary artery open

231
Q

If someone is having an active heart attack, where do they need to go in a hospital and why?

A

They need to go to the cath lab immediately and have an occlusion opened in order to reperfuse the myocardium and prevent as much tissue death as there would have been

232
Q

Occlusion on a Coronary Arteriography appears as …

A

A space in a vessel with no coloring

233
Q

Layers of the Blood Vessels

A

Tunica Adventitia
Tunica Media
Tunica Intima

234
Q

Tunica Adventitia

A

Outermost vessel layer

connective tissue

prevents vessel from moving around

235
Q

Tunica Media

A

Middle vessel layer

vascular smooth muscle

Has its tone controlled by the SNS which determines vasconstriction or dilation

236
Q

Increased Tunica Media Tone leads to

A

Vasoconstriction

237
Q

Decreased Tunica Media tone leads to

A

Vasodilation

238
Q

What has little input on vasculature?

A

PNS

239
Q

Tunica Intima

A

Innermost vessel layer

very smooth single layer of cells permitting laminar blood flow

continuous with the heart

has no stop gaps for debris to collect or clots to occur

240
Q

Two types of Blood Vessesl

A

Resistance Vessels
Capacitance Vessels

241
Q

Resistance Vessels

A

Arteries and Arterioles

No Valves

Thick Muscular Walls

Work under high pressure, therefore no valves

242
Q

Capacitance Vessesl

A

Veins and Venules

Has Valves

Elastic and Distensible

High Capacity to Hold Blood

243
Q

At any time ___% (___L) of blood volume is in the arterial/resistance system, and ___% (__L) are in the venous/capacitance system

A

arterial - 25% (1.25 L)

venous - 75% (3.75L)

244
Q

The pressure in the right atrium is ..

A

almost zero

245
Q

SBP

A

Systolic BP

about 120 mmHg

Highest pressure achieved by contraction of L ventricle

246
Q

DBP

A

Diastolic BP

about 80 mmHg

Blood pressure maintained in aorta between ejections

247
Q

Which blood pressure permits a continuous forward flow of blood?

A

Diastolic Blood Pressure

248
Q

Pulse Pressure

A

SBP - DBP = Pulse Pressure

About 40 mmHg

249
Q

MABP

A

Mean Arterial Blood Pressure

An estimate reflecting average pressure during contraction and relaxation

Good indicator of tissue perfusion in critically ill patients

In premature infants, the MABP should match the gestational age

250
Q

CO

A

Cardiac Output

CO = Stroke Volume (SV) TIMES HR (SVxHR=CO)

ex: CO = 70 mL/beat x 70 beat/min = 4900 mL/min (~5 L)

251
Q

BP equation

A

BP = CP x TPR (Total Peripheral Resistance)

Could use Mean Arterial BP instead of TPR too

252
Q

About how many L of blood is re-circulated every minute?

A

5 Liters (4900 mL or so)

253
Q

SV

A

Stroke Volume

amount of blood ejected with each ventricular contraction

254
Q

What is the mean Stroke Volume?

A

about 70 mL/beat

255
Q

EDV

A

End Diastolic Volume

Total volume of blood in the left ventricle at the end of filling JUST PRIOR TO CONTRACTION

256
Q

About how much volume does the L ventricle hold?

A

about 100 mL

257
Q

What is the EDV a function of?

A
  1. Venous return to R atrium
  2. Strength of atrial contraction (kick) during ventricular filling
  3. Amount of blood pumped out of ventricle during last contraction
258
Q

ESV

A

End Systolic Volume

EDV - SV = ESV

Amount of blood left in heart after systole / after contraction

ex: EDV (100mL) - SV (70mL) = 30 mL ESV

259
Q

EF

A

Ejection Fraction

Percent volume of blood ejected with each ventricular contraction (about 55-75% of total ventricular volume)

EF = (SV/EDV) = (70mL/100mL) = 70%

260
Q

TPR

A

Total Peripheral Resistance (AKA: Systemic Vascular Resistance (SVR) or Peripheral Vascular Resistance (PVR))

Reflects the tone (Degree of vasoconstriction) of resistance vessels as well as the viscosity of the blood

261
Q

Vasoconstriction ___ BP

A

Increases

262
Q

Vasodilation ___ BP

A

Decreases

263
Q

Aortic Impedence

A

Loss of elasticity of the aortic walls (“stiffening)

Increases with aging AND functioning of the aortic valve

common in people >80

Aortic Narrowing Occurs –> L Ventricle must generate higher pressure to get blood through –> Ventricle Hypertrophy may occur

264
Q

Starling’s Law

A

The force of a contraction is directly proportional to the initial length of the cardiac muscle fiber at onset of contraction

Myocardial fiber stretch has an upper optimal limit, and when exceeded, contraction strength decreases
(Basically, if more blood goes into the ventricle a harder contraction occurs but if it keeps occurring contraction strength is loss as cardiac muscles stretch out)

265
Q

According to starling’s law, the degree to which heart muscle is stretched corresponds to …

A

EDV (end diastolic volume)

266
Q

Preload

A

Degree of myocardial muscle stretch / How much blood is returned to the right atrium

So, Increased preload –> increased stretch –> increased force of ventricular contraction

Related to the degree of compliance (ability to stretch) of the ventricular wall

267
Q

What things decrease compliance in the ventricular wall, leading to lower preload?

A

Ischemic heart muscle

Hypertrophied heart muscle

268
Q

Heart Failure does what to compliance?

A

Increases stretching, but without increasing the force of ventricular contraction

269
Q

Afterload

A

the pressure that the left ventricles has to push against (system pressure) - NOT amount of blood after contraction as that is ESV

The pressure the heart must overcome due to resistance of the aortic and pulmonic valves (aortic impedance)

Determined by the condition and tone of the aorta and resistance offered by systemic and pulmonary arterioles (TPR)

270
Q

Things that increase Afterload and what is leads to

A

Aortic Stenosis / Hypertension –> Increased Afterload –> Increased Cardiac workload and increased O2 consumption

271
Q

When myocardial contractility is increased…

A

More Blood is Ejected

Decrease in ESV

Increase in Systolic EF

272
Q

When myocardial contractility is decreased…

A

Less blood is ejected

Increase in ESV

Decreased Systolic EF

273
Q

The most important factor in ventricular performance is …

A

MYOCARDIAL CONTRACTILITY

274
Q

What influences ventricular performance and myocardial contractility?

A

Afterload
Preload
SNS Stimulation

275
Q

What is myocardial contractility dependent on?

A

Concentration of catecholamines in the heart muscle, so EP and NEP directly stimulating Beta Adrenergic receptors in the myocardium to increase contraction force

276
Q

Negative Iontropic Effects

A

Hypoxemia of Myocardium

Hypercapnia

Acidemia (Acidosis)

*All of these depress the myocardium

277
Q

What regulates BP?

A

ANS (SNS and PNS)

278
Q

The sympathetic nervous system uses ____ transmitters to ___ BP; The parasympathetic nervous system uses ___ transmitters to ___ BP

A

Adrenergic, Increase, Cholinergic, Decrease

279
Q

EP and NEP are Positive …

A

Inotropes
Chronotropes
Dromotropes

280
Q

What receptors does NEP go to?

A
  1. Beta 1 in the heart
  2. Beta 2 in the lungs
  3. Alpha 1 in Vascular Smooth muscle
  4. Alpha 2 in the CNS
281
Q

What nerve do PNS impulses travel on?

A

CN X (Vagus)

282
Q

What does cholinergic signals do to the heart?

A

Decrease HR and Force of Contractions (slightly)

Its a negative chronotrope, inotrope, dromotrope

283
Q

The cholinergic system has little control over…

A

blood vessels due to only one nerve pathway

284
Q

What happens when beta 1 receptors receive NEP?

A

Increase HR and Increase Force of Contractions in the heart

285
Q

What happens when beta 2 receptors receive NEP

A

bronchodilation of the lungs

286
Q

What happens when alpha 1 receptors receive NEP?

A

vasoconstriction of the vascular smooth muscles

287
Q

What happens when alpha 2 receptors receive NEP?

A

inhibition of CV center (where PNS works against things)

288
Q

Baroreceptors

A

Work to sense BP changes

289
Q

Where are important baroreceptors found?

A
  1. carotid sinus to monitor Bp in the brain
  2. Aortic Arch to monitor BP to the heart and make sure adequate blood flow gets to the brain
290
Q

Most important function of baroreceptors…

A

to modify BP during postural changes or valsava maneuver

291
Q

What do baroreceptors do exactly when change is detected?

A

Decreased BP –> Decreased Stimulation of Vasoconstriction and cardioinhibitory center to increase HR –> Increased CO and Increase BP

Increased BP –> Stimulation of vasodilation and cardioinhibitory center to decrease HR –> Decreased CO and Decreased BP

292
Q

Chemoreceptors

A

Sensitive receptors to O2, CO2, and H+ in the blood in order to do their primary function of regulation of ventilation

293
Q

Where are chemoreceptors located?

A

In the carotid bodies at bifurcation of common caoritds in aortic bodies of aorta

294
Q

How do chemoreceptors communicate, and when are they stimulated?

A

They are stimulated when arterial pressure drops below a critical level, and they communicate with the vasomotor center and induce widespread vasoconstriction to increase arterial pressure

295
Q

People with chronic lung disease may develop ___ and ___ ___ due to ____

A

systemic and pulmonary HTN d/t hypoxemia (related to chemoreceptors

296
Q

What secretes NEP and EP into the blood?

A

Adrenal Medulla (DUAL-LA)

297
Q

NEP and EP produce ____ chronotropic and inotropic responses

A

Positive

298
Q

NEP and EP hormones travel to the ___

A

heart

299
Q

When is the RAA system initiated?

A

when kidneys sense low pressure, and thus stimulate the SNS

Decreased Pressure in Renal Arteries –> Decreased Na in Renal Tubules –> SNS Stimulation

300
Q

What is the response to RAA initiation?

A

Juxtaglomerular cells secrete renin –> Renin turns angiotensinogen into angiotensin I –> Angiotensin I converted to Angiotensin II by ACE in the lungs –> Vasoconstriction occurs –> BP and Aldosterone levels increase –> Na and H2O retention by kidneys increase —> ECF Volume increases –> Increased BP

301
Q

How can RAA make heart failure worse?

A

The system increases volume and pressure when it drops which is supposed to compensate, but in this case causes increased volume and pressure leading to increased workload for an already struggling heart

302
Q

ADH

A

Antidiuretic Hormone / Vasopressin

Released when Plasma Osmolarity increases (blood is viscous) or BP decreases

potent vasoconstrictor

303
Q

What is the response to increased plasma osmolarity or decreased BP?

A

Posterior pituitary secretes ADH –> ADH directs water in the collecting ducts of the kidney –> Plasma volume increases –> BP and CO increase

304
Q

Angiotensin II is a potent ___

A

vasoconstrictor

305
Q

ADH is a potent ___

A

vasoconstrictor

306
Q

Atrial Stretch Receptors and ANP

A

ANP - Atrial Natriuretic Peptide / Factor

These two things react to the degree of distension of the Left Arterial walls during diastole

307
Q

Problem and Response of Atrial Stretch Receptors

A

Increased Venous Return (Increased BP) –> Increased heart firing rate –> ANP release stimulated from atrial walls –> renal arterioles vasodilate –> glomerular filtration rate increases –> aldosterone inhibited by increased urinary Na loss –> inhibits ADH release from posterior pituitary causing diuresis –> decreased blood volume and BP

308
Q

What does ANP effect?

A

It directs the kidney to get rid of sodium and the water follows it

309
Q

BNP

A

Brain Natriuretic Peptide

Released from ventricles in response to stimulus from ventricular stretch receptors

Opposes RAA activity and is MUCH stronger than ANP’s effect

310
Q

BNP correlates to …

A

Left Ventricular Pressure

311
Q

How does BNP oppose RAA activity?

A
  1. Vasorelaxation
  2. Inhibition of aldosterone secretion from adrenal gland and renin from the kidney
  3. Increased natriuresis and reduction in blood volume
312
Q

Natriuretic means …

A

opposes sodium

ex: BNP is a hormone opposing sodium and telling the body to rid of it

313
Q

____ is a good marker for heart failure with 300 picograms/mL indicating ___ heart failure, 900 picograms/mL indicating ___ heart failure, and 0.5 to 50 picograms/mL indicating ___ heart failure

A

BNP, mild, severe, no

314
Q

Blood pressure is a function of the ___ of the blood vessels

A

tone

315
Q

Essential Hypertension

A

Idiopathic (Don’t Know Why) HTN

Most common cardiovascular disorder

Primary (90%) and Secondary (<10%)

316
Q

What is the blood pressure reading on someone with essential HTN?

A

> 140 SYS OR >90 DIAS

317
Q

Essential hypertension is a strong risk factor for …

A

Heart disease (#1), Stroke (#3) and CRF (chronic renal failure)

318
Q

What is the number 1 killer?

A

HTN (as it causes heart disease) leading to more than 30,000 deaths per year in the US

319
Q

What is the prevalence of Essential HTN

A

60 million (20-25% of US population) and it increases with age

320
Q

When does essential HTN onset occur?

A

Males > Females

20s-30s

African Americans x2 more likely than Whites

321
Q

What are some risk factors increasing essential HTN chance?

A

Some modifiable and some not:

  1. Family History (2x more likely with one)
  2. Age (Increase with age)
  3. Race (more prevalent and severe in A Americans
  4. Obesity (2x more prevalent; especially in apple shape)
  5. Stress (increase BP with pain and family crisis, decrease BP with sleep and rest)
  6. Alcohol (more than 3 drinks a day)
  7. Oral Contraceptives (women over 35 and smoking at greatest risk)
  8. Na Intake (plays a part in some people’s HTN, and its role is unclear as a decrease does not necessarily mean decrease in BP)
322
Q

What body shape is at higher risk of HTN?

A

Apple body shape (Pear shape is okay because ab fat is active fat)

323
Q

Manifestations of Essential Hypertension

A
  • usually asymptomatic ( a silent killer)

complicates detection and treatment

Headache in a small # of patients upon awakening in occipital and neck areas

Nocturia (common early symptom indicating kidney losing ability to concentrate urine)

Ophthalmoscope will show retinal vascular narrowing, AV nicking, hemorrhages, exudates, papilledema (optic disk swelling - emergency as it means brain swelling)

324
Q

Diagnosis of Essential Hypertension

A

At least 3 BP measurements on 3 Different Occasions when it exceeds 90 DIAs or 140 SYS

BP must be taken when rested for at least 5 minutes, they have not smoked or had caffeine in the last half hour, and with a properly sized BP cuff

325
Q

Optimal Blood Pressure

A

< 120 sys AND <80 DIAS

326
Q

Normal Blood Pressure

A

< 130 sys AND < 85 DIAS

327
Q

High Normal Blood Pressure

A

130-139 sys OR 85-89 DIAS

328
Q

Stage 1 - Mild HTN Blood Pressure

A

140-159 sys OR 90-99 DIAS

329
Q

Stage 2 - Moderate HTN Blood Pressure

A

160-179 sys OR 100-109 DIAS

330
Q

Stage 3 - Severe HTN Blood Pressure

A

Greater than or Equal to 180 sys OR greater than or equal to 110 DIAS

331
Q

HTN in infancy is usually due to …

A

something different than in people 6+ (typically renal parenchymal disease)

332
Q

Most Adolescent and Adult HTN is due to ..

A

Essential Hypertension

333
Q

ISH

A

Isolated Systolic Hypertension

HTN in the Elderly

Stiffened arteries –> vessels without contractility during systole –> Increased systolic BP, decreased baroreceptor sensitivity, increase TPR, decreased renal blood flow

334
Q

BP in ISH

A

> 160 sys AND <90 Dias

335
Q

Complications of ISH

A

2x-5x increased risk of CV death (from AMI and CHF)

2x-3x increased risk of stroke (from TIA and CVA)

ISH must be treated to stop heart failure

336
Q

Secondary Hypertension

A

A type of essential hypertension that is NOT idiopathic ( a cause is known)

5-10% of HTN cases are this kind

337
Q

What may cause Secondary HTN

A

Renal Disease
Endocrine Disorders
Vascular Disorders
Chemicals / Medication

338
Q

Malignant Hypertension

A

DIASTOLIC BP above 120 mmHg

Is a medical emergency

A disease more prevalent in younger people (especially A American males, PIH, and those with renal disease)

It gives you a high risk of stroke

339
Q

Response/Manifestation of Malignant Hypertension

A
  1. AMI
  2. Renal Failure
  3. Intense cerebral arterial spasm to protect brain from excess pressure and flow –> cerebral edema and optic nerve swelling occurs –> HTN, Encephalopathy, headache, restlessness, confusion, motor/sensory deficits, visual disturbances
  4. can cause an emergency if anesthesia is taken with it present
340
Q

TOD

A

Target Organ Disease

HTN Progression can lead to this

Diseases of various organs (cardiac, arterioles, kidneys, etc) brought on by HTN progression

341
Q

Cardiac TOD

A

Increased L Ventricle Workload –> hypertrophy and increased O2 demand –> heart failure

342
Q

Why are coronary artery disease and HTN so dangerous together?

A

There is a decreased O2 supply with a larger O2 demand

343
Q

Arterioles TOD

A

smooth muscle hypertrophies –> decreased lumen diameter –> accelerates atherosclerosis

344
Q

Kidney TOD

A

Hypertrophy and sclerosis of arterioles and glomeruli –> decreased GFR –> abnormal concentrating/ diluting mechanisms –> nocturia, proteinuria, microscopic hematuria, CRF, urine with same tenacity as blood if the loop of henle is broken (isosthenuria)

345
Q

Examples of Other TOD

A

Aortic Aneurysm

Retinopathy

Cerebrovascular Diseaese

346
Q

Treatments for Hypertension are ___ Modifications

A

Lifestyle

347
Q

Lifestyle modifications to treat HTN

A
  1. Weight reduction to decrease heart work load (want to drop about 15%)
  2. Regular physical activity to lower resting HR and lower TPR
  3. Decrease alcohol intake
  4. Cease Smoking
  5. Decrease sodium and fat intake while increasing calcium, potassium, magnesium in diet
  6. Use Relaxation techniques to decrease resting HR and lower TPR

N351: Pathophysiology I (11 decks)

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