Perfusion: Myocardial Hemodynamics, Perfusion & Cardiac Cycle Flashcards
perfusion
- the process of nutrient delivery of arterial blood to a cap bed
- supplying an organ or tissue with oxygen and nutrients
What is the purpose of invasive hemodynamic monitoring?
- The primary purpose of invasive hemodynamic monitoring is the early detection, identification, and treatment of life-threatening conditions such as heart failure and cardiac tamponade
- ii. By using invasive hemodynamic monitoring the nurse is able to evaluate the patient.
What are noninvasive assessments of perfusion?
- LOC
- Skin: Tenting of skin
- Urine output
- Low because GFR is reduced
- Color, BP, HR
a. Cyanosis
b. Hypotension
c. Volume status is low so BP goes down - Heart rate
a. Tachycardia: The heart will try to beat really fast to try to compensate - Capillary refill time
a. Longer than 3 seconds
What are 3 types of perfusion scanning methods?
- CT
- MRI
Nuclear medicine perfusion
Cardiac output is characterized by what 2 things?
HR, SV
What is stroke volume made up of?
- preload
- afterload
- contractility
What 2 things make up preload?
- Central venous pressure
2. PAWP
What 2 things make up after load?
- SVR
2. PVR
What 2 things make up contractility?
- EF %
2. SV
What is a normal CO?
4-8 liters/min.
Why is cardiac index a better indicator vs CO?
Because it corrects for body size - someone who is smaller is going to need less pump
What is a normal CI?
2.4-4.0 L/min
What is stroke volume?
volume of blood pumped with each heartbeat
What is a normal SV?
60-70 mL with each ventricular contraction
What will a change in the heart rate have an immediate change in?
Change in the CO if the SV stays constant
What does a severe increase in HR cause?
A decrease in stroke volume, due to decreased filling time. This causes the CO to decrease
Tachycardia with CO?
Reduced CO
AFIB with CO?
reduced CO
Bradycardia with CO?
Increase in CO
Why is having a slow heart rate ok with CO?
Rate is not enough but if they are athletic then their cardiovascular function is very efficient – heart rate doesn’t have to be that high to maintain good heart function.
Vtach with CO?
decrease in CO
Asystole with CO?
Reduced CO
What happens if the SV stays the same but HR goes up?
CO goes up
What is preload?
- the amount of blood in ventricle at the end of diastole
2. the amount of stretch in the myocardial fibers at the end of diastole.
What does high preload mean?
high volume; large volume of blood returns from the venous system to the ventricle, the myocardial fibers are stretched.
What does low preload mean?
low volume; small volume of blood returns from the venous system to the ventricle, the myocardial fibers aren’t stretched
What is contractility?
pump function. The force of myocardial contraction.
What is contractility an indication of?
- INDICATION OF EF
2. CI AND CO ARE INDICATIONS OF CONTRACTILITY
What is after load?
the resistance the ventricle must overcome to eject blood
What does high after load mean?
vasoconstriction; decreased SV
What does low after load mean?
vasodilation; increased SV
So if after load increases then SV does what?
decreases; because there is more resistance pushing against the pump
What does preload represent?
the end diastolic ventricular volume (EDVV)
Preload is a function of what 2 things?
- volume
2. ventricular compliance
What are 3 factors that affect preload.
- volume - venous return, total blood volume, atrial kick.
- compliance
- stiffness and thickness of ventricular wall
Decreased preload is evident with?
a. Tachycardia
b. Decreased U/O
i. Reduced perfusion to the kidneys
c. Increase in specific gravity–> Dehydration
d. Dry mucous membranes
i. Dehydration
ii. Pinch skin it will not return to its normal
e. Tented skin
f. Sunken eyes
g. Orthostatic hypotension
Increased preload is evident when?
- JVD
a. Reliable indicator of volume/pressure in the right side of the heart - Pedal edema
- S3 (increased fluid), S4
a. S4 – S - Crackles
- Fluid overload
- Dyspnea
- Pink frothy sputum
a. Patient might need Lasix or any diuretic - Ascities, hepatic engorgement
What does an increase in JVD tells us?
An increase in JVD tells us about the patient’s CVP (central venous pressure)
- -> CVP low – hypovolemic
- -> CVP high – hypervolemic
How to measure JVD:
a. HOB 45 degrees
b. Head turned to right
c. Identify sternal angle
d. Locate superior sternal notch
e. Measure distance between top pulsation and sternum in centimeters.
What is normal JVD?
4 cm or less
What meds affect preload?
- fluids
- diuretics –> low CO because they are losing volume.
- Venodilators –> vessels are dilated, pressure decreases, low CVP.
a. Nitrates
b. Morphine
- -> Before giving, check vitals especially BP
- -> They may become hypotensive
- -> If their BP is too low, put them on something that doesn’t affect BP - Ace inhibitors
What is the frank starling law of heart regarding preload?
the heart pumps the amount of blood it receives w/each beat. Preload increases, SV increases. Preload decreases, SV decreases.
What is the physiological limit of the heart according to the frank starling law of heart?
300 mL of filling
What can too much preload cause?
cause excessive stretching of the myocardial fibers.
- the ventricles cannot effectively contract
- the SV goes down.
What 4 things affect preload?
- aortic impedance –> 1. Stenosis or regurgitation, there will be an interruption of forward flow
- blood viscosity –> 1. Thicker blood will be more difficult to push out
- blood volume –> 1. Hypervolemic = harder to push out
- vascular tone –> 1. Vessels are constricted which makes it harder for the left ventricle to push the blood out because the diameter is so low.
What does a high after load mean?
vessels are constricted
What are meds that can help with vasodilation?
nitroglycerin
What does a low after load mean?
vessels are dilated
What are meds that help with vasoconstriction?
norepinephrine and epinephrine
What is systemic vascular resistance with after load?
Afterload of the left side of the heart
What does a Low SVR mean?
dilation, so you need vasoconstriction
What is the formula for SVR?
MAP – CVP/CO x 80
What is a normal SVR?
800 - 1200
What is pulmonary vascular resistance with after load?
Resistance to ejection from right side of the heart.
What is a normal PVR?
50 - 250
What are s/sx of increased after load? - constriction
a. Pale, cool, clammy skin
b. HTN
c. Non-healing wounds
i. Low perfusion
d. Thick, brittle nails
e. Slow cap refill
f. Decreased urine output
What are s/sx of decreased after load? - dilation
a. Warm, flushed skin
b. Increased CO
c. Decreased BP
What is ohm’s law?
Pressure = flow x resistance Pressure = BP Flow = CO Resistance = after load
What is contractility?
the ability of a muscle to shorten when stimulated; the force of myocardial contraction.
What are 2 types of meds that are given to induce contractility?
- dopamine
2. digoxin
How is contractility measured? What is the formula?
a. EF
b. Ef = SV/EDV
What is a normal EF?
60-70%
What is the mineral used to control contractility?
calcium
- hypertensive –> calcium channel blocker
- hypotensive –> calcium
When do you see an increased contractility?
increased BP bc sympathetic nervous system stimulation
When do you see a decreased contractility?
- Hypotension
- Fatigue
- SOB
- Dizziness
- Low urine output
bc parasympathetic nervous system stimulation.
When is hemodynamic monitoring indicated?
a. Alterations in CO
b. Alterations in fluid volume
c. Alterations in tissue perfusion
What is CVP w/hemodynamic monitoring?
Volume/pressure on the right side of the heart
Where do you want to take CVP from?
distal port because that is the closest to the right atrium
What does CVP w/hemodynamic monitoring reflect? What does it guide?
Reflects filling pressures in the right ventricle. Guides overall fluid balance.
What are 2 noninvasive hemodynamic technologies?
a. Impedance Cardiography
- -> Assesses cardiac function by measuring resistance to the blow of high-frequency, low-amplitude current. Measures SV, CO, SVR, and contractility
b. Doppler Ultrasound
- -> Measures blood flow velocity in the vessel. Helps to determine CO, preload, afterload, and contractility
What are 3 minimally invasive hemodynamic technologies?
- CVP
- Arterial access line
- MAP
What is the formula for MAP?
Mean Arterial Pressure (MAP) MAP = ((SBP) + 2 (DBP))/3
When is an arterial line indicated?
a. Monitoring blood pressure
- -> Arterial line to measure because if a patient is taking a vasoactive medication you don’t want to have to take BP all the time.
b. Frequent ABG’s, labs
What is the difference between intra-arterial blood pressure monitoring and cuff monitoring?
a. A-line measures flow inside artery; cuff from outside artery
What are the number differences between intra-arterial blood pressure monitoring and cuff monitoring?
5-10 mmHg
When is a cuff unreliable?
shock or low CO
What is the Vigileo monitoring device system?
Minimally invasive; connects to existing arterial line; requires no manual calibration; automatically calculates hemodynamic values every 20 seconds; accurate when validated against swan catheter.
What does the Vigileo monitoring device system provide?
Data on…
a. CO – Cardiac Output
b. CI – Cardiac Index
c. Central Venous Oxygen Saturation: Determine oxygen extraction vs demand. Oxygen utilization.
d. Stroke Volume: Assessment of ventricular performance
e. Stroke volume variation: Variation in stroke volume given as a percentage. >15% may indicate hypovolemia
- -> Reaches 10-12 - stop giving fluids.
f. Systemic Vascular Resistance (SVR): Indicator of afterload.
What kind of measurements does the swan PA Cath provide?
a. Pulmonary artery pressure (PAP) (systolic, diastolic, mean)
i. Pulmonary hypertension
b. Pulmonary artery wedge pressure (PAWP , PCWP, wedge, LVEDP)
c. Central venous pressure (CVP, RAP, RVEDP)
d. Cardiac output (CO), cardiac index (CI)
e. Systemic Vascular resistance (SVR)
f. Pulmonary vascular resistance (PVR)
What are the advantages of a swan Cath?
a. Real-time data
b. Simultaneously measures a variety of hemodynamic parameters
c. Able to rapidly assess pts. Response to interventions.
What are the disadvantages of a swan Cath?
a. Infection
b. Insertion complications: pneumothorax, bleeding, damage to blood vessels or heart, dysrhythmias
c. Air emboli, exsanguination (loose connections)
d. Balloon rupture (rare)
e. Pulmonary artery rupture (rare)
What is a normal PAWP? What does it reflect?
4-12 mmHg; reflects left sided preload
What is a normal CVP? What does it reflect?
2-6 mmHg; reflects right sided preload
What is a normal PAP? What does it reflect?
20-30/10’s mm; reflects blood pressure in the lungs
What is a normal CO? What does it reflect?
4-8 L/min; volume ejected/minute with each beat
What is a normal CI? What does it reflect?
2.4 - 4.0 L/min; Volume ejected/minute with each beat
What is normal PVR? What does it reflect?
50-250 dynes/sec/cm-5; Reflects right sided afterload
What is normal SVR? What does it reflect?
800-1200 dynes/sec/cm-5; Reflects left sided afterload
What are 2 causes of elevated PA pressures?
- Pulmonic valve stenosis/calcification
2. pulmonary hypertension
What does pulmonic valve stenosis/calcification cause?
increased after load on the right ventricle
What does pulmonary hypertension cause?
increased after load on the right ventricle, which impacts right vent. emptying
What are interventions for PH?
- Find the cause/root of problem.
- Reduction in Preload (circulating volume).
- Decrease venous return to the right side.
- Increase/improve contractility.
- MEDS: Vasodilators (Viagra), diuretics, Na and fluid restriction, valve replacement/repair.
a. Aortic valve disease – fluid overload
KNOW THIS
i. Perfusion – supply of oxygen & nutrients
ii. Cardiac Output – Heart Rate X Stroke Volume
iii. Cardiac Index – Best indicator of cardiac function
iv. Preload – Blood presenting to both right & left side of heart
v. Afterload – resistance to contraction both right & left side of heart
What is ANP?
a hormone released during atrial stretch
What is BNP?
a hormone released during ventricular stretch
What is heart failure?
- a condition where the heart can not pump blood at a volume required to meet the body’s needs.
Heart failure occurs due to either…
- systolic dysfunction - poor contraction
2. diastolic dysfunction - poor filling. Or increased increased afterload
What are 5 possible causes of heart failure?
- CAD
- Valvular dysfunction
- Infection
- cardiomyopathy
- uncontrolled hypertension
What are 3 ways that heart failure may be discovered?
- acute MI
- Decreased exercise tolerance
- fluid retention
What 2 things are decreased with left HF?
- contractile function of the left ventricle
2. cardiac ouput
What are 2 things that are increased with left sided HF?
- SVR
2. after load
How does Left HF affect the lungs?
pulmonary congestion and edema. Crackles, rhonci, pink tinged sputum
What are manifestations of left HF?
i. Dyspnea
ii. Restlessness
iii. Confusion
iv. Tachycardia
v. Fatigue
vi. Cyanosis
vii. Orthopnea
viii. Nocturnal dyspnea
ix. Pulmonary edema
- decreased CO
- extra heart sounds
- pale, cool extremities
What is right heart failure?
defined as ineffective right ventricular contractile function
What are 3 causes of right heart failure?
- PE
- right ventricular infarct
- LVF
What are signs and symptoms of RVF?
a. JVD
b. Congestive hepatomegaly
c. Ascites
d. Periperhal edema (dependent)
e. Enlarged liver and spleen
f. Weight gain
g. Increased venous pressure
h. elevated CVP
- extra heart sounds
What is systolic heart failure?
decreased contractility of the heart muscle during systole
What are manifestations of systolic HF?
normal S/sx of HF combined with low EF
What are 2 causes of systolic HF?
- CAD
2. Non-ischemic cardiomyopathy
What happens with ventricles in systolic HF?
ventricular remodeling or hypertrophy
What are the effects of SHF to hemodynamics?
- LVEDV is high
- LVEDVP is high
- rise in left atrial pressure and pulmonary venous pressure
- increase in pressure in right heart
- right sided heart failure
and
pulmonary congestion and pulmonary edema
What is diastolic heart failure?
inability of the heart muscle (left ventricle) to relax, stretch, or fill during diastole
What patients are at risk of developing diastolic heart failure?
- CAD
- Myocardial Ischemia
- A.Fib
- Uncontrolled hypertension
- left ventricular hypertrophy or dysfunction
- cardiomyopathy
- infiltrative disease
- aging process
What is preserved in diastolic heart failure?
EF of 45% and above
What are clinical findings of diastolic heart failure?
a. Signs & Symptoms of Heart Failure
b. Normal or mildly abnormal LV Systolic Dysfunction
i. EF is a little low but ok
c. Abnormal Left ventricular relaxation, filling, diastolic distensibility, or diastolic stiffness
What are the hemodynamic effects of diastolic heart failure?
- increase in LVEDP –> decrease in LVEDV
During exercise - increase in LVEDP –> decrease in SV and CO
What is acute heart failure?
sudden heart failure, with no compensatory mechanism
What are s/sx of acute heart failure?
a. Symptoms similar to chronic heart failure, but more severe and start or worsen suddenly
b. Sudden fluid buildup
c. Rapid or irregular heartbeat (palpitations)
d. S3
e. Sudden, severe shortness of breath and coughing up pink, foamy mucus
f. Chest pain, if heart failure is caused by a heart attack
Why do you hear s3 with acute heart failure?
caused by oscillation of blood back and forth between walls of ventricles of blood from atria
What is a big difference between acute and chronic heart failure?
chronic heart failure patients have a structural heart chamber that is changing
true or false: patients with chronic heart failure are hypovolemic
false; hyper and they need a diuretic
What is the staple test for heart failure?
BNP
What suggests heart failure with BNP?
anything more than 100
What does a chest x-ray help with?
looking for enlarged and fluid buildup
What does an echocardiogram measure?
measures ejection fraction and structure
What are 3 other tests that can be done for HF?
- Stress test
- CT and MRI
- Coronary catheterization
What are 3 compensatory mechanisms for decreased CO associated with HF?
a. The Sympathetic Nervous System (SNS)
b. The Renin-Angiotensin-Aldosterone System (RAAS)
c. Ventricular Hypertrophy if hypertension is present
Describe the baroreceptor response:
a. Triggers brain
b. SNS activation
c. increase in HR, increase in contractility
d. increase in CO
Describe the RAAS response:
a. SNS (hypotension, sodium depletion, dehydration, serum albumin depletion, cardiac failure) signal kidney to release renin
b. Renin activates the conversion of the plasma glycoprotein from the liver to form angiotensin II by an enzyme in lung.
c. Angiotensin II is a very potent vasoconstrictor and stimulates aldosterone secretion.
d. Aldosterone acts on kidneys to retain water and sodium
e. Angiotensin II also stimulates the posterior pituitary gland to secrete ADH signaling kidneys to retain water increasing vascular volume.
f. increase in preload
g. increase in CO
Describe response to increase ventricular wall tension:
a. increase wall tension
b. myocyte growth
c. hypertrophy
What does ventricular remodeling do in regards to stiffness and compliance?
increase in stiffness, decrease in compliance
What are 3 groups of meds used to halt or reduce the progression of HF?
a. ACEI or ARB
b. Aldactone
c. Beta Blocker
- -> LOL
- -> Reduces HR and BP
What is the I NYHA functional classification for HF?
Normal ADLs do not initiate
What is the II NYHA functional classification for HF?
Normal ADLs initiate onset of sx, although sx resolve with rest
What is the III NYHA functional classification for HF?
Minimal activity initiates sx, no sx at rest
What is the IV NYHA functional classification for HF?
Any activity initiates sx and sx present at rest
What is a disease of the heart muscle affecting its ability to contract and adequately perfuse the body’s vital organs, a leaking and/or inflammation of the heart muscle?
cardiomyopathy
Cardiomyopathy is not often curable, so what are some ways that can help it?
a. Stop or slow the progression of damage to heart
b. Improve the function of the heart
c. Reduce or eliminate symptoms
d. Prevent sudden death
e. Treat comorbidities associated conditions that worsen heart function such as sleep apnea or CAD blockages
What is the most common test done for cardiomyopathy?
echocardiogram
What does an EKG show in cardiomyopathy?
wide QRS
Why is a ventriculogram used to diagnose cardiomyopathy?
A MUGA scan. Done in nuclear medicine and looks at pumping chambers of heart
–> Look at size, shape, and function of the ventricles
What are the 3 types of caridomyopathy?
- hypertrophic
- dilated
- restrictive
What is hypertrophic cardiomyopathy?
- thickening of inter ventricular septum
2. enlargement of heart and heart cells
What is the likelihood of inheriting hypertrophic cardiomyopathy?
50%
What is an idiopathic cause of hypertrophic cardiomyopathy>
uncontrolled hypertension
What makes a pt. more likely to inherit hypertrophic cardiomyopathy?
genetic mutation occurs in the gene that codes for the sarcomere contractile protein in the heart.
How does hypertrophic cardiomyopathy affect flow of blood?
- increased resistance to flow from left atrium
2. left ventricle outflow restriction
How does hypertrophic cardiomyopathy affect the left ventricle?
hypertrophy and stiffness
How does hypertrophic cardiomyopathy affect hemodynamics?
a. LVEDP increase
b. increase in PA pressures/wedge venous pressure
What kind of symptoms will a patient have with hypertrophic cardiomyopathy?
a. Dyspnea –most common
b. Angina is common
c. Fatigue
d. Syncope
e. Palpitations/Sudden cardiac death SVT/Vtach.
f. Nocturnal dyspnea
g. SOB with exertion
What diagnostic tests would you see done on a patient with hypertrophic cardiomyopathy?
i. Echo: Determine extent of ventricular septum/ventricle thickening
ii. Holter Monitor: Presence of dysrhythmias and activity intolerance
What would an x-ray show for someone who has hypertrophic cardiomyopathy?
mild/moderate cardiomegaly
What would you hear with someone who has hypertrophic cardiomyopathy?
S4 heart sound. systolic murmur
What would an EKG show with someone who has hypertrophic cardiomyopathy?
- ST segment and T wave abnormalities
- AV dysrhythmias
What is the treatment goal for someone with hypertrophic cardiomyopathy?
to reduce contractility and relieve left ventricular outflow obstruction
What kind of meds would expect to see given to someone with hypertrophic cardiomyopathy?
- Beta blocker
- Ca channel blocker
- Anticoagulant if in Afib
- Antidysrhythmic
What meds do you want to avoid with someone who has hypertrophic cardiomyopathy?
Avoid inotropes and preload reduction meds
What kind of electronic implant devices would you with someone who has hypertrophic cardiomyopathy?
- AICD
2. permanent pacemaker
What might someone get replaced with hypertrophic cardiomypothay?
there mitral valve
What is patient education for someone who has hypertrophic cardiomyopathy?
i. Cardiac rehabilitation consult for less intense exercise
ii. Family genetic screening
iii. AICD
iv. Heart Transplant in small percentage
v. No Basketball!
1. At risk for infective endocarditis
vi. Prophylactic Antibiotics - prevent infective endocarditis.
What is the most common form of cardiomyopathy?
dilated
What are changes in the heart structure associated with dilated cardiomyopathy?
- dilation of the ventricles
- deign of myocardial fibers
- increased fibrotic tissue
- fibrotic tissue not pliable
Are SV and CO increased or decreased with dilated cardiomyopathy?
decreased w/low ejection fraction
What is grossly impaired with dilated cardiomyopathy?
systolic function
What is going to increase to compensate in dilated cardiomyopathy?
HR
What are some of the s/sx you would see in someone who has dilated cardiomyopathy?
- Syncope
- Fatigue
- Angina
- Pulmonary congestion
- Extra heart sounds, murmurs
- Atrial & Ventricular dysrhythmias
- Emboli formation within the heart muscle or pulmonary vasculature
Why is it common for pt.’s to experience clots in dilated cardiomyopathy?
a. Blood pools in the heart because it isn’t being pumped out, so it is very common for it to clot.
b. Clots will move to different parts of the body especially the lungs – causes pulmonary emboli.
What is a structural change associated with dilated cardiomyopathy?
cardiomegaly
What would you hear with a stethoscope in someone who has dilated cardiomyopathy?
- Aortic and mitral valve regurgitation = murmurs
a. Aortic – 2nd intercostal space right sternal border
What would an x-ray show for a patient who has dilated cardiomyopathy?
cardiac enlargement; left ventricular hypertrophy
What would an EKG show for a patient who has dilated cardiomyopathy?
- Sinus tachycardia
- Atrial/ventricular dysrhythmias
- ST segment and T wave abnormalities
- Conduction defects due to myocardial enlargement.
- V-Tach/ V-Fib
Most patients with cardiomyopathy require what?
a pacemaker
What are common meds you will see prescribed to someone who has cardiomyopathy?
a. Diuretics
b. Na restriction: Reduces preload
c. Ace inhibitors –vasodilator, lower BP improve blood flow and decrease work of heart
d. Beta Blockers – slow HR and increase filling time
e. Blood Thinners –> Because blood pools
f. Antidysrhythmics
a. Amiodarone b. Diltiazem
g. Nitroglycerine - Vasodilator
h. Inotropic agents – increase contractility
1. CO and CI are good indicators of contractility
What kind of electronic implant devices would you with someone who has dilated cardiomyopathy?
Pacemakers, AICDS, LVADS
What is the least common form of cardiomyopathy?
restrictive cardiomyopathy
What is restrictive cardiomyopathy?
Infiltrative process that results in fibrosis and thickening of myocardium due to fibrotic infiltration into the myocardium, endocardium, and subendocardium, which decreases ventricular stretch.
What is important distinction between hypertrophic and restrictive cardiomyopathy?
ventricles become stiff, but not necessarily thickened – basically the opposite of hypertrophic
How does restrictive cardiomyopathy impair diastole?
a. Ventricular filling effected during diastole.
ib. Ventricles unable to relax during diastole
How is CO affected in restrictive cardiomyopathy?
decreases because filling pressure increases
What is usually not affected in restrictive cardiomyopathy?
contraction
What is heard with a stethoscope in restrictive cardiomyopathy?
S4 heard (occurs after atria contract, at end of diastole – gallop) –> bc heart is not compliant
What are common s/sx you would see in a patient with restrictive cardiomyopathy?
- CHF
- Cardiomegaly
- Refractory Dysrhythmias
- Fatigue
- Persistent cough
- Activity Intolerance
What would be some pharmacological interventions you would see with restrictive cardiomyopathy?
- Diuretics –> only given for restrictive and dilated
2. Vasodilators
What kind of electronic implant devices would you with someone who has restrictive cardiomyopathy?
- Pacemaker
2. AICD
What would you restrict with someone who has restricted cardiomyopathy?
Na
What is important patient education for someone who has restricted cardiomyopathy?
i. Disease
ii. Medications
iii. Diet
iv. Exercise
v. Smoking cessation
vi. Signs & symptoms to monitor/report
vii. Daily weights
viii. Support groups
ix. Possible Transplantation
What is primary restricted cardiomyopathy associated with?
unknown
What is secondary restricted cardiomyopathy associated with?
CAD, MI, valvular disease, ETOH, severe HTN, viral infections, autoimmune disease
What does the AICD recognize?
Ventricular arrhythmias.
If pt. goes into v. fib what does the AICD do?
If pt. goes into V fib the AICD will shock them at a higher voltage.
What is the AICD do?
- Ability to pace
2. Ability to store retrievable data
What is the battery life for an AICD? When might it be needed to changed earlier?
3-5 years; battery change earlier if it is shocking the patient a lot of times
What is insertion like for an AICD?
frightening
What comes with the AICD that helps to turn off the defibrillator component? What does it continue to do though?
Magnet; pace the patient
What is important patient education with an AICD?
i. Extensive
ii. Know difference b/t MI and Cardiac Arrest
iii. Call MD / Keep a diary
iv. Driving, cell phones, MRI, arc welding
v. Shock (self & others)
What is the LVAD?
Bridge to implant
What does the LVAD help do?
takes over and assists the pumping role of left ventricle
What is the Intra-aortic balloon pump?
inflates during systoles so it can perfuse the organs. Deflates during diastole.
Where is the Intra-aortic balloon pump placed?
either the left or right groin
What does the artificial heart helped to do?
Preserve perfusion by taking over both ventricles and valves
What does the artificial transplant act as a bridge for??
Bridge to transplant for individuals who do not respond to treatment
What is total implanted permanent artificial heart intended for?
people not eligible for heart transplantation
What is a valvular disease?
When the heart valves that move the blood efficiently through the heart chambers do not fully “open” or “close”
What is impaired with valvular disease?
distal perfusion to the heart and tissues is impaired, which puts a strain on the myocardium.
What are the 2 valves that are most commonly affected?
- aortic
2. mitral
What are the 2 types of valvular disease?
- stenotic
2. Regurgitant
What does aortic valvular disease cause?
Causes a decrease in the blood flow from the left ventricle into the aorta and systemic circulation.
How does aortic valvular disease affect the left ventricle?
Causes increased left ventricular pressures –> causing left ventricular hypertrophy
What is the most common cause of aortic valvular disease?
pulmonary hypertension
What is another cause of aortic valvular disease?
rheumatic fever group A
Who is more likely to experience aortic stenosis:
a. patient with Congenital bicuspid aortic valve
b. patient with Rheumatic aortic valve disease
c. Patient with congenital tricuspid aortic valve
d. patient with Calcific (senile) aortic stenosis
a, b, d
Does aortic valvular disease have a slow onset or fast onset?
slow
What symptoms would you find in patients who have aortic valvular disease?
- Chest pain
- syncope due to decrease in CO
- Fatigue
- Nocturnal dyspnea
- Palpitations
- Systolic murmur(more commonly heard)
What would an echo of a patient with aortic valvular disease show?
show thickened and calcified valve that opens poorly, also heart chamber size
What would an X-ray of a patient with aortic valvular disease show?
dilation of the aorta
What would an EKG reflect of a patient with aortic valvular disease show?
heart thickening
What is considered the gold standard for diagnosis the severity of aortic valvular disease?
heart catheterization; there is a gradient to see if it needs replacement or repair
What is done annually on patients with aortic valvular disease?
echocardiogram
What do you want to avoid with aortic valvular disease? why?
strenuous exercise; i. decreases oxygen demand. Don’t want the heart to work hard
What might a doctor order for a patient aortic valvular disease?
antibiotic due to concern for infection
What does significant stenosis with aortic valvular disease require?
balloon valvuloplasty or aortic valve replacement
What is aortic regurgitation?
backward flow, so leaflets are not fully closed during diastole
What does aortic regurgitation allow?
allows some of the blood that was just pumped out of your heart’s main pumping chamber (left ventricle) to leak back into it.
What are s/sx associated with aortic regurgitation?
a. Fatigue and weakness with exertion
b. Shortness of breath with exertion or when you lie flat
c. Chest pain (angina) increasing during exercise
d. Syncope
e. Irregular pulse (arrhythmia)
f. Heart murmur not as commonly heard
g. Heart palpitations
h. Swollen ankles and feet (edema)
What is recommended for treatment of aortic regurgitation?
Early surgical intervention recommended due to increased risk of ventricular dysrhythmias and death
What are pharmacological interventions used for treatment of aortic regurgitation?
a. Dobutamine/Primacor
b. Inotropes (Dopamine)
What needs to be reduced in aortic regurgitation?
LVED pressure reduction
What is mitral valve regurgitation?
The flaps (leaflets) of the mitral valve weaken, causing blood to leak backward into the left atrium of your heart.
What is the most common cause of blood leakage in the mitral valve?
The most common cause of blood leakage is mitral valve prolapse, in which the leaflets bulge back into the left atrium as your heart contracts.
What happens when the mitral valve becomes stiff or scarred, and fails to open during diastolic filling?
mitral valve stenosis
Is mitral valve regurgitation going to have a slow onset or rapid onset?
slow onset
What will you hear using a stethoscope of someone with mitral valve regurgitation?
heart murmur
What are the symptoms that you would find in a patient who has mitral valve regurgitation?
c. Shortness of breath, especially with exertion or when you lie down
d. Fatigue, especially with exertion
e. Lightheadedness
f. Cough, especially at night or when lying down
g. Heart palpitations
h. Swollen feet or ankles
i. Excessive urination
What is a non-pharmacological way of a patient who has mitral valve regurgitation?
Restriction of activities that produce fatigue/dyspnea; optimize oxygenation
What is a pharmacological way of treating a patient who has mitral valve regurgitation?
- diuretics
- ACE inhibitors
- Nitrates
- Digitalis
- Might need a beta blocker at some point
Do younger patients or older patients get mechanical valves usually?
younger; younger than <65 or 70 years old.
What is a medication a patient would be on with mechanical valves?
anticoagulant therapy
What do mechanical valves increase?
increase durability
What are tissue valves made out of?
- porcine or bovine
What two medications would a patient with tissue valves be taking?
- lisinopril
2. metoprolol
Would someone with tissue valves receive anticoagulant therapy?
NO
Which last longer, tissue valves or mechanical valves?
tissue valves
How is mitral valve stenosis managed pharmacologically?
- blood thinners
2. antibiotics before procedures
How is mitral valve stenosis managed surgically?
- mitral valve repair or replacement
2. percutaneous balloon valvuloplasty
When would a percutaneous balloon valvuloplasty be contraindicated?
Not appropriate with too much calcium buildup or if clot present
What are the priorities of care when treating a patient with mitral valve stenosis? (4 things)
- Refer to POC for Cardiomyopathy
- Maintaining adequate cardiac output
- Optimizing fluid balance
- Providing patient education
What is an inflammation on the endothelial surface of the heart?
infective endocarditis
What is infective endocarditis the 4th most common cause of?
4th most common cause of life-threatening infectious syndromes (after urosepsis, PNA, & Intra-abdominal sepsis)
What patients are most at risk for mitral valve stenosis?
- Patients with congenital disease
- Valvular heart disease
- Prosthetic heart valves
- PMR & AICD
- Body piercing
- Intravenous Drug Use
- Degenerative Valve Disease
Which is the most common valve to be affected in infective endocarditis?
tricuspid valve
What are the 3 pathogens associated with infective endocarditis?
- Streptococcus
- Staphylococcus
- Enterococci
What is a common complication of infective endocarditis?
heart failure
What are 3 embolic complications of infective endocarditis?
a. Stroke – Emboli in the CNS
b. Pulmonary Embolism
c. Other Organs – liver, spleen, kidney, abdominal mesenteric artery, & peripheral vessels
How is infective endocarditis treated pharmacologically?
- IV Therapy of Anti-microbial Agents (4-6 weeks)
How is infective endocarditis treated surgically?
cardiac surgery
How to manage infective endocarditis as a nurse:
- timely antimicrobial administration to resolve the infection,
- prevent complication,
- provide pain medication, and
- Individualized patient education
