Test 4 Flashcards
Pathway through the heart?
Superior and inferior vena cava
right atrium
tricuspid
right ventricle
pulmonic valve
to pulmonary artery
left atrium
mitral valve (bicuspid)
left ventricle
aortic valve
what artery in the body has de oxygenated blood?
Pulmonary artery
runs from right ventricle to the lungs
What is a normal amount of blood that is ejected by the heart each minute?
4-8L a min
What is a normal ejection fraction?
50-70%
Abbreviation for ejection fraction?
EF
How do you calculate the cardiac output?
Heart rate X Stroke volume
How do you calculate the BSA?
Weight X height
What is the cardiac index used for?
It is used for the cardiac needs based on the size of the body.
How do you calculate the cardiac index?
CO (which is HRXSV) divided by BSA (HtXWt)
What part of the beat is the ejection happening?
Systole when the ventricles are being contracted.
What is considered a low EF?
<45 can cause poor perfusion - cold extremities
<30 high risk for cardiac death
Is heart failure a progressive or acute disease?
This is a progressive disease.
What is another term to refer to heart failure?
Pump failure.
Since your heart is the pump for the body.
What are the types of heart failure?
Right sided heart failure
Left sided heart failure on systole or diastolic
With right sided heart failure where is the issue?
The right side is unable to pump the blood through the pulmonary arteries
What is the major cause of hospitalization in the elderly according to AHA
for those greater than 65 years old it is heart failure.
What are the common risk factors for heart failure?
Smoking
sleep apnea
CAD
obesity
diabetes
Hypertension
family history
substance abuse
severe lung disease
cardiac defects
valvular disease
How are the risk factors contributing to heart failure?
All of the risks are making the heart work harder, faster and not as efficiently.
How does CAD effect heart disease?
This is the hardening and narrowing of the arteries making the pressure of the blood go up. This makes the heart have to work harder to get past that obstacle.
Which side of the heart is the largest?
Left side
What is the main problem with left sided heart failure?
Inability to pump blood to the extremities. Poor perfusion to the peripherals.
With left sided diastolic failure what can’t happen?
Relaxation of the ventricle allowing for proper filling since the ventricle is stiffening.
With left sided systolic failure what can’t happen?
A proper squeeze or contraction of the heart. Leaving some blood behind in the ventricle not having a good enough EF.
With the left side failing either by failure to fully contract or fully relax what happens to the blood?
The blood will build up in the ventricle and backwards filling up around the lungs.
What is the classic sign of blood backing up to the lungs?
SOB as well fluid buildup in the lungs.
What are some signs and symptoms of left sided heart failure?
Crackles in the lungs upon auscultation (since fluid is backed up to the lungs)
Chronic cough
fatigue and weakness
Dizziness, and confusion
Angina
Pallor (pale skin)
tachypnea, and tachycardia
Weak peripheral pulses
SOB either when moving or while at rest
Murmur
gallop
Frothy pink sputum
What is another name for frothy pink sputum
hemoptysis
What is a gallup?
An abnormal heart rhythm (ventricles firing too quickly)
KEN- TU- KEY
Where is the best point to hear a murmur?
Erb’s point
3rd intercostal space on the left when patient exhales
How can you test for the EF?
Echocardiogram
ultrasound of the heart shows structures and the blood flow
If you have a low EF what else might you have?
Cold extremities
poor perfusion to the brain and extremities
poor tolerance to activity
When diagnosing HF what labs do you want to look for and why?
BNP- this is a protein that is released when the ventricles are being over stretched. (Always in the system but over 100BNP HF is highly probable)
CMP - this will look for if there might be any electrolyte imbalances as well as kidney function.
At what level is BNP a sign for HF?
If the levels are over 100.
what is brain natriuretic peptide
BNP
released from the ventricles when stretched
What are the diagnostic ways to diagnose HF?
Echocardiogram - EF, CO
Labs- BNP, CMP
Chest x-ray - Determines heart size if there is cardiomegaly
EKG - can be used to see if there is LV hypertrophy
What are the two diagnostic ways to see if there is any enlargement of the heart?
Chest x-ray
EKG
What’s the difference from right to left sided heart failure when diagnosing?
Left side will have build up around the lungs. Fluid buildup in the pleural effusion.
increased heart side mainly on the left side to compromise to keep pumping out blood to the body.
Common causes for right sided heart failure.
right sided MI
pulmonary hypertension
left ventricle failure
chronic respiratory disease
Where does the blood go in right sided heart failure?
Blood will back up to the body in the venous systems.
Causing edema
dependent pitting edema
JVD
What is the main problem with right sided heart failure.
right ventricles cannot efficiently pump not allowing for adequate emptying to the lungs.
What are some signs of right sided heart failure?
Weight gain
JVD
Dependent edema
distended abdomen
diuresis at night
Enlarged liver and kidneys
murmur
anorexia
How do you diagnose right sided heart failure?
Same as with left sided
Labs- BNP
chest xray
echocardiogram
EKG
Why do the liver and spleen enlarge with right sided heart failure?
The blood backs up in the body in the vascular space into the organs causing fluid buildup and enlargement.
what are the goals of treatment for HF?
Maximize CO
maximize perfusion
maximize gas exchange
reduce hospitalizations
Signs of worsening heart failure
excessive waking for urination at night.
new angina at rest or with movement
increased swelling and edema in legs/ ankles.
What is a concerning amount of weight to be gained in a week?
2-3 pounds in a day
5 pounds in a week
What are the three parts of the heartbeat that medications try to fix
preload- amount of blood that is returning to the heart
afterload- resistance the ventricles have to overcome to pump blood through the vessels. related to arterial pressure and vessel diameters.
Contractibility- the ability of the heart to squeeze in response of electrical activity.
What is preload
The amount the heart has stretched at the end of diastole
What is afterload
the pressure that that the ventricles have to overcome to push the blood out. Systolic pressure.
What medications are used to treat preload?
Diuretics
Loop diuretics First line
thiazide diuretics
What is a side effect of loop diuretics?
Hypokalemia
hypotension
hypovolemia
ototoxicity
headache
muscle cramps
excessive urination
How do loop diuretics work?
Inhibition of sodium and water reabsorption in loop of Henle and distal tubules
excretes water, sodium, potassium, magnesium, chloride and calcium
Torsemide
Loop diuretic
2X more potent than furosemide
Thiazide action
Works on the distal renal tubules.
promotes sodium, potassium, and water excretion.
How does thiazide help HF?
This will rid the body of fluids helping preload.
This medication also causes vasodilation lowering blood pressure.
What are some side effects to thiazide?
loss of K, ca, Mg causes muscle cramps.
acute angle glaucoma
loss of appetite
upset stomach
Potassium sparing diuretic
Spironolactone, - aldosterone antagonist
Medications used for afterload?
Vasodilators
when EF<40%
ACE
ARB
Beta blocker
What are some side effects of ACE inhibitors?
Hypotension
bradycardia
dry cough!
dizziness/ headache from low BP
What is the mechanism for ACE inhibitors?
Blocks the angiotensin converting enzyme from turning angiotensin 1 to angiotensin 2 in the RAAS system. 1 isn’t as potent of a vasoconstrictor as 2. lowering ones BP.
what’s a way to remember ACE medications?
-pril
Lisinopril
What do you need to check with afterload medications?
Daily weight
BP and HR before each administration.
Why would you use an ARB over an ACE?
If the patient is intolerant to ACE or if one alone isn’t getting the desired effect.
What is the action of ARB’s?
Blocks the receptors at the tissue for angiotensin 2. causes vasodilation and inhibits the secretion of vasopressin, and aldosterone.
What are aldosterone and vasopressin?
Anti-diuretic hormones
How can you tell an ARB
-sartan
What are some side effects for ARB’s?
Monitor for angioedema/ facial swelling
hyperkalemia
hypotension
What should you avoid when giving ARB’s?
NSAID’s
Will reduce the effects of the NSAID’s while increasing chance of kidney issues.
How can you tell if it is a BETA blocker?
- olol
Why would you use a beta blocker?
Reduces the cardiac workload
How do beta blockers work?
inhibits beta-1 adrenergic receptors
Side effects of a beta blocker?
Hypotension
bradycardia
dyspnea (serious complication)
What to watch with beta blockers?
Daily wt
BP/HR
Watch breathing
watch glucose if DM
use caution when changing positions -orthostatic hypotension
do not stop abruptly rebound hypertension
What are some medications that help contractibility?
Positive inotropes
What are some beta blockers for HF?
Metoprolol, atenolol, bisoprolol
How do positive inotropes help with heart failure?
These reduce the heart rate while improving the force in which the heart squeezes.
Digoxin
Cardiac glycoside
Contractibility medication
Positive inotrope medications
Digoxin
Milrinone
Dobutamine (IV only)
Digoxin mechanism of action?
inhibits sodium potassium ATPase pumps leaving more calcium in the myocardial cells for contractile cells.
What electrolyte effects digoxin?
Potassium
What is the narrow therapeutic window for digoxin?
0.5-2ng/ml
What are signs of digoxin toxicity?
N/V
yellow green halos around light
Serious toxicity- bradycardia/dysrhythmias
What position is good for left sided heart failure?
High fowlers
What are modifiable risk factors with HF?
Weight losing weight
Hypertension
smoking
stress
infection
life style modifications
diet
limit alcohol 1-2 drinks
na restrictions
manage diseases
What diet should patients be on with CHF?
DASH diet
limit sodium to less than 2g 1500mg a day
canned veggies
frozen meals
What medication should a patient worry if they get a dry cough?
ACE inhibitors
True or false patients should change positions slowly while on lasix?
True
might become orthostatic hypotension not enough blood moving to the head and will get lightheaded or dizzy.
Is paleness and cool extremities with urine output of 60 over 4 hours an improvement to CHF?
No these are worsening signs
What lab do you want to watch when giving digoxin and lasix?
Serum potassium since it effects the heart
Lasix gets rid of potassium
decrease in potassium as a direct role on digoxin toxicity
What would be common findings of right sided heart failure?
Dependent edema
diuresis nocturia
abdominal distention
What are some common findings in an assessment of left sided heart failure?
Cool extremities
pallor
dyspnea,
crackles in the lungs
fatigue
hemoptysis
What statement would confirm a diagnosis of heart failure?
I get out of breath walking up a flight of stairs.
Day to day activity showing signs of failure.
fatigue, shortness or labored breathing
With CHF you might see patients out of breath needing O2.
If on supplemental O2 what is the primary concern if they complain of difficulty breathing?
Make sure o2 is on and working
vitals to check to see if that is enough/ check BP
if not improving call rapid
What would you call the kind of CHF if symptoms from both sides are seen?
Swelling and hemoptysis
biventricular failure
What is a common combination of medications used for HF
lisinopril (ACE) works for afterload
Digoxin (cardiac glycoside) works on contractibility
furosemide (loop diuretic) reduces preload
Watch potassium labs.
What can chronic circulation disorders lead to?
MI, PE, stroke
What does heparin do and not do?
Heparin is an anticoagulant inhibiting clotting factor Xa
Heparin stops clots from forming
Heparin does not break up clots that have formed.
Arteriosclerosis
General hardening and loss of elasticity of arterial walls
Atherosclerosis
Buildup of plaques in the vessels
Risk factors for atherosclerosis
Elevated cholesterol >200
elevated triglycerides >150
elevated LDL >100
low HDL <60
hypertension
smoking
family history
DM
obesity
Atherosclerosis vs arteriosclerosis
Atherosclerosis is inside the vessel such as a buildup
arteriosclerosis damage to the vessel walls like decrease elasticity
What is the vascular system for?
Transporting waste and nutrients to the cells
What are the steps for atherosclerosis?
Vessel damage
inflammatory response
hardened thickened vessels
formation of plaques
If a plaque forms in an artery and blocks some of the flow what can happen?
Pain or difficulty walking or moving.
Narrow tube leading to higher blood pressure.
Can dislodge creating a emboli
What happens if the vessel if completely occluded?
Leads to cellular death distally to the occlusion.
What do you asses with atherosclerosis?
Bruit: a whooshing noise where the vessel is narrower
palpate all pulse locations
assess cap refill
PAD
Peripheral artery disease
obstruction of blood flow through the large arteries
Risk factors for PAD
Atherosclerosis -buildup of plaque
Smoking
hypertension
diabetes
obesity
sedentary lifestyle
What are non-modifiable risk factors for PAD
age
gender
ethnicity
family history
What are the 6 p’s for?
Arterial insufficiency
What are the 6 p’s?
Pain (numbness burning even at rest)
Pallor = paleness
Pulselessness = lack of a distal pulse such as feet pedal pulse
paresthesia = lack of sensation
paralysis = lack of movement
poikilothermia = coolness
Why does the skin turn pale/ white in arterial insufficiency?
Lack of blood flow
what are some other signs of arterial issues?
Hair loss
mottled skin
thickened toenails
dependent rubor (redness)
muscle atrophy
What is the first noticeable sign of PAD?
Intermittent claudication
What is intermittent claudication? Why do people care?
This is first sign people notice in PAD. Most common reason why people come in for PAD.
This is painful because of a lack of blood flow to the extremities usually one leg.
How do you fix intermittent claudication?
Rest and let it clear. Dangle the legs to have gravity help push blood through.
Dangle
elevate
Arteries A Dangle
Veins e Elevate
What are the two classifications for obstructions in PAD?
Outflow
inflow
What are the signs for an inflow obstruction?
Discomfort or pain in the butt and lower back.
Pain when walking or after walking
What are the signs of outflow obstruction?
Burning or cramping in the calves’ feet and toes.
Pain with walking or after walking.
Which obstruction usually causes the most tissue damage?
inflow usually doesn’t
Outflow typically cause the most tissue damage.
What are some ways to diagnose PAD?
CT angiography
Labs triglycerides, d dimer
Cholesterol
Ankle brachial index
What is the ankle brachial index
Index used to compare blood pressure from the ankle to the arm. Used to diagnose PAD.
Vast difference means there is a occlusion to partial occlusion.
In PAD with a full occlusion will there be a pulse distal to blockage?
No there will be no pulse.
What is a bruit
A whooshing within the artery from a narrowing at the site of blockage.
What is the goals of treatment for PAD
Minimize symptoms
Prevent progression of disease
How can you prevent progression of PAD?
Smoking cessation
Weight loss
Exercise
Low fat diet
What medications are used for PAD therapy and why?
Anti hypertensives lower pressure helps with blood flow. Beta blockers.
Antiplatlets. Stops clots from forming
Plavix -clopidogrel non reversible. Binds to platelet receptors
Statins relieves intermittent claudication controls cholesterol levels
Simvistatin
