PCCN REVIEW: CARDIOVASCULAR EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+

1 PCCN REVIEW: CARDIOVASCULAR EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+ Blood Oxygenation Cycle Correct Answer: 1. venous blood 2. right atrium spid valve 4. right ventricle 5. pulmonic valve 6. lungs (blood becomes oxygenated) 7. left atrium 8. mitral valve 9. left ventricle 10. aorta 11. systemic circulation Cardiac Output Correct Answer: HEART RATE x STROKE VOLUME 2 - amount of blood leaving heart in 1 minute Stroke Volume Correct Answer: amount of volume leave heart each beat Non-modifiable Risk Factors for Heart Failure Correct Answer: 1. Age 2. Gender (men female) 3. Family History 4. Race Modifiable Risk Factors for Heart Failure Correct Answer: 1. Smoking 2. HTN 3. Diabetes 4. Obesity 5. Stress 6. Exercise 7. Hyperlipidemia Cardiac Physical Exam Correct Answer: 1. Color 2. Pulses 3 3. Rate and Rhythm 4. PMI Location 5. Extremity Temperature 6. Dyspnea 7. Fatigue Level 8. Fluid Retention 9. Palpitations 10. Dizziness Class I Heart Failure Correct Answer: -asymptomatic during normal activities with no pulmonary congestion or peripheral hypotension -Prognosis = Good Class II Heart Failure Correct Answer: - Symptoms appear with physical exertion but are usually absent at rest, resulting in some limitations of activities of daily life -slight pulmonary edema may be evident by basilar rales -prognosis is good Class III Heart Failure 4 Correct Answer: - Obvious limitations of ADLs and discomfort on any exertion. - Prognosis is fair. Class IV Heart Failure Correct Answer: - Symptoms at rest. -Prognosis is poor. Chronic Heart Failure Correct Answer: -develops slowly -myocardium damaged by lack of adequate oxygen and nutrition, myocardical cells begin to die, creating areas of necrosis - There is cardiac dilation and increasing vascular resistance (afterload). Acute Heart Failure Correct Answer: -sudden onset -impairment of gas exchange and decreased cardiac output because of changes in preload, contractibility, and heart rhythm 5 -body attempting to compensate for circulatory malfunction by protecting blood flow to vital organs -Increase in the contractibility of the myocardium but peripheral vasoconstriction - fluid and sodium are retained to control hypotension - Capillary Hypertension Correct Answer: decreases oncotic pressure and results in vasodilation and increased loss of fluid from the plasma to the interstitial fluid, resulting in pulmonary edema. Capillary Hypotension Correct Answer: results in increased oncotic pressure and pulls fluid back into the plasma, a result of shock. Management of Acute Heart Failure Correct Answer: -Medical management is aimed at increasing cardiac function, providing support, and monitoring treatment Treatment of Acute Heart Failure Correct Answer: - Careful monitoring of fluid balance and weight to determine changes in fluid retention. 6 - Low sodium diet -restriction of activity -Medications Medications for Heart Failure Treatment Correct Answer: - may include diuretics, vasodilators, or angiotensin converting enzyme (ACE) inhibitors to decrease the heart's workload - Digoxin may be given to increase contractibility -Anticoagulant therapy if distended atria, enlarged ventricles, or atrial fibrillation are present, in order to decrease the danger of thromboembolia Systolic Heart Failure Correct Answer: "left sided" heart failure reduces the amount of blood ejected from the ventricles during contraction (decreasing ejection fraction), stimulating the sympathetic nervous system to produce epinephrine and norepinephrine to support the myocardium - Reduced Perfusion with Systolic HF Correct Answer: -the kidneys produce renin, which promotes angiotensin I, which is converted into angiotensin II, a vasoconstrictor, by the blood vessels 7 -This in turn stimulates production of aldosterone, causing sodium and fluid retention. Diastolic Heart Failure Correct Answer: -The myocardium is unable to sufficiently relax to facilitate filling of the ventricles -more common in females 75 - the relaxation of the heart is delayed, the ventricles do not expand enough for the fill-volume, and the heart cannot increase stroke volume during exercise, so symptoms (dyspnea, fatigue, pulmonary edema) are often pronounced on exertion - EF 40-50% Unstable Angina Correct Answer: - aka "preinfarction" or "crescendo" angina -progression of coronary artery disease 8 -occurs when there is a change in the pattern of stable angina -pain may increase, may not respond to nitro x1 and may persist for 5 minutes -pain is usually more frequent, lasts linger and may occur at rest -may indicate rupture of an atherosclerotic plaque and the beginning of thrombus formation -should be treated as a medical emergency, may indicate MI Variant Angina Correct Answer: - aka prinzmetals angina -results from spasms of the coronary arteries associated with or without atherosclerotic plaques - often related to smoking, etoh, or illicit stimulants -elevation of ST segments usually occurs -often occurs cyclically, often while person is at rest 9 -treated with nitroglycerin or calcium channel blockers Myocardial Infarction Correct Answer: -occurs when there is an imbalance between the hearts demand for oxygen and the supply of it -may result after an episode of unstable angina, rupture of atherosclerotic plague and thrombosis r/t coronary artery spasm -may result from vasoconstriction, acute blood loss, decreased oxygen or ingestion of cocaine Myocardium Damage r/t MI Correct Answer: -typically occurs in stages beginning in the endocardium and progressing to the epicardium -ischemia develops as oxygen levels fall, creating a zone of ischemia with viable cells -cellular injury occurs to those cells surrounding the infarcted area int he zone of injury -infarction with NECROSIS of tissue occurs in the zone of infarction -cells are destroyed in the zone of infarction and eventually replaced with scar tissue 10 -irreversible damage occurs with complete occlusion for 15-20 minutes Q-Wave MI Correct Answer: -characterized by series of abnormal Q waves (wider and deeper) on ECG, especially in early AM (r/t adrenergic activity) -infarction is usually prolonged and results in necrosiss -coronary occlusion is complete in 80-90% -often, but not always, trandsmural (ischemic necrosis) -peak CK levels occur in about 27 hours -Mortality rates are about 10% Non-Q-Wave MI Correct Answer: -characterized by changes in ST-T wave with ST depression (usually reversible within a few days) -usually re-perfusion occurs spontaneously, so infarct size is smaller. 11 -contraction necrosis related to re-perfusion is common -Usually non-transmural -Coronary occlusion is complete in only 20-30% -mortality rates are about 2-3% -re-infarction is common, so 2 year survival rates are similar to Q-wave MI Anterior Wall Infarction Correct Answer: -Occurs with occlusion in the promximal left anterior descending artery and may damage the LEFT ventricle Left Lateral Wall Infarction Correct Answer: -Occurs with occlusion of the circumflex coronary artery and often causes damage to anterior wall as well Inferior Wall Infarction Correct Answer: -Occurs with occlusion of the right coronary artery and causes conduction malfunction Right Ventricular Infarction 12 Correct Answer: -Occurs with occlusion of the proximal section of the right coronary artery and damages the right ventricle and the inferior wall Posterior Wall Infarction Correct Answer: -Occurs with occlusion in the right coronary Artery or Circumflex artery and may be difficult to diagnose Clinical Manifestations of an MI Correct Answer: -males have more "classic" symptoms vs females -Angina with pain in chest that may radiate to neck or arms -palpitations -hypertension or hypotension -ECG changes (st segment and t wave changes, tachycardia, bradycardia, and arrhythmia) -dyspnea, pulmonary edema -nausea/vomiting, indigestion -decreased urinary output -pallor, skin cold and clammy, diaphoresis -dependent edema -neurological/psychological disturbances: anxiety, lightheaded, headache, visual abnormalities, slurred speech and fear 13 Diagnostic Procedures of an MI Correct Answer: -complete physical examination -family history review -ECG (t wave inversion, elevated ST segment, abnormal Q-wave) -Echo: evaluate ventricular function -Cardiac Enzymes (CK-MD, Myoglobin, troponin) CK-MB Correct Answer: -cardiac muscle -increases within a few hours and peaks at about 24-27 hours (earlier with thrombolytic therapy or PTCA) for Q wave MI -peaks at about 12-13 horus for non-Q-wave Myoglobin Correct Answer: -heme protein that transports oxygen -found in both skeletal and cardiac muscles -levels increase in 1-3 hours after an MI and peak within 12 hours 14 -an increase is not specific to an MI, a failure to increase can be used to rule out an MI Troponin Correct Answer: -protein in the myocardium -regulate contraction and their levels increase as with CK-MB but levels remains elevated for up to 3 weeks Papillary Muscle Rupture Correct Answer: -located on the sides of ventricular walls and connect to the valves with fibrous bands (chordae tendineae) -rupture = complication of an MI -usually happens on the left, affecting the mitral valve with the posteromedial papillary muscle more often -occurs in 40% of those with a posterior septal infarctions -rupture on RIGHT sides results in tricuspid regurgitation and right ventricular failure -rupture on LEFT side leads to mitral regurgitation with resultant pulmonary edema and cardiogenic shock 15 -surgical repair is critical Myocarditis Correct Answer: -inflammation of the cardiac myocardium (muscle tissue) -usually triggered by a viral infection such as the influenza virus, coxsackie virus and HIV Diagnosis of Myocarditis Correct Answer: -depends upon the clinical picture because there is no test specific for myocarditis -ECG -Chest Radiograph (may show pulm edema or cardiomegaly) -Echo -Cardiac Catheterization & biposy (confirm 65% of cases, - study does not r/o myocarditis) Myocarditis Treatment Correct Answer: -fix underlying cause (i.e antibiotics) -restriction of activities 16 -careful monitoring for heart failure and medical treatment as indication -oxygen as needed to maintain normal o2 sat -iv gamma globulin for acute stage Pericarditis Correct Answer: -inflammation of the pericardial membrane that surrounds the heart -the layers may become attached to eachother (dry), or the serous fluid may be replaced by purulent material, calcification, fibrinous material or blood -frequently associated with surgical repair of cardiac structural abnormalities -may also be caused by direct trauma, systemic viral, bacterial fungal and parasitic infections -SLE Pericarditis Symptoms Correct Answer: -fever -dysrhythmia -poor appetite -irritability -malaise 17 -sharp, piercing chest pain Pericarditis Diagnosis Correct Answer: -Diagnostic procedures are similar to those for endocarditis and myocarditis -ekg,cxr etc. Pericarditis Treatment Correct Answer: -treat according to the cause, type and extent of inflammation -pain management -anti-inflammatory drugs -activity restriction -corticosteroids when no response to anti inflammatory drugs -Surgical intervention: pericardiocentesis Endocarditis Correct Answer: - Infection of the endothelial surface and valves of the heart -Caused by invasion of the tissue by a pathogen (usually streptococci, staphlococci, enterococci, pneumococci as well as fungi and rickettsia) 18 -often hospital aquired -organisms enter blood stream from portals of entry (surgery, catherization, IVDU) and migrate to the heart, growing on the endothelial tissue and form vegetation (verrucae), collagen deposits and platelet thrombi -valves frequently become deformed -associated with prolonged hospitalization, recent cardiac surgery, pulmonary shunts, invasive devices (central lines), congenital heart disease Endocarditis: Clinical Symptoms Correct Answer: -slow onset with unexplained low grade and often intermittent fever -anorexia and weight loss, difficulty feeding - malaise -splenomegaly (in 60%) and hepatomegaly - anemia -aortic valve insufficiency or mitral valve insufficiency -cyanosis with clubbing of fingers -embolism of other body organs (brain, liver, bones) 19 -CHF -Dysrhythmias -immunological responses: janeway lesions, splinter hemorrhages, petechiae on oral mucosa, roths spots, glomerulonephritis Endocarditis: Diagnosis Correct Answer: - blood cultures (aerobic and anaerobic) -echo (may identify vegetation on valves or increasing heart failure) -ECG (prolonged PR interval) -anemia -increased white cell count -ESR and CRP Endocarditis: Treatment Correct Answer: -general management of symptoms -IV antimicrobials, 4-6 weeks -surgical replacement of aortic/mitral vales if there is no response to treatment and if valve damage is present 20 Valvotomy/Valvuloplasty Correct Answer: -Repairing Cardiac Valves -done through cardiac catheterization -may involves releasing valve leaflet adhesions interfering with functioning of the valve Balloon Valvuloplasty Correct Answer: -a catheter with an inflatable balloon is positioned in the stenotic valve and inflated and deflated a number of times to dilate the opening Aortic Valve Replacement Correct Answer: -open heart proceduRe with cardiopulmonary bypass -repair of aortic valves are usually not possible, so defective valves must be replaces with either mechanical or biological Aortic Homograft Correct Answer: Uses part of donors aorta with the aortic valve attached to replace the recipients faulty aortic valve and part of the ascending aorta Ross Procedure 21 Correct Answer: Uses the patients pulmonary artery with the pulmonary valve to replace the aortic valve and part of the aorta then uses a donor graft to replace the pulmonary artery Coronary Artery Bypass Graft (CABG) Correct Answer: -surgical procedure for treatment of angina that does not respond to medical treatment, unstable angina, blockage of 60% in left main coronary artery, blockage of multiple coronary arteries that include the proximal left anterior descending artery, left ventricular dysfunction and previous unsuccessful PCIs CABG Post Op Complications Correct Answer: -MI -graft failure -occlusion of other arteries -dysrhythmias -emboli -infection Intraaortic Balloon Pump Correct Answer: -most commonly used circulatory assist device -used for unstable angina, MI, cardiogenic shock, papillary muscle dysfunction, ventricular failure after cardiac surgery and dysrhythmias 22 -may be used to facilitate weaning patients from cardiopulmonary bypass after open heart surgery if the heart is not able to pump adequately - catheter is usually inserted through the femoral artery but may be placed during surgery or through a cutdown -catheter is threaded into the descending thoracic aorta, and the balloon inflates during diastole to increase circulation to the coronary arteries then deflates during systole to decrease afterload Intraaortic Balloon Pump Complications Correct Answer: -dysrhythmias -peripheral ischemia from femoral artery occlusion -balloon perforation or migration -tachycardia and dysrhythmias may interfere with timing the pump Minimally-Invasive Direct Coronary Artery Bypass (MIDCAB) Correct Answer: -applies a bypass graft on the beating heart through a 10 cm incision in in the mid chest rather than midsternally, without using cardiopulmonary bypass -suitable only for bypass of 1 or 2 coronary arteries 23 -surgery takes 2-3 hours and recovery time is decreased as patients have less pain -may provide longer lasting relief than angioplasty for single vessel occlusion Percutaneous Transluminal Coronary Angioplasty (PTCA) Correct Answer: -option for poor surgical candidates who have an acute MI or uncontrolled chest pain -Usually done to increase circulation to the mycocardium by breaking through an atheroma if there is collateral circulation -a hallow catheter (sheath) is inserted, usually from the femoral vein or artery, and fed through the vessels to the coronary arteries -after verification, a balloon-tipped catheter is fed over the sheath, and the balloon is inflated with a contrast agent to a specified pressure to compress the atheroma - theballoon may be inflated a number of times to ensure that residual stenosis is 20% Stents Correct Answer: -may be inserted during the angioplasty to maintain patency -may be made of flexible plastic or wire mesh 24 -typically placed over the catheter, which is inflated to expand the stents against the arterial wall Directional Coronary Atherectomy (DCA) Correct Answer: -the removal of an atheroma from an occluded coronary artery -may be more effective than angioplasty because it shaves an atheroma away instead of compressing it -DCA catheter is a large balloon catheter usually inserted over a sheath through the femoral artery -The catheter includes an open window on 1 side of the balloon with a rotational cutting piston that shaves the atheromma with the plaque residue pushed inside the device for removal Rotational Atherectomy (ROTA) Correct Answer: uses a catheter with a diamond chip drill at the tip, rotating and pulverizing the atheroma into microparticles Transluminal Extraction Correct Answer: Uses a motorized cutting head with a suction devices for residue 25 Transmyocardial laser Revascularization Correct Answer: -done percutaneously or through a midsternal or thoracotomy incision -A fiberoptic catheter is positioned inside the ventricle and against the ischemic area -laser bursts are used to cut 20-40 channels into but not through the myocardium -the laser burns create channels and stimulate an inflammatory response, which causes new blood vessels to form angiogenesis, improving circulation to the myocardium and reducing ischemia and pain -reduce symptoms and increase tolerance to activity, improving the quality of life Postoperative Care for Cardiac Surgeries Correct Answer: -cardiovascular support to maintain adequate cardiac output (may require adjustment in heart rate, preload and contractibility) -temperature regulation -bleeding control, blood transfusion -chest tube monitoring and patency -watch for cardiac tamponade -respiratory care extubation, supplemental oxygen 26 -neurological monitoring for postcardiotomy delirium (disorientation progressing to agitation, hallucinations, and paranoid) -wound care (diabetics may require insulin infusions to lower risk of infection) -watch for hemoglobinuria Heart Transplant Correct Answer: -requires cardiopulmonary bypass -orthotopic procedure is most common: posterior portion of the left and right atrium is left for attachment of the new heart -methylprednisolone is adminstered prior to removing aortic cross clamp -isoproterenol is usually given before CPB is discontinued Heart Transplant: Post-Operative Management & treatment Correct Answer: -Mechanical Ventilation: respiratory care with adequate ventilation must be monitored constantly -IVF -prostaglandin is continued for 1-2 days to preclude rebound pulmonary HTN 27 -immunosuppression therapy Basic Cardiac Hemodynamics Correct Answer: -based on the principle that fluid flows from areas of higher pressure to areas of lower pressure: -systole -diastole Systole Correct Answer: -pressure rises in the ventricles, closing tricuspid and mitral valves, stopping flow from the atria and preventing backflow (regurgitation) -Pressure forces the pulmonic and aortic valves open, sending blood into both the aorta and pulmonary artery -early ventricular systolic pressure is high and then falls near the end of systole as the ventricles empty, lowering the pressure in the aorta and pulmonary artery, causing AV valves to close Diastole Correct Answer: -Ventricles are relaxed and AV valves open 28 -Pressure in the atria is lower than in the venae cavas or pulmonary veins, pulling blood into the atria with some into the ventricles -an electrical impulse is generated into the SA node, forcing the atria to contract, increasing the pressure and forcing more blood through the valves and into the ventricles -this period of atrial systole and occurs near the end of ventricular diastole Cardiac Output (CO) Correct Answer: -the amount of blood pumped through the ventricles during a specified period -normal = 5L per minute at rest for and adult CO= Heart Rate x Stroke volume Stroke Volume Correct Answer: - the amount of blood pumped through the ventricles with each contraction -controlled by preload, afterload and contractibility 29 Preload Correct Answer: -refers to the amount of elasticity in the myocardium at the end of diastole when the centricles are filled to their mamximum volumes, and the stretch on the muscle fibers is the greatest -based on the volume in the ventricles -the amount of preload (stretch) affects stroke volume because as stretch increases, the resultant contraction also increases (frank-starling Law -may decrease because of dehydration, diuresis or vasodilation -may increase because of increased venous return, controlled fluid loss, transfusion, or intravenous fluids Afterload Correct Answer: -refers to the amount of systemic vascular resistance to left ventricular ejection of blood and pulmonary vascular resistance to right ventricular ejection of blood -Increases With = HTN, stenotic valves and vasoconstriction Determinants of Afterload 30 Correct Answer: - include the size and elasticity of the great vessels and the functioning of the pulmonary and aortic valves Contractability Correct Answer: -the amount of force exerted by the myocardium during contraction -directly related to both preload (elasticity) and afterload (systemic resistance) Increased Ccntractability Correct Answer: -may be due to changes in body chemistry or the sympathetic nervous system -some drugs (digoxin and dopamine) increase contractibility -increased contractibility results in increased stroke volume and cardiac output Decreased Contractibility Correct Answer: -may be due to hypoxemia and acidosis -some drugs such as beta-adrenergic blocking agents (atenolol), also decrease contractibility Perfusion 31 Correct Answer: -measured by the mean arterial pressure (MAP) - Pulse Pressure Correct Answer: - the difference between systolic and diastolic pressures Necessary Values for MAP Correct Answer: 60 mmHg to perfuse coronary arteries 70-90 mmHg to perfuse the brain and other organs and to maintain cardiac patients and decrease the workload of the left ventricle 90-110 to increase cerebral perfusion after neurosurgical procedures (carotid endarterectomy) Thoracic Electrical Bioimpedance Monitoring Correct Answer: -non-invasive method of monitoring hemodynamics - Cardiac Tamponade 32 Correct Answer: -occurs with pericardial effusion in which fluid accumulates in the pericardial sac, causing pressure against the heart -may be a complication of trauma, pericarditis, cardiac surgery or heart failure -a sudden increase in fluid that circulates in the pericardial area can compress the heart Cardiac Tamponade Symptoms Correct Answer: - feeling of pressure or pain in the chest -dyspnea -pulsus paradoxus 10 mmHg (systolic blood pressure heard during exhalation but not during inhalation) -Beck's Triad (increased central venous pressure with distended neck veins, muffled heart sounds, and hypotension) Cardiac Tamponade Treatment Correct Answer: -Pericardiocentesis with large bore needle or surgical repair to control bleeding and relieve cardiac compression Cardiogenic Shock 33 Correct Answer: - most often secondary to MI damage that reduces the contractibility of the ventricles, interfering with the pumping mechanism of the heart, decreasing oxygen perfusion -3 Characteristics: 1) increased preload 2) increased afterload 3) decreased contractibility - these result in decreased cardiac output and an increase in systemic vascular resistance (SVR) to compensate and protect vital organs Cardiogenic Shock Symptoms Correct Answer: Hypotension with systolic BP 90 mmHg -Tachycardia 100 with weak, thready pulse and dysrhythmias -decreased heart sounds -chest pain -tachypnea and basilar rales -pallor -cool,moist skin 34 Hypertrophic Cardiomyopathy Correct Answer: aka asymmetric septal hypertrophy -rare genetic and occasionally idiopathic disorder that is often undetected until adolescence when the increasing symptoms become noticable -heart mass and size increase, especially with thickness along the septium, resulting in smaller ventricular capacity so that the ventricles fill less efficiently , atria will have to work harder Dilated Cardiomyopathy Correct Answer: -the most frequently occurring type -Occurs with an increase in the size of the ventricles (without a concomitant increase in hypertrophy of the ventricular muscle) as well as systolic dysfuntion -tissue looses elasticity results in less blood being ejected during ventricular systole - as ventricles stretch, valves may be displaced, causing regurgitation. -progress of disease is slow, diagnosis may be delayed until the disease is advanced Causes of Dilated Cardiomyopathy 35 Correct Answer: -pregnancy -alcoholism -toxic compounds -autoimmune disease -viral infections Restrictive Cardiomyopathy Correct Answer: -least common -common complication of heart transplants -may be idiopathic of secondary -often related to amyloidosis -many times the cause is unknown - no cure, early diagnosis and management of symptoms is important -treatment includes: use of beta blockers, heart transplant Arrhythmogenic Right Ventricular Cardiomyopathy Correct Answer: -inherited disease -the myocardium of the right ventricle is slowly replaced with fibrotic and adipose tissue 36 -as disease progresses, R ventricle dilates and develops abnormalities of ventricular walls, losing the ability to contract effectively - may cause sudden death in young athletes -diagnosis is usually made during teens or early 20s 1st Degree AV Block Correct Answer: -occurs when the atrial impulses are conducted through the AV node to the ventricles at a rate that is slower than normal -PR interval is 0.20 seconds -acute: may be related to digoxin toxicity, beta blockers, amiodarone, MI, hyperkalemia or edema -chronic: may be caused by fibrosis/sclerosis of the conduction system r/t CAD, valvular disease 2nd Degree Type I (Wenckebach) Correct Answer: -PR interval progressively increases until 1 QRS complex fails to conducts 37 - usually does not cause significant morbidity unless associated with inferior wall MI 2nd Degree Type II Correct Answer: the PR intervals are the same if impulses are conducted, but the QRS complex is usually widened -Type II blocks are more dangerous than type I because it may progress to complete AV block -transcutaneous pacemaker/defibrillator should be at bedside -symptoms may include chest pain if the heart block is precipitated by myocarditis or myocardial ischemia 3rd Degree AV Block Correct Answer: -more P waves than QRS with no clear relationship between them -PR interval is irregular -the heart still contracts but often ineffectually - the heart m ay compensate at rest but cant keep pace with exertion -Resulting bradycardia may cause CHF, fainting or sudden death 38 Symptoms: dyspnea, chest pain, hypotennsion Treatment: IV atropine, transcutaneous pacing, implanted pacemaker (usually dual chamber) Pacemakers Correct Answer: -used to stimulate the heart when the normal conduction system of the heart is defective -used temporarily or permanently implanted Temporary Pacemakers Correct Answer: -used prophylacticallyr or therapeutically to treat cardiac abnormalities Used: -treat persistent dysrhythmias not responsive to medications -increase cardiac output with bradydysrhythmia by increasing rate -decrease ventricular or SVT by "overdrive" stimulation of contractions -treating secondary heart block -improve cardiac output after cardiac sx -provide diagnostic information 39 Asynchronous Pacemaker Correct Answer: fixed rate pacing Synchronous Pacing Correct Answer: on demand pacing that delivers an impulse if the pulse falls below a preset level Dual Chamber Pacing Correct Answer: AV sequential and delivers an impulse to the atrium and ventricle in sequence, allowing time for the ventricles to fill properly Pacemaker Complications Correct Answer: -infection, bleeding or hematoma -puncture of the subclavian vein or internal mammary artery may cause hemothorax -cardiac tamponade -general malfunctioning bradydysrhythmia Correct Answer: pulse rates that are abnormally slow -complete AV block -sinus bradycardia -junctional/nodal rhythms 40 Complete AV Block Correct Answer: -may be congenital or a response to surgical trauma Sinus Bradycardia Correct Answer: may be caused by the autonomic nervous system or a response to hypotension and decrease in oxygenation HR 60 Sinus Bradycardia Causes Correct Answer: -conditions that lower the body metabolic needs (hypothermia or sleep) -Medications (calcium channel blockers and beta blockers) -vagal stimulation that may result from vomiting, suctioning or defecating -increased intracrainial pressure -MI Sinus Bradycardia Treatment Correct Answer: involves eliminating the cause if possible 41 - changing medications -atropine (.5-0.10 mg) IV to block vagal stimulation Juntional/Nodal Rhythms Correct Answer: often occur in post surgical patients when the absence of a P wave is noted heart rate and output usually remain stable - no treatment necessary unless compromise Tachydysrhythmias Correct Answer: Pulse rates that are abnormally fast -sinus tachycardia -supraventricular Tachycardia Supraventricular Tachycardia Correct Answer: may have sudden onset and result in congestive heart failue Sinus Tachycardia Correct Answer: often caused by illness such as fever or infection 42 -sinus node impulse increases in frequency -regular pulse that is 100 bpm -causes reduced cardiac output and possible hypotension Sinus Tachycardia Causes Correct Answer: -acute blood loss -shock -anemia -hypovolemia -sinus arrhythmia -heart failure (hypovolemic) -hypermetabolic conditions -fever -anxiety -exertion/exercise -Medications (i.e sympathomimetic drugs) Sinus Tachycardia Treatment Correct Answer: includes elimination precipitating factors and prescribing calcium channel blockers and beta blockers to reduce heart rate Atrial Flutter 43 Correct Answer: occurs when the atrial rate is fastee (250-400 bpm) than the AV node conduction rate so that not all of the beats are conducted into the ventricles but are effectively blocked at the AV node -P waves are Saw toothed Atrial Fibrilation/Flutter Causes Correct Answer: -coronary artery disease -valvular disease -pulmonary disease -heavy etoh ingestion -cardiac sx A.Flutter Treatments Correct Answer: -cardioversion if condition is unstable -Medications to slow ventricular rate and conduction through AV node (cardizem, calan) -Medications to convert to sinus rhythm (corvert, cardioquin, norpace, cordarone/amiodarone) Atrial Fibrilation 44 Correct Answer: rapid, disorganized atrial beats that areineffective in emptying the atria so that blood pools and can lead to thrombus formation and emboli -characterized by very irregular pulse with an atrial rate of 300-600 bpm and ventricular rate of 120-200 bom -fibrillatory waves are seen instead of p waves -pr interval cannot be measured -cardioversion may be needed if persists for 48 hours A.fib Medications Correct Answer: Acute: ibutilide: procainamide, digoxin -To maintain Rhythm: Quinidine, Amiodarone -to control ventricular Rate: Beta blockers, calcium channel blocers and verapamil -anticoagulant therapy Junctional Escape Rhythm Correct Answer: Occurs when the AV node takes over as the pacemaker of the heart because the sinus node us depressed 45 -characterized by a regular atrial/ventricular rate of 40-60 bpm -p wave may be inverted, absent, hidden or after QRS - pacemaker is inserted in case AV failure occurs Ventricular Tachycardia Correct Answer: 3 PVCs in a row with a ventricular rate of 100-200 bpm - often related to underlying coronary artery disease -rapid rate of contractions make VT dangerous as theineffective beats and may leave the person unconscious with no palpable pulse -Defibrillation is usually done as an emergency procedure if the patient is unconscious Ventricular Fibrillation (VF) Correct Answer: rapid, very irregular ventricular rate with no atrial activity observable on the EKG, caused by disorganized electrical activity in the ventricles causes: etoh, caffeine, nicotine, underlying CAD 46 -may result in VT if untreated -lack of palpable pulse, immediately life threatening without defibrillation Ventricular Escape Rhythms Correct Answer: (idioventricular) occurs when the purkinje fibers create and impulse -may occur if the sinus node fails to fire, or if there is a blockage at the AV node so that the impulse does not go through 20-40 bpm 40 bpm = accelerated idioventricular rhythm Treatment: defibrillation, IV atropine or vasopressors - underlying cause of the rhythm should be identified and treated to prevent recurrence Ventricular Asystole Correct Answer: the absence of audible heartbeat, palpable pulse "flat lining" or "cardiac arrest" 47 CPR is required -without immediate treatment, patient will suffer from severe hypoxia and brain death within minutes -treatments: epinephrine, atropine Cardioversion Correct Answer: A timed electrical stimulation to the heart to convert a tachydysrhythmia to normal sinus rhythm. -anticoagulation therapy is usually done for at least 3 weeks prior to prevent emboli -digoxin is discontinued for at least 48 hrs before -current is delivered during ventricular depolarization (QRS) Emergency Defibrillatiton Correct Answer: Done to treat acute V.Fib or V.Tach when there is no audible or palpable pulse -higher voltage is used than with cardioversion 48 -Higher voltage causes depolarization of myocardial cells, which can then repolarize to regain a normal sinus rhythm Automatic Implantable Cardioverter Defibrillator (AICD) Correct Answer: Similar to the pacemaker and is implanted in the same way with 1 or more leads to the ventricular myocardium or the epicardium but it is used to control tachycardia and/or fibrillation -when the pulse reaches a certain preset rate, the device automatically provides a small electrical impulse to the atrial or ventricular myocardium to slow the heart Heart Failure Correct Answer: cardiac disease that includes disorders of contractions or filling or both -may include pulmonary, peripheral, or systemic edema -most common causes: CAD, systemic or pulmonary HTN, cardiomyopathy and valvular disorders Management of Acute Heart Failure Correct Answer: -Aimed at increasing cardiac function, providing support and monitoring treatment 49 Treatments of Acute Heart Failure Correct Answer: -careful monitoring of fluid balance and weight to determine changes in fluid retention -low sodium diet -activity restriction -Medications: diuretics, vasodilators, ACE inhibitors (to decrease the hearts workload), digoxin (increase contractibility -patient education Systolic Heart Failure Correct Answer: "Left Sided heart Failure" -reduces the amount of blood ejected from the ventricles during contraction, stimulating the sympathetic nervous system to produce epinephrine and norepinephrine to support myocardium -Reduced perfusion - production of angiotensin I - converted to angiotensin II by blood vessels - stimulates aldosterone production, causing sodium and fluid retention = increases the workload of the heart, cardiac muscle loses contractibility and blood pools in ventricles, enlarging them 50 Hypertensive Emergency Correct Answer: Occurs when acute hypertension, usually 120 mmHg diastolic, must be treated immediately to lower blood pressure in order to prevent damage to vital organs, such as the heart, brain or kidneys Hypertensive Urgency Correct Answer: Occurs when acute hypertension must be treated within a few hours, but the vital organs are not in immediate danger Treatment for Hypertensive Crisis Correct Answer: -short acting beta blockers -ACE inhibitors -Calcium Channel Blockers -Diuretics Peripheral Arterial Disease (PAD) Correct Answer: Involves the aorta, its branches, arteries and arterioles -includes occlusion of the arteries of the lower extremities from atherosclerosis, resulting in severe pain and ischemia -most affected arteries: femoral, popliteal, distal aorta and iliac arteries 51 -characterized by intermittent claudication, tissue changes and ulcerations Peripheral Venous Insufficiency Correct Answer: Results from defective valves in the deep and or superficial veins of the lower extremities. Peripheral Arterial Disease Characteristics Correct Answer: - Pain ranging from intermittent claudication to severe constant -weak or absent pulses -skin is pale, shiny and cool with loss of hair on toes and foot -rubor on dependency but pallor of foot on elevation -nails are tick and ridged -Ulcers are painful, deep, circular and often necrotic on toe tips, toe webs, heels or other pressure areas -extremity edema is minimal Peripheral Venous Disease Characteristics Correct Answer: -aching and cramping feelings 52 -pulses are present - extremity skin is brownish discoloration around ankles and anterior tibial area -venous dermatits evident -Ulcers have varying degrees of pain in superficial, irregular ulcers on medial or lateral malleolus and sometimes the anterior tibial area -extremity edema is moderate to severe Venous Thromboembolism (VTE) Correct Answer: A condition that includes both deep veub thrombosis (DVT) and pulmonary emboli (PE) -possibly precipitated by invasive procedures, lack of mobility, and inflammation -common complication in acute/critial care units Symptoms of VTE Correct Answer: -aching or throbbing pain -positive homans signs (pain in calf when foot is dorsiflexed) -erythema and edema -dilation of vessels -cyanosis 53 VTE Diagnosis Correct Answer: - May be made by ultrasound and or D-Dimer test -CT Scan, Pulmonary angiogram and VQ lung scan = used to diagnosis PE VTE Treatment Correct Answer: -bedrest -elevation of affected limb -anticoagulation therapy -analgesics -Elastic stockings during ambulation Arterial Insufficiency and Ulcers: Surgical/Vascular Interventions Correct Answer: Goals are to improve perfusion and save the limb Indications for Sx Intervention: - poor healing prognosis -failure to respond to conservative treatments (medications and lifestyle changes) -intolerable pain that is incapacitating -severe ischemia, infection and/or gangrene **indicated only for those patients with patent distal vessels as demonstrated by radiologic imaging procedures 54 Peripheral Vascular Surgery Correct Answer: - bypass graft -angioplasty -amputation Peripheral Vascular Surgery: Bypass Graft Correct Answer: A section of the saphenous vein or an upper extremity vein is harvested to use to bypass damaged arteries and supply blood to distal vessels -because veins have valves, they must be reversed or stropped of valves prior to attachment -synthetic grafts are sometimes used; higher failure rate Peripheral Vascular Surgery: Angioplasty Correct Answer: Can be used if disease is not extensive (10 cm in length) -arteries must be large enough to accommodate the procedure safely -initial results are good but long term rates have been less positive although the use of anticoagulants improves success rates Peripheral Vascular Surgery: Amputation 55 Correct Answer: The procedure that treatment tries to avoid, but it is sometimes required if ischemia is irreversible or if there is severe necrosis and infection that is life threatening Pulmonary Edema Correct Answer: Occurs when excess fluid enters the pulmonary interstitium and alveoli because of increased pulmonary capillary pressure combined with decrease in the oncotic pressure, mechanical or phsiologic damage to the capillary-alveolar membrane or obstruction of the lymphatic drainage system Cardiac Related Pulmonary Edema Correct Answer: may result from MI, Chronic HF, volume overload, ischemia or mitral stenosis Symptoms: severe dyspnea, cough with blood tinged frothy sputum, cyanosis and diaphoresis, wheezes/rales/rhonchi Diagnosis: auscultation, CXR, echo Cardiac Related Pulmonary Edema: Treatment Correct Answer: - sitting position with oxygen by mask to achieve Po2 60% 56 -non invasive pressure support ventilation or endotracheal intubation and mechanical ventilation, depending upon severity -morphine -iv diuretics -nitrates -inhaled beta adrenergic agonists Aortic Aneurysm Correct Answer: Occurs when a weakness in the wall of the aorta causes a ballooning dilation of the wall of the aorta -may result from infections or other trauma -atherosclerosis is the most common cause for both thoracic and abdominal aortic aneurysms -1/3 of thoracic aneurysms rupture, surgical repair is indicated Abdominal aneurysms may remain stable for years, at risk if 5 cm wide False Aortic Aneurysm Correct Answer: Caused by a hematoma that may pulsate and erode the wall of the vessel 57 True Bulging Aneurysm Correct Answer: Involves 1-3 layers of the vessel wall Fusiform Aortic Aneurysm Correct Answer: Symmetric bulging about the entire circumfrence of the vessel Saccular Aortic Aneurysm Correct Answer: Ballooning on 1 side of the vessel wall Dissecting Aortic Aneurysm Correct Answer: Splits the layers of the wall, usually caused by an expanding hematoma -Occurs when the wall of the aorta is torn and blood flows between the layers of the wall, dilating and weakening it until it risks rupture Type I Aortic Aneurysm Correct Answer: Begins in the ascending aorta but may spread to include the aortic arch and the descending aorta proximal lesion or Stanford type A 58 -thoracic -repaired surgically d/t danger of rupture and cardiac tamponade Type II Aortic Aneurysm Correct Answer: Restricted to the ascending aorta -also considered proximal lesion or Stanford type A -thoracic --repaired surgically d/t danger of rupture and cardiac tamponade Type III Aortic Aneurysm Correct Answer: Restricted to the descending aorta -distal lesion or Stanford type B -abdominal -medical management, sx delayed until 5cm (abdominal sx repair vs endoluminal stent) Dissecting Aortic Aneurysm Management Correct Answer: Once identified and type is determined, both medical management and surgical repair may be indicated 59 -anti hypertensives -intubation/ventilation -Analgesia/sedation -diagnostic tests: CT, MRI, thoracic echo, TEE Abdominal Aortic Aneurysm Correct Answer: 90% occur below the renal arteries -usually found incidentally -rupture results in severe abdominal pain Open Surgical Repair of Abdominal Aneurysm Correct Answer: abdominal incision is made with dissection of damaged aorta and a graft is sutured in place -aortic blood flow must be interrupted with CPB during this procedure Endovascular Surgical repair of Abdominal Aneurysm Correct Answer: A stent graft is fed through the arteries to line the aorta and exclude the aneurysm Abdominal Aneurysm Complications Correct Answer: -MI 60 -Renal injury -GI Hemorrhage Endo-leaks can occur with a stent graft, increasing the risk of rupture Thoracic Aortic Aneurysm Correct Answer: -usually related to atherosclerosis -may result from Marfan Syndrome, Ehlers-Danlos disease and connective tissue disorders -often asymptomatic; may cause substernal pain, back pain, dyspnea and/or stridor, cough, distention of neck veins, edema of neck and arms -diagnosis often made with xray or CT -surgical repair is more dangerous with higher rates of morbidity/mortality than for abdominal aorta repair Mitral Stenosis Correct Answer: Leaflets of mitral valve thicken and calcify and the junctions fuse, decreasing the size of the valve opening -reduces the flow of blood from the left atrium to the left ventricle 61 Mitral Stenosis Causes Correct Answer: - autoimmune response to rheumatic fever leading to vegetative growths on the mitral valve - infective endocarditis -lupus erythematosus 3 Mechanisms by which mitral stenosis causes pulmonary HTN Correct Answer: - increased left atrial pressure causing backward increase in pressure of pulmonary veins -hypertrophy and pulmonary artery constriction resulting from reactive left atrial and pulmonary venous hypertension -thrombotic/embolitic damage to pulmonary vasculature Treatment of Mitral Valve Stenosis Correct Answer: - drugs to control arrhythmias and hypertension -balloon valvuloplasty -mitral valve replacement Mitral Valve Regurgitation 62 Correct Answer: -may occur with mitral stenosis or independently -can result from damage caused by rheumatic fever, myxomatous degeneration, infective endocarditis, collagen vascular disease or cardiomyopathy -occurs when the mitral valve fails to close completely; there is then backflow into the left atrium from the left ventricle during systole, decreasing cardiac output Mitral Valve Regurgitation: Acute Phase Correct Answer: May occur with rupture of chordae tendieae or papillary muscle causing sudden left ventricular flooding and overload Mitral Valve Regurgitation: Chronic Compensated Correct Answer: Results in enlargement of the left atrium to decrease filling pressure and hypertrophy of the left ventricle to maintain stroke volume and cardiac output Mitral Valve Regurgitation: Chronic Decompensated Correct Answer: Occurs when the left ventricle fails to compensate for the volume overload so that stroke volume and cardiac output decrease Aortic Stenosis Correct Answer: A stricture (narrowing) of the aortic valve that controls the flow of blood from the left ventricle, causing the left ventricle wall to thicken as it increases 63 pressure to overcome the valvular resistance, increasing afterload, and increasing the need for blood supply from the coronary arteries. -may result from a birth defect or childhood rheumatic fever, and it tends to worsen over the years as the heart grows Aortic Stenosis Symptoms Correct Answer: -chest pain on exertion and intolerance of exercise -heart murmur -hypotension on exertion may be associated with sudden fainting -sudden death -tachycardia with faint pulse -poor appetite -increased risk for bacterial endocarditis and coronary insufficiency -increases in mitral regurgitation and secondary pulmonary HTN Aortic Stenosis Treatment Correct Answer: -balloon valvuloplasty to dilate valve non surgically -surgical repair of valve or replacement of valve depending on extent of stricture Pulmonic Stenosis 64 Correct Answer: A stricture of the pulmonic valve that controls the flow of blood from the right ventricle to the lungs resulting in right ventricular hypertrophy as the pressure increases in the right ventricle and decreased pulmonary blood flows -may be asymptomatic or symptoms may not be noticed until adulthood Pulmonic Stenosis Symptoms Correct Answer: -loud heart murmur -congestive heart murmur -mild cyanosis -cardiomegaly -angina -dyspnea -fainting -increased risk of bacterial endocarditis Pulmonic Stenosis Treatment Correct Answer: -balloon valvuloplasty to separate the cusps of the valve for children -surgical repair includes the cardiopulmonary bypass pulmonary valvotomy for older children and adults S1 65 Correct Answer: "lub" -closure of mitral andd tricuspid valves -heard at apex/left ventricular area S2 Correct Answer: "Dub" -closure of the aortic and pulmonic valves -heard at the base of the heart -may be a slight splitting of the s2 s3 Correct Answer: -occurs after s2 in children -may indicate heart failure or left ventricular failure in older adults s4 Correct Answer: occurs before s1 with ventricular hypertrophy occurs with CAD, HTN or aortic valve stenosis 66 Opening Snap Correct Answer: An unusual high pitched sound occurring after s2 with stenosis of mitral valve from rheumatic heart disease Ejection Click Correct Answer: breif high pitched sound occuring immediately after s1 with stenosis of the aortic valve Friction Rub Correct Answer: a harsh, grating sound heard in systole and diastole with pericarditis Murmur Correct Answer: caused by turbulent blood flow from stenotic or malfunctioning valves, congenital defects or increased blood flow -charcterized by location, timing in the cardiac cycle, intensity, pitch, quality and radiation Jugular Venous Pressure Correct Answer: Used to assess the cardiac output and pressure in the right side of the heart because the pulsations are associated with changes in pressure in the right atrium 67 normal height is or = 4 cm above sternal angle -increased pressure indicates increased pressure in Right atrium and right heart failure, pericarditis or tricuspid stenosis Diuretics Correct Answer: Increase renal perfusion and filtration, reducing preload and decreasing peripheral and pulmonary edema, HTN, CHF, diabetes insipidus and osteoporosis Assessing jugular venous pressure Correct Answer: the procedure is usually not accurate if pts pulse rate is 100 -non invasive estimation of central venous pressure and waveform -measurements should be done from internal jugular Elevate the patient's head to 45 (and to 90 if necessary) with patient's head turned to the right. - Position the light at an angle to illuminate veins and shadows. - Measure the height of the jugular vein pulsation above the sternal joint, using a ruler. 68 Fibrinolytic Infusions Correct Answer: Indicated for acute myocardial infarction under these conditions -symptoms of MI, 6-12 hours since onset of symptoms - or = 1 mm elevation of ST in or = continguous leads -no contraindications and no cardiogenic shock -should be administered asap, within 30 minutes for best results - all agents convert plasminogen to plasmin, which breaks down fibrin, dissolving clots ex: -Streptokinase & anistreplase (1st generation) -Alteplase or tissue plasminogen activator (tPA) (second generation) -Reteplase & tenecteplase (3rd generation). Loop Diuretics 69 Correct Answer: -inhibit the reabsorption of sodium and primarily chloride in the ascending loop of Henle -cause increased secretion of calcium, magnesium and potassium side effects: frequent urination, postural hypotension, increased blood sugar and uric acid levels -short acting, less effective than other diuretics Bumetanide / Bumex Correct Answer: Given intravenously after surgery to reduce preload or orally to treat heart failure Ethacrynic Acid / Edecrin Correct Answer: Given intravenously after surgery to reduce preload s or orally to treat heart failure Furosemide / Lasix Correct Answer: Used for the control of congestive heart failure as well as renal insufficiency 70 -used after surgery to decrease preload and to reduce the inflammatory response caused by bypass (post perfusion syndrome) Thiazide Diuretics Correct Answer: Inhibit the reabsorption of sodium and chloride primarily in the early distal tubules, forcing more sodium and water to be excreted -increase secretion of potassium and bicarbonate - first line drugs for HTN -long duration of action ex: chlorothiazide, bendroflumethiazide, chlorthlidone side effects: dizziness, lightheadedness, postural hypotension, headache, blurred vision, itching -causeing sensitivity to sun exposure Potassium-Sparing Diuretics Correct Answer: -Inhibit the reabsorbtion of sodium in the late distal tubule and collecting duct -weaker than thiazide or loop diuretics 71 -if used alone, may cause increase in K+ levels side effects: dehydration, blurred vision, nausea, insomnia, nasal congesion Spironolactone / Aldactone Correct Answer: A synthetic steroid diuretic that increases the secretion of both water and sodium and is used to treat congestive heart failure -PO or IV Eplerenone Correct Answer: Similar to spironolactone, but fewer side effects used with patients who cannot tolerate other drugs Digitalis Correct Answer: -Derived from the foxglove plants - used to increase myocardial contractility, left ventricular output, and slow conduction through the AV node -used to decrease rapid heart rates and promote diuresis - can increase tolerance to activity and reduce hospitalizations for heart failure 72 -therapeutic levels (0.5-2.0 ng/mL) Early Signs of Digitalis Toxicity Correct Answer: -Increasing fatigue -lethargy -depression -nausea/vomitting Digitalis Toxicity symptoms Correct Answer: -sudden change in heart rhthym -SA or AV block -new ventricular dysrhythmias -Tachycardia Treatment of Digitalis Toxicity Correct Answer: -Discontinuing the medication and monitoring serum levels and symptums -digitoxin immune FAB (digibind) may be used to inactivate digoxin Vasodilators Correct Answer: May be used for arterial dilation or venous dilation in order to improve cardiac function 73 -used to treat pulmonary HTN or generalized systemic hypertension -can be used for those who cannot tolerate ACE Inhibitors or angiotensin receptor blockers may dilate arteries, veins or both: -arterial dilation reduces afterload, improving cardiac output -venous dilation reduces preload, reducing filling pressures Glycoprotein IIB / IIIA Inhibitors Correct Answer: Drugs that are used to inhibit platelet binding and prevent clots prior to and following invasive cardiac procedures -used in combination with anticoagulant drugs used for: -ACS (unstable angina / MI) -Percutaneous Coronary intervention (PCI) (angioplasty /stent placement) Medication Treatment for Heart Failure Correct Answer: - ACE Inhibitors (captopril, enalapril, lisinopril): decrease afterload & preload, reverse vent. remodeling 74 -Angiotensin Receptor Blockers (ARBs) (losartan, valsartan): causes vasodilation and reduces blood pressure Beta Blockers: (metoprolol, carvedilol): slows heart rate, reduces HTN, prevents dysrhythmias