NSG 356 EXAM 3!
Evaluation of hypertrophic cardiomyopathies. (10)
- Patient with family history of HCM or sudden death - Asymptomatic - Primary symptoms if any - chest pain, dyspnea, syncope, palpations - Sign may be systolic murmur - Testing- - ECG/EKG - TEE - Cardiac MRI - Genetic testing - Troponin & BNP
What happens during repolarization? (4)
- Na + channels close, K + flows outside cell until the end of repolarization - Outside cell returns to negative electrical potential - Resting state of muscle - Diastole
Describe ventricular fibrillation (VF). (4)
- No measurable - P waves, PR intervals, QRS complexes, ST or T waves - Fine or coarse - Rapid chaotic irregular rhythm - no organization - No Cardiac output - clinical death
Valsartan
Diovan
Causes of sinus pause/arrest.
Diseased SA node, vagal stimulation, MI, Anti - arrhythmic medications
When do we see agonal rhythms?
Dying heart. See this a lot when we take off of life support.
Describe Subset HF.
EF 41-49% Treat as HFrEF
Describe HF with reduced EF (HFrEF).
EF < 40% Systolic HF
Describe HR with preserved EF (HFpEF).
EF > 50% Diastolic HF Exclude other non cardiac causes
If sinus tachycardia is irregular or doesn't stop, then you need an...
EKG
What are the complications of hypertensive crisis? (5)
END ORGAN DAMAGE: - Acute Aortic Dissection - Acute Ischemic Stroke - Acute Intracerebral Hemorrhage - Hypertensive Encephalopathy - Acute Myocardial Infarction
What are the causes of premature ventricular contractions? (5)
Electrolyte causes (Mg+, K+), Enhanced Ventricular automaticity, Digitalis, Catecholemines, Irritation - mechanical (wires) ischemia/infarction
Electrocardiograms measure...
ONLY electrical activity
RECAP OF ELECTRICAL CONDUCTIONS OF THE HEART.
SA node → Atrial Syncytium → Junctional Fibers →AV Node → AV Bundle/ Bundle of His → L and R Bundle Branches → Purkinjie Fibers → Ventricular Syncytium
What does takotsubo cardiomyopathy resemble?
STEMI
Heart failure is a... (5)
Serious progressive disorder including: - Ventricular dysfunction - Decreased cardiac output - Decreased tissue perfusion - Fluid retention
True or false: A premature ventricular contraction (PVC) is characterized by a wide, abnormal QRS complex.
True
True or false: Accurately measuring blood pressure is essential for early recognition and management of hypertension.
True
True or false: Atrial fibrillation can be subtle with some patients asymptomatic or complain of intermittent palpitations or unusual fatigue.
True
True or false: Atrial fibrillation is the most common dysrhythmia.
True
True or false: Blood pressure is one of the most commonly performed procedures in nursing.
True
True or false: Catecholamine surges may play a significant role in Takotsubo cardiomyopathy.
True
True or false: Chronic oral anticoagulation is recommended for most Atrial fibrillation patients.
True
True or false: Complications of Takotsubo cardiomyopathy include cardiogenic shock, ventricular dysrhythmias, heart failure and mitral regurgitation.
True
True or false: Diagnostic studies for Atrial fibrillation include an ECG, transthoracic echocardiogram (TTE) and blood work.
True
True or false: Heart failure is when the heart is not pumping enough blood to meet the body's requirements.
True
True or false: Hypertension is diagnosed by two separate blood pressure readings at two separate times.
True
True or false: Hypotension may result from a reduction in stroke volume because of acute LV dysfunction or outlet flow obstruction.
True
True or false: If there is an increase in PVCs or new groups or "runs" of PVCs , contact the provider for further evaluation.
True
True or false: Improving diet and exercise habits will help lower blood pressure.
True
True or false: Inaccurate measurement of blood pressure may lead to failure to accurately diagnose hypertension.
True
True or false: Multiple ectopic atrial pacemakers take over and cause the atria to quiver instead of contracting in a synchronized way.
True
True or false: No specific treatments or interventions have been developed for Takotsubo cardiomyopathy.
True
True or false: PVCs are caused by irritable ventricular tissue that depolarize early and unpredictably.
True
True or false: PVCs can be triggered by heart failure, electrolyte imbalance, stimulants, hypoxia, acute MI, mitral valve prolapse, and thyroid disease.
True
True or false: Pulmonary edema can be seen on X ray.
True
True or false: Risk factors to develop Atrial fibrillation include hypertension, myocardial infarction, heart failure, obesity, alcohol use, smoking and obstructive sleep apnea.
True
True or false: Start CPR is the patient is unresponsive, apneic, and pulseless.
True
True or false: Synchronized electrical cardioversion is a rhythm control strategy.
True
True or false: Takotsubo cardiomyopathy is also known as "broken heart" syndrome.
True
True or false: Takotsubo cardiomyopathy may mimic acute coronary syndrome (ACS) without obstruction of the coronary arteries.
True
True or false: Takotsubo name refers to the shape of the left ventricle that resembles an octopus-fishing pot called a "takotsubo". .
True
True or false: The RAA system (RAAS) has an important role in regulating blood pressure.
True
True or false: The SA node is a specialized group of cells in the right atrium that depolarizes at the rate of 60-100 times/minute causing the atrium to contract and propel blood into the ventricles.
True
True or false: The ST segment elevation is the key indicator for myocardial infarction.
True
True or false: The bundle branches are high speed conducting fibers that run down the intraventricular septum and transmit the impulse to the Purkinje fibers.
True
True or false: The chest leads or precordial leads lie across the anterior chest wall.
True
True or false: The heart will fail over time if it has to work too hard.
True
True or false: The internal conduction system initiates each heart beat and coordinates all parts of the heart to contract at the proper time.
True
True or false: The last major wave component of the ECG is the T wave that follows the QRS complex and represents ventricular repolarization or a metabolic rest period between heartbeats.
True
True or false: The main treatment goals for Atrial fibrillation include resolution of hemodynamic compromise by controlling heart rate and restoring normal sinus rhythm (NSR).
True
True or false: The next important structure is the AV node which receives the atrial impulse allows a brief pause to allow the ventricles to fill and transmits the impulse to the bundle of his.
True
True or false: The normal PR interval lasts 0.12 to 0.20 seconds.
True
True or false: Two classes include: Primary (essential) Hypertension Secondary Hypertension
True
True or false: Ventricular Tachycardia is characterized by wide, bizarre QRS complexes.
True
True or false: Ventricular Tachycardia takes control away from the sinus node.
True
True or false: Volume overload sign is when the patient may say "I need to sit up to sleep"
True
When are people affected by dilated cardiomyopathies?
Typically presents at age 30-60
Class IV (severe) HF symptoms.
Unable to carry out any physical activity without symptoms of heart failure or symptoms of heart failure at rest
The contraction of the purkinje fibers starts off...
first at the apex of the heart, helping to shove the blood toward either the pulmonary trunk or the aorta
What can dilated cardiomyopathy be classified as?
ischemic and non-ischemic
no electrical activity - measurement line
isoelectric line
Every time the SA node fires...
it begins the entire cardiac cycle
Treatment for sinus bradycardia.
observe for symptoms - if symptomatic - Atropine 0.5 mg - 1 mg IV, Pacemaker on standby
Takotsubo =
octopus pot
What causes takotsubo cardiomyopathy?
often precipitated by acute emotional or physical stress
The SA node has a bigger job than just triggering the atria-- the SA node is responsible for...
setting up the entire pace of the heart
Hypertensive crises refer to patients with...
severe blood pressure elevations (systolic blood pressure > 180 mm Hg or diastolic blood pressure > 120 mm Hg)
What are the causes of ventricular standstill/asystole?
severe metabolic deficit, acute respiratory failure/arrest, extensive MI, ruptured ventricle
Multiple QRS complexes by...
ten
Irregular during pause Underlying sinus rhythm Sudden decrease in rate No P wave or QRS complex during Pause or arrest Sudden decrease in rate, may cause syncope or dizziness
sinus pause/arrest
SA node fails to discharge impulse =
sinus pause/arrest
The AV node is located in the wall between...
the right atrium and right ventricle
What is the treatment for idioventricular rhythm/ventricular escape rhythm?
treat cause, pacemaker
Tx of sinus tachycardia.
treat cause, rhythm can be compensatory. Beta Blockers, Ca+ Channel Blockers
Torsades de pointe →
twisting of the points
LOC for defibrillation.
unconscious
Causes of sinus bradycardia.
vaso vagal maneuvers, intubation, Beta Blockers, Digoxin, IWMI, Sleep, parasympathetic stimulation
Which are worse: ventricular or atrial arrhythmias?
ventricular arrhythmias
What do we use defibrillation for?
ventricular fibrillation (VF)
What is Vfib?
ventricular fibrillation; clinical death
What do we use cardioversion for?
ventricular tachycardia (VTach)
Reversal for Coumadin
vitamin K or fresh frozen plasma for clotting factors
We like bradycardia over tachycardia because..
we know the heart can fill
Who is more commonly affected by takotsubo cardiomyopathy?
women
Side effects of ACE inhibitors.
• Hypotension • Hyperkalemia • Cough • Taste disturbance • Angioedema
Holter Monitoring
•A Holter monitor is a small, wearable device that keeps track of your heart rhythm. •If you have signs or symptoms of a heart problem, such as an irregular heartbeat (arrhythmia) or unexplained fainting, your doctor may order a test called an electrocardiogram. •An electrocardiogram is a brief, noninvasive test that uses electrodes taped to your chest to check your heart's rhythm. •Over that time, the Holter monitor may be able to detect irregularities in your heart rhythm that an electrocardiogram couldn't detect.
Implantable Loop Recorder
•An implantable loop recorder is a type of heart-monitoring device that records your heart rhythm continuously for up to three years. • It records the electrical signals of your heart and allows remote monitoring by way of a small device inserted just beneath the skin of the chest
Chronic HF Nursing Intervention
•Basic principles of care •HF is a progressive disease •Treatment plans established with quality-of-life goals •Symptom management depends on adherence to self-management protocols •Precipitating factors, etiologies, and comorbid conditions must be addressed •Complex care needs often require multiple settings, increasing fragmented care •Support systems are essential to success
Left Sided Heart Failure
•Blood backs up into left atrium (LA) •Increased pulmonary hydrostatic pressure causes fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli. •This results in pulmonary congestion and edema
Education
•Daily weights •Low Na+ diet - 2 gram •Nutritional consult •Early signs of HF
SVT Causes
•Heart failure •Thyroid disease •Heart disease •Chronic lung disease •Smoking •Drinking too much alcohol •Consuming too much caffeine •Drug use, such as cocaine and methamphetamines •Certain medications, including asthma medications and over-the-counter cold and allergy drugs •Surgery •Pregnancy
Sympathetic Nervous System
•Increased catecholamines •Epinephrine and norephinephrine •Leads to vasoconstriction •Stimulation of β-adrenergic receptors increases HR and ventricular contractility (inotropy) •END RESULT: •Increased BP, increased afterload, increased HR
Left-sided HF
•Most common form of HF •Results from inability of LV to •Empty adequately during systole, or •Fill adequately during diastole •Further classified as •HFrEF (systolic HF) •HFpEF (diastolic HF) •Or combination of the two
Non-Vitamin K oral anticoagulants
•Pradaxa (dabigatran) ~ thrombin inhibitor Praxbind antidote reverses the drug •Xarelto (rivaroxaban) antidote andexanet alfa •Eliquis (apixaban) antidote andexanet alfa
Etiology of Heart Failure •Any interference with mechanisms regulating cardiac output (CO) •Primary causes •Precipitating causes
•Primary causes •Conditions that directly damage the heart •Precipitating causes •Conditions that increase workload of the heart
Left side (oxygenated)
•Pulmonary veins to left atrium to mitral valve to left ventricle to aortic valve to systemic circulation
Right side (unoxygenated)
•SVC and IVC to right atrium to tricuspid valve to right ventricle to pulmonic valve to pulmonary artery to lungs
Atrial flutter (A flutter) •If ventricular rate rapid - S/S of ↓CO
•Shortness of breath •Tiredness (fatigue) •Chest pain •Fluttering heartbeats (palpitations) •Lightheadedness •Fainting •Swelling in your feet and legs (fluid retention) if you have heart failure
Acute Exacerbation Goals of therapy Treatment
•Symptom relief •Optimizing volume status •Supporting oxygenation and ventilation •Identifying and addressing causes •Avoiding complications •Teaching related to exacerbations •Continuous monitoring and assessment •VS, O2 saturation, weight, mentation, ECGs, urinary output •High Fowler's position •Medications •Hemodynamic monitoring if unstable •Supplemental oxygen, BiPaP •Mechanical ventilation if unstable
Treatment for Atrial Fibrillation
•Want to reset the rhythm •Electric Cardioversion •Pharmacological Cardioversion - Ca+ Channel Blockers, Amiodarone, Digoxin •Ablation •Anti-coagulation •Left atrial appendage closure ~ Watchman Device
Anti-Coagulation for A-Fib
•Warfarin (coumadin) Blocks the liver from using vitamin K to make clotting factors Vitamin K is the antidote Monitoring required 5-7 days to be effective Inexpensive •International Normalized Ration (INR) Tests how much time it takes for a patient's blood to clot Typical range is 2 to 3 •Diet: avoid foods with high vitamin K levels What foods are high in Vit K?
Management
•Weight gain of 3 pounds (1.4 kg) over 2 days or a 3- to 5 pounds (2.3 kg) gain over a week should be reported to HCP
Regular rhythm P waves - 1 to each QRS complex, all same shape and size and deflection. 0.12-0.20 sec QRS - all same < 0.12 ↓ventricular and coronary artery filling time May cause cardiac ischemia May ↑ or ↓ BP.
sinus tachycardia (ST)
The junctional fibers are designed to be...
slow in action potential to allow the atrium to contract and force blood into the ventricles
What is artifact?
something that is not natural; not "heart-made"; electrical interference by outside sources, electrical noise from elsewhere in the body, poor contact, and machine malfunction; extremely common, and knowledge of them is necessary to prevent misinterpretation of a heart's rhythm
energy level of defibrillation.
starts at 200 joules
energy level of cardioversion.
starts at 25-50 joules
The A-V bundle/Bundle of His splits into two halves when it reaches the intraventricular septum, in order to...
supply both the left and the right ventricles with the activity information
What are the causes of idioventricular rhythm/ventricular escape rhythm?
suppression of upper pacemakers, Drugs, ischemia/infarction, AV Block, end stage cardiac disease
Causes of sinus tachycardia.
sympathetic stimulation, hypovolemia, anxiety, pain, exertion, anemia, fever, hypotension, caffeine, alcohol, heart failure, Nicotine, Cocaine, Amphetamines, Pseudoephedrine, Ephedrine
cardioversion synchronicity.
synchronous with R wave
Hypertrophic cardiomyopathy complications.
syncope, heart failure, sudden death
What heart condition was featured in the notebook?
takotsubo cardiomyopathy
What is broken heart syndrome?
takutsubo cardiomyopathy
Hypertrophic cardiomyopathy is the...
commonly inherited cardiovascular disease
Ability to transmit an impulse
conductivity
LOC for cardioversion.
conscious
Cardiac muscle cells to...
contract - they need to be excited (depolarization)
Ability to respond with pumping action
contractibility
Two PVCs in a row
couplet
grade III and/or IV PVD
critical ischemia; threat of loss of limb
What is the treatment for ventricular tachycardia?
check pt, Amiodarone, Lidocaine (for conscious pt), Cardioversion for pulse, Defibrillation for pulseless - good quality CPR
Treatment for PVCs is..
not needed unless pt is symptomatic
What is included in the treatment of PVD? (6)
- Invasive Interventions - - Angioplasty and stents (contrast used) - Surgical Interventions - ~ Bypass grafts - Post surgical - site, pulse, temp - color
ECRI institute named ______ the #1 health technology safety hazard.
"alarm hazards"
Refers to the system of electrical signaling that instructs these muscle cells to contract
"cardiac conduction system"
What are the most important electrolytes for heart issues?
*potassium, magnesium,* sodium, and calcium
What is the treatment for polymorphic ventricular tachycardia?
*treat with Mg+ IV push,* check pt, Amiodarone, Lidocaine (for conscious pt), Cardioversion for pulse, Defibrillation for pulseless - good quality CPR but less responsive to Lidocaine and Cardioversion
How do we treat PVCs? (4)
- Lidocaine - suppress ventricular irritability - Amiodarone - Treat the cause - Treatment with multifocal, bigeminy, couplets, salvo, runs of VT
What are the causes of PVD? (7)
- #1 - arteriosclerosis - Blood clot - DM (higher the BS more damage to vessels = narrowed or weak - then + HTN and high fat deposits accelerates atherosclerosis - Inflammation of the arteries - autoimmune - Infection - causes inflammation and scarring - Structural defects - Injury
What are the causes of dilated cardiomyopathies? (11)
- *CAD* - Alcoholism - Cocaine - Thyroid disease - DM - Viral infections of the heart (Lyme's disease, HIV, and Chagas disease) - Heart valve abnormalities (aortic regurgitation and mitral regurgitation) - Heart damaging drugs - Postpartum cardiomyopathy - High BP - Nutritional abnormalities
Risk factors for peripheral vascular disease: (8)
- + family history of premature MI or strokes - > 50 y/o - Overweight or obesity - Inactive lifestyle - Smoking - DM - HTN - High LDL and triglycerides
Treatment for hypertensive EMERGENCY: (7)
- Admit the patient to the intensive care unit for IV medications and management of end-organ dysfunction. - For most patients, aim to lower the blood pressure by 10%-15% over the first hour. - Intravenous (IV) medications and doses used to treat hypertensive emergencies include: - nicardipine initial infusion rate 5 mg/hour, increasing by 2.5 mg/hour every 5 minutes to a maximum of 15 mg/hour - sodium nitroprusside 0.3-0.5 mcg/kg/minute, increase by 0.5 mcg/kg/minute every few minutes as needed to a maximum dose 10 mcg/kg/minute - labetalol 10-20 mg IV followed by bolus doses of 20-80 mg at 10-minute intervals until target blood pressure reached to a maximum 300 mg cumulative dose - esmolol initial loading dose 500 mcg/kg/minute over 1 minute, then 50-100 mcg/kg/minute to a maximum dose 300 mcg/kg/minute
Parasympathetic (vagus) nervous system functions. (5)
- Affects primarily the atria - Mediator- acetylcholine Decreases: ~ ↓Rate of SA node ~ ↓Rate of AV conduction ~ ↓Excitability
What is included in the diagnosis of PVD? (3)
- Ankle brachial index (ABI) - Ultrasound Doppler test - Angiogram
What is included in the evaluation of hypertensive crises? (13)
- Assessment of end organ damage *Distinguishing hypertensive urgency from emergency requires tests to evaluate cerebral, cardiovascular, renal, and hematological function and damage:* - blood tests including electrolytes, blood urea nitrogen, creatinine, and complete blood count - cardiac biomarkers - urinalysis (for proteinuria or hematuria consistent with glomerular damage) - toxicology screen - electrocardiogram - careful examination of optic nerve for signs of intracranial hypertension (with pupillary dilation if needed) *imaging based on clinical suspicion for specific conditions including:* - chest x-ray (for signs of left ventricular failure) - chest computed tomography or magnetic resonance imaging in patients with unequal pulses or widened mediastinum on chest x-ray to look for dissecting aortic aneurysm - transthoracic echocardiogram (TTE) in patients presenting with pulmonary edema - to distinguish diastolic dysfunction, transient systolic dysfunction, and mitral regurgitation - transesophageal echocardiography (TEE) is not recommended in patients when dissecting aortic aneurysm is a possibility until adequate blood pressure control is achieved
Placement for continuous monitoring 5 or 6 lead placement.
- Can use with telemetry and hard wired monitors - Monitor in leads II and a precordial lead
What are the symptoms of PVD? (8)
- Claudication - Buttock pain - Numbness/tingling of leg, foot, toe - Changes in skin color - Changes in skin temp - Sores that do not heal - Uncontrolled HTN - Renal insufficiency/failure
PR interval
- Conduction through AV node - Measured from beginning of P to beginning of QRS
Increased renin: (3)
- Converts angiotensinogen to angiotensin - Aldosterone for sodium retention - Increased peripheral vasoconstriction
RAAS responses to: (4)
- Decreased CO - Decreased renal blood flow - Increased renin - Posterior pituitary secretes ADH
Q-T interval
- Depolarization to repolarization - Measured from beginning of QRS to end of T wave
Left HF s/s.
- Dyspnea - Orthopnea - Cough - dry hacking - S3 heart sounds - Pulmonary edema/crackles - Fatigue/weakness
What is included in the initial testing for takotsubo cardiomyopathy? (4)
- ECG/EKG - Cardiac markers - troponin and BNP - Coronary angiography - Echocardiogram
Evaluation of dilated cardiomyopathy. (6)
- Echocardiogram - ECG/EKG - looking for ischemic heart disease - Stress test or coronary angiography for ischemic heart disease - Lab tests for genetic mutations - Cardiac biopsy - Troponin & BNP
What happens during depolarization? (7)
- Electrical impulse causes cell membrane to become permeable to Na + and K + - Na flows into cell, K flows out - Positive electrical potential outside of cell - Systole - Slow calcium-sodium channels open during depolarization - Increases time period of action potential allowing a longer, stronger contraction - Up to 15 x longer than skeletal muscle
Ventricular dilatation: (3)
- Enlargement of chambers of the heart - Muscle fibers stretch to increase contractility - Initially helpful - Eventually - stretch too far
What are the noninvasive treatments for PVD? (9)
- Exercise - Positioning - Elevate feet at rest (avoid above the heart - slows arterial flow) - Promote vasodilation - warmth but not directly on skin - Stop smoking - Avoid cold temps - Decrease caffeine - Control HTN - Medications - anti platelets, lipid lowering agents, Ca+ Channel blockers (relaxes vessels)
What are the three ion channels used in cardiac action potential?
- Fast sodium channels - Slow calcium-sodium channels - Potassium channels
Ventricular hypertrophy: (3)
- Increase in cardiac wall thickness - Initially serves to increase contractility - Decrease inside volume - Over time leads to poor contractility, increased O2 needs, poor coronary artery circulation, and risk for dysrhythmias
Right HF s/s.
- Increased weight gain - JVD + - Edema - Fatigue/weakness - Hypertension - Hepatomegaly
What are the different kind of ventricular arrhythmias? (7)
- Premature Ventricular Contraction (PVC) - Idioventricular Rhythm - Ventricular Tachycardia (VT) - Polymorphic VT/ Torsades de Pointe - Ventricular Fibrillation (V fib) - Agonal - Asystole/Ventricular standstill
How do we reduce alarm fatigue in relation to cardiac monitoring? (8)
- Proper skin preparation before placing electrodes (wash with soap and water - No alcohol. Getting rid of excess body hair) - Proper placement of electrodes - fleshy areas and avoiding boney areas or muscle groups to minimize artifact - Press firmly around the outer areas of the electrode during application and gel center remains intact - Change electrodes daily and prn (electrodes can dry out) - Individualize alarms for patient each shift - Assess alarm audibility - Proper documentation of alarm settings - Maintenance of monitor devices
Describe ventricular tachycardia. (7)
- Rate > 100 bpm - Regular rhythm, monomorphic - No P wave - QRS complex wide - T wave opposite QRS - Not well tolerated - CO extremely ↓, ? LOC, if conscious, S/S of poor perfusion, deteriorate
ACE inhibitors are associated with...
- Reduction in mortality - Improvement in exercise tolerance - Improves symptom control - May see no improvement for weeks to months
How do you calculate heart rate with the Rule of 10? (3)
- Regular or irregular rhythm - Count number of R waves in a 6 second rhythm strip - #of R waves x 10 = HR
How do you calculate heart rate with the Rule of 1500? (3)
- Regular rhythm only - Count the small boxes between two consecutive R waves - 1500 ÷ # of boxes = HR
Describe agonal rhythm. (6)
- Rhythm irregular - Rate < 20 bpm - QRS extremely wide and slurred - No ST or T wave - Last ditch effort of heart to create electrical impulse - Signs of clinical death
Evaluation of restrictive cardiomyopathies. (6)
- S/S of advanced heart failure - Look for H/O radiation treatment, chemo, associated systemic disorders - Echocardiography - Cardiac Cath - Cardiac biopsy - Genetic testing
Care after EPS includes: (4)
- Same as cardiac cath - Check site, pulse, and VS - Monitor for arrhythmias - S/S retroperitoneal bleed - restlessness, back pain, tachycardia, hypotension.
What is the management for takotsubo cardiomyopathy? (5)
- Spontaneous recovery - EF will guide treatment EF < 45% and complications or considered high risk - need high levels of care - Medications are supportive - avoid inotropes and sympathomimetic - May include Beta Blockers and ACE inhibitors Other supportive care - IABP and LVAD - Follow up care a must
Describe ventricular standstill/asystole. (4)
- Standstill - only P waves noted - Asystole - No electrical activity - Clinical Death - 2 leads to confirm asystole
Sympathetic nervous system functions. (6)
- Supplies atria and ventricles - Mediator- norepinephrine Increases: ~ ↑Rate of SA node ~ ↑Rate of AV node ~ ↑Excitability ~ ↑Force of contraction
Treatment of dilated cardiomyopathy. (7)
- Symptomatic heart failure with reduced EF - ACE inhibitors/ ARBs (Angiotensin receptor blockers) - Beta blockers - Treat underlying cause - Implantable cardioverter defibrillator - LVAD (do not have a pulse) - Cardiac transplant
Placement for continuous monitoring 3 lead placement.
- Telemetry monitoring - Monitor in lead II
Cardiac action potential includes... (4)
- Three ion channels - Depolarization - Repolarization - Sodium Potassium pump with Depolarization
The electrode catheters are used to do two main tasks:
- To record the electrical signals generated by the heart and to pace the heart. (Pacing is accomplished by sending tiny electrical signals through the electrode catheter.) - By recording and pacing from strategic locations within the heart, most kinds of cardiac arrhythmias can be fully studied and replicated.
PAD:
- Type of PVD - Arterial blood flow
When are ARBs used?
- Used in HF patients who are ACEI intolerant - May be added to beta blockers, digoxin, diuretics
What is important to know about beta blockers?
- Used to block SNS effects. - Start with hemodynamically stable patient with no fluid retention - Watch for hyperglycemia - Sx may worsen X 3-6 months
What is defibrillation? (3)
- Using electrical current to stop abnormal rhythm in hopes the SA node will restart at a "normal" rhythm - Using high energy starting at 200- 300 joules - SAFETY IS SO IMPORTANT
Describe idioventricular rhythm/ventricular escape rhythm. (6)
- Usually regular - Rate 20-40 (from ventricles) - No P waves - Wide abnormal QRS complex - ↓CO from lack of atrial kick, slow rate, and poor ventricular contraction. - ↓CO may be severe
QRS complex interval
- Ventricular depolarization - Measured from the beginning of the Q to the end of the S wave
Describe takotsubo cardiomyopathy. (2)
- acute cardiac syndrome - acts like acute coronary syndrome minus the occluded coronary artery - left ventricular ballooning
What should we ask about with pts with hypertensive crises? (2)
- ask about recent blood pressure measurements as rate of increase in blood pressure above baseline blood pressure measurements may be more important than absolute blood pressure levels - ask about neurologic symptoms, such as headache, nausea or vomiting, and visual disturbances
Social drugs (hypertensive crises) (4)
- ask about recreational drug use, such as: ~ amphetamines ~ cocaine ~ phencyclidine (PCP)(Ketamine)
What is included in cardiac assessment for hypertensive crises? (2)
- assess for murmurs and gallops - assess for signs of heart failure, which is second most common sign of end-organ damage
What is included in neurological assessment for hypertensive crises? (7)
- assess for neurologic signs ~ stupor ~ seizures ~ delirium ~ agitation ~ mental status exam - altered consciousness may indicate hypertensive encephalopathy - lateralizing signs are uncommon in hypertensive encephalopathy not complicated by ischemic brain injury and suggest vascular event
What are the physiologic properties of the cardiac cell? (4)
- automaticity - excitability - conductivity - contractibility
What is included in abdominal assessment for hypertensive crises? (3)
- bruits suggest renal artery stenosis - abdominal aortic aneurysm - auscultate for murmur, which may suggest aortic dissection
What are the different ischemic causes dilated cardiomyopathies? (2)
- coronary artery disease - myocardial infarction
What are the symptoms of PVD dependent on? (2)
- dependent on artery affected - severity of blood flow reduction
Characteristics of hypertrophic cardiomyopathy. (3)
- diastolic dysfunction - risk of sudden death in young athletes - thickened left ventricular wall
Characteristics of dilated cardiomyopathy. (3)
- enlargement of all cardiac chambers - systolic dysfunction - most common type
What is included in HEENT assessment for hypertensive crises? (6)
- epitaxis - funduscopic exam findings may include: ~ advanced retinopathy with arteriolar changes ~ hemorrhages ~ exudates ~ papilledema
What are the different non-ischemic causes of dilated cardiomyopathies? (6)
- familial (genetics) - autosomal dominant (duchenne muscular dystrophy) - structural heart (valves, pressure or volume overload, L to R shunt) - alcohol - drugs - chemo, cocaine, toxins (CO2, lead, mercury) - endocrine - immune - autoimmune, hypersensitivity, transplant rejection, Infection
High sodium foods.
- frozen meals - tomato sauce - soups - condiments - canned foods - prepared mixes
What are the classification stages of Leriche-Fontaine of PVD?
- grade I-IV
What are the different types of cardiomyopathy? (3)
- hypertrophic - dilated - restrictive
HPI of pts with hypertensive crises. (6)
- most patients have persistently elevated blood pressure for years before presenting with hypertensive emergency - neurologic symptoms - recent BP measurements - sudden onset of severe headache suggests subarachnoid hemorrhage - rapid onset of radiating pain in chest and/or back may suggest aortic dissection - ask about dyspnea, orthopnea, cough, or fatigue, which may suggest cardiac decompensation
S/S of PAD. (4)
- poor wound healing - cold legs - pain during exercise, which is relieved during rest - constant leg pain, tingling, burning, or loss of sensation
Medications (hypertensive crises) (3)
- review all prescription and nonprescription medications (including herbal supplements) - review current antihypertensive regimen, adherence, and time from last dose - ask about use of sildenafil (Viagra) since concomitant nitrate administration can be fatal
Characteristics of restrictive cardiomyopathy. (3)
- rigid ventricular walls - diastolic dysfunction - least common type
What are the risk factors for PAD? (5)
- smoker or used to smoke - high BP - over the age of 50 - have DM - high cholesterol
ACE inhibitors end in..
-pril
QRS complex interval normal time =
0.04 - 0.12
Small horizontal boxes =
0.04 second
PR interval normal time =
0.12-0.20
Small vertical boxes =
0.1mv
Large horizontal boxes =
0.20 second
Large vertical boxes =
0.5mv
How many people over the age of 50 have PAD?
1 in 20
5 large boxes =
1 second
What are the rhythm interpretation questions to ask? (7)
1. Is the rate too slow or too fast? (<60 or > 100) 2. Is the rhythm regular? 3. Are there normal looking P waves? (round and positive deflection, all look the same, and to every QRS complex) 4. Measure PR Interval (in range) 5. Measure QRS complex (in range) 6. Measure QT interval (in range) 7. Interpret rhythm
Purkinje fibers have an inherent rate of
20-40
15 large boxes =
3 seconds
Hypertensive crises may present in ___ of emergency department visits and ___ of all medical urgencies/emergencies
3%; 27%
What is the inherent rate of the AV node?
40-60
What is the normal heart ejection fraction?
50-70%
When do we get concerned with PVCs?
6 PVCs/min
About ______ people in the US have PAD.
8 million
How many bpm in sinus bradycardia?
< 60 bpm
How many bpm in sinus tachycardia?
>100 101-150 bpm
The only irregularly irregular rhythms →
A fib and V fib
What is the AV Bundle/Bundle of His?
A group of fast-conducting fibers carry the A-V node activity to the intraventricular septum really quickly
Supraventricular Tachycardia
A rapid tachyarrhythmia that originates above the ventricle. Can also be called PSVT ~ paroxysmal supraventricular tachycardia
Angiotensin II receptor blockers
ARBs
What connects the AV node with the two bundle branches - left and right?
AV Bundle/Bundle of His
Autorhythmic cells fire much more slowly than SA Node
AV node
What relays impulses from SA Node to ventricles?
AV node
Pressure in aorta to be overcome
Afterload
Ramipril -
Altace
Ejection Fraction
Amount of blood pumped out of the ventricle / Total amount of blood in ventricle
- Disorganized ineffective quivering of the ATRIUMS - No P waves - Ventricular rate is totally irregular and varied - No PRI - Usually normal QRS complex unless there is a Bundle Branch Block - Rapid A fib - uncontrolled A fib > 100 ventricular bpm - Controlled A fib < 100 ventricular bpm - Rhythm may become more regular with Dig Toxicity - Hemodynamics - loss of atrial kick (↓CO by 30%) - May c/o palpations - Apical/Radial pulse deficit
Atrial fibrillation (Afib)
•Sawtooth pattern •Rapid ATRIAL rate (250-350) •Abnormal electrical circuit in the atria •Usually in. a pattern 2:1, 3:1, 4:1 •Ventricular rhythm usually regular •Symptoms depend on ventricular rate
Atrial flutter (A flutter)
- Atrial ectopic focus takes over for sinus node as the pacemaker - May be thought as 3 or more consecutive PACs - P waves may be difficult to see of hidden T waves of previous beats - Rate 151-250 - REGULAR rhythm - PRI may not be measurable d/t rate - QRS normal - If P wave is not seen - may be classified as an SVT - Cardiac ischemia may occur d/t ↑ oxygen demand with ↓ventricular filling and ↓coronary artery perfusion. ↓ Cardiac Output
Atrial tachycardia (SVT)
What happens to the cells in the SA node?
Autorhythmic cells fire rapidly
Pt hospitalized for initiation of treatment for rapid A Fib. Monitoring QT interval. Which med is used?
Betapace -- Sotalol
Tx for atrial fibrillation.
Ca+ Channel Blockers, Amiodorone, Anti - coagulation, Ablation, control ventricular response, Digoxin, synchronized cardioversion with unstable hemodynamics
Tx of atrial flutter.
Ca+ Channel blockers, Cardioversion for hemodynamically unstable, Digoxin
Captopril -
Capoten
- Synchronous defibrillation with less use of energy (joules)(starts at 25 j - 50j) - Pt usually awake and hemodynamically unstable - Painful - need to medicate before - Need to hit synch button on defibrillator machine - Need to have marker on screen
Cardioversion
Nonselective beta blockers.
Carvedilol
What is the etiology of HF?
Caused by anything that interferes with mechanisms that regulate cardiac output (CO= HR x SV)
How do we know that we have good quality CPR?
Check the femoral pulse!
C - (5 or 6 lead placement)
Chest (may be one or two)
What is depolarization?
Contraction of the heart
Carvedilol
Coreg
Losartan
Cozaar
What is the treatment for ventricular fibrillation?
Defibrillation, good quality CPR, ACLS protocol, Epinephrine, Amiodarone, Correct electrolytes
Diagnostics and lab values for HF.
Diagnostics: ECG/EKG Echocardiogram check EF and structures CXR TEE Labs: BNP or NTBNP/proBNP Troponin Other: CBC, CMP, Coagulation panel
True or false: A sign or symptom is S4 heart sound of Heart Failure
False
True or false: Acute viral or bacterial infections precedes symptoms of Takotsubo cardiomyopathy.
False
True or false: All the signs and symptoms of heart failure have to do with failing kidneys.
False
True or false: An echocardiogram can show what is happening in the lungs.
False
True or false: Ascites is located in the ankles.
False
True or false: Atrial depolarization generates the QRS complex.
False
True or false: Atrial fibrillation is coordinated, regular electrical activity.
False
True or false: Blood pressure cuff size does not matter.
False
True or false: Korotkoff sounds are hear by doppler when obtaining a blood pressure.
False
True or false: Most patients (90%) with the diagnosis of Takotsubo cardiomyopathy are men.
False
True or false: Most patients do not recover from Takotsubo cardiomyopathy.
False
True or false: Preventing and controlling valve problems is one way to help with heart failure.
False
True or false: Sinus bradycardia has a rate faster than normal 100 beats/minute.
False
True or false: The patient should rest quietly for 20 minutes prior to taking the blood pressure.
False
True or false: There is no blood test for heart failure.
False
True or false: Thrombus formation is not a risk factor for Atrial fibrillation.
False
True or false: Ventricular Tachycardia is a slow, narrow complex ventricular contractions.
False
True or false: Ventricular depolarization produces the first element in the ECG waveform: the P wave.
False
True or false: When assessing for cardiac abnormalities on the ECG, the monitor should be treated, not the patient.
False
Treatment of hypertrophic cardiomyopathies. (9)
GOAL: IMPROVE VENTRICLE FILLING - No intensive sports - Low intensity workouts if asymptomatic - Beta blockers resting HR 60-65 - Verapamil (Ca+ Channel Blocker) - intolerant to Beta Blockers - Diltiazem (Cardizem) for those can not tolerate Verapamil - Implantable Cardioverter devices - Permanent Pacemakers - Septal Ablation - Heart Transplant
Management of restrictive cardiomyopathies. (7)
GOAL: IMPROVING DIASTOLIC FILLING - Diuretics and or aldosterone antagonists - Permanent pacer for AV blocks - Amyloidosis - consider one either - corticosteroids, melphan, autologous stem cell transplant - Treatment of hemochromatosis - iron depletion - Cardiac transplant - Implantable cardioverter-defibrillator - Treatment for underlying causes
Causes of atrial fibrillation.
Heart valve disorders, Cardiomyopathy, MI, COPD/lung diseases, CHF, pericarditis
Management - Nursing
Key Assessments: •Daily weights (standing) •I&Os •Fluid restriction •Labs - BUN, creatinine, BNP, electrolytes •EF •Diet •Monitor edema •Respiratory status
LA - (3 lead)
Left Arm - Black
LA - (5 or 6 lead placement)
Left Arm - Black
LL - (5 or 6 lead placement)
Left Leg - Red
L is for...
Left and Lungs
HFpEF
Inability of the ventricles to relax and fill during diastole, resulting in decreased stroke volume and CO Primary cause is HTN Result of left ventricular hypertrophy from hypertension, older age, female, diabetes, obesity Same end result as systolic failure
HFrEF
Inability to pump blood effectively Caused by Impaired contractile function Increased afterload Mechanical abnormalities
Posterior pituitary secretes ADH:
Increases water reabsorption with increases blood volume
What is the inherent rate of the SA node?
Inherent rate 60-100
Where do we put the electrode catheters?
Inserted to femoral artery - uses fluoroscopy to confirm placement
PVD:
Issues with blood flow via both arteries and veins
Metoprolol
Lopressor
What can PAC signal?
May signal HF, pericarditis, d/t emotions, hormones, caffeine, electrolyte imbalances, atrial hypertrophy, pulmonary disease, hyperthermia
R-R interval
Measured from one R wave to peak of next R wave
What does an Electrocardiogram EKG/ECG measure?
Measures the direction of the electrical impulses discharged from the cardiac cells
Selective beta blockers.
Metoprolol Bisoprolol
Who is more commonly affected by dilated cardiomyopathies?
More common in males; African American
Intrinsic ability to shorten and develop muscle tension
Myocardial contractility
Does takutsubo cardiomyopathy have a coronary artery occlusion?
NO
Nursing interventions for PVD. (8)
Neurovascular assessment ~ Pulses ~ Temp ~ Color ~ Cap refill ~ Hair distribution ~ Open areas ~ Movement ~ OLD CART - pain/parathesias
Class I (mild) HF symptoms.
No limitation of physical activity Ordinary physical activity does not cause symptoms of heart failure (undue fatigue, palpitations, and dyspnea)
Management
Oxygen Vasodilators Inotropic Support IV Morphine
atrial depolarization
P wave
How would the patient look if they had idioventricular rhythm/ventricular escape rhythm?
Patient would be ashen, lips may be blue, hypoventilating, hypotensive, weak, sleeping, diaphoretic, can be vomiting.
What is the only time we give an electrolyte IV push?
Polymorphic VT/torsades de pointe
Volume in ventricles awaiting delivery
Preload
- Early beat in a normal rhythm - P wave is early (from atrium) - P wave differs in size and shape from other P waves - PR interval (PRI) will be shortened with PAC but will be normal with other complexes - Conduction through ventricles is normal = Normal QRS - May have short pause after (Sinus Node reset) - Few changes in hemodynamics - PACs that arise from different foci causing variations in P wave configurations - May occur in patterns of bigeminal, trigeminal, or couplets - New onset may be a precursor to A fib
Premature Atrial Contraction (PAC)
- Variable rate - Rhythm is irregular where PVC occurs - P wave is absent - QRS complex is wide and bizarre - Complete compensatory pause - ↓CO with PVC - May precipitate VT/VF if falling on vulnerable part of T wave
Premature ventricular contraction (PVC)
Lisinopril -
Prinivil
What does an Electrocardiogram EKG/ECG provide?
Provides a view of the heart's electrical activity between a positive pole and a negative pole.
Then they run back up along the outer edges of the ventricles. Once they start running up the outer edges, they are called...
Purkinje fibers
ventricular depolarization
QRS complex
What does RAAS stand for?
Renin Angiotensin Aldosterone System
___ by itself does not really affect ___ ___. Instead, it floats around and converts inactive forms of angiotensin into angiotensin I. ___ is a peptide hormone that causes vasoconstriction and an increase in blood pressure
Renin by itself does not really affect blood pressure. Instead, it floats around and converts inactive forms of angiotensin into angiotensin I. Angiotensin is a peptide hormone that causes vasoconstriction and an increase in blood pressure
What is repolarization?
Resting state of the heart
RA - (3 lead)
Right Arm - White
RA - (5 or 6 lead placement)
Right Arm - White
RL - (5 or 6 lead placement)
Right Leg - Green
What is the pacemaker of the heart that sets impulses regularly and automatically?
SA node
Class III (moderate) HF symptoms.
Significant limitation of physical activity Comfortable at rest, but less than ordinary activity causes symptoms of heart failure
Cardiac Functioning System
Sinoatrial node → atrial syncytium → junctional fibers → atrioventricular node/AV node → AV bundle → bundle branches → purkinje fibers → ventricular synctium
Regular rhythm P waves - 1 to each QRS complex, all same shape and size and deflection. 0.12-0.20 sec QRS - all same < 0.12 Pt may be asymptomatic SV x HR=CO May impact CO Normal in athletes
Sinus bradycardia
Rate - 60-100 bpm Rhythm - regular P waves - 1 to each QRS complex, all same shape and size and deflection. 0.12-0.20 sec QRS - all same < 0.12
Sinus rhythm
Ideal rhythm. No hemodynamic changes. Adequate ventricular filling and Coronary artery filling
Sinus rhythm (SR/NSR)
Class II (mild) HF symptoms.
Slight limitation of physical activity Comfortable at rest, but ordinary physical activity results in symptoms of heart failure
What is the most sensitive part of our cycle?
T wave
ventricular repolarization (most sensitive)
T wave
Echo BNP
Tells you how the EF, valves, and other structures (thickness and wall function) or abnormalities are doing. Hormone produced in response to atrial pressure (volumes in HF) and high serum sodium levels.
How does the AV node get activated?
The SA node communicates with the AV node through junctional fibers
Horizontal boxes =
Time
What is an example of polymorphic VT?
Torsades de Pointe (twisting of points)
What are the shockable rhythms?
Torsades de pointe/polymorphic VT, Vtach, and Vfib
Treatment for hypertensive URGENCY: (6)
Treat patients without evidence of end-organ damage with 1 of the following orally administered medications: - nicardipine 20-40 mg orally every 8 hours - captopril 25 mg orally every 8 to 12 hours - labetalol initial dose 200 mg orally, then additional 200-400 mg dose after 6-12 hours as needed - Normalize blood pressure gradually over 24-48 hours, as rapid blood pressure decreases may result in dangerously reduced organ perfusion. - Before discharge from the emergency department, observe the patient for several hours and confirm a follow-up visit within several days.
Sinus pause/arrest treatment.
Treatment depends on length of pause - Atropine at bedside and Pacer at bedside
Adenosine
Used to treat tachycardic rhythms Given to the patient very fast Stops all electrical current moving in the heart = stops all mechanical movement in the heart Half-life is about 6 seconds. Stops heart for 6 seconds and restarts the heart in a normal rhythm.
Wide complex tachycardia
V-tach
Enalapril -
Vasotec
Process of changing shape & mass of ventricles
Ventricular Remodeling
Non shockable rhythm. No pulse with this because there is no electrical activity in the heart. confirmation of death.
Ventricular standstill/asystole
Which is worse: Vfib or Vtach?
Vfib
Vertical boxes =
Voltage or amplitude
When is a dilated cardiomyopathy considered *primary/idiopathic*?
When other causes cannot be determined!
What is cardiomyopathy?
a condition which makes it harder for the heart to pump and supply blood to the other parts of the body
Four or more PVCs =
a run of Vtach
Pneumonic for lead placements
White is on the right Snow over grass Smoke over fire. Mud in the middle, or chocolate closest to the heart
What is included in extremities assessment for hypertensive crises?
check pulses in all extremities, where unequal pulses may suggest aortic dissection
Bisoprolol
Zebeta
amount of resistance to ejected blood flow
afterload
What are nonshockable ventricular rhythms?
agonal and ventricular standstill/asystole
EPS tx can also occur with...
ablation
What are the symptoms of takotsubo cardiomyopathy?
acute chest pain with ST elevations
Prevent hypertensive crisis by...
adequately treating patients with essential or secondary hypertension
- Over time, clinicians become accustomed to multitude of alarms and tend to become desensitized. - Leads to lack of or a delay in response - Associated with staff frustration, delay in response to alarms, and poor patient outcomes.
alarm fatigue
The bundle branches run...
all the way down the septum to the apex of the heart
What are the most common identifiable causes of restrictive cardiomyopathies?
amyloidosis, cardiac sarcoidosis, and hemosiderosis
HF refers to...
an inability of the heart to pump enough blood to meet metabolic needs of the body
In larger doses, Lidocaine is an...
antiarrythmic
CHAS VASC score for...
anticoagulants
Confirm blood pressure on both arms using...
appropriately sized blood pressure cuff
If interruption lasts > 3 sec -
arrest
If a patient has a syncopy episode, we look for an...
arrhythmia
What is included in lung assessment for hypertensive crises?
assess for evidence of pulmonary edema (wheezing, rales)
Most patients with a hypertensive crises are...
asymptomatic
grade I PVD
asymptomatic. detectable by ankle-arm index < 0.9
defibrillation synchronicity.
asynchronous
Ability to initiate an impulse
automaticity
-ol
beta blocker.
What is preferred: bradycardia or tachycardia?
bradycardia
The electrophysiology lab is similar to the...
cath lab
Normal QT interval time =
calculated as QTc interval, varies with HR and gender (<.40 sec)
Causes of atrial flutter.
cardiac or pulmonary diseases, Digoxin toxicity, PE •Age. The older you are, the higher the risk. •High blood pressure •Diabetes •Coronary artery disease •Heart failure •Heart valve disease •Congenital heart disease •Past heart surgery •Obesity •Alcohol consumption •Lung disease •Overactive thyroid (hyperthyroidism) •Sleep apnea •Over-exercising such as in endurance athletes •Family history
These junctional fibers are designed to...
carry the action potential rather slowly
As the electrical current travels toward the negative pole, the wave form ___ ___ from the ___ ___.
deflects downward from the isometric line
When it travels toward the positive electrode, the waveform...
deflects upward from isoelectric line
Cardiac muscle cells spread their...
depolarization cell to cell and through gap junctions
Standard color code for monitoring leads to...
designate placement and polarity
Key points of atrial dysrhythmias.
different or variable P waves normal QRS complexes
What is the third leading cause of heart failure?
dilated cardiomyopathies
What is a pumping dysfunction (mostly L ventricle) chamber enlargement?
dilated cardiomyopathy
What is the most common form of cardiomyopathy?
dilated cardiomyopathy
ST segment
early part of repolarization of ventricles
Patches that are placed on the skin and attached to wires called leads
electrodes
grade IV PVD
established gangrene, trophic lesions
Bigeminy PVCs
every other beat is a PVC
Trigeminy PVCs
every third beat is a PVC
Ability to respond to an impulse
excitability
What is the treatment for ventricular standstill/asystole?
good quality CPR, ACLS protocol, pacemaker, poor outcomes, confirmation of death
What is the treatment for agonal rhythm?
good quality CPR, often not treated
G - (3 lead)
ground - red or green
Rise in congestive heart failure fuels the...
growth of dilated cardiomyopathies
Complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill and eject blood
heart failure (HF)
Relatively rapid elevation of blood pressure superimposed on chronic hypertension
hypertensive crises
where severe elevation in blood pressure is accompanied by end-organ damage
hypertensive emergency
Prompt treatment of blood pressure can prevent a...
hypertensive emergency (also known as malignant hypertension - involving retina, may include kidneys, heart, and/or brain)
Hypertensive crises can be further classified as:
hypertensive emergency and hypertensive urgency
where severe elevation in blood pressure occurs without end-organ damage (inadequate treatment or noncompliant)
hypertensive urgency
Physical exam to evaluate for end-organ damage and to differentiate between...
hypertensive urgency and hypertensive emergency
- thickened left ventricular wall - smaller left ventricular cavity - thickened ventricular septum
hypertrophic cardiomyopathy
Often the reason why you hear of young athletes dropping dead during a game/practice.
hypertrophic cardiomyopathy
What is a heart-related disease wherein the muscle of your heart become thick thereby affecting the proper functioning?
hypertrophic cardiomyopathy
Most restrictive cardiomyopathies are...
idiopathic; also called primary restrictive cardiomyopathy
The cause of hypertensive crisis in most patients is...
inadequately treated hypertension or noncompliance with treatment regimen
grade IIb PVD
intermittent claudication limiting the patient
grade IIa PVD
intermittent claudication not limiting the patient's life style
Wires that are attached to the electrodes and a monitor
leads
Causes of HF.
left ventricular dysfunction acute myocarditis or progressive cardiomyopathy (with remodeling) ischemic heart disease acute myocardial infarction tachyarrhythmia (such as atrial fibrillation or ventricular tachycardia) bradyarrhythmia stenotic or regurgitant valvular disease constrictive pericarditis or acute tamponade uncontrolled hypertension, hypertensive urgency or emergency volume overload due to excess dietary sodium excess dietary fluid hepatic dysfunction renal insufficiency or bilateral renovascular disease may lead to fluid retention high output state with increased metabolic demands intracardiac or extracardiac shunt anemia septicemia inflammation or infection thyroid disease major surgery pregnancy Paget's disease arteriovenous fistula hormonal disturbances diabetic ketoacidosis (DKA) adrenal insufficiency pregnancy and peripartum related abnormalities medication-related noncompliance with heart failure medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors excess beta blockade cardiotoxic drugs (for example, daunorubicin) nonsteroidal anti-inflammatory drugs (NSAIDs) corticosteroids negative inotropic agents substance abuse (alcohol or stimulants) infection (such as pneumonia, infective endocarditis, or sepsis) surgery and perioperative complications pulmonary-related acute exacerbation of chronic obstructive pulmonary disease (COPD) pulmonary embolism (PE) cerebrovascular injury acute mechanical-related complications of myocardial infarction (such as free wall rupture, ventricular septal defect, and acute mitral regurgitation) chest trauma or cardiac intervention acute dysfunction of heart valve (native or prosthetic) secondary to endocarditis, aortic dissection, or thrombosis
What is the heart ejection fraction with CHF?
less than 40%
Mutlifocal PVCs
look different bec they are from different groups of cells
Management for HF.
loop diuretics, bumetanide bumex, and diuretic water slide, O2 (can be high flow), vasodilators, bipap/ventilator support, IV morphine, and inotropic support
ARB examples.
losartan valsartan
What are the causes of ventricular fibrillation?
low fibrillatory threshold, prolonged VT, Electrolyte imbalance, R on T, MI, Sudden death syndrome
QT interval can be affected by...
medications (Zofran, anesthetics) and electrolyte imbalances (Mg, K+)
ASK patients with hypertensive crises about....
medications and social drugs
Projects image created by the electrical impulses of the heart in an organized and measurable manner
monitor
Tx for PAC.
monitor patient, treat cause
What are the types of premature ventricular contractions?
multifocal, bigeminy, trigeminy, couplets, salvo, runs of VT (> 4 or more beats)
What is hypertrophic largely caused by?
mutations in genes
What are the causes of polymorphic VT?
myocardial irritability, R on T, ACS/MI, ischemia, MVP, prolonged QT interval, heart failure, cardiomyopathy, electrolyte imbalance (Mg+, K+)
What are the causes of ventricular tachycardia?
myocardial irritability, R on T, ACS/MI, ischemia, MVP, prolonged QT interval, heart failure, cardiomyopathy, electrolyte imbalance (Mg+, K+)
Aldosterone increase =
myocardial vascular fibrosis and direct vascular damage
Treatment for sinus rhythm.
none
Why is sinus tachycardia troublesome?
not enough time to fill
Components of an ECG/EKG.
p wave, QRS wave, t wave, U wave, and isoelectric line
grade III PVD
pain or paresthesias at rest
What is the vagus nerve included in?
parasympathetic nervous system
In most cases, BNP and NT-proBNP levels are higher in...
patients with heart failure than people who have normal heart function
If interruption lasts < 3 sec -
pause
amount of blood in the ventricle just prior to systole
preload
What is polymorphic VT associated with?
prolonged QT intervals (watch QT intervals, Mg+ levels and medications that cause prolonged QT intervals)
Issue with Sotalol
prolongs QT interval, leading to a lethal arrhythmia.
What are the causes of agonal rhythm?
pt dying, multi system organ failure, removal of life support
Increase in systemic vascular resistance by increase in vasoconstriction mechanisms through...
renin-angiotensin activation, pressure natriuresis (excretion of Na+ in urine), hypoperfusion, and ischemia
Heart muscle characterized by impaired ventricular filling with typically preserved systolic function and normal or mildly increased ventricular wall thickness.
restrictive cardiomyopathy
What is the least common type of cardiomyopathy?
restrictive cardiomyopathy
White - (3 lead)
right, red - rib, black - other
Three PVCs in a row =
salvo
Beta blockers are...
selective and nonselective
