CLM Exam 2
Superficial veins used in dorsum of hand:
Cephalic vein Basilic vein Dorsal venous vein
Smoking causes ____ already so adding ____ to that is bad
-calcification in arteries -cholesterol
Other Cardiac Biomarkers B-Type Natriuretic peptide (BNP): (0) hormone synthesized mostly by (1) in response to (2) Known to be a marker of (3) Useful in diagnosing and assessing the severity of (4) Useful test in (5) setting where chest pain is a common presentation
(0) Neuro-cardiac (1) ventricles (2) ventricular wall stress (3) acute and chronic left ventricular dysfunction (4) congestive heart failure (CHF) (5) ER
CK-MB Criteria for diagnosis of an AMI : Serial measurements important as they helps detect (0) Normal: (1) The finding of MB in a patient with (2) is diagnostic of MI If there is a (3) CK-MB for (4) following a clearly defined episode, it is clear the patient has (5)
(0) serum rises, peaks and declines (1) 0-3 µg/L (2) chest pain (3) negative (4) 48 hrs (5) NOT had an MI
Creatine Kinase (CK) (1) Found in: (2) Primary clinical use of CK is in the
(1) Heart muscle Skeletal muscle Brain (2) detection of an AMI
Complete lipoprotein profile recommended: (1) performed when? (2) what is permitted to consume? (3) tube for draw? (4)
(1) Total cholesterol Triglycerides (good gage of how much fat is circulating through blood) HDL LDL (2) Performed after an 8-12 hour fast (3) Only water and black coffee is permitted (4) red tube
Troponin I Criteria for diagnosis of AMI: (1) is suggestive of MI Remains increased longer than (2) and is more (3)
(1) > 1.12 µg/ml (2) CK-MB (3) cardiac specific (Stays elevated even with intervention)
Pathophysiology of Dyslipidemia: (1) established that high cholesterol is a risk factor for (2); The higher the cholesterol, the greater the (3) risk High cholesterol promotes (4) through accumulation and formation of (5) If too much cholesterol in bloodstream, excess is deposited in (6), including (7)
(1) Framingham Heart Study (2) coronary heart disease (CHD) (3) CHD (4) atherosclerosis (5) plaques (6) arteries (7) coronary arteries
Dyslipidemia Treatment: Lower (1) to lower risk of (2) The higher the overall risk factors, the lower the (3) goal should be Treatment strategies: (4)
(1) LDL (2) CHD (3) LDL (4) Therapeutic Lifestyle Changes and Medications
Troponin: Protein that regulates the interaction of (1) in muscle tissue Cardiac troponin is unique to the heart muscle and is highly concentrated in (2) HIGH degree of cardiac (4)! -Protein released (5) hrs after myocardial injury! -Typically detected in the serum around (6) -Levels return to normal within (7)
(1) actin and myosin (2) cardiomyocytes (4) specificity (5) 1-3 (6) 4-8 hours (7) 5-7 days
Myoglobin: Found in (1) Serum myoglobin is found earlier than (2) enzymes in AMI (3) Peaks in (4) Returns to normal in ~ (5) (6) venous blood samples taken (7) hours apart give optimal results in detecting MI
(1) muscle tissue (cardiac & skeletal) (2) CK (3) 1-2 hours after the onset of CP (4) 4-8 hrs (5) 12 hrs (6) 2-3 (7) 1-2
Troponin I: Specific for (1) Binds to (2) of the (3) complex Reference range: (4)
(1) myocardial injury (2) microfilaments (3) troponin (4) < 0.12 ng/ml
CK: Isoenzymes CK-2 (MB): Primarily located in the (1) Levels: Rise seen (2) after MI Peak at (3) Return to normal (4)
(1) myocardium (2) 4-6 hours (3) 18 hrs (4) 2-3 days
Indications: • Primarily indicated to (1) • Used to monitor levels of (2)
(1) obtain a sample of blood for diagnostic testing (2) blood components
Performing venipuncture: • Introduce yourself • Identify the (1) • Properly fill out appropriate (2), indicating the (3) • Verify the patient's (4) • Elicit (5) • Wash hands and (6) • Position the patient • Apply the tourniquet (7) inches above the selected site. • The patient should make a fist without (8). • Select the venipuncture site. • Prepare the patient's arm using an (9). Cleanse in a circular fashion, beginning at the site and working (10). Allow to air dry. • Grasp the patient's arm firmly using your thumb to draw the skin taut and anchor the vein. The needle should form a (11) degree angle with the surface of the arm. Swiftly insert the needle through the skin and into the (12). Avoid trauma and excessive probing • When the last tube to be drawn is filling, (13). • Remove the needle from the patient's arm using a swift (14) motion. • Press down on the gauze once the needle is out of the arm, applying adequate pressure to avoid formation of a (15). • Dispose of contaminated materials/supplies in designated containers. • Mix and label all appropriate tubes at the patient bedside. • Deliver specimens promptly to the laboratory
(1) patient /DOB (2) requisition forms (3) test(s) ordered (4) condition (5) allergies (6) do PPE (7) 3-4 (8) pumping the hand (9) alcohol prep (10) outward (11) 15 to 30 (12) lumen of the vein (13) remove the tourniquet (14) backward (15) hematoma
Patient Education/Preparation • Have they followed (1)? • Ask about prior (2) • Explain why the procedure is being performed and (3) • (4) and (5) questions from patient • Obtain (6) before proceeding
(1) pre-draw instructions (2) surgical Hx (3) how you will do it (4) Elicit (5) answers (6) consent
Dyslipidemia Treatment : Medications
-Bile acid sequestrants (trap bile and release it immediately from body, doesnt let bile reaccumulate) -Nicotinic acid (less commonly used because side effect of fleshing) -Fibric acids -Statins (lipitore) (cause muscle aches)
Dyslipidemia - Secondary Causes:
-Diabetes Type II -Hypothyroidism -Cholestatic Liver Disease (liver not able to properly process endogenous cholesterol) -Chronic Renal Failure -Drugs that raise LDL & lower HDL such as: --Progestins (birth control) --Anabolic steroids --Accutane --Corticosteroids (use to suppress immune response)
Lipoproteins: HDL "____" cholesterol= excess cholesterol sent to the ____ Composed of ____ and one or two ____ LDL ____ cholesterol into ____ and HDL ____ cholesterol from ____ ☼Therefore, low levels of HDL are associated with increased risk for ____
-GOOD -liver for removal -phospholipids -apolipoproteins -moves -arteries -removes -arteries -artherosclerosis
Risk Factors for Coronary Heart Disease (CHD): Emerging Risk factors
-Elevated lipoprotein (a) levels (pre-LDL/HDL guide) -Elevated Homocysteine levels -Impaired fasting glucose (pre-diabetics) -Prothrombotic & Proinflammatory factors (CRP)
____ can over activate and produce too much cholesterol leading to ____
-Liver -heart disease
Apolipoproteins are Important in the metabolism of lipids as they aid in:
-Their solubility and clearance -Their transport from the GI tract to the liver -Serve to inactivate/inhibit enzymes involved in lipid metabolism
S & Sx of an AMI
Chest pain Radiation of pain Dyspnea (shortness of breath) n/v Diaphoresis Syncope/near-syncope without other cause Impaired cognitive function without other cause
All the cholesterol the body needs is made by the ___ and is stored in the ____ or they are produced by the ___
-body -fat (triglycerides) -liver
Phospholipids are usually found with ___ molecules which are found in-between the spaces of the ____
-cholesterol -phospholipid
We need ____ to transport certain ____ throughout the body
-cholesterol -proteins
Majority of cholesterol is produced in the ___ A portion is then excreted into the ____
-liver -bile
Triglycerides over 4000 because of damage to ____ and excess ____ in the body and blood
-liver -fatty deposits
Ischemic signs & symptoms
-pressure like chest pain w/ radiation -women - radiates to neck to jaw -indigestion like symptom -occasionally back pain -diabetic pts may not feel anything -diaphoresis (sweating)
LDL Goals for CHD Risk Fx Pts
1. CHD or Risk Equivalents <100 mg/dL 2. Multiple (2+) Risk Factors <130 mg/dL 3. Zero to 1 Risk Factors <160 mg/dL
Risk Factors for CHD: CHD Equivalents
1. Diabetes 2. Other Atherosclerotic CVD: (5) -Peripheral Vascular Disease (PVD) -Coronary Artery Disease (CAD) -Aortic Aneurysm -Carotid Artery Disease -Cerebrovascular Disease (strokes, TIAs)
Dyslipidemia Treatment : Lifestyle
1. Diet -Weight Management -Low saturated fat & cholesterol diet -Increased dietary fiber 2. Exercise (30 mins 3-4 times a week) 3. Stop smoking (sometimes give meds to help) 4. Decrease ETOH (alc) consumption
anatomy
1. cubital fossa 2. dorsum of hand
Lipid Panel: Recommended Levels HDL: High Low
High Level: > 60 mg/dL Low level:< 40 mg/dL
In the future, LDL might change optimal level to ____
<75 mg/dL
Lipids - 6/10/19
AMLDT pgs. 423-434
What are lipids?
fat that roams in blood
when the ventricles start to fail or don't contract properly to send the perfused blood throughout the body
CHF
Primary isoenzyme of interest in detecting MI
CK-2 (MB)
Ideally should not have any of this in the blood unless there has been damage to myocardium ____ WILL be in the blood if a patient is having an MI
CK-MB
____- is an inflammatory marker and doesn't tell what is independently elevated - Calcified artery and tells if there is inflammation in the space
CRP
Prothrombotic & Proinflammatory factors (CRP)
CRP is an inflammatory marker (nonspecific) if you have a calcified artery, you have inflammation in that space causing plaques to break off
LOW HDL is an independent risk factor of _____
Cardiovascular disease
Waxy, fat-like substance that occurs naturally in all parts of the body
Cholesterol
4 major classes of Lipoproteins
Chylomicrons Very low density lipoproteins (VLDL) Low density lipoproteins (LDL) High density lipoproteins (HDL)
Cardiac Markers
Creatine Kinase (CK) Lactic Dehydrogenase (LD,LDH) Aspartate Aminotransferase (AST) Myoglobin Troponin
Lipid Panel: Recommended Levels Triglycerides: Desirable Borderline High
Desirable: < 150 mg/dL Borderline: 150 - 199 mg/dL High: > 200 mg/dL
Lipid Panel: Recommended Levels Total Cholesterol: Desirable Borderline High
Desirable: < 200 mg/dL Borderline: 200-239 mg/dL High: >/= 240 mg/dL
Risk Factors for CHD: Diabetes (regardless of cholesterol levles)
Diabetes = CHD equivalent 10 year risk for CHD > 20% High mortality when in presence of known CHD, in acute MI and post AMI
Triglycerides are readily available when needed and provide fatty acids for:
Gluconeogenesis Energy production
Risk Factors for Coronary Heart Disease (CHD): Medical conditions
Hypertension Diabetes - role it plays in microvasculature, so microvessels turn to atrophy so adding plaques is a bad combo
Diagnosis of Acute MI (tissue starts to die)
Ischemic signs & symptoms EKG : Pathologic Q waves ST-T wave changes Lab Tests: Cardiac Enzymes!
Not used for initial diagnosis of an MI Once heart tissue becomes necrotic it cannot be used again but there will be an increase in ____ levels - If you are monitoring a patient post MI you would expect this level to go up because there has been tissue death
LDH
tells you how much fat is in the blood
LDL
which is composed of more cholesterol, LDL or HDL?
LDL
_____ is currently the earliest biologic marker of myocardial necrosis
Myoglobin
Most common site for venipuncture
Median cubital vein
Risk Factors for Coronary Heart Disease (CHD): Lifestyle Risk Factors
Obesity Atherogenic Diet Sedentary lifestyle Smoking Excessive alcohol consumption (liver cant filter out extra levels of cholesterol)
Lipid Panel: Recommended Levels LDL: Optimal Good Borderline High Very High
Optimal: < 100 mg/dL Good: 100 - 129 mg/dL Borderline: 130 - 159 mg/dL High: 160 - 189 mg/dL Very High: > 190 mg/dL
____- varicose veins, check for this using pulses, discoloration of lower extremities
PVD
Major Risk Fx (exclusive of LDL) that modify LDL goals:
Smoking HTN Low HDL Family history of premature CHD (under age of 50) (MI, stroke, TIA) Age with these risk factors you want LDL at 75
EKG : Pathologic Q waves ST-T wave changes
ST - slowly starts to rise above baseline
3 major lipids of biologic consequence in the serum:
Triglycerides Cholesterol Phospholipids (get these 3 on a cholesterol or lipid panel)
____ are the markers of choice and should be used in preference to CK-MB
Troponins
Triglycerides stored in ___
adipose tissue (more fat=higher triglycerides)
P wave
atrial contraction
LDL transports fats into ___
blood stream bad cholesterol
Phospholipids Essential components of ___
cell walls
the second someone is diagnosed w/ type 2 diabetes they are put on ____ medication
cholesterol
Most common area for venipuncture
cubital fossa
Vessels are already atrophied in ____ so when you add cholesterol deposits that does not help
diabetes
Atherogenic Diet
diets high in cholesterol (meat, dairy, eggs) lower in veggies, fruits
area used less commonly for venipuncture
dorsum of hand
Exogeneous and Endogenous sources of triglycerides
endogenous - break down of fatty acids in body exogenous - animal products
70% of cholesterol is from
endogenous sources 30% is from exogenous sources
Exogenous and Endogenous sources of cholesterol
exogenous - animal products (dairy, meat) endogenous - from body
If vessels are damaged by collecting of plaque in vessels and you add increased pressure in the vessels to that (____) that would increase risk a lot
hypertension
Phospholipids Plays an important role in ____
lowering the surface tension of fluids in the lungs
Contraindications:
o Areas of skin infection o Areas of extensive scarring o Mastectomy(do not use same arm as side that was removed) o Hematoma o IV therapy/blood transfusions that are running o Fistula o Edematous extremities
Potential complications:
o Cellulitis/phlebitis o Thrombosis o Laceration of vein o Bleeding/hematoma formation o Vasovagal syncope
Superficial veins used in cubital fossa:
o Cephalic vein o Basilic vein o Median cubital vein
HDL transports fats ___
to liver to be processed/removed from the body good cholesterol
Apolipoproteins
transport lipids (HDL and LDL)
alcoholics usually have very high ____
triglycerides level; very high risk for CVD
QRS wave
ventricular contraction
T wave
ventricular repolarization and relaxation
Lactic Dehydrogenase (LDH): Distributed widely throughout (1) -Especially abundant in (2) Used for: -Diagnosis/monitoring of (3) -Diagnosis of (4) In a MI, levels are elevated from (5) the normal Adult normal (6)
(1) body tissues (2) heart muscle, liver, kidney and skeletal muscle (3) hepatic dysfunction (4) MI (5) 3-5 times (6) 140-280 U/L
Creatine Kinase (CK): Isoenzymes CK-1 (BB): Primarily located in (1) Also seen with (2) Contributes little to total (3) and therefore is NOT routinely measured
(1) brain and lung (2) carcinomas (lung, prostate, colon, intestinal, bladder, esophagus) (3) serum CK level
In case of needle stick: • Remove your (1) and dispose of them properly. • Squeeze puncture site to promote (2) from site • Wash the area well with (3) • Record the patient's (4) • Follow institution's guidelines regarding treatment and follow-up (students are to contact (5) as well)
(1) gloves (2) bleeding/expel blood (3) soap and water (4) name and ID number (5) instructor/department
Aspartate Transaminase (AST): AST is an enzyme present in tissues with (1) Enzymes Is released into circulation following (2) Normal Men: (3) Women: (4)
(1) high metabolic activity (liver and heart) (2) injury or death of cells (3) 14-20 U/L (4) 10-36 U/L
LDH: Broken down into (1) Elevations seen (2) hours after MI Rises later than (3) and remains elevated after (3) has normalized (4) Side note: (5) may be accomplished without LDH isoenzymes
(1) isoenzymes (LD1 thru LD5) (2) 36 to 55 (3) CK (4) 3-10 days (5) DDX of AMI
Cardiac Markers Consider the following factors: Time of (1) Time to (2) Time to (3) Specificity to (4)
(1) release (2) peak (3) clear (4) myocardium
Troponin T: More (1), but less (2) Binds to (3) of the (4) complex Reference range Normal (5)
(1) sensitive (2) specific (3) tropomyocin (4) troponin (5) < 0.01µg/L
CK: Isoenzymes CK-3 (MM) Primarily located in (1) Minor portion located in the (2) Most elevations of this enzyme are secondary to (3) such as (4)
(1) skeletal muscle (2) myocardium (3) skeletal muscle injury (4) Trauma or Severe exercise
Myoglobin: Poor (1) If myoglobin level remains within reference range (2) hrs after onset of chest pain, (3) is ruled out Range: (4)
(1) specificity (2) 8 (3) AMI (4) <70 ug/L
Lipoproteins: LDL ___ cholesterol= deposits into ____ When it stays in its lipid form, the waxy deposits collect within the ____ Closely associated with increased incidence of ____ Mainly composed of ____: ____% of total serum ____ is present in LDL
-"BAD" -blood vessels -cell walls -atherosclerosis and CHD -cholesterol -60-70 -cholesterol
HDL of ____ associated with longevity
>75 mg/dL
Homocysteine
found in the body of animals, indicates how fatty your diet it