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