Chapter 19
The diagnosis of chronic stable angina is based on a detailed pain history, the presence of risk factors, invasive and noninvasive studies, and laboratory studies. What test is not used in the diagnosis of angina?
Serum biochemical markers
The major development of the ---- occurs between the fourth and seventh weeks of gestation, and most congenital heart defects arise during this time
fetal heart
Mitral valve ---- represents the incomplete opening of the mitral valve during diastole with left atrial distention and impaired filling of the left ventricle
stenosis
Pericardial effusion can lead to cardiac ----, in which there is compression of the heart due to the accumulation of fluid, pus, or blood in the pericardial sac
tamponade
The ---- have high specificity for myocardial tissue and have become the primary biomarker for the diagnosis of MI
troponin assays
The gastrointestinal symptoms of STEMI are thought to be related to the severity of the pain and ---- stimulation
vagal
The function of the heart ---- is to promote directional flow of blood through the chambers of the heart
valves
Infarcted and noninfarcted areas of the heart muscle in patients with ST-segment elevation myocardial infarction (STEMI) can change size, shape, and thickness, a term referred to as ----
ventricular remodeling
A ---- defect is an opening in the ventricular septum that results from an incomplete separation of the ventricles during early fetal development
ventricular septal
---- disease, also known as mucocutaneous lymph node syndrome, is an acute febrile disease of young children
Kawasaki
The scar tissue that occurs between the layers of the pericardium becomes rigid and constrictive from scar tissue in constrictive pericarditis. What is a physiologic sign of constrictive pericarditis?
Kussmaul sing
Stress cardiomyopathy
Left ventricular dysfunction in response to profound psychological or emotional stress
Cardiac tamponade
Mechanical compression of the heart
Antibodies directed against the M protein of certain strains of streptococcal bacteria seem to cross-react with glycoprotein antigens in the heart, joint, and other tissues to produce an autoimmune response resulting in rheumatic fever and rheumatic heart disease. This occurs through what phenomenon?
Molecular mimicry
---- is the most common, and frequently the first, manifestation of rheumatic fever
Polyarthritis
Angina pectoris is a chronic ischemic CAD that is characterized by a symptomatic paroxysmal chest pain or pressure sensation associated with transient myocardial ischemia. What precipitates an attack of angina pectoris?
Emotional stress
Cardiomyopathies are classified as either primary or secondary. The primary cardiomyopathies are further classified as genetic, mixed, or acquired. Which of the following are genetically based?
- hypertrophic cardiomyopathy - left ventricular noncompaction
Unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI) is a clinical syndrome that ranges in severity between stable angina and MI. It is classified according to its risk of causing an acute MI and is diagnosed based on what?
- serum biomarkers - ECG pattern
Unstable plaque, a condition of atherosclerotic heart disease, occurs in unstable angina nd myocardial infarction. Unstable plaque can rupture, causing platelet aggregation and thrombus formation. What are the major determinants of the vulnerability of plaque to rupture?
- size of lipid rich core - presence of inflammation - thickness of fibrous cap
The ---- is the most frequently used cardiovascular diagnostic procedure
12-lead ECG
Irreversible myocardial cell death occurs after ---- minutes of severe ischemia
20 to 40
During an acute MI, there is ischemic damage to the heart muscle. The location and extent of the ischemic damage is the major predictor of complications, ranging from cardiac insufficiency to death, following an MI. What is the "window of opportunity" in restoring blood flow to the affected area so as to diminish the ischemic damage to the heart and maintain the viability of the cells?
20 to 40 minutes
What is the definition of a cardiomyopathy, according to the American Heart Association?
A heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually exhibits inappropriate ventricular hypertrophy or dilation and is due to a variety of causes that frequently are genetic. Are either confined to the heart or are part of generalized systemic disorders, often leading to cardiovascular death or progressive heart failure-related disability.
Tetralogy of Fallot is a congenital condition of the heart that manifests in 4 distinct anomalies of the infant heart. It is considered a cyanotic heart defect because of the right-to-left shunting of the blood through the ventricular septal defect. A hallmark of this condition is the ""tet spell" that occur in these children. What is the tet spell?
A hypercyanotic attack brought on by periods of stress
It is known that over 100 distinct myocardial disease can demonstrate clinical features associated with dilated cardiomyopathy (DCM). What is the most common identifiable cause of DCM in the United States?
Alcoholic cardiomyopathy
A 55-year-old woman is brought to the emergency department by ambulance and reports severe, acute chest pain. The patient states that "It just came on all of a sudden. Like someone sitting on my chest crushing me." An ECG shows ST-segment elevation, and the presumptive diagnosis is acute STEMI. A. While obtaining a history on this patient, what symptoms would the nurse pay particular attention to as they are further indication of a STEMI? B. What are the priority nursing actions for this client?
A. Classic symptoms include the following: onset of event that is abrupt and having pain as the significant symptom; pain is typically severe and crushing and usually substernal; the pain can radiate to the left arm, neck, or jaw'; pain is not relieved by rest or nitroglycerin; gastrointestinal distress, including nausea and vomiting; fatigue and weakness, especially of the arms and legs; tachycardia, anxiety, restlessness, and feelings of impending doom; pale, cool, moist skin B. Priority actions are as follows: - identification of persons who are candidates for reperfusion therapy - evaluation of the person's chief complaint, typically chest pain, along with other associated symptoms to differentiate ACS from other diagnoses - monitoring should be instituted: a 12-lead ECG should be obtained and read by a physician within 10 minutes of arrival within the ED - administration of oxygen, aspirin, nitrates, pain medications, antiplatelet, and anticoagulant therapy, beta-adrenergic blocking agents, and an angiotensin-converting enzyme inhibitor -persons with ECG evidence of infarction should receive immediate reperfusion therapy with a thrombolytic agent or percutaneous coronary intervention
Pericardial effusion
Accumulation of fluid in the pericardial cavity
ST-elevated myocardial infarction is accompanied by severe, crushing pain. Morphine is the drug of choice used to treat the pain of STEMI when the pain cannot be relieved with oxygen and nitrates. Why is morphine considered the drug of choice in STEMI?
Action decreases metabolic demands of the heart
---- myocardial infarction is characterized by the ischemic death of myocardial tissue associated with atherosclerotic disease of the coronary arteries
Acute ST-segment
Myocarditis
An inflammation of the heart
---- is a mechanical technique to remove atherosclerotic tissue during angioplasty
Atherectomy
Mitral valve prolapse occurs frequently in the population at large. Its treatment is aimed at relieving the symptoms and preventing complications of the disorder. Which drug is used in the treatment of mitral valve prolapse to relieve symptoms and aid in preventing complications?
Beta-adrenergic-blocking drugs
What changes are seen in the blood serum during ACS?
Biomarkers include cardiac-specific troponin I and troponin T, myoglobin, and creatine kinase MB. As the myocardial cells become necrotic, their intracellular enzymes begin to diffuse into the surrounding interstitium and then into the blood.
Describe the clinical manifestations of patent ductus arteriosus.
Blood typically shunts across the ductus from the higher-pressure left side to the lower-pressure right side. A murmur is typically detected within days or weeks of birth. The murmur is loudest at the second left intercostal space, continuous through systole and diastole, and has a characteristic machinery sound. A widened pulse pressure is common because of the continuous runoff of aortic blood into the pulmonary artery.
Prinzmetal angina
Chest pain due to a coronary artery spasm
Unstable angina
Chest pain occurring while at rest
Effusive-constrictive pericarditis
Combination of effusion-tamponade and constriction
Ion channelopathies
Conduction disorders in the heart resulting from abnormal membrane potentials (long QT/short QT syndromes)
When an acute MI occurs, many physiologic changes occur very rapidly. What causes the loss of contractile function of the heart within seconds of the onset of an MI?
Conversion from aerobic to anaerobic metabolism
Ischemia
Decreased blood flow to tissue
---- cardiomyopathies are characterized by atrophic and hypertrophic myocardial fibers and interstitial fibrosis
Dilated
Describe the pathologic process that is seen in unstable angina/non-ST-segment elevation myocardial infarction
Divided into 3 phases: development of the unstable plaque that ruptures, the acute ischemic event, and the long-term risk of recurrent events that remain after the acute event. With inflammatory cells releasing cytokines that cause the fibrous cap to become thinner and more vulnerable to rupture. The acute ischemic event can be caused by an increase in myocardial oxygen demand precipitated by tachycardia or hypertension or, more commonly, by a decrease in oxygen supply related to a reduction in coronary lumen diameter due to platelet-rich thrombi or vessel spasm.
Heart failure in an infant usually manifests itself as tachypnea or dyspnea, both at rest and on exertion. When does this most commonly occur with an infant?
During feeding
---- uses ultrasound signals that are inaudible to the human ear
Echocardiography
Pulsus paradoxus
Exaggeration of the normal variation in the pulse during the inspiratory phase of respiration
Left ventricular noncompaction
Failure of trabecular compaction in the developing myocardium
Describe the tetralogy of Fallot
Four associated defects: ventricular septal defect involving the membranous septum and the anterior portion of the muscular septum; dextroposition or shifting to the right of the aorta; obstruction or narrowing of the pulmonary outflow channel, including pulmonic valve stenosis, a decrease in the size of the pulmonary trunk, or both; and hypertrophy of the right ventricle because of the increase work required to pump blood through the obstructed pulmonary channels.
Nearly everyone with pericarditis has chest pain. With acute pericarditis, the pain is abrupt in onset, sharp, and radiates to the neck, back, abdomen, or sides. What can be done to ease the pain of acute pericarditis?
Have the patient sit up and lean forward
What is the relationship between strep throat and heart valve disorders?
Heart disease is a complication of immune-mediated response to group A streptococcal throat infection.
Secondary cardiomyopathy
Heart muscle disease in the presence of a multisystem disorder
Arrhthmogenic right ventricular cardiomyopathy
Heart muscle disease that affects primarily the right ventricle
Infective endocarditis
Invasion of the heart valves and the mural endocardium by a microbial agent
Peripartum cardiomyopathy
Occurs during the last trimester of pregnancy or the first 6 months after delivery
Silent myocardial ischemia
Occurs in the absence of anginal pain
How does an atherosclerotic plaque stimulate thrombosis?
On rupture, the lipid core provides a stimulus for platelet aggregation and thrombus formation. Both smooth muscle and foam cells in the lipid core contribute to the expression of tissue factor in unstable plaques. Once exposed to blood tissue factor initiates the extrinsic coagulation pathway, resulting in the local generation of thrombin and deposition of fibrin.
Cardiac tamponade is a serious life-threatening condition that can arise from a number of other conditions. What is a key diagnostic finding in a cardiac tamponade?
Pulsus paradoxus
What is meant by "reperfusion therapy", and what is its goal?
Refers to the reestablishment of blood flow through the use of fibrinolytic therapy, percutaneous coronary intervention, or coronary artery bypass grafting. Early reperfusion (within 15-20 minutes) after the onset of ischemia can prevent necrosis and improve myocardial perfusion in the infarct zone. Reperfusion after a longer interval can salvage some of the myocardial cells that would have died owing to longer periods of ischemia. It also may prevent microvascular injury that occurs over a longer period.
Heart attack
ST elevation myocardial infarction
---- is the initial manifestation of ischemic heart disease in approximately half of persons with CAD
Stable angina
The classic ECG changes that occur with ACS involve ----, -----, and ----
T-wave inversion, ST-segment elevation, development of an abnormal Q wave
What is the damage that results from an acute myocardial infarction, and what are the factors that determine severity?
The extent of the infarct depends on the location and extent of occlusion, amount of heart tissue supplied by the vessel, duration of the occlusion, metabolic needs of the affected tissue, the extent of collateral circulation, and other factors such as heart rate, blood pressure, and cardiac rhythm.
Why does pericardial effusion demonstrate signs of right-sided heart failure?
The pericardial cavity has little reserve volume, so small additions of fluid increase the pericardial pressure. Right heart filling pressures are lower than the left, and increases in pericardial fluid pressure will result in decreased right-side filling
What pathologic changes are dependent on the size and pattern of the ST elevation myocardial infarction (STEMI)?
The size and pattern of the infarct depend on the location and extent of occlusion, amount of heart tissue supplied by the vessel, duration of the occlusion, metabolic needs of the affected tissue, the extent of collateral circulation, and other factors such as heart rate, blood pressure, and cardiac rhythm.
In infective endocarditis, vegetative lesions grow on the valves of the heart. These vegetative lesions consist of a collection of infectious organisms and cellular debris enmeshed in the fibrin strands of clotted blood. What are the possible systemic effects of these vegetative lesions?
They can fragment and cause cerebral emboli
A patient with a suspected MI is brought to the ED by ambulance. As the nurse caring for this patient, what laboratory work would you expect to receive an order for, to confirm a diagnosis of MI?
Troponin level
Typically, chronic stable angina is provoked by ---- or ---- stress and relieved within minutes by rest or the use of nitroglycerin
exertion, emotional
Dilated myocardiomyopathy
Ventricular enlargement, a reduction in ventricular wall thickness, and impaired systolic function
Restrictive cardiomyopathy
Ventricular filling is restricted because of excessive rigidity of the ventricular walls
Hypertrophic cardiomyopathy
With disproportionate thickening of the ventricular septum and left ventricle
In ---- pericarditis, fibrous scar tissue develops between the visceral and parietal layers of the serous pericardium
constrictive
In ---- pericarditis, fibrous, calcified scar tissue develops between the visceral and parietal layers of the serous pericardium
constrictive
Congenital heart defects that result in a left-to-right shunt are usually categorized as ---- disorders because they do not compromise oxygenation of blood in the pulmonary circulation
acyanotic
In most cases, coronary artery disease (CAD) is caused by ----
atherosclerosis
Congenital heart defects produce their effects mainly through abnormal shunting of ----, and disruption of ---- blood flow
blood, pulmonary
Coronary artery disease is commonly divided into 2 types of disorders: ---- and ----
chronic ischemic heart disease, acute coronary syndrome
Pericardial ---- refers to the accumulation of fluid in the pericardial cavity, usually because of an inflammatory and/or infectious process
effusion
Pericardial fluid acts as a lubricant that prevents ---- forces from developing as the heart contracts and relaxes
frictional
The ---- cardiomyopathies include hypertrophic and cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular noncompaction cardiomyopathy, inherited conduction system disorders, and ion channelopathies
genetic
The physiologic abnormality in ---- is reduced left ventricular chamber size, poor compliance with reduced stroke volume that results from impaired diastolic filling, and dynamic obstruction of left ventricular outflow
hypertrophic cardiomyopathy
There is little oxygen reserve in the blood; therefore, coronary arteries must increase their flow to meet the metabolic needs of the myocardium during periods of ----
increased activity
Atherosclerosis plaque formation in coronary arteries may result in ---- heart damage due to the lack of blood flow and oxygen delivery
ischemic
Myocardial blood flow, in turn, is largely regulated by the ---- of the myocardium and ---- mechanisms that control vessel dilation
metabolic activity, autoregulatory
The ---- cardiomyopathies, which include dilated cardiomyopathy, are of both genetic and nongenetic origin
mixed
The ---- manifestation of rheumatic fever is Sydenham chorea, in which the child often is fidgety, cries easily, begins to walk clumsily, and drops things
neurologic
The medication used to alleviate angina, ----, is given because of its vasodilating effect
nitroglycerin
Partial or complete rupture of a ---- is a rare but often fatal complication of transmural myocardial infarction
papillary muscle
The manifestations of acute ---- include a triad of chest pain, pericardial friction rub, and ECG changes
pericarditis
The ---- is a double-layered serous membrane that isolates the heart from other thoracic structures, maintains its position in the thorax, prevents it from overfilling, and serves as a barrier to infection
pericardium
Most persons with mitral valve ---- are asymptomatic and the disorder is discovered during a routine physical examination.
prolapse
Aortic ---- is the result of an incompetent aortic valve that allows blood to flow back to the left ventricle during diastole.
regurgitation
Mitral valve ---- is characterized by incomplete closure of the mitral valve, with the left ventricular stroke volume being divided between the forward stroke volume that moves into the aorta and the regurgitant stroke volume that moves back into the left atrium during systole
regurgitation
Acute severe ischemia reduces the ---- and shortens the duration of the action potential in the ischemic area
resting membrane potential
There are 2 types of atherosclerotic lesions: the ---- plaque, which obstructs blood flow, and the ---- plaque, which can rupture and cause platelet adhesion and thrombus formation
stable, unstable
Increased resistance to ejection of blood from the left ventricle into the aorta characterizes aortic valve ----
stenosis