NSG 356 EXAM 3!

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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


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