Cardiac Conditions

Question 1

Hypertension

Answer 1

• Can cause hypertrophy (enlargement/thickening)
• Shee stress on vessels
• Primary (95%; idiopathic) vs Secondary (5%)
• Goal: Decreas both SBP and DBP

Question 2

HTN and CVD

Answer 2

• Increased BP has an relationship with increased in cardiac events.
• Within DBP 70-110 mm Hg, any reducation will decreased risk of CHD or CVA risk
• Lowering HTN is twice the benefit for older adults.

Question 3

Lifestyle Changes to reduce HTN (with #s)

Answer 3

• Physical activity 4-9 mmHg
• Weight Loss (10 kg loss) 5-20 mmHg
• Stop Smoking
• Decrease alcohol 4-9 mmHg
• Decrease sodium (if sodium sensitive) 2-8 mmHg
• DASH diet (5-6 fruits and 5-6 veggies each day)

Question 4

Pharmalogical ways to decrease HTN

Answer 4

Diuretic: Water pill; drop volume, drop level
CCB: Calcium channel blocker
ACEI: Ace inhibitor: often hacking cough
BB: angiotension reg blocker.

Question 5

HTN and Exercise

Answer 5

• Normal Response: SBP increase, DBP stay the same
• Some HTN patient’s: Increase SBP and DBP
• Exercise Training: Post Ex Hypotension
  – Decrease SBP by 4-10 mm Hg
  – Decrease DBP slightly less

Question 6

Guidelines for Ex and HTN

Answer 6

• Resting SBP is >200 mmg or DBP >100 mmHg obtain medical provider clearance pre-exercise
• Discontinue if SBP > 250 mmHg; DBP > 110 mmHg
• Medication effect (may lead to hypotension; chaning position, post-exercise, long term stanfin, in warm water)

This is a guideline NOT an end all be all. Use clinical reasoning.

Question 7

HTN and PT

Answer 7

• All pt’s - screened for BP every 2 yrs
  – However, System Review all pts at eval
• Everyone over 35 should routinely have their BP assessed
  – Part of your examination
• Ask them if they are on medication
  – Ask if they are taking it as prescribed

Question 8

All cardiac condition eventually lead too…

Answer 8

Heart Failure

Question 9

Heart Failure Definition

Answer 9

• Impaired contraction and relaxation of myocardial tissue
  – Decrease CO, Decrease contraction, Decrease stroke volume

Question 10

First degree HF is caused by

Answer 10

pathology of myocardial tissue

Can be genetic, acquired or both.

Question 11

Second degree HF results from…

Can be genetic, acquired or both.

Answer 11

systemic disease process

Question 12

Types of HF

Answer 12

Dialated (Systolic Dysfunction; Ventricles are enlarged; Can be caused by long standing HTN)
Hypertrophic (Diastolic Dysfunction; Muscle is thickened)
Restrictive (Both Systolic and Diastolic; Tissue is stiff or scarred)

Question 13

Pump effectiveness is influenced by…

Answer 13

Preload and afterload

Question 14

Preload

Answer 14

• volume of blood in the ventricle just prior to systole
  – Depends on venous return and compliance
  – Measured by left ventricular end diastolic volume

Question 15

Afterload

Answer 15

• the force against which the left ventricle must pump
  – Clinically, BP is often used to measure it
  – Pulmonary artery pressure

Question 16

Left vs Right Sided HF

Answer 16

Left sides: Blood can’t leave left ventricle. Backs up into the lungs. Hear crackles – fluid backed up in lungs; Pools in bottom of aveoli. Preload is higher when laying flat which leads to paroxysmal nocturnal dyspnea (wake up during sleeping short of breath). Pressure builds up here.

Right Side: Blood leaves heart. JVD, enlarge liver and spleen. Swelling in lower extremities.

Question 17

Left Sided HF Symptoms

Answer 17

• Paroxysmal noctunal dyspnea
• Cyanosis
• Fatigue
• Exertional dyspnea
• Confusion
• Orthopnea

Question 18

Right Sided HF Symptoms

Answer 18

• Fatigue
• Ascites (Build up of fluid)
• Enlarged liver and spleen
• JVD
• Weight gain (fluid in abdomin and legs)
• May be secondary to chronic pulmonary conditions

Question 19

HF Pathogenesis

Answer 19

Initial compensation for impaired contractility:
Frank-Starling mechanism
– Increase EDV (dilation) to increase SV
Neurohumoral activation (medication use)
– Increase HR (tachycardia) to increase CO

Eventual decompensation
– Ventricular remodeling (thickness; less blood flow to portion – ischemia and decrease contractility)
– Myocyte death
– Valvular regurgitation
– Inc. Peripheral Vascular resistance leads to pulmonary and systemic congestion

Question 20

Compensation vs Decompensation

Answer 20

Compensation: body tries to make things work better.
Decompensated: body fails to compensate. Heart failure is dangerous here.

Question 21

HF Clinical Manifestations - Decreased CO

Answer 21

• Tachypnea (fast breathing)
• Decrease BP
• Cold/Cyanotix
• Fatigue
• Decrease exercise capacity
  – Increase HR and RPE
• Sinus Tachycardia

Question 22

HF Clinical Manifestations - Pulmonary/Venous Congestions

Answer 22

• Paroxysmal nocturnal dyspnea
• Orthopnea
• Crackles
• Dyspnea

Question 23

HF Clinical Manifestations - Cardiac

Answer 23

• S3 Heart Sounds (acutely)
• Mitral regurgitation

Question 24

HF Clinical Manifestations - Systemic congestion

Answer 24

• Increased JVD
• Hepatomegaly
• Ascites (fluid in peritoneal/abdomen cavity)
• Peripheral edema (weight gain 3 lbs)

Question 25

Diagnostic Assessment - HF

Answer 25

* Chest X-ray * Echocardiogram (US of heart) * EKG * Angiography (x ray of coronary arteries with dye inserted to look for blockages)

Question 26

Heart Failure Criteria

Answer 26

* **Brain Natriuretic Peptide (BNP)** -- Amino Acid secreted by heart in response to excessive stretching -- **> 700 ng/L**; criteria for **de-compensated** --- HF and admission to hospital -- Normal less than 100 -- 100-700 = **compensated HF** * Typically seen with wt gain (2-3 lbs) overnight

Question 27

Classification of Heart Failure

Answer 27

Class 1: No limitation of PA, Normal PA does not cause symptoms Class 2: Slight limitation of PA, Comfortable at rest, Normal PA caused symptoms Class 3: Marked limitation of PA, Comfortable at rest, but less than ordinary activity causes symptoms Class 4: Severe limitation and discomfort with any PA, symptoms present even at rest.

Question 28

Risk Factors of HF

Answer 28

* Hypertension * Myocardial infarction * Abnormal heart valves * Cardiomyopathy (enlargement of the heart) * Family history of heart disease * Diabetes **Anything that causes CV system can contribute to HF**

Question 29

Complications - HF

Answer 29

* Kidney damage or failure * Dysfunctional heart valves * Arrhythmias * Liver Damage * Pulmonary conditions

Question 29

Complications - HF

Answer 29

* Kidney damage or failure * Dysfunctional heart valves * Arrhythmias * Liver Damage * Pulmonary conditions

Question 30

Coronary Artery Disease (CAD) - Definition

Answer 30

Plaque accumulates in coronary arteries which causes narrowing of the arteries (atherosclerosis) Results in blood, oxygen, and nutrient deprivation to the cardiac muscle cells Most common form of heart disease in the US

Question 31

If I have an coronary artery occlusion of 80% am I going to die?

Answer 31

Not necessarily. Depending on if it is a thick or thin lining will tell you if you if you are at risk of rupture. Thin is more dangerous and we can only test by looking inside the arteries.

Question 31

If I have an coronary artery occlusion of 80% am I going to die?

Answer 31

Not necessarily. Depending on if it is a thick or thin lining will tell you if you if you are at risk of rupture. Thin is more dangerous and we can only test by looking inside the arteries.

Question 32

Pathogenesis - CAD

Answer 32

Plaque buildup (atherosclerosis) in the coronary arteries starts with damage to the endothelium.   * A **clot or spasm** may close the vessel, causing a heart attack (MI) -- **Vasospasm** (Neural input often caused by smoking) – Prinztmetal’s angina * Plaque are either: -- **Stable** (thick lining) -- **Unstable** (thin lining); easily exposed and ACS can develop

Question 33

CAD Modifiable RF

Answer 33

* Hypertension * Smoking * Elevated lipids * Obesity * Poor control of Diabetes * Physical inactivity * Stress Emerging Risk Factor: Men who spend sitting 5 or more hours out side of work are 34% more likely to develop HF than those who sat 2 hours. Additionally, low to mod PA did not eliminate risk.

Question 34

CAD Non-modifable RF

Answer 34

Age  -- Getting older increases risk Gender  -- Men are at a higher risk Family history Race

Question 35

Clinical Manifestations - MI; Male and Female vs Female

Answer 35

* Male and Female -- Angina -- Dizziness -- Dyspnea * Primarily Female  -- Nausea  -- Vomiting -- Fatigue -- Jaw pain * Females may have little or no symptoms

Question 36

Diagnostic - CAD

Answer 36

* EKG * Stress Test * Coronary Angiogram * Echocardiogram (Ultrasound of heart)

Question 37

Complications of CAD

Answer 37

* Heart Failure **(pump dysfunction)** * Electrical problems **(arrhythmias)** -- Afib, AV blocks * Decreased functional capacity * Angina  * Myocardial infarction