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Flashcards in Cardio part 2 Deck (123):
1

Where do acute MI's usually begin?

Subendocardial layer, then progress outward w/ continued ischemia

2

Zone of ischemia

Tissue is O2 deprived but not injured

3

Zone of injury

Tissue is damaged, but not dead

4

Zone of necrosis

Death of myocardial tissue

5

25% of all MIs and highest mortality rate

LAD anterior wall of LV
-Increased risk of heart failure and dysrhythmias

6

MI with increased risk of sinus dysrhythmias

LCX posterior wall of LV
-Due to SA and AV node perfusion

7

17% of MIs, second highest mortality

RCA or LCX inferior wall of LV
-Mitral dysfunction of papillary muscles and chordae tendinae

8

STEMI

ST elevation MI
-Happening in real time, haven't completed the infarct, still happening so you can still do something about it
-Abrupt occlusion
-More damage

9

NSTEMI

NonST elevation MI
-Partial or temp occlusion
-Ruptured plaque

10

What is a STEMI treated with?

PCI (percutaneous coronary intervention)
-Fibrinolytics (anticoagulant, clot buster)

11

What is a NSTEMI treated with?

Antiplatelets (aspirin, plavix)

12

Why does NSTEMI cause less damage than STEMI?

More ongoing process, body has time to generate collateral circulation

13

Leukocytosis with MI

Elevated WBC, usually 10-20,000

14

Cardiac enzymes with MI

CK-MB peak in 12-24 hrs, normal 48-72 hrs

15

Hallmark changes with AMI

-Myocardial ischemia
-Myocardial injury
-Myocardial infarction
*usually show no immediate ECG changes

16

Troponin 1 and T

Myocardial muscle protein, elevated 4-6 hrs after AMI, peaks 10-24 hrs, and remains for 5-7 days

17

Myocardial ischemia

T wave inversion, peaked T waves, ST segment depression (1 mm or one small box)

18

Myocardial injury

ST segment elevation in leads facing affected area show > or = 1 mm above baseline

19

Myocardial infarction

Q waves (pathologic) either >25% of the QRS complex height or >1mm wide

20

ACC goal for AMIs

Time from admit to ER to PCI should be less than 90 minutes

21

What is the recommended mode of treatment when PCI cannot be performed within 90 mins?

Fibrinolysis

22

Absolute contraindications for fibrinolysis

-Intracranial hemorrhage
-Known intracranial malignancy
-Known AV malformation
-Ischemic stroke within past 3 months
-Aortic dissection
-Active bleeding
-Closed head injury

23

Relative contraindications for fibrinolysis

-Uncontrolled HTN
-Active PUD (GI bleed)
-Recent surgery/trauma
-Pregnancy
-Concurrent anticoagulant use

24

Fibrinolytic meds

1. Altepase (tPA)
-bolus then infusion

2. Streptokinase
-infusion
-can only be used once bc body develops antibodies, they'll go into anaphylactic shock
-allergic reactions

25

Pain management with AMI

M-morphine
O-oxygen
N-nitrates
A-aspirin

26

What position should you put your AMI pt in?

Semi-Fowler's

27

How does morphine help with AMIs?

Relaxes smooth muscles and decreases myocardial O2 demand

28

Causes of Infective Endocarditis

-IV drug abuse
-Prosthetic valves
-Systemic infections
-Structural cardiac defects

29

Vegetation w/ infective endo

-Vegetative lesions can develop due to accumulation of fibrin and platelets in abnormal area
-Bacteria collects in vegetation
-Vegetation continues to grow and can obstruct inflow/outflow

30

What might cause valvular insufficiency?

Infective endocarditis

31

Common ports of injury for Infective Endo

-Oral cavity during dental work
-Skin rashes, lesions, abcesses
-Surgery, placement of invasive lines

32

S/S of infective endo

-Fever/chills/night sweats
-Anorexia/weight loss
-Cardiac murmur
-Heart failure
-Systemic embolization
-Petechiae
-Splinter hemorrhage-distal 1/3 of nail bed

33

How to diagnose infective endo

Blood cultures and echoes

34

Non-surgical treatment of infective endo

-4-6 wks of IV ABX, probably with PICC line and home health
-NOT anticoagulants

35

Surgical treatment of infective endo

-Removal/replacement of infected valve/shunt (you can't steralize a fake part w/ abx so it needs to be replaced)
-Repair of chordae if needed
-Complicated post op

36

Where will you hear a murmur with infective endo?

Depends on which valve is affected

37

Causes of acute pericarditis

-Post acute MI
-Pist-pericardectomy syndrome
-Acute exacerbations of systemic connective tissue dz

38

Causes of chronic pericarditis

-Renal failure
-TB
-Radiation
-Trauma

39

Acute pericarditis s/s

-Substernal precordial pain that radiates to neck, back, shoulder
-Pain aggravated by breathing, coughing, swallowing
-Worse pain supine
-Friction rub
-Fever
-Elevated WBC
-ST segment "spiking," may develop Afib
-Thickened pericardium compresses ventricles and restricts filling

40

Signs of right sided heart failure

JVD, hepatic engorgement, dependent edema, ascites

41

Diagnostic test for pericarditis

Echo

42

Interventions with pericarditis

-NSAIDS
-Corticosteroids if not bacterial in nature
-Pt positioning: upright and lean forward slightly

43

Treatment of pericarditis

-Bacterial: ABX
-Malignant: chemo/rad
-Uremic: dialysis for renal failure
-Surgery: pericardiectomy

44

Care for pt with pericarditis

-Auscultate for pericardial friction rub
-Avoid anti-coagulants
-Auscultate BP for paradoxical pulse, systolic BP will be 10+ higher on expiration
-Monitor for signs of cardiac tamponade

45

Excess of fluid within pericardial cavity

Cardiac Tamponade, more than 10mL

46

Effect of fluid accumulation with cardiac tamponade

Compression of the heart's chambers and can cause a sudden decrease in CO, rapidly fatal if not identified and treated quickly

47

S/S of cardiac tamponade

-JVD
-Paradoxical pulse
-Decreased HR/BP
-Dyspnea/Fatigue
-Muffled heart sounds

48

Treatment of Cardiac Tamponade

-Initial fluid resuscitation
-Hemodynamic monitoring-all pressures equalize
-Pericardiocentesis

49

Pericardiocentesis

Drainage of fluid with surgery to open up and drain or with a needle at the bedside, go into pericardium but not through muscle
-If you stick the needle too far you can cause a tamponade

50

HTN

Systolic >140
Diastolic >90

51

What should diabetics with heart dz maintain their BP at?

52

Malignant HTN

>200 systolic
>130 diastolic
*They don't always look/feel sick

53

Arterial baroreceptors

Located around carotid sinus, aorta, LV wall
-Responsive to changes in body fluid volume (increases venous return)

54

Calcium channel blockers for HTN

-Vasodilates
-Reduces HR
-Well tolerated

55

ACE inhibitors for HTN

*prils
-Prevents vasoconstriction
-Postural hypotension
-Cough
-Nephrotoxic

56

1st line treatment for HTN

Diuretics (hydrachlorathiazide)
-cheap

57

Example of vasodilator meds

Nitrates

58

ARBs

Sartans

59

Why do people get put on ARBs instead of ACE inhibitors

Nephrotoxicity

60

When to take diuretics

In the morning

61

Common problem with calcium channel blockers

Orthostatic hypotension

62

PVD inflow obstructions

Above inguinal ligament

63

PVD outflow obstructions

Below inguinal ligament

64

Stage 1 PVD

-Asymptomatic
-Pedal pulses decreased or absent

65

Stage 2 PVD

-Muscle pain/burning with exercise
-S/s reproducible-happens every time you do a certain thing

66

Stage 3 PVD

-Pain at rest
-Distal portion of extremities
-Hang their leg off the bed, sit up w/ legs off bed
-Pain relieved when in dependent position

67

Stage 4 PVD

-Necrosis
-Gangrene

68

What do you do if you can't find a pulse with a doppler

Move up one and let someone know

69

Ankle-Brachial index w/ PVD

Compare BP in arm and in leg, pressures should be equal, PVD will be >0.9

70

Arteriogram w/ PVD

Heart cath of legs

71

Anti platelet med for PVD

Baby aspirin or Persantine

72

Surgical management for PVD

Angioplasty or bypass grafts

73

Where can you have an aneurysm

Any artery

74

Injury or trauma to vessel wall

False aneurysm

75

Fusiform aneurysm

Normal artery, reverse hourglass shape

76

Saccular aneurysm

Comes off on one side

77

True aneurysm

Happens naturally

78

Aortic dissection

Aorta has 3 layers, one layer splits apart. Blood doesn't go to the right spot

79

When do you have surgery for an aneurysm

Nothing till its >5cm in diameter...then risk of rupture is greater than surgical risk

80

How to treat thoracic aneurysm

Not with surgery

81

Buerger's Dz

Uncommon, young men who smoke
-Affects hands/feet
-Fibrosis binds arteries together resulting in impaired circulation
-Typically involves smaller arteries and arterioles

82

Treatment of buerger's dz

-Stop smoking
-Avoid cold temps
-Surgical revascularization

83

Vasospasm of arterioles in upper or lower extremities, unilateral, >30 yrs, either gender

Raynaud's phenomenon

84

Vasospasm of arterioles, bilaterally, ages 17-50, more common in women

Raynaud's Dz

85

Manifestations of Raynaud's

-Skin blanches w/ vasospasm, hyperemic (really red, flushed) when vasospasm goes away
-Int attacks
-Extremities feel cold, tingling, numb
-Ulcers may develop

86

Treatment of Raynaud's

Calcium channel blockers to prevent spasm, vasodilators, avoid cold, stress

87

Thrombosis/thrombus

Blood clot

88

Phlebitis

Inflammation of the vein

89

Thrombophlebitis

Thrombus associated w/ inflammation

90

Most common site of thrombophlebitis

Deep veins of lower extremities

91

Virchow's Triad

-Venous stasis
-Hypercoagulabity (caused by dehydration)
-Endothelial injury

92

DVT

Closely associated w/
-Hip/knee replacement sx
-Immobility
-Ulcerative colitis
-HF
-Prolonged sitting

93

Clinical man of DVT

Calf/groin pain, unilateral swelling

94

Diagnostic procedures

Venous US

95

Medical management of DVT

-Prevention (dorsiflex)
-Bedrest
-Extremity elevation
-Anticoagulants
-Surgery

96

Anticoagulant therapy for DVT

-Heparin bolus/infusion to dissolve clot
-Goal is PTT 1.5-2 x normal level
-Serial monitoring (CBC, PTT, PLT)
-Lovenox (1mg/kg) for prevention, not treatment
-Warfarin long term

97

Venous insufficiency

-Prolonged venous HTN
-Stretches veins/damages valves
-Venous stasis (edema, inability to remove waste products, ulcer formation)

98

Normal PTT

20-30

99

Clinical manifestations of venous insufficiency

Edema, stasis dermatitis (reddish brown discoloration extending up from ankles, chronic ulcers)

100

Management of venous insufficiency

Reduce edema, normal venous return, localized ulcer care

101

Pt education for venous insufficiency

-Avoid long standing periods
-Leg elevation
-Don't cross legs
-Don't wear restrictive clothing
-Ulcer care (unna bood, surgical debridement)

102

Left sided HF

Systolic: heart can't contract forcefully
Diastolic: Loss of ventricular wall compliance, can't fill

103

Right sided HF

RV doesn't empty completely and "backs up" into venous system causing peripheral edema

104

#1 cause of right sided HF

Left sided HF

105

High output failure

Less common, associated with sepsis

106

S/S left sided HF

*Systemic*
-Fatigue
^HR
-DOE
-Crackles, wheezes
-Cool extremities
-Weak pulses

107

S/S right sided HF

-JVD
-Enlarged liver/spleen
-Anorexia
-Peripheral edema
-Polyuria (night)
-Weight gain

108

Classification of HF ACC

A-pts w/ high risk
B-structural problems, no symptoms
C-symptoms
D-refractory HF

109

Classification of HF New York

1: without limiting symptoms
2: slight limitation of activity
3: marked limitation
4. inability to move w/o symptoms, symptoms at rest

110

Meds for HF

-ACEI or ARB
-Beta blockers controversial
-Diuretics
-Nitrates: vasodilate coronary arteries
-Inotropes (Digoxin: lowers HR and increases contractility)

111

Intra-aortic balloon pump for HF

-Placed percutaneously
-Increases coronary perfusion
-Decreases after load
-Increases CO
-Positioning: high enough in aorta that its above superior mesenteric, below carotid and great vessels, stick artery, they'll be on bedrest
-Timing: inflates during diastole, deflates just before systole

112

Pulmonary Edema

Severe HF w/ volume overload, AMI, mitral valve disorders. Fluid leaks across capillaries into lung tissues

113

S/S of pulmonary edema

-Crackles
-Dyspnea at rest
-Confusion
-Anxiety
-Reduced UOP
-Cough
-Frothy, pink sputum

114

Treatment for pulmonary edema

Oxygen, diuresis, nitrates, inotropes

115

Most common cause of mitral stenosis

Rheumatic fever

116

Mitral stenosis

Valve doesn't open fully, increased pressure in LA, then PA, then RV
-Pulmonary congestion
-Right sided heart failure

117

Mitral regurgitation/insufficiency

-Degeneration/infarct of papillary muscle
-Doesn't close: allows for back flow of blood into LA and LV until LV begins to fail due to chronic volume overload
-RV failure results too

118

Aortic stenosis

-Most common valve dz
-Congential/age related
-Doesn't open and obstructs LV outflow
-CO becomes fixed
-LV failure leads to RV failure

119

Aortic regurgitation/insufficiency

-Endocarditis, congenital
-Remain asymptomatic for years
-LV overload leading to LV failure, then RV failure
-Bounding pulse w/ wide pulse pressure

120

Systolic murmurs occur with what?

-Mitral regurgitation
-Aortic stenosis

121

Diastolic murmurs occur with what?

-Mitral stenosis
-Aortic regurgitation

122

Medical management for valvular heart dz

-Diuresis
-Atrial fib management

123

Surgical repair of valvular dz

Metal valves/porcine valves, annuloplasty, balloon dilation