CV Conditions: Ischemic Cond's: Exam 1 Flashcards
(102 cards)
1
Q
Ischemic cond’s or
A
lack of O2
2
Q
Leading cause of death====
A
Heart Disease!!!
3
Q
Myocardial perfusion involves which aa’s
A
CA’s
L and R branch off of aorta
4
Q
Basic rules of hemodynamics
2
same is true for CAs!!!
A
- Fluid flows from an area of HIGH pressure to LOW pressure
- Fluid follows the path of LEAST resist.
NOTE: more blood flow during Diastole=== HIGHER press in aorta
5
Q
Determinants of CA blood flow:
Myocardial perfusion occurs primarily during pds of _______________
A
myocardial relaxation
Diastole
6
Q
Determinants of CA blood flow:
Vasomotor tone (ability to vasodilate) of CAs allows for what?
A
vol. of blood to enter CAs during Diastole
when they are relaxed
7
Q
Determinants of CA blood flow:
O2 attaches to myoglobin to be released as needed during _________
A
Systole
8
Q
Determinants of CA blood flow:
CA perfusion and O2 cont’s to be delivered during __________
A
Systole
as long as pressure is LOW enough
remember HIGH pressure during Diastole and goes to LOW pressure (systole)
9
Q
2 Factors that DECREASE myocardial perfusion
A
- Elevated DBP—-bigger issue vs. SBP
- CA atherosclerosis OR resist. to CA blood flow
10
Q
If the R CA gives NO blood flow to heart=====
A
Dysrhythmias
11
Q
If L CA no blood flow to heart====
A
Heart failure
12
Q
Rt. CA supplies:
A
SA node
R atrium
Post and Inf surf vents
AV node in 80% pop.
13
Q
L CA supplies:
A
Sternocostal surf (ant myocardium) BOTH vents
L atrium
L vent
Septum
14
Q
Anatomy of CA’s
Inner layer
whats here?
A
Intima
15
Q
These are MOST likely to accumulate in the Intima (inner layer of CAs)
A
Lipopro’s and fibrinogen
*this creates hardening
16
Q
MODIFIABLE RISK FACTORS CARDIAC DIS.
A
- smoking
- high BP (>140/90)
- High CHO lvls
- phys inactivity
- obesity
- BMI >/= 30 kg/m2
- normal== <25
- stress/Type A
- metabolic syndrome
17
Q
MODIFIABLE RISK FACTORS CARDIAC DIS.
Talk more about High blood CHO lvls ….
A
- BEST predictor is ratio of tot. CHO to HDL CHO/HDL >4.5
- norm== 3.3
-
Tot. CHO
- <200 = norm
-
HDL <35
- >60= norm
-
Triglycerides >150
- <150= norm
18
Q
NON MODIFIABLE RISK FACTORS CARDIAC DIS.
A
Heredity
sex
female post menopause
age
T2D
19
Q
Risk factors Cardiac Disease
Emerging risk factors
A
- LipoPRO A
- LDL subclasses
- Oxidized LDL
- Homocysteine
- Hematological factors
- Inflamm markers
- C-reactive PRO=== high stress
- infective agents
- C. pneumoniae
- alcohol
20
Q
Clinical Dx from Worse to WORST
A
- CAD
- angina
- acute coronary syndrome (ACS) or MI
- cardiac mm dysf
- Sudden cardiac death
- Other atherosclerotic dis’s
- PAD
- Renal athero –> renal HTN
- Aortic athero–> aortic aneurysms
- Ischemic and Hemorrhagic CVA
21
Q
- CAD or
A
Atherosclerosis
- progress. hardening/narrow of coronary, cerebral, renal, aortic and periph aa’s
***atherosclerotic plaques composed of lipid, fibrin and thrombus
22
Q
CAD
2 step process:
remember this is CHRONIC athero=== long term buildup, slow w/ sx’s
A
-
Atherosis
- fatty streak of lipid laden macrophages causes endothel damage/exposure of endothelium
-
Sclerosis
- “fibrous cap” of thrombi and platelets over advanced plaques dev. on endothelial lining
23
Q
When CAD progresses enough
Total occlusion of aa by thrombus
MI from tot. occlusion
ACUTE— blockage BUT clot lodges
A
MI
Full occlusion
24
Q
CAD Medical mgmt
Dx testss
A
ECHO
Cornoary angio
Ex/pharma stress test
CT
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CAD medical mgmt
## Footnote
**Meds**
Statins
Antithrombotic/Antiplatelets
26
CAD
## Footnote
**PT intervents**
* ASCM:
* Aerobic end training @ least 2d/wk @ \>/= 50% VO2max for \>= 10mins
* **decs athero build up**
* **EX has been proven more effective than ANY med @ preventing and slowing progress of CAD\*\*\*\***
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Angina
* "strangling"
* **sub-sternal pressure**
* Some **imbalance** in **supply and demand of** **_myocardial O2_**
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NOTE: Angina and Myocardial O2 consumption
supply/demand problem
## Footnote
**Rate Pressure Product RPP== HR\*SBP**
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Typical Cardiac Pain Referrals
## Footnote
**visceral or somatic pain referrals bc heart has NO pain receptors----so that's why "referred" pain**
see pics
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Atypical Cardiac Pain Referrals
**More likely Female**
* Can also include:
* breathlessness
* R bicep pain
* acid reflux
* tongue pain
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Angina== **imbalance in Supply and Demand**
## Footnote
**what does that mean?**
Demand \> Supply of O2
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Stages of **Stable Angina**
see pics
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Stable Angina
## Footnote
**stage 1**
initial percept of discomfort
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stable angina
## Footnote
**stage 2**
INC in int. of lvl 1 OR radiation of pain to other areas (jaw, throat, shoulders, arms, other)
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Stable angina
## Footnote
**stage 3**
Relief only obtained through **cessation of activity**
## Footnote
**\*\*\*when demand is relieved\*\***
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stable angina
## Footnote
**Stage 4**
Infarction pain
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6 types of Angina
1. Chronic/Stable or Classic or Exertional
2. Prinzmental or Vasospastic or Variant
3. Nocturnal
4. \*Post-Infarction
5. Metabolic or Diabetic or Macrovascular
6. Unstable
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Chronic Stable/Classic/Exertional Angina
onset @ **specific MET lvl when supply no longer meets demand**
## Footnote
**when you cease activity===GONE**
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Prinzmental or Vasospastic or Variant Angina
CA vasospasms
same time everyday
**restricts supply O2**
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Nocturnal Angina
during sleep
## Footnote
**supply does NOT meet new INCd demand due to INC SNS activation or INCd Preload in Supine**
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Post-Infarction Angina
angina pain exp'd AFTER MI that has been med./sx managed
NOT NORMAL TO HAVE THIS!!!
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Metabolic or Diabetic or Macrovascular Angina
exp'd by persons w/ met. syndrome or DM
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Unstable Angina
**acute onset**
accels in freq & severity
**indicative of MI---\> CALL 911\*\*\*\*\***
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Angina: Med mgmt
## Footnote
**Pharmaceutical**
* NITRATES @ onset of event
* **short-acting nitrates**
* Nitrates **prophylactically**
* **Long-lasting**
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Dx test to det. cause of Angina
CA angio
Ex/pharm stress test
EKG
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Other angina med. mgmt
Treat HTN OR underlying cardiac issues
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Angina:
PT imps
* FULL cardiac assess\*\*\*
* **until angina controlled AND CA bloodflow reestablishing or _meets myocardial demands....._**
* ***Pt @ risk of myocardial ischemia***
* VITALS!!!
\*\*If yesterday angina===\> cardiac screen
\*\*if treated selves w/ **nitrates----\> get med. clear**
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Acute Coronary Syndrome (ACS) or MI
2 types:
* ST-segment elevation MI
* **STEMI**
* **Non-STEMI**
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Acute Coronary Syndrome/MI
or...
* Acute coronary syndrome
* MI
* "Coronary"
* Acute MI
NOTE: **90% MI==\> atherosclerosis (CAD), 10% vasospasms (cocaine, vasoconstrict, aortic stenosis, vasculitis)**
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Acute Coronary Syndrome or MI:
2 types
STEMI and Non-STEMI
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Alterations in Myocardial Perfusion
**Acute:**
NO PRIOR SX'S
* Dislodged embolus
* **ends up in CA**
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Alterations in Myocardial perfusion:
**Chronic**
PRIOR SX'S
* prolonged progress. of athero. over time
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Progression of Myocardial Necrosis
* NOTE:
* **LAD== widow maker**
* **Zone of Perfusion**
* **area @ risk**
* **where MI occurs**
* **Zone of Ischemia**
* **NO O2**
* **Zone of necrosis**
* **perm, irrev dead tissue**
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Acute Coronary Syndrome/MI
## Footnote
**Labs**
**"Biomarkers of Cardiac Injury"**
* **Cardiac Troponin I (cTnI)== BEST INDICATOR OF MI**
* ****
* **whenever trending UP ---\> hold pt**
* **trending DOWN---\> pt OK**
* **Must obtain "trending down lab value" to initiate PT**
* **Cardiac Troponin T (cTnT)**
* **Creatine Kinase (CK-MB)**
**cTnT and CK-MB** take LONGER to peak
55
Anatomy and Loc. of Infarct
* **Right CA**
* ****Loc= inf
* Comps
* risk of AV block and/or arrhythmias
* 50%
* **Left Main**
* ****Loc= Ant and Lat
* Comps
* pump dysf/failure
* **LAD (widow maker)**
* ****Loc= Ant
* Comps
* pump dysf/failure
* **Circumflex**
* ****Loc= Lat
* Comps
* NONE SPECIFIC
56
MI: MED mgmt
## Footnote
**Medical mgmt ACS**
* Cardiac angio (how occluded aa's are) and cardiac angioplasty (PTCA) or stent
* **antithrombotics/antiplatelets**
* anticoagulants
* tPA
* **\<12 hr pd--\> minimize Zone of Necrosis**
* prophylaxis for **arrhythmias**
* nitrates, morphine, beta blocks
* last 2 to dec SNS, relax heart
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MI: med mgmt
GOALS
IMPROVE oxygenation
LIMIT infarct size
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MI
**Prognosis**
* Related to **comps,** infarction size (**zone of necrosis),** presence of dis on other CAs, LV function (EF, SV)
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MI:
**Ventricular Remodeling**
* w/ STEMI
* changes in size, shape and thick. of myocardium
* areas of **vent dilation and vent hypertrophy**
* **Factors that affect remodeling:**
* ****Size infarct
* Vent load
* Patency of the aa infarcted
60
Cardiac mm dysf or
Zone of Necrosis
## Footnote
**Transmural= thru whole depth**
61
Cardiac MM Dysf can include the following
* Dyssynchrony
* Hypokinesis
* Akinesis
* Dyskinesis
* CHF
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Dyssynchrony
timing off
diff timing of contracts
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Hypokinesis
LESS mvmt myocardium
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Akinesis
NO mvmt
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Dyskinesis
**w/in area:** contraction NOT coord'd properly
**area dilated**
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CHF
Pump failure
EF diminished
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Sudden Cardiac Death or
WORST
Myocardial Ischemia
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Sudden Cardiac Death
there are NO\_\_\_\_\_\_
electrical impulses
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Sudden Cardiac Death
## Footnote
**Myocard ischemia leats to ________ and ________ ===\> cessation of CO**
leads to **arrhythmias (Vtach) and vent fibrillation (Vfib) leads to cessation of CO**
70
sudden cardiac death
## Footnote
**when a person has MI...**
PROMPT delivery of CPR w/ AED and entry to ER are necessary to **prevent sudden cardiac death**
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Risk factors assoc'd w/ Sudden Cardiac Death
## Footnote
**Undiagnosed CHD pop.**
age
SBP (elevated)
LV hypertrophy
Intravent block on ECG
Nonspecific ECG abnorms
Serum CHO (elevated)
HR (elevated RHR)
VC (low, esp factor in **females)**
smoking
rel. wt.
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Risk Factors Assoc'd w/ Cardiac Sudden Death
## Footnote
**Diagnosed CHD Pop.**
* DECd LVEF
* **\<35%**
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ALL of these involve **Coronary Atherosclerosis**
* CAD
* Angina
* ACS/MI
* Cardiac MM Dysf.
* Sudden Cardiac Death
74
OTHER dis's of **Athero**
* PAD
* Renal HTN
* Aortic HTN----aortic aneurysms
* Ischemic/Hemorrhagic CVAs
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Vascular Dis's think...
Arterie\*\*\*
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PAD or
Atherosclerotic occlusive disease (AOD)
Atherosclerosis Obliterans
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PAD
## Footnote
**explain**
SAME process as CAs:
## Footnote
**atheromatous plaque obstruction of lg or md sized aa's that supply blood to extremities**
**ACUTE== plaque build up**
**CHRONIC== slow, progressive**
78
PAD can also cause what?
**Aneurysm dilation of aa wall**
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PAD
when will pt be symptomatic?
When blood flow is NOT adequate to meet **demand of periph tissue**
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PAD
what is the **Supply**
HgB
O2
size of aa's
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PAD
what is the **Demand**
whatever pt is doing/activity
82
When **supply DOES meet demand===**
A-VO2
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S/S of PAD
* **Trophic changes**
* hair loss
* thin shiny dry skin
* mm atrophy
* hypERsensitive to palp
* pain w/ **elevation**
* claudication @ certain MET lvl
* pallor
* non-healing wounds
84
PAD Med. Mgmt
## Footnote
**Dx Tests**
ABI
pulses (diminshed or absent)
Arterial dopplers (**check for acute aa clots)**
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PAD med. mgmt
## Footnote
**Pharma. mgmt**
* Ca+ channel blocks
* Alpha inhibitors
86
PAD and PT evals
* **Vitals**
* **HR/BP during PT eval**
* Rubor of Dependency test and Claud. test
* check MET lvl and **onset of PAD s/s**
* **ABI or req. ABI**
* **Doc. sx's and trophic changes**
* check for Wounds
* Check periph pulses
87
PAD and PT
* Ex and PAD
* pts unable to prod **norm inc's in periph blood flow**
* **@ a LOWER threshold:**
* ****pts switch to anaerobic ex
* **intermittent claud** leads to mod-severe impair in ambulation and ADL
88
PAD and PT
**Research and Exercise**
**Reverses sx's!!!**
* **Ex. can improve pain-free and max walking tolerance on lvl ground and during intermitt-load TM**
* **how???**
* ****inc'd walking eff.
* incd periph blood flow (collateral circ)
* **compensates**
* reduced blood viscosity
* **less like tomato sauce**
* regress of **atherosclerotic dis.**
* RAISES pain threshold
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Ex recco's for indiv's w/ **PAD**
see pics
NOTE: **Inc DURATION and FREQ _before_ Intensity\*\*\***
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Renal AA dis
**athero of renal aa (blood to kidneys)**
**inc'd CV dis and mortality**
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Aortic Aneurysms
* patho perm **dilation of aortic wall (around athero) involving any # of segments of aorta (irrev)**
* **described:**
* **loc, size, appearance, origin**
* occurs from:
* athero
* idiopathic
* HTN
* **RUPTURE IS A MAJOR RISK OF ABD AORTIC ANEURYSMS (aneurysm==bulging)**
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Aortic Aneurysm
**PT implications**
* Visceral pain:
* "pressure" on surrounding parts such as **low back**
* ****eval resp to ex
* leg pain/claud pain
* numbness in LEs
* excess fatigue
* poor **distal pulses**
* ESSENTIAL
* **monitor vitals---specifically BP**
93
Cerebrovascular Disease
* **Ischemic** is most likely due to **atherosclerosis --85%**
* **Hemorrhagic** most likely due to **HTN**
## Footnote
**\*\*\*tPA w/in 6 hours!!!**
94
Surgical mgmt:
## Footnote
**CAD**
**@ least 75% occluded**
**usually Radial or Femoral aa's**
* Percutaneous Transluminal Coronary Angioplasty
* **PTCA**
* **Stent**
* where?
* RCA
* RPD (r post descending)
* LCA
* LAD
* Circumflex
95
Surgical Mgmt **CAD**
**Coronary Artery Bypass Graft**
**CABG**
Bypass
"alternate route"
96
Surgical Mgmt CAD:
## Footnote
**Median Sternotomy**
* \*\*Sternal Precautions\*\*\*
* they open the ribs
* **First month after sx:**
* ****cough w/ heart pillow
* do NOT hold breath/NO **valsalve**
* do NOT twist upper body
* use arms as little as poss.
* when using arms to **lift, push, pull**
* ****use BOTH @ same time (B/L)
* NO lifting more than 5-10lbs
* NO reaching
* do not sit in front of air bag in car
97
Pacemakers
explain...
* temp or perm
* pacing location
* programmability
* **Anti-bradycardia arrhythmic function**
* **Anti-tachy arrhythmic function**
**can be Atrial== fake SA node**
**can be Ventricular== fake AV node**
98
Pacemaker and PT
* facility/phys specific
* **No Precautions**
* **Arm in sling 24-48hrs**
* IPSILAT. shoulder elevation restrict \<90o
* 1-14 days
* no heavy lifting 14 days
99
Implantable Cardioverter Defibrillator
## Footnote
**AICD**
detects life-threatening arrhythmias & defibrillates
100
Pts w/ **AICD and PT**
* Facil/phys specific **same as post op pacemaker**
* **\*\*watch HR on EKG/telemetry if avail.**
* **know settings**
* **BE READY!!!**
* ****know WHEN/IF AICD fires\*\*\*
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IF AICD fires.....
* Stop and assess pt
* if **single shock and asymptomatic**
* ****call and notify MD/Cardiologist/referring phys.
* if **mult shocks or pt symptomatic**
* ****call 911 or start hosp emergency med system
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