Foundations Exam 2 - cardiac diseases

General Anestesia

• major surgery for loss of consciousness and sensation

1. Analgesia: lose sensation

2. delirium: unconscious but restless

3. surgical anesthesia: deep breathing without reflexes

4. medullary paralysis: voluntary stops

• inhibit neuronal activity throughout CNS

• Administration: inhaled (slower but easier to adjust) or IV

local anesthetics

• sensation loss in specific body region

• chloroprocaine, lidocaine, bupivacaine, ropivocaine 

• Administration: topical, transdermal, peripheral nv block, neural blockage 

• PT implications 

  • lack sensation and motor

  • Local Anesthetic Systemic Toxicity (LAST) - spreads to blood stream → CNS = sedation or cardiac = dysrhythmias or hypotension

opioids

• mimic neural endorphins (dopamine) binding to receptors to block pain 

• strong → for severe pain

  • morphine, fentanyl, hydromorphone, oxymorphone 

• mild/moderate → moderate pain 

  • codeine, hydrocodone, oxycodone 

• PT considerations 

  • change in mental state 

  • orthostatic hypotension

  • GI dysfunction 

  • decrease RR

  • withdrawal → peak in 2-3 days 

muscle relaxants 

• spasticity: exaggerated stretch reflex caused by motor neuron damage 

• spasm: involuntary muscle tension occurs with pain input that excites motor neuron 

• benzodiazepines (diazepam) 

  • inhibitory and calming affect

• polysynaptic inhibitors

  • cyclobenzaprine, carisoprodol, metaxalone, methocarbamol

• PT consider: sedation and lethargy

Acetaminophen 

analgesic (for pain) and antipyretic (for fever) 

hepatotoxicity! 

NSAIDs

Analgesic (pain), Anti-inflammatory, Antipyretic (fever), antithrombotic (decrease blood clot)

• Aspirin has all 4

• ibuprofen, naproxen, diclofenac, oxaprozin, piroxicam, indomethacin, fenoprofen, flurbiprofen, ketorolac, celecoxib

• PT considerations: GI problems, bleeding, Reye’s syndrome (swelling of liver and brain due to taken with fever), KIDNEY DYSFUNCTION, problems with tissue healing

corticosteroids

• cortisone, dexamethasone, hydrocortisone, prednisone, prednisolone, betamethasone, methylprednisone, methylprednisolone

• PT considerations: catabolic effect (careful with manual therapy), hypertension, immunosuppression, impaired healing, Cushing’s disease (increase fat in face and abdomen)

nociceptive meds 

for pain 

• anesthetics, opioids, muscle relaxants, acetaminophen 

neuropathic

injury to axon/nvs

• anticonvulsants (gabapentin)

• antidepressants

Goodman Screening for Referral

1. client history (medical history and meds)

2. risk factor assessment

3. clinical presentation (s/s)

4. review of systems

   1. general health questions

   2. specific systems

signs and symptoms of cardiovascular disease 

• angina pectoris: chest pain 

  • myocardial ischemia

• dysrhythmias

• dyspnea

• cardiac syncope

• fatigue

• cough

• cyanosis

• edema (pitting)

• claudication: leg pain due to decrease O2 delivery to muscles

• abnormal vital signs

normal control of BP 

1. moment to moment controlled by vessels → vasoconstriction 

2. short term by baroreceptors 

3. long term by RAAS 

orthostatic hypotension

• drop in BP when rising

• etiology: meds, less sensitive baroreceptors, impaired nv signals

• orthostasis: normal reaction = baroreceptors detect decreased BP and will increase resistance and HR in response (fail = syncope)

• more often in morning

• diagnosis: SBP decrease 20 and/or DBP decrease 10

• treatment = contract leg muscles to get blood flowing before standing

Postural Orthostatic Tachycardic Syndrome (POTS)

• excessive tachycardia upon standing (usually in females)

• etiology: neuropathic, autoimmune, virus, trauma

• blood pools in lower body and ANS fails to regulate change in BP

• diagnosis: HR increases > 30 bpm

• treatment: fluid retention, steroids, B-blockers

syncope

• temporary loss of consciousness

• etiology: brain deprived O2

  • cardiac = decreased Q = decreased BP

  • vasovagal: over-activated vagus nv

• result in falls, but don’t remember falling → ask duration of unconsciousness

hypertension 

• persistent elevation of BP 

• essential = 90% cases unknown cause 

• secondary = 10% cases known cause 

• self perpetuates 

• silent killer 

Anti-hypertensive meds

orthostatic hypotension

• B-blockers

  • decrease SNS → decrease HR → decrease BP

  • use RPE scale

  • end in -lol

• a-blockers

  • decrease resistance → decrease BP

  • reflex tachycardia

  • cautious with heat therapy (since vasodilating)

  • end in -osin

• central a-2 agonists

  • decrease SNS in brain → decrease BP 

  • clonidine and methyldopa

• diuretics

  • decrease H2O reabsorption → decrease blood volume → decrease BP

  • Loop diuretics end in -ide (strongest)

  • Thiazide Diuretics end in -thiazide

  • Potassium sparing diuretics (weakest)

• ACE inhibitors

  • prevent vasoconstriction

  • end in -pril 

• Angiotensin 2 receptor blockers 

  • cause vasodilation 

  • end in -artan 

• Renin inhibitors 

  • stop angiotensin 2 production 

  • end in -ren 

• vasodilators 

  • direct: relax vascular muscles

    • hydralazine, minoxidil, nitroprusside 

  • indirect: calcium channel blockers 

    • end in -ipine expect most common = diltiazem

heart valve disease 

• damage to tricuspid, pulmonic, biscuspid/mitral, aortic valve 

• etiology: IHD, infection, rheumatic fever 

• types 

  • stenosis: narrowing of valve

  • regurgitation: back flow due to improper closing

  • prolapse: change in shape, only a problem if causing regurg

• most of time asymptomatic but may cause arrhythmias or heart failure

• diagnose: auscualtion (heart sounds) or echocardiogram

• treat: surgery

cardiac arrhythmias 

• changes in circulatory dynamics 

• etiology: congenital, other pathology, lifestyle 

• risk factors: IHD/MI 

• due to electrical problem 

  • abnormal automaticity: SA node not working

  • abnormal conduction

• mild = no s/s

• severe = decrease Q → cardiac failure, stroke, death

• diagnose: ECG

• treatment: meds, defibrillator (shock), surgical pacemaker

Anti-arrhythmic meds 

all pro-arrhythmic 

• sodium channel blockers 

  • disopyramide, flecainide, quinidine

• B-blockers (end in -lol)

• potassium channel blockers

  • amiodarone → toxicity of eyes, heart, thryroid, liver, blue/grey skin

• calcium channel blockers

  • diltiazem

hyperlipidemia (high cholesterol)

• leads to atherosclerosis (plaques)

• etiology: lifestyle

• HDL target >50 (good type)

• LDL target <100 (bad type)

• diagnose: blood test

• treatment: lifestyle change and meds

hyperlipidemia meds

all cause GI problems

• Statins

  • inhibit enzyme that catalyzes cholesterol synthesis (decrease production of cholesterol)

  • can cause muscle pain

  • end in -statin

• Ezetimibe

  • inhibit cholesterol absorption

• Nicotinic Acid

  • B vitamin that binds to receptors to decrease lipid breakdown

• Fibric Acids (fenofibrate)

  • increase activity of lipoprotein lipase

  • increase free fatty acid uptake in liver

  • Hepatotoxicity and increase risk of gallstones 

• bile acid binding agents (cholestyramine)

  • block reabsorption of bile 

• PCSK-9 inhibitors (alirocumab) 

  • block protein that normally prevents cholesterol removal 

Ischemic Heart Disease (IHD) 

Coronary Artery Disease 

• coronary arteries narrow due to arteriosclerosis 

• due to atherosclerosis (plaque) 

• risk factors: male, age, lifestyle 

• angina pectoris: chest pain 

  • not enough O2 to heart due to clot (emboli) 

  • referred pain to L chest, arm, jaw, and in females abdomen 

• diagnosis: lipid profile, coronary catheterization, echocardiogram 

• treatment: meds, lifestyle change, surgery (PTCA stenting or CABG - bypass) 

Myocardial Infarction (MI) = heart attack

• irreversible necrosis of heart muscle 

• etiology: IHD → embolism (moving clot) 

• risk factors: male, hypertension, hyperlipidemia, valve disease, IHD 

• more often in morning 

• diagnose: lab results, ECG, echocardiogram, angiogram 

• treatment: meds, surgery (PTCA or CABG) 

• 50% deaths occur within 1 hr and usually due to dysrhythmia 

IHD and MI meds

Anti-anginals

• Nitrates

  • Nitroglycerin converted to NO in smooth muscle cells → vasodilation

    • make sure patient has with them before exercise

    • call 911 if no improvement in 15-20 min or symptoms increase

  • orthostatic hypotension, reflex tachycardia, edema, caution with heat therapy

• B-blockers: decrease SNS → decrease HR to decrease O2 needed

• calcium channel blockers

IHD and MI meds

Anticoagulants 

• heparin: increase clot time

  • monitor with aPTT

    • low aPTT = increase risk of clotting

    • high aPTT = increase risk of bleeding

• Warfarin: increase clot time

  • monitor with Prothrombin Time (PT) or INR

• Direct Thrombin Inhibitors

  • fondaparinux or rivaroxaban

PT consideration: increased risk of bleeding, patient must reach level aPTT or PT/INR before starting

IHD and MI meds

Anti-platlets 

• stop platelets from sticking together 

• salicylates → aspirin 

PT consideration: increase risk of bleeding 

IHD and MI meds

fibrinolytics

• dissolve clot

• tenecteplase

• increase risk of bleeding and usually on bed rest for a little while

Heart Failure

• condition where heart is unable. to pump sufficient quantity of blood to meet needs of tissues

• risk factors: hypertension, aging, IHD, etc

• Classifications

  • New York Heart Association functional classifications: based on function → for PT

  • AHA/American College of Cardiology stages: more on anatomy

Left side = congested heart failure

• increase SNS, RAAS system, and ADH to compensate

• difficulty breathing because backs up into lungs

• cyanosis

Right side

• backs up to body (edema, jugular vein distension, weight gain (ascites) 

• jaundice 

Affecting ejection fraction?

• diastolic: dysfunction of relaxation

• systolic: dysfunction of contraction

diagnosis: echocardiogram, ECG, stress test, cardiac catheterization

treatment: lifestyle change!, meds, surgery, heart transplant 

Heart failure meds 

inotropic: affects contractility 

chronotropic: affects HR 
dromotropic: increase rate of conduction through AV node 

Heart failure meds 

• Cardiac Glyosides (digoxin)

  • positive inotropic

  • neg chronotropic and dromotropic

  • digoxin toxicity: narrow therapeutic window → yellow visual halos

  • risk dysrhythmias

• phosphodiesterase inhibitor (milrinone)

  • positive inotropic

  • risk dysrhythmias and OH

• vasopressors and positive inotropes

  • for ICU patients

• to decrease work of heart

  • ACE inhibitors

  • Angiotensin Receptor blockers

  • diuretics

  • vasodilators

  • B-blockers

Peripheral vascular disease 

• more often in LEs 

• changes in skin = first sign 

• vasculitis: vessel inflammation 

• arterial occlusive disease 

  • result of arteriosclerosis, trauma, or vasculitis

  • claudication: pain due to lack of blood flow

  • s/s: thin skin, elevate = pain worse, rubor of dependency (redness), wound = round

• thrombophlebitis

  • swelling of vein

  • DVT: 3rd most common cardiac disease

  • venous stasis + hypercoagulation + vessel injury

  • s/s: dull ache/pain in area, edema, red and warm

  • diagnose: Doppler ultrasound , Well’s Clinical Prediction Rule (2+ = high risk)

• varicose veins 

  • due to elevated venous pressure

  • risk factors: female

• chronic venous insufficiency 

  • inadequate venous return → pooling

  • pain improves with elevation

  • s/s: edema, red/blown skin, wounds=irregular

  • compression socks 

• vasomotor disorders - Raynaud’s

  • usually women 20-50

  • disease: unknown cause, hypersensitive to cold → vasospasm

  • phenomenon: due to underlying disease

  • white → blue → red 

  • calcium channel blockers and avoid triggers  

aneurysms

• etiology: trauma, infection, inflammation

• risk factors: AGE and smoking!

• arterial aneurysms

  • Aortic, Thoracic, Abdominal

    • asymptomatic

    • tachycardic if ruptured

  • intracranial

    • Epidural hematoma: sudden onset, bleeding on brain

    • subdural hematoma: slower, take longer to find, minor trauma 

    • subarachnoid hemorrhage: sudden excruciating headache 

• diagnose: palpation, imaging 

• treatment: watch and wait (control BP) 

• prognosis: rupture = death

Cerebral Vasular Accident (CVA) - stroke

• etiology: arteries in brain damaged

• risk factors: F more in young and over lifetime

• Transient ischemic attack (mini stroke)

  • reversible damage

• Ischemic stroke (85%)

  • occlusion (blood clot) usually from heart

• Hemorrhagic stroke (15%)

  • most deadly → bleeding in brain

• s/s: representative of area of brain affected

  • Face Arm(leg) Speech Time

• diagnose: presentation or CT/MRI

• treatment: PT

• 3rd leading cause of death and 1st cause of disability in adults