CCRN - Cardiovascular

S1 heart sounds are caused by closure of ______ valves and mark the beginning of __________.

AV (mitral, tricuspid), systole

S2 heart sounds are caused by closure of ____________ valves and mark the beginning of ___________.

Semilunar (aortic, pulmonic), diastole

S3 sounds are caused by a rapid rush of blood into a ____________. It occurs right after _______ and sounds like "Kentucky"

Dilated, S2 (split S2)

S4 sounds are caused by atrial contraction of blood into a ___________ ventricle. It occurs right before _____ and sounds like "Tennessee"

Noncompliant, S1

Note: not heard in AFib d/t lack of atrial contraction

How do you calculate pulse pressure?

What is normal?

What causes a narrow or wide pulse pressure?

Systolic - diastolic = pulse pressure

40 - 60 mmHg

Narrow = severe hypovolemia, drop in CO, cardiac tamponade

Wide = vasodilation, drop in SVR, septic shock

SBP is an indirect measurement of ____ and ____.

DBP is an indirect measurement of ______.

CO, SV

SVR

What are some causes of valvular heart disease?

CAD

Ischemia/MI

Dilated CM

BAV

Rheumatic fever

Infection

Connective tissue diseases (Loeys-Dietz, Marfan's)

Murmurs of insufficiency/regurgitation occur when the valve is ________.

Murmurs of stenosis occur when the valve is _____.

Closed, open

If a patient has a PAC, what will mitral insufficiency look like on the PAOP tracing?

Large, giant V-waves

Rationale: wedge pressure shows the pressure on the left side of the heart, insufficiency will cause backflow of blood and increase the pressure reading

Does a murmur d/t a VSD (associated with acute MIs) occur during systole or diastole?

Systole

An acute MI can most commonly cause which type of valve dysfunction?

Mitral regurgitation

Rationale: MV attached to the LV wall by papillary muscles and chordae tendinae, think of it like a rubber band (chords) weakening or snapping when there’s no heart perfusion during MI—>valve is loose and can’t close properly

Types of ACS

Unstable angina: pain at rest, unpredictable, troponin negative, ST depression, inverted T wave

NSTEMI": troponin positive, ST depression, inverted T wave, unrelenting chest pain

STEMI: troponin positive, ST elevation in 2+ leads, unrelenting chest pain

Variant/Prinzmetal angina

Unstable angina associated with transient ST elevation

Occurs at rest or cyclic

Precipitated by a stimulant

NTG relieves pain

Stat EKG must be done and read within ___ minutes with acute chest pain.

EKG allows risk stratification to ____________ (high), ____________ (medium), or ___ _____ _______ (low).

10

STEMI

NSTEMI

No acute change

ACS interventions

Aspirin ASAP

Anticoagulant like heparin or enoxaparin

Antiplatelet (clopidogrel)

BBs (unless ACS is due to cocaine, use cardioselective like metoprolol)

Nitroglycerin

Morphine

What labs are drawn in ACS?

Cardiac biomarkers (troponin, CK-MB, myoglobin)

Lipid panel

CBC

CMP (electrolytes, BUN/Cr)

PT/PTT

What leads are associated with each part of the heart?

II, III, aVF = RCA, inferior LV

V1-4 = LAD, anterior LV

V5, V6, I, aVL = circumflex

Inferior MIs are associated with _____ occlusion.

This means elevations in which leads?

Right coronary artery

II, III, aVF

Note: use beta blockers and NTG with caution d/t risk of inducing severe hypotension and cardiogenic shock due to concurrent RV infarct

Inferior STEMI can cause what kind of systolic murmur?

MV regurgitation

Rationale: posterior papillary muscle is supplied only by the RCA

RCA supplies the inferior wall of the LV and RV, so 30% of inferior wall MI patients will also have a ____ _______. What kind of EKG is needed to show this? S/s? Tx?

RV infarct, right-sided ECG

S/s: JVD at 45º, high CVP, hypotension, bradyarrhythmias

Tx: fluids, positive inotropes

Note: avoid preload reducers and beta blockers because you don’t want to decrease filling time and pressures to keep cardiac output up (think of it like right sided diastolic heart failure)

Anterior MIs are associated with _____ occlusion.

This means elevations in which leads?

Left anterior descending (LAD)

V1-V4

Anterior STEMIs can cause what kind of dysrhythmias?

2nd degree Type II AV block or RBBB (LAD supplies bundle of His) —> ominous

T/F: anterior MI has a higher mortality than an inferior MI.

True

Lateral MIs are associated with _____ ________ occlusion.

This means elevations in which leads?

V5-V6 (low lateral)

I, aVL (high lateral)

Right coronary artery supplies which parts of the heart?

Left anterior descending artery supplies which parts of the heart?

Left circumflex artery supplies which parts of the heart?

RA, RV

RV, LV, intraventricular septum

LA, LV

Note: left coronary artery branches into the left circumflex and LAD

What types of reperfusion are done for STEMIs with an onset of <12 hours?

What are eligibility criteria for them?

PCI (door-to-balloon within 90 minutes) or fibrinolytic drug therapy (within 30 minutes)

ST elevation in 2+ leads or new onset LBBB, chest pain onset <12 hours, chest pain of 30 minutes in duration, unresponsive to SL NTG

What are some complications of PCI?

Reocclusion (chest pain, ST elevation)

Vasovagal during sheath removal (hypotension, pallor, nausea, sweating —> fluids, atropine)

Bleeding at sheath site

RP bleed (sudden hypotension, severe low back pain)

Contraindications to fibrinolytic therapy

Prior ICH

Known cerebral vascular lesion

Known malignant incracranial neoplasm

Ischemic stroke within 3 months (except within 3 hours (two birds one stone))

Suspected aortic dissection

Active bleeding

Significant head or facial trauma within 3 months

What are signs of reperfusion following STEMI?

Chest pain relief

ST back to baseline

Elevation of cardiac biomarkers d/t myocardial “stunning” when vessel opens

Reperfusion arrhythmias (VT, VF) also d/t stunning

What is the most common complication of a PCI? How soon do they occur?

Stent thrombosis

Acutely (<24 hr) or subacutely (<30 days)

Hypertensive crisis is elevated BP with evidence of ___ _____ ________.

Greatest risk is _____.

Treatment?

End organ damage

Stroke

Nipride (reduces preload and afterload, watch for cyanide toxicity (AMS, tachycardia, seizure, metabolic acidosis)) and labetalol IVP (max dose of 300 mg)

What are the 6 Ps of PAD?

Pain

Pallor

Pulselessness

Paresthesia

Paralysis

Poikilothermia (loss of hair on lower legs)h

How is PAD diagnosed?

Ankle-brachial index (ankle/brachial pressure, normal is >0.9)

Also doppler u/s, arteriography

What are s/s for acute carotid artery disease?

Dx?

Tx?

TIA, visual disturbances, aphasia, stroke

Angiography (gold standard), carotid duplex u/s, CTA, MRA

Carotid endart, carotid stent, aspirin, statins

Wolff Parkinson White syndrome is a __________ conduction abnormality that allows a reentrant _____________ to bypass the normal ____ node conduction, resulting in _____.

It can also present as what kind of dysrhythmia?

Genetic, tachycardia, AV, SVT

Pre-excited atrial fibrillation

QT prolongation can lead to which arrhythmia?

What drugs can cause it?

What electrolyte abnormalities can cause it?

Tx?

Torsades de pointes

Amiodarone, quinidine, haloperidol, procainamide, ondansetron

Hypokalemia, hypocalcemia, hypomagnesemia

Magnesium

Explain pacemaker code.

First initial = chamber _______

Second initial = chamber _______

Third initial = response to _______

• I = ______

• D = ______ and _________

• O = none

Paced

Sensed

Sensing

• Inhibits (senses intrinsic activity, withholds pacing)

  • Inhibits and triggers (senses intrinsic activity and fires a pace in response)

Pacer malfunctions.

No spike at all when expected = failure to _____

Spikes without a QRS = failure to _______

Pacing in native beats = failure to _______

Pace

Capture (heart not capturing)

Sense

HF with systolic dysfunction has an EF of ____.

HF with diastolic dysfunction has an EF of ____.

<40%, problem with ejection

>50%, problem with filling

What lab value is associated with HF?

B-type natriuretic peptide

Released by the ventricle when the wall is under stress in attempts to dilate and decrease ventricular wall pressure

Systolic HF is a problem with _____.

S/s?

Tx?

Avoid?

Ejection

Dilated LV, valvular insufficiency, low EF, pulmonary edema, S3, BNP elevated

BBs, ACEIs, diuretics, aldosterone antagonists, positive inotropes

Negative inotropes like CCBs

Note: you can give BBs because they stop long term effects of catecholamines activated when CO is low and lower HR

Diastolic HF is a problem with _______.

S/s?

Tx?

Avoid?

Filling

Ventricular wall hypertrophy, normal ventricular size, normal EF, pulmonary edema, S4, BNP elevated

BBs, ACEIs, CCBs, low dose diuretics, aldosterone antagonists

Positive inotropes, dehydration, tachyarrhythmias

What does the heart look like on a CXR for a patient with systolic vs. diastolic HF?

Systolic = large, dilated heart or normal, PMI shifted to the left

Diastolic = normal size, LV hypertrophy

S/s of RHF

Hepatomegaly

Splenomegaly

Dependent edema

Venous distention

Elevated CVP/JVD

Tricuspid regurgitation

Ab pain

S/s of LHF

Ortho/dys/tachypnea

Hypoxemia

Tachycardia

Crackles

Cough with pink, frothy sputum

Elevated PAOP

Diaphoresis

Anxiety, confusion

AHA Stages of HF

Stage A—High risk; no evidence of dysfunction

Stage B—Heart disorder or structural defect; no symptoms

Stage C—Heart disorder or structural defect, with symptoms (past or present)

Stage D—End-stage cardiac disease, with symptoms despite maximal therapy (inotropic or mechanical support)

NYHA HF Classes

Class I—Ordinary activity does not cause symptoms, although extraordinary activity results in heart failure symptoms

Class II—Comfortable at rest, but ordinary activity results in heart failure symptoms

Class III—Comfortable at rest, but minimal activity causes heart failure symptoms

Class IV—Symptoms of heart failure occur at rest; there is a severe limitation of physical activity

*Class 2-4 eligible for ICD

Systolic dysfunction causes ________ cardiomyopathy, whereas diastolic dysfunction causes __________ cardiomyopathy.

Dilated, hypertrophic

Cardiogenic shock is usually caused by an extreme drop in ____. This results in:

Elevated ________ with associated pulmonary symptoms.

Elevated ______ d/t vasoconstrictive compensatory mechanisms.

Drop in ___ where perfusion is no longer adequate.

SV

PAOP (LV preload)

SVR (LV afterload)

CO

What are some signs of the compensatory stage of cardiogenic shock?

Tachycardia/pnea

Crackles, mild hypoxemia

ABG with respiratory alkalosis or early metabolic acidosis

Anxiety, irritability

Neck vein distention

S3

Cool skin

Low UO

Narrow pulse pressure

What are some signs of the progressive stage of cardiogenic shock?

Hypotension

Worsening tachycardia/pnea

Metabolic acidosis

Worsening crackles and hypoxemia

Clammy, mottled skin

Worsening anxiety

Treatment of cardiogenic shock involves _________ _________ support like norepinephrine, low dose dopamine, and dopamine. You should avoid ___________ ___________ agents like CCBs or BBs. You want to decrease demand on the heart’s pumping by reducing _________ and __________, as well as optimizing oxygenation and ventilation.

Positive inotropic

Negative inotropic

Preload

Afterload

IABP is commonly used in LV HF, cardiogenic shock, and cardiomyopathies. It inflates at the _________ ________ on the a-line waveform at the beginning of _________. It increases coronary artery perfusion and decreases afterload when it deflates.

Dicrotic notch

Diastole

Long term ___________ is needed for mechanical valve replacement, and biological valve replacement requires ____________ therapy.

Anticoagulation

Antiplatelet (aspirin)

What are some signs/symptoms of cardiac tamponade?

Restlessness and agitation

Hypotension

Increased JVD

Muffled heart sounds

Enlarged cardiac silhouette on CXR

What are some changes in vital signs with tamponade?

Equalization of CVP, PAOP, and PA diastolic pressure

Narrowed pulse pressure (like 82/68)

Pulsus paradoxus (drop in >12 mmHg SBP during inspiration)

Which valve is most at risk for rupture d/t trauma?

Aortic valve

Rationale: most anterior in the chest

What are signs of AAAs?

Pulsations in abdominal area

Abdominal or low back pain

NV

Shock

Note: 75% of aneurysms are AAAs

What are signs of thoracic aortic aneurysms?

Sudden tearing, ripping pain in chest that radiates to the shoulders, neck, and back

Cough

Hoarseness

Dysphagia

Dyspnea

Dizziness, difficulty walking and speaking

Widening of mediastinum on CXR

Aneurysms that are < ___ in diameter usually produce no symptoms.

5 cm

Asymptomatic aneurysms require regular ultrasound or ____ scans and are treated with ______ _________.

CT

Beta blockers

An aortic dissection occurs in the __________ _______ or __________ _________.

Ascending aorta

Aortic arch