perfusion 3 - everything else

what is electrocardiogram?

• ECG and EKG

• recording of electrical signals of the heart using electrodes on the skin

what are EKGs diagnostic for?

dysrhythmias, inadequate coronary blood flow, electrolyte disturbances

what is troponin?

• protein found in muscle contractions, released into blood due to myocardial injury

• strong diagnostic factor for acute MI

when may troponin levels increase?

septic shock, renal failure, PE, arterial hypertension without evidence of myocardial necrosis

what are normal troponin levels?

negative

what happens in persistent ischemia?

troponin levels will elevate within 1 hr of injury

how is troponin ordered?

• a “repeating” lab

• q8h x 3

what is coronary artery disease (CAD)?

major blood vessels supplying the heart struggle to send enough oxygen-rich blood

what is stable angina?

• insufficient oxygen supply for myocardial demands

• stable because ischemia is temporary, as the plaque is not fully occluding the vessel and is relieved with rest or antianginal meds

what causes a stable angina?

stenosis and/or vasospasm

what are risk factors for stable angina?

HTN, HLD, smoking, infection, and injury

what are the three acute coronary syndromes?

unstable angina, NSTEMI, and STEMI

what is an unstable angina?

• plaque ruptures or moves away, causing platelets to aggregate on the relocated plaque and vessel is occluded

• can become an MI

what is a NSTEMI

• non-ST-segment elevation MI

• thrombus occludes coronary artery causing an MI

what does the EKG look like for an NSTEMI?

normal rhythm, transient ST elevations, or ST depression

what is a STEMI?

• ST-segment elevation MI

• complete occlusion of blood vessel causing transmural myocardial ischemia

what does an EKG look like for STEMI?

ST elevated

what are clinical manifestations for a stable angina?

• pressure, heaviness, tightness, squeezing across broad area of chest

• mimics indigestion

• SOB, dizziness, fatigue, anxiety, nausea

• radiate from neck and shoulder, down left arm

what are clinical manifestations of an unstable angina?

chest pain triggered by exercise or anything that increases workload of the heart

what are clinical manifestations of an NSTEMI?

• substernal pressure at rest or with minimal exertion

• usually lasts more than 10mins

• may radiate to either arm, neck, or jaw

• may have sweating, SOB, N/V, fainting

what are clinical manifestations of a STEMI?

• intense, severe pain

• “crushing”

• sweating, SOB, irregular heart rhythm, N/V, dizziness, decreased level of consciousness, anxiety

what is the management of CAD regarding prevention?

nutrition, exercise, and smoking cessation

what is the management goal if you have symptomatic CAD?

reduce cardiac ischemia and prevent death

what is the initial treatment for CAD?

• oxygen, nitrates, aspirin

• sometimes morphine

if there is a confirmed occlusion, what is done?

• procedures to restore coronary blood flow

• balloon angioplasty and/or stent

• coronary artery bypass grafting (CABG)

what are types of meds that manage CAD?

antihypertensives, antiplatelets, anticoagulants, statins, low-dose aspirin, and nitrates

what is the therapeutic class of nitroglycerin?

antianginal

what is the pharmacologic class of nitroglycerin?

nitrates

what is the indication of nitroglycerin?

stable angina, unstable angina

what is the MOA for nitroglycerin?

induces smooth muscle relaxation and vasodilation of coronary arteries

what id the route of nitroglycerin?

SL, PO, transdermal patch, topical ointment, and IV

what are side effects of nitroglycerin?

• think widespread vasodilation

• hypotension, reflex tachycardia, flushing, headahce

what are nursing considerations for nitroglycerin?

• monitor BP and HR

• educate → onset on angina, take 0.4 SL q5 minutes up to 3 doses, if not pain relieved, activate emergency services

• educate proper storage in tightly capped dark bottle

• don’t use if hypotensive or taking ED meds

what are examples of fibrinolytics/thrombolytics?

alteplase (t-PA), reteplase, teneceteplase

what is the indication of fibrinolytics/thrombolytics?

• given within 3 hours of onset of STEMI symptoms, can reestablish perfusion to coronary arteries by removing the thrombus obstruction

• acute PE, acute ischemic stroke, acute limb ischemia

what is the MOA of fibrinolytics/thrombolytics?

activate plasminogen to form plasmin, which speeds up lysis of thromboemboli

what is the route of fibrinolytics/thrombolytics?

IV in critical care setting

what are side effects of fibrinolytics/thrombolytics?

bleeding and high risk for hemorrhagic stroke

what are nursing considerations for fibrinolytics/thrombolytics?

• monitor for hemorrhage, particularly stroke

• frequent BP and neuro assessments for 24 hours after given

what is arrhythmia?

parasympathetic and sympathetic not effectively maintaining HR

what is atrial fibrillation?

• irregularly irregular atrial contractions

• most common arrhythmia

• high risk for thrombus → CVA

what is the EKG of an atrial fib?

no p wave and irregular QRS complex

what meds are patients with Afib on?

anticoagulant

what is atrial flutter?

faster atrial contraction rate with fixed or variable ventricular rate

what is an EKG of an atrial flutter?

“sawtooth” pattern, rapid rate

what is ventricular tachycardia?

• electrical signal begins in the ventricles and causes rapid contraction (100+bpm)

• insufficient pumping; less blood pumped to the body

what is ventricular fibrillation?

• chaotic vibrations → ineffective at perfusion

• life threatening and cause death in minutes

what are the shockable rhythms?

ventricular arrhythmias

what are clinical manifestations of arrhythmias?

• asymptomatic → sudden cardiac arrest

• altered heart rate (brady or tachy)

• nonspecific symptoms of low perfusion

what is the goal of managing arrhythmias?

improve perfusion, prevent stroke, and prevent death

how do you manage arrhythmias?

identify the rhythm disturbance and underlying cause (atherosclerosis, STEMI, HF, HTN, etc)

what are nonpharmacologic methods of management for arrhythmias?

• cardioversion, defibrillation, ablation

• implantable cardioverter-defibrillator (ICD), pacemaker

what are pharmacologic methods of management for arrhythmias?

antiarrhythmic medications

what is the therapeutic class of adenosine?

antiarrhythmic

what is the pharmacologic class of adenosine?

class II cardiac autonomic drug

what is the indication of adenosine?

convert supraventricular tachycardia back to normal sinus rhythm

what is the MOA of adenosine?

briefly blocks conduction through the AV node to restore sinus rhythm

what are side effects of adenosine?

headache, dizziness, facial flushing, GI distress

what are adverse effects of adenosine?

proarrhythmia (causes new/worsens the arrhythmia)

what are nursing considerations for adenosine?

• continuous cardiac monitoring: EKG, BP, HR

• given rapidly through IV, may have brief period of asystole after administration

what is the therapeutic class of amiodarone?

antiarrhythmic

what is the pharmacologic class of amiodarone?

class IIIa potassium channel blocker

what are the indications of amiodarone?

life threatening recurrent v-fib or recurrent unstable v-tach

what is the MOA of amiodarone?

blocks K+ channel to prolong action potential in myocardium, decreases AV conduction and sinus node function

what is the route of amiodarone?

IV, oral

what are side effects of amiodarone?

bradycardia, hypotension, skin discoloration

what are adverse effects of amiodarone?

hepatotoxicity, worsening arrhythmia, pulmonary fibrosis, hypo/hyperthyroidism

what are nursing considerations of amiodarone?

• cardiac monitoring: EKG, BP, electrolytes

• monitor liver, lung, and thyroid function

• vesicant → caution with IV administration

what is the therapeutic class of diltiazem hydrochloride?

antiarrhythmic

what is the pharmacologic class of diltiazem hydrochloride?

class IV/CCB

what are the indications of diltiazem hydrochloride?

• angina, afib, a flutter, a tach, supraventricular tachycardia, and HTN

• think rate control

what is the MOA of diltiazem hydrochloride?

blocks calcium ions from entering vascular smooth muscle → vasodilation; slows conduction at AV node → decreases HR

what is the route for diltiazem hydrochloride?

oral, IV

what are side effects for diltiazem hydrochloride?

hypotension, headache, dizziness, constipation

what are adverse effects of diltiazem hydrochloride?

heart failure, pulmonary edema, bradyarrhythmia, hepatotoxicity

what are nursing considerations of diltiazem hydrochloride?

• monitor HR, BP, liver function, renal function

• assess for peripheral edema

what is heart failure?

• progressive syndrome where heart fails to pump adequately

• impaired transport of oxygen

what is the etiology of heart failure?

congenital heart disease, valve disorders, MI or cardiomyopathies, pericardial diseases

what are risk factors of heart failure?

HTN, CAD, DM, obesity, etc

what is heart failure pathophysiology?

• injury/abnormality → decreases CO and increases pressure

• heart adapts to attempt to increase perfusion

• works initially, but there is eventual damage to all organs from poor perfusion

what is ejection fraction?

• amount of blood pumped from ventricles during each contraction

• typically describes LEFT ventricle

what is a healthy heart EF?

50-70%

how is EF measured?

echocardiogram

what is serum B natriuretic peptide?

hormone found in blood in cardiac ventricles

what does it mean when serum B natriuretic peptide is high?

• overstretching of ventricle due to pressure overload

• BNP greater than 100 pg/mL is diagnostic for HF

what is HF with reduced ejection fraction (HFrEF)?

• systolic HF

• left ventricle unable to contract properly and EF less than 40%

what does HFrEF trigger?

increased Na and H2O retention → increased blood volume → congestive heart failure

what is HF with preserved ejection fraction (HFpEF)?

• diastolic HF

• ventricle thick or stiff and has smaller volume capacity, so it doesn’t relax properly

• EF is preserved (70% ejected, but it’s 70% of a less-than-optimal volume)

• amount of blood moving forward is still not enough

what is right sided HF?

• result of LV failure due to volume and pressure overload

• also caused by respiratory conditions of ischemia to that side of the heart

what are forward effects of HF?

• decreases blood to tissues → hypoxia, fatigue, weakness

• dyspnea, SOB

• exercise intolerance

• cold intolerance

• dizziness

what are backup effects of left sided HF?

• dyspnea, orthopnea, cough

• paroxysmal nocturnal dyspnea → increased fluid in alveoli → decreased oxygen diffusion

what are backup effects of right sided failure?

• dependent edema

• hepatomegaly and splenomegaly

• ascites

• distended neck veins, headache

what are lifestyle changes for HF management?

smoking cessation, exercise and weight loss, heart healthy diet, and stress reduction

what medications help HF?

• ACEi or ABRs

• statins

• beta blockers

• diuretics

• sacubitril/valsartan

• digoxin

what is the therapeutic class for sacubitril/valsartan?

drugs for heart failure

what is the pharmacologic class of sacubitril/valsartan?

angiotensin receptor neprilysin inhibitor (ARNI)

what is the indication of sacubitril/valsartan?

HF

what is the MOA of sacubitril/valsartan?

• blocks neprilysin enzyme breakdown and increases availability of natriuretic peptides to produce vasodilation

• causes Na excretion, decreasing BP

what is the route of sacubitril/valsartan?

oral

what are side effects of sacubitril/valsartan?

dizziness, HoTN, fatigue, cough, and impotence