CVP 2.2 - CAD and heart valves

heart disease

what is the leading cause of death n the US

veins

(arteries or veins) have a bigger lumen

• tunica externa

• tunica media

• tunica intima

what are the layers of a vessel? list from outer to inner

intinma

tunica __________ is a single layer of endothelium

media

tunica ___________ allows vessels to stretch and rebound - in the arteries if helps with forward flow and in the veins it helps with storage of excess fluid

• elastic fibers

• collagen fibers

• smooth muscle

what is the tunica media made out of

• loose connective tissue

• elastin

• collagen

what is the tunica externa made out of

tunica externa (vasovasorum are small vessels that supply the walls of the large blood vessel)

which blood vessel layer is the vasovasorum location

tunica media (becasue of the smooth muslce)

which blood vessel layer controls vasoconstriction and vasodilation

atherosclerosis

________________ is progressive hardening and narrowing of medium and large arteries

intima

the tunica ____________ is affected with atherosclerosis

• coronary

• cerebral

• peripheral regions

what 3 locations are common for atherosclerosis

macro (affects the medium and large vessels)

is atherosclerosis a macro or micro vascular disease

1. fatty streak

   1. (LDL moves into vessel → leukocytes → inflammatory response but lumen size and blood flow is fine)

2. plaque progression

   1. (more lipoproteins → lumen starts to decrease in size)

3. plage disruption

   1. (plaque becomes unstable → can result in emboli and thrombus formation)

what is the 3 progression phases of developing atherosclerosis

endothelial (inner layer)

with atherosclerosis, the fatty streak affects the ________ cells in the blood vessel

lipoprotein (LDL… bad cholestrol); inflammatory

with atherosclerosis, the fatty streak is caused by ___________ entry into the vessel, this leads to a __________ response

leukocytes; macrophages

when there is a atherosclerosis fatty streak, extra inflammation happens in the vessel which recruites ____________ cells which later turn into ____________ which get stuck and can lead to blood clots and promote the formation of the atherosclerotic plaques/plaque progression

thrombogenic lipid core

during the plaque formation in atherosclerosis, there is a _______________ beneath the protective fibrous cap that promotes blood clot formation

intima

during the plaque formation in atherosclerosis, smooth muscle migrates from the tunica media to the tunica ___________ which increases collagen synthesis

extracellualr matrix

during the plaque formation in atherosclerosis, metabolism of the ____________ that creates a either stable or unstable fibrous cap (plaque is now more likely to rupture → plaque disruption)

rapid (picture A)

with atherosclerosis, (rapid or slow) occlusion causes myocardial death

slow (picture B - this is why someone can have a 100% occlusion and no symptoms of a MI)

with atherosclerosis, (rapid or slow) occlusion causes collateral formation

• EDUCATION

• diet

• exercise

• meds to control hyperlipidemia (bad cholesterol that builds up in the tunica intima)

what are the 4 ways to medically manage atheroclerosis

men

(men or women) are more likely to develop atherosclerosis

diastole

the coronary arteries are perfused during ventricular (systole or diastole)

ischemic heart disease

_______________ is the imbalance between supply and demand of oxygen

• tissue hypoxemia

• accumulation of waste

what are the two results of ischemic heart disease

• stable angina

on the spectrum of angina pectoris, which is narrowing of the vessel and vasoconstriction - epidose of ischemia

• normal

• stable angina

• unstable angina

• variant angina

• unstable angina

on the spectrum of angina pectoris, which is where the atherosclerotic plaque has been disrupted - vessels always vasoconstricted without medication

• normal

• stable angina

• unstable angina

• variant angina

• variant angina

on the spectrum of angina pectoris, which has no atherosclerosis and intense vasospasm

• normal

• stable angina

• unstable angina

• variant angina

levine; chronic stable angina

when someone places a clenched fist over the sternal region it is called the __________ sign which is a common sign/sx of _____________

“a few minutes” (but less than 5-10min)

how long do the symptoms of a chronic stable angina last

• common locations

  • retrosternal or left precordium - most common

  • chest

  • arms

  • neck

  • lower face

  • upper abdomen

• radiating

  • shoulders

  • inner aspect of arm - usually left arm

where are the 6 common locations of chronic stable angina? which are the most common?

where would one with chronic stable angina feel radiation pain

fixed

when the level of activity to trigger symptoms is relatively constant, it is referred to as ________ threshold angina

variable

when the level of activity to trigger symptoms is dynamic, it is referred to as ________ threshold angina

3-5 min

symptoms of chronic stable angina will usually resolve in ___________

variant

___________ angina is caused by coronary artery spasm

decubitus or resting

____________ angina occurs most often when at rest and frequently occurs at the same time every day

unstable; 2 weeks

new onset angina is considered (stable or unstable) and is defined as having developed for the first time within the last ___________

nocturnal (usually due to inc HR in sleep or in response to underlying heart failure)

____________ angina may awaken a person from sleep with the same sensation experienced with exertion

pre-infarction

______________ angina is defined as lasting over 15 minutes, worsening cardiac ischemia symptoms, and an abrupt change in intensity and/or frequency of symptoms or decreased threshold to onset of sx

post-infarction

______________ angina occurs after MI when residual ischemia triggers episode of pain

organic nitrates

____________ medication for angina pectoris decreases O2 demand by…

• decreasing preload

• increasing O2 supply by…

  • inc coronary perfusion

  • dec coronary vasospasm

beta blockers

____________ medication for angina pectoris decreases O2 demand by…

• decreasing contractility

• decreasing HR

calcium channel blockers

____________ medication for angina pectoris decreases O2 demand by…

• decreasing preload

• decreasing BP

• decreasing contractility

• increasing O2 by…

  • inc coronary perfusion

  • dec coronary vasospasm

ranolazine

____________ medication for angina pectoris decreases O2 demand by…

• decreasing late phase inward sodium current

beta blockers

which medication for angina pectoris can cause bronchoconstriction and can mask hypoglycemia sx

plaque disruption; intracoronary thrombus

acute coronary syndrome is caused by the _____________ phase of atherosclerosis and the formation of ______________

partially; completely

acute coronary syndrome can either be ___________ or ___________ occlusive thrombus

partially

an acute coronary syndrome that has (partially or completely) occlusive thrombus is caused by unstable angina or non-ST segment elevation MI

completely

an acute coronary syndrome that has (partially or completely) occlusive thrombus is caused by ST segment elevation MI

both (they both result in necrosis)

with acute coronary syndrome, does a non-ST segment elevation MI or ST-segment elevation MI result in necrosis

no (but it is a high risk for MI)

can an unstable angina cause necrosis

myocyte necrosis

_____________ is secondary to prolonged ischemia

20-24

ischemia that lasts ______-______ minutes leads to irreversible cell injury

transmural

a _____________ infarct is necrosis that spans to the myocardial wall

subendocardial

a _______________ infarct is necrosis of the inner layers of myocardium

transmural (transmural has much more wall stiffness, outer walls with subendo can still produce force)

the (transmural or subendocardial) infarct produces less contractile force

MI

prompt medical treatment of an unstable angina with acute coronary syndrome can prevent __________

• do not

• rapid

• nitroglycerine

the main clinical presentations that acute MI of acute coronary syndrome is:

• symptoms (do or do not) change with rest

• (rapid or insidious) onset of symptoms

• little effect from use of ________________

ST segment; T

the EKG of an acute coronary syndrome - acute MI will present with the ________ wave depressed and the _______ wave inverted

<14

the normal level of troponins is __________ng/L

NOOOOOOO (indicates cell death and/or heart damage)

can you still do PT with a patient that has increasing levels of troponin

3-5

the normal level of creatine kinase is _____-_____%

nope

can you still do PT with a patient that has increasing levels of creatine kinase

• anti-ischemic (beta-blockers, nitrates, Ca channel antagonists)

• antithrombotic (antiplatelet, anticoagulant)

a pt with acute coronary syndrome should be on ___________ medication with ___________ therapy

• arrhythmias

• heart failure

• cardiogenic shock

what are the 3 main complications of acute coronary syndrome - acute MI for PT

percutaneous coronary intervention (PCI)

the surgical treatment for acute coronary syndrome is ______________

• radial

• femoral

what are the 2 locations for access for percutaneous coronary intervention surgery (treatment for acute coronary syndrome)

but you’re killing it

SO MANY CARDS

4-6

after a pt has percutaneous coronary intervention, PT should ambulate within ______-______ hours

• internal mammary artery

• saphenous vein

which two vessels can be used for a coronary artery bypass treatment

oICU

o Continuous telemetry

o Ventilator vs. Supplemental O2

o Arterial line

o Central venous catheter (R IJ)

o Epicardial pacemaker

oChest tube

mental note - CABG patients have alllllllllllll the leads

epicardial

the _____________ pacemaker is a “temporary pacemaker”

yes (except immediately after wire removal ~2-6 hours, **note it is a heavy device so it must be secured)

can a pt with an epicardial pacemaker do PT

post-op bra

what is a protective device for a female post sternotomy

annulus

the __________ is the base of each valve

chordae tendineae

the ____________ tethers AV valves to papillary muscles

• dense connective tissue

• fibrocartilage

what is the cardiac skeleton made of

papillary muscles

______________ contract during V systole and pull on chordae and prevent valve from opening during systole

tricuspid; pulmonic

the _________ and _________ valves are on the right side of the heart

mitral; aortic

the __________ and _________ valves are on the left side

stenosis

___________ is a valve dysfunction where the valve is narrowed or stiff preventing full opening so there needs to be increased pressure to move blood out of chamber

regurgitation

___________ is a valve dysfunction where the valve doesn’t close all the way so some blood flows backward during systole and reduces ventricular output/ejection fraction

false

T/F: males are more likely to have a valve disease

left atria

with mitral valve stenosis, the _________ chamber of heart is unable to completely empty

• rheumatic fever

• calcification of annulus

• infective endocarditis

• congenital stenosis

what are the 4 etiologies of mitral valve stenosis

increase; decrease

mitral valve stenosis (increase or decrease) pressure in the LA and (increases or decreases) pressure in the LV

false (decrease CO because less flow to the LV → dec stroke volume → dec CO)

T/F: mitral valve stenosis increases cardiac output

forward (decrease vol → dec SV → dec CO)

the effects of (forward or back) flow of mitral valve stenosis is defined as decreased volume in the left ventricle

back

the effects of (forward or back) flow of mitral valve stenosis is defines as increased volume and pressure in the left atria

stays the same (normal)

during forward flow mitral valve stenosis, the pressure in the LV __________

back (causes increased volume and pressure)

the (forward or back) flow of mitral valve stenosis is associated with right sided heart failure, LA enlargement, A-fib, and increased pulmonary pressure

• dyspnea

• reduced exercise capacity

• atrial fibrillation with activity/stress

• increased HR and/or CO induce increased symptoms (caused by fever, anemia, hyperthyroidism, pregnancy, emotional stress, sexual intercourse, etc.)

what are the 4 early signs and sx of mitral valve stenosis

• dyspnea AT REST

• increased fatigue

• pulmonary congestion (orthopnea, paroxysmal nocturnal dyspnea)

• R sided heart failure

• hoarseness (compression of laryngeal nerve by enlarged pulmonary artery or left atria)

what are the 5 late signs and sx of mitral valve stenosis

• mitral

• S1

• pulmonary congestions (remember this is a late sign/sx)

• right

exam results of mitral valve stenosis:

• diastolic heart murmur loudest over area of ________ valve

• change of volume in (S1 or S2)

• lung auscultation _______________

• ______ sided heart failure s/sx

• endocardiogram (thickened MV leaflets, possible atrial thrombus, left atrial enlargement)

• EKG (possible A fib, increase atrial size, and pulmonary hypertension)

• exercise testing with doppler assessment

• cardiac catheterization (measures heart pressures)

primary study = endocardiogram

what the 4 diagnostic studies for mitral valve stenosis? which is the primary study?

• manage vascular congestion (reduce salt, diuretic medication)

• increase diastolic filling time (slow HR: beta blockers, Ca channel blockers)

• prevent thromboembolism (anticoagulation therapy)

• surgical management

what are 4 treatment options for mitral valve stenosis

• cordea tendinaea rupture

• papillary muscle dysfunction or rupture

• left ventricular enlargement or dysfunction

• annular calcification

• diseased leaflets

what are the 5 etiologies of mitral valve regurgitation

LV; LA

mitral valve regurgitation is where a portion of the _________ heart chamber stroke volume is ejected backward into the _________ heart chamber