Perfusion Kruegar

heart failure diagnostics

•History and Physical (they will say my pants are tight. I had to sleep on the lazyboy the past couple of days. I have been SOB.)
•Transthoracic ECHO
•Chest X-ray ( cardiomegaly, cardiac effusions)
•ECG
•Labs (BNP (good marker of HF, know baseline), CMP (lytes/ creatine), troponin, CBC (H and H low bc diluted), Urine?? ( none bc lack of perfusion), Lipid, A1C, thyroid
•MUGA (measure ejection fraction) , nuclear imaging, Angio

PAD diagnostics

•Pulses (diminished in feet) Bruits (femoral artery), Inspection (dependent ruber, arterial wound)
•Ankle-Brachial Index (use doppler, ankle bp divided by brachial artery)
•Treadmill Test
•Ultrasound
•CT, MRI
•Arteriography.Angio

Coronary artery disease/ ACS
Peripheral Arterial Disease/ PVD
Congestive Heart Failure

3 disease processes that alter perfusion

perfusion

refers to the circulation of blood through the vascular bed of tissue.

risks of heart disease

-Family hx of CVD, DM, chronic renal failure, HTN, dyslipidemia,

-nonmodifiable: age, sex, ethnic background

-modifiable: weight, dietary habits, alcohol consumption, smoking

big risks for heart disease

diabetes, hypertension, hyperlipidemia

high glucose and triglycerides

why diabetes is big risk for heart disease

heart works hard and muscle thickens (limits squeeze)

why hypertension is big risk of heart disease?

plaque buildup

why hyperlipidemia big risk of heart disease?

heart disease assessment

Cool and clammy? Dyspneic? Working hard to breathe? Diaphoretic? Look uncomfortable? Cyanosis? When put EKG patch and lay flat, are they orthopneic? Ascites? JVD? Anxious? (MI possible). Stethoscope- listen to 5 points/locations. Murmur? Rubs? Gallops? S3 S4? Heaves and Lifts? (usually CHF) Bruits? Crackles? Decreased breath sounds? Good pulse assessments. Good health history. History at home. What brought to hospital?

heart disease diagnostics

Labs:
•CBC (H and H, WBC, glucose)
•CMP (lytes, BUN/ creatine)
•Lipid Panel (risk factor for heart disease)
•NT-Pro BNP/BNP (elevated for HF/ renal failure)
•CK/Troponin (timing) (elevated renal disease too)
•Blood glucose levels (for diabetes)
•Coagulation studies (cardiac patients need antiplatelets/ anticoagulants--so get PTT, INR)

•EKG
•TTE/TEE
•Chest X-ray (cardiomegaly/ pulmonary effusion)
•Cardiac Stress Testing (use meds for hospital)
•Angiography (gold standard for MI treatment, PAD)
•CT

EKG

what is the gold standard diagnosis of MI?

coronary (or ischemic heart disease/myopathy) artery disease

most common cause of heart disease

-obstructive (active obstruction)
-nonobstructive (reduced flow vascular system)
-plaque (atherosclerosis)

2 types of CAD? Cause?

CAD platelet rupture

platelets aggregate and coagulation cascade activated leading to thrombus

unstable angina, active MI, sudden cardiac death

How is plaque rupture presented in ACS? ___, ____, ___

unstable, stable

2 types of angina (chest pain) in CAD

stable angina

-exercise and get chest pain but rest and pain goes away
-exercise and get chest pain but eat nitro tabs and pain goes away

unstable angina

exercise and take nitro and rest but has chest pain

infarction (cell death)

risk of unstable angina

restore blood flow (time is tissue)

What is your priority intervention for STEMI, NSTEMI?

females pre-menopause, estrogen is cardioprotective, males

population low risk of CAD and MI? why? population high risk of CAD?

-stable angina, unstable angina
-NSTEMI, STEMI

Types of ACS:
ACS with no positive troponin? ACS with positive troponin?

classic MI symptoms

angina that radiates to left arm, back, neck, and jaw

common MI symptoms

diaphoresis, anxiety, dyspnea, dyspepsia, N/V,

diabetic patients, females, geriatric patients

Who presents S/S atypically in MI?

females

Who presents S/S atypically in MI?
____
-really tired, N/V, no classic back pain, jaw pain, etc.

diabetic patients

Who presents S/S atypically in MI?
____
- do not feel chest pain

geriatric patients

Who presents S/S atypically MI?
____
-may not have chest pain

hypotension, bradycardia

Right sided MI S/S

MI treatnent

•Pain better/worse? Hurt with movement? (cardiac pain) Hurt with palpation? (musculoskeletal pain)
Heart and lung assessment sob? dizzy? lightheaded? palpitations?
EKG (Gold Standard diagnosis)
MONA--o2, nitro (vasodilate, lower bp, side effect: HA), morphine (pain relief, vasodilates), aspirin (tell to chew)
IV (heparin)

STEMI

active occlusion, active necrosis, huge emergency. elevated troponin. ST elevation

Intervention:
MONA, heparin drip, antiplatelet- help clots not get bigger. Send to cath lab asap.

NSTEMI

get plague rupture or thrombus and occluded vessel but not active necrosis. No st elevation. ST changes: Flipped T waves. Flatten T waves. Elev troponin.

Can sit on heparin drip and no cath lab for 1-2 days

angioplasty (PTCA or left heart cath)

What is the gold standard treatment of MI?

Fibrinolytic (PCI)

-goes in thru the groin or radial artery or femoral artery.
- negative of ___: you can't have GI bleed, no certain meds, no history of stroke, bp must be in range, must catch chest pain within 6 hours of pain

-Thread catheter in heart. Shoot dye and go under scope to see perfusion. And given clot busting drug?

90 minutes
During STEMI, it takes 90 minutes to take to cath lab to catheterize and fix perfusion

What is the door to balloon time to reperfuse ACS? Meaning?

>60-70%

What is the percentage of ACS blockage that is acceptable for intervention?

6 hours

In the cath lab, if we REPERFUSE within___ hours (PCI or fibrinolytic), there significantly higher survival

6 hours, 2 hours, 2 hours

Post cath care:
+/- closure device--
Sometimes patient will come back with a closure device. Impact bedrest
IF no per close, patient will be on bedrest for ___ hrs and ___ hrs flat on bed. And if fem site, don't move leg. Radial site- ___hours bedrest and get out of bed.

distal, bruit, hold pressure

Post Cath Care:
Cath site (site and pulses) - check ___ pulses. Listen for___. Hematoma? Head can increase little at time. If hematoma, ___

reocclude, dysrhythmias

Post cath care:
VS, chest pain assessment (bc patients can ___vessel), cardiac monitoring (high risk for ___)

nephrotoxic

Post cath care:
Kidney- dye can be ___. Hydrate. Check output. Check kidney labs

CABG

If triple vessel disease (of right coronary artery, left circumflex branch, Left anterior descending branch), then patient may be a candidate for ___

where vein is harvested from other part of body, usually the leg, and grafted onto the blocked vessel creating alternate blood channel

detect damage, necrosis, ventricular changes, heart failure (risk for arrhythmia)

Why might a TTE be needed when someone has had a MI and has a stent placed from cath lab?

cardiac rehab

for STEMI and NSTEMI diagnosed patients -they go to outpatient setting. Walk on threadmill. Hook to 5 lead heart monitor. Look for no ST changes, no chest pain

Site- bleeding/ infections signs
Smoking Cessation
Medication management

what would you teach to ACS patients after cath lab (post-stent) ?

•ACE/ARB (hypertension management, ventricular remodel)
•Statin (for lipid control)
•Antiplatelet (aspirin)
• BB
•Nitroglycerin

What kinds of meds can you teach to ACS patients after cath lab (post-stent)? 6 types

sublingual med, 5 minutes, 3 doses, call 911 (because that is unstable angina)

What do you teach patients about nitroglycerin after cath lab for ACS regarding route? Take one every ___minutes ? Total __doses? What to do on dose 2?

PAD (PVD)

•Progressive and chronic condition where blood flow is obstructed through large peripheral arteries causing partial or total arterial occlusion.

•Lack of perfusion = ischemia, necrosis, cell death
•Atherosclerosis is main contributor to___

RF (same as atherosclerosis):
•Smoking, HTN, DM, dyslipidemia, sedentary lifestyle, obesity, ineffective stress management
•Nonmodifiable: Age, gender, ethnicity, family history

heart

If you have plaque in the legs, you have plaque in the ___, vice versa

What is the ankle brachial index # for PAD?

>1.3

ankle brachial index# for stiff, no blockage?

0-0.4

ankle brachial index # for severe PAD?

PAD symptoms, intermittent claudication

•Atypical Leg Pain (limited or painful joints, cold/ulcerated extremities, painful stretching.
•_____: pain with exercise alleviated with rest
•Limited activity tolerance
•Limb ischemia

stages of PAD

1: Asymptomatic
2: Claudication
3: Rest Pain
4: Necrosis or gangrene

PAD treatment

•Symptom Relief: don't cross legs
•Modifiable RF:
•Meds: Lipid, platelet inhibitors, Vasodilators, Antihypertensive
•Education: meds, lifestyle, positioning, foot inspections,
•Blood pressure bilaterally, pulses, pain

PAD

warning signs of ___ (6Ps)
pain, pallor, pulselessness, paresthesia, paralysis, poichothermia (cold limb)

heart failure

•Progressive disease characterized by myocardial cell dysfunction resulting in the inability of the heart to pump enough cardiac output to meet demands of body.
•Compensatory mechanisms are activated in response to decreased stroke volume and cardiac output.
•SNS activated = epi, Norepinephrine = increased HR, myocardial contractility, vasoconstriction = remodeling = hypertrophy and stiffening
•RAAS activated
•BNP (stretch)

heart failure risk factors

•CAD (patient with MI might have___) , HTN (hypertrophy/stiffness), DM, Metabolic Syndrome, Obesity, Smoking, High Sodium
•Valvular disease; cardiomyopathy; Infectious and inflammatory heart disorders; dysrhythmias (afib); cardiotoxic substances (chemotherapy, illicit drugs- cocaine)

ejection fraction

how is heart failure classified?

55-60%

normal ejection fraction of heart?

ejection fraction of HFrEF?Risk for heart dysrhythmia types? Intervention?

HFpEF

HFrEF or HFpEF?
more common especially with obesity, sleep apnea

right sided heart failure

-JVD
-Dependent edema
-Hepatomegaly
-Ascites

left sided heart failure

-SOB (Dyspnea, orthopnea)
-Crackles (risk for pulmonary edema)
-Pale
-weak pulses
- cool extremities
-slow cap refill
-Fatigue, weakness

hypotensive

heart failure patients are usually ___(hypertensive/ hypotensive)?

2-3, 5, 10, 10

Heart failure patients and weight control:
If gain ___ lbs in day or ___ lbs in week, need to call doctor. If gain less than ___ lbs, you can be kept out of the hospital. If gain more than ___lbs, you need to go to the hospital bc oral diuretics don't help and will need IV diuretics

heart failure treatment

•Medication Management (GDMT- guideline directed medical treatment)- teach med adherence, teach fluid volume management (usually 2000ml restriction), weight management
•Risk Factors--low Na
•Fluid Balance (hospital vs. Home)
•Activity as tolerated esp with sob and chest pain
•Advanced Therapies-transplant, ionotrophs
•Palliative

chronic heart failure, acute heart failure

chronic heart failure/ acute heart failure?
____
outpatient therapy- daily weight, diet control
___
hospital, overload with fluid, SOB, aggressive diuresis. Can quickly go to pulmonary edema with left HF. Need to treat fast. Oxygen status. Intubate and vasodilate needed. Nitro and lasik and oxygen. Maybe morphine