Test 4

Aneurysm

Weakening of an artery, Wall of artery weakens and stretches, risk of clot formation

Where can an artery occur?

abdominal aorta, thoracic aorta, cerebral femoral, and popliteal arteries

Aneurysms can...

rupture - exsanguination (bleeding), hemorrhage

Risk factors of Aneurysms

congenital defects, atherosclerosis, hypertension, dyslipidemia, diabetes mellitus, tobacco, advanced age, trauma

True aneurysms

affect all 3 vessel layers

Saccular aneurysm

bulge on the side

fusiform aneursym

occurs the entire circumference

false aneurysms

does not affect all 3 layers of the vessel

dissecting aneurysms

occurs in inner layer

aortic aneurysm

involve any part of the aorta, look for pulsating mass, most dreaded complication is rupture, risk increases with size of aneurysm, dissecting aneurysm is acute, life threatening

signs and symptoms of aneurysms

depend on location and size, may be asymptomatic, may include: pulsating mass, pain, respiratory difficulty, and neurologic decline

diagnosis of aneurysms

exam, x-ray, echocardiogram, CT, MRI, arteriograph

Tx of aneurysms

eliminating or managing cause and surgery

Risk factors of hypertension

advancing age, ethnicity, family history, being overweight or obese, physical inactive, tobacco use, high-sodium diet, low-potassium diet, high vitamin D intake, excessive alc. intake, stress and other chronic conditions

hypertension

prolonged elevation in bp, excessive cardiac workload due to increased afterload and vasoconstriction

sign & symptoms of hypertension

fatigue, HA, malaise, and dizziness; early detection and management is essential to prevent complications

complications of hypertension

atherosclerosis, aneurysms, heart failure, stroke, hypertensive crisis, renal damage, vision loss, metabolic, syndrome, memory problems

lifestyle modification has been shown to reduce BP

wt reduction, regular exercise, reduce salt, smoking cessation, reduce alc

Primary HTN

most common form, develops gradually over t

secondary HTN

tends to be more sudden & severe
causes: renal disease, adrenal gland tumors, certain congenital heart defects, certain meds, illegal drugs

Hypertensive Crisis/Malignant HTN

acclerated or severe form
may not respond as well to tx
situations in which markedly elevated BP is accompanied by progressive or impending target-organ damage
associated w/ secondary HTN
diastolic BP>120
severe HTN= SBP>180/DBP>110
hypertensive urgency= DBP>110 and HA or dyspnea
hypertensive emergency = DBP>120 and rapidly progressing damage and symptoms

Pregnancy-induced hypertension

S/Sx: high blood pressure, proteinuria, edema
Risk factors: history of pregnancy-induced hypertension, renal disease, diabetes mellitus, multiple fetuses, and maternal age less than 20 years or greater than 40 years
May cause seizures, miscarriages, poor fetal development, and placental abruption
TX: bed rest and magnesium sulfate

Pheochromocytoma

Tumor of chromaffin tissue that contain sympathetic nerve cells
that stain with chromium salts.
Most commonly in adrenal medulla
Can cause serious hypertension
Tumor cells secrete epinephrine and norepinephrine.
Hypertension is from massive release of catecholamines.
Periodic episodes of HEADACHE, excessive sweating, palpitations,
nervousness, tremor, pallor, weakness, fatigue
May have sustained or intermittent HTN.

Coarctation of Aorta

Narrowing of the aorta.
• Results in increase in systolic BP and blood flow to upper body; Blood pressure in lower extremities may be normal or low.
• Need to take BP in both arms and one leg!
• Maintenance of blood pressure to lower body probably a result of
renin-angiotensin-aldosterone system activated by decreased renal blood flow.
TX: surgical repair or balloon angioplasty

Oral Contraceptives

• Most common cause of secondary hypertension in young women.
• Take blood pressure regularly.
• May increase risk of long-term development of hypertension. • Complications usually in >35 and smokers.

Target organ damage

Typically asymptomatic
• Problems usually associated with kidneys, heart, eyes, blood vessels.
• Risk of atherosclerosis
• Increased workload on the heart
• Chronic HTN leads to kidney problems
• Dementia and other cognitive problems more common.

orthostatic hypotension

• Abnormal drop upon standing
• Baroreceptors in thorax and carotid sinus initiate reflex constriction of veins and arteries
• AKA postural hypotension.
• Causes: Reduced blood volume, medications, aging, bedrest and immobility, and autonomic nervous system disorders

varicose veins

• Engorged veins resulting from valve incompetency
• Most common in the legs
• May also occur as esophageal varices and hemorrhoids
• Can cause stasis pigmentation, subcutaneous induration, dermatitis, and thrombophlebitis
• Risk factors: genetic predisposition, pregnancy, obesity, prolonged sitting or standing, alcohol abuse and liver disorders (esophageal varices), and constipation (hemorrhoids)

S/Sx of Veins

–Pedal edema
–Fatigue
–Aching in the legs
–Shiny, pigmented, hairless skin on the legs and feet
–Skin ulcer formation
-Irregular, purplish, bulging veins

Dx & Tx of Varicose Veins

exam, Doppler ultrasound, and venogram

elevate affected leg, compression stockings, avoid prolonged standing or sitting, exercise, sclerotherapy(treat bv malformations), and surgical removal

venous thrombosis

Stationary blood clot
• Virchow’s Triad – endothelial injury, sluggish blood flow, and increased viscosity
• Emboli – traveling body
–Maybe a thrombus, air, fat, tissue, bacteria, amniotic fluid, tumor cells, and foreign substances
–Can become lodged in places like the lungs, brain, and heart

S/sx, DX of venous thrombosis

Depends on location

Arteriography, ultrasound, echocardigram, MRI

Prevention of Venous Thrombosis

increasing mobility, hydration, antiembolism hose,
sequential compression devices, antiplatelet agents, and
anticoagulants

Tx of Venous Thrombosis

thromblytic agents and embolectomy

D/o that affect whole heart

Coronary Artery Disease, Pericardial Disorders, Myocardial Diseases

Coronary Artery disease

Atherosclerotic changes of the coronary arteries, impairs myocardial tissue perfusion, angina (stable & unstable), infarction,
causes are arthrosclerosis, vasospasms, thrombus blood clots and cardiomyopathy

Angina

Intermittent chest pain resulting from myocardium ischemia

Stable angina

Goes away with the demand reduction while doing some thing

Unstable angina

increased intensity or frequency, does not go away with the demand reduction, or occurs at rest

Infarction

Necrotic damage to myocardium

Complications of coronary artery disease

Myocardial infarction, heart failure, dysrhythmias, and sudden death

Signs and symptoms of coronary artery disease

Angina, indigestion like sensation, nausea, vomiting, clammy extremities, diaphoresis, and fatigue

Diagnosis of coronary artery

History, exam, contributing factors, stress test, echocardiogram, ECG

Treatment of coronary artery disease

Similar to dyslipidemia/atherosclerosis but add meds to help reduce workload on the heart and manage blood pressure and dysrhythmias and O2

Acute coronary syndrome

ECG changes and serum cardiac markers

Acute coronary syndrome ECG changes

T-wave inversion, ST segment depression or elevation, abnormal Q wave, T wave and ST segment also known as ventricular repolarization are usually the first involved in myocardial ischemia and injury

Acute coronary syndrome serum cardiac markers

Proteins released from the necrotic heart cells like myoglobin, creatine kinase, troponin

Acute myocardial infarction

Death of the heart muscle, coronary artery blood flow is blocked due to atherosclerosis, thrombus, or vasospasms, risk factors are the same as those for atherosclerosis

Signs and symptoms of acute MI

Some asymptomatic - “silent” MI, includes angina, fatigue, N/V, SOB, sweating, indigestion, elevation in cardiac markers, EKG changes, neck/ear pain and women may present with different symptoms in men

How is chest pain in acute myocardial infarction

Severe, crushing, constrictive or like heartburn

How is the sympathetic nervous system response in acute myocardial infarction

GI distress, nausea, vomiting, tachycardia, vasoconstriction, anxiety, restlessness, feeling of impending doom

Hypotension and shock in acute myocardial infarction

Weakness in arms and legs

Diagnosis of acute MI

Exam, ECG, cardiac markers, stress testing, nuclear imaging and angiography

Treatment of acute MI

Treatment varies depending on timing of treatment, need to reestablish blood flow within 20 to 40 minutes, I want to limit the formation of fibrous scar tissue

Immediately MONA in acute myocardial infarction

Pain management (MORPHINE)
Increase O2 (OXYGEN)
Open up vessels (NITRATE)
Keep platelets from blocking (ASPIRIN)

What else can you administer in acute MI

Thrombolytics which are clot busters

Post MI

Similar to those for atherosclerosis

Complications of acute MI

Heart failure, dysrhythmias, cardiogenic shock, pericarditis, thromboemboli/thrombosis, rupture of the heart, death, ventricular aneurysms

Chronic ischemic heart disease

Imbalance in blood supply and the heart demands for oxygen
When there is less blood… Atherosclerosis, vasospasm, thrombosis
When there is higher oxygen demand… Stress, exercise, cold

Chronic ischemic heart disease – chronic stable angina

Pain when hearts oxygen demand increases

Chronic ischemic heart disease – variant (vasospastic) angina

Pain when coronary arteries spasm

Chronic ischemic heart disease - Silent myocardial ischemia

Myocardial ischemia without pain

Ischemic heart disease is characterized by…

Stable angina, which is associated with plaques that are fixed obstructions

Unstable angina is characterized by…

Plaques with platelets that to them (these are likely to form a thrombus) they cause a range of coronary artery syndromes

Endocardial structures

Lining the heart can cause heart failure

If the AV valves leading into the into the ventricles do not work (mitral or tricuspid) can cause

Heart failure

If the semilunar valves leading out of the ventricles do not work (aortic or pulmonary) problems it can cause

Heart failures

Infective endocarditis

Formally called bacterial endocarditis, commonly caused by staphylococcus, but also streptococcus and enterococci are common, vegetation forms on internal structures and creates small thrombi, micro emboli occur as they are dislodged resulting in micro hemorrhages

Risk Factors of infective endocarditis

IV drug use, valvular disorders, prosthetic heart valves, rheumatic heart disease, coarctation of the aorta, congenital heart defects and Marfan syndrome

Signs and symptoms of infective endocarditis

Flu like symptoms, embolization, heart murmur, petechiae, splinter hemorrhages under the nails like glass, hematuria and Osler‘s nodes

Diagnosis of infective endocarditis

Exam, blood cultures, CBC, urinalysis, serum rheumatoid factor, erythrocytes sedmentation rate, ECG, echocardiogram

Treatment of infective endocarditis

Identify cause, anti-infective meds, bed rest, oxygen therapy, antipyretics, surgical valve repair, and prosthetic valve replacement

Rheumatic heart disease (endocardial d/o)

Immune mediated, multi system inflammatory disease, occurs at a few weeks after group a beta hemolytic streptococcal pharyngitis, inflammation of myocardium, pericardium and heart valves, chronic valvular dysfunction biggest consequence, may have persistent deformity of heart valves from scar tissue (vegetations)

Valvular heart disease

Disrupt blood flow through the heart in any of the four valves, stenosis or regurgitation can occur

stenosis in valvular heart disease

Narrowing, less blood flow can flow through the valve, causes decreased cardiac output, increase cardiac workload, and hypertrophy

Regurgitation in valvular heart disease

Insufficient closure, blood flows in both directions to the valve, cause decreased cardiac output, increase cardiac workload, hypertrophy and dilation

Causes of valvular disorders

Congenital defects, infective endocarditis, rheumatic fever, MI, cardiomyopathy, and heart failure

Signs and symptoms of Valvular disorders

Depends on the valve involved, reflect alteration in blood flow through the heart, may cause signs and symptoms of left-sided or right sided heart failure

Diagnosis of valvular disorders

Exam, heart catheterization, chest x-ray, echocardiogram, MRI, ECG

Treatment of valvular disorders

Diuretics, anti-dysrhythmics, vasodilators, angiotensin converting enzyme inhibitors and beta adrenergic blockers (BP meds), anticoagulants, oxygen therapy, low sodium diet, surgical valve repair and prosthetic valve replacement

Mitral valve disorders

Mitral valve stenosis, mitral valve regurgitation, mitral valve prolapse

Aortic valve disorders

Aortic valve stenosis, aortic valve regurgitation

Mitral valve regurgitation

Mitral valve does not close as it should, portion of the stroke volume (amt of blood ejected by the ventricle) leaks back into the left atrium, decreases the amount of blood that is ejected during that beat (SV), often from rheumatic heart disease

MItral valve prolapse

Seen more in women, may be familial
mucous degeneration of the mitral leaflets, may or may not cause regurgitation
most asymptomatic, but most may have prolonged chest pain, dyspnea, fatigue, anxiety, palpitations and lightheadedness
characterized by spectrum of findings when you listen with a stethoscope
stop stimulants like caffeine, nicotine, alcohol to control symptoms

Identifying Defective Leaflets

The blood going through the valve makes a noise which are called heart murmurs

You can identify heart murmurs by

Where they are which valve are they near?, How they sound high or low pitched?, When they happen systole or diastole?

If a valve is stenotic,

You will hear a murmur of blood shooting through the narrow opening when the valve is open

If a valve is reguritant,

You will hear a murmur of blood leaking back through when the valve should be closed

Acute pericarditis

Inflammation of the pericardium causes: pain, exudate, ECG changes

How is the exudate in acute pericarditis

Serous -> pericardial effusion, cardiac tamponade
Fibrous -> friction rub, adhesions

Cardiac tamponade

Rapid accumulation of accident compresses the heart

Signs and symptoms of pericarditis

Pericardial friction rub, sharp, sudden, severe chest pain that increases with deep inspiration and decreases when sitting up and leaning forward, dyspnea, tachycardia, edema, flu like symptoms (think inflammation)

Pericardial friction rub

Grating sound heard when breath is held

Diagnosis of pericarditis

History, exam, complete blood count, ECG, chest x-ray, echocardiogram, CT, MRI

Treatment of pericarditis

Identify and resolve the underlying cause, NSAIDs, meds for inflammation, pain meds, bed rest, oxygen therapy, pericardiocentesis, and pericardiectomy

Pericardial effusion

Accumulation of fluid in the pericardial cavity, usually result of infectious or inflammatory process including pericarditis, may also develop with neoplasm, cardiac surgery, and trauma, it compresses the chambers of the heart, if small amount may not be symptomatic but if rapid or large rises intra cardiac pressures, echocardiogram can detect

Pericardial effusion cardiac tamponade

Cardiac compression from excessive fluid accumulation, life-threatening

Signs and symptoms of cardiac tamponade

Falling arterial pressures, rising venous pressures, narrowing pulse pressure, and muffled heart sounds

Complications of cardiac tamponade

Heart failure, shock, death

Cardiac tamponade and pulses paradoxus

On inhaling, the right ventricle fills with extra blood because the heart cannot fully expand when the right ventricle is overfilled, the left ventricle is compressed and cannot accept much blood on the next heartbeat, The left ventricle does not send out much blood: systolic blood blood pressure drops