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CCRN cardiovascular barrons notes

  • For normal heart sounds, it is essential to assess the S1 and S2 sounds, which indicate the closing of the heart valves and provide insight into the cardiac cycle. what is the S1 sound? S1 sound, also known as the "lub," occurs when the mitral and tricuspid valves close at the beginning of ventricular contraction, marking the start of systole. loudest at the apex of the heart mid clavicular 5th intercostal space

  • for normal heart sounds what is S2 heart sound? The S2 sound, referred to as the "dub," occurs when the aortic and pulmonic valves close at the end of ventricular contraction, signaling the start of diastole. loudest at the base of the heart right sternal boarder 2nd intercostal space

  • what are Abnormal heart sounds? Abnormal heart sounds, also known as adventitious sounds, may indicate underlying cardiac conditions and can be classified into several categories, including murmurs, gallops, and rubs, each providing important diagnostic information regarding cardiac function and potential pathologies.

  • what are Murmurs? These are abnormal sounds caused by turbulent blood flow, often associated with valve abnormalities or congenital heart defects.

  • what are Gallops? These sounds can indicate heart failure or volume overload, characterized by the presence of an S3 or S4 sound in addition to the normal S1 and S2.

  • what are Rubs? Pericardial friction rubs are indicative of inflammation of the pericardium and can be heard during the cardiac cycle.

  • What is the S3 heart sound? The S3 heart sound, often referred to as a "ventricular gallop," “Kentucky sound” is a low-frequency sound that occurs during the rapid filling phase of the ventricles, typically heard just after the S2 sound. It is commonly associated with heart failure, volume overload, or conditions such as mitral regurgitation pulmonary hypertension. Cor pulmonale, mitral, aortic, tricuspid insufficiency heard best with bell of stethoscope at the apex

  • What is the S4 heart sound? The S4 heart sound, also known as an "atrial gallop" or "Tennessee sound," is a low-frequency sound that occurs just before the S1 sound, during the atrial contraction phase. It is typically associated with conditions such as left ventricular hypertrophy, hypertension, or ischemic heart disease, and indicates a stiff or hypertrophied ventricle, often heard best at the apex with the bell of the stethoscope. associated with myocardial ischemia, infarction, hypertension, aortic stenosis, ventricular hypertrophy

  • Diastolic blood pressure is an indirect measurement of ? systemic vascular resistance (SVR)

  • Coronary arteries are perfused during which phase of the heart? diastole

  • Which is longer, systole or diastole? Diastole is one-third longer than systole, needs time for filling.

  • When are coronary arteries perfused, during systole or diastole? Diastole

  • Why do the cardiac output and blood pressure drop with extreme tachyarrhythmias? No time for filling, therefore less output.

  • name me causes of valvular heart disease ? Coronary artery disease, ischemia, and acute MI, Dilated cardiomyopathy , Degeneration, Bicuspid aortic valve; genetic, Rheumatic fever Infection, Connective tissue diseases

  • Murmurs of INSUFFICIENCY (regurgitation) occur when? the valve is closed.

  • Acute or chronic Murmurs of STENOSIS occur when? the valve is open.

  • What is associated with pain on deep inspiration? pericardial friction rub

  • what is pulse pressure? systolic - diastole= pulse pressure

  • normal pulse pressure is ? 40-60 mmhg

  • systolic murmur’s means there is stenosis of what valves? aortic and pulmonic stenosis

  • for systolic murmurs what do we see for the AV valves? the valves are closed and we see mitral and tricuspid insufficiency

  • For diastolic murmurs what happens to the semilunar valves? the semilunar valves are closed and its aortic and pulmonic insufficiency

  • For diastolic murmurs what happens to the AV valves? the valves are open and mitral stenos and tricuspid stenosis

  • Mitrial stenosis is associated with? atrial fibrillation due to atrial enlargement.

  • Mitral insufficiency occurs when the mitral valve is closed (murmur occurs). When is the mitral valve closed? ​➤​ Systole

  • Mitral stenosis occurs when the mitral valve is open (murmur occurs). When is the mitral valve open? ​➤​ Diastole

  • Aortic insufficiency occurs when the aortic valve is closed. When is the aortic valve closed? ​➤​ Diastole

  • Aortic stenosis occurs when the aortic valve is open. When is the aortic valve open? ​➤​ Systole

  • Does a murmur due to a VSD occur during systole or diastole? systole

  • Papillary muscle dysfunction (Grade I or II), loudest at? the apex

  • Papillary muscle rupture (Grade V or VI), loudest at ? the apex surgical emergency!

  • Ventricular septal defect heard at? Sternal border, 5th ICS

  • Acute coronary syndrome is due to ? platelet mediated thrombosis

  • What are the types of ACS? unstable angina, non-ST elevated Myocardial infarction, ST elevated Myocardial infarction

  • What is Unstable angina? Chest pain at rest, unpredictable, may be relieved with nitroglycerin, troponin negative, ST depression, or T-wave inversion on the ECG

  • what is Non-ST elevation MI? Troponin positive, ST depression, T-wave inversion on the ECG, unrelenting chest pain

  • What is ST elevation MI? Troponin positive, ST elevation in 2 or more contiguous leads, unrelenting chest pain

  • What is variant or Prinzmetals Angina? A type of unstable angina associated with transient ST segment elevation Due to coronary artery spasm with or without atherosclerotic lesions Occurs at rest, may be cyclic (same time each day) May be precipitated by nicotine, ETOH, cocaine ingestion Troponin negative Nitroglycerin (NTG) administration results in relief of chest pain, STs return to normal

  • How do we manage acute chest pain what medications do we give? start ECG and read within 10 minutes, aspirin, anticoagulant: heparin or enoxaparin, Antiplatelet agents such as Clopidogrel (Plavix), Abciximab (Reopro), Eptifibatide (Integrilin), Tirofiban (Aggrastat)

  • why would you not give a Beta blocker during ACS? if due to cocain

  • what beta blocker would you give for ACS? Use cardioselective such as metoprolol (Lopressor); do not use non-cardioselective such as propranolol (Inderal). Contraindications include hypotension, bradycardia, use of phosphodiesterase-inhibitor drugs such as sildenafil

  • How do we treat pain for ACS? nitroglycerin and morphine'

  • Changes in II, III, aVF ? → right coronary artery (RCA), inferior LV

  • Changes in V1, V2, V3, V4 ?→ left anterior descending (LAD), anterior LV

  • Changes in V5, V6, I, aVL? → circumflex, lateral LV

  • Changes in V5, V6 ? → low lateral LV

  • Changes in I, aVL? → high lateral LV

  • Changes in V1, V2 ?→ RCA, posterior LV

  • Changes in V3R, V4R? → RCA, right ventricular (RV) infarct

  • tachycardia is associated with what kind of MI? inferior MI, RV infarction and posterior MI

  • Which artery supplies the inferior wall of the left ventricle and right ventricle? right coronary artery

  • 30% of inferior wall MI patients also have? right ventricular RV infarct

  • Treatment for Right sided infarct? fluids, positive inotropes

  • What to avoid in right sided infarct? preload reduces such as nitrates and diuretics and caution with beta-blockers because of hypotension

  • Anterior MI is associated with ?Associated with left anterior descending (LAD) occlusion ST elevation in V1–V4: precordial leads,

  • Lateral MI is associated with? ST elevation in V5, V6 (low lateral) ST elevation in I, aVL (high lateral) Generally involves left circumflex artery

  • For treatment of STEMI what is the time frames and eligibility criteria? Determine onset of infarct, if symptoms < 12 hours → REPERFUSION. Percutaneous coronary intervention (PCI)—standard is door-to-balloon within 90 minutes. Fibrinolytic drug therapy—standard is door-to-drug within 30 minutes. Eligibility criteria ST elevation in 2 or more contiguous leads or new onset left bundle branch block (LBBB). Onset of chest pain < 12 hours. Chest pain of 30 minutes in duration . Chest pain unresponsive to sublingual (SL) nitroglycerin (NTG)

  • what is contradictions for fibrinolytic therapy? Any prior intracranial hemorrhage. Known structural cerebral vascular lesion (e.g., arteriovenous malformation). Known malignant intracranial neoplasm (primary or metastatic). Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours, aortic bisection, active bleeding, closed head or facial trauma within 3 months.

  • what is evidence of reperfusion from fibrinolytic therapy? Chest pain relief: due to fibrinolysis of clot. Resolution of ST segment deviations: due to return of blood flow. Marked elevation of troponin/CK-MB: due to myocardial “stunning” when vessel opens. Reperfusion arrhythmias (VT, VF, accelerated idioventricular rhythm [AIVR]): due to myocardial “stunning” when vessel opens

  • What is hypertensive emergency crises? elevated BP with evidence of end organ damage (brain, heart, kidney, retina) that can be related to acute hypertension → needs critical care admission. greatest risk for stroke

  • What are some medications used for hypertensive crises? nitroprusside, labetalol

  • What are the 6 Ps of peripheral arterial disease? Pain (activity, rest), Pallor, Pulse absent or diminished, Paresthesia , Paralysis, Poikilothermia: loss of hair on toes or lower legs; glossy, thin, cool, dry skin (chronic sign of PAD)

  • what is ABI ankle -brachial index? Test to assess for PAD, used to assess adequacy of the lower extremity perfusion the normal is >0.90 which is when you divide ankle pressure ny brachial pressure

  • what positioning do your to patients with PAD and what medications ? Bed in reverse Trendelenburg ​✰ ​ Do NOT elevate the affected extremity—will decrease perfusion Medications Thrombolytics (tPA) Anticoagulants (heparin) Antiplatelet agents (ASA, clopidogrel) Vasodilators

  • what is wolf Parkinson white syndrome is a genetic conduction abnormality in which an abnormal conduction pathway exists that allows a reentrant tachycardia pathway to bypass the normal AV node conduction pathway, resulting in supraventricular tachycardia. WPW is primarily seen in those younger than 30-years-old.

  • QT prolongation may lead to ? torsades de pointes

  • Torsades de pointes description? polymorphic VT with prolonged QT interval

  • Treatment of WPW? ablation to eliminate the reentrant pathway

  • if SVT is present during WPW what treatments would you do? cardioversion or adenosine

  • Do not give adeosine , digoxin, or calcium channels blockers for pre existing what and why ? pre-excited AF; these agents may enhance antegrade conduction through the abnormal pathway by increasing the refractory period in the AV node, resulting in ventricular fibrillation.

  • what drugs and electrolyte issues can cause torsades de pointes? Drugs—amiodarone, quinidine, haloperidol, procainamide . Electrolyte problems—hypokalemia, hypocalcemia, hypomagnesemia

  • what is first line drug for Torsades? Magnesium

    what is DNP? B-type natriuretic peptide (BNP) is released by the ventricle when the ventricle is under wall stress in attempts to dilate and decrease ventricular pressure.

  • what is the pathology of acute decompensated heart failure?

    What is the primary problem of systolic vs diastolic heart failure? for sytolic it is an ejection problem with a dilated chamber, for diastolic it is hypertrophied

  • Heart failure is a clinical syndrome characterized by signs and symptoms associated with? high intracardiac pressures and decreased cardiac output

  • What is heart failure with systolic dysfunction? left ventricular systolic dysfunction- LVSD. EF is 40% or less

  • What is heart failure with diastolic dysfunction? when the EF is greater than 50%, problem with with filling, ejection is OKAY

  • BNP elevates when the left ventricle and right ventricle is? under stress (left ventricular failure) or, to a lesser degree, BNP elevates when the right ventricle is under stress (pulmonary hypertension, pulmonary embolism).

  • When systolic dysfunction is prolonged and becomes chronic. hormones lead to? ventricular remodeling over time

  • Signs of sytolic heart failure? dilated left ventricle, valvular insufficiency . EF= <40%, pulmonary edema due to poor ventricular emptying, S3 heart sound, elevated BNP

  • Treatment for systolic heart failure? beta blockers, ACE/ARB, diuretics, dilators, aldosterone antagonist, positive inoptropes

  • What are contradicters for systolic heart failure? negative inotropes, calcium channel blockers, in acute phase beta blockers

  • Signs of diastolic heart failure? normal ventricular size, thick walls or septum, normal EF, pulmonary edema, S4 heart sound, HIGH BP, elevated BNP.

  • treatment for diastolic heart failure? beta blockers, ACE/ARB, calcium channel blockers, diuretics, aldosterone antagonist

  • contraindications for diastolic heart failure ? positive inotropes, dehydration, tachyarythmias

  • what are the findings on a chest xray for systolic heart failure ? evidenced by a large, dilated heart or by a normal heart size on the chest film. An enlarged heart is often associated with a shift of the point of maximal impulse (PMI) from midclavicular to the left

  • what are the xrayb findings on Diastolic HF? is evidenced by a normal heart size on the chest film. However, on the 12-lead ECG, there may be a left ventricular hypertrophy pattern, especially when the patient has a history of uncontrolled hypertension.

  • Causes of right sided HF? acute RV infarct, pulmonary embolism, septal defects, pulmonary stenosis, COPD, pulmonary hypertension, left ventricular HF

  • Causes of left sided HF? CAD, iscemia, MI, cardiomyopathy, fluid overload, HT, valvular insufficiency aortic stenosis, mitral stenosis , tamponade

  • sings of right sided HF? hepatomegaly, splenomegaly, dependent edema, venous distention, elevated CVP/JVD, tricuspid insufficiency , abdominal pain

  • signs of left sided HF? orthopnea,, dyspnea, tachypnea, hypoxemia, tachycardia, crackles, pink frothy sputum, elevated PA, anxiety, diaphoresis, confusion

  • The main cause of death from heart failure is ? the development of sudden death arrhythmia.

  • American Heart Association (AHA) Stages of Heart Failure are ? 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 stages of heart failure are? 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.

  • What is the difference between dilated and hypertrophic cardiomyopathy? dilated cardiomyopathy is when it has diastolic dysfunction, thinning walls, LV enlargement, dilation, MVR regurgitation with similar symptoms to systolic heart failure and treatments include VAD or heart transplant. Hypertrophic cardiomyopathy include diastolic dysfunction with increased thickening of the heart muscle and septum inwardly , symptoms of diastolic heart failure such as fatigue, dyspnea, chest pain, palpations syncope, S3/s4 heart sounds, increased risk of sudden cardiac death

  • Cardiogenic shock is due to? . Most commonly, it is due to an extreme drop in stroke volume secondary to systolic dysfunction,

  • Treatments of cardiogenic shock? manage arrhythmias, reperfusion if STEMI, ruptured papillary muscle surgery, mechanical support . positice inotroc meds norepinephrine/dopamine/dobutamine, avoid negative inotropes such as vasdodilators, mechanical support such as intra aortic balloon pump

  • A balloon pump inflates at the and deflates ? inflates at the dicrotic notch beginning of diastolic , and deflates right before sytsol determines by R wave of ECG or upstroke of arterial pressure wave

  • What are post op complications of CABG? Hemodynamic abnormalities Arrhythmias ​✰ ​ Tamponade, Pericarditis, Electrolyte abnormalities (Hematologic abnormalities, bleeding), Pulmonary problems (pneumonia, atelectasis, difficulty weaning from mechanical ventilation), Pain, anxiety, Renal failure, Endocrine problems (issues with glycemic control) Gastrointestinal problems (nausea, vomiting, ileus), Infections

  • Post-op chest tube management Maintain patency. Do not allow dependent loops. Milking or stripping chest tubes is not routinely indicated. ​–​ If clots appear, gently milk the chest tubes. Mediastinal chest tubes remove serosanguinous fluid from the operative site, whereas pleural chest tubes remove air, blood, or serous fluid from the pleural space. Keep chest tubes lower than patient’s chest. Do not clamp the system unless you are changing the drainage system or there is a system disconnect. When the tube is clamped, the connection to the negative chamber is lost. A chest tube output > 100 mL for 2 consecutive hours generally requires intervention.

  • Considerations for post valve repair or replacement ? Avoid a drop in preload. Most patients who have had valvular stenosis or chronic regurgitation have had elevated end-diastolic volumes. Sudden preload normalization may result in hypotension. Anticoagulation will be needed for mechanical valve replacement; biological valve replacement will require antiplatelet therapy (aspirin). Anticipate conduction disturbances since the mitral, tricuspid, and aortic valves are anatomically close to conduction pathways. Temporary or permanent pacing may be needed.

  • Who is a candidate for a TAVR? low risk

  • Signs and symptoms of cardiac tamponade? Restlessness and agitation Hypotension ↑ JVD Equalization of CVP, pulmonary artery diastolic pressure, and PAOP Muffled heart sounds Enlarging cardiac silhouette and mediastinum on a chest radiograph ​✰ ​ Narrowed pulse pressure (i.e., 82/68) ​✰ ​ Pulsus paradoxus: an excessive drop (greater than 12 mmHg) in the SBP during inspiration, which is the result of cardiac muscle restriction caused by the tamponade with inspiration; the intrathoracic

  • which valve is at most risk for rupture due to trauma? aortic valve because it is most anterior to the chest

  • what percent during Abdominal aortic aneurysms and thoracic aortic aneurysms comprise of? Abdominal 75%, thoracic 25%

  • What is medical pericarditis etiology? Trauma, viral, radiation, dressers syndrome, post op cardiac surgery

  • Signs and symptoms of pericarditis ? Chest pain, pain worsening in inspiration, dyspnea, ST-elevation, tamponade

  • How to treat medical pericarditis? Antibiotics, NSAIDs, steroids, anti-inflammatories