Comprehensive Cardiovascular & Peripheral Vascular Study Notes

Chapter 21 – Assessment of Cardiovascular Function

Cardiac Output & Related Determinants

• Key equation: $CO = SV \times HR$
  • $CO$ = Cardiac output (L/min)
  • $SV$ = Stroke volume (mL/beat)
  • $HR$ = Heart rate (beats/min)

• Ejection Fraction (EF)
  • Percent of end-diastolic volume ejected each beat (normally measured in the left ventricle)
  • Clinical benchmark of systolic function; low EF signals impaired contractility or volume overload.

• Stroke Volume (SV) Drivers
  • Preload ("fluid") – myocardial fiber stretch at end-diastole
  • Afterload ("resistance") – force the ventricle must overcome (systemic or pulmonary vascular resistance)
  • Contractility ("squeeze") – inotropic state of myocardium; ↓ with hypoxemia, acidosis, negative inotropic drugs.

Neural & Hemodynamic Regulation

• HR control – autonomic nervous system (sympathetic ↑, parasympathetic ↓) + baroreflexes.

• SV control – Frank–Starling law (↑ preload → ↑ SV up to physiologic limit).
  • Afterload influenced by $SVR$ & $PVR$.

Foundational Review Question

• “Which best describes stroke volume?” → A. Amount of blood ejected with each heartbeat.

Comprehensive Cardiovascular Health History

• Demographics, family/genetic risk, culture/social habits.

• Risk factors: modifiable (smoking, diet, exercise) vs non-modifiable (age, genetics).

• Cardinal symptoms: chest pain, referred upper-body pain, $\text{SOB}$/dyspnea, edema/weight gain/abdominal distention, palpitations, syncope, LOC changes, fatigue.

• PQRST pain analysis
  • P Provocation – triggers/relief
  • Q Quality – sharp, dull, throbbing, etc.
  • R Region/Radiation
  • S Severity (0–$10$)
  • T Timing (onset, duration, pattern).

• Other past-health domains: meds, nutrition, elimination, activity, sleep, self-concept, roles, coping.

Physical Examination Checklist

• General appearance, skin/extremities (color, temp, lesions, hair loss).

• Vital trends: pulse pressure, BP (include orthostatic), arterial pulses, $JVP$.

• Cardiac inspection/palpation/auscultation; correlate with lung & neuro exams.

Electrocardiography Modalities

• $12$-lead for diagnostics (patient supine & still).

• Continuous hard-wire, telemetry, ambulatory Holter/event monitoring.

Lab Panels

• Troponin I / High-sensitivity Troponin, CK-MB (cardiac-specific when $>10\%$ of total $CK$).

• Chemistry, CBC, coag: identify anemia, lytes, clotting status.

• Lipids, $BNP$ (ventricular stretch), $CRP$ (inflammation), homocysteine (vascular risk).

Stress & Imaging Studies

• Exercise treadmill: progressive protocols → stop at target $HR$, ischemic S/S, or abnormal $ECG$.

• Pharmacologic stress: vasodilators (dipyridamole, adenosine, regadenoson) mimic exercise.

• Radionuclide perfusion, PET, CT angiography, $MRI/MRA$, echocardiography (transthoracic & transesophageal).

• Echo outputs – EF, chamber size, wall motion anomalies.

Cardiac Catheterization

• Right-heart (pressure/O$2$ sat, biopsies) vs left-heart (coronary anatomy w/ contrast).

• Nursing priorities: site/bleeding checks, distal pulses/neurovascular, arrhythmia screen, bed rest $2$–$6$ h, contrast-induced nephropathy prevention (hydration, monitor $Cr$).

Chapter 22 – Arrhythmias & Conduction

Lead Placement & Grid Basics

• Standard $ECG$ paper: $1\ \text{mm}=0.04\ \text{s}$ (small box), $5\ \text{mm}=0.20\ \text{s}$ (large box).

• Lead II commonly used for rhythm surveillance.

Normal Electrical Pathway

$SA \rightarrow AV \rightarrow Bundle\ of\ His \rightarrow L/R\ bundle\ branches \rightarrow Purkinje$

Waveform Interpretation

• P = atrial depolarization/contract.

• PR interval $0.12$–$0.20\ \text{s}$ – atrial → ventricular conduction.

• QRS $<0.12\ \text{s}$ – ventricular depolarization.

• T = ventricular repolarization.

Rhythm Analysis 5-Step Method

1. Rate

2. Regularity

3. $P$ waves (ratio, morphology)

4. $PR$ interval

5. $QRS$ width

Common Sinus Rhythms

• Normal sinus: regular, $60$–$100$ bpm, $1{:}1$ P:QRS.

• Sinus tachycardia: regular, $>100$–$160$ bpm, normal PR/QRS.

• Sinus bradycardia: $<60$ bpm; may accompany 1° AV block ($PR>0.20\ \text{s}$).

• Sinus arrhythmia: cyclic variation with respiration; longest $R–R$ minus shortest $>0.16\ \text{s}$.

Supraventricular & Atrial Arrhythmias

• SVT: rate $>160$–$250$ bpm, narrow QRS, hidden $P$.

• PAC vs PVC vs PJC: use $QRS$ width & $P$ morphology (wide = ventricular).

• Atrial Flutter: saw-tooth $F$ waves, typical $2{:}1$ block.

• Atrial Fibrillation: irregularly irregular, absent $P$, narrow $QRS$.
  • Goals: control rate $<100$ (diltiazem), anticoagulation (CHA$2$DS$2$-VASc).

Ventricular Rhythms

• PVC: premature, wide $QRS >0.12$ s.

• VT: regular wide-complex $\approx150$–$250$ bpm (check pulse!).

• Torsades de Pointes: polymorphic VT, twisting axis, often d/t low $Mg^{2+}$.

• VF: chaotic baseline, no QRS → immediate defibrillation.

• Asystole: flatline; confirm in $2$ leads, initiate CPR.

NCLEX-High-Yield Rhythms List

Sinus rhythm, bradycardia, SVT, AF, flutter, VT, VF, Torsades, asystole.

Chapter 26 – Vascular Disorders & Peripheral Circulation

Vascular System Anatomy & Function

• Dual circuits: right heart → pulmonary; left heart → systemic.

• Vessels: arteries/arterioles (high pressure), capillaries (exchange), veins/venules (capacitance), lymphatics (fluid/protein return).

• Core physiologic tasks: tissue perfusion, BP maintenance, filtration/reabsorption, resistance modulation, autoregulation.

Age-Related Changes

• Vascular stiffening → ↑ peripheral resistance, ↓ flow, ↑ LV workload.

Patient Assessment – PAD/PVD

• History: intermittent claudication, rest pain, skin changes, pulses.

• Physical: cool, pale, rubor, no hair, brittle nails, ulcers; grade pulses.

• Diagnostics: Doppler $ABI$ ($\text{ABI}=\frac{\text{ankle SBP}}{\text{brachial SBP}}$, $<0.9$ = PAD), duplex, $CTA/MRA$, angiography.

Management Goals

• ↑ arterial supply, ↓ venous congestion, pain control, tissue integrity, self-care adherence.

• Improve arterial circulation: dependent limb positioning, walking programs, avoid cold/nicotine, manage stress.

Arteriosclerosis vs Atherosclerosis

• Arteriosclerosis: generalized arterial wall thickening/hardening.

• Atherosclerosis: intimal lipid-rich plaques (atheromas).
  • Progression: fatty streak → fibrous plaque → complicated lesion (calcification, rupture, thrombosis) → clinical events (MI, stroke, gangrene).

PAD Hallmarks & Sites

• Intermittent claudication: cramp/ache with exertion, relieved by rest.

• Ischemic rest pain: persistent, often nocturnal.

• Common occlusive sites: carotids, aorto-iliac, femoral-popliteal, tibial.

Pharmacologic Options

• Cilostazol (PDE-III inhibitor) – ↑ walking distance.

• Antiplatelets: aspirin, clopidogrel.

• Statins – plaque stabilization & lipid control.

Teaching Pearls (NCLEX-Style)

• Keep PAD limbs neutral/dependent, not elevated (opposite of venous insufficiency).

Aneurysms & Dissections

• Definition: localized arterial dilation (saccular vs fusiform).

• Risk factors: atherosclerosis (most common), male sex, uncontrolled HTN, tobacco, lipids, trauma, genetics, age.

• AAA findings: gnawing abd/back pain, pulsatile mass, bruit, ↑ BP initially.

• TAA findings: severe back pain, hoarseness, dysphagia, SOB, neck nodules.

• Dissection: sudden tearing pain, hemodynamic collapse (↓BP, ↑HR), neuro deficits, organ ischemia.

• Management “ABC”: large-bore IV, tight BP control (β-blockers, ARBs, CCBs), urine output, endovascular graft when indicated.

Raynaud’s Phenomenon

• Paroxysmal digital vasospasm (white→blue→red), triggers = cold, stress.
  • Primary (disease) vs secondary (scleroderma, etc.).
  • Education: keep warm, avoid injury, stop smoking.

Venous Disorders

• VTE spectrum: DVT ± PE; risk triad = endothelial damage, venous stasis, hypercoagulability.

• Prevention: early ambulation, leg exercises, compression hosiery, IPC devices, SQ heparin/LMWH, lifestyle (weight, smoking, exercise).

• Highest-risk example: septic patient with central venous catheter.

• Leg ulcers: assess pain, pulses, infection; manage with antibiotics, compression, debridement, nutrition (protein, vit C/A, Fe, Zn), safe mobility.

• Varicose veins: avoid stasis behaviors, elevate legs $3$–$6$ in above heart, daily walking $\ge30$ min, compression stockings, weight control.

• Lymphedema/lymphangitis/lymphadenitis: chronic elevation of limb, avoid heat/sun; antibiotics $3$–$7$ days post-op.

• Cellulitis care: elevate limb $3$–$6$ in, warm moist packs q$2$–$4$ h, skin-foot hygiene.

Chapter 27 – Hypertension

Definitions & Staging (ACC/AHA 2017)

• Normal: $SBP<120$ & $DBP<80$ mm Hg

• Elevated: $SBP~120–129$ & $DBP<80$

• Stage 1: $SBP~130–139$ or $DBP~80–89$

• Stage 2: $SBP\ge140$ or $DBP\ge90$

• Leading chronic disease; $>40,000$ US deaths/yr.

Pathophysiology – 4 Major Controllers

1. Arterial baroreceptors (carotid, aortic, LV) – trigger vaso-motor changes.

2. Renal fluid regulation – Na⁺/H₂O balance.

3. RAAS – renin→ANG II→aldosterone → vasoconstriction & volume.

4. Vascular autoregulation – maintains steady tissue perfusion.

Risk Factors

• Primary (essential): smoking, obesity ($BMI>25$), ↑ Na⁺, inactivity, dyslipidemia, DM, age $>60$/post-meno, family hx, stress, high EtOH.

• Secondary: renal disease, Cushing, primary aldosteronism, pheochromocytoma, brain tumors, drugs (estrogens, steroids, sympathomimetics), pregnancy.

Clinical Features & Target-Organ Damage

• Often asymptomatic (“silent killer”).

• Late: retinal changes, renal insufficiency, LV hypertrophy, MI, stroke, $TIA$, cognitive decline.

Assessment & Diagnosis

• Accurate BP measurement (proper cuff, arm at heart, seated $\ge5$ min, no caffeine ≥$30$ min).

• Confirm with ≥$2$ averages.

• Look for white-coat and masked HTN (ambulatory BP monitoring).

• Work-up: H&P, retinal exam, UA, electrolytes/$Cr$, lipids, ECG.

Lifestyle Therapy – First-Line

• Weight reduction (BMI $18.5$–$24.9$).

• DASH diet (fruits/veg, low saturated fat), Na⁺ <$100$ mmol/day (~$2.3$ g).

• Aerobic exercise ≥$30$ min most days.

• Moderate alcohol.

Pharmacologic Management

• Initial drug (no comorbidity): thiazide diuretic (HCTZ) – give early; monitor $K^{+}$.

• Diuretics: loop (furosemide – risk hypokalemia), K-sparing (spironolactone – hyperK).

• CCBs (verapamil, amlodipine, diltiazem): check HR/BP; avoid grapefruit; constipation (verapamil).

• ACEIs (“-pril”): watch cough, hyperK, teratogenic.

• ARBs (“-sartan”): hyperK, teratogenic.

• β-blockers (“-lol”): mask hypoglycemia, fatigue, depression; avoid in asthma.

• Central α2-agonist (clonidine) & α-blockers (prazosin) as add-ons; monitor for orthostasis.

Patient Education Essentials

• Home BP logging; slow position changes; med adherence; incorporate family/caregivers; simplify regimen (monotherapy) in elders; assess finances/vision/dexterity for refills.

Hypertensive Crises

• Emergency: $BP>180/120$ with acute T-O damage ⇒ IV vasodilators (nitroprusside, nicardipine, fenoldopam, enalaprilat, NTG).
  • Goal: ↓ MAP ≤$25\%$ 1st hr → $160/100$ within $2$–$6$ h → gradual norm ≤$24$–$48$ h (except stroke, dissection).
  • Priority assessment: I&O (volume depletion risk).

• Urgency: same numeric but no TOD; give fast-acting PO (labetalol, captopril, clonidine); normalize over $24$–$48$ h.

Quick Reference – High-Yield NCLEX Q&A Recap

1. Stroke volume definition → blood per beat.

2. PAD teaching → keep legs dependent/neutral.

3. Highest VTE risk → septic pt w/ central line.

4. Lymphedema care → constant limb elevation.

5. First-line uncomplicated HTN med → thiazide diuretic.

6. Lifestyle HTN plan → ≥$30$ min aerobic activity most days.