Alterations in cardiovascular

anatomy/physiology

Point of maximum impulse (PMI)= apex of heart → 5th ICS in left midclavicular line

3 layers: endo (also lines valves) → myo → epi (serous)

→ then pericardium =

• visceral

• parential = is attached to great vessels, diaphragm, sternum, vertebrae = heart attached to thorax

• pericardial space w/ serous fluid

vessels

layers of vessels → tunica

1. adventitia: outside → connective tissue, nerve, vessel

2. media: [sub]/endothelium, elastica lamina

3. intima: smooth muscle, endothelial squamous

function of vessels:

• arteries: high BP from heart

• → arterioles → capillaries (gas exchange, nutrient/waste transfer) → venules

• veins: reservoir of blood and low BP to heart

heart blood supply:

coronary arteries (CA): Left anterior descending, (L)

circumflex, (L/R) coronary artery, Right marginal artery

during diastole → blood to CA

function

electrophysiology: SA → AV - (slight delay to contract ventricles) → bundle of his → Purkinjean fibers

hemodynamics: systole, diastole

CO: amount of blood eject from ventricle/ min (L/min)

• vasocontraction, artery compliance, afterload, blood entering to heart

• normal = 5-6L/min

• CO= SV x HR

  • preload: can be measure w/ pulmonary capillary wedge (PCW)

  • afterload: ~ to BP

  • contractability: influences SV → use inotropic of SNS stim

heart sounds:

• S1: close MV and TV → open AV and PV (systole)

• S2: close AV and PV → open MV and TV (diastole)

• S3: normal in children, HF for >40

  • venticular gallop

  • loud DUB after S2: lubdubDUB

• S4: atrial gallop

  • LUBlubdub

  • low ventricular compliance by HTN, aortic stenosis, CAD, cardiomyopathy

• murmur: turbulence WHOOSH

  • systolic between S1 and S2

  • diastolic between S2 and S1

• pericardial friction rub: left sternal border

  • inflammation, infection, infiltration

  • GRATING

Cardiac rhythms

depolarization (contract) → repolarization (relax)

ECG identify areas w/ low perfusion

ECG Analysis

1. Calculate HR

   1. R to R intervals = count large square then divide by 300 (for ventricular rhythm)

   2. P to P intervals = atrial rhythm

   3. count all QRS in 6sec strip x 10= bpm

2. Determine if heart rhythm is regular.

   1. R to R: P to P = if same is reg if not then irreg

3. Assess for P waves.

   1. more than one before QRS, no P wave, or diff P waves

   2. disturbance between SA and AV

4. Measure PR interval.

   1. beginning of P wave → beginning of QRS

   2. 0.12-0.2

   3. count small boxes then x 0.04sec

5. Measure duration of QRS complex.

   1. until beginning of ST segment

   2. 0.06-0.1

   3. premature ventricular contractions (PVC)

      1. unifocal =same shape in same site

      2. or multifocal = diff shape from diff site

      3. bigeminy( every other), trigeminy, quadrigeminy)

      4. more frequently more lethal

6. Assess ST segment.

   1. 1 small box change (1mm) in elevation or depression in the isoelectric line → E/I or low cardiac perfusion

7. Observe for changes in T wave.

   1. peak = E/I (hyper K)’

   2. inversion = ischemia or PE

8. Measure length of QT interval.

   1. means length of time of ventricular repolarization

   2. no more than 0.45

   3. lethal dysrhythmias → QT prolonged

9. Interpret the rhythm.

sinus bradycardia

NSR but lower than 60

causes:

• people w/ exercise, or Afib or Brugada syndrome

• by MI, sleep apnea, ICP

• low metabolic need : eating disorder, hypothyroidism

• Vagus stim

• Lyme disease, typhoid fever, malaria, or Rocky Mountain spotted fever

meds:

• Parasympathomimetics (acetylcholine) 

• Beta blockers (metoprolol)

• Digitalis glycosides (digoxin)

• Calcium channel blockers (diltiazem)

• Antiarrhythmics (amiodarone)

• Chemotherapy agents (thalidomide)

• Lithium

s/s: no s/s → dizzy, syncopal ep, AMS, SOB, diaphoresis, exercise-fatigue

lab/dx:

E/I: Ca/ Mg, troponin, TH, check U/A or blood for illicit drug

nurse intervention:

• hold BB, fall precaution, toxin or infectious exposure

• s/s = monitor ECG, adm fluids,

tx:

• IV atropine q 3-5mins but not over 3mg

• temporary, transcutaneous pacemakers

sinus tachy

Excessive SNS → prologued → low CO

100<x<150

causes:

• fluid loss/ excess

• pain, fever, shock, anxiety, stress

• MI, hyperTH

• atropine, catecholamines, theophylline, illicit (cocaine, amphetamine), caffeine, nicotine

s/s:

• palpitation, dizzy, ortho hypoTN

• can report high temp, SOB, angina

lab/dx:

CBC: infection, anemia

BMP, heart enzymes, drug screen

ABG, ECG, D-dimer, chest radio

24-hr ECG for abnormal activity

tx:

• teach vagal stim

• IV adenosine: determine if NSR or supraventicular

  • nausea, feeling of doom, sweating, numbness

• BB

• catheter ablation: destroys abnormal excited cardiac cells

  • performed using sedation

  • inserted in femoral → heart

  • postop = monitor bleeding, thrombosis, hematoma

    • keep extremity straight at all time

Premature Ventricular contraction (PVC)

early electrical impulses from irritated ventricular cells

QRS is wider and occur early in cardiac cycle

causes:

• HTN

• MI, Cardiomyopathy, Ventricular tachycardia

• COPD, Pulmonary hypertension

• Sleep apnea

• Electrolyte imbalances: low K/Mg

• Thyroid disorders

• Caffeine sensitivity, :Nicotine, alcohol, or illicit drug use

s/s:

• inc palpitations lying down at night and sleep disturbances

• palpitations

• lightheadness

• chest pain or SOB

lab/dx:

• BMP, TH

• ECG: NRS but w/ premature, widen (>0.12) QRS

  • hiden P wave,

• 24hr monitor = 24-48hr, with diary to note s/s

  • don’t shower

• determine heart sounds

tx:

• metoprolol and carvedilol

• flecainide, propafenone, amiodarone = antiarrhythmics (close monitor for kidney and liver)

• catheter ablation after 30days

tx:

• >50 = annual cardiac health screen

Premature Atrial Contractions (PACs)

benign w/ irritated atrial

causes: unknown

• MI, HTN, DM, CHF

• digoxin, BB, chemo, antidepressant

s/s: no s/s, only anxiety from dx

• may report flutter or SOB w/ exercise

lab/dx:

• ECG: normal NSR but some P wave unidentifiable and PR interval shorten (<0.12)

• BMP

tx:

• lifestyle modification → contact HCP if SOB or angina

• if frequent PAC → BB

1st degree heart block

SA→ AV delay = PR >0.2sec

cause:

• age, hx of cardiac, E/I

• endocarditis, rheumatic fever, and COVID-19

• RA, lupus, sarcoidosis

• higher vagal resting tone

• meds:

  • Sodium channel blockers (Lidocaine)

  • Beta blockers (Metoprolol)

  • Calcium channel blockers (Diltiazem)

  • Potassium channel blockers (Amiodarone)

  • Cardiac glycosides (Digoxin)

  • Magnesium

s/s: no s/s → until ADL interruption (dizzy or SOB)

lab/dx:

• BMP, toxicology

• ECG

tx:

• low sodium, cholesterol, triglycerides

• lifestyle modification

• check for abnormal heart sounds

• → s/s → atropine, isoproterenol

Afib

rapid, chaotic, firing that does not allow atria to properly contract = inc blood clots

causes:

• DM, OSA, hyperTH, smoking, sedentary, cardiac surgery

• HTN, COPD, stroke

s/s:

• dizzy, palpitation,

• stroke → w/ med → inc bleeding

• no s/s unless affect perfusion

• irregular apical pulse, low BP, palpitation, high HR

• weight gain and in urination

lab/dx:

• hyperTH, CBC, glucose, creatinine,

• oral coagulant → INR

• ECG: no P waves

  • HR: normal or <100 (rapid ventricular response RVR)

• Echo: determine size of chambers → transesophageal echocardiogram (TEE)

tx:

• anticoagulant:

  • no catch up w/ doses

  • bleeding precautions → soft-bristle brush, safety razors, no contact sports

  • warfarin (VKA) → q2-4w PT/INR

    • keep normal vit K consumption

  • direct oral anticoagulants (DOACs) =apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto)

    • no testing required

    • only reversal when bleeding emergencies

      • dabigatran (Pradaxa) is idarucizumab (Praxbind).

      • Andexanet alfa= apixaban (Eliquis) and rivaroxaban (Xarelto).

• refrain from high intense activities, stimulants, herbs

  • Decreases the Effect (Increases Risk for Blood Clotting)

    • Coenzyme Q-10

    • Ginseng

    • Licorice

    • St. John's wort

    Increases the Effect (Increases Risk for Bleeding)

    • Danshen

    • Evening primrose

    • Ginkgo biloba

    • Saw palmetto

• assess:

  • pulse deficit (apical pulse - radial pulse)

• synchronized electrical cardioversion: timed electrical shock on R wave to disrupt irregular cycle = when pt unstable and not able to maintain BP

  • 50-200 joules

  • conscious sedation → maintain open airway and continuous cardiac monitoring

  • anticoag 4 weeks after

• antidysrhythmic: BB, CCB, amiodarone, digoxin

  • require monitoring of QT prologue, low HR

  • amiodarone for most complicated

    • ADR: pulmonary fibrosis, or liver = PFT, and LFT

• → electrophysiology (EP) study (map out electricsal system) cardio ablasion

foods w/ vit K:

HIGH amount of vitamin K

• Brussel sprouts

• Greens (beets, collard, mustard, turnips)

• Kale

• Spinach

MODERATE amount of vitamin K

• Asparagus

• Broccoli

• Cabbage

• Carrots

• Cauliflower

• Celery

• Green beans

• Lettuce (butterhead, iceberg, romaine)

• Mixed vegetables

• Okra

• Peas

• Pickles

 LOW amount of vitamin K

• Avocados

• Bananas

• Corn

• Fruit

• Garbanzo beans

• Green or red peppers

• Potatoes

• Tomatoes

Medications that later VKAs:

Increase INR

• Acetaminophen

• Allopurinol

• Antibiotics

• Cephalosporins

• Doxycycline

• Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin)

• Macrolides (azithromycin, erythromycin)

• Metronidazole

• Penicillin (amoxicillin, amoxicillin-clavulanate)​​​​​​​ 

• Antifungals (fluconazole, miconazole)

• Chemotherapy (capecitabine, 5-FU)

• Testosterone

 Decrease INR

• Antibiotics (dicloxacillin, nafcillin, rifampin)

• Antiseizures (carbamazepine, phenobarbital, phenytoin)

• Immunosuppressants (Azathioprine

• Protease inhibitor (ritonavir)

• Sucralfate

• Supplement (St. John’s wort)

• Vitamin K

Atrial flutter

(supraventricular) beating in NR atrial rates = 240-400bpm but ventricular HR = normal

cause: after Afib

• recent MI, or cardiac surgery

• BB, CCB, amiodarone, digoxin

• DM, hyperTH, OSA< obesity, alcohol, smoking

• cardiomyopathy, pericarditis

s/s:

• low BP, dizzy, palpitation, SOB, syncopal ep

lab/dx: check for BMP, LFT, TH, kidney

• ECG: P waves → flutter waves

• echo

tx = Afib tx

supraventricular tachycardia SVT

Paroxysmal supraventricular tachy (PSVT) = AV nodal reentrant tachy (AVNRT) = occur w/o precipitating factors and ends w/o warning

causes:

• inc stress, smoking, alcohol, caffeine, stim

• hx of HF, Wolff-parkinson-White syndrome, pregnancy, COPD

s/s:

• unable to perform normal exercise routine

• dizzy, syncopal ep

• low BP, SOB

• abrupt heart palpitation

lab/dx:

• check for DM, hyperTH, renal disease, CBC, E/I

• ECG: regular rhythm, HR 110-220, narrow QRS<0.12

  • PSVT = same except HR ~ 160bpm

tx:

• valsalva maneuver

• → adenosine → diltiazem, esmolol, or metoprolol

• defibrillator and resuscitation should be at bedside

CAD:

due to atherogenesis, and inflammation of tunica intima

chronic stable angina:

• pain when exercise → nitroglycerin

→acute coronary syndrome (ACS)

• STEMI: abrupt disruption of blood flow by artery blockage due to artery erosion, or dissection of CA = thormbus

• NSTEMI (w/ elevated cardiac markers), unstable angina

  • cause: artery spasm, stable plaque, cardiac embolism, arteritiis

  • → low BP, high HR, aortic stenosis, PE

• complete stop of blood flow

cause: HTN, sedentary, DM, smoking

• age, sex, race, family hx

• poor sleep, HLD, stress

• comorbidities: joint pain, BMI of 30, gout, OA, cancer

s/s: chest pain → HF/ arrhytmias

• mental health = depression, anxiety, stress, PTSD

• no s/s → pain can radiate form left arm, neck, jaw

• unstable = ACS = !!!

• diaphoresis, dizzy, n/v, SOB, weakness

• female = no chest pain = extreme fatigue, abdominal pain, nausea, chest pressure

• DM = right side of the chest, epigastric region, or the back of the neck, or no pain

• check for peripheral edema, lung and heart auscultation

lab/dx:

• cholesterol: high LDL and low HDL, high triglycerides

  • homocysteine (amino acid) → broken down by vit B12/6, folic acid

    • high = high risk of CAD = cause damage to lining of vessels

  • inflammation: CRP

• MI= Troponin I/T detect cardiac injury within 4hrs of MI s/s

  • CK-MB= detect 4hrs and peak in 24hr, goes down ~ 48-72hr so can be used to detect reinfarction

  • myoglobin= one hr after injury but for skeletal and heart

• ECG: ST elevation/ depression, T wave inversion

• cardiac catheterization: (angiogram)

  • use contract for digital photographs

  • ADR: bleeding, blood clot, or vessel damage

    • infection, heart arrhythmias, ischemia, chest pain, MIs, sudden blockage of the coronary artery or damage to the coronary arteries, decreased kidney function due to the contrast, stroke, and death.   

• Stress tests:

  • exercise: treadmill= reach 85% of predicted HR while measuring VS and ECG, if angina → CAD dx

  • echo: send soundwaves to capture heart images to see if there is decrease blood flow to heart → then get target heartrate and another echo

    • use dobutamine for those who are unable to walk on treadmill

  • nuclear stress test :

    •   radioactive for 15-45mins the camera w/ treadmill and take pics

• X-rays

tx:

• educate on lifestyle change (DASH), how to use nitrate, use medical alert bracelet

  • sleep 7-9hr

• obtain blood pressure in both arms, get apical pulse, check capillary refill, JVD, use bell for S3/S4

• continous monitoring

• if elevated troponin = 150-300mg of ASA, heparin, no ticagrelor if thombolysis,

• pain control and O2 sat

• unstable/ NSTEMI → perfusion study (SPECT/ PET)

• all ACS cases = BB, statins, ACE inhibitor STAT

• CABG (bypass)

  • enter by left internal mammary artery, the saphenous vein in a lower extremity, the radial artery, or the gastroepiploic artery.

  • later require ICU

  • complications stroke, infection, failure of graft, kidney failure

  • , Afib development

angioplasty: w/o stent (percutaneous coronary angioplasty (PCI)

• inflatable balloon and plaque pushed into wall

• stent has a wire mesh

• removed with pressure from puncture site

med:

• ACE inhibitors: -pril

• BB: metoprolol, atenolol, esmolol

• CCB: nifedipine, verapamil, diltiazem

• nitrates

• statins

• non statins:

  • ezetimibe, alirocumab, gemfibrozil, fenofibrate

• thermolytic agents: tPA

• antiplatelet: ASA

• anticoagulant: heparin, enoxaparin

DASH diet:

• Eating fruits, vegetables, and whole grains

• Including fish, poultry, beans, and nuts in diet

• Using fat-free or low-fat dairy products

• Using vegetable oils

• Limiting foods high in saturated fat

• Limiting fatty meats

• Limiting sugary foods and beverages

• Limiting sodium intake

M": Morphine

O: O2

N: Nitroglyceride

A: antiplatelet

valvular dysfunction

    valve regurgitation or stenosis (calcification)→ HF, sudden cardiac arrest, death

causes:

• congenital heart valve disease (biscupid)

• RA , endocarditis (ex strep throat)

• HTN, MI, atherosclerosis of the aorta, HF

• lupus, Marfan syndrome, radiation (→ Ca deposits), aging

• high sodium, sweet, smoking, HLD, DM, CAD,

• dilation of left ventricle, or radiation tx, defibrillators or pacemakers

aortic stenosis = HTN (also regurgitation), HLD, Afib, DM

mitral regurgitation = Afib, PVC, HTN

tricupid regurgitation = COPD, pulmonary HTN

s/s:

• fluid overload: edema, SOB

• syncope, fatigues

• chest pain, murmur, palpitation

• abdominal pain due to enlarged liver

lab/dx:    

• Echo= left side → sonographer moves trasducer w/ sound waves → heart pictures = measures pressure fro each valve

•           if stenose = more pressure on front side

  •     can also measure size of valve and EF (50-70% normal)

    • TTE (transthoracic), TEE (also mitral valve disease and chordae problems)

• CXR

• ECG: indicte previous cardiac damage

• cardiac MRI

• cardiac catheter

• stress test

tx:

• check for illicit drug and IV sharing,

• assess pulses, edema, ascultate

• mamnagemetn of s/s: BB, digoxin, CCB

• diuretics for fluid overload, vasodilators

• surgeries:

  • valve repair: no replace but decrease s/s

  • balloon valvuloplasty: expands opening of stenosed valves

  • valve replacemet: from animal, donor, or mechanical (for yonger than 65y or PTH activer extra)

    • biological for CKF, not able to take warfarin, pregnant, for inc for bleeding

      • take 10-15y

      • ICU for 3-7 days

HF

heart not able to meets of the body ← when ventricles not filling properly,

causes:

• CAD, MI, DM

• uncontrolled arrhythmias, HTN, myocarditis, congenital heart disease

• thyrotoxicosis, anemia, thiamine deficiency, pregnancy

• anthracycline (cardiotoxic agent)

• comorbodities: obesity, A-fib, CKD, DM, HTN

s/s:

• SOB, fatigue, difficulty sleeping, LE edema

• may need O2

• L/R side: JVD and SOB, and both L/R manifestations

• L: low BP w/ high HR, orthopnea, paroxysmal nocturnal dyspnea, LE edema, weight gain, inc abdominal girth, pulmonary congestion (rales/ productive cough w/ pink sputum), PMI displaced to one side

• R: S3, murmur, palpitation, ascites, peripheral edema, enlarged spleen/liver

lab/dx:

• Framingham Diagnostic Criteria:

  • major:

    • Acute pulmonary edema, Pulmonary rales

    • Cardiomegaly

    • Hepatojugular reflux

    • JVD, Central venous pressure greater than 16 cm of water

    • Paroxysmal nocturnal dyspnea or orthopnea

    • Third heart sound (S3 Gallop)

    • Weight loss of 4.5 kg or more in five days in response to treatment

    • Radiographic cardiomegaly

  • minor:

    • Ankle edema

    • Dyspnea on exertion, Nocturnal cough, Pleural effusion

    • Hepatomegaly

    • Tachycardia (heart rate greater than 120/min)

    • A decrease in vital capacity by one third the maximal value recorded

• NYHA classification for HF:

  • I: no s/s

  • II: slight limits in ADL, rest has no s/s

  • III: moderate s/s, only comfortable at rest

  • IV: severe limitations, s/s at rest

    • (chest pain, SOB, heart palpitations, fainting)

• check for renal, liver, anemia or iron deficiency,

• BNP

• cardiac catheterization, PCI

• echo: check

  • systolic HF: not enough for to push out to system

  • diastolic HF: not enough space for blood to fill

• CXR, ECG, stress test (determine cause of HF)

tx:

• weight gain of more than 2-3lb/ day or 5lb/week = worsening HF, daily weight

• sodium restrictions 2-3g/day and fluid restrictions 2L/day

• if resp distress: high Fowler, cough and deep q2h, lung sounds reassess q4h

• lifestyle modifications:

meds:

• Sodium-glucose-co-transporter 2 (SGLT-2) ~~

• ACE inhibitor: -pril

• ARBs: -sartan

• angiotensin-receptor neprilysin inhibitors (ARNIs): sacubitril/valsartan

• BB

• aldosterone antagonists: spironolactone, eplerenone

• hydralazine and isosorbide dinitrate (biDil)

• Diuretics: furosemide, chlorothiazide, amiloride

• statins, anticoag, digoxin

surgery:

• cardiac catheterization, percutaneous cardiac intervention if by acute MIO

• enlarged ventricles → ventricular desynchrony (relax at diff times) → cardiac resynchronization therapy( CRT) w/ biventricular pacemaker

• less than 35% EF = implantable cardioverter defibrillators (ICD)= under skin w/ 2 wires one in RA other in RV

• discharge instructions:

  • check for infection,

  • dry for 4-5 days, no tub baths or swim, no rubing,

  • no lifting more than 10-15lb, no twist,pull or push for 2-3w, no lift arm of affected side higher than shoulder,

  • need follow up appt

cardiomyopathy

4 types:

dilated (DCM): weakened ventricles

hypertrophic (HCM): thickened hypertrophy

restrictive (RCM): stiffness of ventricles

arrhythmogenic cardiomyopathy (ACM): wall muscle is replaced w/ fibrous, fatty tissue → dysrhythmias

causes:

DCM: viral infections, autoimmune, myocarditis, sarcoidosis, malnutrition, endocrine, inflammatory, alchohol

HCM: genetic predisposition, occur in athelets

RCM: unknow but ~ hx of amyloidosis, sarcoidosis

ACM: genetic

s/s:

• medications can disrupt libido, mood , urinary continence

• DCM: chest discomfort, peripheral edema, increse levels of fatigue, exertional SOB

• HCM: no s/s → fatigue, syncopal ep, palpitations, exhaustion, SOB, risk of sudden cardiac death (those w/o s/s)

• RCM ~ DCM/HCM

• ACM: ~DCM/HCM + ascites, JVD, lethal dysrhythmias,

lab/dx:

• CXR

• CBC, CMO (liver, thyroid, renal)

• BMP, troponin I/T

• ECG: irregular rhythm, wide QRS (bundle branch block), P/T wave change, lethal dysrhythmias

• Echo

tx:

• may have ICD for abnormal rhythmias supervision

• aviod strenous exercise, lifestyle modification, fluid and sodium restriction, daily weight

• meds: diuretics, vasodilators,

  • DCM: ACE, ARB, BB, mineralocorticoid antagonist

  • HCM: BB, CCB

  • RCM: needs high HR so caution w/ CCB and BB

• surgery:

  • heart transplant

  • LV assist device (LVAD): battery operated mechanical pump

    • ICU 4-5 days

• HCM: septal myectomy (remove peaces of septum for diastolic filling)), alcohol septal ablation w/ cardiac catheterization

• ICD: 6-12y)

Pericarditis:

pericardial sac inflammated (50 mL of fluid in sac)

→ untreated = rigid and constricted

causes:

• idopahic ~ GI or FLU like illness

• cardiac procedures, bacterial infections, cancer (lung, breast, lymphoma), autoimmune (hypoTH)

s/s:

• Dysphagia, low grade fever, recent weight loss, pericardial friction rub, hiccups

• ST elevation, PR depress

Lab/dx:

• WBC, CRP, ESR, temp more of 100.4F, blood cultures

• troponin I/T

• Echo: check for fluid accumulation

• CXR/ cardiac MRI: for pericardial effusion

tx:

• chest pain or discomfort that worsens when inhaling or laying supine and improves when sitting upright

• avois strenous exercise

• hold breath, if rub = cardiac

• meds: antiinflammatory

  • NSAID, colchicine ( targets pericardium), glucocorsteriods

pericardial effusion

effusion compressed all chambers = (50-100) - (100-500)- (>500mL)

→ cardiac tamponade!! = >200mL

causes: cancer, infection, metabolic illness, cardiac trauma (~ pericarditis)

s/s: high temp, chest pain, dry cough, SOB when exertion or laying supine

lab/dx: renal, thyroid, CK-MB, troponin

• ECG: sinus tachy, low QRS voltage, electrical alternans canges beat-to-beat amplitude (vertical) of QRS

• echo

• CXR

tx:

• pericardiocentesis if !!! ← NPO

  • local anesthetic

• assess for bleeding risk

• low blood pressure, muffled heart sounds, rapid pulses, and shortness of breath

PVD

veins, and arteries

Veins: damaged, occluded, or altered

chronic venous disease (CVD): in wall of vein, blood pools in legs → reflux = chronic vein insufficiency (CVI) and VTE → vein distention and varicose veins ( collagen and smooth muscle have low elasticin

→ increased venous pressure → ulcer formation and DVT

DVt (Virchow triad) = injury of wall, abnormalities in clotting, vein stasis

causes:

• abdnormal structure → venous reflux, valcular incompetency

• genetics, progesterone

• family hx, obesity, smoking, pregnancy, hx of WTE, standing for long periods, oral contraceptives, recent surgery/ hospitalization, hypercoagulability

• primary CVD = progressive/ secondary CVD = previous DVT, congenital CVD

s/s:

• → PE

• varicose veins, brown pigmentation w/ leg edema, pruritus, open sores, restless legs, feeling of heaviness in LE

• hemorrhage, phlebitis, and DVT can develop

lab/dx:

• plethysmography = blood volume in LE

• Duplex ultrasound: images of vascular system, direction of blood, and severity of reflux

tx:

• elevate legs higher than heart for 30 mins 3-4/day, ankle pumps

• stop smoking, exercise and walk for 30 mins, no standing for long or cross legs when sitting

• compression sucks

• assess pulse, temp, color, wounds, edema, stasis dermatitis, lipodematosclerosis

• surgery:

  • vein-stripping, ultrasound-guided sclerotherapy (vein assessed w/ catheter and UT), radiofrequency and laser ablation

meds:

• flavonoids (anti-inflammatory) → diosmin

• pentoxifylline→ hemorheologic agen

• ASA

• Saponins

PAD

causes:

ATHEROSCLEROSIS

injury LE, inflammation, radiation, embolisms or thrombosis, vasospasm

BMI 30, DM, Hypercholesterolemia, high homocysteine, smoking, hx of CV

s/s:

• discomfort, weakness, cramping, anxiety

• → nerve damage →functional disability, infection, ulcerations

• intermittent claudication

• shiny appearance, pale, elevated or cyanotic, bruits in iliac and femoral

• if in dependent position → red color

lab/dx:

• ankle-brachial index (ABI)

  • > 1.4 = vessel stiff

  • <0.9 vessel narrowing = PAD

  • measures ankle SBP ratio and compares w/ brachia SBP

  • uses doppler and gel, use blood cuff above ankle and doppler placed in dorsalis pedis → repeated in tibial = use highest reading → repeated in other leg

  • then get branchial

• Duplex UTsonography: gets a 2d image, locates lesions, hemodynamic

• CTA, MRA, peripheral angiogram

tx:

• check 6Ps = pallor, pain, polikilothermia, pulse, paralysis, parathesis

• cessation of smoking, controlling hypertension, maintaining a healthy weight, and reducing cholesterol

• 2 goals:

  • lower CV

  • improve ability to move

• exercise therapy (30-45min 3-4xday for min of 12w)

med:

• cilostazol - antiplatelet

• pentoxifylline

surgery: balloon angioplasty, stent, bypass graft

lead placement

• RA lead—on the right shoulder or arm

• LA lead—on the left shoulder or arm

• RL lead—on the right leg

• LL lead—on the left leg

• V1 lead—at the 4th intercostal space, right sternal border

• V2 lead—at the 4th ​​​​​​​intercostal space, left sternal border

• V3 lead—midway between V2 and V4

• V4 lead—at the 5th intercostal space, left mid-clavicular line

• V5 lead—at the 5th intercostal space between V4 and V6

• V6 lead—at the 5th intercostal space, just left of the spine

tx:

• check foot daily