Important Terms
What is the term for "the load to which a muscle is subjected upon shortening"?
Afterload.
Remember - it is the amount of force the ventricle of the heart has to overcome to eject blood forward.
What is the equation for cardiac output?
CO = Heart rate (HR) x stroke volume (SV).
What is the common ending for angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs)?
Give one example of each.
ACE Inhibitors - "PRIL" such as Lisinopril.
ARBs - "SARTAN" such as Losartan.
Explain the dosing of nitroglycerin including maximum amount of doses, how often to wait in between each dose and when to call 911.
When should you hold nitroglycerin?
For acute angina 3 doses maximum can be given, each dose 5 minutes apart. Remember when taking the 2nd dose, call 911. If the 3rd dose is needed take while EMS is on the way.
Hold for systolic BP less than 90.
What do beta blockers end in?
Give 1 example.
End in "OLOL".
Such as Metoprolol.
What are the 3 types of Angina?
Stable angina.
Variant (vasospastic angina).
Unstable angina.
What population is at greatest risk of silent myocardial ischemia?
Patients with diabetes due to neuropathy. Nerves that signal chest pain may not work well due to chronic hyperglycemia damaging nerves.
What is atherosclerosis?
Buildup of fatty material or cholesterol (also known as plaque) in the intima of the blood vessels.
What is the inotrope and chronotropy of the drug digoxin?
Positive inotropic effect - increases strength of contraction.
Negative chronotropic effect - decreases rate of contraction.
Where are the atrioventricular valves?
What is the one on the right side of the heart and the left side of the heart?
Valves that prevent backflow of blood from the ventricles to the atria during systole.
Tricuspid - Right sided.
Mitral - left sided.
What is the most common cause of acute pericarditis?
Viral infection.
Oral anticoagulants (such as heparin and NOACs) are contraindicated in who?
Contraindicated in pregnancy.
What are the 2 main classifications of calcium channel blockers?
Non dihydropyridines (verapamil and diltiazem)
Dihydropyridines (Nifedipine, end in "IPINE")
What is the term for "the load to which a muscle is subjected before shortening"?
Preload.
Remember - the amount of stretching or tensile strength the muscle endures at the end of diastole.
What serves as the reservoir for blood in our body?
Venous system serves as a reservoir for blood.
Remember - at any one time, majority of our blood is in the veins.
What is a common contraindication for ACE inhibitors and ARBs?
Not for use during pregnancy!
Never combine nitrates or vasodilators with what other medication? Why?
Do not combine with ED drugs, will cause refractory hypotension and can lead to death.
What 2 conditions are nonselective beta blockers contraindicated in?
COPD and asthma due to bronchospasm/bronchoconstriction.
Which type of angina is not reversible?
Unstable angina.
What 2 labs would indicate elevated cardiac enzymes?
Creatine Kinase - MB.
Troponin (remember - anything over 4 is worrisome).
What is the desirable total cholesterol lab value?
Desirable - less than 200
At risk - 200 to 240.
High - greater than 240.
What is considered the pacemaker of the heart?
SA node.
What causes the heart sounds?
What is S1 and S2?
Closing of the valves.
S1 is closing of AV valves.
S2 is closing of semilunar valves.
When listening to the heart, what is a common sound that is heard in a patient with acute pericarditis?
Pericardial friction rub; "leathery" sound.
What is a common adverse effect of hormonal manipulation?
DVT risk.
What is the antidote of calcium channel blockers?
Calcium gluconate.
Explain the difference between the following two terms: stenosis and regurgitation.
Stenosis - constriction or narrowing of a passage.
Regurgitation - backwards flow.
Arteries - thick vessel walls, no valves, carry blood away from the heart, high pressure, smaller lumen.
Veins - thin vessel walls, have valves, carry blood to the heart, low pressure, larger lumen.
Explain how the Renin-Angiotensin System works.
Decrease in blood pressure or renal perfusion is sensed by the kidneys.
Kidneys release renin.
Renin combines with angiotensinogen to form angiotensin 1.
Angiotensin 1 combins with angiontsin converting enzyme (ACE) in the lungs and creates angiotensin 2.
Angiotensin 2 causes vasoconstriction and the release of aldosterone.
Aldosterone promotes the retention of sodium and water; potassium is lost.
Increase in blood pressure and renal perfusion causes the kidneys to stop producing renin and the mechanism to shut off.
What are 2 drug interactions of nitrates or vasodilators?
HINT: These 2 medications can be given with nitrates or vasodilators to help prevent reflex tachycardia.
Beta blockers and calcium channel blockers.
Explain the chronotropic and inotropic effects of beta blockers.
Negative chronotropic (decreases HR).
Negative inotropic (decreases squeeze of the heart).
What is the main cause of variant (vasospastic) angina?
Caused by spasm of vessels, no relationship with plaque or atherosclerosis.
What are 2 contraindications for giving thrombolytics?
Major surgery.
Recent trauma.
Pregnancy.
Hemorrhagic stroke.
What medication is commonly used for cholesterol management?
What is the common ending of this drug class?
HMG CoA Reductase Inhibitors - Statins.
End in "STATIN" such as Atorvastatin.
What Labs should be checked for heparin and warfarin?
Heparin - aPTT or PTT
Warfarin/ INR or PT
Valve prolapse is a precursor to what cardiac disorder?
Precursor to regurgitation.
What are 2 common symptom of pericardial effusion and cardiac tamponade?
Pulsus paradoxes and muffled heart sounds.
A common complication of IV chemotherapy is extravasation. What is the management of extravasation?
Stop the infusion.
Do not remove the IV cannula.
Aspirate as much fluid out as possible.
Notify health care provider immediately.
Prepare/administer antidote and provide supportive care.
When giving verapamil and diltiazem (Non dihydropyridines), which other medication can cause additive effects?
REMEMBER - caution should be used when administering these drugs together.
Beta blockers cause additive effect.
What is pulsus Paradoxus?
When pulse becomes weaker or obliterated during inspiration.
What are the 4 factors that promote blood return to the heart?
Pressure in the venules.
Negative pressure in the right atrium.
Constriction of smooth muscle in the veins.
"Venous Pump" including the venous valves and skeletal muscle contractions.
Explain the difference in mechanism of action of Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARBs).
ACE Inhibitors - inhibit the conversion of angiotensin 1 to angiotensin 2 by blocking the formation of angiotensin converting enzyme (ACE) from the lungs.
ARBs - blocks angiotensin 2 at receptors.
Remember: does not cause increased potassium or cough d/t aldosterone still being produced and released.
Nitroprusside is the preferred drug when?
What do we need to watch for with this drug?
Preferred drug to bring down BP in emergencies.
Watch for thiocyanate (cyanide) poisoning by obtaining labs after 6 hours.
What type of angina are beta blockers used for?
When does variant (vasospastic) angina typically occur?
Occurs during rest.
At bedtime or during sleep.
Ideally revascularization after an MI should occur how many minutes after hospital arrival?
What are 3 examples of revascularization for MI, briefly explain what they do.
Revascularization ideally within 90 minutes of hospital arrival.
PTCA - smushing and flattening of atherosclerotic plaque to increase BV diameter and increase blood flow.
Stent placement - metallic stent holds atherosclerotic plaque out of the way; antiplatelet medication may be on stent to prevent clot formation.
CABG - bypassing area of bad blood vessel with a blood vessel from another part of the body; usually the saphenous vein of the leg.
What should be avoided when taking HMG CoA Reductase Inhibitors - Statins?
Why?
Do not consume grapefruit; it can increase risk of hepatotoxicity and can lead to toxicity in general.
What are 2 symptoms of digoxin toxicity?
What is the antidote?
Hypokalemia and halos around lights.
Antidote = digoxin immune fab (such as DigiFab or DigiBind).
What is valve stenosis?
What are 2 effects this has on the heart?
Obstruction of blood flow due to narrowing of the valve.
Increases pressure/distension of the chamber before the valve, leading to pulmonary (left sided) or systemic (right sided) congestion.
Decreased filling of the chamber after the valve.
Which of the disorders of the pericardium is a medical emergency?
Cardiac tamponade.
What is the main action of monoclonal antibodies?
Give an example or the ending of this class of drug.
Manipulate the immune system to specifically target malignant cells; preservation of normal "self" tissue compared to traditional cytotoxic drugs.
end in "MAB" such as rituximab and trastuzumab.
When giving IV Verapamil and Diltiazem (Non dihydropyridines), what should we be monitoring?
Cardiac monitoring.
Explain the difference between the following two terms: inotropy and chronotropy.
What happens during positive and negative inotropy/chronotropy?
Inotropy - the amount of contractility of the myocardium; the squeeze.
Positive = squeezing with more force; leads to increased cardiac output.
Negative = decreased squeeze; leads to decrease in oxygen demand of myocardium.
Chronotropy - the rate at which the myocardium contracts; the heart rate.
Positive = increased HR.
Negative = decreased HR.
What are the 3 main control systems of hemodynamics in order from fastest to slowest?
ANS - fastest.
Renin-angiotensin - hours to days.
Kidneys - days to weeks.
Why are ACEs used over ARBs?
ACEs have cardioprotective and cardiovascular remodeling effects while ARBs do not.
Give 3 precautions/education of vasodilators and nitrates.
Store away from light, heat, moisture. Keep in original dark glass container.
Should tingle under the tongue.
Do not drink alcohol.
Short term headache is a normal side effect.
Do not combine with ED drugs.
Avoid exertion while taking medication (REST).
Change positions slowly.
What are 3 important considerations (when to hold the medication, contraindications, assessments, drug interactions, etc.) when giving beta blockers?
Always assess clients blood pressure before giving, hold for systolic less than 90.
Always assess the clients apical pulse before giving, hold for heart rate less than 60.
Give patient their beta blocker before going to surgery.
Never abruptly stop beta blockers, always taper to discontinue.
Watch EKG for new or worsening heart block.
Use caution when adminstering with other negative chronotropes.
Avoid the use of nonselective beta blockers in clients with COPD or asthma.
After the 2nd dose, take the 3rd dose while EMS is on the way.
What are the main interventions for a patient experiencing an MI?
HINT: think about the acronym "MONATASS".
Morphine
Oxygen (remember - start with low flow on NC).
Nitroglycerin
Aspirin
Thrombolytics (remember - to dissolve existing clot).
Anticoagulants
Stool Softeners (remember - important to prevent straining).
Sedatives
What are the main differences between HDL and LDL?
What lab values are desirable for HDL and LDL?
HDL (high density lipoproteins) - good cholesterol; protective effects on the blood vessels.
greater than 40 mg/dl - high is desirable (above 60 is considered protective).
LDL (low density lipoproteins) - bad cholesterol; greatest contributor to coronary artery disease.
Less than 130 mg/dl - low is desirable (less than 100 is optimal).
What are the antidotes to the following:
Heparin
Warfarin
Factor Xa (HOACs)
Heparin - protamine sulfate.
Warfarin - vitamin K
HOACs - adexanet alfa or 4-factor PCC
What is valve regurgitation?
What are 2 effects this has on the heart?
Allows back flow of blood due to improper patent seal.
Increases work of the ventricle leading to ventricular hypertrophy.
Leads to decreased ventricle output.
What is the difference between pericardial effusion and cardiac tamponade.
Pericardial effusion - accumulation of fluid in the pericardial cavity.
Cardiac Tamponade - rapid increase in pericardial pressure caused by the accumulation of fluid or more often blood in the pericardial sac.
What is the common hematopoietic-simulating factor for RBC?
What are the 2 hold parameters for this?
Epoetin Alfa (Erythropoietin) - stimulates RBC formation.
Hold for systolic blood pressure greater than 180 and hemoglobin greater than 11.
What are the differences in action between non dihydropyridines and dihydropyridines?
Non dihydropyridines - smaller effect on vasodilation, have negative chronotropic and inotropic effects (decrease heart rate and decrease force of contraction).
Dihydropyridines - more effect on vasodilation. Body responds to vasodilation with positive inotropic and chronotropic effect (increase HR and increase force of contraction).