CAD
Inherited predisposition to develop new blood vessels.
What is angiogenesis?
What are the inclusion criteria for thrombolytic therapy?
•Chest pain < 12 hrs with 12-lead ECG findings of a STEMI
•No absolute contraindications (active internal bleeding, hx of intracranial hemorrhage, etc.)
List two facts about BNP.
•BNP ( B-type Natriuretic Peptide)
•A simple test that helps diagnose patients with CHF
•↑ levels by heart tissue when overloaded with pressure & excess volume
•↑ BNP is highly sensitive and specific for the diagnosis of HF
•Also useful for differentiating pulmonary and cardiac causes of dyspnea
What are the shockable rhythms?
Vfib. and Pulseless Vtach
Common scale used to assess agitation in ICU patients
What is the Richmond Agitation-Sedation Scale (RASS)?
scored -5 to +4. -5 is no response to voice or stimulation and +4 is violent and dangerous to self and others.
Name and describe the 3 developmental stages of atherosclerosis.
Fatty Streak: lipid accumulation into smooth muscle cells, yellow tinged
Fibrous Plaque: collagen covers the fatty streak, vessel lumen narrowed, blood flow reduced, fissures develop; grey/whitish
Complicated Lesion: continued inflammation can result in plaque instability, ulceration, and rupture
For a STEMI, what is "door to balloon" and "door to drug" mean? What are the expected time frames for each?
Door to balloon <90 mins: PCI
Door to drug < 30 mins: Thrombolytics, if no PCI available
Explain the difference between HFrEF and HFpEF.
Systolic/HFrEF - Inability to of the ventricles to eject properly. Will see decrease in EF (<45%). Blood backs up into left atrium & lungs, causing pulmonary edema.
Diastolic/HFpEF - Inability of the ventricles to relax & fill during diastole (usually due to stiffness & noncompliance). Results in decreased SV & CO. Diagnosis by s/s, normal EF, evidence of diastolic dysfunction on imaging
What are the normal ranges for the PR interval, QRS complex, and QT interval?
PR interval: 0.12-0.20
QRS complex: less than 0.12
QT interval: 0.34-0.43 or less than 0.50
Normal CVP values
2-8 mmHg
Name 3 causes of endothelial injury.
1. Hypertension
2. Tobacco use
3. Hyperlipidemia
4. Diabetes
5. Infections
6. Toxins
7. Hyperhomocysteinemia
Explain the diagnostics that differentiate between unstable angina, NSTEMI, and STEMI. (ECG and cardiac markers)
ECG:
•UA or NSTEMI: ST depression and/or T wave inversion facing ischemia/infarction
•UA: negative cardiac markers
•NSTEMI: positive cardiac markers
•STEMI: ST elevation in the leads facing the infarcted wall. ST segment elevation of 1mm or greater in 2 contiguous leads or 2mm or more in V2 and V3; positive cardiac markers
Define ventricular dilation and ventricular hypertrophy.
Ventricular Dilation: Enlargement in the chambers of the heart from the muscle fibers stretching in response to increased preload à causes temporary increased contraction & subsequent increased CO for maintenance of BP & perfusion.
Ventricular Hypertrophy: Increase in the muscle mass and heart wall thickness that occurs from overwork and strain. Initially increases contractile power of the muscle fibers which increases CO & perfusion.
Which dysrhythmia has the following characteristics?
P wave difficult to identify, R-R constant, QRS <0.10, rate: 150-250, regular rhythm.
SVT
How to calculate MAP
[(SBP)+2(DBP)]/3
Normal range 70-105 mmHg (note that in practice you may see acceptable parameters lower than this range).
Name 3 major modifiable risk factors for CAD. Explain how each are risk factors.
•High serum lipids: more available lipids to accumulate within vessels
•Hypertension: ↑ BP = endothelial injury = atherosclerosis = ↑ force = ↑ BP
•Tobacco use: releases catecholamines = ↑ HR, vasoconstriction, and ↑ BP = ↑ heart’s workload
•Physical Inactivity: Exercise = efficient lipid metabolism, ↑ HDL production, ↓ thrombus formation
•Obesity: BMI > 30 and waist circumference > 40 inches (men) and > 35 inches (women)
•Diabetes: causes endothelial injury and changes to lipid metabolism = ↑ cholesterol & ↑ triglycerides
•Metabolic Syndrome: cluster of risk factors for CAD (obesity, HTN, ↑ serum lipids, ↑ glucose)
Name and describe four complications associated with ACS.
•Dysrhythmias: Ventricular tachycardia (VT), Ventricular fibrillation (VF), Heart Blocks
•Heart Failure: Ventricle’s pumping action is reduced
•Cardiogenic Shock: occurs when O2 and nutrients to the tissues are inadequate
•Goal: ↑ O2 delivery, ↓ O2 demand, and prevent complications
•Papillary Muscle Dysfunction/Rupture: occurs if infarct near muscle that attaches to the mitral valve
•New systolic murmur = mitral valve regurgitation
•Left Ventricular Aneurysm: infarcted heart muscle wall thins and bulges out during contraction
•Ventricular Septal Wall Rupture/ Left Ventricular Free Wall Rupture: new loud systolic murmur
•Pericarditis: inflammation of the visceral and/or parietal pericardium
•Dressler Syndrome: pericarditis and fever 1-8 weeks after MI
Define preload, afterload, cardiac output, and ejection fraction.
Cardiac output=amount of blood pumped by the heart in 1 minute (norm 4-8 L/min)
Preload=amount of blood present at the end of diastole prior to the next ventricular contraction (increased by hypertension, aortic valve disease, hypervolemia)
Afterload=peripheral resistance the LV has to pump against in order to open the pulmonic/aortic valves; force opposing the movement of blood
Ejection fraction-the % of blood leaving your heart each time it contracts (norm 55-60%; measured by echocardiogram or cardiac catherization)
What are the two treatment goals for pts with A.fib?
#1 Decrease ventricular rate
• Drugs to slow HR: -adrenergic blockers, IV calcium- channel blockers
#2 Prevent embolic stroke
• Long-term anticoagulation: Coumadin, Alternative anticoagulants
These potential complications of using this catheter include infection, arrhythmias, and, although rare, pulmonary artery rupture.
What is a Swan-Ganz (pulmonary catheter)?
Infection at the insertion site. Thrombosis (blood clot formation). Arrhythmias (irregular heartbeats). Pulmonary artery rupture due to balloon inflation. Air embolism (air bubble in the blood vessel). Pneumothorax (collapsed lung if the subclavian vein is used).
Name the normal ranges for the following: Total cholesterol, LDL, HDL (men and women), Fasting Triglyceride
Total Cholesterol <200 mg/dL
LDL < 130 mg/dL
HDL >40 mg/dL (men) and >50 mg/dL (women)
Fasting triglyceride < 150 mg/dL
Define sudden cardiac death. What are common causes? How can it be prevented? What interventions are to be implemented during a witnessed event?
•Sudden Cardiac Death (SCD): abrupt, unexpected death resulting from a variety of cardiac issues without 1 hour of symptom onset
•Most common cause is acute ventricular dysrhythmias (VT or VF) with or without MI = loss of CO and cerebral blood flow
•Have a history of LV dysfunction (EF <35%), and/or structural heart disease (hypertrophic cardiomyopathy)
•Clinical Manifestations: angina, palpitations, dizziness/lightheadedness
•Use of an implantable cardioverter-defibrillator (ICD) to prevent event
•Rapid CPR, defibrillation and use of an automatic external defibrillator (AED) for witnessed arrest cases
Name two medications that increase contractility of the heart muscle and two different side effects for each.
Dobutamine: Hypertension, dysrhythmias, angina, headache
Digoxin: Dizziness, changes in mood and mental alertness (confusion, depression and lost interest), anxiety, nausea, diarrhea, headache, rash
Name two types of pts who are appropriate for an implantable cardioverter-defibrillator.
• Have survived SCD
• Have spontaneous sustained VT
• Have syncope with inducible ventricular
tachycardia/fibrillation during EPS
• Are at high risk for future life-threatening
dysrhythmias
This invasive monitoring device is indicated for assessing hemodynamic status in critically ill patients, particularly those with complex shock states, severe heart failure, or pulmonary hypertension.
What is a pulmonary artery catheter (Swann-Ganz)?
Some other indications to use a PA catheter: Diagnosis or evaluation of pulmonary hypertension. Assessment of vascular resistance. Determination of etiology in cases of shock. Assessment of volume status in severe shock. Evaluation of pericardial illnesses such as cardiac tamponade or constrictive pericarditis. Assessment of right-sided valvular disease or congenital heart disease. Evaluation of intracardiac shunts.