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129 Cards in this Set
- Front
- Back
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What is Atherosclerosis?
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athere- fatty mush & skleros- hard
soft deposits of fat that harden w/age |
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What are nonmodifiable risk factors for CAD?
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family hx of HTN, DM, stroke, obesity, high cholesterol
age >40 gender- males race- nonwhites |
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What are the modifiable risk factors for CAD?
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environment-higher in urban rather than rural, North America, Australia, Europe, New Zealand
smoking HTN elevated cholesterol DM stress/personality |
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4 major S.E. that smoking has on the body?
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lipid levels
cardiac electrical instability platelet agglutination decreases HDL, increases LDL |
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What are 2 lifestyle changes that have increased women's incidence of CAD?
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working
smoking |
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Which layer of the arterial wall does atherosclerosis affect primarily?
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Intima
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Difference between fatty streaks & plaque?
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fatty streaks are reversible; smooth, yellowish slightly raised streaks on the inner surface of the artery
plaque- irreversible; yellowish gray raised bump on the surface consisting of smooth muscle cells, collagen & lipids |
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Symptoms are the result of what during atherosclerosis?
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critical deficit in blood supply to the heart in proportion to the demands of the myocardium
supply & demand imbalance |
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Medical management of atherosclerosis focuses on what?
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prevention rather than tx
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Patho of Angina?
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when more blood than needed, vessels dilate becoming occluded w/plaque losing ability to dilate & supply blood to the heart
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What blood disorders result in a MI?
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anemia, polycythemia
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What is the actual cause of pain associated with angina?
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lactic acid
cells convert to anaerobic metabolism which produces lactic acid as a waste product = pain |
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Clinical manifestations of angina?
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sensation- squeezing, burning, pressure, choking, feels like gas or heartburn, not localized or sharp
mild to moderate, rarely severe in retro-sternal or left of sternum that may radiate anywhere lasting 2-30mins relieved by rest & NTG |
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What is the typical sequence in the development of angina pain & relief?
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exertion- pain- rest- relief
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Best type of pt that a stress test would be a good dx study on?
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pt w/normal EKG, suspected CAD and not on Digoxin
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Which dx study is the best to determine L ventricular function?
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cardiac catherization
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Primary goals of pharmacological management for angina?
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tx BP, HR & L ventricular volume
decreasing workload, O2 consumption, increasing supply & contractility |
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4 ways vasodilators relieve pain?
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dilating smooth muscle of venous system decreases venous return reducing L ventricular workload & SVR
dilates large coronary arteries for improved blood supply to myocardium improves collateral blood flow decreases myocardial O2 requirements by decreasing preload/afterload |
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Another name for IV NTG?
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Tridil
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Primary effects that beta blockers have?
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decrease everything (SA node discharge, BP, myocardial contractility, myocardial O2 consumption, catecholamine stimulation)
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2 important things to know about Procardia (CCB)?
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Nifedipine
1 decreases workload/contractility 2 compliments vasodilators & beta blockers |
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Why do most ppl die from ACS before they get to the hospital?
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they ignore it, don't go, wait & try to relieve it
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How does cocaine cause an MI?
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increases BP & HR, stimulant, decreases demands on heart
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Why are tricyclic anti-depressants so cardio-toxic?
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increases HR, BP & contractility
block reuptake |
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Why do the myocardial cells release Adenosine?
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protective mechanism
myocardial cells release more than half of their adenosisne supply to dilate the coronary arteries limited supply of adenosine |
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How long is the window of opportunity in which you can limit the size of an MI?
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6hrs
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What are the 3 zones identified?
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infarction
hypoxic injury ischemia |
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What is a transmural MI?
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all 3 layers of myocardium involved
Q wave produced STEMI |
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How do we determine which part of the myocardium was affected?
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12 lead EKG
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Which vessel is named the widow's artery?
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LAD/L Main
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What symptoms usually occur with Anterior wall MI?
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sympathetic
pain, anxiety, HTN, tachycardia |
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What EKG changes are noted with a AWMI?
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ST elevation in leads V1-4
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What vessels are involved in an AWMI?
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L ventricle, septum, bundle of his, R bundle branch, apex
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The R coronary artery feeds what part of the heart?
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Right
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The Inferior wall MI involves what vessel?
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R coronary artery/circumflex
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What EKG changes are seen with an IWMI?
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2, 3, aVF
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What symptoms usually occur with IWMI?
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parasympathetic
bradycardia, junctional rhythms, nausea, hypotension |
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What vessels are involved in an IWMI?
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SA & AV node, R ventricle, R atrium
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What pt typically has a R ventricular infarct?
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inferior wall MI
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How do we tx R ventricular infarct & what not to admin?
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fluids, R sided EKG
NO NTG OR MORPHINE r/t drop in preload |
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What happens with a R ventricular infarct?
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R ventricle becomes stiff and CO drops with increases SVR
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Primary purpose of collateral circulation?
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provide alternate blood routes
limiting extent of damage, preserves healthy heart |
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Why do older pts with MI do better than younger?
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young ppl little to no collateral, elderly have more so they can tolerate MI better
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Description of pain in an MI?
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crushing, severe, prolonged, unrelieved by NTG or rest
radiating to one or both arms, neck, back localized |
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Description of shock in an MI?
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SBP < 80
gray facial color, lethargy, cold diaphoresis, peripheral cyanosis, tachycardia, bradycardia, weakness, thready pulse |
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Other clinical manifestations in an MI?
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oliguria, fever, apprehension, APE, EKG changes
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What are the EKG changes in an MI?
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ST depression- ischemia
ST elevation- injury Q waves- necrosis |
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How are cardiac enzymes used as a dx tool?
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when cell stressed/damaged its contents are released
usually don't leak some enzymes are found in all cells, others are specific to organ |
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CK is found where & norm range?
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heart, brain, skeletal muscles
40-150 |
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CK-MB found where & norm range?
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heart
0-5 or <3% of total CK |
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What is Troponin?
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family of proteins found in skeletal & heart muscle fibers
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How does Troponin help with dx of MI?
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cardiac specific marker
amount of damage correlates to value |
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Troponin I levels?
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<0.02
0.6- 1.5 suspicious >1.5 +MI |
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Why would a MD order an Echo?
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assess function of the heart, check valve funciton, EF
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Within the 1st 6hrs, medical management focuses on what?
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pain!
pain = ischemia |
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What does MONA stand for?
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Morphine sulfate
Oxygen NTG ASA |
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How much O2 is applied & even under what circumstances?
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1-4L/min
even if pulse oxy is >93% |
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What does ASA do & given when?
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prevents formation of Thromboxane A2, a substance released by platelets that promotes coagulation
1st drugs given give even if on Coumadin 160-325mg PO or rectally, chewable best true allergy is only contra |
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NTG admin when?
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1st unless contra by hypotension, HR <50, RVMI
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Morphine sulfate given why & what else can be given?
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vasodilator- decreases preload/afterload
true allergy- give fentanyl |
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Purpose of fibrinolytic agent?
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stimulate lysis of the clot by converting inactive plasminogen to plasmin
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tPA does what?
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binds to fibrin at the clot, promotes activation of plasminogen to plasmin
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CK/Troponin do what?
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rise rapidly & peak early with fibrinolytic therapy
called washout not a tool to determine size of infarct |
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Main reason IV platelet inhibitors are given?
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prevent development of fibrinogen cross-bridges preventing platelets from clumping together
ReoPro |
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3 primary reasons dysrhythmias occur within the 1st 48hrs post- MI?
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K leaks out of damaged cells
acidosis alters resting membrane potential increased release of catecholamine |
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What is Cardiogenic shock?
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deadly cycle that starts with heart failure & rapidly progresses to circulatory collapse, pulmonary edema, ischemia & inadequate perfusion throughout the body
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Tx/prevention of cardiogenic shock?
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rapid relief of pain
fluid replacement vasopressors |
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S&S of Pericarditis, & classic sign?
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friction rub
pain that increases with inspiration & is relieved by leaning forward- classic |
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What are structural problems?
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ventricular free wall rupture, ventricular/septal perforation, papillary muscle/chordae tendinease
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What are 3 goals of cardiac rehab?
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live full, vital & productive life
remain within heart's ability to respond to increases in activity & stress avoid being a cardiac cripple or reckless over doer |
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Closed cardiac surgery is what & its advantages & disadvantages?
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small opening creating & endoscopic tools are used
advant- bypass pump not used, quicker healing disadv- direct visual of vessels |
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Open cardiac surgery is what, advantages & disadvantages?
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cutting the sternum & insertion of chest tubes
advan- direct visualization, dry operative field, lengthy procedures disad- longer recovery time, increased risk of infection, & pulmonary comp |
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Cardiopulmonary Bypass is what?
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Heart-lung machine
machine that uses a mechanical pump that simulates L ventricular pumping action & oxygenator that performs the work of the lungs by creating a blood-gas exchange partial or total bypass |
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Purpose of bypass?
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bloodless field
supplies O2 & removes CO2 filters, cools & rewarms blood circulates oxygenated filtered blood back to arterial system |
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Purpose of cooling blood & to what temp?
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82.4-89.6F
done gradually to prevent shivering which increases metabolic demands & O2 needs prevents ischemia & damage to vital organs |
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What is Hemodilution w/Heart lung machine?
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machine & tubing is primed w/ heparinized RL or Normosol w/ NaHO3 to prevent clotting in the machine
it replaces venous blood as its diverted from the machine, & decreases viscosity of the blood since the blood is cooled |
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Summary of bypass machine?
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reservoir hold blood temporarily, O2 & CO2 exchange, cools then rewarms, pump circulates blood in a non-pulsatile flow, filter/bubble trap removes clots, air & fat emboli
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Complications of Bypass machine?
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altered coagulation: hemolysis results from destruction of RBCs & platelets from trauma & drop in RBC, Hgb, & platelets (return to normal in 3-4days)
hemodilution: priming solution dilutes blood so Hct drops, platelets release substances which decreases plasma oncotic pressure = increased fluid & wt, edema of face & extremities, & 4-10lbs |
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2 other complications of bypass?
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thrombus
increased SVR = high BP & drop in CO - give Tridil IV |
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Effects of bypass?
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hypotension, wt gain, edema, drop in CO, bleeding, pulmonary dysfunction, hemolysis, hyperglycemia, hypokalemia & hypomagnesia (fluids/diluted), neurological dysfunction (pump head), HTN
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Process of stopping bypass?
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blood slowly rewarmed to prevent hypotension,
air vented from heart chambers & aortic root, clamps removed, heart restarted, lungs re-expanded heparinization reversed w/protamine |
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What is valvulotomy?
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opening in L atrium, leaflets are loosened w/ finger or dilator or calcified tissue & tissue fused
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What is valvuloplasty?
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actual repair of the valve done w/bypass, open heart surgery, leaflets are sutured or annuloplasty ring is placed
narrow diameter of valve opening to prevent regurgitation |
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Disadvantages of mechanical valves?
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anticoagulation necessary for life, prophylactic antibiotics prior to invasive procedures, clicking sound
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Heterografts are what & good for?
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tissue valves (porcine & bovine)
older pt >70 lacks durability <10yrs anticoagulation for 1st 3 monts |
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Homografts are what & for?
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human cadavers
excellent hemodynamics not thrombogenic 10-15yr durability |
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Homograft disadvantages?
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limited availability, can be affected by same disease that destroyed original
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Transcatheter & transapical is what & indicated for?
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catheter threaded up femoral artery through heart chambers to aortic valve
transap- catheter passed through wall of R ventricle into aortic valve indicated for? severe symptomatic aortic stenosis, high risk for death with conventional method |
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Contra for transapical/transcatheter?
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<1yr life span, different sizes, GI bleed
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Indications for CABG?
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angina not controlled w/meds, unstable angina, unsuccessful PTCA, blockage >70% or >60% in L main
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Types of grafts?
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saphenous, LIMA, radial, gastroepiglotic
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Saphenous vein graft?
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reversed or anastomosed upside down because of directional valves
anastomosed from aorta to the coronary artery not intended to support additional pressure & volume can do emergent bypass with |
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LIMA graft?
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bypass LAD
can't use RIMA left is longer & larger takes longer to harvest, emergency bypass not an option |
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Radial graft?
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used for individuals undergoing second or re-do CABG in whom LIMA has already been used
don't use in pts with calcium channel blocker allergy (CCB used postop as an antispasmotic) |
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Valvuloplasty is what & its purpose?
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actual repair of the valve done w/bypass, open heart surgery, leaftlets are sutured or an annuloplasty ring is placed
purpose is to narrow diameter of valve opening to prevent regurg contra in valve leaflet calcification |
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Minimally invasive cardiac surgery?
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smaller incision, don't split sternum, no bypass
heart slowed w/ B-adrenergic blocker (Brevibloc) or stopped temporarily w/Adenocard & a mechanical stabilizer used to immobilize the anastomosis site |
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Types of MICS?
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MIDCAB, Beating heart surgery/ off-pump CAB, RACAB, minimally invasive direct view, keyhole heart surgery
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Main cause of inflammation in off & on pump surgeries?
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manipulation of tissue
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What is collateral circulation?
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body makes its own bypass system
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Assessment of complications?
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pulses, cap refill, skin color, c/o chest pain, dyspnea
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Cardiac dysfunction assessment?
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decreased perfusion & oxygenation
tx- BB, ACE inhibitors, mechanical vent- IABP |
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Pulmonary dysfunction assessment?
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ABGs, pulse ox, lung sounds, RR
Tx- O2, ventilation, bronchodilators, anticoagulants |
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Neuro & Bleeding assessment?
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neuro status changes, anticoagulants
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GI dysfunction assessment?
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BUN/Cr, abd tenderness, distention, bowel sounds, NG
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What is transmyocardial laser revascularization?
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create channels between L ventricular cavity & the coronary microcirculation
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What is Maze procedure?
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series of scars are made in the atrial tissue using ablation caths to create an electrical maze that disrupts the reentrant pathways & directs the sinus impulse through the AV node
isolates pulmonary veins goal is to prevent atrial tachycardia & restore sinus rhythm & AV synchrony |
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Pre-op teaching?
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med for pain, normal to see bloody drainage in chest tubes, coughing/deep breathing, splint, OOB 1st day, NPO after midnight, shave prep, bath/shower after shave w/antimicrobial soap, sedative, TED hose, monitor PT, PTT, BP
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Basic nursing care post-op?
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transfer to vent, attach hemodynamics, neuro status, IV, CT, urine output
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Post-op vent?
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extubated in OR or within 4-6hrs post op, gradually decrease FIO2 & rate, once 40% check parameters & extubate
AFM to NC ABGs 30min to 1hr after vent changes |
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Post-op BP management?
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Map 65-85
tx high BP w/vasodilators/Tridil, to prevent collapse of graft tx w/fluids- colloids (albumin, hespan) or dopamine |
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Post-op PAP?
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keep CVP: 5-15
PCWP: around 12 CO >4, CI 2-4 SVO2:- 60-80% SVR: 800-1500 |
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Post-op chest tube?
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100-200mL first 3hrs
taper off to about 50mL/hr call if >100mL/hr unless 1st time pt OOB- gush is normal |
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reverse heparinization med?
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protamine sulfate (vit K)
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Beck's triad?
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increased CVP, decreases BP, muffled heart sounds, pulse paradoxus
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Renal assessment post-op?
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>30mL/hr or 0.5mL/kg
dopamine IV 0.5-3mcg/kg/min |
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Activity progression post-op?
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fatigue, weakness
active/passive ROM TEDs for 6weeks OOB post-op day 1 walks in hall walk 1 flight of stairs prior to discharge no driving 4-6weeks no excessive reaching/lifting sex 3-4weeks part time work at 6weeks |
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Edema in legs post-op?
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doesn't always resolve, may always be an issue
resolve once other veins or collateral vessels take over |
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PTCA used to tx what?
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angina refractory to med therapy, recurrent ischemia after MI, ischemia on resting or ambulatory EKG, ST depression, SOB, chest pain, acute MI w/obstructed or stenosed artery
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Recommendation for emergent PTCA?
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1st line tx for pt w/confirmed ACS (EKG changes + cardiac biomarkers)
goal- open artery within 90mins of arrival to DEM |
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Advantages of PTCA?
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local anesthesia, <3 days in hospital, return to work in 5-7days
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Contras for PTCA?
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all are relative contraindications
calcified, tortuous, completely occluded or thrombus lesions high risk anatomy (L main) no evidence of ischemia absence of on site surg back up |
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How many pumps for how long for PTCA?
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2-3 for 15-30secs
chest pain will go away |
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What needs done for PTCA?
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consent to emergent surgical repairs
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Nursing care after PTCA?
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keep extremity straight & flat for 8-12hrs then HOB 30degrees
apply pressure to site assess for chest pain, 12lead EKG, kidney function labs- K, PT/PTT, electrolytes, H&H, platelet, cardiac enzymes, BUN/Cr |
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What to teach post-PTCA?
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no lifting >10lbs, drive after 48hrs, pain at groin site medicate w/tylenol
(if need more than tylenol = problem) report pain @ site, redness, swelling, tenderness, hematoma |
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What is an angio-seal?
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bioabsorbable active closure system
not for pts w/PAD |
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What is a DES?
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emits a drug that inhibits cell growth to prevent early restenosis
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Coronary stents do what?
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used to mechanically scaffold the arterial lumen
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What is an atherectomy?
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excision & removal of the atheroclerotic plaque by cutting, shaving, or grinding
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