Npte - Cardiovascular/pulmonary Systems Part Ii

Front 1

Alpha Adrenergic Antagonist Agents

Back 1

Reduce peripheral vascular tone -> dilates arterioles and veins & decreases BP
Risk of orthostatic Hypotension

Front 2

ACE Inhibitors

Back 2

Decrease BP and afterload by suppressing the enzyme that converts angiotensin I to angiotensin II
Indications - hypertension, CHF
Orthostatic hypotension

Front 3

Angiotensin II Receptor Antagonist Agents

Back 3

Block angiotension II receptors which limit vasoconstriction
Indications - Hypertension, CHF
Side effects - dizziness, back and leg pain, angina pectoris

Front 4

Antiarrhythmic Agents

Back 4

Class I - Sodium channel blockers - control cardiac excitation and conduction
Class II - Beta blockers - inhibit sympathetic activity by blocking bega adrenergic receptors
Class III - Prolong repolarization by inhibiting both K and Na+ channels and are often considered the most effective antiarrhytmic agent
Class IV - Calcium channel blockers - depress depolarization and slow conduction through AV node

Front 5

ECG

Back 5

P wave - atrial depolarization
PR interval - time for atrial depolarization and conduction from SA to AV node (.12-.2")
QRS complex - depolarization of ventricles
It should be between 0.06-0.10 seconds
QT interval - time for both ventricular depolarization and repolarization (.2-.4")
ST segment - isoelectric period following QRS when the ventricles are depolarized
T wave - ventricular re-polarization

Front 6

Cardiac conduction

Back 6

SA node -> AV node -> Bundle of his -> R/L bundle branches -> Purkinje fibers

Front 7

Anticoagulant Agents

Back 7

Inhibit platelet aggregation and thrombus formation.
Side effects -hemorrhage, GI distress, increased risk of bleeding
Examples - Heparin, Coumadin (warfarin), Lovenox (enoxaparin)

Front 8

Antihyperlipidemia Agentsh

Back 8

5 categories
Most common - statins - inhibit enzyme action in cholesterol synthesis, break down LDL, decrease triglyceride levels, increase HDL levels.
Examples - Lipitor, Zocor, Tricor
Side effects - headache, GI distress, myalgia, rash
Exercise can maximize the effects of drug therapy

Front 9

Antithrombic (Antiplatelet) Agents

Back 9

inhibit platelet aggregation and clot formation
Examples - Bayer (aspirin), Plavix, Persantine
T

Front 10

Thrombocytopenia

Back 10

Decreased platelet count
A normal human platelet count ranges from 150,000 to 450,000 platelets per microlitre of blood

Front 11

Beta Blockers
(Beta-Adrenergic Blocking Agents)
(LOL!)

Back 11

Decrease myocardial oxygen demand by decreasing HR and contractility via blocking B-adrenergic receptors
Indications - Hypertension, angina, arrhythmias, heart failure, migranes, essential tremor
Side effects - bradycardia, arrhythmias, fatigue, depression, dizziness, weakness, blurred vision
Implications for PT - HR and BP response to exercise will be diminished. RPE may be used to monitor exercise intensity. Closely monitor patients during positional changes due to an increased risk for othostatic hypotension.
Examples - Tenormin (adenolol), Lopressor (metoprolol), Inderal (propanolol)
- LOL

Front 12

Calcium Channel Blockers

Back 12

Decrease entry of calcium into vascular smooth muscle cells resulting in diminished myocardial contraction, vasodilation, and decreased oxygen demand of the heart
Indications - hypertension, angina pectoris, ahhrythmias, CHF
Side effects - dizziness, headache, hypotension, peripheral edema
Examples - Norvasc, Procardia, Calan, Cardizem

Front 13

Diuretic Agents

Back 13

Increase excretion of sodium and urine. This reduces plasma volume which decreases BP.
Classifications include thiazide (Diuril), loop(lasix), and K+ sparing agents (dyrenium
Indications - hypetension, edema associated with heart failure, pulmonary edema, glaucoma
Side effects - dehydration, hypotension, electrolye imbalance, polyuria, increased LDL, arrhythmias

Front 14

Nitrate Agents

Back 14

Decrease ischemia through smooth muscle relaxation and dilation of peripheral vessels
Indications - angina pectoris
Examples - nitrostat (Nitroglycerin), isordil (isosorbide dinitrate), Amyl nitritite solution for inhalation

Front 15

Positive Inotropic Agents

Back 15

Increase force and velocity of contraction, slow HR, decrease conduction velocity through AV node, decrease degree of activation of sympathetic nervous system

Front 16

Thrombolytic Agents

Back 16

Clot dissoultion through conversion of plasminogen to plasmin (breaks down clots and allows occluded vessels to reopen)
Indications - Acute MI, PE, ischemic stroke, arterial or venous thrombosis
Ex - Linlytic (urokinase), Activase (alteplase)

Front 17

Antihistamine Agents

Back 17

Block effects of histamine to dec nasal congestion, mucosal irritation, and smptoms of the common cold, sinusitis, conjunctivitis, and allergies
Indications - allergies, cold, motion sickness, Parkinson'sl

Front 18

Anti-inflammatory Agents

Back 18

Indications - brochospasm, asthma
Inhaled corticosteriods, leukotriene modifiers, and mast-cell stabilizers help prevent inflammatory-mediated bronchoconstriction by inhibititing production of inflammatory cells, suppressing release of inflammatory mediators (cytokines, prostaglandins, leukotrienes), and reversing capillary permeability, in turn reducing airway edema
Side effects - Corticosteriod: osteoporosis, glucoma, delayed growth; Leukotriene modifier - Liver dysfunction; mast-cell stabilizer-bronchospasm, throat and nasal irritation, cough, GI distress
Implications for PT- pt ed to rinse mouth after inhalation, these are not bronchodilators and are not for acute episodes of asthma

Front 19

Bronchodilators

Back 19

Releive bronchospasm
Albuterol

Front 20

Expectorants

Back 20

Increase respiratory secrections which helps loosen mucous. Reduces the viscosity of secreations which improve efficiency of the cough reflex and ciliary action in removing it
PT implication - perform airway clearance techniques one hour after drug administration. Take w glass of water
Mucinex (guaifenesin)

Front 21

Mucolytic Agents

Back 21

Decrease viscosity of mucous secretions by altering their composition and consistency, making them easier to expectorate
Given w nebulizer
pneumonya, emphysema, chronic bronchitis, cystic fibrosis
Perform airway clearance one hour after administration

Front 22

Korotkoff sounds

Back 22

During blood pressure assessment
Phase I - first appearance of clear tapping sounds corresponds to appearance of a palpable pulse (SYSTOLIC BP)
Phase II - sounds become softer and longer
Phase III - sounds become crisper and louder
Phase IV - sounds become muffled and softer
Phase V - sounds disappear completely (DIASTOLIC BP)

Front 23

Auscultation of heart souunds - locations

Back 23

Aortic area - 2nd intercostal space at right sternal border
Pulmonic area - 2nd intercostal space at L sternal border
Mitral area - 5th intercostal space, medial to left midclavicular line
Tricuspid area - 4th intercostal spaceat the left sternal border

Front 24

Auscultation of heart sounds - interpretation

Back 24

S1 (lub)
- close of mitral and tricuspid valves at onset of ventricular systole
S2 (dub)
-closure of aortic and pulmonary semilunar valves at onset of ventricular diasole
S3
-abnormal in adults
-vibrations of distended ventricle walls due to passive flow of blood from the atria during filling phase of diastole
S4
- pathological sound of vibration of the ventricular wall when atria contracts and ventricle fills

Front 25

Normal breath sounds

Back 25

Tracheal and broncheal sounds - loud, tubular sounds normally heard over the trachea
Vesicular breath sounds - high pitched, breezy sounds heard over distal airways

Front 26

Abnormal breath sounds

Back 26

Crackle (rales) - movement of fluids or secretions during inspiration (wet crackles), or from sudden opening of closed airways (dry crackles)
- atelectasis, fibrosis, pulmonary edema, or pleural effusion
Pleural friction rub
Ronchi - "snoring/gurgling"
Stridor - continuous high pitched wheeze, indicating upper airway obstruction
Wheeze - "musical" whistling sound of variety of pitches

Front 27

Voice sounds

Back 27

Transmission of sounds in normal lung is usually muffled. Consolidation, atelectasis, or fibrosis improve transmission of vibrations through lung tissue.
Bronchophony - increased vocal resonance with spoken words
Egophony - long "E" sounds like nasally long "A"
Whispered pectoriloquy - Recognition of whispered words

Front 28

Indications for terminating an exercise stress test

Back 28

Absolute:
- 3/4 angina pain
- Increasing nervous system symptoms (ataxia, dizziness)
- Signs of poor perfusion (cyanosis, pallor)
- Sustained ventricular tachycardia
- 1.0mm ST segment elevation in leads without diagnostic Q waves
Relative:
- Drop in SBP >10 mm HG despite increased workload without evidence of ischemia
- >2 mm ST segment depression
- Arrhythmias other than sustained ventricular tachycardia including multifocal PVCs, supraventricular tachycardia, heart block or bradyarrhyhmias
- Fatigue, SOB, wheezing, leg cramps, and claudication
- Development of bundle branch block or intraventricular conduction delay
- Increasing chest pain
- Hypertensive response (SBP>250 or DBP >115)

Front 29

Heart rate norm

Back 29

Infant - 100-130
Child - 80-100
Adult - 60-100
Bradycardia <60
Tachycardia >100

Front 30

Volume/amplitude of pulse

Back 30

3+ large or bouding
2+ normal or average
1+ small or reduced
0 absence

Front 31

Percussion sounds

Back 31

Flat or dull - sounds like thigh percussion; in upper lung, suggests neoplasm, atelectasis, or consolidation of the lung
Resonance - normal
Hyperressonance - intermiediate between resonance and tympany; emphysema or pneumothorax
Tympany - hollow sound vaguely resembling drum beat; occurs almost exclusively with large pneumothorax

Front 32

MET Values for common physical activities

Back 32

Light (<3) - walking around, toileting, driving, deskwork, dishes, making bed, bathing, cooking, playing instrument, fishing

Moderate (3-6) - walking 3 mph (3-4 met), walking 4 mph (4.5-7 met), washing windows or car, sweeping, vacuuming, light gardening, carrying/stacking wood, power lawn mowing, slow dancing (3.0), table tennis, fast dancing (4.5), basketball shooting, sex, golf, swimming, tennis doubles, cycling flat 10-12 mph (6)

Vigorous (>6 MET) - walking 4.5 mph (6.3), Jogging = 8, Running 7 MPH (11.5), shoveling (7), carrying heavy loads (7.5), heavy farmwork (8), digging ditches (9.5), backpacking (5-11), basketball game (8), cycling 12-14 mph (8), cycling 14-16 mph (10.0)

Front 33

MET

Back 33

Metabolic equivalent
1 MET - energy expended while sitting quietly

Front 34

Target Heart Rate
% of max HR

Back 34

Lower THR = HR max x 55%
Upper THR = HR max x 90%
Method 2: Heart rate reserve (HRR) or Karvonen formula
Lower THR = [(HRmax-HRrest)x40%] +HR rest

Front 35

Heart rate reserve (HRR) or Karvonen formula

Back 35

Lower THR = [(HRmax-HRrest)x40%] +HR rest
Lower THR = [(HRmax-HRrest)x85%] +HR rest

Front 36

Cardiorespiratory response to exercise

Back 36

- Increased O2 consumption due to increased cardiac output, increased blood flow, and oxygen utilization in the exercising skeletal muscles
- Linear increase in SBP with increasing workload (8-12 mm Hg per MET
- No change or moderate change in DBP
- Increased respiratory and tidal volume

Front 37

Chronic Adaptations to aerobic exercise

Back 37

- VO2 max - increased at maximal exercise
- HR: no change or decrease at maximal exercise; decreased at submaximal exercise
- Arterovenous oxygen difference - increased at maximal exercise; no change at submaximal exercise
- SBP and DBP - no change or slight increase at maximal exercise; no change or slight decrease at submaximal exercise
- Blood lactate - increased at maximal exercise; decreased at submaximal exercise
- Oxidative capacity of muscle - increased mitochondrial number and size, capillary density, and oxidative enzymes
- Maximal voluntary ventilation - increased at maximal exercise
- Plasma volume - increased
- Skeletal muscle blood flow - increased at maximal exercise, no change at submaximal exercise
- Reduced body mass and body fat and increase in fat free body mass
- Improve body heat transfer due to larger plasma volume and more responsive thermoregulatory mechanisms
- Psychological benefits - reduced anxiety, stress, and depression; improved mood and self-esteem

Front 38

Apnea

Back 38

absence of spontaneous breathing

Front 39

Biot's

Back 39

irregular breathing; varied depth and rate with periods of apnea; often associated with increased intracranial pressure or damage to the medulla

Front 40

Bradypnea

Back 40

slower than normal respiratory rate
<12 breaths per min in adults
May be associated with neurologic or electrolyte disturbance, infection, or high level of cardiovascular fitness

Front 41

Cheyne-Stokes (periodic)

Back 41

decreasing rate and depth of breathing with periods of apnea; can occur due to CNS damage

Front 42

Eupnea

Back 42

normal breathing

Front 43

Hyperpnea

Back 43

Increased rate and depth of breathing

Front 44

Hypopnea

Back 44

decreased rate and depth of breathing

Front 45

Kussmaul's breathing

Back 45

deep and fast breathing; often associated with metabolic acidosis

Front 46

Paradoxical breathing

Back 46

chest wall moves with inhalation and out with exhalation; due to chest trauma or paralysis of the diaphragm

Front 47

Tachypnea

Back 47

Faster than normal respiratory rate; >20 breaths per min in adults

Front 48

Waist circumference

Back 48

- Measured at level of iliac crest during normal exhalation
- Increased risk for type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease is associated with a circumference >102 CM (>40"), for men and >88 cm (>35") for women

Front 49

Obstructive vs Restrictive ventilatory impairment

Back 49

Obstructive - decreased expiratory flows
FEV1/FVC <70%
asthma, emphysema, chronic bronchitis

Restrictive - reduced lung volumes and normal expiratory flow rates
Inferred from spirometry when FVC is reduced and FEV1/FVC is normal or less than 80%

Front 50

When to cease exercise based on SpO2

Back 50

<90% in acutely ill patients
<85% in patients with chronic lung disease

Front 51

Rate Pressure Product

Back 51

AKA "double product"
Index of myocardial oxygen consumption and coronary blood flow
Provides an easy to measure physiologic correlate to onset of angina pectoris or ECG abnormalities

Measure SBP and HR during same exercise workload
RPP = HR x SBP
Usually reported as a 2 digit number (ex 22.5 x 10^3)

Front 52

RPE

Back 52

Rate of perceived exertion
Regular scale - 6-20
Revised - 0-10
RPE of 13-14 represents about 70% max HR
Early cardiac rehab - 11-13 = upper limit

Front 53

Normal Respiratory Rates

Back 53

Newborn - 33-45 breaths/min
1 year - 25-35 breaths/min
10 years - 15-20
Adult - 12-20

Front 54

Respiratory Rhythm

Back 54

Normal - Inspiration is half as long as expiration (I:E = 1:2)
COPD - expiration much longer (1:3 or 1:4)

Front 55

Positions to relieve dyspnea

Back 55

Reverse trendelenberg - decreased weight of abdominal contents on the diaphragm

Semi - Fowler's - Supine with HOB elevated to 45 degrees and pillows under the knees

Front 56

Premature atrial contractions

Back 56

- Occur when ectopic focus in atrium initiates an impulse before the SA node
- P wave is premature with abnormal configuration
- PACs are very common and generally benign, but may progress to atrial flutter, tachycardia, of fibrillation
- May occur with a normal heart (from caffeine, stress, smoking, alcohol) and any type of heart disease

Front 57

Atrial flutter

Back 57

- An ectopic, very rapid atrial tachycardia
- Atrial rate of 250-350 beats per minute; ventricular rate dependent upon AV node conduction
- Saw-tooth shaped P waves (also known as atrial flutter waves)
- Occurs with valvular disease (especially mitral), ischemic heart disease, cardiomyopathy, hypertension, acute MI, COPD, and pulmonary emboli
- s/s include palpitations, lightheadedness, and angina due to rapid rate
- Stagnation of blood may predispose to thrombi in area

Front 58

Atrial fibrillation

Back 58

- Common arrhythmia where the atria are depolarized between 350 and 600 x/min
- ECG shows characteristically irregular undulations of ECG baseline without discrete P waves
- Occurs in healthy hearts and in patients with coronary artery disease, hypertension, and valvular disease
- Symptoms may include palpitations, fatigue, dyspnea, lightheadedness, syncope, and chest pain
- Stagnation of blood may predispose to thrombi in the atria

Front 59

1st degree AV block

Back 59

- PR interval longer than .2 seconds, but relatively constant from beat to beat
- No symptoms or significant change in cardiac function
- PR interval may become prolonged for many reasons including medications that suppress AV conduction

Front 60

2nd degree AV block

Back 60

- AV conduction disturbance in which impulses between the atria and ventricles fail intermittently
-Two major types:
Mobitz Type I (Wenckebach)- progressive prolongation of PR interval until one impulse is not conducted (generally benign)
Mobitz Type II - consecutive PR intervals are the same and normal followed by nonconduction of one or more impulses (a more serious condition). If heart rate is slow, CO will decrease with the blocked impulse. Also, 2nd degree AV block may progress to 3rd degree AV block

Front 61

3rd degree AV block (complete heart block)

Back 61

- All impulses are blocked at the AV node and none are transmitted to the ventricles
- The atria and ventricles are paced independently; atrial rate >ventricular rate
- Considered a medical emergency required a pacemaker
- If the ventricular rate is too slow, the CO drops and the patient may faint
- Common causes include degenerative change of the conduction systems, digitalis, heart surgery, and acute MI

Front 62

Premature Ventricular complex (PVC)

Back 62

- Premature depolarization arising in the ventricles due to an ectopic focus
- Unfocal PVCs arise from same ectopic focus and have the same configuration
- Multifocal PVCs arise from different ectopic foci and have different configurations
- On ECG, the P wave is usually absent and the QRS complex has a wide and aberrant shape
BIGEMINY - Normal sinus impluse followed by PVC
TRIGEMINY - PVC occurs after every two normal sinus impulses
Clinical significance:
- A common arrhythmia that occurs in healthy and diseased hearts
- Patient may be asymptomatic or have palpitations
- Common causes include anxiety, caffeine, stress, smoking, and all forms of heart disease

Front 63

Ventricular tachycardia (v-tach)

Back 63

- 3 or move consecutive PVCs at a ventricular rate of >150 BPM
- P waves are absent and QRS complexes are wide and abberrant in appearance
- V-tach longer than 30 seconds is a life-threatening arrhythmia and requires immediate medical intervention
- Patients are not able to maintain an adequate blood pressure and eventually become hypotensive
- V-tach may degenerate into ventricular fibrillation causing cardiac arrest
- Common causes include: MI, cardiomyopathy, and valvular disease

Front 64

Ventricular fibrillation (v-fib)

Back 64

- Ventricles do not beat in a coordinated fashion, but fibrillate or quiver asynchronously and ineffectively
- No CO, patient becomes unconscious
- ECG shows characteristic fibrillation waves with an irregular pattern that is either coarse or fine
- A lethal tachyarrhythmie requires immediate defibrillation
- Additional measures include medications to support the circulation and IV antiarrhythmic agents
- Common causes include heart disease of any time, MI, and cocaine use

Front 65

Ventricular asystole

Back 65

-Ventricular standstill with no rhythm
- ECG records straight line pattern
- Requires immediate defibrillation and or meds to stimulate cardiac activity
- Common causes include acute MI, ventricular rupture, cocaine use, lightning strikes, and electrical shock

Front 66

Signs of Myocardial Ischemia/Infarction

Back 66

ST Segment Depression
ST Segment Elevation
Q wave
T wave inversion

Front 67

ST Segment depression

Back 67

- A depressed ST segment is a sign of subendocardial ischemia, but also can be due to digitalis toxicity or hypokalemia
- The segment is evaluated relative to isoelectric baseline at 0.08 seconds after the J point
- Deviations from isoelectric baseline are expressed as ST segment depression of 1mm, 2mm, etc

Front 68

J point

Back 68

junction bewteen end of QRS complex and beginning of ST segment

Front 69

ST segment elevation

Back 69

- Earliest sign of acute transmural infarction
- Can also indicate a benign early repolarization pattern in a normal heart
- Deviations from isoelectric baseline are expressed as ST segment elevation of 1mm, 2mm, etc

Front 70

Q wave

Back 70

- A characteristic marker of infarction
- Signifies the loss of positive electrical voltages due to necrosis
- A significant or abnormal Q wave is longer than 0.04 msec and larger than 1/3 the amplitude of the R wave

Front 71

T wave inversion

Back 71

- Occurs hours or days after an MI as the result of a delay in repolarization produced by the injury
- May also occur with R and L bundle branch blocks, after a CVA, and as a normal juvenile T wave pattern in children and some adults