Cardio- Part 2

• *Constricting, squeezing or suffocating sensation
• *Precordial or substernal pain or pressure
• *May radiate to left shoulder, jaw, arm, or other chest areas

Duration = Less Than 5 Minutes (STABLE)

• *Pain when heart's oxygen demands increases
• *Transient myocardial ishemia
• *Fixed coronary obstruction

Pain due to vasospasm of coronary arteries

Myocardial ischemia without pain

*Often times diabetics

• *Unstable angina
•    -symptoms at rest (minimal exertion) > 20 min.
•    -new onset, severe angina, less than 1 month
•    -worsened pattern of angina
• *Non-ST Elevation Myocardial Infarction (non-stemi)
• *ST Elevation Myocardial Infarction (STEMI) - all of the layers of myocardium are being effected

Ischemia

• INJURY
•    *ST depression = subendocardial injury
•    * ST elevation = Transmural injury

Transmural Infarct

• Time of Elevation = Within 1 Hour
• Time of Peak = 4-8hrs

• Time of Elevation = 4-8 Hours
• Time of Peak = 24-36hrs
• Return to Baseline = 2-3 days

Time of Elevation= Within 3 hours

Return to Baseline = 7-10 days

Myocardial Infarction

• Sybendocardial (affects inner 1/3 to 1/2 of wall)
• Trasnmural (affects all 3 layers of the heart wall)

• *Anaerobic metabolism, reversible injury, necrosis, scar tissue
• *"Stunned Myocardium"

Yellow area

Severe, crushing, constrictive, OR like Heartburn

GI distress, nausea, vomiting, tachycardia, vasoconstriction, anxiety, restelessness, feeling of impending doom

Hyportension and Shock

Atypical, Elderly, Shortness of Breath, Fatigued, GI symptoms

• Sudden Death
• Heart Failure
• Cardiogenic Shock
• Pericarditis
• Dressler's syndrome
• Thromboemboli
• Cardiac Rupture
• Ventricular Aneurysm

• Pain 
•    -abrupt, sharp, precordial
•    -worse with deep breathing or swallowing
•    -better with sitting up and leaning forward
• Exudate (if an infectious process...)
•   -Serous --> pericardial effusion
•        *Cardiac tamponade = rapid accumulation of exudate that compresses the heart
•   -Fibrous --> friction rub; adhesions
• ECG changes
• Fever, Malaise, Dyspnea, Leukocytosis

30-55 ml of fluid

Serous exudate filling the pericardial cavity (pericardial effusion)

Fibrous scar tissue making the pericardium stick to the heart (constrictive pericarditis)

Infection, Trauma, Immune/Collagen or Metabolic Disorders, Ischemia, Post-Open Heart Surgery, Radiation

Fluid in the pericardial cavity ---> Restricts heart expansion ---> Left ventricle cannot accept enough blood ---> decreased cardiac output ---> decreased blood pressure and shock

OR

Fluid in pericardial cavity ---> Restricts Heart Expansion ---> Right Ventricle cannot accept enough blood ---> Increased venous pressure; jugular distension

On inhaling, the right ventricle fills with extra blood

Because the heart cannot expand fully when the right ventricle is overfilled, the left ventricle is compressed and cannot accept much blood

On the next heartbeat the left ventricle does not send out much blood: systolic BP drops

Abnormal = 10mmHg or > drop in SBP during inspiration.... ((Cardiac Tamponade))

Cardiomyopathy (CMP)

Primary or Secondary

• Genetic -- Hypertrophic
• Mixed -- Dilated, Restrictive
• Acquired -- Myocarditis, Peripartum & Takotsubo (stress)

"Disease"

Ventricular Hypertrophy with Small LV Chamber Size causing decreased stroke volume due to impaired diastolic filling

Frequent asymmetric septal hypertrophy causing LV outflow obstruction

Obstruction worsened by increased contraction or decreased filling

diastolic filler problems occur (thickening of the septum)

Ventricular Dysrhythmias

Affects young adults.

Manifestations: Gradual Symptoms vs. Sudden Death, Chest Pain, Fatigue, Syncope Worse with Exertion

Dilated Cardiomyopathy

• Idiopathic-- we don't know 100%
• Alcoholism
• Mycoardial Infarct/Ischemia
• Drugs

• Thrombus/Emboli
• Stretch on Mitral Valve
• (low ejection)

....sudden death

• Increased Rigidity of LV restricting Filling
• Contraction relatively normal
• Heart Muscle is not as Compliant

Idiopathic:

Endocardial Infiltrations (Amyloidosis, Sarcoidosis), radiation ribrosis, metastatic tumors, genetic

MYOCARDITIS

None, Flu-Like Syndrome, HF, Emboli, Can mimic ACS, Sudden Death

Peripartum Cardiomyopathy

advanced maternal age, black race, multifetal pregnancies, preeclampsia, tocolytic therapy to prevent premature labor/delivery

• *Transient, Reversible LV dysfunction caused by profound psychological or emotional stress
• *Middle-age women w/ acute STEMI,  but normal coronary arteries
• *Impaired LV contractility with ballooning of apex and basal hypercontractility

Stenosis

Regurgitation (insufficiency)

*the blood going through the valve makes a noise (heart murmurs)

• Where they are--which valve are they near?
• How they sound-- high/low pitched
• When they happen-- systole or diastole

Between S1 and S2

Between S2 and next S1

• If a valve is stenotic, you will hear a murmur of
• blood shooting through the narrow opening when the valve is
• open

• If a valve is regurgitant, you will hear a murmur of
• blood leaking back through when the valve should
• be closed
• (mitral regurgitation)

• Mitral Stenosis
• Mitral Regurgitation
• Mitral Valve Prolapse (backward balloon)

Rhematic Fever

Chronic Valvular Heart Disease

Carditis, Polyarthritis, Aschoff  body (nodules), Erythema marginatum, subcutaneous nodules, Sydenham chorea (involuntary movements), Fever

Infective Endocarditis

Staph. Aureus, Strep. Viridans, Gram neg. & positive bacteria, yeasts, & fungi

• Damaged Endocardial Surface
• Portal of Entry

• Acute
• Subacute
• Chronic

• Fever & Chills
• Change in Murmur
• Anorexia
• Malaise
• Lethargy
• Petechial And Splinter Hemorrhages (Jane Way)
• Cough
• Dyspnea
• Arthritis
• Diarrhea
• Abd./Flank pain

• SA Node
• (impulses travel across the atrium through the AV node to go back to the ventricle)

Sodium Shifts

• Absolute (no stimulus...longest phase...no matter how strong the stimulus is, it will not be able to cause depolarization)
• Relative (stronger stimulus...can depolarize...where abnormal heart rhythms occur)
• Supernormal Excitatory Period (weaker stimulus...very short segment)

Electrocardiography

• P = Atrial Depolarization--Mechanical Event
• QRS = Atrial repolarizing, Ventricular Depolarization-- Ventricle Muscle Contracts

T = Ventricular Repolarization (back to resting state)

Ectopic Beats

• Automaticity -- causes of alteration: injury, hypoxia, electrolyte imbalance, enlargement/hypertrophy of atria or ventricles, exposure to certain chemicals or drugs.....Ectopic Foci: extra focus, start from extra point in heart
• Excitability -- all can receive the stimulus to cause impulse to take route through heart
• Conductivity
• Refractoriness -- go back to resting state

• Cells firing erratically
• Injury to Myocardial Tissue (ischemia)
• Low Oxygen levels in blood (hypoxia)
• Electrolyte Imbalances (Potassium, Magnesium, Calcium)

• Bradicardia -- <60
• Tachycardia -- > 100
• Ectopy -- Premature Contractions
• Fibrillation -- disorganized current flow (quivering, no distinct contraction, blood is stagnant and not effective)
• Supraventricular -- generate from atria or from AV node
• ***Ventricular -- no forward cardiac output...bp drops to nothing...death very quickly
• Heart Block -- Occur in AV node
•     *1st Degree
•     *2nd Degree
•     *3rd Degree

Heart Failure

• Ischemia/MI
• Hypertension
• Cardiomyopathy (abnormality in the ehart muscle causing it to get bigger but not function properly)
• Volume Overload (excessive IV's for several days)
• Excessive Work Demands (severly anemic person struggling to get oxygen to tissues)
• Arrhythmias

• Systolic -- contractility prob; will not send blood forward (low ejection fraction)
• Diastolic -- filling problem, heart cannot relax, the blood backs up and CO is decreased (low ejection fraction)
• Left -- lung symptoms, (vast majority)
• Right -- venous congestion (Emphysema)

**THE PRIMARY CAUSE OF RHF is LHF

Increased Renin, Increased Angiotensin 2 (...leads to Vasoconstriction...leads to Growth Factor For Myocardial Cells...leads to hypertrophy), Increased Aldosterone (...leads to Sodium and Water Retention/excretion of Potassium)

Natriuretic Peptides

• Cause rapid loss of sodium, water, and moderate potassium in urine.
• Inhibit aldosterone and renin secretion (helps vasodilate).
• Inhibit release of epinephrine.

***Lab test can measure the level of BNP

Patients are asymptomatic; patients have no limitation of their activities, and they do not have symptoms from ordinary activities

Patients are Short Of Breath/Fatigued with moderate activity such as climbing two flights of stairs; they are comfortable at rest or with mild exertion and have slight limitation of activity

Patients are Short of Breath/Fatigued with very mild exertion activity, such as climing one half flight of stairs; are comfortable only with rest and have marked limitation of their activity

Patients are Exhausted, Short of Breath, and Fatigued at rest; any activity brings on discomfort and symptoms; they have severe limitations on their activity and are confined to bed or chair

• Fluid Retention and Edema
• Respiratory (Left Side)
•    -Dyspnea
•    -Paroxysmal Nocturnal Dyspnea (PND)
•    -Orthopnea (elevated head makes sleep better)
• Fatigue, Limited Exercise Tolerance
• Cachexia and Malnutrition
• Cyanosis

• Congestion of Peripheral Tissues
• Dependent Edema
• Liver Congestion
• GI tract Congestion
• Anorexia, GI distress, weight loss
• Signs related to impaired liver function

• Decreased CO
• Pulmonary Congestion
• Activity intolerance and signs of decreased tissue perfusion
• Impaired gas exchange
• Pulmonary Edema
• Cyanosis and Signs of Hypoxia
• Cough with Frothy Sputum
• Orthopnea
• Paroxysmal nocturnal Dyspnea

• Capillary fluid moves into alveoli
•     -lung becomes stiffer
•     -harder to inhale
•     -less gas exchange in alveoli
•     -crackles
•     -frothy pink sputum
• Hemoglobin not completely oxygenated
• ***EMERGENCY
• anxious, air hunger, use of accessory muscles, skin cool & clammy, tachycardia, cyanosis

• Nasal Flaring
• Sternal Retraction
• Tripoding
• Use of Accessory Muscles
• Tachypnea
• Cyanotic

• Pump Failure- delivery to tissues
• Circulatory Failure

• Effects: Decreased Tissue Perfusion
• Impaired Cell Metabolism
• Release of Vasoactive Inflammatory Mediators
• LACTIC ACID PRODUCTION (Anaerobic)
• Cell Death

• Cardiogenic -- Pump Failure
• Hypovolemic -- Decreased Blood Volume (dehydration, traumatic car accident)
• Distributive -- Loss of Vascular Tone
•    -Neurogenic
•    -Anaphylactic
•    -Sepsis and Septic Shock

Neurogenic (Distributive)

Anaphylactic Shock

Sepsis/Septic Shock

• ***Change in Skin Temperature (blood is shunted to major organs, autoregulation, cold and clammy)
• Hypotension <bp
• Tachycardia >hr
• Change in LOC- less coherent and sleepy
• Decreased urine output- kidney is not getting adequate perfusion
• Thirst
• MAP (< 70 ) --considered emergency

MODS -- Multi-System Organ Dysfunction Syndrome

Kawasaki's Disease

(7-14 days) with fever, rash, cervical lymphadenopathy, conjunctivitis, redness, and swelling of hands and feet, oropharyngeal effects

(10-24 days) with peeling of the skin on the hands and feet

(8 Weeks) with arthritis, urethritis, pyuria, GI, hepatitis, CNS

CORONARY ANEURYSMS-- with s/s of ischemia, pericarditis, myocarditis, heart failure, and dysrhythmias

• Foramen Ovale
• (allows for complete bypass of the baby's lungs)

• Ductus Arteriosus
• (allows for complete bypass of the liver and goes straight to the baby's heart)

*Placental Oxygenation to pulmonary oxygenation

• *Hypoxemic state to High Oxygen Tension State
• (closure of the ductus arteriosus)

*High pulmonary vascular resistance (PVR) to low PVR

• *Low resistance placental circulation to increased SVR and left heart pressures 
• (Closure of foramen ovale)

Shunt

Heart

• Left;
• Left; Right

***BEFORE BIRTH

foramen ovale

Ductus arteriosus

Ductus Venosus

• Communication b/w heart chambers
• (atrial and ventricular septal defects)

• Altered development of heart chambers/valves
• (pulmonic stenosis, tetralogy of fallot, coarctation of aorta, endocardial cushion defects)

• Malposition of heart chambers and great vessels
• (transposition of the great vessels)

• Altered closure of fetal communication channels
• (patent ductus arteriosus)

• Genetic, environmental
• (ie: mother is exposed to Measles, certain drugs, etc)

Anatomic Defects

• Hemodynamic Alterations
•    shunting of blood

• Effect on Tissue Oxygenation
•    cyanotic defects
•    acyanotic defects

Acyanotic Defects

Cyanotic Defects

• Cyanosis
• Respiratory Difficulty
• Fatigue
• Heart Failure
• Difficulty Feeding
• Failure to Thrive (they don't eat as much or gain weight bc they don't have energy)