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What happens to the PMI during heart failure?
It is displaced to the left
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What causes HF?
Hypertrophy of the left ventricle.
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Which organ's function displays adequate or diminished perfusion?
Kidneys: driven by arterial flow. Urinary output is a sign of perfusion
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When do coronary arteries fill?
During diastole, atrial pressure is the highest
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What happens to your heart perfusion when your heart rate is higher?
Higher chance of having an ischemic heart since the heart gives up diastole to pump faster, leaving the arteries unfilled.
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How does stress affect blood flow to the heart and how can you reverse it?
If the sympathetic NS is being activated consistently, the coronary arteries are not allowed to fill since the heart rate increases, decreasing time in diastole.
Breathing exercises and relaxation techniques help to reduce stress, HR, and longer time in diastole, therefore more blow flow to the heart.
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What artery supplies the posterior and inferior right and left ventricle?
The posterior descending branch of the right coronary artery.
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What artery supplies the anterior wall of the right ventricle?
The acute marginal branch of the right coronary artery.
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What artery supplies the posterior intra-ventricular septum?
The right coronary artery
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What artery supplies the anterior wall of the left ventricle?
Left anterior descending artery
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What artery supplies the anterior wall of inta-ventricular septum?
Left anterior descending artery.
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What artery supplies the right bundle branch?
Left anterior descending artery
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What artery supplies the anterior superior left bundle branch?
Left anterior descending artery
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What artery supplies the lateral myocardium?
Left anterior descending artery
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What structures does the left circumflex artery supply with blood?
- Lateral myocardium
- Posterior wall of the left ventricle
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What is automaticity of the heart?
The heart cells (especially the SA node) create action potentials on their own, with no stimulus from the brain.
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What is the physiology of the heart muscle?
- Automaticity: initiating an impulse
- Excitability: allowing an electrical stimulation
- Conductivity: sending the signal in an organized fashion
- Contractility: mechanical contraction from the stimulation
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What is the route of conduction for the heart?
Starts at the SA node ⇾ Atria ⇾ AV node with slight pause ⇾ Bundle of His (inter-ventricular septum & L/R Bundle Branches) ⇾ Purkinje Fibers ⇾ Ventricles
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What does the P-wave represent on an electrocardiogram?
SA node fires, depolarizing atria
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What does the QRS-wave represent on an electrocardiogram?
Depolarization from the AV node throughout the ventricles.
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What does the T-wave represent on an electrocardiogram?
Repolarization of the ventricles
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Where is the S1 sound on an electrocardiogram?
R in the QRS wave.
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Where is the S2 sound on an electrocardiogram?
Right after the T wave
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How do you position a patient to hear the mitral valve when they have mitral valve problems?
Lean them forward or lay on their left side.
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What is the minimum MAP?
70-100
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What organ is at highest risk when the MAP is too high?
The brain: cerebral edema
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How do you calculate cardiac output?
Stroke volume x Heart rate
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What factors affect stroke volume?
Preload, contractility, afterload
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What is preload?
The volume of the blood in the ventricles at the end of diastole. It determines the amount of stretch put on the ventricles prior to contraction.
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What is afterload?
The peripheral resistance that the left ventricle must overcome.
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How is contractility increased?
Epinephrine or norepinephrine released by the SNS
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What are ionotropic drugs and how do they affect cardiac output? What is an example of one?
- They increase the force of contraction, increasing stroke volume, thus increasing CO.
- Digoxin
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What are chronotropic drugs and how do they affect cardiac output?
They increase the timing/rate of contraction, increasing stroke volume thus increasing CO.
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What medications decrease contractility of the heart?
Anesthetic agents, chemo
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What medications increase afterload?
Epinephrine, norepinephrine, dopamine, vasopressin
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What medications decrease afterload?
Vasodilators (ca channel blockers, anti-hypertensives, ACE inhibitors)
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What subjective data should you collect in a cardiac physical assessment?
- Medications (especially those prolonging QT interval)
- Functional health patterns (sleep, eliminating, eating, activity/exercise, etc)
- Genetics (3 generations)
- Sexuality and BC
- Coping and Stress
- Childhood Diseases (Rheumatic fever)
- Values and Beliefs
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What is Rheumatic Fever?
A condition brought on by not treating strep throat, causes a rash and damage to the heart valves.
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What objective data should you collect during a cardiac physical assessment?
- Vital signs: 2-step BP bilaterally, orthostatic VS, HR
- Physical appearance
- ADLs
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Why do we take orthostatic VS on cardiac patients?
Helps to determine if preload is possibly too low or if there is a malfunction in their baroreceptors.
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If the liver is enlarged and you can palpate it, what could be a possible diagnosis?
Right sided heart failure or liver disease
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What do distended jugular veins suggest?
Right sided heart failure: increased pressure in the right atrium.
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What makes the first (S1) heart sound?
Closure of the tricuspid and mitral valves.
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What makes the second heart sound?
Closure of the aortic and pulmonic valves.
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What is the expected range for HDL?
> 45 mg/dL
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What is the expected range for LDL?
< 130 mg/dL
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What labs are used to indicate an acute MI?
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What lab is indicative of heart failure?
BNP
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What diagnostic procedures are used for cardiac patients?
- EKG
- CXR
- Echocardiogram (ejection fxn)
- Holter monitor
- Stress testing
- Nuclear studies
- Cardiac catheterization
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What does MONAB stand for?
- M: Morphine (Pain/Anxiety/Vasodilator)
- O: Oxygen
- N: Nitroglycerine (Vasodilation)
- A: Aspirin (Pain med/Reduces risk of clotting)
- B: Beta Blockers (Lowers HR, contractility)
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What is cardiac output?
- Heart rate x stroke volume
- The amount of blood ejected from the heart in a minute.
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What do the S3 and S4 sounds indicate?
Left sided HF
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What are the symptoms of right sided heart failure?
- JVD
- Hepatic congestion
- Lower extremity edema
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What are the symptoms of left sided heart failure?
- Pulmonary congestion on CXR
- S3/S4 heart sounds
- Crackles when auscultating the lungs
- Paroxysmal nocturnal dsypnea
- Orthopnea
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What meds decrease cardiac output?
- Beta blockers
- Ca+ Channel Blockers
- Antiarrythmics
- Anesthetics
- Propofol (anesthetic)
- Chemo Agents
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What meds increase cardiac output?
- Inotropes
- Dobutamine
- Dopamine
- Milrinone
- Digoxin
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What cardiac factors affect cardiac output?
- Heart rate
- Contractility
- Conductivity
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What renal system controls fluid volume?
Renin-angiotensin-aldosterone system
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What SNS receptors are vasoconstrictors?
α1 and α2-Adrenergic
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What SNS receptors are vasodilators?
β-1
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What are the symptoms of the effects of hypertension on target organs?
- Fatigue, exhaustion
- Decreased activity intolerance
- Dizziness
- Palpitations
- Angina
- Dypsnea
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What are the effects of hypertension on target organs?
- CAD
- Left ventricular hypertrophy
- Cerebrovascular disease
- Peripheral vascular disease
- Renal insufficiency
- Retinopathy
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What factors contribute to primary hypertension?
- Water and sodium retention when someone is salt-sensitive (high salt diet)
- Stress
- Genetics
- Insulin resistance and hyperinsulinemia
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How does insulin resistance and hyperinsulemia affect hypertension?
It stimulates SNS activity and impairs nitric oxide-mediated vasodilation
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What is secondary hypertension?
HTN that is caused by another medical condition
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What is the BP range for pre-HTN?
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What is the BP range for stage 1 HTN?
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What is the BP range for stage 2 HTN?
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What is the BP range for stage 3 HTN?
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How do you want to reduce BP greater than SBP: 180 or DBP: 110, and why?
Slowly, 25% of the MAP per hour, to prevent brain damage.
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What is the DASH diet?
- Dietary Approaches to Stop Hypertension
- Reduce sodium
- Eat nutrient-rich foods
- Emphasizes fruits, veggies, low-fat dairy
- Moderate amounts of whole grains, fish, poultry and nuts
- Low sugar
- Limited alcohol intake
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What non-pharmacologic interventions can help reduce BP?
- Support groups
- Stress management
- Relaxation exercises
- Yoga
- Cooking classes
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Where do the potassium sparing diuretics work on the nephron of the kidney?
Distal convoluted tubule
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Where do the potassium losing diuretics work on the nephron of the kidney?
Loop of Henle
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What drugs end in -pril?
ACE inhibitors
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What drugs end in -olol?
Beta blockers
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What drugs end in -sartan?
ARBs (Angiotension II Receptor Blockers)
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