HTN (hypertension) high blood pressure

CHF (congestive heart failure) edema, breathlessness, abnormal sodium and water retention (can be
left or right CHF)
CO (cardiac output) heart rate X stroke volume
SV (stroke volume) volume of blood ejected from the ventricle with each beat
HR (heart rate) - number of times heart beats per minute
IVC (inferior vena cava) venous trunk for lower extremities (empties into the right atrium of the heart)
SVC (superior vena cava) venous trunk draining blood from the head, neck, upper extremities (empties
into the right atrium of the heart)
*Cardioversion medical/medicine or mechanical/machine; restoration of the hearts normal sinus
rhythm by delivery of a synchronized electric shock thru two paddles placed on chest; medicine over
long term to put you back in regular rhythm; used to treat Atrial defibrillation*
Dysrrythmia any cardiac rhythm that deviates from normal sinus (SA node) rhythm; also called
arrhythmia
Endarterectomy surgical removal of the intimal lining of an artery (roto-rooter for carotid artery)
Pleural effusion abnormal accumulation of fluid in the thoracic cavity between the visceral and
parietal pleurae
Pulmonary edema acummulation of extravascular (in the tissues)fluid in the lung tissues and alveoli
Body has approx 6 liters of blood
Pericardium sac around the heart
Endocardium innermost layer thin smooth layer
Myocardium heart muscle layer (middle layer) thick strong layer*
Epicardium outermost layer of heart wall

Electrical Conduction system (hearts nervous system)

1- Starts in the roof of the right atrium in the SA node (sinoatrial node) pacemaker of the heart
2- Need proper electrolytes for proper rhythm; potassium channels and calcium channels (muscle
contraction and nerve conduction)
3- SA Node (and left atrium)-> AV node-> bundle ofHis(same as AV bundle)->right and left bundle
branches of AV bundle (contract muscle of septum wall)-> Purkinje fibers (contraction of
ventricles)
4- AV node slows down impulse to allow time for atria to fill with blood
5- Right and left speed up to contract ventricles
6- Systole contraction
7- Diastole relaxation
8- Cardiac cycle 0.8 second - complete diastole and systole of both atria and ventricles
9- Lubb AV (S1)is longer duration and low pitch heard when AV valves close (mitral and
tricuspid)
10- Dubb (S2) is short and sharp heard when semilunar valves close (pulmonary and aortic)
11- Abnormal heart sounds (S3) after S2 (S4) before S1
12- Murmur swishing sound ineffective closure of the valves. Could cause pooling in the atrium
13- MVP mitralvalve prolapse mitral valve not sticking properly. Pooling (regurgitates in left
atrium and maybe into pulmonary veins

Electrocardiographic EKG-ECG are same thing

De-polarization = contraction
Re-polarization = relaxation-rest-recovery
(NORMAL SINUS RHYTHM)

P-wave (first wave on EKG) if problem with P-wave it is in ATRIA

-

Atrial depolarization
Contraction

Q-R-S wave (ventrical contraction atrial resting)

-

Ventricular depolarization (and atrial RE-polarization is occurring at the same time)

Contraction

T-wave (both at rest)

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Ventricular re-polarization
Both Atrial and Ventrical resting

Telemetry EKG monitor by transmitters at separate location

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Blood Flow
2- Pulmonary arteries (brings de-oxygenated blood to lungs)
4- Pulmonary veins (brings in Oxygenated blood)
4 parts of aorta
-

1) ascending aorta
2) the arch
3) the thoracic portion of the descending aorta
4) the abdominal portion of the descending aorta

Returning blood
-

Blood returns to the right atrium via the largest vein the inferior vena cava (blood from lower
part of body)
Blood returns to the right atrium from head-neck and upper extremities from the superior vena
cava
Also coronary sinus empties into right atrium coming from coronary veins

CABG coronary artery bypass graft ; can use saphenous vein (longest vein in leg) Can also use the
mammary ARTERY in the chest.
ie CABG x6 (6 blockages) re-do CABG (blocked again must redo)

Diagnostic Tests
Angiogram blood vessel (gram radioactive dye (iodine)to take pictures) Cardiac catherization catheter is threaded up to heart and coronary arteries. Inserted in groin (femoral artery) (up thru
abdominal aorta-thoracic aorta-descending aorta-aortic arch-ascending aorta-heart or back up to
coronary arteries) Must be careful of bleeding. Shoot in dye (iodine)and take x-rays to see blockage.
Must use pressure dressing after procedure
Telemetry EKG monitor by transmitters at separate location
ECG exercise-stress test - effect on heart during exercise (treadmill, stair climbing, and aerobic)
-

Evalutes ischemia, dysrhythmia, and cardiac capability

If patient cannot tolerate exercise use dipyridamole (Persantine) or adenosine (Adenocard)
which mimics the patients heart under stress or activity; vasodilator and platelet inhibitor

Thallium 201 Scanning (radioactive dye) concentrates in tissue where normal blood flow is occuring
can tell perfusion (normal blood flow) IV injection
*Cardioversion used to treat atrial defibrillation (quivering) SA node to AV node electric problem
Patient with atrial defibrillation has high heart rate and irregular beat. More prone to blood clots on
anti-coagulants because of pooling. Most famous med for a-fib Digoxin digitalis (Lanoxin) cardiac
glycoside (inotrope)(cardiotonics) slows down heart rate and makes each contraction more forceful and
strong Never give Digoxin w/o taking apical pulse first <60 could go to low. *S/S nausea-vomitingblurred vision-yelo green halos-hypokalemia (low potassium)

Lab tests
ESR tells if inflammation is in body
Serum Electrolyte tests monitor Potassium Calcium Sodium
Serum Lipids monitor HDL-LDL
Arterial blood gases monitor Pao2 Paco2 and acid balance pH
Serum Cardiac markers monitor Tropinin I sensative and specific cardiac marker not influenced by
skeletal muscle trauma or renal failure Tropinin I rises 3 hours after MI peaks at 14-18 hours and returns
to normal in 5-7 days*
BNP B-type natriuretic peptide neurohormone secreted by left side of heart in response to ventrical
expansion the greater the BMP level the more severe the heart failure on the left side
Homocysteine (amino acid) bad! Protein elevated blood levels of homocysteine act as a risk factor. An
elevated level results in platelet aggregation (clotting) most common cause is Dietary deficency of
vitamin B6 (pyridoxine) vitamin B12 (cyanocobalamin) and vitamin B9 (folate) Must take B vitamins for
stress!
C-reactive protein (CRP) during times of acute inflammation
Gingivitus - bad gums and teeth lead to cardiac disease right to blood stream and valves
CoQ10 enzyme reduces inflammation for heart disease (coenzyme q10)

Older Adult Cardiac status

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Sclerotic changes (hardening)

Develop collateral coronary circulation
Heart failure can result from rapid IV infusion; can put in CHF if IV too fast give diuretic
between treatments (Lasix furosemide)
Need lower doses of meds because of metabolism

Risk factors for Heart disease

Nonmodifiable family history, age, gender
Modifiable smoking, hyperlipidemia (HDL-LDL), hypertension (High B/P), diabetes, obesity, sedentary
lifestyle, stress (sympathetic nervous system overdrive), psychosocial factors (type A personality)

Types of Cardiac Dysrhythmias (ayrhythmias) Sinus rhythm is NORMAL

Sinus tachycardia rapid, regular rhythm Sanode heartbeat 100-150bpm or more; exercise, anxiety,
fever, shock, medications, HF, excessive caffiene
Sinus bradycardia slow, regular rhythm rate less than 6-bpm; sleep, vomiting, MI, drugs, increased
intercranial pressure, hypothermia if your on Digoxin*
Supraventricular tachycardia (SVT) (above the ventricles) sudden onset of a rapid heartbeat originates
in the atria 150-250bpm
Atrial Fibrillation electrical activity in atria is disorganized; causing atria to fibrillate, quiver rather than
contract beat chaotically and rapid; atrial rate 350-600bpm When we take heart rate it is ventricular
(100-180bpm) not atrial rate
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Feel light headed and dizzy

Heart failure
An embolized clot
Treat with digitalis (Digoxin); cardioversion; anti-coagulants
If patients do not respond to meds or electrical cardioversion we can do catheter ablation*
(cut or remove) with radio frequency energy is used to destroy the areas in the atria that trigger
abnormal eletrical signals

Atrioventricular Block defect in the AV junction slows or impairs conduction of impulses from the SA
node to the ventricles (think AV node when atrioventricular)
Premature Ventricular Contractions (PVC) abnormal heartbeats that arise when ventricles beat too
soon (we cant have perfect rhythm all the time)
Ventricular tachycardia 3 or more successive PCVs in a row heartrate above 100bpm (rgular or
irregular; med management of anti-arrhythmics - IV of procainamide or amiodarone or Lidocaine(they
depress excitability)Ventricular arrhythmias;
Ventricular fibrillation ventricular musculature of the heart is quivering; use Lidocaine or
procainamide; brain damage can accur if not treated then cardiac arrest and A-systole

Acute Myocardial Infarction (MI)

Ischemia -lack of oxygen lack of blood supply to an area necrosis (death to tissue) in heart
EKG changes
-

*ST wave elevation (recent MI)

*Inverted T wave (past MI)

Disorder of heart conduction system

-

Pacemaker end of cardiac lead goes to right atrium and sometimes dual lead right atrium and
right ventricle
Sinus bradycardia atrial fibrillation complete heart block secondary AV block
Holter monitor home use
Cardioversion medical or mechanical treatment of atrial fibrillation; interupts cardiac cycle
at point of abnormal rhythm
Automatic implantable cardiac *defibrillator (AICD) ventricular; pacemaker is atrial
Discharge instructions (defibrillator and pacemaker)
- restrict physical activity for 6 weeks*
- no contact sports*
- no contact with electro magnetic signals
- can last up tp 30 years
- wear ID or bracelet
- antibiotics prior to dental or invasive procedures*
- at risk for endocarditus (inflammation of heart cavity)
Life threatening arrythmias in the ventricles; ventricular tachycardia and ventricular fibrillation

Nitrate Medications Anti anginas

Comes in paste/ointment ordered in inches (topical)
-

Wear gloves (your blood pressure will drop vasodilator can also give you a headache)

Nitro-stat (pill given sublingual) given under the tongue goes systemic can take another in 5 minutes
up to a total of three. If no relief go to ER
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Come in dark bottle (protect from light) replenish every 6 months or before expiration

Transdermal patches take b/p first! Remove old meds(patches) usually legs-chest-arms clean area
then rotate sites (should be charted where meds were given)
*pick something you would NOT do when giving a nitrate med for test
Atrial Fibrillation two s/s high and irregular
Ventricular aarhythmias are most severe over atria
PVCs premature ventricular contractions - beat of the ventricals come prematurely (stress-exercisesmoking-electrolyte imbalance potassium calcium sodium anxiety caffiene energy drinks)
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*Give anti-aaryhthmics for ventricular problems Lidocaine procainamide amiodarone

Ventricular Tachycardia (VT) if PVCs go untreated (3 or more pvcs in a row) Lidocaine procainamide
amiodarone
Ventricular Fibrillation if VTs go untreated (ventricals are quivering) if not treated turns to A-systole
-

Access APICAL pulse not radial to obtain a accurate pulse rate for dysrhythmias Lidocaine
procainamide amiodarone (Bretylium)

Cardiac arrest follow the A-B-Cs (airway breathing circulation)

-

If patient survives problably put in pacemaker (temp or perm) leads end up in right atrium or
right ventricle
Long term pacemaker care; radiation-electrical magnetic fields follow up cardiologist
3 T MRI (pacemaker allowed)

CAD (coronary artery disease) coronary atheroslcerotic disease

Arteriolsclerosis lumen and tissue inside vessel harden and become fibronic
Atherosclerosis plaque and fat build up on the inside cellular debris
Angina Pectoris (major and minor pecs when cardiac muscle is deprived of oxygen pain
(atherosclerosis is most common cause) CAD is nations numer one killer
-

s/s angina pain is outstanding characteristic of angina pectoris; anxiety and dyspenia
*mens pain - left inner arm shoulder and jaw pressure or squeezing sensation on chest
*womens pain heavy squeezing left side of chest abdominal pain arm - midback; flulike
indigestion nausea ache
Angina pain relieved by nitrates if not relieved it may be a MI (nitro does not relieve MI pain)
EKG PET scan (no glucose or dextrose within 4 hours of PET)
Antiplatelet aggregation therapy is first line of treatment of angina ASA aspirin is the drug of
choice chewable place under tongue. * If unable to tolerate aspirin use ticlopidine (Ticlid) or
clopidogrel (Plavix)platelet aggregate inhibitor
81mg baby 325 reg
Nitrates direct relaxing affect on the smooth muscle of your blood vessels (vasodilator)
Calcium channel blockers into the heart muscle
CABG (coronary artery bypass graft) use saphenous vein - calf (lasts 5-10 years) grafts always
come off the aorta. Internal mammory arteries (last more than 15 years)
PTCA (percutaneous transluminal coronary angioplasty) balloon inflated smashes plaque
against wall side fx allergic reaction to dye-tell patient ahead of time effects of dye
Stent permanent (expandable meshlike to keep patency) stents are thrombogenic pt must
take anticoagulants for atleast 3 months primary complications from stent placement are
hemorrhage and vascular injury arryhthmias dyspnea
MYNX new technique for closing cath devise plugs into vessel dissolves evolves

Myocardial Infarction (MI) high corrulation between depression and MI; Complicated MI required
CPR uncomplicated did not require CPR
-

Occlusion of a major coronary artery or one of its branches

Bodies response to cell death is the inflammatory process. Enzymes are released from the dead
cardiac cells these are diagnostic indicators (serum cardiac markers) we will test for these
enzymes. Troponin I is the main test for cardiac other markers go up if inflammation in other
parts of the body. ESR and CEA for general inflammation
T wave inverts
Meds for MI; vasodilators; antiplatelet aggregators; thrombolytics-fibron (clot busters) TPA
(tissue plasminagin activator) Integrilin Activase given IV (work on the fibrin netting)
Reperfusion must occur 3-5 hours after the onset of symptoms ideally 30-60 minutes
Nursing interventions A-B-Cs; EKG Apical pulse qh; drugs bed rest diet withheld; morphine
Fentinal antiplatelets heparin therapy beta blockers stool softeners (calase)
30% calories should come from fat in your diet (1500 calories

Congestive Heart Failure not pumping effectively back up of blood and fluid; over 550,000 new cases
of heart failure in US each year - greastest % is black men (Bidil med first drug for African Americans
approved by FDA cuts number in )
-

Left sided you see in the lung (usually HF begins here) pulmonary congestion
s/s dyspnea-frothy bloody sputum - crackles
Right sided you see in the extremities
s/s liver enlargement-edema in feet ankles sacrum
When heart failure there is in increase in catecholamines (epi norepi) produce negative
effects of the failing heart and circulatory system
Most common diagnosis for a hospitalized pt. over the age of 65
1 liter of fluid = 1 kg (or 2.2 pounds)

Med management with CHF

-

Beta blockers Careg (carvedilol) first beta-blockers approved to treat heart failure (1999)
Treat CHF high blood pressure decreases the risk of second MI
Side fx - bring down b/p and heart rate
Take with food
Huge interaction with Tagamet (interacts with heart meds)

Heart transplants two reasons heart failure and heart megaly (enlarged heart)
*Pulmonary Edema main s/s frothy bloody sputum
- med mang; hi fowlers morphine o2 nitro diuretics inotops (dobutamine) nitroprusside
< b/p reduce Pulmonary edema *(Nipride) treat pulmonary edema lowers b/p vasodilator and
pulmonary edema
Valvular Heart Disease (problems with valves)
-

Two problems occur; stenosis (thickening that causes a narrowing)and insufficiency( valve
unable to close completley regurgitation)
People with history of rheumatic fever
Med mang; diet diuretics digoxin antidysrhthmics; open mitral commissurotomy valve
replacement
Ventricular antiarryhthmics Lidocaine and Procainimide and Amiodarone Bretylium

Rheumatic heart disease

-

Usually appears in childhood

Caused by infection strepto cocci
Onset usually sudden; more prominent in damp cold climates
Effects Peri-Endo(valves)-Myocardium
Nodlues on the A/V node
Drug of choice penicillin PCN (take for full two weeks)
s/s fever and pain
med mang ; corticoid steriods (Prednisone) supplemants vit B and C

Pericarditis (heart sac)

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inflammation of the membranous sac surrounding the heart

pericardium can be removed
s/s debilitating pain like MI alleviated by sitting up and leaning forward
med mang; cardiac tamponade (heart compression by fluid obstructs blood flwo into
ventricals) pericardiocentesis removal of the fluid

Endocaritis (inflammation of endocardium valves)

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bacteria (strep or staph)

abcess (pocket of pus)
aortic and mitral most commonly affected
treat with antibiotics o2 antiinflammatory (steriods) anticoagulants(Pelton)
teach the pt. about antibiotics therapy

Myocarditis (inflammation of the heart muscle)

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ditto on meds
sudden death due to exercise

Cardiomyopathy (hypertophic heart enlarged heart)

-

first heart transplant 1967 Pts with cardiomypathy 50% o cardiac transplant recipients
cyclosprorine first used in 1980 for immunosuppressive therapy