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Cardiology 1

<Cardiology>

 Anatomy of Heart Systole


= contraction of the muscle
→ blood is ejected

Diastole
= relaxation of the muscle
→ chambers fill w/ blood

•Adult heart beat


= 60 – 80 / min

•70 ml of blood / beat

•Output = 5 L / min

 Review of Cardiovascular System


1. Preload
- Degree of stretch of the cardiac muscle fibers at the end of diastole
- Filling pressure of the heart, the pressure the heart has when it is relaxing
- ↑ blood vol = ↑ preload / ↓ blood vol = ↓ preload
2. Afterload
- Amount of resistance to ejection of blood from ventricles
- Pressure of the contracting heat to push out blood
- Affected by
: = Pulmonary vascular resistance
: = Systemic vascular resistance (SVR)/ Peripheral vascular resistance
- Vasoconstriction = ↑ SVR / Vasodilation = ↓ SVR
3. Contractility
- Force generated by contracting myocardium
- ↑ Contractility by
: Preload : Catecholamines
: ↑ Sympathetic activity : Inotropic drugs (digoxin, dopamine, dobutamine)
- ↓ Contractility by
: Hypoxemia : Acidosis
: Beta-adrenergic blockers (Lopressor)

4. Stroke Volume (SV)


- Amount of blood ejected from the ventricle per beat [normal = 70 ml]
- SV is controlled by preload, afterload and contractility Each contraction
doesn’t empty all of the
5. Ejection Fraction (EF) blood out of a ventricle.
- % of end-diastolic blood vol ejected from ventricles per heart beat
- Normal LVEF = ~50% / Normal RVEF = ~42%
- Indicator of myocardial contractility: ↓ EF = ↓ contractility (too relaxed)
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- Measures the capacity at which your heart is pumping

6. Cardiac Output (CO)


- Amount of blood pumped by the ventricle in liters per min.
- Normal resting CO = ~ 5L/min *can increase 4x
- CO = SV x HR

7. Blood Pressure
- Pulse pressure = SBP –DBP [Normal = 40-50 mmHg]
→ narrow = low SV, as in CHF, shock or aortic valve stenosis (constriction or narrowing of a passage)
→ wide = stiffness of the major arteries
- MAP (Mean arterial pressure) = (SBP+2DBP)/3 -- avg pressure in arteries throughout cardiac cycle
[Good perfusion if b/w 50 – 150 mmHg]

8. Peripheral Vascular Resistance (PVR)


- Opposition to blood flow provided by blood vessels
- Contributing factors
: Vessel radius [↑ radius = ↓ PVR]
: Vessel length [↑ length = ↑ PVR]
: Blood viscosity [↑ viscosity = ↑ PVR]
- Small ∆ in vessel radius (vasoconstriction / vasodilation) → large ∆ in PVR

9. Frank-Starling Law
- ↑ Elasticity (the bigger the stretch) = ↑ Contraction (the stronger the contraction)
- ↑ Venous Return = ↑ CO
- Stretch of the myocardium is increased by increased filling.
*increase or decrease in the volume of blood = an increase or decrease in the force of contraction (like a rubber
band flying)
*this can max out...your actin and myosin can disengage and your force of contraction will drop to zero (like a
rubber band breaking)

 Cardiac Assessment and Diagnostic Tests


1. Cardiac S/S

2. Physical assessment
- Skin - Jugular vein pussations
- BP - Heart inspection, palpation, percussion, and auscltation
- Pulse - Lung & Abd assessment

3. Hemodynamic Monitoring
 Intra-artrial BP monitoring (IABP)
- Measures direct and continuous BP
- Useful for freq ABG and blood sample
- MAP = good indicator of perfusion

 Central Venous Pressure (CVP)


- Measures R atria pressure (= preload) and R ventricle fxn
- Normal = 0 – 8 mmHg or 3 – 8 cm H20
- Low pressure = hypovolemia  ↓ R vent preload
- High pressure = hypervolemia  ↓ myocardial contractility

 Pulmonary Artery Pressure (PAP)


- Measures L ventricle fxn
- Normal PAP = 15 – 25 / 8 -15 mmHg  check artery level
- Normal PAWP (Pulmonary Artery Wedge Pressure) = 4.5 – 13 mmHg  check capillary level
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4. Cardiac auscultation

Area Location Note


nd
Aortic (Base) 2 ICS, R sternal border S2 is loudest
Pulmonic 2nd ICS, L sternal border
Erb’s point 3rd ICS, L sternal border
Tricuspid 4th ICS, L sternal border
Mitral (Apex) 5th ICS, L midclavicular line S1 is loudest

- Health Hx: Cardiac S/S


: Chest pain or pressure : Palpitations
: SOB : Fatigue
: Edema and wt gain : Dizziness/syncope (faint)/loss of consciousness [← d/t ↓CO]

5. Heart Sounds
- S1 = closure of mitral & tricuspid valves
- S2 = closure of aortic & pulmonic valves
- S3 gallop Low-pitched "plop"
: After S2, during rapid ventricular filling right after “dub”.
: Ventricles fail to eject all blood during systole (vol overload) Sounds like Ken(S1)-
: Best heard at apex, lying on L side tuc(S2)-ky(S3)
: eg) CHF, MI, normal for children
- S4 gallop
: Before S1, during atrial contraction
: r/t enlarged/hypertrophy of ventricles, resistant to filling
: Best heard at apex in a supine position while holding breath
: eg) HTN, MI
- Murmur
: High- or low-pitched sounds, lasting longer than normal HS
: Caused by blood flowing through a damaged or overworked heart valve
: eg) Ischemia, Infection, Drug toxicity
- Pericardial friction rub
: Leather rubbing sounds
: eg) Pericardititis

6. Laboratory tests
 Cardiac markers
: Enzymes are released from injured cells when the cell membranes rupture
: Enzymes leak into the interstitial spaces of the myocardium
→ Carried into the coronary and lymph circulation  ↑ serum enzymw concentrations.

Earliest Test Running Peak (hr) Return to Normal Note


Inc (hr) Time (min)
Total CK 3-6 30-60 24-36 3 days
CK-MB: Cardiac-specific isoenzyme. ↑ when cardiac
4-8 30-60 12-24 3-4 days
Isoenzyme cells are damaged.
CK-MB:
2-3 30-60 10-18 3-4 days Indicator for acute MI. More sensitive.
Mass assay
Myoglobin 1-3 30-60 4-12 12 hr A heme protein that helps transport O2. Not
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specific but negative result can rule out AMI.
Troponin T / Regulates the myocardial contractile process.
I 3-4 30-60 4-24 1-3 wks Remains elevated for a long period. I is a more
specific marker for MI. Troponin > 0.1 ng = MI

 C-reactive protein (CRP) Inflammation plays a role in the


: A protein produced by the liver in response to systemic inflammation development of atherosclerosis.
= used as an adjunct to other tests to predict CVD risk
: hs-CRP 3.0 mg/dL = at greater risk for CVD

 Lipid profile
: Measured to evaluate a person’s risk of developing atherosclerotic dis.
: Blood specimen should be obtained after a 12-hour fast
- Cholesterol [normal = <200 mg/dL]
- LDLs [normal = <160 mg/dL]
- HDLs [normal = 35 – 70 (♂) or 85 (♀) mg/dL / > 70 mg/dL]
- Triglycerides [normal = 100 – 200 mg/dL]

 Brain (B-type) natriuretic peptide (BNP)


: A neurohormone that helps regulate BP and fluid vol.
: Secreted from the ventricles in response to ↑ preload
: BNP> 51.2 pg/mL = correlated w/ mild HF / BNP> 1000 pg/mL = associated w/ severe HF

 Blood chemistries
- Na+
- K+: hypo- may cause V tach or V fib / hyper- may cause heart block, asystole and vent. dysrhythmia
- Ca2+: hypo- impairs myocardial contractility / hyper- causes ↑ myocardial contractility & ↑ risk of ♥ block.
- Mg2+
- BUN/Creatinine: ↑ when ↓ renal perfusion from ↓CO or intravascular fluid vol deficit
- Glucose: ↑ in stressful situations

 Coagulation studies
- PT [10 – 13 sec] /INR [ 1.0 – 2.0 / 2.0 – 3.0 w/ coagulation therapy / 2.5 – 3.5 w/ mechanical heart valve ]
- PTT [25 – 39 sec]
7. Diagnostic tests
- Chest radiography and fluosroscopy (X-ray w/ motion)
- ECG
- Cardiac stress testing: NPO 4 hrs, withhold some cardiac drugs and caffeine
- Echocardiogram: Non-invasive ultrasound. Examine the size, shape, and motion of cardiac structures. Can
determine the EF.

- Transesophageal echocardiography (TEE): NPO 6hrs pre & 2 hrs post. IV line for mild sedation.

- Radionuclide imaging
: Use of radioisotopes to evaluate coronary artery perfusion noninvasively,
to detect MI
to assess L vent fxn
: SPECT = 3Ds. Pt is @ supine with arms over head for 30 min.
: No need for post radiation precaution because dye is small amount.
: ERNA/MUGA
: CT scan
: MRI = Ask whether pt has a pacemaker, metal plates, or prosthetic joints. Remove nitro patch.
- Cardiac catheterization
: Invasive procedure used to measure cardiac chamber pressures and assess patency of the coronary arteries
: Insert catheter via femoral or radial vein
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: Requires ECG and hemodynamic monitoring. Resuscitation equipment must be ready for when the
myocardium becomes ischemic.
: To prevent renal failure in pt w/ DB or HF, administer IV fluids and the antioxidant acetylcysteine
(Mucomyst)
: IV line for sedatives, fluids, heparin and other meds.
: Usually performed with angiography
: Before catheterization…
√Assess for allergy to iodine-containing agents (seafood etc)
√Blood work to check BUN and creatinine, PT/INR, Hct, Hbt, Plat, and e-lyte levels
√NPO 8-12 hrs before
√Mild sedatives or moderate sedation will be given IV
√Inform pt may feel occasional pounding sensation in the chest (d/t extra systole)
: After catheterization…
√Observe the cath access site for bleeding or hematoma formation
√Assess circulation in the affected ext. q 15 min for 1 hour
√2 – 6 hrs of bed rest w/ the affected leg straight and HOB 30 degrees
√Encourage fluid intake to increase UO in order to prevent renal failure from contrast agent
√Next 24 hrs = do not bend at the waist (to lift anything), strain, or lift heavy objects.
√Avoid tub baths, but shower as desired
√Monitor for bleeding, swelling, new bruising or pain from the puncture site, and temp >38.6°C
(101.5°F)

 Cardiac Cells
 Pacemaker cells
- SA node: Discharge at 60 – 100/min
- AV junction: Possible at 40 – 60/min
- Purkinjie fibers: Possible at 20 – 40/min
 Electrical conducting cells
- Excitability, conductivity
- Conduction pathway
 Mechanical muscle cells
- Myocardial cells

 Cardiac Cycles
 At resting stage = inside of cells are negatively charged ← maintained by membrane pumps [K, Na, Cl, Ca]

Polarized Depolarized Repolarization


In = -, Out = + In = +, Out = - In = -, Out = +
   
Resting state Electrical activation Return to resting state
Diastole = filling stage Contraction follows Relaxation follows

 ECG
 Measures and shows the electrical current (conductivity) of the heart
 Deflections
Positive when depolarization wave move toward a positive electrode = upward slope
Negative when depolarization wave move away a positive electrode = downward slope

Positive when repolarization wave move away a positive electrode = upward slope
Negative when repolarization wave move toward a positive electrode = downward slope
-
 12-Lead ECG
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o 10 electrodes
- Precordial leads
 V1: 4th ICS, R sternal border
 V2: 4th ICS, L sternal border
 V3: b/w V2 & V4
 V4: 5th ICS, L MCL
 V5: 5th ICS, L AAL (Anterior axillary line)
 V6: 5th ICS, L MAL (Mid-axillary line)

- Limb leads
 RA, LA, RL, LL
 Avoid bony, oily and hairy place

o 12 views of the heart at once


- Fontal plane [bipolar limb leads (= V1-V3) &
unipolar leads (= AVR, AVL, AVF)

 ECG Paper
 Duration = fractions of sec.
 Amplitude = generated voltage ← depolarization is higher voltage than repolarization = taller wave
 Configuration = shape (round), peak
 Horizontal axis = time
- small box (1 mm) = 0.04 sec
- large box (5 small sq) = 0.2 sec
 Vertical axis = voltage
- small box (1 mm) = 0.1 mV
- one big box = 0.5 mV

 ECG Basics

 P wave = Atrial depolarization [2.5 mm or less in height / < 0.11 sec]


 QRS complex = Ventricular depolarization [0.04 – 0.12 sec (less than 3 small boxes, narrow)]
 T wave = Ventricular repolarization [variable, usually positive deflection]
 (U wave) = Repolarization of the Purkinjie fibers [seen in hypokalemia, HTN, or HD]
 PR interval = start of atrial depolarization → start of ventricular depolarization [0.12 – 0.20 sec]
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 ST seg = end of ventricular depolarization → start of ventricular repolarization [normal = isoelectric (baseline)]
 QT interval = start of ventricular depolarization → end of ventricular repolarization [0.32 – 0.40 sec]
 TP interval = Isoelectric period
 PP interval = Atrial rhythm and rate
 RR interval = Ventricular rhythm and rate

 3 methods to calculate HR
1. HR regular: count # of large boxes b/w 2 R-R interval
→ 300 / # of boxes (1 min strip has 300 sec mall boxes) More accurate!
2. HR regular: count # of small boxes b/w 2 R-R interval
→ 1500 / # of small boxes
3. HR irregular: count # of R-R intervals in 6 sec
Less accurate
→ # of R-R intervals x 10 (3 sec = 15 large boxes)

 Normal Sinus Rhythm (NSR)

•V rate & A rate = 60 – 100/min


•V & R rhythm = regular
•QRS shape & duration = usually normal [0.04 – 0.12 sec]
•P wave = normal shape, in front of QRS
•PR interval = normal [0.12 – 0.20 sec]
•P:QRS ratio = 1:1

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