PCCN Exam Questions and Correct Answers,

With Complete Verified Solution.

What is the function of the cardiovascular system
to drive O2 to the cell so that the cell can make ATP for energy production
What is the formula for CARDIAC OUTPUT
Stroke volume x Heart Rate

CO = HR X SV ( Preload + Afterload + Contractility)

What is the term for the amount of blood that is pumped out of the ventricle each
MINUTE?
Cardiac Output ( approximately 4 - 8 LPM )
What is the term for the amount of blood that is pumped out of the ventricle each
BEAT?
Stroke Volume
What is the term for the number of contractions / minute?
Heart Rate
IMPORTANT RELATIONSHIPS TO KNOW
1. CO DECREASED -> HR INCREASES ( to maintain adequate stroke volume )

2. CO INCREASED -> HR DECREASES ( as stroke volume decreases )

3. HR DECREASED -> SV DECREASES and CO DECREASES

4. HR INCREASES ( > 150 ) -> SV DECREASES and CO DECREASES

5. SV DECREASES -> CO DECREASES and HR INCREASES

6. SV INCREASES -> CO INCREASES and HR DECREASES

What is the term for the volume of blood ejected from the ventricle per minute
adjusted for body size
Cardiac Index
What is a normal cardiac index?
Normal = 2.5 to 4.4 L/min/m2
**Always utilize CI values on exam (especially for bigger patients)
What is a normal amount (mL/beat) for stroke volume?
60 to 100 mL
What is the term for the end-diastolic volume stretching the ventricle?
Preload

( increased fluid = increased stroke volume )

What is the term for the pressure that the ventricle must OVERCOME in order to
eject blood into the circulatory system?
Afterload
What is the term for the inotropic state the cardiac muscle
Contractility

(how well the heart is contracted)

Preload is the function of which part of the circulatory system?
VEINS

FUNCTION OF VEINS = PRELOAD

What is the RIGHT VENTRICLE PRELOAD assessed by?
CVP (Central venous pressure)

(Normal is approx. 2 - 8 mmhg)

What is a normal central venous pressure ?
Approximately 2 - 8 mmhg
What is the LEFT VENTRICLE PRELOAD assessed by?
PAOP (Pulmonary artery occlusion pressure) / PAW pulmonary artery wedge pressure

-Swans ganns in placed wedge pressure (PA)

What are the signs and symptoms of an altered preload?
1. Dehydration (decreased preload)
2. Fluid overload (increased preload)
What are some causes of a low preload?
1. Hemorrhage
2. Dehydration
3. Burns
4. Over-diuresis
5. Third spacing (fluid moving into spaces they shouldn't be)
What are some causes of high preload?
1. Hypervolemia
2. Heart failure
3. Renal failure
4. Pulmonary HTN
5. Tamponade
6. Tension pneumothorax

(most likely seen in right ventricle preload)

What are the venous dilating drugs?
1. NITRO (given to drop preload)
2. ACE I/ARB
3. Ca-Channel blocker
Which venous dilating drug is given to drop the preload amount?
Nitro
What are some causes that can alter the vascular space?
1. Sepsis
2. Neurogenic shock
3. Anaphylaxis
4. Warming after cardiac surgery
5. Venous dilating drugs
What part of the circulatory system determines the afterload?
Arteries
Afterload determines the functions of the __________
ARTERIES
RIGHT VENTRICLE AFTERLOAD is assessed by
PVR (pulmonary vascular resistance)

Normal is 20 - 200 dynes /sec/cm2

What is a normal range for pulmonary vascular resistance
Normal is 20 - 200 dynes / sec / cm2
What is the LEFT VENTRICLE AFTERLOAD assessed by?
SVR (systemic vascular resistance)

Normal is 800 - 1600 dynes / sec / cm2

What is a normal range for systemic vascular resistance
Normal is 800 - 1600 dynes / sec / cm2
What are the S/S of increased afterload?
1. CVP > 8
2. s/s of fluid overload **
3. CO < 4 LPM ---
4. signs of cardiogenic shock
5. PA wedge > 12 mmhg
6. EF fraction < 60 %
7. MAP < 60 mmhg ---
8. SVR > 1600 dynes / sec / cm5
9. Decreased urine output ---
10. LV hypertrophy

**LEFT VENTRICLE HYPERTROPHY

**SYSTEMIC HTN
What are the main signs of increased afterload?
Left ventricle hypertrophy
Systemic HTN
What are the s/s of decreased afterload?
1. CVP < 4
2. s/s of fluid depletion **
3. CO < 4 LPM ---
4. PA wedge < 8 mmhg
5. MAP < 60 mmhg (b/c patient is vasodilated) ---
6. SVR < 800 dynes / sec/ cm5
7. decreased urine output ---
8. HR > 90 BPM

**common with sepsis

What can affect afterload?
1. Vasodilation
2. Vasoconstriction
What are some causes of vasodilation that can affect the afterload?
1. Nipride **
2. ACE I / ARB
3. Milirinone
4. Ca - Channel blocker
5. Antihypertensives

All arterial dilating drugs

What are some causes of vasoconstrictors that can affect the afterload?
1. Hypertension
2. SNS stimulation
3. Compensatory vasoconstriction (hypothermia, sepsis)
4. Arterial constricting drugs (phenylephrine , norepinephrine, high - dose dopamine,
epinephrine, vasopressin)
This type of heart failure has reduced LV ejection fraction
systolic heart failure ( HFrEF)
Heart failure with ejection fraction

EF < 40 % (leads to increasing end-diastolic volume and pressure)

How does the hearts anatomy change when a pt has systolic heart failure
Ventricle will dilate with the heart wall thinning

large outward bulging of muscle of heart

What causes systolic heart failure?
***USUALLY D/T VOLUME OVERLOAD
1. MI (decreased CO -> fluid retention by kidney)
2. Aortic and mitral regurgitation
3. Congenital defects
This type of heart failure presents with preserved LV ejection fraction
Diastolic heart failure (HFpER)
heart failure with ejection reserved

EF < 40% (increased filling pressures due to stiff, non compliant ventricle)
How does the hearts anatomy change with diastolic HF?
Ventricles become thickened without the dilation of the chamber
What are some causes for diastolic HF?
1. Chronic HTN
2. Aortic Stenosis
3. Hypertrophic cardiomyopathy
Explain the difference between systolic and diastolic's HF heart anatomy change
1. Systolic HF'S ventricle's dilate with wall thinning

2. Diastolic HF'S ventricle's DOES NOT dilate with wall thickening

What is the formula for EF?
Systolic - diastolic = EF
Right sided heart failure is caused by
LUNG conditions
Which medications are usually given to African American males with HTN & has
HF
beta-blocker
Which medications are usually given to White peopled with HTN and HF
Diuretics
What are the MAIN S/S of HF
1. Fluid retention
2. SOB ( esp. at rest ) & orthopnea
3. Paroxsysmal nocturnal dyspnea or cough ( esp in new onset of early HF )
4. Fatigue ( reduction of exercise capacity )
5. Inadequate peripheral oxygenation
6. Pulmonary and or systemic congestion (edema)
7. Ascites / early satiety
8. Depression/weakness/sluggish (esp in elderly) impending doom
S/S OF LEFT SIDED HF
1. Fatigue
2. Chest pain (if coronary arteries are under-perfused)
3. Increased LV - sided volume and pressure ( S3 AND OR S4 GALLOP, increased
PAOP & PAD & Pulmonary capillaries )
4. Crackles, SOB, cough, orthopnea, wheezing, hypoxia, pulmonary edema
5. Increased LAP causing atrial arrhythmias

-PAOP = pulmonary artery wedge pressure

-Difference between PAD and PAOP < 5 mmhg
How does the medication Nitropusside work?
It's an arterio dilator
How does a pt with right sided failure present?
1. Systemic engorgement, poor perfusion
2. Sternal heave, right sided - S3
3. Increased CVP , JVD, Peripheral edema
4. Nausea / anorexia
5. + Abdomino - jugular test
How does nitroglycerin work?
decreases preload
BNP < 100
CHF unlikely
BNP 100 - 500 with baseline LV dysfunction
Exacerbation of CHF
BNP greater than 100 with no baseline LV dysfunction
CHF LIKELY
LVHF on EKG
Check leads: V1, V2, V5, V6
-If greater than 35 boxes, there is left ventricular enlargement in QRS in V5 & V6
RVHF on EKG
Check leads V1, V2, V3

QRS is wide and are all positive (when it's supposed to be negative) meaning it's a
RBBB OR RHF

Appears as bunny ears

Best med for HF
nitroglycerine (preferred)
bc it decreases preload and afterload and improves CO

& lasix
adverse effects of ACE inhibitors
1. Renal impairment
2. Cough ( d/t bradykinen )
3. Angioedema
Which two meds should never be used together?
Ace Inhibitors and ARBs (-sartan drugs)

-ARBs are given if you can't use an ACE inhibitor ( esp if pt has cough and angioedema
from ACE I
When are ARBS contraindicated
if pt has bilateral renal artery stenosis
In ACUTE HF situations with HTN , DO NOT GIVE WHICH MEDICATION?
Beta Blockers!
What are popular aquaretic drugs and how do they work for HF pt
1. Conivaptan (Vapirsol) -> IV V2 antagonist
2. Tolvaptan (Samsca) -> PO V2 antagonist

- gets rid of pure water and keeps sodium intact , pt will be extremely thirsty
Digoxin is mainly given to what type of patients
HF with concomitant atrial fibrilation

-it's a positive ionotrope & slows AV conduction

-monitor for hypokalemia and hypercalcemia
How does Entresto (Sacubitril /Valsartan compound) work with patient's with HF
Prevents break down of BNP, which helps you diurese. (Neprilysin and RAAS inhibition)
Chest pain assessment
P : pain, placement, provocation
Q : quality (sharp, stabbing, pressure), quantity
R : Radiation, relief
S : Severity, systems (nausea, sweaty, dizziness)
T : Timing ( when it started, how long did it last, what makes it better or worse )
this is the amount of blood leaving the heart in over a minute
Cardiac output
this is the amount volume that leaves the heart with each beat ( mL/beat)
Stroke volume
Stroke volume consists of which 3 things
Preload Afterload Contractility
This the volume of blood in the ventricle at the end of diastole
preload (the stretch of the ventricle)
What is the normal preload pressure in the RV and LV
RV : CVP 2- 6 MMHG
LV : PAOP 4 - 12 mmhg
this is how much the ventricles have to overcome to eject the blood into the next
compartment of circulation
Afterload
what is the normal afterload pressures in the RV and LV
RV : PVR = ((MAP - PAOP) X 80) / CO

PVR Normal is 37 - 250

LV : SVR = ((MAP - RAP) X 80) / CO

SVR normal is 900 - 1400

paop = pulmonary artery occlusion pressure

rap = right arterial pressure
Will an MI increase or decrease preload?
Increase preload
Will sepsis increase or decrease preload?
Decrease preload d/t blood in peripheral areas of the body being unable to get to heart
Causes of decreases of preload
1. Hypovolemia
2. Arrhythmia
3. Loss of atrial kick
4. Venous vasodilation
What can decrease contractility
1. Parasympathetic stimulation
2. Negative ionotropic therapies ( beta blockers & ca channel blockers )
3. Hyperkalemia, acidosis
4. Acidosis
What can increase contractility
1. Sympathetic stimulation
2. Inotropic therapies ( epinephrine, dopamine, dig, calcium )
3. Hypercalciemia
What is being activated for a HF patient in the neurohormornal systems
1. Adrenergic
2. Renin - Angiotension Aldosterone
3. Hypothalamic - neurohypohphyseal
4. Endothelium
What is the end result for the activation of the Neurohormonal Systems
1. Increased heart rate
2. Increased contractility
3. Vasoconstriction
4. Sodium and H20 retention

***ULTIMATELY INCREASED CO & BP

How will left sided heart failure appear?
will see fluid on CXR and hear bibaslar rales
Explain a positive hepatojugular reflex
Pushing on the liver on acute pts can cause JVD to appear
what is a major cause of HF
ACUTE CORONARY SYNDROME ( poor coronary perfusion )

may need CABG, PCI , Thrombolytics

What stops the causes of HF
STATINS

-all other drugs block the compensatory mechanisms that makes the patient's
symptomatic
Which 4 classes of drugs are used for HF?
1. Vasodilators
-A. ACE inhibitors
-B. ARBs
-C. Hydralazine (selective arteriole dilator) & Isosorbide dinitrate (isordil, sorbitrate)
(selective veous dilator) are commonly used together to create same result of ACE
inhibitor
-D. Nitroglycerin (venous dilator)
-E. Ca Channel blockers (not rec for tx, can cause opposite effect)
-F. BNP is only avail in IV and not PO (Nesiritide / Natrecor ) increases cardiac output
and GFR ( increasing U/O) & increases calcium to increase contractility

2. Diuretics

3. Inotropic agents (positive)

-A. Cardiac glycosides : Dig
-B. Sympathomimetics: Dobutamine (dobutrex)
-C. Phosphodiesterase inhibitors: Amrinone (Inocor) and Milrinone (Primacor)

4. Beta Blockers (negative ionotropic agents)

how does diuretics work to help patient's with HF
decreases preload and afterload by reducing water retention
it decreases the work of the failing heart muscle, and rec. for all pts who have
symptomatic HF
How do POSITIVE ionotropic agents work
Increases the force of myocardial contraction enhancing stroke volume -> increasing
cardiac output
How does cardiac glycosides work?
AKA Dig
accumulates Ca to increase contractility & decreasing HR by slowing conduction
through the AV node
What other devices can help the patient's heart demands descrease
1. IABP (INTRA-AORTIC BALLOON PUMP)
2. VENTRICULAR ASSIST DEVICES (VAD)
half of the deaths from heart failure occurs suddenly and are most likely due to
the result of what?
dysrhytmia
Treatments for arrhythmia
1. PO meds
2. Pacemakers
3. ICD (implantable cardioverter defibrilators)
4. Heart transplant
5. Quality of life focus
this pacemaker is located in the right atria and spikes before the p wave
Atrial (A) pacing
this pacemaker is in the right ventricle and spikes before the QRS complex
Ventricular (V) pacing
this pacemaker is in both right sided chambers and spike before the P & QRS
complex
Atrial / ventricular (AV) pacing
this pacemaker has electrodes in the RA, RV, AND outside of the LV
Biventricular or Cardiac Resynchronization therapy
trouble shooting pacing
failure to capture , sense, or to fire
What are the 3 types of cardiomyopathy
1. Dilated (congestive) AKA DCM (most common form
-A. Ischemic : MI , alcoholic, DM
-B. Non - ischemic (post partum or viral)
-C. Stress induced (post partum or viral)

2. Hypertrophic
3. Restrictive cardiomyopathy
How will a heart look if it's dilated?
stretched out & stretched out ventricles

causes arrhythmias
Hypertrophic cardiomyopathy or idiopathic subaortic stenosis
1. primarily hereditary
2. will look normal on CXR
3. BUT with ECHO, ventricles are smaller and aortic valve is smaller
4. Usually seen in 20 and 30 year olds
5. Tx with alcohol ablation of septum or heart transplant or ICD
Restrictive cardiomyopathy
caused by sarcardosis
TX for cardiomyopathy
1. rest heart
2. blood thinners to prevent blood clots
3. antidysrhythmic agents / assistive devices
BE CAREFUL WITH THESE DRUGS FOR PT WITH HYPERTROPHIC
CARDIOMYOPATHY
1. Digitalis
2. Diuretics
3. Inotropic agents

** can result in closing ventricular outflow and cause cardiac death

Pharmocology mainly used in cardiomyopahty
1. Digitalis
2. Diuretics
3. Beta blockers , ace inhibitors
4. vasodilators
5. inotropic agents
6. antidysrhythmics
7. anticoagulants
main s/s of dilated cardiomyopathy
1. Arrhythmia (poss a.fib)
2. low amplitude QRS
3. Hypotension
4. pulmonary congestion
diltazem (Cardizem) is what type of pharmalogical drug
calcium channel blocker , you know it's effective when HR decreases
What will you see with a mag toxicity
+ depressed tendon reflexes
Torsades
pt needs mag
What is given for a pt in SVT
Adenosine
potassium abnormalities will result in
depressed or increased T waves
What is integrillin used for?
To help stop bleeding or retroperitoneal bleeding
What is dig toxicity's antidote?
digibind (digoxin immune fab)
Pt on dig that has toxicity will see what?
an aurora
nausea, vomiting, abdominal pain, headache, dizziness, confusion, delirium, vision
disturbance
Lidocaine on an EKG will show
Wide QRS
What is below the SA node?
JR
How will tension pneumothorax present?
JVD, Elevated HR, BP
Dobutrex is used for pt's with
kidney function?
A.fib first line of drugs
Cardizem first then admiodarone
COPD will cause enlargement in which part of the heart
Right ventricular enlargement
What is the antidote for Coumadin?
Vitamin K
What is a therapeutic INR for a pt on Coumadin?
2.5 - 3.5
which test is the most effective to determine an MI
Troponin levels