This action might not be possible to undo. Are you sure you want to continue?
Immunochemical process using monoclonal antibodies that measures this cardiospeciﬁc enzyme. Concentrations 5% of total creatine kinase (CK) are highly indicative of MI. Serum levels increase within 4-6 hr after MI. Contractile proteins that are released following an MI. Both troponin T and troponin I are highly speciﬁc to cardiac tissue. Normal: Troponin T (cTnT): 0.1 ng/ml Troponin I (cTnI): 0.4 ng/ml cTnI 0.5-2.3 ng/ml indeterminate or suspicious for myocardial injury cTnI 2.3 ng/ml positive for myocardial injury Low-molecular-weight protein that is 99%-100% sensitive for myocardial injury. Serum concentrations rise 30-60 min after MI. Normal: 92 ng/ml (men) 76 ng/ml (women) Marker of inﬂammation that can predict risk of cardiac disease and cardiac events, even in patients with normal lipid values. Normal: 1 mg/L Moderate Risk: 1-3 mg/L High Risk: 3 mg/L Amino acid produced during protein catabolism that has been identiﬁed as a risk factor for cardiovascular disease. It is postulated that homocysteine causes damage to the endothelium or has a role in formation of thrombi. Optimal: 12 mol/L Moderate Risk: 12-15 mol/L High Risk: 15 mol/L Peptide that causes natriuresis. Elevation indicates presence of heart failure and distinguishes cardiac vs. respiratory cause of dyspnea. Normal: 100 pg/ml
Explain to patient the purpose of serial sampling (every 6-8 hr 3) in conjunction with serial ECGs. Rapid bedside assays are available. Serial sampling often done in conjunction with CK-MB and ECG.
Cleared from the circulation rapidly and most diagnostic if measured within ﬁrst 12 hr of onset of chest pain.
C-reactive protein (CRP)
Stable levels that can be measured nonfasting and anytime during the day. May be more predictive risk factor of cardiac disease than LDLs for women.
Hyperhomocysteinemia resulting from dietary deﬁciencies is treated with folic acid, B6, and B12 supplements.
Type b natriuretic peptide (BNP)
Infusion of nesiritide (Natrecor) will elevate levels temporarily.
Cholesterol Cholesterol is a blood lipid. Elevated cholesterol is considered a risk factor for atherosclerotic heart disease. Level can be measured at any time of the day in a nonfasting state. Normal: 140-200 mg/dl (3.62-5.17 mmol/L) (varies with age and gender) Triglycerides are mixtures of fatty acids. Elevations are associated with cardiovascular disease. Normal: 40-190 mg/dl (0.45-2.15 mmol/L) (varies with age) Electrophoresis is done to separate lipoproteins into HDL, LDL, and VLDL and chylomicrons. There are marked day-to-day ﬂuctuations in serum lipid levels. More than one determination is needed for accurate diagnosis and treatment. Normal: varies with age. Desirable LDL without CAD is 130 mg/dl (or 3.4 mmol/L). Desirable LDL level with CAD is 100 mg/dl (or 3.4 mmol/L) Desirable HDL is 37-70 mg/dl (0.97-1.83 mmol/L) for men; 40-88 mg/dl (1.05-2.30 mmol/L) for women. Enzyme immunoassay (PLAC test) is done to measure the level of Lp-PLA2. Elevated levels of Lp-PLA2 are associated with vascular inﬂammation and increased risk for CAD. Normal: 131-376 ng/ml (men) 120-342 ng/ml (women) Risk for cardiac disease is assessed by dividing the total cholesterol level by the HDL level. Target values are 5 for men and 4.4 for women. Cholesterol levels can be obtained in a nonfasting state, but for triglyceride levels and lipoproteins, fasting state for at least 12 hr (except for water) is necessary, and no alcohol intake is allowed for 24 hr before testing.
Lipoprotein-associated phospholipase A2 (Lp-PLA2)
Lp-PLA2 levels can be obtained in a nonfasting state.
CAD, Coronary artery disease; ECG, electrocardiogram; HDL, high-density lipoproteins; HR, heart rate; IV, intravenous(ly); LDL, low-density lipoproteins; MI, myocardial infarction; NPO, nothing by mouth; VLDL, very-low-density lipoproteins. Continued
presence of acute injury. Monitor patient’s response throughout procedure. A common protocol uses 3-min stages at set speeds and elevation of the treadmill belt. Teach patient about skin preparation for lead placement or steady skin contact for units not requiring electrodes. Inform patient to carry or pull oxygen if used routinely. Other types are placed directly on patient’s wrist. This will ensure the reception of optimal ECG tracings for analysis. Remove any jewelry or metal objects that may obstruct the view of the heart and lungs. Monitor vital signs and obtain 12-lead ECG before exercise. Instruct patient to wear comfortable shoes. activity of pacemaker. ejection fraction. An exercise bike may be used if the patient is unable to walk on the treadmill. and history of MI. It can be performed on an inpatient or outpatient basis. Exercise Treadmill Test Instruct patient to wear comfortable clothes and shoes that can be used for walking and running. conduction abnormalities. Study Chest X-Ray Nursing Responsibility Inquire about frequency of recent x-rays and possibility of pregnancy. Some units have electrodes that are attached to the chest and have a loop of memory that captures the onset and end of an event. Prepare skin and apply electrodes and leads. and cardiac function. position of heart. ECG Electrodes are placed on the chest and extremities. Patient should be encouraged to walk as quickly as possible. and after exercise until all vital signs and ECG changes have returned to normal. Ambulatory ECG Monitoring • Holter monitoring Recording of ECG rhythm for 24-48 hr and then correlating rhythm changes with symptoms recorded in diary. Electrodes are placed on chest and a recorder is used to store information until it is recalled. Resting images of the heart are taken with ultrasound and then the patient exercises. Tracings can then be erased and the unit can be reused. sex. Inform patient that no discomfort is involved. Records rhythm disturbances that are not frequent enough to be recorded in one 24-hr period. Skin irritation may develop from electrodes. Used to measure response to treatments and functional capacity for activities of daily living. Instruct patient to avoid moving to decrease motion artifact. Various protocols are used to evaluate the effect of exercise tolerance on myocardial function. Contraindications include any reasons patient is unable to reach peak exercise. but record the patient’s ECG in real time. Explain importance of keeping an accurate diary of activities and symptoms. Instruct patient about procedure and importance of reporting any symptoms that may occur. Inform patient of importance of timely return to examination table for imaging after exercise. congenital cardiac defects. and the recordings are printed out for review. and size are noted. Prepare skin and apply electrodes and leads. Continual monitoring of vital signs and ECG rhythms for ischemic changes are important in the diagnosis of left ventricular function and CAD. . Postexercise images are taken immediately after exercise (within 1 min of stopping exercise). Also records direction and ﬂow of blood through the heart and transforms it to audio and graphic data that measure valvular abnormalities. Normal patient activity is encouraged to simulate conditions that produce symptoms. The two common positions are posteroanterior (PA) and lateral. 6-Minute Walk Test Distance patient is able to walk on a ﬂat surface in 6 min. allowing the ECG machine to record cardiac electrical activity from different views. Instruct family and patient about procedure and sensations (pressure and mechanical movement from head of transducer). Stress echocardiogram Instruct and prepare patient for treadmill or exercise bicycle. during each stage of exercise. Place patient in a supine position on left side facing equipment. size of atria and ventricles. Combination of exercise test and echocardiogram. chest. Provide lead shielding to areas not being viewed. Transducer records sound waves that are bounced off the heart. No contraindications to procedure exist. • Transtelephonic event recorder Instruct in the use of equipment for recording and transmitting of transient events. Recordings are transmitted over the phone to a receiving unit. Can detect rhythm of heart. and analyzed for any rhythm disturbance. or ﬁngers and have no loop of memory. Contraindications include any reasons patient is unable to reach peak exercise. printed. wall motion. Normal heart size and contour for the individual’s age. It allows more freedom than a regular Holter monitor. Differences in left ventricular wall motion and thickening before and after exercise are evaluated. Tell patient that no bath or shower can be taken during monitoring. Echocardiogram • • • • • M-mode Two-dimensional (2-D) Color-ﬂow imaging or color Doppler Real-time 3-dimensional (3-D) Contrast Transducer that emits and receives ultrasound waves is placed in four positions on the chest above the heart.772 Cardiovascular System TABLE 32-7 Section 7 Problems of Oxygenation: Perfusion DIAGNOSTIC STUDIES Cardiovascular System—cont’d Description and Purpose Patient is placed in two upright positions to examine the lung ﬁelds and size of the heart.
Explain procedure to patient. Establish IV line for injection of isotopes. Multigated acquisition (MUGA) scan 99m Technetium-sestamibi is mixed with a small amount of the patient’s blood and reinjected (IV). ﬂuoro-18-deoxyglucose. Vasodilation will increase blood ﬂow to well-perfused coronary arteries. Monitor vital signs before. Scanning is done 15-60 min after exercise.. diagnostic amount and will lose most of its radioactivity in a few hours. Exercise nuclear imaging 99m Technetium-sestamibi or other nuclear imaging agent is injected IV and used to evaluate blood ﬂow in different parts of the heart. Explain that radioactive isotope used is a small. Remove dentures. but in an ischemic or damaged heart. A probe with an ultrasound transducer at the tip is swallowed. Monitor vital signs and oxygen saturation levels and perform suctioning continually during procedure. Aminophylline may be given to prevent or reverse side effects. Explain that patient will be scanned by a machine and will need to stay still for a period of time. Establish IV line for removal of blood sample and reinjection of isotope. Explain procedure to patient. wall motion. A 3-4 hr interval between rest and stress studies is required. Indicated for patients with MI. Administer medication per protocol. Assist patient to relax. It also can be used to evaluate the effect of various cardiac or cardiotoxic medications on the heart. bronchospasm). Instruct patient to eat only a light meal between scans. Scanning procedure is same. Certain medications may need to be held for 1-2 days before the scan. Sore throat is temporary. The physician controls angle and depth. Inform patient that procedure involves little or no risk. patient will need to be NPO and refrain from tobacco and caffeine for 24 hr before test. Radioactive uptake is counted over the heart by scintillation camera. it sends back clear images of heart size. Patient’s glucose level must be between 60 and 140 mg/dl (3. Images are acquired at various points in the cardiac cycle.3-7. A second radioactive isotope. Contraindications include any known allergies to medications. Instruct patient to be NPO for at least 6 hr before test. Patient may not eat or drink until gag reﬂex returns. Inform the patient that he or she will be lying still on back with arms extended overhead for 20 min. A bite block is placed in the mouth. Monitor patient for signs and symptoms of distress during procedure. Images are taken at rest and after exercise. Contraindications include any known allergies to medications. The patient may or may not be stressed. 773 Cardiovascular System TABLE 32-7 Study Echocardiogram—cont’d Pharmacologic echocardiogram Nursing Responsibility Start IV infusion. during. A contrast medium may be injected IV for evaluating direction of blood ﬂow if an atrial or ventricular septal defect is suspected. and possible source of thrombi without interference from lungs or chest ribs. For stress testing. the injection is given at maximum heart rate on bicycle or treadmill. A designated driver is needed if done in the outpatient department. A baseline resting scan is usually obtained for comparison. both scans will match. Nitrogen-13-ammonia is injected IV ﬁrst and scanned to evaluate myocardial perfusion. and acute cell injury. Pharmacologic nuclear imaging Dipyridamole or adenosine is used to produce vasodilation when patients are unable to tolerate exercise. Explain procedure to patient. As it passes down the esophagus. In the normal heart. IV sedation is administered and throat is locally anesthetized. A resting scan may have to be performed 60-90 min after initial infusion or it may have to be done 24 hr prior. Instruct patient to hold all caffeine products for 12 hr before procedure. and after test until baseline achieved. Repeat scans are performed within a few minutes to hours after the injection. Explain procedure to patient.g. valvular abnormalities. Positron emission tomography (PET) Uses two radionuclides. Instruct patient on procedure. they will differ. heart failure. Observe patient for side effects (e.Chapter 32 Nursing Assessment: Cardiovascular System DIAGNOSTIC STUDIES Cardiovascular System—cont’d Description and Purpose Used as a substitute for the exercise stress test in individuals unable to exercise. Transesophageal echocardiogram (TEE) Nuclear Cardiology Study involves IV injection of radioactive isotopes. It supplies information about myocardial contractility. Dobutamine is used if vasodilators are contraindicated. Dobutamine (a positive inotropic agent) or dipyridamole is infused IV and dosage is increased in 5-min intervals while echocardiogram is performed to detect wall motion abnormalities at each stage. Follow-up scan may have to be done 24 hr later. myocardial perfusion. If exercise is included as part of testing. is then injected and scanned to show myocardial metabolic function. Continued . Patient is then required to continue exercise for 1 min to circulate the radioactive isotope. Establish ECG monitoring. Doppler ultrasound and color ﬂow imaging can also be used concurrently.8 mol/L) for accurate glucose metabolic activity. Certain medications may need to be held for 1 day before the scan. or valvular heart disease.
Contraindicated for persons with any implanted metallic devices. Serial x-rays taken to detect and visualize any atherosclerotic plaques. Check for iodine sensitivity. Monitor vital signs. and motion after procedure. Contrast medium is injected to assist in examining structure and motion of heart. Before procedure.774 Cardiovascular System TABLE 32-7 Section 7 Problems of Oxygenation: Perfusion DIAGNOSTIC STUDIES Cardiovascular System—cont’d Description and Purpose Noninvasive imaging technique obtains information about cardiac tissue integrity. A very small ultrasound probe is introduced into the coronary artery. pulmonary artery wedge pressure. if ordered. if indicated. assess circulation to extremity used for catheter insertion. Invasive study used to record intracardiac electrical activity using catheters (with multiple electrodes) inserted via the femoral vein into the right side of heart. IV sedation often used during the procedure. dysrhythmias can be induced. Inspect insertion site for bleeding or swelling. Intracoronary ultrasound Same as for cardiac catheterization. The catheter electrodes record the electrical activity in different cardiac structures. It does not involve ionizing radiation and is an extremely safe procedure. Hemodynamic Monitoring Hemodynamic monitoring of arterial blood pressures. color. Inform patient about use of local anesthesia. similar to coronary angiography. Check for iodine allergy. Place compression device over arterial site. Electrophysiology study (EPS) Obtain written consent. Patient must lie still during MRI. cardiac output. obtain written permission. Explain procedure to patient. occlusion. Information obtained is used to assess size and consistency of plaque. may cause panic or anxiety. Coronary angiography Study involves injection of radiopaque contrast medium directly into coronary arteries by same procedure as for cardiac catheterization. Study Magnetic Resonance Imaging (MRI) Nursing Responsibility Explain procedure to patient. Give mild sedative. Antidysrhythmic medications may be discontinued several days before study. aneurysms. Procedure is done by insertion of catheter into a vein (for right side of heart) or an artery (for left side of heart) (see text). Note that patient may be instructed to cough or take a deep breath when catheter is inserted and that patient is monitored by ECG throughout procedure. or traumatic injury. aneurysms. . Invasive study used to provide ultrasound information about the coronary arteries. Same as for cardiac catheterization. Observe patient for allergic reactions to dye. Inform patient that the small diameter of the cylinder. Carefully explain procedure to patient. Inform patient that procedure is quick and involves little or no risk. and effectiveness of intracoronary artery treatment. if ordered. Magnetic resonance angiography (MRA) Electron Beam Computed Tomography (EBCT) Cardiac Catheterization Noninvasive scan used to quantify calcium deposits in coronary arteries and heart valves. *Additional peripheral vascular diagnostic studies are found in Table 38-8. color. and sensation of extremity every 15 min for 1 hr and then with decreasing frequency. Contraindications include any known allergies to contrast medium and persons with any implanted metallic devices. Keep patient NPO 6-8 hr before test. Antianxiety drugs and music may be recommended. Give premedication to promote relaxation and throughout the procedure if ordered. Check peripheral pulses. Withhold food and ﬂuids for 6-18 hr before procedure. It provides images in multiple planes with uniformly good resolution. Patients requiring hemodynamic monitoring are critically ill and are monitored in intensive care units (see Chapter 66). and signs of pulmonary emboli (respiratory difﬁculty). and patency of proximal coronary arteries. Observe puncture site for hematoma and bleeding. warmth. ejection fractions. and cardiac output is done to evaluate cardiovascular status and response to treatment. Peripheral Arteriography and Venography* Study involves injection of radiopaque contrast medium into either arteries or veins. Patient must have continuous ECG monitoring after the procedure. insertion of catheter. Same as MRI but with use of gadolinium as IV contrast medium to evaluate arterial disease. Check extremity with puncture site for pulsation. pulmonary artery pressure. arterial walls. along with loud noise of the procedure. Assess for abnormal HR. dysrhythmias. After procedure. Study involves insertion of catheter into heart to obtain information about O2 saturation and pressure readings within heart chambers. May have clinical applications as a screening test for cardiac disease. It is used to evaluate patency of coronary arteries and collateral circulation. and feeling of warmth when dye is injected and ﬂuttering sensation of heart as catheter is passed. Give sedative. In addition.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.