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CARDIO NOTES  Sources: MS by Brunner, MS by Black and Hawks, nsg review notes and racked-up notes han 3rd

year pa kita.. 
Cardiovascular diseases – one of the leading causes of death and disability ANATOMY AND PHYSIOLOGY (brief) Heart - 4 chambers - 3 layers of pericardium (out to in): epicardium, myocardium and endocardium - Valves: Atrioventricular valves (AV valves – bicuspid/mitral and tricuspid valves) and Semilunar valves (aortic, pulmonic, and heart eps) *heart eps – extra valve found in small proportion of population Arteries, Veins and Capillaries – blood vessels - Layers (out to in): tunica adventitia, tunica media and tunica intima - Capillaries – one cell-thick walls - Largest artery: Aorta - Largest vein: Vena cava *Veins carry 40-55% O2 NOT blood without O2! :) Coronary Circulation:  LADA (Left Anterior Descending Artery) – anterior wall of the heart  LMCA (Left Main Coronary Artery) – main branch of left coronary artery  LCXA (Left Circumflex Artery) – circles around the lateral left wall of the heart  RCA (Right Coronary Artery) – to inferior wall  Posterior Descending Artery – to posterior portion Electrical Conduction:  Starts with the Sinoatrial (SA) node – pacemaker; normal rate: 60-100bpm  Impulses pass to Atrioventricular (AV) node – 0.12-0.20 seconds delay  Then to the Bundle of His, to the Purkinje fibers and to the whole ventricular walls  ECG – measures electrical activity of the heart.

- Either 12 or 15-lead ECG
Can ECG determine structural abnormalities? YES! If there is a defect, electrical activity in that part is abnormal! Cardiac Output = Stroke Volume x Heart rate Note: very high HR can decrease CO (ex: in Ventricular fibrillation or V-fib where the heart “quivers” instead of pumping properly) Carotid Arteries – left and right - Internal and external carotid arteries - In stroke: Middle cerebral artery and internal carotid artery are commonly affected. External Jugular Vein – vein that can be easily assessed (for JVD) Subclavian Vein – can be used for cannulations (e.g. cardiac catheterization) Pulse Pressure = SBP – DBP *if PP = < 20  cardiac tamponade * BP is changed by: > diameter and elasticity of blood vessels (hunahunaa daw an tubo nga guti ngan dako kun hain it mas makusog it awas?) > blood viscosity (the more viscous, the slower blood flow) > force of heart contractions > volume of blood SBP – cardiac output; DBP – resistance to blood flow Control: by epinephrine and norepinephrine ASSESSMENT  Hx - Smoking - HPN - Obesity – heart becomes overworked; increased risk of atherosclerosis - Sex - Activity - Family HX - DM - Age (*menopause – 2x risk of MI) - Respiratory Probs (to determine presence of cor pulmonale or pulmonary hypertension) - Meds  PE - Appearance - V/S – including peripheral pulses

- Weight – if increased to 3 lbs/ 24 hrs (fld retention) - Pulsus alternans – beat to beat change in amplitude; indicates left heart failure - Pulsus paradoxus – exaggerated decline of PP during inspiration; indicates cardiac tamponade and constrictive pericarditis - Kussmaul’s sign – engorged jugular veins during breathing; not to be confused with Kussmaul’s respiration (deep respirations in an attempt to blow off CO2 e.g. in DKA patients) - Chest pain – use COLDSPA questions *most dangerous type of chest pain: UNSTABLE ANGINA AND VARIANT ANGINA (occurs at rest) - Respiratory SOME DX EXAMS:  ECG  2D-Echocardiogram (or simply, 2D-echo) – sees heart structures  Holter monitor – with portable monitor  Cardiac catheterization and Arteriography  Stress test – ECG + exertion (may treadmill iton)  Radionucleide tests – uses isotope to detect CA; CA cells glow indicating that they are hypermetabolic  Pulse oximetry – important nsg responsibility: remove nail polish; stroke patients: on unaffected side  Hemodynamic Monitoring – ex. CVP  MRI – contrarindications: metal implants and claustrophobic patients (e.g. psychiatric patients)  Cardiac enzymes – CPK-MB (increased 2-4 hrs after MI); Troponin I (increases 6-8 hrs after MI) DISORDERS: I. Congenital Disoders/Anomalies > 4 different classifications based on hemodynamics: - Increased pulmonary blood flow - Obstruction of blood flow leaving the heart - Mixed blood flow - Decreased pulmonary blood flow a. disorders with increased pulmonary blood flow – left to right shunt, between 2 systems of great arteries 1. Ventricular Septal Defect (VSD) > opened septum between 2 ventricles

Tricuspid Atresia > closed tricuspid valve > with open foramen ovale >extreme cyanosis. Blalock-Taussig procedure (creating a shunt between aortic and pulmonic artery). open heart surgery (usually done before age 2 to prevent pulmonary hypertension) >complication: endocarditis 2. Preductal – between subclavian artery and ductus arteriosus b. Postductal – after ductus arteriosus > assessment: headache (increased BP on upper side and decreased BP on lower side).Ibuprofen – inhibits release of prostaglandins to close the PDA . Aortic Stenosis > narrowed aortic valve > backpressure to pulmonary vein > congestion to LV > causes pulmonary edema > decreases CO > assessment: faint pulses (decreased CO). interventional cardiography. Pulmonary Stenosis > narrowed pulmonary valve > ventricular hypertrophy occurs > lesser blood for oxygenation > assessment: mild right sided heart failure. sometimes sudden death > mgt: stabilization by beta-blocker and calcium channel blockers. balloon valvuloplasty 3. diuretic therapy to prevent CHF *girls – need repair before childbearing age to be able to adjust to the increased blood volume c. Transposition of Great Arteries > switching of places of the great arteries (aorta and pulmonary artery) > incompatible with life unless the child has ASD. with compromised oxygenation 1.ductal ligation (major surgery) b. dizziness. Atrial Septal Defect (ASD) > hole in between atria > common in girls > foramen ovale did not close > 2 types: a. Patent Ductus Arteriosus (PDA) > DA fails to close > O2-rich blood back to lungs > increases pressure on the left side > with RV hypertrophy >dx: 2d-echo >mgt: . Mitral Valve disease – stenosis. VSD or PDA > with murmurs > mgt: prostaglandin therapy (to open DA) Balloon catheterization (to increase diameter of the septal defect) Surgery (1 week to 3 months to switch back to normal positions) 2. tachycardia >mgt: prostaglandin therapy Glenn Shunt Baffle – restructuring of the right side of the heart 2. Pulmonary Stenosis b. VSD c. regurgitation and prolapse > stenosis – result from acute rheumatic fever (Grp A Betahemolytic Streptococci . Coarctation of the Aorta > narrowed lumen of aorta due to constricting band > one of the causes of CHF > 2 locations: a. thrills > mgt: balloon angioplasty thru cardiac catheterization 2. cardiac catheterization >mgt: elective surgery done within 1-3 yrs * can cause emboli during pregnancy if left undiagnosed! 3. O2.> with RV hypertrophy and pulmonary hypertension >more common in boys > idiopathic > with easy fatigability (poor oxygenation) > harsh loud pansystolic murmur > thrills >dx: echocardiography and MRI >mgt: if hole is small: closes spontaneously. faint brachial pulse >mgt: balloon catheterization. vertigo. chest pain. absence of palpable femoral pulses. RV hypertrophy > abnormal chromosome 22 (long arm) > with polycythemia vera (compensation to provide adequate blood to tissues deprived of O2) >severe dyspnea. Hypoplastic Left Heart Syndrome (HLHS) > atresia of the mirtal and aortic valve > nonfunctional LV > increased pressure on the right side > RV hypertrophy > with PDA >mgt: prostaglandin therapy and heart transplant d. Atrioventricular Canal Defect (AVCD) > or endocardial cushion defect > incomplete fusion of the septum of the heart at the junction of the atria and ventricles > mgt: pulmonary artery bonding – narrowing pulmonary artery to equalize pressure between the left and right sides of the heart 4. hypotension. ASD II/ Osteum Secondum – hole is proximal to center > assessment: harsh systolic murmur in pulmonic area > dx: 2d-echo.cardiac catheterization . clubbing of fingers > with hypoxic episodes >squatting and knee-chest position are the relieving factors (traps blood in lower extremities and thus resting the heart) > mgt: surgery. N&V. surgery to repair the defect. beta-blockers. ASD I / Osteum Primum – hole is distal to center b. Disorders with decreased pulmonary blood flow – obstruction to pulmonary blood flow that would increase the pressure on the right side 1. Structural Cardiac Disorders 1. Disorders with Obstruction to blood flow – caused by valve or vessel that is narrowed 1. musmurs (VSD) >mgt: restructuring by surgery 4. If > 3mm hole. systolic ejection murmur. tachycardia. Truncus Arteriosus > fused aorta and pulmonary artery > accompanied by VSD > assessment: cyanosis. Dextroposition of Aorta (or Overriding Aorta) d.IV indomethacin *prostaglandins – maintains the PDA . Total Anomalous Pulmonary Venous Return > pulmonary veins are attached to superior vena cava > often with patent foramen ovale > found in patients without spleen >mgt: surgery and prostaglandin therapy 3. cyanosis. Tetralogy of Fallot > 4 anomalies in one a. Brock procedure (full repair) II. Disorders with Mixed blood flow – mixing of blood from pulmonary and systemic circulation.can increase pressure on the left atrium .

disorders of the myocardium . Water Hammer Pulse or Corrigan’s pulse (sudden sharp pulse then collapse of diastolic pulse). anticoagulants.can cause pulmonary congestion (backflow) and a-fib (hypertrophy of the atrium) .result of an autoimmune or allergic reaction . O2. diuretics. Myocarditis . Infectious Diseases of the Heart 1.causes: >may be idiopathic > local infection > disorders of connective tissue > allergic reaction > neoplastic > trauma > radiation therapy -clin.high-pitched murmur . hepatic congestion . Anuloplasty.heart walls are replaced by fibrotic tissue .most common . diastolic murmurs -mgt: prophylactic meds. Manifestations: > pain (like MI) aggravated by breathing > pericardial friction rub > signs of infection > tachycardia -complications: Cardiac Tamponade – compression Beck’s triad:  Increased CVP with neck vein distention  Muffled heart sounds  Pulsus paradoxus Intervention: emergency pericardiocentesis 2. Balloon valvuloplasty 5. beta blockers. LV enlargement. monitor for digitalis toxicity -complications: mural thrombi formation and cardiomyopathy 3. myotomy ( surgical incision or resection of a portion of interventricular septum) and heart transplant 3 types of Cardiac Surgery: a. Substitutional Heart Transplantation 2 types: a. Subacute – Streptococcus viridans -with low-grade fever c. Pulmonic Valve disease .regurgitant murmur or midsystolic click . Hypertrophic . overload in LV MR – systolic event -with angina pectoris.hallmark: Pulsus alternans . in LV. surgery for severely stenotic leaflets 4.intervention. prophylactic meds c. aspirin to prevent thrombi formation 2.can create mural thrombi due to blood stasis in LA . murmur increases with inspiration. syncope. emotional support. and vasodilators to prevent heart failure.infection of the inner lining of the heart secondary to bacterial contamination -causes: > prolonged IV therapy > invasive surgical procedure > structural defects of the heart > previous dental extraction .heart enlarges .) ) . small. Tricuspid Valve Disease -manifestaions: pulsations in the jugular veins. Restrictive – deposition of eosinophilic CHONs in the heart muscles . Heterotropic III. or parasitic infection > immunosuppression >allergic reaction . Cardiomyopathy .can decrease CO . avoid vigorous physical activity. no inotropics and nitrates.leads to LSHF * aortic regurgitation vs mitral regurgitation AR – diastolic event.common cause: amyloidosis -can decrease resistance to LV filling leading to low CO and then failure -mgt: Na restriction.congenital or degenerative .heart loses its ability to expand (axa ngani restrictive! . digitalis..inflammation of the pericardium .chest pain .mgt: diurteics. stress importance of follow-up exams. there is compensatory dilation due to vol.can decrease CO .inflammation in the muscles of the heart -causes: > viral.murmurs -dyspnea . Reconstructive c. weight loss. valve reconstruction.3 main classifications: a. nontender red spots on palms and soles Duke’s Criteria for IE . peripheral edema.mgt: prevent beta-hemolytic strep infection (RF and RHD). Aortic Valve Disease – stenosis and regurgitation . diuretics. Orthotropic b. Dilated – LV and RV dilate .manifestations: > loud regurgitant murmurs > petechiae > splinter hemorrhage > Roth’s spots – white/yellow center surrounded by a bright red.leads to increased LV pressure .loud first heart sound – hard valves > regurgitation – failure of the valves to close . Reparative b. pacemaker.splitting of 2nd heart sound (due to increased blood vol.tachycardia .PND (paroxysmal nocturnal dyspnea) and orthopnea occurs . digitalis. auscultate chest. fungal. Infective Endocarditis . no alcohol.3 types: a. bed rest. irregular halo seen in oplthalmoscope > Osler’s nodes – painful. Acute – most fatal -Staphylococcus aureus -with high fever b.there is myocardial degeneration to fibrotic tissue replacement consequently decreases contractility and ultimately leads to clot formation (blood pooling) and heart failure (low CO) b. Chronic – in IV drug users .some of the blood regurgitates back to LA . O2. erythematous nodules >Janeway’s lesions – flat. there is a delay in closure in pulmonic valve) >prolapse .blowing pitch murmur . valve replacement 3.with pumonic stenosis -leads to RSHF -mgt: V/S q1-4 hrs. prevent edema.thickening of interventricular septum leading to decreased size of the chamber of the heart -mgt: rest.with gallop rhythm . beta blockers. Pericarditis .

Rheumatic Fever/Rheumatic Heart Disease (RF/RHD) . BUN and CREA.after MI.caused by Grp A beta-hemolytic Streptococci .interventions: eradicate infection by Penicillin IV or PO or Erythromycin if allergic to Pen.Treatment of CAD:  Lifestyle changes  Angioplasty  Morphine SO4 – pain and improves microcirculation  Anticoagulant  Anti-lipidemic meds  Beta blockers  Calcium channel blockers  Low-dose aspirin therapy (80mg as maintenance)  Nitrates – muscle relaxant (vasodilation) 2. diuretics.TC = HDL + LDL + TRIG .mitral and aortic valves are destroyed as a result of an autoantibody reaction . decrease HR. Coronary Heart Disease . Coronary Artery Disease (CAD) . promote comfort Jones’ Criteria of Diagnosis Major Criteria  Carditis  Painful migratory polyarthritis  Chorea  Erythema marginatum  Subcutaneous nodules Minor Criteria  Elevated ESR  Positive culture  Elevated anti-streptolysin O titer (ASO) IV. step2 . and Ca-channel blockers >weigh everyday >I&O > low fat.S&S: > asymptomatic > headache >blurred vision > possible kidney damage -mgt: >antihypertensives First-line: hydrochlorothiazides (diuretics) Next: ACE inhibitors. decrease no. decrease myocardial O2 demand.diagnosed after 3 consecutive BP takings (6 months interval and BP is 140/90 and above) . :( * cow’s milk has 24g of fat while breastmilk has 4. Hypertension . get medical help Max dose: 3 tabs . digitalis. when residual ischemia may cause episodes of angina Meds to treat acute attack in angina:  Opiate analgesics – reduce pain.silent killer >:) .high LDL and low HDL . decrease demand for O2  Vasodilators  Beta-adrenergic blockers – decrease workload of the heart.V.2 types: essential/primary HPN and secondary HPN .autoimmune disease .risk factors: > age >heredity > smoking > gender – more on men > HPN > elevated serum cholesterol level (240 mg/dL) > sedentary lifestyle > obesity > DM ( >126 mg/dL) > stress > elevated homocysteine levels > menopause – 2x risk S&S (near MI):  N&V  Chest pain  Cold clammy skin Female MI – shows atypical presentation (epigastric pain) Complications of MI:  Dysrhythmias  Heart failure and pulmonary edema  Pulmonary embolism  Recurrent MI  Complications caused by myocardial necrosis  Ventricular rupture  Ventricular aneurysm  Dressler’s syndrome (late pericarditis)  Pericarditis Patterns of Angina:  Stable angina – triggered by predictable degree of exertion or emotion  Unstable angina – triggered by unpredictable degree of exertion or emotion  Variant or Prinzmetal’s angina – occurs during rest  Nocturnal angina – during sleep (REM stage)  Angina decubitus – occurs when the client reclines and lessens when he sits or stand up  Intractable angina – unresponsive to intervention  Postinfarction angina .dx: BP. Functional Disorders 1. low Na diet (NOT Na-restricted diet) > lifestyle changes * weight loss of 7kg = decreased risk of dying from metabolic d/o by 20% . beta-blockers.N.2g of fat *max dose of Captopril: 3 doses * low fat diet: step1 . U/A – (+)CHON. blood sugar levels .<1200mg fat *nitroglycerin use: Store in dark glass container Replace every 4-6 months Take when pain starts and rest Bring the supply with you If there is no relief.<1500 mg fat . increase O2 supply to myocardium  Anriplatelet agents – prevent clot formation Dx:  ECG – ST segment changes (>1mm) *starts in toddlerhood.major risk factor of MI . = <240 mg/dL 3.Major Criteria  Positive blood culture  Vegetations seen in echocardiogram Minor Criteria  Predisposition  Fever  Vascular phenomenon  Microbiologic evidence 4.elevated BP . of angina attacks  Ca-channel blockers – dilate coronary arteries.

LSHF or RSHF . Arrhythmias / Dysrhythmias . Measure the regularity of R waves (ventricular rhythm) .affected artery: LADA .pause of rhythm .monitor K levels . rales.antibedsore mattress .more on pulmonary manifestations (PND.increased vagal tone 3. Sinus Exit Block .<0.<0. Disturbances in Automaticity 1.>100 bpm . 2.not given if HR is < 45 bpm .phasic changes in the automaticity in the SA node. Disturbances in Conduction 1.12-0.RSHF – back to venous circulation (edema.P wave and QRS normal . Examine the T wave . Conduction – speed the impulses travels through SA.persistent sinus bradycardia. Reentry of Impulses – cardiac tissues is depolarized multiple times by the same impulse Ectopic pacemaker – other cardiac cells originating the impulse other than the SA node ECG interpretation steps: 1. SA Arrest .turn to side . hemoptysis.take HR (apical) .) . Congestive Heart Failure (CHF) . Sick Sinus Syndrome . Sinus Tachycardia .unable to pump . etc. Calculate the HR either: a.neither the atria nor the ventricles are stimulated . of large squares until the next R wave. orthopnea. Beats – normal . hepatic congestion.11 s QT interval – male: 0.42 s.) . b.normal: isoelectric – not elevated or depressed -abnormal – abnormality in the onset of recovery of ventricular muscle usually because of injury (acute MI) 7. JVD.12 s (interventricular conduction defect occurs) 6.20 s -abnormal: prolonged or reduced (defect in conduction system between atria and ventricles) 5.43 s REMEMBER: P wave – atrial depolarization QRS complex – ventricular depolarization T wave – Ventricular repolarization A.PMI – 6th-7th ICS left of MCL (cardiomegaly) Normal PMI: 5th ICS at MCL -Mgt: > Fowler’s position > bed rest (cardiomegaly – hypermetabolic state) >I&O >abdominal girth > skin care in edematous areas .12 s bet.normal: P wave then the QRS -abnormal: absence or in abnormal position (ectopic pacemaker) 4.abnormal rhythms Normal sinus rhythm – normal heart rhythm that starts in the SA node (60-100 bpm) -disturbances in 3 major mechanisms: a. Sinus Bradycardia .normal: upright and 1/3 the height of the QRS complex .diet and diabetes E – education and exercise M – morphine SO4 O – O2 therapy N – Nitrates A – Aspirin 5.DON’T MASSAGE!! .P wave and QRS normal . Find an R wave crossing a large square. dyspnea. AV and Purkinje Fibers c.abnormal: inverted – interference to normal repolarization Tall – hyperkalemia Normal values: P wave . female: 0. 3-4 times a week (HR must be 150% of resting HR) >DASH diet *low fat (Mediterranean diet) 4.increase intake of K-rich foods V.use banana leaves for cooling effect > observe for arrhythmia >O2 – hypersaturate the blood with O2 even at low HR > diuretics > watch out for DVT > monitor for digitalis toxicity *digoxin – decreases HR and increases strength of contractions .PQRST will be missing for one or more cycles 2.12-0. Count the no. Examine the ST segment .irregular PP interval 4.11 s PR interval – 0.>0. combination of SA and AV node conduction disturbances and alternating paroxysms of rapid atrial tachycardias b.danger zone: 24-48 hrs after MI . Myocardial Infarction (MI) . Examine the P waves . Beats – abnormal 3.<60 bpm .20 s QRS complex – 0. of R waves in 6-inch strip of ECG tracing (6 secs) x 10 = rate/min. SA NODE DYSRHYTHMIAS a. Count the no. Automaticity – generating a heart rhythm b.12 s bet. Measure duration of QRS complex . etc.S&S: > dyspnea > hypotension >substernal pain Tx:  Thrombolytic drugs  Lidocaine (class I antidysrhythmic)  O2  Morphine SO4  Bypass surgery *follow-up: 10 days after discharge *resume work? 8-10 weeks after *resume sex? After walking 2 flights of stairs Mgt for treatment of MI (think of ABCDE and MONA) A – aspirin and anti-anginal therapy B – beta-blocking therapy and BP control C – cigarettes and cholesterol control D .abnormal: >0. Count the no.>exercise = 30 mins.most common complication: fibrillation (prolonged loss of blood flow plus sudden return) .increased SNS stimulation and decreased vagal stimulation 2. ascites. sinus arrest or pauses.LSHF . Measure the PR interval . causing it to fire at varying speeds . of large squares between R waves.04-0.normal: 0. Sinus Dysrhythmia .

cardiac standstill .” -PhiL :) c..2 types: > Mobitz Type I (Wenckebach phenomenon) – abnormally long refractory period at the AV node.wide (>0. Sudden Cardiac Death . Paroxysmal Atrial Tachycardia (PAT) .formerly Electromechanical Dissociation (EMD) .regular rhythm 2.three or more series of PVCs with no normal beats in between . Premature Ventricular Contractions (PVCs) . Disturbances in Automaticity 1.abrupt loss of heart function GOOD LUCK HA ATON TANAN.impossible to identify P waves 2. VENTRICULAR DYSRHYTMIAS . early firing of junctional ectopic focus .accessory connections between atrium an ventricle are result of anomalous embryonic development of myocardial tissue bridging the fibrous tissues that separates the 2 chambers .150-300 bpm . Disturbances in Impulse Conduction 1. erratic impulse formation and conduction . Disturbances in Conduction 1. Reentry of Impulses 1. Premature Atrial Contractions (PACs) . Bundle Branch Block .wide and bizarre QRS complex (>0.primary cause of sudden cardiac death .trigeminy: 1 normal QRS and 2 abnormal QRS .firing of an irritable pacemaker in the ventricles .12s) .conduction delay occurs between the SA node and the atrial muscle . no palpable pulse.enhanced automaticity of atrial muscle -P waves are premature and often differ in appearance and shape b.20 s) . Ventricular Tachycardia .early beats arising from ectopic foci .no P wave 2. Preexcitation Syndromes .sudden rapid firing from ectopic atrial pacemaker . Disturbances in Automaticity 1.patterns of pauses B.left or right bundle branch block . ATRIAL DYSRHYTHMIAS a. Paroxysmal Junctional Tachycardia (PJT) . Interventricular Impulse Conduction Abnormalities 1.conduction impaired in bundle branches (distal to bundle of His) . First-degree AV block .ex: Wolff-Parkinson-White Syndrome (WPW Syndrome) c.most common supraventricular dysrhythmia .may have 3 P waves for every QRS complex (3:1) C. Ventricular Fibrillation (V-fib or VF) . Atrial Fibrillation (A-fib or AF) .blood pools in the “quivering” atria 3.150-200 bpm 2.tissues allow electrical conduction between atria and ventricles at sites other than the AV node (shortcut??) .polymorphic – multiple foci 3.with electrical activity but no pulse -caused by cardiac tamponade and shock P waves and PR interval absent -100-220 bpm .Ventricular Asystole .20s) or notched QRS complex D.extremely rapid.> 60 bpm junctional rhythm b. HESSONITES!! KAYA NATIN TO! :D \m/ “Simplify complicated things and never try to complicate simple things.complete dissociation of impulse bet. some are blocked .causes greater hemodynamic compromise .wide and bizarre QRS complexes a.prolonged PR interval (>0. may progress to third-degree heart block 3.tx of choice: MgSO4 b. Premature Junctional Contractions (PJCs) .chaotic P wave. Irregular RR interval . initial prolongation then missing QRS > Mobitz Type II – P wave not conducted. Reentry of Impulses 1.single. Third-degree AV block .cardiac arrest . no rhythm 2. Torsades de Pointes -literally means “twisting of points” . no CO.complete heart block .no electrical activity. Atrial Flutter . Second-degree AV block . Pulseless Electrical Activity (PEA) .400-700 bpm .220-350 bpm . not one clear P wave.some impulses are conducted. dropped QRS complex. Atria and ventricles .bigeminy: 1 normal and 1 abnormal QRS 2.QRS complexes constantly changing or twisting around an isoelectric line . ATRIOVENTRICULAR JUCNTIONAL DYSRHYTHMIAS a. Disturbances in Automaticity 1.AV dissociation .monomorphic – one focal site .more serious and life-threatening .“saw-toothed” atrial formations (saw-toothed P waves) .