1
Q
- Caused by closure of AV valves and marks the end of diastole & beginning of systole.
- Loudest at the apex of the heart.
A
S1 “Lub”
2
Q
- Caused by closure of semilunar valves and marks the end of systole & beginning of diastole.
- Loudest at the base.
- Splits on inspiration but wide/fixed splitting is caused by RBBB.
- Loudest with pulmonary embolism.
A
S2 “Dub”
3
Q
- Caused by rapid rush of blood into a dilated ventricle
- Occurs early in diastole, after S2
- Heard best at the apex with the bell of the stethoscope
- Associated with heart failure but also caused by pulmonary hypertension, mitral, aortic, or tricuspid insufficiency.
- “Kentucky”
A
S3
4
Q
- Caused by atrial contraction of blood into a noncompliant ventricle
- Occurs right before S1
- Best heard at the apex with the bell of the stethoscope
- Associated with myocardial ischemia, infarction, hypertension, ventricular hypertrophy. and aortic stenosis
- Not heard with atrial fibrillation because no atrial contraction
- “Tennessee”
A
S4
5
Q
Due to pericarditis, associated with pain on deep inspiration, may be positional.
A
Pericardial friction rub
6
Q
Normal pulse pressure?
A
40-60 mmHg
7
Q
Indirect measurement of cardiac output and stroke volume.
A
Systolic blood pressure
8
Q
Seen most often with severe hypovolemia or sever drop in cardiac output. Usually from drop in systolic pressure.
A
Narrowing or pulse pressure
9
Q
An indirect measurement of the systemic vascular resistance (SVR)
A
Diastolic blood pressure
10
Q
May indicate vasodilation, drop in SVR, and is often seen in sever sepsis/septic shock. Usually from drop in diastolic blood pressure.
A
Widened pulse pressure
11
Q
When are coronary arteries perfused?
A
During diastole
12
Q
Which is longer - diastole or systole?
A
Diastole is 1/3 longer than systole
13
Q
Are murmurs of stenosis acute or chronic?
A
Chronic problem that develops overtime
14
Q
Will cause large, giant V-waves on the PA catheter.
A
Mitral insufficiency
15
Q
Most common with acute MI, may result in systolic murmur, heard at the left sternal border, 5th intercostal space.
A
Ventricular septal defect (VSD)
16
Q
Associated with atrial fibrillation due to atrial enlargement that occurs over time.
A
Mitral stenosis
17
Q
AV valves closed, semi-lunar valves open.
A
Diastolic murmur
18
Q
AV valves open, semi-lunar valve closed.
A
Systolic murmur
19
Q
When does mitral insufficiency occur?
A
Systole
20
Q
When does mitral stenosis occur?
A
Diastole
21
Q
When does aortic insufficiency occur?
A
Diastole
22
Q
When does aortic stenosis occur?
A
Systole
23
Q
Chest pain with activity, predictable, lesions usually fixed and calcified lesions.
A
Stable angina
24
Q
Chest pain at rest, unpredictable, may be relieved with nitro, troponin negative, ST depression, or T-wave inversion on ECG.
A
Unstable angina
25
Troponin positive, ST depression, T-wave inversion on ECG, unrelenting chest pain.
NSTEMI
26
Troponin positive, ST elevation in 2 or more contiguous leads, unrelenting chest pain.
STEMI
27
- A type of unstable angina associated with transient ST segment elevation.
- Due to coronary artery spasm with or without atherosclerotic lesions.
- Occurs at rest, may be cyclic (same time each day)
- May be precipitated by nicotine, ETOH, cocaine ingestion.
- Troponin negative
- Nitro administration results in relief of chest pain and ST returns to normal.
Variant or Prinzmetal's Angina
28
When may patients not experience chest pain with MI?
Women and diabetics
29
Improves morbidity/mortality of ACS
Aspirin
30
When are beta blockers contraindicated in ACS?
When caused by cocaine use, hypotension, bradycardia, or Viagra was taken.
31
ECG changes in II, III, aVF, reciprocal changes in lateral wall (I, aVL)
Right coronary artery (RCA), inferior LV.
32
ECG changes in V1, V2, V3, V4, reciprocal changes (ST depression) in inferior wall (II, III, aVF).
Left anterior descending (LAD), anterior LV.
33
ECG changes (ST elevation) in V5, V6 & (ST elevation) in I, aVL
Circumflex, lateral LV.
34
ECG changes in V1, V2
RCA, posterior LV.
35
ECG changes in V3R, V4R
RCA, right ventricular (RV) infarct.
36
What is the eligibility criteria for treatment of STEMI?
- ST elevation in 2 or > contiguous leads, or new onset LBBB.
- Onset of CP <12 hours
- CP of 30 min in duration
- CP unresponsive to sublingual nitro
37
How long do you hold pressure at sheath site?
20 min (30 min if still on GP IIb/IIIa inhibitors)
38
Signs and symptoms of retroperitoneal bleeding?
Sudden hypotension and severe low back pain.
39
Due to myocardial "stunning" when vessel opens.
Reperfusion arrhythmias
40
Treatment for NSTEMI
No emergent treatment. If high risk score or continues CP, s/s of instability - start GP IIb/IIIa inhibitors and prepare for diagnostic cath within 24h.
41
Associated with AV conduction disturbances: 2nd degree type 1, 3rd degree HB, sick sinus syndrome, sinus brady (if tachycardia=higher mortality), RV infarct & posterior MI.
Inferior MI
42
30% of inferior wall MI patients also have a?
Right ventricular (RV) infarct
43
Signs and symptoms of right ventricular (RV) infarct?
JVD at 45 degrees, high CVP, hypotension, usually clear lungs, brady arrhythmias, & ECG with ST elevation in V4R.
44
Treatment for right ventricular (RV) infarct?
Fluids & inotropes
45
What do you want to avoid with right ventricular (RV) infarct?
Preload reducers -> nitro, diuretics. Caution with beta blockers, often cannot given initially due to hypotension.
46
Ominous sign of anterior MI?
Development of 2nd degree type 2 HB or RBBB. This has a higher mortality than inferior due to HF.
47
Most common complication of acute MI?
Arrhythmias
48
When does stent thrombosis occur?
Most incidents occur acutely within 24 hours of stent placement or subacutely within 30 days.
49
Vasovagal management?
Give Atropine 0.5 mg IV (even in absence of bradycardia if other s/s occur) then fluids
50
Elevated BP with evidence of end-organ damage (brain, heart, kidney, retina) that can be related to acute hypertension.
Hypertensive emergency or crisis.
51
Elevated BP without evidence of acute end-organ damage.
Hypertensive urgency
52
What medication do you need to assess for cyanide toxicity?
Nitroprusside
53
What are the 6 Ps of peripheral arterial disease?
1. Pain
2. Pallor
3. Pulse absent or diminished
4. Parethesia
5. Paralysis
6. Poikilothermia (loss of hair on toes or lower legs; glossy, thin, cool, dry skin)
* Additionally minimal edema
54
- Test to assess for PAD.
- Used to assess adequacy of lower extremity perfusion.
- Determined by dividing the ankle pressure by the brachial pressure on the same side.
- Normal is >1.
Ankle-brachial index (ABI)
55
Best position for someone with PAD?
Bed in reverse trendelenburg. DO NOT elevate the extremity because it will decrease perfusion.
56
First initial in pacemaker code =
Chamber being paced (A, V, or D).
57
Second initial in pacemaker code =
Chamber being sensed (A, V, or D).
58
Third initial in pacemaker code =
Response to sensing.
59
Pacer detects intrinsic cardiac activity and withholds its pacing stimuli. In other words, inhibits pacing in response to sensing.
"I" = inhibits
60
Pacer detects intrinsic cardiac activity and fires a pacing stimulus in response.
"D" = inhibits and triggers
61
No spike at all when expected
Failure to pace
62
Spikes without a QRS for ventricular pacing.
Failure to capture
63
Pacing in native beats
Failure to sense
64
Sense tachyarrhythmias, provide a series of beats faster than the tachyarrythmias, then stop suddenly with hopefully the SA node recovering.
Burst pace
65
Heart failure with EF <40%, problem with ejection.
Systolic dysfunction
66
Heart failure with EF >50%, problem with filling, ejection is OK.
Diastolic dysfunction
67
Often associated with a shift of the point of maximal impulse (PMI) from midclavicular to the left.
Enlarged heart (on xray) which is associated with systolic HF
68
Presents with normal heart size on xray but 12-lead may show changes of left ventricular hypertrophy, especially when the patient has history of uncontrolled hypertension.
Diastolic HF
69
How is heart failure classified?
It is based on patient report of symptoms, not objective findings. And should only be classified after optimal drug therapy has been achieved, not during acute exacerbation.
70
Ordinary activity does not cause fatigue, dyspnea, palpitations, or anginal pain. There is no limitation of physical activity. EXTRAORDINARY ACTIVITY results in heart failure symptoms.
Class 1 of NYHA
71
Comfortable at rest, but ordinary physical activity results in heart failure symptoms. There is some limitations of physical activity. ORDINARY ACTIVITY results in heart failure symptoms.
Class 2 of NYHA
72
Comfortable at rest but less than ordinary activity causes heart failure symptoms. There is marked limitations of physical activity. MINIMAL ACTIVITY results in heart failure symptoms.
Class 3 of NYHA
73
Symptoms of heart failure occur at rest. If any physical activity is attempted, discomfort is increased. There is severe limitations of physical activity. Remaining AT REST results in heart failure symptoms.
Class 4 of NYHA
74
What is the main cause of death in heart failure patients?
Sudden arrhythmias. Patient's with class 2-4 of NYHA qualify for an ICD.
75
- Systolic dysfunction (problem ejecting).
- Classical signs: Thinning, dilation, enlargement of LV chamber, MVR.
- Symptoms: Similar to systolic HF
Dilated cardiomyopathy
76
- Diastolic dysfunction (problem filling)
- Classical signs: Increased thickening of the heart muscle & septum inwardly at the expense of the LV chamber.
- Symptoms: fatigue, dyspnea, CP, palpitations, S3, S4, presynope/syncope.
- Increased risk for sudden death.
Hypertrophic cardiomyopathy
77
What is cardiogenic shock most commonly caused by?
Extreme drop in stroke volume secondary to systolic dysfunction.
78
What is the main purpose of IABP?
It inflates (increased coronary artery perfusion) and dilates (decrease afterload)
79
When does the IABP inflate?
Inflated at dicrotic notch or the arterial waveform, beginning of diastole.
80
When does the IABP deflate?
Deflated right before systole begins, R-wave of ECG or upstroke of the arterial pressure wave.
81
What are the most common cannulations sites for bypass sugery?
Aorta & right atrium
82
The longer the bypass time...?
The more bleeding and more complications post-operatively.
83
What are the FOUR steps to bypass procedure?
1. Priming with isotonic crystalloids (enhances oxygenation by improving blood flow)
2. Hypothermia (28-36 degrees C)
3. Anticoagulation with large heparin doses
4. Circulatory arrest - rapid, during diastole with K cardioplegic agent, reinfused at intervals, may be warm or cold.
84
Remove serosanguinous fluid from the operative site.
Mediastinal chest tubes
85
Remove air, blood, or serous fluid from pleural space.
Pleural chest tubes
86
Abnormal chest tube output?
100 ml/hr for 2 consecutive hours
87
Advantages: Easy to insert, very reliable, last longer.
Disadvantages: High risk for thrombosis (permanent anticoagulation therapy)
Mechanical valve
88
Advantages: Anticoagulation required short term (maybe only ASA)
Disadvantages: Wears down, especially in high pressure systems
Biological valves
89
THREE things to remember with valves repairs
1. Avoid drop in preload (patient is use to elevated end-diastolic volumes.
2. Anticoagulation (aspirin & plavix)
3. Antipate conduction disturbances (TPM of PPM)
90
Signs & symptoms of cardiac tamponade?
Restlessness/agitation, HoTN, increase JVD, CVP = PA diastolic pressure, muffled heart tones, enlarging cardiac silhouette & mediastinum on CXR, narrow pulse pressure.
91
Excessive drop in SBP (>12 mmHg) during inspiration. Cardiac muscle restriction due to tamponade, with inspiration, intrathoracic pressure increases, decreased venous return. Best seen on aline.
Pulses paradoxus
92
Which valve is at most risk for rupture due to trauma?
Aortic valve
93
Pericarditis due to immune response after a MI, surgery, or traumatic injury.
Dressler's syndrome
94
Distinguishing s/s of pericarditis
Pain worsens with inspiration, ST elevation in all leads (medical) or at the area of injury (trauma), low-grade temp.
95
Signs & symptoms of thoracic aortic aneurysms?
- Sudden tearing, ripping pain in chest radiating to shoulders, neck, and back.
- Cough
- Hoarseness
- Dysphagia
- Dizziness, difficulty walking & speaking
- Widening of mediastinum on CXR
* 25% of all CV-related aneurysms
96
Signs & symptoms of abdominal aortic aneurysm
- Asymptomatic if small
- Pulsations in abdominal area
- Abdominal or low back pain
- Nausea, vomiting
- Shock
* 75% of all CV-related aneurysms
97
What is the treatment for aneurysms <5 cm in diameter & no symptoms?
- Monitor regularly (US or CT)
- Treat HTN (beta blockers because they may slow growth)
- People with Marfan's are usually treated sooner
98
What is the treatment for thoracic aneurysm causing symptoms or >6 cm?
- Surgical repair
- Dissection: SURGERY
- Aggressive treatment of HTN & heart rate control (labetalol)
99
What is normal cardiac output?
4-8L
100
What is normal cardiac index?
2.5-4.0 L/min/m2
101
What is normal stroke volume?
50-100 ml per beat
102
What is normal stroke index?
25-45 ml/beat/m2
103
What is normal CVP?
2-6 mmHg or 3-8 cm H2O
104
What is normal PAP?
20-30/8-15 (mean <20)
105
What is normal wedge pressure?
8-12 mmHg
106
What is normal SVR?
800-1200
107
What is a normal mixed venous?
60-75% and is the most sensitive indicator of cellular oxygenation.
108
What is a normal venous O2M?
>70%
109
How could SvO2 be increased?
In the presence of severe sepsis, septic shock, hypothermia, or paralysis.
110
Causes giant V waves on PA catheter wave form.
Acute mitral valve insufficiency (regurgitation)
111
Results in a falsely decreased systolic pressure and false high diastolic pressure and poorly defined components (i.e., dicrotic notch).
Overdamped
- Can be caused by air or blood clot in the system, loose connections, loss of air in pressure bag, or kinking or the catheter tubing.
- More common
112
Results in a false high systolic pressure , possibly low diastolic pressure, and "ringing" artifacts on the waveform.
Underdamped
| -Maybe be causes by pinpoint bubbles in the system, add-on tubing, or defective transducer.
CCRN
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