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PCCN Review - Cardiac
A 67 year old male is admitted with chest pain after collapsing at home. He is arguing with his wife that he should not be admitted because he "just over did it" while working in the world. Lee's wife states to you that his chest pain is more frequent, severe and prolonged than before. You should anticipate what diagnosis?
- Exertional angina
- Unstable angina
- Variant angina
- Stable angina - answer UNSTABLE ANGINA The change in quality, frequency, and duration indicates UNSTABLE ANGINA and may indicate that the pt is at increased risk for an MI. This pt should be closely monitored for EKG changes and rhythm disturbances. Pt/ family teaching should begin on how to identify an MI and basic CPR. A definitive diagnosis of myocarditis can be made via?
- Endomyocardial biopsy
- Transesophageal ultrasound
- Transmural catheterization
- Chest X-ray - answer ENDOMYOCARDIAL BIOPSY A biopsy is the ONLY definitive way to diagnose myocarditis. A diastolic murmur will occur as a result of regurgitant blood flow over which of the following valves? -Mitral and aortic -Mitral and tricuspid -Pulmonic and aortic -Tricuspid and pulmonic - answer Pulmonic and aortic During ventricular diastole, both the aortic and pulmonic valves close. If a valve is incompetent, the blood will flow backwards through the valve, creating turbulent blood flow-- that is, a murmur. A drug that will significantly decrease the INR would be?
- Naficillin
- Vitamin K
- High-dose Vitamin C
- Cyclosporin - answer VITAMIN K
Vitamin K is considered the antidote for warfarin, but can actually lower the INR too much and increase warfarin resistance, so careful monitoring is needed. These cause SIGNIFICANT decrease in INR: Rifampin (ABX) Phenobarbital (barbiturate anticonvulsant) Glutethimide (hypnotic sedative) Those below cause a MODERATE decrease in INR: Naficillin (narrow spectrum ABX) High dose Vitamin C (cancer tx) Cyclosporin (immunosuppressant) A heart murmur associated with acute valvular regurg would be?
- S
- S
- S
- S4 - answer S S1 and S2 are normal heart sounds S3 is associated with fluid status S4 is associated with compliance. A normal value for an EF would be?
- 65%
- 40%
- 30%
- 25% - answer 65% The EF should be more than 50%. It represents the amount of blood ejected from the left ventricle compared to the total amount available, expressed as a %. An EF of 35% or less indicates a problem with contractility, outflow or filling. EXA: If the ventricle contains 90ml of blood and 50mls are ejected, the amount would be expressed as a %, in this case 55%. A patient who is status post heart transplant may have significant bradycardia. The drug of choice in such cases is: -Atropine -Isuproterenol -Apresoline -Adenosine - answer Isuproterenol When the heart is denervated, it has no conduction to the autonomic nervous system, so a reflexive response does not occur. A sympathetic stimulant must be used to
A sign of necrosis on an EKG would include: -Acute ST elevation -A Right BBB -A Left BBB -A Q wave in lead III - answer Acute ST elevation. Along with acute ST elevation, another indicator of necrosis would be an abnormal Q wave. If the Q wave appears within about 6 hours of a transmural MI, it is an ominous sign. If the Q wave is more than 0.04 seconds long, it is a sign of necrosis. In an inferior MI, the Q wave should not exceed 0.03 seconds or it is indicative of necrosis. A vasodilator used in the treatment of anginal pain is: Morphine Ticlid Aspirin NTG - answer Nitroglycerine NTG is a vasodilator for both arterial and venous systems. Sometimes the decreased coronary vessels are stiff and calcified. If the patient has good collateral circulation, O and blood can reach the ischemic areas. NTG is now available in a metered-dose oral spray, in addition to pressed tabs, paste, and IV (nitroprusside) formulations. Actions of beta blockers include?
- Increased myocardial oxygen demand
- Increased heart rate
- Increased diastolic filling time
- Increased afterload - answer INCREASED DIASTOLIC FILLING TIME Afterload - answer Afterload is the amount of pressure the left ventricle must work against to pump blood into the circulation. The greater this resistance, the more the heart works to pump out blood. Afterload refers to the pressure that the ventriclar muscles must generate to overcome the higher pressure in the aorta to get the blood out of the heart. RESISTANCE is teh know on the end of the balloon, which the balloon has to work against to get the air out. Alpha-adrenergic effects of norepinephrine include?
- Increased force of myocardial contraction
- Increased SA node firing
- Increase AV conduction time
- Peripheral arteriolar vasoconstriction - answer Peripheral arteriolar vasoconstriction Increased force of myocardial contraction Increased SA node firing Increase AV conduction time
- These are all affects of beta-adrenergic sympathetic stimulation An absolute contraindication for use of a fibrinolytic would be?
- Traumatic CPR
- Cerebrovascular disease
- Subacute bacterial endocarditis
- Oral anticoagulants - answer TRAUMATIC CPR Other absolute contraindications are: HYPERTENSTION BLEEDING DISORDERS The other options are relative contraindications. An aneurysm that is dissecting upwards (ascending) produces pain: -In the chest and midscapular area -In the back of the neck and left shoulder -From the umbilical area to the shoulder -In the left shoulder and midsternal area. - answer In the chest and midscapular area Quite often the patient will describe a ripping or tearing sensation and severe pain. Hypotension may be present as the dissection progresses. Warning signs include hypertension, a new murmur (aortic insufficiency), weak peripheral pulses, and possible deterioration of LOC. Aneurysms that dissect downwards (decending) radiate pain to the lower abdomen, lower back and legs. An anterior wall infarct may be seen in leads?
- V4, R
- V5, V
- V7, V
- V2, V4 - answer V2, V4 -anterior wall V4, R -right ventricular damage V5, V6 -apical injury V7, V9 - posterior wall An aortic aneurysm that extends more than _____ cm will require surgical repair. -3 cm -5 cm -7 cm -9 cm - answer 5 cm
cardiac tissues cannot be met by the oxygen supply via the ocluded artery. The severity of the pain may be compounded by vasospasms that further restrict blood flow through the coronary arteries. Approximately what % of coronary artery blockage is needed to cause angina?
- 45%
- 60%
- 75%
- 90% - answer 75% Anginal pain usually occurs when approximately 75% of the artery's diameter becomes occluded. Pain is usually more pronounced with exertion or emotional distress, when O2 demand by cardiac tissue cannot be met by O2 supply via the occluded arteries. The severity of the pain may be compounded with vasospams that further restrict blood flow through the coronary arteries. Atrial Kick - answer Atrial kick is a term that represents the amount of the total CO that is supplied via atrial contraction. Atrial systole/ atrial kick - answer Known as the atrial kick as it coincides with late ventricular diastole, supplies the ventricles with the remaining 30% of the blood for each heartbeat. Atrial fibrillation can cause a loss of atrial kick and a subsequent drop in cardiac output. Tachycardia allows for less filling time by shortening diastole. Less filling time means less blood will be ejected during ventricular systole and less will be circulated. Atrioventricular Valves - answer Tricuspid--located between the RIGHT atrium and RIGHT ventricle. Has 3 cusps. Mitral -- located between the LEFT atrium and the LEFT ventricle. Has 2 cusps. Auto-regulatory control of caridac vessels becomes impaired if the coronary perfusion pressure drops below: 35 mm Hg 40 mm Hg 50 mm Hg 60 mm Hg - answer 50 mm Hg A pressure of at least 50 mm Hg is required to maintain auto-regulatory control. Barry has Wolf-Parkinson-White syndrome. He is experiencing increasing bouts of tachycardia. It has been decided to utilize overdrive pacing. How do you explain this type of pacemaker to a new orientee? -The pacer is set to a constant rate of 70 bpm and is synchronized -The pacer or AICD is set on demand mode and is asynchronous -The pacer or AICD is set on demand mode and is synchronous
-The pacer or AICD is set on inhibit mode and is synchronous - answer The pacer or AICD is set on demand mode and is asynchronous This patient needs a pacer or AICD that can deliver a more powerful impulse. The asynchronous mode will override Barry's internal pacer. Beck's triad is a combination of symptoms useful in diagnosing cardiac tamponade. They are?
- Pericardial friction rub, hypertension, RV failure
- Increased pulse pressure, increased JVD, tachycardia
- Tachycardia, hypertension, LV failure
- Distended neck veins, muffled heart sounds, hypotension - answer Distended neck veins Muffled heart sounds Hypotension Tachycardia is an early sign of tamponade. A narrowed pulse pressure occurs, and fluid cannot be ejected from the heart. The muffled heart sounds occur because the fluid in the sac minimized the transmission of sound waves. Bernard was admitted for PNA. He is two years post heart transplant. When you place EKG monitoring leads, you note sinus tachycardia with PVCs and a 2-mm ST elevation. The patient denies pain. This finding is: -Impossible -Normal -Indicative of an RBBB -Indicative of an inferior MI - answer Normal Patients with heart transplants do not feel cardiac pain because the heart has been denervated. Blood flow that moves forward through the stenotic valves can also dause a diastolic murmur. The valves involved are the: -Mitral and aortic -Mitral and tricuspid -Pulmonic and aortic -Tricuspid and pulmonic - answer Mitral and tricuspid During diastole, the tricuspid and mitral valves close just prior to systole. If the valve is stenotic, it will not close completely. When the atria contract, a murmur is heard as blood goes through this narrow opening. Calcium-channel blockers act primarily on?
- Reduction of CO (cardiac output)
Ventricular ejection Isovolumetric relaxation Ventricular filling Atrial systole/ atrial kick Carl was intially admitted to the PCU with a diagnosis of CHF. After further study, it was determined that he has restrictive cardiomyopathy. A common cause of restrictive cardiomyopathy is? -Unknown etiology -Glycogen storage disease -History of diabetes -Viral infection - answer Glycogen storage disease Amyloidosis is another cause of restrictive cardiomyopathy. The myocardium, especially the left ventricle, becomes rigid from fibrosis, which results in inadequate left ventricular filling and increased atrial dilation. Left ventricular diastolic dysfunction occurs, but systolic function remains normal in this type of cafrdiomyopathy. Fluid backs up into the lungs and the patients looks as if he has CHF. There is no cure for restrictive cardiomyopathy; instead symptoms are treated as they occur. Chordae Tendineae - answer Papillary muscles in the heart wall that anchor the heart valve cusps. These cords work together to prevent the cusps from bulging backward into the atria during ventricular contraction. If damage to these cords occur, blood can flow backward into a chamber, resulting in a heart murmur. Complications associated with ventricular assist devices (VADs) include: -Thromboembolism -Thrombocytopenia -Dissection of the aorta -Septicemia - answer Thromboembolism Additional complications that are commonly seen with VADs are infection and bleeding. Thrombocytopenia, aortic dissection and septicemia are complications of an intra-aortic balloon pump (IAPB). Contractility - answer Contractility is the ability of muscle cells to contract after depolarization. This ability depends on how much the muscle fibers are stretched at the end of diastole. Overstretching or understretching these fibers alters contractility and the amount of blood pumped out of the ventricles. Contractility refers to the inherent ability of the myocardium to contract normally. Contractility is influenced by preload. The greater the stretch the more forceful the contraction -- or the more air in the balloon, the greater the stretch, and the farther the balloon will fly when air is allowed to expel.
Coronary Ostium - answer The coronary ostium is an opening in the aorta that feeds blood to the conornary arteries and is located near the Aortic Valve. During systole, when the LEFT ventricle is pumping blood through the aorta and the Aortic Valve is OPEN, the coronary ostium is partially covered. During diastole, when the LEFT ventricle is filling with blood, the Aortic Valve is CLOSED, the coronary ostium is open which allows for blood to fill the coronary arteries. Coronary Sinus - answer Cardiac veins collect deoxygenated blood from the capillaries of the myocardium. These veins join to form an enlarged vessel called the Coronary Sinus. The Coronary Sinus returns the blood to the RIGHT atrium where it continues through circulation. Daniel was involved in a gang fight last week, during which he was stabbed several times in the anterior chest and twice in the abdomen. He has undergone 2 surgeries and is now post splenectomy, small bowel repair, and repair of a small laceration to the left subclavian vein. Daniel has recieved multiple units of blood and blood products. He was extubated this morning, but is now complaining of increased SOB. He is easily fatigued and his pulse oximeter reading is 0.94, down from 0.97. His am CXR shows "bilateral widespread infiltrates." Other labs and parameters are: EKG: ST at 114, isolated PACs Manual cuff BP 114/ Skin warm Temp 101'F RR 30, breath sounds clear, slightly diminished RLL O2 4L/min via mask ABGs: pH 7.32, PaCO2 29, paO2 70, HCO3 19 Mentation: oriented X4 most of the time, two episodes of confusion, easily reoriented Which condition do you believe Daniel is developing? -ARDS -PNA -Pulmonary emboli -Sepsis - answer Sepsis Daniel has all the classic signs of sepsis. He has a low grade fever, increased RR, and subtle changes in mentation. Diastole - answer The ventricles relax, the atria contract. Blood is forced through the OPEN Tricuspid and Mitral valves. The Aortic and Pulmonic valves are CLOSED
During shift report, you are told that your patient has a 90% occlusion to the circumflex artery. Which type of MI is this patient at greatest risk for developing? -Lateral wall infarct -Anterior wall infarct -Posterior wall infarct -Septal wall infarct - answer Lateral wall infarct The circumflex coronary artery feeds the left atrium and left ventricle. Infarctions as a result of occlusion of this artery result in lateral or left-sided heart damage. The left anterior descending artery and circumflex artery both branch off from the left coronary artery. Endocardium - answer The heart's innermost layer contains epithelial tissue with small blood vessels and bundles of smooth muscle. Epicardium - answer The outer layer of the heart muscle is made up of squamous epithelial cells overlying connective tissue. Fibrous Pericardium - answer Fibrous pericardium is composed of tough, white fibrous tissue that loosely fits around the heart to protect it. It also attaches to the great vessels, diaphragm, and sternum. Four days ago, Gert, who is 70 years old, was admitted to your unit status post laparotomy for an unknown abdominal mass. During surgery, Gert had minimal blood loss and an uneventful course. The patient's history includes smoking since she was 15 (unknown number of ppd), DM, a permanent pacemaker, an anterior MI, and a right- sided stroke 20 years ago with no deficits. Three days ago, Gert had a hypotensive episode; her BP dropped to 82/48, HR 70. The doctor ordered dobutamine and the BP increased until the MAP was 72. Today, Gert remains on the dobutamine gtt at 2 mcg/kg/min. Her BP is 108/60, MAP 76, HR 70. Attempts at weaning have failed-- her BP drops precipitously if the dobutamine dosage is lowered. What do you think is the cause Gert's inital hypotensive episode? -Hypovolemic shock -Previous MI -Rapid rewarming postoperatively -Cell mediated response - answer Cell mediated response Approximately 24 hours after a surgical procedure, the release of inflammatory cell mediators can lead to casodilation. Gert has a permanent pacer, but apparently her heart rate cannot compensate for the drop in BP. The caridac output did not increase as a result of the reduced systemic resistance. Her pacer did not allow the HR to climb
above 70. The dobutamine acted on the pump and increased the heart's contractility. Gert also has a history of a previous MI. Four days ago, Gert, who is 70 years old, was admitted to your unit status post laparotomy for an unknown abdominal mass. During surgery, Gert had minimal blood loss and an uneventful course. The patient's history includes smoking since she was 15 (unknown number of ppd), DM, a permanent pacemaker, an anterior MI, and a right- sided stroke 20 years ago with no deficits. Three days ago, Gert had a hypotensive episode; her BP dropped to 82/48, HR 70. The doctor ordered dobutamine and the BP increased until the MAP was 72. Today, Gert remains on the dobutamine gtt at 2 mcg/kg/min. Her BP is 108/60, MAP 76, HR 70. Attempts at weaning have failed-- her BP drops precipitously if the dobutamine dosage is lowered. Which additional action could be taken to improve Gert's cardiac output and help wean her from dobutamine? -Initiate a fluid challenge -Start dopamine -Place a pulmonary artery catheter -Turn up the rate on the pacer - answer Turn up the rate on the pacer Turning up the rate on the pacer should allow for weaning off dobutamine. This patient is also in the beginning stages of cardiogenic shock, but she can easily be helped by simply changing the rate on the pacer. Garrett was admitted to the PCU about 6 hours ago with an inferior MI. He has been medicated for pain and is resting comportably at this time. His wife is visiting when she approaches you and says Garrett is dizzy and cannot catch his breath. His EKG now shows a sinus bradycardia with multifocal PVCs at 4 per minute. Other findings include: EKG: Sinus bradycardia at 52 with rare multifocal PVCs Manual cuff BP 82/46, previous BP 110/76 (30 minutes ago) Skin pale, cool, clammy RR 28 O2 2L/min via NC Mentation: Anxious, oriented X Garrett's current arrhythmia will probably be: -Permanent, asymptomatic -Transient, possibly symptomatic -Permanent, symptomatic -Transient, asymptomatic - answer Transient, possibly symptomatic
Osler's nodes are small, painful nodules found on the fingers and toes. Roth spots are rounded, white spots seen when examining the retina. Pella's sign is not a medical term. Helen developed infective pericarditis after renal failure and sepsis. Morning labs should show a(n): -Increased WBC, decreased ESR, normal CK-MB -Normal WBC, decreased ESR, elevated CK-MB -Increased WBC, increased ESR, elevated CK-MB -Increased WBC, normal ESR, elevated CK-MB - answer Increased WBC, increased ESR, elevated CK-MB Renal failure and sepsis may lead to pericarditis, so AM labs should show an increased WBC, increased ESR, cardiac tissue involvement, and an elevated CK-MB level. Additional lab test would focus on detecting uremia. Assessment would also include checking for ST-segment elevations, arrthythmias, and pleural effusions on echocardiography. Holly recieved 4 mg Morphine IV. She is now unresponsive and her RR and depth are diminished. The antidote for morphine is: -Regitine -Bicarbonate -Naloxone -Atropine - answer Naloxone The antagonist for morphine and other opiods is Narcan (naloxone). Generally, the naloxone dose is 0.4 mg IV. This dose can be repeated about every 3 to 4 minutes for a total of 3 times. When you give Narcan, you must always be alert for the patient to relapse once the dose wears off. Administering multiple follow-up doses is not uncommon. How does HAP (hospital acquired PNA) differ from VAP (ventilator acquired PNA)? -There is no difference -Different sausative organisms -The VAP patient is intubated -Therapies differ - answer The VAP patient is intubated The major difference between HAP and VAP is that the patient who develops VAP is intubated. Both types of PNA are caused by the same organism, Pseudomonas aeuruginosa. How much does the average heart weigh? - answer Typically, the heart weighs 9 to 12 ounces (255 to 340g).
The weight of the heart depends on he person's size, age, sex, and athletic conditioning. If a chronic fluid accumulation occurs, the pericardial sac may hold as much as _____ before the signs of cardiac tamponade will appear. 200 ml 400 ml 1000 ml 2000 ml - answer 2000 ml In a chronic condition, as much as 2000 ml of fluid may collect in the pericardial sac before symptoms appear. This fluid buildup is usually due to a chronic pleural effusion or uremia. Acute tamponade may occur with as little as 50 ml of fluid collects in the pericardial sac. If blood pressure is lower by at least 10-11 mm Hg on inspiration than on expiration, this is known as _____. -Pulsus alternans -Pulse pressure -Pulsus paradoxus -Pulsus parvus - answer Pulsus paradoxus Pulsus paradoxus may be present in conjunction with asthma, emphysema, cardiac tamponade, restrictive pericarditis, or hemorrhagic shock. Pulse pressure is the difference between systolic and diastolic pressures. Pulsus parvus means a small or weak pulse Pulsus alternans means the upstroke is more powerful than the downstroke -- that is, the stokes alternate in strength. If the inferior wall of the heart is infracted, the leads that will most directly reflect the injury are?
- II, aVF
- I, aVL
- V1 - V
- V5 - V6 - answer II, a VF - inferior heart I, aVL - lateral wall V1 - V2 --septal wall V5 - V6 - apical area
You can also try turning up the mA level. Either way, the physician must be notified and vital signs carefully monitored until the physician can reposition the electrodes. If your pt had a cardiac tamponade, which of the following would you expect to see on a CXR?
- A dilated superior vena cava
- Increased JVD
- Narrowed mediastinum
- Delineation of the pericardium and epicardium - answer A DILATED SUPERIOR VENA CAVA The vena cava is dilated because blood couldn't flow into the right atrium. JVD would not be visible on a CXR. The mediastinum would be widened. Delineation of the pericardium or epicardium would not be visible on a CXR. In a patient with cardiogenic shock, an undesirable outcome would produce: -Increased cardiac output -Increased systemic vascular resistance -Decreased ventricular preload -Decreased pulmonary artery pressures - answer Increased systemic vascular resistance A primary goal in cardiogenic shock is to improve the pumping action of the heart (improve myocardial contractility), reduce the workload of the heart, reduced O demand and improve cardiac output. If possible, systemic vascular resistance should be decreased and the left ventricule augmented with an inotrope. Nitoprusside will reduce preload and afterload. The cardiac workload and the myocardial O2 demand should decrease. In myocarditis, which medicatin is typically used to trat venticular failure by improving contractility and reducing ventricular rate? -Inderal -Imuran -Amiodarone -Digoxin - answer Digoxin Digoxin is often used to treat ventricular failure because it improves myocardial contractility and reduces the ventricular rate. Use this drug with caustion when patients have myocarditis because digoxin's cardiac side effects are more likely to occur. In pts with aortic insufficiency, the popliteal BP is often higher than the brachial BP by at least 40 mm HG. This discrepancy between the measurements is known as?
- DeMusset's Sign
- Hill's Sign
- Holmes' Sign
- Rochelle's Sign - answer HILL'S SIGN Hills's sign reflects the rapid rise in pulsation. DeMusset's sign is also found in aortic insufficiency; it consists of the bobbing of the head in time with the forceful pulse. Holmes' and Rochelle's signs are not diagnostic signs. In stable angina, which of the following is true?
- A positive treadmill test will indicate CAD
- A thallium test (myocardial scintigraphy) will not diagnose LV dysfunction
- The treadmill test will miss as many as 20% of cases of single-vessel disease
- CK-MB isoenzymes and troponins will not increase - answer CK-MB ISOENZYMES AND TROPONINS WILL NOT INCREASE A positive treadmill test may not be positive for CAD. LV dysfunction may be diagnosed with a thallium test (myocardial scintigraphy). Treadmill stress tests miss as many as 40% of cases of single-vessel disease. Increased afterload would be seen with _____. -Polycythemia -Aortic insufficiency -Hypovolemia -Sepsis - answer Polycythemia Hypovolemia and Sepsis decrease afterload as does Aortic insufficiency. Aortic stenosis increases afterload, as do peripheral vasoconstriction and hypertension. Indications for use of a VAD include: -Dysrhythmias -As destination therapy -Prolonged cardiac arrest -Extensive organ damage - answer As destination therapy Other indications for use of VAD include use as a bridge to transplant, treatment of cardiogenic shock, and inability to wean from cardiopulmonary bypass. Always be aware of the possibility of device failure. Prolonged cardiac arrest, especially with neuroligical damage is a contraindication for use of a VAD. Extensive organ damage is another contraindication. Dysrhythmias are not indications for use. Integrilin (eptifbatide) is indicated for which condition?
