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BC3 cardiac lecture

BC3 cardiac lecture 1/22/08

Question	Answer
coagulation studies	PTT and the INR
on anticoagulant if ?	had an MI
Heparin works on what cascade	intrinsic cascade
Coumadin works on what clotting cascade	extrinsic cascade
Intrinsic clotting cascade starts at what factor?	V through XII
extrinsic clotting cascade starts at factor	VII
common pathway of clotting cascade at ?	factor X
Therapeutic PTT is ?	2 to 2 1/2 times normal
normal PTT is	25
therapeutic where you want your patience to be is ?	between 45 and 70,that’s 45 to 70 seconds for that blood clot
Why in the world would we want that blood to take 45 to 70 seconds to clot when 25 is normal?	Because they are on an anticoagulant-something to prevent clotting.
An INR is normally around	1.1, 1.2
Therapeutic INR on Coumadin would be about ?? depending on why the patient is on it.	2-3,
if they have a heart valve , keep INR between	2.5 and I believe 3.5; on coumadin
if you have metal, put in a patient - metal causes	clots
therapeutic anticoagulation level	running your INR high due to circumstnaces, IE, they have metal in
hypokalemia. norm K+ 3.5 to 5.3	causes can be vomiting, Diarrhea,Prolonged diuretic therapy – lasix ,some cardiac dysrhythmias if they don’t have enough potassium, a U wave,PVC’s, V-tach, V-fib or death.
hyperkalemia, norm K+ 3.5 to 5.3	from Addison's disease, acute renal failure, Acidosis ,
potassium level of greater than 6-7.	Tall tented T wave on ECG, almost as high as QRS
treat hyperkalemia	use of potassium sparing diuretics,dialysis
Hyperkalemia, you can have What on ECG's	elevated T wave, sinus brady,first degree AV block, V-fib, V-tach or sudden death
Does potassium play a role in a CABG	stops the heart; cardiac standstill
Calcium norm is usually?	8-11; 9-11
hypercalcemia on ECG	shortening of the QT wave
calculate the QT interval	Punch in the QT interval hit the divided sign punch in the RR interval, hit the square root sign and hit equal
What would cause hypercalcemia?	Hyperparathyroidism, and any kind of neoplastic disease : cancer
Causes Hypocalcemia	renal failure, hypoparathyroidism or a malabsorption syndrome.
EKG with hypocalcemia	prolonged or lengthened QT interval
Lipid studies; good cholesterol	HDL, it is about 30% of your total cholesterol and it is considered to be protective want greater than 35
Total cholesterol level should be	below 200
LDL should be	less than 130 / if heart diseasse,less than 100
Triglycerides	want those to be less than 200
if Triglycerides are high? pt. has	increased, the patient tends to have more atherosclerosis and CAD, coronary artery disease.
enzymes	creatinine kinase or creatinine kinase MB, LDH and troponin;normally contained in an intact cell
enzymes are found in blood when	cell wall becomes damaged, the cell wall opens up and releases the enzymes;That’s why you can find them in the blood work.
damaged cells yield	enzymes; creatinine kinase or creatinine kinase MB, LDH and troponin
enzymes that can be found in blood work determine?	if the patient has had an MI.
CKMB specific to	the heart
CK MB is an?	isoenzyme, or a portion of the total CK
CK is broken down into	CKMB, CKBB and CKMM. MM is muscle , BB Brain, MB heart
Your CKMB is elevated	depending on the amount of cellular damage. If one cell is disrupted, you have a little bit; if you have a very large infarct,CKMB is elevated even more; dependent on the amount of necrosis and cellular damage
enzymes peak and decline at different time periods and that is important because ?	helps us pinpoint when the MI has occured.
Your CK goes up and it comes down very quickly, up and down in -______ ? days	elevates and comes down in 3 days
we use other enzymes that stay elevated for a longer period of time to help us determine if the patient is having a MI.	Troponin
a Q wave MI	Q wave never goes away – 1/3 of the total R wave
inverted T wave?	little bit of ischemia
isoenzymes	CKMM; CKMB; CKBB ; AST: LDH they go up and down depending on damage.
Troponin – elevated for	14 days
LDH is an enzyme	distributed through the body through the liver; kidney, the heart and it is in the lungs
when we look at LDH we look at ?	looking at LD1 and LD 2 for heart disease
LDH ratio.	The ratio of LD1 to LD2 is less than 1
a flipped ratio	LD2 is greater than the LD1.accurate in 80% of your MI’s. do LDH with a CPK.
LDH.how long is it elevated ?	up to 12 days
AST and your ALT	liver enzymes: if the AST is 3 times greater than your ALT that tells you that the etiology is cardiac. problem is cardiac
Troponin.	Troponin is one of the 3 proteins that make up the troponin complex. Troponin T and Troponin I.
Cardiac Troponin T has been shown to be elevated in all patient’s within how long of HA?	4 hours of cardiac damage and stays elevated for up to 14 days
Troponin also elevated in ?	unstable angia
does NOT go up with unstable angina?	Creatinine, your AST, your ALT, your LDH,
serial enzymes	do them every 8 hours x 3 along with EKG every 8 hours x 3 to watch the evolution of the damage.
cardiac enzymes are used to:?	Predict the damage to the heart – the higher the level, the more cells involved, the more necrosis, the more heart damage.
BNP	use to determine if the patient has congestive heart failure;greater than 120,patient has CHF
when the left ventricle stretches, it releases?	BNP is captured in the blood, we do blood work, we see that it is elevated = CHF,careful: BNP also elevated in renal disease
CRP – C-reative Protein	predictive test that identifies inflammation and it is thought that many of the MI’s are due to the inflammatory process: high C-reative protein, that is predictive for an MI.
D-dimer	shows the end product of thrombus formation: has had a clot, his D-dimer would be elevated
Myoglobin	goes up quickly; within an hour, but it only stays elevated for 2-4 hours;not specific to the heart; released with any muscle damage.
Coronary angiography	assess the coronary arteries, they shoot dye, they can see the areas of occlusion if there are areas of occlusion. They will insert a stent or just dilate that area.
advance the catheter from the in cath lab	femoral vein to the vena cava and you can evaluate the right atrium, the tricuspid valve, the right ventricle and the pulmonary artery pressure.
a left heart cath	you advance the catheter through the femoral artery, you can check the AV – aortic valve, the mitral valve and you are looking for regurge or you are looking for stenosis.
electrophysiology studies	symptoms such as syncope, fluttering in the chest, irregular heart beat and what we do is we try to stimulate that irregular heart beat
Chest X-ray	evaluate the heart size ; heart is usually less than ½ the size of the diameter of the chest.
Holter monitor ; called an ambulatory EKG as well	portable EKG reporting device ;monitor your heart anywhere up to 48 hours. Along with that, you have to keep a diary. at 8:10 patient complained of heart fluttering feeling, lets look at the EKG at 8:10 – so they can compare the symptoms with the EKG
Electrocardiography, is used to	identify ejection fraction – wall motion
ejection fraction is?	percentage of blood that is ejected from the heart with each beat.
necrotic tissue is ?	scar tissue, less stretch, less movement
echocardiogram to identify	wall motion; also used to identify regurgitation.
echocardiogram to identify	Regurgitation from the left ventricle or right ventricle into the atria or from the vessels.
vegetation on the valves	bacterial endocarditis
mitral valve prolapse	prophylactic antibiotic: bacterial can go into the blood stream from dental work ; set up residency on the valves and that is called vegetation or subacute bacterial endocarditis.
can look for pericardial fluid and we can calculate the gradient	gradient gives us an indication of how much stenosis the valve actually has
echocardiogram M-Mode	very narrow view of the heart ; ice pick view
2-D echo – that is more of a pie shape	more view of the heart; more visualization of the wall motion and the vegetation.
2D echo, we also use it with exercise.	patient can exercise and we look for any heart abnormality during exercise;
persantine, dobutamine or cardiolyte	acts as a stressor to the heart, the same as when you exercise.
Doppler echo	assess the blood flow; looking for regurgitation at the valves.
Doppler echo	color-coded so that one way is blue, one way is red and they can tell the amount of regurgitation by the color of the blood. inject the bubbleslooking for is a break in the septal wall.So, you can have an atrial septal defect or a ventricular septal def.
TEE is a	transesophageal echocardiogram
transesophageal echocardiogram	sink a tube ;through the esophagus ;sits right next to the heart; good visualization of the left atrium
where many of your clots will form if your patient is in atrial fib.	left atrium because it has a left atrial appendage
Atrial fib	heart is not contracting well – it is not causing forward motion of the blood;stasis decreased because you loose your atrial kick
atrial kick	delivers up to 20% of your volume prior to closure of the valve. loose your atrial kick, as a result you do decrease your stroke volume.
Most of your clots will occur in	left atrium, behind that left atrial appendage; TEE, you can look for the clot
patient has a clot, would you want to reverse that dysrhythmia and put them in a normal sinus rhythym	NO; Send that clot to the BRAIN
clot in the brain is called	stroke
do a TEE and they see a clot	send the patient home on Coumadin for 4-6 weeks, keep him in atrial fib, bring him back in after 4-6 weeks, do another TEE ; clot is gone, then they can cardiovert him
prior to a TEE	NPO 6 hours ;mild sedative, probably Versed and they are NPO after the test until the gag reflex returns.
radionuclide imagining	Perfusion scans, perfusion imaging;shows how equal the uptake of the radioactive material tracer is; abnormal will have hot and cold spots
Cold spots	decreased tracer uptake and you can see that on a scanner;inject them; scan them;cold spot =decreased myocardial perfusion.
Hot spots	increased uptake= myocardial necrosis
ischemia – cold spot or hot spot?	cold spot, because it is decreased perfusion, decreased blood flow.
MI? Hot spot or cold spot?	Hot spot because an MI can go to necrosis if it is not treated
Severe ST elevation	having an MI
Nitro works 3 ways	decreases your preload, it decreases your afterload and it increases coronary artery perfusion
preload	venous return to the right side of the heart.
afterload?	pressure the left ventricle has to exert against the aorta to push out the stroke volume, or the ejection fraction.
Nitro is a	massive vaso-active agent that dilates both the superior and inferior vena cava and the aorta and the coronary arteries. It is short acting, but it is very quick acting.
what’s and alpha agent ( epinephrine) do?	vasoconstrict.blood pressure - it goes up
vaso-vagal response	stimulate vegus nerve/ parasympathetic/ lowers BP, and people can pass out
reversible perfusion uptake	you have decreased tracer uptake with exercise but returns to normal at rest
Fixed perfusion defect	decreased uptake at rest and exercise and there is no return to normal. This indicates a previous MI. With a fixed defect, patient has had a MI.
Thalium scans	another exercise stress test; every 3 minutes you increase the incline of the treadmill and you increase the speed of the treadmill until they reach a target heart rate.inject the thalium at peak exercise ;image again within 5 minutes of the inj.
Thalium scans/ hibernating MI.	Non-perfused areas have no thalium, they will be cold spots – this is called a hibernating MI.
Sestamibi Protocol	rest scan first;delay the imaging for 60 minutes ;that long for the liver to take it up ;fatty meal;second dose of Sestamibi@peak exercise scan is done 60 minutes later
Sestamibi collects where?	ischemic areas such as an MI;anything that is ischemic will have increased Sestamibi
patient who is having Sestamibi Protocol	hold caffeine or persantine for 12 hours prior to the test; hold your calcium channel blockers and your beta blockers for 24 hours if the patient is getting Persantine.
patient is getting Persantine	hold your calcium channel blockers and your beta blockers for 24 hours when having sestambi protocol
pulmonary artery catheter does are these 4 things,;.	measures pressure in different areas of the heart;measure cardiac pressure;infuse drugs with this catheter some catheters can even pace.;
Swan/Ganz catheter	pulmonary artery catheter; also called hemodynamic monitoring catheter
proximal port of swan gantz used for?	infuse fluids. You can use it for blousing, for cardiac output.
distal lumen of S/G (Pulmonary artery cath)	used to identify and measure pulmonary artery wedge pressure
thermistor on s/g (pulmonary artery cath)	used to evaluate cardiac output
balloon inflation port on S/G cath	where you inject the fluid for your cardiac output;
balloon inflation port on S/G cath for ?	balloon is used to help identify the pulmonary capillary wedge pressure or pulmonary artery wedge pressure
route of S/G balloon cath to measure pressure	catheter that is advanced through the right atrium down through the tricuspid valve into the right ventricle and then up to the pulmonary artery.
up into the pulmonary artery ; dicrotic notch here	shows closure of the the pulmonic valve
When you inflate the balloon in S/G cath	anything behind the balloon is obliterated. Cause this balloon can only see forward.
if the mitral valve is open in a S/G balloon look through cath then?	there is no obstruction between the tip of the balloon and the left ventricle and you can find out the left ventricular pressure
pulmonary artery catheter, you can	look at the right atrial pressure, the right ventricular pressure, the pulmonary artery pressure and the pulmonary artery wedge pressure which is giving you the left ventricular pressure
in SICU we never	wedge
dicrotic notch ; what does it mean?	closure of the pulmonic valve
arterial line or a hemodynamic monitor (S/G cath) you have to ?	level it; level it with the right atrium; called the phlebostatic axis.
phlebostatic axis is	4th intercostals space of the right mid-axillary line
level the phlebostatic axis	take a carpenter’s level that is 6 foot long ; from the phlebostatic axis over to the transducer to level it.
transducer is too high	pressures are too low
transducer is too low	your pressure is too high.
phlebostatic axis location	5cm below the angle of Louis)
complications of hemodynamic monitoring (swan/ gantz caths)	a pneumothorax can drop a lung when you put that swann in; patient goes for? A chest x-ry.Infection;dysrhythmias, foreign body in the heart Pulmonary artery ruptured/t overinflation of balloon > 1.5cc
inflate that balloon of the S/G cath with how much air	1.5 cc of air, more can cause pulmonary artery rupture
what do you expect to see when you inject 1.5cc?	A change in the wave form;If it doesn’t change after that first injection, you should be a little concerned. don’t get a dampening of this wave form, then you are probably not in the right place.
How much do you need for an air embolism?	5cc’s.
Normally, the CVP pressure is	anywhere from 0-8, that’s your right atrial pressure
what is your normal JVD?	<3cm. Add 5cm and you have your CVP.
right ventricular pressure	20-30 for systolic and the diastolic is 0-8;
Pulmonary artery has a different pressure	systolic again of 20-30; more pressure there because of the valves and has a diastolic of 8-15
pulmonary artery wedge pressure	8-12
cardiac output?	Stroke Volume X Heart Rate
can measure it with the hemodynamic monitor, or the Swan-Ganz, or the pulmonary artery monitor by injecting 10cc of saline in through the port,	draw back the 10cc and inject it at the end of expiration Quickly/ don’t inject it quickly,not an accurate reading.
computer calculates the time it takes for that 70 degrees of saline to change to 98.6 and that gives you your cardiac output.	Swan-Ganz measurement of CO
cardiac output comes from	left ventricle;
what causes a high PAWP? (pulmonary artery wedge pressure)	Too much fluid, too much volume, left ventricular failure
Increased afterload, what does that mean? Where is the pressure increasing –	in the aorta
warm up those blood vessels,what happens?	they no longer constrict they vasodilate.
What causes a decreased cardiac output?	Decreased preload
what causes decreased pressure in the right atrium – what causes pressure?	Dehydration; Sepsis.; Vasodilation,Increased volume ;ventricular failure; anaphylaxis; increased contraction of the heart
Why do you give Dig?	Slow the heart rate, but increase the force of contraction,

Created by: goryan on 2008-01-28

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BC3 cardiac lecture

BC3 cardiac lecture 1/22/08