lecture
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| CAD- coronary artery disease | narrowing of lumen of coronary arteries
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| progression of atherosclerosis plaque | damage to endothelium->increased endothelium permeability->infiltration of cholesterol into myocardium->cholesterol build-up + collagen-> platelet aggregate on top->RBC aggregate=clot
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| stable plaque | small, hard fatty core, thick fibrous cap
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| unstable plaque | large, soft fatty core, thin fibrous cap
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| CAD risk factors | age, heredity, obesity, blood values, DM, HTN, smoking, sedentary lifestyle, male, post menopausal women
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| CAD risk factors- lab values | increased serum cholesterol (over 200), increased triglycerides (over 200), increased LDL (over 130-biggest threat), decreased HDL (less than 40 for men, less than 50 for women), total cholesterol/HDL ratio over 4.5
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| CAD clinical manifestations | No symptoms until 75% occluded (collateral circulation forms), angina pectoris (chest pn, pressure, squeezing in chest), myocardial infarction (blood flow to section of heart occluded. leading cause of sudden death)
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| angina | ischemic pn of the myocardium, "chest pn", pn above the waist
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| angina etiology | 90% caused by atherosclerosis
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| angina S&S | burning, squeezing, tightness in chest, pn btw shd blade, pn into neck, down L or R UE, N&V, anxiety, duration:ave 3 min, <15 ok, >15 unstable, >30 min MI
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| types of angina patterns | unstable, stable, chronic
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| stable angina | with exertion, increased stress
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| unstable angina | more frequent, lasts longer, less responsive to meds (nitroglycerin), at rest, at night, unpredictable
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| chronic angina | long hx of cardiac problems, post MI
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| angina rx | nitroglycerine: vasodilator -methods:usually sublingually, sometimes topically. sedatives
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| myocardial infarction (MI) | coronary artery occlusion causing necrosis of myocardium, medical emergency, most often affects L ventricle
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| MI S&S | burning, squeezing, tightness in chest, pn btw shd blade, pn into neck, down L or R UE, N&V, anxiety, indegestion, shortness of breath, sweating, women:fatigue, N&V, SOB, jaw pn, silent:DM, when:early AM, btw Thanksgiving & New Years, periodontal dx
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| MI healing | inflammation -> scar
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| CAD dx | EKG, cardiac enzymes over 72 hrs (measures cardiac troponin I&T & creatine kinase (CK-MB), coronary angiogram:cardiac cath, echocardiogram, holter monitor, ex tolerance test, stress test
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| CAD rx prevention | diet, exercise, stop smoking, manage HTN, manage DM, pharmocologic (antilipids, statins-antiplatelet, ASA)
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| CAD rx sx | PTCA + stents: percutaneous transluminal coronary angioplasty, "balloon angioplasty". CABG: coronary artery bypass graft (saphenous vein-mammary artery-CABG x(# of bypassed arteries)
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| CAD rx meds | Nitro, betablockers, ace inhibitors, diuretics, calcium channel blockers
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| nitro for angina | 3 doses in 10-15 min (every 5 min) don't give more than 3 doses, more than 15 min call 911
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| anti HTN | betablockers, ace inhibitors
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| betablockers | usually end in "ol"-side effects- decreased endurance, keep abt a 3 on Borg's scale, fatigue, lethargy, hypotension & may mask signs of hypoglycemia
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| ace inhibitors | end in "pril"-these & angiotinsin blockers (end in sartan"-good to decrease blood pressure-side effects-dry cough
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| diuretics | lasix-may have to stay close to bathroom-increased urination, increased risk of falls @ night & dehydration and weakness
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| calcium channel blockers | usually end in "il" or "pine"- side effects- peripheral edema & hypotension
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| atrial fibrillation/arrhythmias | prevalence:2.66 million people have a fib. is most common type of arrhythmia
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| atrial fibrillation/arrhythmias risk factors | HTN, CHF, DM, hyperthyroidism, drug abuse & advanced age
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| atrial fibrillation/arrhythmias complications | stroke- most common significant complication, light-headedness, HF if persistent & severe. the rx has it's own complications
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| atrial fibrillation/arrhythmias meds | anti-arrhythmics (amiodarone-pulmonary, thyroid, and ocular toxicities, drug interactions, heart block. multaq-dronedarone-rhythm. sotalol-rate/rhythm. CCB-rate.) blood thinners-do not rx a fib-used to prevent likelyhood of stroke
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| types of blood thinners | coumadin (warfarin), xarelto (rivaroxaban), pradaxa (dabigatran)
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| digoxin | used in heart failure & atrial fib, cleared by kidneys, numerous drug interactions, digoxin toxicity
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| digoxin toxicity | nausea/vomiting/anorexia/confusion/weakness/ electrolyte abnormalities/death
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| IV anitcoagulants | rapid on/off switch for use around sx or procedures. Heparin-most common-prevention & rx of DVT/PE while hospitalized-new start anticoagulant pt that may undergo sx-coumadin bridging. Bivalirudin & argatroban
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| subcutaneous anitcoagulants | lovenox (enoxaparin), arixtra (fondaparinux)-prevention & rx of DVT/PE while hospitalized-coumadin bridging therapy-less intensive monitoring & can be performed at home with little training
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| PO anitcoagulants | Warfarin (gold standard for comparing blood thinners), Xarelto, Pradaxa
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| anitcoagulants side effects | bleeding-minor bleeding: gum bleeding, nose bleeding, bruising, heavier menstrual bleeding. major bleeding: gastrointestinal bleeding, intracranial hemorrhage, retroperitoneal hematoma. heparin induced thrombocytopenia (HIT/HITT). purple toe syndrome
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| hyperlipidemia | increased risk of heart dx including MI & stroke. statins are the main class of drugs used to rx. lower LDL, lower triglyceride levels, increase HDL
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| hyperlipidemia side effects | mm pain/ mm weakness, rhabdomyolysis-by products of skeletal mm destruction-damages kidneys. greapefruit juice can alter the effects of statins
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| cardiovascular dx processes that can easily impact a PTs work | reduced stamina, weakness, fatigue/SOB, drug therapy can be beneficial to PTs work by reducing these
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| how drugs for cardiovascular dx can negatively impact PT | bradycardia/hypotension, easy bruising/increased bleed risk, mm pn, reduced stamina
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| CAD rx cardiac rehab | pt education + exercise + lifestyle modification
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| phase I cardiac rehab | begins w/ IP & goes thru abt 4 wks-active ex (little warm up, amb 20 min, cool down). we will work on self-care & getting home (progressive amb)-precautions & contras-self monitoring, RPE important
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| phase II cardiac rehab | from 4-12 wks- OP- monitored program-EKG- monitoring common, DR protocol (warm up, aerobic, light resistive & cool down)ex session 15 min-1 hr, target RPE is 10
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| phase III cardiac rehab | lifelong maintenance
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| CAD complications | Arrhythmias, CHF, shock, emboli, cardiac tamponade, pericarditis
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| CAD arrhythmias | PVC (premature ventricular contraction), ventricular tachycardia (3 or more PVC's in a row), ventricular fibrillation (occurs in almost 50% of cardiac arrest)
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| cardiac tamponade | life threatening, damage to heart, pericardial space filled w/fluid, also cardio myopathy
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| pericarditis | fluctuating sharp pn
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| CAD prognosis | depends on size & location of MI, previous MI, complications in 1st 24 hrs leads to CCU monitoring, age, other proglems, results of stress test
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| phase I Inpatient cardiac rehab | MET-based activity, deep breathing, cough w/splint, bed mob, active ex (add 1 ex/day, AROM, NO resistance, isometric), progressive amb: 1st x 2min, add 30 sec/amb per day
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| phase I outpatient cardiac rehab | cont active ex as warm-up for amb, Prog amb-wk 1 5minx4- wk 2 10min x3- wk 3 15 minx 2- wk 4 20 min x1. treadmill or bike test before phase II
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| phase I pt edu cardiac rehab | diet, meds, driving, shower (no bath x 1 mon), monitor incisions (keep clean), watch for fever, weigh daily (2-4 lb gain in 2 days red flag), balance activity w/rest, elevate LE's w/rest, avoid crowds, no smoking, no sex 2-4 wks
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| phase I cardiac rehab monitor: | EKG: ck w/RN:arrhythmias, PR:max rest 100 BPM, max ex 120 BPM, max increase 20 BPM, return to RHR < 5 min, BP:no decrease from rest SBP, no increase >25 mmHg SBP, O2 Sat:keep O2 on if ordered, RPE
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| phase I cardiac rehab monitor/guidelines: | Ex log, talk test, take own PR, no extreme weather or terrain (no hot or cold or hills), strolling (good shoes)
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| phase I cardiac rehab contras to ex | HR beyond guidelines, arrhythmias, excessive coughing, SOB, fatigue, faintness/dizziness/ confused, pale, claudication pn, angina, excessive sweating, N&V, wait 1 hr after eating, no amb if clearly upset (can do light stuff)
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