Cardiac Final Review

Pathology

• Coronary heart disease involves plaque buildup in the heart's arteries, leading to heart attack and potentially heart disease (CAD leading to CHD)
• CHD results in decreased heart function

Risk Factors associated with CHD

• Tobacco use

• Diet high in fats and cholesterol

• Alcohol consumption

• Lack of physical activity

• Obesity

• Family history

• Ischemia is decreased blood flow, which can lead to infarction (cell/tissue death) and sclerosis (hardening)

• Cholesterol is essential for transporting fatty acids and lipids, with 75% produced by the body and 25% from food

• LDL (bad cholesterol) should be <100

• HDL (good cholesterol) should be >60

• Triglycerides are lipoproteins where high levels indicate high risk, fats are carried in the blood from food

• Normal triglycerides should be <150

• Total cholesterol should be <200

• Low LDL:HDL ratio (</= 3:1) decreases risk, while a high ratio (>/= 5:1) increases risk

Coronary Arteries

• The Coronary arteries originate from the aortic sinuses and terminate in capillaries that supply the Myocardium
• The left coronary artery branches into the left circumflex and left anterior descending arteries, supplying blood to most of the left ventricle, left atrium, parts of the right ventricle, and the interventricular septum
• The right coronary artery branches into the right marginal branch and posterior descending artery, supplying blood to the right atrium, right ventricle, IV septum, inferior wall of the LV, and AV/SA nodes

Ischemia & Angina

• Myocardial ischemia occurs when the myocardial oxygen demand exceeds the supply, termed reversible
• Angina is a classic symptom of ischemia, characterized as pressure or heaviness in the mid-chest
  • Chronic stable angina is usually linked to a consistent level of oxygen demand
  • Unstable angina symptoms occur without typical demands such as with plaque rupture or coronary stenosis
  • Prinzmetal's angina occurs at rest due to coronary artery spasm

Myocardial Infarction

• Myocardial infarction is the complete interruption of blood supply to a myocardial area, stemming from ischemia
• Causes include prolonged myocardial ischemia, vasospasm, cocaine use, and embolic occlusion, often leading to focal death of myocardial tissue, frequently in the left ventricle

Myocardial Infarction Response Times

• 18-24 hours: Inflammatory response to necrosis
• 2-4 days: Visible necrosis, myocardial recovery begins
• 4-10 days: Debris clears
• 10-14 days: Weak fibrotic scar formation, which is inelastic and unable to contract/relax

Zones of Impact from Myocardial Infarction

• Zone of infarct refers to tissue death and is not reversible
• Zone of injury has hypoxia and can recover with quick restoration of blood flow
• Zone of ischemia is reversible

Types of Myocardial Infarction

• Subendocardial MI is partial thickness, indicated by ST depression without Q waves on an EKG
• Transmural MI is full thickness, indicated by ST elevation and Q waves on an EKG

Areas of Myocardial Infarction

• Anterior wall MI (LAD)

• Lateral wall MI (LCX)

• Inferior wall MI (RCA)

• Diagnosis of MI requires at least 2/3 criteria: angina symptoms (chest pressure, heavy, pain, arm, jaw, DOE, fatigue, syncope, belching), EKG changes, and rise of cardiac enzymes

EKG Changes Associated with MI

• Peaked T waves

• ST elevation

• Q wave presence

• T wave inversion

• Troponin levels elevate 4-6 hours post-MI, peaking at 24 hours

• Creatine kinase levels elevate 4-8 hours post-MI, normalize in 2-3 days, peaking at 24 hours

Medical Treatment for Myocardial Infarctions

• Pharmaceutical agents that reduce myocardial oxygen demand
• Beta-blockers and calcium channel blockers
• Increase myocardial oxygen supply (vasodilators)
• Improve myocardial muscle function (digitalis)

Surgical treatment for MI

• Thrombolysis
• Intra-aortic balloon pump (IABP)
• Percutaneous transluminal coronary angioplasty/percutaneous coronary intervention (PTCA/PCI)
• Coronary artery bypass graft (CABG)
• Left ventricular assist device (LVAD)

Congestive Heart Failure

• Congestive heart failure (CHF) occurs when the heart can't pump enough output to meet the body's metabolic demands

Risk Factors associated with CHF:

• CAD
• Hypertension
• Diabetes Mellitus

Characteristics of CHF

• Dyspnea
• Tachypnea
• Paroxysmal nocturnal dyspnea (PND)
• Orthopnea
• Fatigue
• Weight gain
• Cyanosis

Systolic Characteristics with CHF

• Preload, afterload, contractility of myocardium, rate of contraction (ventricle contract)

Diastolic Characteristics with CHF

• Frank starling mechanism (fill of ventricle)

• Systolic heart failure involves decreased contractility, increased preload and afterload, and changes in chronotropy (HR too slow or fast)

Diastolic Heart Failure

• Diastolic heart failure which involves excessive hypertrophy of ventricles, EDV may be increased and decreased compliance of LV

Impact of the Left Ventricle

• When the left ventricle isn't working efficiently, the stroke volume (SV) and cardiac output (CO) is decreased
• HFrEF= associated with heart failure (low CO @ rest)
• HFpEF= volume overload

Consequences of CHF: Renal, MSK, hematologist, hepatic, pancreatic

SNS compensation:

• Decreased CO sensed by baroreceptors, increased activity

RAAS compensation:

• Maintains BP and CO in setting of volume depletion, increased venous and atrial tone

Diagnosis of CHF:

• Echocardiogram

• BNP assay

• CXR

• EKG

• Treatment for CHF involves improving the ability to pump, reducing workload, controlling sodium intake, and controlling water retention

• Medical management includes decreasing venous return and work of the heart with diuretics, vasodilators, and beta blockers

• Surgical management includes pacemaker, athrectomy, rotobladder, or bypass

NYHA Classification of CHF

• Class 1: No limits of activity

• Class 2: Slight limits

• Class 3: Marked limits

• Class 4: Inability to carry on activity

• Cardiomyopathy is a diverse group of diseases involving primary disorder of the myocardial cells with ultimate cardiac dysfunction

• Dilated CM increases the cardiac mass leading to HEART DISEASE AND UNCONTROLLED HTN, which results in decreased SV.. prognosis is good Hypertrophic CM increases cardiac mass, LV hypertrophy results in diastolic dysfunction. Its first symptom may be sudden collapse and possible death

• Restrictive CM is rare, caused by amyloidosis leading to diastolic dysfunction, which results in decreased ventricular filling and atrial enlargement

• Treatment for cardiomyopathy is very similar to CHF

• Valvular heart disease occurs when the valves may become stenotic, insufficient, or prolapsed caused by mechanical stress, rheumatic fever, or ischemic heart disease leading to heart failure

Stenosis

• Stenosis occurs when can be found in all valves, narrowing or constriction that prevents valves from fully opening, which is caused by disease (CAD, scars, abnormal deposits)
• Symptoms: DOE and fatigue

Regurgitation

• Regurgitation is most common on the left side of the heart

Prolapse

• Prolapse often causes regurgitation, symptoms include fatigue palpitations, dyspnea, non-angina chest pain

• Treating valve disease is with no medications and usually surgery with commissurotomy or balloon

• Sudden cardiac death accounts for 40% of people with the most common causes being scarring from previous LV dysfunction and ischemic heart disease, outcomes depend on early access to CPR, an early defibrillator, and early ACLS

• Aneurysms are local dilations and weakening of the all blood vessel walls and they are indicated with a pulsating swelling that produce blowing murmur on auscultation

• A true aneurysm is a false/pseudo collection of blood leaking compeltely out of the blood vessel

• Aortic aneurysms are aortic dissection that originates at site of intimate tear and continues distally

• Treatment of aneurysms is surgical excision and grafting

• Endocarditis is inflammation of endocardium (microbial infection)

• Pericarditis is inflammation of pericardial sac (viral infection) and involves pain relieved by positioning

Anatomy

• Mediastinum is the space between right and left pleura, contains all structures except lungs and pleura, it can accommodate movement and volume changes due to the looseness of the connective tissue combined with the elasticity of the lungs and pleura

Pericardium

• Pericardium is a double walled fibrous sac which encloses hearts and roots of great vessels, it is composed of the outer fibrous layer and inner double layered sac
• The pericardial cavity contains the phrenic nerve
• Inflammation of the pericardium is pericarditis (aka pericardial RUB)

Heart Orientation

• The heart is oblique in the mediastinum
• The apex is found in 5th intercostal space as the PMI, most inferior portion
• The base is formed by the 2 atria, most superior portion, 2nd intercostal space

Heart Layers

• Epicardium is the outermost layer
• Endocardium is the innermost layer
• Myocardium is the middle layer with the heart, it is composed of mechanical and conductive cells, with aerobic processes
  • Myocytes are mechanical cells, allowing the heart to pump

Heart Cells

• Automaticity is the ability to contract in absence of stimuli

• Rhythmicity is to contract in a rhythmic manner

• Conductivity is to transmit nerve impulses

• Excitability is to respond to electric stimulus

• Contractility is to stretch as a single unit

• Myocardial cells cannot replace injured cells

• Coronary sinus gives blood to the right atrium and receives blood from the veins of heart

• Cardiac skeleton acts as an electrical insulator between the atria and ventricles so impulses only move through the AV node

Chambers of the Heart

• The 2 upper chambers are ATRIA
• The 2 lower chambers are VENTRICLES
• Pulmonary arterial pressure is 1/6th of systemic pressures
• The right atrium is a thin muscular wall, receiving venous blood (oxygen poor) from superior and inferior vena cava and coronary sinus (during diastole), contains the SA node, normal fillings is 0-8 mmHG
• AV valves separate atrium and ventricle and allow for one way blood flow:
  • Right is tricuspid
  • Left is mitral, and the most frequent valve to be diseased
• The right ventricle receives blood from the RA via tricuspid valve and pumps blood into pulmonary artery via pulmonary valve,, normal systolic= 15-30 mmHG and diastolic= 0-8mmHg
• Semilunar valves are on the right is PULMONARY (2nd intercostal space) and the left is AORTIC

Left Atrium

• Left atrium are thicker walls as there is more pressure and collects blood from right and left pulmonary veins
• It contains oxygenated blood from the lungs , with normal fill= 4-12 mmHG
• The left ventricle is the superior and anterior portion formed by the aortic vestibule with systolic=80-120 mmHG and diastolic=4-12 mmHG
• The interventricular septum is the wall which partitions the right and left ventricles, contains electrical conduction tissue, provides stability to the ventricles
• Arteries deliver oxygenated blood throughout the body
• Veins return deoxygenated blood form the body to the heard
• Capillaries are the smallest of the blood vessels
• Lymphatics contain valves to ensure one way flow to the heart
• Coronary arteries arise from right and left aortic sinuses and travel around the heart in 2 grooves, connect at the posterior aspect of the heart

Left Coronary Artery (LCA)

• Supplies blood to the left atria and most of the LV, parts of the RV as well as the interventricular septum
• LAD travels in the Anterioventricular groove, blood to ant 2/3 of IVS, LV, LBB
• The LCX which supplies blood to most of LA, post and Lat walls of LV
• The right coronary artery supplies blood to the RA, RV, IVS, inf wall of the LV, SA/AV nodes
• Coronary veins tend to follow coronary arteries, collect de-oxygenated blood form the myocardium
• The coronary sinus is the main vein of the heart

Heart muscle cells and Polarization

• Heart muscle cells called cardiomyocytes are polarized, negatively charged at rest
• Depolarization happens when the myocytes become positive they contract
• Repolarication = relaxation
• P wave= atrial depolarization
• QRS= ventricle depolarization
• T wave= ventricular repolarization
• The SA NODE= pacemaker of the heart with 60-100 BPM. and is located at the junction of the SVC and RA
• The AV NODE is located in the right atrial septal wall near tricuspid valve, has 2 functions
  • When an impulse arrives, depolarization slows causing a delay of .04 seconds to allow the ventricles to fill with blood from the atria ("atrial kick") and control # of impulses (40-60 BPM)
• Bundle of HIS= 20-40 BPM and means cardiac impulse is traveling forming AV node to BOH, divides into R & L BB
• SNS= dominates stressful situation
• PNS= dominates relaxed states
• Diastole= relax and systole= contract
• Mid diastole means that ventricles receive blood form atrial (80%)
• Late diastole means that there is the other 20% of blood, atrial kick as the SA node has fired
• Early systole= AV—> ventricles
• Late systole means aortic and pulmonary valves are open, blood flow - aorta and lungs, ejection fraction
• Early diastole occurs when the pulmonary and aortic valves are shut, the AV node is open and the timing of the cardiac cycle lasts 0.8 seconds
• Cardiac output is the amount of blood ejected by the left ventricle into the aorta per minute
• Stroke volume is the amount for blood ejected by each ventricle during one contraction
• FS mechanism is the relationship between ventricle filling pressure and ventricle mechanical activity

DVT (Deep Vein Thrombosis) Study Notes

• PVD is a general term that covers all diseases of the blood vessels outside the heart
• PVD affects arteries and veins
• Arterial are peripheral arterial disease (PAD)
• Venous are peripheral venous disease
• Lymphatic diseases are included

PVD Risk Factors

• Smoking

• Diabetes Mellitus

• Increased cholesterol (high LDL)

• HTN

• Age >50

• Male gender

• Obesity

• Family history

• PAD is a condition that develops when the arteries that supply blood to the internal organs, arms, and legs become completely or partially blocked as a result of atherosclerosis

• Arteries tend to be elastic and muscular, carrying oxygenated blood. Vessels closer to the heart are more elastic as distal vessels are more muscular and branch into arterioles then into capillaries

• Atherosclerosis is characterized by nodular deposits of fatty material that line the walls of the artery (plaques)

• Arteriosclerosis obliterans is peripheral manifestation of atherosclerosis which causes rest pain is when occlusion is greater than 80-90%. Inadequate perfusion (put leg down)

• Intermittent claudication occurs when the supply of blood is less than the muscles demand , the calf muscle os most affected and decreases with rest (pain, aches, weak, numb)

• Acute arterial occlusive disease is arterial thrombosis and embolism which can cause sudden complete blockage leading to cessation of blood flow and tissue death. Its symptoms are abrupt onset of pain, pallor, cyanosis, and lack of pulses

• Arterial thrombus is a blockage that leads to an increase in blood flow turbulence, and can be partial or complete

• Arterial embolism refers to when the blockage break off then block

• Thromboangitis obliterans, aka Burger's Disease affects predominantly young men who smoke heavily with affects smaller vessels and moves proximally

• Raynaud's syndrome refers to a spasm of the arterioles affecting the digits, causing little or no blood flow to affected body parts

Peripheral Vascular Disease and ABI Scoring

• Diagnosis of PVD is done by using an ABI or ankle brachial index (systolic P leg/systolic P arm)
• 0.96-1.00 is normal score
• <.95 is abnormal score that needs stress test
• <.8 probable claudication
• <.5 multi level disease
• <.3 ischemic rest pain
• Duplex ultrasound is a non-invasive technique is done to study the arteries, measure obstruction and shows blood flow
• Angiography is a type of imaging done to study the peripheral blood vessels, most accurate in that it can detect the location of occlusion
• Treatment of PAD is aimed to: relieve pain, improve exercise tolerance, prevent critical artery occlusion, and prevent heart attacks
  • Done through lifestyle chagnes, such as stop smoking, change diet, exercise, and perform skin foot checks
• Medications such as anticlotting medications, lowering cholesterol, increase blood supply, and control blood pressure
• Angioplasty stent to open artery, Thrombolytic being injected and cryoplasty (cold temperature) surgery, endarterectomy cleans plaque build up, bypass grafting, and amputation

Venous Function

• The venous system's function is to bring blood back to the heart, relies on a system of valves to keep blood flowing in one direction, and blood flow is dependent on valve competency and muscle contraction
• The major risk factor for vein diseases is family health history

Chronic Venous Insufficiency

• Chronic venous insufficiency is a condition in which leg veins cant pump enough blood to the heart
• The clinical presentation of it involves edema, erythema, cellulitis, leg ulcerations
• Risk factors and past medical history related to overload, pregnant, decreased exercise, smoking, DM, HTN, CHF, DVT
• Subjective patients may complain of heavy, tires, restless or achy legs (too much blood), edema resolves w/ elevation
• Objective patients may show hemosiderin, warmth, and edema

Varicose Veins

• Varicose veins a prevelance of incompetence valves, increased venous pressure and overstretches the vein, large, bulbous

• Diagnostic testing involves duplex ultrasound, venogram (X-RAY w/ dye)

• Treatment involves increase function and decrease pain through the use of stockings, exercise, vein injections, and bypass

• Arterial ulcers involve perfectly round, well-defined edges, no drainage or odor, may or may not have swelling of LEs with skin often tight hard and shiny, no hair on toes or legs, faint to absent pedal pulse, and legs pale when elevated with potential neuropathy

• Venous ulcers: not perfect, with normal leg and foot pulses, wet at times, there will be edema with probably no pain with walking, and pain with standing, small or large

• DVT is when blood cells clump together and produce chemical that activate the clotting process (thrombin) as the body thinks something is wrong so it makes a clot

• Distal DVT is generally small and asymptomatic, lower rate of PE

• Proximal DVT involves the popliteal vein or more, less common but most severe

• What lead to it, such as compression of veins, trauma, cancer, infections, inflammatory disease, stroke, HF

• Most common risk factors include surgery, immobilization, long haul flights, smoking, obesity, and age

• PE is sudden blockage in a lung artery, may damage part of the lung due to lack of blood flow and lowers oxygen in blood

• Risk factors such as same as DVT, previous DVT, orthopedic surgery of LE, major trauma, spinal cord injury, CHF, acute MI, > 40 yrs, obesity

• Virchows triad is a the 3 main factors that cause thrombosis/ hypercoagulability

  • Increased clot
  • Hemodynamic changes
  • Endothelial injury

• Wells criteria means 2+ is bad and <2 is good

• = 6 points is high risk of PE

• Low risk for DVT/PE if you have the age < 40, uncomplicated or minor surgery

• Mod risk if one has minor surgery in age 40-60 or major surgery

• High risk if one had major surgery with the age >40 yrs, history of DVT/PE/cancer, hip or knee surgery, major trauma, or SCI

• Signs and symptoms of DVT are swelling, pain, tender, warmth, red, fever, chills, malaise, cyanosis S&S of PE are suddenly chest pain, SOB, tachypena, tachycardia, cough with blood, and persistent cough

• Diagnosis of DVT can be done through the use of venography, duplex or Doppler US and MRI

• Diagnosis of PE can be done through medical history, spiral CT scan, VQ scan, pulmonary angiography, or blood test There are no diagnostic tests done by PTs

Factors that Reduce Risk of DVT

• Mobilization

• Hydration

• Anti coagulation

• Graduated pressure stocking

• Mechanical such as IVC filter, inserted through the femoral vein, and primary concern is is new DVT

• Graduated compression stocking are worn on legs to promote venous return, prevent venous distinction, with a goal of preventing venous stasis while considering poor pt compliance, improper use and fit

• Aspirin is an anti platelet drug, that is cheap, readily available, with no monitoring, and simple dosing, however there are cons such as GI bleed risk It works by inhibiting the production of thromboxane A2 and other prostaglandins

• Heparin is an antithrombin agent that stops formation of fibrin, and can be used to prevent and treat blood clots

• LMWH which are prevention drugs through injection which is used to prevent or treat thrombosis

• Warfarin is oral, a prevention drug for long term treat of DVT/PE, which works by inhibiting vitamin K regeneration in the liver

Lab Values

• Serum enzymes are use to determine if someone is having an MI

  • Troponin which is a gold standard showing normal levels are .02-.04 and if in blood would remain for 7 days
  • CPK-MB is conclusive for myocardial damage with normal levels of 0-3%

• Blood lipids are major risk factors CAD and total cholesterol >240 is high, LDL should be >130 and HDL should <40.

• Hemoglobin normals are from 12-16, but low hemoglobin isn't always a sign of illness

• Hematocrit are 36-44 which determines the percentage of the blood that consists of RBC, low means anemia and high might be attributed to high altitudes, chronic smokers, dehydration, and blood doping

• WBC count should be 4-12, a low number means leukopenia and may be due to bone marrow deficiency, collagen vascular disease, and liver or spleen disease and radiation and a high number means leukocytosis with possible causes such as bone marrow tumors, infectious disease, and leukemia

• Platelets should be 150-450

• Parital thromboplastin time- normal range is 25-39 sec and may be elevated from patients with Heparin

• INR should range 1-1.5..(2 and 3 for AFIB factor Xa reflects patients on LMWH (wrenox)

• Electrolytes are involved with managing cell membrane potential:

  • Sodium should be 135-147 and helps regulate H20 levels and nerve conduction
  • Potassium should be 3.5-5, and is Essential for normal cell function, involved in contraction of heart, nerve conduction

• BUN should be 8-23 which is formed when protein breaks down and CNA indicate HF or renal failure

• Creatine should be .5-1.5 and measure effectiveness of kidneys

• Serum glucose levels should be from 80-110

• BNP brain natriuretic peptide is secreted by ventricles of the heart in response to pressure changes that occur when heart failure develops or worsen which contributes to vasodilation, increase sodium and water retention by kidneys, and relax myocardium

Testing and Procedures

• Invasive procedures use catheterization, EPS, lines, and labs

• Non-invasive procedures will use EKG, holster, PET, CT, CXR, MUGA, MRI

• Catheterization goal is to determine extent of CAP. and indications are cardiac arrest and pulmonary edema, this procedures goes into the femoral artery, where dye is released, flow of dye is recorded and it involves 6 hours of bed rest follow

• EPS is used to diagnose arrhythmias, or as an ablation procedure

• Holter is 24+ hr EKG monitoring, useful to diagnose and manage arrhythmias

• Echocardiogram uses pulses of reflected ultrasound to assess hearts function and structures (SV, CO, and EF)

• CXR can be used to assess heart size and pulmonary edema

• Pet scans can be used in showing where heart problems and show areas where poor blood flows to heart

• CT scans use contrast dye to identify problems with the aorta, PE, heart function, valve problems, and pericardial disease

• MUGA scan measures how well the heart is pumping for each beat and measures the LVEF

• Cardiac MRI scan creates still and moving pictures of heart and blood vessels which assess and diagnose CHD, MI, heart failure, congenital heart defects and regional blood flow problems

• In a Thalium cardiac perfusion testing if is good at predicting risk of recurrent MI and areas of decreased blood flow show have less Uptake, areas that ARE NOT perfumed immediately post-exercise but re-perfuse 2-4 hours is showing ischemia

• Cardiac viability testing is performed to examine hearts metabolism, assess how blood flow to heart muscle is, look is for damaged heart muscle with SPT and PET

Lines and Entry Points

• Lines include
  • Sheath introducer which is placed in blood vessel as entryway for other lines
  • Swans ganz catheter offers direct info relevant to cardiac function
• A-LINE is indwelling catheter with a pressure transducer attached to end and is used to measure arterial blood pressure and obtain ABGs
• CVP reflects right sided heart function, and measures blood volume, vascular tone, and venous return

Interventions and Surgeries

• Cardiac catheterization involve evaluate or confirm presence of CAD, valve disease or disease of AORTA

• Percutaneous transluminal coronary angioplasty or balloon angioplasty is when a balloon is inflated and the fatty plaque is compressed against the artery wall, the diameter of the blood vessel is widened to increase blood flow to the heart

• Stents may be introduced such as the bare metal (BMS) one and drug alluding stents

• Atherectomy removes plaque and special catheter with acorn shaped diamond to grinds the plaque on the wall

• brachyclerapt- intracoronary radiation therapy decreases the rate of in-stent restenosis caused by tissue growth

• Sternal precautions: avoid lifting heavy objects or doing overhead activities, and pushing

• Coronary artery bypass grafting is when blocked coronary arteries are bypassed and revascularizes the myocardium, after surgery, mobilize as early as 24-48 hours

• IMA grafts are most common and produces long term results over SVG grafts

• The heart-lung machine helps a perform surgery, performs work of lungs stopping heart activity

• LVAD increases exercise tolerance

• Valve replacements pros and cons, and is life longer (10 years)

• Sternal precautions should be used too

• Vascular bypass for PVD is where saphenous vein handles 10% venous return

Assessment

• Starts with medical chart, and risk factor analysis with subjective interview
• Check respiration distress symptoms such as SOB and using of extra respiratory support
• Check position of the body
• Check head and neck region regarding jugular venous distension

Heart sounds

• S1: LUB.. closing of AV valves, beginning of systole, loudest at mitral area... auscultation w/ diaphragm (firm).. mitral and tricuspid valves
• S2: DUB.. closing of SL valves, end of systole, loudest at aortic and pulmonic area (firm).. aortic and pulmonic valves
• S3: LUB-DUB-DUB... occur in early diastole.. aka ventricular GALLOP.. represents loss of ventricular compliance, heard right after S2... low pitch- use bell to ausculate (light pressure)
• S4: LA-LUB-DUB.. occur in late diastole.. atrial GALLOP.. represents increased resistance to ventricular filling- immediately before S1.. (light pressure)
• Loud S2 heart sound
• Summation gallop is one heart sound of S3 and S4 being added
• Heart sounds known as murmurs are increased turbulence blood flow and are abnormal indicating a diseased heart
• Regurgitation is typically caused by backward flow

Ausculation

• Create a quiet environment
• Position the patient supine
• Position the stethoscope

Cardiac areas

• Mitral is on the 5th ICS

Peripheral cyanosis

decreases by decrease of perfusion

• Pitting edema
  • 2mm depths and 4mm depths
• Use 0-4 to grade pulses

Blood pressure

• Can't be loose on patient

Ankle branchial

• Can't be low

Exercise

• Start slow
• Oxygen all increasing
• Heart rate and by should be responding to the work
• Look at legs on patients
• Always take into account conditioning

Heart Failure

• Due to low levels, not good with exercise
• Exercise may be limited due to PVD

Cardiovascular

• genetic issues known
• cancerous

EKG

• EKG DO NOT MEASURE FUNCTION, ONLY ELECTRICAL ACTIVITY
• EKG are moving towards the positive electrode which causes positive deflection and away is negative (2nd int. Right sternal border Aortc is on right, pul is now 2nd inter left sternal right for lead placement)

Conduction

• resting polarization state/ Negative charge
• Depolarization- positive movement

Intrinsic Ability

SNS and PNS

Leads

• AV nose- PR segment

  • Tachycardia: greater than 100 bpm

Heart Block Treatment

• Pvc- irritable in ventricles

• High SBP >200 and DBP >110 exercise is needed

• Beta blocker helps too

• Low heart rate needed

• Good QOL helps too

Exercise Testing

• Walking with a long test up

EKG:

• telemetry: 5 colored wires (White clouds over Green grass