Physiological Changes with AgeCardiac Valves: stiffen, calcify, degenerate = expect murmurs ("swish") | Conduction System: coronary arteries get poor blood = necrosis, arrhythmias; lose pacemaker cells, lose conduction, fat in SA node, coming from ectopic muscle | Left Ventricle: atrophies, stiffens, enlarges, becomes less distensible, dec. SV & CO, dec. EF, most noticeable w/ physical activity | Aorta & Large Arteries: thicken, stiffen, less distensible = pumps harder ( inc. HR) & inc. systemic vascular resistance | Baroreceptors: located in carotid arteries; help regulate BP; less sensitive w/ age; most noticeable w/ position changes |
Framingham Heart Study (1948): Landmark study done in Framingham, MA looking at cardiac risk and what we can do--modifiable & non-modif. risk factors
- 5,209 subjects (mean age 47) & offsprings
- Established the CV risk profile! Assessment: PsychosocialAsk about... | Occupation? | Insurance? | Support system? | Pets at home? | Hobbies that may help? |
* Patients won't get better if they're stressed! | | Assessment: Modifiable & Non-Modif. Risk FactorsMODIFIABLE RISK FACTORS | Age: symptoms start by 40yo, unlikely to survive MI if <30yo b/c collateral circulation | Ethnicity: more prevalent in non-Hispanics, death rate higher in African Amer. (HTN) | Heredity: HTN, inc. lipids, DM, obesity | Gender: men > women until menopause, childbearing women have 25% chance, women >40yo & after menopause > men (r/t heart size & collateral circulation) | NON-MODIFIABLE RISK FACTORS | BP: biggest problem = insidious - take meds if needed | HLD: goals - total cholesterol < 200; HDL > 50, LDL < 70 - take meds if needed | Smoking: temp of vape = hyperplasia, asthma-like symptoms; causes 21% of CVD deaths; carcinogenic; inc. epic & norepi = heart works harder, vasoconstriction & dec. circulation, C monoxide = inc. vessel perm. | DM: r/t early atherosclerosis, inc. thickening of blood | Physical Inactivity: "new smoking", exercise inc. collateral circulation | Obesity: extra burden on heart | Personal Factors: stress, psych. response |
Collateral circulation: inc. angiogenesis; adding vessels to supply cardiac circulation
Obese: BMI >30 / Morbid Obese: BMI >45
Super Morbid Obese: BMI >65 | | Assessment: Subjective & Objective DataSUBJECTIVE DATA (History of Symptoms) | Chest Pain: (activity w/) onset? location? severity? type? precipitating factors? other Sx? may c/o nausea, indigestion
- Causes: cardiac (myocardial), pulm., m/s | Dyspnea or SOB: often assoc. w/ left side heart pain, dec. perfusion, orthopnic | Palpitations: usually PAC, c/o rapid HR = dec. EF & CO (caffeine) | Fatigue: mild to severe, may attribute to getting older (compare to daily activity) | Extremity Pain: arm (may be R), jaw | Syncope: if issue w/ CO | Weight Gain: fluid, daily wt, anasarca | OBJECTIVE DATA | General Appearance: AAOx3?, posture
- Restlessness assoc. w/ change in O2 | Vital Signs: BP? HTN < 130/80, check BP bilat., may see a paradoxical change in BP | Heart Sounds: S1, S2; may hear S3 & S4, murmurs, clicks | Cyanosis & JVD: pallor; JVD = R-sided HF (cor pulmonale), seen w/ OSA; = give Lasix |
Subjective Data: Ask for chief complaint (usually CP), PMH, current health
- Dehydrated = lose H20 & electrolytes
Objective Data:
Pulse Pressure: SBP - DBP; normally 30-40
- Closer (~20): r/t vasc. resistance = dec. CO & SV
- Widened (~40): r/t slow HR, atherosclerosis, inc. w/ age Diagnostic StudiesSERUM CARDIAC ENZYMES (SERUM MARKERS) OR CARDIAC BIOMARKERS | Troponin: GOLD STANDARD OF CP; appears 2-4 hr after damage to myocardial muscle, inc. further depending on damage | CK-MB: r/t cardiac muscle; detected 2-4 hr after damage, elevated 72 hr max | CK-MM: r/t skeletal muscle | CK-BB: r/t brain tissue | Myoglobin: byproduct of muscle breakdown, appears in 2-4 hr, then dec.; affects kidneys; rhabdomyolysis | BNP: r/t stretch of heart; correlates + w/ HF; secreted by ventricles r/t stress | CRP: non-specific inflammatory marker; correlates + w/ atherosclerosis; good for determining severity of disease process | Myeloperoxidase: leukocyte enzyme r/t plaque instability and enzyme production | Ischemia Modified Albumin: circulating albumin touches ischemic tissues | Homocysteine: get from eating meat (in amino acids), linked to disease development | Serum Lipids: correlates + w/ intravascular plaques | COAGULATION STUDIES | Unfractionated Heparin: if elevated, give protamine sulfate | APTT | PT/INR: if elevated, give vitamin K |
Why do coagulation studies? To know if pt is anti-coagulated in case of procedure
Antidotes
* Coumadin = vitamin K
* Many newer generation anti-coagulants don't have antidotes! = Give cryoprecipitate More Diagnostic StudiesOTHER | EKG | shows issues r/t heart rhythm; 12-lead EKG w/ age 40yo+ | Telemetry | continuously monitoring EKG, ambulatory | Holter Monitor | ambulatory type, pt takes it home & writes down what they do to compare it to the rhythm | X-Ray | shows enlargement, fluid; pulmonary edema r/t CHF? | STRESS, NUCLEAR, & ULTRASOUND TESTS | Exercise Stress Test | look at BP and HR w/ inc. exercise and inc. myocardial O2 demand | Nuclear Perfusion Imaging | stress test & blood flow through the heart | Echocardiogram | shows wall movement, overall ventilatory performance; can tell how badly heart was damaged | TTE | 2-D | TEE | 3-D (better) |
Serum Electrolytes & the HeartK | biggest electrolyte r/t heart | | | Hypokalemia: inc. electrical instability, a fib, digoxin toxicity | | | Hyperkalemia: P-wave issues, bradycardia, asystole, ventricle issues; give Kayexalate, insulin (IVP 10 units) + D50; give Lasix | Na | r/t CHF | | | Hyponatremia | | | Hypernatremia | Ca | Hypocalcemia | | | Hypercalcemia | Mg | Hypomagnesemia | | | Hypermagnesemia | P | Hypophosphatemia | | | Hyperphosphatemia |
Insulin: K follows glucose into cells |
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