Physiological Changes with Age
Cardiac 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: Psychosocial
Ask about... |
Occupation? |
Insurance? |
Support system? |
Pets at home? |
Hobbies that may help? |
* Patients won't get better if they're stressed!
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Assessment: Modifiable & Non-Modif. Risk Factors
MODIFIABLE 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
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Assessment: Subjective & Objective Data
SUBJECTIVE 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 Studies
SERUM 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 Studies
OTHER |
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 Heart
K |
biggest electrolyte r/t heart |
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Hypokalemia: inc. electrical instability, a fib, digoxin toxicity |
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Hyperkalemia: P-wave issues, bradycardia, asystole, ventricle issues; give Kayexalate, insulin (IVP 10 units) + D50; give Lasix |
Na |
r/t CHF |
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Hyponatremia |
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Hypernatremia |
Ca |
Hypocalcemia |
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Hypercalcemia |
Mg |
Hypomagnesemia |
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Hypermagnesemia |
P |
Hypophosphatemia |
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Hyperphosphatemia |
Insulin: K follows glucose into cells
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You have modifiable & nonmodifiable risk factors switched around
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