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Pt Management & Problems of the CV System - Part 2 Cheat Sheet by

Cardiac Cathet­eri­zation

What is the purpose?
The most definitive way to identify and diagnose CVD
Can determine if any vessels are blocked, congenital issues, CAD, blood flow issues, valve issues, oxygen­ation
May use US at the same time
Con: expensive
Pre-Pr­ocedure
Treat like surgery--cannot do without consent for cath AND heart surgery
Use dye to see how blood perfuses through the arteries
Ask person to cough = changes intrat­horacic pressure (helps to move dye
Give fluid (dye is dehydr­ating & damages kidneys)
Post-P­roc­edure
Less limitation w/ radial, lay flat
Femoral: check pulses & mark w/ X's, make sure same strength
Biggest compli­cation: arrhyt­hmias, bleeding (check all around wrist/leg, every time heart is accessed = inc. risk for a fib)
Pay close attention! High risk for problems!
If pt is allergic to dye: give Benadryl (anti-­his­tam­ine), Tylenol (anti-­pyr­etic), Hydroc­ort­isone (steroid)

L- vs. R-Sided Cardiac Cath

R-Sided Cath: inc. risk for PE or vagal nerve (= pass out)
L-Sided Cath: inc. risk for MI
Both: inc. risk for cardiac tamponade
Cardiac Tamponade: perica­rdial sac fills w/ blood = inc. pressure on heart

Mean Arterial Pressure (MAP)

Systolic BP + [ (2 x Diastolic BP) / 3 ]
Example: 125/75
125 + [ (2 x 75) / 3]
MAP = 92 mm Hg
MAP must be at least 60+ (60-70 mm Hg) for adequate coronary pressure!

Monitoring

Hemody­namic Monitoring: used to look at pressure in the heart
- Pt must lie flat to zero out the heart
Invasive vs. Non-In­vasive
Central Venous Pressure (CVP): R atrial pressure; mirrors fluid status in the body
Arterial Lines: accurately monitor BP & MAP; may be radial, brachial
Pulmonary Artery Catheter: R artium to R ventricle to pulmonary arteries
- Can compare R and L side pressures
- Example: SWAN catheter

Allen's Test

1. Hold both arteries. (Hand blanches white.)
2. Open hand and release ulnar artery. (Hand should pink up.)
Pink hand = safe to use

Diagnostic Studies

Electr­oph­ysi­ology Studies (EPS): looks at intrac­ardiac conduction system
- Identify arrythmias
- Differ­entiate between arryth­mias, if person needs pacema­ker­/ICD, are meds effective = may need to take for surgery
PET Scan: compares cardiac perfusion & metabolic functions
- If mismatched = ischemia
MRI/MRA: may use dye & do angiog­raphy at the same time
Electr­oni­c-Beam Tomography: similar to CT scan but more for the heart

Disorders of Myocardial Perfusion

Coronary Artery Disease: ACS & athero­scl­erosis
Acute Coronary Syndrome (ACS): results from fibrous tissue & plaque accumu­lation
1. Unstable angina
2. NSTEMI
3. STEMI
Athero­scl­erosis: often takes years
- Response to injury theory: fatty streaks fibrous plaques plaques rupture & form thrombus inflam­matory cells (clot forms on plaque & clot breaks free)
 

Angina

Causes: myocardial ischemia (dec. supply & inc. demand), aortic stenosis, cardio­myo­pathies
Assessment: pain, onset, duration, severity
Types:
- Stable: at expected time (ex: w/ exercise)
- Unstable: pain "for no reason­", no predic­table pattern; indicates major coronary event
- Nocturnal Angina: wake up in the middle of the night
Diagnosis: get an EKG, change in ST segment = something going on
* CHEW an aspirin
Pharma­col­ogical Interv­entions:
- Aspirin (dec. platelet aggreg­ation)
- Nitrat­es/­ant­i-a­nginals (coronary vasodi­lators, not selective for cardiac vessels (= MASSIVE HA, pass out = wear gloves!)
- Beta-b­lockers (dec. HR = dec. O2 demand, open blood vessels = inc. circul­ation)
- Statins (dec. plaque buildup)
- CCB (dec. heart contra­ctility [of smooth muscles in arteries = vasodi­late] & O2 demand)
- ACEI (help to vasodilate = dec. BP = dec. afterload & makes it easier for heart to work)
BIGGEST CONCERN = pain relief inc. O2 demand and perfusion
Lifestyle Changes:
- Diet: no smoking, healthy diet (dec. sat fat & processed foods), control choles­terol
- Exercise
- Lipids: control & check levels
- Weight: lose if possible
- Comorb­idities: control them!
- Other: avoid stress (= inc. plaque, constricts blood flow)

Myocardial Infarction (MI)

Assessment: CP unreli­eve­d/u­nre­len­ting, nausea, dyspnea
- Not everyone gets arm/jaw pain
Diagnosis: EKG! (ST-seg changes) & inc. enzymes (trop, CK-MB, others; WBC r/t inflam­mation)
Severity depends on which vessel is blocked
STEMI: complete occlusion of a major vessel w/ full thickness damage
- Inc. risk for compli­cations
- 10-15% mortality rate during admission
1. Inc. enzymes
2. Inc.
3. Inc. risk of compli­cations
Non-STEMI: complete occlusion of a minor coronary artery OR partial occlusion of a major coronary artery
- Mortality rate = 3-5%
- Happens more w/ vasospasm
Troponin level correlates to damage!
Heart Zones
- Zone of ischemia: T-wave inversion - can come back
- Zone of injury: ST elevation
- Zone of necrosis: abnormal Q = never coming back

Surgical MI Interv­entions

Coronary Artery Bypass Graft (CABG)
1. On-Pump: put pt on bypass machine, reoxyg­enate blood and return to body
- Heart stopped = inc. risk for compli­cations (bleeding, stroke, etc.)
2. Off-Pump: risks w/ beating heart
Venous graft & placement: mammary vessels are best, preferred for off-pump
Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)
- Dec. healing time
- Dec. time in critical care
- Off-pump procedure

MI Interv­entions

Revasc­ula­riz­ation: first choice treatment
Percut­aneous Coronary Interv­ention (PCI): invasive; a catheter is placed in a coronary artery to remove a blockage
- Includes: balloon angioplasy, athere­ctomy
- Revasc­ularize & reoxyg­enate
- Want to do ASAP for STEMI
- May treat NSTEMI a bit more medically
Percut­aneous Transl­uminal Coronary Angiop­lasty (PCTA): inflated balloon compresses plaque against artery walls
- May need to premed­itate for allergies
- May bleed
- May have MI (dislodge clots)
- May worsen kidney problems
- May have a fib, V-tach
Athere­ctomy
Stent: a metal cage holding plaque against the vessel
- Not a permanent fix, must change lifestyle
- Various types
Thromb­olytic Therapy: used w/ pt contra­ind­icated for surgery
- Want to give within 12 hr
- Tissue plasmi­nogen activator (TPA)
- Worry about hemorr­hagic strokes - will cause bleeding = carefully monitored
Laser: burns out plaque
- Next choice if can't do within minutes
Transm­yoc­ardial Laser
Intra-­Aortic Balloon Catheter: artificial L ventricle; can pump blood
- Inc. contra­­ct­ility of heart & workload by pumping for heart
- MI: balloon can pump and heart can rest
- In sync w/ conduction system
- Frequently check and compare pulses
- Comp­l­ic­­ati­­ons: dissected aorta, plaques can break if in aorta, ________, can burst
 

Pharma­col­ogical Interv­entions

Hepari­n/C­oumadin (prevent clot formation)
Nitrates (inc. circul­ation, area well-p­erf­used)
Narcotics (morphine - dec. O2 demand and pain control)
Adjunct meds: Beta-b­lockers,ACEI, statins
Oxygen (Always; issue of supply & demand)

Post-Op Care

Highest risk for...
Dec. CO
Pulmonary edema
Dysrhy­thmias
Perica­rditis
Cardio­genic shock
Cardiac tamponade
CHF

Post-Op Assess­ments

(BOLT Handout)
Pacer wires connected just in case
Cardiac Tamponade: change in HR & BP; filling of perica­rdial sac with blood/­fluid
- BIGGEST RISK!
Beck's Triad =
1. Muffled heart sounds
2. JVD w/ neck assessment
3. Hypote­nsion (can't effect­ively contract)
After 6 hr, lines pulled and extubated

Post-Op Evaluation

Improved tissue perfusion
Pain diminished or absent
Anxiet­y/fear diminished
Cardiac Rehab:
Phase 1 - in hospital, walk w/ telemetry
Phase 2 - D/C to rehab exercise program
Phase 3 - Follow-up & continue w/ exercise
               
 

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