CARDIOLOGY & EKGS

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ANATOMY & PHYSIOLOGY
BLOOD FLOW THROUGH THE HEART
HEMODYNAMICS
● Preload
○ Amount of blood returning to right side of the heart
● Afterload
○ Pressure against which the left ventricle must pump to eject blood
● Compliance
○ How easily the heart muscle expands when filled with blood
● Contractility
○ Strength of contraction of the heart muscle
● Stroke volume
○ Volume of blood pumped out of the ventricles with each contraction
● Cardiac output
○ The amount of blood the heart pumps through the circulatory system in a minute
CARDIAC OUTPUT
WHY is cardiac output SO important?!

● Tissue perfusion!
● End organ function
● Delivery of oxygen and nutrients to each and every cell in the body!
● Poor cardiac output??
○ Decreased LOC (not enough blood flow to the BRAIN)
○ Chest pain, weak peripheral pulses (not enough blood flow to the HEART)
○ SOB, crackles, rales (not enough blood flow to the LUNGS)
○ Cool, clammy, mottled extremities (not enough blood flow to the SKIN)
○ Decreased UOP (not enough blood flow to the KIDNEYS)

CO = SV X HR
 CAUSES OF CAUSES OF
DECREASED CO INCREASED CO
● Bradycardia
● Arrhythmias ● Increased blood volume...sometimes
○ Pulseless v-tach ● Tachycardia...sometimes
○ V-fib ● Medications
○ Asystole ○ ACE Inhibitors
○ SVT ○ ARBS
● Hypotension ○ Nitrates
● MI ● Inotropes
● Cardiac muscle disease
 EKG

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 P-wave: normal
PR Interval: 0.12-0.20
QRS: <0.12
Rate: 60-100
Regularity: Regular

Normal Sinus Rhythm

 P-wave: Normal Causes:
PR Interval: 0.12-0.20 -Sleep
QRS: <0.12 -Inactivity
Rate: <60 -Very athletic
Regularity: Regular -Drugs
-MI

Sinus Bradycardia
 P-wave: Normal Causes:
PR Interval: 0.12-0.20 -Caffeine
QRS: <0.12 -Exercise
Rate: >100 -Fever
Regularity: Regular -Anxiety
-Drugs
-Pain
Sinus Tachycardia -Hypotension
-Volume depletion
 P-wave: “saw-tooth” Causes:
PR Interval: none -Heart disease
QRS: <0.12 -MI
Rate: 250-400 -CHF
Regularity: Regular or -Pericarditis
Irregular

Atrial Flutter
 P-wave: ‘wavy’ Causes:
PR Interval: none -Heart Disease
QRS: <0.12 -Pulmonary Disease
Rate: >400 -Stress
Regularity: irregular -Alcohol
-Caffeine

Atrial Fibrillation
 P-wave: hidden Causes:
PR Interval: -Caffeine
immeasurable -CHF
QRS: <0.12 -Fatigue
Rate: 150-250 -Hypoxia
Regularity: Regular -Altered pacemaker in heart

Supraventricular Tachycardia (SVT)

 Causes:
P-wave: none -MI
PR Interval: none -Ischemia
QRS: >0.11 - ‘wide -Digoxin toxicity
complex & bizarre’ -Hypoxia
Rate: 150-250 -Acidosis
Regularity: Regular -Hypokalemia
-Hypotension
Ventricular Tachycardia (V-Tach)
 Causes:
-MI
P-wave: none
-Ischemia
PR Interval: none
-Hypoxia
QRS: none
-Acidosis
Rate: none
-Hypokalemia
Regularity: Irregular
-Hypotension
-Most common cause of sudden
death
Ventricular Fibrillation (V-fib)
 P-wave: possible to Causes:
have some random p- -Follows VT/VF in cardiac
waves arrest
PR Interval: none -Acidosis
QRS: none -Hypoxia
Rate: none -Hypokalemia
Regularity: n/a -Hypothermia

Asystole -Overdose
CORONARY ARTERY DISEASE
(CAD)
WHAT IS CORONARY ARTERY DISEASE?
● The most common type of cardiovascular disease.
● Includes two types
○ Chronic stable angina
○ Acute coronary syndrome (aka MI)
CHRONIC STABLE ANGINA
● Chronic disease caused by narrowing of coronary
arteries and plaque build up.
● There are periods of decreased blood flow to the
heart muscle
● Decreased blood flow leads to decreased oxygen,
and ischemia.
● Ischemia causes chest pain
TREATMENT
● Nitroglycerin
○ Venous and arterial dilation → decreased afterload → increased CO
○ Given sublingual
○ Administer 1 pill q5 minutes for 3 doses
○ Do not swallow
○ Keep in a dark bottle in dry, cool place
○ Expected side effect = headache
EDUCATION
● DECREASE THE WORKLOAD OF THE HEART!
○ Rest
○ Do not overeat
○ No caffeine
○ Avoid temperature extremes
○ No smoking
○ Promote weight loss
○ Reduce stress
MYOCARDIAL INFARCTION
(MI)
WHAT IS A MYOCARDIAL INFARCTION
Myocardial infarction = acute coronary syndrome = unstable angina

● There is decreased blood flow to the heart, leading to decreased oxygen, and not only ischemia, but also
necrosis.
● Goal is to act quickly and limit the damage.
ASSESSMENT
● Chest pain
○ Crushing
○ Radiating to left arm or jaw
○ Between shoulder blades
● Epigastric discomfort/indigestion
● Fatigue
● SOB
● Vomiting
LABS
● CPK-MB
○ Cardiac specific isoenzyme
○ Increases with damage to cardiac cells
● Troponin
○ Cardiac biomarker
○ Increases with myocardial damage
● Myoglobin
○ Protein in muscle cells
○ Increases with damage to ANY muscle cell
○ Negative results can help rule out an MI, but positive results are not specific.
TREATMENT
● Cath lab within 90 minutes for PCI
○ Especially important if it’s a STEMI!
● Oxygen
● Aspirin
● Nitroglycerin
● Morphine
EDUCATION
● Quit smoking
● Increase activity gradually
● Diet
○ Low fat
○ Low salt
○ Low cholesterol
● Exercise
○ Avoid isometric exercises
○ Walking is a good choice
HEART FAILURE
WHAT IS HEART FAILURE?
The inability of the heart muscle to pump enough blood to meet the body's needs for blood and oxygen.

● Often results as a complication of other diseases

● #1 cause of HF is hypertension
● Other causes:
○ Cardiomyopathy
○ Endocarditis
○ MI
● Two types: Left and Right
LEFT-SIDED HEART FAILURE
Left side of the heart cannot move blood forward to the body.

Blood is backing up in the LUNGS.

Assessment:

● Pulmonary congestion
● Wet lung sounds
● Dyspnea
● Cough
● Blood tinged sputum
● S3
● Orthopnea
RIGHT HEART FAILURE
Right side of the heart cannot move blood forward to the lungs.

Blood is backing up in the BODY.

Assessment:

● Jugular venous distention

● Dependent edema
● Hepatomegaly
● Splenomegaly
● Ascites
● Weight gain
● Fatigue
● Anorexia
TREATMENT
● DECREASE THE WORKLOAD OF THE HEART!
● Primary strategy is to decrease afterload:
○ ACE Inhibitors
■ Arterial dilation→ decreased afterload → Increased stroke volume
○ ARBS
■ Decrease BP → decreased afterload → Increased CO
● Increase contractility
○ Digoxin
● Diuresis
○ Pt needs help reducing excess fluid
EDUCATION
● Take diuretic medications in the AM
● Monitor electrolyte levels while on diuretics
● Low sodium diet
○ This helps decrease fluid
● Elevate the HOB
○ Will help with diuresis
● Daily weight
○ Same time
○ Same scale
○ Same clothes
● Report any increase of 2-3 lbs in one day
HYPERTENSION
WHAT IS HYPERTENSION?
High blood pressure!

Normal <120/80
Elevated 120-129/80
Hypertension >130/>80
Hypertensive Crisis >180/>120
CAUSES & RISK FACTORS
● Family history
● African american race
● Increased age
● Obesity
● HLD
● CAD
● Stress
● Smoking
● High salt intake
● Caffeine
ASSESSMENT
● Often asymptomatic until very severe
● Vision changes
● Headaches
● Dizziness
● Nosebleeds
● SOB
● Angina
COMPLICATIONS
● Stroke
● MI
● Renal Failure
● Heart Failure
● Vision loss
TREATMENT & EDUCATION
● Medications
○ ACE inhibitors
○ Beta Blockers
○ CCB
○ Diuretics
● Diet
○ DASH
○ Low salt
○ Avoid caffeine and alcohol
○ Weight loss
○ Smoking cessation
● Lifestyle
○ Less sitting more walking
SHOCK
WHAT IS SHOCK??
● A state where the vital organs are not receiving adequate oxygenation.
● This lack of oxygenation causes organ damage and forces the cells to use anaerobic metabolism to create
energy….producing lactate.

● Cardiovascular system is composed of:

○ The blood
○ The vasculature
○ The heart
● A disruption in any of these three components can cause a lack of oxygen delivery to the organs, causing shock.
● Which component is ‘broken’ determines the type of shock.
 Hypovolemic
TYPES OF SHOCK Cardiogenic
Distributive
HYPOVOLEMIC SHOCK
PATHOPHYSIOLOGY
● Low blood flow
● There is a loss of the circulating volume
● Not enough blood to enter the heart (preload), which
decreases cardiac output.
● The body will vasoconstrict to compensate.
CAUSES
● Hemorrhage
● Traumatic injury
● Dehydration
○ Vomiting
○ Diarrhea
● Burns
ASSESSMENT
● Compensation
○ Weak
○ Pale
○ Tachycardic
○ Anxious
● Failing
○ Hypotension
○ Weak pulses
○ Tachycardic
○ Decreased LOC
○ Pale
○ Cool
○ Clammy
○ Decreased UOP
TREATMENT
● Fix the cause
○ Stop vomiting/diarrhea
○ Stop bleeding
■ Repair in OR
● Replace volume
○ Isotonic IVF
■ NS
■ LR
○ Blood products
● Support perfusion
○ Vasopressors
CARDIOGENIC SHOCK
PATHOPHYSIOLOGY
● The heart fails to pump sufficient blood out to the organs
● “Pump failure”
● Something is stopping the heart itself from getting blood out to the body
● Without sufficient blood delivered to the body, there is inadequate oxygenation
● Lack of oxygen impairs normal cellular metabolism
CAUSES
● MI
● Cardiac tamponade
● Pulmonary embolism
ASSESSMENT
● Decreased perfusion
○ Hypotension
○ Weak pulses
○ Cool, pale, clammy
○ Decreased UOP
○ Decreased LOC
● Volume overload
○ JVD
○ Crackles
○ SOB
○ Muffled heart sounds
○ S3
TREATMENT
● TREAT THE CAUSE ● IABP
○ MI ● LVAD
■ PCI ● Transplant
■ CABG
○ PE
■ Thrombolytics
○ Tamponade
■ Pericardiocentesis
● Improve contractility
○ Dopamine
○ Dobutamine
● Decrease afterload
○ Diuretics
○ Dobutamine
DISTRIBUTIVE SHOCK
PATHOPHYSIOLOGY
● Something causes an immune or autonomic response in the body
● This alters vascular tone
● The result is massive peripheral vasodilation
● With so much vasodilation, the blood pressure is inadequate to provide blood flow to the vital organs.
● Without sufficient blood delivered to the body, there is inadequate oxygenation
● Lack of oxygen impairs normal cellular metabolism
CAUSES
● Anaphylactic
○ Allergic reaction
● Neurogenic
○ SCI
● Septic
○ Systemic infection
○ Causes release of inflammatory cytokines
ASSESSMENT
Specific:
● Decreased oxygen
● Hypotension ● Anaphylactic
● Tachycardia ○ Hives
● Tachypnea ○ Rash
● Warm, flushed skin ○ Swelling
● Decreased LOC ○ Wheezing
● Neurogenic
○ SCI
○ Priapism
● Septic
○ Hyperthermic
○ Infection
TREATMENT
● Anaphylactic
○ Epinephrine
○ Corticosteroids
○ Bronchodilators
● Neurogenic
○ Cooling
○ Supportive care
● Septic
○ IV antibiotics
○ IVF