CARDIAC TERMS
CARDIAC OUTPUT (CO)
↓ CO = ↓ perfusion to the body
Total volume pumped per minute
• ↓ LOC
•
• Shortness of breath
• Skin will be cold & clammy
• ↓ UOP
• Weak peripheral pulses
Normal 4 - 8 L/min
Less volume = ↓ CO
More volume = ↑ CO
CO = HR x Stroke Volume
Cardiac
Output
Heart
Rate
STROKE VOLUME
CONTRACTILITY
Amount of blood pumped
out of the ventricle with
each beat or contraction
Force / strength
of contraction of
the heart muscle
EJECTION FRACTION (EF)
% of blood expelled from the left
ventricle with every contraction
Normal EF: 50 - 70%
EXAMPLE:
If the EF is 55%, the heart is pumping out
55% of what’s inside of the left ventricle
PRELOAD
AFTERLOAD
Amount of blood returned to
the right side of the heart at
the end of diastole
Pressure that the left ventricle has to pump against
(the resistance it must overcome to circulate blood)
Clinically measured by systolic blood pressure!
Hemodynamic Parameters
Cardiac output
(CO)
Total volume pumped per minute
Cardiac Index
Cardiac output per body surface area
Central Venous Pressure
Pressure in the superior vena cava.
Shows how much pressure from the
blood is returned to the right atrium
from the superior vena cava.
(CI)
(CVP)
Mean Arterial Pressure
CI =
CO
surface area
(MAP)
Average pressure in the systemic circulation
(your body) through the cardiac cycle
Systemic Vascular resistance
The resistance it takes to push
blood through the circulatory
(SVR)
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Normal 4 - 8 L/min
2.5 – 4.0 L/min/m2
2 – 8 mmHg
70 – 100 mmHg
At least 60 mm Hg is require to
adequately perfuse the vital organs
800 – 1200 dynes/sec/cm
101
FLOW OF BLOOD THROUGH THE HEART
RIGHT SIDE
LEFT SIDE
Deoxygenated Blood
Oxygenated Blood
Carries oxygen poor
blood from the body
back to the right side of
the heart
Oxygenated blood
from the lungs
1. Superior / Inferior Vena Cava
7. Pulmonary Vein
2. Right Atrium
8. Left Atrium
3. Tricuspid Valve
9. Bicuspid / Mitral Valve
4. Right Ventricle
10. Left Ventricle
5. Pulmonic Valve
11. Aortic Valve
6. Pulmonary Artery
12. Aorta
Deoxygenated blood
to the lungs
Oxygenated blood
to the body
VASCULAR SYSTEM FACTS
ARTERIES - Carry oxygenated blood to tissues → (think Away from the heart)
VEINS - Carry deoxgenated blood back to the heart
Electrical Conduction of the Heart
MNEMONIC
Send
A
Big
Bounding
Pulse
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SA Node
↓
AV Node
↓
Bundle of His
↓
Bundle Branches
↓
Purkinje Fibers
102
AUSCULTATING HEART SOUNDS
5 Areas for Listening to the Heart
All People Enjoy Time Magazine
Aortic
Right 2nd intercostal space
Pulmonic
Left 2nd intercostal Space
ERB’s Point
(S1, S2) Left 3rd intercostal space
Tricuspid
Lower left sternal border 4th intercostal
Mitral
Left 5th intercostal, medial to midclavicular line
TIP
NORMAL
Tricuspid & mitral valve closure
S2
Aortic & pulmonic valve closure
LUB
↓
Closing of the valves
Valve opening does not
normally produce a sound
S3
Early Diastole in rapid ventricle filling
S4
Late Diastole & high atrial pressure
(forcing blood into a stiff ventricle)
↓
SYSTOLE: Ventricle pump / ejection = LUB (S1)
DIASTOLE:
M
S1
DUB
ABNORMAL
M
DUB (S2)
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ry
Memo
Trick
Extra
q sounds
“COZY RED”
CO (contract) ZY (systole)
RE (relax) D (diastole)
103
EKG WAVEFORMS
SIGNS & SYMPTOMS
PQRST
P
Atrial contraction (squeeze)
DE-polarization
DE-compressing
QRS
Ventricle contraction (squeeze)
DE-polarization
P
COMPLEX DE-compressing
T
T
Ventricles
RE-laxing
RE-polarizing
PR INTERVAL
QRS
ST SEGMENT
Movement of electrical
Time between ventricular deactivity from atria to ventricles polarization and repolarization
(ventricular contraction)
QT INTERVAL
Time take from ventricles
to depolarize, contract,
and repolarize
5-LEAD PLACEMENT
WHITE ON RIGHT
RA
CHOCOLATE
IN MY HEART
GREEN GOES LAST
la
SMOKE OVER...
v
rl
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ll
FIRE
104
6 STEPS TO INTERPRETING EKG’S
BASIC RHYTHMS
#1 P WAVE
NORMAL SINUS 60 - 100 bpm
SINUS TACHYCARDIA > 100 bpm
SINUS BRADYCARDIA < 60 bpm
Identify & examine the P waves
• Should be present & upright
• Comes before QRS complex
• One P wave for every QRS complex
#2 PR INTERVAL
Measure PR interval
#3 QRS WAVE
Is every P wave
followed by a
QRS complex?
1 sec.
Normal PR interval:
0.12 - 0.2 seconds
Normal QRS complex:
0.06 - 012
0.04
sec.
• Should not be widened or shortened W
iden is ofte
n
– this may indicate problems!
seen in PV
C’s,
Electrolyte
imbalances
#4 R-R
0.20 sec.
1 large box = 0.20 seconds
5 large boxes = 1 second
Are the R to R intervals consistent
1 small box = 0.04 seconds
• Regular or irregular?
#5 DETERMINE THE HEART RATE
6 SECOND METHOD
Be sure
and chec
k th
the strip
is 6 seco at
nds!
Count th
e boxes
Count the number of R’s in between
the 6 second strips & multiply by 10
BIG BOX METHOD
300 divided by the number
of big boxes between 2 R’s
1 2 3 4 5
6 R’s X 10 = 60 beats per minutes
300 / 5 = 60 BPM
#6 IDENTIFY THE EKG FINDING!
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105
EKG’S
NORMAL SINUS RHYTHM
RATE
RHYTHM
P WAVE
PR INTERVAL
QRS COMPLEX
60 - 100 bpm
Regular
Upright & uniform before each QRS
Normal
R
Normal
T
P
QS
SINUS BRADY
KEY
The sinus node creates an impulse
at a slower-than-normal rate
RATE
RHYTHM
P WAVE
PR INTERVAL
QRS COMPLEX
< 60 bpm
Regular
Upright & uniform before each QRS
Normal
Normal
CAUSES
TREATMENT
q Lower metabolic needs
• Sleep, athletic training, hypothyroidism
q Correct the underlying cause!
q Vagal stimulation
q Medications
• Calcium channel blockers, beta blockers, Amiodarone
q
↑ the heart rate to normal
SINUS TACHY
KEY
The sinus node creates an impulse
at a faster-than-normal rate
RATE
RHYTHM
P WAVE
PR INTERVAL
QRS COMPLEX
> 100 bpm
Regular
Upright & uniform before each QRS
Normal
Normal
CAUSES
TREATMENT
q Physiologic or psychological stress
• Blood loss, fever, exercise, dehydration
q Identify the underlying cause!
q Certain medications
• Stimulants - caffeine, nicotine
• Illict drugs - cocaine, amphetamines
• Stimulate sympathetic response - epinephrine
q
↓ the heart rate to normal
q Heart failure
q Cardiac tamponade
q Hyperthyroidism
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106
EKG’S
VENTRICULAR TACHYCARDIA (VT)
ick:
Memory tr
e
lik
s
ok
lo
s
tombstone
RATE
RHYTHM
P WAVE
PR INTERVAL
QRS COMPLEX
100 - 250 bpm
Regular
Not visible
None
Wide (like tombstones) > 0.12 seconds
Irregular, coarse waveforms of different
shapes. The ventricles are quivering
and there is no contractions or cardiac
output which may be fatal!
CAUSES
MANIFESTATIONS
q Myocardial ischemia / infarction
q
q Electrolyte imbalances
q Digoxin toxicity
q Stimulants: caffeine & methamphetamines
q
q
q
q
Chest pain
Lethargy
Anxiety
Syncope
q Palpitations
No Card
iac Outp
=
Low Oxy
g
ut
en
TREATMENT
UNSTABLE CLIENTS
WITHOUT A PULSE
STABLE CLIENT
WITH A PULSE
Also called PULSLESS V-TACH
q Oxygen
q Antidysrhythmics (ex. Amiodarone...stabilizes
the rhythm)
q Synchronized Cardioversion
• Synchronized administration of shock
(delivery in sync with the QRS wave).
q CPR
q
q Possible intubation
q Drug therapy
SHOCK!
• Epinephrine, vasopressin, amiodarone
• Cardioversion is NOT defibrillation!
(defibrillation is only given with deadly
rhythms!)
UNTREATED VT CAN LEAD TO
↓
VENTRICULAR FIBRILLATION
↓
DEATH
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107
EKG’S
VENTRICULAR FIBRILLATION (V-FIB)
Rapid, disorganized pattern of electrical activity
in the ventricle in which electrical impulses
arise from many different foci!
RATE
RHYTHM
P WAVE
PR INTERVAL
QRS COMPLEX
Unknown
Chaotic & irregular
Not visible
Not visible
Not visible
CAUSES
MANIFESTATIONS
q Cardiac injury
q Loss of consciousness
q Medication toxicity
q May not have a pulse or blood pressure
q Electrolyte imbalances
q Respirations have stopped
q Untreated ventricular tachycardia
q Cardiac arrest & death!
No Card
Outputiac
no Ox
to the ybgen
ody
=
TREATMENT
q CPR
q Drug Therapy
• Vasoconstriction: Epinephrine
q Oxygen
q Defib (follow ACLS protocol for
defibrillation)
q Possible intubation
TIP
• Antiarrhythmic: Amoidaraon, lidocaine
• Possibly magnesium
“Defib the Vfib”
Cardioversion vs. Defibrillation
CARDIOVERSION
DEFIBRILLATION
q Synchronized shock
q Asynchronous
q Lower amount of energy
q Higher amount of energy
q Not done with CPR
q Resume CPR after shock
q Stable clients
q Unstable clients
q Ex. A-fib
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KEY
q Example: pulseless VT or VF
108
EKG’S
ATRIAL FIBRILLATION (A-FIB)
irregular r-r intervals
↓↓ ↓ ↓ ↓
RATE
RHYTHM
P WAVE
PR INTERVAL
QRS COMPLEX
Usually over 100 BPM
Irregular
Visible
Normal
Uncoordinated electrical activity in the atria
of the muscles in the atrium.
The atri
a is
quiverin
g!
CAUSES
MANIFESTATIONS
q Open heart surgery
q Most commonly asymptomatic
q Heart failure
q Fatigue
q COPD
q Malaise
q Hypertension
q Dizziness
q Ischemic heart disease
q Shortness of breath
q Tachycardia
All due
to
low 02
q Anxiety
q Palpitations
TREATMENT
STABLE PT.
UNSTABLE PT.
q Oxygen
q Oxygen
q Drug therapy!
q Cardioversion
• Synchronized administration of shock
(delivery in sync with the QRS wave).
• Beta blockers
• Calcium channel blockers
• Digoxin
• Amiodarone
defibrillation
• Anticoagulant therapy
to prevent clots
Risk for clots!
Defibrillation is only given
with deadly rhythms!
The atria quiver causes pooling
of blood in the heart which increases
the risk for clots = increased risk for
MI, PE, CVA’s, & DVTs!
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109
EKG’S
PREMATURE VENTRICULAR CONTRACTIONS (PVCS)
RATE Depends on the underlying rhythm
RHYTHM Regular but interrupted due to early P waves
P WAVE Visible but depends on timing of PVC
(may be hidden)
PVC
PR INTERVAL Slower than normal but still 0.12 - 0.20 seconds
QRS COMPLEX Sharp, bizarre, and abnormal during the PVC
Early “premature” conduction of a QRS complex
CAUSES
BIGEMINY: every other beat
TRIGEMINY: every 3rd beat
QUADRAGEMINY: every 4th beat
q Heart failure
q Myocardial ischemia / infarction
q Drug toxicity
q Caffeine, tobacco, alcohol
q Stress or Pain
Exercise
Fever
Hypervolemia
Heart failure
Tachycardia
R-ON-T PHENOMENON: PVC arises
spontaneously from the repolarization
q Increased workload on the heart
TREATMENT
MANIFESTATIONS
q May be asymptomatic
*TX based on underlying cause*
q Feels like your heart...
q May not be harmful if the client has a healthy heart
• “Skipped a beat”
q Oxygen
• “Heart is pounding”
q Decrease caffeine intake
q Chest pain
q Correct the electrolyte imbalances
q D/C or adjust the drug causing toxicity
q Decrease stress or pain
Chest pain
Notify the healthcare provider if
the client complains of chest pain,
if the PVC’s increase in frequency or if the PVC’s occur on the T
wave (R-on-T phenomenon).
ASYSTOLE
RATE
RHYTHM
P WAVE
PR INTERVAL
QRS COMPLEX
CAUSES
q Myocardial ischemia/infarction
q Heart failure
q Electrolyte imbalances
(common: hypo/hyperkalemia)
q Severe acidosis
q Cardiac tamponade
Flatline
TREATMENT
q High quality CPR
• Heel of hand on the center of the chest
• Arms straights
• Shoulders aligned over hands
• Compress at 2 - 2.4 inches at a rate of 100 - 120 min
• 30 compressions to 2 rescue breaths
• Minimal interruptions
q Cocaine overdose
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110
EKG’S
ATRIAL FLUTTER
Sawtooth
RATE 75-150 BPM
RHYTHM Usually regular
P WAVE “Sawtooth
PR INTERVAL Unable to measure
QRS COMPLEX Usually normal & upright
signals spread through the atria. The heart’s
upper chambers (atria) beat too quickly
but at a regular rhythm.
CAUSES
MANIFESTATIONS
q Coronary artery disease (CAD)
q May be asymptomatic
q Hypertension
q Fatigue / syncope
q Heart failure
q Valvular disease
q Hyperthyroidism
q Chronic lung disease
q Chest pain
q Shortness of breath
q Low blood pressure
q Pulmonary embolism
q Cardiomyopathy
TREATMENT
STABLE PT.
UNSTABLE PT.
q Drug therapy!
q Cardioversion
• Calcium channel blockers
• Antiarrhythmics
• Synchronized administration of shock
(delivery in sync with the QRS wave).
• Anticoagulants
Risk for clots!
defibrillation
Atrial flutter causes pooling of
blood in the atria = risk for clots
Defibrillation is only given
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111
HEART FAILURE
TOMS
SIGNS & SYMP
LEFT SIDED HF
RIGHT SIDED HF
Left Side Think Lungs
Fluid is backing up into the
lungs = pulmonary symptoms
d yspnea
OTHER S&
S
r ales (crackles)
↑ UOP
Hypote
nsion
S3 Gall
op
o rthopnea
w eakness / fatigue
Fluid is backing up into
the venous system
s welling of the legs & hands
w eight gain
e dema (pitting)
l arge neck veins (JVD)
l ethargy / fatigue
n octurnal paroxysmal dyspnea
i rregular heart rate
i ncreased HR
n agging cough (frothy, blood tinged sputum)
g aining weight (2 -3 lb's a day)
n octuria
g irth (Ascites)
OTHER S&
S
Hepato
megaly
Spleno
megaly
Anorex
ia
SYSTOLIC HF VS. DIASTOLIC HF
SYSTOLIC HF
DIASTOLIC HF
Weakened
heart muscle
Stiff & non-compliant
heart muscle
The ventricle does not
EJECT properly
The ventricle does not
FILL properly
EF Reduced
Normal EF
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EJECTION FRACTION (EF)
Amount of blood pumped out
Amount of blood in the chamber
% EF
Normal Ejection Fraction
50% - 70%
112
HEART FAILURE: DIAGNOSIS & INTERVENTIONS
DIAGNOSIS
BNP
CHEST X-RAY
ECHOCARDIOGRAM
B-TYPE NATRIURETIC PEPTIDE
Secreted when
there is ↑ pressure
in the ventricle
Looks at ejection fraction,
Enlarged heart
&
EF is ↓ in most
types of HF
BNP ↑ in HF
INTERVENTIONS
Diet Modifications
Monitor
Fluid restrictions
↓ Sodium
↓ Fat
↓ Cholesterol
Strict I&O’s
Daily weights
Edema
Same time
Same scale
Same clothes
Report S&S of
fluid retention
Rep
ort
w
(2-3 t. gai
lbs) n
Spread fluids out during the day
Suck on hard candy to ↓ thirst
Elevate hob
(Semi-Fowler’s position)
Balance periods
of activity & rest
Edema
Weight gain
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113
CORONARY ARTERY DISORDERS (CAD)
PATHO
RISK FACTORS
Non-modifiable
Age
Gender
Race
Family history
Modifiable
Diabetes
Obesity
Hypertension
Physical inactivity
Smoking
High cholesterol
Metabolic Syndrome
SIGNS & SYMPTOMS
ISCHEMIA
Inadequate blood supply to
the heart = ↓ O2 to the heart.
Ischemia: ↓ O2
Infarction: Death
ANGINA PECTORIS
Chest pain that is caused
by myocardial ischemia
• Chest pain w/ activity
• Shortness of breath
• Fatigued
Cholesterol
Called atherosclerosis
↓
Restriction of blood flow
to the heart
• Management
of hypertension
• Management
of diabetes
• Smoking cessation
• Diet
• Exercise
TREATMENT
blood test • LDL
• HDL
• Total Cholesterol
• Triglycerides
ECG
• Assess for changes in ST segments
or T waves!
Low Density
Lipoprotein
↓
PREVENTION
DIAGNOSIS
LDL
Fatty plaques develop
Want LOW Levels (<100 mg/dL)
BAD CHOLESTEROL
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• Lipid-lowering medications “Statins”
• Heart-healthy diet
WEEKL
• Physical activity
EXERCISE GOY
ALS
Moderate
• Smoking cessation
: 75 min
Vigorous:
150 min
• Stress management
• Hypertension management
• Diabetes management
• Coronary stent / angioplasty
• Coronary Artery Bypass Graft (CABG)
HDL
High Density
Lipoprotein
Want HIGH Levels (>60 mg/dL)
HAPPY CHOLESTEROL
114
PERIPHERAL VASCULAR DISEASE
is an umbrella term for...
PERIPHERAL
VENOUS DISEASE
(PVD)
PERIPHERAL
ARTERIAL DISEASE
(PAD)
Narrow artery (atherosclerosis) where
oxygenated blood can’t get to the
distal extremities (hands & feet).
Deoxygenated blood
can’t get back to the heart.
Pooling of oxygenated blood
in the extremities.
Dull, constant, achy pain!
Pulse ?
May not be palpable
due to edema
Edema ?
TE
AR
ART
RY
IN
VE
VEI
N
x
po
of boling
lood
Ischemia & necrosis
of the extremities
ER
Y
pain ?
Think
“BAD”
lood
no bo O 2
n
Sharp pain: Gets worse at night
“rest pain”
pain ?
Intermittent claudication
Pulse ?
Very poor or even absent
x
Edema ?
Blood
is POOLING
the leg
No blood
in theinextremities
No blood in the extremities
Temp ?
Warm legs
(Blood is warm)
Temp ?
Cool No blood = cool leg
Color ?
Stasis dermatitis
(Brown/yellow)
Color ?
Pale, hairless, dry, scaly, thin skin
due to lack of nutrients (↓ O2 )
Wounds ?
Venous STASIS ulcers,
Irregular shaped wounds, shallow
Wounds ?
Regular in shape, red sores
round appearance “punched out”
Gangrene ?
Elevate
Veins
Tissue death caused by
a lack of blood supply
Gangrene ?
We have too much blood! Gangrene is
caused by insufficient amounts of blood.
Positioning ?
(blood is warm)
Positioning ?
Positions that make it worse: dangling,
sitting/standing for long periods of time
Dangle arteries
CAUSES OF BOTH
Smoking • Diabetes • High cholesterol • Hypertension
DX: Doppler Ultrasound or Ankle Brachial Index (ABI)
TREAMENT
• Elevate
KEEP VEIN OPEN!
Veins
• Medications
TREAMENT
A
GET BLOOD MOVING!
• D ngle Arteries
(Dependent position)
• Perform daily skin care with moisturizer
- Aspirin or Clopidogrel
• Stop smoking
- Cholesterol lowering drugs “statin”
• Avoid tight clothing (vasoconstriction)
• Surgery
- Angioplasty
•
• Medications
- Bypass (CABG)
- Vasodilators
- Endarterectomy
- Antiplatelets
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115
ANGINA PECTORIS
Chest pain that is caused by myocardial ischemia
TYPES OF ANGINA
STABLE
UNSTABLE
PRINZMETAL’S / VARIANT
“Predictable”
“Preinfarction”
“Coronary artery vasospasm”
Occurs with
Occurs at
Pain at rest with reversible
↑ myocardial
demand for oxygen
& more frequently
st-elevation
rest
exertion
MANIFESTATIONS
INTERVENTIONS
Goal:
• Chest pain (heavy sensation) may radiate to neck,
jaw, or shoulders
• Unusual fatigue
• Weakness
• Shortness of breath
• Pallor
• Diaphoresis
↓ oxygen demand
Reperfusion Procedures
PCI
Percutaneous
Coronary
Interventions
CABG
Coronary Artery
Bypass Graft
DRUG THERAPY
nitrates
Calcium Channel
Blockers
beta blockers
• Vasodilators
• Relaxes blood vessels
• ↓myocardial oxygen
• Prevents platelet
• ↓ischemia = ↓pain
• ↑oxygen supply to the
consumption
aggregation &
• Usually administered
heart
sublingually
• ↓workload of heart
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Antiplatelet /
Anticoagulant
thrombosis
116
MYOCARDIAL INFARCTION (MI)
angina
Coronary arteries
become narrow
due to plaque
build-up
↓
artherosclerosis
SIGNS & SYMPTOMS
Sudden, crushing,
radiating chest pain
that continues despite
rest & medications
• Shortness of breath
• Nausea & vomiting
• Sweating
• Pale & dusty skin
WOMEN PRESENT WITH
DIFFERENT SYMPTOMS
Due to
ischemia
(low O2)
↓
PATHO
Complete blockage in one
or more arteries of the heart
Pain felt in the...
• Left arm
• Mid back/shoulder
• Heartburn
• Fatigue
• Shoulder blade discomfort
• Shortness of breath
Myocardial
Infarction (mI)
Plaque rupture
become a blood clot
that blocks arteries of
the heart
DIAGNOSIS
- ECG
• ST-Elevation
(no O2)
• ST-Depression
(low O2)
T-wave inversion
- Troponin
- Stress test
• Chemical &
excercise
TREATMENT
immediate
m
MORPHINE
o
OXYGEN
n
a
↓workload of the heart & ↓ pain
↑O2 to the heart
NITROGLYCERIN
opens up the vessels
ASPRIN
Prevents platelets from sticking together
cath lab or
clot buster
Medications
• Thrombolytics
(clot busters)
Prevention &
Rest
-teplase
-ase
prevent / stabilize clot
• Heparin IV
• Example: Streptokinase
Rest the heart with...
Surgery
• Nitro
• PCI “Percutaneous
• Beta-Blockers
Coronary Intervention”
• Calcium channel blockers
• CABG
• Endarterectomy
ANY TIM
E YOU GI
- Cut out the blockage
V
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E
A THROM
BOLYTIC,
WATCH F
OR SIGNS
BLEEDING OF
!
117
CARDIAC BIOMARKERS
TROPONIN
Protein released in the blood stream
when the heart muscle is damaged.
There are 3 isomers of troponin
Troponin C: binds calcium to activate
muscle contraction
Troponin I & T:
TROPONIN I
RANGE
PEAK
0 - 0.4 ng/mL
> 0.4 = Heart attack!
Can remain elevated
for as long as 3 weeks
BEST indicator of an acute MI
CK-MB
Creatine Kinase - MB
An enzyme released in the bloodstream
when the heart, muscles or brains are damaged!
Cardiac-specific isoenzyme
BUT less reliable than Troponin
MYOGLOBIN
Myoglobin is found in cardiac & skeletal muscle
but a (-) sign is good for ruling out an acute MI
Myoglobin Think Muscle
BNP
Brain Natriuretic peptide
RANGE
PEAK
RANGE
PEAK
RANGE
0 - 5 ng/mL
24 Hours
5 - 70 ng/mL
12 hours
Normal: <100 pg/mL
Mild HF: 100 - 300
Moderate HF: 300 - 700
Severe HF: >700
Indicates heart failure (HF)
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118