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Jenniffer TorralbaPaguio, RN
Review of Cardiac Physiology
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Jenniffer TorralbaPaguio, RN 9
Hollow, muscular organ
300 grams (size of a fist) 4 chambers
found in chest between lungs
surrounded by membrane called Pericardium
Pericardial space is fluid-filled to nourish and
protect the heart.
CARDIAC ANATOMY
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC ANATOMY
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC FUNCTIONS
Generates blood pressure
Routes blood
Heart separates pulmonary and systemic circulation
Ensures one-way blood flow
Heart valves ensure one-way flow
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC FUNCTIONS
Regulates blood supply Changes in contraction rate and force match blood delivery
to changing metabolic needs
Most healthy people can increase cardiac output by 300500%
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN 13
The heart is acomplex muscularpump that
maintains bloodpressure and flowthrough the lungsand the rest of thebody.
The heart pumpsabout 100,000times and moves7200 liters (1900gallons) of bloodevery day.
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Jenniffer TorralbaPaguio, RN
Disturbances in HEART as a Pump
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CARDIAC ANATOMY
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN 16
Layers of the Heart:
Epicardium
Lines the pericardial
cavity
Myocardium
Muscle layer
Endocardium
Lines the chambers of the heart
CARDIAC ANATOMY
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN 17
Layers of the Heart:
Pericardium
Physical protection & barrier
Highly resistant to distension
Epicardium: visceral layer covering the heart &
great vessels
Contains the pericardial cavity (bet the visceral &
parietal layers)
CARDIAC ANATOMY
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN 18
Layers of the Heart:
Myocardium
Muscular portion of the
heart
Cardiac muscle cells
behaving as a single unit d/t:
Intercalated disks low
resistance for passage of
ions & electrical impulses
CARDIAC ANATOMY
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN 19
Layers of the Heart:
Endocardium
Membrane that lines the
heart
Lines with blood vessels,
connective tissues with
elastic fibers & branches
of the conduction system
of the heart
CARDIAC ANATOMY
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Jenniffer TorralbaPaguio, RN
CARDIAC ANATOMY
Heart Valves:
2 Atrioventricular
Tricuspid & Mitral
Has cordae tendinae
2 Semilunar
Pulmonic & Aortic
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC ANATOMY & PHYSIOLOGY
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Contraction of Cardiac Muscle
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Electrical Activity of Cardiac Muscle
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Conducting System of the Heart
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Jenniffer TorralbaPaguio, RN
Steps in Impulse
Conduction
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CARDIAC CYCLE
The heart is two pumps that work together, right
(pulmonary) and left (systemic) half
Repetitive, sequential contraction (systole) and
relaxation (diastole) of heart chambers
Blood moves through circulatory system from areas
of higher to lower pressure.
o Contraction of heart produces the pressure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC CYCLE
The rhythmic pumping action of the heart
Phases:
Sytole
The period at which the ventricles are contracting
Diastole
The period at which ventricles are relaxed & filled with
blood
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
The Electrocardiogram
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC CYCLE
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC CYCLE
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CARDIAC CYCLE
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CARDIAC PREFORMANCE REGULATION
Cardiac Output Measure used to determine efficiency of cardiacperformance
Amount of blood the heart pumps each minute
CO = SV x HR
Varies with body size & metabolic needs
Increased in stress & physical activity
Decreased in sleep & rest
Average: 3.5 8L/min
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Regulation of Cardiac Output
Cardiac Output is
determined by
stroke volume and
heart rate each
can be regulated!!
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC PREFORMANCE REGULATION
Cardiac Reserve
Maximum percentage of increase in cardiac output
that can be achieved above the normal resting level
N: 300-400%
Dependent on:
1. Preload
2. Afterload
3. Cardiac contractility
4. Heart Rate
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC PREFORMANCE REGULATION
Preload Represents the amount of blood that the heart must pump
with each beat
Determined by venous return to the heart & stretch of the
muscle fibers
Frank-Starling mechanism
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CARDIAC PREFORMANCE REGULATION
Afterload
The pressure that the heart must generate to move blood
into the aorta
Sources of afterload:
o L Heart: Systemic arterial BP
oR Heart: Pulmonary arterial pressure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC PREFORMANCE REGULATION
Contractility
The ability of the heart to change its force of contraction
without changing its resting length
Influenced by number of calcium ions available in the
contractile process
SNS stimulation: + inotropic effect by increasing Ca+
available
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CARDIAC PREFORMANCE REGULATION
Heart Rate
Determines the frequency with which blood is ejected
from the heart
HR CO
HR time spent in diastole, less time to fill
ventricles BUT same time in systole
EFFECT: SV but CO
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Review of Cardiac Output
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Pump Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
PUMP FAILURE
Inability to pump blood, oxygen and nutrients tomeet metabolic needs
NOT a disease per se BUT a syndrome due to a
variety of disruptions that place an increased
demand to the heart
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Jenniffer TorralbaPaguio, RN
OUTLINE
1. Disturbances of BP regulation
2. Conduction disturbances (Arrythmia)3. Perfusion disturbances (Coronary Artery Disease &
Acute Coronary Syndrome, Cardiomyopathy)
4. Structural defects (Congenital Heart Disease,
Valvular Heart Disease)
5. Heart Failure (Heart Failure & Cardiogenic Shock)
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
DISORDERS OF BP REGULATIONHypertension
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Diastolic BP
Maintained by the energy that has been stored in
the elastic walls of the aorta during systole
Based on:1. Condition of the vessel wall
2. Ability to stretch
3. Competency of the aortic valve4. Arteriolar resistance
Diastolic BP
Maintained by the energy that has been stored in
the elastic walls of the aorta during systole
Based on:1. Condition of the vessel wall
2. Ability to stretch
3. Competency of the aortic valve4. Arteriolar resistance
BLOOD PRESSURE
Determined by CO and PVR, where
BP = CO X PVR
Systolic BP
Reflects the rhythmic ejection of blood into the aorta
Increases with rapid ejection of large SV or when SV is
ejected into a rigid aorta
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Regulatory Mechanisms of BP Maintenance
Short-Term
Vagal stimulation
ANS, barroreceptors
Renin-Angiotensin-Aldosteronemechanism
Vasopressin (ADH)
Long-Term
Renal Mechanisms
Extracellular fluid volume
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
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Jenniffer TorralbaPaguio, RN
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
What is NORMAL?
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Specific Factors - Sites of Blood Pressure Control
Renal sodium and water excretion
Arterial resistance
Venous capacitance
Tissue remodeling
CNS influence on the autonomic
nervous system.
HR can be affected by
multiple factors
SV can be affected by venous return
RAS
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Increased arterial
resistance
renin release
blood volume by directly promotingsodium and water retention
increased cardiac rate
and force
venous
compliance
Specific Factors - Sites of Blood Pressure Control
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Risk Factors
Family history of hypertension
Race
Age-related increases in BP
Insulin Resistance & Metabolic Abnormalities
Lifestyle Factors
High Salt Intake
Excess alcohol consumption
Dietary intake of potassium, calcium & magnesium
Stress
Obesity
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
HYPERTENSION
Classification:1. Essential chronic elevation in BP that
occurs without evidence of other disease
Systolic
Diastolic
2. Secondary HPN resulting from other
diseases (eg. Kidney disease)
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HYPERTENSION cascade
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
HYPERTENSION cascade
Elevated BP
(systole)
LV hypertrophy
Increased myocardialO2 demand
L heart failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
HYPERTENSION cascade
L heart failure
End-Organ Damage:
Heart, Brain, CKD, PeripheralVascular Disease,
Retinopathy
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Secondary Hypertension
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Secondary Hypertension
1. Renal Hypertension d/t reduced blood flowexcessive release of
Renin Angiotensin II PVR & aldosterone
& Na retention
2. Adrenocorticosteroid Hormone-Related HPN
d/t increased sodium retention SV
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Secondary Hypertension
3. Pheochromocytoma d/t increased catecholamine release
4. Coarctation of the aorta
Narrowing of the aorta
Reduced blood flow from the lower part of the body
& kidneys SV CO BUT supplying only to the
upper parts of the body
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Jenniffer TorralbaPaguio, RN
CONDUCTION DISTURBANCESArrythmias
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Cardiac Conduction System
Controls the rate and direction of electric impulse
conduction of the heart
SA AV His Bundle Purkinjie Fibers
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Cardiac Conduction System
Phases of Cardiac Action Potential
Phase 0 - r apid upstroke
Phase 1 - early repolarization
Phase 2 - the Plataeu
Phase 3 - final repolarization period
Phase 4 - diastolic repolarization period
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Electrical Activity of Cardiac Muscle
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
REVIEW!!
Properties of the Cardiac Muscle
1. Automaticity
Ability of the cells in the conduction system to initiate
impulse spontaneously
2. Excitability
Ability of the cell to respond to an impulse & generate
action potential
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
REVIEW!!
Properties of the Cardiac Muscle
3. Conductivity
Ability to conduct impulses
4. Refractoriness
The extent to which the cell is able to respond to an
incoming stimulus
Represents temporary interruptions in conductivity r/t
repolarization phase of the action potential
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Jenniffer TorralbaPaguio, RN
Electrical Activity of Cardiac Muscle
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
Automaticity Problems
Arise when the SA node does not fire, fires slowly or
SA node is blocked where another site takes over
Possible that the SA is functioning we BUT cardiac
cells assume accelerated properties of automaticity
generating impulses independently
Conduction System Firing Rate
SA Node 60 100 beats/ minute
AV Node 40 60 beats/ minute
Purkingie system 20 40 beats/ minute
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
Automaticity Problems
Promotive Factors
Myocardial tissue injury, hypoxia
Electrolyte disturbances
Hypertrophy (atrial/ventricular)
Medications
Ectopic Pacemaker
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
Premature Atrial Contractions
Premature Ventricular Contractions
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
Excitability Problems
Requires normal functioning myocardial cells
Ex. Injured myocardium 2 to ischemia
Injured myocardium
Depolarization of myocardial cells
Ischemic cells remain depolarized
Induces re-excitation of other Normal myocardium
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
Conductivity & Refractoriness Problems
Re-entry
Fibers that are inactive are activated
BEFORE the initial impulse dies out
re-excites areas of the heart that were
JUST discharged and have already
recovered
Requires a stimulus
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Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
Conductivity & Refractoriness Problems
Re-entry Contributing Factors
Ischemia
Infarction
Elevated serum K+
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
Conductivity & Refractoriness Problems
Re-entry
Injured myocardium
Increased resistance to impulse
Slow impulse transmission
Asynchronous myocardial activation
Predisposition to BLOCKS
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
Conductivity & Refractoriness Problems
Re-entry
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Mechanisms of Conduction Disorders
Conductivity & Refractoriness Problems
Re-entry
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
PERFUSION DISTURBANCES
Coronary Artery DiseaseAcute Coronary Syndrome
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
An abnormal accumulation of lipid, or fatty,substances and fibrous tissue in the vessel wall
Involves a repetitious inflammatory response to
artery wall injury and an alteration in the
biophysical & biochemical properties of the walls
Progressive disease resulting in coronary arterial
narrowing or complete occlusion
Preventable and Manageable
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Coronary Artery Disease
Etiology:
Exists even at childhood as fatty streaks Becomes symptomatic once occlusion is at
75%, usually at middle age
Epidemiologic data demonstrate association
between specific Risk Factors and CAD
development
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
RISK FACTORS
Major:
1. Tobacco Use
2. Hypertension
3. Elevated Blood lipid levels (LDL)
4. Family history of premature CVD (1st degree
relative w/ CVD at 55 or younger for men & 65 or
younger in women)
5. Age (>45 for men & >55 for women)Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults (Adult Treatment Panel III ; 2001)
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
RISK FACTORS
CAD Risk Equivalents (High risk for cardiac event in 10
years):
6. Diabetes
7. Peripheral Arterial Disease
8. Abdominal Aortic Aneurysm
9. Carotid Artery Disease
Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III ; 2001)
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
RISK FACTORS Minor:
1. Physical Inactivity
2. Obesity
3. Metabolic Syndrome (composite of lipid & non-
lipid RFs of metabolic origin: abdominal obesity,
elevated triglyceride levels, low HDL, elevated BP, &
impaired insulin function)
4. StressThird Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III ; 2001)
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
RISK FACTORS
Minor:
5. Gender & Estrogen Levels
Women tend to have a higher incidence of
complications from CAD (AHA, 2002)
Women tend to not recognize the symptoms as early as
men & wait longer to report and seek medical
assistance (Meische et al.,1999;Penque et al., 1998)
Long-tern HRT may have more risks than benefits, &
that HRT should not be initiated or continued for
primary prevention of CAD (Womens Health Initiative,
Gebbie, 2002)
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Coronary Artery Disease
RISK FACTORS
Minor:
6. Behavioral Patterns (Type A personality:excessive competitiveness, sense of time urgency,
aggressiveness, hostility)
Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III ; 2001)
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Risk Factors:
Explored in the Framingham Study
Non-Modifiable FRAG
1. Family History
2. Race
3. Age
4. Gender
Coronary Artery Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Risk Factors:
Modifiable OCHIPED
1. Obesity
2. Cigarette Smoking
3. Hypertension
4. Impaired glucose tolerance
5. Physical Inactivity (Sedentary Lifestyle)
6. Elevated Serum lipids
7. Diet high in saturated fat, cholesterol and calories
Coronary Artery Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Atherosclerotic Plaque Development
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
Deposition of fattystreaks in the
arterial wall intima
inflammatoryresponse
development offibrous capATHEROMA
narrowing of bloodvessel &
obstruction ofblood flow
decreased O2 in themyocardium(ISCHEMIA)
chest pain(ANGINA)
thrombusformation may
develop
myocardialinfarction
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Disturbances in HEART as a Pump
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This coronary artery
demonstrates yellowish
atherosclerotic p laques grossly.
This coronary artery
opened longitudinally
demonstrates severe
atherosclerosis.
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
HEMODYNAMIC EFFECTS
Imbalance in myocardial oxygen supply and demand
1. Flow restricted under normal conditions
2. Stiffened vessels and inability to dilate causing
decreased driving pressure beyond the site of lesion
and less oxygenated blood available to the myocardial
cells perfused by the affected vessel
AerobicAnaerobic MetabolismTISSUE HYPOXIA
Coronary Artery Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ACUTE CORONARY SYNDROMES
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Jenniffer TorralbaPaguio, RN
ANGINA A clinical syndrome usually characterized by
episodes of paroxysms of pain or pressure on the
anterior chest
Usually d/t insufficient blood flow that results to a
decreased O2 supply to meet an increased
myocardial demand for O2 in response to physical
exertion or emotional stress
Coronary Artery Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ANGINA
Urden, et al.
Thelans Critical Care Nursing.2002
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ANGINA
Types:
1. Stable Angina2. Unstable Angina
3. Variant Angina
4. Silent Ischemia
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ANGINA
Types:
1. Stable Angina
Predictable, caused by similar risk factors
(eg. Exercise, emotional upset,
tachycardia)
Occurs when myocardial O2 demand
exceeds supply
usual chest pain
Relieved by rest, NTG
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ANGINA
Types:
2. Unstable Angina
Change in previously established pattern
of angina OR a new onset of severe
angina
More intense
Preinfarction or cresendo unstable
angina unrelieved for >15 minutes
Atherosclerotic plaque instability Admitted as NSSTSE r/o MI
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ANGINA
Types:
3. Variant Angina
Caused by coronary artery spasm
Commonly occurs when the patient is at
rest and can be cyclic
Associated with ST segment elevation &
transient abnormal Q waves
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ANGINA
Types:
4. Silent Ischemia
Defined as objective evidence of
myocardial ischemia (ST segment
changes) WITHOUT the patient
experiencing any symptoms of angina
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ANGINA
PATHOPHYSIOLOGYPathogenic Mechanisms causing chest pain d/t ischemia:
1. Atherosclerosis
2. Platelet aggregation in diseased vessels
3. Transient coronary artery thrombosis
4. Hemorrhage into atheromatous plaque
5. Abnormal vassoconstriction(spasm) of a
coronary artery
6. Extracardiac factors (anemia, thyrotoxicosis)
Coronary Artery Disease
Decreased coronary perfusion OR increased oxygen demand
chest pain
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ANGINADIAGNOSTIC FINDINGS
1. ECG: may be normal (ST segment depression
with/without T wave inversion; ST segment may
be elevated during episode)
2. Positive Stress Test (at least 1mm horizontal
depression or down sloping ST segment lasting
0.08 sec)
3. No changes in serum electrolytes
4. Elevated C-reactive protein (marker for
inflammation of vascular endothelium)
Coronary Artery Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ACUTE CORONARY SYNDROMES
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Jenniffer TorralbaPaguio, RN
MYOCARDIAL INFARCTION
Describes irreversible myocardial necrosis resulting
from an abrupt decrease or total cessation of coronary
blood flow to a specific area of the myocardium.
ETIOLOGY:
1. Plaque rupture
2. New coronary artery thrombosis
3. Coronary artery spasm
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Deposition of fatty streaks
in the arterial wall intima
inflammatory
response
development of fibrous cap
ATHEROMA
narrowing of blood vessel &
obstruction of blood flow
chest pain (ANGINA)
decreased O2 in the myocardium
(ISCHEMIA)
thrombus formation may develop
myocardial infarction
Complete & irreversible
myocardial necrosis in
3-4 hours
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
MYOCARDIAL INFARCTION
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
MYOCARDIAL INFARCTIONLOCATION
1. Anterior wall
2. Anteroseptal
3. Anterolateral
4. Inferior wall
5. Right ventricular
6. Posterior wall
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MYOCARDIAL INFARCTIONCLINICAL PRESENTATION
Cardiovascular Chest pain, palpitations
S3, S4, new onset murmur
JVD
BP (may be elevated/decreased)
Pulse deficit (Af)
ECG (dysrythmias, ST, T wave changes, Q wave
presence)
Coronary Artery Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
MYOCARDIAL INFARCTIONCLINICAL PRESENTATION
Respiratory SOB
Dyspnea
Tachypnea
Crackles
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
MYOCARDIAL INFARCTIONCLINICAL PRESENTATION
Gastrointestinal
Nausea & vomiting
GUT
Decreased UO (maybe d/t
cardiogenicshock)
Skin
Cool,clammy,diaphoretic, pallor Dependent edema
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
MYOCARDIAL INFARCTIONCLINICAL PRESENTATION
Neurologic
Anxiety,restlessness, light-headedness
Headache, visual disturbances
Altered speech, motor functions
Changes in LOC
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Coronary Artery Disease
MYOCARDIAL INFARCTIONCLINICAL PRESENTATION
Electrocardiogram:
T wave inversion
ST segment elevation
Development of abnormal Q wave
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
MYOCARDIAL INFARCTIONPOSSIBLE COMPLICATIONS
1. Dysrhythmias
Sinus dysrhythmias
Ventricular/Atrialdysrhythmias
AV Heart Block
2. Acute MI
Coronary Artery Disease
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Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
MYOCARDIAL INFARCTIONPOSSIBLE COMPLICATIONS
3. Structural Problems
Ventricular aneurysm
VSD
Papillary Muscle rupture
Cardiac wall rupture
Pericarditis
Coronary Artery Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
STRUCTURAL DEFECTS
Congenital Heart Defects
Valvular Defects
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
TYPES:
1. Mitral valve stenosis
2. Mitral Valve Regurgitation
3. Aortic Valve stenosis
4. Aortic valve regurgitation
5. Tricuspid valve stenosis
6. Tricuspid valve regurgitation
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Describes structural and/or functionalabnormalities of single or multiple cardiac valves
Causes alteration in blood flow across the valve
Types:
1. Stenotic
2. Regurgitant
Usual reason for ICU admission if for Heart Failure or for
cardiac surgical valve replacement
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Etiology:
Secondary to Rheumatic Heart Disease
Direct result of damage caused by
hemolytic streptococcal pharyngitis
Secondary to degenerative valve changes
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Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Rheumatic Heart Disease:
Inflammatory process that may affect the
myocardium, pericardium and or endocardium Usually results in distortion and scarring of the valves
Subjective Symptoms Objective Symptoms
Prior history of rheumatic fever
General malaise
Pain may or may not be present
Temperature
Murmurs
Dyspnea
Polyarthritis
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Mechanisms:
Obstruction to forward flow (stenosis) or
insufficiency of the valve, allowing backwardflow (regurgitation).
Caused by sclerosing, thickening and calcificationof the valve leaflets.
May be caused by rheumatic heart disease,dilatation of the valve ring, or damage to thenearby valve structures
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Recall of Normal Flow
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Mitral Valve Stenosis
LA must generate more pressure
to propel blood beyondthe lesion
Rise in LA pressure & volume is
reflected retrograde into
pulmonaryvessels
RV hypertrophy
RV failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Mitral Valve StenosisManifestations:
Exertionaldyspnea
Weakness, fatigue
Pronounced respiratory
symptoms (orthopnea, PND)
Mild hemoptysis with bronchial
capillary rupture
Susceptibility to pulmonary
infections
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Mitral Valve Stenosis
Manifestations
1. CXR: pulmonary congestion, redistribution of blood
flow to upper lobes
2. ECG: Atrial Fib & other atrial dysrrhythmias
3. Auscultation: Diastolic murmur, accentuated S1,
opening snap
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Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Mitral Valve Regurgitation
Pathophysiologic Consequences
LVdilation & hypertrophy
Left atrial dilation and
hypertrophy
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Mitral Valve Regurgitation
MANIFESTATIONS
Weakness & fatigue
Exertionaldyspnea
Palpitations
Severe symptoms precipitated
by LV fai lure, with low output
and pulmonary congestion
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Aortic Valve Stenosis
PathophysiologicConsequence
LV hypertrophy
Progressive failure of ventricular
emptying
Pulmonary congestion
Failure of R-side of heart, with
systemicvenous congestion Sudden Cardiac Death
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Aortic Valve Stenosis
Manifestations
Exertionaldyspnea
Exercise intolerance
Syncope
Angina
HF (left-ventricular failure)
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Aortic Valve Regurgitation
PathophysiologicConsequence
Increased volume load imposed
on left ventricle
LVdilation and hypertrophy
Manifesting
Fatigue
Exertionaldyspnea
Palpitations
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Tricuspid Valve Stenosis
PathophysiologicMechanisms
RA must generate higher
pressure to eject blood
beyondthe lesion
Right atrial dilation
Systemic venous
engorgement
Increasedvenous pressures
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Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Tricuspid Valve Stenosis
Manifestations
Venousdistension
Peripheral edema
Ascites
Hepatic engorgement
Anorexia
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Tricuspid Valve Regurgitation
PathophysiologicConsequence
RV dilation and hypertrophy
Manifestations
Decreased CO
NVE
Hepatic engorgement
Ascites
Edema
Pleural effusion
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Valvular Heart Disease
Diagnostic Tests:1.Cardiac catheterization
assist in visualization of blood flow.
Measurement of chamber assists in determining
type of disorder present and the degree of
severity.
2.Echocardiography
determine ventricular function, chamber size,
and valve function
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Congenital Heart Diseases
Classification based on effect:
1. Acyanotic
Ventricular Septal Defect (VSD)
Atrial Septal Defect (ASD)
Patent Ductus Arteriosus (PDA)
2. Cyanotic
Tertralogy of Fallot
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Congenital Heart Diseases
Classification based on hemodynamic & blood
flow patterns:
1. Increased pulmonary blood flow
2. Obstruction to blood flow leaving the heart
3. Mixed blood flow (oxygenated &
deoxygenated blood mixing in the heart or
great vessels)
4. Decreased pulmonary blood flow
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Congenital Heart Diseases
Acyanotic Congenital Heart Disease
LeftRight SHUNT (oxygenated unoxygenated)
Involves heart & circulatory anomalies on:
Stricture to the flow of blood; OR
Shunt that moves blood from the arterial to the
venous system
Causes the heart to become an INEFFECTIVE
PUMP and predisposes the child to HF
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Jenniffer TorralbaPaguio, RN
Congenital Heart Diseases
Ventricular Septal Defect
Opening is present in the septum between the 2ventricles.
LV pressure > RV pressure blood flows from the
L to the R across the septum
Impairment of the effort of the heart to the
systemic circulation
L R back to pulmo circulation ventricular
hypertrophy &pulmonary arterial pressure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Congenital Heart Diseases
Atrial Septal Defect
Abnormal communication between the 2 atria shift of blood from L to R
Types:
1. Ostrium Primum opening at the lower end
of the septum
2. Ostrium Secundum opening near the center
of the septum
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Congenital Heart Diseases
Patent Ductus Arteriosus
DA is an accessory fetal structure that connects the
pulmonary artery to the aorta closes at birth
Blood shunts from the aorta (oxygenated blood) to
the pulmonary artery (unoxygenatedblood)
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Congenital Heart Diseases
Cyanotic Congenital Heart Disease
Right Left SHUNT (unoxygenated oxygenated)
Presence of strictures in this disease causes blood
to be shunted from the venous arterial system
as a result of abnormal communication between
the L & R side of the heart
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Congenital Heart Diseases
Tetralogyof Fallot
Four Anomalies:
1. Pulmonary stenosis
2. VSD
3. Dextropositionof the aorta
4. RV hypertrophy
Causes blood to shunt from the R L and
overriding the aorta CYANOSIS
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
HEART FAILURE
Heart Failure & Cardiogenic Shock
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Jenniffer TorralbaPaguio, RN
Heart Failure
A response to cardiac dysfunction
A condition where the heart cannot pumpblood at a volume required to meet the
bodys needs
Results in failure to deliver blood to the
pulmonary and arterial circulations
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Heart Failure
Precipitating Factors Reduction or cessation of medication
Dysrrhythmias
Systemic infection
Pulmonary embolism
Physical, environmental and emotional stress
Pericarditis, myocarditis and endocarditis
High ventricular output states
Development of serious systemic illness
Administration of cardiac depressant or salt -retaining
drug
Development of a second form of heart disease
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Heart Failure
Classifications:
1. Using the NYHA classification
2. Based on primary ventricular involvement (Left
vs. Right)
3. As pressure extending backward or forward
4. Based on chronicity (Acute vs. Chronic)
5. As primary Systolic or Diastolic LV dysfunction
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
NEW YORK HEART ASSOCIATION
Functional Classification
Heart Failure
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Jenniffer TorralbaPaguio, RN
NEW YORK HEART ASSOCIATION
Functional Classification
Sources: American Heart Association. Heart and Stroke Facts; National Heart, Lung, and Blood Institute. Diseases and Conditions Index: Angina; American
Heart Association.Angina Pectoris Treatment;Patient Health International.Angina Fact and Figures;American Heart Association. Transmyocardial
Revascularization (TMR); American Heart Association. Heart Disease and Stroke Statistics-2004 Update. Dallas,Tex. American Heart Association;2003.
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
VENTRICULAR INVOLVEMENT:
Right Heart Failure:
Ineffective right ventricular contractile function
Secondary to acute conditions such as:
1. Pulmonary embolism
2. MI
3. Secondary to Left-sided heart failure or
backward failure
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
VENTRICULAR INVOLVEMENT:
Right Heart Failure:Common Manifestations:
Weakness
Peripheral edema
JVD
Organomegaly
Elevated CVP
Compromised peripheral perfusion
GI: anorexia, nausea, feeling of fullness
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
VENTRICULAR INVOLVEMENT:
Left Failure:
Disturbed contractile function of the left side of
the ventricle resulting in:
Pulmonary congestion & edema
Decreased CO
Secondary to acute conditions such as:
1. Left ventricular MI
2. Aortic or MV stenosis
3. Hypertension
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
VENTRICULAR INVOLVEMENT:
Left Heart Failure:Common Manifestations:
Tachypnea, tachycardia
Cough
Basilar crackles
Pulmonary edema, Hemoptysis
Decreased peripheral perfusion (weak,
diminished pulses; cool, pale extremities;
peripheral cyanosis
Eventual right side of the heart involvement
Heart Failure
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Jenniffer TorralbaPaguio, RN
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
PRESSURE COMPROMISE: Forward Heart Failure
Inadequate delivery of blood into the arterialsystem
Occurs when there is increased systemic vascular
resistance (afterload) causing decreased CO
Secondary to acute conditions such as:
1. Aortic stenosis
2. Hypertension
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
PRESSURE COMPROMISE: Backward Heart Failure
Causes inadequate emptying of the ventricle
Secondary to acute conditions such as:
1. LV systolic dysfunction d/t MI
2. Cardiomyopathy
Manifests as:
1. Increased LVEDP
2. Secodary increased atrial pressure &
pulmonary pressure
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CHRONICITY:
Acute
Sudden onset, no compensatory mechanism
Experienced as acute pulmonary edema, low
cardiac output, or cardiogenic shock
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
CHRONICITY:
Chronic With compensatory mechanism involvement CO
1. Frank-Starling mechanism
2. Sympathetic reflexes
3. RAA system
4. Myocardial hypertrophy
Hypervolemic with Na and H2O retention; chamber
changes
Deterioration secondary to: dyrhythmias, acute
ischemia, cessation of medication
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Heart Failure
Systolic VS Diastolic Failure
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Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
COMPENSATORY MECHANISMS:
1. Adrenergic System
2. Renin-Angiotensin-Aldosterone System
3. Sinus Tachycardia
4. Ventricular Hypertrophy
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Possible Complications:
1. Shortness of Breath
Dyspnea
Orthopnea
Paroxysman Nocturnal
Dyspnea
Cardiac Asthma
2. Pulmonary Edema
Heart Failure
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
SHOCK
is a complex clinical syndrome characterized by
impaired cellular metabolism due to decreased
tissue perfusion.
inadequacy in tissue perfusion results in cellular
hypoxia, accumulation of cellular metabolic
wastes, cellular destruction , and, ultimately,
organ and system failure.
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Cardiogenic Shock
it results from the impaired ability of the heart topump blood severe in perfusion
is a complex clinical syndrome characterized by:
Hypotension
Tachycardia
impaired mentation
urinary output level below 20ml/hour, and
peripheral vascular collapse
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Cardiogenic Shock
it results from the impaired ability of the heart topump blood severe in perfusion
symptoms are caused by inadequate delivery of
blood to major body organs, particularly the
heart, brain, and kidneys.
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Jenniffer TorralbaPaguio, RN
CLASSIFICATIONS other than CARDIOGENIC:
1. HYPOVOLEMIC Shock
exists when the volume of blood is inadequate to
fill the intravascular space.
2. DISTRIBUTIVE Shock
happens when there is massive peripheralvasodilation because the blood volume, althoughwithin normal limits, is insufficient to fill theenlarged vascular capacity.
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Differentiating Cardiogenic Shock
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Distributive shock
SEPTIC
- any type of microorganism can produce septic shock,cellular derangement precede and contribute tocardiovascular abnormalities.
ANAPHYLACTIC
as the result of a severe allergic, antigen-antibodyreaction.
NEUROGENIC
there is a reduction in vasomotor tone, which occurs inthe vasomotor centers in the brainstem and causes
decreased vasoconstriction, resulting in generalizedsystemic vasodilation
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Cardiogenic Shock
Possible Causes:
1. MYOPATHIC factors
SYSTOLIC dysfunction
Ex: Acute MI, congestive cardiomyopathy
DIASTOLIC dysfunction
Ex: cardiac tamponade
2. MECHANICAL factors regurgitant lesions
ruptured interventricularseptum
3. DYSRHYTHMIAS Bradydysrhythmias
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Cardiogenic Shock
Etiologic Classifications:
1. Coronary occurs when a significant amount of the
LV myocardium has been destroyed
More common
Eg. Anterior wall MI
2. Non-Coronary usually r/t severe metabolic
problems and tension pneumothorax
Eg. Severe hypoxemia, acidosis, hypoglycemia,
hypocalcemia
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
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Primary ventricular
ischemia
Structural problems Arrhythmias
Systolic dysfunction: ineffective forward movement of blood
Decreased stoke
volume
Diastolic dysfunction:
ineffective filling
Decreased cardiac
output
Increased pulmonary
pressures
Pulmonary edema
Decreased oxygenation
Decreased cellular oxygen supply
Decreased tissue perfusion
Impaired cellular metabolism
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Cardiogenic Shock
Clinical Manifestations:
1. Anginalpain
2. Dysrhythmia
3. Hemodynamic
instability
Initial Stage
CompensatoryStage
ProgressiveStage
RefractoryStage
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Stages of Cardiogenic Shock
INITIAL: no apparent signs or symptoms
subtle nonspecific changes occur at the
cellular level
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Stages of Cardiogenic Shock
COMPENSATORY: there is declining systemic arterial blood pressure,
right ventricular failure, and acidosis
SNS is stimulated and so second stage of chock
begins
Nervous, Endocrine, Chemical Homeostatic
compensatory mechanism are triggered
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Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Stages of Cardiogenic Shock
PROGRESSIVE: compensatory mechanism are not enough to reverse
the shock state. They will eventually fail destructive cellular and systemic changes ensue
there will be impaired cellular function related tonutritional blood flow
results to anaerobic metabolism and eventuallyacidosis
increase capillary hydrostatic pressure forces fluid tothe extravascular spaces.
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Stages of Cardiogenic Shock
PROGRESSIVE: Heart eventually fails from deprivation of adequate
perfusion Cerebral blood flow is decreased as a result of the
reduced cardiac output secondary to altered capillarydynamics
Decreased pulmonary vascular blood flow causesischemic and necrotic cellular changes.
The already compromised lungs become wet, stiff, andnoncompliant
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Stages of Cardiogenic Shock
REFRACTORY:
when death is imminent the patient in shock no longer
responds to any form of therapy
severe vasoconstriction continues
cardiac output falls even further
build up of acidosis further impairs respiratory and
cerebral function and tissue perfusion.
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ORGAN/
SYSTEM
COMPENSATORY
Mechanisms
S/Sx of Decompensation
Brain/Neuroph
ysiologic
>decreased impulse transmission
of Baroreceptors
>vasomotor center removes
inhibition of the vasoconstriction
>SNS stimulation
>anterior pituitary and
hypothalamus is stimulated
>restlessness
>deterioration in sensorium
>cerebral ischemia/infarct
Heart and
vascular system
>increased heart rate
>enhanced contractility
>coronary vessels dilate
>peripheral vessels constrict
>decreased tissue perfusion
>myocardial ischemia/infarct
>congestive heart failure
>arrythmias
>failure of microcirculation
>DIC
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
ORGAN/
SYSTEM
COMPENSATORY
Mechanisms
S/Sx of Decompensation
Pulmo >chemoreceptor senses
poor ventilatory status
>increase in respiratory rate>stimulation of vasomotor
center
>hypoxia
>acidosis
>decreased pulmonary compliance>pulmonary interstitial edema
GIT >severe vasoconstriction
>RBCs are squeezed into
the circulation by liver and
spleen
>intestinal ischemia
>depressed protective action of RES
>anoxic liver
>release of toxic substances
>impaired portal blood flow
Renal >excitation of renal pressor
substance
>activation of R-A-A-S
>decreased renal perfusion
>oliguria/anuria
>renal shutdown
Disturbances in HEART as a Pump
Jenniffer TorralbaPaguio, RN
Renal >triggers posterior pituitary for
release of ADH
>stimulates erythropoeitin
production which stimulates the bone
marrow to produce RBC
>loose ability to regulate electrolyte
and acid-base balance
Endo
Hormone
>adrenal medulla releases
epinephrine and norepinephrine
>pitiutary gland releases ACTH to
stimulate adrenal cortex to produce
cortocisteroids:
-hydrocortisone
-aldosterone
>prolonged sever vasoconstriction
>enhances fluid retention and fluid
shift aggravating interstitial edema
Skin/
musculo
skeletal
>needs less oxygen and blood supply >peripheral circulatory prolapse
>cool,pale, clammy, mottled skin
>cyanosis
>muscle and tissue wasting
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Given the following diseases conditions, identify the pathophysiologic mechanisms involved in
terms of its effects on the pump variables (Preload, Afterload, Contractility), possible causes &
Clinical Manifestations.
Condition Variable
OR Possible
Causes
Signs & Symptoms
MI Contractility CAD, chronic
HPN
S: Chest pain unrelieved by rest
O: diaphoresisLabs: cardiac enzymes
Aortic/Mitral
Regurgitation
Pulmonary HPN
Cardiomyopathy
VSD
Pulmonic Valve
stenosis
Systemic HPN
Cardiogenic Shock
Arrhythmia HODS - November 2006 197
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