CARDIOvascular LABS Mendocino COllege SPRING 2009 VIKI CHAUDRUE RN, MSN

1. CARDIOvascular LABSMendocino COllegeSPRING 2009VIKI CHAUDRUE RN, MSN

2. Cardiovascular disease Heart disease - leading cause of death for both women and men in the United States In 2005, 652,091 people died of heart disease (50.5% of them women) Estimated that 47% of cardiac deaths occur before emergency services or transport to a hospital 2009 - heart disease�s projected cost $304.6 billion, including health care services, medications, and lost productivity

3. Cardiovascular disease RiSK FACTORS Sedentary lifestyle Diabetes Hypertension Obesity Stress Hostile personality Cigarette smoking Anabolic steroids Amphetamines Oral contraceptives Diet high in saturated fats Heredity

4. Myocardial Infarction

5. MYOCARDIAL INFARCTION heart burn or indigestion nausea, dizziness, shortness of breath, acute onset of extreme fatigue, pain in one or both arms, pain in the neck or the jaw,

6. Labs Pertaining to an MI Troponins CKMB LDH Myoglobin Magnesium, Potassium, Calcium

7. Troponin Troponin consists of three regulatory proteins which are essential for skeletal and cardiac muscle contraction (not smooth muscle) Two cardiac troponins (T & I) which are very specific to myocardial muscle injury These biochemical markers are drawn on patients with chest pain to determine if cardiac ischemia is occurring Elevate 3 hours after cardiac muscle injury and can remain elevated for 2 weeks

8. Creatinine PhosphokinaseCK-MB (specifc isoenzyme) Creatine kinase is composed of two subunits, CK-M (muscle type) and CK-B (brain type), which are combined into three distinct isoenzymes: CK-MM, CK-MB, and CK-BB

9. Lactate dehydrogenase (LDH) Intracellular enzyme located in the heart, liver, RBCs, brain, kidneys, lungs and skeletal muscle Used to determine injury or disease of any of the above (due to cell lysis) 5 separate isoenzymes make up total LDH LDH-1 is mainly from the heart An elevated LDH level with greater than 40% of LDH-1 is indicative of heart injury

10. Myoglobin Myoglobin is an oxygen carrying heme protein present in high concentrations in the cytoplasm of cardiac and skeletal muscle Excreted in urine and nephrotoxic Elevated serum levels are not specific for acute myocardial infarction Can have elevated levels after exercise,intramuscular injections,skeletal muscle damage, renal failure, or shock

11. Cardiac Markers

12. Calcium, Magnesium, Potassium Recognize that serum calcium is vital to muscle contractility and cardiac function Magnesium is critical in ALL metabolic processes increased Mg slows cardiac conduction thus widening EKG values decreased Mg causes cardiac irritability and aggravates arrhythmias Potassium regulates neuromuscular excitability, cardiac contractility, cardiac rhythm, and extracellular volume

13. Congestive Heart Failure Failure of the heart to pump blood with normal efficiency-unable to provide adequate blood flow to other organs such as the brain, liver and kidneys Causes - (1) coronary artery disease leading to heart attacks and heart muscle deterioration (2) hyperlipidemia (3) viral infections or toxins (4) heart valve disease (5) hypertension (6) other- hyperthyroidism, vitamin deficiency, or excess amphetamine use.

14. CHF Signs and Symptoms SOB and DOE Cyanosis Left ventricular hypertrophy Cor Pulmonale- right sided heart failure r/t resp issues Pedal/generalized edema

15. Labs r/t the CV System B-Type Natriuretic Peptide (BNP) C Reactive Protein Digoxin Lipid Panel Apolipoproteins

16. B (brain)-Type Natriuretic Peptide (BNP) First isolated from pork brain Synthesized primarily by ventricular myocytes. Continuously released in response to both ventricle volume expansion and pressure overload Lab values have high fluctuation rate (time of day) Differentiates CHF from pulmonary disease Screens for CHF in high risk patients Determines CHF severity Monitors CHF therapy Risk stratification after acute MI Assesses left ventricular hypertrophy in dialysis patients Assesses chemotherapy cardiotoxicity

17. Mean BNP Concentration by Age

18. Digoxin Digoxin is a cardiac glycoside used to treat congestive heart failure, atrial fibrillation and atrial flutter Digoxin toxicity-nausea is the most common symptom, anorexia, diarrhea, ECG Changes heart block, bradycardia, and junctional tachycardia

19. C Reactive Protein C-reactive protein (CRP) is an acute phase protein synthesized in the liver The most sensitive indicator of small inflammatory stimuli that begins to rise four to six hours after tissue injury and peaks around 48 hours Inflammation plays a central role in the pathogenesis of atherosclerosis and thrombosis CRP is a marker of low-grade vascular inflammation that is predictive of future cardiovascular events

20. Lipid Panel Fasting Total Cholesterol High Density Lipoprotein Low Density Lipoprotein Very Low Density Lipoprotein Triglycerides

21. Total Cholesterol Measure of the cholesterol and triglycerides in your blood. Cholesterol is a soft, fatty, wax like substance known as �lipids� which is found in all body cells Cholesterol is a major predictor of coronary artery disease Optimal level (healthy person) is < 200mg/dl Values for patients with known coronary artery disease are different from those patients without coronary artery disease

22. High Density Lipoproteins �Good� cholesterol - removes excess cholesterol from your cells and the walls of your arteries and transports the cholesterol back to your liver for disposal (> 40mg/dl) Each 1 mg/dL increase in HDL results in a 2% decrease in CHD in men and a 3% decrease in women The ratio of total cholesterol to HDL is believed to be a more sensitive indicator of CHD (risk is high when total cholesterol is high and HDL is low)

23. Low Density Lipoprotein �Bad� cholesterol - too much LDL in the blood is a major cause of CHD The majority of the cholesterol in your blood is found in LDL (60-130 mg/dl).

24. Triglycerides Form of fat in the blood stream Triglycerides combine with cholesterol and protein to form lipoproteins The main form of storage lipid Transported via LDL and VLDL Diets high in fat cause increased levels of LDL and VLDL Normal is around 30-199 mg/dl

25. Very Low Density Lipoproteins VLDL contains a large amount of triglycerides and minimal protein Main purpose of VLDL is to distribute the triglycerides produced by the liver Also a �Bad� cholesterol and high levels contribute to CHD Normal value 2-38 mg/dl

26. Apolipoproteins (at least 9) Better indicators of CHD risks than lipoproteins Produce and transport cholesterol around the body Binds lipoproteins to lipoproteins for uptake into the cell APO A is the major polypeptide of HDL-increases with HDL increase

27. Diagnostic Tests r/t the CV System Electrocardiogram (ECG/EKG) Echocardiography (Echo) Magnetic Resonance Angiography (MRA) Coronary Angiography or cardiac catheterization Cardiac Nuclear Scanning

28. Electrocardiogram (ECG or EKG)Evaluates arrythmias, conduction defects, myocardial injury, hypertrophy and pericardial disease Translates the heart's electrical activity into line tracings on paper The spikes and dips in the line tracings are called waves. The P wave represents the electrical activity in the atria The Q, R, and S waves-called the QRS complex-represent the electrical activity in the ventricles The T wave represents the electrical recovery, or repolarization, of the ventricles

29. Echocardiography (Echo) Kind of ultrasound that picks up echoes of sound waves as they bounce off the parts of the heart and turned into moving, video pictures Transthoracic, Stress, Doppler, Transesophageal Evaluates heart wall motion, measures heart wall function, detects valvular disease, evaluates the heart during stress testing and identifies and quantifies pericardial fluid

30. Magnetic Resonance Angiography (MRA) Type of MRI scan that uses a magnetic field and pulses of radio wave energy to provide pictures of blood vessels inside the body Can provide information that cannot be obtained from an ultrasound or CT scan Detects clots, stenosed vessels, aneurysms and dissections

31. Coronary Angiography Cardiac Catheterization Used to visualize heart chambers, arteries, and great vessels, usually performed after a positive stress test A long catheter is passed through a peripheral vein (right-heart) or artery (left-heart) Right-heart cath measures cardiac output and identifies PEs Dye can be injected through the catheter to see whether the coronary arteries are blocked, how well the heart chambers are pumping, and whether heart valves are leaking. Can dilate stenosed arteries (angioplasty) with subsequent stent placement

32. Cardiac Nuclear Scanning Used to detect myocardial ischemia, infarction, wall dysfunction, and decreased ejection fraction. Commonly used as the imaging portion of cardiac stress testing (Thallium scan) Indications: chest pain/EKG changes,screening of adults for past and recent infarction, quantification and surveillance of myocardial infarction changes, myocardial perfusion before and after surgery, effectiveness of therapy for coronary artery perfusion, and status of patients receiving cardiotoxic drugs.

33. Stem Cells A �magic bullet� for cardiomyopathies Autologous Embryonic Placental Bone Marrow -mesenchymal Menstrual blood Adipose tissue http://www.ncbi.nlm.nih.gov/pubmed/18549704 http://www.mdconsult.com/das/article/body/132607011-2/jorg=journal&source=&sp=21979581&sid=0/N/692648/1.html?issn=0090-3493

34. Case Study Mr. Smith, a 55-year-old executive, has been brought to the emergency room after experiencing chest pain and shortness of breath during a board meeting. He has a history of hypertension and elevated cholesterol and lipoproteins and smokes one pack of cigarettes per day. He appears anxious and diaphoretic, and now complains of substernal chest pain rated 9 on a scale of 10. He is worked up for an MI and transferred to the Critical Care Unit.

35. Which of the following ECG readings is typical of changes resulting from an acute MI? a. An elevated ST segment b. Shortened P-R interval c. Altered Q-T interval d. A flat line

36. Which of the following is the most specific indicator of cardiac tissue damage? a. Lactate dehydrogenase (LDH) b. CRP c. Aspartate aminotransferase d. CK-MB

37. Which of the following is released into the circulation immediately after cardiac damage, but is rapidly excreted in the urine and lacks cardiac specificity? a. CPK b. Troponin c. Myoglobin d. LDH

38. The inflammatory process may cause a stable plaque to weaken and rupture. Which test is a nonspecific but sensitive indicator of inflammation? a. CRP b. CK-MB c. Troponin d. Myoglobin

39. Which of the following diagnostic procedures are used to reveal clinical information about coronary blood flow, ventricular size and ventricular function? a. ECG b. Echo c. MRA d. cardiac nuclear scans

40. References Center for Disease Control and Prevention, (2009). Heart Disease Facts and Statistics. Retrieved on 4/18/2009 from http://www.cdc.gov/heartDisease/statistics.htm ClinLab Navigator (2006). Test Interpretation of Serum Myoglobin. Retrieved on 4/19/2009 from http://www.clinlabnavigator.com/Tests/Myoglobin.html Mosby�s Medical Dictionary, 8th ed. (2009). Cardiac Nuclear Scanning. Retreived on April 19, 2009 from http://medical-dictionary.thefreedictionary.com/cardiac+nuclear+scanning Nucleus Communications, Inc. (2002). EKG Components and Intervals. Retrieved on April 19, 2009 from http://www.webmd.com/heart-disease/electrocardiogram