CARDIOVASCULAR REVIEW

Heart blood flow starts on the right side of the heart with deoxygenated blood
entering the right atrium (through vena cava), flowing through the tricuspid valve,
into the right ventricle, up through the pulmonic valve, into the pulmonary artery.

Then into the lungs for gas exchange (the blood now is oxygenated), it now enters
into the left side of the heart via the left atrium, down through the mitral valve,
into the left ventricle, up through the aortic valve, into the aorta, and lastly
throughout the body.
** Remember that depolarization of the heart cells leads to contraction, and
repolarization leads to relaxation
P wave: this represents atrial depolarization (leads to the atria contraction), which is
created by the SA node. The atria receive blood and they must push it down to the
ventricles by contracting. In other words, the p-wave is showing you that the atria are
contracting.

PR segment: this demonstrates the delay created by the AV node (remember it’s
the gatekeeper and gives the atria time to dump blood into the ventricles before they
contract). It’s a flat line after the p-wave.

PR interval: this interval starts at the beginning of the p wave and extends to the
beginning of the QRS complex. It demonstrates the amount of time it takes for the
electrical signal to go from the atria to the AV node (if this is too long in time it could
indicate a heart block). This is a part that is measured on the ECG.

QRS complex: this represents ventricle depolarization beginning which leads to the
contraction of the ventricles and in this waveform is also atrial repolarization
(relaxation of the atria), but it’s overshadowed by the large ventricles, so you can’t
really see it. This is a part that is measured on the ECG.
J-point: this is the point where the QRS complex meets the ST segment

ST segment: this represents the completion of ventricular depolarization and

beginning of ventricle repolarization. It starts at the end of the QRS and ends at the
beginning of the T-wave. The segment should be flat, hence isoelectric (no
depression or elevation of more than 1 mm).

T wave: this represents the beginning of ventricular repolarization which leads to

ventricle relaxation. The ventricles are so big that when they relax it creates the t
wave.

QT interval: starts at the beginning of the QRS complex and ends after the t wave. It
demonstrates the time it takes for electrical signals to cause the ventricles to contract
and then rest. This is a part that is measured on the ECG.

*U-wave: not always present but may indicate hypokalemia or another abnormality
in your patient.

CONCEPTS

Preload: blood returning to the right side of the heart

Afterload: pressure in which the ventricle ejects the blood

Compliance: how easily the heart expands when its full

Contractility: strength of the heart muscle when contracting

Stroke volume: volume of blood pumped out of the ventricle

Cardiac output: amount of blood the heart pumps to the circulatory system in 1
minute (affects tissues and organ function)

CO = stoke volume x heart rate

Poor cardiac output:

- decreased LOC (level of consciousness)

- chest pain
- weak pulse
- shortness of breath as well as crackles and rales
- cool, clammy and mottled skin
- decreased urine output
SINUS RHYTHM

PR interval: 0.12 - 0.20

QRS: <0.12

HR: 60-100

Regular

SINUS BRADYCARDIA

HR: <60

Causes: sleep, inactivity, drugs (propanolol, digoxin), MI, athletic

Regular

Treatment: pacemakers, atropine 0.5 mg IV every 3 to 5 minutes to a maximum total

dose of 3 mg, low salt diet

SINUS TACHYCARDIA
HR: >100

Causes: caffeine, exercise, fever, anxiety, drugs, pain, hypotension, volume

depletion

Regular

Treatment: Eliminate potential triggers or stimulants in your diet such as

caffeine, nicotine, and alcohol. Take medicine to slow the heart rate such as
ivabradine, beta-blockers, or calcium channel blockers. Exercise to improve quality
of life and to maintain a healthy heart.

ATRIAL FLUTTER

“Saw tooth” P-wave

No PR interval

HR: 250-400

Regular or irregular

Cause: heart disease, MI, CHF (congestive heart failure), pericarditis

Treatment: antiarrhythmic drugs, blood thinners, cardioversion, catheter ablation,

calcium-channel blockers (diltiazem) and beta-blockers (metoprolol).

ATRIAL FIBRILLATION
“Wavy” P-wave
No PR interval
HR: >400
Irregular
Cause: heart disease, pulmonary disease, stress, alcohol, caffeine
Treatment: beta blockers, blood thinners, cardioversion, catheter ablation

SUPRAVENTRICULAR TACHYCARDIA

Hidden P-wave
Immeasurable PR interval
HR: 150-250
Regular
Cause: caffeine, CHF, fatigue, hypoxia, altered pacemaker
Treatment: Bear down (like having a bowel movement), adenosine, cardioversion

VENTRICULAR TACHYCARDIA
No P-wave
No PR interval
QRS “wide and bizarre”
HR: 150-250
Regular
Cause: MI, ischemia, digoxin toxicity, hypoxia, acidosis, hypokalemia, hypotension,
pneumothorax, thrombosis, toxins
Treatment: catheter ablation, cardioversion, beta blocker, antiarrhythmic drugs

VENTRICULAR FIBRILLATION

No P-wave
No PR interval
No QRS
No HR
Irregular
Causes: MI, ischemia, hypoxia, acidosis, hypokalemia, hypotension, decreased
blood flow
Treatment: Implantable cardioverter-defibrillator (ICD), coronary angioplasty,
cardioversion, coronary bypass surgery

Premature ventricular contractions (PVCs) are extra heartbeats that begin in one
of the heart's two lower pumping chambers (ventricles). These extra beats disrupt
the regular heart rhythm, sometimes causing a sensation of a fluttering or a skipped
beat in the chest.
DEFINITIONS:

Beta blockers - Beta blockers, also known as beta-adrenergic blocking agents, are
medications that reduce blood pressure. Beta blockers work by blocking the
effects of the hormone epinephrine, also known as adrenaline.
Beta blockers cause the heart to beat more slowly and with less force, which
lowers blood pressure. Beta blockers also help widen veins and arteries to improve
blood flow.

ACE inhibitors - Angiotensin-converting enzyme (ACE) inhibitors are medications

that help relax the veins and arteries to lower blood pressure. ACE inhibitors
prevent an enzyme in the body from producing angiotensin II, a substance that
narrows blood vessels.

ARBS - Angiotensin receptor blockers (ARBs), also known as angiotensin II receptor

antagonists, are used to treat high blood pressure and heart failure. They are
also used for chronic kidney disease and prescribed following a heart attack. They
include irbesartan, valsartan, losartan and candesartan.

MI LABS

Troponin: cardiac biomarker; increases with myocardial damage

Levels are between 0 and 0.04 ng/mL.
CK-MB: cardiac isoenzyme; increases with damage to cardiac cells.
Levels are between 3 to 5% (percentage of total CK) or 5 to 25 IU/L.

MI TREATMENT

- Cath lab in 90 minutes

- Oxygen to help O2 delivery to heart
- Aspirin to prevent clots
- Nitroglycerin to vasodilate
- Morphine to decrease the workload of the heart

EDUCATION (MI)
- Quit smoking
- Increase activity
- Low fat, low salt, low cholesterol diet (fish, chicken, less red meat, fruit and
veggies)

PAM = PAS + (PAD x 2) / 3 or

MAP = (2 times the diastolic + systolic) / 3