CLINICAL KNOWLEDGE BASIC

 Superior Vena Cava

o Unoxygenated blood from upper organs
 Inferior Vena Cava
o Unoxygenated blood from lower organs
4 Chamber of the Heart
 Pumps the blood
o Right Atrium
o Right Ventricle
o Left Atrium
o Left Ventricles
 Valves Of The Heart
o Prevent backflow
o Tricuspid
o Pulmonary
o Mitral
o Aortic
 Lungs
o Converts unoxygenated blood to oxygenated blood
 Arteries
o Away from the heart
 Veins
o Back to the heart
 Aorta
o Largest artery
o Carries the oxygenated blood to the different organs
 Sinoatrial Node
o Natural pacemaker of the heart
o Sends signals to the chamber to pump
 Atrioventricular Node
o Delays the signal sent by SA Node to the ventricles by .11 seconds

Bundle of His
 Carries the signal to ventricles
o Left Bundle Branches
o Right Bundle Branches
 Purkinje Fibers
o Rapidly transmit cardiac action potentials from the atrioventricular bundle to the myocardium of
the ventricles.
o responsible for coordinated ventricular contraction

CIRCULATORY SYSTEM PROCESS

1. Unoxygenated blood from upper part of the body that passes through the superior vena cava and the
unoxygenated blood from lower part that passes through inferior vena cava will enter the right atrium.
2. The right atrium pumps the unoxygenated blood to the right ventricle passing through tricuspid valve.
3. The right ventricle pumps the unoxygenated blood passing through pulmonary valve, then enters the
lungs via pulmonary artery.
4. In the lungs, the unoxygenated blood converts to oxygenated blood. The oxygenated blood will now enter
the left atrium via pulmonary vein.
5. The left atrium pumps the oxygenated blood to the left ventricle passing through mitral valve.
6. The left ventricle pumps the oxygenated blood passing through Aortic valve then the aorta and distributed
to the different organs of the body via arteries.

CARDIAC CONDUCTION SYSTEM PROCESS

1. Unoxygenated blood enters the right atrium. It stimulates the SA node to start fire the signals.
2. SA node starts the heartbeat, causing the atria to contract then the signal travels through the AV
node.
3. AV node delays the signal that SA node transmitted by .11 seconds then the signal travels to the
bundle of His.
4. Bundle of His transmits the signal to left and right bundle branches.
5. The left and right bundle branches are where the signal splits as it travel to the purkinje fibers.
6. The purkinje fibers then transmit the signal to the ventricles.
7. Ventricles start to pump.

Anatomy and Physiology of Cardiovascular System

Cardiovascular System
Three Major Components of the Cardiovascular System

1. Heart
o A muscular organ, about a size of a fist. Located just behind slightly left of the breast bone.
o It has 4 chambers namely:
• Left and Right Atrium
• Left and Right Ventricle
2. Blood
o The blood has 4 main components:
 o Red Blood Cells
o White Blood Cells
o Plasma
o Platelets
3. Blood Vessels
o Veins – blood vessels which carry blood from the body back to the heart
o Arteries – blood vessels that carry blood from the heart back to the body
o Capillaries – Microscopic blood vessels that connects arteries and veins together

Anatomy and Physiology of the Heart

Four Chambers of the Heart and its Functions

1. Right Atrium
o receives un-oxygenated blood from the veins and pumps it to the right ventricle.
2. Left Atrium
o receives oxygenated blood from the lungs and pump it to the left ventricle.
3. Right Ventricle
o receives un-oxygenated blood from the right atrium and pumps it to the lungs.
4. Left Ventricle
o pumps the oxygenated blood to the rest of the body

What is the normal rhythm of heart?

o The normal rhythm of the heart of also known as the “Normal Sinus Rhythm”.
o It means the electrical impulse from your Sinus node is being properly transmitted.
o For adults, the normal sinus rhythm usually accompanies a heart rate of 60-100 beats per minute.

Discuss the relationship of Circulatory and Conduction Process

o The circulatory process of the heart involves the blood flow while conduction process involves the
contraction of the heart.
o For each process is interrelated, if one process will not function well it will affect the other and vice
versa.
o It will cause disease of the heart and may cause a death of a person.
Intrinsic Conduction System – Arrhythmias

Definition:

o An arrhythmia is a problem with the rate or rhythm of your heartbeat. It means that your heart
beats too quickly, too slowly, or with an irregular pattern.
o Arrhythmias occur when the electrical signals to the heart that coordinate heartbeats are not
working properly. For instance, some people experience irregular heartbeats, which may feel like a
racing heart or fluttering.

Arrhythmias are broken down into:

• Slow heartbeat: bradycardia.
• Fast heartbeat: tachycardia.
• Irregular heartbeat: flutter or fibrillation.
• Early heartbeat: premature contraction.
Most arrhythmias are not serious, but some can predispose the individual to stroke or cardiac arrest.

Causes of arrhythmia

o Alcohol abuse can be a cause of arrhythmia, as can drug abuse.

o Any interruption to the electrical impulses that cause the heart to contract can result in arrhythmia.
o For a person with a healthy heart, they should have a heart rate of between 60-100 beats per
minute when resting.
o The more fit a person is, the lower their resting heart rate.
o Olympic athletes, for example, will usually have a resting heart rate of under 60 beats per minute
because their hearts are very efficient.
o A number of factors can cause the heart to work incorrectly, they include:
o alcohol abuse
o diabetes
o drug abuse
o excessive coffee consumption
o heart disease like congestive heart failure
o hypertension (high blood pressure)
o hyperthyroidism (an overactive thyroid gland)
o mental stress
o scarring of the heart, often the result of a heart attack
o smoking
o some dietary supplements
o some herbal treatments
o some medications
o Structural changes of the heart

Arrhythmia Symptoms
o Some patients have no symptoms, but a doctor might detect an arrhythmia during a routine
examination or on an EKG.
o Even if a patient notices symptoms, it does not necessarily mean there is a serious problem; for
instance, some patients with life-threatening arrhythmias may have no symptoms while others with
symptoms may not have a serious problem.
o Symptoms depend on the type of arrhythmia; we will explain the most common next:

Symptoms of tachycardia

o Tachycardia is when the heart beats quicker than normal; symptoms include:
o breathlessness (dyspnea)
o dizziness
o syncope (fainting, or nearly fainting)
o fluttering in the chest
o chest pain
o lightheadedness
o sudden weakness
Symptoms of bradycardia
o Bradycardia is when the heart beats slower than normal; symptoms include:
o angina (chest pain)
 o trouble concentrating
o confusion
o Difficulties when exercising
o dizziness
o fatigue (tiredness)
o lightheadedness
o palpitations
o shortness of breath
o syncope (fainting or nearly fainting)
o diaphoresis, or sweating

Types of Arrhythmias

Atrial fibrillation

• This is an irregular beating of the atrial chambers - nearly always too fast. Atrial fibrillation is
common and mainly affects older patients. Instead of producing a single, strong contraction, the
chamber fibrillates (quivers). In some cases, the atrium can fibrillate at 350 beats per minute and, in
extreme cases, up to 600.

Atrial flutter

• While fibrillation consists of many random and different quivers in the atrium, atrial flutter is usually
from one area in the atrium that is not conducting properly, so the abnormal heart conduction has a
consistent pattern. Neither are ideal for pumping blood through the heart.

• Some patients may experience both flutter and fibrillation. Atrial flutter can be a serious condition,
and untreated usually leads to fibrillation. A patient with atrial flutter will typically experience 250-
350 beats per minute.

Supraventricular tachycardia (SVT)

• A regular, abnormally rapid heartbeat. The patient experiences a burst of accelerated heartbeats
that can last from a few seconds to a few hours. Typically, a patient with SVT will have a heart rate of
160-200 beats per minute. Atrial fibrillation and flutter are classified under SVTs.

Ventricular tachycardia

• Abnormal electrical impulses that start in the ventricles and cause an abnormally fast heartbeat. This
often happens if the heart has a scar from a previous heart attack. Usually, the ventricle will contract
more than 200 times a minute.

Ventricular fibrillation

• An irregular heart rhythm consisting of very rapid, uncoordinated fluttering contractions of the
ventricles. The ventricles do not pump blood properly, they simply quiver. Ventricular fibrillation is
life threatening and usually associated with heart disease. It is often triggered by a heart attack.

Long QT syndrome

• A heart rhythm disorder that sometimes causes rapid, uncoordinated heartbeats. This can result in
fainting, which may be life-threatening. It can be caused by genetic susceptibility or certain
medications.
Arrhythmia versus dysrhythmia

• The words arrhythmia and dysrhythmia are interchangeable. In other words, they mean the same
thing. However, arrhythmia tends to be used more frequently.

EKG INTERPRETATION

Complications of Arrhythmias

o Stroke - fibrillation (quivering) means that the heart is not pumping properly. This can cause blood to
collect in pools and clots can form.
o If one of the clots dislodges it may travel to a brain artery, blocking it, and causing a stroke. Stroke
can cause brain damage and can sometimes be fatal.
o Heart failure - prolonged tachycardia or bradycardia can result in the heart not pumping enough
blood to the body and its organs - this is heart failure.
o Sudden Cardiac Arrest (SCA) - is a condition in which the heart suddenly and unexpectedly stops
beating. If this happens, blood stops flowing to the brain and other vital organs. SCA usually causes
death if it's not treated within minutes.

Sudden Cardiac Arrest (SCA) kills more people than all of the following combined (list):

o AIDS
o BREAST CANCER
o LUNG CANCER
o GUN SHOTS
o CAR ACCIDENTS

What is Blood Pressure?

 Blood pressure is the force of your blood pushing against the walls of your arteries. Each time your
heart beats, it pumps blood into the arteries. Your blood pressure is highest when your heart beats,
pumping the blood. This is called systolic pressure.

 The diastolic reading, or the bottom number, is the pressure in the arteries when the heart rests
between beats. This is the time when the heart fills with blood and gets oxygen. This is what your
diastolic blood pressure number means: Normal: Lower than 80.

What is Cardiac Output?

 term that describes the amount of blood your heart pumps each minute. Doctors think about cardiac
output in terms of the following equation: Cardiac output = stroke volume × heart rate. CO= SV*HR
  It's different for different people, depending on their size. Usually, an adult heart pumps about 5 liters
of blood per minute at rest. But when you run or exercise, your heart may pump 3-4 times that much to
make sure your body gets enough oxygen and fuel.

Why is maintaining cardiac output so important?

 Sufficient cardiac output helps keep blood pressure at the levels needed to supply oxygen-rich blood
to your brain and other vital organs.

What are the determinants of Cardiac Output?

1. Heart Rate- beats per min.

a. Chronotropes factors; influence heart rate.

a1. positive means increasing heart rate (Sympathetic stimulation adrenaline, such as drug
called Atropine.
a2. negative, decreased heart rate.
Parasympathetic stimulation decrease heart rate, a drug called Acetylcholine and
Adenosine .
* 3 Factors that affect Stroke Volume*

2. Preload- the amount of blood entering the ventricle during diastole (relax). Volume entering the ventricle
is influenced by; Venous return (the flow of blood from the periphery back to the right atrium,) Atrial
contraction (“atrial kick,” occurs at the end of diastole just before the closing of the mitral valve and after
passive flow has reached the diastasis. Fluid Volume (bodily fluids or bio fluids are liquids within the human
body).
3. Afterload- ventricle resistance must overcome blood:
2 factors affect Afterload;
A1. Atherosclerosis- the buildup of fats, cholesterol and other substances in and on your artery
walls. This buildup is called plaque. The plaque can cause your arteries to narrow, blocking blood flow. The
plaque can also burst, leading to a blood clot.
A2. Vasoconstriction - the narrowing (constriction) of blood vessels by small muscles in their walls.
When blood vessels constrict, blood flow is slowed or blocked. Vasoconstriction may be slight or severe. It
may result from disease, drugs, or psychological conditions.
4. Contractility- actions on how hard myocardium contracts for a given Preload.
Things that influence Contractility:
4A. Positive Inotropes- increase contractility (Dobutamine)
4B. Negative Inotropes- decrease contractility (Calcium Channel Blockers/ Beta-Blockers drug).

What is Ejection Fraction?

o Hearts ability to contract well to pump blood. (Compares amount of blood in chambers to the %
amount of blood pumped out).

o A.50-70% normal EF pumping of blood (perform regular activity).

o B. 41-49% Borderline EF (symptoms you felt in your body such as shortness of breath
noticeable).
o C. 40% and below – Reduced EF (symptoms is noticeable even in rest).
 Heart Failure; the heart's difficulties in pumping enough blood in the body.
EF= EDV- ESV x100
 EDV
o EF- Ejection Fraction
o EDV- End Diastolic Volume

What is Pulse Pressure?

 the difference between the upper and lower numbers of your blood pressure. This number can be
an indicator of health problems before you develop symptoms. Your pulse pressure can also sometimes that
you're at risk for certain diseases or conditions.
* Hydrostatic Pressure- Refers to the pressure that any fluid in a confined space exerts. Capillaries are known
as the pressure that Blood exerts
• Systolic- Augmented Wave Hydrostatic Pressure
• Diastolic- Standing Pressure Hydrostatic
Normal Pulse Pressure?

 The normal range of pulse pressure is between 40 and 60 mm Hg. Pulse pressure tends to increase
after the age of 50. This is due to the stiffening of arteries and blood vessels as you age.
 Narrow/ Wide Pulse Pressure Pathology

What is Mean Arterial Pressure?

 MAP is a clinical indicator of the degree of perfusion (blood flow) from systemic arteries to the
tissues. All tissues need sufficient O2, glucose, and other nutrients.
* To calculate MAP = (Systolic- Diastolic )+ Diastolic
3

* Normal Range

70 mmHg < MAP < 110 mmHg

* Low Tissue Perfusion * High Resistance

* 60 mmHg under, indicates your * 100mmHg over, a lot of pressure in

blood may not reach your major organ arteries, which can lead to blood cloths
Begins to die and permanent organ damage and damages the heart muscle.

What are the Wave Components of the

Cardiac Conduction System?
 o P Wave- Atrial Depolarization (represents the electrical depolarization of the Atria of the heart. A
small positive deflection from the isoelectric baseline that occurs before QRS complex).
o QRS Wave- Ventricular Depolarization (represents a electrical phenomenon as an crucial stage in
electrical cardiac activity. Expressed EKG by the interval of the QRS complex and the end of the T
wave or U
o Wave).
o T Wave- Ventricular Repolarization (complex electrical phenomenon which represents a crucial stage
in electrical cardiac activity. It is expressed on the surface electrocardiogram by the interval between
the start of the QRS complex and the end of the T wave or U wave (QT).

Chronic Obstructive Pulmonary Disease

o Trachea – also known as windpipe, is a tube about 4 inches long & less than an inch diameter in
most people. The trachea then divides into two smaller tubes called bronchi: one bronchus for each
lung.
o Bronchi – are the two large tubes (left & right main bronchus) that carry air from your windpipe to
your lungs. After the main bronchi, these tubes branch out into segments that look like tree
branches.
o Bronchioles – are air passages inside the lungs that branch off like tree limbs from the bronchi. The
bronchioles deliver air to tiny sacs called alveoli where oxygen & and carbon dioxide are exchanged.
o Alveoli – are where the lungs and the blood exchange oxygen and carbon dioxide during the process
of breathing in and breathing out.

What is Alveoli?

➢ Little sacs for oxygen.

➢ Alveoli are tiny air sacs in your lungs that take up the oxygen you breathe in and keep your body
going. Although they’re microscopic, alveoli are the workhorses of your respiratory system.

➢ You have about 480 million alveoli, located at the end of bronchial tubes. When you breathe in, the
alveoli expand to take in oxygen. When you breathe out, the alveoli shrink to expel carbon dioxide.

How alveoli work

 There are three overall processes involved in your breathing:

o moving air in and out of your lungs (ventilation)
o oxygen-carbon dioxide exchange (diffusion)
o pumping blood through your lungs (perfusion)
 Although tiny, the alveoli are the center of your respiratory system’s gas exchange.
 As it moves through blood vessels (capillaries) in the alveoli walls, your blood takes the oxygen from
the alveoli and gives off carbon dioxide to the alveoli.
Alveoli and your respiratory system
  Picture your lungs as two well-branched tree limbs, one on each side of your chest. The right lung
has three sections (lobes), and the left lung has two sections (above the heart). The larger branches
in each lobe are called bronchi.
 The bronchi divide into smaller branches called bronchioles. And at the end of each bronchiole is a
small duct (alveolar duct) that connects to a cluster of thousands of microscopic bubble-like
structures, the alveoli.
Impacts to Alveoli
 Smoking
o Tobacco smoke irritates your bronchioles and alveoli and damages the lining of your lungs.
o Tobacco damage is cumulative. Years of exposure to cigarette smoke can scar your lung tissue so
that your lungs can’t efficiently process oxygen and carbon dioxide. The damage from smoking
isn’t reversible.
 Pollution
o Indoor pollution from secondhand smoke, mold, dust, household chemicals, radon, or asbestos
can damage your lungs and worsen existing lung disease.
o Outdoor pollution, such as car or industrial emissions, is also harmful to your lungs.

What is Chronic Obstructive Pulmonary Disease?

COPD refers to a group of diseases that cause airflow blockage and breathing-related problems. It
includes emphysema and chronic bronchitis.

Key Facts:
 COPD is the third leading cause of death worldwide, causing 3.23 M deaths in 2019.
➢ Nearly 90% of COPD deaths in those under 70 years of age occur in low- and middle-income
countries.
➢ COPD causes persistent and progressive respiratory symptoms, including difficulty in breathing,
cough and phlegm production.
➢ COPD results rom long-term exposure to harmful gases and particles combined with individual
factors, including events which influence lung growth in childhood and genetics.
➢ Environmental exposure to tobacco smoke, indoor air pollution and occupational dusts, fumes and
chemicals are important risk factors for COPD.
➢ Early diagnosis and treatment, including smoking cessation support, is needed to slow the
progression of symptoms and reduce flare-ups.
Common Causes of COPD

➢ Cigarette Smoking – most common reason people get COPD.

➢ Secondhand smoke
➢ Pollution and fumes (dust, toxic substances at work)
➢ Your genes - in rare cases, people with COPD have a defect in their DNA, This defect is called “Alpha-
1 antitrypsin deficiency”.
➢ Asthma

Emphysema

 This results from damage to your lungs’ air sacs (alveoli) that destroys the walls inside them and
causes them to merge into one giant air sac. It can’t absorb oxygen as well, so you get less oxygen in
your blood.
  Damaged alveoli can make your lungs stretch out and lose their springiness. Air gets trapped in your
lungs and you can’t breathe it out, so you feel short of breath.

Bronchitis

 is when the tubes that carry air to your lungs, called the bronchial tubes, get inflamed and swollen.
You end up with a nagging cough and mucus.

There are two types:

o Acute bronchitis. This is more common. Symptoms last a few weeks, but it doesn’t usually cause
problems past that time.
o Chronic bronchitis. This one is more serious. It keeps coming back or doesn’t go away.

Lung Conditions
 Asthma - is a long-term disease of the lungs. It causes your airways to get inflamed and narrow, and
it makes it hard to breathe. Severe asthma can cause trouble talking or being active. You might hear
your doctor call it a chronic respiratory disease.
 An asthma attack is a sudden worsening of asthma symptoms caused by the tightening of muscles
around your airways. This tightening is called a bronchospasm. During the asthma attack, the lining
of the airways also becomes swollen or inflamed and thicker mucus -- more than normal -- is
produced.
 Obesity Hypoventilation Syndrome- Extra weight makes it difficult to expand the chest when
breathing. This can lead to long-term breathing problems.
 Obesity means too much body fat. It's usually based on your body mass index (BMI), which you can
check using a BMI calculator. BMI compares your weight to your height.
 If your BMI is 25 to 29.9, you're overweight but not obese. A BMI of 30 or more is in the obese
range.
How Obesity Can Affect Your Health
• High blood pressure, Heart disease and stroke
• Type 2 Diabetes
• High cholesterol
• Joint problems caused by extra weight
• Trouble breathing, including sleep apnea, in which you briefly stop breathing while you're asleep

Overview
 COPD is a common, preventable and treatable chronic lung disease.
 Abnormalities in the small airways of the lungs lead to limitation of airflow in and out of the lungs.
Several processes cause airways to become narrow, destruction of parts of the lung, mucus blocking
the airways, inflammation, and swelling of the airway lining.
 COPD sometimes called emphysema or chronic bronchitis.
 COPD and asthma share common symptoms (cough, wheeze, DOB) and people may have both
conditions.
Blood Pressure and Hypertension
Blood pressure
• is the pressure of circulating blood on the walls of blood vessels. It is essential to life
because it forces the blood around the body, delivering all the nutrients (oxygen) it needs.
 • The first (or top) number is your systolic blood pressure. It is the highest level your blood
pressure reaches when your heart beats. The second (or bottom) number is your diastolic
blood pressure. It is the lowest level your blood pressure reaches as your heart relaxes
between beats.
Normal (Normotensive)
• Normal blood pressure is defined as a systolic (top number) BP between 100 and 119 mm Hg (less
than 120 mmHg) and a diastolic (bottom number) BP below/ less than 80 mm Hg.

Elevated

• Elevated blood pressure means your blood pressure is slightly above normal. It will likely turn into
high blood pressure (hypertension) unless you make lifestyle changes, such as getting more exercise
and eating healthier foods.
• 120/70 – 129/79

Hypertension

• Is when your blood pressure, the force of your blood pushing against the walls of your blood vessels,
is consistently too hi gh. It is a common condition in which the long-term force of the blood against
your artery walls is high enough that it may eventually cause health problems, such as heart
disease. ... The more blood your heart pumps and the narrower your arteries, the higher your blood
pressure.
• #1 Cause of Stroke (Philippine Stroke Society)
• #2 Cause of Fatalities (death) in the Philippines

Hypotension

• Also known as low blood pressure, is a blood pressure under 90/60 mm/Hg.
• It can happen either as a condition on its own or as a symptom of a wide range of conditions. It may
not cause symptoms, but when it does, it can require medical attention.
Hypotension has two definitions:

1. Absolute Hypotension: Your resting blood pressure is below 90/60 mmHg.

2. Orthostatic Hypotension: Your blood pressure drops within three minutes of you standing up from
sitting position. The drop must be 20 mmHg or more for your systolic (top) pressure and 10 mmHg or
more for your diastolic (bottom) pressure.
o Also known as Postural Hypotension because it happens with changes in posture.
What causes low blood pressure?

o Orthostatic Hypotension
o Central Nervous System Diseases (Parkinson’s Disease)
o Low Blood Volume
o Life-threatening conditions (irregular heart rhythms (arrhythmias), pulmonary embolism, heart
attacks and collapsed lung, allergic reactions, sepsis)
o Bradycardia
o Tachycardia
o Medications (Lasix, beta blockers)
o Drugs
o Alcohol
o Extreme temperatures
o Blood Loss
 o Pregnancy

Types of Hypertension

1. White Coat (WCH)

o Prevalent is up to 20% of patients appearing to have HTN from clinic BP readings by nurses;
employers may be concerned.
2. Masked (MH)
o Prevalent in 15 – 30% of patients appearing to have normal HTN in clinic setting; referred to
as reverse WCH, It is hidden until ABPM is performed.
3. Nocturnal
o HTN at night only, but normal during the day.
4. Resistant
o HTN that does not improve after pharmacologic therapy.
5. Non-Dipper
o BP that doesn’t drop > 10% of average daytime BP.

Types of Hypertension (broad)

Primary (essential) Hypertension

For most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure, called
primary (essential) hypertension, tends to develop gradually over many years.

Secondary Hypertension

• Some people have high blood pressure caused by an underlying condition. This type of high blood
pressure, called secondary hypertension, tends to appear suddenly and cause higher blood pressure
than does primary hypertension. Various conditions and medications can lead to secondary
hypertension, including:

• Obstructive sleep apnea

• Kidney problems
• Adrenal gland tumors
• Thyroid problems
• Certain defects you're born with (congenital) in blood vessels
• Certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain
relievers and some prescription drugs
• Illegal drugs, such as cocaine and amphetamines

Ambulatory BP Monitor vs Clinic BP Monitor vs Home BP Monitor

Variable ABPM CBPM HBPM

True, or mean BP Yes Questionable Yes
Diurnal BP rhythm Yes No No
Dipping status Yes No No
Morning surge Yes No Questionable
Blood-pressure variability Yes No Questionable
Duration of drug effects Yes No Yes
DIPPING STATUS AND MORNING SURGE

One of the unique aspects of ambulatory blood pressure (BP) monitoring is its ability to record the diurnal
variation of BP. The normal pattern is a decrease of around 10%−20% during the night, which coincides with
the hours of sleep, and is commonly referred to as dipping status.

Dipping Status

• Fall in pressure during sleep time

• Associated to Nocturnal Blood Pressure
• defined as the difference between daytime mean systolic pressure and nighttime mean systolic
pressure expressed as a percentage of the day value
Dipping Status Formula

Sample Computation:
• Day BP
 135/95
 123/72
 140/85
• Night BP
 110/70
 90/68
 130/79

Range Class Higher-risk of Left Ventricular Hypertrophy and

<0% Reverse Dipper cardiovascular mortality
0% - 9.9% Non-Dipper
10% - 15% (0r 20%) Dipper Normal
>15% (or >20%) Extreme Dipper Likely to have Silent Cerebral Infarct
High-risk for Stroke

Morning Surge

1. Sleep-Trough Surge
o defined as the morning BP (2-hour average of four 30-minute BP readings just after waking
up) minus the lowest nocturnal BP (1-hour average of the 3 BP readings centered on the
lowest nighttime reading
o STS = [(AWBP1+AWBP2+AWBP3+AWBP4)/4]-[(LNBP1+LNBP2+LNBP3)/3]
2. Pre-waking Surge
o defined as the morning BP (2-hour average of 4 BP readings just upon waking up) minus the
pre-waking BP (2-hour average of 4 BP readings just before waking up)
o PWS = [(AWBP1+AWBP2+AWBP3+AWBP4)/4]-[(PWBP1+PWBP2+PWBP3+PWBP4)/4]

SPIROMETRY
 “SPIRO” – from the Greek word for breathing
 “METRY” – measurement
 “SPIROMETRY” – the measurement of breathing
What is Spirometry?

 A measure of airflow and lung volumes during a Forced Expiratory Maneuver from Full Inspiration
 A method of assessing Lung Function by measuring the total volume of air the patient can expel from
the lungs after a maximal inhalation.

LUNG VOLUMES Forced Vital Capacity Maneuver

Spirometry Indications
o Smoking / Smoking with symptoms
o Shortness of breath / Shortness of breath during exercise or other physical exertion
o Chronic cough
o Frequent colds
o Allergic rhinitis
o Known or possible asthma
o Known or possible bronchitis
o Known or possible COPD
o Wheezing
o Exposure to environmental air pollution
o Determine severity of impairment and disability in patients with respiratory disease
o Follow the course of the disease in a patient including the response to therapy
o Assess preoperative risk for predicting postoperative respiratory complications

Why do office Spirometry?

o Diagnostic accuracy. 30% of the time diagnosis changes.
o Was not COPD; heart failure or asthma
o Was COPD rather than asthma
o If spirometry is normal, then expensive meds discontinued
o Respect.
o Patients respect physicians who use technology
o Patient convenience.
o You can avoid an unnecessary referral and additional visit
o Diagnostic power:
o You can connect diagnostic information with the rest of the clinical encounter
o Financial benefit to practice.
Definitions
 o FVC – Forced Vital Capacity
o Volume of air exhaled after a maximal inspiration to total lung capacity. This volume is
expressed in Liters
o FEV1 – Forced Expiratory Volume in 1 second
o Volume of air exhaled in the first second of expiration.
o This volume is expressed in Liters
o FEF 25-75%
o Mean expiratory flow during the middle half of the FVC maneuver; reflects flow through
later emptying airways, not necessarily the small airways
o FEV1/FVC – Ratio (%)
o Volume of air expired in the first second, expressed as a percent of FVC

Performance of FVC maneuver

 Patient assumes the position (typically standing)

o Puts nose clip on
o Inhales maximally
o Puts mouthpiece in mouth and closes lips around mouthpiece (open circuit)
o Exhales as hard and fast and long as possible
o Repeat instructions if necessary – effective coaching is essential
o Give simple instructions
o Repeat a minimum of three times (check for repeatability)

Special Considerations in Pediatric Patients

o Ability to perform spirometry dependent on the developmental age of the child, personality, and
interest.
o Patients need a calm, relaxed environment and good coaching. Patience is key.
o Be creative
o Use incentives
o Even with the best of environments and coaching, a child may not be able to perform spirometry.

None of the following should occur:

o Unsatisfactory start, with excessive hesitation or false start

o Air leak
o Coughing during the first second
o Early termination of forced expiration
o Glottis closure
o Obstructed mouthpiece
o Tongue
o False teeth
o Chewing gum

Contraindications

o Hemoptysis of unknown origin

o Pneumothorax
o Unstable cardiovascular status or recent MI or PE
o Thoracic, abdominal, or cerebral aneurysms
 o Recent eye, thorax or abdomen surgery

Individual variation according to age, height, ethnicity and gender

1. Height - Tall people have larger lungs

2. Age - Respiratory function declines with age
3. Sex - Lung volumes smaller in females
4. Race - Studies show Blacks and Asians have smaller lung volumes (-12%)
5. Posture - Little difference between sitting and standing; reduced in supine position

Measurements for Simple Spirometry

Abbreviation Characteristic measured

FEV1 Forced expired volume in 1 second

FVC Forced vital capacity
FEV1 /FVC Ratio Ratio of the above

Flow Volume Loops

Bronchodilator reversibility testing

o Beta-agonist
o Short-acting – wait 20 minutes before retesting
o Long-acting – wait 2 hours before retesting
o Do not take bronchodilator the day of testing
o Measured reversibility will be limited if the patient is bronchodilated for the pretest.
Definition of reversibility
o Pre-Bronchodilator
o FEV1/FVC <70% of predicted
o Post-Bronchodilator
o Increase 12% predicted and at least 200 cc on FEV1 and/or FVC
Reversibility = Asthma!

Common Obstructive Pulmonary Disorders

Diffuse Airway Disease Upper-Airway Obstruction

Asthma Foreign body
COPD Neoplasm
Bronchiectasis Tracheal stenosis
Cystic fibrosis Tracheomalacia
 Vocal cord paralysis

Diagnostic Flow Diagram for Obstruction

FEV1 / FVC Ratio Low? (<70%)

Severity of obstruction
FEV1 % of predicted
Mild >70
Moderate 60 to 69
Moderately Severe 50 to 59
Severe 35-49
Very Severe 34 and below

Spirometry Exercises
Example
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured % Measured % % change
FVC 4.65 4.65 100 4.95 106 6
FEV1 3.75 3.13 83 3.34 89 6
FEV1/ 80 67 -13 67 -13 0
FVC
Is there an obstruction?
FEV1/FVC = 67% of predicted; therefore, obstruction present
Is there a restriction?
FVC = 100% of predicted; therefore, no restriction present
How severe is the Obstruction?
FEV1 = 83 of predicted; therefore, mild
Is there reversibility after post-bronchodilator?
% change is 6 on FVC and 6 on FEV1
actual volume is 300 on FVC and 210 on FEV1
 NONE
INTERPRETATION:
Mild Obstructive Ventilatory Defect with no significant response to bronchodilator

Common Restrictive Pulmonary Disorders

“Full” Pulmonary Function Testing (PFT’s)

 Assessment of Oxygenation
o Transcutaneous oxygen saturation
o Arterial blood gasses
 Diffusion test to evaluate alveolar exchange (DLCO)
 Plethysmography
o To objectively assess lung volumes
o Delineate air-trapping versus restriction
 May also include Spirometry
 Peripheral Arterial Disease
o PAD is caused by atherosclerosis, or plaque buildup, that reduces the flow of blood in the
peripheral arteries, the blood vessels that carry blood away from the heart to other parts of the
body, including in the heart, brain, arms, legs, pelvis and kidneys.
o If you have PAD, you may also have plaque buildup in other arteries leading to and from your
heart and brain, putting you at higher risk of stroke or heart attack.
o 70% of patients with PAD do not experience traditional symptoms and are not diagnosed.
o Many people mistake the symptoms of PAD for something else.
o PAD often goes undiagnosed by health care professionals.
o Left untreated, PAD can lead to gangrene and amputation.
o According to American Heart Association and the European Society of Cardiology Guidelines on
the prevention CVD, both guidelines recommend ABI measurement as the first step to early
discover LEAD and lower the number of deaths caused by CVD.

What Is Atherosclerosis?

o Is a hardening and narrowing of your arteries

caused by cholesterol plaques lining the artery
over time. It can put blood flow at risk as your
arteries become blocked
 What Causes Atherosclerosis?

o High cholesterol
o High blood pressure
o Obesity
o Diabetes
o Smoking

What Are the Risk Factors for PAD?

o If you have heart disease, you have a 1-in-3 chance of having PAD. Other things that raise your
chance of having PAD include:
Age (older than 50), Diabetes, High cholesterol, High blood pressure, Obesity,
Not being active, Smoking
o According to the latest International Guidelines on Peripheral Arterial Disease (PAD), it is essential to
discover it in the early stage. The goal is to prevent its dangerous outcomes such as:
Heart Attacks, Strokes, Ulcerations, Amputations
Ankle Brachial Index (ABI)

o A non-invasive method of obtaining the blood

pressure readings in the lower extremities to
check PERIPHERAL ARTERIAL DISEASE (PAD),
and is the first-line test to diagnose
Peripheral Arterial Disease.
o It can help determine patients needing
further testing for PAD via duplex.

ABI Indications:

o Patient’s clinic BP is >120/80 mmHg

o Chronic Kidney Disease
o Diabetes
o Individuals over 50 years old with cardiovascular risk factors: (Hypertensive, Overweight,
Ulcerations, Diabetes, Smoker, History of heart attack & stroke)
o Wound Care Assessment
o Useful for the diagnosis of LEAD (Lower Extremity Arterial Disease)

24-Hours Ambulatory EKG/ Holter Monitoring

What is a 24-hour Ambulatory EKG/ Holter Monitoring?

o 24-hour Holter Monitoring is a continuous test to record your heart's rate and rhythm for 24 hours
by using a 24-hour Holter Monitor.
o You wear the Holter monitor for 24 to 48 hours as you go about your normal daily routine and even
as you sleep.
o This device has electrodes and electrical leads exactly like a regular EKG, but it has fewer leads.

Holter Indications

o Shortness of breath
o Palpitations (43% of patients have cardiology etiology)
o Chest pain
o Abnormal ECG (Skipped beats, PVCs; PACs)
o Syncope (dizziness; fainting)
o Unexplained syncopal episode, transient episode of cerebral ischemia
o Significant cardiac or conduction disorder
o Heart condition associated with a high incidence of serious cardiac arrhythmias and/or myocardial
ischemia
o Cardiac arrhythmias, cardiac condition, and cardiac medication which affects the electrical
conduction system
o Whenever adding or changing a heart medication (is. ARB; ACE inhibitor, Beta Blocker)
o Check effectiveness of anti-arrhythmias
o Post AF catheter-ablation
o When starting new heart medications
o Post MI
o Hypertension
ECG Artifacts
o ECG artifacts were originally classified as pseudo-arrhythmias and nonarrhythmia artifacts.
o Pseudo-arrhythmias were classified into pseudo-tachyarrythmias and pseudo-bradyarrythmias.
o Pseudo-tachyarrhythmias artifacts are most related to body movement, temporary impairment of
skin-electrode contact, loose electrode connections, broken leads, skeletal myopotentials (electric
signal arising in skeletal muscle activity), and ambient noise which can generate deflections that can
stimulate pseudo-atrial arrhythmias or pseudo-VT.
o Pseudo-bradyarrthymias artifacts are most probably related to intermittent impairment of electrode
contact.
Causes of artifacts on ECG/ Holter result & how to avoid/lessen.
o Perform good skin preparation- Good skin preparation should include:
o Shaving or clipping the patient’s chest hair if present.
o Rubbing the skin with a gauze pad with isopropyl alcohol.
o Ensure the electrodes are well secured before the patient leave the clinic - This will reduce
movement of electrodes as much as possible. Remember excessive sweating, which may cause the
leads to loosen or come off. Loose electrodes connections can impair the quality of ECG recordings
(artifacts).
o Use high-quality of ECG electrodes- Ensure you are using a high quality of ECG electrode which
features a highly conductive wet gel that has been specially formulated to provide the best adhesion
possible.
 o Ensure correct electrode & lead wire positioning- electrodes/ lead wire are not placed over bones,
irritated skin or areas where there are lots of muscle movement. (Male chest vs Female chest)
o It is also advised the patient to stay away from metal detectors or large magnets, high-voltage
electrical wires, and electrical appliances such as electric shavers, microwave ovens. Cellphones can
also interfere with the signals and should be kept at least 6 inches away from the
o Clean your Holter lead wires properly- Should be cleaned prior to every hook up. This helps to
prevent the build-up of gel, and tape residue on the lead wires and each top of its channel (head). -
Ask each AE how they clean lead wires?
o Check the device and lead wires-
o Ensure the lead wires is correctly connected to the Holter monitor. You should check the device
calibration date, the lead wires for breaks and cracks and replaced as required.
o Avoid pulling out the lead wires when cleaning, twisting it or even braiding it like your hair.

Important Reminder

o Please don’t use holter device with the defibrillation device.

o Please don’t use device which has High level electromagnetic radiation in the vicinity of the
recorder/ when scanning MRI.
o Avoid the recorder to be wet and damaging it (no showering, bathing, swimming, etc).
o Do not participate into rough activities that may damage the device.
o Avoid repeat test by not tampering with Holter monitor or the electrodes on your skin.

24-Hours Ambulatory Blood Pressure Monitoring

What is a 24-Hour Ambulatory Blood Pressure Monitoring?

o 24-Hour Ambulatory Blood Pressure Monitoring is a method or procedure to measure blood

pressure on a routine daily living by using a 24-Hour Ambulatory Blood Pressure Monitor even as you
sleep.
o The on-going data helps your doctor get a more accurate picture of your blood pressure numbers.
INDICATIONS OF ABPM

o Patient with BP ≥ 120/80 mmHg

o New Hypertension Guideline by AHA
o To rule out Hypertension (White Coat, Masked, Nocturnal HPN)
o Overweight. Body Mass Index > 25%
o Smokers and high Alcohol Intakes
o Mental Stress
o Family History of Hypertension
o Patients with Diabetes and Chronic kidney disease
o To check effectiveness of anti-Hypertensive drugs
o Repeat ABPM/Assessment of treatment

What are the importance of mastering the knowledge about Cardiovascular System, Circulatory Process,
and Cardiac Conduction Process to you as an AE/DSL?

o Product knowledge is a very important key point of selling.

 o We are dealing with medical professionals, and the best way to represent one self is being
knowledgeable.
o Learning and mastering the basics and to have a better understanding of the target organs of our
devices will be a big advantage in the field.
Role of Account Executive

o Ensure patient identification and review indications for procedure.

o Explain purpose of the procedure and clarify requirements of the patient including diary and
acknowledgment form.
o Prepare skin sites appropriately prior to electrode application.
o Upon patient return, disconnect monitor/ recorder.
o Inspect equipment to ensure proper working order and take any actions as required.
o The recorder can be clean with the use of grade ethanol and dried in air or with dry and clean cloth.
Please take out the batteries if the recorder is not in use for a long time and proper safekeeping.