A patient presents to the emergency department with a diastolic blood pressure of 132 mm Hg, retinopathy, and symptoms of an ischemic stroke. This symptomology is likely the result of

hypertensive crisis.

Which serum biomarker(s) are indicative of irreversible damage to myocardial cells?

Elevated CK-MB, troponin I, and troponin T

While hospitalized, an elderly patient with a history of myocardial infarction was noted to have high levels of low-density lipoproteins (LDLs). What is the significance of this finding?

Increased LDL levels are associated with increased risk of coronary artery disease.

Critically ill patients may have parenterally administered vasoactive drugs that are adjusted according to their _____ pressure.

mean arterial

A loud pansystolic murmur that radiates to the axilla is most likely a result of

mitral regurgitation.

After being diagnosed with hypertension, a patient returns to the clinic 6 weeks later. The patient reports “moderate” adherence to the recommended lifestyle changes and has experienced a decreased from 165/96 to 148/90 mm Hg in blood pressure. What is the most appropriate intervention for this patient at this time?

Continue lifestyle modifications only.

Primary treatment for myocardial infarction (MI) is directed at

decreasing myocardial oxygen demands.

A patient has a history of falls, syncope, dizziness, and blurred vision. The patient’s symptomology is most likely related to

hypotension

TRUE/FALSE, The ingestion of certain drugs, foods, or chemicals can lead to secondary hypertension.

True

Patent ductus arteriosus is accurately described as a(n)

communication between the aorta and the pulmonary artery.

What compensatory sign would be expected during periods of physical exertion in a patient with limited ventricular stroke volume?

Tachycardia

Myocarditis should be suspected in a patient who presents with

acute onset of left ventricular dysfunction.

An elderly patient’s blood pressure is measured at 160/98. How would the patient’s left ventricular function be affected by this level of blood pressure?

Left ventricular workload is increased with high afterload.

Restriction of which electrolytes is recommended in the management of high blood pressure?

Sodium

The most reliable indicator that a person is experiencing an acute myocardial infarction (MI) is

ST-segment elevation.

Aortic regurgitation is associated with

diastolic murmur.

Which blood pressure reading is considered to be indicative of prehypertension according to the JNC-7 criteria?

128/82

The prevalence of high blood pressure is higher in

non-Hispanic black adults

Rheumatic heart disease is most often a consequence of

β-hemolytic streptococcal infection.

A middle-aged patient has a follow up visit for a recorded blood pressure of 162/96 mm Hg taken 3 weeks ago. The patient has no significant past medical history and takes no medications, but smokes 1 1/2 packs of cigarettes per day, drinks alcohol regularly, and exercises infrequently. The patient is about 40 lbs. overweight and admits to a high-fat, high-calorie diet. At the office visit today, the patient’s blood pressure is 150/92 mm Hg. What is the least appropriate intervention for this patient at this time?

Begin antihypertensive drug therapy.

Tumor necrosis factor α and interleukin-1 contribute to shock states because they induce production of

nitric oxide.

In which stage of shock is a patient who has lost 1200 mL of blood, who has normal blood pressure when supine, but who experiences orthostatic hypotension upon standing?

Class II, Compensated Stage

The progressive stage of hypovolemic shock is characterized by

tachycardia.

Hypotension associated with neurogenic and anaphylactic shock is because of

peripheral pooling of blood.

Hypertrophy of the right ventricle is a compensatory response to

pulmonary stenosis

Low cardiac output in association with high preload is characteristic of ________ shock.

cardiogenic

First-degree heart block is characterized by

prolonged PR interval.

Second-degree heart block type I (Wenckebach) is characterized by

lengthening PR intervals and dropped P wave

TRUE/FALSE

A type of shock that includes brain trauma that results in depression of the vasomotor center is cardiogenic

False

A type of shock that includes brain trauma that results in depression of the vasomotor center is neurogenic shock

TRUE/FALSE

Disseminated intravascular coagulation is a serious complication of septic shock characterized by abnormal clot formation in the microvasculature throughout the body.

True

In which dysrhythmias should treatment be instituted immediately?

Atrial fibrillation with a ventricular rate of 220 beats/minute

Which dysrhythmia is thought to be associated with reentrant mechanisms?

Preexcitation syndrome tachycardia (Wolf-Parkinson-White syndrome)

Administration of which therapy is most appropriate for hypovolemic shock?

Crystalloids

The majority of tachydysrhythmias are believed to occur because of

reentry mechanisms.

A patient who was involved in a fall from a tree becomes short of breath. The lung sounds are absent on one side. This patient is experiencing ________ shock.

obstructive

Patients with structural evidence of heart failure who exhibit no signs or symptoms are classified into which New York Heart Association heart failure class?

Class I

Administration of a vasodilator to a patient in shock would be expected to

decrease left ventricular afterload.

Improvement in a patient with septic shock is indicated by an increase in

systemic vascular resistance

The effect of nitric oxide on systemic arterioles is

vasodilation.

A laboratory test that should be routinely monitored in patients receiving digitalis therapy is

serum potassium.

A measurement of blood pressure in which it represents the peak pressure during cardiac_______. This is _________ __________ _________.

120/72

Systole, systolic blood pressure

A measurement of blood pressure in which it represents the lowest pressure during cardiac ________. This is __________ ___________ _________.

120/72

Diastole, diastolic blood pressure.

What is the most accurate method for measuring blood pressure?

Direct measurement of blood pressure.

Where is the catheter in direct measurement of blood pressure commonly placed?

radial artery

What auscultation of Korotkoff sound is heard during systolic blood pressure (SBP)?

Onset of Korotkoff sounds.

What auscultation of Korotkoff sound is heard during diastolic blood pressure (DBP)?

Disappearance of Korotkoff sounds.

What are the determinants of systemic blood pressure (SBP and DBP)?

Cardiac output (CO), and the resistance to the ejection of blood from the heart.

End-Diastolic volume is the.....

preload

In End-Diastolic volume~preload, what is the amount of blood returned to the heart called?

Venous return.

Systemic vascular resistance (SVR) us the.....

afterload

Systemic vascular resistance is determined by....

the radius of arteries and degree of vessel compliance.

Mechanism of BP regulation:

in short-term regulation of systemic blood pressure, changes in BP are mediated through activation of the _______ __________ ___________.

Sympathetic nervous system: epinephrine and norepinephrine

What are the 3 effect of Beta 1 in the heart

Stimulating SA node, ~cause increase in HR

Increase conduction time in AV node ~cause increase in HR

Increased contractility in the heart muscle.

Long Tem Regulation of Systemic BP-1:

In RAAS angiotensin I when in contact with ACE activates.....

Angiotensin II

Long Term Regulation of Systemic BP-1:

What are the two effects of Angiotensin II....

Potent vasoconstriction (afterload) and stimulates the release of aldosterone.

Everytime constriction happens what happens to BP?

It goes up.

Long Term Regulation of Systemic BP-1

When aldosterone is released, sodium and water retention caused an ________ in blood pressure.

increase

Long Term Regulation of Systemic BP- RAAS and fluid volume is regulated by ________, _________, __________.

neural, hormonal. renal

Long Term Regulation of Systemic BP-RAAS & fluid volume:

Increase in extracellular fluid volume (preload) =

________ CO and SVR= _____________.

Increased, elevated BP.

Long Term Regulation of Systemic BP-RAAS & fluid volume:

Increased serum sodium level = _________osmolarity =___________ADH secretion.

Increased, increased

Where are baroreceptors located?

Aorta arch and carotid sinus.

What do baroreceptors sense?

Osmolarity

Increased serum sodiun level = increased osmolarity = increased ADH secretion causes _______ ____ _______ ______/________ _________.

kidneys to reabsorb water/increase preload.

Long-Term Regulation of Systemic BP--2:

Causes kidney to increase sodium and water excretion by increasing the glomerular filtration rate (resulting in a decrease in preload).

Atrial natriuretic peptides/ANP

Adult Blood Pressure:

Normal BP:

SBP: < 120

DBP: < 80

Adult Blood Pressure

Prehypertension:

SBP: 120-139

DBP: 80-89

Adult Blood Pressure:

Stage 1 hypertension

SBP: 140-159

DBP: 90-99

Adult Blood Pressure:

Stage 2 hypertension

SBP: > 160

DBP: >100

Primary Hypertension:

What subtype is presented when systolic BP is >140mm Hg while diastolic pressure remains <90mm Hg?

Isolated systolic hypertension

Primary Hypertension:

What subtype is presented when diastolic pressure is >90mm Hg with a systolic pressure of <140mm Hg?

Isolated diastolic hypertension

Primary Hypertension:

What subtype is presented when both systolic and diastolic exceed prehypertension levels?

Combines systolic and diastolic hypertension

TRUE/FALSE

The highest reading will determine the degree of hypertension

True

Primary Hypertension:

End organ damage causes ______ ______ ________ __________.

Renal failure, stroke, heart disease

Primary Hypertension:

In end-organ damage, damage to arterial system and acceleration of atherosclerosis leads to ________ ___________.

Cardiovascular disease.

Primary Hypertension:

In end-organ damage, increased myocardial work results in ______ _______.

Heart failure

In Primary Hypertension, what results from end-organ damage and glomerular damage _______ _________,

Kidney failure

In primary hypertension end-organ damage affects ___________ ___ _____ ________.

microcirculation of the eyes.

In primary Hypertension, end-organ damage increases pressure in cerebral vasculature that can result in _______.

Hemorrhage

What are the non-modifiable risk factors in primary hypertension?

family history, age, ethnicity and genetics.

Primary hypertension is also called ________ ________.

Essential hypertension

What are modifiable risk factors in primary hypotension?

dietary factors, sedentary lifestyle, obesity/weight gain, metabolic syndrome, elevated blood glucose levels/ diabetes, elevated total cholesterol, alcohol and smoking.

In treatment for primary hypertension, what non-medical modification can be made as a form of treatment?

Weight loss, exercise, DASH diet, alcohol moderation, decrease sodium intake.

Treatment for primary hypertension affects _____ _______ _______.

heart rate, SVR, and/or stroke volume

What type of hypertension is most common from in infants and preschool children?

secondary hypertension

The most common cause for childhood secondary hypertension is relation to ______ _______ _____ ____ _____ _______.

renal disease, and coarctation of the aorta (aortic narrowing).

A hypertensive emergency is a........

sudden increase in either systolic or diastolic pressure with evidence of end-organ damage.

Hypertensive urgency is.......

blood pressure elevation without evidence of end-organ damage.

High blood pressure increases the workload of the left ventricle, because it increases

afterload

Hypertension with a specific, identifiable cause is known as ____ hypertension.

Secondary

TRUE/FALSE

Lactated Ringer solution and normal saline are commonly used crystalloid solutions that contain electrolytes.

True

An erroneously low blood pressure measurement may be caused by

Positioning the arm above the heart level

TRUE/FALSE

A patient is diagnosed with cardiogenic shock. The patient is hyperventilating and is therefore at risk for the respiratory complication of respiratory acidosis.

False

A patient diagnosed with cardiogenic shock who is hyperventilating is at risk for respiratory alkalosis

Angina caused by coronary artery spasm is called _____ angina.

Prinzmetal variant

Patients presenting with symptoms of unstable angina and no ST-segment elevation are treated with

Antiplatelet drugs

Constrictive pericarditis is associated with

Impaired cardiac filling

An elderly patient’s blood pressure is measured at 160/98. How would the patient’s left ventricular function be affected by this level of blood pressure?

Left ventricular workload is increased with high afterload.

Hypotension, distended neck veins, and muffled heart sounds are classic manifestations of

Cardiac Tamponade

Hypertension is closely linked to

obstructive sleep apnea

What results when systemic blood pressure is increased?

vasoconstriction

Increased preload of the cardiac chambers may lead to which patient symptom?

Edema

Cor pulmonale refers to

Right ventricular hypertrophy secondary to pulmonary hypertension.

A patient is diagnosed with heart failure with normal ejection fraction. This patient is most likely characterized by a(n)Correct!

Elderly woman without a previous history of MI.

The majority of cases of anaphylactic shock occur when a sensitized individual comes in contact with

Antibiotics

Cardiogenic shock is characterized by

Reduced cardiac output

Sepsis has been recently redefined as

A systemic inflammatory response to infection

TRUE/FALSE

Chronic elevation of myocardial wall tension results in atrophy.

FALSE

Chronic elevation of myocardial wall tension results in hypertrophy

Beta-blockers are advocated in the management of heart failure because they

Reduce cardiac output

Tachycardia is an early sign of low cardiac output that occurs because of

Baroreceptor activity

Heart Failure

Is the inability of heart to maintain sufficient cardiac output

Heart Failure results

Congestion of blood flow in the systemic (RHF) or Pulmonary (LHF) venous circulation

What is the short term compensatory mechanism of Heart failure

SNS activation

- Heart rate and contractility increase

What is the long term compensatory mechanism of heart failure

RAAS system

- increases preload thus increasing cardiac output

Which ventricular failure is the most common?

Left Ventricular failure

What are the clinical manifestations of Heart Failure

Forward failure= insufficient cardiac pumping manifested by poor CO/hypoxia

Backward failure = congestion of blood behind the pumping chamber/ede,a

What is the underlying issue of Heart failure

90% is due to ischemic issues

10% is due to hypertension or valvular disease

What are the forward effects of heart failure

Systemic Hypoxia and SNS activation:

Fatigue, oliguria, anxiety, confusion, HR increase, faint pulses, restlessness

What are the backward effects of LHF

Pulmonary congestion and edema

dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea

cough, respiratory crackles, hypoxemia, and high left-atrial pressure, cyanosis, S3 sound

What are the backward effects of RHF

Congestion in the systemic venous system/systemic edema

Edema, ascites, jugular veins distended, impaired mental functioning, hepatomegaly, splenomegaly

Coronary heart disease is characterized by....

Insufficient delivery of oxygenated blood to the myocardium due to atherosclerotic coronary arteries (CAD)

Sequelae of CHD include...

Angina pectoris (myocardial infarction), dysrhythmias, heart failure, and sudden cardiac death.

99% of cases of coronary heart disease are associated with....

Atherosclerosis

In ischemia, what are the two main factors that determine oxygen demand?

Rate of coronary perfusion and myocardial workload.

Coronary perfusion can be altered by?

Large, stable atherosclerotic plaque, vasospasm, failure of autoregulation by the microcirculation, poor perfusion pressure, acute platelet aggregation, and thrombosis.

Chronic occlusion of a coronary vessel results in...

Stable angina

Plaque disruption and thrombus formation result in unstable angina or MI called?

Acute occlusion

Angina pectoris results in....

Chest pain associated with intermittent myocardial ischemia.

What type of angina is chronic occlusion of a coronary vessel?

Stable angina

What type of angina is associated with plaque disruption and thrombus formation?

Unstable angina/MI

Myocardial ischemia may also uncommonly be caused by?

Coronary vasospasm-prinzmental or variant angina

Hypoxemia and low perfusion pressure from volume depletion or shock

What type of pattern angina pectoris?

- Most common (Classic)

- Onset of anginal pain is generally predictable and elicited by similar stimuli each time.

-Relieved by rest and nitroglycerin

-Characterized by stenotic atherosclerotic coronary vessels.

Stable or typical angina

What type of pattern angina pectoris?

- No relief without medical help

- May progress to MI or acute ischemia

Unstable or crescendo angina

What type of pattern angina pectoris?

- Unpredictable

-Onset of symptoms is unrelated.to physical or emotional exertion, heart rate, or other obvious causes of increased myocardial oxygen demand.

-Characterized by vasospasm, atherosclerosis-included, hyper contractility, abnormal secretion of a vasospastic chemical by local mast cells, abnormal calcium influx across vascular smooth muscle.

Prinzmetal or variant angina

Acute coronary syndromes/unstable or crescendo angina causes....

plaque rupture with acute thrombus development

What are sign and symptoms of acute coronary syndromes

Severe chest pain, last longer than 15 minutes and is not relieved by rest or nitroglycerin.

When diagnosing acute coronary syndrome what must be elevated?

specific marker proteins in the blood

TRUE/FALSE

In acute coronary syndrome, electrocardiographic changes are seen.

True

TRUE/FALSE

The following sign and symptoms are seen when diagnosing acute coronary syndrome: severe crushing, excruciating chest pain that may radiate to the arm, shoulder, jaw or back accompanied by nausea, vomiting, diaphoresis, shortness of breath.

True

Finish the acute coronary syndrome pathway

signs and symptoms of cardiac ischemia -> ACS -> ST elevation -> +biomarkers ->

STEMI

Finish the acute coronary syndrome pathway

signs and symptoms of cardiac ischemia -> ACS ->NO ST elevation ->

-biomarkers ->

Unstable angina

Finish the acute coronary syndrome pathway

signs and symptoms of cardiac ischemia -> ACS ->NO ST elevation -> +biomarkers ->

NSTEMI

What serum makers will increase within 24 hours in diagnosing myocardial infarction?

CK-MB and troponin I and T

In a typical ECG which pattern represents ventricle repolarization?

T wave

In a typical ECG which pattern represents depolarization of atria in response to SA node triggering?

P wave

In a typical ECG what represents the delay of AV node to allow filling of ventricles?

PR interval

In a typical ECG what represent the depolarization of ventricle triggers main pumping contractions?

QRS complex

In a typical ECG what represent the beginning of ventricle repolarization and should be flat?

ST segment

A patient with chest pain and evidence of acute ischemia will show _________ ___________ in ECG.

ST-segment elevation

What type of therapy could be used when there is evidence of ST-segment elevation?

acute reperfusion therapy

A patient presenting with symptoms of unstable angina and no ST elevation on the ECG will show _______ _______.

non-STEMI (NSTEMI)

Patients with NSTEMI are candidates for _______________ drugs.

antiplatelet

In acute coronary syndrome MI leads to drop in CO, triggering _________ ___________.

compensatory responses

What leads to increase myocardial workload by increasing heart rate, contractility,and blood pressure.

Sympathetic nervous system activation

What are the clinical treatments for Acute coronary syndrome?

Morphine, Oxygen, Nitroglycerin, Anticoagulants

What are the three treatment principles for acute coronary syndrome?

Decreasing myocardial oxygen demand, increasing myocardial oxygen supply, and monitoring and managing complications (SNS activation).

Common factor among all types of shock is.....

Hypoperfusion and impaired cellular oxygen utilization.

What does hypoperfusion mean?

oxygen supply is going down

Inadequate cellular oxygenation may result from....

decreased cardiac output, maldistribution of blood flow, reduced blood oxygen content

Pump failure causes...,

Cardiogenic issues- MI, valves are not working, cardiomyopathy

Hypovolemia causes....

Bleeding (internal or external)

Vasodilation causes....

septic shock

What type of shock causes the following:

-MI. -Cardiomyopathy. -Valvular heart disease

-Ventricular rupture. -Congenital heart defects

-Papillary muscle rupture.

Cardiogenic shock

What type of shock causes the following:

-Pulmonary embolism. -Cardiac tamponade. -Tension pneumothorax

-Dissecting aortic aneurysm

Obstructive shock

What type of shock causes the following:

-Acute hemorrhage. -Dehydration from vomiting & diarrhea

-Overuse of diruetics. -Burns. -Pancreatitis

Hypovolemic shock

Macrophage induction will release....

cytokines producing: Alpha TNF, IL1

That can attack blood vessel walls, and cause vasodilation.

Alpha TNF can cause coagulation leading to clot formation

What type of shock causes the following:

-Anaphylaxis. -Neurotrauma. -Spinal cord trauma

-spinal anesthesia. -sepsis

Distributive shock

Lack of oxygen causes several outcomes and....

Reperfusion injury

During shock, your heart rate _________.

your urine output___________.

your respiratory rate ____________.

Increase, decrease, increase

During shock your level of consciousness _____________.

Your blood pressure _____________.

Specific gravity_________________.

Decrease, decreases (hypotension), increase.

TRUE OR FALSE

During shock constriction of splanchnic vessels cause nausea and abdominal pain?

True

During shock a decrease in capillary refill causes....

clammy cool skin, and a blush gray color to the skin.

What is released during shock?

Cortisol and aldosterone

The following clinical findings distinguish which type of shock?

-Hypotension. -High vascular resistance -Low cardiac output

-High cardiac preload -Low venous oxygen saturation

-Low urine output. -Cool skin temperature

-Myocadiac muscle dysfunction -HF management

Cardiogenic

The following clinical findings distinguish which type of shock?

-Hypotension -High systemic vascular resistance. -Low cardiac output

-Low cardiac preload. -Low venous oxygen saturation

-Low urine output. -Cool skin temperature -Fluid resurrection

Hypovolemic

The following clinical findings distinguish which type of shock?

-Hypotension -Low systemic vascular resistance. -High cardiac output

-Low cardiac preload. -High venous oxygen saturation

-Low urine output. -Warm skin temperature -excessive vasodilation

-Anti-infection + FR

Septic

What type of distributive shock?

Mast cells release vasodilatory mediators such as histamine that will result in severe hypotension

Anaphylactic shock- Type 1 hypersensitivity

What type of distributive shock?

Loss of sympathetic activation of arteriolar smooth muscle.

Neurogenic shock

What type of distributive shock?

Severe systemic inflammatory response to infection (NO and Kinin)

Septic shock

TRUE OR FALSE

Complications in shock DO NOT cause inflammation.

False, complications in shock causes inflammation in nature,

What type of complication of shock is the following?

- Commonly associated with septic shock

-Development of refractory hypoxemia, decreased pulmonary compliance and pulmonary edema.

Acute respiratory distress syndrome (ARDS)

What is the cause of death in ARDS?

multiple organ failure

TRUE or FALSE

in ARDS exudate leaks in the interstitial spaces and alveoli of the lung.

True

What type of complication of shock is the following?

-Wide spread clot formation consumes platelets and clotting factors.

-Usually occurs in septic shock

-Activation of the clotting cascade

-Platelet count and fibrinogen levels are low, and fibrin degradation-producing D dimer is elevated.

DIC - Disseminated intravascular coagulation

What type of complication of shock is the following?

-Acute tubular necrosis (ATN) is associated with decreased urinary exertion of waste products (creatinine and urea).

-Kidneys undergo long periods of hypoperfusion.

-Vasoconstriction causes decreased glomerular blood flow, reduced hydrostatic pressure and filtration causing low urine output.

Acute renal failure.

What type of complication of shock is the following?
- Two or more systems are affected

- Mostly in sepsis

-Initiated by immune mechanisms that are overactive and destructive.

-Cytokines affect endothelium, recruit neutrophils, and activate inflammation in vascular beds, leading to tissue destruction and organ dysfunction.

MODS- Multiple organ dysfunction syndrome