1. Assessment of Cardiovascular Function
Brunner 2012.
Chapter 26

2. S1—First Heart Sound
Closure of the mitral and tricuspid valves creates the first heart sound (S1), although vibration of the myocardial wall also may contribute to this sound.
S1 ,is heard best at the apex of the heart .
Its intensity increases when the valve leaflets are made rigid by calcium in rheumatic heart disease .

5. S2 Second Heart Sound
Closing of the aortic and pulmonic valves produces the second heart sound (S2 ).
The splitting is more likely to be accentuated on inspiration and to disappear on exhalation.
(More blood is ejected from the right ventricle during inspiration than during exhalation.)

6. S2 is heard loudest at the base of the heart.
The aortic component of S2 is heard clearly in both the aortic and pulmonic areas,and less clearly at the apex.
The pulmonic component of S2 , if present, may be heard only over the pulmonic area.

7. Gallop Sounds
Gallop sounds are very low-frequency sounds and may be heard only with the bell of the stethoscope placed very lightly against the chest.
They are heard best at the apex, although occasionally, when emanating from the right ventricle, they may be heard to the left of the sternum.

8. Gallop Sounds

9. Murmurs. Murmurs are created by the turbulent flow of blood.
The causes of the turbulence may be a critically arrowed valve,a malfunctioning valve that allows regurgitant blood flow:
a congenital defect of the ventricular wall, a defect between the aorta and the pulmonary artery, or an increased flow of blood through a normal structure (eg, with fever, pregnancy, hyperthyroidism).

12. Friction Rub.
In pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub.
It is caused by abrasion of the pericardial surfaces during the cardiac cycle.
A pericardial friction rub can be heard best using the diaphragm of the stethoscope, with the patient sitting up and leaning forward.

14. Cardiac Enzyme Analysis
Enzymes are released from injured cells when the cell membranes rupture.
Lactic dehydrogenase(LDH) and its isoenzymes also are analyzed in patients who have delayed seeking medical attention, because these blood levels rise and peak in 2 to 3 days, much later than CK levels.

15. Myoglobin
Myoglobin, an early marker of MI, is a heme protein with a small molecular weight.
This allows it to be rapidly released from damaged myocardial tissue and accounts for its early rise, within 1 to 3 hours after the onset of an acute MI.
Myoglobin peaks in 4 to 12 hours and returns to normal in 24 hours.
Myoglobin is not used alone to diagnose MI, because elevations can also occur in patients with renal or musculoskeletal disease.
However, negative results are helpful in ruling out an early diagnosis of MI.

16. troponin
After myocardial injury, elevated serum troponin I concentrations can be detected within 3 to 4 hours; they peak in 4 to 24 hours and remain elevated for 1 to 3 weeks.
These early and prolonged elevations make very early diagnosis of MI possible or allow for late diagnosis if the patient has delayed seeking treatment.

19. CHOLESTEROL LEVELS
Cholesterol (normal level, less than 200 mg/dL) is a lipid required for hormone synthesis and cell membrane formation.
It is found in large quantities in brain and nerve tissue.
Two major sources of cholesterol are diet (animal products) and the liver,where cholesterol is synthesized.

20. …CHOLESTEROL LEVELS
Elevated cholesterol levels are known to increase the risk for CAD.
LDLs (normal level, less than 130 mg/dL) are the primary transporters of cholesterol and triglycerides into the cell.
One harmful effect of LDL is the deposition of these substances in the walls of arterial vessels. Elevated LDL levels are associated with a greater incidence of CAD.
In people with known CAD or diabetes, the primary goal for lipid management is reduction of LDL levels to less than 100 mg/dL.

21. HDL(High Density Lipoprotein)
HDLs (normal range in men, 35 to 65 mg/dL; in women, 35 to 85 mg/dL) have a protective action.
They transport cholesterol away from the tissue and cells of the arterial wall to the liver for excretion.
Therefore, there is an inverse relationship between HDL levels and risk for CAD.
Factors that lower HDL levels include smoking, diabetes, obesity, and physical inactivity.
In patients with CAD, a secondary goal of lipid management is the increase of HDL levels to more than 40 mg/dL.

22. Triglycerides
Triglycerides (normal range, 40 to 150 mg/dL), composed of free fatty acids and glycerol, are stored in the adipose tissue and are a source of energy.
Triglyceride levels increase after meals and are affected by stress.
Diabetes, alcohol use, and obesity can elevate triglyceride levels.
These levels have a direct correlation with LDL and an inverse one with HDL.

23. SERUM ELECTROLYTE LEVELS
Sodium, potassium, and calcium are ions that are vital to cellular depolarization and repolarization.
In addition, the serum sodium concentration reflects relative fluid balance.
Generally, hyponatremia (low sodium level) indicates fluid excess, and hypernatremia (high sodium level) indicates fluid deficit.
On the ECG, hypomagnesemia lengthens the QT interval, predisposing the patient to life hreatening dysrhythmias.

24. Coagulation Studies
Coagulation studies are routinely performed before invasive procedures, such as cardiac catheterization, electrophysiology testing, and coronary or cardiac surgery.

25. Partial thromboplastin time (PTT)
Partial thromboplastin time (PTT) and activated partial thromboplastin time (aPTT) measure the activity of the intrinsic pathway.
The values of PTT and aPTT are used to assess the effects of heparin therapy.
Patients receiving heparin have their PTT or aPTT levels maintained at 1.5 to 2.5 times their baseline values (reference range, 25 to 38 seconds

26. Prothrombin time (PT)
Prothrombin time (PT) measures the extrinsic pathway activity and is used to monitor the effects of therapeutic anticoagulation with warfarin (Coumadin).
Laboratory results of PT also include the International Normalized Ratio (INR) .
The INR provides a standard method for reporting PT levels, eliminating the variation of PT results from laboratory to laboratory.
The INR is maintained between 2.0 and 3.0 for patients with deep vein thrombosis, pulmonary embolism, valvular heart disease, or atrial fibrillation, and between 2.5 and 3.5 for patients with mechanical prosthetic heart valve replacements.

29. CHEST X-RAY AND FLUOROSCOPY

30. ELECTROCARDIOGRAPHY

31. Continuous Electrocardiographic Monitoring
HARDWIRE CARDIAC MONITORING
TELEMETRY
CONTINUOUS AMBULATORY MONITORING(Holter monitor).
TRANSTELEPHONIC MONITORING

32. CONTINUOUS AMBULATORY MONITORING(Holter monitor).

33. CARDIAC STRESS TESTING or Exercise Tolerance Test(ETT)
helps determine the following:
(1) CAD, (2) cause of chest pain, (3) functional capacity of the heart after an MI or heart surgery, (4) effectiveness of antianginal or antiarrhythmic medications, (5) dysrhythmias that occur during physical exercise,and (6) specific goals for a physical fitness program.

34. Contraindications
Contraindications to stress testing include severe aortic stenosis, acute myocarditis or pericarditis, severe hypertension, suspected left main CAD, HF, and unstable angina.
Because complications associated with stress testing can be life-threatening (MI, cardiac arrest,HF, and severe dysrhythmias), testing facilities must have staff and equipment ready to provide advanced cardiac life support.
NURSING INTERVENTIONS

36. ECHOCARDIOGRAPHY

39. Transesophageal Echocardiography

40. RADIONUCLIDE IMAGING
Radionuclide imaging studies involve the use of radioisotopes to evaluate coronary artery perfusion noninvasively, to detect myocardial ischemia and infarction, and to assess left ventricular function.
Thallium 201 (Tl 201) and technetium 99m (Tc 99m) are two of the most common radioisotopes used in cardiac nuclear medicine studies.

41. RADIONUCLIDE IMAGING

42. RADIONUCLIDE IMAGING
As they decay, they give off small amounts of energy in the form of gamma rays.
When they are injected intravenously into the bloodstream, the energy emitted by the radioisotope can be detected by a gamma scintillation camera positioned over the body.

43. CARDIAC CATHETERIZATION
Cardiac catheterization is an invasive diagnostic procedure in which radiopaque arterial and venous catheters are introduced into selected blood vessels of the right and left sides of the heart.
Catheter advancement is guided by fluoroscopy

46. ANGIOGRAPHY
Common sites for selective angiography are the aorta, the coronary arteries, and the right and left sides of the heart

49. HEMODYNAMIC MONITORING
Central Venous Pressure Monitoring
(0 to 8 mm Hg)

51. Pulmonary Artery Pressure Monitoring
Normal pulmonary artery pressure is 25/9 mm Hg, with a mean pressure of 15 mm Hg.

53. Intra-arterial Blood Pressure Monitoring