Chapter 32: Cardiology.

Chapter 32: Cardiology

Learning Outcomes Cognitive Domain
Note: AAMA/CAAHEP 2015 Standards are italicized. 1. Spell key terms 2. Define medical terms and abbreviations related to all body systems 3. Describe structural organization of the human body 4. List major organs in each body system 5. Identify the anatomical location of major organs in each body system 6. Describe the normal function of each body system

Learning Outcomes (cont’d.)
7. Identify common pathology related to each body system including signs, symptoms, and etiology A. List and describe common cardiovascular procedures and tests 8. Describe the roles and responsibilities of the medical assistant during cardiovascular examinations and procedures 9. Discuss the information recorded on a basic 12-lead electrocardiogram 10. Explain the purpose of a Holter monitor

Psychomotor Domain Note: AAMA/CAAHEP 2015 Standards are italicized. 1. Perform electrocardiography (Procedure 32-1) A. Instruct and prepare a patient for a procedure or treatment B. Coach patients appropriately considering cultural diversity, developmental life stage, and communication barriers C. Coach patients regarding disease prevention and treatment plans D. Document patient care accurately in the medical record

2. Apply a Holter monitor for a 24-hour test A. Instruct and prepare a patient for a procedure or treatment B. Coach patients appropriately considering cultural diversity, developmental life stage, and communication barriers C. Coach patients regarding disease prevention and treatment plans D. Document patient care accurately in the medical record

Affective Domain Note: AAMA/CAAHEP 2015 Standards are italicized. 1. Incorporate critical thinking skills in performing patient assessment 2. Incorporate critical thinking skills in performing patient care 3. Show awareness of a patient’s concerns related to the procedure being performed 4. Demonstrate empathy, active listening, and nonverbal communication

5. Demonstrate respect for individual diversity, incorporating awareness of one’s own biases in areas including gender, race, religion, age, and economic status 6. Explain to a patient the rationale for performance of a procedure 7. Demonstrate sensitivity to patient right 8. Protect the integrity of the medical record

ABHES Competencies 1. Assist the physician with the regimen of diagnostic and treatment modalities as they relate to each body system 2. Perform electrocardiograms 3. Comply with federal, state, and local health laws and regulations 4. Communicate on the recipient’s level of comprehension 5. Serve as a liaison between the physician and others 6. Show empathy and impartiality when dealing with patients 7. Document accurately

Introduction Because medical assistants see patients who have cardiovascular disorders regardless of the medical specialty, you must understand the cardiovascular system, associated disorders, and common tests and procedures that are ordered for diagnosis and treatment. The cardiologist is a physician who specializes in disorders of the heart, and many patients with chronic cardiac conditions are referred to the cardiology office for treatment and follow-up. Back to Learning Outcomes

Common Disorders of the Cardiovascular System
Heart Blood vessels: Arteries Capillaries Veins Closed system of blood flow Back to Learning Outcomes

Common Disorders of the Cardiovascular System (cont’d.)
Symptoms: Chest pain Dyspnea Fatigue Diaphoresis Nausea and vomiting Irregular heartbeat Changes in peripheral circulation Edema Skin ulcers that do not heal Pain that increases with walking and decreases with rest Skin color change Back to Learning Outcomes

The heart and great vessels. Back to Learning Outcomes

Blood vessels form a closed system for the flow of blood. Blood high in oxygen (oxygenated) is shown in red; blood low in oxygen (deoxygenated) is shown in blue. Changes in oxygen content occur as blood flows through capillaries. Back to Learning Outcomes

pericarditis: inflammation of the sac that covers the heart Disorders of the Heart Carditis Pain, dyspnea, neck vein distention, pallor, hypertension Types — pericarditis, myocarditis, endocarditis Sharp pain increases on inspiration and lying down, decreases on sitting up, leaning forward Treatment — symptomatic relief, antibiotics myocardial infarction (MI): death of cardiac muscle due to lack of blood flow to the muscle; also known as heart attack myocarditis: inflammation of the myocardial layer of the heart cardiomegaly: enlarged heart muscle endocarditis: inflammation of the inner lining of the heart Cardiac inflammation, or carditis, may affect any of the layers of the heart muscle, and, although other factors may be involved, it is usually the result of a systemic infection. Back to Learning Outcomes

Checkpoint Question How would Abby describe the difference in pain due to pericarditis from the pain of myocardial infarction? Back to Learning Outcomes

Checkpoint Answer With pericarditis, pain increases with inspiration and movement; pain during MI will not change with patient positioning. Back to Learning Outcomes

Congestive Heart Failure Edema, dyspnea Types — left side, right side, or both Many causes — include coronary artery disease, hypertension, myocardial disease, and valvular heart disease No cure — treat to increase heart function congestive heart failure (CHF): condition in which the heart cannot pump effectively Failure of the right ventricle causes congestion of the peripheral extremities, while failure of the left ventricle leads to pulmonary congestion. Back to Learning Outcomes

Myocardial Infarction Irreversible death of heart muscle — medical emergency Due to occlusion causing lack of blood flow Crushing, radiating pain lasts 20 to 30 minutes, is unrelieved by rest angina pectoris: paroxysmal chest pain usually caused by a decrease in blood flow to the heart muscle due to coronary artery occlusion. electrocardiography (ECG): procedure that produces a record of the electrical activity of the heart Death of any part of the heart muscle, called myocardial infarction, occurs when one or more of the coronary arteries becomes totally occluded, usually by atherosclerotic plaques or by an embolism. Back to Learning Outcomes

percutaneous transluminal coronary angioplasty (PTCA): procedure that improves blood flow through a coronary artery by pressing the plaque against the wall of the artery with a balloon on a catheter, allowing for more blood flow Can be “silent” — nonspecific symptoms such as indigestion, anxiety Treatment — PTCA and CABG coronary artery bypass graft (CABG): surgical procedure that increases the blood flow to the heart by bypassing the occluded or blocked vessel with a graft Back to Learning Outcomes

Percutaneous transluminal coronary angioplasty (PTCA). (A) A guide is threaded into the coronary artery. (B) A balloon catheter is inserted through the occlusion. (C) The balloon is inflated and deflated until plaque is flattened and the vessel is opened. Back to Learning Outcomes

Back to Learning Outcomes

Checkpoint Question Why is it important to treat a patient with myocardial infarction as early as possible? Back to Learning Outcomes

Checkpoint Answer It is important to treat a person suffering a myocardial infarction as soon as possible to decrease the amount of cardiac muscle damaged from lack of oxygen. Back to Learning Outcomes

Cardiac Arrhythmia Dizziness, syncope, cardiac arrest Bradycardia: abnormally slow (< 60 bpm) Tachycardia: abnormally fast (>100 bpm) bradycardia: heart rate of less than 60 beats per minute tachycardia: heart rate of more than 100 beats per minute Cardiac arrhythmia or dysrhythmia is an abnormal heart rhythm that may occur as a primary disorder or as a response to a systemic problem. More serious arrhythmias occur when the ventricles beat too fast, a condition known as ventricular tachycardia (VT). Back to Learning Outcomes

Ventricular fibrillation — medical emergency; disorganized contractions do not pump blood Use AED or CPR Frequent defibrillation —pacemaker Ventricular fibrillation is a medical emergency that occurs when the heart is quivering rather than contracting in an organized fashion. Back to Learning Outcomes

Conduction system of the heart. Back to Learning Outcomes

Chest x-ray of an intracardiac pacemaker showing the leads (arrows) in the right atrium and right ventricle. Artificial Pacemakers Electrical replacement for sinoatrial node Programmed for continuous or selective firing Telephone monitoring available Battery operated — charge lasts up to 20 years The permanent or temporary artificial pacemaker is surgically implanted either between the chest wall and the rib cage or within the chest cavity. Back to Learning Outcomes

Checkpoint Question Which two cardiac arrhythmias are emergencies requiring immediate intervention by the medical assistant? Back to Learning Outcomes

Checkpoint Answer Two arrhythmias that require immediate intervention are ventricular tachycardia and ventricular fibrillation. Back to Learning Outcomes

Congenital and Valvular Heart Diseases Heart valve disease — stenosis, obstructed blood flow Dyspnea, pulmonary edema Left side most often affected Treatment depends on type — medication, diet, antibiotics, surgery Valvular disease is an acquired or congenital abnormality of any of the four cardiac valves. Rheumatic heart disease, an acquired valvular disease, presents clinically as a generalized inflammatory disease occurring 10 to 21 days after an upper respiratory infection caused by group A beta-hemolytic streptococci. Treatment of valvular disease depends on the type and severity of the abnormality. Back to Learning Outcomes

Checkpoint Question What microorganism may be responsible for rheumatic heart disease and cardiac valvular damage? Back to Learning Outcomes

Checkpoint Answer Rheumatic heart disease and cardiac valvular disease may be caused by an upper respiratory infection caused by group A beta-hemolytic streptococci. Back to Learning Outcomes

Disorders of the Blood Vessels Atherosclerosis Obstruct blood flow — remain as thrombus, break off as embolus Coronary artery disease (CAD) most common type of heart disease and the leading cause of death in men and women in the United States Factors — high saturated fat diet, family history of high cholesterol, smoking, diabetes, hypertension Treat with lipid-lowering drugs, lifestyle changes, surgery Atherosclerosis: buildup of fatty plaque on the interior lining of arteries Diseases of blood vessels—arteries or veins—often begin with collection of fatty plaques made of calcium and cholesterol inside the walls of the vessels. Back to Learning Outcomes

Coronary atherosclerosis. (A) Fat deposits narrow an artery, leading to ischemia. (B) Blockage of the coronary artery. (C) Formation of a blood clot (thrombus), leading to MI. Back to Learning Outcomes

CAD is most common type of heart disease and the leading cause of death in men and women in the United States Symptoms: Angina pectoris (pain radiating to the arm, jaw, shoulder, back, or neck) Pressure or fullness in the chest Syncope (fainting) Edema of the extremities, especially the legs Unexplained cough, generally without respiratory symptoms Excessive fatigue Dyspnea Predisposing conditions for atherosclerosis and coronary artery disease (CAD) include a diet high in saturated fats and a family history of hypercholesterolemia. Back to Learning Outcomes

Diagnosis: Angiography Doppler ultrasonography (echocardiography) Cardiac calcium scoring A relatively new noninvasive test for CAD is cardiac calcium scoring using electron beam computed tomography (CT). Your responsibilities will include coordinating diagnostic procedures based on the physician’s orders and insurance requirements and teaching patients about behaviors that can prevent atherosclerosis and CAD. Back to Learning Outcomes

Atherosclerotic coronary occlusion. Back to Learning Outcomes

What are four predisposing factors for heart disease?
Checkpoint Question What are four predisposing factors for heart disease? Back to Learning Outcomes

Four predisposing factors for heart disease are:
Checkpoint Answer Four predisposing factors for heart disease are: History of elevated cholesterol Smoking Diabetes mellitus Hypertension Back to Learning Outcomes

Hypertension Resting blood pressure repeatedly above 140/90 Often no symptoms (“silent killer”) Treat with diet, exercise, medication, weight reduction Hypertension cannot be diagnosed on the basis of one blood pressure measurement, since other factors, such as emotional upset or anxiety, may cause a temporary increase in blood pressure. One type of hypertension, essential hypertension, is a major cause of stroke and renal failure and is a major consequence of atherosclerosis anywhere in the circulatory system. Malignant hypertension is severe and sudden in onset and is most common in African-American men under age 40 years regardless of other risk factors. Back to Learning Outcomes

Checkpoint Question Several patients in the Great Falls Medical Center cardiology office are being seen for hypertension. What two disorders may result from untreated hypertension? Back to Learning Outcomes

Stroke and renal failure may result from untreated hypertension.
Checkpoint Answer Stroke and renal failure may result from untreated hypertension. Back to Learning Outcomes

Varicose Veins Caused by excessive sitting, standing, heredity Pain, or no symptoms Treat by decreased sitting or standing, support stockings, surgery Varicose veins of the lower extremities. Varicosities, the most common circulatory disease of the lower extremities, occur when the superficial veins of the legs swell and distend. Back to Learning Outcomes

Venous Thrombosis and Pulmonary Embolism Blood clot in peripheral or pulmonary veins Can be inherited or secondary to cardiovascular disease Can cause stasis ulcers due to reduced blood flow Stasis dermatitis with venous stasis ulcer. Thrombi, or blood clots, in the peripheral or pulmonary veins commonly affect patients with underlying cardiovascular disease. Back to Learning Outcomes

Embolus — thrombus breaks off, lodges in: Pulmonary circulation — pulmonary embolus Cardiac circulation — MI Cerebral circulation — CVA Treat peripheral occlusions with support stockings, weight reduction, limb elevation Treat pulmonary embolism with rest, medication, surgery cerebrovascular accident (CVA): ischemia of the brain due to an occlusion of the blood vessels supplying the brain, resulting in varying degrees of debilitation Back to Learning Outcomes

Checkpoint Question What disease occurs when the superficial veins in the legs become swollen and distended? Back to Learning Outcomes

Checkpoint Answer Varicose veins occur when the superficial veins in the legs become swollen and distended. Back to Learning Outcomes

Cerebrovascular Accident (CVA) Stroke — death of brain tissue due to blood vessel damage Bleeding, blockage — thrombus, embolus Can cause paralysis, death CVA, sometimes called stroke, results suddenly when damage to the blood vessels in the brain occurs. Back to Learning Outcomes

transient ischemic attack (TIA): acute episode of cerebrovascular insufficiency, usually a result of narrowing of an artery by atherosclerotic plaques, emboli, or vaso-spasm; usually passes quickly but should be considered a warning for predisposition to cerebrovascular accidents TIA — ministroke Most TIA patients later have CVAs Numbness or tingling, difficulty swallowing or speaking, coughing or choking, visual disturbance, dizziness Medical emergency Treat by reducing further damage, regaining lost function You must remember that, although these patients may not be able to communicate effectively with you, they are capable of understanding and should be treated with respect, dignity, and compassion. Any patient who has the signs and symptoms of a TIA or a CVA should be sent to the emergency room following all physician instructions and office policies. Back to Learning Outcomes

Aneurysm Can cause death Types: Dissecting — tears and allows bleeding Sacculated — balloons, may burst Berry — congenital defect Causes — trauma, hypertension, atherosclerosis, fungal infection, syphilis, congenital Symptoms — Pain or pressure Treatment — surgery Aneurysm: local dilation in a blood vessel wall Weakened blood vessel walls are predisposed to abnormal dilation. Back to Learning Outcomes

The locations of aneurysms. Back to Learning Outcomes

What is the physiologic reason for a stroke?
Checkpoint Question What is the physiologic reason for a stroke? Back to Learning Outcomes

Checkpoint Answer The physiologic cause of a cerebrovascular accident, or stroke, is a decrease in oxygen to part of the brain due to a blockage in the artery from an embolism or hemorrhage. The part of the brain that does not receive oxygen dies. Back to Learning Outcomes

Anemia Deficiency in hemoglobin or red blood cell numbers Symptom, not disease Caused by: Blood loss Blood cell destruction Reduced blood cell formation Vitamin B12 deficiency Genetic Tachycardia, anorexia, weight loss, dyspnea on exertion, fatigue Treat cause Deficiencies in hemoglobin or in the numbers of red blood cells result in anemia. Back to Learning Outcomes

Common Diagnostic and Therapeutic Procedures
Invasive — catheterization, arteriography Noninvasive — auscultation, ECG, X-ray, Holter monitor Physical Examination Obtain information: Reason for visit Describe symptoms How long? Location of pain or discomfort Pain associated with other symptoms—nausea, weakness Short of break? Smoker or drink alcoholic beverages? Testing for cardiovascular disorders may be either invasive or noninvasive. Back to Learning Outcomes

Common Diagnostic and Therapeutic Procedures (cont’d.)
Visual inspection: General appearance, Circulation, swelling of the extremities Color of the skin Jugular vein distention Palpation to evaluate efficiency of circulatory pathways and peripheral pulses Auscultation to evaluate sounds made as blood flows through heart and valves open and close The cardiovascular examination is the most basic noninvasive procedure used to assess the heart and blood vessels. Back to Learning Outcomes

Checkpoint Question The cardiologist tells a patient he has a heart murmur. How would Abby explain a heart murmur to a patient? Back to Learning Outcomes

Checkpoint Answer A murmur is an abnormal heart sound caused by incomplete closing of one or more of the valves. Back to Learning Outcomes

Electrocardiogram Graphic record via leads of electrical current through heart Diagnose ischemia, conduction abnormalities, chamber hypertrophy, and arrhythmias lead: electrode or electrical connection attached to the body to record electrical impulses in the body, especially the heart or brain One of the most valuable diagnostic tools for evaluating the electrical pathway through the heart is the electrocardiogram, known by the acronym ECG or EKG. Back to Learning Outcomes

ECG graph paper. (A) Each small square is 1 mm x 1 mm. Each fifth line is marked darker to make a cube of 5 mm x 5 mm (actual size). Back to Learning Outcomes

ECG graph paper. (B) Horizontally, the graph paper represents time in seconds. Each small square represents 0.04 seconds, and each large square represents 0.2 seconds. Five large squares = 1 second (5 x 0.2). Back to Learning Outcomes

ECG Leads Record heart’s currents from different angles — provide a “three-dimensional” view 12 leads, 4 color-coded wires: Lead I measure differences in electrical potential between the RA and the LA Lead II measures the difference in electrical potential between the RA and LL Lead III measures the difference in electrical potential between the LA and LL Electrodes placed directly on anterior chest wall—for closer look Each lead records the electrical impulse through the heart from a different angle. The first three combinations, which are standard bipolar leads also known as Einthoven leads, allow frontal visualization of the heart’s electrical activity from side to side. Back to Learning Outcomes

Lead aVR (LL + LA) to RA measures the potential at the right arm Lead aVL (LL + RA) to LA measures the potential at the left arm Lead aVF (RA + LA) to LL measures the potential at the left foot Recording of ECG on paper varies—but principles and techniques are universal These second three combinations, the augmented unipolar limb leads, allow visualization from a frontal view top to bottom. For a closer look at the electrical conduction through the heart, electrodes are placed directly on the anterior chest wall, but the limb electrodes must remain attached to the patient. Back to Learning Outcomes

ECG Interpretation Examination of various wave forms associated with the cardiac cycle The cardiac cycle waves, segments, and intervals. The physician’s interpretation of the standard 12-lead ECG includes an examination of various waveforms associated with the cardiac cycle. Back to Learning Outcomes

PR Interval Time from beginning of P wave to beginning of QRS complex Atrial depolarization PR Segment Period between P wave and QRS complex ST Segment Distance between QRS complex and T wave from point where QRS complex ends (J-point) to onset of ascending limb of T wave On ECG, ST segment is sensitive indicator of myocardial ischemia or injury Back to Learning Outcomes

Ventricular Activation Time Time from beginning of QRS complex to peak of R wave = time necessary for depolarization wave to travel from endocardium to epicardium Normally >0.12 seconds During the ECG, the paper speed on the machine should be set at 25 mm per second, which allows the electrical impulses (seen as waves) on the ECG to be measured using the blocks on the ECG paper as a reference (each small horizontal block is 0.04 seconds). Back to Learning Outcomes

Consider: Rate: how fast the heart is beating Rhythm: regularity of cardiac cycles and intervals Axis: position of heart and direction of depolarization through heart Hypertrophy: size of heart Ischemia: decrease in blood supply to an area of heart Infarction: death of heart muscle resulting in loss of function Your responsibility to provide artifact-free tracing artifact: activity recorded in an electrocardiogram caused by extraneous activity such as patient movement, loose lead, or electrical interference Back to Learning Outcomes

Which three waves represent a cardiac cycle on an ECG?
Checkpoint Question Which three waves represent a cardiac cycle on an ECG? Back to Learning Outcomes

P, QRS, and T waves represent a cardiac cycle on an ECG.
Checkpoint Answer P, QRS, and T waves represent a cardiac cycle on an ECG. Back to Learning Outcomes

A Holter monitor. Holter Monitor Portable ECG Monitors 24+ hours for intermittent abnormalities Patient keeps diary of activities to compare with ECG The Holter monitor is small and portable and can be worn comfortably for long periods without interfering with daily activities. Back to Learning Outcomes

Chest Radiography Anatomic features of heart Evaluates disorders, including: Congestive heart failure Pericardial effusions Pulmonary problems Hypertrophy Chest radiography provides valuable basic information about the anatomic location and gross structures of the heart, great vessels, and lungs. Back to Learning Outcomes

Cardiac Stress Test Constant ECG tracing as patient exercises on treadmill Routine test or diagnostic Palpitations: feeling of an increased heart rate or pounding heart that may be felt during an emotional response or a cardiac disorder To measure the response of the cardiac muscle to increased demands of oxygen, the physician may request a cardiac stress test. Emergency resuscitation equipment should be available in case of cardiac or respiratory difficulties. Back to Learning Outcomes

Walking on a treadmill while monitoring the heart’s activity with an ECG machine is one way to determine the ability of the heart to adapt to increased work during exercise. Back to Learning Outcomes

What is the purpose of a cardiac stress test?
Checkpoint Question What is the purpose of a cardiac stress test? Back to Learning Outcomes

Checkpoint Answer A cardiac stress test measures the response of the myocardium to increased demands for oxygen. Back to Learning Outcomes

Echocardiography Sound waves travel through heart — create image of chambers, walls, valves Valvular disease, cardiomyopathy, traumatic injury cardiomyopathy: any disease affecting the myocardium An echocardiogram, or echo, uses sound waves generated by a small device called a transducer. Back to Learning Outcomes

Cardiac Catheterization and Coronary Arteriography Catheterization — insertion of flexible tube through blood vessel into heart Arteriography — injection of contrast media into heart via catheterization tube Can perform angioplasty if atherosclerosis found Cardiac catheterization is a common invasive procedure used to help diagnose or treat conditions affecting the coronary arterial circulation. Cardiac catheterization is not done in the medical office, but the medical assistant may be responsible for scheduling diagnostic cardiac catheterizations at a local outpatient facility or hospital and giving the patient any instructions required by the outpatient facility. Back to Learning Outcomes

How is the echocardiography obtained?
Checkpoint Question How is the echocardiography obtained? Back to Learning Outcomes

Echocardiography uses sound waves.
Checkpoint Answer Echocardiography uses sound waves. Back to Learning Outcomes

Chapter 32: Cardiology.

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Chapter 32: Cardiology.

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