Cardiac/Vascular Nurse Exam Secrets Study Guide (10 page)

Angina pectoris

Angina pectoris is a condition defined by chest pain and/or discomfort due to myocardial ischemia. The condition is reversible and dissipates over a short period. It can be associated with pain that radiates to the shoulders, neck, or jaw.

In the United States, the prevalence of angina pectoris is over 6 million individuals. The condition is more prevalent among women than men, with more than 4 million women being affected and over 2 million men affected. Individuals over the age of 50 are at an increased risk for angina pectoris, especially those individuals with other cardiovascular comorbid conditions.

Causes and risk factors

Angina pectoris is typically caused by the presence of atherosclerotic disease or blood clot formation in the coronaries. Other conditions contributing to angina pectoris include valvular disease, coronary artery spasm or abnormalities and other cardiovascular conditions. Angina pectoris is typically precipitated by cold, stress, exertion, or large meals.

Non-modifiable risk factors for angina pectoris include a medical history of cardiovascular disease, family history of heart disease, increasing age, female gender, and African American or Hispanic American descent. Modifiable risk factors include cigarette smoking, hypertension, elevated low-density lipoprotein levels, elevated triglycerides, low serum high-density lipoprotein, diabetes, previous stroke, alcohol or illicit drug abuse, obesity and/or physical inactivity.

Symptoms

Patient diagnosed with angina pectoris typically present with chest pain, vomiting, nausea, fatigue and other cardiovascular symptoms. The pain often radiates across the precordium, to the jaw, and to the shoulders. The degree and extent of symptoms depend on the condition, underlying cause of the condition, age of the patient and/or presence of other comorbid conditions.

Chronic stable angina pectoris typically presents with increased symptoms upon physical exertion and/or fatigue. Individuals with unstable angina pectoris typically present with similar symptoms but the symptoms are typically more severe, frequent, and /or prolonged.

Physical findings upon diagnosis include S4 heart sounds, cardiac murmur, dysrhythmia, tachycardia, hypertension, and/or hypotension.

Diagnosis and screening

Physical examination, medical history, and diagnostic tools are used to screen for angina pectoris. Practicing clinicians examine the patient for abnormal heart sounds, evidence of heart enlargement, presence of other cardiovascular comorbid conditions and/or fluid buildup in the lungs. Individuals suspected of angina pectoris or other comorbid conditions may be observed over a few days in a hospital setting to determine the reason for their chest pain and/or discomfort, specifically to rule out myocardial infarction.

Diagnostic tools used to diagnose angina pectoris include response to nitroglycerin and echocardiography. Other diagnostic tools used in the screening for angina pectoris to exclude other comorbid conditions include echocardiography, electrocardiogram, magnetic resonance imaging, ultrasound and chest x-ray. Other more invasive diagnostic approaches include cardiac catheterization and cardiac stress testing.

Atrial fibrillation

Atrial fibrillation is a dysfunctional cardiac arrhythmia. The condition is caused by absent p waves, irregular R-R intervals and f waves of variable shape and amplitude. Atrial fibrillation can occur as an acute condition or a chronic condition. Chronic atrial fibrillation is better tolerated than acute atrial fibrillation.

The incidence of atrial fibrillation increases with age and is the most common dysrhythmia. The condition occurs in approximately 20% to 30% of individuals undergoing coronary artery bypass surgery. In the general population, atrial fibrillation occurs in just under 10% of individuals over the age of 70. In the United States, the prevalence of atrial fibrillation is approximately 2 million.

Causes and risks

The key risk factors for atrial fibrillation include increasing age, heart disease, other chronic diseases such as thyroid dysfunction or lung disease, alcohol abuse and/or family history

Other risk factors associated with atrial fibrillation include pulmonary disease, valvular disease, congenital heart disease, coronary artery bypass surgery, congestive heart failure, atherosclerosis, myocardial infarction, rheumatic heart disease, and thyrotoxicosis.

Other possible causes of atrial fibrillation include high blood pressure, congenital heart defects, hyperthyroidism, metabolic imbalance, exposure to stimulants such as caffeine, illicit drugs, alcohol or tobacco, sick sinus syndrome, emphysema, lung disease, previous heart surgery, viral infections, stress due to pneumonia or other illnesses, and/or sleep apnea.

Symptoms

Many individuals with atrial fibrillation do not have any symptoms of disease but are diagnosed during routine physical examination or when being assessed for another ailment or condition. However, some patients present with more-extensive symptoms. Symptoms may also vary from patient to patient. In addition, the severity of symptoms and impact on quality of life parameters may vary from patient to patient.

Symptoms associated with atrial fibrillation include fatigue, dizziness, weakness, physical activity intolerance, hypotension, inability to perform daily living activities, cardiac palpitations, shortness of breath, fainting, confusion, chest pain, and lightheadedness.

Diagnosis and screening

Symptoms of atrial fibrillation vary, and therefore, patients may not present with symptoms upon diagnosis. Physical examination, medical history, and diagnostic tools are used to screen for atrial fibrillation. Upon physical examination, practicing clinicians will look for rapid or irregular heart rate, varying intensity and frequency of S1 and hypotension. Diagnostic screening tools used to confirm diagnosis of atrial fibrillation and likely etiologies include echocardiogram, electrocardiogram, Holter monitor, event recorder, chest x-ray, magnetic resonance imaging, and thyroid function tests.

Also, blood work may be completed to access other contributing factors including thyroid function tests, electrolyte levels, and metabolic function tests.

Arrhythmia

Arrhythmia is defined as a condition that involves dysregulation of cardiac electrical activity. Arrhythmia can cause a slowing, speeding up, or irregular heartbeat. Tachycardia is a condition that occurs when an arrhythmia is faster than normal, whereas bradycardia is a condition that occurs when an arrhythmia beats slower than normal.

There are many types of arrhythmias including premature beats, supraventricular arrhythmias, ventricular arrhythmias, and bradyarrhythmias. Premature beats can originate in both atria and the ventricles. Supraventricular arrhythmias originate in the atria and include atrial fibrillation, atrial flutter, and Wolf-Parkinson-White syndrome. Arrhythmias that originate in the ventricles include ventricular tachycardia, ventricular fibrillation, and long QT syndrome. Bradycardias occur when the heart rate is below 60 beats per minute and can be categorized as sick sinus or conduction block.

Causes and risk factors

Both genetic and environmental factors can contribute to the development of arrhythmias. However, sometimes the cause of an arrhythmia may remain unknown. Factors that increase an individual’s risk for developing arrhythmias include age; family history; medical history of cardiovascular conditions such as congestive heart failure, rheumatic heart disease, coronary artery disease, or previous heart surgery; thyroid dysfunction, including hyperthyroidism and hypothyroidism; drugs containing pseudoephedrine or other stimulants; alcohol or illicit drug abuse; high blood pressure; obesity; diabetes; stress; excessive exercise; obstructive sleep apnea; electrolyte imbalance; and/or stimulant use such as caffeine or tobacco.

Symptoms

Some patients who are diagnosed with an arrhythmia present with few or no symptoms. However, many patients present with symptoms upon diagnosis. Yet, these symptoms vary from patient to patient and in terms of severity. Cardiovascular comorbid conditions may also impact the symptoms that patients diagnosed with arrhythmias present with.

Symptoms commonly associated with different types of arrhythmias include cardiac palpitations, slow heartbeat/heart rate, irregular heartbeat, skipped heartbeats, feeling of pauses between heartbeats, anxiety, weakness, dizziness, lightheadedness, fainting, sweating, shortness of breath, chest pain, inability to perform activities of daily living, confusion, fatigue, physical activity intolerance, and hypotension.

Diagnosis and screening

Diagnosis of arrhythmias can be difficult if patients present with few or no symptoms. Physical examination, medical history, and diagnostic tools are used to screen to atrial fibrillation. Upon physical examination, practicing clinicians will look for rapid or irregular heart rate of varying heart rate and/or hypotension.

Diagnostic screening tools used to confirm diagnosis of an arrhythmia primarily include electrocardiogram, Holter monitor, and event recorders. Of note, echocardiography chest x-ray, magnetic resonance imaging, and thyroid function tests will help elucidate the underlying cause. Also, blood work may be completed to assess other contributing factors including thyroid function tests, electrolyte levels, and metabolic function tests. More invasive diagnostic tools used include stress test, tilt table test, and/or electrophysiologic testing.

Atrial flutter

Atrial flutter is a condition that is similar to atrial fibrillation. However, the condition presents with a more organized and less chaotic abnormal heartbeat, compared with atrial fibrillation. Yet, atrial flutter may develop into atrial fibrillation, and the reverse is possible.

In atrial flutter, the atrial rhythm is regular and the ventricular rhythm may be regular or irregular. In atrial fibrillation, the atrial rhythm is irregular, so the ventricular rhythm is also irregular.

The symptoms, diagnosis, risk factors, and complications of atrial flutter are similar to atrial fibrillation. However, atrial flutter is as not life threatening as atrial fibrillation. Also, patients diagnosed with atrial flutter respond better to catheter ablation than patients diagnosed with atrial fibrillation. Both conditions are more common in elderly patients.

Causes and risk factors

The causes and risk factors for atrial flutter are similar to that of atrial fibrillation. Both genetic and environment factors can lead to the onset of atrial flutter.

The most common causes include rheumatic heart disease, high blood pressure, coronary artery disease, alcohol or illicit drug abuse, hyperthyroidism, hypothyroidism, pulmonary disease, valvular disease, congenital heart disease, coronary artery bypass surgery, congestive heart failure, atherosclerosis, myocardial infarction, rheumatic heart disease, metabolic imbalance, exposure to stimulants such as caffeine or tobacco, sick sinus syndrome, emphysema, lung disease, previous heart surgery, viral infections, stress due to pneumonia or other illnesses, and/or sleep apnea.

Symptoms

Some patients diagnosed with an atrial flutter present with few or no symptoms. However, many patients present with a variety of symptoms upon diagnosis. Yet, these symptoms vary from patient to patient and in terms of severity. Cardiovascular comorbid conditions may also affect the symptoms that are presented in patients diagnosed with atrial flutter.

Symptoms commonly associated with atrial flutter include cardiac palpitations, irregular heartbeat, anxiety, weakness, dizziness, lightheadedness, fainting, sweating, shortness of breath, chest pain, inability to perform activities of daily living, confusion, fatigue, physical activity intolerance, and hypotension.

Diagnosis and screening

The diagnosis of atrial flutter can be difficult if patients present with few or no symptoms. Physical examination, medical history, and diagnostic tools are used to screen to atrial fibrillation. Upon physical examination, practicing clinicians will look for rapid or irregular heart rate and/or hypotension.

Diagnostic screening tools used to confirm diagnosis and cause of atrial flutter include echocardiogram, electrocardiogram, Holter monitor, event recorder, chest x-ray, magnetic resonance imaging, and thyroid function tests. Also, blood work may be completed to assess other contributing factors including thyroid function tests, electrolyte levels and metabolic function tests. More invasive diagnostic tools used include stress test, tilt table test, and/or electrophysiologic testing.

Wolff-Parkinson-White syndrome

Wolf-Parkinson-White syndrome develops because of the formation of extra electrical circuits within the heart. The condition leads to rapid heart rate and abnormal electrocardiogram.

In the United States, Wolf-Parkinson-White syndrome occurs in less than 0.2% of the general population. Most patients diagnosed with the syndrome have no evidence of other cardiovascular comorbid conditions. Wolf-Parkinson-White syndrome is the most common cause of tachycardia in young children, toddlers, and infants. The syndrome is more common in men than women, with 60% to 70% of cases in men. However, the syndrome can occur in individuals of all ages and ethnic/racial descents. The highest incidence occurs in individuals between the ages of 30 and 40.

Causes and risks

Wolf-Parkinson-White syndrome is a syndrome, and by definition, an identifiable external cause is not known. It is caused by an accessory pathway in the cardiac conduction system that causes arrhythmias in some individuals. The condition is congenital, and thus, there are no risk factors.