Assessment of Cardiac

Function
Chapter 26
Assessment of the Cardiovascular
System
On Your Own:
• Review the anatomy of the heart and
vessels
• Review normal circulation
• Review coronary circulation
• Review conduction
Coronary Circulation
 Mean Arterial Pressure
• “average pressure at which blood moves
through vasculature” (B&S, p. 358

• MAP = Systolic BP + 2(diastolic BP)

3
 Mean Arterial Pressure
• The Mean Arterial Pressure (MAP) is 80 mm Hg.
What does this mean?

• The MAP drops to 60 mm Hg. What are the

implications of this value?

• The MAP drops to 55 mm Hg. What are the

implications of this value? What should be
administered to the patient?
Conduction System of the Heart
 Impulse Conduction
• The heart rate is 80 bpm. From where is this impulse
originating? What does this mean?

• The heart rate is 50 bpm. From where is this impulse

originating? Are there any other possibilities? What
does this mean? What could be the cause?

• The heart rate is 30 bpm. From where is this impulse

originating? What does this mean? What could be the
cause?
 Cardiac Hemodynamics
• Key principle:
– Blood flow, in part, is determined by the flow
of blood from an area of higher pressure to
one of lower pressure

In what chamber would you expect to have the

highest pressure?
 Cardiac Cycle
Diastole
• 2/3 of the cardiac cycle
• Relaxation and filling of the atria and ventricles

Systole
• 1/3 of the cardiac cycle
• Contraction and emptying of the atria and
ventricles
 Mechanical Properties
• Cardiac output • Heart rate
– What is it? – What is it?
– What is normal? – What is normal?
– Why is it important? • Stroke volume
• Cardiac index – What is it?
– What is it? – What is normal?
– What is normal? – What factors influence
it?
 Variables that Influence Stroke
Volume
Preload
• Degree of myocardial fiber stretch at the
end of diastole and just before contraction
• Determined by LVED pressure and blood
return from the venous system
• Starlings Law: the more the heart fills
during diastole, the more forcefully it
contracts
 Variables that Influence Stroke
Volume
Afterload
• Pressure or resistance that the ventricles must
overcome to eject blood through the semilunar
valves and into the peripheral blood vessels.

Impedance (the peripheral component of afterload)

• Pressure heart must overcome to open the
aortic valve
• Amount of impedance depends upon aortic
compliance and total systemic vascular
resistance, a combination of blood viscosity and
arteriolar constriction
 Critical Thinking Question
• You have a ¾ inch and 1 inch diameter
garden hose. You are pumping the same
amount of water through each one.
– Which one will have to pump against more
resistance?
– Which one will have a lower pressure?
– How does this analogy correlate to blood
vessels?
Preload and Afterload
 Contractility
 What is it?

 What drug is often given to increase

contractility?

 What increases contractility?

 What decreases contractility?

 Vascular System
• On Your Own
– Review Purpose, Structure and Function
– Physiology of blood pressure
 Blood Pressure
• What is blood pressure?

• What two factors are the primary determinants of blood

pressure?

• How do increases or decreases in either or both of these

factors affect blood pressure values?

• What body systems are involved in the regulation of blood

pressure?

• What external factors can affect blood pressure?

 Assessment: History
Patients will be queried regarding:
• History of cardiac • Syncope
symptoms • Cough
• Dyspnea • Past health history
• Fatigue • Medications
• Paroxysmal nocturnal • Risk factors
dyspnea – Age
• Orthopnea – Diet
• Chest pain – Activity
• palpatations – Smoking
 Additional Assessment Areas
• Health perception and management
• Nutrition and metabolism
• Elimination
• Activity and exercise
• Sleep rest patterns
• Cognition and perception
• Self-perception and self-concept
• Roles and relationships
• Sexuality and reproduction
• Coping and stress tolerance
 Pack-years
Smoking history should be reported in pack
years:
• Number of packs per day multiplied by the
number of years has smoked

(0.5 pack X 10 years = 5 pack years)

 Physical Exam
• Cyanosis • Neck vein distention
• Petechiae • Skin color
• Edema • Hair distribution on
• Pulses extremities
• Heart sounds • Lesions
• Murmurs • Clubbing
• Bruits • dysrhythmias
• Blood pressure
 Postural BP Changes

Compare and contrast normal

and abnormal blood pressure
responses to postural position
changes.
What do orthostatic changes
indicate?
 Assessment of Clubbing
Schamroth Method
• Place fingernails of the ring fingers
together and hold up to light
• If a diamond shape can be seen between
the nails findings are normal
• Absence of the diamond shape indicates
clubbing
Assessing for Clubbing
 Diagnostic Tests
• Cardiac Biomarkers • Echocardiography
• Chemistries • Radionuclide imaging
• CXR & Fluroscopy • Cardiac
• ECG catheterization
• Continuous Cardiac • Angiography
Monitoring • Hemodynamic
• Cardiac Stress monitoring
Testing
 Important Markers of Myocardial
Damage
Creatine Kinase–
• specific to brain, myocardial, and skeletal
muscle cells
• Presense in blood indicates tissue
necrosis or injury
• Isoenzymes identify specific source
– CK-MB activity is most specific for MI with
predictable rise over 3 days (peak at 24 hours
after onset of chest pain)
 Early Markers
• CK-MB antibody assay can detect
myocardial necrosis within 3 hours of ED
admission
• CK-MB subforms 1 and 2 (early and
specific indicators)
• Myoglobin (early, sensitive, but non-
specific)
• Troponin T and I (early with wide
diagnostic time frame)
 Additional Labs
• Blood Chemistries
• Coagulation studies
• Hematologic studies
• Lipid Profile
• Cholesterol and Triglycerides
• BNP
• CRP
• Homocysteine
 Other Diagnostic Tests
• ECG
• Continuous electrocardiographic monitoring
– Hardwire vs. Telemetry
– Signal averaged
– Continuous Ambulatory ECG (Holter Monitor)
• Echocardiography
– Traditional vs. Transesophageal
• Cardiac Stress Testing
– Exercis, Pharmacologic, Mental
• Radionuclide Imaging
– Myocardial Nuclear Perfusion Imaging
– ERNA (aka MUGA)
– Computed Tomography (CT)
– Positron Emission Tomography (PET)
• Heart Catheterization /Angiography
• Electrophysiologic Studies
 Cardiac Catheterization
Provides:
• Visualization of coronary blood flow
• Measurement of pressures in heart chambers
• Determination of O2 saturation of the blood
• Visualization of the valves
Procedure:
• One or more catheters inserted (femoral;
brachial)
• Dye injected
• Takes about 1 hour
 Cardiac Catheterization
Before the test: • Patient Education
• ECG – Length of procedure
• Chest x-ray – May feel palpitations
and flushing
• Urine
• Blood • Basic Pre-op
• BUN/Creatinine preparation
• Fast 8-12 hours
• IV started
 Cardiac Catheterization
• Indications: Complications
– Confirm suspected • Rt: thrombophlebitis, PE,
disease vagal response
– Determine location and
• Lt: MI, Stroke, arterial
extent of disease
bleeding or thrombo-
– To assess stable
embolism, dysrhythmias
angina, uncontrolled HF
– To determine best • Rt. or Lt.: cardiac
therapeutic options tamponade, hypovolemia,
pulmonary edema,
– To evaluate effects of
hematoma, contrast
treatment
media reaction
 Cardiac Catheterization
During the test:
• May be asked to cough or deep breathe
After the test:
• Firm pressure over site– observe for bleeding,
hematoma
• Circulatory checks every 15 minutes for 1-2
hours then every 1-2 hours after stable
• Observe for dysrhythmias
• Keep leg or arm straight for several hours
• Increase fluids to flush out dye
• Watch for orthostatic hypotension when first up
 Hemodynamic Monitoring
• Invasive system used in critical care to
provide quantitative information about
vascular capacity, blood volume, pump
effectiveness, and tissue perfusion.
• Directly measures pressures in heart and
great vessels
– CVP, PA, Intraarterial BP
• Provides more accurate measurements of
blood pressure, heart function and volume
status
 Hemodynamic Monitoring
• Involves significant risks, informed consent
is required
• Components
– Catheter with infusion system
– Transducer
– Monitor
Hemodynamic Monitoring
Central Venous Pressure (CVP)
• Pressure in vena cave or right atrium
– Indirect measurement of right ventricular pressure
• Normal 0-8 mm Hg
• Elevated:
– hypervolemia, Heart failure
• Low:
– decreased preload related to hypovolemia
• Complications
– Infection, Pneumothorax, Air embolism
 Pulmonary Artery Pressure
• Normal: 25/9; mean 15 mm Hg
• Measurement helpful:
– Assesses LV function
– Assists in determining etiology of shock
– Evaluates response to medical interventions
• Capable of measuring:
– RA pressure
– PA systolic pressure
– PA diastolic pressure
– Mean pulmonary artery pressure (4.5–13 mm Hg)
– Pulmonary artery wedge pressure
 Pulmonary Artery Pressure
• Elevated PA wedge pressure:
– LV failure; hypervolemia; regurgitation;
intracardiac shunt
• Low PA wedge pressure:
– Hypovolemia; afterload reduction
• Complications:
– Infection, PA rupture, Pulmonary thrombo-
embolism, Pulmonary infarction, Catheter kink,
Dyrhythmias, Air embolism
 Intrarterial BP Monitoring
• Direct and continuous BP measurement
• Provides access for ABG or blood samples
• Must have collateral circulation
– Allen test
– Ultrasound Doppler study
• Complications:
– Local obstruction, air embolism, pain and arterial
spasm, infection