The Cardiac Cycle and Cardiac Output

• Cardiac cycle – the contraction and

relaxation of the heart constitutes one
heart beat
-Systole – a phase during which ventricles
contract and eject blood into the
pulmonary and systemic circulation
-Diastole – atrial contraction (relaxation)
phase
• Stroke volume – ejection of blood volume
in each contraction (ave. 70ml/beat)
• Cardiac Output – amount of blood pumped by the
ventricles into the pulmonary and systemic circulation
in 1 minute.
- Indicator of how well the heart is functioning as a
pump
- If the heart cannot pump effectively cardiac output
and tissue perfusion are decreased that may become
ISCHEMIC.
(Ave. 4-8L/min) CO x HR = SV

• Ejection fraction – percentage of total blood in the

ventricle at the end of the diastole ejected from the
heart with each beat (Normal EF 50% - 70%,
• Cardiac reserve – the ability of the heart to respond
body’s changing need.
 Cardiac Output
• Cardiac output = heart rate X stroke
volume
• Normal cardiac output ranges from
4-8 liters per minute.
• Variances in CO are caused by either
changes in HR or SV
 Heart Rate Control
• Nervous system control
– Parasympathetic: decreases
automaticity, contractility, conduction
velocity, and chronotropy (rate)
– Sympathetic: Increase automaticity,
contractility, conduction velocity, and
chronotropy
 Heart Rate Control
• Intrinsic regulation
– Baroreceptors: located in the aortic arch and the
carotid sinuses. As changes in wall strain are
sensed they stimulate the autonomic nervous
system to either raise or lower the heart rate.
– Arterial Chemoreceptors: located in the aortic
arch. Their main function is to sense changes in
pH, PaCO2 , and oxygen tension. Stimulation of
the these receptors normally causes increases in
respiratory rate and depth.
 Stroke Volume Control
• Stroke volume is the volume of blood
ejected from the ventricle with each
beat and is influenced by three factors
(ejection of blood volume in each
contraction) ave. 70ml/beat:
– The amount of blood in the ventricles prior
to systole (Preload)
– The amount of pressure that the ventricle
has to pump against (Afterload)
– The degree of myocardial contractility
 Preload
• The length of the myocardial fibers
at the end of diastole just prior to
systole.
• Clinically it relates to the volume of
blood in the ventricle just prior to
systole.
• Referred to as left ventricle end
diastolic volume (LVEDV), left
ventricle filling pressure, or venous
return.
 Preload
• Preload is measured clinically by
observing the central venous
pressure (right ventricular preload)
and the pulmonary capillary wedge
pressure (left ventricular preload).
 Preload
• Elevated preload could indicate
cardiac failure or hypervolemia.

• Reduced preload could indicate

hypovolemia.
 Afterload
• The amount of myocardial wall
tension the ventricle has to generate
to pump blood out of the ventricle
during systole.
• It indicates how hard the ventricle
has to work to pump blood out.
 Afterload
• Afterload is influenced by:
– Aortic end diastolic pressure
– Compliance of the arterial system
– Peripheral vascular resistance
– Blood volume
– The status of the aortic valve
• Afterload is measured by measuring
peripheral or systemic vascular resistance
(PVR or SVR)
 Contractility
• The force of the myocardial
contraction
• Contractility may be influenced by
medications, electrolyte imbalances,
fluid volumes, etc
– Positive inotrope = increases the force of
the contraction.
– Negative inotrope = decreases the force
of the contraction.
 Systemic Vascular
Resistance
• The measurement of left ventricular
afterload
• Normal SVR is between 900 and 1400
dynes/sec/cm-5
• SVR is increased by aortic valve
disease and elevated blood pressure
• SVR is decreased with the use of
vasodilators.
 Pulmonary Vascular Resistance
• The measurement of right ventricular
afterload
• Normal PVR is between 100 and 250
dynes/sec/cm-5
• PVR is increased by a diseased pulmonary
valve or anything that causes increased
resistance in the pulmonary vascular
system (PE, pulmonary vasoconstriction
secondary to COPD)
 Cardiac Index
• A calculation of cardiac output that
considers the patient’s size.
• CI = CO / BSA
• Normal CI is between 2.5 and 4
liters/minute/m2
Advanced Cardiovascular
Assessment
 Assessment of Cardiac
System
• Health History
• Symptom Analysis
• Physical exam
– General
appearance
– Chest discomfort
– Head –to- Toe
Assessment
 Nursing History
➢ Modifiable
▪ Risk Factors ✓ Stress
✓ Diet
✓ Exercise
➢ Non-modifiable ✓ Cigarette smoking
✓ Age ✓ Alcohol
✓ Gender ✓ HPN
✓ Race ✓ Hyperlipidemia
✓ DM
✓ Heredity
✓ Obesity
✓ Contraceptive pill
✓ Personality type
Expected Manifestations of
Cardiac Disease
• Chest Pain
• Irregular rhythm
• Dyspnea
• Syncope
• Fatigue
• Weight gain
• Cyanosis
• Hemoptysis
 Assessment of Chest
• Need a system
• Inspection
• Palpation
• Auscultation
 Auscultation Areas……….
• A =aortic, 2nd ICS, right sternal
border
• P = pulmonic, 2nd ICS, left
• E = Erb’s point, 3rd ICS, left
• T = tricuspid, 4th ICS, left
• M = mitral, 5th ICS, left medial
Precordium
Precordium
 Normal Heart Sounds
• S1 – created by the closing of the
AV valves (tricuspid and mitral)
– Occurs at the beginning of ventricular
systole
– Best heard at the apex
– “Lub”
 Normal Heart Sounds
• S2 – created by the semi-lunar
valves closing (aortic and pulmonic
valve)
– Occurs at the end of systole and the
beginning of ventricular diastole
– Heard best at aortic area or pulmonic
area
– “dub”
 Abnormal Heart Sounds
• S3 – occurs during the rapid phase of
ventricular filling
– As blood tries to enter the ventricle during
diastole it is interrupted or stopped from
flowing freely, so it produces a vibration or
extra sound
– Can be normal in kids, pregnancy, and young
adults
– Heard right after S2, low frequency
– Best heard when client lying on left side at apex
 S3…………

• Lub dub a or Lub dab

dadab

• Gallop sound (ken tucky)

 Abnormal Heart Sounds
• S4 – occurs as blood enters
ventricles at the end of
ventricular diastole,
corresponding to atrial kick
– Heard just before S1
– Best heard with client lying on left
side
 S4……………….
• LA lub dub
• TEN nes see
 Murmurs
• Due to alteration in blood flow or
turbulent blood flow
• Timing
– Systolic murmurs – heard best between
S1 and S2;
– Diastolic Murmurs – heard between S2
and S3;
• Lub shh dub

• Lub dub shh

 Murmurs…..
• Location – where can it be
heard best
• Intensity- Graded on scale 1-
6
• Pitch -Low? High?
• Radiation
 Diagnostic tests

• Electrocardiogram (EKG)
• Blood Test
– CBC
– Cardiac enzymes
– Coagulation Studies
– Lipids
– Electrolytes
 ECG
• Graphic recording of heart electrical activity.
– Electrical impulse are converted into
waveforms
– Current flowing the positive electrode =
Upward waveform
– Current flowing away from the positive
electrode = Downward waveform
– Current flowing perpendicular to the
positive pole = biphasic waveform
– Absence of electrical activity is
represented by a straight line = isoelectric
line
Leads of the ECG (12 Leads)
• Frontal plane of the heart = 3 bipolar
leads (Lead I. II, III) and 3 unipolar
leads aVR, aVL, aVF
• Precordial Leads also known as Chest
Leads (V1 to V6 Leads) Unipolar
– View the heart in horizontal plane
– Measures electrical activity between the
center of the heart and a postive
electrodes on the chest wall.
A. ECG
1. strip: small square: 0.04secs.
large square: 0.2secs.
2. P wave: produced by atrial depolarization;
indicates SA (sinus) node function
3. P-R interval (N˚= 0.12 - 0.20 secs.)
a. indicates AV conduction time or the time
it takes an impulse to travel from the atria
down and through the AV node
b. measured from beginning of P wave to
beginning of QRS complex
ECG
4. QRS complex (N˚= 0.06-0.10 secs.)
a. indicates ventricular depolarization
b. measured from onset of Q wave to end of S
wave
5. ST segment
a. indicates time interval between complete
depolarization of ventricles and repolarization
of ventricles
b. measured after QRS complex to beginning of
T wave
6. T wave
a. represents ventricular repolarization
b. follows ST segment
ECG
 Interpreting an ECG
Step 1 – Determine the rate
• 6 Second rhythm strip
• Triplicate method = 300, 150, 100, 75, 60,
50, 45….
• Caliper Method = 1500 /number of small
boxes
 Interpreting an ECG
Step 2 – Determine the Regularity
• Use a caliper
– Regular if all caliper points fall succeeding
wave peaks
– Irregularly irregular = if the intervals have no
patterns
– Regularly irregular = if a consistent pattern to
the irregularity are identified
 Interpreting an ECG
Step 3 – Assess P waves
• If P waves are not seen or differ in shape,
the rhythm may not originate in sinus node.
Step 4: Assess P to QRS relationship
• There should be only one P wave in every
QRS complex.
Step 5: Determine interval durations
Step 6: Identify abnormalities
– Abnormalities in waveform and duration
 Lipids
• HDL- High Density Lipoproteins
– Protective, carries “bad” cholesterol from
arteries
– The higher the better
– Increases with exercise and low fat diet
– Desirable = 35 or greater
• LDL – Low Density Lipoproteins
– “bad” cholesterol, adheres to the arteries
– Desirable = Less than 130, unless heart disease
already present then less than 100 is desirable
 Cardiac Enzymes……..
• Myoglobin – found in many tissues
• Creatine Kinase – Normal values:
– Males -38-174 U/L and Females 26-140
U/L
– Isoenzymes
• CKMM- skeletal ( 96-100%)
• CKBB – brain (0%)
• CKMB – cardiac (0-4%)
 Cardiac Enzymes……..
• Troponin – normal level is <0.6 mg/ml
• Lactic acid dehydrogenase (LDH) –
found in many tissues
– Isoenzymes
• LDH1
• LDH2
 Cardiac Enzymes
MARKER BEGINNING PEAK AFTER RETURN TO
OF RISE INJURY NORMAL
AFTER
INJURY

Myoglobin 1-2 hours 4 – 6 hours 20-24 hours

Creatine kinase 4-6 hours 24 hours 3-4 days

CK –MB 6-8 hours 14 -36 hours 48 – 72 hours

Troponin I 1-6 hours 14-18 hours 6-14 days

Lactic Acid 24 hours 72 hours 10 days

Dehydrogenase
 Other Diagnostics………
• Stress testing
• Echocardiography
• MUGA scan (multi-gated acquisition
scanning)
• Cardiac Catheterization
• Electrophysiology Study (EPS)
 Cardiovascular Bedside
Assessment
• Apical Pulse • Peripheral Pulses
• Heart Sounds • Calve Tenderness
• Lung sounds • History of pain
• Jugular vein • History of SOB
distention • Vital signs
• Capillary refill time • EKG
 Hemodynamic Monitoring
• Evaluates the patient's cardiac
function, circulating blood volume,
and physiologic response to
treatment.
• Indications: patients with alterations
in cardiac output, alterations in fluid
volume and alterations in tissue
perfusion.
 Components of Hemodynamic
Pressure Monitoring
• The invasive
catheter and the
high pressure
tubing connecting
the patient to the
transducer
• The transducer
• The flush system
• The bedside
monitor
 Types of Hemodynamic
Pressure Monitoring

• Intraaterial blood pressure

monitoring
• Central venous pressure monitoring
• Pulmonary artery pressure monitoring
• Left atrial pressure monitoring
 Intraaterial Pressure
Monitoring
• The monitoring of blood pressure by
means of a short Teflon catheter
inserted into an artery (radial,
brachial, axillary, or femoral)
• Indications:
– Patients with compromised cardiac
output, tissue perfusion, or fluid volume
status.
– Patients in acute respiratory failure who
require frequent arterial blood gases.
 Alterations in Arterial
Pressure
• Elevated Pressure • Reduced Pressure
– Systemic – Low cardiac output
hypertension – Aortic stenosis
– Arteriosclerosis – Dysrhythmias
– Renal Failure – Vasodilator therapy
– Aortic
regurgitation
 Potential Complications of
Arterial Pressure Monitoring

• Hemorrhage
• Hematoma at the insertion site
• Infection
• Embolization of the Artery
Central Venous Pressure
Monitoring
• Measures the pressure within the
superior vena cava and reflects the
pressure under which the blood is
returned to the right atrium.
• Normal CVP is between 4-10 cm H20
or 3-11mm Hg.
• It is more important to follow trends
than to look at isolated numbers.
 Measurement of Central
Venous Pressure
• The catheter is usually placed in the right
subclavian vein and attached to either the
the hemodynamic line as previously
described or to a manometer attached to a
regular IV line.
• CVP readings are most accurate if taken at
end expiration. This minimizes the effects
of changes in intrapleural pressures on the
readings.
 Alterations in Central
Venous Pressure
• Elevations in CVP
– Increased blood – Cardiac tamponade
volume – Positive pressure
– Congestive heart ventilation
failure
– Vasoactive drugs
– Right ventricular
that cause
failure
vasoconstriction
– Tricuspid value
disease
– Pulmonary
hypertension
 Alterations in Central
Venous Pressure

• Reductions in CVP
– Decreased blood volume
– Beta adrenergic stimulation (causing
vascular dilatation)
Potential Complications of CVP
Pressure Monitoring

• Pneumothorax • Fluid volume

• Phlebitis overload
• Air embolus • Arrhythmias
• Pulmonary embolus • Sepsis
• Micro electric
shock
 Pulmonary Artery
Pressure Monitoring
• Obtained from a catheter inserted
into the right side of the heart and
threaded thru the right atrium and
ventricle and into the pulmonary
artery.
• Potential insertion sites:
– Subclavian - femoral
– Jugular - brachial
 Pulmonary Artery
Pressure Monitoring
• Is capable of measuring several
hemodynamic parameters:
– Pulmonary artery systolic pressure
– Pulmonary artery diastolic pressure
(PAD)
– Pulmonary artery mean pressure (PAM)
– Pulmonary artery wedge pressure
(PAWP or PACP)
 Pulmonary Artery
Pressure Monitoring
• Is capable of calculating several
hemodynamic parameters from the
measurements obtained:
– Cardiac output (CO)
– Cardiac index (CI)
– Pulmonary vascular resistance (PVR)
– System vascular resistance (SVR)
Measurement of Cardiac
Output
• Obtained by injecting 10 ml of a
known temperature injected into the
proximal lumen of the pulmonary
artery catheter (CVP port). The fluid
passes over the thermistor
(temperature sensor) at the end of
the pulmonary artery catheter and
the change in temperature of the
flow is noted. CO is calculated by the
time it takes to detect a
temperature change.
 Potential Complications of PA
Pressure Monitoring
• Ventricular arrhythmias
• Pulmonary emboli
• Air embolus
• Pulmonary infarction
• Infection
• Fluid volume over load
Cardiac Catheterization
 Right Heart
Catheterization
• Performed using a thermodilution
pulmonary artery catheter.
• Insertion site is venous (usually the
femoral vein)
• All Hemodynamic values obtained by
bedside monitoring can be obtained.
 Left Heart
Catheterization
• Performed to visualize the left side of the
heart.
• Insertion site is arterial (usually the
femoral artery)
• Left heart hemodynamic values are
obtained.
• Dye is injected into the coronary arteries
to visualize flow and detect areas of
occlusions.
 Indications for Cardiac
Catheterization

• Myocardial ischemia
• Unstable angina
• Myocardial infarction
• heart failure
• Possible cardiac valvular disease
 Post Catheterization
Care
• Monitor PTT and H&H.
• Monitor arterial and venous puncture
sites for bleeding every hour.
• Maintain pressure dressing on
insertion sites.
• Maintain patient flat in bed for 6
hours.
• Monitor peripheral pulses every hour.
• Rehydrate to flush dye through
kidneys.
 Electrophysiology Study
• An invasive diagnostic tool used to record
intracardiac electrical activity.
• Indicated for patients with syncope
episodes, rapid wide complex tachycardia
or other cardiac electrical problems not
diagnosed by other studies.
• Catheters are inserted into the right side
of the heart through the femoral vein to
detect ectopic sites. Once the problem is
identified treatment can be instituted.
Electrocardiography (ECG,
EKG)
• Waves, Complexes:
➢ P wave
➢ PR interval
➢ QRS complex
➢ ST segment
➢ T wave
 Common ECG Changes
• Hypokalemia
➢ U-wave
➢ Depressed ST • Myocardial
segment Infarction
➢ Short T wave ➢ Elevated ST
• Hyperkalemia segment
➢ Prolonged QRS ➢ Inverted T wave
complex ➢ Pathologic Q wave
➢ Elevated ST
segment
➢ Peaked T wave
 Holter Monitoring
➢Continuous (24 hr) ECG monitoring
➢Utilizes telemetry unit
➢Detects activities which precipitates
dysrhythmias, it’s onset
➢The nurse should log/record the
activities of the client, an any unusual
sensations experienced
 Invasive Hemodynamic
Monitoring
• Central Venous • PA Pressure/PCWP
Pressure ➢ Reflects pressure in L
➢ Monitors pressure heart
within R atrium ➢ Swan-Ganz cath-flow
➢ Monitors blood vol, directed, balloon
venous return, pump tipped, 4-lumen cath
function of R side of ➢ Cath tip at PA
heart ➢ NV: 4-12 mmHg
➢ Supine position ➢ >25 mmHg suggest
➢ 0 level at RMAL, 4th impending pulmonary
ICS edema
➢ Strict asepsis
 Pulmonary Capillary Wedge
Pressure
• Nursing Interventions:
➢Inflate balloon only when reading
➢Observe catheter insertion site
➢Culture site every 48 hrs
➢Assess extremity – color, temp, capillary
filling, sensation
 Sonic Studies
• Echocardiography • Transesophageal
➢ Assess cardiac Echocardiography
structure, mobility ➢ Imaging cardiac
➢ No special prep structures and
➢ Painless great vessels via
➢ Takes 30-60 esophagus
minutes
➢ Client in still supine
position, sl turned to
the left side,
➢ HOB in 20-30o
elevation
 Transesophageal
Echocardiography (TEE)
Nursing ▪ After
Intervention: ➢ NPO until gag reflex
return
▪ Before
➢ Lateral or semi fowler’s
➢ History position
➢ NPO 4-6 hrs prior ➢ Encourage to cough
➢ Remove dentures, oral ➢ May give throat lozenge
prosthetics
➢ Watch out for
➢ Sedatives as ordered complication –
➢ Suction & resuscitating pharyngeal bleeding,
equipment at bedside cardiac dysrythmias,
➢ Cardiac monitor vasovagal rxn, transient
➢ Topical anaesthetic hypoxemia
➢ Chin to chest position
Stress testing/Exercise
Testing
• Purpose
➢Identify ischemic heart disease
➢Evaluate patients with chest pain
➢Evaluate effectiveness of therapy
➢Develop individual fitness program
Stress Testing/Exercise
Testing
Nursing Intervention
➢ Get adequate sleep before the test
➢ Avoid tea, coffee, alcohol on the day of test
➢ Avoid smoking, taking nitroglycerine 2 hrs prior
to the test
➢ Wear comfortable loose-fitting clothes
➢ Eat light meal at least 2 hours prior
➢ Wear low-heeled, rubber-soled pair of shoes
➢ Inform MD for unusual sensation that develop
during the test
➢ Rest after the test
 Radiologic Tests

• Chest Roentgenogram ➢ R sided heart

(X-Rays) catheterization -
• Cardiac fluoroscopy medial cubital or
brachial vein
• Cardiac
➢ L sided heart
Catheterization catheterization
➢ Assess O2 level, – brachial or
pulmonary blood flow, femoral artery
CO, heart structures
➢ Coronary artery
visualization
Cardiac Catheterization
Nursing Intervention ➢ Mark distal pulses
▪ Before ➢ Do cardiac
➢ Provide psychosocial monitoring
support ➢ Done under local
➢ Assess allergy to anesthesia
iodine/seafoods ➢ May experience
➢ Obtain baseline VS flushing sensation
as dye is introduced
➢ Withold meals
before procedure ➢ Fluttering sensation
as cath enters
➢ Have client void
chambers of the
➢ Sedative as ordered heart
Cardiac Catheterization
Nursing Intervention
➢ Immobilize and
▪ After extend affected
➢ Bed rest – until extremities
stable VS if UE, 24 ➢ Do not elevate HOB
hrs if LE > 30o if femoral site
➢ Monitor VS, is used
peripheral pulses ➢ Monitor extremities
➢ ECG monitoring for color,
➢ Apply pressure temperature ,
dressing or ice over tingling
puncture site
Angiography/Arteriography

➢Contrast medium to the vascular system

to outline the heart and vascular system
➢May be done during cardiac
catheterization
➢Nursing interventions are same with
cardiac catheterization
➢Observe for hypotension after the
procedure
 Magnetic Resonance
Imaging/MRI
Nursing Intervention
➢Secure written consent
➢Inform client about the procedure
➢Remove all metal items
➢Instruct client to remain still during
procedure
➢No client with pacemakers, prosthetic
valves, recently implanted clip or wires
Myocardial Scintigraphy
➢IV injection of radioactive isotope via a
cath
➢Studies myocardial function, motion and
perfusion through the use of ext gamma
cam
➢Techniques used are:
✓Thallium 201 scintigraphy
✓Dypiridamole-thallium-201 test
✓Technetium 99 m ventriculography
✓First pass cardiac study
Myocardial Scintigraphy
Nursing Intervention
➢Inform client that ECG or treadmill test
may be done during the procedure
➢Assess for pregnancy
➢Instruct client to have light meal
➢Omit usual dose of B-blockers, Ca-
channel blockers, xanthines before the
procedure
➢Instruct client to report any chest pain
during the procedure
 Non-Invasive Hemodynamic
Monitoring
Intra Arterial Pressure Monitoring
➢Continuous detection of arterial BP via
indwelling intra-arterial cath
➢Valuable in clients with low CO,
fluctuating hemodynamic status and
excessive peripheral vasoconstriction,
and in cuff BP is undetectable
➢At least 10 mmHg higher than cuff
reading
➢Intra arterial line can be utilized for
blood studies
 Non-Invasive Hemodynamic
Monitoring

Nursing Intervention
➢Heparinize catheter to maintain patency
➢Check cath insertion site for
hemorrhage, hematoma, redness or signs
of infection
➢Do neurovascular check distal to cath
insertion site – color, temp, capillary
filling, sensation