Course: / Biomedical Treatment of Disease 2 / Date: / July 29, 2010
Class #: / 2

Heart Rate

Ranges of heart rates are as follows:

  1. Bradycardia - Below 60bpm
  2. 60-90 bmp
  3. 90+
  4. Tachycardia - 120+ bpm when pulse felt for 1+ minutes

Bradycardias

Bradycardia. Rhythms between 50 and 45 bpm require a pacemaker. Atheletes might have rates this low and for them that’s normal.
Possible causes:

  1. Drugs: drugs given for tachycardia and arrhythmias such as beta blockers and digoxin which treats CHF and rhythm issues such as atrial fibrillation for instance.
  2. Endocrine diseases: hypothyroidism
  3. Hyperkalcemia: metastatic bone cancer patients and thyroid dysfunction patients
  4. Acute MI can produce either bradycardia or tachycardia.

In the clinic when seeing a patient with a low heart rate for the first time, check their med list and ask if they’ve had an ECG. If the volume of the pulse is also low, look at BP and see if that is also low. Patient will likely complain about fatigue (due to lack of O2), might have black outs, experience chest discomfort, SOB.

Tachycardias

Results in improper cardiac output. Patients will experience fatigue, anxiety, extreme discomfort, distress, difficulty breathing, palpitations.
160-220 bpm indicates a Ventricular Event. 300+ is called Supra Ventricular Event. Anything ventricular requires a 911 call.

Both the Vagus nerve and the sympathetic nervous system control heart rate.

Slowing the heart rate:

While you’re waiting for 911 to get there you can do the following to slow the heart rate. Stimulate the Vagus nerve to slow the heart rate and the sympathetic NS to increase it. To increase the vagal tone, squeeze the eyeballs very tightly or rub them with eyelids closed. You can also strongly massage the ears. Stimulating the gag reflex will also stimulate the vagus nerve. You can also put a finger between the SCM and the adams apple on one side at a time! And move your thumb in a circular motion to massage the carotid. Use your fingers to gently feel the carotid pulse on the other side of the neck.

Atrial flutter or fibrillation:

Irregularly irregular pulse indicates atrial anomalies. Volume will vary from beat to beat and will thus fluctuate from weak to strong and back again. This is the most likely thing we will see in the clinic.

Age matters

  1. Atrial fib in young people
    If atrial fib in young people, these are the common events that can produce it:
  2. Thyrotoxicosis. Weight loss, sweating, heat, loss of hair and TSH and T4 levels will help you determine this. Both low and high thyroid can cause this.
  3. Cocaine
  4. Crystal Meth
  5. Rheumatic heart disease or history thereof resulting in mitral valve stenosis/narrowing.
  6. Atrial fib in patients age 60+
    Reasons:
  7. Thyrotoxicosis. Weight loss, sweating, heat, loss of hair and TSH and T4 levels will help you determine this. Both low and high thyroid can cause this.
  8. Ischemia of the sinoatrial node – loss of blood supply to the area.

Treatment

  1. Digoxin. Reduces the number of impulses reaching the ventrical
  2. Pacemakers.
  3. Calcium channel blockers – diltazem or verapamil

Lone fibrillators

None of the reasons above, yet still atrial fibrillation. For these patients, can give a sedative then use a synchronized current (as opposed to a defibrillator). This sends an impulse between the S and T wave, the low electrical impulse point, synchronizing the heart rate.

Complications of Atrial Fib.

Blood stagnates and clots in the atrium, resulting in embolism. This can happen in the cerebrum, peripheral areas, etc. These patients are given long term/lifelong blood thinners such as cumidin or warfarin…which comes with more complications still.

Corpulmonae

Right heart failure + lung dysfunction. AKA, Congestive Heart Failure. Pink puffers and blue bloaters.

Pink puffers are emphysema

Blue bloaters are chronic bronchitis.

Both end up with CHF.

Fluids are controlled with diuretics, some of which are potassium losers such as Lasix and Thiazides. Potassium sparers are aldolactone/spirolactone which block aldosterone, a sodium retainer and potassium loser in the kidneys. Amiloride and Triamterene are also potassium sparing diuretics

Ace inhibitors, digoxin.

Complicatons:

Venous stasis  DVT, leads to tissue deoxygenation. Blood stagnates in lungs leading to pneumonias.

Aggressive mgmt needed. Bronchitis/blue bloater patients generally have a standing order for antibiotics and take them when the sputum changes color – prevents pneumonia. Flu vaccines and pneumonia vaccines recommended after age of 65 for these patients.

Cholesterol Control

Extremely pertainent for cardiac patients. Check the family history from age of 20 up. Check it every 5 years. Look at Total chol + HDL/LDL and TGL levels. No meds needed below 240 total. Targets are below

TC = 200 or less

HDL = 45-50

LDL = 131

TGL = 150

If patient has already had a heart attack, HDL should be even higher – maybe even 100. LDL numbers change based on what the CDC thinks today…used to say 161, now lower due to America’s increasingly crappy diet and lifestyle. Statins are the common treatment. Statins increase HDL, lower LDL.

Up to 20% will experience side effects. 3% will experience really bad side effects…you have to monitor for LFT numbers. Herb/drug interactions can result. And by the way, no grapefruit.

High TGL’s often in ppl with diabetes, metabolic syndrome. May need meds or high fiber diet or herbs (aloe for instance – that’s an Ayurvedic remedy…guggul also) that prevent absorption of triglycerides.

Western remedies to reduce triglycerides:

Genfibrozil or fibric acid.

Slow Niacin (B3) – give 2-4 grams per day. These come with side fx such as flushing, throbbing head. These only last 6-8 weeks and should subside. Uric acid levels may go up. Severe gastritis. Liver enzymes can go up. Will also aggravate active liver disease or peptic ulcer.

Control the diet to control cholesterol and manage cardiac issues:

Reduce or cut out red meat – reduce to 1ce of 2ce per week. Better: eat fish/chicken

2g or less of salt per day

Increase fibers. Just insoluble fiber (Metamucil, cellulose) won’t work – you must increase soluble fibers also. Just insoluble will inerfere with vitamin absorption.

Calories: reduction of calories is essential. You can’t follow a diet without counting. 1600 calories per day are all that are needed. You also have to pay attention to what kind of calories.

  • Carbs – 55-60%
  • Protein – 25-30%
  • Fat – 20-27% tops
  • 80% of that should be unsaturated
  • 7% tops for saturated fat…this is the flavor part. You gotta have this because otherwise the food tastes like styrofoam.

Sugars…a 6oz cup of coffee should have no more than ½ tsp of sugar! The more refined sugars you eat the more likely diabetes is.

3 meals per day is ideal. You could also do up to 6 small meals per day.

Exercise – 1 hour per day 5 days per week
Brisk walking works just fine. Pulse rate must double and you must sweat. If you don’t, you’re not exercising. Shoot for 1 mile in 8 minutes if walking…which is damn fast. This isn’t a hard rule, just something to shoot for. Walking is better for heart patients as running can push people into failure of heart or movement of clots. Not good.

C reactive proteins is a marker here.

Test next Tuesday, read article posted on portal.

Note about cholesterol deposits – sometimes won’t show as the yellow cholesterol deposits, but will look like pimples sometimes or those flat red round keloid looking bumps (but keloids are more likely to be flat and along injury areas).
Blood Pressure Related Diseases

High BP can be controlled, but not cured. (?! Mandyam says it, not me. I think he’s referring to primary hypertension, not 2ndary.) HTN usually starts 30-35. Unusual to see it in the 20’s or under age 25. If they have it, it’s most likely curable for them. Most common in Afro-Americans for several genetic and social reason.

Lots of complications due to HTN.

One BP reading not diagnostic enough to dx HTN. They need to journal it.

Blood vessels in the retina give a good indication as to blood vessels in the body.

No one should be started on HTN meds on the first visit! Docs that do this are probably trying to just cover their asses. Jerks. ABPM above indicates BP reading right after waking.

Remember that narrowing of the renal artery can also push B up.

Younger people – pay more attention to the diastolic. Older people, systolic is more crucial.

Blood pressure categorized in stages.

Normal

Prehypertensive
120-139 systolic over 80-89 diastolic. This is a kind of grey area. You don’t define it by numbers alone. If there’s a strong family history, meds are recommended. The longer you maintain near normal pressures, the better the quality of life is long term. Every 10 points above 90 diastolic will reduce life expectancy by 1 year.
Losing weight is the single greatest thing to do. Lower sodium, exercise are also key.

Stage 1 hypertension

Stage 2 hypertension

The DASH Diet:

Some conditions mandate drugs. Here we go:

HIGH RISK CONDITIONS / DIURETIC / β BLOCKER / ACEi / ARB / CCB / ALDOSTERONE
ANTAGONIST
HEART FAILURE / $ / $ / $ / $ / $
POST MYOCARDIAL INFARCTION / $ / $ / $
HIGH CAD RISK / $ / $ / $ / $
DIABETES MELLITUS / $ / $ / $ / $ / $
CRHONIC KIDDNEY DISEASE / $ / $
REURRENT STROKE PREVENTION / $ / $

Primary hypertension has no identifiable cause. Often multifactorial – genetic, fat, salt intake (you only need 2g, most people get 10), personality and sympathetic overdrive, normal cardiac development, renen/angiotensin activity, alcohol, cigarettes, polycythemia, etc. Cigarettes cause vasoconstriction and pushes bp up. COPD patients have more red blood cells (polycythemia), as do ppl living at high altitudes.

Sleep apnea is a conributing cause also. So is use of ibuprofen on a daily basis. Here are other associated causes:

Sleep apnea

Drug-induced or drug-related

Chronic kidney disease

Primary aldosteronism
check the plasma levels.

Renovascular disease

Long-term corticosteroid therapy and

Cushing's syndrome
Purple stretchmarks, increased renin-antiogensin activiety due to steroid use for control.

Pheochromocytoma
Spots on trunk – café au lait spots. Sometimes come with pressure so high you can’t measure it!

Coarctation of the aorta

Thyroid or parathyroid disease
hypo and hyper can cause HTN.

Renal artery stenosis
Affects 1-2% of htn patients. If you put someone on ACE inhib’s and pressure gets worse, this is likely the cause.
There are several tests for this including radioisotope renography, ultrasounds, angiography, arteriograms, etc.

Complications:

Morbidity and mortality.

Cardiac

  • Left vent enlargement, arrhymia, ischemia and death.

Long term results in stroke, multiinfarc dementia, alzheimers. CT scans of brain will show lots of black holes called lacunar infarcts. Reduced by bp control.

Kidney disease
More common in afroamericans, renal insufficiency, hypertensive nephropathy, etc.

Aortic dissection

Increased atherosclerosis – increase of chol deposits

Symptoms:

Depends on what organ is involved. Heart, brain, kidneys, eyes, and peripheral arteries are all likely affected. Most are asymptomatic. If one wakes with suboccipital pulsating HA, this is a sign. Heart can show enlargement. Lab workup will show all kinds of fun things. See slides.

Goal in tracking:

  1. establish dx
  2. stage it
  3. rule out 2ndary causes
  4. identify end organs
  5. asdf

Stopped at slide 35.

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