MA114

1. MA114 Assisting Lab
Diseases Medical and
Disorders of the Heart
Week 5

2. Coronary Artery Disease

4.  A heart attack or myocardial
infarction (MI) occurs when blood
supply to a part of the
myocardium is severely reduced
or stopped.
 The blockage is usually due to
atherosclerosis, preventing blood
flow in the coronary arteries.

5. Heart Attack
 Myocardial Infarction (MI), commonly
called heart attack, is defined as the
death of heart muscle related to coronary
artery occlusion (blockage), which cuts off
the supply of oxygen and nutrients.
 Over 1 million individuals in the US suffer
from and MI each year and about half of
them die.

8. Diagnosis of MI
 Based on presenting signs and symptoms
and results of diagnostic testing.
Immediate tests include a 12-lead EKG
and blood tests to check cardiac enzymes.
 The blood test that is considered most
reliable is the troponin level, which
determines how much heart muscle
damage has occurred.

9. Diagnosis of MI
 When the patient is stable, testing may be
done to determine the extent of CAD and
whether surgical intervention is needed.
Such tests may include a nuclear heart
scan, cardiac catheterization, and
coronary angiography.
 These tests allow close inspection of heart
chambers, valves, and coronary arteries.

10. EKG

11. Congestive Heart Failure
 Congestive Heart Failure (CHF), or heart failure,
is a condition in which the heart cannot pump
enough blood to the body’s other organs.

12. Diagnosis of Heart Failure
 Diagnosis of heart failure is based on
signs and symptoms, medical history, and
diagnostic testing. An echocardiogram,
which creates a moving picture of the
heart using sound waves, is one of the
most useful tests.
 Chest x-ray revels pulmonary edema and
cardiomegaly. A blood test of B-type
natriuretic peptide (BNP) will be elevated.

13.  Treatment of heart failure includes the
administration of diuretics,
antihypertensives, and digoxin (Lanoxin).
Diuretics stimulate filtration and excretion
of urine.
 Excretion of urine reduces intravascular
fluid and allows fluid to shift from the
lungs back into blood vessels, thereby
relieving dyspnea. Antihypertensives
decrease the workload of the heart.
 Digoxin increase cardiac muscle
contractility, thereby strengthening the
pumping force of the heart .

14. Atrial Fibrillation
 There are many types of heart
arrhythmias. By far, the most common is
atrail fibrillation. It occurs when irritable
myocardial cells in the atrium, other than
the SA note, fire chaotically.
 As a result, the atria quiver uncontrollably
rather than contracting normally.

16. Atrial Fibrillation
 Atrial fibrillation affects as many as 10% of
all individuals over the age of 70, or about
2.2 million Americans, the underlying cause
of atrial fibrillation is not always clear.
 Individuals with atrial fibrillation are
sometimes asymptomatic. However, most
experience rapid, irregular heart beat;
hypotension; and chest palpitations. Others
include shortness of breath, dizziness, and
exercise intolerance.

17. Atrial Fibrillation Diagnosed
 Atrial fibrillation is sometimes intermittent
in nature and may be missed by an EKC.
 Accurate diagnosis may require the
patient to wear a Holter monitor or an
event recorder.
 This allows the detection of abnormal
heart beats as the individual goes about
their daily routine.
 Other diagnostic techniques may include
echocardiography and transesophageal
echocardiography.

18. Treatment
 Conservative treatment of atrial fibrillation
includes medication, such as digoxin, that
slows the heart rate and may restore
normal sinus rhythm.
 If medication is not successful the patient
will undergo cardioversion, which is a
synchronized shock of electrical current
delivered to the chest wall while the
patient is under sedation.

20. Ablation
 If these measures are unsuccessful, the
patient may undergo ablation (destruction
of electrical conduction pathways) of the
AV node.
 Subsequent placement of a pacemaker
may prevent the chaotic atrial impulses
from affecting the ventricles and ensure a
stable heart rate.

22. Implantable Cardioverter
 Implantable cardioverter-
defibrillator (ICD) implanted in
the chest under the skin and
attached to the heart.
 Delivers an electric shock to the
myocardium to correct
arrhythmias.

24. Rheumatic Heart Disease
 Reaction to untreated beta-hemolytic
streptococcal infection.
 All 3 layers of the Heart can be affected.
 The endocardium is most frequently involved
 Fibrosis of the affected Valves can cause:
◦ Stenosis or Narrowing
 And/or
-- Widening
◦ Regurgitation/Reverse flow occurs with
incompetent Valves

25. Causes
◦Pericarditis
◦Pericardial infusion
◦Myocarditis
◦Endocarditis

26. Valvular Disorders
Caused by a congenital defect
or an infection.
Valves can harden, do not
close completely.
Most common is mitral valve
prolapse

27. Vascular Disorders
 The vascular system is the body's network of
blood vessels. It includes the arteries, veins and
capillaries that carry blood to and from the heart.
 Problems of the vascular system are common
and can be serious. Arteries can become thick
and stiff, a problem called arteriosclerosis.
 Blood clots can clog vessels and block blood flow
to the heart or brain. Weakened blood vessels
can burst, causing bleeding inside the body.

28. Varicose VeinsVaricose veins are enlarged,
dilated superficial veins that most
commonly develop in the legs.
An estimated 12 million Americans
suffer from varicose veins.
Women suffer from varicose veins
more than men, with over 40% of
all women over age 50 affected.

29. Varicose Veins
 Venous blood travels under low pressure and
must fight against gravity to return to the
heart. Blood flow is helped along by the
presence of one-way valves in veins as well
as the pumping action of surrounding leg
muscles.
 However, when valves become incompetent
and fail to close properly, blood movement
becomes sluggish. This sluggishness results
in vein engorgement, which further
exacerbates valvular incompetence.

31. Treatment
 Patients should avoid activities that
impede circulation, including wearing hose
with tight leg bands, wearing girdles,
crossing legs, and sitting or standing for
prolonged time.
 Weight loss is encouraged
 More aggressive treatment includes
ligation and stripping or injection of a
sclerosing solution that caused the vein to
collapse, harden, and eventually atrophy.

32. Deep Vein Thrombosis
Also known as thrombophlebitis,
occurs when a blood clot develops in
a deep vein, usually in the legs.
This condition most commonly
develops in adults over the age of 60
and those with impaired mobility,
such as those with paralysis.

33. DVT
 Usually occurs secondary to vessel injury and
blood stasis caused by poor circulation and
immobility.
 Platelets begin to gather and fibrin formation
occurs in areas of injury, creating a blood clot,
and then inflammation ensures.
 Other contributing factors include clotting
disorders, heart failure, estrogen use,
malignancy, obesity and pregnancy.

35. Symptoms
Dull ache in the area of the clot, a
feeling of heaviness, and localized
edema, redness, and heat.
Diagnosis can be confirmed with
compression ultrasonography,
which reveals the failure of a vein
to compress where a clot is
located. Radiographic
venography may also help
confirm the diagnosis.

36. Treatment
Include administration of an
anticoagulant medication,
such as heparin or enoxaprin
(Lovenox), followed by
warfarin (Coumadin).
The patient should rest and
refrain from exercise until the
condition resolves.

37. Other Diagnostic Tests
A D-dimer test
This test measures a substance in the blood
that’s released when a blood clot dissolves.
If the test shows high levels of the substance,
you may have a deep vein blood clot.
If your test is normal and you have few risk
factors, DVT isn’t likely.

38. Venography
This test is used if ultrasound doesn’t provide a
clear diagnosis.
Dye is injected into a vein, and then an x ray is
taken of the leg.
The dye makes the vein visible on the x ray.
The x ray will show whether blood flow is slow
in the vein. This may indicate a blood clot.

40. Arteriosclerosis and
Atherosclerosis
 Arteries are blood vessels that carry oxygen and nutrients
from your heart to the rest of your body.
 Health arteries are flexible, strong and elastic.
 Over time, however, too much pressure in your arteries can
make the walls thick and stiff—sometimes restricting blood
flow to your organs and tissues.
 This process is called arteriosclerosis, or hardening of the
arteries.
 Atherosclerosis is a specific type of arteriosclerosis, but
the terms are often used interchangeably.

41. Atherosclerosis

42. Signs and Symptoms
 The specific signs and symptoms
depend on which arteries are
affected. For example:
◦Heart arteries.
◦Obstruction of the arteries to your
heart (coronary arteries) may
cause symptoms of heart attack,
such as chest pain.

43. The damage may be caused
by:
--High blood pressure
◦High cholesterol
◦An irritant, such as nicotine
◦Certain diseases, such as
diabetes

44. Screening and Diagnosis
 The doctor may find signs of
narrowed, enlarged or hardened
arteries during a physical exam.
These include:
◦A weak or absent pulse below the
narrowed area of your artery

45. Screening and Diagnosis
◦Decreased blood pressure
in an affected limb
◦Whooshing sounds
(bruits) over your
arteries, heard with a
stethoscope.

46. Testing
Doppler ultrasound.
Measures your blood
pressure at various points
along your arm and leg.
◦Ankle-brachial index.
Blood pressure in your ankle
with the blood pressure in
your arm.

47. ◦ View blood flow through the
heart, the doctor may inject a
special dye into your arteries
before a chest x-ray.
◦ The dye outlines narrow spots
and blockages on the x-ray
images.
Angiogram

49.  An aneurysm is a permanent ballooning
in the wall of an artery.
 The pressure of blood passing through
can force part of a weakened artery to
bulge outward, forming a thin-skinned
blister.
Aneurysm

50. 

51.  The gravest threat an aneurysm poses
is that it will burst and cause a stroke
or life-threatening massive bleeding
(hemorrhage).
 If an aneurysm ruptures, the patient
must be treated within minutes in order
to have a chance of survival.

52.  A Doppler ultrasound is a noninvasive
test that can be used to evaluate blood
flow and pressure by bouncing high-
frequency sound waves (ultrasound) off
red blood cells.
Doppler Studies

53.  A Doppler ultrasound may help
diagnose many conditions, including:
◦ Blood clots
◦ Incompetent valves in your leg veins, which
cause fluid to accumulate (venous insufficiency)
◦ Heart valve defects and congenital heart
disease
◦ A blocked artery (arterial occlusion)
◦ Narrowing (stenosis) of an artery

54. Angiography is an x-ray exam of the
arteries and veins to diagnose
blockages and other blood vessel
problems.
Angiography

55.  During the angiogram, the doctor
inserts a thin tube (catheter) into the
artery through a small nick in the skin
about the size of the tip of a pencil.
 A substance called a contrast agent (x-
ray dye) is injected to make the blood
vessels visible on the x-ray.
Angiogram

56.  Echocardiography is a painless test that
uses sound waves to create images of
your heart.
 It provides your doctor with information
about the size and shape of your heart
and how well your heart’s chambers
and valves are working.
Echocardiography

58.  The test also can identify areas of heart
muscle that aren’t contracting normally
due to poor blood flow or injury from
previous heart attack(s).
 Echocardiography can detect possible
blood clots in the heart, fluid buildup in
the sac around the heart (pericardium),
and problems with the aorta (the main
artery that carries oxygen-rich blood
out of the heart).

59. Cardiac Catheterization
and
Angioplasty

60.  Cardiac catheterization is used to study
the various functions of the heart.
 Using different techniques, the
coronary arteries can be viewed by
injecting dye or opened using balloon
angioplasty.
 The oxygen concentration can be
measured across the valves and walls
(septa) of the heart and pressures
within each chamber of the heart and

61. Cardiac Catherization

62. Angioplasty

63.  The Holter Monitor is a portable device
that records the patient's cardiac
rhythm over a 24- or 48 hour period.
 This type of testing, also known as
ambulatory electrocardiography, is
useful when the patient complains of an
irregular heartbeat or other symptoms
that are intermittent and therefore
difficult to obtain on a 12-Lead EKG in
the medical office.
Holter Monitor

64.  The Holter is named after its inventor,
Norman Holter.
Holter Monitor

66.  The medical assistant should apply the
Holter monitor electrodes to the patient
and show him or her how to carry the
monitor in a small pouch with a
shoulder strap.
 The medical assistant should instruct
the patient to wear the device while
participating in normal daily activities
and to record in a journal when they
feel any symptoms, such as heart
palpitations and dizziness, or if he
engages in heavy physical activity.

67.  The purpose of ambulatory monitoring
is to document the electrical activity in
the heart and identify any abnormal
heart behaviors such as dysrhythmias.
 Abnormal heart behaviors can occur
randomly or spontaneously and may be
sleep related, disease related, or diet or
stress induced.

68.  The physician may want to evaluate the
effectiveness of cardiac medications such as anti-
arrhythmic drug therapy (medication given to
prevent cardiac rhythm abnormalities).
 Ambulatory monitoring is also used to evaluate
artificial pacemaker functioning.
 Pacemaker functioning is evaluated after
implantation or if problems arise.
 Ambulatory monitoring can also evaluate the
function of the heart after a recent myocardial
infarction.

69.  The two most common types of
ambulatory monitoring are continuous
and intermittent.
 Continuous monitoring provides a
complete tracing of the ECG from the
time the monitor is applied until it is
removed.
 During continuous monitoring, the
patient may be asked to press a button
on the machine to mark the tracing
whenever a symptom is felt.

70. This is known as an “event marker”.
The marker marks the tracing at the
exact time the event occurs.
The monitor has an accurate clock that
indicates the time the marker is
applied.
The clock is necessary for the physician
to be able to correlate the diary entries
with what is happening on the ECG

71.  Two other variations of ambulatory
monitoring include telemetry and
transtelephonic monitoring.
 Telemetry monitoring is performed
within a medical facility such as a
hospital, whereas transteleponic
monitoring is performed outside the
medical facility.
 Both of these types of monitoring are
performed on patients who can
ambulate.

72.  Telemetry monitoring is done with a small transmitting
device attached to the chest with three or five electrodes.
 A continuous tracing of the heart is recorded and sent
directly to a monitoring station.
 Telemetry monitors are only transmitting devices designed
to send the electrical signal of the heart to a central
location to be evaluated continuously.
 At this location, single or multiple patients may be
monitored at the same time on multiple screens.
 There is no need for a patient diary since the patient is
admitted to the facility and will be observed and monitored
at all times.

73.  There are two types of transtelephonic monitors.
One type is known as a postsymptom event
monitor.
 This type is used when a patient is experiencing
symptoms. It is worn like a wristwatch or it can
be handheld.
 The handheld type should be kept in a
convenient place by the patient and is activated
when pressed on the chest.
 The patient should activate the monitor while
experiencing symptoms. The handheld monitor
record a lead II tracing.

76. Educating the Patient

77.  Prior to having an ambulatory monitor, the
patient must be thoroughly instructed on its
proper use.
 Maintaining a diary is vital for accurate
interpretation and evaluation of the results of the
ECG tracing.
 The ECG tracing alone is not helpful unless the
physician can correlate the results with the
activities and symptoms the patient was
experiencing during the tracing.
 Your responsibility is to ensure that the patient
understands the monitoring procedure, why it is
being done, and what he or she must do while
the monitor is in place.

78. The Patient Diary

79.  The patient diary must be an accurate record of
the events and symptoms that occur while the
monitor is in place.
 Most diaries provide time blocks to mark when
activities and symptoms occur, making entry
easy for the patient.
 The patient must record all activities, including
physical and emotional stress and all usual and
unusual daily events, such as urinating, bowel
movements, sexual activities, walking, emotional
upset, eating, and sleeping.

80. Patients may sleep in any position that
does not apply tension on the lead wires
or electrodes.
Avoiding magnets, metal detectors, high-
voltage areas, and electric blankets is
necessary because these devices can
interfere with the tracing.
The patient should also know how the
monitoring equipment works and can be
instructed to check that it is working
properly during the procedure.
Documentation of accurate patient
education is necessary and must be
included on the patient’s chart.

81.  Before entering the room to begin the
procedure, you should prepare the
monitor and review the manufacturer’s
instructions for the type of monitor you
are using.
 Check to see that the monitor is
adequately charged. You will need to
insert new batteries to ensure that the
monitor will not lose charge during the
procedure.
 Insert a new blank tape or disk if

82. For telemetry monitoring, it is
recommended that the chest hair be
clipped not shaved.
This prevents irritation and keeps the
patient from scratching, which can
cause artifact on the tracing.
Check the manufacturer’s instructions
and the policy of your facility for proper
electrode placement.

83. If the leadwires are the “snap-on”
type, you should attach the electrodes
to the lead wires prior to placing them
on the patient to reduce discomfort.
Remove the backing from the adhesive,
then apply each electrode to its proper
position by pressing firmly at the
center.
Run your finger around the edge of
each electrode to ensure firm
attachment.

84.  Attach the cable to an electrocardiograph and run
a baseline ECG tracing. Make sure the tracing is
correct and that the machine is not
malfunctioning.
 Have the patient put on his or her shirt and run
the lead wire between the buttons or out the
bottom of the shirt.
 Attach the cable to the monitor, place it in the
carrying case, and attach it comfortably to the
patient’s waist or shoulder.
 Double-check the lead wires and electrodes to
ensure that there is no pulling on them.

85.  Start the monitor and have the patient
place the first entry into the diary.
 Make sure the beginning time is noted
in the diary.
 Review all instructions with the patient
and set the date and time for him or
her to return for removal.
 Make sure the patient knows how to
get assistance in case problems arise.

86.  Abnormal results may indicate any of
the following:
◦ Electrical-conduction defects in the heart’s rate
and rhythm-controlling system
◦ Rhythm abnormalities
◦ Premature atrial or ventricular contractions.