Cardiac/Vascular Nurse Exam Secrets Study Guide (3 page)

Symptoms

Typically, atherosclerosis is asymptomatic until plaques grow large enough to cause symptoms or rupture. The disease typically progresses slowly over time and the symptoms vary by location of the condition. The most common site of atherosclerotic formation is the lower abdominal aorta. Other sites include coronary arteries, popliteal arteries, descending thoracic aorta, internal carotid arteries, and other vessels.

Common symptoms include chest pain, peripheral pain, weakness, numbness, shortness of breath, dizziness, intermittent claudication, and erectile dysfunction in men. Specifically, individuals presenting with obstruction to coronary arteries experience chest pain, weakness, and fatigue. Individuals who present with obstruction of carotid arteries may experience weakness, numbness, and dizziness. Obstruction of peripheral arteries to extremities may result in intermittent claudication.

Screening and diagnosis

Physical examination often hints at atherosclerosis, but further blood testing and medical imaging is needed for diagnosis. For example, a bruit heard over the carotid artery or abdomen is suggestive of atherosclerosis in the carotids or abdominal aorta. Hairless legs are suggestive of peripheral atherosclerosis. Initial blood tests showing elevated low-density lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol, and elevated triglycerides also suggest it. Diagnostic tools used to determine the presence of plaque formation include electrocardiogram, exercise stress test, echocardiogram, nuclear scan, coronary angiography, electron beam computed tomography, coronary computed tomography (CT) angiography, and magnetic resonance angiography.

Screening for atherosclerosis includes annual blood tests in patients over 20 years of age with a history of cardiovascular disease. Patients 20 years or older should have cholesterol levels checked every 5 years including LDL cholesterol, HDL cholesterol, and triglycerides.

Assessment of other atherosclerosis risk factors should be done as well including modifiable risk factors such as smoking, uncontrolled diabetes, and obesity as well as unmodifiable risk factors such as family history and aging. Individuals with multiple risk factors should be followed on a more regular basis than every 5 years.

Buerger’s disease

Buerger’s disease, also known as
Thromboangiitis obliterans
, is a rare condition resulting impaired blood flow to extremities due to clot formation and inflammation in peripheral arteries and veins. The disease typically progresses from the hands and feet and extends to arms and legs.

The disease is more common in men than in women and typically occurs between 20 and 45 years of age. However, women over the age of 50 have more recently been diagnosed with the condition. The disease is most common in East Asia and the Middle East and rare in the Americas.

Complications of the disease include ulcerations, infections, and gangrene, which result from tissue damage.

Risk factors and complications

The main risk factor for Buerger’s disease is smoking. The onset of Buerger’s disease is dependent on the degree and extent of cigarette smoking. Nearly all cases of Buerger’s disease occur in patients who are current smokers or tobacco users, previous smokers or tobacco users, or were exposed to smoke for an extended period.

Symptoms of Buerger’s disease include pain and weakness in extremities, swelling of hands and feet, Raynaud’s phenomenon, open sores on digits.

Complications of Buerger’s disease include gangrene in digits, infection of the hands and feet, as well as amputation of digits/extremities. Symptoms associated with gangrene include black or blue digits, numbness or tingling in digits, and foul smell from infected area.

Diagnosis and screening

Physical examination, specifically distal ischemia and ulcerations, suggests Buerger’s disease, especially in a male smoker under 45 years old. A positive Allen test also suggests the disorder. Blood tests are useful to rule out other etiologies. However, there are currently no definitive tests available to diagnose the disease and diagnosis is based on a process of elimination.

Diagnostic screening tools used to aid in diagnosis of Buerger’s disease include blood tests to rule out scleroderma, lupus, diabetes and other blood clotting conditions. Allen test is used to assess blood flow to the hands and feet. Angiography, ultrasound, and echocardiography can be used to assess vascular flow.

The most commonly used criteria used for the diagnosis of Buerger’s disease: individuals younger than 45 years of age, past or present tobacco use, presence of distal extremity ischemia (ischemic ulcers and gangrene), exclusion of autoimmune disorders, and consistent angiographic findings in extremities.

Raynaud’s phenomenon

Raynaud’s phenomenon is a condition where an individual’s fingers and toes become discolored, pale, numb, and/or cold due to exposure to changes in temperature or emotional stress. Typical color changes are white, blue, and then red. The symptoms of Raynaud’s syndrome occur due to the mechanism of action, where the small arteries carrying blood to the digits constrict and spasm. Thus, oxygen-rich blood is denied to the distal extremities and this causes the corresponding symptoms.

Raynaud’s phenomenon is used to describe 2 conditions: 1) Raynaud’s disease, also known as primary Raynaud’s phenomenon, and 2) Raynaud’s syndrome, also known as secondary Raynaud’s phenomenon, where the condition is secondary to another comorbid disease.

Recent data has shown that Raynaud’s syndrome is more common in women than men. Symptoms of Raynaud’s syndrome typically present within the 4
^th
decade of life, whereas symptoms of Raynaud’s disease occur earlier in life.

Primary Raynaud’s or Raynaud’s disease is typically an inherited condition, exacerbated by smoking, with a hormonal component.

However, Raynaud’s syndrome, or secondary Raynaud’s is associated with numerous environmental factors and diseases. Those most often associated include scleroderma, lupus, rheumatoid arthritis, eating disorders, atherosclerosis, Buerger’s disease, and drugs such as beta-blockers, cytotoxins, cyclosporin, ergotamine, or sulfasalazine. Additionally, occupational hazards including exposure to vibrating equipment, vinyl chloride and cold as well as other comorbid conditions like hypothyroidism, cryoglobulinemia, cancer and reflex sympathetic dystrophy have also been associated with secondary Raynaud’s phenomenon.

Risk factors

The exact cause of Raynaud’s disease and Raynaud’s syndrome is unknown. In this phenomenon, blood vessels in the digits overreact to cold temperatures or stress.

Risk factors of primary Raynaud’s disease include sex, age, residing in colder climates and family history. Women tend to present with primary Raynaud’s phenomenon more often than men. Also, individuals ages 15 to 25 present with primary Raynaud’s disease more often than individuals in other age groups. Additionally, individuals that live in colder climates and with a family history of the phenomenon also present more frequently with primary Raynaud’s disease.

The risk factors for secondary Raynaud’s syndrome include patients with underlying comorbid conditions such as lupus and diabetes as well as individuals who operate machinery for their occupation.

Symptoms

Patients with either primary or secondary Raynaud’s phenomenon present with painful, pale, discolored, and/or cold digits. Patients may also experience numbness or tingling as well as dull sensory perception in response to cold or stress.

Primary Raynaud’s phenomenon, or Raynaud’s disease, is considered systemic, whereas secondary Raynaud’s phenomenon typically only presents in the extremities. Patients with secondary Raynaud’s phenomenon also experience symptoms of the comorbid condition when experiencing Raynaud’s symptoms. The symptoms of the phenomenon depend on the extent and degree of vasospasm the individual is experiencing.

For the most part, Raynaud’s phenomenon mainly affects the digits, but can cause symptoms in other areas of the body including nose, nipples, lips, and ears. Also, the phenomenon may not always affect the same digits or areas of the body. The phenomenon can occur for short or long durations, ranging from minutes up to several hours.

Diagnosis and screening

Physical examination and diagnostic screening are typically used to diagnose both Raynaud’s disease and syndrome, as no single test is available to diagnose these disorders.

Although clinical practitioners can easily diagnose Raynaud’s phenomenon by the signs and symptoms patients present with (cold extremities with color changes onset by cold or stress), it remains difficult to determine if the phenomenon is primary or secondary. In order to distinguish between Raynaud’s disease and Raynaud’s syndrome, a nail fold capillaroscopy is typically performed. Distorted or fewer capillaries than normal suggests secondary Raynaud’s. Diagnostic measurement of hand temperature gradients, digital artery pressure measurements, Doppler ultrasound, blood counts, and measurement of urea and electrolyte levels are other tools used to distinguish between primary and secondary forms of the phenomenon.

Additionally, blood tests to assess for secondary disorders like lupus or hypothyroidism are helpful.

Cardiomyopathy

Cardiomyopathy is defined as deterioration of myocardium function. The World Health Organization categorizes cardiomyopathy into 2 categories including extrinsic cardiomyopathy and intrinsic cardiomyopathy. Cardiomyopathies are considered extrinsic if their primary pathology is outside the myocardium. However, intrinsic cardiomyopathies are either secondary to genetic, infectious, or idiopathic.

Cardiomyopathy can also be classified as primary or secondary. Primary cardiomyopathy is idiopathic in nature, whereas secondary cardiomyopathies can be attributed to a specific cause such as high blood pressure, heart valve disease, or coronary heart disease.

More specific subtypes of cardiomyopathies include dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy, and arrhythmogenic right ventricular dysplasia.

Dilated cardiomyopathy is the most common type of cardiomyopathy. It presents most often in individuals ages 20 to 60 years, with the condition more common in men than women.

Hypertropic cardiomyopathy can occur at any age and occurs due to abnormal thickening of cardiac muscle. Hypertropic cardiomyopathy consists of 2 types of disease including obstructive and nonobstructive. Both types lead to thickening of cardiac muscle that, in turn, reduces the size of the left ventricle.

Restrictive cardiomyopathy tends to affect elderly patients. It occurs because the ventricles become thick due to abnormal tissue growth that replaces cardiac tissue, reducing blood flow and proper cardiac muscle function.

Arrhythmogenic right ventricular dysplasia is a rare cardiomyopathy that typically affects young adults. It is the leading cause of sudden death in young athletes. The disease presents due to formation of scar tissue in the right ventricle, which can lead to arrhythmias.

Causes

Factors that increase risk of cardiomyopathy include ischemic damage to the heart musculature from a heart attack, hypertension, gene mutation, and/or viral infection. However, in some cases, the actual cause of cardiomyopathy remains unknown.

In terms of the specific subtypes of cardiomyopathies, dilated cardiomyopathy can be inherited but also can be caused by coronary heart disease, heart attacks, infections, alcohol consumption, pregnancy complications, toxins, certain drugs such as amphetamines, or other disease such as diabetes or thyroid disease. Hypertropic cardiomyopathy can also be inherited, but can be caused by high blood pressure or natural aging. Restrictive cardiomyopathy can be caused by hemochromatosis, amyloidosis, sarcoidosis, and connective tissue disorders.

Risk factors

Natural aging is an independent risk factor for cardiomyopathy. However, certain types of cardiomyopathies are more prevalent in certain age and ethnic groups. Male gender and individuals of African American descent are at increased risk for dilated cardiomyopathy as compared to women and individuals of Caucasian descent. Also, young adults are more prone to arrhythmogenic right ventricular dysplasia as compared to elderly individuals.

Other risk factors include family history of cardiomyopathy, congestive heart failure, and sudden cardiac death. The presence of other comorbid conditions includes coronary heart disease, diabetes, metabolic disorders, alcohol abuse, and high blood pressure.

Symptoms

Typically, cardiomyopathies are asymptomatic until they inhibit blood flow or restrict cardiac muscle contraction. They also vary by type of cardiomyopathy. With progression of disease, symptoms include fatigue, weakness, shortness of breath with exertion, swelling of abdomen and extremities, dizziness, fainting, and palpitations. These symptoms tend to get worse as the degree and extent of disease progresses. However, the time to progression varies from patient to patient and ranges from sudden attack to a slow progression.

Diagnosis and screening

Physical examination and diagnostic screening tools are typically used to diagnose cardiomyopathies. However, cardiomyopathies are typically found when assessing other conditions or during routine examinations.

Hypertension is a risk factor for cardiomyopathy and can be diagnosed by measurement of blood pressure. Symptoms of high blood pressure include headaches, fatigue, dizziness, blurred vision, nausea and vomiting, facial flushing or tinnitus.