CV-BC cheat sheet

S1 is closure of the mitral and tricuspid valves at the start of systole; S2 is closure of the aortic and pulmonic valves at end-systole, with A2 preceding P2.

S2 splitting widens with inspiration and narrows with expiration; a fixed split suggests atrial septal defect, and paradoxical (expiratory) splitting suggests right bundle branch block or pulmonary stenosis.

S3 is an early diastolic ventricular gallop heard in volume overload or heart failure; S4 is a late diastolic atrial gallop heard with a stiff ventricle from hypertension or ischemia.

Systolic murmurs: aortic stenosis is crescendo-decrescendo and radiates to the carotids; mitral regurgitation is holosystolic and radiates to the axilla; mitral valve prolapse produces a mid-systolic click.

Diastolic murmurs are always abnormal: aortic regurgitation is a decrescendo early diastolic murmur at the left sternal border; mitral stenosis is a low-pitched rumble with an opening snap.

JVP is assessed with the head of bed at 30-45 degrees; a venous column more than 3 cm above the sternal angle indicates elevated right atrial pressure.

Troponin rises 3-6 hours after myocardial injury, peaks at 12-24 hours, and stays elevated 7-14 days; CK-MB normalizes in 48-72 hours and is therefore useful for detecting reinfarction.

Normal ECG intervals: PR 0.12-0.20 s, QRS under 0.12 s, QTc under 0.44 s in men and under 0.46 s in women.

MAP = (SBP + 2 x DBP) / 3 and must be at least 60 mm Hg for organ perfusion; pulse pressure = SBP minus DBP.

STEMI: ST elevation of at least 1 mm in two contiguous limb leads, or at least 2 mm in V2-V3 in men 40 years or older (2.5 mm in men under 40, 1.5 mm in women), or new left bundle branch block.

Heart failure by ejection fraction: HFrEF 40% or less, HFmrEF 41-49%, HFpEF 50% or greater.

NYHA class I (no symptoms) through IV (symptoms at rest); Killip class I-IV grades mortality risk in acute MI, from no rales to cardiogenic shock.

Severe aortic stenosis: valve area under 1.0 cm2, peak velocity 4 m/s or greater, mean gradient 40 mm Hg or greater; the classic symptom triad is angina, syncope, and dyspnea.

Atrial fibrillation is irregularly irregular with absent P waves; rate control targets are under 110 bpm (lenient) or under 80 bpm (strict).

Cardiogenic shock: SBP under 90 mm Hg, cardiac index under 2.2 L/min/m2, PCWP over 15 mm Hg, with hypoperfusion such as oliguria and cool extremities.

Volume overload in heart failure is flagged by weight gain of 2-3 lb in a day or 5 lb in a week, plus orthopnea, paroxysmal nocturnal dyspnea, crackles, S3, and elevated JVP.

Acute pericarditis: sharp pleuritic pain worse when supine and relieved by leaning forward, diffuse ST elevation with PR depression, and a pericardial friction rub.

Acute myocardial infarction requires a rise and/or fall in troponin plus one of: ischemic symptoms, new ST-T changes, Q waves, or imaging evidence of new loss of viable myocardium.

Ankle-brachial index of 0.90 or less diagnoses peripheral artery disease; under 0.40 indicates critical limb ischemia; over 1.30 suggests noncompressible calcified arteries and a toe-brachial index is needed.

Intermittent claudication is reproducible exercise-induced muscle pain relieved by rest within 2-5 minutes at a constant walking distance; rest pain or tissue loss marks critical limb ischemia.

Virchow triad: venous stasis, endothelial injury, and hypercoagulability are the three contributors to venous thromboembolism.

Aortic dissection presents with abrupt tearing chest or back pain, pulse deficits, and an interarm systolic difference over 20 mm Hg; type A involves the ascending aorta and requires surgery.

Abdominal aortic aneurysm: 3 cm or greater is dilated; repair threshold is over 5.5 cm in men or over 5.0 cm in women, or growth over 0.5 cm in 6 months.

Hypertension stages: normal under 120/80, elevated 120-129/under 80, stage 1 130-139/80-89, stage 2 140/90 mm Hg or higher.

Venous ulcers occur at the medial malleolus, are shallow and moist with hemosiderin staining; arterial ulcers occur at toes or lateral ankle, are punched-out and dry with absent pulses.

Compartment syndrome: pain out of proportion and pain on passive stretch are the earliest findings; pulselessness and paralysis are late and unreliable.

Anticoagulation for a provoked proximal DVT is typically 3 months; extended therapy is used when the provoking factor is absent or persistent.

After ACS or PCI, dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) is continued for 12 months unless bleeding risk outweighs benefit.

HFrEF quadruple therapy: ARNI or ACE inhibitor/ARB, an evidence-based beta-blocker (carvedilol, metoprolol succinate, bisoprolol), a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor.

Allow 36 hours between the last ACE inhibitor dose and starting sacubitril/valsartan to prevent angioedema.

Digoxin therapeutic range in heart failure is 0.5-0.9 ng/mL; hypokalemia, hypomagnesemia, and renal impairment increase toxicity risk; the antidote is digoxin immune Fab.

Amiodarone requires baseline and periodic thyroid, hepatic, pulmonary, and ophthalmologic monitoring because of its long half-life and organ toxicity.

Unfractionated heparin is titrated to an aPTT 1.5-2.5 times control; a platelet drop over 50% suggests HIT, so stop heparin and start argatroban or another non-heparin anticoagulant.

Warfarin target INR is 2.0-3.0 for most indications and 2.5-3.5 for a mechanical mitral valve; vitamin K is the reversal agent.

Nitrates are contraindicated within 24 hours of sildenafil and 48 hours of tadalafil because of severe hypotension.

High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) targets LDL under 70 mg/dL in very high-risk atherosclerotic disease.

Daily weights: same time each morning, after voiding, same scale and clothing; report a gain of 2-3 lb in one day or 5 lb in one week.

Heart failure sodium restriction is commonly 2-3 g per day; fluid restriction of 1.5-2 L per day is reserved for hyponatremia or persistent congestion.

Teach-back, having the patient restate instructions in their own words, verifies comprehension better than asking whether they understand.

Cardiac rehabilitation typically provides 36 supervised sessions over 12 weeks and reduces mortality and rehospitalization after a cardiac event.

Sexual activity may resume after an uncomplicated MI once the patient can climb two flights of stairs or walk briskly without symptoms.

The 5 A's of smoking cessation are Ask, Advise, Assess, Assist, Arrange, delivered at every encounter.

Warfarin teaching: keep vitamin K intake consistent, avoid NSAIDs and excess alcohol, use soft toothbrushes and electric razors, and carry a medical alert card.

For suspected MI, activate EMS and chew one 325 mg non-enteric aspirin unless allergic; do not drive to the hospital.

The aerobic activity goal is 150 minutes per week of moderate exercise; heavy isometric lifting is avoided early after MI or sternotomy.

SBAR (Situation, Background, Assessment, Recommendation) is the standard structured handoff and escalation format.

STEMI reperfusion times: door-to-balloon 90 minutes or less, or 120 minutes or less when transfer for PCI is required; door-to-needle fibrinolysis 30 minutes or less.

Assessment, teaching, evaluation, and clinical judgment are non-delegable RN responsibilities; only tasks with predictable outcomes may be assigned to unlicensed assistive personnel.

Medication reconciliation is required at admission, transfer, and discharge to reduce preventable adverse drug events.

Root cause analysis is a systems-focused review after a sentinel event; just culture distinguishes human error from at-risk or reckless behavior.

Core quality measures for cardiac care include 30-day readmission, risk-adjusted mortality, HCAHPS experience scores, and door-to-ECG time of 10 minutes or less.

Informed consent requires capacity, disclosure of risks, benefits, and alternatives, and voluntariness; the provider obtains consent and the nurse witnesses and verifies understanding.

Heart failure discharge planning uses a multidisciplinary team (case management, pharmacist, dietitian, rehabilitation) with follow-up arranged within 7 days.